Preventive Services

The Affordable Care Act requires coverage of recommended preventive services without cost-sharing for the following health plans:

1. Non-grandfathered private health insurance plans – Most private insurance plans, including all plans on the Health Insurance Marketplace, and all group or individual health insurance plans that did not exist on March 23, 2010 or that have made significant changes to benefits, cost-sharing, or limits since that time are required to cover services without cost-sharing.¹
2. Medicare – All USPSTF recommended services that have a Grade “A” or “B” and that are covered by Medicare must be covered without cost-sharing.²
3. Medicaid expansion plans in states that expanded (i.e. Alternative Benefit Plans) – Medicaid expansion plans offered by states that extend Medicaid eligibility to non-elderly individuals with annual incomes at or below 133 percent of the federal poverty level ($15,880 for an individual or $32,319 for a family of 4 in 2016) are required to cover services without cost-sharing.^3,4
4. Traditional Medicaid plans – Those states that, at their option, cover without cost-sharing in their standard Medicaid benefit package all USPSTF-recommended services that have a Grade “A” or “B” and all ACIP-recommended vaccines receive an increase in their federal medical assistance for such services and vaccines.⁵

¹ Preventive Services Covered Under the ACA. U.S. Department of Health & Human Services.

² Patient Protection and Affordable Care Act, Pub. L. No. 111-148, §4104, 124 Stat. 125, 557-558 (2010)

³ Patient Protection and Affordable Care Act, Pub. L. No. 111-148, §2001, 124 Stat. 121, 271-272 (2010)

⁴ Medicaid and Children's Health Insurance Programs: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment. 78 FR 42159; 42224-42226

⁵ Patient Protection and Affordable Care Act, Pub. L. No. 111-148, §4106, 124 Stat. 125, 559-560 (2010)