May 12, 2015 — The Obama administration on Monday issued new guidance clarifying several aspects of the Affordable Care Act's (PL 111-148) requirement that plans provide a range of preventive services at no cost, the New York Times reports.
The guidance was jointly released by HHS and the departments of Labor and Treasury (Pear, New York Times, 5/11). It will go into effect in 60 days, although most consumers will not experience major changes until their next plan year, according to AP/U-T San Diego (Alonso-Zaldivar, AP/U-T San Diego, 5/11).
The ACA's preventive services provision, which took effect in 2012, requires insurers to cover a range of services without copayments or deductibles.
Federal guidance on the contraceptive coverage rules under the ACA states that insurers must cover the full range of FDA-approved contraceptive methods without cost-sharing. Insurers are permitted to use "reasonable medical management techniques" to curb costs, such as only covering the generic version of an approved contraceptive (Women's Health Policy Report, 4/30).
However, some insurers have not been adhering to the ACA's preventive services requirements, according to a Kaiser Family Foundation report and two separate National Women's Law Center studies, all released last month. KFF and NWLC both found that some plans were not covering all FDA-approved contraceptives without copayments (New York Times, 5/11). Meanwhile, the NWLC report also found that some insurers were not covering care for transgender individuals (Owens, National Journal, 5/11).
Guidance Details on Birth Control
The new guidance states that insurers must cover at least one version of each of the 18 FDA-approved birth control methods without cost-sharing (AP/U-T San Diego, 5/11). However, the guidance also states that insurers are permitted to charge a copayment or deductible to encourage beneficiaries to use a particular brand or generic version of a given contraceptive method (Galewitz, Kaiser Health News, 5/11).
NWLC had found that some insurers said they did not provide coverage for the ring or the patch because they already covered oral contraceptives, which deliver the same hormones (Women's Health Policy Report, 4/30). However, the new guidance clarifies that insurers "may not impose cost-sharing on the ring or the patch" (New York Times, 5/11).
Additional Guidance Details
In addition, the guidance states that insurers are required to cover, without cost-sharing, maternity care and all other women's health services for dependents also covered by a plan (Radnofsky, Wall Street Journal, 5/11). It notes that insurers must cover without copayments or deductibles prenatal benefits and other services intended to assist with healthy pregnancies for plans that have children covered as dependents (AP/U-T San Diego, 5/11).
Further, the guidance clarifies that insurers are required to cover "preventive screening, genetic counseling, and genetic testing" for BRCA1 and BRCA2 genetic mutations "without cost-sharing, if appropriate, for a woman as determined by her attending provider." The requirement applies "[a]s long as the woman has not been diagnosed with BRCA-related cancer."
The genetic tests -- which the guidance states could be appropriate for women with family histories of breast, ovarian, peritoneal or tubal cancer-- can help women determine whether to have pre-emptive surgery to reduce their cancer risk (Berkrot, Reuters, 5/11).
Meanwhile, the guidance also clarifies that insurers cannot limit "sex-specific recommended preventive services" based on the sex an individual was assigned at birth or an individual's gender identity (New York Times, 5/11). For example, insurers cannot refuse to cover a mammogram for a transgender woman over age 50, even if the woman's insurance records lists her as a man (National Journal, 5/11).
Sen. Patty Murray (D-Wash.) said the new guidance would help make sure that "women receive 'the health care they are entitled to" under the ACA, including birth control.
Gretchen Borchelt, NWLC's vice president for health and reproductive rights, commended the guidance, saying, "It is now absolutely clear that all means all -- all unique birth control methods for women must be covered" (New York Times, 5/11).
Meanwhile, America's Health Insurance Plans CEO Karen Ignagni said the "guidance takes important steps to support health plans' use of medical management in providing women with safe, affordable healthcare services" (Herman, Modern Healthcare, 5/11).
Op-Ed Urged Obama Administration To Ensure Contraceptive Coverage Under the ACA
Just before the administration issued the new guidance, Deborah Nucatola, senior director of medical services at Planned Parenthood Federation of America, and Hal Lawrence, executive vice president and CEO of the American Congress of Obstetricians and Gynecologists, explained why "[o]ffering women the full range of FDA-approved birth control methods is an essential part of health care" in a Roll Call opinion piece urging such guidance.
For example, the authors note that "[s]ome insurers restrict access to certain birth control methods ... by forcing women to undergo 'step therapy,'" under which a woman "may be forced to use one birth control method, such as the pill, regardless of whether it works for her, before getting coverage for the ring, patch, [intrauterine device] or other method she and her doctor have decided is best for her." Meanwhile, "[s]ome insurers ... requir[e] prior authorization, an extra step that gives the insurer the right to reject a doctor's prescription," Nucatola and Lawrence write.
The authors explain that as medical professionals, they "see firsthand there is no one-size-fits-all method of birth control." For example, they note that some women cannot use certain methods because of "medical conditions," some "suffer from side effects when they use certain contraceptives" and "conversely, some may seek out hormonal methods to regulate conditions such as endometriosis." Further, they point out that "[s]ome women have lifestyles that just don't allow for birth control that depends on daily doses for effectiveness."
In addition, Nucatola and Lawrence write that "[m]any forms of birth control are prohibitively expensive for many women if they must foot the bill out of pocket." They note that "more than half of all American female voters ages 18 to 34 have struggled with the cost of birth control at some point, and as a result have used birth control inconsistently." However, the authors add that "[t]hanks to the birth control benefit, women and families saved more than $483 million in out-of-pocket costs for the birth control pill -- an average of $269 per woman -- in the first year alone" and "prevented unintended pregnancies" (Nucatola/Lawrence, Roll Call, 5/8).