Federally Mandated Contraceptive Services Coverage
What is it?
Under the Affordable Care Act (ACA), all non-grandfathered health plans must cover approved prescription contraceptive methods for women without charging plan participants and beneficiaries a copayment, coinsurance or deductible. However, the ACA grants an accommodation to this requirement for certain eligible religious nonprofit organizations.
The employer groups listed above certified that their group health plan qualifies for an accommodation with respect to the federal requirement to cover contraceptive services for women, as prescribed by a health care provider, without cost sharing. This means that they will not contract, arrange, pay or refer for contraceptive coverage including the following contraceptive or sterilization services:
- FDA-approved contraceptive methods for women
- Elective non-surgical sterilization procedures for women and surgical tubal ligation procedures for women
- Patient education and counseling related to contraception for all women of reproductive capacity
Instead, Dean Health Plan will provide or arrange separate payments for these contraceptive services, without cost sharing and at no other cost, for as long as a woman is enrolled in their employer health plan and services are performed by an in-network provider.
What is covered?
- This plan covers evidence-informed preventive care and screenings for women provided for in current HRSA-approved guidelines. This includes:
- FDA-approved contraceptives (drugs and devices) prescribed by a health care provider
- Outpatient consultations, examinations, procedures and medical services that are necessary to prescribe, administer, maintain or remove a contraceptive
- Sterilization procedures for women
- Patient education and counseling related to contraception for all women with reproductive capacity
Benefits under this Plan are covered at first dollar coverage. Benefits are only available through in-network providers.
See Summary Plan Description (SPD) for more details on coverage and eligibility.
How does it work?
- For Medical claims
- Members/Providers will use the existing employer group medical plan when receiving contraceptive services.
- If the claim is an approved contraceptive service (see SPD for details), then the claim will be denied on the employer group plan and automatically submitted and paid from the Dean Health Plan contraceptive services plan.
- You will receive two Explanations of Benefits (denial from group medical plan and approval from contraceptive services plan).
- Note that only in-network providers are covered under the contraceptive services plan. In-network providers will be determined based on your in-network provider list on your employer group medical plan.
- Transactions are handled as point of sale
- Member should use their employer group ID card
- Pharmacist will receive a message back to resubmit with an alternate federally-mandated contraceptive-only plan carrier number
- Member will not have cost share
- Contact Navitus Customer Service with any questions at (866) 333-2757
Dean Health Plan and Navitus Health Solutions have developed a drug formulary to assist you, our members and your providers with an easy reference to obtain a list of drugs that are covered under this plan.