Schedule H HMO Benefits Summary and Claims Paid Data.xlsx
XLSX spreadsheet 35 KB Posted
- Attached to
- HMO Services for MPSERS
- Solicitation number
- RFP - 171 - 230000003226
- Issued by
- Ingham County, Lansing City, Michigan
About this file
This document is a Request for Proposal (RFP) issued by the Michigan Office of Retirement Services (ORS) on behalf of the Michigan Public School Employees' Retirement System (MPSERS) to solicit proposals for fully-insured HMO health coverage (medical and prescription drug services) for Medicare-Eligible and non-Medicare Eligible Members, including Retirees, beneficiaries, COBRA participants, and Dependents. The contract resulting from this RFP will have a term of one (1) year, with four (4) one-year renewal options. All current HMO offerings are fully insured, and the Contractor must be able to provide and administer both a non-Medicare and a Medicare product inclusive of prescription drug coverage.
The RFP includes detailed benefit summaries and claims data for the current HMO offerings. Bidders are not required to replicate the benefits stated, but their proposals must include benefits that are actuarially equivalent to those specified. The RFP is open to all eligible bidders, and there are no set-asides or incumbent information provided. Funding for this contract will come from MPSERS, and the RFP outlines the specific jurisdictions involved, which include Ingham County and the City of Lansing.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Schedule G - Contractor Performance Evaluation Survey.doc | DOC document | |
| Schedule I1 PPO Non Medicare Summary of Benefits.pdf | ||
| Schedule P TRR Report Template.xlsx | XLSX spreadsheet | |
| Schedule R Payment Discrepancy Report Template.xlsx | XLSX spreadsheet | |
| 230000003226 HMO Services RFP.docx | DOCX document | |
| 230000003226 Questions Answers.pdf | ||
| Schedule I4 Medicare Prescription Drug Summary of Benefits.pdf | ||
| Schedule K 834 Use Case and Example.docx | DOCX document | |
| Schedule N Section 2 Solutions Table.xlsx | XLSX spreadsheet | |
| Schedule F Definitions.docx | DOCX document | |
| Schedule I2 PPO Medicare Summary of Benefits.pdf | ||
| Schedule L Benefit Comparison and Actuarial Attestation.xlsx | XLSX spreadsheet | |
| Schedule Q RFI Report Template.xlsx | XLSX spreadsheet | |
| Schedule B Pricing.xlsx | XLSX spreadsheet | |
| Schedule I3 Non-Medicare Prescription Drug Summary of Benefits.pdf | ||
| Schedule J Dependent Coverage.pdf | ||
| Schedule M HMO Census Data REVISED.xlsx | XLSX spreadsheet |
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Medicare Paid Claims
| RFP No. 230000003226 | ||||||
| Schedule: H | ||||||
| Month | Enrollee Count (#) HMO 1 | Medical Paid ($) HMO 1 | Prescription Drug Paid ($) HMO 1 | Enrollee Count (#) HMO 2 | Medical Paid ($) HMO 2 | Prescription Drug Paid ($) HMO 2 |
| Mar-23 | 5,815 | $ 3,355,393 | $ 2,202,767 | 23,216 | $13,660,345.78 | $8,100,730.78 |
| Feb-23 | 5,787 | $ 3,424,590 | $ 1,975,021 | 23,166 | $13,175,839.33 | $6,757,016.13 |
| Jan-23 | 5,743 | $ 3,971,967 | $ 2,521,608 | 23,183 | $15,796,136.12 | $7,509,301.38 |
| Dec-22 | 5,717 | $ 3,928,024 | $ 1,710,960 | 23,303 | $15,116,578.35 | $8,204,613.54 |
| Nov-22 | 5,696 | $ 3,793,910 | $ 1,570,271 | 23,275 | $14,874,876.64 | $7,697,727.58 |
| Oct-22 | 5,651 | $ 4,172,675 | $ 1,616,153 | 23,248 | $17,821,250.21 | $7,707,101.72 |
| Sep-22 | 5,622 | $ 3,036,258 | $ 2,359,273 | 23,229 | $12,890,313.37 | $7,825,469.80 |
| Aug-22 | 5,569 | $ 3,634,314 | $ 1,574,722 | 23,151 | $13,223,031.48 | $7,713,319.90 |
| Jul-22 | 5,522 | $ 3,430,789 | $ 1,491,245 | 23,103 | $15,632,532.78 | $7,188,554.87 |
| Jun-22 | 5,447 | $ 3,039,705 | $ 1,457,265 | 22,990 | $12,660,936.90 | $7,669,435.61 |
