Women s Preventive Benefits as part of Patient Protection and Affordable Care Act (PPACA)

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1 205 Park Club Lane, Buffalo, NY Women s Preventive Benefits as part of Patient Protection and Affordable Care Act (PPACA) Summary: The Patient Protection and Affordable Care Act (PPACA) requires health plans to cover designated women s preventive services without cost sharing for the member. Cost sharing includes deductibles, copayments and coinsurance. Some of the benefits and services outlined in the women s preventive guidelines are already included within the existing PPACA preventive services requirements. For non grandfathered products, the provision states coverage must go into effect for new commercial health plans and commercial health plan renewals on or after August 1, Current Status: Many of the screenings/services included in this provision would be provided at the annual well women visits. Impact on Health Plans: Q1: What health plans will change and when? Question and Answer A1: This provision applies to all new commercial health plans and commercial health plan renewals for individuals, fully insured group and self funded plans that are not grandfathered starting on or after August 1, Grandfathered health plans may choose to be included by contacting your Sales Account Consultant. These provisions do not apply to the following products: Medicare Supplemental, Medicare Advantage, Medicaid, Family Health Plus and Child Health Plus.

2 Q2: What preventive services are impacted? A2: Many of the screenings/services included in this provision would be provided at the time of the annual well women visit. The following preventive services must be covered with no cost sharing: a) Well woman visits: Including coverage for pre natal visits that are billed separately from the delivery and post partum care. b) Gestational Diabetes Screening* c) Human Papillomavirus (HPV) Testing* d) Counseling for Sexually Transmitted Diseases e) HIV Testing and Counseling* f) Contraceptive Methods and Counseling g) Breastfeeding Support, Supplies and Counseling h) Domestic Violence Screening and Counseling (* laboratory services associated with the screening are covered at no cost share) Q3: The existing PPACA preventive benefits had age, gender and frequency restrictions. Does the women s preventive services provision contain any restrictions? A3: Yes, there are certain benefits and services that contain frequency restrictions. Some services/benefits are provided to pregnant women only or for women who are sexually active. For a full list of restrictions and guidelines, visit: Q4: What are health plans required to do? A4: The women s preventive care benefits will expand the current PPACA preventive health services. The premium rate adjustments will be made to accommodate these additional benefits that are required to be covered in full. Q5: What action should sales staff and brokers take at this time? A5: Sales staff and brokers do not need to take specific action at this time. If sales and broker personnel receive questions, please refer employers to the Health Reform page on our website for updates.

3 Impact on Employer Groups: Q6: What employers need to know and what they need to do: A6: Fully insured employer groups will not need to take any action. The Health Plan will amend the contracts to bring the group into compliance with the new mandate. The benefits will change automatically for members and no action is required. Grandfathered groups will not receive the new benefits unless they confirm, in writing, with their sales representative/broker that they wish to have the benefits implemented. Self funded employer groups will need to make changes to their benefit plans and communicate those changes to their members. Q7: Are religious groups still exempt from covering contraceptives? A7: Yes. Certain religious employers and group health plans are exempt from the requirement to cover contraceptive services. For additional information, please follow the link: /pdf/ pdf Q8: What does the "Safe Harbor Transition Period" mean? A8: The Temporary Enforcement Safe Harbor transition period is an accommodation to employers who are not exempt religious employers but who object to providing coverage for contraceptive services for religious reasons. Employers falling within the Safe Harbor will have additional time to comply with the contraceptive coverage requirements. During the transition period, the federal agencies will not take any enforcement action against employers qualifying for the regulatory forbearance. Q9: What employers will qualify for the Safe Harbor transition period? A9: An employer (or association of employers) will qualify for the Safe Harbor if it meets all of the following criteria: (a) It is organized and operated as a non profit entity. (b) From February 10, 2012 onward, the group health plan established or maintained by the organization has consistently not provided all or the same subset of the contraceptive coverage otherwise required at any point, consistent with any applicable State law, because of the religious beliefs of the organization. (c) The group health plan established or maintained by the organization (or another entity on behalf of the plan, such as a health insurance issuer or third party administrator) provided to participants a notice, consistent with the regulatory guidance issued by the Center for Consumer Information and Insurance Oversight and the Centers for Medicare & Medicaid

4 Services (the Guidance), that states that some or all contraceptive coverage will not be provided under the plan for the first plan year beginning on or after August 1, (d) The organization self certified that it satisfied criteria 1 3 above, and documented its selfcertification in accordance with the Guidance. Q10: If a group has Grandfathered one or more of their products, will these new benefits be implemented on the Grandfathered Product? A10: No. A letter will be sent to all Grandfathered Groups advising that since they are not required to add these benefits, we will not automatically change their benefit package to include these benefits, unless they advise their Account Consultant that they wish to have these additional benefits added. Q11: My group does not wish to cover contraceptives due to religious beliefs. Can we be exempt from this requirement? A11: For purposes of the exemption only, a religious employer is one that: (a) has the inculcation of religious values as its purpose; (b) primarily employs person who share its religious tenets; (c) primarily services persons who share its religious tenets; and (d) is a non profit organization as described in section 6033(a)(3)(A)(i) or (iiii) of the Internal Revenue Code. Groups that meet this criteria need to complete and sign the form located on our website and give to their Account Consultant. Impact on Members: Q12: Are there circumstances where a member may be billed for these services? A12: Yes, members could receive a bill in the following circumstances: If the member receives care from an out of network provider. If the primary purpose of an office visit is not for the rendering of the preventive service, cost sharing may be applied to the office visit. If there are additional office visits and/or services required based on the result of the preventive service or screening. Office visits billed independently of the preventive service. Q13: How will the health plan pay for the OTC contraceptives? A13: In order to obtain coverage for OTC contraceptives, including female condoms, spermicide (foam and gel), members will need to obtain a prescription from their provider, and

5 have the item filled at a participating pharmacy. The morning after pill, however, is not included as part of Preventive Services for Women.