Clinical Preventive Services for Women Closing the Gaps (2011) / Chapter Skim
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3 Existing Coverage Practices of National, State, and Private Health Plans
3 Existing Coverage Practices of National, State, and Private Health Plans
Pages 47-66
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From page 47... ...
This section of the law adds to and amends the Public Health Services Act and the Employee Retirement Income Security Act and, as such, has jurisdiction over plans that are sold on the individual, small-group, and large-group markets by insurers as well as self-insured plans that are funded by employers. These new rules require that private plans cover all United States Preventive Services Task Force (USPSTF)
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From page 48... ...
RULES GOVERNING COVERAGE REQUIREMENTS BEFORE AND AFTER THE ACA The coverage of preventive care provided under the individual and group markets and through self-funded employer health plans has been highly variable, differing by employer, insurer, and plan type. The Federal Employee Retirement and Income Security Act of 1974 regulates the coverage offered by self-insured or self-funded employer health plans as well as health insurance plans.
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From page 49... ...
. Despite this ruling, the EEOC finding still stands, and the vast majority of health plans cover contraceptives, and in 2002, more than 89 percent of insurance plans covered contraceptive methods (Sonfield et al., 2004)
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From page 50... ...
State Coverage Requirements The business of insurance is regulated at the state level, and state requirements for the preventive services that health plans must cover vary
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From page 51... ...
.2 In recent years, state lawmakers have enacted a wide range of mandates for different types of health care services. The reach of these benefit mandates is limited, however, as they apply only to insurance plans that are sold to employers and individuals in the state and do not apply to self-funded employer health plans, which are plans that provide coverage for the majority of the employer's workers and their dependents.
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From page 52... ...
This law created multiple public and private health insurance pathways and initiated a system of shared responsibility among the stakeholders in health care provision. Chapter 58 also created a health insurance exchange, known as the Commonwealth Connector, to make health coverage available to residents and to regulate the insurance products offered through the exchange to ensure that individuals have minimum creditable coverage.
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From page 53... ...
Private Insurance Coverage Practices Detailed information on the coverage and benefits provided by private insurance plans and employers and on the scope of the preventive benefits that they cover is often proprietary and difficult to obtain. This information is enormously complex, and details about the coverage provided differ considerably from plan to plan and employer to employer.
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From page 54... ...
Gynecological examinations and services, such as pelvic examinations and Pap smears were covered for 60 percent of participants of employerbased health plans, usually under headings such as "well-woman exams." However, these services were often subject to plan or separate limits, and copayments were commonly required. Plans often limited the number of examinations per year and the dollar amount on the services covered during examinations.
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From page 55... ...
In a 2006–2007 survey of individual insurance plans conducted by American's Health Insurance Plans, the trade association for health insurers in the United States (AHIP, 2007) , coverage levels were found to vary considerably by type of plan, with all HMO plans responding to the survey indicating that they covered physical examinations for adults, annual visits to an obstetrician-gynecologist, and cancer screening; but far
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From page 56... ...
for women with a high risk of breast cancer or surgical removal of the breasts or ovaries. Cervical Cancer: The purchaser's guide recommends coverage of conventional Pap smears.
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From page 57... ...
Coverage rates for oral contraceptives were also lower, ranging from 39 percent for HMOs for single individuals to 79 percent for PPOs and POS plans for single individuals. Federal Employees Health Benefits Program Millions of federal workers and their dependents receive their health insurance coverage through the Federal Employee Health Benefits (FEHB)
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From page 58... ...
The rules in Section 2713 only amend and add to the Public Health Services Act and the Federal Employee Retirement and Income Security Act and therefore do not affect the coverage offered by military health care programs, such as TRICARE and VA program, or the IHS. It is useful, however, to understand how these different programs have handled policies for coverage of preventive services important to women.
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From page 59... ...
. At this visit, the medical and family health histories are reviewed, basic health measurements are taken, a screening for the preventive services required is performed, and risk factors and treatment options are identified.
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From page 60... ...
Intensive counseling to manage obesity 13 (adults aged 21–64) FIGURE 3-2 Number of state Medicaid programs that reported covering certain recommended preventive services for adults and health risk assessments or welladult checkups.
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From page 61... ...
. For example, services such as cervical cancer screening and mammography were covered by nearly all state Medicaid programs, but far fewer states covered well-adult checkups or cholesterol tests (GAO, 2009)
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From page 62... ...
A 2001 review of CHIP coverage of reproductive health services conducted by the Guttmacher Institute found that of the 29 states that operated separate state programs, 16 specifically identified that family planning services and supplies were covered and most of the remaining plans covered these services through the general category "prenatal care and prepregnancy family planning services" (Gold and Sonfield, 2001)
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From page 63... ...
. The scope of care offered to women veterans is broad and includes the following preventive services important to women: health evaluation and counseling, disease prevention, nutrition counseling, weight control, smoking cessation, and substance abuse counseling and treatment, as well as gender-specific primary care, including Pap smears, mammogram, birth control, preconception counseling, human papillomavirus vaccine, and menopausal support (hormone replacement therapy)
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From page 64... ...
The ACA requirements will make important strides in ensuring that most Americans have coverage for the full range of recommended preventive services. REFERENCES AHIP (America's Health Insurance Plans)
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From page 65... ...
2010a. Interim final rules for group health plans and health insurance issuers relating to coverage of preventive services under the patient protection and affordable care act.
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From page 66... ...
2009a. State Medicaid coverage of family planning services: Summary of state survey findings.
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