On May 11, 2015, the Departments of Health and Human Services (HHS), Labor (DOL), and Treasury issued FAQs clarifying the preventive care services that must be covered at 100% by non-grandfathered medical and pharmacy plans. The FAQs acknowledge that insurance carriers had different interpretations of the law. All insurers must comply with these clarifications for plan years beginning on or after July 11, 2015.
The preventive care FAQs covered the following topics:
- Plans must provide 100% coverage for at least one form of contraception in each of the 18 contraceptive methods for women that are identified by the Food and Drug Administration (FDA).
- Cost sharing can be applied to brand name drugs and devices as long as other contraceptives in the same category are available with no cost sharing.
- Insurers that currently base their contraceptive coverage on broader categories of contraceptives rather than the 18 specific methods may need to expand their list of contraceptives covered at 100% to include additional products, specifically contraceptive rings and patches. This change is effective for plan years beginning on or after July 11, 2015.
Other Preventive Care Services
- Plans must cover well-woman preventive care services for dependent children who are covered under a parent’s plan. This includes age-appropriate preventive services related to pregnancy, such as preconception and prenatal care. Note that this does not require coverage of maternity care; only preventive care services such as folic acid, gestational diabetes screening and prenatal care provided as part of an annual well-woman visit.
- Plans must cover preventive screening, genetic counseling and genetic testing for mutations in the BRCA genes without cost-sharing for women who have a family history of breast or ovarian cancer. The FAQ expands this coverage to include women who have not had BRCA-related cancer, but have previously had breast or ovarian cancer.
- Plans must cover sex-specific preventive services for transgender individuals when a doctor determines that the services are medically appropriate.
- If a colonoscopy is performed as a preventive screening, any related anesthesia services must also be covered at 100%.