The Affordable Care Act (ACA) requires nearly all health plans to cover a wide range of free preventive care benefits (meaning the patient doesn’t have to pay any deductibles, copayments, or coinsurance).
Services have to fall into one of three categories in order to be under the umbrella of preventive care that non-grandfathered health insurance plans must provide at no cost to the consumer. (The cost of preventive care is wrapped into the premiums that we all pay each month.)
KFF’s preventive services tracker includes a note for each service, clarifying which body recommends it. That’s important in terms of the lawsuit over covered preventive care, which the author will discuss in a moment.
In March 2023, a federal trial court overturned some aspects of ACA’s preventive services coverage requirement, in Braidwood v. Becerra. However, the Department of Justice appealed the ruling 6 to the 5th Circuit Court of Appeals in New Orleans, and asked the court for a temporary stay. 7
In June 2024, the appeals court issued a “mixed bag” ruling. 2 The ruling allows the plaintiffs in the case to no longer provide coverage that includes zero-cost preventive care recommended by the USPSTF. But it overturned the district court’s ruling that had extended that provision to all health plans.
So with the exception of those covered by the Braidwood decision, non-grandfathered health plans must continue to cover USPSTF-recommended preventive care with no cost-sharing. However, other plaintiffs could bring similar legal challenges in the future. And the appeals court has also sent the case back to the lower court for further review of the coverage requirements under HRSA and ACIP recommendations. 8
So for the time being, preventive care benefits will remain unchanged for most people with ACA-compliant health insurance. And carriers are well into the process of filing their rates and plans for 2025 individual and small-group health plans (deadlines for that vary by state, but range from May to August 2024). 9 These filings are based on the requirements of the ACA currently in place, including the preventive coverage mandate. The Braidwood case is likely to result in additional litigation, however, and could eventually make its way to the Supreme Court. So it’s possible that the rules could apply differently in the future.
In a statement issued soon after the June 2024 ruling, United States of Care, a nonpartisan organization that works to ensure access to quality, affordable health care, noted that while they had hoped for “a complete reversal of the District Court’s ruling, this decision is a sigh of relief for the 151 million people – including 37 million children – whose access to free preventive services has been hanging in the balance for over a year. By overturning part of the District Court’s ruling, this decision protects access to free preventive services like colorectal cancer screenings, PrEP for HIV prevention, and mental health screenings for now.” 10
But they also noted that “while people’s access to these free preventive services is preserved for the time being, continued access is still at risk.” This is because the issue of coverage requirements for HRSA and ACIP recommendations has been sent back to the district court for further consideration, and because, as noted by Families USA, the ruling regarding USPSTF recommendations “paves the way for future lawsuits that jeopardize access to lifesaving preventive services.” 11
The lower court’s ruling in Braidwood v. Becerra overturned some aspects of the ACA’s preventive care coverage rules, but left others intact. The appeals court’s ruling limited the scope of the lower court’s decision, but left the door open for future litigation and also remanded some questions back to the lower court for further consideration. The case is expected to reach the Supreme Court, so the eventual outcome is still uncertain.
But here’s an overview of what’s happened thus far:
In the 2023 ruling, the U.S. District Court in the Northern District of Texas ruled that requiring health plans to cover services recommended by the USPSTF violates the Appointments Clause of the U.S. Constitution, because members of the USPSTF have not been nominated by the president or confirmed by the Senate. (This is by design. Congress intended this body to be comprised of experts who are free from political interference. On each USPSTF recommendation page, they clarify that “Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.” 13 ) Had that ruling been allowed to stand, health plans would no longer have been required to cover USPSTF-recommended preventive care with no cost-sharing.
The court also ruled that requiring health plans to cover PrEP (for prevention of HIV transmission) is a violation of the plaintiffs’ religious freedom under the Religious Freedom Restoration Act, meaning that plans would no longer have had to cover it. But the appeals court’s ruling limited that to only the coverage offered by the Braidwood plaintiffs, as opposed to all plans. 14 (As noted above, PrEP has an “A” rating from the USPSTF that was issued in 2019, so if recent USPSTF recommendations were to be eliminated from health plan coverage requirements, that would effectively remove the requirement to cover PrEP.)
The appeals court upheld the lower court’s ruling against coverage requirements for USPSTF- recommended services, but only for the Braidwood plaintiffs. For now, other health plans must continue to cover those services without cost-sharing. 2
The district court did not rule against ACIP and HRSA having the authority to recommend preventive care requirements for health plans. So under that ruling, some currently covered preventive services (those recommended by USPSTF) would have become optional for health plans to cover with zero cost-sharing, while others (those recommended by HRSA and ACIP) would not. However, the appeals court has remanded the question of ACIP and HRSA recommendations back to the district court for further consideration of whether the HHS Secretary has properly ratified the recommendations made by ACIP and HRSA.
As noted above, an appeals court has limited the district court’s ruling that initially called for health plans to no longer have to cover USPSTF-recommended preventive care guidelines issued since the ACA was enacted. Other than the plaintiffs, health plans must still continue to cover those services for now. Even if the case were to be taken up by the Supreme Court and the Court were to eventually uphold the district court’s ruling, health plans would continue to have to cover some cancer screenings at no cost to their enrollees:
Contraceptive coverage was not affected by the 2023 or 2024 court rulings, although as noted above, the issue of HRSA recommendations has been remanded to the district court for further consideration.
