February 16, 2016
The contraceptive coverage guarantee of the Affordable Care Act (ACA) requires that privately insured women receive insurance coverage for US Food and Drug Administration (FDA)–approved contraceptive methods, sterilization procedures, and patient education and counseling without any out-of-pocket costs. Medicaid recipients have been excluded from this requirement. This coverage must encompass the clinical visit, services needed for provision of contraception, follow-up and management of adverse effects, counseling for continued adherence, and device removal.1
The guarantee is not absolute and does not apply to supplies (such as emergency contraception) obtained without a prescription nor does it apply to methods used by men (eg, vasectomy, male condoms). Plans can exclude coverage or require cost sharing for out-of-network services and supplies. Some plans are exempt, including so-called grandfathered plans (preexisting plans given a temporary reprieve from many ACA rules) and plans of some religious employers.
Despite these limitations, the ACA provision has already directly benefited millions of women who use contraceptives by decreasing their total out-of-pocket spending on contraceptives.2 Prior to the ACA, high initial costs were barriers to women using highly effective contraceptive methods such as intrauterine devices (IUDs) and implants.3 Cost also affected adherence to commonly used refillable methods such as oral contraceptive pills, the contraceptive patch, or the vaginal ring with recurring prescription co-payments previously required.
The provision has the potential to substantially improve public health. Access to contraception without financial barriers reduces unintended pregnancies and births, which in turn can improve maternal and infant health.4 Contraceptive access also can help women achieve their educational and workplace goals and support themselves and their families.5 Insurance companies benefit from the contraceptive coverage provision because all methods are cost saving after accounting for the costs of unintended pregnancies and births.6
Despite the benefits of this provision, challenges to implementation exist for physicians and other clinicians, patients, and payers that may result in patients continuing to pay for all or part of covered contraceptive services.
Some insurers have limited which contraceptive methods are available without cost sharing. For example, some plans only cover generic versions of oral contraceptives or have excluded certain methods of contraception (eg, the vaginal ring) because they have a similar mechanism of action as oral contraceptives. These issues should be ameliorated by the most recent federal guidance, released in May 2015, which states that plans “must cover without cost sharing at least one form of contraception” in each of the 18 categories for women identified by the FDA.1
The federal guidance allows plans to use “reasonable medical management techniques” to control costs, but only within—not across—method categories. Moreover, the guidance specifies that plans must provide a clear and efficient process that “is not unduly burdensome” to accommodate situations when a clinician recommends an uncovered method based on medical necessity. Plans must defer to the clinicians’ recommendation.1 It is not yet clear whether insurers have put such a process in place.7
Insurers and practitioners may be unsure about how to address situations in which women receive contraceptives for indications other than, or in addition to, pregnancy prevention. For example, some women receive oral contraceptives or hormonal IUDs to treat abnormal uterine bleeding. Although the federal guidance does not directly address such situations, these contraceptives still serve a contraceptive purpose and should therefore still be covered under the ACA’s guarantee.
The ACA states that clinical services required to provide the contraceptive method must also be provided with no cost sharing. This should include patient education and counseling, the injection or insertion of a contraceptive drug or device, anesthesia necessary for sterilization, follow-up care, and other related services. However, insurers have been inconsistent about covering such clinical services,7 and federal guidance has not included every relevant example. Inappropriate insurance practices may therefore lead to patients being erroneously charged for services that should be covered with no out-of-pocket costs, potentially interfering with patients’ ability to practice contraception consistently and effectively.
Physicians, other clinicians, and health care organizations may find it difficult to appropriately bill for contraceptive services in a way that ensures that patients are properly exempt from cost sharing. If a patient receives contraceptive counseling as part of a well-woman examination, the situation is straightforward because the well-woman examination has a specific Current Procedural Terminology code and is considered a covered preventive service. However, if a patient has an office visit solely for contraceptive counseling (which does not have a specific billing code), the clinician or health care center must bill an appropriate evaluation and management code (which can be used for many purposes) and billing modifier (ie, 33) to specify that the visit was for the preventive service, contraceptive counseling. Many clinicians and health organizations are unaware of this modifier, and some insurers have been slow to program their billing systems so that this modifier automatically triggers the patient’s exemption from cost sharing when the included diagnosis codes (formerly International Classification of Diseases, Ninth Revision [ICD-9], now ICD-10) indicate that primarily preventive services were provided.
An additional challenge arises if care that involves diagnostic testing is provided during a visit, even when the initial visit was scheduled for contraceptive counseling or maintenance. Under the ACA provision, a visit should be considered preventive—and therefore exempt from cost sharing—if the primary purpose of the visit is for preventive care. However, the primary purpose may not always be clear to patients, clinicians, and payers when additional care is provided. Clinicians can use 2 separate billing codes, one for the preventive care and an additional code for the diagnostic care, but this could lead to confusion and disagreement about when patients will be charged. Greater transparency could help clinicians and health care centers communicate with patients about these potential fees.
A final complication is that insurers may exclude coverage or require cost sharing for out-of-network services and supplies, unless the service is unavailable in network. However, patients and practitioners are not always aware of this limitation or the exception, and patients may not always realize that they are accessing out-of-network care. For example, even if a patient uses an in-network hospital for her sterilization procedure, the anesthesiologist may not be in network. The out-of-network restriction also can apply to pharmacies.
The federal government has already released detailed guidance for contraceptive coverage, more than for the other preventive services that the ACA requires insurance plans to cover. Additional guidance about such matters as the process for waiving medical management requirements or what qualifies as a preventive visit vs diagnostic visit would certainly be welcome. Beyond that, state regulators, insurance companies, and health care professionals each have their own responsibilities in addressing the challenges of implementing the contraceptive coverage guarantee.
State regulators, for example, are responsible for ensuring that insurance companies maintain health care networks that provide access to covered services and could prioritize network adequacy related to contraceptive care. Insurance companies could do much more to conform to the law and the spirit of the contraceptive coverage guarantee and to provide clear information to clinicians and patients about this coverage and its limitations. Health care professionals could do more to become educated and to educate their patients about insurers’ rules and procedures. They could also learn more about how to properly bill services so that patients are not inappropriately charged for care. Each of these steps could help ensure that the contraceptive coverage guarantee fully meets its potential to improve women’s health and well-being.