Several federal agencies jointly issued new guidance on Monday clarifying the Affordable Care Act’s requirement that health plans cover FDA-approved birth control and other preventive services at no additional cost to the insured. Specifically, the guidance addresses mandatory insurance coverage of the following:
1. Birth Control
Federal officials explained that insurers must cover “the full range” of FDA-approved methods of contraception, without cost-sharing. Namely, they must cover at least one form of birth control among each of the 18 categories of contraceptives recognized by the FDA—including the pill, patch, ring, IUDs, and emergency birth control such as Plan B. For example, if a plan covers one form of birth control, like oral contraceptives, it may not require co-payments for other categories of birth control.
If multiple types of FDA-approved birth control are medically appropriate for a particular patient, then a health plan may use “reasonable medical management techniques” to select which products to cover without cost-sharing for that individual. However, if a specific method is medically necessary for that patient as determined by her doctor, the insurer may not deny coverage or impose cost-sharing on that method.
2. BRCA Genetic Testing
The guidance further clarifies that health plans must cover, at no additional cost to the patient, preventive services related to genetic testing and counseling for women with a family history of breast or ovarian cancer. Services now covered pursuant to this new directive include testing for mutations in the BRCA1 and BRCA2 cancer susceptibility genes, which can increase a woman’s risk of developing breast or ovarian cancer.
Importantly, this guidance makes clear that insurers must cover such services for women who previously have been diagnosed with non-BRCA-related breast cancer, ovarian cancer, or other cancer.
3. Preventive Services for Transgender Persons
Additionally, insurers cannot deny coverage or charge for “sex-specific recommended preventive services” for transgender individuals. Instead, health plans should defer to the patient’s provider. As long as a doctor finds that the services are medically appropriate (e.g. “providing a mammogram or pap smear for a transgender man who has residual breast tissue or an intact cervix”), then the health plan must provide coverage for that service, without cost-sharing, “regardless of sex assigned at birth, gender identity, or gender of the individual otherwise recorded by the plan or issuer.”
4. Anesthesia Services During Colonoscopies
Federal officials also clarified that insurers may not impose cost-sharing for anesthesia services provided during colonoscopies when performed as a preventive service, i.e. for someone with no signs of colon cancer. Two years ago, the government told insurers they could not require their insureds to bear the cost of removing a polyp during a colonoscopy performed as a screening procedure.
This guidance will become effective 60 days after publication. However, the new rules will only impact plan or policy years beginning on or after that date, so consumers may not experience changes until next year. The full text of the new guidance can be found here: “FAQs About Affordable Care Act Implementation (Part XXVI) (May 11, 2015).”