The Patient Protection and Affordable Care Act (PPACA) requires non-grandfathered health plans to cover preventive health services without imposing cost-sharing requirements for the services. PPACA’s preventive care mandate is generally effective for plan years beginning on or after Sept. 23, 2010. On Aug. 1, 2011, the Department of Health and Human Services (HHS) issued new preventive care guidelines for women. These new guidelines, which are effective for plan years beginning on or after Aug. 1, 2012, require non-grandfathered health plans to cover women’s preventive health services (such as well-woman visits, breastfeeding support, domestic violence screening and contraceptives) without charging a copayment, a deductible or coinsurance.

This Compliance Alert provides a summary of HHS’s preventive care guidelines for women.

BACKGROUND

For plan years beginning on or after Sept. 23, 2010, non-grandfathered group health plans must cover certain preventive health services without any cost-sharing. The preventive care mandate does not apply to grandfathered plans.

In July 2010, HHS, along with the Departments of Labor and Treasury, issued interim final rules relating to coverage of preventive health services. The interim final rules identified the following recommended preventive health services as those that must be covered without cost-sharing requirements:

·          Evidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force, including certain preventive care for women, such as mammograms, cervical cancer screenings and prenatal care;

·          Immunizations for routine use in children, adolescents and adults that are currently recommended by the Centers for Disease Control and Prevention (CDC) and included on the CDC’s immunization schedules;

·          Evidence-informed preventive care and screenings for infants, children and adolescents, as provided for in the Health Resources and Services Administration (HRSA) guidelines; and

·          Evidence-informed preventive care and screening for women, as provided in guidelines supported by HRSA, which were required to be developed by Aug. 1, 2011.

More information on PPACA’s preventive care mandate, including specific information on the covered preventive health services, is available at: www.healthcare.gov/law/provisions/preventive/index.html.

COVERAGE GUIDELINES

On Aug. 1, 2011, HHS issued the HRSA-supported preventive care guidelines for women to fill the gaps in the current preventive health services guidelines for women. According to HHS, these new guidelines will help ensure that women receive a comprehensive set of preventive health services without having to pay a copayment, a deductible or coinsurance. Non-grandfathered health plans will need to include these services without cost-sharing for plan years beginning on or after Aug. 1, 2012 (Jan. 1, 2013, for calendar year plans).

The new preventive care guidelines for women cover the following health services:

·          Well-woman visits – Includes an annual well-woman preventive care visit for adult women to obtain the recommended preventive services, and additional visits if women and their providers determine they are necessary.

·          Gestational diabetes screening – Screening for women 24-28 weeks pregnant, and those at high risk of developing gestational diabetes.

·          Human papilloma virus (HPV) DNA testing for women age 30 and older – Women who are age 30 or older will have access to high-risk HPV DNA testing every three years, regardless of Pap smear results.

·       Sexually transmitted infection (STI) counseling – Sexually active women will have access to annual counseling on STIs.

·           Human immunodeficiency virus (HIV) screening and counseling – Sexually active women will have access to annual screening and counseling on HIV infections.

·          FDA-approved contraception methods and contraceptive counseling – Women will have access to all FDA-approved contraceptive methods, sterilization procedures and patient education and counseling. These recommendations do not include abortifacient drugs.

·          Breastfeeding support, supplies and counseling – Pregnant and postpartum women will have access to comprehensive lactation support and counseling from trained providers, as well as breastfeeding equipment.

·          Domestic violence screening and counseling – Screening and counseling for interpersonal and domestic violence.

According to HHS, health plans may use reasonable medical management techniques for women’s preventive care to help define the nature of the covered service, consistent with guidance provided in the interim final rules. For example, health plans may control costs and promote efficient delivery of care by continuing to charge cost-sharing for brand-name drugs if a safe and effective generic version is available. In addition, the interim final rules confirmed that plans may continue to impose cost-sharing requirements on preventive services that employees receive from out-of-network providers.

In connection with this guidance, HHS issued an amendment to the interim final rules to allow religious institutions offering health coverage to decide whether or not to cover contraceptive services, consistent with their beliefs.

CONSIDERATIONS FOR EMPLOYERS

Employers with non-grandfathered health plans should confirm with their insurance coverage issuers that the preventive health services for women will be covered, without cost-sharing, effective for plan years beginning on or after Aug. 1, 2012. Employers may see a rise in insurance premiums related to this expanded coverage.