2017 Benchmark MICHIGAN ESSENTIAL HEALTH BENEFITS COMPARISON BCBSM FEHBP BCBS

2017 Benchmark
MICHIGAN ESSENTIAL HEALTH BENEFITS COMPARISON
Benefits provided by potential benchmark major medical plans - data as of 3/31/14
Grouped in the 10 categories of Essential Health Benefits required by the ACA.
http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/ehb-2-20-2013.html
Small Group
BCBSM
Community
Blue
PPO Plan 4
Benefits
1. Ambulatory patient services - EHB Category
Primary Care Visit to Treat an Injury or
Yes
Illness
Specialist Visit
Yes
State Employee Plans
HMO
Priority Health BCBSM Simply Priority Health
BCBSM
(HMO)
Blue 2500
(HMO)
(Self-insured)
Federal Employee Plans
PHP
(HMO)
Priority Health
(HMO)
FEHBP BCBS
Standard
Option
FEHBP BCBS
Basic Option
FEHB GEHA
Standard
Option
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Michigan
Mandate
500.3519(3)
500.3519(3)
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 Services - home
Breast Cancer Outpatient Treatment
Services
Abortion for Which Public Funding is
Prohibited
Chemotherapy (Antineoplastic)
Radiation
Dialysis
Infusion Therapy
2. Emergency Services - EHB Category
Emergency Room Services
Emergency Transportation/Ambulance
June 16, 2015
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
limited to 60
visits per
calendar year
Yes
Yes
Yes
Yes - 50 visit
limit
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes - $15,000
limit
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
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
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
500.3519(3)
500.3406c
500.3406d
Act 182 of 2013
500.3406e
500.3406k
500.3406l
500.3519(3)
2017 Benchmark
MICHIGAN ESSENTIAL HEALTH BENEFITS COMPARISON
Small Group
BCBSM
Community
Blue
PPO Plan 4
Benefits
Urgent Care Centers or Facilities
3. Hospitalization - EHB Category
Inpatient Hospital Services (e.g.,
Hospital Stay)
Inpatient Hospice
Inpatient Physician and Surgical
Services
Transplants
State Employee Plans
HMO
Priority Health BCBSM Simply Priority Health
BCBSM
(HMO)
Blue 2500
(HMO)
(Self-insured)
PHP
(HMO)
Priority Health
(HMO)
FEHBP BCBS
Standard
Option
FEHBP BCBS
Basic Option
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
maximum of 45
days per
contract year,
combined with
inpatient rehab
facility,
subacute
facility, and
skilled nursing
facility
Yes
Yes
maximum of 45
days per
contract year,
combined with
inpatient rehab
facility,
subacute
facility, and
skilled nursing
facility
Yes
Yes
Yes - maximum
of 120 days per
confinement,
combined with
inpatient rehab
facility,
subacute
facility, and
skilled nursing
facility
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 - Plan pays
$700/day
Yes
Yes
Yes
Yes
500.3519(3)
Yes
Yes
Yes
Yes
500.3519(3)
Yes
Yes
Yes
Yes
500.3406b
Yes
Yes
maximum of 45
maximum of 45
Yes
days per
days per
maximum of 120
contract year,
contract year,
days for each
Yes - nonYes - up to a
Yes - up to a
combined with
combined with benefit period,
network
maximum of 120
maximum of 120
inpatient rehab
in a SNF for
benefits are
Skilled Nursing Facility
inpatient rehab
days per
days per member
facility,
general
limited to 100
facility,
member per year
per year
subacute
conditions.
