Clinton’s Health Plan : Health Plan: A User’s Guide : What’s Covered, What Isn’t

President Clinton’s health plan allows access to a basic set of health benefits. However, your co-payments and deductibles will vary whether you choose a low-cost plan similar to today’s health maintenance organizations or a higher-cost plan called “fee-for-service.” There are also expected to be hybrid plans that combine some of the elements of both.

Nonetheless, all plans will offer coverage for similar ailments. Here’s an alphabetical listing of what’s covered and what isn’t:

* AMBULANCE: Covered, but co-payments and deductibles are not specified.

* CHILDBIRTH: See INPATIENT HOSPITAL.

* COSMETIC SURGERY: Not covered, except in cases of medical necessity.

* DENTAL-EMERGENCY: Covered; $10 per visit in HMO; 20% co-payment in fee-for-service.

* DENTAL-PREVENTIVE: Check-ups covered for children under 18. HMO co-payment is $10 per visit; fee-for-service requires 20% co-payment. Preventative dental services not covered for adults.

* DOCTOR VISITS: $10 co-payment in HMO; 20% co-insurance in fee-for-service.

* EDUCATION: Family planning and health education classes covered.

* EMERGENCY: HMOs can charge $25 per visit, but fee waived in true emergencies; 20% co-insurance payments in fee-for-service.

* EYE EXAMS: $10 per exam in HMO; 20% co-insurance in fee-for-service.

* EYEGLASSES: Children can receive one set of glasses annually for $10 in HMO or with a 20% co-payment in fee-for-service. Adult eyeglasses and contact lenses not covered.

* HEARING AIDS: Not covered.

* HOME HEALTH/EXTENDED CARE/REHAB HOSPITAL: HMO offers full coverage “as inpatient alternative” with 100-day annual limit on use of extended care facilities. Fee-for-service requires 20% co-payment with same coverage and limitations. Coverage triggered by patient’s inability to complete certain “activities of daily living,” including eating, walking, talking and bathing without help.

* HOSPICE: Fully covered in HMOs with no co-payments; 20% co-payment in fee-for-service.

* HOSPITALIZATION: Inpatient stays fully covered, with no patient co-payments under HMO;20% co-insurance for hospital stays in fee-for-service. Private room not covered unless medically necessary.

* INVESTIGATIONAL/EXPERIMENTAL TREATMENTS: Not covered, except where medically necessary and provided as part of an approved research trial.

* IN VITRO FERTILIZATION: Not covered.

* LAB SERVICES: Fully covered in HMO; 20% co-insurance in fee-for-service.

* MEDICAL EQUIPMENT: “Durable” medical equipment fully covered by HMO; 20% co-insurance in fee-for-service.

* MENTAL HEALTH/SUBSTANCE ABUSE: Inpatient mental health and substance abuse treatments fully covered by HMO for 30 days per episode and 60 days per year. Same coverage limits apply to fee-for-service, with one-day deductible and 20% co-insurance payments. Outpatient limits vary depending on treatment and plan.

* OPTIONAL TREATMENTS: “Not medically necessary or appropriate” services are not covered.

* ORTHODONTIA: Cosmetic orthodontia, such as teeth braces, not covered except when medically necessary.

* PERSONAL COMFORT: Personal comfort services and supplies, such as aspirin and hemorrhoid cushions, not covered.

* PRENATAL CARE: Fully covered with no co-payments in both HMO and fee-for-service.

* PRESCRIPTION DRUGS: $5 per prescription in HMO; $250 annual deductible and 20% co-insurance in fee-for-service.

* PREVENTIVE CARE: Range of services fully covered with no co-payments under HMO and fee-for-service. But full coverage only for set number of times, depending on service: Cholesterol screening, once every five years for individuals over 20.

Immunizations: Children generally receive full coverage for all normal immunizations. Adults get one tetanus/diphtheria toxoid shot every 10 years; those over 65 get annual influenza shots and one pneumococcal vaccine. Mammograms. One every two years for women over the age of 50. Pap/pelvic. One exam/papanicolaou smear every three years for women of childbearing age at risk of cervical cancer. After age 50, exams and Pap smears every two years.

* PRIVATE DUTY NURSING: Not covered.

* PROSTHETIC DEVICES: Covered. However, co-payments not clearly specified. Coverage not clear for sophisticated prosthetics, such as manufactured legs and arms that move via electronic impulses.

* REHABILITATION-INPATIENT: (See HOME HEALTH/EXTENDED CARE/REHAB HOSPITAL).

* REHABILITATION-OUTPATIENT: $10 per visit in HMO; 20% co-payment in fee-for-service. If rehabilitation treatments seem ineffective after 60 days, coverage may be cut off.