DOL Issues New FAQs on Women’s Preventive Services

On October 21, 2024, the DOL updated its FAQs for the ACA and the Women’s Health and Cancer Rights Act (WHCRA) by adding FAQ Part 68. These new FAQs concern issues relating to preventive services, including coverage of Pre-Exposure Prophylaxis (PrEP) and insurance coding practices, as well as coverage for a specific breast reconstruction technique. 

As background, the ACA requires non-grandfathered group health plans and issuers to cover certain in-network preventive services with zero cost-sharing for participants. The WHCRA mandates coverage of breast reconstruction after a mastectomy. 

In Q1, the DOL clarifies changes made by the US Preventive Services Task Force (USPSTF) in 2023 regarding coverage of PrEP to those who are at high risk of contracting HIV. Specifically, the USPSTF recommended coverage of three different formulations of PrEP: two oral and one injectable. Plans and issuers must cover all three of those formulations without cost-sharing and may not use medical management techniques to direct participants towards one formulation over another. 

In Q2 through Q7, the DOL addresses common medical service coding issues that arise during the processing of claims for preventive items and services. Q2 clarifies that when a carrier receives an in-network claim that uses an industry-standard ICD-10 or CPT code to denote that it is preventive in nature, the carrier should go ahead and process it without cost-sharing. Q3 and Q4 discuss the circumstances under which a carrier may use additional information to process the claim without zero cost-sharing. 

Q5 encourages plans and issuers to review their coding practices and to provide clear guidance to their network providers on how to submit preventive service claims accurately. Q6 consists of several examples illustrating the guidance provided in Q2 through Q4.

Finally, the DOL confirms in Q7 that plans must cover a specific type of breast reconstruction – namely, chest wall reconstruction with aesthetic flat closure – under the WHCRA. If this specific procedure is elected by the patient in consultation with their attending physician after a mastectomy, then it is subject to the WHCRA’s mandate. Plans may impose cost-sharing for these benefits in a manner consistent with other benefits provided under the plan. 

Ultimately, the issues discussed in these FAQs will need to be implemented and administered by a plan’s medical carrier or TPA. Accordingly, plan sponsors should contact their carrier or TPA, as applicable, with any questions.

DOL, FAQs About Affordable Care Act and Women's Health and Cancer Rights Act