Departments Issue Reminder To Group Health Plans: ACA Requires Contraception Coverage Without Cost-Sharing
Published June 28, 2022
U.S. Secretary of Health and Human Services Xavier Becerra and U.S. Secretary of Labor Marty Walsh met with leaders from health insurers and employee benefit plans to call on the insurance industry to commit to meeting their obligations to provide access to contraception as required by the law. On Aug. 1, 2011, the Departments of Labor, Health and Human Services, and Treasury issued amended regulations requiring coverage of women’s preventive services, as required by the Affordable Care Act (ACA). Non-grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage must comply with the requirements under section 2713 of the Public Health Service (PHS) Act (incorporated into section 715 of the Employee Retirement Income Security Act (ERISA) and section 9815 of the Internal Revenue Code) and its implementing regulations, by providing coverage without cost sharing for preventive care and screenings. This requirement includes coverage of the full range of contraceptive products approved, cleared, or granted by the Food and Drug Administration (FDA).
On June 27, 2022, Secretaries Walsh and Becerra joined Treasury Secretary Janet L. Yellen in issuing a letter to group health plans and health insurance companies reminding them of their obligations under the ACA to provide coverage for contraceptive services at no cost. The letter discusses the general contraceptive coverage requirements and reported instances of potential non-compliance, and warns that enforcement actions may be taken if non-compliance continues.
The departments strongly encourage plans and issuers to immediately ensure they comply with these
standards to avoid future enforcement actions. Steps should include:
- Developing an easily accessible, transparent, and sufficiently expedient exceptions process for contraceptive products that is not unduly burdensome to the individual, provider, or other individual acting as a patient’s authorized representative) if one is not already in place (i.e., not requiring individuals to appeal an adverse benefit determination for a contraceptive using the plan’s or issuer’s internal claims and appeals process as the means to obtain an exception).
- Review exception processes for contraceptive products to ensure that these processes are easily accessible, transparent, sufficiently expedient, and not unduly burdensome on the individual or provider (or another individual acting as a patient’s authorized representative).
- Developing and using a standard form and instructions for the exceptions process.
- Ensuring that information regarding the availability and instructions for the exceptions process, including any standard form, are clearly described to individuals and their providers in plan documentation and online resources.
- Deferring to an attending provider’s recommendation regarding a contraceptive product based on determining medical necessity in consultation with their patient.
- Eliminating the application of overly burdensome, inappropriate, and unreasonable medical management techniques.