CurrentConnecticut Insurance DepartmentPolicy HC-100

Health Insurance Coverage for Preventive Services

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Coverage of ACA-required and Connecticut-mandated preventive and wellness services, with a focus on women's health, cost-sharing restrictions, medical-management limits, and related plan language in Connecticut.

Policy Summary

PayerConnecticut Insurance Department

PolicyHealth Insurance Coverage for Preventive Services

Policy CodePolicy HC-100

Change TypeRevised and clarified

Effective DateJanuary 1, 2015

Next Review DateN/A

Key ActionDocument medical necessity, including the service's clinical appropriateness, frequency, extent, site, duration, and effectiveness.

SourceLink

POLICY UPDATE CHANGES

The Department states that insurers may no longer limit breastfeeding support and counseling except on the basis of medical necessity.

The bulletin clarifies that ACA women's contraceptive coverage includes FDA-approved over-the-counter contraceptive methods and women's sterilization procedures without cost sharing.

The bulletin clarifies that preventive services identified by HRSA guidelines and USPSTF A and B recommendations generally may not have cost sharing or limits unless the applicable guidance specifies a limit.

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CurrentConnecticut Insurance DepartmentPolicy HC-100

Health Insurance Coverage for Preventive Services

Customize your policy alerts

Sign up for Connecticut Insurance Department Policy HC-100 alerts

Get alerted when Policy HC-100 changes without checking for updates manually.

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Policy Summary

PayerConnecticut Insurance Department

PolicyHealth Insurance Coverage for Preventive Services

Policy CodePolicy HC-100

Change TypeRevised and clarified

Effective DateJanuary 1, 2015

Next Review DateN/A

Key ActionDocument medical necessity, including the service's clinical appropriateness, frequency, extent, site, duration, and effectiveness.

SourceLink

POLICY UPDATE CHANGES

The Department states that insurers may no longer limit breastfeeding support and counseling except on the basis of medical necessity.

The bulletin clarifies that ACA women's contraceptive coverage includes FDA-approved over-the-counter contraceptive methods and women's sterilization procedures without cost sharing.

Preventive and Women's Health Coverage

ACA preventive services

Covered when all applicable conditions are met.

Preventive-service coverage

Eligibility and clinical criteria
- The service is identified in HRSA guidelines or has a USPSTF A or B recommendation.
- The plan is a non-grandfathered group health plan or provides group or individual coverage subject to the ACA.
- The service is medically necessary.

Breastfeeding support and counseling

Covered when all applicable conditions are met.

Breastfeeding support

Breastfeeding supplies, support, and counseling are provided for the duration of breastfeeding.
Lactation support and counseling are provided in conjunction with each birth for the medically managed postpartum period.Postpartum duration determined by medical management
The service is medically necessary.

Contraception and women's sterilization

Covered when all applicable conditions are met.

Women's contraception

Covered service
- The service is an FDA-approved contraceptive method for a woman with reproductive capacity, including FDA-approved over-the-counter methods.
- The service is a women's sterilization procedure.
- The service is patient education and counseling.
The service is medically necessary.
Coverage is provided without patient cost sharing.

Maternity and prenatal preventive services

Covered when all applicable conditions are met.

Preventive maternity care

Covered preventive service
- The service is prenatal care included as part of a well-woman visit.
- The service is an age- and developmentally appropriate preventive service.
- The service has a USPSTF A or B recommendation.
- The service is another HRSA-directed preventive maternity service.
The service is medically necessary.

Frequency or other limits may apply to designated preventive services when the applicable HRSA guideline or USPSTF recommendation expressly identifies a limit, such as recommending coverage for an annual visit. Otherwise, the ACA does not permit cost sharing or limits for these services, subject to reasonable medical management and medical-necessity requirements.

Maternity-related services that are not preventive may be subject to applicable patient cost sharing. Preventive prenatal care, including covered prenatal care provided as part of a well-woman visit and USPSTF A or B recommended services, is addressed separately under the preventive-coverage requirements.

Men's sterilization is not covered under the ACA women's contraception provisions. It may be covered separately by the insurer under the applicable insurance benefit, and utilization of covered contraception and sterilization services may be limited based on medical necessity.

Diagnostic services provided in relation to preventive and wellness services may require patient cost sharing. Coverage documents should distinguish these services from the preventive services themselves and direct members to the applicable coverage information or member services representative for questions about cost sharing.

