HIV/AIDS Preventive Services Coverage

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: Screeningexternal icon for additional information.)

Non-grandfathered private health insurance plans

Medicareexternal icon

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 Guidelinesexternal icon 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 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.

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 Prophylaxisexternal 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.

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 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.2

(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.6 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.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.

Page last reviewed: May 5, 2020