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Women's Preventive Services

July 10, 2012

In accordance with the Patient Protection and Affordable Care Act (PPACA), non-grandfathered health plans will cover designated women’s preventive services without cost sharing for their members when the services are provided by a network provider. Cost sharing includes deductibles, copayments and coinsurance.

While the provision is effective August 1, 2012, it will generally phase in at the beginning of the next benefit period on or after August 1, 2012. This increased coverage applies to non-grandfathered individual policies and group health plans, whether fully insured or self-funded.

Covered Services:

Many of the screenings or services included in this provision would be provided during an annual well-woman visit. Some are already included in the existing PPACA preventive services requirements. We will cover these benefits and services with no cost sharing:

  • Well-woman visits
  • Gestational diabetes screening
  • Human papillomavirus (HPV) testing
  • HIV testing and counseling
  • Counseling for sexually transmitted diseases
  • Contraceptive methods and counseling
  • Breastfeeding support, supplies and counseling
  • Domestic violence screening and counseling

See the chart below for additional information. Please note that PPACA preventive services have certain restrictions. Some have frequency restrictions. Some are for pregnant women only or for women who are sexually active. Also, please keep in mind that a member may be billed for certain services if:

  • She receives care from an out-of-network provider.
  • The primary purpose of an office visit is not for the preventive service (cost sharing may be applied to the office visit).
  • Additional services are needed to treat conditions identified by the screening.
  • Office visits are billed independently of the preventive service.

 

Women’s Preventive Care Benefit
Description
Well-woman preventive care visits
Two per year; the member may receive care from her primary care physician and her OB-GYN. 
Gestational diabetes screening
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.
Lactation support/counseling and supplies
Support and counseling are generally included in the maternity office visits and hospitalization visits at time of birth.
 
We are covering the purchase of ONE breast pump per 12-month period. 
Counseling on sexually transmitted infections / Counseling and screening for HIV infection (for sexually active women)
Two per year; the member may receive care from her primary care physician and her OB-GYN. These are the standard Evaluation and Management (E&M) codes for preventive office visit, along with an appropriate preventive ICD-9 (diagnosis) code. 
Contraceptives, sterilization and patient education
Generic oral contraceptives are covered without cost-sharing; other oral contraceptives are covered as regular prescription benefits as shown on the member’s schedule.
 
Some non-oral contraceptives are covered without cost-sharing, but may be limited to specific brands or types, also shown in a member’s schedule.
 
Sterilization for a female member is covered without cost-sharing, as is patient education related to the use of contraceptives or sterilization.  
High-risk HPV DNA testing
Women ages 30 or older; limited to one every three years.
Screening and counseling for interpersonal and domestic violence
Two per year; the member may receive care from her primary care physician and her OB-GYN. 

 
For a full list of restrictions and guidelines, please visit: http://www.hrsa.gov/womensguidelines/.

 

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