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ACA FAQs Address Coverage of Preventive Services

On Behalf of | May 21, 2015 |

DOL, HHS and IRS (the “Departments”) have released FAQs About Affordable Care Act (ACA) Implementation Part XXVI (“FAQ XXVI”). FAQ XXVI provides clarification of the no-cost preventive services required under ACA for non-grandfathered group health plans.

Background. ACA requires non-grandfathered group health plans to cover the following preventive services without cost sharing:

  • evidence-based items and services given an “A” or “B” rating by the United States Preventive Services Task Force (“USPSTF”) with respect to the individual involved;
  • immunizations as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control;
  • children’s preventive care and screenings as recommended by Health Resources and Services Administration (“HRSA”) guidelines; and
  • Women’s preventive care and screenings as recommended by HRSA guidelines. The HRSA guidelines specifically require coverage of all FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity, as prescribed by a health care provider.

If the relevant preventive services recommendation or guideline does not specify the frequency, method, treatment, or setting for a recommended preventive service, ACA allows the group health plan to use reasonable medical management techniques to limit coverage.

FAQ XXVI. FAQ XXVI provides further clarification on the responsibilities of group health plans to cover contraceptives and other preventive services.

Contraceptives. FAQ XXVI explains that group health plans must cover, without cost sharing, at least one type of each of the 18 methods of birth control identified by the FDA. This coverage must include clinical services, including patient education and counseling needed for the provision of the contraceptive method. Within each method, group health plans may use reasonable medical management techniques, including the imposition of cost-sharing on some types of birth control to encourage the use of other types when several types are available within a particular method.

FAQ XXVI clarifies that if a provider recommends a particular type as medically necessary for an individual, the group health plan must defer to the professional’s determination. Medical necessity considerations include the severity of side effects, differences in permanence and reversibility of contraceptives, and an individual’s ability to appropriately use the item or service.

Because the Departments’ prior guidance may reasonably have been interpreted as not requiring cost-free coverage of at least one type of contraceptive treatment within each of the 18 methods identified by the FDA, the Departments will only enforce this guidance with respect to plan or policy years beginning 60 days from the publication of FAQ XXVI.

Other Preventive Services. With respect to other ACA-required preventive services, FAQ XXVI explains that:

  • Under the USPSTF guidelines, a woman who has not been diagnosed as having a breast cancer susceptibility gene (BRCA) must be offered preventive screening and genetic counseling and testing as determined appropriate by her attending provider;
  • Sex-specific recommended preventive services must be provided without cost sharing to transgender individuals, if recommended as medically appropriate for the particular individual by that individual’s attending provider, regardless of the gender assigned at birth, gender identity, or recorded gender (within plan records);
  • Health plans must cover, without cost sharing, preventive services for covered dependents of enrollees that are determined to be age and developmentally appropriate by the dependent’s provider, including services related to pregnancy, such as preconception and prenatal care; and
  • Health plans must cover, without cost sharing, anesthesia for a colonoscopy, if determined to be medically appropriate by a covered individual’s attending provider.

FAQ XXVI may be accessed at: