Sexually Transmitted Disease Preventive Services Coverage

Chlamydia Testing

Chlamydia Testing
Recommending Authority Eligible Populations and Service Specifics Plans That Cover Without Cost-Sharing
USPSTF
(Grade “B”, September 2014)
Screen the following groups for chlamydia:
  • Sexually active women (including pregnant women) age 24 years and younger
  • Sexually active older women (including pregnant women) who are at increased risk for chlamydia infection1

(See Chlamydia and Gonorrhea: Screening external iconfor additional information.)

Non-grandfathered private health insurance plans

Medicareexternal icon

Medicaid expansion plans

Traditional Medicaid plans*

Bright Futures/AAP Recommendations for Pediatric Preventive Health Care
(March 2020)
Screen all adolescents between the ages 11 and 21 according to recommendations in the current edition of the AAP Red Book: Report of the Committee on Infectious Diseases. These include at least annual screening for:
  • All sexually active girls and young women
  • Sexually active boys and young men who are at increased risk for infection (e.g., men who have sex with men)2

(See Recommendations for Preventive Pediatric Health Carepdf iconexternal icon 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

Syphilis Testing

Syphilis Testing
Recommending Authority Eligible Populations and Service Specifics Plans That Cover Without Cost-Sharing
USPSTF
(Grade “A”; June 2016)
Screen nonpregnant adults and adolescents at increased risk for syphilis infection.3

(See Syphilis Infection in Nonpregnant Adults and Adolescents: Screeningexternal icon for additional information)

Non-grandfathered private health insurance plans

Medicareexternal icon

Medicaid expansion plans

Traditional Medicaid plans*

USPSTF
(Grade “A”, September 2018)
Screen all pregnant women for syphilis infection.4

(See Syphilis Infection in Pregnant Women: Screeningexternal icon for additional information)

Non-grandfathered private health insurance plans

Medicareexternal icon

Medicaid expansion plans

Traditional Medicaid plans*

Bright Futures/AAP Recommendations for Pediatric Preventive Health Care
(March 2020)
Screen sexually active adolescents between the ages 11 and 21 who are at increased risk for infection, in accordance with recommendations in the current edition of the AAP Red Book: Report of the Committee on Infectious Diseases 2

(See Recommendations for Preventive Pediatric Health Carepdf iconexternal icon 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

Gonorrhea Testing

Gonorrhea Testing
Recommending Authority Eligible Populations and Service Specifics Plans That Cover Without Cost-Sharing
USPSTF
(Grade “B”; September 2014)
Screen the following groups for gonorrhea:
  • Sexually active women (including pregnant women) age 24 years and younger;
  • Sexually active older women (including pregnant women) who are at increased risk for chlamydia infection1

(See Chlamydia and Gonorrhea: Screeningexternal icon for additional information.)

Non-grandfathered private health insurance plans

Medicareexternal icon

Medicaid expansion plans

Traditional Medicaid plans*

Bright Futures/AAP Recommendations for Pediatric Preventive Health Care
(March 2020)
Screen all adolescents between the ages 11 and 21 according to recommendations in the current edition of the AAP Red Book: Report of the Committee on Infectious Diseases. These include at least annual screening for:
  • All sexually active girls and young women
  • Sexually active boys and young men who are at increased risk for infection (e.g., men who have sex with men) 2

(See Recommendations for Preventive Pediatric Health Carepdf iconexternal icon 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

Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum

Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum
Recommending Authority Eligible Populations and Service Specifics Plans That Cover Without Cost-Sharing
USPSTF
(Grade “A”; January 2019)

Provide prophylactic ocular topical medication to all newborns for the prevention of gonococcal ophthalmia neonatorum.5

(See Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum: Preventive Medicationexternal icon 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

Human Papillomavirus: Testing

Human Papillomavirus: Testing
Recommending Authority Eligible Populations and Service Specifics Plans That Cover Without Cost-Sharing
Women’s Preventive Services Guidelines
(December 2016)
Screen average-risk women aged 21 to 65 years for cervical cancer.
  • For women aged 21 to 29 years, using cervical cytology (Pap test) every 3 years.
  • Women aged 30 to 65 years should be screened with cytology and human papillomavirus testing every 5 years or cytology alone every 3 years.6

(See Women’s Preventive Services Guidelinesexternal icon for additional information.)