There have been other challenges to the contraceptive mandate over the years, and the Trump administration made it easier for health plan sponsors to get an exemption from the coverage requirement if they have religious or moral objections to contraception. But the Biden-Harris administration proposed new rules in 2023 that would roll back some of those changes and ensure that women could still have access to zero-cost contraception even if their employer or school has a religious exemption. Those rules had not yet been finalized as of mid-2024.
One note about free contraception: Although non-grandfathered health plans are required to cover all types of FDA-approved female-specific contraception, they’re only required to offer one version of each type with no cost-sharing. They can impose cost-sharing for other versions. So it’s not true that all contraception is covered for free. Rather, at least one version of each type of contraception is covered for free. But CMS issued guidance in 2024 to clarify that health plans must have exception protocols in place to allow women to access, without cost-sharing, specific contraception that’s considered medically necessary for the individual. The guidance noted that the exceptions process cannot “impose unduly burdensome administrative requirements.” 15
Yes. Vaccine coverage is not affected by the 2023 or 2024 court rulings. Under current rules, non-grandfathered health plans have to fully cover the cost of vaccines recommended by ACIP. But as noted above, the issue of coverage requirements based on ACIP recommendations has been remanded to the trial court for further consideration.
The federally mandated preventive care rules require health plans to cover obesity screening and counseling and diet counseling for people at high risk of chronic disease. 16 But federal rules do not require any coverage of other weight loss treatments.
For health plans offered in the individual/family and small group markets, states set their own Essential Health Benefits benchmark plans to define what essential health benefits must be covered by plans issued in the state. Almost half of the states have bariatric surgery in their benchmark plans, but anti-obesity medications are very rarely included. In part, this is because most states’ current benchmark plans date back to 2013, before these medications became available.
Fully insured large group plans are not subject to the ACA’s essential health benefit rules, although states can impose coverage mandates for these plans. Self-insured plans, which cover the majority of people with employer-sponsored coverage, 17 are not subject to state rules. They are, however, subject to various federal rules, including ERISA, HIPAA, COBRA, some ACA provisions.
So in most states, the current rules mostly leave it up to insurers and employers in terms of whether they want to cover weight loss drugs. As time goes by, we might see changes to coverage requirements pertaining to weight loss treatment. This could come via updates to federal preventive care guidelines, or changes at the state level via updated benchmark plans and state mandates.
No. Even if the Supreme Court were to eventually overturn the ACA’s preventive coverage requirement, health plans would still have the option to cover members’ preventive care without requiring members to share the cost. The ACA’s preventive coverage mandate is among the law’s most popular features, and the benefits are used by about 150 million Americans each year. 10 Employers use their benefits package as a tool to attract and retain employees, and free preventive care tends to be relatively inexpensive to provide. 18
The Association for Community Affiliate Plans, which represents 79 health plans covering 25 million people, criticized the 2023 ruling and urged the Justice Department to appeal it. And in a statement clarifying that benefits would not change immediately and that the case would be appealed, AHIP – which represents health plans – noted that “every American deserves access to high-quality affordable coverage and health care, including affordable access to preventive care and services that help avoid illnesses and other health problems.”
For health plans that are regulated at the state level (meaning plans that aren’t self-insured), states could require health plans to continue to cover USPSTF-recommended care with no cost-sharing, even if that requirement were to be eliminated at the federal level. States could ensure this is part of their benchmark plan, which would apply to individual and small group plans, or could impose legislation that applies to all state-regulated plans, including large group plans.
Several states have already taken action on this, and others could follow suit. But states do not regulate self-insured health plans, which cover the majority of people who have employer-sponsored health coverage in the U.S. 17
Mammograms and colonoscopies are examples of procedures that can be classified as “screening” or “diagnostic” procedures, depending on the circumstances. This matters a lot in terms of health coverage, because health plans are only required to cover the full cost if it’s a screening procedure. If it’s diagnostic, your plan’s regular cost-sharing can apply.
For a mammogram or colonoscopy to be considered a screening procedure, it has to be done on the timelines recommended by USPSTF or HRSA, and in the absence of any symptoms.
One note about colonoscopies: CMS has confirmed that health plans are not allowed to impose out-of-pocket costs for polyp removal performed during a regular screening colonoscopy (see Q5 in these FAQs), and the plan must also pay for pathology testing for the polyps. So if you go in for a screening colonoscopy and polyps are found, removed, and tested, the health plan still has to cover the procedure with no out-of-pocket costs. But your doctor will likely then have you return for another colonoscopy in three or five years, and you should expect to have out-of-pocket costs for that follow-up procedure, since it’s being done more frequently than the regular screening schedule.
(Note that the coverage rule is different for Original Medicare, which does impose cost-sharing if a polyp is found and removed during a screening colonoscopy. 19 )
In normal circumstances, there’s a delay that can last nearly two years before recommendations from USPSTF, HRSA, or ACIP are built into health insurance plans. But for COVID-19 vaccines, that was shortened to just 15 business days. ACIP finalized their recommendation for the COVID-19 vaccine in mid-December 2020, so all non-grandfathered health plans had to cover COVID-19 vaccines with zero-cost sharing as of early January 2021 (which was well before the vaccines were available for most people).
Preventive care recommendations have evolved considerably over time, and the recommendations have been gradually incorporated into health coverage as they were updated. For example, in 2021, USPSTF lowered the recommended age to begin screening colonoscopies from 50 to 45, and health plans had until 2023 to implement that change (many of them did so well before that).
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.
