Moral Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act, 47838-47862 [2017-21852]

Download as PDF 47838 Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations DEPARTMENT OF THE TREASURY Internal Revenue Service 26 CFR Part 54 [TD–9828] RIN 1545–BN91 DEPARTMENT OF LABOR Employee Benefits Security Administration 29 CFR Part 2590 RIN 1210–AB84 DEPARTMENT OF HEALTH AND HUMAN SERVICES 45 CFR Part 147 [CMS–9925–IFC] RIN 0938–AT46 Moral Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act Internal Revenue Service, Department of the Treasury; Employee Benefits Security Administration, Department of Labor; and Centers for Medicare & Medicaid Services, Department of Health and Human Services. ACTION: Interim final rules with request for comments. AGENCY: The United States has a long history of providing conscience protections in the regulation of health care for entities and individuals with objections based on religious beliefs or moral convictions. These interim final rules expand exemptions to protect moral convictions for certain entities and individuals whose health plans are subject to a mandate of contraceptive coverage through guidance issued pursuant to the Patient Protection and Affordable Care Act. These rules do not alter the discretion of the Health Resources and Services Administration, a component of the United States Department of Health and Human Services, to maintain the guidelines requiring contraceptive coverage where no regulatorily recognized objection exists. These rules also provide certain morally objecting entities access to the voluntary ‘‘accommodation’’ process regarding such coverage. These rules do not alter multiple other Federal programs that provide free or subsidized contraceptives for women at risk of unintended pregnancy. DATES: asabaliauskas on DSKBBXCHB2PROD with RULES SUMMARY: VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 Effective date: These interim final rules are effective on October 6, 2017. Comment date: Written comments on these interim final rules are invited and must be received by December 5, 2017. ADDRESSES: Written comments may be submitted to the Department of Health and Human Services as specified below. Any comment that is submitted will be shared with the Department of Labor and the Department of the Treasury, and will also be made available to the public. Warning: Do not include any personally identifiable information (such as name, address, or other contact information) or confidential business information that you do not want publicly disclosed. All comments may be posted on the Internet and can be retrieved by most Internet search engines. No deletions, modifications, or redactions will be made to the comments received, as they are public records. Comments may be submitted anonymously. Comments, identified by ‘‘Preventive Services,’’ may be submitted one of four ways (please choose only one of the ways listed) 1. Electronically. You may submit electronic comments on this regulation to https://www.regulations.gov. Follow the ‘‘Submit a comment’’ instructions. 2. By regular mail. You may mail written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS–9925–IFC, P.O. Box 8016, Baltimore, MD 21244–8016. Please allow sufficient time for mailed comments to be received before the close of the comment period. 3. By express or overnight mail. You may send written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS–9925–IFC, Mail Stop C4–26–05, 7500 Security Boulevard, Baltimore, MD 21244–1850. 4. By hand or courier. Alternatively, you may deliver (by hand or courier) your written comments ONLY to the following addresses prior to the close of the comment period: a. For delivery in Washington, DC— Centers for Medicare & Medicaid Services, Department of Health and Human Services, Room 445–G, Hubert H. Humphrey Building, 200 Independence Avenue SW., Washington, DC 20201. (Because access to the interior of the Hubert H. Humphrey Building is not readily available to persons without Federal government identification, commenters are encouraged to leave PO 00000 Frm 00002 Fmt 4701 Sfmt 4700 their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.) b. For delivery in Baltimore, MD— Centers for Medicare & Medicaid Services, Department of Health and Human Services, 7500 Security Boulevard, Baltimore, MD 21244–1850. If you intend to deliver your comments to the Baltimore address, call telephone number (410) 786–9994 in advance to schedule your arrival with one of our staff members. Comments erroneously mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period. Comments received will be posted without change to www.regulations.gov. FOR FURTHER INFORMATION CONTACT: Jeff Wu (310) 492–4305 or marketreform@cms.hhs.gov for Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services (HHS), Amber Rivers or Matthew Litton, Employee Benefits Security Administration (EBSA), Department of Labor, at (202) 693–8335; Karen Levin, Internal Revenue Service, Department of the Treasury, at (202) 317–5500. Customer Service Information: Individuals interested in obtaining information from the Department of Labor concerning employment-based health coverage laws may call the EBSA Toll-Free Hotline at 1–866–444–EBSA (3272) or visit the Department of Labor’s Web site (www.dol.gov/ebsa). Information from HHS on private health insurance coverage can be found on CMS’s Web site (www.cms.gov/cciio), and information on health care reform can be found at www.HealthCare.gov. SUPPLEMENTARY INFORMATION: I. Background In the context of legal requirements touching on certain sensitive health care issues—including health coverage of contraceptives—Congress has a consistent history of supporting conscience protections for moral convictions alongside protections for religious beliefs, including as part of its efforts to promote access to health services.1 Against that backdrop, 1 See, for example, 42 U.S.C. 300a–7 (protecting individuals and health care entities from being required to provide or assist sterilizations, abortions, or other lawful health services if it would violate their ‘‘religious beliefs or moral convictions’’); 42 U.S.C. 238n (protecting individuals and entities that object to abortion); Consolidated Appropriations Act of 2017, Div. H, Title V, Sec. 507(d) (Departments of Labor, HHS, E:\FR\FM\13OCR3.SGM 13OCR3 Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations asabaliauskas on DSKBBXCHB2PROD with RULES Congress granted the Health Resources and Services Administration (HRSA), a component of the United States Department of Health and Human Services (HHS), discretion under the Patient Protection and Affordable Care Act to specify that certain group health plans and health insurance issuers shall cover, ‘‘with respect to women, such additional preventive care and screenings . . . as provided for in comprehensive guidelines supported by’’ HRSA (the ‘‘Guidelines’’). Public Health Service Act section 2713(a)(4). HRSA exercised that discretion under the last Administration to require health coverage for, among other things, certain contraceptive services,2 while the and Education, and Related Agencies Appropriations Act), Public Law 115–31 (protecting any ‘‘health care professional, a hospital, a provider-sponsored organization, a health maintenance organization, a health insurance plan, or any other kind of health care facility, organization, or plan’’ in objecting to abortion for any reason); Id. at Div. C, Title VIII, Sec. 808 (regarding any requirement of ‘‘the provision of contraceptive coverage by health insurance plans’’ in the District of Columbia, ‘‘it is the intent of Congress that any legislation enacted on such issue should include a ‘conscience clause’ which provides exceptions for religious beliefs and moral convictions.’’); Id. at Div. C, Title VII, Sec. 726(c) (Financial Services and General Government Appropriations Act) (protecting individuals who object to prescribing or providing contraceptives contrary to their ‘‘religious beliefs or moral convictions’’); Id. at Div. I, Title III (Department of State, Foreign Operations, and Related Programs Appropriations Act) (protecting applicants for family planning funds based on their ‘‘religious or conscientious commitment to offer only natural family planning’’); 42 U.S.C. 290bb–36 (prohibiting the statutory section from being construed to require suicide related treatment services for youth where the parents or legal guardians object based on ‘‘religious beliefs or moral objections’’); 42 U.S.C. 1395w–22(j)(3)(B) (protecting against forced counseling or referrals in Medicare Choice, now Medicare Advantage, managed care plans with respect to objections based on ‘‘moral or religious grounds’’); 42 U.S.C. 1396a(w)(3) (ensuring particular Federal law does not infringe on ‘‘conscience’’ as protected in State law concerning advance directives); 42 U.S.C. 1396u–2(b)(3) (protecting against forced counseling or referrals in Medicaid managed care plans with respect to objections based on ‘‘moral or religious grounds’’); 42 U.S.C. 2996f(b) (protecting objection to abortion funding in legal services assistance grants based on ‘‘religious beliefs or moral convictions’’); 42 U.S.C. 14406 (protecting organizations and health providers from being required to inform or counsel persons pertaining to assisted suicide); 42 U.S.C. 18023 (blocking any requirement that issuers or exchanges must cover abortion); 42 U.S.C. 18113 (protecting health plans or health providers from being required to provide an item or service that helps cause assisted suicide); see also 8 U.S.C. 1182(g) (protecting vaccination objections by ‘‘aliens’’ due to ‘‘religious beliefs or moral convictions’’); 18 U.S.C. 3597 (protecting objectors to participation in Federal executions based on ‘‘moral or religious convictions’’); 20 U.S.C. 1688 (prohibiting sex discrimination law to be used to require assistance in abortion for any reason); 22 U.S.C. 7631(d) (protecting entities from being required to use HIV/AIDS funds contrary to their ‘‘religious or moral objection’’). 2 This document’s references to ‘‘contraception,’’ ‘‘contraceptive,’’ ‘‘contraceptive coverage,’’ or VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 administering agencies—the Departments of Health and Human Services, Labor, and the Treasury (collectively, ‘‘the Departments’’),3 exercised both the discretion granted to HHS through HRSA, its component, in PHS Act section 2713(a)(4), and the authority granted to the Departments as administering agencies (26 U.S.C. 9833; 29 U.S.C. 1191c; 42 U.S.C. 300gg–92) to issue regulations to guide HRSA in carrying out that provision. Through rulemaking, including three interim final rules, the Departments exempted and accommodated certain religious objectors, but did not offer an exemption or accommodation to any group possessing non-religious moral objections to providing coverage for some or all contraceptives. Many individuals and entities challenged the contraceptive coverage requirement and regulations (hereinafter, the ‘‘contraceptive Mandate,’’ or the ‘‘Mandate’’) as being inconsistent with various legal protections. These challenges included lawsuits brought by some non-religious organizations with sincerely held moral convictions inconsistent with providing coverage for some or all contraceptive services, and those cases continue to this day. Various public comments were also submitted asking the Departments to protect objections based on moral convictions. The Departments have recently exercised our discretion to reevaluate these exemptions and accommodations. This evaluation includes consideration of various factors, such as: The interests served by the existing Guidelines, regulations, and accommodation process; 4 the extensive litigation; Executive Order 13798, ‘‘Promoting Free Speech and Religious Liberty’’ (May 4, 2017); Congress’ history of providing protections for moral convictions alongside religious beliefs regarding certain health services (including contraception, sterilization, and items or services believed to involve abortion); the discretion afforded under PHS Act section 2713(a)(4); the structure and intent of that provision in the broader context of section 2713 and the Patient Protection and Affordable Care Act; and the history of the regulatory process and comments submitted in various requests for public comments (including in the ‘‘contraceptive services’’ generally includes contraceptives, sterilization, and related patient education and counseling, unless otherwise indicated. 3 Note, however, that in sections under headings listing only two of the three Departments, the term ‘‘Departments’’ generally refers only to the two Departments listed in the heading. 4 In this IFR, we generally use ‘‘accommodation’’ and ‘‘accommodation process’’ interchangeably. PO 00000 Frm 00003 Fmt 4701 Sfmt 4700 47839 Departments’ 2016 Request for Information). Elsewhere in this issue of the Federal Register, the Departments published, contemporaneously with these interim final rules, companion interim final rules expanding exemptions to protect sincerely held religious beliefs in the context of the contraceptive Mandate. In light of these considerations, the Departments issue these interim final rules to better balance the Government’s interest in promoting coverage for contraceptive and sterilization services with the Government’s interests in providing conscience protections for individuals and entities with sincerely held moral convictions in certain health care contexts, and in minimizing burdens imposed by our regulation of the health insurance market. A. The Affordable Care Act Collectively, the Patient Protection and Affordable Care Act (Pub. L. 111– 148), enacted on March 23, 2010, and the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111– 152), enacted on March 30, 2010, are known as the Affordable Care Act. In signing the Affordable Care Act, President Obama issued Executive Order 13535 (March 24, 2010), which declared that, ‘‘[u]nder the Act, longstanding Federal laws to protect conscience (such as the Church Amendment, 42 U.S.C. 300a–7, and the Weldon Amendment, section 508(d)(1) of Pub. L. 111–8) remain intact’’ and that ‘‘[n]umerous executive agencies have a role in ensuring that these restrictions are enforced, including the Department of Health and Human Services (HHS).’’ Those laws protect objections based on moral convictions in addition to religious beliefs. The Affordable Care Act reorganizes, amends, and adds to the provisions of part A of title XXVII of the Public Health Service Act (PHS Act) relating to group health plans and health insurance issuers in the group and individual markets. In addition, the Affordable Care Act adds section 715(a)(1) to the Employee Retirement Income Security Act of 1974 (ERISA) and section 9815(a)(1) to the Internal Revenue Code (Code) to incorporate the provisions of part A of title XXVII of the PHS Act into ERISA and the Code, and thereby make them applicable to certain group health plans regulated under ERISA or the Code. The sections of the PHS Act incorporated into ERISA and the Code are sections 2701 through 2728 of the PHS Act. These interim final rules concern section 2713 of the PHS Act. Where it applies, section 2713(a)(4) of the PHS E:\FR\FM\13OCR3.SGM 13OCR3 asabaliauskas on DSKBBXCHB2PROD with RULES 47840 Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations Act requires coverage without cost sharing for ‘‘such additional’’ women’s preventive care and screenings ‘‘as provided for’’ and ‘‘supported by’’ guidelines developed by HRSA/HHS. The Congress did not specify any particular additional preventive care and screenings with respect to women that HRSA could or should include in its Guidelines, nor did Congress indicate whether the Guidelines should include contraception and sterilization. The Departments have consistently interpreted section 2713(a)(4)’s of the PHS Act grant of authority to include broad discretion to decide the extent to which HRSA will provide for and support the coverage of additional women’s preventive care and screenings in the Guidelines. In turn, the Departments have interpreted that discretion to include the ability to exempt entities from coverage requirements announced in HRSA’s Guidelines. That interpretation is rooted in the text of section 2713(a)(4) of the PHS Act, which allows HRSA to decide the extent to which the Guidelines will provide for and support the coverage of additional women’s preventive care and screenings. Accordingly, the Departments have consistently interpreted section 2713(a)(4) of the PHS Act reference to ‘‘comprehensive guidelines supported by the Health Resources and Services Administration for purposes of this paragraph’’ to grant HRSA authority to develop such Guidelines. And because the text refers to Guidelines ‘‘supported by the Health Resources and Services Administration for purposes of this paragraph,’’ the Departments have consistently interpreted that authority to afford HRSA broad discretion to consider the requirements of coverage and cost-sharing in determining the nature and extent of preventive care and screenings recommended in the guidelines. (76 FR 46623). As the Departments have noted, these Guidelines are different from ‘‘the other guidelines referenced in section 2713(a), which pre-dated the Affordable Care Act and were originally issued for purposes of identifying the non-binding recommended care that providers should provide to patients.’’ Id. Guidelines developed as nonbinding recommendations for care implicate significantly different legal and policy concerns than guidelines developed for a mandatory coverage requirement. To guide HRSA in exercising the discretion afforded to it in section 2713(a)(4), the Departments have previously promulgated regulations defining the scope of permissible religious exemptions and accommodations for VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 such guidelines. (45 CFR 147.131). The interim final rules set forth herein are a necessary and appropriate exercise of the authority delegated to the Departments as administrators of the statutes. (26 U.S.C. 9833; 29 U.S.C. 1191c; 42 U.S.C. 300gg–92). Our interpretation of section 2713(a)(4) of the PHS Act is confirmed by the Affordable Care Act’s statutory structure. The Congress did not intend to require entirely uniform coverage of preventive services. (76 FR 46623). To the contrary, Congress carved out an exemption from section 2713 for grandfathered plans. This exemption is not applicable to many of the other provisions in Title I of the Affordable Care Act—provisions previously referred to by the Departments as providing ‘‘particularly significant protections.’’ (75 FR 34540). Those provisions include: Section 2704, which prohibits preexisting condition exclusions or other discrimination based on health status in group health coverage; section 2708, which prohibits excessive waiting periods (as of January 1, 2014); section 2711, which relates to lifetime limits; section 2712, which prohibits rescissions of health insurance coverage; section 2714, which extends dependent coverage until age 26; and section 2718, which imposes a medical loss ratio on health insurance issuers in the individual and group markets (for insured coverage), or requires them to provide rebates to policyholders. (75 FR 34538, 34540, 34542). Consequently, of the 150 million nonelderly people in America with employer-sponsored health coverage, approximately 25.5 million are estimated to be enrolled in grandfathered plans not subject to section 2713 of the PHS Act.5 As the Supreme Court observed, ‘‘there is no legal requirement that grandfathered plans ever be phased out.’’ Burwell v. Hobby Lobby Stores, Inc., 134 S. Ct. 2751, 2764 n.10 (2014). The Departments’ interpretation of section 2713(a)(4) of the PHS Act to permit HRSA to establish exemptions from the Guidelines, and of the Departments’ own authority as administering agencies to guide HRSA in establishing such exemptions, is also consistent with Executive Order 13535. That order, issued upon the signing of the Affordable Care Act, specified that ‘‘longstanding Federal laws to protect conscience . . . remain intact,’’ including laws that protect religious beliefs and moral convictions from 5 Kaiser Family Foundation & Health Research & Educational Trust, ‘‘Employer Health Benefits, 2017 Annual Survey,’’ available at https://files.kff.org/ attachment/Report-Employer-Health-BenefitsAnnual-Survey-2017. PO 00000 Frm 00004 Fmt 4701 Sfmt 4700 certain requirements in the health care context. Although the text of Executive Order 13535 does not require the expanded exemptions issued in these interim final rules, the expanded exemptions are, as explained below, consistent with longstanding Federal laws to protect conscience regarding certain health matters, and are consistent with the intent that the Affordable Care Act would be implemented in consideration of the protections set forth in those laws. B. The Regulations Concerning Women’s Preventive Services On July 19, 2010, the Departments issued interim final rules implementing section 2713 of the PHS Act (75 FR 41726). Those interim final rules charged HRSA with developing the Guidelines authorized by section 2713(a)(4) of the PHS Act. 1. The Institute of Medicine Report In developing the Guidelines, HRSA relied on an independent report from the Institute of Medicine (IOM, now known as the National Academy of Medicine) on women’s preventive services, issued on July 19, 2011, ‘‘Clinical Preventive Services for Women, Closing the Gaps’’ (IOM 2011). The IOM’s report was funded by the HHS Office of the Assistant Secretary for Planning and Evaluation, pursuant to a funding opportunity that charged the IOM to conduct a review of effective preventive services to ensure women’s health and well-being.6 The IOM made a number of recommendations with respect to women’s preventive services. As relevant here, the IOM recommended that the Guidelines cover the full range of Food and Drug Administration (FDA)-approved contraceptive methods, sterilization procedures, and patient education and counseling for women with reproductive capacity. Because FDA includes in the category of ‘‘contraceptives’’ certain drugs and devices that may not only prevent conception (fertilization), but may also prevent implantation of an embryo,7 the IOM’s recommendation included 6 Because section 2713(a)(4) of the PHS Act specifies that the HRSA Guidelines shall include preventive care and screenings ‘‘with respect to women,’’ the Guidelines exclude services relating to a man’s reproductive capacity, such as vasectomies and condoms. 7 FDA’s guide ‘‘Birth Control: Medicines To Help You,’’ specifies that various approved contraceptives, including Levonorgestrel, Ulipristal Acetate, and IUDs, work mainly by preventing fertilization and ‘‘may also work . . . by preventing attachment (implantation) to the womb (uterus)’’ of a human embryo after fertilization. Available at https://www.fda.gov/forconsumers/byaudience/ forwomen/freepublications/ucm313215.htm. E:\FR\FM\13OCR3.SGM 13OCR3 Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations asabaliauskas on DSKBBXCHB2PROD with RULES several contraceptive methods that many persons and organizations believe are abortifacient—that is, as causing early abortion—and which they conscientiously oppose for that reason distinct from whether they also oppose contraception or sterilization. One of the 16 members of the IOM committee, Dr. Anthony LoSasso, a Professor at the University of Illinois at Chicago School of Public Health, wrote a formal dissenting opinion. He stated that the IOM committee did not have sufficient time to evaluate fully the evidence on whether the use of preventive services beyond those encompassed by section 2713(a)(1) through (3) of the PHS Act leads to lower rates of disability or disease and increased rates of wellbeing, such that the IOM should recommend additional services to be included under Guidelines issued under section 2713(a)(4) of the PHS Act. He further stated that ‘‘the recommendations were made without high quality, systematic evidence of the preventive nature of the services considered,’’ and that ‘‘the committee process for evaluation of the evidence lacked transparency and was largely subject to the preferences of the committee’s composition. Troublingly, the process tended to result in a mix of objective and subjective determinations filtered through a lens of advocacy.’’ He also raised concerns that the committee did not have time to develop a framework for determining whether coverage of any given preventive service leads to a reduction in healthcare expenditure.8 IOM 2011 at 231–32. In its response to Dr. LoSasso, the other 15 committee members stated in part that ‘‘At the first committee meeting, it was agreed that cost considerations were outside the scope of the charge, and that the committee should not attempt to duplicate the disparate review processes used by other bodies, such as the USPSTF, ACIP, and Bright Futures. HHS, with input from this committee, may consider other factors including cost in its development of coverage decisions.’’ 2. HRSA’s 2011 Guidelines and the Departments’ Second Interim Final Rules On August 1, 2011, HRSA released onto its Web site its Guidelines for women’s preventive services, adopting the recommendations of the IOM. https://www.hrsa.gov/ womensguidelines/ The Guidelines 8 The Departments do not relay these dissenting remarks as an endorsement of the remarks, but to describe the history of the Guidelines, which includes this part of the report that IOM provided to HRSA. VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 included coverage for all FDA-approved contraceptives, sterilization procedures, and related patient education and counseling for women with reproductive capacity, as prescribed by a health care provider (hereinafter ‘‘the Mandate’’). In administering this Mandate, on August 1, 2011, the Departments promulgated interim final rules amending our 2010 interim final rules. (76 FR 46621) (2011 interim final rules). The 2011 interim final rules specified that HRSA has the authority to establish exemptions from the contraceptive coverage requirement for certain group health plans established or maintained by certain religious employers and for health insurance coverage provided in connection with such plans.9 The 2011 interim final rules only offered the exemption to a narrow scope of employers, and only if they were religious. As the basis for adopting that limited definition of religious employer, the 2011 interim final rules stated that they relied on the laws of some ‘‘States that exempt certain religious employers from having to comply with State law requirements to cover contraceptive services.’’ (76 FR 46623). Several comments were submitted asking that the exemption include those who object to contraceptive coverage based on nonreligious moral convictions, including pro-life, non-profit advocacy organizations.10 3. The Departments’ Subsequent Rulemaking on the Accommodation and Third Interim Final Rules Final regulations issued on February 10, 2012, adopted the definition of ‘‘religious employer’’ in the 2011 interim final rules without modification (2012 final regulations).11 (77 FR 8725). The exemption did not require exempt employers to file any certification form or comply with any other information collection process. Contemporaneously with the issuance of the 2012 final regulations, HHS— with the agreement of the Department of Labor (DOL) and the Department of the Treasury—issued guidance establishing a temporary safe harbor from enforcement of the contraceptive coverage requirement by the Departments with respect to group 9 The 2011 amended interim final rules were issued and effective on August 1, 2011, and published in the Federal Register on August 3, 2011. (76 FR 46621). 10 See, for example, Americans United for Life (‘‘AUL’’) Comment on CMA–9992–IFC2 at 10 (Nov. 1, 2011), available at https://www.regulations.gov/ #!documentDetail;D=HHS-OS-2011-0023-59496. 11 The 2012 final regulations were published on February 15, 2012 (77 FR 8725). PO 00000 Frm 00005 Fmt 4701 Sfmt 4700 47841 health plans established or maintained by certain nonprofit organizations with religious objections to contraceptive coverage (and the group health insurance coverage provided in connection with such plans).12 The temporary safe harbor did not include nonprofit organizations that had an objection to contraceptives based on moral convictions but not religious beliefs, nor did it include for-profit entities of any kind. The Departments stated that, during the temporary safe harbor, the Departments would engage in rulemaking to achieve ‘‘two goals— providing contraceptive coverage without cost-sharing to individuals who want it and accommodating nonexempted, nonprofit organizations’ religious objections to covering contraceptive services.’’ (77 FR 8727). On March 21, 2012, the Departments published an advance notice of proposed rulemaking (ANPRM) that described possible approaches to achieve those goals with respect to religious nonprofit organizations, and solicited public comments on the same. (77 FR 16501). Following review of the comments on the ANPRM, the Departments published proposed regulations on February 6, 2013 (2013 NPRM) (78 FR 8456). The 2013 NPRM proposed to expand the definition of ‘‘religious employer’’ for purposes of the religious employer exemption. Specifically, it proposed to require only that the religious employer be organized and operate as a nonprofit entity and be referred to in section 6033(a)(3)(A)(i) or (iii) of the Code, eliminating the requirements that a religious employer—(1) have the inculcation of religious values as its purpose; (2) primarily employ persons who share its religious tenets; and (3) primarily serve persons who share its religious tenets. The proposed expanded 12 Guidance on the Temporary Enforcement Safe Harbor for Certain Employers, Group Health Plans, and Group Health Insurance Issuers with Respect to the Requirement to Cover Contraceptive Services Without Cost Sharing Under section 2713 of the Public Health Service Act, Section 715(a)(1) of the Employee Retirement Income Security Act, and Section 9815(a)(1) of the Internal Revenue Code, issued on February 10, 2012, and reissued on August 15, 2012. Available at: https:// www.lb7.uscourts.gov/documents/12cv3932.pdf. The guidance, as reissued on August 15, 2012, clarified, among other things, that plans that took some action before February 10, 2012, to try, without success, to exclude or limit contraceptive coverage were not precluded from eligibility for the safe harbor. The temporary enforcement safe harbor was also available to insured student health insurance coverage arranged by nonprofit institutions of higher education with religious objections to contraceptive coverage that met the conditions set forth in the guidance. See final rule entitled ‘‘Student Health Insurance Coverage’’ published March 21, 2012 (77 FR 16457). E:\FR\FM\13OCR3.SGM 13OCR3 asabaliauskas on DSKBBXCHB2PROD with RULES 47842 Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations definition still encompassed only religious entities. The 2013 NPRM also proposed to create a compliance process, which it called an accommodation, for group health plans established, maintained, or arranged by certain eligible nonprofit organizations that fell outside the houses of worship and integrated auxiliaries covered by section 6033(a)(3)(A)(i) or (iii) of the Code (and, thus, outside of the religious employer exemption). The 2013 NPRM proposed to define such eligible organizations as nonprofit entities that hold themselves out as religious, oppose providing coverage for certain contraceptive items on account of religious objections, and maintain a certification to this effect in their records. The 2013 NPRM stated, without citing a supporting source, that employees of eligible organizations ‘‘may be less likely than’’ employees of exempt houses of worship and integrated auxiliaries to share their employer’s faith and opposition to contraception on religious grounds. (78 FR 8461). The 2013 NPRM therefore proposed that, in the case of an insured group health plan established or maintained by an eligible organization, the health insurance issuer providing group health insurance coverage in connection with the plan would provide contraceptive coverage to plan participants and beneficiaries without cost sharing, premium, fee, or other charge to plan participants or beneficiaries enrolled in the eligible organization’s plan—and without any cost to the eligible organization.13 In the case of a self-insured group health plan established or maintained by an eligible organization, the 2013 NPRM presented potential approaches under which the third party administrator of the plan would provide or arrange for contraceptive coverage to plan participants and beneficiaries. The proposed accommodation process was not to be offered to non-religious nonprofit organizations, nor to any forprofit entities. Public comments again included the request that exemptions encompass objections to contraceptive coverage based on moral convictions and not just based on religious beliefs.14 On August 15, 2012, the Departments extended our temporary safe harbor until the first plan year beginning on or after August 1, 2013. The Departments published final regulations on July 2, 2013 (July 2013 final regulations) (78 FR 39869). The July 2013 final regulations finalized the expansion of the exemption for houses of worship and their integrated auxiliaries. Although some commenters had suggested that the exemption be further expanded, the Departments declined to adopt that approach. The July 2013 regulations stated that, because employees of objecting houses of worship and integrated auxiliaries are relatively likely to oppose contraception, exempting those organizations ‘‘does not undermine the governmental interests furthered by the contraceptive coverage requirement.’’ (78 FR 39874). However, like the 2013 NPRM, the July 2013 regulations assumed that ‘‘[h]ouses of worship and their integrated auxiliaries that object to contraceptive coverage on religious grounds are more likely than other employers to employ people of the same faith who share the same objection’’ to contraceptives. Id. The July 2013 regulation also finalized an accommodation for eligible organizations, which were then defined to include solely organizations that are religious. Under the accommodation, an eligible organization was required to submit a self-certification to its group health insurance issuer or third party administrator, as applicable. Upon receiving that self-certification, the issuer or third party administrator would provide or arrange for payments for the contraceptive services to the plan participants and beneficiaries enrolled in the eligible organization’s plan, without requiring any cost sharing on the part of plan participants and beneficiaries and without cost to the eligible organization. With respect to self-insured plans, the third party administrators (or issuers they contracted with) could receive reimbursements by reducing user fee payments (to Federally facilitated Exchanges) by the amounts paid out for contraceptive services under the accommodation, plus an allowance for certain administrative costs, as long as the HHS Secretary requests and an authorizing exception under OMB Circular No. A–25R is in effect.15 With respect to fully insured group health 13 The NPRM proposed to treat student health insurance coverage arranged by eligible organizations that are institutions of higher education in a similar manner. 14 See,for example, AUL Comment on CMS– 9968–P at 5 (Apr. 8, 2013), available at https:// www.regulations.gov/#!documentDetail;D=CMS2012-0031-79115. 15 See also 45 CFR 156.50. Under the regulations, if the third party administrator does not participate in a Federally-facilitated Exchange as an issuer, it is permitted to contract with an insurer which does so participate, in order to obtain such reimbursement. The total contraceptive user fee adjustment for the 2015 benefit year was $33 million. VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 PO 00000 Frm 00006 Fmt 4701 Sfmt 4700 plans, the issuer was expected to bear the cost of such payments,16 and HHS intended to clarify in guidance that the issuer could treat those payments as an adjustment to claims costs for purposes of medical loss ratio and risk corridor program calculations. The Departments extended the temporary safe harbor again on June 20, 2013, to encompass plan years beginning on or after August 1, 2013, and before January 1, 2014. 4. Litigation Over the Mandate and the Accommodation Process During the period when the Departments were publishing and modifying our regulations, organizations and individuals filed dozens of lawsuits challenging the Mandate. Plaintiffs included religious nonprofit organizations, businesses run by religious families, individuals, and others, including several non-religious organizations that opposed coverage of certain contraceptives under the Mandate on the basis of non-religious moral convictions. Religious for-profit entities won various court decisions leading to the Supreme Court’s ruling in Burwell v. Hobby Lobby Stores, Inc. 134 S. Ct. 2751 (2014). The Supreme Court ruled against the Departments and held that, under the Religious Freedom Restoration Act of 1993 (RFRA), the Mandate could not be applied to the closely held for-profit corporations before the Court because their owners had religious objections to providing such coverage.17 On August 27, 2014, the Departments simultaneously issued a third set of interim final rules (August 2014 interim final rules) (79 FR 51092), and a notice of proposed rulemaking (August 2014 proposed rules) (79 FR 51118). The August 2014 interim final rules changed the accommodation process so that it could be initiated either by selfcertification using EBSA Form 700 or through a notice informing the Secretary of HHS that an eligible organization had religious objections to coverage of all or a subset of contraceptive services (79 FR 51092). In response to Hobby Lobby, the August 2014 proposed rules extended the accommodation process to closely held for-profit entities with religious objections to contraceptive coverage, by including them in the definition of eligible organizations (79 FR 51118). Neither the August 2014 interim final rules nor the August 2014 proposed rules extended the exemption; neither added a certification requirement for 16 ‘‘[P]roviding payments for contraceptive services is cost neutral for issuers.’’ (78 FR 39877). 17 The Supreme Court did not decide whether RFRA would apply to publicly traded for-profit corporations. See 134 S. Ct. at 2774. E:\FR\FM\13OCR3.SGM 13OCR3 asabaliauskas on DSKBBXCHB2PROD with RULES Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations exempt entities; and neither encompassed objections based on nonreligious moral convictions. On July 14, 2015, the Departments finalized both the August 2014 interim final rules and the August 2014 proposed rules in a set of final regulations (the July 2015 final regulations) (80 FR 41318). (The July 2015 final regulations also encompassed issues related to other preventive services coverage.) The July 2015 final regulations allowed eligible organizations to submit a notice to HHS as an alternative to submitting the EBSA Form 700, but specified that such notice must include the eligible organization’s name and an expression of its religious objection, along with the plan name, plan type, and name and contact information for any of the plan’s third party administrators or health insurance issuers. The Departments indicated that such information represents the minimum information necessary for us to administer the accommodation process. Meanwhile, a second series of legal challenges were filed by religious nonprofit organizations that stated the accommodation impermissibly burdened their religious beliefs because it utilized their health plans to provide services to which they objected on religious grounds, and it required them to submit a self-certification or notice. On November 6, 2015, the U.S. Supreme Court granted certiorari in seven similar cases under the title of a filing from the Third Circuit, Zubik v. Burwell. On May 16, 2016, the Supreme Court issued a per curiam opinion in Zubik, vacating the judgments of the Courts of Appeals—most of which had ruled in the Departments’ favor—and remanding the cases ‘‘in light of the substantial clarification and refinement in the positions of the parties’’ that had been filed in supplemental briefs. 136 S. Ct. 1557, 1560 (2016). The Court stated that it anticipated that, on remand, the Courts of Appeals would ‘‘allow the parties sufficient time to resolve any outstanding issues between them.’’ Id. The Court also specified that ‘‘the Government may not impose taxes or penalties on petitioners for failure to provide the relevant notice’’ while the cases remained pending. Id. at 1561. After remand, as indicated by the Departments in court filings, meetings were held between attorneys for the Government and for the plaintiffs in those cases. The Departments also issued a Request for Information (‘‘RFI’’) on July 26, 2016, seeking public comment on options for modifying the accommodation process in light of the supplemental briefing in Zubik and the VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 Supreme Court’s remand order. (81 FR 47741). Public comments were submitted in response to the RFI, during a comment period that closed on September 20, 2016. Those comments included the request that the exemption be expanded to include those who oppose the Mandate for either religious ‘‘or moral’’ reasons, consistent with various state laws (such as in Connecticut or Missouri) that protect objections to contraceptive coverage based on moral convictions.18 Beginning in 2015, lawsuits challenging the Mandate were also filed by various non-religious organizations with moral objections to contraceptive coverage. These organizations asserted that they believe some methods classified by FDA as contraceptives may have an abortifacient effect and therefore, in their view, are morally equivalent to abortion. These organizations have neither received an exemption from the Mandate nor do they qualify for the accommodation. For example, the organization that since 1974 has sponsored the annual March for Life in Washington, DC (March for Life), filed a complaint claiming that the Mandate violated the equal protection component of the Due Process Clause of the Fifth Amendment, and was arbitrary and capricious under the Administrative Procedure Act (APA). Citing, for example, (77 FR 8727), March for Life argued that the Departments’ stated interests behind the Mandate were only advanced among women who ‘‘want’’ the coverage so as to prevent ‘‘unintended’’ pregnancy. March for Life contended that because it only hires employees who publicly advocate against abortion, including what they regard as abortifacient contraceptive items, the Departments’ interests were not rationally advanced by imposing the Mandate upon it and its employees. Accordingly, March for Life contended that applying the Mandate to it (and other similarly situated organizations) lacked a rational basis and therefore doing so was arbitrary and capricious in violation of the APA. March for Life further contended that because the Departments concluded the government’s interests were not undermined by exempting houses of worship and integrated auxiliaries (based on our assumption that such entities are relatively more likely than other religious nonprofits to have employees that share their views against 18 See, for example, https://www.regulations.gov/ document?D=CMS-2016-0123-54142; see also https://www.regulations.gov/document?D=CMS2016-0123-54218 and https://www.regulations.gov/ document?D=CMS-2016-0123-46220. PO 00000 Frm 00007 Fmt 4701 Sfmt 4700 47843 contraception), applying the Mandate to March for Life or similar organizations that definitively hire only employees who oppose certain contraceptives lacked a rational basis and therefore violated their right of equal protection under the Due Process Clause. March for Life’s employees, who stated they were personally religious (although personal religiosity was not a condition of their employment), also sued as co-plaintiffs. They contended that the Mandate violates their rights under RFRA by making it impossible for them to obtain health insurance consistent with their religious beliefs, either from the plan March for Life wanted to offer them, or in the individual market, because the Departments offered no exemptions in either circumstance. Another nonreligious nonprofit organization that opposed the Mandate’s requirement to provide certain contraceptive coverage on moral grounds also filed a lawsuit challenging the Mandate. Real Alternatives, Inc. v. Burwell, 150 F. Supp. 3d 419 (M.D. Pa. 2015). Challenges by non-religious nonprofit organizations led to conflicting opinions among the Federal courts. A district court agreed with the March for Life plaintiffs on the organization’s equal protection claim and the employees’ RFRA claims (not specifically ruling on the APA claim), and issued a permanent injunction against the Departments that is still in place. March for Life v. Burwell, 128 F. Supp. 3d 116 (D.D.C. 2015). The appeal in March for Life is pending and has been stayed since early 2016. In another case, Federal district and appellate courts in Pennsylvania disagreed with the reasoning from March for Life and ruled against claims brought by a similarly non-religious nonprofit employer and its religious employees. Real Alternatives, 150 F. Supp. 3d 419, affirmed by 867 F.3d 338 (3d Cir. 2017). One member of the appeals court panel in Real Alternatives dissented in part, stating he would have ruled in favor of the individual employee plaintiffs under RFRA. Id. at *18. On December 20, 2016, HRSA updated the Guidelines via its Web site, https://www.hrsa.gov/ womensguidelines2016/. HRSA announced that, for plans subject to the Guidelines, the updated Guidelines would apply to the first plan year beginning after December 20, 2017. Among other changes, the updated Guidelines specified that the required contraceptive coverage includes followup care (for example, management and evaluation, as well as changes to, and removal or discontinuation of, the E:\FR\FM\13OCR3.SGM 13OCR3 47844 Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations asabaliauskas on DSKBBXCHB2PROD with RULES contraceptive method). They also specified, for the first time, that coverage should include instruction in fertility awareness-based methods for women desiring an alternative method of family planning. HRSA stated that, with the input of a committee operating under a cooperative agreement, HRSA would review and periodically update the Women’s Preventive Services’ Guidelines. The updated Guidelines did not alter the religious employer exemption or accommodation process, nor did they extend the exemption or accommodation process to organizations or individuals that oppose certain forms of contraception (and coverage thereof) on moral grounds. On January 9, 2017, the Departments issued a document entitled, ‘‘FAQs About Affordable Care Act Implementation Part 36.’’ 19 The FAQ stated that, after reviewing comments submitted in response to the 2016 RFI and considering various options, the Departments could not find a way at that time to amend the accommodation so as to satisfy objecting eligible organizations while pursuing the Departments’ policy goals. The Departments did not adopt the approach requested by certain commenters, cited above, to expand the exemption to include those who oppose the Mandate for moral reasons. On May 4, 2017, the President issued Executive Order 13798, ‘‘Promoting Free Speech and Religious Liberty.’’ Section 3 of that order declares, ‘‘Conscience Protections with Respect to PreventiveCare Mandate. The Secretary of the Treasury, the Secretary of Labor, and the Secretary of Health and Human Services shall consider issuing amended regulations, consistent with applicable law, to address conscience-based objections to the preventive-care mandate promulgated under section 300gg–13(a)(4) of title 42, United States Code.’’ II. Expanded Exemptions and Accommodations for Moral Convictions These interim final rules incorporate conscience protections into the contraceptive Mandate. They do so in part to bring the Mandate into conformity with Congress’s long history of providing or supporting conscience protections in the regulation of sensitive health-care issues, cognizant that Congress neither required the Departments to impose the Mandate nor prohibited them from providing 19 Available at: https://www.dol.gov/sites/default/ files/ebsa/about-ebsa/our-activities/resource-center/ faqs/aca-part-36.pdf and https://www.cms.gov/ CCIIO/Resources/Fact-Sheets-and-FAQs/ Downloads/ACA-FAQs-Part36_1-9-17-Final.pdf. VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 conscience protections if they did so. Specifically, these interim final rules expand exemptions to the contraceptive Mandate to protect certain entities and individuals that object to coverage of some or all contraceptives based on sincerely held moral convictions but not religious beliefs, and these rules make those exempt entities eligible for accommodations concerning the same Mandate. A. Discretion To Provide Exemptions Under Section 2713(a)(4) of the PHS Act and the Affordable Care Act The Departments have consistently interpreted HRSA’s authority under section 2713(a)(4) of the PHS Act to allow for exemptions and accommodations to the contraceptive Mandate for certain objecting organizations. Section 2713(a)(4) of the PHS Act gives HRSA discretion to decide whether and in what circumstances it will support Guidelines providing for additional women’s preventive services coverage. That authority includes HRSA’s discretion to include contraceptive coverage in those Guidelines, but the Congress did not specify whether or to what extent HRSA should do so. Therefore, section 2713(a)(4) of the PHS Act allows HRSA to not apply the Guidelines to certain plans of entities or individuals with religious or moral objections to contraceptive coverage, and by not applying the Guidelines to them, to exempt those entities from the Mandate. These rules are a necessary and appropriate exercise of the authority of HHS, of which HRSA is a component, and of the authority delegated to the Departments collectively as administrators of the statutes. (26 U.S.C. 9833; 29 U.S.C. 1191c; 42 U.S.C. 300gg–92). Our protection of conscience in these interim final rules is consistent with the structure and intent of the Affordable Care Act. The Affordable Care Act refrains from applying section 2713(a)(4) of the PHS Act to millions of women in grandfathered plans. In contrast, we anticipate that conscientious exemptions to the Mandate will impact a much smaller number of women. President Obama emphasized in signing the Affordable Care Act that ‘‘longstanding Federal law to protect conscience’’—laws with conscience protections encompassing moral (as well as religious) objections— specifically including (but not limited to) the Church Amendments (42 U.S.C. 300a–7), ‘‘remain intact.’’ Executive Order 13535. Nothing in the Affordable Care Act suggests Congress’ intent to deviate from its long history, discussed PO 00000 Frm 00008 Fmt 4701 Sfmt 4700 below, of protecting moral convictions in particular health care contexts. The Departments’ implementation of section 2713(a)(4) of the PHS Act with respect to contraceptive coverage is a context similar to those encompassed by many other health care conscience protections provided or supported by Congress. This Mandate concerns contraception and sterilization services, including items believed by some citizens to have an abortifacient effect—that is, to cause the destruction of a human life at an early stage of embryonic development. These are highly sensitive issues in the history of health care regulation and have long been shielded by conscience protections in the laws of the United States. B. Congress’ History of Providing Exemptions for Moral Convictions In deciding the most appropriate way to exercise our discretion in this context, the Departments draw on nearly 50 years of statutory law and Supreme Court precedent discussing the protection of moral convictions in certain circumstances—particularly in the context of health care and health insurance coverage. Congress very recently expressed its intent on the matter of Government-mandated contraceptive coverage when it declared, with respect to the possibility that the District of Columbia would require contraceptive coverage, that ‘‘it is the intent of Congress that any legislation enacted on such issue should include a ‘conscience clause’ which provides exceptions for religious beliefs and moral convictions.’’ Consolidated Appropriations Act of 2017, Division C, Title VIII, Sec. 808, Public Law 115–31 (May 5, 2017). In support of these interim final rules, we consider it significant that Congress’ most recent statement on the prospect of Government mandated contraceptive coverage specifically intends that a conscience clause be included to protect moral convictions. The many statutes listed in Section IBackground under footnote 1, which show Congress’ consistent protection of moral convictions alongside religious beliefs in the Federal regulation of health care, includes laws such as the 1973 Church Amendments, which we discuss at length below, all the way to the 2017 Consolidated Appropriations Act discussed above. Notably among those laws, the Congress has enacted protections for health plans or health care organizations in Medicaid or Medicare Advantage to object ‘‘on moral or religious grounds’’ to providing coverage of certain counseling or referral services. 42 U.S.C. 1395w– E:\FR\FM\13OCR3.SGM 13OCR3 Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations asabaliauskas on DSKBBXCHB2PROD with RULES 22(j)(3)(B) (protecting against forced counseling or referrals in Medicare Choice, now Medicare Advantage, managed care plans with respect to objections based on ‘‘moral or religious grounds’’); 42 U.S.C. 1396u–2(b)(3) (protecting against forced counseling or referrals in Medicaid managed care plans with respect to objections based on ‘‘moral or religious grounds’’). The Congress has also protected individuals who object to prescribing or providing contraceptives contrary to their ‘‘religious beliefs or moral convictions.’’ Consolidated Appropriations Act of 2017, Division C, Title VII, Sec. 726(c) (Financial Services and General Government Appropriations Act), Public Law 115–31. C. The Church Amendments’ Protection of Moral Convictions One of the most important and wellestablished federal statutes respecting conscientious objections in specific health care contexts was enacted over the course of several years beginning in 1973, initially as a response to court decisions raising the prospect that entities or individuals might be required to facilitate abortions or sterilizations. These sections of the United States Code are known as the Church Amendments, named after their primary sponsor Senator Frank Church (D–Idaho). The Church Amendments specifically provide conscience protections based on sincerely held moral convictions. Among other things, the amendments protect the recipients of certain Federal health funds from being required to perform, assist, or make their facilities available for abortions or sterilizations if they object ‘‘on the basis of religious beliefs or moral convictions,’’ and they prohibit recipients of certain Federal health funds from discriminating against any personnel ‘‘because he refused to perform or assist in the performance of such a procedure or abortion on the grounds that his performance or assistance in the performance of the procedure or abortion would be contrary to his religious beliefs or moral convictions’’ (42 U.S.C. 300a–7(b), (c)(1)). Later additions to the Church Amendments protect other conscientious objections, including some objections on the basis of moral conviction to ‘‘any lawful health service,’’ or to ‘‘any part of a health service program.’’ (42 U.S.C. 300a–7(c)(2), (d)). In contexts covered by those sections of the Church Amendments, the provision or coverage of certain contraceptives, depending on the circumstances, could constitute ‘‘any lawful health service’’ or a ‘‘part of a health service program.’’ As such, the VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 protections provided by those provisions of the Church Amendments would encompass moral objections to contraceptive services or coverage. The Church Amendments were enacted in the wake of the Supreme Court’s decision in Roe v. Wade, 410 U.S. 113 (1973). Even though the Court in Roe required abortion to be legal in certain circumstances, Roe did not include, within that right, the requirement that other citizens must facilitate its exercise. Thus, Roe favorably quoted the proceedings of the American Medical Association House of Delegates 220 (June 1970), which declared ‘‘Neither physician, hospital, nor hospital personnel shall be required to perform any act violative of personally-held moral principles.’’ 410 U.S. at 144 & n.38 (1973). Likewise in Roe’s companion case, Doe v. Bolton, the Court observed that, under State law, ‘‘a physician or any other employee has the right to refrain, for moral or religious reasons, from participating in the abortion procedure.’’ 410 U.S. 179, 197–98 (1973). The Court said that these conscience provisions ‘‘obviously . . . afford appropriate protection.’’ Id. at 198. As an Arizona court later put it, ‘‘a woman’s right to an abortion or to contraception does not compel a private person or entity to facilitate either.’’ Planned Parenthood Ariz., Inc. v. Am. Ass’n of Pro-Life Obstetricians & Gynecologists, 257 P.3d 181, 196 (Ariz. Ct. App. 2011). The Congressional Record contains relevant discussions that occurred when the protection for moral convictions was first proposed in the Church Amendments. When Senator Church introduced the first of those amendments in 1973, he cited not only Roe v. Wade but also an instance where a Federal court had ordered a Catholic hospital to perform sterilizations. 119 Congr. Rec. S5717–18 (Mar. 27, 1973). After his opening remarks, Senator Adlai Stevenson III (D–IL) rose to ask that the amendment be changed to specify that it also protects objections to abortion and sterilization based on moral convictions on the same terms as it protects objections based on religious beliefs. The following excerpt of the Congressional Record is particularly relevant to this discussion: Mr. STEVENSON. Mr. President, first of all I commend the Senator from Idaho for bringing this matter to the attention of the Senate. I ask the Senator a question. One need not be of the Catholic faith or any other religious faith to feel deeply about the worth of human life. The protections afforded by this amendment run only to those whose religious beliefs would be offended by the necessity of performing or PO 00000 Frm 00009 Fmt 4701 Sfmt 4700 47845 participating in the performance of certain medical procedures; others, for moral reasons, not necessarily for any religious belief, can feel equally as strong about human life. They too can revere human life. As mortals, we cannot with confidence say, when life begins. But whether it is life, or the potentiality of life, our moral convictions as well as our religious beliefs, warrant protection from this intrusion by the Government. Would, therefore, the Senator include moral convictions? Would the Senator consider an amendment on page 2, line 18 which would add to religious beliefs, the words ‘‘or moral’’? Mr. CHURCH. I would suggest to the Senator that perhaps his objective could be more clearly stated if the words ‘‘or moral conviction’’ were added after ‘‘religious belief.’’ I think that the Supreme Court in considering the protection we give religious beliefs has given comparable treatment to deeply held moral convictions. I would not be averse to amending the language of the amendment in such a manner. It is consistent with the general purpose. I see no reason why a deeply held moral conviction ought not be given the same treatment as a religious belief. Mr. STEVENSON. The Senator’s suggestion is well taken. I thank him. 119 Congr. Rec. S5717–18. As the debate proceeded, Senator Church went on to quote Doe v. Bolton’s reliance on a Georgia statute that stated ‘‘a physician or any other employee has the right to refrain, for moral or religious reasons, from participating in the abortion procedure.’’ 119 Congr. Rec. at S5722 (quoting 410 U.S. at 197–98). Senator Church added, ‘‘I see no reason why the amendment ought not also to cover doctors and nurses who have strong moral convictions against these particular operations.’’ Id. Considering the scope of the protections, Senator Gaylord Nelson (D–WI) asked whether, ‘‘if a hospital board, or whatever the ruling agency for the hospital was, a governing agency or otherwise, just capriciously—and not upon the religious or moral questions at all— simply said, ‘We are not going to bother with this kind of procedure in this hospital,’ would the pending amendment permit that?’’ 119 Congr. Rec. at S5723. Senator Church responded that the amendment would not encompass such an objection. Id. Senator James L. Buckley (C–NY), speaking in support of the amendment, added the following perspective: Mr. BUCKLEY. Mr. President, I compliment the Senator from Idaho for proposing this most important and timely amendment. It is timely in the first instance because the attempt has already been made to compel the performance of abortion and sterilization operations on the part of those who are fundamentally opposed to such procedures. And it is timely also because the E:\FR\FM\13OCR3.SGM 13OCR3 47846 Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations asabaliauskas on DSKBBXCHB2PROD with RULES recent Supreme Court decisions will likely unleash a series of court actions across the United States to try to impose the personal preferences of the majority of the Supreme Court on the totality of the Nation. I believe it is ironic that we should have this debate at all. Who would have predicted a year or two ago that we would have to guard against even the possibility that someone might be free [sic] 20 to participate in an abortion or sterilization against his will? Such an idea is repugnant to our political tradition. This is a Nation which has always been concerned with the right of conscience. It is the right of conscience which is protected in our draft laws. It is the right of conscience which the Supreme Court has quite properly expanded not only to embrace those young men who, because of the tenets of a particular faith, believe they cannot kill another man, but also those who because of their own deepest moral convictions are so persuaded. I am delighted that the Senator from Idaho has amended his language to include the words ‘‘moral conviction,’’ because, of course, we know that this is not a matter of concern to any one religious body to the exclusion of all others, or even to men who believe in a God to the exclusion of all others. It has been a traditional concept in our society from the earliest times that the right of conscience, like the paramount right to life from which it is derived, is sacred. 