Federal Government Leans In on Contraception Access

By Sarah Johanek, MPH

The Affordable Care Act (ACA) requires private health plans and issuers of health insurance to cover the full range of birth control methods approved by the Food and Drug Administration (FDA) without cost-sharing. Although the contraceptive requirements in the ACA have expanded access to contraceptive products for millions of Americans, public reporting shows that people are still experiencing barriers to accessing full-range, FDA-approved contraception without cost-sharing. The U.S. House of Representative’s Committee on Oversight and Reform investigated these barriers and issued a report on October 25th, 2022, titled Barriers to Birth Control: An Analysis of Contraceptive Coverage and Costs for Patients with Private Insurance. In support of reducing barriers to contraceptive care, the Biden-Harris Administration issued an Executive Order on June 23rd, 2023, on Strengthening Access to Affordable, High-Quality Contraception and Family Planning Services. This was the third Executive Order the Biden-Harris Administration issued on contraceptive access since the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization. 

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The U.S. House of Representative’s Committee on Oversight and Reform issued a report on October 25th, 2022, titled Barriers to Birth Control: An Analysis of Contraceptive Coverage and Costs for Patients with Private Insurance. The committee obtained information from five of the nation’s largest health insurers and four of the largest pharmacy benefit managers (PBMs) to assess how companies are providing access to birth control, cost-sharing requirements, and coverage exclusions. 

This investigation found the following: 

  • Health Insurers and PBMs have cost-sharing requirements or coverage exclusions for at least 34 different birth control products. Research shows that five of the largest insurers and four of the largest PBMs require cost-sharing for certain contraceptives or exclude them from coverage altogether. The report states that “although cost-sharing obligations vary by plan and by product, the companies surveyed reported monthly cost-sharing obligations of up to $178 per month for certain non-pill contraceptives like the Twirla patch, and approximately $218 per month for certain birth control pills.” 
  • Insurers and PBMs disproportionately require cost-sharing or have coverage exclusions for newer FDA- approved contraceptive products. The investigation found that half of the contraceptive products approved by the FDA after 2011 are subject to cost-sharing or excluded from coverage. The research also indicates that patients faced with cost-sharing for a contraceptive product are less likely to access and utilize the product. Additionally, lengthy exception processes have been shown to reduce the patient’s ability to use their preferred form of contraception.
  • Contraceptive products used by patients with health care needs or disproportionately used by people with lower incomes are subject to cost-sharing or exclusions. Increasing barriers to specific products, implementing cost-sharing requirements and exclusions diminishes efforts to provide equitable access to contraception. Research shows that people with incomes below the federal poverty line use implants at higher rates. Because many non-pill methods of contraception require cost-sharing or are excluded from coverage altogether, this creates a massive barrier to access.
  • The process to seek exceptions to cost-sharing and coverage restrictions are inefficient and can be burdensome for patients and providers. The investigation found that health insurers and PBMs deny at least 40% of exception requests and that the exception reviewal process under some plans is extensive. Under guidance issued by the Department of Health and Human Services, Department of Labor, and Department of the Treasury (known as the Tri-Departments), contraceptive exception processes must be “expedient.” While most companies have a process that takes 24 to 72 hours, UnitedHealthcare has a 15-day review period for requested exceptions. This prolonged waiting period can increase the likelihood of an unintended pregnancy and health impacts. Additionally, the Committee found that health insurers and PBMs require documentation that patients have tried other forms of contraception before waiving out-of-pocket costs. In July 2022, the Tri-Departments issued guidance stating that “requiring individuals to fail first using numerous other services or FDA-approved, cleared, or granted contraceptive products before approving coverage for a product determined by the patient’s health care provider to be medically appropriate is considered unreasonable medical management.” Lastly, Tri-Departments issued guidance that plans have “an easily accessible, transparent, and sufficiently expedient exceptions process” for contraceptive coverage. The investigation found that many patient populations have difficulty learning about contraceptive exception processes due to a lack of transparency and requiring patients to seek out information themselves.

In response to these findings, the Committee recommends that the Tri-Departments issue further guidance on the following: 

  • Requirements regarding appropriate medical management for coverage of contraceptives 
  • Automatic exception processes at the point of prescribing 

Because it is critical to have access to all FDA-approved contraceptive methods without financial or procedural barriers, the Policy Center applauds the Biden-Harris Administration for issuing the Executive Order on June 23rd, 2023, on Strengthening Access to Affordable, High-Quality Contraception and Family Planning Services. This was the third Executive Order the Biden-Harris Administration issued on contraceptive access since the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization. This Executive Order specifically focuses on protecting and expanding access to contraception, a key component of family planning services, and outlines the following actions: 

  • Improve Contraception Access and Affordability for Women with Private Health Insurance by directing the Secretaries of the Treasury, Labor, and Health and Human Services to issue new guidance ensuring that private health insurers cover all FDA-approved contraceptives without cost-sharing.
  • Promote Increased Access to Over-the-Counter (OTC) Contraception by directing the Secretaries of the Treasury, Labor, and Health and Human Services to take action to increase access to affordable OTC contraception. These actions may include meeting with pharmacies, employers, and insurers to discuss coverage opportunities, issuing guidance for coverage, and developing best practices to expand access to affordable OTC contraception. 
  • Support Family Planning Services and Supplies through the Medicaid Program by directing HHS to develop new actions to increase access to family planning services and products under Medicaid programs. 
  • Improve the Coverage of Contraception through the Medicare Program by directing HHS to take action to strengthen contraception coverage through Medicare Advantage and Medicare Part D plans.
  • Support Access to Contraception for Service Members, Veterans, and Federal Employees by directing the Secretary of Defense, the Secretary of Veterans Affairs, and the Director of the Office of Personnel Management to consider new actions to ensure comprehensive coverage of contraception for service members, veterans, and federal employees. 
  • Bolster Contraception Access Across Federally-Supported Health Care Programs by directing HHS to expand the availability and quality of contraceptive care delivered by federally-supported health care and human services entities. This includes Title X family planning clinics, community health centers, and Indian Health Services. Potential actions include issuing new guidance, providing technical assistance, and training resources to these health centers. 
  • Support Access to Affordable Contraception for Employees and College Students by directing the Secretary of Labor to identify and share best practices with employers and insurers to expand access to affordable contraception for employees. The Secretary of Education will share these best practices with colleges to help ensure students know their options to access contraception. 
  • Promote Research and Data Analysis on Contraception Access by documenting gaps and disparities in contraception access and supporting research and data analysis on contraception access. 
Learn more about the link between Family Planning and Maternal Mental Health

The Policy Center for Maternal Mental Health released an updated version of the issue brief titled “The Link: Family Planning and Maternal Mental Health” on July 12th, 2023, in conjunction with the Congressional Briefing: The Latest Insights and Opportunities for Improving Family Planning Options for Maternal Wellbeing.