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Appendix: Methodology.

The 1993 AGI survey of health insurers had three components: commercial insurance companies, Blue Cross/Blue Shield plans and health maintenance organizations (HMOs). The survey instruments used for the first two were identical. The survey for the HMOs included identical questions on the coverage of specific reproductive health care services and other questions specifically relevant to managed care plans. The survey instruments were developed in conjunction with a panel of experts in the health care and employee benefits fields.

Components

The procedure and response rates were similar for the three components of the study.

Commercial insurance companies

The commercial insurance survey was sent to the 100 largest commercial insurance companies in the United States based on the ranking of insurance companies, according to their net accident and health premiums written included in National Underwriters Profiles: 1993 Health Insurers. (1) The name and address of the chief executive officer (CEO) of each insurance company was obtained from Best's Insurance Reports: Life/Health Edition. (2)

Data in National Underwriters Profiles on the total net accident and health premiums written for all insurers were used to calculate the share of the total health insurance market that was covered by the sample of the 100 largest commercial insurers. Together, these insurers accounted for 97% of total net accident and health premiums written by all insurers.

The 12-page survey instrument was mailed to the CEO of each insurer on October 19, 1993. A second mailing was sent on November 12, and telephone follow-up both to obtain additional responses and to clarify issues arising from responses continued through December 1993.

Insurers were given the following instructions for completing the questionnaire: "Please answer the questions pertaining to your policy/contract written for groups to cover employees and their dependents in 1993. These questions do not apply to coverage written for persons not part of a group or to coverage supplementing Medicare benefits."

There are five types of policies/contracts that commercial insurance companies and Blue Cross/Blue Shield plans write and the survey was divided into five parts, essentially repeating a single set of questions for each type of policy/contract:

* insured indemnity (fee-for-service) health insurance policies/contracts for groups with fewer than 100 employees (with a special subsection concerning policies for groups with 15 or fewer employees);

* insured indemnity health insurance policies/contracts written for groups with 100 or more employees;

* self-insured indemnity policies/contracts administered under Administrative Services Only agreements (a self-insured plan is one in which the employer, rather than the insurer, bears the risk of providing care to the insured group; many self-insured plans hire insurers--either commercial companies or Blue Cross/Blue Shield plans--to administer their plans through Administrative Services Only contracts);

* preferred provider organizations (PPOs), both insured and self-insured; and

* point-of-service (POS) networks, both insured and self-insured.

Of the 100 surveys mailed, 45 were returned. Of the balance, 23 insurers indicated that the survey was not applicable and 32 did not participate in the project. (The "not-applicable" firms generally did not write group health insurance policies, with most offering only either nongroup coverage or Medicare supplement policies.) The most frequently given reasons for not responding to the survey were the length of the questionnaire and the level of detail required. In total, 58% of the firms for whom the survey is applicable responded. These responding insurers account for 68% of the applicable health insurance market, calculated on net premiums written. Eight of the 10 largest commercial insurance companies responded. Because commercial insurance companies write policies nationwide, it is not possible to determine whether the respondents are geographically representative.

Not all participating insurers wrote all five types of coverage about which they were questioned in the survey. All data presented concern only those insurers that write the relevant type of plan and responded concerning the specific service. See appendix, Table 1, for N's.

Note that the survey provides information only on self-insured plans administered by either commercial companies or Blue Cross/Blue Shield plans; it does not provide information on self-insured plans that are administered by either the insuring employer or a third party administrator. Similarly, the survey provides information on only those PPOs or P05 networks administered by commercial companies or Blue Cross/Blue Shield plans, and not independent networks.

Blue Crass/Blue Shield Plans

The survey was sent to all 73 Blue Cross/Blue Shield plans in the United States, based on the listing in the Blue Cross-Blue Shield Association Winter 1993 Directory. (3) The survey was sent to the CEO of each plan on October 19, 1993, with a second mailing sent November 8. Telephone follow-up continued through December 1993.

The survey instrument was identical to that mailed to commercial insurance companies.

Underwriters of a total of 38 plans responded to the survey Thirty-four insurers did not participate, including one potential respondent that indicated that the survey was not applicable since the organization is an association office that does not actually write insurance coverage. As a result, the response rate is 53% of the 72 applicable plans. At least two respondents come from each of the 10 federal geographical regions.

Health Maintenance Organizations

The sample of HMOs was constructed using the 1993 National Directory of HMOS (4) published by the Group Health Association of America. This directory lists the 546 HMOs in operation as of December 1992. The sample included:

* All 106 HMOs with 100,000 or more enrollees. (These 106 HMOs represent approximately 20% of all HMOs and account for 68% of all HMO enrollees nationwide.)

* A sample of 107 of the smaller HMOs. To obtain this sample, the remaining 440 smaller HMOs were stratified according to enrollment size (HMOs with less than 20,000 enrollees and HMOs with 20,000 to 99,000 enrollees) and region of the country (northeast, central, south and west). Every fourth HMO within region and enrollment size categories was then selected.

Overall, the 213 HMOs included in the sample account for 32.4 million enrollees, 76% of all HMO enrollees in 1992.

