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BLUE CROSS® PHYSICIAN CHOICE PPO GROUP BENEFITS

CERTIFICATE SG (for small, insured group customers)

© 2019 Blue Cross Blue Shield of Michigan


PREFERRED RX PROGRAM CERTIFICATE SG

This contract is between you and Blue Cross Blue Shield of Michigan. Because we are an independent corporation licensed by the Blue Cross and Blue Shield Association - an association of independent Blue Cross and Blue Shield plans - we are allowed to use the Blue Cross and Blue Shield names and service marks in the state of Michigan. However, we are not an agent of BCBSA and, by accepting this contract, you agree that you made this contract based only on what you were told by BCBSM or its agents. Only BCBSM has an obligation to provide benefits under this certificate and no other obligations are created or implied by this language.



CERTIFICATE SG

Dear Subscriber: We are pleased you have selected Blue Cross Blue Shield of Michigan for your health care coverage under the Blue Cross® Physician Choice PPO. Through this program, we have established a network of physicians, facilities and other health care professionals to provide your medical care through organized systems of care. To have the lowest out-of-pocket expenses under this program, members will select and use a primary care physician within a high-performing organized system of care. If you do not choose a primary care physician, yet continue to access services through our extensive PPO network of providers, your out-of-pocket expenses will be slightly higher. Health care services you obtain from providers who are not in our PPO network are referred to as "out-of-network" providers. Services obtained from out-of-network providers are subject to the largest out-of-pocket expenses. Other sections of this book, which is your Certificate, explain the Blue Cross® Physician Choice PPO in more detail, describe the program's benefits and limitations and outline other aspects of the program. These will help you understand your benefits and financial responsibilities before you require services.

Your certificate, your signed application and your BCBSM identification card are your contract with us. You may also have riders. Riders make changes to your certificate and are an important part of your coverage. When you receive riders, keep them with this book.

Please read it carefully. If you have any questions about your coverage, call us at the customer service telephone numbers listed in the "How to Reach Us" section of this book. Every Blue Cross Blue Shield employee is dedicated to giving you the finest service. We look forward to serving you for many years. Sincerely, Daniel J. Loepp President and Chief Executive Officer Blue Cross Blue Shield of Michigan




CERTIFICATE SG

About Your Certificate This certificate is arranged to help you locate information easily. You will find: • A Table of Contents — for quick reference

• Information About Your Contract

• Blue Cross® Physician Choice PPO

• What You Must Pay • What BCBSM Pays For

• How Providers Are Paid • General Services That Are Not Payable • General Conditions of Your Contract • Definitions — explanations of the terms used in your certificate

• Additional Information You Need to Know

• How to Reach Us

• Index This certificate provides you with the information you need to get the most from your BCBSM health care coverage. Please call us if you have any questions.


i TABLE OF CONTENTS


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TABLE OF CONTENTS ABOUT YOUR CERTIFICATE ............................................................................................................... I SECTION 1: INFORMATION ABOUT YOUR CONTRACT ................................................................... 1

ELIGIBILITY ....................................................................................................................................... 2 Who is Eligible to Receive Benefits ................................................................................................. 2

Changing Your Coverage ................................................................................................................... 4 TERMINATION................................................................................................................................... 4

How to Terminate Your Coverage ................................................................................................... 4 How We Terminate Your Coverage ................................................................................................. 5 Rescission ...................................................................................................................................... 6

CONTINUATION OF BENEFITS ........................................................................................................ 6 Consolidated Omnibus Budget Reconciliation Act (COBRA) ........................................................... 6 Individual Coverage ........................................................................................................................ 7

SECTION 2: BLUE CROSS® PHYSICIAN CHOICE PPO .................................................................... 8 SECTION 3: WHAT YOU MUST PAY ................................................................................................. 10

Level 1 and Level 2 (In-Network) Providers ................................................................................... 14 Level 3 (Out-of-Network) Providers ............................................................................................... 19 Benefit-Specific Cost-Sharing Requirements ................................................................................ 23 Maximums for Days of Care or Visits ............................................................................................ 24

SECTION 4: WHAT BCBSM PAYS FOR ............................................................................................ 25 Allergy Testing and Therapy ......................................................................................................... 26 Ambulance Services ..................................................................................................................... 27 Anesthesiology Services ............................................................................................................... 29 Audiologist Services ...................................................................................................................... 30 Autism Disorders ........................................................................................................................... 31 Behavioral Health Services (Mental Health and Substance Use Disorder) .................................... 35 Cardiac Rehabilitation ................................................................................................................... 43 Chemotherapy .............................................................................................................................. 44 Chiropractic Services and Osteopathic Manipulative Therapy ....................................................... 45 Chronic Disease Management ...................................................................................................... 46 Clinical Trials (Routine Patient Costs) ........................................................................................... 47 Contraceptive Services ................................................................................................................. 48 Dental Services ............................................................................................................................. 49 Diagnostic Services....................................................................................................................... 51 Dialysis Services ........................................................................................................................... 53 Durable Medical Equipment .......................................................................................................... 56 Emergency Treatment ................................................................................................................... 58 Gender Dysphoria Treatment ........................................................................................................ 59 Home Health Care Services .......................................................................................................... 60 Hospice Care Services .................................................................................................................. 62 Hospital Services .......................................................................................................................... 66 Infertility Treatment ....................................................................................................................... 67 Infusion Therapy ........................................................................................................................... 68 Long-Term Acute Care Hospital Services ..................................................................................... 69 Maternity Care .............................................................................................................................. 70 Medical Supplies ........................................................................................................................... 72


TABLE OF CONTENTS ii



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Newborn Care ............................................................................................................................... 73 Occupational Therapy ................................................................................................................... 74 Office, Outpatient and Home Medical Care Visits .......................................................................... 77 Oncology Clinical Trials ................................................................................................................. 79 Optometrist Services ..................................................................................................................... 84 Outpatient Diabetes Management Program (ODMP) .................................................................... 85 Pain Management ......................................................................................................................... 86 Physical Therapy .......................................................................................................................... 87 Prescription Drugs ........................................................................................................................ 90 Preventive Care Services .............................................................................................................. 93 Professional Services .................................................................................................................... 96 Prosthetic and Orthotic Devices .................................................................................................... 97 Pulmonary Rehabilitation ............................................................................................................ 100 Radiology Services ..................................................................................................................... 101 Skilled Nursing Facility Services.................................................................................................. 102 Special Medical Foods for Inborn Errors of Metabolism .............................................................. 104 Speech and Language Pathology ............................................................................................... 105 Surgery ....................................................................................................................................... 108 Temporary Benefits ..................................................................................................................... 111 Transplant Services .................................................................................................................... 117 Urgent Care Services .................................................................................................................. 124 Value Based Programs ............................................................................................................... 125

