A COMPARISON OF THE BENEFITS OFFERED BY GROUP HOSPITALIZATION-MEDICAL SERVICE AND THE BENEFITS OFFERED BY THE PRESENT PLAN OF GROUP INSURANCE FOR THE MEMBERS OF THE GOVERNMENT EMPLOYEES HEALTH ASSOCIATION WASHINGTON, D.C.

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP57-00384R001200020001-8
• Release Decision: RIFPUB
• Original Classification: K
• Document Page Count: 10
• Document Creation Date: December 9, 2016
• Document Release Date: August 6, 2000
• Sequence Number: 1
• Content Type: REPORT

Approved For Release 2001/08/17 : CIA-RDP57-00384R001200020001-8
A COMPARISON OF THE BENEFITS
OFFERED BY
GROUP HOSPITALIZATION--MEDICAL SERVICE
and
THE BENEFITS OFFERED BY
The Present Plan of Group Insurance
for the Members of the
GOVERNMENT EMPLOYEES HEALTH ASSOCIATION
Washington, D. C.
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COMPARISON
of
THE BENEFITS
Offered By
Group Hospitalization, Inc.
No Dollar
Limit --
These
Services
Covered
In. Full
Regardless
Of Cost
For 21 Days
Each
Hospital
Confinement
UNLIMITED
UNLIMITED
UNLIMITED
(Those listed
in official
formularies)
UNLIMITED
UNLIMITED
UNLIMITED
UNLIMITED
UNLIMITED
UNLIMITED
UNLIMITED
UNLIMITED
UNLIMITED
(Blood and
blood plasma
not included)
HOSPITAL SERVICES
Semi-private accommodations
(cost in Washington area,
$9 to $13.50 a day)
Meals and special diets
General nursing care
Cystoscopic room
Sterile Tray Service
Dressings
Plaster casts
Intravenous solutions
and injections
Sera (except blood and
blood plasma)
Analgesic care
Recovery room
Oxygen and use of equipment
for administering oxygen
Blood Transfusions
UNLIMITED Operating room
LIMITED Laboratory Examinations
(1st uri-
nalysis and
blood count)
LIMITED Maternity Benefits
($9 a day for 8 days;
full service benefits
for ectopic pregnancy,
miscarriage. $80 for
normal delivery; $150
Caesarean section, plus
anesthesia, x-ray and
pathology if required.)
Offered By
GEHA's Present Plan(1)
LIMITED
LIMITED
LIMITED
$6 A Day
There Are
No Benefits
For These
Hospital
Services
Included in
LIMITED $30 Miscella-
neous Expense
Allowance
LIMITED (See also
Services
Related to
Surgery,
page 2)
LIMITED
($6 a day for 14 days
plus $30 for delivery
room, anesthetics,
pathology and x-ray.
$40 for miscarriage;
$50 for delivery;
$100 for Caesarean
section.)
(1) Dependents must be hospitalized at least 18 hours to obtain benefits.
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COMPARISON - Continued
Offered By Offered By
Medical Service(l) GEHA's Present Plan
Up to $250(2) Physician
SERVICES RELATED M SURGERY
Up to $150
$10 to $40 Anesthetist LIMITED
(For each ad- Included In
Iministration
No Limit On of anesthesia) $30 Miscel-
Number Of $5 to $35 X-ray LIMITED laneous
(For each
Procedures X-ray) Expense
Up to $25 Clinical Laboratory LIMITED Allowance
(For each Examinations
laboratory
examination)
(1) Medical Service allowances available while subscriber is hospi-
talized for and is receiving surgical or obstetrical services
covered by the Plan. Complete coverage regardless of cost if
subscriber's income is within specified level.
(2) Complete coverage for eligible participants.
THE COST (Per Month)
Group Hospitalization GEHA'
s
Classification
and Medical Service Present
Plan
I.
Single member only
$2.70 $1.60
II.
Married member and spouse
6.90 4.75
III.
Married member, spouse and
all children
6.90 6.00
IV.
Member and all children, where
there is no adult dependent
6.90 4.75
V.
Member and one child, where
there is no adult dependent
5.40
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BENEFITS OFFERED BY GROUP HOSPITALIZATION, INC. BENEFITS OFFERED BY GEHA'S PRESENT PLAN
(BLUE CROSS)
Benefit Days
When a participant is admitted to a partici-
pating hospital the Hospital Service Con-
tract will offer, for each hospital confine-
ment 21 days of hospital care with full
service benefits in semi-private accommoda-
tions, plus 180 additional days for which
the Plan will provide an allowance of $5 a
day -- a total of 201 benefit days for each
confinement. Successive confinements shall
be considered to be continuous and to con-
stitute a single confinement if discharge
from and readmission to a hospital occur
within a 90-day period.
