EXHIBIT 1 MICHIGAN ESSENTIAL HEALTH BENEFITS COMPARISON* BCBSM FEHBP

EXHIBIT 1
MICHIGAN ESSENTIAL HEALTH BENEFITS COMPARISON*
Benefits provided by potential benchmark major medical plans - data as of 3/31/12
Grouped in the 10 categories of Essential Health Benefits required by the ACA.
See http://www.healthcare.gov/news/factsheets/2011/12/essential-health-benefits12162011a.html
Terms:
MB - Michigan mandated benefit
Small Group
Benefits [3]
BCBSM
Community
Blue
PPO Plan 4
1. Ambulatory patient services - Federal Mandate
Primary Care Visit to Treat an Injury or
Yes
Illness
Specialist Visit
Other Practitioner Office Visit
(Nurse, Physician Assistant)
Outpatient Surgery
Physician/Surgical Services
Outpatient Facility Fee
(e.g., Ambulatory Surgery Center)
Home Health Care Services
Hospice Care
Breast Cancer Outpatient Treatment
Services
Yes
State Employee Plans
HMO
Federal Employee Plans
Priority
Health
(HMO)
BCN10
(HMO)
Priority
Health
(HMO)
BCBSM
(Self-insured)
PHP
(HMO)
Priority
Health
(HMO)
FEHBP
BCBSM
Standard
Option
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
MB
500.3519(3)
Yes
Yes
Yes
Yes
Yes
Yes
MB
500.3519(3)
Yes
Yes
must be
must be
participating
participating
Yes
provider
provider
referral
A nonA nonrequired except
participating
participating
OB/GYN
provider
provider
requires prior
requires prior
approval
approval
5/21/2012
FEHB GEHA
Standard
Option
Michigan
Mandate
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
MB
500.3519(3)
Yes
Yes
Yes
Yes
MB
500.3406c
550.1417
Yes
Doesn't
specifically
include or
exclude this
benefit
Doesn't
specifically
include or
exclude this
benefit
Doesn't
specifically
include or
exclude this
benefit
MB
500.3406d
550.1416
Yes
MB
500.3406k
500.3519(3)
550.1418
Yes
Yes
Yes
Yes
maximum of 45
days per
contract year
Yes
Yes
maximum of 45
days per
contract year
Yes
limited to 60
visits per
calendar year
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
2. Emergency Services - Federal Mandate
Emergency Room Services
FEHBP BCBS
Basic Option
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Page 1 of 8
EXHIBIT 1
MICHIGAN ESSENTIAL HEALTH BENEFITS COMPARISON*
Small Group
State Employee Plans
HMO
BCBSM
Community
Blue
PPO Plan 4
Priority
Health
(HMO)
BCN10
(HMO)
Priority
Health
(HMO)
BCBSM
(Self-insured)
PHP
(HMO)
Emergency Transportation/Ambulance
Yes
Yes
Yes
Yes
Yes
Urgent Care Centers or Facilities
3. Hospitalization - Federal Mandate
Inpatient Hospital Services (e.g.,
Hospital Stay)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Inpatient Physician and Surgical Services
Yes
Yes
Transplants
Yes
Antineoplastic Surgery Drugs
Inpatient Hospital Services Other Than
Those for the Treatment of Mental
Illness
Benefits [3]
Priority
Health
(HMO)
FEHBP BCBS
Basic Option
FEHB GEHA
Standard
Option
Michigan
Mandate
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
MB
500.3406l
500.3519(3)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
MB
500.3519(3)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
500.3519(3)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
500.3519(3)
MB
500.3406e
550.1416a
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
730 days per
confinement
Yes[1]
Yes[1]
Yes
Yes
Yes
Yes
Yes
500.3519(3)
Yes
Yes
Yes
Yes
500.3519(3)
Yes
Yes
Yes
Yes
MB
500.3406b
550.1401b
Yes
Yes
Yes
Yes
MB
500.3519(3)
Yes
Yes
Yes
Yes
Yes
Yes
non-network
maximum of 45 maximum of 45 maximum of 45 120 days per
up to a
Skilled Nursing Facility
benefits are
admission for indays per
days per
days per
maximum of
limited to 100
network
contract year contract year contract year
120 days
days per year
