When Jennifer Shipe found out she was carrying twins in 2015, she knew it wasn’t going to be easy. Just 20 weeks into her first pregnancy, Shipe and her husband Patrick Pintar were at a friend's 4th of July party when she went to the restroom gushing blood.
“At that point, I wasn't sure if the babies were going to survive,” Shipe said.
Her husband drove her to the hospital, where doctors were able to stop the bleeding. They diagnosed her with a chronic placental abruption, a serious complication that occurs in pregnancy when the placenta separates from the uterine wall.
Four weeks later, Shipe hemorrhaged again and was hospitalized. She remained in the hospital for five weeks — under constant monitoring. Two months before their due date, Guy and Calvin Pintar were born and immediately whisked away to neonatal intensive care.
“It's bittersweet,” she said. “I have a lot of PTSD. You know, it wasn't the happy birth announcement. It was; they're here. They're here too early, but everybody's doing well.”
Shipe says every day doctors would determine if she was stable, if her life was at risk, if the bleeding was controlled and if the babies were in distress.
After the twins were born, she feared another pregnancy would put her life on the line, and she says it was very important to get on birth control.
“I, you know, made the decision that these guys were my miracles and that I need to do everything in my power to stay here for them because another pregnancy could have killed me,” she said.
A few months after the twins were born, Shipe chose to get a Mirena intrauterine device, also known as an IUD. It’s a long-acting birth control device that is inserted in the uterus and can prevent pregnancy for up to eight years. It worked, Shipe says, for years. She had no problems until 2023 when she had some spotted bleeding and discomfort. Her symptoms were a normal indication it was time to replace her IUD, so she made an appointment with her OBGYN.
Her doctor attempted a routine removal in the clinic, but she couldn’t find the strings to pull the IUD out.
After two unsuccessful attempts to remove the device, her doctor recommended trying again under anesthesia at the hospital. Shipe agreed, expecting the procedure to be fully covered by her insurance. She said before the removal, she called her insurance company and confirmed the costs would be 100% covered.
In January, she went to Jefferson Einstein Montgomery Hospital in East Norriton, Pennsylvania, where her doctor successfully removed and replaced her IUD. But months later, Shipe received a bill in the mail: she owed $2,854.40.
“I was in shock,” she said. “I'm thinking, how are we going to budget for this?”
It’s a shock Scripps News found many women seeking reproductive care in the U.S. are experiencing.
Despite a federal law requiring most health insurance plans to pay for birth control care at no cost to the patient, Scripps News learned thousands of women like Shipe have received bills for contraception care.
Scripps News found cases of women being asked to pay as little as $35 a month for birth control pills to nearly $5,000 for a sterilization procedure.
All care experts and government officials told Scripps News this should have cost the patients nothing.
‘It’s happening everywhere’
When it was signed into law in 2010, part of the promise of the Affordable Care Act was to expand access to coverage of women’s reproductive care through what is known as the birth control mandate.
The ACA prohibits cost-sharing for most contraceptive care. Cost-sharing is a practice where the patient pays for a portion of their medical care out of pocket. Instead, under the ACA most health insurance plans are required to fully pay for at least one in each of the 18 FDA-approved birth control methods and the medical services related to contraception.
Doctor visits, counseling, follow-up care, management of side effects and removal of IUDS should be free.
But a Scripps News investigation found that coverage isn’t always guaranteed. Scripps News spent months reviewing complaints, sifting through government investigations and speaking with nearly two dozen women who voiced frustration on social media about unexpected bills they received for contraception.
In total, Scripps News calculated more than 17,000 reports across all 50 states of patients who claimed their insurers failed to cover contraceptive and follow-up care. In the majority of those cases, government officials later determined that care should have been fully paid for by health insurance plans.
“It's happening everywhere to a lot of people,” said Lauren Wallace, senior counsel for the reproductive rights and health team at the National Women’s Law Center a nonprofit organization that fights for gender justice.
Wallace spent the last five years running the center’s CoverHer hotline. It’s a website that has helped women navigate birth control access since 2013.
Wallace said over the years, she has seen more women seeking long-lasting birth control being denied coverage, especially since the Supreme Court decision Dobbs v. Jackson Women's Health Organization struck down Roe V. Wade in the summer of 2022.
“The issues are a bit more complex now,” she said. “Now in a post-Dobbs world, something that I see a lot is issues with sterilization, surgery issues with related services. For example, individuals who are seeking coverage for IUD, but their ultrasound related to their IUD is not getting covered.”
The federal birth control coverage guidelines have been around for more than a decade, but Wallace says women continue to receive bills for care that should be covered by their insurance.
