New ACA FAQ Clarifies Coverage Requirements for Lactation, Obesity and More

The Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury have released the twenty-ninth FAQ regarding the Affordable Care Act (ACA). These FAQs are released periodically to answer questions from stakeholders regarding ACA implementation.

FAQ XXIX addresses coverage of preventive services, including lactation services, obesity treatment, colonoscopies, and BRCA genetic testing, as well as wellness program regulations and mental health treatment under the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).

Lactation counseling
The FAQ states that lactation counseling should be covered by health insurance plans subject to ACA coverage rules, and that lactation counseling and supplies should be easily accessible to pregnant and breastfeeding women. Lactation counseling should be covered when provided by any health care provider acting within the scope of his or her license, and coverage of such counseling (and of breastfeeding equipment or rental) should be available for the entire duration of breastfeeding. Additionally, lactation counseling providers must be listed on a plan’s list of in-network providers. If there are no providers in-network who can provide lactation counseling, the plan must pay an out-of-network provider at in-network rates for the service, as previously stated in FAQ XII.

Regarding obesity, the FAQ says that health insurance plans cannot exclude coverage for all weight management services. Obesity screening for adults must be covered without cost-sharing, although plans can use medical management techniques like providing a limited number of weight management counseling sessions or specifying the setting in which services must take place to be covered (for example, covering outpatient treatment only). The U.S. Preventive Services Task Force (USPSTF) recommends that in addition to screening adults for obesity, providers should offer or refer patients to intensive, multicomponent behavioral interventions. The USPSTF notes that plans should cover between 12 and 26 group or individual intervention sessions per year, including activities like exercising, setting weight loss goals, and learning about diet and nutrition.

Colonoscopies have been the subject of several ACA FAQs. This FAQ addresses pre-procedure specialist consultations. If a consultation with a specialist prior to a preventive colonoscopy is medically appropriate, the health insurance plan must cover the consultation without cost-sharing. Additionally, pathology exams on polyp biopsies taken during a preventive colonoscopy must be covered without cost-sharing. The colonoscopy guidance is applicable to plans with plan years beginning on or after December 22, 2015.

BRCA testing
Another preventive service, BRCA testing, must be covered without cost-sharing regardless of whether the patient has previously suffered from cancer. BRCA testing, which looks for genetic mutations that indicate increased risk of breast and gynecological cancers, must be covered without cost-sharing as long as the patient is currently symptom-free and not receiving active treatment for a related cancer.

Contraceptive coverage
The FAQ also lists the two methods for qualifying non-profits or closely held for-profits with self-insured plans to opt out of providing contraceptive coverage for religious reasons.

Wellness programs
Additionally, the FAQ clarifies regulations on rewards for participation in employer wellness programs and explains patients’ rights to access information regarding coverage appeals and medical necessity determinations for mental health or substance abuse treatment under MHPAEA.

Preventive services
The recommendations of the U.S. Preventive Services Task Force (USPSTF) are used to determine which preventive services must be covered without cost-sharing. In October, USPSTF published a new recommendation regarding blood glucose and type 2 diabetes screening. In 2008, USPSTF recommended that adults with high blood pressure over 135/80 mm Hg be screened for abnormal blood glucose levels and type 2 diabetes. The new recommendation is that all overweight adults ages 40 through 70 be offered blood glucose testing. Patients with abnormal blood glucose levels should be referred to intensive behavioral counseling interventions, which the USPSTF defines as multiple sessions of counseling about healthy eating and exercise.

In light of the new ACA FAQ and updated USPSTF recommendations, plan sponsors should make appropriate changes to plan policies and documents as needed.

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