Maternal and Child Health
Plan Benefit Model:
Evidence-Informed Coverage
2
Introduction............................................................................................................................................................... 2
Plan Benefit Model Design .................................................................................................................................... 2
Development
Content and Data Sources
Review
Evidence-Informed Coverage
Plan Benefit Model Guidance ............................................................................................................................... 5
Covered Population
Referenced Health Plans
Covered Services
Plan Benefit Model Key Concepts ........................................................................................................................ 6
Cost-Sharing
Communication
Plan Structure
Key Definitions that Govern Plan Benefit Model Provisions .......................................................................... 9
Medical Necessity
Children With Special Health Care Needs
Case Management
Experimental Treatment Modalities
Plan Integration ..................................................................................................................................................... 11
Actuarial Analysis ................................................................................................................................................. 11
Purpose
Process
PPO/HMO Benchmark Model .............................................................................................................................. 12
PPO/HMO Benchmark Model Terminology
Maternal and Child Health Plan Benefit Model Actuarial Analysis ............................................................ 14
Estimated Cost Impact of the Plan Benefit Model
How to Use the Actuarial Analysis Information
Explanation of Terms Used in the Actuarial Analysis Documents
Summary Points .................................................................................................................................................... 16
Pricing Analysis of the Maternal and Child Health Plan Benefit Model (HMO Plan Design) ................ 18
Pricing Analysis of the Maternal and Child Health Plan Benefit Model (PPO Plan Design) ................. 24This document provides a description of the Maternal and Child Health Plan Benefit Model and guidance for its
implementation. It also includes an actuarial analysis illustrating the financial impact of the Maternal and Child Health Plan
Benefit Model on both HMO and PPO plan designs. Employers can use this information to estimate the cost implications of
adopting the recommended benefits in their own covered population.Plan Implementation Guidance Document