Federal
Plans must cover preventive care as outlined by the U.S. Department of Health and Human Services (HHS) without copay, coinsurance or deductible when provided by a network provider.
This applies to individual and group plans, including self-funded plans, but not grandfathered plans.
A full list of covered preventive health services can be found on HealthCare.gov.
Value Based Insurance Plan Designed (VBID) plans are described as including information and incentives for consumers that promote access to and use of higher value providers, treatments and services.
General highlights of the regulations:
- Non-grandfathered plans must comply with the no-cost-sharing requirement
- Preventive services are to be covered without any cost-sharing requirement when delivered by a network provider. This includes provider and facility charges (e.g., colonoscopy). The interim final regulations allow preventive limits for non-network services, but not for network services.
Billing and Office Visits
If a recommended preventive item or service is billed separately from an office visit, cost-sharing may be applied to the office visit.
If a recommended preventive item or service is not billed separately from an office visit and the primary purpose of the office visit is the delivery of such item or service, then cost-sharing requirements may not be imposed with respect to the office visit.
If a recommended preventive item or service is not billed separately from an office visit and the primary purpose of the office visit is not the delivery of the preventive item or service, then cost-sharing may be applied to the office visit.
Women’s preventive and contraceptive coverage includes:
- FDA approved contraceptive methods
- Sterilization procedures
- Gestational diabetes screening
- Human Papillomavirus testing for women age 30 and over every 3 years
- HIV screening and HIV and STI (sexually transmitted infection) counseling
- Contraceptive counseling
- Breastfeeding supplies and counseling
- Domestic violence screening
Plans may continue to charge cost sharing for branded drugs if a generic version is available and is just as effective and safe.
The rules governing coverage of preventive services allows plans to use reasonable medical management to help define the nature of the covered service, also apply to the Guidelines for Women’s Preventive Services. Plans will retain the flexibility to control costs and promote efficient delivery of care. For more information, visit the Health Resources and Services Administration’s website.
Exemption for Religious Employers
Group health plans of “religious employers” are exempt from having to provide contraceptive coverage, if they have religious objections to contraception.
As of July 2, 2013, the existing definition of a “religious employer” as it relates to contraceptive coverage eliminates criteria that a religious employer:
- Have the inculcation of religious values as its purpose;
- primarily employ persons who share its religious tenets; and
- primarily serve persons who share its religious tenets.
This change is intended to clarify that a house of worship would not be excluded from the exemption because, for example, it provides charitable social services to persons of different religious faiths or employs persons of different religious faiths. The Departments believe that this proposal would not expand the universe of employer plans that would qualify for the exemption beyond that which was intended in the previous final rules.
Applicable entities include:
- Churches, integrated auxiliaries, and religious orders with religious objections
- Nonprofit organizations with religious or moral objections
- For-profit entities that are not publicly traded, with religious or moral objections
- For-profit entities that are publicly traded, with religious objections
- Other non-governmental employers with religious objections
- Non-governmental institutions of higher education with religious or moral objections
- Individuals with religious or moral objections, with employer sponsored or individual market coverage, where the plan sponsor and/or issuer (as applicable) are willing to offer them a plan omitting contraceptive coverage to which they object
- Issuers with religious or moral objections, to the extent they provide coverage to a plan sponsor or individual that is also exempt
Creating Accommodations for Non-Profit Religious Organizations
An eligible organization would be defined as an organization that:
- Opposes providing coverage for some or all of any contraceptive services required to be covered under Section 2713 of the PHS Act, on account of religious objections;
- Is organized and operates as a nonprofit entity;
- Holds itself out as a religious organization; and
- Self-certifies that it meets these criteria and specifies the contraceptive services for which it objects to providing coverage.
The eligible organizations would not have to contract, arrange, pay or refer for any contraceptive coverage to which they object on religious grounds.
Plan participants would receive contraceptive coverage through separate individual health insurance policies, without cost sharing or additional premiums. The issuer would work to ensure a seamless process for plan participants to receive contraceptive coverage.
With respect to insured group health plans, the eligible organization would provide the self-certification to the health insurance issuer, which in turn would automatically provide separate, individual market contraceptive coverage at no cost for plan participants. Issuers generally would find that providing such contraceptive coverage is cost neutral because they would be insuring the same set of individuals under both policies and would experience lower costs from improvements in women’s health and fewer childbirths.
With respect to self-insured group health plans, the eligible organization would notify the third-party administrator, which in turn would automatically work with a health insurance issuer to provide separate, individual health insurance policies at no cost for participants. The costs of both the health insurance issuer and third-party administrator would be offset by adjustments in Federally-facilitated Exchange user fees that insurers pay.
An eligible religious nonprofit organization that is an institution of higher education that arranges for student health insurance coverage may avail itself of an accommodation comparable to that for an eligible organization that is an employer with an insured group health plan.
For more information, visit CMS.gov.
The Notice of Proposed Rulemaking on women’s preventive services coverage is available HERE.
Hobby Lobby Lawsuit
In a lawsuit against the federal government, Hobby Lobby claimed the ACA’s contraception mandate for employer-provided insurance violated its religious beliefs. While Hobby Lobby is a for-profit company, they are owned by a family of persons who object to contraceptive coverage for their employees.
On June 30, 2014, the Supreme Court ruled in Hobby Lobby’s favor based on the Religious Freedom Restoration Act of 1993. The ruling extends religious rights to “closely held” corporations who do have the right to seek exclusion of such coverage. See IRS Publication 542 for the definition of a closely held corporation.
The question remains regarding if the exclusion is for abortifacients (morning after pills) and IUDs only or if it applies to all 20 birth control medications.
- Contraceptive coverage accommodation. Status as a closely held for-profit company is determined as at least 50% of the company must be directly or indirectly owned by five or fewer individuals. The final regulations also provide attribution rules and prohibit the company from having any publicly traded ownership interests. The company’s highest governing body must adopt a resolution or similar formal action establishing its objection to providing contraceptive services on account of its owners’ sincerely held religious beliefs. EBSA Form 700 must be used for notifying the DOL or HHS.
- Out-of-network providers. A plan will be required to cover out-of-network preventive services without cost-sharing if the plan does not have an in- network provider who can provide a required preventive service.
- Midyear plan changes. A service that constitutes a recommended preventive service on the first day of a plan year must be provided through the end of the plan year even if the recommendation changes, except that a plan may drop coverage midyear for any service that is downgraded to a “D” rating (by the applicable task force or advisory body), is subject to a safety recall, or is otherwise deemed by the applicable federal agency to pose a significant safety concern.
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