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The Department of Labor, Health and Human Services, and Treasury jointly released FAQs that provide additional guidance on women’s preventive care under the ACA.

Pursuant to the ACA, all non-grandfathered group health plans are required to cover the following preventive services without cost sharing:

  • Evidenced-based items or services that have a rating of “A” or “B” from the United States Preventive Services Task Force (USPSTF)
  • Immunizations for routine use in children, adolescents, and adults that have a recommendation from the Advisory Community on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC)
  • Preventive care and screenings for infants, children, and adolescents that have a recommendation by the Health Resources and Services Administration (HRSA); and
  • Preventive care and screening for women that are follow guidelines supported by the HRSA.

The FAQs also clarify that insurance carriers and group health plans are required to cover, without cost sharing, the full range of FDA-identified contraceptive methods. This means that plans and carriers must cover, without cost sharing, at least one form of contraception in each of the 18 identified methods of contraception.

However, a plan or carrier may continue to use reasonable medical management techniques, such as imposing cost sharing to encourage patients to use specific items or services within a contraceptive method.

For example, plans or carriers may impose cost sharing on brand name options to encourage participants to use generic brands. If a plan or carrier uses such reasonable medical management techniques, they must have an easily accessible, transparent, and sufficiently expedient exceptions process that is not unduly burdensome on the individual. Additionally, if an individual’s doctor recommends a particular service or FDA-approved item based on a determination of medical necessity, the plan or issue must cover that service or item without cost-sharing.

The following items were also clarified by the FAQs:

  • If preventive screening and BRCA testing is recommended by an individual’s doctor, it must be offered.
  • Preventive services without cost sharing must be provided, as recommended by an individual’s doctor, regardless of the sex assigned to the individual at birth, gender identity, or gender recorded by the plan or carrier.
  • If a plan or carrier covers dependent children, such dependent children must be provided the full range of recommended preventive services applicable for their age group without cost sharing and subject to reasonable medical management techniques.
  • If determined to be medically appropriate by an individual’s doctor, plans and carriers must cover anesthesia for a preventive colonoscopy, without cost sharing.

 

Additional Resources

Please visit the Department of Labor’s FAQ page.

 

 

The information and materials on this blog are provided for informational purposes only and are not intended to constitute legal or tax advice. Information provided in this blog may not reflect the most current legal developments and may vary by jurisdiction. The content on this blog is for general informational purposes only and does not apply to any particular facts or circumstances. The use of this blog does not in any way establish an attorney-client relationship, nor should any such relationship be implied, and the contents do not constitute legal or tax advice. If you require legal or tax advice, please consult with a licensed attorney or tax professional in your jurisdiction. The contributing authors expressly disclaim all liability to any persons or entities with respect to any action or inaction based on the contents of this blog.

Bonnie Mangels – Bonnie is the Corporate Counsel and Senior Compliance Manager for Sequoia. When not inundated in paperwork and legal briefs, her interests include arts and crafts, bunnies, and the Bay Area.