1. What preventive services are covered? 

Generally, group health plans that are not "grandfathered health plans" must cover and waive all cost-sharing requirements for the following "recommended preventive services":

• Evidence-based items or services with an "A" or "B" rating from the U.S. Preventive Services Task Force (USPSTF) ;

• Immunizations for routine use in children, adolescents, and adults with a recommendation in effect from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention;

• Evidence-informed preventive care screenings for infants, children, and adolescents provided in guidelines supported by the Health Resources and Services Administration (HRSA);and

• Evidence-informed preventive care and screening for women provided in guidelines supported by HRSA and not otherwise addressed by the USPSTF.

Plans are not required to provide coverage (or waive cost-sharing) for any item or service that ceases to be a recommended preventive service, for example, if the USPSTF downgrades a recommended preventive service from a rating of "B" to a rating of "C" or "D." Likewise, plans may provide coverage for items and services in addition to those included in the recommendations and guidelines (and such services may be subject to cost sharing).

2. Are there any limits on the frequency, method, treatment, or setting for preventative services to prevent patients from abusing this rule?

Yes. Reasonable medical management techniques can be used when the applicable recommendations and guidelines do not specify the frequency, method, treatment, or setting for a particular preventive service. Plans and insurers may use reasonable medical management techniques to determine any coverage limitations.

3. What are the requirements as to the prohibition on patient payment, i.e., cost-sharing requirements? 

Generally, cost sharing for network providers with respect to "recommended preventive services" is prohibited. "Cost sharing" for these rules include deductibles, copayments, and coinsurance. Cost sharing is permitted for any item or service that ceases to be a recommended preventive service or for services or treatments in addition to those included in the specified recommendations. 

Cost-sharing is permitted for office visits when preventive services are billed or tracked as individual encounter data separately or are not the primary purpose of an office visit. Conversely, cost-sharing cannot be imposed when preventive services are not billed or not tracked as individual encounter data separately and are the primary purpose of an office visit.

Example: A child visits an in-network pediatrician for a preventive care screening. As a result of the screening, the pediatrician recommends that the child undergo surgery for a heart disorder. Because the preventive care screening is a recommended preventive service, the plan cannot impose a cost-sharing requirement. However, the plan may impose a cost-sharing requirement for the child's heart surgery, which resulted from the preventive care screening.

Example: A child covered by a group health plan visits an in-network pediatrician to receive an annual physical exam that is a recommended preventive service. During the office visit, the child receives additional services that are not recommended preventive services. The provider bills the plan for the office visit. Because the primary purpose for the office visit was to provide recommended preventive services, and the plan was not billed separately for the additional services, the plan may not impose a cost-sharing requirement with respect to the office visit.

Example: A patient is covered by a group health plan and visits an in-network healthcare provider. While visiting the provider, the patient is screened for cholesterol abnormalities with a rating of A or B (which are recommended preventive services). The provider bills the plan separately for the 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 separately billed laboratory work of the cholesterol screening test. However, the plan may impose cost-sharing requirements for the office visit since it was billed separately from the recommended preventive service.

Example: A patient visits his network provider for abdominal pain. During the visit, he has a blood pressure screening that is a recommended preventive service. The provider bills the plan for the office visit, and there is no separate bill for the blood pressure screening. The plan may impose cost sharing on the office visit because the primary purpose of the office visit was not the delivery of a recommended preventive service. 

4. How do these rules deal with in-network and out-of-network providers? 

The regulations clarify that a network-based plan is not required to provide coverage for recommended preventive services delivered by an out-of-network provider and may impose cost-sharing requirements for any such out-of-network services that are offered.

5. What rules apply for women's preventive services? 

New rules went into effect for women's preventive health benefits on August 1, 2012, and for health plans, other than grandfathered plans, for the first plan year beginning on or after August 1, 2012, except for contraception and sterilization services for women employed by certain religious organizations or social organizations operated by religious organizations, which are exempt or have a delayed effective date, respectively.

In addition to previously discussed mandated preventive services the enhanced services mandate requires no cost sharing for women for:

• Well-woman visits;

• Screening for gestational diabetes;

• HPV and DNA testing for women thirty years and older;

• Sexually transmitted infection counseling;

• HIV screening and counseling;

• FDA-approved contraceptive methods and contraceptive counseling. (Some religious groups may qualify for a complete or temporary exemption from covering contraceptive counseling and methods as discussed in Q 208.);

• Breastfeeding support, supplies, and counseling;

• Domestic violence screening and counseling.

6. How does health reform deal with contraception and sterilization services for employees of religious organizations and social organizations sponsored by religious groups? 

Section 2713(a)(4) of the PHS Act requires that non-grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage provide benefits for certain women's preventive health services without cost sharing, as provided by Health Resources and Services Administration (HRSA) guidelines. The August 1, 2011, HRSA Guidelines include all FDA approved contraceptive methods, sterilization procedures, and patient education and counseling for women with reproductive capacity, as prescribed by a health care provider (collectively, contraceptive services). The HRSA guidelines do not cover men.

