Preventive Services in the Affordable Care Act
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1 Preventive Services in the Affordable Care Act
2 What You Will Learn Today The Affordable Care Act s requirement about the coverage of many preventive services at no additional cost. When health plans have to provide this coverage. Which preventive services must be covered. What to do if a plan is not providing this coverage. Resources from the National Women s Law Center to help understand the requirement and to assist in making plans comply.
3 A Health Care System that Promotes Better Health Increase Access to and Use of Preventive Services Key ACA Provisions Investing in proven community-based prevention programs Increasing federal support for preventive services covered through Medicare and Medicaid Increasing public payments to primary care providers Improving access to public and private coverage including preventive care Requiring coverage of preventive services with no cost sharing
4 Affordable Care Act Requirement Plans must cover, without cost sharing: 1) Preventive services based on recommendations from the United States Preventive Services Task Force 2) Certain immunizations 3) Preventive services for infants, children, and teens 4) Certain preventive services for women
5 Which Plans Must Cover Preventive Services? Private Health Plans That Are Not Grandfathered Both Fully-insured and Self-funded Plans Exception: Self-Funded Student Health Plans Coverage through the Medicaid Expansion After Jan. 1, 2014, in states that have accepted federal funds to expand coverage NOTE: current Medicaid programs do not have to comply
6 What Cost Sharing Is Prohibited? Cost sharing requirements are defined by the ACA to include: Co-payments Co-insurance Deductibles
7 Some Key USPSTF Recommendations for Women Mammograms for women over 40* Cervical cancer screening (women 21-65, every 3 years) Colonoscopy (ages 50-75) Smoking and alcohol cessation programs Diabetes screening and counseling Blood pressure screening and counseling Depression screening for adolescents and adults And more *USPSTF recommends mammograms for women over 50, but the ACA requires coverage without cost sharing for women over 40
8 Women s Preventive Services Guidelines Breastfeeding support, supplies, and counseling Screening and counseling for interpersonal and domestic violence Screening for gestational diabetes DNA testing for high-risk strains of HPV Counseling regarding sexually transmitted infections, including HIV Screening for HIV All FDA approved contraceptive methods, sterilization procedures and counseling Well Woman Visits
9 Details of Required Coverage Plans can charge for out-of-network services, unless there is no innetwork provider Colonoscopy: includes polyp removal during screening procedure Genetic counseling and evaluation for BRCA gene includes BRCA testing, for women with a family history of breast cancer Screening for HIV means testing More than one well woman visit per year may be necessary based on a woman s health needs and must be covered without cost sharing Pre-natal visits are considered well-woman visits Coverage of breastfeeding equipment and counseling lasts as long as the woman breastfeeds her child.
10 Details of Required Contraceptive Coverage All methods must be covered; plans cannot limit coverage to pills. If a generic version is available, the plan can charge for the brand version. If there is no generic version, the brand version must be covered. Plans must have a waiver process to allow women to access medically appropriate contraceptives without cost sharing. Services related to the contraceptive are covered without cost sharing (like insertion, follow-up, and removal) Over-the-counter products require a prescription to be covered without cost sharing
11 Contraceptive Coverage Accommodation for Certain Employers Religious entities exempted (e.g., churches and other houses of worship) Some non-profit entities are accommodated (i.e. contraceptives paid for by a third party) Non-profit must hold itself out as religious and oppose some or all contraceptives based on religious standards. Non-profit must self-certify to this For-profit entities must comply with the contraceptive coverage requirement
12 What If Someone Isn t Getting Coverage? If the answer to either of these questions is yes, the ACA s coverage requirement does not yet apply: 1) Is she in a public insurance program? 2) Is the plan grandfathered?
13 If the Plan Charges Cost Sharing, What Do You Do? 1) Contact the insurer 2) Appeal the coverage denial 3) If the plan still does not comply, you can go to: State insurance commissioner U.S. Department of Labor (if plan is self-funded) Additional options
14 NWLC Resources Preventive Services Toolkit Assistance calling your plan about grandfathered status Template letters to appeal common coverage problems Hotline for Additional Help PILL4US
15 For more information visit: Contact: Karen Davenport Sharon Levin Our Preventive Services Hotline: PILL4US or
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Qualified High Deductible Health Plan PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $6,600 Individual $20,000 Individual $13,200 Family $40,000 Family All covered expenses accumulate simultaneously toward both the
Covered 100%; deductible waived 40%; after deductible
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $500 Individual $1,000 Individual $1,500 Family $3,000 Family All covered expenses accumulate simultaneously toward both the preferred
Covered 100%; deductible waived 35%; after deductible
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible $300 Individual $1,000 Individual $600 Family $2,000 Family All covered expenses accumulate simultaneously toward both the preferred and non-preferred
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