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American Health Benefit Exchanges B

Preventive Services Covered Under the Affordable Care Act

February 2014; material added June 30, 2014

The federal Affordable Care Act (ACA) includes a special focus on providing newly required coverage for a wide range of health preventive and screening services.  In particular, the 63 distinct preventive services listed below must be covered without the enrollee having to pay a copayment or co-insurance or meet a deductible. This coverage began back in September 2010 for some newly issued health plans; effective January 1, 2014, it applies much more broadly, to plans offered in the individual, small, and some large group markets.  There are and can be exceptions for some grandfathered employer plans and policies bought by persons who are exempt from the individual coverage mandate. For commercial health insurance, both inside and outside of health exchanges, this no-cost feature applies only when these services are delivered by a network provider.  The material and service-specific links below includes material posted online by HHS at www.healthfinder.gov/prevention

 

15 Covered Preventive Services for Adults

  1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
  2. Alcohol Misuse screening and counseling
  3. Aspirin use for men and women of certain ages
  4. Blood Pressure screening for all adults
  5. Cholesterol screening for adults of certain ages or at higher risk
  6. Colorectal Cancer screening for adults over 50
  7. Depression screening for adults
  8. Type 2 Diabetes screening for adults with high blood pressure
  9. Diet counseling for adults at higher risk for chronic disease
  10. HIV screening for all adults at higher risk
  11. Immunization vaccines for adults--doses, recommended ages, and recommended populations vary:
  12. Obesity screening and counseling for all adults
  13. Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
  14. Tobacco Use screening for all adults and cessation interventions for tobacco users
  15. Syphilis screening for all adults at higher risk

22 Covered Preventive Services for Women, Including Pregnant Women

The eight new prevention-related health services marked with an asterisk ( * ) must be covered with no cost-sharing in plan years starting on or after August 1, 2012.

  1. Anemia screening on a routine basis for pregnant women
  2. Bacteriuria urinary tract or other infection screening for pregnant women
  3. BRCA counseling about genetic testing for women at higher risk
  4. Breast Cancer Mammography screenings every 1 to 2 years for women over 40
  5. Breast Cancer Chemoprevention counseling for women at higher risk
  6. Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women*
  7. Cervical Cancer screening for sexually active women
  8. Chlamydia Infection screening for younger women and other women at higher risk
  9. Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs*
    UPDATE: On June 30, 2014, the U.S. Supreme Court ruled that the ACA contraception coverage mandate cannot be applied to require "closely held" for-profit employers to pay for certain contraception services. For more information see post-decision legal analyses, with text of court ruling], online at http://www.ncsl.org/research/health/state-laws-and-actions-challenging-ppaca.aspx#Contraception .
  10. Domestic and interpersonal violence screening and counseling for all women*
  11. Folic Acid supplements for women who may become pregnant
  12. Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes*
  13. Gonorrhea screening for all women at higher risk
  14. Hepatitis B screening for pregnant women at their first prenatal visit
  15. Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women*
  16. Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older*
  17. Osteoporosis screening for women over age 60 depending on risk factors
  18. Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk
  19. Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users
  20. Sexually Transmitted Infections (STI) counseling for sexually active women*
  21. Syphilis screening for all pregnant women or other women at increased risk
  22. Well-woman visits to obtain recommended preventive services*

Learn more about Affordable Care Act Rules on Expanding Access to Preventive Services for Women. (Effective August 1, 2012)


26 Covered Preventive Services for Children

  1. Alcohol and Drug Use assessments for adolescents
  2. Autism screening for children at 18 and 24 months
  3. Behavioral assessments for children of all ages
    Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
  4. Blood Pressure screening for children
    Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
  5. Cervical Dysplasia screening for sexually active females
  6. Congenital Hypothyroidism screening for newborns
  7. Depression screening for adolescents
  8. Developmental screening for children under age 3, and surveillance throughout childhood
  9. Dyslipidemia screening for children at higher risk of lipid disorders
    Ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
  10. Fluoride Chemoprevention supplements for children without fluoride in their water source
  11. Gonorrhea preventive medication for the eyes of all newborns
  12. Hearing screening for all newborns
  13. Height, Weight and Body Mass Index measurements for children
    Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
  14. Hematocrit or Hemoglobin screening for children
  15. Hemoglobinopathies or sickle cell screening for newborns
  16. HIV screening for adolescents at higher risk
  17. Immunization vaccines for children from birth to age 18 —doses, recommended ages, and recommended populations vary:
  18. Iron supplements for children ages 6 to 12 months at risk for anemia
  19. Lead screening for children at risk of exposure
  20. Medical History for all children throughout development  Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
  21. Obesity screening and counseling
  22. Oral Health risk assessment for young children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years.
  23. Phenylketonuria (PKU) screening for this genetic disorder in newborns
  24. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk
  25. Tuberculin testing for children at higher risk of tuberculosis.  Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
  26. Vision screening for all children

