ASPE RESEARCH BRIEF
This Issue Brief is available on the Internet at:
Printer friendly version in PDF format (7 pages)
[Free PDF reader ]
How to Obtain a Printed Copy
|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.|
[ Go to Contents ]
 Essential health benefits requirements are specified in Section 1302 of the Affordable Care Act (42 U.S.C. 18022).
 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).
 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).
 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.
 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.
 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.
 Full report available at: http://ribgh.org/resources/Mercer%20Survey%20Report%20201105.pdf
[ Go to Contents ]
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. 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.
|Services||Three largest small group products in each State
|State Employee Plans
|Federal Employee Plans|
|Total % Covered (including with limits)||% Optional Coverage||% Not Covered||% Covered
|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|
|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||Yes|
|Emergency Room Services||100%||0%||0%||100%||Yes||Yes|
|Urgent Care Centers or Facilities||100%||0%||0%||100%||Yes||Yes|
|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|
|Preferred Brand Drugs||84%||16%||0%||100%||Yes||Yes|
|Non-Preferred Brand Drugs||82%||16%||2%||86%||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|
|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|
|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
 See http://www.naic.org/documents/committees_b_consumer_information_hhs_dol_submission_1107_soc_blank.pdf
 The three largest small group products by enrollment were included in this aggregation regardless of product type (PPO, HMO, etc).
 The denominator for this column is the number of plans whose summary plan document mentioned the service, not the total number of plans examined.
 The FEHBP BCBS Standard and Basic options cover skilled nursing facilities only when approved by a case manager.
[ Go to Contents ]
To obtain a printed copy of this report, send the title and your mailing information to:Health Policy, Room 447D
Top of Page | Contents
Health Policy (HP)
Assistant Secretary for Planning and Evaluation (ASPE)
U.S. Department of Health and Human Services (HHS)
Last updated: 12/16/11