2019 plan year - mchcp.org · state members 3 all copayment and coinsurance costs shown in this...

2019 Plan YearSummary of Benefits and CoverageState Members

2 Summary of Benefits & Coverage

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019 – 12/31/2019MCHCP: Health Savings Account Plan Coverage for: Individual + Family | Plan Type: High-Deductible

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan wouldshare the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, www.mchcp.org or call

1-800-487-0771. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or otherunderlined terms see the Glossary. You can view the Glossary at http://www.mchcp.org/documents/glossary.pdf or call 1-800-487-0771 to request a copy.Important Questions Answers Why This Matters:

What is the overall deductible?

$1,650 individual/$3,300 family(network)Does not apply to preventive care$3,300 individual/$6,600 family(non-network)

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, the overall family deductiblemust be met before the plan begins to pay.

Are there services covered before you meet your deductible?

Yes. Preventive care is coveredbefore you meet your deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive serviceswithout cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there otherdeductibles for specific services?

No. You don’t have to meet other deductibles for specific services.

What is the out-of-pocket limit for this plan?

$4,950 individual/$9,900family (network)$9,900 individual/$19,800 family(non-network)

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, the overall family out-of-pocket limit must be met, unless anindividual exceeds $7,900 (network).

What is not included inthe out-of-pocket limit?

Premium, balance bill charges,penalties, health care services this plan doesn’t cover

Even though you pay these expenses, they don’t count toward the out–of–pocket limit.

Will you pay less if you use a network provider?

Yes. Contact ESI, UMR or Aetnafor a list of network providers.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network.You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral.

3State Members

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important InformationNetwork Provider

(You will pay the least)Out-of-Network Provider(You will pay the most)

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness 20% coinsurance 40% coinsurance None

Specialist visit 20% coinsurance 40% coinsurance None

Preventive care/screening/immunization

No chargeDeductible does not apply 40% coinsurance

You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. Non-network immunizations have no charge from birth to 72 months.

If you have a test

Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance None

Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance Preauthorization (PA) required. If you fail to get PA, the service may not be covered.

If you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at www.mchcp.org or by calling 1-800-487-0771

Preferred generic drugs 10% coinsurance 40% coinsurance Some prescriptions are subject to PA, quantity level limits or step therapy requirements. If you fail to follow requirements, the prescription may not be covered.

Network: No charge for preventive preferred prescriptions and flu/shingles vaccinations.

Specialty drugs must be filled through Accredo, with the exception of the first fill of drugs needed immediately. Members who go to a retail pharmacy will be charged the full discounted price of the drug.

Preferred brand drugs 20% coinsurance 40% coinsuranceNon-preferred brand drugs 40% coinsurance 50% coinsurance

Specialty drugs 20% coinsurance No coverage

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance PA required. If you fail to get PA, the service

may not be covered.Physician/surgeon fees 20% coinsurance 40% coinsurance





If you need immediate medical attention

Emergency room care 20% coinsurance20% coinsuranceafter networkdeductible

Emergency medical transportation 20% coinsurance

20% coinsuranceafter networkdeductible

PA required for non-emergent use ofemergency medical transportation. If you fail to get PA, the service may not be covered.

Urgent care 20% coinsurance20% coinsuranceafter networkdeductible

If you have a hospital stay

Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurancePA required except for an observation stay or if admitted from the ER.If you fail to get PA, the service may not be covered.

Physician/surgeon fees 20% coinsurance 40% coinsurance NoneIf you need mental health, behavioral health, or substance abuse services

Outpatient services 20% coinsurance 40% coinsurance PA required for services provided at hospital except for an observation stay. If you fail to get PA, the service may not be covered.Inpatient services 20% coinsurance 40% coinsurance

If you are pregnant

Office visits 20% coinsurance 40% coinsurance No charge for routine prenatal care.Childbirth/delivery professional services 20% coinsurance 40% coinsurance PA required for some services. If you fail to

get PA, the service may not be covered.Childbirth/delivery facility services 20% coinsurance 40% coinsurance

If you need help recovering or have other special health needs

Home health care 20% coinsurance 40% coinsurance PA required. If you fail to get PA, the service may not be covered.

Rehabilitation services 20% coinsurance 40% coinsurance PA required for some services. If you fail to get PA, the service may not be covered.Habilitation services 20% coinsurance 40% coinsurance

Skilled nursing care 20% coinsurance 40% coinsuranceLimited to 120 days per calendar year. PA required for some services. If you fail to get PA, the service may not be covered.

Durable medical equipment 20% coinsurance 40% coinsurancePA required for some services. If you fail to get PA, the service may not be covered. No charge for breast pumps.

5State Members




Hospice services 20% coinsurance 40% coinsurance PA required. If you fail to get PA, the service may not be covered.

If your child needs dental or eye care

Children’s eye exam 20% coinsurance 40% coinsurance Coverage limited to one exam/calendar year.

Children’s glasses 20% coinsurance 40% coinsurance Coverage limited to fitting of eye glasses or contact lenses following cataract surgery.

Children’s dental check-up No covered Not covered None

Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

AcupunctureCosmetic surgeryDental Care (adult)Exercise equipment

Infertility treatmentLong-term carePrivate-duty nursingRoutine foot care

Strive for Wellness® Health Center

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Bariatric SurgeryChiropractic CareHearing Aids

Non-emergency care when traveling outside the U.S. covered as a non-network benefitRoutine eye care (adult)

Weight-loss programs

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Health & Human Services, Center for Consumer Information and Insurance Oversight at 1-877-267-2323 x: 61565 or www.cciio.cms.gov.Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: UMR at 888-200-1167; Aetna at 800-245-0618; or ESI at 800-797-5754. Additionally, a consumer assistance program can help you file your appeal. Contact the Missouri Department of Insurance, 301 W. High St., Room 530, Jefferson City, MO 65101; call 800-726-7390; visit www.insurance.mo.gov; or email [email protected].

Does this plan provide Minimum Essential Coverage? Yes.If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.


Does this plan meet Minimum Value Standards? Yes.If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:[Spanish (Español): Para obtener asistencia en Español, llame al 1-800-487-0771.]

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

7State MembersThe plan would be responsible for the other costs of these EXAMPLE covered services.

