On May 11, 2015, the Departments of Labor (DOL), Health and Human Services (HHS) and Treasury (the Departments) issued additional FAQ guidance addressing coverage of preventive services (including contraceptives) under the Affordable Care Act (ACA). Under the ACA's preventive services rules, nongrandfathered group health plans and insurers must provide coverage for certain preventive services without cost-sharing (see Practice Notes, Preventive Health Services Under the ACA, Other Than Contraceptives and Contraceptives Coverage Under the ACA: Overview). Specifically, the FAQs address the scope of ACA coverage for:

The ACA's preventive services rules require coverage for evidence-based items or services with an "A" or "B" rating under current USPSTF recommendations (see Practice Note, Preventive Health Services Under the ACA, Other Than Contraceptives: Evidence-Based Items or Services With Grade A or B Ratings). The USPSTF recommends (using a "B" rating) that women who have family members with breast, ovarian, tubal or peritoneal cancer be screened with certain screening tools designed to identify a family history that may be associated with increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA 1 or BRCA 2). In a previous FAQ, the Departments concluded that women with positive screening results should receive:

In the May 2015 FAQs, the Departments clarify that coverage (without cost-sharing) must be provided for recommended genetic counseling and BRCA genetic testing for women who have not been diagnosed with BRCA-related breast cancer, but who previously had breast cancer, ovarian cancer or other cancer. This coverage applies to preventive screening, genetic counseling and genetic testing that is determined to be appropriate by a woman's attending physician.

The Health Resources and Services Administration (HRSA) Guidelines recommend coverage that includes all FDA-approved contraceptive methods. In a previous FAQ, however, the Departments clarified that plans may use reasonable medical management techniques to control costs, if a recommendation or guideline does not specify the frequency, method, treatment or setting for a particular preventive service (see Practice Note, Contraceptives Coverage Under the ACA: Reasonable Medical Management Techniques Permitted). For example, a plan may cover a generic drug without cost-sharing but may impose cost-sharing on equivalent brand name drugs. However, a plan also must have a mechanism for waiving cost-sharing if a particular drug would be medically inappropriate for an individual, as determined by the individual's physician (see Legal Update, FAQs Address Cost-sharing Limits and Coverage of Preventive Services Under the ACA).

In the FAQs, the Departments offer further guidance on the scope of contraceptive services that must be covered and the extent that medical management techniques may be used. According to the FAQs, plans and insurers:

In the context of medical management techniques, the Departments note that if an individual's attending physician recommends a particular service or FDA-approved item due to medical necessity, the plan or insurer must:

For more information on contraceptives coverage, see Practice Note, Contraceptives Coverage Under the ACA: Scope of Contraceptive Services.

In some cases, multiple services and FDA-approved items for a given contraceptive method may be medically appropriate for an individual. If this occurs, a plan or insurer may use reasonable medical management techniques to determine which specific products to cover without cost-sharing for an individual. However, if the individual's physician recommends a particular service item based on a determination of medical necessity for individual, the plan or insurer must:

In another FAQ, the Departments indicate that plans and insurers may not limit sex-specific recommended preventive services based on an individual's sex assigned at birth, gender identity or recorded gender. Whether a sex-specific recommended preventive service is medically appropriate is determined by the individual's physician. A plan or insurer must provide coverage for a recommended preventive service where:

According to one FAQ, a plan or insurer that covers dependent children also must cover (without cost-sharing) recommended women's preventive care services for dependent children. The plan must provide the full range of recommended preventive services applicable to the dependent child for their age group, including those related to pregnancy (such as preconception and prenatal care), without cost-sharing and subject to reasonable medical management techniques. For example, well-woman visits, as recommended under the HRSA Guidelines, must be covered if the physician determines that well-woman preventive services are age and developmentally appropriate for the dependent child.

Under a related ACA requirement, plans or insurers that cover dependent children must make this coverage available until a child is age 26 (see Practice Note, Coverage for Adult Children to Age 26 Under the ACA). For additional information on well-woman visits, see Practice Note, Preventive Health Services Under the ACA, Other Than Contraceptives: Well-Woman Visits.

The Departments clarify in an FAQ that if a colonoscopy is performed as a preventive screening procedure for colorectal cancer under an USPSTF recommendation, the plan or insurer may not impose cost-sharing regarding anesthesia services performed in connection with the colonoscopy. This rule assumes that the individual's attending physician has determined that anesthesia is medically appropriate for the individual.

Probably the most interesting development in these FAQs is the Departments' clarification of their requirement that plans and insurers cover at least one form of contraception in each of the 18 (at present) methods identified under current FDA guidelines. In a footnote to its FAQs, the Departments provide the complete list of 18 contraception methods. Given the confusion over this rule, the Departments offer additional lead time for plans and insurers to comply with its clarification of this issue; for calendar year plans, the clarification will apply beginning in January 2016.