___________

Appendix C

Examples of Possible Degrees of Specificity of
Inclusions in Small Group and Individual Markets

This appendix first provides illustrative information on health plan inclusions as reported through surveys (BLS, 2009; Mercer, 2009, 2011), plan documents (DOL, 2011), and a listing of Maryland’s guidance on comprehensive standard health plan requirements for plans offered to small businesses (Table C-1) (MHCC, 2011). Subsequent tables provide detailed inclusion information for standard small group and individual policies for three insurers: CIGNA (Table C-2),1 UnitedHealthcare (Table C-3),2 and WellPoint (Table C-4).3 Each of these insurers responded in their own words and their own understanding of the terms, so the manner in which they responded varies slightly. Also it should be noted that while some services are listed under headings using the 10 categories of care, this does not mean that the other services listed later in the table could not be classified under one of those headings.

1 Personal communication with Rosemary Lester, CIGNA Product, September 9, 2011.

2 Personal communication with Sam Ho, UnitedHealthcare, September 28, 2011.

3 Personal communication with Ruth Raskas, WellPoint, September 9, 2011.



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Appendix C Examples of Possible Degrees of Specificity of Inclusions in Small Group and Individual Markets This appendix first provides illustrative information on health plan inclusions as reported through surveys (BLS, 2009; Mercer, 2009, 2011), plan documents (DOL, 2011), and a listing of Maryland’s guidance on com - prehensive standard health plan requirements for plans offered to small businesses (Table C-1) (MHCC, 2011). Subsequent tables provide detailed inclusion information for standard small group and individual policies for three insurers: CIGNA (Table C-2),1 UnitedHealthcare (Table C-3),2 and WellPoint (Table C-4).3 Each of these insurers responded in their own words and their own understanding of the terms, so the manner in which they responded varies slightly. Also it should be noted that while some services are listed under headings using the 10 categories of care, this does not mean that the other services listed later in the table could not be classified under one of those headings. 1 Personal communication with Rosemary Lester, CIGNA Product, September 9, 2011. 2 Personal communication with Sam Ho, UnitedHealthcare, September 28, 2011. 3 Personal communication with Ruth Raskas, WellPoint, September 9, 2011. 169

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TABLE C-1 Reported Frequency of Benefit Coverage 170 Category (Section 1302 category shaded in grey)a BLS 2009 BLS 2009 Mercer Mercer Mercer [Note: organization of table Large Small 2009 2009 2011 Maryland’s Standard Health does not endorse classification DOL 2011 Employer Employer Large Small All Benefit Plan Requirements for of service into category] (%)b (%)c (%)d (%)e (%)f (%)g Small Businesses (MHCC, 2011) Ambulatory patient services Kidney dialysis 27%h 95% Outpatient facility charges 98% Covered (outpatient hospital services) Outpatient surgery 97% 98% Covered Physician office visits 100% 100% 100% Urgent care facility services Allergy testing and injections Emergency services Ambulance services 64%i Covered Emergency room visits 91%j Covered Hospitalization Hospital room and board 99% 99% 100% Covered (hospitalization) Inpatient surgery 98% 99% Organ and tissue transplantation 45%k 95% (organ Covered (for bone marrow, transplants) cornea, kidney, liver, lung, heart, heart-lung, pancreas, and pancreas-kidney transplants) Maternity and newborn care Maternity care 66%l Covered (pregnancy and maternity) Mental health and substance use disorder services, including behavioral health treatment Autism services 80% 69% Applied behavioral 50% analysis for autism Speech, occupational, and 61% physical therapies for autism

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TABLE C-1 Reported Frequency of Benefit Coverage, Continued Category (Section 1302 category shaded in grey)a BLS 2009 BLS 2009 Mercer Mercer Mercer [Note: organization of table Large Small 2009 2009 2011 Maryland’s Standard Health does not endorse classification DOL 2011 Employer Employer Large Small All Benefit Plan Requirements for of service into category] (%)b (%)c (%)d (%)e (%)f (%)g Small Businesses (MHCC, 2011) Mental health and substance abusem Covered Inpatient 99% Covered Outpatient 85% Covered Inpatient substance abuse 98% Covered detoxification Inpatient substance abuse 78% rehabilitation Outpatient substance abuse 79% rehabilitation Prescription drugs Covered (generic and brand name drugs) Pharmacy (full generic + brand coverage) Pharmacy (generic only to full generic + brand coverage) Pharmacy (generic +1 to full generic + brand coverage) Specific types of drugs Smoking cessation drugs 64% (for nicotine addiction) Weight loss drugs Infertility drugs Contraceptives 88% Sexual dysfunction drugs 171 continued

