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):
- Rated “A” or “B” in the current United States Preventive Services Task Force (USPSTF) recommendations.
- Recommended in the guidelines from the Health Resources and Services Administration (HRSA), including the Women’s Preventive Services Guidelines and the Bright Futures recommendations for children (infancy through age 21).
- Recommended by the Centers for Disease Control & Prevention’sAdvisory Committee on Immunization Practices (ACIP).
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).
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. 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.
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.)
The contraception exception
Although most recommended preventive care for men is covered at no cost under the ACA’s preventive care guidelines, one exception is contraceptives. 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) is 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.
While 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 healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.