MIT Affiliate Health Plans

Transcription

1 MIT Affiliate Health Plans Overview In this book: Insurance plans and rates How to enroll Your medical benefits Commonly used terms Useful contact information 1

2 Insurance plans and rates MIT Affiliate Medical Plan The MIT Affiliate Medical Plan covers most services provided at MIT Medical, our multi-specialty, on-campus health center. You can sign up for this plan for yourself, and you can also enroll family members for an additional charge (see table below). When you enroll, you must sign up for at least three months of coverage. If you choose to enroll in the MIT Affiliate Medical Plan only, you must have other health insurance that meets Massachusetts and U.S. visa requirements. MIT Affiliate Extended Insurance Plan This plan was specifically designed to supplement the coverage provided by the MIT Affiliate Medical Plan. The MIT Affiliate Extended Insurance Plan provides comprehensive coverage, including coverage for prescription medication and off-campus services such as emergency room visits, surgical procedures, and hospital stays (including childbirth and inpatient mental health/substance abuse care). You cannot sign up for the Affiliate Extended Plan without the Affiliate Medical Plan. Cost of coverage for Just you spouse / You and your partner You and your dependent(s) You, your spouse / partner, and your dependent(s) Academic year Sept. 1, 2017 Aug. 31, 2018 MIT Affiliate Medical Plan $1,524 MIT Affiliate Extended Insurance Plan $3,072 $1,524 + $1,524 = $3,048 $ 3,072 + $1,728 = $4,800 $1,524 + $756 = $2,280 $3,072 + $276 = $3,348 $1,524 + $1,524 + $756 = $3,804 $3,072 + $1,728 + $276 = $5,076 Both plans $4,596 $7,848 $5,628 $8,880 } Note: You must enroll in the Affiliate Medical Plan before you may purchase Affiliate Extended Insurance Plan coverage. Three months You must pay for at least three months of coverage at a time. (Price per month is listed in parentheses.) MIT Affiliate Medical Plan $381 ($127) $381 + $381 = $762 ($254) $381 + $189 = $570 ($190) $381 + $381 + $189 = $951 ($317) $768 + $432 + $69 = $1,269 $2,220 ($740) The separate Extended Plan rates are shown here for reference only. MIT Affiliate Extended Insurance Plan $768 Both plans $1,149 ($383) $768 + $432 = $1,200 $1,962 ($654) $768 + $69 = $837 $1,407 ($469) 2

3 How do I enroll? Affiliates Just schedule an orientation at the MIT Health Plans Office by calling When you come to our office (E23-308) for the orientation, we will help you understand how the MIT Affiliate Medical Plan works. If you decide to enroll in an MIT health plan, you can sign up at that time. You need to enroll within 30 days of your arrival at MIT. You must have an MIT appointment (at least 50% time) for at least three months and meet other eligibility requirements. For more information, see medical.mit.edu/healthplans/affiliate. MIT Medical will verify your eligibility before you enroll. Every three months, you will receive a bill by for the cost of the MIT Affiliate Medical Plan. Click on the link in the to pay your bill online. Family members Affiliates may enroll spouses, partners or spousal equivalents, and dependents (children up to 26 years old) in the Affiliate Medical Plan and the Affiliate Extended Insurance Plan. Please note: to enroll in the Extended Plan, family members must also enroll in the Affiliate Medical Plan. When you enroll family members in an MIT insurance plan, you must show us proof that they are eligible. Proof of eligibility includes: A marriage certificate for you and your spouse. A signed Affidavit of Spousal Equivalent Partnership form for you and your spousal equivalent and proof that you are living together. You can get the form and examples of acceptable documentation at the Health Plans Office, or download them at medical.mit.edu/pdf/spousal.pdf. A birth certificate for your dependent child that shows the name of the child and the name of the parent, or a passport that shows the parent/child relationship. You can enroll family members at the same time as you enroll or at the beginning of an academic semester in September or February. If your family members come from another country after you arrive, you must enroll them in the health plan within 30 days of their arrival in the United States. You will need to provide proof of the date they arrived, such as a stamped passport, visa, or airline ticket or boarding pass. Note: you cannot buy MIT insurance for your family members if you do not have MIT coverage yourself. What if I don t want to enroll? If you already have insurance that is similar to MIT s insurance plans, you do not have to buy the MIT Affiliate Medical Plan or the MIT Affiliate Extended Insurance Plan. How do I cancel coverage? You may cancel your coverage after three months. Or you can cancel during an open enrollment period or when a qualifying event occurs. See page 7 for information about qualifying events. 3

