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Dawn Stacey M.Ed, LMHC

Why Do I Still Need to Pay for My Contraception? What Happened to the Affordable Care Act?

By August 4, 2012

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So, the internet has been a buzz since August 1... the day that the new insurance coverage requirements -- specifically, preventative services for women -- took effect. Under the Affordable Care Act, for the first time, insurance companies will be required to cover additional preventive health benefits for women to fill the gaps in current preventive services. About a year ago, Department of Health and Human Services announced that beginning in August 2012, insurance companies will have to cover, without out-of-pocket costs, all FDA-approved birth control options as well as permanent sterilization procedures and contraceptive counseling. Keep in mind though, that medical abortions and drugs like RU-486 are not included under these new preventative services.

All this sounds good, right? But some confusion seems to be going on. Take Becca, who commented to my site on August 2, 2012:

"Today I whet to buy my NuvaRing and my insurance company still thinks they don't have to pay for it. I have been on the phone all day with them and I guess we just understand the law differently."

So... who is right in this scenario? Unfortunately, they both are. You see, even though the law went into effect on August 1, 2012, this doesn't mean that YOU will receive these benefits AUTOMATICALLY on this day. In fact, most people will likely start benefiting from this law in January 2013 because this is the time of year when most insurance plans are renewed for the year. So basically, your current private insurance plan will have to cover these services, but is only be required to do so when it is time for the plan to be renewed.

Some more things to keep in mind, as per the Affordable Health Care Act, "Women will have access to all Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling." Unfortunately, this is a bit misleading... in this case, ALL types does not equal to all brands. Under this law, plans will still have the flexibility to control costs and promote efficient delivery of care by, for example, continuing to charge cost sharing (co-pays, coinsurance, deductibles) for branded drugs if a generic version is available and just as effective and safe.

Many insurers have "tiered" pharmacy benefits where you pay differing amounts for brand-name, as opposed to generic products. Some plans may require that, if you choose a brand-name drug (when an equivalent generic is available) you to pay the price difference between the two. These new guidelines still allow insurance companies to use reasonable medical management to help control costs. This means that if your contraceptive has a generic version, your insurance plan can choose to only offer the generic for free. Since emergency contraception is an included benefit, this may mean that you can get Next Choice for free, but may have to pay to use Plan B One-Step. For certain brands that don't have a generic (like NuvaRing, Ortho Evra Patch, Nexplanon, etc.), companies should cover these.

Also -- remember these preventative services guidelines apply to women only. So as of now, male-based contraceptive methods, like vasectomies or condoms, are not covered under these new benefits. It seems that the requirement to waive contraceptive co-payments does not apply to methods and procedures intended for males. Finally, OTC female contraceptives (spermicides, female condoms, Today Sponge) are covered by the Affordable Care Act, BUT in order for these to be covered without cost-sharing, you must have your doctor write a prescription for these products. So even though they are available over-the-counter, if you don't want to have to pay for them, you need to get a prescription first.

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