FAQs address ACA coverage of preventive services, Women’s Health and Cancer Rights Act

The departments of Labor, Health and Human Services, and the Treasury have issued ACA FAQs Part 68 providing new guidance on the Affordable Care Act’s (ACA’s) mandate that employer-sponsored group health plans cover preventive care services with no cost sharing. In addition, the FAQs offer guidance on compliance with the Women’s Health and Cancer Rights Act (WHCRA), which provides protections for individuals who elect breast reconstruction in connection with a mastectomy.

ACA coverage of preventive services

Coverage of pre-exposure prophylaxis

The ACA requires certain preventive care services to be provided by non-grandfathered employer-sponsored group health plans and health insurance issuers without cost sharing (i.e., no copay, coinsurance or deductible). These include evidence-based items or services with an “A” or “B” rating in the current recommendations of the United States Preventive Services Task Force (USPSTF).

On June 11, 2019, the USPSTF released a recommendation with an “A” rating that clinicians offer pre-exposure prophylaxis (PrEP) with “effective antiretroviral therapy to persons who are at high risk of HIV acquisition.” The departments subsequently issued an FAQ clarifying that the 2019 USPSTF recommendation for PrEP encompasses U.S. Food and Drug Administration (FDA)-approved PrEP antiretroviral medications as well as specified baseline and monitoring services that are essential to the efficacy of PrEP. On August 22, 2023, the USPSTF updated its recommendation with respect to PrEP and identified two additional FDA-approved formulations of PrEP.

The new FAQs clarify that plans and issuers must cover, without cost sharing, specified oral and injectable formulations of PrEP, as well as certain baseline and monitoring services, consistent with the 2023 USPSTF recommendation, for plan years beginning on or after one year from the issue date of the recommendation (i.e., plan years beginning on or after August 31, 2024, or January 1, 2025, for calendar-year plans). The 2023 USPSTF recommendation for PrEP specifies three formulations of medications approved by the FDA for use as PrEP. Therefore, plans and issuers must cover, without any out-of-pocket costs for individuals, the three FDA-approved PrEP formulations (two oral and one injectable); also they may not use medical management techniques to direct individuals prescribed PrEP to use one formulation over another.

Coding for recommended preventive items and services

The new guidance is intended to ensure that individuals receive coverage consistent with the ACA’s preventive services mandate. The FAQs include several examples of how plans and issuers, working with their network providers, can ensure that they cover recommended preventive items and services without cost sharing. Some key points in the guidance are as follows:

• Generally, if a plan or issuer receives a claim from an in-network provider that identifies an item or service as a recommended preventive item or service using industry-standard coding practices, it should cover the item or service without cost sharing.
• However, if a plan or issuer is able to establish, based on other individualized information received with the claim or maintained by the plan or issuer, that an item or service was not furnished as a recommended preventive item or service (or was not integral to the furnishing of a recommended preventive item or service), it does not have to cover the services without cost sharing. Note: The participant would have the right to appeal an adverse benefit determination, pursuant to the plan procedures.
• Plans and issuers should review their coding guidelines, claims processing systems and other relevant internal protocols and make any necessary modifications to ensure that claims for recommended preventive items or services (including items and services that are integral to the furnishing of a recommended preventive item or service) are covered without cost sharing.

Women’s Health and Cancer Rights Act

WHCRA provides protections for individuals who elect breast reconstruction in connection with a mastectomy. The FAQs clarify that if a plan subject to WHCRA provides medical and surgical benefits for a mastectomy, it must provide coverage for all stages of breast reconstruction, including surgery and reconstruction of the other breast, if only one was treated, to produce a symmetrical appearance, in a manner determined in consultation with the attending physician and the patient. This includes coverage for chest wall reconstruction with aesthetic flat closure if the patient so chooses after consulting with the attending physician.

Going forward

• Employer plan sponsors should review their group health plan provisions with their third-party administrators (TPAs) or insurance carriers to determine if they are providing the appropriate ACA preventive care services with no cost sharing.
• Employer plan sponsors and their TPAs or carriers should review their coding guidelines, claims processing systems and other relevant internal protocols and modify them as necessary to ensure that claims for ACA mandated preventive items or services are covered without cost sharing.
• Employer plan sponsors and their TPAs or carriers should confirm their plan is complying with the WHCRA requirements for individuals who elect breast reconstruction in connection with a mastectomy.