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Fertile Ground: New Data on Reproductive Health Benefits

by Paul A. Welcher

Bureau of Labor Statistics

Originally Posted: June 29, 2011

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

employer-provided benefits.1 The article presents data on four of the benefits, each within the general area of reproductive

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

The National Compensation Survey (NCS)2 has recently published new data on 12 employer-provided medical benefits in

private industry from the health plan documents of its 2009 sample of establishments.3 The 12 types of medical benefits data

are emergency room visits, ambulance services, maternity care, infertility treatment, sterilization, gynecological exams and

services, diabetes care management, kidney dialysis, physical therapy, durable medical equipment, prosthetics, and organ

and tissue transplantation. The estimates include the incidence of coverage as well as plan limits and copayment amounts.

The first article in this series focused on medical benefits related to emergencies: emergency room visits and ambulance

services. This article, the second in the series, presents data on reproductive health benefits: maternity care, infertility

treatment, sterilization, and gynecological exams and services.

Maternity Care

Maternity care can refer to a variety of services. It may mean care throughout the womans pregnancy, or it may mean care

during the time spent in the hospital just before and after giving birth. For the purpose of this study, maternity care was

defined as the medical coverage throughout the womans pregnancy; it included such diagnostic testing as ultrasounds and

fetal monitor procedures.

Plan documents often separated maternity care into three stages: prenatal, delivery, and postnatal. The stages included

different types of services; in some plans the stages were covered differently. Hospitalization for delivery was often covered

in the same way as regular inpatient care; prenatal care was sometimes subject to a copayment per office visit or per

pregnancy. When there were differences in coverage, provisions for prenatal care were reported. In addition, when coverage

varied by the type of doctor performing the treatment, the copayment rate for a specialist was reported rather than the

copayment rate for a primary care physician.

Two-thirds of the medical care participants in the survey had coverage specified for maternity care, with almost all of the

remaining third in plans in which the benefit was not mentioned. The vast majority of workers with coverage were in plans

that imposed some type of limitation (58 percent out of the 66 percent with coverage). A small group of workers were in plans

in which maternity care was covered in full.

Maternity care was most likely to be subject to either plan limits or both separate limits and plan 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 an individual benefit, rather than a group of benefits. The most prevalent separate limit

appearing in the survey was a copayment.

When there were separate limits on maternity care, it was usually in the form of a copayment per visit. The median

copayment was $20, with amounts generally ranging from $10 to $40 per visit. Copayments per visit for maternity care

applied either throughout the pregnancy or for a limited number of visits.

In addition to providing weighted estimates that represent all private industry workers, BLS reviewed plan documents to

obtain additional plan features. This review showed that if the plan required copayments per visit for a limited number of
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visits, the plan almost always required the copayment only for the initial visit. Another separate limit for maternity care less

frequently found in plan documents was a higher coinsurance rate than the plan coinsurance rate.

Maternity care coverage was provided to 66 percent of those in a fee-for-service plan and 66 percent of those covered by a

health maintenance organization. However, there were differences in the extent of coverage between these two types of

plans. It was far more likely for health maintenance organizations to cover maternity care in full than fee-for-service plans (16

percent and 4 percent, respectively). Fee-for-service plans were more likely than health maintenance organizations to cover

maternity care subject to plan limits (55 percent and 32 percent, respectively).

Table 1 summarizes coverage for maternity care:

Table 1. Maternity Care: 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 66 66 66

Without coverage — — —

Not mentioned in plan documents 33 33 34

Extent of Coverage (1):

Covered in full 6 4 16

Subject to limits 58 61 49

Not mentioned in plan documents 2 2 1

Limits on Coverage (2):

Subject to plan limits 50 55 32

Subject to separate limits 36 34 45

With a copayment per visit 30 27 41

Copayment at 10th percentile $10 $15 $10

Copayment at 25th percentile $15 $20 $15

Copayment at 50th percentile

(median) $20 $20 $20

Copayment at 75th percentile $30 $30 $30

Copayment at 90th percentile $40 $40 $40

Not mentioned in plan documents 2 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 due to 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 due to rounding, suppression of data that do not meet publication criteria,

and the fact that 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. Infertility Treatment

Infertility treatments include services to diagnose and treat the causes of infertility, and may include many different methods

for assisted reproduction such as artificial insemination, ovulation induction, in-vitro fertilization, and other advanced
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reproductive techniques. Infertility treatment was not considered as covered in plans that covered only diagnosis and not

treatment.

