Schedule F Plan Designs.pdf

SCHEDULE F – 1

PLAN DESIGN AND CLAIM PAYMENT RULES

State Health Plan PPO Active Employee Plan Design Your behavioral health/substance use disorder benefits, A–Z

Your plan offers comprehensive benefits for behavioral health services. Behavioral health services treat mental health and substance use disorder conditions. Mental health and substance use disorder treatment provided by nonparticipating providers are covered. Members seeking services from these providers are responsible for the out-of-network deductible and coinsurance, plus the difference between the charge and the Blue Cross approved amount.

Autism spectrum disorders Applied Behavioral Analysis (ABA) (requires authorization)

In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

You are covered for ABA services administered by a licensed clinician, such as a board-certified behavior analyst, working in association with a paraprofessional. To be eligible for benefits, the paraprofessional must be supervised by the licensed clinician. Your benefit covers autism spectrum disorders to treat ABA.

Consultations – hospital (inpatient)

In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

Medical consultations are payable when a physician requires assistance in diagnosing or treating a condition relating to behavioral health or substance use disorder. Hospital outpatient consultations rendered by your primary care physician will be covered under the State’s medical plan regardless if the diagnosis is medical or behavioral health.

Electroconvulsive Therapy (ECT) In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

You are covered for medically necessary ECT treatment including anesthesia services for this benefit.

Anesthesia services for ECT are covered at 90% after deductible.

Emergency care $200 copay for emergency room (waived if admitted to the same hospital)

Your benefit plan covers emergency care for behavioral health and substance use disorder diagnoses.

Emergency care not resulting in a hospital admission is covered under the State’s medical plan regardless if the diagnosis is medical or behavioral health or substance use disorder.

Halfway house In-network – Covered

Out-of-network – Covered 80% after deductible

Halfway houses provide substance-free residences for those in recovery from alcohol and substance use.

Prior authorization is required.

Hospital care – inpatient behavioral health (requires authorization)

In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

You are covered for behavioral health care services that require a hospital stay. Your benefit allows for 365 days per year.

Hospital care – inpatient substance use disorder (requires authorization)

In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

You are covered for inpatient substance use disorder services as well as sub-acute detoxification services.

Hospital care – outpatient office visit (physician services) In-network – $20 copay Out-of-network – Covered

80% after deductible

Your benefit covers office visits rendered in an outpatient hospital setting for the medically necessary behavioral health and substance use disorder diagnoses from behavioral health providers. Outpatient office visits rendered by your primary care physician will be covered under the State’s medical plan regardless if the diagnosis is medical or behavioral health.

Intensive Outpatient Program (IOP) – behavioral health

In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

You are covered for IOP mental health services provided on an outpatient basis. These services involve frequent visits (usually three to five days per week) and may include, but are not limited to individual, group and family counseling, medical testing, diagnostic evaluation and referral to other services in a treatment plan. Two IOP days equal one inpatient day.

substance use disorder

In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

You are covered for IOP substance use disorder services provided on an outpatient basis. These services involve frequent visits (usually three to five days per week) and may include individual, group and family counseling, medical testing, diagnostic evaluation and referral to other services in a treatment plan. Two IOP days equal one inpatient day.

Neuropsychological and psychological testing – inpatient

In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

Your benefit covers medically necessary neuropsychological and psychological testing for behavioral health diagnoses.

psychological testing – office setting

In-network – Covered $20 copay

Out-of-network – Covered 80% after deductible

Your benefit covers medically necessary neuropsychological and psychological testing for behavioral health psychological testing – outpatient Covered 90% after deductible

Your benefit covers medically necessary neuropsychological and psychological testing for behavioral health

Office visits and office consultations In-network – Covered $20 copay

Out-of-network – Covered 80% after deductible

Your benefit covers office visits and office consultations when rendered in an office setting for the medically necessary behavioral health and substance use disorder diagnoses from behavioral health providers. Office visits and office consultations rendered by your primary care physician will be covered under the State’s medical plan regardless if the diagnosis is medical or behavioral health.

Outpatient care – behavioral health (no authorization required)

In-network – Covered $20 copay

Out-of-network – Covered 80% after deductible

You are covered for individual, conjoint, family or group psychotherapy and crisis intervention services.

Hospital outpatient visits rendered by your primary care physician will be covered under the State’s medical plan regardless if the diagnosis is medical or behavioral health.

Outpatient care – substance use disorder (no authorization required)

In-network – Covered $20 copay

Out-of-network – Covered 80% after deductible

Services include office based opioid treatment and methadone maintenance. Outpatient visits rendered by your primary care physician will be covered under the State’s medical plan regardless if the diagnosis is medical or behavioral health.

