Recent guidance issued jointly by the U.S. Departments of Labor, Health and Human Services, and the Treasury clarifies how the Affordable Care Act's requirement to provide cost-free coverage for preventive care applies to several types of products and services. 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.

As the federal health care reform effort gained steam, Ballard Spahr attorneys established the Health Care Reform Initiative to monitor and analyze legislative developments. With federal health care reform now a reality, our attorneys are assisting health care entities and employers in understanding the relevant changes and planning for the future. They also have launched the Health Care Reform Dashboard, an online resource center for news and analysis on developments under the Affordable Care Act.

If you have questions about the coverage of preventive care products and services, contact Edward I. Leeds, counsel in Ballard Spahr’s Employee Benefits and Executive Compensation Group, at 215.864.8419 or leeds@ballardspahr.com; Jean C. Hemphill, practice leader of the firm's Health Care Group, at 215.864.8539 or hemphill@ballardspahr.com; or the member of either group with whom you regularly work.


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This alert is a periodic publication of Ballard Spahr LLP and is intended to notify recipients of new developments in the law. It should not be construed as legal advice or legal opinion on any specific facts or circumstances. The contents are intended for general informational purposes only, and you are urged to consult your own attorney concerning your situation and specific legal questions you have.

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