Peg is Having a Baby(9 months of in-network pre-natal care and a

hospital delivery)

Mia’s Simple Fracture(in-network emergency room visit and follow up

care)

Managing Joe’s type 2 Diabetes(a year of routine in-network care of a well-

controlled condition)

The plan’s overall deductible $1,650Specialist copayment $0Hospital (facility) coinsurance 20%Other coinsurance 20%

This EXAMPLE event includes services like: Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)

Total Example Cost $12,800

In this example, Peg would pay:Cost Sharing

Deductibles $1,650Copayments $0Coinsurance $2,000

What isn’t coveredLimits or exclusions $0The total Peg would pay is $3,650


This EXAMPLE event includes services like: Primary care physician office visits (including disease education)Diagnostic tests (blood work)Prescription drugs Durable medical equipment (glucose meter)


In this example, Joe would pay:Cost Sharing

Deductibles $1,650Copayments $0Coinsurance $300

What isn’t coveredLimits or exclusions $60The total Joe would pay is $2,010


This EXAMPLE event includes services like: Emergency room care (including medical supplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy)


In this example, Mia would pay:Cost Sharing

Deductibles $1,650Copayments $0Coinsurance $60

What isn’t coveredLimits or exclusions $0The total Mia would pay is $1,710

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharingamounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.


Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019 – 12/31/2019MCHCP: PPO 750 Plan Coverage for: Individual + Family | Plan Type: PPO


1-800-487-0771. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at http://www.mchcp.org/documents/glossary.pdf or call 1-800-487-0771 to request a copy.Important Questions Answers Why This Matters:


$750 individual/$1,500 family(network)Does not apply to preventive care$1,500 individual/$3,000 family(non-network)

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.


Yes. Preventive care, nutrition counseling, certified diabetes education, preferred glucometer and test strips, and prescriptions, are covered before you meet your deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive serviceswithout cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.


No. You don’t have to meet deductibles for specific services.


$2,250 individual/$4,500family (network medical)$4,500 individual/$9,000 family(non-network medical)$4,150 individual/$8,300 family(network prescription)

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Note: there is no maximum for non-network pharmacies.


Premium, balance bill charges,penalties, health care this plan doesn’t cover


9State Members










Primary care visit to treat an injury or illness 20% coinsurance 40% coinsurance None

Specialist visit 20% coinsurance 40% coinsurance None


No charge.Deductible doesnot apply.

40% coinsurance


If you have a test

Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance None

Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance Preauthorization (PA) required. If you fail to get PA, the service may not be covered.





If you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at www.mchcp.org or by calling 1-800-487-0771

Preferred generic drugs

$10/$20/$30copayment for upto 31/60/90 days(retail)$25 copayment61 to 90 days(mail order)

You pay full priceof prescription andfile claim.

You are reimbursedthe cost of thedrug based on thenetwork discountedamount, less theapplicable networkcopayment.

Some prescriptions are subject to PA, quantity level limits or step therapy requirements. If you fail to follow requirements, the prescription may not be covered.

Network: No charge for preventive preferredprescriptions and flu/ shingles vaccinations.

If members purchase a brand-name drug when a generic is available, they pay the generic copayment plus the difference in the cost of the drugs.

Preferred brand drugs


Non-preferred brand drugs


Specialty drugs $75 for up to31 days No coverage

Specialty drugs must be filled through Accredo, with the exception of the first fill of drugs needed immediately. Members who go to a retail pharmacy will be charged the full discounted price.




11State Members


Emergency room care$250 copaymentplus 20%coinsurance

$250 copaymentplus 20%coinsurance afternetwork deductible

Copayment applies to the out-of-pocket maximum, but not the deductible. The copayment is waived if admitted to the hospital or if the service is considered a “true emergency”.



PA required for non-emergent use of emergency medical transportation. If you fail toget PA, the service may not be covered.

Urgent care 20% coinsurance20% coinsuranceafter networkdeductible

None


Facility fee (e.g., hospital room)$200 copaymentplus 20%coinsurance

$200 copaymentplus 40%coinsurance

PA required except for an observation stay or if admitted from the ER. If you fail to get PA, the service may not be covered.

Physician/surgeon fees 20% coinsurance 40% coinsurance None

If you need mental health, behavioralhealth, or substance abuse services

Outpatient services 20% coinsurance 40% coinsurance PA required for services provided at hospital except for an observation stay. If you fail to get PA, the service may not be covered.Inpatient services



If you are pregnant

Office visits 20% coinsurance 40% coinsurance No charge for routine prenatal care.Childbirth/delivery professional services 20% coinsurance 40% coinsurance PA required for some services. If you fail to get

PA, the service may not be covered.Childbirth/delivery facility services 20% coinsurance 40% coinsurance



Rehabilitation services 20% coinsurance 40% coinsurance PA required for some services. If you fail to getPA, the service may not be covered.Habilitation services 20% coinsurance 40% coinsurance






Children’s eye exam 20% coinsurance 40% coinsurance Coverage limited to one exam/calendar year.

Children’s glasses 20% coinsurance 40% coinsurance Coverage limited to fitting of eye glasses or contact lenses following cataract surgery.

Children’s dental check-up Not covered Not covered None


AcupunctureCosmetic surgeryDental Care (adult)Exercise equipment

Infertility treatmentLong-term carePrivate-duty nursingRoutine foot care


Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Bariatric surgeryChiropractic careHearing aids

Non-emergency care when traveling outsideThe U.S. covered as a non-network benefitRoutine eye care (adult)


Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Health & Human Services, Center for Consumer Information and Insurance Oversight at 1-877-267-2323 x: 61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.



13State Members




14 Coverage ExamplesThe plan would be responsible for the other costs of these EXAMPLE covered services.


hospital delivery)


care)



The plan’s overall deductible $750Specialist copayment $0Hospital (facility) copayment $200Other coinsurance 20%




Deductibles $750Copayments $300Coinsurance $1,300






Deductibles $750Copayments $1,000Coinsurance $90






Deductibles $750Copayments $0Coinsurance $200

What isn’t coveredLimits or exclusions $0The total Mia would pay is $950



15State Members

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019 – 12/31/2019MCHCP: PPO 1250 Plan Coverage for: Individual + Family | Plan Type: PPO


1-800-487-0771. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at http://www.mchcp.org/documents/glossary.pdf or call 1-800-487-0771 to request a copy.Important Questions Answers Why This Matters:


$1,250 individual/$2,500 family(network)Does not apply to preventive care$2,500 individual/$5,000 family(non-network)

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.


