How can I get my health insurance to cover Implanon?
February 11, 2016 8:03 AM Subscribe
Asking for a friend. How can I get my health insurance to cover Implanon or another contraceptive implant?
From what I can tell, I have to have a doctor saying it is a medical necessity? Is that true? Any other tips?
From what I can tell, I have to have a doctor saying it is a medical necessity? Is that true? Any other tips?
Should be covered 100% as with any other form of contraception post-ACA (and because there is no generic and it's the only one of its kind, shouldn't be excluded as some brands of pills are under some plans.) It doesn't need to be the only medically acceptable option, just the one that the patient and doctor decide is best for the circumstances.
As for other tips: wear a sleeveless shirt for the appointment so as not to have to strip down more than necessary, and be ready for some entertaining-looking bruising for a few days.
posted by asperity at 8:14 AM on February 11, 2016 [1 favorite]
As for other tips: wear a sleeveless shirt for the appointment so as not to have to strip down more than necessary, and be ready for some entertaining-looking bruising for a few days.
posted by asperity at 8:14 AM on February 11, 2016 [1 favorite]
Your health insurance should just straight up cover it. (Implanon has mostly been replaced by Nexplanon. There are no hormonal differences, just a change in the insertion device to make it easier to place, and the Nexplanon implant is radiopaque so that it can be located on an x-ray).
posted by The Elusive Architeuthis at 8:20 AM on February 11, 2016 [1 favorite]
posted by The Elusive Architeuthis at 8:20 AM on February 11, 2016 [1 favorite]
Could you clarify as to whether you've tried to have it covered and been denied, or if you're just worried about that scenario. I remember when I recently changed insurance I was freaked out about whether my chosen birth control method would be covered (not helped by a shitty doctor who was all "Oh gee, I just don't know....."), but ultimately it was no problem at all and was covered with zero fight from my new insurance company. Depending on the situation, I think your approach here would be very different. If you do end up having to fight it, I would work with your doctor to put together documentation that it is a medical necessity (whatever that means -- I mean, if you are sexually active and don't want to become pregnant, I'd say it's pretty f-ing medically necessary, right?!)
posted by rainbowbrite at 8:58 AM on February 11, 2016 [1 favorite]
posted by rainbowbrite at 8:58 AM on February 11, 2016 [1 favorite]
Not only should the implant be covered automatically without prior authorization from insurance, but one annual exam to talk about getting Implanon and get any screenings done, and an additional follow up visit to implant the device should be covered 100% no copay. Expect to have to fight your insurer on the office visit portion. Even that is mandated to be covered but often insurance will try to force a copay illegally. Go ahead and call your insurance ahead of time to be sure, and dispute bills if you get them for things directly related to any contraceptive
posted by slow graffiti at 9:01 AM on February 11, 2016
posted by slow graffiti at 9:01 AM on February 11, 2016
(Also, make sure the person you're seeing is actually certified to put in an Implanon/Nexplanon--you have to go through a short training and get put on a list of approved providers. The training is NBD and most MDs/NPs who do a lot of women's health are certified, but if, for instance, you usually go to an internist or FP, I'd check, as some people haven't done it yet).
posted by The Elusive Architeuthis at 9:29 AM on February 11, 2016
posted by The Elusive Architeuthis at 9:29 AM on February 11, 2016
Response by poster: Clarification, I meant Nexplanon when I said Implanon.
Friends response to questions:
The insurance company said it was not covered unless it is a documented medical necessity. I called my doctor on Monday and they said "it's not going to be covered trust me".
posted by czytm at 10:43 AM on February 11, 2016
Friends response to questions:
The insurance company said it was not covered unless it is a documented medical necessity. I called my doctor on Monday and they said "it's not going to be covered trust me".
posted by czytm at 10:43 AM on February 11, 2016
Best answer: unless it is a documented medical necessity
I worked for an insurance company and I do freelance writing. I have researched the ACA a bit. I know of two potential solutions here:
1) Come up with a reason why this is a medical necessity and have the doctor write a letter to the insurance company stating why it is a medical necessity. Talk to the doctor about what might be typical reasons given for this being prescribed as a medical necessity. Perhaps she qualifies and just does not know it. Then it is a matter of the doctor putting it in her medical record and writing a letter of necessity to the insurance company.
