The landmark Affordable Care Act (ACA), enacted on March 23, 2010, revolutionized access to healthcare in the United States. A cornerstone of this health care reform is its commitment to making preventive services both affordable and readily available for all Americans. This is achieved by mandating that most health insurance plans cover a range of recommended preventive services without imposing cost-sharing burdens like copayments, coinsurance, or deductibles. For consumers, this means that when these essential preventive services are delivered by an in-network provider, they are accessible at no direct cost.
A particularly impactful aspect of the ACA is its focus on women’s health. Recognizing the unique healthcare needs women face throughout their lives, the law stipulates that most private health insurance plans must provide comprehensive coverage for women’s preventive healthcare. This includes vital services such as mammograms for breast cancer screening, cervical cancer screenings, and essential prenatal care, alongside a spectrum of other preventive measures, all without cost sharing. Section 2713 of the Public Health Service Act, as amended by the ACA, explicitly requires non-grandfathered group health plans and non-grandfathered individual health insurance coverage to cover these specified preventive services. This coverage extends to preventive care and screenings for women, as detailed in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA). These provisions are critical in ensuring that financial constraints do not hinder women from accessing necessary preventive care.
The underlying principle of these guidelines is the understanding that women have distinct health requirements across their lifespan. The Women’s Preventive Services Initiative (WPSI) plays a crucial role in this framework. Its primary goal is to continuously improve women’s health by identifying and recommending preventive services and screenings that are grounded in scientific evidence and suitable for clinical practice. When these recommendations receive HRSA support, they are incorporated into the official Guidelines, further shaping the landscape of women’s preventive healthcare coverage under health care reform.
The Foundation of Women’s Preventive Services Guidelines: HRSA and WPSI
The HRSA-supported Women’s Preventive Services Guidelines are not static; they are built upon a foundation of ongoing scientific review and adaptation. The initial Guidelines were established in 2011, drawing from a comprehensive study commissioned by the Department of Health and Human Services and conducted by the Institute of Medicine (IOM), now known as the National Academy of Medicine (NAM). This initial framework was crucial in setting the stage for expanded preventive care for women.
However, healthcare is a field of constant advancement. Recognizing the progress in scientific understanding and the identification of gaps in clinical practice, HRSA took proactive steps to ensure the Guidelines remained current and effective. In 2016, HRSA awarded a significant five-year cooperative agreement to the American College of Obstetricians and Gynecologists (ACOG), launching the Women’s Preventive Services Initiative (WPSI). This initiative brought together a coalition of experts – clinicians, academics, and consumer health advocates – to rigorously review and update the Guidelines. The WPSI adopted a scientifically robust approach, aligning with the model established by the NAM’s Clinical Practice Guidelines We Can Trust, ensuring the recommendations were evidence-based and trustworthy. ACOG established an expert panel, also named WPSI, to spearhead this important work.
Continuing this commitment to up-to-date guidelines, ACOG received a subsequent cooperative agreement in March 2021. This ongoing agreement mandates WPSI to regularly review and recommend updates to the Women’s Preventive Services Guidelines at least every five years, or more frequently as new scientific evidence emerges or when new preventive service topics warrant consideration. The WPSI also provides a mechanism for continuous improvement, accepting suggestions for new topics for future guideline consideration through the Women’s Preventive Services Initiative website. This ensures that the guidelines remain responsive to the evolving landscape of women’s health and preventive care.
HRSA-Supported Women’s Preventive Services: A Detailed Look
HRSA formally supports the Women’s Preventive Services Guidelines, a comprehensive list addressing the specific health needs of women. These guidelines are not just recommendations; they are the basis for mandatory coverage without cost-sharing under the ACA, impacting how healthcare is delivered and accessed.
In a significant update in December 2024, HRSA approved revisions to the Guidelines for two critical preventive services: Screening and Counseling for Intimate Partner and Domestic Violence, and Breast Cancer Screening for Women at Average Risk. Furthermore, a new guideline was introduced for Patient Navigation Services for Breast and Cervical Cancer Screening. These updated and new guidelines are designed to enhance the effectiveness and accessibility of preventive care, and are set to be implemented for plan years starting in 2026. The following tables detail these changes and the scope of current guidelines.
