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Benefits Strategy

Preventive Care Regulatory Framework

Updates to clinical guidelines related to screening frequency, age, method or setting can lead to a change in plan coverage levels. What can be covered as a “free” preventive screening?

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January 09, 2025

Exploring Innovation in Preventive Care
A fresh look at updated screening guidelines and evolving testing methods to assist employers in evaluating ways to improve their members’ screening compliance and reduce hidden cost barriers to accessing preventive care.
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In the U.S., USPSTF creates recommendations for clinical preventive services with respect to age, frequency and the conditions for which these measures have been proven to manage risk. The USPSTF aims to promote better health for Americans by offering recommendations based on scientific data regarding the best way to prevent illness and extend life. The Affordable Care Act (ACA), in turn, requires most group health plans and insurers to cover procedures and medicines rated ‘A’ or ‘B’ by the USPSTF without cost sharing. Such coverage levels may also extend to other services recommended based on other federal agency guidelines, including recommendations for women and children from HRSA and immunizations recommended by the CDC Advisory Committee on Immunization Practices (ACIP).1-3

For plan designs that come with tax-advantaged health savings accounts (HSAs), employers must also follow the Internal Revenue Service (IRS) rules. These rules dictate which procedures and treatments can bypass the deductible but still may carry a coinsurance cost. The IRS issued guidance for high-deductible health plans (HDHPs) with HSAs expands the definition of preventive care that plans can cover before the deductible is satisfied, going beyond the original ACA list of services.

U.S. Supreme Court Decisions Affecting Coverage of Preventive Services

On March 30, 2023, a federal district court judge issued a decision in the case of Braidwood Management v. Becerra finding that the ACA’s requirement for no-cost coverage of preventive services recommended by the USPSTF violated the Constitution, citing issues with how the USPSTF was appointed under the Appointments Clause. The court also ruled that the ACA’s mandate to cover pre-exposure prophylaxis (PrEP) medications for HIV prevention violated the rights of the plaintiffs under the Religious Freedom Restoration Act due to their religious objections.

On June 21, 2024, the U.S. Court of Appeals for the Fifth Circuit affirmed the district court’s opinion that USPSTF was unconstitutionally appointed and therefore its recommended services and items could not be required for plans to cover – however, the Appellate Court’s ruling was limited in scope and only exempted the plaintiffs in the case from the ACA requirements. This means that, for the time being, the ACA’s preventive service coverage requirements continue to be broadly applicable to employer sponsored plans.

The Department of Health and Human Services (HHS) and the Braidwood plaintiffs have cross-appealed to the U.S. Supreme Court (SCOTUS) requesting review of the Fifth Circuit Court decision. If SCOTUS reviews this case and applies the decision more broadly, it could significantly affect employer and plan sponsor obligations with regard to ACA preventive care requirements. For more information on this issue as well as other court cases with potential implications for employer-sponsored health plans in the U.S., check out Supreme Court 2024 New Term Update.


For plan designs that come with tax-advantaged health savings accounts (HSAs), employers must also follow the Internal Revenue Service (IRS) rules. These rules dictate which preventive items and services may be covered on a low/no-cost basis before the otherwise required minimum deductible. The IRS issued guidance in 2019 and again in 2024 for high-deductible health plans (HDHPs) with HSAs that expands the definition of preventive care that plans can cover before the deductible is satisfied, going beyond the original ACA list of services.

Preventive Care Framework Considerations Around the World

Outside of the U.S., there are a plethora of nonprofit organizations and regulatory bodies tasked with informing evidence-based preventive health care guidelines, including the World Health Organization (WHO) and other country/regional-specific decisionmakers. For example, in the UK, the National Institute for Health and Care Excellence (NICE) assesses evidence-based research to develop clinical guidance for the National Health Service (NHS). Moreover, the NHS is prioritizing preventive care as part of their Long Term Plan and has a Prevention Programme in place with various initiatives focused on specific conditions (e.g., cancer and diabetes prevention).4

Aside from regulatory framework, fronting networks and global brokers are emphasizing preventive care services to employer clients. As such, large employers in India are shifting their benefit coverage to include outpatient services with an emphasis on preventive care; historically, coverage was limited to in-patient hospitalization care.5 As employers try to manage health care costs, having a global strategy focused on prevention can help to mitigate the downstream health care costs associated with chronic conditions.


Preventive Care Visits and the Role of PCPs

Primary care accounts for less than 10% of total health care expenditures: Primary care providers (PCPs) are often seen by their patients as their most trusted health advisors. In the U.S., two-thirds of the population has an established PCP; the remaining third lacks access to these physicians mainly due to a national shortage of practitioners in rural areas.6 Lack of access to primary health care is a problem that translates outside of the U.S. as well. For example, in rural areas in India, informal health care providers play a significant role in delivering primary care although they lack formal medical training.7

Establishing a relationship with a PCP is an essential part of prevention, as this relationship helps patients adopt healthier habits and improves patient education and adherence to preventive screening guidelines.8 Furthermore, most preventive services are delivered within the primary care setting. The most basic form of preventive care is an annual preventive exam performed by the patient’s PCP to assess their overall health and screen for health risks. Basic screenings, including those for cholesterol, blood pressure and blood sugar, allow a PCP to identify any issues that may become medical concerns in the future. Mental health screenings are also increasingly incorporated into routine primary care visits.

Since the pandemic, health care has been engaged in a transition from brick-and-mortar care to widespread adoption of telehealth. This transition has led to many changes for providers and patients alike. Telehealth-enabled primary care allows some patients easier access to care, more flexible follow-up and faster specialty referrals.9 One study from Elevance Health found that 32% of individuals in the U.S. had used virtual primary care (VPC). Of that third, 94% were satisfied with the experience and 79% indicated that VPC has helped them take charge of their health.10

Several providers are beginning to offer virtual primary care services to develop ongoing relationships with their patients. In late 2021, multiple carriers, including UnitedHealth Group, Humana and Aetna, as well as other regional plans, announced virtual-first primary care initiatives focused on longitudinally connecting patients to PCPs via telehealth.11 Building these longitudinal relationships can create a better connection between patients and their PCPs. In addition, positioning primary care to maximize its convenience may be a crucial step to improving overall compliance with preventive care guidelines.

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Resource icon_right_chevron_dark Plan Design & Administration icon_right_chevron_dark Preventive Services icon_right_chevron_dark Primary Care icon_right_chevron_dark
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  1. Preventive Care Visits and the Role of PCPs