FAQ 68 Addresses Preventive Care and Mastectomy Coverage

Overview

On October 21, 2024, the Departments of Labor, Health and Human Services, and the Treasury issued FAQ Part 68 to provide updated guidance on preventive care services and mastectomy coverage under group health plans. This includes details on Pre-Exposure Prophylaxis (PrEP), claims management, and coverage requirements under the Women’s Health and Cancer Rights Act (WHCRA).

Key Highlights

Coverage of PrEP

  • Preventive Care: Under the ACA, non-grandfathered group health plans must provide certain preventive care services without cost-sharing.

  • Updated PrEP Guidelines:

    • PrEP antiretroviral medications approved by the FDA include:

      • 2019: Truvada (TF/FTC) - Daily oral medication.

      • 2023: Descovy (TAF/FTC) - Daily oral medication.

      • 2023: Apretude (Cabotegravir) - Long-acting injectable medication.

    • Effective August 31, 2024, health plans must cover all three formulations without cost-sharing. Medical management techniques may guide, but not limit, the use of specific formulations.

Coding and Claims Management

  • Proper coding is essential to ensure preventive care services are processed correctly and without cost-sharing.

  • The Current Procedural Terminology (CPT®) system includes "modifier 33" for identifying preventive care items under the ACA.

  • Participants have the right to appeal adverse benefit determinations under ERISA’s requirements.

Mastectomy-Related Required Coverages

  • WHCRA Requirements: Health plans must include coverage for:

    • All stages of care for the breast on which a mastectomy was performed.

    • Surgery and reconstruction of the other breast for symmetrical appearance.

    • Prostheses and treatment of complications, such as lymphedema.

    • Chest wall reconstruction with aesthetic flat closure, if chosen by the patient and attending physician.

  • Cost Sharing: Deductibles and coinsurance may apply, provided they align with other benefits under the plan.

Employer Action Steps

Employers should:

  1. Ensure PrEP formulations are covered as preventive care services starting August 31, 2024.

  2. Verify that carriers and TPAs use appropriate practices for identifying preventive care services.

  3. Review mastectomy-related coverage for any exceptions or limitations, including cost-sharing policies.

  4. Monitor ongoing litigation that could affect preventive care requirements for group health plans.

Dexter Dible