SECOND OPINIONS: Covering Women’s Preventive Care – Part II

February 29, 2012 ( - In a column earlier this month, we answered questions about the new preventive care guidelines for women adopted under PPACA.

See “Covering Women’s Preventive Care – Part I”.  Plans must begin covering these services at 100% with no cost sharing for plan years that start on or after 8/1/12 (1/1/13 for calendar year plans).  A list of the new guidelines can be found at and include the following categories:   

  • Well-woman visits; 
  • Screening for gestational diabetes; 
  • HPV testing; 
  • Counseling for STD infections; 
  • Counseling and screening for HIV; 
  • Contraceptive methods and counseling (with an exemption for certain religious employers); 
  • Breastfeeding support, supplies, and counseling; and 
  • Screening and counseling for interpersonal and domestic  violence.  

We continue to answer questions on these new requirements. 

If a plan must cover prescription contraceptives, can it limit benefits to generic drugs only? 

Yes – the preventive care rules provide that the plan must cover the recommended preventive care services at 100% with no cost-sharing, but a plan is permitted to establish “reasonable medical management techniques” to determine the frequency, method, or setting for an item or service to be covered at 100%, unless otherwise specified in the recommendations.  An HHS Fact Sheet provides an example where a plan covers generic contraceptives at 100%, but charges cost-sharing for brand name contraceptives.  The Fact Sheet suggests that this type of distinction would be permitted as a “reasonable medical management” technique.  

Do the new preventive care rules for women require coverage of sterilizations? 

Yes – the recommendations require coverage for all FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity.  So it appears that plans must cover sterilization procedures for women (including voluntary procedures) at 100% with no cost sharing. 

If a preventive care test results in an abnormal result, must further services be covered at 100%? 

No, the PPACA rules only require coverage at 100% for preventive care services.  If a service is being provided as treatment for a condition or because there is a risk factor indicating that the service is medically necessary, the service likely would no longer be considered preventive (and likely would be coded differently).  Then, the plan would be permitted to apply its otherwise applicable plan rules, such as coinsurance, copayments, and deductible amounts. 

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Christy Tinnes is a Principal in the Health & Welfare Group of Groom Law Group in Washington, D.C.  She is involved in all aspects of health and welfare plans, including ERISA, HIPAA portability, HIPAA privacy, COBRA, and Medicare.  She represents employers designing health plans as well as insurers designing new products.  Most recently, she has been extensively involved in the insurance market reform and employer mandate provisions of the health-care reform legislation.   

Brigen Winters is a Principal at Groom Law Group, Chartered, where he co-chairs the firm's Policy and Legislation group. He counsels plan sponsors, insurers, and other financial institutions regarding health and welfare, executive compensation, and tax-qualified arrangements, and advises clients on legislative and regulatory matters, with a particular focus on the recently enacted health-reform legislation.   


PLEASE NOTE:  This feature is intended to provide general information only, does not constitute legal advice, and cannot be used or substituted for legal or tax advice.