The ACA requires that group health plans cover certain preventive care services at 100% with no cost sharing. Prior guidance clarifies that plans are permitted to limit such coverage to in-network only and to set other “reasonable medical management techniques,” as long as these limits are not contrary to the express recommendations identified by the preventive care guidelines.
HHS adopted women’s preventive care guidelines that plans were required to cover at 100% for plan years starting on or after 8/1/12 (except grandfathered plans). In particular, coverage for contraceptives under the women’s preventive health rules has raised many questions. Some of these were addressed in the new FAQs, which we highlight here.
What contraceptives must a plan cover?
The women’s preventive care guidelines (found at http://www.hrsa.gov/womensguidelines/), require that a health plan cover all FDA-approved contraceptives for women. The guidelines also require that the plan cover sterilization procedures and patient and education and counseling for all women of reproductive capacity. This coverage must be at 100% with no cost-sharing.
May a plan cover only oral contraceptives, such as birth control pills, and still satisfy the ACA requirements?
No, the FAQs clarify that plans must cover the “full range” of FDA-approved methods, including barrier methods, hormonal methods, and implanted devices.
Is the plan required to cover other over the counter (OTC) contraceptives, such as sponges and spermicides?The FAQs state that items that are generally available “over the counter” only must be covered if they are: (1) FDA-approved; and (2) prescribed for a woman by her health care provider. This means that a plan can require a prescription for these items, but if a woman obtains a prescription, the plan must cover the item or service at 100%.
Are plans required to cover IUDs and other implants? What about removal of such devices?
Yes - the FAQs clarify that if the device is an FDA-approved contraceptive device, it must be covered at 100%. The FAQs also state that services related to follow-up, management of side effects, counseling for continued adherence, and device removal would be required to be covered at 100%.
Must a plan cover contraceptives for men, such as male condoms?
No - the FAQs state that the required coverage does not include contraception for men.
What limits may a plan implement with respect to women's contraceptive coverage?
As discussed above, the FAQs re-state the regulation that allows a plan to impose "reasonable medical management techniques" to limit coverage where not contrary to the specific preventive care guidelines. The FAQ provides clarification on the types of medical management techniques that would be permitted. For example, a plan may require a prescription for over-the-counter drugs or devices or may limit coverage to generic drugs only. The FAQ goes on to clarify that, for this type of limitation, the plan must accommodate any individual for whom the generic drug is not available or would be medically inappropriate, as determined by the individual's health care provider. In that case, the plan may need to cover a brand drug at 100% with no cost sharing.
The FAQs can be found at www.dol.gov.ebsa (ACA FAQs Part VII).
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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.