___________
Examples of Possible Degrees of Specificity of
Inclusions in Small Group and Individual Markets
This appendix first provides illustrative information on health plan inclusions as reported through surveys (BLS, 2009; Mercer, 2009, 2011), plan documents (DOL, 2011), and a listing of Maryland’s guidance on comprehensive standard health plan requirements for plans offered to small businesses (Table C-1) (MHCC, 2011). Subsequent tables provide detailed inclusion information for standard small group and individual policies for three insurers: CIGNA (Table C-2),1 UnitedHealthcare (Table C-3),2 and WellPoint (Table C-4).3 Each of these insurers responded in their own words and their own understanding of the terms, so the manner in which they responded varies slightly. Also it should be noted that while some services are listed under headings using the 10 categories of care, this does not mean that the other services listed later in the table could not be classified under one of those headings.
1 Personal communication with Rosemary Lester, CIGNA Product, September 9, 2011.
2 Personal communication with Sam Ho, UnitedHealthcare, September 28, 2011.
3 Personal communication with Ruth Raskas, WellPoint, September 9, 2011.
Category (Section 1302 category shaded in grey)a [Note: organization of table does not endorse classification of service into category] | DOL 2011 (%)b | BLS 2009 Large Employer(%)c | BLS 2009 Small Employer (%)d | Mercer 2009 Large(%)e | Mercer 2009 Small (%)f | Mercer 2011 All (%)g | Maryland’s Standard Health Benefit Plan Requirements for Small Businesses (MHCC, 2011) |
Ambulatory patient services | |||||||
Kidney dialysis | 27%h | 95% | |||||
Outpatient facility charges | 98%. | Covered (outpatient hospital services) | |||||
Outpatient surgery | 97% | 98% | Covered | ||||
Physician office visits | 100% | 100% | 100% | ||||
Urgent care facility services | |||||||
Allergy testing and injections | |||||||
Emergency services | |||||||
Ambulance services | 64%i | Covered | |||||
Emergency room visits | 91%j | Covered | |||||
Hospitalization | |||||||
Hospital room and board | 99% | 99% | 100% | Covered (hospitalization) | |||
Inpatient surgery | 98% | 99% | |||||
Organ and tissue transplantation | 45%k | 95%. (organ transplants) | Covered (for bone marrow, cornea, kidney, liver, lung, heart, heart-lung, pancreas, and pancreas-kidney transplants) | ||||
Maternity and newborn care | |||||||
Maternity care | 66%l | Covered (pregnancy and maternity) | |||||
Mental health and substance use disorder services, including behavioral health treatment | |||||||
Autism services | 80%. | 69% | |||||
Applied behavioral analysis for autism | 50% | ||||||
Speech, occupational, and physical therapies for autism | 61% |
Mental health and substance abusem | Covered | ||||||
Inpatient | 99% | Covered | |||||
Outpatient | 85% | Covered | |||||
Inpatient substance abuse detoxification | 98% | Covered | |||||
Inpatient substance abuse rehabilitation | 78% | ||||||
Outpatient substance abuse rehabilitation | 79%. | ||||||
Prescription drugs | |||||||
Covered (generic and brand name drugs) | |||||||
Pharmacy (full generic + brand coverage) | |||||||
Pharmacy (generic only to full generic + brand coverage) | |||||||
Pharmacy (generic +1 to full generic + brand coverage) | |||||||
Specific types of drugs | |||||||
Smoking cessation drugs | 64% (for nicotine addiction) | ||||||
Weight loss drugs | |||||||
Infertility drugs | |||||||
Contraceptives | 88%. | ||||||
Sexual dysfunction drugs |
Rehabilitative and habilitative services and devices | |||||||
Habilitative services | Habilitative: covered (for children 0-19 for treatment of congenital or genetic birth defects) | ||||||
Cardiac rehabilitation | |||||||
Durable medical equipment | 67%n | 97% | Covered | ||||
Early intervention services | |||||||
Hearing tests and hearing aids | Covered (audiology screening for newborns) | ||||||
Hearing aids | 43% | Covered (for children 0-18) | |||||
Orthotics | |||||||
Occupational therapy | 92% | Covered (outpatient, short term) | |||||
Speech therapy (general) | 85*3 | Covered (outpatient, short term) | |||||
Physical therapy | 70%o | 99% | |||||
Prosthetics | 46%p | 86% | |||||
Pulmonary rehabilitation | |||||||
Laboratory services | |||||||
Laboratory and diagnostic services | Covered (outpatient laboratory and diagnostic services) | ||||||
Blood and blood products | All cost recovery for blood derivatives, components, biologies, and serums, to include autologous services and albumin | ||||||
Preventive and wellness services and chronic disease management | |||||||
Case management | Program available for medically complex and costly services | ||||||
