Summary of Proposed Rules Enhancing Coverage of Preventive Services Under the Affordable Care Act
Author: Richard Caldwell, ASA, MAAA
Executive Summary
The Departments of the Treasury, Labor, and Health and Human Services (HHS) (“Departments”) recently issued proposed guidance related to the coverage of preventive services in the Affordable Care Act (ACA) markets.[1] A fact sheet accompanied this.[2]
The document, CMS-9887-P, outlines proposed rules to enhance preventive services coverage under the Affordable Care Act (ACA). It details changes to the requirements for health plans, focusing on accessibility, transparency, and equity in coverage for preventive care, including contraceptive services and over the counter (OTC) products. The requirements included are proposed to be effective January 1, 2026.
The guidance primarily addresses two topics related to preventive services. The first is about the Exceptions Process that issuers must implement for medical management techniques to be considered reasonable. This section proposes to clarify and codify guidance related to the process for which an enrollee could access alternative preventive treatments and services without cost-sharing if the treatments and services provided under current medical management techniques are not medically appropriate. It also discusses how the process should be clear and not burdensome to the enrollee or their medical provider.
The second topic is related to coverage for contraceptives. The Departments cited several studies showing the barriers in place for enrollees to access the full range of contraceptive services. The Departments believe guidance to address these barriers would require significant changes to plan and issuer current processes and, therefore, have proposed an incremental approach. These particular proposals primarily discuss OTC contraceptive coverage, including discussions around networks, medical management techniques, exceptions process, and communication.
[1] https://www.cms.gov/files/document/cms-9887-p.pdf
[2] https://www.cms.gov/newsroom/fact-sheets/enhancing-coverage-preventive-services-under-affordable-care-act-proposed-rules