Current through Register Vol. 49, No. 24, December 16, 2024
PURPOSE: This rule establishes the policy of the
board of trustees in regard to the PPO 1250 Benefit Provisions and Covered
Charges for members of the Missouri Consolidated Health Care
Plan.
(1) Deductible-per
calendar year for network: per individual, one thousand two hundred fifty
dollars ($1,250); family, two thousand five hundred dollars ($2,500) and for
non-network: per individual, two thousand five hundred dollars ($2,500);
family, five thousand dollars ($5,000).
(A)
Network and non-network deductibles are separate. Expenses cannot be shared or
transferred between network and non-network benefits.
(B) Claims will not be paid until the
applicable deductible is met.
(C)
Services that do not apply to the deductible and for which applicable costs
will continue to be charged include, but are not limited to: copayments,
charges above the usual, customary, and reasonable (UCR) limit; the amount the
member pays due to noncompliance; non-covered services and charges above the
maximum allowed.
(D) The family
deductible is an embedded deductible with two (2) parts: an individual
deductible and an overall family deductible. Each family member must meet
his/her own individual deductible amount until the overall family deductible
amount is reached. Once a family member meets his/her own individual
deductible, the plan will start to pay claims for that individual and any
additional out-of-pocket expenses incurred by that individual will not be used
to meet the family deductible amount. Once the overall family deductible is
met, the plan will start to pay claims for the entire family even if some
family members have not met his/her own individual deductible.
(2) Coinsurance-coinsurance
amounts apply to covered services after deductible has been met. Coinsurance is
no longer applicable for the remainder of the calendar year once the
out-of-pocket maximum is reached.
(A) Network
claims are paid at eighty percent (80%) until the out-of-pocket maximum is
met.
(B) Non-network claims are
paid at sixty percent (60%) until the out-of-pocket maximum is met.
(3) Out-of-pocket maximum-per
calendar year for network: per individual, three thousand seven hundred fifty
dollars ($3,750); family, seven thousand five hundred dollars ($7,500) and for
non-network: per individual, seven thousand five hundred dollars ($7,500);
family, fifteen thousand dollars ($15,000).
(A) Network and non-network out-of-pocket
maximums are separate. Expenses cannot be shared or transferred between network
and non-network benefits.
(B)
Services that do not apply to the out-of-pocket maximum and for which
applicable costs will continue to be charged include, but are not limited to:
charges above the usual, customary, and reasonable (UCR) limit; the amount the
member pays due to noncompliance; non-covered services and charges above the
maximum allowed.
(C) The family
out-of-pocket maximum is an embedded out-of-pocket maximum with two (2) parts:
an individual out-of-pocket maximum and an overall family out-of-pocket
maximum. Each family member must meet his/her own individual out-of-pocket
maximum amount until the overall family out-of-pocket maximum amount is
reached. Once a family member meets his/her own individual out-of-pocket
maximum, the plan will start to pay claims at one hundred percent (100%) for
that individual. Once the overall family out-of-pocket maximum is met, the plan
will start to pay claims at one hundred percent (100%) for the entire family
even if some family members had not met his/her own individual out-of-pocket
maximum.
(4) The
following services will be paid as a network benefit when provided by a
non-network provider:
(A) Emergency services
and urgent care;
(B) Covered
services that are not available through a network provider within one hundred
(100) miles of the member's home. The member must contact the claims
administrator before the date of service in order to have a closer non-network
provider's claims approved as a network benefit. Such approval is for three (3)
months. After three (3) months, the member must contact the claims
administrator to reassess network availability; and
(C) Covered services when such services are
provided in a network hospital or ambulatory surgical center and are an adjunct
to a service being performed by a network provider. Examples of such adjunct
services include, but are not limited to, anesthesiology, assistant surgeon,
pathology, or radiology.
(5) The following services are not subject to
deductible, coinsurance, or copayment requirements and will be paid at one
hundred percent (100%) when provided by a network provider:
(A) Preventive care;
(B) Nutrition counseling;
(C) A newborn's initial hospitalization until
discharge or transfer to another facility if the mother is a Missouri
Consolidated Health Care Plan (MCHCP) member at the time of birth;
(D) Four (4) Diabetes Self-Management
Education visits;
(E) Sterilization
procedure for men;
(F) Virtual
visits offered through the vendor's telehealth tool;
(G) Diagnostic breast examinations,
supplemental breast examinations as defined in section
376.1183, RSMo, and low-dose
mammography screenings; and
(H)
Diagnostic colorectal screenings.
