Therefore, for the first time in U.S. history, federal rules stipulate the preventive services that private plans must cover and prohibit out-of-pocket payments for individuals who obtain these covered services from in-network providers (Federal Register, 2010a; HHS, 2010). Only new plans or those plans that change are affected by these new requirements.1 Private plans that do not change their benefits or cost-sharing requirements are considered to be grandfathered and are not initially subject to the new requirements for the preventive services that must be covered.
HHS estimates that 78 million people enrolled in group plans and approximately 10 million people with individual policies will be subject to the prevention provisions in the ACA (HHS, 2010). These provisions will also apply to the plans that will be offered to consumers under the new state health insurance exchanges, although these exchanges and plans will not become operational until 2014.
This chapter reviews the policies and practices of private plans and publicly sponsored programs regarding the coverage before and after the enactment of the ACA of preventive services important to women. It describes the federal and state rules that are in effect today as well as identifies the types of plans or programs that will be affected by the new rules outlined in Section 2713 of 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. An estimated 59 percent of covered workers are enrolled in self-insured group health plans (Claxton et al., 2010).
Federal Rules and Coverage Requirements
With few exceptions, federal rules do not specify what benefits plans must cover. The exceptions are that all self-funded employer health plans and health insurance issuers must offer coverage for a 48-hour hospital stay
1 Plans will lose their “grandfather” status if, compared to March 23, 2010, they significantly cut or reduce benefits, raise co-insurance charges or significantly raise co-payment charges or deductibles, significantly reduce employer contributions, tighten annual limits on what insurers will pay, or change insurers. Plans that make any of these changes can be deemed to lose their grandfather status and will be required to follow the ACA preventive benefit coverage rules (Federal Register, 2010b).