Study finds gaps in women's health coverage under ACA

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Many marketplace health plans exclude coverage for health services that are more often used by women, resulting in a disproportionate affect on women's care coverage, a recent study found.

For the study, 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.

The study found that six types of services are frequently excluded from insurance coverage: treatment of conditions resulting from non-covered services, maintenance therapy, genetic testing, fetal reduction surgery, treatment of self-inflicted conditions and preventive services not covered by law.

Researchers said 46 of the 109 insurers examined exclude coverage of services that are related to, or arise from, other non-covered services. What's more, 29 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." Nine of the 29 insurers omit both types of treatment.

Furthermore, 16 of the 109 insurers exclude coverage of genetic testing not expressly required by law; 15 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; and 12 exclude services for self-inflicted injuries or conditions, the study found. Eleven of the 109 insurers apply exclusions to preventive services.

"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 authors concluded.

But Clare Krusing, a spokeswoman for America's Health Insurance Plans, a trade group, told Kaiser Health News the study doesn't address whether treatments are safe and effective for all patients, whether alternative treatments are covered or the processes in place to enable patients to access treatments if a plan doesn't provide coverage.

"If a patient has a medically necessary reason for this care, it will likely be covered," Ms. Krusing added.

Researchers recommended prohibiting variations within states' "essential health benefits" benchmark plans and requiring transparency and simplified language in plan documents.

 

More articles about payer issues:
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Medical University Hospital sues BlueCross BlueShield of SC for alleged nonpayment

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