The Affordable Care Act, or Obamacare, was enacted in 2010 to provide health insurance to all Americans. It was also enacted in an attempt to decrease healthcare costs. The purpose of the Act is to spread the cost of health care insurance by having as many people as possible pay for it.
The Act created an individual mandate for all Americans to purchase healthcare insurance, effective 2014. Those without insurance can purchase insurance through online “marketplace insurance exchanges,” which are set up by either the state or federal government. If a person does not have enough income to purchase insurance, they may qualify for a federal insurance subsidy.
The Affordable Care Act intends to cover previously uninsured Americans by making it illegal for health care insurance companies to deny coverage based on pre-existing conditions. Additionally, expanding Medicare eligibility for low-income individuals was attempted.
However, that specific provision of the Affordable Care Act was declared optional for the states by the United States Supreme Court. As a result, many states have declined to expand Medicare to its residents, including:
- Texas;
- Florida;
- Mississippi;
- Louisiana; and
- South Carolina.
In 2017, the Trump administration opted not to provide Obamacare subsidies to insurance companies in order to help fund certain insurance plans. The Trump administration also revoked two contraceptive mandates which were previously established.
The first was a mandate in which employers must include birth control in their insurance plans, except if the employer has a religious or moral objection. The second revoked rule waives costs of birth control for consumers, thereby shifting the cost to insurance companies and/or employers.
What Are Essential Health Provisions?
Under the ACA, healthcare insurance plans must meet a minimal standard of coverage. In order for an insurance plan to be legal under the Affordable Care Act, the insurance plan must contain essential health benefits. Additionally, it must have limited cost-sharing. If a plan does not meet either of those requirements, that plan is subject to cancellation.
The essential health provision requires that the insurance plan must contain the following benefits:
- Ambulatory Care;
- Emergency Care;
- Maternity Care;
- Substance Abuse Treatment and Rehabilitation Services;
- Laboratory Services;
- Prescription Services;
- Children’s Dental and Vision Care;
- Mental Health Care;
- Preventative Services and Chronic Disease Management; and
- Coverage of Hospitalization.
The Affordable Care Act requires that all preventative services be covered with no out-of-pocket costs, and that mental health and substance abuse treatments meet federal standards. Additionally, insurance companies cannot impose annual dollar limits on the coverage of any benefit that is considered to be essential.
However, many of these are unnecessary for many patients. An example of this would be how some people will never have children, while some patients will never abuse substances. In response, many state plans do not include some benefits even when they are considered to be essential. If you feel that an essential benefit is not needed, you can seek a grandfather plan exception.
What Are Contraceptive Equity Laws?
Many states currently have contraceptive equity laws which generally require health insurance policies that provide coverage for prescription drugs to also provide coverage for prescription drugs or devices that are contraceptives. In order for the drug or device to be considered a contraceptive, the U.S. Food and Drug Administration (“FDA”) must have approved the use of the drug or device as a contraceptive. As was previously mentioned, the Affordable Care Act (“ACA”) required all new insurance plans to provide coverage for the full range of FDA-approved contraceptives without cost-sharing for those who require contraceptives.
Many laws require any insurance policy that provides coverage for outpatient health care services to also provide coverage for outpatient contraceptive services. Examples include:
- Consultations;
- Procedures;
- Examinations; and
- Other medical services as needed.
Additionally, most of these laws require that any deductible, copayment, or coinsurance that is applied to contraceptives must not be greater than the deductible, copayment, or coinsurance that is applied to other prescription drugs. The contraceptive coverage must be available to the insured’s covered spouse and other dependents as well. Nearly all of the contraceptive equity laws are statutes which have been passed by the legislature and signed into state law.
What Are Some Of The Limitations Of Contraceptive Equity Laws?
State contraceptive equity laws apply to insurance policies that are regulated under state law. However, this is not true if the insurance provided by an employer is through a self-funded or self-insured plan. A self-funded or self-insured plan is any plan in which the employer uses its own funds to pay for the health care claims of its employees. Self-funded plans are governed by federal law.
Some states have exemptions for religious reasons to their contraceptive equity laws. Religious employers or insurers whose religious tenets prohibit the use of contraceptives are not required to comply with these laws. However, the scope of the religious exemption varies in different states; this is because the term “religious employer” can be defined differently depending on the state.
The ACA narrowed the religious refusal clause which resulted in less employers being exempted. State laws with broader religious refusal clauses were expected to align with the federal definition. In some states, the religious employer is required to provide clear notice of its refusal to cover contraception. Additionally, some states do not allow for religious exemptions if the prescription is ordered for reasons other than birth control.
An example of this would be how in California, churches and associations of churches are considered to be religious employers. Consequently, they are exempt from the state contraceptive equity law meaning that they are not required to provide contraceptive coverage. However, the religious employer must provide written notice which lists the contraceptive health services that the employer refuses to cover, especially if an offer of employment has been made. The notice must be given before the employee starts employment, and the religious employer is required to provide coverage for contraceptives that are requested for reasons other than to prevent unintended pregnancy. Finally, the religious employer must provide contraception when it is necessary to preserve the life or health of the enrollee.
How Can I Protect My Rights Under State Contraceptive Equity Laws?
Insurance complaint procedures differ from state to state. You can generally file a complaint with the state insurance department for a complaint regarding the exclusion of contraceptive coverage. The department will then investigate the matter and attempt to resolve it with the insurance company.
As such, you may first need to attempt to resolve the issue with the insurance company prior to filing a complaint with the state insurance department. Employers are required to comply with all of the applicable laws against sex discrimination, which may provide you with a separate basis to assert your right to contraceptive coverage.
An employee is generally required to file with a government agency before they can file a lawsuit for employment discrimination. This is generally done by filing with the Equal Employment Opportunity Commission (“EEOC”), which will conduct an investigation into the discrimination claim and prescribe an appropriate remedy. If the remedy is not sufficient or satisfactory, the employee can then file a private lawsuit against their discriminatory employer.
Do I Need A Lawyer For Help With The Contraceptive Equity Act?
You may not be receiving the contraceptive coverage which you are legally entitled to. In order to ensure that your rights are protected, or to assert your rights in a dispute, you should consult with an experienced workers compensation lawyer.