 

  • Increased Coverage of Preventive Services with Zero Cost Sharing under the Affordable Care Act (PDF-8 Pages), An U.S. HHS/ASPE Issue Brief, published June 2014. (Summary) This brief estimates the number of people newly eligible for preventive services coverage with no cost sharing, including contraception, because of the Affordable Care Act. The Affordable Care Act ensures that most insurance plans (so-called ‘non-grandfathered’ plans) provide coverage for certain preventive health services without cost sharing. Based in part on recommendations from the U.S. Preventive Services Task Force, this includes colonoscopy screening for colon cancer, Pap smears and mammograms for women, contraception, well-child visits, flu shots for all children and adults, and many more services. Estimates of people affected by these provisions are available by age, gender, race and ethnicity, and at the state-level. In addition, the brief reports findings from the IMS Institute for Healthcare Informatics of the change in the number of prescriptions for oral contraceptives with no co-pay between 2012 and 2013 and the reduction in out-of-pocket costs to women associated with this change. 

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American Health Benefit Exchanges (2010 NCSL Archive edition - PDF File - 2 pages)

Overview
The 2010 Affordable Care Act (the act) requires that, by January 1, 2014, states have a fully functional American Health Benefit Exchange that facilitates insurance purchasing through qualified health plans and a Small Business Health Options Program. States may establish and operate one or more exchanges, join with another state or states to do so, or defer to the federal government to establish and operate the exchanges in the state.

Federal Provisions
For most states, health benefit exchanges are new entities that will function as a marketplace for health insurance purchasers by providing choices to consumers who are shopping for health coverage. Exchanges will offer a variety of qualified health plans and will provide information and educational services to help consumers understand their options for coverage.

Exchanges will offer “qualified health plans” based on requirements related to marketing, choice of providers, plan networks, essential benefits and other features. States will license issuers of qualified health plans to provide coverage through the exchanges.

Exchanges will initially target those who purchase coverage on their own and small businesses with up to 100 employees. In the future, exchanges may be expanded
to larger employers. The Congressional Budget Office estimates that approximately 30 million people will be covered through an exchange by 2019, most of whom will be eligible for a subsidy available through the exchange.1

The act lists broad categories of services that must be included, called “essential health benefits,” and requires the secretary of the Department of Health and Human Services (DHHS) to define additional essential health benefits. In November 2010 the first in a series of guidances was released by DHHS. Additional guidance will be released over the next three years as required under Section 1311 (b) of the act.

Exchanges will offer insurance plans with different levels—bronze, silver, gold and platinum—depending upon the services the consumer prefers and cost sharing determined by the actuarial value of the coverage compared to the actuarial value of the “essential health benefits.” Health insurers must offer silver and gold plans in the exchange.

 

The actuarial value of a health insurance policy is the percentage of the total covered expenses that the plan would, on average, cover. A plan with a 70 percent actuarial value
means that consumers would on average pay 30 percent of the cost of health care expenses through features such as deductibles and coinsurance.

Source: Kaiser Family Foundation

Subsidies
To help ease the financial burden of the requirement for insurance coverage in 2014, the act provides federal subsidies for people with incomes between 133 percent and 400 percent of federal poverty guidelines in the form of a premium credit. Those who have employer-sponsored coverage are not eligible for the exchange and/or subsidies, with exceptions related to the actuarial value of the employer health plan and the employee contribution. If an employer health plan does not have an actuarial value of at least 60 percent or if an employee’s share of the employer premium exceeds 9.5 percent of the employee’s income, then the individual can enroll in the exchange and qualifies for subsidies.