Updated Guidelines for Implementation in 2026
| Type of Preventive Service | Current Guidelines | Updated Guideline Beginning with Plan Years Starting in 2026 |
|---|---|---|
| Screening and Counseling for Intimate Partner and Domestic Violence | WPSI recommends screening adolescents and women for interpersonal and domestic violence, at least annually, and, when needed, providing or referring for initial intervention services. Interpersonal and domestic violence includes physical violence, sexual violence, stalking and psychological aggression (including coercion), reproductive coercion, neglect, and the threat of violence, abuse, or both. Intervention services include, but are not limited to, counseling, education, harm reduction strategies, and referral to appropriate supportive services. | The Women’s Preventive Services Initiative recommends screening adolescent and adult women for intimate partner and domestic violence, at least annually, and, when needed, providing or referring to intervention services. Intimate partner and domestic violence includes physical violence, sexual violence, stalking and psychological aggression (including coercion), reproductive coercion, neglect, and the threat of violence, abuse, or both. Intervention services include, but are not limited to, counseling, education, harm reduction strategies, and appropriate supportive services. |
| Breast Cancer Screening for Women at Average Risk | WPSI recommends that average-risk women initiate mammography screening no earlier than age 40 and no later than age 50. Screening mammography should occur at least biennially and as frequently as annually. Screening should continue through at least age 74 and age alone should not be the basis to discontinue screening. These screening recommendations are for women at average risk of breast cancer. Women at increased risk should also undergo periodic mammography screening, however, recommendations for additional services are beyond the scope of this recommendation. | The Women’s Preventive Services Initiative recommends that women at average risk of breast cancer initiate mammography screening no earlier than age 40 years and no later than age 50 years. Screening mammography should occur at least biennially and as frequently as annually. Women may require additional imaging to complete the screening process or to address findings on the initial screening mammography. If additional imaging (e.g., magnetic resonance imaging (MRI), ultrasound, mammography) and pathology evaluation are indicated, these services also are recommended to complete the screening process for malignancies. Screening should continue through at least age 74 years, and age alone should not be the basis for discontinuing screening. Women at increased risk also should undergo periodic mammography screening, however, recommendations for additional services are beyond the scope of this recommendation. |
New Guideline Expanding Access to Care
| Type of Preventive Service | New Guideline Beginning with Plan Years Starting in 2026 |
|---|---|
| Patient Navigation Services for Breast and Cervical Cancer Screening | The Women’s Preventive Services Initiative recommends patient navigation services for breast and cervical cancer screening and follow-up, as relevant, to increase utilization of screening recommendations based on an assessment of the patient’s needs for navigation services. Patient navigation services involve person-to-person (e.g., in-person, virtual, hybrid models) contact with the patient. Components of patient navigation services should be individualized. Services include, but are not limited to, person-centered assessment and planning, health care access and health system navigation, referrals to appropriate support services (e.g., language translation, transportation, and social services), and patient education. |
Current Guidelines Ensuring Comprehensive Preventive Care
| Type of Preventive Service | Current Guidelines |
|---|---|
| Screening for Anxiety | WPSI recommends screening for anxiety in adolescent and adult women, including those who are pregnant or postpartum. Optimal screening intervals are unknown and clinical judgement should be used to determine screening frequency. Given the high prevalence of anxiety disorders, lack of recognition in clinical practice, and multiple problems associated with untreated anxiety, clinicians should consider screening women who have not been recently screened. |
| Screening for Cervical Cancer | WPSI recommends cervical cancer screening for average-risk women aged 21 to 65 years. For women aged 21 to 29 years, the Women’s Preventive Services Initiative recommends cervical cancer screening using cervical cytology (Pap test) every 3 years. Cotesting with cytology and human papillomavirus testing is not recommended for women younger than 30 years. Women aged 30 to 65 years should be screened with cytology and human papillomavirus testing every 5 years or cytology alone every 3 years. Women who are at average risk should not be screened more than once every 3 years. |
| Obesity Prevention in Midlife Women | WPSI recommends counseling midlife women aged 40 to 60 years with normal or overweight body mass index (BMI) (18.5-29.9 kg/m2) to maintain weight or limit weight gain to prevent obesity. Counseling may include individualized discussion of healthy eating and physical activity. |
| Breastfeeding Services and Supplies | WPSI recommends comprehensive lactation support services (including consultation; counseling; education by clinicians and peer support services; and breastfeeding equipment and supplies) during the antenatal, perinatal, and postpartum periods to optimize the successful initiation and maintenance of breastfeeding.Breastfeeding equipment and supplies include, but are not limited to, double electric breast pumps (including pump parts and maintenance) and breast milk storage supplies. Access to double electric pumps should be a priority to optimize breastfeeding and should not be predicated on prior failure of a manual pump. Breastfeeding equipment may also include equipment and supplies as clinically indicated to support dyads with breastfeeding difficulties and those who need additional services. |
