FAQs address array of preventive care coverage issues

The Departments of Labor (DOL), Health and Human Services (HHS) and the Treasury (Departments) have jointly issued a set of Frequently Asked Questions (FAQs) that address the coverage of preventive services under the market reforms of the Patient Protection and Affordable Care Act (ACA). The FAQs also address issues regarding implementation of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), as amended by the ACA.

Disclosure of lactation counseling providers. ACA requires coverage of preventive care and screenings provided for in Health Resources and Services Administration (HRSA) guidelines. These guidelines provide for coverage of comprehensive prenatal and postnatal lactation support, counseling, and equipment rental as part of their preventive service recommendations, including lactation counseling.

The FAQs indicate that plans and issuers are required to provide a list of the lactation counseling providers within the network. Although the preventive services requirements do not include specific disclosure requirements, provisions of other applicable laws require disclosure of lactation counseling providers available under the plan or coverage. Group health plans and health insurance issuers offering group or individual health insurance coverage must provide a Summary of Benefits and Coverage (SBC) that includes an Internet address (or other contact information) for obtaining a list of the network providers.

In addition, group health plans subject to ERISA must provide a Summary Plan Description (SPD) that describes provisions governing the use of network providers, the composition of the provider network, and whether, and under what circumstances, coverage is provided for out-of-network services. For those plans with provider networks, the listing of providers can be furnished in a separate document accompanying the SPD, as long as the SPD describes the provider network and states that provider lists are furnished automatically, without charge, as a separate document.

Also, issuers of qualified health plans (QHP) in the exchanges and the Small Business Health Options Program (SHOP) must make their provider directories available online.

Cost sharing for lactation counseling services. The FAQs also indicate that group health plans cannot impose cost sharing with respect to lactation counseling services obtained outside the network. If a plan or issuer does not have in its network a provider who can provide lactation counseling services, the plan or issuer must cover the item or service when performed by an out-of-network provider without cost sharing.

In the case where a state does not license lactation counseling providers, subject to reasonable medical management techniques, lactation counseling must be covered without cost sharing by the plan or issuer when it is performed by any provider acting within the scope of his or her license or certification under applicable state law. Lactation counseling could be provided by another provider type acting within the scope of his or her license or certification (for example, a registered nurse), and the plan or issuer would be required to provide coverage for the services without cost sharing.

The FAQs also provide that plans or issuers cannot impose cost sharing with respect to lactation counseling received on an outpatient basis. If a recommendation or guideline does not specify the frequency, method, treatment, or setting for the provision of a recommended preventive service, then the plan or issuer may use reasonable medical management techniques to determine any such coverage limitations. However, it is not a reasonable medical management technique to limit coverage for lactation counseling to services provided on an in-patient basis, according to the FAQs.

Breastfeeding equipment. Plans and issuers are not permitted to require individuals to obtain breastfeeding equipment within a specified time period (for example, within 6 months of delivery) in order for the breastfeeding equipment to be covered without cost sharing. The requirement to cover the rental or purchase of breastfeeding equipment without cost sharing extends for the duration of breastfeeding, provided the individual remains continuously enrolled in the plan or coverage.

Weight management. The FAQs also indicate that non-grandfathered plans and issuers must cover, without cost sharing, screening for obesity in adults. In addition to such screening, the United States Preventive Services Task Force (USPSTF) currently recommends, for adult patients with a body mass index (BMI) of 30 kg/m2 or higher, intensive, multicomponent behavioral interventions for weight management. The recommendation specifies that intensive, multicomponent behavioral interventions include, for example, the following:

• group and individual sessions of high intensity (12 to 26 sessions in a year),
• behavioral management activities, such as weight-loss goals,
• improving diet or nutrition and increasing physical activity,
• addressing barriers to change,
• self-monitoring, and
• strategizing how to maintain lifestyle changes.

Colonoscopy. A plan or issuer may not impose cost sharing with respect to a required consultation prior to a colonoscopy screening procedure if the attending provider determines that the pre-procedure consultation would be medically appropriate for the individual, because the pre-procedure consultation is an integral part of the colonoscopy. In addition, the plan or issuer is required to cover any pathology exam on a polyp biopsy without cost sharing.

Contraceptive coverage accommodations. The FAQs also address the contraception coverage accommodation methods for non-profit or closely held for-profit employers who sponsor ERISA-covered self-insured plans and who have a sincerely held religious objection to providing contraceptive coverage. There are two methods:

• Complete the EBSA Form 700 (accessible at www.dol.gov/ebsa/pdf/preventiveserviceseligibleorganizationcertificationform.pdf) and
• Provide appropriate notice of the objection to the Department of HHS. A model notice is available at www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Model-Notice-8-22-14.pdf.

BRCA testing. PHS Act section 2713 addresses coverage for evidence-based items or services with a rating of “A” or “B” in the current recommendations of the USPSTF. The USPSTF recommends with a “B” rating to “screen women who have family members with breast, ovarian, tubal or peritoneal cancer with 1 of several screening tools designed to identify a family history that may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA 1 or BRCA 2). Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing.”

As such, the FAQs provide that women found to be at increased risk using a screening tool designed to identify a family history that may be associated with an increased risk of having a potentially harmful gene mutation must receive coverage without cost sharing for genetic counseling, and, if indicated, testing for harmful BRCA mutations. This is true regardless of whether the woman has previously been diagnosed with cancer, as long as she is not currently symptomatic of or receiving active treatment for breast, ovarian, tubal, or peritoneal cancer.

Wellness programs. Group health plans that give rewards in the form of non-financial (or in-kind) incentives (for example, gift cards, thermoses, and sports gear) to participants who adhere to a wellness program are subject to the wellness program regulations issued by the Departments. If a group health plan provides a “reward” based on an individual satisfying a standard that is related to a health factor, the wellness program is subject to the Department’s wellness regulations.

As provided in the regulations, a reward may be financial or non-financial (or in-kind). More specifically, the regulations provide that reference to an individual obtaining a reward includes both “obtaining a reward (such as a discount or rebate of a premium or contribution, a waiver of all or part of a cost-sharing mechanism (such as a deductible, copayment, or coinsurance), an additional benefit, or any financial or other incentive) and avoiding a penalty (such as the absence of a surcharge or other financial or nonfinancial disincentives).”

MHPAEA disclsoures. MHPAEA amended the PHS Act, ERISA, and the Code to provide increased parity between mental health and substance use disorder (MH/SUD) benefits and medical/surgical benefits. In general, MHPAEA requires that the financial requirements (such as coinsurance and copays) and treatment limitations (such as visit limits), imposed on MH/SUD benefits cannot be more restrictive than the predominant financial requirements and treatment limitations that apply to substantially all medical/surgical benefits.

The FAQs indicate that the criteria for making medical necessity determinations, as well as any processes, strategies, evidentiary standards, or other factors used in developing the underlying nonquantitative treatment limitation (NQTL) and in applying it, must be disclosed with respect to both MH/SUD benefits and medical/surgical benefits, regardless of any assertions as to the proprietary nature or commercial value of the information.

In addition, although not required to do so, group health plans and issuers can provide a document that provides a description of the medical necessity criteria in layperson’s terms. However, providing such a summary document is not a substitute for providing the actual underlying medical necessity criteria, if such documents are requested.

SOURCE: FAQs about Affordable Care Act Implementation (Part XXIX) and Mental Health Parity Implementation, October 23, 2015.

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