Table 4.
Comparison of true† versus claims-derived†† measures when both sources indicated that out-of-network inpatient coinsurance was required
| Carve-in plan-years | Carve-out plan-years | |||
|---|---|---|---|---|
| % Total |
Among plans on row: Mean Difference (SD) |
% Total |
Among plans on row: Mean Difference (SD) |
|
| Out-of-Network Inpatient Coinsurance | N=623 | N=315 | ||
| Plan-year value derived from the minimum value observed in claims | ||||
| Derived < true | 89 | −28 ( 12) | 90 | −25 (13) |
| Derived = true | 10 | 0 (0) | 10 | 0 (0) |
| Derived > true | 1 | 13 (13) | 0 | NA |
| Plan-year value derived from the 25th percentile value observed in claims | ||||
| Derived < true | 89 | −27 (12) | 90 | −24 (13) |
| Derived = true | 10 | 0 (0) | 10 | 0 (0) |
| Derived > true | 1 | 13 (13) | 0 | NA |
| Plan-year value derived from the 50th percentile value observed in claims | ||||
| Derived < true | 87 | −22 (10) | 88 | −20 (12) |
| Derived = true | 12 | 0 (0) | 12 | 0 (0) |
| Derived > true | 1 | 11 (12) | 0 | NA |
| Plan-year value derived from the 75th percentile value observed in claims | ||||
| Derived < true | 75 | −18 (11) | 79 | −16 (11) |
| Derived = true | 23 | 0 (0) | 21 | 0 (0) |
| Derived > true | 23 | 14 (10) | 0.3 | 18 (0) |
| Plan-year value derived from the maximum value observed in claims | ||||
| Derived < true | 67 | −18 (11) | 72 | −16 (11) |
| Derived = true | 30 | 0 (0) | 28 | 0 (0) |
| Derived > true | 3 | 15 (9) | 0.3 | 18 (0) |
| Out-of-Network Outpatient Professional Coinsurance | N=2092 | N=2043 | ||
| Plan-year value derived from the minimum value observed in claims | ||||
| Derived < true | 97 | −37 (8) | 85 | −36 (9) |
| Derived = true | 3 | 0 (0) | 16 | 0 (0) |
| Derived > true | 0.2 | 32 (33) | 0.05 | 5 (0) |
| Plan-year value derived from the 25th percentile value observed in claims | ||||
| Derived < true | 82 | −36 (10) | 70 | −35 (11) |
| Derived = true | 18 | 0 (0) | 30 | 0 (0) |
| Derived > true | 0.4 | 24 (25) | 0.05 | 5 (0) |
| Plan-year value derived from the 50th percentile value observed in claims | ||||
| Derived < true | 48 | −35 (12) | 38 | −34 (12) |
| Derived = true | 51 | 0 (0) | 62 | 0 (0) |
| Derived > true | 1 | 20 (17) | 0.05 | 5 (0) |
| Plan-year value derived from the 75th percentile value observed in claims | ||||
| Derived < true | 24 | −33 (13) | 16 | −32 (13) |
| Derived = true | 75 | 0 (0) | 84 | 0 (0) |
| Derived > true | 2 | 18 (14) | 0.2 | 4 (2) |
| Plan-year value derived from the maximum value observed in claims | ||||
| Derived < true | 5 | −16 (10) | 3 | −19 (10) |
| Derived = true | 87 | 0 (0) | 96 | 0 (0) |
| Derived > true | 9 | 21 (14) | 0.8 | 12 (16) |
SD: Standard deviation; OON: Out-of-network
†:
True measures are drawn from an insurer’s claims processing engine database, and reflect the values present in the “Description of Benefits” documents issued by the insurer.
††:
Claims-derived measures are based on expenditures from coinsurance in specialty mental health claims data.