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TABLE C-1 Reported Frequency of Benefit Coverage, Continued 172 Category (Section 1302 category shaded in grey)a BLS 2009 BLS 2009 Mercer Mercer Mercer [Note: organization of table Large Small 2009 2009 2011 Maryland’s Standard Health does not endorse classification DOL 2011 Employer Employer Large Small All Benefit Plan Requirements for of service into category] (%)b (%)c (%)d (%)e (%)f (%)g Small Businesses (MHCC, 2011) Rehabilitative and habilitative services and devices Habilitative services Habilitative: covered (for children 0-19 for treatment of congenital or genetic birth defects) Cardiac rehabilitation Durable medical equipment 67%n 97% Covered Early intervention services Hearing tests and hearing aids Covered (audiology screening for newborns) Hearing aids 43% Covered (for children 0-18) Orthotics Occupational therapy 92% Covered (outpatient, short term) Speech therapy (general) 85% Covered (outpatient, short term) Physical therapy 70%o 99% Prosthetics 46%p 86% Pulmonary rehabilitation Laboratory services Laboratory and diagnostic services Covered (outpatient laboratory and diagnostic services) Blood and blood products All cost recovery for blood derivatives, components, biologics, and serums, to include autologous services and albumin Preventive and wellness services and chronic disease management Case management Program available for medically complex and costly services Diabetes care management 27%q Gynecological exams and services 60%r

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TABLE C-1 Reported Frequency of Benefit Coverage, Continued Category (Section 1302 category shaded in grey)a BLS 2009 BLS 2009 Mercer Mercer Mercer [Note: organization of table Large Small 2009 2009 2011 Maryland’s Standard Health does not endorse classification DOL 2011 Employer Employer Large Small All Benefit Plan Requirements for of service into category] (%)b (%)c (%)d (%)e (%)f (%)g Small Businesses (MHCC, 2011) Nutritional counseling 53% Covered (nutritional services for cardiovascular disease, diabetes, malnutrition, cancer, cerebral vascular disease, or kidney disease) Medical nutritional therapy (diabetes-related) Medical nutritional therapy (obesity-related) Preventive care services Covered (services rated by the USPSTF as A or B) Well child and immunization 77%s Covered (well child visits children benefits 0-24 months and visits including immunizations in children 24 months to 13 years) Pediatric services, including oral and vision care Pediatric dental 46% Pediatric vision 44% Specific types of services Advanced imaging Alternative medicine (acupuncture, acupressure, massage therapy, etc.) Acupuncture 35% 24% 41% Massage therapy 22% 18% Bariatric surgery and treatment of 60% (bariatric morbid obesity surgery) Biofeedback 7% 6% Chiropractic 89% 72% 94% Covered Adult dental care—preventive and basic Elective abortion 173 continued

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TABLE C-1 Reported Frequency of Benefit Coverage, Continued 174 Category (Section 1302 category shaded in grey)a BLS 2009 BLS 2009 Mercer Mercer Mercer [Note: organization of table Large Small 2009 2009 2011 Maryland’s Standard Health does not endorse classification DOL 2011 Employer Employer Large Small All Benefit Plan Requirements for of service into category] (%)b (%)c (%)d (%)e (%)f (%)g Small Businesses (MHCC, 2011) Family planning services Covered Home health care 73% 71% 75% 93% Covered Homeotherapy 12% 11% Hospice care 67% 66% 69% 91% (hospice Covered and palliative care) Infertility and assisted 27%t 58% 34% 51% Covered (after diagnosis of reproduction services infertility) Evaluation by specialist 53% 29% Drug therapy 35% 20% Artificial insemination 24% 9% In vitro fertilization 23% 9% Excluded Advanced reproductive 12% 3% procedures Medical food Covered (for persons with metabolic disorders) Orthodontia 49% Private duty nursing Skilled nursing care 93% Covered Skilled nursing facility 70% 69% 72% Sterilization 26%u TMJ treatment and appliances 55% Therapy services (radiation, chemo, non-preventive infusion and injection) Vision exam, refraction Vision therapy 42% a With the exception of “specific types of services,” which is not one of the Section 1302 categories.

