ACA Contraceptive Coverage Exemptions Additional Clarifications on Coverage of Recommended Preventive Services

ACA Contraceptive Coverage Exemptions Additional Clarifications on Coverage of Recommended Preventive Services


        Final Rule Issued on ACA Contraceptive Coverage Exemptions

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The final regulations include the following clarifications related to the women’s preventive care coverage requirement:

     • Scope of recommended preventive services: The regulations finalize
     the requirement to provide coverage without cost sharing with respect to the
     following three categories of recommendations and guidelines (in addition to those
     provided for in the Health Resources and Services Administration (HRSA)
     guidelines for women):

        ◦ Evidence-based items or services that have in effect a rating of “A” or “B”
        in the current recommendations of the U.S. Preventive Services Task Force

        ◦ Immunizations for routine use that have in effect a recommendation from
        the CDC’s Advisory Committee on Immunization Practices

        ◦ Evidence-informed preventive care and screenings for infants, children
        and adolescents, provided for in guidelines supported by HRSA

     • Office visits: The final regulations clarify that, when a recommended preventive
     service is not billed separately (or is not tracked as individual encounter data
     separately) from an office visit, plans and issuers must look to the primary purpose
     of the office visit when determining whether they may impose cost sharing with
     respect to the office visit. The Departments anticipate that the determination of the
     primary purpose of the visit will be resolved through normal billing and coding
     activities, as they are for other services.

     • Out-of-network providers: The final regulations do not require plans or issuers
     to provide coverage for recommended preventive services delivered by an out-of-
     network provider. However, the regulations clarify that a plan or issuer that does
     not have a provider in its network who can provide a particular recommended
     preventive service is required to cover the preventive service when performed by
     an out-of-network provider, and the plan or issuer may not impose cost sharing
     with respect to the preventive service.

     • Reasonable medical management: Plans and issuers may use reasonable
     medical management techniques to determine the frequency, method, treatment or
     setting for required preventive coverage items or services to the extent they are not
     specified in the relevant recommendation or guideline. A plan or issuer may rely on
     the relevant clinical evidence base and established reasonable medical
     management techniques to determine the frequency, method, treatment or
     setting for coverage of a recommended preventive health service.

     • Services not described: The final regulations clarify that a plan or issuer may
     cover preventive services in addition to those required to be covered under
     the ACA. For these additional preventive services, a plan or issuer may impose
     cost sharing at its discretion, consistent with applicable law. A plan or issuer
     may also impose cost sharing for a treatment that is not a recommended
     preventive service, even if the treatment results from a recommended
     preventive service.

     • Timing: The preventive coverage requirement took effect for plan years beginning
     on or after Sept. 23, 2010. Coverage pursuant to recommendations or guidelines
     issued after that date must be provided for plan years beginning one year after the
     date the recommendation or guideline is issued.

Also, required coverage must be provided through the end of the plan year, even if the recommendation or guideline changes during the plan year. This rule does not apply if a recommendation or guideline is downgraded to a “D” rating or if any related item or service is subject to a safety recall or is otherwise determined to pose a significant safety concern by an authorized federal agency.

Under the Affordable Care Act (ACA), non-grandfathered health plans must cover certain preventive health services for women, including contraceptives, without imposing cost-sharing requirements for the services.

On July 10, 2015, the Departments of Labor (DOL), Health and Human Services (HHS) and the Treasury (Departments) released final regulations on the ACA’s women’s preventive care coverage requirement.

These regulations:

     • Finalize an accommodation for eligible nonprofit organizations and for-
     profit businesses with religious objections to providing contraceptive coverage,
     including related documentation standards.

     • Clarify general rules on the coverage of preventive services generally.

The regulations are applicable on the first day of the first plan or policy year beginning on or after Sept. 12, 2015.


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