FAQs on Contraceptive Coverage

FAQs on Contraceptive Coverage

Most non-grandfathered group health plans are required to provide coverage with no cost-sharing for preventive coverage, including contraceptives. Despite these requirements being in place for a long time, and numerous attempts by the agencies to clarify contraceptive coverage requirements, there continue to be issues with compliance. Employers likely have very little control over how their group health plans administer contraceptives coverage and medical management techniques for such coverage, but it may be appropriate for employers to push their carriers and TPAs to confirm that they are aware of this guidance and taking steps to comply.

Agency FAQs issued in August 2022 clarified that plans are permitted to impose reasonable medical management techniques for contraceptive coverage so long as the plan covers at least one method of contraception in each HRSA-recommended (Health Resources and Services Administration) category along with an exception process providing coverage when a provider determines another FDA-approved method to be medically necessary. Another set of FAQs released this week claims ongoing findings of non-compliance and restates much of the guidance provided in the 2022 FAQs. In addition, the new FAQs suggest an alternative approach to compliance called the "therapeutic equivalence approach," which would consider a plan in compliance so long as coverage is available for all contraceptives without a therapeutic equivalent (so long as the exception process remains available). 

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