4. Maternity and newborn care - Federal Mandate
Prenatal and Postnatal Care
Yes
Yes
Yes
Yes
Yes
Yes
Delivery and All Inpatient Services for
Yes
Yes
Yes
Yes
Yes
Yes
Maternity Care
5. Mental health and substance use disorder services, including behavioral health treatment - Federal Mandate
Yes
Yes
Yes
Mental/Behavioral Health Inpatient
up to 20 days up to 30 days up to 20 days
Yes[2]
Yes
Yes
Services
per contract
per calendar
per contract
year
year
year
Yes
Yes
Yes
up to 20 visits
Mental/Behavioral Health Outpatient
up to 20 days
up to 20 days
Yes
Yes[2]
Yes
per member
Services
per contract
per contract
per calendar
year
year
year
May 21, 2012
Federal Employee Plans
FEHBP
BCBSM
Standard
Option
MB
500.3519(3)
Page 2 of 8
EXHIBIT 1
MICHIGAN ESSENTIAL HEALTH BENEFITS COMPARISON*
Small Group
Benefits [3]
BCBSM
Community
Blue
PPO Plan 4
Priority
Health
(HMO)
State Employee Plans
HMO
BCN10
(HMO)
Yes
limited to one
program of
treatment per
12 month
period.
Combined with
outpatient
services
Yes
limited to one
program of
treatment per
12 month
period.
Combined with
inpatient
services
Federal Employee Plans
Priority
Health
(HMO)
BCBSM
(Self-insured)
PHP
(HMO)
Priority
Health
(HMO)
FEHBP
BCBSM
Standard
Option
Yes
Yes[2]
Yes
Yes
Yes
Yes
Yes
MB
550.1414a(1)
Yes
Yes[2]
Yes
Yes
Yes
Yes
Yes
MB
500.3425
500.3519(3)
550.1414a(4)
[4]
FEHBP BCBS
Basic Option
FEHB GEHA
Standard
Option
Michigan
Mandate
Substance Abuse Disorder
Inpatient Services
Yes
Yes
Substance Abuse Disorder
Outpatient Services
Yes
Yes
Autism Therapy
No
No
No
No
No
No
No
Covers
PT/ST/OT
Covers
PT/ST/OT
Covers
PT/ST/OT
Generic Drugs
Yes
with pharmacy
rider
Yes
Yes
with pharmacy
rider
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Preferred Brand Drugs
Yes
with pharmacy
rider
Yes
Yes
with pharmacy
rider
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Non-Preferred Brand Drugs
Yes
with pharmacy
rider
Yes
Yes
with pharmacy
rider
Yes
Yes
Yes[2]
Yes[2]
Yes[2]
Yes[2]
Yes[2]
Specialty Drugs
Yes
with pharmacy
rider
Yes
Yes
with pharmacy
rider
Yes
Yes
Yes[2]
Yes[2]
Yes[2]
Yes[2]
Yes[2]
Preferred Tobacco Cessation
Yes
Products must be prescribed by a
with pharmacy
Physician and obtained from a Network
rider
Retail Pharmacy
Yes
Yes
with pharmacy
rider
Yes
Yes
Yes
Yes
Yes
Yes
Yes
6. Prescription drugs - Federal Mandate
May 21, 2012
Page 3 of 8
EXHIBIT 1
MICHIGAN ESSENTIAL HEALTH BENEFITS COMPARISON*
Small Group
BCBSM
Community
Blue
PPO Plan 4
Benefits [3]
Priority
Health
(HMO)
State Employee Plans
HMO
BCN10
(HMO)
Priority
Health
(HMO)
BCBSM
(Self-insured)
PHP
(HMO)
Federal Employee Plans
Priority
Health
(HMO)
FEHBP
BCBSM
Standard
Option
FEHBP BCBS
Basic Option
FEHB GEHA
Standard
Option
Yes
Yes
Yes
Michigan
Mandate
7. Rehabilitative and habilitative services and devices - Federal Mandate
Outpatient Rehabilitation Services
Yes
Yes
maximum of 30 limited to one
visits per
period of
Yes
contract year treatment for
limited to a
each for: (1)
any
combined
PT/OT/Chiro- combination of
maximum of 60
practic office
therapies
visits for
visits; (2) ST;
within 60
PT/ST/OT
and (3) cardiac consecutive
and pulmonary
days per
episode
rehab
Habilitation Services
No
No
No
Yes
maximum of 30
visits per
Yes
contract year
limited to a
each for: (1)
combined
PT/OT/Chiro- maximum of 90
practic office
days per
visits; (2) ST; calendar year for
and (3) cardiac
PT/ST/OT
and pulmonary
rehab
No
No
Yes
Yes
limited to 60 maximum of 30
visits per
visits per year
for a combo of contract year
PT/ST/OT and each for: (1)
PT/OT/Chiropulmonary
practic office
rehab. Any
visits; (2) ST;
combo of
cardiac rehab and (3) cardiac
limited to 36 and pulmonary
rehab
visits per year.
