ACA Preventive Care Coverage Guidelines

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

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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.

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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.

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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,

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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.

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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.

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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

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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.

ACA Preventive Care Coverage Guidelines

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