12 health insurers deny claims, limit access to reproductive care, Oregon says
Twelve health insurance providers in Oregon failed to fully comply with the state's Reproductive Health Equity Act, according to the Division of Financial Regulation at Oregon Department of Consumer and Business Services.
A report released this week by DCBS stated all 12 insurers applied copays, coinsurance, and deductibles not permitted by RHEA. Some also denied claims that should have been covered under the act.
Customers were not provided with enough information to understand what is covered under RHEA and some were given inaccurate information over the phone lines, according to the report.
DCBS Division of Financial Regulation partnered with three companies to conduct a “market conduct examination,” or formal investigation, of claims made to all 12 companies from Jan. 1, 2019, through Dec. 31, 2020.
What Oregon's Reproductive Health Equity Act covers
The Reproductive Health Equity Act is an Oregon law enacted in 2017 to make access to reproductive health care more equitable by providing services to customers without any out-of-pocket costs.
Services covered under RHEA include abortion, annual gynecology visits, anemia screening, contraception, pregnancy screening, sterilization, cervical and breast cancer screening, breast feeding support and counseling, and sextually transmitted infection screening.
For example, people covered with an Oregon individual, small group or large-group insurer should not have to pay anything for a routine mammogram or pap smear. Medicaid, or Oregon Health Plan, does not have to comply. The act also does not cover people who have health insurance through an out-of-state company.
"We wanted all women in Oregon to be able to get reproductive health care without anything holding them up," said Jeff Barker, a former state representative who sponsored RHEA in 2017.
Routine data call prompts investigation
The state's investigation was initiated after a routine data call in 2020 showed potential “widespread noncompliance” with RHEA.
The Division of Financial Regulation, which monitors compliance with Oregon laws, uses data calls for “reporting, general information, statistics, and to get a better understanding of the market,” said Jason Horton, public information officer of the Division of Financial Regulation.
The 2020 data call was done as part of an evaluation for a report to the Oregon Legislature to update them on RHEA implementation, explained Horton.
DCBS' Division of Financial Regulation declined requests for further comment or an interview. “The exam reports speak for themselves,” Horton said.
The Statesman Journal wanted to report how many claims were impacted by noncompliance, but found discrepancies and errors in the data. DCBS' Division of Financial Regulation confirmed the errors and said they could provide corrections. Horton said they were errors in transposition.
The individual reports for each insurance company can be viewed at this link. For a detailed breakdown of the investigation pross, view the preliminary compliance report. For a quick overview of both the investigation process and findings view this info sheet.
Denying claims, limiting access to contraceptives, failure to cover reproductive care
The market examination, required under statute, looked at all paid claims, denied claims and complaint monitoring of the 12 insurers identified as:
Aetna Life Insurance Company
BridgeSpan Health Company
Cigna Health and Life Insurance Company
HealthNet Health Plan of Oregon
Kaiser Foundation Health Plan of the Northwest
Moda Health Plan
PacificSource Health Plans
Providence Health Plan
Regence BlueCross BlueShield of Oregon
Samaritan Health Plans
UnitedHealthcare Insurance Company
UnitedHealthcare of Oregon
The investigation required all 12 companies to give access to their claims systems. Examiners found some systems were outdated and limited in data storage and retrieval. Some systems for customer complaints and appeals also were limited.
Cigna, Samaritan, HealthNet and Kaiser failed to properly resolve customer complaints in a timely manner, the report says.
All insurance companies applied member cost share — costs that are paid by customers — to services that should have been fully covered under RHEA.
Aetna, BridgeSpan, and Regence failed to consistently reimburse or cover contraceptives, limiting clients' access to contraceptive refills.
In some cases, claims that should have been covered by RHEA were denied, failing to cover reproductive care such as contraceptives, emergency room pregnancy tests, anemia screening, and sexually-transmitted infection testing.
Many instances of noncompliance were found to be related to internal system errors, according to the reports.
What happens now that the investigation is over
The Division of Financial Regulation said it will work with each insurer to implement recommendations for regaining compliance.
That process will include:
Reviewing and updating claims policies, procedures and systems
Reviewing contraceptive claim processing
Training employees in RHEA requirements
Monitoring complaint systems
Implementing a third-party review process
PacificSource, which was found to have applied cost shares on RHEA claims and have inadequate claims processing systems, told the Statesman Journal they already have developed procedures to improve their billing system to gain compliance.
"PacificSource will continue to support RHEA and remain compliant in all aspects of the statute," a representative said in a statement.
An Aetna Life Insurance Company representative said while the insurer is committed to maintain compliance, they feel RHEA is ambiguous and there is a "lack of guidance."
"We strongly dispute the findings of fact and conclusions of law in the Final Report," Aetna said in a statement to the Statesman Journal. "Rather than provide specific examples of claims that we processed during the Examination period in violation of RHEA, the Final Report instead makes general statements and draws inferences from hypothetical scenarios that are not supported by the data that we actually submitted."
In an Aetna response letter to the investigation report, they said those who conducted the investigation did not have the "appropriate skill level, training, and understanding of applicable state laws and examination guidelines."
Aetna concluded by saying they object to the findings made against them in the Division of Financial Regulation report and would rather work with the division to expand guidance on RHEA compliance.
During the process of working toward compliance, the Division of Financial Regulation will work to determine what, if any, penalties or reimbursements are to be paid by each company.
If you believe you have not been provided with services required to you by RHEA law, you can contact your insurer or call the Division of Financial Regulation’s advocacy team at 888-877-4894.
Sydney Wyatt covers healthcare inequities for the Statesman Journal. Send comments, questions, and tips to her at SWyatt@gannett.com, (503) 399-6613, or on Twitter @sydney_elise44
The Statesman Journal’s coverage of healthcare inequities is funded in part by the M.J. Murdock Charitable Trust, which seeks to strengthen the cultural, social, educational, and spiritual base of the Pacific Northwest through capacity-building investments in the nonprofit sector.
This article originally appeared on Salem Statesman Journal: Oregon says insurers erroneously denied reproductive claims