aca preventive services :: Article CreatorWhat Effect Does The Affordable Care Act Have On Medicare?
The purpose of the Affordable Care Act (ACA) was to make healthcare more affordable. It has had various effects on Medicare, including eliminating the drug coverage gap (donut hole) and improving coverage.
According to the Centers for Medicare and Medicaid Services (CMS), more than 68 million people in the United States are enrolled in Medicare.
The main goal of the Affordable Care Act (ACA) has been to provide affordable healthcare to everyone in the United States. To that end, the ACA made various changes and improvements to the Medicare program.
Glossary of Medicare terms
Out-of-pocket cost: This is the amount a person must pay for care when Medicare does not pay the total amount or offer coverage. Costs can include deductibles, coinsurance, copayments, and premiums.
Premium: This is the amount of money someone pays each month for Medicare coverage.
Deductible: This is an annual amount a person must spend out of pocket within a certain period before Medicare starts to fund their treatments.
Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, coinsurance is 20%.
Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
About the Affordable Care Act
In 2010, President Barack Obama signed the ACA (also known as Obamacare) into law. This marked an overhaul of the U.S. Healthcare system. Before the ACA, many people were uninsured due to exclusions based on preexisting conditions, a lack of affordability, high out-of-pocket costs, and coverage limits.
The ACA affects nearly every aspect of the U.S. Healthcare system, including:
employers
state governments
taxpayers
consumers
insurers
providers
Read more about the Affordable Care Act.
What is the effect of the ACA on Medicare?
The ACA has various provisions that are designed to improve and strengthen Medicare. The ACA aims to sustain Medicare for years to come by:
reducing annual payment increases to hospitals, nursing homes, and insurance companies
eliminating fraud, waste, and inefficiency through methods such as:
detecting, preventing, and fighting fraud
providing incentives to transition to Electronic Health Records
bundling payments for services
The ACA also aims to improve coverage in various ways, including:
eliminating the prescription drug coverage gap (donut hole)
providing a free annual medical exam
eliminating coinsurance for preventive services
Eliminating the donut hole
As of 2025, the donut hole has been replaced with an out-of-pocket spending cap due to both the ACA and the Inflation Reduction Act (IRA).
When someone with Medicare Part D reaches $2,000 of out-of-pocket expenses, they automatically enter catastrophic coverage. This means they pay nothing for their prescriptions for the rest of the year.
Previously, when a person with Part D coverage reached a certain amount of out-of-pocket costs, they would enter the coverage gap or donut hole. While in the donut hole, they were responsible for 100% of the costs of their prescription drugs until they reached the set limit and entered catastrophic coverage.
Free medical exam
The ACA also made another change to Medicare that involved providing each enrollee with an annual wellness visit. During this visit, individuals can update or develop a personalized plan to help prevent disability or disease based on their current health or risk factors.
During the first year a person has Medicare Part B, they can get a free "Welcome to Medicare" preventive visit. They can then use the annual wellness visit each year.
Eliminating coinsurance for preventive services
The ACA also aims to encourage prevention by making it less expensive for people to keep healthy. As part of this goal, the ACA eliminated the coinsurance (the percentage of treatment a person must self-fund) for preventive services such as:
Preventive services also include shots and vaccines such as those for:
Learn more about what Medicare covers.
Medicare Eligibility
To be eligible for Medicare, you must meet the following requirements:
How does the Healthcare Marketplace help those not eligible for Medicare?
If a person does not have Medicare, is not eligible for Medicare, or does not have health coverage through another means, the Healthcare Marketplace can help them find insurance coverage that fits their budget and needs.
Individuals are eligible to enroll in coverage through the Marketplace if they:
People cannot buy a Marketplace plan if they already have Medicare. It may be possible for them to choose a Marketplace plan instead of Medicare, but generally, this is not the case.
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
Summary
The ACA has made various changes and improvements to the Medicare system. For example, it eliminated the prescription drug donut hole, provides free annual wellness exams, and eliminated coinsurance on preventive services.
If a person is not eligible for Medicare, the Health Insurance Marketplace can help them find health coverage that meets their needs and budget.
View the original article on Medical News Today
Plans Will Keep Preventive Screening Benefits Even If Supreme Court Zaps ACA Provision, Exec Predicts
The head of a screening test firm thinks that quality rating programs and market forces will cause employers and other payers to continue to cover common cancer screening tests, even if the U.S. Supreme Court kills the process that put the tests in the Affordable Care Act preventive health services package.
Kevin Conroy, the chief executive officer of Exact Sciences, talked about the forces shaping preventive services benefits at employer plans and other plans Wednesday, during a conference call with securities analysts.
No matter what courts do to the Affordable Care Act, "payers are highly motivated to get their patients screened," Conroy told the analysts.
The backdrop: The ACA requires all major medical insurance policies sold since March 23, 2010, and all self-funded employer health plans started since that date to cover a standard package of preventive services package without imposing deductibles, co-payments or other cost-sharing requirements on the patients.
The U.S. Preventive Services Task Force is one of the bodies that can recommend adding procedures to the ACA preventive services package. One of the procedures it put in is colon cancer screenings.
Exact Sciences is interested in the preventive services package because it sells the Cologuard colon cancer home screening test. Many patients use their health plans' ACA preventive services package benefits to pay for their colon cancer screening tests.
The litigation: Braidwood Management, a health care company with a self-insured health plan, and Kelley Orthodontics, an employer that uses fully insured group health insurance, teamed up with several patients to sue the head of the U.S. Department of Health and Human Services in the U.S. District for the Northern District of Texas over the preventive services package requirements.
