This ACA Overview is not intended to be exhaustive nor should any discussion or

opinions be construed as legal advice. Readers should contact legal counsel for

legal advice.

PREVENTIVE CARE COVERAGE

Under the ACA, non-grandfathered

group health plans:

Must cover certain preventive care services; and

May not charge copayments, coinsurance or deductibles for those services when delivered by a network provider.

ADDED GUIDELINES FOR WOMEN

Additional coverage guidelines apply

for women’s preventive care services,

such as:

Well-woman visits;

Breastfeeding support;

Domestic violence screening; and

Contraceptives.

Preventive Care Coverage Guidelines

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 preventive care coverage

requirement, which generally took effect for plan years beginning on or

after Sept. 23, 2010, does not apply to grandfathered health plans.

Additional preventive care guidelines for women took effect for plan

years beginning on or after Aug. 1, 2012, requiring non-grandfathered

health plans to cover women’s preventive health services without cost-

sharing. Also, special rules regarding contraceptive coverage apply to

religious employers, including churches and other religious-based

institutions, such as schools, hospitals, charities and universities.

This ACA Overview describes the preventive care coverage guidelines

that apply under the ACA.

LINKS AND RESOURCES

On July 19, 2010, the Departments of Labor (DOL), Health and

Human Services (HHS) and the Treasury (Departments) issued

interim final rules regarding coverage of preventive care services.

In August 2011, HHS issued additional preventive care guidelines

for women under the ACA.

A list of recommended preventive services is available at:

www.healthcare.gov/what-are-my-preventive-care-benefits.

Provided by Encompass HR Solutions

2 This ACA Overview is not intended to be exhaustive nor should any discussion or opinions be construed as legal

advice. Readers should contact legal counsel for legal advice.

© 2016 All rights reserved.

COVERAGE OF PREVENTIVE CARE SERVICES

For plan years beginning on or after Sept. 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 Aug. 1, 2012).

A list of recommended preventive services is available at: www.healthcare.gov/what-are-my-preventive-

care-benefits.

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.

Office Visits

The Departments’ 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 whether the preventive care service is billed or tracked separately, and 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.

3 This ACA Overview is not intended to be exhaustive nor should any discussion or opinions be construed as legal

advice. Readers should contact legal counsel for legal advice.

© 2016 All rights reserved.

EXAMPLES

Example 1—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 2—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 3—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 on Tobacco Cessation Interventions

The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation

interventions for those who use tobacco products. An FAQ issued on May 2, 2014, clarifies what plans

and issuers are expected to provide as preventive coverage for tobacco cessation interventions.

According to the Departments, evidence-based clinical practice guidelines can provide useful guidance

for plans and issuers. The Departments will consider a group health plan or health insurance issuer to be

in compliance with the requirement to cover tobacco use counseling and interventions, if, for example,

the plan or issuer covers, without cost-sharing:

Screening for tobacco use; and

For those who use tobacco products, at least two tobacco cessation attempts per year. For this

purpose, covering a cessation attempt includes coverage for:

o Four tobacco cessation counseling sessions of at least 10 minutes each (including telephone

counseling, group counseling and individual counseling) without prior authorization; and

o All Food and Drug Administration (FDA)-approved tobacco cessation medications (including

both prescription and over-the-counter medications) for a 90-day treatment regimen, when

prescribed by a health care provider, without prior authorization.

4 This ACA Overview is not intended to be exhaustive nor should any discussion or opinions be construed as legal

advice. Readers should contact legal counsel for legal advice.

© 2016 All rights reserved.

This guidance is based on the Public Health Service-sponsored Clinical Practice Guideline, Treating

Tobacco Use and Dependence: 2008 Update.

Coverage of Colonoscopies Pursuant to USPSTF Recommendations

An FAQ issued on May 11, 2015, provided that, if a colonoscopy is scheduled and performed as a

preventive screening procedure for colorectal cancer pursuant to the USPSTF recommendation, a plan

or issuer is not permitted to impose cost-sharing with respect to anesthesia services performed in

connection with the preventive colonoscopy, if the attending provider determines that anesthesia

would be medically appropriate for the individual.

