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Coverage of Preventive Services

FAQs Part XXVI - Coverage of Preventive Services
Frequently Asked Questions (FAQs) are regularly sent out by the Department of Labor (DOL), Health and Human Services (HHS) and the Treasury (collectively, the Departments). FAQ Part XXVI answers questions about cost-sharing expectations for preventive services. 

The Affordable Care Act (ACA) required that coverage offered in the individual or group market provide benefits for, and prohibit covered individuals to pay for, certain preventive services. These are called cost-sharing requirements. Preventive services generally cover:

  1. Certain evidence-based services or items recommended by the United State Preventive Services Task Force (USPSTF);
  2. Routine immunization for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices (ACIP);
  3. Preventive care and screenings for infants, children, and adolescents supported by the Health Resources and Services Administration (HRSA); and
  4. Preventive care and screening provided to women by comprehensive guidelines supported by HRSA.

Following the release of the first set of cost-sharing requirements in September 2010, many questions arose concerning all the various charges surrounding preventive service requirements. For instance, colonoscopies were to be performed with no cost sharing to participants. It then became a general practice to charge the participant for anesthesia services and other peripheral items or services.

BRCA Testing

Q-1. Must a plan or issuer cover without cost sharing recommended genetic counseling and BRCA genetic testing for a woman who has not been diagnosed with BRCA-related cancer but who previously had breast cancer, ovarian cancer, or other cancer?

A-1. Yes. Primary care providers should screen women who have family members with breast, ovarian, tubal, or peritoneal cancer with tools designed to identify a family history that may be associated with an increased risk for potentially harmful mutations – BRCA1 or BRCA2. As long as the woman has not been diagnosed with BRCA-related cancer, a plan or issuer must cover preventive screening, genetic counseling, and genetic testing without cost sharing.

FDA-Approved Contraceptives

Q-2. If a plan or issuer covers some forms of oral contraceptives, some types of IUDs, and some types of diaphragms without cost sharing, but excludes completely other forms of contraception, will the plan or issuer comply with PHS Act section 2713 and its implementing regulations?

A-2. No. Plans and issuers must cover without cost sharing the full range of FDA-identified methods. Thus, plans and issuers must cover without cost sharing at least one form of contraception in each of the 18 methods that are identified by the FDA. A plan or issuer generally may use reasonable medical management techniques and impose cost sharing (including full cost sharing) to encourage an individual patient to use specific services or FDA-approved items within the chosen contraceptive method. Plans and issuers must have an easily accessible, transparent, and sufficiently expedient exceptions process that is not unduly burdensome on the individual, provider, or patient's representative to ensure coverage without cost sharing of any service or FDA-approved item within the specified method of contraception as described in Q&A-3 below.

Because the Departments' prior guidance may reasonably have been interpreted in good faith as not requiring coverage without cost sharing of at least one form of contraception in each FDA method, the Departments will apply this clarifying guidance for plan or policy years beginning on or after the date that is 60 days after publication of these FAQs. That date is July 10, 2015.

Q-3. If multiple services and FDA-approved items within a contraceptive method are medically appropriate for an individual patient, what is a plan or issuer required to cover without cost sharing?

A-3. If the individual's attending provider recommends a particular service or FDA-approved item based on a determination of medical necessity with respect to that individual, the plan or issuer must cover that service or item without cost sharing.

Q-4. If a plan or issuer covers oral contraceptives, can it impose cost sharing on all items and services within other FDA-identified hormonal contraceptive methods (such as vaginal contraceptive ring or the contraceptive patch)?

A-4. No. Plans and issuers must cover without cost sharing at least one form of contraception within each FDA method. For the hormonal contraceptive methods, coverage therefore must include, but is not limited to, all three oral contraceptive methods (combined, progestin-only, and extended/continuous use), injectables, implants, the vaginal contraceptive ring, the contraceptive patch, and emergency contraception. Accordingly, a plan or issuer may not impose cost sharing on the ring or the patch.

Sex-specific Recommended Preventive Services

Q-5. Can plans or issuers limit sex-specific recommended preventive services based on an individual's sex assigned at birth, gender identity, or recorded gender?

A-5. No. Preventive service, regardless if sex-specific, that is required to be covered without cost sharing if medically appropriate for a particular individual is determined by the individual's attending provider. The plan or the issuer must provide coverage for the recommended preventive service, without cost sharing, regardless of sex assigned at birth, gender identity, or gender of the individual otherwise recorded by the plan or issuer.

Well-woman Preventive Care for Dependents

Q-6. If a plan or issuer covers dependent children, is the plan or issuer required to cover without cost sharing recommended women's preventive care services for dependent children, including recommended preventive services related to pregnancy, such as preconception and prenatal care?

A-6. Yes. All participants and beneficiaries under a group or individual health plan must cover the eight preventive care services for women, issued August 1, 2011, without cost sharing. If the plan or issuer covers dependent children, such dependent children must be provided the full range of recommended preventive services applicable to them without cost sharing where an attending provider determines that well-woman preventive services are age- and developmentally-appropriate for the dependent.

Colonoscopies

Q-7. If a colonoscopy is scheduled and performed as a preventive screening procedure for colorectal cancer pursuant to the USPSTF recommendation, is it permissible for a plan or issuer to impose cost sharing with respect to anesthesia services performed in connection with the preventive colonoscopy?

A-7. No. The plan or issuer may not impose cost sharing with respect to anesthesia services performed in connection with the preventive colonoscopy if the attending provider determines that anesthesia would be medically appropriate for the individual.

Previous FAQs cited that polyp removal was an integral part of a colonoscopy. Accordingly, the plan or issuer may not impose cost-sharing with respect to polyp removal during a colonoscopy performed as a screening procedure. On the other hand, a plan or issuer may impose cost sharing for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service.

For the complete text of FAQ Part XXVI, click here. To see the complete list of all FAQs issued in conjunction with the ACA implementation, go to: http://www.dol.gov/ebsa/healthreform/regulations/acaimplementationfaqs.html

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