By: Danielle Capilla
Chief Com­pli­ance Offi­cer at Unit­ed Ben­e­fit Advisors

PreventiveCareOn May 11, 2015, the Depart­ment of Labor (DOL) along with oth­er fed­er­al agen­cies issued an FAQ regard­ing the imple­men­ta­tion of the Patient Pro­tec­tion and Afford­able Care Act (PPACA) that focused on cov­er­age of pre­ven­tive ser­vices. Non-grand­fa­thered group health plans and health insur­ance offered in the indi­vid­ual or group mar­kets must pro­vide cer­tain list­ed ben­e­fits with no cost-shar­ing to the ben­e­fi­cia­ry. The FAQ pro­vid­ed infor­ma­tion on some com­mon­ly con­fus­ing or ambigu­ous requirements.

BRCA Test­ing

PPACA requires health plans to offer evi­dence-based ser­vices with a rat­ing of A or B in the cur­rent rec­om­men­da­tions pro­vid­ed by the Unit­ed States Pre­ven­tive Ser­vices Task Force (USPSTF), as well any addi­tion­al cov­er­age for women pro­vid­ed in guide­lines sup­port­ed by the Health Resources and Ser­vices Admin­is­tra­tion (HRSA). A 2013 FAQ left con­fu­sion as to whether the rec­om­men­da­tion to pro­vide BRCA screen­ing applies to women who have had a pri­or non-BRCA-relat­ed breast can­cer or ovar­i­an can­cer diag­no­sis, even if they are asymp­to­matic and can­cer-free. The DOL clar­i­fied that a plan or issuer must cov­er (with­out cost-shar­ing) genet­ic coun­sel­ing and BRCA genet­ic test­ing for women who have not been diag­nosed with a BRCA-relat­ed can­cer but pre­vi­ous­ly had breast can­cer, ovar­i­an can­cer, or oth­er spe­cif­ic cancers.


The FAQ pro­vid­ed infor­ma­tion relat­ing to con­tra­cep­tion cov­er­age that is applic­a­ble to plan years or poli­cies begin­ning on or after July 10, 2015 (60 days from issuance of the FAQ). It made clear that if a plan or issuer cov­ers some forms of con­tra­cep­tion with­out cost-shar­ing, but com­plete­ly excludes oth­er forms of con­tra­cep­tion, it will not be in com­pli­ance with reg­u­la­tions. Plans and issuers must cov­er the full range of FDA-iden­ti­fied meth­ods and must cov­er with­out cost-shar­ing at least one form of con­tra­cep­tion in each method iden­ti­fied by the FDA. There are 18 FDA-iden­ti­fied meth­ods of con­tra­cep­tion for women. The cov­er­age must include clin­i­cal ser­vices, includ­ing patient edu­ca­tion and coun­sel­ing that is need­ed for the pro­vi­sion of the con­tra­cep­tion method.

Plans and issuers may uti­lize rea­son­able med­ical man­age­ment tech­niques. The plan may dis­cour­age the use of brand name phar­ma­cy items over gener­ic phar­ma­cy items, or use cost shar­ing to encour­age the use of one of sev­er­al FDA-approved intrauter­ine devices (IUDs) with prog­estin. When uti­liz­ing rea­son­able med­ical man­age­ment tech­niques the plans and issuers must have an eas­i­ly acces­si­ble, trans­par­ent, and suf­fi­cient­ly expe­di­ent excep­tions process that is not undu­ly bur­den­some on either the patient or the provider. If an indi­vid­u­al’s attend­ing provider rec­om­mends a par­tic­u­lar ser­vice or FDA-approved item based on med­ical neces­si­ty, the item must be cov­ered with­out cost-shar­ing and the plan or issuer must defer to the med­ical provider.

Sex-Spe­cif­ic Rec­om­mend­ed Pre­ven­tive Services

The FAQ made clear that plans or issuers may not lim­it sex-spe­cif­ic rec­om­mend­ed pre­ven­tive ser­vices based on an indi­vid­u­al’s sex assigned at birth, gen­der iden­ti­ty, or record­ed gen­der. The deci­sion regard­ing the med­ical appro­pri­ate­ness of a pre­ven­tive ser­vice is to be deter­mined by the indi­vid­u­al’s attend­ing provider.

Well-Woman Pre­ven­tive Care for Dependents

Plans or issuers that cov­er depen­dent chil­dren must cov­er rec­om­mend­ed pre­ven­tive ser­vices relat­ed to preg­nan­cy, such as pre­con­cep­tion and pre­na­tal care for depen­dent chil­dren, with­out cost-sharing.

Colono­scopies and Anes­the­sia Charges

Colono­scopies that are sched­uled and per­formed as a pre­ven­tive screen­ing pro­ce­dure for col­orec­tal can­cer pur­suant to USPSTF rec­om­men­da­tions may not charge the patient for anes­the­sia ser­vices per­formed in con­nec­tion with the colonoscopy.

For this and oth­er free pub­li­ca­tions relat­ed to PPACA com­pli­ance, vis­it UBA’s Com­pli­ance Solu­tions resource cen­ter.

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