Once an underused component of the health care world that benefits both employees’ health and employers’ health care spending, preventive care is now a mandatory part of any health benefits package. Preventive care consists of measures taken to prevent diseases, rather than curing them or treating their symptoms.
There is significant research demonstrating that increased use of effective preventive services will result in less suffering from ailments that could have been prevented had they been detected and treated early on. Preventive care is often more cost-effective than treating diseases once symptoms appear. Some preventive care services even save more money than it costs to implement them.
This Benefits Insights is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice.
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Under the Affordable Care Act (ACA), private insurers—except for plans that have been grandfathered—are required to cover certain preventive services without any cost to the patient. Medical services such as immunizations, screening tests, medications and any other services that would prevent disease, injury and premature death fall under the umbrella of preventive care.
Preventive care should be incorporated into employer-sponsored health plans to lessen the cost and number of future medical claims by helping employees and their families stay healthy, while also complying with the provisions of the ACA.
Preventive Care for Adults
The following types of preventive care are available to all adults within specified age ranges or risk groups.
- Abdominal aortic aneurysm screening: A one‐time screening for abdominal aortic aneurysm by ultrasonography in men ages 65 to 75 who have ever smoked.
- Alcohol misuse screening and counseling: A risk assessment available for all adults and voluntary counseling for those who are found to have a substance abuse problem. Many do not realize that their alcohol use is excessive and contributes to other health and lifestyle problems.
- Aspirin use: Counseling on the use of aspirin for men ages 45 to 79 and women ages 55 to 79, when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage.
- Blood pressure screening: Routine measurements of adult blood pressure and treatment with anti-hypertension medication to prevent cardiovascular disease. Hypertension and related complications account for $100 billion in medical costs every year, yet only 1 in 3 people with hypertension actually controls it.
- Cholesterol screening: Screenings for lipid disorders in men over 35 and women over 45, and treatment with lipid-lowering medications to prevent cardiovascular disease. One out of 4 adults with high cholesterol will suffer a heart attack, and 1 in 3 adults will die from coronary heart disease. Screening to detect high cholesterol is effective in identifying those who need medication to control cholesterol levels.
- Colorectal cancer screening: Screenings for colorectal cancer using fecal occult blood testing, sigmoidoscopy or colonoscopy, beginning at age 50 and continuing until age 75. The risks and benefits of these screening methods vary. About 19,000 diagnoses could be prevented annually if people get screened, yet only one-third of adults complete regular screenings.
- Depression screenings: Screenings for depression when staff-assisted depression care supports are in place to ensure accurate diagnosis and effective treatment and follow-up.
- Diabetes screening: Screenings for adults 40 to 70 years who are overweight or obese.
- Diet counseling: Intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet‐related chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians.
- HIV screenings: Screenings for everyone ages 15 to 65 and other ages at increased risk
- Obesity screening and counseling: Screening for all adults; clinicians should offer or refer patients with a body mass index (BMI) of 30 or higher to intensive, multi-component behavioral interventions.
- Sexually transmitted infection (STI) prevention counseling: Counseling for adults at higher risk
- Syphilis screening: Screenings for adults at greater risk
- Tobacco use screening: Screenings for adults at higher risk; tobacco users may receive intervention and cessation support. A comprehensive, effective smoking cessation program usually costs less than 50 cents per member per month, or less than $6 per member per year. You can save an average of $210 on yearly health care costs for each smoker who quits.
- Vaccinations: Shots for hepatitis A, hepatitis B, herpes zoster, human papillomavirus (HPV), influenza, measles, mumps, rubella, meningitis, pneumococcal disease, tetanus, diphtheria, pertussis and varicella; doses, recommended ages and populations vary
Preventive Care for Women
In addition to the services listed above, the ACA also mandates coverage for the following preventive services for adult women as part of all non-grandfathered health plans.
- Anemia screening: Screenings for iron deficiency in pregnant women
- Breast cancer genetic test counseling (BRCA): Screenings designed to identify women with increased risk of developing breast cancer due to family history. Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing.
- Breast cancer mammography screening: Mammograms for women age 40 or over every one to two years, with or without clinical breast examination
- Breast cancer chemoprevention: Discussions with clinicians about benefits, risks and adverse effects of chemoprevention for women at high risk of developing breast cancer
- Breastfeeding support and counseling: Guidance from trained providers and access to breastfeeding supplies for pregnant and nursing women
- Cervical cancer screening: Screenings for cervical cancer in women ages 21 to 65 with a Pap smear every three years; for women who want to lengthen the screening interval, screenings with a combination of Pap smear and HPV testing every five years, for women ages 30 to 65
- Chlamydia infection screening: Screenings for chlamydial infection in all sexually active nonpregnant young women age 24 years and younger and for older nonpregnant women who are at increased risk
- Contraception: U.S. Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity. It does not include abortifacient drugs. This does not apply to health plans sponsored by certain exempt “religious employers.”
