HEALTH CARE : Coverage and Benefits

The two major plans being considered by Congress to reform the nation’s health care system are both Democratic: one written by Senate Majority Leader George J. Mitchell of Maine and the other by House Majority Leader Richard A. Gephardt of Missouri. Other plans are expected to be offered this week. The Mitchell and Gephardt proposals both offer a list of standard benefits that would be required in all insurance plans. Some new benefits, such as outpatient prescription drugs and long-term care, that are not widely available would be added to standard insurance policies. Here is an outline of the benefits packages in the Mitchell and Gephardt plans:

SENATE (MITCHELL PLAN)

A National Health Benefits Board would be established with the authority to determine the scope, duration and co-payments of services. The seven-member board would be appointed by the President and would have to be confirmed by the Senate. The board would also develop medical practice standards. The Mitchell proposal outlines these 16 areas of coverage in a standard benefits plan:

COVERAGE

* Hospital services.

* Doctors’ and other health professionals’ services.

* Emergency and ambulatory medical and surgical services.

* Preventive services--no co-payment required.

* Mental illness and substance abuse services. The board is instructed to seek the same co-payments, co-insurance and deductibles as for other services. If the board cannot initially design a package with parity, it may limit coverage, first on hospitalizations and subsequently on outpatient psychotherapy for adults.

* Family planning and services for pregnant women, with no co-payment for prenatal services. Abortion is covered, but providers who do not believe in abortion are not required to provide the service.

* Hospice care.

* Home health care, including nursing care and physical therapy.

* Extended care services.

* Ambulance service.

* Outpatient laboratory, radiology and diagnostic services.

* Outpatient prescription drugs.

* Outpatient rehabilitation, including occupational therapy, physical therapy, respiratory therapy and speech and audiology services.

* Durable medical equipment (such as wheelchairs and walkers), prosthetics and orthotics.

* Vision, hearing and dental care for those under 22.

* Investigational treatments that are part of an approved research program.

ELDERLY AND DISABLED BENEFITS

* Long-term care: $48 billion from 1995-2004 will be given to states to provide home and community-based services to those with severe mental retardation, severe cognitive or mental impairment or those who need assistance with three or more basic daily living activities (such as eating, dressing, bathing, movement, toilet).

Standards for long-term care insurance will be developed.

* Life care program: creates a voluntary, self-financed public insurance program to cover the costs of extended nursing home stays. People can purchase coverage when they reach ages of 35, 45, 55 or 65.

* Medicare drug benefits: Effective in 1999, Medicare recipients will be able to obtain outpatient drugs under a variety of insurance programs.

OTHER PROVISIONS

* Choice of doctor and choice of plan: Everyone would have the choice of at least three insurance plans, one of which must be a traditional fee-for-service plan in which an individual can choose his or her own doctor.

* Access to specialized treatment: Plans that require a patient to see a primary care physician before seeing any specialist must show must show that enrollees have access to specialized treatment expertise.

* Coverage for temporarily unemployed and uninsured workers: Beginning in 1997, unemployed workers will be eligible for subsidies for six months to help pay for insurance premiums.

HOUSE (GEPHARDT PLAN)

The Gephardt plan includes a nationally guaranteed benefit package, which is essentially the services covered under Medicare with some enhancements. The amount of coverage and co-payments (with a few exceptions) would be determined by the kind of plan chosen, but all the services would be covered to some degree.

COVERAGE

* Unlimited hospital care without a co-payment.

* Skilled nursing facility care up to 100 days after hospitalization. After the first 20 days there is a daily co-payment.

* Home health care, including nursing care, physical therapy or speech therapy on an intermittent basis.

* Hospice care.

* Doctors’ services, including surgery, consultation and home office and institutional visits.

* Laboratory, diagnostic tests, X-ray and other radiation therapy.

* Home dialysis supplies and equipment, prosthetics.

* Physical and speech therapy.

* Ambulance services.

* Single deductible of $500 per individual, $750 per family.

* An out-of-pocket cap on what anyone would have to spend on deductibles and co-payments, $3,000 for an individual, $6,000 for a family.

* Preventive and well-child services for children without co-payments and preventive services for adults, including mammograms, Pap smears, colo-rectal and infectious-disease screening.

* Prescription drug coverage: 20% co-payment, a separate $500 deductible and a separate $1,000 out-of-pocket annual limit.

* Comprehensive mental health and substance abuse benefits.

* Pregnancy-related services and family planning services. Abortion is covered but may be dropped on the House floor.

ELDERLY AND DISABLED BENEFITS

* Long-term care: a new program that would give states the option to provide home- and community-based services to individuals with severe disabilities for all ages and income. The benefits could vary from state to state.

Medicare recipients would gain prescription drug benefits, improved preventive health and mental health benefits.

OTHER PROVISIONS

* Medicare C: The plan would set up a Medicare Part C program that would cover individuals who are not employed, part-time and seasonal workers and low-income people and their dependents employed by firms with fewer than 100 workers. Employers with fewer than 100 workers would have the option of enrolling their workers in Part C. Medicare Part C would consist of fee-for-service and managed care plans. Those receiving Medicaid would be enrolled in Part C or a private health insurance plan.

* Choice of doctor and plan: The proposal would require employers to offer their workers a choice of a traditional fee-for-service plan, in which they could choose any doctor, a managed-care plan, in which consumers are required to seek treatment within a network of providers, or a high-deductible medical savings account plan.

TOMORROW

* How much will it cost? On Wednesday, a look at financing and cost controls.