Medical management techniques not so reasonable, report says

Variation exists in how health plans are interpreting the regulation allowing them to apply “reasonable medical management” (RMM) techniques to allow coverage of prescribed FDA-approved contraceptive services and supplies without cost sharing. In a recent report on health insurance coverage of contraceptive services in five states, the Kaiser Family Foundation and The Lewin Group noted that, while most carriers are complying with the spirit of the law, some are circumventing it, in particular by refusing to cover multiple contraceptive methods with the same chemical formulation. The report’s authors note that this action fails to support family planning guidelines issued by the Centers for Disease Control and Prevention and the HHS Office of Population Affairs.

Coverage without cost sharing

Section 1001 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) amended section 2713 of the Public Health Service Act to require nongrandfathered health plans to provide certain preventive services, without copays, to plan recipients, including FDA-approved contraceptive services and supplies. However, 45 C.F.R. section 147.130(a)(4) allows plans and issuers to use RMM techniques, to determine the frequency, method, treatment, or setting for an item or service . . . to the extent not specified in the recommendation or guideline.” There is no clear definition of RMM.

Methodology

The authors focused on California, Georgia, Michigan, New Jersey, and Texas, five states that were geographically and politically diverse and differed as to type of Marketplace utilized, Medicaid expansion status, and pre-ACA status of contraceptive coverage mandates. They conducted interviews and/or examined plan documents for 20 of the carriers with the largest market shares with respect to coverage of the ring, the patch, injections, implants, and intrauterine devices (IUDs), along with emergency contraception and sterilization. The study did not review medical management techniques of oral contraceptives because of the large scale of availability of various formulations, brands, and generics.

Results

The vaginal ring is a hormonal contraceptive that is inserted into the vagina and works by releasing the same hormones as the combination pill. The birth control patch is applied to the skin and also releases those hormones. A small minority of carriers does not cover the ring or the patch or require cost sharing because the chemical composition is equivalent to less expensive generic oral contraceptives. Still, 12 carriers covered the vaginal ring with no RMM limitations and no cost sharing. The contraceptive method that was most frequently covered without RMM limitations and cost sharing was generic Plan B emergency contraception, with 19 or 20 carriers providing that type of coverage, followed by the generic Depo-Provera injection at 16 carriers, and the generic Xulane patch and the copper ParaGard® IUD, with 14 carriers. Other types of RMM techniques applied to different forms of contraceptive methods, as well as to other preventive services, include step therapy, in which a carrier requires a member to try a lower tier formulary drug and will only cover a higher tier drug if the lower tier drug fails, and prior authorization, in which providers must secure carrier approval prior to prescribing a service or medication.

Waivers

The study authors also note that the Department of Labor issued a series of frequently asked questions (FAQs) in which it noted that carriers should have a process in place for members to seek waivers of cost sharing when medically necessary. The authors note that some carriers were confused about the definition of “waiver.” Members may generally request “an exception to the initial coverage decision” or follow the appeals process outlined by the ACA. However, the authors expressed concern that the procedures are time-consuming and “not in the best interest of standards for quality contraceptive care.”