The right to get your Fertility Awareness-Based Method training reimbursed by insurance is now at risk  

Editor’s Note: In December of 2022, a federal court rejected the Biden administration’s illegal attempt to end insurance coverage for FABM instruction. In July of 2023, that same court ordered the Biden administration to cover $65,000 in attorney’s fees incurred by Dr. Cami Jo Tice-Harouff while the case was litigated.

How the current Health and Human Services administration is trying to take it away  

While Fertility Awareness-Based Methods (FABM) are a sustainable, cost-effective family planning option for many women and couples, learning a method comes with an upfront cost of between $100 and $500, depending on the method and how much personal support is needed. As we learned when we launched our FABM scholarship fund here at Natural Womanhood, quite a few families may be challenged to fund this training when they need it most.  

But in 2016, “instruction in fertility awareness-based methods” was added to the list of “preventative care and screenings” for which the Affordable Care Act (ACA) prohibits insurers from imposing cost-sharing measures on patients. In other words, as of 2016, insurance providers were required to pay for FABM instruction when rendered by a licensed medical professional. While this was a welcome change and a huge win for the FABM industry, it is now being challenged by the Biden Administration’s Department of Health and Human Services (HHS).  

In this article, we’re exploring what changed in 2016, what it meant in practice, and how recent actions by the Biden Administration’s HHS could threaten this change.  

HRSA’s Women’s Preventive Services Guidelines for Contraception: What changed in 2016 

In 2016, for the first time ever, “instruction in fertility awareness-based methods” was included under the Contraceptive coverage heading in the “Women’s Preventive Services Guidelines” established by the Health Resources & Services Administration (HRSA) of HHS. These Guidelines mandate certain services to be covered in group health plans and coverage, and have specific requirements for the coverage of contraceptive services. 

Under the Contraception heading in the 2016 and 2019 versions of the Guidelines, we read:

“The Women’s Preventive Services Initiative recommends that adolescent and adult women have access to the full range of female-controlled contraceptives to prevent unintended pregnancy and improve birth outcomes.”

What follows is a comprehensive list of 18 various contraceptive methods, again, for which cost-sharing is prohibited. What changed in 2016, was that following the list of conventional contraceptive methods, was this significant sentence:

“Additionally, instruction in fertility awareness-based methods, including the lactation amenorrhea method, although less effective, should be provided for women desiring an alternative method.” 

It cannot be overstated what an important step this was in the recognition of FABMs as a valid form of family planning in the medical and health insurance world. Of course, we could have done without the “although less effective” part (which is woefully inaccurate), but we will always take incremental improvements where we can get them (especially if it means more women and couples finally have access to these methods!). 

Practically speaking, the inclusion of FABMs within the Contraceptive heading in the Guidelines meant that FABM instruction became a covered expense under the ACA. Even better, this change applied to state and local government employee insurance plans, private employee plans, Medicare and Medicaid insurance plans, and ACA exchange insurance plans.  

How does FABM instruction coverage work under ACA? 

This, of course, was great news for many current and future FABM users. And it did not only apply to those who use FABMs for family planning, but also for those who chart for medical reasons (such as the treatment of infertility, or menstrual cycle-related issues).  

Under the 2016 ACA Guidelines, additional assistance from instructors (which costs around $50 a session) could be covered as women and couples navigated these issues, as long as the instructor was a licensed medical professional or covered under the license of a medical professional. Practically speaking, this allowed medical professionals , such as OB/GYNs, family practice doctors, physician’s assistants, or nurse practitioners, to partner with non-medically licensed instructors to provide FABM instruction for their patients. (In these cases, the license of the OBGYN, etc., was used to procure reimbursement for instruction via insurance).  

As of 2016, and up until recently, you could ask your healthcare professional to check with your insurance provider about coverage for these services, using the appropriate treatment codes (footnote 1). Note, however, that application of the Guidelines under state Medicaid programs could vary by state (footnote2). 

