Benefit Guide - Missouri Consolidated Health Care Plan

Transcription

2016 Benefit Guide
Public Entity Members
2016 Benefit Guide
(This page intentionally left blank)
1 Summary of Benefits & Coverage
3 Member Information
Health Savings Account Plan
Notice of Privacy Practices
PPO 600 Plan
Appeal Procedures
PPO 1000 Plan
Uniform Glossary
4 Contact
2 Coverage Information
Medical Plan Overview
Health Savings Account Plan Overview
Health Savings Account
PPO 600 Plan Overview
Prescription Drug Plan
Vision Plan
Dental Plan
Employee Assistance Program
Disease Management Services
Women’s Health and Cancer Rights Notice
Contact Information
Section 1
Summary of
Benefits & Coverage
PPO 600 Plan
PPO 1000 Plan
Uniform Glossary
MCHCP: Health Savings Account Plan
Coverage Period: 1/1/2016 — 12/31/2016
Summary of Benefits and Coverage: What This Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: High-Deductible
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.mchcp.org or by calling 800-487-0771.
Important Questions
Answers
Why this Matters:
What is the overall
deductible?
$1,650 individual/$3,300 family
(network)
Does not apply to preventive care
(non-network)
You must pay all the costs up to the deductible amount before this plan begins to
pay for covered services you use. The deductible starts over each year on Jan. 1.
See the chart starting on Page 7 for how much you pay for covered services after
you meet the deductible.
Are there other
deductibles for specific
services?
No.
You don’t have to meet deductibles for specific services, but see the chart
starting on Page 7 for other costs for services this plan covers.
Is there an
out-of-pocket limit
on my expenses?
Yes. $3,300 individual/$6,600
family (network)
(non-network)
The out-of-pocket limit is the most you could pay during a coverage period
(usually one year) for your share of the cost of covered services. This limit helps
you plan for health care expenses.
What is not included in
the out-of-pocket limit?
Premium, balance bill charges,
health care this plan doesn’t cover
Even though you pay these expenses, they don’t count toward the
out-of-pocket limit.
Is there an overall annual
limit on what the plan
No.
pays?
The chart starting on Page 7 describes any limits on what the plan will pay for
specific covered services, such as office visits.
Does this plan use a
network of providers?
If you use a network doctor or other health care provider, this plan will pay
some or all of the costs of covered services. Be aware, your network doctor or
hospital may use a non-network provider for some services. Plans use the term
in-network, preferred, or participating for providers in their network. See the
chart starting on Page 7 for how this plan pays different kinds of providers.
Yes. Contact UMR or ESI for a
list of network providers.
Do I need a referral to see
No.
a specialist?
You can see the specialist you choose without permission from this plan.
Are there services this
Some of the services this plan doesn’t cover are listed on Page 10. See your
Yes.
plan doesn’t cover?
policy or plan document for additional information about excluded services.
Questions: Call 1-800-487-0771 or visit us at www.mchcp.org.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 33.
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Summary of Benefits & Coverage
Coverage Period: 1/1/2016 — 12/31/2016
Copayments are fixed dollar amounts (for example, $35 for a formulary brand prescription) you pay for covered health care, usually
when you receive the service.
• Coinsurance is your share of the cost of a covered service, calculated as a percent of the allowed amount for the service. You pay
the deductible amount. Once the deductible has been met, you pay coinsurance. For example, if the health plan’s allowed amount
for an overnight hospital stay is $1,000 and you’ve met your deductible, your coinsurance payment of 20% would be $200. If you
haven’t met any of the deductible, you would pay the full cost of the hospital stay.
• The amount the plan pays for covered services is based on the allowed amount. If a non-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if a non-network hospital charges $1,500 for an overnight stay
and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
• This plan encourages you to use network providers by charging you lower deductibles, copayments and coinsurance amounts.
•
Common
Medical Event
Services You May Need
Primary care visit to treat an injury or
illness
20% coinsurance
40% coinsurance
Specialist visit
20% coinsurance
40% coinsurance
If you visit a health
care provider’s
Other practitioner/chiropractor office visit
office or clinic
If you have a test
Your cost if you use a
Network
Non-network
Provider
Provider
Limitations &
Exceptions
None
20% coinsurance
40% coinsurance
Preauthorization (PA) required
for some visits. If you fail to
get PA, the service may not be
covered.
Preventive care/screening/immunization
No Charge
40% coinsurance
Non-network Immunizations: No
charge from birth to 72 months
Diagnostic test (X-ray, blood work)
20% coinsurance
40% coinsurance
None
Imaging (CT/PET scans, MRIs)
20% coinsurance
40% coinsurance
PA required. If you fail to get PA,
the service may not be covered.
2016 Benefit Guide
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Coverage Period: 1/1/2016 — 12/31/2016
Common
Medical Event
Generic drugs
Network
Non-network
Provider
Provider
10% coinsurance
40% coinsurance
Formulary brand drugs
If you need drugs Non-formulary drugs
to treat your
illness or condition
Specialty drugs
If you have
outpatient surgery
If you need
immediate medical
attention
20% coinsurance
40% coinsurance
50% coinsurance
20% coinsurance
No coverage
Some prescriptions are subject
to PA, quantity level limits or
step therapy requirements. If you
fail to follow requirements, the
prescription may not be covered.
Network: No charge for
preventive formulary
prescriptions and flu/shingles
vaccinations
Specialty drugs must be filled
through Accredo, with the
exception of the first fill of drugs
needed immediately. Members
who go to a retail pharmacy will
be charged the full discounted
price of the drug.
Facility fee (e.g., ambulatory surgery center) 20% coinsurance
40% coinsurance
Physician/surgeon fees
20% coinsurance
40% coinsurance
Emergency room services
20% coinsurance
20% coinsurance
after network
deductible
None
20% coinsurance
20% coinsurance
after network
deductible
PA required for non-emergent
use of emergency medical
transportation. If you fail to
covered.
Emergency medical transportation
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Limitations &
Exceptions
Coverage Period: 1/1/2016 — 12/31/2016
Common
Medical Event
If you need
immediate medical Urgent care
attention
If you have a
hospital stay
If you have
mental health,
behavioral health,
or substance abuse
needs
Network
Non-network
Provider
Provider
20% coinsurance
20% coinsurance
after network
deductible
None
Facility fee (e.g., hospital room)
20% coinsurance
40% coinsurance
PA required except for an
observation stay. If you fail to
covered.
Physician/surgeon fee
20% coinsurance
40% coinsurance
None
Mental/behavioral health outpatient services 20% coinsurance
40% coinsurance
Mental/behavioral health inpatient services
20% coinsurance
40% coinsurance
Substance abuse disorder outpatient services 20% coinsurance
40% coinsurance
Substance abuse disorder inpatient services
20% coinsurance
40% coinsurance
PA required for services
provided at hospital except for
an observation stay. If you fail to
covered.
Prenatal and postnatal care
20% coinsurance
40% coinsurance
No charge for routine
prenatal care
If you are pregnant
If you need help
recovering or
have other special
health needs
Limitations &
Exceptions
Delivery and all inpatient services
20% coinsurance
40% coinsurance
PA required for some services.
If you fail to get PA, the service
may not be covered.
Home health care
20% coinsurance
40% coinsurance
Rehabilitation services
20% coinsurance
40% coinsurance
Habilitation services
20% coinsurance
40% coinsurance
may not be covered.
2016 Benefit Guide
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Coverage Period: 1/1/2016 — 12/31/2016
Common
Medical Event
Skilled nursing care
If you need help
recovering or
have other special
health needs
Network
Non-network
Provider
Provider
20% coinsurance
Limitations &
Exceptions
40% coinsurance
Limited to 120 days per calendar
year. PA required for some
services. If you fail to get PA, the
service may not be covered.
Durable medical equipment
20% coinsurance
40% coinsurance
may not be covered. No charge
for breast pumps.
Hospice service
20% coinsurance
40% coinsurance
Eye exam
20% coinsurance
40% coinsurance
One per calendar year
20% coinsurance
40% coinsurance
Coverage limited to fitting of
eye glasses or contact lenses
following cataract surgery
Not covered
Not covered
None
If you need
Glasses
dental or eyeServices
care
Excluded
& Other Covered Services:
Dental checkup
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
• Acupuncture
• Cosmetic Surgery
• Dental care (adult)
• Exercise equipment
• Infertility treatment
• Long-term care
• Private-duty nursing
• Routine foot care
• Weight-loss programs
Other Covered Services (This isn’t a complete list. Check your policy for other covered services and your costs for these services.)
• Bariatric surgery
• Chiropractic care
• Hearing aids
• Routine eye care (adult)
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• Non-emergency care when traveling
outside the U.S. covered as a non-network
benefit
Coverage Period: 1/1/2016 — 12/31/2016
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending on the circumstances, federal and state laws may provide protections that allow you to keep
health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the
premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 800-487-0771. You may also contact your state insurance department,
the U.S. Department of Labor, Employee Benefits Security Administration at 866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health
and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Your Appeal Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal. For questions about your
rights, this notice, or assistance, you can contact UMR at 888-200-1167 or ESI at 800-797-5754. Additionally, a consumer assistance program can
help you file your appeal. Contact the Missouri Department of Insurance, 301 W. High St., Room 530, Jefferson City, MO 65101; call 800-726-7390;
visit www.insurance.mo.gov; or email [email protected].
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have coverage that qualifies as “minimum essential coverage.” This plan or policy does provide
minimal essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits for a health plan. The minimum value standard is 60% (actuarial value).
This health coverage does meet the minimum value standard for the benefits it provides.
Language Access Services:
Para obtener asistencia en Español, llame MCHCP al 800-701-8881.
To see examples of how this plan might cover costs for a sample medical situation, see the next page.
2016 Benefit Guide
11
Coverage Period: 1/1/2016 — 12/31/2016
Coverage for: Individual + Family | Plan Type: High-Deductible
Coverage Examples
About these
Coverage Examples:
These examples show how this plan might
cover medical care in given situations. Use
these examples to see, in general, how much
financial protection a sample patient might get
if they are covered under different plans.
This is
not a cost
estimator.
Don’t use these examples
to estimate your actual
costs under this plan. The
actual care you receive
will be different from these
examples, and the cost of that
care also will be different.
See the next page for
important information about
these examples.
Having a baby
Managing type 2 diabetes
(normal delivery)
(routine maintenance
of a well-controlled condition)
■■Amount owed to providers: $7,540
■■Plan pays $3,490
■■Patient pays $4,050
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Pharmacy
Radiology
Vaccines, other preventive
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Patient pays:
Deductible
Copayments
Coinsurance
Limitations or exclusions
Total
$3,300
$0
$600
$150
$4,050
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Sample care costs:
Pharmacy
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductible
Copayments
Coinsurance
Total
$3,300
$0
$200
$80
$3,580
Coverage Examples
Coverage Period: 1/1/2016 — 12/31/2016
Coverage for: Individual + Family | Plan Type: High-Deductible
Questions and answers about the Coverage Examples:
What are some of the assumptions
behind Coverage Examples?
•
•
•
•
•
•
•
•
Costs don’t include premiums.
Costs are based on family coverage benefit
levels.
Sample care costs are based on national
averages supplied to the U.S. Department
of Health and Human Services, and are not
specific to a particular geographic area or
MCHCP.