4 Your medical benefits Your cost for services at MIT Medical (covered under the Affiliate Medical Plan unless otherwise indicated) services outside MIT Medical (covered only if you are also enrolled in the Affiliate Extended Insurance Plan) In-network providers (some services are subject to the annual in-network deductible of $100 per individual; see page 7) Out-of-network providers (most services are subject to the annual out-of-network deductible of $500 per individual; see page 7) Outpatient care Acupuncture (20 visits per calendar year) Not available at MIT Medical $25 copay (patients will be billed in full and can submit a claim for reimbursement) $25 copay (you will be billed in full and can submit a claim for reimbursement) Allergy serums No charge if you are also enrolled in the Extended Plan $25 copay Not covered Allergy testing No charge $25 copay Not covered Chiropractor office visits Not available at MIT Medical $25 copay 20% coinsurance after deductible Diagnostic X-rays, lab tests, and other tests Emergency room visits No charge Not available at MIT Medical $50 copay for CT scans, PET scans, MRIs, and nuclear imaging; no charge for other services $100 copay per visit (waived if admitted for inpatient care) 20% coinsurance after deductible Deductible waived; $100 copay per visit (waived if admitted for inpatient care) Family planning services office visits, purchase and insertion of IUD No charge Not covered Not covered Flu shots No charge No charge Not covered Habilitative services Not available at MIT Medical $25 copay 20% coinsurance after deductible Infertility services Maternity care Office visits (up to 12 visits outside MIT Medical per year. Routine/ preventive services covered at MIT Medical only.) Oxygen and equipment for its administration No charge (services available at MIT Medical are limited) No charge if you are also enrolled in the Extended Plan No charge (no visit limit) $25 copay for office visits; 10% coinsurance on all other services No charge $25 copay, up to the benefit limit; then you pay all costs 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible, up to the benefit limit; then you pay all costs Not available at MIT Medical No charge 20% coinsurance after deductible Psychopharmacology No charge $25 copay 20% coinsurance after deductible Psychotherapy Routine adult physical exams, including related tests Routine gynecological exams, including related tests (one per calendar year) Routine immunizations No charge Deductible waived; no charge for visits 1 12; $25 copay per visit for all additional visits No charge Not covered Not covered No charge Not covered Not covered No charge (Gardasil, Bexsero, and Trumenba are covered only by the Extended Plan) Not covered Deductible waived; visits 1 12 covered in full up to the allowed amount; 20% coinsurance on all additional visits Not covered 4

5 Your medical benefits Your cost for services at MIT Medical (covered under the Affiliate Medical Plan unless otherwise indicated) services outside MIT Medical (covered only if you are also enrolled in the Affiliate Extended Insurance Plan) In-network providers (some services are subject to the annual in-network deductible of $100 per individual; see page 7) Out-of-network providers (most services are subject to the annual out-of-network deductible of $500 per individual; see page 7) Outpatient care Routine vision exam (one every 12 months) Short-term rehabilitation therapy occupational, physical, and speech (up to 60 visits per calendar year) Surgery and related anesthesia in an office setting, ambulatory surgical facility, hospital, or surgical day care unit Travel vaccines (yellow fever, typhoid, etc.) No charge if you are also enrolled in the Extended Plan Not available at MIT Medical No charge (services available at MIT Medical are limited) Limited coverage for children through age 5 $25 copay up to the benefit limit; then you pay all costs No charge; $25 copay for office/ ambulatory services Not covered $25 copay per vaccine Not covered Not covered 20% coinsurance after deductible, up to the benefit limit; then you pay all costs 20% coinsurance after deductible Urgent care visits No charge $50 copay 20% coinsurance after deductible Well-child visits No charge Covered through age 5 Not covered Inpatient care General or chronic disease hospital care, including maternity services Mental hospital or substance abuse facility treatment Rehabilitation hospital care (up to 60 days per calendar year) Not available at MIT Medical $100 copay per admission 20% coinsurance after deductible Not available at MIT Medical $100 copay per admission 20% coinsurance after deductible Not available at MIT Medical $100 copay per admission, up to the benefit limit; then you pay all costs 20% coinsurance after deductible, up to the benefit limit; then you pay all costs Other services Ambulance services Durable medical equipment such as wheelchairs, crutches, etc. Pediatric eyewear (covered through age 18) Prescription drugs (up to a 30-day supply for each prescription) No charge for MIT EMS ambulance service when available. No charge (equipment available at MIT Medical is limited) At MIT Optical, if you are also enrolled in the Extended Plan, 50% coinsurance (you will be billed in full and can submit a claim for reimbursement) At the MIT Pharmacy, if you are also enrolled in the Extended Plan, copays as follows: $0 for Tier 1 contraceptives $10 for Tier 1 medications $20 for Tier 2 medications $30 for Tier 3 medications No charge Deductible waived; covered in full 10% coinsurance 20% coinsurance after deductible 50% coinsurance (you will be billed in full and can submit a claim for reimbursement) At a participating Express Scripts pharmacy, copays as follows: $0 for Tier 1 contraceptives $20 for Tier 1 medications $30 for Tier 2 medications $40 for Tier 3 medications Maximum benefit: $20,000 per calendar year 50% coinsurance (you will be billed in full and can submit a claim for reimbursement) Not covered you pay all costs 5

