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Humanizing Healthcare: Benefit Equity Audits

Language is powerful. The words used in the Summary of Plan Design (SPD) and Summary of Benefits and Coverage (SBC) will dictate the care that is covered under a member’s policy. According to federal ERISA law, employers are required to create and distribute SPDs to plan participants within 90 days of being covered by the plan. This document describes the plan and how it operates in words that can be easily understood by consumers, including translation of the document to non-English speakers. Under the Affordable Care Act (ACA), employers are also required to create and distribute SBCs, which contain standard definitions of medical terms, and describe the coverage and cost-sharing methods for different types of services as well as any coverage limitations. SBCs are created under a uniform format to allow for easy comparisons between plans.

For many plan sponsors, the language used in their plan documents has not been reviewed beyond ensuring compliance since their initial creation. Insurance companies typically have standard language to describe their plan provisions that may be traditional; this standard language often does not reflect the changing demographics of the population covered. Consequently, if a healthcare professional provides a service that is not explicitly covered in these documents, the claims administrator can refuse to accept the claim. This can be a financial strain for members seeking less traditional forms of care. In order to remain inclusive of a plan participants’ diverse healthcare needs, plan sponsors must routinely review the language in their documents and make revisions as needed in accordance with their values.

Healthcare consultants can assist plan sponsors in reviewing this through benefit equity audits. These audits typically consist of reviewing plan documents and plan design language provided by the plan administrators, and summarizing recommendations for revisions based on benchmarking and best practices. Reviewing a census of eligible plan participants also helps plan sponsors understand the prevalence (or lack of) populations that may be more likely to seek less traditional forms of care. Where possible, gathering aggregated information that provides insights into race, ethnicity and gender distributions, part-time and full-time split, salary tiers, percent that identify as LGBTQ+, and other distinct demographics that are associated with health disparities can help plan sponsored make informed decisions and prioritize changes based on the plan participants’ needs. And if the goal is to diversify their employee population, modernizing their benefits is one way to attract a diverse workforce.

Here are some questions plan sponsors can ask themselves about common inequitable benefits.

How am I defining family?

When creating benefit programs for family, plan sponsors should keep in mind the different family structures we see today. A good benefit program should address the needs of different family structures -- from conception where families may need fertility treatment to create their families, to birth, adopting, or fostering a child. These benefits should be described with non-heteronormative language, acknowledging that families are made up of opposite-sex, same-sex, and nonbinary couples.

Plan sponsors may also review how other benefits perceive a family unit. For example, bereavement leave policies may unintentionally exclude extended family members such as grandparents, aunts, uncles, and cousins, though for many individuals they may have closer relationships with these extended family members than with their own immediate family. Also, providing bereavement for the loss of their pet may be the way to validate their relationship as a true familial bond.

Do our maternity benefits support our diverse populations?

The racial disparities in maternal health are stark. The rates of life-threatening pregnancy-related complications, also known as severe maternal morbidity (SMM) are 63% higher for women in majority Black communities than women in majority white communities, and 32% higher for women in majority Hispanic communities (1). These racial and ethnic groups also have a greater prevalence of risk factors including hypertension, anemia, and pre-existing diabetes. Though it is important to manage these risks, mothers of color are less likely to receive the necessary care or complete all recommended prenatal visits. One potential improvement to a plan’s maternity benefit is providing coverage for or educational materials on doulas. A doula is a “trained, non-clinical professionals who can give a mother emotional, physical and educational support” throughout their pregnancy (2). Connecting Black mothers with doulas improves outcomes for both the mothers and the babies. They can help them navigate their options, advocate for the mother’s desired birth plan, and inform the mother of helpful resources.

Who is considered an eligible dependent?

Prior to same-sex marriage becoming legalized, same-sex couples sought for an alternative recognition of their relationship to receive access to similar benefits that are granted by marriage. As a result, certain states have recognized domestic partnerships between same and (in most cases) opposite sex couples. However, once marriage equality became law, the prevalence of states and employers recognizing domestic partnerships declined. Revoking this recognition takes away this benefit from couples who do not wish to be married, either same or opposite sex. Plan sponsors should determine whether they would like to extend eligibility to same and opposite sex spouses and domestic partners, particularly if they reside in a state or municipality that recognizes these relationships.

Do members have access to gender-affirming care?

Most healthcare providers do not receive cultural competency training to provide appropriate care to transgender and gender-diverse individuals. According to an online survey conducted by the Center for American Progress in June 2020, “nearly half of transgender adults report[ed] having negative or discriminatory experiences with a health care provider” (3). The same survey also showed about the same percentage of respondents have been denied coverage for gender-affirming care. As a baseline, plan sponsors should ensure that their benefits are in alignment with The World Professional Association for Transgender Health (WPATH) Standards of Care. To provide more comprehensive coverage, plan sponsors can also add coverage for additional gender reaffirming services including tracheal shave, electrolysis, and facial feminization procedures.

Crafting thoughtful policy language and designing a communication campaign is key to creating an inclusive benefits package. The Benefits Equity Audit services at Athena Actuarial Consulting can help your benefits team with this. If you would like to receive more information, please contact us at and 954-516-7117.


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