5. Federally Mandated Contraceptive Coverage

Federally mandated contraceptive coverage

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For ASO members

What is it?

Under the Affordable Care Act (ACA), all non-grandfathered health plans must cover approved prescription contraceptive methods for women without charging plan participants and beneficiaries a copayment, coinsurance or deductible. However, the ACA grants an accommodation to this requirement for certain eligible religious nonprofit organizations.

The employer groups listed above certified that their group health plan qualifies for an accommodation with respect to the federal requirement to cover contraceptive services for women, as prescribed by a health care provider, without cost sharing. This means that they will not contract, arrange, pay or refer for contraceptive coverage including the following contraceptive or sterilization services:

  • FDA-approved contraceptive methods for women
  • Elective non-surgical sterilization procedures for women and surgical tubal ligation procedures for women
  • Patient education and counseling related to contraception for all women of reproductive capacity

Instead, Dean Health Plan will provide or arrange separate payments for these contraceptive services, without cost sharing and at no other cost, for as long as a woman is enrolled in their employer health plan and services are performed by an in-network provider.

What is covered?

This plan covers evidence-informed preventive care and screenings for women provided for in current HRSA-approved guidelines. This includes:

  • FDA-approved contraceptives (drugs and devices) prescribed by a health care provider
  • Outpatient consultations, examinations, procedures and medical services that are necessary to prescribe, administer, maintain or remove a contraceptive
  • Sterilization procedures for women
  • Patient education and counseling related to contraception for all women with reproductive capacity

Benefits under this Plan are covered at first dollar coverage. Benefits are only available through in-network providers. See Summary Plan Description (SPD) for more details on coverage and eligibility.

How does it work?

  • Members/providers will use the existing employer group medical plan when receiving contraceptive services.

  • If the claim is an approved contraceptive service (see SPD for details), then the claim will be denied on the employer group plan and automatically submitted and paid from the Dean Health Plan contraceptive services plan.

  • You will receive two Explanations of Benefits (denial from group medical plan and approval from contraceptive services plan).

  • Note that only in-network providers are covered under the contraceptive services plan. In-network providers will be determined based on your in-network provider list on your employer group medical plan.

  • Transactions are handled as point of sale.

  • Member should use their employer group ID card.

  • Pharmacist will receive a message back to resubmit with an alternate federally-mandated contraceptive-only plan carrier number.

  • Member will not have cost share.

  • Contact your pharmacy benefits manager for pharmacy-specific questions.

Common questions

You are automatically enrolled in this plan based on enrollment in your employer group plan. If your employer‐based coverage is terminated, your participation in this plan will also automatically be terminated. 

We are required by law to provide this benefit. However, you are not required to use the benefit.  

Refer to your Summary Plan Description located at deancare.com/aso/contraceptives or call the Customer Service
number on your ID card.

There will not be a separate insurance card for this benefit. You should use the insurance card provided by your
employer group.  

This benefit is limited to in‐network providers only, based on your employer group plan’s provider network.

We will apply the same network rule as your employer health plan.  If you have questions, please contact the
Customer Service number located on your ID card.

There will be a separate Explanation of Benefit statement for contraceptive claims.

You will receive a statement indicating that the claim has been denied on your employer group plan and then a separate Explanation of Benefit statement stating that the claim has been processed under the Federally‐Required Contraceptive Services Plan and paid for by Dean Health Plan.

Contact your pharmacy benefits manager located on your health plan or pharmacy ID card.

The federal law requires that we enroll all participants and beneficiaries of this plan and does not distinguish between male and female enrollees. Even though all participants and beneficiaries are enrolled, the covered benefits only apply to women. 

Yes. As long as you are enrolled in your employer group plan, you will remain enrolled in this plan.  

Call the Customer Service number located on your employer group health plan ID card.