(6) Influenza vaccinations provided by a
non-network provider will be reimbursed up to twenty-five dollars ($25) once
the member submits a receipt and a reimbursement form to the claims
administrator.
(7) Married, active
employees who are MCHCP subscribers and have enrolled children may meet only
one (1) family deductible and out-of-pocket maximum. Both spouses must enroll
in the same medical plan option through the same carrier, and each must provide
the other spouse's Social Security number (SSN) and report the other spouse as
eligible for coverage when newly hired and during the open enrollment process.
In the medical plan vendor and pharmacy benefit manager systems, the spouse
with children enrolled will be considered the subscriber and the spouse that
does not have children enrolled will be considered a dependent. If both spouses
have children enrolled, the spouse with the higher Social Security number (SSN)
will be considered the subscriber. Failure to report an active employee spouse
when newly hired and/or during open enrollment will result in a separate
deductible and out-of-pocket maximum for both active employees.
(8) Each subscriber will have access to
payment information of the family unit only when authorization is granted by
the adult covered dependent(s).
(9)
Expenses toward the deductible and out-of-pocket maximum will be transferred if
the member changes non-Medicare medical plans or continues enrollment under
another subscriber's non-Medicare medical plan within the same plan
year.
(10) Copayments. Copayments
apply to network services unless otherwise specified.
(A) Office visit-primary care: twenty-five
dollars ($25); mental health: twenty-five dollars ($25); specialist: forty
dollars ($40); chiropractor office visit and/or manipulation: the lesser of
twenty dollars ($20) or fifty percent (50%) of the total cost of services;
urgent care: fifty dollars ($50) network and non-network. All lab, X-ray, or
other medical services associated with the office visit apply to the deductible
and coinsurance.
(B) Emergency
room-two hundred fifty dollars ($250) network and non-network. Deductible and
coinsurance requirements apply to emergency room services in addition to the
copayment. If a member is admitted to the hospital or the claims administrator
considers the claim to be for a true emergency, the copayment is
waived.
(C) Inpatient
hospitalization-two hundred dollars ($200) per admission for network and
non-network. Deductible and coinsurance requirements apply to inpatient
hospitalization services in addition to the copayment.
(11) Non-network plan payment-non-network
medical claims are processed following the claim administrator's standard
practice for non-network facility claims. Members may be held liable for the
amount of the fee above the allowed amount.
(12) Any claim must be initially submitted
within twelve (12) months following the date of service, unless otherwise
specified in the network provider contract. The plan reserves the right to deny
claims not timely filed. A provider initiated correction to the originally
filed claim must be submitted within the timeframe agreed in the provider
contract, but not to exceed three hundred sixty-five (365) days from
adjudication of the originally filed claim. Any claims reprocessed as primary
based on action taken by Medicare or Medicaid must be initiated within three
(3) years of the claim being incurred.
(13) For a member who is an inpatient on the
last calendar day of a plan year and remains an inpatient into the next plan
year, the prior plan year's applicable copayment, deductible and/or coinsurance
amounts will apply to the in-hospital facility and related ancillary charges
until the member is discharged.
(14) Services performed in a country other
than the United States may be covered if the service is included in
22 CSR
10-2.055. Emergency and urgent care services are
covered as a network benefit. All other non-emergency services are covered as
determined by the claims administrator. If the service is provided by a
non-network provider, the member may be required to provide payment to the
provider and then file a claim for reimbursement subject to timely filing
limits.
(15) Medicare.
(A) If a Medicare primary member chooses a
provider who has opted out of Medicare, the member will be responsible for
paying the portion Medicare would have paid if the service was performed by a
Medicare provider. An estimate of Medicare Part A and/or Part B benefits shall
be made and used for coordination or reduction purposes in calculating
benefits. Benefits will be calculated on a claim-submitted basis so that if,
for a given claim, Medicare reimbursement would be for more than the benefits
provided by this plan without Medicare, the balance will not be considered when
calculating subsequent claims for this plan's deductible and out-of-pocket
maximum expenses.
