Prevention in Medicaid

May 1, 2014

Prevention in Medicaid and the Health Care Law

Preventing disease in low-income and vulnerable populations

Before the Affordable Care Act, coverage of preventive services in Medicaid was inconsistent across states. All states provided mammograms as required by the Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA). However, access to preventive services such as tobacco cessation and colorectal cancer screenings varied significantly because of different enrollment requirements by state. Fast Facts

When given access to preventive services programs, Medicaid beneficiaries use these benefits more often.

Medicaid coverage of preventive services is essential to improving the long-term health and well-being of our nation’s most vulnerable populations. 

Highlights of Medicaid Prevention in the Health Care Law

The Affordable Care Act is making prevention a priority in Medicaid by requiring coverage of recommended preventive services at no cost to the patient in Medicaid programs that serve newly eligible individuals. This critical provision of the law means millions of Americans now have access to these services. Additionally, Medicaid programs based on eligibility categories that pre-dated the law, including children, pregnant women and the disabled, are required to cover tobacco cessation for pregnant women and are incentivized to cover all recommended preventive services. Combined, these actions have the potential to significantly reduce the number of preventable cancer deaths in the U.S.

While the law improves access to prevention for individuals in Medicaid programs serving newly eligible individuals, 25 states have not increased access to Medicaid, leaving nearly 6 million low-income Americans without access to affordable coverage. Because of inconsistent definitions and eligibility criteria for recommended preventive benefits, providers and consumers are confused about which services should be administered and covered at no cost. Further Medicaid programs based on eligibility categories that pre-dated the law are not required to cover any preventive services, with the exception of tobacco cessation services for pregnant women.

Provisions of the health care law:

  • Requires that Medicaid programs serving newly eligible individuals provide preventive services graded “A” or “B” by the U.S. Preventive Services Task Force (USPSTF) at no cost to the patient (Effective 2014)
  • Provides states the option to include preventive services graded “A” or “B” by the USPSTF in their Medicaid programs based on eligibility categories that pre-dated the law in exchange for a 1% increase in the Federal Medical Assistance Percentage (FMAP) for those services.
  • Requires Medicaid programs based on eligibility categories that pre-dated the law to cover cessation services for pregnant women. These services are available without cost-sharing requirements such as co-pays or deductibles.

 

  • Eliminates exclusions in drug coverage for prescription tobacco cessation treatments and FDA-approved over-the-counter tobacco cessation tools if the pharmaceutical company has an existing rebate agreement with Health and Human Services. (Effective 2014)

 

Implications for the American Cancer Society and American Cancer Society Cancer Action Network (ACS CAN)

  • ACS CAN is working to ensure that critical provisions of the health care law work as intended to improve patient access to quality health care.
  • ACS CAN will work with Congress, the Secretary of Health and Human Services (HHS Secretary), and state Medicaid programs to ensure all recommended preventive services, regardless of diagnosis, are offered and administered at no cost to patients in all Medicaid programs.
  • ACS CAN will work with Congress, the HHS Secretary, and state Medicaid programs to ensure preventive benefit coverage definitions and eligibility criteria are clear and consistent for consumers and providers.
  • ACS CAN places high priority on public policies that help reduce health disparities by confronting the sources of illness before they develop and detecting diseases such as cancer early, when it is easier to survive and less expensive to treat.
  • ACS CAN will urge the HHS Secretary to consider the Society’s preventive services guidelines that have proven effective in reducing cancer risk along with recommendations of the USPSTF.