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Principal Findings.

Major results of the 1993 AGI Study of Private-Sector Insurance Coverage of Reproductive Health Services fall into the three categories mentioned above: specific reproductive health care services, dependent coverage, and confidentiality provisions for patients.

Coverage of Specific Reproductive Health Care Services

Survey respondents were given a list of 25 health care services and asked to indicate whether, in the typical policy of each plan type they wrote, these services were

* covered when considered medically necessary or appropriate by the physician ("routinely covered");

* covered only when additional requirements were met; or

* not covered at all.

Gynecological Care

Insurers were asked about both the actual annual gynecological exam and the associated tests and medical procedures. Coverage of the annual exam differs according to the type of policy. Half of the large-group plans (49%) and 39% of the small-group plans routinely cover an annual exam, compared with 64% of typical PPOs, 88% of POS networks and 99% of HMOs (Table 1).

Specific medical procedures, such as a Pap test, chlamydia culture and mammogram, are more likely to be covered. For example, chlamydia cultures are routinely covered by 70% of large-group plans, 78% of PPOs and 98% of either POS networks or HMOs. Pap tests are routinely covered by 67% of large-group plans, 76% of PPOs, 93% of POS networks and 100% of HMOs.

Some plans cover these services only when requirements in addition to the service being considered medically necessary or appropriate are met. For example, 10% of large-group plans require the provider to certify a specific medical indication for a Pap test, and 9% require a specific medical indication for a chlamydia culture. Such requirements are found less frequently in POS networks or HMOs (Table 2).

Some plans do not cover certain gynecological services at all (Table 3).

While all HMOs and almost all POS networks provide at least some coverage of Pap tests and chlamydia cultures, that is not true of large-group plans and PPOs. Twenty-three percent of large-group plans and 14% of PPOs do not cover Pap tests at all, while 21% of large-group plans and 16% of PPOs do not cover chlamydia cultures.

Maternity Care

Obstetric care is routinely covered in almost all of the typical plans of each type: 97% of large-group plans, 99% of PPOs, 95% of POS networks and 98% of HMOs (26)

Interestingly, 97% of the fee-for-service plans written for groups with fewer than 15 employees typically include coverage of maternity care, even though they are not specifically required to do so by the federal Pregnancy Discrimination Act (PDA), a 1978 law that requires coverage of maternity care in employment-based group health insurance plans (to the same extent and subject to the same limitations as other health services covered under the plan), but only in plans written for groups with 15 or more employees. In the past, voluntary coverage had not been as extensive in these smaller plans; a study conducted for the U.S. Small Business Administration in 1984 found that 18% of employers with fewer than 25 employees did not include coverage of maternity care in their health insurance plans.(17)

Reversible Contraception

Almost half of all typical large-group plans (49%) do not routinely cover any contraceptive method at all, and only 15% cover all five reversible methods included in the study: IUD insertion, diaphragm fitting, Norplant insertion, Depo-Provera (DMPA) injection and oral contraception (Figures 2 and 3). However, there are significant differences between commercial companies and Blue Cross/Blue Shield plans. Thus, 59% of typical policies written by the former do not routinely cover any contraceptive method as opposed to 36% of typical policies written by the latter, and 8% of the former versus 24% of the latter cover all five reversible methods. None of these five methods is routinely covered by more than 40% of typical large group plans (coverage ranges from 21% for diaphragm fitting to 39% for DMPA injection; Figure 4). The extent to which individual contraceptive methods are covered in large-group policies also varies significantly between the two in some cases: Blue Cross/Blue Shield plans are significantly more likely to cover IUD insertion, diaphragm fitting, and DMPA injection than are commercial companies.

Oral contraceptives, the most commonly used reversible method in the United States, are routinely covered by 33% of large-group plans. (18) The failure of plans to cover oral contraceptives is not the result of an overall failure to cover prescription drugs; 97% of large-group plans typically include coverage of prescription drugs (Figure 5). Thus, 66% of plans that cover prescription drugs in general do not routinely cover oral contraceptives in their typical policy.

Along the same lines, while 92% of typical large-group plans routinely cover medical devices in general, 18% routinely cover IUDs, 15% cover diaphragms and 24% cover the Norplant device.

Coverage of reversible contraception in PPOs follows a pattern similar to that of conventional fee-for-service plans. Forty-nine percent of PPOs routinely cover no reversible contraceptive method, with 18% covering all five of the reversible methods in the survey. Ninety-nine percent of PPOs cover prescription drugs in general, while 41% routinely cover oral contraceptives.

Coverage in POS networks is, however, somewhat different. Nineteen percent routinely cover no reversible contraception (35% of networks administered by commercial companies but only 8% administered by Blue Cross/Blue Shields); 33% routinely cover all five reversible methods. Sixty percent routinely cover oral contraceptives (as opposed to 92% for prescription drugs in general); coverage of individual methods ranges from 46% for IUD insertion and diaphragm fitting to 72% for DMPA injection.

