Health Insurance Exclusions Resulting from Health Care Reform

Despite what proponents of the  Patient Protection and Affordable Care Act say, the law doesn’t change everything. In fact, according to HealthPocket, many services often excluded from insurance coverage before health reform remain that way under PPACA.

HealthPocket, in analyzing 3,094 health plans in the 2014 individual and family health insurance market, examined what medical services were most frequently excluded from health insurance coverage in 2014 and compared the results to the most common exclusions in the pre-reform health insurance market. HealthPocket found that 80 percent of exclusions remained the same between the 2013 and 2014 lists of medical services most frequently not covered by plans in the individual health insurance market.

Still, of course, some have changed.

Here are the top 10 health care services most often excluded under PPACA:

10. Weight loss surgery

Percentage of plans excluding benefit: 59 percent

There have been great strides in just a year with regard to weight loss surgeries being covered by health plans. In the pre-reform market, weight loss surgery wasn’t covered by 90 percent of plans while under Obamacare this exclusion has improved to 59 percent of plans.

Despite this, researchers say they’re surprised weight loss surgery — and weight loss programs, in general — are still excluded so often, especially since obesity preventative services are now mandatory. Under PPACA, obesity screening and counseling must be delivered as preventive care with no out-of-pocket costs.

9. Adult eye exam

Percentage of plans excluding benefit: 61 percent

Adult eye exams is a new inclusion on the list. And benefits professionals say that’s a shame since eye exams are critical to overall health.

“With a vision exam, the doctor can catch all kinds of medical maladies during the course of that exam,” says Greg Rudisill, senior vice president of strategic partnerships at Careington. “Cancer problems, diabetic conditions — they can save a person’s eyesight and life and get them in to get treated more quickly so medical costs for some of those serious conditions aren’t as expensive.”

Many companies don’t offer stand-alone vision plans  at the same rate they offer dental ones. According to data from the Bureau of Labor Statistics, 50 percent of large employers offered a stand-alone dental plan vs. 19 percent that offered vision plans.

8. Private nursing

Percentage of plans excluding benefit: 67 percent

Private nursing is often left out of health plans, with 67 percent of carriers not willing to pay for the benefit. That number is still better than last year, when 92 percent of insurers weren’t willing to pay for the benefit.

7. Infertility treatment

Percentage of plans excluding benefit: 67 percent

Good news for couples looking to expand their families: There has been a decrease in coverage exclusions for infertility treatments since PPACA went into effect.

Infertility treatments such as in vitro fertilization are excluded from health insurance coverage in two-thirds of individually purchased PPACA health plans. In the pre-reform market, 94 percent of health plans didn’t cover infertility treatments; now 67 percent of plans exclude it.

With the average cost of a treatment cycle at $12,400, and multiple cycles often needed for success, lack of coverage for in vitro fertilization can make the procedure inaccessible for many Americans, researchers argue.

6. Routine foot care

Percentage of plans excluding benefit: 72 percent

Routine foot care is a new item on the Top 10 list with the advent of PPACA.

HealthPocket researchers say overall, while PPACA has “exerted an enormous influence over the individual health insurance market, its effect upon the most commonly excluded medical services has been less extensive.”

“It is unclear whether the currently polarized discussion of health care reform will allow for a meaningful consideration of many of the excluded services within the top 10 list. These items, while important, are not likely to have the same public significance as overall healthcare spending, premium inflation, and network provider breadth. Consequently, it seems that these exclusions are more likely to be addressed at the state level if addressed at all.”

5. Acupuncture

Percentage of plans excluding benefit: 84 percent

Last year, 92 percent of plans exclude acupuncture as part of their benefits.

A study in the Archives of Internal Medicine found that acupuncture is a good treatment for chronic pain and argued that doctors should start recommending it as treatment for arthritis and other chronic ailments.

4. Weight loss program

Percentage of plans excluding benefit: 88 percent

Like weight loss surgeries, there is a little relief here: The 88 percent of plans that exclude weight loss programs from their benefits is down from the 93 percent of plans that did so last year, however.

3. Adult dental services

Percentage of plans excluding benefit: 89 percent

Under PPACA, adult dental services are now more excluded than before. In 2013, 81 percent of health plans excluded it. That percentage jumped to 89 this year.

Though PPACA has a mandate for pediatric dental care — and accordingly, children’s dental check-ups and children’s eyeglass coverage are no longer in the top 10 list of health care services excluded from insurance coverage — there’s no mandate for adults to get dental coverage.

2. Cosmetic surgery

Percentage of plans excluding benefit: 92 percent

Cosmetic surgery is often not included by insurance policies, though post-PPACA, more are covering it. Last year, 98 percent of health plans didn’t cover cosmetic surgery.

1. Long-term care

Percentage of plans excluding benefit: 99 percent

Long-term care benefits are still not a part of most insurers’ plans, as almost all plans exclude the benefit.

This remains virtually unchanged from last year, when 98 percent of plans excluded long-term care. It remains the most frequently excluded health care service.

LTC 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 recipients though younger age groups also receive this type of care.

The 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.

About Gary Chavez

Gary is a trusted advisor to small and mid-sized businesses. He offers a comprehensive system to outsource the administrative, tactical and strategic aspects of Human Resources, allowing entrepreneurs to delegate important but often mundane duties to human resource professionals. He helps business owners save time and reduce expenses related to having employees while improving their performance.

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