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CME/CE

Preventive Services for Women: New and Important Changes in Covered Services

  • Authors: Rebekah E. Gee MD, MPH
  • CME/CE Released: 11/15/2012
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 11/15/2013
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Target Audience and Goal Statement

This activity is intended for internists, family physicians, obstetricians, gynecologists, pharmacists, nurses, nurse practitioners, and physician assistants.

The goal of this activity is to make healthcare providers aware of the preventive services to be provided to women under the Affordable Care Act without cost sharing.

Upon completion of this activity, participants will be able to:

  1. Identify the preventive services mandated for women with no cost-sharing under the Affordable Care Act
  2. Review the rules for medical management with respect to covered preventive services


Disclosures

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Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


Author

  • Rebekah E. Gee MD, MPH

    Director, Louisiana Birth Outcomes Initiative; Assistant Professor, Louisiana State University Schools of Public Health and Medicine, New Orleans, LA

    Disclosures

    Disclosure: Dr. Gee has disclosed no relevant financial relationships.

    Dr. Gee does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

    Dr. Gee does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

Editors

  • Jane Lowers

    Group Scientific Director, Medscape, LLC

    Disclosures

    Disclosure: Jane Lowers has disclosed no relevant financial relationships.

  • Neil Chesanow

    Senior Clinical Editor, Medscape, LLC

    Disclosures

    Disclosure: Neil Chesanow has disclosed no relevant financial relationships.

CME Reviewer

  • Nafeez Zawahir, MD

    CME Clinical Director, Medscape, LLC

    Disclosures

    Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.

Nurse Planner

  • Laurie E. Scudder, DNP, NP

    Nurse Planner, Continuing Professional Education Department, Medscape, LLC; Clinical Assistant Professor, School of Nursing and Allied Health, George Washington University, Washington, DC

    Disclosures

    Disclosure: Laurie E. Scudder, DNP, NP, has disclosed no relevant financial relationships.


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CME/CE

Preventive Services for Women: New and Important Changes in Covered Services

Authors: Rebekah E. Gee MD, MPHFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME/CE Released: 11/15/2012

Valid for credit through: 11/15/2013

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This activity has expired.

The accredited provider can no longer issue certificates for this activity. Medscape cannot attest to the timeliness of expired CME activities.

Moreover, because statutes, regulations, and policy information may change over time, the information available in this course may be out-of-date. If you need additional information concerning CMS programs, we recommend that you access www.cms.gov.

Under the Patient Protection and Affordable Care Act of 2010 (ACA), coverage for a variety of important preventive health care services is required by new (non-grandfathered) health plans with no cost sharing as of September 23, 2010, when services are rendered by an in-network provider.[1] However, although women's healthcare needs are widely recognized as different from those of men, no single body of recommendations specific to women's preventive services existed at the time the ACA was signed into law.[2,3] As such, the law required coverage of: "with respect to women, evidence-informed preventive care and screening provided for in comprehensive guidelines supported by [The Health Resources and Services Administration] (not otherwise addressed by the recommendations of the [U.S. Preventive Services] Task Force)."

At the request of the US Department of Health and Human Services' (HHS) Assistant Secretary for Planning and Evaluation and the Health Resources and Services Administration, the Institute of Medicine (IOM) assembled a 16-member committee to identify critical gaps in preventive services for women and recommend measures to further ensure women's health and well-being.[3] Preventive health services were defined as measures (including medications, procedures, devices, tests, education, and counseling) shown to improve the well-being, reduce the likelihood or delay the onset of a targeted disease or condition, or both.[2]

Rebekah Gee, MD, MPH, a practicing obstetrician/gynecologist in New Orleans, Louisiana, and professor at the Louisiana State University Schools of Public Health and Medicine, served on the IOM panel and believes that preventive services are most effective when the approach to women's health is on a continuum, or holistic in nature.

