As we discussed in an earlier post, non-grandfathered group health plans must cover certain women’s preventive services without cost-sharing for plan years beginning on or after August 1, 2012 (which would be January 1, 2013 for calendar-year plans). Several of the FAQs in the recently released 12th set of FAQs relating to health care reform provide additional guidance on such coverage of women’s preventive services.
The FAQs clarified the following points, which may not have previously been apparent to plan sponsors:
1) 100% Payment of “Out-of-Network” Coverage: Although the requirement to cover preventive services without cost-sharing generally does not apply to services that are performed out-of-network, FAQ Q&A-3 clarifies that if a plan does not have a network provider who can provide the particular service, then the plan must cover such service at 100% even if it is performed by an out-of-network provider.
2) 100% Payment Not Necessarily Limited to Generics: Plans are allowed to use reasonable medical management techniques to control costs and promote efficient delivery of care by covering generic contraceptives without cost-sharing, but imposing cost-sharing for an equivalent brand-name drug. However, FAQ Q&A-14 provides that if a generic version is not available, or would not be as “medically appropriate for the patient as a prescribed brand name contraceptive method (as determined by the attending provider, in consultation with the patient), then a plan or issuer must provide coverage for the brand name drug in accordance with the requirements of the interim final regulations (that is, without cost-sharing, subject to reasonable medical management).”
3) Over-the-Counter Contraceptives Must Be Covered if Prescribed: While plans may generally choose not to pay 100% for “over-the-counter” contraceptives (e.g., sponges and spermicides), FAQ Q&A-15 states that “if the method is both FDA-approved and prescribed for a woman by her health care provider,” then they must be covered without cost-sharing.
Plan sponsors should review any previously distributed employee communications regarding plan coverage of women’s preventive services to determine whether any revisions need to be made to reflect this new guidance.