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Prevention of HIV/AIDS, Viral Hepatitis, STDs, and TB Through Health Care

HIV/AIDS Preventive Services

Health plans that cover recommended preventive services without cost-sharing under the Affordable Care Act:

  1. 1. Non-grandfathered private health insurance plans – Most private insurance plans, including all plans on the Health Insurance Marketplace, and all group or individual health insurance plans that did not exist on March 23, 2010 or that have made significant changes to benefits, cost-sharing, or limits since that time are required to cover services without
    cost-sharing.1
  2. 2. Medicare – All USPSTF recommended services that have a Grade “A” or “B” and that are covered by Medicare must be covered without cost-sharing.2
  3. 3. Medicaid expansion plans in states that expand (i.e. Alternative Benefit Plans) – Medicaid expansion plans offered by states that extend Medicaid eligibility to non-elderly individuals with annual incomes at or below 133 percent of the federal poverty level ($15,521 for an individual or $31,720 for a family of 4 in 2014) are required to cover these services without cost-sharing.3,4
  4. 4. Traditional Medicaid plans – Those states that, at their option, cover, without cost-sharing in their standard Medicaid benefit package, all USPSTF-recommended services that have a Grade “A” or “B” and all ACIP-recommended vaccines receive an increase in their federal medical assistance for such services and vaccines.5

In addition to these services, private and public plans may cover other preventive services without cost-sharing.



Preventive Service Recommending Authority (authorized under Section 1001 of the Patient Protection and Affordable Care Act) Eligible Populations and Service Specifics Health Insurance Plans That Cover the Service Without Cost-Sharing Additional Resources
HIV testing

USPSTF
(Grade “A” Recommendation issued April 30, 2013)



Screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened

Screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown6

(See “Clinical Considerations” in the USPSTF Recommendation Statement for a discussion of risk factors.)
  • Non-grandfathered health insurance plans
    Coverage must be in effect for plan years beginning after April 30, 2014.1
  • Medicare
    Medicare covers a maximum of one, annual HIV screening of Medicare beneficiaries at increased risk for HIV infection; and a maximum of three, voluntary HIV screenings of pregnant Medicare beneficiaries: (1) when the diagnosis of pregnancy is known, (2) during the third trimester, and (3) at labor, if ordered by the woman’s clinician.7
  • Medicaid expansion plans
  • Traditional Medicaid plans
    Optional as above.
Women’s Preventive Services, Supported by HRSA
(Coverage guidelines adopted August 1, 2011)
Annual screening for HIV infection for all sexually active women8

(See IOM Report – Clinical Preventive Services for Women: Closing the Gaps for a discussion of risk factors.)
  • Non-grandfathered private health insurance plans
  • Medicaid expansion plans
  • Traditional Medicaid plans
    Optional as above.
Bright Futures Recommendations for Pediatric Preventive Health Care, Supported by HRSA
(Recommendations issued 2014 by the American Academy of Pediatrics)
All adolescents should be screened for HIV once between the ages of 16 and 18; those at increased risk of HIV infection, including those who are sexually active, participate in injection drug use, or are being tested for other STIs, should be tested for HIV and reassessed annually9

(See Adolescents and HIV Infection: The Pediatrician's Role in Promoting Routine Testing for a discussion of risk factors.)
  • Non-grandfathered private health insurance plans
  • Medicaid expansion plans
  • Traditional Medicaid plans
    Optional as above. In general, preventive services for children are covered Included as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit for children; cost-sharing may apply in some cases.
Sexually Transmitted Infection (STI) and HIV Prevention Counseling USPSTF
(Grade “B” recommendation issued October 2008)
High-intensity behavioral counseling to prevent sexually transmitted infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs10

(See “Clinical Considerations” in the USPSTF Recommendation Statement for a discussion of risk factors.)
  • Non-grandfathered private health insurance plans
  • Medicare
    Medicare covers up to two individual 20 to 30 minute, face to face counseling sessions annually for Medicare beneficiaries for HIBC to prevent STIs for all sexually active adolescents and for adults at increased risk for STIs, if referred for this service by a primary care provider and provided by a Medicare eligible primary care provider in a primary care setting.11
  • Medicaid expansion plans
  • Traditional Medicaid plans
    Optional as above.
Women’s Preventive Services, Supported by HRSA
(Coverage guidelines adopted August 1, 2011)
Annual counseling on sexually transmitted infections for all sexually active women

Annual counseling for HIV infection for all sexually active women8

(See IOM Report – Clinical Preventive Services for Women: Closing the Gaps for a discussion of risk factors.)
  • Non-grandfathered private health insurance plans
  • Medicaid expansion plans
  • Traditional Medicaid plans
    Optional as above.

NOTE: Programs in states that are implementing “alternative” means to expand Medicaid (i.e. expanding Medicaid through “premium assistance”) should be mindful of state decisions regarding coverage and cost-sharing of these preventive services for newly eligible Medicaid enrollees.


1 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, §1001, 124 Stat. 119, 131-132 (2010). Available at: http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf
2 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, §4104, 124 Stat. 125, 557-558 (2010). Available at: http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf
3 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, §2001, 124 Stat. 121, 271-272 (2010). Available at: http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf
4 Medicaid and Children's Health Insurance Programs: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment. 78 FR 42159; 42224-42226. Issued 2013 July 15. Accessed 2013 October 31. Available at: http://www.gpo.gov/fdsys/pkg/FR-2013-07-15/pdf/2013-16271.pdf
5 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, §4106, 124 Stat. 125, 559-560 (2010). Available at: http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf
6 U.S. Preventive Services Task Force. Screening for HIV: Recommendation Statement. Issued April 2013.AHRQ Publication No. 12-05173-EF-3. Accessed 2013 May 8. Available at: http://www.uspreventiveservicestaskforce.org/uspstf13/hiv/hivfinalrs.htm
7 Centers for Medicare and Medicaid Services, “Medicare National Coverage Determinations Manual”, Chapter 1, Part 4, Sections 200-310.1. Issued 2013 March 8. Accessed 2013 May 8. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf
8 Health Resources and Services Administration. Women’s Preventive Services: Required Health Plan Coverage Guidelines. Accessed 2012 May 3. Available at: http://www.hrsa.gov/womensguidelines/
9 Simon GR, Baker C, Barden GA III., et al. 2014 Recommendations for Preventive Pediatric Health Care. Pediatrics 2014;133:568–70. 2014 2014. Accessed 2014 October 17. Available at: http://pediatrics.aappublications.org/content/133/3/568.full
10 U.S. Preventive Services Task Force. Behavioral Counseling to Prevent Sexually Transmitted Infections: U.S. Preventive Services Task Force Recommendation Statement. Issued October 2008. AHRQ Publication 08-05123-EF-2. Accessed 2012 May 3. Available at: http://www.uspreventiveservicestaskforce.org/uspstf08/sti/stirs.htm
11 Centers for Medicare and Medicaid Services, “Pub 100-03 Medicare National Coverage Determinations”, Chapter 1, Section 210.10. Issued 2012 January 26. Accessed 2013 May 6. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R141NCD.pdf

 
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