Federal agencies have come down on the side of maximizing the scope of major medical plan preventive services benefits requirements in a new batch of guidance.
Officials at the U.S. Department of Labor, the U.S. Department of Health and Human Services (HHS), and the U.S. Treasury Department give their views on how employers, insurers and others should interpret the Patient Protection and Affordable Care Act (PPACA) preventive services coverage mandate in a new set of answers to frequently asked questions (FAQs) about PPACA implementation.
PPACA requires the HHS secretary to work with an HHS medical advisory panel to develop a set of preventive benefits that appear to greatly improve the quality of health care. Health insurers and employer plans are supposed to cover the products and services in the package without imposing deductibles or other cost-sharing requirements on patients who get that form of preventive care from a provider in the plan’s provider network.
In some cases, employers with conscience-based objections to the contraceptive coverage requirement may be able to get a complete or partial exemption.
Critics have argued that insurers and plans have been finding ways to hold down preventive services package costs by taking measures that, from the critics’ perspective, amount to skimping on benefits. In New York state, for example, Attorney General Eric Schneiderman has objected to reports that health insurers are refusing to provide birth control benefits for men, or refusing to cover attractive brand-name prescription drugs when cheaper but less convenient generic alternatives exist.
For a look at what Obama administration regulators said the federal guidance issued today, read on.
1. When patients who are getting colonoscopies for screening purposes need anesthesia, the plan must cover the anesthesia without imposing cost-sharing requirements. The attending provider is responsible for deciding whether the patient needs anesthesia, officials say.
2. A plan subject to the birth control coverage requirements must cover at least one service or item within each of the 18 method categories identified by the U.S. Food and Drug Administration (FDA). Some plans noted that they already cover hormonal birth control medications delivered in the form of pills. They objected to the idea of having to offer access to more expensive hormonal birth control delivery mechanisms, such as contraceptive rings or contraceptive patches. A plan must cover the ring or the patch as well as the pill, because the FDA puts the ring and the patch in a category separate from the category for birth control pills, officials say.
3. In some cases, a plan or issuer may have to cover a brand-name birth control option, or some other option that’s not on the plan’s preferred option list within an FDA method category. A patient’s attending provider is responsible for determining whether a particular item or service is medically necessary for a particular patient, even if the plan or issuer would normally require the patient to use another option. If a provider says one option is medically necessary, the plan or issuer must cover that without imposing cost-sharing requirements.
4. If a woman has had cancer, but does not appear to currently have a BRCA-gene-related cancer, a plan or issuer must cover genetic counseling or BRCA testing for her as a preventive service, without imposing a cost-sharing requirement. The plan must cover that screening without cost-sharing, officials say.
Karen Ignagni, president of America’s Health Insurance Plans (AHIP), said in a statement that the guidance “takes important steps to support health plans’ use of medical management in providing women with safe, affordable health care services.”
“Health plans are committed to promoting evidenced-based decision-making and to ensuring all consumers understand how their coverage works,” Ignagni said.