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, seven hundred fifty
dollars ($750); family, one thousand five hundred dollars ($1,500) and for
non-network: per individual, one thousand five hundred dollars ($1,500);
family, three thousand dollars ($3,000).
(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no longer applicable for the remainder of the calendar year once the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, two thousand two hundred fifty
dollars ($2,250); family, four thousand five hundred dollars ($4,500) and for
non-network: per individual, four thousand five hundred dollars ($4,500);
family, nine thousand dollars ($9,000).
(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;
(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 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.
(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 during the plan year or continues
enrollment under another subscriber's non-Medicare medical plan within the same
plan year.
(10) Copayments.
(A) 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.
(B) 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
processed 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
10-3.057. 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.
