Opinion ID: 2778691
Heading Depth: 4
Heading Rank: 1

Heading: The Affordable Care Act, the Preventive

Text: Services Coverage Requirement, and the Accommodation for Religious Nonprofit Organizations In 2010, Congress passed the ACA, which requires group health plans and health insurance issuers offering health insurance coverage1 to cover preventive care and screenings for women, without cost sharing (such as a copayment, coinsurance, or a deductible), as provided for in guidelines established by the Department of Health and 1 Eligible organizations may be either “insured” or “selfinsured.” An employer has an “insured” plan if it contracts with an insurance company to bear the financial risk of paying its employees’ health insurance claims. An employer has a “self-insured” plan if it bears the financial risk of paying its employees’ claims. Many self-insured employers use third-party administrators to administer their plans and process claims. See Cong. Budget Office, Key Issues in Analyzing Major Health Insurance Proposals 6 (2008). The appellees here fall into both categories. 12 Human Services (“HHS”). 42 U.S.C. § 300gg-13(a)(4).2 HHS requested assistance from the Institute of Medicine (“IOM”), a nonprofit arm of the National Academy of Sciences, to develop guidelines regarding which preventive services for women should be required. Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services Under the Patient Protection and Affordable Care Act, 77 Fed. Reg. 8725, 8726 (Feb. 15, 2012) (codified at 26 C.F.R. pt. 54; 29 C.F.R. pt. 2590; and 45 C.F.R. pt. 147). The IOM issued a report recommending a list of preventive care services, including all contraceptive methods approved by the Food and Drug Administration (“FDA”). The regulatory guidelines accordingly included “[a]ll Food and Drug Administration . . . approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity,” as prescribed by a health care provider. 77 Fed. Reg. at 8725 (alteration in original). The relevant regulations require coverage of the contraceptive services recommended in the guidelines. See 26 C.F.R. § 54.9815-2713(a)(1)(iv); 29 C.F.R. § 2590.715-2713(a)(1)(iv); 45 C.F.R. § 147.130(a)(1)(iv). 2 The ACA’s preventive care requirements apply only to nongrandfathered group health plans and health insurance issuers offering non-grandfathered health insurance coverage. See 45 C.F.R. § 147.140 (exempting “grandfathered” plans— “coverage provided by a group health plan, or a group or individual health insurance issuer, in which an individual was enrolled as of March 23, 2010,” the date on which the ACA was enacted “for as long as it maintains that status under the rules of this section”). 13 The implementing regulations authorize an exemption from contraceptive coverage for the group health plan of a “religious employer.” 45 C.F.R. § 147.131(a). The regulations define a religious employer as a nonprofit organization described in the Internal Revenue Code provision referring to churches, their integrated auxiliaries, and conventions or associations of churches, and the exclusively religious activities of any religious order. Id. (citing 26 U.S.C. § 6033(a)(3)(A)(i), (iii)). After notice-and-comment rulemaking, the Department of the Treasury, the Department of Labor, and the Department of Health and Human Services (the “Departments”) published final regulations in July 2013 that provided relief for organizations that, while not “religious employers,” nonetheless oppose coverage on account of their religious objections. These regulations include an “accommodation” for group health plans established or maintained by “eligible organizations” (and group health coverage provided in connection with such plans). See 26 C.F.R. § 54.98152713A(a), 29 C.F.R. § 2590-2713A(a), 45 C.F.R. § 147.131(b); Coverage of Certain Preventive Services Under the Affordable Care Act, 78 Fed. Reg. 39,870 (July 2, 2013) (codified at 26 C.F.R. pt. 54; 29 C.F.R. pts. 2510 & 2590; and 45 C.F.R. pts. 147 & 156). An “eligible organization” means a nonprofit organization that “holds itself out as a religious organization” and “opposes providing coverage for some or all of any contraceptive services required to be covered . . . on account of religious objections.” 45 C.F.R. § 147.131(b). To invoke this accommodation, an employer must certify that it is such an organization. Id. § 147.131(b)(4). Here, there is no dispute that the nonprofit religious organization appellees are eligible organizations under these regulations. 14 To take advantage of the accommodation to the contraceptive coverage requirement, the eligible organization must complete the self-certification form, EBSA Form 700, issued by the Department of Labor’s Employee Benefits Security Administration, indicating that it has a religious objection to providing coverage for the required contraceptive services. The eligible organization then is to provide a copy of the form to its insurance issuer or third-party administrator. 