The patient’s condition was not an excluded
or pre-existing condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for any
member covered under this plan.
Out-of-pocket expenses are based only on
treating the condition in the example.
The patient received all care from network
providers. If the patient had received care
from non-network providers, costs would
have been higher.
What does a Coverage Example show?
For each treatment situation, the Coverage
Example helps you see how deductibles,
copayments and coinsurance can add up. It
also helps you see what expenses might be
left up to you to pay because the service or
treatment isn’t covered or payment is limited.
Does the Coverage Example predict my
own care needs?
No. Treatments shown are just examples.
The care you would receive for this
condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
future expenses?
No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on the
care you receive, the prices your providers
charge, and the reimbursement your health
plan allows.
Can I use Coverage Examples to
compare plans?
Yes. When you look at the Summary of
Benefits & Coverage for other plans, you’ll
find the same Coverage Examples. When
you compare plans, check the “Patient
Pays” box in each example. The smaller
that number, the more coverage the plan
provides.
Are there other costs I should consider
when comparing plans?
Yes. An important cost is the premium you
pay. Generally, the lower your premium,
the more you’ll pay in out-of-pocket costs,
such as copayments, deductibles and
coinsurance. You also should consider
contributions to accounts such as health
savings accounts (HSAs), flexible
spending arrangements (FSAs) or health
reimbursement accounts (HRAs) that help
you pay out-of-pocket expenses.
2016 Benefit Guide
13
MCHCP: PPO 600 Plan
Coverage Period: 1/1/2016 — 12/31/2016
Summary of Benefits and Coverage: What This Plan Covers & What it Costs
Coverage for: Individual + Family | Plan Type: PPO
Important Questions
What is the overall
deductible?
Answers
$600 individual/$1,200 family
(network)
Does not apply to preventive care
(non-network)
Why This Matters:
pay for covered services you use. The deductible starts over each year on
Jan. 1. See the chart starting on Page 15 for how much you pay for covered
services after you meet the deductible.
Are there other
services?
No.
Is there an
out-of-pocket limit
on my expenses?
Yes. $1,500 individual/$3,000
family (network medical)
(non-network medical)
$5,100 individual/$10,200 family you plan for health care expenses.
(prescription)
health care this plan doesn’t cover out-of-pocket limit.
No.
pays?
No.
a specialist?
Yes.
14
MCHCP: PPO 600 Plan
Coverage Period: 1/1/2016 — 12/31/2016
• Copayments are fixed dollar amounts (for example, $35 for a formulary brand prescription) you pay for covered health care, usually
when you receive the service.
• Coinsurance is your share of the cost of a covered service, calculated as a percent of the allowed amount for the service. You pay the
deductible amount. Once the deductible has been met, you pay coinsurance. For example, if the health plan’s allowed amount for
an overnight hospital stay is $1,000 and you’ve met your deductible, your coinsurance payment of 10% would be $100. If you haven’t
met any of the deductible, you would pay the $600 deductible plus 10% coinsurance on the $400 balance, for a total of $640.
• This plan encourages you to use network providers by charging you lower deductibles, copayments and coinsurance amounts.
Common
Medical Event
Your cost if
you use a NonNetwork
Provider
Primary care visit to treat an injury or
illness
10% coinsurance
30% coinsurance
Specialist visit
10% coinsurance
30% coinsurance
Limitations & Exceptions
None
10% coinsurance
30% coinsurance
Preauthorization (PA) required
for some visits. If you fail to
covered.
Preventive care/screening/immunization
100% coverage
30% coinsurance
Non-network Immunizations: No
charge from birth to 72 months
10% coinsurance
30% coinsurance
None
10% coinsurance
30% coinsurance
PA required for some visits. If
you fail to get PA, the service
may not be covered.
care provider’s
Other practitioner/chiropractor office visit
office or clinic
If you have a test
Your cost if you
use a Network
Provider
2016 Benefit Guide
15
MCHCP: PPO 600 Plan
Coverage Period: 1/1/2016 — 12/31/2016
Common
Medical Event
Generic drugs
Formulary brand drugs
If you need drugs
to treat your
Non-formulary drugs
Specialty drugs
Network
Non-network
Provider
Provider
$8/$16/$24
copayment for up
to 31/60/90 days
(retail)
$20 copayment 61
to 90 days
You pay full price
(mail order)
of prescription and
$35/$70/$105
file claim.
copayment for up
You are reimbursed
to 31/60/90 days
the cost of the
(retail)
drug based on the
$87.50 copayment
network discounted
61 to 90 days
amount, less
(mail order)
the applicable
$100/$200/$300
copayment.
copayment for up
to 31/60/90 days
(retail)
$250 copayment
61 to 90 days
(mail order)
$8 formulary
generic copayment;
$35 formulary
No coverage
brand copayment;
$100 non-formulary
brand copayment
16
Limitations &
Exceptions
vaccinations
If non-Medicare members
purchase a brand-name drug
when a generic is available, they
pay the generic copayment plus
the difference in the cost of the
drugs.
exception of the first fill of drugs
needed immediately. Members
who go to a retail pharmacy will
be charged the full discounted
price.
MCHCP: PPO 600 Plan
Coverage Period: 1/1/2016 — 12/31/2016
Common
Medical Event
If you have
outpatient surgery
Network
Non-network
Provider
Provider
30% coinsurance
30% coinsurance
10% coinsurance
Urgent care
If you have a
hospital stay
$100 copayment
plus 10%
coinsurance
$100 copayment
plus 10%
coinsurance after
network deductible
Copayment applies to the outof-pocket maximum, but not the
deductible. The copayment is
waived if admitted to the hospital
or if the service is considered
a “true emergency”. Medicare
retirees will not owe copayments;
they are only charged
coinsurance.
10% coinsurance
10% coinsurance
after network
deductible
covered.
10% coinsurance
10% coinsurance
after network
deductible
None
If you need
immediate medical
attention
Limitations &
Exceptions
10% coinsurance
30% coinsurance
PA required except for an
observation stay. If you fail to
covered.
10% coinsurance
30% coinsurance
None
2016 Benefit Guide
17
MCHCP: PPO 600 Plan
Coverage Period: 1/1/2016 — 12/31/2016
Common
Medical Event
Network
Non-network
Provider
Provider
Mental/behavioral health outpatient services 10% coinsurance
30% coinsurance
If you have
mental health,
Mental/behavioral health inpatient services 10% coinsurance
behavioral health,
or substance abuse Substance abuse disorder outpatient services 10% coinsurance
needs
Substance abuse disorder inpatient services 10% coinsurance
Prenatal and postnatal care
10% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
No charge for routine prenatal
care.
Delivery and all inpatient services
10% coinsurance
30% coinsurance
may not be covered.
Home health care
10% coinsurance
30% coinsurance
10% coinsurance
30% coinsurance
10% coinsurance
30% coinsurance
10% coinsurance
10% coinsurance
may not be covered.
30% coinsurance
year. PA required. If you fail to
covered.
30% coinsurance
for breast pumps.
18
an observation stay. If you fail to
covered.
30% coinsurance
If you are pregnant
If you need help
recovering or
have other special
health needs
Limitations &
Exceptions
MCHCP: PPO 600 Plan
Coverage Period: 1/1/2016 — 12/31/2016
Common
Medical Event
If you need help
recovering or
have other special
health needs
If you need
dental or eye care
Network
Non-network
Provider
Provider
Limitations &
Exceptions
Hospice service
10% coinsurance
30% coinsurance
Eye exam
10% coinsurance
30% coinsurance
Glasses
10% coinsurance
30% coinsurance
Dental checkup
Not covered
Not covered
None
• Acupuncture
• Long-term care
• Hearing aids
benefit
2016 Benefit Guide
19
MCHCP: PPO 600 Plan
Coverage Period: 1/1/2016 — 12/31/2016
Your Appeal Rights:
20
MCHCP: PPO 600 Plan
Coverage Period: 1/1/2016 — 12/31/2016
Coverage Examples
About these
Coverage Examples:
This is
not a cost
estimator.
these examples.
Having a baby
(normal delivery)
Sample care costs:
Anesthesia
Laboratory tests
Pharmacy
Radiology
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Patient pays:
Deductible
Copayments
Coinsurance
Total
$600
$10
$600
$150
$1,360
Sample care costs:
Pharmacy
Education
Laboratory tests
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductible
Copayments
Coinsurance
Total
$500
$600
$0
$80
$1,180
2016 Benefit Guide
21
MCHCP: PPO 600 Plan
Coverage Period: 1/1/2016 — 12/31/2016
Coverage Examples
•
•
•
•
•
•
•
•
levels.
MCHCP.
have been higher.
own care needs?
future expenses?
plan allows.
22
compare plans?
Yes. When you look at the Summary of
find the same Coverage Examples. When
you compare plans, check the “Patient
Pays” box in each example. The smaller
that number, the more coverage the plan
provides.
MCHCP: PPO 1000 Plan
Coverage Period: 1/1/2016 — 12/31/2016
Important Questions
Answers
(network)
(non-network)
Why This Matters:
pay for covered services you use. The deductible starts over each year on
Jan. 1. See the chart starting on Page 24 for how much you pay for covered
services after you meet the deductible.
Are there other
services?
No.
Is there an
out-of-pocket limit
on my expenses?
Yes, $4,500 individual/$9,000
family (network medical)
(non-network medical)
(prescription)
you plan for health care expenses.
health care this plan doesn’t cover out-of-pocket limit.
What is the overall
deductible?
No.
pays?
No.
a specialist?
Yes.
2016 Benefit Guide
23
Coverage Period: 1/1/2016 — 12/31/2016
• Copayments are fixed dollar amounts (for example, $25 for a primary care office visit) you pay for covered health care, usually when
you receive the service.
• Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. You pay
the deductible amount you owe under this plan. Once the deductible has been met, you pay coinsurance. For example, if the plan’s
allowed amount for an overnight hospital stay is $1,000 and you’ve met your deductible, your coinsurance payment of 10% would be
$100. If you haven’t met any of the deductible you would pay the full cost of the hospital stay.
• This plan encourages you to use network providers by charging you lower deductibles and coinsurance amounts.
Common
Medical Event
Primary care visit to treat an injury $25 copayment and/
or 10% coinsurance
or illness
30% coinsurance
$40 copayment and/
or 10% coinsurance
30% coinsurance
Specialist visit
care provider’s
office or clinic
Network
Non-network
Provider
Provider
Other practitioner/chiropractor
office visit
Chiropractor:
$20 copayment and/
or 10% coinsurance
30% coinsurance
Preventive care/screening/
immunization
100% coverage
30% coinsurance
24
Limitations &
Exceptions
Medicare retirees are not charged
copayments. They will pay coinsurance
for the visit. Copayment covers office
visit only. Coinsurance will be applied
to lab, X-ray or other services associated
with the visit.
Chiropractor copayment may be less
than $20 if it is more than 50% of the
total cost of the service.
Preauthorization (PA) required for some
visits. If you fail to get PA, the service
may not be covered.
Non-network Immunizations: No charge
from birth to 72 months
Coverage Period: 1/1/2016 — 12/31/2016
Common
Medical Event
If you have a test
Network
Non-network
Provider
Provider
10% coinsurance
30% coinsurance
10% coinsurance
Generic drugs
$8/$16/$24 copayment for
up to 31/60/90 days (retail)
$20 copayment 61 to 90
days (mail order)
If you need drugs Formulary brand drugs
to treat your
Non-formulary drugs
30% coinsurance
You pay full price
of prescription and
file claim.