| Contraception | WPSI recommends that adolescent and adult women have access to the full range of contraceptives and contraceptive care to prevent unintended pregnancies and improve birth outcomes. Contraceptive care includes screening, education, counseling, and provision of contraceptives (including in the immediate postpartum period). Contraceptive care also includes follow-up care (e.g., management, evaluation and changes, including the removal, continuation, and discontinuation of contraceptives). WPSI recommends that the full range of U.S. Food and Drug Administration (FDA)- approved, -granted, or -cleared contraceptives, effective family planning practices, and sterilization procedures be available as part of contraceptive care. The full range of contraceptives includes those currently listed in the FDA’s Birth Control Guide: (1) sterilization surgery for women, (2) implantable rods, (3) copper intrauterine devices, (4) intrauterine devices with progestin (all durations and doses), (5) injectable contraceptives, (6) oral contraceptives (combined pill), 7) oral contraceptives (progestin only), (8) oral contraceptives (extended or continuous use), (9) the contraceptive patch, (10) vaginal contraceptive rings, (11) diaphragms, (12) contraceptive sponges, (13) cervical caps, (14) condoms, (15) spermicides, (16) emergency contraception (levonorgestrel), and (17) emergency contraception (ulipristal acetate), and any additional contraceptives approved, granted, or cleared by the FDA. Additionally, instruction in fertility awareness-based methods, including the lactation amenorrhea method, although less effective, should be provided for women desiring an alternative method. |
| Counseling for Sexually Transmitted Infections (STIs) | WPSI recommends directed behavioral counseling by a health care clinician or other appropriately trained individual for sexually active adolescent and adult women at an increased risk for STIs. WPSI recommends that clinicians review a woman’s sexual history and risk factors to help identify those at an increased risk of STIs. Risk factors include, but are not limited to, age younger than 25, a recent history of an STI, a new sex partner, multiple partners, a partner with concurrent partners, a partner with an STI, and a lack of or inconsistent condom use. For adolescents and women not identified as high risk, counseling to reduce the risk of STIs should be considered, as determined by clinical judgment. |
| Human Immunodeficiency Virus Infection (HIV) | WPSI recommends all adolescent and adult women, ages 15 and older, receive a screening test for HIV at least once during their lifetime. Earlier or additional screening should be based on risk, and rescreening annually or more often may be appropriate beginning at age 13 for adolescent and adult women with an increased risk of HIV infection.WPSI recommends risk assessment and prevention education for HIV infection beginning at age 13 and continuing as determined by risk. A screening test for HIV is recommended for all pregnant women upon initiation of prenatal care with rescreening during pregnancy based on risk factors. Rapid HIV testing is recommended for pregnant women who present in active labor with an undocumented HIV status. Screening during pregnancy enables prevention of vertical transmission. |
| Well-Woman Preventative Visits | WPSI recommends that women receive at least one preventive care visit per year beginning in adolescence and continuing across the lifespan to ensure the provision of all recommended preventive services, including preconception and many services necessary for prenatal and interconception care, are obtained. The primary purpose of these visits should be the delivery and coordination of recommended preventive services as determined by age and risk factors. These services may be completed at a single or as part of a series of visits that take place over time to obtain all necessary services depending on a woman’s age, health status, reproductive health needs, pregnancy status, and risk factors. Well-women visits also include prepregnancy, prenatal, postpartum and interpregnancy visits. |
| Screening for Diabetes in Pregnancy | The Women’s Preventive Services Initiative recommends screening pregnant women for gestational diabetes mellitus after 24 weeks of gestation (preferably between 24 and 28 weeks of gestation) to prevent adverse birth outcomes. WPSI recommends screening pregnant women with risk factors for type 2 diabetes or GDM before 24 weeks of gestation—ideally at the first prenatal visit. |
| Screening for Diabetes after Pregnancy | The WPSI recommends screening for type 2 diabetes in women with a history of gestational diabetes mellitus (GDM) who are not currently pregnant and who have not previously been diagnosed with type 2 diabetes. Initial testing should ideally occur within the first year postpartum and can be conducted as early as 4–6 weeks postpartum. Women who were not screened in the first year postpartum or those with a negative initial postpartum screening test result should be screened at least every 3 years for a minimum of 10 years after pregnancy. For those with a positive screening test result in the early postpartum period, testing should be repeated at least 6 months postpartum to confirm the diagnosis of diabetes regardless of the type of initial test (e.g., fasting plasma glucose, hemoglobin A1c, oral glucose tolerance test). Repeat testing is also indicated for women screened with hemoglobin A1c in the first 6 months postpartum regardless of whether the test results are positive or negative because the hemoglobin A1c test is less accurate during the first 6 months postpartum. |
| Screening for Urinary Incontinence | The Women’s Preventive Services Initiative recommends screening women for urinary incontinence annually. Screening should assess whether women experience urinary incontinence and whether it impacts their activities and quality of life. If indicated, facilitating further evaluation and treatment is recommended. |
Implementing Guidelines in Practice: Considerations for Healthcare Providers
While the HRSA-supported guidelines themselves are focused on clinical recommendations, the Women’s Preventive Services Initiative, through ACOG, has also developed crucial implementation considerations. These resources, available on the Women’s Preventive Services Initiative website, offer practical guidance on integrating the guidelines into everyday clinical practice. It’s important to note that these implementation considerations are separate from the formal clinical recommendations and serve as informational tools to aid in effective guideline adoption.
For health insurance plans, particularly non-grandfathered plans (those created or significantly changed after March 23, 2010), these Guidelines carry significant weight. Coverage without cost-sharing is mandated to align with these Guidelines, beginning with the first plan year (or individual market policy year) that starts on or after one year from the date of HRSA Administrator’s acceptance of the updated Guidelines. In the period between updates, plans are generally required to adhere to the previously updated Guidelines, ensuring consistent access to preventive services. Understanding these timelines is crucial for both healthcare providers and patients to navigate the landscape of preventive care coverage under health care reform. Accurate utilization of preventive diagnosis codes is essential for proper billing and ensuring patients receive the no-cost preventive services they are entitled to under the ACA.