She shared exclusive complaint data for the first time with Scripps News. An analysis of the data revealed the country's largest insurance providers, such as UnitedHealthcare, Cigna Healthcare and companies affiliated with Blue Cross Blue Shield, are among those accused of denying contraceptive coverage.
Scripps News asked the insurance plans what they were doing to ensure the ACA is followed, and all three affirmed their compliance with the ACA. UnitedHealthcare said they “provide access to more than 150 FDA-approved contraceptive options with $0 cost-share.”
Cigna Healthcare said it covers many birth control pills at no cost and a doctor can request coverage for a brand that’s not covered.
A spokesperson for the Blue Cross Blue Shield Association, a group that represents companies associated with the branch told Scripps News in part: “While each Blue Cross and Blue Shield company makes its own coverage decisions, we all meet federal and state requirements and often exceed them.” The company said it will continue to work with regulators to make sure their policies follow the law.
Wallace says while the ACA guidelines say related services are covered, the guidance isn’t specific about what those related services entail.
“So, what we end up seeing is that ... it’s like a fight that the insurance plans are willing to have,” she said.
Not all health insurance plans are subject to consumer protections under the ACA: plans that are sponsored by exempt religious employers, like churches, don’t have to cover birth control.
Certain plans grandfathered in are not subject to the ACA. Other plans that provide limited medical coverage, like short-term medical insurance, also don’t need to follow ACA rules.
“But essentially, every other plan — Medicaid expansion, private health plans from an employer or the health care marketplace — should be covered under the law,” said Wallace. “It is clear the plans know that things should be covered. But then we're dealing with the complexity of just the US health care system. You know, there's so many stakeholders, there's so many moving parts. That this law, this one part of a big law gets confusing very quickly.”
A full-time job
Scripps News spoke to 21 women who have struggled to get their insurance companies to cover birth control. For a dozen of those cases, Scripps News reviewed medical records, bills and correspondence with insurance. Women described the process as “insane,” “frustrating,” and “a nightmare.”
Olivia J. is a graduate student in Alabama. Scripps News agreed to only use her first name and last initial to protect her privacy, including from religious family members. After Roe v. Wade was overturned, she started thinking about longer-lasting birth control. This year, her OBGYN recommended the contraceptive Nexplanon, a small rod that is inserted under the skin of the upper arm that lasts up to three years.
She thought she did everything right.
“I called my insurance, and I verified that it was covered under my plan,” she said. “Then in June, I got a bill.”
Records show Olivia J. was stuck paying $1,318.16 for her Nexplanon and $150 for the device insertion. She says she immediately called her insurance to make sure the coding was correct.
“They said that it wasn't a mistake,” she said. “I feel like they almost purposefully gave me the runaround.”
After months of back and forth, Olivia J. filed a formal appeal with Blue Cross Blue Shield of Alabama. In August she won her appeal and received a letter saying the $1,318.16 claim determination had been “incorrect”.
She says she filed a second appeal for the $150 insertion fee but has yet to get a response from the insurance company.
“It makes me think about all the people who aren’t able to spend that time to get this stuff reversed,” Olivia J. said. “It’s frustrating, especially when there is so much legislation being written about what we can and cannot do with our bodies that the birth control that is legal is still made inaccessible.”
Kim Philips of Tennessee shared the sentiment. She’s been in appeals with Blue Cross Blue Shield of Tennessee for months, arguing that her bilateral salpingectomy — a form of permanent birth control where both fallopian tubes are removed — should be covered under the ACA.
She had to postpone her sterilization surgery until her insurer sent her a letter agreeing to pay for the procedure. But then, to her surprise, weeks after her surgery in July, she received a bill in the mail for $4,499.11 from the surgery center.
“When I saw the bill, I was furious! I just spent so long fighting with insurance and thought everything was good to go,” Philips said.
Once again, Philips fought her insurance company, and records show they eventually paid her bill.
“I don't wish this nightmare on anyone,” she said.
It’s a nightmare that’s become an all-too-common reality for women, contraception care coverage is not as cut and dry as many believed it would be when the ACA became the law of the land.
Some women said they gave up fighting for contraceptive coverage and paid their bills.
“It got to the point where like, this is a full-time job for me,” said Jennifer Demetriades of Minnesota. “I have two little kids, like I don't have the bandwidth to just like devote my entire existence to this.”
Other women didn’t fight at all because they didn’t know their bills for contraceptive care should have been free.
Jenny Lee of Illinois found out her IUD had partially migrated through her lower uterine wall during a CT scan she was getting due to an inflammation of her bowel.
Lee’s doctor told her she needed to get the IUD removed before they could treat her bowel condition.
“We just needed to get it out,” Lee said. “Quickly. Yes, it was in the spot that it shouldn't be.”
She says she didn’t check that the surgery would be covered by her insurance provider because the hospital had told her she was good to go.