- Domestic and interpersonal violence screening and counseling: Screenings for women of childbearing age for intimate partner violence, such as domestic violence, and provision of or referral to intervention services
- Folic acid supplements: A supplement for women who are pregnant or planning to become pregnant
- Gestational diabetes screening: Screenings for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes
- Gonorrhea screening: Screenings for all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk.
- Hepatitis B screening: Screenings for pregnant women at first prenatal visit
- Human papillomavirus (HPV) DNA test: Screenings every three years for women with normal Pap smear results who are 30 or older; for women who want to lengthen the screening interval, screenings with a combination of Pap smear and HPV testing every five years for women ages 30 to 65
- Osteoporosis screening: Screenings for women at high risk of developing osteoporosis starting at age 60, and for all women beginning at age 65
- RH incompatibility screening: Testing for pregnant women at their first doctor visit after becoming pregnant and again at 24 to 28 weeks
- Urinary tract or other infection screening: Screenings for pregnant women
- Well-woman visits: Annual visits for adult women to obtain the recommended preventive services, including preconception and prenatal care
Preventive Care for Children
Most health plans must also cover a set of preventive health services for children. These services must be provided at no cost to beneficiaries if they are requested from and delivered by an in-network provider.
- Autism screening: Behavioral screenings for children at 18 to 24 months
- Behavioral assessments: Screenings for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years and 15 to 17 years
- Blood pressure screening: Testing for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years and 15 to 17 years
- Cervical dysplasia screening: Testing for sexually active females
- Depression screening: Assessments for adolescents
- Developmental screening: Learning assessments for children under age 3
- Dyslipidemia screening: Testing for children at higher risk of lipid disorders at the following ages: 1 to 4 years, 5 to 10 years, 11 to 14 years and 15 to 17 years
- Fluoride chemoprevention supplements: Supplements for children without fluoride in their water source
- Gonorrhea preventive medication: Medication for newborns to prevent conjunctivitis caused by gonorrheal bacteria
- Hearing screening: Screenings for all newborns
- Height, weight and body mass index: Measurements for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years and 15 to 17 years
- Hematocrit or hemoglobin screening: Testing for anemia for all children
- HIV screening: Testing for high-risk adolescents
- Hypothyroidism screening: Testing for underactive thyroid for newborns
- Iron supplements: Supplements for children ages 6 to 12 months at risk for anemia
- Lead screening: Testing for children at risk of exposure
- Obesity screening and counseling: Screening for children beginning at age 6, and referral to comprehensive, intensive behavioral interventions to promote improvement in weight status
- Oral health risk assessment: Screening for young children ages 0 to 11 months, 1 to 4 years and 5 to 10 years
- Phenylketonuria (PKU) screening: Testing for this genetic disorder in newborns
- STI prevention counseling and screening: Screening for high-risk adolescents
- Tuberculin testing: Screening for children at higher risk of tuberculosis at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years and 15 to 17 years
- Vaccinations: Shots for diphtheria, tetanus, pertussis, Haemophilus influenzae type B, hepatitis A, hepatitis B, HPV, polio, flu, measles, mumps, rubella, meningitis, pneumococcal disease, rotavirus and varicella; doses, recommended ages and recommended populations vary
- Vision screening: Screenings for all children
In addition to mandated no-cost preventive care, there are other existing preventive services that may be included by an insurer as part of a health group plan. These include things like adult vision and hearing screenings and vitamin and mineral supplements. Check with your insurer to see if additional preventive services are available for your plan’s recipients.
Maximizing Your Health Plan
How can you take advantage of the cost-saving potential of some of these preventive care services? Here are some ways that you can maximize your health care investment:
- Educate your employees on the preventive care services that your health plan offers, their potential risk factors and the benefits of preventive medicine.
- Find ways to make preventive care more convenient for your employees by working with nearby clinics, developing an on-site clinic or hosting a mobile van for vaccinations and screenings.
- Educate your employees on preventable health conditions. Your TPG Insurance Services representative can provide you with payroll stuffers, flyers and posters to help educate your employees.