ACA §2713 (Preventive Services)
ACA §2713 requires non-grandfathered plans to cover specified preventive services with ZERO cost-sharing — no deductible, no copay, no coinsurance. Plans frequently apply cost-sharing in error or when a preventive screening is recoded as diagnostic.
What ACA §2713 (Preventive Services) does
ACA §2713 (42 U.S.C. §300gg-13) requires non-grandfathered group health plans and individual health insurance to cover the following preventive services with NO cost-sharing when delivered by an in-network provider: (1) services rated A or B by the U.S. Preventive Services Task Force (USPSTF), (2) immunizations recommended by the CDC ACIP, (3) preventive care for infants/children/adolescents per HRSA Bright Futures guidelines, (4) preventive care for women per HRSA Women's Preventive Services Initiative guidelines including contraception. The implementing regulation specifies that recommendations effective on or before the first day of the plan year govern that plan year.
When to invoke it
Cite ACA §2713 when: (a) a screening colonoscopy is billed as diagnostic because a polyp was found and removed (USPSTF guidance treats this as preventive); (b) annual mammogram or well-woman visit is being copayed; (c) HPV vaccine, flu shot, or childhood immunization is being copayed; (d) contraception is being denied or copayed; (e) PrEP for HIV prevention is being copayed.
Key deadlines and thresholds
| Requirement | Deadline / threshold |
|---|---|
| Cost-sharing on covered preventive service | $0 — no deductible, copay, or coinsurance |
| New USPSTF recommendation effective date | First day of plan year ≥1 year after recommendation issued |
Plans this applies to
- Non-grandfathered group health plans
- Non-grandfathered individual health insurance
- ACA Marketplace plans
Frequently asked questions
What does ACA §2713 (Preventive Services) require?
ACA §2713 (42 U.S.C. §300gg-13) requires non-grandfathered group health plans and individual health insurance to cover the following preventive services with NO cost-sharing when delivered by an in-network provider: (1) services rated A or B by the U.S. Preventive Services Task Force (USPSTF), (2) immunizations recommended by the CDC ACIP, (3) preventive care for infants/children/adolescents per HRSA Bright Futures guidelines, (4) preventive care for women per HRSA Women's Preventive Services Initiative guidelines including contraception. The implementing regulation specifies that recommendations effective on or before the first day of the plan year govern that plan year.
When do I cite ACA §2713 (Preventive Services) in an appeal?
Cite ACA §2713 when: (a) a screening colonoscopy is billed as diagnostic because a polyp was found and removed (USPSTF guidance treats this as preventive); (b) annual mammogram or well-woman visit is being copayed; (c) HPV vaccine, flu shot, or childhood immunization is being copayed; (d) contraception is being denied or copayed; (e) PrEP for HIV prevention is being copayed.
What are the key deadlines under ACA §2713 (Preventive Services)?
Cost-sharing on covered preventive service: $0 — no deductible, copay, or coinsurance. New USPSTF recommendation effective date: First day of plan year ≥1 year after recommendation issued
Which plans does ACA §2713 (Preventive Services) apply to?
Non-grandfathered group health plans; Non-grandfathered individual health insurance; ACA Marketplace plans.
Related
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- CARC 96Common denial code where ACA §2713 (Preventive Services) applies.
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Sources
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