2008 State Benefi ts. Member Handbook. Plan Year 2008 M C H C P. Missouri Consolidated Health Care Plan

Transcription

1 2008 State Benefi ts Member Handbook Plan Year 2008 M C H C P Missouri Consolidated Health Care Plan

2 State 2008 Member Handbook READ CAREFULLY. Important Information Enclosed. The Member Handbook is provided as a summary plan description. Benefits and costs are subject to change by action of the Missouri Consolidated Health Care Plan (MCHCP) Board of Trustees. Title 22, Division 10 of the State Code of Regulations is the plan document as adopted by the MCHCP Board of Trustees. Refer to Chapter 103 of the Revised Statutes of Missouri for additional governing information.

3 CONTENTS WHAT S NEW FOR 2008?...4 WELCOME...5 PAGE 9 PAGE 43 Table of Contents MEDICAL PLANS & EAP HEALTH MAINTENANCE ORGANIZATION (HMO) through Coventry Health Care of Kansas and Mercy Health Plans COPAY PLAN through Coventry Health Care PHARMACY BENEFITS through Express Scripts, Inc EMPLOYEE ASSISTANCE PROGRAM through Magellan Health Services HMO & COPAY PLAN BENEFITS...18 LIMITATIONS & EXCLUSIONS...27 USING YOUR MEDICAL PLAN...32 Copay Plan Through Coventry Health Care...32 Coventry Health Care of Kansas HMO...34 Mercy HMO - Central & East Regions...36 Mercy HMO - Southwest Region...38 BENEFITS & RIGHTS PRESCRIBED BY LAW...40 WELLNESS PROGRAM through Gordian Health Solutions DISEASE MANAGEMENT through CareAllies Smart Steps DENTAL PLAN through Delta Dental VISION PLAN through Vision Service Plan & ENROLLMENT...54 Change of Address MCHCP Identification Cards Eligibility Information Employee Eligibility Requirements, Eligible Dependents...54 Coordination of Benefits, Eligibility Date...55 Effective Date, Changes in Dependent Status...56 Vested Subscribers...57 Elected State Officials & Employees, Participation After Retirement...58 Enrollment Opportunities New Employees, Life Events, Open Enrollment...58 Requirements for Enrollment Proof of Eligibility, Coverage Levels...59 Enrollment Guidelines Adding New Dependents Access to MCHCP...61 Late Entrants, Enrolling Due to Life Events, Enrolling Due to Loss of Eligibility...62 Enrolling Due to Loss of Medicaid Status, Enrolling Dependents Due to Court Order, Termination of Employment, Coverage Changes Due to Death...63 Coverage During a Leave of Absence Coverage During a Layoff, Participation for LTD Recipients...65 Military Leave, Terminating Coverage, Reinstatement of Coverage After Dismissal...66 Failure to Pay Premiums...67 Medicare Eligible Participants Group Health Continuation Coverage Under COBRA State Member Handbook

4 CONTENTS PLAN AVAILABILITY...6 CONTACT INFORMATION...8 PAGE 71 PAGE Transferring Coverage...72 Coverage as a Retiree...73 Participating as a Retiree, Adding New Dependents, Military Leave...73 Terminating Coverage, Contribution Toward Retiree Premium Retirement Incentive Law...74 Medicare Eligible Participants...75 Medicare Benefits Coordination & Claims...75 HMO Claims, Copay Plan Through Coventry Health Care...76 Retiree Guidelines for MCHCP Coverage...76 Examples of Coordination of Benefits...77 COMPLAINTS, UTILIZATION REVIEW, GRIEVANCE PROCEDURES & APPEALS...80 Service Complaints...80 Utilization Review...80 Grievance Procedure for Claims & Services...81 Appeals to the MCHCP Board of Trustees...82 Administrative Appeals...82 Judicial Reviews...82 Other Insurance Rights...83 MCHCP s Privacy Practices...84 What are your rights as a member with MCHCP?...84 HIPAA Form Instructions...86 Forms: General Authorization to Release Protected Health Information to Member Designee...87 Member Record Amendment/Correction...89 Request for Restriction on Use & Disclosure of Health Care Information and/or Confidential Communication Authorization to Release Protected Health Information...93 Notice of Privacy Practices...95 FREQUENTLY ASKED QUESTIONS...99 DEFINITIONS Table of Contents Customer Service:

5 Important Changes WHAT S NEW FOR 2008? What s New Dependent Coverage Extended to Age 25 House Bill 818 was signed into law and changes the maximum age of covered dependent children from 23 to 25. Retirees & Adding Dependent Coverage Senate Bill 406 was signed into law. It allows retirees to add a dependent that is covered under another employer sponsored group health plan if that coverage ends due to: Termination of employment or Termination of group coverage by the employer. You must add the dependent(s) to your coverage within 60 days of the loss and provide proof that the coverage was in effect for at least 12 months immediately prior to the loss. Proof of eligibility is required. Vision Plan for Retirees, Terminated Vested, Longterm Disability and Survivor Subscribers The vision plan through Vision Service Plan has been expanded to cover retired, terminated-vested, long-term disability and survivor subscribers. Members in these categories will have a one-time opportunity to enroll in the vision plan. If coverage is not elected during this year s Open Enrollment, you cannot enroll at a later date. You and your dependents must be enrolled in the medical plan to enroll in the vision plan. If you cancel vision coverage at any time, you cannot enroll at a later date. You may elect vision coverage at the time of retirement if you meet certain criteria. Refer to PAGE 72. Wellness Program Changes for Lifestyle Ladder include: All PHAs must be taken online during Open Enrollment. Paper copies of the PHA are not available. The deadline to take the PHA is October 31. If you discontinue participation during the year, the incentive rate no longer applies, and your premium will increase. Federal regulation requires members be allowed to participate each year. New employees are not eligible to take the PHA and participate in Lifestyle Ladder until the Open Enrollment following their hire date. TRICARE Supplement Plan Not Available in 2008 The medical plans offered through MCHCP remain the same for 2008 with the exception of the TRICARE Supplement Plan. Due to federal law, 10 USC 1097c, MCHCP is no longer able to offer the TRICARE Supplement Plan as an option for health coverage after December 31, Dental Plan Delta Dental has enhanced benefits to include: Two additional cleanings per calendar year for patients that are pregnant, diabetic, have a suppressed immune system or have a history of periodontal therapy. Sealants for all eligible participants, limited to caries-free occlusal surfaces of the first and second permanent molars - once in 5 years. Alternate treatment is covered for implants in which case the benefits will not exceed the cost of a removable partial denture or fixed bridge - once in 7 years per tooth. Brush biopsy to detect oral cancer. PIN Requests When you request your PIN, it can be ed if MCHCP has your current address. (Visit mymchcp to update your address with MCHCP.) Otherwise, the PIN is mailed to your home. It is not provided by phone. Each enrolled subscriber was mailed his/her PIN prior to Open Enrollment. Benefit Design Changes: Changes in coinsurance or copayment amounts have been made in the following benefit categories: dental care/accidental injury, oral surgery and hearing aids. See the HMO & COPAY PLAN BENEFITS for details State Member Handbook

6 Welcome MISSOURI CONSOLIDATED HEALTH CARE PLAN Take this opportunity to browse your health benefits through Missouri Consolidated Health Care Plan (MCHCP). Explore MCHCP and your benefit package. Who is MCHCP? MCHCP was created by law in It is a stand-alone state entity and a part of State government. MCHCP s staff members are State employees. A provision of this law allows public entities access to insurance coverage through MCHCP. What does MCHCP do? MCHCP serves as a large group purchaser of medical, dental and vision insurance. In addition, MCHCP provides an employee assistance program (EAP) and programs for wellness and disease management. MCHCP operates under the direction of a Board of Trustees and is committed to providing quality health benefit programs through quality companies and providers. The health care plans offered through MCHCP include a wide range of coverage and ensure network providers meet specific credentialing requirements. What is MCHCP s mission? MCHCP s mission is to purchase and offer comprehensive health insurance for state and local governments. We accomplish this by: Consolidating purchasing power and administration to achieve benefits not available to individual employer members. Communicating 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 workforce. What is the Member Handbook? The Member Handbook provides a summary plan description of the medical, dental, vision, wellness, disease management and EAP plans offered by MCHCP. Benefits are effective January 1, This book is a guide to your health care benefits and replaces previous Member Handbooks. Keep it with your important documents. CONTACT US or TDD Line: M C H C P Monday - Friday 8:30 am - 4:30 pm (excluding state & federal holidays) Alternative forms of this handbook can be requested through our website or by phone. Alternative forms include text only and large font versions. Welcome Customer Service:

7 Plan Availability PLAN OPTIONS BY COUNTY Find the plan names that correspond with the plan codes in the chart. MISSOURI MISSOURI MISSOURI CODE COUNTY PLAN CODES CODE COUNTY PLAN CODES CODE COUNTY PLAN CODES 001 Adair 57, 78, Andrew 57, 78, Atchison 57, 78, Audrain 57, 78, 91, Barry 57, 78, 93, Barton 57, 78, 93, Bates 57, 61, 78, Benton 57, 78, 91, Bollinger 57, 78, Boone 57, 78, 91, Buchanan 57, 78, Butler 57, 78, Caldwell 57, 78, Callaway 57, 78, 91, Camden 57, 78, 91, Cape Girardeau 57, 78, Carroll 57, 61, 78, Carter 57, 78, Cass 57, 61, 78, Cedar 57, 78, 93, Chariton 57, 78, 91, Christian 57, 78, 93, Clark 57, 78, Clay 57, 61, 78, Clinton 57, 78, Cole 57, 78, 91, Cooper 57, 78, 91, Crawford 57, 78, 91, Dade 57, 78, 93, Jasper 57, 78, 93, Jefferson 57, 78, 91, Johnson 57, 61, 78, Knox 57, 78, Laclede 57, 78, 93, Lafayette 57, 61, 78, Lawrence 57, 78, 93, Lewis 57, 78, Lincoln 57, 78, 91, Linn 57, 78, Livingston 57, 78, McDonald 57, 78, 93, Macon 57, 78, Madison 57, 78, 91, Maries 57, 78, 91, Marion 57, 78, Mercer 57, 78, Miller 57, 78, 91, Mississippi 57, 78, Moniteau 57, 78, 91, Monroe 57, 78, 91, Montgomery 57, 78, 91, Morgan 57, 78, 91, New Madrid 57, 78, Newton 57, 78, 93, Nodaway 57, 78, Oregon 57, 78, Osage 57, 78, 91, Ozark 57, 78, St. Louis City 57, 78, 91, Saline 57, 78, 91, Schuyler 57, 78, Scotland 57, 78, Scott 57, 78, Shannon 57, 78, Shelby 57, 78, Stoddard 57, 78, Stone 57, 78, 93, Sullivan 57, 78, Taney 57, 78, 93, Texas 57, 78, Vernon 57, 78, 93, Warren 57, 78, 91, Washington 57, 78, 91, Wayne 57, 78, Webster 57, 78, 93, Worth 57, 78, Wright 57, 78, 99 KANSAS CODE COUNTY PLAN CODES 202 Atchison 57, 61, 78, Johnson 57, 61, 78, Leavenworth 57, 61, 78, Linn 57, 61, 78, Miami 57, 61, 78, Wyandotte 57, 61, 78, 99 Plan Availability 030 Dallas 57, 78, 93, Daviess 57, 78, De Kalb 57, 78, Dent 57, 78, 91, Douglas 57, 78, Dunklin 57, 78, Franklin 57, 78, 91, Gasconade 57, 78, 91, Gentry 57, 78, Greene 57, 78, 93, Grundy 57, 78, Harrison 57, 78, Henry 57, 61, 78, Hickory 57, 78, 93, Holt 57, 78, Howard 57, 78, 91, Howell 57, 78, Iron 57, 78, 91, Jackson 57, 61, 78, Pemiscot 57, 78, Perry 57, 78, Pettis 57, 78, 91, Phelps 57, 78, 91, Pike 57, 78, 91, Platte 57, 61, 78, Polk 57, 78, 93, Pulaski 57, 78, 91, Putnam 57, 78, Ralls 57, 78, Randolph 57, 78, 91, Ray 57, 61, 78, Reynolds 57, 78, 91, Ripley 57, 78, St. Charles 57, 78, 91, St. Clair 57, 78, 93, St. Francois 57, 78, 91, Ste. Genevieve 57, 78, 91, St. Louis 57, 78, 91, 99 ILLINOIS CODE COUNTY PLAN CODES 301 Bond 57, 78, 91, Calhoun 57, 78, 91, Clinton 57, 78, 91, Jersey 57, 78, 91, Macoupin 57, 78, 91, Madison 57, 78, 91, Monroe 57, 78, 91, Randolph 57, 78, 91, St. Clair 57, 78, 91, Greene 57, 78, 91, Williamson 57, 78, 91, 99 OTHER OUT-OF-STATE CODE COUNTY PLAN CODES 999 Out-of-State Counties 57, 78, State Member Handbook

8 REGIONS FOR 2008 PLAN YEAR Atchison 003 Holt 044 Nodaway Buchanan Platte 083 Worth 113 Gentry 038 Clinton 025 Clay 024 Jackson 048 Cass 019 Bates 007 Vernon 108 Barton 006 Jasper 049 Newton 073 McDonald 060 Harrison 041 Ray 089 Lafayette 054 Johnson 051 Henry 042 Dade 029 Lawrence 055 Barry 005 Pettis 080 Polk 084 Greene 039 Stone 104 Saline 097 Benton 008 Christian 022 Taney 106 Morgan 071 Camden 015 Webster 112 Schuyler 098 Adair 001 Grundy NORTHWEST Andrew DeKalb Daviess Linn Livingston 058 Macon Caldwell 013 WEST St. Clair 093 Cedar 020 Mercer 065 Carroll 017 Hickory 043 SOUTHWEST Putnam 086 Sullivan 105 Dallas 030 NORTHEAST Chariton 021 Howard 045 Randolph 088 Cooper 027 Moniteau 068 Laclede 053 Douglas 034 Miller 066 Wright 114 Ozark 077 Scotland 099 Knox 052 Boone 010 Cole 026 Pulaski 085 Shelby 102 CENTRAL Monroe 069 Audrain 004 Callaway 014 Osage 076 Maries 063 Texas 107 Howell 046 Clark 023 Lewis 056 Phelps 081 Marion 064 Ralls 087 Montgomery 070 Gasconade 037 Dent 033 Pike 082 Crawford 028 Shannon 101 SOUTH CENTRAL Oregon 075 Warren 109 Lincoln 057 Franklin 036 EAST St. Charles 092 Washington 110 Reynolds 090 Carter 018 Ripley 091 St. Louis 096 Jefferson 050 Iron 047 Ste. Genevieve St. Francois Wayne 111 Madison 062 Butler 012 Bollinger 009 Perry 079 SOUTHEAST Stoddard 103 Cape Girardeau 016 Scott 100 New Madrid 072 Mississippi 067 PLAN CODES CODE PLAN MEDICAL PLAN(S) Pemi - scot Dunklin 61 Coventry Health Care of Kansas HMO 78 Copay Plan through Coventry 91 Mercy (Central & East Regions) 93 Mercy (Southwest Region) DENTAL PLAN 57 Delta Dental VISION PLAN 99 Vision Service Plan CANCEL COVERAGE 00 Cancel Coverage Plan Availability Customer Service:

9 Contact Information CONTACT INFORMATION All plans offer websites with the most current provider directories which can be accessed at The inclusion of, or linking to other website URLs, does not imply our endorsement of, nor responsibility for, those websites but has been provided as a convenience to our website visitors. For a printed provider directory which includes lists of participating physicians, hospitals, etc., contact the appropriate HMO plans or request a Copay Plan directory from MCHCP. Note: Participating providers may change during the year. Contact the plan or the provider to verify participation. MEDICAL PLANS Copay Plan through Coventry Health Care (Self-insured) Physical Address: PO Box 8401 London KY Client ID: DCC Claims Address: PO Box 8401 London KY Client ID: DCC Coventry Health Care of Kansas HMO (Self-insured) Physical Address: 8320 Ward Parkway Kansas City, MO Claims Address: PO Box 7109 London, KY Mercy Health Plans HMO Central and East Regions (Self-insured) Physical Address: PO Box 4568 Springfield, MO Claims Address: HMO Claims Department Mercy Health Plans PO Box 4568 Springfield, MO Mercy Health Plans HMO Southwest Region Physical Address: PO Box 4568 Springfield, MO Claims Address: HMO Claims Department Mercy Health Plans PO Box 4568 Springfield, MO DENTAL Delta Dental STATEOFMO PO Box 8690 St. Louis, MO VISION Vision Service Plan (VSP) Claims Address: Attn: Claims PO Box Sacramento, CA EMPLOYEE ASSISTANCE PROGRAM Magellan Health Services Who to Contact: Your Medical Plan for HMO provider directories. Claim questions. Referral questions. Medical ID cards. MCHCP for General benefit questions. Plan questions. Copay Plan provider directories. Address changes or forms. MCHCPid and PIN requests. Use your PIN with either your MCHCPid or SSN when contacting MCHCP or using MYMCHCP. mymchcp (A secure area on WWW. MCHCP.ORG) for Your specific insurance coverage. Demographic changes to your MCHCP records. Changes to your insurance coverage during Open Enrollment. PHARMACY BENEFIT MANAGER Express Scripts, Inc. (Self-insured) Mail Pharmacy Service: PO Box St. Louis, MO WELLNESS - Lifestyle Ladder Gordian Health Solutions, Inc Seaboard Lane Suite 200-C Franklin, TN DISEASE MANAGEMENT - Smart Steps CareAllies Password: MCHCP State Member Handbook

10 MEDICAL PLANS & EAP Get the information you need to make your medical plan choices. Review the Employee Assistance Program and your state and federally mandated benefits. IN THIS SECTION MEDICAL BENEFITS HEALTH MAINTENANCE ORGANIZATIONS (HMOS) COPAY PLAN THROUGH COVENTRY HEALTH CARE PHARMACY BENEFIT Your PHARMACY BENEFIT is part of the medical coverage. The premium is included with the medical plan premium. BENEFITS & RIGHTS PRESCRIBED BY LAW EMPLOYEE ASSISTANCE PROGRAM (EAP) If you are an active employee, the EAP benefit is provided to you. The premium is funded by the State of Missouri. COMPARISON OF HMO & COPAY PLAN BENEFITS Review the benefits from A to Z. Check how services are covered in HMO & COPAY PLAN BENEFITS. Keep in mind that HMO plans are only available in certain areas of the State. Copayment and coinsurance amounts referenced in this section indicate the amount or portion you pay for services. Review LIMITATIONS & EXCLUSIONS for benefit restrictions. Learn how to access benefits in USING YOUR MEDICAL PLAN.

11 HEALTH MAINTENANCE ORGANIZATION (HMO) Availability: Available in Central, East, Southwest and West Regions Contact: Locate medical plan contact information on PAGE 8. What is an HMO? The Health Maintenance Organizations (HMOs) feature low copayments for your health care needs. HMOs work on the premise that more costly services are reduced by providing preventive care and early detection. Joining an HMO means medical care must be received in an HMO facility and by an HMO physician, except for emergencies and pre-approved services. Network providers must meet specific credentialing standards. SAMPLE OF BENEFITS Deductible: Office Visit: Hospital (Inpatient): Lab & X-ray (Outpatient Diagnostic) Maternity: Preventive Care: Outpatient Surgery: No deductible $25 copayment $300 copayment per admission 100% coverage $25 copayment for initial visit 100% coverage $75 copayment If you fail to select a PCP, you have coverage for emergencies only until one is selected or Mercy assigns one for you. It is your responsibility to make sure the PCP is accepting new patients. NOTE If your PCP or Specialist withdraws from your medical plan, you are required to choose another network physician. You may not change plans at this time. No other MCHCP plan requires the use of Primary Care Physicians. HMO Plan Available Services HMO network providers include, but are not limited to: Physicians. Hospitals. Other ancillary facilities and providers necessary to administer the basic benefits of the plan. Other features include: No deductibles. No pre-existing condition limitations. Copayments for office visits including charges for laboratory work, minor surgical procedures, x-rays, etc., performed during the office visit. Preventive services covered at 100%. Worldwide emergency services. Annual routine vision and hearing exams. A benefits sample is listed above. For complete information, refer to the HMO & COPAY PLAN BENEFITS. How to Use HMO Plans For information specific to your medical plan, see USING YOUR MEDICAL PLAN. Primary Care Physician (PCP) Primary Care Physicians only apply to members enrolled in Mercy Health Plans in the Southwest region. Your medical care must be directed by your Primary Care Physician (PCP) or gatekeeper. He/she determines treatment and provides referrals to specialists if necessary. You and your dependents may choose different PCPs from a listing of network providers supplied by the HMO. Family or general practitioners, internists or pediatricians can be selected as a PCP. You may change PCPs during the year. Specialty Care If you need ongoing care from a specialist and the medical plan requires referrals, the plan must have a procedure in place to allow a standing referral to that specialist. Treatment plans must be preapproved by your HMO and may be limited to a specific number of visits or period of time. If specialty care cannot be provided by a network provider, services may be obtained through a non-network provider. To receive network benefits from a non-network provider, authorization must be obtained in advance from your HMO. Contact your HMO for the proper procedure in obtaining care.! To enroll in an HMO, you must live or work in a county where the HMO is available. You may only enroll in a plan where you work if it is not available where you live State Member Handbook

12 Pre-Authorization Pre-authorization must be obtained by your HMO provider. Verify the approval from your plan. For example, if you are being admitted to the hospital, your physician must obtain pre-approval. Care Received Outside the Service Area Services outside of the network are not covered except in case of emergency care. However, if services cannot be provided from your HMO network of providers, you may contact your HMO for the proper procedure in obtaining care outside of the network. You must obtain approval from the HMO prior to seeking care. If approval is not obtained, charges are not covered except for emergency care. Urgent Care Contact your HMO for the proper procedure in obtaining care. If procedure is not followed, charges are not covered. Emergency Care Emergency care is any emergency medical condition leading a prudent layperson to seek immediate medical attention. This normally means the sudden onset of a health condition that manifests itself by acute symptoms and severity (including severe pain). Notify your HMO within 48 hours or as soon as possible after seeking care. Examples of medical emergencies include, but are not limited to: Conditions placing a person s health in significant jeopardy. Serious impairment to a bodily function. Serious dysfunction of any bodily organ or part. Inadequately controlled pain. Situations when the health of a pregnant woman or her unborn child are threatened. Continuation of Care State law provides that contracts between the medical plans and their providers include provisions for continuation of care for a period of up to 90 days. If a provider terminates or is terminated from the network and the continuation of care is medically necessary (i.e. disability, pregnancy, or life-threatening illness) the medical plan may authorize continued care from the terminated provider. You are responsible for applicable network copayment amounts. Contact your medical plan for authorization. Claims for Non-Network Providers Contact the appropriate plan to find: 1. How, when and where to obtain claim forms, if required. 2. The requirements for providing notice of claim and proof of loss. Claims shall not be invalidated or reduced if it was not reasonably possible to give notice within the specified time.! For non-network services, claims must be filed within 12 months of the date of service. Out-of-Pocket Maximums Network out-of-pocket maximums are limited to no more than 50% of the cost of providing a single service. Participating providers may change during the year. It is your responsibility to contact the medical plan to verify provider participation. Telephone number(s), websites and addresses are found on PAGE 8. Copayments are limited to no more than 20% of the cost of providing basic health care services for the total benefit period. In addition, copayments may not exceed 200% of the total annual premium. Coordination of Benefits Benefits payable from MCHCP medical plans are subject to coordination of benefits. MCHCP medical plans work with the various group plans to make sure each pays what it should up to the total amount of medical allowable expenses. Through coordination of benefits, the cost of health care is managed by avoiding two payments for the same charge. (This provision does not apply to individual policies you may own.) Under coordination of benefits, one plan is designated as primary (which means it pays first) and the other is designated as secondary (which means it pays up to any covered expenses that are not paid by the primary plan). In some instances you may also be eligible for benefits under a third plan. It is likely your medical plan will require you to complete a questionnaire asking if you or your dependents have other insurance coverage. If you have other coverage, your plan will ask for the name of the company. This verifies how benefits are coordinated and must be answered before claims are paid. HMO Plan Customer Service:

