First Dollar Coverage Required for Women’s Preventive Health Care Services

November 2011Newsletters For Your Benefit

The Patient Protection and Affordable Care Act, the health insurance reform legislation signed into law in March 2010, is intended to make preventive care affordable and accessible by requiring health plans to cover preventive services and eliminating cost sharing for those preventive services. Last year, the Departments of Health and Human Services, Labor, and Treasury issued interim regulatory guidance as to the services subject to these requirements. The regulations identified four categories of preventive health services encompassed by the requirements: (1) certain individual services covered by recommendations of the United States Preventive Services Task Force, (2) immunizations as recommended by the Centers for Disease Control and Prevention, (3) guidelines for children and adolescents supported by the Health Resources and Services Administration (HRSA) and (4) preventive care and screening for women.

HRSA now has adopted amendments to the regulations to fill some of the gaps in existing guidance, specifically in the fourth category (preventive care and screening for women). These expanded guidelines are effective as of August 1, 2011. Non-grandfathered health plans and issuers are required to provide coverage without cost sharing (i.e., first dollar coverage) for the first plan year or policy year that begins on or after August 1, 2012; for calendar year plans and policies, the effective date will be January 1, 2013. Specifically, the following preventive services must be provided without cost sharing:

  • Well-women visits;
  • Screening for gestational diabetes;
  • Human papillomavirus testing;
  • Counseling for sexually transmitted infections;
  • Counseling and screening for human immune-deficiency virus;
  • Contraceptive methods and counseling;
  • Breastfeeding support, supplies and counsel; and
  • Screening and counseling for interpersonal and domestic violence.

The regulations grant to HRSA the discretion to exempt certain religious employers and the group health plans sponsored by those employers from these guidelines insofar as contraception services are concerned. For purposes of this exemption policy, a “religious employer” is one that (1) has the inculcation of religious values as its purpose, (2) primarily employs persons who share its religious tenets, (3) primarily serves persons who share its religious tenets, and (4) is a nonprofit organization under Internal Revenue Code Section 6033(a)(1) and Internal Revenue Code Section 6033(a)(3)(A)(i) or (iii). (The latter two references apply to churches, their integrated auxiliaries, and conventions or associations of churches, as well as to the exclusively religious activities of any religious orders.) This definition of religious employer is based upon existing definitions used by most states that exempt religious employers from having to comply with state law requirements pertaining to coverage of contraceptive services.

For more information regarding this topic, please contact Susan Foreman Jordan at 412.391.1334 or [email protected] or any member of Fox Rothschild’s Employee Benefits & Compensation Planning Practice Group.