119 Congr. Rec. at S5723. In support of the same protections when they were debated in the U.S. House, Representative Margaret Heckler (R–MA) 21 likewise observed that ‘‘the right of conscience has long been recognized in the parallel situation in which the individual’s right to conscientious objector status in our selective service system has been protected’’ and ‘‘expanded by the Supreme Court to include moral conviction as well as formal religious belief.’’ 119 Congr. Rec. H4148–49 (May 31, 1973). Rep. Heckler added, ‘‘We are concerned here only with the right of moral conscience, which has always been a part of our national tradition.’’ Id. at 4149. These first of the Church Amendments, codified at 42 U.S.C. 300a–7(b) and (c)(1), passed the House 372–1, and were approved by the Senate 94–0. 119 Congr. Rec. at H4149; 119 Congr. Rec. S10405 (June 5, 1973). The subsequently adopted provisions that comprise the Church Amendments similarly extend protection to those organizations and individuals who object to the provision of certain services on the basis of their moral convictions. And, as noted above, subsequent statutes add protections for 20 The Senator might have meant ‘‘[forced] . . . against his will.’’ 21 Rep. Heckler later served as the 15th Secretary of HHS, from March 1983 to December 1985. VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 moral objections in many other situations. These include, for example: • Protections for individuals and entities that object to abortion: See 42 U.S.C. 238n; 42 U.S.C. 18023; 42 U.S.C. 2996f(b); and Consolidated Appropriations Act of 2017, Div. H, Title V, Sec. 507(d), Public Law 115–31; • Protections for entities and individuals that object to providing or covering contraceptives: See id. at Div. C, Title VIII, Sec. 808; id. at Div. C, Title VII, Sec. 726(c) (Financial Services and General Government Appropriations Act); and id. at Div. I, Title III; and • Protections for entities and individuals that object to performing, assisting, counseling, or referring as pertains to suicide, assisted suicide, or advance directives: See 42 U.S.C. 290bb–36; 42 U.S.C. 14406; 42 U.S.C. 18113; and 42 U.S.C. 1396a(w)(3). The Departments believe that the intent behind Congress’ protection of moral convictions in certain health care contexts, especially to protect entities and individuals from governmental coercion, supports our decision in these interim final rules to protect sincerely held moral convictions from governmental compulsion threatened by the contraceptive Mandate. D. Court Precedents Relevant to These Expanded Exemptions The legislative history of the protection of moral convictions in the first Church Amendments shows that Members of Congress saw the protection as being consistent with Supreme Court decisions. Not only did Senator Church cite the abortion case Doe v. Bolton as a parallel instance of conscience protection, but he also spoke of the Supreme Court generally giving ‘‘comparable treatment to deeply held moral convictions.’’ Both Senator Buckley and Rep. Heckler specifically cited the Supreme Court’s protection of moral convictions in laws governing military service. Those legislators appear to have been referencing cases such as Welsh v. United States, 398 U.S. 333 (1970), which the Supreme Court decided just 3 years earlier. Welsh involved what is perhaps the Government’s paradigmatic compelling interest—the need to defend the nation by military force. The Court stated that, where the Government protects objections to military service based on ‘‘religious training and belief,’’ that protection would also extend to avowedly non-religious objections to war held with the same moral strength. Id. at 343. The Court declared, ‘‘[i]f an individual deeply and sincerely holds beliefs that are purely ethical or moral in source and content but that PO 00000 Frm 00010 Fmt 4701 Sfmt 4700 nevertheless impose upon him a duty of conscience to refrain from participating in any war at any time, those beliefs certainly occupy in the life of that individual ‘a place parallel to that filled by . . . God’ in traditionally religious persons. Because his beliefs function as a religion in his life, such an individual is as much entitled to a ‘religious’ conscientious objector exemption . . . as is someone who derives his conscientious opposition to war from traditional religious convictions.’’ The Departments look to the description of moral convictions in Welsh to help explain the scope of the protection provided in these interim final rules. Neither these interim final rules, nor the Church Amendments or other Federal health care conscience statutes, define ‘‘moral convictions’’ (nor do they define ‘‘religious beliefs’’). But in issuing these interim final rules, we seek to use the same background understanding of that term that is reflected in the Congressional Record in 1973, in which legislators referenced cases such as Welsh to support the addition of language protecting moral convictions. In protecting moral convictions parallel to religious beliefs, Welsh describes moral convictions warranting such protection as ones: (1) That the ‘‘individual deeply and sincerely holds’’; (2) ‘‘that are purely ethical or moral in source and content; (3) ‘‘but that nevertheless impose upon him a duty’’; (4) and that ‘‘certainly occupy in the life of that individual a place parallel to that filled by . . . God’ in traditionally religious persons,’’ such that one could say ‘‘his beliefs function as a religion in his life.’’ (398 U.S. at 339–40). As recited above, Senators Church and Nelson agreed that protections for such moral convictions would not encompass an objection that an individual or entity raises ‘‘capriciously.’’ Instead, along with the requirement that protected moral convictions must be ‘‘sincerely held,’’ this understanding cabins the protection of moral convictions in contexts where they occupy a place parallel to that filled by sincerely held religious beliefs in religious persons and organizations. In the context of this particular Mandate, it is also worth noting that, in Hobby Lobby, Justice Ginsburg (joined, in this part of the opinion, by Justices Breyer, Kagan, and Sotomayor), cited Justice Harlan’s opinion in Welsh, 398 U.S. at 357–58, in support of her statement that ‘‘[s]eparating moral convictions from religious beliefs would be of questionable legitimacy.’’ 134 S. Ct. at 2789 n.6. In quoting this passage, the Departments do not mean to suggest that all laws protecting only religious E:\FR\FM\13OCR3.SGM 13OCR3 Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations participation or attendance contrary to medical ethics.’’ (28 CFR 26.5).23 Forty-five States have health care conscience protections covering objections to abortion, and several of those also cover sterilization or contraception.24 Most of those State laws protect objections based on ‘‘moral,’’ ‘‘ethical,’’ or ‘‘conscientious’’ grounds in addition to ‘‘religious’’ grounds. Particularly in the case of abortion, some Federal and State conscience laws do not require any specified motive for the objection. (42 U.S.C. 238n). These various statutes and regulations reflect an important governmental interest in protecting moral convictions in appropriate health contexts. The contraceptive Mandate implicates that governmental interest. Many persons and entities object to this E. Conscience Protections in Regulations Mandate in part because they consider and Among the States some forms of FDA-approved contraceptives to be abortifacients and The tradition of protecting moral convictions in certain health contexts is morally equivalent to abortion due to not limited to Congress. Multiple federal the possibility that some of the items may have the effect of preventing the regulations protect objections based on implantation of a human embryo after moral convictions in such contexts.22 fertilization. Based on our knowledge Other federal regulations have also from the litigation, all of the current applied the principle of respecting litigants asserting purely non-religious moral convictions alongside religious objections share this view, and most of beliefs when they have determined that the religious litigants do as well. The it is appropriate to do so in particular Supreme Court, in describing family circumstances. The Equal Employment business owners with religious Opportunity Commission has consistently protected ‘‘moral or ethical objections, explained that ‘‘[t]he owners of the businesses have religious beliefs as to what is right and wrong objections to abortion, and according to which are sincerely held with the their religious beliefs the four strength of traditional religious views’’ contraceptive methods at issue are alongside religious views under the ‘‘standard [] developed in United States abortifacients. If the owners comply with the HHS mandate, they believe v. Seeger, 380 U.S. 163 (1965) and they will be facilitating abortions.’’ [Welsh].’’ (29 CFR 1605.1). The Hobby Lobby, 134 S. Ct. at 2751. Department of Justice has declared that, Outside of the context of abortion, as in cases of capital punishment, no cited above, Congress has also provided officer or employee may be required to health care conscience protections attend or participate if doing so ‘‘is pertaining to sterilization, contrary to the moral or religious contraception, and other health care convictions of the officer or employee, services and practices. or if the employee is a medical F. Founding Principles professional who considers such The Departments also look to 22 See, for example, 42 CFR 422.206 (declaring guidance from the broader history of that the general Medicare Advantage rule ‘‘does not asabaliauskas on DSKBBXCHB2PROD with RULES beliefs constitute an illegitimate ‘‘separat[ion]’’ of moral convictions, nor do we assert that moral convictions must always be protected alongside religious beliefs; we also do not agree with Justice Harlan that distinguishing between religious and moral objections would violate the Establishment Clause. Instead, the Departments believe that, in the specific health care context implicated here, providing respect for moral convictions parallel to the respect afforded to religious beliefs is appropriate, draws from long-standing Federal Government practice, and shares common ground with Congress’ intent in the Church Amendments and in later Federal conscience statutes that provide protections for moral convictions alongside religious beliefs in other health care contexts. require the MA plan to cover, furnish, or pay for a particular counseling or referral service if the MA organization that offers the plan—(1) Objects to the provision of that service on moral or religious grounds.’’); 42 CFR 438.102 (declaring that information requirements do not apply ‘‘if the MCO, PIHP, or PAHP objects to the service on moral or religious grounds’’); 48 CFR 1609.7001 (‘‘health plan sponsoring organizations are not required to discuss treatment options that they would not ordinarily discuss in their customary course of practice because such options are inconsistent with their professional judgment or ethical, moral or religious beliefs.’’); 48 CFR 352.270–9 (‘‘Non-Discrimination for Conscience’’ clause for organizations receiving HIV or Malaria relief funds). VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 23 See also 18 CFR 214.11 (where a law enforcement agency (LEA) seeks assistance in the investigation or prosecution of trafficking of persons, the reasonableness of the LEA’s request will depend in part on ‘‘[c]ultural, religious, or moral objections to the request’’). 24 According to the Guttmacher Institute, 45 states have conscience statutes pertaining to abortion (43 of which cover institutions), 18 have conscience statutes pertaining to sterilization (16 of which cover institutions), and 12 have conscience statutes pertaining to contraception (8 of which cover institutions). ‘‘Refusing to Provide Health Services’’ (June 1, 2017), available at https:// www.guttmacher.org/state-policy/explore/refusingprovide-health-services. PO 00000 Frm 00011 Fmt 4701 Sfmt 4700 47847 respect for conscience in the laws and founding principles of the United States. Members of Congress specifically relied on the American tradition of respect for conscience when they decided to protect moral convictions in health care. As quoted above, in supporting protecting conscience based on non-religious moral convictions, Senator Buckley declared ‘‘[i]t has been a traditional concept in our society from the earliest times that the right of conscience, like the paramount right to life from which it is derived, is sacred.’’ Rep. Heckler similarly stated that ‘‘the right of moral conscience . . . has always been a part of our national tradition.’’ This tradition is reflected, for example, in a letter President George Washington wrote saying that ‘‘[t]he Citizens of the United States of America have a right to applaud themselves for having given to mankind examples of an enlarged and liberal policy: A policy worthy of imitation. All possess alike liberty of conscience and immunities of citizenship.’’ 25 Thomas Jefferson similarly declared that ‘‘[n]o provision in our Constitution ought to be dearer to man than that which protects the rights of conscience against the enterprises of the civil authority.’’ 26 Although these statements by Presidents Washington and Jefferson were spoken to religious congregations, and although religious and moral conscience were tightly intertwined for the Founders, they both reflect a broad principle of respect for conscience against government coercion. James Madison likewise called conscience ‘‘the most sacred of all property,’’ and proposed that the Bill of Rights should guarantee, in addition to protecting religious belief and worship, that ‘‘the full and equal rights of conscience [shall not] be in any manner, or on any pretext infringed.’’ 27 These Founding Era statements of general principle do not specify how they would be applied in a particular health care context. We do not suggest that the specific protections offered in this rule would also be required or necessarily appropriate in any other context that does not raise the specific concerns implicated by this Mandate. These interim final rules do not address in any way how the Government would balance its interests with respect to 25 From George Washington to the Hebrew Congregation in Newport, Rhode Island (Aug. 18, 1790), available at https://founders.archives.gov/ documents/Washington/05-06-02-0135. 26 Letter to the Society of the Methodist Episcopal Church at New London, Connecticut (February 4, 1809), available at https://founders.archives.gov/ documents/Jefferson/99-01-02-9714. 27 James Madison, ‘‘Essay on Property’’ (March 29, 1792); First draft of the First Amendment, 1 Annals of Congress 434 (June 8, 1789). E:\FR\FM\13OCR3.SGM 13OCR3 47848 Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations other health services not encompassed by the contraceptive Mandate.28 Instead we highlight this tradition of respect for conscience from our Founding Era to provide background support for the Departments’ decision to implement section 2713(a)(4) of the PHS Act, while protecting conscience in the exercise of moral convictions. We believe that these interim final rules are consistent both with the American tradition of respect for conscience and with Congress’ history of providing conscience protections in the kinds of health care matters involved in this Mandate. asabaliauskas on DSKBBXCHB2PROD with RULES G. Executive Orders Relevant to These Expanded Exemptions Protecting moral convictions, as set forth in the expanded exemptions and accommodations of these rules, is consistent with recent executive orders. President Trump’s Executive Order concerning this Mandate directed the Departments to consider providing protections, not specifically for ‘‘religious’’ beliefs, but for ‘‘conscience.’’ We interpret that term to include moral convictions and not just religious beliefs. Likewise, President Trump’s first Executive Order, EO 13765, declared that ‘‘the Secretary of Health and Human Services (Secretary) and the heads of all other executive departments and agencies (agencies) with authorities and responsibilities under the [ACA] shall exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications.’’ This Mandate imposes both a cost, fee, tax, or penalty, and a regulatory burden, on individuals and purchasers of health insurance that have moral convictions opposed to providing contraceptive coverage. These interim final rules exercise the Departments’ discretion to grant exemptions from the Mandate to reduce and relieve regulatory burdens and promote freedom in the health care market. 28 As the Supreme Court stated in Hobby Lobby, the Court’s decision concerns only the contraceptive Mandate, and should not be understood to hold that all insurance-coverage mandates, for example, for vaccinations or blood transfusions, must necessarily fail if they conflict with an employer’s religious beliefs. Nor does the Court’s opinion provide a shield for employers who might cloak illegal discrimination as a religious (or moral) practice. 134 S. Ct. at 2783. VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 H. Litigation Concerning the Mandate The sensitivity of certain health care matters makes it particularly important for the Government to tread carefully when engaging in regulation concerning those areas, and to respect individuals and organizations whose moral convictions are burdened by Government regulations. Providing conscience protections advances the Affordable Care Act’s goal of expanding health coverage among entities and individuals that might otherwise be reluctant to participate in the market. For example, the Supreme Court in Hobby Lobby declared that, if HHS requires owners of businesses to cover procedures that the owners ‘‘could not in good conscience’’ cover, such as abortion, ‘‘HHS would effectively exclude these people from full participation in the economic life of the Nation.’’ 134 S. Ct. at 2783. That would be a serious outcome. As demonstrated by litigation and public comments, various citizens sincerely hold moral convictions, which are not necessarily religious, against providing or participating in coverage of contraceptive items included in the Mandate, and some believe that some of those items may cause early abortions. The Departments wish to implement the contraceptive coverage Guidelines issued under section 2713(a)(4) of the PHS Act in a way that respects the moral convictions of our citizens so that they are more free to engage in ‘‘full participation in the economic life of the Nation.’’ These expanded exemptions do so by removing an obstacle that might otherwise lead entities or individuals with moral objections to contraceptive coverage to choose not to sponsor or participate in health plans if they include such coverage. Among the lawsuits challenging the Mandate, two have been filed based in part on non-religious moral convictions. In one case, the Departments are subject to a permanent injunction requiring us to respect the non-religious moral objections of an employer. See March for Life v. Burwell, 128 F. Supp. 3d 116 (D.D.C. 2015). In the other case, an appeals court recently affirmed a district court ruling that allows the previous regulations to be imposed in a way that violates the moral convictions of a small nonprofit pro-life organization and its employees. See Real Alternatives, 2017 WL 3324690. Our litigation of these cases has led to inconsistent court rulings, consumed substantial governmental resources, and created uncertainty for objecting organizations, issuers, third party administrators, and employees and beneficiaries. The PO 00000 Frm 00012 Fmt 4701 Sfmt 4700 organizations that have sued seeking a moral exemption have all adopted moral tenets opposed to contraception and hire only employees who share this view. It is reasonable to conclude that employees of these organizations would therefore not benefit from the Mandate. As a result, subjecting this subset of organizations to the Mandate does not advance any governmental interest. The need to resolve this litigation and the potential concerns of similar entities, and our requirement to comply with permanent injunctive relief currently imposed in March for Life, provide substantial reasons for the Departments to protect moral convictions through these interim final rules. Even though, as discussed below, we assume the number of entities and individuals that may seek exemption from the Mandate on the basis of moral convictions, as these two sets of litigants did, will be small, we know from the litigation that it will not be zero. As a result, the Departments have taken these types of objections into consideration in reviewing our regulations. Having done so, we consider it appropriate to issue the protections set forth in these interim final rules. Just as Congress, in adopting the early provisions of the Church Amendments, viewed it as necessary and appropriate to protect those organizations and individuals with objections to certain health care services on the basis of moral convictions, so we, too, believe that ‘‘our moral convictions as well as our religious beliefs, warrant protection from this intrusion by the Government’’ in this situation. I. The Departments’ Rebalancing of Government Interests For additional discussion of the Government’s balance of interests concerning religious beliefs issued contemporaneously with these interim final rules, see the related document published by the Department elsewhere in this issue of the Federal Register. There, we acknowledge that the Departments have changed the policies and interpretations we previously adopted with respect to the Mandate and the governmental interests that underlying it, and we assert that we now believe the Government’s legitimate interests in providing for contraceptive coverage do not require us to violate sincerely held religious beliefs while implementing the Guidelines. For parallel reasons, the Departments believe Congress did not set forth—and we do not possess—interests that require us to violate sincerely held moral convictions in the course of generally requiring contraceptive coverage. These changes in policy are E:\FR\FM\13OCR3.SGM 13OCR3 Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations asabaliauskas on DSKBBXCHB2PROD with RULES within the Departments’ authority. As the Supreme Court has acknowledged, ‘‘[a]gencies are free to change their existing policies as long as they provide a reasoned explanation for the change.’’ Encino Motorcars, LLC v. Navarro, 136 S. Ct. 2117, 2125 (2016). This ‘‘reasoned analysis’’ requirement does not demand that an agency ‘‘demonstrate to a court’s satisfaction that the reasons for the new policy are better than the reasons for the old one; it suffices that the new policy is permissible under the statute, that there are good reasons for it, and that the agency believes it to be better, which the conscious change of course adequately indicates.’’ United Student Aid Funds, Inc. v. King, 200 F. Supp. 3d 163, 169–70 (D.D.C. 2016) (citing FCC v. Fox Television Stations, Inc., 556 U.S. 502, 515 (2009)); see also New Edge Network, Inc. v. FCC, 461 F.3d 1105, 1112–13 (9th Cir. 2006) (rejecting an argument that ‘‘an agency changing its course by rescinding a rule is obligated to supply a reasoned analysis for the change beyond that which may be required when an agency does not act in the first instance’’).29 The Departments note that the exemptions created here, like the exemptions created by the last Administration, do not burden third parties to a degree that counsels against providing the exemptions. In addition to the apparent fact that many entities with non-religious moral objections to the Mandate appear to only hire persons that share those objections, Congress did not create a right to receive contraceptive coverage, and Congress explicitly chose not to impose the section 2713 requirements on grandfathered plans benefitting millions of people. Individuals who are unable to obtain contraceptive coverage through their employer-sponsored health plans because of the exemptions created in these interim final rules, or because of other exemptions to the Mandate, have other avenues for obtaining contraception, including through various other mechanisms by which the Government advances contraceptive coverage, particularly for low-income women, and which these interim final rules leave unchanged.30 As the 29 See also Chevron, U.S.A., Inc. v. Natural Resources Defense Council, Inc., 467 U.S. 837, 863– 64 (1984) (‘‘The fact that the agency has adopted different definitions in different contexts adds force to the argument that the definition itself is flexible, particularly since Congress has never indicated any disapproval of a flexible reading of the statute.’’) 30 See, for example, Family Planning grants in 42 U.S.C. 300, et seq.; the Teenage Pregnancy Prevention Program, Public Law 112–74 (125 Stat 786, 1080); the Healthy Start Program, 42 U.S.C. 254c–8; the Maternal, Infant, and Early Childhood Home Visiting Program, 42 U.S.C. 711; Maternal VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 Government is under no constitutional obligation to fund contraception, cf. Harris v. McRae, 448 U.S. 297 (1980), even more so may the Government refrain from requiring private citizens to cover contraception for other citizens in violation of their moral convictions. Cf. Rust v. Sullivan, 500 U.S. 173, 192–93 (1991) (‘‘A refusal to fund protected activity, without more, cannot be equated with the imposition of a ‘penalty’ on that activity.’’). The Departments acknowledge that coverage of contraception is an important and highly controversial issue, implicating many different views, as reflected for example in the public comments received on multiple rulemakings over the course of implementation of section 2713(a)(4) of the PHS Act. Our expansion of conscience protections for moral convictions, similar to protections contained in numerous statutes governing health care regulation, is not taken lightly. However, after reconsidering the interests served by the Mandate in this particular context, the objections raised, and the relevant Federal law, the Departments have determined that expanding the exemptions to include protections for moral convictions is a more appropriate administrative response than continuing to refuse to extend the exemptions and accommodations to certain entities and individuals for whom the Mandate violates their sincerely held moral convictions. Although the number of organizations and individuals that may seek to take advantage of these exemptions and accommodations may be small, we believe that it is important formally to codify such protections for objections based on moral conviction, given the long-standing recognition of such protections in health care and health insurance context in law and regulation and the particularly sensitive nature of these issues in the health care context. These interim final rules leave unchanged HRSA’s authority to decide whether to include contraceptives in the women’s preventive services Guidelines for entities that are not exempted by law, regulation, or the Guidelines. These rules also do not change the many other mechanisms by which the Government advances contraceptive coverage, particularly for low-income women. and Child Health Block Grants, 42 U.S.C. 703; 42 U.S.C. 247b–12; Title XIX of the Social Security Act, 42 U.S.C. 1396, et seq.; the Indian Health Service, 25 U.S.C. 13, 42 U.S.C. 2001(a), & 25 U.S.C. 1601, et seq.; Health center grants, 42 U.S.C. 254b(e), (g), (h), & (i); the NIH Clinical Center, 42 U.S.C. 248; and the Personal Responsibility Education Program, 42 U.S.C. 713. PO 00000 Frm 00013 Fmt 4701 Sfmt 4700 47849 III. Provisions of the Interim Final Rules With Comment Period The Departments are issuing these interim final rules in light of the full history of relevant rulemaking (including 3 previous interim final rules), public comments, and the longrunning litigation from non-religious moral objectors to the Mandate, as well as the information contained in the companion interim final rules issued elsewhere in this issue of the Federal Register. These interim final rules seek to resolve these matters by directing HRSA, to the extent it requires coverage for certain contraceptive services in its Guidelines, to afford an exemption to certain entities and individuals with sincerely held moral convictions by which they object to contraceptive or sterilization coverage, and by making the accommodation process available for certain organizations with such convictions. For all of the reasons discussed and referenced above, the Departments have determined that the Government’s interest in applying contraceptive coverage requirements to the plans of certain entities and individuals does not outweigh the sincerely held moral objections of those entities and individuals. Thus, these interim final rules amend the regulations amended in both the Departments’ July 2015 final regulations and in the companion interim final rules concerning religious beliefs issued contemporaneously with these interim final rules and published elsewhere in this issue of the Federal Register. These interim final rules expand those exemptions to include additional entities and persons that object based on sincerely held moral convictions. These rules leave in place HRSA’s discretion to continue to require contraceptive and sterilization coverage where no objection specified in the regulations exists, and if section 2713 of the PHS Act otherwise applies. These interim final rules also maintain the existence of an accommodation process as a voluntary option for organizations with moral objections to contraceptive coverage, but consistent with our expansion of the exemption, we expand eligibility for the accommodation to include organizations with sincerely held moral convictions concerning contraceptive coverage. HRSA is simultaneously updating its Guidelines to reflect the requirements of these interim final rules.31 31 See https://www.hrsa.gov/womensguidelines/ and https://www.hrsa.gov/womensguidelines2016/ index.html. E:\FR\FM\13OCR3.SGM 13OCR3 asabaliauskas on DSKBBXCHB2PROD with RULES 47850 Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations 1. Exemption for Objecting Entities Based on Moral Convictions In the new 45 CFR 147.133 as created by these interim final rules, we expand the exemption that was previously located in § 147.131(a), and that was expanded in § 147.132 by the companion interim final rules concerning religious beliefs issued contemporaneously with these interim final rules and published elsewhere in this issue of the Federal Register. With respect to employers that sponsor group health plans, § 147.133(a)(1) and (a)(1)(i) provide exemptions for certain employers that object to coverage of all or a subset of contraceptives or sterilization and related patient education and counseling based on sincerely held moral convictions. For avoidance of doubt, the Departments wish to make clear that the expanded exemption in § 147.133(a) applies to several distinct entities involved in the provision of coverage to the objecting employer’s employees. This explanation is consistent with how prior rules have worked by means of similar language. Section 147.133(a)(1) and (a)(1)(i), by specifying that ‘‘[a] group health plan and health insurance coverage provided in connection with a group health plan’’ is exempt ‘‘to the extent the plan sponsor objects as specified in paragraph (a)(2),’’ exempt the group health plans the sponsors of which object, and exempt their health insurance issuers in providing the coverage in those plans (whether or not the issuers have their own objections). Consequently, with respect to Guidelines issued under § 147.130(a)(1)(iv), or the parallel provisions in 26 CFR 54.9815– 2713T(a)(1)(iv) and 29 CFR 2590.715– 2713(a)(1)(iv), the plan sponsor, issuer, and plan covered in the exemption of that paragraph would face no penalty as a result of omitting contraceptive coverage from the benefits of the plan participants and beneficiaries. Consistent with the restated exemption, exempt entities will not be required to comply with a selfcertification process. Although exempt entities do not need to file notices or certifications of their exemption, and these interim final rules do not impose any new notice requirements on them, existing ERISA rules governing group health plans require that, with respect to plans subject to ERISA, a plan document must include a comprehensive summary of the benefits covered by the plan and a statement of the conditions for eligibility to receive benefits. Under ERISA, the plan VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 document provides what benefits are provided to participants and beneficiaries under the plan and, therefore, if an objecting employer would like to exclude all or a subset of contraceptive services, it must ensure that the exclusion is clear in the plan document. Moreover, if there is a reduction in a covered service or benefit, the plan has to disclose that change to plan participants.32 Thus, where an exemption applies and all or a subset of contraceptive services are omitted from a plan’s coverage, otherwise applicable ERISA disclosures should reflect the omission of coverage in ERISA plans. These existing disclosure requirements serve to help provide notice to participants and beneficiaries of what ERISA plans do and do not cover. The Departments invite public comment on whether exempt entities, or others, would find value either in being able to maintain or submit a specific form of certification to claim their exemption, or in otherwise receiving guidance on a way to document their exemption. The exemptions in § 147.133(a) apply ‘‘to the extent’’ of the objecting entities’ sincerely held moral convictions. Thus, entities that hold a requisite objection to covering some, but not all, contraceptive items would be exempt with respect to the items to which they object, but not with respect to the items to which they do not object. Likewise, the requisite objection of a plan sponsor or institution of higher education in § 147.133(a)(1)(i) and (ii) exempts its group health plan, health insurance coverage offered by a health insurance issuer in connection with such plan, and its issuer in its offering of such coverage, but that exemption does not extend to coverage provided by that issuer to other group health plans where the plan sponsors have no qualifying objection. The objection of a health insurance issuer in § 147.133(a)(1)(iii) similarly operates only to the extent of its objection, and as otherwise limited as described below. 2. Exemption of Certain Plan Sponsors The rules cover certain kinds of nongovernmental employer plan sponsors with the requisite objections, and the rules specify which kinds of entities qualify for the exemption. Under these interim final rules, the Departments do not limit the exemption 32 See, for example, 29 U.S.C. 1022, 1024(b), 29 CFR 2520.102–2, 2520.102–3, & 2520.104b–3(d), and 29 CFR 2590.715–2715. See also 45 CFR 147.200 (requiring disclosure of the ‘‘exceptions, reductions, and limitations of the coverage,’’ including group health plans and group & individual issuers). PO 00000 Frm 00014 Fmt 4701 Sfmt 4700 with reference to nonprofit status as previous rules have done. Many of the federal health care conscience statutes cited above offer protections for the moral convictions of entities without regard to whether they operate as nonprofits or for-profit entities. In addition, a significant majority of states either impose no contraceptive coverage requirement, or offer broader exemptions than the exemption contained in the July 2015 final regulations.33 States also generally protect moral convictions in health care conscience laws, and they often offer those protections whether or not an entity operates as a nonprofit.34 Although the practice of states is by no means a limit on the discretion delegated to HRSA by the Affordable Care Act, nor is it a statement about what the Federal Government may do consistent with other protections or limitations in federal law, such state practice can be informative as to the viability of offering protections for conscientious objections in particularly sensitive health care contexts. In this case, the existence of many instances where conscience protections are offered, or no underlying mandate of this kind exists that could violate moral convictions, supports the Departments’ decision to expand the Federal exemption concerning this Mandate as set forth in these interim final rules. Section 147.133(a)(1)(i)(A) of the rules specifies that the exemption includes the plans of a plan sponsor that is a nonprofit organization with sincerely held moral convictions. Section 147.133(a)(1)(i)(B) of the rules specifies that the exemption includes the plans of a plan sponsor that is a forprofit entity that has no publicly traded ownership interests (for this purpose, a publicly traded ownership interest is any class of common equity securities required to be registered under section 12 of the Securities Exchange Act of 1934). Extending the exemption to certain for-profit entities is consistent with the Supreme Court’s ruling in Hobby Lobby, which declared that a corporate entity is capable of possessing and pursuing nonpecuniary goals (in Hobby Lobby, religion), regardless of whether the entity operates as a nonprofit organization, and rejecting the 33 See Guttmacher Institute, ‘‘Insurance Coverage of Contraceptives’’ (Aug. 1, 2017), available at https://www.guttmacher.org/state-policy/explore/ insurance-coverage-contraceptives. 34 See, for example, Guttmacher Institute, ‘‘Refusing to Provide Health Services’’ (Aug. 1, 2017), available at https://www.guttmacher.org/ state-policy/explore/refusing-provide-healthservices. E:\FR\FM\13OCR3.SGM 13OCR3 Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations asabaliauskas on DSKBBXCHB2PROD with RULES Departments’ argument to the contrary. 134 S. Ct. 2768–75. Some reports and industry experts have indicated that not many for-profit entities beyond those that had originally brought suit have sought relief from the Mandate after Hobby Lobby.35 The mechanisms for determining whether a company has adopted and holds certain principles or views, such as sincerely held moral convictions, is a matter of wellestablished State law with respect to corporate decision-making,36 and the Departments expect that application of such laws would cabin the scope of this exemption. The July 2015 final regulations extended the accommodation to forprofit entities only if they are closely held, by positively defining what constitutes a closely held entity. Any such positive definition runs up against the myriad state differences in defining such entities, and potentially intrudes into a traditional area of state regulation of business organizations. The Departments implicitly recognized the difficulty of defining closely held entities in the July 2015 final regulations when we adopted a definition that included entities that are merely ‘‘substantially similar’’ to certain specified parameters, and we allowed entities that were not sure if they met the definition to inquire with HHS; HHS was permitted to decline to answer the inquiry, at which time the entity would be deemed to qualify as an eligible organization. Instead of attempting to positively define closely held businesses for the purpose of this rule, the Departments consider it much more clear, effective, and preferable to define the category negatively by reference to one element of our previous definition, namely, that the entity has no publicly traded ownership interest (that is, any class of common equity securities required to be registered under section 12 of the Securities Exchange Act of 1934). In this way, these interim final rules differ from the exemption provided to plan sponsors with objections based on sincerely held religious beliefs set forth in § 147.132(a)(1)—those extend to forprofit entities whether or not they are closely held or publicly traded. The Departments seek public comment on 35 See Jennifer Haberkorn, ‘‘Two years later, few Hobby Lobby copycats emerge,’’ Politico (Oct. 11, 2016), available at https://www.politico.com/story/ 2016/10/obamacare-birth-control-mandateemployers-229627. 36 Although the Departments do not prescribe any form or notification, they would expect that such principles or views would have been adopted and documented in accordance with the laws of the jurisdiction under which they are incorporated or organized. VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 whether the exemption in § 147.133(a)(1)(i) for plan sponsors with moral objections to the Mandate should be finalized to encompass all of the types of plan sponsors covered by § 147.132(a)(1)(i), including publicly traded corporations with objections based on sincerely held moral convictions, and also non-federal governmental plan sponsors that may have objections based on sincerely held moral convictions. In the case of particularly sensitive health care matters, several significant federal health care conscience statutes protect entities’ moral objections without precluding publicly traded and governmental entities from using those protections. For example, the first paragraph of the Church Amendments provides certain protections for entities that object based on moral convictions to making their facilities or personnel available to assist in the performance of abortions or sterilizations, and the statute does not limit those protections based on whether the entities are publicly traded or governmental. (42 U.S.C. 300a–7(b)). Thus, under section 300a–7(b), a hospital in a publicly traded health system, or a local governmental hospital, could adopt sincerely held moral convictions by which it objects to providing facilities or personnel for abortions or sterilizations, and if the entity receives relevant funds from HHS specified by section 300a– 7(b), the protections of that section would apply. The Coats-Snowe Amendment likewise provides certain protections for health care entities and postgraduate physician training programs that choose not to perform, refer for, or provide training for abortions, and the statute does not limit those protections based on whether the entities are publicly traded or governmental. (42 U.S.C. 238n). The Weldon Amendment 37 provides certain protections for health care entities, hospitals, provider-sponsored organizations, health maintenance organizations, and health insurance plans that do not provide, pay for, provide coverage of, or refer for abortions, and the statute does not limit those protections based on whether the entity is publicly traded or governmental. The Affordable Care Act provides certain protections for any institutional health care entity, hospital, provider-sponsored organization, health maintenance organization, health insurance plan, or any other kind of health care facility, that does not provide any health care item or service 37 Consolidated Appropriations Act of 2017, Div. H, Title V, Sec. 507(d), Pub. L. 115–31. PO 00000 Frm 00015 Fmt 4701 Sfmt 4700 47851 furnished for the purpose of causing or assisting in causing assisted suicide, euthanasia, or mercy killing, and the statute similarly does not limit those protections based on whether the entity is publicly traded or governmental. (42 U.S.C. 18113).38 Sections 1395w–22(j)(3)(B) and 1396u–2(b)(3) of 42 U.S.C. protect organizations that offer Medicaid and Medicare Advantage managed care plans from being required to provide, reimburse for, or provide coverage of a counseling or referral service if they object to doing so on moral grounds, and those paragraphs do not further specify that publicly traded entities do not qualify for the protections. Congress’ most recent statement on Government requirements of contraceptive coverage specified that, if the District of Columbia requires ‘‘the provision of contraceptive coverage by health insurance plans,’’ ‘‘it is the intent of Congress that any legislation enacted on such issue should include a ‘conscience clause’ which provides exceptions for religious beliefs and moral convictions.’’ Consolidated Appropriations Act of 2017, Division C, Title VIII, Sec. 808. Congress expressed no intent that such a conscience should be limited based on whether the entity is publicly traded. At the same time, the Departments lack significant information about the need to extend the expanded exemption further. We have been subjected to litigation by nonprofit entities expressing objections to the Mandate based on non-religious moral convictions, and we have been sued by closely held for-profit entities expressing religious objections. This combination of different types of plaintiffs leads us to believe that there may be a small number of closely held for-profit entities that would seek to use an exemption to the contraceptive Mandate based on moral convictions. The fact that many closely held forprofit entities brought challenges to the Mandate has led us to offer protections that would include publicly traded entities with religious objections to the Mandate if such entities exist. But the combined lack of any lawsuits challenging the Mandate by for-profit entities with non-religious moral convictions, and of any lawsuits by any kind of publicly traded entity, leads us to not extend the expanded exemption in these interim final rules to publicly traded entities, but rather to invite public comment on whether to do so in 38 The lack of the limitation in this provision may be particularly relevant since it is contained in the same statute, the ACA, as the provision under which the Mandate—and these exemptions to the Mandate—are promulgated. E:\FR\FM\13OCR3.SGM 13OCR3 asabaliauskas on DSKBBXCHB2PROD with RULES 47852 Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations a way parallel to the protections set forth in § 147.132(a)(1)(i). We agree with the Supreme Court that it is improbable that many publicly traded companies with numerous ‘‘unrelated shareholders—including institutional investors with their own set of stakeholders—would agree to run a corporation under the same religious beliefs’’ (or moral convictions) and thereby qualify for the exemption. Hobby Lobby, 134 S. Ct. at 2774. We are also not aware of other types of plan sponsors (such as non-Federal governmental entities) that might possess moral objections to compliance with the Mandate, including whether some might consider certain contraceptive methods as having a possible abortifacient effect. Nevertheless, we would welcome any comments on whether such corporations or other plan sponsors exist and would benefit from such an exemption. Despite our a lack of complete information, the Departments know that nonprofit entities have challenged the Mandate, and we assume that a closely held business might wish to assert nonreligious moral convictions in objecting to the Mandate (although we anticipate very few if any will do so). Thus we have chosen in these interim final rules to include them in the expanded exemption and thereby remove an obstacle preventing such entities from claiming an exemption based on nonreligious moral convictions. But we are less certain that we need to use these interim final rules to extend the expanded exemption for moral convictions to encompass other kinds of plan sponsors not included in the protections of these interim final rules. Therefore, with respect to plan sponsors not included in the expanded exemptions of § 147.133(a)(1)(i), and non-federal governmental plan sponsors that might have moral objections to the Mandate, we invite public comment on whether to include such entities when we finalize these rules at a later date. The Departments further conclude that it would be inadequate to merely provide entities access to the accommodation process instead of to the exemption where those entities object to the Mandate based on sincerely held moral convictions. The Departments have stated in our regulations and court briefings that the existing accommodation with respect to self-insured plans requires contraceptive coverage as part of the same plan as the coverage provided by the employer, and operates in a way ‘‘seamless’’ to those plans. As a result, in significant respects, the VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 accommodation process does not actually accommodate the objections of many entities. This has led many religious groups to challenge the accommodation in court, and we expect similar challenges would come from organizations objecting to the accommodation based on moral convictions if we offered them the accommodation but not an exemption. When we took that narrow approach with religious nonprofit entities it led to multiple cases in many courts that we needed to litigate to the Supreme Court various times. Although objections to the accommodation were not specifically litigated in the two cases brought by nonprofit non-religious organizations (because we have not even made them eligible for the accommodation), those organizations made it clear that they and their employees strongly oppose coverage of certain contraceptives in their plans and in connection with their plans. 3. Exemption for Institutions of Higher Education The plans of institutions of higher education that arrange student health insurance coverage will be treated similarly to the way that plans of employers are treated for the purposes of such plans being exempt or accommodated based on moral convictions. These interim final rules specify, in § 147.133(a)(1)(ii), that the exemption is extended, in the case of institutions of higher education (as defined in 20 U.S.C. 1002), to their arrangement of student health insurance coverage, in a manner comparable to the applicability of the exemption for group health insurance coverage provided in connection with a group health plan established or maintained by a plan sponsor. The Departments are not aware of institutions of higher education that arrange student coverage and object to the Mandate based on non-religious moral convictions. We have been sued by several institutions of higher education that arrange student coverage and object to the Mandate based on religious beliefs. We believe the existence of such entities with nonreligious moral objections, or the possible formation of such entities in the future, is sufficiently possible so that we should provide protections for them in these interim final rules. But based on a lack of information about such entities, we assume that none will use the exemption concerning student coverage at this time. PO 00000 Frm 00016 Fmt 4701 Sfmt 4700 4. Exemption for Issuers These interim final rules extend the exemption, in § 147.133(a)(1)(iii), to health insurance issuers offering group or individual health insurance coverage that sincerely hold their own moral convictions opposed to providing coverage for contraceptive services. As discussed above, where the exemption for plan sponsors or institutions of higher education applies, issuers are exempt under those sections with respect to providing coverage in those plans. The issuer exemption in § 147.133(a)(1)(iii) adds to that protection, but the additional protection operates in a different way than the plan sponsor exemption operates. The only plan sponsors, or in the case of individual insurance coverage, individuals, who are eligible to purchase or enroll in health insurance coverage offered by an exempt issuer that does not cover some or all contraceptive services are plan sponsors or individuals who themselves object and are otherwise exempt based on their objection (whether the objection is based on moral convictions, as set forth in these rules, or on religious beliefs, as set forth in exemptions created by the companion interim final rules published elsewhere in this issue of the Federal Register). Thus, the issuer exemption specifies that where a health insurance issuer providing group health insurance coverage is exempt under paragraph (a)(1)(iii), the plan remains subject to any requirement to provide coverage for contraceptive services under Guidelines issued under § 147.130(a)(1)(iv) unless the plan is otherwise exempt from that requirement. Accordingly, the only plan sponsors, or in the case of individual insurance coverage, individuals, who are eligible to purchase or enroll in health insurance coverage offered by an issuer that is exempt under this paragraph (a)(1)(iii) that does not include some or all contraceptive services are plan sponsors or individuals who themselves object and are exempt. Under the rules as amended, issuers with objections based on sincerely held moral convictions could issue policies that omit contraception to plan sponsors or individuals that are otherwise exempt based on either their religious beliefs or their moral convictions, and issuers with sincerely held religious beliefs could likewise issue policies that omit contraception to plan sponsors or individuals that are otherwise exempt based on either their religious beliefs or their moral convictions. Issuers that hold moral objections should identify to plan sponsors the E:\FR\FM\13OCR3.SGM 13OCR3 asabaliauskas on DSKBBXCHB2PROD with RULES Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations lack of contraceptive coverage in any health insurance coverage being offered that is based on the issuer’s exemption, and communicate the group health plan’s independent obligation to provide contraceptive coverage, unless the group health plan itself is exempt under regulations governing the Mandate. In this way, the issuer exemption serves to protect objecting issuers both from being asked or required to issue policies that cover contraception in violation of the issuers’ sincerely held moral convictions, and from being asked or required to issue policies that omit contraceptive coverage to non-exempt entities or individuals, thus subjecting the issuers to potential liability if those plans are not exempt from the Guidelines. At the same time, the issuer exemption will not serve to remove contraceptive coverage obligations from any plan or plan sponsor that is not also exempt, nor will it prevent other issuers from being required to provide contraceptive coverage in individual insurance coverage. Protecting issuers that object to offering contraceptive coverage based on sincerely held moral convictions will help preserve space in the health insurance market for certain issuers so that exempt plan sponsors and individuals will be able to obtain coverage. The Departments are not currently aware of health insurance issuers that possess their own religious or moral objections to offering contraceptive coverage. Nevertheless, many Federal health care conscience laws and regulations protect issuers or plans specifically. For example, as discussed above, 42 U.S.C. 1395w–22(j)(3)(B) and 1396u–2(b)(3) protect plans or managed care organizations in Medicaid or Medicare Advantage. The Weldon Amendment protects HMOs, health insurance plans, and any other health care organizations from being required to provide coverage or pay for abortions. See, for example, Consolidated Appropriations Act of 2017, Div. H, Title V, Sec. 507(d), Public Law 115–31. The most recently enacted Consolidated Appropriations Act declares that Congress supports a ‘‘conscience clause’’ to protect moral convictions concerning ‘‘the provision of contraceptive coverage by health insurance plans.’’ See id. at Div. C, Title VIII, Sec. 808. The issuer exemption does not specifically include third party administrators, for the reasons discussed in the companion interim final rules concerning religious beliefs issued contemporaneously with these interim final rules and published VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 elsewhere in this issue of the Federal Register. The Departments solicit public comment; however, on whether there are situations where there may be an additional need to provide distinct protections for third party administrators that may have moral convictions implicated by the Mandate.39 5. Scope of Objections Needed for the Objecting Entity Exemption Exemptions for objecting entities specify that they apply where the entities object as specified in § 147.133(a)(2). That section specifies that exemptions for objecting entities will apply to the extent that an entity described in § 147.133(a)(1) objects to its establishing, maintaining, providing, offering, or arranging (as applicable) for coverage, payments, or a plan that provides coverage or payments for some or all contraceptive services, based on its sincerely held moral convictions. 6. Individual Exemption These interim final rules include a special rule pertaining to individuals (referred to here as the ‘‘individual exemption’’). Section 147.133(b) provides that nothing in § 147.130(a)(1)(iv), 26 CFR 54.9815– 2713T(a)(1)(iv) and 29 CFR 2590.715– 2713(a)(1)(iv), may be construed to prevent a willing plan sponsor of a group health plan and/or a willing health insurance issuer offering group or individual health insurance coverage, from offering a separate benefit package option, or a separate policy, certificate, or contract of insurance, to any individual who objects to coverage or payments for some or all contraceptive services based on the individual’s sincerely held moral convictions. The individual exemption extends to the coverage unit in which the plan participant, or subscriber in the individual market, is enrolled (for instance, to family coverage covering the participant and his or her beneficiaries enrolled under the plan), but does not relieve the plan’s or issuer’s obligation to comply with the Mandate with respect to the group health plan at large or, as applicable, to any other individual policies the issuer offers. 39 The exemption for issuers, as outlined here, does not make a distinction among issuers based on whether they are publicly traded, unlike the plan sponsor exemption for business entities. Because the issuer exemption operates more narrowly than the exemption for business plan sponsors operates, in the ways described here, and exists in part to help preserve market options for objecting plan sponsors, the Departments consider it appropriate to not draw such a distinction among issuers. PO 00000 Frm 00017 Fmt 4701 Sfmt 4700 47853 This individual exemption allows plan sponsors and issuers that do not specifically object to contraceptive coverage to offer morally acceptable coverage to their participants or subscribers who do object, while offering coverage that includes contraception to participants or subscribers who do not object. This individual exemption can apply with respect to individuals in plans sponsored by private employers or governmental employers. For example, in one case brought against the Departments, the State of Missouri enacted a law under which the State is not permitted to discriminate against insurance issuers that offer health plans without coverage for contraception based on employees’ moral convictions, or against the individual employees who accept such offers. See Wieland, 196 F. Supp. 3d at 1015–16 (quoting Mo. Rev. Stat. 191.724). Under the individual exemption of these interim final rules, employers sponsoring governmental plans would be free to honor the sincerely held moral objections of individual employees by offering them plans that omit contraception, even if those governmental entities do not object to offering contraceptive coverage in general. This ‘‘individual exemption’’ cannot be used to force a plan (or its sponsor) or an issuer to provide coverage omitting contraception, or, with respect to health insurance coverage, to prevent the application of state law that requires coverage of such contraceptives or sterilization. Nor can the individual exemption be construed to require the guaranteed availability of coverage omitting contraception to a plan sponsor or individual who does not have a sincerely held moral objection. This individual exemption is limited to the requirement to provide contraceptive coverage under section 2713(a)(4) of the PHS Act, and does not affect any other federal or state law governing the plan or coverage. Thus, if there are other applicable laws or plan terms governing the benefits, these interim final rules do not affect such other laws or terms. The Departments believe the individual exemption will help to meet the Affordable Care Act’s goal of increasing health coverage because it will reduce the incidence of certain individuals choosing to forego health coverage because the only coverage available would violate their sincerely held moral convictions.40 At the same 40 This prospect has been raised in cases of religious individuals—see, for example, Wieland, E:\FR\FM\13OCR3.SGM Continued 13OCR3 47854 Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations asabaliauskas on DSKBBXCHB2PROD with RULES time, this individual exemption ‘‘does not undermine the governmental interests furthered by the contraceptive coverage requirement,’’ 41 because, when the exemption is applicable, the individual does not want the coverage, and therefore would not use the objectionable items even if they were covered. In addition, because the individual exemption only operates when the employer and/or issuer, as applicable, are willing, the exemption will not undermine any governmental interest in the workability of the insurance market, because we expect that any workability concerns will be taken into account in the decision of whether to be willing to offer the individual morally acceptable coverage. For similar reasons, we have changed our position and now believe the individual exemption will not undermine any Government interest in uniformity in the health insurance market. At the level of plan offerings, the extent to which plans cover contraception under the prior rules is already far from uniform. The Congress did not require compliance with section 2713 of the PHS Act by all entities—in particular by grandfathered plans. The Departments’ previous exemption for houses of worship and integrated auxiliaries, and our accommodation of self-insured church plans, show that the importance of a uniform health insurance system is not significantly harmed by allowing plans to omit contraception in many contexts.42 With respect to operationalizing this provision of these rules, as well as the similar provision protecting individuals with religious objections to purchasing insurance that covers some or all contraceptives, in the interim final rules published elsewhere in this issue of the Federal Register, the Departments note that a plan sponsor or health insurance issuer is not required to offer separate and different benefit package options, or separate and different forms of policy, certificate, or contract of insurance with respect to those individuals who object 196 F. Supp. 3d at 1017, and March for Life, 128 F. Supp. 3d at 130—where the courts noted that the individual employee plaintiffs indicated that they viewed the Mandate as pressuring them to ‘‘forgo health insurance altogether.’’ 