Feds release detailed guidance on birth control coverage

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The contraceptive mandate under the Affordable Care Act has been a hot-button issue for many companies, with some religious employers fighting the federal government in court for the right to be exempt from parts of it. But for the majority of companies that are complying with the mandate, a new FAQ from the Departments of Labor, Health and Human Services and Treasury offers quite prescriptive guidance on the types of contraceptives plans must offer and pay for,  and to whom they must be offered.

“It’s helpful to get clarification of some of these required preventive services and exactly how they’re structured,” says Amy Bergner, managing director, health care and benefits, with consulting firm PricewaterhouseCoopers. “It’s actually a little surprising to me how specific this guidance is and how prescriptive it is. It’s getting to a very granular level of exactly what a plan has to cover in this whole area of contraception and testing.”

For example, health plans must cover – without cost-sharing – at least one form of contraception in each of the 18 method categories defined by Federal Drug Administration. “For the hormonal contraceptive methods, coverage therefore must include (but is not limited to) all 3 oral contraceptive methods (combined, progestin-only, and extended/continuous use), injectables, implants, the vaginal contraceptive ring, the contraceptive patch, emergency contraception (Plan B/Plan B One Step/Next Choice), emergency contraception (Ella), and IUDs with progestin. Accordingly, a plan or issuer may not impose cost sharing on the ring or the patch,” according to the FAQ.

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Moreover, plans cannot limit sex-specific recommended preventive services based on an individual’s assigned sex at birth or recorded gender. The FAQ notes that where a health care provider determines that a recommended preventive service is medically appropriate for an individual – “such as, for example, providing a mammogram or pap smear for a transgender man who has residual breast tissue or an intact cervix” – the plan or issuer must provide coverage for the recommended preventive service without cost-sharing.

“That’s a level of detail I don’t think we’ve seen elsewhere either in the preventive services guidance under ACA or the other ACA guidance,” notes Bergner.

The FAQ also notes that plans must implement an exceptions process so that if a patient’s medical provider recommends a different contraceptive based on medical necessity within a certain category, that contraceptive must also be covered without cost-sharing.  “That’s a whole new process that may need to be instituted,” says Bergner.

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In light of the FAQ, Bergner recommends employers review their plan coverage for contraception both with their regular medical plan administrator or insurer, as well as their pharmacy benefit manager since some of these contraceptive methods are provided under the pharmacy benefit.

“Not only will this require some administrative changes, potentially, for the way plans are administered and communicated, but it’s potentially going to increase costs because everything is moving in the direction of covering a broader scope of services or devices,” says Bergner. “More things have to be covered without cost-sharing and for maybe a broader range of people than had previously been covered.”

The changes will take effect the next plan year. “For most plans, this will take effect next January, but for some it could take effect sooner,” says Bergner. “I would expect the communications would come along with an explanation of changes for the next year in the medical plan.”

The FAQ also includes additional details on genetic testing and counseling for women who’ve been diagnosed with breast cancer, ovarian cancer or other cancer.  

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