About That “Free” Birth Control …

By Kait Scalisi, MPH

From the start, the Obamacare contraceptive coverage provision has been controversial. Now, a new report shows that the promise of free birth control may, in fact, be too good to be true.

The provision itself requires most private insurance plans to cover all FDA-approved contraceptive devices without any cost-sharing (e.g., co-pays). Federal guidelines, however, state that individual plans may apply limitations in an effort keep costs down and care efficient. Additionally, carriers should have a process for waiving coverage limitations for patients who need a form of contraception that the plan either limits or does not cover.

The Kaiser Family Foundation recently released a report exploring these limitations. They looked at the insurance coverage policies of 20 insurance carriers for twelve forms of contraception, not including oral contraceptive. Information was gathered by interviewing plan officials and reviewing publicly available coverage documents. The short version of their findings? Most insurers do not cover all forms of birth control. More specifically:

There is a lot of variation in how carriers are interpreting and implementing the contraceptive provision. In many cases, the limit coverage of certain methods by either denying coverage completely or requiring policy holders to cover a portion of the method’s costs.
NuvaRing is the method that is the least likely to be covered by carriers. They report they do not want to cover multiple forms of birth control with the same chemical formulation, such as the ring and at least one birth control pill, despite the fact that the ring is defined as a distinct form of contraception.
There is a lot of variability in whether and how IUDs, the implant, and the patch is covered. Some plans cover all of the methods without any limitations while others cover some with limitations and some without.
Plan B is widely covered but ella, which has a longer window to work and is recommended for women with BMIs above 25 is not.
Half of the plans cover sterilizations completely, including associated services such as anesthesia and follow-up visits.
None of the carriers have an established process for policy holders to appeal limitations based on medical need.

The goal of the Affordable Care Act is to provide coverage to anyone who needs it, and especially those who need it the most. However, these limitations in contraceptive coverage mean that many women still do not have full access to contraception, including the method that might be best for them.

The lack of a formal appeals process specific to contraception is particularly alarming. Susie Poppick wrote about her experience with these limitations and though she eventually got her birth control, she had to make several calls to her carrier. More importantly, she knew how to and had the time to do so. This is a privilege not everyone has, whether its the wherewithal to ask for a manager, the cell minutes and time to spend making multiple phone calls and waiting on hold at least once, or even that contraception is supposed to be covered.

All of this is not to diminish the fact that the ACA did increase birth control access for many women. Confusion, bumps, and negative outcomes are bound to happen, making reports such both vital and valuable. Now that we know the state of contraceptive coverage limitations, it is up to the government to clarify the guidelines related to different forms of contraception and for insurance companies to take the next steps in making their policies clear and accessible.