Diabetes care management | 27%q | ||||||
Gynecological exams and services | 60%r |
Nutritional counseling | 53% | Covered (nutritional services for cardiovascular disease, diabetes, malnutrition, cancer, cerebral vascular disease, or kidney disease) | |||||
Medical nutritional therapy (diabetes-related) | |||||||
Medical nutritional therapy lobesity-related) | |||||||
Preventive care services | Covered (services rated by the USPSTF as A or B) | ||||||
Well child and immunization benefits | 77%s | Covered (well child visits childrei 0-24 months and visits including immunizations in children 24 months to 13 years) | |||||
Pediatric services, including oral and vision care | |||||||
Pediatric dental | 46% | ||||||
Pediatric vision | 44% | ||||||
Specific types of services | |||||||
Advanced imaging | |||||||
Alternative medicine (acupuncture, acupressure, massage therapy, etc.) | |||||||
Acupuncture | 35% | 24% | 41% | ||||
Massage therapy | 22% | 18% | |||||
Bariatric surgery and treatment of morbid obesity | 60% (bariatric surgery) | ||||||
Biofeedback | 7% | 6% | |||||
89% | 72% | 94% | Covered | ||||
Adult dental care-preventive and basic | |||||||
Elective abortion |
Family planning services | Covered | ||||||
Home health care | 73% | 71% | 75% | 93% | Covered | ||
Homeotherapy | 12% | 11% | |||||
Hospice care | 67% | 66%. | 69% | 91% (hospice and palliative care) | Covered | ||
Infertility and assisted reproduction services | 27%t | 58% | 34% | 51% | Covered (after diagnosis of infertility) | ||
Evaluation by specialist | 53% | 29% | |||||
Drug therapy | 35% | 20% | |||||
Artificial insemination | 24% | 9% | |||||
In vitro fertilization | 23% | 9% | Excluded | ||||
Advanced reproductive procedures | 12% | 3% | |||||
Medical food | Covered (for persons with metabolic disorders) | ||||||
Orthodontia | 49% | ||||||
Private duty nursing | |||||||
Skilled nursing care | 93% | Covered | |||||
Skilled nursing facility | 70% | 69% | 72% | ||||
Sterilization | 26%u | ||||||
TMJ treatment and appliances | 55% | ||||||
Therapy services (radiation, chemo, non-preventive infusion and injection) | |||||||
Vision exam, refraction | |||||||
Vision therapy | 42% |
a With the exception of “specific types of services,” which is not one of the Section 1302 categories.
b The DOL report (2011) presents data from the National Compensation Survey and a separate plan abstraction exercise as a percentage of workers who are participating in medical care plans. For plan abstraction data, the portion of workers whose plan documents do not mention a service is reported. Many of the services examined are reported by extent of coverage (e.g., coverage in full, subject to overall plan limits or separate limits, co-payment requirements), and the report provides some detail on median co-payments, for example: hospital room and board per admission ($250), physician office visits ($20), ER visits ($50-$150), physical therapy visits ($10-$40), maternity care ($10-$40), and gynecological exams and services ($10-$35).
c 100+workers; the Bureau of Labor Statistics (BLS) National Compensation Survey data reports so that all workers in the medical plans equal 100 percent.
d 1-99 workers.
e 500+workers.
f 10-499 workers.
g The Mercer report presents all data as a percentage of “typical” employer health plans. Most coverage is broken down by percentage offering coverage, percentage with some type of coverage limit in 2010, the median dollar amount for those plans with annual dollar limits in 2010, and of the plans with limits, the percentage making a change due to PPACA for 2011.
h 73 percent of workers’ plans reviewed by the DOL do not mention coverage.
i 35 percent of workers’ plans reviewed by the DOL do not mention coverage.
j 9 percent of workers’ plans reviewed by the DOL do not mention coverage.
k 55 percent of workers’ plans reviewed by the DOL do not mention coverage.
l 33 percent of workers’ plans reviewed by the DOL do not mention coverage.
m The DOL data predate implementation of the Mental Health Parity and Addiction Equity Act of 2008.
n 33 percent of workers’ plans reviewed by the DOL do not mention coverage.
o 30 percent of workers’ plans reviewed by the DOL do not mention coverage.
p 54 percent of workers’ plans reviewed by the DOL do not mention coverage.
q 73 percent of workers’ plans reviewed by the DOL do not mention coverage.
r 40 percent of workers’ plans reviewed by the DOL do not mention coverage.
s Well baby care.
t 53 percent of workers’ plans reviewed by the DOL do not mention coverage, and an additional 20 percent do not have coverage.
u 73 percent of workers’ plans reviewed by the DOL do not mention coverage, and an additional 2 percent do not have coverage.
