Implementing Health Reform: Clarifying Requirements For Coverage Of Contraceptives And Other Preventive Services

The Affordable Care Act requires nongrandfathered individual and group insurers and group health plans to cover certain preventive services without cost sharing. Specifically, it requires coverage of:

• evidence-based items and services given an “A” or “B” rating by the United States Preventive Services Task Force (USPSTF) with respect to the individual involved;
• immunizations as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control;
• children’s preventive care and screenings as recommended by Health Resources and Services Administration (HRSA) guidelines;
• Women’s preventive care and screenings as recommended by HRSA guidelines. The HRSA guidelines specifically require coverage of all FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity, as prescribed by a health care provider.

If the relevant preventive services recommendation or guideline does not specify the frequency, method, treatment, or setting for a recommended preventive service, the ACA allows the insurer or health plan to use reasonable medical management techniques to limit coverage.

Reports Of Coverage Omissions

Despite these requirements, there have been reports recently of plans failing to cover recommended preventive services, and more specifically contraceptives. A report from the Kaiser Family Foundation of contraceptive coverage in five states found that many plans were not covering all forms of birth control and that none of the plans studied had an exceptions process for waiving coverage limitations for patients with a medical need for contraceptives not otherwise covered. Another study by the National Women’s Law Center of coverage in 15 states found similar restrictions on contraceptive coverage.

Clarifying Coverage Obligations

On May 11, 2015, the Departments of Health and Human Services, Labor, and Treasury, which jointly interpret and enforce the ACA insurance reforms, issued a set of frequently asked questions further clarifying the responsibilities of insurers and group health plans to cover contraceptives and other preventive services.

Contraceptives

The FAQ states that insurers and group health plans must cover without cost sharing at least one of each of the methods (currently 18) that the FDA has identified in its current birth control guide. These are:

• sterilization surgery for women;
• surgical sterilization implant for women;
• implantable rod;
• IUD copper;
• IUD with progestin;
• shot/injection;
• oral contraceptives (combined pill);
• oral contraceptives (progestin only);
• oral contraceptives extended/continuous use;
• patch;
• vaginal contraceptive ring;
• diaphragm;
• sponge;
• cervical cap;
• female condom;
• spermicide;
• emergency contraception (Plan B/Plan B One Step/Next Choice); and
• emergency contraception (Ella).

Coverage must include clinical services, including patient education and counseling.

Within each method, plans may use reasonable medical management techniques, including imposing cost-sharing on some items or services to encourage the use of others when multiple items are available within a particular method. If an insurer uses medical management techniques, however, it must have an easily accessible, transparent, and sufficiently expedient exceptions process available that is not unduly burdensome to the enrollee or provider to provide access to alternatives.

Specifically, if a provider recommends a particular service or FDA-approved item as medically necessary for an individual, the insurer or plan must defer to the professional’s judgment. Medical necessity considerations may include the severity of side effects, differences in permanence and reversibility of contraceptives, and ability to adhere to the appropriate use of the item or service.

Because the Departments believe that their earlier guidance may have been interpreted in good faith as not requiring coverage without cost sharing of at least one form of contraceptive in each method, the Departments will only enforce this guidance with respect to plan or policy years beginning on or after 60 days from the publication of the FAQs.

Other Preventive Services

The FAQs address a number of other preventive services issues as well. First, they clarify that under the USPSTF guidelines, a woman who has not been diagnosed as having breast cancer susceptibility gene (BRCA)-related cancer must be offered preventive screening and genetic counseling and testing as determined appropriate by her attending provider, even if she has previously had breast, ovarian, or other cancer.

Second, the FAQ clarifies that sex-specific recommended preventive services must be provided without cost sharing to transgender individuals if recommended as medically appropriate for the particular individual by that individual’s treating physician, regardless of the sex assigned to the individual at birth, gender identify, or gender of the individual recorded by the plan or insurer.

Third, the FAQ clarifies that health plans and insurers must cover without cost sharing preventive services for covered dependents of enrollees as determined to be age and developmentally appropriate by the dependent’s attending provider. This includes services related to pregnancy, such as preconception and prenatal care.

Finally, the FAQ states that a health plan or insurer must cover without cost sharing anesthesia for a preventive colonoscopy, if determined to be medically appropriate by a covered individual’s attending provider.