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Guest Article

Deloitte logo

(From the May 2, 2011 issue of Deloitte's Washington Bulletin, a periodic update of legal and regulatory developments relating to Employee Benefits.)

Health Benefits Provided Under a "Typical Employer Plan"


The Labor Department released a report on the health benefits provided under a typical employer plan. The typical benefits will provide a baseline for the Department of Health and Human Services in defining "essential health benefits" under the Patient Protection and Affordable Care Act (PPACA). The PPACA requires that the scope of "essential health benefits" be equal to the scope of benefits provided under a typical employer plan.

The April 15 report, Selected Medical Benefits: A Report from the Department of Labor to the Department of Health and Human Services, utilized information from the Bureau of Labor Statistics' National Compensation Survey for years 2008 and 2009. While the survey captures data from about 36,000 employers, including those in private industry as well as State and local governments, the data on employment-based health benefits is from a representative sample of about 3,900 private sector employers. Additional data was also extracted from approximately 3,200 plan documents from 2009. The report does not purport to identify all the health benefits in a typical employer plan, but only a subset for which data are available. Data were presented on the following medical benefits, among others that appear to be provided less typically.

Labor Department Report
on Selected Medical Benefits in Private Sector Employer Plans in 2009
Medical Benefit
Percent of Participants
Covered
Percent of Participants
Subject to Limits
Limits
Hospital Room and Board 99% in All Plans
99% in Fee-for-Service Plans
100% in HMOs
88% in All Plans
92% in Fee-for-Service Plans
71% in HMOs
Limits include:
  • co-payments per admission,
  • deductibles, and
  • coinsurance.
The median copayment per
admission is $250.
Surgical Procedures Nearly Always Provided 90% in Fee-for-Service Plans
46% in HMOs for inpatient surgery
66-2/3% in HMOs for outpatient surgery
When plans subject outpatient
surgery to a copayment, the median
is $50 per visit in Fee-for-Service plans
and $75 per visit in HMOs.
Physician Office Visits 100% in All Plans
100% in Fee-for-Service Plans
100% in HMOs
97% in All Plans
97% in Fee-for-Service Plans
98% in HMOs
The median copayment per
visit is $20 (and $15 per visit
for HMOs).
Alternatives to Hospital Care:
  • Skilled Nursing Facility
  • Home Health
  • Hospice

  • 70% in All Plans for Skilled Nursing
  • 73% in All Plans for Home Health
  • 67% in All Plan for Hospice
  The median day limit for
skilled nursing facility
coverage is 90 days per
admission; the median day
limit for home health care is
100 days per year.
Preventive Care
  • 80% in All Plans for Adult
    Physicals
  • 77% in All Plans for Well-
    Baby Care
  • 56% in All Plans for Adult
    Immunizations and
    Inoculations
   
Prescription Drugs Nearly All Plan Participants,
and
  • 79% Have a Mail-Order Program
  The median copayment for
generic drugs is $10, while the
median copayment for brand-name
drugs is $25.
Mental Health and
Substance Abuse

(Note: This data predates
implementation of
the Mental Health
Parity and Addiction
Equity Act.)

Inpatient Mental Health Care:
  • 99% in All Plans
  • 99% in Fee-for-Service Plans
  • 98% in MHOs
  Mental health and substance
abuse coverage is nearly
always subject to limits.
Frequently a limit is imposed
on the number of days of
coverage: the median limit is
30 days per year.
  Outpatient Mental Health Care:
  • 85% in All Plans
  • 84% in Fee-for-Service Plans
  • 87% in MHOs
   
Not applicable Inpatient Substance Abuse
Detoxification:
  • 98% in All Plans
  • 98% in Fee-for-Service Plans
  • 98% in MHOs
   
. Inpatient Substance Abuse
Rehabilitation:
  • 78% in All Plans
  • 80% in Fee-for-Service Plans
  • 72% in MHOs
   
  Outpatient Substance Abuse
Rehabilitation:
  • 79% in All Plans
  • 79% in Fee-for-Service Plans
  • 79% in MHOs
   