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TABLE C-1 Reported Frequency of Benefit Coverage, Continued b The DOL report (2011) presents data from the National Compensation Survey and a separate plan abstraction exercise as a percentage of workers who are participating in medical care plans. For plan abstraction data, the portion of workers whose plan documents do not mention a service is reported. Many of the services examined are reported by extent of coverage (e.g., coverage in full, subject to overall plan limits or separate limits, co-payment requirements), and the report provides some detail on median co-payments, for example: hospital room and board per admission ($250), physician office visits ($20), ER visits ($50-$150), physical therapy visits ($10-$40), maternity care ($10-$40), and gynecological exams and services ($10-$35). c 100+ workers; the Bureau of Labor Statistics (BLS) National Compensation Survey data reports so that all workers in the medical plans equal 100 percent. d 1-99 workers. e 500+ workers. f 10-499 workers. g The Mercer report presents all data as a percentage of “typical” employer health plans. Most coverage is broken down by percentage offering coverage, percentage with some type of coverage limit in 2010, the median dollar amount for those plans with annual dollar limits in 2010, and of the plans with limits, the percentage making a change due to PPACA for 2011. h 73 percent of workers’ plans reviewed by the DOL do not mention coverage. i 35 percent of workers’ plans reviewed by the DOL do not mention coverage. j 9 percent of workers’ plans reviewed by the DOL do not mention coverage. k 55 percent of workers’ plans reviewed by the DOL do not mention coverage. l 33 percent of workers’ plans reviewed by the DOL do not mention coverage. m The DOL data predate implementation of the Mental Health Parity and Addiction Equity Act of 2008. n 33 percent of workers’ plans reviewed by the DOL do not mention coverage. o 30 percent of workers’ plans reviewed by the DOL do not mention coverage. p 54 percent of workers’ plans reviewed by the DOL do not mention coverage. q 73 percent of workers’ plans reviewed by the DOL do not mention coverage. r 40 percent of workers’ plans reviewed by the DOL do not mention coverage. s Well baby care. t 53 percent of workers’ plans reviewed by the DOL do not mention coverage, and an additional 20 percent do not have coverage. u 73 percent of workers’ plans reviewed by the DOL do not mention coverage, and an additional 2 percent do not have coverage. SOURCE: BLS (Bureau of Labor Statistics), 2009, Table 14. Medical care benefits: Coverage for selected services, private industry workers, National Compensation Survey, 2008, in National Compensation Survey: Health plan provisions in private industry in the United States, 2008, Washington, DC: U.S. Bureau of Labor Statistics; DOL (Department of Labor), 2011, Selected medical benefits: A report from the Department of Labor to the Department of Health and Human Services, http://www.bls.gov/ncs/ebs/sp/selmedbensreport.pdf (accessed June 13, 2011); Mercer, 2009, National survey of employer-sponsored health plans, New York: Mercer, Inc.; Mercer, 2011, Health care reform: The question of essential benefits. The third report in Mercer’s ongoing series of topical surveys on health reform, New York: Mercer, Inc., MHCC (Maryland Health Care Commission), 2011, Maryland’s comprehensive standard benefit plan for small businesses, http://mhcc.maryland.gov/smallgroup/cshbp_brochure.htm (accessed November 7, 2011). 175

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TABLE C-2 CIGNA Inclusions 176 In some instances, the plan language in the “Category” column 1 varies slightly from CIGNA’s plan language. The information is being provided with the understanding that the intent of the request is to identify service benefits and not to validate plan language. This reflects “typical” individual and small group employer plans and is subject to change. Category (1302 category shaded in greyv) [Note: organization of table CIGNA Typical Small Group Employer Plan CIGNA Typical Individual Benefit Plan does not endorse classification of service into category] (Includes Limitsw) (Includes Limitsw) Ambulatory patient services Dialysis/hemodialysis Benefit Benefit (facility/professional services) Outpatient facility charges Benefit (facility services) Benefit (facility services) Outpatient surgery Benefit Benefit (facility/professional services) Physician office visits (primary care, specialist, pre and post natal) Benefit (PCP/specialist) Benefit (PCP/specialist) Urgent care facility services Benefit Benefit Allergy testing and injections Benefit Benefit Outpatient hospital professional services (surgeon, radiologist, pathologist, Benefit Benefit anesthesiologist) Emergency services Ambulance services Benefit Benefit Emergency room visits Benefit Benefit Facility charge Benefit Benefit Hospitalization Hospital room and board Benefit (inpatient) Benefit (inpatient, semi-private room rate) Inpatient physician services (general medical care, surgery) Benefit (hospital physician’s visits/ Benefit (hospital physician’s visits/ consultations) and professional services consultations) and professional services (surgeon, radiologist, pathologist, (surgeon, radiologist, pathologist, anesthesiologist) anesthesiologist) Inpatient surgery Benefit Benefit Organ and tissue transplantation (in network only) Benefit (with limits)x Benefit (with limits)x Maternity and newborn care Normal pregnancy/delivery is Not a Benefit unless mandated; ONLY complications of pregnancy as defined in the Policy are Benefit Maternity care Benefit Not a Benefit for normal pregnancy/delivery; Benefit ONLY for complications of pregnancy as defined in the Policy Mental health and substance use disorder services, including behavioral health treatment Autism services Coverage varies by service Coverage varies by service Applied behavioral analysis for autism Not a Benefit, unless state mandates apply Not a Benefit, unless state mandates apply Speech, occupational and physical therapies for autism Not a Benefit, unless state mandates apply Not a Benefit, unless state mandates apply