$35/$70/$105 copayment
for up to 31/60/90 days
You are reimbursed
(retail)
$87.50 copayment 61 to 90 the cost of the
drug based on the
days (mail order)
network discounted
amount, less
the applicable
$100/$200/$300 copaycopayment.
ment for up to 31/60/90
days (retail)
$250 copayment 61 to 90
days (mail order)
Limitations &
Exceptions
None
PA required. If you fail to get
PA, the service may not be
covered.
vaccinations
If non-Medicare members
purchase a brand-name drug
when a generic is available, they
pay the generic copayment plus
the difference in the cost of the
drugs.
2016 Benefit Guide
25
Coverage Period: 1/1/2016 — 12/31/2016
Common
Medical Event
If you need drugs
to treat your
Specialty drugs
If you have
outpatient surgery
Network
Non-network
Provider
Provider
$8 formulary
generic copayment;
$35 formulary brand
No coverage
copayment;
$100 non-formulary
brand copayment
30% coinsurance
10% coinsurance
30% coinsurance
$100 plus 10%
coinsurance
$100 plus 10%
coinsurance after
network deductible
10% coinsurance
10% coinsurance
after network
deductible
If you need
immediate medical
attention
26
Limitations &
Exceptions
exception of the first fill of
drugs needed immediately.
Members who go to a retail
pharmacy will be charged the
full discounted price.
covered.
Copayment applies to the outof-pocket maximum, but not
the deductible. The copayment
is waived if admitted to the
hospital or if the service is
considered a “true emergency”.
Medicare retirees are not
charged copayments; they are
only charged coinsurance.
covered.
Coverage Period: 1/1/2016 — 12/31/2016
Common
Medical Event
If you need
immediate medical Urgent care
attention
If you have a
hospital stay
Network
Non-network
Provider
Provider
$50 copayment and/
$50 copayment and/ or 10% coinsurance
or 10% coinsurance after network
deductible
10% coinsurance
30% coinsurance
10% coinsurance
30% coinsurance
Mental/behavioral health outpatient
services
$25 copayment and/
30% coinsurance
or 10% coinsurance
Mental/behavioral health inpatient services 10% coinsurance
30% coinsurance
If you have
mental health,
Substance abuse disorder outpatient
$25 copayment and/
behavioral health,
30% coinsurance
or 10% coinsurance
services
or substance abuse
needs
Substance abuse disorder inpatient services 10% coinsurance
If you are pregnant Prenatal and postnatal care
10% coinsurance
30% coinsurance
30% coinsurance
Limitations &
Exceptions
Copayment covers office visit
only. Coinsurance will be applied
to lab, X-ray or other services
associated with the visit.
copayments; they are charged
coinsurance.
PA required except for
observation. If you fail to get
covered.
None
copayments; they are charged
coinsurance.
an observation stay.
No charge for routine prenatal
care
2016 Benefit Guide
27
Coverage Period: 1/1/2016 — 12/31/2016
Common
Medical Event
If you are pregnant Delivery and all inpatient services
If you need help
recovering or
have other special
health needs
If you need help
recovering or
have other special
health needs
Network
Non-network
Provider
Provider
10% coinsurance
30% coinsurance
may not be covered.
covered.
Home health care
10% coinsurance
30% coinsurance
10% coinsurance
30% coinsurance
10% coinsurance
30% coinsurance
10% coinsurance
may not be covered.
30% coinsurance
year. PA required. If you fail to
covered.
10% coinsurance
30% coinsurance
for breast pumps.
Hospice service
10% coinsurance
30% coinsurance
covered.
28
Limitations &
Exceptions
Coverage Period: 1/1/2016 — 12/31/2016
Common
Medical Event
Network
Non-network
Provider
Provider
$40 copayment or
10% coinsurance
Eye exam
30% coinsurance
If you need
dental or eye care
Glasses
10% coinsurance
30% coinsurance
Dental checkup
Not covered
Not covered
Limitations &
Exceptions
Medicare retirees are not
charged a copayment; they are
charged coinsurance.
None
• Acupuncture
• Long-term care
• Hearing aids
benefit
2016 Benefit Guide
29
Coverage Period: 1/1/2016 — 12/31/2016
Your Appeal Rights:
30
Coverage Period: 1/1/2016 — 12/31/2016
Coverage Examples
About these
Coverage Examples:
This is
not a cost
estimator.
these examples.
Having a baby
(normal delivery)
Sample care costs:
Anesthesia
Laboratory tests
Pharmacy
Radiology
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Patient pays:
Deductible
Copayments
Coinsurance
Total
$1,000
$10
$500
$150
$1,660
Sample care costs:
Pharmacy
Education
Laboratory tests
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductible
Copayments
Coinsurance
Total
$300
$850
$0
$80
$1,230
2016 Benefit Guide
31
Coverage Period: 1/1/2016 — 12/31/2016
Coverage Examples
•
•
•
•
•
•
•
•
levels.
MCHCP.
have been higher.
own care needs?
future expenses?
plan allows.
32
compare plans?
Yes. When you look at the Summaries of
find the same coverage examples. When you
compare plans, check the “Patient Pays” box
in each example. The smaller that number,
the more coverage the plan provides.
2016 Benefit Guide
33
34
2016 Benefit Guide
35
36
Section 2
Coverage
Information
Medical Plan Overview
Health Savings Account Information
Vision Plan
Dental Plan
Employee Assistance Program
Women’s Health and Cancer Rights Notice
Medical & Pharmacy Plan Overview
Benefit
Health Savings Account Plan (HSA Plan)
Through UMR
Network
Non-Network
You pay the deductible and coinsurance amounts until you reach the
out-of-pocket maximum. Your HSA can be used to help pay medical and
prescription expenses.
Plan Description
Individual
$1,650
$4,000
Family
$3,300
$8,000
Medical
Out-of-Pocket Maximum
Individual
$3,300
$5,000
Family
$6,600
$10,000
Prescription
Individual
Preventive Services
Annual physical exams, Immunizations
Age-specific screenings
Deductible
Family
Combined with medical
MCHCP pays 100%
40% coinsurance
Office Visit
20% coinsurance
40% coinsurance
Urgent Care
20% coinsurance
20% coinsurance after network deductible
Emergency Room
20% coinsurance
Hospital (Inpatient)
20% coinsurance
40% coinsurance
Lab and X-ray
20% coinsurance
40% coinsurance
Surgery
20% coinsurance
40% coinsurance
Generic:
10% coinsurance
Brand:
20% coinsurance
Non-formulary:
40% coinsurance
Generic and Brand:
40% coinsurance
Non-Formulary:
50% coinsurance
Prescription Drugs
Deductible: The annual amount a member must pay before the plan begins to pay for covered medical services. Coinsurance: The percentage of a medical bill that a member must pay after
the deductible is met. Out-of-Pocket Maximum: The maximum amount a member must pay before the plan pays 100 percent of covered services for the rest of the year.
38
Coverage Information
Medical & Pharmacy Plan Overview
PPO 600 Plan
Through UMR
PPO 1000 Plan
Through UMR
Network
Non-Network
Network
Non-Network
You pay the deductible and coinsurance
amounts until you reach the out-of-pocket
maximum.
You pay a higher deductible and
coinsurance amounts until you reach
the out-of-pocket maximum.
You pay the deductible and
You pay a higher deductible and
$600
$1,200
$1,000
$2,000
$1,200
$2,400
$3,000
$6,000
$1,500
$3,000
$4,500
$10,000
$3,000
$6,000
$9,000
$30,000
$5,100
$2,100
$10,200
$4,200
MCHCP pays 100%
30% coinsurance
MCHCP pays 100%
30% coinsurance
10% coinsurance after deductible
30% coinsurance
Primary Care or
Mental Health: $25 copayment
Specialist: $40 copayment
Chiropractor: $20 copayment or 50% of
total cost of service, whichever is less
30% coinsurance
10% coinsurance after deductible
$50 copayment
$50 copayment
$100 copayment plus 10% coinsurance
$100 copayment plus 10%
coinsurance after network deductible
coinsurance
coinsurance after network deductible
10% coinsurance
30% coinsurance
10% coinsurance
30% coinsurance
10% coinsurance
30% coinsurance
10% coinsurance
30% coinsurance
10% coinsurance
30% coinsurance
10% coinsurance
30% coinsurance
Days’ Supply
Generic
Brand
Non-Formulary
1 to 31 days
$8
$35
$100
32 to 60 days
$16
$70
$200
61 to 90 days (home delivery)
$20
$87.50
$250
61 to 90 days (retail)
$24
$105
$300
Prescription Drug
PPO Plan Copayments
Apply when filled at a network pharmacy
*See page 46 for non-network pharmacy benefits.
2016 Benefit Guide
39
UMR
Website
www.umr.com
Phone
888-200-1167
Availability
Check with your employer to see
which plan is offered
ID Cards
Issued
Go to Page 6 to review the
HSA Plan Summary of Benefits
and Coverage
Network
Deductible
To enroll in the Health Savings Account
Plan (HSA Plan), you cannot be covered by
another medical plan unless it is a qualified
high deductible health plan, and cannot be
claimed as a dependent on someone else’s
tax return.
Network providers have contracts with your
plan that limit the amount they can bill you
for services. Services from these providers
cost less than services from non-network
providers.
The plan will not pay for medical and
prescription drug expenses until the entire
deductible is met. If two or more family
members are covered, the family deductible
must be met before the plan begins claims
payment for any family member. Premiums,
balance-billed charges or non-covered
services do not apply to the deductible.
You do not qualify if you are also enrolled
in:
• Medicare
• TRICARE
• Health care flexible spending account
(FSA)
• Health Reimbursement Account (HRA)
• Veteran’s benefits that have been used
in the past three months
You qualify for this plan even if you are
covered by any of the following:
•
•
•
•
•
•
Drug discount cards
Accident insurance
Disability insurance
Dental insurance
Vision insurance
Long-term care insurance
When you enroll in an MCHCP medical
plan, you are automatically enrolled in a
prescription drug plan. You will receive
separate ID cards from the prescription
benefit administrator. To learn more about
the prescription drug plan, go to page 46.
Preventive Care
Preventive care — such as preventive
exams, vaccinations and age-specific
screenings — is covered at 100 percent by
MCHCP, regardless of whether you have
met your deductible.
40
Present your ID card at the time of service.
Network providers will submit the claim for
you. Non-network providers may request
full payment at the time of service, and you
may need to file the claim with your plan to
be reimbursed.
MCHCP limits the amount it will pay to
non-network medical providers to 80
percent of usual and customary charges.
Non-network providers may bill you the
difference between the amount MCHCP
pays and the billed charge.
You will owe the allowed amount — the
maximum a provider may bill you for a
service, based on the provider’s agreement
with the plan — until you have met
the deductible. After you have paid the
deductible amount, the plan will begin
paying a percentage of the fees charged
by providers and pharmacies for covered
services.
Billing
Coinsurance
After the claim is processed, you will receive
an explanation of benefits (EOB) from
your medical plan. The EOB is not a bill.
It details the service received, the amount
covered by the plan and the amount the
provider may bill you. The EOB also
lists the deductibles and out-of-pocket
maximums for your plan. Keep the EOB for
your records, so you can keep track of your
deductible and out-of-pocket balances.
