In a survey of more than 100 insurers in 15 states, the National Women's Law Center found that many insurers aren't properly covering birth control, maternity care, preventive services, and care related to gender transition.

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Some insurance companies are violating the law by offering women incomplete health coverage under the Affordable Care Act (ACA), according to two new reports from the National Women’s Law Center (NWLC).

The ACA was designed to end the practice of forcing women to pay more for their insurance simply because they are women. The health law required insurers to cover maternity care, and to charge no copays for preventive services like birth control, breastfeeding support, and well-woman visits.

But in a survey of more than 100 insurers in 15 states, NWLC found a wide range of violations to the law.

These violations are making some women pay more for health care than they should, the report says, and could jeopardize health outcomes for women or their infants. Insurance companies also failed almost across the board to offer adequate coverage for transgender people.

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The NWLC findings on birth control echo those of the Kaiser Family Foundation just a few weeks ago. Both organizations found that, in violation of the law, some insurers only cover generic birth control pills or aren’t fully covering non-pill birth control methods like the vaginal ring or IUD. NWLC found that some plans improperly charge for services like family planning counseling or follow-up appointments after an IUD insertion.

Both also found that despite the ACA’s requirements, no companies reviewed had a clear waiver process for women who need a specific birth control method that isn’t covered under their plan. Women are told to go through the agency’s existing claims processes, which either don’t solve the problem or take too long for such a time-sensitive medical need.

NWLC, along with the insurance plans they reviewed, heard from women in all 50 states through their national hotline:

These women have spent hours on the phone with their insurance company trying to find out why they still have to pay for their birth control. They often are given conflicting information about their coverage by the insurance company. And, too often, the insurance company tells them their method of birth control simply is not covered, or that they should switch birth control methods if they do not want to pay out-of-pocket for the method prescribed for them.

A total of 33 insurers out of more than 100 plans NWLC surveyed, in 13 out of the 15 states, had some kind of birth control coverage violation.

A handful of insurers across seven states denied women the full range of maternity coverage that they’re entitled to, which can “pose serious threats to women and newborns” if women forgo essential prenatal care due to high costs, the report says.

The United States has higher rates of preterm birth and infant mortality than other developed countries, and it’s also the only advanced economy in the world in which maternal mortality rates are rising.

Five insurers in three states—Colorado, South Dakota, and Alabama—broke the rules by limiting a woman’s number of ultrasounds or prenatal visits, restricting coverage based on age, or refusing to cover certain prenatal screening tests.

Two insurers in Tennessee and Ohio refused to cover maternity care for dependents. The ACA explicitly prohibits this since so many women of reproductive age are covered through a spouse or parent.

Six plans in three states deny maternity coverage outside of the plan’s service area, which would leave women who go into early labor while traveling without options.

Twenty plans in six states didn’t adequately cover breast pumps or breastfeeding counseling. Some didn’t cover the services at all, and some imposed things like time limits on how long a breast pump could be rented.

By far the most widespread violation was failing to cover transgender people, which breaks rules against discrimination based on sex, gender identity, or health condition. In 12 of the 15 states studied, 92 insurers explicitly excluded services or surgery related to gender transition.

And even though abortion coverage is severely limited under the ACA, Colorado still managed to violate the law by refusing to cover any abortion services for women who receive financial help with their premiums.

The NWLC report authors note that, given how extensive all of the different violations were in this sample, it’s likely that insurers in other states are also failing to live up to their obligations to women.

The violations may be honest mistakes and miscommunications, or they may be deliberate efforts to avoid paying for care. Either way, the reports say, federal and state regulators need to get better at enforcing the law and informing women of their rights, and insurers need to be much more transparent about the coverage they offer.