In the current individual and family health insurance market, coverage of medical services is not standardized and a variety of important services, ranging in expense and medical necessity, are not included within the benefits of most insurance plans.1 HealthPocket examined 11,365 health plans in the individual and family market to determine which medical services were most likely to be excluded from coverage.
One of the most paradoxical findings within the list of excluded medical services concerned weight loss interventions. Weight loss programs and weight loss surgery (i.e. bariatric surgery) were ranked #4 and #8 respectively in the top 10 listing. In comparison, chiropractic care (ranked #23) was far more likely to be covered than weight loss programs and surgery. Current statistics from the Centers for Disease Control and Prevention estimate that over one third of the adult Americans are obese.2 Given the relationship of obesity to higher lifetime medical expenses3 as well as the development of costly chronic conditions such as diabetes, lack of coverage for weight loss programs is curious. However, until 2014 insurance plans can reject insurance applicants for medical considerations such as obesity and some insurers may have reduced their need for weight loss benefit coverage by virtue of which insurance applicants they rejected. Additionally, given the rapid customer turn-over rates in the individual and family health insurance market, an insurer may not retain the average customer long enough to realize the financial benefits of covering an expensive weight loss surgery such as gastric bypass. To provide some perspective on this issue, a recent medical study found that the average cost of weight loss surgery for study participants was $29,500 and that healthcare costs for those patients in the 6 years following surgery were not lower than for similar patients who did not receive surgery.4
The Affordable Care Act requires obesity screening and counseling among health plan preventive services with no out-of-pocket expenses owed by the patient. Weight counseling can take many forms depending on the insurer, such as group sessions and telephone counseling.5 Coverage of weight loss surgery is not required nor is coverage for a specific 3rd party weight loss program such as Weight Watchers.
The American Medical Association (A.M.A.) recently declared obesity a disease,6 a decision that may have far-reaching implications for insurance coverage as well as the medical service exclusion rankings. Federal and state governments may use the A.M.A.’s announcement as a justification to require insurance coverage for weight loss surgery, weight loss medications, and other interventions. Likewise, employers may be required to make special accommodations for obese workers if the definition of obesity as a disease becomes normative. However, it should be noted that the A.M.A.'s characterization of obesity as a disease was in opposition to its own Council on Science and Public Health that had recommended obesity not be considered a disease but rather a condition or disorder.7
The medical service most frequently excluded in health insurance is long-term care. 98% of health plans examined did not cover long-term care (LTC) expenses. LTC is a broad benefit category that, in the context of health insurance, includes professional health services for people requiring assistance for an extended period of time due to a chronic condition or disability. The elderly have disproportionate representation among long-term care recipients8 though younger age groups also receive this type of care.
By definition, LTC represents a lengthy period of financial responsibility for care and the high associated expense can plausibly be assumed to be the reason why most insurers do not cover this service. The CLASS (Community Living Assistance Service and Supports) Act, a federal LTC insurance program championed by the Obama Administration, was suspended in 2011 before the insurance was available due to concerns about the program’s financial sustainability and then subsequently repealed in The American Taxpayer Relief Act of 2012.9 For those buying long-term care coverage on the private market, the number of insurers in the market has dwindled and recent premium increases on existing policies have been reported to be as high as 80%.10
Infertility treatment was the third most frequently excluded medical service, with consequences for a considerable portion of the American population. Government research has observed that over 1-in-10 women of reproductive age had pursued some form of infertility services during their lives.11 With respect to couples, the ratio is 1-in-8.12 By 2012, various states had mandated health insurance plans cover infertility treatment in some manner but the laws vary with respect the conditions under which infertility treatment must be offered as an option or required as a standard benefit.13
A combination of factors may contribute to insurance companies reluctance to cover infertility treatments. The government’s 2010 Assisted Reproductive Technology Fertility Clinic Success Rates Report documented that 70% of assisted reproductive technology cycles in 2010 failed.14 Data published in 2008 estimated the average cost of an in vitro fertilization (IVF) treatment cycle to be $12,400 with the prospect that multiple IVF cycles may be needed to achieve a live birth.15 Additionally, children born from IVF have a higher incidence of birth defects according to UCLA researchers.16 In context of potential insurance expenses and its implications for coverage decisions, it is relevant to note that the "management of birth defects accounts for a large part of pediatric surgical care and demands significant health care resources."17
Ranked #11, hearing aids narrowly missed inclusion within the list of top excluded medical services. 77% of health plans examined did not cover hearing aids. Medicare, the health insurance program primarily serving individuals age 65 and older, also does not cover hearing aid expenses. According to Kaiser Health News, hearing aids can cost thousands of dollars and are obtained for only one quarter of the thirty five million Americans who would benefit from the technology.18 Only 19 states require health insurance coverage to include hearing aids.19 As was the case for long-term care exclusion, hearing aid exclusions affect seniors more frequently than younger age groups.