SECTION 5: HOW PROVIDERS ARE PAID ..................................................................................... 129 PPO Level 1 and Level 2 Providers (Hospitals, Facilities, Physicians and Health Care Professionals .............................................................................................................................. 130 Level 3 Participating Providers (Hospitals, Facilities, Physicians and Health Care Professionals Not in the PPO Network) ................................................................................................................... 131 Level 3 Nonparticipating Providers (Physicians and Health Care Professionals Not in the PPO Network) ..................................................................................................................................... 133 Level 3 Nonparticipating Hospitals and Facilities Performing Non- Emergency Services ........... 135 Level 3 Nonparticipating Hospitals and Facilities Performing Emergency Services .................... 135 BlueCard® PPO Program ............................................................................................................ 137 Negotiated (non-BlueCard Program) Arrangements .................................................................... 140 Blue Cross Blue Shield Global Core Program ............................................................................. 141

SECTION 6: GENERAL SERVICES WE DO NOT PAY FOR ........................................................... 144 SECTION 7: GENERAL CONDITIONS OF YOUR CONTRACT ....................................................... 147

Assignment ................................................................................................................................. 147 Changes in Your Address ........................................................................................................... 147 Changes in Your Family .............................................................................................................. 147 Changes to Your Certificate ........................................................................................................ 147 Coordination of Benefits .............................................................................................................. 147 Coordination of Coverage for End Stage Renal Disease (ESRD) ................................................ 148 Coverage for Drugs and Devices ................................................................................................ 149 Deductibles, Copayments and Coinsurances Paid Under Other Certificates ............................... 149 Enforceability of Various Provisions ............................................................................................ 149 Entire Contract; Changes ............................................................................................................ 149 Experimental Treatment .............................................................................................................. 150 Fraud, Waste, and Abuse ........................................................................................................... 152


iii TABLE OF CONTENTS


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Genetic Testing ........................................................................................................................... 152 Grace Period ............................................................................................................................... 152 Guaranteed Renewability ............................................................................................................ 153 Improper Use of Contract ............................................................................................................ 153 Individual Coverage .................................................................................................................... 153 Notification .................................................................................................................................. 153 Payment of Covered Services ..................................................................................................... 153 Personal Costs ............................................................................................................................ 153 Pharmacy Fraud, Waste, and Abuse ........................................................................................... 154 Physician of Choice..................................................................................................................... 154 Preapproval ................................................................................................................................ 154 Prior Authorization ...................................................................................................................... 154 Release of Information ................................................................................................................ 155 Reliance on Verbal Communications .......................................................................................... 155 Right to Interpret Contract ........................................................................................................... 155 Semiprivate Room Availability ..................................................................................................... 155 Services Before Coverage Begins or After Coverage Ends ......................................................... 155 Services That Are Not Payable ................................................................................................... 156 Subrogation: When Others Are Responsible for Illness or Injury ................................................. 156 Subscriber Liability ...................................................................................................................... 157 Termination of Coverage ............................................................................................................. 157 Time Limit for Filing Pay-Provider Medical Claims ...................................................................... 158 Time Limit for Filing Pay-Subscriber Medical Claims ................................................................... 158 Time Limit for Legal Action .......................................................................................................... 158 Unlicensed and Unauthorized Providers ..................................................................................... 158 What Laws Apply ........................................................................................................................ 159 Workers’ Compensation .............................................................................................................. 159

SECTION 8: DEFINITIONS ............................................................................................................... 160 SECTION 9: ADDITIONAL INFORMATION YOU NEED TO KNOW ................................................ 192

Grievance and Appeals Process ................................................................................................. 192 Standard Internal Review Process ............................................................................................................. 193 Expedited Internal Review Process ........................................................................................................... 195 Expedited External Review Process .......................................................................................................... 196

Pre-Service Appeals ................................................................................................................... 197 Need More Information? ............................................................................................................................ 198

We Speak Your Language .......................................................................................................... 199 Important Disclosure ................................................................................................................... 200

SECTION 10: HOW TO REACH US .................................................................................................. 201 To Call ........................................................................................................................................ 201 To Visit ........................................................................................................................................ 201


SECTION 1: INFORMATION ABOUT YOUR CONTRACT 1



CERTIFICATE SG

Section 1: Information About Your Contract This section provides answers to general questions you may have about your contract. Topics include: • ELIGIBILITY

− Who is Eligible to Receive Benefits • CHANGING YOUR COVERAGE • TERMINATION

− How to Terminate Your Coverage

− How We Terminate Your Coverage

− Rescission • CONTINUATION OF BENEFITS

− Consolidated Omnibus Budget Reconciliation Act (COBRA)

− Individual Coverage


2 SECTION 1: INFORMATION ABOUT YOUR CONTRACT


CERTIFICATE SG

ELIGIBILITY You will need to fill out an application for coverage. We will review your application to determine if you and the people you list on it are eligible. Our decision will be based on the eligibility rules in this certificate and our underwriting policies.

If you or anyone applying for coverage on your behalf commits fraud or intentionally lies about a material fact in your application, your coverage may be rescinded. See “Rescission” on Page 6.

Who is Eligible to Receive Benefits • You • Dependents listed on your contract:

– Your spouse – Your children

A person who marries a member who already has coverage as a surviving spouse is not eligible for coverage under this certificate.

Children are covered through the end of the calendar year when they become age 26 as long as the subscriber is covered under this certificate. The children must be related to you by: • Birth • Marriage • Legal adoption • Legal guardianship • Becoming a dependent due to a child support order or other court order • Foster child placement by agency or court order

Your child’s spouse is not eligible for coverage under this certificate. Your grandchildren may be covered in limited circumstances.

You, your spouse, or your adult dependents must notify us if your spouse or any dependents are living outside our service area. In that case, Level 1 Cost-Sharing will be assigned for as long as they live outside the service area. If your spouse and/or dependents do not live in the service area, they are not required to select a PCP in the service area and referrals are not needed. You or your spouse can request this exception on behalf of your dependents living outside the service area.





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Eligibility (continued) Who is Eligible to Receive Benefits (continued) Newborn children, including your grandchildren, may qualify for limited benefits immediately following their birth even if they are not listed on your contract. If the member who gave birth to the newborn is covered under this contract, see Section 3 in this certificate for Maternity Care. When a newborn is added to the contract they will be placed into Level 1 Cost-Sharing for their first 31 days of life. Afterward, the child will remain in Level 1 if the parent chooses a PCP from a Provider Level 1 Organized System of Care (OSC). Otherwise, the child will be eligible for Level 2 Cost-Sharing. Your children will be removed from your contract at the end of the year in which they turn 26. They may be eligible for their own contract through the Consolidated Omnibus Budget Reconciliation Act (COBRA) or a BCBSM individual plan. To learn more about COBRA, see the Continuation of Benefits subsection. Disabled Unmarried Children Disabled unmarried children may remain covered after they turn age 26 if all of the following apply: • They cannot support themselves due to a diagnosis of:

− A physical disability or − A developmental disability

• They depend on you for support and maintenance.

Your employer must send us a physician’s certification proving the child’s disability. We must receive it by 31 days after the end of the year of the child’s 26th birthday. We will decide if the child meets the requirements.

You may also be eligible for group coverage if: • You lose your Medicaid coverage (you must apply for BCBSM coverage within 60 days) • Your dependents lose their CHIP coverage (Children’s Health Insurance Program) (you must apply

for BCBSM coverage within 60 days)

• You or your dependent become eligible for a premium assistance subsidy from the state you live in for employer group health care coverage. Michigan does not provide state premium assistance subsidies at this time. For additional information regarding eligibility for a state premium assistance subsidy, please contact Customer Service.