6 Things to remember Services outside the U.S. If you need health care treatment while traveling outside the United States, the Affiliate Extended Insurance Plan provides the same coverage as within the U.S.; all covered services are considered to be out-of-network. Many facilities require that you pay when you receive care and then file a claim with Blue Cross Blue Shield of Massachusetts. If you need to locate a doctor or hospital, or need medical assistance services, call Blue Cross Blue Shield Global Core at (or call collect at ), 24 hours a day, seven days a week. An assistance coordinator, in conjunction with a medical professional, will arrange a physician appointment or hospitalization, if necessary. See bcbsglobalcore.com for more information. If traveling on an MIT-sponsored trip, you should register with International SOS prior to your departure. See links on vpf.mit.edu/insurance for more information. Your privacy is protected Unless you give us permission, we can t share anything about your visits to MIT Medical with people outside of MIT Medical. Exceptions would be made only in certain lifethreatening situations. For more information on our privacy policy and your rights and responsibilities as a patient, visit medical.mit.edu/privacy. Know your insurance Some services at MIT Medical like routine eye exams, prescriptions, allergy serum, Gardasil, Meningococcal serogroup B vaccines, and obstetrics are not covered under the Affiliate Medical Plan but are covered under the Affiliate Extended Insurance Plan. These services may also be covered under other plans, so even if you waive the Extended Plan, your other insurance may pay for you to receive some of these services at MIT Medical. You will be responsible for any charges that your other insurance does not pay. Make sure you know what medications you re taking and any allergies. Always carry your insurance card, no matter what insurance coverage you have. Useful contact information 24-hour help line Urgent Care Appointments MIT Pharmacy Mental Health & Counseling For urgent concerns: during the day nights/weekends Community Wellness Limitations and exclusions All benefits are effective September 1, 2017 through August 31, This is a quick overview. If there is a conflict between this overview and the Blue Cross Preferred Provider Benefit Description, including the addendum (both available at medical.mit.edu/healthplans/affiliate), the Benefit Description and/or addendum govern. The MIT Affiliate Medical Plan and the MIT Affiliate Extended Insurance Plan cover only medically necessary services, as defined in the Blue Cross Preferred Provider Benefit Description. Certain services are not covered under either plan, including, but not limited to, custodial care, most educational testing and evaluation, most experimental treatments, hearing aids and hearing aid evaluations, eyeglasses and contact lenses for patients age 19 and older, over-the-counter medicines and products, diet drugs, cosmetic surgery, orthotics, psychoanalysis, dental care, and prescription vitamins. If you have questions, contact Member Services at or mservices@med.mit.edu. 6

