What is the ACA’s preventive health services coverage mandate?

As noted above, an appeals court has limited the district court’s ruling that initially called for health plans to no longer have to cover USPSTF-recommended preventive care guidelines issued since the ACA was enacted. Other than the plaintiffs, health plans must still continue to cover those services for now. Even if the case were to be taken up by the Supreme Court and the Court were to eventually uphold the district court’s ruling, health plans would continue to have to cover some cancer screenings at no cost to their enrollees:

• Screening mammograms for breast cancer are recommended by HRSA, so that coverage would continue to be required. (As noted above, the appeals court has asked the district court to consider whether HRSA recommendations have been properly ratified by the Secretary of HHS, so this issue is not entirely settled.)
• HRSA also recommends pap smears with HPV tests for women age 30 and older, so that coverage wouldn’t change. But USPSTF has issued updated pap smear guidelines for younger women, which could be affected by a future ruling in this case or by additional litigation brought by new plaintiffs regarding USPSTF recommendations.
• Colonoscopy screening was already recommended by USPSTF prior to March 2010, so it would still have to be covered. But the guidelines were updated in 2021 to include people as young as age 45. Screening recommendations previously started at age 50, and could revert to that guideline if the lower court’s ruling is ultimately upheld by the Supreme Court (assuming the case is taken up by the Supreme Court).
• Lung cancer screening for current and former smokers was added to the USPSTF list of recommendations in 2013, so it’s an example of a screening test that health plans would no longer have to cover if the district court’s ruling is ultimately upheld, since it was added after the ACA was signed into law.

Non-grandfathered health plans must cover at least one version of each FDA-approved method of contraception for women without any cost-sharing (meaning free for the enrollee), as long as the contraception is prescribed by a health care provider (see below for more details on a 2024 proposal that would eliminate the prescription requirement for contraception that’s available over-the-counter).

Although non-grandfathered health plans are required to cover all types of FDA-approved female-specific contraception, they’re only required to offer one version of each type with no cost-sharing. They can impose cost-sharing for other versions.

So it’s not true that all contraception is covered for free. Rather, at least one version of each type of female contraception is covered for free. But CMS issued guidance in 2024 to clarify that health plans must have exception protocols to allow women to access, without cost-sharing, specific contraception that’s considered medically necessary for the individual. The guidance noted that the exceptions process cannot “impose unduly burdensome administrative requirements.”¹⁵

Starting in 2023, male condoms have to be covered with zero-cost sharing as long as they’re prescribed by a health provider to someone who can become pregnant (so a woman can have coverage for male condoms without cost-sharing as long as her health care provider prescribes them for her).¹⁶

The Biden administration issued additional proposed rules in October 2024. If finalized, these rules would require non-grandfathered health plans to cover the cost of over-the-counter contraception, including Opill, spermicides, condoms (for plan enrollees who can become pregnant), and emergency contraception, without any cost-sharing for the enrollee, and without the need for a prescription (this would be a significant change, as coverage of over-the-counter contraception currently requires a prescription).⁵

The proposed rules include various options for how a health plan might go about implementing this coverage, as long as the protocol doesn’t “present unreasonable barriers to accessing OTC contraceptive items.” For example, a health plan could allow female members to obtain OTC contraception at the pharmacy counter by presenting their health plan ID card or a pre-paid debit card provided by the health plan, or possibly a reimbursement approach that isn’t considered burdensome. (Note that if a health plan has a network contract with a pharmacy that’s inside a retail store, the health plan enrollee may need to use the pharmacy counter to obtain zero-cost contraception, and might not be able to check out at the registers at the front of the retail store.)⁵

Contraceptive coverage was not affected by the 2023 or 2024 court rulings, although as noted above, the issue of HRSA recommendations was remanded to the district court for further consideration.

There have been other challenges to the contraceptive mandate over the years, and the Trump administration made it easier for health plan sponsors to get an exemption from the coverage requirement if they have religious or moral objections to contraception. But the Biden-Harris administration proposed new rules in 2023 that would roll back some of those changes and ensure that women could still have access to zero-cost contraception even if their employer or school has a religious exemption. Those rules had not yet been finalized as of late 2024.

Yes. Non-grandfathered health plans have to fully cover the cost of vaccines recommended by ACIP. But as noted above, the issue of coverage requirements based on ACIP recommendations was remanded to the trial court for further consideration in 2024.

The federally mandated preventive care rules require health plans to cover obesity screening and counseling and diet counseling for people at high risk of chronic disease.¹⁷ But federal rules do not require any coverage of other weight loss treatments.

For health plans offered in the individual/family and small group markets, states set their own Essential Health Benefits benchmark plans to define what essential health benefits must be covered by plans issued in the state. Almost half of the states have bariatric surgery in their benchmark plans, but anti-obesity medications are very rarely included. In part, this is because most states’ current benchmark plans date back to 2013, before these medications became available.

