Frequently Asked Questions about the Affordable Care Act (ACA)

Click on any of the frequently asked questions about the Affordable Care Act below to see an answer from HealthKY.com.

Women's Health

I am purchasing health insurance in my state’s health insurance Marketplace. Is my plan required to cover contraceptives without cost?

Yes, your plan must cover the full range of FDA-approved contraceptive methods, but can impose some restrictions on the contraceptives offered at no cost to you. For example, the plan may require that you choose a provider within the network, and use generic rather than brand name contraceptives, unless the brand name is medically necessary. If the generic drug or device does not work for you, you can, with the help of your doctor, ask your insurer to pay the full cost of the brand name drug or device.

I would like to get an IUD. Is my plan required to cover birth control without cost sharing?

If your plan is “grandfathered” then it is not required to pay for contraceptives without cost-sharing. If you are in a non-grandfathered plan, however, your contraceptive costs should be covered. Your plan must cover at least one type of IUD, and the provider visits for insertion and removal, with no co-payment. You should talk to your provider about which IUD is best for you. If your plan will not initially cover this IUD with no co-payment, you should ask your provider to request a “waiver” from your insurance plan.

I have employer-based coverage and I know my plan is not “grandfathered”. Yet, when I recently filled my prescription for birth control pills, I was charged a co-payment. Aren’t those plans required to cover all contraceptives without cost sharing now?

Yes, all non-grandfathered plans (plans that started or made changes after March 23, 2010) must provide contraception with no cost sharing. If there is a generic alternative to your birth control pills, you can be charged a co-payment for the brand name pill. Check with your provider if there is a generic birth control pill available that will work for you. If your birth control pills are already a generic then contact your insurer and request coverage with no co-payment. If there is a medical reason you need to use a brand name birth control pill, ask your doctor to help you request a “waiver” from the insurance company. The “waiver” would allow you to use the brand name drug with no co-payment.

I get insurance from my employer, which is a large Catholic University. Is my plan required to cover contraceptives without co-payments?

Yes, your insurance company is required to cover contraceptives without co-payments. Your employer may have applied for an accommodation which allows your employer not to pay for contraceptives. Your insurance plan will still cover contraceptives at no cost to you, not using any of your employers’ money. You should receive information directly from your insurance plan about this coverage. Like all other plans, your plan can impose some restrictions on no cost contraceptives. For example, the plan may require that you must get your care from a provider within the network, and use generic rather than brand name contraceptives, unless the brand name is medically necessary.

I was told that my college insurance plan does not pay for contraceptives. Can that be right?

If your college has a self-funded health plan, then it is not subject to requirements under the Affordable Care Act, including covering contraceptives with no cost sharing. Ask your college if the plan is self-funded. If it is self-funded, it is still subject to state laws that may require some coverage of contraceptives. Check with your State Insurance Department about the state law. If you are under 26, you should check if you are eligible as a dependent in your parent’s health plan. If your parent’s health plan began after March 23, 2010, then it must cover contraceptives with no cost sharing.

I’ve been uninsured and just enrolled in a health plan through my Marketplace. I’ve been getting my birth control at a Family Planning Clinic. Will I still be able to go there to get my birth control for free?

You should check if your Family Planning Clinic is listed in the network for your new insurance plan. If the Family Planning Clinic is listed in the network you will be able to continue to go there for your birth control. If your Family Planning Clinic is not in the network, you may still qualify for free or reduced cost services from the clinic. If you would like to continue going to the clinic, check with your clinic about continued services.

My husband would like to get a vasectomy but when I checked with our insurer, they told me that the plan would cover my sterilization without cost sharing but we would have to pay part of the costs for his procedure. What is the reason for that?

Contraceptives, including sterilization, are covered only for women as preventive services. Since sterilization for men is not considered a preventive service under the Affordable Care Act, plans are not required to cover and can charge a co-payment for vasectomies.

I am currently uninsured and plan to purchase coverage through the health insurance Marketplace. Do the insurance plans in the Marketplace cover abortions?

It depends on where you live and the specific plan you choose. Some states allow plans in the Marketplace to cover all abortions and some states prohibit or limit plans’ coverage of abortion to certain cases. In about half the states, Marketplace plans are prohibited from offering coverage that includes abortions, or are restricted to covering abortions in very limited circumstances. You should check the plan details to find out whether your plan covers abortion services.

Does Medicaid cover abortions?

In general, Medicaid coverage for abortion is very limited.  In most states, Medicaid covers abortions only when the pregnancy is the result of rape or incest or if the woman’s life is endangered because federal law limits the use of federal funds to these circumstances.   However, 17 states do go beyond this limit and use state funds to cover other abortions.

Do I need a referral to go to my OBGYN if I am enrolled in a non-grandfathered plan?

If you are enrolled in a non-grandfathered plan, then you must be allowed to see your OBGYN without a referral. Women in grandfathered plans and Medicaid may be able to schedule a visit with an OBGYN without a referral. Check with your plan.

