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NAHU Looks at What Group Plans Really Cover

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The National Association of Health Underwriters (NAHU) has shed light on health plan features that other organizations, rarely, if ever, ask about.

NAHU, Washington, sent a survey to about 16,000 members in an effort to get data to support benefits advisors’ belief that most U.S. employers with health plans provide for their employees.

NAHU received a total of about 1,100 responses, including 923 describing benefits at the producers’ small group plans, or plans with fewer than 100-full time employees, and 170 describing benefits at producers’ large group plans.

NAHU conducted the survey in response to efforts by the U.S. Department of Health and Human Services (HHS) to implement the essential health benefits (EHB) provisions of the Patient Protection and Affordable Care Act of 2010 (PPACA).

The PPACA EHB provisions require HHS to develop minimum benefit plan coverage standards, to keep plans from shortchanging enrolling or using skimpy benefits in some areas to scare off applicants with health problems.

HHS officials say they would like to let each state develop its own EHB standards, within guidelines set by HHS. Officials have noted that they would like to see the minimum plan standards reflect the kinds of features included in affordable small group plans rather than the kinds of features included in high-end large group plans.

The brokers who participated in the NAHU study said the small groups they serve do a good job of covering key procedures and services, NAHU says.

About 90% cover hospice care, for example, and 97% cover in-patient rehab. Nearly all cover prenatal care, infant care and organ transplants.

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NAHU Chief Executive Janet Trautwein says in a statement that she supports HHS moves to look to current employer coverage when designing the EHB pakage.

“For many individuals, coverage that’s exceedingly generous but unaffordable is equivalent to no coverage at all,” Trautwein says.

NAHU asked about typical hot-button coverage topics, such as transplants. Brokers said 99% of the small group plans they serve cover bone marrow transplants found to be medically necessary, but only 38% cover transplants classified as experimental.

Large group plans were equally likely to cover medically necessary bone marrow transplants, and 67% cover transplants classified as experimental.

Just 21% of the small group plans and 24% of the large group plans cover the special feeds that people with phenylketonuria need to eat to avoid complications.

About 75% of the small group plans and 99% of the large group plans cover air ambulance transportation services in at least some situations.

Correction: An earlier version of this article described NAHU’s location incorrectly. NAHU has moved to Washington.