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TABLE C-2 CIGNA Inclusions, Continued Category (1302 category shaded in greyv) [Note: organization of table CIGNA Typical Small Group Employer Plan CIGNA Typical Individual Benefit Plan does not endorse classification of service into category] (Includes Limitsw) (Includes Limitsw) Mental health and substance abuse Inpatient mental health Benefit Usually a Benefit, with limits Outpatient mental health Benefit Usually a Benefit, with limits Inpatient substance abuse detoxification Benefit Benefit Inpatient substance abuse rehabilitation Not a Benefit, unless state mandates apply Not a Benefit, unless state mandates apply Outpatient substance abuse rehabilitation Not a Benefit, unless state mandates apply Not a Benefit, unless state mandates apply Prescription drugs Prescription drugs Benefit, deductible applies Benefit, deductible applies Pharmacy (full generic + brand coverage) Benefit, deductible applies Benefit, deductible applies Pharmacy (generic only to full generic + brand coverage) N/A N/A Pharmacy (generic + 1 to full generic + brand coverage) N/A N/A Specific types of drugs Smoking cessation drugs Not a Benefit Not a Benefit Weight loss drugs Not a Benefit Not a Benefit Infertility drugs Not a Benefit, unless state mandates apply Not a Benefit, unless state mandates apply Prescribed contraceptives Policyholder Option Benefit (with co-payment) OTC contraceptives Not a benefit Not a Benefit Sexual dysfunction drugs Not a Benefit Not a Benefit Rehabilitative and habilitative services and devices Habilitative services Not a Benefit Not a Benefit Cardiac rehabilitation Benefit (short term, with benefit limits) Benefit (short term, with benefit limits) Durable medical equipment Benefit, with benefit limits Benefit, with benefit limits Early intervention services Not a Benefit, unless state mandates apply Not a Benefit, unless state mandates apply Hearing tests and hearing aids Not a Benefit, unless state mandates apply Not a Benefit, unless state mandates apply Hearing aids Not a Benefit, unless state mandates apply Not a Benefit, unless state mandates apply Orthotics Not a Benefit, unless state mandates apply Not a Benefit, unless state mandates apply Occupational therapy Benefit (short term, with benefit limits) Benefit (short term, with benefit limits) Speech therapy (general) Benefit (short term, with benefit limits) Not a Benefit, unless state mandates apply Physical therapy Benefit (short term, with benefit limits) Benefit (short term, with benefit limits) Prosthetics (external prosthetic appliances only) Benefit Benefit Pulmonary rehabilitation Benefit, with limits Benefit (short term, with benefit limits) 177 continued

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TABLE C-2 CIGNA Inclusions, Continued 178 In some instances, the plan language in the “Category” column 1 varies slightly from CIGNA’s plan language. The information is being provided with the understanding that the intent of the request is to identify service benefits and not to validate plan language. This reflects “typical” individual and small group employer plans and is subject to change. Category (1302 category shaded in greyv) [Note: organization of table CIGNA Typical Small Group Employer Plan CIGNA Typical Individual Benefit Plan does not endorse classification of service into category] (Includes Limitsw) (Includes Limitsw) Laboratory services Laboratory and diagnostic services Benefit Benefit Other diagnostic tests (hearing, EKG) Benefit Benefit Other facility charges (diagnostic lab/x-ray/supplies) Benefit Benefit Advanced imaging (MRI, CT scan, etc.) Benefit Benefit Blood and blood products Benefit Benefit Preventive and wellness services and chronic disease management Case management Not a Benefit Not a Benefit Diabetes care management Not a Benefit Not a Benefit Gynecological exams and services Benefit Benefit Nutritional counseling Benefit for specific conditions Benefit for specific conditions Medical nutritional therapy (diabetes-related) Benefit Not a Benefit, unless state mandates apply Medical nutritional therapy (obesity-related) Not a Benefit Not a Benefit Preventive care services Benefit Benefit Well child and immunization benefits Benefit Benefit Pediatric services, including oral and vision care Pediatric dental Not a Benefit Not a Benefit Pediatric vision Not a Benefit Not a Benefit Specific types of services Advanced imaging Benefit Benefit Alternative medicine (acupuncture, acupressure, massage therapy, etc.) Not a Benefit Not a Benefit Acupuncture Not a Benefit Not a Benefit unless mandated Massage therapy Not a Benefit Not a Benefit Bariatric surgery and treatment of morbid obesity Not a Benefit, unless state mandates apply Not a Benefit, unless state mandates apply Biofeedback Not a Benefit Not a Benefit Chiropractic Not a separate Benefit Not a separate Benefit Adult dental care—preventive and basic Not a Benefit Not a Benefit Dental care—injury to sound natural teeth Benefit Benefit Elective abortion Policyholder Option Not a Benefit, unless state mandates apply (non-elective abortion is a Benefit)

