Short-Term Analysis to Support Mental Health and Substance Use Disorder Parity Implementation. Appendix 2: Plan Benefit Detail and Construction of Measures


Appendix Table A1 (next page) provides a complete listing of available benefit information in the MarketScandata and the number of plans for which these data were available in 2008. The rest of this Appendix describes the construction of specific variables related to benefit design or management of care that were also examined.

We defined a plan as having equal inpatient co-insurance rates (value = 1) if the plan had the same co-insurance rate for general inpatient services as that listed for inpatient psychiatric visits and inpatient substance abuse visits, and neither were “missing”. If any of the co-insurance rates were not equal, then the plan was deemed not to have equal co-insurance parity (value = 0). Similarly, equality in outpatient co-insurance rates was determined if the co-insurance rate for general outpatient office visits was equal to that for outpatient psychiatric visits and outpatient substance abuse visits, and neither was missing. If no values were missing and all values were the same, then we deemed the plan to have equal outpatient co-insurance rates.

The data provide no specific information about the degree to which plans attempt to control costs through managing care but they do include a range of management techniques. We used the information regarding use of specific health management strategies to construct a composite indicator of the number of techniques required by the plan either generally or for specified diagnoses. The specific health management tools captured in our composite indicator (called “Num NQTLs,”) are: case management, pre-certification, utilization review, step therapy required for certain drugs, and use of a prescription drug formulary. None of these management techniques is used exclusively for behavioral health, and indeed it is not clear from the reported information contained in the benefits database whether the management techniques apply to just physical health, behavioral health, or both. Nonetheless, it is reasonable to assume that a plan that reports using more of these techniques is generally more aggressive at managing care and containing costs than a plan that applies fewer of them. The average value for our NQTL variable (which ranges from 0 to 5) is 3.5 (median = mean in this case).

The Thomson Reuter data have their own measure of whether a plan carves out behavioral health care (“pscarve”). The measure is based on Thomson Reuter’s reading of benefit plan pamphlets provided to them by the plans; they believe the information in the pamphlets is not very reliable. Indeed, the measure contained in the database shows very little variation: 91% of the plans in our plan-by-region data set showed a behavioral health carve-out -- far higher than conventional wisdom. We therefore decided to construct our own measure of a behavioral health carve-out, using information in the data about how financial claims were paid. In those cases where the data show an “encounter” with a single payment for the entire package of behavioral health services, we assume the service was carved out. Based on this assumption, we estimate that approximately 75% of the large insurance plans in our plan-by-region dataset carved out behavioral health services, a percentage far more consistent with conventional wisdom.

