Post-ACA Insurer Exclusions Threaten Some Women's Health Coverage

Although many more women have health insurance now than before the enactment of the Affordable Care Act, gaps in women’s health coverage persist, leaving them vulnerable to higher costs and denied claims.

Although many more women have health insurance now than before the enactment of the Affordable Care Act (ACA), gaps in women’s health coverage persist, leaving them vulnerable to higher costs and denied claims, and threatening their economic security and physical health, according to a new report from The Commonwealth Fund.

The August 2016 report, by Dania Palanker, JD, MPP, of the National Women’s Law Center, and Karen Davenport, MPA, a researcher with The Commonwealth Fund, recommended that allowed variations within states’ “essential health benefits” benchmark plans be prohibited and that transparency and simplified language in plan documents be required.

The researchers examined qualified health plans from 109 insurers across 16 states for 2014, 2015, or both years to uncover the types and incidence of insurer exclusions that may disproportionately affect women’s coverage. They found that although insurers can no longer deny coverage or charge higher premiums based on gender because of the ACA, and all individual market plans must cover maternity services, birth control, mammograms, and mental health services, there are nonetheless 6 types of services frequently excluded from insurance coverage: treatment of conditions resulting from noncovered services, maintenance therapy, genetic testing, fetal reduction surgery, treatment of self-inflicted conditions, and preventive services. All of these aspects of health coverage are not covered by the ACA.

“Such exclusions can undermine a primary goal of the ACA: to improve women’s health and eliminate gender discrimination in health insurance markets,” the authors wrote.

The service exclusions identified are often described in health plan materials for consumers in language that is difficult to understand for people with limited health literacy, and often appear only in detailed plan documents that many consumers do not read. Thus, women purchasing insurance may be unaware of the exclusions and the effect they have on their coverage.

For example, in the category of conditions resulting from noncovered services, the authors explain that insurers may deny a claim for needed medical care after the provision of an excluded service, such as the treatment of an infection arising from a prophylactic mastectomy. In the study, 46 of the 109 insurers examined excluded coverage of services that are related to, or arise from, other noncovered services.

Another example cited is that 29 of the 109 insurers exclude coverage of maintenance therapy—treatments that maintain health but are not expected to lead to improvements—or exclude other ongoing medical treatments that “prevent regression of functions in conditions that are resolved or stable.” Nine of the 29 insurers omit both types of treatment. Women are more likely than men to have lupus, depression, chronic pain, and other chronic health conditions that require maintenance therapy, the study notes, and are also more likely to have breast and lung cancers, the 2 most common forms of cancer in women—conditions that also require maintenance therapy to prevent or slow their progression.

Another important gap is in preventive services not currently required by the ACA. Eleven of the 109 insurers applied exclusions to prophylactic services such as prophylactic mastectomies and removal of ovaries and fallopian tubes for women with certain genetic mutations and family history, as well as antiretroviral prophylaxis for individuals exposed to HIV or other sexually transmitted diseases—especially significant in sexual assault cases.

The report asks regulators to address these problems by prohibiting exclusions that undermine the ACA’s protections and increasing transparency in plans so women are aware of exclusions when choosing coverage. States can also prohibit substitution of benefits to ensure that states qualified health plans must offer the same benefits as the ACA’s benchmark plans.