SEATTLE, WA – The Consumer Representatives to the National Association of Insurance Commissioners (NAIC) released a report today identifying significant gaps in insurance plan compliance with the Affordable Care Act’s (ACA’s) preventive services coverage and cost-sharing protections. The report assessed challenges in access to a subset of ACA preventive services: smoking cessation, pre-exposure prophylaxis (PrEP) for the prevention of HIV, colorectal cancer screening, and postpartum depression screening. Based on a sample review of six plans in six states, the report found that:
- Plan information describing preventive services varied, with gaps and inconsistencies in how services and coverage were described in consumer-facing brochures and fact sheets;
- Formularies did not consistently list preventive medications as covered without cost sharing and even formularies that did include a notation for preventive medications were often difficult to navigate; and
- Plan payer guidance that informs how providers code services as preventive was inconsistently available and rarely provided the full gamut of information providers would need to appropriately code and bill preventive services to ensure they are adjudicated as preventive (without cost sharing) instead of diagnostic.
With the Affordable Care Act’s preventive services under attack in courts, state and federal regulators need to step up compliance efforts to make sure people get the care they need.
“Too often, insurance companies unlawfully deny coverage or charge cost sharing for preventive services, causing many, especially low-income people, to go without life-saving care,” said Wayne Turner, senior attorney at the National Health Law Program and a Consumer Representative to the NAIC. “With the Affordable Care Act’s preventive services under attack in courts, state and federal regulators need to step up compliance efforts to make sure people get the care they need.”
“The ACA recognized the value of preventive services to individual health, public health, and reducing healthcare costs. They also help identify conditions early on when more can be done to treat them or prevent disease acquisition altogether. Insurers are simply not doing a good job of making it easy for consumers to utilize them and regulators must take action to ensure access to these mandated life-saving services,” said Carl Schmid, Executive Director of the HIV+Hepatitis Policy Institute and a Consumer Representative to the NAIC.
The report identified a number of steps state insurance regulators can take to improve enforcement and noted that these protections remain the law of the land despite ongoing legal attacks. The report calls for regulators to monitor insurance plan documents to ensure that preventive services descriptions are easy-to-find and accurate. Recommendations also include increasing oversight of plan coverage policies to ensure they are in line with clinical guidelines for preventive services.
“State regulators have an important role to play in making sure that plans are playing by the rules when it comes to providing access to preventive services coverage without cost-sharing requirements,” said Anna Schwamlein Howard, Principal, Policy Development, Access to and Quality of Care at the American Cancer Society, Cancer Action Network. “We know access to free preventive services works to identify diseases early, prevent disease and to improve health equity. Yet we are failing to do all that can be done to ensure these services are available without cost sharing to the communities who need them most.”
Support for the report was provided by the Robert Wood Johnson Foundation. The views expressed in the report do not necessarily reflect the views of the Foundation.
###
About the Consumer Representatives to the NAIC: The NAIC works closely with Consumer Representatives to assist state regulators in their primary objective of protecting insurance consumers. The Consumer Representatives do not represent or work for the NAIC, and the views expressed in today’s report do not necessarily reflect the views of the NAIC. More information about consumer participation at the NAIC is available here.