41 78 FR 39874. 42 See also Real Alternatives, 2017 WL 3324690 at *36 (3d Cir. Aug. 4, 2017) (Jordan, J., concurring in part and dissenting in part) (‘‘Because insurance companies would offer such plans as a result of market forces, doing so would not undermine the government’s interest in a sustainable and functioning market. . . . Because the government has failed to demonstrate why allowing such a system (not unlike the one that allowed wider choice before the ACA) would be unworkable, it has not satisfied strict scrutiny.’’ (citation and internal quotation marks omitted)). VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 on moral bases from those who object on religious bases. That is, a willing employer or issuer may offer the same benefit package option or policy, certificate, or contract of insurance— which excludes the same scope of some or all contraceptive coverage—to individuals who are exempt from the Mandate because of their moral convictions (under these rules) or their religious beliefs (under the regulations as amended by the interim final rules pertaining to religious beliefs). 7. Optional Accommodation In addition to expanding the exemption to those with sincerely held moral convictions, these rules also expand eligibility for the optional accommodation process to include employers with objections based on sincerely held moral convictions. This is accomplished by inserting references to the newly added exemption for moral convictions, 45 CFR 147.133, into the regulatory sections where the accommodation process is codified, 45 CFR 147.131, 26 CFR 54.9815–2713AT, and 29 CFR 2590.715–2713A. In all other respects the accommodation process works the same as it does for entities with objections based on sincerely held religious beliefs, as described in the companion interim final rules concerning religious beliefs issued contemporaneously with these interim final rules and published elsewhere in this issue of the Federal Register. The Departments are not aware of entities with objections to the Mandate based on sincerely held moral convictions that wish to make use of the optional accommodation, and our present assumption is that no such entities will seek to use the accommodation rather than the exemption. But if such entities do wish to use the accommodation, making it available to them will both provide contraceptive coverage to their plan participants and respect those entities’ objections. Because entities with objections to the Mandate based on sincerely held non-religious moral convictions have not previously had access to the accommodation, they would not be in a position to revoke their use of the accommodation at the time these interim final rules are issued, but could do so in the future under the same parameters set forth in the accommodation regulations. 8. Regulatory Restatements of Section 2713(a) and (a)(4) of the PHS Act These interim final rules insert references to 45 CFR 147.133 into the restatements of the requirements of PO 00000 Frm 00018 Fmt 4701 Sfmt 4700 section 2713(a) and (a)(4) of the PHS Act, contained in 26 CFR 54.9815– 2713T(a)(1) introductory text and (a)(1)(iv), 29 CFR 2590.715–2713(a)(1) introductory text and (a)(1)(iv), and 45 CFR 147.130(a)(1) and (a)(1)(iv). 9. Conclusion The Departments believe that the Guidelines, and the expanded exemptions and accommodations set forth in these interim final rules, will advance the legitimate but limited purposes for which Congress imposed section 2713 of the PHS Act, while acting consistently with Congress’ wellestablished record of allowing for moral exemptions with respect to various health care matters. These interim final rules maintain HRSA’s discretion to decide whether to continue to require contraceptive coverage under the Guidelines if no regulatorily recognized exemption exists (and in plans where Congress applied section 2713 of the PHS Act). As cited above, these interim final rules also leave fully in place over a dozen Federal programs that provide, or subsidize, contraceptives for women, including for low income women based on financial need. The Departments believe this array of programs and requirements better serves the interests of providing contraceptive coverage while protecting the moral convictions of entities and individuals concerning coverage of some or all contraceptive or sterilization services. The Departments request and encourage public comments on all matters addressed in these interim final rules. IV. Interim Final Rules, Request for Comments and Waiver of Delay of Effective Date Section 9833 of the Code, section 734 of ERISA, and section 2792 of the PHS Act authorize the Secretaries of the Treasury, Labor, and HHS (collectively, the Secretaries) to promulgate any interim final rules that they determine are appropriate to carry out the provisions of chapter 100 of the Code, part 7 of subtitle B of title I of ERISA, and part A of title XXVII of the PHS Act, which include sections 2701 through 2728 of the PHS Act and the incorporation of those sections into section 715 of ERISA and section 9815 of the Code. These interim final rules fall under those statutory authorized justifications, as did previous rules on this matter (75 FR 41726; 76 FR 46621; and 79 FR 51092). Section 553(b) of the APA requires notice and comment rulemaking, involving a notice of proposed rulemaking and a comment period prior E:\FR\FM\13OCR3.SGM 13OCR3 Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations asabaliauskas on DSKBBXCHB2PROD with RULES to finalization of regulatory requirements—except when an agency, for good cause, finds that notice and public comment thereon are impracticable, unnecessary, or contrary to the public interest. These provisions of the APA do not apply here because of the specific authority granted to the Secretaries by section 9833 of the Code, section 734 of ERISA, and section 2792 of the PHS Act. Even if these provisions of the APA applied, they would be satisfied: The Departments have determined that it would be impracticable and contrary to the public interest to delay putting these provisions in place until a full public notice-and-comment process is completed. As discussed earlier, the Departments have issued three interim final rules implementing this section of the PHS Act because of the immediate needs of covered entities and the weighty matters implicated by the HRSA Guidelines. As recently as December 20, 2016, HRSA updated those Guidelines without engaging in the regulatory process (because doing so is not a legal requirement), and announced that it plans to so continue to update the Guidelines. Two lawsuits have been pending for several years by entities raising nonreligious moral objections to the Mandate.43 In one of those cases, the Departments are subject to a permanent injunction and the appeal of that case has been stayed since February 2016. In the other case, Federal district and appeals courts ruled in favor of the Departments, denying injunctive relief to the plaintiffs, and that case is also still pending. Based on the public comments the Departments have received, we have reason to believe that some similar nonprofit entities might exist, even if it is likely a small number.44 For entities and individuals facing a burden on their sincerely held moral convictions, providing them relief from Government regulations that impose such a burden is an important and urgent matter, and delay in doing so injures those entities in ways that cannot be repaired retroactively. The burdens of the existing rules undermine these entities’ and individuals’ participation in the health care market because they provide them with a 43 March for Life, 128 F. Supp. 3d 116; Real Alternatives, 867 F.3d 338. 44 See, for example, Americans United for Life (‘‘AUL’’) Comment on CMA–9992–IFC2 at 10 (Nov. 1, 2011), available at https://www.regulations.gov/ #!documentDetail;D=HHS-OS-2011-0023-59496, and AUL Comment on CMS–9968–P at 5 (Apr. 8, 2013), available at https://www.regulations.gov/ #!documentDetail;D=CMS-2012-0031-79115. VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 serious disincentive—indeed a crisis of conscience—between participating in or providing quality and affordable health insurance coverage and being forced to violate their sincerely held moral convictions. The existence of inconsistent court rulings in multiple proceedings has also caused confusion and uncertainty that has extended for several years, with different federal courts taking different positions on whether entities with moral objections are entitled to relief from the Mandate. Delaying the availability of the expanded exemption would require entities to bear these burdens for many more months. Continuing to apply the Mandate’s regulatory burden on individuals and organizations with moral convictions objecting to compliance with the Mandate also serves as a deterrent for citizens who might consider forming new entities consistent with their moral convictions and offering health insurance through those entities. Moreover, we separately expanded exemptions to protect religious beliefs in the companion interim final rules issued contemporaneously with these interim final rules and published elsewhere in this issue of the Federal Register. Because Congress has provided many statutes that protect religious beliefs and moral convictions similarly in certain health care contexts, it is important not to delay the expansion of exemptions for moral convictions set forth in these rules, since the companion rules provide protections for religious beliefs on an interim final basis. Otherwise, our regulations would simultaneously provide and deny relief to entities and individuals that are, in the Departments’ view, similarly deserving of exemptions and accommodations consistent, with similar protections in other federal laws. This could cause similarly situated entities and individuals to be burdened unequally. In response to several of the previous rules on this issue—including three issued as interim final rules under the statutory authority cited above—the Departments received more than 100,000 public comments on multiple occasions. Those comments included extensive discussion about whether and to what extent to expand the exemption. Most recently, on July 26, 2016, the Departments issued a request for information (81 FR 47741) and received over 54,000 public comments about different possible ways to resolve these issues. As noted above, the public comments in response to both the RFI and various prior rulemaking proceedings included specific requests PO 00000 Frm 00019 Fmt 4701 Sfmt 4700 47855 that the exemptions be expanded to include those who oppose the Mandate for either religious or ‘‘moral’’ reasons.45 In connection with past regulations, the Departments have offered or expanded a temporary safe harbor allowing organizations that were not exempt from the HRSA Guidelines to operate out of compliance with the Guidelines. The Departments will fully consider comments submitted in response to these interim final rules, but believe that good cause exists to issue the rules on an interim final basis before the comments are submitted and reviewed. Issuing interim final rules with a comment period provides the public with an opportunity to comment on whether these regulations expanding the exemption should be made permanent or subject to modification without delaying the effective date of the regulations. As the U.S. Court of Appeals for the D.C. Circuit stated with respect to an earlier IFR promulgated with respect to this issue in Priests for Life v. U.S. Department of Health and Human Services, 772 F.3d 229, 276 (D.C. Cir. 2014), vacated on other grounds, Zubik v. Burwell, 136 S. Ct. 1557 (2016), ‘‘[S]everal reasons support HHS’s decision not to engage in notice and comment here.’’ Among other things, the Court noted that ‘‘the agency made a good cause finding in the rule it issued’’; that ‘‘the regulations the interim final rule modifies were recently enacted pursuant to notice and comment rulemaking, and presented virtually identical issues’’; that ‘‘HHS will expose its interim rule to notice and comment before its permanent implementation’’; and that not proceeding under interim final rules would ‘‘delay the implementation of the alternative opt-out for religious objectors.’’ Id. at 277. Similarly, not proceeding with exemptions and accommodations for moral objectors here would delay the implementation of those alternative opt-outs for moral objectors. Delaying the availability of the expanded exemption could also increase the costs of health insurance for some entities. As reflected in litigation pertaining to the Mandate, some entities are in grandfathered health plans that do not cover 45 See, for example, https://www.regulations.gov/ #!documentDetail;D=HHS-OS-2011-0023-59496, https://www.regulations.gov/ #!documentDetail;D=CMS-2012-0031-79115, https://www.regulations.gov/document?D=CMS2016-0123-54142, https://www.regulations.gov/ document?D=CMS-2016-0123-54218, and https:// www.regulations.gov/document?D=CMS-2016-012346220. E:\FR\FM\13OCR3.SGM 13OCR3 47856 Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations asabaliauskas on DSKBBXCHB2PROD with RULES contraception. As such, they may wish to make changes to their health plans that will reduce the costs of insurance coverage for their beneficiaries or policyholders, but which would cause the plans to lose grandfathered status. To the extent that entities with objections to the Mandate based on moral convictions but not religious beliefs fall into this category, they may be refraining from making those changes—and therefore may be continuing to incur and pass on higher insurance costs—to prevent the Mandate from applying to their plans in violation of their consciences. We are not aware of the extent to which such entities exist, but 17 percent of all covered workers are in grandfathered health plans, encompassing tens of millions of people.46 Issuing these rules on an interim final basis reduces the costs of health insurance and regulatory burdens for such entities and their plan participants. These interim final rules also expand access to the optional accommodation process for certain entities with objections to the Mandate based on moral convictions. If entities exist that wish to use that process, the Departments believe they should be able to do so without the delay that would be involved by not offering them the optional accommodation process by use of interim final rules. Proceeding otherwise could delay the provision of contraceptive coverage to those entities’ employees. For the foregoing reasons, the Departments have determined that it would be impracticable and contrary to the public interest to engage in full notice and comment rulemaking before putting these interim final rules into effect, and that it is in the public interest to promulgate interim final rules. For the same reasons, the Departments have determined, consistent with section 553(d) of the APA (5 U.S.C. 553(d)), that there is good cause to make these interim final rules effective immediately upon filing for public inspection at the Office of the Federal Register. V. Economic Impact and Paperwork Burden We have examined the impacts of the interim final rules as required by Executive Order 12866 on Regulatory Planning and Review (September 30, 1993), Executive Order 13563 on Improving Regulation and Regulatory Review (January 18, 2011), the 46 Kaiser Family Foundation & Health Research & Educational Trust, ‘‘Employer Health Benefits, 2017 Annual Survey,’’ available at https://files.kff.org/ attachment/Report-Employer-Health-BenefitsAnnual-Survey-2017. VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96–354, section 1102(b) of the Social Security Act, section 202 of the Unfunded Mandates Reform Act of 1995 (March 22, 1995; Pub. L. 104–4), Executive Order 13132 on Federalism (August 4, 1999), the Congressional Review Act (5 U.S.C. 804(2) and Executive Order 13771 on Reducing Regulation and Controlling Regulatory Costs (January 30, 2017). A. Executive Orders 12866 and 13563— Department of HHS and Department of Labor Executive Orders 12866 and 13563 direct agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, and public health and safety effects; distributive impacts; and equity). Executive Order 13563 emphasizes the importance of quantifying both costs and benefits, reducing costs, harmonizing rules, and promoting flexibility. Section 3(f) of Executive Order 12866 defines a ‘‘significant regulatory action’’ as an action that is likely to result in a regulation: (1) Having an annual effect on the economy of $100 million or more in any 1 year, or adversely and materially affecting a sector of the economy, productivity, competition, jobs, the environment, public health or safety, or State, local, or tribal governments or communities (also referred to as ‘‘economically significant’’); (2) creating a serious inconsistency or otherwise interfering with an action taken or planned by another agency; (3) materially altering the budgetary impacts of entitlement grants, user fees, or loan programs or the rights and obligations of recipients thereof; or (4) raising novel legal or policy issues arising out of legal mandates, the President’s priorities, or the principles set forth in the Executive Order. A regulatory impact analysis must be prepared for major rules with economically significant effects ($100 million or more in any one year), and an ‘‘economically significant’’ regulatory action is subject to review by the Office of Management and Budget (OMB). As discussed below regarding anticipated effects of these rules and the Paperwork Reduction Act, these interim final rules are not likely to have economic impacts of $100 million or more in any one year, and therefore do not meet the definition of ‘‘economically significant’’ under PO 00000 Frm 00020 Fmt 4701 Sfmt 4700 Executive Order 12866. However, OMB has determined that the actions are significant within the meaning of section 3(f)(4) of the Executive Order. Therefore, OMB has reviewed these final regulations and the Departments have provided the following assessment of their impact. 1. Need for Regulatory Action These interim final rules amend the Departments’ July 2015 final regulations and do so in conjunction with the amendments made in the companion interim final rules concerning religious beliefs issued contemporaneously with these interim final rules and published elsewhere in this issue of the Federal Register. These interim final rules expand the exemption from the requirement to provide coverage for contraceptives and sterilization, established under the HRSA Guidelines, promulgated under section 2713(a)(4) of the PHS Act, section 715(a)(1) of the ERISA, and section 9815(a)(1) of the Code, to include certain entities and individuals with objections to compliance with the Mandate based on sincerely held moral convictions, and they revise the accommodation process to make entities with such convictions eligible to use it. The expanded exemption would apply to certain individuals, nonprofit entities, institutions of higher education, issuers, and for-profit entities that do not have publicly traded ownership interests, that have a moral objection to providing coverage for some (or all) of the contraceptive and/or sterilization services covered by the Guidelines. Such action is taken, among other reasons, to provide for conscientious participation in the health insurance market free from penalties for violating sincerely held moral convictions opposed to providing or receiving coverage of contraceptive services, to resolve lawsuits that have been filed against the Departments by some such entities, and to avoid similar legal challenges. 2. Anticipated Effects The Departments acknowledge that expanding the exemption to include objections based on moral convictions might result in less insurance coverage of contraception for some women who may want the coverage. Although the Departments do not know the exact scope of that effect attributable to the moral exemption in these interim final rules, they believe it to be small. With respect to the expanded exemption for nonprofit organizations, as noted above the Departments are aware of two small nonprofit E:\FR\FM\13OCR3.SGM 13OCR3 asabaliauskas on DSKBBXCHB2PROD with RULES Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations organizations that have filed lawsuits raising non-religious moral objections to coverage of some contraceptives. Both of those entities have fewer than five employees enrolled in health coverage, and both require all of their employees to agree with their opposition to the coverage.47 Based on comments submitted in response to prior rulemakings on this subject, we believe that at least one other similar entity exists. However, we do not know how many similar entities exist. Lacking other information we assume that the number is small. Without data to estimate the number of such entities, we believe it to be less than 10, and assume the exemption will be used by nine nonprofit entities. We also assume that those nine entities will operate in a fashion similar to the two similar entities of which we are aware, so that their employees will likely share their views against coverage of certain contraceptives. This is consistent with our conclusion in previous rules that no significant burden or costs would result from exempting houses of worship and integrated auxiliaries. (See 76 FR 46625 and 78 FR 39889). We reached that conclusion without ultimately requiring that houses of worship and integrated auxiliaries only hire persons who agree with their views against contraception, and without even requiring that such entities actually oppose contraception in order to be exempt (in contrast, the expanded exemption here requires the exempt entity to actually possess sincerely held moral convictions objecting to the coverage). In concluding that the exemption for houses of worship and integrated auxiliaries would result in no significant burden or costs, we relied on our assumption that the employees of exempt houses of worship and integrated auxiliaries likely share their employers’ opposition to contraceptive coverage. A similar assumption is supported with respect to the expanded exemption for nonprofit organizations. To our knowledge, the vast majority of organizations objecting to the Mandate assert religious beliefs. The only nonprofit organizations of which we are aware that possess non-religious moral convictions against some or all contraceptive methods only hire persons who share their convictions. It 47 Non-religious nonprofit organizations that engage in expressive activity generally have a First Amendment right to hire only people who share their moral convictions or will be respectful of them—including their convictions on whether the organization or others provide health coverage of contraception, or of certain items they view as being abortifacient. VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 is possible that the exemption for nonprofit organizations with moral convictions in these interim final rules could be used by a nonprofit organization that employs persons who do not share the organization’s views on contraception, but it was also possible under our previous rules that a house of worship or integrated auxiliary could employ persons who do not share their views on contraception.48 Although we are unable to find sufficient data on this issue, we believe that there are far fewer non-religious moral nonprofit organizations opposed to contraceptive coverage than there are churches with religious objections to such coverage. Based on our limited data, we believe the most likely effect of the expanded exemption for nonprofit entities is that it will be used by entities similar to the two entities that have sought an exemption through litigation, and whose employees also oppose the coverage. Therefore, we expect that the expanded exemption for nonprofit entities will have no effect of reducing contraceptive coverage to employees who want that coverage. These interim final rules expand the exemption to include institutions of higher education that arrange student coverage and have non-religious moral objections to the Mandate, and they make exempt entities with moral objections eligible to use the accommodation. The Departments are not aware of either kind of entity. We believe the number of entities that object to the Mandate based on nonreligious moral convictions is already very small. The only entities of which we are aware that have raised such objections are not institutions of higher education, and appear to hold objections that we assume would likely lead them to reject the accommodation process. Therefore, for the purposes of estimating the anticipated effect of these interim final rules on contraceptive coverage of women who wish to receive such coverage, we assume that—at this time—no entities with non-religious moral objections to the Mandate will be institutions of higher education that arrange student coverage, and no entities with non-religious moral objections will opt into the accommodation. We wish to make the expanded exemption and accommodation available to such entities in case they do exist or might 48 Cf., for example, Gallup, ‘‘Americans, Including Catholics, Say Birth Control Is Morally OK,’’ (May 22, 2012) (‘‘Eighty-two percent of U.S. Catholics say birth control is morally acceptable’’), available at https://www.gallup.com/poll/154799/ americans-including-catholics-say-birth-controlmorally.aspx. PO 00000 Frm 00021 Fmt 4701 Sfmt 4700 47857 come into existence, based on similar reasons to those given above for why the exemptions and accommodations are extended to other entities. We invite public comment on whether and how many such entities will make use of these interim final rules. The expanded exemption for issuers will not result in a distinct effect on contraceptive coverage for women who wish to receive it because that exemption only applies in cases where plan sponsors or individuals are also otherwise exempt, and the effect of those exemptions is discussed elsewhere herein. The expanded exemption for individuals that oppose contraceptive coverage based on sincerely held moral convictions will provide coverage that omits contraception for individuals that object to contraceptive coverage. The expanded moral exemption would also cover for-profit entities that do not have publicly traded ownership interests, and that have non-religious moral objections to the Mandate. The Departments are not aware of any forprofit entities that possess non-religious moral objections to the Mandate. However, scores of for-profit entities have filed suit challenging the Mandate. Among the over 200 entities that brought legal challenges, only two entities (less than 1 percent) raised nonreligious moral objections—both were nonprofit. Among the general public polls vary about religious beliefs, but one prominent poll shows that 89 percent of Americans say they believe in God.49 Among non-religious persons, only a very small percentage appears to hold moral objections to contraception. A recent study found that only 2 percent of religiously unaffiliated persons believed using contraceptives is morally wrong.50 Combined, this suggests that 0.2 percent of Americans at most 51 might believe contraceptives are morally wrong based on moral convictions but not religious beliefs. We have no information about how many of those persons run closely held businesses, offer employer sponsored health insurance, and would make use of the expanded exemption for moral 49 Gallup, ‘‘Most Americans Still Believe in God’’ (June 14–23, 2016), available at https:// www.gallup.com/poll/193271/americans-believegod.aspx. 50 Pew Research Center, ‘‘Where the Public Stands on Religious Liberty vs. Nondiscrimination’’ at page 26 (Sept. 28, 2016), available at https:// assets.pewresearch.org/wp-content/uploads/sites/ 11/2016/09/Religious-Liberty-full-for-web.pdf. 51 The study defined religiously ‘‘unaffiliated’’ as agnostic, atheist or ‘‘nothing in particular’’ (id. at 8), as distinct from several versions of Protestants, or Catholics. ‘‘Nothing in particular’’ might have included some theists. E:\FR\FM\13OCR3.SGM 13OCR3 47858 Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations asabaliauskas on DSKBBXCHB2PROD with RULES convictions set forth in these interim final rules. Given the large number of closely held entities that challenged the Mandate based on religious objections, we assume that some similar for-profit entities with non-religious moral objections exist. But we expect that it will be a comparatively small number of entities, since among the nonprofit litigants, only two were non-religious. Without data available to estimate the actual number of entities that will make use of the expanded exemption for forprofit entities that do not have publicly traded ownership interests and that have objections to the Mandate based on sincerely held moral convictions, we expect that fewer than 10 entities, if any, will do so—we assume nine forprofit entities will use the exemption in these interim final rules. The expanded exemption encompassing certain for-profit entities could result in the removal of contraceptive coverage from women who do not share their employers’ views. The Departments used data from the Current Population Survey (CPS) and the Medical Expenditure Panel Survey-Insurance Component (MEPS– IC) to obtain an estimate of the number of policyholders that will be covered by the plans of the nine for-profit entities we assume may make use of these expanded exemptions.52 The average number of policyholders (9) in plans with under 100 employees was obtained. It is not known what size the for-profit employers will be that might claim this exemption, but as discussed above these interim final rules do not include publicly traded companies (and we invite public comments on whether to do so in the final rules), and both of the two nonprofit entities that challenged the Mandate included fewer than five policyholders in each entity. Therefore we assume the for-profit entities that may claim this expanded exemption will have fewer than 100 employees and an average of 9 policyholders. For nine entities, the total number of policyholders would be 81. DOL estimates that for each policyholder, there is approximately one dependent.53 This amounts to 162 52 ‘‘Health Insurance Coverage Bulletin’’ Table 4, page 21. Using March 2015 Annual Social and Economic Supplement to the Current Population Survey. https://www.dol.gov/sites/default/files/ ebsa/researchers/data/health-and-welfare/healthinsurance-coverage-bulletin-2015.pdfEstimates of the number of ERISA Plans based on 2015 Medical Expenditure Survey—Insurance 53 ‘‘Health Insurance Coverage Bulletin’’ Table 4, page 21. Using March 2015 Annual Social and Economic Supplement to the Current Population Survey. https://www.dol.gov/sites/default/files/ ebsa/researchers/data/health-and-welfare/healthinsurance-coverage-bulletin-2015.pdf. VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 covered persons. Census data indicate that women of childbearing age—that is, women aged 15–44—comprise 20.2 percent of the general population.54 This amounts to approximately 33 women of childbearing age for this group of individuals covered by group plans sponsored by for-profit moral objectors. Approximately 44.3 percent of women currently use contraceptives covered by the Guidelines.55 Thus we estimate that 15 women may incur contraceptive costs due to for-profit entities using the expanded exemption provided in these interim final rules.56 In the companion interim final rules concerning religious beliefs issued contemporaneously with these interim final rules and published elsewhere in this issue of the Federal Register, we estimate that the average cost of contraception per year per woman of childbearing age that use contraception covered by the Guidelines, within health plans that cover contraception, is $584. Consequently, we estimate that the anticipated effects attributable to the cost of contraception from for-profit entities using the expanded exemption in these interim final rules is approximately $8,760. The Departments estimate that these interim final rules will not result in any additional burden or costs on issuers or third party administrators. As discussed above, we assume that no entities with non-religious moral convictions will use the accommodation, although we wish to make it available in case an entity voluntarily opts into it in order to allow contraceptive coverage to be provided to 54 U.S. Census Bureau, ‘‘Age and Sex Composition: 2010’’ (May 2011), available at https://www.census.gov/prod/cen2010/briefs/ c2010br-03.pdf. The Guidelines’ requirement of contraceptive coverage only applies ‘‘for all women with reproductive capacity.’’ https://www.hrsa.gov/ womensguidelines/; see also 80 FR 40318. In addition, studies commonly consider the 15–44 age range to assess contraceptive use by women of childbearing age. See, Guttmacher Institute, ‘‘Contraceptive Use in the United States’’ (Sept. 2016), available at https://www.guttmacher.org/factsheet/contraceptive-use-united-states. 55 See https://www.guttmacher.org/fact-sheet/ contraceptive-use-united-states. 56 We note that many non-religious for-profit entities which sued the Departments challenging the Mandate, including some of the largest employers, only objected to coverage of 4 of the 18 types of contraceptives required to be covered by the Mandate—namely, those contraceptives which they viewed as abortifacients, and akin to abortion —and they were willing to provide coverage for other types of contraception. It is reasonable to assume that this would also be the case with respect to some for-profits that object to the Mandate on the basis of sincerely held moral convictions. Accordingly, it is possible that even fewer women beneficiaries under such plans would bear out-ofpocket expenses in order to obtain contraceptives, and that those who might do so would bear lower costs due to many contraceptive items being covered. PO 00000 Frm 00022 Fmt 4701 Sfmt 4700 its plan participants and beneficiaries. Finally, because the accommodation process was not previously available to entities that possess non-religious moral objections to the Mandate, we do not anticipate that these interim final rules will result in any burden from such entities revoking their accommodated status. The Departments believe the foregoing analysis represents a reasonable estimate of the likely impact under the rules expanded exemptions. The Departments acknowledge uncertainty in the estimate and therefore conducted a second analysis using an alternative framework, which is set forth in the companion interim final rule concerning religious beliefs issued contemporaneously with this interim final rule and published elsewhere in this issue of the Federal Register. Under either estimate, this interim final rule is not economically significant. We reiterate the rareness of instances in which we are aware that employers assert non-religious objections to contraceptive coverage based on sincerely held moral convictions, as discussed above, and also that in the few instances where such an objection has been raised, employees of such employers also opposed contraception. We request comment on all aspects of the preceding regulatory impact analysis. B. Special Analyses—Department of the Treasury For purposes of the Department of the Treasury, certain Internal Revenue Service (IRS) regulations, including this one, are exempt from the requirements in Executive Order 12866, as supplemented by Executive Order 13563. The Departments estimate that the likely effect of these interim final rules will be that entities will use the exemption and not the accommodation. Therefore, a regulatory assessment is not required. C. Regulatory Flexibility Act The Regulatory Flexibility Act (5 U.S.C. 601 et seq.) (RFA) imposes certain requirements with respect to Federal rules that are subject to the notice and comment requirements of section 553(b) of the APA (5 U.S.C. 551 et seq.) and that are likely to have a significant economic impact on a substantial number of small entities. Under Section 553(b) of the APA, a general notice of proposed rulemaking is not required when an agency, for good cause, finds that notice and public comment thereon are impracticable, unnecessary, or contrary to the public E:\FR\FM\13OCR3.SGM 13OCR3 Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations asabaliauskas on DSKBBXCHB2PROD with RULES interest. The interim final rules are exempt from the APA, both because the PHS Act, ERISA, and the Code contain specific provisions under which the Secretaries may adopt regulations by interim final rule and because the Departments have made a good cause finding that a general notice of proposed rulemaking is not necessary earlier in this preamble. Therefore, the RFA does not apply and the Departments are not required to either certify that the regulations or this amendment would not have a significant economic impact on a substantial number of small entities or conduct a regulatory flexibility analysis. Nevertheless, the Departments carefully considered the likely impact of the rule on small entities in connection with their assessment under Executive Order 12866. The Departments do not expect that these interim final rules will have a significant economic effect on a substantial number of small entities, because they will not result in any additional costs to affected entities. Instead, by exempting from the Mandate small businesses and nonprofit organizations with moral objections to some or all contraceptives and/or sterilization, the Departments have reduced regulatory burden on small entities. Pursuant to section 7805(f) of the Code, these regulations have been submitted to the Chief Counsel for Advocacy of the Small Business Administration for comment on their impact on small business. D. Paperwork Reduction Act— Department of Health and Human Services Under the Paperwork Reduction Act of 1995 (the PRA), federal agencies are required to publish notice in the Federal Register concerning each proposed collection of information. Interested persons are invited to send comments regarding our burden estimates or any other aspect of this collection of information, including any of the following subjects: (1) The necessity and utility of the proposed information collection for the proper performance of the agency’s functions; (2) the accuracy of the estimated burden; (3) ways to enhance the quality, utility, and clarity of the information to be collected; and (4) the use of automated collection techniques or other forms of information technology to minimize the information collection burden. We estimate that these interim final rules will not result in additional burdens not accounted for as set forth in the companion interim final rules concerning religious beliefs issued VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 contemporaneously with these interim final rules and published elsewhere in this issue of the Federal Register. As discussed there, regulations covering the accommodation include provisions regarding self-certification or notices to HHS from eligible organizations (§ 147.131(c)(3)), notice of availability of separate payments for contraceptive services (§ 147.131(f)), and notice of revocation of accommodation (§ 147.131(c)(4)). The burdens related to those ICRs are currently approved under OMB Control Numbers 0938–1248 and 0938–1292. These interim final rules amend the accommodation regulations to make entities with moral objections to the Mandate eligible to use the same accommodation processes. The Departments will update the forms and model notices regarding these processes to reflect that entities with sincerely held moral convictions are eligible organizations. As discussed above, however, we assume that no entities with nonreligious moral objections to the Mandate will use the accommodation, and we know that no such entities were eligible for it until now, so that they do not possess accommodated status to revoke. Therefore we believe that the burden for these ICRs is accounted for in the collection approved under OMB Control Numbers 0938–1248 and 0938– 1292, as described in the interim final rules concerning religious beliefs issued contemporaneously with these interim final rules. We are soliciting comments on all of the possible information collection requirements contained in these interim final rules, including those discussed in the companion interim final rules concerning religious beliefs issued contemporaneously with these interim final rules and published elsewhere in this issue of the Federal Register, for which these interim final rules provide eligibility to entities with objections based on moral convictions. In addition, we are also soliciting comments on all of the related information collection requirements currently approved under 0938–1292 and 0938–1248. To obtain copies of a supporting statement and any related forms for the proposed collection(s) summarized in this notice, you may make your request using one of following: 1. Access CMS’ Web site address at https://www.cms.gov/Regulations-andGuidance/Legislation/ PaperworkReductionActof1995/PRAListing.html. 2. Email your request, including your address, phone number, OMB number, and CMS document identifier, to Paperwork@cms.hhs.gov. PO 00000 Frm 00023 Fmt 4701 Sfmt 4700 47859 3. Call the Reports Clearance Office at (410) 786–1326. If you comment on these information collections, that is, reporting, recordkeeping or third-party disclosure requirements, please submit your comments electronically as specified in the ADDRESSES section of these interim final rules with comment period. E. Paperwork Reduction Act— Department of Labor Under the Paperwork Reduction Act, an agency may not conduct or sponsor, and an individual is not required to respond to, a collection of information unless it displays a valid OMB control number. In accordance with the requirements of the PRA, the ICR for the EBSA Form 700 and alternative notice have previously been approved by OMB under control numbers 1210–0150 and 1210–0152. A copy of the ICR may be obtained by contacting the PRA addressee shown below or at https:// www.RegInfo.gov. PRA ADDRESSEE: G. Christopher Cosby, Office of Policy and Research, U.S. Department of Labor, Employee Benefits Security Administration, 200 Constitution Avenue NW., Room N–5718, Washington, DC 20210. Telephone: 202–693–8410; Fax: 202–219–4745. These are not toll-free numbers. Consistent with the analysis in the HHS PRA section above, although these interim final rules make entities with certain moral convictions eligible for the accommodation, we assume that no entities will use it rather than the exemption, and such entities were not previously eligible for the accommodation so as to revoke it. Therefore we believe these interim final rules do not involve additional burden not accounted for under OMB control number 1210–0150. Regarding the ICRs discussed in the companion interim final rules concerning religious beliefs issued contemporaneously with these interim final rules and published elsewhere in this issue of the Federal Register, the forms for which would be used if any entities with moral objections used the accommodation process in the future, DOL submitted those ICRs in order to obtain OMB approval under the PRA for the regulatory revision. The request was made under emergency clearance procedures specified in regulations at 5 CFR 1320.13. OMB approved the ICRs under the emergency clearance process. In an effort to consolidate the number of information collection requests, DOL indicated it will combine the ICR related to the OMB control number 1210–0152 with the ICR related to the OMB control number 1210–0150. Once E:\FR\FM\13OCR3.SGM 13OCR3 47860 Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations asabaliauskas on DSKBBXCHB2PROD with RULES the ICR is approved, DOL indicated it will discontinue 1210–0152. OMB approved the ICR under control number 1210–0150 through [DATE]. A copy of the information collection request may be obtained free of charge on the RegInfo.gov Web site at https:// www.reginfo.gov/public/do/ PRAViewICR?ref_nbr=201705-1210-001. This approval allows respondents temporarily to utilize the additional flexibility these interim final regulations provide, while DOL seeks public comment on the collection methods— including their utility and burden. Contemporaneously with the publication of these interim final rules, DOL will publish a notice in the Federal Register informing the public of its intention to extend the OMB approval. F. Regulatory Reform Executive Orders 13765, 13771 and 13777 Executive Order 13765 (January 20, 2017) directs that, ‘‘[t]o the maximum extent permitted by law, the Secretary of Health and Human Services (Secretary) and the heads of all other executive departments and agencies (agencies) with authorities and responsibilities under the Act shall exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications.’’ In addition, agencies are directed to ‘‘take all actions consistent with law to minimize the unwarranted economic and regulatory burdens of the [Affordable Care Act], and prepare to afford the States more flexibility and control to create a more free and open healthcare market.’’ These interim final rules exercise the discretion provided to the Departments under the Affordable Care Act and other laws to grant exemptions and thereby minimize regulatory burdens of the Affordable Care Act on the affected entities and recipients of health care services. Consistent with Executive Order 13771 (82 FR 9339, February 3, 2017), we have estimated the costs and cost savings attributable to this interim final rule. As discussed in more detail in the preceding analysis, this interim final rule lessens incremental reporting costs.57 Therefore, this interim final rule 57 Other noteworthy potential impacts encompass potential changes in medical expenditures, VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 is considered an EO 13771 deregulatory action. G. Unfunded Mandates Reform Act The Unfunded Mandates Reform Act of 1995 (section 202(a) of Pub. L. 104– 4), requires the Departments to prepare a written statement, which includes an assessment of anticipated costs and benefits, before issuing ‘‘any rule that includes any Federal mandate that may result in the expenditure by State, local, and tribal governments, in the aggregate, or by the private sector, of $100,000,000 or more (adjusted annually for inflation) in any one year.’’ The current threshold after adjustment for inflation is $148 million, using the most current (2016) Implicit Price Deflator for the Gross Domestic Product. For purposes of the Unfunded Mandates Reform Act, these interim final rules do not include any Federal mandate that may result in expenditures by State, local, or tribal governments, nor do they include any Federal mandates that may impose an annual burden of $100 million, adjusted for inflation, or more on the private sector. H. Federalism Executive Order 13132 outlines fundamental principles of federalism, and requires the adherence to specific criteria by Federal agencies in the process of their formulation and implementation of policies that have ‘‘substantial direct effects’’ on States, the relationship between the Federal Government and States, or the distribution of power and responsibilities among the various levels of Government. Federal agencies promulgating regulations that have these federalism implications must consult with state and local officials, and describe the extent of their consultation and the nature of the including potential decreased expenditures on contraceptive devices and drugs and potential increased expenditures on pregnancy-related medical services. OMB’s guidance on E.O. 13771 implementation (https://www.whitehouse.gov/thepress-office/2017/04/05/memorandumimplementing-executive-order-13771-titledreducing-regulation) states that impacts should be categorized as consistently as possible within Departments. The Food and Drug Administration, within HHS, and the Occupational Safety and Health Administration (OSHA) and Mine Safety and Health Administration (MSHA), within DOL, regularly estimate medical expenditure impacts in the analyses that accompany their regulations, with the results being categorized as benefits (positive benefits if expenditures are reduced, negative benefits if expenditures are raised). Following the FDA, OSHA and MSHA accounting convention leads to this interim final rule’s medical expenditure impacts being categorized as (positive or negative) benefits, rather than as costs, thus placing them outside of consideration for E.O. 13771 designation purposes. PO 00000 Frm 00024 Fmt 4701 Sfmt 4700 concerns of state and local officials in the preamble to the regulation. These interim final rules do not have any Federalism implications, since they only provide exemptions from the contraceptive and sterilization coverage requirement in HRSA Guidelines supplied under section 2713 of the PHS Act. VI. Statutory Authority The Department of the Treasury temporary regulations are adopted pursuant to the authority contained in sections 7805 and 9833 of the Code. The Department of Labor regulations are adopted pursuant to the authority contained in 29 U.S.C. 1002(16), 1027, 1059, 1135, 1161–1168, 1169, 1181– 1183, 1181 note, 1185, 1185a, 1185b, 1185d, 1191, 1191a, 1191b, and 1191c; sec. 101(g), Public Law 104–191, 110 Stat. 1936; sec. 401(b), Public Law 105– 200, 112 Stat. 645 (42 U.S.C. 651 note); sec. 512(d), Public Law 110–343, 122 Stat. 3881; sec. 1001, 1201, and 1562(e), Public Law 111–148, 124 Stat. 119, as amended by Public Law 111–152, 124 Stat. 1029; Secretary of Labor’s Order 1– 2011, 77 FR 1088 (Jan. 9, 2012). The Department of Health and Human Services regulations are adopted pursuant to the authority contained in sections 2701 through 2763, 2791, and 2792 of the PHS Act (42 U.S.C. 300gg through 300gg–63, 300gg–91, and 300gg–92), as amended; and Title I of the Affordable Care Act, sections 1301– 1304, 1311–1312, 1321–1322, 1324, 1334, 1342–1343, 1401–1402, and 1412, Pub. L. 111–148, 124 Stat. 119 (42 U.S.C. 18021–18024, 18031–18032, 18041–18042, 18044, 18054, 18061, 18063, 18071, 18082, 26 U.S.C. 36B, and 31 U.S.C. 9701). List of Subjects 26 CFR Part 54 Excise taxes, Health care, Health insurance, Pensions, Reporting and recordkeeping requirements. 29 CFR Part 2590 Continuation coverage, Disclosure, Employee benefit plans, Group health plans, Health care, Health insurance, Medical child support, Reporting and recordkeeping requirements. 45 CFR Part 147 Health care, Health insurance, Reporting and recordkeeping E:\FR\FM\13OCR3.SGM 13OCR3 Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations Kirsten B. Wielobob, Deputy Commissioner for Services and Enforcement. Approved: October 2, 2017. David J. Kautter, Assistant Secretary for Tax Policy. Signed this 4th day of October, 2017. Timothy D. Hauser, Deputy Assistant Secretary for Program Operations, Employee Benefits Security Administration, Department of Labor. DEPARTMENT OF THE TREASURY Internal Revenue Service For the reasons set forth in this preamble, 26 CFR part 54 is amended as follows: PART 54—PENSION EXCISE TAXES 1. The authority citation for part 54 continues to read, in part, as follows: ■ 3. The authority citation for part 2590 continues to read as follows: ■ Authority: 29 U.S.C. 1027, 1059, 1135, 1161–1168, 1169, 1181–1183, 1181 note, 1185, 1185a, 1185b, 1191, 1191a, 1191b, and 1191c; sec. 101(g), Pub. L. 104–191, 110 Stat. 1936; sec. 401(b), Pub. L. 105–200, 112 Stat. 645 (42 U.S.C. 651 note); sec. 512(d), Pub. L. 110–343, 122 Stat. 3881; sec. 1001, 1201, and 1562(e), Pub. L. 111–148, 124 Stat. 119, as amended by Pub. L. 111–152, 124 Stat. 1029; Division M, Pub. L. 113–235, 128 Stat. 2130; Secretary of Labor’s Order 1–2011, 77 FR 1088 (Jan. 9, 2012). [Amended] 4. Section 2590.715–2713, as amended elsewhere in this issue of the Federal Register], is further amended in paragraph (a)(1)(iv) by removing the reference ‘‘147.131 and 147.132’’ and adding in its place the reference ‘‘147.131, 147.132, and 147.133’’. ■ [Amended] 2. Section 54.9815–2713T, as added elsewhere in this issue of the Federal Register, is amended in paragraph (a)(1)(iv) by removing the reference ‘‘147.131 and 147.132’’ and adding in its place the reference ‘‘147.131, 147.132, and 147.133’’. ■ § 2590.715–2713A [Amended] 5. Section 2590.715–2713A, as revised elsewhere in this issue of the Federal Register], is further amended— ■ a. In paragraph (a)(1) by removing ‘‘(ii)’’ and adding in its place ‘‘(ii), or 45 CFR 147.133(a)(1)(i) or (ii)’’; ■ b. In paragraph (a)(2) by removing the reference ‘‘147.132(a)’’ and adding in its place the reference ‘‘147.132(a) or 147.133(a)’’; ■ c. In paragraph (b)(1)(ii) introductory text by removing the reference ‘‘147.132’’ and adding in its place the reference ‘‘147.132 or 147.133’’; ■ d. In paragraph (b)(1)(ii)(B) by removing the reference ‘‘147.132’’ and adding in its place the reference ‘‘147.132 or 147.133’’; ■ e. In paragraph (c)(1)(ii) introductory text by removing the reference ‘‘147.132’’ and adding in its place the reference ‘‘147.132 or 147.133’’; ■ f. In paragraph (c)(1)(ii)(B) by removing the reference ‘‘147.132’’ and ■ [Amended] 3. Section 54.9815–2713AT, as added elsewhere in this issue of the Federal Register], is amended— ■ a. In paragraph (a)(1) by removing ‘‘or (ii)’’ and adding in its place ‘‘or (ii), or 45 CFR 147.133(a)(1)(i) or (ii)’’; ■ b. In paragraph (a)(2) by removing the reference ‘‘147.132(a)’’ and adding in its place the reference ‘‘147.132(a) or 147.133(a)’’; ■ c. In paragraph (b)(1)(ii) introductory text by removing the reference ‘‘147.132’’ and adding in its place the reference ‘‘147.132 or 147.133’’; ■ d. In paragraph (b)(1)(ii)(B) by removing the reference ‘‘147.132’’ and adding in its place the reference ‘‘147.132 or 147.133’’; ■ e. In paragraph (c)(1)(ii) introductory text by removing the reference ‘‘147.132’’ and adding in its place the reference ‘‘147.132 or 147.133’’; ■ asabaliauskas on DSKBBXCHB2PROD with RULES PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS § 2590.715–2713 Authority: 26 U.S.C. 7805. * * * 00:09 Oct 13, 2017 For the reasons set forth in the preamble, the Department of Health and Human Services amends 45 CFR part 147 as follows: For the reasons set forth in the preamble, the Department of Labor amends 29 CFR part 2590 as follows: Approved: October 4, 2017. Donald Wright, Acting Secretary, Department of Health and Human Services. VerDate Sep<11>2014 adding in its place the reference ‘‘147.132 or 147.133’’; and ■ g. In paragraph (c)(2) introductory text by removing the reference ‘‘147.132’’ and adding in its place the reference ‘‘147.132 or 147.133’’. ■ Employee Benefits Security Administration Dated: October 4, 2017. Seema Verma, Administrator, Centers for Medicare & Medicaid Services. § 54.9815–2713AT f. In paragraph (c)(1)(ii)(B) by removing the reference ‘‘147.132’’ and adding in its place the reference ‘‘147.132 or 147.133’’; and ■ g. In paragraph (c)(2) introductory text by removing the reference ‘‘147.132’’ and adding in its place the reference ‘‘147.132 or 147.133’’. DEPARTMENT OF LABOR requirements, State regulation of health insurance. § 54.9815–2713T Jkt 244001 47861 PO 00000 Frm 00025 Fmt 4701 Sfmt 4700 DEPARTMENT OF HEALTH AND HUMAN SERVICES PART 147—HEALTH INSURANCE REFORM REQUIREMENTS FOR THE GROUP AND INDIVIDUAL HEALTH INSURANCE MARKETS 6. The authority citation for part 147 continues to read as follows: ■ Authority: Secs 2701 through 2763, 2791, and 2792 of the Public Health Service Act (42 U.S.C. 300gg through 300gg–63, 300gg–91, and 300gg–92), as amended. § 147.130 [Amended] 7. Section 147.130, as amended elsewhere in this issue of the Federal Register, is further amended in paragraphs (a)(1) introductory text and (a)(1)(iv) by removing the reference ‘‘§§ 147.131 and 147.132’’ and adding in its place the reference ‘‘§§ 147.131, 147.132, and 147.133’’. ■ § 147.131 [Amended] 8. Section 147.131, as revised elsewhere in this issue of the Federal Register, is further amended— ■ a. In paragraph (c)(1) by removing the reference ‘‘(ii)’’ and adding in its place the reference ‘‘(ii), or 45 CFR 147.133(a)(1)(i) or (ii)’’. ■ b. In paragraph (c)(2) by removing the reference ‘‘§ 147.132(a)’’ and adding in its place the reference ‘‘§ 147.132(a) or 147.133’’; and ■ c. In paragraphs (d)(1)(ii) introductory text, (d)(1)(ii)(B) and (d)(2) by removing the reference ‘‘§ 147.132’’ and to adding in its place the reference ‘‘§ 147.132 or 147.133’’. ■ 9. Add § 147.133 to read as follows: ■ § 147.133 Moral exemptions in connection with coverage of certain preventive health services. (a) Objecting entities. (1) Guidelines issued under § 147.130(a)(1)(iv) by the Health Resources and Services Administration must not provide for or support the requirement of coverage or payments for contraceptive services with respect to a group health plan established or maintained by an objecting organization, or health insurance coverage offered or arranged by an objecting organization, and thus E:\FR\FM\13OCR3.SGM 13OCR3 47862 Federal Register / Vol. 82, No. 197 / Friday, October 13, 2017 / Rules and Regulations asabaliauskas on DSKBBXCHB2PROD with RULES the Health Resources and Service Administration will exempt from any guidelines’ requirements that relate to the provision of contraceptive services: (i) A group health plan and health insurance coverage provided in connection with a group health plan to the extent one of the following nongovernmental plan sponsors object as specified in paragraph (a)(2) of this section: (A) A nonprofit organization; or (B) A for-profit entity that has no publicly traded ownership interests (for this purpose, a publicly traded ownership interest is any class of common equity securities required to be registered under section 12 of the Securities Exchange Act of 1934); (ii) An institution of higher education as defined in 20 U.S.C. 1002 in its arrangement of student health insurance coverage, to the extent that institution objects as specified in paragraph (a)(2) of this section. In the case of student health insurance coverage, this section is applicable in a manner comparable to its applicability to group health insurance coverage provided in connection with a group health plan established or maintained by a plan sponsor that is an employer, and references to ‘‘plan participants and beneficiaries’’ will be interpreted as references to student enrollees and their covered dependents; and (iii) A health insurance issuer offering group or individual insurance coverage VerDate Sep<11>2014 00:09 Oct 13, 2017 Jkt 244001 to the extent the issuer objects as specified in paragraph (a)(2) of this section. Where a health insurance issuer providing group health insurance coverage is exempt under paragraph (a)(1)(iii) of this section, the group health plan established or maintained by the plan sponsor with which the health insurance issuer contracts remains subject to any requirement to provide coverage for contraceptive services under Guidelines issued under § 147.130(a)(1)(iv) unless it is also exempt from that requirement. (2) The exemption of this paragraph (a) will apply to the extent that an entity described in paragraph (a)(1) of this section objects to its establishing, maintaining, providing, offering, or arranging (as applicable) coverage or payments for some or all contraceptive services, or for a plan, issuer, or third party administrator that provides or arranges such coverage or payments, based on its sincerely held moral convictions. (b) Objecting individuals. Guidelines issued under § 147.130(a)(1)(iv) by the Health Resources and Services Administration must not provide for or support the requirement of coverage or payments for contraceptive services with respect to individuals who object as specified in this paragraph (b), and nothing in § 147.130(a)(1)(iv), 26 CFR 54.9815–2713(a)(1)(iv), or 29 CFR 2590.715–2713(a)(1)(iv) may be PO 00000 Frm 00026 Fmt 4701 Sfmt 9990 construed to prevent a willing health insurance issuer offering group or individual health insurance coverage, and as applicable, a willing plan sponsor of a group health plan, from offering a separate policy, certificate or contract of insurance or a separate group health plan or benefit package option, to any individual who objects to coverage or payments for some or all contraceptive services based on sincerely held moral convictions. (c) Definition. For the purposes of this section, reference to ‘‘contraceptive’’ services, benefits, or coverage includes contraceptive or sterilization items, procedures, or services, or related patient education or counseling, to the extent specified for purposes of § 147.130(a)(1)(iv). (d) Severability. Any provision of this section held to be invalid or unenforceable by its terms, or as applied to any person or circumstance, shall be construed so as to continue to give maximum effect to the provision permitted by law, unless such holding shall be one of utter invalidity or unenforceability, in which event the provision shall be severable from this section and shall not affect the remainder thereof or the application of the provision to persons not similarly situated or to dissimilar circumstances. [FR Doc. 2017–21852 Filed 10–6–17; 11:15 am] BILLING CODE 4830–01–P; 4510–029–P; 4120–01–P; 6325–64–P E:\FR\FM\13OCR3.SGM 13OCR3

