Essential Health Benefits Balancing Coverage and Cost (2012) / Chapter Skim
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Appendix C: Examples of Possible Degrees of Specificity of Inclusions in Small Group and Individual Markets
Appendix C: Examples of Possible Degrees of Specificity of Inclusions in Small Group and Individual Markets
Pages 169-190
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From page 169... ...
, and a listing of Maryland's guidance on com prehensive standard health plan requirements for plans offered to small businesses (Table C-1)
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From page 170... ...
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)
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From page 171... ...
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)
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From page 172... ...
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
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From page 173... ...
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.)
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From page 174... ...
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)
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From page 175... ...
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.
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From page 176... ...
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
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From page 177... ...
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)
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From page 178... ...
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)
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From page 179... ...
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)
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From page 180... ...
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
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From page 181... ...
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)
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From page 182... ...
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.)
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From page 183... ...
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)
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From page 184... ...
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*
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From page 185... ...
Inpatient substance abuse rehabilitation Covered* Covered*
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From page 186... ...
for Small Business for Individual Business Rehabilitative and habilitative services and devices Habilitative servicesdd Covered* by most plans Covered*
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From page 187... ...
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*
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From page 188... ...
for Small Business for Individual Business Specific types of services Advanced imaging Covered* Covered*
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From page 189... ...
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)
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