13 COPAY PLAN through Coventry Health Care Availability: Available to all members Contact: Copay Plan What is the Copay Plan? The Copay Plan is administered by Coventry Health Care and uses The Coventry Health Care National Network of providers. With this plan you have network and non-network benefits. Available Services The Copay Plan through Coventry Health Care features: The freedom to choose care from any primary care physician, specialist or hospital. No referrals. Specific copayments for most services. Non-network benefits. When services are received from non-network providers, deductible and coinsurance amounts apply. Non-network charges are limited to the usual, customary and reasonable charges (UCR), unless otherwise indicated. You may have to file your own claims and pay higher out-ofpocket costs if you use non-network providers. Claims for network services are filed for you. Complete benefits for the Copay Plan are in the HMO & COPAY PLAN BENEFITS section. If you require covered services which are not available through a network provider in your area, the claims may be paid at 80/20 rather than 70/30. Contact Coventry Health Care to have a local provider approved prior to receiving services. Keep in mind that approval granted for a provider is not permanent. It may be granted per condition only and for a specific amount of time. For a complete list of benefits, see the HMO & COPAY PLAN BENEFITS section. SAMPLE OF BENEFITS YOU PAY NETWORK NON-NETWORK Deductible Individual: Family: N/A N/A $500 $1,000 Office Visit: $25 copayment 30% coinsurance* Hospital (Inpatient): $300 copayment per admission 30% coinsurance* Lab & X-ray: 100% coverage 30% coinsurance* Maternity: $25 copayment for initial visit 30% coinsurance* Preventive Care: 100% coverage 30% coinsurance* Outpatient Surgery: $75 copayment 30% coinsurance* *Non-network coinsurance amounts apply after your deductible has been met. The deductible is waived and claims are paid at 80/20 rather than 70/30 for: Home health care. Infusion. Durable Medical Equipment (DME). Audiologists. If you receive treatment in a network hospital or facility, certain types of services such as physician, radiology, emergency, anesthesiology and pathology are sometimes performed by non-network providers. Expenses for these services are paid as network benefits and are not subject to UCR State Member Handbook

14 How to Use the Copay Plan There are no deductibles when using network providers. If using nonnetwork providers, you must meet a deductible before claims are paid. You are also responsible to pay a specific copayment or coinsurance amount on most medical services. Deductibles When using non-network providers, a deductible is the amount of expense that you must pay before the plan begins to pay for covered services and supplies. The deductible is not reimbursable by the plan. When a benefit is subject to a deductible, only expenses allowable under that benefit count toward the deductible. Unless otherwise indicated, the plan allows benefits to the extent that they are usual, customary and reasonable (UCR). OUT-OF-POCKET MAXIMUMS YOU PAY Deductible Individual: Family: Out-of-Pocket Maximum Individual: Family: NETWORK N/A N/A $2,000 $4,000 NON- NETWORK $500 $1,000 $4,000 $8,000 Out-of-Pocket Maximum An out-of-pocket maximum is the maximum amount you must pay before the plan begins to pay 100% of covered charges for the remainder of the calendar year. Payments you are responsible for that do not apply to the out-of-pocket maximum amount are: Copayment amounts for services including: Office visits. Emergency room. Hospital admissions. Outpatient surgery. Claims for services paid at 100%. Charges above the UCR limit. Percentage amount coinsurance is reduced as a result of noncompliance with pre-certification. Other specific expenses noted in HMO & COPAY PLAN BENEFITS section. Lifetime Maximums Network: When using The Coventry Health Care National Network, the Copay Plan has an unlimited lifetime maximum. Non-Network: When using nonnetwork providers, the Copay Plan covers each person up to a lifetime maximum of $3,000,000. Each participant may have up to $5,000 of incurred claims per calendar year deducted from his/her accumulated lifetime maximum. Pre-existing Conditions The Copay Plan through Coventry Health Care contains a six-month pre-existing condition limitation. If you were seen or treated for an illness in the three months prior to coverage with MCHCP, claims are not paid if related to that specific illness during the six month period following your enrollment date. However, if you or your dependents were previously covered by other health insurance coverage and the break in coverage was less than 63 days, the preexisting limitation is reduced by the time covered under the previous plan. The pre-existing condition limitation applies to: New members without prior coverage. Subscribers and/or dependents enrolling as late entrants. The pre-existing condition limitation does not apply to: Members enrolled in a different plan through MCHCP for six months prior to enrollment in the Copay Plan. Pregnancies, newborn children or children placed for adoption. Pre-certification for Services Coventry Health Care carefully reviews requests for all inpatient hospital admissions and outpatient mental health services. This process, called pre-certification, allows Coventry Health Care to help you manage your health care benefits and learn more about services recommended by your doctor. Call for pre-certification on: All hospitalizations. Outpatient treatment for chemical dependency. Outpatient treatment for a mental/nervous disorder. Transplant services.! You must call Coventry Health Care for pre-certification of these services or your claims payment will be reduced by 10%. Most maternity stays do not require pre-certification. However, you must notify Coventry Health Care for maternity stays extending beyond 48 hours following a normal vaginal delivery or 96 hours following a Cesarean section delivery. Copay Plan Customer Service:

15 Written Notification After careful review, Coventry Health Care sends a letter to you and your physician outlining a recommendation either for certification or non-certification of services. If determined that services are medically necessary, a notice of certification is sent to you and your provider. If determined that services are not medically necessary or adequate medical information was not received, Coventry Health Care sends a notice of non-certification to you and your provider. You or your provider can request an appeal. These notifications do not verify eligibility for coverage or payment, nor do they assure coverage is provided if: Such authorization is based on a material misrepresentation or omission about the person s health condition or the cause of the condition. The health benefit plan terminates before the health care services are provided. The covered person s coverage under the plan terminates before the health care services are provided. The review recommendation is not a treatment decision. Decisions regarding treatment are always between patient and physician. Filing a Claim When using a provider who participates in The Coventry Health Care National Network, the provider sends the claim to Coventry Health Care. Carry your ID card since it includes the claims address used by the provider. If using a provider who does not participate in The Coventry Health Care National Network, file a claim form for the services received within 12 months of the date of service. Claim forms can be requested from MCHCP. Send medical claims to: Coventry Health Care PO Box 8401 London, KY All claims must be submitted within 12 months of the date of service or they are denied. If not reasonably possible to give notice within this time, claims shall not be invalidated or reduced.! Coventry Health Care identification (ID) cards are issued in the subscriber s name only. Coordination of Benefits Benefits payable from MCHCP medical plans are subject to coordination of benefits. MCHCP medical plans work with the various group plans to make sure each pays what it should up to the total amount of medical allowable expenses. Through coordination of benefits, the cost of health care is managed by avoiding two payments for the same charge. (This provision does not apply to individual policies you may own.) Under coordination of benefits, one plan is designated as primary (which means it pays first) and the other is designated as secondary (which means it pays up to any covered expenses that are not paid by the primary plan). In some instances you may also be eligible for benefits under a third plan. It is likely your medical plan will require you to complete a questionnaire asking if you or your dependents have other insurance coverage. If you have other coverage your plan will ask for the name of the company. This verifies how benefits are coordinated and must be answered before claims are paid. Copay Plan Emergency Services In an emergency situation, call 911 or go directly to the nearest hospital or emergency care facility. If admitted to the hospital, call Coventry Health Care at within 48 hours or as soon as possible State Member Handbook

16 PHARMACY BENEFITS through Express Scripts Availability: Available to all members Contact: What is Express Scripts, Inc.? When you enroll in an MCHCP HMO or Copay plan, you are also enrolled in the pharmacy plan at no additional cost. Express Scripts, Inc. (ESI), a pharmacy benefits manager (PBM), administers the benefits. This plan maintains a broad choice of covered drugs and promotes the use of generic drugs. The ESI nationwide pharmacy network includes most large pharmacy chains and small independently owned pharmacies. You can fill a prescription from any physician at a network pharmacy or through ESI s mail order program. New enrollees receive a packet of information from ESI containing: A pharmacy ID card. A network directory. A formulary list. Information on the mail order program. How to Use the Pharmacy Plan RETAIL (Network) Generic Formulary: $8 Brand Formulary: $35* Non-Formulary: $55 * If for any reason you purchase a brand name drug and a generic drug is available, you pay the generic copayment ($8) plus the difference in the cost of the drugs. EXAMPLE If the generic drug costs $69 and the brand name drug costs $93, you pay: Generic Copayment: $8 Cost difference: $24 Your total cost: $32 If you purchase a second step drug without completing step one, you pay the full cost of the drug. (Refer to STEP THERAPY.) If a copayment amount is more than the cost of the drug, you pay the cost of the drug. A limited number of local network pharmacies offer up to a 90-day supply for two and a half copayments. Call ESI at to locate a 90- day pharmacy. Mail Order The mail order benefit covers up to a 90-day supply of maintenance medications for two and a half copayments. Generic Formulary: $20 Brand Formulary: $87.50* Non-Formulary: $ This may not apply to drugs which require prior authorization or quantity level limits. CuraScript Pharmacy, Inc., is Express Scripts mail order pharmacy provider for specialty prescriptions. Specialty drugs are high cost and are primarily self-injectible but sometimes oral medications. If your prescription is transferred to CuraScript Pharmacy for processing, you are assigned a Patient Care Coordinator who: Follows your prescription needs. Monitors your progress. Communicates with your providers. Coordinates with Express Scripts, Inc. Retail & Mail Order Coverage also includes: Diabetic supplies such as: Insulin. Syringes. Test strips. Lancets. Glucometers. Certain vitamins (not overthe-counter), self-injectables, oral chemotherapy agents, and hematopoietic stimulants. Growth hormones with prior authorization. Infertility drugs with 50% member coinsurance. Smoking cessation prescriptions (formulary) - limited to $500 annual benefit. For more detailed information, contact ESI. RETAIL (Non-Network) For prescriptions filled at a nonnetwork pharmacy, you must: Pay the full price of the prescription. Obtain a receipt from the pharmacy. Pharmacy Benefits Customer Service:

17 Pharmacy Benefits File a claim with ESI for reimbursement within 365 days (12 months) of the incurred expense. ESI reimburses the cost of the drug at the network discounted amount less the appropriate copayment. You are responsible for the appropriate copayment plus any charges which exceed the network discounted amount. Non-Covered Prescription Drugs You can purchase certain noncovered prescription drugs for weight or hair loss through an ESI participating pharmacy and pay the discounted rate instead of the full retail amount. This category includes: Weight Management/Obesity Xenical - Orlistat Didrex - Benzphetamine Tenuate - Diethylpropion Bontril, Melfiat Phendimetrazine Ionamin, Adipex-P, Fastin - Phentermine Meridia - Sibutramine Hair Loss Treatment Propecia Excessive Hair Treatment Vaniqa This list is subject to change. Prior Authorization ESI requires prior authorization for specific medications. Prior authorization 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 the 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 for approval State Member Handbook Quantity Level Limits Quantities of some medications may be limited based on recommendations by the Food & Drug Administration (FDA) and medical literature. Limits are in place to ensure safe and effective drug use and guard against stockpiling of medicines. Examples include Viagra, Sporonax, Imitrex, Relenza, Tamiflu, Ambien and Lunesta. The list is subject to revision. How to File a Claim With ESI Claims must be filed within 12 months of receiving a prescription. Request a claim form by calling ESI s or MCHCP s customer service lines or downloading a copy through ESI s website. Complete the claim form. Attach a prescription receipt or label with the claim form. The receipt or label must include: Pharmacy name/address. Patient s name. Price. Date filled. Step Therapy Step Therapy is the practice of beginning drug therapy for a medical condition with the most cost-effective and safest drug therapy and moving to other more costly therapy, if necessary. This program is a series of steps involving your doctor. It is only for people who take prescription drugs to treat certain ongoing medical conditions. First Step Uses primarily generic drugs. Lowest copayment applies. First step drugs must be used before the plan pays for second step drugs. Second Step Uses primarily brand name drugs. Higher copayment normally applies. The program moves you to this step if your treatment plan requires a different medication. NOTE Drug name, strength, and NDC. Prescription number. Quantity. Days supply. Patient history printouts from the pharmacy are also acceptable but must be signed by the pharmacist. Cash register receipts are not acceptable for any prescriptions except diabetic supplies. The formulary may have new drugs added during the year. Otherwise it remains the same throughout the year, unless: A generic drug becomes available to replace the brand name drug. The copayment reflects a change. A drug becomes available over-thecounter. It is no longer covered under the pharmacy benefit. ESI must notify member 30 days in advance of any deletions in formulary other than generics. Prescriptions for a second step drug processed at your pharmacy for the first time triggers a message to your pharmacist indicating the use of Step Therapy. You pay full price for the prescription drug unless your doctor prescribes a first step drug. Only your doctor can change the prescription. If your doctor decides, for medical reasons, your treatment plan requires a different medication without trying a first step drug, he/she must request a prior authorization from ESI. You could pay a higher copayment than for a first step drug, and if it cannot be covered, you pay full price. If you have an active prescription (filled within the last 130 days) for a second step medication, it is not affected by this program.

18 EMPLOYEE ASSISTANCE PROGRAM through Magellan Health Services Availability: Available to all active employees and members of their households Contact: What is the EAP? The Employee Assistance Program (EAP) is provided to all active employees and members of their households and offers access to short term, solution focused counseling. The premium is funded by the State. The EAP was created to benefit you and your family. Your involvement in the plan remains confidential in accordance with all state and federal laws, so all questions and concerns are directed to Magellan Health Services at ! Available Services Free EAP sessions with a local counselor*. *If additional counseling, resources or specialized treatment is needed, refer to HMO & COPAY PLAN BENEFITS. Services may involve additional costs. Phone consultation and referral. Assessment, referral and brief solution focused counseling and education services. One to six sessions per episode/ annually for each household member. There is no maximum on the number of episodes, but there is a limit of up to six sessions per episode/annually per household when counseling sessions are shared between/ among household members. An episode is a particular situation or event in which an EAP participant is seeking services authorized according to the EAP. Legal and Financial Solutions Access to lawyers, financial specialists, certified public accountants and financial planners. A free, initial consultation of up to 60 minutes. Additional services discounted by 25% of the attorney s usual hourly rate. Identity Theft and Consumer Fraud Protection. Access to trained fraud resolution specialists. Contact Magellan Health Services at the beginning of a fraud-related emergency and receive a free 60 minute consultation. Interactive online tools including: NOTE Self assessments for anger management and healthy aging. Tools and calculators for retirement and investment planning, checking body mass index, lifestyle test and more. If mandatory counseling is required by your employer, these visits are not counted toward your six visit/ episode benefit. When to Use the EAP This program is strictly confidential and can be used to help prevent minor difficulties from developing into major problems. Contact the EAP for: Stress. Financial pressures. Emotional, marital, or family problems. Drug and alcohol problems. Depression. Parenting challenges. How to Use the EAP Call a Magellan clinician seven days a week, 24 hours a day, 365 days a year at The clinician asks for basic information such as your Social Security number, address and employer to determine eligibility. Speak to a licensed mental health professional about your needs. He/she pre-authorizes a provider referral. The EAP is only available to active employees and their household members. It is not extended to retirees, COBRA participants, or vested subscribers who are not actively employed. Employee Assistance Program Customer Service:

19 HMO & COPAY PLAN BENEFITS HMO PLANS COPAY PLAN BENEFITS HMO NETWORK NETWORK NON-NETWORK Allergy Serum Multi-Dose Vial $25 copayment or the cost of the vial, whichever is less. If more than one vial is obtained, only one copayment applies. $25 copayment or the cost of the vial, whichever is less. If more than one vial is obtained, only one copayment applies. 30% coinsurance after deductible. Ambulance Service (Air or ground - non-emergent excluded unless prior authorized by the Medical Plan.) Annual Physical Exam (Preventive) 100% coverage. 100% coverage. 100% coverage. 100% coverage. 100% coverage. 30% coinsurance after deductible. Bariatric Surgery Covered only when morbid obesity has persisted for at least five years. Member must be at least 18 years of age and must provide documentation of at least two failed attempts at weight loss with a duration of at least six months each. Only one operative procedure for treatment of obesity per lifetime is covered. (Prior authorization by the Medical Plan is required. Refer to PG 26 for qualifying criteria. See Definitions for MORBID OBESITY.) $500 surgical copayment. $300 hospital inpatient copayment. $500 surgical copayment. $300 hospital inpatient copayment. Coverage is limited to the following bariatric procedures: Roux-en-Y Gastric Bypass open and laparoscopic (RYGBP); Laparoscopic Adjustable Gastric Banding (LAGB); or Open and Laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS). Not covered. Birth Control Prescriptions & Devices If non-formulary and obtained through ESI Pharmacy Benefit, appropriate copayments apply. 100% coverage. (ESI formulary) 100% coverage. (ESI formulary) 30% coinsurance after deductible. HMO & Copay Plan Benefits Devices or injections administered in the physician s office. Cardiac & Pulmonary Rehabilitation Up to 36 visits within a 12-week period per incident. Prior authorization by Medical Plan. $25 copayment. $25 copayment. 30% coinsurance after deductible. $15 copayment. $15 copayment. 30% coinsurance after deductible. Note regarding HMOs: Only services and supplies provided by network providers are covered. The only exceptions are in cases of: 1) a medical emergency (see Definitions for EMERGENCY) or 2) prior approved services which cannot be provided in the network. Copay Plan non-network claims are limited to UCR charges. Medical plan benefits apply even when you are out of the country. However, the HMO plans restrict benefits to network providers except in the case of an emergency. Carefully review this handbook to understand your benefits from network and non-network providers. Plans may not terminate contracts with MCHCP during a plan year. Renewals or awards of contracts are at the discretion of the MCHCP Board of Trustees. continued State Member Handbook

20 HMO & COPAY PLAN BENEFITS HMO PLANS COPAY PLAN BENEFITS HMO NETWORK NETWORK NON-NETWORK Chiropractic Benefits Member may self-refer to a network chiropractor for a total of 26 visits. Additional visits require prior authorization by Medical Plan. Cochlear Implant Device Surgery and office visit copayments also apply. Subject to medical necessity and prior authorization by Medical Plan. $25 copayment. $25 copayment. 30% coinsurance after deductible. $50 maximum per visit, $2,000 annual maximum. Diagnostic lab and x-ray charges not included in the $50 per visit but are included in the $2,000 annual maximum. 20% coinsurance on device. 20% coinsurance on device. 30% coinsurance on device after deductible. Deductible N/A. N/A. $500 Individual; $1,000 Family. Dental Care/Accidental Injury Treatment to reduce trauma and restorative services only when the result of accidental injury to sound natural teeth and tissue that are viable, functional, and free of disease. (Treatment must be initiated within 60 days of accident.) See ORAL SURGERY. $25 copayment. $25 copayment. $75 copayment. Durable Medical Equipment/ Medically Necessary Disposable Supplies (Basic equipment that meets the medical needs) DME includes, but not limited to, augmentative communication devices, manual and powered mobility devices. Includes repair and replacement due to normal wear and tear if there is a change in medical condition, if growth related or if medically necessary. Disposable supplies that do not withstand prolonged use and are periodically replaced include, but are not limited to, colostomy and ureterostomy bags, and prescription compression stockings (limited to two pairs or four individual stockings per plan year). 20% coinsurance. 20% coinsurance. 20% coinsurance. Note regarding HMOs: Only services and supplies provided by network providers are covered. The only exceptions are in cases of: 1) a medical emergency (see Definitions for EMERGENCY) or 2) prior approved services which cannot be provided in the network. Copay Plan non-network claims are limited to UCR charges. Medical plan benefits apply even when you are out of the country. However, the HMO plans restrict benefits to network providers except in the case of an emergency. Carefully review this handbook to understand your benefits from network and non-network providers. Plans may not terminate contracts with MCHCP during a plan year. Renewals or awards of contracts are at the discretion of the MCHCP Board of Trustees. continued Contact plan prior to purchasing durable medical equipment. HMO & Copay Plan Benefits Customer Service:

21 HMO & COPAY PLAN BENEFITS HMO PLANS COPAY PLAN BENEFITS HMO NETWORK NETWORK NON-NETWORK Emergency Room Services If admitted to hospital, may be required to transfer to network facility for maximum benefit. Paid as network benefit in or out of network. $75 copayment. No additional copayment for physician fees. Waived if admitted as an inpatient. $75 copayment. No additional copayment for physician fees. Waived if admitted as an inpatient. $75 copayment. No additional copayment for physician fees. Waived if admitted as an inpatient. Growth Hormone Therapy (Authorized by ESI) Hair Prosthesis Limited to prosthesis and expenses for scalp hair prosthesis worn from hair loss suffered as a result of alopecia areata or alopecia totalis for children 18 years of age or younger. Annual maximum $200. Lifetime maximum $3,200. ESI Network Pharmacy: Subject to appropriate copayment. Non-Network Pharmacy: Appropriate copayment plus the difference in the drug cost from the network discounted amount. 20% coinsurance. 20% coinsurance. 30% coinsurance. Hearing Aids (Per Ear) Covered once every two years. Member pays copayment or coinsurance amount. If hearing aid cost exceeds the amount listed below, member is also responsible for charges over that amount. Conventional: $1,000 Programmable: $2,000 Digital: $2,500 BAHA: $3,500 Conventional: $150 copayment. Programmable: $300 copayment. Digital: $350 copayment. BAHA: $500 copayment. - Surgery copayment applies. Conventional: $150 copayment. Programmable: $300 copayment. Digital: $350 copayment. BAHA: $500 copayment. - Surgery copayment applies. 30% member coinsurance after deductible. Hearing Testing One hearing test per year. Additional hearing tests are covered if recommended by physician. $25 copayment. $25 copayment. 20% coinsurance. If in conjunction with office visit, one copayment applies. HMO & Copay Plan Benefits Home Health Care/Rehabilitation Services Performed at Home/ Palliative Services (Prior Authorization by Medical Plan) Hospice Care Inpatient or Outpatient (Prior Authorization by Medical Plan) 100% coverage. 100% coverage. 20% coinsurance. 100% coverage. 100% coverage. 30% coinsurance after deductible. Note regarding HMOs: Only services and supplies provided by network providers are covered. The only exceptions are in cases of: 1) a medical emergency (see Definitions for EMERGENCY) or 2) prior approved services which cannot be provided in the network. Copay Plan non-network claims are limited to UCR charges. Medical plan benefits apply even when you are out of the country. However, the HMO plans restrict benefits to network providers except in the case of an emergency. Carefully review this handbook to understand your benefits from network and non-network providers. Plans may not terminate contracts with MCHCP during a plan year. Renewals or awards of contracts are at the discretion of the MCHCP Board of Trustees. continued State Member Handbook

