Missouri Code of State Regulations
Title 22 - MISSOURI CONSOLIDATED HEALTH CARE PLAN
Division 10 - Health Care Plan
Chapter 2 - State Membership
Section 22 CSR 10-2.053 - Health Savings Account Plan Benefit Provisions and Covered Charges

(1) Deductible-per calendar year for network: per individual, one thousand six hundred fifty dollars ($1,650); family, three thousand three hundred dollars ($3,300) and for non-network: per individual, three thousand three hundred dollars ($3,300); family, six thousand six hundred dollars ($6,600).

(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 Coinsurance is no longer applicable for the remainder of the calendar year once the out-of-pocket maximum is reached.

(3) Out-of-pocket maximum.

(4) The following services will be paid as a network benefit when provided by a non-network provider:

(5) Preventive care is not subject to deductible or coinsurance requirements and will be paid at one hundred percent (100%) when provided by a network provider.

(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) Nutritional counseling is paid at one hundred percent (100%) when provided by a network provider after deductible is met.

(8) Four (4) Diabetes Self-Management Education visits received through a network provider are covered at one hundred percent (100%) after deductible is met.

(9) Sterilization procedure for men is paid at one hundred percent (100%) when provided by a network provider after deductible is met.

(10) Virtual visits offered through the vendor's telehealth tool are covered at one hundred percent (100%) after deductible is met.

(11) Newborn's claims will be subject to deductible and coinsurance.

(12) 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 system, 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.

(13) Each subscriber will have access to payment information of the family unit only when authorization is granted by the adult covered dependent(s).

(14) 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 nonMedicare medical plan within the same plan year.

(15) Maximum plan payment-Non-network medical claims that are not otherwise subject to a contractual discount arrangement are processed at one hundred ten percent (110%) of Medicare reimbursement for non-network professional claims and following the claims administrator's standard practice for non-network facility claims. Members may be held liable for the amount of the fee above the allowed amount.

(16) 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.

(17) 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 deductible and/or coinsurance amounts will apply to the in-hospital facility and related ancillary charges until the member is discharged.

(18) 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.

(19) An active employee subscriber does not qualify for the HSA Plan if s/he is claimed as a dependent on another person's tax return or, except for the plans listed in section (20) of this rule, is covered under or enrolled in any other health plan that is not a high deductible health plan, including, but not limited to, the following types of insurance plans or programs:

(20) If an active employee subscriber and/or his/her dependent(s) is enrolled in the HSA Plan and becomes ineligible for the HSA Plan during the plan year, the subscriber and/or his/her depen-dent(s) will be enrolled in the PPO 1250 Plan. The subscriber may enroll in a different non-HSA Plan within thirty-one (31) days of notice from MCHCP.

(21) A subscriber may qualify for this plan even if s/he is covered by any of the following:

(22) Health Savings Account (HSA) Contributions.