On June 27, 2022, Secretaries Xavier Becerra, Marty Walsh and Janet L. Yellen of the U.S. Departments of Health and Human Services, Labor, and Treasury (the departments) issued an open letter to group health plans and health insurance issuers addressing obligations under the Affordable Care Act (ACA) to cover contraceptive services at no cost. Though these coverage requirements have been in place for more than a decade, the departments noted persistent and troubling reports of noncompliance. Declaring it “more important than ever to ensure access to contraceptive coverage without cost-sharing, as afforded by the ACA,” the departments expressed an expectation for industry commitment to promptly correct all areas of potential non-compliance.
Specifically, the ACA requires coverage of the full range of contraceptive products approved, cleared, or granted by the FDA and determined appropriate by an individual’s medical provider. Coverage must include the clinical services, including patient education and counseling, needed for the provision of the contraceptive product or service, and items that are integral to the delivery of the recommended preventive service, regardless of how such items or services are billed. While reasonable medical management techniques are allowed, they must be applied through an easily accessible, transparent, and expedient exceptions process that defers to the attending provider’s recommendation. For example, a plan may cover a generic drug without cost-sharing and impose cost-sharing for equivalent branded drugs. However, the plan must accommodate individuals for whom the generic drug would be medically inappropriate, as determined by the attending provider. In such circumstances, accommodation would mean waiving the otherwise applicable cost-sharing for the brand version. The process to obtain an exception must not be unduly burdensome on the individual or their provider (i.e., not require an appeal). Note that these guidelines are not new; rather, they repeat guidance from the departments issued in several previous FAQs.
Employers should ensure their group health plans comply with the ACA’s contraceptive services coverage requirements, including a review of medical management techniques and exceptions processes.
Letter to Plans and Issuers on Access to Contraceptive Coverage »