QUESTION

There’s a co-pay for my brand name birth control pills, but not for the generic brand. I thought birth control bills had to be covered without any cost-sharing, is this allowed?

Post enrollment issues | Individual Health Insurance
ANSWER

In general, under an ACA plan, contraceptive methods that have been approved by the U.S. Food and Drug Administration have to be provided without cost-sharing; FDA-approved contraceptive methods include items like oral contraceptives (i.e., the pill) and IUDs. However, health plans can impose cost-sharing on items and services within the contraceptive method to encourage the use of other items or services, as long as there is one item or services within the contraceptive method provided without cost-sharing. For example, an insurer can impose cost-sharing on a brand-name birth control pill so long as enrollees can obtain the generic alternative without cost-sharing. Note that an insurer can impose a separate cost-sharing limit for prescription drugs versus medical services, but the total combined limit cannot exceed $7,900 for self-coverage and $15,800 for family coverage in 2019.

If you are enrolled in a grandfathered plan, it does not have to provide coverage of contraceptives without cost sharing, though it may decide to provide coverage of select forms. There are other forms of coverage do not have to comply with the Affordable Care Act’s requirements, including short-term limited duration insurance, association health plans, and Health Care Sharing Ministries. See the Resources tab for more information on how the Affordable Care Act's insurance rules apply to different plans. (45 C.F.R. § 147.130; CMS, FAQs about ACA Implementation – Part 26; HHS, Notice of Benefit and Payment Parameters for 2019, April 17, 2018).

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