HIV/AIDS Preventive Services

The Affordable Care Act requires coverage of recommended preventive services without cost-sharing for the following health plans:

Non-grandfathered private health insurance plans – Most private insurance plans, including all plans on the Health Insurance Marketplace, and all group or individual health insurance plans that did not exist on March 23, 2010 or that have made significant changes to benefits, cost-sharing, or limits since that time are required to cover services without cost-sharing.¹
Medicare – All USPSTF recommended services that have a Grade “A” or “B” and that are covered by Medicare must be covered without cost-sharing.²
Medicaid expansion plans in states that expanded (i.e. Alternative Benefit 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 ($15,880 for an individual or $32,319 for a family of 4 in 2016) are required to cover services without cost-sharing.^3,4
Traditional Medicaid plans – Those states that, at their option, cover without cost-sharing in their standard Medicaid benefit package all USPSTF-recommended services that have a Grade “A” or “B” and all ACIP-recommended vaccines receive an increase in their federal medical assistance for such services and vaccines.⁵

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

Preventive Service	Recommending Authority (authorized under Section 1001 of the Patient Protection and Affordable Care Act)	Eligible Populations and Service Specifics	Health Insurance Plans That Cover the Service Without Cost-Sharing
HIV Testing	USPSTF (Grade “A” Recommendation issued April 30, 2013)	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.⁶ (See USPSTF Clinical Considerations for HIV Testing for additional information.)	Non-grandfathered health insurance plans Coverage must be in effect for plan years beginning after April 30, 2014.¹ Medicare Medicare covers a maximum of one, annual, voluntary screening for all adolescents and adults between the age of 15 and 65, without regard to perceived risk; and covers a maximum of one annual HIV screening for individuals <15 or >65 who are at increased risk of HIV. Medicaid expansion plans Traditional Medicaid plans Optional as above.
	Women’s Preventive Services, Supported by HRSA (Coverage guidelines adopted August 1, 2011, and updated December 20, 2016)	Annual screening for HIV infection for all sexually active women.⁸ (See Clinical Preventive Services for Women: Closing the Gaps for additional information.)	Non-grandfathered private health insurance plans Medicaid expansion plans Traditional Medicaid plans Optional as above.
	Bright Futures Recommendations for Pediatric Preventive Health Care, Supported by HRSA (Recommendations issued 2008 by the American Academy of Pediatrics)	HIV testing for sexually active adolescents (11-21 years of age) as per recommendations in current edition of AAP Red Book.⁹ Additionally, as per AAP Statement all adolescents should be screened once, between 16-18 years, making every effort to preserve confidentiality of the adolescent. Those at increased risk should be reassessed annually.	Non-grandfathered private health insurance plans Medicaid expansion plans Traditional Medicaid plans Optional as above. In general, preventive services for children are covered, included as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit for children; cost-sharing may apply in some cases.
Sexually Transmitted Infection (STI) and HIV Prevention Counseling	USPSTF (Grade “B” recommendation issued September 2014)	Sexually Transmitted Infections: Behavioral Counseling, September 2014 Intensive behavioral counseling for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections (STIs).¹⁰ (See Final Update Summary: Sexually Transmitted Infections: Behavioral Counseling - US Preventive Services Task Force for additional information.)	Non-grandfathered private health insurance plans Medicare Medicare covers up to two individual 20 to 30 minute, face-to-face counseling sessions annually for Medicare beneficiaries for HIBC to prevent STIs for all sexually active adolescents and for adults at increased risk for STIs, if referred for this service by a primary care provider and provided by a Medicare eligible primary care provider in a primary care setting.¹¹ Medicaid expansion plans Traditional Medicaid plans Optional as above.
	Women’s Preventive Services Supported by HRSA (Coverage guidelines adopted August 1, 2011, and updated December 20, 2016)	Annual counseling on sexually transmitted infections for all sexually active women. Annual counseling for HIV infection for all sexually active women.⁸ (See Clinical Preventive Services for Women: Closing the Gaps for additional information.)	Non-grandfathered private health insurance plans Medicaid expansion plans Traditional Medicaid plans Optional as above.

References

NOTE: Programs in states that are implementing “alternative” means to expand Medicaid (i.e. expanding Medicaid through “premium assistance”) should be mindful of state decisions regarding coverage and cost-sharing of these preventive services for newly eligible Medicaid enrollees.

¹ Preventive Services Covered Under the ACA. U.S. Department of Health & Human Services.

² Patient Protection and Affordable Care Act, Pub. L. No. 111-148, §4104, 124 Stat. 125, 557-558 (2010)

³ Patient Protection and Affordable Care Act, Pub. L. No. 111-148, §2001, 124 Stat. 121, 271-272 (2010)

⁴ 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. 78 FR 42159; 42224-42226

⁵ Patient Protection and Affordable Care Act, Pub. L. No. 111-148, §4106, 124 Stat. 125, 559-560 (2010)

⁶ Screening for HIV: Recommendation Statement. U.S. Preventive Services Task Force.

⁷ Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Sections 200-310. Centers for Medicare and Medicaid Services.

⁸ Women’s Preventive Services: Required Health Plan Coverage Guidelines. Health Resources and Services Administration.

⁹ 2016 Recommendations for Preventive Pediatric Health Care. Committee on Practice and Ambulatory Medicine and Bright Futures Periodicity Schedule Workgroup. Pediatrics 2016;137

¹⁰ Final Recommendation Statement: Sexually Transmitted Infections: Behavioral Counseling. U.S. Preventive Services Task Force.

¹¹ Pub 100-03 Medicare National Coverage Determinations, Chapter 1, Section 210.10. Centers for Medicare and Medicaid Services.