78 Fed. Reg. at 39,875.3 3 After these suits had been filed, the Supreme Court granted an injunction pending appeal in Wheaton College v. Burwell, 134 S. Ct. 2806 (2014), and ordered that the eligible organization applicant need not use EBSA Form 700 to notify its insurance issuer or third-party administrator of its religious objection to the contraceptive coverage requirement; instead, if the organization notifies the government in writing of its objection, the government is enjoined from enforcing the contraceptive coverage requirement against the organization. Id. at 2807. In response, interim final regulations were issued in August 2014 allowing an eligible organization to opt out by notifying HHS directly, rather than notifying its insurance issuer or third-party administrator; the eligible organization also need not use EBSA Form 700. Coverage of Certain Preventive Services Under the Affordable Care Act, 79 Fed. Reg. 51,092 (Aug. 27, 2014) (codified at 26 C.F.R. pt. 54; 29 C.F.R. pts. 2510 & 2590; and 45 C.F.R. pt. 147); see also 29 C.F.R. § 2590.715-2713A(b)(1)(ii)(B), (c)(1)(ii); 45 C.F.R. § 147.131(c)(1)(ii). We conclude here that the accommodation, even when utilizing EBSA Form 700, poses no substantial burden. To the extent that the Supreme Court’s order in Wheaton may be read to signal that the alternative 15 The submission of the form has no real effect on the plan participants and beneficiaries. They still have access to contraception, without cost sharing, through alternate mechanisms in the regulations.4 Under these regulations, an eligible organization is not required “to contract, arrange, pay, or refer for contraceptive coverage” to which it objects on religious grounds. 78 Fed. Reg. at 39,874. As a result, either the health insurance issuer or the third-party administrator is required by regulation to provide separate payments for contraceptive services for plan participants and beneficiaries. The ACA’s prohibition on cost sharing for preventive services, including contraception, bars the insurance issuer or third-party administrator from imposing any premium or fee on the group health plan, or plan participants and beneficiaries. Furthermore, the accommodation prohibits the insurance issuer or third-party administrator from imposing such fees on the eligible organization. See 42 U.S.C. notification procedure is less burdensome than using EBSA Form 700, we also conclude that the alternative compliance mechanism set forth in the August 2014 regulations poses no substantial burden. 4 The Supreme Court has recognized that the accommodation ensures that employees of entities with religious objections have the same access to all FDA-approved contraceptives as employees of entities without religious objections to providing such coverage. “The effect of the HHS-created accommodation on the women employed . . . would be precisely zero. Under that accommodation, these women would still be entitled to all FDA-approved contraceptives without cost sharing.” Burwell v. Hobby Lobby Stores, Inc., 134 S. Ct. 2751, 2760 (2014). 16 § 300gg-13(a); 29 C.F.R. § 2590.715-2713A(b)(2), (c)(2)(ii); 45 C.F.R. § 147.131(c)(2)(ii). The insurance issuer or thirdparty administrator must “[e]xpressly exclude contraceptive coverage from the group health insurance coverage provided in connection with the [eligible organization’s] group health plan” and “segregate premium revenue collected from the eligible organization from the monies used to provide payments for contraceptive services.” 29 C.F.R. § 2590.7152713A(c)(2)(i)(A), (ii); 45 C.F.R. § 147.131(c)(2)(i)(A), (ii). The third-party administrator may seek reimbursement for payments for contraceptive services from the federal government. 29 C.F.R. § 2590.715-2713A(b)(3). Furthermore, the health insurance issuer or third-party administrator, not the eligible organization, provides notice to the plan participants and beneficiaries regarding contraceptive coverage “separate from” materials that are distributed in connection with the eligible organization’s group health coverage, specifying that “the eligible organization does not administer or fund contraceptive benefits, but that the third party administrator or issuer, as applicable, provides separate payments for contraceptive services, and must provide contact information for questions and complaints.” See 26 C.F.R. § 54.9815-2713A(d); 29 C.F.R. § 2590.715-2713A(d); 45 C.F.R. § 147.131(d).5 This is in accordance with the preventive services requirement of the ACA. 5 As part of this separate notice regime, eligible organizations do not need to provide the names of their beneficiaries to their insurance issuers or third-party administrators, or otherwise coordinate notices with them. See Priests for Life v. U.S. Dep’t of Health & Human Servs., 772 F.3d 229, 254 (D.C. Cir. 2014) (agreeing that “[n]o regulation related to the 17