ABCDEFGHIJKLMNOPQRSTUVWXYZ
1
Employer Name:South Holland SD 150
2
Employer State of Situs:ILLINOIS
3
Name of Issuer:BCBS OF IL
4
Plan Marketing Name:PK0689 - Blue Print PPO
5
Plan Year:9/1/2022 - 6/30/2023
6
7
Ten (10) Essential Health Benefit (EHB) Categories:
8
9

- Ambulatory patient services (outpatient care you get without being admitted to a hospital)
- Emergency services
- Hospitalization (like surgery and overnight stays)
- Laboratory services
- Mental health and substance use disorder (MH/SUD) services, including behavioral health treatment (this includes counseling and psychotherapy)
- Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)
- Pregnancy, maternity, and newborn care (both before and after birth)
- Prescription drugs
- Preventive and wellness services and chronic disease management
- Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
10
2020-2022 Illinois Essential Health Benefit (EHB) Listing (P.A. 102-0630)Employer Plan Covered Benefit?
11
ItemEHB BenefitEHB CategoryBenchmark Page
# Reference
12
1Accidental Injury -- Dental AmbulatoryPgs. 10 & 17Yes
13
2Allergy Injections and Testing AmbulatoryPg. 11Yes
14
3Bone anchored hearing aidsAmbulatoryPgs. 17 & 35Yes
15
4Durable Medical EquipmentAmbulatoryPg. 13Yes
16
5HospiceAmbulatoryPg. 28
Yes
17
6Infertility (Fertility) TreatmentAmbulatoryPgs. 23 - 24 Yes
18
7Outpatient Facility Fee (e.g., Ambulatory Surgery Center)AmbulatoryPg. 21
Yes
19
8Outpatient Surgery Physician/Surgical Services (Ambulatory Patient Services)AmbulatoryPgs. 15 - 16Yes
20
9Private-Duty NursingAmbulatoryPgs. 17 & 34Yes
21
10Prosthetics/OrthoticsAmbulatoryPg. 13Yes
22
11Sterilization (vasectomy men)AmbulatoryPg. 10Yes
23
12Temporomandibular Joint Disorder (TMJ)AmbulatoryPgs. 13 & 24Yes
24
25
13Emergency Room Services
(Includes MH/SUD Emergency)		Emergency servicesPg. 7Yes
26
14Emergency Transportation/ AmbulanceEmergency servicesPgs. 4 & 17Yes
27
28
15Bariatric Surgery (Obesity)HospitalizationPg. 21Yes
29
16Breast Reconstruction After MastectomyHospitalizationPgs. 24 - 25 Yes
30
17Reconstructive SurgeryHospitalizationPgs. 25 - 26, & 35Yes
31
18Inpatient Hospital Services (e.g., Hospital Stay)HospitalizationPg. 15Yes
32
19Skilled Nursing FacilityHospitalizationPg. 21Yes
33
20Transplants - Human Organ Transplants (Including transportation & lodging)HospitalizationPgs. 18 & 31Yes
34
35
21Diagnostic ServicesLaboratory servicesPgs. 6 & 12Yes
36
37
22Intranasal opioid reversal agent associated with opioid prescriptionsMH/SUDPg. 32Yes
38
23Mental (Behavioral) Health Treatment (Including Inpatient Treatment)MH/SUDPgs. 8 -9, 21Yes
39
24Opioid Medically Assisted Treatment (MAT)MH/SUDPg. 21Yes
40
25Substance Use Disorders (Including Inpatient Treatment)MH/SUDPgs. 9 & 21Yes
41
26Tele-PsychiatryMH/SUDPg. 11Yes
42
27Topical Anti-Inflammatory acute and chronic pain medicationMH/SUDPg. 32Yes
43
44
28Pediatric Dental CarePediatric Oral and Vision CareSee AllKids Pediatric Dental DocumentNo
45
29Pediatric Vision CoveragePediatric Oral and Vision CarePgs. 26 - 27No
46
47
30Maternity ServicePregnancy, Maternity, and Newborn CarePgs. 8 & 22Yes
48
49
31Outpatient Prescription DrugsPrescription drugsPgs. 29 - 34Yes
50
51
32Colorectal Cancer Examination and ScreeningPreventive and Wellness ServicesPgs. 12 & 16Yes
52
33Contraceptive/Birth Control ServicesPreventive and Wellness ServicesPgs. 13 & 16Yes
53
34Diabetes Self-Management Training and EducationPreventive and Wellness ServicesPgs. 11 & 35
Yes
54
35Diabetic Supplies for Treatment of DiabetesPreventive and Wellness ServicesPgs. 31 - 32Yes
55
36Mammography - ScreeningPreventive and Wellness ServicesPgs. 12, 15, & 24Yes
56
37Osteoporosis - Bone Mass MeasurementPreventive and Wellness ServicesPgs. 12 & 16Yes
57
38Pap Tests/ Prostate- Specific Antigen Tests/ Ovarian Cancer Surveillance TestPreventive and Wellness ServicesPg. 16Yes
58
39Preventive Care ServicesPreventive and Wellness ServicesPg. 18Yes
59
40Sterilization (women)Preventive and Wellness ServicesPgs. 10 & 19Yes
60
61
41Chiropractic & Osteopathic ManipulationRehabilitative and Habilitative Services and DevicesPgs. 12 - 13Yes
62
42Habilitative and Rehabilitative ServicesRehabilitative and Habilitative Services and DevicesPgs. 8, 9, 11, 12, 22, & 35Yes
63
Special Note: Under Pub. Act 102-0104, eff. July 22, 2021, any EHBs listed above that are clinically appropriate and medically necessary to deliver via telehealth services must be covered in the same manner as when those EHBs are delivered in person.
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100