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HHS Announces Preventive Health Care for Women

The Department of Health and Human Services (HHS) has just announced additional preventive care services for women covered under "non-grandfathered" health care plans. Under the Affordable Care Act, these services must be provided with no cost-sharing in plan years starting on or after August 1, 2012.

Action to Take: Plan sponsors that are no longer grandfathered or anticipate losing grandfathered status need to carefully determine how they are going to interpret and implement these newly listed preventive services.

Background

In July 2010, HHS issued interim final regulations1 under section 2713 of the Public Health Service Act as amended by the Affordable Care Act. Under the interim regulation, preventive health services must be provided under a group health plan, and the plan may not impose any cost-sharing (such as copayment, coinsurance, or deductible). The rules with respect to preventive health care services do not apply to grandfathered group health plans.

Preventive Health Care Services

Under the July 2010 regulations, preventive care services generally are defined as in-network coverage for the following:

1. 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;

2. Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention;

3. With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration; and

4. With respect to women, to the extent not listed with an A or B rating by the United States Preventive Services Task Force, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration.

At the time the regulations were issued, the Health Resources and Services Administration (HRSA) had not issued any comprehensive guidelines.

New Preventive Care Guidelines

On August 1, 2011, HRSA issued new guidelines specifying additional preventive care for women. The new guidelines were developed by the Institute of Medicine (IOM) (which is part of the National Academy of Sciences) and adopted by HRSA. See the IOM's July 2011 report titled Clinical Preventive Services for Women: Closing the Gaps. The additional preventive services and frequency are as follows:

Preventive Service Frequency
Well-woman visits - includes preventive services that are age and risk factor appropriate Annual, but more than one visit may be needed to obtain all necessary services*
Screening for gestational diabetes Between 24 and 28 weeks of gestation and at first prenatal visit identified at high risk for diabetes
Human papillomavirus (HPV) testing Beginning at 30 years of age and no more frequently than every 3 years
Counseling for sexually transmitted infections (STIs) Annual
Counseling and screening for HIV Annual
Contraceptive methods, sterilization, and counseling - using FDA approved methods As prescribed**
Breastfeeding support, supplies, and counseling In conjunction with each birth
Screening and counseling for interpersonal and domestic violence Annual

*The IOM report lists a number of services that are under the well-woman visit category. Many of the listed services are already part of the recommendations of the United States Preventive Services Task Force recommendations with an A or B rating.

**Under a revision to the July 2010 regulations that was issued on August 1, 2011, as well, group health plans sponsored by certain religious organizations, and group health insurance coverage in connection with such plans, are exempt from the requirement to cover contraceptive services.

Under the July 2010 regulations, plans may apply reasonable medical management techniques to determine coverage limitations. Thus, it appears that plans may require a mandatory generic provision for the oral contraceptive method. It also appears that plans would have to cover the "morning after pill" as an FDA-approved form of contraception. Medical management and legal interpretation will determine if that results in an additional office visit and/or urgent care with an emergency room visit.

Cheiron Observations: While it is clear that these expanded preventive care provisions will save money for impacted women using such services, the long- and short-term Plan Sponsor savings or costs of these new preventive care provisions will vary greatly depending upon:

  • the existing plan and current utilization levels,
  • the interpretation of the new regulations, and
  • the medical management of these expanded benefits.

Furthermore, because there can be no cost-sharing with respect to the listed services, health care providers may need to unbundle their charges to separately reflect the listed services. Historically, unbundling of services has increased costs.

Cheiron consultants can assist with the analysis of the effect of providing the listed services on your plan.


1The regulations were jointly issued by HHS, the Internal Revenue Service, and the Department of Labor (DOL) under the sections of law for which the agencies have responsibility.

 
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