The new recommendations will be required to be covered under the PPACA preventive care rules for plan years that start on or after 8/1/12 (1/1/13 for calendar year plans).
We have been receiving a number of questions on these new requirements. As we have reported previously, in August 2011 the Department of Health and Human Services (HHS) adopted several new preventive care guidelines for women. The new recommendations will be required to be covered under the PPACA preventive care rules for plan years that start on or after 8/1/12 (1/1/13 for calendar year plans). We have been receiving a number of questions on these new requirements.
Where can we find a list of services that must be covered?
The new guidelines are based on recommendations from the Institutes of Medicine and are found at www.hrsa.gov/womensguidelines. They require coverage in a number of categories, including:
Screening for gestational diabetes;
Counseling for STD infections;
Counseling and screening for HIV;
Contraceptive methods and counseling (with an exemption for certain religious employers);
Breastfeeding support, supplies, and counseling; and
Screening and counseling for interpersonal and domestic violence.
Must a plan cover these services at 100%?
Under PPACA’s preventive care rules, group health plans and individual and group health insurance policies must cover recommended preventive care services adopted by the Secretary (including the new guidelines) at 100% with no cost-sharing. The plan can require that enrollees go in-network in order for services to be covered at 100%. The plan also can establish “reasonable medical management techniques” to determine the frequency, method, or setting for an item or service to be covered at 100%, unless otherwise specified in the recommendations.
What contraceptives must a plan cover?The new guidelines require a plan to cover “all FDA-approved contraceptive methods.” FDA-approved contraceptives include prescription drugs, such as birth control pills, as well as over-the-counter items such as condoms, spermicides, and the “morning after” pill.
Can a plan require a prescription for contraceptive services covered under these new guidelines?
The guidelines list contraceptives as a preventive care recommendation, with a note regarding frequency: “as prescribed.” It is not clear whether this means only with a prescription or simply at the intervals suggested by the physician. However, as discussed above, plans are permitted to establish "reasonable medical management techniques" to determine how to provide preventive care services. We think that requiring a prescription for contraceptives (even over-the-counter items) arguably would be such a reasonable medical management technique. Many plans already are requiring a prescription for other over-the-counter preventive care items, such as aspirin for those with heart disease. Similarly, we are seeing plans consider a prescription requirement for contraceptives in order to be covered at 100%.
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Christy Tinnes is a Principal in the Health & Welfare Group of Groom Law Group in Washington, D.C. She is involved in all aspects of health and welfare plans, including ERISA, HIPAA portability, HIPAA privacy, COBRA, and Medicare. She represents employers designing health plans as well as insurers designing new products. Most recently, she has been extensively involved in the insurance market reform and employer mandate provisions of the health-care reform legislation.
Brigen Winters is a Principal at Groom Law Group, Chartered, where he co-chairs the firm's Policy and Legislation group. He counsels plan sponsors, insurers, and other financial institutions regarding health and welfare, executive compensation, and tax-qualified arrangements, and advises clients on legislative and regulatory matters, with a particular focus on the recently enacted health-reform legislation.
PLEASE NOTE: This feature is intended to provide general information only, does not constitute legal advice, and cannot be used or substituted for legal or tax advice.