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Implications for Health Care Reform.

What emerges from these findings is a portrait of insurance mechanisms that offer uneven and unequal protection to individuals seeking reproductive health care services. Conventional indemnity insurance plans, in sharp contrast to HMOs, often follow the traditional patterns of health insurance coverage, favoring surgical care over nonsurgical procedures and curative care over preventive care. In addition, these plans sometimes exclude spouses and nonspouse dependents from services covered for employees, and most have claims processing and reimbursement procedures that preclude the possibility of dependents obtaining confidential care. Taken together, these patterns of coverage can leave individuals with little or no accessible coverage for key reproductive health care services.

Emerging national health care reform plans provide us with the opportunity to retain the strengths of the current system--such as the widespread coverage of surgical reproductive health care services--and at the same time address the failure of many traditional plans and, in many instances, newer types of coverage such as PPOs and POS networks as well as HMOs, to provide meaningful coverage of some preventive reproductive health care services, such as reversible contraception.

Four Necessary Conditions

To transform our current patchwork into a rational system that effectively finances and promotes good reproductive health care while addressing the needs and circumstances of women, men and their families today, any health care reform package must meet several minimal conditions:

* Insurance plans must cover the full range of reproductive health care services.

The full range of reproductive health services, which must be covered in insurance plans, includes contraceptive services and supplies, abortion services, voluntary sterilization services, basic infertility services, screening for STDs and cancers of the reproductive system, preconception risk assessment and care, and maternity care.

The AGI study provides ample evidence for the proposition that, in order for coverage to be guaranteed, these services must be included explicitly. General coverage of physician and surgical services, or even of prescription drugs and medical devices, is inadequate to ensure that each specific reproductive health care service will in fact be covered. All medically appropriate methods of family planning--including all appropriate drugs and devices--must be specified. Coverage should be defined as including not only the particular drug or device but also any associated medical procedures and the counseling and education services necessary to ensure proper and effective use.

* Dependents must be covered for all reproductive health care services covered for employees under insurance plans.

Plan documents must explicitly ensure that all individuals covered under the plan, including spouses and nonspouse dependents of employees, are covered for the full range of reproductive health care services. This can be accomplished either by covering the same package of services for dependents as for employees or by enrolling all individuals directly rather than as dependents.

* Reproductive health care services must be available confidentially to all individuals covered under the plan.

Billing and reimbursement procedures that preclude confidentiality must be replaced with procedures that allow both spouses and nonspouse dependents to receive confidential care. The procedures used by some plans to ensure that disclosure does not occur should be expanded to all plans. This problem is particularly acute for reproductive health care both because of the importance of confidentiality to individuals seeking the services and because women of childbearing age are disproportionately insured as dependents on a parent's or spouse's insurance policy.

For example, fee-for-service plans could be required to allow dependents to sign and submit a claim form and receive the reimbursement and EOB form directly and confidentially, as is being done by some fee-for-service plans. To ensure that disclosure does not occur as a result of calculating a deductible, reproductive health care services should be exempt from any deductibles otherwise required under the plan. Similarly, procedures currently in use by some HMOs to allow dependents who are not accompanied by the employee to receive care without subsequent notification of the employee could be expanded to all HMOs.

Alternately the current system of insuring some individuals as dependents could be replaced by a system in which each individual is insured directly rather than indirectly as a dependent.

* Preventive reproductive health care services must be exempt from cost- sharing requirements.

Key preventive services--including contraceptive services and supplies, prenatal care, screening for sexually transmitted diseases--should be exempt from copayments and deductibles both to ensure that these requirements do not constitute impediments to the receipt of these vital preventive care services and to facilitate the receipt of confidential care.

These four are the minimum conditions for ensuring reproductive health care for Americans. Health care reform provides an important opportunity to institute coverage that is adequate and fair, even and equal.
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Title Annotation:on women's reproductive health insurance
Publication:Uneven & Unequal: Insurance Coverage and Reproductive Health Services
Article Type:Topic Overview
Geographic Code:1USA
Date:Jan 1, 1995
Previous Article:Principal Findings.
Next Article:Appendix: Methodology.

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