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CHANGING YOUR COVERAGE If there is a change in your family, you must notify your group. The changes include: • Birth • Adoption • Gaining a dependent due to:

− A child support order or other court order − Foster child placement by agency or court order

• Marriage • Divorce • The death of a member • Start or end of military service Your change takes effect as of the date it happens. Your group must notify us directly of any changes within: • 30 days of when a dependent is removed • 31 days of when a dependent is added. If a dependent cannot be covered by your contract anymore, they may be eligible for their own contract through COBRA or a BCBSM individual plan. TERMINATION How to Terminate Your Coverage Send your written request to terminate coverage to your employer. We must receive it from your employer within 30 days of the requested cancellation date. Your coverage will then be terminated and all benefits under this certificate will end. However, if you are an inpatient at a hospital or facility on the date your coverage ends, please see “Services Before Coverage Begins or After Coverage Ends” in Section 7.





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Termination (continued) How We Terminate Your Coverage We may terminate your coverage if: • Your group does not qualify for coverage under this certificate • Your group does not pay its bill on time

If you are responsible for paying all or a portion of the bill then you must pay it on time or your coverage will be terminated. For example, if you are a retiree or enrolled under COBRA and you pay all or part of your bill directly to BCBSM, we must receive your payment on time.

• You are serving a criminal sentence for defrauding BCBSM • You no longer qualify to be a member of your group • Your group changes to a non-BCBSM health plan • We no longer offer this coverage • You misuse your coverage

Misuse includes illegal or improper use of your coverage such as:

− Allowing an ineligible person to use your coverage − Requesting payment for services you did not receive

• You fail to repay BCBSM for payments we made for services that were not a benefit under this

certificate, subject to your rights under the appeal process. • You are satisfying a civil judgment in a case involving BCBSM • You are repaying BCBSM funds you received illegally • You no longer qualify as a dependent Your coverage ends on the last day covered by the last premium payment we receive. However, if you are an inpatient at a hospital or facility on the date your coverage ends, please see “Services Before Coverage Begins or After Coverage Ends" in Section 7.




CERTIFICATE SG

Rescission We will rescind your coverage if you, your group or someone seeking coverage on your behalf has: • Performed an act, practice, or omission that constitutes fraud, or • Made an intentional misrepresentation of material fact to BCBSM or another party, which results in

you or a dependent obtaining or retaining coverage with BCBSM or the payment of claims under this or another BCBSM certificate.

We may rescind your coverage back to the effective date of your contract. If we do, we will provide you with a 30-day notice. Once we notify you that we are rescinding your coverage, we may hold or reject claims during this 30-day period. You will have to repay BCBSM for its payment for any services you received.

CONTINUATION OF BENEFITS Consolidated Omnibus Budget Reconciliation Act (COBRA) COBRA is a federal law that applies to most employers with 20 or more employees. It allows you to continue your employer group coverage if you lose it due to a qualifying event; e.g., you are laid off or fired. (“Qualifying events” are listed in Section 8.) Your employer must send you a COBRA notice. You have 60 days to choose to continue your coverage. The deadline is 60 days after you lose coverage or 60 days after your employer sends you the notice, whichever is later. If you choose to keep the group coverage you must pay for it. The periods of time you may keep it for are: • 18 months of coverage for an employee who is terminated, other than for gross misconduct, or

whose hours are reduced • 29 months of coverage for all qualified beneficiaries if one member is determined by the Social

Security Administration to be disabled at the time of the qualifying event or within 60 days thereafter • 36 months of coverage for qualified beneficiaries in case of the death of the employee, divorce,

legal separation, loss of dependency status, or employee entitlement to Medicare COBRA coverage can be terminated because: • The 18, 29 or 36 months of COBRA coverage end • The required premium is not paid on time • The employer terminates its group health plan • The qualified beneficiary becomes entitled to Medicare coverage • The qualified beneficiary obtains coverage under a group health plan • Please contact your employer for more details about COBRA.





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Individual Coverage If you choose not to enroll in COBRA, or if your COBRA coverage period ends, coverage may be available through a BCBSM individual plan. Contact BCBSM Customer Service for information about what plan best meets your needs.


8 SECTION 2: BLUE CROSS PHYSICIAN CHOICE PPO


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Section 2: Blue Cross® Physician Choice PPO Before we discuss your benefits under this certificate, the following information should help you understand how the Blue Cross® Physician Choice PPO functions. The Blue Cross® Physician Choice PPO allows you full access to our Preferred Provider Organization (PPO) network of health care providers (physicians, hospitals and other health care professionals). PPO providers, also referred to as “in-network providers,” have agreed to participate in our PPO Program. Within this network of PPO providers are more select groupings, or levels, that BCBSM designates Organized Systems of Care (OSCs). An OSC consists of physicians (M.D.s and D.O.s), specialists and acute care hospitals. You should choose a Primary Care Physician (PCP) from within a Provider Level 1 OSC and notify BCBSM of your selection. Your PCP will coordinate all of your medical care, including specialty and hospital care. Under your benefit plan, covered services will be subject to one of three cost-sharing levels. They are: • Level 1 Cost-sharing – lowest member cost-sharing • Level 2 Cost-sharing – moderate member cost-sharing • Level 3 Cost-sharing – highest member cost-sharing LEVEL 1 COST-SHARING To receive Level 1 cost-sharing for covered services you must: • Select a PCP from a designated Provider Level 1 OSC, • Obtain services from providers within your PCP’s OSC,

• Obtain a referral from your PCP when using services outside of your OSC, or • Obtain services from a provider not designated as an OSC provider (i.e., not a PCP, specialist, or

acute care hospital). You, your spouse and your covered dependent children may all choose different PCPs and OSCs. For example, while general practice or family practice physicians are usually chosen, a dependent child may have a pediatrician as their PCP. A PCP selection can be changed at any time, as long as BCBSM is notified of each change. If you select a Provider Level 1 OSC PCP, you may seek services from any provider within that OSC without a referral to obtain Level 1 Cost-Sharing. You will also receive Level 1 Cost-Sharing when obtaining covered services from a provider type not designated as an OSC provider (i.e., not a PCP, specialist, or acute care hospital) as long as you have a Provider Level 1 OSC PCP. To receive Level 1 Cost-Sharing when obtaining covered services outside of your selected Provider Level 1 OSC, you must have a referral from your PCP.

Certain benefits require no referrals. See a list at the end of this section.


SECTION 2: BLUE CROSS PHYSICIAN CHOICE PPO 9



CERTIFICATE SG

LEVEL 2 COST-SHARING If you decide not to select a PCP from a Provider Level 1 OSC and obtain services instead from another “in-network” PPO provider, covered services will be subject to the Level 2 Cost-Sharing requirements.

If you have a Provider Level 1 PCP, but seek physician or acute care hospital services outside of your OSC, you must have a referral from your PCP. If you do not have a Provider Level 1 PCP referral, benefits will be subject to Level 2 cost-sharing.

