Are you complying with ACA coverage requirements?

July 13, 2015

A recent report claims that many insurers are failing to comply with ACA coverage requirements. Here are some of the key requirements to pay attention to.

In April, the Washington, D.C.-based National Women’s Law Center (NWLC) released a report claiming that many payers are failing to comply with several of the Affordable Care Act (ACA) coverage requirements. The report is one of the latest in a string of complaints lodged by organizations and regulators.

Read: Exchange plans fail to offer required smoking cessation coverage

According to the NWLC report, which analyzed coverage offered on health insurance marketplaces by more than 100 insurance companies in 15 states,

of health plans aren't complying with many of the ACA standards related to women's health. Some of the key findings from the report include:

• Fourteen issuers across seven states offer maternity coverage that does not comply with the ACA, such as excluding maternity care coverage for dependents.

• Fifty-six issuers across 13 states offer coverage of preventive services that does not comply with the ACA, from imposing limits on breastfeeding supports and supplies, to not covering well-woman visits, to offering coverage of genetic testing that does not comply with the law, to failing to offer birth control coverage as required.

• Seven issuers in four states impermissibly limit essential health benefits in ways that restrict women’s access to critical services, such as improperly limiting drug coverage and maintenance therapies or establishing waiting periods for certain services.

The outgoing president and chief executive officer of America’s Health Insurance Plans, Karen Ignagni, was critical of the NWLC report, telling The New YorkTimes in an April 29 article that the report presented “a distorted picture of reality.” She also said that “Health plans provide access to care for millions of women each day and receive high marks in customer satisfaction surveys,” and noted that payers can use “reasonable medical management techniques” to control costs and encourage the efficient delivery of care.”

NEXT: Other organizations voice similar concerns

 

 

Still, other organizations, have voiced concerns similar to those included in the NWLC report. 

The Kaiser Family Foundation (KFF) along with the Lewin Group, for instance, recently issued a report noting a variation in how the contraceptive coverage provision is being interpreted and implemented by health plans.

"While most carriers are complying with the spirit of this requirement, there are exceptions," the executive summary states. "Because of these coverage differences some women may not have coverage without cost-sharing to the contraceptive method of their choice."

A September 2014 study conducted by the New York City-based Guttmacher Institute found that “the contraceptive coverage guarantee under the ACA is working as intended.” The organization, however, found that there are still gaps in coverage, due largely to federal guidelines that allow insurers to charge copays in limited situations.

Next: What health plans need to cover

 

Under Section 2713 of the ACA, most private health plans are required to provide coverage for several preventive services without requiring a copay from patients, according to the KFF. Individual and small group plans in the marketplaces also must cover an essential health benefit (EHB) package.

Read: Your essential benefits checklist

Women’s preventive healthcare, including mammograms, cervical cancer screenings and prenatal care, generally must be covered with no cost sharing.

In a May 14 press release, the Department of Health and Human Services (HHS) outlined the preventative services that Americans with private insurance have access to, without being held responsible for a copay. These preventative services include “well-woman” visits and FDA-approved contraceptive methods.

Others include:

• Blood pressure screening

• Obesity screening and counseling

• Well-baby and well-child visits

• Flu vaccination and other immunizations

• Domestic violence screening and counseling

• Tobacco cessation interventions

• Vision screening for children

• HIV screening

• Breastfeeding support and supplies

• Depression screening

Next: Mental health coverage concerns

 

 

The ACA also requires that most individual and small employer health insurance plans, including all plans offered through the marketplaces cover mental health and substance use disorder services, according to HHS. In addition, as of 2014, most plans cannot deny coverage or charge consumers more due to pre-existing health conditions, including mental illnesses.

Still, some groups and lawmakers claim that more steps need to be taken to ensure consumer access to mental health coverage. 

On May 8, 17 senators issued a letter to HHS Secretary Sylvia M. Burwell, urging her to increase consumer protections for patients seeking coverage for mental health and substance use services and treatments.

The letter cites a recent study from the Arlington, Virginia-based National Alliance of Mental Illness that found nearly one-third of respondents surveyed has or has a family member who has been denied mental healthcare, despite medical necessity. The senators closed their letter with a request that Secretary Burwell remedy these coverage gaps for the 2016 plan year.