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TABLE C-2 CIGNA Inclusions, Continued Category (1302 category shaded in greyv) [Note: organization of table CIGNA Typical Small Group Employer Plan CIGNA Typical Individual Benefit Plan does not endorse classification of service into category] (Includes Limitsw) (Includes Limitsw) Family planning services (tests/counseling only) Benefit Benefit Home health care services Benefit, with benefit limits Benefit, with benefit limits Home dialysis Benefit, with limits Benefit, with limits Home infusion therapy Benefit Benefit, with limits Homeotherapy Not a Benefit Not a Benefit Hospice care Benefit Benefit Infertility and assisted reproduction services Evaluation by specialist Not a Benefit Not a Benefit Drug therapy Not a Benefit Not a Benefit Artificial insemination Not a Benefit Not a Benefit In vitro fertilization Not a Benefit Not a Benefit Advanced reproductive procedures Not a Benefit Not a Benefit Medical food Not a Benefit, unless state mandates apply Not a Benefit, unless state mandates apply Orthodontia Not a Benefit Not a Benefit Private duty nursing Not a Benefit Not a Benefit Residential treatment center Benefit, with benefit limits Benefit, with benefit limits Skilled nursing care Benefit, with benefit limits Benefit, with benefit limits Skilled nursing facility Benefit, with benefit limits Benefit, with benefit limits Sterilization Benefit Benefit TMJ treatment and appliances Benefit, treatment only (appliances are Benefit, treatment only (appliances are Not a Benefit) Not a Benefit) Therapy services (radiation, chemo, non-preventive infusion and injection) Benefit Benefit (inpatient and outpatient) Vision exam/refraction Not a Benefit Not a Benefit Vision therapy Not a Benefit Not a Benefit v With the exception of “specific types of services.” w Typical small group employer plans provide broad health care coverage while including limits on certain services, but that would meet the majority of the overall population’s health care needs. x Also covers for organ transplants—travel, with benefit limits. 179

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TABLE C-3 UnitedHealthcare (UHC) Inclusions 180 Category (1302 category shaded in greyy) [Note: organization of table UHC Typical Small UHC Typical does not endorse classification of service into category] Group Employer Plan Individual Plan Ambulatory patient services Dialysis/hemodialysis Covered Covered Outpatient facility charges Covered Covered Outpatient surgery Covered Covered Physician office visits (primary care, specialist, pre and post natal) Covered Covered, except pre and post natal excluded Urgent care facility services Covered Covered Allergy testing and injections Covered Covered Outpatient hospital professional services (surgeon, radiologist, pathologist, anesthesiologist) Covered Covered Emergency services Ambulance services Covered Covered, ground and air Emergency room visits Covered Covered Facility charge Covered Covered Hospitalization Hospital room and board Covered Covered Inpatient physician services (general medical care, surgery) Covered Covered Inpatient surgery Covered Covered Organ and tissue transplantation Covered Covered Maternity and newborn care Maternity care Covered Routine maternity and newborn excluded Complications of pregnancy covered Mental health and substance use disorder services, including behavioral health treatment Autism services Covered, for eligible Limited Coverage services Applied behavioral analysis for autism Covered—only in states Limited Coverage where mandated Speech, occupational and physical therapies for autism Covered Limited Coverage Mental health and substance abuse Covered Excluded, unless Optional benefit purchased Inpatient Covered Excluded, unless Optional benefit purchased Outpatient Covered Excluded, unless Optional benefit purchased Inpatient substance abuse detoxification Covered Excluded, except for alcohol detox covered Inpatient substance abuse rehabilitation Covered Excluded Outpatient substance abuse rehabilitation Covered Excluded, unless Optional benefit purchased

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TABLE C-3 UHC Inclusions, Continued Category (1302 category shaded in greyy) [Note: organization of table UHC Typical Small UHC Typical does not endorse classification of service into category] Group Employer Plan Individual Plan Prescription drugs Prescription drugs Covered if rider purchased Covered Pharmacy (full generic + brand coverage) Generally covered Covered Pharmacy (generic only to full generic + brand coverage) Generally covered Covered Pharmacy (generic + 1 to full generic + brand coverage) Generally covered Covered Specific types of drugs Smoking cessation drugs Covered—only in states Excluded where mandated Weight loss drugs Covered—only in states Excluded where mandated Infertility drugs Covered—only in states Excluded where mandated Contraceptives Covered Covered Sexual dysfunction drugs Covered Excluded Rehabilitative and habilitative services and devices Habilitative services Not covered Limited Coverage Cardiac rehabilitation Covered Limited Coverage Durable medical equipment Covered Limited Coverage Early intervention services Not covered Excluded, unless state mandate Hearing tests and hearing aids Covered Covered Hearing aids Covered Excluded, unless state mandate Orthotics Varies based on orthotic type Excluded, except one pair foot orthotics per person Occupational therapy Covered Excluded Speech therapy (general) Covered Excluded Physical therapy Covered Covered Prosthetics Covered Limited Coverage Pulmonary rehabilitation Covered Covered Inpatient, Outpatient, must be covered provider Laboratory services Laboratory and diagnostic services Covered Covered Other diagnostic tests (hearing, EKG) Covered Covered Other facility charges (diagnostic lab/x-ray/supplies) Covered Covered 181 continued