Partial Hospitalization Program (PHP) – behavioral health (requires authorization)

In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

PHP is a comprehensive care given for a minimum of 6 hours per day, 5 days a week. Treatment may include counseling, medical testing, diagnostic evaluations and referral to other services in a treatment plan. PHP services are often provided in lieu of inpatient behavioral health for non-acute conditions. Two PHP days equal one inpatient day.

(PHP) – substance use disorder (requires authorization)

In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

Program offered at least five hours of therapy a day, up to seven days a week. Two PHP days equal one inpatient day.

Physical, occupational, and speech therapy

In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

Physical therapy, speech and language pathology services, and occupational therapy are payable when provided for behavioral health and substance use disorder treatment.

Residential mental health treatment (requires authorization)

In-network – Covered 90% after deductible

Out-of-network – Not covered

A specialized form of inpatient care. It includes supervision and monitoring within a non-hospital setting.

Residential substance use disorder treatment (requires authorization)

In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

Acute care services provided in a structured full day setting when patient is ambulatory and does not require medical hospitalization. Residential services may include 24-hour supervision, counseling, detox, medical testing, diagnostic evaluation and referral or other services specified in a treatment plan.

Rural health clinic In-network – Covered

Out-of-network – Covered 80% after deductible

Your benefit covers visits rendered at a rural health clinic relating to behavioral health. Services rendered at a rural health clinic relating to a medical are covered under the State’s medical plan.

Telehealth – Blue Cross online tool (online visits) In-network – $0 copay Out-of-network –

Not covered

You have access to online behavioral health and substance use disorder powered by Virtual Care, available 24 hours a day, seven days a week from any mobile device or computer.

Telehealth services offered using your provider’s online tool In-network – $20 copay Out-of-network – Covered

You have access to online behavioral health and substance use disorder using your provider’s online tool.

Transcranial magnetic stimulation (TMS) (Requires authorization)

In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

TMS is a treatment technique that uses a magnetic field to influence brain activity. It can treat depression, obsessive-compulsive disorder and other brain-related conditions. A prior authorization is required for in-network, out-of-network and non-participating providers.

Benefit summary

In network Out of network Cost share

Out-of-pocket dollar maximums $2,000 per member $4,000 per family

$3,000 per member $6,000 per family

Deductible $400 per member $800 per family

$800 per member $1,600 per family

Coinsurance 10% (where applicable) 80% for most services

Fixed dollar copay

$20 copay for outpatient behavioral health/substance use disorder care $0 copay for online telehealth visits (Blue Cross online tool), $20 copay for online telehealth visits (Provider’s tool)

Note: Fixed dollar copays do not apply out of network. See appropriate section below for out of network coverage.

Emergency Care

Emergency room $200 copay (waived if admitted to the same hospital)

Hospital care (Inpatient)

Hospital care – behavioral health (requires authorization)

Covered 90% after deductible

Covered 80% after deductible

Hospital care – substance use disorder (requires authorization)

Consultations

Neuropsychological and psychological testing

Behavioral health

Autism spectrum disorders – ABA (requires authorization)

Covered 90% after deductible

Covered 80% after deductible Electro-Convulsive Therapy (ECT)

Intensive outpatient program (IOP)

Neuropsychological and psychological testing

– outpatient

Covered 90% after deductible

Outpatient behavioral health $20 copay Covered 80% after deductible Partial Hospitalization Program (PHP) (requires authorization)

Covered 90% after deductible

Residential Mental Health treatment (requires authorization)

Covered 90% after deductible Not covered

Telehealth (Online visits) – Blue Cross Online Tool $0 copay Not covered

Telehealth (Online visits) – Provider’s Tool $20 copay Covered 80% after deductible

Substance use disorder

Intensive Outpatient Program (IOP) Covered 90% after deductible

Covered 80% after deductible

Outpatient care – substance use disorder (includes office based opioid treatment and methadone maintenance)

$20 copay

Partial Hospitalization Program (PHP) (requires authorization) Covered 90% after deductible Residential Substance Use Disorder treatment

What is not covered

The following behavioral health services aren’t covered under the State Health Plan:

• Art therapy

• Biofeedback

• Claims deemed fraudulent which, through the exercise of due diligence by contractor, could have been prevented

• Completion on any insurance form

• Counseling for vocational, academic, or education purposes

• Court-ordered psychotherapy, including substance use disorder

• Hypnotherapy

• Medical services or drugs not administered for BH/SU treatment

• Music therapy

• Phone consultations or therapeutic phone questions

• Psychodrama

• Recreation therapy

• Services provided by practitioners not designated as eligible providers including those the health professional or facility is not licensed to provide

• Services received at private residences (except for autism spectrum disorder to treat ABA)

• Services provided or covered by any state or governmental agency, by Workers’ Compensation or similar occupational law, or for which no charge is made to the member

• Services provided while the member is not covered for this benefit

• Services which are not medically necessary or are experimental or research in nature, according to accepted standards of practice

• Wilderness Therapy (including health resorts, recreational programs, outdoor skills programs, relaxation or lifestyle programs, residential treatment centers and services provided in conjunction with or as part of these programs)

Glossary

Accidental injury is physical damage caused by an action, object or substance outside the body.

