Barriers to ACA's Contraception Mandate Remain: Part III

The Affordable Care Act (ACA) has provided coverage for more than 55 million women for preventive services without any cost sharing for contraceptive services and supplies. However, despite the expanded coverage, millions of women still face barriers as they try to access their new benefits. (Read part 1 and part 2.)

Awareness, clarity needed

Promoting greater awareness among providers and the public would be a step toward ensuring that all women enrolled in private plans have a chance to benefit from the contraceptive coverage guarantee.

For instance, some providers may not realize how to properly code all visits related to contraception as a preventive service so that patients aren’t charged, noted a Kaiser Family Foundation study on contraceptive coverage.

Health insurance carriers may also introduce further restrictions. Plans are allowed to impose “reasonable medical management techniques,” such as step therapy, prior authorization, and quantity limits. They may cover a generic drug without cost sharing while requiring cost sharing for equivalent branded drugs. However, a plan must accommodate any individual for whom a particular drug (generic or brand name) would be medically inappropriate, as determined by that patient’s healthcare provider.

“We were seeing plans using those medical management techniques to undercut ‘the all-means-all,’” said Susan Berke Fogel, JD, director of reproductive health at the National Health Law Program in Los Angeles, which advocates for the rights of low-income and underserved individuals and families on federal and state levels. “For example, plans were lumping oral contraceptive pills, vaginal rings and patches into one category, therefore only covering pills.”

As a result, in May 2015, HHS released additional guidance clarifying plans’ responsibilities, requiring coverage of at least 1 product in each of 18 FDA-approved contraceptive method categories: sterilization surgery; surgical sterilization implant; implantable rod; copper intrauterine device; intrauterine devices (IUDs) with progestin; shot/injection; oral contraceptives with estrogen and progestin; oral contraceptives with progestin only; oral contraceptives that delay menstruation; the patch; vaginal contraceptive ring; diaphragm; sponge; cervical cap; female condom; spermicide; emergency contraception known as Plan B or the morning-after pill; and a different emergency contraception pill called Ella.

But further clarity is still needed. For instance, of the 4 IUDs on the market, the copper device falls under 1 of the 18 categories, while the other 3 IUDs are in a different category. Those 3 devices use varying amounts of progestin, but because they are in the same category, an insurance plan has the option to cover only 1 of them.

Uncertainty also remains among providers and insurers about cases in which women take contraceptives for medical reasons, such as the treatment of abnormal uterine bleeding.

The federal guidelines do not directly address these circumstances.

Other challenges to access

At the same time, some of the barriers to access fall outside the law’s purview—including variations in individual health providers’ approaches to contraception.

“Women seeking some forms of contraception face additional challenges that are not related to the ACA contraceptive coverage guarantee,” said Mary C. Politi, PhD, an associate professor in the Division of Public Health Sciences at Washington University School of Medicine in St. Louis. “For example, some individual practices have policies prohibiting same-day insertion of IUDs, which can create barriers for women choosing this method.”

In addition, the contraceptive guarantee does not include male contraceptive methods.

“One thing that still needs to be fixed is recognizing the role of men in preventing pregnancy,” said Fogel. “The contraceptive coverage rule only applies to women.”