Biden Administration Proposes New Preventative Care Rule

The Departments of Health and Human Services, Labor, and Treasury recently proposed new regulations that would significantly change the delivery mechanisms associated with the Affordable Care Act’s (ACA) preventive care requirements. As a reminder, the ACA requires non-grandfathered individual and group health insurance plans to cover certain preventive care services on a “first-dollar” basis. This type of care must be provided before the application of any deductible, copayment, coinsurance, or other cost-sharing. The draft regulation would change this requirement in the following three ways:

1. It would require first-dollar coverage of over-the-counter (OTC) contraceptive methods without a prescription, including condoms and emergency contraception. Health plans would need to cover all FDA-approved contraceptives available OTC unless a therapeutic equivalent is available.
2. The draft rule would amend the federal Transparency in Coverage rules and require insurers and group health plan sponsors to update their existing online price transparency tools. The tools would need to tell participants that OTC contraceptives available at pharmacies are covered with no cost-sharing. When plan participants search for coverage information about OTC contraceptives, the tool would have to generate a phone number and internet link for users to access more detailed coverage information.
3. The measure would prevent the application of utilization management techniques, such as step therapy or limiting coverage to certain settings, to any services classified as ACA preventive care unless the plan has a clear exceptions process in place. Acceptable exception processes would have to be easily accessible, transparent, and expedient so they are not unduly burdensome on plan participants and their medical providers.

It is important to note that the proposed rule is just a draft measure and does not yet have the force of law. The public has until December 27, 2024, to submit comments on the proposal, and the Biden Administration must review those comments and make necessary changes. However, the measure could be finalized before the start of the next presidential administration. We will continue tracking these regulations and will publish updates when final rules are issued.