The Affordable Care Act (ACA) recognizes that preventive health services in general, and women?s preventive health services in particular, are critical to individual and community health, and that cost is often a barrier to accessing needed preventive care. In addition to the Essential Health Benefits requirement to cover maternity care and preventive services, the ACA adds § 2713(a)(4) to the Public Health Service Act (the Women’s Health Amendment) to require coverage of women’s health preventive services, including prenatal care, without cost sharing.
The ACA Requires Coverage of Preventive Services for Women
Most new health plans and health insurance issuers, operating inside and outside of
state health insurance Exchanges, must cover the following preventive services without
cost-sharing:[1]
- Items or services that have a rating of A or B in the recommendations of the U.S. Preventive Services Task Force,
- The Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (ACIP) recommended vaccinations,
- Preventive care and screenings for infants, children, and adolescents, as provided for in guidelines supported by the Health Resources and Services Administration (HRSA),
- Additional women’s health preventive care and screenings, to fill in the gaps and supplement the U.S. Preventive Services Task Force recommendations, and as provided for in guidelines supported by HRSA’s the Women’s Health Amendment.[2]
The Women’s Health Amendment
To implement the Women’s Health Amendment, HRSA commissioned the independent Institute of Medicine of the National Academies (IOM) to conduct a scientific review and provide recommendations on specific preventive measures that meet women?s unique health needs and help keep women healthy. The IOM identified eight women’s health preventive services. HRSA adopted all eight of those IOM recommendations and issued “Women’s Preventive Services: Required Health Plan Coverage Guidelines” (the Guidelines).[3] As a consequence, well-woman visit(s) are a type of preventive service that health plans must cover without cost-sharing.[4]
Well-Woman Visits Include Prenatal Care
The Guidelines define a “well-woman preventive care visit” as a: . . . 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 section 2713.[5]
The Guidelines refer to the IOM report for further clarification about what services a woman may receive during a well-woman preventive service visit. With regard to prenatal care, the IOM report provides that:
The recommended content of the [well-woman prenatal care] visit includes specific tests and procedures (e.g., blood pressure, weight, urine test, uterine size and fetal heart rate assessment, glucose tolerance testing, and screening for specific sexually transmitted infections and genetic or developmental conditions), as well as topics for counseling and guidance (e.g., tobacco avoidance and nutrition).[6]
Frequency of Well-Woman Visits
The Guidelines clarify that[the U.S. Department of Health and Human Services] recognizes that several visits per year may be needed to obtain all necessary recommended preventive services, depending on a woman’s health status, health needs, and other risk factors.[7] This provision explicitly incorporates by reference the IOM report, which states that “women with high-risk pregnancies may need more frequent visits [than women with uncomplicated pregnancies,]” and “that pregnant women are likely to make more well-woman preventive care visits than non-pregnant women.”[8]
The U.S. Departments of Labor, Health and Human Services, and the Treasury’s Frequently Asked Questions about implementation of various provisions of the ACA further confirms that insurers must cover as many well-woman visits as a woman’s provider determines are medically appropriate without cost-sharing.[9]
——————————————–
[1] Patient Protection and Affordable Care Act (ACA), Pub. L. No. 111-148, 124 Stat. 119 (2010), amended by Health Care and Education Reconciliation Act, Pub. L. No. 111-152, 124 Stat. 1029 (2010), § 1001, 42 U.S.C. § 300gg-13 (amending § 2713 of the Public Health Services Act).
[2] Id.2
[3] U.S. Dep’t of Health & Human Servs., Health Res. & Servs. Admin., Women’s Preventive Services: Required Health Plan Coverage Guidelines, http://www.hrsa.gov/womensguidelines.
[4] Id.
[5] Id.
[6] Inst. of Medicine of the Nat’l Academies, Clinical Preventive Services for Women: Closing the Gaps 133
(2011), www.iom.edu/~/media/Files/Report%20Files/2011/Clinical-Preventive-Services-for-WomenClosing-the- Gaps/preventiveservicesforwomenreportbrief_updated2.pdf.
[7] Id.
[8] Id.
[9] U.S. Dep’t of Labor, Employee Benefits Sec. Admin., FAQs about Affordable Care Act Implementation
Part XII (Feb. 20, 2013), http://www.dol.gov/ebsa/faqs/faq-aca12.html#5.