This includes:

• Strains

• Sprains

• Cuts and bruises

• Allergic reactions

• Frostbite

• Sunburn and sunstroke

• Swallowing poison

• Medication overdosing

• Inhaling smoke, carbon monoxide or fumes

Acute care facility is a facility that offers a wide range of medical, surgical, obstetric and pediatric services.

These facilities primarily treat patients with conditions that require a hospital stay of less than 30 days.

The facility is not primarily for:

• Custodial, convalescent or rest care

• Care of the aged

• Skilled nursing care or nursing home care

• Substance use disorder treatment

Adequate access is defined by how far you live from PPO providers and hospitals. The SHP PPO access standards are:

• Two family care physicians within 15 miles of your home

• Two specialty care physicians within 20 miles of your home

• One hospital within 25 miles of your home

Affordable Care Act (ACA), also known as the Patient Protection and Affordable Care Act (PPACA), is the health reform legislation that includes health-related provisions intended to extend coverage to uninsured Americans, to implement measures that will lower health care costs and improve system efficiency.

Allowed amount is the maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance” or “negotiated rate.” If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance billing.)

Ambulatory Detoxification is non-residential service to which a person may be admitted for a systematic reduction of physical dependence upon a substance. This service utilizes prescribed chemicals and provides an assessment of the client’s needs and motivation toward continuing participation in the treatment process.

Ambulatory surgery facility is a separate outpatient facility that is not part of a hospital, where surgery is performed, and care related to the surgery is given. The procedures performed in this facility can be performed safely without overnight inpatient hospital care.

Appeal and/or grievance is a member’s written request for review of an adverse determination, which reduced or denied benefits or services in whole or in part, including the availability, delivery, or quality of health care services, including an adverse determination arising from a complaint.

Applied Behavioral Analysis (ABA) is the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences to produce significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior.

Approved amount is the Blue Cross maximum payment level or the provider’s billed charge for the covered service, whichever is lower. Deductibles and copays are deducted from the approved amount.

Approved Autism Evaluation Center (AAEC) is an academic and/or hospital-based, multidisciplinary center experienced in the assessment, work-up, evaluation and diagnosis of the Autism Spectrum Disorders (ASD). AAEC evaluation is necessary for Applied Behavioral Analysis (ABA).

Approved facility is a hospital that provides medical and other services, such as skilled nursing care or physical therapy, and has been approved as a provider by Blue Cross. Approved facilities must meet all applicable local and state licensing and certification requirements. Approved facilities must also be accredited by either the Joint Commission on Accreditation of Hospitals or the American Osteopathic Association.

Approved hospital is a facility that meets all applicable local and state licensure and certification requirements, is accredited as a hospital by state or national medical or hospital authorities or associations and has been approved as a provider by Blue Cross or an affiliate of Blue Cross.

Autism Spectrum Disorders (ASD) are disorders that are defined by the most recent edition of the Diagnostic and Statistical Manual published by the American Psychiatric Association.

Balance billing means that a provider will bill you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the Blue Cross allowed amount is $70, the provider may bill you for the remaining $30. A Blue Cross PPO network provider may not balance bill you.

Benefit is coverage for health care services available according to the terms of your health care plan.

Blue Cross and Blue Shield Association is an association of independent Blue Cross and Blue Shield Plans that licenses individual Plans to offer health benefits under the Blue Cross Blue Shield name and logo.

The Association establishes uniform financial standards but does not guarantee an individual Plan’s financial obligations.

Blue Cross Blue Shield of Michigan (Blue Cross) is a nonprofit, independent company. Blue Cross is one of many individual Plans located throughout the U.S. committed to providing affordable health care. It is managed and controlled by a board of directors comprised of a majority of community-based public and subscriber members.

Clinical trial is a study conducted on a group of patients to determine the effect of a treatment. It generally includes the following phases:

• Phase I – A study conducted on a small number of patients to determine what the side effects and appropriate dose of treatment may be for a certain disease or condition

• Phase II – A study conducted on a large number of patients to determine whether the treatment has a positive effect on the disease or condition as compared to the side effects of the treatment

• Phase III – A study on a much larger group of patients to compare the results of a new treatment of a condition to a conventional or standard treatment Phase III gives an indication as to whether the new treatment leads to better, worse or no change in outcome.

COBRA is continuation coverage required by the Consolidated Omnibus Budget Reconciliation Act of 1986.