A separate FAQ issued on Oct. 23, 2015, clarified that after a colonoscopy is scheduled and performed as

a screening procedure pursuant to the USPSTF recommendation, the plan or issuer is required to cover

all of the following without cost-sharing:

The required specialist consultation prior to the screening procedure—The plan or issuer may

not impose cost-sharing with respect to a required consultation prior to the screening procedure

if the attending provider determines that the pre-procedure consultation would be medically

appropriate for the individual, because the pre-procedure consultation is an integral part of the

colonoscopy. As with any invasive procedure, the consultation before the colonoscopy can be

essential in order for the consumer to obtain the full benefit of the colonoscopy safely. The

medical provider examines the patient to determine if the patient is healthy enough for the

procedure and explains the process to the patient, including the required preparation for the

procedure, all of which are necessary to protect the health of the patient.

Any pathology exam on a polyp biopsy—The Departments view these services as an integral part

of a colonoscopy, similar to polyp removal during a colonoscopy. The pathology exam is essential

for the provider and the patient to obtain the full benefit of the preventive screening, since the

pathology exam determines whether the polyp is malignant. Since the primary focus of the

colonoscopy is to screen for malignancies, the pathology exam is critical for achieving the primary

purpose of the colonoscopy screening.

Because the Departments' prior guidance may reasonably have been interpreted in good faith as not

requiring coverage without cost-sharing of consultation prior to a colonoscopy screening procedure or a

pathology exam on a polyp biopsy performed in connection with a colonoscopy screening procedure,

the Departments will apply this clarifying guidance for plan years (or, in the individual market, policy

years) beginning on or after Dec. 22, 2015.

The Departments also issued an FAQ on April 20, 2016, providing that a plan or issuer cannot impose

cost sharing for the bowel preparation medications prescribed for a colonoscopy that is scheduled and

performed as a screening procedure pursuant to the USPSTF recommendation. According to the FAQ,

the required preparation for a preventive screening colonoscopy is an integral part of the procedure.

Bowel preparation medications, when medically appropriate and prescribed by a health care provider,

5 This ACA Overview is not intended to be exhaustive nor should any discussion or opinions be construed as legal

advice. Readers should contact legal counsel for legal advice.

© 2016 All rights reserved.

are an integral part of the preventive screening colonoscopy, and therefore, are required to be covered

without cost sharing, subject to reasonable medical management.

Coverage of Weight Management Services for Adult Obesity

According to an FAQ issued on Oct. 23, 2015, non-grandfathered plans and issuers must cover screening

for obesity in adults without cost-sharing. In addition, the USPSTF currently recommends intensive,

multicomponent behavioral interventions for weight management for adult patients with a body mass

index (BMI) of 30 kg/m2 or higher. The recommendation specifies that intensive, multicomponent

behavioral interventions include, for example, the following:

Group and individual sessions of high intensity (12 to 26 sessions in a year);

Behavioral management activities, such as weight-loss goals;

Improving diet or nutrition and increasing physical activity;

Addressing barriers to change;

Self-monitoring; and

Strategizing how to maintain lifestyle changes.

While plans and issuers may use reasonable medical management techniques to determine the

frequency, method, treatment or setting for a recommended preventive service (to the extent not

specified in the recommendation or guideline regarding that preventive service) plans are not permitted

to impose general exclusions that would encompass recommended preventive services.

Additionally, with respect to individual and small group market issuers subject to the ACA’s essential

health benefits (EHB) requirements, to the extent the applicable EHB-benchmark plan does not include

coverage of the required preventive services (including obesity screening and counseling) the issuer

must, nonetheless, provide coverage for those preventive services consistent with the ACA.

WOMEN’S PREVENTIVE CARE SERVICES

On Aug. 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 guidelines 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 were required to cover these services without cost-sharing for plan

years beginning on or after Aug. 1, 2012 (Jan. 1, 2013, for calendar year plans), subject to the special

provisions described below for religious employers. The list of recommended preventive services for

women is available through HHS at: www.healthcare.gov/what-are-my-preventive-care-benefits.

6 This ACA Overview is not intended to be exhaustive nor should any discussion or opinions be construed as legal

advice. Readers should contact legal counsel for legal advice.

© 2016 All rights reserved.

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.

On May 11, 2015, the Departments issued a set of FAQs, followed by a separate set of FAQs on Oct. 23,

2015, to address additional issues related to women’s preventive care services.

