You don’t want babies right now. Or any more babies than you currently have. Or any babies ever. Whatever your exact situation, getting the right birth control is critical.
“We know when women are using the method that’s not the best match for them, they’re less likely to use it correctly or consistently,” says Mara Gandal-Powers, director of birth control access and senior counsel for the National Women’s Law Center. Incorrect or inconsistent use can lead to an unintended pregnancy, and nearly half of all pregnancies in the US are unintended. The average American woman who has two kids will still spend about three decades trying to avoid unintended pregnancy, says the Guttmacher Institute.
The Affordable Care Act (ACA) has been a game-changer when it comes to women’s ability to control if and when they get pregnant. The law required most plans to cover birth control with no out-of-pocket costs and also led to millions more people getting health coverage. In 2013, 12.5 million reproductive-age women didn’t have insurance; and thanks to Medicaid expansion and gains in private insurance, that number fell to 7.4 million in 2016, according to data from the Guttmacher Institute.
I have insurance. What family planning services are covered?
Again, birth control is covered at no cost, but we’ll get to that in a minute. Whether you’re covered under Medicaid, a plan you bought on the ACA Marketplace, or insurance you get through an employer or school, here is what’s covered with no out-of-pocket costs (that is, without a copay, coinsurance, or deductible). If you wrongly get charged for any of these things, you can push back on your insurance company—more on how to do that below.
An annual well-woman exam
Even if you don’t need a Pap smear or HPV test this year, you should still go in for this exam. This is essentially a physical, though it needs to be billed as a “well-woman visit” to be fully covered. There, you’ll chat about your medical and family health history, sexual health concerns, lifestyle habits, mental health, and relationship safety. You’ll also receive a pelvic exam (if you’re over 21), and you may get a breast exam as well. Any immunizations and other screenings will also be given depending on your health needs. Cervical cancer screening through a Pap smear is recommended for women every 3 years starting at age 21. The HPV test can be done along with a Pap every five years starting at age 30.
As part of preventive care benefits for women, All Marketplace plans are required to cover certain STD screenings for people at a higher risk without a copay or coinsurance when you see an in-network doctor. (This applies to many insurance plans as well. Ask yours what they cover.) The covered tests include HIV tests for all sexually active women, chlamydia and gonorrhea screenings for all sexually active women younger than 25, or women over 25 who who have new or multiple sex partners, or a sex partner who has an STD, or people who use condoms inconsistently in relationships that aren’t mutually monogamous. Insurance plans also have to cover syphilis tests for women with HIV and women who are pregnant. If you’re not in any of these groups and you want an STD test, ask your doctor if your insurance will cover it. (For information about coverage of tests for men, see here.)
One in four people have HPV (human papillomavirus), a virus that can cause cancer in both men and women. The ACA requires most private insurance plans to cover vaccination at no cost for people ages 9 through 26 (both men and women), though following FDA approval for people ages 27 to 45, insurance plans might start covering the vaccine for this group as well. Preteens and teens ages 9 through 14 need two doses, while those ages 15 to 26 need three doses. If you received Medicaid through the ACA expansion, the HPV vaccine is covered; otherwise, Medicaid coverage of the vaccine is state-dependent, though most states offer coverage for women, according to the Kaiser Family Foundation.
This is one of the reasons why the ACA is so critical for women’s health when it comes to their reproductive decisions. “There are 62.4 million women who are eligible for birth control without out-of-pocket costs thanks to the ACA. That’s huge,” Gandal-Powers says. “For the vast majority of people who have birth control coverage due to the ACA, they’re experiencing good coverage.” But that’s not always true across the board, and “when it doesn’t work, it’s extremely frustrating,” she says.
There are some common loopholes and roadblocks you may need to clear to get free birth control. We’ve all heard stories of friends whose insurance wouldn’t cover such-and-such brand name or who were charged for an IUD when they shouldn’t have been. Keep reading to fully equip yourself with what you need to know.
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Which birth control methods does insurance cover?
The ACA requires that 18 methods of contraception for women (the 20 types listed here minus vasectomies and male condoms) are covered for free, without co-pay or co-insurance, when prescribed by a doctor in your insurance network. This includes pills, patches, rings, diaphragms, sponges, the implant, intrauterine devices (IUDs) with and without hormones, emergency contraception (e.g. Plan B), and female sterilization. (Note: The sterilization implant is on the FDA’s list but the only one sold in the US, Essure, will be taken off the market by 2019 following lawsuits.)
