Preventive Care Mandate

Under the Patient Protection and Affordable Care Act (PPACA), non-grandfathered plans are required to provide coverage for certain preventive care services with no cost-sharing for participants effective for plan years beginning on or after Sept. 23, 2010. No cost-sharing means that the covered service would be provided without being subject to a deductible, co-payment, or co-insurance.

The following services are covered under the mandate:

  • evidence-based items or services with an A or B rating recommended by the United States Preventive Services Task Force;
  • immunizations for routine use in children, adolescents, or adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention;
  • evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA) for infants, children, and adolescents; and
  • other evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by HRSA for women

When one of these entities issues a new recommendation, non-grandfathered group health plans must provide coverage for the recommended service beginning with the plan year that starts one year after the recommendation is issued.

Examples of covered services include:

  • Breast cancer screening (i.e.-mammogram) every 1-2 years for women aged 40 and older
  • Colorectal cancer using blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years
  • Iron supplements for children aged 6 to 12 months at risk for anemia

A detailed listing of the services, which are currently covered under the mandate, is listed on theHHS healthcare.gov website

Recent Developments

On Aug. 2, 2011, the HRSA issued comprehensive guidelines related to women’s preventive care. The covered services include: well-women visits, screening for gestational diabetes, human papillomavirus testing, and contraceptive methods and counseling. Non-grandfathered plans are required to provide coverage for these services within the recommended guidelines effective the plan year beginning on or after Aug. 1, 2012.

On June 28, 2013, the U.S. Department of Health and Human Services (HHS), Internal Revenue Service (IRS) and the U.S. Department of Labor (DOL)) issued final rules related to contraceptive coverage and religious organizations. Certain religious employers are exempted from providing such coverage. For this purpose, a religious employer is defined as a nonprofit entity referred to in Section 6033(a)(3)(A)(i) and (ii) of the Internal Revenue Code (IRC). This generally includes churches, conventions or associations of churches and other houses of worship.

  • Many religiously affiliated employers, such as schools or hospitals, may not meet this definition. If such employers meet the following criteria, the plan is eligible for a temporary delay from providing contraception coverage. The temporary delay applies for plan years beginning on or before Dec. 31, 2013. Is organized and operated as a non-profit entity
  • Contraceptive coverage has not been provided by the group health plan since Feb. 10, 2012 because of the religious beliefs of the organization
  • The organization serves primarily persons who share the religious tenets of the organization
  • The organization distributes a notification to participants informing them that the plan will not cover contraceptive services without cost sharing because of the one year safe harbor
  • The organization certifies their qualifications for the safe harbor in writing by the first day of the plan year

For plan years beginning on or after Jan. 1, 2014, non-profit religiously affiliated employers, that do not meet the definition of an exempt church, will need to provide contraceptive coverage to plan participants. However, the employer is not required to arrange or pay for contractive services coverage on account of religious objections. The women enrolled under the plan will still be eligible for contraceptive coverage at no cost. The insurer or third party administrator (TPA) will provide the coverage to the insureds with no cost to the nonprofit entity.

A nonprofit entity wanting to take advantage of this accommodation should complete a self-certification and provide it to the plan’s insurer or TPA. The new certification applies to plan years beginning on or after Jan. 1, 2014, and must be completed prior to the first day of the applicable plan year. The DOL has provided a model notice for this purpose. The insurer or TPA will then notify the participants of the plan’s certification and the availability of coverage through the insurer or TPA.

Employer Action Required

A religiously affiliated employer who wishes to certify that they qualify for the temporary delay related to contraceptive coverage must complete a written certification before the applicable plan year starting on or before Dec. 31, 2013. The certification should be signed by an authorized officer or employee of the employer and maintained on file.

The employer must also distribute a notice to employees notifying them of the safe harbor delay and that the plan will not be offering contraceptive coverage in the next plan year. The notice must be distributed with enrollment materials for coverage. The employer is responsible for distributing the notice but may contract with the insurance carrier or third party administrator to send on their behalf.

For plan years starting on or after Jan. 1, 2014, a religiously affiliated non-profit entity wishing to take advantage of the accommodation where they do not have to contribute to or pay for contraceptive coverage, must complete a revised certification form. The insurer or TPA associated with the plan must notify participants of how to receive contraceptive coverage under the plan.

Penalties for Noncompliance

Failure to comply with PPACA will potentially trigger an excise tax of $100 per day for each individual for whom the failure applies, if the failure is not corrected within 30 days of knowledge. The tax would be self-reported on Form 8928.

The DOL may bring civil action against an employer for failure to comply. Additionally, participants may file a lawsuit under ERISA that seeks unpaid benefits, interest and attorney fees.

Finally, HHS may impose a civil penalty up to $100 per day for failures not corrected within 30 days of knowledge.

Frequently Asked Questions

Q1: Our plan uses a provider network. Can we require that participants use in-network providers to receive the covered preventive services with no cost sharing?
A: Plans that use provider networks are permitted to impose cost sharing requirements on preventive services that are provided by out-of-network providers. Additionally, such a plan is not even required to provide coverage for preventive services provided by out-of-network providers. For example, a plan may choose to outright deny or impose a co-payment for a preventive care service if the participant received the service from a provider outside the network.

Q2: Sometimes a participant will receive a preventive care service during an office visit with a provider. How does the cost sharing requirement work in this situation?
A: It depends upon how the services are billed and the primary purpose of the office visit. If the preventive service is not the primary purpose of the visit and the services are billed separately, cost-sharing is permitted for the office visit but not for the preventive service. If the preventive service is not the primary purpose of the visit and services are not billed separately, cost-sharing may be applied for the cost of the entire visit. Finally, if the preventive service is the primary purpose of the visit, the patient receives other services, and the services are not billed separately, cost-sharing is not permitted on any part of the visit.

Additional Resources

Citations

  • 45 CFR 147.130
  • 42 USC 300gg-13
  • 26 CFR 54.9815-2713T