The Departments of Labor, Health and Human Services, and the Treasury (Departments) recently released a set of frequently asked questions (FAQs) on the Affordable Care Act’s (ACA) contraceptive coverage mandate. The FAQ responses restate the mandate, acknowledge the compliance barriers, and outline a new approach for using medical management techniques for contraceptive drugs.
Contraceptive Coverage Mandate
Non-grandfathered health plans and health insurance issuers, under the ACA, must cover certain preventive care services without cost sharing. This includes contraceptive coverage, as stated in the Health Resources and Services Administration (HRSA). Please note, exemptions are available to religious employers and eligible employees.
The Department’s FAQs state that health plans and insurers must cover, without cost sharing, at least one form of contraception in each of the categories (i.e., intrauterine devices with progestin, injectable contraceptives, oral contraceptives-combined pill, and emergency contraception-levonorgestrel) listed by HRSA.
Additionally, any contraceptive services and FDA-approved, -cleared, or -granted products that a member’s health care provider deems medically necessary, including newer products that may not be under HRSA’s guidelines, must be covered by health plans and insurers without cost sharing.
The Departments have been made aware of reports that health plans and issues are barring access to contraceptive coverage by:
- Requiring individuals to satisfy step-therapy protocols before the plan or issuer will approve coverage or the product that is deemed medically necessary by a provider;
- Applying age restrictions for contraceptive services or products that are deemed medically necessary;
- Appling unnecessary, burdensome administrative requirements as a part of an exceptions process;
- And requiring cost-sharing services that are needed for the preventive services provided, even if the items and services are billed separately.
To combat compliance issues, the Departments have announced the therapeutic equivalence approach. A contraceptive drug or product is considered therapeutically equivalent to another if it is identified as a therapeutic equivalent in the FDA’s Approved Drug Products with Therapeutic Equivalence Evaluations.
Through this approach, a health plan’s or issuer’s medical management techniques for FDA-approved contraceptive drugs (and drug-led devices) within a specific category in HRSA’s guidelines will be considered reasonable if:
- The plan or issuer covers all FDA-approved contraceptive drugs in that category without cost-sharing, with the exception of those that have at least one therapeutic equivalent that the plan or issuer covers without cost sharing,
- And the plan or issuer provides an exceptions process, allowing an individual to access the medically necessary specific contraceptive that is a therapeutic equivalent without cost sharing.
If you have any questions regarding compliance with the ACA’s contraceptive coverage mandate, please contact your dedicated Creative Benefits, Inc. team member.