National Partnership for Women & Families

In the News

Study finds health plan coverage exclusions can disproportionately affect women

Services that Affordable Care Act (ACA) (PL 111-148) marketplace plans may refuse to cover often disproportionately affect women, according to a recent study from the National Women's Law Center (NWLC), Kaiser Health News reports.

Under the ACA, insurers must provide a summary of benefits and coverage that discloses whether a plan excludes coverage for 13 specific services, including acupuncture and infertility treatment. The summaries are available online or in print and may not exceed eight pages in length. However, insurers also may refuse to cover certain other services without making a disclosure in the summary.

For the study, NWLC researchers reviewed coverage exclusions in marketplace health plans from 109 insurers. The plans were sold in 16 states in 2014 and 2015.

Key findings

The researchers found six categories of exclusions that could disproportionately affect women. For instance, 14 percent of plans refused to cover fetal reduction surgery, which a doctor may recommend when the number of fetuses a woman is carrying presents a threat to her health or to the likelihood that the pregnancy will continue to term.

Regarding the other categories of exclusions, the researchers found that 42 percent of plans did not cover care for conditions caused by non-covered health care services; 27 percent of plans did not cover maintenance therapy for a chronic condition or other care to prevent regression from a stable state; 15 percent did not cover genetic testing when the coverage is not required by law, including certain tests for breast and ovarian cancers; 11 percent did not cover treatment for self-inflicted conditions; and 10 percent did not cover preventive services not required by law.

According to the researchers, several of the exclusions they identified also could affect men.


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

Separately, Lisa Schlager -- vice president of community affairs and public policy at Force, an advocacy organization for people affected by hereditary breast, ovarian and related cancers -- discussed how the issue is particularly relevant for women with a family history of breast cancer or ovarian cancer who are seeking genetic testing or other preventive care.

Schlager explained that while insurers are required by law to cover testing for certain genetic mutations linked to breast or ovarian cancer, they are not obligated to cover all relevant genetic testing, nor do they have to cover other preventive services related to the conditions. "We are in this strange scenario where insurers are paying for the testing and then not paying for the breast MRIs or prophylactic mastectomies," she said.

Separately, Kirsten Sloan, senior policy director at the American Cancer Society Cancer Action Network, said patients may be confused by coverage distinctions. She cited a need for more transparency regarding covered services (Andrews, Kaiser Health News, 8/16).