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«© January 2011, University of Connecticut Connecticut Mandated Health Insurance Benefit Reviews Volume II. Introduction Volume II contains eleven of ...»

-- [ Page 1 ] --

Connecticut Mandated

Health Insurance Benefits

Reviews

Volume II

The Center for Public Health and Health Policy, a research and programmatic center founded in

2004, integrates public health knowledge across the University of Connecticut campuses and leads

initiatives in public health research, health policy research, health data analysis, health information

technology, community engagement, service learning, and selected referral services.

http://publichealth.University of Connecticut.edu/aboutus.php © January 2011, University of Connecticut Connecticut Mandated Health Insurance Benefit Reviews Volume II. Introduction Volume II contains eleven of the forty-five comprehensive reviews of existing health insurance required benefits (mandates) completed by the University of Connecticut Center for Public Health and Health Policy pursuant to Public Act 09-179. (P.A. 09-179 is attached to this report as Appendix I.) The mandates in Volume II are found in Title 38a of the Connecticut General Statutes Annotated and apply to certain individual and group health insurance policies delivered, issued for delivery, renewed or continued in this state after the effective date of the respective statute. The types of policies to which health insurance

mandates may apply as described in CGSA § 38a-469 include:

• Basic hospital expense coverage (Subsection 1) • Basic medical-surgical expense coverage (Subsection 2) • Hospital confinement indemnity coverage (Subsection 3) • Major medical expense coverage (Subsection 4) • Disability income protection coverage (Subsection 5) • Accident only coverage (Subsection 6) • Long term care coverage (Subsection 7) • Specified accident coverage (Subsection 8) • Medicare supplement coverage (Subsection 9) • Limited benefit health coverage(Subsection 10) • Hospital or medical service plan contract (Subsection 11) • Hospital and medical coverage provided to subscribers of a health care center (Subsection 12) • Specified disease coverage (Subsection 13).

Volume II is intended to be read in conjunction with the General Overview and the actuarial report for these mandates prepared by Ingenix Consulting. The Ingenix Consulting report for this set of mandates is attached to this Volume as Appendix II.

The following table lists the mandates covered in this volume and the chapter in which each is reviewed;

their statutory references (from CGSA Title 38a); and the applicable policy types. The order in which they are listed coincides with the order in which they are reviewed in the Ingenix Consulting report.

Index of Mandates: Volume II Policy Types Group

–  –  –

Each chapter reviews a single mandate and includes five sections: Overview, Background, Methods, Social Impact, and Financial Impact. The Overview includes the statutory references and the language of the mandate, the effective date, the premium impact, and the extent to which the mandated benefit is included in self-funded plans. The Background describes the disease, condition, treatment or provider to which the mandate applies, provides information on the current research and other pertinent information for each mandate. The Methods section documents the research methods followed by the mandate review team.

The Social Impact section addresses the sixteen criteria contained in section 1(d)(1) of P.A. 09-179. The Financial Impact section addresses the nine criteria contained in section 1(d)(2) of P.A. 09-179.

The following table summarizes the expected medical costs of each mandate in this volume for group plans.

Medical cost is the primary component of health insurance premiums. See the Ingenix Consulting report (Appendix II) for further details.

–  –  –

Volume II. Table of Contents Chapter I. Mammography and Breast Ultrasound

Overview

Background

Methods

Social Impact

Financial Impact

Chapter 2. Maternity Care Minimum Stay

Overview

Background

Methods

Social Impact

Financial Impact

Chapter 3. Mastectomy Care Minimum Stay

Overview

Background

Methods

Social Impact

Financial Impact

Chapter 4. Prescription Contraceptives

Overview

Background

Methods

Social Impact

Financial Impact

Chapter 5. Infertility Diagnosis and Treatment

Overview

Background

Methods

Social Impact

Financial Impact

Chapter 6. Autism Spectrum Disorder Therapies

Overview

Background

Methods

Social Impact

Financial Impact

Chapter 7. Coverage for Newborn Infants

Overview

Background

Methods

Social Impact

Financial Impact

Chapter 8. Blood Lead Screening and Risk Assessment

Overview

Background

Methods

Social Impact

Financial Impact

Chapter 9. Low Protein Modified Food Products, Amino Acid Modified Preparations and Specialized Formulas

