Birth Control

The Affordable Care Act and Contraceptive Benefits

November 30, 2018

With Obamacare up and running, this new health care reform is leaving many wondering: why do I still need to cover contraception? It appears that navigating through the Affordable Care Act has made many with more questions than answers. 

The brand new Obamacare insurance coverage requirements, especially the preventative solutions for women, took effect.

Under the Affordable Care Act, for the first time, insurance companies will have to cover additional preventative health benefits for girls to fill the gaps in present preventive services. The newest guidelines given under the Affordable Care Act allow girls to receive a detailed set of preventive services without needing to pay a copayment, coinsurance or a contingency (also referred to as cost-sharing).

Moreover, the Affordable Care Act (with its women’s preventative health services) requires all health insurance plans through your employer, condition market/exchange or which you purchase yourself (with the exception of those sponsored by spiritual companies ) to pay, without any cost-sharing, all FDA-approved birth control options and marital counselling. This usually means that you ought to have the ability to acquire your monthly source of birth control together with no out-of-pocket costs, because the complete cost will be covered by your monthly premium.

Your insurance provider won’t be able to charge extra payments for these services, like copayments or deductibles.

Confusion About Contraceptive Coverage

All this sounds great, right? But there appears to be a great deal of confusion going on. By Way of Example, let us consider Becca, who emailed me the following comment:

“Today I went to buy my NuvaRing and my insurance provider still believes they don’t have to pay for it. I’ve been on the phone all day together and I figure we just understand the law otherwise.”

So. . .who is right in this situation? Unfortunately, they are. Obamacare only needs new health programs to comply with the contraception coverage requirement — therefore it just applies to programs that were written or purchased after the Affordable Health Care was passed.

Health insurance plans that occur before Obamacare happen to be grandfathered in (meaning, they don’t have to supply you with these contraception benefits). This usually means that the plan can continue to function just as it has. But if the insurance company makes any significant adjustments to the plan (such as increasing coinsurance, copayments, or deductibles, considerably cutting benefits, or raising out-of-pocket limits by specific amounts), the plan will no longer be grandfathered. So, the fantastic thing is that these plans will not be grandfathered forever. Most programs have already lost this status.

So return to Becca’s question about her insurance not covering NuvaRing, this might be because her strategy is grandfathered, and that is precisely why she is being denied coverage.

Why Could You Be Needing to Pay for Contraception?

There also seems to be some confusion concerning what contraceptives are covered. Though the Affordable Care Act says that women will have access to all FDA-approved contraceptives — all types does not equal all brands. Under Obamacare, plans still have the flexibility to control costs and promote efficient delivery of care , for instance, continuing to charge cost-sharing (co-pays, coinsurance, deductibles) for branded drugs in case a generic version is available and just as safe and effective.

Most insurance companies are interpreting the section of the law that enables them to”use reasonable medical management to help control costs” to mean that they can bill a co-pay for some kinds of birth control but not others.

That is the reason you could be told that you need to pay a co-pay to get the NuvaRing, or only generic birth control pills have been insured without a co-pay.

So, What Are My Contraceptive Benefits under Obamacare?

What are insurance companies permitted to perform or if is your insurance company merely picking and choosing which contraceptives will be free?

  1. If your contraceptive has a generic version, your insurance plan can decide to only supply the generic alternative for free. They may require that in the event you select a brand-name medication (if an equivalent generic is available), you to cover the cost difference between both.
  2. If there is not a generic version of your contraceptive, they have to cover the name-brand drug without a co-pay. This means that under the Affordable Care Act, insurance plans must cover, at no expense to you, NuvaRing, Ortho Evra Patch, Depo-Provera, Mirena, ParaGard, and Nexplanon because there are no generic options to those contraceptives.
  3. When there’s only one FDA-approved contraceptive option available from the U.S., your plan must cover it (e.g. NuvaRing is the only contraceptive ring, so it must be covered). But because there are lots of kinds of combination birth control pills, health insurance companies may cover some of them. So which tablets are especially covered without a co-pay might vary by plan.
  4. If your doctor decides that the name-brand drug is”medically appropriate” for you, then your insurance company must offer a waiver process which will allow you to get your name-brand birth control with no co-pay.
  5. Plans have to provide more than birth control pills at no cost. They must supply you with access to the full range of FDA-approved contraceptive methods — that includes prescription procedures and over-the-counter stimulants.
  6. All contraception-related services needed to add contraceptives (like IUDs), prescribe birth control, follow-up and handle contraceptive side effects, counselling for continued adherence, and elimination of implantable devices must be covered with $0%.
  7. Permanent contraception, for example Essure and tubal ligation, must also be offered with no cost-sharing.

Some Frequent Things to Remember:

  • Emergency contraception is considered an added benefit. But, remember that Plan B One-Step is a branded product, which means that your insurance policy may only pay its generic choices, Next Choice One Dose, My Way and Take Action for free and cost a co-pay for Strategy B One-Step.
  • Over-the-counter female contraceptives such as spermicides, female condoms, and Today Sponge are insured by the Affordable Care Act. But, in order for these to be covered with no out-of-pocket costs, you should have your physician write a prescription for all these contraceptives. So although they are available OTC, if you do not need to have to cover them, you’ll need to acquire a prescription first. Given that the morning-after pill also has OTC status, you’ll also need a prescription (no matter your age) should you need your insurance company to pay for it. It’s still possible to purchase these contraceptives without a prescription — they just won’t be liberated.
  • The preventative services advantages only apply to women. So underneath the Affordable Care Act, your insurance company can charge copayments or deductibles for male-based contraceptive methods, such as vasectomies or condoms.
  • Medical abortions and medications like RU-486 are not included in the Affordable Care Act’s preventative services, so insurance companies aren’t required to supply these services without cost-sharing.

Need Help?

Because of all of the confusion surrounding contraception coverage under Obamacare, you could be requested to cover birth control that should be free. If you think that your insurance company is not following the Affordable Care Act, there are actions you may take.

  1. Telephone the member services number on the back of your insurance card or talk with your employer’s benefits administrator to determine if your strategy is grandfathered and/or to ask about what contraceptives are insured.
  2. The National Women’s Law Center has created a helpful toolkit to help you fight to the coverage provided to you under the Affordable Care Act. This toolkit includes:
    • A flowchart that will help you to find out if your contraceptive is coated.
    • A script to use whenever you phone your insurance company for answers/information.
    • Sample letters to send your insurance company if they charge a co-pay for your particular kind of birth control in addition to links to incorporate that back-up your own rights.
    • Directions on how to file an appeal.