LEVEL 3 COST-SHARING Services performed by a facility or provider that has not agreed to be part of our PPO program are referred to as “Out-of-Network.” For out-of-network services, you will be responsible for Level 3 Cost-Sharing, which has the greatest out-of-pocket expenses. It is important to remember that if you decide to go out-of-network for any services and the provider of those services is a nonparticipating provider, you may have to pay any remaining balance between our approved amount and the provider’s charge. More detailed cost-sharing information is available in “Section 3: What You Must Pay.” BENEFITS EXEMPT FROM REFERRAL REQUIREMENTS: The following benefits will not require a referral from a primary care physician: • Autism Diagnostic Services (rendered by an Approved Autism Evaluation Center)

• Specified Human Organ Transplant Benefits – Transplant and Post-Transplant Services (must be

performed in a designated facility)

• Inpatient Hospital Admissions when the member is admitted from the emergency room after being treated for the episode of care that warranted the emergency room visit

• Mental Health and Substance Use Disorder Treatment Services – Inpatient, Outpatient, Office

• Obstetrical or Gynecological Woman’s Services For the above covered services, a referral from a PCP is not required. Members who have selected a Provider Level 1 OSC PCP will be eligible for Level 1 Cost-Sharing for these services outside of their OSC (in-network) without a referral. If you have not selected a Provider Level 1 OSC PCP, these services will be subject to Level 2 Cost-Sharing when performed by an in-network provider. Services by an out-of-network provider will be subject to Level 3 Cost-Sharing. If you have any questions regarding this program, please feel free to contact your local Customer Service center (see Section 10).


10 SECTION 3: WHAT YOU MUST PAY


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Section 3: What You Must Pay You have PPO coverage under this certificate. PPO coverage uses a “Preferred Provider Organization” provider network. What you must pay depends on the type of provider you choose. If you choose an “in-network” provider, you most often pay less money than if you choose an “out-of-network” provider. If you choose a Primary Care Physician (PCP) from a Provider Level 1 Organized System of Care (OSC) within the PPO, you will realize even greater savings. The types of providers you may get services from are in the chart below.

Choosing Your Provider If you select a PCP from a Provider Level 1 OSC and receive services from a

Provider Level 1 OSC PCP, Specialist or Acute Care Hospital Provider Level 1 Cost Share PCP, specialists and acute care hospitals accept the BCBSM-approved amount as payment-in-full for covered services.

You will pay the least out-of-pocket costs:

• Lowest deductibles, coinsurances and copayments

• Embedded coinsurance maximums

• No deductibles, copayments or coinsurances for certain preventive care benefits • No claim forms to file

If you select a PCP from a Provider Level 1 OSC and receive services outside of your OSC from a PPO In-Network PCP, Specialist or Acute Care Hospital Provider

Level 1 Cost Share With a referral from your PCP…

Provider accepts the BCBSM-approved amount as payment-in-full for covered services.

You will pay the least out-of-pocket costs:

• Lowest deductibles, coinsurances and copayments

• Embedded coinsurance maximums

• No deductibles, copayments or coinsurances for certain preventive care benefits • No claim forms to file Level 2 Cost Share Without a referral from your PCP…

Provider accepts the BCBSM-approved amount as payment-in-full for covered services.

You will pay out-of-pocket costs that are still lower than Level 3 costs:

• Lower deductibles, coinsurances and copayments than Level 3 Cost-Sharing

• No deductibles, copayments or coinsurances for certain preventive care benefits • No claim forms to file

What You Must Pay (continued)


SECTION 3: WHAT YOU MUST PAY 11



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Choosing Your Provider (continued)

If you select a PCP from a Provider Level 1 OSC and receive services from a PPO In-Network Provider other than a PCP, Specialist or Acute Care Hospital

Level 1 Cost Share Provider accepts the BCBSM-approved amount as payment-in-full for services. You will pay the least out-of-pocket costs: • Lowest deductibles, coinsurances and copayments

• Embedded coinsurance maximums • No deductible, copayment or coinsurance for certain preventive care benefits • No claim forms to file

Examples of these services would include (but are not limited to) care provided by certified nurse practitioners, ambulatory surgical facilities, skilled nursing facilities, chiropractors and physical therapists.

If you do not select a PCP from a Provider Level 1 OSC and receive services

from a PPO In-Network PCP, Specialist or Acute Care Hospital Provider Level 2 Cost Share Provider accepts the BCBSM-approved amount as payment-in-full for covered services. You will pay lower out-of-pocket costs while still within the PPO Network: • Lower deductibles, coinsurances and copayments than Level 3 Cost-Sharing • No deductible, copayment or coinsurance for certain preventive care benefits • No claim forms to file

If you do not select a PCP from a Provider Level 1 OSC and receive services from a PPO In-Network Provider other than a PCP, Specialist or Acute Care Hospital

Level 2 Cost Share Provider accepts the BCBSM-approved amount as payment-in-full for covered services. You will pay lower out-of-pocket costs while still within the PPO Network: • Lower deductibles, coinsurances and copayments than Level 3 Cost-Sharing • No deductible, copayment or coinsurance for certain preventive care benefits • No claim forms to file




CERTIFICATE SG

What You Must Pay (continued) Choosing Your Provider (continued)

If you receive services from a Level 3 (Out-of-Network) Provider Participating Provider* This out-of-network provider participates with BCBSM. Provider accepts the BCBSM-approved amount as payment-in-full for covered services. You will pay more out-of-pocket costs than what you pay if you see an in-network provider: • A Level 3 deductible • Level 3 coinsurance amounts • No claim forms to file Nonparticipating Provider* This out-of-network provider chooses not to participate with BCBSM. Provider does not accept the BCBSM-approved amount as payment-in-full for covered services** You will pay the highest out-of-pocket costs: • A Level 3 deductible

• Level 3 coinsurance amounts

• You pay all charges that exceed the amount we pay for a service

• You must file claim forms

*Important: A provider can either be participating or nonparticipating. Participating providers cannot

bill you for more than our payment plus what you pay in Level 3 Cost-Sharing. Nonparticipating providers can bill you for an amount that is more than what we pay. BCBSM will not pay for medical services from nonparticipating hospitals unless it is for the treatment of accidental injuries or medical emergencies. Otherwise, you will need to pay most of those charges yourself.

** Some nonparticipating providers can agree to accept our payment for a service as payment in full. When this occurs, you only have to pay your out-of-network cost-share requirement. Other nonparticipating providers may not accept our payment as payment in full. In this instance, you will have to pay your out-of-network cost share requirement and the difference between the amount paid to the provider and the provider’s charge. Section 5 explains more about professional providers, hospitals and other providers and how we pay them.





CERTIFICATE SG

The deductibles, copayments and coinsurances you must pay each calendar year are illustrated in the chart below and explained in more detail in the pages that follow. These are standard amounts associated with this certificate. The amounts you have to pay may differ depending on what riders your particular plan has.