Tax credits also will subsidize small businesses with fewer than 25 employees. Eligible individuals must meet certain criteria, such as being a U.S. citizen or legal immigrant. Premium credits will be based on a sliding scale related to income, ranging from 3 percent of income for people with incomes at 133 percent up to 9.5 percent for those with incomes between 300 percent and 400 percent of the federal poverty guideline. Cost-sharing subsidies also are available to limit out-of-pocket expenses and allow people to enroll in health plans with higher actuarial value.

Interoperability with Health and Human Services Programs
State exchanges also must screen enrollees for eligibility in health and human services programs, such as Medicaid, which will require transfer of data for verification and screening. The data must be compatible between the exchange and public programs such as Medicaid.

States will need to evaluate their existing information technology systems to determine if an upgrade or replacement is required. Legislators may need to address the cost of these system changes for both the purchase of new technology and the personnel to meet requirements and operate the systems.

State Roles in Implementation
Establishing an exchange will require a great deal of planning. Most states already have started the process of examining and analyzing the feasibility of an exchange. The following key issues are among those that states will want to consider.

  • Should the state establish an exchange? Does it have the capacity to establish, operate and sustain an exchange? What are the pros and cons of allowing the federal government to set up the exchange?
  • What legislation or regulations are needed to create, implement and administer the exchange?
  • How will the exchange be governed and administered, by a government agency or a nonprofit organization?
  • Who will pay for it?
  • What data are needed to make policy decisions regarding the exchange, and who will collect it?
  • How will the state make the exchange “interoperable” with the Medicaid program?

State Experiences
In 2006, Massachusetts passed health reform legislation that created the Commonwealth Health Insurance Connector Authority. The Connector is an independent, quasi-government agency that helps small businesses and people who purchase insurance on their own. The Connector serves many functions and manages two health insurance programs: Commonwealth Care, which subsidizes insurance purchases for adults who do not have employer-sponsored insurance; and Commonwealth Choice, which offers commercial insurance plans for those who are not eligible for Care, and for small employers. The Connector offers levels of coverage designated as bronze, silver and gold, based on the actuarial value. The Connector facilitates enrollment, regulates the plans offered in the Connector, conducts outreach programs, and helps make administrative policy decisions related to the state’s broad-based health reform law. Since the 2006 health reform legislation, 360,000 people have been newly insured in the state, which now has the lowest uninsured rate in the nation.

Utah laws passed in 2008 and 2009 led to development and implementation of a statewide health insurance exchange. Since fall 2009, the Utah Health Exchange allowed employees of small employers, on a pilot basis, to compare, select and enroll in commercial health insurance through an entirely online, Internet-based process. The exchange was opened to all small employers in fall 2010 and to large employers on a pilot basis. The exchange includes 146 plans (both required and optional), that rely mainly on partnering with the private sector. It allows employers to determine their contribution levels (a defined contribution arrangement) and allows employees to aggregate contributions from several employers, including those of other household members. Utah currently is developing a blueprint for how the exchange will operate under new federal requirements.

California was the first state to enact legislation designed to set up an exchange in response to the requirements of the act to date, although specific federal requirements will be forthcoming. Like the Massachusetts exchange, California’s will be governed by an independent board responsible for setting up and determining which plans can participate.

Funding
On Sept. 20, 2010, DHHS released $49 million in planning grants to 48 states and the District of Columbia. Grants will be renewed if a state is making progress toward establishing an exchange, implementing insurance market reforms, and meeting other benchmarks in the law.2 Grants also will be available to certain states to support innovative information technology infrastructure that can be used as models for other states.

Resources
Brief Series: "States Implement Health Reform" Main Page
American Health Benefit Exchange
Massachusetts Connector
National Association of Insurance Commissioners Model Legislation
State Actions to Implement the American Health Benefit Exchange
Utah Exchange

Notes
1. Congressional Budget Office, August 2010 Baseline: Health Insurance Exchanges, (Washington, D.C.: CBO, August 2010); http://www.cbo.gov/budget/factsheets/2010d/ExchangesAugust2010FactSheet.pdf

2. U.S. Department of Health and Human Services, Exchange Planning Grants: Grant Award List, (Washington, D.C.: HHS, July 29, 2010);
http://www.healthcare.gov/news/factsheets/grantawardslist.html

© 2010 by the National Conference of State Legislatures. All rights reserved.

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