ASPE RESEARCH BRIEF
Essential Health Benefits:
Comparing Benefits in Small Group Products
and State and Federal Employee Plans
December 2011
This Issue Brief is available on the Internet at:
http://aspe.hhs.gov/health/reports/2011/MarketComparison/rb.shtml
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About This Research Brief
This paper examines benefit coverage in employer-sponsored insurance
in the small group market and State and Federal employee plans. This
brief was written by Laura Skopec, M.S.P.P.M, Ashley Henderson, M. P.A.,
Susan Todd, M.P.Aff., and Pierre L. Yong, M.D., M.P.H. |
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The Affordable Care Act identified ten categories of services and items included
in essential health benefits (EHBs), and specified that the scope of EHBs
must be equal to the scope of benefits provided under a typical employer
plan.
-
In evaluating the scope of benefits of employer plans, we found that overall,
it appears that small group products and State and Federal employee plans
cover similar services.
-
Coverage for a few specific services, including preventive and basic dental
care, acupuncture, bariatric surgery, and hearing aids appears to vary across
and within markets.
-
While small group products and State and Federal employee plans cover similar
services in most of the ten categories of EHBs, coverage in some of the statutory
EHB categories is limited, including behavioral health treatment, habilitative
services, and pediatric oral and vision services.
-
These results are generally consistent with other surveys of employer sponsored
health coverage conducted by the Department of Labor, Mercer, and Kaiser
Family Foundation/Health Research & Educational Trust (KFF/HRET).
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The Affordable Care Act identified ten categories of services and items
to be included in essential health benefits (EHBs), and specified that the
scope of EHBs must be equal to the scope of benefits provided under a typical
employer plan.[1] The ten
categories include: ambulatory patient services; emergency services;
hospitalization; maternity and newborn care; mental health and substance
use disorder services, including behavioral health treatment; prescription
drugs; rehabilitative and habilitative services and devices; laboratory services;
preventive and wellness services and chronic disease management; and pediatric
services, including oral and vision care.
-
In evaluating the scope of benefits of employer plans, we found that overall,
it appears that small group products and State and Federal employee plans
cover similar services. Based on publicly available State and Federal
employee summary plan documents[2] and
data from HealthCare.gov on small
group products, more than 94 percent of the small group products, and all
State and Federal employee plans examined appear to generally cover the
following: physician and specialist office visits, inpatient and outpatient
surgery, hospitalization, emergency services, maternity care, inpatient and
outpatient mental health and substance use disorder services, outpatient
rehabilitation services, durable medical equipment, laboratory services,
imaging services (e.g., CT scans, MRIs), preventive care, and
immunizations. In addition, generic and brand prescription drugs were
covered by 84 percent of small group products (the remaining 16 percent of
small group products offered this coverage as an optional benefit), and all
State and Federal employee plans examined. These results are generally
consistent with surveys of employer sponsored coverage that include large
employers.
-
Coverage for a few specific services appears to vary across markets and
within markets. Some services including preventive
and basic dental care, acupuncture, bariatric surgery, and hearing
aids are covered by the Federal Employees Health Benefits Plan
(FEHBP) Blue Cross Blue Shield (BCBS) Standard and Basic Options and Government
Employees Health Association (GEHA) plans, but were not typically covered
by small group products unless required by a State benefit
mandate.[3] Small group plans
in certain States cover in vitro fertilization and applied behavior analysis
therapy for autism, as required by State
mandates.[4] Both of these services
are excluded by the FEHBP BCBS Standard Option and Basic Option plans, which
are not subject to State mandates.
-
While small group products and State and Federal employee plans cover
similar services within most of the ten categories of EHBs, coverage in some
of the statutory EHB categories is limited, including behavioral health
treatment, habilitative services, and pediatric oral and vision services.
-
The extent to which plans and products cover behavioral treatment, a component
of the mental health and substance use disorder EHB category, is unclear.
Behavioral health treatment (separate from mental health and substance abuse
services) was not frequently mentioned in plan booklets.
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While some issuers and products indicated that they do not cover habilitative
services,[5] physical, occupational,
and speech therapies may be available for habilitative purposes under the
rehabilitative services benefit of some health plans.
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Routine pediatric dental and vision services are not frequently covered in
health products in the small group market, although many people have coverage
through stand alone dental or vision plans. According to HealthCare.gov
data on the benefits offered by the largest three small group products in
each State, five percent of these small group products cover dental check-ups
for children. Sixty percent of the small group products examined cover
vision screenings for children, and eight percent cover eye glasses for
children. The Federal employee plans and some State employee plans
examined provide limited coverage of routine dental benefits.