Yes. Preventive care, office visits, nutrition counseling, certified diabetes education, preferredglucometer and test strips, and prescriptions, are covered before you meet your deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. Buta copayment or coinsurance may apply. For example, this plan covers certain preventive serviceswithout cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.


No. You don’t have to meet deductibles for specific services.


$3,750 individual/$7,500family (network medical, includescopayments)$7,500 individual/$15,000 family(non-network medical)$4,150 individual/$8,300 family(network prescription)

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Note: there is no maximum for non-network pharmacies.


Premium, balance bill charges,penalties, health care this plan doesn’t cover












Primary care visit to treat an injury or illness

$25 copaymentand/or 20%coinsurance

40% coinsuranceCopayment covers office visit only. Coinsurance will be applied to lab, X-ray or other services associated with the visit.

Chiropractor copayment may be less than $20 if it is more than 50% of the total cost of the service.

Preauthorization (PA) required for some visits. If you fail to get PA, the service may not be covered.

Specialist visit$40 copaymentand/or 20%coinsurance

40% coinsurance


No charge.Deductible doesnot apply.

40% coinsurance


If you have a test Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance None

17State Members




Imaging (CT/PET scans, MRIs) 10% coinsurance 40% coinsurance PA required. If you fail to get PA, the service may not be covered.

If you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at www.mchcp.org

Preferred generic drugs


You pay full priceof prescription andfile claim.

You are reimbursedthe cost of the drug based on thenetwork discountedamount, lessthe applicablecopayment.

Some prescriptions are subject to PA, quantity level limits or step therapy requirements. If you fail to follow requirements, the prescription may not be covered.

Network: No charge for preventive preferredprescriptions and flu/ shingles vaccinations

If members purchase a brand-name drug when a generic is available, they pay the generic copayment plus the difference in the cost of the drugs.

Preferred brand drugs


Non-preferred brand drugs


Specialty drugs $75 for up to31 days No coverage

Specialty drugs must be filled through Accredo, with the exception of the first fill of drugs needed immediately. Members who go to a retail pharmacy will be charged the full discounted price.






Emergency room care$250 copaymentplus 20%coinsurance

$250 copaymentplus 20%coinsurance afternetwork deductible

Copayment applies to the out-of-pocket maximum, but not the deductible. The copayment is waived if admitted to the hospital or if the service is considered a “true emergency”.



PA required for non-emergent use of emergency medical transportation. If you fail to get PA, the service may not be covered.

Urgent care$50 copaymentand/or 20%coinsurance

$50 copaymentand/or 20%coinsurance afternetwork deductible

Copayment covers office visit only. Coinsurance will be applied to lab, X-ray or other services associated with the visit.


Facility fee (e.g., hospital room)$200 copaymentplus 20%coinsurance


PA required except for an observation stay or if admitted from the ER. If you fail to get PA, the service may not be covered.

Physician/surgeon fees 20% coinsurance 40% coinsurance None

If you need mental health, behavioral health, or substance abuse services

Outpatient services$25 copaymentand/or 20%coinsurance

40% coinsuranceCopayment covers office visit only. Coinsurance will be applied to lab, X-ray or other services associated with the visit.

PA required for services provided at hospital except for an observation stay. If you fail to getPA, the service may not be covered.

Inpatient services$200 copaymentplus 20%coinsurance


If you are pregnant

Office visits$25 copaymentplus 20%coinsurance

40% coinsurance No charge for routine prenatal care.

Childbirth/delivery professional services 20% coinsurance 40% coinsurance PA required for some services. If you fail to get

PA, the service may not be covered.Childbirth/delivery facility services 20% coinsurance 40% coinsurance

19State Members



Rehabilitation services 20% coinsurance 40% coinsurance PA required for some services. If you fail to get PA, the service may not be covered.Habilitation services 20% coinsurance 40% coinsurance





Children’s eye exam$40 copaymentand/or 10%coinsurance

40% coinsurance

Copayment covers office visit only. Coinsurance will be applied to lab, X-ray or other services associated with the visit.

Coverage limited to one exam/calendar year.

Children’s glasses 10% coinsurance 40% coinsurance Coverage limited to fitting of eye glasses or contact lenses following cataract surgery

Children’s dental check-up No covered Not covered None


AcupunctureCosmetic surgeryDental Care (adult) Exercise equipment

Infertility treatmentLong-term care Private-duty nursingRoutine foot care


Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Bariatric surgery Chiropractic careHearing Aids

Non-emergency care when traveling outsidethe U.S. covered as a non-network benefitRoutine eye care (adult)



Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Health & Human Services, Center for Consumer Information and Insurance Oversight at 1-877-267-2323 x: 61565 or www.cciio.cms.gov.Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.






21State Members


hospital delivery)


care)







Deductibles $1250Copayments $300Coinsurance $2,000






Deductibles $500Copayments $1,200Coinsurance $0






Deductibles $1250Copayments $30Coinsurance $100

What isn’t coveredLimits or exclusions $0The total Mia would pay is $1380



The plan would be responsible for the other costs of these EXAMPLE covered services.


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aini

ng $

90.

Thi

s hap

pens

mos

t ofte

n w

hen

you

see

an o

ut-o

f-ne

twor

k pr

ovid

er (n

on-p

refe

rred

pr

ovid

er).

A n

etw

ork

prov

ider

(pre

ferr

ed p

rovi

der)

may

no

t bill

you

for c

over

ed se

rvic

es.

Cla

im

A re

ques

t for

a b

enef

it (in

clud

ing

reim

burs

emen

t of a

he

alth

car

e ex

pens

e) m

ade

by y

ou o

r you

r hea

lth c

are

prov

ider

to y

our h

ealth

insu

rer o

r pla

n fo

r ite

ms o

r se

rvic

es y

ou th

ink

are

cove

red.

C

oins

uran

ce

You

r sha

re o

f the

cos

ts

of a

cov

ered

hea

lth c

are

serv

ice,

calc

ulat

ed a

s a

perc

enta

ge (f

or

exam

ple,

20%

) of t

he

allo

wed

am

ount

for t

he

serv

ice.