days per year
subacute
facility, and
Period renews
facility, and
inpatient
after 90 days
inpatient
hospice facility
hospice facility
4. Maternity and newborn care - EHB Category
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 - EHB Category
Yes - 20 days
Yes - 20 days
Yes - 60 days per
per contract
per contract
Mental/Behavioral Health Inpatient
year
Yes
year
year
Yes
Yes
Services
Must be
Must be
Must be
supplemented
supplemented
supplemented
June 16, 2015
Federal Employee Plans
Yes - maximum
of 120 days per
confinement,
combined with
inpatient rehab
facility,
subacute
facility, and
inpatient
hospice facility
500.3519(3)
500.3519(3)
500.3519(3)
2017 Benchmark
MICHIGAN ESSENTIAL HEALTH BENEFITS COMPARISON
Small Group
BCBSM
Community
Blue
PPO Plan 4
Benefits
Mental/Behavioral Health Outpatient
Services
Yes
Substance Abuse Disorder
Inpatient Services
Yes
Substance Abuse Disorder
Outpatient Services
Yes
6. Prescription drugs - EHB Category
Generic Drugs
Preferred Brand Drugs
Non-Preferred Brand Drugs
Specialty Drugs
Preferred Tobacco Cessation
Products must be prescribed by a
Physician and obtained from a Network
Retail Pharmacy
Growth Hormone Therapy
Infertility Treatment Prescription Drugs
State Employee Plans
HMO
Priority Health BCBSM Simply Priority Health
BCBSM
(HMO)
Blue 2500
(HMO)
(Self-insured)
Yes - 20 days
per contract
year
Must be
supplemented
Yes - 10 days
per contract
year
Must be
supplemented
Yes - 30 days
per contract
year
Must be
supplemented
Yes 50 visits per
year/ 120 visits lifetime
maximum
Must be
supplemented
Yes - 60 days per
year
Must be
supplemented
Yes
Yes - 20 days
per contract
year
Must be
supplemented
Yes - 10 days
per contract
year
Must be
supplemented
Yes - 30 days
per contract
year
Must be
supplemented
Yes
Federal Employee Plans
PHP
(HMO)
Priority Health
(HMO)
FEHBP BCBS
Standard
Option
FEHBP BCBS
Basic Option
FEHB GEHA
Standard
Option
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
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
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 - 75 Visits
per Year/All
therapies
combined
Yes - 60
visits/all
therapies
combined
7. Rehabilitative and habilitative services and devices - EHB Category
Rehabilitative Services
Habilitative Services & Devices
June 16, 2015
Yes 30
Yes - 30
Yes - 30
Yes - 60
combined visits
combined visits
combined visits
combined visits
w/chiro per
per contract
per contract year
per contract year
contract year
year
No
Must be
supplemented
Yes - 30
combined visits
per contract
year
No
Must be
supplemented
Yes - 30
combined visits
per contract
year
Michigan
Mandate
Yes
90 Visits per
member, per
calendar year
Yes
Yes - 60
Yes - 75 Visits
90 OT/PT/St
combined visits
per Year/All
Combined visits
per contract
therapies
per contract
year
combined
year
No
Must be
supplemented
Only for Autism
No
Must be
supplemented
No
No
Must be
Must be
supplemented supplemented
Yes
500.3425
500.3519(3)
2017 Benchmark
MICHIGAN ESSENTIAL HEALTH BENEFITS COMPARISON
Small Group
BCBSM
Community
Blue
PPO Plan 4
Benefits
State Employee Plans
HMO
Priority Health BCBSM Simply Priority Health
BCBSM
(HMO)
Blue 2500
(HMO)
(Self-insured)
Federal Employee Plans
PHP
(HMO)
Priority Health
(HMO)
FEHBP BCBS
Standard
Option
Physical,
Physical,
Occupational, Occupational,
Speech
Speech
No
500.3406s
Therapies - No Therapies - No
Must be
Order 14-017-M
ABA
ABA
supplemented
Must be
Must be
supplemented supplemented
FEHBP BCBS
Basic Option
FEHB GEHA
Standard
Option
Michigan
Mandate
Yes
Yes - ABA limited
to annual
maximum
$50,000
Must be
supplemented
Yes
Yes
Yes
Yes with 135
days per
contract for
ABA therapy
Must be
supplemented
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
500.3406a
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
500.3519(3)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Imaging (CT and PET Scans, MRIs)
Yes
Yes
Yes
Breast Cancer Diagnostic Services
Yes
Yes
Yes
9. Preventive and wellness services and chronic disease management - EHB Category
Preferred Tobacco Cessation
Products must be prescribed by a
Yes
Yes
Yes
Physician and obtained from a Network
Retail Pharmacy
Preventive
Yes
Yes
Yes
Care/Screening/Immunization
Routine Foot Care
No
No
No
Yes
Yes
Yes
Allergy Testing
Yes
Yes
Yes
Diabetes Education
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
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes - six visits
per contract
year
Yes
Yes
Yes
Yes
Yes
Yes
Autism Therapy
