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In Case of Emergency: New Data on Medical Benefits

by Paul A. Welcher

Bureau of Labor Statistics

Originally Posted: April 15, 2011

This article is the first in a three-part series on data newly released by the BLS National Compensation Survey on 12

employer-provided benefits. The article presents data on 2 of the benefits, each within the general area of emergency care:

emergency room visits and ambulance services.

Most medical insurance plans provide coverage for emergency care, including visits to emergency rooms and transportation

by ambulance, according to a recent study by the Bureau of Labor Statistics based on the National Compensation Survey

(NCS).1 The study also found that emergency care coverage was subject to a variety of limits, including copayments and

deductibles.

The NCS has compiled data on 12 employer-provided medical benefits in private industry from its ongoing survey of benefit

plan provisions.2 The 12 types of medical benefits data are emergency room visits, ambulance services; maternity care,

infertility treatment, sterilization, gynecological exams, diabetes care management, kidney dialysis, physical therapy, durable

medical equipment, prosthetics, and organ and tissue transplantation. The data are from the 2009 NCS sample and include

the incidence of coverage as well as plan limits and copayment amounts.

The estimation and publication of the new data stems from a directive of the Patient Protection and Affordable Care Act of

2010 (PPACA).3 In addition to the 2009 NCS private industry data on provisions of employer-provided health benefit plans,

the Department of Health and Human Services (HHS) identified other services for which information on coverage and cost

sharing would be helpful. This resulted in national private industry estimates on these 12 additional medical benefits. A team

of researchers reviewed the entire sample of employee health plan documents, which were collected from establishments in

the survey, to tabulate survey results for the 12 benefits. Weights from the published 2009 survey were applied to these

tabulations to make nationally representative estimates. The complete findings of the survey are compiled in a formal report

titled, “Selected Medical Benefits: A Report from the Department of Labor to the Department of Health and Human Services,”

which is available on the NCS website.4

This article is the first of three articles, the purpose of which is to highlight the findings of the formal report. The 12 health

benefits data are presented in three basic groups. This article presents health benefits related to emergencies. The formal

report included two benefits of this nature: emergency room visits and ambulance services. The second article will present

data on reproductive health benefits: maternity care, infertility treatment, sterilization, and gynecological exams and services.

The third article will present data on health benefits involving chronic illness and maintenance care: diabetes care

management, kidney dialysis, physical therapy, durable medical equipment, prosthetics, and organ and tissue

transplantation.

The March 2009 NCS data show that 52 percent of private industry workers participate in an employer-provided medical care

(insurance) plan.5 The data discussed in this article refer to only those who participate in medical care plans. These plans

may be family or individual plan; both types are included in the estimates. The tables show separate estimates for fee-forservice plans and health maintenance organizations.

Emergency Room Visits

The term “emergency room visits” was defined as visits to a hospital emergency facility or emergency room because of an

accidental injury or a sudden and serious medical condition. Emergency room physician charges were not included under the

benefit--that is, only the facility charges were included.
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The data show that 9 in 10 medical care participants in the survey were covered by emergency care visits, with the remainder

in plans in which there was no mention of this medical service. Virtually all (89 percent out of 91 percent) of the workers with

this benefit had some form of limitation placed on the service; the few remaining workers were provided with full coverage or

the extent of their coverage was not mentioned in plan documents.

When limits were present for emergency room visits, it was most common for the workers to be subject to both plan limits

and separate limits. Plan limits are restrictions on coverage that apply to most or all medical benefits in the plan. The most

common types of plan limits are deductibles, plan coinsurance, maximum out-of-pocket expense provisions, and maximum

lifetime dollar limits. Separate limits are restrictions that apply to a singular benefit, rather than a group of benefits. The most

prevalent separate limit appearing in the survey is a copayment.

The data show that 7 in 10 medical care participants in the survey had their coverage restricted by some form of separate

limit. Virtually all of those workers (68 percent out of 70 percent) were subject to a copayment per visit. The median

copayment was $100. A review of plan documents--not of national estimates from the weighted plan data--revealed that

copayments of $50, $75, and $100 were the most prevalent amounts with this restriction. In some instances workers subject

to a limit of copayments per visit were also covered at a higher coinsurance rate for this benefit than the overall plan

coinsurance.