Services that are not clinically appropriate, effective, consistent with generally accepted medical practice, or appropriate in type, frequency, extent, site, or duration are not required to be covered. Services provided primarily for convenience, or that are more costly than an equally effective alternative, may also be limited or excluded.

Early-Discharge Follow-Up Requirements

Early-discharge breastfeeding follow-up

First follow-up visitWithin 48 hours of discharge

Second follow-up visitWithin 7 days of discharge

Included assistanceAssistance and training in breast or bottle feeding

Documentation and Coverage Risk

Documentation Required

Support Medical Necessity

Document the clinical rationale supporting medical necessity for the requested service, including why it is appropriate for the patient's condition and why the requested parameters are warranted.

Support the service's type, frequency, extent, site, duration, and effectiveness.
Document that the service accords with generally accepted standards of medical practice and is not primarily for convenience or more costly than an equally effective alternative.

Denial Risk

Medical-Necessity Failure

Coverage may be denied or limited when the requested service does not meet Connecticut's statutory definition of medical necessity under Conn. Gen. Stat. § 38a-482a.

The service must be clinically appropriate and effective for the patient's illness, injury, or disease.

Regulatory Context

The Affordable Care Act (ACA) requires non-grandfathered group health plans and issuers offering group or individual coverage to cover designated preventive services without patient cost sharing. Designated services are identified through applicable HRSA guidelines and USPSTF recommendations, including services receiving an A or B recommendation from the USPSTF; reasonable medical management and applicable medical-necessity standards continue to apply.

Key Terms

Medical necessity

Clinical purposeServices provided to prevent, evaluate, diagnose, or treat an illness, injury, disease, or its symptoms

Clinical standardsIn accordance with generally accepted standards of medical practice and clinically appropriate in type, frequency, extent, site, and duration

EffectivenessConsidered effective for the patient's illness, injury, or disease

Prohibited basisNot primarily for convenience and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results

Designated preventive services

HRSA servicesPreventive services identified in Health Resources and Service Administration guidelines

Policy Summary

PayerConnecticut Insurance Department

PolicyHealth Insurance Coverage for Preventive Services

Policy CodePolicy HC-100

Change TypeRevised and clarified

Effective DateJanuary 1, 2015

Next Review DateN/A

Key ActionDocument medical necessity, including the service's clinical appropriateness, frequency, extent, site, duration, and effectiveness.

SourceLink

On This Page

Documentation Required

Document Breastfeeding Support

Document breastfeeding-related needs and the medically managed postpartum period for lactation support, counseling, supplies, and related follow-up services.

Breastfeeding support and counseling are required for the duration of breastfeeding without copayments, deductibles, or coinsurance.
Lactation support and counseling associated with each birth extend for the duration of the postpartum period, as determined through medical management and medical necessity.
For early hospital discharge, follow-up visits within 48 hours and within seven days may include assistance and training in breast or bottle feeding.

Billing Rule

Apply Guideline and Medical-Management Limits

Preventive services may be subject to reasonable medical management, including frequency or extent limits, when applicable HRSA or USPSTF guidance identifies such limits or otherwise permits medical-management decisions.

No cost sharing or limits apply to designated HRSA and USPSTF A and B preventive services unless the applicable guidance identifies an explicit limit.
In the absence of applicable guidance, preventive services may be subject to medical necessity.

Billing Rule

Men's Sterilization Is Outside the Women's ACA Provision

Men's sterilization is not covered under the ACA women's contraception provisions. It may be covered separately under applicable insurer contract terms, and utilization may be limited based on medical necessity.

Do not apply the ACA women's no-cost-sharing contraception requirement to men's sterilization.
Verify the applicable benefit, contract terms, and medical-necessity requirements before billing or representing coverage.

Billing Rule

Nonpreventive Maternity Services May Have Cost Sharing

Maternity-related services that are not preventive may be subject to applicable patient cost sharing.

Prenatal care included in a well-woman visit and USPSTF A and B recommended preventive services are subject to the applicable preventive-services cost-sharing protections.
Apply the plan's cost-sharing terms to nonpreventive maternity services.

ACA applicationServices subject to the ACA preventive-coverage requirement for applicable non-grandfathered group health plans and group or individual coverage

Cost sharing and limitsNo cost sharing or limits are permitted unless the applicable guideline or recommendation specifies an explicit limit

Postpartum period

Fixed definitionNo generally accepted or fixed definition is provided in the cited authorities

Determination methodMedical management determines the postpartum period for each woman

Clinical contextThe determination applies as it relates to breastfeeding support and counseling