Cost-Sharing Chart LEVEL 1

Deductibles $500 for one member

$1,000 for the family (when two or more members are covered under your contract) Copayments $150 per emergency room visit

$20 per office visit and office consultation with a primary care physician, online visit, or visit in a retail health clinic

$40 per office visit or office consultation with a specialist

$30 per chiropractic and osteopathic manipulative treatment, when services are given in a physician’s office

$60 per urgent care visit Coinsurance requirements

20% for most covered services

50% for bariatric surgery Embedded coinsurance maximum

$3,000 for one member

$6,000 for the family (when two or more members are covered under your contract) Annual out-of-pocket maximums


$13,200 for the family (when two or more members are covered under your contract) LEVEL 2

Deductibles $1,500 for one member

$3,000 for the family (when two or more members are covered under your contract) Copayments $150 per emergency room visit

$40 per office visit and office consultation with a primary care physician, online visit, or visit in a retail health clinic

$60 per office visit or office consultation with a specialist

$40 per chiropractic and osteopathic manipulative treatment, when services are given in a physician’s office

$60 per urgent care visit Coinsurance requirements


50% for bariatric surgery Annual out-of-pocket maximums


$13,200 for the family (when two or more members are covered under your contract)




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Cost-Sharing Chart (continued)

LEVEL 3 Deductibles $3,000 for one member

$6,000 for the family (when two or more members are covered under your contract) Copayments $150 per emergency room visit Coinsurance requirements


50% for bariatric surgery Annual out-of-pocket maximums


$26,400 for the family (when two or more members are covered under your contract)

For a list of in-network primary care physicians and specialists, including information on OSC affiliations, visit our website at www.bcbsm.com or call our Customer Service department. The phone numbers are listed in Section 10. Some services have benefit-specific cost-sharing requirements. These are listed starting on Page 23. Level 1 and Level 2 (In-Network) Providers Deductible Requirements Each calendar year, you must pay a deductible for covered services by Level 1 and Level 2 providers. Provider Level 1 • $500 for one member • $1,000 for the family (when two or more members are covered under your contract)

- Two or more members must meet the family deductible. - If the one-member deductible has been met, but not the family deductible, we will pay covered

services only for that member who has met the deductible. - Covered services for the remaining family members will be paid when the full family deductible

has been met.

The approved amount that is applied to your Level 1 and Level 2 deductibles for covered services received in the last three months of a calendar year will be applied toward your Level 1 and Level 2 deductible requirements for the next calendar year.

http://www.bcbsm.com/





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Level 1 and Level 2 (In-Network) Providers (continued) Deductible Requirements (continued) Provider Level 2 • $1,500 for one member • $3,000 for the family (when two or more members are covered under your contract)

- Two or more members must meet the family deductible. - If the one-member deductible has been met, but not the family deductible, we will pay covered

services only for that member who has met the deductible. - Covered services for the remaining family members will be paid when the full family deductible

has been met.

The approved amount that is applied to your Level 2 deductible also counts toward your Level 1 deductible. However, the approved amount that is applied to your Level 1 deductible does not apply to your Level 2 or Level 3 deductibles.

The approved amount that is applied to your Level 1 and Level 2 deductibles for covered services received in the last three months of a calendar year will be applied toward your Level 1 and Level 2 deductible requirements for the next calendar year.

Your annual Level 1 or Level 2 deductibles will be imposed for most covered services except the following:

• Services subject to a copayment requirement • Presurgical consultations • Professional services for the initial exam and treatment of a medical emergency or an accidental

injury in the outpatient department of a hospital, urgent care center or physician’s office • Hospice care benefits • Prenatal care

• Select preventive care services




CERTIFICATE SG

Level 1 and Level 2 (In-Network) Providers (continued) Copayment Requirements You must pay the following copayment for covered services by Level 1 and Level 2 providers: Provider Level 1 • $150 per visit for facility services in a hospital emergency room (waived if the member is admitted).

• $20 per office visit and office consultation with a primary care physician, online visit, or visit in a

retail health clinic • $40 per office visit or office consultation with a specialist

For a list of “specialists”, visit our website at www.bcbsm.com or contact Customer Service (see Section 10).

• $30 per chiropractic and osteopathic manipulative treatment, when services given in physician’s

office

When an office visit and manipulative treatment are billed on the same day, by the same Level 1 physician, you must pay only the copayment for the office visit.

• $60 per urgent care visit Provider Level 2 • $150 per visit for facility services in a hospital emergency room (waived if the member is admitted). • $40 per office visit and office consultation with a primary care physician, online, or visit in a retail

health clinic • $60 per office visit or office consultation with a specialist

For a list of “specialists”, visit our website at www.bcbsm.com or contact Customer Service (see Section 10).

• $40 per chiropractic and osteopathic manipulative treatment, when services given in physician’s

office

When an office visit and manipulative treatment are billed on the same day, by the same Level 2 physician, you must pay only the copayment for the office visit.

• $60 per urgent care visit

http://www.bcbsm.com/http://www.bcbsm.com/





CERTIFICATE SG

Level 1 and Level 2 (In-Network) Providers (continued) Coinsurance Requirements In addition to your deductibles, you must pay the following coinsurance for covered services by Level 1 and Level 2 providers: Provider Level 1 • 20 percent of the approved amount for most covered services, except:

− Services subject to a copayment requirement − Presurgical consultations − Professional services for the initial exam and treatment of a medical emergency or an accidental

injury in the outpatient department of a hospital, urgent care center or physician’s office − Hospice care benefits − Prenatal care − Select preventive care services

• 50 percent of the approved amount for bariatric surgery Provider Level 2 • 40 percent of the approved amount for most covered services, except:

− Services subject to a copayment requirement − Presurgical consultations − Professional services for the initial exam and treatment of a medical emergency or an accidental

injury in the outpatient department of a hospital, urgent care center or physician’s office − Hospice care benefits − Prenatal care − Select preventive care services

• 50 percent of the approved amount for bariatric surgery




CERTIFICATE SG

Level 1 and Level 2 (In-Network) Providers (continued) Embedded Coinsurance Maximum Provider Level 1

The coinsurance you pay for most covered Level 1 services is limited to the following maximums each calendar year:

• $3,000 for one member

• $6,000 for the family (when two or more members are covered under your contract)

− Two or more members must meet the family embedded coinsurance maximum − If the one-member embedded coinsurance maximum has been met, but not the family

embedded coinsurance maximum, we will pay covered services only for that member who has met the one-member embedded coinsurance maximum

− Covered services for the remaining family members will be paid when the full family embedded coinsurance maximum has been met.

Exceptions Payments applied to the following are not applied toward the embedded coinsurance maximum: • Deductibles • Services that require copayments • Prescription drug services Annual Out-of-Pocket Maximums Your annual out-of-pocket maximum for covered Level 1 and Level 2 services is: • $6,600 for one member • $13,200 for a family (when two or more members are covered under your contract)

– Two or more members must meet the family out-of-pocket maximum. − If the one-member maximum is met even if the family maximum is not, that member does not

pay any more cost share for the rest of the calendar year. − Cost share for the remaining family members must still be paid until the annual family maximum

is met.





CERTIFICATE SG

Level 1 and Level 2 (In-Network) Providers (continued) Annual Out-of-Pocket Maximums (continued) The Level 1 and Level 2 in-network deductibles, copayments and coinsurance that you pay are combined to meet the annual Level 1 and Level 2 out-of-pocket maximums. This also includes what you pay for prescription drugs covered within your BCBSM prescription drug certificate. Any coupon, rebate or other credits received directly or indirectly from the drug manufacturer may not be applied to your annual out-of-pocket maximum. The following prescription drug expenses will NOT apply towards the annual out-of-pocket maximum: • Payment for noncovered drugs or services • Any difference between the Maximum Allowable Cost and BCBSM’s approved amount for a

covered brand name drug • The 25 percent member liability for covered drugs obtained from a nonparticipating pharmacy The following prescription drug expenses WILL apply towards the annual out-of-pocket maximum: • A drug manufacturer coupon amount you received toward cost sharing for prescription drugs that

do not have an available and medically appropriate generic equivalent.