“The urgency of it all with the other medical condition that I, I just had to do what I had to do. I just really couldn't ponder on it,” she said.
After her surgery, she got a bill in the mail for $3,297.08. Lee said she doesn’t remember if she questioned the bill, but she thought if they sent her one then she would have to pay it.
“The hospital wants their money. So, I had a set up with the payment plan or it gets into collections,” she said. It took her 24 months to pay off the surgery.
Lee says she didn’t think to fight the cost until a Scripps News reporter contacted her asking questions about her bill.
“It was that duh moment for myself and why didn't I ever look into that?” Lee said.
Lauren Wallace says the experience of these women mirrors what she has seen through the hotline, but it’s not always insurance companies at fault here. Billing errors by doctors and hospitals can also leave women with exorbitant bills. Together these mistakes have cost people across the country more than a million dollars in the last decade.
“Currently, there's no entity that's supposed to fix it, it is essentially a pointing game,” said Wallace. “So, it often requires individuals to go back and forth between provider and plan, and it often leaves them burnt out.”
A coding error
Jennifer Shipe found herself in the middle of that pointing game when she began to ask questions about the nearly $3,000 bill she received from Jefferson Einstein Montgomery Hospital.
She says the insurance company representative told her the procedure she was billed for wasn’t considered contraceptive care.
So Shipe called her OBGYN’s office. The person who answered the phone looked over her bill and found Shipe was billed for a procedure she never received.
She learned the hospital billed the insurance company for a dilation and curettage procedure known as a D&C, which is a procedure usually done to terminate an early pregnancy. Shipe — who had an IUD for eight years — was not pregnant at the time of her surgery.
“I didn't even know what a D&C was,” she said.
Shipe says the OBGYN office told her the coding error is not something they can change; it was the hospital that did the billing.
This was the beginning of months of exchanges between her providers and insurance. Shipe took copious notes from calls and even sent follow-up emails to her OBGYN’s office summarizing conversations with the hospital and insurance company. Detailed logs show the difficulty Shipe had trying to get her bill resolved.
“The frustration started to build because all of these phone calls, hours of time calling every couple of days,” said Shipe. “I'm a working parent. Like, I don't have time to dedicate as a side hustle to try to get my insurance coverage.”
She says her OBGYN tried to point out the billing error to the hospital, but the hospital denied the initial appeal, arguing the bill was correct even though it contradicted Shipe’s medical records.
Both pre-operation forms and post-operation documents explicitly detailed that Shipe received an IUD removal and insertion procedure. Nowhere did the records say she obtained a D&C.
“I'm not going to pay something that I shouldn't, so I'm going to fight it to the bone,” Shipe said. “Somebody should be held accountable.”
Little enforcement
The system for patients to get accountability is mired in confusion. Many women we spoke to said when they needed help, they didn’t know which government agencies to go to.
“We have an education gap and so that makes it also an enforcement gap,” said Christina Piecora, a senior policy analyst at the National Health Law Program. She works on contraception and all family planning initiatives, including trying to get states to pass contraceptive protections that go further than the ACA.
“We see a lot of investigations but not as much enforcement,” said Piecora.
Scripps News reached out to the three agencies that oversee and enforce the ACA, the Department of Labor, Health and Human Services and the Treasury, requesting an interview regarding cases like Shipe’s, but they declined. Instead, an administration official acknowledged there are several open investigations looking into birth control coverage denials from across the country.
Throughout the years, federal agencies have published guidance and sent letters to health insurers, reminding them of the birth control coverage requirements under the ACA.
This year the Centers for Medicare and Medicaid Services published three reports looking into systemic issues with preventative care coverage that included contraception. The investigation found Blue Cross Blue Shield of Texas, Christus Health Plan of Texas and Celtic Insurance Company failed to cover contraception among other preventative services and were told to self-audit their claims and reimburse patients.
But it’s unclear if the plans were penalized for denying coverage in the first place or how much was reimbursed. A spokesperson said CMS has two additional reports that will be posted soon.
The little enforcement Scripps News did find came from state agencies. Scripps News learned that 19 states with the power to enforce no cost-sharing requirements for contraceptive care. Some of those states went beyond the ACA by mandating full coverage of vasectomies and 12-month supplies of birth control pills.
However, their jurisdiction is limited to insurance plans that are state-regulated. After receiving a few complaints, the Vermont Department of Financial Regulation investigated three insurance companies for violating their state law that mirrors the ACA.
“We realized kind of pretty quickly that it was a broader issue,” said Emily Brown, deputy commissioner at the Vermont Department of Financial Regulation.
The department reviewed over 200,000 claims focused on medical services related to contraceptive care, including vasectomies, received from October 2017 until December 2021. Investigators found Blue Cross Blue Shield of Vermont, MVP Health Care and Cigna were not compliant with the law.
