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Life Health > Health Insurance > Health Insurance

Researchers: Small Plans, Government Plans Not So Different

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An arm of the U.S. Department of Health and Human Services (HHS) recently suggested that the new “essential health benefits” (EHB) package ought to be somewhere in the Goldilocks zone: Not too skimpy but not too rich.

HHS officials said the benefits in the EHB package probably ought to be similar to the benefits that small employers typically offer.

Insurers, brokers, employers and some consumer groups have welcomed the HHS officials’ emphasis on affordability. Some consumer groups have suggested an EHB package based on the recommendations might be too spartan and leave out important benefits.

Now Laura Skopec and other researchers in the office of the HHS Assistant Secretary for Planning and Evaluation (ASPE) — staff members in a department that enrolls employees in the Federal Employees Health Benefits Plan (FEHBP) — are suggesting in a new paper that the core benefits in mall group plans may not be so different from FEHBP benefits or the benefits in plans for state government employees.

“In evaluating the scope of benefits of employer plans, we found that overall, it appears that small group products and state and federal employee plans cover similar services,” the researchers write in the paper.

Public documents show that all state and federal employee plans — and 94% of the small group products studied — generally cover physician and specialist office visits, inpatient and outpatient surgery, hospitalization, emergency services, maternity care, inpatient and outpatient mental health and substance use disorder services, outpatient rehabilitation services, durable medical equipment, laboratory services, imaging services such as CT scans, preventive care, and immunizations. 

Similarly, all government plans studied cover mental and behavioral health inpatient services, but so do 95% of the small group plans reviewed, the researchers say.

The gap was larger for prescription drug coverage, the researchers say.

They note that all of the government plans studied and just 84% of the small group plans offer prescription coverage as a basic benefit. Another 16% of the small group plans offered drug benefits as an option.

Services covered by federal plans but generally not covered by small group plans, unless required by mandates, include dental care, acupuncture, bariatric surgery, and hearing aids, the researchers say.

But, because of state mandates, some small group plans do cover services, such as in vitro fertilization, that are not covered by typical FEHBP carrier, the researchers say.


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