New ACA Guidance Addresses Preventive Care, Wellness

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Oct. 23 — Health plans or issuers aren't permitted to impose cost-sharing on lactation services, or services related to colonoscopies, according to the 29th set of answers to frequently asked questions on Affordable Care Act implementation.

The departments of Labor, Health and Human Services and Treasury have been providing this guidance since the ACA's inception to help stakeholders understand the laws. The new guidance, issued Oct. 23, covers a broad range of issues, addressing several topics related to preventive care, as well as wellness programs and mental health parity.

In the section on preventive care, the agencies said health plans and issuers are required to provide a list of lactation counseling providers within their network. Additionally, it isn't permissible for a plan to impose cost-sharing for lactation counseling services obtained outside of the plan's provider network, they said.

It also isn't permissible for plans to impose cost-sharing for outpatient lactation services, or to restrict a plan participant from obtaining that counseling in another state if the state in which the participant resides doesn't provide such services, the guidance said. Health plans or issuers also aren't permitted to impose cost-sharing on a required visit to a specialist prior to the colonoscopy, or a pathology exam on a biopsy of a polyp, the agencies said.

On wellness programs, the guidance said that plans offering non-financial incentives are still subject to guidance on wellness plans that was published in 2013 that increased the maximum permissible reward of a health-contingent wellness program offered through a group health plan (64 BTM 177, 6/4/13).

The agencies addressed an instance regarding a participant being denied authorization for a 30-day inpatient stay to treat anorexia because the plan said the stay wasn't medically necessary. When the participant requested the medical necessity criteria for making decisions on medical and surgical benefits and mental health benefits that cover anorexia, the participant's request was denied because the plan claimed this was proprietary information.

According to the guidance, plans are required to disclose this information, “regardless of any assertions as to the proprietary nature or commercial value of the information.”

For More Information

Text of the guidance is available at