New Guidance Clarifying Preventive Services under the Affordable Care Act

One of the major consumer-facing provisions under the Affordable Care Act requires most health plans to provide coverage of preventive services without cost-sharing. This enable consumers to access evidence-based medical care to prevent or to detect early medical conditions like breast, ovarian or colon cancer. It also helps parents afford immunizations from preventable diseases like measles or whooping cough for their children.

However, this critically important ACA protection has had some bumps as it has been implemented in real life. In some cases, consumers have received bills for cost-sharing for preventive services that should have been covered at no charge.

In response to these and other concerns, the Obama administration has issued a Frequently Asked Questions (FAQ) document clarifying this requirement as it relates to cancer-related counseling and genetic testing, contraceptives, sex-specific preventive services, well-women preventive services for dependents, and coverage of anesthesia for a preventive colonoscopy. As we summarize below, the FAQ clarifies that health plans must provide coverage without cost-sharing for:

  • Cancer-related counseling and if needed, genetic testing for women with a family history that puts them at an increased risk for having mutations in the breast cancer susceptibility gene (BRCA 1 or BRCA 2). The guidance clarifies that health plans must cover the genetic counseling and BRCA genetic testing for women that have not been diagnosed with BRCA-related cancer, but have had breast cancer, ovarian cancer or another type of cancer regardless of whether they have symptoms or are in remission.
  • Contraceptive methods that the FDA has identified, meaning that health plans must cover at least one form of contraception in each of the eighteen FDA-identified methods. If health plans cover more than one type of contraception within an FDA-identified method, they can use reasonable medical management to encourage one particular type of contraception over another. For example, if a health plan covers both generic and brand name birth control bills, the health plan can impose cost sharing on the brand name over the generic. However, the guidance is clear that if a provider recommends a particular type of contraception; for example, the brand birth control in the example above, the health plan must cover the provider recommended contraception without cost sharing. If the health plan uses medical management, it must have an accessible process in place through which enrollees or their providers can request coverage of contraceptives without cost-sharing.
  • Sex-specific preventive services that a provider determines is medically appropriate. This means that health plans cannot limit or deny sex-specific preventive services to individuals based on that individual’s sex assigned at birth, gender identify or recorded gender.
  • Well-women preventive services for dependents, as determined by a provider, if a health plan covers dependents.
  • Coverage of anesthesia for preventative colonoscopies.

The guidance is welcome news for consumers who have too often paid the price for a lack of clarity and confusion among both providers and insurers about this important ACA provision. However, as the evidence base for a wide range of preventive services evolves, the Administration will need to answer questions and issue guidance to ensure that consumers can take full advantage of the services they need to stay healthy.