Schedule J - Benefit Comparison, Actuarial Attestation.xlsx
XLSX spreadsheet 21 KB Posted
- Attached to
- HMO Services for MPSERS
- Solicitation number
- RFP 171 190000002803 2
- Issued by
- Michigan
About this file
This is a Benefit Comparison and Actuarial Attestation document for the MPSERS Master Health Care Plan, detailing non-Medicare and Medicare benefit offerings for health plan bidders. The document outlines comprehensive medical coverage including office visits, routine preventive care, hospital services, emergency and urgent care, mental health services, prescription drugs, durable medical equipment, and hearing benefits. Bidders are required to submit responses demonstrating benefit comparisons that meet or exceed the specified coverage levels. The plan covers members with no geographic county restrictions, applying statewide across Michigan through the Blue Cross Blue Shield of Michigan (BCBSM) network, with specialty pharmacy services provided exclusively through BriovaRx and hearing services through TruHearing providers.
The benefit structure establishes specific cost-sharing parameters including deductibles, coinsurance percentages, and copayments designed to manage member out-of-pocket expenses. Non-Medicare members face a $1,000 individual deductible with a $1,900 total medical out-of-pocket maximum, while Medicare members have an $800 individual deductible with a $1,700 total out-of-pocket maximum. Prescription drug coverage includes 20% coinsurance for preferred brands with specified minimums and maximums for retail and mail-order supplies, and 40% coinsurance for non-preferred brands. Bidders must submit an Attestation of Actuarial Equivalence certified by an actuary or provide underwriter demonstration of actuarial equivalence to confirm their proposed benefit plans meet the established standards. The document serves as the baseline specification against which all bidder responses will be evaluated for compliance and comparative analysis.
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Text version
Non Medicare
| Benefit | MPSERS Master Health Care Plan | Bidder Response |
| Non Medicare Benefits Summary Comparison | ||
| Office Calls | 10% coinsurance plus deductible | |
| Routine Physical Exams | Covered in full once annually | |
| Routine Pap Smears | Covered in full - Dr. office and Quest Labs; 10% coinsurance after deductible - outpatient | |
| Routine Mammograms | 10% coinsurance plus deductible | |
| Allergy Testing and Treatment | 10% coinsurance plus deductible | |
| Chiropractic Visits | 10% coinsurance plus deductible; up to 26 visits annually | |
| Hospital Inpatient Care | 10% coinsurance plus deductible | |
| Hospital Outpatient Care (inc. diagnostic services) | 10% coinsurance plus deductible | |
| Med / Surg Care (inc. surgery, anesthesia, tech. surg. assist.) | 10% coinsurance plus deductible | |
| Emergency Medical Care | 10% coinsurance plus deductible, $120 copay/visit after coinsurance maximum met. |
Waived if admitted within 72 hours.
| Urgent Medical Care | 10% coinsurance plus deductible, $65 copay/visit after coinsurance maximum met |
| Care Outside Michigan | Same in US through BlueCard; outside US, hospital coverage through BlueCard. |
| Care Outside the Network, but in Michigan | Additional 20% out of network fee. Waived if member has referral from Blue Preferred PPO physician |
| Home Health Care | Deductible |
| Skilled Nursing Facility | 10% coinsurance plus deductible, up to 100 days |
| Hospice | Covered in full |
| Outpatient Mental Health Services | 10% coinsurance plus deductible |
| Prescription Drugs | 20% coinsurance Preferred Brand and Generic plus $10 minimum/$40 maximum retail (30 day); $25 minimum /$100 maximum mail (90 day) |
40% coinsurance Non-Preferred Brand plus $10 minimum/ no maximum (30 day); $25 minimum / no maximum (90 day) Additional 10% coinsurance on maintenance drugs on and after 4th refill at retail. Exclusive Specialty pharmacy medications through BriovaRx.
Durable Medical Equipment In Network: 10% coinsurance plus deductible.
