Covering Contraception

​While contraceptive coverage is on the rise, some newer methods may not be covered.

Little more than a decade ago, half the indemnity health plans offered by employers didn’t cover any prescription contraceptives, and managed-care plans often weren’t much more generous. Today it’s a different story: Surveys indicate that more than four-fifths of employee health plans include such coverage.

While more plans have shifted to offer contraceptive coverage, however, some may not have adjusted that coverage to take advantage of the latest developments in contraceptive care, even though the factors that spurred the increase in coverage of birth control pills—the first covered form of prescription contraception—apply equally well to newer forms of contraception.

Susanne Martinez, vice president for public policy at Planned Parenthood Federation of America in Washington, D.C., says the increase in employer coverage of contraceptives has been spurred by three factors: “litigation, legislation and greater public awareness that led more employees to request it.”

Many employers might add another factor: cost-effectiveness. Because contraceptive coverage helps employers avoid the health care costs and lost productivity associated with unintended pregnancies, some economic analysts have concluded that providing such coverage is actually less expensive than not providing it.

Yet, companies that cover prescription contraceptives under their health insurance but do not offer a wide spectrum of products—including those that reflect the latest options—may not be getting the most out of their benefit program dollars.

Coverage Grows, Gaps Remain

The Society for Human Resource Management 2005 Benefits Survey found that 82 percent of human resource professionals said their companies offer contraceptive coverage, up from 70 percent three years ago.

Recent surveys from other organizations also found high coverage rates. For example, a benefits survey of large employers by the Kaiser Family Foundation reported that 89 percent of covered workers have coverage for oral contraceptives. And a national study of employee health plans by the Alan Guttmacher Institute in Washington, D.C., a nonprofit organization focused on sexual and reproductive health research, found that almost every type of contraceptive product or service was typically covered by at least 89 percent of plans (not including self-insured plans).

Some data, however, suggest that gaps exist in the extent of contraceptive coverage offered. A national survey released last year, sponsored in part by the Association of Reproductive Health Professionals (ARHP)—a nonprofit association of health care providers, researchers and educators—found that many contraceptive options weren’t covered nearly as often as that old standby, the pill.

Among the less frequently covered options were the patch, vaginal rings, diaphragms, injections, IUDs and emergency contraceptives (known as the “morning-after pill”). (For more on these options, see “ Rx Contraceptives at a Glance”.) In general, there seems to be a trend for “newer products to be less likely to be covered,” says ARHP President and CEO Wayne Shields.

One caveat: The Guttmacher study didn’t find these types of discrepancies, so more research is needed to determine just how big the coverage gap is between the pill and other methods.

A Lack Of Knowledge?

In cases where certain contraceptives are excluded, it may be due primarily to a lack of familiarity with these products, rather than differences in cost or effectiveness.

“Unfortunately, the insurance companies don’t keep up-to-date,” says Shields. “A lot of newer methods are less expensive than the pill,” he points out, so cost presumably isn’t the reason companies aren’t offering these new options. What is? “It’s lack of knowledge,” he concludes.

If that’s the case, it may be up to human resource professionals to become familiar with the latest options and discuss coverage with insurance providers to make sure that their employers’ contraceptive coverage truly meets the needs of the business and of employees.

Why Fewer Options Matters

Does it really matter if an insurance plan covers only one or two types of prescription contraceptives, rather than all of them?

“Absolutely,” says Dr. David Grimes, vice president of biomedical affairs at Family Health International, a nonprofit public health organization based in Research Triangle Park, N.C. Grimes, a practicing obstetrician/gynecologist, says, “Based on empirical studies, we know that when clinicians try to steer women in the direction we think they ought to go, the women don’t continue [using the contraceptive] as well. So in general, the best method for any woman is whatever she wants.”

Further, while personal preference will be the key determiner for most young, healthy women, in some cases there are medical reasons why a woman cannot or should not use a certain method of contraception.

Says Grimes, “In that situation, it’s all the more important to have options to fall back on.”

Offering more than one contraceptive option also may make sense for other reasons. In fact, the same reasons companies had for opening the door to contraceptive care in the first place should prompt them to consider expanding care to include new methods. Most notably, these factors include legal requirements and cost issues.