22 HMO & COPAY PLAN BENEFITS HMO PLANS COPAY PLAN BENEFITS HMO NETWORK NETWORK NON-NETWORK Hospital Benefits - Inpatient Room & Board (Based on semi-private room.) Medical Mental & Nervous Disorder Chemical Dependency $300 copayment per admission. $1,200 annual maximum inpatient copayment. $300 copayment per admission. $1,200 annual maximum inpatient copayment. Copayment does not apply to stays defined as Observation. 30% coinsurance after deductible. Failure to precertify results in a 10% reduction in claims payment. Immunizations Specified Schedule of Childhood Immunizations include, but are not limited to, Poliomyelitis, Rubella, Rubeola, Mumps, Tetanus, Pertussis, Diphtheria, Hepatitis B, Hemophilus Influenza Type B, Human Papilloma Virus, Varicella and Meningococcal. 100% coverage. 100% coverage. 100% coverage for childhood. (Birth to 72 months). Immunizations required by the Missouri Department of Health and Senior Services or recommended by the Centers for Disease Control, regardless of age. Six years and older: 30% coinsurance after deductible. Infertility In vivo (intrauterine, intracervical, intravaginal fertilization). See Limitations & Exclusions for services not covered. 50% coinsurance applies to all services. 50% coinsurance applies to all services. Coinsurance does not apply to out-of-pocket maximum. Prescription drugs for infertility covered through network ESI Pharmacy Benefit. 50% coinsurance applies. Not covered. Injections Administered in physician s office. For coverage of birth control injections, see BIRTH CONTROL on page 18. Mammograms One mammogram per year. Additional mammograms are covered if recommended by physician. 100% coverage. 100% coverage. 30% coinsurance after deductible. 100% coverage. 100% coverage. 30% coinsurance after deductible. Mastectomies Reconstructive surgery or prosthetic devices following mastectomies necessary to restore symmetry, as recommended by physician. Outpatient surgery: $75 copayment. Hospital inpatient: $300 copayment. Outpatient surgery: $75 copayment. Hospital inpatient: $300 copayment. 30% coinsurance after deductible. Note regarding HMOs: Only services and supplies provided by network providers are covered. The only exceptions are in cases of: 1) a medical emergency (see Definitions for EMERGENCY) or 2) prior approved services which cannot be provided in the network. Copay Plan non-network claims are limited to UCR charges. Medical plan benefits apply even when you are out of the country. However, the HMO plans restrict benefits to network providers except in the case of an emergency. Carefully review this handbook to understand your benefits from network and non-network providers. Plans may not terminate contracts with MCHCP during a plan year. Renewals or awards of contracts are at the discretion of the MCHCP Board of Trustees. continued HMO & Copay Plan Benefits Customer Service:

23 HMO & COPAY PLAN BENEFITS HMO PLANS COPAY PLAN BENEFITS HMO NETWORK NETWORK NON-NETWORK Maternity Coverage Newborns and their mothers are allowed hospital stays of at least 48 hours if normal birth and 96 hours if Cesarean birth. If discharge occurs earlier than specific time periods, the plan shall provide coverage for post discharge care which shall consist of a two visit minimum, at least one in the home. No travel exclusions, restrictions or limitations allowed. $25 copayment for initial visit. All other prenatal visits, delivery costs and routine post-natal visit covered at 100%. $300 hospital inpatient copayment. $25 copayment for initial visit. All other prenatal visits, delivery costs and routine post-natal visit covered at 100%. $300 hospital inpatient copayment. Hospital inpatient copayment not required for newborn unless hospital stay exceeds that of the mother. 30% coinsurance after deductible. Nutrient Supplements Formula and low protein modified food products recommended by physician and limited only to treatment of Phenylketonuria (PKU) or any inherited disease of amino and organic acids. Nutritional Counseling Up to three sessions per year with registered dietician without referral, not limited by diagnosis. Up to three additional sessions considered with referral and medical diagnosis. Subject to medical necessity and prior authorization by Medical Plan. 100% coverage. 100% coverage. 100% coverage. $25 copayment. $25 copayment. 30% coinsurance after deductible. Oral Surgery Covered when medically necessary as a direct result from injury, tumors or cysts. (If in the case of an accident, treatment must be initiated within 60 days.) Outpatient (surgery center or hospital): $75 copayment. Inpatient: $300 hospital copayment. Outpatient (surgery center or hospital): $75 copayment. Inpatient: $300 hospital copayment. 30% coinsurance after deductible. It s your responsibility to pre-authorize nonnetwork procedures. Failure to precertify inpatient surgery results in a 10% reduction in claims payment. HMO & Copay Plan Benefits Orthotics (Custom Made) Includes, but not limited to, braces, trusses, splints, collars and foot orthotics which are custom made. Subject to medical necessity and prior authorization by Medical Plan. 20% coinsurance. 20% coinsurance. 30% coinsurance after deductible. Note regarding HMOs: Only services and supplies provided by network providers are covered. The only exceptions are in cases of: 1) a medical emergency (see Definitions for EMERGENCY) or 2) prior approved services which cannot be provided in the network. Copay Plan non-network claims are limited to UCR charges. Medical plan benefits apply even when you are out of the country. However, the HMO plans restrict benefits to network providers except in the case of an emergency. Carefully review this handbook to understand your benefits from network and non-network providers. Plans may not terminate contracts with MCHCP during a plan year. Renewals or awards of contracts are at the discretion of the MCHCP Board of Trustees. continued State Member Handbook

24 HMO & COPAY PLAN BENEFITS HMO PLANS COPAY PLAN BENEFITS HMO NETWORK NETWORK NON-NETWORK Outpatient Benefits for Mental & Nervous Disorder/Chemical Dependency Outpatient Office Visit: $25 copayment. Outpatient Hospital: 100% coverage. Outpatient Office Visit: $25 copayment. Outpatient Hospital: 100% coverage. 30% coinsurance after deductible. Failure to precertify results in a 10% reduction in claims payment. Outpatient Diagnostic Lab & X-ray 100% coverage. 100% coverage. 30% coinsurance after deductible. Outpatient Diagnostic Procedures Including, but not limited to, diagnostic sigmoidoscopies and colonoscopies. Oxygen Outpatient (Covered under Durable Medical Equipment) Subject to prior authorization by Medical Plan. Physical, Speech & Occupational Therapy & Rehabilitation Services - Outpatient Up to sixty (60) combined visits allowed per incident per calendar year if showing significant improvement. Additional visits subject to medical review. $75 copayment. $75 copayment. 30% coinsurance after deductible. It is your responsibility to pre-authorize nonnetwork procedures. 20% coinsurance. 20% coinsurance. 20% coinsurance. $15 copayment. $15 copayment. 30% coinsurance after deductible. Physician Charges Hospital: 100% coverage. Office visit: $25 copayment. Hospital: 100% coverage. Office visit: $25 copayment. 30% coinsurance after deductible. Annual physical exam - 100% coverage. Plan Maximum No limit. No limit. $3,000,000. Note regarding HMOs: Only services and supplies provided by network providers are covered. The only exceptions are in cases of: 1) a medical emergency (see Definitions for EMERGENCY) or 2) prior approved services which cannot be provided in the network. Copay Plan non-network claims are limited to UCR charges. Medical plan benefits apply even when you are out of the country. However, the HMO plans restrict benefits to network providers except in the case of an emergency. Carefully review this handbook to understand your benefits from network and non-network providers. Plans may not terminate contracts with MCHCP during a plan year. Renewals or awards of contracts are at the discretion of the MCHCP Board of Trustees. continued HMO & Copay Plan Benefits Customer Service:

25 HMO & COPAY PLAN BENEFITS HMO PLANS COPAY PLAN BENEFITS HMO NETWORK NETWORK NON-NETWORK Prescription Drugs Pharmacy benefit through ESI. Covers diabetic supplies including: insulin, syringes, test strips, lancets and glucometers. Some prescriptions are subject to quantity level limits, prior authorizations and step therapy. Retail - Up to a maximum 30 day supply (A limited number of local network pharmacies offer up to a 90 day supply for two and a half copayments.) : Generic formulary: $8 copayment. *Brand formulary: $35 copayment. Non-formulary: $55 copayment. Retail: Only one copayment is charged if a combination of different manufactured dosage amounts must be dispensed in order to fill a prescribed single dosage amount. Non-covered prescription drugs: ESI discounted amount. Non-Network Pharmacy: Appropriate copayment plus the difference in the drug cost at the non-network pharmacy and the network discounted amount. *When you purchase a brand name drug and a generic drug is available, you owe the generic copayment plus the difference in the cost of the drugs. If you purchase a second step drug without completing step one, you pay the full cost of the drug. Mail Order Pharmacy (A limited number of local network pharmacies offer up to a 90 day supply for two and a half copayments.) Preventive Services Age specific cancer screenings: Mammograms Pap smears Prostate cancer screenings Colorectal screenings Colonoscopy and sigmoidoscopy screenings Annual physical exams Immunizations Well-child care Maintenance medications through mail order: Up to 90 day supply for two and a half copayments, or the cost of the drug, whichever is less. Generic formulary: $20 copayment. *Brand formulary: $87.50 copayment. Non-formulary: $ copayment. 100% coverage. 100% coverage. 30% coinsurance after deductible. For benefits to be covered as preventive, including x-rays and lab services, they must be coded by your physician as routine, without indication of an injury or illness. Advise your provider that wellness services should be coded as routine. HMO & Copay Plan Benefits Prosthetics (Basic equipment that meets the medical needs) Skilled Nursing Facility Benefits are limited to 120 days per calendar year. (Subject to medical review) 100% coverage for initial placement. 20% coinsurance. 100% coverage for initial placement. 20% coinsurance. 30% coinsurance after deductible. 100% coverage. 100% coverage. 30% coinsurance after deductible. Contact plan prior to admission. Note regarding HMOs: Only services and supplies provided by network providers are covered. The only exceptions are in cases of: 1) a medical emergency (see Definitions for EMERGENCY) or 2) prior approved services which cannot be provided in the network. Copay Plan non-network claims are limited to UCR charges. Medical plan benefits apply even when you are out of the country. However, the HMO plans restrict benefits to network providers except in the case of an emergency. Carefully review this handbook to understand your benefits from network and non-network providers. Plans may not terminate contracts with MCHCP during a plan year. Renewals or awards of contracts are at the discretion of the MCHCP Board of Trustees. continued Coinsurance applies for repair or replacement due to normal wear and tear, if there is a change in medical condition, or if growth related State Member Handbook

26 HMO & COPAY PLAN BENEFITS HMO PLANS COPAY PLAN BENEFITS HMO NETWORK NETWORK NON-NETWORK Surgery Including Sterilization Outpatient (surgery center or hospital): $75 copayment. Inpatient: $300 hospital copayment. Bariatric surgery: $500 surgical copayment. Outpatient (surgery center or hospital): $75 copayment. Inpatient: $300 hospital copayment. Bariatric surgery: $500 surgical copayment. 30% coinsurance after deductible. It s your responsibility to pre-authorize nonnetwork procedures. Failure to precertify inpatient surgery results in a 10% reduction in claims payment. Transplants When neither experimental nor investigational and medically necessary: bone marrow, cornea, kidney, liver, heart, lung, pancreas, intestinal or any combination. Includes services related to organ procurement and donor expenses if not covered under another plan. Contact Medical Plan for arrangements, prior authorization and transplant network. Travel, if approved, is limited to $10,000 maximum per transplant. Outpatient (surgery center or hospital): $75 copayment. Inpatient: $300 hospital copayment. Includes travel, lodging and meal allowance for recipient and his/her immediate family travel companion (under age 19, both parents). National Transplant Program (NTP) through Coventry: 100% coverage. No copayment. Includes travel, lodging and meal allowance for recipient and his/her immediate family travel companion (under age 19, both parents). Coventry Health Care PPO Network Facility (Non-NTP): Outpatient (surgery center or hospital): $75 copayment. Inpatient: $300 hospital copayment. 10% coinsurance plus charges above the maximum limits. Contact Coventry Health Care for the limits. 30% coinsurance after deductible. Reimbursement limited to maximum schedule. (Contact Coventry Health Care.) Charges above the maximum are your responsibility and do not apply to your deductible or out-of-pocket maximum. Travel not covered. Travel not covered. Note regarding HMOs: Only services and supplies provided by network providers are covered. The only exceptions are in cases of: 1) a medical emergency (see Definitions for EMERGENCY) or 2) prior approved services which cannot be provided in the network. Copay Plan non-network claims are limited to UCR charges. Medical plan benefits apply even when you are out of the country. However, the HMO plans restrict benefits to network providers except in the case of an emergency. Carefully review this handbook to understand your benefits from network and non-network providers. Plans may not terminate contracts with MCHCP during a plan year. Renewals or awards of contracts are at the discretion of the MCHCP Board of Trustees. continued The following are not included in the NTP but are available through the PPO network facility: Intestinal transplant covered for specific diagnoses subject to medical necessity and case management. Cornea tissue transplant: covered under surgical benefit. Failure to precertify results in a 10% reduction in claims payment. HMO & Copay Plan Benefits Customer Service:

27 HMO & COPAY PLAN BENEFITS HMO PLANS COPAY PLAN BENEFITS HMO NETWORK NETWORK NON-NETWORK Urgent Care $35 copayment. $35 copayment. 30% coinsurance after deductible. Vision - Routine Exam (including refractions) One per person/per calendar year. $25 copayment. $25 copayment. 30% coinsurance after deductible. Well-Child Care 100% coverage. 100% coverage. 30% coinsurance after deductible. Wellness Exams for Men & Women 100% coverage. 100% coverage. 30% coinsurance after deductible. Note regarding HMOs: Only services and supplies provided by network providers are covered. The only exceptions are in cases of: 1) a medical emergency (see Definitions for EMERGENCY) or 2) prior approved services which cannot be provided in the network. Copay Plan non-network claims are limited to UCR charges. HMO & Copay Plan Benefits Bariatric Surgery Additional Qualifying Criteria - 1. Presence of morbid obesity that has persisted for at least 5 years defined as BMI greater than or equal to 40 or BMI greater than or equal to 35 with at least two or more of the following uncontrolled comorbidities: coronary heart disease, type 2 diabetes mellitus, clinically significant obstructive sleep apnea, pulmonary hypertension, hypertension, or other obesity related conditions will be considered based on clinical review; and 2. Member must be 18 years of age or older; and 3. Documented evidence of at least two failed attempts at weight loss each with a minimum duration of at least six months with the member achieving at least a 10% weight loss and meeting the following additional criteria: one attempt must be in a physician supervised weight loss program and fully documented in the physician s record; the program must use a multi-disciplinary approach including dietician consultation, low calorie diet, increased physical activity and behavioral modification; nationally recognized program such as Jenny Craig or Weight Watchers (This does not include self-directed low calorie diets such as the Atkins Diet or South Beach Diet.); and the most recent attempt must have been within the twelve month period prior to the requested surgery; and Documented evidence the member is on a nutrition and exercise program immediately prior to the surgery request; and Evidence the member and the attending physician have a life-long plan for compliance with lifestyle modification requirements; and Documentation the member has completed a psychological evaluation and if appropriate, behavior modification, and should be free of major psychiatric diagnosis or a current behavior which would significantly reduce long term effectiveness of the proposed treatment; and Procedures must be performed by a physician fully trained, board certified surgeon with training in bariatric surgery. The surgeon must perform 100 cases per year and complete 20 Continuing Medical Education (CME) credits in bariatric surgery every 2 years in conjunction with state medical board licensing requirements; and 8. Procedure must be performed at a Centers of Excellence (COE) facility if such COE has been determined by the plan. If such COE has not been designated then facility must: perform at least 200 bariatric surgeries a year; and provide routine educational/staff training on bariatric surgery and obesity; and should provide documentation of the following: full time bariatric dedicated nurse, full time bariatric dedicated registered dietitian, psychologist/psychiatrist with bariatric expertise, program directed support group, ICU with full time coverage. The following specialists on site: pulmonology, cardiology, interventional radiology, infectious diseases. See LIMITATIONS & EXCLUSIONS for the list of covered procedures and restrictions State Member Handbook

28 LIMITATIONS & EXCLUSIONS SERVICES HMO COPAY PLAN/Coventry Health Care Abortion Allergy Services Alternative Therapies Including, but not limited to, acupuncture, acupressure, homeopathy, hypnosis, massage therapy, reflexology, biofeedback and other forms of alternative therapy. Ambulance Services - Transcontinental Air or medivac services from outside of the U.S. Limited to situations when the life of the mother is endangered if the fetus is carried to term or due to death of the fetus. No coverage for non-physician allergy services or associated expenses relating to an allergic condition, including installation of air filters, air purifiers, or air ventilation system cleaning. Not covered. Not covered. Limited to situations when the life of the mother is endangered if the fetus is carried to term or due to death of the fetus. No coverage for non-physician allergy services or associated expenses relating to an allergic condition, including installation of air filters, air purifiers, or air ventilation system cleaning. Not covered. Not covered. Autopsy Not covered. Not covered. Bariatric Surgery MCHCP covers revisions and corrections of bariatric procedures only when the revision is used to treat life threatening complications (e.g. wound infection, abscess, dehiscence, gastric leaking, and embolism.) Coverage is limited to the following bariatric procedures: Roux-en-Y Gastric Bypass open and laparoscopic (RYGBP); Laparoscopic Adjustable Gastric Banding (LAGB); or Open and Laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS). Limited to one operative procedure for the treatment of obesity per lifetime. Limited to one operative procedure for the treatment of obesity per lifetime. Blood Storage (Whole blood, blood plasma and blood products) Not covered. Not covered. Breast Augmentation Mammoplasty Not covered unless associated with breast reconstruction surgery following a medically necessary mastectomy incurred secondary to active disease. Care Received Without Charge Not covered. Not covered. Charges Resulting From Your Failure to Appropriately Cancel a Scheduled Appointment Not covered. Not covered unless associated with breast reconstruction surgery following a medically necessary mastectomy incurred secondary to active disease. Not covered. Comfort/Convenience Items Not covered. Not covered. Cosmetic/Reconstructive Surgery Not covered except if medically necessary to repair a functional disorder caused by disease, injury or congenital defect or abnormality (for a member under the age of 19) or to restore symmetry following a mastectomy. Not covered except if medically necessary to repair a functional disorder caused by disease, injury or congenital defect or abnormality (for a member under the age of 19) or to restore symmetry following a mastectomy. continued Limitations & Exclusions Customer Service:

29 LIMITATIONS & EXCLUSIONS SERVICES HMO COPAY PLAN/Coventry Health Care Custodial or Domiciliary Care Includes services and supplies that assist members in the activities of daily living like bathing, feeding, administration of oral medicines or other services that can be provided by persons without the training of a health care provider. Dental Treatment must be initiated within 60 days of accident. Durable Medical Equipment/ Disposable Supplies Non-reusable disposable supplies including but not limited to bandages, wraps, tape, disposable sheets and bags, fabric supports, surgical face masks, incontinent pads, irrigating kits, pressure leotards, surgical leggings and support hose. Over the counter medications and supplies including oral appliances. Educational or Psychological Testing Not covered. Limited to treatment of accidental injury to sound natural teeth. Oral surgery is covered only when medically necessary as a direct result from injury, tumors or cysts. Dental care, including oral surgery, as a result of poor dental hygiene is not covered. Extractions of bony or partial bony impactions are excluded. Not covered. Prescription compression stockings are limited to two pairs or four individual stockings per plan year. Not covered unless part of a treatment program for covered services. Not covered. Limited to treatment of accidental injury to sound natural teeth. Oral surgery is covered only when medically necessary as a direct result from injury, tumors or cysts. Dental care, including oral surgery, as a result of poor dental hygiene is not covered. Extractions of bony or partial bony impactions are excluded. Not covered. Prescription compression stockings are limited to two pairs or four individual stockings per plan year. Not covered unless part of a treatment program for covered services. Examinations (Requested by third party) Not covered. Not covered. Excessive Charges Any otherwise eligible expenses that exceed the maximum allowance or benefit limit. Not covered. Not covered. Exercise Equipment Not covered. Not covered. Limitations & Exclusions Experimental Services Eye Glasses and Contact Lenses Charges incurred in connection with the fitting of eye glasses or contact lenses except for initial placement immediately following cataract surgery. Eye Services Health services and associated expenses for orthoptics, eye exercises, radial keratotomy, LASIK and other refractive eye surgery. Experimental or investigational services, procedures, supplies or drugs as determined by the HMO are not covered, except clinical trials for cancer treatment as specified in BENEFITS & RIGHTS PRESCRIBED BY LAW. Not covered. Not covered. Experimental or investigational services, procedures, supplies or drugs as determined by Coventry Health Care are not covered, except clinical trials for cancer treatment as specified in BENEFITS & RIGHTS PRESCRIBED BY LAW. Not covered. Not covered. Government Facility Not covered if non-network provider. Not covered if care is provided without charge to the member at a government facility. continued State Member Handbook

30 LIMITATIONS & EXCLUSIONS SERVICES HMO COPAY PLAN/Coventry Health Care Hair Analysis, Wigs, and Hair Transplants Services related to the analysis of hair unless used as a diagnostic tool to determine poisoning. Also, hairstyling wigs, hairpieces and hair prostheses, including those ordered by a participating provider. Health and Athletic Club Membership (Costs of enrollment) Immunizations (Requested by third party or for travel) Infertility Reversal of voluntary sterilization In vitro fertilization Gamete Intrafallopian Transfer (GIFT) Zygote Intrafallopian Transfer (ZIFT). Level of Care (If greater than is needed for the treatment of your illness or injury.) Medical Care and Supplies Medical Service Performed by Family Member Professional services performed by a person who ordinarily resides in your household or is related to the covered person, such as a spouse, parent, child, sibling or brother/sister-in-law. Not covered except for members ages 18 and under with alopecia as specified in BENEFITS & RIGHTS PRESCRIBED BY LAW. Annual maximum: $200. Lifetime maximum: $3,200. Not covered. Not covered. Not covered. Those health services and associated expenses for the treatment of infertility including intracytoplasmic sperm injection (ICSI), in vitro fertilization, GIFT and ZIFT procedures; embryo transport; donor sperm and related cost for collection; no cryopreservation of sperm or eggs; and non-medically necessary amniocentesis. Not covered. Not covered when they are payable under a plan or program operated by a national government or one of its agencies, including any group insurance policy approved under such law. Not covered. Not covered except for members ages 18 and under with alopecia as specified in BENEFITS & RIGHTS PRESCRIBED BY LAW. Annual maximum: $200. Lifetime maximum: $3,200. Not covered. Not covered. Not covered. Those health services and associated expenses for the treatment of infertility including intracytoplasmic sperm injection (ICSI), in vitro fertilization, GIFT and ZIFT procedures; embryo transport; donor sperm and related cost for collection; no cryopreservation of sperm or eggs; and non-medically necessary amniocentesis. Not covered. Not covered when they are payable under a plan or program operated by a national government or one of its agencies, including any group insurance policy approved under such law. Not covered. Military Service - Connected Injury/Illness Not covered while on active duty. Not covered - including expenses relating to Veteran s Administration or military hospital. Non-Network Providers Not Medically Necessary Services (Except preventive services) Obesity Not covered unless in case of emergency or with prior approval from the HMO. Not covered. Surgical interventions are limited to coverage for morbid obesity as specified in HMO & COPAY PLAN BENEFITS. Subject to prior authorization from the medical plan. Subject to deductible and non-network coinsurance. Not covered. Orthognathic Surgery Not covered. Not covered. Orthoptics Not covered. Not covered. Surgical interventions are limited to coverage for morbid obesity as specified in HMO & COPAY PLAN BENEFITS. Subject to prior authorization from the medical plan. continued Limitations & Exclusions Customer Service:

