The Departments of Labor, Health, and Human Services and the Treasury have once again issued a set of FAQs regarding the implementation of the Patient Protection and Affordable Care Act (ACA). This recent guidance, the 12th in a series of FAQs that the agencies have published, focuses primarily on preventive care issues. Below is a summary of some of the issues addressed by the recent guidance.
Out-of-network coverage of preventive care services. Under the ACA, non-grandfathered group health plans are required to provide first dollar coverage of certain preventive care services. One of the recent FAQs clarifies that this no cost-sharing requirement applies to preventive services provided by an out-of-network provider when the plan does not have any in-network provider that offers the particular required preventive service.
Aspirin as preventive care. The U.S. Preventive Services Task Force recommends the use of aspirin for certain patients to reduce the risk of heart attacks. An FAQ in the recent guidance states that, when prescribed by a health care provider, aspirin must be covered without cost-sharing.
Polyp removal during a colonoscopy screening. If a polyp is discovered and removed during a colonoscopy that was performed as part of a screening procedure, a plan cannot impose cost-sharing on a participant. This is because the medical community regards polyp removal as an integral part of a colonoscopy. The FAQ notes, however, that cost-sharing may be imposed where a treatment is not a recommended preventive service, even if the treatment results from a preventive service.
First dollar coverage of contraceptives. As mentioned, non-grandfathered group health plans are prohibited from imposing cost-sharing on certain preventive care services, including all Food and Drug Administration approved contraceptive methods. Accordingly, a plan may not limit coverage to only oral contraceptives. However, plans may use reasonable medical management techniques to control costs. For example, a plan may cover a generic drug without cost-sharing and impose cost-sharing for an equivalent branded drug. In this instance, however, a plan must have a mechanism for waiving the cost-sharing for a branded drug if an individual’s health care provider determines the generic drug would be medically inappropriate.
All the DOL FAQs on the new health care law can be found by clicking on the FAQs tab on the left side of the DOL Employee Benefit Security Administration website. You can go directly to this recent release by clicking here.