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New Guidelines on Preventative Care Benefits

on Friday, 22 March 2013 in Labor & Employment Law Update: Sarah M. Huyck, Editor

The Departments of Labor, Health and Human Services, and Treasury recently issued guidance in the form of frequently asked questions (“FAQs”) that clarify and expand the rules regarding preventive care benefits that non-grandfathered group health plans must provide to a participant with no cost-sharing.  Specifically, the new guidance addresses the following preventive care benefits:  over-the-counter (OTC) drugs and medications prescribed by a doctor, polyp removal during a colonoscopy, genetic testing for breast cancer, and contraceptive support.


By way of background, the Patient Protection and Affordable Care Act (“PPACA”) requires that non-grandfathered group health plans provide benefits for certain preventive services at no cost to participants.  The frequently asked questions guidance provides specific clarity on the preventive care benefits identified above as follows:


  • Prescribed OTC Drugs and Medications.  The FAQs provide that OTC drugs and medications that are prescribed by a health care provider must be covered at no cost-sharing to the participant by the group health plan.  The FAQs specifically listed aspirin as such an OTC medication to be covered, but did not specifically identify other OTC drugs and medications.

  • Polyp Removal During Preventative Colonoscopy.  The FAQ’s state that a group health plan may not impose cost-sharing for removal of a polyp during a colonoscopy performed as a screening procedure.

  • Genetic Testing for Breast Cancer.  The FAQ’s provide that a group health plan is required to pay for genetic counseling and genetic testing for breast cancer without cost-sharing, if appropriate, as determined by the woman’s health care provider.

  • Contraceptive Coverage.  The FAQ’s clarify that plans must cover the full range of FDA-approved contraceptive methods for women including, but not limited to, barrier methods, hormonal methods, and implanted devices, as well as patient education and counseling, as prescribed by a health care professional.


As the agencies further clarify the required mandates under PPACA, it will be important to continually address these items during the plan design process of your group health plan. 

Adam L. Cockerill

Read the Full Newsletter: Labor & Employment Law Alert March 22, 2013

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