Preventive Services Covered Under Health Reform

Under health reform, non-grandfathered plans are required to provide coverage for certain “Recommended Preventive Services” (such as mammograms, colonoscopies and immunizations) without cost-sharing. The rule generally applies to group health plans for plan years beginning on or after September 23, 2010 (January 1, 2011 for calendar year plans). See the Conner Strong July Update for more background information on these rules.


If a plan is “grandfathered,” these preventive benefit requirements do not apply. If a non- grandfathered plan is subject to these new requirements, participants will not have to pay a co-payment, co-insurance, or any deductible to receive preventive health services, such as recommended screenings, vaccinations, and counseling. If a health plan uses a network of providers, the health plan is only required to provide these preventive services through an in-network provider. The health plan may allow these services from an out-of-network provider, but may charge a fee. If a doctor provides a preventive service, such as a cholesterol screening test, as part of an office visit, the plan can require that a participant pay some costs of the office visit if the preventive service is not the primary purpose of the visit or if the doctor bills for the preventive services separately from the office visit.

The healthcare.gov website lists the following as covered preventive services:


Covered Preventive Services for Adults

  • Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked

  • Alcohol Misuse screening and counseling

  • Aspirin use for men and women of certain ages

  • Blood Pressure screening for all adults

  • Cholesterol screening for adults of certain ages or at higher risk

  • Colorectal Cancer screening for adults over 50

  • Depression screening for adults

  • Type 2 Diabetes screening for adults with high blood pressure

  • Diet counseling for adults at higher risk for chronic disease

  • HIV screening for all adults at higher risk

  • Immunization vaccines for adults--doses, recommended ages, and recommended populations vary:

  • Hepatitis A

  • Hepatitis B

  • Herpes Zoster

  • Human Papillomavirus

  • Influenza

  • Measles, Mumps, Rubella

  • Meningococcal

  • Pneumococcal

  • Tetanus, Diphtheria, Pertussis

  • Varicella

  • Obesity screening and counseling for all adults

  • Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk

  • Tobacco Use screening for all adults and cessation interventions for tobacco users

  • Syphilis screening for all adults at higher risk

Covered Preventive Services for Women, Including Pregnant Women

  • Anemia screening on a routine basis for pregnant women

  • Bacteriuria urinary tract or other infection screening for pregnant women

  • BRCA counseling about genetic testing for women at higher risk

  • Breast Cancer Mammography screenings every 1 to 2 years for women over 40

  • Breast Cancer Chemoprevention counseling for women at higher risk

  • Breast Feeding interventions to support and promote breast feeding

  • Cervical Cancer screening for sexually active women

  • Chlamydia Infection screening for younger women and other women at higher risk

  • Folic Acid supplements for women who may become pregnant

  • Gonorrhea screening for all women at higher risk

  • Hepatitis B screening for pregnant women at their first prenatal visit

  • Osteoporosis screening for women over age 60 depending on risk factors

  • Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk

  • Tobacco Use screening and interventions for all women, and expanded counseling for pregnant

  • Tobacco users

  • Syphilis screening for all pregnant women or other women at increased risk

Covered Preventive Services for Children


  • Alcohol and Drug Use assessments for adolescents

  • Autism screening for children at 18 and 24 months

  • Behavioral assessments for children of all ages

  • Cervical Dysplasia screening for sexually active females

  • Congenital Hypothyroidism screening for newborns

  • Developmental screening for children under age 3, and surveillance throughout childhood

  • Dyslipidemia screening for children at higher risk of lipid disorders

  • Fluoride Chemoprevention supplements for children without fluoride in their water source

  • Gonorrhea preventive medication for the eyes of all newborns

  • Hearing screening for all newborns

  • Height, Weight and Body Mass Index measurements for children

  • Hematocrit or Hemoglobin screening for children

  • Hemoglobinopathies or sickle cell screening for newborns

  • HIV screening for adolescents at higher risk

  • Immunization vaccines for children from birth to age 18 —doses, recommended ages, and recommended populations vary:

  • Diphtheria, Tetanus, Pertussis

  • Haemophilus influenzae type b

  • Hepatitis A

  • Hepatitis B

  • Human Papillomavirus

  • Inactivated Poliovirus

  • Influenza

  • Measles, Mumps, Rubella

  • Meningococcal

  • Pneumococcal

  • Rotavirus

  • Varicella

  • Iron supplements for children ages 6 to 12 months at risk for anemia

  • Lead screening for children at risk of exposure

  • Medical History for all children throughout development

  • Obesity screening and counseling

  • Oral Health risk assessment for young children

  • Phenylketonuria (PKU) screening for this genetic disorder in newborns

  • Sexually Transmitted Infection (STI) prevention counseling for adolescents at higher risk

  • Tuberculin testing for children at higher risk of tuberculosis

  • Vision screening for all children

The complete list of recommendations and guidelines that must be covered by plans will be continually updated to reflect both new recommendations and guidelines and revised or removed guidelines. Should you have questions about this or any aspect of federal health insurance reform, contact your Conner Strong account representative toll free at 1-877- 861-3220. For a complete list of Legislative Updates issued by Conner Strong, visit our Resource Center.


This Legislative Update is provided for general informational purposes only and is not intended to be legal advice. Readers are urged to contact an attorney for legal advice or assistance.

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