HMOs provide more comprehensive coverage of contraception than do fee-for-service plans. Only 7% of HMOs provide no contraceptive coverage at all, and 39% routinely cover all five methods. Coverage across the various methods ranges widely, however, from 59% for Norplant insertion to 86% for IUD insertion. Oral contraceptives are covered almost as often as prescription drugs in general: 84% as opposed to 89%.

Sterilization

As would be expected, given the long-standing tradition of health insurance to cover surgical procedures, surgical reproductive health care services are well covered in typical insurance policies. Tubal ligation is routinely covered by 86% of large-group plans, PPOs and HMOs and 90% of POS networks (Figure 6). Similarly, vasectomy is covered by 85% of large-group plans, 86% of PPOs, 90% of POS networks and 88% of HMOs.

Induced Abortion

Two-thirds or more of all the types of plans included in this survey--including 66% of large-group fee-for-service plans, 67% of PPOs, 83% of POS networks and 70% of HMOs--routinely cover induced abortions performed by dilation and curettage/suction aspiration in their typical policy.

In addition to those plans that routinely cover this procedure, 23% of large-group plans and 20% of PPOs and HMOs provide restricted coverage, generally by requiring the provider to certify the presence of a specific medical indication (beyond pregnancy itself) for the procedure; 5% of POS networks include these restrictions.

Eleven percent of large-group plans, 13% of PPOs and POS networks and 10% of HMOs do not cover abortion services at all in their typical plans (Table 3). In general, coverage of induced abortion by dilation and evacuation was similar to coverage of abortion by dilation and curettage/suction aspiration.

Infertility Diagnosis and Treatment

Coverage of infertility services varies greatly depending on the specific service. Sixty-one percent of large-group plans, 57% of PPOs, 66% of POS networks and 91% of HMOs routinely cover semen analysis in their typical policy. Endometrial biopsy is covered by 76% of large-group plans, 73% of PPOs, 78% of POS networks and 90% of HMOs.

Clomid, a prescription drug widely used to treat infertility in women, is routinely covered by 40% of large-group plans and PPOs and 48% of POS networks and 67% of HMOs. Thus, 59% of large-group plans, 59% of PPOs, 46% of POS networks and 32% of HMOs that cover prescription drugs in general do not routinely cover clomid in their typical plans.

In vitro fertilization (IVF) is rarely covered, regardless of the type of plan. IVF is routinely covered by 14% of large-group plans, 16% of PPOs and 17% of POS networks and HMOs.

Coverage for Dependents

Plans may not always include the same coverage for dependents that they offer to employees. To examine the question of dependent coverage--including both spouse and nonspouse dependents--respondents were given a list of 10 specific reproductive health care services (19) and asked to indicate whether each of these services was covered for the spouse and nonspouse dependents of employees enrolled in the typical plan of each type. Data are presented only for those services for which at least 15 plans of each type covered the service for employees and provided data on dependent coverage.

The PDA requires insurance plans that include maternity coverage for an employee to include these benefits for the employee's spouse. Almost all plans that typically include maternity coverage for the employee adhere to this requirement (98% of such large-group plans, 97% of the PPOs and 99% of the HMOs and all POS networks). (20)

Plans sometimes exclude spouses from coverage for other reproductive health services. Most frequently excluded are abortion services (covered for the spouse in 87% of typical large-group plans, 86% of PPOs, 97% of POS networks and 99% of HMOs that cover abortion services for the employee) and oral contraceptives (covered in 89% of typical large-group plans covering oral contraceptives for the employee, 86% of PPOs, 95% of POS networks and 91% of HMOs). In contrast, all or virtually all large-group plans, PPOs, POS networks and HMOs that cover physician services, surgical services and prescription drugs in general for the employee also cover these services for the employee's spouse.

The PDA does not require that insurance plans include maternity benefits for nonspouse dependents, such as the teenage daughter of an insured employee. (21) As a result, some types of plans that typically include maternity benefits for employees and spouses do not do so for nonspouse dependents. Of plans in which the employee is covered for maternity benefits, 79% of large-group plans, 82% of PPOs, 97% of POS networks and 95% of HMOs also include maternity benefits for nonspouse dependents. These levels of coverage represent an improvement over 1985, when 65% of fee-for-service plans were found to typically include

these benefits. (22)

Some plans also exclude nonspouse dependents from other reproductive health care services covered for employees or for employees and spouses. As for spouses, the services most likely to be excluded for nonspouse dependents are abortion (covered by 83% of large-group plans, 82% of PPOs, 93% of POS networks and 99% of HMOs) and oral contraceptives (covered by 84% of large-group plans, 82% of PPOs, 91% of POS networks and 91% of HMOs). In contrast, at least 98% of the large-group plans, PPOs, POS networks and HMOs cover physician services, surgical services and prescription drugs in general for nonspouse dependents in their typical policy.

In short, dependents are not always covered for the entire package of services covered for the employee, with non-spouse dependents more likely to be excluded than spouses.

