LIKE A LOT OF U.S. MILLENNIALS, I’ve finally reached the age at which I’m responsible for purchasing my own insurance plan. As a person with chronic health conditions, I have to compare more than out-of-pocket maximums and office-visit costs. I pour over formularies, checking the tier assigned to each medication, calculating monthly costs on the low-deductible plan with uncovered generics and the high-deductible plan with free generics.
Perhaps because of my thoroughness, it never occurred to me that I might have overlooked gaps in coverage that I might one day need. But, according to a new study from the National Women’s Law Center and The Commonwealth Fund, however, I may have done exactly that.
The Affordable Care Act (ACA) created a uniform model for insurance plans, dictating which procedures and tests must always be covered, and forbidding insurers from charging higher premiums — or outright denying coverage — to people with pre-existing conditions, victims of sexual assault, and women. For the vast majority of U.S. citizens, the ACA provides a better health care system than we were stuck in before.
To comply with one ACA requirement, insurers must provide prospective buyers with a summary of benefits and coverage (SBC) that lists, among other things, whether or not the plan covers a range of services, including weight loss and cosmetic surgeries. But there exists a wide range of services that insurers may exclude without alerting individuals and families in advance. The bulk of these excluded services disproportionately affect women, and they represent contingencies that many of us don’t plan for.
Your insurance plan must cover routine gynecological visits, contraceptives, and maternity care. It must provide treatment for pre-existing and chronic conditions, and must cover both inpatient and outpatient services. However, if you are hospitalized for complications resulting from uncovered procedures or self-inflicted injury, your insurer is not required to help you defray the expenses of your stay. That means women who develop infections after cosmetic or bariatric surgeries, have eating disorders, or attempt suicide may find themselves buried under mountains of medical debt as a result.
A note, before we delve further into this: I do not intend to address here whether insurers should provide coverage for these conditions, or if a single-payer health care system could more adequately address women’s needs. These are valid, important arguments to have, but my concern lies with providing the information women need to select the best health insurance plans for themselves and their families.
So what are these excluded services that seem to target women? In addition to the aforementioned complication situations, insurers may also refuse to provide assistance for preventive or suppressive care for relapsing conditions. Plans do not have to offer a full range of genetic tests, and they may not cover fetal reduction procedures.
In 2014 and 2015, researchers examined 109 comprehensive health insurance plans from 16 states. Forty-six of those — a whopping 42 percent — did not provide coverage for complications arising from elective or non-covered procedures. An additional 11 percent of plans did not offer treatment for self-inflicted conditions. Twenty-seven percent refused to provide maintenance therapy. Genetic testing (15 percent) and fetal reduction services (14 percent) were, thankfully, among the procedures that were most likely to be covered.
Although health insurance providers may exclude these services, the National Women’s Law Center’s research suggests that the vast majority do offer some form of coverage for them. That’s wonderful, but it may leave some insurance shoppers expecting coverage where there will be none.
It’s unlikely that a woman will know, when she sits down to buy a plan, whether that year will involve medical problems. Investigating further into which of these excluded services your prospective providers will cover is important, even if you do not expect to find yourself in any of the situations listed above. Having a little knowledge and forethought will bring your finances into perspective, and can prevent you from falling into dire straits, should tragedy strike after you make a large purchase or take another monetary risk.
Start by acquainting yourself with the SBC format. When you’re shopping on the health insurance marketplace, these documents serve as quick-reference guides to the plans you examine. Decide which excluded services — including the 13 that appear on every SBC — are most important to you, and then place phone calls to each insurer’s customer service line. This will take a while, so start early, and keep track of everything you learn.
My intention is not to frighten anyone into obsessively documenting every detail about each and every marketplace health plan. You should be living your best life, and that’s not it. The simple fact remains that, as hard as you might try, you’ll never plan for every possible contingency; life throws some strange curve balls. However, knowing which ones your insurance will cover makes you that much more prepared when the time comes.
