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Health Reform: Implications for Women's Access to Coverage and Care

Table 1:  Adult Preventive Services Covered Without Cost Sharing in Private Plans
Cancer Chronic Conditions Immunizations Healthy Behaviors Pregnancy-Related** Reproductive Health
Breast Cancer
  • Mammography for women 40+*
  • Genetic (BRCA) screening and counseling
  • Preventive medication counseling
Cervical Cancer
  • Pap testing (women 21-65)
  • High-risk HPV DNA testing
Colorectal Cancer
  • One of the following: fecal occult blood testing, colonoscopy, sigmoidoscopy
Cardiovascular health
  • Hypertension screening
  • Lipid disorders screenings
  • Aspirin
Type 2 Diabetes screening
  • (adults w/ elevated blood pressure)
Depression screening
  • (adults, when follow up supports available)
Osteoporosis screening
  • (all women 65+, women 60+ at high risk)
Obesity
  • Screening
    (all adults)
  • Counseling and behavioral interventions (obese adults)
  • Td booster, Tdap
  • MMR 
  • Meningococcal
  • Hepatitis A, B
  • Pneumococcal
  • Zoster 
  • Influenza
  • Varicella
  • HPV (women 19-26 and men 19-21)
  • Alcohol misuse screening and counseling (all adults)
  • Intensive healthy diet counseling (adults w/high cholesterol, CVD risk factors, diet-related chronic disease)
  • Tobacco counseling and cessation interventions (all adults)
  • Interpersonal and domestic violence screening and counseling, (women 18-64)
  • Well-woman visits, (women 18-64)
Tobacco and cessation interventions
Alcohol misuse screening/counseling
Rh incompatibility screening
Gestational diabetes screenings
  • 24-28 weeks gestation
  • First prenatal visit (women at high risk for diabetes)
Screenings
  • Hepatitis B-
  • Chlamydia (<24,high risk)
  • Gonorrhea
  • Syphilis
  • Bacteriurea
Folic acid supplements (women w/repro capacity)
Iron deficiency anemia screening
Breastfeeding Supports
  • Counseling
  • Consultations with trained provider
  • Equipment rental
STI and HIV counseling (adults at high risk; all sexually-active women)
Screenings
  • Chlamydia (sexually active women <24, older women at high risk)
  • Gonorrhea (sexually active women at high risk)
  • Syphilis (adults at high risk)
  • HIV
Contraception***, (women w/repro capacity)
  • All FDA approved methods as prescribed
  • Sterilization procedures
  • Patient education and counseling

Notes:  Age ranges are meant to encompass the broadest range possible. Each service may only be covered for certain age groups or based on risk factors. For specific details on recommendations, please consult the websites listed below.
    *The ACA defines the recommendations of the USPSTF regarding breast cancer services to “the most current other than those issued in
      or around November 2009.” Thus, coverage for mammography is guided by the 2002 USPSTF guideline.
  **Services in this column apply to all pregnant or lactating women, unless otherwise specified.
***Certain religious employers exempt from this requirement. 
    Recommendation from HRSA Women’s Preventive Services. Coverage without cost sharing in “non grandfathered” plans began
       Aug. 1, 2012. Coverage without cost sharing for other services began Sep. 23, 2010.

Sources:  U.S. DHHS, “Recommended Preventive Services.” Available at http://www.healthcare.gov/center/regulations/prevention/recommendations.html

More information about each of the services in this table, including details on periodicity, risk factors, and specific test and procedures are available at the following websites:  USPSTF:  http://www.uspreventiveservicestaskforce.org/recommendations.htm

ACIP:  http://www.cdc.gov/vaccines/pubs/ACIP-list.htm#comp HRSA Women’s Preventive Services:  http://www.hrsa.gov/womensguidelines/

Table 2: Summary of Selected Coverage and Benefits Provisions Affecting Women in the Patient Protection and Affordable Care Act (P.L. 111-148)

Expanding coverage

  • States can extend Medicaid coverage to uninsured citizens with incomes less than 138% of federal poverty level ($26,951 for a family of three in 2013) but states are not required to expand Medicaid. Federal government bears full costs of expansion through 2016 and phases down to 90% by 2020.
  • Legal residents with incomes between 100% and 399% of poverty can purchase insurance through state exchanges and receive tax credits to subsidize premium costs. Uninsured with higher incomes also can purchase coverage but will not receive subsidies.
  • Tax credits for certain small employers who offer coverage. Larger employers (at least 50 employees) required to offer coverage to workers or pay a penalty beginning 2015.
  • U.S. citizens and legal residents required to have qualifying health coverage or pay a penalty.
  • Exemptions for financial hardship, religious objections, American Indians, those uninsured less than 3 months, undocumented immigrants, incarcerated individuals, if plan cost exceeds 8% of income, if income is below tax filing threshold.

Insurance reforms

  • Requires guarantee issue and renewability of policies (regardless of health status).
  • Prohibits higher premium charges based on gender, health status, or occupation; allows variations in premiums based on age (3 to 1) and tobacco use (1.5 to 1) only.
  • Bans pre-existing condition exclusions and prohibits annual and lifetime limits on coverage.

Benefits

  • Essential health benefits:  Requires new plans to offer minimum coverage, referred to as essential health benefits. This benefit package includes the following categories of services:  Ambulatory care, emergency services, hospitalization, maternity and newborn care, mental health and substance abuse disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services, and chronic disease management.
  • Preventive care:  Requires coverage and eliminates cost-sharing for U.S. Preventive Services Task Force (USPSTF) recommended services, Advisory Committee on Immunization Practices recommended immunizations and HRSA women’s preventive services in qualified health plans and Medicare. Financial incentives (no requirement) for Medicaid to cover these services without cost-sharing.
  • Maternity care:  Maternity and newborn care included as essential benefit in plans; requires Medicaid coverage of tobacco cessation supports for pregnant women; new grants to states for home visiting and postpartum depression services; new workplace protections for nursing mothers (break time and private space to express milk).
  • Family Planning and Teen Pregnancy Prevention:  Contraceptives included in HRSA women’s preventive services package, but exemption for houses of worship; states can establish Medicaid family planning programs without federal permission; provides $75 million/year to states for evidence based sex education programs; and restores $50 million/year for abstinence unless married educational programs.
  • Abortion:  Bans any federal subsidies from being used to purchase coverage for abortion beyond federal limits (to save the life of the woman and in cases of rape and incest);  At least one plan within a state exchange must limit abortion coverage to only those permitted by federal law; excluded from essential benefit list, and states can prohibit abortion coverage in their exchange; New state Pre-existing Condition Insurance Plans cannot cover abortions beyond those permitted by federal law.

Medicare

  • Eliminates cost-sharing for USPSTF recommended services; added personalized health plan benefit with an annual comprehensive risk assessment.
  • Enrollees received a $250 rebate if they had any spending in the coverage gap (doughnut hole) and will be eligible for a new phased in discount program to reduce costs of brand name and generic drugs. Reduces the prescription drug coinsurance rate to 25% of costs by 2020.

Women’s health

  • Codifies the establishment of Offices on Women’s Health in major federal agencies, including HHS, CDC, FDA, HRSA, and AHRQ; Establishes an HHS Coordinating Committee on Women’s Health and a National Women’s Health Information Center.
Issue Brief Appendix

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