Plan Changes:
Preventive Care
The Affordable Care Act (ACA) requires non-grandfathered health plans to cover certain preventive health services without imposing cost-sharing requirements for the services.
This requirement generally became effective for plan years beginning on or after September 23, 2010. It does not apply to grandfathered health plans.
On July 19, 2010, the Departments of Health and Human Services (HHS), Labor and the Treasury issued interim final rules relating to coverage of preventive care services.
In August 2011, HHS issued additional preventive care guidelines for women. These additional guidelines, which are generally effective for plan years beginning on or after August 1, 2012, require non-grandfathered health plans to cover women’s preventive health services (such as well-woman visits, breastfeeding support, domestic violence screening and contraceptives) without charging a copayment, a deductible or coinsurance.
Special rules regarding contraceptive coverage apply to religious employers, including churches and other religious-based institutions, such as schools, hospitals, charities and universities.
Coverage of Preventive Care Services
For plan years beginning on or after September 23, 2010, non-grandfathered group health plans must cover certain preventive care services and may not charge copayments, coinsurance or deductibles for these services when delivered by a network provider.
The recommended preventive care services covered by these requirements are:
- Evidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force;
- Immunizations for routine use in children, adolescents and adults that are currently recommended by the Centers for Disease Control and Prevention (CDC) and included on the CDC’s immunization schedules;
- For infants, children and adolescents, evidence-informed preventive care and screenings provided for in the Health Resources and Services Administration (HRSA) guidelines; and
- For women, evidence-informed preventive care and screening provided in guidelines supported by HRSA (for plan years beginning on or after August 1, 2012).
These recommended preventive services include screening for a number of conditions, as well as counseling for various health-related issues. The complete list of recommended preventive services that must be covered can be found at www.HealthCare.gov/center/regulations/prevention.html.
Office Visits
The interim final rules clarify the cost-sharing requirements when a recommended preventive care service is provided during an office visit. Whether cost-sharing requirements may be imposed will depend on: (a) whether the preventive care service is billed or tracked separately, and (b) whether the preventive care service is the primary purpose of the office visit. Cost-sharing is permitted only if:
- The recommended preventive care service is billed separately (or is tracked as individual encounter data separately) from an office visit; or
- The recommended preventive care service is not billed separately from the office visit and the primary purpose of the office visit is not to obtain the recommended preventive care service.
Cost-sharing requirements are not allowed in cases where the recommended preventive care service is not billed separately, but it is the primary purpose of the office visit.
Example - An individual covered by a group health plan visits an in-network health care provider. While visiting the provider, the individual is given a cholesterol screening (a recommended preventive care service). The provider bills the plan for an office visit and for the laboratory work of the cholesterol screening test. The plan may not impose any cost-sharing requirements with respect to the laboratory work. Because the office visit is billed separately from the cholesterol test, the plan may impose cost-sharing requirements for the office visit.
Example - An individual covered by a group health plan visits an in-network health care provider to discuss recurring abdominal pain. During the visit, the individual has a blood pressure screening (a recommended preventive care service). The provider bills the plan for an office visit. The blood pressure screening was not the primary purpose of the visit. Therefore, the plan may impose a cost-sharing requirement for the office visit charge.
Example - A child covered by a group health plan visits an in-network pediatrician to receive an annual physical exam (a recommended preventive care service). During the office visit, the child receives additional items and services that are not recommended preventive services. The provider bills the plan for an office visit. The recommended preventive care service was not billed as a separate charge and was the primary purpose of the visit. Therefore, the plan may not impose a cost-sharing requirement for the office visit.
Additional Clarifications
The interim final rules make clear that plans may continue to impose cost-sharing requirements on preventive care services that employees receive from out-of-network providers.
Also, plans may use reasonable medical management techniques to determine the frequency, method, treatment or setting for preventive care services, as long as they are not specified in the recommendation or guideline.
Women’s Preventive Care Services
On August 1, 2011, HHS issued the HRSA-supported preventive care guidelines for women to fill the gaps in the current preventive health services guidelines for women. According to HHS, these new guidelines will help ensure that women receive a comprehensive set of preventive health services without having to pay a copayment, a deductible or coinsurance.
Non-grandfathered health plans will need to include these services without cost-sharing for plan years beginning on or after August 1, 2012 (January 1, 2013, for calendar year plans), subject to the special provisions described below for religious employers.