7 Commonly used terms Blue Cross Blue Shield ID card A card issued to members of the MIT affiliate health plans by Blue Cross Blue Shield of Massachusetts (BCBS). About a month after you enroll in the health plan for the first time, BCBS will mail ID cards to you and enrolled family members. BCBS will mail the cards to the address we have on file at MIT Medical. To make sure you receive your card, please update your address with the MIT Benefits Office and at MIT Medical once you know where you will be living. If you haven t received your ID card or you need a replacement, call us at , or affplan@med.mit.edu. Coinsurance The portion of eligible expenses you are responsible for paying, most often after the deductible is met. Coinsurance is usually calculated as a percentage of the amount approved by BCBS for the service. If the amount charged by an out-of-network provider is greater than the amount approved by BCBS, you will be responsible for paying coinsurance on the allowed amount, plus 100% of the remaining charges. Copay or Copayment The fixed dollar amount you must pay for a covered health care service, usually when you receive the service. Deductible The total amount you must pay for certain covered services each year before your health plan will begin covering additional costs. The Affiliate Extended Insurance Plan has two distinct deductibles: In-network services: $100 per individual per calendar year. This applies to all outpatient services except mental health care. Out-of-network services: $500 per individual per calendar year. This applies to all services except emergency care. Dependent Your child, up to 26 years old. In-network provider Any healthcare provider (physician, hospital, or other entity) that belongs to the Blue Cross Blue Shield (BCBS) PPO (preferred provider organization). Using an in-network provider will usually cost you less in copays or coinsurance. Out-of-network provider Any healthcare provider that does not belong to the Blue Cross Blue Shield (BCBS) PPO (preferred provider organization). You can use out-of-network providers, but your out-of-pocket expenses will be greater. If an out-of-network provider charges more for a service than BCBS allows for the service, you will be responsible for paying the difference, and that payment is not included in your out-of-pocket maximum. Out-of-pocket maximum An annual limit on the amount of money individuals are required to pay out of pocket for covered healthcare costs, excluding premiums. When the amount you ve paid in a calendar year reaches the out-of-pocket maximum, additional services during the same calendar year will be covered in full. You may still be responsible for the difference between the approved amount and the actual charge for out-of-network services. The Affiliate Extended Insurance Plan has three distinct out-of-pocket maximums: 1. For medical services: $4,000 per individual or $8,000 per family per calendar year. 2. For prescriptions filled at MIT Pharmacy: $1,000 per individual or $2,000 per family per calendar year. 3. For prescriptions filled through the Express Scripts pharmacy network, there is a separate out-of-pocket maximum of $1,000 per individual or $2,000 per family per calendar year. Qualifying life event A change in your circumstances that makes you eligible to change your health insurance enrollments outside of the normal schedule. Examples of qualifying life events include: Turning 26 and becoming ineligible for your parent s plan. The involuntary loss of other health insurance coverage. A dependent s entry into the country. Marriage or qualified same-sex partnership. The birth of a child, legal adoption, or legal guardianship. For more information, see medical.mit.edu/qualifying-events. 7

8 Health Plans offices Member Services E23, first floor Go to Member Services for questions about What your plan covers Insurance ID cards Referrals Claim-reimbursement forms PCP selection or changes Claims Health Plans E23, third floor Go to Health Plans for questions about Enrolling in a health plan Adding family members to a health plan or taking them off Health plan costs Waivers Verification of enrollment Billing Office E23, third floor billing@med.mit.edu Mailing Address MIT Affiliate Health Plan E23-308, 77 Massachusetts Ave. Cambridge, MA Care right here on campus Remember, with the Affiliate Medical Plan, you can use most services at MIT Medical at no additional charge even if you decide not to purchase the Extended Plan. Here are some things you should know: Choose a primary care provider (PCP) Your PCP will coordinate all your care, including necessary referrals to specialists at MIT Medical (usually covered by the Affiliate Medical Plan) or elsewhere (covered by the Affiliate Extended Insurance Plan or, possibly, another insurance plan that you have). Visit medical. mit.edu/choose to see names and photos of PCPs who are accepting new patients, get more information about individual providers, and fill out the online form to make your choice. If you are unhappy with your choice of PCP, you can change your selection at any time. Make an appointment If you need to be seen by a clinician, you can call your primary care provider s office directly. If you re sick and need to be seen the same day, let us know. Urgent Care MIT Medical s Urgent Care Service is open 7 a.m. 11 p.m., seven days a week (check medical.mit.edu for information about holiday and summer hours). To check on wait times or the availability of pediatric clinicians, call ahead: Mental Health and Counseling Service On-campus clinicians provide consultation, crisis intervention, and ongoing treatment, including individual and group counseling and psychopharmacology. Services are available to all MIT affiliates with no out-of-pocket cost and no referrals required. Walk-in hours are available on the third floor of MIT Medical Monday through Friday from 2 to 4 p.m. Call to make an appointment or to talk to a clinician in urgent situations. Overnight or on weekends, you can reach a mental health clinician by calling MIT Medical s 24-hour number, For more information, see medical.mit.edu/mentalhealth. Community Wellness at MIT Medical Explore resources and programs that can help you make healthy choices to get the most out of your time at MIT. Stop by E23, call , or learn more at medical.mit.edu/wellness. Learn more about MIT Medical at medical.mit.edu 8