After you receive the EOB, you can expect
a bill from the provider. The amount
billed should match the amount listed on
the EOB. Send payment to the provider.
Sometimes you may receive a bill from your
provider before you receive the EOB. If this
occurs, contact the medical plan before you
pay your provider to ensure you’re paying
the proper amount.
Once the deductible is met, you will pay a
percentage of the fees charged by providers
and pharmacies for covered services. This is
your coinsurance. You pay the coinsurance
until you reach the entire out-of-pocket
maximum for the year.
The amounts you pay toward your
deductible and for coinsurance are applied
to the out-of-pocket maximum. The plan
will begin paying 100 percent of covered
services once the entire out-of-pocket
maximum amount is met. If two or more
family members are covered, the family outof-pocket maximum must be met before
the plan begins paying 100 percent of
covered services. Premiums, balance-billed
charges or non-covered services do not
apply to the out-of-pocket maximum.
Central Bank
Website
mohsa.centralbank.net
Phone
573-634-1243 or 877-554-5535
Availability
If offered by employer, available to
employees with a Health Savings
Account Plan
Health Savings Account Information
HSAs allow you to enjoy tax reductions
and more affordable health insurance
premiums. Among the benefits:
• Contributions are 100 percent tax
deductible
• HSA balance rolls over from year to
year. You own the funds, and they
go with you at retirement or with a
job change
• Tax-deferred interest or earnings
on the HSA
• Funds can be used tax-free for
qualified medical expenses
To make voluntary pre-tax payroll
contributions as a public entity
employee, you must open an HSA with
MCHCP’s partner bank.
The IRS establishes a maximum
annual contribution amount each
year, but there is no limit on the
balance in the HSA. Once your
account is open, you will receive:
• A debit card
• Access to your account using online
banking
• A variety of investment options,
including self-directing your funds
with an investment representative
You can use your HSA funds to pay
for qualified medical expenses. IRS
Publications 969 and 502 explain the
rules for how you can use your HSA
funds. For example, non-prescription
medicines (other than insulin) are not
considered qualified medical expenses
for HSA purposes. A medicine or drug
will be a qualified medical expense for
HSA purposes only if the medicine or
drug:
The IRS family contribution limit is
based on your family as reported to
the IRS on your federal tax return
and applies regardless of whether two
employees are married and eligible
for the HSA. For example, if one
employee is covering a dependent
and the other employee is covered
as subscriber-only, the maximum
contribution for the entire family is
$6,750.
1. Requires a prescription,
2. Is available without a prescription
(an over-the-counter medicine or
drug) and you get a prescription
for it, or
3. Is insulin.
2016 HSA Annual Contribution Limits
Subscriber Only
Subscriber/Spouse, Subscriber
Child(ren) or Subscriber/Family
IRS Contribution Limit1
$3,350
$6,750
IRS Contribution Limit
Age 55 and older
$4,350
$7,750
Contributions
1
1. Contribution rules for HSAs are complex. You should consult your tax advisor about your individual circumstances and the maximum
contribution you can make. MCHCP does not provide individual tax advice.
2016 Benefit Guide
41
UMR
Website
www.umr.com
Phone
888-200-1167
Availability
ID Cards
Issued
PPO plans offer members the
following:
• Freedom to choose care from any
primary care provider, specialist or
hospital
• No referrals are needed to make
appointments with specialists
• Non-network benefits are available
PPO 600 Plan Summary of
Benefits and Coverage
When you enroll in an MCHCP
medical plan, you are automatically
enrolled in a prescription drug plan.
To learn more about the prescription
drug plan, go to page 46. You will
receive separate ID cards from the
prescription benefit administrator.
Preventive Care
screenings — is covered at 100 percent
by MCHCP, regardless of whether you
have met your deductible.
Network
Network providers have contracts with
your plan that limit the amount they
can bill you for services. Services from
these providers cost less than services
from non-network providers.
Present your ID card at the time of
service. Network providers will submit
the claim for you. Non-network
providers may request full payment at
the time of service, and you may need
to file the claim with your plan to be
reimbursed.
42
MCHCP limits the amount it will pay
to non-network medical providers to
80 percent of usual and customary
charges. Non-network providers may
bill you the difference between the
amount MCHCP pays and the billed
charge.
Billing
After the claim is processed, you will
receive an explanation of benefits
(EOB) from your medical plan. The
EOB is not a bill. It details the service
received, the amount covered by the
plan and the amount the provider
may bill you. The EOB also lists
the deductibles and out-of-pocket
maximums for your plan. Keep the
EOB for your records, so you can keep
track of your deductible and out-ofpocket balances.
After you receive the EOB, you can
expect a bill from the provider. The
amount billed should match the
amount listed on the EOB. Send
payment to the provider. Sometimes
you may receive a bill from your
provider before you receive the EOB.
If this occurs, contact the medical plan
before you pay your provider to ensure
you’re paying the proper amount.
Deductible
You will owe the allowed amount —
the maximum a provider may bill you
for a service, based on the provider’s
agreement with the plan — until you
have met the deductible for your plan.
Premiums, copayments, balance-billed
apply to the deductible.
If two or more family members are
covered and one family member
reaches the individual deductible,
the medical plan begins paying a
percentage of the fees for covered
services charged by providers for the
individual. No more charges incurred
by the individual may be used to satisfy
the family deductible.
If one or more additional family
members meet the individual
deductible, the medical plan begins
paying a percentage of the fees for
covered services charged by providers
for the entire family.
Coinsurance
Once the deductible is met, you will
pay a percentage of the fees charged
by providers for covered services.
This is your coinsurance. You pay the
coinsurance until you reach the entire
out-of-pocket maximum for the year.
Copayments
You have a copayment for emergency
room (ER) services. Copayments do
not count toward your deductible.
The ER copayment is in addition to
your deductible and coinsurance that
you may also owe for the ER service.
The copayment is waived if you
are admitted to the hospital or the
services are considered by your plan
UMR
Website
www.umr.com
Phone
888-200-1167
Availability
ID Cards
Issued
to be a “true emergency.” Even if the
copayment is waived, you will still have
to pay any deductible or coinsurance
that may be owed for the ER service.
You will pay a copayment until you
meet your out-of-pocket maximum for
the year.
Go to page 46 to learn about
copayments for pharmacy services.
The amounts you pay for your
deductible, ER copayment and
coinsurance are applied to the outof-pocket maximum. The plan will
begin paying 100 percent of covered
services once the entire out-of-pocket
maximum amount is met. Premiums,
balance-billed charges or non-covered
services do not apply to the out-ofpocket maximum.
reaches the individual out-ofpocket maximum, the medical plan
begins paying 100 percent covered
individual.
If one or more additional family
members meet the individual out-ofpocket maximum, the medical plan
begins paying 100 percent for covered
entire family.
Go to page 46 to learn about the outof-pocket maximum for pharmacy
services.
2016 Benefit Guide
43
UMR
Website
www.umr.com
Phone
888-200-1167
Availability
ID Cards
Issued
Preferred Provider Organization
(PPO) Plans
PPO plans offer members the
following:
• Freedom to choose care from any
primary care physician, specialist or
hospital
• No referrals are needed to make
appointments with specialists
• Non-network benefits are available
To learn more about the prescription
drug plan, go to page 46. You will
receive separate ID cards from the
prescription benefit administrator.
Preventive Care
screenings — is covered at 100 percent
by MCHCP, regardless of whether you
have met your deductible.
Network
Network providers have contracts with
your plan that limit the amount they
can bill you for services. Services from
these providers cost less than services
from non-network providers.
Present your ID card at the time of
service. Network providers will submit
the claim for you. Non-network
44
providers may request full payment at
the time of service, and you may need
to file the claim with your plan to be
reimbursed.
MCHCP limits the amount it will
pay to a non-network provider to
80 percent of usual and customary
charges. Non-network providers may
bill you the difference between the
amount MCHCP pays and the billed
charge.
Billing
After the claim is processed, you will
receive an explanation of benefits
(EOB) from your medical plan. The
EOB is not a bill. It details the service
received, the amount covered by the
plan and the amount the provider
may bill you. The EOB also lists
the deductibles and out-of-pocket
maximums for your plan. Keep the
EOB for your records, so you can keep
track of your deductible and out-ofpocket balances.
After you receive the EOB, you can
expect a bill from the provider. The
amount billed should match the
amount listed on the EOB. Send
payment to the provider. Sometimes
you may receive a bill from your
provider before you receive the EOB.
If this occurs, contact the medical plan
before you pay your provider to ensure
you’re paying the proper amount.
Deductible
You will owe the allowed amount —
the maximum a provider may bill you
for a service, based on the provider’s
agreement with the plan — until you
have met the deductible for your plan.
Premiums, copayments, balance-billed
apply to the deductible.
reaches the individual deductible,
the medical plan begins paying a
percentage of the fees for covered
individual. No more charges incurred
by the individual may be used to satisfy
the family deductible.
If three family members meet the
individual deductible or out-of-pocket
maximum, the medical plan begins
paying a percentage of the fees for
covered services charged by providers
for the entire family.
Coinsurance and Out-of-Pocket
Maximum
The remaining percentage, which you
must pay, is your coinsurance. You pay
the coinsurance for your plan until
you reach the plan’s out-of-pocket
maximum for the year. After that, the
plan pays for 100 percent of covered
services for the rest of the year.
Copayments
UMR
Website
www.umr.com
Phone
888-200-1167
Availability
ID Cards
Issued
You have a copayments for office visits,
urgent care and emergency room (ER)
services. Copayments do not count
toward your deductible.
The ER copayment is in addition to
your deductible and coinsurance that
you may also owe for the ER service.
The ER copayment is waived if you
are admitted to the hospital or the
services are considered by your plan
to be a “true emergency.” Even if the
copayment is waived, you will still have
to pay any deductible or coinsurance
that may be owed for the ER service.
You will pay copayments until you meet
your out-of-pocket maximum for the
year.
Go to Page 46 to learn about
copayments for pharmacy services.
2016 Benefit Guide
45
Express Scripts, Inc.
Website
www.express-scripts.com
Phone
800-797-5754
Availability
Available to all eligible members
ID Cards
Issued
The non-Medicare prescription
copayment and coinsurance
information may be found in the
section of this guide.
Express Scripts, Inc. (ESI) administers
the prescription drug benefits. This
plan maintains a broad choice of
covered drugs and promotes the
use of generic drugs. ESI maintains
a nationwide pharmacy network.
You can fill a prescription from any
provider at a network pharmacy or
through ESI’s home delivery program.
For additional information on the
formulary, contact ESI.
Drug Formulary
The drug formulary is a list of Food
and Drug Administration (FDA)approved prescription drugs and
supplies developed by ESI. The
formulary is updated on a semiannual
basis, but it can change throughout
the year.
Generic drugs, approved by the
FDA, are proven to provide the same
reliable, effective treatment as brandname versions, but at lower prices. If
a generic drug is not available, talk to
your doctor about taking a lower-cost
brand-name drug on the formulary.
If you purchase a brand drug when a
generic is available, you will pay the
generic copayment plus the difference
in the cost of the drugs unless your
46
health care provider has indicated you
must take the brand drug.
Most, but not all, prescribed drugs that
are not on the formulary may still be
covered at a higher copayment level.
