With the release of the new Affordable Care Act health plans, HealthPocket examined what medical services were most frequently excluded from health insurance coverage in 2014 and compared the results to the most common exclusions in the pre-reform health insurance market. HealthPocket found that 80% of exclusions were the same between the 2013 and 2014 lists of medical services most frequently not covered by plans in the individual health insurance market.
The Essential Health Benefits requirements within the Affordable Care Act (also known as Obamacare) mandated that individually purchased health plans in 2014 include pediatric dental and vision coverage.1 Accordingly, children’s dental check-ups and children’s eyeglass coverage are no longer in the top 10 list of healthcare services excluded from insurance coverage. The absence of these two services allowed routine foot care and adult eye exams to enter the top 10 list for 2014.
The Essential Health Benefits mandate has increased the coverage of many other benefits such as maternity care but these benefits were not so scarce they were included in the top list of excluded healthcare services in the pre-Obamacare market. For example, services like doctor visits, hospitalization, lab tests, and emergency medical care already were covered by nearly all health plans in the pre-reform market.2 Maternity care, in comparison, was absent in two thirds of privately purchased health insurance plans.3 However, in the 2013 top 10 ranking the bottom ranked service was absent in 81% of plans.4
The Centers for Disease Control and Prevention has estimated that over one third of adults in the United States are obese.5 Under the Affordable Care Act, obesity screening and obesity counseling are mandatory medical services. These health benefits must be delivered as preventive care with no out-of-pocket costs.6 Despite these requirements, a lack of uniformity in coverage for obesity-related services persists in the individual health insurance market. Nanci Hellmich, writing for USA Today, commented, “Plans vary widely in what they will do. Some insurers are offering telephone counseling; others cover visits with a health coach, and some cover group sessions that offer lifestyle advice. Some are even referring patients to Weight Watchers.”7
HealthPocket found that despite Obamacare’s support of obesity-related preventive services weight loss surgery (e.g. gastric bypass) and weight loss programs are not covered by the majority of health insurance plans in the individual market. However, in 2013 93% of individual health plans did not cover weight loss programs while in 2014 that number had lowered to 88% of health plans. Likewise, in the pre-reform market weight loss surgery was not covered by 90% of plans while under Obamacare this exclusion has lowered to 59% of health plans.
Infertility treatments such as In Vitro Fertilization (IVF) are excluded from health insurance coverage in two thirds of individually purchased Obamacare health plans. In the pre-reform market, 94% of health plans had not covered Infertility treatments.8
As noted in HealthPocket’s previous study of coverage exclusions in the pre-reform market, 1-in-10 women of reproductive age pursue infertility services during their lives with the ratio reducing to 1-in-8 for couples.9 2008 data estimated the average cost of a single IVF cycle of treatment to be $12,400.10 Moreover, multiple cycles may be required before a live birth results.
The 10 Essential Health Benefits mandated by the Affordable Care Act include a degree of ambiguity. For example, the Affordable Care Act requires health plans to cover prescription drugs but the legislation does not instruct which drugs should be covered nor does it dictate the cost-sharing level to which the various covered drugs should be assigned. Through the selection of a “benchmark plan,” a state provides specificity to the Essential Health Benefits obligation. The benchmark plan’s benefit within each Essential Health Benefit category establishes the minimum acceptable coverage within that category for the state’s individual and small group health plans.
The table11 below documents each state’s benchmark plan coverage status for 4 different medical services within the top 10 list of excluded medical services. Coverage for infertility treatments and weight loss programs is noted as well as routine foot care and adult eye exams (the latter two being new to the list of medical services from insurance coverage).
While the Affordable Care Act has exerted an enormous influence over the individual health insurance market, its effect upon the most commonly excluded medical services has been less extensive. Most of the healthcare services excluded in the pre-reform market have remained in the Obamacare era. Nevertheless, there has been a marked decrease in coverage exclusions for items such as infertility treatments and weight loss surgery.
It is unclear whether the currently polarized discussion of healthcare reform will allow for a meaningful consideration of many of the excluded services within the top 10 list. These items, while important, are not likely to have the same public significance as overall healthcare spending, premium inflation, and network provider breadth. Consequently, it seems that these exclusions are more likely to be addressed at the state level if addressed at all.
All medical service exclusion data pertained to the four Affordable Care Act metal plans: bronze, silver, gold, and platinum. All plans investigated in this study belong to the individual & family insurance market. Medicare, Medicaid, short-term health insurance, and group health insurance plans were not analyzed as part of this study.
Data records for 3,094 health plans in the 2014 individual & family health insurance market were obtained on February 18, 2014. HealthPocket collected health plan data from the health plan data API provided by the Department of Health & Human Services.
Data regarding medical exclusions in the pre-reform 2013 market was taken from the HealthPocket study “Top 10 Medical Services Excluded by Health Insurance” (see endnotes for full citation).
This analysis was written by Kev Coleman, Head of Research & Data at HealthPocket, with data analysis performed by Jesse Geneson, data researcher at HealthPocket. Correspondence regarding this study can be directed to Mr. Coleman at firstname.lastname@example.org.
Feedback and questions are welcome but, given the volume of email, personal responses may not be feasible.
1 “What’s Covered in the Health Insurance Marketplace.” https://www.healthcare.gov/blog/10-health-care-benefits-covered-in-the-health-insurance-marketplace/
2 Kev Coleman. “Almost No Existing Health Plans Meet New ACA Essential Health Benefit Standards.” HealthPocket.com (March 7, 2013). /healthcare-research/infostat/few-existing-health-plans-meet-new-aca-essential-health-benefit-standards/.
4 Kev Coleman. “Top 10 Medical Services Excluded by Health Insurance” HealthPocket.com (July 31, 2013). /healthcare-research/infostat/few-existing-health-plans-meet-new-aca-essential-health-benefit-standards/.
5 Adult Obesity Facts. http://www.cdc.gov/obesity/data/adult.html
6 “What are my preventive care benefits?” https://www.healthcare.gov/what-are-my-preventive-care-benefits/
7 Nanci Hellmich. “Obamacare requires most insurers to tackle obesity.” USA Today. (July 4, 2013).
8 Coleman. “Top 10 Medical Services Excluded by Health Insurance.”
9 2% had an infertility-related medical appointment within the previous 12 months while additional 10% had obtained infertility services at some previous time. Centers for Disease Control and Prevention, American Society for Reproductive Medicine, Society for Assisted Reproductive Technology. 2010 Assisted Reproductive Technology Fertility Clinic Success Rates Report. Atlanta: U.S. Department of Health and Human Services; 2012. p.3. http://www.cdc.gov/art/ART2010/PDFs/ART_2010_Clinic_Report-Full.pdf. See also
10 Adrienne Asch and Rebecca Marmor, "Assisted Reproduction," in From Birth to Death and Bench to Clinic: The Hastings Center Bioethics Briefing Book for Journalists, Policymakers, and Campaigns, ed. Mary Crowley (Garrison, NY: The Hastings Center, 2008). p.6.
11 All data taken from the government’s web site The Center for Consumer Information & Insurance Oversight (CCIIO). http://www.cms.gov/cciio/resources/data-resources/ehb.html#review%20benchmarks
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