In some instances, the plan language in the “Category” column 1 varies slightly from CIGNA’s plan language. The information is being provided with the understanding that the intent of the request is to identify service benefits and not to validate plan language. This reflects “typical” individual and small group employer plans and is subject to change. | ||
Category (1302 category shaded in greyv) [Note: organization of table does not endorse classification of service into category] | CIGNA Typical Small Group Employer Plan (Includes Limitsw) | CIGNA Typical Individual Benefit Plan (Includes Limitsw) |
Ambulatory patient services | ||
Dial ysis/hemodialy sis | Benefit | Benefit (facility/professional services) |
Outpatient facility charges | Benefit (facility services) | Benefit (facility services) |
Outpatient surgery | Benefit | Benefit (facility/professional services) |
Physician office visits (primary care, specialist, pre and post natal) | Benefit (PCP/specialist) | Benefit (PCP/specialist) |
Urgent care facility services | Benefit | Benefit |
Allergy testing and injections | Benefit | Benefit |
Outpatient hospital professional services (surgeon, radiologist, pathologist, anesthesiologist) | Benefit | Benefit |
Emergency services | ||
Ambulance services | Benefit | Benefit |
Emergency room visits | Benefit | Benefit |
Facility charge | Benefit | Benefit |
Hospitalization | ||
Hospital room and board | Benefit (inpatient) | Benefit (inpatient, semi-private room rate) |
Inpatient physician services (general medical care, surgery) | Benefit (hospital physician’s visits/ consultations) and professional services (surgeon, radiologist, pathologist, anesthesiologist) | Benefit (hospital physician’s visits/ consultations) and professional services (surgeon, radiologist, pathologist, anesthesiologist) |
Inpatient surgery | Benefit | Benefit |
Organ and tissue transplantation (in network only) | Benefit (with limits)x | Benefit (with limits)x |
Maternity and newborn care | Normal pregnancy/delivery is Not a Benefit unless mandated; ONLY complications of pregnancy as defined in the Policy are Benefit | |
Maternity care | Benefit | Not a Benefit for normal pregnancy/delivery; Benefit ONLY for complications of pregnancy as defined in the Policy |
Mental health and substance use disorder services, including behavioral health treatment | ||
Autism services | Coverage varies by service | Coverage varies by service |
Applied behavioral analysis for autism | Not a Benefit, unless state mandates apply | Not a Benefit, unless state mandates apply |
Speech, occupational and physical therapies for autism | Not a Benefit, unless state mandates apply | Not a Benefit, unless state mandates apply |
Menial health and substance abuse | ||
Inpatient mental health | Benefit | Usually a Benefit, with limits |
Outpatient mental health | Benefit | Usually a Benefit, with limits |
Inpatient substance abuse detoxification | Benefit | Benefit |
Inpatient substance abuse rehabilitation | Not a Benefit, unless state mandates apply | Not a Benefit, unless state mandates apply |
Outpatient substance abuse rehabilitation | Not a Benefit, unless state mandates apply | Not a Benefit, unless state mandates apply |
Prescription drugs | ||
Prescription drugs | Benefit, deductible applies | Benefit, deductible applies |
Pharmacy (full generic + brand coverage) | Benefit, deductible applies | Benefit, deductible applies |
Pharmacy (generic only to full generic + brand coverage) | N/A | N/A |
Pharmacy (generic + 1 to full generic + brand coverage) | N/A | N/A |
Specific types of drugs | ||
Smoking cessation drugs | Not a Benefit | Not a Benefit |
Weight loss drugs | Not a Benefit | Not a Benefit |
Infertility drugs | Not a Benefit, unless state mandates apply | Not a Benefit, unless state mandates apply |
Prescribed contraceptives | Policyholder Option | Benefit (with co-payment) |
OTC contraceptives | Not a benefit | Not a Benefit |
Sexual dysfunction drugs | Not a Benefit | Not a Benefit |
Rehabilitative and habilitative services and devices | ||
Habilitative services | Not a Benefit | Not a Benefit |
Cardiac rehabilitation | Benefit (short term, with benefit limits) | Benefit (short term, with benefit limits) |
Durable medical equipment | Benefit, with benefit limits | Benefit, with benefit limits |
Early intervention services | Not a Benefit, unless state mandates apply | Not a Benefit, unless state mandates apply |
