Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This amendment adds one hundred percent
(100%) coverage of diagnostic breast examinations and colorectal screenings at
a network provider.
(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 Coinsurance is no longer applicable for the remainder of the calendar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) Maximum plan payment-non-network medical
claims that are not otherwise subject to a contractual discount arrangement are
allowed at one hundred ten percent (110%) of Medicare reimbursement for
non-network professional claims and 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) When MCHCP becomes aware that the member
is eligible for Medicare benefits claims will be processed reflecting Medicare
coverage.
(B) If a member does not
enroll in Medicare when s/he is eligible and Medicare should be the member's
primary plan, the member will be responsible for paying the portion Medicare
would have paid. 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.
(C) 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.
