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APPENDIX II
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Premium Estimates for Substance Abuse Parity Provisions for Commercial Health Insurance Products
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Summary of Plan Provisions of "Typical" Benefit Plans
A. HMO/EPO plan
|
Service Category |
Benefit Provision |
|
Hospital Inpatient
Medical
Behavioral
|
100% paid by plan
$100 copay per day, up to 30 days per year
(substance abuse treatment programs limited to 2 per lifetime) |
|
Outpatient
Medical
Behavioral
|
$10 copay per visit
$10 copay per visit, up to 20 visits per year, subject to $1,000 maximum benefit per calendar year |
|
Prescription Drugs |
$10 copay per script |
B. PPO/POS Plan
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Benefit Provision |
|
Service Category |
In-Network |
Out-of-Network |
|
Hospital Inpatient
Medical
Behavioral
|
100% paid by plan
$100 copay per day up to 30 days per year (substance abuse treatment programs limited to 2 per lifetime) |
70% paid by plan, $250 deductible per admission
50% paid by plan, up to 30 days per year, $250 deductible per admission
(substance abuse treatment programs limited to 2 per lifetime) |
|
Outpatient
Medical
Behavioral
|
$10 copay per visit
$10 copay per visit, up to 20 visits per year, subject to $1,000 maximum benefit per calendar year |
70% paid by plan
50% paid by plan, up to 20 visits per year, subject to $1,000 maximum benefit per calendar year |
|
Prescription Drug |
$10 copay per script |
60% paid by plan |
C. Fee-for-Service Plan
|
Service Category |
Benefit Provision |
|
Hospital Inpatient
Medical
Behavioral
|
80% paid by plan, $250 deductible per admission
50% paid by plan, $250 deductible per admission, up to 30 days per calendar year
(substance abuse treatment programs limited to 2 per lifetime) |
|
Outpatient
Medical
Behavioral
|
80% paid by plan
50% paid by plan, up to 20 visits per calendar year, subject to $1,000 maximum benefit per calendar year |
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Prescription Drug |
80% paid by plan |
Actual benefit plan provisions are generally far more complex than the "typical" plans outlined above. However, we used these "typical" benefit outlines to simplify the calculations of premium rate estimates.
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