Title 45: Public Welfare [Full
The Obama administration has decided that, as a matter of public
policy, individual women should not have to pay for
contraceptive services," which include surgical sterilization,
contraceptives, and embryocides.
for this policy are mainly economic and socio-political.
Since sterilization and birth control have to be paid for by
someone, the administration intends to force others to pay for them
through insurance plans, even if they object to doing so for reasons
of conscience or religion.
This regulation was written by the U.S. Department of Health and
Human Services for this purpose. It is authorized by
the United States Code made by Section 1001 of the
Protection and Affordable Care Act, the American health care
reform law passed in 2010.
requires all group health care plans (the kind of plan usually
offered by businesses or oganizations) to offer coverage and
fully pay for "preventive services"identified in Section
147.130 (reproduced below, in part). Businesses with 50 or
more employees must offer such coverage by 2014, or face penalties.1
Health insurance issuers (like insurance companies) must also make
available group and individual plans that fully pay for "preventive
Most of the services are not
identified in the regulation. They are itemized in separate
recommendations and guidelines.
What follows is the part of the regulation (as
amended in June, 2013) that is related to the
demand by the Department of Health and Human Services that employers
must pay for insurance coverage for surgical sterilization,
contraceptives and embryocides.2
Key terms are highlighted, links have been added for the
convenience of readers, and annotations are provided in text boxes to
PART 147-HEALTH INSURANCE REFORM REQUIREMENTS FOR THE GROUP AND INDIVIDUAL
HEALTH INSURANCE MARKETS
Â§ 147.130 Coverage of preventive health services.
(a) Services -(1) In general.
Beginning at the time
described in paragraph (b) of this section, a group health plan, or a health
insurance issuer offering group or individual health insurance coverage,
must provide coverage for all
of the following items and services, and
not impose any cost-sharing requirements (such as a copayment, coinsurance,
or deductible) with respect to those items or services:
(i) essentially repeats
Â§300gg-13(a)(1) in the statute.
(ii) is drawn from
Â§300gg-13(a)(2) in the statute,
and explains how recommendations will be identified.
(ii) Immunizations for routine use in children, adolescents, and adults
that have in effect a recommendation from the
Advisory Committee on Immunization Practices of
the Centers for Disease Control and Prevention
with respect to the individual involved (for this purpose, a recommendation
from the Advisory Committee on Immunization Practices of the Centers for
Disease Control and Prevention is considered in effect after it has been
adopted by the Director of the Centers for Disease Control and Prevention,
and a recommendation is considered to be for routine use if it is listed on
the Immunization Schedules of the Centers for Disease Control and
(iii) With respect to infants, children, and adolescents,
evidence-informed preventive care and screenings provided for in
comprehensive guidelines supported by the Health Resources and Services
Subsection (iv) refers to
legal guidelines that set out required "preventive care and screenings".
The meaning and effect of the regulation depends upon those guidelines.
(A) Note the word "may."
There is no requirement to provide an exemption, and any exemption provided
can be revised or revoked by the Department. "Contraceptive services"
are defined in legal guidelines, not in this regulation.
(A) In developing the
binding health plan coverage guidelines
in this paragraph (a)(1)(iv), the Health Resources and Services
Administration shall be informed by evidence and may
from such guidelines with respect to group health plans established or
maintained by religious employers and health insurance coverage provided in
connection with group health plans established or maintained by religious
employers with respect to any requirement to cover contraceptive services
under such guidelines.
Â§ 147.131 Exemption and accommodations in connection with coverage of
preventive health services.
(a) Religious employers.
In issuing guidelines under Â§ 147.130(a)(1)(iv), the Health Resources and
establish an exemption from such guidelines with respect to a group health
plan established or maintained by a religious employer (and health insurance
coverage provided in connection with a group health plan established or
maintained by a religious employer) with respect to any requirement to cover
guidelines. For purposes of this paragraph (a), a
(b) Eligible organizations.
An eligible is an organization that satisfies
all of the
(1) The organization opposes providing coverage for some or all of any
services required to be covered under Â§147.130(a)(1)(iv) on account of
(2) The organization is organized and operates as a .
(3) The organization holds itself out as a organization.
(4) The organization in a form and manner specified by
the Secretary, that it
satisfies the criteria in paragraphs (b)(1) through (3) of this section, and
self-certification available for examination upon request by the first day
of the first plan year to
which the accommodation in paragraph (c) of this section applies. The
self-certification must be executed by a person authorized to make the
certification on behalf of the organization, and must be maintained in a
manner consistent with the record retention requirements under section 107
of the Employee Retirement Income Security Act of 1974.
(c) Contraceptive coverage - insured group health plan coverage.