This birth control benefit applies to most private health insurance plans, as well as plans people buy themselves. We say “most” plans because a small number of employer plans remain grandfathered under the ACA, so they don’t have to comply with this benefit, and if your employer is religiously affiliated, there are other exemptions (more on that below).
The office visit to get the prescription and counseling on the right method for you are also fully covered—and it’s important that you take advantage of this benefit, since, as mentioned above, women who have the birth control that best suits them are more likely to use it and use it correctly, Gandal-Powers says. The ACA’s contraceptive coverage provision allows you to pick which method works best for you without having to worry how much it will cost. So, for instance, if you know you’re not consistent at taking the pill, maybe you’ll opt for a long-acting device that might have been too expensive for you before the ACA required it to be covered. (Power to Decide also offers a Bedsider tool that explains your range of contraceptive choices and helps you compare multiple methods.)
However, as the Guttmacher Institute points out, there are certain loopholes that can saddle you with an unexpected bill, writing that “under the guarantee, health plans may apply formularies, prior authorization requirements, and similar restrictions within a method category.” This may be to influence patient choice, which isn’t very helpful since drugs within the same category—like birth control pills, for example—can cause different side effects or may not be right for every woman.
Some states may have even more generous coverage than what the ACA offers, like covering a full year’s supply of contraception at once or even vasectomies. Check out Guttmacher’s chart to see what your state specifically covers.
What religious exemptions do I need to know about?
If your employer is a religious institution like a church, they don’t have to cover contraception and you may have to pay out of pocket. If you work for a non-profit religious hospital, university, or other organization, they also don’t have to pay for contraception—but the insurance company does so you can still get it at no cost anyway. The insurance company is supposed to step in and arrange birth control coverage on your plan, Gandal-Powers says. (If not, check out the section below on what to do if you get charged.)
Now, let’s talk about something that happened in October 2017. A mandate from the Trump administration expanded employer’s rights to deny insurance coverage for birth control for any ethical, religious, or moral objection, and it extends to for-profit companies. “This would have basically driven a Mack truck through the contraceptive accommodations,” says Gandal-Powers. However, she notes that these rules are currently stalled by two nationwide injunctions in the circuit courts. Right now, they are not in effect—a very good thing for your health.
I don’t trust my insurance company. Can I just ask my doctor if it’s covered?
Yup. It’s easy to assume that they’re there for your physical care, but they can also help with insurance concerns. So, don’t be afraid to ask them if the prescription is covered under your plan. “If I don’t know the answer, I know someone in my office does. At every office there is usually a point person to talk to about insurance issues and logistics,” says Kristyn Brandi, an OB/GYN in New Jersey and board member with Physicians for Reproductive Health.
I think I want an IUD or implant. Anything else I should know about getting one of those?
Yes, glad you asked. Some clinics and doctor’s offices carry these super-effective, long-acting methods—which last between three and ten years—and some don’t, Brandi says. If yours doesn’t, the office will have to order it and you’ll need to come back to get it inserted. If you think you may be interested in an IUD or implant, ask the doctor’s office while making your appointment if they stock those.
For these more expensive devices or sterilization procedures, it’s always a good idea to call your insurer to ask if the specific one you’re getting is covered. Ask the administrative team in the office for the insurance codes (for the counseling, the device itself, and the insertion procedure) and call your insurance company to double check your coverage. You have a right to your Summary of Benefits, which outlines these details. This small amount of work on your part can save you from a surprise bill.
While we’re talking about these devices, you should ask yourself if you want to get pregnant within the next year or so—and share this info with your OB/GYN so they can help counsel you on what method is best. If you do want to get pregnant in the near future, then a hormonal or barrier method (like the pill or diaphragm) may be best for you. An IUD or implant can still work in this case, but be prepared that there’s legwork to get the device put in and taken out, and you have to decide if that’s worth it for you, Brandi says. (She, however, does not recommend the birth control shot, brand name Depo-Provera, if you’re planning on getting pregnant soon. “Studies show that it can take up to a year to return to fertility after the shot,” she says.)
Ugh, my insurance sent me a bill. What now?
You thought that the Rx your doctor gave you would naturally be covered. But now you went to the pharmacy and they asked you to pay up. Or you got an IUD and then were sent a bill for it in full. Don’t stand for it. “If you’re new to insurance coverage, it can be daunting to take on your insurance company, or you might not know you can. But it’s worth it,” says Gandal-Powers.