Agencies

[Federal Register Volume 82, Number 197 (Friday, October 13, 2017)]
[Rules and Regulations]
[Pages 47838-47862]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-21852]

[[Page 47837]]

Vol. 82

Friday,

No. 197

October 13, 2017

Part III

Department of the Treasury

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Internal Revenue Service

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26 CFR Part 54

Department of Labor

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Employee Benefits Security Administration

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29 CFR Part 2590

Department of Health and Human Services

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45 CFR Part 147

Moral Exemptions and Accommodations for Coverage of Certain Preventive
Services Under the Affordable Care Act; Final Rule

Federal Register / Vol. 82 , No. 197 / Friday, October 13, 2017 /
Rules and Regulations

[[Page 47838]]

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DEPARTMENT OF THE TREASURY

Internal Revenue Service

26 CFR Part 54

[TD-9828]
RIN 1545-BN91

DEPARTMENT OF LABOR

Employee Benefits Security Administration

29 CFR Part 2590

RIN 1210-AB84

DEPARTMENT OF HEALTH AND HUMAN SERVICES

45 CFR Part 147

[CMS-9925-IFC]
RIN 0938-AT46

Moral Exemptions and Accommodations for Coverage of Certain
Preventive Services Under the Affordable Care Act

AGENCY: Internal Revenue Service, Department of the Treasury; Employee
Benefits Security Administration, Department of Labor; and Centers for
Medicare & Medicaid Services, Department of Health and Human Services.