| May-22 | 5,402 | $ 3,839,669 | $ 1,508,793 | 22,974 | $17,012,479.72 | $6,678,925.82 |
| Apr-22 | 5,366 | $ 2,790,859 | $ 2,467,914 | 22,925 | $12,910,090.89 | $7,448,786.64 |
| Mar-22 | 5,338 | $ 2,901,456 | $ 1,522,080 | 22,890 | $12,434,268.90 | $7,555,269.90 |
| Feb-22 | 5,297 | $ 2,962,372 | $ 1,409,125 | 22,834 | $13,689,042.68 | $6,343,420.11 |
| Jan-22 | 5,269 | $ 3,424,002 | $ 1,398,237 | 22,799 | $15,797,375.61 | $6,627,007.19 |
| Dec-21 | 5,317 | $ 3,488,762 | $ 1,443,269 | 22,851 | $14,008,475.41 | $7,233,359.94 |
| Nov-21 | 5,283 | $ 4,235,047 | $ 1,391,398 | 22,809 | $14,379,605.55 | $6,396,874.43 |
| Oct-21 | 5,250 | $ 2,928,787 | $ 2,052,668 | 22,793 | $17,297,949.78 | $6,983,689.12 |
| Sep-21 | 5,231 | $ 3,337,499 | $ 1,186,864 | 22,752 | $13,000,592.09 | $6,722,206.99 |
| Aug-21 | 5,185 | $ 3,501,231 | $ 1,218,233 | 22,689 | $15,483,813.68 | $6,248,847.23 |
| Jul-21 | 5,136 | $ 2,584,798 | $ 1,199,579 | 22,602 | $12,344,200.90 | $6,441,088.63 |
| Jun-21 | 5,053 | $ 4,082,799 | $ 1,214,373 | 22,404 | $12,229,391.07 | $6,222,430.75 |
| May-21 | 5,014 | $ 2,513,823 | $ 1,156,222 | 22,362 | $17,457,831.00 | $5,964,991.84 |
| Apr-21 | 4,983 | $ 2,963,922 | $ 1,792,390 | 22,311 | $10,528,856.84 | $6,370,976.30 |
| Mar-21 | 4,954 | $ 3,375,029 | $ 1,131,956 | 22,225 | $11,627,366.96 | $6,278,337.70 |
Non-Medicare Paid Claims
| RFP No. 230000003226 | ||||||
| Schedule H: | ||||||
| Month | Enrollee Count (#) HMO 1 | Medical Paid ($) HMO 1 | Prescription Drug Paid ($) HMO 1 | Enrollee Count (#) HMO 2 | Medical Paid ($) HMO 2 | Prescription Drug Paid HMO 2 |
| Mar-23 | 3,479 | $ 1,467,664 | $ 846,090 | 4,057 | $1,632,454.96 | $708,355.31 |
| Feb-23 | 3,485 | $ 1,834,276 | $ 657,060 | 3,962 | $1,842,085.21 | $664,493.83 |
| Jan-23 | 3,505 | $ 1,855,856 | $ 737,875 | 3,926 | $2,390,835.28 | $685,017.37 |
| Dec-22 | 3,624 | $ 1,789,887 | $ 732,779 | 3,879 | $1,568,902.27 | $626,702.21 |
| Nov-22 | 3,648 | $ 1,526,335 | $ 789,974 | 4,033 | $1,691,150.56 | $671,995.63 |
| Oct-22 | 3,691 | $ 1,643,976 | $ 884,532 | 4,013 | $2,129,593.73 | $695,985.25 |
| Sep-22 | 3,711 | $ 1,744,847 | $ 840,024 | 4,059 | $1,605,079.90 | $778,414.61 |
| Aug-22 | 3,683 | $ 2,140,144 | $ 807,113 | 4,023 | $2,529,943.52 | $725,332.85 |
| Jul-22 | 3,706 | $ 1,444,204 | $ 759,961 | 3,970 | $2,130,622.89 | $689,306.35 |
| Jun-22 | 3,535 | $ 1,835,249 | $ 796,764 | 3,903 | $1,502,082.90 | $745,250.19 |
| May-22 | 3,574 | $ 2,300,436 | $ 700,424 | 3,764 | $1,992,310.12 | $686,771.02 |
| Apr-22 | 3,596 | $ 1,841,315 | $ 812,968 | 3,664 | $2,022,578.92 | $572,383.46 |
| Mar-22 | 3,624 | $ 1,698,036 | $ 806,801 | 3,583 | $1,984,920.29 | $755,940.11 |
| Feb-22 | 3,632 | $ 1,645,093 | $ 611,770 | 3,519 | $1,344,723.45 | $745,597.43 |
| Jan-22 | 3,614 | $ 2,040,249 | $ 873,100 | 3,447 | $2,369,048.45 | $569,626.05 |
| Dec-21 | 3,690 | $ 1,447,436 | $ 671,338 | 3,410 | $1,334,044.56 | $777,258.41 |
| Nov-21 | 3,736 | $ 1,799,791 | $ 646,755 | 3,487 | $1,352,105.97 | $614,241.30 |
| Oct-21 | 3,773 | $ 1,564,312 | $ 1,022,492 | 3,428 | $1,353,817.50 | $628,232.38 |
| Sep-21 | 3,782 | $ 1,592,964 | $ 591,244 | 3,406 | $1,123,353.94 | $612,908.81 |
| Aug-21 | 3,704 | $ 2,218,859 | $ 617,263 | 3,350 | $1,698,463.12 | $583,621.31 |
| Jul-21 | 3,699 | $ 1,657,410 | $ 584,094 | 3,280 | $1,540,083.61 | $637,859.63 |
| Jun-21 | 3,445 | $ 1,869,720 | $ 544,921 | 3,212 | $1,571,894.47 | $542,129.31 |
| May-21 | 3,481 | $ 1,617,386 | $ 517,801 | 3,101 | $1,726,815.18 | $600,647.21 |
| Apr-21 | 3,495 | $ 1,392,944 | $ 884,168 | 3,065 | $1,537,316.92 | $511,209.03 |
| Mar-21 | 3,509 | $ 1,702,091 | $ 587,311 | 3,015 | $1,790,968.05 | $683,695.48 |
Medicare Benefit Summary
RFP #: 230000003226
Schedule H:
FOR INFORMATIONAL PURPOSES ONLY. Bidder need not replciate the benefits stated here. Bidder proposal must include benefits that are actuarially equivalent to those in Schedule I2 and I4. See also Schedule A, Section 1.2.1.
| 2021 | 2022 | 2023 | |||||
| HMO 1 | HMO 2 | HMO 1 | HMO 2 | HMO 1 | HMO 2 | ||
| Hospital Care | |||||||
| Inpatient hospital care | 10% coinsurance after deductible | 10% coinsurance after deductible | 10% coinsurance after deductible. | 10% coinsurance after deductible | 10% coinsurance, after deductible | 10% coinsurance, after deductible | |
| Outpatient hospital care, including diagnostic services | 10% coinsurance after deductible. Office visit copay may apply. $150 copay after deductible for high tech imaging services. | 10% coinsurance after deductible. Diagnostic labs, pathology, x-rays, $10 copay after deductible. $150 copay, deductible does not apply for high tech imaging services. | 10% coinsurance after deductible. Office visit copay may apply. $150 copay or 50% coinsurance after deductible for high tech imaging services. | 10% coinsurance after deductible. Diagnostic labs, pathology, X-rays $10 copay after deductible. | 10% coinsurance, after deductible. Office visit copay may apply. | ||
| $150 copay or 50% coinsurance, after deductible, for high tech imaging services. | 10% coinsurance, after deductible. Diagnostic labs, pathology, X-rays $10 copay after deductible. | ||||||
| Alternatives to Hospital Care | |||||||
| Home healthcare | Covered in full after deductible; copay may apply for physician's visit. | Covered in full, deductible does not apply. | Covered in full. | Covered in full. Deductible does not apply. | Covered in full, after deductible | Covered in full. | |
| Skilled nursing facility | Covered in full after deductible for 100 days (can be renewed after 60 days) | 10% coinsurance 100 days (can be renewed after 60 days) after deductible. | Covered in full after deductible up to 100 days per benefit period. | 10% coinsurance after deductible for 100 days. Can be renewed after 60 days. | Covered in full up to 100 days per benefit period. | 10% coinsurance, after deductible for 100 days. Can be renewed after 60 days. | |
| Hospice | Covered by Original Medicare | Covered by Original Medicare | Covered by Original Medicare | Covered by Original Medicare. | Covered by Original Medicare | Covered by Original Medicare | |
| Emergency Services | |||||||
| Emergency room care | $100 copay after deductible; waived if admitted | $90 copay, waived if admitted. Deductible does not apply. | $100 copay after deductible, waived if admitted. | $120 copay, waived if admitted. Deductible does not apply. | $100 copay, waived if admitted. Deductible does not apply. | $120 copay, waived if admitted. Deductible does not apply. | |
| Urgent care | $50 copay | $45 copay. Deductible does not apply. | $50 copay | $45 copay. Deductible does not apply. | $50 copay | $45 copay. Deductible does not apply. | |
| Surgical Services | |||||||
| Surgical Services | 10% coinsurance after deductible | 10% coinsurance after deductible | 10% coinsurance after deductible | 10% coinsurance after deductible. | 10% coinsurance, after deductible | 10% coinsurance, after deductible. | |
| Doctor Office Visits and Services | |||||||
| Office Visits | $25 copay primary. $45 copay after deductible specialist. $40 copay outpatient therapy services. | $10 copay Primary. $35 copay specialist, deductible does not apply. | Primary: Covered - $25 copay | ||||
| Specialist: Covered - $45 copay after deductible | Primary: $10 copay | ||||||
| Specialist: $35 copay. Deductible does not apply. | Primary doctor: $10 copay. | ||||||
| Specialist: $35 copay. Deductible does not apply. | Primary doctor: $10 copay. |
Specialist: $35 copay. Deductible does not apply.