What services do plans have to cover for pregnant women?

Although most employer plans were already required to cover maternity care prior to enactment of the ACA, most individual plans did not cover maternity care. Starting in 2014, new plans in the nongroup market, including those available through the Marketplaces, are required to cover maternity services including child birth and newborn care. All new private plans must cover prenatal visits and screenings, folic acid supplements, tobacco cessation, and breastfeeding services without any co-pay because they are considered preventive services. All state Medicaid programs cover maternity care without cost-sharing to low-income women who qualify for coverage.

I just found out that I’m pregnant and my baby is due in June 2014. Can I enroll in a plan through the health insurance Marketplace?

Yes, you may enroll and your plan will be required to cover maternity services. You may also qualify for a premium subsidy, depending on your family income and your eligibility for employer coverage, or, depending on your income you might also qualify for Medicaid .

I am pregnant and plan to breastfeed my baby. How does the ACA affect breastfeeding services?

The ACA requires that all new private plans, including those in the employer market, individual market, and health insurance Marketplaces, cover lactation counseling and breast pump rental without any charge. Check your plan details to find out the specific number of counseling sessions and type of breast pump that it covers. If you are nursing and work for a large employer (50 or more employees), your employer must provide access to a private room (that is not a bathroom) and break time for you to express milk.

I have been trying to get pregnant. Will the plans on the exchanges cover infertility services?

This will vary by state. Some states have requirements that plans cover some infertility services, but there is no national requirement for coverage of infertility services. If you need these services and are shopping for coverage, check the plan details about coverage and out of pocket charges for infertility care.

Does pregnancy trigger a special enrollment opportunity to buy or change coverage?

No it does not. However, when the baby is born you will be eligible for a special enrollment opportunity. You can enroll your baby in coverage at that point. You (and your spouse) can also change health plans during this special enrollment opportunity.

How do I project my household size/income for next year if I’m pregnant now? I’m married and this pregnancy will be our first child. We want to find subsidized coverage in the Marketplace.

This fall you and your husband will apply as a household of two. When the baby is born, you can update your family information with the Marketplace to reflect that you have become a household of three. At that point, you may qualify for a larger premium tax credit. (For example, if you and your spouse together earned $30,000, as a household of two you would be required to contribute 6% of your household income toward the premium for the benchmark plan in the Marketplace. Once the baby is born and you are a household of three, you would only be required to contribute 4.17% of your income.) When you report your new family status to the Marketplace you will also have a 60-day special enrollment opportunity to add the baby to your plan, and you will be able to change health plans during that period if you want to do that.

I heard that plans have to cover preventive services without cost sharing. Is this every preventive service and are there any limits to what is covered?

If you are in a non-grandfathered, or a new private plan, including those available through health insurance Marketplaces, then your plan is required to cover a wide range of preventive services and may not impose cost-sharing charges (such as copayments, deductibles, or co-insurance). The ACA requires private plans to provide coverage for services under four broad categories: evidence-based screenings and counseling, routine immunizations, childhood preventive services, and preventive services for women. So long as the preventive service is performed by an in-network provider, is not billed separately from the office visit, and is the main reason for the office visit, then the visit and the preventive service will be covered by the insurer without cost-sharing.

If you buy coverage on your own and you first purchased your policy prior to March 23, 2010, it may be a grandfathered plan. These plans are not required to cover preventive services without cost sharing. If you are not sure if your plan is grandfathered, check with your employer or your insurance plan.

Are there any preventive services for women specifically?

The ACA includes a number of preventive services for women that “non-grandfathered” private plans are now required to cover without cost sharing. For example, these include counseling and screening services including prenatal and preconception care; breast and cervical cancer screening; genetic counseling and testing for women at high risk of breast cancer; Chlamydia and Gonorrhea screening and counseling for high risk women; at least one well woman visit a year; contraceptive counseling, services and supplies including prescriptions for FDA approved contraceptives; breastfeeding counseling and support services including breast pump rental; and intimate partner violence screening and counseling. So long as the preventive service is performed by an in-network provider, is not billed separately from the office visit, and is the main reason for the office visit, then the visit and the preventive service will be covered by the insurer without cost-sharing.

I am 35 and I have a family history of breast cancer. What services are covered?

If you are considered to have a family history that makes you at high risk for certain genetic mutations that are associated with increased risk of breast cancer (BRCA1 and BRCA2) and are enrolled a non-grandfathered plan, then your insurance should pay for the both the counseling and the genetic testing without charging you cost-sharing.

Screening mammography is included as a recommended preventive service that will be available to women in private plans. The coverage rule is based on the U.S. Preventive Services Task Force Recommendation from 2002 that recommends screening mammography every one to two years for women age 40 years and older. Since you are under age 40, federal rules do not require your plan to cover the costs of the screening mammogram without cost sharing, so you may have to pay out-of-pocket for some or all of the costs of that screening mammogram.