PPACA Update : Expanded Preventive Services for Women

August 2011

Section 2713 of the Public Health Service Act (“PHSA”), adopted as part of the Patient Protection and Affordable Care Act (“PPACA”), requires health plans and health insurance issuers to cover a lengthy list of preventive services with no cost sharing. These rules apply only to non-grandfathered plans and policies. One of the categories of preventive services to be covered is preventive services and screenings for women based on guidelines issued by the Health Resources and Services Administration (HRSA), an agency of HHS. When the PPACA was enacted in March 2010 and the interim final rules were issued in July, 2010, no such guidelines existed.

On August 1, 2011, new guidelines were issued by HRSA, which will require health plans and health insurance issuers to cover additional preventive services for women with no co-pay or other cost sharing. The HRSA guidelines were recommended by the independent Institute of Medicine and based on scientific evidence.

The additional preventive services are:

1. Well-woman visits - annually;
2. 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;
3. Human papillomavirus (HPV) DNA testing - every 3 years beginning at age 30;
4. Counseling for sexually transmitted infections - annually;
5. Counseling and screening for human immune-deficiency virus (HIV) - annually;
6. FDA-approved contraceptive methods, sterilization procedures and patient education and counseling - as prescribed;
7. Breastfeeding support, supplies and counseling - in conjunction with each birth; and
8. Screening and counseling for interpersonal and domestic violence - annually.

The Department of Health and Human Services simultaneously published an amendment to the July 2010 interim final rules allowing HRSA to adopt an exemption to the guidelines so that a religious employer may choose not to cover contraceptives. In its guidelines, HRSA adopted such an exemption with respect to group health plans sponsored by religious employers, and group health insurance coverage in connection with such plans. The exemption does not apply to an individual health insurance policy.

The new HRSA guidelines are effective August 1, 2011. Under PHSA Section 2713(b), there is a one-year delay before any new preventive service guidelines are required to be covered. Accordingly, nongrandfathered plans and policies must cover the expanded preventive services for women, with no cost sharing, in the first plan year (in the individual market, policy year) that begins on or after August 1, 2012. For calendar year plans, the effective date will be January 1, 2013.

Neither HHS nor HRSA provided an estimate of the increased costs that a group health plan or health insurance issuer will experience as a result of the expanded preventive services for women. The website www.healthcare.gov notes that the rules governing coverage of preventive services, which allow plans to use reasonable medical management to help define the nature of the covered service, will apply to women’s preventive services.

IF YOU HAVE ANY QUESTIONS ABOUT THE NEW RULES, PLEASE CONTACT:

Cynthia A. Moore a member and Practice Department
Manager: Employee Benefits, Estate Planning, Gaming,
Health Care, Immigration, and Tax in Dickinson Wright’s
Troy office and can be reached at 248.433.7295 or
cmoore@dickinsonwright.com.

Deborah L. Grace, is a member in Dickinson Wright’s
Troy office and can be reached at 248.433.7217 or
dgrace@dickinsonwright.com.