Out of Network: 30% coinsurance plus deductible and difference in cost between provider's charge and the BCBSM approved amount.
Hearing Benefits Hearing Exam: $45 copay ** Hearing Aids:
$499** copay per hearing aid for advanced aids $799** copay per hearing aid for premium aids Initial hearing exam and hearing aids for both ears covered once every 36 months, exclusively through TruHearing providers.
| Deductible | $1,000 Individual *** |
| Pharmacy Max | $1,500 Individual |
| Medical Max | Coinsurance max: $900 Individual |
Total medical out-of-pocket maximum** (Deductible + coinsurance maximum): $1,900 Individual
Notes: *This is only a summary. Benefit levels are subject to change.
** Copays for routine hearing care are not included in the medical out-of-pocket maximum.
*** BCBSM Members enrolled in the Living Well program have the opportunity to reduce their deductibles.
| Counties: | |
| *Please list each covered county. | No County restrictions. |
Actuarial Equivalence Bidder must submit an Attestation of Actuarial Equivalence certified by an actuary or a demonstration of actuarial equivalence from an underwriter.
Medicare
| Benefit | MPSERS Master Health Care Plan | Bidder Response |
| Medicare Benefits Summary Comparison | ||
| Office Calls | 10% coinsurance plus deductible | |
| Routine Physical Exams | Covered in full once annually | |
| Routine Pap Smears | Covered in full | |
| Routine Mammograms | Covered in full | |
| Allergy Testing and Treatment | 10% coinsurance plus deductible | |
| Chiropractic Visits | 10% coinsurance plus deductible | |
| Hospital Inpatient Care | 10% coinsurance plus deductible | |
| Hospital Outpatient Care (inc. diagnostic services) | 10% coinsurance plus deductible | |
| Med / Surg Care (inc. surg, anesthesia, tech. surg. assistance) | 10% coinsurance plus deductible | |
| Emergency Medical Care | $120 copay, waived if admitted within 72 hours | |
| Urgent Medical Care | $65 copay | |
| Care Outside of Michigan | Same in US; outside US, member pays for services up front & BCBSM will reimburse member | |
| Care Outside the Network, but in Michigan | Same as in network | |
| Home Health Care | Covered in full | |
| Skilled Nursing Facility | 10% coinsurance plus deductible, up to 100 days | |
| Hospice | Covered by Original Medicare | |
| Outpatient Mental Health Services | 10% coinsurance plus deductible | |
| Prescription Drugs | 20% coinsurance Preferred Brand and Generic |
$10 minimum / $40 maximum retail (30 day); $25 minimum / $100 maximum mail (90 day) 40% coinsurance Non-Preferred Brand Additional 10% coinsurance on maintenance drugs on and after 4th refill at retail Preferred Specialty medications through BriovaRx Durable Medical Equipment Supplier In network: 10% coinsurance plus deductible Out of network: 30% coinsurance plus deductible Hearing Benefits Hearing Exam: $45 copay ** Hearing Aids:
$499 copay** per hearing aid for advanced aids $799 copay** per hearing aid for premium aids Initial hearing exam and hearing aids for both ears covered once every 36 months, exclusively through TruHearing providers
| Deductible | $800 Individual *** |
| Pharmacy Maximum | Coinsurance maximum: $1,500 Individual |
| Medical Maximum | Coinsurance maximum: $900 Individual |
Total medical out-of-pocket maximum (Deductible + Coinsurance maximum + copays**): $1,700 Individual
Notes: *This document is only a summary. Benefit levels are subject to change.
**Copays for routine hearing care are not included in the medical out-of-pocket maximum ***BCBSM Medicare Members are automatically enrolled in the LivingWell Program and receive the lower deductible for being part of the program.
| Counties: | |
| *Please list each covered county. | No county restrictions. |
Actuarial Equivalence Bidder must submit an Attestation of Actuarial Equivalence certified by an actuary or a demonstration of actuarial equivalence from an underwriter.
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