December 22, 2004 |
2004-R-0976 | |
HUSKY AND MEHIP BENEFITS COMPARED | ||
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By: Saul Spigel, Chief Analyst | ||
You asked for a comparison of benefits offered under the state’s HUSKY B and Municipal Employees Health Insurance (MEHIP) plans.
As Table 1 shows, with the exception of dental care, HUSKY B and MEHIP cover essentially the same services, but MEHIP enrollees pay more for them. Unlike HUSKY B, MEHIP does not pay for eyeglasses, contact lenses, or hearing aids. HUSKY B does not appear to cover allergy or urgent care services and MEHIP does not seem to cover short-term rehabilitation, family planning services, or midwives, but these may be covered under different benefit categories in each plan. HUSKY B covers only children under age 19, while MEHIP covers both children and adults.
MEHIP offers three types of plans: (1) gatekeeper point of entry (an enrollee must obtain authorization from a primary care physician before seeking service from a specialist), (2) non-gatekeeper point of entry (an enrollee can go to any provider in the insurer’s network without a referral), and (3) point of service (an enrollee can go to any network provider and, if he pays a deductible and a higher co-pay, to outside providers). Each of these plans is available with varying co-pay requirements. The benefits described in Table 1 are those for the point of entry plans (both gatekeeper and non-gatekeeper) with a $ 10 co-pay, which we believe most resemble the HUSKY B model.
HUSKY B caps co-pays for some enrollees depending on their income. Families with household incomes between 185% and 235% of federal poverty level (currently, between $ 34,873 and $ 44,298 for a family of four) are limited to $ 650 annually in co-pays; families with household incomes between 235% and 300% of poverty (between $ 44,298 and $ 56,550 for a family of four) have a $ 1,250 annual aggregate limit for co-pays and premiums. No limit applies to families with household incomes over 300% of poverty.
Table 1: HUSKY B/MEHIP Benefit Comparison
BENEFIT |
HUSKY B |
MEHIP |
Outpatient Physician |
$ 5 co-pay |
$ 10 co-pay, including physicals (referrals required for specialists under gatekeeper POE plan) |
Preventive Care |
100% for periodic well-child visits, immunizations, Women Infant, Children (WIC) program evaluations, prenatal care; $ 5 co-pay for other visits |
100% for well-child and immunizations on an age-based schedule, prostate screenings, mammograms |
Allergy Services |
Not specifically mentioned |
60 treatments in 2 years; no co-pay for injections |
Pre-Admission Testing |
100% |
100% (pre-certification required) |
Inpatient Physician |
100% |
100% (pre-certification required) |
Inpatient Hospital |
100% |
$ 250 co-pay per admission |
Outpatient Surgical |
100% |
$ 50 co-pay (pre-certification required) |
Prescriptions |
$ 3 co-pay for generic drugs $ 6 co-pay for brand names (includes oral contraceptives) |
$ 7 co-pay for generic drugs $ 15 co-pay for formulary drugs $ 30 co-pay for nonformulary (includes contraceptive drugs & devices) |
Mental Health |
Inpatient: 100%, except 60 days maximum for mental retardation, learning and communication disorders, relational problems, and other conditions not defined in DSM Outpatient: $ 5 co-pay, except 30 days for conditions listed above at 100% for days 1-10, $ 25 co-pay for days 11-20, and lesser of $ 50 co-pay or 50% of cost |
Inpatient: $ 250 per admission (pre-certification required) Outpatient: $ 10 co-pay |
-Continued-
BENEFIT |
HUSKY B |
MEHIP |
Substance Abuse: |
Detox: 100% Inpatient: 100%, except for conditions listed above 60 days for drugs and 45 days for alcohol Outpatient: 100%, except for conditions listed above 60 visits per calendar year |
Detox: 100% (pre-certification required) Inpatient: $ 250 per admission (pre-certification required) $ 10 co-pay |
Skilled Nursing |
100% with prior authorization |
100% up to 90 days annually (pre-certification required) |
Home Health |
100% |
100% up to 100 visits annually (pre-certification required) |
Hospice |
100% |
100% (pre-certification required) |
Short-Term Rehab |
100% |
Not specifically mentioned |
Lab & X-Ray |
100% |
100% |
Ambulance |
100% if emergency under state law |
100% if emergency |
Emergency Care |
$ 25 co-pay unless an emergency under state law or patient is admitted to hospital |
$ 50 co-pay, waived if admitted |
Urgent Care |
Not specifically mentioned |
$ 25 co-pay |
Durable Medical Equipment |
100% with prior authorization |
100% (pre-certification required); unlimited calendar year maximum |
Prosthetics |
100% with prior authorization |
100% (pre-certification required) |
Eye Care |
$ 5 co-pay for exams; partial coverage for optical hardware |
$ 10 co-pay; 1 exam every two years; no optical hardware |
Hearing Exam |
$ 5 co-pay |
$ 10 co-pay; 1 exam every two years; no hearing aids or fittings |
Nurse Midwife/Nurse Practitioner |
$ 5 co-pay |
Not specifically mentioned |
Chiropractor, Podiatrist, Naturopath |
$ 5 co-pay |
$ 10 co-pay (only chiropractors covered), 40 visits |
Speech/Occupational/Physical Therapy |
Physical: $ 10 co-pay, 40 visits Speech/Occupational: Short-term coverage with prior authorization |
$ 10 co-pay, 40 visits |
BENEFIT |
HUSKY B |
MEHIP |
Dental |
100% for exams, x-rays, fillings, sealants, oral surgery Co-pay (unspecified) for bridge and crown, root canal, extractions, dentures Orthodontia covered up to allowance |
No coverage unless accident related |
Family Planning Services |
100% |
Not specifically mentioned |
Source: DSS, Comptroller’s Office
SS: ts