Women unaware of ACA coverage

Despite law, half of insured women have partial or no birth control coverage

By Tara Bannow / The Bulletin / @tarabannow

Preventive services for women required to be covered under ACA

All Affordable Care Act-compliant health insurance policies must cover the following services for women without a copayment or coinsurance, even if they have not met their annual deductible.

• Well-woman visits to get recommended services for women younger than 65

• Mammography screenings every 1 to 2 years for women older than 40

• Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity. This does not apply to plans sponsored by certain exempt religious employers.

• Breast Cancer Genetic Test Counseling (BRCA) for women at higher risk for breast cancer

• Cervical cancer screening for sexually active women

• Breast Cancer Chemoprevention counseling for women at higher risk

• HIV screening and counseling for sexually active women

• Osteoporosis screening for women older than age 60 depending on risk factors

• Breastfeeding comprehensive support and counseling from trained providers, plus access to breastfeeding supplies, for pregnant and nursing women

• Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes

• Chlamydia screening for younger women and other women at higher risk

• Intimate partner violence screening and counseling for all women

• Folic Acid supplements for women who may become pregnant

• Gonorrhea screening for all women at higher risk

• Hepatitis B screening for pregnant women at their first prenatal visit

• Human Papillomavirus (HPV) DNA test every 3 years for women with normal cytology results who are 30 or older

• Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk

• Sexually transmitted infections counseling for sexually active women

• Tobacco use screening and interventions for all women

• Urinary tract or other infection screening for pregnant women

• Routine anemia screenings for pregnant women

• Syphilis screening for all pregnant women or other women at increased risk

-Source: healthcare.gov

Every once in a while, Dr. Lauren O’Sullivan will see a patient who – just as she’s about to leave after a routine check-up — asks whether Sullivan tested for a certain sexually transmitted infection.

“Patients think that there is just a set group, like they come in and say, ‘I want routine labs.’ Well, there is no such thing,” said O’Sullivan, a gynecologist and surgeon in Bend.

Rather, doctors like O’Sullivan decide what tests to run based on things like age, gender and risk factors.

“I would say a lot of women don’t understand exactly what has been tested for and what hasn’t,” she said.

Although Affordable Care Act-compliant health insurance plans must cover testing for certain STIs among women, a recent Kaiser Family Foundation survey showed more than half of women don’t understand that they have to specifically ask for such services, as they’re not part of a routine exam. It was one of several areas where the survey highlighted dramatic lapses in women’s understanding of the health care system and the new services available to them with no out-of-pocket costs under the Affordable Care Act.

Survey responses from more than 1,400 women ages 15 to 44 were included in the report, which covered subjects such as insurance status, access to contraceptives, preventive services like mammograms and pap tests, STI testing and provider counseling on an array of topics.

According to the report, 40 percent of women said they had received an STI test within the past two years. Among those, 53 percent assumed it was part of a routine physical exam — but it’s not.

Because of that incorrect assumption, it’s impossible to know how many women actually received STI testing, said, Alina Salganicoff, vice president and director of women’s health policy for the Kaiser Family Foundation.

Often the misunderstanding happens when patients receive pap tests, which test for cervical cancer, she said. That’s an invasive test in which the doctor collects cells from the cervix for testing.

“Unless the doctor tells you they’re going to do a test for chlamydia or for gonorrhea or an HPV test, you can’t be sure that you’re actually getting that test,” Salganicoff said.

The solution is simple, O’Sullivan said: Don’t assume anything.

“Ask the question, be engaged in your own health care,” she said. “Even if it’s a quote ‘routine’ visit, ask ‘Hey, what are we going to do today?’”

Preventive coverage

Perhaps the biggest change the Affordable Care Act brought for women was its requirement that new insurance policies cover preventive services without any co-pays, coinsurance or other out-of-pocket costs.

Although the law that passed outlined a series of specific preventive services for everyone — such as routine screenings and counseling — it also directed the U.S. Health Resources and Services Administration to decide which preventive services insurance plans would have to cover specifically for women. The eight-item list — implemented about a year after the Affordable Care Act was passed — includes well-woman visits, contraceptives, preventative screenings like mammograms and pap tests and counseling on issues like STIs and HIV.

“It’s a huge change and it’s really, really important for health care,” said Michelle Berlin, an OB-GYN and co-director of Oregon Health & Science University’s Center for Women’s Health. “There’s no question about it.”

