Clarification on Coverage of Preventive Contraceptives and Colonoscopies

The Departments of Health and Human Services, Labor, and Treasury recently provided guidance regarding coverage of certain preventive benefits. The Affordable Care Act requires non-grandfathered health plans to cover, without any cost sharing requirements, certain preventive benefits as determined by the United States Preventive Services Task Force (USPTF), the Advisory Committee on Immunization Practice, and the Health Resources and Services Administration (HRSA).

In 2016, the USPTF first recommended coverage of for colorectal cancer screenings and then updated those recommendations in 2021. While unclear from the 2016 recommendation, the recent guidance clarified that the 2021 update requires plans to cover a follow-up colonoscopy conducted after a positive non-invasive stool-based screening test or direct visualization test (e.g., sigmoidoscopy, CT colonography). The updated recommendation states that the follow-up colonoscopy is an integral part of the preventive screening without which the screening would not be complete, and thus must be covered as a preventive benefit. Plans must begin complying with this recommendation for plan or policy years beginning on or after May 31, 2022.

The recent guidance also provides details on contraception coverage. The HRSA guidelines provide that adolescent and adult women must have access to the full range of female-controlled FDA-approved contraceptive methods, including contraceptive counseling, initiation of contraceptive use, and follow-up care. The Departments later clarified that plans must cover, without cost sharing, at least one form of contraceptive in each method that is identified by the FDA. A plan may use reasonable medical management techniques—such as only covering a generic drug without cost sharing and imposing cost sharing on brand name drugs. However, the plan must have a mechanism for waiving the otherwise applicable cost sharing if the individual’s medical provider determines that only a particular brand name contraceptive is medically appropriate.

In this recent guidance, the Departments report that they have received a number of complaints that participants have been improperly denied contraceptive coverage. Examples of impermissible actions include:

· Denying coverage for a certain type of or particular brand name of contraceptives, even after the individual’s medical provider determines and communicates to the plan that a particular contraceptive is medically appropriate;

· Requiring individuals to fail first using various contraceptive products before the plan will cover the contraceptive that the medical provider has determined is medically appropriate;

· Failing to provide an easily accessible, transparent, and expedient exception process that is not unduly burdensome, for example by requiring individuals to appeal an adverse benefit determination using internal claims and appeals process as the means to obtain an exception.

The Departments report that they are actively investigating these complaints and reports and may take enforcement or other corrective actions.

Plans should take this opportunity to correct any impermissible coverage requirements related to contraceptive products as soon as possible, and be prepared to revise their colorectal cancer screening guidelines soon.