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Do Obamacare’s preventive care mandates only help women?

Do Obamacare’s preventive care mandates only help women?

Q. I’ve heard that Obamacare’s preventive care mandates only help women. I’m a man, and I feel like I’m getting the short end of the stick.

A: Never fear, the ACA mandates free preventive care for everyone. There are certain services that are specific to all adults, some for children, and a separate subset that apply to women. HHS has explained why there was a special need for mandated benefits that apply to women’s health – for the most part, it’s preventive care that applies to illnesses or conditions that only – or predominantly – impact women.

What preventive services are free?

Free preventive care is not a catch-all phrase. The service in question has to fall into one of three categories in order to be under the umbrella of preventive care that non-grandfathered health insurance plans must provide at no cost to the consumer (at the time of service; it’s understood that the cost of preventive care is wrapped into the premiums that we all pay each month):

KFF’s preventive services tracker includes a note for each service, clarifying which body recommends it. That’s important in terms of the lawsuit over covered preventive care, which we’ll discuss in a moment.

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 cover COVID-19 vaccines with zero-cost sharing as of early January 2021 (which was well before the vaccines were actually available for most people).

Has a judge ruled that health plans will no longer cover preventive care?

In September 2022, Judge Reed O’Connor issued a ruling in Braidwood v. Becerra that potentially threatens the ongoing coverage of services recommended by the USPSTF. But for the time being, nothing has changed. The judge has asked the parties in the lawsuit to submit additional information and we do not yet know the scope of the eventual ruling (whether it will apply only to the plaintiffs, or potentially nationwide) or whether it will be stayed (not go into effect) while the case is appealed.

Judge O’Connor ruled that requiring health plans to cover services recommended by the USPSTF violates the Appointments Clause, because members of the USPSTF have not been nominated by the president or confirmed by the Senate (this is by design; Congress intended this body to be comprised of experts who are free from political interference).

He also ruled that requiring health plans to cover PrEP (for prevention of HIV transmission) is a violation of the Religious Freedom Restoration Act. Also note that PrEP has an “A” rating from the USPSTF, so if USPSTF recommendations were to be eliminated from health plan coverage requirements, that would effectively remove the requirement to cover PrEP.

Judge O’Connor did not rule against ACIP and HRSA having authority to recommend preventive care requirements for health plans. So if his ruling were to eventually be upheld by a higher court, it would potentially mean that some currently-covered preventive services would become optional for health plans to cover with zero cost-sharing, while others would not (here’s a list of which services are recommended by each entity).

For health plans that are regulated at the state level (ie, 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 is 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.

Are any free preventive services specific to men?

A one-time abdominal aortic aneurysm screening for men age 65-75 who have ever smoked is a covered preventive service that only applies to men (note that this is covered because it gets a “B” rating from the USPSTF; if Judge O’Connor’s ruling in Braidwood v. Becerra were to eventually be upheld and put into effect, it’s possible that health plans could stop covering this).

But in general, the recommended preventive health care services for men also fall into the category of preventive health care for adults: Things like alcohol screening, blood pressure and cholesterol screening, colonoscopies, STI screening, and Type 2 Diabetes screening (for adults with hypertension) are all preventive services that apply to both men and women — and again, these are covered because the USPSTF recommends them.

What about PSA screening, you might ask? Why is that not one of the adult preventive services covered at no cost by all plans? Well, because it’s actually not recommended at all past age 70, and has mixed reviews for younger men. The USPSTF gives it a grade of C for men age 55-69, and D for men age 70 or older, and “recommends against PSA-based screening for prostate cancer in men 70 years and older.”

There are lots of preventive care services that get ratings below a B on the USPSTF grading system. Unless they’re otherwise covered under the recommendations from HRSA or the CDC, they’re not considered recommended preventive care, and are thus not required to be covered by health insurance plans (note that insurers can cover them at no cost to the member, they just aren’t required to do so).

One note about preventive screening coverage: A screening is only required to be covered with zero cost-sharing if it’s truly just a screening test, following the recommended screening guidelines in terms of age and frequency. If a test is done because of a medical concern, or conducted more frequently than the normal recommended schedule based on a person’s medical history, the health plan’s regular deductible and coinsurance can apply.

So for example, a routine mammogram would be free, whereas a mammogram done to check out a lump that the patient or doctor discovered would not be free. The same holds true for colonoscopies: Starting at age 45, a routine colonoscopy every ten years is recommended, and these are covered in full by non-grandfathered health plans — and note that the health plan still has to cover the screening colonoscopy with zero cost-sharing even if polyps are discovered and removed during the procedure (see Question 5 in this CMS guidance). But if a person has colonoscopies before age 45 or more frequently due to family history or symptoms, the health plan can apply regular cost-sharing requirements.

Do health plans have to cover the cost of vasectomies?

No, unless it’s a state-regulated plan and the state has imposed its own requirement for male contraception coverage. Although most recommended preventive care for men is covered at no cost under the ACA’s preventive care guidelines, contraceptives are an exception. The Women’s Preventive Services Guidelines include all FDA-approved methods of contraception for women, which means that insurers have to cover at least one type of each method at no cost to the member. But there is no requirement that insurers pay for FDA-approved contraceptives for men.

Virtually all of the FDA-approved methods of contraception apply to women — the only exceptions are condoms and vasectomies. Female condoms are covered under the ACA’s preventive care rules if they’re prescribed by a doctor. Insurers do not have to cover male condoms, but those are generally purchased over the counter anyway, without a prescription.

But vasectomies can be expensive, and are obviously not available in a drugstore. Although female sterilization (which costs a lot more than a vasectomy) has to be covered in full by non-grandfathered health plans, the same is not true for male sterilization.

Some health plans do cover all or part of the cost of a vasectomy, but they are not required to do so. Some states have enacted laws requiring state-regulated health plans to fully cover the cost of vasectomies, but state laws do not apply to self-insured health plans, which account for the majority of employer-sponsored health plans. (Rhode Island might be the latest state to adopt rule requiring state-regulated health plans to cover all types of FDA-approved contraception, including vasectomies and male condoms; that will be the case if H.5477 is enacted during the 2023 legislative session.)

It’s important to note, however, that although mandated contraceptive and maternity coverage under the ACA are specific to women, there is no doubt that they are beneficial to both men and women, since babies – and unintended pregnancies – have fathers.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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