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These results are generally consistent with other surveys of
employer-sponsored health coverage conducted by the Department of Labor,
Mercer, and Kaiser Family Foundation/Health Research & Educational Trust
(KFF/HRET). The Department of Labor survey found that employees
enrolled in health plans had broad coverage for medical services such as
inpatient hospital services, hospital room and board, emergency room visits,
ambulance service, maternity, durable medical equipment, and physical
therapy.[6] Similarly, Mercer
found employers provided widespread coverage for medical services such as
durable medical equipment, outpatient facility charges, and physical,
occupational, and speech
therapy.[7] The KFF/HRET survey
also found broad coverage of prescription drugs among employees with
employer-sponsored coverage.
[ Go to Contents ]
[1] Essential health benefits
requirements are specified in Section 1302 of the Affordable Care Act (42
U.S.C. 18022).
[2] Ten State employee plans were
evaluated as well as the top three FEHBP plans by enrollment
the Blue Cross and Blue Shield (BCBS) Standard and Basic Options (summary
plan booklet available at
http://www.opm.gov/insure/health/planinfo/2011/brochures/71-005.pdf)
and the Government Employees Health Association (GEHA) Standard Option (summary
plan booklet available at
http://www.opm.gov/insure/health/planinfo/2011/brochures/71-006.pdf).
[3] According to the Institute
of Medicines survey of small group issuers, smoking cessation medications
and programs, which are covered by both BCBS and GEHA federal employee plans,
were also frequently excluded by small group issuers (see
http://www.iom.edu/Reports/2011/Essential-Health-Benefits-Balancing-Coverage-and-Cost.aspx).
[4] See discussion of State mandated
benefits in the Institute of Medicine report available at
http://www.iom.edu/Reports/2011/Essential-Health-Benefits-Balancing-Coverage-and-Cost.aspx.
[5] The National Association of
Insurance Commissioners has proposed a definition of habilitative services.
See
http://www.naic.org/documents/committees_b_consumer_information_ppaca_glossary.pdf.
[6] Full report available at:
http://www.bls.gov/ncs/ebs/sp/selmedbensreport.pdf.
For the services listed, no employees were enrolled in plans excluding the
service, and more than two-thirds of employees were enrolled in plans that
specifically cover the service. It is unclear whether employees enrolled
in plans in which particular services were not mentioned have coverage for
those services or not.
[7] Full report available at:
http://ribgh.org/resources/Mercer%20Survey%20Report%20201105.pdf
[ Go to Contents ]
Appendix A:
Coverage of Selected Benefits in the Small Group Market and State and Federal
Employee Plans
The following table shows coverage of benefit categories as they were defined
and included in the Summary of Benefits and Coverage proposed by the
NAIC.[1] This table includes
data collected by HealthCare.gov for the largest three small group products
in each State by enrollment, ten State employee plans, and three Federal
employee plans examined by the Department of Health and Human Services.
All data on small group products was collected in October 2011 for HealthCare.gov
and includes only open products that successfully submitted benefits data.
Data on State and Federal employee plans were collected from publicly available
summary plan documents.
Coverage of Selected Benefits in the Small Group Market
and State and Federal Employee Plans
Services |
Three largest small group products in each State
and DC
(N=153)[2] |
State Employee Plans
(N=10)[3] |
Federal Employee Plans |
Total % Covered (including with limits) |
% Optional Coverage |
% Not Covered |
% Covered
(if mentioned) |
BCBS Standard and Basic Options |
GEHA Standard Option |
Ambulatory Patient Services |
Primary Care Visit to Treat an Injury or Illness |
100% |
0% |
0% |
100% |
Yes |
Yes |
Specialist Visit |
100% |
0% |
0% |
100% |
Yes |
Yes |
Other Practitioner Office Visit (Nurse, Physician
Assistant) |
99% |
0% |
1% |
100% |
Yes |
Yes |
Outpatient Surgery Physician/Surgical Services |
100% |
0% |
0% |
100% |
Yes |
Yes |
Outpatient Facility Fee (e.g., Ambulatory Surgery
Center) |
100% |
0% |
0% |
100% |
Yes |
Yes |
Home Health Care Services |
100% |
0% |
0% |
90% |
Yes |
Yes |
Skilled Nursing Facility |
97% |