| Online visits | $25 copay in network | $0 copay, deductible does not apply. | Covered - $25 copay in network | $0 copay. Deductible does not apply. | Covered in full. | Covered in full. | |
| Allergy testing and treatment | Covered in full. Office visit copay may apply after deductible. | Covered in full. Office visit copay may apply, deductible does not apply. | Covered in full after deducible. Office visit copay may apply per member, per visit. | Covered in full. Office visit copay may apply. Deductible does not apply. | Covered in full after deductible. Office visit copay may apply per member, per visit. | Covered in full. Office visit copay may apply. Deductible does not apply. | |
| Chiropractic visits | $20 copay after deductible when referred | $10 copay, deductible does not apply. | Covered - $20 copay after deductible | $10 copay. Deductible does not apply. | $20 copay, after deductible. | $10 copay. Deductible does not apply. | |
| Physical, occupational, speech therapy | $40 copay after deductible | $35 copay. Deductible does not apply. | Covered - $40 copay after deductible | $10 copay. Deductible does not apply. | $40 copay, after deductible. | $10 copay. Deductible does not apply. | |
| Preventive Services | |||||||
| Annual routine physical exams | Medicare Wellness Exam covered in full once annually. | Covered in full, deductible does not apply. | Covered in full | Covered in full. Deductible does not apply. | Covered in full. | Covered in full. | |
| Routine pap smears | Covered in full | Covered in full, deductible does not apply. | Covered in full | Covered in full. Deductible does not apply. | Covered in full. | Covered in full. | |
| Routine mammograms | Covered in full | Covered in full, deductible does not apply. | Covered in full | Covered in full. Deductible does not apply. | Covered in full. | Covered in full. | |
| Screening colonoscopy | Covered in full (screening colonoscopy or screening barium enema as an alternative) every 24 months. Not high risk of colorectal cancer: Screening colonoscopy every 10 years (120 months), but not within 48 months of a screening sigmoidoscopy. | Covered in full, deductible does not apply. | Covered in full. | Covered in full. Deductible does not apply. | Covered in full. | Covered in full. | |
| Vaccines (Influenza, Pneumonia, Hepatitis B) | Covered in full | Covered in full. | Covered in full | Covered in full. | Covered in full. | Covered in full. | |
| Mental Health | |||||||
| Outpatient mental health services | Covered in full | $10 copay, deductible does not apply. | Covered in full, unlimited days | $10 copay. Deductible does not apply. | Covered in full, unlimited days. | $10 copay. Deductible does not apply. | |
| Substance Use Disorder Treatment | |||||||
| Outpatient facility | Covered in full, unlimited days | $10 copay. Deductible does not apply. | Covered in full, unlimited days | $10 copay. Deductible does not apply. | Covered in full, unlimited days. | $10 copay. Deductible does not apply. | |
| Durable Medical Equipment | |||||||
| Durable Medical Equipment | 20% coinsurance | 20% coinsurance after deductible. | 20% coinsurance | 20% coinsurance after deductible. | 20% coinsurance. | 20% coinsurance, after deductible. | |
| Hearing | |||||||
| Routine hearing care | Hearing exam: Covered in full. One exam every 36 months. Hearing aids: Covered in full. One hearing aid per year every 36 months. | Hearing exam: Covered in full. One hearing exam, one audiometric exam every 24 months. | |||||
| Hearing aids: $499 copay per hearing aid for advanced aids, $799 copay per hearing aid for premium aids. One basic hearing aid per ear every 12 months. Exclusively through Rehearing providers. | Hearing exam: One exam every 36 months. | ||||||
| Hearing aids: One hearing aid per ear every 36 months. | Hearing exam: Covered in full. One hearing exam, one audiometric exam every 24 months. Hearing aids: $499 copay per hearing aid for advanced aids, $799 copay per hearing aid for premium aids. One basic hearing aid per ear every 12 months. Exclusively through TruHearing providers. | Hearing exam: Covered in full. One exam every 36 months. | |||||
| Hearing aids: Covered in full. One hearing aid every 36 months. | Hearing exam: Covered in full. One hearing exam, one audiometric exam every 24 months. |
Hearing Aids: $499 copay per hearing aid for advanced aids, $799 copay per hearing aid for premium aids. One basic hearing aid per ear every 12 months. Exclusively through TruHearing providers.
