Commercial plan coverage requirements for LARC methods
Most commercial insurance plans must cover LARC methods without cost-sharing.
Under the ACA, all new insurance plans (both individual and employer-sponsored plans) are required to cover all FDA-approved methods of contraception, sterilization, and related education and counseling without cost-sharing. (Note: the ACA contraceptive coverage requirement described in this section also applies to Medicaid “Alternative Benefit Plans,” explained in the Medicaid section.) No cost-sharing means that patients should not have any out-of-pocket costs, including payment of deductibles, co-payments, co-insurance, fees, or other charges for coverage of contraceptive methods, including LARC. Patients cannot be asked to pay upfront and then be reimbursed.
There are a limited number of commercial plans to which the ACA contraceptive coverage requirements do not apply. In general, the best way to determine whether a patient’s plan falls into any of these categories is to have her ask the plan administrator, or (in the case of an employer plan) the human resources department. Additionally, the following information may help to further clarify a patient’s coverage policy.
Which LARC methods must be covered with no cost-sharing?
The ACA requires that applicable plans cover all FDA-approved methods of contraception for women. The government has consistently been clear that LARC methods must be covered. In guidance released in 2013, it affirmed both IUDs and implantable rods must be covered under the ACA. Additional guidance from the federal government in 2015 has clarified that plans must cover at least one form of contraception in each method category for women listed on the FDA's Birth control Guide. Insurers must ensure that plans comply with this guidance in teh first health plan year that starts o nor after July 10, 2015. Currently, there are three FDA-approved LARC methods on the FDA's guide:
- implantable rod,
- IUD copper, and
- IUD with progestin.
Which LARC-associated services must be covered with no cost-sharing?
Services related to a LARC method should be covered without cost-sharing. This incluses "clinical services, including patient education and counseling needed for provision of the contraceptive method," and “[s]ervices related to follow-up and management of side effects, counseling for continued adherence, and device removal”
What is allowed within “reasonable medical management”?
“Medical management” is broadly understood to encompass insurer practices that aim to control costs and promote efficient delivery of care. Insurers routinely use medical management techniques to govern the availability of benefits. Although plans are allowed to use “reasonable” medical management techniques to control utilization of contraceptives, their ability to do this is limited under the law. Plans may use medical management techniques only within a birth control method category, not between categories. For example plans may cover one IUD with progestin without cost-sharing, while imposing cost sharing on others. Additionally plans may impose cost-sharing for:
- Services and contraceptives provided at out-of-network providers and pharmacies. However, plans must cover out-of-network services without cost-sharing if there is no provider in-network who can perform the service.
- Brand-name drugs and devices that have a generic equivalent as long as a generic equivalent is covered without cost-sharing.
If a plan uses medical management techniques within a specified birth control method category, it must have an "expedient exceptions process" so that the patient can access the specific birth control her health care provider determines is medically necessary. Medical necessity includes such factors as "severity of side effects, differences in permanence and reversibility of contraceptives, and ability to adhere to the appropriate use of the item or service, as determined by the attending provider." The exceptions process must defer to the provider's determination.
Furthermore, any rule that, in effect, denies coverage without cost-sharing for an entire method category of contraception is not allowed. For example, a plan cannot say it only covers generic forms of birth control and therefore deny coverage for all IUDs.
How can a provider help a patient who has trouble accessing LARC methods without cost-sharing?
- Confirm with the patient's health plan the documentation required for appropriate coverage without cost-sharing. See related coding guidance.
- If appropriate contact the plan to request an exception, sometimes called a "waiver." Insurance plans subject to the ACA contraceptive coverage requirements must allow access to an off-formulary contraceptive if medically indicated.
- Contact the plan’s medical director to voice concerns with barriers to accessing care.
- Contact (or direct the patient to contact) NWLC’s CoverHer hotline ([email protected], 1-866-745-5487). NWLC can help the patient navigate this process.