Clinton’s Health Package to Offer Spectrum of Care : Medicine: After three-day push, details of benefits emerge, including coverage for mental illness, abortion. Some lawmakers are likely to get a preview next week.

President Clinton has decided on a proposal to guarantee every American a broad health benefits package that would cover an array of medical procedures, from preventive services and long-term care to mental health treatments and abortion, White House sources said Friday.

The standard benefits package forms the underpinnings of the President’s comprehensive health care reform agenda. If enacted by Congress, it would not only cover the estimated 37 million uninsured Americans but also set the minimum standard that all private insurance plans would be required to meet.

Clinton’s decisions on the benefits package, according to the White House, mean that by no later than December, 1997, every uninsured or inadequately insured American citizen and legal resident will be guaranteed coverage under a plan much like those already enjoyed by the vast majority of Americans.

But it also means that people with employer-provided health plans more generous than the Clinton-designed plan eventually will have to pay extra for those additional benefits.

Details of the Administration’s “standard package” emerged Friday night as the President completed three intensive days of meetings to put the finishing touches on his proposals. Aides will make more adjustments over the weekend, with the expectation that the package will be sent informally to members of Congress next week.

White House officials emphasized that the President may well change his mind on certain elements of the benefits package--as well as on any other part of his overhaul agenda--as a result of those congressional consultations.

“A lot of these things can change, but this is the tentative shape,” one White House official said Friday night.

The formal unveiling of the proposal is expected the week of Sept. 20, in a presidential address to a joint session of Congress.

Undoubtedly the most controversial element of the standard benefits package will be coverage for “pregnancy-related services”--a phrase that includes abortions. Many members of Congress, including Democrats, have vowed to fight the inclusion of abortion in a government-guaranteed health insurance plan.

The benefits package--the centerpiece of Clinton’s reform agenda--would cover a battery of preventive measures, including cholesterol screening, childhood immunizations, blood lead-level tests, mammograms and pelvic examinations for early detection of breast and cervical cancer, sources said.

Children under 18 would be covered for eyeglasses and routine eye and ear examinations, as well as certain dental services. Adults would not be covered for those services, but Administration officials said that they hope to extend such coverage to adults once sufficient cost savings are realized as a result of systemic health care reform.

White House health analysts also expressed disappointment that the package cannot be broader than it is, but said that the President is constrained from doing more by the cost of reform.

Administration officials have estimated the initial price tag at $50 billion. But other than an increase in the federal cigarette tax, they expect to finance the effort through savings in the current $875-billion-a-year medical system, a goal that has aroused considerable skepticism among independent health policy analysts and economists.

The President also intends to require all businesses to pay at least 80% of every full-time worker’s insurance premiums, with the employee paying the rest. But there will be a limit on how much companies and workers must pay--about 7% of payroll for businesses and 2% of wages for individuals. The government will subsidize discounts for low-wage earners and small businesses that hire them, as well as for the unemployed.

The cost of the Administration’s standard benefits package is put at $1,800 for an individual policy and $4,200 for a family, subject to some regional variations.

The benefits package also comes with a proposed fee schedule that beneficiaries will be required to pay in the form of annual deductibles and co-payments, which are made at the time of each visit, sources said. The fee schedules vary depending on the type of plan one chooses.

The Clinton plan would organize consumers into large insurance-purchasing alliances that would shop among provider networks for the best price and quality. Each of these alliances is expected to offer a variety of plans from which its members would choose, such as fee-for-service and health maintenance organizations.

An individual opting for the traditional fee-for-service plan would be required to pay the first $200 of medical expenses each year and 20% thereafter--up to a $1,500 ceiling. Families in this plan would pay the first $400 and then 20% thereafter, up to a maximum of $3,000.

Under an alternative health delivery plan, known as managed care, which is modeled after HMOs, a $10-per-visit fee may be required. But under this option, the choice of a physician would be restricted to a prescribed pool of providers and every consumer would be assigned a primary care physician who would act as a “gatekeeper,” controlling that person’s access to most medical services or specialists.

According to White House sources, the Clinton-designed standard benefits package includes coverage for hospital charges and doctors’ fees, home health care, emergency and ambulance services, family planning services, outpatient laboratory and diagnostic services, outpatient prescription drugs and rehabilitation services. It also includes durable medical equipment, prosthetic and orthotic devices, vision and hearing care and health education classes.

Officials said there is no lifetime dollar limit on benefits except for orthodontics, which is limited to $2,500.

But several kinds of services are restricted under the plan in other ways. For instance, they said, coverage for inpatient and residential mental-health, and drug and alcohol abuse treatment would be limited to 30 days per episode and 60 days per year. Hospital care for such problems would be available “only when less restrictive non-residential or residential services are ineffective or inappropriate,” according to White House working documents.

The papers state that people would be eligible for coverage “if they have, or have had in the past year, a diagnosable mental or substance-abuse disorder . . . that results in or poses a significant risk for functional impairment in family, work, school or community activities.”

The standard benefits plan limits psychotherapy visits to 30 a year; other non-residential treatment services, such as detoxification and home-based services for severely mentally ill children, are limited to 120 days annually.

Home health care, including skilled nursing, physical, occupational and speech therapy, is limited to 60 days and may be extended “only if the risk of hospitalization or institutionalization exists.”