Health Reform Coverage for Prevention: Sexual Health Services
Federal health reform expanded private health plan coverage for preventive services that can keep people healthy, save lives and reduce health care costs, which many Americans do not receive. Starting Jan. 1, 2011, new group and individual private health plans are required to cover recommended preventive services, and patients do not have copayments or deductibles when in-network providers are used. To prevent sexually transmitted diseases and HIV/AIDS, covered services include screening tests, prevention counseling and immunizations. Coverage for preventive services by Medicare and Medicaid is also expanded.
Many Americans do not receive recommended preventive services, such as testing and immunizations, which can keep people healthy, save lives and reduce health care costs. Federal health reform addressed a major barrier to this evidence-based care—lack of health insurance coverage for preventive services. Beginning Jan. 1, 2011, new group and individual health insurance plans cover recommended preventive services, and patients do not have copayments or deductibles when in-network providers are used. To prevent sexually transmitted diseases and HIV/AIDS, covered services include screening tests, prevention counseling and immunizations.
- Many preventive services have been proved effective in preventing disease or enabling early detection and treatment of disease, but many people fail to receive these services. Further, racial and ethnic minority populations use preventive services much less often than the general population.1
- According to a Partnership for Prevention study, five preventive services could save 100,000 lives annually if 90 percent of eligible patients received the services: counseling about daily aspirin use, smoking cessation counseling, adult influenza immunizations, and screenings for colorectal and breast cancers.2
- In the area of sexual health, preventive services for chlamydia infection can result in significant savings. Screening 90 percent of eligible patients for chlamydia infection would prevent 30,000 cases of pelvic inflammatory disease each year,3 and routine screening of women younger than 25 can save $45 annually for each woman screened.4 Untreated chlamydia infections result in more than $3 billion annually for treatment of resulting infertility and pregnancy complications.5 In addition, untreated sexually transmitted infections cause fetal and perinatal health problems and cancer, and make it more likely that someone will contract HIV when exposed.6
- People fail to receive preventive services due to inadequate health insurance coverage, but also because their health care provider may emphasize treatment over prevention services. Patients also may be unaware of the services recommended for their age, gender, health history or risk factors, so they do not ask for them.7
- New group and individual health plans must cover recommended services with no patient cost-sharing.8 Existing health plans are “grandfathered” and are not required to change coverage for preventive services until they lose their grandfathered status, which may happen when substantive changes occur in the health insurance plan.9
The recommended preventive services that insurance must cover are determined through studies completed by health care experts, including:
Services with “A” and “B” recommendations from the U.S. Preventive Services Task Force. Services receive these high recommendations if research shows convincing evidence of improved health outcomes. The task force, an independent panel of scientific experts in evidence-based medicine, ranks preventive services based on the strength of the scientific evidence on their benefits.
The Department of Health and Human Services convenes the task force, which has been making recommendations on preventive services since 1989 based on reviews of published evidence. The recommendations do not consider financial costs, but do summarize cost-effectiveness information if available.10
- Immunizations recommended by the Advisory Committee on Immunization Practices, an expert panel that advises the Centers for Disease Control and Prevention.
- Preventive services for children up to age 21 as defined in the Bright Futures guidelines developed by the Health Resources and Services Administration and the American Academy of Pediatrics.
- Services with “A” and “B” recommendations from the U.S. Preventive Services Task Force. Services receive these high recommendations if research shows convincing evidence of improved health outcomes. The task force, an independent panel of scientific experts in evidence-based medicine, ranks preventive services based on the strength of the scientific evidence on their benefits.
- Health reform also offers incentives to Medicaid programs to expand coverage for preventive services. The federal government provides a minimum of 50 percent of the funding for state Medicaid programs and has historically covered preventive services for children. Starting in 2013, state Medicaid programs may receive a 1 percentage point increase in federal matching payments for recommended adult preventive services if provided with no patient cost-sharing.11
- Medicare coverage for preventive services also expanded as of Jan. 1, 2011. Specifics include eliminating the copayment for the “Welcome to Medicare” physical exam, annual wellness exams, health risk assessments, U.S. Preventive Services Task Force-recommended services and vaccines for flu, hepatitis B and pneumonia.12
Preventive services are important because sexually transmitted diseases often produce no
- Immunizations for two sexually transmitted infections: Hepatitis B and Human papillomavirus,known as HPV.
- Screening tests for women for cervical cancer, Pap smears, which detect abnormal cells that can be treated to prevent cervical cancer;
- Screening tests for young women for curable chlamydia infection, which can prevent costly cases of pelvic inflammatory disease, infertility and pregnancy complications;
- Testing all pregnant women for syphilis and hepatitis B to reduce risk of infections being passed to newborns; and
- Testing high-risk individuals for HIV, gonorrhea and syphilis.
- Prevention counseling for sexually transmitted diseases for high-risk adults and adolescents; and
- Screening and counseling services for adolescents and adults for alcohol and drug use. Using alcohol or drugs has been shown to lower inhibitions and make people more likely to engage in unsafe sexual behavior, which in turn can lead to sexually transmitted infections.14
This publication was supported by Cooperative Agreement 1H25PS00138-03 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.