-~nefit days will be fully renewed when 90
avs have elapsed between the patient's
last discharge from the hospital and his
next hospital admission.
Benefits during the full benefit days will
include the following hospital services
regardless of cost:
Semi-private room -
2, 3 or 4 persons
in the Washington
from $9 to413. 50
cipant occupies a
choice or because
accommodations for
(prevailing rates
area hospitals range
a day). If a parti-
private room, by
of his condition, he
will receive a credit
toward the hospital's
room occupied.
of $10 a day
charge for the
Meals - including special
General nursing service
Cystoscopic room
Analgesic care
Recovery room
All drugs and medicines listed in
the official formularies
Dressings
Plaster casts
Intravenous solutions and injections
Sterile Tray Service
First urinalysis and complete blood count
Operating room
Oxygen
Use of equipment for administering oxygen
Benefit Days
The GEHA policy will pay expenses actually
incurred in a hospital not exceeding $6 a
day for not exceeding 31 hospital days for
any one disability.
Benefit days will be fully renewed for
each new illness and each new accident.
The GEHA policy offers a total maximum
allowance of $6 a day (as noted above)
toward the hospital's charge for room
accommodations, meals and special diets,
and general nursing service.
The Insurance Company offers not to exceed
$30 as the result of any one accident or
sickness for laboratory services, use of
operating room, administration of anes-
thetics, and x-ray services.
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BENEFITS OFFERED BY GROUP HOSPITALIZATION, INC. BENEFITS OFFERED BY GEHA'S PRESENT PLAN
(BLUE CROSS)
Maternity 9enef:its
The Family Hospital Service Contract pro-
vides an allowance of up to $9 a day for
a maximum of eight days of hospital care
for any one pregnancy after the Contract
has been in continuous effect for a period
of 10 months.
Full Hospital Service Benefits, including
use of the delivery room and labor room
will be provided for Caesarean deliveries,
termination of ectopic pregnancies, and
,tscarriages.
VOW
(See also Surgical Benefits for Obste-
trics.)
Emergency First Aid -- Out-Patient Service
An allowance up to $10 is provided for out-
patient service for (1) emergency first aid
within two hours after an accident, or (2)
use of operating room facilities when a
general anesthetic is used.
Tonsils or Adenoids
~ef its for the removal of tonsils or
'voids are provided after the Contract
has been in effect continuously for 10
months, and are limited to one day for
children and two days for adults.
Maternity Benefits
If a member of thefined to a hospita
miscarriage or any pregnancy while th
nine months after
policy will pay no
Family Group is con-
l
for childbirth, abortion,
other complication of
e
policy is in force and
i
ts date of issue, the
t
to exceed $6 for not
exceeding 14 days toward hospital charges.
In addition, there is an allowance of up
to $30 toward the charges for delivery or
operating room, anesthetics, routine labora-
tory services and x-ray services. Female
members are covered effective with date of
policy. There is a nine month waiting period
for wives of members.
Accidental Emergency Benefit Outside Hospital
Dependents must be hospitalized at least 18
hours to obtain benefits. Members are
covered with effective date of policy if ad-
mitted to hospital as out-patient.
Tonsils or Adenoids
$6 a day plus $30 toward miscellaneous
hospital expense. No waiting period.
Pulmonary Tuberculosis -- Pulmonary Tuberculosis --
Mental or Nervous Disorders Mental or Nervous Disorders
When the participant is accepted for treat-
ment by a general hospital, up to 10 days'
care will be provided for pulmonary tuber-
culosis and mental or nervous disorders
during any 12 consecutive months.
for pulmonary tuberculosis, mental or
nervous disorders.
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BENEFITS OFFERED BY MEDICAL SERVICE OF D. C.
(BLUE SHIELD)
Surgical Service benefits are available as
often as necessary to help pay the doctor
for the following services rendered in a
hospital by a participating physician:
For Surgery -including the
fractures and dislocations
tomies and adenoidectomies
a 10-month waiting period.
provided for more than one
dare regardless of whether
through the same abdominal
treatment of
Tonsillec-
are covered after
(Benefits are
surgical proce-
they are performed
incision.)
