Affordable Care Act – Changes to the Preventive Care Coverage Requirements
The Affordable Care Act (ACA) is the comprehensive health reform law enacted in March 2010 (aka – ACA, PPACA, or ‘Obamacare’) to make affordable health insurance available to more people. The ACA offers rights and protections to consumers so more people can obtain coverage (e.g., requiring coverage for all consumers, including those with pre-existing conditions) and to ensure their benefits are easier to understand.
A key provision of the ACA requires that insurance plans cover recommended preventive services without any patient cost-sharing.1 Research indicates that evidenced-based preventive services can save lives and improve health outcomes by identifying health conditions earlier, managing these health conditions more effectively, and treating health conditions before they develop into more complicated, debilitating conditions.2 Treatment, loss of productivity, and health care costs are significant burdens to the economy, families, and employers.
Early identification, accurate diagnosis and effective treatment of health conditions reduces these burdens, in addition to improving the length and quality of people’s lives. The cost of treatment may also be a barrier to care for many patients. A recent publication by Kaiser reports that about 1 in 10 adults report that they delayed or did not get care because of treatment costs.3 The ACA preventive care coverage requirements attempts to alleviate these cost barriers to provide more patients with access to preventive care services.
Pharmacy services that are covered under the ACA’s preventive care coverage requirements include:
- Aspirin to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years of age with a high cardiovascular risk;
- Bowel preparation kits used for colorectal screening in adult patients 50 to 75 years;
- Immunizations (this may also be covered under the medical benefit to meet ACA preventive care coverage requirements);
- Statin preventive medications for adults age 40 to 75 at high risk for stroke and/or heart attacks
- Cessation interventions for tobacco users (this may be a combination of medical interventions via counseling and pharmaceutical interventions with smoking cessation medications)
- Contraception for women (this does not apply to health plans sponsored by certain exempt ‘religious employers’)
- Folic acid supplements for women who may become pregnant
- Tamoxifen for women who are at increased risk for breast cancer
- Oral fluoride supplements for children ages 6 months to 5 years who do not have fluoride in their water source
- Vitamin D supplements for fall prevention for adults 65 years and older, living in a community setting (this requirement is being removed for 2019)
In April of 2018, the U.S. Preventive Task Force (USPSTF) updated its recommendations for fall prevention in community-dwelling older adults. A systemic review determined that multifactorial and exercise interventions were associated with fall-related benefit and vitamin D supplementation interventions had mixed results, with a high dose being associated with higher rates of fall-related outcomes.4 As a result of the inconsistent evidence, vitamin D supplementation was downgraded to a grade of “D.” A grade “D” means the USPSTF recommends against the service, as there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits and suggestions for practice discourage the use of this service. The USPSTF now recommends against vitamin D supplementation to prevent falls in community-dwelling adults 65 years or older, and vitamin D supplementation will be removed from the preventive care coverage requirements for 2019.
- The Patient Protection and Affordable Care Act (https://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf)
- Maciosek, Michael V. ‘Greater Use of Preventive Services in U.S. Health Care Could Save Lives at Little or No Cost.’ Health Affairs 29.9 (2010): 1656-660.
- Cox, C and Sawyer, B. (2018, January 17). How does cost affect access to care? Retrieved from https://www.healthsystemtracker.org.
- Guirguis-Blake, JM, Michael, YL, et.al. (2018). Interventions to Prevent Falls in Older Adults: Updated Evidence Report and Systemic Review for the US Preventive Services Task Force. JAMA. Retrieved from https://www.uspreventiveservicestaskforce.org
2018 Quarter Four WellInformed Table Contents
- National Diabetes Month and the Importance of Prevention
- WellManaged – Clinical Programs
- Annual Formulary Updates
- WellDyneRx’s Mail Order Pharmacy Drives Better Clinical Outcomes, Greater Affordability and Higher Adherence Rates
- US Specialty Care Achieves Accreditation with ACHC
- Upcoming Conferences & Tradeshows
- FDA Approved List