| Location of Care | ||||||
| Care in Michigan, but outside the network | Emergency and Urgent care covered. Other care not covered unless member has prior authorization on file. | Emergency and Urgent Care same as in-network. Most other covered services, travel deductible and coinsurance apply. | Emergency and urgent care covered. Other care not covered unless member has prior authorization on file. | Emergency and urgent care same as in network. Most other covered services, travel deductible, and coinsurance apply. | Emergency and urgent care covered. Other care not covered unless member has prior authorization on file. | Emergency and urgent care same as in network. Most other covered services, travel deductible, and coinsurance apply. |
| Care outside Michigan | Routine, urgent and follow-up care through BlueCard. | Emergency and Urgent Care same as in-network. Out of state benefit covers out of state care the same as in-network when you visit a Multiplan Medicare participating provider. | Routine, urgent, and follow-up care through BlueCard. | Emergency and urgent care same as in network. Out-of-state benefit covers out-of-state care the same as in network when you visit a Multiplan Medicare participating provider. | Routine, urgent, and follow-up care through BlueCard. | Emergency and urgent care same as in network. Out-of-state benefit covers out-of-state care the same as in network when you visit a Multiplan Medicare participating provider. |
| Medical Deductible | ||||||
| Deductible | $400 individual | $300 individual | $400 individual | $450 individual | $400 individual | In network: $525 individual |
Out of network: $725 individual
| Medical Maximum | ||||||
| Medical Coinsurance / copay Maximum | $1,700 individual | $1,800 individual | $1,700 individual | $1,650 individual | $1700 individual | In network: $1,775 individual |
Out of network: $2,475 individual Total medical out of pocket maximum $2,100 individual $2,100 individual $2,100 individual $2,100 individual $2100 individual In network: $2,300 individual Out of network: $3,200 individual
| Prescription Drugs | |
| Traditional prescription drugs | Preferred Pharmacy: $12 copay Generic. |
$55 copay Preferred Brand.
$80 copay Non-Preferred Drugs.
50% coinsurance sexual dysfunction drugs (31-day supply) Standard Pharmacy:
$20 copay generic $75 copay Preferred Brand $100 copay Non-Preferred Drugs Mail Order: 32 day to 90-day supply for 2 copays Deductible does not apply Preferred Pharmacy:
$9 copay Tier 1 Generic $40 copay Tier 2 Preferred Brand $70 copay Tier 3 Non Preferred Brand
Non-Preferred Pharmacy:
$15 copay Tier 1 Generic $45 copay Tier 2 Preferred Brand $75 copay Tier 3 Non-Preferred Brand
Mail Order: Up to 90-day supply for 2 copays. Tier 1 generic $0 copay. Preferred Pharmacy:
Preferred Generic and Generic: $12 copay Preferred Brand: $55 copay Non-Preferred Drugs: $80 copay 50% coinsurance sexual dysfunction drugs (31-day supply) Standard Pharmacy:
Preferred Generic and Generic: $20 copay Preferred Brand: $75 copay Non-Preferred Drugs: $100 copay
Mail Order: 32-day to 90-day supply for two copays Preferred Pharmacy:
Generic: $9 copay Preferred Brand: $40 copay Non-Preferred Brand: $70 copay Standard Retail Pharmacy:
Generic: $15 copay Preferred Brand: $45 copay Non-Preferred Brand: $75 copay Mail Order: Up to 90-day supply for two copays. Tier 1 generic $0 copay. Preferred Pharmacy:
Preferred Generic and Generic: $5 copay Preferred Brand: $40 copay Non-Preferred Brand: $70 copay.
50% coinsurance sexual dysfunction drugs (31-day supply).
Standard Pharmacy:
Preferred Generic and Generic: $10 copay Preferred Brand: $45 copay Non-Preferred Brand: $75 copay
Mail Order: 32-day to 90-day supply for two copays. Tier 1 and Tier 2 generic $0 copay Preferred pharmacy:
Preferred Generic and Generic: $9 copay.
Preferred Brand: $55 copay.
Non-Preferred Brand: $85 copay
Standard Retail Pharmacy:
Preferred Generic and Generic: $15 copay Preferred Brand: $60 copay Non-Preferred Brand: $90 copay.
