Plans and insurers must cover all 18 contraception methods approved by the U.S. Food and Drug Administration, according to a new set of questions and answers on the Affordable Care Act’s preventive care coverage requirements.
“Reasonable medical management” still may be used to steer members to specific products within those methods of contraception. A plan or insurer may impose cost-sharing on non-preferred items within a given method, as long as at least one form of contraception in each method is covered without cost-sharing.
However, an individual’s attending provider must be allowed to override the plan’s drug management techniques if the provider finds it medically necessary to cover without cost-sharing an item that a given plan or insurer has classified as non-preferred, according to one of the frequently asked questions from the U.S. Departments of Labor, Health and Human Services and the Treasury.
The ACA mandated all plans and insurers to cover preventive care items, as defined by the Public Health Service Act, without cost-sharing. Eighteen forms of female contraception are included under the preventive care list. The individual FAQs on contraception clarified the following requirements.
- Plans and insurers must cover without cost-sharing at least one version of all the contraception methods identified in the FDA Birth Control Guide. Currently, the guide lists 18 forms of contraception that must be thus covered.
Plans may use “reasonable medical management” to control the offerings within the 18 contraceptive forms covered. This includes encouraging the use of generic instead of brand-name drugs, by imposing cost-sharing on non-preferred brand-name drugs or items.
However, policies that impose costs on non-preferred drugs and items must be subject to an exception process that is “easily accessible, transparent and sufficiently expedient.” The process must not be unduly burdensome on the individual, provider or individual acting on the individual’s behalf, and must cover an item or service without cost-sharing if a treating physician deems it medically necessary. “The plan or issuer must defer to the determination of the attending provider with respect to the individual involved,” the guidance states. - Plans that try to offer coverage for some — but not all — FDA-identified contraceptive methods will not comply with the health care reform law and its rules. For example, plans cannot cover barrier and hormonal methods of contraception while excluding coverage for implants or sterilization.
The FAQ comes just weeks after reports and news coverage detailed health plan violations of the women coverage provisions of the ACA.
Testing and Dependent Care Answers
In questions separate from contraception, plans and insurers were told they must cover breast cancer susceptibility (BRCA-1 or BRCA-2) testing without cost-sharing. The test identifies whether the woman has genetic mutations that make her more susceptible to BRCA-related breast cancer.
Another question stated that if colonoscopies are performed as preventive screening without cost-sharing, then plans could not impose cost-sharing on the anesthesia component of that service.
For more on the ACA preventive care rules, consult Section 370 of the New Health Care Reform Law: What Employers Need to Know.