The controversy about the breadth of exemptions has fueled more controversy. ACA's confusing birth control rules

Listen to the political rhetoric around the contraception mandate, and you might think that employers must provide women with free birth control of every kind.

It’s not quite that simple.


Employer plans don’t have to cover every type of birth control approved by the Food and Drug Administration — they have to cover some. They can often charge a co-pay for some brands or products as long as they offer others for free.

And a woman may not know precisely which category her specific prescription falls into until the pharmacy rings it up.

“[The idea that] everything must be covered every time and one side saying, ‘It’s good,’ and the other side saying, ‘It’s bad’ — that’s not quite right,” said Judy Waxman, vice president for health and reproductive rights at the National Women’s Law Center.

The requirement that employer-sponsored health plans offer contraception without a co-pay is part of the women’s preventive health section of Obamacare. The political controversy and court cases about the breadth of religious exemptions have only fueled more controversy about the health law, its mandates and the clarity of the messaging.

The details of how the contraception policy actually works can become blurry amid ongoing battles over whether it violates the religious liberty of Catholics and others who say they’re morally opposed to paying for birth control.

Churches and some religious organizations have exemptions or accommodations, but dozens of religious business owners are suing for exemption, too, on the grounds that the requirement violates their beliefs. In one of the highest-profile cases, brought by the Christian owners of the Hobby Lobby craft stores, a judge Friday issued a temporary order until Oct. 1 that means the business does not have to offer the free birth control pending a full hearing.

When administration officials and the law’s backers talk about the contraceptive coverage, the details can get lost in their eagerness to tout the law’s benefits.

“The Institute of Medicine recommended a whole array of preventive care for women, including the range of contraceptive coverage authorized by the FDA,” Health and Human Services Secretary Kathleen Sebelius said on MSNBC last month. “That will be available to women free of charge with their health insurance because we know that’s good for women.”

But a woman with employer-sponsored coverage generally doesn’t have free access to every kind of FDA-approved contraception, with some exceptions if her doctor gives a specific prescription for health reasons. And backers of the requirement are concerned that insurers are imposing limits on coverage that go beyond what HHS intended.

The most in-depth guidance to date — released by the administration earlier this year — doesn’t detail exactly which birth control the health plans must cover without a co-pay.

Instead, the rule permits plans to exercise “reasonable medical management.” That means the coverage requirement is satisfied if the plan offers options in each of five major contraceptive categories: barrier methods, hormonal methods, implanted devices, emergency contraception and permanent methods.

That has some worried insurers are taking advantage of the wiggle room.

The NWLC has set up a hotline for women to share difficulties paying for or accessing contraception through their insurer. The group is compiling anecdotes and following up to identify systemic problems. The center plans to eventually release a report with findings, Waxman said.

“From the anecdotal evidence, there are real, clear problems,” said Adam Sonfield, a senior public policy associate with the Guttmacher Institute, which backs abortion rights and broader access to contraception. He’s heard of women having trouble getting access for contraceptive rings or patches.

The rule does provide a backup: Plans must cover a specific contraceptive without cost-sharing if it’s ordered by a woman’s doctor for medical reasons.

“There’s an out if there’s a specific reason for medical reasons why you need that particular method,” said Debbie Harrison, public policy manager for the National Business Group on Health.

But otherwise, plans can treat contraception much like other prescription drugs, categorizing them in a tiered system in which some are available for free — often the cheaper, generic drugs — and others, like more expensive, brand-name drugs, come with varying co-pays.

“There is still a lot of flexibility for insurers as part of these guidelines,” Sonfield said. “It’s clear they’re allowed to use formularies; it’s clear that if you have a brand name, you can put a generic equivalent. But there are a lot of other things that aren’t clear.”