Mail Order: Up to 90-day supply, for two copays. Tier 1 generic $0 copay.
| Specialty Prescription Drugs | 20% coinsurance ($200 maximum per prescription) | 20% coinsurance ($100 maximum per prescription) | 20% coinsurance with $200 maximum per prescription | Preferred and Non Preferred Specialty: 20% coinsurance with $100 maximum per prescription. | Specialty: 20% coinsurance, with $100 maximum per prescription | Preferred and Non-Preferred Specialty: 20% coinsurance, with $120 maximum per prescription. |
| Prescription Drug Maximum | ||||||
| Prescription Drug coinsurance maximum | No pharmacy out of pocket maximum | No pharmacy out of pocket maximum | No pharmacy out-of-pocket maximum. | No pharmacy out-of-pocket maximum. | No pharmacy out of pocket maximum | No pharmacy out-of-pocket maximum. |
Non Medicare Benefit Summary
| RFP #: 230000003226 |
| Schedule H: |
| Non-Medicare Benefits Summary and Claims Paid Data |
| FOR INFORMATIONAL PURPOSES ONLY. Bidder need not replciate the benefits stated here. Bidder proposal must include benefits that are actuarially equivalent to those in Schedule I1 and I3. See also Schedule A, Section 1.2.1. |
| 2021 | 2022 | 2023 | |||||
| HMO 1 | HMO 2 | HMO 1 | HMO 2 | HMO 1 | HMO 2 | ||
| Hospital Care | |||||||
| Inpatient hospital care | 10% coinsurance after deductible | 10% coinsurance after deductible | 10% coinsurance after deductible | 10% coinsurance after deductible. | 10% coinsurance, after deductible | 10% coinsurance, after deductible. | |
| Outpatient hospital care, including diagnostic services | 10% coinsurance after deductible. $150 copay after deductible for high tech imaging services | 10% coinsurance after deductible. $150 copay, deductible does not apply, for high tech imaging services. | 10% coinsurance after deductible. $150 copay after deductible for high tech imaging services. | 10% coinsurance after deductible. $150 copay, deductible does not apply, for high tech imaging services. | 10% coinsurance, after deductible. $150 copay, after deductible for high tech imaging services. | 10% coinsurance, after deductible. $150 copay, deductible does not apply, for high tech imaging services. | |
| Alternatives to Hospital Care | |||||||
| Home healthcare | $35 copay after deductible | 10% coinsurance after deductible. | $35 copay after deductible | 10% coinsurance after deductible | $35 copay, after deductible. | 10% coinsurance, after deductible. | |
| Skilled nursing facility | 10% coinsurance after deductible up to 120 days per calendar year | 10% coinsurance, 100 days (can be renewed) after deductible. | 10% coinsurance after deductible up to 120 days per calendar year. | 10% coinsurance, 100 days (can be renewed) after deductible. | 10% coinsurance, after deductible up to 120 days per calendar year. | 10% coinsurance, 100 days (can be renewed) after deductible. | |
| Hospice | Covered in full after deductible; inpatient hospice care requires prior authorization | 10% coinsurance after deductible. | Covered in full after deductible. Inpatient hospice care requires prior authorization. | 10% coinsurance after deductible. | Covered in full, after deductible, Inpatient hospice care requires prior authorization. | 10% coinsurance, after deductible. | |
| Emergency Services | |||||||
| Emergency room care | $150 copay after deductible, waived if admitted | $150 copay, waived if admitted. Deductible does not apply. | $150 copay after deductible, waived if admitted. | $150 copay, waived if admitted. Deductible does not apply. | $150 copay after deducible, waived if admitted. | $150 copay, waived if admitted. Deductible does not apply. | |
| Urgent care | $65 copay | $60 copay. Deductible does not apply. | $65 copay | $60 copay. Deductible does not apply. | $65 copay. | $60 copay. Deductible does not apply. | |
| Surgical Services | |||||||
| Surgical Services | 10% coinsurance after deductible | 10% coinsurance after deductible | 10% coinsurance after deductible. | 10% coinsurance after deductible. | 10% coinsurance, after deductible. | 10% coinsurance, after deductible. | |
| Doctor Office Visits and Services | |||||||
| Office Visits | $25 copay primary | ||||||
| $35 copay after deductible specialist | $25 copay primary | ||||||
| $40 copay specialist, deductible does not apply | $25 copay, primary | ||||||
| $35 copay after deductible, specialist | $25 copay, primary |
$40 copay, specialist. Deductible does not apply.
Primary doctor: $25 copay.
Specialist: $35 copay after deductible.
Primary doctor: $25 copay.