Covered Health Services
The preventive care guidelines for women cover the following health services:Well-woman visits |
Well-woman preventive care visit annually for adult women to obtain the recommended preventive services that are age and developmentally appropriate, including preconception and prenatal care. This well-woman visit should, where appropriate, include other preventive care services covered under ACA. |
Annual, although several visits may be needed to obtain all necessary recommended preventive care services, depending on a woman’s health status, health needs and other risk factors |
Screening for gestational diabetes |
Screening for gestational diabetes | In pregnant women between 24 and 28 weeks of gestation and at the first prenatal visit for pregnant women identified to be at high risk for diabetes |
Human papillomavirus (HPV) testing |
High-risk HPV DNA testing in women with normal cytology results |
Screening should begin at 30 years of age and should occur no more frequently than every three years. |
Counseling for sexually transmitted infections |
Counseling on sexually transmitted infections for all sexually active women |
Annual |
Counseling and screening for human immunodeficiency virus (HIV) |
HIV counseling and screening for all sexually active women |
Annual |
Contraceptive methods and counseling |
All FDA-approved contraceptive methods, sterilization procedures and patient education and counseling for all women with reproductive capacity |
As prescribed |
Breastfeeding support, supplies and counseling |
Comprehensive lactation support and counseling by a trained provider during pregnancy and/or in the postpartum period and costs for renting breastfeeding equipment |
In conjunction with each birth |
Screening and counseling for interpersonal and domestic violence |
Screening and counseling for interpersonal and domestic violence |
Annual |
According to HHS, health plans may use reasonable medical management techniques for women’s preventive care to help define the nature of the covered service, consistent with guidance provided in the interim final rules. For example, health plans may control costs and promote efficient delivery of care by continuing to charge cost-sharing for brand-name drugs if a safe and effective generic version is available. In addition, the interim final rules confirmed that plans may continue to impose cost-sharing requirements on preventive services that employees receive from out-of-network providers.
Contraceptive Coverage and Religious Employers
Exemption
On August 3, 2011, HHS issued an amendment to the interim final rules to allow certain non-profit religious employers offering health coverage, such as churches, to decide whether or not to cover contraceptive services, consistent with their beliefs. A non-profit religious employer, for this purpose, is an employer that:
- Has the inculcation of religious values as its purpose;
- Primarily employs persons who share its religious beliefs; and
- Primarily serves persons who share its religious beliefs.
HHS finalized this amendment on February 15, 2012.
Temporary Safe Harbor
On January 20, 2012, HHS announced that it would amend the interim final rules to allow non-profit employers that, based on religious beliefs do not currently provide contraceptive coverage to their employees, an additional year to comply with the new requirements. The amendment would allow these employers to delay covering contraceptive services until the first plan year beginning on or after August 1, 2013 (January 1, 2014 for calendar year plans). This extension covers church-affiliated organizations that do not qualify for the exception for non-profit religious employers, such schools, hospitals, charities and universities.
On August 15, 2012, HHS released a bulletin describing the temporary enforcement safe harbor for nonprofit organizations that do not provide some or all of the required contraceptive coverage based on their religious beliefs.
Accommodation Approach
- On March 21, 2012, the Departments issued an advance notice of proposed rulemaking to outline draft proposals and seek input on the contraceptive coverage requirement for religious employers. This proposal would not require religious organizations, such as schools, charities, hospitals and universities, to provide contraceptive coverage, refer their employees to organizations that provide contraception or subsidize the cost of contraception. However, contraceptive coverage would be provided to female employees by an independent third party, such as an insurance company or third-party administrator (TPA), directly and free of charge.
On February 1, 2013, the Departments issued a proposed rule that would exempt additional religious employers from the requirement to cover contraceptive services. Under the proposed accommodations, 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.
For insured group health plans, the religious organization would provide the self-certification to the health insurance issuer, which would be required to automatically provide separate, individual market contraceptive coverage at no cost for plan participants. For self-insured group health plans, the religious organization would notify its third-party administrator (TPA), which would be required to automatically work with a health insurance issuer to provide separate, individual health insurance policies at no cost for participants.
The Departments also proposed rules for religious non-profit organizations that are institutions of higher education. If this type of organization arranges for student health insurance coverage, it is eligible for an accommodation comparable to the type available for a religious organization with an insured group health plan.