Durable Medical Equipment
Prosthetic Devices including
Mastectomy Prosthetics
8. Laboratory services - EHB Category
X-Rays & Diagnostic Imaging
Laboratory Outpatient and Professional
Services
Nutritional Counseling
Yes - ABA limited
to annual
maximum
$50,000
Must be
supplemented
Yes - nutritional
therapy in
Autism
Yes - six visits
per contract
year
10. Pediatric services, including oral and vision care - EHB Category
No
No
Basic Dental Care (Child)
Must be
Must be
supplemented supplemented
Routine Eye Exam (Child)
June 16, 2015
No
Must be
supplemented
Screening only
as part of
physical exam
No
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes - this is listed
under weight
Yes - 3 sessions
loss with
per year inlifetime
network only
maximum of
$300
Yes - nutritional
therapy in Autism
Yes - six visits
per contract
year
No
Must be
supplemented
No
Must be
supplemented
Yes
No
Must be
supplemented
Yes
No
Must be
supplemented
Screening only
as part of
physical exam
Yes
No
Must be
supplemented
No
Must be
supplemented
No
No
Must be
Must be
supplemented supplemented
Yes
500.3519(3)
500.3406d
500.3406p
2017 Benchmark
MICHIGAN ESSENTIAL HEALTH BENEFITS COMPARISON
Small Group
BCBSM
Community
Blue
PPO Plan 4
Benefits
State Employee Plans
HMO
Priority Health BCBSM Simply Priority Health
BCBSM
(HMO)
Blue 2500
(HMO)
(Self-insured)
Federal Employee Plans
PHP
(HMO)
Priority Health
(HMO)
FEHBP BCBS
Standard
Option
No
No
No
Must be
Must be
Must be
supplemented supplemented supplemented
FEHBP BCBS
Basic Option
FEHB GEHA
Standard
Option
No
Must be
supplemented
No
Must be
supplemented
No
Must be
supplemented
No
Must be
supplemented
Yes
No
Must be
supplemented
No
Must be
supplemented
No
No
No
No
Yes
No
No
No
Must be
supplemented
No
Must be
supplemented
No
Must be
supplemented
No
Must be
supplemented
Yes
No
Must be
supplemented
No
Must be
supplemented
General Pediatric Care
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Well Baby Visits and Care
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Miscellaneous
Accidental Dental
Routine/Basic Dental Care (Adult)
Yes
No
No
No
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes - 20 visits
per year
Yes- 30
combined visits
per contract
year
Yes
Yes
Yes - 12 visits
per year
No
No
No
No
Yes
Yes
Yes
Yes
Major Dental Care (Child)
Orthodontia (Child)
Eye Glasses for Children
Chiropractic Care
Cosmetic Surgery
Diagnosis and treatment of infertility,
e.g. endometriosis, blockage of
fallopian tubes, varicocele
June 16, 2015
Yes - spinal
Yes- 30
Yes- 30
Yes - 24 visits per
manipulation
combined visits Yes - limited to 12 combined visits
member per
limited 24 visits per contract visits per member per contract
calendar year
reduced to 12
year with rehab per calendar year year with rehab combined in &
visits with
OT/PT
out of network
OT/PT
optional rider
Yes
No
Yes
No
Yes
Yes - limited
infertility
services
Yes
Yes - limited
infertility services
Yes
No - excluded
under what is
not covered
No
Yes - 5 office
visits & 3
diagnositic/
surgical
procedures
annual benefit
limit per
covered person
artificial
insemination
included
No
No
Michigan
Mandate
No
No
No
No
Must be
Must be
Must be
supplemented supplemented supplemented
500.3406n
500.3519(3)
2017 Benchmark
MICHIGAN ESSENTIAL HEALTH BENEFITS COMPARISON
Small Group
BCBSM
Community
Blue
PPO Plan 4
Benefits
Hearing Aids
State Employee Plans
HMO
Priority Health BCBSM Simply Priority Health
BCBSM
(HMO)
Blue 2500
(HMO)
(Self-insured)
PHP
(HMO)
Federal Employee Plans
Priority Health
(HMO)
Yes - includes
one hearing
Yes - includes
exam, one
hearing aids
audiometric
Yes
limited to $880 exam, and one
standard or
for monaural or basic hearing
binaural once
$1600 binaural
aid per ear
every 36 months
once every 36
every 36
months
months; hearing
aid is limited to
$500 per aid
FEHBP BCBS
Standard
Option
FEHBP BCBS
Basic Option
FEHB GEHA
Standard
Option
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
Yes
Yes
No
Yes
No
Yes
No
No
No
No
Yes
Yes
Yes
No
No
No
No
Yes
No
No
No
No
No
Yes
No
Yes
No
Yes
No
Yes
No
No
No
Routine Eye Exam (Adult)
No
Screening only
No
Screening only
Covered under
Blue Vision cert
Yes
Screening only
No
No
No
Weight Loss Programs
No
Yes
No
Yes
Yes - $300
lifetime
maximum
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes - $350
lifetime
maximum
Yes
Yes - 20
treatments per
year
Long Term/Custodial Nursing Home
Care
Major Dental Care (Adult)
Non-Emergency Care When Traveling
Outside the U.S.
