COMPLIANCE ALERT
New Guidance Expands ACA-Approved List of Women & Children’s No-Cost, Preventive Services
Quick Facts
- The Affordable Care Act (ACA) provides 58 million women and 37 million children access to preventive services with no cost-sharing.
- Additions to the list of covered preventive screenings aim to further reduce out-of-pocket expenses for women, infants, children and adolescents.
- Updates to preventive services include coverage for breast pumps and lowering the age for at-risk teens to 13 years of age for Human Immunodeficiency Virus (HIV) screening.
- The new guidelines take effect for plans starting in 2023.
Background
Under the ACA which was signed into law in March 2010, certain preventive services and screenings covered by non-grandfathered health plans are available without a copay, deductible, or coinsurance.
The list of preventive items includes:
- Mammograms
- Screenings
- Contraceptives
- Immunizations
New Additions
Recent updates from the Health Resources and Service Administration (HRSA) results in a more comprehensive list of preventive and screening guidelines for women and children, the Department of Health and Human Services (HHS) announced on December 30, 2021. The additions, including for the first time, a requirement for certain group health plans to cover double electric breast pumps, increase the number of preventive services available to women and children with no cost-sharing. The new guidelines take effect for plans starting on or after December 30, 2022, and are updated periodically as specified by the HRSA, the United States Preventive Services Task Force (USPSTF) and the Centers for Disease Control and Prevention (CDC). Health plans generally must cover the preventive service on the first day of the new plan year following the date the guideline was put into place.
New Guidelines for Children
The Bright Futures Program was launched by the HRSA in 1990 to design the most modern efficient and comprehensive pediatric checkups for the nation’s infants, children and adolescents. Their recommendations are included in the ACA no-cost preventive care and screenings guidelines.
Additional program objectives include:
- Reviewing new scientific evidence on an ongoing basis and annually publishing relevant updates to Bright Futures periodicity schedule and related resources.
- Ensuring that accredited pediatric residency programs integrate Bright Futures Guidelines within training.
- Training practicing primary care clinicians on the use of Bright Futures Guidelines and resources within clinical preventive services.
- Providing annual training for each of the maternal and child health (MCH) programs on the use of Bright Futures resources.
- Providing families with Bright Futures resources to help them prepare for preventive checkup visits with their primary care clinician.
The main component of Bright Futures is the Periodicity Schedule which recommends services that should be offered at every well-child visit from birth to age 21.
Examples recommended at each visit include:
- Questions about emotional and physical development
- Performing a physical examination and tracking physical growth and development
- Providing recommended immunizations
- Sharing guidance to help children and adolescents stay healthy
As part of the ACA, all non-grandfathered group health plans and health insurance issuers offering group health insurance coverage must cover the services and screenings listed on the current Bright Futures Periodicity Schedule.
The latest updates to the Periodicity Schedule include:
| Two existing category updates: |
| Add screening for suicide risk for ages 12-21 to the current Depression Screening category. |
| Change the Psychosocial/Behavioral Assessment to the Behavioral/Social/Emotional Screening for newborns to 21-year-olds. |
| Two new categories: |
| An assessment for risks for cardiac arrest or death in ages 11-21 years. |
| An assessment for hepatitis B virus infection in newborns to 21-year-olds. |
| Two clarifying references on: |
| Dental fluoride varnish. |
| Fluoride supplementation. |
NOTE: Read the Bright Futures Pocket Guide providing guidelines for Health Supervision of Infants, Children and Adolescents.
Guidelines for Women’s Preventive Care and Screenings
Women’s Preventive Services (WPS) Guidelines were originally established in 2011 based on recommendations from a Department of Health and Human Services’ commissioned study.
The new guidelines, as approved by the HRSA, provide updates to five existing preventive services for women and will go into effect for plan years starting on or after December 30, 2022.
