Birth Control Coverage For Women
Updated February 2014
Note: This information was developed to provide consumers with general information and guidance about insurance coverages and laws. It is not intended to provide a formal, definitive description or interpretation of Department policy. For specific Department policy on any issue, regulated entities (insurance industry) and interested parties should contact the Department.
The Federal ACA does not apply to Excepted Benefits as defined 42 U.S.C. 300gg-91.
Excepted Benefits include but are not limited to:
- Short-term limited duration insurance;
- Accident or disability income insurance;
- Liability insurance, including general liability and auto liability and auto medical payment;
- Worker’s compensation or similar insurance;
- Credit only insurance;
- Coverage for on-site medical clinics;
- Long-term care, nursing home care, home health care and community based care;
- Medicare supplements;
- Specified disease or illness;
- Limited dental and vision;
- Hospital indemnity or other fixed indemnity insurance
Note: Student health plans are impacted by the Federal ACA with respect to the requirement for birth control coverage for women as discussed in this fact sheet.
Federal Law – ACA
Section 2713 of the Federal Affordable Care Act (ACA) requires group plans (including self-insured plans and employers) and individual health insurance plans and policies to provide coverage of preventive health services without cost-sharing (subject to reasonable medical management technique) when they are delivered by a network provider. These preventive health services include all FDA approved contraceptive methods and patient education and counseling, as prescribed by a provider, for all women with reproductive capacity.
These provisions apply to non-grandfathered group and individual insurance coverage without cost-sharing, in plan years (or, in the individual market, policy years) beginning on or after August 1, 2012. This provision of the ACA does not apply to “grandfathered” plans. A “grandfathered” plan is a plan that existed on March 23, 2010.
Women have access the full range of the Food and Drug Administration (FDA) approved contraceptive methods including but not limited to Barrier Methods, Hormonal Methods and implanted devices, as well as patient education and counseling, as prescribed by a health care provider.
Additional information on the methods can be found at: http://www.fda.gov/ForConsumers/ByAudience/ForWomen/FreePublications/ucm313215.htm
Each method contains different types of drugs and/or biologics. For example, within the “Hormonal Method” the FDA lists the following drugs/biologics: (1) oral contraceptives; (2) patch; (3) vaginal contraceptive ring and (4) shot/injection. The Health Resources Services Administration (HRSA) guidelines require coverage for a variety of contraceptives within each method. The law does not require coverage of every FDA-approved contraceptive with no cost-sharing.
For instance, plans and issuers may cover a generic drug without cost-sharing and impose cost-sharing for equivalent branded drugs. A plan or issuer must accommodate any individual for whom the generic drug (or a brand name drug) would be medically inappropriate as determined by the individual’s health care provider by having a mechanism for waiving the otherwise applicable cost-sharing for the branded or non-preferred brand version.
Exemptions for Religious Organizations
There are special rules for religious employers including churches, other houses of worship and similar organizations to become exempt under federal law from covering contraceptive benefits. The religious organization is required to self-certify that their organization:
- Opposes providing coverage for some or all of the contraceptive services required to be covered on account of religious objections;
- Is organized and operates as a non-profit entity;
- Holds itself out as a religious organization.
The self-certification must be provided to all group health insurance issuers and/or third party administrators (TPA) with which it is contracted. Upon acceptance by the group health insurance issuer or TPA, the issuer or TPA will become the plan administrator and claims administrator for contraceptive benefits.
For the self-certification form for eligible organizations visit:
Frequently Asked Questions About the Federal Law
Following are frequently asked questions regarding the Federal law and birth control mandates.
Q1) My qualified health plan (QHP) has a $250.00 deductible for office visits and procedures performed in the office. Does this deductible apply to my office visit to consult my physician about birth control? Does it apply to the office procedures such as an insertion of an intrauterine device (IUD)?
