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Essential Health Benefits: Balancing Coverage and Cost (2012)

Chapter: Appendix D: Examples of Benefit Package Statutory Guidance

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Suggested Citation:"Appendix D: Examples of Benefit Package Statutory Guidance." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
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___________

Appendix D

Examples of Benefit Package
Statutory Guidance

This appendix includes a display of benefit categories in statute for various health insurance programs.

Suggested Citation:"Appendix D: Examples of Benefit Package Statutory Guidance." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×

Federal Employees Health Benefits Program (FEHBP) Medicare Medicaid Knox-Keene Health Care Service Plan Act (CA) Maryland Massachusetts Exchange
Year Created 1959 1965 1965 1975 1993 2006
Categorization of Benefits Service Benefit Plan Part A Mandatory Services Basic Health Care Services Comprehensive Standard Health Benefit Plan (CSHBP) Minimum Creditable Coverage Standards
  • Hospital benefits
  • Surgical benefits
  • In-hospital medical benefits
  • Ambulatory patient benefits
  • Supplemental benefits
  • Obstetrical benefits
  • Inpatient hospital
  • Skilled nursing facility
  • Home health
  • Hospice
  • Inpatient psychiatric hospital
  • Physician services
  • Lab and X-ray services
  • Inpatient hospital services
  • Outpatient hospital services
  • Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services for children under 21
  • Family planning services
  • Federally qualified health center services
  • Rural health clinic services
  • Nurse midwife services
  • Certified nurse practitioner services
  • Nursing facility services for those ages 21 and over
  • Home health care services
  • Hospital inpatient services
  • Physician services
  • Outpatient and ambulatory care
  • Lab and radiology
  • Home health
  • Preventive health services
  • Emergency services (including ambulance and out-of-area coverage)
  • Hospice (section 1368.2-only for group coverage)
  • Ambulance service
  • Audiology screening for newborns
  • Blood and blood products
  • Case management program
  • Chiropractic services
  • Durable medical equipment
  • Emergency room
  • Family planning services
  • Habilitative services
  • Hearing aids
  • Home health care
  • Hospice
  • Hospitalization, includes detoxification
  • Infertility services
  • Medical food
  • Mental health and substance abuse
  • Nutritional services
  • Outpatient hospital services and surgery
  • Outpatient laboratory and diagnostic services
  • Outpatient short-term rehabilitative services
  • Pregnancy and maternity
  • Prescription drugs
  • Ambulatory patient services (including outpatient day surgery and related anesthesia)
  • Diagnostic imaging and screening procedures (including x-rays)
  • Emergency services
  • Hospitalization (including at a minimum, inpatient acute care services, which are generally provided by an acute care hospital for covered benefits in accordance with the member’s subscriber certificate or plan description)
  • Maternity and newborn care
  • Medical or surgical care (including preventative and primary care)
  • Mental health and substance abuse services
  • Prescription drugs
  • Radiation therapy and chemotherapy
  • Doctor visits for preventive care, without a deductible
Suggested Citation:"Appendix D: Examples of Benefit Package Statutory Guidance." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
  • Preventive services rated by the U.S. Preventive Services Task Force as A or B not subject to deductible and no cost sharing if provided in-network
  • Skilled nursing facility
  • Transplants
  • Well child and immunization benefits
Indemnity Benefit Plan Part B
  • Hospital care
  • Surgical care and treatment
  • Medical care and treatment
  • Obstetrical benefits
  • Prescribed drugs, medicines, and prosthetic devices
  • Other medical supplies and services
  • Physician and other medical services
  • Outpatient hospital care
  • Ambulatory surgical services
  • Diagnostic tests, x-rays, and lab services
  • Durable medical equipment
  • Physical, occupational, and speech therapy
  • Clinical laboratory services
  • Home health care
  • Outpatient mental health services
  • One-time “Welcome to Medicare” physical exam
  • Preventive servicesa
Suggested Citation:"Appendix D: Examples of Benefit Package Statutory Guidance." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
Part C (Medicare Advantageb)
Is required to provide all Medicare-covered benefits to enrollees, with at least one plan with basic drug coverage (MA-PD plan)
Part D