See how the list compares to existing guidelines:
| Type of Preventive Service | Updated Guidelines Beginning with Plan Years Starting in 2023 |
|---|---|
| Obesity Prevention in Midlife Women | Recommends counseling midlife women aged 40 to 60 years with normal or overweight body mass index (BMI) (18.5-29.9 kg/m2) to maintain weight or limit weight gain to prevent obesity. Counseling may include individualized discussion of healthy eating and physical activity. |
| Breastfeeding Services and Supplies | Recommends comprehensive lactation support services (including consultation; counseling; education by clinicians and peer support services; and breastfeeding equipment and supplies) during the antenatal, perinatal, and postpartum periods to optimize the successful initiation and maintenance of breastfeeding. Breastfeeding equipment and supplies include, but are not limited to, double electric breast pumps (including pump parts and maintenance) and breast milk storage supplies. Access to double electric pumps should be a priority to optimize breastfeeding and should not be predicated on prior failure of a manual pump. Breastfeeding equipment may also include equipment and supplies as clinically indicated to support dyads with breastfeeding difficulties and those who need additional services. |
| Contraception | Recommends that adolescent and adult women have access to the full range of contraceptives and contraceptive care to prevent unintended pregnancies and improve birth outcomes. Contraceptive care includes screening, education, counseling, and provision of contraceptives (including in the immediate postpartum period). Contraceptive care also includes follow-up care (e.g., management, evaluation and changes, including the removal, continuation and discontinuation of contraceptives). Recommends that the full range of U.S. Food and Drug Administration (FDA)- approved, -granted, or -cleared contraceptives, effective family planning practices, and sterilization procedures are available as part of contraceptive care. The full range of contraceptives includes those currently listed in the FDA’s Birth Control Guide****: (1) sterilization surgery for women, (2) implantable rods, (3) copper intrauterine devices, (4) intrauterine devices with progestin (all durations and doses), (5) injectable contraceptives, (6) oral contraceptives (combined pill), (7) oral contraceptives (progestin only), (8) oral contraceptives (extended or continuous use), (9) the contraceptive patch, (10) vaginal contraceptive rings, (11) diaphragms, (12) contraceptive sponges, (13) cervical caps, (14) condoms, (15) spermicides, (16) emergency contraception (levonorgestrel), and (17) emergency contraception (ulipristal acetate), and any additional contraceptives approved, granted, or cleared by the FDA. |
| Counseling for Sexually Transmitted Infections (STIs) | Recommends directed behavioral counseling by a healthcare clinician or other appropriately trained individual for sexually active adolescent and adult women at an increased risk for STIs. The Women’s Preventive Services Initiative (WPSI) recommends that clinicians review a woman’s sexual history and risk factors to help identify those at an increased risk of STIs. Risk factors include, but are not limited to, age younger than 25, a recent history of an STI, a new sex partner, multiple partners, a partner with concurrent partners, a partner with an STI, and a lack of or inconsistent condom use. For adolescents and women not identified as high risk, counseling to reduce the risk of STIs should be considered, as determined by clinical judgment. |
| Screening for Human Immunodeficiency Virus Infection (HIV) | Recommends all adolescent and adult women, ages 15 and older, receive a screening test for HIV at least once during their lifetime. Earlier or additional screening should be based on risk, and rescreening annually or more often may be appropriate beginning at age 13 for adolescent and adult women with an increased risk of HIV infection. The WPSI recommends risk assessment and prevention education for HIV infection beginning at age 13 and continuing as determined by risk. A screening test for HIV is recommended for all pregnant women upon initiation of prenatal care with rescreening during pregnancy based on risk factors. Rapid HIV testing is recommended for pregnant women who present in active labor with an undocumented HIV status. Screening during pregnancy enables the prevention of vertical transmission. |
| Well-Woman Preventive Visits | Recommends that women receive at least one preventive care visit per year beginning in adolescence and continuing across the lifespan to ensure the provision of all recommended preventive services, including preconception and many services necessary for prenatal and interconception care, are obtained. The primary purpose of these visits should be the delivery and coordination of recommended preventive services as determined by age and risk factors. These services may be completed at a single or as part of a series of visits that take place over time to obtain all necessary services depending on a woman’s age, health status, reproductive health needs, pregnancy status, and risk factors. Well-woman visits also include pre-pregnancy, prenatal, postpartum and interpregnancy visits. |
**** This refers to FDA’s Birth Control Guide (PDF – 450 KB) as posted on December 22, 2021, with the exception of sterilization surgery for men, which is beyond the scope of the WPSI.
Summary
Plans, insurers and providers should keep abreast of the newly released guidelines and ensure that coverage and documentation reflect the most recent changes.
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EPIC offers this material for general information only. EPIC does not intend this material to be, nor may any person receiving this information construe or rely on this material as, tax or legal advice. The matters addressed in this document and any related discussions or correspondence should be reviewed and discussed with legal counsel prior to acting or relying on these materials.
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