The ACA guarantees full contraceptive coverage. Why are women getting denied?

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As Whitney* approached the end of her medical residency more than two years ago, she discovered a new birth control device that seemed like a perfect fit for her needs.

The contraceptive — a one-year vaginal ring — meant she’d only need one prescription annually instead of the monthly refills required for most hormonal rings. She also liked that the ring didn’t require insertion or removal by a healthcare provider (HCP) like an intrauterine device (IUD). Whitney knew she wanted children “soon-ish,” making a one-year contraceptive a better option than an IUD that could prevent pregnancy for three or more years.

And hormonal birth control had long provided another, non-contraceptive benefit — it helped minimize the migraine attacks Whitney experienced during her menstrual cycles. She discussed her choice with her HCP, who wrote the prescription and submitted it to her insurer.

Whitney thought that was the end of it. Her previous birth control methods, which included an IUD, had been 100% covered since full coverage for contraceptive methods and counseling without any out-of-pocket costs had become mandated by federal law under the Affordable Care Act (ACA).

Instead, Whitney learned that her insurer had declined to cover the one-year ring without providing an explanation why.“

I was just frustrated and shocked,” Whitney said. “I made this decision, and my doctor supported my choice. Why should the insurer be in the position of making these decisions instead of the patient and her provider?”

Whitney soon learned her experience wasn’t unusual. While 64.3 million American women have birth control coverage through their insurers, women’s health advocates and lawmakers are saying too many insurers are in violation of the law. They’ve been collecting reports from patients about health insurance companies denying contraceptive coverage or charging for contraceptive-related healthcare visits despite ACA requirements, notably seeing an uptick in complaints when the Trump administration issued regulations offering exemptions to employers who chose not to offer birth control coverage.

In late 2021, U.S. Sens. Patty Murray, D-W.A., and Ron Wyden, D-O.R., sent a letter to Secretary of Health and Human Services Xavier Becerra, Secretary of Labor Marty Walsh and Treasury Secretary Janet Yellen imploring the Biden administration to be more forceful with insurers about the ACA guidelines and to take action against companies who continue to deny coverage. In January, they responded by issuing new guidance emphasizing the contraception mandates. Thirty-four other senators signed on to a February 16 letter pressing for updated guidance and enforcement.

“We made it very clear when the ACA was passed that insurers had to cover birth control,” Murray told HealthyWomen. “The denials we’ve been hearing about are absolutely egregious, and these companies are getting away with that. There has to be some accountability and strict enforcement. They need to know they’re being watched.”

Murray said she’d received reports from women who heard from insurers that they had to try — and fail — other methods of birth control before having their original choice approved. In the most extreme case, one patient was told she had to try and “fail” five other contraceptive methods.

“Talk about messing with someone’s health care,” Murray said. “To tell a woman she needs to try five forms of birth control and have them all fail before approving the method of her choice — that’s just nuts.”

The changing landscape of birth control coverage

Dr. Raegan McDonald-Mosley, an OB-GYN with decades of national and international experience in reproductive health, serves as CEO of Power to Decide, an organization working to help young people prevent unintended pregnancies. She said the ACA has helped providers deliver the best possible care for patients by allowing them to choose the right contraceptive method for them based on what’s safe and best fits their lifestyle.

She’s concerned about those possibilities being taken away because of outside factors. One common complaint is that insurers have been less likely to approve newer birth control methods, like the one-year ring, or non-hormonal birth control methods like a gel that’s inserted into the vagina before sex.

“If somebody finds what works for them — it helps with their acne, prevents migraine [attacks] or mood disorders associated with their cycle — however it’s helping them prevent pregnancy or with their health issues, they should be able to stay on it,” McDonald-Mosley said. “They shouldn’t have to make decisions to go off that method or try something else or be told they can’t start something because of barriers at the level of the insurance coverage.”

Mara Gandal-Powers, director of birth control access and senior counsel for reproductive rights and health at the National Women’s Law Center, said that while most people have been able to get their birth control covered without out-of-pocket costs thanks to the ACA, women have reported being charged for follow-up visits that are required following an IUD insertion or when seeing a HCP for side effects related to their current method. Those, in addition to coverage denials for new methods, create an undue burden for many women.

“When plans aren’t covering these new methods, there’s a real equity issue,” Gandal-Powers said. “The people who don’t have access to the new technologies and will be forced to rely on the old technologies are the ones that face the greatest barriers to care.”

The center has a hotline women can call and an email address women can contact for advice, along with an online database of information on birth control coverage. Instructions and sample letters are also available to appeal an insurer’s denial. Women are encouraged to share the outcomes with the center so it can track trends and better advocate with insurance plans and government officials.

As a busy doctor working to establish her new practice, Whitney said she hasn’t had time to appeal her insurer’s decision. She initially found a workaround by securing the one-year ring from an online source, where she was able to use her insurance to obtain it for free, but she was unable to get a second year approved when she changed insurance plans.

In the meantime, she’s settled on a daily hormonal pill that her insurance will cover as she plans her appeal. She’s also fighting back by sharing her story with organizations advocating for greater enforcement of the contraceptive mandate.

“It’s important for women to be able to make these decisions about our health without interference,” Whitney said.

*Last name withheld by request

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