CONTRACEPTIVE COVERAGE AND RELIGIOUS EMPLOYERS

Exemption for Churches

In 2011, the Departments provided an exemption from the ACA’s contraceptive coverage requirement

for group health plans of certain nonprofit religious employers (such as churches and other houses of

worship). Under this exemption, eligible employers offering health coverage may decide whether or not

to cover contraceptive services, consistent with their beliefs. A “religious employer” was defined as 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.

On July 2, 2013, the Departments published a final rule that simplifies the definition of a “religious

employer” as it relates to the contraceptive coverage exemption, effective for plan years beginning on

or after Jan. 1, 2013.

Under the simplified definition, a religious employer will qualify for the exemption to the contraceptive

coverage mandate if it is a nonprofit entity that is referred to in Section 6033(a)(3)(A)(i) or (iii) of the

Internal Revenue Code. This definition primarily includes churches, other houses of worship and their

affiliated organizations. The simplified definition is intended to clarify that a house of worship is not

excluded from the exemption because, for example, it provides charitable social services to, or employs,

persons of different religious faiths.

The preventive care guidelines for women include FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity. The Departments have provided special contraceptive coverage rules for nonprofit religious employers and organizations. These rules exempt churches and other houses of

worship from the ACA’s requirement to cover contraceptives. For other church-affiliated institutions that object to contraceptive coverage, such as schools, charities, hospitals and universities, these

rules establish a temporary enforcement delay and an accommodations approach.

7 This ACA Overview is not intended to be exhaustive nor should any discussion or opinions be construed as legal

advice. Readers should contact legal counsel for legal advice.

© 2016 All rights reserved.

Temporary Safe Harbor

HHS established a temporary enforcement safe harbor for nonprofit organizations that do not provide

some or all of the required contraceptive coverage based on their religious beliefs. The enforcement

safe harbor is effective for plan years beginning before Jan. 1, 2014. For plan years beginning on or

after Jan. 1, 2014, the accommodations approach described below is effective.

Under the terms of the safe harbor, the Departments will not take any enforcement action against

employers, group health plans or group health issuers that meet the eligibility criteria for the safe

harbor and that fail to cover some or all of the recommended contraceptive services without cost

sharing. This safe harbor covers church-affiliated organizations that do not qualify for the exception for

non-profit religious employers, such schools, hospitals, charities and universities.

Accommodations Approach

The June 2013 final rule provides accommodations for nonprofit religious organizations that object to

contraceptive coverage on religious grounds and do not qualify for the church exemption. The

accommodations are effective for plan years beginning on or after Jan. 1, 2014. The temporary safe

harbor applies until then. An eligible organization is one that:

Opposes providing coverage for some or all of any contraceptive services which are required to be

covered 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.

Under the accommodations, eligible organizations do not have to contract, arrange, pay or refer for any

contraceptive coverage to which they object on religious grounds. However, separate payments for

contraceptive services will be provided to females in the health plan by an independent third party, such

as an insurance company or third-party administrator (TPA), directly and free of charge.

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.

On June 30, 2014, in Burwell v. Hobby Lobby Stores, Inc. et al., the U.S. Supreme Court created a narrow

exception to the contraceptive mandate for closely held for-profit businesses that object to providing

coverage for certain types of contraceptives based on their sincere religious beliefs. In light of the

Supreme Court’s decision, the Departments published a final rule on July 14, 2015, that amends the

definition of an “eligible organization” for purposes of the accommodations approach described above.

The amended definition includes a closely held for-profit entity that has a religious objection to

8 This ACA Overview is not intended to be exhaustive nor should any discussion or opinions be construed as legal

advice. Readers should contact legal counsel for legal advice.

© 2016 All rights reserved.

providing coverage for some or all of the contraceptive services otherwise required to be covered. This

change extends the accommodations approach available for non-profit entities to group health plans

established or maintained by certain closely held for-profit entities with similar religious objections to

contraceptive coverage.

Thus, under the final rules, a qualifying closely held for-profit entity is not required to contract, arrange,

pay or refer for contraceptive coverage. Instead, payments for contraceptive services provided to

participants and beneficiaries in the eligible organization’s plan would be provided or arranged

separately by an issuer or a TPA.