Employees with group health care coverage through their employers often benefit from additional services covered as preventive beyond the list required by the ACA. (Photo: Shutterstock)
The Affordable Care Act introduced mandatory coverage with no cost-sharing for services that were determined to be preventive. But what exactly is the coverage trying to prevent?
Milliman, a provider of actuarial and related products and service, answered that question in a recent white paper. Preventive services as defined by the ACA are far-reaching and varied, including blood-pressure screening for adults; depression screening for adolescents and adults; intimate partner violence screening for women of reproductive age; and skin cancer behavioral counseling.
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The U.S. Preventive Services Task Force uses three criteria to determine if a service is preventive:
- The service has a high probability that the net benefit is substantial, or
- There is a high probability that the net benefit is moderate, or
- There is a moderate probability that the net benefit is moderate to substantial.
Preventive coverage can be found across most markets, although the ACA preventive list is a fairly common reference point throughout. Medicare uses a list similar to the ACA preventive services list, though other statutory and regulatory provisions define the specific services covered. Employees with group health care coverage through their employers often benefit from additional services covered as preventive beyond the list required by the ACA, such as weight-loss programs or certain generic drugs. Medicaid also provides preventive service coverage, although the financial impact to beneficiaries generally is not a significant, because member cost-sharing is minimal.
Preventive services have the potential to help improve outcomes in several major U.S. health-care markets by preventing beneficiaries from contracting conditions, identifying diseases before symptoms occur or preventing the spread of conditions to other people.
The pandemic already has prompted Congress to pass legislation that removes cost-sharing for COVID-19 related testing and treatment, including the eventual vaccine. This new environment also could prompt government organizations, individual states or health plans to consider waiving cost-sharing for mental health and substance-abuse disorder services to help the public return to a healthier state as quickly as possible.
"Providers are likely to administer new preventive services, when clinically appropriate, because they can be billed back to the plan," the white paper concluded. "Plans may want to understand their historical preventive service utilization and understand the financial impact of potential future changes to the list of the preventive services. The projection of financial impacts of change to the preventive service list can benefit from actuarial modeling and strategic expertise."
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Alan Goforth
Alan Goforth is a freelance writer in suburban Kansas City. In addition to freelancing for several publications, he has written a dozen books about sports and other topics.
