The Affordable Care Act is already increasing the number of women and LGBT people with health coverage. But we must work to ensure that coverage is affordable and non-discriminatory, covers the services we need and provides quality care.
Realizing the promise of the ACA for diverse women and our families will require active engagement of women’s health advocates in influencing ACA implementation at both the federal and state levels. One key component of this work is advocacy for “women-and-LGBT-friendly” policies and procedures in the new marketplaces. Some of these marketplaces are run by states, others by the federal government, and a third group is operated as federal-state partnerships.
Raising Women’s Voices is working with our regional coordinators and allies in a number of states that have established their own state-based marketplaces, including California, Colorado, Connecticut, Maryland, New York, Oregon, Rhode Island and Washington. Together, we are identifying needed policies and procedures that will address women’s and LGBT people’s health needs, including coverage of reproductive health care, and that will be user-friendly for diverse groups of uninsured women seeking coverage. We are seeking adoption of these policies and procedures, documenting “best practices” and sharing them with other RWV coordinators and our allies for potential adoption in additional states.
We have identified some key elements of women-and-LGBT-friendly marketplaces, which are listed below. If you are a women’s health advocate working on ACA implementation at the state level, and would like to learn more about these recommended policies and procedures, and see examples of models developed so far, please email us.
1. Active engagement of women and LGBT people.
Health insurance marketplaces must actively engage women and LGBT people, and seek our views on policies governing outreach, enrollment, coverage benefits, affordability, non-discrimination and more. RWV provides financial and technical support to 28 regional coordinators around the country so they can get seats at the table when marketplace policies are being developed.
2. Making coverage more affordable through Medicaid expansion and adoption of the Basic Health Program.
Under the ACA, states can expand their Medicaid programs to cover adults with incomes below 138% of the federal poverty level. Unfortunately, some states have refused to expand Medicaid, creating a coverage and affordability gap. RWV works to raise awareness of Medicaid expansion as a reproductive justice issue and to highlight the needs of low-income women, LGBT people and families who have fallen in the coverage gap in some states. RWV is also working with allies in progressive states to win adoption of the ACA’s Basic Health Program (BHP) option. The BHP can provide very low-cost insurance for people at or below 200% of the federal poverty level who still cannot afford private health insurance, even with available financial aid.
3. Adoption of explicit non-discrimination policies.
The Affordable Care Act prohibits discrimination in health care programs on the basis of race, color, national origin, sex, sex stereotypes, gender identity, age, or disability. Some RWV regional coordinators have won adoption of specific non-discrimination language in marketplace operating policies and in their contracts with insurers. We are also are working with LGBT health advocates to end insurance discrimination against transgender individuals by private and public health plans that exclude coverage for gender transition care and related health services.
4. Coverage of comprehensive reproductive health services.
Women and LGBT people deserve health plans that cover the care we need. RWV and our regional coordinators are pressing marketplace officials to ensure that health plans fully comply with ACA contraceptive coverage requirements, and are not impermissibly using “medical management” techniques to impose cost-sharing for certain contraceptive methods or brands. We are encouraging more health plans to cover abortion services in states that allow it, while working long-term to lift abortion coverage bans. In states that do allow abortion coverage, we are working to minimize the burdens on enrollees and insurers of complying with the Nelson Amendment payment segregation rules.
5. Continuity of coverage and care for women enrolled in private Qualified Health Plans who become eligible for Medicaid due to pregnancy.
Some women who initially purchase a private Qualified Health Plan (QHP) through a marketplace may become eligible for Medicaid when they become pregnant. States are permitted to allow women to choose between staying in their QHP or switching to Medicaid. RWV coordinators are encouraging policy makers to adequately inform pregnant women of their options, establish policies that allow women to keep their preferred health providers, and ensure continuity of coverage.
6. Privacy protections for women and LGBT people, especially dependents using health care they don’t want disclosed to a parent or abusive spouse.
Increasing numbers of young people are remaining on their parents’ insurance policies until age 26 and more uninsured families are gaining coverage. As a result, more people are listed as “dependents” on family health insurance policies. When a dependent uses health services, the insurer sends the primary policy holder an Explanation of Benefits (EOB). This practice can create privacy issues for dependents who have used a service—such as mental health care, sexually transmitted infection treatment, contraception or abortion care—that they do not want disclosed to the policy holder. Raising Women’s Voices is working with its partners to develop policy options that can protect the privacy of women and LGBT people who are “dependents.”
7. Insurance plan networks that include sufficient numbers of reproductive health and LGBT health providers.
Many of the health plans being offered in ACA marketplaces have limited provider networks and do not offer out-of-network coverage. Network adequacy can be a special problem for women who need comprehensive reproductive health care and for individuals seeking LGBT-friendly providers. Access can be further complicated by language and cultural issues, lack of transportation in rural areas and other barriers. RWV has identified network adequacy as a priority issue for 2015.
8. Robust enrollee data collection as a first step in addressing health disparities.
The ACA contains provisions aimed at eliminating health disparities, including data collection requirements for enrollees’ race, ethnicity, sex, primary language, and disability status. RWV is working with state and national partners to advocate for the addition of voluntary questions about enrollees’ sexual orientation and gender identity, and to improve low response rates to race and ethnicity questions. As states more effectively collect this data, it can be used to track enrollment patterns and assess enrollees’ satisfaction with or complaints about their coverage.
9. Quality measures for delivery of reproductive health care, such as offering of contraceptive care.
Under the ACA, state marketplaces can encourage the provision of quality health care in a number of ways, including improving insurance plan transparency, setting common quality improvement requirements, and collecting quality and cost data to inform improvements. Raising Women’s Voices is working to urge marketplaces to set quality standards that reveal plans’ performance in meeting the health needs of women and LGBT people, and doing so in a culturally-competent manner. For example, plans should be rated on whether they consistently offer contraceptive care to women of reproductive age who do not wish to become pregnant. Marketplaces should also set quality measures to assess plans’ performance in delivery of culturally-competent care to LGBT people. All participating health plans should be required to collect and report data that could reveal any patterns of discrimination.