Principal Findings.

Major results of the 1993 AGI Study of Private-Sector Insurance Coverage of Reproductive Health Services fall into the three categories mentioned above: specific reproductive health care services, dependent coverage, and confidentiality provisions for patients.

Coverage of Specific Reproductive Health Care Services

Survey respondents were given a list of 25 health care services and asked to indicate whether, in the typical policy of each plan type they wrote, these services were

* covered when considered medically necessary or appropriate by the physician ("routinely covered");

* covered only when additional requirements were met; or

* not covered at all.

Gynecological Care

Insurers were asked about both the actual annual gynecological exam and the associated tests and medical procedures. Coverage of the annual exam differs according to the type of policy. Half of the large-group plans (49%) and 39% of the small-group plans routinely cover an annual exam, compared with 64% of typical PPOs, 88% of POS networks and 99% of HMOs (Table 1).

Specific medical procedures, such as a Pap test, chlamydia culture and mammogram, are more likely to be covered. For example, chlamydia cultures are routinely covered by 70% of large-group plans, 78% of PPOs and 98% of either POS networks or HMOs. Pap tests are routinely covered by 67% of large-group plans, 76% of PPOs, 93% of POS networks and 100% of HMOs.

Some plans cover these services only when requirements in addition to the service being considered medically necessary or appropriate are met. For example, 10% of large-group plans require the provider to certify a specific medical indication for a Pap test, and 9% require a specific medical indication for a chlamydia culture. Such requirements are found less frequently in POS networks or HMOs (Table 2).

Some plans do not cover certain gynecological services at all (Table 3).

While all HMOs and almost all POS networks provide at least some coverage of Pap tests and chlamydia cultures, that is not true of large-group plans and PPOs. Twenty-three percent of large-group plans and 14% of PPOs do not cover Pap tests at all, while 21% of large-group plans and 16% of PPOs do not cover chlamydia cultures.

Maternity Care

Obstetric care is routinely covered in almost all of the typical plans of each type: 97% of large-group plans, 99% of PPOs, 95% of POS networks and 98% of HMOs (26)