2) The ACA requires that most plans that are sold through the marketplace or otherwise meet Obomacare criteria must offer one form of birth control for women completely for free. It also requires each marketplace to offer at least one plan that does not cover controversial things like birth control and religious organizations are generally exempt from having to cover birth control. So option 2 is wait until next year and look to change plans and research which plan covers the exact form of birth control desired.
This is one of the aspects of the ACA where you have to know what you want and do a lot of research beforehand because they are trying to simultaneously appease (as best I can tell) feminists and religious people at the same time, so the weeds are thick and tall when it comes to birth control under the ACA.
posted by Michele in California at 11:47 AM on February 11, 2016
I worked for an insurance company and I do freelance writing. I have researched the ACA a bit. I know of two potential solutions here:
1) Come up with a reason why this is a medical necessity and have the doctor write a letter to the insurance company stating why it is a medical necessity. Talk to the doctor about what might be typical reasons given for this being prescribed as a medical necessity. Perhaps she qualifies and just does not know it. Then it is a matter of the doctor putting it in her medical record and writing a letter of necessity to the insurance company.
2) The ACA requires that most plans that are sold through the marketplace or otherwise meet Obomacare criteria must offer one form of birth control for women completely for free. It also requires each marketplace to offer at least one plan that does not cover controversial things like birth control and religious organizations are generally exempt from having to cover birth control. So option 2 is wait until next year and look to change plans and research which plan covers the exact form of birth control desired.
This is one of the aspects of the ACA where you have to know what you want and do a lot of research beforehand because they are trying to simultaneously appease (as best I can tell) feminists and religious people at the same time, so the weeds are thick and tall when it comes to birth control under the ACA.
posted by Michele in California at 11:47 AM on February 11, 2016
Best answer: Plans that are subject to the provisions of the Affordable Care Act*** are required to cover without cost-sharing at least one form of contraceptive in each of 18 categories the FDA has identified in its birth control guide. (See the section "Coverage of Food and Drug Administration (FDA)-approved Contraceptives" in the FAQs about Affordable Care Act Implementation (Part XXVI), jointly released by DOL, HHS, and the IRS in 2015.) Those 18 categories include: (1) sterilization surgery for women; (2) surgical sterilization implant for women; (3) implantable rod; (4) IUD copper; (5) IUD with progestin; (6) shot/injection; (7) oral contraceptives (combined pill); (8) oral contraceptives (progestin only); (9) oral contraceptives extended/continuous use; (10) patch; (11) vaginal contraceptive ring; (12) diaphragm; (13) sponge; (14) cervical cap; (15) female condom; (16) spermicide; (17) emergency contraception (Plan B/Plan B One Step/Next Choice); and (18) emergency contraception (Ella). (This list is in footnote 12 of the FAQ.) I believe Nexplanon is an implantable rod, so unless your friend's policy is exempt from the requirements of the ACA, they'd be required to cover at least one implantable rod (whether Naxplanon or an alternative) with zero cost sharing in order to be in compliance with current regulation.
***Some health plans are not subject to the requirements for the ACA, in which case your friend may be out of luck, at least for the moment. This includes plans that are "grandfathered in" because they have been in existence since early 2010 without making any significant changes in coverage (they can't have changed copay levels, deductibles, or benefits without losing grandfathered status, so the expectation is that the number of plans meeting this exemption will fall over time). Less than a quarter of employer-based plans fall into the grandfathered-in category. Also some plans sponsored by certain types of employers (religious orgs or "closely held" for-profit companies) can apply for an exemption to the contraceptive mandate, but I don't believe that's terribly common. So, it's possible that your friend's plan isn't subject to these new regulations, but it's just as possible (and frankly more likely) that their health plan is simply not in compliance with the regs; there's been a lot of confusion on the part of health plans about whether it's allowable to cover a single type of contraceptive (e.g., a generic pill) and still meet the requirement.
