Under health reform, non-grandfathered plans are required to provide coverage for certain recommended preventive services (such as mammograms, colonoscopies and immunizations) without charging a copayment, deductible, or coinsurance. This preventive services at no additional cost rule generally applies to group health plans for plan years beginning on or after September 23, 2010(January 1, 2011for calendar year plans). See the Conner Strong & Buckelew November Update for more background information on these rules. Note that if a plan is “grandfathered,” these preventive benefit requirements do not apply.
Women’s Preventive Service Guidelines Adopted: Under the existing health reform rules and the 2010 preventive care regulations, women’s preventive health care services – such as mammograms, screenings for cervical cancer, and other services – are already covered with no cost-sharing under non-grandfathered health plans. The Department of Health and Human Services (HHS) has just announced the adoption of guidelines for women developed by the Institute of Medicine (IOM). These concern additional, recommended preventive health services. The new guidelines supplement the preventive care regulations issued in 2010 and have the effect of expanding on the list of preventive health care services that must be covered on a first-dollar basis. Most notably, the new rules require non-grandfathered group health plans to cover all FDA-approved contraceptive methods and contraceptive counseling with no cost-sharing. The new rules do not require non-grandfathered group health plans to cover fertility services.
The required preventive services that must be offered to women at no additional cost now include:
Well-woman visits: This would include 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: This screening is for women24 to 28 weeks pregnant, and those at high risk of developing gestational diabetes.
HPV DNA testing: Women who are 30 or older will have access to high-risk human papillomavirus (HPV)DNA testing every three years, regardless of pap smear results.
STI counseling, and HIV screening and counseling: Sexually-active women will have access to annual counseling on human immunodeficiency virus (HIV) and sexually transmitted infections (STIs).
Contraception and contraceptive counseling: Women will have access to all FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling.
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: Women will have access to screening and counseling for interpersonal and domestic violence.
The rules governing coverage of preventive services, which allow plans to use reasonable medical management to help define the nature of the covered service, apply to women’s preventive services. Plans will retain the flexibility to control costs and promote efficient delivery of care by, for example, continuing to charge cost-sharing for branded drugs if a generic version is available and is just as effective and safe for the patient to use.
New health plans must cover the new guidelines on women’s preventive services with no cost-sharing in plan years starting on or after August 1, 2012. Non-grandfathered health plans (both insured and self-insured) will have at least one year to include these services without cost (by January 1, 2013 for calendar year plans).
The agencies have also released an amendment to the original preventive care regulations that allows religious institutions that offer insurance to their employees the choice of whether or not to cover contraception services. This regulation is modeled on the most common accommodation for churches available in the majority of the 28 states that already require insurance companies to cover contraception. HHS welcomes comment on this policy (due by September 30, 2011).
For more information on the HHS guidelines for expanding women’s preventive services, please link to the press release, the fact sheet, and to the IOM’s July 2011 report titled Clinical Preventive Services for Women: Closing the Gaps. Share your comments on the guidelines at email@example.com.
The complete list of preventive service recommendations and guidelines that must be covered by plans will be continually updated to reflect both new recommendations and guidelines and revised or removed guidelines. Should you have questions about this or any aspect of federal health insurance reform, contact your Conner Strong & Buckelew account representative toll free at 1-877-861-3220. For a complete list of Legislative Updates issued by Conner Strong & Buckelew, visit our online Resource Center.