April 12, 2024 SUMMARY OF MODIFICATIONS As requested, effective January 1, 2024, the following provision(s) were updated in, added to, or deleted from your Health Plan document. The change(s) are shaded in the plan document, with the exception of deleted wording: • Medical Schedule of Benefits, Benefit Plan(s) 001. • Medical Schedule of Benefits, Benefit Plan(s) 002, 003. • Medical Schedule of Benefits, Benefit Plan(s) 004, 005. • Medical Schedule of Benefits, Benefit Plan(s) 006. • Covered Medical Benefits. • Teladoc Services. • UMR CARE: Clinical Advocacy Relationships to Empower. As required, effective January 1, 2024, the following changes were made to your Health Plan document. The change(s) are shaded in the plan document, with the exception of deleted wording: • As part of Non-Quantitative Treatment Limitations (NQTL), the following have been revised throughout the document to add clarity and directive: ➢ Alternative / Complementary Treatment. ➢ Conditions Listed in the most recent American Psychiatric Association Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases – Clinical Modification (ICD-CM) manual (most recent revision) in the following categories: Personality disorders, behavior and impulse control disorders, “Z” codes. ➢ Developmental Delays. ➢ Mental Health Benefits: Mental Health Exclusions – the entire section – has been removed as items are included in classification sections. ➢ Nocturnal Enuresis Alarm. ➢ Substance Use Disorder and Chemical Dependency Benefits: Substance Use Disorder Exclusions – the entire section has been removed as items are included in classification sections. • Eligibility and Enrollment: Eligibility Requirements language has been revised to be broader to meet the requirements of any of the Affordable Care Act (ACA) Measurement Methods. • COBRA Continuation of Coverage: ➢ Making an Election to Continue Group Health Coverage: Language has been added regarding online election, if available, so that such election will not be rejected by stop loss. ➢ Payment for Continuation of Coverage: Language has been added regarding online elections so that such elections will not be rejected by stop loss. • Provider Network: Provider agreements and/or network providers entering into agreements for only certain covered health services, not all covered health services, has been removed. This language was unnecessary and was causing member confusion. • Covered Medical Benefits: ➢ Ambulance Transportation: Language has been clarified for coverage of emergency ambulance transportation to an appropriate hospital for consistency with No Surprises Act coverage of emergencies. ➢ Gender Dysphoria: A clarifying change has been made to the existing benefit description to supplement the general statement of coverage with sufficient benefit detail to better align with the current administration of this benefit. ➢ Hospital Services language has been revised to clarify coverage for semi-private and private rooms and that rate reductions may apply. ➢ Therapy Services: Speech Therapy has been revised to align with current policies and procedures and remove specific references to Autism Spectrum Disorder. • Telemedicine Services – OC24health: Behavioral Health Program language regarding the Covered Person Follow-Up procedure has been removed because the process has been discontinued.