Issue: Since enactment of the Affordable Care Act (ACA), many more women have health insurance than before the law, in part because it prohibits insurer practices that discriminate against women. However, gaps in women’s health coverage persist. Insurers often exclude health services that women are likely to need, leaving women vulnerable to higher costs and denied claims that threaten their economic security and physical health. Goal: To uncover the types and incidence of insurer exclusions that may disproportionately affect women’s coverage. Method: The authors examined qualified health plans from 109 insurers across 16 states for 2014, 2015, or both years. Key findings and conclusions: Six types of services are 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 not covered by law. Policy change recommendations include prohibiting variations within states’ “essential health benefits” benchmark plans and requiring transparency and simplified language in plan documents.
The Affordable Care Act (ACA) changed the landscape of the individual health insurance market for women. Before its full implementation, women were routinely charged higher premiums than men, prevented from purchasing coverage for services they needed, or denied coverage altogether. Insurers regularly denied coverage for a range of “preexisting conditions”: being pregnant, having undergone a Cesarean section, and even receiving health services after sexual assault.1 Women commonly paid more than men for their insurance, at an additional cost of approximately $1 billion per year, and many plans excluded maternity coverage.2,3 Such discriminatory practices led women to bear significant costs for health insurance or to forgo care altogether.4
Because of the ACA’s rules, insurers can no longer deny coverage or charge higher premiums because of gender or because of current or prior health conditions (Exhibit 1). All individual market plans must cover essential health benefits that include maternity services, birth control, mammograms and other preventive care, and mental health services.
Improvements in Individual Market Health Insurance That Benefit Women
However, there are still insurance practices that can leave women without adequate coverage. One such practice is the exclusion of certain services from plan coverage.
In this brief, we present results from our analysis of exclusions in qualified health plans (QHPs) from 109 insurers in 16 states. We identify six categories, and numerous examples, of exclusions that may prevent women from being covered for conditions that disproportionately affect them, or for services they access—even those that are also available to men. Such exclusions can undermine a primary goal of the ACA: to improve women’s health and eliminate gender discrimination in health insurance markets.
The service exclusions we identify are often described in health plan materials for consumers in language that is difficult to understand for somebody with limited health literacy, and often they appear only in detailed plan documents that many consumers do not read. As a result, women purchasing insurance may be unaware of this practice and the effect it may have on their coverage.
We review only exclusions described in QHPs’ evidence of coverage, or similar documents; we do not address services excluded based on medical necessity determinations, medical policies, or other guidelines. Readers also should note that an insurer that excludes a particular service generally also excludes that service in all or most of the QHPs it offers within a state.
INSURER PLAN EXCLUSIONS THAT AFFECT WOMEN’S HEALTH
Conditions Resulting from Noncovered Services
Health insurers make determinations of medical necessity and formulate guidelines based in part on medical research—an area that tends to underrepresent women and their particular health needs.5 As a result, women’s health needs are not always incorporated into medical policies and guidelines informed by such research. Insurers also may deny a claim for needed medical care following the provision of an excluded service, such as treatment of an infection arising from a prophylactic mastectomy. In our study, 46 of the 109 insurers examined exclude coverage of services that are related to, or arise from, other noncovered services (Exhibit 2 and Exhibit 3).
Twenty-nine of the 109 insurers exclude coverage of maintenance therapy—treatments that maintain health but generally 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.”6 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.7,8 They are also more likely to have breast and lung cancers, the two most common forms of cancer in women; these conditions also require maintenance therapy to prevent or slow their progression.9,10
Sixteen of the 109 insurers exclude coverage of genetic testing not expressly required by law. Women often rely on genetic testing to determine the need for prophylactic, or preventive, services. For example, genetic testing can reveal increased risk for breast or gynecological cancers; although many genetic mutations are connected with this greater risk, insurance plans are required to cover the testing of only two genes.11
For men and women who risk passing on serious genetic conditions, such as sickle cell disease or Tay-Sachs disease, to their child, preconception genetic counseling and testing are also common medical practice.12 And women with various risk factors commonly receive prenatal genetic testing to help them make informed decisions about pregnancy and prepare for a child with health needs.13
Fetal Reduction Surgery
Fifteen of the 109 insurers exclude coverage for fetal reduction surgery, a service that may be recommended for a pregnant woman’s health or to increase the chances of a successful pregnancy. Multifetal pregnancies carry numerous risks, including hypertension, preeclampsia, and postpartum hemorrhage,14 and risks increase with the number of fetuses.15 Only one insurer’s exclusion for fetal reduction surgery contains an exception for medical necessity.16
Treatment for Self-Inflicted Injuries or Illnesses
