Smart Benefits: Preventive Services Requirement Clarified

Monday, June 08, 2015

Rob Calise, GoLocalWorcester Business/Health Expert

Under the ACA, non-grandfathered group health plans and health insurance offered in the individual or group markets must provide certain benefits with no cost-sharing to the beneficiary. Last month, an FAQ issued on the coverage of preventive services under the ACA cleared up ambiguity surrounding some of the requirements.

• BRCA Testing. PPACA requires health plans to offer evidence-based services rated A or B by the US Preventive Services Task Force (USPSTF), as well any other coverage for women provided in guidelines supported by the Health Resources and Services Administration (HRSA). Following a 2013 FAQ, there was confusion about whether the recommendation to provide BRCA screening applies to women who have had a prior non-BRCA-related breast cancer or ovarian cancer diagnosis, even if they are asymptomatic and cancer-free. The FAQ clarified that a plan or issuer must cover (without cost-sharing) genetic counseling and BRCA genetic testing for women who have not been diagnosed with a BRCA-related cancer but previously had breast cancer, ovarian cancer, or other specific cancers.

• Contraception. The FAQ provided information about contraception coverage applicable to plan years or policies beginning July 10, 2015, making clear that if a plan or issuer covers some forms of contraception without cost-sharing, but completely excludes other forms, it won’t be in compliance with regulations. Plans and issuers must cover the full range of FDA-identified methods and must cover at least one form of contraception in each method without cost-sharing. The coverage must include clinical services, including patient education and counseling. However, plans and issuers can use reasonable medical management techniques, such as discouraging the use of brand name pharmacy items over generics or using cost sharing to encourage the use of one of several FDA-approved intrauterine devices (IUDs) with progestin. If an individual's provider recommends a particular service or FDA-approved item based on medical necessity, the item must be covered without cost-sharing.

• Sex-Specific Recommended Preventive Services. The FAQ made clear that plans or issuers may not limit sex-specific recommended preventive services based on an individual's sex assigned at birth, gender identity, or recorded gender. The decision regarding the medical appropriateness of a preventive service is to be determined by the individual's provider.

• Well-Woman Preventive Care for Dependents. Plans or issuers that cover dependent children must cover recommended preventive services related to pregnancy, such as preconception and prenatal care for dependent children, without cost-sharing.

• Colonoscopies and Anesthesia Charges. For colonoscopies scheduled and performed as a preventive screening for colorectal cancer pursuant to USPSTF recommendations, patients can’t be charged for anesthesia services performed in connection with the procedure.

Rob Calise is a founding partner of Cornerstone Group, where he helps clients control the costs of employee benefits by focusing on consumer driven strategies and on how to best utilize the tax savings tools the government provides. Rob serves as Chairman of the Board of United Benefit Advisors, and is a board member of the Blue Cross & Blue Shield of RI Broker Advisory Board, United HealthCare of New England Broker Advisory Board and Rhode Island Business Healthcare Advisors Council. He is also a member of the National Association of Health Underwriters (NAHU), American Health Insurance Association (AHIA) and the Employers Council on Flexible Compensation (ECFC), as well as various human resource associations. Rob is a graduate of Bryant University with a BS in Finance.

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