Women’s Health

When can plans limit coverage of particular contraceptives?

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There are a number of ways that plans or employers can limit contraceptive services.  Federal law requires that ACA-compliant plans must cover at least one form of each the 18 contraceptive methods for women identified by the FDA. But, a plan may apply reasonable medical management techniques such as prior authorization or step-therapy, and require cost-sharing for certain contraceptive drugs or devices to encourage an individual to use specific services or items within a chosen FDA approved contraceptive method. However, the plan must have a process in place to ensure that your particular contraceptive service or product is covered without cost sharing when your specific provider recommends it based on medical necessity.  In addition, you must get your contraceptive care from an in-network provider.  Insurers may charge cost sharing if you go to an out-of-network provider for contraceptive care.

In addition, if your employer is affiliated with a faith-based organization, they can limit the types of contraceptives they wish to cover based on religious objections.  Specifically, all houses of worship are exempt.  Other employers and universities that are affiliated with faith-based organizations that oppose some or all contraceptive methods may also opt to exclude coverage, and have the insurance company provide the contraceptive coverage directly to policyholders.  There is ongoing litigation about which employers are exempt and can exclude contraceptive services.

Short-term health insurance policies do not have to provide benefits required by the ACA and may not cover preventive services including contraceptive services.

While we have made every effort to provide accurate information in these FAQs, people should contact the health insurance Marketplace or Medicaid agency in their state for guidance on their specific circumstances.