Hearing tests and hearing aids | Not a Benefit, unless state mandates apply | Not a Benefit, unless state mandates apply |
Hearing aids | Not a Benefit, unless state mandates apply | Not a Benefit, unless state mandates apply |
Orthotics | Not a Benefit, unless state mandates apply | Not a Benefit, unless state mandates apply |
Occupational therapy | Benefit (short term, with benefit limits) | Benefit (short term, with benefit limits) |
Speech therapy (general) | Benefit (short term, with benefit limits) | Not a Benefit, unless state mandates apply |
Physical therapy | Benefit (short term, with benefit limits) | Benefit (short term, with benefit limits) |
Prosthetics (external prosthetic appliances only) | Benefit | Benefit |
Pulmonary rehabilitation | Benefit, with limits | Benefit (short term, with benefit limits) |
Laboratory services | ||
Laboratory and diagnostic services | Benefit | Benefit |
Other diagnostic tests (hearing. EKG) | Benefit | Benefit |
Other facility charges (diagnostic lab/x-ray /supplies) | Benefit | Benefit |
Advanced imaging (MRI, CT scan, etc.) | Benefit | Benefit |
Blood and blood products | Benefit | Benefit |
Preventive and wellness services and chronic disease management | ||
Case management | Not a Benefit | Not a Benefit |
Diabetes care management | Not a Benefit | Not a Benefit |
Gynecological exams and services | Benefit | Benefit |
Nutritional counseling | Benefit for specific conditions | Benefit for specific conditions |
Medical nutritional therapy (diabetes-related) | Benefit | Not a Benefit, unless state mandates apply |
Medical nutritional therapy (obesity-related) | Not a Benefit | Not a Benefit |
Preventive care services | Benefit | Benefit |
Well child and immunization benefits | Benefit | Benefit |
Pediatric services, including oral and vision care | ||
Pediatric dental | Not a Benefit | Not a Benefit |
Pediatric vision | Not a Benefit | Not a Benefit |
Specific types of services | ||
Advanced imaging | Benefit | Benefit |
Alternative medicine (acupuncture, acupressure, massage therapy, etc.) | Not a Benefit | Not a Benefit |
Acupuncture | Not a Benefit | Not a Benefit unless mandated |
Massage therapy | Not a Benefit | Not a Benefit |
Bariatric surgery and treatment of morbid obesity | Not a Benefit, unless state mandates apply | Not a Benefit, unless state mandates apply |
Biofeedback | Not a Benefit | Not a Benefit |
Chiropractic | Not a separate Benefit | Not a separate Benefit |
Adult dental care-preventive and basic | Not a Benefit | Not a Benefit |
Dental care-injury to sound natural teeth | Benefit | Benefit |
Elective abortion | Policyholder Option | Not a Benefit, unless state mandates apply (non-elective abortion is a Benefit) |
Family planning services (tests/counseling only) | Benefit | Benefit |
Home health care services | Benefit, with benefit limits | Benefit, with benefit limits |
Home dialysis | Benefit, with limits | Benefit, with limits |
Home infusion therapy | Benefit | Benefit, with limits |
Homeotherapy | Not a Benefit | Not a Benefit |
Hospice care | Benefit | Benefit |
Infertility and assisted reproduction services | ||
Evaluation by specialist | Not a Benefit | Not a Benefit |
Drug therapy | Not a Benefit | Not a Benefit |
Artificial insemination | Not a Benefit | Not a Benefit |
In vitro fertilization | Not a Benefit | Not a Benefit |
Advanced reproductive procedures | Not a Benefit | Not a Benefit |
Medical food | Not a Benefit, unless state mandates apply | Not a Benefit, unless state mandates apply |
Orthodontia | Not a Benefit | Not a Benefit |
Private duly nursing | Not a Benefit | Not a Benefit |
Residential treatment center | Benefit, with benefit limits | Benefit, with benefit limits |
Skilled nursing care | Benefit, with benefit limits | Benefit, with benefit limits |
Skilled nursing facility | Benefit, with benefit limits | Benefit, with benefit limits |
Sterilization | Benefit | Benefit |
TMJ treatment and appliances | Benefit, treatment only (appliances are Not a Benefit) | Benefit, treatment only (appliances are Not a Benefit) |
Therapy services (radiation, chemo, non-preventive infusion and injection) (inpatient hnd outpatient) | Benefit | Benefit |
Vision exam/refraction | Not a Benefit | Not a Benefit |
Vision therapy | Not a Benefit | Not a Benefit |
v With the exception of “specific types of services.”
