Navigator Guide FAQs of the Week: Coverage of Reproductive Health Care

In most states, it’s the last week to sign up for marketplace plan that begins January 1. The Affordable Care Act expanded access to reproductive health services. As part of CHIR’s weekly installment of FAQs from our updated Navigator Resource Guide, we highlight questions about the marketplace and reproductive health care.

I thought that contraceptives were now covered, but I heard on the news that some employers don’t have to cover them. Is that true?

Generally, employer-sponsored health insurance must provide contraceptive coverage without cost-sharing unless your plan is a grandfathered plan. See Resources, ACA Consumer Protections for Private Coverage for information about grandfathered plans.

Note that federal rules allow eligible organizations including employers and insurers that have an objection based on “sincerely held religious beliefs or moral convictions” to exclude some or all contraceptives from a health plan, and a previous process in place to ensure enrollees still had access to contraceptive coverage is no longer required. The U.S. Supreme Court recently allowed these rules to go into effect, and while may be subject to further legal proceedings and additional rule-making efforts, they remain in effect. However, some fully insured employer coverage is also subject to state laws that require contraceptive coverage. To determine if your current policy covers contraceptives, and what methods are covered, check with your plan administrator. You should be able to request plan materials that list covered and excluded services, including contraceptives.

This is an area of law that is constantly evolving. Contact the National Women’s Law Center here if your employer or insurer says contraception is not covered or you experience cost-sharing that is not allowed under the law. Also, check with your state insurance department to see if there are other ways to access free or low-cost contraception if your employer plan does not provide coverage. (CMS, FAQS About Affordable Care Act Implementation Part 48, Aug. 16, 2021; CMS, ACA Implementation FAQs – Set 36, Jan. 9, 2017; 29 C.F.R. § 2520.104b-2; 45 C.F.R. §§ 147.131–147.133).

I heard marketplace plans have to cover certain health benefits referred to as essential. What are essential health benefits?

All qualified health plans offered in the marketplace (as well as certain non-grandfathered individual plans sold outside the marketplace) will cover essential health benefits. Categories of essential health benefits include:

Ambulatory patient services (outpatient care you get without being admitted to a hospital)
Emergency services
Hospitalization
Maternity and newborn care (care before and after your baby is born)
Mental health and substance use disorder services, including behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including dental and vision care

The precise details of what is covered within these categories may vary somewhat from plan to plan. (45 C.F.R. § 147.150).

Does my health insurance plan cover abortion care? 

Most health insurance plans do not have to cover abortion care, and some are prohibited from covering these services. However, protections and limitations vary across states and health coverage programs:

Medicaid: Due to federal funding restrictions, state Medicaid programs generally only cover abortion in the case of rape, incest, or life endangerment, and some states have imposed further restrictions on coverage and/or delivery of abortion services within the state. A number of states also use state funds to cover “medically necessary” abortions for Medicaid enrollees.

Marketplace plans: Half of all states restrict coverage of abortion care in marketplace plans, ranging from limiting coverage to certain scenarios, such as life endangerment, to outright coverage bans. However, several states require marketplace plans to cover abortion care. Absent a requirement or ban, the insurer may opt to cover or not cover abortion services. Check your plan’s Summary of Benefits and Coverage to find out if abortion services are covered beyond cases of rape, incest, and life endangerment. (42 U.S.C. § 18023(b)(3))

Other private plans: Non-marketplace private plans may also be subject to state restrictions or mandates related to abortion coverage. If your plan is not subject to such state requirements, the insurer (or your employer) can decide whether or not to cover abortion services. Reach out to your insurer (or, if you are enrolled in your employer’s health plan, your plan administrator) to find out what services are covered.

If you need access to abortion care and your health insurance plan does not cover these services, check to see if there are local or national organizations offering financial assistance. Some clinics also charge for services on a sliding scale, or may have discounts if you are uninsured, a Medicaid enrollee, or otherwise cannot afford the full cost of the procedure.

December 15 is the deadline to enroll in marketplace coverage that begins the first of the year in most states, but consumers in almost every state (other than Idaho) will be able to enroll in a 2023 plan until January 15, and we’ll continue to post weekly FAQs throughout the open enrollment season. Visit our Navigator Resource Guide for additional FAQs and enrollment resources.