TABLE A1. MarketScan Benefit Information

Specified Benefits Variable
# of
Range Notes
Outpatient (OP)
Co-payment individual primary care copaypc 65 $5-$30 37 plans where copaypc is missing have non-zero co-insurance rate (coins in range of 70-100%). So 102 plans have either co-pay or co-insurance for general medical. 2 plans with neither are plantyp=”comprehensive”.
Co-payment individual -- specialist copaysp 56 $5-$50 All 56 plans also have non-zero copaypc.
Co-payment individual psych SA: paid by patient copayps 38 $5-$50 Generally plans have copayps OR copays copayp. In one case, plan has both copayp ($100) and copayps ($20).
Co-pay individual OP SA: paid by patient copays 8 $5 - $20  
Co-pay individual OP psych: paid by patient copayp 9 $5 - $100  
Co-insurance flag: indicates “whether the same in network co-insurance applies to all service types captured in the benefit plan design database” coinflg 103 1 = no;
2 = yes
2 = yes, 96 plans said yes; 7 said no.
Co-insurance: “% of medical costs that a plan pays for most medical services after med deductible is met” coins 96 70% - 100% These 96 plans are the firms that said yes to coinflg; 6 plans with missing coins report co-payment for primary care (copaypc of $10-$20).
Co-insurance office visit: percent plan pays coinsov 103 70% - 100%  
Co-insurance other outpatient: percent plan pays coinsop 101 70% - 100%  
Co-insurance individual OP psych: percent plan pays after deductible met coinpso 75 0 - 100% 1 plan says 0, 2 plans say 50%, and all others say 70% or more. Only 20 plans (26% cover 100%.
Co-insurance individual OP SA: percent plan pays coinso 23 0 - 100% 2 plans (8.7%) say 0, otherwise all other plans are 75% or higher. 11 plans (47%) report 100% coverage.
Annual max visits individ OP SA iamxso 15 20 - 60  
Annual max visits individual OP psych ialpo 0   None exist probably due to previous MH parity law.
Annual limit individual OP SA ialso 0   None of these plans have annual limits (per previous mental health parity law).
Annual limit individual psych ialpo 0  
Annual limit individual OP psych ialpo 0  
Inpatient (IP)
Co-insurance IP, amt paid by plan after deductible is met coinsip 103 70% - 100%  
Co-insurance individual IP psych, amt paid by plan after deductible met coinpi 23 75% - 100% Note, when coinpi has a value, 60% of the time coinsip = 100%, 17% it is 90%.
Co-insurance individual IP SA, amt paid by plan after deductible met coinsi 21 0 - 100% Note, when coinsi has a value, coinsip = 80%, 90%, or 100%.
Co-insurance individual IP psych SA, amt paid by plan after deductible met coinpsi 75 70% - 100%  
Annual max days individ IP SA iamxsi 8 20 - 60 days  
Annual limit individual IP psych SA ailpsi 0    
Annual limit individual IP SA ialsi 3 $2,00 - $12,000  
General Benefit Info
Type of plan plantyp 103 1 = Basic/Major medical (0); 2 = Comprehensive (7); 3 = EPO (4); 4 = HMO (18); 5 = Non-capitated PPO (6); 6 = PPO (57); 7 = POS (1); 8 = CDHP (11).
Preventive care coverage indicator prev 103 0 = unknown (10); 1 = covered (63); 2 = not covered (1); 3 = covered in
Case management of high cost diagnoses and procedures cm 103 0 = unknown (51); 1 = required (51); 3 = required OON only (2).
Utilization review of inpatient stays ur 103 0 = unknown (65); 1 = required (39).
Pre-certification for surgery precrt 103 0 = unknown (39); 1 = required (65).
Step therapy for certain drugs steprx 96 0 = unknown (0); 1 = yes (48); 2 = no (48).
Formulary indicator rxform 96 0 = unknown (0); 1 = yes (87); 2 = no (7).
Psychiatric and SA carve-out indicator pscarve 103 1 = no;
2 = yes
Only 7 plans indicate they do not carve-out MH/SUD. 97 plans (93%) say they do. Plans reporting they do not include 1 HMO, 1 Non-cap POS, 3 PPO, and 2 CDHP.
Psychiatric and SA coverage different from medical indicator psychsub 103 1 = yes covered differently;
2 = no not different
55 plans (53%) are shown to have no different coverage from medical, but as the above information above suggests, this can’t be right. We don’t know what criteria it is being based off of however.
Annual limit individual IP psych SA ailps 6 $500  
Annual limit individual psych ialp 0    
Annual limit individual SA ials 2 $25,000  
Annual max out-of-pocket individual ioop 80 $300 - $5,500  
Annual max out-of-pocket -- family foop 78 $600 - $11,500  
Annual max out-of-pocket for medical services -- indiv loop 80 $300 - $5,500  
Annual max out-of-pocket for medical services -- family foop 78 $600 - $11,500  
Individual deductible ided 60 $100 - $2,000  
Individual deductible psych SA idedps 6 $75 - $500  
Family deductible fded 60 $100 - $4,000  
Lifetime limit individual ilifelim 52 $300K - $5 mil  
Lifetime limit flag -- modifies the lifetime limit for medical services ilifeflg 103 0 = set limit;
4 = no lifetime limit
50 plans (48%) do not set a lifetime limit. 54 plans do, although we only have data on 52 report (per previous variable ilifelim).
Lifetime limit individual psych ialponi 0    
Lifetime limit individual psych SA illps 0    
Co-insurance ER coinser 101 70% - 100%  
Co-payment ER copayer 47 $5 - $250  
Employer contribution -- family fempcon 9 $800 - $2,000  
Employer contribution -- individual iempcon 9 $400 - $1,000  

CDHP = consumer-directed health plan 
EPO = exclusive provider organization 
ER = emergency room 
HMO = health maintenance organization 
IP = inpatient 
MH = mental health
OON = out-of-network 
OP = outpatient 
POS = point of service 
PPO = preferred provider organization 
SA = substance abuse

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