31 LIMITATIONS & EXCLUSIONS SERVICES HMO COPAY PLAN/Coventry Health Care Other Charges Over-the-Counter Medications Over-the-Counter Supplies Non-reusable disposable supplies including but not limited to bandages, wraps, tape, disposable sheets and bags, fabric supports, surgical face masks, incontinent pads, irrigating kits, pressure leotards, surgical leggings and support hose. No coverage for charges that would not be incurred if you were not covered. Charges for which you or your dependents are not legally obligated to pay including, but not limited to, any portion of any charges that are discounted. Charges made in your name but which are actually due to the injury or illness of a different person not covered by the Plan. Miscellaneous service charges - telephone consultations, charges for failure to keep a scheduled appointment (unless the scheduled appointment was for a Mental Health service), or any late payment charge. Not covered, except insulin (ESI formulary only). Not covered. No coverage for charges that would not be incurred if you were not covered. Charges for which you or your dependents are not legally obligated to pay including, but not limited to, any portion of any charges that are discounted. Charges made in your name but which are actually due to the injury or illness of a different person not covered by the Plan. Miscellaneous service charges - telephone consultations, charges for failure to keep a scheduled appointment (unless the scheduled appointment was for a Mental Health service), or any late payment charge. Not covered, except insulin (ESI formulary only). Not covered. Physical Fitness Not covered. Not covered. Pre-existing Conditions Do not apply. Not covered for charges associated with pre-existing conditions (excluding pregnancy) until the individual has been covered for six consecutive months. Exception: Pre-existing condition clause will be waived if proof of coverage for six consecutive months prior to enrollment is provided, including effective dates of coverage and termination date. Private Duty Nursing Not covered. Not covered. Prosthetic Repair or Replacement Not covered unless due to normal wear and tear, if there is a change in medical condition, if growth related or medically necessary. Not covered unless due to normal wear and tear, if there is a change in medical condition, if growth related or medically necessary. Limitations & Exclusions Services Not Specifically Included as Benefits Services Rendered After Termination of Coverage Those services otherwise covered under the agreement, but rendered after the date coverage under the agreement terminates, including services for medical conditions arising prior to the date individual coverage under the agreement terminates. Smoking Cessation (Through ESI Pharmacy Benefit) Not covered. Not covered. Patches or gum - not covered. Prescription drugs (formulary) limited to $500 annual benefit. Not covered. Not covered. Patches or gum - not covered. Prescription drugs (formulary) limited to $500 annual benefit. continued State Member Handbook

32 LIMITATIONS & EXCLUSIONS SERVICES HMO COPAY PLAN/Coventry Health Care Speech Therapy Health services and associated expenses for developmental delay. Stimulators (For bone growth) Surrogacy Temporo-Mandibular Joint Syndrome (TMJ) Transsexual Surgery Health services and associated expenses in the transformation operations regardless of any diagnosis or gender role disorientation or psychosexual orientation or any treatment or studies related to sex transformation. Also excludes hormonal support for sex transformation. Not covered. Not covered unless authorized by HMO. Pregnancy coverage is limited to plan member. Not covered. Not covered. Not covered. Not covered unless authorized by Coventry Health Care. Pregnancy coverage is limited to plan member. Not covered. Not covered. Travel Expenses Not covered. Not covered. Travel Expenses for Transplants Requires authorization from HMO. Limited to $10,000 maximum per transplant. Requires authorization from Coventry Health Care. Limited to $10,000 maximum per transplant. Treatment for Disorders Relating to Delays in Learning, Motor Skills and Communication Including any Therapy for Developmental Delay Not covered. Not covered. Trimming of Nails, Corns or Calluses Not covered except for persons being treated for diabetes, peripheral vascular disease or blindness. Not covered except for persons being treated for diabetes, peripheral vascular disease or blindness. Usual, Customary and Reasonable (UCR) (Charges exceeding) Not applicable. Network: Not applicable. Non-Network: Not covered. Vitamins/Nutrients (Through ESI Pharmacy Benefit) Limited to prenatal agents for pregnancy, therapeutic agents for specific deficiencies and conditions and hemopoetic agents. Limited to prenatal agents for pregnancy, therapeutic agents for specific deficiencies and conditions and hemopoetic agents. War or Insurrection Workers Compensation Charges for services or supplies for an illness or injury eligible for, or covered by, any federal, state or local government Workers Compensation Act, occupational disease law or other legislation of similar program. Liability to provide services limited in the event of a major disaster, epidemic, riot or other circumstances beyond the control of the HMO. Not covered. Liability to provide services limited in the event of a major disaster, epidemic, riot or other circumstances beyond the control of Coventry Health Care. Not covered. Limitations & Exclusions Customer Service:

33 USING YOUR MEDICAL PLAN Copay Plan through Coventry Health Care QUESTION ANSWER Primary Care Physician (PCP) and Referrals Is a PCP required? No. Selection of a PCP is not required. If plan authorizes referral to non-network provider for specialty care, what form of authorization is required (written, verbal, etc.)? If network provider refers to non-network provider without plan approval, is member responsible for charges? Medicare If Medicare is primary payor, does member need a referral? Verbal authorization may be obtained by calling The member will be responsible for any applicable penalties plus deductibles, copayments and/or coinsurance amounts if authorization is not obtained prior to receiving services. Authorization may be obtained from the plan by calling Referrals are not required. If Medicare is primary payor, must member use network providers? If Medicare is secondary payor, must member use network providers? No. Members are not required to stay in the network. Services performed by non-network providers are subject to applicable deductibles, copayments and/or coinsurance amounts. N/A. Accessing Services List the Nurse Line phone number and hours of operation Available 24 hours a day/7 days a week. What does the annual vision exam cover in addition to refractions? How is the annual vision exam accessed? Routine eye exam. Network or non-network provider. How are mental health benefits accessed? If a separate phone number is required for mental health benefits, list the number. Which transplant network is used? Network or non-network provider. Call Coventry Health Care at prior to receiving treatment. National Transplant Program through Coventry. Using Your Medical Plan How are hearing tests accessed? Flu shots are covered at 100% in a network physician s office. When a shot is obtained elsewhere, what must the member do to be reimbursed? How is the per year limit calculated for preventive services such as well-woman exams, annual physicals and mammograms? Are members allowed access to convenient care clinics? If so, indicate which network is used and the copayment charged. Network or non-network provider. The member should obtain a dated, itemized receipt for the service and submit it to Coventry Health Care for full reimbursement of the vaccination. Once per calendar year. Yes. Minute Clinics and Take Care Clinic locations participate in the Coventry Health Care National Network. Locations may be found by calling A $25 copayment applies per visit. continued State Member Handbook

34 USING YOUR MEDICAL PLAN Copay Plan through Coventry Health Care QUESTION ANSWER Disease Management Programs: Diabetes, coronary artery disease, congestive heart failure and asthma are covered through MCHCP s disease management program, Smart Steps. Indicate any other chronic conditions treated in disease management programs through your medical plan. What services are available through the disease management programs? How are disease management programs accessed? Chronic obstructive pulmonary disease, depression, end-stage renal disease (ESRD), high-risk maternity, organ transplant, wound care, hemophilia, multiple sclerosis, crohns, low back pain and HIV/AIDS. Individual disease and case management and access to a general health information nurse line is available 24 hours a day, 365 days a year. For individualized support, a single nurse case manager is assigned to work with the member for all of their diseases/conditions. The disease management program is an opt-out model. Once identified, members are considered to be participating unless they opt out. Members can also enroll online or by calling Website Services In addition to provider directories, what services can be accessed on your website? Provide examples of specialized website features available to members only. Indicate discounts that are available to members online. What types of educational programs are available to members? Coventry National Accounts has an enhanced website, My Online Services, with a new look and feel. Through My Online Services, members can view or edit personal information, review claims history, search for providers and utilize tools such as the Coventry WellBeing programs and hospital comparison tools. Members can view eligibility, the benefit plan summary and claims history. In addition, members have access to Coventry WellBeing, Coventry s web-based wellness tool and decision support tools designed to help members make informed decisions about their healthcare. Coventry WellBeing includes a health risk assessment, My ephit - a customized individual health improvement tool and the Kids Health library. The decision support tools include a hospital comparison tool, a cost comparison tool and a budgeting tool. Through the Coventry WellBeing program, Coventry will indicate applicable preferred or discount pricing for wellness and self-care programs. Coventry has established a variety of web solutions in order to meet member needs: A Health Risk Assessment tool that analyzes the member s responses to questions about health history and lifestyle. Coventry s HRA provides results to members indicating the member may be at risk for a specific condition, and offers suggestions on how to reduce or eliminate risk. A comprehensive online solution using ephit. This tool offers customized individual health improvement plans to address such issues as obesity, inactivity and poor lifestyle habits. The Kids Health library of parenting and health information written for three distinct audiences: parents, pre-teen and teenage kids. An Employee Budgeting Tool enabling members to estimate their out-of-pocket expenses quickly and easily. The provider search tool allows members to choose a hospital or physician by rating cost, quality and performance at the condition level. The search tool also includes an advanced transparency solution enabling members to find the best overall health care value for their dollar. The hospital comparison module includes metrics such as: patient severity, volume, complications, mortality, avoidable bed days, length of stay and cost. Using Your Medical Plan Customer Service:

35 USING YOUR MEDICAL PLAN Coventry Health Care of Kansas HMO QUESTION ANSWER Primary Care Physician (PCP) and Referrals Is a PCP required? No. Selection of a PCP is not required. If plan authorizes referral to non-network provider for specialty care, what form of authorization is required (written, verbal, etc.)? If network provider refers to non-network provider without plan approval, is member responsible for charges? The authorization may initially be made verbally, then followed by a confirmation letter to the physician and member. Yes. Medicare If Medicare is primary payor, does member need a referral? Referrals are not required. If Medicare is primary payor, must member use network providers? If Medicare is secondary payor, must member use network providers? No. The member does not need to stay in network. As the secondary payor, the plan only pays up to the Medicare allowed fee. However, if services are received from a non-network provider and are not Medicare eligible, the claim will not be paid by Medicare or the plan. Yes. Accessing Services List the Nurse Line phone number and hours of operation Available 24 hours a day/7 days a week. What does the annual vision exam cover in addition to refractions? How is the annual vision exam accessed? Hardware is not included. Coventry offers discounts for hardware. Please contact Coventry s Customer Service Department for additional information. Self-referral to a network optometrist. Using Your Medical Plan How are mental health benefits accessed? If a separate phone number is required for mental health benefits, list the number. Which transplant network is used? How are hearing tests accessed? Flu shots are covered at 100% in a network physician s office. When a shot is obtained elsewhere, what must the member do to be reimbursed? How is the per year limit calculated for preventive services such as well-woman exams, annual physicals and mammograms? Are members allowed access to convenient care clinics? If so, indicate which network is used and the copayment charged. Self-referral by calling United Behavioral Health at Coventry Transplant Network, Inc. Self-referral to appropriate network specialist. Mail receipt to: Coventry Health Care of Kansas Attn: Flu Shots 1720 S. Sykes Street Bismarck, ND Once per calendar year or as directed by physician. Yes. CVS Minute Clinics and Walgreens Take Care Clinics. A $25 copayment applies per visit. continued State Member Handbook

36 USING YOUR MEDICAL PLAN Coventry Health Care of Kansas HMO QUESTION ANSWER Disease Management Programs: Diabetes, coronary artery disease, congestive heart failure and asthma are covered through MCHCP s disease management program, Smart Steps. Indicate any other chronic conditions treated in disease management programs through your medical plan. What services are available through the disease management programs? How are disease management programs accessed? End stage renal disease (ESRD). Healthy maternity. End stage renal disease: Members receive personal case management regarding dialysis and self care. Healthy maternity: Members receive a resource guide, self care booklet and a Coventry baby blanket. Case management would apply to any one identified as high risk. Through physician referral or prior authorization process. Members may also call Customer Service at Special Services In addition to provider directories, what services can be accessed on your website? Access member specific information, wellness programs, health education, patient safety tips, privacy statement and release forms, Kids Health Site and consumer alert product safety. Provide examples of specialized website features available to members only. Indicate discounts that are available to members online. What types of educational programs are available to members? Coventry WellBeing program, Self-Care and Wellness Programs, Health Risk Assessment, ability to view claims status, print Explanation of Benefits (EOB), wellness reminders, Kids Health, HospitalQualityTool, request and print ID card. The Members Choice program offers discounts on vitamins, health products, fitness clubs, massage therapy and acupuncture. Healthy Heart, Healthy Back and Healthy Weight. Using Your Medical Plan Customer Service:

37 USING YOUR MEDICAL PLAN - Mercy HMO - Central & East Regions QUESTION ANSWER Primary Care Physician (PCP) and Referrals Is a PCP required? No. Selection of a PCP is not required. If plan authorizes referral to non-network provider for specialty care, what form of authorization is required (written, verbal, etc.)? If network provider refers to non-network provider without plan approval, is member responsible for charges? If a visit to a non-network provider is approved, this is communicated in writing and verbally. Yes. Medicare If Medicare is primary payor, does member need a referral? Referrals are not required. If Medicare is primary payor, must member use network providers? If Medicare is secondary payor, must member use network providers? No. The member does not need to stay in network. As the secondary payor, the plan only pays up to the Medicare allowed fee. However, if services are received from a non-network provider and are not Medicare eligible, the claim will not be paid by Medicare or the plan. Yes. Accessing Services List the Nurse Line phone number and hours of operation Available 24 hours a day/7 days a week. What does the annual vision exam cover in addition to refractions? How is the annual vision exam accessed? Eye exam with refraction is covered. Member must select from network ophthalmologists or optometrists. Self-refer to network ophthalmologist or optometrist. How are mental health benefits accessed? If a separate phone number is required for mental health benefits, list the number. Which transplant network is used? Self-refer by calling or United Resource Network and Interlink. Using Your Medical Plan How are hearing tests accessed? Flu shots are covered at 100% in a network physician s office. When a shot is obtained elsewhere, what must the member do to be reimbursed? How is the per year limit calculated for preventive services such as well-woman exams, annual physicals and mammograms? Self-refer to a network provider. If a member is unable to obtain a flu shot at a participating provider, submit a copy of the paid receipt and the Take Along form by mail to Mercy Health Plans Member Services Department or fax to Once per calendar year or as recommended by nationally recognized preventive guidelines. continued State Member Handbook

38 USING YOUR MEDICAL PLAN - Mercy HMO - Central & East Regions QUESTION ANSWER Are members allowed access to convenient care clinics? If so, indicate which network is used and the copayment charged. No. Mercy Health Plans does not currently contract with convenient care clinics. Disease Management Programs: Diabetes, coronary artery disease, congestive heart failure and asthma are covered through MCHCP s disease management program, Smart Steps. Indicate any other chronic conditions treated in disease management programs through your medical plan. Mercy Health Plans Care Management and ExtraCare by ForeSee Health, a Mercy Health Plans Company, provide care coordination for our highest risk members living with complex or multiple chronic diseases such as chronic obstructive pulmonary disease (COPD), high blood pressure, end stage renal disease, hepatitis, multiple sclerosis, rheumatoid arthritis, chronic pain, cancer, seizure disorders and complex pediatric conditions. What services are available through the disease management programs? Educational mailings related to the chronic condition; health risk assessments; assistance with psychosocial and financial issues; care coordination with a registered nurse care manager; information on wellness and age specific preventive health measures; and collaboration with your physician, treating providers and other care team members. How are disease management programs accessed? Member can contact member services for information at and Special Services In addition to provider directories, what services can be accessed on your website? Mercy Health Plans general information, Health Headlines, I m a Member, Your Health and Wellness, and Healthwise Knowledgebase. Provide examples of specialized website features available to members only. Indicate discounts that are available to members online. What types of educational programs are available to members? Online benefit information, graphic surgery, ability to change PCP, request ID cards, change address and change password. Available discounts to members are listed in the member newsletter. Community health events are also found in the member newsletter. Graphic surgery, Your Health and Wellness, member newsletter listing of events and programs at our participating facilities and in your community. Mercy Health Plans Health Education Department can coordinate health fairs and other educational promotions. Using Your Medical Plan Customer Service:

39 USING YOUR MEDICAL PLAN - Mercy HMO - Southwest Region QUESTION ANSWER Primary Care Physician (PCP) Is a PCP required? What is the procedure to change PCP? How often can a member change PCPs? Can a member choose a network PCP out of the region in which they select a plan? What happens if member does not select a PCP? Can member choose a Nurse Practitioner or Physician Assistant as a PCP? Members must choose a PCP. Contact Member Service and a new ID card is mailed. Member may change PCP and order a new card online. As often as desired. Yes. Mercy assigns a PCP to the member. No. The member would be assigned to the PCP who is the collaborating physician for the Nurse Practitioner or Physician Assistant. Referrals How does a member obtain a referral? What specialty care does not require a referral other than those listed below? If required, member obtains referral from PCP. Referrals are valid for a specific number of visits and/or days. Based on diagnosis, some referrals may be valid for more than 90 days. Referral is not required for annual vision exam at participating ophthalmologist or optometrist. No referral required to a: network chiropractor for up to 26 visits. network obstetrician or gynecologist for obstetrical or gynecological diagnosis, treatment or referral. If PCP refers to non-network provider without HMO approval, is member responsible for charges? If plan authorizes referral to non-network provider for specialty care, what form of authorization is required (written, verbal, etc.)? Yes. If a visit to a non-network provider is approved, this is communicated in writing and verbally. Medicare If Medicare is primary payor, does member need a referral? Referrals are not required for Medicare primary members. Using Your Medical Plan If Medicare is primary payor, must member use network providers? If Medicare is secondary payor, must member use network providers? Accessing Services No. The member does not need to stay in network. As the secondary payor, the plan only pays up to the Medicare allowed fee. However, if services are received from a non-network provider and are not Medicare eligible, the claim will not be paid by Medicare or the plan. List the Nurse Line phone number and hours of operation or Available 24 hours a day/7 days a week. Yes. continued State Member Handbook

40 USING YOUR MEDICAL PLAN - Mercy HMO - Southwest Region QUESTION ANSWER What does the annual vision exam cover in addition to refractions? Eye exam with refraction is covered. Member must select from network ophthalmologists or optometrists. How is the annual vision exam accessed? Self-refer to network ophthalmologist or optometrist. How are mental health benefits accessed? If a separate phone number is required for mental health benefits, list the number. Which transplant network is used? Member must obtain referral from PCP. United Resource Network and Interlink. How are hearing tests accessed? PCP referral to network provider. Flu shots are covered at 100% in a network physician s office. When a shot is obtained elsewhere, what must the member do to be reimbursed? How is the per year limit calculated for preventive services such as well-woman exams, annual physicals and mammograms? Are members allowed access to convenient care clinics? If so, indicate which network is used and the copayment charged. If a member is unable to obtain a flu shot at a participating provider, submit a copy of the paid receipt and the Take Along form by mail to Mercy Health Plans Member Services Department or fax to Once per calendar year or as recommended by a nationally recognized preventive guideline. No. Mercy Health Plans does not currently contract with convenient care clinics. Disease Management Programs Indicate the chronic conditions treated in disease management programs through your medical plan. What services are available through the disease management programs? How are disease management programs accessed? Asthma, chronic obstructive pulmonary disease, congestive heart failure and diabetes under the direction of St. John s Health System. Multiple services are available dependent on the particular program. Physician referral or self-referral. For further information, contact Utilization Management at or Special Services In addition to provider directories, what services can be accessed on your website? Mercy Health Plans general information, Health Headlines, I m a Member, Your Health and Wellness, and Healthwise Knowledgebase. Provide examples of specialized website features available to members only. Indicate discounts that are available to members online. What types of educational programs are available to members? Online benefit information, graphic surgery, ability to change PCP, request ID cards, change address and change password. Discounts available are listed in the member newsletter. Community health events are also found in the member newsletter. Graphic surgery, Your Health and Wellness, member newsletter listing of events and programs at our participating facilities and in your community. Mercy Health Plans Health Education Department can coordinate health fairs and other educational promotions. Support group listings are available. Using Your Medical Plan Customer Service:

41 BENEFITS & RIGHTS PRESCRIBED BY LAW MCHCP medical plans comply with state and federally mandated benefits. Benefits & Rights Prescribed By Law Approved Cancer Screenings Some of the benefits provided through MCHCP for cancer screenings are listed below. These guidelines are based on the recommendations made by the American Cancer Society and may be age specific. (Contact the American Cancer Society at for age specific guidelines.) Pelvic examination and pap smear for any woman without symptoms Prostate examination and laboratory tests for any man without symptoms Colorectal cancer examination and laboratory tests for any person without symptoms Annual mammogram for any woman without symptoms Additional mammograms are covered for women if recommended by a physician, for any woman with a history of breast cancer or whose mother or sister has prior history of breast cancer. Scalp Hair Prosthesis Missouri law requires coverage for members 18 years of age or younger with expenses for scalp hair prosthesis worn for hair loss suffered as a result of alopecia areata or alopecia totalis. There is a maximum benefit of $200/calendar year, not to exceed a lifetime maximum benefit of $3,200 for persons who select a more permanent scalp hair prosthesis. A one-time expenditure of up to $3,200 may be requested, and benefits expire when a total of $3,200 has been spent or the member reaches 19 years of age. Clinical Cancer Trials Missouri law requires coverage for routine patient care costs incurred as the result of phase II, III or IV of a clinical trial that is approved by an appropriate entity and is undertaken for the purposes of the prevention, early detection or treatment of cancer. Coverage includes routine patient care costs incurred for drugs and devices that have been approved for sale by the Food and Drug Administration (FDA), regardless of whether approved by the FDA for use in treating the patient s particular condition. Coverage includes reasonable and medically necessary services needed to administer the drug or use the device under evaluation in the clinical trial. The following limitations apply to phase II coverage: 1. Routine patient care costs are limited to those incurred within the plan s provider network; and 2. The member must be enrolled in the clinical trial. Coverage is not available to those merely following the protocol of phase II clinical trial. See section , Revised Statutes of Missouri for further information. Women s Health Law Missouri laws require: Direct access to a network obstetrician, gynecologist or OB/GYN for obstetrical or gynecological diagnosis, treatment or referral. Coverage for the diagnosis, treatment and appropriate management of osteoporosis, which may include bone mass measurement when medically indicated. Coverage is the same as for any other test and/or office visit. Coverage for all prescription drugs and devices approved by the FDA for use as a contraceptive. Coverage is not required for those drugs and devices that are intended to induce an abortion. There is no timeframe on reconstructive surgery or prosthetic devices following a mastectomy. If an individual had a mastectomy and changes medical plans, the new plan shall provide coverage consistent with the federal Women s Health and Cancer Rights Act. Newborn Screenings Missouri law requires coverage for: Newborn hearing screenings. Necessary rescreenings. Audiological assessment. Follow-up and initial amplification State Member Handbook