Only payments toward your cost share are applied toward your out-of-pocket maximum. If you receive services from a nonparticipating provider and you are required to pay that provider for the difference between the charge for the services and our approved amount, your payment will not apply to your out-of-pocket maximum.

Once you meet the maximums for the year, we pay for all covered benefits at 100 percent of our approved amount for the rest of the calendar year. Level 3 (Out-of-Network) Providers Deductible Requirements Each calendar year, you must pay a deductible for covered services provided by Level 3 providers: • $3,000 for one member • $6,000 for the family (when two or more members are covered under your contract)

− Two or more members must meet the family deductible. − If the one-member deductible has been met, but not the family deductible, we will pay covered

services only for that member who has met the deductible. − Covered services for the remaining family members will be paid when the full family deductible

has been met.

The approved amount that is applied to your Level 3 deductible also counts toward your Level 1 and Level 2 deductibles. However, the approved amounts that is applied to your Level 1 and Level 2 deductibles does not count toward your Level 3 deductible.




CERTIFICATE SG

Level 3 (Out-of-Network) Providers (continued) Deductible Requirements (continued) You do not pay the Level 3 deductible for:

• Professional Services for the initial exam and treatment of a medical emergency or accidental injury

in the outpatient department of a hospital, urgent care center or physician’s office • Services from a provider for which there is no PPO network • Services from a Level 3 provider in a geographic area of Michigan deemed a “low-access area” by

BCBSM for that particular provider specialty. In limited instances, you may not have to pay a Level 3 deductible for: • Select professional services performed by Level 3 providers in a Level 1 or Level 2 hospital,

participating freestanding ambulatory surgery facility or any other location identified by BCBSM, or • The reading and interpretation of select routine or screening services when a Level 1 or Level 2

provider performs the services, but a Level 3 provider does the analysis and interprets the results.

If one of the above applies and you do not have to pay the Level 3 deductible, you may still need to pay the Level 1 or Level 2 deductible.

You may contact BCBSM for more information about these services. Copayment Requirements You must pay the following copayment for covered services by Level 3 providers: • $150 per visit for facility services in a hospital emergency room (waived if the member is admitted).

For your requirements on services in a Michigan nonparticipating hospital, see Section 5.





CERTIFICATE SG

Level 3 (Out-of-Network) Providers (continued) Coinsurance Requirements In addition to your deductible, you must pay the following coinsurance for covered services by Level 3 providers: • 50 percent of the approved amount for most covered services

Online visits by an out-of-network professional provider will be subject to applicable out-of-network cost-sharing requirements. Online visits by an online vendor that was not selected by BCBSM will not be covered.

You will not be required to pay this coinsurance for:

− Professional Services for the initial exam and treatment of a medical emergency or accidental

injury in the outpatient department of a hospital, urgent care center or physician’s office − A prescription for a contraceptive device obtained from an out-of-network provider − Services from a provider for which there is no PPO network − Services from a Level 3 provider in a geographic area of Michigan deemed a “low-access area”

by BCBSM for that particular provider specialty. In limited instances, you may not have to pay this coinsurance for: − Select professional services performed by Level 3 providers in a Level 1 or Level 2 hospital,

participating freestanding ambulatory surgery facility or any other location identified by BCBSM, or

− The reading and interpretation of select routine or screening services when a Level 1 or Level 2 provider performs the services, but a Level 3 provider does the analysis and interprets the results.

If one of the above applies and you do not have to pay the Level 3 coinsurance, you may still need to pay the Level 1 or Level 2 coinsurance.

• 50 percent of the approved amount for bariatric surgery You may contact BCBSM for more information about these services.




CERTIFICATE SG

Level 3 (Out-of-Network) Providers (continued) Annual Out-of-Pocket Maximums Your annual out-of-pocket maximum for covered Level 3 services is: • $13,200 for one member • $26,400 for a family (when two or more members are covered under your contract)

– Two or more members must meet the family out-of-pocket maximum. − If the one-member maximum is met even if the family maximum is not, that member does not

pay any more cost share for the rest of the calendar year. − Cost share for the remaining family members must still be paid until the annual family maximum

is met. The Level 3 deductible, copayments and coinsurance that you pay are combined to meet the annual Level 3 out-of-pocket maximum. This also includes what you pay for prescription drugs covered within your BCBSM prescription drug certificate. Any coupon, rebate or other credits received directly or indirectly from the drug manufacturer may not be applied to your annual out-of-pocket maximum. The following prescription drug expenses will NOT apply towards the annual out-of-pocket maximum: • Payment for noncovered drugs or services • Any difference between the Maximum Allowable Cost and BCBSM’s approved amount for a

covered brand name drug • The 25 percent member liability for covered drugs obtained from a nonparticipating pharmacy The following prescription drug expenses WILL apply towards the annual out-of-pocket maximum: • A drug manufacturer coupon amount you received toward cost sharing for prescription drugs that

do not have an available and medically appropriate generic equivalent.

Only payments toward your cost share are applied toward your out-of-pocket maximum. If you receive services from a nonparticipating provider and you are required to pay that provider for the difference between the charge for the services and our approved amount, your payment will not apply to your out-of-pocket maximum.

Once you meet the maximums for the year, we pay for all covered benefits including prescription drugs at 100 percent of our approved amount for the rest of the calendar year.

What you pay in Level 3 cost sharing counts toward your Level 1 and Level 2 out-of-pocket maximums. However, what you pay in Level 1 and Level 2 cost sharing does not count toward your Level 3 maximum.





CERTIFICATE SG

Benefit-Specific Cost-Sharing Requirements The benefits below differ in what you pay for them: Contraceptive Devices When received from a Level 1 or Level 2 provider, you do not pay any cost share. When received from a Level 3 provider, you must pay your Level 3 deductible but no other cost share. Contraceptive Injections When received from a Level 1 or Level 2 provider, you do not pay any cost share. When received from a Level 3 provider, you must pay your Level 3 cost share. Hospice Services You do not pay any cost sharing for hospice services from approved physicians, facilities and other approved providers. Mental Health Services and Substance Use Disorder Treatment Services You pay the same cost-sharing for mental health services and substance use disorder treatment that you would for many other covered services, in Levels 1, 2 or 3, depending on the provider you choose.

Your deductible and coinsurance apply for these services, no matter the location. Your office visit or online visit copay does not apply.

Outpatient Diabetes Management Program (ODMP) Under the ODMP, we pay to train you to manage your diabetes, when needed. • When received from a Level 1 or Level 2 provider, you pay no cost share.

• When received from a Level 3 provider, you pay Level 3 cost share. For all other services and supplies you get under the ODMP, you do pay cost share. You pay Level 1, 2 or 3 cost share, depending on the provider you choose. See Page 10. Presurgical Consultations When received from a Level 1 or Level 2 provider, you do not pay any cost sharing for presurgical consultations.




