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Implementation FAQs Address Preventive Services, Including Coverage of Genetic Testing, Contraceptives, and More

FAQs About Affordable Care Act Implementation Part XXVI (May 11, 2015)

DOL website

HHS website

Visit the Health Care Reform Community on Checkpoint to join the discussion on this development (for Checkpoint subscribers to EBIA’s Health Care Reform manual).

The IRS, HHS, and DOL have jointly issued FAQ guidance on coverage of preventive health services. As background, health care reform requires non-grandfathered, nonexcepted group health plans to provide coverage for various preventive services delivered by in-network providers without cost-sharing—thus, no deductibles, copayments, coinsurance, or other cost-sharing may be imposed on these services. Here are highlights of this latest guidance:

  • BRCA-Related Cancer Screening, Counseling, and Testing. Q/A-1 clarifies that the United States Preventive Services Task Force (USPSTF) recommendation for breast cancer susceptibility gene (BRCA) screening, genetic counseling, and testing applies to women who are asymptomatic and have not received a BRCA-related cancer diagnosis, but who previously had breast, ovarian, or other cancer, as well as to women whose family history is associated with an increased risk of BRCA-related cancer. According to the current USPSTF recommendation, women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing. [EBIA Comment: Previous FAQ guidance had clarified HHS’s position that the scope of this USPSTF recommendation includes both genetic counseling and BRCA testing, if appropriate, for a woman as determined by her provider (see our article).]
  • FDA-Approved Contraceptives. Q/As-2 through -4 clarify that plans and insurers must cover without cost-sharing the full range of FDA-identified contraceptive methods. This means that coverage must be provided without cost-sharing for at least one form of contraception in each method that is identified for women by the FDA in its current Birth Control Guide (currently 18 distinct methods). This coverage must also include the clinical services, including patient education and counseling. Significantly, the agencies acknowledge that prior guidance may have been interpreted as not requiring coverage without cost-sharing of at least one form of contraception in each method identified by the FDA, so this clarification will apply as of plan years beginning on or after 60 days after these FAQs were issued (i.e., July 10, 2015). These FAQs also provide further guidance on the extent to which plans and insurers may utilize reasonable medical management.
  • Sex-Specific Recommended Preventive Services. According to Q/A-5, a plan or insurer must provide coverage for a recommended preventive service, without cost-sharing, regardless of the sex assigned at birth, gender identity, or gender of the individual otherwise recorded by the plan or insurer. For example, a plan must provide a recommended mammogram or pap smear for a transgender man. [EBIA Comment: Employers should also keep in mind that the EEOC is currently pursuing Title VII sex discrimination enforcement efforts for lesbian, gay, bisexual, and transgender (LGBT) individuals (see our article).]
  • Well-Woman Preventive Care for Dependents. Q/A-6 makes clear that plans must cover the recommended preventive care services for all participants and beneficiaries. Thus, if a plan covers dependent children, then they must be provided the full range of recommended preventive services applicable to them without cost-sharing and subject to reasonable medical management techniques. For example, well-woman visits for adult women (including preconception care and many services necessary for prenatal care) must be covered for dependent children where an attending provider determines that the services are age-appropriate and developmentally appropriate. [EBIA Comment: Employers with small group market insurance plans should be aware that they may also be required to cover maternity care of dependent children as one of the essential health benefits (see our Question of the Week).]
  • Colonoscopies. Q/A-7 clarifies that a plan or insurer may not impose cost-sharing for anesthesia services performed in connection with a colonoscopy performed as a preventive screening procedure (if the attending provider determines that anesthesia would be medically appropriate for the individual).

EBIA Comment: Given the broad range of preventive services described in governmental recommendations and guidelines that are required to be covered, issues continue to arise under this mandate. These FAQs provide essential information to those involved in scoping the coverage for health plans. The guidance on required coverage for dependent children underscores how health care reform has changed the rules for plans that restrict access to maternity-related expenses for children. And the BRCA genetic testing guidance should serve as a reminder to employers that the Genetic Information Nondiscrimination Act (GINA) prohibits discrimination based on genetic information and places strict limits on the disclosure of genetic information. For more information, see EBIA’s Health Care Reform manual at Section XII.C (“Coverage of Preventive Health Services”); see also EBIA’s Group Health Plan Mandates manual at Sections XIII.C(“Coverage of Preventive Health Services”) and XXII.A (“What Are the Nondiscrimination Requirements in GINA and Who Must Comply?”), as well as EBIA’s Self-Insured Health Plans manual at Section XIII.E (“Coverage Limitations and Exclusions”).

Contributing Editors: EBIA Staff.

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