Recommended Preventive Services Covered by Medicaid

The 62 million Americans who are Medicaid beneficiaries tend to have lower incomes and greater health needs compared with those who have private health insurance. Reducing the risk of developing chronic conditions relies on preventive services for early diagnosis of health problems and promotion of healthy behaviors. Medicaid currently plays a major role in providing preventive services to beneficiaries; the Patient Protection and Affordable Care Act includes provisions allowing states to increase Medicaid’s role in providing access preventive services.

One such provision will take effect on January 1, 2013. States now have the opportunity to receive a 1 percentage point increase in their federal matching rate if they cover the immunizations recommended by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices and the preventive services rated grade A or B by the United States Preventive Services Task Force (USPSTF) with no cost-sharing for the beneficiaries.

The Henry J. Kaiser Family Foundation’s Commission on Medicaid and the Uninsured recently released a report highlighting findings from a survey of Medicaid coverage of 42 recommended preventive services for beneficiaries in fee-for-service programs as of October 2010.

Of the 42 services included in the survey, 44 states reported covering at least 30. Forty states covered ≥40 of the 42 services. In the states that covered the services, there was some variation in which services Medicaid covered for nonelderly adults; however, each preventive service was covered by at least half if not two-thirds of states. 

Thirteen states reported covering all of the preventive services and immunizations for nonelderly adult beneficiaries included in the survey; Minnesota, New Jersey, New Mexico, Rhode Island, and Vermont reported covering all 42 services without cost-sharing. Cost-sharing for preventive services varied among the states. Twenty-five states reported cost-sharing for at least 1 of the 42 services included in the survey.

Virtually every state covered cancer screenings, sexually transmitted infection (STI) screenings, and most of the recommended pregnancy-related services. Cancer screenings covered by all 48 states responding to the survey are breast cancer screening, mammography, and screenings for cervical and colorectal cancer as recommended by the USPSTF. All responding states, with the exception of North Dakota, reported covering screenings for HIV, chlamydia, gonorrhea, and syphilis; however, USPSTF-recommended STI counseling was not commonly covered.

Questions remain about the ACA provision, including how it will be administered by the Centers for Medicare & Medicaid Services. Other areas of concern include whether states can receive the increased federal match for preventive services covered without cost-sharing if they do not cover all of the recommended services; if states are required to cover these services and screenings routinely or if limiting coverage under the state’s definition of medical necessity will still allow the state to qualify; and if states will need to eliminate cost-sharing for related office visits as well as the specific service.

In conclusion, the authors of the report stated, “The ACA provides a number of opportunities to improve access to, and quality of care for, many adults currently in Medicaid programs and those who will be eligible to enroll beginning January 12, 2014. Research has shown that evidence-based preventive services can significantly improve the health of individuals at little or no additional cost. Results from the 2012 update of this survey will provide a better idea of the impact of recent changes on coverage of preventive services in state Medicaid programs ahead of the implementation of this provision in January 2013.”