CERTIFICATE SG

Benefit-Specific Cost-Sharing Requirements (continued) Routine Colonoscopy Hospital and physician benefits for your first colonoscopy of the calendar year. • When received from a Level 1 or Level 2 provider, you pay no cost share

• When received from a Level 3 provider, you will have to pay your out-of- network cost share

If you have another colonoscopy done in the same calendar year, you will have to pay your in-network or out-of-network cost share. Specified Organ Transplants If you need an organ transplant that we cover, you pay no cost share during the benefit period for the transplant and transplant related services. The benefit period begins five days before the transplant and ends one year after the transplant. Value Based Programs When received from a Level 1 or Level 2 provider, you do not pay a deductible, copayment, or coinsurance for “care management” services (see Section 8 for the definition). These services include: • Provider-delivered care management

− Services obtained only in Michigan from providers designated by BCBSM • Blue distinction total care

− Services obtained outside of Michigan from providers designated by the local Blue Cross Blue Shield plan in that state.

When received from a Level 3 provider, you are responsible for the provider’s full charge. Voluntary Sterilization for Female Members We pay for voluntary sterilizations for female members. We cover services for a physician in a participating hospital. • When received from a Level 1 or Level 2 provider, you pay no cost sharing.

• When received from a Level 3 provider, you pay Level 3 cost sharing. Maximums for Days of Care or Visits You might have other maximums for days or visits. If so, they are described elsewhere in this book.


SECTION 4: WHAT BCBSM PAYS FOR 25



CERTIFICATE SG

Section 4: What BCBSM Pays For This section describes the services we pay for and the extent to which they are covered. • We pay for admissions and services when they are provided according to this certificate. Some

admissions and services must be approved before they occur. Emergency services do not need to be preapproved.

You should call BCBSM Customer Service for a list of admissions and services requiring preapproval. Payment will be denied if preapproval is not obtained.

• We pay only for “medically necessary” services (see Section 8 for the definition). This includes

services that may not be covered under this certificate but are part of a treatment plan approved by us. There are exceptions to this rule, Here are some examples:

− Voluntary sterilization − Screening mammography − Preventive care services − Contraceptive services

We will not pay for medically necessary services in an inpatient setting if they can be safely given in an outpatient location or office setting.

• We pay our approved amount (see Section 8 for the definition) for the services you receive that are

covered in this certificate and any riders you may have. Riders change your certificate and are an important part of your coverage.

Prescription drugs obtained from a pharmacy are not covered under this certificate. But, they may be covered if you have prescription drug coverage in addition to this certificate. You must pay your cost share for many of the benefits listed, see Section 3. We pay for services received from: • Hospitals and other facilities

We pay for covered services you receive in hospitals and other BCBSM-approved facilities. A physician must prescribe the services before we will cover them.

• Physicians and other professional providers Covered services must be provided by BCBSM-approved providers who are legally qualified or licensed to provide them.

Some physicians and other providers do not participate with BCBSM. They do not bill BCBSM, but bill you instead. If you receive services from such a provider, the provider may bill you more than what we pay. We will reimburse you our approved amount but you must pay your cost share and the difference between what we pay and the provider’s charge. See Section 5 for “Nonparticipating Physicians and Other Providers”.


26 SECTION 4: WHAT BCBSM PAYS FOR


CERTIFICATE SG

Allergy Testing and Therapy See Section 3 beginning on Page 10 for what you may be required to pay for these services. For other diagnostic services, see Page 51. Locations: We pay for allergy testing and therapy in: • A participating hospital

• A participating ambulatory surgery facility

• An office. We pay for: • Allergy Testing

− Survey, including history, physical exam, and diagnostic laboratory studies − Intradermal, scratch and puncture tests − Patch and photo tests − Double-blind food challenge test and bronchial challenge test

• Allergy Therapy

− Allergy immunotherapy by injection (allergy shots) − Injections of antiallergen, antihistamine, bronchodilator or antispasmodic agents

We do not pay for: • Fungal or bacterial skin tests (such as those given for tuberculosis or diphtheria)

• Self-administered, over-the-counter drugs

• Psychological testing, evaluation, or therapy for allergies

• Environmental studies, evaluation, or control





CERTIFICATE SG

Ambulance Services See Section 3 beginning on Page 10 for what you may be required to pay for these services. For emergency treatment services, see Page 58. We pay for: Ground and air ambulance services to take a member to a covered destination. For ground ambulance, a covered destination may include: • A hospital

• A skilled nursing facility • A member’s home • A dialysis center For air ambulance, a covered destination may include: • A hospital • Another covered facility, with BCBSM’s preapproval We will pay for a member to be taken to the nearest approved destination capable of providing the level of care necessary to treat the member’s condition.

Transfer of the member between covered destinations must be prescribed by the attending physician.

In every case, the following conditions must be met: • The service must be medically necessary. Any other means of transport would endanger the

member’s health. • We only pay for the transportation of the member and whatever care is required during transport.

We do not pay for other services that might be billed with it.

• The service must be provided in a vehicle licensed as a ground or air ambulance, which is part of a licensed ambulance operation.

We also pay ground and air for ambulance services when: • The ambulance arrives at the scene but transport is not needed or is refused. • The ambulance arrives at the scene but the member has expired.




CERTIFICATE SG

Ambulance Services (continued) We pay for: (continued) Air Ambulance Air ambulance services must also meet these requirements: • No other means of transportation are available

• The member’s condition requires transportation by air ambulance rather than ground ambulance

• The provider is not a commercial airline • The member is taken to the nearest facility capable of treating the member 's condition.

If your air ambulance transportation does not meet the above requirements, the services may be eligible for review under case management. They may approve the services for transportation that positively impacts clinical outcomes, but not for a member’s or family’s convenience.

We do not pay for: • Services provided by fire departments, rescue squads or other emergency transport providers

whose fees are in the form of donations. • Air ambulance services when the member’s condition does not require air ambulance transport. • Air ambulance services when a hospital or air ambulance provider is required to pay for the

transport under the law.





CERTIFICATE SG

Anesthesiology Services See Section 3 beginning on Page 10 for what you may be required to pay for these services. Locations: We pay for anesthesiology services in: • A participating hospital • A participating ambulatory surgery facility • An office We pay for: • Anesthesiology during surgery

Anesthesia services given to members undergoing covered surgery are payable to:

− A physician other than the operating physician

If the operating physician gives the anesthetics, the service is included in our payment for the surgery.

− A physician who orders and supervises anesthesiology services − A certified registered nurse anesthetist (CRNA)

CRNA services must be:

• Directly supervised by the physician performing the surgery or procedure, or • Under the indirect supervision of the physician responsible for anesthesiology services

If a CRNA is an employee of a hospital or facility, we pay the facility directly for the anesthesia services.

• Anesthesia during infusion therapy

We pay for local anesthesia only when needed as part of infusion therapy done in an office.

• Other Services

Anesthesia services may also be covered as part of electroconvulsive therapy (see Page 35) and for covered dental services (see Page 49).




