What constitutes reasonable limitations and management of contraception as an essential preventive health benefit? In the wake of new data and some consumer complaints, HHS may try to resolve gray areas.
Some women are facing some barriers in accessing certain birth control medications and devices, according to a new study by the Kaiser Family Foundation.
Researchers with the Kaiser Family Foundation and the Lewin Group examined both ACA exchange and nonexchange plans sold by 20 insurers in California, Georgia, Michigan, New Jersey and Texas, to gauge their performance in meeting essential health benefits rules mandating coverage for all FDA-approved contraceptive products and services without cost-sharing.
While many insurers are "complying with the spirit" of the regulation, "several carriers require cost sharing, decline coverage, or otherwise limit coverage of certain contraceptive methods, in particular the vaginal ring, the patch and implants," wrote KFF researchers Laurie Sobel, Alina Salganicoff and Nisha Kurani.
Almost all plans cover both hormonal and non-hormonal intrauterine devices, which is now the third most popular form of reversible contraception. But only half of the insurers in the study covered all three FDA-approved IUDs without coverage limitations or cost-sharing, and one insurer wasn't covering ParaGard the only non-hormonal IUD available.
Most insurers in the study were also covering the progestin-based Plan B emergency contraceptive pill or its generic equivalents, although several carriers don't cover it, place coverage limitations, or charge cost-sharing for the ella EC pill. The ella EC uses a different formulation, and is more effective in women with higher body mass indexes, but lacks a generic equivalent.
The study also found that while 12 of the 20 insurers covered the NuvaRing without medical management limitations or cost-sharing, five insurers only cover NuvaRing with cost-sharing and one plan does not cover it all--making it the contraception least likely to be covered by carriers. (The researchers excluded oral contraceptives, as there are a large number of different formulations, brands and generics that are available.)
The ACA allows insurers to use reasonable medical management for contraceptive coverage, but the current regulations and FAQs issued by the Department of Health and Human Services do not specifically proscribe how health plans should implement the essential health benefit or set limits standards for reasonable medical management.
The Department of Labor has outlined a process for waiving coverage limitations for patients who have a medical need for contraceptives otherwise subject to cost-sharing or not covered, although none of the carriers reviewed have a formal 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," wrote Sobel, Salganicoff and Kurani.
America's Health Insurance Plans responded to the study by arguing that insurers are helping expand access to contraception on the whole, while employing reasonable limitations and relying on generics when available to try to balance choice with affordability.
Sobel, Salganicoff and Kurani found that when a generic is not available, many carriers cover all the available alternatives--though not all of the insurers.
Ten of the insurers studied covered both of the brand-name implants Implanon and Nexplanon, with no cost-sharing and no RMM limitations, but two insurers were founded to be not covering either of the implants, even with cost-sharing. Also, the NuvaRing is not available as a generic and seven of the carriers interviewed apply RRM limitations and/or cost-sharing.
"Their rationale is that the chemical compounds are the same as other covered forms of contraception that are covered with no RMM limitations and no cost-sharing," Sobel, Salganicoff and Kurani wrote. "This can also limit coverage without cost-sharing to implants and contraceptive patches."
The study has brought out some worry from consumer health advocates and regulators. Gretchen Borchelt, VP at the National Women's Law Center, told the National Journal that the kinds of medical management and limitations being used by plans in the Kaiser study could be considered "violations of the law."
The Department of Health and Human Services has generally approved of the various management techniques. But now, the agency is promising to issue more guidance on contraceptive coverage, which could set standards and resolve some concerns.