Transamerica Institute

New Benefits Required by the Affordable Care Act

Preventive Health Services

As of 2010, all new group and individual plans are required to provide preventive care for certain recommended services without a co-payment or coinsurance.  Most health plans must cover a set of preventive services like shots and screening tests at no out-of-pocket cost to you. This includes plans purchased through the State Exchanges. (Grandfathered plans are excluded from these requirements).

Plans must cover the following list of preventive services without charging a copayment or coinsurance. This is true even if you have not met your yearly deductible.

  • Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
  • Alcohol Misuse screening and counseling
  • Aspirin use to prevent cardiovascular disease for men and women of certain ages
  • Blood Pressure screening for all adults
  • Cholesterol screening for adults of certain ages or at higher risk
  • Colorectal Cancer screening for adults over 50
  • Depression screening for adults
  • Diabetes (Type 2) screening for adults with high blood pressure
  • Diet counseling for adults at higher risk for chronic disease
  • HIV screening for everyone ages 15 to 65, and other ages at increased risk
  • Immunization vaccines for adults 
  • Obesity screening and counseling for all adults
  • Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
  • Syphilis screening for all adults at higher risk
  • Tobacco Use screening for all adults and cessation interventions for tobacco users

Children’s Health

Under the ACA, most health plans must cover a set of preventive health services for children at no cost out-of-pocket when delivered by an in-network provider. This includes plans purchased through the State Exchanges and Medicaid coverage. All plans purchased through the State Exchanges and many other private plans must cover the following list of preventive services for children without charging  a copayment or coinsurance.(Grandfathered plans are excluded from these requirements).

  • Autism screening for children at 18 and 24 months
  • Behavioral assessments for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
  • Blood Pressure screening for children at the following ages: 0 to 11 months, 1 to 4 years , 5 to 10 years, 11 to 14 years, 15 to 17 years
  • Cervical Dysplasia screening for sexually active females
  • Depression screening for adolescents
  • Developmental screening for children under age 3
  • Dyslipidemia screening for children at higher risk of lipid disorders at the following ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
  • Fluoride Chemoprevention supplements for children without fluoride in their water source
  • Gonorrhea preventive medication for the eyes of all newborns
  • Hearing screening for all newborns
  • Height, Weight and Body Mass Index measurements for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
  • Hematocrit or Hemoglobin screening for children
  • Hemoglobinopathies or sickle cell screening for newborns
  • HIV screening for adolescents at higher risk
  • Immunization vaccines for children from birth to age 18
  • Iron supplements for children ages 6 to 12 months at risk for anemia
  • Lead screening for children at risk of exposure
  • Medical History for all children throughout development at the following ages: 0 to 11 months, 1 to 4 years , 5 to 10 years , 11 to 14 years , 15 to 17 year
  • Obesity screening and counseling
  • Oral Health risk assessment for young children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years
  • Phenylketonuria (PKU) screening for this genetic disorder in newborns
  • Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk
  • Tuberculin testing for children at higher risk of tuberculosis at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
  • Vision screening for children

Women’s Health

Under the ACA, most health plans must cover additional health services for women,with no out-of-pocket ensuring a comprehensive set of services like breast cancer screenings.  All health plans purchased through the State Exchanges and many other plans must cover the following list of preventive services for women without charging a copayment or coinsurance. This is true even if you have not met your yearly deductible.(Grandfathered plans are excluded from these requirements).

  • Anemia screening on a routine basis for pregnant women
  • Breast Cancer Genetic Test Counseling (BRCA) for women at higher risk for breast cancer
  • Breast Cancer Mammography screenings every 1 to 2 years for women over 40
  • Breast Cancer Chemoprevention counseling for women at higher risk
  • Breastfeeding comprehensive support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
  • Cervical Cancer screening for sexually active women
  • Chlamydia Infection screening for younger women and other women at higher risk
  • Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt Religious Employers.
  • Domestic and interpersonal violence screening and counseling for all women
  • Folic Acid supplements for women who may become pregnant
  • Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes
  • Gonorrhea screening for all women at higher risk
  • Hepatitis B screening for pregnant women at their first prenatal visit
  • HIV screening and counseling for sexually active women
  • Human Papillomavirus (HPV) DNA Test every 3 years for women with normal cytology results who are 30 or older
  • Osteoporosis screening for women over age 60 depending on risk factors
  • Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk
  • Sexually Transmitted Infections (STI) counseling for sexually active women
  • Syphilis screening for all pregnant women or other women at increased risk
  • Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users 
  • Urinary tract or other infection screening for pregnant women
  • Well-woman visits to get recommended services for women under 65

Doctor Choice and Emergency Room Access

You have the right to choose the doctor you want from your health plan’s provider network.

  • You pick your doctor
  • You can choose any available primary care provider in your insurance plan’s network.
  • You can choose any available network pediatrician as your child’s primary care doctor.
  • No referrals needed for OB-GYN services:
  • You do not need to get a referral from a primary care provider before you seek obstetrical or gynecological (OB-GYN) care from a specialist.
  • Access to out-of-network emergency room services: Insurance plans cannot require higher copayments or coinsurance if you receive emergency care from an out-of-network hospital. They also cannot require you to obtain prior approval before getting emergency room services from a medical provider or hospital outside of your plan’s network.

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