Covers
Covers
Covers
PT/ST/OT for
PT/ST/OT for PT/ST/OT for
conditions
conditions
conditions
such as
such as autism such as autism
autism
No
No
Yes
Includes
hearing aids
limited to $880
for monaural or
$1600 binaural
once every 36
months
Yes
Includes 1
hearing exam,
1 audiometric
exam, and 1
basic hearing
aid per ear
every 36
months.
Hearing aid is
limited to $500
per aid.
Yes
Yes
Yes
Durable Medical Equipment
Yes
Yes
Yes
Yes
Yes
Includes hearing
care benefits
limited to once
every 36 months
unless significant
hearing loss
occurs earlier
and is certified
by your physician
Breast Cancer Rehabilitation Services
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Mastectomy Prosthetics
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
8. Laboratory services - Federal Mandate
Diagnostic Test (X-Ray and Laboratory
Tests)
Imaging (CT and PET Scans, MRIs)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
May 21, 2012
[4]
MB
500.3406d
550.1416
MB
500.3406a
550.1415
MB
500.3519(3)
500.3519(3)
Page 4 of 8
EXHIBIT 1
MICHIGAN ESSENTIAL HEALTH BENEFITS COMPARISON*
Small Group
State Employee Plans
HMO
BCBSM
Community
Blue
PPO Plan 4
Priority
Health
(HMO)
BCN10
(HMO)
Priority
Health
(HMO)
BCBSM
(Self-insured)
PHP
(HMO)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
10. Pediatric services, including oral and vision care - Federal Mandate
Dental Check-Up for Children
No
No
Vision Screening for Children
No
Yes
Eye Glasses for Children
No
No
No
Yes
No
General Pediatric Care
Yes
Benefits [3]
Breast Cancer Diagnostic Services
Federal Employee Plans
Priority
Health
(HMO)
FEHBP
BCBSM
Standard
Option
FEHBP BCBS
Basic Option
FEHB GEHA
Standard
Option
Michigan
Mandate
Yes
Yes
Yes
Yes
Yes
MB
500.3406d
550.1416
Yes
Yes
Yes
Yes
Yes
Yes
MB
500.3519(3)
No
Yes
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
9. Preventive and wellness services and chronic disease management - Federal Mandate
Preventive
Care/Screening/Immunization
Yes
panel physician
only
Yes
Yes
Yes
Miscellaneous
Chiropractic Office Visits
Diagnosis and treatment of infertility,
e.g. endometriosis, blockage of fallopian
tubes, varicocele
Morbid Obesity weight management
program
May 21, 2012
Yes
visits are
included in the
24 visits per
maximum of 30
calendar year
visits per
contract year
for PT/OT
No
Yes
Prescription
drugs to treat
infertility with
purchase of Rx
rider
No
Yes
Yes
MB
500.3406n
500.3519(3)
550.1401g
Yes
Yes
Osteo and
Osteo and
Yes
Yes
chiro
chiro
Yes
visits are
visits are
manipulative manipulative 12 visits per
24 visits per
included in the
included in the treatment
treatment
person per
calendar year for 20 visits per
maximum of 30
maximum of 30 limited to
limited to
calendar year
chiropractic
calendar year
visits per
visits per
combined
combined
for
manipulation
contract year
contract year
total of 12
total of 12
manipulation
for PT/OT
for PT/OT
visits per
visits per
of the spine
person, per
person, per
calendar year calendar year
Yes
Yes
Yes
Yes
Yes
Yes
Yes
subject to
No
Infertility
Infertility
Prescription
$10,000 per
Prescription
medical
unless it treats a
drugs used in drugs used in Limited to a
drugs to treat
calendar year; drugs to treat
criteria.