Retail (Network)
You may obtain up to a 31-day supply
of a non-specialty prescription at a
retail pharmacy. Select pharmacies
provide up to a 90-day supply of some
medication.
Retail (Non-Network)
For prescriptions filled at a nonnetwork pharmacy, you must:
• Pay the full price of the
prescription
• Request a claim form from ESI or
MCHCP, or download a copy from
ESI or MCHCP’s website
• File the claim with ESI within
365 days of when you filled the
prescription. ESI reimburses
the cost of the drug at the
network discounted amount,
less the applicable copayment or
coinsurance
• Attach a prescription receipt
or label from the pharmacy to
the claim form. Patient history
printouts from the pharmacy are
acceptable but must be signed
by the pharmacist. Cash register
receipts are acceptable only for
diabetic supplies.
Home Delivery Option
The ESI home delivery program
provides convenient home or office
delivery of maintenance medications
while saving you money. Maintenance
medications are taken on a longterm basis and are available in more
economical quantities through the
home delivery program.
Members must decide how they want
to get their maintenance prescriptions
filled: either by a retail pharmacy
or home delivery. You may fill a
maintenance prescription twice at
a retail pharmacy while you decide.
If you do not contact ESI and notify
them of your decision by the third fill
of a prescription, you will pay the full
allowed amount for the prescription.
100% Coverage
There are certain medications that
MCHCP will pay the complete cost,
when accompanied by a prescription
and filled at a network pharmacy:
• Formulary birth control (nonformulary may be covered if criteria
is met)
• Generic vitamin D, 1,000 IU or less
• Over-the-counter (OTC) nicotine
replacement therapy
• Formulary tobacco cessation for
members aged 18 and over
• Generic Tamoxifen, generic
Raloxifene, and brand Soltamox
(Tamoxifen liquid for patients
who have difficulty swallowing
Tamoxifen tablets) for the
prevention of breast cancer
• Generic Aspirin, 81mg for women
up to age 55 with preeclampsia risk
Website
Phone
800-797-5754
Availability
ID Cards
Issued
• Generic Aspirin, up to 325mg for men
45-79 years of age and women 55-79
years of age for the prevention of
cardiovascular events
• Generic Folic Acid, 400 to 800 mcg/
day for women up to age 50
• Generic bowel prep (formulary and
OTC)
• Influenza vaccination – members aged
6 months and over
• Shingles vaccination – members aged
50 and over (pharmacists in Missouri
may only be able to administer the
vaccination to those aged 60 and over)
• Fluoride for children aged 6 months
through 12 years
• Iron Supplement for members aged 6
months through 12 months
Preauthorization
ESI requires preauthorization, or prior
authorization for specific medications.
This means proof of medical necessity is
required before a prescription for certain
drugs is paid by the plan. The purpose
is to prevent misuse and off-label use
of expensive and potentially dangerous
drugs. If you take a new prescription to
the pharmacy and the pharmacist says
it requires prior authorization, ask your
physician to call ESI’s Prior Authorization
line at 800-417-8164.
Quantity Level Limits
Quantities of some medications may
be limited based on FDA labeling and
medical literature. Limits are in place to
ensure safe and effective drug use and to
guard against stockpiling of medicines.
Step Therapy
Step therapy is designed for people who
have certain ongoing medical conditions
that require them to take medications on
a regular basis. MCHCP uses step therapy
to ensure members get the safest drugs at
the best cost possible before moving to a
more costly therapy.
The step therapy program varies
based on the drug prescribed and your
doctor’s recommended treatment plan.
Occasionally, you may be required to try
more than one first-step drug.
• First-Step Drugs
–– Primarily generic drugs that have
been proven safe and effective
–– Lowest copayment or cost applies
–– Drugs must be tried before the
plan pays for a second-step drug
• Second-Step Drugs
–– Drugs recommended if first-step
drugs don’t work
–– Primarily brand-name drugs
–– Higher copayment or cost normally
applies
Second-step drug prescriptions processed
at your pharmacy for the first-time trigger
a message to your pharmacist indicating
the use of step therapy. You’ll need to
speak with your doctor about the next
plan of action.
One of the following may occur:
• Your doctor may decide to prescribe
a first-step drug because he or she
thinks it will work with your treatment
plan. Only your doctor can change the
prescription.
• If your doctor decides, for medical
reasons, your treatment requires
a second-step drug without trying
a first-step drug, your doctor must
request prior authorization from ESI.
You could pay a higher copayment
than a first-step drug.
Pharmacy Lock-In Program
The Pharmacy Lock-In Program applies
to members that have been identified
as misusing pharmacy benefits. Once
identified, the member will be limited to
a designated network pharmacy for filling
of prescriptions for controlled substances
and muscle relaxants for a minimum of
twelve (12) months. The lock-in period
may be extended if it is determined the
member continues to misuse benefits.
Specialty Medications
Specialty medications are drugs that
treat chronic, complex conditions. They
require frequent dosage adjustments,
clinical monitoring, specialty handling,
and are often unavailable at retail
pharmacies.
Accredo is ESI’s home delivery specialty
pharmacy provider. Specialty drugs must
be filled through Accredo. You may get
the first fill at a retail pharmacy only
of those specialty drugs that ESI has
identified as being needed immediately.
After the first fill for those specialty
drugs that met criteria, you must get
those drugs through Accredo. Members
who continue to go to a retail pharmacy
will be charged the full discounted price
of the specialty drug.
2016 Benefit Guide
47
Website
Phone
800-797-5754
Availability
ID Cards
Issued
You can receive up to a 30-day supply of
each specialty medication each time. The
medications are delivered to your home
or any approved location at no additional
charge. Expert clinical support staff is
available to answer all of your medication
questions.
Split-Fill Program
Many times, a member’s provider will
advise them to stop taking a specialty
medication before the 30-day supply is
depleted, typically due to undesirable
side effects or lack of effectiveness.
To help avoid cost for medications that
will go unused and to reduce waste, the
split-fill program provides members with
a 15-day supply of some specialty drugs,
rather than a full 30-day supply. Once it is
determined that the member can tolerate
the medication, the remaining 15-day
supply will be filled. The copayment will
be prorated based on the given days’
supply dispensed. For example, if your
copayment is $35 for a 30-day supply, you
will pay $17.50 for the first 15-day supply
and then $17.50 for the second 15-day
supply, if a second supply is filled.
For the first three (3) months of taking
a new prescription, the member will be
in regular contact with a Therapeutic
Resource Center (TRC)— specialist
pharmacists, nurses and doctors — as
well as their own health care provider,
48
in order to monitor for any potential
complications. By the fourth (4th)
month, if the medication is to be
continued, a full 30-day supply will be
dispensed.
The split-fill program only applies to
specialty drugs that are packaged to allow
split-filling and those that are filled via
Accredo specialty mail order pharmacy,
beginning with the first fill.
Disease Management Rewards
Members enrolled and actively
participating in a Disease Management
(DM) Program through Alere may see
reductions in prescription drug costs.
Please see pages 53 for more details.
Delta Dental of
Missouri
Website
www.deltadentalmo.com
Phone
866-737-9802
Availability
Dental Plan
You may visit the dentist of your choice
and select dentists on a treatment-bytreatment basis. Your out-of-pocket
costs may vary depending on your
choice. You have three options:
Delta Dental PPO Network
Check with your employer to see if
this plan is offered
This network offers you cost-control
and claim-filing benefits.
ID Card
Delta Dental Premier Network
Issued
This network also offers you costcontrol and claim-filing benefits.
However, out-of-pocket expenses
(coinsurance amounts) may be higher
with a Premier dentist.
All participating dentists (PPO and
Premier) have the forms to submit
your claim. Delta Dental (DDMO)
participating dentists will usually file
claims for you, and DDMO will pay
them directly.
Visit MCHCP’s or DDMO’s website to
find out if your dentist participates, or
contact DDMO for PPO and Premier
participating dentists in your area.
Non-Participating Dentist
If you go to a dentist not contracted
with a Delta Dental plan, DDMO
will make payment directly to you. It
will be your obligation to make full
payment to the dentist and file your
claim. Obtain a claim form from
MCHCP’s or DDMO’s website.
The chart below is a summary of the
covered services. Visit the MCHCP
website for more information.
Additional Benefits
Two additional cleanings are allowed
per calendar year for members who are
pregnant, diabetic, have a suppressed
immune system or have a history of
periodontal therapy.
Dental Services*
Coverage
Service
You Pay
Note
To be eligible for the additional
cleanings, you must submit a SelfReport form, which can be obtained
from MCHCP’s or DDMO’s website or
by contacting DDMO.
Diagnostic and
Preventive
Examinations
Prophylaxes (teeth cleaning)
Fluoride
Bitewing X-rays
Sealants
No deductible
0% coinsurance
Dental exams, X-rays, cleanings and
fluoride treatment do not apply to the
individual plan maximum
If periodontal therapy has already
been reported on your claims, the SelfReport form is not necessary.
Basic and
Restorative
Emergency Palliative Treatment
Space Maintainers
All Other X-rays
Minor Restorative Services (fillings)
Simple Extractions
$50/person
deductible1
20% coinsurance
X-rays do not apply to the individual
plan maximum
Major Services
Prosthetic Device Repair
All Other Oral Surgery
Periodontics
Endodontics
Prosthetic devices (bridges, dentures)
Major Restorative Services
(crowns, inlays, onlays)
Implants/Bone Grafts
$50/person
deductible1
50% coinsurance
12-month waiting period for Major
Services. The waiting period is waived
with proof of 12 months of continuous
dental coverage for Major Services
immediately prior to the
effective date of coverage in MCHCP’s
dental plan
* Coverage is limited to $1,000 per person per calendar year benefit period.
1. Coinsurance amounts apply after the $50 individual deductible is met under either Basic and Restorative or Major Services combined
2016 Benefit Guide
49
National Vision
Administrators, L.L.C.
Website
www.e-nva.com
User Name mchcp
Password vision1
Vision Plan
When receiving services from a National
Vision Administrators (NVA) provider,
NVA pays the provider directly. If you use
a non-network provider, you must pay the
provider and file the claim.
Phone
877-300-6641
ID Card
Issued
Availability
EyeEssential Discount Plan
When members exhaust their annual
benefits, NVA offers the EyeEssential
Discount Plan — a low cost, memberfriendly vision plan, which includes
significant discounts on materials
Vision Services – Basic Plan
Benefit
Service
Network
Non-network
Exams
Once every calendar year
Vision Exam (Two annual exams
covered for children up to age 18)
$10 copayment
Reimbursed up to $45
Lenses
One $25 copayment for
lenses
Single-vision lenses (per pair)
$25 copayment
Bifocal lenses (per pair)
$25 copayment
Trifocal lenses (per pair)
$25 copayment
Lenticular lenses (per pair)
$25 copayment
Polycarbonate lenses (per pair)
Applies to children up to age 18
100% coverage
Not covered
Frames
Once every 2 calendar years
Once every calendar year for
children up to age 18
Up to $125 retail allowance and
20% discount off remaining
balance1
Contact lenses
in place of eye glass lenses
Elective
If member prefers contacts
to glasses
Up to $125 retail allowance and
15% discount off conventional
or 10% discount off disposable
remaining balance2
Contact lenses
reimbursed
up to $105
Necessary
Additional costs covered at 100%
Contact lenses
reimbursed up to $210
Fitting and Evaluation
$20 copayment for daily contact
lenses
$30 copayment for extended contact
Reimbursed up to $20 for
daily contact lenses or $30
for extended or specialty
lenses
$50 copayment for specialty contact
lenses
contact lenses
Discount applied to all lens
options
Not covered
Other
Optional Items (cosmetic extras)
1. At Walmart or Sam’s Club Locations, frame price point is $55
2. At Walmart or Sam’s Club Locations, contact lens price point is $92
50
through participating NVA network
providers. For example, the plan covers
one pair of frames every 2 calendar years
for adults, but you can get discounts on
additional frames purchased throughout
the 24-month period.
