In particular, the guidance clarifies that:
- Coverage for all types of contraception (currently 18 different types are recognized) must be provided cost-free to plan participants. Plans may implement cost-sharing for medical management purposes (for example, to encourage the use of generic over brand-name products), but must have an efficient and transparent process in place to make exceptions to those cost-sharing requirements in accordance with an attending physician's recommendation.
- Coverage of well-woman care that is subject to the preventive care rules must be offered cost-free to qualifying dependent children as well as to employees and spouses.
- In applying preventive service recommendations that are sex-specific to particular individuals (for example, a transgender individual), the recommendations of the attending physician need to be observed.
- Certain counseling, screening and testing for breast cancer must be provided cost-free to women with a personal history of breast cancer that has not been diagnosed as having certain genetic links.
- Cost-free coverage for colonoscopies includes anesthesia services.
The guidance specifically provides that the Departments will not apply the requirement to cover each type of recommended contraceptive coverage to plan years beginning before July 10, 2015. Otherwise, the clarifications appear to be already in effect.
Sponsors of grandfathered plans remain exempt from the preventive care rules, including this new guidance. Sponsors of self-funded plans may consider whether any of these clarifications carry design and cost implications that they wish to discuss with their vendors or consultants.
Plan sponsors may also consider whether to make any adjustments in plan documentation or communication.
Edward I. Leeds, counsel at law firm
The information in this legal alert is for educational purposes only and should not be taken as specific legal advice.