For Obstetrics---care of miscarriage, ectopic
pregnancy or delivery, including aftercare
.-1 the hospital by the physician -- to sub-
ribers enrolled under the Family Contract
after a 10-month waiting period. (See
page 6 for allowances.)
For Related Services--Administration of
anesthetics, diagnostic x-ray services,
clinical laboratory examinations. These
related services are available while a sub-
scriber is hospitalized for and is receiv-
ing surgical or obstetrical services
covered by the Plan.
Home and Office Care
The Surgical Plan offers benefits for the
flowing currently specified services when
idered in the home or in the doctor's of-
fice: emergency treatment of fractures and
dislocations; excision of superficial tumors
and cysts; external thrombosed hemorrhoids;
delivery; suturing lacerations (up to $15);
nasal polyp removal; chalazion removal;
probing tear duct (initial); and circumci-
sion.
Eli ibility for Full Service Benefits
The Surgical Plan offers service benefits
that will cover the phyysician's chars in
full (including charges for x-ray, anesthe-
tics and pathology) if the subscriber is a
single participant and his income does not
exceed $3,000 a year or a family partici-
pant and the family income does not exceed
$5,500 a year. If the subscriber's income
exceeds these amounts, the Plan offers up
to $250 (depending upon the surgical pro-
cedure) to help pay the doctor.
Surgical benefits are offered if any member
of the Family Group undergoes an operation
named in the Schedule of Operations.
Any operation not enumerated will be covered
and the Association will determine the amount
of reimbursement, if any. Two or more sur i-
cal procedures performed through same abdominal
incision considered as one operation.
(See examples, pages 8 and 9)
The GEHA policy offers the maternity benefits
set forth in the examples of payments on
page 6.
These Related Services are included in
Miscellaneous Hospital expense for which the
allowance of $30 is provided.
Home and Office Care
Surgery performed at the doctor's office is
covered.
(Lo Service Benefits
The GEHL policy does not offer service
benefits. It provides only the amounts
set forth in the Schedule of Operations re-
gardless of the policy. holder's income.
Maximum allowance $150.
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EXAMPLES OF PAYMENTS OFFERED BY MEDICAL SERVICE TO SUBSCRIBERS WHOSE
INCOMES EXCEED THE AMOUNT THAT ENTITLES THEM TO FULL SERVICE BENE-
FITS, AND OF PAYMENTS OFFERED BY THE GEHA POLICY
Medical
Service
Plan
GEHA. Policy
Hernia (Inguinal Unilateral)
$100
$ 50
Hernia (Inguinal Bilateral)
140
75
Appendectomy
100
100
Fracture of Spine
125
50
Dislocation (Hip)
75
35
Prostatectomy
200
150
Pregnancy (Normal Delivery)
80
50
Pregnancy (Caesarean)
150
100
Removal of Kidney
175
100
Mastoidectomy (One Side)
150
100
(Both Sides)
Brain tumor or abscess
250
150
Hemorrhoidectomy (Internal)
60
25
Tonsillectomy and Adenoidectomy
50-55
25
Administration of Anesthetics
(depending upon surgical or
obstetrical procedure)
Diagnostic X-ray Service
(depending upon part of
body x-rayed)
Clinical Laboratory Examinations
(depending upon type of
examination,, in addition to
first urinalysis and blood
count provided by Group Hos-
pitalization)
$10 to $40(1)
(For each
administration
of anesthesia)
$5 to $35(1)
(For each
x-ray)
Up to $25(l)
(For each
laboratory
examination)
These services
included in
Miscellaneous
Hospital expense
for which maximum
allowance is $30
(1) Available while a subscriber is hospitalized for and is receiving
surgical or obstetrical services covered by Medical Service.
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The Hospital and Surgical Service Plans do
not cover: Workmen's Compensation cases;
military service connected disabilities;
congenital anomalies; plastic or cosmetic
surgery (unless required because of in-
juries received after the participant is
enrolled). The Hospital Service Contract Benefits are not provided if the loss arises
does not cover rest cures, nor hospitali- out of or in the course of the member's
zation required primarily for diagnosis or occupation as this is covered by Employee's
physical therapy. The Surgical Service Compensation Act.
Contract does not cover dental services,
sprains, strains, contusions, steriliza-
tion except for valid medical reasons,
any services in home or office other
than those specified in the Schedule of
Fees in effect when the service is pro-
vided.