ACTION: Interim final rules with request for comments.

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SUMMARY: The United States has a long history of providing conscience
protections in the regulation of health care for entities and
individuals with objections based on religious beliefs or moral
convictions. These interim final rules expand exemptions to protect
moral convictions for certain entities and individuals whose health
plans are subject to a mandate of contraceptive coverage through
guidance issued pursuant to the Patient Protection and Affordable Care
Act. These rules do not alter the discretion of the Health Resources
and Services Administration, a component of the United States
Department of Health and Human Services, to maintain the guidelines
requiring contraceptive coverage where no regulatorily recognized
objection exists. These rules also provide certain morally objecting
entities access to the voluntary ``accommodation'' process regarding
such coverage. These rules do not alter multiple other Federal programs
that provide free or subsidized contraceptives for women at risk of
unintended pregnancy.

DATES:
Effective date: These interim final rules are effective on October
6, 2017.
Comment date: Written comments on these interim final rules are
invited and must be received by December 5, 2017.

ADDRESSES: Written comments may be submitted to the Department of
Health and Human Services as specified below. Any comment that is
submitted will be shared with the Department of Labor and the
Department of the Treasury, and will also be made available to the
public.
Warning: Do not include any personally identifiable information
(such as name, address, or other contact information) or confidential
business information that you do not want publicly disclosed. All
comments may be posted on the Internet and can be retrieved by most
Internet search engines. No deletions, modifications, or redactions
will be made to the comments received, as they are public records.
Comments may be submitted anonymously. Comments, identified by
``Preventive Services,'' may be submitted one of four ways (please
choose only one of the ways listed)
1. Electronically. You may submit electronic comments on this
regulation to https://www.regulations.gov. Follow the ``Submit a
comment'' instructions.
2. By regular mail. You may mail written comments to the following
address ONLY: Centers for Medicare & Medicaid Services, Department of
Health and Human Services, Attention: CMS-9925-IFC, P.O. Box 8016,
Baltimore, MD 21244-8016.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address ONLY: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-9925-IFC, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
4. By hand or courier. Alternatively, you may deliver (by hand or
courier) your written comments ONLY to the following addresses prior to
the close of the comment period:
a. For delivery in Washington, DC--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, Room 445-G, Hubert
H. Humphrey Building, 200 Independence Avenue SW., Washington, DC
20201.
(Because access to the interior of the Hubert H. Humphrey Building
is not readily available to persons without Federal government
identification, commenters are encouraged to leave their comments in
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing
by stamping in and retaining an extra copy of the comments being
filed.)
b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, 7500 Security
Boulevard, Baltimore, MD 21244-1850.
If you intend to deliver your comments to the Baltimore address,
call telephone number (410) 786-9994 in advance to schedule your
arrival with one of our staff members.
Comments erroneously mailed to the addresses indicated as
appropriate for hand or courier delivery may be delayed and received
after the comment period.
Comments received will be posted without change to
www.regulations.gov.

FOR FURTHER INFORMATION CONTACT: Jeff Wu (310) 492-4305 or
marketreform@cms.hhs.gov for Centers for Medicare & Medicaid Services
(CMS), Department of Health and Human Services (HHS), Amber Rivers or
Matthew Litton, Employee Benefits Security Administration (EBSA),
Department of Labor, at (202) 693-8335; Karen Levin, Internal Revenue
Service, Department of the Treasury, at (202) 317-5500.
Customer Service Information: Individuals interested in obtaining
information from the Department of Labor concerning employment-based
health coverage laws may call the EBSA Toll-Free Hotline at 1-866-444-
EBSA (3272) or visit the Department of Labor's Web site (www.dol.gov/ebsa). Information from HHS on private health insurance coverage can be
found on CMS's Web site (www.cms.gov/cciio), and information on health
care reform can be found at www.HealthCare.gov.

SUPPLEMENTARY INFORMATION:

I. Background

In the context of legal requirements touching on certain sensitive
health care issues--including health coverage of contraceptives--
Congress has a consistent history of supporting conscience protections
for moral convictions alongside protections for religious beliefs,
including as part of its efforts to promote access to health
services.\1\ Against that backdrop,

[[Page 47839]]

Congress granted the Health Resources and Services Administration
(HRSA), a component of the United States Department of Health and Human
Services (HHS), discretion under the Patient Protection and Affordable
Care Act to specify that certain group health plans and health
insurance issuers shall cover, ``with respect to women, such additional
preventive care and screenings . . . as provided for in comprehensive
guidelines supported by'' HRSA (the ``Guidelines''). Public Health
Service Act section 2713(a)(4). HRSA exercised that discretion under
the last Administration to require health coverage for, among other
things, certain contraceptive services,\2\ while the administering
agencies--the Departments of Health and Human Services, Labor, and the
Treasury (collectively, ``the Departments''),\3\ exercised both the
discretion granted to HHS through HRSA, its component, in PHS Act
section 2713(a)(4), and the authority granted to the Departments as
administering agencies (26 U.S.C. 9833; 29 U.S.C. 1191c; 42 U.S.C.
300gg-92) to issue regulations to guide HRSA in carrying out that
provision. Through rulemaking, including three interim final rules, the
Departments exempted and accommodated certain religious objectors, but
did not offer an exemption or accommodation to any group possessing
non-religious moral objections to providing coverage for some or all
contraceptives. Many individuals and entities challenged the
contraceptive coverage requirement and regulations (hereinafter, the
``contraceptive Mandate,'' or the ``Mandate'') as being inconsistent
with various legal protections. These challenges included lawsuits
brought by some non-religious organizations with sincerely held moral
convictions inconsistent with providing coverage for some or all
contraceptive services, and those cases continue to this day. Various
public comments were also submitted asking the Departments to protect
objections based on moral convictions.
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\1\ See, for example, 42 U.S.C. 300a-7 (protecting individuals
and health care entities from being required to provide or assist
sterilizations, abortions, or other lawful health services if it
would violate their ``religious beliefs or moral convictions''); 42
U.S.C. 238n (protecting individuals and entities that object to
abortion); Consolidated Appropriations Act of 2017, Div. H, Title V,
Sec. 507(d) (Departments of Labor, HHS, and Education, and Related
Agencies Appropriations Act), Public Law 115-31 (protecting any
``health care professional, a hospital, a provider-sponsored
organization, a health maintenance organization, a health insurance
plan, or any other kind of health care facility, organization, or
plan'' in objecting to abortion for any reason); Id. at Div. C,
Title VIII, Sec. 808 (regarding any requirement of ``the provision
of contraceptive coverage by health insurance plans'' in the
District of Columbia, ``it is the intent of Congress that any
legislation enacted on such issue should include a `conscience
clause' which provides exceptions for religious beliefs and moral
convictions.''); Id. at Div. C, Title VII, Sec. 726(c) (Financial
Services and General Government Appropriations Act) (protecting
individuals who object to prescribing or providing contraceptives
contrary to their ``religious beliefs or moral convictions''); Id.
at Div. I, Title III (Department of State, Foreign Operations, and
Related Programs Appropriations Act) (protecting applicants for
family planning funds based on their ``religious or conscientious
commitment to offer only natural family planning''); 42 U.S.C.
290bb-36 (prohibiting the statutory section from being construed to
require suicide related treatment services for youth where the
parents or legal guardians object based on ``religious beliefs or
moral objections''); 42 U.S.C. 1395w-22(j)(3)(B) (protecting against
forced counseling or referrals in Medicare Choice, now Medicare
Advantage, managed care plans with respect to objections based on
``moral or religious grounds''); 42 U.S.C. 1396a(w)(3) (ensuring
particular Federal law does not infringe on ``conscience'' as
protected in State law concerning advance directives); 42 U.S.C.
1396u-2(b)(3) (protecting against forced counseling or referrals in
Medicaid managed care plans with respect to objections based on
``moral or religious grounds''); 42 U.S.C. 2996f(b) (protecting
objection to abortion funding in legal services assistance grants
based on ``religious beliefs or moral convictions''); 42 U.S.C.
14406 (protecting organizations and health providers from being
required to inform or counsel persons pertaining to assisted
suicide); 42 U.S.C. 18023 (blocking any requirement that issuers or
exchanges must cover abortion); 42 U.S.C. 18113 (protecting health
plans or health providers from being required to provide an item or
service that helps cause assisted suicide); see also 8 U.S.C.
1182(g) (protecting vaccination objections by ``aliens'' due to
``religious beliefs or moral convictions''); 18 U.S.C. 3597
(protecting objectors to participation in Federal executions based
on ``moral or religious convictions''); 20 U.S.C. 1688 (prohibiting
sex discrimination law to be used to require assistance in abortion
for any reason); 22 U.S.C. 7631(d) (protecting entities from being
required to use HIV/AIDS funds contrary to their ``religious or
moral objection'').
\2\ This document's references to ``contraception,''
``contraceptive,'' ``contraceptive coverage,'' or ``contraceptive
services'' generally includes contraceptives, sterilization, and
related patient education and counseling, unless otherwise
indicated.
\3\ Note, however, that in sections under headings listing only
two of the three Departments, the term ``Departments'' generally
refers only to the two Departments listed in the heading.
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The Departments have recently exercised our discretion to
reevaluate these exemptions and accommodations. This evaluation
includes consideration of various factors, such as: The interests
served by the existing Guidelines, regulations, and accommodation
process; \4\ the extensive litigation; Executive Order 13798,
``Promoting Free Speech and Religious Liberty'' (May 4, 2017);
Congress' history of providing protections for moral convictions
alongside religious beliefs regarding certain health services
(including contraception, sterilization, and items or services believed
to involve abortion); the discretion afforded under PHS Act section
2713(a)(4); the structure and intent of that provision in the broader
context of section 2713 and the Patient Protection and Affordable Care
Act; and the history of the regulatory process and comments submitted
in various requests for public comments (including in the Departments'
2016 Request for Information). Elsewhere in this issue of the Federal
Register, the Departments published, contemporaneously with these
interim final rules, companion interim final rules expanding exemptions
to protect sincerely held religious beliefs in the context of the
contraceptive Mandate.
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\4\ In this IFR, we generally use ``accommodation'' and
``accommodation process'' interchangeably.
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In light of these considerations, the Departments issue these
interim final rules to better balance the Government's interest in
promoting coverage for contraceptive and sterilization services with
the Government's interests in providing conscience protections for
individuals and entities with sincerely held moral convictions in
certain health care contexts, and in minimizing burdens imposed by our
regulation of the health insurance market.

A. The Affordable Care Act

Collectively, the Patient Protection and Affordable Care Act (Pub.
L. 111-148), enacted on March 23, 2010, and the Health Care and
Education Reconciliation Act of 2010 (Pub. L. 111-152), enacted on
March 30, 2010, are known as the Affordable Care Act. In signing the
Affordable Care Act, President Obama issued Executive Order 13535
(March 24, 2010), which declared that, ``[u]nder the Act, longstanding
Federal laws to protect conscience (such as the Church Amendment, 42
U.S.C. 300a-7, and the Weldon Amendment, section 508(d)(1) of Pub. L.
111-8) remain intact'' and that ``[n]umerous executive agencies have a
role in ensuring that these restrictions are enforced, including the
Department of Health and Human Services (HHS).'' Those laws protect
objections based on moral convictions in addition to religious beliefs.
The Affordable Care Act reorganizes, amends, and adds to the
provisions of part A of title XXVII of the Public Health Service Act
(PHS Act) relating to group health plans and health insurance issuers
in the group and individual markets. In addition, the Affordable Care
Act adds section 715(a)(1) to the Employee Retirement Income Security
Act of 1974 (ERISA) and section 9815(a)(1) to the Internal Revenue Code
(Code) to incorporate the provisions of part A of title XXVII of the
PHS Act into ERISA and the Code, and thereby make them applicable to
certain group health plans regulated under ERISA or the Code. The
sections of the PHS Act incorporated into ERISA and the Code are
sections 2701 through 2728 of the PHS Act.
These interim final rules concern section 2713 of the PHS Act.
Where it applies, section 2713(a)(4) of the PHS

[[Page 47840]]

Act requires coverage without cost sharing for ``such additional''
women's preventive care and screenings ``as provided for'' and
``supported by'' guidelines developed by HRSA/HHS. The Congress did not
specify any particular additional preventive care and screenings with
respect to women that HRSA could or should include in its Guidelines,
nor did Congress indicate whether the Guidelines should include
contraception and sterilization.
The Departments have consistently interpreted section 2713(a)(4)'s
of the PHS Act grant of authority to include broad discretion to decide
the extent to which HRSA will provide for and support the coverage of
additional women's preventive care and screenings in the Guidelines. In
turn, the Departments have interpreted that discretion to include the
ability to exempt entities from coverage requirements announced in
HRSA's Guidelines. That interpretation is rooted in the text of section
2713(a)(4) of the PHS Act, which allows HRSA to decide the extent to
which the Guidelines will provide for and support the coverage of
additional women's preventive care and screenings.
Accordingly, the Departments have consistently interpreted section
2713(a)(4) of the PHS Act reference to ``comprehensive guidelines
supported by the Health Resources and Services Administration for
purposes of this paragraph'' to grant HRSA authority to develop such
Guidelines. And because the text refers to Guidelines ``supported by
the Health Resources and Services Administration for purposes of this
paragraph,'' the Departments have consistently interpreted that
authority to afford HRSA broad discretion to consider the requirements
of coverage and cost-sharing in determining the nature and extent of
preventive care and screenings recommended in the guidelines. (76 FR
46623). As the Departments have noted, these Guidelines are different
from ``the other guidelines referenced in section 2713(a), which pre-
dated the Affordable Care Act and were originally issued for purposes
of identifying the non-binding recommended care that providers should
provide to patients.'' Id. Guidelines developed as nonbinding
recommendations for care implicate significantly different legal and
policy concerns than guidelines developed for a mandatory coverage
requirement. To guide HRSA in exercising the discretion afforded to it
in section 2713(a)(4), the Departments have previously promulgated
regulations defining the scope of permissible religious exemptions and
accommodations for such guidelines. (45 CFR 147.131). The interim final
rules set forth herein are a necessary and appropriate exercise of the
authority delegated to the Departments as administrators of the
statutes. (26 U.S.C. 9833; 29 U.S.C. 1191c; 42 U.S.C. 300gg-92).
Our interpretation of section 2713(a)(4) of the PHS Act is
confirmed by the Affordable Care Act's statutory structure. The
Congress did not intend to require entirely uniform coverage of
preventive services. (76 FR 46623). To the contrary, Congress carved
out an exemption from section 2713 for grandfathered plans. This
exemption is not applicable to many of the other provisions in Title I
of the Affordable Care Act--provisions previously referred to by the
Departments as providing ``particularly significant protections.'' (75
FR 34540). Those provisions include: Section 2704, which prohibits
preexisting condition exclusions or other discrimination based on
health status in group health coverage; section 2708, which prohibits
excessive waiting periods (as of January 1, 2014); section 2711, which
relates to lifetime limits; section 2712, which prohibits rescissions
of health insurance coverage; section 2714, which extends dependent
coverage until age 26; and section 2718, which imposes a medical loss
ratio on health insurance issuers in the individual and group markets
(for insured coverage), or requires them to provide rebates to
policyholders. (75 FR 34538, 34540, 34542). Consequently, of the 150
million nonelderly people in America with employer-sponsored health
coverage, approximately 25.5 million are estimated to be enrolled in
grandfathered plans not subject to section 2713 of the PHS Act.\5\ As
the Supreme Court observed, ``there is no legal requirement that
grandfathered plans ever be phased out.'' Burwell v. Hobby Lobby
Stores, Inc., 134 S. Ct. 2751, 2764 n.10 (2014).
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\5\ Kaiser Family Foundation & Health Research & Educational
Trust, ``Employer Health Benefits, 2017 Annual Survey,'' available
at https://files.kff.org/attachment/Report-Employer-Health-Benefits-Annual-Survey-2017.
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The Departments' interpretation of section 2713(a)(4) of the PHS
Act to permit HRSA to establish exemptions from the Guidelines, and of
the Departments' own authority as administering agencies to guide HRSA
in establishing such exemptions, is also consistent with Executive
Order 13535. That order, issued upon the signing of the Affordable Care
Act, specified that ``longstanding Federal laws to protect conscience .
. . remain intact,'' including laws that protect religious beliefs and
moral convictions from certain requirements in the health care context.
Although the text of Executive Order 13535 does not require the
expanded exemptions issued in these interim final rules, the expanded
exemptions are, as explained below, consistent with longstanding
Federal laws to protect conscience regarding certain health matters,
and are consistent with the intent that the Affordable Care Act would
be implemented in consideration of the protections set forth in those
laws.

B. The Regulations Concerning Women's Preventive Services

On July 19, 2010, the Departments issued interim final rules
implementing section 2713 of the PHS Act (75 FR 41726). Those interim
final rules charged HRSA with developing the Guidelines authorized by
section 2713(a)(4) of the PHS Act.
1. The Institute of Medicine Report
In developing the Guidelines, HRSA relied on an independent report
from the Institute of Medicine (IOM, now known as the National Academy
of Medicine) on women's preventive services, issued on July 19, 2011,
``Clinical Preventive Services for Women, Closing the Gaps'' (IOM
2011). The IOM's report was funded by the HHS Office of the Assistant
Secretary for Planning and Evaluation, pursuant to a funding
opportunity that charged the IOM to conduct a review of effective
preventive services to ensure women's health and well-being.\6\
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\6\ Because section 2713(a)(4) of the PHS Act specifies that the
HRSA Guidelines shall include preventive care and screenings ``with
respect to women,'' the Guidelines exclude services relating to a
man's reproductive capacity, such as vasectomies and condoms.
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The IOM made a number of recommendations with respect to women's
preventive services. As relevant here, the IOM recommended that the
Guidelines cover the full range of Food and Drug Administration (FDA)-
approved contraceptive methods, sterilization procedures, and patient
education and counseling for women with reproductive capacity. Because
FDA includes in the category of ``contraceptives'' certain drugs and
devices that may not only prevent conception (fertilization), but may
also prevent implantation of an embryo,\7\ the IOM's recommendation
included

[[Page 47841]]

several contraceptive methods that many persons and organizations
believe are abortifacient--that is, as causing early abortion--and
which they conscientiously oppose for that reason distinct from whether
they also oppose contraception or sterilization. One of the 16 members
of the IOM committee, Dr. Anthony LoSasso, a Professor at the
University of Illinois at Chicago School of Public Health, wrote a
formal dissenting opinion. He stated that the IOM committee did not
have sufficient time to evaluate fully the evidence on whether the use
of preventive services beyond those encompassed by section 2713(a)(1)
through (3) of the PHS Act leads to lower rates of disability or
disease and increased rates of well-being, such that the IOM should
recommend additional services to be included under Guidelines issued
under section 2713(a)(4) of the PHS Act. He further stated that ``the
recommendations were made without high quality, systematic evidence of
the preventive nature of the services considered,'' and that ``the
committee process for evaluation of the evidence lacked transparency
and was largely subject to the preferences of the committee's
composition. Troublingly, the process tended to result in a mix of
objective and subjective determinations filtered through a lens of
advocacy.'' He also raised concerns that the committee did not have
time to develop a framework for determining whether coverage of any
given preventive service leads to a reduction in healthcare
expenditure.\8\ IOM 2011 at 231-32. In its response to Dr. LoSasso, the
other 15 committee members stated in part that ``At the first committee
meeting, it was agreed that cost considerations were outside the scope
of the charge, and that the committee should not attempt to duplicate
the disparate review processes used by other bodies, such as the
USPSTF, ACIP, and Bright Futures. HHS, with input from this committee,
may consider other factors including cost in its development of
coverage decisions.''
---------------------------------------------------------------------------

\7\ FDA's guide ``Birth Control: Medicines To Help You,''
specifies that various approved contraceptives, including
Levonorgestrel, Ulipristal Acetate, and IUDs, work mainly by
preventing fertilization and ``may also work . . . by preventing
attachment (implantation) to the womb (uterus)'' of a human embryo
after fertilization. Available at https://www.fda.gov/forconsumers/byaudience/forwomen/freepublications/ucm313215.htm.
\8\ The Departments do not relay these dissenting remarks as an
endorsement of the remarks, but to describe the history of the
Guidelines, which includes this part of the report that IOM provided
to HRSA.
---------------------------------------------------------------------------

2. HRSA's 2011 Guidelines and the Departments' Second Interim Final
Rules
On August 1, 2011, HRSA released onto its Web site its Guidelines
for women's preventive services, adopting the recommendations of the
IOM. https://www.hrsa.gov/womensguidelines/ The Guidelines included
coverage for all FDA-approved contraceptives, sterilization procedures,
and related patient education and counseling for women with
reproductive capacity, as prescribed by a health care provider
(hereinafter ``the Mandate'').
In administering this Mandate, on August 1, 2011, the Departments
promulgated interim final rules amending our 2010 interim final rules.
(76 FR 46621) (2011 interim final rules). The 2011 interim final rules
specified that HRSA has the authority to establish exemptions from the
contraceptive coverage requirement for certain group health plans
established or maintained by certain religious employers and for health
insurance coverage provided in connection with such plans.\9\ The 2011
interim final rules only offered the exemption to a narrow scope of
employers, and only if they were religious. As the basis for adopting
that limited definition of religious employer, the 2011 interim final
rules stated that they relied on the laws of some ``States that exempt
certain religious employers from having to comply with State law
requirements to cover contraceptive services.'' (76 FR 46623). Several
comments were submitted asking that the exemption include those who
object to contraceptive coverage based on non-religious moral
convictions, including pro-life, non-profit advocacy organizations.\10\
---------------------------------------------------------------------------

\9\ The 2011 amended interim final rules were issued and
effective on August 1, 2011, and published in the Federal Register
on August 3, 2011. (76 FR 46621).
\10\ See, for example, Americans United for Life (``AUL'')
Comment on CMA-9992-IFC2 at 10 (Nov. 1, 2011), available at https://www.regulations.gov/#!documentDetail;D=HHS-OS-2011-0023-59496.
---------------------------------------------------------------------------

3. The Departments' Subsequent Rulemaking on the Accommodation and
Third Interim Final Rules
Final regulations issued on February 10, 2012, adopted the
definition of ``religious employer'' in the 2011 interim final rules
without modification (2012 final regulations).\11\ (77 FR 8725). The
exemption did not require exempt employers to file any certification
form or comply with any other information collection process.
---------------------------------------------------------------------------

\11\ The 2012 final regulations were published on February 15,
2012 (77 FR 8725).
---------------------------------------------------------------------------

Contemporaneously with the issuance of the 2012 final regulations,
HHS--with the agreement of the Department of Labor (DOL) and the
Department of the Treasury--issued guidance establishing a temporary
safe harbor from enforcement of the contraceptive coverage requirement
by the Departments with respect to group health plans established or
maintained by certain nonprofit organizations with religious objections
to contraceptive coverage (and the group health insurance coverage
provided in connection with such plans).\12\ The temporary safe harbor
did not include nonprofit organizations that had an objection to
contraceptives based on moral convictions but not religious beliefs,
nor did it include for-profit entities of any kind. The Departments
stated that, during the temporary safe harbor, the Departments would
engage in rulemaking to achieve ``two goals--providing contraceptive
coverage without cost-sharing to individuals who want it and
accommodating non-exempted, nonprofit organizations' religious
objections to covering contraceptive services.'' (77 FR 8727).
---------------------------------------------------------------------------

\12\ Guidance on the Temporary Enforcement Safe Harbor for
Certain Employers, Group Health Plans, and Group Health Insurance
Issuers with Respect to the Requirement to Cover Contraceptive
Services Without Cost Sharing Under section 2713 of the Public
Health Service Act, Section 715(a)(1) of the Employee Retirement
Income Security Act, and Section 9815(a)(1) of the Internal Revenue
Code, issued on February 10, 2012, and reissued on August 15, 2012.
Available at: https://www.lb7.uscourts.gov/documents/12cv3932.pdf.
The guidance, as reissued on August 15, 2012, clarified, among other
things, that plans that took some action before February 10, 2012,
to try, without success, to exclude or limit contraceptive coverage
were not precluded from eligibility for the safe harbor. The
temporary enforcement safe harbor was also available to insured
student health insurance coverage arranged by nonprofit institutions
of higher education with religious objections to contraceptive
coverage that met the conditions set forth in the guidance. See
final rule entitled ``Student Health Insurance Coverage'' published
March 21, 2012 (77 FR 16457).
---------------------------------------------------------------------------

On March 21, 2012, the Departments published an advance notice of
proposed rulemaking (ANPRM) that described possible approaches to
achieve those goals with respect to religious nonprofit organizations,
and solicited public comments on the same. (77 FR 16501). Following
review of the comments on the ANPRM, the Departments published proposed
regulations on February 6, 2013 (2013 NPRM) (78 FR 8456).
The 2013 NPRM proposed to expand the definition of ``religious
employer'' for purposes of the religious employer exemption.
Specifically, it proposed to require only that the religious employer
be organized and operate as a nonprofit entity and be referred to in
section 6033(a)(3)(A)(i) or (iii) of the Code, eliminating the
requirements that a religious employer--(1) have the inculcation of
religious values as its purpose; (2) primarily employ persons who share
its religious tenets; and (3) primarily serve persons who share its
religious tenets. The proposed expanded

[[Page 47842]]

definition still encompassed only religious entities.
The 2013 NPRM also proposed to create a compliance process, which
it called an accommodation, for group health plans established,
maintained, or arranged by certain eligible nonprofit organizations
that fell outside the houses of worship and integrated auxiliaries
covered by section 6033(a)(3)(A)(i) or (iii) of the Code (and, thus,
outside of the religious employer exemption). The 2013 NPRM proposed to
define such eligible organizations as nonprofit entities that hold
themselves out as religious, oppose providing coverage for certain
contraceptive items on account of religious objections, and maintain a
certification to this effect in their records. The 2013 NPRM stated,
without citing a supporting source, that employees of eligible
organizations ``may be less likely than'' employees of exempt houses of
worship and integrated auxiliaries to share their employer's faith and
opposition to contraception on religious grounds. (78 FR 8461). The
2013 NPRM therefore proposed that, in the case of an insured group
health plan established or maintained by an eligible organization, the
health insurance issuer providing group health insurance coverage in
connection with the plan would provide contraceptive coverage to plan
participants and beneficiaries without cost sharing, premium, fee, or
other charge to plan participants or beneficiaries enrolled in the
eligible organization's plan--and without any cost to the eligible
organization.\13\ In the case of a self-insured group health plan
established or maintained by an eligible organization, the 2013 NPRM
presented potential approaches under which the third party
administrator of the plan would provide or arrange for contraceptive
coverage to plan participants and beneficiaries. The proposed
accommodation process was not to be offered to non-religious nonprofit
organizations, nor to any for-profit entities. Public comments again
included the request that exemptions encompass objections to
contraceptive coverage based on moral convictions and not just based on
religious beliefs.\14\ On August 15, 2012, the Departments extended our
temporary safe harbor until the first plan year beginning on or after
August 1, 2013.
---------------------------------------------------------------------------

\13\ The NPRM proposed to treat student health insurance
coverage arranged by eligible organizations that are institutions of
higher education in a similar manner.
\14\ See,for example, AUL Comment on CMS-9968-P at 5 (Apr. 8,
2013), available at https://www.regulations.gov/#!documentDetail;D=CMS-2012-0031-79115.
---------------------------------------------------------------------------

The Departments published final regulations on July 2, 2013 (July
2013 final regulations) (78 FR 39869). The July 2013 final regulations
finalized the expansion of the exemption for houses of worship and
their integrated auxiliaries. Although some commenters had suggested
that the exemption be further expanded, the Departments declined to
adopt that approach. The July 2013 regulations stated that, because
employees of objecting houses of worship and integrated auxiliaries are
relatively likely to oppose contraception, exempting those
organizations ``does not undermine the governmental interests furthered
by the contraceptive coverage requirement.'' (78 FR 39874). However,
like the 2013 NPRM, the July 2013 regulations assumed that ``[h]ouses
of worship and their integrated auxiliaries that object to
contraceptive coverage on religious grounds are more likely than other
employers to employ people of the same faith who share the same
objection'' to contraceptives. Id.
The July 2013 regulation also finalized an accommodation for
eligible organizations, which were then defined to include solely
organizations that are religious. Under the accommodation, an eligible
organization was required to submit a self-certification to its group
health insurance issuer or third party administrator, as applicable.
Upon receiving that self-certification, the issuer or third party
administrator would provide or arrange for payments for the
contraceptive services to the plan participants and beneficiaries
enrolled in the eligible organization's plan, without requiring any
cost sharing on the part of plan participants and beneficiaries and
without cost to the eligible organization. With respect to self-insured
plans, the third party administrators (or issuers they contracted with)
could receive reimbursements by reducing user fee payments (to
Federally facilitated Exchanges) by the amounts paid out for
contraceptive services under the accommodation, plus an allowance for
certain administrative costs, as long as the HHS Secretary requests and
an authorizing exception under OMB Circular No. A-25R is in effect.\15\
With respect to fully insured group health plans, the issuer was
expected to bear the cost of such payments,\16\ and HHS intended to
clarify in guidance that the issuer could treat those payments as an
adjustment to claims costs for purposes of medical loss ratio and risk
corridor program calculations. The Departments extended the temporary
safe harbor again on June 20, 2013, to encompass plan years beginning
on or after August 1, 2013, and before January 1, 2014.
---------------------------------------------------------------------------

\15\ See also 45 CFR 156.50. Under the regulations, if the third
party administrator does not participate in a Federally-facilitated
Exchange as an issuer, it is permitted to contract with an insurer
which does so participate, in order to obtain such reimbursement.
The total contraceptive user fee adjustment for the 2015 benefit
year was $33 million.
\16\ ``[P]roviding payments for contraceptive services is cost
neutral for issuers.'' (78 FR 39877).
---------------------------------------------------------------------------

4. Litigation Over the Mandate and the Accommodation Process
During the period when the Departments were publishing and
modifying our regulations, organizations and individuals filed dozens
of lawsuits challenging the Mandate. Plaintiffs included religious
nonprofit organizations, businesses run by religious families,
individuals, and others, including several non-religious organizations
that opposed coverage of certain contraceptives under the Mandate on
the basis of non-religious moral convictions. Religious for-profit
entities won various court decisions leading to the Supreme Court's
ruling in Burwell v. Hobby Lobby Stores, Inc. 134 S. Ct. 2751 (2014).
The Supreme Court ruled against the Departments and held that, under
the Religious Freedom Restoration Act of 1993 (RFRA), the Mandate could
not be applied to the closely held for-profit corporations before the
Court because their owners had religious objections to providing such
coverage.\17\
---------------------------------------------------------------------------

\17\ The Supreme Court did not decide whether RFRA would apply
to publicly traded for-profit corporations. See 134 S. Ct. at 2774.
---------------------------------------------------------------------------

On August 27, 2014, the Departments simultaneously issued a third
set of interim final rules (August 2014 interim final rules) (79 FR
51092), and a notice of proposed rulemaking (August 2014 proposed
rules) (79 FR 51118). The August 2014 interim final rules changed the
accommodation process so that it could be initiated either by self-
certification using EBSA Form 700 or through a notice informing the
Secretary of HHS that an eligible organization had religious objections
to coverage of all or a subset of contraceptive services (79 FR 51092).
In response to Hobby Lobby, the August 2014 proposed rules extended the
accommodation process to closely held for-profit entities with
religious objections to contraceptive coverage, by including them in
the definition of eligible organizations (79 FR 51118). Neither the
August 2014 interim final rules nor the August 2014 proposed rules
extended the exemption; neither added a certification requirement for

[[Page 47843]]

exempt entities; and neither encompassed objections based on non-
religious moral convictions.
On July 14, 2015, the Departments finalized both the August 2014
interim final rules and the August 2014 proposed rules in a set of
final regulations (the July 2015 final regulations) (80 FR 41318). (The
July 2015 final regulations also encompassed issues related to other
preventive services coverage.) The July 2015 final regulations allowed
eligible organizations to submit a notice to HHS as an alternative to
submitting the EBSA Form 700, but specified that such notice must
include the eligible organization's name and an expression of its
religious objection, along with the plan name, plan type, and name and
contact information for any of the plan's third party administrators or
health insurance issuers. The Departments indicated that such
information represents the minimum information necessary for us to
administer the accommodation process.
Meanwhile, a second series of legal challenges were filed by
religious nonprofit organizations that stated the accommodation
impermissibly burdened their religious beliefs because it utilized
their health plans to provide services to which they objected on
religious grounds, and it required them to submit a self-certification
or notice. On November 6, 2015, the U.S. Supreme Court granted
certiorari in seven similar cases under the title of a filing from the
Third Circuit, Zubik v. Burwell. On May 16, 2016, the Supreme Court
issued a per curiam opinion in Zubik, vacating the judgments of the
Courts of Appeals--most of which had ruled in the Departments' favor--
and remanding the cases ``in light of the substantial clarification and
refinement in the positions of the parties'' that had been filed in
supplemental briefs. 136 S. Ct. 1557, 1560 (2016). The Court stated
that it anticipated that, on remand, the Courts of Appeals would
``allow the parties sufficient time to resolve any outstanding issues
between them.'' Id. The Court also specified that ``the Government may
not impose taxes or penalties on petitioners for failure to provide the
relevant notice'' while the cases remained pending. Id. at 1561.
After remand, as indicated by the Departments in court filings,
meetings were held between attorneys for the Government and for the
plaintiffs in those cases. The Departments also issued a Request for
Information (``RFI'') on July 26, 2016, seeking public comment on
options for modifying the accommodation process in light of the
supplemental briefing in Zubik and the Supreme Court's remand order.
(81 FR 47741). Public comments were submitted in response to the RFI,
during a comment period that closed on September 20, 2016. Those
comments included the request that the exemption be expanded to include
those who oppose the Mandate for either religious ``or moral'' reasons,
consistent with various state laws (such as in Connecticut or Missouri)
that protect objections to contraceptive coverage based on moral
convictions.\18\
---------------------------------------------------------------------------

\18\ See, for example, https://www.regulations.gov/document?D=CMS-2016-0123-54142; see also https://www.regulations.gov/document?D=CMS-2016-0123-54218 and https://www.regulations.gov/document?D=CMS-2016-0123-46220.
---------------------------------------------------------------------------

Beginning in 2015, lawsuits challenging the Mandate were also filed
by various non-religious organizations with moral objections to
contraceptive coverage. These organizations asserted that they believe
some methods classified by FDA as contraceptives may have an
abortifacient effect and therefore, in their view, are morally
equivalent to abortion. These organizations have neither received an
exemption from the Mandate nor do they qualify for the accommodation.
For example, the organization that since 1974 has sponsored the annual
March for Life in Washington, DC (March for Life), filed a complaint
claiming that the Mandate violated the equal protection component of
the Due Process Clause of the Fifth Amendment, and was arbitrary and
capricious under the Administrative Procedure Act (APA). Citing, for
example, (77 FR 8727), March for Life argued that the Departments'
stated interests behind the Mandate were only advanced among women who
``want'' the coverage so as to prevent ``unintended'' pregnancy. March
for Life contended that because it only hires employees who publicly
advocate against abortion, including what they regard as abortifacient
contraceptive items, the Departments' interests were not rationally
advanced by imposing the Mandate upon it and its employees.
Accordingly, March for Life contended that applying the Mandate to it
(and other similarly situated organizations) lacked a rational basis
and therefore doing so was arbitrary and capricious in violation of the
APA. March for Life further contended that because the Departments
concluded the government's interests were not undermined by exempting
houses of worship and integrated auxiliaries (based on our assumption
that such entities are relatively more likely than other religious
nonprofits to have employees that share their views against
contraception), applying the Mandate to March for Life or similar
organizations that definitively hire only employees who oppose certain
contraceptives lacked a rational basis and therefore violated their
right of equal protection under the Due Process Clause.
March for Life's employees, who stated they were personally
religious (although personal religiosity was not a condition of their
employment), also sued as co-plaintiffs. They contended that the
Mandate violates their rights under RFRA by making it impossible for
them to obtain health insurance consistent with their religious
beliefs, either from the plan March for Life wanted to offer them, or
in the individual market, because the Departments offered no exemptions
in either circumstance. Another non-religious nonprofit organization
that opposed the Mandate's requirement to provide certain contraceptive
coverage on moral grounds also filed a lawsuit challenging the Mandate.
Real Alternatives, Inc. v. Burwell, 150 F. Supp. 3d 419 (M.D. Pa.
2015).
Challenges by non-religious nonprofit organizations led to
conflicting opinions among the Federal courts. A district court agreed
with the March for Life plaintiffs on the organization's equal
protection claim and the employees' RFRA claims (not specifically
ruling on the APA claim), and issued a permanent injunction against the
Departments that is still in place. March for Life v. Burwell, 128 F.
Supp. 3d 116 (D.D.C. 2015). The appeal in March for Life is pending and
has been stayed since early 2016. In another case, Federal district and
appellate courts in Pennsylvania disagreed with the reasoning from
March for Life and ruled against claims brought by a similarly non-
religious nonprofit employer and its religious employees. Real
Alternatives, 150 F. Supp. 3d 419, affirmed by 867 F.3d 338 (3d Cir.
2017). One member of the appeals court panel in Real Alternatives
dissented in part, stating he would have ruled in favor of the
individual employee plaintiffs under RFRA. Id. at *18.
On December 20, 2016, HRSA updated the Guidelines via its Web site,
https://www.hrsa.gov/womensguidelines2016/. HRSA announced
that, for plans subject to the Guidelines, the updated Guidelines would
apply to the first plan year beginning after December 20, 2017. Among
other changes, the updated Guidelines specified that the required
contraceptive coverage includes follow-up care (for example, management
and evaluation, as well as changes to, and removal or discontinuation
of, the

[[Page 47844]]

contraceptive method). They also specified, for the first time, that
coverage should include instruction in fertility awareness-based
methods for women desiring an alternative method of family planning.
HRSA stated that, with the input of a committee operating under a
cooperative agreement, HRSA would review and periodically update the
Women's Preventive Services' Guidelines. The updated Guidelines did not
alter the religious employer exemption or accommodation process, nor
did they extend the exemption or accommodation process to organizations
or individuals that oppose certain forms of contraception (and coverage
thereof) on moral grounds.
On January 9, 2017, the Departments issued a document entitled,
``FAQs About Affordable Care Act Implementation Part 36.'' \19\ The FAQ
stated that, after reviewing comments submitted in response to the 2016
RFI and considering various options, the Departments could not find a
way at that time to amend the accommodation so as to satisfy objecting
eligible organizations while pursuing the Departments' policy goals.
The Departments did not adopt the approach requested by certain
commenters, cited above, to expand the exemption to include those who
oppose the Mandate for moral reasons.
---------------------------------------------------------------------------

\19\ Available at: https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-36.pdf and
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/ACA-FAQs-Part36_1-9-17-Final.pdf.
---------------------------------------------------------------------------

On May 4, 2017, the President issued Executive Order 13798,
``Promoting Free Speech and Religious Liberty.'' Section 3 of that
order declares, ``Conscience Protections with Respect to Preventive-
Care Mandate. The Secretary of the Treasury, the Secretary of Labor,
and the Secretary of Health and Human Services shall consider issuing
amended regulations, consistent with applicable law, to address
conscience-based objections to the preventive-care mandate promulgated
under section 300gg-13(a)(4) of title 42, United States Code.''