National Vision
Administrators, L.L.C.
Website
www.e-nva.com
User Name mchcp
Password vision1
Vision Plan
LASIK Discounts
Applies to Basic and Premium Plans
NVA members will pay a maximum
amount for corrective laser surgery:
• Traditional PRK – $1,500 per eye
Phone
• Traditional LASIK – $1,800 per eye
• Custom LASIK – $2,300 per eye
Members may receive additional benefits
at LasikPlus locations nationwide:
• Special pricing on select technologies
877-300-6641
Vision Services – Premium Plan
ID Card
Benefit
Service
Issued
• Free initial consultation and
comprehensive LASIK vision exam
• Advanced laser technologies including
Wavefront and IntraLase (All-Laser
LASIK)
• Financing options available
Network
Non-network
$10 copayment
Exams
Vision Exam (Two annual exams
Availability
covered for children up to age 18)
Lenses
Single-vision lenses (per pair)
$25 copayment
Bifocal lenses (per pair)
$25 copayment
Trifocal lenses (per pair)
$25 copayment
Lenticular lenses (per pair)
$25 copayment
100% coverage
Not covered
Standard anti-reflective coating
$30 copayment
Not covered
Standard progressive multifocal Discount applied to all lens options
$50 copayment
Not covered
Frames
Once every 2 calendar years
Once every calendar year for
Up to $175 retail allowance
and 20% discount off
children up to age 18
remaining balance1
One $25 copayment for lenses
Polycarbonate lenses (per pair)
Applies to children up to age 18
Contact lenses
in place of eye glass lenses
Elective
If member prefers contacts
to glasses
Necessary
Fitting and Evaluation
Up to $175 retail allowance
Contact lenses reimbursed
and 15% discount off
up to $105
conventional or 10% discount off
disposable remaining balance2
Additional costs covered at
Contact lenses reimbursed
100%
up to $210
$20 copayment for daily
Reimbursed up to $20 for
contact lenses
$30 copayment for extended
daily contact lenses or $30
for extended or specialty
contact lenses
contact lenses
$50 copayment for specialty
contact lenses
Other
Optional Items (cosmetic extras)
Discount applied to all lens
options
Not covered
1. At Walmart or Sam’s Club Locations, frame price point is $77
2. At Walmart or Sam’s Club Locations, contact lens price point is $129
2016 Benefit Guide
51
ComPsych
Website
www.guidanceresources.com
Phone
800-808-2261
ID Card
Not Issued
Availability
Employee Assistance Program (EAP)
The Employee Assistance Program (EAP)
through ComPsych is a confidential
counseling and referral service that
can help employees and their families
successfully deal with life’s challenges.
EAP services are available at no cost
24 hours a day, every day of the year.
Resources include timely articles,
HelpSheetsSM, tutorials, streaming videos
and self-assessments.
Identity Theft and Consumer
Fraud Protection
The EAP can help with challenges such as:
EAP offers assistance with work-life
balance by helping clients locate quality
child care, elder care, education,
adoption, and pet care.
•
•
•
•
•
•
•
•
•
Stress;
Parenting;
Alcohol and drug abuse;
Marital problems;
Anxiety and/or depression;
Identity theft;
Consumer fraud;
Legal issues; and
Financial concerns.
The EAP covers up to six sessions
per problem, per year for individual
household members. There is no
annual limit on the number of different
problems. Counseling required by the
employer is covered, but will not count
as one of the six sessions. Additional
counseling sessions may be covered by the
employee’s medical plan.
Legal and Financial Concerns
For legal and financial concerns, the EAP
offers unlimited phone consultations
with ComPsych’s financial services
professionals and attorneys. For in-person
legal representation, the employee may
receive a 30-minute consultation at no cost
and a 25% reduction in customary legal
fees with a ComPsych network attorney.
52
Contact the EAP at the beginning of
a fraud-related emergency and receive
a 60-minute consultation at no cost to
employees. Trained fraud-resolution
specialists will assist with expediting fraud
claims and restoring credit.
FamilySource®
The FamilySource® program offers
personalized and comprehensive referral
packets which include:
• A minimum of three local referrals
with detailed maps to each
• Specific state-licensing standards for
facilities and providers
• HelpSheetsSM related to the individual’s
concerns
• Checklists to evaluate facilities and
providers
Alere
Website
my.mchcp.org
Phone
844-246-2427 (844-24MCHCP)
ID Card
Not Issued
Disease Management (DM) is a
program offered to help manage
specific chronic conditions. This
program is available at no cost to the
member.
To qualify for DM, members must be 18
or over (unless otherwise noted), not
have primary Medicare or TRICARE
Supplement coverage, and have one of
the following conditions:
• Asthma (6 years and older);
• Chronic Obstructive Pulmonary
Disease (COPD);
• Congestive heart failure;
• Coronary artery disease;
• Depression;
• Diabetes (6 years and older);
• Musculoskeletal/Chronic pain,
including low back pain;
• Obesity, defined as having a Body
Mass Index more than or equal to
30; or
• Hypertension, when managed with
another condition above.
Members identified with one of these
conditions, through medical and
pharmacy claims, may participate in
a DM program through Alere. Once
enrolled, members will receive regular
phone calls from a DM nurse, helping
the member better understand and
manage their condition.
Alere may also communicate with the
member’s health care provider, so that
the provider can make health care
decisions that are right for the member.
The DM program is completely
confidential and follows medical privacy
standards established by federal and
state law.
Disease Management Rewards
Upon participating in a DM program
through Alere, eligible members can
receive the following rewards:
• Formulary glucometer (one per
year), and prescribed formulary test
strips and lancets*
• Four visits with a Certified Diabetes
Educator*
*Covered at 100 percent for PPO members
or 100 percent after deductible is met for
HSA Plan members, when received through
a network provider.
• Lower prescription copayments/
coinsurance
Disease Management participants
receive reduced prescription drug costs
HSA Plan Coinsurance
Reduced coinsurance amount
Generic
5% coinsurance after
deductible has been met
(Diabetes medication only)
Brand
(Diabetes medication only)
Non-Formulary
(All medications)
PPO Plan Copayments
Supply
Generic
Brand
(Diabetes
(Diabetes
NonFormulary
medication only)
medication only)
(All medications)
Up to 31-day
$4
$17.50
$50
Up to 60-day
$8
$35
$100
Up to 90-day (Retail) $12
$52.50
$150
Up to 90-day
(Home Delivery)
$43.75
$125
$10
2016 Benefit Guide
53
Alere
Website
my.mchcp.org
Phone
844-246-2427 (844-24MCHCP)
ID Card
Not Issued
Alere will contact all eligible members
three times by phone to enroll and
begin a DM program. Eligible members
may also self-enroll by contacting Alere
directly. If Alere is unable to reach a
member over the phone, Alere will mail
the member a notice to contact a DM
nurse.
Upon receiving the notice to contact,
it is the member’s responsibility to call
Alere within two (2) weeks of the letter
date to begin participation. Once a
member has completed the first call
with a DM nurse, they have started
participation in a DM program.
Participation means one of the
following:
• Work one-on-one with a DM nurse;
or
• Meet initial goals to control the
condition and receive up to two
(2) calls per year from a DM nurse
until the condition can be managed
independently.
DM Rewards begin no earlier than
Jan. 1, 2016, and end on Dec. 31, 2016.
Members who are participating in a DM
program on Dec. 1, 2015, will begin
receiving DM Rewards on Jan. 1, 2016. If
a member starts after Dec. 1, 2015, DM
Rewards begin the 1st day of the 2nd
month after the member has completed
the first one-on-one phone call with a
DM nurse. For example, if a member
completes a call on Feb. 19, 2016, he/
she will begin receiving DM Rewards on
April 1.
54
Members who stop participating will
lose DM Rewards for the remainder
of the year. The loss effective date is
the 1st day of the 2nd month after
MCHCP learns the member has stopped
participating. For example, if MCHCP
is notified on Feb. 19, 2016, the member
will lose DM Rewards beginning on
April 1.
Women’s Health
and Cancer Rights Notice
If you have had or are going to have a
mastectomy, you may be entitled to certain
benefits under the Women’s Health and
Cancer Rights Act of 1998 (WHCRA).
For individuals receiving mastectomyrelated benefits, coverage will be provided
in a manner determined in consultation
with the attending physician and the
patient, for:
• All stages of reconstruction of the
breast on which the mastectomy was
performed;
• Surgery and reconstruction of the
other breast to produce a symmetrical
appearance;
• Prostheses; and
• Treatment of physical complications
of the mastectomy, including
lymphedema.
These benefits will be provided subject
to the same deductibles and coinsurance
applicable to other medical and surgical
benefits provided under this plan.
If you would like more information on
WHCRA benefits, call UMR at
888-200-1167.
2016 Benefit Guide
55
56
Member Information
Section 3
Member
Information
Appeal Procedures
Effective
September 1, 2013
This notice describes how medical information about you may be used and disclosed and how
you can get access to this information. Please review it carefully.
If you have any questions about
this notice, please contact Missouri
Consolidated Health Care Plan’s Privacy
Officer at 832 Weathered Rock Court,
disclose protected health information
with your providers (pharmacies,
physicians, hospitals, etc.) to assist in
your treatment.
PO Box 104355, Jefferson City, MO
65110, or by calling 573-751-8881 or toll
free 800-701-8881.
For Payment
We may use and disclose protected
health information about you so that the
treatment and services you receive will be
paid. For example, we may use or disclose
protected health information in order for
your claims to be processed, coordinate
your benefits, review health care services
provided to you and evaluate medical
necessity or appropriateness of care or
charges. We may also use or disclose
your protected health information to
determine whether a treatment is a
covered benefit under the health plan.
We may use and disclose your protected
health information to determine
eligibility for coverage, in order to obtain
pretax payment of your premiums from
your employer or sponsoring entity,
and for determining wellness premium
incentives. We may use and disclose
your protected health information for
underwriting purposes, but, if we do, we
are prohibited from using your genetic
information for such purposes.
This notice describes the information
privacy practices followed by workforce
members of Missouri Consolidated
Health Care Plan. For purposes of this
notice, the pronouns “we”, “us” and “our”
and the acronym “MCHCP” refer to
Missouri Consolidated Health Care Plan.
This notice applies to the information
and records we have about your health
care and the services you receive. We are
required by law to maintain the privacy
of your protected health information and
to notify you if there has been a breach
of your protected health information.
We are also required by law to give you
this notice. It will tell you about the
ways in which we may use and disclose
health information about you and
describes your rights and our obligations
regarding the use and disclosure of that
information.
