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FAQ: No-Cost Preventive Services for Women

Reading the Fine Print on the No Copay Regulation

Elizabeth Rich explains how to find out if and when the Affordable Care Act’s promise of no-cost coverage for women’s preventive services will apply to you.

One way women benefit from the Affordable Care Act is through a regulation guaranteeing coverage for women’s preventive services without cost sharing. These services include annual well-woman visits; gestational diabetes screenings; testing for human papillomavirus; counseling for sexually transmitted infections; screening and counseling for HIV; contraception methods and counseling; breastfeeding support, supplies, and counseling; and screening and counseling for domestic and interpersonal violence.

The regulation went into effect on August 1, 2012, but there are important details about the regulation that many people do not know about. Below, we help you figure out if you are eligible for these benefits.

Q: Which plans must comply with this regulation?

This regulation applies to private, nongrandfathered health insurance plans. Private insurance plans include individual and most group insurance policies, insurance plans purchased by students at most colleges and universities, and plans in the Federal Employee Health Benefits program. The regulation does not apply to Medicaid, Medicare, the military health care plan known as TRICARE, or other government health insurance programs.

Q: What is a grandfathered plan?

A grandfathered plan is one that was in existence as of March 23, 2010, when the Affordable Care Act was enacted. In order to retain grandfathered status, plans must not have made any major coverage changes since March 23, 2010. Examples of major changes include:

  • Reducing how much of the premium one’s employer pays by more than 5 percentage points
  • Increasing the deductibles patients pay before their coverage begins “by more than the cumulative growth in medical inflation since March 23, 2010 plus 15 percentage points”
  • No longer providing benefits for diagnosing or treating a particular condition

Q: When will the benefits begin?

The benefits will begin when the next plan year starts or renews—in August for most student plans and in January for most employer-sponsored plans.

Q: What if I receive health insurance from a religious institution?

Houses of worship are entirely exempt from covering contraception under the regulation. In addition, religiously affiliated nonprofit organizations that object to contraception may opt for a one-year waiver to avoid compliance with the regulation until August 1, 2013. After that point, enrollees will receive their contraceptive benefits without cost sharing directly from the insurance company whenever their next plan year begins. All religious institutions will still have to comply with the no-cost coverage requirement for all other noncontraceptive preventive services under the rule.

Q: How do I know if my plan must cover these services with no cost sharing?

To find out whether your plan is required to comply with the regulation, you can follow these instructions from the National Women’s Law Center regarding potential questions to ask your insurance company.

Q: If my plan is required to comply with the regulation, will it be required to cover every brand of birth control?

No. The Department of Health and Human Services said that health insurance plans will be allowed to “use reasonable medical management to help define the nature of the covered service[s],” meaning that although insurance plans are required to cover every type of contraceptive method, they might not cover every brand. Thus, as a cost-containment measure, insurers will be allowed to charge patients for brand-name drugs, while only being required to cover medically equivalent generic drugs without cost sharing. Plans, however, will have to waive the cost-sharing fee for brand-name products for those beneficiaries for whom generic versions are medically inappropriate.

Q: Will men have coverage for preventive sexual health services without cost sharing?

In addition to the rule that went into effect on August 1 this year that requires coverage for services recommended specifically for women, plans must also cover HIV screenings, sexually transmitted infection prevention counseling, and syphilis screenings for all adults at higher risk. These services were covered under the original preventive services rule in the law and were required to be covered without cost sharing for new health insurance policies beginning on or after September 23, 2010.

Q: Will this requirement raise my insurance premiums?

According to the Kaiser Family Foundation, the effect of the preventive services requirement on insurance premiums will vary “from state to state and plan to plan, as some plans already cover many preventive services and several states already have laws mandating coverage for insured plans.” Not only will one’s state and insurance plan influence whether premiums rise but so will what services a person uses and whether those services effectively reduce future medical conditions.

The Affordable Care Act includes a number of provisions, however, intended to curb premium costs and ensure more value for every premium dollar spent. State health insurance exchanges will only allow entry to low-cost, high-quality plans. Medicare beneficiaries will benefit from the Independent Payment Advisory Board, which will contain growth in Medicare costs. Health insurers are required to justify rate increases of 10 percent or more. And gender rating—the practice of charging women higher premiums than men for the same benefits—will be prohibited starting in 2014.

Elizabeth Rich is an Intern with the Women’s Health and Rights program at the Center for American Progress. The author would like to thank CAP Health Policy Analyst Emily Oshima for her research contributions.

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