Incidence of coverage and the existence of limits for emergency room benefits were similar in fee-for-service plans and

health maintenance organization plans. However, plan limits were far more likely in fee-for-service plans than in health

maintenance organization plans (80 percent and 56 percent, respectively). On the other hand, separate limits were more

likely in health maintenance organization plans than in fee-for service plans (88 percent and 64 percent, respectively). This

pattern will be seen in many of the other benefits because fee-for-service plans typically use overall limits to control costs,

while health maintenance organizations are more likely to use separate limits to control costs.

Table 1 summarizes the plan provisions for emergency room visits.

Table 1. Emergency Room Visits: Type of coverage, private industry workers, National Compensation Survey, 2009

(All workers participating in medical care plans = 100 percent)

Benefit coverage All plans Fee-for-service Health maintenance organizations

Existence of Coverage:

With coverage 91 90 93

Without coverage - - - Not mentioned in plan documents 9 10 7

Extent of Coverage: (1)

Covered in full 1 - - Subject to limits 89 88 92

Not mentioned in plan documents 1 - - Limits on Coverage: (2)

Footnotes:

(1) All data are presented as a percent of workers participating in medical care plans. The sum of individual items under "Extent of Coverage"

may not equal the "With coverage" value because of rounding and suppression of data that do not meet publication criteria.

(2) All data other than dollar amounts are presented as a percent of workers participating in medical plans. The sum of individual items under

"Limits on Coverage" may not equal the "Subject to limits" value because of rounding, suppression of data that do not meet publication

criteria, and because some plans may impose more than one limit.

NOTE: Dashes indicate that no data were reported or that data do not meet publication criteria. For standard errors see Selected Medical

Benefits: A Report from the Department of Labor to the Department of Health and Human Services, April 15, 2011, online at http://

www.bls.gov/ncs/ebs/sp/selmedbensreport.pdf; for definitions of terms, see National Compensation Survey: Glossary of Employee Benefit

Terms, online at http://www.bls.gov/ncs/ebs/glossary20092010.htm.
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Benefit coverage All plans Fee-for-service Health maintenance organizations

Subject to plan limits 75 80 56

Subject to separate limits 70 64 88

With a copayment per visit 68 62 87

Copayment at 10th percentile $50 $50 $50

Copayment at 25th percentile $50 $75 $50

Copayment at 50th percentile

(median) $100 $100 $100

Copayment at 75th percentile $100 $100 $100

Copayment at 90th percentile $150 $150 $150

Not mentioned in plan documents - - - Footnotes:

(1) All data are presented as a percent of workers participating in medical care plans. The sum of individual items under "Extent of Coverage"

may not equal the "With coverage" value because of rounding and suppression of data that do not meet publication criteria.

(2) All data other than dollar amounts are presented as a percent of workers participating in medical plans. The sum of individual items under

"Limits on Coverage" may not equal the "Subject to limits" value because of rounding, suppression of data that do not meet publication

criteria, and because some plans may impose more than one limit.

NOTE: Dashes indicate that no data were reported or that data do not meet publication criteria. For standard errors see Selected Medical

Benefits: A Report from the Department of Labor to the Department of Health and Human Services, April 15, 2011, online at http://

www.bls.gov/ncs/ebs/sp/selmedbensreport.pdf; for definitions of terms, see National Compensation Survey: Glossary of Employee Benefit

Terms, online at http://www.bls.gov/ncs/ebs/glossary20092010.htm. Ambulance Services

The term “ambulance services” was defined as transportation by licensed ambulance services to a hospital or an emergency

room. When coverage for ambulance services varied by type of medical condition, the provisions for emergencies were

recorded. When provisions differed for medically necessary conditions and nonmedically necessary conditions, the provisions

for medically necessary conditions were recorded.

Just under two-thirds of the medical care participants in the survey were provided coverage for ambulance services, with just

about all the remaining third in plans in which there was no reference to the benefit. Fifty-two percent of workers had plans

that subjected ambulance services to some type of limit, while 10 percent had full coverage. The few remaining workers

covered by ambulance services were in plans in which the extent of coverage was not described in plan documents.

