Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 169
Appendix C
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 com -
prehensive 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.
169
OCR for page 170
TABLE C-1 Reported Frequency of Benefit Coverage
170
Category (Section 1302
category shaded in grey)a BLS 2009 BLS 2009 Mercer Mercer Mercer
[Note: organization of table Large Small 2009 2009 2011 Maryland’s Standard Health
does not endorse classification DOL 2011 Employer Employer Large Small All Benefit Plan Requirements for
of service into category] (%)b (%)c (%)d (%)e (%)f (%)g 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 Covered (for bone marrow,
transplants) 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 50%
analysis for autism
Speech, occupational, and 61%
physical therapies for
autism
OCR for page 171
TABLE C-1 Reported Frequency of Benefit Coverage, Continued
Category (Section 1302
category shaded in grey)a BLS 2009 BLS 2009 Mercer Mercer Mercer
[Note: organization of table Large Small 2009 2009 2011 Maryland’s Standard Health
does not endorse classification DOL 2011 Employer Employer Large Small All Benefit Plan Requirements for
of service into category] (%)b (%)c (%)d (%)e (%)f (%)g Small Businesses (MHCC, 2011)
Mental health and substance abusem Covered
Inpatient 99% Covered
Outpatient 85% Covered
Inpatient substance abuse 98% Covered
detoxification
Inpatient substance abuse 78%
rehabilitation
Outpatient substance abuse 79%
rehabilitation
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
171
continued
OCR for page 172
TABLE C-1 Reported Frequency of Benefit Coverage, Continued
172
Category (Section 1302
category shaded in grey)a BLS 2009 BLS 2009 Mercer Mercer Mercer
[Note: organization of table Large Small 2009 2009 2011 Maryland’s Standard Health
does not endorse classification DOL 2011 Employer Employer Large Small All Benefit Plan Requirements for
of service into category] (%)b (%)c (%)d (%)e (%)f (%)g Small Businesses (MHCC, 2011)
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% 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,
biologics, 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
OCR for page 173
TABLE C-1 Reported Frequency of Benefit Coverage, Continued
Category (Section 1302
category shaded in grey)a BLS 2009 BLS 2009 Mercer Mercer Mercer
[Note: organization of table Large Small 2009 2009 2011 Maryland’s Standard Health
does not endorse classification DOL 2011 Employer Employer Large Small All Benefit Plan Requirements for
of service into category] (%)b (%)c (%)d (%)e (%)f (%)g Small Businesses (MHCC, 2011)
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
(obesity-related)
Preventive care services Covered (services rated by the
USPSTF as A or B)
Well child and immunization 77%s Covered (well child visits children
benefits 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 60% (bariatric
morbid obesity surgery)
Biofeedback 7% 6%
Chiropractic 89% 72% 94% Covered
Adult dental care—preventive and
basic
Elective abortion
173
continued
OCR for page 174
TABLE C-1 Reported Frequency of Benefit Coverage, Continued
174
Category (Section 1302
category shaded in grey)a BLS 2009 BLS 2009 Mercer Mercer Mercer
[Note: organization of table Large Small 2009 2009 2011 Maryland’s Standard Health
does not endorse classification DOL 2011 Employer Employer Large Small All Benefit Plan Requirements for
of service into category] (%)b (%)c (%)d (%)e (%)f (%)g Small Businesses (MHCC, 2011)
Family planning services Covered
Home health care 73% 71% 75% 93% Covered
Homeotherapy 12% 11%
Hospice care 67% 66% 69% 91% (hospice Covered
and palliative
care)
Infertility and assisted 27%t 58% 34% 51% Covered (after diagnosis of
reproduction services infertility)
Evaluation by specialist 53% 29%
Drug therapy 35% 20%
Artificial insemination 24% 9%
In vitro fertilization 23% 9% Excluded
Advanced reproductive 12% 3%
procedures
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.
OCR for page 175
TABLE C-1 Reported Frequency of Benefit Coverage, Continued
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.
SOURCE: BLS (Bureau of Labor Statistics), 2009, Table 14. Medical care benefits: Coverage for selected services, private industry workers, National Compensation Survey, 2008, in
National Compensation Survey: Health plan provisions in private industry in the United States, 2008, Washington, DC: U.S. Bureau of Labor Statistics; DOL (Department of Labor), 2011,
Selected medical benefits: A report from the Department of Labor to the Department of Health and Human Services, http://www.bls.gov/ncs/ebs/sp/selmedbensreport.pdf (accessed June 13,
2011); Mercer, 2009, National survey of employer-sponsored health plans, New York: Mercer, Inc.; Mercer, 2011, Health care reform: The question of essential benefits. The third report in
Mercer’s ongoing series of topical surveys on health reform, New York: Mercer, Inc., MHCC (Maryland Health Care Commission), 2011, Maryland’s comprehensive standard benefit plan
for small businesses, http://mhcc.maryland.gov/smallgroup/cshbp_brochure.htm (accessed November 7, 2011).