Orthodontia (Adult)
Private-Duty Nursing
Bariatric Surgery
Yes
in-network only,
medically
Yes - once per Yes - if medically
Yes - once per
necessary, order
lifetime
lifetime
necessary
by primary care
physician; one
per lifetime
Yes - if medically
necessary
Yes - once per
lifetime
Yes - if medically
necessary
Acupuncture
No
No
No
No
Yes - 20
treatments per
calendar year
No
No
Wigs and supplies (cancer or alopecia
only)
No
No
No
No
Yes - lifetime
maximum $300
No
No
Genetic Testing
Evaluation and treatment of chronic
pain
Reconstructive Surgery
No
Yes
No
Yes
Yes
Yes
Yes
Yes - $350
lifetime
maximum
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
June 16, 2015
No
Yes
Michigan
Mandate
2017 Benchmark
MICHIGAN ESSENTIAL HEALTH BENEFITS COMPARISON
Small Group
Benefits
Blepharoplasty of upper lids
Breast Reduction
Surgical Treatment of Male
Gynecomastia
Rhinoplasty and Septorhinoplasty
(sleep apnea treatment)
Panniculectomy
Treatment for Temporomandibular
Joint Disorders
Orthognathic Surgery
BCBSM
Community
Blue
PPO Plan 4
State Employee Plans
HMO
Priority Health BCBSM Simply Priority Health
BCBSM
(HMO)
Blue 2500
(HMO)
(Self-insured)
Federal Employee Plans
PHP
(HMO)
Priority Health
(HMO)
FEHBP BCBS
Standard
Option
FEHBP BCBS
Basic Option
FEHB GEHA
Standard
Option
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Michigan
Mandate
No
No
only
only
Behavioral
Transgender/gender Reassisgnment
No
reconstructive
reconstructive
No
No
No
Health Services
Services
procedures of
procedures of the
genitalia
the genitalia
Abbreviations: BCBSM = Blue Cross Blue Shield of Michigan; PHP = Physicians Health Plan; 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
Any covered services may be subject to medical management techniques, cost sharing, etc.
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 Department of Insurance and Financial Services
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 2014. The data provided in this chart is subject to change as additional federal guidance is provided with
regard to EHB.
June 16, 2015
MICHIGAN ESSENTIAL HEALTH BENEFITS COMPARISON
DENTAL AND VISION
DENTAL
State of MI
Federal Employee Plans
MIChild
BCBSM
FEDVIP Dental
MetLife
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
under age 14
Yes
under age 14
Yes
Yes
Yes
up to age 22
Yes
No
No
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Periodontics
Periodontal scaling and root planing
Gingivectomy or gingivoplasty
No
No
Yes
Yes
Prosthodontics (removable)
Maxillary dentures
No
Yes
Benefits
Diagnostic
Initial exam
Routine checkup
Bitewing X-rays
Diagnostic tests
Preventive
Cleanings
Flouride treatments
Space maintainers
Dental sealants on first and second permanent molars
Restorative
Fillings of amalgam, plastic composite or similar materials and stainless steel
crowns
Metallic onlays
Porcelain or ceramic crown substrate
Endodontics
Pulpotomy for primary teeth
Anterior, bicuspid and molar root canal
Anterior, bicuspid and molar root canal therapy
June 16, 2015
Yes
Yes
Benefits
Prosthodontics (fixed)
State of MI
Federal Employee Plans
MIChild
BCBSM
FEDVIP Dental
MetLife
Porcelain, ceramic and cast metal retainers for resin bonded fixed prosthesis
Oral & Maxillofacial Surgery
Simple extractions
No
Yes
Yes
Yes
Adjunctive General Services
Consultation by a second dentist not providing treatment
Yes
Yes
Exams and treatment for an emergency condition
Emergency treatment for temporary relief of pain
Yes
Yes
Yes
Yes
VISION
Benefits
Vision exam and glaucoma test
Eyeglass frames (wire, plastic or metal)
Eyeglass lenses
Medically necessary contact lenses
June 16, 2015
Federal Employee Plans
FEDVIP Vision
FEP BlueVision
Yes
Glaucoma test is not specifically included or excluded
Yes
Yes
Yes