Insurers facing widely disparate rules for reproductive health coverage

By John Hilton

Health insurance coverage of women’s reproductive services, including abortion, is fast becoming a confusing terrain that apparently not even insurers fully understand.

The Affordable Care Act requires most private health insurance plans to cover a set of essential health benefits, including reproductive health services. Likewise, several states have passed laws mandating additional coverage of reproductive healthcare.

When the Supreme Court of the United States overturned Roe vs. Wade in June and eliminated a woman's constitutional right to an abortion, it further muddied the waters.

Insurers are receiving a failing grade in some states. Oregon announced last week that all 12 insurers it audited failed to comply with the state’s Reproductive Health Equity Act.

“Insurers had an obligation to fully and timely implement each aspect of RHEA across all of their systems,” said Oregon Insurance Commissioner Andrew Stolfi. “It is disappointing to see that this did not happen. We will continue to monitor each insurer until they fully comply with RHEA and make whole any consumer harmed by these failures.”

Several consumer and women’s health groups are also monitoring the healthcare landscape.

“Across the country, vigorous monitoring and oversight continues to be necessary to guarantee that insurers, both in the private context as well as in Medicaid managed care, are meeting the requirements of the law, often across areas of health care services, including reproductive and sexual health care services,” said Amy Chen, senior attorney in the Los Angeles office of the National Health Law Program, a health care advocacy organization.

Free means free

Passed by the Oregon Legislature in 2017, RHEA covers annual wellness visits, birth control, abortions, cancer and sexually transmitted infection screenings, breastfeeding support and other services. Company insurance plans and Medicare are exempt from its mandates.

State regulators found that each of the 12 insurers failed to pay all eligible claims according to RHEA requirements. They applied copays, coinsurance, and deductibles, which are prohibited under RHEA for reproductive health and preventive care services. In some cases, insurers improperly denied claims for covered services.

In addition, the reports found that three insurers – Aetna, BridgeSpan, and Regence BlueCross BlueShield – failed to cover certain types of contraceptives or applied improper limitations on the amount or timing of when a member could refill a prescription.

Other insurers cited were Cigna Health and Life Insurance Co., HealthNet Health Plan of Oregon, Kaiser Foundation Health Plan of the Northwest, Moda Health Plan, PacificSource Health Plans, Providence Health Plan, Samaritan Health Plans, UnitedHealthcare Insurance Co., and UnitedHealthcare of Oregon.

All of the insurers, with the exception of Moda Health, filed responses with the state as of the publication of this article.

Three insurers accepted the audit findings: PacificSource, Kaiser and UnitedHealthcare of Oregon. Other insurers contested all or parts of Oregon’s report. Aetna, in particular, took issue with how regulators treated its responses to the evidence before and after a Dec. 16 hearing.

“Aetna continues to dispute the remaining findings of fact and conclusions of law contained therein,” wrote Kenneth G. Kubes, executive director and senior counsel for Aetna. “Rather than provide specific examples of claims that Aetna processed during the examination period in violation of RHEA, the final report instead makes general statements and draws inferences from hypothetical scenarios that are not supported by the data that Aetna actually submitted.”

A pair of insurers, Regence and BridgeSpan, suggested that Oregon regulators enact a rule that explains the requirements of the act.

“We support the intent and spirit of this important law to provide access to reproductive health services and contraceptives for Oregonians,” wrote Christopher G. Blanton, senior vice president of health plan operations for Regence. “The results of the market-wide examination indicate inconsistency with how the RHEA statute has been interpreted and implemented.”

Contraception coverage disputes with insurers are not new, said Laurie Sobel, associate director, women’s health policy for the Kaiser Family Foundation.

She pointed to “issues around what is considered reasonable medical management from insurance companies” who want to be able to put parameters around personalized contraception plans.

“Adoption of these changes will reduce barriers and expand access to comprehensive reproductive health care...”New Jersey Insurance Commissioner Marlene Caride

“Insurance companies are sort of used to being able to set parameters even when there's a mandate of some kind,” she explained.

The Colorado Division of Insurance recently reminded insurers to know their obligations. Colorado law ensures that anyone seeking contraceptive services, including tubal ligation surgery, can receive services without costs for the insured member.

“The division has recently become aware of instances where individuals may have received erroneous information that they would be responsible for some portion of costs for a surgical sterilization procedure,” said Colorado Insurance Commissioner Michael Conway.

Abortion fight

The debate over coverage of reproductive health services such as birth control largely generated back-page headlines in the decade since the ACA became law. That all changed once word leaked that the Supreme Court would overturn abortion.

Policy fights quickly ramped up and state legislators took sides. According to the Guttmacher Institute, one of several groups charting the abortion debate, eight states require abortion coverage in private health insurance plans.

On the other side, eleven states have laws in effect restricting insurance coverage of abortion in all private insurance plans written in the state, including those offered through health insurance exchanges established under the ACA.

“While some anti-abortion state lawmakers are rushing to ban abortion, we have seen bold, proactive action from states like California, Massachusetts, New Jersey, New York, and Oregon, which have allocated state funds to help people with the financial costs of getting an abortion,” said Morgan Hopkins, president of All Above All, an abortion rights group based in Washington, D.C. “So did many cities, including Atlanta, Chicago, and St. Louis.”

New Jersey is a typical of the blue-state approach to expanding health coverage for reproductive rights and abortion. The state Department of Banking and Insurance spent 2022 studying the issues for a 13-page report submitted to Gov. Phil Murphy in November.

Insurance Commissioner Marlene Caride cited the report’s findings in announcing new requirements for comprehensive abortion coverage among insurers in the individual and small employer markets, which took effect for the start of the 2023 plan year on Jan. 1.

As part of its report, carriers in the individual and small employer markets in New Jersey were asked to provide the impact of covering abortion without exception as part of their 2023 rate filings. Carriers estimated a range of zero impact to .1% of premium.

“Adoption of these changes will reduce barriers and expand access to comprehensive reproductive health care in the new year,” Caride said.

InsuranceNewsNet Senior Editor John Hilton has covered business and other beats in more than 20 years of daily journalism. John may be reached at [email protected]. Follow him on Twitter @INNJohnH.