New Guidance on Birth Control Coverage Informs Insurers That If They F^%! Around, They WILL Find Out
Recently, the Departments of Health & Human Services, Treasury, and Labor announced new guidance on the Affordable Care Act (ACA)’s birth control benefit which requires most health insurance to cover contraception without out-of-pocket costs. We know that many health insurance companies are not complying with the law, and this guidance puts them on notice (AGAIN) about contraception and related services they are required to cover. The new guidance specifically addresses the three major non-compliance trends the Law Center identified last fall based on complaints reported to our CoverHer hotline. We are very pleased the administration took further action to ensure that the ACA’s birth control coverage requirement is working for the people it is meant to serve. The Departments clearly identify the importance of addressing gaps that prevent people from accessing their benefits.
Here are some of the most important things you should know about your birth control coverage from the guidance:
- Plans MUST cover anything related to your chosen contraceptive, even if that specific thing is billed to your insurance separately from the contraception.
- For example, plans must cover anesthesia needed for a tubal ligation procedure (sterilization), or an ultrasound needed to check placement of the IUD.
- Plans MUST cover (without out-of-pocket costs ) ANY contraceptive services and FDA-approved, cleared, or granted contraceptive products that an individual and their provider have determined to be medically appropriate for the individual.
- Coverage applies even if the chosen service or product is not explicitly named on the list of types of contraceptives that the Administration has endorsed, which often happens with newer contraceptives. They didn’t exist when the list was first published, but they are contraceptives and should be covered.
- Plans may use “reasonable medical management techniques” to determine which specific products are covered without cost-sharing, but there are limitations on this power. Plans can only deny you coverage if another covered product is “substantially similar” and the plan has a quick and simple process for you to get the specific product you need if it usually would have cost-sharing. Here’s how this works in real life:
- If your health care provider recommends a certain contraception for you based on a determination of medical necessity, the plan MUST cover it without cost-sharing. The plan must defer to your provider’s expertise.
- Information about how you get this coverage must be easily available for you to find, such as in plan documents or attached to your plan’s drug formulary.
- Plans cannot require you to appeal a coverage denial before providing coverage without cost-sharing. It should be quick and easy.
- Examples of Unreasonable Medical Management Techniques:
- Denying coverage for brand name contraceptives, even after the individual’s provider determines that the product or service is medically necessary.
- Requiring individuals to fail first using several contraceptive products within the same category OR in other contraceptive categories, such as requiring you to try a vaginal ring before getting coverage of an IUD.
- Imposing an age limit on contraceptive coverage.
- Plans MUST cover:
- Fertility awareness-based methods, including lactation amenorrhea, without cost-sharing.
- FDA-approved emergency contraception, including over-the-counter products .
You can fight back when your insurance company violates the ACA birth control benefit.
Plans that violate the contraceptive coverage requirement may be subject to monetary penalties and forced to fix their policies for everyone enrolled in the plan. This shows how important it is to file a complaint if your plan does not comply with the ACA’s contraceptive coverage requirement. The Departments provided detailed information about how to file a complaint:
- If you are covered by a private-sector, employer-sponsored group health plan, and have concerns about compliance, you may contact the Department of Labor at https://www.dol.gov/agencies/ebsa/about-ebsa/ask-a-question/ask-ebsa or by calling toll-free at 1-866-444-3272.
- If you are covered by a state or local government employee plan, and have concerns about compliance, you may contact CMS at: [email protected] or by calling toll-free at 1-888-393-2789.
- If you have fully insured coverage, you can also contact their State Department of Insurance, using the tool here. If you have concerns that your State Department of Insurance is not enforcing the coverage requirement, contact CMS at: [email protected].
Here is the bottom line: health plans and issuers still need handholding from the federal government to comply with this part of the law that has been in effect for a decade. But the Departments have made absolutely clear: no more gaslighting by insurance companies when it comes to the ACA birth control benefit. If they don’t comply, the Departments are coming for them. You can help make sure the plans are held accountable.
In addition to reporting noncompliance to the government, if you or someone you know is experiencing barriers to accessing contraceptive coverage without cost-sharing, CoverHer is here to help. Questions can be directed to our CoverHer hotline, here.