Confidentiality

Confidentiality is often more important to reproductive health services than to other types of medical care. Considering the sensitivity of some of the specific services involved--sterilization, abortion, contraception, screening and diagnosis for STDs, infertility diagnosis and treatment--both men and women may be wary of letting either employers or family members know of the services they have sought or received. Confidentiality might also be a concern for a woman seeking maternity care early in pregnancy, before the fact of her pregnancy becomes evident.

In the context of insurance coverage, confidentiality involves both whether an employer is informed that specific employees or their dependents have used specific medical services and whether employees are informed that their dependents, either spouses or nonspouse dependents such as teenage children, have used specific medical services. The former involves everyone covered under the plan; the latter is an issue that is exclusive to dependents. In order to explore these issues, the AGI study included several questions concerning the extent to which insurers' billing and claims processing procedures result in the notification of employers, parents or spouses that a dependent has obtained medical care. Such insurance industry practices would be independent of, and in addition to, any legal requirements that parents or spouses be notified or consent to a dependent's care.

Few plans typically notify employers of the names of individuals who have received specific medical services: 6% of large-group plans and PPOs, 5% of POS networks and 4% of HMOs. (23) However, it should be noted that the AGI survey did not, and could not, address the specific practices of individual employers in the submission of claims or notification of claims that had been paid by an insurer.

In a fee-for-service, or conventional indemnity plan system, a patient generally pays the provider the full amount of the charge at the time of service and obtains reimbursement from the insurer after the fact. (In some cases, a provider may be willing to forgo payment at the time of service and be paid directly for the care by the insurer once a claim is filed.) Assuming a dependent can obtain access to a claim form, the first issue that arises in the claims process in a fee-for-service system is whether the dependent is able to file the claim with the insurer without having to obtain the employee's signature. For dependents under age 18, 57% of large-group plans, 64% of PPOs and 62% of POS networks do not require the employee's signature on the claim form. For dependents age 18 or over, 77% of large-group plans, 79% of PPOs and 85% of POS networks do not require the employee's signature on the form.

The second issue arises with the transmission of the Explanation of Benefits (EOB) form, a form that is generally returned to the employee either with the insurer's reimbursement for costs that have been incurred or to inform the employee that a health care provider has been paid directly. Although this form may not indicate a specific medical procedure, it identifies the provider, which, in the case of many reproductive health care services, may be tantamount to an identification of the type of service obtained.

In most cases, the EOB is sent to the employee, even if the services were obtained by the employee's spouse or nonspouse dependent. However, in 15% of the large-group plans, 12% of PPOs and 10% of POS networks the dependent may receive the EOB directly.

Twelve percent of large-group plans, 11% of PPOs and 10% of POS networks allow dependents, regardless of their ages, to obtain confidential care by allowing them to both sign the claim form and receive the EOB directly (Figure 7). In 88% of typical large-group plans and similar proportions of PPOs and POS networks, however, the employee is involved in submitting the claim and/or receiving the EOB.

The process is different in HMOs, where the services are essentially prepaid and the copayment, if any, generally is made at the time services are received. The key issues in this situation, then, are whether a dependent who is able to demonstrate enrollment in the HMO may receive services and whether the employee is subsequently notified that care has been provided.

Ninety-six percent of HMOs reported that the enrollee's spouse who is not accompanied by the enrollee may obtain care if able to demonstrate enrollment in the HMO; 95% said the same concerning nonspouse dependents age 18 or over, as did 87% concerning nonspouse dependents under age 18.

Approximately four in 10 HMOs indicated that unaccompanied dependents may obtain care without making any out-of pocket payment that day (41% for spouses, 88% for nonspouse dependents age 18 or over and 37% for nonspouse dependents under 18), either because cost-sharing is not required under the typical plan or because they may elect to be billed themselves for the entire copayment. Most of the remaining HMOs indicated that unaccompanied dependents may obtain care upon payment of the required cost-sharing amount.

Seventy-four percent of HMOs indicated that they do not send the employee a written statement of services received by dependents; 9% said that a written statement is sent whenever a dependent receives care, while 17% said that they send a statement only when the account has an outstanding balance.

Thus, in a majority of HMOs, dependents may obtain confidential care. In 71% of HMOs, a spouse or a nonspouse dependent who is at least 18 may receive services when not accompanied by the employee and not have the employee notified that services have been provided; 64% of HMOs provide the same level of confidentiality to dependents under age 18.

In sum, the billing and claims processing procedures used by a large percentage of insurers, and especially in conventional indemnity policies but to a lesser extent in HMOs as well, often preclude the possibility of dependents obtaining confidential care. This can leave some individuals seeking reproductive heath services to have to finance this care out-of-pocket rather than through their health plans.

