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UnitedHealthcare’s Approach to Expanded Women’s Preventive Care Services Effective On or After Aug.
July 3, 2012
New coverage guidelines under the Patient Protection and Affordable Care Act (PPACA) require health plans to cover an expanded list of women’s preventive care services with no cost-share (copayment, coinsurance or deductible) as long as services are received in the health plan’s network:
- Breast-feeding counseling and supplies
- Contraception methods and counseling
- HPV DNA testing
- Well-woman visits
- Domestic violence screening
- Gestational diabetes screening
- HIV screening and counseling
- Sexually transmitted infections counseling
Coverage for expanded women’s preventive care services becomes effective the first plan year beginning on or after Aug. 1, 2012. It is important to note that for renewing fully insured plans, the effective dates for medical coverage and pharmacy coverage may be different. Medical coverage begins on the fully insured plan’s first renewal date on or after Aug. 1, 2012, and pharmacy coverage begins on Aug. 1, 2012, regardless of the plan’s renewal date as long as the group has oral contraceptive coverage today. For all other new or renewing plans, pharmacy and medical coverage becomes effective as of the first plan year, or the first health plan renewal date, on or after Aug. 1, 2012.
The preventive care services provision applies to both fully insured and self-funded (ASO) plans that are non-grandfathered plans under the health reform law. While grandfathered plans are not required to implement these changes, some grandfathered plans have chosen to offer preventive care services at no cost-share.
Breast-Feeding Counseling and Supplies
Under the health reform law, lactation support and counseling as well as costs for renting breast-feeding equipment for each child’s birth are covered at no cost-share. UnitedHealthcare believes some members may prefer to purchase a breast pump rather than rent hospital-grade equipment. To offer a range of choices for our members, UnitedHealthcare will cover the purchase of a personal, double-electric breast pump at no cost to the member.
To rent or purchase breast pumps, members will be required to contact UnitedHealthcare or a network physician, hospital or durable medical equipment (DME) supplier. The physician, hospital or DME supplier will bill UnitedHealthcare directly for reimbursement. Members will not be able to purchase supplies, such as breast pumps, at retail and send the receipt for reimbursement.
If a member chooses to purchase or rent a breast pump from a non-network provider or DME supplier, then non-network preventive benefits would apply, if available. If no non-network preventive benefits are available, the breast pump would not be covered.
Contraceptive Methods and Counseling
Under the health reform law, health plans must cover FDA-approved contraceptive methods for women without cost-share. Some contraceptives, like oral contraceptives, are covered under the pharmacy benefit when the prescription is filled at a network pharmacy. The administration of contraceptives by a network physician in a medical setting (sterilization, services to place/remove/inject contraceptive methods) will be covered without deductible, copayment or coinsurance under the medical benefit.
The new requirement covers prescribed contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity.
UnitedHealthcare has determined that contraceptives with the same progestin are equivalent to each other. Therefore, each unique progestin contraceptive medication will be represented in Tier 1 without cost-share. A limited number of higher cost Tier 1 contraceptives will move to Tier 2 on July 1, 2012. Note that this will be for the Advantage Prescription Drug List (PDL) only.
Review the new list of Tier 1 contraceptives on the Advantage PDL and the Traditional PDL that also includes pharmacy frequently asked questions (FAQs). The Advantage PDL Tier 1 contraceptives posted to myuhc.com July 1.
Under the health reform law, religious institutions that offer insurance to their employees may be able to choose whether or not to cover contraception services.
Domestic Violence Screening
Today and going forward, UnitedHealthcare covers age-appropriate preventive visits, including risk identification and guidance for risk reduction at no cost to the member. Domestic violence screening is included in the wellness examination codes provided under preventive care services benefits.
Gestational Diabetes Screening
Gestational diabetes screening is required for coverage as a preventive service under the health reform law for 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. UnitedHealthcare will cover gestational diabetes screening for all pregnant women, regardless of gestational week.
HPV DNA Testing
Today and going forward, UnitedHealthcare provides coverage for cervical cancer screening. Under the expanded women’s preventive care services benefit, UnitedHealthcare will provide coverage for human papillomavirus (HPV) screening in all women age 30 and over to be paid without cost-share to the member. HPV is the most common cause of cervical cancer, so HPV testing can help prevent cervical cancer.
HIV Screening and Counseling and Sexually Transmitted Infections Counseling
The health reform law requires health plans to cover counseling and screening for human immunodeficiency virus for all sexually active women, not just women at risk. The law also requires counseling for other sexually transmitted diseases.
Under the health reform law, well-woman visits include well-woman preventive care visits to obtain the recommended preventive services, including preconception and prenatal care. Today, UnitedHealthcare covers many women’s preventive health care services, including mammograms, screenings for cervical cancer and immunizations, with no cost-sharing for qualifying health plans.
The new coverage for well-woman visits under the health reform law will require multiple preventive visits in the same year for a woman to receive all recommended services, including prenatal care. Prenatal services covered with no cost-sharing include:
- Routine prenatal obstetrical office visits
- All lab services explicitly identified in the health reform law
- Tobacco cessation counseling specific to pregnant women
- Immunizations recommended by the Advisory Committee on Immunization Practices
Prenatal services not covered under the women’s preventive coverage include, but are not limited to radiology (i.e., obstetrical ultrasounds), delivery and high-risk prenatal services.
Visit the United for Reform Resource Center for fliers on UnitedHealthcare’s Approach to Women’s Preventive Care Services and Women’s Preventive Care Services: Contraception Methods & Counseling. Look for more support materials on the site soon.
May 31 Consultant Webinar Playback Available
The presentation from the May 31 webinar is available with accompanying audio. Dial the phone number and code provided for an overview of the meeting if you were unable to attend.Presentation from Consultant Webinar: Expanded Women's Preventive, MLR and PCORI - May 31
WebEx Phone Number: (800) 475-6701
Access Code: 248168
For more information, contact your UnitedHealthcare representative.
April 15 Webinar
Join us on Tuesday, April 15 at 3 p.m. ET, to hear the results from Optum's 5th Annual Wellness in the Workplace Study. Register now.
Listen to this webinar playback to see and hear how our clinical synchronization approach works to help members maximize their pharmacy benefit.
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