Sam ChavarrĂa said her doctor was clear about the birth defects her medication could cause if she became pregnant but agreed to keep her on it as long as she had an IUD.
As she was waiting to get her contraceptive intrauterine device replaced at her local clinic, however, the billing nurse told her that her insurance wouldnât cover the removal â or a new IUD. ChavarrĂa didnât understand why not.
âThen she said very delicately, âWell, people on this insurance typically tend to be older,ââ ChavarrĂa recalled.
Although ChavarrĂa is 34, she is enrolled in Medicare, the government insurance program designed for those 65 and older. ChavarrĂa, who lives in Houston, is disabled by fibromyalgia, rheumatoid arthritis, and mental health issues. Medicare automatically enrolls anyone who has received for two years and this was her first time getting an IUD while in the government program.
Without insurance, just removing her expired IUD would cost ChavarrĂa $350 out-of-pocket, exchanging it for a new one would be $2,000. She left the clinic in tears.
ChavarrĂaâs experience is not rare. Medicare was originally intended for people of retirement age. Over the years, the program has evolved to include new populations, such as those who have disabilities or are critically ill, said , a public health expert at Yale University. In 2020, 1.7 million people ages 18 through 44 in Medicare.
An are also eligible for Medicaid, a state and federal program for those with low incomes, which should fill the gap for contraception. Itâs not clear how many transgender or nonbinary people â who also might need contraception â are on Medicare or are eligible for Medicaid.
, like the plans offered via the federal Affordable Care Act, mandates coverage of birth control. But those who arenât eligible for Medicaid are left in the lurch â Medicareâs origins mean it does not require access to birth control.
Traditional Medicare includes two parts: Part A covers hospital costs, while Part B covers physicians’ care and certain other services, such as ambulance rides. Neither ordinarily includes contraception.
People can get contraception through a Medicare Advantage plan or Part D of Medicare, which covers prescription drugs, but those come at a cost. And even people who pay for Part D often arenât covered for some types of birth control, such as IUDs.
âSo, if you are disabled, if you are locked outside of the labor market, if you do not have the means or any other way to financially support yourself, you were likely still on traditional Medicare, which is Part A and Part B,â Huer said. âIn which case, your access to contraception is incredibly difficult.â
Contraception for those with traditional Medicare is given on a case-by-case basis, Huer said. It can be covered only if a doctor can make a credible case that the patient needs it for medical reasons â because their body cannot sustain a pregnancy â as opposed to merely wanting to avoid one.
âYou have to have a champion physician who’s willing to partner with you and make those arguments,â Huer said.
Thatâs what ChavarrĂaâs doctor tried to do. Before she left the clinic, staffers there told her they would try to make the case she needed the IUD for medical reasons. The IUD exchange was scheduled almost 10 weeks later, but during those weeks, she got pregnant. Her body couldnât sustain a pregnancy, so she and her partner rushed to get an abortion just before Sept. 1, 2021.
âIf Medicare had just covered the IUD removal or exchange to begin with, none of this would have happened,â ChavarrĂa said. âIt would have saved me having to make a really tough decision that I never thought Iâd have to make.â
Women with disabilities often face a stigma from health care practitioners, especially when it comes to birth control, said , a public health researcher specializing in disabilities at Oregon Health & Science University. In her research, women with disabilities have described being treated like children or having to go to multiple doctors to find someone with whom they felt comfortable.
âWe donât want to acknowledge that disabled people have sex,â said Miriam Garber, a 36-year-old sex worker who lives in Rhode Island and is also on Medicare because of her disabilities. Garber got an IUD from Planned Parenthood because her insurance wouldnât cover it.
Even those who pay for Part D to have their prescription drugs covered and have a âchampion physicianâ face difficulties. Liz Moore, a nonbinary person in their 30s who lives in the Washington, D.C., area, could not get Medicare to pay for the Mirena IUD their doctor prescribed for their polycystic ovary syndrome. Moore is disabled with fibromyalgia and dysautonomia, a condition of the autonomic nervous system, which regulates breathing, heart rate, and more.
âAfter literally months of phone calls, it seemed like my Medicare Part D, and original Medicare could not agree on who should pay for my IUD,â they wrote in a direct message. âWas it a prescription or durable medical equipment?â
When Moore finally learned it would cost $800 upfront, they said, they decided to get a hysterectomy â which Medicare would pay for â instead.
ChavarrĂa’s doctor told her a tubal ligation also was more likely to be approved by Medicare than an IUD, since older people have that procedure more often. Like all surgeries, both come with risks of complications and recovery.
Even for those on both Medicare and Medicaid, getting contraception also isnât always easy, as in Katie Elizabeth Walshâs case.
Walsh, 34, who lives in northeastern Connecticut, is disabled by a traumatic brain injury, depression, and chronic fatigue syndrome. She got an IUD at an OB-GYN clinic and was told there her insurance would cover it.
Then she got a bill for nearly $2,000.
Medicaid should cover contraceptive devices for dual-eligibility people, according to , but when Walsh tried to get her bill covered, Medicare and Medicaid could not agree on which of them should pay.
âEvery single time I have called one of the insurance offices, they are like, âOh, no, you have to talk to the other one, and we don’t really talk to each other,ââ Walsh said.
Walsh said the hassle to get her contraception covered feels like a kick in the stomach: âLike truly you do not have a place in this world, and your insurance is telling you that.â
