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Outline of Women's Preventive Coverage Changes
Detailed below are the additional benefits BCBSTX has determined are necessary to comply with the new requirements and will be added to fully insured plans.
Contraceptives
- Prescription - We will cover one or more products within the 11 categories of FDA-approved contraception methods.
- The morning-after pill (Plan B) will be included in preventive care.
- FDA-approved over-the-counter contraceptives for women (e.g., foam, sponge, female condoms, etc.) are covered under these amendments when prescribed.
- Over-the-counter contraceptives for male use (condoms) are not covered.
- Medical devices such as intrauterine devices (IUDs), diaphragms, cervical caps and levonorgestrel implants are covered under medical at 100 percent.
Sterilization
- Covered for procedures to the female body for all women with reproductive capacity. Vasectomies are not included.
- When tubal ligation is performed during a hospital admission, but is not the primary reason for the admission and not performed as a secondary procedure, professional surgical fees, operating room fees and anesthesia for tubal ligation are covered as preventive care. Inpatient facility charges would not be considered part of the preventive service, since they would attach to the primary reason for admission. (Example: vaginal delivery, tubal ligation performed on different days while member still hospitalized.)
- When billed as a secondary procedure, professional surgical fees for tubal ligation are covered as preventive care. Facility and anesthesia charges would not be considered part of the preventive service since they would attach to the primary procedure. (Example: Tubal ligation and C-section performed as part of same surgical procedure.)
- Hysterectomy is not considered preventive - sterilization is a secondary benefit and not a sole reason to have the procedure.
Prenatal
- Prenatal labs will be treated as part of maternity care and not considered routine preventive care.
- Screening for gestational diabetes will be covered at 100 percent for symptomatic individuals at high risk of diabetes.
Breastfeeding
- Covers comprehensive lactation support and counseling by a trained provider during pregnancy and/or in the postpartum period.
- Only covers lactation specialist/nurse practitioner with state-recognized certification
- Frequency coverage will be in conjunction with each birth for duration determined using reasonable medical management.
- Covers breastfeeding equipment rentals (or purchase, if more cost-effective) under durable medical equipment policies.
- We will cover the manual breast pump as part of the preventive care benefits. Electronic and hospital-grade pumps will not be covered at the no cost-sharing preventive care level.
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