By Danielle Capilla
Chief Com­pli­ance Offi­cer at Unit­ed Ben­e­fit Advisors

QuestionMarkThe Depart­ment of Labor (DOL) recent­ly pro­vid­ed an infor­ma­tion­al FAQ relat­ing to the Men­tal Health Par­i­ty and Addic­tion Equi­ty Act (MHPAEA) and Patient Pro­tec­tion and Afford­able Care Act (ACA) mar­ket reform pro­vi­sions. Non-grand­fa­thered group health plans and indi­vid­ual or group mar­ket health insur­ance must cov­er a vari­ety of pre­ven­tive ser­vices with­out any cost-shar­ing require­ments. Required pre­ven­tive ser­vices include “breast­feed­ing com­pre­hen­sive sup­port and coun­sel­ing from trained providers, and access to breast­feed­ing sup­plies,” obe­si­ty screen­ing and weight man­age­ment ser­vices for cer­tain indi­vid­u­als, colono­scopies for cer­tain age groups, and con­tra­cep­tion cov­er­age for women.

Lac­ta­tion Counseling

The FAQ clar­i­fied that plans and issuers are required to pro­vide a list of lac­ta­tion coun­sel­ing providers with­in the net­work. The plan’s Sum­ma­ry of Ben­e­fits and Cov­er­age (SBC) should include an Inter­net address or oth­er con­tact infor­ma­tion so a ben­e­fi­cia­ry may be able to obtain a list of net­work providers. Fur­ther, plans sub­ject to ERISA must ensure that provider net­work infor­ma­tion accom­pa­ny the Sum­ma­ry Plan Descrip­tion (SPD). Sim­i­lar oblig­a­tions exist for issuers of qual­i­fied health plans and the ACA’s Mar­ket­place plans and SHOP plans.

If a plan does not have in-net­work lac­ta­tion coun­sel­ing providers, the plan may not impose cost shar­ing for lac­ta­tion coun­sel­ing ser­vices obtained out of net­work. If a state does not license lac­ta­tion coun­selors and plans require providers to be licensed by the state, and the ser­vice could not be pro­vid­ed in the scope of anoth­er type of provider license (such as a reg­is­tered nurse), the plan will have to pro­vide cov­er­age for the ser­vices with­out cost shar­ing. Plans may not lim­it lac­ta­tion coun­sel­ing ser­vices with­out cost shar­ing to an inpa­tient basis. Cov­er­age for lac­ta­tion sup­port ser­vices must extend for the dura­tion of breast­feed­ing. Plans may not require indi­vid­u­als to obtain equip­ment with­in a spec­i­fied time peri­od, such as with­in six months of deliv­ery, in order for it to be cov­ered with­out cost sharing.

Obe­si­ty Screen­ing and Interventions

The FAQ clar­i­fied that non-grand­fa­thered group health plans and issuers must cov­er, with­out cost shar­ing, screen­ing for obe­si­ty in adults. In addi­tion, fed­er­al guide­lines rec­om­mend that, for an adult patient with a body mass index of 30 or high­er, inten­sive mul­ti­com­po­nent behav­ior inter­ven­tions should be pro­vid­ed. Plans and issuers may use rea­son­able med­ical man­age­ment tech­niques to deter­mine the scope of such ser­vices, but may not impose gen­er­al exclu­sions on those ser­vices which can encom­pass group and indi­vid­ual high inten­si­ty ses­sions, behav­ior man­age­ment activ­i­ties, and others.


Plans may not impose cost shar­ing for the required spe­cial­ist con­sul­ta­tion pri­or to colonoscopy screen­ings, if a provider deter­mines the pre-pro­ce­dure con­sul­ta­tion is med­ical­ly appro­pri­ate. Fur­ther­more, pathol­o­gy exams on a polyp biop­sy from a colonoscopy per­formed as a pre­ven­tive ser­vice must be cov­ered with­out cost sharing.

Con­tra­cep­tion Cov­er­age Accom­mo­da­tions for Self-Fund­ed Plans

Qual­i­fy­ing non-prof­it or close­ly held for-prof­it employ­ers with an ERISA-cov­ered self-insured plan have two meth­ods for obtain­ing their reli­gious accom­mo­da­tion in rela­tion to the objec­tion to pro­vide cov­er­age of con­tra­cep­tive ser­vices. They may either com­plete EBSA Form 700 or pro­vide a let­ter to the Depart­ment of Health and Human Ser­vices. The DOL will use either method to noti­fy the plan’s third par­ty admin­is­tra­tor (TPA) so the TPA may pro­vide cov­er­age for con­tra­cep­tion separately.

BRCA Test­ing

The DOL has pre­vi­ous­ly pro­vid­ed FAQs regard­ing BRCA test­ing (relat­ing to breast can­cer sus­cep­ti­bil­i­ty) require­ments. The DOL now clar­i­fies that women found to be at increased risk for breast can­cer, using a screen­ing tool designed to iden­ti­fy fam­i­ly his­to­ry that may be asso­ci­at­ed with an increased risk of hav­ing a poten­tial­ly harm­ful gene muta­tion, must receive cov­er­age, with­out cost shar­ing, to test for BRCA mutations.

Well­ness Programs

The FAQ clar­i­fied that well­ness pro­grams with non-finan­cial or in-kind incen­tives, such as gift cards, ther­moses and sports gear, for well­ness pro­gram par­tic­i­pants that sat­is­fy a stan­dard relat­ing to a health fac­tor are sub­ject to fed­er­al well­ness pro­gram regulations.

Men­tal Health Parity

The MHPAEA amend­ed var­i­ous laws and reg­u­la­tions to pro­vide increased par­i­ty between men­tal health and sub­stance use dis­or­der ben­e­fits and medical/surgical ben­e­fits. Gen­er­al­ly finan­cial require­ments such as coin­sur­ance and copays and treat­ment lim­i­ta­tions for men­tal health and sub­stance use dis­or­der ben­e­fits can­not be more restric­tive than require­ments for med­ical and sur­gi­cal ben­e­fits. Reg­u­la­tions also pro­vide that a plan or issuer may not impose a non­quan­ti­ta­tive treat­ment lim­i­ta­tion (NQTL) unless it is com­pa­ra­ble and no more strin­gent than lim­i­ta­tions on med­ical and sur­gi­cal ben­e­fits in the same classification.

The FAQ pro­vid­ed that any cri­te­ria for mak­ing med­ical neces­si­ty deter­mi­na­tions, as well as process­es, strate­gies, evi­den­tiary stan­dards, or oth­er fac­tors used in devel­op­ing NQTLs and apply­ing them must be dis­closed for both men­tal health and sub­stance use dis­or­der ben­e­fits and med­ical and sur­gi­cal ben­e­fits, regard­less of asser­tions that the infor­ma­tion is pro­pri­etary or has com­mer­cial val­ue. Fur­ther­more, although group health plans are not required to pro­vide a sum­ma­ry descrip­tion of med­ical neces­si­ty cri­te­ria that is writ­ten to be under­stand­able for a layper­son, they may do so. It is not, how­ev­er, a sub­sti­tute for pro­vid­ing the under­ly­ing cri­te­ria if the doc­u­ments are requested.

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