Now this rule is being challenged, and FABM instruction coverage is at risk 

Unfortunately, all of the above may soon become a moot point.  

In October 2021, the Department of Health and Human Resources published a new notice about a draft recommendation concerning the recommendations for providing contraception as part of the HRSA-supported Women’s Preventive Services Guidelines.  

The recommendation claimed to only be asking whether to add condoms to the list of contraceptive methods, but in the list of covered contraceptives, they no longer included the sentence covering instruction for fertility awareness-based methods. It was not clear whether this was an intentional omission with the goal of removing FABMs from the original guideline, or an oversight on the part of HHS.  

Regardless, HHS opened a 30-day public comment period about the draft rule, which ended on November 31, 2021. Several FABM organizations, including Natural Womanhood, posted comments in response, but these comments have not been made public to this date, and no response to the comments has been made public.  

Then, in December 2021, HHS officially removed “instruction in fertility awareness-based methods” from its list of covered contraceptive services. They did so without first allowing for a notice-and-comment period, nor without providing any rationale for the removal, both of which are mandated by the Administrative Procedure Act, according to the Alliance Defending Freedom (ADF). ADF is currently suing the federal government for their violation of the Administrative Procedure Act on behalf of a Texas-based FABM instructor and nurse practitioner, Dr. Cami Jo Tice-Harouff, but if they are unsuccessful, the new rule will go into effect in December 2022, and coverage for instruction in fertility awareness-based methods will literally be a thing of the past.  

Will HHS walk back progress in authentic women’s health by removing FABM coverage?

Natural Womanhood Editor Grace Emily Stark commented to Catholic News Agency (CNA), “What’s at stake here is this coverage being rescinded not only for couples to learn fertility awareness for family planning purposes, but also for women to use it for infertility diagnosis, for cycle issue diagnosis and treatment. It’s really disheartening.”

There was progress to be celebrated when the top US public health authority recognized FABMs as a valid method of family planning, and required its instruction to be covered by insurance in the same way other family planning methods are. It was a move that gave women and couples more, better choices for family planning, and provided women with access to an important tool for monitoring their health. The current attempt to take FABM instruction away from ACA insurance coverage is a step backwards, and a slight to the women and couples who need these effective, side effect-free methods of family planning.  

Are you a patient, healthcare provider, or FABM instructor who has obtained insurance coverage or reimbursement for receiving or providing FABM instruction? Please share your experience with us in the comments.  

Footnotes: 

Footnote 1: The 2016 change may or may not have applied to certain non-ACA compliant, “grandfathered” plans, and one would need to check ACA compliance before filing a FABM instruction claim. (According to this podcast transcript published by National Clinical Training Center for Family Planning and the Family Planning National Training Center, the correct CPT code for someone learning FABM for Family planning would be H1010, along with the diagnosis code Z30.02 if it is to avoid pregnancy, or Z31.61 if it is to achieve pregnancy. Note that different codes would be used if the purpose is different such as a well exam or a problem-focused treatment, according to the same podcast transcript.) 

Footnote 2: Another coverage hurdle concerns whether one’s state Medicaid plan covers FABM training. According to the CDC, any State that adopted the ACA Medicaid expansion that “extends Medicaid eligibility to non-elderly individuals with annual incomes at or below 133 percent of the federal poverty level ($16,611 for an individual or $34,247 for a family of 4 in 2019) are required to cover the full range of preventive services required in the essential health benefits (EHB) final rule.”  According to the Kaiser Family Foundation (KFF), 39 states and DC have adopted Medicaid expansion. In states that did not implement the ACA’s Medicaid expansion, patients would need to check what their state Medicaid plan covers under the umbrella of women’s preventive services. 

Of note is the State of Maryland, which adopted a code in 2018 that specifically defines and requires coverage for FABMs, listing the various methods covered, which plans are subject to this code, and who benefits (licensed health professionals). There is no mention of coverage for FABM tools such as hormone tacking monitors.