"We often think of women's health in separate silos," she explains. "There is the pediatric and adolescent silo, the obstetric silo, and the older-women silo, when in fact these life stages are all connected. The decisions, behaviors, and exposures that a woman has in any 1 of those periods affects her health later in life. "One example, Dr Gee points out, is the current national focus on the "life course for women," particularly as it applies to birth outcomes. The life-course theory says that events that happen earlier in life, whether they be stress or chronic disease, impact the course of a pregnancy. Therefore it is no surprise that prenatal care doesn't necessarily improve birth outcomes. By the time a woman is pregnant, issues such as chronic disease, obesity, and diabetes impact the physical health of both mother and baby, particularly through the uterine environment, implantation of an embryo, and the development of the placenta, which feeds the baby. When these events happen during the first weeks of pregnancy, it is long before prenatal care begins for most women, and many issues cannot be resolved. "Thinking about being healthy prior to pregnancy pays much bigger dividends than treating acute conditions once they occur," she states. Life course is not only important for pregnancy but also for chronic disease. "The choices women make about their health -- whether about diet, exercise, or even whether to breastfeed -- have profound impacts later in life," says Dr Gee.

Recommended services considered by the IOM committee also met the following criteria[2]:

  1. The condition to be prevented affects a broad population;
  2. The condition to be prevented has a large potential impact on health and well-being;
  3. The quality and strength of the evidence is supportive.

In July 2011, the IOM report was submitted to HHS identifying 8 additional preventive services for women recommended for inclusion in private health coverage without cost-sharing (Table 1).[2-4] HRSA adopted these recommendations and issued Women’s Preventive Services Guidelines on August 1, 2011. Non-grandfathered plans and issuers are required to provide coverage without cost sharing consistent with the guidelines for plan years (group health plans and group health insurance coverage) or policy years (individual health insurance coverage) beginning on or after August 1, 2012.

Table 1. Health Resources and Services Administration Supported Women's Preventive Services: Required Health Plan Coverage Guidelines[2-4]

Type of Preventive Service HHS Guideline for Health Insurance Coverage Frequency
Well-woman visits A well-woman preventive care visit annually for adult women to obtain the recommended preventive services that are age- and developmentally appropriate, including preconception and prenatal care; this well-woman visit should, where appropriate, include other preventive services listed in this set of guidelines, as well as others referenced in section 2713 Annual, although HHS recognizes that several visits may be needed to obtain all necessary recommended preventive services, depending on a woman's health status, health needs, and other risk factorsa
Screening for gestational diabetes Screening for gestational diabetes In pregnant women between 24 and 28 weeks of gestation and at the first prenatal visit for pregnant women identified to be at high risk for diabetes
Human papillomavirus testing High-risk human papillomavirus DNA testing in women with normal cytology results Screening should begin at age 30 years and should occur no more frequently than every 3 years
Counseling for sexually transmitted infections Counseling for sexually transmitted infections for all sexually active women Annual
Counseling and screening for human immunodeficiency virus (HIV) Counseling and screening for HIV infection for all sexually active women Annual
Contraceptive methods and counselingb All FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity As prescribed
Breastfeeding support, supplies, and counseling Comprehensive lactation support and counseling by a trained provider during pregnancy, in the postpartum period, or both, and costs for renting breastfeeding equipment In conjunction with each birth
Screening and counseling for interpersonal and domestic violence Screening and counseling for interpersonal and domestic violence Annual
FDA = US Food and Drug Administration; HHS = US Department of Health and Human Services.

aRefer to recommendations listed in the July 2011 IOM report titled Clinical Preventive Services for Women: Closing the Gaps, concerning individual preventive services that may be obtained during a well-woman preventive-service visit.

bGroup health plans sponsored by certain religious employers, and group health insurance coverage in connection with such plans, are exempt from the requirement to cover contraceptive services. A religious employer is one that: (1) has the inculcation of religious values as its purpose; (2) primarily employs persons who share its religious tenets; (3) primarily serves persons who share its religious tenets; and (4) is a nonprofit organization under Internal Revenue Code section 6033(a)(1) and section 6033(a)(3)(A)(i) or (iii). 45 C.F.R. §147.130(a)(1)(iv)(B). See the Federal Register notice: Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services Under the Patient Protection and Affordable Care Act. In addition, certain non-profit employers with religious objections to contraceptive services are able temporarily to exclude such coverage under their group health plans (and related group health insurance coverage) due to an enforcement safe harbor. See the bulletin from the Center for Consumer Information and Insurance Oversight (CCIIO).

