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May Our Plan Impose Cost-Sharing on FDA-Approved Contraceptives?

03.19.2018
Question: Our company sponsors a nongrandfathered self-insured group health plan, and we’re subject to the Affordable Care Act’s (ACA’s) preventive services mandate. Can our plan impose cost-sharing on some methods of contraception for women if we provide first-dollar coverage for other methods?

Answer: Your plan must provide women access to the full range of contraceptive methods identified by the Food and Drug Administration (FDA), as prescribed by a health care provider.

Under the ACA, nongrandfathered health plans need to provide coverage for certain preventive services without cost-sharing when delivered by in-network providers. Preventive services for women include coverage for a broad array of items and services, including contraceptives.

Exemptions and accommodations are provided for certain religious employers and others with sincerely held religious beliefs or sincerely held moral convictions if they meet specified requirements. (There have been ongoing court challenges to the scope and nature of the exemptions and accommodations.)

Covered methods

For plans subject to the contraceptive coverage mandate, the full range of FDA-approved contraceptive methods includes, but isn’t limited to:

  • Several different barrier methods (for example, diaphragms and sponges),
  • Hormonal methods (for instance, oral contraceptives and contraceptive patches), and
  • Implanted device methods (for example, intrauterine devices).

Any method must be prescribed by a health care provider.

At least one

Employers need to provide coverage without cost-sharing for at least one form of contraception within each method identified by the FDA. For example, because the FDA identifies diaphragms and sponges as separate methods, at least one contraceptive product within each method must be covered without cost-sharing.

Note that, if multiple services and FDA-approved items within a contraceptive method are medically appropriate for an individual, the plan is permitted to use reasonable medical management techniques to determine which specific products to cover without cost-sharing with respect to that individual. But if the individual’s attending provider recommends a service or FDA-approved item based on a determination of medical necessity, the plan must cover that service or item without cost-sharing.

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