Notes and References

(16.) This finding is similar to that in an earlier study by AGI, in which 99% of insurers surveyed in 1985 indicated that their typical policies included maternity benefits for the employee (The Alan Guttmacher Institute, The Financing of Maternity Care in the United States [New York, 1987]). It is also in line with the finding of the Health Insurance Association of America that "more than 95 percent of employees under employer-sponsored group policies underwritten by commercial insurance companies have maternity benefits." (Source Book of Health Insurance Data, 1992 [Washington, D.C., 1992]).

(17.) Office of Advocacy, United States, Small Business Administration, "Health Care Coverage and Costs in Small and Large Businesses: Final Report" (Washington, D.C., 1987).

(18.) An additional 8% of typical largegroup plans include restricted coverage of oral contraceptives, generally covering them as a treatment for a specific medical problem, such as menstrual irregularities, but not for purposes of contraception.

(19.) Information concerning coverage for dependents was sought for the following 10 specific reproductive health care services: annual gynecological examination, Norplant insertion, IUD insertion, laparoscopic tubal ligation, preconception risk assessment, dilation and curettage/suction aspiration, routine obstetric care, Norplant device, IUD device and oral contraceptives. Data are not presented here for contraceptive counseling and Norplant and IUD insertions and devices. In each case, less than 15 plans covered these services for employees and provided data on dependent coverage.

(20.) These data do not distinguish between a plan that routinely covers a service and a plan that conditions coverage on the provision of a specific medical justification by the provider.

(21.) Equal Employment Opportunity Commission, "Guidelines on Sex Discrimination; Adoption of Final Interpretive Guidelines; Questions and Answers," Federal Register, 44:28803,1979.

(22.) The Alan Guttmacher Institute, Blessed Events and the Bottom Line (New York, 1987), p.21.

(23.) Self-insured indemnity plans administered by either commercial companies or Blue Cross/Blue Shield plans seem slightly more likely to notify employers; 13% of these plans indicated that employers are routinely notified.
Table 1.

Percentage of Typical Plans in  Which Specific Service is Routinely
Covered, by Type of Plan

Services                            Commercial Insurance
                                      Companies and Blue
                                       Cross/Blue Shield
                                           Plans(N = 83)
                                   ConventionalIndemnity
                                                   Plans




                                Insured
                                Plans [less than or
                                equal to 15]
                                Employees


General Care
Prescription drugs              95
Medical devices                 89

Routine Gynecological Care
Annual gynecological exam       40
Pap test                        NA
Chlamydia culture               NA
Mammogram                       NA

Maternity Care
Routine obstetric care          97
Chorionic villus                NA

Reversible Contraception
IUD insertion (+)               25
Diaphragm/cervical cap fitting  NA
Norplant insertion (+)          25
Norplant removal                NA
DMPA(Depo Provera)injection(+)  NA
Diaphragm device (+)            NA
IUD device (+)                  18
Norplant device                 23
Oral contraceptives             31

Contraceptive Sterilization
Laparoscopic tubal ligation     86
Vasectomy                       NA

Induced Abortion
Dilation and curettage/suction  79
aspiration
Dilation and evacuation         NA

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

Services                               Commercial Insurance
                                         Companies and Blue
                                Cross/Blue Shield Plans(N =
                                                        83)
                                ConventionalIndemnity Plans




                                Insured
                                Plans < 100
                                Employees



General Care
Prescription drugs              97
Medical devices                 91

Routine Gynecological Care
Annual gynecological exam       39
Pap test                        63
Chlamydia culture               69
Mammogram                       76

Maternity Care
Routine obstetric care          93
Chorionic villus                79

Reversible Contraception
IUD insertion (+)               23
Diaphragm/cervical cap fitting  19
Norplant insertion (+)          26
Norplant removal                30
DMPA(Depo Provera)injection(+)  34
Diaphragm device (+)            15
IUD device (+)                  16
Norplant device                 23
Oral contraceptives             32

Contraceptive Sterilization
Laparoscopic tubal ligation     86
Vasectomy                       85

Induced Abortion
Dilation and curettage/suction  64
aspiration
Dilation and evacuation         66

Infertility
Endometrial biopsy              77
Semen analysis                  62
In vitro fertilization          17
Clomid medication               40

Services                          Commercial Insurance Companies
                                      and Blue Cross/Blue Shield
                                                   Plans(N = 83)
                                     ConventionalIndemnity Plans




                                Insured              Self-
                                Plans [greater than  insured
                                or equal to 100]     Plans (*)
                                Employees


General Care
Prescription drugs              97                   98
Medical devices                 92                   98

Routine Gynecological Care
Annual gynecological exam       49                   53
Pap test                        67                   67
Chlamydia culture               70                   71
Mammogram                       77                   71

Maternity Care
Routine obstetric care          97                   98
Chorionic villus                83                   83

Reversible Contraception
IUD insertion (+)               26                   25
Diaphragm/cervical cap fitting  21                   21
Norplant insertion (+)          28                   30
Norplant removal                32                   36
DMPA(Depo Provera)injection(+)  39                   32
Diaphragm device (+)            15                   16
IUD device (+)                  18                   20
Norplant device                 24                   27
Oral contraceptives             33                   38

