For a PDF version of this FAQ with footnotes, please see below.
The health care law makes preventive care more accessible and affordable to millions of Americans. This is especially important to women, who are more likely than men to go without necessary health care, including preventive care, because of cost. To help address these cost barriers and make sure all women have access to preventive health care, the health care law requires all new and non-grandfathered private insurance plans to cover a wide range of preventive services without co-payments or other cost sharing requirements.
I heard about this new law that requires health plans to cover preventive care like mammograms and contraceptives. What is it and what does it require?
The health care law (the Affordable Care Act) requires certain preventive health services and screenings to be covered in all new health insurance plans without cost sharing. This means that, for these services, you will not be charged a co-payment or co-insurance for the services, nor will you need to pay out-of-pocket if you have not yet met your deductible.
What are the Women’s Preventive Services that began on August 1, 2012?
As of August 1, 2012, all new health plans must cover a range of women’s preventive services without cost sharing. These services have been identified by the Institute of Medicine and endorsed by the Health Resources and Services Administration. They include:
(1) Breastfeeding support, supplies, and counseling;
(2) Screening and counseling for interpersonal and domestic violence;
(3) Screening for gestational diabetes;
(4) DNA testing for high-risk strains of HPV;
(5) Counseling regarding sexually transmitted infections, including HIV;
(6) Screening for HIV;
(7) Contraceptive methods and counseling; and
What other preventive services are already covered under the law?
All new health insurance plans must cover, without cost-sharing, preventive services derived from four sets of expert recommendations: (1) services given an “A” or “B” recommended by the U.S. Preventive Services Task Force; (2) all vaccinations recommended by the Center for Disease Control’s Advisory Committee on Immunization Practices; (3) a set of evidence-based services for infants, children, and adolescents based on guidelines developed by the American Academy of Pediatrics and the Department of Health and Human Services; and (4) as noted above, a set of additional evidence-based preventive services for women recommended by the Institute of Medicine and supported by the Health Resources and Services Administration.
The U.S. Preventive Services Task Force recommendations include a number of preventive services that are of critical importance for women, including:
(1) Mammograms every 1-2 years for women over 40;
(2) Cervical cancer screening;
(3) Smoking and alcohol cessation programs for adults;
(4) A wide range of prenatal screenings and tests;
(5) Diabetes and blood pressure screening and counseling; and
(6) Depression screening for adolescents and adults.
The Advisory Committee on Immunization Practices includes a number of vaccines important to women, including vaccines for HPV, the flu, and Hepatitis, among others.
Does this mean I won’t have to pay anything for preventive services?
You will be able to get the included preventive services with no co-pay. While some plans previously covered preventive services with no cost sharing requirements, many only paid a portion of the cost, while the patient would have to pay a co-payment or co-insurance. Now, the full range of services will be fully covered by insurance plans and you will not need to make a separate payment to your doctor or pharmacy.
Won’t this make my monthly premiums go up?
While we can’t say for certain, it is unlikely. There is significant evidence that many of the preventive services included on this list, such as tobacco cessation, obesity reduction services, immunizations and contraceptives, are cost-saving.
When do these new requirements take effect?
MMany private insurance plans are already required to provide some of the preventive services without cost sharing—those recommended by the U.S. Preventive Services Task Force, the Advisory Committee on Immunization Practices, and the American Academy of Pediatrics. All new plans are required to cover the additional Women’s Preventive Services beginning August 1, 2012, but since most plan changes take effect at the beginning of a new plan year, the requirements will be in effect for most plans on January 1, 2013. School health plans should already be providing coverage, since most begin their health plan years around the beginning of the school year.
I get health insurance through my employer, how do I know if my plan is new and if these requirements apply to my plan?
Health plans that existed before the health care law are considered “grandfathered” into the new system. Grandfathered plans don’t have to follow the new preventive services coverage rules. This means that the plan can continue to operate just as it has until it makes significant changes to the plan. These changes include: cutting benefits significantly; increasing co-insurance, co-payments, or deductibles or out-of-pocket limits by certain amounts; decreasing premium contributions by more than 5%; or, adding or lowering annual limits.
Un-grandfathered plans are group health plans created after March 23, 2010, group health plans that have implemented significant changes, or individual plans purchased after that date, which is when the health care law was signed by the President. All un-grandfathered private health plans have to follow the new preventive health services coverage and cost-sharing rules. When you hear that “all new health plans” have to cover these services, it means that all “un-grandfathered” plans must cover them.
Will my plan ever become “un-grandfathered” and have to follow the new rule?
Yes. A survey found that 90% of all large U.S. companies expect that their health plans will lose grandfathered status by 2014. Eventually all plans will lose their grandfathered status and distinctions between the two types of plans will disappear. At that point, all plans will cover these important preventive health services without cost sharing.
What about women on Medicaid?
Many states already cover a wide range of preventive services for Medicaid recipients with nominal or no co-pays. While existing Medicaid plans won’t be required to cover these services without co-payments, the health care reform law provides a financial incentive for states to do so. The health care law also expands the group of people who are eligible for Medicaid and requires that this new group of Medicaid enrollees have access to the preventive health services, including the full range of contraceptive coverage, without cost sharing. This means that some women on Medicaid in some states may have access to these benefits, but women in other states may not.
What about women who are students and enrolled in a student health plan?
The new provisions apply to both group and individual health insurance. Student health plans are considered a type of individual health insurance, and therefore must generally comply with the preventive health services requirement and cover these services without cost-sharing. However, if you joined your student health plan before enactment of the Affordable Care Act (March 23, 2010) it may still be grandfathered and therefore need not comply with this requirement. Other plans excepted from this requirement are self-funded student health plans.
I’ve heard about something called the essential health benefits. How are they different from this preventive health services requirement?
Under the health care law, health plans in the individual and small group markers will be required to provide coverage for 10 categories of care, such as maternity and newborn care, and rehabilitative and habilitative care, which the law calls “essential health benefits.” Because all of these plans will cover services in these 10 categories, consumers can be sure that the plan they choose will at least provide this minimum coverage and it will be easier for consumers to compare plans. The Administration has made clear that the preventive services that require coverage without cost sharing are part of the essential health benefits category referred to as “preventive and wellness services and chronic disease management.”
If you feel you are not receiving the women’s preventive health services benefits to which you are entitled, contact the National Women’s Law Center at 1-866-PILL4US or pill4us@nwlc.org.
