ACA News & Publications

ACA Pathways: Additional Guidance Released Regarding ACA’s Preventive Services Coverage Requirement

May 14, 2015

The Departments of Labor (DOL), Health and Human Services (HHS) and the Treasury (collectively, the Departments) have jointly released additional Frequently Asked Questions (FAQs) to assist in the implementation of the preventive services coverage requirement under the Affordable Care Act (ACA) that apply to non-grandfathered group and individual health plans. In particular, these FAQs provide the following clarifications to existing guidance:

  • Plans must cover preventive screening, genetic counseling, and BRCA genetic testing without cost sharing, as appropriate, for women who have family members with breast, ovarian, tubal, or peritoneal cancer, even though they may have not been actually diagnosed with BRCA-related cancer;
  • Plans must cover at least one form of contraception in each of the 18 methods that the FDA has identified for women in its current Birth Control Guide without cost sharing, along with associated clinical services (a chart of the minimum contraceptive coverage requirements prepared by the Kaiser Family Foundation is available at http://kff.org/womens-health-policy/issue-brief/minimum-contraceptive-coverage-requirements-clarified-by-hhs-guidance/ );
  • Plans may utilize reasonable medical management techniques within a specified contraception method (for example, plans may discourage the use of brand name pharmacy items over generic brands by imposing cost sharing on the brand name products), as long as there is an exceptions process that is easily accessible, transparent, and sufficiently expedient such that it is not unduly burdensome on the individual or provider;
  • If multiple services and FDA-approved items within a contraceptive method are medically appropriate for an individual, reasonable medical management techniques may be used to determine which specific products to cover without cost sharing with respect to that individual;
  • Plans must cover a particular service or FDA-approved contraceptive item without cost sharing if recommended by an individual’s physician based on medical necessity;
  • Plans may not limit sex-specific recommended preventive services based on an individual’s sex assigned at birth, gender identity, or gender of the individual. What is medically appropriate for a particular individual must be determined by the individual’s attending provider (this would include covering medically appropriate preventive services without cost sharing for transgender individuals);
  • If the plan covers dependent children, they also must be provided the full range of recommended preventive services that might apply to them (e.g., for their age group) without cost sharing, subject to reasonable medical • management techniques. For example, well-woman preventive services that are determined to be age and developmentally appropriate to a dependent must be provided without cost sharing; and
  • Plans cannot impose cost sharing on anesthesia services performed in connection with a preventive colonoscopy if the attending provider determines that anesthesia would be medically appropriate for that individual.

The FAQs can be found on the DOL website at http://www.dol.gov/ebsa/faqs/faq-aca26.html . Please also visit http://www.dol.gov/ebsa/healthreform/regulations/acaimplementationfaqs.html for other FAQs related to ACA implementation.

For More Information
For more information about this ACA Pathways or about any other health care reform-related provisions, please contact your Burnham Benefits consultant or Burnham Benefits at:

Burnham Benefits
949.833.2983
inquiries@burnhambenefits.com


[1] Available at http://www.fda.gov/downloads/ForConsumers/ByAudience/ForWomen/FreePublications/UCM356451.pdf.

This ACA Pathways is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice. The information contained in this ACA Pathways includes emerging health care news from a limited perspective and does not encompass all views. The information was selected from a wide range of sources selected on the basis of their potential impact on employers and/or their employee benefit plans. For more information, please contact Burnham Benefits.

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