Emergency Room Visits At least:
  • 91% in All Plans
  • 90% in Fee-for-Service Plans
  • 93% in MHOs
  • 89% in All Plans
  • 88% in Fee-for-
    Service Plans
  • 92% in MHOs
Subject to Plan Limits:
  • 75% in All Plans
  • 80% in Fee-for-Service
    Plans
  • 56% in MHOs
Subject to Separate Limits:
  • 70% in All Plans
  • 64% in Fee-for-Service
    Plans
  • 88% in MHOs
Subject to a Copayment Per
Visit:
  • 68% in All Plans
  • 62% in Fee-for-Service
    Plans
  • 87% in MHOs
Ambulance Service At least:
  • 64% in All Plans
  • 65% in Fee-for-Service
    Plans
  • 62% in MHOs
  • 52% in All Plans
  • 56% in Fee-for-Service
    Plans
  • 38% in MHOs
Subject to Plan Limits:
  • 49% in All Plans
  • 54% in Fee-for-Service Plans
  • 30% in MHOs
Subject to Separate Limits:
  • 13% in All Plans
  • 10% in Fee-for-Service Plans
  • 22% in MHOs
Physical Therapy At least:
  • 70% in All Plans
  • 69% in Fee-for-Service
    Plans
  • 72% in MHOs
  • 68% in All Plans
  • 68% in Fee-for-Service
    Plans
  • 69% in MHOs
Subject to Plan Limits:
  • 56% in All Plans
  • 59% in Fee-for-Service Plans
  • 43% in MHOs
Subject to Separate Limits:
  • 55% in All Plans
  • 51% in Fee-for-Service Plans
  • 67% in MHOs
Subject to a Copayment Per
Visit:
  • 29% in All Plans
  • 22% in Fee-for-Service Plans
  • 55% in MHOs
Durable Medical
Equipment
At least:
  • 67% in All Plans
  • 66% in Fee-for-Service
    Plans
  • 67% in MHOs
  • 57% in All Plans
  • 61% in Fee-for-Service
    Plans
  • 45% in MHOs
Subject to Plan Limits:
  • 51% in All Plans
  • 56% in Fee-for-Service Plans
  • 32% in MHOs
Subject to Separate Limits:
  • 24% in All Plans
  • 21% in Fee-for-Service Plans
  • 36% in MHOs
Maternity Care At least:
  • 66% in All Plans
  • 66% in Fee-for-Service
    Plans
  • 66% in MHOs
  • 58% in All Plans
  • 61% in Fee-for-Service
    Plans
  • 49% in MHOs
Subject to Plan Limits:
  • 50% in All Plans
  • 55% in Fee-for-Service Plans
  • 32% in MHOs
Subject to Separate Limits:
  • 36% in All Plans
  • 34% in Fee-for-Service Plans
  • 45% in MHOs
Subject to a Copayment Per
Visit:
  • 30% in All Plans
  • 27% in Fee-for-Service Plans
  • 41% in MHOs
Gynecological Services At least:
  • 60% in All Plans
  • 62% in Fee-for-Service
    Plans
  • 52% in MHOs
  • 56% in All Plans
  • 58% in Fee-for-Service
    Plans
  • 47% in MHOs
Subject to Plan Limits:
  • 44% in All Plans
  • 49% in Fee-for-Service Plans
  • 28% in MHOs
Subject to Separate Limits:
  • 51% in All Plans
  • 53% in Fee-for-Service Plans
  • 45% in MHOs
Subject to a Copayment Per
Visit:
  • 33% in All Plans
  • 31% in Fee-for-Service Plans
  • 39% in MHOs
Organ and Tissue
Transplant
At least:
  • 45% in All Plans
  • 48% in Fee-for-Service
    Plans
  • 31% in MHOs
  • 39% in All Plans
  • 44% in Fee-for-Service
    Plans
  • 18% in MHOs
Subject to Plan Limits:
  • 32% in All Plans
  • 37% in Fee-for-Service Plans
  • 11% in MHOs
Subject to Separate Limits:
  • 17% in All Plans
  • 18% in Fee-for-Service Plans
  • 10% in MHOs

The PPACA states that "essential health benefits" will include at least the following general categories (and the items and services covered within them):

  • 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.

Effective with the plan year beginning on or after September 23, 2010, group health plans are prohibited from imposing lifetime limits on "essential health benefits." Group health plans are also restricted in imposing annual limits on "essential health benefits" until the plan year beginning on and after January 1, 2014, when annual limits are prohibited altogether on "essential health benefits." Until guidance is issued on what constitutes "essential health benefits," plans need to operate in good faith compliance with a reasonable interpretation of that term.


Deloitte logoThe information in this Washington Bulletin is general in nature only and not intended to provide advice or guidance for specific situations.

If you have any questions or need additional information about articles appearing in this or previous versions of Washington Bulletin, please contact:

Robert Davis 202.879.3094, Elizabeth Drigotas 202.879.4985, Mary Jones 202.378.5067, Stephen LaGarde 202.879-5608, Bart Massey 202.220.2104, Erinn Madden 202.220.2692, Tom Pevarnik 202.879.5314, Sandra Rolitsky 202.220.2025, Deborah Walker 202.879.4955.

Copyright 2011, Deloitte.


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