Plans must cover the full range of FDA-approved contraceptive methods without cost sharing

To be compliant with the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), health care plans must cover, without cost sharing, the full range of FDA-approved methods for contraception, according to recently-released frequently asked questions from the Departments of Labor, HHS, and the Treasury (the Departments). The FAQs specified that there are currently 18 distinct methods of contraception for women (FAQs about Affordable Care Act Implementation (Part XXVI), May 11, 2015).

Preventive care

The ACA added PHSA Sec. 2713, which requires non-grandfathered group health plans to provide coverage for preventive care services without cost sharing. This includes: certain evidence-based items (with A or B ratings) in the recommendations of the United States Preventive Services Task Force; immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; evidence-based preventive care and screenings for infants, children, and adolescents provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA); and additional women’s preventive care and screenings “in comprehensive guidelines supported by the HRSA.”

Contraceptive coverage

While all 18 FDA-approved contraceptive methods must be made available without cost sharing, health plans are allowed to use reasonable medical management techniques and impose cost sharing to encourage the use of specific services or items within the chosen contraceptive method, the Departments noted. For example, a plan may discourage use of brand name pharmacy items over generic pharmacy items through the imposition of cost sharing.

The FAQs further state that if multiple services and FDA-approved items within a contraceptive method are medically appropriate for an individual, the plan may use reasonable medical management techniques to determine which specific products to cover without cost sharing. However, the plan must defer to an individual’s attending provider and if the provider recommends a particular item, the plan must cover the recommended item without cost sharing.

Other topics

The FAQs also touch briefly on the coverage of several other preventive care services:

  • Breast cancer susceptibility. Plans must cover, without cost sharing, recommended genetic counseling and breast cancer susceptibility genetic testing for a woman as determined by her attending provider.
  • Sex-specific preventive services. Where an attending provider determines that a recommended preventive service is medically appropriate, the plan must provide coverage for the recommended preventive service, without cost sharing, regardless of the sex assigned at birth, gender identity, or gender of the individual otherwise recorded by the plan.
  • Preventive care for dependents. Non-grandfathered group health plans and issuers offering non-grandfathered coverage must cover specified recommended preventive services for all participants in a plan, including dependents. This includes recommended preventive services related to pregnancy, such as preconception and prenatal care for dependent children.
  • If a colonoscopy is scheduled and performed as a preventive screening, the plan may not impose cost sharing with respect to anesthesia services performed in connection with the preventive colonoscopy.