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TABLE C-3 UHC Inclusions, Continued 182 Category (1302 category shaded in greyy) [Note: organization of table UHC Typical Small UHC Typical does not endorse classification of service into category] Group Employer Plan Individual Plan Advanced imaging (MRI, CT scan, etc.) Covered Covered Blood and blood products Covered Excluded Preventive and wellness services and chronic disease management Case management Program available Excluded Diabetes care management Program available Covered Gynecological exams and services Covered Covered Nutritional counseling Covered for management of Excluded specific clinical conditions Medical nutritional therapy (diabetes-related) Covered Excluded Medical nutritional therapy (obesity-related) Weight loss programs Excluded excluded Preventive care services Covered Covered subject to HCR Guidelinesz Well child and immunization benefits Covered Covered subject to HCR Guidelinesz Pediatric services, including oral and vision care Pediatric dental Excluded Excluded Pediatric vision Covered—refractive exams Excluded only, every other year Specific types of services Advanced imaging Covered Covered Alternative medicine (acupuncture, acupressure, massage therapy, etc.) Excluded Excluded Acupuncture Excluded Excluded Massage therapy Excluded Excluded Bariatric surgery and treatment of morbid obesity Excluded Excluded Biofeedback Coverage varies by Excluded condition Chiropractic Covered Covered Adult Dental care—preventive and basic Excluded Excluded Dental care—injury to sound natural teeth Covered Covered Elective abortion Covered Excluded Family planning services Covered Covered Home health care services Covered Covered Home dialysis Covered Covered

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TABLE C-3 UHC Inclusions, Continued Category (1302 category shaded in greyy) [Note: organization of table UHC Typical Small UHC Typical does not endorse classification of service into category] Group Employer Plan Individual Plan Home infusion therapy Covered Covered Homeotherapy Excluded Excluded Hospice care Covered Covered Infertility and assisted reproduction services Covered through to the Excluded point of diagnosis. Assisted reproductive services excluded. Evaluation by specialist Assisted reproductive Excluded services excluded. Drug therapy Assisted reproductive Excluded services excluded. Artificial insemination Assisted reproductive Excluded services excluded. In vitro fertilization Assisted reproductive Excluded services excluded. Advanced reproductive procedures Assisted reproductive Excluded services excluded. Medical food Excluded Excluded Orthodontia Excluded Excluded Private duty nursing Excluded Excluded Residential treatment center Covered for MHSA Excluded Skilled nursing care Covered Excluded Skilled nursing facility Covered Limited Coverage Sterilization Covered Excluded TMJ treatment and appliances Some services excluded Surgical treatment only, $10,000 limit Therapy services (radiation, chemo, non-preventive infusion and injection) (inpatient and Covered Covered outpatient) Vision exam/refraction Covered Excluded Vision therapy Covered Excluded y With the exception of “specific types of services.” z HCR means health care reform. 183

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TABLE C-4 WellPoint Inclusions 184 Wellpoint Wellpoint Category (1302 category shaded in greyaa) [Note: organization Anthem Blue Standard Anthem Blue Standard of table does not endorse classification of service into category] for Small Business for Individual Business Ambulatory patient services Dialysisbb/hemodialysis Covered* Covered* Outpatient facility charges Covered* Covered* Outpatient surgery Covered* Covered* Physician office visits (primary care, specialist, pre and post natal Covered* Covered* except for pre and post maternity visits visits) as maternity not covered in most planscc unless purchase maternity rider or state mandated. Urgent care facility services Covered* Covered* Allergy testing and injections Covered* Covered* Emergency services Ambulance services Covered* Covered* Facility charge Covered* Covered* Emergency room visits Covered* Covered* Hospitalization Hospital room and board Covered* Covered* Inpatient surgery Covered* Covered* Organ and tissue transplantation Covered* Covered* Maternity and newborn care Maternity care Covered* Complications of pregnancy Covered* by most plans; otherwise Not Covered unless purchase maternity rider or state mandated. Mental health and substance use disorder services, including behavioral health treatment Autism services Autism diagnosis is Covered* according Autism diagnosis is Covered* according to service type; Coverage criteria may be to service type; Coverage criteria may be determined by mandate. determined by mandate. Applied behavioral analysis for autism Covered* by most plans when required by Covered* by most plans when required by mandate. mandate.

