May 11, 2015
Latest FAQ Provides Guidance on Coverage of Preventive Services under PPACA
The U.S. departments of Labor (DOL), Health and Human Services (HHS) and Treasury released FAQs About Affordable Care Act Implementation (Part XXVI) on May 11, providing additional guidance addressing specific questions regarding the coverage of recommended preventive services under the Patient Protection and Affordable Care Act (PPACA).
Under Section 2713 of the Public Health Services Act (as added by PPACA) and interim final regulations issued in July 2010, non-grandfathered health plans are required to provide certain preventive care services without cost-sharing. The latest FAQ provides clarifications specific to BRCA (breast cancer genetic marker) testing, contraception, sex-specific recommended preventive services, recommended preventive services for dependents covered under a plan or policy and colonoscopies.
Most significantly, the FAQ clarifies a matter related to the departments’ FAQs Part XII, released in February 2013, which stated that the prevailing guidelines “ensure women’s access to the full range of FDA-approved contraceptive methods.” The prior FAQ permitted plans and issuers to use reasonable medical management techniques to control costs and promote efficient delivery of care, as long as there is a mechanism for accommodating any individual for whom a particular drug (generic or brand name) would be medically inappropriate.
FAQs Part XXVI provides further guidance on the scope of coverage required for contraception and the extent to which plans and issuers may use reasonable medical management. But it also acknowledges that “prior guidance may reasonably have been interpreted in good faith as not requiring coverage without cost sharing of at least one form of contraception in each method identified by the FDA.” Therefore, the departments will apply this clarifying guidance for plan years (or, in the individual market, policy years) beginning on or after July 10 (the date that is 60 days after publication of these FAQs).
FAQs Part XXVI provides the following clarifications:
- a plan or issuer must cover preventive screening, genetic counseling and BRCA genetic testing without cost-sharing for women who previously had breast cancer, ovarian cancer or other non-BRCA-related cancer.
- Plans and issuers must cover without cost sharing at least one form of contraception in each of the methods (of which there are currently 18) that the FDA has identified for women in its current Birth Control Guide. The coverage must also include the clinical services, including patient education and counseling, needed for provision of the contraceptive method.
- If an individual’s attending provider recommends a particular service or FDA-approved item based on a determination of medical necessity with respect to that individual, the plan or issuer must cover that service or item without cost sharing, even if multiple services and FDA-approved items within a contraceptive method might generally be considered medically appropriate for an individual patient.
- Even if a plan or issuer covers oral contraceptives, it may not impose cost sharing on all items and services within other FDA-identified hormonal contraceptive methods.
- Plans or issuers may not limit sex-specific recommended preventive services based on an individual’s sex assigned at birth, gender identity or recorded gender.
- If a plan or issuer covers dependent children, it must also cover, without cost sharing, recommended preventive health services, including women’s preventive care where an attending provider determines that well-woman preventive services are age-and developmentally-appropriate for the dependent.
- A plan or issuer may not impose cost sharing with respect to anesthesia services performed in connection with a preventive colonoscopy if the colonoscopy is scheduled and performed as a preventive screening procedure pursuant to the U.S. Preventive Services Task Force (USPSTF) recommendation.
For more information, contact Kathryn Wilber, senior counsel, health policy, at (202) 289-6700.