You

gen

eral

ly

pay

coin

sura

nce

plus

an

y de

duct

ible

s you

ow

e. (F

or e

xam

ple,

if th

e he

alth

in

sura

nce

or p

lan’

s allo

wed

am

ount

for a

n of

fice

visit

is

$100

and

you

’ve m

et y

our d

educ

tible

, you

r coi

nsur

ance

pa

ymen

t of 2

0% w

ould

be

$20.

The

hea

lth in

sura

nce

or

plan

pay

s the

rest

of t

he a

llow

ed a

mou

nt.)

Com

plic

atio

ns o

f Pre

gnan

cy

Con

ditio

ns d

ue to

pre

gnan

cy, l

abor

, and

del

iver

y th

at

requ

ire m

edic

al c

are

to p

reve

nt se

rious

har

m to

the

heal

th

of th

e m

othe

r or t

he fe

tus.

Mor

ning

sick

ness

and

a n

on-

emer

genc

y ca

esar

ean

sect

ion

gene

rally

are

n’t

com

plic

atio

ns o

f pre

gnan

cy.

Cop

aym

ent

A fi

xed

amou

nt (f

or e

xam

ple,

$15)

you

pay

for a

cov

ered

he

alth

car

e se

rvic

e, us

ually

whe

n yo

u re

ceiv

e th

e se

rvic

e.

The

am

ount

can

var

y by

the

type

of c

over

ed h

ealth

car

e se

rvic

e.

Cos

t Sha

ring

You

r sha

re o

f cos

ts fo

r ser

vice

s tha

t a p

lan

cove

rs th

at

you

mus

t pay

out

of y

our o

wn

pock

et (s

omet

imes

cal

led

“out

-of-

pock

et c

osts

”).

Som

e ex

ampl

es o

f cos

t sha

ring

are

copa

ymen

ts, d

educ

tible

s, an

d co

insu

ranc

e. F

amily

co

st sh

arin

g is

the

shar

e of

cos

t for

ded

uctib

les a

nd o

ut-

of-p

ocke

t cos

ts y

ou a

nd y

our s

pous

e an

d/or

chi

ld(r

en)

mus

t pay

out

of y

our o

wn

pock

et.

Oth

er c

osts

, inc

ludi

ng

your

pre

miu

ms,

pena

lties

you

may

hav

e to

pay

, or t

he

cost

of c

are

a pl

an d

oesn

’t co

ver u

sual

ly a

ren’

t con

sider

ed

cost

shar

ing.

C

ost-

shar

ing

Red

uctio

ns

Disc

ount

s tha

t red

uce

the

amou

nt y

ou p

ay fo

r cer

tain

se

rvic

es c

over

ed b

y an

indi

vidu

al p

lan

you

buy

thro

ugh

the

Mar

ketp

lace

. Y

ou m

ay g

et a

disc

ount

if y

our i

ncom

e is

belo

w a

cer

tain

leve

l, an

d yo

u ch

oose

a S

ilver

leve

l he

alth

pla

n or

if y

ou're

a m

embe

r of a

fede

rally

-re

cogn

ized

trib

e, w

hich

incl

udes

bei

ng a

shar

ehol

der i

n an

A

lask

a N

ativ

e C

laim

s Set

tlem

ent A

ct c

orpo

ratio

n.

(See

pag

e 6

for a

det

aile

d ex

ampl

e.)

Jane

pay

s 20

%

Her

pla

n pa

ys

80%

23State Members

Glo

ssar

y of

Hea

lth C

over

age

and

Med

ical

Ter

ms

Page

2 of

6

Ded

uctib

le

An

amou

nt y

ou c

ould

ow

e du

ring

a co

vera

ge p

erio

d (u

sual

ly o

ne y

ear)

for

cove

red

heal

th c

are

serv

ices

bef

ore

your

pla

n be

gins

to p

ay.

An

over

all

dedu

ctib

le a

pplie

s to

all o

r al

mos

t all

cove

red

item

s an

d se

rvic

es.

A p

lan

with

an

ove

rall

dedu

ctib

le m

ay

also

hav

e se

para

te d

educ

tible

s tha

t app

ly to

spec

ific

serv

ices

or g

roup

s of s

ervi

ces.

A p

lan

may

also

hav

e on

ly

sepa

rate

ded

uctib

les.

(For

exa

mpl

e, if

your

ded

uctib

le is

$1

000,

you

r pla

n w

on’t

pay

anyt

hing

unt

il yo

u’ve

met

yo

ur $

1000

ded

uctib

le fo

r cov

ered

hea

lth c

are

serv

ices

su

bjec

t to

the

dedu

ctib

le.)

D

iagn

ostic

Tes

t T

ests

to fi

gure

out

wha

t you

r hea

lth p

robl

em is

. Fo

r ex

ampl

e, an

x-r

ay c

an b

e a

diag

nost

ic te

st to

see

if yo

u ha

ve a

bro

ken

bone

. D

urab

le M

edic

al E

quip

men

t (D

ME)

Eq

uipm

ent a

nd su

pplie

s ord

ered

by

a he

alth

car

e pr

ovid

er

for e

very

day

or e

xten

ded

use.

DM

E m

ay in

clud

e: ox

ygen

eq

uipm

ent,

whe

elch

airs

, and

cru

tche

s. Em

erge

ncy

Med

ical

Con

ditio

n A

n ill

ness

, inj

ury,

sym

ptom

(inc

ludi

ng se

vere

pai

n), o

r co

nditi

on se

vere

eno

ugh

to ri

sk se

rious

dan

ger t

o yo

ur

heal

th if

you

did

n’t g

et m

edic

al a

ttent

ion

right

aw

ay.

If

you

didn

’t ge

t im

med

iate

med

ical

atte

ntio

n yo

u co

uld

reas

onab

ly e

xpec

t one

of t

he fo

llow

ing:

1) Y

our h

ealth

w

ould

be

put i

n se

rious

dan

ger;

or 2

) You

wou

ld h

ave

serio

us p

robl

ems w

ith y

our b

odily

func

tions

; or 3

) You

w

ould

hav

e se

rious

dam

age

to a

ny p

art o

r org

an o

f you

r bo

dy.