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TABLE C-4 WellPoint Inclusions, Continued Wellpoint Wellpoint Category (1302 category shaded in greyaa) [Note: organization Anthem Blue Standard Anthem Blue Standard of table does not endorse classification of service into category] for Small Business for Individual Business Speech, occupational and physical therapies for autism Covered.* Coverage criteria may be Covered.* Coverage criteria may be determined by mandate. determined by mandate. Mental health and substance abuse Covered* Covered* by most plans. Coverage criteria may be determined by mandate. Inpatient Covered* by most plans Covered* by most plans. Coverage criteria may be determined by mandate. Outpatient Covered* Covered* by most plans. Coverage criteria may be determined by mandate. Inpatient substance abuse detoxification Covered* by most plans Covered* by most plans. Coverage criteria may be determined by mandate. Inpatient substance abuse rehabilitation Covered* Covered* by most plans. Coverage criteria may be determined by mandate. Outpatient substance abuse rehabilitation Covered* Covered* by most plans. Coverage criteria may be determined by mandate. Prescription drugs Prescription drugs Covered* Covered* for all non-grandfathered plans post 9/23/2010 Pharmacy (full generic + brand coverage) Covered* by most plans (generic + brand) Covered* by some planscc (generic + brand) Pharmacy (generic only to full generic + brand coverage) Covered* by some plans (generic only) Covered* by some grandfathered plans prior to 3/23/10 (generic only) Pharmacy (generic + 1 to full generic + brand coverage) Covered* by very few planscc (generic + Covered* by some plans (generic + at least 1 at least 1 brand class) brand class) Specific types of drugs Smoking cessation drugs Covered* by some plans Covered* by some plans Weight loss drugs Not Covered Not Covered Infertility drugs Covered* by some plans as required by Covered* by some plans as required by mandates mandates Contraceptives Covered* Covered* Sexual dysfunction drugs Covered* by most plans Covered* by most plans *Covered subject to terms and conditions of the contract. For example, there may be network limitations, medical policy limitations, cost-sharing requirements, dollar caps, visit limits, etc. 185 continued

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TABLE C-4 WellPoint Inclusions, Continued 186 Wellpoint Wellpoint Category (1302 category shaded in greyaa) [Note: organization Anthem Blue Standard Anthem Blue Standard of table does not endorse classification of service into category] for Small Business for Individual Business Rehabilitative and habilitative services and devices Habilitative servicesdd Covered* by most plans Covered* by most plans Coverage criteria may be determined by Coverage criteria may be determined by mandates mandates Cardiac rehabilitation Covered* Covered* Durable medical equipment Covered* Covered* Early intervention services Covered* by most plans Covered* by most plans Coverage criteria may be determined by Coverage criteria may be determined by mandates mandates Hearing tests and hearing aids Covered* by most plans as required by Covered* by most plans as required by mandates mandates Hearing aids Covered* by some plans as required by Covered* by some plans as required by mandates mandates Medical devices Covered* Covered* Medical supplies received from supplier Covered* Covered* Orthotics Covered* by most plans Covered* by most plans Occupational therapy Covered* Covered* Speech therapy (general) Covered* Covered* Physical therapy Covered* Covered* Prosthetics Covered* Covered* Pulmonary rehabilitation Covered* Covered* Laboratory services Laboratory and diagnostic services Covered* Covered* Other diagnostic tests (hearing, EKG) Covered* Covered* Advanced imaging (MRI, CT scan) Covered* Covered* Blood and blood products Covered* Covered*

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TABLE C-4 WellPoint Inclusions, Continued Wellpoint Wellpoint Category (1302 category shaded in greyaa) [Note: organization Anthem Blue Standard Anthem Blue Standard of table does not endorse classification of service into category] for Small Business for Individual Business Preventive and wellness services and chronic disease management Case management Included as member program Included as member program Diabetes care management Included as member program Included as member program Gynecological exams and services Covered* for all non-grandfathered plans post Covered* for all non-grandfathered plans post 9/23/2010, and for some grandfathered plans 9/23/2010, and for some grandfathered plans Nutritional counseling Covered* for all non-grandfathered plans post Covered* for all non-grandfathered plans post 9/23/2010, and for some grandfathered plans 9/23/2010, and for some grandfathered plans Medical nutritional therapy (diabetes-related) Covered* for all non-grandfathered plans post Covered* for all non-grandfathered plans post 9/23/2010, and for some grandfathered plans 9/23/2010, and for some grandfathered plans Medical nutritional therapy (obesity-related) Covered* for all non-grandfathered plans post Covered* for all non-grandfathered plans post 9/23/2010, and for some grandfathered plans 9/23/2010, and for some grandfathered plans Preventive care services Covered* for all non-grandfathered plans post Covered* for all non-grandfathered plans post 9/23/2010, and for some grandfathered plans 9/23/2010, and for some grandfathered plans Well child and immunization benefits Covered* for all non-grandfathered plans post Covered* for all non-grandfathered plans post 9/23/2010, and for some grandfathered plans 9/23/2010, and for some grandfathered plans Pediatric services, including oral and vision care Pediatric dental Pediatric oral health screening Covered* for all Pediatric oral health screening Covered* for all non-grandfathered plans post 9/23/2010 non-grandfathered plans post 9/23/2010 and for Full dental coverage offered as Rider some grandfathered plans Full dental coverage offered as Rider with most plans Pediatric vision Pediatric vision screening Covered* for all Pediatric vision screening Covered* for all non-grandfathered plans post 9/32/2010 non-grandfathered plans post 9/32/2010 and for some grandfathered plans Vision exam/refraction/eyewear coverage Vision exam/refraction/eyewear coverage in few varies across states plans Full vision coverage offered as Rider *Covered subject to terms and conditions of the contract. For example, there may be network limitations, medical policy limitations, cost-sharing requirements, dollar caps, visit limits, etc. 187 continued