CERTIFICATE SG

Audiologist Services See Section 3 beginning on Page 10 for what you may be required to pay for these services. Locations: We pay for audiology services performed by an audiologist in: • An office

• Other approved outpatient locations. We pay for: • Services performed by an audiologist, if they are prescribed by a provider who is legally authorized

to prescribe the services.





CERTIFICATE SG

Autism Disorders See Section 3 beginning on Page 10 for what you may be required to pay for these services. Locations: We pay for treatment of identified autism spectrum disorders in the following locations: • An office • A member’s home • Other approved outpatient locations. Covered Autism Spectrum Disorders We pay for the diagnosis and outpatient treatment of autism spectrum disorders, including: • Autistic Disorder

• Asperger’s Disorder

• Pervasive Developmental Disorder Not Otherwise Specified

A BCBSM-approved autism evaluation center (AAEC) must confirm that the member has one of the covered autism spectrum disorders.

Covered Services We pay for:

• Diagnostic services provided by a licensed physician or a licensed psychologist.

These services include: − Assessments − Evaluations or tests, including the Autism Diagnostic Observation Schedule




CERTIFICATE SG

Autism Disorder (continued) We pay for: (continued) • Treatment prescribed by a physician or licensed psychologist:

These services include:

− Applied Behavior Analysis (ABA) treatment • Applied Behavior Analysis (ABA) is covered subject to the following requirements:

— Treatment plan – A BCBSM-approved autism evaluation center that evaluates the

member will recommend a treatment plan. The plan must include ABA treatment. If BCBSM requests treatment review, BCBSM will pay for it.

— Preapproval – ABA treatment must be approved by BCBSM before treatment is given. If not, you will have to pay for it. Other autism services do not have to be approved beforehand.

• Treatment must be provided or supervised by one of the following:

— A board-certified behavior analyst

• We do not cover any other services provided by a board-certified behavior analyst

including, but not limited to, treatment of traumatic brain injuries.

— A licensed psychologist

• The psychologist must have adequate formal university training and supervised experience in ABA.

− Behavioral health treatment (BHT) – Evidence-based counseling is part of BHT. A licensed

psychologist must perform or supervise this treatment. The psychologist must have adequate formal university training and supervised experience in BHT.

− Psychiatric care – It includes a psychiatrist’s direct or consulting services. The psychiatrist must be licensed in the state where they practice.

− Psychological care. It includes a psychologist’s direct or consulting services. The psychologist must be licensed in the state where they practice.

− Therapeutic care. Evidence-based services from licensed providers. It includes:

• Physical therapy • Occupational therapy • Speech and language pathology • Services from a social worker • Nutritional therapy from a physician • Genetic testing, as recommended in the treatment plan

Benefits for autism treatment are in addition to any other mental health or medical benefits you have under this certificate.





CERTIFICATE SG

Autism Disorder (continued) Coverage Requirements All autism services and treatment must be: • Medically necessary and appropriate • Comprehensive and focused on managing and improving the symptoms directly related to a

member’s Autism Spectrum Disorder. • Deemed safe and effective by BCBSM.

Autism treatment or services deemed experimental or investigational by BCBSM, such as ABA treatment, are covered only if:

– Preapproved by BCBSM – Included in the treatment plan recommended by a BCBSM-approved autism

evaluation center that evaluated and diagnosed the member’s condition

Limitations and Exclusions In addition to those listed in your certificate and riders the following limitations and exclusions apply: • We pay for ABA treatment for members through the age of 18. This limitation does not apply to:

− Other mental health services to treat or diagnose autism − Medical services, such as physical therapy, occupational therapy, speech and language

pathology services, genetic testing or nutritional therapy to treat or diagnose autism • All covered autism benefits are subject to the cost-sharing requirements in this certificate. • We do not pay for treatments that are not covered benefits. Examples are:

− Sensory integration therapy − Chelation therapy

• We do not pay for treatment of conditions such as:

− Rett’s Disorder − Childhood Disintegrative Disorder

• When a member receives physical therapy, occupational therapy or speech and language

pathology for treatment of a covered autism disorder, those services do not apply to the benefit maximums listed in this certificate.




CERTIFICATE SG

Autism Disorder (continued) Limitations and Exclusions (continued) • When a member receives preapproved services for covered autism disorders, coverage for the

services under this autism benefit overrides certain exclusions in your certificate such as the exclusion of:

− Experimental treatment − Treatment of chronic, developmental or congenital conditions − Treatment of learning disabilities or inherited speech abnormalities − Treatment solely to improve cognition, concentration and/or attentiveness, organizational or

problem-solving skills, academic skills, impulse control or other behaviors for which behavior modification is sought

• We only pay for autism services performed in Michigan from participating or nonparticipating

providers who are registered with BCBSM.

• We only pay for autism services performed outside Michigan from providers who participate with their local Blue Cross/Blue Shield plan.

You are not required to obtain a referral from your PCP to obtain covered autism benefits.





CERTIFICATE SG

Behavioral Health Services (Mental Health and Substance Use Disorder) See Section 3 on Page 10 for what you may be required to pay for these services. For autism disorders, please see Page 31. For emergency services to treat behavioral health conditions, please see Page 58. Coverage Requirements BCBSM covers medically necessary and medically appropriate services to evaluate, diagnose, and treat behavioral health conditions in accordance with generally accepted standards of practice. Medically necessary covered services are those considered by a professional provider, exercising prudent clinical judgment, to be clinically appropriate, and effective for the member’s illness, injury, or disease. The services must not be more costly than an alternative service or sequence of services that are at least as likely to produce equivalent results. For diagnostic testing, the results must be essential to, and used in the diagnosis or management of, the member’s condition. BCBSM does not cover treatment or services that: • Have not been determined as medically necessary or appropriate

• Are mainly for the convenience of the member or health care provider

• Are considered experimental or investigational

See Section 8 for a definition of “medically necessary” and “experimental treatment.” When a member receives behavioral health services under a case management agreement that they, their provider and a BCBSM case manager have signed, the member will pay their in-network cost share even if the provider is out-of-network and/or does not participate with BCBSM. Mental Health Locations: We pay for mental health services in: • A participating hospital • A participating psychiatric residential treatment facility (PRTF)

• A participating outpatient psychiatric care (OPC) facility.

• An office




CERTIFICATE SG

Behavioral Health Services (Mental Health and Substance Use Disorder) (continued) Mental Health (continued) We pay for: • Electroconvulsive Therapy (ECT)

− Only covered in an inpatient or outpatient hospital location − When administered by, or under the supervision, of a physician − Anesthetics for ECT when administered by, or under the supervision of, a physician other than

the physician giving the ECT • Transcranial Magnetic Stimulation (TMS)

− Must be provided by a board-certified psychiatrist in an outpatient setting.

TMS services are payable as professional services only. • Inpatient hospital-mental health services

The following services are payable when provided by a physician or by a fully licensed psychologist with hospital privileges:

− Individual psychotherapeutic treatment − Family counseling − Group psychotherapeutic treatment − Psychological testing prescribed or performed by a physician. The tests must be directly related

to the condition for which the member is admitted or have a full role in rehabilitative or psychiatric treatment programs

− Inpatient consultations. If a physician needs help diagnosing or treating a member’s condition, we pay for inpatient consu

physician choice ppo sg - bcbsm.com · when a newborn is added to the contract they will be placed...

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