42 Dental Care: Anesthesia & Hospital Charges Missouri law requires health insurers and similar entities to cover the administration of general anesthesia and hospital charges for dental care to children under age five, the severely disabled, or a person with a medical or behavioral condition that requires hospitalization. It mandates coverage of general anesthesia when dental care is provided in a participating or non-participating hospital or surgical center. Prior authorization may be required by the health carrier. Patient s Rights Under Missouri Law The plans offered through MCHCP may use the following managed care processes. If you participate in one of MCHCP s fully-insured plans and, at any time during the process, do not agree with the initial determination, concurrent review, retrospective review or adverse determination, you may contact the Missouri Department of Insurance, Financial Institutions & Professional Registration (DIFP) at for assistance. the provider by telephone within one working day of the certification. Written or electronic confirmation of the telephone call is required within one working day of making the certification. Retrospective Review Determinations Determination must be made by the health care plan within 30 working days of receiving the necessary information. You should receive written notice within ten working days of the plan making the determination. Referrals Referrals to non-participating specialists and facilities are covered subject to the same copayment amounts as participating providers if the health plan determines that its network does not contain a provider with appropriate training, experience or specialty. Second Opinions Physician visits to seek second opinions are covered at the same copayment cost as initial visits. Utilization Review For certain hospitalizations, surgical procedures and tests, it is necessary for the medical plans to pre-authorize or evaluate the necessity, appropriateness and efficiency of the use of medical services, procedures and facilities on a prospective, concurrent or retrospective basis. Initial Determination In the case of proposed hospital admissions and procedures or services requiring review, the medical plan is required to notify the provider within two working days of obtaining the necessary information. The medical plan confirms to you and the provider by written or electronic confirmation within two working days of making the initial certification. Concurrent Review Determinations In the case of certifying an extended stay or additional services, the medical plan is required to notify Adverse determinations When the procedure, hospitalization and/or test is denied, reduced or terminated, it is called adverse determination. The medical plan is required to notify the provider by telephone within 24 hours of making the adverse determination and to furnish you and the provider with a written or electronic confirmation within one working day of the telephone call. Reconsideration of Adverse Determination The provider of a service may request reconsideration of adverse determination on your behalf. Reconsideration must be made within one day of receipt of the request between the provider and the reviewer who denied the request or a clinical peer of the reviewer. If the difference is not resolved, you or the provider on your behalf, have the right to appeal. continued Benefits & Rights Prescribed By Law Customer Service:

43 Prior Authorization Prior authorization does not verify eligibility for coverage or payment, nor does it assure coverage is provided if any of the following apply: Such authorization is based on a material misrepresentation or omission about the person s health condition or the cause of the condition. The health benefit plan terminates before the health care services are provided. The covered person s coverage under the plan terminates before the health care services are provided.!! Self-insured plans are subject to subrogation. Subrogation enables the insurer to rights belonging to the subscriber against a third party. For a complete definition, see SUBROGATION Definitions section. For example: MCHCP paid a medical claim due to your automobile accident when your automobile insurer should have covered the claim. Subrogation allows MCHCP to stand in your place and recover the money from the automobile insurer. Right of Recovery If the amount of the payment made by the Plan, including the reasonable cash value of any benefits provided in the form of services, is more than it should have paid under the terms of the Agreement, the Plan may recover the excess payments from one (1) or more of : The persons it has paid, For whom it has paid, Insurance companies, or Other oganizations. Benefits & Rights Prescribed By Law State Member Handbook

44 Learn more about the optional benefit plans through MCHCP. Review guidelines for eligibility and enrollment. IN THIS SECTION MEDICAL PLANS & EAP WELLNESS & DISEASE MANAGEMENT PROGRAM LIFESTYLE L ADDER SMARTSTEPS It is your choice to take the annual online Personal Health Analysis (PHA). If you take the PHA, the results and your health status determine your placement in a program. The online PHA must be taken each year to be eligible for the incentive rate. DENTAL PLAN DENTAL PLAN VISION PLAN VISION PLAN & ENROLLMENT Review the AND ENROLLMENT guidelines.

45 WELLNESS PROGRAM through Gordian Health Solutions Availability: Available to all active, non-medicare eligible retired, terminated vested, long-term disability (LTD), survivor and COBRA subscribers and their spouses Wellness Program Contact: What is the Wellness Program? The wellness program, Lifestyle Ladder is provided through Gordian Health Solutions. The program is designed to: Improve health. Educate members of the forces that can impact their health and quality of life. When health risks are identified and managed appropriately, the result is a healthier, happier person. Healthier members result in lower individual and employer health care costs. Available Services Professional Health Coaches: Help you target specific health risks and lifestyle behaviors. Help you set attainable goals. Monitor your progress and provide timely feedback. Provide one-on-one personal counseling by telephone. Are available Monday - Friday from 7 a.m p.m. and Saturdays from 9 a.m. - 4 p.m. at You don t have to wait for a health coach to contact you. Call a health coach when you are in need of wellness advice or support. Online Healthy Living Programs through Miavita provide: Health improvement tools which help you take action to reverse risky lifestyle behaviors such as poor diet and low levels of activity. Interactive tools to age healthy, maintain a healthy heart, manage weight, improve cholesterol levels, boost metabolism, etc. Self-help tools that encourage you to take the walking challenge, find healthy recipes, develop a healthy shopping list, set your own fitness planner and much more. Accessing Miavita does not qualify as participation in the wellness program. How to Use the Wellness Program Gordian identifies members who can benefit from the program by analyzing data received through a personal health analysis (PHA). Each year, eligible members must complete the online PHA and participate in the wellness program to receive a lower health insurance premium or incentive rate. After completing the online PHA, you will receive an electronic personal wellness report. All information disclosed in the analysis and your involvement in this program is confidential. If identified with a preventable health risk, participation involves speaking with a health coach periodically by telephone. You can get unlimited support as your health coach works with you to develop personal health goals and strategies to help you reach those! You can only take the Personal Health Analysis (PHA) online. Paper PHAs are not available. goals. Your health coach monitors your progress annually and provides: Educational information. Health advice. Motivational techniques. Eligibility Guidelines To participate, you and your spouse (if covered) must be enrolled in an MCHCP medical plan. Taking the online PHA during Open Enrollment and participation in the Lifestyle Ladder program qualifies you for a lower health insurance premium or incentive rate. Participation is actively speaking to a health coach when you are contacted. If you cover your spouse, you both must take the PHA each year and participate in either the Lifestyle Ladder or the Smart Steps program to qualify for the incentive rate. If you qualify for Smart Steps, you are not eligible to participate in Lifestyle Ladder. If you or your spouse discontinues participation during the year, your premium will increase. New employees are not eligible for participation in Lifestyle Ladder until the following plan year. However, you will receive the incentive rate until the end of the current plan year. During the next Open Enrollment, you must take the online PHA to participate in a program and receive the incentive rate. Federal regulation allows enrollment in wellness programs annually State Member Handbook

46 DISEASE MANAGEMENT through CareAllies Smart Steps Availability: Available to all qualifying active, non-medicare eligible retired, terminated vested, long-term disability (LTD), survivor and COBRA subscribers and their spouses What is the Disease Management Program? As part of your benefit, MCHCP includes Smart Steps, a disease management program through CareAllies. This program can help prevent recurring symptoms and maintain a higher quality of life. Mercy Health Plan in the southwest region has its own disease management programs which are not available through CareAllies. Available Services Members with these chronic health conditions are enrolled in the program: Contact: Asthma. Coronary artery disease. Congestive heart failure. Diabetes. You are identified for participation in the program through medical and pharmaceutical claims. However, you must take the personal health analysis (PHA) each year to qualify for the incentive rate. Smart Steps offers free and confidential support in addition to: One-on-one consultation with a health care professional. Personalized counseling. Round-the-clock access to registered nurses - 24-hours a day, 7 days a week. A customized health care plan. Support from a registered nurse to coach you towards meeting your individualized health care goals. Educational materials to help you learn more about your chronic condition. How to Use the Disease Management Program This program translates your doctor s treatment plan into daily actions to improve your health and avoid the health crises and relapses that can lead to emergency room visits. If you are enrolled in Smart Steps, a nurse specializing in your condition will contact you to start the program. Through regular phone calls with a Smart Steps nurse and input from your doctor, you will: Come to better understand your illness. Set personal health goals. Make informed care decisions. Receive help navigating the complex health care system. If you take the PHA and participate in the program by taking regular phone calls from your coach and setting goals, you qualify for a lower health insurance premium or incentive rate. Your involvement in this program is confidential.! You can only take the Personal Health Analysis (PHA) online. Paper PHAs are not available. Eligibility Guidelines To participate, you and your spouse (if covered) must be enrolled in an MCHCP medical plan. Taking the PHA and participation in the Smart Steps program qualifies you for a lower health insurance premium or incentive rate. If you cover your spouse, you both must take the online PHA each year and participate in either the Lifestyle Ladder or the Smart Steps program to qualify for the incentive rate. If you qualify for Smart Steps, you are not eligible to participate in Lifestyle Ladder. If you or your spouse discontinues participation during the year, your premium will increase. New employees are eligible for participation in Smart Steps, and you will receive the incentive rate until the end of the current plan year. The next Open Enrollment, you may take the online PHA to continue receiving the incentive rate and participate in the program. Additional disease management programs may be available through your medical plan. Refer to USING YOUR MEDICAL PLAN. Disease Management Customer Service:

47 DENTAL PLAN through Delta Dental Availability: Available to all members Contact: Dental Plan Available Services The Delta Dental plan offers a nationwide network of participating providers that includes over 95% of dentists in Missouri. You may choose network or non-network providers for treatment. Your out-of-pocket costs may be less when using a network dentist. Network providers are reimbursed based on what Delta Dental determines to be the usual, customary and reasonable (UCR) fee for services and accept the UCR amount as payment in full. When you use a network provider, the provider will file claims for you and will not bill you for any amount that exceeds the UCR amount. You are responsible for any applicable deductible, coinsurance amount or amount over your annual maximum (per person). You are also responsible for any procedures not covered by the dental plan.! Retired, terminated vested, long-term disability (LTD) and survivors: You may enroll in dental when State employment ends if: You had dental coverage for 6 months prior to your status change or since the last Open Enrollment period, AND You maintain medical coverage through MCHCP. How to Use the Dental Plan Your dental plan has three categories of coverage. An annual individual deductible of $50 must be met before your dental plan reimburses you for services under Coverage B or Coverage C services. The deductible can be met with Coverage B and C services combined. Coverage is limited to $1,000 per person per calendar year. Orthodontic services are not covered under this plan. COVERAGE A Diagnostic & Preventive (paid at 100% with no deductible) Oral examinations (includes all types) - twice per calendar year. Bitewing radiographs (x-rays) - one set per calendar year. Dental prophylaxis (cleaning, scaling and polishing including periodontal maintenance visits) - twice per calendar year. Two additional cleanings allowed per calendar year for patients that are pregnant, diabetic, have a suppressed immune system or have a history of periodontal therapy. To be eligible for the additional cleaning benefits, you must submit a completed Self-Report form which can be obtained at or by contacting customer service. If periodontal therapy has already been reported on your claims, the Self-Report form is not necessary. Topical fluoride application for patients up to age 14 - once per calendar year. Sealants for all eligible participants, limited to caries-free occlusal surfaces of the first and second permanent molars - once in 5 years. Brush biopsy to detect oral cancer. COVERAGE B Basic & Restorative (paid at 80% after $50 annual individual deductible is met) Emergency palliative treatment (minor procedures to temporarily reduce or eliminate pain) - as needed. Space maintainers that replace prematurely lost teeth of eligible dependent children up to age 14 - once in five years. Restorative services using amalgam, synthetic porcelain and plastic filling material. Periapical radiographs (x-rays) - as required. Full-mouth radiographs (x-rays) - once in 5 years. Simple extractions. COVERAGE C Major Services (paid at 50% after $50 annual individual deductible is met) 12 month waiting period to qualify for these services* Denture repairs and relines. Oral surgery, including surgical extractions, other than simple extractions in Coverage B State Member Handbook

48 Periodontics: Treatment for diseases of the gums and bone supporting the teeth. Endodontics: Root canal filling and pulpal therapy. Prosthodontics (bridges, dentures, and partials). Dental benefits for an initial or replacement crown, jacket, labial veneer, inlay or onlay on or for a particular tooth will only be provided once in seven years, unless the damage to that tooth was caused by an accidental injury not related to the normal function of a tooth or teeth. General anesthesia: when administered by a dentist properly licensed to administer general anesthesia for a covered surgical procedure. Implants are not a covered benefit, however, an alternate benefit allowance will be provided based on the cost of a removable partial denture or fixed bridge - once in 7 years per tooth. *The waiting period is waived with proof of 12 month continuous dental coverage for major services immediately prior to enrollment in MCHCP s dental plan. Coverage A - No Deductible Examinations Prophylaxes (teeth cleaning) Fluoride Bitewing Radiographs (x-rays) Sealants SERVICE Coverage B - $50 per Person Deductible* Emergency Palliative Treatment Space Maintainers All Other Radiographs (x-rays) Minor Restorative Services (fillings) Simple Extractions Coverage C - $50 per Person Deductible* Prosthetic Repair All Other Oral Surgery Periodontics Endodontics Prosthodontics (bridges, dentures, partials) Major Restorative Services (crowns, inlays, onlays) 12 month waiting period for these services. The waiting period is waived with proof of 12 month continuous dental coverage for major services immediately prior to enrollment in MCHCP s dental plan. NETWORK You Pay 0% You Pay 20% You Pay 50% *Coinsurance amounts apply after the $50 individual deductible is met under either Coverage B or C or combined. Coverage is limited to $1,000 per person per calendar year. Delta Dental issues an identification card which you provide at the time of service. If you lose your ID card, call Delta Dental for a replacement or download one from the website at STATEOFMO.! Delta Dental of MO identification (ID) cards are issued in the subscriber s name only. Visit Delta Dental s website to locate participating providers near you. If you use a non-network provider, it is your obligation to make full payment to the dentist and file your own claim. Delta Dental reimburses continued Dental Plan Customer Service:

49 covered expenses. The dentist may bill you for expenses above the amount Delta Dental reimburses. If you go to a non-participating provider in Missouri, Delta Dental pays you directly based on the provider s fee or the prevailing fee, whichever is less. If you go to an out-of-state non-participating provider, Delta Dental will pay you directly on the same basis as the local Delta Dental plan reimburses its non-participating dentists. Obtain a claim form from MCHCP or download from WWW. DELTADENTALMO.COM/STATEOFMO. Claim Pre-determination If the care you need costs less than $200 or is emergency care, have your dentist proceed with treatment. If it costs $200 or more and is not emergency care, you could ask your dentist to submit a treatment plan to Delta Dental of Missouri and receive a pre-determination of benefits before you proceed with treatment. The predetermination of benefits provides you with an estimate of costs and enables you to know, in advance, the amount to be reimbursed by Delta Dental and how much is your responsibility. ENROLLMENT GUIDELINES To enroll dependents in the dental plan, you must also enroll. You may select different levels of coverage for the dental, vision and medical plans. The effective date of coverage is the first of the month coinciding with or following receipt of your enrollment. If adding dependent(s), proof of eligibility must be sent to MCHCP following enrollment. Enrollment on dependent(s) is not complete until proof of eligibility is received by MCHCP. After receiving proof, effective dates of coverage are the same for you and your dependent(s). You may only terminate dental plan coverage when one of the following occurs: The end of the plan year. Termination of employment. Retirement. Termination of medical coverage. Claim Filing Deadline Your claims must be filed by the end of the calendar year following the year in which services were rendered. Delta Dental of Missouri is not obligated to pay claims submitted after this period. If a claim is denied due to a participating dentist s failure to make timely submission, you are not liable to such dentist for the amount which would have been payable by Delta Dental, provided you advised the dentist of your eligibility for benefits at the time of treatment. NOTE If you are a State employee married to another State employee, each of you must enroll in the dental plan under your own Social Security number. Coordination of Benefits If you have other dental coverage, benefits under this program are coordinated with benefits under any such other program to avoid duplication of payment. The two programs together will not pay more than 100% of covered expenses. Dental Plan State Member Handbook

50 Limitations & Exclusions All benefits provided are subject to limitations and exclusions. Complete details are available in the Delta Dental of MO Membership Certificate which governs provisions of your benefit plan. A summary is listed in the following paragraphs. Alternative Treatment Plans When there are alternate plans of treatment, coverage is provided for the applicable percentage of the least costly, professionally satisfactory, course of treatment. This includes, but is not limited to, services such as composite resin fillings on molar teeth, in which case the benefits are based on the cost of the amalgam (silver) filling. This also includes fixed bridges and implants, in which case the benefits will be based on the cost of a removable partial denture or fixed bridge. If you receive care from more than one dentist for the same procedure, benefits will not exceed what would have been paid for one dentist for that procedure (including, but not limited to, prosthetics and root canal therapy). If you transfer care from one dentist to another during the course of treatment or if more than one dentist renders services for one dental procedure, the program pays no more than the amount it would have paid if only one dentist had rendered the service. Coverage Limitations Oral examinations, including those by a specialist, are limited to twice per calendar year. Prophylaxes (teeth cleaning), including periodontal prophylaxes, are limited to twice per calendar year. Two additional cleanings allowed per calendar year for patients that are pregnant, diabetic, have a suppressed immune system or have a history of periodontal therapy. To be eligible for the additional cleaning benefits, you must submit a completed Self-Report form which can be obtained at WWW. DELTADENTALMO.COM or by contacting customer service. If periodontal therapy has already been reported on your claims, the Self-Report form is not necessary. Topical application of fluoride is limited to once per calendar year for children up to age 14. Space maintainers are limited to once in five years for children up to age 14. Bitewing radiographs (x-rays) are limited to one set per calendar year and full-mouth radiographs (x-rays) are limited to once in a five year period. Dental benefits for an initial or replacement crown, jacket, labial veneer, inlay or onlay on or for a particular tooth will only be provided once in seven years, unless the damage to that tooth was caused by an accidental injury not related to the normal function of a tooth or teeth. If an existing bridge or denture cannot be made satisfactory, a replacement will be covered only once in seven years. Exclusions (Dental Services Not Covered) Services for which the participant, absent this coverage, would normally incur no charge, such as care rendered by a dentist to a member of his immediate continued Dental Plan Customer Service:

51 Dental Plan family or the immediate family of his spouse. Services for which coverage is available under Workers Compensation or Employers Liability Laws. Services performed for cosmetic purposes or to correct congenital malformations except for newborns with congenital dental defects. Charges for services that require multiple visits, which commenced prior to the membership effective date (including, but not limited to, prosthetics and orthodontic care.) Services or supplies related to temporomandibular joint (TMJ) dysfunction (this involves the jaw hinge joint connecting the upper and lower jaws.) Any services not specifically stated as Covered Services (including hospital, prescription drug charges and orthodontics.) Replacement of dentures and other dental appliances which are lost or stolen. Services rendered by a dentist beyond the scope of his license. Hypnosis. Duplicate services provided by another group dental plan. Diseases contracted or injuries or conditions sustained as a result of any act of war. Denture adjustments for the first six months after the dentures are initially received. Separate fees may not be charged by participating dentists. Charges for complete occlusal adjustments, crowns for occlusal correction, nightguards, bruxism appliances and bite therapy appliances. Tooth preparation, temporary crowns, bases, impressions and anesthesia or other services which are part of the complete dental procedure. These services are considered components of, and included in the fee for, the complete procedure. Separate fees may not be charged by participating dentists. Analgesia, including nitrous oxide. Charges covered under a terminal liability, extension of benefits, or similar provision, of a program being replaced by this program. Services rendered by a dental or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trustee or similar person or group. Services provided or paid for by any governmental agency or under any governmental program or law, except charges which the person is legally obligated to pay (this exclusion extends to any benefits provided under the U.S. Social Security Act and its Amendments.) Charges for duplication of radiographs. Charges for temporary appliances. Implants and related procedures are not covered. However, an alternate benefit allowance will be provided for an implant based on the cost of a removable partial denture or fixed bridge. Charges for experimental or investigational services or supplies. Services that the dentist feels, in his or her professional judgment, should not be provided. Instructions in dental hygiene, dietary planning or plaque control. Missed appointments or completion of claim forms. Infection control, including sterilization of supplies and equipment. Removal of third molars without symptoms State Member Handbook

52 Appeals Delta Dental of Missouri (DDMO) has established a first-level and second-level review process for written complaints. A first-level review, whether related to an adverse benefit determination or for reasons other than an adverse benefit determination, must be submitted in writing to DDMO s Customer Service Department. You have 180 days to submit your written complaint after receiving the denial or the notice that gave rise to the complaint. DDMO shall allow 180 days from the date allowed to file the first level complaint or 180 days from the date DDMO sent notification to the person who submitted the complaint of DDMO s resolution of said first level complaint, whichever is later. Any complaint should be accompanied by documents or records in support of the complaint. You may review pertinent documents relating to the claim and submit issues and comments in writing for consideration. DDMO will acknowledge receipt in writing within ten working days and will investigate the complaint within twenty working days after receipt of a complaint. If additional time is needed to complete the investigation, DDMO will notify you in writing on or before the twentieth working day with the investigation completed within thirty working days thereafter. DDMO will notify you in writing of the decision within five working days following the investigation. You have the right to request a second-level review, in which case, DDMO shall follow the same time frames as a firstlevel review except in the case of a request for an expedited review where life or health of an enrollee may be in jeopardy. Any first-level complaint should be sent to: Delta Dental of Missouri Customer Service Department Gravois Rd St. Louis, MO Second-level appeals should be sent to: Delta Dental of Missouri Appeals Committee Gravois Rd St. Louis, MO You have the right to file an appeal with the Director of the Missouri Department of Insurance, Financial Institutions & Professional Registration (DIFP) at any time. For detailed information on filing an appeal with the Missouri Department of Insurance, Financial Institutions & Professional Registration (DIFP) contact: Missouri Department of Insurance, Financial Institutions & Professional Registration Attn: Consumer Affairs PO Box 690 Jefferson City, MO Or call: Dental Plan Customer Service:

53 VISION PLAN through Vision Service Plan Availability: Available to all members Contact: Vision Plan This plan does not replace medical coverage for eye disease or injury. Contact your medical plan for these services. How to Use the Vision Plan The vision plan offers specific copayments for services at VSP doctors and gives allowances when you obtain services from non-network doctors. (Refer to the CHART.) To access services, call a VSP doctor to make an appointment. The doctor will need the subscriber s full name and last four digits of the Social Security number to verify eligibility. Call VSP for a provider directory or access it at VSP does not issue identification cards. When services are received from a VSP doctor, reimbursement is made directly to the physician. You only owe your copayments unless optional items are selected that the plan does not cover. Optional items include, but are not limited to: Frames that exceed the plan s allowance. Oversized lenses. Tints. Coatings. No-line multifocal lenses. Ask the VSP doctor the cost of optional items before ordering; however, VSP doctors charge the recommended fees for optional items, so your costs are controlled. Frequencies are from last date of service: Examination, once every 12 months (365 days). Contact lenses obtained once every 12 months in lieu of eyeglass lenses. Lenses, once every 12 months. Frames, once every 24 months. Additional Services Polycarbonate Lenses Covered at a VSP doctor for dependent children up to age 25 at no additional cost. Value-Added Discount Program In addition to the discounts you currently receive on prescription glasses, you can now enjoy a 20% discount on additional nonprescription sunglasses. Value-Added discounts are available from any VSP doctor (not only the doctor who performed the exam) within 12 months of the last covered eye exam. Corrective Laser Surgery VSP approved laser surgeons and centers provide different types of corrective laser surgeries. The maximum amount you pay is $1,500 per eye for PRK, $1,800 per eye for LASIK or $2,300 per eye for Custom LASIK. Call your VSP provider to check participation in the program. For additional information regarding the Laser Vision Care program, contact VSP at or online at Soft Contact Lenses Current soft contact lens wearers may qualify for a special contact lens program that includes a contact lens evaluation and initial supply of replacement lenses. Learn more from your doctor or at ENROLLMENT GUIDELINES To enroll dependents in the vision plan, you must also enroll. You may select different levels of coverage for the vision, dental and medical plans. The effective date of coverage is the first of the month coinciding with or following receipt of your enrollment. If adding dependent(s), proof of eligibility must be sent to MCHCP following enrollment. Enrollment on dependent(s) is not complete until proof of eligibility is received by MCHCP. After receiving proof, effective dates of coverage are the same for you and your dependent(s). You may only terminate vision plan coverage when one of the following occurs: The end of the plan year. Termination of employment. Retirement. Termination of medical coverage. NOTE If you are a State employee married to another State employee, each of you must enroll in the vision plan under your own Social Security number State Member Handbook

54 BENEFIT SUMMARY BENEFITS NETWORK** NON-NETWORK** Examinations $10 copayment Reimbursed up to $36 Materials* Single vision lenses (per pair) $25 copayment Reimbursed up to $28 Bifocal lenses (per pair) $25 copayment Reimbursed up to $45 Trifocal lenses (per pair) $25 copayment Reimbursed up to $56 Lenticular lenses (per pair) $25 copayment Reimbursed up to $80 Frames - once every 24 months* $25 copayment ($120 retail allowance + 20% discount on any out-of-pocket costs) Polycarbonate lenses for dependent children are covered at a VSP doctor at no additional cost. Reimbursed up to $45 Not covered Optional Items (cosmetic extras) Not covered Not covered Contact Lenses and Associated Service Including Evaluation, Design and Fitting Elective (If member prefers contacts to glasses) $10 copayment for exam Up to $125 allowance for cost of contacts and contact lens exam (fitting and evaluation) - This exam is in addition to your vision exam to ensure proper fit of contacts. 15% discount on the cost of contact lens exam (fitting and evaluation) Reimbursed up to $36 for exam Contact lenses and fitting and evaluation exam reimbursed up to $105 allowance Necessary*** (If medically necessary with prior approval) $10 copayment for exam Additional costs covered at 100% Reimbursed up to $36 for exam Contact lenses and fitting and evaluation exam reimbursed up to $210 allowance Receive 20% off additional prescription and non-prescription glasses and sunglasses. Current soft contact lens wearers may qualify for a special contact lens program that includes a contact lens evaluation and initial supply of replacement lenses. Learn more from your doctor or at * One $25 copayment for lens and frame ** All applicable copayments apply *** Requires prior approval from VSP Vision Plan Customer Service:

55 Eligibility & Enrollment & ENROLLMENT Change of Address Address changes can be made: Online using MYMCHCP. In writing. By calling MCHCP directly. If you move, MCHCP or your human resource/payroll representative can determine the available plans and premium rates for your new location. If you decide to change plans, you must do so within 31 days of your address change. Changes are effective the first day of the following month. MCHCP Identification Cards Use your PIN and MCHCPid card when contacting our office or accessing MYMCHCP. You receive an MCHCPid card when you become eligible for benefits, and information from your human resources/payroll office is received by MCHCP. NOTE New employees: Enrollment or waiver must be completed through the Statewide Employee Benefit Enrollment System (SEBES) at and required documentation sent to MCHCP. All required information and documentation must be sent to MCHCP within 31 days of your enrollment. Eligibility Information Employee Eligibility Requirements You may enroll in one of MCHCP s plans if you are an active State of Missouri employee in a position covered by the Missouri State Employees Retirement System (MOSERS) and are not currently covered under another retirement or benefit plan supported by State contributions, unless the agency sponsoring the other retirement or benefit plan joins MCHCP. You may also enroll if you are a member of the Public School Retirement System (PSRS) and employed by a State agency. If you are a part-time employee, check with your human resource/payroll representative to determine if you are eligible for MCHCP participation. To enroll yourself and/or your dependents when first eligible, submit a completed Change/Cancellation (M-2) form to MCHCP. You must provide Social Security numbers for yourself and your dependents when you enroll with MCHCP in addition to proof of eligibility for your dependents. See PAGE 59. A person who fails to meet the eligibility requirements specified in this handbook shall not be eligible to enroll or continue enrollment with MCHCP. A person whose coverage with MCHCP was terminated due to a violation of a material provision of the Plan (such as fraud) shall not be eligible to enroll with the Plan for coverage. Eligible Dependents You may enroll eligible dependents in the Plan as long as you are also enrolled. Eligible dependents include: Your spouse, unless he/she is covered through MCHCP where he/she works, If you and your spouse are both State employees, you must each enroll under your own coverage. Newborn of a member, Your unemancipated dependent children through the end of the month in which they turn age 25, including: Natural children Adopted children from the date you assume the legal obligation for total or partial support of the child Those children who live with you and are either: Stepchildren Foster children Children for whom you or your spouse are the courtappointed legal guardian Children for whom you are required to provide coverage under a Qualified Medical Child Support Order (QMCSO) Your unemancipated stepchildren not residing with you provided the natural parent who is legally responsible for providing coverage is also covered by the Plan. Your unemancipated dependent (disabled) children who are over age 25, but only when first eligible or when covered before age State Member Handbook

56 ! Coverage may continue beyond age 25 for unemancipated dependent children who are permanently disabled before age 25. In these cases, medical coverage may continue for as long as the child is disabled (and you remain a covered subscriber). Before the child s 25th birthday, you must provide MCHCP with written documentation of the medical condition and a doctor s statement verifying the child s condition. Proof of continuing disability must be provided at the request of MCHCP but not more than once annually. Children must be under age 25 and unmarried to qualify as dependents. Dependent children must live with a parent, adult family member, or someone appointed by an agency with legal jurisdiction unless they are students in an accredited school or institution of higher learning. Appropriate documentation may be required. You must terminate coverage on dependents who no longer qualify, such as a divorced spouse or a dependent child who becomes emancipated. Coverage ends on the last day of the month of the occurrence. (For definition of EMANCIPATED CHILD, see Definitions.) Note the reason for terminating your dependent, along with the date of loss of eligibility, on the Change/ Cancellation (M-2) form. Refer to CHANGES IN DEPENDENT STATUS. W Forms can be faxed to MCHCP s toll free fax line at Coordination of Benefits The coordination of plan benefits, meaning which plan pays primary, for your dependents are determined as follows: 1. If your spouse has group insurance coverage and he/she is not eligible for Medicare, his/her employer s plan is always the primary plan for your spouse. 2. The primary plan for your dependent child(ren) is the parent s plan whose birthday occurs first in the calendar year. If both parents have the same birthday, the plan that has been in force for the longest period of time is the primary carrier. 3. EXAMPLE If the mother s birthday is March 15 and the father s birthday is June 24, the mother s insurance plan is the primary plan for the dependent children. If there is a court decree which establishes financial responsibility for a dependent child s health care expenses, the plan of the parent with that responsibility is primary. NOTE It is likely your medical plan will require you to complete a questionnaire asking if you or your dependents have other insurance coverage. If you have other coverage your plan will ask for the name of the company. This verifies how benefits are coordinated and must be answered BEFORE claims are paid. Eligibility Date You are eligible to participate in MCHCP s plans on the first of the month following your date of employment. This is called your eligibility date; it is the earliest date that coverage can begin. Your employment date starts the 31 day eligibility period when you may apply for coverage for yourself and/or your dependents. After the eligibility period has expired, you and/or your dependents are considered late entrants. Refer to the LATE ENTRANTS section. EXAMPLE If you start employment in a qualifying position on June 15, your eligibility date is July 1. Your eligibility period is June 15 through July 15. If you were employed by another state agency, were provided coverage under another medical plan and transferred to an agency covered under MCHCP, your eligibility date is the date of your transfer. Your eligible dependents covered by the other medical plan are able to participate as of your eligibility date. There is no break in coverage provided you complete and submit a Change/Cancellation (M-2) form within 31 days. EXAMPLE Your employment with the Department of Conservation terminated on June 15 and you transferred to the Department of Economic Development on June 20. Your eligibility date is June 20, and coverage is continuous. continued Eligibility & Enrollment Customer Service:

57 Eligibility & Enrollment If your employment is terminated (not transferred between State agencies) and you are hired as a new State employee before your participation in the Plan has terminated, or you are hired in the following month, your coverage is continuous provided you submit a completed Change/ Cancellation (M-2) form within 31 days. If your coverage is continuous, you cannot increase your level of coverage or change plans. However, you may request coverage to begin the first of the month following your employment. Note: If you elect not to have continuous coverage, claims are not paid for the time your coverage was not in force. EXAMPLE You are enrolled in one of the MCHCP s plans with subscriber/ family coverage and your employment terminates with the Department of Economic Development on June 15. You began employment with the Department of Agriculture on June 25. Your coverage is continuous under the Plan with subscriber/ family coverage. Coverage under Economic Development continues through June 30 and begins under the Department of Agriculture on July 1. OR! EXAMPLE Your employment with the Department of Economic Development terminates on June 15, and you began employment with the Department of Agriculture on July 15. Coverage under the Department of Economic Development continues through June 30 and coverage under the Department of Agriculture is effective July 1. Your coverage under the same MCHCP plan with subscriber/family coverage is continuous. OR You may elect coverage effective August 1. Your coverage under the Department of Economic Development continues through June 30, and coverage under the Department of Agriculture is effective August 1. You must select a plan and indicate level of coverage since coverage is not continuous. Effective Date The effective date of your coverage is the first of the month coinciding with or following your eligibility date and the date your enrollment is received by MCHCP. If your enrollment is received by MCHCP prior to your eligibility date, you may elect coverage on your eligibility date or the first of the month following that date. Specify on the Change/ Cancellation (M-2) form the date you want coverage to begin. In all cases, your enrollment must be submitted within 31 days of your hire date. EXAMPLE Your eligibility date is June 1 and you completed your enrollment on June 20. Your effective date is July 1. If your enrollment is received by MCHCP on May 31, your coverage goes into effect on June 1 or (if requested) July 1. Your effective date of coverage cannot be prior to the date of receipt of your enrollment by MCHCP. Payment for your first month s premium must be made by check or regular payroll deduction. Double deductions may be taken to pay for your first month s coverage depending upon the date your enrollment is received and the date you specify as your effective date. Subsequent premium payments are deducted from your payroll. If you do not elect coverage during your eligibility period, you are considered a late entrant. Refer to the LATE ENTRANTS section. Changes in Dependent Status If a covered dependent loses his/her eligibility, you must immediately notify MCHCP and terminate his/her coverage. MCHCP must be provided with the date of loss of eligibility (i.e. date of marriage of child, date of divorce from spouse, date of emancipation of child, etc.) The dependent s coverage will terminate at the end of the month in which such loss of eligibility occurs. Should MCHCP later discover a non-eligible dependent covered by the Plan, MCHCP will take all necessary actions, including legal actions against the subscriber, to recover costs incurred for such ineligible dependents. Further, should MCHCP determine that you knowingly engaged in fraudulent State Member Handbook

58 activity by providing someone with coverage who was not eligible, MCHCP may immediately terminate your coverage and refuse to provide you with coverage in the future. If your emancipated child regains dependent status, the child may be added to your coverage if application is made within 31 days of the status change. Submit the following: Change/Cancellation (M-2) form Proof of eligibility AND, either Letter from previous insurance carrier or former employer (if dependent had group insurance while emancipated) stating that the coverage has been terminated, the reason for coverage termination (i.e. reduction in hours), individual covered, and the date coverage was terminated OR Documentation that proves the child meets the requirements to qualify as an eligible dependent (i.e. proof of student status, divorce documentation, proof of address change) EXAMPLE Your 20 year old child is covered under group health insurance through his/her employer. He/she decides to quit work and attend college. He/she has regained dependent status and can be added to your coverage with proof of: Class schedule. Loss of coverage. Eligibility. Vested Subscribers You may participate in an MCHCP plan when your employment with the State terminates provided you are a vested member and meet certain requirements. To be vested means you were employed by the State a minimum of five years and you are eligible for a benefit from the Missouri State Employees Retirement System (MOSERS) or the Public School Retirement System (PSRS) as a State employee when you reach retirement age. As prescribed by law, you must meet one of the following requirements to participate in an MCHCP plan as a vested subscriber, you: Have had coverage through MCHCP since the effective date of the last Open Enrollment period. Have had other health insurance for the six months immediately prior to the termination of state employment - proof of insurance including effective dates of coverage and termination date is required. Have had coverage since first eligible. You must elect to continue coverage (as defined by law) within 31 days from the last day of the month in which your employment terminated. You are responsible for the full cost of the coverage from the date of termination. If you are a terminated vested subscriber and are also the spouse of a State subscriber (either active or retired), you may choose to be covered under your spouse. If you do not elect coverage, or if you cancel coverage, for yourself or your dependents as a vested subscriber you cannot enroll at a later date. You may continue coverage under the provisions of COBRA; however, when COBRA coverage ends, you cannot enroll as a vested or retired subscriber. An Employment Record (M-1) must be completed by your human resource/payroll representative and sent to MCHCP indicating the termination date. Once MCHCP receives the termination, a letter and enrollment form are sent to you to complete and return to MCHCP in order for you to be enrolled as a vested subscriber. If you participate in an MCHCP plan as a vested subscriber, your dependents may also participate if they meet one of the previously listed qualifications. If your dependents do not meet the qualifications to participate as dependents, they are eligible to retain coverage for up to 36 months under COBRA. See COBRA section for additional information. New dependents of a terminated vested subscriber may be enrolled when first eligible (within the first 31 days of a marriage, birth, or adoption). If you do not add new dependents when first eligible, they cannot be enrolled at a later date, unless they qualify for coverage due to a loss of coverage as described on PAGE 72. See SURVIVOR(S) OF SUBSCRIBER section for additional information. NOTE As a vested subscriber, if you take your retirement as one lump sum, you forfeit your right as a vested employee. Coverage can only be continued under COBRA for 18 months if you meet the definition of a COBRA principal qualified beneficiary. See COBRA section for additional information. continued Eligibility & Enrollment Customer Service:

59 Eligibility & Enrollment Elected State Officials & Employees You may continue to participate in an MCHCP plan if you are a member of the General Assembly, a State official holding a statewide elective office or you are employed by an elected State official or member of the General Assembly and your employment was terminated because the State official or member of the General Assembly ceases to hold elective office. If you elect to continue coverage through MCHCP, you must do so within 31 days of your termination of employment. You are charged the vested rate. If you do not elect to continue coverage at the time your appointment ends, you cannot enroll at a later date. Participation After Retirement When you retire you may participate in an MCHCP plan, provided at the time of your termination of state employment: You are eligible to receive, now or at a later date, a monthly retirement benefit from either the Missouri State Employees Retirement System (MOSERS) or from the Public School Retirement System (PSRS) for state employment. PSRS retirees must provide MCHCP with a statement from PSRS which indicates the effective date of the subscriber s retirement; AND, either You have had coverage through MCHCP since the effective date of the last Open Enrollment period, OR You have had other health insurance for the six months immediately prior to the termination of state employment - proof of insurance including effective dates of coverage and termination date is required, OR You have had coverage since first eligible. Refer to the section for additional information including continuing dependent coverage during retirement. NOTE When you terminate employment, as a terminated vested subscriber or retiree, if you do not elect coverage for yourself and/or your dependents, or if you terminate your medical coverage during retirement for yourself and/or your dependents, you CANNOT enroll in an MCHCP plan at a later date. However, as a terminated vested subscriber or retiree, you can add dependent coverage if your dependent s employer sponsored group coverage has ended due to termination of employment or termination of group coverage by the employer. This must be done within 60 days of the loss and you must provide proof that the coverage was in effect for at least 12 months immediately prior to the loss. Proof of eligibility and prior coverage is required. Enrollment Opportunities New Employees As a new employee, you and your dependent(s) may enroll when first eligible (within the first 31 days of employment with the State). You can make changes in your coverage during the first 31 days of your hire date. Coverage is effective the first of the month following receipt of the change. After this time, you can only change plans if you have a change of address or during the next Open Enrollment period. Life Events You may enroll yourself and any eligible dependents within 31 days of the occurrence of a life event, such as marriage or birth/adoption of a child. For retirees, terminated vested members or survivors, dependents must be added when first eligible (within the first 31 days of marriage, birth or adoption). If you do not elect coverage when your dependents are first eligible, you cannot enroll them at a later date. Open Enrollment During the annual Open Enrollment period you, as an active employee, may change plans and/or your level of coverage. If you are retired, terminated vested, on long term disability or a survivor, you may change from one plan to another during Open Enrollment but you CANNOT add dependent(s). If Open Enrollment is over and you need to change your Open Enrollment plan selection, an appeal must be made to the MCHCP Board of Trustees by the end of January. After January 31, NO APPEALS FOR PLAN CHANGES can be made. You may change plans during the next Open Enrollment period. As an active employee, you must enroll in a plan where you live. If a plan is available where you work, but NOT where you live, you may enroll where you work. If you are retired, terminated vested, long-term disability (LTD), survivor or COBRA subscriber, you can only enroll where you live State Member Handbook

60 Carefully read the appropriate section in the following pages for complete details. Requirements for Enrollment New employees must enroll or waive coverage through the Statewide Employee Benefit Enrollment System (SEBES) at within 31 days of employment. If enrolling dependent(s), proof of eligibility must be sent to MCHCP following enrollment. Enrollment on dependent(s) is not complete until proof of eligibility is received by MCHCP. After receiving proof, effective dates of coverage are the same for you and your dependent(s). A Change/Cancellation (M-2) form is required for: Enrollment of yourself and/or your dependents due to a life event. If adding dependent coverage or enrolling dependent(s) when first eligible (within 31 days of the event), the form should be accompanied by proof of eligibility. If you have not yet received a Social Security number for the child, send the Change/ Cancellation (M-2) form and birth certificate if you have it. Do not delay in applying for coverage. If you don t have the birth certificate or SSN, make certain application is made by the 31 day deadline as it is strictly enforced. Changes to your coverage due to the following events: Loss of Eligibility or Medicaid Status. Military Leave. Return to employment following Military Leave, Leave of Absence, or Leave of Absence due to Workers Compensation or Family Medical Leave. Termination of coverage. Transfer of employment to another State agency covered under MCHCP. Proof of Eligibility MCHCP requires proof of eligibility* for all dependents added to your coverage. Enrollment on dependent(s) is not complete until proof of eligibility is received by MCHCP. Required documentation should accompany the Change/ Cancellation (M-2) form. If you are a new employee, proof of eligibility should be sent after completing your enrollment through SEBES. You should include your MCHCPid or Social Security number on the documentation. If proof of eligibility is not provided, a letter will be sent requesting it. Documentation must be received within 30 days of the date of the letter or your dependents will not be added. They are not eligible for coverage until the next Open Enrollment period except in the case of a life event. Documentation is also required in the event of death or divorce. Proof of eligibility documents are kept on file for future reference. * Refer to the CHART on the following page. Coverage Levels There are four levels of coverage: 1. Subscriber Only 2. Subscriber/Spouse 3. Subscriber/Child(ren) 4. Subscriber/Family continued Coverage is effective the first of the month following or coinciding with the receipt of your enrollment, you must also provide proof of eligibility for dependents.* Enrollment must be received within a specific time frame. Refer to ENROLLMENT GUIDELINES for this information. Change/Cancellation (M-2) form and proof of eligibility (if required) must be sent to MCHCP s form fax line at or mailed to: MCHCP PO Box Jefferson City, MO Do not give the Change/ Cancellation (M-2) form to your Human Resource/Payroll office. The Change/Cancellation (M-2) form can be obtained at ORG or through your human resources/payroll office. *Except in cases of life events or military leave. See ENROLLING DUE TO LIFE EVENTS or MILITARY LEAVE for more information. ENROLLMENT TIPS New Employee: Enroll within 31 days of employment. Life Events (birth, marriage or adoption): Enroll within 31 days of event. Loss of Coverage: Enroll within 60 days of loss. COBRA Coverage: Enroll within 60 days of qualifying event. Eligibility & Enrollment Customer Service:

61 PROOF OF Enrollment Guidelines CIRCUMSTANCE COPIES OF DOCUMENTATION Adding New Dependents Addition or Birth of dependent(s) Addition of step-child(ren) Addition of fosterchild(ren) Adoption of dependent(s) Legal guardianship of dependent(s) Newborn of covered dependent Birth certificate* or Hospital certificate Marriage license + to biological parent of child(ren) and Birth* or hospital certificate for child(ren) that names the subscriber s spouse as a parent Placement papers in subscriber s care Adoption papers or Placement papers Court-documented guardianship papers (Power of Attorney is not acceptable) Birth certificate* for subscriber s child(ren) and Birth certificate* for subscriber s grandchild(ren) Marriage Marriage license + Marriage certificate or Newspaper notice of the wedding Divorce Death Final divorce decree or Notarized letter from spouse stating he/she is agreeable to termination of coverage pending divorce Death certificate* Subscriber must be listed as parent. Adding a Spouse: Enrolling BEFORE Date of Marriage If you marry after participation in the Plan and you want your spouse s coverage to go into effect on the marriage date, you must enroll your prospective spouse prior to the date of marriage. EXAMPLE Your wedding date is June 15 and you apply for coverage on June 7. Your spouse s coverage would begin June 15. Note: You are responsible for premium payment for the entire month of June. Enrolling AFTER Date of Marriage You may enroll your spouse within 31 days of the marriage. The appropriate premium is required for the month your spouse s coverage goes into effect. EXAMPLE Your wedding date is June 15 and you apply for coverage and submit a copy of your marriage license on June 20. Coverage will go into effect on July 1. Eligibility & Enrollment *Copies of birth and death certificates filed in Missouri can be obtained from the Missouri Department of Health and Senior Services. + Copies of marriage licenses filed and divorce decrees granted in Missouri can be obtained from the Recorder of Deeds or Circuit Clerk, respectively, in the county where the event occurred. MCHCP must receive: Enrollment form within 31 days of the date of marriage, AND Proof of eligibility. If proof of eligibility is not received, you will be unable to enroll your spouse until the next Open Enrollment for coverage to be effective the following January. continued State Member Handbook

