ACA Update: Proposed Rules to Enhance Coverage of Preventive Services

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On October 21, 2024, the Departments of Health and Human Services, Labor, and Treasury released proposed rules aimed at expanding access to preventive services under the Affordable Care Act (ACA). These rules, titled “Enhancing Coverage of Preventive Services Under the Affordable Care Act,” focus on reducing barriers to coverage, particularly for contraceptive services, including over-the-counter (OTC) contraceptives.

The ACA requires non-grandfathered group health plans and insurers to cover certain preventive services without imposing cost-sharing requirements, such as copayments or deductibles. These services include evidence-based recommendations by the U.S. Preventive Services Task Force and preventive care and screenings for children and women under guidelines supported by the Health Resources and Services Administration (HRSA).

Key Proposals

1. Exceptions Process for Preventive Services: The proposed rules codify the requirement that plans using medical management techniques must offer an accessible exceptions process. This process would allow individuals to receive preventive services without cost-sharing if deemed medically necessary by their provider, even if the service is not generally covered.
2. Expanded Contraceptive Coverage: The rules would require plans to cover recommended OTC contraceptive items without a prescription and without cost-sharing. This would align coverage requirements with the ACA’s preventive service mandates, removing cost and prescription barriers to accessing contraception.
3. Enhanced Disclosure Requirements: Plans would be required to disclose in their Transparency in Coverage tools that OTC contraceptives are covered without cost-sharing or a prescription, with links and contact information for further details.

These proposed changes would go into effect for plan years beginning on or after January 1, 2026, and the Departments are accepting comments for 60 days following publication in the Federal Register. HR professionals should review these proposals to anticipate changes in benefit offerings and ensure compliance with ACA regulations.