How We May Use and Disclose
Health Information About You
For Treatment
We may use or disclose protected health
information about you to assist in
providing you with medical treatment or
services. For example, we may use and
58
Member Information
For Health Care Operations
We may use and disclose protected
health information for our health care
operations. For example, we may use
and disclose your protected health
information to address or resolve
complaints or appeals regarding your
medical benefits. We may use or disclose
protected health information with
our wellness or disease management
programs in which you participate.
We may use your protected health
information to conduct audits, for
purposes of rate-making, as well as
for purposes of risk management.
We may also disclose your protected
health information to our attorneys,
accountants and other consultants who
assist us in performing our functions.
We may disclose your protected health
information to health care providers or
entities for certain health care operations
activities, such as quality assessment and
improvement activities, case management
and care coordination. In this case, we
will only disclose your protected health
information to these entities if they
have or have had a relationship with you
and your protected health information
pertains to that relationship, such as with
other health plans or insurance carriers
in order to coordinate benefits, if you
or your family members have coverage
through another health plan.
Disclosures to Employer
We may also use and disclose protected
health information with your employer
as necessary to perform administrative
functions. Employers who receive this
type of information are required by law
to have safeguards in place to protect
against inappropriate use or disclosure of
your information.
Effective
September 1, 2013
Disclosures to Family Members
or Others
We may disclose health information
about you to your family members
or friends if we obtain your written
authorization to do so. Also, unless you
object, we may disclose relevant portions
of your protected health information to
a family member, friend, or other person
you indicate is involved in your health
care or in helping you receive payment
for your health care. For example, we may
assume you agree to our disclosure of
your personal health information to your
spouse when you bring your spouse with
you to a meeting or have your spouse on
the telephone while such information is
discussed. We may also disclose claim and
payment information of family members
to the subscriber in a family plan.
If you are not capable of agreeing or
objecting to these disclosures because of,
for instance, an emergency situation, we
will disclose protected health information
(as we determine) in your best interest.
After the emergency, we will give you
the opportunity to object to future
disclosures to family and friends.
Disclosures to Business Associates
We contract with individuals and
entities (business associates) to perform
various functions on our behalf or
provide certain types of services. To
perform these functions or provide these
services, our business associates will
receive, create, maintain, use or disclose
protected health information. We require
the business associates to agree in writing
to contract terms to safeguard your
information, consistent with federal and
state law. For example, we may disclose
your protected health information to a
business associate to administer claims
or provide service support, utilization
management, subrogation or pharmacy
benefit management.
Special Situations
We may use or disclose health
information about you without
your permission for the following
purposes, subject to all applicable legal
requirements and limitations:
To Avert a Serious Threat to Health
or Safety
We may use and disclose health
information about you when necessary
to prevent a serious threat to your health
and safety or the health and safety of the
public or another person.
Required By Law
We will disclose your health information
when required to do so by federal, state
or local law.
Public Health Activities
We may disclose your health information
to a public health authority that is
authorized by law to collect or receive
such information for the purpose of
preventing disease or injury.
For Research
Under certain circumstances, and only
after a special approval process, we may
use and disclose your health information
to help conduct research.
To a Health Oversight Agency
to a health oversight agency for oversight
activities authorized by law.
Judicial and Administrative
Proceedings
in the course of any judicial or
administrative proceeding in response
to an order of a court or administrative
tribunal. We may disclosure your health
information in the course of any judicial
or administrative proceeding in response
to a subpoena, discovery request, or other
lawful process if we receive satisfactory
assurance that you have been given notice
of the request or that there is a qualified
protective order for the information.
Workers’ Compensation
We may release health information
about you for workers’ compensation
or similar programs. These programs
provide benefits for work-related injuries
or illness.
Law Enforcement
We may release health information if
asked to do so by a law enforcement
official in response to a court order,
subpoena, warrant, summons or similar
2016 Benefit Guide
59
Effective
September 1, 2013
process, subject to all applicable legal
requirements.
For Military, National Security,
or Incarceration/Law Enforcement
Custody
If you are involved with the military,
national security or intelligence
activities, or you are in the custody of law
enforcement officials or an inmate in a
correctional institution, we may release
your health information to the proper
authorities so they may carry out their
duties under the law.
Information Not Personally
Identifiable
We may use or disclose health
information about you in a way that does
not personally identify you or reveal who
you are.
Other Uses & Disclosures of
Health Information
We will not use or disclose your health
information for any purpose other
than those identified in the previous
sections without your specific, written
Authorization. If you give us Authorization
to use or disclose health information about
you, you may revoke that Authorization,
in writing, at any time. If you revoke
your Authorization, we will no longer
use or disclose information about you
for the reasons covered by your written
Authorization, but we cannot take back any
uses or disclosures already made with your
permission.
60
Member Information
If we have HIV or substance abuse
information about you, we cannot release
that information without a special signed,
written authorization from you. In
order to disclose these types of records
for purposes of treatment, payment or
health care operations, we will have to
have a special written Authorization that
complies with the law governing HIV or
substance abuse records.
If we have psychotherapy notes, we will
not use or disclose that information
without authorization unless the use or
disclosure is used to defend MCHCP in a
legal action or other proceeding brought
by you.
MCHCP will not use or disclose
your protected health information
for marketing purposes without an
authorization, except if the marketing
communication is in the form of a faceto-face communication made by MCHCP
to you or in the form of a promotional
gift of nominal value provided by
MCHCP. MCHCP will not sell your
protected health information without
your authorization.
Your Rights Regarding Health
Information About You
You have the following rights regarding
health information we maintain about
you:
Right to Inspect and Copy
You have the right to inspect and
copy your health information, such
as enrollment, eligibility and billing
records. You must submit a written
request to MCHCP’s Privacy Officer in
order to inspect and/or copy your health
information. If you request a copy of the
information, we may charge a fee for
the costs of copying, mailing or other
associated supplies. We may deny your
request to inspect and/or copy in certain
limited circumstances. If you are denied
access to your health information, you
may ask that the denial be reviewed. If
such a review is required by law, we will
select a licensed health care professional
to review your request and our denial. The
person conducting the review will not be
the person who denied your request, and
we will comply with the outcome of the
review.
Right to Amend Incorrect or
Incomplete PHI
If you believe health information we have
about you is incorrect or incomplete, you
may ask us to amend the information.
You have the right to request an
amendment as long as the information is
kept by this office.
To request an amendment, complete and
submit a Member Record Amendment/
Correction Form to MCHCP’s Privacy
Officer. We may deny your request for
an amendment if it is not in writing or
does not include a reason to support
the request. In addition, we may deny
your request if you ask us to amend
information that:
Effective
September 1, 2013
Complaints
If you believe your privacy rights
have been violated, you may file a
complaint with our office or with
the federal office of the Secretary
of the Department of Health and
Human Services - Office of Civil
Rights. To file a complaint with
our office, contact MCHCP’s
Privacy Officer at 573-751-8881 or
toll free 800-701-8881. You will not
be penalized or retaliated against
for filing a complaint.
You may contact the Department
of Health and Human Service on
your rights under HIPAA at:
Office for Civil Rights, DHHS
601 East 12th St. – Room 248
Kansas City, MO 64106
(816) 426-7277
(816) 426-7065 (TDD)
www.hhs.gov
1. We did not create, unless the
person or entity that created the
information is no longer available to
make the amendment;
2. Is not part of the health information
that we keep;
3. You would not be permitted to
inspect and copy; or
4. Is accurate and complete.
Right to an Accounting of Certain
Disclosures
You have the right to request an
“accounting of disclosures.” This is a list
of the disclosures we made of medical
information about you for purposes other
than treatment, payment and health
care operations. To obtain this list, you
must submit your request in writing to
MCHCP’s Privacy Officer. It must state a
time period, which may not go back more
than six years from the date of the request.
Your request should indicate in what form
you want the list (for example, on paper
or electronically). We may charge you
for the costs of providing the list. We will
notify you of the cost involved and you may
choose to withdraw or modify your request
at that time before any costs are incurred.
Right to Request Restrictions
You have the right to request a
restriction or limitation on the health
information we use or disclose about you
for treatment, payment or health care
operations. You also have the right to
request a limit on the health information
we disclose about you to someone who is
involved in your care or the payment for
it, like a family member or friend. For
example, you could ask that we not use or
disclose information about a particular
health care treatment you received.
We are Not Required to Agree to
Your Request
We are not required to agree to your
request for restrictions. If we do agree,
we will comply with your request unless
the information is needed to provide you
emergency treatment. If your request
restricts us from using or disclosing
information for purposes of treatment,
payment or health care operations, we
have the right to discontinue providing
you with health care treatment and
services.
Request Restrictions
To request restrictions, you may complete
and submit the Request for Restriction
on Use/Disclosure of Health Care
Information to MCHCP’s Privacy Officer.
Right to Request Confidential
Communications
You have the right to request that we
communicate with you about medical
matters in a certain way or at a certain
location. For example, you can ask that
we only contact you at work or by mail.
To request confidential communications,
you may complete and submit the
Request for Restriction on Use and
Disclosure of Health Care Information
and/or Confidential Communication to
MCHCP’s Privacy Officer. We will not ask
you the reason for your request. We will
accommodate all reasonable requests.
Your request must specify how or where
you wish to be contacted.
Right to a Paper Copy of This Notice
You have the right to a paper copy of this
notice. You may ask us to give you a copy
of this notice at any time. Even if you have
agreed to receive it electronically, you are
still entitled to a paper copy. To obtain
such a copy, contact MCHCP’s Privacy
Officer.
Changes to This Notice
MCHCP is required to abide by the terms
of the notice currently in effect. We
reserve the right to change this notice,
and to make the revised or changed
notice effective for medical information
we already have about you, as well as any
information we receive in the future.
We will post the revised notice to our
website prior to the effective date of
the change, and we will distribute any
amended notice or information about
the change and how to obtain a revised
notice in the next annual communication
to members, either by mail or
electronically if you have agreed to
receive communications in that manner.
Please note that the amended notice may
be part of another mailing from MCHCP.
In addition, we will post the current
notice in our office and on www.mchcp.
org with its effective date directly under
the heading. You are entitled to a copy of
the notice currently in effect.
2016 Benefit Guide
61
Appeal Procedures
Claim Submissions and Initial
Denials
You must use the claims and
administrative procedures established
by the health plan administering the
particular service for which coverage,
authorization or payment is sought.
Pre-Service Claims
Pre-service claims are requests made to
the health plan before getting medical
care, such as prior authorization or
a decision on whether a treatment or
procedure is medically necessary. Preservice claims must be decided no later
than 15 days from the date the health plan
receives the request. If the health plan
requires more time for reasons beyond
its control, it must notify you before the
end of the first 15-day period, explain
the reason for the delay and request
any additional information. If more
information is requested, you have at least
45 days to provide the information. The
health plan must decide the claim no later
than 15 days after receiving the additional
information or after the period allowed to
supply it ends, whichever is first.
Urgent Care Claims
Urgent care claims are a special type of
pre-service claim that require a quicker
decision because waiting the standard
time could seriously jeopardize you or your
family member’s life, health or ability to
regain maximum function. A request for
an urgent care claim must be submitted
verbally or in writing and will be decided
within 72 hours and followed by a written
confirmation of the decision.