Overview

Background

Methods

Social Impact

Financial Impact

Chapter 10. Neuropsychological Testing for Children Diagnosed with Cancer

Overview

Background





Methods

Social Impact

Financial Impact

Chapter 11. Preventive Pediatric Care and Blood Lead Screening and Risk Assessment

Overview

Background

Methods

Social Impact

Financial Impact

Appendix I. Public Act No. 09-179 Appendix II. Ingenix Consulting Actuarial and Economic Report Appendix III. Index of Mandates

–  –  –

Chapter 1. Table of Contents I.

Overview

II. Background

III. Methods

IV. Social Impact

V. Financial Impact

I. Overview The Connecticut General Assembly directed the Connecticut Insurance Department (CID) to review the health benefits required by Connecticut law to be included in group and individual health insurance policies as of July 1, 2009. Reviews are conducted following the requirements stipulated under Public Act 09-179 (Appendix I) and are collaborative efforts of Connecticut Insurance Department and the University of Connecticut Center for Public Health and Health Policy (CPHHP).

Connecticut General Statutes, Chapter 700, §§ 38a-530 and 38a-503 state that each group and individual and health insurance policy...

...shall provide benefits for mammographic examinations to any woman covered under the policy which are at least equal to the following minimum requirements: (1) A baseline mammogram for any woman who is thirty-five to thirty-nine years of age, inclusive; and (2) a mammogram every year for any woman who is forty years of age or older. Such policy shall provide additional benefits for comprehensive ultrasound screening of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing or other indications as determined by a woman’s physician or advanced practice registered nurse.

In April 2010, CPHHP and Ingenix Consulting (IC) requested and received mammography and breast ultrasound claims data from six insurers and managed care organizations (MCOs) domiciled in Connecticut that cover over 90 percent of the population in fully insured group and individual health insurance plans in Connecticut (1.25 million persons). Claims data shows that claims are being paid for mammography and breast ultrasound by health insurers and MCOs.

Current coverageThis mandate went into effect on October 1, 1988 (P.A. 90-243, S. 114).

Premium Impact Group plans: On a 2010 basis, medical cost is estimated to be $2.54 per member per month (PMPM).

Estimated total cost (insurance premium, administrative fees, and profit) of the mandated services in 2010 in group plans is $3.05 PMPM which is approximately 0.8 percent of estimated total costs in group plans.

Estimated cost sharing in 2010 in group plans is $0.13 PMPM.

Individual policies: Four of the six insurers/MCOs provided claims data for individual health insurance policies. On a 2010 basis, medical cost is estimated to be $1.88 PMPM. Estimated total cost (insurance premium, administrative fees, and profit) of the mandated services in 2010 in individual policies is $2.45 PMPM, approximately 0.9 percent of estimated total costs in individual policies. Estimated cost sharing in 2010 in individual policies is $0.44 PMPM. Individual policies data is less credible than group plans data primarily due to small sample size.

Self-funded plans Five health insurers/MCOs domiciled in Connecticut provided information about their self-funded plans, which represents an estimated 47 percent of the total population in self-funded plans in Connecticut.

These five insurers/MCOs report that 95.6 percent of enrollees in their self-funded plans have coverage for

–  –  –

This report is intended to be read in conjunction with the General Introduction to this volume and the Ingenix Consulting Actuarial and Economic Report which is included as Appendix II.