Coinsurance is a member’s out-of-pocket percentage of the Blue Cross allowed amount for covered services.

Complications of pregnancy are conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a nonemergency caesarean section are not considered complications of pregnancy.

Confinement is a medically necessary inpatient stay that is due to injury or illness.

Coordination of benefits is a program that coordinates your health benefits when you have coverage under more than one group health plan.

Copayment (or copay) is the designated portion of the approved amount you are required to pay for covered services.

Covered services are services, treatments or supplies identified as payable under the SHP PPO. Covered services must be medically necessary to be payable, unless otherwise specified.

Crisis Stabilization Bed (CARES Unit) is an inpatient crisis intervention service that provides intensive short-term rapid assessment, stabilization, and disposition management for children under the age of 18 experiencing an acute behavioral health crisis who can be stabilized or discharged within 72 hours. The CARES Unit is designed to provide diversion from inpatient care for those children/adolescents who are in psychiatric crisis and who can be rapidly stabilized. Referrals will come primarily from local Emergency Mobile Psychiatric Services (EMPS) and affiliated Hospital Emergency Departments.

Custodial care is care mainly for helping a person with activities of daily living, such as walking, getting in and out of bed, bathing, dressing, eating or taking medicine. Custodial care can be provided safely and reasonably by people without professional skills or training to help patients with daily activities or personal needs, such as walking, getting in and out of bed, bathing, dressing and taking medicine. It also includes medical services, such as respiratory care, that a dedicated lay person can learn to perform. Custodial care is not covered by the SHP PPO.

Deductible is the specified amount you pay each calendar year for services before your plan begins to pay.

Designated cancer center is a site approved by the National Cancer Institute as a comprehensive cancer center, clinical cancer center, consortium cancer center or an affiliate of one of these centers.

Designated facility is a facility that Blue Cross determines to be qualified to perform a specific organ and bone marrow transplant.

Detoxification is an immediate and short-term clinical support to individuals who are withdrawing from alcohol and other drugs.

Diabetes - Self management See the document entitled, ‘State Health Plan PPO - Preventive services for active employees’ located at bcbsm.com/som for benefit details.

Durable medical equipment (DME) is equipment that is able to withstand repeated use, is primarily and customarily used to serve a medical purpose and is not generally useful to a person in the absence of illness or injury. A physician must prescribe this equipment.

Electro Convulsive Therapy (ECT) is brain stimulation techniques such as electroconvulsive therapy (ECT) can be used to treat major depression that hasn’t responded to standard treatments.

Emergency first aid is the initial exam and treatment of conditions resulting from accidental injury. First aid may include the following conditions which may require first aid treatment:

• Allergic reactions to bee stings or insect bites

• Attempted suicide

• Food poisoning

• Ingestion of poisons (accidental or intentional)

• Inhalation of smoke, carbon monoxide or fumes

• Sprains, strains

• Rape, attempted rape, questionable rape

• Cuts, abrasions, bruises

• Contusions

• Epitasis (nose bleed) if no packing or cautery is performed

• Sunburn or frostbite if no dressing is applied

• Application of butterfly suture

• Splinting or strapping billed along with traumatic diagnosis or as initial treatment of fracture

• Gastric lavage

Emergency medical condition is an illness, injury, symptom or condition so serious that you must seek care right away to avoid severe harm.

Emergency medical transportation is an ambulance that is used for an emergency medical condition.

Emergency room care provides emergency services in an emergency room.

Emergency services provide an evaluation of an emergency medical condition and treatment to keep the condition from getting worse. Emergency services include medical screening exams that are within the capability of an emergency room department of a hospital or independent freestanding emergency department and includes ancillary services routinely available in a hospital’s emergency room to evaluate an emergency medical condition. Services also include, within the capabilities of the staff and facilities available at the hospital, additional medical exams and treatment to stabilize the member.

End Stage Renal Disease is permanent and irreversible kidney failure that can no longer be controlled by medication or fluid and dietary restriction and, as such, requires a regular course of dialysis or a kidney transplant to maintain the patient’s life.

Excluded services are health care services for which your health plan does not pay or cover.

Experimental or investigative is a service, procedure, treatment, device or supply that has not been scientifically demonstrated to be safe and effective for treatment of the patient’s condition. Blue Cross makes this determination based on a review of established criteria, such as:

• Opinions of local and national medical societies, organizations, committees or governmental bodies

• Accepted national standards of practice in the medical profession

• Scientific data such as controlled studies in peer review journals or literature

• Opinions of the Blue Cross and Blue Shield Association or other local or national bodies

Extended Day Treatment (EDT) is a community-based program for children and their families that offers a structured, intensive, therapeutic milieu with group, family and individual therapy services. Services are typically after school for several days per week and the program can last up to six months. EDT provides a broad range of treatment services and psycho-social interventions.