medical
conjunction
conjunction max of $3000
infertility with
Artificial
infertility with
per person per
Includes
condition other
with ART
with ART
purchase of Rx
Insemmina- purchase of Rx
coverage for
than infertility
procedures
procedures calendar year
rider
tion covered
rider
infertility drugs
excluded
excluded
No
Yes
weight
Yes
1 weight
management
Yes
lifetime max of management
Yes
Yes
Yes
Yes
programs
$300
program per
offered at a
lifetime
discount rate
Page 5 of 8
EXHIBIT 1
MICHIGAN ESSENTIAL HEALTH BENEFITS COMPARISON*
Small Group
Benefits [3]
BCBSM
Community
Blue
PPO Plan 4
Morbid Obesity surgical treatment
Acupuncture only for certain conditions
specified in contract
Wigs and supplies (cancer or alopecia
only)
Yes
Yes
1 per lifetime
No
No
No
No
No
Yes
coverage for
women only
including
pregnant
women
Genetic Testing
May 21, 2012
Priority
Health
(HMO)
State Employee Plans
HMO
BCN10
(HMO)
Priority
Health
(HMO)
Yes
Yes
subject to
1 per lifetime
medical criteria
BCBSM
(Self-insured)
Priority
Health
(HMO)
Yes
Must be
ordered by
primary care
physician,
provided by a
Yes
network
If this is for
physician in a
weight loss
designated
Yes
surgery, this is
facility, and
1 per lifetime
payable if the covered person
medical criteria must qualify
is met
under current
morbid obesity
policy which
included
medically
necessary
services
No
Yes
20 treatments
per calendar
year
No
No
Yes
$300 per lifetime
except for
children
Yes
when
authorized by
BCN
Yes
coverage for
women only
including
pregnant
women
No
No
PHP
(HMO)
Federal Employee Plans
FEHBP
BCBSM
Standard
Option
FEHBP BCBS
Basic Option
FEHB GEHA
Standard
Option
Yes
Yes
Yes
No
Yes
Yes
Yes
24 visits per 24 visits per
20 visits per
calendar year calendar year calendar year
No
No
Yes
Yes
Any amount Any amount
over $350 for over $350 for
one wig per
one wig per
lifetime (no
lifetime (no
deductible)
deductible)
Yes
coverage for
certain
Medically
Necessary
Genetic Tests
with prior
author-ization
Yes
coverage for
women only
including
pregnant
women
No
Yes
Diagnostic
only
Yes
Diagnostic
only
Michigan
Mandate
No
Yes
Requires
referral,
precertification, prior
authorization
Page 6 of 8
EXHIBIT 1
MICHIGAN ESSENTIAL HEALTH BENEFITS COMPARISON*
Small Group
Benefits [3]
Evaluation and treatment of chronic
pain
Reconstructive Procedures - covers
medically necessary services for
reconstructive procedures when a
physical impairment exists and the
primary purpose of the procedure is to
improve or restore physiologic function
Blepharoplasty of upper lids, breast
reduction, panniculectomy*,
rhinoplasty*, septorhinoplasty*, and
surgical treatment of male
gynecomastia
*sleep apnea treatment procedures
May 21, 2012
BCBSM
Community
Blue
PPO Plan 4
Yes
Yes
Yes
provided
BCBSM's
specific medical
criteria is met
Priority
Health
(HMO)
Yes
Yes
Yes
HMO
BCN10
(HMO)
Yes
Yes
Yes
subject to
medical criteria
State Employee Plans
Federal Employee Plans
Priority
Health
(HMO)
FEHBP
BCBSM
Standard
Option
FEHBP BCBS
Basic Option
FEHB GEHA
Standard
Option
Doesn't
specifically
include or
exclude this
benefit
Doesn't
specifically
include or
exclude this
benefit
Yes
Yes
No
Yes
Requires
referral,
precertification, prior
authorization
Priority
Health
(HMO)
BCBSM
(Self-insured)
Yes
Doesn't
specifically
include or
exclude this
benefit
Yes
