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Women’s Preventive Services Coverage and Non-Profit Religious Organizations

Fact Sheet:  Women’s Preventive Services Coverage, Non-Profit Religious Organizations, and Closely-Held For-Profit Entities

Most health plans are required to cover recommended preventive services, including certain women’s preventive health services, without charging cost-sharing, like a co-pay, co-insurance, or a deductible.

The independent Institute of Medicine (IOM) provided recommendations to the Department of Health and Human Services (HHS) regarding which preventive services help keep women healthy. The IOM recommended covering all FDA-approved contraceptive services for women with child-bearing capacity, as prescribed by a provider, because there are tremendous health benefits for women that come from using contraception. In fact, nearly 99 percent of women in the United States have relied on contraceptive services at some point in their lives, but more than half, between the ages of 18 and 34, have struggled to afford it.

Under final Affordable Care Act (ACA) rules, women are afforded coverage for recommended preventive care, including all FDA-approved contraceptive services prescribed by a health care provider, without cost-sharing.

Exemption for Religious Employers

Group health plans of "religious employers" are exempted from having to provide contraceptive coverage. Under final rules issued in June 2013, the definition of "religious employer" for purposes of the exemption is based solely on Section 6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code, which primarily concerns churches and other houses of worship.

A house of worship is exempted even if it provides charitable social services to, or employs, persons of different religious faiths

Accommodations for Additional Non-Profit Religious Organizations under the July 2013 Final Rules

The final rules issued in July 2013 also provide an accommodation for other non-profit religious organizations that object to contraceptive coverage on religious grounds. An eligible organization, under the July 2013 final rules, is one that:

  1. on account of religious objections, opposes providing coverage for some or all of any contraceptive services otherwise required to be covered;
  2. is organized and operates as a nonprofit entity;
  3. holds itself out as a religious organization; and
  4. self-certifies that it meets these criteria in accordance with the provisions of the final regulations.  

Under the accommodation, an eligible organization does not have to contract, arrange, pay or refer for contraceptive coverage. At the same time, separate payments for contraceptive services are available for women in the health plan of the organization, at no cost to the women or to the organization.

Under the 2013 final rules, with respect to insured health plans, including student health plans, to be eligible for the accommodation, an eligible organization provides a copy of its self-certification to its health insurance issuer.  These issuers must then provide separate payments for contraceptive services for the women in the health plan of the organization, at no cost to the women or to the organization.  As explained in the final rules, issuers will find that providing such payments is cost-neutral.

Also under the 2013 final rules, with respect to self-insured health plans, to be eligible for the accommodation, an eligible organization provides a copy of its self-certification to its third party administrator (TPA).  The TPA must then provide or arrange separate payments for contraceptive services for the women in the health plan of the organization, at no cost to the women or to the organization.  The costs of such payments can be offset by adjustments in Federally-facilitated Marketplace user fees paid by a health insurance issuer with which the TPA has an arrangement.

Additional Notification Option for Non Profit Religious Organizations under the August 2014 IFR

In August 2014, in light of the Supreme Court’s recent interim order in a case involving Wheaton College, interim final regulations were published to establish another option for an eligible organization to avail itself of the accommodation. Under the interim final regulations, an eligible organization may notify the Department of Health and Human Services (HHS) in writing of its religious objection to contraception coverage. HHS will then notify the insurer for an insured health plan, or the Department of Labor will notify the TPA for a self-insured plan, that the organization objects to providing contraception coverage and that the insurer or TPA is responsible for providing enrollees in the health plan separate no-cost payments for contraceptive services for as long as they remain enrolled in the health plan. Regardless of whether the eligible organization self-certifies in accordance with the July 2013 final rules, or provides notice to HHS in accordance with the August 2014 IFR, the obligations of insurers and/or TPAs regarding providing or arranging separate payments for contraceptive services are the same, as discussed in this Fact Sheet. The interim final rule solicits comments but is effective on date of publication in the Federal Register.

Proposal to Expand the Accommodation to Certain Closely Held For-Profit Entities

Also in August 2014, in response to the Supreme Court’s recent decision, in Burwell v. Hobby Lobby Stores, Inc., 134 S. Ct. 2751 (2014), proposed rules were published that solicit comments on expanding the availability of the accommodation to include a closely held for-profit entity that has a religious objection to providing coverage for some or all contraceptive services. The proposed rules describe two alternative approaches for defining such an entity. Under one approach, the entity could not be publicly traded, and ownership of the entity would be limited to a certain number of owners. Under an alternative approach, the entity could not be publicly traded, and a minimum percentage of ownership would be concentrated among a certain number of owners. The number and concentration is not specified in the proposed rules, which solicit public comment on an appropriate number and/or concentration. The rule also solicits comments on other possible approaches and on documentation and disclosure of a closely held for-profit entity’s decision not to provide contraceptive coverage. The proposed rules further provide that valid corporate action taken in accordance with the entity’s governing structure, in accordance with state law, stating its owners’ religious objection can serve to establish that the entity objects to providing contraceptive coverage on religious grounds. Comments on these proposed rules are being accepted for 60 days after publication in the Federal Register

The final rules on women’s preventive services coverage are available here: http://www.gpo.gov/fdsys/pkg/FR-2013-07-02/pdf/2013-15866.pdf - Opens in a new window

Today’s interim final rule and proposed rule can be found here:  http://www.ofr.gov/inspection.aspx

For more information on women’s preventive services coverage visit: http://www.hhs.gov/healthcare/facts/factsheets/2011/08/womensprevention08012011a.html - Opens in a new window

For required health plan coverage guidelines for women’s preventive services visit: http://www.hrsa.gov/womensguidelines - Opens in a new window

For the self-certification form for eligible organizations visit: http://cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/index.html#Prevention