Facility is a hospital that offers medical care or specialized treatment, such as rehabilitation treatment, skilled nursing care or physical therapy.

Freestanding facility is a facility separate from a hospital that provides outpatient services, such as skilled nursing care or physical therapy.

Freestanding outpatient physical therapy facility is an independently owned and operated facility, separate from a hospital that provides outpatient physical therapy services and occupational or functional occupational therapy or speech and language pathology services.

Health insurance is a contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.

Home health care is a range of health care services that can be given in the home. Home health care is usually less expensive, more convenient, but as effective as care in a hospital or skilled nursing facility.

The goal of home health care is to treat an illness or injury.

Hospice services provide comfort and support for persons in the last stages (usually six months or less) of a terminal illness and their families.

Hospital is a facility that provides inpatient diagnostic and therapeutic services for injured or acutely ill patients 24 hours every day. The facility also provides a professional staff of licensed physicians and nurses to supervise the care of patients.

Hospital outpatient care is care in a hospital that usually does not require an overnight stay.

Hospitalization is care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.

Independent physical therapist is a licensed physical therapist that is not employed by a hospital, physician or freestanding outpatient physical therapy facility and who maintains an office separate from a hospital or freestanding outpatient physical therapy facility with the equipment necessary to provide adequately physician-prescribed physical therapy.

In-network copayment is the fixed amount you pay for covered health care services to providers who contract with your health insurance or plan. In-network copayments usually are usually less than out-of-network copayments.

In-network providers are providers who have met PPO standards and signed agreements to participate in the Community Blue network and to accept our approved amount as payment in full for covered services.

Intensive Outpatient Services (IOP) is an integrated program of outpatient psychiatric services that are designed for more intensive treatment than routine outpatient psychiatric services and are provided at a psychiatric outpatient clinic for adults, an outpatient treatment service for substance use disorder, or an outpatient psychiatric clinic for children.

Medical emergency is a condition that occurs suddenly, producing severe signs and symptoms, such as acute pain. A person expects that this condition could result in serious bodily harm without prompt medical treatment.

Medical necessity for payment of hospital services requires that all of the following conditions are met:

• The covered service is for the treatment, diagnosis of the symptoms of an injury, condition or disease.

• The service, treatment or supply is appropriate for the symptoms and is consistent with the diagnosis.

— Appropriate means the type, level and length of care, treatment or supply and setting are needed to provide safe and adequate care and treatment.

For inpatient hospital stays, acute care as an inpatient must be necessitated by the patient’s condition because safe and adequate care cannot be received as an outpatient or in a less intense medical setting.

This means that:

• The services are not mainly for the convenience of the member or health care provider.

• The treatment is not generally regarded as experimental or investigational by Blue Cross.

• The treatment is not determined to be medically inappropriate by the Utilization Management and

Quality Assessment programs.

In some cases, you may be required to pay for services even when they are medically necessary. These limited situations are:

• When you do not inform the hospital that you are a Blue Cross member at the time of admission or within 30 days after you have been discharged.

• When you fail to provide the hospital with information that identifies your coverage.

Medical necessity for payment of physician services is determined by physicians acting for their respective provider types or medical specialty and is based on criteria and guidelines developed by physicians and professional providers. It requires that the covered service is:

• Generally accepted as necessary and appropriate for the patient’s condition, considering the symptoms.

The covered service is consistent with the diagnosis.

• Essential or relevant to the evaluation or treatment of the disease, injury, condition or illness. It is not mainly for the convenience of the member or physician.

• Reasonably expected to improve the patient’s condition or level of functioning. In the case of diagnostic testing, the results are used in the diagnosis and management of the patient’s care.

Medically necessary are health care services or supplies needed to prevent, diagnose or treat an illness, injury, disease or its symptoms and that meet accepted standards of medicine.

Medication Assisted Treatment (MAT) is an approach to treating both opioid and alcohol substance use disorders. The FDA has approved several different medications to treat Opioid Use and Alcohol Use

Disorders. These medications relieve withdrawal symptoms and psychological cravings that cause chemical imbalances in the body. MAT programs provide a safe and controlled level of medication to overcome the use of an abused substance. Research has shown that when provided at the proper dose, MAT medications used have no negative effects on a person’s intelligence, mental capability, physical functioning, or employability.

Member is any person covered under the SHP PPO plan. This includes the subscriber and any eligible dependents listed in Blue Cross membership records.

Methadone Maintenance is treatment where the goal is to stabilize a member on methadone or other federally approved medication for as long as is needed to avoid return to previous patterns of substance use disorder.

Network is a group of doctors, hospitals, DME and other health care providers contracted with Blue Cross to provide services to members. Members typically pay less for using a network provider.

