Tag: 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.

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.

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.

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.