Private health insurance for adolescents: is it adequate?

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Purpose To examine the nature and extent of private insurance coverage available for health services needed by six hypothetical adolescents with physical and mental health conditions. Methods Health insurance information was obtained from the most commonly sold product of the largest health maintenance organization (HMO) and preferred provider organization (PPO) in each state and the District of Columbia. Contract documents were collected in 1999 and were in effect at the end of 1998. Our response rate was 97% and included 49 HMOs and 49 PPOs. The extent of coverage was analyzed according to benefit availability, structure, limits, and protections, as well as condition and treatment restrictions. Results The two hypothetical adolescents with asthma and depression had coverage for their recommended health services in most of the 98 plans. However, the four hypothetical adolescents whose conditions included pregnancy and sexually transmitted disease, anorexia nervosa, injury, and substance abuse and bipolar disorder would rarely have access to coverage for all of their recommended services. Ancillary and behavioral health therapies were least likely to be available in the amounts considered necessary by medical experts. All of the hypothetical adolescents would be more likely to obtain coverage for certain services in HMO than in PPO plans. Conclusions Despite the obvious value of the private health insurance system, insurance benefits are not always matched to the needs of the adolescent. Employers and policymakers may want to consider financial or other incentives to create more uniformity in employer-based coverage, particularly for preventive care, prescription drugs, and reproductive services; greater availability of mental health and substance abuse benefits; and new mechanisms to support access to confidential care.