w Typical small group employer plans provide broad health care coverage while including limits on certain services, but that would meet the majority of the overall population’s health care needs.
x Also covers for organ transplants—travel, with benefit limits.
Category (1302 category shaded in greyy) [Note: organization of table does not endorse classification of service into category] | UHC Typical Small Group Employer Plan | UHC Typical Individual Plan |
Ambulatory patient services | ||
Dial ysis/hemodialy sis | Covered | Covered |
Outpatient facility charges | Covered | Covered |
Outpatient surgery | Covered | Covered |
Physician office visits (primary care, specialist, pre and post natal) | Covered | Covered, except pre and post natal excluded |
Urgent care facility services | Covered | Covered |
Allergy testing and injections | Covered | Covered |
Outpatient hospital professional services (surgeon, radiologist, pathologist, anesthesiologist) | Covered | Covered |
Emergency services | ||
Ambulance services | Covered | Covered, ground and air |
Emergency room visits | Covered | Covered |
Facility charge | Covered | Covered |
Hospitalization | ||
Hospital room and board | Covered | Covered |
Inpatient physician services (general medical care, surgery) | Covered | Covered |
Inpatient surgery | Covered | Covered |
Organ and tissue transplantation | Covered | Covered |
Maternity and newborn care | ||
Maternity care | Covered | Routine maternity and newborn excluded Complications of pregnancy covered |
Mental health and substance use disorder services, including behavioral health treatment | ||
Autism services | Covered, for eligible services | Limited Coverage |
Applied behavioral analysis for autism | Covered-only in states where mandated | Limited Coverage |
Speech, occupational and physical therapies for autism | Covered | Limited Coverage |
Mental health and substance abuse | Covered | Excluded, unless Optional benefit purchased |
Inpatient | Covered | Excluded, unless Optional benefit purchased |
Outpatient | Covered | Excluded, unless Optional benefit purchased |
Inpatient substance abuse detoxification | Covered | Excluded, except for alcohol detox covered |
Inpatient substance abuse rehabilitation | Covered | Excluded |
Outpatient substance abuse rehabilitation | Covered | Excluded, unless Optional benefit purchased |
Prescription drugs | ||
Prescription drugs | Covered if rider purchased | Covered |
Pharmacy (full generic + brand coverage) | Generally covered | Covered |
Pharmacy (generic only to full generic + brand coverage) | Generally covered | Covered |
Pharmacy (generic + 1 to full generic + brand coverage) | Generally covered | Covered |
Specific types of drugs | ||
Smoking cessation drugs | Coveretl-only in states where mandated | Excluded |
Weight loss drugs | Coveretl-only in states where mandated | Excluded |
Infertility drugs | Coveretl-only in states where mandated | Excluded |
Contraceptives | Covered | Covered |
Sexual dysfunction drugs | Covered | Excluded |
Rehabilitative and habilitative services and devices | ||
Habiliiative services | Not covered | Limited Coverage |
Cardiac rehabilitation | Covered | Limited Coverage |
Durable medical equipment | Covered | Limited Coverage |
Early intervention services | Not covered | Excluded, unless state mandate |
Hearing tests and hearing aids | Covered | Covered |
Hearing aids | Covered | Excluded, unless state mandate |
Orthotics | Varies based on orthotic type | Excluded, except one pair foot orthotics per person |
Occupational therapy | Covered | Excluded |
Speech therapy (general) | Covered | Excluded |
Physical therapy | Covered | Covered |
Prosthetics | Covered | Limited Coverage |
Pulmonary rehabilitation | Covered | Covered Inpatient, Outpatient, must be covered provider |
Laboratory services | ||
Laboratory and diagnostic services | Covered | Covered |
Other diagnostic tests (hearing. EKG) | Covered | Covered |
Other facility charges (diagnostic lab/x-ray/supplies) | Covered | Covered |
Advanced imaging IMRI, CT scan, etc.) | Covered | Covered |
Blood and blood products | Covered | Excluded |
Preventive and wellness services and chronic disease management | ||
Case management | Program available | Excluded |
Diabetes care management | Program available | Covered |
Gynecological exams and services | Covered | Covered |
Nutritional counseling | Covered for management of specific clinical conditions | Excluded |
Medical nutritional therapy (diabetes-related) | Covered | Excluded |