62 Adding Newborn Children: Coverage is provided for a newborn of a member from the moment of birth. However, appropriate forms must be completed and submitted for claims to be paid. Premium is not due for the first 31 days of coverage, however, premium will be due if coverage is to continue beyond the first 31 days. To enroll a newborn or adopted child, notify MCHCP of the event, either orally or in writing, within 31 days of the date of birth. You are allowed an additional 10 days from the date the forms and instructions are provided to enroll the newborn child. Coverage will not continue past the first 31 days unless required documentation is received. If you have not yet received a Social Security number for the child, send the Change/Cancellation (M-2) form and birth certificate if you have it. DO NOT WAIT FOR A SOCIAL SECURITY NUMBER TO BE ASSIGNED. The 31 day enrollment period is strictly enforced. Advise MCHCP in writing of your new dependent s Social Security number as soon as you receive it. Failure to provide proof of the dependent s Social Security number in a timely manner may result in loss of coverage. If your covered dependent has a child, the newborn must be added within 31 days of the birth for coverage. If you do not elect to enroll the newborn at the time of birth, you cannot enroll the child at a later date. Once your dependent loses coverage or is no longer eligible for coverage, his/her child is no longer eligible for coverage through MCHCP. NOTE The date of birth starts day one in determining when the baby turns 32 days old. Adding Adopted Children: When a child is placed for adoption, the child has the same eligibility requirements and procedures as a newborn. (See guidelines in preceding section.) Children who are adopted or placed for adoption are eligible for coverage on the date that child is placed for adoption. Apply for coverage within 31 days of placement for adoption. NOTE There are no pre-existing condition limitations on newborns, adopted children, or children placed for adoption. To enroll your new dependent child, you have the following options: Applying for Coverage PRIOR to Birth or Adoption Complete the Change/Cancellation (M-2) form and indicate the child s expected date of birth or placement of child for adoption. Once the child is born or placed for adoption, complete a Change/Cancellation (M-2) form and provide proof of eligibility. If you have child(ren) coverage, no additional premium is due. If you do not have child(ren) coverage, the appropriate premium is required for the month in which the newborn turns 32 days old or 32 days from the placement of newborn adopted child(ren). For children adopted other than at birth, premium is due the month of placement. EXAMPLE You apply for coverage for your child which is expected to be born mid-june. The baby is born on June 15. The baby is covered from the date of his/her birth. Premium is required for the month of July. Applying for Coverage AFTER Birth or Adoption Coverage is effective on the day your child is born or placement of your adopted child. To enroll your child, submit the completed Change/Cancellation (M-2) form and proof of eligibility. The appropriate premium is required for the month in which your newborn turns 32 days old or 32 days from the placement of your adopted newborn child. For adopted children that are not newborns, premium is due the month of placement. Access to MCHCP If you are a Missouri state employee married to another Missouri state employee, a Missouri state retiree, or to a public entity employee, there are rules that apply to coverage. If you are an active State employee and you are married to another active State employee, you must enroll individually. You are not able to enroll under one another s coverage. If you are a State employee eligible for coverage through MCHCP and you are married to a public entity employee eligible for coverage through MCHCP, you may be covered individually OR under one of Eligibility & Enrollment Customer Service:

63 Eligibility & Enrollment the employers. However, you cannot have coverage both places. If you are an active State employee married to a State retiree or if you are a State retiree married to a State retiree (provided both are eligible for coverage through MCHCP), you may be covered separately or together. If you are a State employee covered by MCHCP and are married to a State employee covered under the Missouri Departments of Conservation, Highway Patrol or Transportation (MoDOT), you must be covered separately. However, if you wish to cover your spouse under the MCHCP plan when you retire, you must elect coverage for your spouse at the time you retire. Your spouse cannot be enrolled at a later date, even if it is financially beneficial to do so. However, as a terminated vested subscriber or retiree, you can add dependent coverage if your dependent s employer sponsored group coverage has ended due to termination of employment or termination of group coverage by the employer. This must be done within 60 days of the loss and the coverage must have been in effect for at least 12 months immediately prior to the loss. EXAMPLE You are employed by the Department of Corrections and your spouse is retired from the Department of Conservation. You elect coverage only for yourself when you retire. Your spouse can be added to your coverage at a later date when his/her employment ends with the Department of Conservation. Late Entrants (This section only applies to Active Employees) You and/or your dependents are considered late entrants if one of the following occurs: You waive your right to insurance when you are first eligible. You do not enroll your eligible dependents. You drop coverage on yourself or your dependents throughout the year. You may enroll yourself and/or dependents in one of the MCHCP plans during the annual Open Enrollment period for coverage to be effective the following January 1. To enroll, complete the Open Enrollment Worksheet for yourself and/or eligible dependents or enroll online through MYMCHCP. Enrolling Due to Life Events Under the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), an employee who experiences certain life events may enroll under a special enrollment period. These life events include marriage, birth and adoption or placement of an adopted child. When one of these events occurs, you and any eligible dependents may enroll in the medical, dental and/or vision plans. Changes must be consistent with the life event. If you qualify to enroll due to a life event, you have 31 days within the date of the occurrence to enroll. The appropriate premium is required for the entire month coverage becomes effective. (See ADDING NEW DEPENDENTS for more information.) Although newborns will be added the month of their birth, other dependents effective date of coverage will be the first of the month following or coinciding with receipt of the form and proof of eligibility. Enrolling Due to Loss of Eligibility If you waive enrollment for yourself or your dependent(s) because of other health insurance coverage, you may enroll yourself and/or your dependent(s) due to loss of eligibility of that coverage. You must enroll within 60 days after the other coverage ends. For this provision to apply, MCHCP must have a Change/Cancellation (M-2) form on file specifying that you had other insurance coverage at the time of the waiver. Refer to PAGE 72 for additional information on loss of coverage. You may enroll in any of the MCHCP plans if one of these applies: You no longer qualify for coverage under your spouse s plan. Your spouse s employment is terminated or he/she is no longer eligible for coverage under his/her employer s plan. Your spouse s employer-sponsored medical plan is terminated. All employer contributions toward your spouse s plan cease. Your COBRA coverage ends. You may apply for late entrant coverage in any of the MCHCP plans for dependent(s) covered through a spouse s, ex-spouse s (who is the natural parent providing coverage) or a legal custodian s insurance coverage if coverage is lost for one of these reasons: Your dependent no longer qualifies due to his/her age. Your spouse, ex-spouse or legal guardian is no longer eligible for State Member Handbook

64 coverage under his/her employer s plan or coverage is terminated. Employer-sponsored medical plan is terminated. Employer contributions toward the plan cease. COBRA coverage ends. Submit the following: Change/Cancellation (M-2) form. Proof of eligibility. Letter from the previous insurance carrier or former employer stating coverage is terminated, the reason for coverage termination (i.e. spouse lost eligibility because he/she terminated employment), list of dependents covered and the date coverage was terminated. Enrolling Due to Loss of Medicaid Status If you or your dependent loses Medicaid coverage, you have 60 days from the date of loss to enroll yourself or your dependent with MCHCP. Coverage is effective on the first of the month following receipt of the form and required documentation. However coverage can be effective the first of the month in which Medicaid coverage is lost if forms are received by MCHCP prior to the first of the month of the loss. Submit the following: Change/Cancellation (M-2) form. Proof of eligibility. Letter from Medicaid stating who was covered and the date Medicaid terminated. Enrolling Dependents Due to Court Order Qualified Medical Child Support Orders (QMCSO) Dependent child(ren) may be added at other times of the year if you receive a court order stating responsibility for coverage of the dependent child(ren). A qualified medical child support order comes from a court of competent jurisdiction or state child care agency and requires the Plan to provide coverage for a dependent child if the Plan normally provides coverage for dependent children. Application must be made within 60 days of the court order. To apply for court ordered dependent child(ren) coverage, Submit the following: Change/Cancellation (M-2) form. Proof of eligibility. Copy of the court order. Coverage is effective on the date specified by the court order or on the first of the month following receipt of the form and required documentation. MCHCP also accepts legal documentation directly from a court of law or a third party. Termination of Your Employment Your health insurance ends on the last day of the month in which your employment terminates (regardless of whether you quit your job or you were fired). See COBRA section for additional information. Coverage Changes Due to Death Survivor(s) of Active Subscribers Your eligible dependents may participate in one of the MCHCP plans if one of the following conditions is met, they: Have had coverage through MCHCP since the effective date of the last Open Enrollment period. Have had other health insurance for the six months immediately prior to your death - proof of insurance including effective dates of coverage and termination date is required. Have had coverage since first eligible. AND You, the subscriber, die: as an active vested employee. while vested and are receiving a long-term disability benefit from MOSERS or PSRS based on State employment. To enroll as a survivor, your dependent(s) must notify MCHCP within 31 days of your death. They must also submit an Application for Survivor to Retain Medical Coverage (M-7) form, a copy of the death certificate and pay the required premium. If survivors do not elect coverage within 31 days, they cannot enroll at a later date. If the survivor marries, has a child, or adopts a child, the dependent must be added when first eligible. If dependents are not enrolled when first eligible, they cannot be enrolled at a later date. Under certain circumstances, your dependents may qualify for continued medical coverage under provisions of COBRA. (Refer to COBRA section). Your dependents are responsible for the full cost of the premium from the date of their loss of coverage. Survivor(s) of Terminated Vested Subscribers or Retired Subscribers If you, the subscriber, die as a Missouri State Employees Retirement System (MOSERS) Eligibility & Enrollment Customer Service:

65 Eligibility & Enrollment retiree or as a terminated vested subscriber, OR Public School Retirement System (PSRS) retiree based on State employment, dependents covered under your MCHCP plan at the time of your death may continue in one of the MCHCP plans. Coverage must be elected within 31 days of your death. To continue coverage, your dependents must submit an Application for Survivor to Retain Medical Coverage (M-7) form, a copy of the death certificate and pay the required premium. (To obtain the form, contact MCHCP or download it from our website at If coverage is not elected within 31 days, dependents cannot enroll at a later date. If the survivor marries, has a child, or adopts a child, the dependent must be added when first eligible. If dependents are not enrolled when first eligible, they cannot be enrolled at a later date. Death of a Dependent When a covered dependent dies, the dependent s coverage ends on the date of death. If there is a change in your level of coverage, your premium is pro-rated the month of the death. Submit a Change/Cancellation (M-2) form and copy of the death certificate within 31 days of the death. (Contact MCHCP to obtain the form, or download it from our website at Coverage During a Leave of Absence If you are approved for a leave of absence without pay, you can continue to participate in your MCHCP plan. You are billed for the full cost of the coverage for yourself and your eligible dependents unless your leave of absence is due to Workers Compensation (WC) or under the Family Medical Leave Act (FMLA). If your Leave of Absence is due to Workers Compensation or FMLA, talk with your human resources/payroll office to see that the proper forms have been filed with MCHCP. MCHCP will not continue your coverage (medical, vision, and/or dental) unless you elect to have it continued. Prior to your leave, you may elect to continue coverage by completing and signing Continuation of Coverage During Leave (M-3) form. If you do not complete the Continuation of Coverage During Leave (M-3) form, you are sent a letter asking if you want to continue coverage while you are on leave. If so, you can sign the letter and return it to MCHCP within ten days. If, after electing to continue coverage while on leave, you fail to pay the premium due, coverage on you and your dependents is terminated. You are not allowed to enroll in the plan again until the Open Enrollment following your return to work. If you maintain coverage for yourself but not your covered dependents you are eligible to regain coverage for your dependents when you return to work. However, if you participate in the Copay Plan, the pre-existing condition limitation applies if more than 63 days has lapsed between coverage. This does not apply if you are a participant in an HMO. If you do not elect to continue your insurance, coverage for yourself and/or your dependents is suspended effective the last day of the month in which you are an active employee. In order for your coverage to be reinstated when you return to work, you must complete the Change/ Cancellation (M-2) form within 31 days. Your coverage is reinstated on the first of the month following the date your form is received. You may regain the same level of coverage you had with the plan in which you were enrolled prior to the leave. However, if you participate in the Copay Plan, the pre-existing condition limitation applies if more than 63 days has lapsed between dates of coverage. This does not apply if you participate in an HMO. If you are an active State subscriber and are placed on Leave Without Pay or Layoff status and are also the spouse of a State subscriber (either active or retired), you may choose to be covered under your spouse. You are not required to wait until Open Enrollment to make the change. If, at a later date, you wish to be covered individually, you can make that change as long as the coverage is continuous. A subscriber transferring under a spouse s coverage is enrolled in the plan in which the spouse is enrolled. When you return to work, you and your spouse must be covered individually. Leave of Absence - Workers Compensation If you are on a leave of absence due to illness or injury and you are receiving weekly Workers Compensation (WC) benefits, the normal monthly contribution toward your medical coverage continues. You are responsible for the premium payments that were normally deducted from your payroll prior to your leave of absence. Medical coverage is extended to you during the time period in which you are receiving weekly WC benefits. Once you are no longer eligible for the weekly WC benefits, you are State Member Handbook

66 responsible for paying the applicable monthly Leave of Absence rate for your medical coverage, unless you return to active State employment. When your status changes from WC to Leave of Absence, you may elect to suspend coverage. If coverage is suspended, at that time, you may reenroll within 31 days of your return to work. Leave of Absence - Family Medical Leave If you are approved for a leave of absence under the Family Medical Leave Act of 1993 and have met the requirements and guidelines set forth by the FMLA law and your employing agency, the State continues to pay its monthly contribution toward you and your dependents coverage. You are responsible for the premium payments that were normally deducted from your payroll prior to your leave of absence. At the end of your FMLA leave, if you are still unable to return to work, you may elect to suspend your coverage. If coverage is suspended at that time, you can enroll within 31 days of your return to work. Coverage During a Layoff If you are on a leave due to a layoff, you can elect to continue to participate in MCHCP for a maximum of 24 months. You are responsible for paying the required premium amount for coverage for both yourself and your eligible dependents. Premium amount is based on the Leave of Absence rate. Recertification of your status by your employing department is required at least every 12 months. If you are an active State employee, placed on layoff, and are married to a State subscriber, you may transfer under your spouse s coverage. If, at a later date, you wish to be covered individually and are eligible to do so, you may make that change as long as coverage is continuous. The change can be made any time it is financially advantageous. Once you are eligible for other health benefits as an employee of another company, eligibility under this plan ends. If your participation in an MCHCP plan terminates and you are later recalled to State service, you are considered a new employee for eligibility purposes of MCHCP. Participation for Long-Term Disability Recipients If you become eligible for long-term disability from the Missouri State Employees Retirement System (MOSERS), you are eligible to continue participation in your MCHCP plan provided you have had coverage since the effective date of the last Open Enrollment period. At the date of disability, if you did not have coverage through MCHCP but had other health insurance coverage for the six months immediately prior to your disability, you may enroll in an MCHCP plan. Proof of other insurance including effective dates of coverage and termination date is required. You may continue coverage on your dependents, or they may be added to the MCHCP plan at the date of your disability if they had other health insurance coverage for the six months immediately prior to the date of your disability. Proof of other insurance coverage is required when you enroll with MCHCP. You may also add new dependents when they are first eligible. Once your coverage has terminated as an active employee, you pay the cost for the coverage for both yourself and your eligible dependents. A portion of the premium amount is paid by MCHCP, however, you are responsible for paying premiums whether or not you are notified by MCHCP. If you are married to a State subscriber, you may transfer under your spouse s coverage. If, at a later date, you wish to be covered individually and are eligible to do so, you may make that change as long as coverage is continuous. This change can be made any time it is financially advantageous. If you become ineligible for disability benefits, you may continue coverage on yourself and your eligible dependents as a terminated vested subscriber, retired subscriber or through COBRA (whichever is applicable), unless you return to active state employment. If coverage is not maintained while on disability, you may enroll yourself and/or your dependents at the date you are eligible for retirement benefits as long as you had other health insurance coverage for the six months immediately prior to your retirement date. Proof of other health insurance coverage is required. These provisions also apply to members of the Public School Retirement System who are eligible employees of a State agency. NOTE If you or your spouse become Medicare eligible, you must notify MCHCP and submit a copy of your and/or your spouse s Medicare card(s). continued Eligibility & Enrollment Customer Service:

67 Eligibility & Enrollment Military Leave When you go on active military leave, your coverage ends the date your coverage through the military is effective. For absence of 30 days or less, health insurance benefits continue as if you have not been absent. For absence of 31 days or more, coverage stops unless you elect to pay for COBRA coverage. If you are on leave without pay status, coverage on your dependent(s) is continued through the end of the month in which the leave begins. You or your dependent(s) are eligible to continue coverage under COBRA provisions during your military leave. If you are utilizing annual and/or compensatory balances and remain on the payroll, the dependent coverage is at the active employee rate. Active Employees: Upon return to employment, you and your previously covered dependents are eligible for immediate coverage. Coverage may be reinstated the first of the month in which you return to employment, the first of the month following your return to employment, or the first of the month following the loss of military coverage. In order for your coverage to be reinstated, you must submit the completed Change/Cancellation (M-2) form within 31 days of your return to work. Premium is due for that entire month, unless you elect coverage effective the first of the following month. If you fail to reinstate your coverage, you cannot enroll in an MCHCP plan until the next Open Enrollment. Terminated Vested Subscribers or Retirees: If you are terminated vested or retired and are activated into military service, you may elect to suspend coverage while on active duty. If you suspend your coverage, coverage for your dependents would also be suspended. The same level of coverage with the same plan may be reinstated upon discharge if application is made within 31 days of discharge. As a terminated vested or retired member, submit a copy of your active duty orders and complete a Change/Cancellation (M-2) form. When you are separated from active duty, you can re-enroll with MCHCP by submitting an official document reflecting the separation date with a Change/Cancellation (M-2) form within 31 days of your release/discharge. Coverage may be reinstated the first of the month in which you return from active duty, the first of the month following your return, or the first of the month following the loss of military coverage. If you fail to reinstate coverage within 31 days from release/discharge, you cannot enroll at a later date. Terminating Coverage You may terminate medical coverage at any time during the year. The termination takes place at the end of the month in which the form is received by MCHCP. However, if you participate in the Cafeteria plan, changes that affect your deduction must be approved by them. Contact the Cafeteria plan for additional information. If you terminate coverage, you cannot reenroll in an MCHCP plan until the next Open Enrollment.! NOTE You may NOT terminate dental and/or vision coverage on yourself or your dependents during the year unless you also termine medical coverage, terminate employment or retire. Special Notes Concerning Dependent Coverage: You cannot terminate coverage on your spouse or children of the marriage during divorce or legal separation proceedings. If you drop dependent coverage due to a divorce or legal separation, note this information on your form and supply a copy of the divorce decree. MCHCP is required to notify these dependents regarding eligibility for COBRA coverage. Therefore, you must advise MCHCP of the current address of the affected dependents. Reinstatement of Coverage After Dismissal If you are approved to return to work as a result of legal or administrative action after being terminated by a State agency covered under an MCHCP plan, you are allowed to reinstate your medical benefits retroactively to the date of your dismissal. If you are reinstated with back pay, you are responsible for paying any contribution normally made for either your coverage or your covered dependents. If you participate in the Copay Plan, no pre-existing condition limitation applies. If you are reinstated without back pay, your leave is considered a leave of absence. Consequently, you are responsible for making any State Member Handbook

68 required contribution toward the cost of your medical benefits. If you do not purchase coverage for the period between termination and reinstatement, you may regain the same level of coverage you had prior to termination. If you are a participant in the Copay Plan, the preexisting condition limitation applies if coverage lapsed more than 63 days. This does not apply if you participate in an HMO. Failure to Pay Premiums If you fail to make the necessary premium payments, your coverage and that of your dependents terminates on the last day of the month for which full premium payment was received. You may not enroll until the next Open Enrollment period. Medicare Eligible Participants If you are enrolled in Medicare, you must submit a copy of your Medicare card to MCHCP and the reason for your Medicare coverage. After your card is received in our office, you will receive an authorization to release information for Medicare form. This form enables our representatives to assist you with Medicare claims. Medicare must receive a copy of the authorization from MCHCP prior to discussing any claims problems with our representatives. Benefits payable under MCHCP plans are subject to coordination of benefits with Parts A and B of Medicare. When you are no longer actively employed, Medicare becomes your primary payor for claims. Therefore, you must take both Parts A and B to maximize your coverage. If MCHCP does not receive verification of Medicare Part B, you are responsible for the claims amount Medicare Part B would have covered. Medicare Part D is Medicare s prescription drug program. Each year MCHCP s prescription drug plan is evaluated by a third party to determine if it is creditable (considered equal to or better than Medicare Part D). You will receive notification of the outcome from MCHCP. If MCHCP s plan is considered creditable, you do not need to enroll in Medicare Part D and will not be penalized if you signup for Part D at a later date. For information on how benefits are coordinated with Medicare, call your medical plan for details. Active Employees Covered by Medicare If you are actively employed, your MCHCP plan is the primary plan for you and/or your dependents and Medicare is secondary. Retired or Vested Subscribers Covered by Medicare If you are a retired or terminated vested subscriber covered by Medicare while maintaining coverage through one of the MCHCP plans, Medicare is the primary payor and your MCHCP plan is secondary. When you and/or your spouse become Medicare eligible, you must notify MCHCP and submit a copy of your and/or your spouse s Medicare cards. To reflect your and/or your spouse s Medicare status, the cost of your MCHCP plan premium may be adjusted. Keep in mind that although the percentage amount contributed for retirees remains the same, the decrease in premium also means a decrease in the dollar amount contributed. Review information specific to Medicare eligible participants. Members Eligible for Medicare Due to End Stage Renal Disease (ESRD) If you or your dependent is eligible for Medicare solely because of end stage renal disease, your MCHCP plan is primary to Medicare during the first 30 months of Medicare eligibility. After 30 months, Medicare becomes primary and claims are submitted first to Medicare, then to your MCHCP plan. NOTE If you are enrolled in Medicare due to disability or end stage renal disease (ESRD), you must submit a copy of your Medicare card to MCHCP and the reason for your Medicare coverage. After your card is received, you will receive a Medicare Disability Questionnaire. You must submit the completed questionnaire to our office in order for your Medicare eligibility to be sent to your medical plan. Medicare Coverage for Long- Term Disability Subscribers If you are on long-term disability and eligible for Medicare, Medicare is your primary plan and your MCHCP plan is secondary. Group Health Continuation Coverage Under COBRA On April 7, 1986, a federal law, the Consolidated Omnibus Budget Reconciliation Act, (commonly known as COBRA) was enacted. continued Eligibility & Enrollment Customer Service:

