The Departments of Labor (DOL), Health and Human Services (HHS), and Treasury (collectively, the Departments) issued guidance in the form of FAQs on the ACA’s preventive services mandate. The ACA requires non-grandfathered plans to cover certain preventive services, including contraceptive coverage and BRCA testing (screening and genetic counseling for breast cancer susceptibility genes), among others, at no cost to participants. The FAQs provided guidance on the following preventive services topics.
The guidance provided that plans must cover without cost-sharing at least one form of contraception in each contraceptive method identified by the Food and Drug Administration (FDA). The FDA has currently identified 18 separate contraceptive methods in its Birth Control Guide. The coverage must also include clinical services, such as patient education and counseling, as needed for each contraceptive method.
The FAQs stated that plans may utilize “reasonable medical management techniques” within each contraceptive method, which includes imposing cost-sharing on some items and services to encourage individuals to use other specific items and services within the contraceptive method. However, the guidance provided, if an individual’s physician recommends a particular service or FDA-approved item based on a determination of medical necessity, the plan must cover that service or item without cost-sharing.
The FAQs clarified that non-grandfathered plans must cover BRCA testing and genetic counseling for women who have not been diagnosed with BRCA-related cancer, but who previously had breast cancer, ovarian cancer, or other cancer.
Coverage of Sex-Specific Preventive Services
Regarding coverage of preventive services for transgender individuals, the guidance stated that non-grandfathered plans cannot restrict coverage of sex-specific preventive services (e.g., mammograms or pap smears) based on an individual’s sex at birth, gender identity, or sex of the individual otherwise recorded by the plan.
Coverage of Women’s Preventive Services for Dependent Children
The FAQs stated that if a non-grandfathered plan provides coverage for dependent children, it must also cover certain women’s preventive care services, including services related to pregnancy, preconception and prenatal care, without cost-sharing, as developmentally appropriate.
Coverage of Anesthesia During Colonoscopy Screenings
The ACA’s preventive services mandate requires that non-grandfathered plans cover colonoscopy screenings without cost-sharing. The guidance states that plans must also cover anesthesia services performed in connection with preventive colonoscopies if the attending physician determines that anesthesia would be medically appropriate.