Emer

genc

y M

edic

al T

rans

port

atio

n A

mbu

lanc

e se

rvic

es fo

r an

emer

genc

y m

edic

al c

ondi

tion.

T

ypes

of e

mer

genc

y m

edic

al tr

ansp

orta

tion

may

incl

ude

tran

spor

tatio

n by

air,

land

, or s

ea.

You

r pla

n m

ay n

ot

cove

r all

type

s of e

mer

genc

y m

edic

al tr

ansp

orta

tion,

or

may

pay

less

for c

erta

in ty

pes.

Em

erge

ncy

Roo

m C

are

/ Em

erge

ncy

Serv

ices

Se

rvic

es to

che

ck fo

r an

emer

genc

y m

edic

al c

ondi

tion

and

trea

t you

to k

eep

an e

mer

genc

y m

edic

al c

ondi

tion

from

ge

tting

wor

se.

The

se se

rvic

es m

ay b

e pr

ovid

ed in

a

licen

sed

hosp

ital’s

em

erge

ncy

room

or o

ther

pla

ce th

at

prov

ides

car

e fo

r em

erge

ncy

med

ical

con

ditio

ns.

Excl

uded

Ser

vice

s H

ealth

car

e se

rvic

es th

at y

our p

lan

does

n’t p

ay fo

r or

cove

r. Fo

rmul

ary

A li

st o

f dru

gs y

our p

lan

cove

rs.

A fo

rmul

ary

may

in

clud

e ho

w m

uch

your

shar

e of

the

cost

is fo

r eac

h dr

ug.

You

r pla

n m

ay p

ut d

rugs

in d

iffer

ent c

ost s

harin

g le

vels

or ti

ers.

For

exa

mpl

e, a

form

ular

y m

ay in

clud

e ge

neric

dr

ug a

nd b

rand

nam

e dr

ug ti

ers a

nd d

iffer

ent c

ost s

harin

g am

ount

s will

app

ly to

eac

h tie

r.

Grie

vanc

e A

com

plai

nt th

at y

ou c

omm

unic

ate

to y

our h

ealth

insu

rer

or p

lan.

H

abili

tatio

n Se

rvic

es

Hea

lth c

are

serv

ices

that

hel

p a

pers

on k

eep,

lear

n or

im

prov

e sk

ills a

nd fu

nctio

ning

for d

aily

livi

ng.

Exam

ples

in

clud

e th

erap

y fo

r a c

hild

who

isn’

t wal

king

or t

alki

ng a

t th

e ex

pect

ed a

ge.

The

se se

rvic

es m

ay in

clud

e ph

ysic

al

and

occu

patio

nal t

hera

py, s

peec

h-la

ngua

ge p

atho

logy

, an

d ot

her s

ervi

ces f

or p

eopl

e w

ith d

isabi

litie

s in

a va

riety

of

inpa

tient

and

or o

utpa

tient

setti

ngs.

H

ealth

Insu

ranc

e A

con

trac

t tha

t req

uire

s a h

ealth

insu

rer t

o pa

y so

me

or

all o

f you

r hea

lth c

are

cost

s in

exch

ange

for a

pre

miu

m.

A h

ealth

insu

ranc

e co

ntra

ct m

ay a

lso b

e ca

lled

a “p

olic

y”

or “

plan

”.

Hom

e H

ealth

Car

e H

ealth

car

e se

rvic

es a

nd su

pplie

s you

get

in y

our h

ome

unde

r you

r doc

tor’s

ord

ers.

Ser

vice

s may

be

prov

ided

by

nurs

es, t

hera

pist

s, so

cial

wor

kers

, or o

ther

lice

nsed

hea

lth

care

pro

vide

rs.

Hom

e he

alth

car

e us

ually

doe

sn’t

incl

ude

help

with

non

-med

ical

task

s, su

ch a

s coo

king

, cle

anin

g, o

r dr

ivin

g.

Hos

pice

Ser

vice

s Se

rvic

es to

pro

vide

com

fort

and

supp

ort f

or p

erso

ns in

th

e la

st st

ages

of a

term

inal

illn

ess a

nd th

eir f

amili

es.

Hos

pita

lizat

ion

Car

e in

a h

ospi

tal t

hat r

equi

res a

dmiss

ion

as a

n in

patie

nt

and

usua

lly re

quire

s an

over

nigh

t sta

y. S

ome

plan

s may

co

nsid

er a

n ov

erni

ght s

tay

for o

bser

vatio

n as

out

patie

nt

care

inst

ead

of in

patie

nt c

are.

Hos

pita

l Out

patie

nt C

are

Car

e in

a h

ospi

tal t

hat u

sual

ly d

oesn

’t re

quire

an

over

nigh

t sta

y.

(See

pag

e 6

for a

det

aile

d ex

ampl

e.)

Jane

pay

s 10

0%

Her

pla

n pa

ys

0%


Glo

ssar

y of

Hea

lth C

over

age

and

Med

ical

Ter

ms

Page

3 of

6

Indi

vidu

al R

espo

nsib

ility

Req

uire

men

t So

met

imes

cal

led

the

“ind

ivid

ual m

anda

te”,

the

duty

you

m

ay h

ave

to b

e en

rolle

d in

hea

lth c

over

age

that

pro

vide

s m

inim

um e

ssen

tial c

over

age.

If y

ou d

on’t

have

min

imum

es

sent

ial c

over

age,

you

may

hav

e to

pay

a p

enal

ty w

hen

you

file

your

fede

ral i

ncom

e ta

x re

turn

unl

ess y

ou q

ualif

y fo

r a h

ealth

cov

erag

e ex

empt

ion.

In

-net

wor

k C

oins

uran

ce

You

r sha

re (f

or e

xam

ple,

20%

) of t

he a

llow

ed a

mou

nt

for c

over

ed h

ealth

care

serv

ices

. Y

our s

hare

is u

sual

ly

low

er fo

r in-

netw

ork

cove

red

serv

ices

. In

-net

wor

k C

opay

men

t A

fixe

d am

ount

(for

exa

mpl

e, $1

5) y

ou p

ay fo

r cov

ered

he

alth

car

e se

rvic

es to

pro

vide

rs w

ho c

ontr

act w

ith y

our

heal

th in

sura

nce

or p

lan.

In-

netw

ork

copa

ymen

ts u

sual

ly

are

less

than

out

-of-

netw

ork

copa

ymen

ts.