Specialist: $40 copay. Deductible does not apply.
| Online visits | $25 copay | $0 copay, deductible does not apply. | $25 copay | $0 copay. Deductible does not apply. | $25 copay. | Covered in full. | |
| Allergy testing and treatment | 50% coinsurance after deductible | ||||||
| $5 copay for allergy injections | Included in office visit, deductible does not apply | 50% coinsurance after deductible | |||||
| $5 copay for allergy injections | Included in office visit. Deductible does not apply. | 50% coinsurance, after deductible. | |||||
| $5 copay for allergy injections. | Included in office visit. Deductible does not apply. | ||||||
| Chiropractic visits | $35 copay after deductible | $30 copay, maximum benefit 30 visits/year with PT & OT, deductible does not apply. | $35 copay after deductible | $30 copay, maximum benefit 30 visits / year with PT and OT. Deductible does not apply. | $35 copay, after deductible. | $30 copay, maximum benefit 30 visits / year with PT and OT. Deductible does not apply. | |
| Physical, occupational, speech therapy | $35 copay after deductible | $30 copay, maximum benefit 30 visits / year with PT and OT. Deductible does not apply. | $35 copay after deductible, limited to 60 consecutive days per episode. | $30 copay, maximum benefit 30 visits / year with PT and OT. Deductible does not apply. | $35 copay after deductible, limited to 60 consecutive days per episode. | $30 copay, maximum benefit 30 visits / year with PT and OT. Deductible does not apply. | |
| Preventive Services | |||||||
| Annual routine physical exams | $25 copay primary | ||||||
| $35 copay after deductible specialist | Covered in full, deductible does not apply. | $25 copay, primary | |||||
| $35 copay after deductible, specialist | Covered in full. Deductible does not apply. | Primary doctor: $25 copay. |
Specialist: $35 copay, after deductible.
| Covered in full. | ||||||
| Routine pap smears | Covered in full. | Covered in full, deductible does not apply. | Covered in full | Covered in full. Deductible does not apply. | Covered in full | Covered in full. |
| Routine mammograms | Covered in full. | Covered in full, deductible does not apply. | Covered in full | Covered in full. Deductible does not apply. | Covered in full. | Covered in full. |
| Screening colonoscopy | Covered in full | Covered in full, deductible does not apply. | Covered in full | Covered in full. Deductible does not apply. | 10% coinsurance, plus deductible. | Covered in full. |
| Vaccines (Influenza, Pneumonia, Hepatitis B) | Covered in full. | Influenza and Hepatitis B vaccines are covered in full. |
Pneumonia vaccine is only covered in full if a member is considered high risk or with a history of asthma or smoking. Covered in full. Influenza and Hepatitis B vaccines are covered in full.
Pneumonia vaccine is only covered in full if a member is considered high risk or with a history of asthma or smoking. Covered in full. Influenza and Hepatitis B vaccines are covered in full.
Pneumonia vaccine is only covered in full if a member is considered high risk or with a history of asthma or smoking.
| Mental Health | |||||||
| Outpatient mental health services | 50% coinsurance, up to 20 visits / calendar year | $25 copay, deductible does not apply | 50% coinsurance, up to 20 visits / calendar year. | $25 copay. Deductible does not apply. | |||
| 50% coinsurance, up to 20 visits/calendar year. | $25 copay. Deductible does not apply. | ||||||
| Substance Use Disorder Treatment | |||||||
| Outpatient facility | 50% coinsurance | $25 copay. Deductible does not apply. | |||||
| 50% coinsurance | $25 copay. Deductible does not apply. | ||||||
| 50% coinsurance. | $25 copay. Deductible does not apply. | ||||||
| Durable Medical Equipment | |||||||
| Durable Medical Equipment | 50% coinsurance of the Approved Amount when authorized and obtained from a participating provider. | 20% coinsurance after deductible. | 50% coinsurance of the approved amount when authorized and obtained from a participating provider. | 20% coinsurance after deductible. | 50% coinsurance of the approved amount when authorized and obtained from a participating provider. | 20% coinsurance, after deductible. | |
| Hearing | |||||||
| Routine hearing care | Hearing exam: Covered in full. One exam every 36 months. | ||||||
| Hearing aids: Covered in full. One hearing aid every 36 months. | Hearing exam: covered in full. One hearing exam, one audiometric exam every 24 months. | ||||||
| Hearing aids: $499 copay per hearing aid for advanced aids, $799 copay per hearing aid for premium aids. One basic hearing aid per ear every 12 months. Exclusively through TruHearing providers. | Hearing exam: Covered in full. One exam every 36 months. | ||||||
| Hearing aids: Covered in full. One hearing aid every 36 months. | Hearing exam: Covered in full. One hearing exam, one audiometric exam every 24 months. | ||||||
| Hearing aids: $499 copay per hearing aid for advanced aids, $799 copay per hearing aid for premium aids. One basic hearing aid per ear every 12 months. Exclusively through TruHearing providers. | Hearing exam: Covered in full. One exam every 36 months. | ||||||
| Hearing aids: Covered in full. One hearing aid every 36 months. | Hearing exam: Covered in full. One hearing exam, one audiometric exam every 24 moths. |
Hearing aids: $499 copay per hearing aid for advanced aids, $799 copay per hearing aid for premium aids. One basic hearing aid per ear every 12 months. Exclusively through TruHearing providers.
