Completing a two-stage rollout begun on July 14, 2011, Health and Human Services Secretary Kathleen Sebelius announced the latest preventive care rules of the Patient Protection and Affordable Care Act (PPACA) on August 1.

The new rules apply to all private health insurance providers, including LIUNA health & welfare plans unless they have grandfathered status. All non-grandfathered plans must provide these services in the first plan year that begins on or after August 1, 2012. For LIUNA health & welfare funds that are grandfathered, the services must begin to be covered upon loss of grandfathered status.

The rules will require health insurance plans to cover evidence-based health services while eliminating any cost sharing requirements (copays, coinsurance or deductibles) for members and covered dependents. Evidence-based services are those deemed to hold strong promise of improved health outcomes when applied in clinical settings.

The best example, perhaps, is routine immunization. Under the rules issued by Sebelius, all private health insurance plans must cover a standard set of vaccines recommended by the Advisory Committee on Immunization Practices. These range from routine childhood immunizations to periodic tetanus shots for adults.

Other preventive services are rated by the U.S. Preventive Services Task Force, an independent panel of scientific experts. Based on the strength of scientific evidence documenting their health benefits, services are graded. Services with a grade of A or B will be mandated under the new rules. These include breast and colon cancer screenings; screenings for vitamin deficiencies during pregnancy; screenings for diabetes, high cholesterol and high blood pressure; and tobacco cessation counseling.

For children, in addition to vaccinations, health plans must cover a variety of preventive services recommended by the Bright Futures guidelines developed by the American Academy of Pediatrics. Among these are pediatrician visits, vision and hearing screening, developmental assessments and screening and counseling to address obesity and help children maintain healthy weights.

Prevention for Women

The new rules also included required prevention services for women. These were recommended in July by a panel of experts from the National Academy of Sciences Institute of Medicine.

Health plans must cover all prescription contraception approved by the Food and Drug Administration. Asserting the rationale behind this requirement, Sebelius told a Washington Post reporter, “Since birth control is the most common drug prescribed for women ages 18 to 44, insurance plans should cover it. Not doing it would be like not covering flu shots.”

The proposed rule, however, allows an exception for religious institutions that offer insurance to their employees. If an institution’s purpose is to instill religious values and it primarily employs and serves people who share the institution’s religious tenets, it need not cover contraceptive services. The exception was criticized as too narrow by the U.S. Conference of Catholic Bishops because the Church, whose social service and health care providers often serve non-Catholic customers, opposes contraception and does not wish the association. At the same time, the National Women’s Law Center decried the exception’s failure to ensure contraceptive services for all women workers who want them, regardless of the views of their employer.

Some anti-abortion groups also objected to the inclusion of emergency contraception, such as Plan B and Ella, among the covered services, asserting that these drugs sometimes cause an abortion by preventing an already-fertilized egg from implanting in the womb.

In addition to contraceptives, the new rules require insurers to provide other services at no cost to women:

  • “Well-woman” check-ups at least once a year and more frequently if necessary
  • Mammograms and Pap smears
  • Screening for diabetes in pregnant women
  • DNA testing every three years for human papillomavirus (HPV) – linked to certain cancers – among women 30 years and older
  • Annual screening and counseling for HIV
  • Counseling to determine whether a woman is at risk for other sexually transmitted diseases
  • Breast-feeding support, counseling and supplies, such as breast pumps
  • Annual screening and counseling for domestic violence
  • Sterilization methods

Cost Impacts

The presumption behind mandated preventive services is that the nation will achieve long term savings in treatment costs by encouraging exams and wellness screenings. However, these savings may accrue most to Medicare which provides health care to older Americans. Because most people do not work for the same employer or hold the same insurance policy throughout their lifetimes, private insurance companies may not benefit as much and have been inconsistent in providing such services. A government mandate will help ensure this coverage.

The LHSFNA’s Health Promotion Division continues to track developments associated with PPACA. These may be viewed on the Fund’s Health Care Reform Updates page.

[Steve Clark]