Women s Preventive Services Amendment to Federal Health Care Reform Act Goes into Effect August 1

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1 For Distribution to Brokers/General Producers/Full-Service Producers Only (Not Intended for Distribution to Groups and Members) Date: July 16, 2012 Market: All Groups Women s Preventive Services Amendment to Federal Health Care Reform Act Goes into Effect August 1 On August 3, 2011 HHS published an amendment to the Preventive Services at zero cost-share provision of the Patient Protection and Affordable Health Care Act (known as PPACA or Federal Health Care Reform) that went into effect September 23, The original regulation specified that, at a later date, additional services targeted at women would be added to the list of preventive services that must be covered at zero cost-share. The amendment released on February 15, 2012 specified that these services, referred to as Women s Preventive Services (WPS), have an effective date of August 1, Woman s Preventive Services Covered at No-Cost The amendment added several services that were not previously included on the list of Preventive Services effective in These services will be added to plans which currently cover the PPACA Preventive Services: (see implementation strategy below) Screening for gestational diabetes. Breastfeeding support, supplies, and counseling Screening and counseling for interpersonal and domestic violence FDA approved contraceptive methods and counseling (*See Appendix A) o o Includes surgical, prescription, medical and OTC services/products Note: Sterilization is considered a contraceptive method. Abortion IS NOT considered a contraceptive method Services mentioned in the amendment, but previously included on the list of covered Preventive Services include: Annual well-women visit HPV (Human Papilloma Virus) testing Annual counseling for sexually transmitted infections Annual counseling and screening for HIV (Human Immunodeficiency Virus) Implementation Strategy CareFirst will implement the additional WPS benefits in a similar manner as the original implementation. As you may remember in 2010, CareFirst added the Preventive Services turnkey to both Grandfathered and Non-Grandfathered plans in the under-200 risk market. Since the WPS are services to be provided in addition to the current services, all plans in the under-200 risk market will receive the benefits turnkey. Refer to the following table for the implementation dates for the over-200 market plans.

2 Segment Risk plans (standard and nonstandard) Risk o Non-grandfathered plans o Grandfathered plans that voluntarily selected the Preventive Services at no cost-share provision Non-Risk o Non-Grandfathered plans o Grandfathered plans that voluntarily selected the Preventive Services at no cost-share provision Implementation Turnkey effective date : 8/1/12 Turnkey effective date: 8/1/12 Upon first renewal on or after August 1, 2012 Religious Exemption to Exclude Contraceptives: The regulations provide for an exemption for coverage of contraceptive services for eligible religious employers who object to providing the coverage. Requests for removal of contraceptive coverage must be reviewed by External Mandates & Compliance Implementation, as the rules of coverage vary between jurisdictions and are dependent on the group meeting specific criteria. Mandates will work with the legal department to ensure that CareFirst appropriately administers this exclusion based on the federal definition of religious employer. Federal Definition of Religious Employer: Defined as a tax exempt organization (non-profit) 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. Example organizations include: churches, church auxiliaries, conventions, associations of churches, and religious orders. Procedure for Requesting Religious Exemption Insured groups that wish to exclude contraceptive service coverage must complete the Request/Certification for Religious Employer Exemption Form for either non-msgr, 51+ groups or MSGR. Once the group has completed the form they should return it to the Broker, who will then forward the form for review to the following Broker Sales addresses: For DC: brokersales4@carefirst.com For MD: brokersalesmd@carefirst.com Please note that these boxes are only for groups External Mandates & Compliance Implementation will validate the request. If the group is approved, the form will be returned to the Sales Representative, who will inform the Broker of the approval and forward to them the approved form. The Broker should then submit the form along with any other documentation required for a group benefit change.

3 Self-Insured accounts who choose to remove coverage of contraceptive services or who wish to have the services excluded at their next renewal should also complete the Request/Certification for Religious Employer Exemption Form and forward it to their Broker, who will then provide the form to their CareFirst Sales Representative. External Mandates & Compliance Implementation will not review the requests of ASO accounts as CareFirst is not able to provide legal guidance. The account is at risk if they are found to have excluded coverage inappropriately. Advance Notification to Member Groups that are approved for the religious exemption must notify their employees, in advance of the benefits being removed, that contraceptive coverage will not be provided under their plan. Attached to this Broker Sales Flash are the following WPS supplementary documents. These documents will be available on the Broker Portal. WPS Request/Certification Form for a Religious Organization Under Maryland Small Group Regulation WPS Request/Certification Form for Religious Employer Exemption Contract Amendment Mailing All groups will receive updated contract amendments in the upcoming weeks. Frequently Asked Questions (FAQs): Q. Will the zero cost share benefit apply to both in-network and out-of-network providers? A. CareFirst will offer these mandated women s health services at zero cost when delivered by in-network providers. Q. How does the mandate affect prescription drug benefits? A. Prescription drug products will be expanded to include generic Food and Drug Administration-approved contraceptives as appropriate. Q. Will contraception coverage have to be offered to members of religious plans that qualify for the exemption? A. No, not until and unless directed by further legislation. Q. Will 200+ grandfather risk groups that do not currently offer the Preventive Services at no cost-share receive the WPS benefit turnkey 8/1/12? A. No, WPS is an amendment to the PPACA 100% Preventive Service mandate (zero cost share) and only groups that have the initial 100% Preventive Service benefit coverage will receive the WPS benefit. Q. How am I to be reimbursed for qualified OTC (Over-the-Counter) services? A. Eligible OTC services (Spermicides, Female Condoms) will require a prescription from a physician and must be purchased at a pharmacy to obtain the zero-cost share. Q. Is the zero copay allowed only for generic drugs? A. The zero copay is applicable when a generic is available, but if a generic equivalent is not available, the zero copay will be allowed for a brand contraceptive drug.