| Location of Care | |||||||
| Care in Michigan, but outside the network | Emergency and urgent care covered; other care not covered unless member has prior authorization on file. | Emergency and Urgent Care same as in-network. | Emergency and urgent care covered; other care not covered unless member has prior authorization on file. | Emergency and urgent care same as in network, | Emergency and urgent care covered; other care not covered unless member has prior authorization on file. | Emergency and urgent care same as in network. | |
| Care outside Michigan | Routine, urgent and follow-up care through BlueCard | Emergency and Urgent Care same as in-network. Most other covered services, travel deductible and coinsurance apply. | Routine, urgent, and follow-up care through BlueCard. | Emergency and urgent care same as in network. Most other covered services, travel deductible and coinsurance apply. | Routine, urgent, and follow-up care through BlueCard. | Emergency and urgent care same as in network. Most other covered services, travel deductible, and coinsurance apply. | |
| Medical Deductible | |||||||
| Deductible | $400 individual / $800 family | In-network: $750 individual / $1,500 Family | |||||
| Out-of-Network: $1,500 individual / $3000 family | $400 individual/ $800 family | In Network: $750 individual / $1,500 family | |||||
| Out of Network: $1,500 individual / $3,000 family | $400 individual / $800 family. | In network: $750 individual / $1,500 family. |
Out of network: $1,500 individual / $3,000 family.
| Medical Maximum | |||
| Medical Coinsurance Maximum | $750 individual / $1,500 family | In network: $1,000 individual / $2,000 family | |
| Out-of-network: $2,000 individual / $4,000 family | Coinsurance maximum: $750 individual / $1,500 family | Coinsurance maximum: |
In network: $5,000 individual / $10,000 family Out of Network: $10,000 individual / $20,000 family $750 individual / $1,500 family. In network: $5,000 individual / $10,000 family.
Out of network: $10,000 individual / $20,000 family.
| Prescription Drugs | |
| Traditional prescription drugs | $20 copay Generic |
$60 copay Preferred Brand $80 copay Non-Preferred Brand 50% coinsurance sexual dysfunction drugs (30-day supply)
Mail Order: Up to 90-day supply for 2 copays Deductible does not apply $10 copay Tier 1 $50 copay Tier 2 $80 copay Tier 3 Mail Order: 90-day supply for 2 copays Generic: $20 copay Preferred Brand: $60 copay Non-Preferred brand: $80 copay 50% coinsurance sexual dysfunction drugs (30-day supply)
Mail Oder: Up to 90-day supply for two copays. Tier 1: $10 copay Tier 2: $50 copay Tier 3: $80 copay Mail Order: 90-day supply for two copays Generic: $20 copay.
Preferred Brand: $60 copay.
Non-Preferred Brand: $80 copay.
50% coinsurance sexual dysfunction drugs (30-day supply).
Mail Order:
Up to 90-day supply for two copays. Generics: $10 copay.
Preferred brand (may include some high-cost generics): $50 copay Non-Preferred Brand (may include some high-cost generics): $80 copay Mail Order: 90-day supply for two copays.
| Specialty Prescription Drugs | 20% coinsurance ($200 maximum per prescription Tier 4, $400 maximum per prescription Tier 5) | 20% coinsurance ($150 maximum per prescription) | Preferred Specialty: 20% coinsurance with $200 maximum per prescription | ||||
| Non-Preferred Specialty: 20% coinsurance with $400 maximum per prescription. | Specialty: 20% coinsurance with $150 maximum per prescription. | Preferred Specialty: 20% coinsurance, with $200 maximum per prescription. | |||||
| Non-Preferred Specialty: 20% coinsurance, with $400 maximum per prescription. | Specialty: 20% coinsurance, with $150 maximum per prescription. | ||||||
| Prescription Drug Maximum | |||||||
| Prescription Drug coinsurance maximum | Specialty only: $4,800 individual pharmacy out of pocket maximum | No pharmacy out of pocket maximum | Specialty only: $4,800 individual pharmacy out-of-pocket maximum. | No pharmacy out-of-pocket maximum. | Specialty only: $4,800 individual pharmacy out-of-pocket maximum. | No pharmacy out-of-pocket maximum. |
File details come from the government source that posted it. Updated .