Infertility treatment can take place in a variety of settings, in large part because treatment can involve several stages. Some

plans only pay for treatment of the underlying conditions causing infertility. Other plans pay for various methods of promoting

pregnancy, which can require treatment ranging from consultations, examinations, and procedures accomplished during

physician office visits to inpatient surgery.

Plan coverage provisions were fairly easy to summarize when the provisions were directly comparable; for example, a

copayment for treatment at a doctors office and a copayment for treatment at a hospital outpatient facility. At the other

extreme, the coverage provisions could include a mix of plan and separate limits for different treatment settings, so that the

recording of plan provisions for the entire benefit was complex. If coverage for infertility services varied by location, the

provisions for “outpatient settings” were recorded. Also, coinsurance rates for infertility services that differed from the overall

plan coinsurance rate were recorded. Other separate limits, such as copayments for physician office visits and maximum

dollar limits for infertility services, were recorded but not weighted to create national estimates.

Infertility treatment was mentioned in the plan documents for 47 percent of medical plan participants. Almost 3 in 5

participants were covered (27 percent out of 47 percent); the remaining 2 in 5 participants (20 percent out of 47 percent)

were specifically excluded from coverage. Covered services were almost always subject to plan or separate limits.

Participants in health maintenance organization plans that mentioned infertility treatment had coverage more often than those

in fee-for-service plans (32 percent out of 44 percent that mentioned the benefit, compared with 26 percent out of 48 percent

for fee-for-service plans).

Nearly all covered participants had limits on this benefit. For example, 30 percent out of 32 percent of participants in health

maintenance organizations and 25 percent out of 26 percent of participants in fee-for-service plans had such limits. Coverage

for participants in plans imposing limits more frequently included separate limits in health maintenance organization plans (28

percent out of 30 percent with limits) compared with fee-for-service plans (17 percent out of 25 percent with limits). The

reverse was true for plan limits (16 percent out of 30 percent and 21 percent out of 25 percent, respectively).

Separate limits for infertility treatments were varied. Separate coinsurance rates for infertility services were observed in plans

covering about 1 in 4 participants with separate limits for infertility treatments (5 percent out of 19 percent). The coinsurance

rate most often seen was 50 percent, although the 50-percent coinsurance rate tabulated for the 75th percentile has a large

standard error (17.5 percent).4 A review of plan documents revealed that separate limits commonly included copayments for

physician office visits and maximum dollar limits per year or per lifetime for infertility treatment coverage.

Table 2 summarizes the plan provisions for infertility treatment:
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Table 2. Infertility Treatment: 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 27 26 32

Without coverage 20 22 12

Not mentioned in plan documents 53 52 56

Extent of Coverage (1):

Covered in full (2) — (2)

Subject to limits 26 25 30

Not mentioned in plan documents 1 — 1

Limits on Coverage (3):

Subject to plan limits 20 21 16

Subject to separate limits 19 17 28

With a coinsurance per visit 5 2 15

Coinsurance at 10th percentile 50 50 50

Coinsurance at 25th percentile 50 50 50

Coinsurance at 50th percentile

(median) 50 50 50

Coinsurance at 75th percentile 50 90 50

Coinsurance at 90th percentile 90 100 70

Not mentioned in plan documents 2 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 due to rounding and suppression of data that do not meet publication criteria.

(2) Less than 0.5 percent

(3) All data other than coinsurance rates at the 10th percentile and other percentiles 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 due to rounding,

suppression of data that do not meet publication criteria, and the fact that 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. Sterilization

Sterilization includes surgical procedures for men and women to prevent future pregnancies, commonly vasectomy for men

and tubal ligation for women. Sterilization reversal was not included as part of this benefit. Sterilization can take place in a

variety of treatment settings: physician offices and surgical centers, as well as outpatient and inpatient hospital surgical

facilities. Additionally, surgery is often preceded by visits to the surgeons office for examinations and consultations.

As shown in table 3, sterilization coverage was not mentioned in plan documents for 73 percent of plan participants. When it

was mentioned, sterilization was a covered benefit for about 9 in 10 participants.

Because sterilization was mentioned in so few documents, information on the extent of coverage did not meet publication

standards.
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Table 3. Sterilization: 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 26 27 20

Without coverage 2 2 1

Not mentioned in plan documents 73 71 79

NOTE: Because of rounding, sums of individual items may not equal totals. 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. Gynecological Exams And Services

Gynecological exams and services include routine gynecological exams and pelvic examinations, which often include

Papanicolaou (PAP) tests. Plan documents often called gynecological exams “well woman exams” and “pelvic exams.”

