Report Shows Health Plan Exclusions Leave Gaps in Women’s Care

Report Shows Health Plan Exclusions Leave Gaps in Women’s Care

Since enactment of the Affordable Care Act (ACA), many more women have health insurance in part because this law prohibits insurer practices that discriminate. However, gaps in women’s health coverage persist, with insurers often excluding health services that women are likely to need, leaving them vulnerable to higher costs and denied claims that threaten their economic security and physical health.

Because of ACA rules, insurers can no longer deny coverage or charge higher premiums because of gender or current or prior health conditions. All individual plans must cover essential health benefits that include maternity services, birth control, mammograms and other preventive care, and mental health services.

A new study by the National Women’s Law Center found that hidden in the fine print of many health plans is language that allows them to reject coverage of some services, many of which affect women’s healthcare. The report, “Women’s Health Coverage Since the ACA: Improvements for Most, But Insurer Exclusions Put Many at Risk,” was published by the Commonwealth Fund.

It’s uncertain the magnitude to which these coverage “exclusions” have banned patients from getting the treatments they needed. An insurance industry representative said patients usually get the care they need if it’s the right treatment for them. However, some women with inherited ovarian and breast cancer may have care gaps because of these exclusions.

Specialists believe the results of the new report provide a valuable roadmap to possible coverage problems that may still need to be addressed, despite the improvements succeeding the passage of the federal health law.

To uncover the types and incidence of insurer exclusions that may disproportionately affect women’s coverage, researchers at the National Women’s Law Center, an advocacy group based in Washington, D.C., examined qualified health plans from 109 insurers across 16 states for 2014, 2015, or both years.

They identified language regarding excluded health services (exclusions) that leave gaps in coverage for women’s healthcare needs.

Specifically, the experts found that six types of services are frequently excluded from insurance coverage: treatment of conditions resulting from non-covered services (for example, infections from cosmetic surgery, 42 percent of plans); maintenance therapy (27 percent of plans); genetic testing (15 percent); fetal reduction surgery (14 percent); treatment of self-inflicted conditions (11 percent); and preventive services not covered by law (10 percent). Some of these treatments could have a disproportionate impact on women’s healthcare.

“We wanted to highlight issues that would have a particular impact on women as well as show how broad some of the exclusions are,” Dania Palanker, study co-author and assistant research professor at Georgetown University’s Center on Health Insurance Reforms, said in a news release.

According to Lisa Schlager, vice president of community affairs and public policy at Force, it’s not unusual for women with a family history of ovarian or breast cancer to run into this barrier when they require genetic testing or preventive services.

According to the law, insurers are required to cover services that are recommended by the U.S. Preventive Services Task Force without consumers having to pay anything. The task force recommends that women with a family history of ovarian or breast cancers have access to genetic counseling and, if needed, testing for BRCA1 or BRCA2 genetic mutations that increase the risk of developing those cancers.

But insurers are not obligated to cover testing for the 40 or so other genetic mutations that increase the risk of ovarian or breast cancers. If a woman tests positive for a BRCA mutation, insurers may not cover earlier or more regular screening or other preventive services a woman may need.

“We are in this strange scenario where insurers are paying for the testing and then not paying for the breast MRIs or prophylactic mastectomies,” Schlager said.

Clare Krusing, a representative for America’s Health Insurance Plans, said the report is exaggerated because it does not address certain issues, such as whether treatments are effective and safe for all patients; if there are alternative therapies that are covered; and the procedures in place to enable patients to receive treatments when an insurance plan doesn’t offer coverage.

“If a patient has a medically necessary reason for this care, it will likely be covered,” Krusing said.

People who use the society’s call center aren’t usually complaining about plan coverage exclusions, but the distinctions may be confusing for patients, said Kirsten Sloan, senior policy director at the American Cancer Society Cancer Action Network, highlighting the need for more coverage information communication transparency.

Gwen Darien, from the National Patient Advocate Foundation, said additional studies are necessary to understand how these exclusions are affecting patient care.

“What the study does and calls for is further uncovering where the exclusions are and to make sure plans cover them as part of the essential health benefits,” she said.

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