Contraceptive Sterilization
Laparoscopic tubal ligation     86                   86
Vasectomy                       85                   86

Induced Abortion
Dilation and curettage/suction  66                   68
aspiration
Dilation and evacuation         69                   68

Infertility
Endometrial biopsy              76                   81
Semen analysis                  61                   64
In vitro fertilization          14                   16
Clomid medication               40                   52

Services                              Commercial Insurance
                                        Companies and Blue
                                 Cross/Blue Shield Plans(N
                                                     = 83)

                                                          Health
                                                          Maintenance
                                Preferred    Point        Organi-
                                Provider     of           zations
                                Organi-      Service      (N = 106) (*)
                                zations (*)  Network (*)




General Care
Prescription drugs              99           92           89
Medical devices                 94           95           83

Routine Gynecological Care
Annual gynecological exam       64           88           99
Pap test                        76           93           100
Chlamydia culture               78           98           98
Mammogram                       82           93           99

Maternity Care
Routine obstetric care          99           95           98
Chorionic villus                83           92           77

Reversible Contraception
IUD insertion (+)               25           46           86
Diaphragm/cervical cap fitting  23           46           81
Norplant insertion (+)          29           54           59
Norplant removal                33           54           58
DMPA(Depo Provera)injection(+)  35           72           74
Diaphragm device (+)            17           30           52
IUD device (+)                  21           33           47
Norplant device                 27           48           44
Oral contraceptives             41           60           84

Contraceptive Sterilization
Laparoscopic tubal ligation     86           90           86
Vasectomy                       86           90           88

Induced Abortion
Dilation and curettage/suction  67           83           70
aspiration
Dilation and evacuation         67           83           70

Infertility
Endometrial biopsy              73           78           90
Semen analysis                  57           66           91
In vitro fertilization          16           17           17
Clomid medication               40           48           67

Notes: "Typical" is defined as "that which represents the coverage
written for most of the lives covered under each policy type." NA
indicates that questions converning coverage of these services were not
asked. (*)Includes plans of all sizes. (+)For these services Blue Cross/
Blue Shield plans were significantly more likely than commercial
insurers to provide unrestricted coverage in at least two plan
categories (Chi-square significant at the .05 level). For example, among
conventional indemnity plans, coverage for these services varied between
4% and 26% for commercial insurers and between 29% and 55% for Blue
Shield plans. Source: The Alan Guttmacher Institute Study of
Private-Sector Insurance Coverage of Reproductive Health Services, 1993.
Table 2.

Percentage of Typical Plans in Which Specific Service is Covered Subject
to Additional Requirements, by Type of Plan

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               0                 0
Medical devices                  0                 0

Routine Gynecological Care
Annual gynecological exam        5                 5
Pap test                        NA                10
Chlamydia culture               NA                 8
Mammogram                       NA                 7

Maternity Care
Routine obstetric care           0                 0
Chorionic villus                NA                 8

Reversible Contraception
IUD insertion                    0                 0
Diaphragm/cervical cap fitting  NA                 1
Norplant insertion               0                 0
Norplant removal                NA                 6
DMPA (Depo Provera) injection   NA                 4
Diaphragm device                NA                 0
IUD device                       0                 0
Norplant device                  0                 0
Oral contraceptives              7                 8

Contraceptive Sterilization
Laparoscopic tubal ligation      3                 4
Vasectomy                       NA                 4

Induced Abortion
Dilation and curettage/
suction aspiration              13                21
Dilation and evacuation         NA                18

Infertility
Endometrial biopsy              NA                 4
Semen analysis                  NA                 3
In vitro fertilization          NA                 1
Clomid medication               NA                 4


Services                        Commercial Insurance Companies and
                                      Blue Cross/Blue Shield Plans
                                                            (N=83)
                                      Conventional Indemnity plans
                                Insured              Self-
                                Plans [greater than  insured
                                or equal to]100      Plans (*)
                                Employees


General Care
Prescription drugs               0                    0
Medical devices                  0                    0

Routine Gynecological Care
Annual gynecological exam        5                    5
Pap test                        10                   10
Chlamydia culture                9                   12
Mammogram                        7                    9

Maternity Care
Routine obstetric care           0                    0
Chorionic villus                 8                    9

Reversible Contraception
IUD insertion                    0                    0
Diaphragm/cervical cap fitting   1                    0
Norplant insertion               0                    0
Norplant removal                 4                    4
DMPA (Depo Provera) injection    4                    5
Diaphragm device                 0                    0
IUD device                       0                    0
Norplant device                  0                    0
Oral contraceptives              8                   11

Contraceptive Sterilization
Laparoscopic tubal ligation      4                    5
Vasectomy                        4                    5

Induced Abortion
Dilation and curettage/
suction aspiration              23                   18
Dilation and evacuation         20                   18

Infertility
Endometrial biopsy               4                    4
Semen analysis                   3                    3
In vitro fertilization           1                    2
Clomid medication                7                    4


