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Why your birth control isn't always free under Obamacare

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There's one question I get a lot when my friends (particularly female friends in their 20s and 30s) find out I cover Obamacare: why isn't my birth control free?

One of Obamacare's best-known and most controversial mandates is the requirement that insurance plans cover contraceptives at no cost to the subscriber. The law says health plans can't charge co-payments for even the most expensive types of birth control, like intrauterine devices.

I know this as a reporter who covers Obamacare — but I've also heard anecdotally from friends who report getting charged a co-payment or some other fee for their contraceptives. And I've never had a great answer for why this happens — until now.

The Kaiser Family Foundation on Thursday published an excellent report that looks at how health insurance plans are interpreting Obamacare's birth control mandate. It shows that the requirement isn't entirely ironclad, and some insurers still are limiting access to certain types of birth control, particularly the birth control ring, the patch, and IUDs.

"There is variation in how insurance carriers are interpreting the guidelines for contraceptive coverage issued by HHS, and that not all methods may be covered without cost-sharing to women policyholders," the report finds.

Some insurers limit access to IUDs, the patch, and the ring

Some insurers seem to be blatantly disregarding the Obamacare mandate. The KFF study — which looked at a sample of 20 insurers in five states — found one that simply didn't cover the birth control ring (NuvaRing) and four that "couldn't ascertain" whether they cover birth control implants. These are potential violations of the law.

What was more common, however, was insurers using something called "reasonable medical management." This is where insurers restrict access to certain medications when they think there might be a cheaper, equally effective way for patients to get the same treatment — and this does seem to be legal under the health law's birth control mandate.

This seems to be especially prevalent with birth control patches and rings. These contraceptives use the same hormones as pills. And they have a slightly worse failure rate than the pill: 9 percent (meaning that of 100 women who use these methods, nine will become pregnant in a year), versus a 6 percent failure rate with the pill.

Then there's another advantage the pill has over the patch and the ring: it tends to be slightly less expensive. So the KFF study finds that some plans are limiting access to rings and patches, offering the pill as an equally effective option.

One insurer that KFF talked to said it "cover[s] a birth control pill with no cost-sharing and therefore charges cost-sharing for the NuvaRing, which has the same chemical composition." Another charges cost-sharing and requires enrollees to "show medical necessity on why oral contraceptives are not suitable before they will cover the NuvaRing."

Some insurance plans also appear to be doing something similar when it comes to the two hormonal IUDs, Mirena and Skyla. The two contraceptives are really similar — they use the same hormone (levonorgestrel) and are manufactured by the same pharmaceutical company (Bayer). The only difference is how long they last: Mirena can prevent pregnancy for five years, whereas Skyla is FDA-approved for three years.

The KFF finds that all insurers it surveyed cover Mirena (the longer-lasting IUD) with no cost-sharing — but there are three that exclude Skyla. What could be happening here could be a different version of reasonable medical management: insurers exclude the shorter-term IUD because they believe the longer-term version, which uses identical hormones, is more cost-effective.

Does limiting access to birth control violate Obamacare?

The KFF report finds that in general, insurance plans are following the spirit of the law: they really are making contraceptives more available to women, often at no cost. There's evidence this really is working: two-thirds of women with insurance now don't pay for their birth control, way more than just a few years ago.

At the same time, there doesn't appear to be anything in the law that bars insurance plans from using the type of medical management techniques that allow them to charge or deny coverage of some contraceptives. But as the KFF report points out, the guidance from the government on this point is a bit confusing.

The government released an FAQ in February 2013 that was arguably the Obama administration's best attempt at explaining when insurers can and can't limit birth control access. It said that yes, insurance plans can use "reasonable medical management" the way they have in the past:

Plans and issuers may use reasonable medical management techniques to control costs and promote efficient delivery of care. For example, plans may cover a generic drug without cost-sharing and impose cost-sharing for equivalent branded drugs. However, in these instances, 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

So this answers one specific question, about when insurers can substitute generic birth control for brand-name prescriptions. But it doesn't actually weigh in on the issues the KFF report raises: is it okay for an insurance plan to charge cost-sharing for the birth control patch, for example, because the research shows that the pill is a more effective and cheaper option?

The FAQ doesn't really address that type of issue — and the Obama administration, in light of the KFF findings, now plans to issue further guidance on the issue.

"The Administration strongly supports ensuring that women can access contraceptive services as authorized by the women's preventive services provision in the ACA," Health and Human Services spokeswoman Katie Hill wrote in an email. "We appreciate the importance of this issue and plan to release more guidance soon."

What to do if your birth control isn't free

It's possible that your insurance company is in the right — that because of the leeway outlined in the FAQ, it really doesn't have to pay for the type of birth control you want.

That being said, it can never hurt to call and ask: anyone can challenge an insurance company's coverage decision and find out why a specific type of birth control was denied or came with a co-payment.

The National Women's Law Center is another good resource in this space, offering guidance on how to make sure women get the best access to contraceptives. The nonprofit also offers help to women who are having difficulty accessing no-cost contraceptives. More information is available here.