Gynecological services were considered as covered if the plan included coverage for a PAP test or if the plan made any

reference to the obstetrical and gynecological medical specialties. Plan references only to “preventive care” and “annual

physicals” were not considered gynecological exams and services.

Sixty percent of participants had coverage for gynecological exams and services; for almost all of the remaining 40 percent of

participants, plan documents did not mention these services.

In plans in which gynecological exams and services were mentioned, the services were almost always subject to plan or

separate limits. Separate limits were imposed on 9 in 10 participants in plans with limits on this service (51 percent out of 56

percent), and for a sizeable majority of them (33 percent out of 51 percent), a copayment was required for physician office

visits. Copayments commonly ranged from $15 to $25. Copayments for physician office visits often varied by type of doctor.

The copayment rate for a specialist was recorded instead of the copayment rate for a primary care physician unless the plan

stated otherwise or indicated that the obstetrician-gynecologist medical specialist was considered a primary care physician.

The copayment estimates for this service represent a mix of primary care physician and specialist copayment rates.

The plan documents also included information on other separate limits; however this information was not weighted to create

estimates. Other separate limits for gynecological exams and services commonly included a limit on the number of exams

per year (one per year was most common), a dollar limit on the covered costs for the exam, and higher coinsurance rates

than paid by the plan (100 percent was common).

When plan documents for fee-for-service and health maintenance organization plans mentioned gynecological exams and

services, coverage provisions were somewhat similar. If the benefit was mentioned in the plan, both types of plans almost

always provided coverage. Regardless of plan type, 9 in 10 of those covered had limits on these services (56 percent out of

60 percent). However, the use of plan limits was far more common in fee-for-service plans (49 percent out of 62 percent)

than in health maintenance organizations (28 percent out of 52 percent).

Table 4 summarizes the plan provisions for gynecological exams and services:
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Table 4. Gynecological Exams and 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 60 62 52

Without coverage — — —

Not mentioned in plan documents 40 38 48

Extent of Coverage (1):

Covered in full — — —

Subject to limits 56 58 47

Not mentioned in plan documents — — —

Limits on Coverage (2):

Subject to plan limits 44 49 28

Subject to separate limits 51 53 45

With a copayment per visit 33 31 39

Copayment at 10th percentile $10 — $10

Copayment at 25th percentile $15 — $15

Copayment at 50th percentile

(median) $20 — $20

Copayment at 75th percentile $25 — $30

Copayment at 90th percentile $35 — $40

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 due to 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 due to rounding, suppression of data that do not meet publication criteria,

and the fact that 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. The third article in this three-part series will discuss data on health benefits involving chronic illness, care for limited mobility,

and rehabilitation and related services. These benefits include diabetes care management, kidney dialysis, physical therapy,

durable medical equipment, prosthetics, and organ and tissue transplantation. It will be published in an upcoming issue of 

Compensation and Working Conditions Online. 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 recently

available medical benefits estimates.

Paul A. Welcher

The author formerly worked in the Division of Directly Collected Periodic Surveys, Office of Technology and Survey Processing,

Bureau of Labor Statistics. For more information, contact the Office of Compensation and Working Conditions. Telephone: (202)

691-6199; E-mail: CWCInfo@bls.gov.
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End Notes

1 The first of the three articles is Paul A. Welcher, “In Case of Emergency: New Data on Medical Benefits,” CWC Online, April 15, 2011,

available on the Internet at http://www.bls.gov/opub/cwc/cm20110325ar01p1.htm. The third article is forthcoming. For a more comprehensive

recent study of these data, see Selected Medical Benefits: A Report from the Department of Labor to the Department of Health and Human

Services, April 15, 2011, available on the Internet at http://www.bls.gov/ncs/ebs/sp/selmedbensreport.pdf. 2 The NCS is an establishment-based national survey that provides comprehensive measures of employee compensation and detailed

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

3 The 12 additional benefits come from the same sample that yielded estimates for the publication 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 on

the Internet at http://www.bls.gov/ncs/ebs/detailedprovisions/2009/ebbl0045.pdf. For a more complete description of the NCS scope and

methods, see BLS Handbook of Methods, Chapter 8, “National Compensation Measures,” on the Internet at http://www.bls.gov/opub/hom/pdf/

homch8.pdf. 4 For standard errors of the 12 additional benefits see the Technical note of “Report from the Department of Labor to the Department of Health

and Human Services,” April 15, 2011, available online at http://www.bls.gov/ncs/ebs/sp/selmedbensreport.pdf. U.S. Bureau of Labor Statistics | Division of Information and Marketing Services, PSB Suite 2850, 2 Massachusetts Avenue, NE Washington, DC

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