•  Prescription Drugs
Optional Services
  • Medical care, remedial care by licensed practitioners
  • Prescription drugs
  • Diagnostic, screening, preventive, and rehabilitative services
  • Clinic services
  • Primary care case management
  • Dental services and dentures
  • Physical therapy
  • Prosthetic devices and eyeglasses
  • Tuberculosis-related services
  • Other specified medical and remedial care
  • Intermediate care facility for the mentally retarded (ICF/MR) services
  • Institute for mental diseases services for those ages 65 and over
  • Outpatient prescription drugs [42.7, Rule 300.67.24]
  • Chiropractic services
  • Dental care
  • Hearing aids
Suggested Citation:"Appendix D: Examples of Benefit Package Statutory Guidance." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
  • Inpatient psychiatric care for children under 21
  • Home- and community-based care waiver services
  • Other home health care services
  • Targeted case management
  • Respiratory care services for ventilator-dependent individuals
  • Personal care services
  • Hospice care
Statutory Authority U.S. Code: Title 5-Government Organization & Employees Part III-Employees Subpart G-Insurance & Annuities-Chapter 89-Health Insurance-Section 8904 Title XVIII of the Social Security Act Title XIX of the Social Security Act
  • Section 1345(b)
  • Section 1367(i), rule 1300.67
Chapter 58-956 CMR 5.00

a Flu shot, pneumococcal shot (no coinsurance); limit of one flu shot per flu season; hepatitis B shot, colorectal and prostate cancer screening, pap smear, mammogram, cardiovascular screening, abdominal aortic aneurysm (AAA) screening, bone mass measurement, diabetes screening and monitoring, glaucoma screening, smoking cessation.

b Private health plans that receive payments from Medicare to provide Medicare-covered benefits to enrollees.

SOURCE: Families USA, 2006; GPO, 2007; KFF, 2010; O’Malley et al., 2009; State of California, 2011; State of Massachusetts, 2008.

Suggested Citation:"Appendix D: Examples of Benefit Package Statutory Guidance." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×

REFERENCES

Families USA. 2006. Medicaid benefit package changes: Coming to a state near you? http://www.familiesusa.org/assets/pdfs/DRA-Benefit-Package.pdf (accessed August 4, 2011).

GPO (Government Printing Office). 2007. Title 5 government organization and employees. Part III—employees. Subpart g—insurance and annuities. Chapter 89—health insurance. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=browse_usc&docid=Cite+5USC8904 (accessed August 4, 2011).

KFF (Kaiser Family Foundation). 2010. Medicare: A primer. Menlo Park, CA: Kaiser Family Foundation.

O’Malley, M., M. Moon, and R. W. Cowdry. 2009. Maryland’s Comprehensive Standard Health Plan for Small Businesses. Annapolis, MD:Maryland Health Care Commission.

State of California. 2011. Knox-Keene Health Care Service Plan Act of 1975. http://wpso.dmhc.ca.gov/regulations/11kkap/index.htm (accessed August 4, 2011).

State of Massachusetts. 2008. 956 CMR 5.00: Minimum creditable coverage. http://www.lawlib.state.ma.us/source/mass/cmr/cmrtext/956CMR5.pdf (accessed August 4, 2011).

Suggested Citation:"Appendix D: Examples of Benefit Package Statutory Guidance." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
Page 191
Suggested Citation:"Appendix D: Examples of Benefit Package Statutory Guidance." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
Page 192
Suggested Citation:"Appendix D: Examples of Benefit Package Statutory Guidance." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
Page 193
Suggested Citation:"Appendix D: Examples of Benefit Package Statutory Guidance." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
Page 194
Suggested Citation:"Appendix D: Examples of Benefit Package Statutory Guidance." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
Page 195
Suggested Citation:"Appendix D: Examples of Benefit Package Statutory Guidance." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
Page 196
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In 2010, an estimated 50 million people were uninsured in the United States. A portion of the uninsured reflects unemployment rates; however, this rate is primarily a reflection of the fact that when most health plans meet an individual's needs, most times, those health plans are not affordable. Research shows that people without health insurance are more likely to experience financial burdens associated with the utilization of health care services. But even among the insured, underinsurance has emerged as a barrier to care.

The Patient Protection and Affordable Care Act (ACA) has made the most comprehensive changes to the provision of health insurance since the development of Medicare and Medicaid by requiring all Americans to have health insurance by 2016. An estimated 30 million individuals who would otherwise be uninsured are expected to obtain insurance through the private health insurance market or state expansion of Medicaid programs. The success of the ACA depends on the design of the essential health benefits (EHB) package and its affordability.

Essential Health Benefits recommends a process for defining, monitoring, and updating the EHB package. The book is of value to Assistant Secretary for Planning and Evaluation (ASPE) and other U.S. Department of Health and Human Services agencies, state insurance agencies, Congress, state governors, health care providers, and consumer advocates.

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