Women enrolled in new insurance plans are eligible for these additional preventive services with no cost-sharing when their new plan or policy years start on or after August 1, 2012.[5] The recommendations, Dr Gee reports, offer major opportunities to improve the health of women, but of particular importance are improved access to contraceptives and well-woman visits. "The removal of the copayment for contraceptives is huge," she says. "The range of all US Food and Drug Administration (FDA)-approved methods of contraception will be allowed without cost-sharing, so now we can offer intrauterine devices (IUDs) and oral contraceptives without fear that they will be cost-prohibitive to the patient. That will change our practice and the way patients think about making choices about their contraception."

Well-woman visits present additional opportunities, Dr Gee says, because more than 1 visit can occur annually. "This will enable us to do more counseling in the office and patients need not be concerned that their health insurance plans will deny that visit." For example, women can see a generalist if they have high blood pressure or diabetes, and they can also see an obstetrician/gynecologist for preconception care if they are considering pregnancy, with preventive care coverage for both visits.

Preventive services recommended for annual well-woman visits include United States Preventive Services Task Force (USPSTF) recommendations and the additional services included in the guidelines issued by HRSA (Table 2).[2] These services largely address issues associated with reproductive health, early cancer detection, mental health, and screening for chronic conditions such as diabetes, obesity, and osteoporosis.[6] Women should discuss with their healthcare provider the appropriate services for their situation.

Table 2. Suggested List of Preventive Services to Be Obtained During Well-Woman Preventive Visits[2] a

Topic Description
US Preventive Services Task Force (USPSTF) Grade-A and -B Recommended Services
Alcohol misuse counseling Screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings
Anemia screening: pregnant women Routine screening for iron deficiency anemia in asymptomatic pregnant women
Aspirin to prevent cardiovascular disease For women aged 55 to 79 years to prevent ischemic stroke
Bacteriuria screening: pregnant women Screening for asymptomatic bacteriuria with urine culture for pregnant women at 12 to 16 weeks' gestation or at the first prenatal visit, if later
Blood pressure screening Screening for high blood pressure in adults aged 18 years and older
BRCA screening/counseling Women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes can be referred for genetic counseling and evaluation for BRCA testing
Breast cancer preventive medication Discussion of chemoprevention (potential benefits and harms) with women at high risk for breast cancer and at low risk for adverse effects of chemoprevention
Breast cancer screening Screening mammography for women, with or without clinical breast examination, every 1 to 2 years for women aged 40 years and older.
Breastfeeding counseling Interventions during pregnancy and after birth to promote and support breastfeeding
Cervical cancer screening Screening for cervical cancer in women who have been sexually active and have a cervix
Chlamydial infection screening: non-pregnant women Screening for chlamydial infection for all sexually active non-pregnant young women aged 24 years and younger and for older non-pregnant women who are at increased risk
Chlamydial infection screening: pregnant women Screening for chlamydial infection for all pregnant women aged 24 years and younger and for older pregnant women who are at increased risk
Cholesterol abnormalities screening: women 45 years and older Screening for women aged 45 years and older for lipid disorders if they are at increased risk for coronary heart disease
Cholesterol abnormalities screening: women younger than 45 years Screening for women aged 20 to 45 years for lipid disorders if they are at increased risk for coronary heart disease
Colorectal cancer screening Screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until age 75 years
Depression screening: adolescents Screening of adolescents (aged 12 to 18 years) for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive behavioral or interpersonal), and follow-up
Depression screening: adults Screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up
Diabetes screening Screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg
Fall prevention: vitamin D The USPSTF recommends vitamin D supplementation for community-dwelling adults 65 years or older at increased risk for falls
Fall prevention: exercise/physical therapy The USPSTF recommends exercise or physical therapy for community-dwelling adults 65 years or older at increased risk for falls
Folic acid supplementation All women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 μg) of folic acid
Gonorrhea screening: women Screening for all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection (that is, if they are young or have other individual or population risk factors)
Healthy diet counseling Intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease
Hepatitis B screening: pregnant women Screening for hepatitis B virus infection in pregnant women at their first prenatal visit
Human immunodeficiency virus (HIV) screening Screening for HIV for all adolescents and adults at increased risk for HIV infection, and all pregnant women
Obesity screening and counseling: adults Screening for obesity in all adults, with intensive counseling and behavioral interventions to promote sustained weight loss for obese adults
Osteoporosis screening: women Screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors
Rh incompatibility screening: first pregnancy visit Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care
Rh incompatibility screening: 24 to 28 weeks gestation Repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 24 to 28 weeks gestation, unless the biological father is known to be Rh (D) negative
Skin cancer counseling Behavioral counseling about skin cancer for children, adolescents, and young adults aged 10 to 24 years
Sexually transmitted infections (STIs) counseling High-intensity behavioral counseling to prevent STIs for all sexually active adolescents and for adults at increased risk for STIs
Syphilis screening: non-pregnant persons Screening in persons at increased risk for syphilis infection
Syphilis screening: pregnant women Screening in all pregnant women for syphilis infection
Tobacco use counseling and interventions: non-pregnant adults Screening in all adults regarding tobacco use, and interventions for those using tobacco products
Tobacco use counseling: pregnant women Screening in pregnant women regarding tobacco use and intervention with augmented, pregnancy-tailored counseling to those who smoke
aThe preventive services included in the ACA requirement were based on recommendations of the USPSTF Grade A and B recommendations (moderate to high certainty of benefit); the Advisory Committee on Immunization Practices (ACIP); and, for adolescents, the American Academy of Pediatrics (AAP) Bright Futures initiative.[2]