Nonparticipating providers are providers that have not signed participation agreements with Blue Cross agreeing to accept the Blue Cross payment as payment in full. However, nonparticipating professional (non-facility) providers may agree to accept the Blue Cross-approved amount as payment in full on a per claim basis.

Observation consists of services up to 48 hours at a hospital to assess whether further inpatient services or community-based services might be needed; usually following a visit to the Emergency Room.

Occupational therapy is treatment consisting of specifically designed therapeutic tasks or activities that:

• Improve or restore a patient’s functional level when illness or injury has affected muscles or joints

• Help the patient apply the restored or improved function to daily living

Out-of-network refers to services not rendered by a Blue Cross PPO network provider.

Out-of-network costs are increased copayment and deductible amounts members may incur if they receive services from a provider that does not belong to the Blue Cross PPO network without a referral. These costs could also include charges from a nonparticipating provider that are above the approved Blue Cross amount.

Outpatient Services (for behavioral health and substance use disorder) includes behavioral health evaluation and treatment services such as individual, group, family therapy, medication management, Autism Spectrum Disorder services, psychological and developmental testing, consultation, and case management that are provided to people who have a primary behavioral health diagnosis. Services may be provided in a freestanding clinic, hospital outpatient clinic, or by a group practice or solo practitioner who is a licensed behavioral health professional.

Out-of-pocket maximum is the dollar amount you pay in deductibles, copayments, and coinsurance during the calendar year. Once you satisfy your out-of-pocket maximum, the plan will cover 100% of the allowed amount for covered services. Certain coinsurance, deductibles and other charges cannot be used to meet your out-of-pocket maximum, such as out-of-network coinsurance, out-of-network deductible and charges for non-covered services.

Partial Hospitalization Program (PHP) is a program used to treat mental health and/or substance use disorders. In partial hospitalization, the member continues to live at home, but commutes to a hospital-based or clinic-based program several days per week.

Participating providers are providers who have signed agreements with Blue Cross to accept the Blue Cross-approved amount for covered services as payment in full.

Patient is the subscriber or eligible dependent (member) who is awaiting or receiving medical care and treatment.

Per claim is a provider’s acceptance of the Blue Cross-approved amount as payment in full for a specific claim or procedure.

Physical therapy is treatment intended to restore or improve the patient’s use of specific muscles or joints, usually through exercise and therapy. The treatment is designed to improve muscle strength, joint motion, coordination and general mobility.

Physician or professional provider is a medical doctor (MD), doctor of osteopathy (DO), doctor of podiatric medicine (DPM), doctor of dental surgery (DDS), doctor of medical dentistry (DMD), or a fully licensed psychologist.

Provider is a person (such as a physician) or a facility (such as a hospital) that provides services or supplies related to medical care.

Psychiatric Hospitalization consists of services where a member stays overnight at a hospital (inpatient) either at a general hospital, psychiatric hospital, or freestanding detox service in the case of a substance use disorder.

Reconstructive surgery is surgery or follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.

Referral process is the formal process members must follow when referred to a non-Blue Cross PPO network provider by a network provider. The referring network provider must provide a completed Preferred Provider Organization Program Referral form to the member and the physician before the referred services are provided. A verbal referral is not acceptable.

Residential Mental Health Treatment Program is a specialized form of inpatient care in a participating psychiatric residential treatment facility (PRTF) that typically includes 24-hour supervision and monitoring within a non-hospital setting, often aimed at providing an intensive therapeutic environment and treatment for members with mental health issues.

Residential Substance Use Disorder Treatment Program is a community based (non-hospital) facility that provides medical and other services specifically for substance use disorder in a facility that operates 24 hours a day, seven days a week. Treatment in this type of a program is sometimes called intermediate care and may include subacute detoxification early in the treatment course.

Skilled nursing care is furnished or supervised by a licensed nurse under the general direction of a physician to ensure the patient’s safety and to achieve a medically desired result. Eligible members are eligible for services when they require care that is at a lower level than provided in a hospital but is at a higher level than is generally available on an outpatient basis, in the home or basic nursing home.

Skilled nursing facility is a facility that provides short or long-term illness care with continuous nursing and other health care services by or under the supervision of a physician and a registered nurse. The facility may be operated independently or as part of an accredited acute care hospital. It must meet all applicable local and state licensing and certification requirements.

Specialty hospital is a hospital, such as a children’s hospital or a chronic disease hospital that provides care for a specific disease or population.

Speech therapy is active treatment of speech, language or voice impairment due to illness, injury or as a result of surgery.

Stem cells are primitive blood cells originating in the marrow but also found in small quantities in the blood.

These cells develop into mature blood elements including red cells, white cells and platelets.

