Birth Control & Health Insurance—When You Have To Pay
Updated May 29, 2015.
Because contraceptive services are considered preventive health care for women, the Affordable Care Act was supposed to prohibit health insurers from charging cost-sharing fees like deductibles, copays, and coinsurance for birth control. So, why are some insured women still paying for birth control?
There are several situations in which insurers are allowed to impose cost-sharing for contraceptives.
Here’s a rundown of them:
Out-of-Network Care
If you have managed care health insurance with a provider network, the prohibition against cost-sharing for preventive care only applies to services received from an in-network provider. If you get your birth control pills from an out-of-network pharmacy or have your IUD placed by an out-of-network gynecologist, you’ll pay more. In fact, if your health plan is an HMO or EPO that doesn’t reimburse for out-of-network care, you might have to pay the entire bill yourself. If you have a PPO or POS plan, you’ll likely have to pay the out-of-network deductible and coinsurance rate for your plan. If you don’t want to pay these charges, stay in-network when getting contraceptive services.
Only One Offering From Each Category Has to Be Free
At the time of this writing, there are 18 FDA-approved categories of contraceptives intended for women’s use. Your health plan only has to make one offering from each category free of cost-sharing.
For example, there are many combination birth control pills.
Your insurer must offer one without cost-sharing but can charge a copay for other combination birth control pills. There is only one contraceptive ring; it’s the only product in its FDA category. So, your insurer must pay for the NuvaRing without cost-sharing.
If your physician feels there is a medical reason why your health plan’s preferred offering from that FDA category isn’t medically appropriate for you, then your health insurer must make the medically-appropriate choice available to you without cost-sharing.
Your health plan is allowed to use medical management techniques to encourage you to use its preferred option within each FDA category. For example, it may offer a generic version of a particular birth control pill for free, but charge a copay for the brand-name version of the same drug. However, if there is no generic version available in that category, it must offer a brand-name version without cost-sharing.
Prescription Required
Over-the-counter contraceptives for use by women are included in the contraceptive mandate. However, they’re only included if prescribed by your health care provider. So, if you don’t want to have to pay for your over-the-counter contraceptive, get a prescription for it. Take the prescription to the pharmacy counter and have it filled.
Grandfathered Plans Are Exempt
Grandfathered health plans are exempt from some of the ACA’s consumer protections; they don’t have to offer any preventive health care free of cost-sharing. If your health plan is grandfathered, it must say so in the plan literature. You could also find out by calling the customer service number on your health insurance ID card or by asking your employee benefits representative if it’s job-based health insurance.
Religious Objection
Certain religious employers are exempt from the contraceptive mandate. If you work for a church or house of worship and have health insurance through your job, your health insurance may not cover contraceptives at all, or may offer limited choices and require cost-sharing.
Also, the Supreme Court ruled in Burwell V. Hobby Lobby that certain closely-held for-profit businesses whose owners have a religious objection to certain types of contraceptives cannot be forced by the ACA to provide their employees with these types of contraceptives. If you work for a closely-held corporation whose owners have religious objections to certain types of birth control, you may find that you’ll pay 100% of the cost of those particular contraceptive methods.
Men
Contraceptives are considered preventive health care for women, but not for men. Health insurers don’t have to cover contraceptives for men at all.
Sources:
FAQS ABOUT AFFORDABLE CARE ACT IMPLEMENTATION (PART XXVI), The Center for Consumer Information & Insurance Oversight, The Centers for Medicare & Medicaid Services. Accessed may 29, 2015.
