Preventive Services vs. Preventive Care

In the context of medical coverage, the terms “Preventive Services” and “Preventive Care” are often used interchangeably. The two terms, however, have very different meanings. Understanding the difference can have significant implications for plan sponsors and participants alike.

For example, we recently fielded a question from a client who had moved to a new health insurance carrier/third party administrator (TPA) regarding preventive breast ultrasounds. The client soon learned that the new TPA, unlike its prior TPA, refused to provide this coverage at no cost, even though the plan was fully insured and coverage of breast ultrasounds was a state insurance mandate. The client was adamant that the Affordable Care Act (ACA) required this preventive coverage at no cost, as did state law. The TPA was equally adamant that the ACA did not require no cost coverage of preventive breast ultrasounds. Furthermore, the TPA asserted that, because the client offered a High Deductible Health Plan (HDHP) coupled with a Health Savings Account (HSA), covering breast ultrasounds with no cost sharing would constitute disqualifying other health coverage,[1] thereby jeopardizing the tax-qualified status of the HDHP/HSA arrangement. The TPA maintained that despite a state insurance mandate for preventive breast ultrasounds, protecting the tax-qualified status of the HDHP/HSA trumped state law.

We quickly realized that both parties were right—and wrong—and that the genesis of at least part of the disagreement was the conflation of the terms “Preventive Services” and “Preventive Care.”

Preventive Services

The ACA introduced the concept of no cost Preventive Services when it was signed into law on March 23, 2010. Specifically, the ACA provides that group health plans had to begin covering in-network Preventive Services at no cost to participants by September 23, 2010. “Preventive Services” are defined as a list of services recommended by the U.S. Preventive Services Task Force (USPSTF), the Health Resources and Services Administration (HRSA), and the Advisory Committee on Immunization Practices (ACIP). The list of Preventive Servicesranges from immunizations to cancer screenings to reproductive health care. Since 2010, the list of Preventive Services has been changed, expanded, and challenged,[2] but as of this writing, the ACA’s Preventive Services list and mandate remain intact.

Preventive Care

The concept of Preventive Care is relevant in the context of HDHPs[3] coupled with HSAs[4]. Preventive Care refers to those services that can be covered at no cost or reduced cost by HDHPs without constituting disqualifying other health coverage that would prohibit a participant (or their employer) from contributing to an HSA. The list of Preventive Care is found in a series of IRS Notices[5] dating back to 2004 and is more extensive than the ACA’s list of Preventive Services. Unlike Preventive Services, there is no federal mandate that group health plans, even HDHPs, cover every item or service identified as Preventive Care. The IRS guidance simply provides that if an item or service of Preventive Care is covered at no cost by an HDHP, a participant (or their employer) can still make tax-favored contributions to an HSA. It is important to note, however, that fully insured group health plans may be subject to state insurance mandates requiring coverage of services on the Preventive Care list. This is because insurance carriers are required by law to adhere to the insurance mandates of the state in which the insurance policy is issued.

Where the Confusion Arises

As stated at the outset, the terms Preventive Services and Preventive Care are often used interchangeably, giving rise to confusion and misunderstanding. Returning to our example, it quickly became apparent that the client incorrectly believed that breast ultrasounds were an ACA-mandated Preventive Service. In fact, while the list of Preventive Services includes mammograms, the USPSTF currently does not recommend “screening for breast cancer with breast ultrasound or MRI, regardless of breast density,”[6] reasoning that there is inadequate evidence on the benefits of such screening. The TPA, therefore, was correct that the ACA does not mandate coverage of preventive breast ultrasounds as a Preventive Service.

However, it appears the TPA next incorrectly concluded that, because breast ultrasounds are not an ACA Preventive Service, neither are they Preventive Care for purposes of the HDHP/HSA requirements. Whether the TPA jumped to this conclusion because it did not recognize the difference between Preventive Services and Preventive Care, because it did not know that the USPSTF was not the controlling authority for determining the approved list of Preventive Care, or for some other reason remains unclear; but the fact is that the IRS’s original, 2004 guidance about HDHPs (Notice 2004-23) includes breast cancer screening on its list of Preventive Care services. While Notice 2004-23 used mammography as an example for breast cancer screening, it did not exclude other forms of screening for breast cancer. To further clarify this point of coverage, in October of 2024, the IRS published Notice 2024-75, which explicitly provides: “breast cancer screening may include imaging other than mammograms,” and requires that “the reference in Notice 2004-23 to breast cancer screening . . . be changed to ‘Breast Cancer (e.g., Mammograms, Magnetic Resonance Imaging (MRIs), Ultrasounds, and similar breast cancer screening services).’ This language change is effective as of the date of publication of Notice 2004-23 (April 12, 2004).”

In the end, because the plan was fully insured, it was required to comply with the state insurance mandate, and in connection with this, the TPA was persuaded that such compliance was supported by the IRS’s Preventive Care guidance and therefore would not jeopardize the tax-qualified status of the HDHP/HSA arrangement. The client was pleased with the outcome for its plan participants, and all parties involved gained a new appreciation for the importance of recognizing and thoroughly understanding the difference between Preventive Services and Preventive Care.

If you have questions about whether a service should be covered by your group health plan as a Preventive Service or Preventive Care, please contact any member of Verrill’s Employee Benefits and Executive Compensation practice group.

[1] In general, to be eligible for an HSA under Section 223 of the Internal Revenue Code (Code) and thus be eligible to make tax-favored contributions to the HSA, an individual must have HDHP coverage, cannot be claimed as a dependent on another individual’s income tax return, must not be entitled to Medicare, and must not have any other health coverage.

[2] One recent challenge is Kennedy v. Braidwood Mgmt. Inc., a case in which the plaintiffs have challenged certain portions of the ACA’s Preventive Services mandate on constitutional grounds, asserting that members of the USPSTF were not appointed by the President or approved by the Senate and therefore do not have the constitutional authority to create this type of mandate. The U.S. Supreme Court heard oral arguments on April 21, 2025, and a decision is expected this summer.

[3] A HDHP is a medical plan that meets certain requirements for annual deductibles and out-of-pocket expenses and provides “significant benefits.” See Code Section 223(c)(2).

[4] An HSA is a tax-favored individual savings account that works in combination with an HDHP to save for and pay for qualified health care expenses. See Code Section 223.

[5] See Notice 2004-23 (the original list, which includes such items as annual physicals, certain diagnostic procedures and bloodwork, immunizations, and pre-natal care), Notice 2004-50 (expanded Preventive Care to include treatment incidental to another preventive care service, such as the removal of polyps during a diagnostic colonoscopy), Notice 2013-57 (expanded Preventive Care to include all Preventive Services under the ACA), Notice 2019-45 (expanded Preventive Care to include certain prescription drugs for chronic conditions), and Notice 2024-75 (expanded Preventive Care to include over the counter contraceptives, all types of breast cancer screening, continuous glucose monitors for diabetics, and certain insulin products).

[6] See the USPSTF recommendation here.