Subscriber is the person who signed and submitted the application for SHP PPO Drug plan coverage.

Urgent care covers an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.

We, Us, Our are used when referring to Blue Cross Blue Shield of Michigan.

You and Your are used when referring to any person covered under the SHP PPO.

SCHEDULE F – 2

State Health Plan PPO Non-Medicare Retiree Plan Design

Your plan offers comprehensive benefits for behavioral health services. Behavioral health services treat mental health and substance use disorder conditions. Mental health and substance use disorder treatment provided by nonparticipating providers are covered. Members seeking services from these providers are responsible for the out-of-network deductible and coinsurance, plus the difference between the charge and the Blue Cross-approved amount.

In-network Out-of-network

Ambulance Covered 90% after deductible (No network required)

You are covered for ambulance services to transport you to the nearest medical facility capable of treating your condition for behavioral health or substance use disorders. To be covered, the services must be medically necessary.

Applied Behavioral Analysis (ABA) (Requires authorization)

In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

You are covered for ABA services administered by a licensed clinician, such as a board-certified behavior analyst, working in association with a paraprofessional. To be eligible for benefits, the paraprofessional must

Consultations – hospital (inpatient) In-network – Covered

Out-of-network – Covered 80% after deductible

Medical consultations are payable when a physician requires assistance in diagnosing or treating a condition relating to behavioral health or substance use disorder.

Electroconvulsive Therapy (ECT) In-network – Covered

Out-of-network – Covered 80% after deductible

You are covered for medically necessary ECT treatment including anesthesia services for this benefit.

Your benefit plan covers emergency care for behavioral health and substance use disorder diagnoses.

Emergency care not resulting in a hospital admission is covered under the State’s medical plan regardless if

Halfway house In-network – Covered

Out-of-network – Covered 80% after deductible

Halfway houses provide substance-free residences for those in recovery from alcohol and substance use.

health (requires authorization)

In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

You are covered for behavioral health care services that require a hospital stay. Your benefit allows for unlimited days.

$200 copay for emergency room (waived if admitted to the same hospital) Emergency care

Hospital care – inpatient

(requires authorization)

In-network – Covered 90% after deductible

Out-of-network – Covered

You are covered for inpatient substance use disorder services as well as sub-acute detoxification services.

Hospital care – outpatient office visit (physician services) In-network – $20 copay Out-of-network – Covered

80% after deductible

Your benefit covers office visits rendered in an outpatient hospital setting for the medically necessary behavioral health and substance use disorder diagnoses from behavioral health providers. Outpatient office visits rendered by your primary care physician will be covered under the State’s medical plan regardless if the diagnosis is medical or behavioral health.

behavioral health

In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

You are covered for IOP mental health services provided on an outpatient basis. These services involve frequent visits (usually 3 to 5 days per week) and may include, but are not limited to individual, group and family counseling, medical testing, diagnostic evaluation and referral to other services in a treatment plan.

Two IOP days equal one inpatient day.

In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

You are covered for IOP substance use disorder services provided on an outpatient basis. These services involve frequent visits (usually three to five days per week) and may include individual, group and family counseling, medical testing, diagnostic evaluation and referral to other services in a treatment plan. Two IOP psychological testing – inpatient

In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

Your benefit covers medically necessary neuropsychological and psychological testing for behavioral health psychological testing – office setting

In-network – Covered $20 copay

Out-of-network – Covered 80% after deductible

Your benefit covers medically necessary neuropsychological and psychological testing for behavioral health psychological testing – outpatient Covered 90% after deductible

Your benefit covers medically necessary neuropsychological and psychological testing for behavioral health

Office visits and office consultations In-network – Covered

Out-of-network – Covered 80% after deductible

Your benefit covers office visits and office consultations when rendered in an office setting for the medically necessary behavioral health and substance use disorder diagnoses from behavioral health providers. Office visits and office consultations rendered by your primary care physician will be covered under the State’s

Outpatient care – behavioral health (no authorization required)

In-network – Covered $20 copay

Out-of-network – Covered 80% after deductible

You are covered for individual, conjoint, family or group psychotherapy and crisis intervention services.

Hospital outpatient visits rendered by your primary care physician will be covered under the State’s medical disorder (no authorization required)

In-network – Covered $20 copay

Out-of-network – Covered 80% after deductible

Services include office based opioid treatment and methadone maintenance. Outpatient visits rendered by your primary care provider will be covered under the State’s medical plan regardless if the diagnosis is medical or behavioral health.

