Many women were thrilled when the Affordable Care Act became law in 2010, because it required insurance companies to cover a broad array of women's health services without any out-of-pocket costs.
Five years later, however, the requirement isn't being enforced, according to two new studies. Health insurance plans around the country are failing to provide many of those legally mandated services including birth control and cancer screenings.
The studies by the National Women's Law Center looked at health plan coverage documents and consumer complaints in 15 states. One of the studies focused on contraception, while the other looked at a range of women's health issues, including maternity care, breast-feeding support and other services.
"We found some very clear violations of the law," said Karen Davenport, the group's director of health policy. Among the companies named as not complying with the law's requirements in at least some states are Aetna, Cigna, Physicians Plus and Anthem Blue Cross Blue Shield.
For example, Physicians Plus, a plan offered in Wisconsin in 2014, limited coverage of prenatal vitamins to women under the age of 42. And several companies in the study refused to provide coverage for birth control for women over age 50, despite the fact that many women are able to get pregnant long after that.
The report on required coverage of birth control found numerous instances where health plans impermissibly try to impose cost-sharing on all except generic products. There are, however, no generic intrauterine devices, and in some cases women have a medical need for brand-name products. Many plans in the study also failed to cover costs associated with birth control, such as follow-up appointments, researchers found.
One woman in Washington, D.C., who complained to the organization's "CoverHer" hotline, said she was told her IUD would be covered, then, after it was inserted, her claim was denied. "The insurance company says I can appeal their decision by writing a letter telling them how the decision 'made me feel,' " she said, according to the report.
The study's authors called for more and better enforcement of the rules regarding women's health coverage. "We don't need legislation," said Sharon Levin, who runs the group's reproductive health policy program. "We have that. We need better enforcement."
The insurance industry disputed the reports' conclusion that the problem is widespread. "This report presents a distorted picture of reality," said Karen Ignagni, president and CEO of America's Health Insurance Plans, the industry's primary trade group. "Health plans provide access to care for millions of women each day and receive high marks in customer satisfaction surveys. To use highly selective anecdotes to draw sweeping conclusions about consumers' coverage does nothing to improve the quality, accessibility, or affordability of health care for individuals and families."
Researchers examined publicly available documentation for more than 100 separate policies in 15 states for plan years 2014 and 2015, including plans in states running their own insurance exchanges and those using the federal HealthCare.gov. It found that more than half of the plan documents described coverage at odds with the health law.
The findings in the birth control report are similar to those in a report released earlier this month by the Kaiser Family Foundation. That study looked at 20 insurance carriers in five states and found that almost all the plans limited access to some forms of birth control in some way, either by not covering them at all or by charging a copay.
One source of confusion is the fact that under federal implementation guidelines, insurance plans may use so-called medical management techniques that are aimed at keeping overall costs (and premiums) down.
But Levin said it remains unclear what counts as "acceptable" medical management tools. Some plans, she said, count any contraceptive that uses hormones as a single method. That lumps together pills, patches, and vaginal rings, and then covers just one generic version of the treatment. Yet the law requires plans to make available all FDA-approved methods of birth control without cost-sharing. "We need better clarification" from the federal government, she said.
In at least some cases, consumers and advocates complained to insurers and policies were changed. "Calling and complaining to your insurance company works," said Levin, noting that Aetna has reversed a decision not to cover the vaginal ring.