This week, the Departments of Labor, Health and Human Services and the Treasury jointly released a new FAQ on the coverage of preventive services. The notice includes clarification on contraception coverage, advanced preventive breast cancer screenings, coverage for transgender individuals and coverage for dependent children. The guidance clarified that insurers must cover without cost-sharing at least one form of contraception in each of the 18 FDA identified methods. It must also cover clinical services, including education and counseling, necessary for obtaining contraception. However, insurers can continue to use cost-sharing on products so long as one version is available without cost-sharing, such as covering a generic but not a brand name. Providers can override these if they determine that a product is medically necessary.
This guidance was largely in response to confusion raised by women’s advocacy groups claiming that insurers were not adhering to the law’s requirement to cover all forms of contraception without cost-sharing. The National Women’s Law Center and Kaiser Family Foundation published studies earlier this year highlighting the gaps in coverage, which prompted Senate Democrats to write a letter asking for clarification. The guidance is set to take effect in 60 days.
Also, late last week the Centers for Medicare and Medicaid Services released guidance clarifying the 2016 Notice of Benefit and Payment Parameters that insurers must limit out-of-pockets costs to the individual limit, regardless if the enrollee is in a family plan with a higher out-of-pocket cap. The maximum out-of-pocket spending in 2016 will be $6,850 for individuals and $13,700 for families. The guidance also clarified how plans can offer a family deductible of $10,000 and remain in compliance with the requirement; so long as each individual is not subjected to more than the $6,850 out-of-pocket maximum as the limit applies to each person individually.