62
Member Information
Concurrent Claims
Concurrent claims are claims related to
an ongoing course of previously approved
treatment. If the health plan approved
ongoing treatment over a period of time
or number of treatments and later reduces
or terminates the course of treatment, it
will be treated as a benefit denial. The
health plan must notify you in writing
before reducing or ending a previously
approved course of treatment, in sufficient
time to allow you to appeal and obtain
a determination before the benefit is
reduced or terminated.
Post-Service Claims
Post-service claims are all other claims for
services, including claims after services
have been provided, such as requests for
reimbursement or payment of the costs
of services. Post-service claims must be
decided no later than 30 days from the
date the health plan receives the claim.
If the health plan requires more time for
reasons beyond its control, it must notify
you before the end of the first 15-day
period, explain the reason for the delay
and request any additional information. If
more information is requested, you have
at least 45 days to provide the information.
The health plan must decide the claim
no later than 15 days after receiving the
additional information or after the period
allowed to supply it ends, whichever is first.
Claim Filing Deadline
• Claims must be filed by the provider
or you to the health plan as soon
as reasonably possible. Claims filed
more than one year after charges are
incurred will not be honored.
Initial Denial Notice
If you, your provider or your authorized
representative submits a request for
coverage or claim for services that is
denied, in whole or in part, you will
receive an initial denial notice with the
following information:
1. Reason for denial
2. Reference to plan provisions,
regulation, statute, clinical criteria
or guideline on which the denial was
based, and directions on how you can
obtain access to this information free
of charge
3. If documentation or information
is missing, a description of the
documentation or information
necessary for you to provide, and an
explanation as to why it is necessary
4. Information as to the steps you can
take to submit an appeal of the denial
Adverse Benefit Determinations
You have the right to appeal adverse
benefit determinations. Adverse benefit
determinations include the following:
• Denial, reduction, termination of, or
failure to provide or make payment
for a benefit based on an individual’s
eligibility to participate in the plan
• Denial, reduction, termination of, or
failure to provide or make payment for
a benefit based on utilization review
or failure to cover a service because
it is determined to be experimental,
investigational, or not medically
necessary or appropriate
• Rescission of coverage after an
individual has been covered under the
plan
Appeal Procedures
Appeals of adverse benefit determinations
must be submitted in writing to the entity
that issued the original determination
giving rise to the appeal.
Medical Appeals
First-Level Appeal
A first-level appeal of an adverse benefit
determination for medical services must
be submitted in writing within 180 days
of the date on the original claim decision
notice. Include any additional information
or documentation to support the reason
the original claim decision should be
overturned. The health plan will have
someone review the appeal who was not
involved in the original decision, and
will consult with a qualified medical
professional if a medical judgment is
involved. The health plan must respond
to you in writing within 30 days for postservice claims and 15 days for pre-service
claims from the date the health plan
received the first-level appeal request.
Submit the first-level appeal in writing to
the medical plan:
UMR
Pre-service/Concurrent claim appeals
UMR Appeals
PO Box 400046
San Antonio, TX 78229
Fax: 888-615-6584
Post-service claim appeals
UMR Claims Appeal Unit
PO Box 30546
Salt Lake City, UT 84130-0546
Fax: 877-291-3248
Second-Level Appeal
A second-level appeal for medical services
must be submitted in writing within 60 days
of the date of the first-level appeal decision
letter that upholds the original decision.
Include any additional information or
documentation to support the reason
the first-level appeal decision should be
overturned. The health plan will have
someone review the appeal who was
not involved in the original decision or
first-level appeal, and will consult with a
qualified medical professional if a medical
judgment is involved. The health plan
must respond in writing within 30 days for
post-service claims and within 15 days for
pre-service claims from the date the health
plan received the second-level appeal
request. Submit the second-level appeal in
writing to the medical plan:
UMR
Pre-service/Concurrent claim appeals
UMR Appeals
PO Box 400046
Fax: 888-615-6584
Post-service claim appeals
PO Box 30546
Fax: 877-291-3248
Pharmacy Appeals
The pharmacy benefit manager will have
involved. The pharmacy benefit manager
must respond in writing within 60 days
for post-service claims and within 30 days
for pre-service claims from the date the
pharmacy benefit manager received the
appeal request.
Non-Medicare Prescription Drug
Plan Appeals
An appeal of an adverse benefit
determination for pharmacy services must
be submitted in writing within 180 days
of the date on the original claim decision
notice. Include the date you attempted
to fill the prescription, the prescribing
physician’s name, the drug name and
quantity, the cost of the prescription, if
applicable, the reason you believe the
claim should be paid, and any additional
information or documentation to support
your belief that the original decision
should be overturned.
Submit the appeal to the pharmacy benefit
manager:
Express Scripts
P.O. Box 66588
St. Louis, MO 63166-6588
Attn: Clinical Appeals Department
Phone: 800-753-2851
Expedited Appeals
An expedited appeal may be requested
when a decision is related to a pre-service
claim for urgent care. The health plan
or pharmacy benefit manager will have
involved.
2016 Benefit Guide
63
Appeal Procedures
The health plan or pharmacy benefit
manager must respond verbally within
72 hours of receiving a request for
an expedited review, with written
confirmation of the decision within three
working days of providing notification of
the determination.
Submit the expedited appeal to the
health plan or pharmacy benefit manager
by telephone or fax:
UMR
Phone: 800-808-4424, ext. 15227
Fax: 888-615-6584
Attn: Appeals Unit
Express Scripts
Phone (Non-Medicare): 800-753-2851
Phone (Medicare): 800-935-6103
External Review
After completion of the internal appeals
process for medical or pharmacy services,
an external appeal is available for covered
medical and pharmacy benefits through
the U.S. Office of Personnel Management
(OPM) and the U.S. Department of
Health and Human Services (HHS).
Members may file a written request for
external review within four months of
receiving a final internal adverse benefit
determination. The request should be
sent to:
MAXIMUS Federal Services, INC.
MAXIMUS Federal Services
3750 Monroe Ave Suite 705
Pittsford, NY 14534
Fax: 888-866-6190
www.externalappeal.com
64
Member Information
Contact MAXIMUS Federal Services at
888-866-6205 if you have any questions
or concerns during the external review
process. A decision will be made within
45 days of the request.
You may file an expedited review if
the standard review time frame would
seriously jeopardize your life or health,
or your ability to regain maximum
function, or if the final internal adverse
benefit determination involves admission,
availability of care, continued stay, or an
item or service for which you received
services but have not been discharged
from the facility.
Dental and Vision Appeals
Appeals involving services from the
dental and vision plans must be submitted
to the dental and vision plans.
Delta Dental
First-Level Appeal
Attn: Customer Service
12399 Gravois Road
St. Louis, MO 63127
Second-Level Appeal
Attn: Appeals Committee
12399 Gravois Road
St. Louis, MO 63127
National Vision Administrators
National Vision Administrators, L.L.C.
Attn: Complaints, Grievances, Appeals
PO Box 2187
Clifton, NJ 07015
Administrative Appeals
Administrative appeals involve issues
regarding MCHCP eligibility, plan
effective dates, premium payments,
Partnership Incentive, TobaccoFree Incentive and plan choices.
Administrative appeals must be submitted
in writing within 180 days of the date
of the notice of administrative decision
or written denial of your administrative
request.
All administrative appeals should be
addressed to:
Missouri Consolidated Health
Care Plan
Attn: Appeal
PO Box 104355
Jefferson City, MO 65110-4355
Section 4
Contact
Contact Information
Who to Contact
Your plan for:
Claim questions
ID cards
Specific benefit questions
Appeal information
MCHCP for:
General benefit questions
Eligibility questions
Enrollment questions
Address changes or forms
MCHCPid requests
HIPAA forms and questions
Contact Information
Medical Plan
Dental Plan
HSA Plan, PPO 600 and PPO 1000
www.umr.com
888-200-1167
www.deltadentalmo.com
800-335-8266
PO Box 8690
St. Louis, MO 63126-0690
UMR
Claims Address
PO Box 30787
Appeals Addresses
Pre-service and Concurrent Claims
UMR Appeals
PO Box 400046
Post-service Claims
PO Box 30546
Delta Dental
Claims Address
PO Box 8690
St. Louis, MO 63126-0690
Appeals Addresses
First-Level Appeals Address
Attn: Customer Service
12399 Gravois Road
St. Louis, MO 63127
Second-Level Appeals Address
Attn: Appeals Committee
12399 Gravois Road
St. Louis, MO 63127
Express Scripts, Inc. (ESI)
800-797-5754
TTY: 866-707-1862
Home Delivery Pharmacy Service
PO Box 66773
St. Louis, MO 63166-6773
Appeals Address
Express Scripts
PO Box 66588
St. Louis, MO 63166-6588
Attn: Clinical Appeals Department
800-753-2851
Accredo Specialty Pharmacy
800-803-2523
TTY: 877-804-9222
66
Vision Plan
National Vision Administrators,
L.L.C. (NVA)
www.e-nva.com
User Name: mchcp
Password: vision1
877-300-6641
Claims Address
Attn: Claims
PO Box 2187
Clifton, NJ 07015
Appeals Address:
Attn: Complaints, Grievances & Appeals
PO Box 2187
Clifton, NJ 07015
Contact Information
Disease Management
Program
Alere
www.my.mchcp.org
844-246-2427 (844-24MCHCP)
Employee Assistance
Program
ComPsych®
www.guidanceresources.com
800-808-2261
Nurse Call Lines
All MCHCP members have access to
24-hour nurse call lines for health-related
questions.
If you’re unsure whether to go to the
doctor for an illness or just want more
information about a treatment or
condition, registered nurses are on hand
all day, every day to help.
Helpful Tips
Websites
Plan websites are provided as a
convenience to our members. The
inclusion of other websites does not mean
MCHCP endorses or is responsible for
those websites.
Provider Directories
Participating providers may change
during the year. Contact the plan or the
provider to verify participation. Contact
UMR for a list of network providers.
Benefit Information
This guide provides a summary of your
benefits. More detailed information is
available at www.mchcp.org or from the
plans.
To use this service, call your medical plan:
UMR NurseLine
888-200-1167
2016 Benefit Guide
67
About Us
Website
Missouri Consolidated Health Care Plan
www.mchcp.org
Hours
8:30 a.m.– 4:30 p.m.,
Monday – Friday
Phone
800-487-0771 or 573-751-0771
Fax
800-834-5181
Address
832 Weathered Rock Court
PO Box 104355
Jefferson City, MO 65110-4355
Our vision is to be recognized
and valued by our members
as their advocate in providing
affordable, accessible, quality
health care options.
Who We Are
MCHCP’s Mission
MCHCP provides coverage to
employees and retirees of most state
agencies as well as public entities that
have joined MCHCP. Nearly 100,000
state and public entity members are
covered by MCHCP.
To provide access to quality and
affordable health insurance to state
and local government employees. We
will accomplish this by:
MCHCP is a separate, stand-alone state
entity created by statute and organized
under the direction of a 13-member
board of trustees.
• Consolidating purchasing power
and administration to achieve
benefits not available to individual
employer members
• Creating collaborations to ensure
the needs of individual members
are understood and met
• Ensuring fiscal responsibility
• Developing innovative delivery
options and incentives
• Identifying and contracting with
high-value plans
• Maintaining a high-quality and
knowledgeable work force
832 Weathered Rock Court
Jefferson City, MO 65101
800-487-0771
573-751-0771
www.mchcp.org
myMCHCP

Benefit Guide - Missouri Consolidated Health Care Plan

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