Susan Kreimer

Susan Kreimer is passionate about good health—a person's most precious asset. Without it, she believes little else matters. She has spent most of her 20-year career as a journalist reporting on healthcare and informing consumers, physicians, hospital executives, and other stakeholders about issues that resonate with them. Her articles have appeared in many major newspapers, magazines, and trade publications. She has written on an array of topics that delved into numerous clinical aspects of medicine and the costs of delivering quality care. Raised in the Chicago area, Susan earned a master's degree in journalism from Columbia University and now lives in New York City.

The Affordable Care Act (ACA) has provided coverage for more than 55 million women for preventive services without any cost sharing for contraceptive services and supplies. However, despite the expanded coverage, millions of women still face barriers as they try to access their new benefits. (Read 

Promoting greater awareness among providers and the public would be a step toward ensuring that all women enrolled in private plans have a chance to benefit from the contraceptive coverage guarantee.

For instance, some providers may not realize how to properly code all visits related to contraception as a preventive service so that patients aren’t charged, noted a Kaiser Family Foundation study on contraceptive coverage.

Health insurance carriers may also introduce further restrictions. Plans are allowed to impose “reasonable medical management techniques,” such as step therapy, prior authorization, and quantity limits. They may cover a generic drug without cost sharing while requiring cost sharing for equivalent branded drugs. However, a plan must accommodate any individual for whom a particular drug (generic or brand name) would be medically inappropriate, as determined by that patient’s healthcare provider.

“We were seeing plans using those medical management techniques to undercut ‘the all-means-all,’” said Susan Berke Fogel, JD, director of reproductive health at the National Health Law Program in Los Angeles, which advocates for the rights of low-income and underserved individuals and families on federal and state levels. “For example, plans were lumping oral contraceptive pills, vaginal rings and patches into one category, therefore only covering pills.”

As a result, in May 2015, HHS released additional guidance clarifying plans’ responsibilities, requiring coverage of at least 1 product in each of 18 FDA-approved contraceptive method categories: sterilization surgery; surgical sterilization implant; implantable rod; copper intrauterine device; intrauterine devices (IUDs) with progestin; shot/injection; oral contraceptives with estrogen and progestin; oral contraceptives with progestin only; oral contraceptives that delay menstruation; the patch; vaginal contraceptive ring; diaphragm; sponge; cervical cap; female condom; spermicide; emergency contraception known as Plan B or the morning-after pill; and a different emergency contraception pill called Ella.

But further clarity is still needed. For instance, of the 4 IUDs on the market, the copper device falls under 1 of the 18 categories, while the other 3 IUDs are in a different category. Those 3 devices use varying amounts of progestin, but because they are in the same category, an insurance plan has the option to cover only 1 of them.

Uncertainty also remains among providers and insurers about cases in which women take contraceptives for medical reasons, such as the treatment of abnormal uterine bleeding.

The federal guidelines do not directly address these circumstances.

At the same time, some of the barriers to access fall outside the law’s purview—including variations in individual health providers’ approaches to contraception.

“Women seeking some forms of contraception face additional challenges that are not related to the ACA contraceptive coverage guarantee,” said Mary C. Politi, PhD, an associate professor in the Division of Public Health Sciences at Washington University School of Medicine in St. Louis. “For example, some individual practices have policies prohibiting same-day insertion of IUDs, which can create barriers for women choosing this method.”

In addition, the contraceptive guarantee does not include male contraceptive methods.

“One thing that still needs to be fixed is recognizing the role of men in preventing pregnancy,” said Fogel. “The contraceptive coverage rule only applies to women.”

Articles

For millions, the Affordable Care Act promised relief from the expenses of contraception. So why are many still not feeling it?

Barriers to ACA's Contraception Mandate Remain: Part III

The Affordable Care Act (ACA) has provided coverage for more than 55 million women for preventive services without any cost sharing for contraceptive services and supplies. However, despite the expanded coverage, millions of women still face barriers as they try to access their new benefits. (

Despite the ACA’s focus on making many forms of contraceptive coverage available without any cost sharing under most health plans, important administrative and legal barriers remain.

The contraceptive guarantee doesn’t, for instance, cover emergency contraception obtained without a prescription, and it excludes male contraceptive methods, such as vasectomy and condoms.

Plans also can make ACA-mandated contraception harder to access by requiring some services to be obtained from in-network providers, or by imposing higher copays and deductibles for out-of-network services.