175
OCR for page 176
TABLE C-2 CIGNA Inclusions
176
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 CIGNA Typical Small Group Employer Plan CIGNA Typical Individual Benefit Plan
does not endorse classification of service into category] (Includes Limitsw) (Includes Limitsw)
Ambulatory patient services
Dialysis/hemodialysis 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, Benefit Benefit
anesthesiologist)
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/ Benefit (hospital physician’s visits/
consultations) and professional services consultations) and professional services
(surgeon, radiologist, pathologist, (surgeon, radiologist, pathologist,
anesthesiologist) 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
OCR for page 177
TABLE C-2 CIGNA Inclusions, Continued
Category (1302 category shaded in greyv) [Note: organization of table CIGNA Typical Small Group Employer Plan CIGNA Typical Individual Benefit Plan
does not endorse classification of service into category] (Includes Limitsw) (Includes Limitsw)
Mental 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)
177
continued
OCR for page 178
TABLE C-2 CIGNA Inclusions, Continued
178
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 CIGNA Typical Small Group Employer Plan CIGNA Typical Individual Benefit Plan
does not endorse classification of service into category] (Includes Limitsw) (Includes Limitsw)
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)
OCR for page 179
TABLE C-2 CIGNA Inclusions, Continued
Category (1302 category shaded in greyv) [Note: organization of table CIGNA Typical Small Group Employer Plan CIGNA Typical Individual Benefit Plan
does not endorse classification of service into category] (Includes Limitsw) (Includes Limitsw)
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 duty 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 Benefit, treatment only (appliances are
Not a Benefit) Not a Benefit)
Therapy services (radiation, chemo, non-preventive infusion and injection) Benefit Benefit
(inpatient and outpatient)
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.
179
OCR for page 180
TABLE C-3 UnitedHealthcare (UHC) Inclusions
180
Category (1302 category shaded in greyy) [Note: organization of table UHC Typical Small UHC Typical
does not endorse classification of service into category] Group Employer Plan Individual Plan
Ambulatory patient services
Dialysis/hemodialysis 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 Limited Coverage
services
Applied behavioral analysis for autism Covered—only in states Limited Coverage
where mandated
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
OCR for page 181
TABLE C-3 UHC Inclusions, Continued
Category (1302 category shaded in greyy) [Note: organization of table UHC Typical Small UHC Typical
does not endorse classification of service into category] Group Employer Plan Individual Plan
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 Covered—only in states Excluded
where mandated
Weight loss drugs Covered—only in states Excluded
where mandated
Infertility drugs Covered—only in states Excluded
where mandated
Contraceptives Covered Covered
Sexual dysfunction drugs Covered Excluded
Rehabilitative and habilitative services and devices
Habilitative 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
181
continued
OCR for page 182
TABLE C-3 UHC Inclusions, Continued
182
Category (1302 category shaded in greyy) [Note: organization of table UHC Typical Small UHC Typical
does not endorse classification of service into category] Group Employer Plan Individual Plan
Advanced imaging (MRI, 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 Excluded
specific clinical conditions
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 Excluded
only, every other year
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 Excluded
condition
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
OCR for page 183
TABLE C-3 UHC Inclusions, Continued
Category (1302 category shaded in greyy) [Note: organization of table UHC Typical Small UHC Typical
does not endorse classification of service into category] Group Employer Plan Individual Plan
Home infusion therapy Covered Covered
Homeotherapy Excluded Excluded
Hospice care Covered Covered
Infertility and assisted reproduction services Covered through to the Excluded
point of diagnosis. Assisted
reproductive services
excluded.
Evaluation by specialist Assisted reproductive Excluded
services excluded.
Drug therapy Assisted reproductive Excluded
services excluded.
Artificial insemination Assisted reproductive Excluded
services excluded.
In vitro fertilization Assisted reproductive Excluded
services excluded.
Advanced reproductive procedures Assisted reproductive Excluded
services 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 Covered Covered
outpatient)
Vision exam/refraction Covered Excluded
Vision therapy Covered Excluded
y With the exception of “specific types of services.”
z HCR means health care reform.
183
OCR for page 184
TABLE C-4 WellPoint Inclusions
184
Wellpoint Wellpoint
Category (1302 category shaded in greyaa) [Note: organization Anthem Blue Standard Anthem Blue Standard
of table does not endorse classification of service into category] for Small Business 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 Covered* Covered* except for pre and post maternity visits
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 disorder services, including
behavioral health treatment
Autism services Autism diagnosis is Covered* according Autism diagnosis is Covered* according
to service type; Coverage criteria may be to service type; Coverage criteria may be
determined by mandate. determined by mandate.
Applied behavioral analysis for autism Covered* by most plans when required by Covered* by most plans when required by
mandate. mandate.
