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.
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.
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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|
|Date:||Jan 1, 1995|
|Previous Article:||Implications for Health Care Reform.|