Market: HIOS Cost Sharing % Non-Mandated % change Service Area Product Network Type Product Plan ID Change* change Benefit Changes (For each (Counties added or removed) 2018 2019 benefit and Level (Standard (include section/ (plan (include section/ item/ total) Component) item/page number) adjusted page number) HIOS ID rate) Example Deductible + 4% + Acupuncture Sect.2 +1% +Macomb POS PPO SOB-pg.2 item 5 page 3 -2.5% -Clinton Added co-pay + 1% - Fertility Treatment -1.5% -Eaton SOB-pg. 3 Sect. 2 item 7 page 3
Market: Product Level HIOS ID HIOS Plan ID (Standard Component) Cost Sharing Change* (include section/ item/page number) % change (plan adjusted rate) Non-Mandated Benefit Changes (include section/ item/ page number) % change (For each benefit and total) Service Area (Counties added or removed) Product Network Type 2018 2019 Example Deductible SOB-pg.2 Added co-pay SOB-pg. 3 + 4% + 1% + Acupuncture Sect.2 item 5 page 3 - Fertility Treatment Sect. 2 item 7 page 3 +1% -2.5% -1.5% +Macomb -Clinton -Eaton POS PPO
MI_Uniform_Modification_555756_7.docx