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FAQs Address Required Preventive Services under the ACA

07.16.2015

doctor, little boy & dadThe IRS, Department of Health and Human Services (HHS) and Department of Labor have jointly issued FAQ guidance on the required coverage of preventive health services. The Affordable Care Act (ACA) requires nongrandfathered, nonexcepted group health plans to provide coverage for various preventive services delivered by in-network providers without cost-sharing. In other words, no deductibles, copayments, coinsurance or other cost-sharing may be imposed on these services. Here are highlights of this latest guidance.

BRCA-related services

The FAQs clarify that the U.S. Preventive Services Task Force (USPSTF) recommendation for breast cancer susceptibility gene (BRCA) screening, genetic counseling and testing applies to women:

  • Who are asymptomatic and haven’t received a BRCA-related cancer diagnosis, but who previously have had breast, ovarian, or other cancer, or
  • Whose family history is associated with an increased risk of BRCA-related cancer.

According to the current USPSTF recommendation, women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing. Previous FAQ guidance had clarified the HHS’s position that the scope of this USPSTF recommendation includes both genetic counseling and BRCA testing, if appropriate, for a woman as determined by her provider.

FDA-approved contraceptives

The FAQs point out that plans and insurers must cover — without cost-sharing — the full range of FDA-identified contraceptive methods. This means that coverage must be provided without cost-sharing for at least one form of contraception in each method that is identified for women by the FDA in its latest Birth Control Guide (which currently lists 18 distinct methods). Coverage must also include the clinical services, including patient education and counseling.

Significantly, the agencies acknowledge that previous guidance may have been interpreted as not requiring coverage without cost-sharing of at least one form of contraception in each method identified by the FDA. So this clarification will apply as of plan years beginning on or after 60 days after these FAQs were issued — in other words, July 10, 2015. The FAQs also provide further guidance on the extent to which plans and insurers may use reasonable medical management.

Gender-specific recommended services

According to the FAQs, a plan or insurer must provide coverage for a recommended preventive service, without cost-sharing, regardless of the sex assigned at birth, gender identity or gender of the individual otherwise recorded by the plan or insurer. For example, a plan must provide a recommended mammogram or pap smear for a transgender man.

Employers should also keep in mind that the Equal Employment Opportunity Commission is currently pursuing Title VII sex discrimination enforcement efforts for lesbian, gay, bisexual and transgender individuals.

Well-woman care for dependents

The FAQs make clear that plans must cover the recommended preventive care services for all participants and beneficiaries. Thus, a plan that covers dependent children must provide the full range of recommended preventive services applicable to them without cost-sharing and be subject to reasonable medical management techniques.

For example, well-woman visits for adult women (including preconception care and many services necessary for prenatal care) must be covered for dependent children where an attending provider determines that the services are age-appropriate and developmentally appropriate. Employers with small group market insurance plans should be aware that they may also be required to cover maternity care of dependent children as an essential health benefit.

Colonoscopies

One of the FAQs explains that a plan or insurer may not impose cost-sharing for anesthesia services performed in connection with a colonoscopy performed as a preventive screening procedure. An attending provider, however, must determine that anesthesia would be medically appropriate for the individual.

Essential information

Governmental recommendations and guidelines have required nongrandfathered, nonexcepted group health plans to cover a broad range of preventive services. So it’s not surprising that issues related to preventive care coverage continue to arise under the ACA.

These latest FAQs provide essential information to those involved in scoping the coverage for health plans. The guidance on required coverage for dependent children underscores how the ACA has changed the rules for plans that restrict access to maternity-related expenses for children. And the BRCA genetic testing guidance should serve as a reminder to employers that the Genetic Information Nondiscrimination Act prohibits discrimination based on genetic information and places strict limits on the disclosure of such information.

Present_RonIf you have questions about the FAQ guidance, contact  Ron Present, Partner and Health Care Industry Group Leader, at 314.983.1358 or rpresent@bswllc.com.


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