The State of Coverage Karen Davenport Director of Health Policy Stephanie Glover

1. The State of Coverage Karen Davenport Director of Health Policy Stephanie Glover Health Policy Fellow Dania Palanker Senior Counsel

2. Presentation Outline • Findings and Violations in Qualified Health Plans • State Partners Update • Oversight and Enforcement • Connection to Essential Health Benefits Work • Discussion

3. Introduction • Over 4.3 million women have enrolled in a qualified health plan • 56 percent of all Marketplace enrollees • The ACA promises improved coverage for women’s health – which must be backed up by health plans that meet women’s needs • What does women’s health coverage look like? • Are QHPs complying with the ACA? • Are QHPs meeting the needs of women?

4. Scope of Analysis • Reviewed plan documents from 56 issuers across ten states • CO, CT, ME, MD, NV, RI, SD, TN, WA, WI • Focused exclusively on language in plan documents • Analysis of women’s preventive services, including such as contraception, well-woman visits, and lactation supports; prenatal and other maternity care; abortion services; genetic testing; and exclusion policies.

5. Findings: Maternity Coverage • Limited information provided on details of maternity and newborn coverage • Major violations: • Coverage excluded for dependents • Service area restrictions • Limit on ultrasounds

6. Findings: Preventive Services • The vast majority of issuers reference USPSTF and HRSA guidelines in the preventive service sections. • Language elsewhere in the documents often contradicts this coverage • Major violations: • Cost sharing for preventive services • Time limits on breastfeeding support and supplies • Failure to cover brand name contraception • Genetic testing exclusion

7. Findings: Abortion Coverage • Issuers are not required to provide abortion coverage but as a critical area for women’s health, we reviewed to make sure the coverage policies were clear for consumers. • Problems and concerns: • Different abortion coverage for enrollees receiving a tax credit • Plans that cover abortion but don’t apply costs to the deductible • Lack of definition around “elective”

8. Findings: Other Major Concerns • Coverage Details Undermine ACA Requirements • Example: limited to a manual breast pump • Overly Restrictive Coverage • Example: off-label use of Rx medications excluded from coverage • Misleading or Contradictory Information • Example: excluding contraceptive drugs and devices from coverage “except as required by law”

9. Problematic for Women’s Health • These violations and concerns could lead to major problems for women’s health and finances. Women could: • Be denied coverage for services required to be covered by their QHP • Face unnecessary cost-sharing or pay out-of-pocket for services their plan should cover, • Or go without needed health care

10. Summary • Health plans must comply with the ACA and implementing regulation • State and federal regulators need to provide strong oversight to ensure plans are complying • Plans should be required to fix current problems • 2015 plans should be better • And, consumers need complete and accurate information about their coverage policies

11. Oversight and Enforcement • State work: • CO, MD, WA: ongoing enforcement work with state partners • WI: beginning stages of state developing strategy • CT, NV, RI, SD, TN: no current partners, NWLC will contact regulators directly • Federal work: • HHS advocacy: encouraging stronger oversight of plans in FFM states • OPM advocacy: encouraging stronger oversight of multi-state plans • OCR complaints where possible

12. Essential Health Benefits • Opportunity to re-visit EHB for 2016 plan year • What we’re doing: EHB workgroup • Areas for improvement: • Maternity • Prescription Drugs • Mental Health • Other?

13. Discussion • What coverage issues are you seeing in your state? • What is the status of oversight and enforcement in your state? • How are SBCs enforced? • What are the most important coverage areas to improve through EHB advocacy? • Are there other avenues for improving coverage (for example, state initiatives)?