OCR for page 185
TABLE C-4 WellPoint Inclusions, Continued
Wellpoint Wellpoint
Category (1302 category shaded in greyaa) [Note: organization Anthem Blue Standard Anthem Blue Standard
of table does not endorse classification of service into category] for Small Business for Individual Business
Speech, occupational and physical therapies for autism Covered.* Coverage criteria may be Covered.* Coverage criteria may be
determined by mandate. 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) Covered* by some plans (generic only) Covered* by some grandfathered plans prior to
3/23/10 (generic only)
Pharmacy (generic + 1 to full generic + brand coverage) Covered* by very few planscc (generic + Covered* by some plans (generic + at least 1
at least 1 brand class) 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 Covered* by some plans as required by
mandates mandates
Contraceptives Covered* Covered*
Sexual dysfunction drugs Covered* by most plans Covered* by most plans
*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.
185
continued
OCR for page 186
TABLE C-4 WellPoint Inclusions, Continued
186
Wellpoint Wellpoint
Category (1302 category shaded in greyaa) [Note: organization Anthem Blue Standard Anthem Blue Standard
of table does not endorse classification of service into category] for Small Business for Individual Business
Rehabilitative and habilitative services and devices
Habilitative servicesdd Covered* by most plans Covered* by most plans
Coverage criteria may be determined by Coverage criteria may be determined by
mandates 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 Coverage criteria may be determined by
mandates mandates
Hearing tests and hearing aids Covered* by most plans as required by Covered* by most plans as required by
mandates mandates
Hearing aids Covered* by some plans as required by Covered* by some plans as required by
mandates 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*
OCR for page 187
TABLE C-4 WellPoint Inclusions, Continued
Wellpoint Wellpoint
Category (1302 category shaded in greyaa) [Note: organization Anthem Blue Standard Anthem Blue Standard
of table does not endorse classification of service into category] for Small Business for Individual Business
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 Covered* for all non-grandfathered plans post
9/23/2010, and for some grandfathered plans 9/23/2010, and for some grandfathered plans
Nutritional counseling Covered* for all non-grandfathered plans post Covered* for all non-grandfathered plans post
9/23/2010, and for some grandfathered plans 9/23/2010, and for some grandfathered plans
Medical nutritional therapy (diabetes-related) Covered* for all non-grandfathered plans post Covered* for all non-grandfathered plans post
9/23/2010, and for some grandfathered plans 9/23/2010, and for some grandfathered plans
Medical nutritional therapy (obesity-related) Covered* for all non-grandfathered plans post Covered* for all non-grandfathered plans post
9/23/2010, and for some grandfathered plans 9/23/2010, and for some grandfathered plans
Preventive care services Covered* for all non-grandfathered plans post Covered* for all non-grandfathered plans post
9/23/2010, and for some grandfathered plans 9/23/2010, and for some grandfathered plans
Well child and immunization benefits Covered* for all non-grandfathered plans post Covered* for all non-grandfathered plans post
9/23/2010, and for some grandfathered plans 9/23/2010, and for some grandfathered plans
Pediatric services, including oral and vision care
Pediatric dental Pediatric oral health screening Covered* for all Pediatric oral health screening Covered* for all
non-grandfathered plans post 9/23/2010 non-grandfathered plans post 9/23/2010 and for
Full dental coverage offered as Rider some grandfathered plans
Full dental coverage offered as Rider with most
plans
Pediatric vision Pediatric vision screening Covered* for all Pediatric vision screening Covered* for all
non-grandfathered plans post 9/32/2010 non-grandfathered plans post 9/32/2010 and for
some grandfathered plans
Vision exam/refraction/eyewear coverage Vision exam/refraction/eyewear coverage in few
varies across states plans
Full vision coverage offered as Rider
*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.
187
continued
OCR for page 188
TABLE C-4 WellPoint Inclusions, Continued
188
Wellpoint Wellpoint
Category (1302 category shaded in greyaa) [Note: organization Anthem Blue Standard Anthem Blue Standard
of table does not endorse classification of service into category] for Small Business for Individual Business
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 Covered* by some plans mostly as required by
mandates mandates
Biofeedback Covered* by some plans Covered* by some plans
Chiropractic Covered* (spinal manipulation) Covered* (spinal manipulation)
Adult dental care—preventive and basic Covered* by very few plans Covered* by very few plans
Full dental coverage offered as Rider Full dental coverage offered as Rider
Dental services related to an accident Covered* 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 Covered* by most plans to diagnose and to
treat underlying cause treat underlying cause
Drug therapy Covered* by some plans as required by Covered* by some plans as required by
mandates mandates
Artificial insemination Covered* by some plans as required by Covered* by some plans as required by
mandates mandates
In vitro fertilization Covered* by some plans as required by Covered* by some plans as required by
mandates mandates
Advanced reproductive procedures Covered* by some plans as required by Covered* by some plans as required by
mandates mandates
OCR for page 189
TABLE C-4 WellPoint Inclusions, Continued
Wellpoint Wellpoint
Category (1302 category shaded in greyaa) [Note: organization Anthem Blue Standard Anthem Blue Standard
of table does not endorse classification of service into category] for Small Business for Individual Business
Medical food Covered* by most plans Covered* by most plans
Orthodontia Full dental (including orthodontia) offered as Full dental (including orthodontia) offered as
Rider 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 Covered* as part of Home Health Care or
Inpatient 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 Covered* Covered*
home infusion, and injection)
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).
189
OCR for page 190
