Some insurance plans still aren’t complying with the Affordable Care Act.
You probably know that birth control is free without a co-pay under the Affordable Care Act (ACA).
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And if you didn’t…surprise! Now you know. The ACA went into effect back in August 2012, and one of the benefits is that all FDA-approved birth control methods are covered without a co-pay as long as you have insurance. This applies to you if you get your plan through the Health Insurance Marketplace or if you get your plan through your employer. This should also apply to anyone on Medicaid, but full coverage may vary from state to state. The only exceptions to the rule are religious exemptions and grandfathered plans (ones that haven’t been updated in a while) — but more on those later.
For most people, this benefit didn’t kick in immediately — you may have had to wait until you renewed your plan or until your company changed their plan. But by now, the majority of people should be receiving this benefit, Mara Gandal-Powers, senior counsel in health and reproductive rights for National Women’s Law Center (NWLC), tells BuzzFeed Life.
And it’s not just free birth control — this benefit also covers the doctor’s appointments to get birth control, any insertion or removal costs for long-acting methods, and any counseling or follow-up visits relating to your birth control. So if the sole reason for your doctor’s office visit is birth control-related, you shouldn’t be charged a co-pay for that visit, says Gandal-Powers.
But some people are still getting charged for their birth control when they should be getting it for free.
A new report from NWLC found that some plans are still not complying with the ACA. They run a website and hotline called CoverHer, which assists women who are having trouble getting their birth control coverage. Since August 2012, nearly 2,800 people have contacted them for help. For this review, they went over all those interactions, plus documents from 100 insurance plans in 15 states.
Here’s what they found: Some plans aren’t covering all FDA-approved methods or they’re charging co-pays for them, some plans are only covering generic birth control, and some plans aren’t covering doctor’s visits or counseling associated with birth control. Under the Affordable Care Act, that’s illegal.
1. Find out if you’re on a grandfathered plan.
This means that your insurance plan hasn’t gone through any major updates or changes since the ACA went into effect. To find out, call up your insurance and ask, “Am I on a grandfathered plan?” They’ll know what that means. Grandfathered plans are not required to cover birth control without a co-pay, but they might still cover some methods for free.
Even if you JUST signed on to a new plan (like if you changed jobs or enrolled in a new plan recently), it’s still possible that you’re in a grandfathered plan. That’s because grandfathered plans can still enroll new people. They only become “un-grandfathered” if they change in a way that substantially cuts benefits or increases costs for consumers, according to Healthcare.gov. With each year, there are a fewer and fewer grandfathered plans, but it’s still possible that you might have one.
How To Get Birth Control For Free: Some grandfathered plans actually do offer some birth control methods at no cost, so call your insurance company to see what options are available, says Gandal-Powers. Then find out when your next open enrollment is, since that’s when most grandfathered plans will change.
2. Find out if your plan has a religious exemption.
If your insurance plan comes from a house of worship; a religiously affiliated nonprofit organization or college; or a family-owned, closely held corporation with religious objections, they may not have to cover birth control without a co-pay due to a religious exemption.
How To Get Birth Control For Free: If you have one of these plans, you should be getting access to no-co-pay birth control through a third-party company. There is ongoing litigation regarding religious exemptions, and there are a small number of employers (mostly houses of worship) that are entirely exempt, says Gandal-Powers. If you haven’t been contacted by a third party yet, contact CoverHer for help.
3. Check if how you’re getting your birth control affects the cost.
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In some plans, birth control is only offered at no cost if you get it through an in-network pharmacy or healthcare provider, says Gandal-Powers. Your plan might also require that you use a mail-order prescription service in order to get it for free.
How To Get Birth Control For Free: Call your insurance company or the benefits department at your job to find out if this is case. If so, they can help direct you to in-network providers and pharmacies where you can get it for free, or they can help set you up with the mail-order prescription service.
4. STILL getting charged? Call up your insurance company and ask why your method isn’t covered without a co-pay — and if other methods are free.
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Plans are allowed to say that they’ll only cover the full cost of certain brands or generics, and then charge a co-pay or full price for other types that are essentially the same, says Gandal-Powers. For example, they can offer you one free generic version of a certain birth control pill, but then charge you a co-pay for Ortho Tri-Cyclen (the name brand) or any of the other generics. In some cases they may even offer a name brand like Yasmin for free, but then charge you for the generics. It’s up to the insurance plan to decide which ones they cover, but they do have to cover at least one type of each FDA-approved birth control method WITHOUT a co-pay.
How To Get Birth Control For Free: Call your insurance company and ask why you’re being charged for your birth control. If they tell you that they just don’t cover your method, ask which one they cover that is the most similar to the method you are on.
If it’s just a matter of switching between a generic or name brand in order to get your birth control for free, ask your doctor if there’s any reason why you shouldn’t switch to the free one. For the most part, generics and name brand meds are pretty much the same, but there is a possibility you could have an interaction or side effect to one that you wouldn’t get on the other, so always ask your doctor before agreeing to switch, says Gandal-Powers.
If you and your doctor decide that you should not switch to the free option and there is a medical reason why you need to be on the one that you’re prescribed, your insurance must provide a waiver for you to fill out so that you can get that birth control without a co-pay, according to the Centers for Medicare and Medicaid Services. You can ask your doctor or insurance company for this waiver, then have your doctor help you fill it out and submit it.
5. If your plan says they don’t cover certain methods — like the IUD, implant, or ring — fight it.
As we mentioned above, plans are allowed to charge you for certain methods ONLY IF there is a free generic option available that is medically appropriate for you. But there aren’t generic options for all methods (like IUDs and NuvaRing), and they have to cover at least one type of every FDA-approved contraceptive. So…this is not allowed. Unfortunately, this was actually a trend found in the NWLC report.
How To Get Birth Control For Free: If your plan says they don’t cover an FDA-approved method of birth control AND they don’t cover a generic alternative for it, you can try to fight it. The first step would be talking to someone at your insurance company. Depending on how that goes, you might need to file an appeal. You might also want to talk to someone in the benefits department at your job if you feel comfortable doing that. They’ll probably want to know that the insurance company they’re using is refusing coverage under the ACA.
– Be prepared when you call your insurance company. The number is on the back of your insurance card. Keep your card handy, since they’re going to ask for your plan number, your group number, and if you’re the primary policy holder.
– TAKE NOTES when talking to anyone at your insurance agency or in the benefits department. Like, really good notes, suggests Gandal-Powers. It’s rare that something like this will be resolved in one phone call (sorry), so those notes will be really helpful. – If you’re not getting anywhere, hang up and call back. Yes, you may have to wait on hold again, but you could also be connected to someone more helpful. They might confirm what you already heard or give you totally different information, which is frustrating, but will help you out in the end. If you’re still getting nowhere, ask to speak to a supervisor.
– Be patient and polite. This simple tip will get you farther than you realize, says Gandal-Powers. Customer service representatives will be more inclined to help you figure something out when you’re not snapping at them over the phone.
– If your insurance company isn’t complying with the ACA (and they should be), file an appeal. You can find instructions and even appeal letter templates at CoverHer. You can also check with your doctor or employer to see if they might be able to help you with your appeal or get it expedited in any way. Insurance companies are required to respond to appeals, but it may take a month or more, so be patient. If they reject your appeal, they’ll give you information on how to submit a second-level appeal. If that also gets rejected, you can file a complaint with the government agency that oversees that plan, says Gandal-Powers.
– Contact the CoverHer hotline at any point for one-on-one help. You can email or call them here.