Medical nutritional therapy (obesity-related) | Weight loss programs excluded | Excluded |
Preventive care services | Covered | Covered subject to HCR Guidelinesz |
Well child and immunization benefits | Covered | Covered subject to HCR Guidelinesz |
Pediatric services, including oral and vision care | ||
Pediatric dental | Excluded | Excluded |
Pediatric vision | Covered-refractive exams only, every other year | Excluded |
Specific types of services | ||
Advanced imaging | Covered | Covered |
Alternative medicine (acupuncture, acupressure, massage therapy, etc.) | Excluded | Excluded |
Acupuncture | Excluded | Excluded |
Massage therapy | Excluded | Excluded |
Bariatric surgery and treatment of morbid obesity | Excluded | Excluded |
Biofeedback | Coverage varies by condition | Excluded |
Chiropractic | Covered | Covered |
Adult Dental care-preventive and basic | Excluded | Excluded |
Dental care-injury to sound natural teeth | Covered | Covered |
Elective abortion | Covered | Excluded |
Family planning services | Covered | Covered |
Home health care services | Covered | Covered |
Home dialysis | Covered | Covered |
Home iniusion therapy | Covered | Covered |
Homeotherapy | Excluded | Excluded |
Hospice care | Covered | Covered |
Infertility and assisted reproduction services | Covered through to the point of diagnosis. Assisted reproductive services excluded. | Excluded |
Evaluation by specialist | Assisted reproductive services excluded. | Excluded |
Drug therapy | Assisted reproductive services excluded. | Excluded |
Artificial insemination | Assisted reproductive services excluded. | Excluded |
In vitro fertilization | Assisted reproductive services excluded. | Excluded |
Advanced reproductive procedures | Assisted reproductive services excluded. | Excluded |
Medical food | Excluded | Excluded |
Orthodontia | Excluded | Excluded |
Private duty nursing | Excluded | Excluded |
Residential treatment center | Covered for MHSA | Excluded |
Skilled nursing care | Covered | Excluded |
Skilled nursing facility | Covered | Limited Coverage |
Sterilization | Covered | Excluded |
TMJ treatment and appliances | Some services excluded | Surgical treatment only, $10,000 limit |
Therapy services (radiation, chemo, non-preventive infusion and injection) (inpatient and outpatient) | Covered | Covered |
Vision exam/refraction | Covered | Excluded |
Vision therapy | Covered | Excluded |
y With the exception of “specific types of services.”
z HCR means health care reform.
Category (1302 category shaded in greyaa) [Note: organization of table does not endorse classification of service into category] | Wellpoint Anthem Blue Standard for Small Business | Wellpoint Anthem Blue Standard for Individual Business |
Ambulatory patient services | ||
Dialysisbb/hemodialysis | Covered* | Covered* |
Outpatient facility charges | Covered* | Covered* |
Outpatient surgery | Covered* | Covered* |
Physician office visits (primary care, specialist, pre and post natal visits) | Covered* | Covered* except for pre and post maternity visits as maternity not covered in most planscc unless purchase maternity rider or state mandated. |
Urgent care facility services | Covered* | Covered* |
Allergy testing and injections | Covered* | Covered* |
Emergency services | ||
Ambulance services | Covered* | Covered* |
Facility charge | Covered* | Covered* |
Emergency room visits | Covered* | Covered* |
Hospitalization | ||
Hospital room and board | Covered* | Covered* |
Inpatient surgery | Covered* | Covered* |
Organ and tissue transplantation | Covered* | Covered* |
Maternity and newborn care | ||
Maternity care | Covered* | Complications of pregnancy Covered* by most plans; otherwise Not Covered unless purchase maternity rider or state mandated. |
Mental health and substance use behavioral health treatment disorder services, including | ||
Autism services | Autism diagnosis is Covered* according to service type; Coverage criteria may be determined by mandate. | Autism diagnosis is Covered* according to service type; Coverage criteria may be determined by mandate. |
Applied behavioral analysis for autism | Covered* by most plans when required by mandate. | Covered* by most plans when required by mandate. |
Speech, occupational and physical therapies for autism | Covered.* Coverage criteria may be determined by mandate. | Covered.* Coverage criteria may be determined by mandate. |
Mental health and substance abuse | Covered* | Covered* by most plans. Coverage criteria may be determined by mandate. |
