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. In the years immediately prior to the passage of the ACA, coverage for prescription contraceptives in private plans was widespread, but not universal. Between 1998 and 2003, more than half of states (28 states) had enacted contraceptive coverage mandates, and around the same time, discussions were occurring at the federal level surrounding contraceptive parity legislation. The state mandates typically required contraceptive parity in the small group and individual insurance markets but did not require the coverage be offered without cost-sharing. State laws, however, fell short of universal coverage as they only applied to state regulated plans, but not self-funded plans where 61% of covered workers are insured.1 In 2000, The Equal Employment Opportunity Commission ruled that employers with more than 15 employees must cover contraceptives for women if they offer health plans that cover preventive services and prescription drugs.
The Patient Protection and Affordable Care Act (ACA) took state laws further by requiring most private plans (including self-funded, small and large group, and individual plans) to cover a wide range of recommended preventive clinical services without cost to policy holders. For adults, this far-reaching requirement includes all of the services that received highly rated recommendations from the independent United States Preventive Services Task Force (USPSTF), and immunizations recommended by the Centers’ for Disease Control and Prevention (CDC) Advisory Committee for Immunization Practices (ACIP). The law also specifies that plans cover preventive services for women that are recommended by the Health Resources and Services Administration (HRSA).
To inform the development of these guidelines, HRSA commissioned the Institute of Medicine (IOM) to review existing evidence and make recommendations to fill in the gaps in the services for women identified by the USPSTF. In its report, the IOM identified eight new services, including contraceptive services and supplies.2 The IOM recommendations also specified that the most appropriate method of contraception varies according to each woman’s needs and medical history, and therefore, the full range of contraceptive methods is necessary to ensure that women have “options depending upon their life stage, sexual practices, and health status.”3 HRSA adopted the IOM’s eight recommendations, including the requirement that plans provide no-cost coverage of all FDA-approved contraceptive methods as prescribed.4 The women’s health provision became effective on August 1, 2012 and affected most women with private health insurance coverage starting in January 2013.
The HRSA Guidelines include a recommendation for all Food and Drug Administration (FDA) approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity, as prescribed by a health care provider.
While most health plans are now required to provide contraceptive methods and counseling to women with reproductive capacity with no out-of-pocket costs to beneficiaries, there are certain conditions that must be met. Women must be enrolled in a non-grandfathered plan5 and they must get services from an in-network provider. In addition, the federal regulations implementing the preventive services coverage requirement explicitly permit plans and issuers to use reasonable medical management to control cost and promote efficient delivery of care.6 This applies to coverage of all preventive services, not just contraceptive care. Neither the Women’s Preventive Service Guidelines nor the PHS Act, however, offers a specific definition or parameters for reasonable medical management, how it should be applied, or identification of all the FDA-approved contraceptive methods.
In an attempt to provide additional clarification on the implementation of the preventive services provisions of the ACA, the US Department of Labor’s Employee Benefits Security Administration addressed the issue through a response to a series of Frequently Asked Questions (FAQs).7 The clarification states that a plan may limit the frequency, method, treatment or setting for the provision of a recommended preventive health service based on relevant evidence,8 but still does not provide a specific definition for reasonable medical management.
Since the provisions became effective, there have been multiple media reports of women experiencing difficulties in accessing no-cost coverage for the full range of FDA-approved methods of contraception. These anecdotal reports include women experiencing difficulty in securing coverage for brand named contraceptives as well as certain types of contraceptive methods.9
To better understand how this policy is being implemented by plans, the Kaiser Family Foundation undertook a study to examine how the contraceptive coverage provision and the reasonable medical management rules are being interpreted by plans and how the interpretation could affect the availability of the full range of contraceptive services and supplies to which women are entitled under the law. Kaiser Family Foundation (KFF) staff with the Lewin Group reviewed the contraceptive coverage policies used by health plans in five states, and conducted interviews to collect more detailed information about how plans are applying reasonable medical management (RMM) in their coverage of women’s contraceptive services. The specific methodology is described in the following section.