Services                           Commercial Insurance Companies
                                 and Blue Cross/Blue Shield Plans
                                                           (N=83)
                                Perferred          Point
                                Provider           of
                                Organizations (*)  Service
                                                   Networks (*)



General Care
Prescription drugs               0                  0
Medical devices                  0                  0

Routine Gynecological Care
Annual gynecological exam        4                  2
Pap test                        10                  2
Chlamydia culture                7                  3
Mammogram                        8                  2

Maternity Care
Routine obstetric care           0                  0
Chorionic villus                 7                  5

Reversible Contraception
IUD insertion                    0                  0
Diaphragm/cervical cap fitting   0                  0
Norplant insertion               0                  0
Norplant removal                 4                  5
DMPA (Depo Provera) injection    7                  3
Diaphragm device                 0                  3
IUD device                       0                  0
Norplant device                  0                  0
Oral contraceptives              7                  3

Contraceptive Sterilization
Laparoscopic tubal ligation      4                  8
Vasectomy                        4                  5

Induced Abortion
Dilation and curettage/
suction aspiration              20                  5
Dilation and evacuation         19                  5

Infertility
Endometrial biopsy               6                  3
Semen analysis                   3                  5
In vitro fertilization           1                  2
Clomid medication                5                  3


Services                        Health
                                Maintenance
                                Organizations
                                (N=106) (*)




General Care
Prescription drugs               0
Medical devices                  0

Routine Gynecological Care
Annual gynecological exam        1
Pap test                         0
Chlamydia culture                2
Mammogram                        1

Maternity Care
Routine obstetric care           1
Chorionic villus                15

Reversible Contraception
IUD insertion                    0
Diaphragm/cervical cap fitting   0
Norplant insertion               3
Norplant removal                 7
DMPA (Depo Provera) injection    6
Diaphragm device                 0
IUD device                       0
Norplant device                  3
Oral contraceptives              2

Contraceptive Sterilization
Laparoscopic tubal ligation      8
Vasectomy                        6

Induced Abortion
Dilation and curettage/
suction aspiration              20
Dilation and evacuation         20

Infertility
Endometrial biopsy               4
Semen analysis                   4
In vitro fertilization           7
Clomid medication                8


Notes: "Typical" is defined as "that which represents the coverage
written for most of the lives covered under each policy type." 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 Reproduction Health Services, 1993.
Table 3.

Percentage of Typical Plans in Which Service is Not Covered, by Type of
Plan

                                     Commercial Insurance Companies
                                         and Blue Cross/Blue Shield
                                                       Plans (N=83)
                                       Conventional Indemnity Plans

                                    Insured
                                    Plans [less than or equal to]
Services                            15 Employees


General Care
Prescription drugs                   5
Medical devices                     11

Routine Gynecological Care
Annual gynecological exam           55
Pap test                            NA
Chlamydia culture                   NA
Mammogram                           NA

Maternity Care
Routine obstetric care               3
Chorionic villus                    NA

Reversible Contraception
IUD insertion (+)                   75
Diaphragm/cervical cap fitting (+)  NA
Norplant insertion (+)              75
Norplant removal (+)                NA
DMPA (Depo-Provera) injection (+)   NA
Diaphragm device (+)                NA
IUD device (+)                      82
Norplant device                     77
Oral contraceptives                 62

Contraceptive Sterilization
Laparoscopic tubal ligation         11
Vasectomy                           NA

Induced Abortion
Dilation and curettage/
 suction aspiration                  8
Dilation and evacuation             NA

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

                                     Commercial Insurance
                                       Companies and Blue
                                        Cross/Blue Shield
                                             Plans (N=83)
                                             Conventional
                                          Indemnity Plans

                                    Insured
                                    Plans <100
Services                            Employees


General Care
Prescription drugs                   3
Medical devices                      9

Routine Gynecological Care
Annual gynecological exam           56
Pap test                            27
Chlamydia culture                   22
Mammogram                           17


Maternity Care
Routine obstetric care               7
Chorionic villus                    13

Reversible Contraception
IUD insertiont (+)                  77
Diaphragm/cervical cap fitting (+)  80
Norplant insertion (+)              74
Norplant removal (+)                64
DMPA (Depo-Provera) injection (+)   62
Diaphragm device (+)                85
IUD device (+)                      84
Norplant device                     77
Oral contraceptives                 60

Contraceptive Sterilization
Laparoscopic tubal ligation         10
Vasectomy                           11

Induced Abortion
Dilation and curettage/
 suction aspiration                 15
Dilation and evacuation             16

Infertility
Endometrial biopsy                  19
Semen analysis                      36
In vitro fertilization              82
Clomid medication                   56

                                        Commercial Insurance
                                          Companies and Blue
                                     Cross/Blue Shield Plans
                                                      (N=83)
                                      Conventional Indemnity
                                                       Plans

                                    Insured
                                    Plans [greater than or
Services                            equal to]100 Employees


