19 states consider mandating contraceptive coverage

Former welfare recipients lose contraceptives under private insurance

As thousands of women leave the welfare rolls and enter the work force, they may be lucky enough to get employer-sponsored health insurance. But many are finding that a basic benefit they took for granted under Medicaid is not available through commercial insurance: coverage for contraceptives.

Today, only Massachusetts has mandated contraceptive coverage for these women, but another 19 states are developing legislation that would follow Massachusetts' lead.

Little more than half of the commercial managed care plans in five states with heavy managed care penetration offer members a choice of all five federally approved contraceptives, and 10% offered no coverage at all, according to a recent study by a reproductive health policy organization.

"What we’ve found is that women enrolled in Medicaid are, in fact, better off than women enrolled in some forms of private insurance," says Rachel Gold, Alan Guttmacher Institute (AGI) assistant director of policy analysis and a coauthor of the study.

The five common forms of birth control—oral contraceptives, intrauterine devices, Norplant, diaphragm, and Depo-Provera injections—are covered by 79% of commercial HMOs and point-of-service plans, and 29% of PPOs, reports the AGI.

Some 57% of PPOs and 15% of HMOs/POS plans paid for some services. Among PPOs, 14% offered no coverage, compared to 6% of HMOs/POS plans that did not pay for contraceptive services or medications.

Even within the plans that covered contraceptive services there was variation, the report found. For example, while 97% of HMO/POS plans covered IUD insertion, 78% covered the device itself, and 89% paid for removal.

"We do know that in terms of coverage for family planning, private insurance has more flexibility about what they will cover. They might say, We’ll cover pills, but not other methods,’" says Lourdes Rivera, a staff attorney in the Los Angeles headquarters of the National Health Law Program (NHeLP). She points out that even legislative mandates for coverage will not affect self-insured plans, which are exempted from such state requirements under the 1974 federal Employee Retirement Income Security Act.

In contrast, the Medicaid plans surveyed all covered the five methods, as required by law. The study revealed, however, that two plans reported charging women to contribute toward contraceptive care—a violation of federal law.

Researchers studied managed care plans in Colorado, Massachusetts, Michigan, and parts of California and Florida and reported their findings in the September/October issue of Family Planning Perspectives, an AGI publication.

"In these mature markets, coverage is more extensive than we had found in the past," Ms. Gold says, "but there are still some very serious problems." She says the first step to expanding coverage is to ensure that women who have commercial contraceptive coverage are at least aware of the benefit. "It was quite distressing to find the number of women who didn’t know what sorts of coverage that were available," she says.

Women’s health advocates contend that few leaders have come to grips with the public policy implications of restricted access to contraceptive care, but the issue could prove difficult to ignore in the coming years as more women join managed care plans. Women leaving Medicaid for private insurance are part of the 74% of U.S. women ages 15 to 44 who have some form of private insurance. Coverage for women in their reproductive years is dominated by managed care plans.

State efforts

The first step in expanding access is making women aware of the full range of benefits already available to them. Then coverage must be made available to those who do not have it, Ms. Gold and others say. While individual states can mandate that commercial insurers provide such coverage, only one—Maryland—has imposed such a requirement. As of Oct. 1, Maryland required that plans with a pharmaceutical benefit cover the five FDA-approved contraceptive methods and associated services.

A number of states have tried to pass a similar law. During this year’s legislative session, the concept was discussed in 19 states and got as far as a legislative committee in 10: Alaska, Connecticut, Florida, Georgia, Indiana, Missouri, New York, Ohio, Oklahoma, and Utah.

Florida Rep. Elaine Bloom (D-Miami), a strong supporter of mandatory contraceptive care coverage, plans to introduce a bill revisiting the issue in the 1999 session, according to an aide in her office.

A handful of other states—Hawaii, Montana, New Mexico, Texas, West Virginia, and Virginia—already have some regulation governing contraceptive benefits, although they are generally less ironclad than Maryland’s, according to AGI.

In California, a mandate for contraceptive coverage was passed but vetoed several times by Republican Gov. Pete Wilson, but advocates aren’t giving up, says Ms. Rivera, the NHeLP staff attorney. Mr. Wilson did not run for re-election and was succeeded Nov. 3 by Democrat Gray Davis.

While NHeLP hasn’t attacked the issue head-on, it is working "in a roundabout way" to ensure women have access to family planning services, Ms. Rivera says. NHeLP is lobbying the Health Care Financing Administration, for example, to ensure that states make transitional Medicaid benefits available to women who lose eligibility for Temporary Assistance to Needy Families; redetermine eligibility as required; and maintain eligibility when appropriate.

The AGI study found that Medicaid and commercial plans both have room to increase outreach and improve access to contraceptive coverage. Among those surveyed, 33% of commercial members and 28% of Medicaid enrollees reported some problem in obtaining contraceptive services. For example, having to wait four weeks or longer for an appointment for contraceptive care was reported by 13% of women in commercial plans and 7% in Medicaid plans. In addition, only half the commercial plans and a third of the Medicaid plans said they routinely provided members with information about what kinds of contraceptive services and methods they covered. Such information often was given only to the employee, and not directly to his or her spouse or dependents.

Wanted: A national champion’

Plans also need to have better links to community family planning agencies, which might have prior relationships with some current and former Medicaid recipients, the report says. Slightly more than one-quarter of the plans surveyed had contracts with community-based family planning agencies for contraceptive services.

Nationally, the disparity between what Medicaid covers and what insurance pays for can be leveled only through the passage of federal legislation, and women’s advocates are hoping that happens next year. "We think it very much needs a national champion," Ms. Gold says.

As part of the 1999 omnibus budget law, Congress in October mandated contraceptive coverage for about 1.2 million women insured through 374 health plans in the Federal Employees Health Benefits Program (FEHBP). Before the mandate, only 19% of the plans covered all five birth control methods and 10% had offered no coverage at all.

The amendment was a last-ditch effort to increase reproductive coverage for women following the failure of the Equity in Prescription and Contraceptive Coverage Act, which would have required insurers who cover prescription drugs and outpatient medical care in general to cover all FDA-approved contraceptives and associated outpatient services.

U.S. Rep. Nita Lowey (D-NY), who sponsored the contraceptive amendment, will introduce a bill in the 1999 session that would extend that benefit to all women who are insured, according to a spokeswoman in her office. Even without further legislation, Congress’ action "should be a model for insurers," the spokeswoman says.

No way, says AAHP

Both the Health Insurance Association of America and the American Association of Health Plans (AAHP) oppose federal benefits mandates, generally calling them costly and unnecessary. "This [contraceptive care] is a widely available benefit among HMO members," says Don White, AAHP spokesman. Mr. White cites a Kaiser Family Foundation study from 1994 that found nearly 90% of plans covered IUDs, diaphragms, and oral contraceptives.

A mandate to cover all federally approved prescription contraceptive coverage would cost $21.40 a year per employee, the AGI estimates. Of that amount, employers would pay $17.12 annually, or $1.43 per member per month. The employee share would be $4.28 per year, or 36 cents a month, for the added coverage.

Contact Ms. Gold at (202) 296-4012, Ms. Rivera at (310) 204-6010, Ms. Lowey at (202) 225-6506, and Ms. Bloom at (305) 864-8648.