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When can plans limit coverage of particular contraceptives?

There are a number of ways that plans or employers can limit contraceptive services.  Federal law requires that ACA-compliant plans must cover at least one form of each the 18 contraceptive methods for women identified by the FDA. But, a plan may apply reasonable medical management techniques such as prior authorization or step-therapy, and require cost-sharing for certain contraceptive drugs or devices to encourage an individual to use specific services or items within a chosen FDA approved contraceptive method. However, the plan must have a process in place to ensure that your particular contraceptive service or product is covered without cost sharing when your specific provider recommends it based on medical necessity.  In addition, you must get your contraceptive care from an in-network provider.  Insurers may charge cost sharing if you go to an out-of-network provider for contraceptive care.

In addition, if your employer is affiliated with a faith-based organization, they can limit the types of contraceptives they wish to cover based on religious objections.  Specifically, all houses of worship are exempt.  Other employers and universities that are affiliated with faith-based organizations that oppose some or all contraceptive methods may also opt to exclude coverage, and have the insurance company provide the contraceptive coverage directly to policyholders.  There is ongoing litigation about which employers are exempt and can exclude contraceptive services.

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 was told that my college insurance plan does not pay for contraceptives. Can that be right?

The rules affecting student health plans are complicated and depend on the type of plan your college or university may offer.  If your student health plan is fully-insured, it should cover all 18 FDA-approved contraceptive methods for women as prescribed, without cost sharing.  However, if your college or university has a religious objection to providing contraceptive coverage, then it may have opted to have the insurance company provide the coverage directly to policyholders.  Some universities have legally challenged the contraceptive coverage rule.  While this litigation is ongoing, some universities may have excluded contraceptive coverage from their student health plan.

If your college has a self-funded health plan, then it is not subject to requirements under the Affordable Care Act, including covering contraceptives with no cost sharing. Ask your college if the plan is self-funded. If it is self-funded, state laws that may require some coverage of contraceptives. Check with your State Insurance Department about the state law. You may have other options as well. If you are under 26, you should check if you are eligible as a dependent in your parent’s health plan.  You can also consider buying coverage on your own through the Marketplace. If your income is between 100% and 400% of the federal poverty level and you meet other requirements, you can qualify for premium tax credits; if you income is between 100% and 250% of the federal poverty level, you can also qualify for cost sharing reductions. In addition, you might be eligible for Medicaid. Check with your state Marketplace to find out if you meet the income and other eligibility standards to enroll in Medicaid coverage.

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?

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.

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?

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?

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.

Does my student health plan have to cover contraceptives?

Generally, yes it does, if it is a fully insured plan. A fully insured plan is one that your college or university purchases from a health insurance company. These plans are required to provide, without cost sharing, access to all FDA-approved contraceptive methods, sterilization procedures, patient education and counseling prescribed by a health care provider.

However, exceptions are made for institutions of higher education that have religious objections to providing contraceptive services. If you attend such a college or university, the college or university can opt to have the insurance company provide the contraceptive coverage directly to you, separate from the student health plan. Some universities have legally challenged this contraceptive coverage rule. While the litigation is ongoing, some universities may have excluded contraceptive coverage from their fully-insured health plan.

If your student health plan is a self-insured plan, it might not be required to cover contraceptive services. It’s up to states to regulate self-insured student health plans.  Check with your college or university to find out what type of student health plan they offer, or check with your state insurance regulator to find out what rules apply to your student health coverage.

You may have other options as well. If you are under 26, you should check if you are eligible as a dependent in your parent’s health plan. You can also consider buying coverage on your own through the Marketplace. If your income is between 100% and 400% of the federal poverty level and you meet other requirements, you can qualify for premium tax credits; if your income is between 100% and 250% of the federal poverty level you can also qualify for cost-sharing reductions. In addition, if your income is low you might be eligible for Medicaid. Check with your state Marketplace to see if you may be eligible for Marketplace subsidies or Medicaid.

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