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Category: Frequently Asked Questions

I have employer-based coverage and I know my plan is not “grandfathered.” Yet, when I recently filled my prescription for birth control pills, I was charged a co-payment. Aren’t those plans required to cover all contraceptives without cost sharing now?

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Most non-grandfathered plans (plans that started or made changes after March 23, 2010) must provide contraceptives and related services with no cost sharing when they are obtained through an in-network provider. Plans must cover at least one type of each of the 18 FDA approved methods for women. There are three categories of birth control pills that must be covered: combined hormone, progestin only, and extended/continuous use. However, plans may use reasonable medical management to limit the scope of oral contraceptive coverage within each of these three categories. For example, plans may cover generic oral contraceptives without cost sharing but impose some out-of-pocket charges for equivalent branded drugs. Check with your provider if there is a generic birth control pill available that will work for you. If there is no generic alternative or there is a medical reason you need to use a brand name birth control pill or device, ask your provider to help you request a “waiver” or “exception” from the insurance company. The “waiver” or “exception” would allow you to use the brand name drug or device with no co-payment.

I would like to get a NuvaRing but my insurer says that they do not have to cover it since they cover other hormonal methods. I thought all FDA approved contraceptives for women are covered.

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In May 2015, the federal government clarified that ACA-compliant plans must cover at least one type of each of the 18 FDA approved methods for women. The NuvaRing is the only available vaginal ring, so plans must cover the NuvaRing without cost sharing.

If your plan does not cover the NuvaRing without a co-payment, you should file an appeal with your insurance plan or check with your State Department of Insurance if you are on an individual plan or with the Federal Department of Labor if you are on a group plan.

Short-term health insurance policies do not have to provide benefits required by the ACA and may not cover preventive services, including contraceptive services.

I would like to get an IUD. Is my plan required to cover the full cost of the brand I would like get?

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There are two kinds of IUDs: Hormonal and Copper. The federal law requires most ACA-compliant, “non-grandfathered” plans to cover at least one hormonal IUD (marketed as Mirena, Skyla, Lilleta or Kyleena) as well as the copper IUD (brand name ParaGard) with no cost sharing. The plans must also cover the provider visits for insertion and removal, with no cost sharing. You should talk to your provider about which IUD is best for you. If your plan will not initially cover the hormonal IUD your provider recommends, you should ask your provider to request a “waiver” or “exception” from your insurance plan. However, there are certain types of employers with religious objections to contraception that are not required to provide contraceptive services to their workers and dependents.

Short-term health insurance policies do not have to provide benefits required by the ACA, including contraceptive services.

I am purchasing health insurance in my state’s health insurance Marketplace. Is my plan required to cover contraceptives without cost?

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Yes, your plan must cover the full range of FDA-approved contraceptive methods, but can impose some restrictions on the contraceptives offered at no cost to you. For example, the plan may require that you choose a provider within the network, and use generic rather than brand name contraceptives, unless the brand name is medically necessary. If the generic drug or device does not work for you, you can ask your doctor to request a waiver from the insurance plan to receive the brand name drug or device without cost sharing.

I am 35 and I think that I am at higher risk for breast cancer because my mother had it. What services must my insurer cover?

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If you believe you are at higher risk, you should discuss with your provider. There are a number of breast cancer screenings and preventive services that insurers must cover for women. If you are enrolled in an ACA-compliant, non-grandfathered plan, your insurance must pay for your provider to assess whether you have a have a family history that makes you at higher risk for certain genetic mutations that are associated with increased risk of breast cancer (BRCA1 and BRCA2). If your provider determines that your family history makes you at increased risk for genetic mutations, your plan must cover the full cost of genetic counseling and genetic testing if recommended. If you end up having one of these genetic mutations, your insurer is also required to cover the full cost of certain preventive medications which can greatly reduce your risk of getting breast or ovarian cancer.

The coverage rule for mammography is based on the Women’s Preventive Services Initiative, adopted by HRSA, that recommends screening mammography every one to two years for women age 40 – 74 years. Since you are under age 40, federal rules do not specify whether your plan must cover the costs of the screening mammogram without cost sharing.

Short-term health insurance policies do not have to provide benefits required by the ACA, including preventive services such as mammography.

Are there any preventive services for women specifically?

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The ACA includes a number of preventive services for women that ACA-compliant, “non-grandfathered” private plans are required to cover without cost sharing. For example, these include counseling and screening services including prenatal and preconception care; breast and cervical cancer screening; genetic counseling and testing for women at high risk of breast cancer; Chlamydia and Gonorrhea screening and counseling for high risk women; at least one well woman visit a year; contraceptive counseling, services and supplies including prescriptions for FDA approved contraceptives; breastfeeding counseling and support services including breast pump rental; and intimate partner violence screening and counseling. So long as the preventive service is performed by an in-network provider, is not billed separately from the office visit, and is the main reason for the office visit, then the visit and the preventive service will be covered by the insurer without cost sharing.

Short-term health insurance policies do not have to provide benefits required by the ACA and may not cover preventive services.

I heard that plans have to cover preventive services without cost sharing. Does this include every preventive service and are there any limits to what is covered?

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Your plan is required to cover a wide range of preventive services and may not impose cost-sharing charges (such as copayments, deductibles, or co-insurance) If you are enrolled in an ACA-compliant, non-grandfathered plan, including plans offered through the Marketplace.  The ACA requires private plans to provide coverage for services under four broad categories: evidence-based screenings and counseling, routine immunizations, childhood preventive services, and preventive services for women. So long as the preventive service is performed by an in-network provider, is not billed separately from the office visit, and is the main reason for the office visit, then the visit and the preventive service will be covered by the insurer without cost-sharing.

If you buy coverage on your own and you first purchased your policy prior to March 23, 2010, it may be a grandfathered plan. These plans are not required to cover preventive services without cost sharing. If you are not sure if your plan is grandfathered, check with your employer or your insurance plan.

In addition, short-term health insurance policies do not have to provide benefits required by the ACA and may not cover preventive services.

What is a Catastrophic Health Plan?

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A “Catastrophic plan” is a qualified health plan offered through the Marketplace that covers essential health benefits and requires the highest level of cost sharing allowable for essential health benefits. In 2019, under a “catastrophic policy,” the annual deductible for covered services is $7,900 for an individual (twice that amount for a family policy.) After you have satisfied the deductible, the plan will pay 100% for covered essential health benefit services that you receive from in-network providers for the remainder of the year. “Catastrophic policies” may also be sold by insurers outside of the health insurance Marketplace.