On January 22, 2024, pivotal guidance was issued by the Departments of Labor, Health and Human Services, and the Treasury, providing fresh insight into the Affordable Care Act’s mandate for contraception coverage. This blog post delves into the crucial aspects of the new FAQs, aimed at ensuring comprehensive contraceptive care without cost-sharing, and outlines the steps employers should take for compliance.

Background and Key Highlights The Affordable Care Act requires non-grandfathered medical plans to cover a broad spectrum of preventive services, including a wide array of contraceptive methods, without imposing cost-sharing on the beneficiaries. The recent FAQs address common questions and provide an alternative compliance method, while also acknowledging exemptions for certain religious employers and entities.

Coverage Requirements Overview:

• Plans must cover at least one form of contraception in various categories, including sterilization surgery, implantable rods, various oral contraceptives, contraceptive patches, vaginal rings, and emergency contraception, among others.
• Coverage must extend to any additional FDA-approved contraceptive methods deemed medically appropriate by the patient’s provider.
• Plans are permitted to use reasonable medical management techniques but must cover at least one similar product or service without cost-sharing if deemed medically necessary.

Addressing Unreasonable Practices: The guidance specifically targets unreasonable medical management techniques that hinder access to necessary contraceptive care, such as:

• Excessive step therapy or “fail first” protocols.
• Age-related restrictions not based on medical necessity.
• Onerous administrative requirements for exceptions processes.
• Cost-sharing for integral services related to contraceptive care.

Promoting Compliance Through Therapeutic Equivalence:

• A new approach allows plans to utilize the FDA’s “Orange Book” to determine therapeutic equivalence among contraceptive drugs and devices, ensuring coverage without cost-sharing for all FDA-approved options in a category, barring those with a therapeutic equivalent that is covered.

The Exceptions Process:

• Regardless of the approach taken, plans must offer an exceptions process allowing coverage without cost-sharing for medically necessary products or services not covered under the plan’s standard options.

Employer Action Steps:

1. Review Plan Design: Ensure your health plan covers the required contraceptive methods and incorporates the latest guidance on medical management techniques.
2. Implement an Effective Exceptions Process: Establish a transparent, accessible, and expedient process for handling exceptions, minimizing burdens on individuals and healthcare providers.
3. Educate Employees: Inform your workforce about their contraceptive coverage options and the processes in place for accessing necessary treatments without cost-sharing.
4. Consult with Carriers and Administrators: For fully insured plans, coordinate with your insurance carrier to confirm compliance. Self-insured employers should work closely with their third-party administrators to review and adjust plan designs as necessary.

Conclusion: The latest guidance on the contraception coverage mandate clarifies and expands the requirements for ensuring access to a wide range of contraceptive options without cost-sharing. By following the outlined steps and fostering a clear understanding of the mandate, employers can ensure compliance, support their employees’ health needs, and uphold the principles of the Affordable Care Act.