4 Should you have any questions, please contact your Broker Sales Representative. Shekar Subramaniam Associate Vice President, Broker Sales

5 Female Condom (OTC*) Diaphragm (P) with Spermicide (OTC*) Sponge (OTC) with Spermicide (OTC*) Cervical Cap (P) with Spermicide (OTC*) Spermicide (OTC*) Oral Contraceptive (P) Combined Pill Progestin Extended/Continuous Patch (P) Vaginal Contraceptive Ring (P) Shot/Injection (P) Morning After Pill Over 17 years of age (OTC*) Under 17 years of age (P) IUD (P) Implantable Rod (inserted by doctor) Sterilization Surgery Sterilization Implant (OTC) Over the Counter (P) Prescription Required *Appendix A: FDA Approved Contraceptives * Requires a prescription from a physician and must be purchased at a pharmacy to obtain the zero-cost share.

6 Request/Certification for Recognition as a Religious Org. under MD Small Group Regulation A Maryland Small Group Policyholder that qualifies as a religious organization under Maryland Regulations, COMAR , may request an exemption from providing coverage for some services otherwise mandated under Maryland s Comprehensive Standard Health Benefit Plan, if provision of the service is in conflict with the Policyholder s bona fide religious beliefs and practices. This exemption arises only under Maryland law. Recognition as a religious organization under Maryland law does not permit the Policyholder to exclude any benefit required by federal law, including the contraceptive services specified under the preventive health services mandated by Section 2713 of the Public Health Service Act and the related Guidelines adopted by the Department of Health and Human Services. The Policyholder must provide all federally mandated benefits unless the Policyholder qualifies for an exemption specified in federal law. This form must be completed by each Group Policyholder that wishes to be treated as a religious organization under Maryland law and to exclude coverage for a specific service and the Policyholder must certify to CareFirst that each of the below requirements have been met. Please fill out this form completely. Group Number Name of the organization sponsoring the plan ( the Sponsoring Organization ) Name of the individual who is authorized to make, and makes, this certification on behalf of the organization Mailing and addresses and phone number for the individual listed above. Description of services(s) to be excluded from coverage (may not include contraception services) By checking the boxes below, I certify as follows: 1. The Sponsoring Organization identified above wishes to be exempt from providing certain services under Maryland Small Group Regulation ( the Exemption ). 2. The Sponsoring Organization has provided or will timely provide any notifications to its employees relating to the Exemption, as required by applicable Maryland state regulation. 3. The services identified above, and to be excluded from coverage, conflict with the Policyholder s bona fide religious beliefs and practices. 4. The Sponsoring Organization meets each of the requirements of a religious organization set out in COMAR (B)(58), including (check each box): The Sponsoring Organization is an entity that is organized and operated exclusively for religious purposes; and The Sponsoring Organization has obtained a tax exemption under 501(c)(3) of the U.S. Internal Revenue Code I declare that I have made this certification, and that, to the best of my knowledge and belief, it is true and correct. I also declare that this certification is complete. I also recognize that the requirements for the Maryland Exemption may change, and agree to provide CareFirst with such additional information as may be needed to maintain the Exemption. Signature of the individual listed above Date

7 Request/Certification for WPS Religious Employer Exemption This form must be completed by each Group Policyholder that wishes to be treated as a religious employer and exempt from the federal requirement to provide contraceptive services as one of the preventive health services mandated by Section 2713 of the Public Health Service Act and the related Guidelines adopted by the Department of Health and Human Services. The exemption is only available to an organization that meets each of the requirements for a religious employer specified by 45 C.F.R , and a group health plan that seeks to claim this exemption must certify to CareFirst, using this form, that the requirements have been met. Please fill out this form completely. Group Number / State of Jurisdiction (i.e. state in which policy was issued or delivered) Name of the organization sponsoring the plan ( the Sponsoring Organization ) Name of the individual who is authorized to make, and makes, this certification on behalf of the organization Mailing and addresses and phone number for the individual listed above. On February 10, 2012, my organization Excluded / Did not exclude contraceptive coverage in its health benefit plan. By checking the boxes below, I certify as follows: 5. The Sponsoring Organization identified above wishes to be exempt from providing contraceptive services as a preventive service under Section 2713 of the Public Health Service Act ( the Exemption ). 6. The Sponsoring Organization has provided or will timely provide any notifications to its employees relating to the Exemption, to the extent notification is required by federal or applicable state law. 7. The Sponsoring Organization meets each of the requirements of a religious employer set out in 45 C.F.R , including (check each box): The inculcation of religious values is the purpose of the Sponsoring Organization. The Sponsoring Organization primarily employs persons who share its religious tenets The Sponsoring Organization primarily serves persons who share its religious tenets; and The Sponsoring Organization is a non-profit organization described in Section 6033(a)(1) and Section 6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code of (These code sections refer to churches, integrated church auxiliaries, conventions or associations of churches, and exclusively religious activities of a religious order). I declare that I have made this certification, and that, to the best of my knowledge and belief, it is true and correct. I also declare that this certification is complete. I also recognize that the federal requirements for the Exemption may change, and agree to provide CareFirst with such additional information as may be needed to maintain the Exemption. Signature of the individual listed above Date