Because of the ACA, you should be able to get the method of birth control the doctor prescribed. If it’s a brand name, insurance plans have a process in place to get you this prescription (versus them trying to stick you on a generic). While it should be covered, “we know this doesn’t always work perfectly with insurance companies,” Gandal-Powers says. In that event, the National Women’s Law Center has their free CoverHer hotline (phone or email). The site also outlines what your rights are and includes templates of appeal letters to send to your insurance.
The good news is that since the NWLC published a report in 2015 detailing problems with insurance companies not complying with the ACA (like only covering the pill or the ring, not both, since both are hormonal options), additional guidelines circulated at the end of the Obama administration that made insurance companies more accommodating, Gandal-Powers explains.
What if I want my tubes tied?
The official name for this is a tubal ligation, a surgical female sterilization procedure where the two fallopian tubes are blocked or cut so sperm can’t reach an egg. The surgery is fully covered by insurance thanks to the ACA. While it can be reversed in some instances with another surgery, a tubal ligation is usually permanent. For that reason, some women report that their doctors sometimes won’t do the procedure, warning them that they may change their mind.
“It personally makes me very angry when I hear those stories,” Brandi says. “If a woman decided she doesn’t want children or more children, that’s it. End of conversation—regardless of her age or partner status.” Of course, your doctor may give their medical opinion on your specific case. If your doctor is pushing back based on their views on your family wants (rather than if, say, it wouldn’t be medically safe for you), seek a second opinion.
If you’re unsure if it’s right for you, you can reach out to the office of a doctor who does tubal ligations of people your age and ask if you can talk to a similar patient, Brandi suggests. It can be a little tough to coordinate, but sometimes they will refer to another patient so you can understand the procedure in a new way.
All this is nice, but I don’t have health insurance. How can I get low-cost birth control?
If you don’t have insurance, the difficult reality is that you have to be your own advocate, says Jennifer Johnsen, senior director of digital programs and education at Power to Decide, a non-profit that works to prevent unplanned pregnancy. This can be tough depending on your job, access to transportation, and availability of health clinics that provide contraceptive services at low or no cost.
Power to Decide’s Bedsider database can help you find a health center near you to get birth control, and they also have a tool to help you determine if you qualify for free contraception. According to Planned Parenthood, you may be able to get it for free if you qualify for Medicaid or state programs even if you’re not enrolled in them. Both Planned Parenthood health centers and health clinics that get federal family planning funds known as Title X grants will provide low- or no-cost birth control, cancer screenings, and STD tests depending on your income. You can search for Planned Parenthood health centers here and search for Title X health centers here. You can also search “sliding scale birth control” and your city name. (If you just need STD testing, you can search this database from the Centers for Disease Control and Prevention and select “show only free or low cost providers.”)
Before you go, know that it may not be as simple as going in for an appointment and walking out with birth control. Some health centers will dispense prescriptions on site, while others require you to make a separate trip to a pharmacy to fill it. And if it’s a long-acting method like the shot, implant, or IUD, you may have to go back to the center to get it administered or implanted.
This large amount of commitment can be a deterrent to going, but knowing what you’re in for first can help you make arrangements for transportation and time off. If you have children but are hesitant to go because you don’t have childcare available, some of these centers have accommodations that you can bring your kids.
From there, you can call the clinic and ask about their birth control options and how they can help you get the method you want without health insurance. (They may say they can’t, and you’ll have to look at another center.) Johnsen also notes that a telemedicine provider, who prescribes birth control through an app or online video consultation, can be a more accessible way for some people to get birth control. Some will require a flat fee of as low as $15 a month without insurance (and many do take insurance).
The Affordable Care Act has done a lot of good but, yes, there are still many people without insurance. These 7.4 million women of reproductive age without insurance fall into a “coverage gap,” Johnsen says.
“[Many of] these women do not have children, they have incomes below 138 percent of the poverty line, and they live in one of the 17 states that have not yet expanded Medicaid,” she says. Johnsen adds that 11 of these states have Medicaid Family Planning Waivers, which allow women with low incomes to qualify specifically for family planning coverage, rather than full health insurance. Check to see if your state lets women get Medicaid coverage for birth control.
Additional coverage gaps include legal immigrants (some green-card holders have to wait 5 years before enrolling in Medicaid) and undocumented people. Then, there’s geographical concerns. So-called “contraceptive deserts” leave 19 million women without access to health clinics that provide the full range of FDA-approved birth control methods.
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