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Can Employers Apply Cost-Sharing to Some Contraceptive Methods?

02.28.2017

pexels-photo-163944Note to readers: As of this writing, efforts are underway in Washington to repeal the Affordable Care Act. Both the Republican-majority House and Senate have approved a resolution to begin repeal proceedings, while President Trump has issued an Executive Order calling for the law’s “prompt repeal.” Please bear this in mind as you read the article below, and consult your benefits advisor for the latest developments.

Question: Our company sponsors a nongrandfathered self-insured group health plan, and we’re subject to the Affordable Care Act’s (ACA’s) preventive services mandate. Can our plan impose cost-sharing on some methods of contraception for women so long as we provide first-dollar coverage for other methods?

Answer: Your plan must provide women access to the full range of contraceptive methods identified by the Food and Drug Administration (FDA), as prescribed by a health care provider.

The ACA requires nongrandfathered health plans to provide coverage for certain preventive services without cost-sharing when delivered by in-network providers. Preventive services for women include coverage for a broad array of items and services, including contraceptives — though there is an exemption for qualifying religious employers and an accommodation process available to certain other employers with religious objections to contraceptives.

The full range of FDA-approved contraceptive methods includes, but is not limited to, a number of different:

  • Barrier methods (such as diaphragms and sponges)
  • Hormonal methods (such as oral contraceptives and contraceptive patches)
  • Implanted device methods (such as intrauterine devices)

Again, all methods must be prescribed by a health care provider.

Employers need to provide coverage without cost-sharing for at least one form of contraception within each method identified by the FDA. For example, because the FDA identifies diaphragms and sponges as separate methods, a plan cannot impose cost-sharing on items and services within either of those methods.

If multiple services and FDA-approved items within a contraceptive method are medically appropriate for an individual, however, the plan is permitted to use reasonable medical management techniques to determine which specific products to cover without cost-sharing with respect to that individual. But if the individual’s attending provider recommends a particular service or FDA-approved item based on a determination of medical necessity, the plan must cover that service or item without cost-sharing.

Ron M. Present, CALA, CNHA, LNHAIf you have questions about cost-sharing, please contact Ron Present, Partner and Health Care Industry Group Leader, at rpresent@bswllc.com or 314.983.1358.

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