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Excluding Our Health: The Women’s Health Services that Plans Leave Out

Have you ever been surprised to receive a medical bill for a service that you thought would be covered by your health insurance? You get a service, you pay your copay, and you expect that is all you owe.  Then, you get a bill and find out that your insurance doesn’t pay for—or “excludes”—the service you received. These exclusions of women’s health services are the topic of a new report authored by the National Women’s Law Center and supported by the Commonwealth Fund—Women’s Health Coverage Since the ACA: Improvements for Most, But Insurer Exclusions Put Many at Risk.

Thanks to the Affordable Care Act, aka Obamacare, 89% of Americans now have health insurance. The uninsured rate is at a historic low. Subsidies have made premiums and cost sharing affordable for millions. Americans have unprecedented access to health care.  The ACA created a whole new marketplace that now includes many who were previously excluded from coverage—including many women.  But, health insurance does not guarantee access to every health care service that women need.

Some health care services are excluded from insurance.

After a claim is processed, insurance companies usually send you a notice called an Explanation of Benefits that tells you how much your plan paid and how much you owe. Often, an Explanation of Benefits will tell you that you owe your $20 copay or 20% coinsurance amount. But, sometimes the “Paid by Insurer” column is filled with zeros which means that the service isn’t paid for/covered by the plan.

Our new report reviewed insurance plans offered on the Health Insurance Marketplace websites.  We found that most of these plans included exclusions that can prevent women from accessing important health services.

What services were excluded from coverage?

The report examines six exclusions found in plans offered by 10% or more of the health insurers reviewed—and you may be surprised at some of these excluded services! For example, we found the following services that may be excluded under these plans:

  • Infection following a surgery not covered by the plan;
  • An allergic reaction from a medication not covered by the plan—such as an allergic reaction to preventative drugs given to a woman following a sexual assault;
  • Medication taken following breast cancer treatment to slow or prevent the cancer from returning;
  • Genetic testing if your heritage places you in a high risk to be a carrier for Tay Sachs disease or sickle cell anemia;
  • Surgery to reduce the number of fetuses if your pregnancy or your health is at risk because of a multiple pregnancy with complications;
  • Hospitalization related to a suicide attempt if you are not diagnosed with a mental health condition related to the attempt. This is an issue for women because women are more likely to survive a suicide attempt and be in need of hospitalization following an attempt than men; or
  • Prophylactic mastectomy if you are at a high risk of aggressive breast cancer.

What can you do?

Before you receive health care services, it is always a good idea to confirm what services are covered with your health plan.  This can help you to not only identify if services are excluded, but will also confirm if the health providers you may need are in your plan’s network  and  whether there are any costs you may be responsible for.

Before you enroll in health insurance, ask the insurer for a copy of the policy or plan document. You may need to contact an insurance broker if you are having difficulty accessing the document. Tell the insurer or broker that you want a full list of excluded services and covered benefits.  Be aware that the “Summary of Benefits and Coverage” and the plan brochure will only provide partial information.

Finally—you must still get covered! Just because health insurance does not cover every single health care service does not mean that it isn’t important. Health insurance plans do cover many important health services and all new health insurance plans must cover women’s preventive services, such as birth control, without cost sharing. So get educated. Get informed. And get covered!