II. Expanded Exemptions and Accommodations for Moral Convictions

These interim final rules incorporate conscience protections into
the contraceptive Mandate. They do so in part to bring the Mandate into
conformity with Congress's long history of providing or supporting
conscience protections in the regulation of sensitive health-care
issues, cognizant that Congress neither required the Departments to
impose the Mandate nor prohibited them from providing conscience
protections if they did so. Specifically, these interim final rules
expand exemptions to the contraceptive Mandate to protect certain
entities and individuals that object to coverage of some or all
contraceptives based on sincerely held moral convictions but not
religious beliefs, and these rules make those exempt entities eligible
for accommodations concerning the same Mandate.

A. Discretion To Provide Exemptions Under Section 2713(a)(4) of the PHS
Act and the Affordable Care Act

The Departments have consistently interpreted HRSA's authority
under section 2713(a)(4) of the PHS Act to allow for exemptions and
accommodations to the contraceptive Mandate for certain objecting
organizations. Section 2713(a)(4) of the PHS Act gives HRSA discretion
to decide whether and in what circumstances it will support Guidelines
providing for additional women's preventive services coverage. That
authority includes HRSA's discretion to include contraceptive coverage
in those Guidelines, but the Congress did not specify whether or to
what extent HRSA should do so. Therefore, section 2713(a)(4) of the PHS
Act allows HRSA to not apply the Guidelines to certain plans of
entities or individuals with religious or moral objections to
contraceptive coverage, and by not applying the Guidelines to them, to
exempt those entities from the Mandate. These rules are a necessary and
appropriate exercise of the authority of HHS, of which HRSA is a
component, and of the authority delegated to the Departments
collectively as administrators of the statutes. (26 U.S.C. 9833; 29
U.S.C. 1191c; 42 U.S.C. 300gg-92).
Our protection of conscience in these interim final rules is
consistent with the structure and intent of the Affordable Care Act.
The Affordable Care Act refrains from applying section 2713(a)(4) of
the PHS Act to millions of women in grandfathered plans. In contrast,
we anticipate that conscientious exemptions to the Mandate will impact
a much smaller number of women. President Obama emphasized in signing
the Affordable Care Act that ``longstanding Federal law to protect
conscience''--laws with conscience protections encompassing moral (as
well as religious) objections--specifically including (but not limited
to) the Church Amendments (42 U.S.C. 300a-7), ``remain intact.''
Executive Order 13535. Nothing in the Affordable Care Act suggests
Congress' intent to deviate from its long history, discussed below, of
protecting moral convictions in particular health care contexts. The
Departments' implementation of section 2713(a)(4) of the PHS Act with
respect to contraceptive coverage is a context similar to those
encompassed by many other health care conscience protections provided
or supported by Congress. This Mandate concerns contraception and
sterilization services, including items believed by some citizens to
have an abortifacient effect--that is, to cause the destruction of a
human life at an early stage of embryonic development. These are highly
sensitive issues in the history of health care regulation and have long
been shielded by conscience protections in the laws of the United
States.

B. Congress' History of Providing Exemptions for Moral Convictions

In deciding the most appropriate way to exercise our discretion in
this context, the Departments draw on nearly 50 years of statutory law
and Supreme Court precedent discussing the protection of moral
convictions in certain circumstances--particularly in the context of
health care and health insurance coverage. Congress very recently
expressed its intent on the matter of Government-mandated contraceptive
coverage when it declared, with respect to the possibility that the
District of Columbia would require contraceptive coverage, that ``it is
the intent of Congress that any legislation enacted on such issue
should include a `conscience clause' which provides exceptions for
religious beliefs and moral convictions.'' Consolidated Appropriations
Act of 2017, Division C, Title VIII, Sec. 808, Public Law 115-31 (May
5, 2017). In support of these interim final rules, we consider it
significant that Congress' most recent statement on the prospect of
Government mandated contraceptive coverage specifically intends that a
conscience clause be included to protect moral convictions.
The many statutes listed in Section I-Background under footnote 1,
which show Congress' consistent protection of moral convictions
alongside religious beliefs in the Federal regulation of health care,
includes laws such as the 1973 Church Amendments, which we discuss at
length below, all the way to the 2017 Consolidated Appropriations Act
discussed above. Notably among those laws, the Congress has enacted
protections for health plans or health care organizations in Medicaid
or Medicare Advantage to object ``on moral or religious grounds'' to
providing coverage of certain counseling or referral services. 42
U.S.C. 1395w-

[[Page 47845]]

22(j)(3)(B) (protecting against forced counseling or referrals in
Medicare Choice, now Medicare Advantage, managed care plans with
respect to objections based on ``moral or religious grounds''); 42
U.S.C. 1396u-2(b)(3) (protecting against forced counseling or referrals
in Medicaid managed care plans with respect to objections based on
``moral or religious grounds''). The Congress has also protected
individuals who object to prescribing or providing contraceptives
contrary to their ``religious beliefs or moral convictions.''
Consolidated Appropriations Act of 2017, Division C, Title VII, Sec.
726(c) (Financial Services and General Government Appropriations Act),
Public Law 115-31.

C. The Church Amendments' Protection of Moral Convictions

One of the most important and well-established federal statutes
respecting conscientious objections in specific health care contexts
was enacted over the course of several years beginning in 1973,
initially as a response to court decisions raising the prospect that
entities or individuals might be required to facilitate abortions or
sterilizations. These sections of the United States Code are known as
the Church Amendments, named after their primary sponsor Senator Frank
Church (D-Idaho). The Church Amendments specifically provide conscience
protections based on sincerely held moral convictions. Among other
things, the amendments protect the recipients of certain Federal health
funds from being required to perform, assist, or make their facilities
available for abortions or sterilizations if they object ``on the basis
of religious beliefs or moral convictions,'' and they prohibit
recipients of certain Federal health funds from discriminating against
any personnel ``because he refused to perform or assist in the
performance of such a procedure or abortion on the grounds that his
performance or assistance in the performance of the procedure or
abortion would be contrary to his religious beliefs or moral
convictions'' (42 U.S.C. 300a-7(b), (c)(1)). Later additions to the
Church Amendments protect other conscientious objections, including
some objections on the basis of moral conviction to ``any lawful health
service,'' or to ``any part of a health service program.'' (42 U.S.C.
300a-7(c)(2), (d)). In contexts covered by those sections of the Church
Amendments, the provision or coverage of certain contraceptives,
depending on the circumstances, could constitute ``any lawful health
service'' or a ``part of a health service program.'' As such, the
protections provided by those provisions of the Church Amendments would
encompass moral objections to contraceptive services or coverage.
The Church Amendments were enacted in the wake of the Supreme
Court's decision in Roe v. Wade, 410 U.S. 113 (1973). Even though the
Court in Roe required abortion to be legal in certain circumstances,
Roe did not include, within that right, the requirement that other
citizens must facilitate its exercise. Thus, Roe favorably quoted the
proceedings of the American Medical Association House of Delegates 220
(June 1970), which declared ``Neither physician, hospital, nor hospital
personnel shall be required to perform any act violative of personally-
held moral principles.'' 410 U.S. at 144 & n.38 (1973). Likewise in
Roe's companion case, Doe v. Bolton, the Court observed that, under
State law, ``a physician or any other employee has the right to
refrain, for moral or religious reasons, from participating in the
abortion procedure.'' 410 U.S. 179, 197-98 (1973). The Court said that
these conscience provisions ``obviously . . . afford appropriate
protection.'' Id. at 198. As an Arizona court later put it, ``a woman's
right to an abortion or to contraception does not compel a private
person or entity to facilitate either.'' Planned Parenthood Ariz., Inc.
v. Am. Ass'n of Pro-Life Obstetricians & Gynecologists, 257 P.3d 181,
196 (Ariz. Ct. App. 2011).
The Congressional Record contains relevant discussions that
occurred when the protection for moral convictions was first proposed
in the Church Amendments. When Senator Church introduced the first of
those amendments in 1973, he cited not only Roe v. Wade but also an
instance where a Federal court had ordered a Catholic hospital to
perform sterilizations. 119 Congr. Rec. S5717-18 (Mar. 27, 1973). After
his opening remarks, Senator Adlai Stevenson III (D-IL) rose to ask
that the amendment be changed to specify that it also protects
objections to abortion and sterilization based on moral convictions on
the same terms as it protects objections based on religious beliefs.
The following excerpt of the Congressional Record is particularly
relevant to this discussion:

Mr. STEVENSON. Mr. President, first of all I commend the Senator
from Idaho for bringing this matter to the attention of the Senate.
I ask the Senator a question.
One need not be of the Catholic faith or any other religious
faith to feel deeply about the worth of human life. The protections
afforded by this amendment run only to those whose religious beliefs
would be offended by the necessity of performing or participating in
the performance of certain medical procedures; others, for moral
reasons, not necessarily for any religious belief, can feel equally
as strong about human life. They too can revere human life.
As mortals, we cannot with confidence say, when life begins. But
whether it is life, or the potentiality of life, our moral
convictions as well as our religious beliefs, warrant protection
from this intrusion by the Government. Would, therefore, the Senator
include moral convictions?
Would the Senator consider an amendment on page 2, line 18 which
would add to religious beliefs, the words ``or moral''?
Mr. CHURCH. I would suggest to the Senator that perhaps his
objective could be more clearly stated if the words ``or moral
conviction'' were added after ``religious belief.'' I think that the
Supreme Court in considering the protection we give religious
beliefs has given comparable treatment to deeply held moral
convictions. I would not be averse to amending the language of the
amendment in such a manner. It is consistent with the general
purpose. I see no reason why a deeply held moral conviction ought
not be given the same treatment as a religious belief.
Mr. STEVENSON. The Senator's suggestion is well taken. I thank
him.

119 Congr. Rec. S5717-18.
As the debate proceeded, Senator Church went on to quote Doe v.
Bolton's reliance on a Georgia statute that stated ``a physician or any
other employee has the right to refrain, for moral or religious
reasons, from participating in the abortion procedure.'' 119 Congr.
Rec. at S5722 (quoting 410 U.S. at 197-98). Senator Church added, ``I
see no reason why the amendment ought not also to cover doctors and
nurses who have strong moral convictions against these particular
operations.'' Id. Considering the scope of the protections, Senator
Gaylord Nelson (D-WI) asked whether, ``if a hospital board, or whatever
the ruling agency for the hospital was, a governing agency or
otherwise, just capriciously--and not upon the religious or moral
questions at all--simply said, `We are not going to bother with this
kind of procedure in this hospital,' would the pending amendment permit
that?'' 119 Congr. Rec. at S5723. Senator Church responded that the
amendment would not encompass such an objection. Id.
Senator James L. Buckley (C-NY), speaking in support of the
amendment, added the following perspective:

Mr. BUCKLEY. Mr. President, I compliment the Senator from Idaho
for proposing this most important and timely amendment. It is timely
in the first instance because the attempt has already been made to
compel the performance of abortion and sterilization operations on
the part of those who are fundamentally opposed to such procedures.
And it is timely also because the

[[Page 47846]]

recent Supreme Court decisions will likely unleash a series of court
actions across the United States to try to impose the personal
preferences of the majority of the Supreme Court on the totality of
the Nation.
I believe it is ironic that we should have this debate at all.
Who would have predicted a year or two ago that we would have to
guard against even the possibility that someone might be free [sic]
\20\ to participate in an abortion or sterilization against his
will? Such an idea is repugnant to our political tradition. This is
a Nation which has always been concerned with the right of
conscience. It is the right of conscience which is protected in our
draft laws. It is the right of conscience which the Supreme Court
has quite properly expanded not only to embrace those young men who,
because of the tenets of a particular faith, believe they cannot
kill another man, but also those who because of their own deepest
moral convictions are so persuaded.
---------------------------------------------------------------------------

\20\ The Senator might have meant ``[forced] . . . against his
will.''
---------------------------------------------------------------------------

I am delighted that the Senator from Idaho has amended his
language to include the words ``moral conviction,'' because, of
course, we know that this is not a matter of concern to any one
religious body to the exclusion of all others, or even to men who
believe in a God to the exclusion of all others. It has been a
traditional concept in our society from the earliest times that the
right of conscience, like the paramount right to life from which it
is derived, is sacred.
119 Congr. Rec. at S5723.
In support of the same protections when they were debated in the
U.S. House, Representative Margaret Heckler (R-MA) \21\ likewise
observed that ``the right of conscience has long been recognized in the
parallel situation in which the individual's right to conscientious
objector status in our selective service system has been protected''
and ``expanded by the Supreme Court to include moral conviction as well
as formal religious belief.'' 119 Congr. Rec. H4148-49 (May 31, 1973).
Rep. Heckler added, ``We are concerned here only with the right of
moral conscience, which has always been a part of our national
tradition.'' Id. at 4149.
---------------------------------------------------------------------------

\21\ Rep. Heckler later served as the 15th Secretary of HHS,
from March 1983 to December 1985.
---------------------------------------------------------------------------

These first of the Church Amendments, codified at 42 U.S.C. 300a-
7(b) and (c)(1), passed the House 372-1, and were approved by the
Senate 94-0. 119 Congr. Rec. at H4149; 119 Congr. Rec. S10405 (June 5,
1973). The subsequently adopted provisions that comprise the Church
Amendments similarly extend protection to those organizations and
individuals who object to the provision of certain services on the
basis of their moral convictions. And, as noted above, subsequent
statutes add protections for moral objections in many other situations.
These include, for example:
Protections for individuals and entities that object to
abortion: See 42 U.S.C. 238n; 42 U.S.C. 18023; 42 U.S.C. 2996f(b); and
Consolidated Appropriations Act of 2017, Div. H, Title V, Sec. 507(d),
Public Law 115-31;
Protections for entities and individuals that object to
providing or covering contraceptives: See id. at Div. C, Title VIII,
Sec. 808; id. at Div. C, Title VII, Sec. 726(c) (Financial Services and
General Government Appropriations Act); and id. at Div. I, Title III;
and
Protections for entities and individuals that object to
performing, assisting, counseling, or referring as pertains to suicide,
assisted suicide, or advance directives: See 42 U.S.C. 290bb-36; 42
U.S.C. 14406; 42 U.S.C. 18113; and 42 U.S.C. 1396a(w)(3).
The Departments believe that the intent behind Congress' protection
of moral convictions in certain health care contexts, especially to
protect entities and individuals from governmental coercion, supports
our decision in these interim final rules to protect sincerely held
moral convictions from governmental compulsion threatened by the
contraceptive Mandate.

D. Court Precedents Relevant to These Expanded Exemptions

The legislative history of the protection of moral convictions in
the first Church Amendments shows that Members of Congress saw the
protection as being consistent with Supreme Court decisions. Not only
did Senator Church cite the abortion case Doe v. Bolton as a parallel
instance of conscience protection, but he also spoke of the Supreme
Court generally giving ``comparable treatment to deeply held moral
convictions.'' Both Senator Buckley and Rep. Heckler specifically cited
the Supreme Court's protection of moral convictions in laws governing
military service. Those legislators appear to have been referencing
cases such as Welsh v. United States, 398 U.S. 333 (1970), which the
Supreme Court decided just 3 years earlier.
Welsh involved what is perhaps the Government's paradigmatic
compelling interest--the need to defend the nation by military force.
The Court stated that, where the Government protects objections to
military service based on ``religious training and belief,'' that
protection would also extend to avowedly non-religious objections to
war held with the same moral strength. Id. at 343. The Court declared,
``[i]f an individual deeply and sincerely holds beliefs that are purely
ethical or moral in source and content but that nevertheless impose
upon him a duty of conscience to refrain from participating in any war
at any time, those beliefs certainly occupy in the life of that
individual `a place parallel to that filled by . . . God' in
traditionally religious persons. Because his beliefs function as a
religion in his life, such an individual is as much entitled to a
`religious' conscientious objector exemption . . . as is someone who
derives his conscientious opposition to war from traditional religious
convictions.''
The Departments look to the description of moral convictions in
Welsh to help explain the scope of the protection provided in these
interim final rules. Neither these interim final rules, nor the Church
Amendments or other Federal health care conscience statutes, define
``moral convictions'' (nor do they define ``religious beliefs''). But
in issuing these interim final rules, we seek to use the same
background understanding of that term that is reflected in the
Congressional Record in 1973, in which legislators referenced cases
such as Welsh to support the addition of language protecting moral
convictions. In protecting moral convictions parallel to religious
beliefs, Welsh describes moral convictions warranting such protection
as ones: (1) That the ``individual deeply and sincerely holds''; (2)
``that are purely ethical or moral in source and content; (3) ``but
that nevertheless impose upon him a duty''; (4) and that ``certainly
occupy in the life of that individual a place parallel to that filled
by . . . God' in traditionally religious persons,'' such that one could
say ``his beliefs function as a religion in his life.'' (398 U.S. at
339-40). As recited above, Senators Church and Nelson agreed that
protections for such moral convictions would not encompass an objection
that an individual or entity raises ``capriciously.'' Instead, along
with the requirement that protected moral convictions must be
``sincerely held,'' this understanding cabins the protection of moral
convictions in contexts where they occupy a place parallel to that
filled by sincerely held religious beliefs in religious persons and
organizations.
In the context of this particular Mandate, it is also worth noting
that, in Hobby Lobby, Justice Ginsburg (joined, in this part of the
opinion, by Justices Breyer, Kagan, and Sotomayor), cited Justice
Harlan's opinion in Welsh, 398 U.S. at 357-58, in support of her
statement that ``[s]eparating moral convictions from religious beliefs
would be of questionable legitimacy.'' 134 S. Ct. at 2789 n.6. In
quoting this passage, the Departments do not mean to suggest that all
laws protecting only religious

[[Page 47847]]

beliefs constitute an illegitimate ``separat[ion]'' of moral
convictions, nor do we assert that moral convictions must always be
protected alongside religious beliefs; we also do not agree with
Justice Harlan that distinguishing between religious and moral
objections would violate the Establishment Clause. Instead, the
Departments believe that, in the specific health care context
implicated here, providing respect for moral convictions parallel to
the respect afforded to religious beliefs is appropriate, draws from
long-standing Federal Government practice, and shares common ground
with Congress' intent in the Church Amendments and in later Federal
conscience statutes that provide protections for moral convictions
alongside religious beliefs in other health care contexts.

E. Conscience Protections in Regulations and Among the States

The tradition of protecting moral convictions in certain health
contexts is not limited to Congress. Multiple federal regulations
protect objections based on moral convictions in such contexts.\22\
Other federal regulations have also applied the principle of respecting
moral convictions alongside religious beliefs when they have determined
that it is appropriate to do so in particular circumstances. The Equal
Employment Opportunity Commission has consistently protected ``moral or
ethical beliefs as to what is right and wrong which are sincerely held
with the strength of traditional religious views'' alongside religious
views under the ``standard [] developed in United States v. Seeger, 380
U.S. 163 (1965) and [Welsh].'' (29 CFR 1605.1). The Department of
Justice has declared that, in cases of capital punishment, no officer
or employee may be required to attend or participate if doing so ``is
contrary to the moral or religious convictions of the officer or
employee, or if the employee is a medical professional who considers
such participation or attendance contrary to medical ethics.'' (28 CFR
26.5).\23\
---------------------------------------------------------------------------

\22\ See, for example, 42 CFR 422.206 (declaring that the
general Medicare Advantage rule ``does not require the MA plan to
cover, furnish, or pay for a particular counseling or referral
service if the MA organization that offers the plan--(1) Objects to
the provision of that service on moral or religious grounds.''); 42
CFR 438.102 (declaring that information requirements do not apply
``if the MCO, PIHP, or PAHP objects to the service on moral or
religious grounds''); 48 CFR 1609.7001 (``health plan sponsoring
organizations are not required to discuss treatment options that
they would not ordinarily discuss in their customary course of
practice because such options are inconsistent with their
professional judgment or ethical, moral or religious beliefs.''); 48
CFR 352.270-9 (``Non-Discrimination for Conscience'' clause for
organizations receiving HIV or Malaria relief funds).
\23\ See also 18 CFR 214.11 (where a law enforcement agency
(LEA) seeks assistance in the investigation or prosecution of
trafficking of persons, the reasonableness of the LEA's request will
depend in part on ``[c]ultural, religious, or moral objections to
the request'').
---------------------------------------------------------------------------

Forty-five States have health care conscience protections covering
objections to abortion, and several of those also cover sterilization
or contraception.\24\ Most of those State laws protect objections based
on ``moral,'' ``ethical,'' or ``conscientious'' grounds in addition to
``religious'' grounds. Particularly in the case of abortion, some
Federal and State conscience laws do not require any specified motive
for the objection. (42 U.S.C. 238n). These various statutes and
regulations reflect an important governmental interest in protecting
moral convictions in appropriate health contexts.
---------------------------------------------------------------------------

\24\ According to the Guttmacher Institute, 45 states have
conscience statutes pertaining to abortion (43 of which cover
institutions), 18 have conscience statutes pertaining to
sterilization (16 of which cover institutions), and 12 have
conscience statutes pertaining to contraception (8 of which cover
institutions). ``Refusing to Provide Health Services'' (June 1,
2017), available at https://www.guttmacher.org/state-policy/explore/refusing-provide-health-services.
---------------------------------------------------------------------------

The contraceptive Mandate implicates that governmental interest.
Many persons and entities object to this Mandate in part because they
consider some forms of FDA-approved contraceptives to be abortifacients
and morally equivalent to abortion due to the possibility that some of
the items may have the effect of preventing the implantation of a human
embryo after fertilization. Based on our knowledge from the litigation,
all of the current litigants asserting purely non-religious objections
share this view, and most of the religious litigants do as well. The
Supreme Court, in describing family business owners with religious
objections, explained that ``[t]he owners of the businesses have
religious objections to abortion, and according to their religious
beliefs the four contraceptive methods at issue are abortifacients. If
the owners comply with the HHS mandate, they believe they will be
facilitating abortions.'' Hobby Lobby, 134 S. Ct. at 2751. Outside of
the context of abortion, as cited above, Congress has also provided
health care conscience protections pertaining to sterilization,
contraception, and other health care services and practices.

F. Founding Principles

The Departments also look to guidance from the broader history of
respect for conscience in the laws and founding principles of the
United States. Members of Congress specifically relied on the American
tradition of respect for conscience when they decided to protect moral
convictions in health care. As quoted above, in supporting protecting
conscience based on non-religious moral convictions, Senator Buckley
declared ``[i]t has been a traditional concept in our society from the
earliest times that the right of conscience, like the paramount right
to life from which it is derived, is sacred.'' Rep. Heckler similarly
stated that ``the right of moral conscience . . . has always been a
part of our national tradition.'' This tradition is reflected, for
example, in a letter President George Washington wrote saying that
``[t]he Citizens of the United States of America have a right to
applaud themselves for having given to mankind examples of an enlarged
and liberal policy: A policy worthy of imitation. All possess alike
liberty of conscience and immunities of citizenship.'' \25\ Thomas
Jefferson similarly declared that ``[n]o provision in our Constitution
ought to be dearer to man than that which protects the rights of
conscience against the enterprises of the civil authority.'' \26\
Although these statements by Presidents Washington and Jefferson were
spoken to religious congregations, and although religious and moral
conscience were tightly intertwined for the Founders, they both reflect
a broad principle of respect for conscience against government
coercion. James Madison likewise called conscience ``the most sacred of
all property,'' and proposed that the Bill of Rights should guarantee,
in addition to protecting religious belief and worship, that ``the full
and equal rights of conscience [shall not] be in any manner, or on any
pretext infringed.'' \27\
---------------------------------------------------------------------------

\25\ From George Washington to the Hebrew Congregation in
Newport, Rhode Island (Aug. 18, 1790), available at https://founders.archives.gov/documents/Washington/05-06-02-0135.
\26\ Letter to the Society of the Methodist Episcopal Church at
New London, Connecticut (February 4, 1809), available at https://founders.archives.gov/documents/Jefferson/99-01-02-9714.
\27\ James Madison, ``Essay on Property'' (March 29, 1792);
First draft of the First Amendment, 1 Annals of Congress 434 (June
8, 1789).
---------------------------------------------------------------------------

These Founding Era statements of general principle do not specify
how they would be applied in a particular health care context. We do
not suggest that the specific protections offered in this rule would
also be required or necessarily appropriate in any other context that
does not raise the specific concerns implicated by this Mandate. These
interim final rules do not address in any way how the Government would
balance its interests with respect to

[[Page 47848]]

other health services not encompassed by the contraceptive Mandate.\28\
Instead we highlight this tradition of respect for conscience from our
Founding Era to provide background support for the Departments'
decision to implement section 2713(a)(4) of the PHS Act, while
protecting conscience in the exercise of moral convictions. We believe
that these interim final rules are consistent both with the American
tradition of respect for conscience and with Congress' history of
providing conscience protections in the kinds of health care matters
involved in this Mandate.
---------------------------------------------------------------------------

\28\ As the Supreme Court stated in Hobby Lobby, the Court's
decision concerns only the contraceptive Mandate, and should not be
understood to hold that all insurance-coverage mandates, for
example, for vaccinations or blood transfusions, must necessarily
fail if they conflict with an employer's religious beliefs. Nor does
the Court's opinion provide a shield for employers who might cloak
illegal discrimination as a religious (or moral) practice. 134 S.
Ct. at 2783.
---------------------------------------------------------------------------

G. Executive Orders Relevant to These Expanded Exemptions

Protecting moral convictions, as set forth in the expanded
exemptions and accommodations of these rules, is consistent with recent
executive orders. President Trump's Executive Order concerning this
Mandate directed the Departments to consider providing protections, not
specifically for ``religious'' beliefs, but for ``conscience.'' We
interpret that term to include moral convictions and not just religious
beliefs. Likewise, President Trump's first Executive Order, EO 13765,
declared that ``the Secretary of Health and Human Services (Secretary)
and the heads of all other executive departments and agencies
(agencies) with authorities and responsibilities under the [ACA] shall
exercise all authority and discretion available to them to waive,
defer, grant exemptions from, or delay the implementation of any
provision or requirement of the Act that would impose a fiscal burden
on any State or a cost, fee, tax, penalty, or regulatory burden on
individuals, families, healthcare providers, health insurers, patients,
recipients of healthcare services, purchasers of health insurance, or
makers of medical devices, products, or medications.'' This Mandate
imposes both a cost, fee, tax, or penalty, and a regulatory burden, on
individuals and purchasers of health insurance that have moral
convictions opposed to providing contraceptive coverage. These interim
final rules exercise the Departments' discretion to grant exemptions
from the Mandate to reduce and relieve regulatory burdens and promote
freedom in the health care market.

H. Litigation Concerning the Mandate

The sensitivity of certain health care matters makes it
particularly important for the Government to tread carefully when
engaging in regulation concerning those areas, and to respect
individuals and organizations whose moral convictions are burdened by
Government regulations. Providing conscience protections advances the
Affordable Care Act's goal of expanding health coverage among entities
and individuals that might otherwise be reluctant to participate in the
market. For example, the Supreme Court in Hobby Lobby declared that, if
HHS requires owners of businesses to cover procedures that the owners
``could not in good conscience'' cover, such as abortion, ``HHS would
effectively exclude these people from full participation in the
economic life of the Nation.'' 134 S. Ct. at 2783. That would be a
serious outcome. As demonstrated by litigation and public comments,
various citizens sincerely hold moral convictions, which are not
necessarily religious, against providing or participating in coverage
of contraceptive items included in the Mandate, and some believe that
some of those items may cause early abortions. The Departments wish to
implement the contraceptive coverage Guidelines issued under section
2713(a)(4) of the PHS Act in a way that respects the moral convictions
of our citizens so that they are more free to engage in ``full
participation in the economic life of the Nation.'' These expanded
exemptions do so by removing an obstacle that might otherwise lead
entities or individuals with moral objections to contraceptive coverage
to choose not to sponsor or participate in health plans if they include
such coverage.
Among the lawsuits challenging the Mandate, two have been filed
based in part on non-religious moral convictions. In one case, the
Departments are subject to a permanent injunction requiring us to
respect the non-religious moral objections of an employer. See March
for Life v. Burwell, 128 F. Supp. 3d 116 (D.D.C. 2015). In the other
case, an appeals court recently affirmed a district court ruling that
allows the previous regulations to be imposed in a way that violates
the moral convictions of a small nonprofit pro-life organization and
its employees. See Real Alternatives, 2017 WL 3324690. Our litigation
of these cases has led to inconsistent court rulings, consumed
substantial governmental resources, and created uncertainty for
objecting organizations, issuers, third party administrators, and
employees and beneficiaries. The organizations that have sued seeking a
moral exemption have all adopted moral tenets opposed to contraception
and hire only employees who share this view. It is reasonable to
conclude that employees of these organizations would therefore not
benefit from the Mandate. As a result, subjecting this subset of
organizations to the Mandate does not advance any governmental
interest. The need to resolve this litigation and the potential
concerns of similar entities, and our requirement to comply with
permanent injunctive relief currently imposed in March for Life,
provide substantial reasons for the Departments to protect moral
convictions through these interim final rules. Even though, as
discussed below, we assume the number of entities and individuals that
may seek exemption from the Mandate on the basis of moral convictions,
as these two sets of litigants did, will be small, we know from the
litigation that it will not be zero. As a result, the Departments have
taken these types of objections into consideration in reviewing our
regulations. Having done so, we consider it appropriate to issue the
protections set forth in these interim final rules. Just as Congress,
in adopting the early provisions of the Church Amendments, viewed it as
necessary and appropriate to protect those organizations and
individuals with objections to certain health care services on the
basis of moral convictions, so we, too, believe that ``our moral
convictions as well as our religious beliefs, warrant protection from
this intrusion by the Government'' in this situation.

I. The Departments' Rebalancing of Government Interests

For additional discussion of the Government's balance of interests
concerning religious beliefs issued contemporaneously with these
interim final rules, see the related document published by the
Department elsewhere in this issue of the Federal Register. There, we
acknowledge that the Departments have changed the policies and
interpretations we previously adopted with respect to the Mandate and
the governmental interests that underlying it, and we assert that we
now believe the Government's legitimate interests in providing for
contraceptive coverage do not require us to violate sincerely held
religious beliefs while implementing the Guidelines. For parallel
reasons, the Departments believe Congress did not set forth--and we do
not possess--interests that require us to violate sincerely held moral
convictions in the course of generally requiring contraceptive
coverage. These changes in policy are

[[Page 47849]]

within the Departments' authority. As the Supreme Court has
acknowledged, ``[a]gencies are free to change their existing policies
as long as they provide a reasoned explanation for the change.'' Encino
Motorcars, LLC v. Navarro, 136 S. Ct. 2117, 2125 (2016). This
``reasoned analysis'' requirement does not demand that an agency
``demonstrate to a court's satisfaction that the reasons for the new
policy are better than the reasons for the old one; it suffices that
the new policy is permissible under the statute, that there are good
reasons for it, and that the agency believes it to be better, which the
conscious change of course adequately indicates.'' United Student Aid
Funds, Inc. v. King, 200 F. Supp. 3d 163, 169-70 (D.D.C. 2016) (citing
FCC v. Fox Television Stations, Inc., 556 U.S. 502, 515 (2009)); see
also New Edge Network, Inc. v. FCC, 461 F.3d 1105, 1112-13 (9th Cir.
2006) (rejecting an argument that ``an agency changing its course by
rescinding a rule is obligated to supply a reasoned analysis for the
change beyond that which may be required when an agency does not act in
the first instance'').\29\
---------------------------------------------------------------------------

\29\ See also Chevron, U.S.A., Inc. v. Natural Resources Defense
Council, Inc., 467 U.S. 837, 863-64 (1984) (``The fact that the
agency has adopted different definitions in different contexts adds
force to the argument that the definition itself is flexible,
particularly since Congress has never indicated any disapproval of a
flexible reading of the statute.'')
---------------------------------------------------------------------------

The Departments note that the exemptions created here, like the
exemptions created by the last Administration, do not burden third
parties to a degree that counsels against providing the exemptions. In
addition to the apparent fact that many entities with non-religious
moral objections to the Mandate appear to only hire persons that share
those objections, Congress did not create a right to receive
contraceptive coverage, and Congress explicitly chose not to impose the
section 2713 requirements on grandfathered plans benefitting millions
of people. Individuals who are unable to obtain contraceptive coverage
through their employer-sponsored health plans because of the exemptions
created in these interim final rules, or because of other exemptions to
the Mandate, have other avenues for obtaining contraception, including
through various other mechanisms by which the Government advances
contraceptive coverage, particularly for low-income women, and which
these interim final rules leave unchanged.\30\ As the Government is
under no constitutional obligation to fund contraception, cf. Harris v.
McRae, 448 U.S. 297 (1980), even more so may the Government refrain
from requiring private citizens to cover contraception for other
citizens in violation of their moral convictions. Cf. Rust v. Sullivan,
500 U.S. 173, 192-93 (1991) (``A refusal to fund protected activity,
without more, cannot be equated with the imposition of a `penalty' on
that activity.'').
---------------------------------------------------------------------------

\30\ See, for example, Family Planning grants in 42 U.S.C. 300,
et seq.; the Teenage Pregnancy Prevention Program, Public Law 112-74
(125 Stat 786, 1080); the Healthy Start Program, 42 U.S.C. 254c-8;
the Maternal, Infant, and Early Childhood Home Visiting Program, 42
U.S.C. 711; Maternal and Child Health Block Grants, 42 U.S.C. 703;
42 U.S.C. 247b-12; Title XIX of the Social Security Act, 42 U.S.C.
1396, et seq.; the Indian Health Service, 25 U.S.C. 13, 42 U.S.C.
2001(a), & 25 U.S.C. 1601, et seq.; Health center grants, 42 U.S.C.
254b(e), (g), (h), & (i); the NIH Clinical Center, 42 U.S.C. 248;
and the Personal Responsibility Education Program, 42 U.S.C. 713.
---------------------------------------------------------------------------

The Departments acknowledge that coverage of contraception is an
important and highly controversial issue, implicating many different
views, as reflected for example in the public comments received on
multiple rulemakings over the course of implementation of section
2713(a)(4) of the PHS Act. Our expansion of conscience protections for
moral convictions, similar to protections contained in numerous
statutes governing health care regulation, is not taken lightly.
However, after reconsidering the interests served by the Mandate in
this particular context, the objections raised, and the relevant
Federal law, the Departments have determined that expanding the
exemptions to include protections for moral convictions is a more
appropriate administrative response than continuing to refuse to extend
the exemptions and accommodations to certain entities and individuals
for whom the Mandate violates their sincerely held moral convictions.
Although the number of organizations and individuals that may seek to
take advantage of these exemptions and accommodations may be small, we
believe that it is important formally to codify such protections for
objections based on moral conviction, given the long-standing
recognition of such protections in health care and health insurance
context in law and regulation and the particularly sensitive nature of
these issues in the health care context. These interim final rules
leave unchanged HRSA's authority to decide whether to include
contraceptives in the women's preventive services Guidelines for
entities that are not exempted by law, regulation, or the Guidelines.
These rules also do not change the many other mechanisms by which the
Government advances contraceptive coverage, particularly for low-income
women.

III. Provisions of the Interim Final Rules With Comment Period

The Departments are issuing these interim final rules in light of
the full history of relevant rulemaking (including 3 previous interim
final rules), public comments, and the long-running litigation from
non-religious moral objectors to the Mandate, as well as the
information contained in the companion interim final rules issued
elsewhere in this issue of the Federal Register. These interim final
rules seek to resolve these matters by directing HRSA, to the extent it
requires coverage for certain contraceptive services in its Guidelines,
to afford an exemption to certain entities and individuals with
sincerely held moral convictions by which they object to contraceptive
or sterilization coverage, and by making the accommodation process
available for certain organizations with such convictions.
For all of the reasons discussed and referenced above, the
Departments have determined that the Government's interest in applying
contraceptive coverage requirements to the plans of certain entities
and individuals does not outweigh the sincerely held moral objections
of those entities and individuals. Thus, these interim final rules
amend the regulations amended in both the Departments' July 2015 final
regulations and in the companion interim final rules concerning
religious beliefs issued contemporaneously with these interim final
rules and published elsewhere in this issue of the Federal Register.
These interim final rules expand those exemptions to include
additional entities and persons that object based on sincerely held
moral convictions. These rules leave in place HRSA's discretion to
continue to require contraceptive and sterilization coverage where no
objection specified in the regulations exists, and if section 2713 of
the PHS Act otherwise applies. These interim final rules also maintain
the existence of an accommodation process as a voluntary option for
organizations with moral objections to contraceptive coverage, but
consistent with our expansion of the exemption, we expand eligibility
for the accommodation to include organizations with sincerely held
moral convictions concerning contraceptive coverage. HRSA is
simultaneously updating its Guidelines to reflect the requirements of
these interim final rules.\31\
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\31\ See https://www.hrsa.gov/womensguidelines/ and https://www.hrsa.gov/womensguidelines2016/.

