Ohio Essential Health Benefits Benchmark Plan Template Page 1 of 7

Ohio Essential Health Benefits Resource Document for 2015 Plan YearBenefits Covered? Benefit DescriptionQuantitativeLimit onService?LimitQuantityLimit Units"Other" LimitUnits DescriptionMinimumStayExclusionsAdditional ExplanationDoes this benefit haveadditional limitations orrestrictions?Inpatient HospitalServices (e.g., HospitalStay)Covered Inpatient Hospital Services No Oral surgery that is dental in origin; Removal of impacted wisdom teeth;Reversal of voluntary sterilization; radial keratotomy, keratoplasty, Lasik andother surgical procedures to correct refractive defects; surgeries for sexualdysfunction; surgeries or services for sexual transformation; surgical treatmentof flat feet, subluxation of the foot, weak, strained, unstable feet, tarsalgia,metatarsalgia, hyperkeratoses; surgical treatment of gynecomastia; treatmentof hyperhidrosis; sclerotherapy for treatment of varicose veins of the lowerextremity; treatment of telangiectatic dermal veins.Facility billed services while in an inpatient facility. Includes roomand board, nursing services, and ancillary services and supplies.Yes - also see specificexceptions to theseexclusons and/or additionalexclusions that are detailedunder separately listedbenefits or services (e.g.,bariatric surgery, cosmeticsurgery)Inpatient Physicianand SurgicalServicesCoveredInpatient Physician andSurgical ServicesYes 1 Other One (1)Inpatientvisit/day perPhysician orotherProfessionalProviderOral surgery that is dental in origin; Removal of impacted wisdom teeth;Reversal of voluntary sterilization; radial keratotomy, keratoplasty, Lasik andother surgical procedures to correct refractive defects; surgeries for sexualdysfunction; surgeries or services for sexual transformation; surgical treatmentof flat feet, subluxation of the foot, weak, strained, unstable feet, tarsalgia,metatarsalgia, hyperkeratoses; surgical treatment of gynecomastia; treatmentof hyperhidrosis; sclerotherapy for treatment of varicose veins of the lowerextremity; treatment of telangiectatic dermal veins.Facility billed services while in an inpatient facility. Includes roomand board, nursing services, and ancillary services and supplies.Yes - also see specificexceptions to theseexclusons and/or additionalexclusions that are detailedunder separately listedbenefits or services (e.g.,bariatric surgery, cosmeticsurgery)Bariatric Surgery Not Covered Bariatric Surgery Bariatric surgery, regardless of the purpose it is proposed or performed. Thisincludes Roux- en-Y(RNY), Laparoscopic gastric bypass surgery or other gastricbypass surgery (surgical procedures that reduce stomach capacity and divertpartially digested food from the duodenum to the jejunum, the section of thesmall intestine extending from the duodenum), or Gastroplasty, (surgicalprocedures that decrease the size of the stomach), or gastric bandingprocedures. Complications directly related to bariatric surgery that results inan Inpatient stay or an extended Inpatient stay for the bariatric surgery, asdetermined by Us, are not covered. This exclusion applies when the bariatricsurgery was not a Covered Service under this Plan or any previous Anthemplan, and it applies if the surgery was performed while the Member wascovered by a previous carrier/self-funded plan prior to coverage under thisCertificate. Directly related means that the Inpatient stay or extended Inpatientstay occurred as a direct result of the bariatric procedure and would not havetaken place in the absence of the bariatric procedure.Page 3 of 12