“It actually ended up being $2,169,857 that's going back to in Vermonters pockets,” said Brown. “I think it was the largest number that the department has ever had.”
Part of that amount included a 12% interest. In the end, 9,826 people were reimbursed for contraceptive care that the insurance companies didn’t initially pay for.
Brown says the insurance companies were very responsive to the investigation and officials found the plans weren’t intentionally trying to not cover contraceptive care. She says part of the problem was the guidance for the insurance plans to process claims wasn’t always clear, but more states and the federal government should do their own investigations.
“It's an important issue, you know, it has to do with access to care and health equity,” said Brown. “So based on our findings, I think it's something worthwhile for the states to look into ... to make sure that people are getting a benefit that they're legally entitled to get.”
Other states have penalized insurance plans for denying coverage. In addition to requiring patients to be reimbursed, New York fined four plans more than $2 million in the last eight years.
One of those cases was settled in June. New York Attorney General Letitia James and UnitedHealthcare entered a $1 million agreement after an investigation found a patient in Brooklyn was denied coverage for birth control pills.
California, Illinois and Oregon have also found health insurance plans they regulate have failed to pay for contraceptive care.
Many of the companies are national providers and advocates like Wallace believe the limited state enforcements point to a need for federal action.
The problem has already captured the attention of Congress.
Two years ago, the Committee on Oversight and Reform in the House of Representatives published a report looking into barriers to contraception. The investigation focused on private insurance plans, the cost and the coverage gaps for birth control.
They found five of the largest insurers and pharmacy benefit manager companies “routinely require cost-sharing for certain birth control products or exclude them from coverage altogether.”
“It's unconscionable that insurance companies or PBMs would get in the way of the spirit of the law and block women from getting access to contraception,” said Pennsylvania Congresswoman Madeleine Dean. She was one of 150 Democratic lawmakers to sign a letter demanding answers from AHIP, a group representing the country's major health insurance plans.
She says she found their response to the letter “unacceptable” and “filled with euphemism."
Scripps News reached out to AHIP for an interview, but a spokesperson declined. Instead, they provided a statement that read in part: “Health plans provide access to the full range of contraceptives and contraceptive care without cost sharing, consistent with federal law.”
Dean called on the Department of Justice to get involved to look at where the teeth are in the laws to hold insurance companies accountable.
“Congress has to demand of the insurance companies that they stop hiding behind the denials,” Dean said. “When women cannot simply get what they're entitled to under the Affordable Care Act, it takes us back to second-class citizen and preexisting condition. We're not going back.”
In June, The Washington Post reported Sen. Bernie Sanders asked the U.S. Government Accountability Office to investigate if the federal agencies in charge are holding insurance plans accountable for improperly denying coverage for contraception. A spokesperson for the GAO confirmed to Scripps News the agency accepted Sen. Sanders' request, and the investigation is expected to begin in the new year.
Lauren Wallace of the National Women’s Law Center says the government is not yet doing enough to make certain the ACA is fulfilling its promises to women.
“This shouldn't be a thing,” said Wallace. “I'm very frustrated to work around the corner from a government that still allows this thing to happen. It's hard, it's very difficult.”
The Biden administration recently proposed a new rule to make private health insurance plans pay for over-the-counter birth control without a prescription. In theory, the move expands access to contraception but it’s not clear how the government would make sure plans follow through given the struggle women go through to get other contraception methods covered that for the last decade were supposed to be free.
‘It took a news outlet’
In the days before Scripps News met up with Jennifer Shipe at her Pennsylvania home, Scripps News contacted Jefferson Einstein Montgomery Hospital, where she had her procedure. Scripps News pressed for answers on Shipe’s case.
Forty-eight hours before interviewing Shipe, the hospital sent Scripps News an email, which was shared with Shipe. It said, in part, “Once this matter is brought to our attention, Jefferson Einstein Montgomery Hospital promptly investigated the issue and identified an error in the coding of the procedure. The patient's bill has since been updated to reflect the correct coding.”
After months of fighting, Shipe’s coding issue had been resolved.
Shipe was emotional and expressed anger.
“It took a news outlet,” she said. “Yet I have record of dozens of phone calls begging them, to somebody to help me.”
She said she was relieved she no longer needed to deal with the bill, but she wants to know how many other women this happened to.
“I'm frustrated that it came to this,” Shipe said. “And I think about every other woman who hasn't gotten that far.”
If you have been billed for contraception and related services, contact reporter Karen Rodriguez at Karen.rodriguez@scripps.com.
Editor's note: This story has been updated with more information about insurance companies' obligations to cover birth control methods under the ACA.
