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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.



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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. 191

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Federal Employees Knox-Keene Health 192 Health Benefits Care Service Plan Act Program (FEHBP) Medicare Medicaid (CA) Maryland Massachusetts Exchange Year Created 1959 1965 1965 1975 1993 2006 Categorization Service Benefit Part A Mandatory Services Basic Health Care Comprehensive Minimum Creditable of Benefits Plan Services Standard Health Coverage Standards Benefit Plan (CSHBP) • Hospital benefits • Inpatient hospital • Physician services • Hospital inpatient • Ambulatory patient • Surgical benefits • Skilled nursing facility • Lab and X-ray services • Ambulance service services (including • In-hospital medical • Home health services • Physician services • Audiology screening outpatient day surgery benefits • Hospice • Inpatient hospital • Outpatient and for newborns and related anesthesia) • Ambulatory patient • Inpatient psychiatric services ambulatory care • Blood and blood • Diagnostic imaging benefits hospital • Outpatient hospital • Lab and radiology products and screening • Supplemental benefits services • Home health • Case management procedures (including • Obstetrical benefits • Early and Periodic • Preventive health program x-rays) Screening, services • Chiropractic services • Emergency services Diagnosis, and • Emergency services • Durable medical • Hospitalization Treatment (EPSDT) (including ambulance equipment (including at a services for and out-of-area • Emergency room minimum, inpatient children under 21 coverage) • Family planning acute care services, • Family planning • Hospice (section services which are generally services 1368.2—only for • Habilitative services provided by an acute • Federally qualified group coverage) • Hearing aids care hospital for health center • Home health care covered benefits in services • Hospice accordance with the • Rural health clinic • Hospitalization, member’s subscriber services includes detoxification certificate or plan • Nurse midwife • Infertility services description) services • Medical food • Maternity and newborn • Certified nurse • Mental health and care practitioner services substance abuse • Medical or surgical • Nursing facility • Nutritional services care (including services for those • Outpatient hospital preventative and ages 21 and over services and surgery primary care) • Home health care • Outpatient laboratory • Mental health and services and diagnostic substance abuse services services • Outpatient short-term • Prescription drugs rehabilitative services • Radiation therapy and • Pregnancy and chemotherapy maternity • Doctor visits for • Prescription drugs preventive care, without a deductible

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Federal Employees Knox-Keene Health Health Benefits Care Service Plan Act Program (FEHBP) Medicare Medicaid (CA) Maryland Massachusetts Exchange • 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 Part B Plan • Hospital care • Physician and other • Surgical care and medical services treatment • Outpatient hospital • Medical care and care treatment • Ambulatory surgical • Obstetrical benefits services • Prescribed drugs, • Diagnostic tests, medicines, and x-rays, and lab prosthetic devices services • Other medical • Durable medical supplies and equipment services • Physical, occupational, and speech therapy • Clinical laboratory services • Home health care • Outpatient mental health services • One-time “Welcome to Medicare” physical exam • Preventive servicesa 193 continued

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Federal Employees Knox-Keene Health 194 Health Benefits Care Service Plan Act Program (FEHBP) Medicare Medicaid (CA) Maryland Massachusetts Exchange 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, • Outpatient prescription remedial care drugs [42.7, Rule by licensed 300.67.24] practitioners • Chiropractic services • Prescription drugs • Dental care • Diagnostic, • Hearing aids 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

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Federal Employees Knox-Keene Health Health Benefits Care Service Plan Act Program (FEHBP) Medicare Medicaid (CA) Maryland Massachusetts Exchange • 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 U.S. Code: Title XVIII of the Title XIX of the • Section 1345(b) Chapter 58—956 CMR Authority Title 5— Social Security Act Social Security Act • Section 1367(i), 5.00 Government rule 1300.67 Organization & Employees Part III-Employees Subpart G—Insurance & Annuities-Chapter 89— Health Insurance- Section 8904 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. 195

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196 ESSENTIAL HEALTH BENEFITS 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 annu- ities. 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).