Mar

ketp

lace

A

mar

ketp

lace

for h

ealth

insu

ranc

e w

here

indi

vidu

als,

fam

ilies

and

smal

l bus

ines

ses c

an le

arn

abou

t the

ir pl

an

optio

ns; c

ompa

re p

lans

bas

ed o

n co

sts,

bene

fits a

nd o

ther

im

port

ant f

eatu

res;

appl

y fo

r and

rece

ive

finan

cial

hel

p w

ith p

rem

ium

s and

cos

t sha

ring

base

d on

inco

me;

and

choo

se a

pla

n an

d en

roll

in c

over

age.

Also

kno

wn

as a

n “E

xcha

nge”

. T

he M

arke

tpla

ce is

run

by th

e st

ate

in so

me

stat

es a

nd b

y th

e fe

dera

l gov

ernm

ent i

n ot

hers

. In

som

e st

ates

, the

Mar

ketp

lace

also

hel

ps e

ligib

le c

onsu

mer

s en

roll

in o

ther

pro

gram

s, in

clud

ing

Med

icai

d an

d th

e C

hild

ren’

s Hea

lth In

sura

nce

Prog

ram

(CH

IP).

Ava

ilabl

e on

line,

by p

hone

, and

in-p

erso

n.

Max

imum

Out

-of-

pock

et L

imit

Yea

rly a

mou

nt th

e fe

dera

l gov

ernm

ent s

ets a

s the

mos

t ea

ch in

divi

dual

or f

amily

can

be

requ

ired

to p

ay in

cos

t sh

arin

g du

ring

the

plan

yea

r for

cov

ered

, in-

netw

ork

serv

ices

. A

pplie

s to

mos

t typ

es o

f hea

lth p

lans

and

in

sura

nce.

Thi

s am

ount

may

be

high

er th

an th

e ou

t-of

-po

cket

lim

its st

ated

for y

our p

lan.

M

edic

ally

Nec

essa

ry

Hea

lth c

are

serv

ices

or s

uppl

ies n

eede

d to

pre

vent

, di

agno

se, o

r tre

at a

n ill

ness

, inj

ury,

con

ditio

n, d

iseas

e, or

its

sym

ptom

s, in

clud

ing

habi

litat

ion,

and

that

mee

t ac

cept

ed st

anda

rds o

f med

icin

e.

Min

imum

Ess

entia

l Cov

erag

e H

ealth

cov

erag

e th

at w

ill m

eet t

he in

divi

dual

re

spon

sibili

ty re

quire

men

t. M

inim

um e

ssen

tial c

over

age

gene

rally

incl

udes

pla

ns, h

ealth

insu

ranc

e av

aila

ble

thro

ugh

the

Mar

ketp

lace

or o

ther

indi

vidu

al m

arke

t po

licie

s, M

edic

are,

Med

icai

d, C

HIP

, TR

ICA

RE,

and

ce

rtai

n ot

her c

over

age.

M

inim

um V

alue

Sta

ndar

d A

bas

ic st

anda

rd to

mea

sure

the

perc

ent o

f per

mitt

ed

cost

s the

pla

n co

vers

. If

you

’re o

ffer

ed a

n em

ploy

er p

lan

that

pay

s for

at l

east

60%

of t

he to

tal a

llow

ed c

osts

of

bene

fits,

the

plan

off

ers m

inim

um v

alue

and

you

may

not

qu

alify

for p

rem

ium

tax

cred

its a

nd c

ost s

harin

g re

duct

ions

to b

uy a

pla

n fr

om th

e M

arke

tpla

ce.

N

etw

ork

The

faci

litie

s, pr

ovid

ers a

nd su

pplie

rs y

our h

ealth

insu

rer

or p

lan

has c

ontr

acte

d w

ith to

pro

vide

hea

lth c

are

serv

ices

. N

etw

ork

Prov

ider

(Pre

ferr

ed P

rovi

der)

A

pro

vide

r who

has

a c

ontr

act w

ith y

our h

ealth

insu

rer o

r pl

an w

ho h

as a

gree

d to

pro

vide

serv

ices

to m

embe

rs o

f a

plan

. Y

ou w

ill p

ay le

ss if

you

see

a pr

ovid

er in

the

netw

ork.

Also

cal

led

“pre

ferr

ed p

rovi

der”

or

“par

ticip

atin

g pr

ovid

er.”

O

rtho

tics a

nd P

rost

hetic

s Le

g, a

rm, b

ack

and

neck

bra

ces,

artif

icia

l leg

s, ar

ms,

and

eyes

, and

ext

erna

l bre

ast p

rost

hese

s afte

r a m

aste

ctom

y.

The

se se

rvic

es in

clud

e: ad

just

men

t, re

pairs

, and

re

plac

emen

ts re

quire

d be

caus

e of

bre

akag

e, w

ear,

loss

, or

a ch

ange

in th

e pa

tient

’s ph

ysic

al c

ondi

tion.

O

ut-o

f-ne

twor

k C

oins

uran

ce

You

r sha

re (f

or e

xam

ple,

40%

) of t

he a

llow

ed a

mou

nt

for c

over

ed h

ealth

car

e se

rvic

es to

pro

vide

rs w

ho d

on’t

cont

ract

with

you

r hea

lth in

sura

nce

or p

lan.

Out

-of-

netw

ork

coin

sura

nce

usua

lly c

osts

you

mor

e th

an in

-ne

twor

k co

insu

ranc

e.

Out

-of-

netw

ork

Cop

aym

ent

A fi

xed

amou

nt (f

or e

xam

ple,

$30)

you

pay

for c

over

ed

heal

th c

are

serv

ices

from

pro

vide

rs w

ho d

o no

t con

trac

t w

ith y

our h

ealth

insu

ranc

e or

pla

n. O

ut-o

f-ne

twor

k co

paym

ents

usu

ally

are

mor

e th

an in

-net

wor

k co

paym

ents

.