The HMO survey was mailed on October 25, 1993, with a second mailing November 12. Telephone follow-up continued through December 1993.

Overall, 106 of the 213 HMOs sampled responded with completed surveys, a response rate of 50%. Of the 106 HMOs with 100,000 or more enrollees, 61 responded, a response rate of 58%. Of the 107 HMOs with less than 100,000 enrollees, 45 responded, a response rate of 42%.

The HMOs responding to the survey include 17.6 million enrollees, 56% of all enrollees covered by the HMOs included in the sample and 43% of all HMO enrollees in 1992. In terms of geographic location, age of the plan, model type and tax status, no significant differences exist between respondent and nonrespondent HMOs. For example, individual practice associations, the most common model type, comprise 69% of all HMOs and 71% of respondents, and staff model HMOs comprise 10% of all HMOs and 8% of respondents.

The Survey Instrument

Each of the five major sections of the 12-page survey sent to commercial health insurance companies and Blue Cross/Blue Shield plans contained questions concerning the coverage typically available for employees for a list of 25 specific reproductive health care services (each of which was identified by either CPT-4 codes or codes from the HCFA Common Procedure Coding System), the coverage typically available for spouse and nonspouse dependents for a list of 10 specific services, and provisions for confidentiality for spouses and nonspouse dependents. Additional questions concerned the details of the availability of services in POS networks. The subsection concerning groups with fewer than 15 employees asked about a list of 10 medical services.

For each medical service included in the survey, insurers were asked to indicate whether, in the typical employment-related policy of each of the types included in the survey, the service was

* not covered at all;

* covered when considered medically necessary or appropriate by the physician; or

* covered only when additional requirements (i.e., an additional written report from the physician providing specific medical justification, prior authorization, etc.) are met.

For purposes of the survey, the term "typical" was defined as "that which represents the coverage written for most of the lives covered under each policy type." Respondents were asked to check one of the three categories. A respondent indicating that a service was covered subject to additional requirements was asked to specify these requirements. In general, the additional requirements reported fell into two categories. The first was that a provider specify the presence of a specified medical indication; the second was that prior authorization be obtained.

The 12-page HMO survey instrument contained instructions similar to those in the two other survey instruments concerning benefits provided in the typical plan written to cover employees and their dependents. The same definition of "typical" was used, and the same list of services and categories of responses were provided. In-plan services were defined to include services provided by an out-of-network provider under a subcontract with the HMO. In addition, the HMO survey asked questions about coverage of out-of-plan services and services to Medicaid recipients, as well as questions concerning primary care providers and gatekeepers.

Statistical Significance

For all three components of this study--commercial insurance companies, Blue Cross/Blue Shield plans and HMOs--a purposive sampling methodology was used to ensure that those companies that provide coverage to the largest number of enrollees were included. The survey results are expressed as percentages of plans providing coverage for specific services (not of individuals covered).

Based on a sample of 100 respondent companies, the individual percentages are accurate within approximately plus or minus 10 percentage points with 95% confidence. For a reported value of 50% there is a 95% likelihood that the true value falls somewhere between 40% and 60%. (The interval will be slightly narrower for HMOs and slightly wider for commercial companies and Blue Cross/Blue Shield plans combined because of differences in the number of respondent plans--106 HMOs and 83 commercial and Blue Cross/Blue Shield plans.) The 95% confidence interval around percentage values that are above or below 50% becomes progressively smaller, so that for a reported value of 90% the true value in a sample of 100 companies would likely fall between 84% and 96%.

Tabulations for the coverage of specific services were done combining the information provided by commercial companies and Blue Cross/Blue Shield plans. Separate tabulations were also done, and the significance of the observed differences was tested by computing chi-square values for the coverage of each service by private companies compared with Blue Cross/Blue Shield plans. Cases where the chi-square values were significant at the .05 level have been noted in the text.

References to Appendix

(1.) National Underwriters Profiles: 1993 Health Insurers (National Underwriter Co., Cincinnati, OH, 1993).

(2.) Best's Insurance Reports: Life/Health Edition (A.M. Best Co., Oldwick, N.J., 1993).

(3.) Blue Cross-Blue Shield Association Winter 1993 Directory (Blue Cross/Blue Shield Association, Washington, D.C., 1993).

(4.) 1993 National Directory of HMOs (Group Health Association of America, Washington, D.C., 1993).
Appendix Table 1.