Although 74 percent of women Kaiser surveyed knew about the Affordable Care Act’s insurance mandate, only 60 percent knew it required plans to pay the full cost of an annual preventive visit, coverage that’s not mandated for men. Another 57 percent knew about the coverage for preventative services, and 34 percent knew it requires insurers to cover the full cost of breast pump rentals for new mothers.

Such figures weren’t surprising for Salganicoff, who regularly works on similar surveys for the Kaiser Family Foundation. The survey was performed in the fall and early winter of 2013, just before open enrollment began to sign up for health insurance in 2014. The idea was to get a baseline idea of people’s understanding early on, and then measure whether that changes over time, she said.

O’Sullivan, of Bend, said it’s disappointing that patients don’t understand the basics, but she doesn’t blame them. Health insurance is confusing, and insurance companies only make things more complicated, she said.

“When you sign your contract, it’s this long thing, it is really very difficult for just the average person to understand what’s being covered,” O’Sullivan said. “Even as a physician, I have difficulty understanding insurance companies and I have to ask my specialist in the office when they start throwing around different terms — deductible, co-pay, coinsurance.”

Birth control coverage

Despite the requirement that new insurance plans cover birth control for women, Kaiser’s survey found that more than half of women with private insurance still have either partial or no coverage for the medication.

That’s because plans created before federal health care reform was implemented do not have to comply with its coverage mandates, they’re considered grandfathered out of the requirements.

For the 35 percent of women whose private insurance does fully cover birth control, it’s likely a big change, as co-pays on birth control had posed a barrier for some women in the past, O’Sullivan said.

An intrauterine device (IUD), a T-shaped device that’s inserted into the uterus to prevent pregnancy, could run women up to $1,000, O’Sullivan said. If they were young and healthy and covered under a policy with a $5,000 deductible, they likely had to pay the full cost of the IUD, she said.

“Even $40 a month for the pill, I definitely think it was a barrier,” she said.

More and more insurance plans are moving out of their grandfather status and beginning to cover services the Affordable Care Act requires, Salganicoff said. When a plan’s co-pays or deductibles fluctuate a certain amount, it must be considered a new plan, she said.

The Supreme Court put a crimp in the Affordable Care Act’s contraceptive coverage mandate last week when it ruled that family-owned private companies can refuse to cover employees’ contraceptives if they violate the owners’ religious beliefs. While the ruling opens the door for many companies to stop paying for birth control, most are likely to continue covering the medication, as they already covered it before the Affordable Care Act was passed. A 2010 Kaiser Family Foundation poll found that 85 percent of large U.S. companies already covered birth control for their employees, although some of those required out-of-pocket costs.

Newly insured patients

Since the Affordable Care Act’s insurance mandate kicked in at the beginning of 2014, O’Sullivan said she’s seen middle-aged patients who have never had insurance before, sometimes with disastrous consequences.

Just last week, she saw a 45-year-old patient who was insured for the first time and was there for her first mammogram. O’Sullivan found a large tumor in her breast.

“She is someone who just hadn’t had insurance, so had sort of ignored it,” she said.

O’Sullivan has seen a few serious cervical cancer cases as well among women who had not previously been insured. She said women should not be getting cervical cancer because it’s easily detected in annual pap tests.

The Affordable Care Act also ensures full coverage for physician counseling on things like HIV, STIs, drug and alcohol use, intimate partner violence and breastfeeding, but doctors say those subjects might not all fit into a typical 15-minute annual exam. Rather, a physician might rotate subjects and discuss them every other year or in separate visits from the annual exam.

Overall, Salganicoff said she’s optimistic that women’s understanding of the services covered under their insurance policies will improve, but it will be a slow, steady change that will require public education from many messengers: insurance carriers, doctors and advocacy groups.

The issue is not just insurance literacy, it’s medical literacy, too: Understanding which tests a woman needs so that she knows to ask for them, Salganicoff said.

“We’ve found that both of those – general medical literacy and insurance literacy – are low among the American public,” she said.

— Reporter: 541-383-0304,

tbannow@bendbulletin.com

Editor’s note: This article has been corrected. A previous version mis-characterized the insurance eligibility of low-cost clinics. The Bulletin regrets the error.