By Adam Sonfield
Senior Public Policy Associate
Guttmacher Institute
Washington, DC
On May 11, the federal government issued expanded guidance for private health plans about how to implement the Affordable Care Act’s (ACA’s) requirement to cover dozens of preventive care services, including the full range of contraceptive methods, services, and counseling, without any out-of-pocket costs, such as copayments and deductibles.1
The guidance comes in the wake of studies released in April by the Kaiser Family Foundation and the National Women’s Law Center (NWLC) that provided new evidence that many insurance plans have not been fully complying with the ACA’s contraceptive coverage guarantee and many of the law’s other coverage requirements.2-4 Those studies had confirmed earlier anecdotal reports in the media and more limited reviews of plan documents.5 The study results also had prompted calls from key Democrats in Congress for the Obama administration to ratchet up oversight and enforcement of the federal guarantee.6
Most notably, the new federal guidance clarifies that the contraceptive coverage guarantee encompasses every distinct contraceptive method used by women, and it lists 18 methods as identified by the Food and Drug Administration. (See box in this issue.) Two other methods, vasectomy and male condoms, are not included in the guidance because they are used by men and have been determined by federal officials to fall outside the legal scope of the ACA’s provision.
Prior federal guidance, from February 2013, had not clearly defined the “full range” of methods,7 and the national studies identified numerous plans that failed to fully cover certain methods. In some cases, insurers excluded specific methods, such as the vaginal ring, the patch, the implant, or the copper intrauterine device (IUD). Several justified those exclusions by incorrectly claiming that they were medically equivalent to other methods, for example, by claiming that the ring and patch were equivalent to certain generic oral contraceptives. In other cases, insurers limited their coverage to generic contraceptive products, even in cases in which a brand-name product had no generic equivalent; for example, there are no generic IUDs on the U.S. market.
The new guidance also clarifies and expands an earlier statement that the contraceptive coverage guarantee encompasses “services related to follow-up and management of side effects, counseling for continued adherence, and device removal.”7 Now, plans are on notice that they must fully cover all clinical services “needed for provision of the contraceptive method.”1
One of the national studies, for example, had identified limits on ultrasounds to assess proper placement of an IUD and even anesthesia for sterilization. In addition, plans were reminded that the preventive services coverage requirements apply to all plan enrollees, including those enrolled as dependents. Several plans identified by the NWLC, for example, had excluded coverage of maternity care or sterilization for dependents.
Plans also were given further guidance on what they can and cannot do in using so-called reasonable medical management techniques, such as drug formularies, prior authorization, and step therapy. They might use such techniques only within a given method (for example, to promote one hormonal IUD over another), but not across methods (for example, to promote oral contraceptives over copper or hormonal IUDs). The guidance also provides more details about the waiver process that plans must have in place if they do use such techniques.
The new federal guidance on contraceptive coverage officially will take effect for new plan years beginning in July, which is in time for student health plans that begin in the fall and for ACA marketplace plans and employer-based plans that begin in January 2016.
The guidance should help to bolster a contraceptive coverage guarantee that already was having a widespread, beneficial impact for women. According to a national survey of women by the Guttmacher Institute, the proportion of privately insured women paying zero dollars out of pocket for oral contraceptives increased substantially, from 15% to 67%, between fall 2012 (before the guarantee was binding on many plans) and spring 2014 (after it had taken root).8 The study found similar results for injectable contraception, vaginal rings, and IUDs. A 2014 report from the IMS Institute for Healthcare Informatics had similar findings, including an estimate that women saved nearly half a billion dollars in out-of-pocket costs for contraception in 2013 after the guarantee took effect.9
In the meantime, state policymakers have been taking action to provide clarity and to strengthen the contraceptive coverage guarantee. California enacted legislation in 2014 addressing some of the same issues with insurers’ coverage, including the failure to cover all methods and all related services and the imposition of inappropriate medical management techniques. Connecticut took similar action in 2014 through an insurance bulletin. In March 2015, Washington State’s insurance commissioner extracted commitments from his state’s insurers to improve their customer service training about the contraceptive coverage guarantee and make corrections to their formularies. And in May 2015, New York regulators announced they were investigating insurers’ contraceptive coverage practices. The state’s attorney general introduced legislation to expand on the coverage requirements, including requiring plans to cover a full year’s worth of a contraceptive and to fully cover men’s methods. Several other states have proposed similar legislation this year.
Contraceptive Methods Covered in Guarantee
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Sterilization surgery for women
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Surgical sterilization implant for women
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Implantable rod
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Copper IUD
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Progestin IUD
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Contraceptive shot/injection
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OCs (combined pill)
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OCs (progestin-only)
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OCs (extended/continuous use)
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Contraceptive patch
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Contraceptive vaginal ring
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Diaphragm
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Sponge
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Cervical cap
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Female condom
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Spermicide
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EC (levonorgestrel)
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EC (ulipristal acetate)
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Employee Benefits Security Administration, Department of Labor. FAQs about Affordable Care Act implementation part XXVI. Accessed at http://1.usa.gov/1E2hZpF.
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Sobel L, Salganicoff A, Kurani N. Coverage of Contraceptive Services: A Review of Health Insurance Plans in Five States. Menlo Park, CA: Kaiser Family Foundation; 2015. Accessed at http://bit.ly/1aCj0xJ.
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National Women’s Law Center. State of birth control coverage: health plan violations of the Affordable Care Act. 2015. Accessed at http://bit.ly/1bMCqR4.
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National Women’s Law Center. State of women’s coverage: health plan violations of the Affordable Care Act. 2015. Accessed at http://bit.ly/1H2GASE.
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Sonfield A. Implementing the federal contraceptive coverage guarantee: Progress and prospects. Guttmacher Policy Review 2013; 16(4):8-12.
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Aleccia J. Sen. Patty Murray urges stronger enforcement of birth-control coverage. The Seattle Times, May 5, 2015: Accessed at http://bit.ly/1PECqzN.
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Employee Benefits Security Administration, Department of Labor. FAQs about Affordable Care Act implementation part XII. 2013. Accessed at http://1.usa.gov/1PguzO7.
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Sonfield A, Tapales A, Jones RK, et al. The impact of the federal contraceptive coverage guarantee on out-of-pocket payments for contraceptives: 2014 update. Contraception 2014; 91(1):44-48.
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IMS Institute for Healthcare Informatics. Medicine use and shifting costs of healthcare, a review of the use of medicines in the United States in 2013. Accessed at http://bit.ly/1zXWb3J.
