Preventive Care Q&A


The ACA requires non-grandfathered plans to provide coverage for certain “preventive care”. This coverage must be provided without cost sharing (e.g., coinsurance, deductible or copayment) for services provided in network.

Does ACA require coverage of preventive care?

All non-grandfathered group health plans (insured and self-funded) and non-grandfathered individual policies issued or renewed on or after September 23, 2010 must cover preventive services without cost share (e.g., coinsurance, deductible or copayment). With respect to the new guidance issued August 1, 2011 on women's preventive health services, these preventive services are generally applicable to non-grandfathered plans with effective or renewal dates on or after August 1, 2012.

What services are considered preventive care?

ACA defines preventive care services as follows:

  • Items or services recommended with an A or B rating by the U.S. Preventive Services Task Force
  • Immunizations recommended by the Advisory Committee on Immunization Practices of the CDC
  • Preventive care and screenings for infants, children and adolescents supported by the Health Resources and Services Administration
  • Preventive care and screenings for women supported by the Health Resources and Services Administration per the August 1, 2011 guidance:
    • well-woman visits
    • screening for gestational diabetes
    • human papillomavirus DNA testing
    • counseling for sexually transmitted infections
    • counseling and screening for human immune-deficiency virus
    • contraceptive methods and counseling*
    • breastfeeding support, supplies and counseling
    • screening and counseling for interpersonal and domestic violence

* The regulation exempts certain religious employers with respect to coverage of contraceptive services. Other religiously affiliated employers/organizations also may be able to qualify for a religious accommodation (additional details on both exceptions are below). In addition, certain states have insurance mandates for contraceptive coverage that must also be taken into consideration.

A listing of recommendations and guidelines can be found at:
www.HealthCare.gov/center/regulations/prevention.html

Do the requirements apply to both in-network and out-of-network services? 

No, plans are not required to provide coverage for recommended preventive services delivered by out-of-network providers. Cost-sharing may be applied for recommended preventive services delivered by an out-of-network provider.

Do the requirements apply to other preventive services that are included as a benefit under the plan?

No, a plan is not required by ACA or the regulations promulgated under it to provide coverage or waive cost-sharing requirements for any item or service that is not on the compilation of recommended preventive services.

How often will plans be expected to review and update the listings of recommended preventive services?

The website provided above will keep an updated listing. Plans are only required to provide coverage and waive cost-sharing requirements for preventive services that are in this listing. When new recommendations or guidelines are adopted, a plan is not required to make changes to coverage or cost-sharing until the first plan year/policy year beginning one year after the effective date of the new recommendation or guideline. For example, recommendations/ guidelines issued prior to 9/23/09 must be provided for plan years beginning on or after 9/23/10.

If preventive care is provided during an office visit, can cost-sharing requirements be imposed?

It depends on the situation. For preventive services that must be covered, an office visit cost-share may apply to the office visit (a) if the preventive service is billed separately (or is tracked as individual encounter data separately) from the office visit, or (b) if the primary purpose of the office visit is other than the delivery of preventive service and the preventive service is not billed separately (or is not tracked as individual encounter data separately) from the office visit.
An office visit cost-share may not be applied to the office visit if (a) the preventive service is not billed separately (or is not tracked as individual encounter data separately) from the office visit and (b) the primary purpose of the visit is the delivery of the preventive service.

Is medical management of preventive services permitted?

Yes, plans may apply reasonable medical management techniques to determine frequency, treatment, or setting for a recommended preventive service to the extent not specified in the recommendation or guideline.

Have guidelines been established for value-based insurance designs?

ACA gives the federal agencies the authority to develop guidelines for plans and issuers to utilize value-based insurance designs as part of their offering of preventive services. These guidelines are currently being developed.

What religious employers qualify for the exemption with respect to coverage of contraceptive services?

The exemption applies to religious employers and is limited to an organization that meets certain criteria. The regulation defines a ‘‘religious employer’’ as an organization that operates as a nonprofit entity and is referred to under Section 6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code (i.e., non-profit houses of worship, integrated auxiliaries, conventions or associations of churches, or religious orders).

Is there any other relief with respect to the requirement to cover contraceptive services for employers who do not qualify for the exemption?

For certain employers and or schools that are religious organizations, yes.

On February 10, 2012, HHS posted guidance on the temporary safe harbor for certain entities that are not otherwise exempt from the contraceptive coverage mandate. The temporary safe harbor was initially available through the first plan year that begins on or after August 1, 2012 and prior to August 1, 2013, but has been extended through plan years beginning prior to January 1, 2014. To qualify for the safe harbor the entity must meet the following criteria:

  1. The organization is organized and operates as a non-profit entity.
  2. From February 10, 2012 and onward, all or the same subset of contraceptive coverage has not been provided at any point by the group health plan established or maintained by the organization, consistent with applicable State law, because of the religious beliefs of the organization.
  3. The plan provides a mandated notice to participants indicating that contraceptive coverage will not be provided for the first plan year beginning on or after August 1, 2012.
  4. The organization self-certifies that it satisfies these criteria and documents its self-certification.

What are the religious accommodation requirements? And when are they applicable?

On July 2, 2013, a final rule was issued that will allow certain nonprofit religious organizations that do not qualify for the religious exemption to qualify for a religious accommodation. For plan years on or after January 2, 2014, a religious organization that is an eligible organization (defined below) can exclude coverage of contraceptive services from its group health plan (or group health insurance policy). When a self-certification is presented to a carrier (in the case of an insured plan sponsor) or a third party administrator (TPA) (in the case of a self funded plan sponsor), the carrier/TPA will be required to make payments for the required contraceptive services to individuals who are covered by the employer’s group health plan.

How are “eligible organizations” defined?

It includes non-profit organizations that hold themselves out as religious organizations that oppose providing coverage for some or all contraceptive services on account of religious objections.

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