The extension of coverage for lactation support and counseling, Dr Gee points out, presents an opportunity for a positive impact on the health of both mothers and children. "We know that breastfeeding has incredible benefits such as decreased obesity and diabetes in both mom and baby, and even higher IQ has been found in babies who are breastfed, but the costs associated with breast pumps and the supplies that support breastfeeding efforts are prohibitive for many women," she says. "Now when I talk to my patients about breastfeeding, I can be confident that they will be able to afford the equipment."

In addition to these preventive services, women enrolled in new insurance plans are also eligible for a number of immunizations with no cost sharing (Table 3 and Table 4).[2]

Table 3. Recommended Ages and Intervals Between Vaccine Doses[2]

Vaccine Recommended Age Recommended Interval to Next Dose Minimum Interval to Next Dose
LAIV 2 to 49 years 1 month 4 weeks
MCV4-1 11 to 12 years 5 years 8 weeks
MCV4-2 16 years    
HPV-1 11 to 12 years 2 months 4 weeks
HPV-2 11 to 12 years 4 months 12 weeks
HPV-3 11 to 12 years (plus 6 months)    
Td 11 to 12 years 10 years 5 years
Tdap 11 to 12 years    
HPV = human papillomavirus vaccine; LAIV = live attenuated influenza vaccine; MCV = meningococcal conjugate vaccine; Td = tetanus/diphtheria vaccine; Tdap = tetanus/diphtheria/acellular pertussis vaccine.

Table 4. Combination Vaccines[2]

Vaccine Age Range Schedule
Hep A-Hep B > 18 years 3 doses on a schedule of 0, 1, and 6 months
MMRV At 12 months to 12 years 2 doses, one at 12 to 15 months, one at 4 to 6 years
Hep = hepatitis vaccine; MMRV = measles/mumps/rubella vaccine.

The rules governing coverage allow plans to use reasonable medical management to help define the nature of the covered service.[7] Plans retain some flexibility to control costs, for example, by being able to require cost-sharing for branded drugs if the plan provides coverage without cost sharing for a safe and effective generic version of the same drug.

Dr Gee sees an opportunity in the recent efforts to achieve transformation in health information to engage both patients and clinicians in preventive measures. "Most clinicians have moved to electronic medical records (EMRs) in their offices, which can be used to remind us about preventive services in the clinical flow of EMR use," she explains. "We can do a better job of tracking preventive service delivery and results and reminding ourselves when preventive services are due for each patient." EMRs are often interactive with patients as well; they enable patients to track their health information online and interact with providers, she adds.

Physicians themselves can benefit from tracking preventive services, Dr Gee notes, because they often forget about their own needs. "Physicians can be the worst at taking care of themselves because they are so focused on taking care of others," she says.

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