CurrentMedicarePolicy N/A

Enforcement of Section 1303 (QHP coverage of non-Hyde abortion services)

Guidance for Qualified Health Plan (QHP) issuers and Exchanges on compliance and enforcement of PPACA section 1303 requirements related to coverage, notice, separate enrollee payments, and segregation of funds for non-Hyde abortion services; applies to issuers offering QHPs on individual market Exchanges and to Federal and State Exchanges.

Policy Summary

PayerMedicare

PolicyEnforcement of Section 1303 (QHP coverage of non-Hyde abortion services)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2018

Next Review DateN/A

Key ActionIssuers must collect at least $1 per enrollee per month for non-Hyde abortion coverage, deposit those funds into a segregated account, and not use premium tax credits or CSRs to pay for such services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2014GAO report year

18Issuers surveyed

17Failed separate payment req't

$1Minimum monthly payment

Coverage requirements and enforcement under Section 1303

Requirements for QHP issuers that include coverage of non‑Hyde abortion services:

ALL of the following

Issuers shall not use premium tax credits to pay for non‑Hyde abortion services.
Issuers shall not seek reimbursement for cost‑sharing reductions (CSRs) for non‑Hyde abortion services.
Issuers must provide an annual notice in the Summary of Benefits and Coverage that describes whether non‑Hyde abortion services are covered by the QHP; issuers may also provide itemized monthly invoices or a separate monthly bill showing the separate payment portion for such coverage.
Issuers must determine and collect a separate payment from enrollees for coverage of non‑Hyde abortion services, no less than $1 per enrollee per month; where premiums are paid via payroll deposit, the separate payment must be collected as a separate deposit.

Policy Summary

PayerMedicare

PolicyEnforcement of Section 1303 (QHP coverage of non-Hyde abortion services)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2018

Next Review DateN/A

SourceLink

On This Page

Procedural and payment coding / Separate enrollee payment

Procedural/Coverage codingmixed

No specific CPT/HCPCS/ICD-10 codes specified; policy addresses funding, notice, and accounting requirements for QHP coverage of non-Hyde abortions.

Separate enrollee payment minimum

Minimum separate enrollee payment$1 per enrollee per month

Calculation basisAmount must equal cost determined on an average actuarial basis (but no less than $1/month).

Payroll-paid premiumsIf premiums are paid via payroll deposit, the separate payment must be a separate deposit.

Demonstrating complianceIssuers should provide enrollee notice that part of the premium is a separate payment (e.g., at enrollment, on an itemized monthly invoice, or a separate monthly bill).

Enforcement and issuer responsibilities

Prior Authorization

Section 1303 enforcement: separate payment, notice, and prohibition on federal funds

Issuers must not seek premium tax credits or cost-sharing reduction reimbursements for coverage of non‑Hyde abortion services; they must provide an annual notice in the Summary of Benefits and Coverage stating whether such services are covered; collect a separate enrollee payment of at least $1 per enrollee per month for that coverage; and deposit those collected amounts into a segregated allocation account used only to pay for non‑Hyde abortions. Failure to comply may lead to civil monetary penalties or enforcement action beginning with the 2018 plan year.

Do not seek premium tax credit payments for coverage of non‑Hyde abortion services.
Do not seek reimbursement for cost‑sharing reductions (CSRs) for non‑Hyde abortion services.
Provide an annual notice in the Summary of Benefits and Coverage indicating whether non‑Hyde abortion services are covered.
Charge and collect no less than $1 per enrollee per month specifically for non‑Hyde abortion coverage, and clearly notify enrollees that a portion of the premium is a separate payment for those services (e.g., enrollment notice, itemized monthly invoice, or separate bill).
Deposit all collected separate payments into a separate allocation account used exclusively to cover non‑Hyde abortions.
CMS will enforce these requirements in Federally‑facilitated Exchanges beginning with the 2018 plan year and may seek civil monetary penalties for noncompliance.

Key definitions

Hyde Amendment / Hyde exception

DefinitionExisting appropriations provision prohibiting taxpayer funding for abortion except for pregnancies resulting from rape or incest, or when the woman's life is endangered as certified by a physician.

Relation to section 1303Section 1303 prohibits use of premium tax credits or CSRs to pay for abortions that do not fall under a Hyde exception (non-Hyde abortions).

Policy implicationIssuers offering coverage for non-Hyde abortions must follow notice, separate payment, and fund segregation requirements to avoid use of Federal funds.

Non-Hyde abortion services

DefinitionAbortion services that do not fall under Hyde exceptions; taxpayer funding (premium tax credits or CSRs) may not be used to pay for these services.

Coverage triggersIf a QHP covers non-Hyde abortion services, section 1303 requires issuer notice in the summary of benefits and collection of a separate payment.

Funding restrictionIssuers may not seek premium tax credit payments or reimbursement for CSRs for non-Hyde abortion services.

Separate allocation account

DefinitionA segregated allocation account where issuers must deposit separately collected enrollee payments for non-Hyde abortion coverage and from which only payments for such abortions may be made.

Use restrictionFunds in the separate allocation account must be used exclusively to pay for non-Hyde abortions and cannot be used for any other purpose.

Recordkeeping/demonstrationIssuers must be able to demonstrate compliance, including evidence of deposits into and disbursements from the segregated account.