NEW AFFORDABLE CARE ACT PREVENTIVE SERVICES FOR WOMEN

August 2011

INSIGHT

As part of the Affordable Care Act, the Department of Health and Human Services (HHS) directed the Institute of Medicine (IOM) to conduct a scientific review and report its findings regarding Recommended Preventive Services (RPS) for women. On August 1, 2011, HHS adopted IOM recommendations which will require non-grandfathered fully insured and self-funded plans to cover additional preventive services for women with no member cost sharing. Certain exemptions apply for religious organizations. More information on Recommended Preventive Services can be found on the HHS website.

IMPLICATIONS

Plan sponsors of non-grandfathered fully insured and self-funded plans will be required to incorporate these additional services on the first plan year that begins on or after August 1, 2012 (to the extent they are not currently offered with no member cost sharing). Calendar year plans will be required to comply on January 1, 2013. Plan sponsors should review the new requirements and potential cost increases with their Chernoff Diamond consultant.

The required women’s services that must be provided with no deductible, copayment or coinsurance payments are as follows:

Annual well-woman visits for preventive care services that are age and developmentally appropriate.
Gestational diabetes screening for women 24–28 weeks pregnant and women at high risk for developing gestational diabetes.
Family planning services including Food and Drug Administration approved contraceptives, sterilization procedures, as well as education and counseling services.
High-Risk Human Papillomavirus DNA testing every three years for women age 30 and older, regardless of Pap smear test results.
Annual HIV and sexually transmitted disease screenings.
Breastfeeding support and counseling services as well as lactation supplies and devices.
Domestic violence screening and counseling.

Background

Under the Affordable Care Act, non-grandfathered plans must provide certain Recommended Preventive Services (based on certain task force and advisory committee guidelines) with no cost sharing to plan participants. At the time the law was passed, the Health Resources and Services Administration (HRSA), one of the advisory agencies cited in the law, had not issued evidence‐informed preventive care and screening guidelines for women. As a result, the Department of Health and Human Services directed the IOM to conduct this scientific research and report its findings regarding Recommended Preventive Services for women. The study results, supported by the HRSA, now form the basis for the “Women’s Preventive Services: Required Health Plan Coverage Guidelines” under the Affordable Care Act.

Plan sponsors may continue to use reasonable medical management techniques to help define the nature and extent of the required preventive service coverage. According to HHS “plans will retain 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 just as effective and safe.”

Exception for Religious Organizations

Group health plans sponsored by religious employers are exempt from the requirement to cover contraceptive services. In order to qualify for the exemption, the employer must satisfy the following criteria (modeled after the most common exemption available in 28 states). The public has 60 days to comment on this exemption.

Has the inculcation of religious values as its purpose;
Primarily employs persons who share its religious tenets;
Primarily serves persons who share its religious tenets; and
Is a non-profit organization under Internal Revenue Code 6033(a)(1) and Section 6033(a)(3)(A)(i) or (iii).

HRSA Guidelines

The following table provides additional details on the HRSA “Women’s Preventive Services: Required Health Plan Coverage.”

These guidelines are effective August 1, 2011. Group health plans will have to comply on the first plan year that begins one year from the effective date of the issued guidelines.

Type of Preventive Service	HHS Guidelines for Health Insurance Coverage	Frequency
Well-woman visits.	Well-woman preventive care visit annually for adult women to obtain the recommended preventive services that are age and developmentally appropriate, including preconception and prenatal care. This well-woman visit should, where appropriate, include other preventive services listed in this set of guidelines, as well as others referenced in the ACA.	Annual, although HHS recognizes that several visits may be needed to obtain all necessary recommended preventive services, depending on a woman’s health status, health needs, and other risk factors.*

Screening for gestational diabetes.	Screening for gestational diabetes.	In pregnant women between 24 and 28 weeks of gestation and at the first prenatal visit for pregnant women identified to be at high risk for diabetes.
Human papillomavirus testing.	High-risk human papillomavirus DNA testing in women with normal cytology results.	Screening should begin at 30 years of age and should occur no more frequently than every 3 years.
Counseling for sexually transmitted infections.	Counseling on sexually transmitted infections for all sexually active women.	Annual.
Counseling and screening for human immune-deficiency virus.	Counseling and screening for human immune-deficiency virus infection for all sexually active women.	Annual.
Contraceptive methods and counseling. **	All Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity.	As prescribed.
Breastfeeding support, supplies, and counseling.	Comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for renting breastfeeding equipment.	In conjunction with each birth.
Screening and counseling for interpersonal and domestic violence.	Screening and counseling for interpersonal and domestic violence.	Annual.

* Refer to recommendations listed in the July 2011 IOM report entitled Clinical Preventive Services for Women: Closing the Gaps concerning individual preventive services that may be obtained during a well-woman preventive service visit.

** Group health plans sponsored by certain religious employers, and group health insurance coverage in connection with such plans, are exempt from the requirement to cover contraceptive services. A religious employer is one that: (1) has the inculcation of religious values as its purpose; (2) primarily employs persons who share its religious tenets; (3) primarily serves persons who share its religious tenets; and (4) is a non-profit organization under Internal Revenue Code section 6033(a)(1) and section 6033(a)(3)(A)(i) or (iii).

ADDITIONAL INFORMATION

For specific questions concerning information contained in this INSIGHTS & IMPLICATIONS, please contact your Chernoff Diamond consultant.

Information contained in this INSIGHTS & IMPLICATIONS is not intended to render tax or legal advice. Employers should consult with qualified legal and/or tax counsel for guidance with respect to matters of law, tax and related regulation.

Chernoff Diamond & Co., LLC provides comprehensive consulting and administrative services with respect to all forms of employee benefits, risk management, qualified and non-qualified retirement plans, private client services, and compensation and human resources.

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