Coverage of Contraceptive Services: A Review of Health Insurance Plans in Five States

Insurance coverage of contraceptives has been the focus of legislative efforts at the state and federal level for many decades. With the passage of the Patient Protection and Affordable Care Act (ACA) came the requirement that most private plans provide coverage for women’s preventive health care, including all prescribed FDA-approved contraceptive services and supplies, without cost-sharing. Federal guidance issued on preventive services coverage requirements states that plans are permitted to apply reasonable medical management techniques to “control cost and promote efficient delivery of care.”¹ Since the provision became effective in August 2012, there have been ongoing anecdotal reports of some women experiencing difficulties in securing no-cost coverage from their plans.

To better understand how this provision is being implemented by health plans, Kaiser Family Foundation (KFF) staff, with the Lewin Group, reviewed the insurance plan coverage policies for 12 prescribed contraceptive methods (excluding oral contraceptives). Information was collected from 20 different insurance carriers in five states (California, Georgia, Michigan, New Jersey, and Texas) about how they are applying reasonable medical management (RMM) techniques in their coverage of women’s contraceptive services. Interviews were conducted with plan officials for nine carriers and reviews of publicly available plan documents on contraceptive coverage policies were conducted for an additional 11 carriers. In total, the information collected from the interviews and document review represent well over 200 different lines of business across the nation.

Key findings include:

There is variation in how the contraceptive coverage provision is being interpreted and implemented by health plans. While most carriers are complying with the spirit of this requirement, there are exceptions. Because of these coverage differences some women may not have coverage without cost-sharing to the contraceptive method of their choice. Specifically, we found that a higher share of plans place limits on certain contraceptive methods:

• Vaginal Ring: While 12 carriers of the 20 we reviewed cover NuvaRing placing no RMM limitations or no cost-sharing requirements to policyholders, five plans only cover NuvaRing with cost-sharing and one plan does not cover it all. We found this to be the contraceptive method that is least likely to be covered by carriers (Table A). Some carriers report that they do not cover different contraceptive methods with the same chemical formulation. Because the carriers provide no-cost coverage of oral contraceptives, they may not cover or may charge cost-sharing for the NuvaRing or Patch, because it has the same chemical formulation that they are already covering with oral contraceptive pills.
• Implants and Patch: Some carriers place limitations in coverage of the contraceptive implants, with two carriers failing to offer coverage of any implant available, even with cost-sharing and with three carriers covering the contraceptive patch, but only with cost-sharing.
• Intrauterine Devices: Ten carriers cover all three FDA-approved IUDs with no RMM limitations and no cost-sharing. One carrier, however, does not cover ParaGard, which is the only non-hormonal IUD available to women.
• Emergency Contraceptive Pills: While most carriers covered the progestin-based Plan B emergency contraceptive (EC) pill or its generic equivalents, only 11 carriers cover the ella emergency contraceptive pill without RMM limitations or cost-sharing. The ella EC pill is a different formulation and has a longer window of effectiveness and it may be preferable for women with a higher body mass index (BMI) than progestin-based EC pills, however, it does not have a generic equivalent. Two carriers do not cover ella at all.

Table A: Coverage of Female Contraceptive Methods Addressed in this Study
Method	Brand	Covered			Not Covered	Coverage or Limitations on Coverage Unknown
		With no RMM Limitations and No Cost-Sharing	With RMM Limitations and No Cost-Sharing	With Cost-Sharing with or without RMM limitations
Ring	NuvaRing	12	1	5	1	1
Patch	OrthoEvra	7	1	5	5	2
Patch	Xulane (Generic)	14	–	3	1	2
Injection	Depo-Provera	6	1	3	8	2
Injection	Depo-ProveraGeneric	16	–	2	–	2
Injection	Depo-SubQ Provera 104	7	–	5	6	2
Implant	Implanon	11	1	–	4	4
Implant	Nexplanon	10	1	–	3	6
IUD –hormonal	Mirena	13	1	–	–	6
IUD – hormonal	Skyla	10	1	–	3	6
IUD – copper	ParaGard	14	–	–	1	5
Emergency Contraception	Ella	11	–	6	2	1
Emergency Contraception	Plan B*	5	–	5	10	1
Emergency Contraception	Generic Plan B	19	–	–	–	1
Female Sterilization	All procedures	10				10
NOTE: 20 carriers were reviewed.*One carrier’s coverage varies by product line and as result the responses to this item total 21.

While the law permits carriers to employ RMM limitations for contraceptive coverage, the FAQs issued by the Department of Labor specify that carriers should have a process in place for waiving coverage limitations for patients who have a medical need for contraceptives that are otherwise subject to cost-sharing or not covered.² None of the carriers we reviewed have established a formal process for beneficiaries to file a waiver contesting limitations on coverage for preventive services; carriers refer consumers to their usual appeal process. It is also not clear whether any carrier has an established expedited appeal process that would allow a woman timely access to emergency contraceptives that are not covered under the policy.

Ten carriers cover sterilizations without cost-sharing. However, it was difficult to ascertain coverage for sterilization from both the interviews and the plan document review for seven other carriers. In particular, there is uncertainty about the extent to which carriers cover the ancillary services associated with female sterilization, such as follow up visits and anesthesia.

Despite significant national attention to the availability of a religious accommodation to plans serving employers with a religious objection to some or all contraceptive methods, insurers reported that they have received very few notifications from employers qualifying for the accommodation. Carriers have not identified difficulties in implementing the accommodations that have been requested by employers.

Information about the contraceptive coverage policies used by health insurance carriers is not easily accessible. Many carriers we approached for this project were unwilling to participate in an interview; only nine out of 24 carriers invited agreed to be interviewed, and some of the individuals that participated in interviews (such as medical directors, pharmacy care managers, public policy executives, and attorneys) were not always able to address the full range of contraceptive topics included in the study. Furthermore, many of the publicly available documents do not clearly identify plan coverage decisions when it comes to how different contraceptive methods are covered and the limitations of the coverage. This makes it extremely difficult, if not impossible for policyholders to ascertain their current plan’s contraceptive coverage policies.

For many women, the ACA’s contraceptive coverage provision has reduced their out-of-pocket health care costs and given them the opportunity to use more effective, but more costly, methods of contraception that had been unaffordable to them in the past. This report finds that there is variation in how insurance carriers are interpreting the guidelines for contraceptive coverage issued by HHS, and that not all methods may be covered without cost-sharing to women policyholders. The CDC and the Office of Population Affairs have clearly stated that offering women the full range of FDA-approved contraceptive methods is an element of high quality family planning services and emphasizes the importance of contraceptive choice in reducing a woman’s risk of unintended pregnancy. For many women with private insurance coverage, access to this range of options is now a reality; for some however, their choice of plan may still result in limitations of their contraceptive options.