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Guidance on Coverage for Preventive Items and Services

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Frequently asked questions (FAQs), prepared jointly by the Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury were issued on May 12, 2015 with respect to the Affordable Care Act (ACA) requirement for a non-grandfathered group health plan to provide coverage for in-network preventive items and services (including contraception) without any cost-sharing requirements, as summarized below.

Contraception

Plans must cover without cost sharing at least one form of contraception in each method that is identified by the FDA. FAQs provide that, therefore:

1. Because a plan covers some forms of oral contraceptives, some types of IUDs, and some types of diaphragms without cost sharing does not mean that it can exclude completely other forms of contraception.

2. If multiple services and FDA-approved items within a contraceptive method are medically appropriate for an individual patient, the plan may use reasonable medical management techniques to determine which specific products to cover without cost sharing with respect to that individual. However, if the 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 must cover that service or item without cost sharing.

3. For hormonal contraceptive methods, coverage must include all 3 oral contraceptive methods (combined, progestin-only, and extended/continuous use), injectables, implants, the vaginal contraceptive ring, the contraceptive patch, emergency contraception (Plan B/Plan B One Step/Next Choice, Ella), and IUDs with progestin.

This clarifying guidance applies to plan years beginning on or after August 1, 2015.

Well-woman Preventive Care for Dependents

If a plan covers dependent children, the plan is required to cover without cost sharing recommended women’s preventive care services for dependent children, including recommended preventive services related to pregnancy, such as preconception and prenatal care.

Colonoscopies

It is not permissible for a plan to impose cost sharing with respect to anesthesia services performed in connection with the preventive colonoscopy if the attending provider determines that anesthesia is medically appropriate for the individual.

BRCA Genetic Testing

Plans must cover without cost sharing recommended genetic counseling and breast cancer (“BRCA”) genetic testing for a woman who has not been diagnosed with BRCA-related cancer but who previously had breast cancer, ovarian cancer, or other cancer as long as the woman has not been diagnosed with BRCA-related cancer.

Sex-specific Recommended Preventive Services

Plans cannot limit sex-specific recommended preventive services based on an individual’s sex assigned at birth, gender identity, or recorded gender. Whether a sex-specific recommended preventive service that is required to be covered without cost sharing is medically appropriate for a particular individual is determined by the individual’s attending provider such as, for example, providing a mammogram or pap smear for a transgender man who has residual breast tissue or an intact cervix.

For the FAQs, visit: http://www.dol.gov/ebsa/pdf/faq-aca26.pdf

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Arthur Grutt