General Care
Prescription drugs                   3
Medical devices                      8

Routine Gynecological Care
Annual gynecological exam           47
Pap test                            23
Chlamydia culture                   21
Mammogram                           16

Maternity Care
Routine obstetric care               3
Chorionic villus                     9

Reversible Contraception
IUD insertiont (+)                  74
Diaphragm/cervical cap fitting (+)  78
Norplant insertion (+)              72
Norplant removal (+)                64
DMPA (Depo-Provera) injection (+)   57
Diaphragm device (+)                85
IUD device (+)                      82
Norplant device                     76
Oral contraceptives                 58

Contraceptive Sterilization
Laparoscopic tubal ligation         10
Vasectomy                           11

Induced Abortion
Dilation and curettage/
 suction aspiration                 11
Dilation and evacuation             11

Infertility
Endometrial biopsy                  20
Semen analysis                      37
In vitro fertilization              84
Clomid medication                   53

                                    Commercial Insurance Companies and
                                          Blue Cross/Blue Shield Plans
                                                                (N=83)
                                       Conventional
                                    Indemnity Plans

                                    Self-          Preferred
                                    insured        Provider
Services                            Plans (*)      Organizations (*)


General Care
Prescription drugs                   2              1
Medical devices                      2              6

Routine Gynecological Care
Annual gynecological exam           42             31
Pap test                            22             14
Chlamydia culture                   17             16
Mammogram                           21             10

Maternity Care
Routine obstetric care               2              1
Chorionic villus                     9             10

Reversible Contraception
IUD insertiont (+)                  75             75
Diaphragm/cervical cap fitting (+)  79             77
Norplant insertion (+)              70             71
Norplant removal (+)                61             62
DMPA (Depo-Provera) injection (+)   63             58
Diaphragm device (+)                84             83
IUD device (+)                      80             79
Norplant device                     73             73
Oral contraceptives                 52             52

Contraceptive Sterilization
Laparoscopic tubal ligation          9             10
Vasectomy                            9             10

Induced Abortion
Dilation and curettage/
 suction aspiration                 14             13
Dilation and evacuation             14             14

Infertility
Endometrial biopsy                  16             21
Semen analysis                      33             40
In vitro fertilization              83             83
Clomid medication                   45             55

                                        Commercial
                                         Insurance
                                     Companies and
                                              Blue
                                        Cross/Blue
                                      Shield Plans
                                            (N=83)

                                                  Health
                                    Point of      Maintenance
                                    Service       Organizations
Services                            Networks (*)  (N=106) (*)


General Care
Prescription drugs                   8            11
Medical devices                      5            17

Routine Gynecological Care
Annual gynecological exam           10             0
Pap test                             5             0
Chlamydia culture                    0             0
Mammogram                            5             0

Maternity Care
Routine obstetric care               5             1
Chorionic villus                     3             8

Reversible Contraception
IUD insertiont (+)                  54            14
Diaphragm/cervical cap fitting (+)  54            19
Norplant insertion (+)              46            39
Norplant removal (+)                42            35
DMPA (Depo-Provera) injection (+)   26            20
Diaphragm device (+)                68            48
IUD device (+)                      68            53
Norplant device                     53            54
Oral contraceptives                 38            14

Contraceptive Sterilization
Laparoscopic tubal ligation          3             7
Vasectomy                            5             7

Induced Abortion
Dilation and curettage/
 suction aspiration                 13            10
Dilation and evacuation             13            10

Infertility
Endometrial biopsy                  20             6
Semen analysis                      29             5
In vitro fertilization              81            76
Clomid medication                   50            24

Notes: "Typical" is defined as "that which represents the coverage
written for most of the lives covered under each policy type." NA
indicates that questions concerning coverage of these services were not
asked.

(*)Includes plans of all sizes.

(+)For these services Blue Cross/ Blue Shield plans were significantly
more likely than commercial insurers to provide no coverage at all in at
least two plan categories.

Source: The Alan Guttmacher Institute Study of Private-Sector Insurance
Coverage of Reproductive Health Services, 1993.
Figure 2

Reversible Contraception Not Covered

Half of typical fee-for-service plans written for large groups or PPOs
cover no reversible contraception at all.

                         % of plans typically
                         including no cover-
                         age for reversible
                         contraception

Indemnity plans
[less than or equal to]
100 employees                 49
PPOs                          49
POS networks                  19
HMOs                           7

(*)The methods referred to are IUD insertion, diaphragm fitting.
Norplant insertion, DMPA (Depo-Provera) injection and oral
contraceptives.

Note: "Typical" is defined as "that which represents the coverage
written for most of the lives covered under each policy type."

Source: The Alan Guttmacher Institute Study of Private-Sector Insurance
Coverage of Reproductive Health Services, 1993.

Note: Table made from bar graph
Figure 3

Five Reversible Contraceptives Covered

Less than 20 percent of large group indemnity plans or PPOs and less
than 40 percent of POS networks and HMOs routinely cover all five
reversible methods in their typical plans.

