Essential Health Benefits: Balancing Coverage and Cost (2012)

Chapter: Appendix D: Examples of Benefit Package Statutory Guidance

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Part C (Medicare Advantage^b)

Is required to provide all Medicare-covered benefits to enrollees, with at least one plan with basic drug coverage (MA-PD plan)

Part D

• Prescription Drugs

Optional Services

Medical care, remedial care by licensed practitioners

Prescription drugs

Diagnostic, screening, preventive, and rehabilitative services

Clinic services

Primary care case management

Dental services and dentures

Physical therapy

Prosthetic devices and eyeglasses

Tuberculosis-related services

Other specified medical and remedial care

Intermediate care facility for the mentally retarded (ICF/MR) services

Institute for mental diseases services for those ages 65 and over

Outpatient prescription drugs [42.7, Rule 300.67.24]

Chiropractic services

Dental care

Hearing aids

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Previous Chapter: Appendix C: Examples of Possible Degrees of Specificity of Inclusions in Small Group and Individual Markets

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Suggested Citation: "Appendix D: Examples of Benefit Package Statutory Guidance." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.

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Appendix D

Examples of Benefit Package
Statutory Guidance

This appendix includes a display of benefit categories in statute for various health insurance programs.

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	Federal Employees Health Benefits Program (FEHBP)	Medicare	Medicaid	Knox-Keene Health Care Service Plan Act (CA)	Maryland	Massachusetts Exchange
Year Created	1959	1965	1965	1975	1993	2006
Categorization of Benefits	Service Benefit Plan	Part A	Mandatory Services	Basic Health Care Services	Comprehensive Standard Health Benefit Plan (CSHBP)	Minimum Creditable Coverage Standards
	Hospital benefits Surgical benefits In-hospital medical benefits Ambulatory patient benefits Supplemental benefits Obstetrical benefits	Inpatient hospital Skilled nursing facility Home health Hospice Inpatient psychiatric hospital	Physician services Lab and X-ray services Inpatient hospital services Outpatient hospital services Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services for children under 21 Family planning services Federally qualified health center services Rural health clinic services Nurse midwife services Certified nurse practitioner services Nursing facility services for those ages 21 and over Home health care services	Hospital inpatient services Physician services Outpatient and ambulatory care Lab and radiology Home health Preventive health services Emergency services (including ambulance and out-of-area coverage) Hospice (section 1368.2-only for group coverage)	Ambulance service Audiology screening for newborns Blood and blood products Case management program Chiropractic services Durable medical equipment Emergency room Family planning services Habilitative services Hearing aids Home health care Hospice Hospitalization, includes detoxification Infertility services Medical food Mental health and substance abuse Nutritional services Outpatient hospital services and surgery Outpatient laboratory and diagnostic services Outpatient short-term rehabilitative services Pregnancy and maternity Prescription drugs	Ambulatory patient services (including outpatient day surgery and related anesthesia) Diagnostic imaging and screening procedures (including x-rays) Emergency services Hospitalization (including at a minimum, inpatient acute care services, which are generally provided by an acute care hospital for covered benefits in accordance with the member’s subscriber certificate or plan description) Maternity and newborn care Medical or surgical care (including preventative and primary care) Mental health and substance abuse services Prescription drugs Radiation therapy and chemotherapy Doctor visits for preventive care, without a deductible

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		Preventive services rated by the U.S. Preventive Services Task Force as A or B not subject to deductible and no cost sharing if provided in-network Skilled nursing facility Transplants Well child and immunization benefits
Indemnity Benefit Plan	Part B
Hospital care Surgical care and treatment Medical care and treatment Obstetrical benefits Prescribed drugs, medicines, and prosthetic devices Other medical supplies and services	Physician and other medical services Outpatient hospital care Ambulatory surgical services Diagnostic tests, x-rays, and lab services Durable medical equipment Physical, occupational, and speech therapy Clinical laboratory services Home health care Outpatient mental health services One-time “Welcome to Medicare” physical exam Preventive services^a

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			Inpatient psychiatric care for children under 21 Home- and community-based care waiver services Other home health care services Targeted case management Respiratory care services for ventilator-dependent individuals Personal care services Hospice care
Statutory Authority	U.S. Code: Title 5-Government Organization & Employees Part III-Employees Subpart G-Insurance & Annuities-Chapter 89-Health Insurance-Section 8904	Title XVIII of the Social Security Act	Title XIX of the Social Security Act	Section 1345(b) Section 1367(i), rule 1300.67		Chapter 58-956 CMR 5.00

^a Flu shot, pneumococcal shot (no coinsurance); limit of one flu shot per flu season; hepatitis B shot, colorectal and prostate cancer screening, pap smear, mammogram, cardiovascular screening, abdominal aortic aneurysm (AAA) screening, bone mass measurement, diabetes screening and monitoring, glaucoma screening, smoking cessation.

^b Private health plans that receive payments from Medicare to provide Medicare-covered benefits to enrollees.

SOURCE: Families USA, 2006; GPO, 2007; KFF, 2010; O’Malley et al., 2009; State of California, 2011; State of Massachusetts, 2008.

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REFERENCES

Families USA. 2006. Medicaid benefit package changes: Coming to a state near you? http://www.familiesusa.org/assets/pdfs/DRA-Benefit-Package.pdf (accessed August 4, 2011).

GPO (Government Printing Office). 2007. Title 5 government organization and employees. Part III—employees. Subpart g—insurance and annuities. Chapter 89—health insurance. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=browse_usc&docid=Cite+5USC8904 (accessed August 4, 2011).

KFF (Kaiser Family Foundation). 2010. Medicare: A primer. Menlo Park, CA: Kaiser Family Foundation.

O’Malley, M., M. Moon, and R. W. Cowdry. 2009. Maryland’s Comprehensive Standard Health Plan for Small Businesses. Annapolis, MD:Maryland Health Care Commission.

State of California. 2011. Knox-Keene Health Care Service Plan Act of 1975. http://wpso.dmhc.ca.gov/regulations/11kkap/index.htm (accessed August 4, 2011).

State of Massachusetts. 2008. 956 CMR 5.00: Minimum creditable coverage. http://www.lawlib.state.ma.us/source/mass/cmr/cmrtext/956CMR5.pdf (accessed August 4, 2011).