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Clarification to Certain Preventive Services Coverage

The Department of Labor, Health and Human Services and the Treasury (collectively, the Departments), recently issued Frequently Asked Questions (FAQs) related to the preventive services mandate.  

 

Background
Under healthcare reform, any non-grandfathered health plan must provide coverage at no cost (no copays, deductibles or coinsurance can be imposed) for certain in-network recommended preventive services, including preventive immunizations, women’s preventive care and coverage for contraceptive services. If a service is identified as being a recommended preventive service, the plan must provide coverage of that service. A plan may impose cost-sharing for a treatment not included in the specified recommendations, even if the treatment is deemed a preventive service.

 

A complete list of the recommended preventive services that are required to be covered without cost sharing can be found at http://www.hhs.gov/healthcare/facts/factsheets/2010/07/preventive-services-list.html. This list is updated throughout the year, so plans should review this website once annually to ensure full compliance. Any recommendation that is added or changed throughout the year is not required to be complied with until the first plan year, beginning on or after the date that is one year after the new recommendation is added.

 

To whom do the FAQs apply? 
The FAQs apply to any non-grandfathered group health plan, as well as to coverage offered in the individual or group market. 

 

Do these FAQs provide clarification or new guidance that will require changes?
The FAQs provide clarification. Our systems are currently built to comply with the preventive services related to pregnancy for dependent children and the colonoscopy clarifications. Scrip World’s systems are currently built to comply with the contraceptive clarification.

 

What do the FAQs say?
Below is a summary, by topic, of the clarifications provided in the recently released FAQs:

 

FAQ Summary
BRCA Testing:
Any woman who has a history of breast cancer, ovarian cancer or any other cancer is still eligible to receive genetic counseling and BRCA genetic testing without cost sharing, as long as she has not been diagnosed with BRCA-related cancer previously.
Gender Specific Recommended Preventive Services:
Gender specific preventive services cannot be based on the member's sex at the time of birth, gender identity or based on his/her recorded gender. If the transgender member's attending physician has determined the service is medically necessary and all the required criteria are met, services must be provided without cost share.
Contraceptive Coverage:
  • Plans are not required to cover all forms of contraceptives, but they must cover at least one form of contraception in each of the 18 FDA-approved categories of contraceptives without cost share.
  • Reasonable management techniques may be used to encourage individuals to use other specific items and services within a specific category (e.g., cost sharing imposed on brand items, but not on generic).
  • If multiple methods of contraceptives are approved for a member's use, reasonable medical management techniques to determine which methods are covered without cost share must be used. If the member's attending physician determines a particular item or service is medically necessary, the plan must defer to the determination of the attending provider.
Preventive Services related to Pregnancy and Impact on Dependents:
If dependent coverage is offered, recommended preventive services related to pregnancy care (e.g., preconception and prenatal care) must be extended to covered dependent children.
Colonoscopy Benefit:
Cost share may not be imposed for anesthesia services in connection with a preventive colonoscopy.

What are the 18 categories of FDA-approved contraceptive methods?
The eighteen methods of contraceptives are as follows: sterilization surgery, surgical sterilization implants, implantable rods, IUD copper, IUD with progestin, shots/injections, oral contraceptives (combined bill), oral contraceptives (progestin only), oral contraceptives extended/continuous use, pat, vaginal ring, diaphragm, sponge, cervical cap, female condom, spermicide, emergency contraception (Plan B) and emergency contraception (ELLA).

 

What if my plan is not already offering coverage of at least one form of contraception in each of the 18 FDA-approved categories of contraceptive methods? 
The Departments recognize that their prior guidance may not have been clear on this matter. They have stated they will allow non-grandfathered plans until the first plan year on or after July 11 to come into compliance. For most non-grandfathered plans, this means beginning with plans years on or after August 1, they must make sure the plan is set up to comply with this clarification.  

 

If I am a Scrip World client, is my plan already set up to offer coverage in at least one of the 18 FDA-approved categories of contraceptive methods?
Yes. If you are a Scrip World client, your plan is already set up to be compliant with this requirement.

 

Will changes be required in regards to preventive services related to pregnancy care for dependent children and colonoscopies?
No. Our systems are currently built to cover preventive services for dependent children. We are also set up to cover anesthesia for preventive colonoscopies.

 

Please contact your client relationship manager if you have any questions.

 

Compliance Quarterly is being provided as an informational tool. It is recommended that plans consult with their own experts or counsel to review all applicable federal and state legal requirements that may apply to their group health plan. By providing this publication and any attachments, Meritain Health is not exercising discretionary authority over the plan and is not assuming a plan fiduciary role, nor is Meritain Health providing legal advice.