U.S. closes insurance loophole
Rules on costs for preventive care, including birth control, are clarified.
WASHINGTON — The Obama administration Monday closed a series of insurance loopholes on coverage of preventive care.
The Department of Health and Human Services said insurers must cover at least one birth control option under each of 18 methods approved by the FDA — without copays.
Also, insurers can’t charge patients for anesthesia services in connection with colonoscopies to screen for cancer risk.
President Obama’s healthcare law requires most insurance plans to cover preventive care at no charge to patients. That includes employer plans serving about 3 in 4 workers.
The types of services covered generally dovetail with the recommendations of a government advisory panel. Also on the list are birth control pills and other contraceptives.
But independent experts and women’s groups had recently found coverage gaps for some birth control methods. Insurers said they were trying to comply with the law but that federal rules did not provide enough detail.
“This has been a problem for women,” said Cindy Pearson, executive director of the National Women’s Health Network.
“It seems like some insurers were trying to control costs under cover of medical management.” Her organization advocates on reproductive health and other issues.
Other services covered without copays or cost sharing include:
Preventive screening, genetic counseling and BRCA genetic testing for women at increased risk for having a potentially harmful mutation in genes that suppress cancerous tumors.
Prenatal care and other services to promote healthy pregnancies. The requirement applies to insurance plans that cover children as dependents.
Certain preventive services for transgender people. For example, a mammogram for a transgender man with residual breast tissue.
On birth control, insurers will be required to offer at least one no-cost option in each FDA-approved category. These include daily birth control pills as well as longer-acting hormonal patches and IUDs, and the morning-after pill.
The option provided can be a generic, but if a woman’s doctor says a more expensive alternative is medically necessary, the plan must cover it without a copay.
Insurance billing is notorious for breaking down procedures into subcategories. The new rules made it clear that patients cannot be billed a copay for anesthesia during a colonoscopy.
“The plan or issuer may not impose cost sharing with respect to anesthesia services performed in connection with the preventive colonoscopy if the attending provider determines that anesthesia would be medically appropriate for the individual,” HHS said in its guidance document.
For insurers, the new government requirements take effect in 60 days. In practice, most consumers will not notice major changes until their coverage renews for 2016.