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AGI Study of Private-Sector Health Insurance Coverage.

This report, based on the first large-scale, comprehensive study of private insurance coverage of reproductive health care services, (12) addresses three issues critical to ensuring that people not only are insured for, but also are able to access, the care they need:

* whether specific reproductive health care services are covered,

* whether the dependents of insured individuals are covered for all services included in the plan and

* whether plans have provisions for patients to obtain confidential care.

To obtain a comprehensive picture of the different kinds of coverage Americans have, The Alan Guttmacher Institute (AGI) in 1993 wrote to the 100 largest commercial insurance companies, all 73 Blue Cross/Blue Shield plans, all 106 health maintenance organizations (HMOs) with 100,000 or more enrollees and a sample of 107 smaller HMOs. A total of 189 responses was received (45 commercial insurance companies, 38 Blue Cross/Blue Shield plans, 61 large HMOs and 45 smaller HMOs). See appendix on methodology for details.

The survey collected data on six types of employment-related insurance policies, the first five of which are issued or administered by commercial insurance companies and Blue Cross/Blue Shield plans: insured indemnity plans written for groups with under 100 employees, insured indemnity plans written for groups with 100 or more employees, self-insured plans administered by a commercial company or Blue Cross/Blue Shield plan (these three conventional indemnity, or fee-for-service, plans together account for 58% of insured employees), preferred provider organizations (PPOs, which account for 20%) and point-of-service networks (POS networks, which account for 3%) and HMOs (which account for 19%). (13) In each case, insurers were asked to describe the coverage included in the "typical" (14) plan of each type. (See Figure 1.)

Fifty-eight percent of the commercial companies for whom the study was applicable responded, (15) as did 53% of the applicable Blue Cross/Blue Shield plans and 50% of the HMOs surveyed. The respondent Blue Cross/Blue Shield plans are geographically representative of the United States, with at least two plans responding for each of the 10 federal regions. The respondent EMOs represent the geographic distribution of all HMOs and are similar to nonrespondent HMOs in terms of model type, age of plan and tax status. As stated above, a total of 189 responses is included in the analysis. The individual proportions reported here are accurate within a range of plus or minus 10 percentage points with 95% confidence.

Since only minor differences were found among the three types of fee-for-service plans included in the survey, the discussion in the text focuses largely on insured indemnity plans written for groups with 100 or more employees. (Tables 1-3 present data for all types of fee-for-service plans, including plans for groups with 15 or fewer employees, looked at as a subtype of groups with under 100 employees. See appendix, Table 1, for N's.) Coverage of reproductive health care in these large-group plans is compared with the coverage provided by PPOs, POS networks and HMOs. In general, both in text and in tables the data presented group commercial companies and Blue Cross/Blue Shield plans together; when the differences between the two are significant (based on chi-square values at the .05 level), the data for each are indicated.

Notes and References

(12.) Charlotte Muller conducted two similar but smaller scale studies in the 1970s: C.F. Muller, "Health Insurance for Abortion Costs: A Survey," Family Planning Perspectives, Vol. 2, NO. 4, 1970, pp. 12-20; and C.F. Muller, "Insurance Coverage of Abortion, Contraception and Sterilization," Family Planning Perspectives, VoL 10, No. 2, 1978, pp. 71-77. A study of insurance coverage of maternity care is included in The Alan Guttmacher Institute, The Financing of Maternity Care in the United States (New York, 1987).

(13.) M. Miller and T.H. Dial, Employer-Sponsored Health insurance in Private Sector Firms in 1992 (Health Insurance Association of America, Washington, D.C., 1993).

(14.) For the purposes of this project, "typical" is defined as "that which represents the coverage written for most of the lives covered by each policy type or by the individual HMO."

(15.) Some commercial insurance companies included in the survey indicated that the survey was not applicable to their business, generally because they write only nongroup coverage or policies specifically designed to supplement Medicare coverage.
Figure 1

Health Insurance Coverage

Over half of all U.S. employees with health insurance are covered by
conventional indemnity plans.

Preferred provider organizations  (20%)
Health Maintenance organizations  (19%)
Point of service networks          (3%)
Conventional indemnity plans      (58%)

Source: HIAA Employer Survey, 1992, of 2,516 private firms and 95 state
and local government employers. M. Miller and T.H. Dial, Employer-
Sponsored Health Insurance in Private Sector Firms in 1992 (Health
Insurance Association of America, Washington, D.C., 1993).

Note: Table made from pie chart

RELATED ARTICLE: Definitions of plans

Conventional indemnity plan

--One in which a patient or a provider is reimbursed for covered services up to a specified dollar limit.

Preferred provider organization (PPO)

--A system in which enrollees are given the option to either obtain care from a designated "preferred" provider or from an outside provider of their choice; an enrollee obtaining care from an out-of-network provider typically will pay a higher cost-sharing amount.

Point-of-service (POS) network

--A managed care system in which a primary physician acts as a gatekeeper to a network of specialists. Employees who use plan providers pay little or nothing out-of-pocket. Those who receive care from outside providers are reimbursed, but must pay much higher deductibles and copayments.

Health maintenance organization (HMO)

--Provider of a defined, comprehensive set of health services to an enrolled population within a specified geographic service area. Providers are typically reimbursed on a capitated or other "at risk" arrangement. There are several different types of HMOs.
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Title Annotation:Alan Guttmacher Institute
Publication:Uneven & Unequal: Insurance Coverage and Reproductive Health Services
Article Type:Topic Overview
Geographic Code:1USA
Date:Jan 1, 1995
Previous Article:Background.
Next Article:Principal Findings.

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