                                 % of plans typically
                                 including coverage for
                                 five reversible methods

Indemnity plans [greater
than or equal to] 100 employees          15
PPOs                                     18
POS networks                             33
HMOs                                     39

(*)The five methods covered are IUD insertion, diaphragm fitting,
Norplant insertion, DMPA (Depo-Provera) injection and oral
contraceptives.

Note: "Typical" is defined as "that which represents the coverage
written for most of the lives covered under each policy type."

Source: The Alan Guttmacher Institute Study of Private-Sector Insurance
Coverage of Reproductive Health Services, 1993.

Note: Table Made from bar graph
Figure 4

Specific Reversible Contraceptive Methods Covered

Many large--group indemnity plans and PPOs do not routinely cover key
reversible contraceptive methods in their typical plans, compared with
much more extensive coverage of these services in HMOs.


                                 % of plans typically including
                                            coverage
                               IUD insertion  Diaphragm fitting

Indemnity plans [greater than
or equal to] 100 employees          26               21
PPOs                                25               23
POS networks                        46               46
HMOs                                86               81

                                  % of plans typically including
                                             coverage
                               Norplant insertion  DMPA injection

Indemnity plans [greater than
or equal to] 100 employees             28                39
PPOs                                   29                35
POS networks                           54                72
HMOs                                   59                74

                               % of plans typically
                                including coverage
                               Oral contraceptives

Indemnity plans [greater than
or equal to] 100 employees             33
PPOs                                   41
POS networks                           60
HMOs                                   84

Note: "Typical" is defined as "that which represents the coverage
written for most of the lives covered under each policy type."

Source: The Alan Guttmacher Institute Study of Private-Sector Insurance
Coverage of Reproductive Health Services, 1993.

Note: Table made from bar graph
Figure 5

Prescription Drugs and Oral Contraceptives

Coverage of prescription drugs in general does not necessarily mean that
oral contraceptives are covered in large group indemnity plans or PPOs;
only four in 10 routinely cover oral contraceptives. Coverage of oral
contraceptives is much higher in POS networks and HMOs.

                               % of plans typically
                                including coverage
                          Prescription          Oral
                              drugs        contraceptives

Indemnity plans
[greater than or equal
to] 100 employees              97                33
PPOs                           99                41
POS networks                   92                60
HMOs                           89                84

Notes: "Typical" is defined as "that which represents the coverage
written for most of the lives covered under each policy type."

Source: The Alan Guttmacher institute Study of Private-Sector Insurance
Coverage of Reproductive Health Services, 1993.

Note: Table made from bargraph
Figure 6

Tubal Ligation and Abortion Services

At least 86% of all types of typical plans routinely cover tubal
ligation; at least two-thirds cover abortion services when considered
medically necessary or appropriate by the health care provider.

                                          % of plans
                                           typically
                                      including coverage
                                     Tubal        Abortion
                                   ligation       services (*)

Indemnity plans [greater than
or equal to] 100 employees            86             66
PPOs                                  86             67
POS networks                          90             83
HMOs                                  86             70

(*)Dilation and curettage/suction aspiration.

Note: "Typical" is defined as "that which represents the coverage
written for most of the lives covered under each policy type."

Source: The Alan Guttmacher Institute Study of Private-Sector Insurance
Coverage of Reproductive Health Services, 1993.

Note: Table made from bar graph
Figure 7

Confidentiality

Typical large-group indemnity plans, PPOs and POS networks are less
likely than HMOs to have billing and claims processing procedures that
allow spouses and nonspouse dependents, such as teenagers, to obtain
confidential reproductive health services.

                                 % of plans typically including
                                     confidential procedures
                                 For Spouse and      For nonspouse
                                   non-spouse          dependent
                                   dependents          unders 18
                                  18 and over

Indemnity plans [greater
than or equal to] employees            12                 12
PPOs                                   11                 11
POS networks                           10                 10
HMOs                                   71                 64

Note: "Typical" is defined as "that which represents the coverage
written for most of the lives covered under each policy type."
Confidential care can be obtained in an indemnity plan when the
dependent can both sign the claim form and receive reimbursement
directly; in an HMO, confidential care can be obtained when a
dependent who is not accompanied by the employee may receive care
and the employee is not notified that care has been provided.

Source: The Alan Guttmacher Institute Study of Private-Sector
Insurance Coverage of Reproductive Health Service, 1993.

Note: Table made for bargraph
COPYRIGHT 1995 Guttmacher Institute
No portion of this article can be reproduced without the express written permission from the copyright holder.
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Title Annotation:results of the AGI Study of Private-Sector Insurance Coverage of Reproductive Health Services
Publication:Uneven & Unequal: Insurance Coverage and Reproductive Health Services
Article Type:Topic Overview
Geographic Code:1USA
Date:Jan 1, 1995
Words:6031
Previous Article:AGI Study of Private-Sector Health Insurance Coverage.
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