Essential Health Benefits Balancing Coverage and Cost (2012) / Chapter Skim
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Appendix E: Description of Small Group Market Benefits, Provided by WellPoint
Appendix E: Description of Small Group Market Benefits, Provided by WellPoint
Pages 197-208
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From page 197... ...
Appendix E Description of Small Group Market Benefits, Provided by WellPoint The IOM committee found the WellPoint analysis of their products helpful in understanding benefit inclusions and exclusions in the small group market to complement the listing of covered services and exclusions found in Appendix C and F, respectively.
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From page 198... ...
. Helpful Definitions for Exhibit A "Anthem/Blue Standard Coverage/Typical SG Plans" cover a standard set of medically necessary services including inpatient and outpatient hospital services, diagnostic services, physician visits and medical care, maternity care, surgical services, mental health and substance abuse services, therapy services, skilled nursing facility services, home health care services, preventive care services, and medical equipment and supplies.
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From page 199... ...
In several states, we offer plans, "Anthem/Blue Limited Coverage", in the small group market that provide for a more restricted set of covered services. These plans are low cost options that primarily cover hospital and surgical services, and provide limited or no coverage for other medical services that are generally covered under the more standard plans.
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From page 200... ...
Allergy Testing and Injections 0-1% No Covered Not covered Alternative Medicine (Acupuncture, Coverage varies across, acupressure, massage therapy, 0-1% In few states Not covered but not within, states etc.) Coverage varies Coverage varies across, Autism Services 0-1% across, but not within, In several states but not within, states states Coverage varies Coverage varies across, across, but not within, but not within, states states Bariatric Surgery and Treatment of Some change to coverage Some change to Morbid Obesity (Rider pricing can 0-1% In a few states for services related to coverage for services be 3 to 10 times higher)
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From page 201... ...
for services related to obesity resulting from PPACA preventive care implementation. Not covered Mental Health and Substance 1-3% (optional coverage In several states Covered Abuse Services available)
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From page 202... ...
Specific Types of Drugs (Not included in pharmacy impacts above) : Smoking Cessation Drugs 0-1% Weight Loss Drugs 0-1% Coverage varies In a few states except Coverage varies across, across, but not within, contraceptive mandates but not within, states states in most states Infertility Drugs 0-1% Contraceptives 0-1% Sexual Dysfunction Drugs 0-1% Coverage varies Coverage varies across, across, but not within, but not within, states states Preventive Care Services Including All states mandate at This has changed to This has changed to Specific Screenings (Excludes 3-5% least some preventive comply with PPACA and comply with PPACA vision exam cost listed below)
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From page 203... ...
Urgent Care Facility Services 0-1% No Covered Not covered Coverage varies Coverage varies across, Vision Exam/Refraction 0-1% No across, but not within, but not within, states states Actuarial Pricing Assumptions All cost impacts were trended to 1/1/2011 based on HAUS or Cost of Care Trends projections through 1/1/2011. WellPoint's commercial group pricing model was utilized to value cost impacts where claims experience was not readily available.
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From page 204... ...
o Outpatient Mental Health and Substance Abuse (Professional) o Diagnostic Lab o Diagnostic X-Ray o Other Diagnostic (EKG, EEG, etc.)
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From page 205... ...
Mental Health / Substance Abuse Facility Residential Treatment Center o Facility Other Charges (Diagnostics Lab / X-Ray, Supplies, etc.) o Physician Services for: General Medical Care Surgery Maternity Mental Health Substance Abuse Home Care o Home Health Care Services o Home Dialysis o Home Infusion Therapy Other o Ambulance (Ground and Air)
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From page 206... ...
Commercial Weight Loss o Exclude Commercial Weight Loss Programs from core medical benefit. Complications of Experimental Services o Exclude services related to complications resulting or arising from excluded services except where mandated or where DOI agreements have been made to cover.
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From page 207... ...
o Other Oral Surgical Services are covered, including: Treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; Orthognathic surgery that is required because of a medical condition or injury which prevents normal function of the joint or bone and is deemed medically necessary to attain functional capacity of the affected part; Oral/surgical correction of accident related injuries Treatment of lesions, removal of tumors and biopsies Incision and drainage of infection of soft tissue not including tooth-related cysts or abscesses. Private Duty Nursing o Exclude private duty nursing provided in an inpatient setting (acute care or skilled nursing facility)
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From page 208... ...
o Exclusion does not apply to medical and surgical services for the treatment of injuries and diseases affecting the eye (examples include eye exams for diabetics, eyewear/contacts and related services to replace human lenses following surgery or injury, etc.)
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