Affordable Care Act (ACA)

• ACA Preventive Health Services

ACA Preventive Health Services

We believe that a well-designed, evidence-based health maintenance program is important to the long-term health of our members. We follow the recommendations of the US Preventive Services Task Force (USPSTF) to determine what tests and examinations are appropriate as preventive or screening services. Also, we cover immunizations based on the recommendations of the Advisory Committee on Immunization Practices (ACIP) as interpreted in our immunization policies.

In addition to the standard wellness benefits, the federal Affordable Care Act (ACA) addresses preventive services. The preventive services component of the law became effective September 23, 2010. The law requires all “non-grandfathered” health plans to cover preventive medicine services given an “A” or “B” recommendation by USPSTF. For detailed information, see Preventive Health Benefit (QCP.PP.016). However, if there are multiple equivalent testing options available to fulfill a USPSTF “A” or “B” recommendation (such as for colorectal cancer screening), less cost-effective options may not be covered.

Task Force recommendations are graded on a five-point scale (A-E), reflecting the strength of evidence in support of the intervention.

• Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination.
• Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination.
• Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds.
• Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.
• Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.

Those preventive services listed as Grade A and B recommendations are covered under preventive health benefits as specified in the member’s plan documents. Please note that it may take up to twelve (12) months following an A or B rating by the USPSTF for QualChoice to implement coverage as a preventive service. For most plans, these services will be covered without cost sharing (i.e., deductible, coinsurance or copayment) by health plans for services provided by an in-network provider (for these plans, preventive services are not covered if provided by an out-of-network provider). If the primary purpose for the office visit is other than a Grade A or B USPSTF preventive care service, then deductible, coinsurance or copayment may apply.

For questions, contact your Provider Network Territory Map.