Common use of Health Plan Benefit Package Clause in Contracts

Health Plan Benefit Package. The Benefit Grid (Grid) below describes the Health Plan’s Customized Benefit Package (CBP). The Health Plan’s CBP must meet actuarial equivalency and sufficiency standards for the population or populations which will be covered by the CBP. The Health Plan shall submit its CBP for recertification of actuarial equivalency and sufficiency standards on an annual basis. The Grid displays the services to be covered and the areas that are customized by the Prepaid Health Plan, whether that is co-pays, or the amount, duration or scope of the services. The shaded areas indicate that no changes to the services in that part of the Grid can be changed from the Medicaid fee-for-service coverage limits. If the Health Plan submits a Benefit Grid with any input cells left blank, that indicates the coverage level of the respective benefit is at the fee-for-service coverage limits. If the CBP includes expanded services, beginning with #10 of the Grid, the Prepaid Health Plan must submit additional information with the Grid including projected PMPM costs for the target population, as well as the actuarial rationale for them. This rationale shall include utilization and unit cost expectations for services provided in the benefit. The Health Plan shall submit its CBP for recertification of actuarial equivalency and sufficiency standards no later than June 30th of each year. All Listed Services must be covered for Children and Pregnant Adults if medically necessary with no co-pay 1 Hospital Inpatient 45 days Behavioral Health day or admit Physical Health day or admit 2 Transplant Services all medically nec 3 Outpatient Services Emergency Room all medically nec Medical/Drug Therapies (Chemo, Dialysis) all medically nec Ambulatory Surgery - ASC all mecially nec. Hospital Outpatient Surgery all medically nec visit Independent Lab / Portable X-ray all medically nec day Hospital Outpatient Services NOS sufficiency tested visit Outpatient Therapy (PT/RT) coverage visit Outpatient Therapy (OT/ST) not applicable

Health Plan Benefit Package. 1. The Benefit Grid (Grid) below describes the Health Plan’s Customized Benefit Package (CBP). The Health Plan’s CBP must meet actuarial equivalency and sufficiency standards for the population or populations which will be covered by the CBP. The Health Plan shall submit its CBP for recertification of actuarial equivalency and sufficiency standards on an annual basis. 2. The Grid displays the services to be covered and the areas that are customized by the Prepaid Health Plan, whether that is co-pays, or the amount, duration or scope of the services. The shaded areas indicate that no changes to the services in that part of the Grid can be changed from the Medicaid fee-for-service coverage limits. 3. If the Health Plan submits a Benefit Grid with any input cells left blank, that indicates the coverage level of the respective benefit is at the fee-for-service coverage limits. 4. If the CBP includes expanded services, beginning with #10 of the Grid, the Prepaid Health Plan must submit additional information with the Grid including projected PMPM costs for the target population, as well as the actuarial rationale for them. This rationale shall include utilization and unit cost expectations for services provided in the benefit. 5. The Health Plan shall submit its CBP for recertification of actuarial equivalency and sufficiency standards no later than June 30th of each year. All Listed Services must be covered for Children and & Pregnant Adults if medically necessary with no co-pay 1 Hospital Inpatient 45 days Behavioral Health day or admit Physical Health day or admit 2 Transplant Services all medically nec 3 Outpatient Services Emergency Room all medically nec Medical/Drug Therapies (Chemo, Dialysis) all medically nec Ambulatory Surgery - ASC all mecially nec. Hospital Outpatient Surgery all medically nec visit Independent Lab / Portable X-ray all medically nec day Hospital Outpatient Services NOS sufficiency tested visit Outpatient Therapy (PT/RT) coverage visit Outpatient Therapy (OT/ST) not applicable

Health Plan Benefit Package. The Benefit Grid (Grid) below describes the Health Plan’s Customized Benefit Package (CBP). The Health Plan’s CBP must meet actuarial equivalency and sufficiency standards for the population or populations which will be covered by the CBP. The Health Plan shall submit its CBP for recertification of actuarial equivalency and sufficiency standards on an annual basis. The Grid displays the services to be covered and the areas that are customized by the Prepaid Health Plan, whether that is co-pays, or the amount, duration or scope of the services. The shaded areas indicate that no changes to the services in that part of the Grid can be changed from the Medicaid fee-for-service coverage limits. If the Health Plan submits a Benefit Grid with any input cells left blank, that indicates the coverage level of the respective benefit is at the fee-for-service coverage limits. If the CBP includes expanded services, beginning with #10 of the Grid, the Prepaid Health Plan must submit additional information with the Grid including projected PMPM costs for the target population, as well as the actuarial rationale for them. This rationale shall include utilization and unit cost expectations for services provided in the benefit. The Health Plan shall submit its CBP for recertification of actuarial equivalency and sufficiency standards no later than June 30th of each year. All Listed Services must be covered for Children and Pregnant Adults if medically necessary with no co-pay 1 Hospital Inpatient 45 days Behavioral Health day or admit Physical Health day or admit 2 Transplant Services all medically nec 3 Outpatient Services Emergency Room all medically nec Medical/Drug Therapies (Chemo, Dialysis) all medically nec Ambulatory Surgery - ASC all mecially nec. Hospital Outpatient Surgery all medically nec visit Independent Lab / Portable X-ray all medically nec day Hospital Outpatient Services NOS sufficiency tested visit Outpatient Therapy (PT/RT) coverage visit Outpatient Therapy (OT/ST) not applicable

Health Plan Benefit Package. 1. The Benefit Grid (Grid) below describes the Health Plan’s Customized Benefit Package (CBP). The Health Plan’s CBP must meet actuarial equivalency and sufficiency standards for the population or populations which will be covered by the CBP. The Health Plan shall submit its CBP for recertification of actuarial equivalency and sufficiency standards on an annual basis. 2. The Grid displays the services to be covered and the areas that are customized by the Prepaid Health Plan, whether that is co-pays, or the amount, duration or scope of the services. The shaded areas indicate that no changes to the services in that part of the Grid can be changed from the Medicaid fee-for-service coverage limits. 3. If the Health Plan submits a Benefit Grid with any input cells left blank, that indicates the coverage level of the respective benefit is at the fee-for-service coverage limits. 4. If the CBP includes expanded services, beginning with #10 of the Grid, the Prepaid Health Plan must submit additional information with the Grid including projected PMPM costs for the target population, as well as the actuarial rationale for them. This rationale shall include utilization and unit cost expectations for services provided in the benefit. 5. The Health Plan shall submit its CBP for recertification of actuarial equivalency and sufficiency standards no later than June 30th of each year. Health Plan: _________________ Target Population: _________________ All Listed Services must be covered for Children and & Pregnant Adults if medically necessary with no co-pay 1 Hospital Inpatient 45 days Behavioral Health day or admit Physical Health day or admit 2 Transplant Services all medically nec 3 Outpatient Services Emergency Room all medically nec Medical/Drug Therapies (Chemo, Dialysis) all medically nec Ambulatory Surgery - ASC all mecially nec. Hospital Outpatient Surgery all medically nec visit Independent Lab / Portable X-ray all medically nec day Hospital Outpatient Services NOS sufficiency tested visit Outpatient Therapy (PT/RT) coverage visit Outpatient Therapy (OT/ST) not applicable