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Women’s Access to Preventive Services Affirmed by HHS

For a PDF version of this factsheet, please see below.

On February 20, 2013, the Department of Health and Human Services released a set of Frequently Asked Questions which clarified many issues related to implementation of the Affordable Care Act’s preventive services requirement.  The FAQ is an important step towards ensuring that insurance plans and issuers implement the Women’s Preventive Health Services provision so that women get the comprehensive and affordable services guaranteed by the Affordable Care Act.  While the FAQ leaves some implementation questions unanswered, the National Women’s Law Center is pleased that the Department addressed several major issues to make sure that women have the coverage required by the law.  The charts below summarize implementation issues and how the FAQ responds to them.

General Issues

Issue FAQ
Can women get preventive services from an out-of-network provider? Yes, in some circumstances. For any preventive service, if the plan or issuer does not have a provider in its network who can provide that service, the plan cannot impose cost-sharing when a person accesses the service from an out-of-network provider. (see Question 3 of the FAQ)
Are over-the-counter products that are preventive services covered without cost sharing? Yes, in some circumstances. When an over-the-counter product is prescribed by a health care provider, it is covered without cost sharing. (see Question 4 of the FAQ) For an over-the-counter contraceptive method to receive the no cost sharing protection, it must be both FDA-approved and prescribed for a woman by her provider. Thus, over-the-counter methods that are prescribed are available without cost-sharing. (see Question 15 of the FAQ)

 

Specific Preventive Services

Issue FAQ
Does the no cost sharing requirement extend to the removal of a polyp during a colonoscopy if the colonoscopy is scheduled and performed as a screening procedure? Yes. Clinical practice and the opinion of multiple medical associations show that polyp removal is an integral part of a colonoscopy. Thus, when the procedure is performed for screening, polyp removal cannot have cost sharing. (see Question 5 of the FAQ)
Does the recommendation for genetic counseling and evaluation for routine breast cancer susceptibility gene (BRCA) testing include the BRCA test itself? Yes. The recommendation includes both genetic counseling and BRCA testing for a woman if determined appropriate by her health care provider. (see Question 6 of the FAQ)

 

Women's Preventive Services

Contraceptive Coverage

Issue FAQ
Are plans and issuers required to cover all contraceptive methods without cost sharing? Yes. The FAQ requires that women have access to the full range of FDA-approved contraceptive methods. This includes, but is not limited to, barrier methods, hormonal methods, and implanted devices, as well as patient education and counseling. Therefore, women should have coverage of all FDA-approved contraceptive methods, meaning a range of pills, the ring, the patch, the shot, implants, hormonal intrauterine devices, non-hormonal intrauterine devices, barrier methods, and sterilization procedures. (see Question 14 of the FAQ)
Are plans and issuers required to provide coverage of contraceptives other than the pill? Yes. Plans and issuers cannot limit their contraceptive coverage to only oral contraceptives. The HRSA Guidelines require women to have access to the full range of contraceptive methods. (see Question 14 of the FAQ) Additionally, FDA-approved intrauterine devices (IUDs) and implantable contraceptives, prescribed by a provider, are specifically required to be covered. (see Question 17 of the FAQ)
Are plans and issuers required to cover the specific contraceptive prescribed by a woman's health care provider? Yes, although plans and issuers have limited use of reasonable medical management techniques to control costs and promote efficient delivery of care. For example, if a provider prescribes a drug and there is a generic equivalent available, a plan or issuer may cover the generic without cost-sharing and impose cost-sharing on the branded drug. If a generic version is not available, then a plan or issuer must provide coverage for the brand name drug without cost-sharing. However, the plan must have a waiver process that enables the woman to access the branded drug without cost-sharing when a generic drug is available but her provider determines that the branded drug is medically appropriate for her. (see Question 14 of the FAQ)
Can plans and issuers use so-called "reasonable medical management techniques" to limit contraceptive coverage? Yes, in some circumstances. While the FAQ did not clarify the term "reasonable medical management techniques," it requires every plan and issuer to have a waiver process that would enable women to have access to the contraceptive method that her provider determines is medically appropriate for her needs, in consultation with the woman. This waiver process could override a "medical management technique." (see Question 14 of the FAQ)
Are contraceptives for men included in the preventive services? No. The FAQ states that contraceptives for men, such as condoms and vasectomies, are excluded from the HRSA Guidelines. (see Question 15, footnote 10 of the FAQ)
Will services related to the contraceptive coverage be covered? Such as to remove an IUD? Yes. All services related to follow-up and management of side effects, counseling for continued adherence, and device removal are part of the services included in the HRSA Guidelines. Therefore, all such services must be covered without cost-sharing. (see Question 16 of the FAQ)
Can plans and issuers place quantity limits on contraceptives of less than one year? Not addressed in FAQ.
How should plans and issuers update their coverage when new contraceptives are approved by the FDA? Not specifically addressed in the FAQ, but because plans and issuers have to cover the full range of FDA-approved contraceptives, newly approved products must be covered promptly.

 

Well-woman Visits

Issue FAQ
Will plans have to cover multiple well-woman visits without cost sharing each year? Yes. The Department acknowledged that it is sometimes necessary for a woman to have more than one well-woman visit to obtain all of the necessary preventive services, depending on her individual health status, needs, and other risk factors. If a woman's health care provider determines that more than one well-woman visit is necessary to meet her needs, then the plan must cover the additional visits without cost sharing. (see Question 10 of the FAQ)
What is included in a well-woman visit? Well-woman visits include the women's preventive services in the HRSA Guidelines, other preventive services in § 2713 of the Public Health Service Act, and preconception and prenatal care. Women should therefore have access to a wide range of clinical services, counseling, and education. (see Question 10 of the FAQ)

 

Breastfeeding Support, Supplies, and Counseling

Issue FAQ
Can women get coverage of lactation support, counseling, and equipment the entire time they breastfeed their child? Yes. The coverage without cost sharing lasts as long as the woman is breastfeeding her child. However, plans can use reasonable medical management techniques to determine the frequency, method, treatment, or setting for the preventive service. (see Question 20 of the FAQ)
How are lactation consultants reimbursed for services under the HRSA Guidelines? Unanswered. This is outside the scope of the HRSA Guidelines and the Department's regulations. (see Question 19 of the FAQ)

 

Screening and Counseling for Interpersonal and Domestic Violence

Issue FAQ
What must health care providers know to conduct "screening" for interpersonal and domestic violence? The screening can be a few, brief, open-ended questions and can use brochures and forms or other assessment tools. The Department referred providers to the CDC's Abuse Assessment Screening tool and the HHS-funded Domestic Violence Resource Network for resources. (see Question 11 of the FAQ)

 

HPV Testing

Issue FAQ
When should the high-risk HPV DNA test be administered to women? It should be administered to women who are 30 years of age or older and who have normal cytology results, but no more frequently than every three years. (see Question 12 of the FAQ)

 

Counseling and Screening for HIV

Issue FAQ
Does "screening" in this recommendation mean testing for HIV? Yes. All sexually active women will have coverage of annual counseling and testing for HIV. (see Question 13 of the FAQ)