II. Background An estimated 207,090 new cases of breast cancer are expected to occur among women in the US during 2010; about 1,970 new cases are expected in men.1 Excluding cancers of the skin, breast cancer is the most frequently diagnosed cancer in women. An estimated 40,230 breast cancer deaths (39,840 women; 390 men) are expected in 2010.2 The American Cancer Society estimates that 2,790 new breast cancer cases were discovered and 480 women died of breast cancer in Connecticut in 2009.3 Breast cancer ranks second as a cause of cancer death in women, after lung cancer. Death rates for breast cancer have steadily decreased in women since 1990.4 The decrease in breast cancer death rates represents progress in both earlier detection and improved treatment.

Mammography is a low-dose x-ray procedure that allows visualization of the internal structure of the breast.

Mammography is highly accurate, but like most medical tests is not infallible. On average, mammography will detect about 80-90 percent of breast cancers in women without symptoms.5 The small percentage of cancers that are not identified by mammography may be missed for several reasons, including breast density, tumor growth rate, inadequate positioning of the breast, or interpretation error (failure to see indications of an abnormality).

Breast ultrasound is useful in the evaluation of palpable masses that are mammographically occult, in evaluation of clinically suspected breast lesions in women younger than 30 years of age, and when a mammogram shows an abnormality in the breast tissue.6 An abnormality may be a non-cancerous cyst, plugged milk duct or tumor.

According to data from the 2006 Behavioral Risk Factor Surveillance System (BRFSS), 69.9 percent of women aged 40 and older in Connecticut had a mammogram within the past year. Connecticut ranks fourth among states in this regard, trailing only Massachusetts (71.4 percent), Rhode Island (70.8 percent) and Delaware (70.2 percent).7 Women who have less than a high school education, who have no health insurance coverage, or who are recent immigrants to the US are least likely to have had a recent mammogram. White women have a higher incidence of breast cancer than African American women after age 40. In contrast, African American women have a higher incidence rate before age 40 and are more likely to die from breast cancer at every age.

Incidence and death rates from breast cancer are lower among women of other racial and ethnic groups than

American Cancer Society. 2010. Cancer facts and figures, 2010. Atlanta: American Cancer Society. Available at:

http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-026238.pdf. Accessed August 18, 2010.

Ibid.

American Cancer Society. Cancer Facts and Figures 2009. Atlanta: American Cancer Society; 2009.

Ibid.

American Cancer Society. 2010. Breast cancer facts and figures, 2009-2010. Atlanta: American Cancer Society Inc. Available at:

http://www.cancer.org/acs/groups/content/@nho/documents/document/f861009final90809pdf.pdf. Accessed September 15, 2010.

Perlmutter S. 2008. Breast cancer, ultrasonography. eMedicine Clinical Knowledge Base, Institutional Edition.

Available at: http://www.imedicine.com/DisplayTopic.asp?bookid=12&topic=795. Accessed September 17, 2010.

National Center for Chronic Disease Prevention and Health Promotion. 2007. Behavioral Risk Factor Surveillance System Public Use Data Tape, 2006. Centers for Disease Control and Prevention.

10 Volume II. Chapter 1among white and African American women.8

Medicare, Medicaid, and most private health insurance plans cover mammography costs or a percentage of them. Low-cost or free mammograms are available in most communities. The Connecticut Department of Health sponsors the Connecticut Breast and Cervical Cancer Early Detection Program (CBCCEDP), a comprehensive screening program available throughout Connecticut for medically underserved women.

Mammography is the most common health insurance mandate in the United States. Forty-nine states and the District of Columbia require health insurance plans to cover mammography.9 National guidelines for breast cancer screening using mammography exist from several organizations, including the American Cancer Society (ACS), American College of Radiology, and the United States Preventive Services Task Force (USPSTF). Following years of broad agreement about the guidelines among multiple organizations, the USPSTF changed its recommendations in December 2009. The USPSTF currently recommends against routine mammography for women under age 50 who are not at increased risk for breast cancer by virtue of a known underlying genetic mutation or a history of chest radiation and recommends biennial screening mammography for women 50-74 years of age. The ACS and American College of Radiology continue to recommend yearly mammograms starting at age 40 and continuing for as long as a woman is in good health.



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