In response to continued complaints of non-compliance, the Department of Labor, Department of Health and Human Services, and the Department of Treasury (collectively, the Departments) recently issued a letter encouraging group health plans to provide coverage for contraception at no cost, as required by the Affordable Care Act (ACA), and they released related FAQs.

Background

Per Section 2713 of the Public Health Service Act (PHSA), non-grandfathered group health plans (except for certain employers with a religious or moral exemption) and insurers are required to cover contraceptives (aligned with guidelines issued by the Health Resources and Services Administration (HRSA)) without cost sharing. Further, the ACA requires that all Food and Drug Administration (FDA) approved contraceptives that are determined to be medically appropriate by an individual’s medical provider be covered without cost sharing.

This means that plans are required to cover at no cost:

  • At least one form of contraception in each HSRA contraceptive category; and
  • Contraceptive services or FDA approved, cleared, or granted contraceptive products advised by a health care provider as medically appropriate for an individual.

In addition, plans may use reasonable medical management techniques per category.

The Departments’ Recent Guidance

These coverage requirements are not new; however, the Departments are concerned about the continued complaints of noncompliance and clarify that enforcement and corrective action may be taken as a result, as explained further in their letter and FAQs (and prior guidance as mentioned in our blog, New Guidance and Reminders on Certain Services Covered Without Cost Sharing).

As described further in their letter, highlights of action items to ensure compliance include:

  • Developing an exceptions process for contraceptive products that is not unduly burdensome (or review existing exceptions process for the same);
  • Creating and implementing standardized forms for the exceptions process;
  • Communicating information related to the exceptions process to individuals through plan documentation and online resources;
  • Removing any unreasonable medical management techniques; and
  • Deferring to provider’s recommendations regarding medical necessity determination.

For more information on contraceptive coverage requirements, see the Departments most recent FAQs on the topic.

Employer Action

Employers should be aware of these coverage requirements and discuss with their carriers (if fully insured) or their third-party administrators (if self-insured/level funded) to ensure their plans are compliant with the contraception coverage requirements (if not exempt) to avoid future enforcement actions that could impose penalty.

Additional Resources

Diane Cross — Diane is a Client Compliance Consultant for Sequoia, where she works with our clients to optimize and streamline benefits compliance. In her free time, Diane enjoys spending time with her family, live music, and cycling.