The first thing you should know about birth control coverage is that it may be changing. The Affordable Care Act, approved in 2010, says that insured women will qualify for contraceptives without any out-of-pocket expenses, starting August 2012. However, many details remain to be worked out by insurers, and the future of health care reform could change depending on the outcome of the November 2012 presidential election.
In the meantime, the best thing to do is check with your insurer to see if your coverage has changed—or may soon change—to lower your costs for birth control.
Under the health care law, all contraceptives approved by the U.S. Food and Drug Administration are included among preventive health services available to insured women without deductibles or co-payments. This includes oral contraceptives (the pill), injectable contraceptives, the hormonal ring, contraceptive implants, diaphragms, cervical caps, nonsurgical permanent contraception and surgical sterilization.
But there may be some exceptions, such as for brand-name contraceptives or certain medical costs. Even insurers aren't sure exactly what they must provide or how to do it.
America's Health Insurance Plan (AHIP), an industry lobbying group, sent a list of questions to the Department of Health and Human Services (HHS) in September 2011 asking for details on what types of contraceptives are covered and how insurance policies will work. Here are those questions and the answers AHIP received, as reported by Kaiser Health News:
1. Are male-based contraceptive methods, such as vasectomies or condoms, covered under health reform?
An HHS official responded that women’s preventive services guidelines apply to women only, based on guidelines issued by the Health Resources and Services Administration, part of HHS. AHIP also said in its letter to HHS that insurers are interpreting the rule to include only female-based contraception.
But a senior public policy associate at the Guttmacher Institute, a reproductive health research group, says the language is unclear. Adam Sonfield says it would be foolish to exclude vasectomies, because they are less expensive and pose a lower risk of complications than female surgical sterilization. Also, waiving co-payments for services for one sex but not the other could be challenged as discriminatory, he notes.
2. Are over-the-counter products like female condoms, spermicides and sponges covered by the rules? If so, will they require a prescription, and how will insurers reimburse policyholders for purchases?
Over-the-counter contraceptives will be covered without cost sharing when they are prescribed by doctors, the HHS official said. But advocates and insurers are not sure how this will work. Insurers caution that requiring prescriptions for over-the-counter contraceptives could increase the burden on already overburdened primary care providers and drive up costs. Setting up systems to track the costs and reimburse women for these products could prove more costly than the products themselves, the insurers contend.
Because of those potential costs and inconveniences to women, prescriptions should not be required for over-the-counter contraceptives, says Judith Lichtman, senior advisor to the National Partnership for Women and Families, an advocacy group in Washington, DC.
3. If a hospital stay is required for surgical procedures, such as for female sterilization, would the procedure be covered without cost sharing?
HHS has not answered this question yet, and insurers remain uncertain whether hospitalization or complications that might occur from surgery would be covered without a patient co-pay or deductible.
4. Will insurers be required to cover all products in a class, such as all IUDs or all birth control pills? Can insurers require a co-pay for a brand-name drug if a generic is available?
The HHS says that insurers may continue to offer "tiered" pharmacy benefits. Under this structure, patients pay differing amounts for brand-name products, as opposed to generics. Some insurers require patients who choose a brand-name drug over an equivalent generic to pay the price difference between the two. The insurers say HHS guidance allows them to use such "reasonable medical management" to help control costs.
The HHS confirmed that charges for brand name drugs would be allowed, but stressed that plans must "accommodate any individuals for whom it would be medically inappropriate by having a mechanism for waiving the otherwise applicable cost-sharing for the branded version."
5. Who will be covered for contraceptives without co-payments?
Health reform requires that the package of women’s preventive care benefits must be offered in all new insurance policies sold to individuals and employers starting Aug. 1, 2012. Many existing policies will include the benefits on the date that they renew after Aug. 1, which for many companies will be Jan. 1, 2013. Health plans that existed before health reform passed in 2010 may be "grandfathered," but most must comply by 2014. Some nonprofit religious employers who object to birth control are exempt from providing coverage for contraceptives.
If you use birth control or are considering using or changing birth control, talk to your health care professional and your insurance company to find out what kind of birth control coverage is available. And keep in mind that coverage may change as details are ironed out or the health reform act itself is changed.
If you think you have been denied coverage for which you are eligible, contact the state office that enforces these laws where you live. This federal website will help you identify the appropriate agency: http://www.healthcare.gov/using-insurance/managing/consumer-help/index.html
For additional details on the Affordable Care Act, visit the Kaiser Foundation website at: healthreform.kff.org.