In the U.S. healthcare system, emphasis on preventive care has increased exponentially since the passage of the Affordable Care Act (ACA). We now see plan designs that are required to cover certain services with no out-of-pocket liability for the individual.
A point that’s often overlooked in our benefits compliance world is that “preventive services” for purposes of the ACA means something different than “preventive care” for purposes of Qualified High Deductible Health Plans (QHDHPs) coupled with Health Savings Accounts (HSAs). Let’s take a closer look at the differences between these two terms that, while often used interchangeably, have distinct legislative backgrounds and contextual implications.
Preventive Services Under the ACA
Looking back to March 23, 2010, when the ACA was signed, non-grandfathered group health plans needed to begin covering in-network “preventive services” at no cost to participants by September 23, 2010. Those services were those recommended by the U.S. Preventive Services Task Force, the Health Resources and Services Administration, and the Advisory Committee on Immunization Practices. The list of covered services was indeed extensive, ranging from cancer screenings, chronic conditions, counseling on health promotion, immunizations, and reproductive health and pregnancy-related issues. Generally, if a new service or item is added to the list of recommended preventive services, plans are required to cover it beginning with the first plan year starting on or after the date the recommendation is made.
Though this preventive service coverage mandate still remains in place today, there have been numerous proposed rule changes, updates, and challenges to the list of covered services throughout the past fourteen years. As recently as October of 2024, the Departments of Health and Human Services, Labor, and of the Treasury (the Departments) issued a proposed rule that would expand access to coverage, with a focus on over-the-counter contraceptives.
Preventive Care for QHDHPs
In the context of QHDHPs, preventive care specifically addresses those services that can be provided pre-deductible at no cost/reduced cost to participants without jeopardizing the plan’s HSA-QHDHP status. This list of services dates back to 2004 and Notice 2004-23, which outlines the pre-deductible care that QHDHPs can cover, and has been expanded multiple times since then. The evolution of the list of preventive care is summarized below:
- Notice 2004-23 includes things like health evaluations, diagnostic procedures and bloodwork as part of a routine exam, pre-natal care, child and adult immunizations, and tobacco cessation and weight loss programs.
- Notice 2004-50 subsequently clarified and expanded the services that can qualify as pre-deductible preventive care. Most notably, it indicates that preventive care includes any treatment incidental to another preventive service as described in Notice 2004-23, such as the removal of polyps during a diagnostic colonoscopy.
- Notice 2013-57 further expanded the list of care QHDHPs can cover pre-deductible to include preventive services under the ACA.
- Notice 2019-45 permits QHDHPs to cover prescription drugs used for certain chronic conditions pre-deductible such as asthma, congestive heart failure, depression, diabetes, etc. The items and services that QHDHPs can cover at no cost for the treatment of these conditions range from beta blockers, blood pressure monitors, and statins, to LDL testing and screenings.
- Notice 2024-75 expanded the list of QHDHP preventive care benefits to include over-the-counter oral contraceptives.
Comparison of Preventive Services & Preventive Care
As one can reasonably expect, the fact that what services qualify as “preventive” can depend on the context of the conversation often leads to confusion. Ultimately, the list of preventive services that most plans need to cover at $0.00 cost to participants under the ACA is more narrow than the list of care that QHDHPs may cover pre-deductible at no/reduced participant cost without risking participants’ ability to contribute to an HSA. Of course, those items and services that qualify as preventive both under the ACA and according to the QHDHP notices should be covered free of charge. Beyond what is required to be covered as preventive services under the ACA, the plan has flexibility to cover additional preventive care with no cost/reduced cost, but is not required to do so (unless required by state insurance mandates).
Given these preventive care nuances, we encourage employers and plan fiduciaries to keep abreast of potential changes to this guidance and to update their plan documents as needed. Ensuring employees are informed about their benefits is crucial as we head into a new year.
A final note before we close: let’s take a brief moment to discuss a nagging dilemma, “preventive” versus “preventative.” While there is virtually no difference between the two words in definition, “preventive” is the more commonly used word today, while “preventative” is a bit more obsolete. In the world of medicine, “preventive medicine” is recognized as more science-based, whereas “preventative medicine” is typically unproven or unscientific. While you can certainly find both words in a dictionary, for 2025 let’s increase our usage of the word “preventive” as it relates to healthcare.
