The Affordable Care Act’s New Rules on Preventive Care and You

July 14, 2010

Too many Americans don’t get the preventive health care they need to stay healthy, avoid or delay the onset of disease, lead productive lives, and reduce health care costs. Cost-sharing (including copays, co-insurance and deductibles) reduces the likelihood that preventive services will be used.

Often because of cost, Americans use preventive services at about half the recommended rate.

Yet chronic diseases such as heart disease, cancer, and diabetes – which are responsible for 7 of 10 deaths among Americans each year and account for 75% of the nation’s health spending – often are preventable.

The Affordable Care Act will help make wellness and prevention services affordable and accessible to you by requiring health plans to cover preventive services and by eliminating cost-sharing. According to a new regulation released by the Department of Health and Human Services, the Department of Treasury and the Department of Labor, if you or your family enroll in a new health plan on or after September 23, 2010, then that plan will be required to cover recommended preventive services without charging you a copay, co-insurance or deductible.

What This Means for You

Depending on your age and health plan type, you may have easier access to such services as:

• Blood pressure, diabetes, and cholesterol tests
• Many cancer screenings
• Counseling on such topics as quitting smoking, losing weight, eating better, treating depression, and reducing alcohol use
• Routine vaccines for diseases such as measles, polio, or meningitis
• Flu and pneumonia shots
• Counseling, screening and vaccines for healthy pregnancies
• Regular well-baby and well-child visits, from birth to age 21

Learn more about the covered services.

Keeping Your Children Healthy

Many children don’t get the preventive care they need.

• 12% of children have not had a doctor’s visit in the past year, and a recent study found that children receive recommended care less than half of the time.  
• Nearly one-third of kids are overweight or obese, putting them at risk for conditions such as diabetes and heart disease. 
• While approximately 12% to 16% of children experience developmental problems, only one-third of those children are identified in pediatric practices prior to school entry.  Early identification helps kids get the developmental services they need.

The new regulation ensures that a comprehensive set of preventive services is available in new health plans for children with no cost-sharing.  These services include:

• Well-baby and well-child visits:  This includes a doctor’s visit every few months when your baby is young, and a visit every year until your child is age 21.  These visits will cover a comprehensive array of preventive health services:
  • Physical exam and measurements
  • Vision and hearing screening
  • Oral health risk assessments
  • Developmental assessments to identify any development problems
  • Screenings for hemoglobin level, lead, tuberculin, and other tests
  • Counseling and guidance from your doctor about your child’s health development

• Screenings and counseling to prevent, detect, and treat common childhood problems like:
  • obesity to help children maintain a healthy weight
  • depression among adolescent children
  • dental cavities and anemia

• Immunizations like an annual flu vaccine and many other childhood vaccinations and boosters, from the measles to polio.

Promoting Healthy Pregnancy

The U.S. infant mortality rate is a troublingly high 6.8 deaths for every 1,000 live births, and 8.2% of babies have a low birth weight, up 17% since 1990. At least 13% of American women smoke during pregnancy, and 12% of women drink alcohol during pregnancy. 

The new law and regulations make sure that more mothers have access to services they need to ensure a healthy pregnancy. These services include:

• Screening for conditions that can harm pregnant women or their babies, including iron deficiency, hepatitis B, a pregnancy related immune condition called Rh incompatibility, and a bacterial infection called bacteriuria
• Special, pregnancy-tailored counseling from a doctor that will help pregnant women quit smoking and avoid alcohol use
• Counseling to support breast-feeding and help nursing mothers

Learn more about the Affordable Care Act and services for pregnant women.

Preventing Heart Disease and Obesity

Keeping your family healthy means keeping yourself healthy, too.  Heart disease is the number one cause of death for women.  More women than men are have weight problems; 36% of women are obese, significantly increasing their risk of cardiovascular disease.

New health plans must offer coverage without cost-sharing for services that will prevent and control these diseases. These services include:  

• Screening for obesity, and counseling to promote sustained weight loss
• Blood pressure screening
• Counseling on the use of daily aspirin to reduce the risk of a stroke
• Tests to screen for high cholesterol and diabetes

Preventing and Controlling Breast and Other Types of Cancer

Despite our progress in controlling cancer, breast cancer, cervical cancer, colon cancer, and lung cancer continue to cause thousands of preventable deaths in the U.S. each year.  About 210,000 new cases of invasive breast cancer will occur among women in the United States during 2010, and an estimated 40,000 women are expected to die from breast cancer this year. African American women are about one-third more likely to die from breast cancer compared to others. 

In 2006, 12,000 women in the U.S. were told that they had cervical cancer, and nearly 4,000 women died from the disease.  More than 16% of women in the U.S. smoke, significantly increasing their risk of lung cancer and other tobacco-related illness.

The new regulations ensure that new health plans offer coverage without cost-sharing for a variety of important cancer prevention tools. These include:

• Preventing breast cancer: Annual mammograms for women over 40.  Other services to prevent breast cancer will also be covered, including a referral to genetic counseling and a discussion of chemoprevention for certain women at increased risk.
• Preventing cervical cancer: Regular Pap smears to screen for cervical cancer and coverage for the HPV vaccine that can prevent cases of cervical cancer.
• Tobacco cessation interventions, such as counseling or medication to help individuals quit.
• Preventing colon cancer: Screening tests for colon cancer for adults over 50.

Learn more background on the new prevention rules, including sources for statistics cited.

Learn more

Learn how the Affordable Care Act’s new prevention regulations will affect African Americans, Latinos, Asian Americans and Pacific Islanders, Seniors, and women and children.

HHS will not enforce these rules against issuers of stand-alone retiree-only plans in the private health insurance market.