When ambulance services were subject to limits, they were most commonly subject to plan limits--for example, deductible

and coinsurance. A few of plan documents--not of national estimates created from the weighted plan data showed that

separate limits for this benefit often came in the form of either a different coinsurance than the plan coinsurance or a

copayment per trip, commonly ranging from roughly $25 to $100.6

Table 2 summarizes the plan provisions for ambulance services.
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Table 2. Ambulance services: type of coverage, private industry workers, National Compensation Survey, 2009

(All workers participating in medical care plans = 100 percent)

Benefit coverage All plans Fee-for-service Health maintenance organizations

Existence of Coverage:

With coverage 64 65 62

Without coverage - - - Not mentioned in plan documents 35 35 38

Extent of Coverage: (1)

Covered in full 10 7 - Subject to limits 52 56 38

Not mentioned in plan documents 2 2 - Limits on Coverage: (2)

Subject to plan limits 49 54 30

Subject to separate limits 13 10 22

Not mentioned in plan documents 1 1 - Footnotes:

(1) All data are presented as a percent of workers participating in medical care plans. The sum of individual items under "Extent of Coverage"

may not equal the "With coverage" value because of rounding and suppression of data that do not meet publication criteria.

(2) All data are presented as a percent of workers participating in medical plans. The sum of individual items under "Limits on Coverage" may

not equal the "Subject to limits" value because of rounding, suppression of data that do not meet publication criteria, and because some

plans may impose more than one limit.

NOTE: Because of rounding, sums of individual items may not equal totals. Dashes indicate that no data were reported or that data do not

meet publication criteria. For standard errors see Selected Medical Benefits: A Report from the Department of Labor to the Department of

Health and Human Services, April 15, 2011, online at http://www.bls.gov/ncs/ebs/sp/selmedbensreport.pdf; for definitions of terms, see

National Compensation Survey: Glossary of Employee Benefit Terms, online at http://www.bls.gov/ncs/ebs/glossary20092010.htm. The second article in the series of three will discuss new data on four health benefits in the area of reproductive health

benefits: maternity care, infertility treatment, sterilization, and gynecological exams. It will be published in an upcoming issue

of Compensation and Working Conditions Online. The NCS is an establishment-based national survey that provides comprehensive measures of employee compensation and

detailed provisions of employee health benefit plans.7 Data are collected and published annually.

NOTE: The author would like to thank Alan P. Blostin, Jordan N. Pfuntner, and Paul S. Scheible, the team of researchers

who analyzed and tabulated the data from the 2009 NCS sample of medical plan documents to create the 12 newly available

medical benefits estimates.

Paul A. Welcher

Division of Directly Collected Periodic Surveys, Office of Technology and Survey Processing, Bureau of Labor Statistics.

Telephone: (202) 691-7048; E-mail: Welcher.Paul@bls.gov. Notes

1 “Selected Medical Benefits: A Report from the Department of Labor to the Department of Health and Human Services,” April 15, 2011,

available at http://www.bls.gov/ncs/ebs/sp/selmedbensreport.pdf.

2 See National Compensation Survey: Health and Retirement Plan Provisions in Private Industry in the United States, 2009, Bulletin 2749

(Bureau of Labor Statistics, July 2010), available at http://www.bls.gov/ncs/ebs/detailedprovisions/2009/ebbl0045.pdf.

3 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), available at http://www.gpo.gov/fdsys/pkg/

PLAW-111publ148/content-detail.html.
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4 “Selected Medical Benefits: A Report from the Department of Labor to the Department of Health and Human Services,” April 15, 2011, at

http://www.bls.gov/ncs/ebs/sp/selmedbensreport.pdf. This report includes data on the percent of workers covered and not covered, the percent

having medical plans that dont mention coverage, for each of the 12 benefits studied, as well as coverage limits and copayment and

coinsurance provisions if estimates were publishable. The study also includes a glossary of medical and plan terms and a section on data

analysis procedures.

5 See National Compensation Survey: Employee Benefits in the United States, 2009, Bulletin 2731 (Bureau of Labor Statistics, September

2009), table 9, on the Internet at http://www.bls.gov/ncs/ebs/benefits/2009/ownership/private/table05a.htm.

6 These data on the type of separate limits were based upon a simple count of plans; they were not statistically weighted, but rather, just

based upon observation of the raw data.

7 For a complete description of the NCS scope and methods, please see BLS Handbook of Methods, Chapter 8, “National Compensation

Measures,” on the Internet at http://www.bls.gov/opub/hom/pdf/homch8.pdf.

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