Yes
Doesn't
specifically
include or
exclude this
benefit
Yes
Reconstructive
surgery is
covered only for
the correction of
1) birth defects
2) conditions
resulting from
accidental
injuries 3)
deformities
resulting from
certain surgeries,
such as breast
reconstruction
following
mastectomies
Yes
Yes
Yes
Yes
Blepharoplasty is
only procedure
specifically
mentioned based on
medical policy. If
the reason for
the service is
cosmetic, the
service is not
payable
PHP
(HMO)
Yes
Yes
No
Michigan
Mandate
Page 7 of 8
EXHIBIT 1
MICHIGAN ESSENTIAL HEALTH BENEFITS COMPARISON*
Small Group
Benefits [3]
Services related to Temporomandibular
Joint Syndrome or Dysfunction
Orthognathic Surgery
BCBSM
Community
Blue
PPO Plan 4
Yes
dental surgery
directly to the
temporomandibular
joint and
related
anesthesia
services
Yes
surgical
corrections of
skeletal
abnormalities
Priority
Health
(HMO)
Yes
Yes
State Employee Plans
HMO
BCN10
(HMO)
Yes
Yes
Priority
Health
(HMO)
Yes
Yes
BCBSM
(Self-insured)
PHP
(HMO)
Benefits for TMJ
or jaw-joint
disorder are
limited to: 1)
Yes
surgery directly
if medically
to the jaw joint,
necessary and
2) x-rays
not part of
(including MRIs),
dental
3) trigger point
treatment
injections, 4)
arthrocentesis
(injection
procedures)
Yes
Yes
covered if
medically
necessary
Federal Employee Plans
Priority
Health
(HMO)
FEHBP
BCBSM
Standard
Option
FEHBP BCBS
Basic Option
FEHB GEHA
Standard
Option
Yes
No
Surgery only
No
Surgery only
No
Surgery only
No
Yes
Severe sleep
apnea only,
cleft palate,
and Pierre
Robin
Syndrome
Yes
50% coverage
No
Michigan
Mandate
Abbreviations: BCBSM = Blue Cross Blue Shield of Michigan; BCN = Blue Care Network; CT = computed tomography; GEHA = Government Employees Health Association; MRI = magnetic resonance imaging; PET = positron emission tomography; PT
= physical therapy; OT = occupational therapy; ST = speech therapy; ART = Assisted Reproductive Technology
Footnotes for table
[1] The FEHBP BCBS Standard and Basic options cover skilled nursing facilities only when approved by a case manager.
[2] Coverage for Non-Preferred Brand Drugs and Specialty Drugs requires special permission.
[3] The chart greatly simplifies the benefits offered. For more specificity, please refer to the Certificates of Coverage for each plan that are linked in the column headings.
[4] Implementation of Autism Bill (Senate Bill 414, 415, and 918) will take place 10/2012. Not part of Essential Health Benefits as these are defined as of 3/31/12.
*The data provided in this chart is not legal advice and is intended for informational purposes only. This chart has been compiled by the Michigan Office of Financial and Insurance
Regulation based on presently available enrollment data and benefit design, utilizing the essential health benefit (EHB) definitions and categories as delineated in the most recent guidance
provided by the federal government. The U.S. Department of Health and Human Services (HHS) has directed states to choose the EHB benchmark from certain enumerated plans, including
the largest HMO and small group plans in the state, identified by enrollment data as reported to HHS for the first quarter of 2012. The data provided in this chart is subject to change as
additional federal guidance is provided with regard to EHB.
May 21, 2012
Page 8 of 8