The final contraception regulations promote two goals. First, they provide women with access to contraceptive coverage without cost sharing, thereby advancing the compelling government interests in safeguarding public health and ensuring that women have equal access to health care. Second, they protect certain not-for-profit religious organizations with religious objections to providing contraceptive coverage from having to contract, arrange, pay, or refer for such coverage.

In July 2013, the agencies (DOL, HHS, and IRS) issued revised final regulations, changing how the previous 2012 regulations applied the contraceptive coverage mandate to not-for-profit religious organizations. Under the 2013 final regulations, a religious employer includes (1) churches, their integrated auxiliaries, and conventions or associations of churches or (2) the exclusively religious activities of any religious order and is exempt from the mandate. With the exception of the amendments to the religious employer exemption, which apply to group health plans and health insurance issuers for plan years beginning on or after August 1, 2013, these 2013 final regulations apply to group health plans and health insurance issuers for plan years beginning on or after January 1, 2014.

The prior exemption requirements that the organization had to have as its purpose the inculcation of religious values and had to primarily employ and serve persons who share its religious tenets were removed. Under the 2013 final regulation, an eligible organization is an organization that (1) opposes providing coverage for some or all of the contraceptive services required to be covered under section 2713 of the PHSA on account of religious objections; (2) is organized and operates as a not-for-profit entity; (3) holds itself out as a religious organization; and (4) certifies that it satisfies the first three criteria. An eligible organization also includes student health insurance coverage arranged by eligible organizations that are institutions of higher learning.

Therefore, group health plans of not-for-profit houses of worship that provide educational, charitable, or social services to their communities qualify for the exemption. An employer that is a not-for-profit entity is not limited to any particular form of entity under state law, and it is not necessary to determine the federal tax-exempt status of a not-for-profit entity in determining whether the religious employer exemption applies.

The accommodation for eligible organizations with nongrandfathered insured plans requires the insurer to assume sole responsibility for providing separate payment for contraceptive services directly to participants and beneficiaries, without cost-sharing, premium, fee, or other charge to plan participants, beneficiaries, or to the religious organization or its plan. The payments are not individual health insurance policies.

For eligible organizations with self-insured plans, the TPA becomes an ERISA plan administrator and claims administrator solely for the purpose of providing payments for contraceptive services for participants and beneficiaries at no cost to plan participants or beneficiaries or to the eligible organization. The TPA must provide or arrange separate payments for contraceptive services for participants and beneficiaries in the plan without cost-sharing, premium, fee, or other charge to plan participants, beneficiaries, the eligible religious organization, or its plan. The TPA can provide the payments on its own, or it can arrange for an insurer or other entity to provide the payments. Like the payments for contraceptive services under the accommodation for insured plans, the payments are not health insurance policies.

Any organization seeking accommodation as an eligible organization certifies to its insurer or TPA that it meets the definition of an eligible organization. In turn, insurers or TPAs provide an annual notice of the availability of the coverage to participants and beneficiaries.

Employers participating in a multiple employer plan are required to independently qualify as religious employers or eligible organizations to take advantage of the exemption or accommodations.

Not-for-profit employers that do not fit within the previously outlined exemption and do not currently cover contraceptive services are not required to provide contraception coverage until plan years beginning on or after Jan. 1, 2014.

• The safe harbor is also available to not-for-profit organizations with religious objections to some but not all contraceptive coverage;
• Group health plans will not be ineligible for the safe harbor merely because an attempt made before February 10, 2012, to exclude or limit contraceptive coverage proved unsuccessful; and
• The safe harbor may be invoked without prejudice by not-for-profit organizations that are uncertain whether they qualify for the religious employer exemption (i.e., doing so will not preclude an otherwise-eligible employer from later invoking the exemption). 

The HHS bulletin requires specific notice and certification requirements that these organizations must meet in order to qualify. Specific language must be used to satisfy these requirements. The notice must be distributed "in connection with enrollment (or re-enrollment)" for coverage that is effective beginning each plan year before January 1, 2014. Thus, for a calendar-year plan with an open enrollment period beginning November 1, the notice must be provided to participants on or after November 1, 2013. The notice is required to be provided by the plan, although the plan may delegate this responsibility to its insurer or TPA. With respect to insured coverage, unless it accepts in writing the responsibility to provide the notice, an insurer does not lose protection under the temporary enforcement safe harbor solely because the notice is not distributed by the plan or because the insurer relies in good faith on a representation by the plan that turns out to be incorrect.

7. Are there any other options for religious organizations that object to these rules? 

Employers that do not intend to comply with Section 2713 could terminate their group health plan and encourage their employees to obtain individual policies. As of January 1, 2014, such individual policies must be offered on state health insurance exchanges on a guaranteed issue, guaranteed renewability basis. However, employers with at least fifty full-time equivalent employees or with at least thirty-one full-time employees that do not offer health coverage are subject to penalties.