Top 5 Women's Services Excluded from ACA Plans

Coverage gaps in women’s health coverage can lead to poor patient outcomes and increased costs.

A recent study found major gaps in women’s health coverage in plans sold on Affordable Care Act (ACA) exchanges. These gaps could potentially leave women with higher out-of-pocket costs and poor health outcomes.

Under the ACA, health insurers cannot legally deny coverage or charge higher premiums due to gender or previous health conditions, a practice widely used before the health law, according to a study published by the Commonwealth Fund.

Individual plans must cover maternity services, birth control, mammograms, and other preventative services related to women’s health. Although the coverage has improved, exclusion of services for women still exist.

In the study, researchers examined exclusions in qualified health plans (QHPs) from 109 health insurers. Insurers determine the medical necessity of services based on research that tends to underrepresent women, according to the study.

This leaves significant gaps in women’s health coverage.

Top 5 excluded services for women:

1. Treatment for conditions resulting from non-covered services

Nearly half (42%) of insurers included in the study did not cover services that arise from other non-covered services, such as an infection from a non-covered procedure.

2. Maintenance therapy

Approximately 27% of insurers exclude maintenance therapy. Some insurers also exclude ongoing treatment that prevent regression in conditions that are considered to be stable.

Conditions such as lupus, depression, chronic, pain, and chronic conditions are more likely to affect men than women, and require maintenance therapy, according to the study. Other conditions that require maintenance therapy are breast and lung cancers.

3. Genetic testing

For genetic testing, 15% of insurers excluded this service that could determine the need for preventative services. These tests can examine the risk of breast and gynecological cancers. Currently, only 2 gene mutations related to the cancers are covered, although many more are associated, according to the study.

Preconception genetic testing is a common practice that can prepare patients to make informed decisions about pregnancy risks, and to prepare for any health needs that may arise.

4. Fetal reduction surgery

Fetal reduction surgery was excluded by 14% of insurers. Multifetal pregnancies can cause serious health risks in women and could potentially endanger the life of the mother and fetus. This service could improve the chances of a successful pregnancy in some patients since these pregnancies can cause hypertension, preeclampsia, and postpartum hemorrhage.

5. Treatment of self-inflicted conditionsSince women are more likely to attempt and survive a suicide attempt, excluding these services could result in large out-of-pocket costs for patients. Additionally, these plans do not provide a concrete definition of “self-inflicted.”

This can lead to denial of coverage for serious conditions resulting from a physical or mental health condition such as an eating disorder or depression. Out of the 12 insurers that exclude this treatment, 4 exempt effects of these conditions.