You don't mention whether your friend's health plan is through an employer (either hers or her parents' or her partner/spouse), but if so, the first place to go would be the HR department for that company to ask whether the policy is subject to the ACA or still grandfathered in. (You could also call the insurance company and ask, as they should be able to easily tell you this.) If she doesn't discover that there's some reason these regulations wouldn't apply, the next step would be to file a formal complaint with her state department/division of insurance, which is the entity usually responsible for enforcing the ACA.
posted by iminurmefi at 11:57 AM on February 11, 2016 [2 favorites]
***Some health plans are not subject to the requirements for the ACA, in which case your friend may be out of luck, at least for the moment. This includes plans that are "grandfathered in" because they have been in existence since early 2010 without making any significant changes in coverage (they can't have changed copay levels, deductibles, or benefits without losing grandfathered status, so the expectation is that the number of plans meeting this exemption will fall over time). Less than a quarter of employer-based plans fall into the grandfathered-in category. Also some plans sponsored by certain types of employers (religious orgs or "closely held" for-profit companies) can apply for an exemption to the contraceptive mandate, but I don't believe that's terribly common. So, it's possible that your friend's plan isn't subject to these new regulations, but it's just as possible (and frankly more likely) that their health plan is simply not in compliance with the regs; there's been a lot of confusion on the part of health plans about whether it's allowable to cover a single type of contraceptive (e.g., a generic pill) and still meet the requirement.
You don't mention whether your friend's health plan is through an employer (either hers or her parents' or her partner/spouse), but if so, the first place to go would be the HR department for that company to ask whether the policy is subject to the ACA or still grandfathered in. (You could also call the insurance company and ask, as they should be able to easily tell you this.) If she doesn't discover that there's some reason these regulations wouldn't apply, the next step would be to file a formal complaint with her state department/division of insurance, which is the entity usually responsible for enforcing the ACA.
posted by iminurmefi at 11:57 AM on February 11, 2016 [2 favorites]
I'm a benefits attorney who used to practice under the ACA, and I successfully convinced my new employer that it was, in fact, in violation of the ACA.
iminurmefi's explanation is exactly right. I did not find NWLC's resources particularly helpful. Instead, I wrote my employer's HR department an email and included links to the relevant regulations and other guidance. If you'd like me to share that with you, please memail me.
posted by mchorn at 12:05 PM on February 11, 2016 [2 favorites]
iminurmefi's explanation is exactly right. I did not find NWLC's resources particularly helpful. Instead, I wrote my employer's HR department an email and included links to the relevant regulations and other guidance. If you'd like me to share that with you, please memail me.
posted by mchorn at 12:05 PM on February 11, 2016 [2 favorites]
Best answer: My insurance company gave me the same run around when I got my Nexplanon. I knew that they had to cover it under ACA, but each time I called, they kept saying I needed "pre-authorization" aka proof that it was "medically necessary". I thought it fishy, so I called the nurse line at the clinic I go to, and she basically said the same thing...that it was absolutely incorrect that I needed pre-authorization. Next time I called the insurance company, I immediately was like, look, legally you have to cover this, so stop it with the BS. The rep put me on hold for about 20 mins, then came back with no more pre-authorization needed. It was super frustrating, especially because I know there are probably many women out there that could not spend the time that I had pushing back, and therefore did not get access to the birth control of their choice. So, please tell your friend not to give up!
posted by gollie at 7:00 PM on February 11, 2016 [2 favorites]
posted by gollie at 7:00 PM on February 11, 2016 [2 favorites]
This thread is closed to new comments.
(The government's resources are de minimus)
posted by crush-onastick at 8:07 AM on February 11, 2016 [1 favorite]