Pre-existing Conditions - Waiting Periods Pre-existing Conditions - Waiting Periods
Pre-existing conditions, other than exclu-
sions noted above, are covered after a 10- There is a nine month waiting period ap-
month waiting period. Benefits for ob- plicable only to maternity benefits for
stetrical care and for the removal of the wives of members.
tonsils and adenoids are available after
10 months.
For a comparison of the dollar value of benefits
received by Group Hospitalization and Medical.
Service subscribers (actual cases) and the dollar
value of the benefits they would have received
under the GEHA policy, see pages 8 and 9.
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Diagnosis: Diaphragmatic Hernia
Services
hares
Charges Covered
By GHI-MSDC
Charges Covered
By GEHA. Plan
4 days private accommo-
dations @ $17
$ 68.00
$ 40.00
$ 24.00
14 days semi-private ac-
commodations @ $11
154.00
154.00
84.00
Operating room
42.00 *
42.00
Total Allow-
Laboratory examinations
12.00 *
8.75
ance for "Mis-
Anesthetist
50.00 *
50.00
30.00
cellaneous
X-ray
185.00 *
185.00
Hospital
Pathologist
41.50 *
41.50
Expenses',
Recovery room
2.50
2.50
Medicines
181.60
181.60
Oxygen
10.00
10.00
Physician
410.00
410.00
150.00
Miscellaneous
14.00
Totals
$1,170.60
$1,125.35
$288.00
Amount paid by subscriber
$ 45.25
Amount subscriber would have paid if
covered by GEHL policy
$882.60
NOTE: All of the charges for hospital services required by the patient in this
case were covered in full by the subscriber's Group Hospitalization Contract
except $45.25 of which $28 was for a private room, $3.25 for laboratory examina-
tions, and $14 for miscellaneous items. His income was within the prescribed
amount that entitled him to full Surgical Service Benefits and his Surgical
Contract covered the charges for physicians' services in full. The amount
the GEHA policy would have allowed for the physician in this case is not
]mown.; however, in this example, the maximum allowance of $150 has been used.
Under the GEHA Plan which offers $6-$30-$150, the subscriber would have had to
pay $882.60 of the above bill.
The GEHA Plan provides no benefits for use of recovery room, medicines and
oxygen which, in this case, cost a total of $194.10.
* These charges which amounted to $330.50 are covered in full by the subscriber's
Group Hospitalization and Surgical Contracts except for $3.25. These charges
are included in "Miscellaneous Charges" by the GEHA Plan and are covered only
by the maximum allowance for miscellaneous charges which in this example, is
$30. "Miscellaneous Charges" exceed the indemnity plan's allowance by $300.50.
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Diagnosis: Cancer
Charges Covered
Charges Covered
Services
Charges:
By GHI-MSDC
By GEHA Plan
16 days semi-private accom-
modations @ $13.50
$216.00
$216.00
$ 96.00
Operating room
82.50 *
82.50
First urinalysis and
Total Allow-
complete blood count
7.00 *
7.00
ance for "Mis-
Anesthetist
70.00 *
70.00
cellaneous
Laboratory Services
194.00 *
194.00
Expenses"
Roentgenologist (X-ray)
125.00 *
125.00
Medications (including sera
and intravenous solutions)
180.65
180.65
Oxygen
254.75
254.75
Dressings
154.65
154.65
Physician
500.00
05 0.00
150.00
Totals
$1,784.55
$1,784.55
$ 276.00
Amount paid by subscriber
NONE
Amount subscriber would have paid if
covered by GEHA policy
$1,508.55
NOTE: All of the charges for hospital services required by the patient in
this case were covered in full by the subscriber's Group Hospitalization Con-
tract. Her income was within the prescribed amount that entitled her to
full Surgical Service Benefits and her Surgical Contract covered the charges
for physicians' services in full.
Under GEHA's Plan offering $6-$30-$150, the subscriber would have had to
pay $1,508.55 of the above bill.
The GEHA Plan provides no benefits for medicines, oxygen and dressings which,
in this case, cost $590.05.
* These charges, which amounted to $478.50, were covered in full by the sub-
scriber's Group Hospitalization and Surgical Contracts. These charges are
included in "Miscellaneous Expenses" by the GEHA Plan and are covered only
by the maximum allowance for miscellaneous charges which is $30. "Miscel-
laneous Expenses" exceed the indemnity plan's allowance by $448.50.
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