Non-grandfathered private health insurance plans

Medicaid expansion plans

USPSTF
(Grade “A”; August 2018)
Screen women ages 21 to 65 for cervical cancer.

Age 21–29:

  • Every 3 years with cervical cytology testing

Age 30–65:

  • Every 3 years with cervical cytology testing
  • OR every 5 years with high-risk human papillomavirus testing (hrHPV)
  • OR every 5 years with hrHPV testing in combination with cytology testing (co-testing).7

(See Cervical Cancer: Screeningexternal icon for additional information)

Non-grandfathered private health insurance plans

Medicareexternal icon

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

Human Papillomavirus: Vaccination

Human Papillomavirus: Vaccination
Recommending Authority Eligible Populations and Service Specifics Plans That Cover Without Cost-Sharing
ACIP
(August 2019)
Vaccination against human papillomavirus (HPV) is routinely recommended at age 11 or 12 years.
  • For persons initiating vaccination before their 15th birthday, the recommended immunization schedule is 2 doses of HPV vaccine.
  • For persons initiating vaccination on or after their 15th birthday, or for persons with certain immunocompromising conditions, the recommended immunization schedule is 3 doses of HPV vaccine. 8

(See Human Papillomavirus Vaccination for Adults: Updated Recommendations of the Advisory Committee on Immunization Practices for additional details)

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

Sexually Transmitted Infection and HIV Prevention Counseling

Sexually Transmitted Infection (STI) and HIV Prevention Counseling
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. 9

(See Sexually Transmitted Infections: Behavioral Counselingexternal icon for a discussion of risk factors.)

Non-grandfathered private health insurance plans

Medicareexternal icon

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.6

(See Women’s Preventive Services Guidelinesexternal icon for additional information.)

Non-grandfathered private health insurance plans

Medicaid expansion 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


 

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-grandfatheredexternal icon 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.10 These preventive services include:

  1. Evidence-based items or services that have an “A” or “B” recommendation rating from the United States Preventive Services Task Force (USPSTF).
  2. Immunizations recommended for routine use in children, adolescents, and adults by the Advisory Committee on Immunization Practices (ACIP).
  3. 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.
  4. 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.11
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)12,13
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.14

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

References
  1. Chlamydia and Gonorrhea: Screeningexternal icon; U.S. Preventive Services Task Force. September 2014
  2. Bright Futures/AAP Recommendations for Pediatric Preventive Health Carepdf iconexternal icon; American Academy of Pediatrics. March 2020
  3. Syphilis Infection in Nonpregnant Adults and Adolescents: Screeningexternal icon; U.S. Preventive Services Task Force. June 2016
  4. Syphilis Infection in Pregnant Women: Screeningexternal icon; U.S. Preventive Services Task Force. September 2018
  5. Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum: Preventive Medicationexternal icon; U.S. Preventive Services Task Force. January 2019
  6. Women’s Preventive Services Guidelinesexternal icon; Health Resources and Services Administration. December 2016.
  7. Cervical Cancer: Screeningexternal icon; U.S. Preventive Services Task Force. August 2018
  8. Human Papillomavirus Vaccination for Adults: Updated Recommendations of the Advisory Committee on Immunization Practices Centers for Disease Control and Prevention. MMWR 2019; 68(32);698–702
  9. Sexually Transmitted Infections: Behavioral Counselingexternal icon; U.S. Preventive Services Task Force. September 2014
  10. Coverage of Certain Preventive Services Under the Affordable Care Actexternal icon; U.S. Department of Health & Human Services. July 2015
  11. U.S.C. § 1395lexternal icon (see U.S.C. § 1395x(ddd)external icon for definitions of preventive services)
  12. Annual Update of the HHS Poverty Guidelinespdf iconexternal icon. 84 FR 1167; 1167-1168. February 2019.
  13. 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.  pdf iconexternal icon78 FR 42159; 42224-42226. July 2013
  14. State Medicaid Director letter #13-002, regarding “Affordable Care Act Section 4106”pdf iconexternal icon. 2013. Centers for Medicare & Medicaid Services (CMS).

Page last reviewed: August 18, 2020