It’s the Law, Part I

Providing full contraceptive coverage is a legal requirement for many employers, according to the Equal Employment Opportunity Commission (EEOC).

In 2000, the EEOC issued a decision finding merit in two charges of sex discrimination based on the exclusion of prescription contraceptives from employee health plans that covered other prescription drugs and devices.

“The EEOC decision is a very clear signal that the nation’s foremost antidiscrimination agency views this as discrimination,” says Roberta Riley, a staff attorney at Planned Parenthood of Western Washington in Seattle, who represented the women who brought the charges.

In its decision, the EEOC noted that employers not only must provide coverage for contraceptives on par with the coverage for other prescription drugs and devices, but also must cover the full range of contraceptive choices. In addition, the EEOC said that employers need to include such coverage in each of the health plans offered to employees.

The EEOC decision applies to companies with 15 or more employees, which are covered by Title VII of the Civil Rights Act of 1964. Smaller employers may have similar obligations under state laws that ban sex discrimination.

The EEOC decision was reinforced by the ruling of a federal district court in Seattle in Erickson v. Bartell Drug Co., which became a key test case. The judge, ruling in favor of the plaintiff, found that the exclusion of contraceptives from an otherwise comprehensive health plan was sex discrimination in violation of Title VII. The judgment was not appealed, and no court has subsequently ruled to the contrary.

“I would predict that there will be more of these lawsuits in the future,” says Riley, who was involved in the Erickson case. “We’re not talking about many companies who still refuse to cover contraception at this point, but I think those who do are really opening themselves up to lawsuits.”

States that Mandate Equality in Insurance Coverage

Arizona	Massachusetts
Arkansas	Missouri
California	NHampshire
Connecticut	New Mexico
Delaware	New York
Georgia	North Carolina
Hawaii	Rhode
Illinois	Island
Iowa	Vermont
Maine	Wisconsin
Maryland	Washington
Arkansas	Nevada

Its the Law, Part II

Along with litigation, state-level legislation has helped spur the expansion of contraceptive coverage. The push for such legislation started with the widespread acceptance of Viagra.

“When Viagra was approved by the FDA, it was picked up right away by a lot of health insurance plans,” says Judy Appelbaum, vice president and legal director at the National Women’s Law Center in Washington, D.C. “Women started asking why their birth control pills still were being excluded from insurance plans after 40 years, while something for male impotence was covered immediately.”

In response, a number of states enacted laws or regulations that require private insurance companies to cover prescription contraceptives if they cover other prescription drugs and devices. So far, 22 states have passed comprehensive laws or regulations that mandate this type of equity in insurance coverage. (For a list of these states, see “ States That Mandate Equality in Insurance Coverage.”)

The laws do not apply to self-insured plans, and several contain clauses that exempt certain employers or insurers based on moral or religious grounds.

According to the Guttmacher study, coverage of contraceptives is significantly higher for plans in states with mandates. Further, Adam Sonfield, a public policy associate at Guttmacher and lead author of the study, says the state laws may be having an impact beyond their immediate jurisdictions. He notes that nationally determined plans that operate both in states with and without mandates may provide coverage everywhere in accordance with the mandates. The Guttmacher study found, he notes, that 100 percent of nationally determined plans covered almost all contraceptives.

Assessing the Benefit

Employers not legally required to provide coverage for the latest forms of contraception may consider doing so for business reasons. An analysis by the Washington Business Group on Health looked at both the direct and indirect costs of unintended pregnancies.

The direct costs included medical expenses for prenatal care, childbirth, abortions, miscarriages and pregnancy complications. The indirect costs included employee absences, maternity leave, pregnancy-related sick days, reduced productivity during pregnancy and replacing employees who didn’t return to work after a pregnancy.

When these figures were compared to the cost of contraceptives, it was concluded that not covering contraceptives could actually cost employers 15 percent to 17 percent more than providing the coverage.

Getting More Information

If you are charged with the task of sorting out the pros and cons of contraceptive coverage, start by familiarizing yourself with the issues and the options that exist today.

“You don’t have to be an expert on medical issues,” says Shields. “You can do a lot of really good initial research simply by going out there on the web. It’s just a matter of having this topic on the radar screen in the first place, then setting aside a little bit of time to educate yourself about it.”