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[[Page 47850]]

1. Exemption for Objecting Entities Based on Moral Convictions
In the new 45 CFR 147.133 as created by these interim final rules,
we expand the exemption that was previously located in Sec.
147.131(a), and that was expanded in Sec. 147.132 by the companion
interim final rules concerning religious beliefs issued
contemporaneously with these interim final rules and published
elsewhere in this issue of the Federal Register.
With respect to employers that sponsor group health plans, Sec.
147.133(a)(1) and (a)(1)(i) provide exemptions for certain employers
that object to coverage of all or a subset of contraceptives or
sterilization and related patient education and counseling based on
sincerely held moral convictions.
For avoidance of doubt, the Departments wish to make clear that the
expanded exemption in Sec. 147.133(a) applies to several distinct
entities involved in the provision of coverage to the objecting
employer's employees. This explanation is consistent with how prior
rules have worked by means of similar language. Section 147.133(a)(1)
and (a)(1)(i), by specifying that ``[a] group health plan and health
insurance coverage provided in connection with a group health plan'' is
exempt ``to the extent the plan sponsor objects as specified in
paragraph (a)(2),'' exempt the group health plans the sponsors of which
object, and exempt their health insurance issuers in providing the
coverage in those plans (whether or not the issuers have their own
objections). Consequently, with respect to Guidelines issued under
Sec. 147.130(a)(1)(iv), or the parallel provisions in 26 CFR 54.9815-
2713T(a)(1)(iv) and 29 CFR 2590.715-2713(a)(1)(iv), the plan sponsor,
issuer, and plan covered in the exemption of that paragraph would face
no penalty as a result of omitting contraceptive coverage from the
benefits of the plan participants and beneficiaries.
Consistent with the restated exemption, exempt entities will not be
required to comply with a self-certification process. Although exempt
entities do not need to file notices or certifications of their
exemption, and these interim final rules do not impose any new notice
requirements on them, existing ERISA rules governing group health plans
require that, with respect to plans subject to ERISA, a plan document
must include a comprehensive summary of the benefits covered by the
plan and a statement of the conditions for eligibility to receive
benefits. Under ERISA, the plan document provides what benefits are
provided to participants and beneficiaries under the plan and,
therefore, if an objecting employer would like to exclude all or a
subset of contraceptive services, it must ensure that the exclusion is
clear in the plan document. Moreover, if there is a reduction in a
covered service or benefit, the plan has to disclose that change to
plan participants.\32\ Thus, where an exemption applies and all or a
subset of contraceptive services are omitted from a plan's coverage,
otherwise applicable ERISA disclosures should reflect the omission of
coverage in ERISA plans. These existing disclosure requirements serve
to help provide notice to participants and beneficiaries of what ERISA
plans do and do not cover. The Departments invite public comment on
whether exempt entities, or others, would find value either in being
able to maintain or submit a specific form of certification to claim
their exemption, or in otherwise receiving guidance on a way to
document their exemption.
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\32\ See, for example, 29 U.S.C. 1022, 1024(b), 29 CFR 2520.102-
2, 2520.102-3, & 2520.104b-3(d), and 29 CFR 2590.715-2715. See also
45 CFR 147.200 (requiring disclosure of the ``exceptions,
reductions, and limitations of the coverage,'' including group
health plans and group & individual issuers).
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The exemptions in Sec. 147.133(a) apply ``to the extent'' of the
objecting entities' sincerely held moral convictions. Thus, entities
that hold a requisite objection to covering some, but not all,
contraceptive items would be exempt with respect to the items to which
they object, but not with respect to the items to which they do not
object. Likewise, the requisite objection of a plan sponsor or
institution of higher education in Sec. 147.133(a)(1)(i) and (ii)
exempts its group health plan, health insurance coverage offered by a
health insurance issuer in connection with such plan, and its issuer in
its offering of such coverage, but that exemption does not extend to
coverage provided by that issuer to other group health plans where the
plan sponsors have no qualifying objection. The objection of a health
insurance issuer in Sec. 147.133(a)(1)(iii) similarly operates only to
the extent of its objection, and as otherwise limited as described
below.
2. Exemption of Certain Plan Sponsors
The rules cover certain kinds of non-governmental employer plan
sponsors with the requisite objections, and the rules specify which
kinds of entities qualify for the exemption.
Under these interim final rules, the Departments do not limit the
exemption with reference to nonprofit status as previous rules have
done. Many of the federal health care conscience statutes cited above
offer protections for the moral convictions of entities without regard
to whether they operate as nonprofits or for-profit entities. In
addition, a significant majority of states either impose no
contraceptive coverage requirement, or offer broader exemptions than
the exemption contained in the July 2015 final regulations.\33\ States
also generally protect moral convictions in health care conscience
laws, and they often offer those protections whether or not an entity
operates as a nonprofit.\34\ Although the practice of states is by no
means a limit on the discretion delegated to HRSA by the Affordable
Care Act, nor is it a statement about what the Federal Government may
do consistent with other protections or limitations in federal law,
such state practice can be informative as to the viability of offering
protections for conscientious objections in particularly sensitive
health care contexts. In this case, the existence of many instances
where conscience protections are offered, or no underlying mandate of
this kind exists that could violate moral convictions, supports the
Departments' decision to expand the Federal exemption concerning this
Mandate as set forth in these interim final rules.
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\33\ See Guttmacher Institute, ``Insurance Coverage of
Contraceptives'' (Aug. 1, 2017), available at https://www.guttmacher.org/state-policy/explore/insurance-coverage-contraceptives.
\34\ See, for example, Guttmacher Institute, ``Refusing to
Provide Health Services'' (Aug. 1, 2017), available at https://www.guttmacher.org/state-policy/explore/refusing-provide-health-services.
---------------------------------------------------------------------------

Section 147.133(a)(1)(i)(A) of the rules specifies that the
exemption includes the plans of a plan sponsor that is a nonprofit
organization with sincerely held moral convictions.
Section 147.133(a)(1)(i)(B) of the rules specifies that the
exemption includes the plans of a plan sponsor that is a for-profit
entity that has no publicly traded ownership interests (for this
purpose, a publicly traded ownership interest is any class of common
equity securities required to be registered under section 12 of the
Securities Exchange Act of 1934).
Extending the exemption to certain for-profit entities is
consistent with the Supreme Court's ruling in Hobby Lobby, which
declared that a corporate entity is capable of possessing and pursuing
non-pecuniary goals (in Hobby Lobby, religion), regardless of whether
the entity operates as a nonprofit organization, and rejecting the

[[Page 47851]]

Departments' argument to the contrary. 134 S. Ct. 2768-75. Some reports
and industry experts have indicated that not many for-profit entities
beyond those that had originally brought suit have sought relief from
the Mandate after Hobby Lobby.\35\ The mechanisms for determining
whether a company has adopted and holds certain principles or views,
such as sincerely held moral convictions, is a matter of well-
established State law with respect to corporate decision-making,\36\
and the Departments expect that application of such laws would cabin
the scope of this exemption.
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\35\ See Jennifer Haberkorn, ``Two years later, few Hobby Lobby
copycats emerge,'' Politico (Oct. 11, 2016), available at https://www.politico.com/story/2016/10/obamacare-birth-control-mandate-employers-229627.
\36\ Although the Departments do not prescribe any form or
notification, they would expect that such principles or views would
have been adopted and documented in accordance with the laws of the
jurisdiction under which they are incorporated or organized.
---------------------------------------------------------------------------

The July 2015 final regulations extended the accommodation to for-
profit entities only if they are closely held, by positively defining
what constitutes a closely held entity. Any such positive definition
runs up against the myriad state differences in defining such entities,
and potentially intrudes into a traditional area of state regulation of
business organizations. The Departments implicitly recognized the
difficulty of defining closely held entities in the July 2015 final
regulations when we adopted a definition that included entities that
are merely ``substantially similar'' to certain specified parameters,
and we allowed entities that were not sure if they met the definition
to inquire with HHS; HHS was permitted to decline to answer the
inquiry, at which time the entity would be deemed to qualify as an
eligible organization. Instead of attempting to positively define
closely held businesses for the purpose of this rule, the Departments
consider it much more clear, effective, and preferable to define the
category negatively by reference to one element of our previous
definition, namely, that the entity has no publicly traded ownership
interest (that is, any class of common equity securities required to be
registered under section 12 of the Securities Exchange Act of 1934).
In this way, these interim final rules differ from the exemption
provided to plan sponsors with objections based on sincerely held
religious beliefs set forth in Sec. 147.132(a)(1)--those extend to
for-profit entities whether or not they are closely held or publicly
traded. The Departments seek public comment on whether the exemption in
Sec. 147.133(a)(1)(i) for plan sponsors with moral objections to the
Mandate should be finalized to encompass all of the types of plan
sponsors covered by Sec. 147.132(a)(1)(i), including publicly traded
corporations with objections based on sincerely held moral convictions,
and also non-federal governmental plan sponsors that may have
objections based on sincerely held moral convictions.
In the case of particularly sensitive health care matters, several
significant federal health care conscience statutes protect entities'
moral objections without precluding publicly traded and governmental
entities from using those protections. For example, the first paragraph
of the Church Amendments provides certain protections for entities that
object based on moral convictions to making their facilities or
personnel available to assist in the performance of abortions or
sterilizations, and the statute does not limit those protections based
on whether the entities are publicly traded or governmental. (42 U.S.C.
300a-7(b)). Thus, under section 300a-7(b), a hospital in a publicly
traded health system, or a local governmental hospital, could adopt
sincerely held moral convictions by which it objects to providing
facilities or personnel for abortions or sterilizations, and if the
entity receives relevant funds from HHS specified by section 300a-7(b),
the protections of that section would apply. The Coats-Snowe Amendment
likewise provides certain protections for health care entities and
postgraduate physician training programs that choose not to perform,
refer for, or provide training for abortions, and the statute does not
limit those protections based on whether the entities are publicly
traded or governmental. (42 U.S.C. 238n).
The Weldon Amendment \37\ provides certain protections for health
care entities, hospitals, provider-sponsored organizations, health
maintenance organizations, and health insurance plans that do not
provide, pay for, provide coverage of, or refer for abortions, and the
statute does not limit those protections based on whether the entity is
publicly traded or governmental. The Affordable Care Act provides
certain protections for any institutional health care entity, hospital,
provider-sponsored organization, health maintenance organization,
health insurance plan, or any other kind of health care facility, that
does not provide any health care item or service furnished for the
purpose of causing or assisting in causing assisted suicide,
euthanasia, or mercy killing, and the statute similarly does not limit
those protections based on whether the entity is publicly traded or
governmental. (42 U.S.C. 18113).\38\
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\37\ Consolidated Appropriations Act of 2017, Div. H, Title V,
Sec. 507(d), Pub. L. 115-31.
\38\ The lack of the limitation in this provision may be
particularly relevant since it is contained in the same statute, the
ACA, as the provision under which the Mandate--and these exemptions
to the Mandate--are promulgated.
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Sections 1395w-22(j)(3)(B) and 1396u-2(b)(3) of 42 U.S.C. protect
organizations that offer Medicaid and Medicare Advantage managed care
plans from being required to provide, reimburse for, or provide
coverage of a counseling or referral service if they object to doing so
on moral grounds, and those paragraphs do not further specify that
publicly traded entities do not qualify for the protections. Congress'
most recent statement on Government requirements of contraceptive
coverage specified that, if the District of Columbia requires ``the
provision of contraceptive coverage by health insurance plans,'' ``it
is the intent of Congress that any legislation enacted on such issue
should include a `conscience clause' which provides exceptions for
religious beliefs and moral convictions.'' Consolidated Appropriations
Act of 2017, Division C, Title VIII, Sec. 808. Congress expressed no
intent that such a conscience should be limited based on whether the
entity is publicly traded.
At the same time, the Departments lack significant information
about the need to extend the expanded exemption further. We have been
subjected to litigation by nonprofit entities expressing objections to
the Mandate based on non-religious moral convictions, and we have been
sued by closely held for-profit entities expressing religious
objections. This combination of different types of plaintiffs leads us
to believe that there may be a small number of closely held for-profit
entities that would seek to use an exemption to the contraceptive
Mandate based on moral convictions. The fact that many closely held
for-profit entities brought challenges to the Mandate has led us to
offer protections that would include publicly traded entities with
religious objections to the Mandate if such entities exist. But the
combined lack of any lawsuits challenging the Mandate by for-profit
entities with non-religious moral convictions, and of any lawsuits by
any kind of publicly traded entity, leads us to not extend the expanded
exemption in these interim final rules to publicly traded entities, but
rather to invite public comment on whether to do so in

[[Page 47852]]

a way parallel to the protections set forth in Sec. 147.132(a)(1)(i).
We agree with the Supreme Court that it is improbable that many
publicly traded companies with numerous ``unrelated shareholders--
including institutional investors with their own set of stakeholders--
would agree to run a corporation under the same religious beliefs'' (or
moral convictions) and thereby qualify for the exemption. Hobby Lobby,
134 S. Ct. at 2774. We are also not aware of other types of plan
sponsors (such as non-Federal governmental entities) that might possess
moral objections to compliance with the Mandate, including whether some
might consider certain contraceptive methods as having a possible
abortifacient effect. Nevertheless, we would welcome any comments on
whether such corporations or other plan sponsors exist and would
benefit from such an exemption.
Despite our a lack of complete information, the Departments know
that nonprofit entities have challenged the Mandate, and we assume that
a closely held business might wish to assert non-religious moral
convictions in objecting to the Mandate (although we anticipate very
few if any will do so). Thus we have chosen in these interim final
rules to include them in the expanded exemption and thereby remove an
obstacle preventing such entities from claiming an exemption based on
non-religious moral convictions. But we are less certain that we need
to use these interim final rules to extend the expanded exemption for
moral convictions to encompass other kinds of plan sponsors not
included in the protections of these interim final rules. Therefore,
with respect to plan sponsors not included in the expanded exemptions
of Sec. 147.133(a)(1)(i), and non-federal governmental plan sponsors
that might have moral objections to the Mandate, we invite public
comment on whether to include such entities when we finalize these
rules at a later date.
The Departments further conclude that it would be inadequate to
merely provide entities access to the accommodation process instead of
to the exemption where those entities object to the Mandate based on
sincerely held moral convictions. The Departments have stated in our
regulations and court briefings that the existing accommodation with
respect to self-insured plans requires contraceptive coverage as part
of the same plan as the coverage provided by the employer, and operates
in a way ``seamless'' to those plans. As a result, in significant
respects, the accommodation process does not actually accommodate the
objections of many entities. This has led many religious groups to
challenge the accommodation in court, and we expect similar challenges
would come from organizations objecting to the accommodation based on
moral convictions if we offered them the accommodation but not an
exemption. When we took that narrow approach with religious nonprofit
entities it led to multiple cases in many courts that we needed to
litigate to the Supreme Court various times. Although objections to the
accommodation were not specifically litigated in the two cases brought
by nonprofit non-religious organizations (because we have not even made
them eligible for the accommodation), those organizations made it clear
that they and their employees strongly oppose coverage of certain
contraceptives in their plans and in connection with their plans.
3. Exemption for Institutions of Higher Education
The plans of institutions of higher education that arrange student
health insurance coverage will be treated similarly to the way that
plans of employers are treated for the purposes of such plans being
exempt or accommodated based on moral convictions. These interim final
rules specify, in Sec. 147.133(a)(1)(ii), that the exemption is
extended, in the case of institutions of higher education (as defined
in 20 U.S.C. 1002), to their arrangement of student health insurance
coverage, in a manner comparable to the applicability of the exemption
for group health insurance coverage provided in connection with a group
health plan established or maintained by a plan sponsor.
The Departments are not aware of institutions of higher education
that arrange student coverage and object to the Mandate based on non-
religious moral convictions. We have been sued by several institutions
of higher education that arrange student coverage and object to the
Mandate based on religious beliefs. We believe the existence of such
entities with non-religious moral objections, or the possible formation
of such entities in the future, is sufficiently possible so that we
should provide protections for them in these interim final rules. But
based on a lack of information about such entities, we assume that none
will use the exemption concerning student coverage at this time.
4. Exemption for Issuers
These interim final rules extend the exemption, in Sec.
147.133(a)(1)(iii), to health insurance issuers offering group or
individual health insurance coverage that sincerely hold their own
moral convictions opposed to providing coverage for contraceptive
services.
As discussed above, where the exemption for plan sponsors or
institutions of higher education applies, issuers are exempt under
those sections with respect to providing coverage in those plans. The
issuer exemption in Sec. 147.133(a)(1)(iii) adds to that protection,
but the additional protection operates in a different way than the plan
sponsor exemption operates. The only plan sponsors, or in the case of
individual insurance coverage, individuals, who are eligible to
purchase or enroll in health insurance coverage offered by an exempt
issuer that does not cover some or all contraceptive services are plan
sponsors or individuals who themselves object and are otherwise exempt
based on their objection (whether the objection is based on moral
convictions, as set forth in these rules, or on religious beliefs, as
set forth in exemptions created by the companion interim final rules
published elsewhere in this issue of the Federal Register). Thus, the
issuer exemption specifies that where a health insurance issuer
providing group health insurance coverage is exempt under paragraph
(a)(1)(iii), the plan remains subject to any requirement to provide
coverage for contraceptive services under Guidelines issued under Sec.
147.130(a)(1)(iv) unless the plan is otherwise exempt from that
requirement. Accordingly, the only plan sponsors, or in the case of
individual insurance coverage, individuals, who are eligible to
purchase or enroll in health insurance coverage offered by an issuer
that is exempt under this paragraph (a)(1)(iii) that does not include
some or all contraceptive services are plan sponsors or individuals who
themselves object and are exempt.
Under the rules as amended, issuers with objections based on
sincerely held moral convictions could issue policies that omit
contraception to plan sponsors or individuals that are otherwise exempt
based on either their religious beliefs or their moral convictions, and
issuers with sincerely held religious beliefs could likewise issue
policies that omit contraception to plan sponsors or individuals that
are otherwise exempt based on either their religious beliefs or their
moral convictions.
Issuers that hold moral objections should identify to plan sponsors
the

[[Page 47853]]

lack of contraceptive coverage in any health insurance coverage being
offered that is based on the issuer's exemption, and communicate the
group health plan's independent obligation to provide contraceptive
coverage, unless the group health plan itself is exempt under
regulations governing the Mandate.
In this way, the issuer exemption serves to protect objecting
issuers both from being asked or required to issue policies that cover
contraception in violation of the issuers' sincerely held moral
convictions, and from being asked or required to issue policies that
omit contraceptive coverage to non-exempt entities or individuals, thus
subjecting the issuers to potential liability if those plans are not
exempt from the Guidelines. At the same time, the issuer exemption will
not serve to remove contraceptive coverage obligations from any plan or
plan sponsor that is not also exempt, nor will it prevent other issuers
from being required to provide contraceptive coverage in individual
insurance coverage. Protecting issuers that object to offering
contraceptive coverage based on sincerely held moral convictions will
help preserve space in the health insurance market for certain issuers
so that exempt plan sponsors and individuals will be able to obtain
coverage.
The Departments are not currently aware of health insurance issuers
that possess their own religious or moral objections to offering
contraceptive coverage. Nevertheless, many Federal health care
conscience laws and regulations protect issuers or plans specifically.
For example, as discussed above, 42 U.S.C. 1395w-22(j)(3)(B) and 1396u-
2(b)(3) protect plans or managed care organizations in Medicaid or
Medicare Advantage. The Weldon Amendment protects HMOs, health
insurance plans, and any other health care organizations from being
required to provide coverage or pay for abortions. See, for example,
Consolidated Appropriations Act of 2017, Div. H, Title V, Sec. 507(d),
Public Law 115-31. The most recently enacted Consolidated
Appropriations Act declares that Congress supports a ``conscience
clause'' to protect moral convictions concerning ``the provision of
contraceptive coverage by health insurance plans.'' See id. at Div. C,
Title VIII, Sec. 808.
The issuer exemption does not specifically include third party
administrators, for the reasons discussed in the companion interim
final rules concerning religious beliefs issued contemporaneously with
these interim final rules and published elsewhere in this issue of the
Federal Register. The Departments solicit public comment; however, on
whether there are situations where there may be an additional need to
provide distinct protections for third party administrators that may
have moral convictions implicated by the Mandate.\39\
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\39\ The exemption for issuers, as outlined here, does not make
a distinction among issuers based on whether they are publicly
traded, unlike the plan sponsor exemption for business entities.
Because the issuer exemption operates more narrowly than the
exemption for business plan sponsors operates, in the ways described
here, and exists in part to help preserve market options for
objecting plan sponsors, the Departments consider it appropriate to
not draw such a distinction among issuers.
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5. Scope of Objections Needed for the Objecting Entity Exemption
Exemptions for objecting entities specify that they apply where the
entities object as specified in Sec. 147.133(a)(2). That section
specifies that exemptions for objecting entities will apply to the
extent that an entity described in Sec. 147.133(a)(1) objects to its
establishing, maintaining, providing, offering, or arranging (as
applicable) for coverage, payments, or a plan that provides coverage or
payments for some or all contraceptive services, based on its sincerely
held moral convictions.
6. Individual Exemption
These interim final rules include a special rule pertaining to
individuals (referred to here as the ``individual exemption''). Section
147.133(b) provides that nothing in Sec. 147.130(a)(1)(iv), 26 CFR
54.9815-2713T(a)(1)(iv) and 29 CFR 2590.715-2713(a)(1)(iv), may be
construed to prevent a willing plan sponsor of a group health plan and/
or a willing health insurance issuer offering group or individual
health insurance coverage, from offering a separate benefit package
option, or a separate policy, certificate, or contract of insurance, to
any individual who objects to coverage or payments for some or all
contraceptive services based on the individual's sincerely held moral
convictions. The individual exemption extends to the coverage unit in
which the plan participant, or subscriber in the individual market, is
enrolled (for instance, to family coverage covering the participant and
his or her beneficiaries enrolled under the plan), but does not relieve
the plan's or issuer's obligation to comply with the Mandate with
respect to the group health plan at large or, as applicable, to any
other individual policies the issuer offers.
This individual exemption allows plan sponsors and issuers that do
not specifically object to contraceptive coverage to offer morally
acceptable coverage to their participants or subscribers who do object,
while offering coverage that includes contraception to participants or
subscribers who do not object. This individual exemption can apply with
respect to individuals in plans sponsored by private employers or
governmental employers. For example, in one case brought against the
Departments, the State of Missouri enacted a law under which the State
is not permitted to discriminate against insurance issuers that offer
health plans without coverage for contraception based on employees'
moral convictions, or against the individual employees who accept such
offers. See Wieland, 196 F. Supp. 3d at 1015-16 (quoting Mo. Rev. Stat.
191.724). Under the individual exemption of these interim final rules,
employers sponsoring governmental plans would be free to honor the
sincerely held moral objections of individual employees by offering
them plans that omit contraception, even if those governmental entities
do not object to offering contraceptive coverage in general.
This ``individual exemption'' cannot be used to force a plan (or
its sponsor) or an issuer to provide coverage omitting contraception,
or, with respect to health insurance coverage, to prevent the
application of state law that requires coverage of such contraceptives
or sterilization. Nor can the individual exemption be construed to
require the guaranteed availability of coverage omitting contraception
to a plan sponsor or individual who does not have a sincerely held
moral objection. This individual exemption is limited to the
requirement to provide contraceptive coverage under section 2713(a)(4)
of the PHS Act, and does not affect any other federal or state law
governing the plan or coverage. Thus, if there are other applicable
laws or plan terms governing the benefits, these interim final rules do
not affect such other laws or terms.
The Departments believe the individual exemption will help to meet
the Affordable Care Act's goal of increasing health coverage because it
will reduce the incidence of certain individuals choosing to forego
health coverage because the only coverage available would violate their
sincerely held moral convictions.\40\ At the same

[[Page 47854]]

time, this individual exemption ``does not undermine the governmental
interests furthered by the contraceptive coverage requirement,'' \41\
because, when the exemption is applicable, the individual does not want
the coverage, and therefore would not use the objectionable items even
if they were covered. In addition, because the individual exemption
only operates when the employer and/or issuer, as applicable, are
willing, the exemption will not undermine any governmental interest in
the workability of the insurance market, because we expect that any
workability concerns will be taken into account in the decision of
whether to be willing to offer the individual morally acceptable
coverage.
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\40\ This prospect has been raised in cases of religious
individuals--see, for example, Wieland, 196 F. Supp. 3d at 1017, and
March for Life, 128 F. Supp. 3d at 130--where the courts noted that
the individual employee plaintiffs indicated that they viewed the
Mandate as pressuring them to ``forgo health insurance altogether.''
\41\ 78 FR 39874.
---------------------------------------------------------------------------

For similar reasons, we have changed our position and now believe
the individual exemption will not undermine any Government interest in
uniformity in the health insurance market. At the level of plan
offerings, the extent to which plans cover contraception under the
prior rules is already far from uniform. The Congress did not require
compliance with section 2713 of the PHS Act by all entities--in
particular by grandfathered plans. The Departments' previous exemption
for houses of worship and integrated auxiliaries, and our accommodation
of self-insured church plans, show that the importance of a uniform
health insurance system is not significantly harmed by allowing plans
to omit contraception in many contexts.\42\
---------------------------------------------------------------------------

\42\ See also Real Alternatives, 2017 WL 3324690 at *36 (3d Cir.
Aug. 4, 2017) (Jordan, J., concurring in part and dissenting in
part) (``Because insurance companies would offer such plans as a
result of market forces, doing so would not undermine the
government's interest in a sustainable and functioning market. . . .
Because the government has failed to demonstrate why allowing such a
system (not unlike the one that allowed wider choice before the ACA)
would be unworkable, it has not satisfied strict scrutiny.''
(citation and internal quotation marks omitted)).
---------------------------------------------------------------------------

With respect to operationalizing this provision of these rules, as
well as the similar provision protecting individuals with religious
objections to purchasing insurance that covers some or all
contraceptives, in the interim final rules published elsewhere in this
issue of the Federal Register, the Departments note that a plan sponsor
or health insurance issuer is not required to offer separate and
different benefit package options, or separate and different forms of
policy, certificate, or contract of insurance with respect to those
individuals who object on moral bases from those who object on
religious bases. That is, a willing employer or issuer may offer the
same benefit package option or policy, certificate, or contract of
insurance--which excludes the same scope of some or all contraceptive
coverage--to individuals who are exempt from the Mandate because of
their moral convictions (under these rules) or their religious beliefs
(under the regulations as amended by the interim final rules pertaining
to religious beliefs).
7. Optional Accommodation
In addition to expanding the exemption to those with sincerely held
moral convictions, these rules also expand eligibility for the optional
accommodation process to include employers with objections based on
sincerely held moral convictions. This is accomplished by inserting
references to the newly added exemption for moral convictions, 45 CFR
147.133, into the regulatory sections where the accommodation process
is codified, 45 CFR 147.131, 26 CFR 54.9815-2713AT, and 29 CFR
2590.715-2713A. In all other respects the accommodation process works
the same as it does for entities with objections based on sincerely
held religious beliefs, as described in the companion interim final
rules concerning religious beliefs issued contemporaneously with these
interim final rules and published elsewhere in this issue of the
Federal Register.
The Departments are not aware of entities with objections to the
Mandate based on sincerely held moral convictions that wish to make use
of the optional accommodation, and our present assumption is that no
such entities will seek to use the accommodation rather than the
exemption. But if such entities do wish to use the accommodation,
making it available to them will both provide contraceptive coverage to
their plan participants and respect those entities' objections. Because
entities with objections to the Mandate based on sincerely held non-
religious moral convictions have not previously had access to the
accommodation, they would not be in a position to revoke their use of
the accommodation at the time these interim final rules are issued, but
could do so in the future under the same parameters set forth in the
accommodation regulations.
8. Regulatory Restatements of Section 2713(a) and (a)(4) of the PHS Act
These interim final rules insert references to 45 CFR 147.133 into
the restatements of the requirements of section 2713(a) and (a)(4) of
the PHS Act, contained in 26 CFR 54.9815-2713T(a)(1) introductory text
and (a)(1)(iv), 29 CFR 2590.715-2713(a)(1) introductory text and
(a)(1)(iv), and 45 CFR 147.130(a)(1) and (a)(1)(iv).
9. Conclusion
The Departments believe that the Guidelines, and the expanded
exemptions and accommodations set forth in these interim final rules,
will advance the legitimate but limited purposes for which Congress
imposed section 2713 of the PHS Act, while acting consistently with
Congress' well-established record of allowing for moral exemptions with
respect to various health care matters. These interim final rules
maintain HRSA's discretion to decide whether to continue to require
contraceptive coverage under the Guidelines if no regulatorily
recognized exemption exists (and in plans where Congress applied
section 2713 of the PHS Act). As cited above, these interim final rules
also leave fully in place over a dozen Federal programs that provide,
or subsidize, contraceptives for women, including for low income women
based on financial need. The Departments believe this array of programs
and requirements better serves the interests of providing contraceptive
coverage while protecting the moral convictions of entities and
individuals concerning coverage of some or all contraceptive or
sterilization services.
The Departments request and encourage public comments on all
matters addressed in these interim final rules.

IV. Interim Final Rules, Request for Comments and Waiver of Delay of
Effective Date

Section 9833 of the Code, section 734 of ERISA, and section 2792 of
the PHS Act authorize the Secretaries of the Treasury, Labor, and HHS
(collectively, the Secretaries) to promulgate any interim final rules
that they determine are appropriate to carry out the provisions of
chapter 100 of the Code, part 7 of subtitle B of title I of ERISA, and
part A of title XXVII of the PHS Act, which include sections 2701
through 2728 of the PHS Act and the incorporation of those sections
into section 715 of ERISA and section 9815 of the Code. These interim
final rules fall under those statutory authorized justifications, as
did previous rules on this matter (75 FR 41726; 76 FR 46621; and 79 FR
51092).
Section 553(b) of the APA requires notice and comment rulemaking,
involving a notice of proposed rulemaking and a comment period prior

[[Page 47855]]

to finalization of regulatory requirements--except when an agency, for
good cause, finds that notice and public comment thereon are
impracticable, unnecessary, or contrary to the public interest. These
provisions of the APA do not apply here because of the specific
authority granted to the Secretaries by section 9833 of the Code,
section 734 of ERISA, and section 2792 of the PHS Act.
Even if these provisions of the APA applied, they would be
satisfied: The Departments have determined that it would be
impracticable and contrary to the public interest to delay putting
these provisions in place until a full public notice-and-comment
process is completed. As discussed earlier, the Departments have issued
three interim final rules implementing this section of the PHS Act
because of the immediate needs of covered entities and the weighty
matters implicated by the HRSA Guidelines. As recently as December 20,
2016, HRSA updated those Guidelines without engaging in the regulatory
process (because doing so is not a legal requirement), and announced
that it plans to so continue to update the Guidelines.
Two lawsuits have been pending for several years by entities
raising non-religious moral objections to the Mandate.\43\ In one of
those cases, the Departments are subject to a permanent injunction and
the appeal of that case has been stayed since February 2016. In the
other case, Federal district and appeals courts ruled in favor of the
Departments, denying injunctive relief to the plaintiffs, and that case
is also still pending. Based on the public comments the Departments
have received, we have reason to believe that some similar nonprofit
entities might exist, even if it is likely a small number.\44\
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\43\ March for Life, 128 F. Supp. 3d 116; Real Alternatives, 867
F.3d 338.
\44\ See, for example, Americans United for Life (``AUL'')
Comment on CMA-9992-IFC2 at 10 (Nov. 1, 2011), available at https://www.regulations.gov/#!documentDetail;D=HHS-OS-2011-0023-59496, and
AUL Comment on CMS-9968-P at 5 (Apr. 8, 2013), available at https://www.regulations.gov/#!documentDetail;D=CMS-2012-0031-79115.
---------------------------------------------------------------------------

For entities and individuals facing a burden on their sincerely
held moral convictions, providing them relief from Government
regulations that impose such a burden is an important and urgent
matter, and delay in doing so injures those entities in ways that
cannot be repaired retroactively. The burdens of the existing rules
undermine these entities' and individuals' participation in the health
care market because they provide them with a serious disincentive--
indeed a crisis of conscience--between participating in or providing
quality and affordable health insurance coverage and being forced to
violate their sincerely held moral convictions. The existence of
inconsistent court rulings in multiple proceedings has also caused
confusion and uncertainty that has extended for several years, with
different federal courts taking different positions on whether entities
with moral objections are entitled to relief from the Mandate. Delaying
the availability of the expanded exemption would require entities to
bear these burdens for many more months. Continuing to apply the
Mandate's regulatory burden on individuals and organizations with moral
convictions objecting to compliance with the Mandate also serves as a
deterrent for citizens who might consider forming new entities
consistent with their moral convictions and offering health insurance
through those entities.
Moreover, we separately expanded exemptions to protect religious
beliefs in the companion interim final rules issued contemporaneously
with these interim final rules and published elsewhere in this issue of
the Federal Register. Because Congress has provided many statutes that
protect religious beliefs and moral convictions similarly in certain
health care contexts, it is important not to delay the expansion of
exemptions for moral convictions set forth in these rules, since the
companion rules provide protections for religious beliefs on an interim
final basis. Otherwise, our regulations would simultaneously provide
and deny relief to entities and individuals that are, in the
Departments' view, similarly deserving of exemptions and accommodations
consistent, with similar protections in other federal laws. This could
cause similarly situated entities and individuals to be burdened
unequally.
In response to several of the previous rules on this issue--
including three issued as interim final rules under the statutory
authority cited above--the Departments received more than 100,000
public comments on multiple occasions. Those comments included
extensive discussion about whether and to what extent to expand the
exemption. Most recently, on July 26, 2016, the Departments issued a
request for information (81 FR 47741) and received over 54,000 public
comments about different possible ways to resolve these issues. As
noted above, the public comments in response to both the RFI and
various prior rulemaking proceedings included specific requests that
the exemptions be expanded to include those who oppose the Mandate for
either religious or ``moral'' reasons.\45\ In connection with past
regulations, the Departments have offered or expanded a temporary safe
harbor allowing organizations that were not exempt from the HRSA
Guidelines to operate out of compliance with the Guidelines. The
Departments will fully consider comments submitted in response to these
interim final rules, but believe that good cause exists to issue the
rules on an interim final basis before the comments are submitted and
reviewed. Issuing interim final rules with a comment period provides
the public with an opportunity to comment on whether these regulations
expanding the exemption should be made permanent or subject to
modification without delaying the effective date of the regulations.
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\45\ See, for example, https://www.regulations.gov/#!documentDetail;D=HHS-OS-2011-0023-59496, https://www.regulations.gov/#!documentDetail;D=CMS-2012-0031-79115, https://www.regulations.gov/document?D=CMS-2016-0123-54142, https://www.regulations.gov/document?D=CMS-2016-0123-54218, and https://www.regulations.gov/document?D=CMS-2016-0123-46220.
---------------------------------------------------------------------------

As the U.S. Court of Appeals for the D.C. Circuit stated with
respect to an earlier IFR promulgated with respect to this issue in
Priests for Life v. U.S. Department of Health and Human Services, 772
F.3d 229, 276 (D.C. Cir. 2014), vacated on other grounds, Zubik v.
Burwell, 136 S. Ct. 1557 (2016), ``[S]everal reasons support HHS's
decision not to engage in notice and comment here.'' Among other
things, the Court noted that ``the agency made a good cause finding in
the rule it issued''; that ``the regulations the interim final rule
modifies were recently enacted pursuant to notice and comment
rulemaking, and presented virtually identical issues''; that ``HHS will
expose its interim rule to notice and comment before its permanent
implementation''; and that not proceeding under interim final rules
would ``delay the implementation of the alternative opt-out for
religious objectors.'' Id. at 277. Similarly, not proceeding with
exemptions and accommodations for moral objectors here would delay the
implementation of those alternative opt-outs for moral objectors.
Delaying the availability of the expanded exemption could also
increase the costs of health insurance for some entities. As reflected
in litigation pertaining to the Mandate, some entities are in
grandfathered health plans that do not cover

[[Page 47856]]

contraception. As such, they may wish to make changes to their health
plans that will reduce the costs of insurance coverage for their
beneficiaries or policyholders, but which would cause the plans to lose
grandfathered status. To the extent that entities with objections to
the Mandate based on moral convictions but not religious beliefs fall
into this category, they may be refraining from making those changes--
and therefore may be continuing to incur and pass on higher insurance
costs--to prevent the Mandate from applying to their plans in violation
of their consciences. We are not aware of the extent to which such
entities exist, but 17 percent of all covered workers are in
grandfathered health plans, encompassing tens of millions of
people.\46\ Issuing these rules on an interim final basis reduces the
costs of health insurance and regulatory burdens for such entities and
their plan participants.
---------------------------------------------------------------------------

\46\ Kaiser Family Foundation & Health Research & Educational
Trust, ``Employer Health Benefits, 2017 Annual Survey,'' available
at https://files.kff.org/attachment/Report-Employer-Health-Benefits-Annual-Survey-2017.
---------------------------------------------------------------------------

These interim final rules also expand access to the optional
accommodation process for certain entities with objections to the
Mandate based on moral convictions. If entities exist that wish to use
that process, the Departments believe they should be able to do so
without the delay that would be involved by not offering them the
optional accommodation process by use of interim final rules.
Proceeding otherwise could delay the provision of contraceptive
coverage to those entities' employees.
For the foregoing reasons, the Departments have determined that it
would be impracticable and contrary to the public interest to engage in
full notice and comment rulemaking before putting these interim final
rules into effect, and that it is in the public interest to promulgate
interim final rules. For the same reasons, the Departments have
determined, consistent with section 553(d) of the APA (5 U.S.C.
553(d)), that there is good cause to make these interim final rules
effective immediately upon filing for public inspection at the Office
of the Federal Register.

V. Economic Impact and Paperwork Burden

We have examined the impacts of the interim final rules as required
by Executive Order 12866 on Regulatory Planning and Review (September
30, 1993), Executive Order 13563 on Improving Regulation and Regulatory
Review (January 18, 2011), the Regulatory Flexibility Act (RFA)
(September 19, 1980, Pub. L. 96-354, section 1102(b) of the Social
Security Act, section 202 of the Unfunded Mandates Reform Act of 1995
(March 22, 1995; Pub. L. 104-4), Executive Order 13132 on Federalism
(August 4, 1999), the Congressional Review Act (5 U.S.C. 804(2) and
Executive Order 13771 on Reducing Regulation and Controlling Regulatory
Costs (January 30, 2017).