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TABLE C-4 WellPoint Inclusions, Continued 188 Wellpoint Wellpoint Category (1302 category shaded in greyaa) [Note: organization Anthem Blue Standard Anthem Blue Standard of table does not endorse classification of service into category] for Small Business for Individual Business Specific types of services Advanced imaging Covered* Covered* Alternative medicine (acupuncture, acupressure, massage therapy, etc.) Covered* by few plans Covered* by few plans Acupuncture Covered* by some plans Covered* by few plans Massage therapy Covered* by few plans Not Covered Bariatric surgery and treatment of morbid obesity Covered* by some plans mostly as required by Covered* by some plans mostly as required by mandates mandates Biofeedback Covered* by some plans Covered* by some plans Chiropractic Covered* (spinal manipulation) Covered* (spinal manipulation) Adult dental care—preventive and basic Covered* by very few plans Covered* by very few plans Full dental coverage offered as Rider Full dental coverage offered as Rider Dental services related to an accident Covered* Covered* Elective abortion Coverage varies across plans Coverage varies across plans Family planning services Covered* (counseling) by most plans Covered* (counseling) by most plans Home health care Covered* Covered* Homeotherapy Not Covered Not Covered Hospice care Covered* Covered* Infertility and assisted reproduction services Evaluation by specialist Covered* by most plans to diagnose and to Covered* by most plans to diagnose and to treat underlying cause treat underlying cause Drug therapy Covered* by some plans as required by Covered* by some plans as required by mandates mandates Artificial insemination Covered* by some plans as required by Covered* by some plans as required by mandates mandates In vitro fertilization Covered* by some plans as required by Covered* by some plans as required by mandates mandates Advanced reproductive procedures Covered* by some plans as required by Covered* by some plans as required by mandates mandates

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TABLE C-4 WellPoint Inclusions, Continued Wellpoint Wellpoint Category (1302 category shaded in greyaa) [Note: organization Anthem Blue Standard Anthem Blue Standard of table does not endorse classification of service into category] for Small Business for Individual Business Medical food Covered* by most plans Covered* by most plans Orthodontia Full dental (including orthodontia) offered as Full dental (including orthodontia) offered as Rider Rider Private duty nursing Covered* by some plans Covered* by some plans Residential treatment center Covered* by most plans Covered* by most plans Skilled nursing care Covered* as part of Home Health Care or Covered* as part of Home Health Care or Inpatient Inpatient Skilled nursing facility Covered* Covered* Sterilization Covered* except plans in one state Covered* except plans in one state TMJ treatment and appliances Covered* by some plans Covered* by some plans Therapy services (radiation, chemo, non-preventive infusion, including Covered* Covered* home infusion, and injection) Vision exam/refraction Covered* by some plans Covered* by some plans Vision therapy Not Covered by most plans Not Covered * Covered subject to terms and conditions of the contract. For example, there may be network limitations, medical policy limitations, cost-sharing requirements, dollar caps, visit limits, etc. aa With the exception of “other types of categories/services.” bb Home dialysis is also a covered service. cc WellPoint defined few as generally less than 5; some is 5 through 10; and more is greater than 10. dd Habilitation: This is a broad category, and there is likely to be variation in what an insurer defines as habilitative. We do not have a specific habilitation benefit or exclusion, but we do have “habilitative” services that may be covered. We were defining habilitative care as a category that include services such as (1) early intervention; (2) autism mandates (i.e., improving language skills); (3) congenital defect mandates; and (4) home health care services provided by a licensed home health agency (i.e., skilled nursing and physical therapy), not services such as meal preparation, bathing, and medication management). 189

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