ERISA-DOL Provides Guidance On Coverage Of Preventive Services Under The Affordable Care Act

The U.S. Department of Labor (the “DOL”) has issued FAQs about Affordable Care Act Implementation (Part XIX), which provide guidance on the coverage of preventive services under the Affordable Care Act (the “ACA”). Here is what the FAQs say:

In General. PHS Act section 2713 and the interim final regulations relating to coverage of preventive services require non-grandfathered group health plans offered in the group market to provide benefits for, and prohibit the imposition of cost-sharing requirements with respect to, the following:

• Evidenced-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (the “USPSTF”) with respect to the individual involved, except for the recommendations of the USPSTF regarding breast cancer screening, mammography, and prevention issued in or around November 2009, which are not considered current;

• Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices (the “ACIP”) of the Centers for Disease Control and Prevention (the “CDC”) with respect to the individual involved;

• With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration (the “HRSA”); and
• With respect to women, evidence-informed preventive care and screening provided for in comprehensive guidelines supported by HRSA, to the extent not already included in certain recommendations of the USPSTF.(10)

If a recommendation or guideline does not specify the frequency, method, treatment, or setting for the provision of that service, the plan can use reasonable medical management techniques to determine any such coverage limitations.
These requirements do not apply to grandfathered health plans.

Tobacco Use. Plans may use reasonable medical management techniques to determine the frequency, method, treatment, or setting for a recommended preventive service, to the extent not specified in the recommendation or guideline regarding that preventive service. Evidence-based clinical practice guidelines can provide useful guidance. The DOL will consider a group health plan to be in compliance with the requirement to cover tobacco use counseling and interventions, if, for example, the plan covers without cost-sharing:

1. Screening for tobacco use; and,

2. For those who use tobacco products, at least two tobacco cessation attempts per year. For this purpose, covering a cessation attempt includes coverage for:

o Four tobacco cessation counseling sessions of at least 10 minutes each (including telephone counseling, group counseling and individual counseling) without prior authorization; and
o All Food and Drug Administration (“FDA”)-approved tobacco cessation medications (including both prescription and over-the-counter medications) for a 90-day treatment regimen when prescribed by a health care provider without prior authorization.

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