Need birth control? Here's what the ACA requires - and what it doesn't

The ACA makes birth control much more accessible and affordable
Most health plans must cover at least one version of each of the 18 types of FDA approved contraceptives, with no copay. BSIP/Universal Images Group/Getty Images

Free preventive care - one of the ACA's essential health benefits - is among the more popular provisions of the Affordable Care Act. Insureds on all ACA-compliant plans don't have to pay anything for a long list of preventive services that apply to women, children, and all adults. 

Free preventive care applies to most health plans in the US now, and was enacted prior to the bulk of the ACA's provisions in 2014.

The provision applies to individual plans as well as large and small group plans. Grandfathered health plans are exempt from the requirement to cover preventive care with no cost-sharing (grandfathered plans are those that were already in effect as of March 23, 2010 wen the ACA was signed into law). In 2014, roughly a quarter of workers with employer-sponsored plans had grandfathered coverage.but the prevalence of grandfathered plans has been steadily declining since 2010.

Contraceptives - what's covered for free?

HHS enacted a list of women-specific preventive care that went into effect for all new and renewing non-grandfathered plans as of August 2012. It includes contraceptive coverage with no cost-sharing. But that doesn't mean that every available birth control option will be provided by your health insurance carrier at no cost. 

HHS clarified that health plans must cover at least one version of all FDA-approved methods of female contraception, with the exception of abortifacient drugs (health plans are not required to cover contraceptives for men, including vasectomies).

 When generic versions of a certain type of contraception are available, a health plan can offer the generic with no cost-sharing but impose a copay if the insured prefers a brand-name version (there's a requirement that the copay be waived if the insured's doctor determines that the alternative offered at no charge by the health plan would be medically inappropriate for the patient).

There are currently 18 different types of female contraceptives approved by the FDA:

• Sterilization surgery
• Surgical sterilization implant
• Implantable rod
• Copper intrauterine device (IUD)
• IUD with progestin 
• Shot/injection (Depo-Provera)
• Oral contraceptives (the pill), with estrogen and progestin
• Oral contraceptives with progestin only (the "mini-pill")
• Oral contraceptives with extended use that delays menstruation (also known as menstrual suppression pill)
• The patch
• Vaginal contraceptive ring
• Diaphragm
• Sponge
• Cervical cap
• Female condom
• Spermicide
• Emergency contraception (Plan B/morning-after pill)
• Emergency contraception (Ella/Ulipristal acetate)

Your health insurance carrier has to provide you with at least one option from each of those 18 categories, with no out-of-pocket cost. For some types of contraception, there are numerous options available, and your health insurance carrier can impose a copay for most of them, as long as at least one is offered to you at no charge.

LARC - affordable under the ACA

The requirement that each type of contraceptive be available with no cost-sharing is particularly important for long-acting reversible contraceptives (IUDs and implantable rods). These options were often prohibitively expensive in terms of up-front costs prior to the ACA's contraceptive mandate (although over the life of the product, they're often less expensive than oral contraceptives). But they're highly effective and studies have found that women prefer them to other contraceptive methods when cost is no longer a barrier. Long-acting reversible contraceptive use was already increasing by 2012, and experts project that their utilization will increase further as a result of the ACA.

challenges to the contraceptive mandate

The ACA excluded churches and religious non-profits from the contraceptive mandate, but other organizations have railed against the mandate and some have prevailed in court. In 2014, Hobby Lobby sued for the right to exclude four types of contraceptives (both IUDs, along with Plan B and Ella) from their employees' health plan. The Supreme Court sided with Hobby Lobby, ruling that the government must find a way to ensure that "closely held" corporations (like Hobby Lobby) with an objection to some or all methods of birth control would be able to avoid paying for them as part of their health plan. 

In July 2015, in response to the Burwell v. Hobby Lobby ruling, HHS finalized a ruling that allows an accomodation for "a closely held for-profit entity that has a religious objection to providing coverage for some or all contraceptive services," while still ensuring that women have access to the full range of FDA-approved contraceptives. Under the accomodation, the health insurer (or third-party administrator in the case of self-employed plans) takes on the cost of covering some or all contraceptives, at no cost to the woman or the employer. The accomodation for closely-held for-profit entities is the same as the accomodation that HHS had previously provided for religious non-profits. 

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