Denominators for Tables 1-3

Services                            Commercial Insurance Companies and
                                   Blue Cross/Blue Shield Plans (N=83)
                                          Conventional Indemnity Plans
                                Insured           Insured
                                Plans [Less than  Plans < 100
                                or equal to] 15   Employees
                                Employees

General Care
Prescription drugs              62                72
Medical devices                 62                70

Routine Gynecological Care
Annual gynecological exam       62                66
Pap test                        NA                71
Chlamydia culture               NA                72
Mammogram                       NA                72

Maternity Care
Routine obstetric care          62                74
Chorionic villus                NA                72

Reversible Contraception
IUD insertion                   63                74
Diaphragm/cervical cap fitting  NA                74
Norplant insertion              63                72
Norplant removal                NA                73
DMPA (Depo Provera) injection   NA                73
Diaphragm device                NA                74
IUD device                      61                74
Norplant device                 61                73
Oral contraceptives             61                73

Contraceptive Sterilization
Laparoscopic tubal ligation     62                72
Vasectomy                       NA                72

Induced Abortion
Dilation and curettage/
 suction aspiration             62                73
Dilation and evacuation         NA                73

Infertility
Endometrial biopsy              NA                73
Semen analysis                  NA                73
In vitro fertilization          NA                72
Clomid medication               NA                73

Services                          Commercial Insurance
                                     Companies and Blue
                                Cross/Blue Shield Plans
                                                (N=83)
                                 Conventional Indemnity
                                                 Plans
                                Insured Plans [great
                                er than or equal to]
                                100 Employees


General Care
Prescription drugs              72
Medical devices                 72

Routine Gynecological Care
Annual gynecological exam       66
Pap test                        69
Chlamydia culture               70
Mammogram                       70

Maternity Care
Routine obstetric care          71
Chorionic villus                71

Reversible Contraception
IUD insertion                   72
Diaphragm/cervical cap fitting  72
Norplant insertion              72
Norplant removal                72
DMPA (Depo Provers) injection   72
Diaphragm device                72
IUD device                      72
Norplant device                 72
Oral contraceptives             72

Contraceptive Sterilization
Laparoscopic tubal ligation     71
Vasectomy                       71

Induced Abortion
Dilation and curettage/
 suction aspiration             70
Dilation and evacuation         70

Infertility
Endornetrial biopsy             71
Semen analysis                  71
In vitro fertilization          70
Clomid medication               70

Services                         Commercial Insurance Companies and
                                Blue Cross/Blue Shield Plans (N=83)
                                Conventional Indemnity  Preferred
                                                Plans
                                Self-                Provider
                                insured              Organi-
                                Plans (*)            zations (*)


General Care
Prescription drugs              58                   70
Medical devices                 56                   70

Routine Gynecological Care
Annual gynecological exam       57                   70
Pap test                        58                   71
Chlamydia culture               58                   71
Mammogram                       58                   71

Maternity Care
Routine obstetric care          58                   70
Chorionic villus                58                   71

Reversible Contraception
IUD insertion                   56                   71
Diaphragm/cervical cap fitting  56                   70
Norplant insertion              56                   69
Norplant removal                56                   69
DMPA (Depo Provers) injection   56                   71
Diaphragm device                56                   71
IUD device                      56                   71
Norplant device                 56                   70
Oral contraceptives             56                   71

Contraceptive Sterilization
Laparoscopic tubal ligation     57                   69
Vasectomy                       57                   69

Induced Abortion
Dilation and curettage/
 suction aspiration             57                   70
Dilation and evacuation         57                   70

Infertility
Endornetrial biopsy             58                   70
Semen analysis                  58                   70
In vitro fertilization          57                   70
Clomid medication               58                   67

Services                            Commercial  Health
                                     Insurance
                                 Companies and
                                          Blue
                               Cross/Blue Shie
                                      ld Plans
                                        (N=83)
                                Point         Maintenance
                                of            Organi-
                                Service       zations
                                Networks (*)  (N=106) (*)


General Care
Prescription drugs              39            104
Medical devices                 40            89

Routine Gynecological Care
Annual gynecological exam       41            105
Pap test                        41            105
Chlamydia culture               40            105
Mammogram                       41            104

Maternity Care
Routine obstetric care          41            105
Chorionic villus                39            100

Reversible Contraception
IUD insertion                   41            105
Diaphragm/cervical cap fitting  41            105
Norplant insertion              41            104
Norplant removal                41            103
DMPA (Depo Provers) injection   39            98
Diaphragm device                40            103
IUD device                      40            104
Norplant device                 40            101
Oral contraceptives             40            102

Contraceptive Sterilization
Laparoscopic tubal ligation     40            105
Vasectomy                       40            105

Induced Abortion
Dilation and curettage/
 suction aspiration             40            104
Dilation and evacuation         40            104

Infertility
Endornetrial biopsy             41            100
Semen analysis                  41            100
In vitro fertilization          41            97
Clomid medication               40            95

Notes: The response rate for the commercial insurance companies and the
Blue cross/ Blue Shield plans was 56% (83 respondents among the 149
companies and plans with relevant policies). The response rate for the
health maintenance organizations was 50% (106 respondents among the 213
HMOs--106 larger and 107 smaller). NA indicates that questions
concerning coverage of these services were not asked. (*)Includes plans
of all sizes.

Source: The Alan Guttmacher Institute Study of Private-Sector Insurance
Coverage of Reproductive Health Services, 1993.
COPYRIGHT 1995 Guttmacher Institute
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1995 Gale, Cengage Learning. All rights reserved.

Article Details
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Title Annotation:to survey of health insurance agencies
Publication:Uneven & Unequal: Insurance Coverage and Reproductive Health Services
Article Type:Topic Overview
Geographic Code:1USA
Date:Jan 1, 1995
Words:2498
Previous Article:Implications for Health Care Reform.
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