Inpatient | Covered* by most plans | Covered* by most plans. Coverage criteria may be determined by mandate. |
Outpatient | Covered* | Covered* by most plans. Coverage criteria may be determined by mandate. |
Inpatient substance abuse detoxification | Covered* by most plans | Covered* by most plans. Coverage criteria may be determined by mandate. |
Inpatient substance abuse rehabilitation | Covered* | Covered* by most plans. Coverage criteria may be determined by mandate. |
Outpatient substance abuse rehabilitation | Covered* | Covered* by most plans. Coverage criteria may be determined by mandate. |
Prescription drugs | ||
Prescription drugs | Covered* | Covered* for all non-grandfathered plans post 9/23/2010 |
Pharmacy (full generic + brand coverage) | Covered* by most plans (generic + brand) | Covered* by some planscc (generic + brand) |
Pharmacy (generic only to full generic + brand coverage) Pharmacy (generic + 1 to full generic + brand coverage) | Covered* by some plans (generic only) Covered* by very few plans" (generic + at least 1 brand class) | Covered* by some grandfathered plans prior to 3/23/10 (generic only) Covered* by some plans (generic + at least 1 brand class) |
Specific types of drugs | ||
Smoking cessation drugs | Covered* by some plans | Covered* by some plans |
Weight loss drugs | Not Covered | Not Covered |
Infertility drugs | Covered* by some plans as required by mandates | Covered* by some plans as required by mandates |
Contraceptives | Covered* | Covered* |
Sexual dysfunction drugs | Covered* by most plans | Covered* by most plans |
Rehabilitative and habilitative services and devices | ||
Habilitative servicesdd | Covered* by most plans | Covered* by most plans |
Coverage criteria may be determined by mandates | Coverage criteria may be determined by mandates | |
Cardiac rehabilitation | Covered* | Covered* |
Durable medical equipment | Covered* | Covered* |
Early intervention services | Covered* by most plans | Covered* by most plans |
Coverage criteria may be determined by mandates | Coverage criteria may be determined by mandates | |
Hearing tests and hearing aids | Covered* by most plans as required by mandates | Covered* by most plans as required by mandates |
Hearing aids | Covered* by some plans as required by mandates | Covered* by some plans as required by mandates |
Medical devices | Covered* | Covered* |
Medical supplies received from supplier | Covered* | Covered* |
Orthotics | Covered* by most plans | Covered* by most plans |
Occupational therapy | Covered* | Covered* |
Speech therapy (general) | Covered* | Covered* |
Physical therapy | Covered* | Covered* |
Prosthetics | Covered* | Covered* |
Pulmonary rehabilitation | Covered* | Covered* |
Laboratory services | ||
Laboratory and diagnostic services | Covered* | Covered* |
Other diagnostic tests (hearing, EKG) | Covered* | Covered* |
Advanced imaging (MRI, CT scan) | Covered* | Covered* |
Blood and blood products | Covered* | Covered* |
Preventive and wellness services and chronic disease management | ||
Case management | Included as member program | Included as member program |
Diabetes care management | Included as member program | Included as member program |
Gynecological exams and services | Covered* for all non-grandfathered plans post 9/23/2010, and for some grandfathered plans | Covered* for all non-grandfathered plans post 9/23/2010, and for some grandfathered plans |
Nutritional counseling | Covered* for all non-grandfathered plans post 9/23/2010, and for some grandfathered plans | Covered* for all non-grandfathered plans post 9/23/2010, and for some grandfathered plans |
Medical nutritional therapy (diabetes-related) | Covered* for all non-grandfathered plans post 9/23/2010, and for some grandfathered plans | Covered* for all non-grandfathered plans post 9/23/2010, and for some grandfathered plans |
Medical nutritional therapy (obesity-related) | Covered* for all non-grandfathered plans post 9/23/2010, and for some grandfathered plans | Covered* for all non-grandfathered plans post 9/23/2010, and for some grandfathered plans |
Preventive care services | Covered* for all non-grandfathered plans post 9/23/2010, and for some grandfathered plans | Covered* for all non-grandfathered plans post 9/23/2010, and for some grandfathered plans |
Well child and immunization benefits | Covered* for all non-grandfathered plans post 9/23/2010, and for some grandfathered plans | Covered* for all non-grandfathered plans post 9/23/2010, and for some grandfathered plans |
Pediatric services, including oral and vision care | ||