Grandfathered plans are exempt from the certain contraceptive coverage requirements (until the plan changes significantly enough to no longer be considered grandfathered). To be grandfathered, a group plan must have existed — or an individual plan must have been sold – before President Obama signed the ACA on March 23, 2010.

Although, it is projected that nearly all grandfathered plans will eventually lose that status, in 2015, 35% of companies offering health benefits offered at least one grandfathered plan—and 25% of covered workers were enrolled in grandfathered plans, according to the Kaiser Family Foundation.

In addition, some religious employers’ health plans may also be partially or wholly exempt from the contraceptive coverage after suing to be exempt from the mandate. In 2014, the Supreme Court ruled that some closely held corporations had a right to an exemption from the mandate. After that decision, the Obama administration announced a workaround “to make sure all women continue to have access to all methods of birth control with no cost sharing, no matter where they work, while respecting others’ religious beliefs.”

To avoid some of these pitfalls, consumers will need to do a little legwork, starting with confirming that their contraceptive of choice is covered on a prospective insurance policy. They also should seek contraceptive counseling from a clinician in their plan’s network, said Mary C. Politi, PhD, an associate professor in the Division of Public Health Sciences at Washington University School of Medicine in St. Louis.

“Contraceptive counseling can ensure that individuals select a method that works for them and matches their personal preferences,” said Politi, who authored a contraceptive opinion piece published in the February 16, 2016, issue of 

“Clinicians and patients should work together to address some of the implementation challenges related to billing and covered contraceptive methods,” she added. “They can talk about methods that are covered by one’s plan, talk about less expensive alternatives if some methods are not covered, and communicate openly about whether any out-of-pocket costs will fall on patients.”

Barriers to ACA's Contraception Mandate Remain: Part II

For millions of women, the contraceptive coverage guarantee under the Affordable Care Act (ACA) has already had profoundly positive effects. A 2015 report by HHS estimated that more than 55 million women now have preventive services coverage without any cost sharing for contraceptive services and supplies.

But even with the promise of expanded contraceptive coverage, millions of American women are facing daunting barriers as they attempt to access those benefits.

Obamacare’s impact on access to contraceptives

The impressive gains cited in that HHS report have occurred largely since female contraception was added to a list of preventive services covered by the ACA in 2011. The federal mandate applies to all new health insurance plans with plan years beginning on or after Aug. 1, 2012.

Since then, private insurers have been required to pay for birth control methods approved by the FDA, sterilization procedures for women, and patient education without out-of-pocket costs. These benefits must cover the clinical visit and services, follow-up care and management of side effects, counseling for continued compliance, and device insertion and removal at an in-network provider.

The contraceptive mandate’s impact on public health has been huge.

“The ACA is insistent that we include contraception coverage as regular health care,” said Georges Benjamin, MD, executive director of the American Public Health Association. “It expands the access significantly and normalizes it as part of regular medical care.”

During their medical appointments, patients have the opportunity to discuss the full range of contraceptive choices. “It’s not just about pills,” Benjamin added. “It’s about sexual health. It’s about reproductive health and various options. It allows that discussion to occur in a trusted environment.”

ACA’s relief from expense of contraception

For decades, the overall cost—including deductibles and co-payments&mdash;had posed significant barriers for women to access their preferred contraceptive methods, said Susan Berke Fogel, JD, director of reproductive health at the National Health Law Program in Los Angeles. (NHeLP advocates for the rights of low-income and underserved individuals and families on federal and state levels.) Many of those barriers have been lifted&mdash;to a large degree&mdash;through the implementation of the law’s contraception mandate.

“When women have the contraceptive that works best for them and their lifestyle, they’re more likely to use it consistently,” Fogel said. And consistent usage reduces unintended pregnancies.

Empowerment to control their own reproductive lives also contributes greatly to the economic prosperity of women and families. Having a child has implications for a woman’s financial well-being, job security, workforce participation, and education, according to the National Women’s Law Center. “Access to reproductive health care helps to ensure that women and families make that decision for themselves, when they are ready,” the organization has posted on its website.

Without insurance coverage, those health care services can be costly. The average cost of a year’s worth of birth control pills amounts to approximately $370—or about 51 hours of work for a woman earning the federal minimum wage of $7.25. An intrauterine device “can cost a month’s salary for a woman working full time at minimum wage,” according to the Guttmacher Institute, a research and policy organization focused on advancing sexual and reproductive health and rights.