HHS issued guidance today clarifying coverage consumers are entitled to under the Affordable Care Act.  This guidance indicates that issuers cannot impose cost-sharing for anesthesia services performed in connection with preventive colonoscopies.

Download FAQ’s here

Coverage of Colonoscopies Pursuant to USPSTF Recommendations

Q7: If a colonoscopy is scheduled and performed as a preventive screening procedure for colorectal cancer pursuant to the USPSTF recommendation, is it permissible for a plan or issuer to impose cost sharing with respect to anesthesia services performed in connection with the preventive colonoscopy?

No. The plan or issuer may not impose cost sharing with respect to anesthesia services performed in connection with the preventive colonoscopy if the attending provider determines that anesthesia would be medically appropriate for the individual.

The guidance on BRCA-1 and BRCA-2 testing may also be of interest.

Coverage of BRCA Testing

Q1: Must a plan or issuer cover without cost sharing recommended genetic counseling and BRCA genetic testing for a woman who has not been diagnosed with BRCA-related cancer but who previously had breast cancer, ovarian cancer, or other cancer?

Yes. The USPSTF recommends that “primary care providers 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 (BRCA1 or BRCA2). Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing.” The USPSTF’s Final Recommendation Statement related to BRCA testing indicates that the recommendation “applies to asymptomatic women who have not been diagnosed with BRCA-related cancer.”

Therefore, as set out in the recommendations described above, as long as the woman has not been diagnosed with BRCA-related cancer, a plan or issuer must cover preventive screening, genetic counseling, and genetic testing without cost sharing, if appropriate, for a woman as determined by her attending provider, consistent with PHS Act section 2713 and its implementing regulations.

See the notice below for more details.

May 11, 2015

From: Paul Dioguardi

Director, Office of Intergovernmental and External Affairs

U.S. Department of Health and Human Services

RE:  Guidance on Preventive Services Including Contraception

The U.S. Departments of Health and Human Services, Labor and the Treasury are issuing important guidance to insurance companies and consumers today to help ensure that Americans have the coverage they are entitled to under the Affordable Care Act.

The law required that important preventive services, such as contraception and well-woman visits, be covered without out-of-pocket expenses (such as a co-pay or deductible).  These recommended preventive services are designed to help people stay healthy and to catch illnesses earlier on, when treatments can be more successful and costs are often lower.

But as the law has been implemented, issues have been raised by some women and from Members of Congress that insurance companies were not covering the contraceptive method recommended by doctors, as well as concerns from issuers that the existing guidance did not provide enough detail about how specific types of contraception should be covered.

Today’s guidance seeks to eliminate any ambiguity. Insurers must cover without cost-sharing at least one form of contraception in each of the methods (currently 18) that the FDA has identified for women in its current Birth Control Guide, including the ring, the patch and intrauterine devices, according to the guidance.

Additionally, the Departments are further clarifying a series of other important preventive services protections. The guidance:

• Clarifies that if a woman is at increased risk for having a potentially harmful mutation in genes that suppress tumors – the BRCA-1 or BRCA-2 cancer susceptibility gene – a plan or issuer must cover the preventive screening, genetic counseling, and BRCA genetic testing with no cost-sharing, as long as the woman had not been diagnosed with BRCA-related cancer. Women with the BRCA-1 and 2 mutation have a risk of breast cancer that is about five times the normal risk, and a risk of ovarian cancer that is about 10 to 30 times normal.
• Makes clear for transgender people that issuers cannot limit preventive services based on an individual’s sex assigned at birth, gender identity or recorded gender. Issuers should cover the preventive services that an individual’s provider, not an insurance company, determines are medically appropriate.
• Clarifies that if a plan or issuer covers dependent children, they must provide recommended preventive services for those dependent children. This includes recommended services related to pregnancy, including preconception and prenatal care.
• Indicates that issuers cannot impose cost-sharing for anesthesia services performed in connection with preventive colonoscopies.

The following quote can be attributed to Health and Human Services Secretary Sylvia M. Burwell –

“The Affordable Care Act was a major step forward in helping women get the health care services they need to stay healthy. Tens of millions of women are eligible to receive coverage of recommended preventive services without having to pay a co-pay or deductible, including contraception,” said Health and Human Services Secretary Sylvia M. Burwell. “Today, we are clarifying these coverage requirements, including access to the full range of contraceptive methods identified by the FDA, access to genetic counseling and testing for the BRCA gene as a preventative tool in the fight against cancer, and access to preventive services for transgender individuals.”

The FAQs are attached and are posted here.

Questions or Concerns? Contact [email protected].