While there is a great deal of consistency in coverage for doctor visits, emergency care, and hospitalization, in the current health insurance market there are numerous healthcare services not included within the benefits of most insurance plans. The Affordable Care Act attempts to normalize much of health insurance coverage through a minimum set of benefit categories for health insurance known as the Essential Health Benefits. All qualified health plans will need to meet this benefit standard by January 1, 2014. With respect to the top 10 excluded medical services, the Essential Health Benefits will eliminate some exceptions and introduce partial coverage to other exceptions. Both children’s eyeglasses (ranked #9) and dental check-ups (ranked #7) will be covered under the Affordable Care Act. As mentioned earlier in the study, weight loss diagnosis and varying degrees of counseling will be covered as preventive services under the Affordable Care Act but not specific weight loss programs such as Weight Watchers or Jenny Craig. Newborn hearing screenings are also covered as a preventive service under the Affordable Care Act but not hearing aids.
Maternity-related benefits will also be required under the Essential Health Benefits. Consequently, prenatal and post natal care (ranked #15) as well as delivery (ranked #13) will no longer be excluded benefits in 2014 for qualified health plans.
An additional aspect of the Affordable Care Act’s affect upon excluded medical services pertains to the use of "benchmark" health plans. A benchmark plan is a health insurance plan selected by each state (and D.C.) to provide specificity to generalized insurance coverage requirements of the Essential Health Benefits. If a benchmark plan includes one of the excluded benefits listed in this study, it would be covered by all qualified health plans in the state that selected that benchmark plan.
Results were based on an analysis of 11,365 health plans from the individual and family health insurance market. Plan information was collected from Health & Human Services records on July 25, 2013. Exclusion analysis was based on medical services explicitly noted as excluded or "not covered" within health plan records.
All analysis assumes the accuracy of the underlying government data. While every effort was made towards a comprehensive collection of plans, HealthPocket makes no representation that every plan within the individual insurance market or in an individual state was included in this study. Statistics are not weighted by plan enrollment or application volume. Percentages are rounded according to standard industry practices.
This survey analysis was completed by Kev Coleman, Head of Research & Data at HealthPocket.com. Correspondence regarding this study can be directed to Mr. Coleman at email@example.com.
Feedback and questions are welcome but, given the volume of email, personal responses may not be feasible.
1 For a review of benefit levels within the current individual and family health insurance market, see 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/
3 "Overweight or obese patients have higher health care expenditures: Research Activities." December 2011, No. 376. December 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/newsletters/research-activities/dec11/1211RA12.html
4 Genevra Pittman. "No long-term cost savings with weight loss surgery" Reuters. February 20, 2013. http://www.reuters.com/article/2013/02/20/us-no-long-term-cost-savings-with-weight-idUSBRE91J18Y20130220. Last accessed July 29, 2013. See the original study at JAMA Surgery, http://archsurg.jamanetwork.com/article.aspx?articleid=1653574.
5 Nanci Hellmich, "Obamacare requires most insurers to tackle obesity" USA Today. July 4, 2013. http://www.usatoday.com/story/news/nation/2013/07/04/obesity-disease-insurance-coverage/2447217/. Accessed July 26, 2013.
6 Andrew Pollack. "A.M.A. Recognizes Obesity as a Disease" New York Times. June 18, 2013. http://www.nytimes.com/2013/06/19/business/ama-recognizes-obesity-as-a-disease.html?_r=0. Accessed July 26, 2013.
10 Phyllis Furman. "Long-term care insurance is pricier than ever, but for some the peace of mind is worth it." New York Daily News. July 22, 2013. http://www.nydailynews.com/new-york/long-term-care-insurance-pricier-peace-mind-worth-article-1.1403931?localLinksEnabled=false. Accessed July 26, 2013.
11 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
14 2010 Assisted Reproductive Technology Fertility Clinic Success Rates Report. p.21. The report documents 100,824 assisted reproductive technology cycles in 2010 that resulted in 30,439 live births.
15 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.
16 Amy Albin. "In vitro fertilization linked to increased risk of birth defects." UCLA Newsroom. October 22, 2012. http://newsroom.ucla.edu/portal/ucla/in-vitro-fertilization-ivf-linked-239713.aspx. Accessed July 26, 2013.
18 Michelle Andrews. "Say What? Most Insurance Covers Little Of The Cost Of Hearing Aids." Kaiser Health News. April 9, 2012. http://www.kaiserhealthnews.org/features/insuring-your-health/2012/hearing-aids-coverage-skimpy-michelle-andrews-041012.aspx. Accessed July 26, 2013.
19 Jen Christensen. "Hearing loss an 'invisible,' and widely uninsured, problem." CNN. July 10, 2012. http://www.cnn.com/2012/07/10/health/hearing-aid-insurance. Accessed July 26, 2013.
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