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Guidance Needed To Clarify Preventive Care Coverage Under ACA, Experts Say

Guidance Needed To Clarify Preventive Care Coverage Under ACA, Experts Say

January 22, 2014 — Although the Affordable Care Act (PL 111-148) requires health plans to cover many preventive services without cost-sharing, some patients are facing bills and other challenges when obtaining such care, Kaiser Health News/Washington Post reports.

The ACA requires health plans to cover many preventive services without consumer cost-sharing, including services recommended by the U.S. Preventive Services Task Force, many vaccines and a slate of women's health services. The requirements apply to all health plans except those that have been grandfathered under the law and those that qualify for religious exemptions under the federal contraceptive coverage rules.

Barriers to Contraception Access

The federal contraceptive coverage rules require most health plans to cover "the full range of FDA-approved contraceptive methods, including, but not limited to, barrier methods, hormonal methods, and implanted devices." However, a Guttmacher Institute study found that a number of plans exclude coverage for the contraceptive ring and patch.

Adam Sonfield, a senior public policy associate at Guttmacher who wrote the report, said insurers are "claiming that [the methods are] the same hormones as the pills, so it's the same method."

An HHS official wrote in an email, "The pill, the ring and the patch are different types of hormonal methods," adding, "It is not permissible to cover only the pill, but not the ring or the patch."

Calls for Clarification

Advocates and policy experts are urging HHS to issue more guidance on how various preventive services should be covered.

The lack of clarity has led to instances of patients being billed for costs related to services and procedures that should be covered, according to American Cancer Society Cancer Action Network Associate Director of Federal Relations Mona Shah.

The problem often is related to how services are coded for billing purposes, Shah explained. For example, a specific procedure might be covered, but related anesthesia and facility fees are not (Andrews, Kaiser Health News/Washington Post, 1/20).