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Coverage of Preventive Health Services

The Affordable Care Act (ACA) requires non-grandfathered group health plans to cover certain preventive health services with no cost-sharing for in-network services. No co-payments, coinsurance or deductibles may be imposed on the following services:

  • Items or services with a rating recommendation of A or B from the United States Preventive Services Task Force;
  • Immunizations for routine use in children, adolescents and adults as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; and
  • Preventive care and screenings supported by the Health Resources and Services Administration for infants, children, adolescents and women.

For plan years beginning or after September 23, 2010, group health plans were required to comply with the recommendations and guidelines issued on or before September 23, 2009. Group health plans must comply with any recommendations or guidance issued after September 23, 2009 by the beginning of the plan year that begins one year after the recommendations or guidelines are issued.

Coverage of Preventive Health Services for Women

For plan years beginning on or after August 1, 2012, non-grandfathered group health plans must cover the following expanded preventive health services for women with no cost-sharing for in-network services:

  • Well-woman visits
  • Screening for gestational diabetes
  • FDA-approved contraceptive methods and counseling
  • Human papillomavirus (HPV) testing for all women over 30
  • Counseling for sexually transmitted infections
  • Screening and counseling for human immunodeficiency virus (HIV)
  • Breastfeeding support, supplies and counseling
  • Domestic violence screening and counseling

Contraceptive Coverage – Exemption for Religious Employers

Group health plans maintained by religious employers are exempt from any requirement to include contraceptive coverage.A religious employer is defined to include any non-profit organization described in Internal Revenue Code section 6033(a)(3)(A)(i) or (iii), which refers to churches, their integrated auxiliaries and conventions or association of churches, as well as the exclusively religious activities of any religious order.

Contraceptive Coverage – Non-Profit Religious Organizations

For plan years starting on or after January 1, 2014, an accommodation is available for Eligible Organizations (i.e., religiously affiliated employers such as schools, hospitals, charities, etc.) with religious objections to covering some or all of the mandated contraceptive services.Organizations meeting the following requirements are not required to arrange or pay for contraceptive services:

  • Opposes providing coverage of some, or all, of the required contraceptive services based on religious objections;
  • Is organized and operates as a non-profit entity;
  • Holds itself out as a religious organization; and
  • Self-certifies that it meets the above criteria either by completing EBSA Form 700 or providing written notice to the Department of Health and Human Services (HHS).

For fully-insured plans, Form 700 is provided to the issuer or carrier.For self-insured plans, the form is provided to the third-party administrator.If written notice is provided to HHS, then HHS will be responsible for notifying the issuer for fully-insured plans and will work with the Department of Labor (DOL) to notify third-party administrators of self-insured plans.

Contraceptive Coverage – Certain Closely Held For-Profit Entities

Under the U.S. Supreme Court’s ruling in Burwell v. Hobby Lobby, a closely held for-profit entity with religious objections may also claim an accommodation if it:

  • Is not a non-profit entity;
  • Has no publicly traded ownership interests; and
  • More than 50 percent of the value of its ownership interest is owned directly or indirectly by five or fewer individuals.

To be eligible for the accommodation, the for-profit entity’s governing body (e.g., board of directors) must adopt a resolution establishing that it objects to covering all or some contraceptive services based on the owners’ sincerely held religious beliefs. The entity must then self-certify that it meets the criteria for an accommodation by using either Form 700 or providing written notice to HHS.

Contraceptive Coverage – Expanded Exemptions

The DOL, HHS and the Treasury issued two interim final rules in October 2017 expanding exemptions from the ACA’s contraceptive coverage mandate. The new rules extend the prior exemption to certain entities that object to providing contraceptive coverage based on sincerely held religious beliefs or moral convictions. However, several states filed suit to prevent the rules from going into effect and courts in Pennsylvania and California issued injunctions blocking their implementation while the cases make their way through the courts.

Despite these pending lawsuits, the agencies finalized the rules in November 2018. The expanded exemptions apply only to the ACA’s contraceptive coverage mandate, however. State insurance laws may also require contraceptive coverage. For example, the Contraceptive Coverage Equity Act, passed by the California Legislature in 2014, requires fully-insured plans to provide contraceptive coverage. Self-insured plans are not subject to this California law so employers sponsoring self-insured plans may be able to use the expanded exemption so long as they are otherwise eligible.

Additional Information

New Guidelines Issued for Coverage of Women’s Preventive Care
     This Briefing outlines guidance from the Department of Health and Human Services on Women’s Preventive Care services.