Impacts all non-grandfathered, self-funded plans now:
The agencies have received many questions about the requirement to provide first-dollar preventive care. They have now issued a FAQ that clarifies that:
- While plans generally do not need to provide out-of-network preventive care if there are no in-network providers able to provide the needed preventive care service, out-of-network care must be provided at no cost
- Preventive over-the-counter drugs, such as aspirin for those at risk for heart attacks, must be covered at 100 percent only if the over-the-counter drug is actually prescribed
- Routine immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) must be covered without cost-sharing beginning with the plan year that begins one year after the recommendation is adopted by the Centers for Disease Control and Prevention (CDC)
- When a screening or immunization recommendation applies only to those who are “high risk,” the attending provider is the one who determines if the person is high risk
- If a polyp is removed during a screening colonoscopy, the entire procedure must be covered without cost-sharing, as a preventive service
- The BRAC test itself, as well as genetic testing, must be covered at 100 percent if the attending provider determines the woman is at high risk for the BRAC mutation based on family history
- Required contraceptive coverage does not include male contraceptives
- Plans may not limit coverage to oral contraceptives and must cover IUDs, implants, sterilization, device removal, etc. Plans may impose reasonable management techniques, such as limiting first dollar coverage to generics unless use of the generic would be medically inappropriate for the individual. Over-the-counter contraceptives must be covered only if they are FDA-approved and prescribed by the woman’s health care provider
- Annual HIV testing and triennial HPV DNA testing must be covered as part of well-woman care
The text of the FAQs on preventive services is here:
FAQs About Affordable Care Act Implementation Part XII
