Insurers reminded they must cover contraceptives

Insurance plans are required to cover contraceptive care without cost sharing, whether or not a service or produce is identified in the current FDA Birth Control Guide.

That’s according to new joint guidelines from the U.S. Department of Health and Human Services, Department of Labor, and Treasury Department. Insurance companies are required to cover these services without cost sharing under the Affordable Care Act. There have been reports that insurance companies have been shirking their responsibilities, or making patients jump through hoops to receive coverage.

The guidance states plainly that women, including adolescent and adult women, will have access “to the full range of female-controlled FDA-approved contraceptive methods, effective family planning practices and sterilization procedures to prevent unintended pregnancy and improve birth outcomes.” 

 

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This includes contraceptive counseling, initiation of contraceptive use, and follow-up care. Guidelines from 2013 state that insurance companies may use generic drugs without cost sharing, and impose cost sharing for equivalent branded drugs. However, insurance companies must still pay for the particular drug without cost sharing, either generic or brand name, that a health care provider determines is appropriate. 

This guidance has been stated again in the years since. However, the Departments last month issued further guidance, following complaints and public reports of insurance companies violating these requirements. 

“This FAQ makes clear that all FDA-approved cleared, or granted contraceptive products that are determined by an individual’s medical provider to be medically appropriate for such individuals must be covered without cost sharing, whether or not specifically identified in the current FDA Birth Control Guide,” the guidance states. 

In December, Sen. Patty Murray (D – WA) along with Sen. Ron Wyden (D – OR), sent a letter to the three departments expressing their concern over reports that insurers were illegally putting up barriers to birth control coverage. They asked that the Departments issue new guidance to ensure access to ensure that more than 64 million women in the U.S. who were covered under qualifying plans could receive contraceptive care without out-of-pocket costs. The letter states that:

“Unfortunately, we have heard from patients and providers that some insurers are requiring patients to show they have failed with as many as five different birth control options before the insurer will pay for the method of their choice.”

The complaints include reports that people are being denied contraceptive coverage for all or some brand name contraceptives, even after their physician determined and told the insurance plan that a particular service or product is medically necessary. Plans have also required people to first fail using numerous other devices or contraceptive products before covering the medically appropriate medical recommendation. 

The guidance states that the Departments are actively investigating these complaints and may take enforcement action. 

“Plans and issuers subject to these requirements are reminded of their responsibility to fully comply with the requirements,” the guidance states.