April 30, 2015 — Not all insurers are meeting the Affordable Care Act's (PL 111-148) requirement that plans provide a range of preventive services at no cost, with some insurers not covering or requiring cost-sharing for several women's health benefits, according to new studies from the National Women's Law Center, Kaiser Health News reports (Rovner, Kaiser Health News, 4/30).
The ACA's preventive services provision, which took effect in 2012, requires insurers to cover a range of services, including comprehensive coverage of breastfeeding equipment and support, without copayments or deductibles (Women's Health Policy Report, 3/9).
Meanwhile, federal guidance on the contraceptive coverage rules under the ACA states that insurers must cover the full range of FDA-approved contraceptive methods without cost sharing. However, insurers are permitted to use "reasonable medical management techniques" to curb costs, such as only covering the generic version of an approved contraceptive (Women's Health Policy Report, 4/17).
Details of Studies
According to KHN, one study specifically addressed contraceptive coverage, while a second study analyzed coverage for several women's health benefits, such as breastfeeding support and maternity care.
For the studies, researchers analyzed publicly available insurance documents for more than 100 plans in 15 states, including states operating their own marketplace and those using the federal marketplace. They looked at policies from plan years 2014 and 2015 (Kaiser Health News, 4/30).
In addition, the study on contraception also included information from NWLC's communication with insurers and with women calling into NWLC's CoverHer hotline, which assists women who are not receiving contraceptive coverage as required by the ACA (NWLC release, 4/29).
Key Findings: Contraceptive Coverage
In the contraceptive coverage study, NWLC found that several plans either did not provide certain FDA-approved contraceptives to some or all women or required cost-sharing for the products. For example, several plans did not cover contraceptives for women ages 50 and above, and some plans did not cover follow-up visits or other costs associated with contraceptives (Kaiser Health News, 4/30).
Researchers said insurers most often violated ACA requirements by not adequately covering intrauterine devices, hormonal patches or vaginal rings. According to NWLC, some insurers "suggest[ed] that a woman switch methods if she [did] not want any out-of-pocket costs" (Ferris, The Hill, 4/29).
For example, NWLC found that some insurers were not covering the copper IUD, which does not have a generic equivalent (Radnofsky, Wall Street Journal, 4/29). In addition, some insurers covered generic versions of certain contraceptives without also covering the brand-name versions.
Further, some insurers said they did not provide coverage for the ring or the patch because they already covered oral contraceptives, which deliver the same hormones (Pear, New York Times, 4/29). However, HHS officials have previously said that because oral contraceptives are different types of methods than the ring or the patch, they all must be covered (Women's Health Policy Report, 4/17).
Key Findings: Other Women's Health Benefits
In the second study, researchers found that more than 50% of the plan documents analyzed appeared to be in violation of ACA requirements (Kaiser Health News, 4/30).
For example, NWLC found that some health plans did not cover maternity care for dependents (Johnson, AP/Sacramento Bee, 4/29). In addition, some plans did not provide certain breastfeeding supplies (Wall Street Journal, 4/29).
The study cited several other examples, such as a Wisconsin plan that in 2014 provided only limited coverage for prenatal vitamins for women younger than age 42 (Kaiser Health News, 4/30). Meanwhile, an Alabama plan would cover only six annual prenatal visits for women, and plans in Colorado and South Dakota limited ultrasounds for pregnant women.
NWLC Recommendations, Comments
NWLC urged regulators to increase oversight of health plans and called on insurers to comply with the ACA. In addition, researchers called for increased public access to insurers' coverage documents, particularly to help individuals who want to compare plans.
Gretchen Borchelt, NWLC's vice president for health and reproductive rights, said "The health care law has done so much for women. We now need to make sure it reaches every woman and every woman gets the full range of benefits required by the law" (AP/Sacramento Bee, 4/29).
Rep. Rosa DeLauro (D-Conn.) said, "The rules prohibiting cost-sharing on preventive care, including contraception, are clear, and insurers who are not following them are in violation of the law. Insurance companies need to come into compliance immediately. [HHS] and state regulators need to crack down on those who do not."
Similarly, Sen. Patty Murray (D-Wash.) said she is "extremely disappointed" by the findings, and she urged HHS Secretary Sylvia Mathews Burwell to address the issue (New York Times, 4/29).
Meanwhile, HHS spokesperson Katie Hill said the Obama administration takes allegations of insurers not complying with the ACA "very seriously." She said, "HHS continues to work with the states, which play a key role in ensuring that insurance plans follow the law." Hill added that HHS "will continue to provide guidance to help ensure that women have access to recommended preventive benefits and will explore whether additional measures are necessary" (Wall Street Journal, 4/29).
According to Burwell, the administration intends to clarify its guidance for states' insurance regulators (New York Times, 4/29).
Meanwhile, some insurers said that they had made changes to their policies after recognizing coverage problems or that they would rework the language in their plans' coverage certificates to clarify what services are covered (Wall Street Journal, 4/29).
Karen Ignagni, America's Health Insurance Plans' president and CEO, said the "report presents a distorted picture of reality." She noted that insurers "provide access to care for millions of women each day and receive high marks in customer satisfaction surveys" (Kaiser Health News, 4/30).
Sen. Murray Urges Wash. Plans To Comply With ACA
In related news, Murray on Tuesday sent a letter to the eight Washington state insurers who offer marketplace coverage in the state expressing concern that they are not complying with the ACA's contraceptive coverage rules, The Hill reports.
Murray sent the letter in response to a report by NARAL Pro-Choice Washington and Northwest Health Law Advocates on the eight health plans. According to the report, the insurers sometimes gave beneficiaries erroneous information about having to pay for contraceptives.
In the letter, Murray said the insurers' lack of transparency about their coverage "is unacceptable." She added, "A benefit that's hidden from consumers is the same as having no benefit at all. Insurers must do their part to provide accurate information to all Washingtonians."
According to The Hill, the Washington insurance commissioner said this month that the insurers cited in the report have agreed to rework their benefit information. Murray indicated in her letter that she would monitor their work to ensure compliance (Sullivan, The Hill, 4/28).