A1) If an item or service is billed separately (or is tracked as an individual encounter separately) from an office visit and the primary purpose of the office visit is not the delivery of such item or service, then a plan or issuer may impose cost sharing requirements with respect to the office visit. For example, if you visit your physician for the treatment of an illness such as a urinary tract infection, and birth control is prescribed during that visit, the office visit would be subject to the deductible (however, the actual birth control would be provided at no cost sharing). If you visit your physician for an annual well woman exam and birth control guidance, the office visit would be paid with no cost sharing to you.
Q2) Are condoms covered under the law?
A2) No. Contraceptive methods that are generally available over the counter are only included if the method is both FDA approved and prescribed for a woman by her health care provider. Federal law does not require contraception for men. (See 78FR 8456, 8458, footnote 3 which provides that HRSA guidelines “exclude services relating to a man’s reproductive capacity, such as vasectomies and condoms.”)
Q3) Will I have to pay anything for my birth control under my insurance coverage?
A3) There are brands and methods of birth control which will be covered without co-pays. Insurance companies are allowed to limit drugs and devices to some generic options which will not require a co-payment. Other birth control options such as brand name drugs may have copayments which will be required to be paid.
Effective January 1, 2004 Illinois law, 215 ILCS 5/356z.4 required all individual and group insurance and health maintenance organizations (HMO) policies that provide coverage for outpatient services and outpatient prescription drugs or devices, must also provide coverage for all outpatient contraceptive drugs or devices approved by the FDA. Deductibles and coinsurance under that law are the same as those imposed for any other outpatient drug or device under the policy.
The federal ACA pre-empts the Illinois law. Therefore, the Illinois law applies to:
- fully insured grand-fathered health plans which are plans which were in effect on March 23, 2010;
- fully insured transitional plans which are plans that were in effect on October 1, 2013 and renewed for policy years starting between January 1, 2014 and October 1, 2014;
- fully insured Marketplace health plans in instances when a contraceptive method is approved by the FDA but not part of the formulary of the issuer.
Pursuant to 215 ILCS 5/356z.16, the state law does not apply to:
- Short-term insurance;
- Travel insurance;
- Long-term care insurance;
- Accident only insurance;
- Limited or specified disease insurance;
- Blanket policies.
Following are frequently asked questions regarding the state law. These questions apply to fully insured Illinois policies which are grand-fathered plans.
Q1) My plan has a $35.00 copayment for prescription drugs. My birth control pills cost $32.00 so my plan does not pay anything. Is that acceptable under the law?
A1) Yes. The law requires the plan to pay for birth control at the same benefit level as similar services under the policy. If your prescription drug copayment is $35.00, then the copayment applies to the birth control pills.
Q2) My major medical policy has a $250.00 deductible for office visits and procedures performed in the office. Does this deductible apply to my office visit to consult my physician about birth control? Does it apply to office procedures such as insertion of an IUD (Intrauterine Device)?
A2) Yes. The deductible that applies to office visits and procedures also applies when those services are necessary for purposes of birth control.
Q3) Do contraceptive drugs only need to be covered if the insurance policy covers both outpatient services and outpatient prescription drugs?
A3) The Illinois law only applies to insurance plans that provide coverage for both types of services in order for birth control to be covered.
Q4) Will I have to pay anything for my birth control under my insurance coverage?
A4) There are brands and methods of birth control which will be covered without co-payment. Insurance companies are allowed to limit drugs and devices to some generic options which will not require a copayment. Other birth control options such as brand name drugs may have copayments which will be required to be paid.
For More Information
Call our Office of Consumer Health Insurance toll free at (877) 527-9431
or visit us on our website at http://insurance.illinois.gov
215 ILCS 5/356z.4 can be found at Illinois Compiled Statutes 215, Article XX, Accident and Health Insurance (scroll to approximately 1/3 of the way down the page or use find and search for "356z.4"), or by clicking on 215 ILCS 5/356z.4.
Information regarding the Affordable Care Act can be found at http://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Prevention.html.