0% |
3% |
100% |
Yes[4] |
Yes |
Emergency Services |
Emergency Room Services |
100% |
0% |
0% |
100% |
Yes |
Yes |
Emergency Transportation/Ambulance |
100% |
0% |
0% |
100% |
Yes |
Yes |
Urgent Care Centers or Facilities |
100% |
0% |
0% |
100% |
Yes |
Yes |
Hospitalization |
Inpatient Hospital Services (e.g., Hospital Stay) |
100% |
0% |
0% |
100% |
Yes |
Yes |
Inpatient Physician and Surgical Services |
100% |
0% |
0% |
100% |
Yes |
Yes |
Maternity and Newborn Care |
Prenatal and Postnatal Care |
95% |
5% |
0% |
100% |
Yes |
Yes |
Delivery and All Inpatient Services for Maternity
Care |
95% |
5% |
0% |
100% |
Yes |
Yes |
Mental Health and Substance Use Disorder
Services, Including Behavioral Health Treatment |
Mental/Behavioral Health Inpatient Services |
95% |
5% |
0% |
100% |
Yes |
Yes |
Mental/Behavioral Health Outpatient Services* |
95% |
5% |
0% |
100% |
Yes |
Yes |
Substance Abuse Disorder Inpatient Services |
94% |
5% |
1% |
100% |
Yes |
Yes |
Substance Abuse Disorder Outpatient Services |
95% |
5% |
0% |
100% |
Yes |
Yes |
Prescription Drugs |
Generic Drugs |
84% |
16% |
0% |
100% |
Yes |
Yes |
Preferred Brand Drugs |
84% |
16% |
0% |
100% |
Yes |
Yes |
Non-Preferred Brand Drugs |
82% |
16% |
2% |
86% |
Yes |
Yes |
Specialty Drugs |
85% |
15% |
0% |
100% |
Yes |
Yes |
Rehabilitative and Habilitative Services
and Devices |
Outpatient Rehabilitation Services |
100% |
0% |
0% |
100% |
Yes |
Yes |
Habilitation Services |
59% |
0% |
41% |
100%** |
Covers PT/ST/OT for conditions such as autism |
Covers PT/ST/OT for conditions such as autism |
Durable Medical Equipment |
99% |
0% |
1% |
100% |
Yes |
Yes |
Laboratory Services |
Diagnostic Test (X-Ray and Laboratory Tests) |
99% |
1% |
0% |
100% |
Yes |
Yes |
Imaging (CT and PET Scans, MRIs) |
100% |
0% |
0% |
100% |
Yes |
Yes |
Preventive and Wellness Services
and Chronic Disease Management |
Preventive Care/Screening/Immunization |
100% |
0% |
0% |
100% |
Yes |
Yes |
Pediatric Services, Including Oral
and Vision Care |
Dental Check-Up for Children |
5% |
55% |
40% |
40% |
Yes |
Yes |
Vision Screening for Children |
60% |
21% |
19% |
20% |
Yes |
Yes |
Eye Glasses for Children |
8% |
54% |
38% |
0% |
No |
No |
* The denominator for the largest three products for
this service is 152. A data error was found in one product so it was
dropped from the analysis.
** Mentioned by only two State employee plans. All other services were
mentioned by five or more plans.
Abbreviations: BCBS = Blue Cross Blue Shield; CT = computed tomography;
DC = District of Columbia; GEHA = Government Employees Health Association;
MRI = magnetic resonance imaging; PET = positron emission tomography; PT
= physical therapy; OT = occupational therapy; ST = speech therapy
KEY:
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% Covered (including with limits): The percent of the 153 largest
small group products that reported a benefit as covered or
covered with limits.
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% Optional Coverage: The percent of the 153 largest small group
products that reported a benefit as optional coverage available for
additional premium. This selection would apply if the benefit
is offered as a rider, not as part of the core plan.
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% Not Covered: The percent of the 153 largest small group products
that reported a benefit as not covered.
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% Covered (if mentioned): The percent of the 10 State employee
plans examined that offer coverage of a benefit. The denominator is
the number of plans that mention the benefit, not the total number of
plans. All benefits were mentioned by 5 or more plans, with the exception
of habilitative services.
|
Footnotes for table
[1] See
http://www.naic.org/documents/committees_b_consumer_information_hhs_dol_submission_1107_soc_blank.pdf
[2] The three largest small
group products by enrollment were included in this aggregation regardless
of product type (PPO, HMO, etc).
[3] The denominator for this
column is the number of plans whose summary plan document mentioned the service,
not the total number of plans examined.
[4] The FEHBP BCBS Standard
and Basic options cover skilled nursing facilities only when approved by
a case manager.
[ Go to Contents ]
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Last updated: 12/16/11