HIV Preventive Services Coverage

The Affordable Care Act (ACA) includes several provisions aimed at improving coverage of, and access to, certain preventive health services. These services and the health insurance plans that cover them without cost-sharing are summarized here in these Preventive Services Coverage Tables. Additional details around select ACA provisions and their application to specific health plan types are included below the tables.

HIV Testing

HIV Testing table
Recommending Authority	Eligible Populations and Service Specifics	Plans That Cover Without Cost-Sharing
USPSTF (Grade “A”, June 2019)	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 unknown.¹ (See Human Immunodeficiency Virus (HIV) Infection: Screening for additional information.)	Non-grandfathered private health insurance plans Medicare Medicaid expansion plans Traditional Medicaid plans*
Women’s Preventive Services Guidelines (December 2016)	Screen for HIV infection annually for all sexually active women.² (See Women’s Preventive Service Guidelines for additional information.)	Non-grandfathered private health insurance plans Medicaid expansion plans
Bright Futures/AAP Recommendations for Pediatric Preventive Health Care (March 2020)	Adolescents should be screened for HIV according to the USPSTF recommendations once between the ages of 15 and 18, making every effort to preserve confidentiality of the adolescent. Adolescents ages 11 through 21 who are at increased risk of HIV infection, including those who are sexually active, participate in injection drug use, or are being tested for other sexually transmitted infections (STIs), should be tested for HIV and reassessed annually.³ (See Recommendations for Preventive Pediatric Health Care for additional information.)	Non-grandfathered private health insurance plans Medicaid expansion plans Traditional Medicaid plans

*Optional for adults, depending on state policy; however, preventive services for children are often covered as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit for children.

HIV Preexposure Prophylaxis

HIV Preexposure Prophylaxis table
Recommending Authority	Eligible Populations and Service Specifics	Plans That Cover Without Cost-Sharing
USPSTF (Grade “A”, June 2019)	The USPSTF recommends that clinicians offer preexposure prophylaxis (PrEP) with effective antiretroviral therapy to persons who are at high risk of HIV acquisition.⁴ (See Prevention of Human Immunodeficiency Virus (HIV) Infection: Preexposure Prophylaxis for additional information.)	Non-grandfathered private health insurance plans Medicaid expansion plans Traditional Medicaid plans*

Sexually Transmitted Infection and HIV Prevention Counseling

Sexually Transmitted Infection (STI) and HIV Prevention Counseling table
Recommending Authority	Eligible Populations and Service Specifics	Plans That Cover Without Cost-Sharing
USPSTF (Grade “B”, September 2014)	Provide intensive behavioral counseling to prevent sexually transmitted infections (STIs) to all sexually active adolescents and for adults at increased risk for STIs.⁵ (See Sexually Transmitted Infections: Behavioral Counseling for a discussion of risk factors.)	Non-grandfathered private health insurance plans Medicare Medicaid expansion plans Traditional Medicaid plans*
Women’s Preventive Services Guidelines (December 2016)	Provide counseling on sexually transmitted infections, including HIV, for all sexually active women.² (See Women’s Preventive Services Guidelines for additional information.)	Non-grandfathered private health insurance plans Medicaid expansion plans

Provisions and application to plan types

Non-grandfathered private health insurance plans

Section 2713 of the Public Health Service (PHS) Act, as added by the Affordable Care Act and incorporated into ERISA (The Employee Retirement Income Security Act of 1974) and the Code, requires that non-grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage provide coverage of certain specified preventive services without cost sharing.⁶ These preventive services include:

Evidence-based items or services that have an “A” or “B” recommendation rating from the United States Preventive Services Task Force (USPSTF).
Immunizations recommended for routine use in children, adolescents, and adults by the Advisory Committee on Immunization Practices (ACIP).
Evidence-informed recommendations to improve the health and wellbeing of infants, children, and adolescents that are included in the Health Resources and Services Administration’s (HRSA’s) Bright Futures Project.
Recommended services included in the HRSA-supported Women’s Preventive Services Guidelines, including all Food and Drug Administration (FDA)-approved contraceptives, sterilization procedures, and patient education and counseling for women with reproductive capacity, as prescribed by a health care provider.

Medicare

Under the ACA, USPSTF services with a Grade “A” or “B” must be covered without cost sharing if the Secretary determines they are a) reasonable and necessary for the prevention or early detection of an illness or disability, and b) appropriate for individuals entitled to benefits under part A or enrolled under part B preventive care recommendations.⁷

Medicaid expansion 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 ($16,611 for an individual or $34,247 for a family of 4 in 2019) are required to cover the full range of preventive services required in the essential health benefits (EHB) final rule. This encompasses coverage without cost sharing for all services outlined in Section 2713 of the PHS Act (see above under “Non-grandfathered private health insurance plans)^8,9

Traditional Medicaid plans

Section 4106 provides that states who elect to cover all USPSTF Grade “A” or “B” recommended preventive services, as well as ACIP recommended vaccines and their administration, without cost-sharing shall receive a one percentage point increase in the federal medical assistance percentage (FMAP) for those services.¹⁰

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

References

Human Immunodeficiency Virus (HIV) Infection: Screening; U.S. Preventive Services Task Force. June 2019
Women’s Preventive Services Guidelines; Health Resources and Services Administration. December 2016.
Bright Futures/AAP Recommendations for Pediatric Preventive Health Care; American Academy of Pediatrics. March 2020
Prevention of Human Immunodeficiency Virus (HIV) Infection: Preexposure Prophylaxis; U.S. Preventive Services Task Force. June 2019
Sexually Transmitted Infections: Behavioral Counseling; U.S. Preventive Services Task Force. September 2014
Coverage of Certain Preventive Services Under the Affordable Care Act; U.S. Department of Health & Human Services. July 2015
U.S.C. § 1395l (see U.S.C. § 1395x(ddd) for definitions of preventive services)
Annual Update of the HHS Poverty Guidelines. 84 FR 1167; 1167-1168. February 2019.
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; Final Rule. 78 FR 42159; 42224-42226. July 2013
State Medicaid Director letter #13-002, regarding “Affordable Care Act Section 4106”. 2013. Centers for Medicare & Medicaid Services (CMS).

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