Fully insured large group plans are not subject to the ACA’s essential health benefit rules, although states can impose coverage mandates for these plans. Self-insured plans, which cover the majority of people with employer-sponsored coverage,¹⁸ are not subject to state rules. They are, however, subject to various federal rules, including ERISA, HIPAA, COBRA, some ACA provisions.

So in most states, the current rules mostly leave it up to insurers and employers in terms of whether they want to cover weight loss drugs. As time goes by, we might see changes to coverage requirements pertaining to weight loss treatment. This could come via updates to federal preventive care guidelines, or changes at the state level via updated benchmark plans and state mandates.

No. Even if the Supreme Court were to eventually overturn the ACA’s preventive coverage requirement, health plans would still have the option to cover members’ preventive care without requiring members to share the cost. The ACA’s preventive coverage mandate is among the law’s most popular features, and the benefits are used by about 150 million Americans each year.¹⁰ Employers use their benefits package as a tool to attract and retain employees, and free preventive care tends to be relatively inexpensive to provide.¹⁹

The Association for Community Affiliate Plans, which represents 79 health plans covering 25 million people, criticized the 2023 ruling and urged the Justice Department to appeal it. And in a statement clarifying that benefits would not change immediately and that the case would be appealed, AHIP – which represents health plans – noted that “every American deserves access to high-quality affordable coverage and health care, including affordable access to preventive care and services that help avoid illnesses and other health problems.”

For health plans that are regulated at the state level (meaning plans that aren’t self-insured), states could require health plans to continue to cover USPSTF-recommended care with no cost-sharing, even if that requirement were to be eliminated at the federal level. States could ensure this is part of their benchmark plan, which would apply to individual and small group plans, or could impose legislation that applies to all state-regulated plans, including large group plans.

Several states have already taken action on this, and others could follow suit. But states do not regulate self-insured health plans, which cover the majority of people who have employer-sponsored health coverage in the U.S.¹⁸

Mammograms and colonoscopies are examples of procedures that can be classified as “screening” or “diagnostic” procedures, depending on the circumstances. This matters a lot in terms of health coverage, because health plans are only required to cover the full cost if it’s a screening procedure. If it’s diagnostic, your plan’s regular cost-sharing can apply.

For a mammogram or colonoscopy to be considered a screening procedure, it has to be done on the timelines recommended by USPSTF or HRSA, and in the absence of any symptoms.

• Timing: For mammograms, that means no more than once per year starting at age 40. For colonoscopies, it means no more than once every ten years, starting at age 45. So if you have a screening colonoscopy and a polyp is found and your doctor tells you to come back in three or five years, that second colonoscopy is going to be considered diagnostic (which means there will be out-of-pocket costs), since it will have been less than ten years since your last one.
• Absence of symptoms: The procedure has to be performed simply because it’s time to do so, and not due to anything you or your doctor have noticed. So if you’ve had blood in your stool or have found a lump in your breast, a colonoscopy or mammogram to check things out will be considered diagnostic and there will be out-of-pocket costs. This is true even if you would otherwise qualify for a screening test due to your age. For example, if you’re due for your annual mammogram and your doctor finds a lump during your annual exam and then sends you to get your mammogram, it will be considered diagnostic due to the presence of the lump.

One note about colonoscopies: CMS has confirmed that health plans are not allowed to impose out-of-pocket costs for polyp removal performed during a regular screening colonoscopy (see Q5 in these FAQs), and the plan must also pay for pathology testing for the polyps. So if you go in for a screening colonoscopy and polyps are found, removed, and tested, the health plan still has to cover the procedure with no out-of-pocket costs. But your doctor will likely then have you return for another colonoscopy in three or five years, and you should expect to have out-of-pocket costs for that follow-up procedure, since it’s being done more frequently than the regular screening schedule.

CMS has also confirmed that if a person opts for a preventive colon cancer screening test other than a colonoscopy (meaning a non-invasive stool-based screening test or direct visualization via flexible sigmoidoscopy or CT colonography) and the results are abnormal, non-grandfathered health plans must cover a follow-up colonoscopy without the patient having to pay any cost-sharing.²⁰ This is because the USPSTF has noted that in these situations, “follow-up with colonoscopy is needed for further evaluation.”²¹

(Note that the coverage rule is different for Original Medicare, which does impose cost-sharing if a polyp is found and removed during a screening colonoscopy.²²)

In normal circumstances, there’s a delay that can last nearly two years before recommendations from USPSTF, HRSA, or ACIP are built into health insurance plans. But for COVID-19 vaccines, that was shortened to just 15 business days. ACIP finalized their recommendation for the COVID-19 vaccine in mid-December 2020, so all non-grandfathered health plans had to cover COVID-19 vaccines with zero-cost sharing as of early January 2021 (which was well before the vaccines were available for most people).

Preventive care recommendations have evolved considerably over time, and the recommendations have been gradually incorporated into health coverage as they were updated. For example, in 2021, USPSTF lowered the recommended age to begin screening colonoscopies from 50 to 45, and health plans had until 2023 to implement that change (many of them did so well before that).