Insurance coverage of women’s health services to be expanded: End in sight for contraceptive co-pays
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* Donya Currie

In a major step toward recognizing the value of prevention, women’s health services such as contraception, domestic violence counseling and cervical cancer screening will be covered by health insurance plans without co-pays, the U.S. Department of Health and Human Services announced in August.

Adopted as part of the Affordable Care Act, the new guidelines for health insurance plans are geared toward closing gaps in existing preventive services for women. New health plans will be required to cover the benefits as of August 2012.

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/41/7/1.3/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/41/7/1.3/F1)

The new prevention guidelines were based on a report from an Institute of Medicine committee, which was charged with identifying gaps in women’s preventive services. New insurance plans must provide the services without co-pay by August 2012.

Photo by Jose Girarte, courtesy iStockphoto

“These historic guidelines are based on science and existing literature and will help ensure women get the preventive health benefits they need,” Health and Human Services Secretary Kathleen Sebelius said.

The move to cover contraception without co-pays was widely praised by health advocates and heralded as a way to reduce the nation’s unintended pregnancy rate, which stands at about 50 percent. The guidelines specify that women have access without co-pay to all U.S. Food and Drug Administration-approved contraception, including sterilization procedures. HHS also released a rule, now open for comment, that exempts religion-based employers from providing coverage for contraceptive services.

“Too many times, I have seen women who became pregnant when they didn’t want to because their insurance failed them — by limiting them to contraceptives that weren’t right for them or refusing to pay for any form of birth control,” said Nancy Stanwood, MD, MPH, secretary of the board of directors for Physicians for Reproductive Choice and Health, in a statement praising the new contraceptive guidelines.

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[Figure2](http://www.thenationshealth.org/content/41/7/1.3/F2)

Nurse midwife Kate Curtis performs an ultrasound on a pregnant patient at a Washington, D.C., health center in 2007. New federal guidelines state that health insurance must cover preconception and prenatal care as part of wellness visits.

Photo by Susan Biddle, courtesy The Washington Post/Getty Images

Besides contraception, the guidelines require health plans to cover without co-pay an annual “well-woman” visit that provides preventive services, including preconception and prenatal care; screening for gestational diabetes; and DNA human papillomavirus screening. Other new requirements call for coverage of counseling for sexually transmitted infections as well as screening and counseling for domestic violence and HIV.

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[Figure3](http://www.thenationshealth.org/content/41/7/1.3/F3)

The new federal guidelines require health plans to cover without co-pay an annual “well-woman” visit that provides developmentally and age-appropriate preventive services.

Photo by Nicholas Monu, courtesy iStockphoto

While the Affordable Care Act already addressed breastfeeding when it was passed, requiring employers to provide breaks and lactation areas for nursing mothers, the new guidelines further that progress, requiring coverage of lactation support and counseling as well as costs for breastfeeding equipment.

Health insurance plans that are grandfathered are not affected by the new guidelines, but may choose to adopt them. Grandfathered plans are those that were created or purchased on or before March 23, 2010, when the Affordable Care Act was signed into law. Most health plans are expected to lose their grandfather status over time, according to HHS.

The new guidelines are based on recommendations of an Institute of Medicine committee, which released a report on women’s preventive services in July. Created at the request of HHS, the report examined women’s preventive services covered under the Affordable Care Act and determined whether the list was incomplete.

“Our charge, very specifically, was to look at the evidence on whether services work or not,” said APHA member Linda Rosenstock, MD, MPH, chair of the report’s authoring committee and dean of the University of California, Los Angeles, School of Public Health. “We do approach this task, and so does the Affordable Care Act, that where you’re successful with prevention, that’s a very cost-effective tool.”

Following the report release, APHA Executive Director Georges Benjamin, MD, FACP, FACEP (E), sent a letter to Sebelius “in strong support” of the report and urged HHS to adopt the evidence-based recommendations.

“This will, hopefully, at least result in the removal of some financial barriers to preventive services for individuals,” APHA member Alina Salganicoff, PhD, a member of the report’s authoring committee and vice president and director of women’s health policy for the Henry J. Kaiser Family Foundation, told *The Nation’s Health*.

Salganicoff said numerous studies have shown co-pays and other costs hinder preventive care, especially for people with low incomes.

“It is a new direction for the whole idea of prevention,” committee member Al Berg, MD, MPH, professor in the Department of Family Medicine at the University of Washington, told *The Nation’s Health*. “It has major implications for health and public health.”

As the committee conducted a thorough review of scientific evidence linking preventive services with outcomes, members also held public hearings allowing for input. After many months of public testimony, particularly on the issue of contraception, the deciding factor in the report’s recommendations, Salganicoff said, was science.

“At the end of the day, what we did was, we considered the suggestions, but we actually went to the research and looked at the evidence,” she said. “And that was our charge.And we looked at many issues that we ultimately didn’t end up recommending either because there was no evidence or because we felt the issues were important to men and women but were not exclusively a women’s concern.”

For example, there is proven evidence that preventive oral health care is effective, but that is true for both sexes, she said.

APHA member Cindy Pearson, executive director of the National Women’s Health Network, was one of many health advocates who testified to the report’s authoring committee about the importance of evidence-based preventive services recommendations. She said she was pleased with the results.

“They really did what they were asked to and looked at the science, and we were delighted with what they came up with,” Pearson said.

Judy Waxman, JD, vice president for health and reproductive rights for the National Women’s Law Center, said the federal health reform law’s prevention focus has paved the way for an important shift in health care.

“The statute itself, the fact that the Affordable Care Act had this provision that acknowledged that women’s preventive health needs should be specifically examined, was sort of amazing in and of itself and really groundbreaking in and of itself because we know historically that lots of health care has really been built on the male model,” Waxman told *The Nation’s Health*. “The fact that the law has a provision that says there needs to be a specific look at what women need and isn’t covered, that was really groundbreaking.”

In addition to making specific recommendations on preventive health services for women, the report also calls for a process by which such recommendations can be developed in the future to keep pace with medical advances.

“In the long run, having a way to update recommendations and keep track of science is really the way to go,” Berg said.

The committee recommended a federally sponsored prevention commission and also said such a body could focus on updating recommendations not only for women but also men, children and adolescents.

For more information on the new guidelines, visit [www.hrsa.gov/womensguidelines](http://www.hrsa.gov/womensguidelines).

To download a copy of the full Institute of Medicine report, “Clinical Preventive Services for Women: Closing the Gap,” visit [www.iom.edu](http://www.iom.edu).

*   Copyright The Nation’s Health, American Public Health Association