(PHP) – behavioral health (requires authorization)

In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

PHP is a comprehensive care given for a minimum of 6 hours per day, 5 days a week. Treatment may include counseling, medical testing, diagnostic evaluations and referral to other services in a treatment plan. PHP services are often provided in lieu of inpatient behavioral health for non-acute conditions. Two PHP days

(PHP) – substance use disorder (requires authorization)

In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

Program offered at least five hours of therapy a day, up to seven days a week. Two PHP days equal one therapy

In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

Residential mental health treatment

In-network – Covered 90% after deductible

Out-of-network – Not covered

A specialized form of inpatient care. It includes supervision and monitoring within a non-hospital setting.

Residential substance use disorder treatment (requires authorization)

In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

Acute care services provided in a structured full day setting when patient is ambulatory and does not require medical hospitalization. Residential services may include 24-hour supervision, counseling, detox, medical

Rural health clinic In-network - Covered

Out-of-network – Covered 80% after deductible

Your benefit covers visits rendered at a rural health clinic relating to behavioral health. Services rendered at a rural health clinic relating to a medical are covered under the State’s medical plan.

Telehealth – Blue Cross online tool (online visits)

In-network – Covered $0 copay

Out-of-network – Not covered

You have access to online behavioral health and substance use disorder powered by Virtual Care, available 24 hours a day, seven days a week from any mobile device or computer.

your provider’s online tool

In-network – Covered $20 copay

Out-of-network – Covered

You have access to online behavioral health and substance use disorder using your provider’s online tool.

(TMS) (requires authorization)

In-network – Covered 90% after deductible

Out-of-network – Covered 80% after deductible

TMS is a treatment technique that uses a magnetic field to influence brain activity. It can treat depression, obsessive-compulsive disorder and other brain-related conditions. A prior authorization is required for in-network, out-of-network and non-participating providers.

Out-of-pocket dollar maximums $2,000 per member $4,000 per family

$3,000 per member $6,000 per family

Deductible $400 per member $800 per family

$800 per member $1,600 per family

Coinsurance 10% (where applicable) 20% for most services

Fixed dollar copay

$20 copay for outpatient behavioral health/substance use disorder care $0 copay for telehealth (Blue Cross online tool)

$20 copay for online telehealth visits (Provider’s tool)

Note: Fixed dollar copays do not apply out of network. See appropriate section below for out of network coverage.

Emergency Care Ambulance – medically necessary ambulance charges

Covered 90% after deductible

Emergency room Covered, $200 copay (waived if admitted to the same hospital)

Hospital care (Inpatient) Consultations

Covered 90% after deductible

Covered 80% after deductible

Hospital care – behavioral health (requires authorization)

Hospital care – substance use disorder (requires authorization) Neuropsychological and psychological testing Behavioral health

Autism spectrum disorders – ABA (requires authorization)

Covered 90% after deductible

Covered 80% after deductible

Electro-Convulsive Therapy (ECT)

Intensive Outpatient Program (IOP)

Neuropsychological and psychological testing

– outpatient

Covered 90% after deductible

Behavioral health (continued)

Outpatient behavioral health $20 copay Covered 80% after deductible

Partial Hospitalization Program (PHP) (requires authorization)

Covered 90% after deductible

Residential Mental Health treatment (requires authorization)

Covered 90% after deductible Not covered

Telehealth (Online visits) – Blue Cross Online Tool

$0 copay

Telehealth (Online visits) – Provider’s Tool $20 copay Covered 80% after deductible

Substance use disorder

Intensive Outpatient Program (IOP) Covered 90% after deductible

Covered 80% after deductible

Outpatient care – substance use disorder (includes office based opioid treatment and methadone maintenance)

$20 copay

Partial Hospitalization Program (PHP) (requires authorization) Covered 90% after deductible Residential Substance Use Disorder treatment

• Biofeedback

• Claims deem fraudulent which, through the exercise of due diligence by contractor could have been prevented

• Completion on any insurance form

• Counseling for vocational, academic, or education purposes

• Court-ordered psychotherapy, including substance use disorder

• Hypnotherapy

• Marital counseling

• Medical services or drugs not administered for BH/SU treatment

• Music therapy

• Phone consultations or therapeutic phone questions

• Psychodrama

• Recreation therapy

• Services provided by practitioners not designated as eligible providers including those the health professional or facility is not licensed to provide

• Services received at private residences (except for autism spectrum disorder to treat ABA)

• Services provided or covered by any state or governmental agency, by Workers’ Compensation or similar occupational law, or for which no charge is made to the member

• Services provided while the member is not covered for this benefit

• Services which are not medically necessary or are experimental or research in nature, according to accepted standards of practice

Accidental injury is physical damage caused by an action, object or substance outside the body. This includes:

• Strains

• Sprains

• Cuts and bruises

• Allergic reactions

• Frostbite

• Sunburn and sunstroke

• Swallowing poison

• Medication overdosing

• Inhaling smoke, carbon monoxide or fumes

Acute care facility is a facility that offers a wide range of medical, surgical, obstetric and pediatric…