White House Clarifies ACA Contraceptive, Preventive Services Rules

On Monday, the Obama administration issued new guidance clarifying several aspects of the Affordable Care Act's requirement that plans provide a range of preventive services at no cost, the New York Times reports.

The guidance was jointly released by HHS and the departments of Labor and Treasury (Pear, New York Times, 5/11). It will go into effect in 60 days, although most consumers will not experience major changes until their next plan year, according to AP/U-T San Diego (Alonso-Zaldivar, AP/U-T San Diego, 5/11).

Background

Under the ACA's contraceptive coverage rules, employers are required to offer health insurance plans that include contraception at no cost. Houses of worship are exempt from the requirement (California Healthline, 4/28).

Federal guidance on the contraceptive coverage rules under the ACA states that insurers must cover the full range of FDA-approved contraceptive methods without cost-sharing. Insurers are permitted to use "reasonable medical management techniques" to curb costs, such as only covering the generic version of an approved contraceptive.

However, some insurers have not been adhering to the ACA's preventive services requirements, according to a Kaiser Family Foundation report and a two separate National Women's Law Center studies, all released last month. KFF and NWLC both found that some plans were not covering all FDA-approved contraceptives without copayments (New York Times, 5/11). Meanwhile, the NWLC report also found that some insurers were not covering care for transgender individuals (Owens, National Journal, 5/11).

Guidance Details: Birth Control

The new guidance states that insurers must cover one or more version of all 18 FDA-approved birth control methods without cost-sharing (AP/U-T San Diego, 5/11).

NWLC had found that some insurers said they did not provide coverage for the ring or the patch because they already covered oral contraceptives, which deliver the same hormones. However, the new guidance clarifies that insurers "may not impose cost-sharing on the ring or the patch" (New York Times, 5/11).

Guidance Details: Other Women's Health Benefits

In addition, the guidance states that insurers are required to cover maternity care and all other women's health services for dependents also covered by a plan with no cost-sharing (Radnofsky, Wall Street Journal, 5/11). It notes that insurers must cover without copayments or deductibles prenatal benefits and other services intended to assist with healthy pregnancies, including for plans that have children covered as dependents (AP/U-T San Diego, 5/11).

Further, the guidance clarifies that insurers are required to cover without cost-sharing "preventive screening, genetic counseling and genetic testing" for BRCA and BRCA2 genetic mutations "without cost-sharing, if appropriate, for a woman as determined by her attending provider." The requirement applies "[a]s long as the woman has not been diagnosed with BRCA-related cancer."

The genetic tests -- which the guidance states could be appropriate for women with family histories of breast, ovarian, peritoneal or tubal cancer-- can help women determine whether to have pre-emptive surgery to reduce their cancer risk (Berkrot, Reuters, 5/11).

Additional Guidance Details

Meanwhile, the guidance also clarifies that insurers cannot limit "sex-specific recommended preventive services" based on the sex to which an individual was assigned at birth or an individual's gender identity (New York Times, 5/11). For example, insurers cannot refuse to cover a mammogram for a transgender woman over age 50, even if the woman's insurance records lists her as a man (National Journal, 5/11).

In addition, the administration also clarifies that insurers must cover anesthesia services connected to preventive colonoscopies for individuals that do not have signs of having colon cancer without cost-sharing.

Reaction

In a release, Sen. Patty Murray (D-Wash.) said the new guidance would help make sure that women receive "the health care they are entitled to" under the ACA, including birth control.

Gretchen Borchelt, NWLC's vice president for health and reproductive rights, in a release said, "Insurance companies have been breaking the law, and today the Obama administration underscored that it will not tolerate these violations" (New York Times, 5/11).

Meanwhile, America's Health Insurance Plans CEO Karen Ignagni said that the "guidance takes important steps to support health plans' use of medical management in providing women with safe, affordable health care services" (Herman, Modern Healthcare, 5/11).