New Rules Expand Services Covered with No Cost-Sharing

Apr 6, 2022

The Department of Health and Human Services has issued some new “frequently asked questions” for its Affordable Care Act pages, and new guidelines that require group health plans to expand what they are required to cover with no cost-sharing.

The new FAQ section expands the age group for which insurers must cover colonoscopies and adds some women’s services that must also be covered with no out-of-pocket costs on the part of the insured patient.

Additionally, the HHS updated its rules on women’s breastfeeding supplies, coverage for obesity treatment in some women, as well as adding screening for suicide risk for some age groups.

The new FAQs and rules by the HHS will require health plan sponsors to ensure that their health plans have made the necessary policy changes to comply with the new guidance.

It’s also important that employers inform their employees about these rule changes, so they know of the added services and treatments that are available without out-of-pocket costs on their part.

Here’s a rundown of the new rules:

Colonoscopy rules

Under current Affordable Care Act rules, non-grandfathered health plans are required to cover without cost-sharing regular colorectoral screening starting at the age of 50 and through the age of 75. That includes:

  • Required specialist consultant prior to the screening procedure;
  • Bowel preparation medications prescribed for the screening procedure;
  • Anesthesia services performed in connection with a preventive colonoscopy;
  • Polyp removal performed during the screening procedure; and
  • Any pathology exam on a polyp biopsy performed as part of the screening procedure.

The new rules extend that coverage to people between the ages of 45 and 49 if they get abnormal results from a stool-based test.

These new rules take effect on health plan years that start on or after May 31, 2022. That means most people won’t see the changes until Jan. 1, 2023 since most plans run on calendar years.

Coverage of contraceptives

The ACA requires non-grandfathered health plans to cover FDA-approved contraceptives with no cost-sharing. More importantly, if a patient’s doctor recommends a particular service or specific FDA-approved based on their determination that is of medical necessity, the plan must cover that service with no patient out-of-pocket costs.

However, the HHS says it’s been receiving complaints about health plans sometimes denying some of these FDA-approved services despite the patients’ doctors determining it to be of medical necessity. In some cases, the insurer is requiring patients to try other services first or fail in their use of other services before approving use of the FDA-approved contraceptive method.

The HHS is reminding plans and insurers of their obligation to cover these contraceptives, regardless of if they are in the current FDA Birth Control Guide or not, as it does not include every FDA-approved method.

Other changes

HHS guidelines allow for certain breastfeeding services and supplies to be covered with no cost-sharing. There are a number of services and supplies already covered, but the new guidelines add coverage for double breast pumps.

The HHS also approved a new guideline aiming to prevent and reduce obesity in midlife women (ages 40 to 60) through counseling with no cost-sharing required.

The HHS has also issued new guidelines requiring universal screening for suicide risk to the current Depression Screening category for individuals ages 12 to 21, and new guidance for behavioral, social and emotional screening. There are also new guidelines for assessing risks for cardiac arrest or death for individuals ages 11 to 21 and assessing risks for hepatitis B virus infection in newborns to 21-year-olds.

These too are services that would have to be covered with no out-of-pocket costs to the insured patient.

Employer responsibility

You should check with your plan sponsor that their plans will add the new guidelines to their coverages.

If your plan does not run on a calendar year, you’ll have to do this earlier. Additionally, during the next Open Enrollment, make sure to cover these changes when you hold your Open Enrollment meeting for your staff.