A recent American College of Obstetricians and Gynecologists webinar focused on the Affordable Care Act and its birth control coverage requirement. It looked at the legal requirements of public and private coverage for women’s preventive services with no cost-sharing.
- In May 2015, the federal government issued expanded guidance for private health plans about how to implement the Act’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. All of the contraceptive methods approved by the FDA are covered, the guidance states.
- Plans are required to cover “services related to follow-up and management of side effects, counseling for continued adherence, and device removal” without cost-sharing.
What do you know about the Affordable Care Act (ACA) and its birth control coverage requirement?
A recent American College of Obstetricians and Gynecologists webinar has the bases covered when it comes to the legal requirements of public and private coverage for women’s preventive services with no cost-sharing, including long-acting reversible contraceptives (LARCs) and other contraceptive methods.
In May 2015, the federal government issued expanded guidance for private health plans about how to implement the 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 (Contraceptive Technology Update reported on the guidance. See the July 2015 Washington Watch column at http://bit.ly/1Om7iuE.)
What contraceptive methods are covered? All of the following methods approved by the FDA:
- sterilization surgery for women;
- surgical sterilization implant for women;
- contraceptive implant;
- copper intrauterine device (IUD);
- progestin intrauterine device (IUD);
- contraceptive shot/injection;
- oral contraceptives (combined pill);
- oral contraceptives (progestin-only);
- oral contraceptives (extended/continuous use);
- contraceptive patch;
- contraceptive vaginal ring;
- cervical cap;
- female condom;
- emergency contraception (levonorgestrel);
- emergency contraception (ulipristal acetate).
The guidance followed studies released by the Kaiser Family Foundation and the National Women’s Law Center that provided evidence that many insurance plans were not fully complying with the ACA’s contraceptive coverage guarantee and with 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, says Adam Sonfield, MPP, senior public policy associate in the Guttmacher Institute’s Washington, DC, office. Sonfield and Mara Gandal-Powers, JD, counsel for health and reproductive rights at the National Women’s Law Center, served as co-presenters.
Plans are required to cover “services related to follow-up and management of side effects, counseling for continued adherence, and device removal” without cost-sharing, notes Gandal-Powers. Examples of such services include IUD insertion, clinically indicated ultrasound to confirm placement, removal, sterilization anesthesia, and confirmation tests.
Has the following scenario ever occurred at your facility? You and your patient decide that the copper IUD is the best method for her. The patient (or a member of your staff) checks the coverage in the patient’s insurance plan and is told the IUD is covered at 100%. With this information in hand, the patient makes an insertion appointment, and an IUD order is placed. The patient has the device inserted, with both covered at 100%.
However, when the patient returns to address the bleeding pattern with her IUD, she receives an explanation of benefits indicating she owes money for the follow-up visit. When she calls the insurance company, she is given an explanation of “Follow-up visit is not a preventive service” or “We cover the device, insertihttps://admin-ahcmedia.epublishing.com/admin/article/general/xml#on, and removal, and that’s it.”
“This violates the ACA’s birth control coverage requirement because plans are required to cover services related to follow-up for birth control without cost-sharing,” explains Gandal-Powers. “When IUDs necessitate follow-up visits, those visits should be covered without cost-sharing.”
Providers now can refer patients to the CoverHer Hotline (1-866-745-5487) at the National Women’s Law Center to determine if the law applies to her plan and for help with the appeals process. The Hotline’s companion website, which can be accessed at www.coverher.org, includes a flowchart for calling a plan, instructions for filing an appeal, and sample appeals letters.
The CoverHer resources should be shared with all members of a family planning facility, from the front office staff to the staff members who take medical histories and vital signs, says Gandal-Powers.
Numbers Are Up
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 been implemented).5
The study found similar results for injectable contraception, vaginal rings, and IUDs. A 2014 report from the IMS Institute for Healthcare Informatics in Danbury, CT, 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.6
“Nearly nine out of 10 insured women can now pay zero dollars for an IUD,” says Sonfield. (View the webinar, “The State of Reproductive Health Care in 2016: Impact of the Affordable Care Act and Birth Control Coverage Requirement,” online at http://bit.ly/1ZgSHks.)
- Employee Benefits Security Administration, Department of Labor. FAQs about Affordable Care Act implementation part XXVI. Accessed at http://1.usa.gov/1E2hZpF.
- 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.
- 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.
- 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.
- 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.
- 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.