The plaintiffs are seeking permission to represent a class of employers and individuals who oppose part or all of the ACA preventive care coverage requirements because they believe the requirements conflict with their religious principles. The plaintiffs also contend that the process for adding procedures to the package violates the U.S. Constitution because the members of the U.S. Preventive Services Task Force are not nominated by the president or confirmed by the Senate.
At this point, the Trump administration appears to be defending the new secretary of Health and Human Services, Robert J. Kennedy Jr., against the suit.
"That's obviously a positive sign for the whole field of prevention," Conroy said.
What it means: If Conroy is right, most employer-sponsored health plans may continue to cover roughly the same kinds of cancer screening tests, with no patient cost-sharing or low patient cost-sharing, even if the Supreme Court rules in favor of the employer plans and individuals in the Braidwood case.
For employers, however, one question may be which of the preventive services in the current ACA package really pay for their keep. In theory, the services in the package are supposed to save money, but government analyses of the impact of the preventive services requirements tend to focus on the potential benefits of providing more access to preventive services and not on the cost of the services.
Researchers reported in the summer that screening for five types of cancer — cancers of the breast, cervix, colon, lung and prostate — cost Americans about $43 billion per year, and some experts questioned whether the health benefits or financial benefits justify that extra spending.
Trump Administration's Message To Supreme Court Puts New Wrinkle In Braidwood Case
The Trump administration argues that HHS Secretary Robert F. Kennedy Jr can overrule the US Preventive Services Task Force to determine the preventive services covered under the Affordable Care Act.
Preventive services covered by the Affordable Care Act (ACA) have been under fire for in recent years, as the requirement for private insurers to cover these services with no cost sharing has been left up in the air amid an ongoing lawsuit. The case, which was first decided in 2022 by a lower court, will go before the Supreme Court to decide whether the US Preventive Services Task Force (USPSTF) had the authority to regulate the preventive services covered under the ACA. With a new brief filed by the Trump administration, the case could become more complicated.
The Braidwood Management v Becerra lawsuit initially was brought with the argument that Braidwood Management was not required to cover services based on religious views.1 This included pre-exposure prophylaxis (PrEP) for HIV, which private insurers were required to cover under the ACA. Braidwood Management argued that, under the appointments clause in the Constitution, the USPSTF did not have the authority to determine what services should be covered because the task force was not appointed by the Senate. The case is set to be decided by the Supreme Court later this year.
However, the Trump administration has now indicated in a new brief that it is willing to protect the preventive services measure of the ACA.2 Of note, the Justice Department claims that it will be maintaining the arguments first brought by the Biden administration, which contended that the USPSTF members serve as inferior officers, with the HHS secretary was overseeing the decisions, meaning they need not be presidentially appointed and confirmed by the Senate.
The Trump administration indicated its intent to protect insurance coverage of preventive servicesImage credit: yavdat - stock.Adobe.Com
The Trump administration is adding to the argument laid out by the Biden administration, stating that the HHS secretary has the final say in whether the USPSTF recommendations would have any legal effect.2 The authority attributed to the HHS secretary could potentially include using their power of removal if there are delays in the process of making recommendations, denying a binding effect to the task force's recommendations, and steering the USPSTF to focus on a particular service.3 The proposed reasoning for allowing USPSTF to continue giving recommendations would put more power in the HHS secretary's hands, which could have major implications given newly confirmed secretary Robert F. Kennedy Jr's stated beliefs surrounding public health, including his skepticism regarding vaccines and FDA policies.4
Regardless of the arguments used to keep the preventive services measure intact, experts say that requiring preventive services be covered under the ACA is important to patients across the country. More than 30 preventive services would be affected by a ruling against the legality of requiring insurance cover the services.5 Along with PrEP, the lawsuit could affect services such as screenings for colorectal cancer, HIV, hepatitis C, lung cancer, and vision in children aged 6 months to 5 years. The lawsuit could potentially roll back requirements to only cover preventive services given an A or B rating by the USPSTF prior to 2010, with all major changes since then not guaranteed coverage.
It remains to be seen how the arguments before the Supreme Court and its eventual decision could be affected by the new brief from the Trump administration. The HHS secretary could claim more authority over the USPSTF than before, which would have major implications for future preventive services being given A and B ratings that would force coverage from private insurers.
References
Bonavitacola J. Federal judge's ruling throws preventive care access into question. AJMC®. April 4, 2023. Accessed February 21, 2025. Https://www.Ajmc.Com/view/federal-judge-s-ruling-throws-preventive-care-access-into-question Bettelheim A. Trump administration to defend ACA preventive services mandate. Axios. February 20, 2025. Accessed February 21, 2025. Https://www.Axios.Com/2025/02/20/trump-admin-defend-aca-mandate Ollstein AM. Trump defends Obamacare at the Supreme Court—stressing RFK Jr.'s in charge now. PoliticoPro. February 21, 2025. Accessed February 21, 2025. Https://subscriber.Politicopro.Com/article/2025/02/trump-obamacare-supreme-court-rfk-jr-00205261 Grossi G. 5 health policy stances of Robert F. Kennedy Jr. AJMC. November 15, 2024. Accessed February 21, 2025. Https://www.Ajmc.Com/view/5-health-policy-stances-of-robert-f-kennedy-jr Bonavitacola J. Braidwood case headed to Supreme Court, coverage for preventive care in jeopardy. AJMC. February 4, 2025. Accessed February 21, 2025. Https://www.Ajmc.Com/view/braidwood-case-headed-to-supreme-court-coverage-for-preventive-care-in-jeopardy
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