Pediatric dental | Pediatric oral health screening Covered* for all non-grandfathered plans post 9/23/2010 Full dental coverage offered as Rider | Pediatric oral health screening Covered* for all non-grandfathered plans post 9/23/2010 and for some grandfathered plans Full dental coverage offered as Rider with most plans |
Pediatric vision | Pediatric vision screening Covered* for all non-grandfathered plans post 9/32/2010 | Pediatric vision screening Covered* for all non-grandfathered plans post 9/32/2010 and for some grandfathered plans |
Vision exam/refraction/eye wear coverage varies across states Full vision coverage offered as Rider |
Vision exam/refraction/eyewear coverage in few plans |
Specific types of services | ||
Advanced imaging | Covered* | Covered* |
Alternative medicine (acupuncture, acupressure, massage therapy, etc.) | Covered* by few plans | Covered* by few plans |
Acupuncture | Covered* by some plans | Covered* by few plans |
Massage therapy | Covered* by few plans | Not Covered |
Bariatric surgery and treatment of morbid obesity | Covered* by some plans mostly as required by mandates | Covered* by some plans mostly as required by mandates |
Biofeedback | Covered* by some plans | Covered* by some plans |
Chiropractic | Covered* (spinal manipulation) | Covered* (spinal manipulation) |
Adult dental care-preventive and basic Dental services related to an accident | Covered* by very few plans Full dental coverage offered as Rider Covered* | Covered* by very few plans Full dental coverage offered as Rider Covered* |
Elective abortion | Coverage varies across plans | Coverage varies across plans |
Family planning services | Covered* (counseling) by most plans | Covered* (counseling) by most plans |
Home health care | Covered* | Covered* |
Homeotherapy | Not Covered | Not Covered |
Hospice care | Covered* | Covered* |
Infertility and assisted reproduction services | ||
Evaluation by specialist | Covered* by most plans to diagnose and to treat underlying cause | Covered* by most plans to diagnose and to treat underlying cause |
Drug therapy | Covered* by some plans as required by mandates | Covered* by some plans as required by mandates |
Artificial insemination | Covered* by some plans as required by mandates | Covered* by some plans as required by mandates |
In vitro fertilization | Covered* by some plans as required by mandates | Covered* by some plans as required by mandates |
Advanced reproductive procedures | Covered* by some plans as required by mandates | Covered* by some plans as required by mandates |
Medical food | Covered* by most plans | Covered* by most plans |
Orthodontia | Full dental (including orthodontia) offered as Rider | Full dental (including orthodontia) offered as Rider |
Private duty nursing | Covered* by some plans | Covered* by some plans |
Residential treatment center | Covered* by most plans | Covered* by most plans |
Skilled nursing care | Covered* as part of Home Health Care or Inpatient | Covered* as part of Home Health Care or Inpatient |
Skilled nursing facility | Covered* | Covered* |
Sterilization | Covered* except plans in one state | Covered* except plans in one state |
TMJ treatment and appliances | Covered* by some plans | Covered* by some plans |
Therapy services (radiation, chemo, non-preventive infusion, including home infusion, and injection) | Covered* | Covered* |
Vision exam/refraction | Covered* by some plans | Covered* by some plans |
Vision therapy | Not Covered by most plans | Not Covered |
*Covered subject to terms and conditions of the contract. For example, there may be network limitations, medical policy limitations, cost-sharing requirements, dollar caps, visit limits, etc.
aa With the exception of “other types of categories/services.”
bb Home dialysis is also a covered service.
cc WellPoint defined few as generally less than 5; some is 5 through 10; and more is greater than 10.
dd Habilitation: This is a broad category, and there is likely to be variation in what an insurer defines as habilitative. We do not have a specific habilitation benefit or exclusion, but we do have “habilitative” services that may be covered. We were defining habilitative care as a category that include services such as (1) early intervention; (2) autism mandates (i.e., improving language skills); (3) congenital defect mandates; and (4) home health care services provided by a licensed home health agency (i.e., skilled nursing and physical therapy), not services such as meal preparation, bathing, and medication management).
This Page is blank