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1 [1] (May 23, 2025)

handle is hein.crs/acapvesscov0001 and id is 1 raw text is: Congressional Research Serice Inforrning the legislative debate since 1914 S May 23, 2025 The ACA Preventive Services Coverage Requirement Per the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended), most private health insurance plans are required to cover specified preventive services and items without consumer cost sharing. This includes coverage of dozens of preventive services and items-such as screenings, counseling, vaccines, and preventive medications-for millions of women, men, and children. This In Focus provides an overview of the preventive services coverage requirement. It includes enrollee estimates and outlines considerations for potential legislative changes. It also provides context relevant to the Kennedy v. Braidwood challenge to this coverage requirement, currently before the Supreme Court. A CRS Legal Sidebar provides more information on the Braidwood case. Overview Section 1001 of the ACA, adding Section 2713 of the Public Health Service Act (PHSA), requires private health insurance coverage without cost sharing of specified preventive services and items. Per statute and regulations, this includes at least the preventive services and items in the following four categories: * Evidence-based items or services recommended with an A or B rating by the United States Preventive Services Task Force (USPSTF); * Immunizations recommended by the Advisory Committee on Immunization Practices (ACIP), adopted by the Centers for Disease Control and Prevention (CDC), for routine use for a given individual; * Evidence-informed preventive care and screenings for infants, children, and adolescents as provided in guidelines supported by the Health Resources and Services Administration (HRSA); and * Additional preventive care and screenings for women as provided in guidelines supported by HRSA. Four Preventive Services Categories Following are examples of recommendations and guidelines in each of the four categories above. Additional details are available on the relevant websites (e.g., USPSTF). The complete list of preventive services and items required to be covered, per all categories, is available at HealthCare.gov. USPSTF A and B Recommendations The USPSTF is an independent, volunteer panel of experts that issues evidence-based recommendations on the provision of clinical preventive services for patients across the lifespan. The USPSTF generally assigns grades (A, B, C, D, and I) to recommend or discourage a preventive service, or to indicate uncertain evidence. Relevant to the preventive services coverage requirement, there are currently about 50 USPSTF recommendations with A and B grades, many of which are related to * Cancer screenings and preventive care; * Mental health and substance use screenings and referrals; * Cardiovascular disease (CVD), healthy weight, and diabetes prevention screenings and care; * Sexually transmitted infection (STI) and other infectious disease preventive screenings and care; and * Preventive care for prenatal and postpartum individuals, for newborns and children, and for older adults. Most recommendations are population-based (e.g., based on age and/or sex) and may specify frequency or other details. For example, cervical cancer screenings are recommended every three years for women aged 21-29 and every three to five years for women aged 30-65, using specified methods. Many of the recommendations are for preventive services, such as diabetes screenings for certain adults and primary care education or counseling to prevent tobacco use among school-age children and adolescents. There are also recommendations for preventive medications such as statins for adults at increased risk of CVD and preexposure prophylaxis (PrEP) therapy for adolescents and adults at increased risk of human immunodeficiency virus (HIV). ACIP Recommended Vaccines The ACIP is a federal advisory committee that makes recommendations on pediatric and adult vaccines. For purpose of the preventive services coverage requirement, ACIP recommendations are considered adopted by the CDC for routine use if they are listed on the CDC immunization schedules. These schedules currently include * Pediatric vaccines through the age of 18, including to protect against diphtheria, tetanus, and pertussis; measles, mumps, and rubella; influenza; COVID-19; and human papillomavirus (HPV); and * Adult vaccines for individuals aged 19 and older, including to protect against respiratory syncytial virus (RSV), shingles, mpox, influenza, and COVID-19. The immunization schedules include recommendations by age and for other population or risk-based groups (e.g., by sex or health condition) and include any precautions or contraindications. Coverage of COVID-19 vaccines, as recommended by ACIP, also is required per Section 3203 of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act; P.L. 116-136), added as a note to PHSA Section 2713. igross.gov