25State Members

Glo

ssar

y of

Hea

lth C

over

age

and

Med

ical

Ter

ms

Page

4 of

6

Out

-of-

netw

ork

Prov

ider

(Non

-Pre

ferr

ed

Prov

ider

) A

pro

vide

r who

doe

sn’t

have

a c

ontr

act w

ith y

our p

lan

to

prov

ide

serv

ices

. If

you

r pla

n co

vers

out

-of-

netw

ork

serv

ices

, you

’ll u

sual

ly p

ay m

ore

to se

e an

out

-of-

netw

ork

prov

ider

than

a p

refe

rred

pro

vide

r. Y

our p

olic

y w

ill

expl

ain

wha

t tho

se c

osts

may

be.

May

also

be

calle

d “n

on-p

refe

rred

” or

“no

n-pa

rtic

iapt

ing”

inst

ead

of “

out-

of-n

etw

ork

prov

ider

”.

Out

-of-

pock

et L

imit

The

mos

t you

coul

d pa

y du

ring

a co

vera

ge

perio

d (u

sual

ly o

ne y

ear)

fo

r you

r sha

re o

f the

co

sts o

f cov

ered

se

rvic

es.

Afte

r you

m

eet t

his l

imit

the

pl

an w

ill u

sual

ly p

ay

100%

of t

he

allo

wed

am

ount

. T

his l

imit

help

s you

pla

n fo

r hea

lth

care

cos

ts.

Thi

s lim

it ne

ver i

nclu

des y

our p

rem

ium

, ba

lanc

e-bi

lled

char

ges o

r hea

lth c

are

your

pla

n do

esn’

t co

ver.

Som

e pl

ans d

on’t

coun

t all

of y

our c

opay

men

ts,

dedu

ctib

les,

coin

sura

nce

paym

ents

, out

-of-

netw

ork

paym

ents

, or o

ther

exp

ense

s tow

ard

this

limit.

Ph

ysic

ian

Serv

ices

H

ealth

car

e se

rvic

es a

lice

nsed

med

ical

phy

sicia

n,

incl

udin

g an

M.D

. (M

edic

al D

octo

r) o

r D.O

. (D

octo

r of

Ost

eopa

thic

Med

icin

e), p

rovi

des o

r coo

rdin

ates

. Pl

an

Hea

lth c

over

age

issue

d to

you

dire

ctly

(ind

ivid

ual p

lan)

or

thro

ugh

an e

mpl

oyer

, uni

on o

r oth

er g

roup

spon

sor

(em

ploy

er g

roup

pla

n) th

at p

rovi

des c

over

age

for c

erta

in

heal

th c

are

cost

s. A

lso c

alle

d "h

ealth

insu

ranc

e pl

an",

"p

olic

y", "

heal

th in

sura

nce

polic

y" o

r "he

alth

in

sura

nce"

. Pr

eaut

horiz

atio

n A

dec

ision

by

your

hea

lth in

sure

r or p

lan

that

a h

ealth

ca

re se

rvic

e, tr

eatm

ent p

lan,

pre

scrip

tion

drug

or d

urab

le

med

ical

equ

ipm

ent (

DM

E) is

med

ical

ly n

eces

sary

. So

met

imes

cal

led

prio

r aut

horiz

atio

n, p

rior a

ppro

val o

r pr

ecer

tific

atio

n. Y

our h

ealth

insu

ranc

e or

pla

n m

ay

requ

ire p

reau

thor

izat

ion

for c

erta

in se

rvic

es b

efor

e yo

u re

ceiv

e th

em, e

xcep

t in

an e

mer

genc

y. P

reau

thor

izat

ion

isn’t

a pr

omise

you

r hea

lth in

sura

nce

or p

lan

will

cov

er

the

cost

.

Prem

ium

T

he a

mou

nt th

at m

ust b

e pa

id fo

r you

r hea

lth in

sura

nce

or p

lan.

You

and

or y

our e

mpl

oyer

usu

ally

pay

it

mon

thly

, qua

rter

ly, o

r yea

rly.

Prem

ium

Tax

Cre

dits

Fi

nanc

ial h

elp

that

low

ers y

our t

axes

to h

elp

you

and

your

fam

ily p

ay fo

r priv

ate

heal

th in

sura

nce.

You

can

get

th

is he

lp if

you

get

hea

lth in

sura

nce

thro

ugh

the

Mar

ketp

lace

and

you

r inc

ome

is be

low

a c

erta

in le

vel.

A

dvan

ce p

aym

ents

of t

he ta

x cr

edit

can

be u

sed

right

aw

ay to

low

er y

our m

onth

ly p

rem

ium

cos

ts.

Pres

crip

tion

Dru

g C

over

age

Cov

erag

e un

der a

pla

n th

at h

elps

pay

for p

resc

riptio

n dr

ugs.

If th

e pl

an’s

form

ular

y us

es “

tiers

” (le

vels)

, pr

escr

iptio

n dr

ugs a

re g

roup

ed to

geth

er b

y ty

pe o

r cos

t.

The

am

ount

you

'll p

ay in

cos

t sha

ring

will

be

diff

eren

t fo

r eac

h "t

ier"

of c

over

ed p

resc

riptio

n dr

ugs.

Pres

crip

tion

Dru

gs

Dru

gs a

nd m

edic

atio

ns th

at b

y la

w re

quire

a p

resc

riptio

n.

Prev

entiv

e C

are

(Pre

vent

ive

Serv

ice)

R

outin

e he

alth

car

e, in

clud

ing

scre

enin

gs, c

heck

-ups

, and

pa

tient

cou

nsel

ing,

to p

reve

nt o

r disc

over

illn

ess,

dise

ase,

or o

ther

hea

lth p

robl

ems.

Pr

imar

y C

are

Phys

icia

n A

phy

sicia

n, in

clud

ing

an M

.D. (

Med

ical

Doc

tor)

or

D.O

. (D

octo

r of O

steo

path

ic M

edic

ine)

, who

pro

vide

s or

coo

rdin

ates

a ra

nge

of h

ealth

car

e se

rvic

es fo

r you

. Pr

imar

y C

are

Prov

ider

A

phy

sicia

n, in

clud

ing

an M

.D. (

Med

ical

Doc

tor)

or

D.O

. (D

octo

r of O

steo

path

ic M

edic

ine)

, nur

se

prac

titio

ner,

clin

ical

nur

se sp

ecia

list,

or p

hysic

ian

assis

tant

, as a

llow

ed u

nder

stat

e la

w a

nd th

e te

rms o

f the

pl

an, w

ho p

rovi

des,

coor

dina

tes,

or h

elps

you

acc

ess a

ra

nge

of h

ealth

car

e se

rvic

es.