69 Eligibility & Enrollment This law required that most employers sponsoring group health plans offer employees, former employees, and their families the opportunity for a temporary extension of health coverage (called continuation coverage ) at group rates in certain instances where coverage under the plan would otherwise end. Both you and your spouse should read this section carefully. As a COBRA participant, you and/or your dependents have the same health insurance benefits as an actively employed person. You are able to add dependents during Open Enrollment and for certain life events. However, if you terminate coverage, you cannot enroll at a later date. Qualifying Events - Subscriber If you are an employee of the State of Missouri covered by a group health plan offered through MCHCP, you have a right to choose this continuation coverage if you lose your group health plan coverage because of a reduction in your hours of employment or the termination of your employment (for reasons other than gross misconduct on your part). Qualifying Events - Spouse If you are the spouse of an employee covered by a group health plan offered through MCHCP, you have the right to choose continuation coverage for yourself if you lose group health coverage under a plan offered through MCHCP for any of the following reasons: The death of your spouse. A termination of your spouse s employment (for reasons other than gross misconduct) or reduction in your spouse s hours of employment with the State of Missouri. Divorce or legal separation from your spouse. Your spouse becomes entitled to Medicare. Qualifying Events - Dependent Children In the case of a dependent child of an employee covered by a group health plan offered by MCHCP, he or she has the right to continuation coverage if group health coverage under a plan offered through MCHCP is lost for any of the following reasons: The death of the employee. A termination of the employee s employment (for reasons other than gross misconduct) or reduction in your hours of employment with the State of Missouri. The employee s divorce or legal separation. The employee becomes entitled to Medicare. The dependent child ceases to be a dependent child under MCHCP s eligibility rules. Required Notifications Under the law, the employee or a family member has the responsibility to inform MCHCP of a divorce, legal separation, or a child losing dependent status under MCHCP within 60 days of the date of the event. The State of Missouri has the responsibility to notify MCHCP of the employee s death, termination, reduction of hours of employment, or Medicare entitlement. Election Period When MCHCP is notified that one of these events has occurred, MCHCP notifies you that you have the right to choose continuation coverage. Under the law, you have at least 60 days from the date you would lose coverage (because of one of the events described above) to inform MCHCP that you want continuation coverage. The initial premium payment for continuation coverage must be received within 45 days of your election of that coverage. If you choose continuation coverage, MCHCP is required to give you coverage which, at the time coverage is being provided, is identical to the coverage provided under the plan to similarly situated employees or family members. If you do not choose continuation coverage in a timely basis, your group health insurance coverage ends and is not reinstated. NOTE If you have Medicare prior to becoming eligible for COBRA coverage, you are entitled to coverage under both. However, Medicare is always primary, and COBRA is secondary. Your coverage with MCHCP shall terminate if any one of the following events occurs: You no longer meet the eligibility requirements set forth in this handbook including, without limitation, upon termination of the subscriber from employment; divorce or legal separation from the subscriber; or when a dependent child reaches the limiting age. You fail to pay required premiums. Note: In the event State Member Handbook

70 that the Plan has not received payment of premium at the end of the 31 day grace period, you will be retroactively terminated to the date covered by your last paid premium. You will be responsible for the value of services rendered after the retroactive termination date (including but not limited to the grace period). You knowingly misrepresenting or giving false information on any enrollment form which is material to the Plan s acceptance of such enrollment. You participate in fraudulent or criminal behavior, including but not limited to: Performing an act or practice that constitutes fraud or intentionally misrepresenting material facts including using your identification card to obtain goods or services which are not prescribed or ordered for you or to which you are otherwise not legally entitled. In this instance, coverage for the subscriber and all dependents will be terminated. Allowing any other person to use you your identification card to obtain services. If a dependent allows any other person to use his/her identification card to obtain services, the coverage of the dependent who allowed the misuse of the card will be terminated. If the subscriber allows any other person to use his/her identification card to obtain services, the coverage of the subscriber and his/her dependents will be terminated. Threatening or perpetrating violent acts against the Plan or an employee of the Plan. In this instance, coverage for the subscriber and all dependents will be terminated. If your coverage under this agreement is terminated under this section, all rights to receive covered services shall cease as of the date of termination. Your coverage cannot be terminated on the basis of the status of your health or the exercise of your rights under the Plan s grievance and complaint procedures. The Plan may not terminate an agreement solely for the purpose of effecting the disenrollment of an individual member for either of these reasons. If the member receives covered services after the termination of coverage, the plan may recover the contracted charges for such covered services from you or the provider, plus its cost to recover such charges, including attorneys fees. Under certain circumstances, members may be eligible for continuation of coverage benefits or to convert to another policy as described in the following section. Length of Continuation Coverage The law requires that you be given the opportunity to maintain continuation coverage for 36 months, unless you lost group health coverage because of a termination of employment or reduction in hours. In that case, the required continuation coverage period is 18 months. This 18 months may be extended for affected individuals to 36 months from termination of employment if other events (such as a death, divorce, legal separation or Medicare entitlement) occur during the 18- month period. In no event will continuation coverage last beyond 36 months from the date of the event that originally made a qualified beneficiary eligible to elect coverage. The 18 months may be extended to 29 months if a qualified beneficiary is determined by the Social Security Administration to be disabled (for Social Security disability purposes) at any time during the first 60 days of COBRA coverage. This 11-month extension is available to all individuals who are qualified beneficiaries due to a termination or reduction in hours of employment. To benefit from this extension, a qualified beneficiary must notify MCHCP of that determination within 60 days and before the end of the original 18-month period. The affected individual must also notify MCHCP within 30 days of any final determination that the individual is no longer disabled. New Dependents A child who is born to or placed for adoption with a covered member during a period of COBRA coverage is eligible to become a qualified beneficiary. In accordance with the terms of MCHCP and the requirements of federal and state laws, these qualified beneficiaries can be added to COBRA coverage upon proper notification. Refer to ENROLLMENT GUIDELINES for further details. Termination of Continuation Coverage The law also provides that continuation coverage may be cut short for any of these reasons: The State of Missouri no longer provides group health coverage to any of its employees. The premium for continuation coverage is not paid on time. continued Eligibility & Enrollment Customer Service:

71 Eligibility & Enrollment The qualified beneficiary becomes covered (after the date he or she elects COBRA coverage) under another group health plan that does not contain any exclusion or limitation with respect to any pre-existing condition he or she may have. The qualified beneficiary becomes entitled to Medicare after the date he/she elects COBRA coverage. The qualified beneficiary extends coverage for up to 29 months due to disability and there has been a final determination that the individual is no longer disabled. Premium Payment Under the law, you are responsible for payment of all applicable premiums from the date coverage was initially lost, even if the election is made after that date. In addition to the normal premium, MCHCP charges a 2% administration charge for continuation coverage. Once the initial premium payment has been received, MCHCP bills you monthly. There is a grace period of 31 days for payment of the regularly scheduled monthly premiums. Spousal Continuation Coverage (COBRA Wrap-Around) Missouri law provides that if you lose your group health insurance coverage because of a divorce, legal separation, or the death of your spouse, you may continue until age 65 if: You continue and maintain coverage under the 36 month provision of COBRA, AND You are at least 55 years old when your COBRA benefits end. Within 60 days of legal separation or the entry of a decree of dissolution of marriage or prior to the expiration of a 36 month COBRA period, the legally separated or divorced spouse who seeks such coverage shall give MCHCP written notice of the qualifying event including his/her mailing address. Within 30 days of the death of an employee whose surviving spouse is eligible for continued coverage or prior to the expiration of a 36 month COBRA period, the human resource/payroll representative shall give MCHCP written notice of the death and the mailing address of the surviving spouse. Within 14 days of receipt of the notice, MCHCP shall notify the legally separated, divorced or surviving spouse that coverage may be continued. The notice shall include: 1. A form for election to continue the coverage. 2. The amount of premiums to be charged, the method and place of payment. 3. Instructions for returning the elections form by mail within 60 days after the plan administrator mails the notice. The principal qualified beneficiary must apply for continuation coverage through the spousal continuation provisions and has to pay all of the applicable premiums. MCHCP may charge up to an additional 25% of the applicable premium. The right to continuation coverage shall terminate upon the earliest of any of the following: The failure to pay premiums when due, including any grace period allowed by the policy. The date that the State of Missouri s insurance is terminated to all group members. The date on which the legally separated, divorced or surviving spouse becomes insured under any other group health plan. The date on which the legally separated, divorced or surviving spouse remarries and becomes insured under another group health plan. The date on which the legally separated, divorced, or surviving spouse attains his/her 65th birthday State Member Handbook

72 Understand how medical, dental and vision coverage work after retirement. IN THIS SECTION If you are a retired member or are approaching retirement, read this section carefully for an understanding of how medical, dental and vision coverage work after retirement. Look for: RETIREE GUIDELINES FOR MCHCP COVERAGE. EXAMPLES OF COORDINATION OF BENEFITS BETWEEN MEDICARE AND YOUR MEDICAL PLAN THROUGH MCHCP. For complete information, it is necessary to review the entire Member Handbook.

73 Retirement Eligibility As a retiree, you may participate in an MCHCP medical, dental and/or vision plan(s) provided, at the time of termination of state employment, you were: Eligible to receive a monthly retirement benefit from either the Missouri State Employees Retirement System (MOSERS) OR from the Public School Retirement System (PSRS) for State employment, AND you have met one of the following requirements, you: Have had coverage through MCHCP since the effective date of the last Open Enrollment period. Have had other medical dental, and/or vision insurance for the six months immediately prior to termination of state employment (proof of insurance including effective dates of coverage and termination date is required). Have had coverage since first eligible. If you participate in an MCHCP plan as a retiree, your dependents may also participate if they meet one of the previously listed requirements. To participate in the dental and/or vision plan(s), you must also participate in medical. If your dependent s employer sponsored group coverage ends due to: Termination of employment or Termination of group coverage by the employer, you can add the dependent(s) to your coverage within 60 days of the loss and provide proof that the coverage was in effect for at least 12 months immediately prior to the loss. You must attach proof of the other coverage including effective dates of coverage, termination date and reason for coverage terminating. If you die as a covered retired subscriber, your dependents covered at that time are eligible to continue coverage. Refer to the COVERAGE CHANGES DUE TO DEATH section. If you and/or your dependents are not eligible to participate in MCHCP under these rules, coverage may be extended for a period of time under COBRA provisions. Refer to the COBRA section. Transferring Coverage If you are a retiree of the State, and your spouse is also either an active State employee or a retiree of the State, you may transfer coverage from under your own to your spouse s or from under your spouse s to your own coverage (provided both are eligible for coverage through MCHCP). This may be done at any time during the year that is financially advantageous for you. However, coverage must be continuous. If you terminate coverage at any time, you cannot enroll at a later date. If you are married to a State employee covered under the Missouri Departments of Conservation, Highway Patrol or Transportation (MoDOT) and you wish to cover your spouse under the MCHCP plan when you retire, you must elect coverage for your spouse at the time you retire. Your spouse cannot be enrolled at a later date, even if it is financially beneficial to do so. However, as a retiree or terminated vested subscriber, you can add dependent coverage if your dependent s employer sponsored group coverage has ended due to termination of employment or termination of group coverage by the employer. This must be done within 60 days of the loss and the coverage must have been in effect for at least 12 months immediately prior to the loss.! If you retire from PSRS, it is your responsibility to notify MCHCP. PSRS does not notify MCHCP of your retirement State Member Handbook

74 Coverage As a Retiree Participating as a Retiree To participate as a retiree, apply for coverage prior to your retirement but no later than 31 days after the date of your retirement. This also applies to currently enrolled terminated-vested subscribers who wish to continue coverage into retirement. If you are enrolled in a plan where you work as an active employee, when you retire, you must change to a plan that is available where you live. Coverage is effective on the date of your retirement. There can be no lapse in coverage. To apply for coverage, complete the Retiree Health Insurance Election (M-5) form. If you enroll under provisions of having other insurance coverage for six months, you must attach proof of the other coverage including effective dates of coverage and termination date to the Retiree Health Insurance Election (M-5) form. You may obtain this form online at ORG, or you can request one from MCHCP or your human resources/payroll office. Return the completed form and applicable attachments directly to MCHCP. As a retired member, you receive a contribution towards your premium. The remainder of the premium is deducted from your retirement check. If your retirement check is not large enough to cover the premium, you are billed each month. If you participate in the Cafeteria Plan the year of your retirement and have your premium deducted pre-tax, you can request all payroll reductions remaining at the time of retirement be deducted from your payroll. The request must be listed on your Retiree Health Insurance Election (M-5) form and submitted at least 30 days prior to your retirement. EXAMPLE If you marry after you retire, you may enroll your new spouse: 1. For coverage effective the date of your marriage, enroll your prospective spouse prior to your marriage. 2. For coverage effective after your marriage, enroll your spouse within 31 days of your marriage. Adding New Dependents After retirement, you may enroll new dependents when they are first eligible. Submit a completed Change/Cancellation form (M-2) and proof of eligibility within 31 days of the qualifying event (marriage, birth, or adoption). See ELIGIBLE DEPENDENTS section. Military Leave If you are terminated vested or retired and are activated into military service, you may elect to suspend coverage while on active duty. If you suspend your coverage, coverage for your dependents would also be suspended. The same level of coverage with the same plan may be reinstated upon discharge if application is made within 31 days of discharge. As a terminated vested or retired member, submit a copy of your active duty orders and complete a Change/Cancellation (M-2) form. When you are separated from active duty, you can re-enroll with MCHCP by submitting an official document reflecting the separation date with a Change/Cancellation (M-2) form within 31 days of your release/discharge. Coverage may be reinstated the first of the month in which you return from active duty, the first of the month following your return, or the first of the month following the loss of military coverage. If you fail to reinstate coverage within 31 days from release/ discharge, you cannot enroll at a later date. continued Retirement Customer Service:

75 Retirement 2003 Retirement Incentive Law (Provision Ends in 2008) If you retired with a retirement date effective February 1, 2003, through September 1, 2003, provisions of SB 248 dictate that you may continue your medical insurance coverage based on the active member rate. The medical incentive ends the earlier of: Five years* Eligibility for Medicare *This provision continues for five years from the effective date of this law or your retirement date, whichever is later. The earliest premium changes due to the incentive will occur July 1, 2008, unless you become eligible for Medicare. When the incentive ends, the contribution will change to reflect a percentage based on your years of service and the retiree rate. You will be notified of the rate change in a Confirmation Letter. Terminating Coverage You may terminate medical insurance coverage on yourself or your dependents at any time. However, as prescribed by State statute, if you terminate coverage on yourself and/or your dependents, you CANNOT enroll in the plan at a later date. In addition, if you terminate medical coverage, then your dental and vision coverage are also cancelled. Retirees cannot maintain dental and/or vision coverage without medical. You may only terminate dental and/or vision insurance coverage on yourself and/or your dependents: At the end of the plan year. When you terminate medical coverage. If you terminate dental and/or vision coverage, you cannot enroll in these plans at a later date. If a covered dependent dies, coverage ends on the date of death. If there is a change in your level of coverage, your premium is pro-rated the month of the death. You must submit a Change/ Cancellation (M-2) form and a copy of the death certificate to MCHCP within 31 days of the death. To obtain a copy of the form, you can contact MCHCP or download it from our website at Contribution Toward Retiree Premium As of July 1, 2002, the contribution toward retirees premiums is based on the amount of time an employee worked for the State. The contribution for a retiree is calculated using the number of full years of service as reported to MCHCP by MOSERS or PSRS (if your State service is with them) times 2.5%. The maximum percentage cannot exceed 75% and is determined by State appropriations. The current maximum is 65%. After the percentage is computed, the dollar amount is figured on the low cost plan in the region where you live. Then that amount is deducted from the total premium rate leaving the amount you must pay. NOTE If you retired prior to July 1, 2002, and the amount of the contribution based on your years of service is less than the amount that was being paid toward your premium at that date, you continue to receive the contribution amount that was in place prior to July 1, Each year for January coverage, a new calculation is run. You will receive the contribution amount that is higher State Member Handbook

76 You may access the retiree calculator on the MCHCP website or call MCHCP s Customer Service Department for assistance. The Enrollment Guide also includes examples of how to calculate the contribution amount paid toward your premium (for Retiree Only coverage). Medicare Eligible Participants As a retiree, if you or your spouse become(s) eligible for Medicare while maintaining coverage under an MCHCP plan, Medicare Part A is automatic, but you should also enroll in Medicare Part B for the maximum benefit. Notify MCHCP and submit a copy of your Medicare card(s). If you do not sign up for Medicare Part B, your MCHCP plan will reimburse your claims as if you have Part B. The cost of your MCHCP plan coverage may be adjusted because Medicare becomes your primary plan. If your contribution is based on years of service, although the percentage amount contributed remains the same, the decrease in premium also means a decrease in the dollar amount of the contribution. If you retired under the 2003 Retirement Incentive Law, the contribution will change to reflect a percentage based on your years of service and you will be charged the retiree rate. If you want Medicare coverage to begin the month in which you become age 65, you must file a Medicare application sometime during the three months prior to your 65th birthday. For more details regarding Medicare enrollment, contact your local Social Security office. If you are a retiree with Medicare as your primary insurance, you are responsible for copayment amounts. However, providers that accept Medicare cannot collect more than Medicare s reasonable charge. The payments from Medicare, the MCHCP medical plan, and the copayment cannot exceed the amount of Medicare s reasonable charge. Medicare Benefits: Coordination & Claims Benefits payable from MCHCP plans are subject to coordination of benefits. MCHCP plans work with the various group plans to make sure each pays what it should up to the total amount of medical allowable expenses. Through coordination of benefits, the cost of health care is managed by avoiding two payments for the same charge. (This provision does not apply to individual policies you may own.) Under coordination of benefits, one plan is designated as primary (which means it pays first) and the other is designated as secondary (which means it pays up to any covered expenses that are not paid by the primary plan). In some instances you may also be eligible for benefits under a third plan. When you are retired and are or become eligible for Medicare, Medicare is your primary payor except for end stage renal disease. (Refer to MEMBERS ELIGIBLE FOR MEDICARE DUE TO END STAGE RENAL DISEASE (ESRD) in the Eligibility section). Benefits of the plans are the same for active and retired members. However, in order to obtain maximum benefits, remember to follow your medical plan s guidelines. Also, refer to USING YOUR MEDICAL PLAN for more information. As the secondary payor, claims payments are based on benefits provided by MCHCP, not Medicare eligible benefits. continued Retirement Customer Service:

77 Retirement If you are retired and eligible for Medicare, take note of the following statements. (These also apply to your spouse.) To receive maximum benefits, you must be enrolled in both Medicare Parts A and B. If you are not enrolled in Medicare Parts A and B, you are responsible for the amount Medicare would have paid. Medicare is primary; your MCHCP health insurance plan is secondary. You are not subject to precertification for hospital admissions or outpatient surgical procedures. Any of your covered dependents who are not Medicare eligible are subject to the pre-certification process. HMO Claims The HMO provider files all claims with Medicare. You do not have to meet Medicare Part A or B deductibles before your medical plan pays claims. You are responsible for paying copayments and coinsurance amounts, the same as if you were an active employee, unless the payments from Medicare and your MCHCP medical plan exceed the amount of Medicare allowable charges. To further explain, you do not owe a copayment to the provider if: Your Medicare deductible has been satisfied, AND The payments made to your provider by Medicare and your MCHCP medical plan met Medicare s allowable fee. If the amount paid by Medicare and your MCHCP medical plan are less than the Medicare allowable fee, you can be charged up to the amount of your copayment. Refer to the EXAMPLES OF COORDINATION OF BENEFITS BETWEEN MEDICARE AND MEDICAL PLAN THROUGH MCHCP (FOR MEDICARE PRIMARY MEMBER) later in this section of your Handbook. Section of the Medicare Carrier Manual indicates that a provider who accepts Medicare assignments is prohibited from collecting amounts in excess of Medicare s reasonable charge (Medicare s allowable fee). If you receive care from a non-network provider and the claim is for noneligible Medicare charges, neither Medicare nor your HMO plan will pay toward the charges. Copay Plan through Coventry Health Care Network claims Network providers file claims for you. Non-network claims You may be responsible for filing the claim with Medicare. When you receive the Explanation of Medicare Benefits (EOMB), you may have to file the claim with Coventry Health Care including a copy of the EOMB.! Retiree Guidelines for MCHCP Coverage: If you terminate MCHCP coverage, you CANNOT enroll at a later date. MCHCP CANNOT cancel your insurance EXCEPT for non-payment of premiums. MCHCP rates are based on group claims experience not individual claims experience. MCHCP benefits are the same for retirees as active members. Claims payments are based on MCHCP benefits, not benefits determined to be eligible by Medicare. MCHCP emergency coverage is worldwide State Member Handbook

78 EXAMPLES OF COORDINATION OF BENEFITS Between Medicare & Medical Plan Through MCHCP (for Medicare Primary Member) Assumptions: Billed amounts are not in excess of Medicare allowable amounts, and MCHCP contracted providers were used. Example of Several Small Claims - HMO MEDICARE Billed amount for 1st office visit to PCP $ Applied to Medicare Part B deductible Amount of Medicare Part B deductible met Amount paid by Medicare Member owes prior to MCHCP coverage $ MEDICAL PLAN THROUGH MCHCP Billed amount for 1st office visit to PCP $ Copayment Amount paid by Medicare Amount paid by Medical Plan** Member owes $ Billed amount for 2nd office visit to PCP $ Applied to Medicare Part B deductible Amount of Medicare Part B deductible met Amount paid by Medicare Member owes prior to MCHCP coverage $ Billed amount for 2nd office visit to PCP $ Copayment Amount paid by Medicare Amount paid by Medical Plan** Member owes $ Billed amount for 3rd office visit to PCP $ Applied to Medicare Part B deductible Amount of Medicare Part B deductible met Amount paid by Medicare (80% of $20)* Member owes prior to MCHCP coverage $ Billed amount for 3rd office visit to PCP $ Copayment Amount paid by Medicare Amount paid by Medical Plan** Member owes $ 0 Example of One Large Claim - HMO MEDICARE Billed amount for 1st hospitalization $ 1, Applied to Medicare Part A deductible** Amount of Medicare Part A deductible met Amount paid by Medicare Member owes prior to MCHCP coverage $ MEDICAL PLAN THROUGH MCHCP Billed amount for 1st hospitalization $ 1, Copayment Amount paid by Medicare Amount paid by Medical Plan Member owes $ 0 *Once the deductible is met, Medicare pays 80% of the remaining Medicare allowable amount left. **Maximum amount paid by MCHCP = Total Bill - Copayment. Payments are based on Medicare allowable amount. Medicare Part B deductible for 2007 is $131. Medicare Part A deductible for 2007 is $992. At the time this handbook was printed, Medicare had not yet determined the deductible amounts for Retirement Customer Service:

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80 This section provides general need-to-know information. IN THIS SECTION COMPLAINTS, UTILIZATION REVIEW, GRIEVANCE PROCEDURES & APPEALS PRIVACY PRACTICES FREQUENTLY ASKED QUESTIONS DEFINITIONS