A. Executive Orders 12866 and 13563--Department of HHS and Department
of Labor

Executive Orders 12866 and 13563 direct agencies to assess all
costs and benefits of available regulatory alternatives and, if
regulation is necessary, to select regulatory approaches that maximize
net benefits (including potential economic, environmental, and public
health and safety effects; distributive impacts; and equity). Executive
Order 13563 emphasizes the importance of quantifying both costs and
benefits, reducing costs, harmonizing rules, and promoting flexibility.
Section 3(f) of Executive Order 12866 defines a ``significant
regulatory action'' as an action that is likely to result in a
regulation: (1) Having an annual effect on the economy of $100 million
or more in any 1 year, or adversely and materially affecting a sector
of the economy, productivity, competition, jobs, the environment,
public health or safety, or State, local, or tribal governments or
communities (also referred to as ``economically significant''); (2)
creating a serious inconsistency or otherwise interfering with an
action taken or planned by another agency; (3) materially altering the
budgetary impacts of entitlement grants, user fees, or loan programs or
the rights and obligations of recipients thereof; or (4) raising novel
legal or policy issues arising out of legal mandates, the President's
priorities, or the principles set forth in the Executive Order.
A regulatory impact analysis must be prepared for major rules with
economically significant effects ($100 million or more in any one
year), and an ``economically significant'' regulatory action is subject
to review by the Office of Management and Budget (OMB). As discussed
below regarding anticipated effects of these rules and the Paperwork
Reduction Act, these interim final rules are not likely to have
economic impacts of $100 million or more in any one year, and therefore
do not meet the definition of ``economically significant'' under
Executive Order 12866. However, OMB has determined that the actions are
significant within the meaning of section 3(f)(4) of the Executive
Order. Therefore, OMB has reviewed these final regulations and the
Departments have provided the following assessment of their impact.
1. Need for Regulatory Action
These interim final rules amend the Departments' July 2015 final
regulations and do so in conjunction with the amendments made in the
companion interim final rules concerning religious beliefs issued
contemporaneously with these interim final rules and published
elsewhere in this issue of the Federal Register. These interim final
rules expand the exemption from the requirement to provide coverage for
contraceptives and sterilization, established under the HRSA
Guidelines, promulgated under section 2713(a)(4) of the PHS Act,
section 715(a)(1) of the ERISA, and section 9815(a)(1) of the Code, to
include certain entities and individuals with objections to compliance
with the Mandate based on sincerely held moral convictions, and they
revise the accommodation process to make entities with such convictions
eligible to use it. The expanded exemption would apply to certain
individuals, nonprofit entities, institutions of higher education,
issuers, and for-profit entities that do not have publicly traded
ownership interests, that have a moral objection to providing coverage
for some (or all) of the contraceptive and/or sterilization services
covered by the Guidelines. Such action is taken, among other reasons,
to provide for conscientious participation in the health insurance
market free from penalties for violating sincerely held moral
convictions opposed to providing or receiving coverage of contraceptive
services, to resolve lawsuits that have been filed against the
Departments by some such entities, and to avoid similar legal
challenges.
2. Anticipated Effects
The Departments acknowledge that expanding the exemption to include
objections based on moral convictions might result in less insurance
coverage of contraception for some women who may want the coverage.
Although the Departments do not know the exact scope of that effect
attributable to the moral exemption in these interim final rules, they
believe it to be small.
With respect to the expanded exemption for nonprofit organizations,
as noted above the Departments are aware of two small nonprofit

[[Page 47857]]

organizations that have filed lawsuits raising non-religious moral
objections to coverage of some contraceptives. Both of those entities
have fewer than five employees enrolled in health coverage, and both
require all of their employees to agree with their opposition to the
coverage.\47\ Based on comments submitted in response to prior
rulemakings on this subject, we believe that at least one other similar
entity exists. However, we do not know how many similar entities exist.
Lacking other information we assume that the number is small. Without
data to estimate the number of such entities, we believe it to be less
than 10, and assume the exemption will be used by nine nonprofit
entities.
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\47\ Non-religious nonprofit organizations that engage in
expressive activity generally have a First Amendment right to hire
only people who share their moral convictions or will be respectful
of them--including their convictions on whether the organization or
others provide health coverage of contraception, or of certain items
they view as being abortifacient.
---------------------------------------------------------------------------

We also assume that those nine entities will operate in a fashion
similar to the two similar entities of which we are aware, so that
their employees will likely share their views against coverage of
certain contraceptives. This is consistent with our conclusion in
previous rules that no significant burden or costs would result from
exempting houses of worship and integrated auxiliaries. (See 76 FR
46625 and 78 FR 39889). We reached that conclusion without ultimately
requiring that houses of worship and integrated auxiliaries only hire
persons who agree with their views against contraception, and without
even requiring that such entities actually oppose contraception in
order to be exempt (in contrast, the expanded exemption here requires
the exempt entity to actually possess sincerely held moral convictions
objecting to the coverage). In concluding that the exemption for houses
of worship and integrated auxiliaries would result in no significant
burden or costs, we relied on our assumption that the employees of
exempt houses of worship and integrated auxiliaries likely share their
employers' opposition to contraceptive coverage.
A similar assumption is supported with respect to the expanded
exemption for nonprofit organizations. To our knowledge, the vast
majority of organizations objecting to the Mandate assert religious
beliefs. The only nonprofit organizations of which we are aware that
possess non-religious moral convictions against some or all
contraceptive methods only hire persons who share their convictions. It
is possible that the exemption for nonprofit organizations with moral
convictions in these interim final rules could be used by a nonprofit
organization that employs persons who do not share the organization's
views on contraception, but it was also possible under our previous
rules that a house of worship or integrated auxiliary could employ
persons who do not share their views on contraception.\48\ Although we
are unable to find sufficient data on this issue, we believe that there
are far fewer non-religious moral nonprofit organizations opposed to
contraceptive coverage than there are churches with religious
objections to such coverage. Based on our limited data, we believe the
most likely effect of the expanded exemption for nonprofit entities is
that it will be used by entities similar to the two entities that have
sought an exemption through litigation, and whose employees also oppose
the coverage. Therefore, we expect that the expanded exemption for
nonprofit entities will have no effect of reducing contraceptive
coverage to employees who want that coverage.
---------------------------------------------------------------------------

\48\ Cf., for example, Gallup, ``Americans, Including Catholics,
Say Birth Control Is Morally OK,'' (May 22, 2012) (``Eighty-two
percent of U.S. Catholics say birth control is morally
acceptable''), available at https://www.gallup.com/poll/154799/americans-including-catholics-say-birth-control-morally.aspx.
---------------------------------------------------------------------------

These interim final rules expand the exemption to include
institutions of higher education that arrange student coverage and have
non-religious moral objections to the Mandate, and they make exempt
entities with moral objections eligible to use the accommodation. The
Departments are not aware of either kind of entity. We believe the
number of entities that object to the Mandate based on non-religious
moral convictions is already very small. The only entities of which we
are aware that have raised such objections are not institutions of
higher education, and appear to hold objections that we assume would
likely lead them to reject the accommodation process. Therefore, for
the purposes of estimating the anticipated effect of these interim
final rules on contraceptive coverage of women who wish to receive such
coverage, we assume that--at this time--no entities with non-religious
moral objections to the Mandate will be institutions of higher
education that arrange student coverage, and no entities with non-
religious moral objections will opt into the accommodation. We wish to
make the expanded exemption and accommodation available to such
entities in case they do exist or might come into existence, based on
similar reasons to those given above for why the exemptions and
accommodations are extended to other entities. We invite public comment
on whether and how many such entities will make use of these interim
final rules.
The expanded exemption for issuers will not result in a distinct
effect on contraceptive coverage for women who wish to receive it
because that exemption only applies in cases where plan sponsors or
individuals are also otherwise exempt, and the effect of those
exemptions is discussed elsewhere herein. The expanded exemption for
individuals that oppose contraceptive coverage based on sincerely held
moral convictions will provide coverage that omits contraception for
individuals that object to contraceptive coverage.
The expanded moral exemption would also cover for-profit entities
that do not have publicly traded ownership interests, and that have
non-religious moral objections to the Mandate. The Departments are not
aware of any for-profit entities that possess non-religious moral
objections to the Mandate. However, scores of for-profit entities have
filed suit challenging the Mandate. Among the over 200 entities that
brought legal challenges, only two entities (less than 1 percent)
raised non-religious moral objections--both were nonprofit. Among the
general public polls vary about religious beliefs, but one prominent
poll shows that 89 percent of Americans say they believe in God.\49\
Among non-religious persons, only a very small percentage appears to
hold moral objections to contraception. A recent study found that only
2 percent of religiously unaffiliated persons believed using
contraceptives is morally wrong.\50\ Combined, this suggests that 0.2
percent of Americans at most \51\ might believe contraceptives are
morally wrong based on moral convictions but not religious beliefs. We
have no information about how many of those persons run closely held
businesses, offer employer sponsored health insurance, and would make
use of the expanded exemption for moral

[[Page 47858]]

convictions set forth in these interim final rules. Given the large
number of closely held entities that challenged the Mandate based on
religious objections, we assume that some similar for-profit entities
with non-religious moral objections exist. But we expect that it will
be a comparatively small number of entities, since among the nonprofit
litigants, only two were non-religious. Without data available to
estimate the actual number of entities that will make use of the
expanded exemption for for-profit entities that do not have publicly
traded ownership interests and that have objections to the Mandate
based on sincerely held moral convictions, we expect that fewer than 10
entities, if any, will do so--we assume nine for-profit entities will
use the exemption in these interim final rules.
---------------------------------------------------------------------------

\49\ Gallup, ``Most Americans Still Believe in God'' (June 14-
23, 2016), available at https://www.gallup.com/poll/193271/americans-believe-god.aspx.
\50\ Pew Research Center, ``Where the Public Stands on Religious
Liberty vs. Nondiscrimination'' at page 26 (Sept. 28, 2016),
available at https://assets.pewresearch.org/wp-content/uploads/sites/11/2016/09/Religious-Liberty-full-for-web.pdf.
\51\ The study defined religiously ``unaffiliated'' as agnostic,
atheist or ``nothing in particular'' (id. at 8), as distinct from
several versions of Protestants, or Catholics. ``Nothing in
particular'' might have included some theists.
---------------------------------------------------------------------------

The expanded exemption encompassing certain for-profit entities
could result in the removal of contraceptive coverage from women who do
not share their employers' views. The Departments used data from the
Current Population Survey (CPS) and the Medical Expenditure Panel
Survey-Insurance Component (MEPS-IC) to obtain an estimate of the
number of policyholders that will be covered by the plans of the nine
for-profit entities we assume may make use of these expanded
exemptions.\52\ The average number of policyholders (9) in plans with
under 100 employees was obtained. It is not known what size the for-
profit employers will be that might claim this exemption, but as
discussed above these interim final rules do not include publicly
traded companies (and we invite public comments on whether to do so in
the final rules), and both of the two nonprofit entities that
challenged the Mandate included fewer than five policyholders in each
entity. Therefore we assume the for-profit entities that may claim this
expanded exemption will have fewer than 100 employees and an average of
9 policyholders. For nine entities, the total number of policyholders
would be 81. DOL estimates that for each policyholder, there is
approximately one dependent.\53\ This amounts to 162 covered persons.
Census data indicate that women of childbearing age--that is, women
aged 15-44--comprise 20.2 percent of the general population.\54\ This
amounts to approximately 33 women of childbearing age for this group of
individuals covered by group plans sponsored by for-profit moral
objectors. Approximately 44.3 percent of women currently use
contraceptives covered by the Guidelines.\55\ Thus we estimate that 15
women may incur contraceptive costs due to for-profit entities using
the expanded exemption provided in these interim final rules.\56\ In
the companion interim final rules concerning religious beliefs issued
contemporaneously with these interim final rules and published
elsewhere in this issue of the Federal Register, we estimate that the
average cost of contraception per year per woman of childbearing age
that use contraception covered by the Guidelines, within health plans
that cover contraception, is $584. Consequently, we estimate that the
anticipated effects attributable to the cost of contraception from for-
profit entities using the expanded exemption in these interim final
rules is approximately $8,760.
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\52\ ``Health Insurance Coverage Bulletin'' Table 4, page 21.
Using March 2015 Annual Social and Economic Supplement to the
Current Population Survey. https://www.dol.gov/sites/default/files/ebsa/researchers/data/health-and-welfare/health-insurance-coverage-bulletin-2015.pdfEstimates of the number of ERISA Plans based on
2015 Medical Expenditure Survey--Insurance
\53\ ``Health Insurance Coverage Bulletin'' Table 4, page 21.
Using March 2015 Annual Social and Economic Supplement to the
Current Population Survey. https://www.dol.gov/sites/default/files/ebsa/researchers/data/health-and-welfare/health-insurance-coverage-bulletin-2015.pdf.
\54\ U.S. Census Bureau, ``Age and Sex Composition: 2010'' (May
2011), available at https://www.census.gov/prod/cen2010/briefs/c2010br-03.pdf. The Guidelines' requirement of contraceptive
coverage only applies ``for all women with reproductive capacity.''
https://www.hrsa.gov/womensguidelines/; see also 80 FR 40318. In
addition, studies commonly consider the 15-44 age range to assess
contraceptive use by women of childbearing age. See, Guttmacher
Institute, ``Contraceptive Use in the United States'' (Sept. 2016),
available at https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states.
\55\ See https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states.
\56\ We note that many non-religious for-profit entities which
sued the Departments challenging the Mandate, including some of the
largest employers, only objected to coverage of 4 of the 18 types of
contraceptives required to be covered by the Mandate--namely, those
contraceptives which they viewed as abortifacients, and akin to
abortion --and they were willing to provide coverage for other types
of contraception. It is reasonable to assume that this would also be
the case with respect to some for-profits that object to the Mandate
on the basis of sincerely held moral convictions. Accordingly, it is
possible that even fewer women beneficiaries under such plans would
bear out-of-pocket expenses in order to obtain contraceptives, and
that those who might do so would bear lower costs due to many
contraceptive items being covered.
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The Departments estimate that these interim final rules will not
result in any additional burden or costs on issuers or third party
administrators. As discussed above, we assume that no entities with
non-religious moral convictions will use the accommodation, although we
wish to make it available in case an entity voluntarily opts into it in
order to allow contraceptive coverage to be provided to its plan
participants and beneficiaries. Finally, because the accommodation
process was not previously available to entities that possess non-
religious moral objections to the Mandate, we do not anticipate that
these interim final rules will result in any burden from such entities
revoking their accommodated status.
The Departments believe the foregoing analysis represents a
reasonable estimate of the likely impact under the rules expanded
exemptions. The Departments acknowledge uncertainty in the estimate and
therefore conducted a second analysis using an alternative framework,
which is set forth in the companion interim final rule concerning
religious beliefs issued contemporaneously with this interim final rule
and published elsewhere in this issue of the Federal Register. Under
either estimate, this interim final rule is not economically
significant.
We reiterate the rareness of instances in which we are aware that
employers assert non-religious objections to contraceptive coverage
based on sincerely held moral convictions, as discussed above, and also
that in the few instances where such an objection has been raised,
employees of such employers also opposed contraception.
We request comment on all aspects of the preceding regulatory
impact analysis.

B. Special Analyses--Department of the Treasury

For purposes of the Department of the Treasury, certain Internal
Revenue Service (IRS) regulations, including this one, are exempt from
the requirements in Executive Order 12866, as supplemented by Executive
Order 13563. The Departments estimate that the likely effect of these
interim final rules will be that entities will use the exemption and
not the accommodation. Therefore, a regulatory assessment is not
required.

C. Regulatory Flexibility Act

The Regulatory Flexibility Act (5 U.S.C. 601 et seq.) (RFA) imposes
certain requirements with respect to Federal rules that are subject to
the notice and comment requirements of section 553(b) of the APA (5
U.S.C. 551 et seq.) and that are likely to have a significant economic
impact on a substantial number of small entities. Under Section 553(b)
of the APA, a general notice of proposed rulemaking is not required
when an agency, for good cause, finds that notice and public comment
thereon are impracticable, unnecessary, or contrary to the public

[[Page 47859]]

interest. The interim final rules are exempt from the APA, both because
the PHS Act, ERISA, and the Code contain specific provisions under
which the Secretaries may adopt regulations by interim final rule and
because the Departments have made a good cause finding that a general
notice of proposed rulemaking is not necessary earlier in this
preamble. Therefore, the RFA does not apply and the Departments are not
required to either certify that the regulations or this amendment would
not have a significant economic impact on a substantial number of small
entities or conduct a regulatory flexibility analysis.
Nevertheless, the Departments carefully considered the likely
impact of the rule on small entities in connection with their
assessment under Executive Order 12866. The Departments do not expect
that these interim final rules will have a significant economic effect
on a substantial number of small entities, because they will not result
in any additional costs to affected entities. Instead, by exempting
from the Mandate small businesses and nonprofit organizations with
moral objections to some or all contraceptives and/or sterilization,
the Departments have reduced regulatory burden on small entities.
Pursuant to section 7805(f) of the Code, these regulations have been
submitted to the Chief Counsel for Advocacy of the Small Business
Administration for comment on their impact on small business.

D. Paperwork Reduction Act--Department of Health and Human Services

Under the Paperwork Reduction Act of 1995 (the PRA), federal
agencies are required to publish notice in the Federal Register
concerning each proposed collection of information. Interested persons
are invited to send comments regarding our burden estimates or any
other aspect of this collection of information, including any of the
following subjects: (1) The necessity and utility of the proposed
information collection for the proper performance of the agency's
functions; (2) the accuracy of the estimated burden; (3) ways to
enhance the quality, utility, and clarity of the information to be
collected; and (4) the use of automated collection techniques or other
forms of information technology to minimize the information collection
burden.
We estimate that these interim final rules will not result in
additional burdens not accounted for as set forth in the companion
interim final rules concerning religious beliefs issued
contemporaneously with these interim final rules and published
elsewhere in this issue of the Federal Register. As discussed there,
regulations covering the accommodation include provisions regarding
self-certification or notices to HHS from eligible organizations (Sec.
147.131(c)(3)), notice of availability of separate payments for
contraceptive services (Sec. 147.131(f)), and notice of revocation of
accommodation (Sec. 147.131(c)(4)). The burdens related to those ICRs
are currently approved under OMB Control Numbers 0938-1248 and 0938-
1292. These interim final rules amend the accommodation regulations to
make entities with moral objections to the Mandate eligible to use the
same accommodation processes. The Departments will update the forms and
model notices regarding these processes to reflect that entities with
sincerely held moral convictions are eligible organizations.
As discussed above, however, we assume that no entities with non-
religious moral objections to the Mandate will use the accommodation,
and we know that no such entities were eligible for it until now, so
that they do not possess accommodated status to revoke. Therefore we
believe that the burden for these ICRs is accounted for in the
collection approved under OMB Control Numbers 0938-1248 and 0938-1292,
as described in the interim final rules concerning religious beliefs
issued contemporaneously with these interim final rules.
We are soliciting comments on all of the possible information
collection requirements contained in these interim final rules,
including those discussed in the companion interim final rules
concerning religious beliefs issued contemporaneously with these
interim final rules and published elsewhere in this issue of the
Federal Register, for which these interim final rules provide
eligibility to entities with objections based on moral convictions. In
addition, we are also soliciting comments on all of the related
information collection requirements currently approved under 0938-1292
and 0938-1248.
To obtain copies of a supporting statement and any related forms
for the proposed collection(s) summarized in this notice, you may make
your request using one of following:
1. Access CMS' Web site address at https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing.html.
2. Email your request, including your address, phone number, OMB
number, and CMS document identifier, to Paperwork@cms.hhs.gov.
3. Call the Reports Clearance Office at (410) 786-1326.
If you comment on these information collections, that is,
reporting, recordkeeping or third-party disclosure requirements, please
submit your comments electronically as specified in the ADDRESSES
section of these interim final rules with comment period.

E. Paperwork Reduction Act--Department of Labor

Under the Paperwork Reduction Act, an agency may not conduct or
sponsor, and an individual is not required to respond to, a collection
of information unless it displays a valid OMB control number. In
accordance with the requirements of the PRA, the ICR for the EBSA Form
700 and alternative notice have previously been approved by OMB under
control numbers 1210-0150 and 1210-0152. A copy of the ICR may be
obtained by contacting the PRA addressee shown below or at https://www.RegInfo.gov. PRA ADDRESSEE: G. Christopher Cosby, Office of Policy
and Research, U.S. Department of Labor, Employee Benefits Security
Administration, 200 Constitution Avenue NW., Room N-5718, Washington,
DC 20210. Telephone: 202-693-8410; Fax: 202-219-4745. These are not
toll-free numbers.
Consistent with the analysis in the HHS PRA section above, although
these interim final rules make entities with certain moral convictions
eligible for the accommodation, we assume that no entities will use it
rather than the exemption, and such entities were not previously
eligible for the accommodation so as to revoke it. Therefore we believe
these interim final rules do not involve additional burden not
accounted for under OMB control number 1210-0150.
Regarding the ICRs discussed in the companion interim final rules
concerning religious beliefs issued contemporaneously with these
interim final rules and published elsewhere in this issue of the
Federal Register, the forms for which would be used if any entities
with moral objections used the accommodation process in the future, DOL
submitted those ICRs in order to obtain OMB approval under the PRA for
the regulatory revision. The request was made under emergency clearance
procedures specified in regulations at 5 CFR 1320.13. OMB approved the
ICRs under the emergency clearance process. In an effort to consolidate
the number of information collection requests, DOL indicated it will
combine the ICR related to the OMB control number 1210-0152 with the
ICR related to the OMB control number 1210-0150. Once

[[Page 47860]]

the ICR is approved, DOL indicated it will discontinue 1210-0152. OMB
approved the ICR under control number 1210-0150 through [DATE]. A copy
of the information collection request may be obtained free of charge on
the RegInfo.gov Web site at https://www.reginfo.gov/public/do/PRAViewICR?ref_nbr=201705-1210-001. This approval allows respondents
temporarily to utilize the additional flexibility these interim final
regulations provide, while DOL seeks public comment on the collection
methods--including their utility and burden. Contemporaneously with the
publication of these interim final rules, DOL will publish a notice in
the Federal Register informing the public of its intention to extend
the OMB approval.

F. Regulatory Reform Executive Orders 13765, 13771 and 13777

Executive Order 13765 (January 20, 2017) directs that, ``[t]o the
maximum extent permitted by law, the Secretary of Health and Human
Services (Secretary) and the heads of all other executive departments
and agencies (agencies) with authorities and responsibilities under the
Act shall exercise all authority and discretion available to them to
waive, defer, grant exemptions from, or delay the implementation of any
provision or requirement of the Act that would impose a fiscal burden
on any State or a cost, fee, tax, penalty, or regulatory burden on
individuals, families, healthcare providers, health insurers, patients,
recipients of healthcare services, purchasers of health insurance, or
makers of medical devices, products, or medications.'' In addition,
agencies are directed to ``take all actions consistent with law to
minimize the unwarranted economic and regulatory burdens of the
[Affordable Care Act], and prepare to afford the States more
flexibility and control to create a more free and open healthcare
market.'' These interim final rules exercise the discretion provided to
the Departments under the Affordable Care Act and other laws to grant
exemptions and thereby minimize regulatory burdens of the Affordable
Care Act on the affected entities and recipients of health care
services.
Consistent with Executive Order 13771 (82 FR 9339, February 3,
2017), we have estimated the costs and cost savings attributable to
this interim final rule. As discussed in more detail in the preceding
analysis, this interim final rule lessens incremental reporting
costs.\57\ Therefore, this interim final rule is considered an EO 13771
deregulatory action.
---------------------------------------------------------------------------

\57\ Other noteworthy potential impacts encompass potential
changes in medical expenditures, including potential decreased
expenditures on contraceptive devices and drugs and potential
increased expenditures on pregnancy-related medical services. OMB's
guidance on E.O. 13771 implementation (https://www.whitehouse.gov/the-press-office/2017/04/05/memorandum-implementing-executive-order-13771-titled-reducing-regulation) states that impacts should be
categorized as consistently as possible within Departments. The Food
and Drug Administration, within HHS, and the Occupational Safety and
Health Administration (OSHA) and Mine Safety and Health
Administration (MSHA), within DOL, regularly estimate medical
expenditure impacts in the analyses that accompany their
regulations, with the results being categorized as benefits
(positive benefits if expenditures are reduced, negative benefits if
expenditures are raised). Following the FDA, OSHA and MSHA
accounting convention leads to this interim final rule's medical
expenditure impacts being categorized as (positive or negative)
benefits, rather than as costs, thus placing them outside of
consideration for E.O. 13771 designation purposes.
---------------------------------------------------------------------------

G. Unfunded Mandates Reform Act

The Unfunded Mandates Reform Act of 1995 (section 202(a) of Pub. L.
104-4), requires the Departments to prepare a written statement, which
includes an assessment of anticipated costs and benefits, before
issuing ``any rule that includes any Federal mandate that may result in
the expenditure by State, local, and tribal governments, in the
aggregate, or by the private sector, of $100,000,000 or more (adjusted
annually for inflation) in any one year.'' The current threshold after
adjustment for inflation is $148 million, using the most current (2016)
Implicit Price Deflator for the Gross Domestic Product. For purposes of
the Unfunded Mandates Reform Act, these interim final rules do not
include any Federal mandate that may result in expenditures by State,
local, or tribal governments, nor do they include any Federal mandates
that may impose an annual burden of $100 million, adjusted for
inflation, or more on the private sector.

H. Federalism

Executive Order 13132 outlines fundamental principles of
federalism, and requires the adherence to specific criteria by Federal
agencies in the process of their formulation and implementation of
policies that have ``substantial direct effects'' on States, the
relationship between the Federal Government and States, or the
distribution of power and responsibilities among the various levels of
Government. Federal agencies promulgating regulations that have these
federalism implications must consult with state and local officials,
and describe the extent of their consultation and the nature of the
concerns of state and local officials in the preamble to the
regulation.
These interim final rules do not have any Federalism implications,
since they only provide exemptions from the contraceptive and
sterilization coverage requirement in HRSA Guidelines supplied under
section 2713 of the PHS Act.

VI. Statutory Authority

The Department of the Treasury temporary regulations are adopted
pursuant to the authority contained in sections 7805 and 9833 of the
Code.
The Department of Labor regulations are adopted pursuant to the
authority contained in 29 U.S.C. 1002(16), 1027, 1059, 1135, 1161-1168,
1169, 1181-1183, 1181 note, 1185, 1185a, 1185b, 1185d, 1191, 1191a,
1191b, and 1191c; sec. 101(g), Public Law 104-191, 110 Stat. 1936; sec.
401(b), Public Law 105-200, 112 Stat. 645 (42 U.S.C. 651 note); sec.
512(d), Public Law 110-343, 122 Stat. 3881; sec. 1001, 1201, and
1562(e), Public Law 111-148, 124 Stat. 119, as amended by Public Law
111-152, 124 Stat. 1029; Secretary of Labor's Order 1-2011, 77 FR 1088
(Jan. 9, 2012).
The Department of Health and Human Services regulations are adopted
pursuant to the authority contained in sections 2701 through 2763,
2791, and 2792 of the PHS Act (42 U.S.C. 300gg through 300gg-63, 300gg-
91, and 300gg-92), as amended; and Title I of the Affordable Care Act,
sections 1301-1304, 1311-1312, 1321-1322, 1324, 1334, 1342-1343, 1401-
1402, and 1412, Pub. L. 111-148, 124 Stat. 119 (42 U.S.C. 18021-18024,
18031-18032, 18041-18042, 18044, 18054, 18061, 18063, 18071, 18082, 26
U.S.C. 36B, and 31 U.S.C. 9701).

List of Subjects

26 CFR Part 54

Excise taxes, Health care, Health insurance, Pensions, Reporting
and recordkeeping requirements.

29 CFR Part 2590

Continuation coverage, Disclosure, Employee benefit plans, Group
health plans, Health care, Health insurance, Medical child support,
Reporting and recordkeeping requirements.

45 CFR Part 147

Health care, Health insurance, Reporting and recordkeeping

[[Page 47861]]

requirements, State regulation of health insurance.

Kirsten B. Wielobob,
Deputy Commissioner for Services and Enforcement.
Approved: October 2, 2017.
David J. Kautter,
Assistant Secretary for Tax Policy.

Signed this 4th day of October, 2017.
Timothy D. Hauser,
Deputy Assistant Secretary for Program Operations, Employee Benefits
Security Administration, Department of Labor.

Dated: October 4, 2017.
Seema Verma,
Administrator, Centers for Medicare & Medicaid Services.

Approved: October 4, 2017.
Donald Wright,
Acting Secretary, Department of Health and Human Services.

DEPARTMENT OF THE TREASURY

Internal Revenue Service

For the reasons set forth in this preamble, 26 CFR part 54 is
amended as follows:

PART 54--PENSION EXCISE TAXES

0
1. The authority citation for part 54 continues to read, in part, as
follows:

Authority: 26 U.S.C. 7805. * * *

Sec. 54.9815-2713T [Amended]

0
2. Section 54.9815-2713T, as added elsewhere in this issue of the
Federal Register, is amended in paragraph (a)(1)(iv) by removing the
reference ``147.131 and 147.132'' and adding in its place the reference
``147.131, 147.132, and 147.133''.

Sec. 54.9815-2713AT [Amended]

0
3. Section 54.9815-2713AT, as added elsewhere in this issue of the
Federal Register], is amended--
0
a. In paragraph (a)(1) by removing ``or (ii)'' and adding in its place
``or (ii), or 45 CFR 147.133(a)(1)(i) or (ii)'';
0
b. In paragraph (a)(2) by removing the reference ``147.132(a)'' and
adding in its place the reference ``147.132(a) or 147.133(a)'';
0
c. In paragraph (b)(1)(ii) introductory text by removing the reference
``147.132'' and adding in its place the reference ``147.132 or
147.133'';
0
d. In paragraph (b)(1)(ii)(B) by removing the reference ``147.132'' and
adding in its place the reference ``147.132 or 147.133'';
0
e. In paragraph (c)(1)(ii) introductory text by removing the reference
``147.132'' and adding in its place the reference ``147.132 or
147.133'';
0
f. In paragraph (c)(1)(ii)(B) by removing the reference ``147.132'' and
adding in its place the reference ``147.132 or 147.133''; and
0
g. In paragraph (c)(2) introductory text by removing the reference
``147.132'' and adding in its place the reference ``147.132 or
147.133''.

DEPARTMENT OF LABOR

Employee Benefits Security Administration

For the reasons set forth in the preamble, the Department of Labor
amends 29 CFR part 2590 as follows:

PART 2590--RULES AND REGULATIONS FOR GROUP HEALTH PLANS

0
3. The authority citation for part 2590 continues to read as follows:

Authority: 29 U.S.C. 1027, 1059, 1135, 1161-1168, 1169, 1181-
1183, 1181 note, 1185, 1185a, 1185b, 1191, 1191a, 1191b, and 1191c;
sec. 101(g), Pub. L. 104-191, 110 Stat. 1936; sec. 401(b), Pub. L.
105-200, 112 Stat. 645 (42 U.S.C. 651 note); sec. 512(d), Pub. L.
110-343, 122 Stat. 3881; sec. 1001, 1201, and 1562(e), Pub. L. 111-
148, 124 Stat. 119, as amended by Pub. L. 111-152, 124 Stat. 1029;
Division M, Pub. L. 113-235, 128 Stat. 2130; Secretary of Labor's
Order 1-2011, 77 FR 1088 (Jan. 9, 2012).

Sec. 2590.715-2713 [Amended]

0
4. Section 2590.715-2713, as amended elsewhere in this issue of the
Federal Register], is further amended in paragraph (a)(1)(iv) by
removing the reference ``147.131 and 147.132'' and adding in its place
the reference ``147.131, 147.132, and 147.133''.

Sec. 2590.715-2713A [Amended]

0
5. Section 2590.715-2713A, as revised elsewhere in this issue of the
Federal Register], is further amended--
0
a. In paragraph (a)(1) by removing ``(ii)'' and adding in its place
``(ii), or 45 CFR 147.133(a)(1)(i) or (ii)'';
0
b. In paragraph (a)(2) by removing the reference ``147.132(a)'' and
adding in its place the reference ``147.132(a) or 147.133(a)'';
0
c. In paragraph (b)(1)(ii) introductory text by removing the reference
``147.132'' and adding in its place the reference ``147.132 or
147.133'';
0
d. In paragraph (b)(1)(ii)(B) by removing the reference ``147.132'' and
adding in its place the reference ``147.132 or 147.133'';
0
e. In paragraph (c)(1)(ii) introductory text by removing the reference
``147.132'' and adding in its place the reference ``147.132 or
147.133'';
0
f. In paragraph (c)(1)(ii)(B) by removing the reference ``147.132'' and
adding in its place the reference ``147.132 or 147.133''; and
0
g. In paragraph (c)(2) introductory text by removing the reference
``147.132'' and adding in its place the reference ``147.132 or
147.133''.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

For the reasons set forth in the preamble, the Department of Health
and Human Services amends 45 CFR part 147 as follows:

PART 147--HEALTH INSURANCE REFORM REQUIREMENTS FOR THE GROUP AND
INDIVIDUAL HEALTH INSURANCE MARKETS

0
6. The authority citation for part 147 continues to read as follows:

Authority: Secs 2701 through 2763, 2791, and 2792 of the Public
Health Service Act (42 U.S.C. 300gg through 300gg-63, 300gg-91, and
300gg-92), as amended.

Sec. 147.130 [Amended]

0
7. Section 147.130, as amended elsewhere in this issue of the Federal
Register, is further amended in paragraphs (a)(1) introductory text and
(a)(1)(iv) by removing the reference ``Sec. Sec. 147.131 and 147.132''
and adding in its place the reference ``Sec. Sec. 147.131, 147.132,
and 147.133''.

Sec. 147.131 [Amended]

0
8. Section 147.131, as revised elsewhere in this issue of the Federal
Register, is further amended--
0
a. In paragraph (c)(1) by removing the reference ``(ii)'' and adding in
its place the reference ``(ii), or 45 CFR 147.133(a)(1)(i) or (ii)''.
0
b. In paragraph (c)(2) by removing the reference ``Sec. 147.132(a)''
and adding in its place the reference ``Sec. 147.132(a) or 147.133'';
and
0
c. In paragraphs (d)(1)(ii) introductory text, (d)(1)(ii)(B) and (d)(2)
by removing the reference ``Sec. 147.132'' and to adding in its place
the reference ``Sec. 147.132 or 147.133''.

0
9. Add Sec. 147.133 to read as follows:

Sec. 147.133 Moral exemptions in connection with coverage of certain
preventive health services.

(a) Objecting entities. (1) Guidelines issued under Sec.
147.130(a)(1)(iv) by the Health Resources and Services Administration
must not provide for or support the requirement of coverage or payments
for contraceptive services with respect to a group health plan
established or maintained by an objecting organization, or health
insurance coverage offered or arranged by an objecting organization,
and thus

[[Page 47862]]

the Health Resources and Service Administration will exempt from any
guidelines' requirements that relate to the provision of contraceptive
services:
(i) A group health plan and health insurance coverage provided in
connection with a group health plan to the extent one of the following
non-governmental plan sponsors object as specified in paragraph (a)(2)
of this section:
(A) A nonprofit organization; or
(B) A for-profit entity that has no publicly traded ownership
interests (for this purpose, a publicly traded ownership interest is
any class of common equity securities required to be registered under
section 12 of the Securities Exchange Act of 1934);
(ii) An institution of higher education as defined in 20 U.S.C.
1002 in its arrangement of student health insurance coverage, to the
extent that institution objects as specified in paragraph (a)(2) of
this section. In the case of student health insurance coverage, this
section is applicable in a manner comparable to its applicability to
group health insurance coverage provided in connection with a group
health plan established or maintained by a plan sponsor that is an
employer, and references to ``plan participants and beneficiaries''
will be interpreted as references to student enrollees and their
covered dependents; and
(iii) A health insurance issuer offering group or individual
insurance coverage to the extent the issuer objects as specified in
paragraph (a)(2) of this section. Where a health insurance issuer
providing group health insurance coverage is exempt under paragraph
(a)(1)(iii) of this section, the group health plan established or
maintained by the plan sponsor with which the health insurance issuer
contracts remains subject to any requirement to provide coverage for
contraceptive services under Guidelines issued under Sec.
147.130(a)(1)(iv) unless it is also exempt from that requirement.
(2) The exemption of this paragraph (a) will apply to the extent
that an entity described in paragraph (a)(1) of this section objects to
its establishing, maintaining, providing, offering, or arranging (as
applicable) coverage or payments for some or all contraceptive
services, or for a plan, issuer, or third party administrator that
provides or arranges such coverage or payments, based on its sincerely
held moral convictions.
(b) Objecting individuals. Guidelines issued under Sec.
147.130(a)(1)(iv) by the Health Resources and Services Administration
must not provide for or support the requirement of coverage or payments
for contraceptive services with respect to individuals who object as
specified in this paragraph (b), and nothing in Sec.
147.130(a)(1)(iv), 26 CFR 54.9815-2713(a)(1)(iv), or 29 CFR 2590.715-
2713(a)(1)(iv) may be construed to prevent a willing health insurance
issuer offering group or individual health insurance coverage, and as
applicable, a willing plan sponsor of a group health plan, from
offering a separate policy, certificate or contract of insurance or a
separate group health plan or benefit package option, to any individual
who objects to coverage or payments for some or all contraceptive
services based on sincerely held moral convictions.
(c) Definition. For the purposes of this section, reference to
``contraceptive'' services, benefits, or coverage includes
contraceptive or sterilization items, procedures, or services, or
related patient education or counseling, to the extent specified for
purposes of Sec. 147.130(a)(1)(iv).
(d) Severability. Any provision of this section held to be invalid
or unenforceable by its terms, or as applied to any person or
circumstance, shall be construed so as to continue to give maximum
effect to the provision permitted by law, unless such holding shall be
one of utter invalidity or unenforceability, in which event the
provision shall be severable from this section and shall not affect the
remainder thereof or the application of the provision to persons not
similarly situated or to dissimilar circumstances.

[FR Doc. 2017-21852 Filed 10-6-17; 11:15 am]
BILLING CODE 4830-01-P; 4510-029-P; 4120-01-P; 6325-64-P

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