On May 23, 2025, the Congressional Research Service (CRS) published an overview of the ACA’s preventive services coverage requirement. According to this report, between 150 million and 180 million individuals are enrolled in a plan subject to the preventive services coverage requirement.
The ACA requires group health plans (including most private health insurance plans, but not grandfathered plans) and insurers to cover certain preventive care without cost-sharing. The required covered care includes services given an “A” or “B” rating from the U.S. Preventive Services Task Force (USPSTF), vaccines recommended by the Advisory Committee on Immunization Practices (ACIP), and preventive care and screenings for children and women recommended by the Health Resources and Services Administration (HRSA).
The report provides examples of these services. Services given an “A” or “B” rating from the USPSTF include cancer screenings and preventive care; preventive care for prenatal and postpartum individuals, for newborns and children, and for older adults; and cardiovascular disease, healthy weight, and diabetes prevention screenings and care. Most USPSTF recommendations are based on age or sex and include preventive medications as well as services.
The ACIP recommends pediatric and adult vaccines, including vaccines for diphtheria, tetanus, pertussis, measles, mumps, rubella, influenza, and COVID-19. The recommendations are further refined by age and other factors, such as gender or health condition, and include precautions and contraindications.
The HRSA provides guidelines for both pediatric and women’s preventive services. Services for children include both physical and developmental screenings. Services for women include breast and cervical cancer screenings, well-woman visits, and contraceptive services and contraceptive care.
As noted above, the ACA requires plans to provide coverage of recommended services and items without consumer cost-sharing, including deductibles, copayments, or coinsurance. This includes items and services that are “integral to the furnishing of a recommended preventive service.”
The report clarifies that if the service is provided for a purpose other than prevention, then the ACA will likely not require that it be covered as preventive care. Further, plans can impose coverage limits if the recommendation or guideline does not specify the frequency, method, treatment, or setting for the service. That said, if there are changes in recommendations or guidelines, plans generally must provide coverage as of plan years that begin one year after the change.
The report concludes by highlighting several considerations for Congress. For instance, the report suggests that Congress may wish to revise the coverage requirement by eliminating categories of coverage, requiring coverage beyond what is currently recommended, or basing coverage requirements on something other than the categories of recommendations. In making these suggestions, the CRS cautions that any changes could affect access to and utilization of preventive care, which may in turn affect health outcomes. In addition, changes to the requirement must consider factors such as cost, access, and variations in existing coverage.
Employer Takeaway
Given that the U.S. Supreme Court is soon expected to weigh in on this requirement in Braidwood Management Inc. v. Becerra, the CRS report provides context for what is at issue in the case. Our latest article on the case can be found in the February 25, 2025, edition of Compliance Corner. As we discussed in that article, it is important for employers to monitor developments, but group health plans should generally continue to follow all applicable preventive care services rules and guidance, including, for fully insured plans, requirements imposed at the state level.