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

Related Coverage Issues

Process for Waiving coverage Limitations

While carriers may employ reasonable medical management techniques, the FAQs issued by the DOL specify that carriers should have a “waiver” process for patients who have a medical need for contraceptives that are otherwise subject to cost-sharing or not covered.¹ The Center for Consumer Information & Insurance Oversight published the following illustration of this requirement:

For example, plans may cover a generic drug without cost-sharing and impose cost-sharing for equivalent branded drugs. However, in these instances, a plan or issuer must accommodate any individual for whom the generic drug (or a brand name drug) would be medically inappropriate, as determined by the individual’s health care provider, by having a mechanism for waiving the otherwise applicable cost-sharing for the branded or non-preferred brand version.²

There was some confusion among the carriers interviewed about what was meant by a “waiver” of cost-sharing requirement. However, carriers identified two mechanisms by which a member can request a waiver of cost-sharing based on medical necessity. One way is for the member to request an “exception to the initial coverage decision.” This usually requires that patient’s provider submit a request demonstrating medical necessity for the contraceptive method or product that is normally not covered without cost-sharing.

The second way this is handled by carriers is through the appeals process required by the ACA. The interim final rules issued by HHS codify a member’s right to appeal a claim or coverage denial to the carrier and their right to external review. States may use the standards issued by the National Association of Insurance Commissioners (NAIC) in their external review process. Alternatively, they may utilize the HHS-administered federal external review process or contract with an accredited independent review organization to review external appeals on their behalf.³ This timing, however, may be problematic and lead to delays which are not in the best interest of standards for quality contraceptive care. Regardless of the process, the carrier’s responses to the waiver request varies, and may not result in a woman obtaining the contraceptive method of her choice without cost-sharing. For example, one carrier will charge the member the difference in cost between the brand-name and generic contraceptive.

Of concern, none of the carriers interviewed had an expedited waiver or appeal processes for emergency contraceptives other than the expedited appeal process required for all other benefits, which may not be timely enough for women seeking emergency contraceptives.

Religious Exemptions and Accommodations

Certain religious employers have a religious objection to some all or contraceptive methods and may be “exempt” from the ACA contraceptive coverage mandate. Specifically “religious employers”, primarily churches and other institutions of worship, are exempt. An exemption means that the employer does not have to include contraceptive coverage for their workers and their dependents in their health plan.

There is also an accommodation available to nonprofit religiously-affiliated organizations that object to contraceptive coverage on religious grounds. Under the accommodation, a religiously affiliated nonprofit employer does not have to contract, arrange, pay or refer their employees for contraceptive coverage. To obtain an accommodation, nonprofit employers with religious objections to contraceptives are required to provide a copy of its self-certification that it qualifies for the accommodation to its health insurance carrier or third party administrator, or notify HHS of their objection. However, the health carrier used by the nonprofit employer must provide coverage of contraceptives, at no cost, to the women and dependents covered by to the employer. The carrier is responsible for notifying the policy holders, and must provide coverage of the contraceptive methods separately. Very little is known, however, about the frequency of such requests to insurers and how insurers have responded to this requirement.

In general, the carriers we interviewed did not report difficulties in providing religious accommodation to the very few employers requesting it. All the carriers interviewed indicated that the number of employers requesting accommodation represented only a small fraction of their consumers and that they had “very few, if any” requests for the religious accommodation.

Carriers interviewed noted that they notify members of the employer’s accommodation in two primary ways. One method is to inform members, upon enrollment and in the standard annual notification of coverage, that payment for contraceptive services is provided by the carrier and excluded by their employer. Another method is to send a separate communication to members once the employer is flagged as “religiously affiliated” in the carrier’s system. One of the interviewed carriers issues a separate ID card for members to use to obtain contraceptive services.

HHS guidance suggests that the religious accommodation will be cost neutral to carriers and KFF asked carriers if they adjusted premiums as a result of the accommodation. Only one carrier indicated that they adjusted premiums for employers requesting the accommodation.

With respect to self-insured health plans, an employer can either provide a copy of its self-certification to its third party administrator (TPA) or notify HHS in writing. The TPA must then provide contraceptive services for the women in the health plan, at no cost to the women or employer. These costs can be offset by adjustments in Federally-Facilitated Marketplace user fees paid by a health insurance carrier with which the TPA has an arrangement. If the carrier does not offer exchange products, they may request that the funds are passed through a carrier that does offer exchange products. None of the interviewed carriers with self-funded products reported that they are pursuing adjustments at this time.

Well Woman Office Visits and Counseling

One of the women’s preventive services recommended by the Institute of Medicine and adopted by HRSA is the well woman visit. The HRSA guidelines specify that plans should cover an annual visit, “although HHS recognizes that several visits may be needed to obtain all necessary recommended preventive services, depending on a woman’s health status, health needs, and other risk factors.” The February 20, 2013 FAQs further clarify that, “If the clinician determines that a patient requires additional well woman visits for this purpose, then the additional visits must be provided…without cost-sharing and subject to reasonable medical management.”⁴

Generally carriers that were reviewed did not place limits on the number of well woman visits with network providers and stated they will cover all visits for preventive care, without cost-sharing. For example, one carrier indicated that claims with preventive care CPT4 codes are covered as preventive when received from in-network providers. This highlights the important role of provider billing in ensuring access to contraceptive services.

One carrier indicated that well woman visits with no cost-sharing are limited to one per year, “with consideration given for additional visits.” In the document review of another carrier it is specified that that one annual visit and one additional visit are covered without cost-sharing, but no mention of how it would be handled if women required additional preventive visits.

Interestingly, a different carrier indicated that medical visits for the purpose of obtaining a prescription for an emergency contraceptive are covered without cost-sharing. All of the carriers reviewed by this study cover medical visits for contraceptives, including counseling, and consider them preventive visits and cover them without cost-sharing. Additional preventive visits later in the year (after the annual well woman visit) are also covered without cost-sharing.