Twelve of the 109 insurers exclude services for self-inflicted injuries or conditions. Because women are more likely than men to both attempt suicide and survive a suicide attempt, for example, such exclusions have a disproportionately harmful impact.17 Women and their families often face the financial burden of large medical bills as a result. Moreover, plans do not define “self-inflicted,” leaving the scope of the exclusions uncertain. An insurer might rely on this exclusion to, as an example, deny coverage of services to treat malnourishment resulting from an eating disorder, claiming that malnourishment is a self-inflicted condition. Four of the 12 insurers with self-inflicted exclusions have exceptions for injuries or conditions resulting from a physical or mental health condition such as anorexia or depression.18 However, insurers may still deny claims for treatment if the provider does not list a diagnostic code for the underlying condition. This can be problematic for women with undiagnosed conditions, such as postpartum depression.19
Preventive Services Not Currently Required by Law
Eleven of the 109 insurers apply exclusions to prophylactic services. Prophylactic mastectomies and the removal of ovaries and fallopian tubes are widely considered appropriate procedures for women who have inherited particular genetic mutations or have a certain family or personal health history.20 Antiretroviral prophylaxis is available for individuals exposed to HIV or other sexually transmitted diseases—particularly significant in the case of sexual assault.21 The ACA requires coverage of a broad array of preventive services, but the list of services covered is based on those recommended for the general population, leaving out additional preventive services needed by many women (or other individuals with higher risk profiles).22
PROBLEMS FROM LACK OF TRANSPARENCY
There is little transparency in plan documents regarding health insurance exclusions. As a result, women may unwittingly enroll in plans containing exclusions that impact their coverage, and remain unaware of the exclusions until they seek services or have a claim denied. The short overview of coverage provided for each plan on the marketplace—called the “Summary of Benefits and Coverage”—includes space for information on exclusions. However, only 13 exclusions are required to be listed, and none of the exclusions described in this brief are in that group. Identifying all exclusions requires reading the underlying plan document, such as the evidence of coverage; yet some plan documents are over 100 pages long and exclusions appear in various sections. Terminology also varies among insurers; for example, some plans exclude “maintenance therapy” and others exclude “maintenance care.” In addition, some exclusions appear among only a small number of insurers, so women cannot know all the exclusions to look for in their plans. For example, six insurers exclude services resulting from an enrollee’s failure to comply with or accept recommended treatment, which is problematic for women who are less likely than men to adhere to prescription protocols.23 These factors make it difficult for women to identify and compare exclusions across plans.
The ACA has vastly improved health insurance coverage on the individual market for women. But coverage exclusions still impact women’s access to health care and continue to impede federal efforts to improve women’s health and eliminate gender discrimination in health insurance markets.24 As discussed above, exclusions on maintenance therapy to manage chronic conditions, for example, can have the same effect as denying women coverage because of preexisting conditions, by excluding care for preexisting chronic conditions that are disproportionately prevalent in women. Regulators can address these problems through two approaches: prohibiting exclusions that undermine protections in the ACA and increasing transparency in their plans, so that women are aware of exclusions when choosing coverage.
Reduce Variability in State Requirements for Essential Health Benefits
ACA regulations require states to select a plan to use as a benchmark for the law’s essential health benefits (EHB) requirements;25 states that did not choose a benchmark plan were assigned a state-specific default plan that became the benchmark. However, insurers are allowed to offer benefit packages that substitute some benefits included in the benchmark plan for others, as long as the benefits are in the same category—such as hospitalization—and actuarially equivalent (meaning they provide the same level of coverage).26 On the other hand, states may prohibit benefit substitution, which means that those states’ QHPs must offer the same benefits as the benchmark.27
Both federal and state regulators can improve the EHB process to ensure that exclusions, like those identified in this brief, do not impede women’s access to health care and coverage. Federal regulators could limit or prohibit exclusions through a number of regulatory strategies. For example, they could:
- prohibit benefit substitution in the EHB so that QHPs cannot contain any exclusions that do not exist in a state’s benchmark plan
- ban specific exclusions in QHPs or plans offering the EHB
- clarify that an insurer is violating the EHB requirements if it selectively uses exclusions to prevent high-cost claims or encourage high-cost enrollees to drop coverage.
State regulators can limit exclusions through the following actions:
- prohibit substitutions in the EHB, allowing only those exclusions contained in the state’s EHB benchmark plan, and reviewing compliance when approving plans
- require insurers whose plans contain exclusions that are not in the EHB benchmark to demonstrate that benefits are substantially similar to the benchmark, in compliance with federal regulations
- review plans for discriminatory exclusions and require insurers to revise these plans.
Ensure Transparency in Plan Documents
Plan summaries of benefits and coverage provide clear information to enrollees and potential enrollees about cost-sharing for certain services. However, because of a statutory page limit, they cannot describe all excluded services.28 While summaries for QHPs must now include information about how enrollees can receive the evidence of coverage or contract, more can be done to improve transparency regarding plan exclusions.29
Online marketplaces can increase transparency using these strategies:
- require QHPs to provide a detailed list of exclusions
- post the complete list of exclusions on the marketplace website in a searchable format
- remind enrollees to review exclusions before completing enrollment.
The ACA has improved women’s access to health coverage and care, yet exclusions create gaps in coverage that threaten their full access to health care and economic security. Regulators and insurers must take concrete steps to eliminate exclusions that disproportionately affect women, improve transparency in plan documents, and achieve the law’s goal of ensuring that women can obtain the coverage and care they need.