(1) General rule. A group
health plan established or maintained by an eligible organization
that provides benefits through one or more group health insurance issuers
complies for one or more plan years with
any requirement under Â§ 147.130(a)(1)(iv) to provide contraceptive coverage
if the eligible organization or group health plan
a copy of the self-certification described in paragraph (b)(4) of this
section to each issuer that would otherwise provide such coverage in
connection with the group health plan. An issuer may not require any
documentation other than the copy of the self-certification from the
eligible organization regarding its status as such.
(2) Payments for contraceptive services--(i)
A group health insurance issuer that receives
a copy of the self-certification described
in paragraph (b)(4) of this section with respect to a
group health plan established or maintained by an eligible organization in
connection with which
the issuer would otherwise provide contraceptive coverage under Â§
147.130(a)(1)(iv) must -
(A) Expressly exclude contraceptive coverage from the
group health insurance coverage
provided in connection with the group health plan; and
(B) Provide separate payments for any contraceptive
services required to be covered
under Â§ 147.130(a)(1)(iv) for plan participants and beneficiaries for so
long as they remain enrolled in the plan.
(ii) With respect to payments for contraceptive services,
(such as a copayment, coinsurance, or a deductible), or impose any premium,
fee, or other charge, or any portion thereof, directly or indirectly, on the
organization, the group health plan, or plan
participants or beneficiaries. The issuer must
segregate premium revenue collected from the eligible organization from the
monies used to
provide payments for contraceptive services. The issuer must provide
contraceptive services in a manner that is consistent with the requirements
under sections 2706, 2709, 2711, 2713, 2719, and 2719A of the PHS Act. If
the group health plan of the eligible organization provides coverage for
some but not all of any contraceptive services required to be covered under
Â§ 147.130(a)(1)(iv), the issuer is required to provide payments only for
those contraceptive services for which the group health plan does not
provide coverage. However, the issuer may provide payments for all
contraceptive services, at the issuer's option.
(d) Notice of availability of contraceptive coverage for contraceptive
services-- insured group health plans and student health insurance coverage.
For each plan year to which the accommodation in paragraph (c) of
this section is to apply, an
required to provide payments for contraceptive services pursuant to
paragraph (c) of this section must provide to plan participants and
beneficiaries written notice of the availability of separate payments for
contraceptive services contemporaneous with (to the extent possible), but
separate from, any application materials distributed in connection with
enrollment (or re-enrollment) in group health coverage that is
effective beginning on the first day of each applicable plan year.
The notice must specify that the eligible
organization does not administer or fund contraceptive benefits, but that
the issuer provides separate payments for contraceptive services, and
must provide contact information for questions and complaints. The following
model language, or substantially similar language, may be used to satisfy
the notice requirement of this paragraph (d):
"Your [employer/institution of higher education] has
certified that your [group health plan/student health insurance coverage]
qualifies for an accommodation with respect to the federal requirement to
cover all Food and Drug Administration-approved contraceptive services for
women, as prescribed by a health care provider, without cost sharing. This
means that your [employer/institution of higher education] will not
contract, arrange, pay, or refer for contraceptive coverage. Instead, [name
of health insurance issuer] will provide separate
payments for contraceptive services that you use, without cost sharing and
at no other cost, for so long as you are enrolled in your [group health
plan/student health insurance coverage]. Your [employer/institution of
higher education] will not administer or fund these payments. If you have
any questions about this notice, contact [contact information for health
(1) If an issuer relies reasonably and in good faith on a representation
by the eligible organization as to its eligibility for the accommodation in
paragraph (c) of this section, and the representation is later determined to
be incorrect, the issuer is considered to comply with any requirement under
Â§ 147.130(a)(1)(iv) to provide contraceptive coverage if the issuer complies
with the obligations under this section applicable to such issuer.
(2) A group health plan is considered to comply with any requirement
under Â§ 147.130(a)(1)(iv) to provide contraceptive coverage if the plan
complies with its obligations under paragraph (c) of this section, without
regard to whether the issuer complies with the obligations under this
section applicable to such issuer.
(f) Application to student health insurance coverage.
The provisions of this section apply to student health insurance coverage
arranged by an eligible organization that is an
in a manner comparable to that in which they apply to group health insurance
coverage provided in connection with a group health plan established or
maintained by an eligible organization that is an employer. In applying this
section in the case of student health insurance coverage, a reference to
"plan participants and beneficiaries" is a reference to student enrollees
and their covered dependents.
Provided by the Protection of Conscience Project
"The New Health
Care Reform Law: How Will it Affect Non-Profit Employers?" The
Arc, National Policy Matters, Issue #9, July 15, 2012.
The term "contraceptives," as it is used in the guidelines (and, thus,
the regulation) includes sterilization and drugs and devices that may
cause the death of a human embryo before implantation ("embryocide"). For an explanation of this
terminology, see Clearing