TB Preventive Services Coverage

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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.

Tuberculosis Testing

tb testing table
Recommending Authority Eligible Populations and Service Specifics Plans That Cover Without Cost-Sharing
USPSTF

(Grade “B”; September 2016)

Screen for latent tuberculosis infection (LTBI) in adult populations at increased risk. 1

(See Latent Tuberculosis Infection: Screening for additional details.)

Non-grandfathered private health insurance plans

Medicaid expansion plans

Traditional Medicaid plans*
Bright Futures/AAP Recommendations for Pediatric Preventive Health Care
(March 2020)
 Test adolescents and children <= 21 years of age based on recognition of high-risk factors.2

(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

Provisions and application to plan types
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.3
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.4 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.
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)5,6
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.7

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

References
  1. Latent Tuberculosis Infection: Screening; U.S. Preventive Services Task Force. September 2016
  2. Bright Futures/AAP Recommendations for Pediatric Preventive Health Care; American Academy of Pediatrics. March 2020
  3. Coverage of Certain Preventive Services Under the Affordable Care Act; U.S. Department of Health & Human Services. July 2015
  4. U.S.C. § 1395l (see U.S.C. § 1395x(ddd) for definitions of preventive services)
  5. Annual Update of the HHS Poverty Guidelines. 84 FR 1167; 1167-1168. February 2019.
  6. 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
  7. State Medicaid Director letter #13-002, regarding “Affordable Care Act Section 4106”. 2013. Centers for Medicare & Medicaid Services (CMS).
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