The landmark Affordable Care Act (ACA), enacted on March 23, 2010, revolutionized healthcare access in the United States. A cornerstone of this legislation is its commitment to preventive care, ensuring that essential services are not only available but also affordable for all Americans. For women, this meant a significant expansion of preventive health services coverage, eliminating cost-sharing barriers for crucial screenings and care. This article delves into the details of how the ACA, particularly in the context of the evolving healthcare landscape around 2016, enhanced preventive care for women, guided by the Health Resources and Services Administration (HRSA)-supported Women’s Preventive Services Guidelines. Understanding the framework of these guidelines is essential for healthcare providers and individuals alike to navigate and utilize these vital services effectively.
At its core, the ACA mandates that most health insurance plans cover a range of recommended preventive services without imposing cost-sharing measures like copayments, coinsurance, or deductibles. This provision directly addresses financial obstacles that previously hindered access to preventive care. When delivered by in-network providers, these services, backed by robust scientific evidence, are accessible without upfront financial burden on the patient. Section 2713 of the Public Health Service Act, as amended by the ACA, explicitly requires non-grandfathered health plans to cover specified preventive services, including comprehensive preventive care and screenings for women, as outlined in guidelines supported by HRSA. These guidelines acknowledge and address the distinct health needs of women throughout their lives. The Women’s Preventive Services Initiative (WPSI) plays a pivotal role in this process, dedicated to improving women’s health by identifying and recommending preventive services and screenings for clinical practice, which are then considered for incorporation into the HRSA Guidelines.
HRSA-Supported Women’s Preventive Services Guidelines: A Closer Look
The foundation of the HRSA-supported Women’s Preventive Services Guidelines was laid in 2011, drawing upon recommendations from a comprehensive study commissioned by the Department of Health and Human Services and conducted by the Institute of Medicine (IOM), now recognized as the National Academy of Medicine (NAM). This initial framework was crucial in establishing a baseline for women’s preventive healthcare under the ACA.
Recognizing the dynamic nature of medical science and the evolving understanding of clinical practice gaps, HRSA initiated a significant update process in 2016. A five-year cooperative agreement was awarded to the American College of Obstetricians and Gynecologists (ACOG) to lead the Women’s Preventive Services Initiative (WPSI). This initiative brought together a coalition of experts from various sectors—clinicians, academics, and consumer-focused health professional organizations—to undertake a rigorous scientific review. The goal was to develop updated guidelines based on the established NAM Clinical Practice Guidelines We Can Trust model. ACOG subsequently formed an expert panel, also named WPSI, to spearhead this crucial endeavor. This update in 2016 marked a significant step in refining and enhancing the preventive services available to women.
Continuing this commitment to evidence-based guidelines, ACOG received a subsequent cooperative agreement in March 2021 to further review and recommend updates. WPSI, under ACOG’s leadership, is tasked with reviewing the Women’s Preventive Services Guidelines at least every five years, or more frequently as new scientific evidence emerges and new preventive service topics arise. The initiative also maintains an open channel for continuous improvement, allowing for the submission of new topics for consideration via the Women’s Preventive Services Initiative website. This ongoing process ensures that the guidelines remain current, relevant, and reflective of the latest advancements in women’s healthcare.
HRSA-Supported Women’s Preventive Services Guidelines: Key Updates and Current Recommendations
HRSA actively supports the Women’s Preventive Services Guidelines, which are specifically designed to address the unique health needs of women across different life stages. These guidelines are regularly reviewed and updated to incorporate the latest scientific evidence and clinical best practices.
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. Additionally, a new guideline was introduced for Patient Navigation Services for Breast and Cervical Cancer Screening. These updates, detailed in the tables below, are set to take effect for plan years starting in 2026, further enhancing the scope and effectiveness of preventive care for women.
Updated Guidelines
| 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
| 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: A Comprehensive Suite of Preventive Services
Beyond the updated and new guidelines, a comprehensive suite of preventive services for women remains in place, ensuring broad coverage across various health needs. These current guidelines encompass a wide spectrum of screenings, counseling, and support services, all aimed at promoting women’s health and well-being.
| 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. |
Implementation and Access: Ensuring Women Benefit from Preventive Care
While the HRSA-supported guidelines provide a robust framework, the Women’s Preventive Services Initiative, through ACOG, also developed implementation considerations to facilitate the practical application of these guidelines in clinical settings. These considerations, available on the Women’s Preventive Services Initiative website, offer valuable insights into how healthcare providers can effectively integrate these guidelines into their practice. It is important to note that these implementation considerations are distinct from the clinical recommendations themselves and serve as informational resources to aid in guideline adoption.
For non-grandfathered health plans and coverage, compliance with these Guidelines is mandatory. Generally, plans created or significantly changed after March 23, 2010, fall under this category. Coverage without cost-sharing, consistent with the updated Guidelines, is required starting from the first plan year (or individual market policy year) that begins on or after one year from the date the updated Guidelines are accepted by the HRSA Administrator. In the period between updates, non-grandfathered plans are generally expected to maintain coverage consistent with the previously updated Guidelines. These regulations ensure a continuous commitment to providing women with access to essential preventive services without financial barriers.
* Religious and moral exemptions related to the coverage of certain preventive health services are detailed in 45 CFR 147.132 and 45 CFR 147.133.
** Education and counseling encompasses all methods of contraception, including hormonal, devices, surgical, barrier, and fertility-based awareness methods, including lactation amenorrhea.
*** The FDA’s Birth Control Guide referenced here is the version posted on December 22, 2021, excluding sterilization surgery for men, which falls outside the scope of the WPSI guidelines.
**** The inclusion of fertility awareness-based methods in the “Contraception” section of the 2021 Guidelines, consistent with footnote ** above, is maintained as per a Final Order issued on December 6, 2022, in Tice-Harouff v. Johnson, Eastern District of Texas (Tyler Division), Case No. 6:22-cv-201-JDK.
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