Prov

ider

A

n in

divi

dual

or f

acili

ty th

at p

rovi

des h

ealth

car

e se

rvic

es.

Som

e ex

ampl

es o

f a p

rovi

der i

nclu

de a

doc

tor,

nurs

e, ch

iropr

acto

r, ph

ysic

ian

assis

tant

, hos

pita

l, su

rgic

al c

ente

r, sk

illed

nur

sing

faci

lity,

and

reha

bilit

atio

n ce

nter

. T

he

plan

may

requ

ire th

e pr

ovid

er to

be

licen

sed,

cer

tifie

d, o

r ac

cred

ited

as re

quire

d by

stat

e la

w.

(See

pag

e 6

for a

det

aile

d ex

ampl

e.)

Jane

pay

s 0%

H

er p

lan

pays

10

0%


Glo

ssar

y of

Hea

lth C

over

age

and

Med

ical

Ter

ms

Page

5 of

6

Rec

onst

ruct

ive

Surg

ery

Surg

ery

and

follo

w-u

p tr

eatm

ent n

eede

d to

cor

rect

or

impr

ove

a pa

rt o

f the

bod

y be

caus

e of

birt

h de

fect

s, ac

cide

nts,

inju

ries,

or m

edic

al c

ondi

tions

. R

efer

ral

A w

ritte

n or

der f

rom

you

r prim

ary

care

pro

vide

r for

you

to

see

a sp

ecia

list o

r get

cer

tain

hea

lth c

are

serv

ices

. In

m

any

heal

th m

aint

enan

ce o

rgan

izat

ions

(HM

Os)

, you

ne

ed to

get

a re

ferr

al b

efor

e yo

u ca

n ge

t hea

lth c

are

serv

ices

from

any

one

exce

pt y

our p

rimar

y ca

re p

rovi

der.

If

you

don

’t ge

t a re

ferr

al fi

rst,

the

plan

may

not

pay

for

the

serv

ices

. R

ehab

ilita

tion

Serv

ices

H

ealth

car

e se

rvic

es th

at h

elp

a pe

rson

kee

p, g

et b

ack,

or

impr

ove

skill

s and

func

tioni

ng fo

r dai

ly li

ving

that

hav

e be

en lo

st o

r im

paire

d be

caus

e a

pers

on w

as si

ck, h

urt,

or

disa

bled

. T

hese

serv

ices

may

incl

ude

phys

ical

and

oc

cupa

tiona

l the

rapy

, spe

ech-

lang

uage

pat

holo

gy, a

nd

psyc

hiat

ric re

habi

litat

ion

serv

ices

in a

var

iety

of i

npat

ient

an

dor

out

patie

nt se

tting

s. Sc

reen

ing

A ty

pe o

f pre

vent

ive

care

that

incl

udes

test

s or e

xam

s to

dete

ct th

e pr

esen

ce o

f som

ethi

ng, u

sual

ly p

erfo

rmed

w

hen

you

have

no

sym

ptom

s, sig

ns, o

r pre

vaili

ng m

edic

al

hist

ory

of a

dise

ase

or c

ondi

tion.

Sk

illed

Nur

sing

Car

e Se

rvic

es p

erfo

rmed

or s

uper

vise

d by

lice

nsed

nur

ses i

n yo

ur h

ome

or in

a n

ursin

g ho

me.

Ski

lled

nurs

ing

care

is

not t

he sa

me

as “

skill

ed c

are

serv

ices

”, w

hich

are

serv

ices

pe

rfor

med

by

ther

apist

s or t

echn

icia

ns (r

athe

r tha

n lic

ense

d nu

rses

) in

your

hom

e or

in a

nur

sing

hom

e. Sp

ecia

list

A p

rovi

der f

ocus

ing

on a

spec

ific

area

of m

edic

ine

or a

gr

oup

of p

atie

nts t

o di

agno

se, m

anag

e, pr

even

t, or

trea

t ce

rtai

n ty

pes o

f sym

ptom

s and

con

ditio

ns.

Spec

ialty

Dru

g A

type

of p

resc

riptio

n dr

ug th

at, i

n ge

nera

l, re

quire

s sp

ecia

l han

dlin

g or

ong

oing

mon

itorin

g an

d as

sess

men

t by

a h

ealth

car

e pr

ofes

siona

l, or

is re

lativ

ely

diff

icul

t to

disp

ense

. G

ener

ally

, spe

cial

ty d

rugs

are

the

mos

t ex

pens

ive

drug

s on

a fo

rmul

ary.

UC

R (U

sual

, Cus

tom

ary

and

Rea

sona

ble)

T

he a

mou

nt p

aid

for a

med

ical

serv

ice

in a

geo

grap

hic

area

bas

ed o

n w

hat p

rovi

ders

in th

e ar

ea u

sual

ly c

harg

e fo

r the

sam

e or

sim

ilar m

edic

al se

rvic

e. T

he U

CR

am

ount

som

etim

es is

use

d to

det

erm

ine

the

allo

wed

am

ount

. U

rgen

t Car

e C

are

for a

n ill

ness

, inj

ury,

or c

ondi

tion

serio

us e

noug

h th

at a

reas

onab

le p

erso

n w

ould

seek

car

e rig

ht a

way

, but

no

t so

seve

re a

s to

requ

ire e

mer

genc

y ro

om c

are.

27State Members

Glossary of Health Coverage and Medical Terms Page 6 of 6

How You and Your Insurer Share Costs - Example Jane’s Plan Deductible: $1,500 Coinsurance: 20% Out-of-Pocket Limit: $5,000

Jane reaches her $1,500 deductible, coinsurance begins Jane has seen a doctor several times and paid $1,500 in total, reaching her deductible. So her plan pays some of the costs for her next visit.

Office visit costs: $125 Jane pays: 20% of $125 = $25 Her plan pays: 80% of $125 = $100

Jane pays 20%

Her plan pays 80%

Jane pays 100%

Her plan pays 0%

Jane hasn’t reached her $1,500 deductible yet Her plan doesn’t pay any of the costs.

Office visit costs: $125 Jane pays: $125 Her plan pays: $0

January 1st

Beginning of Coverage Period December 31st

End of Coverage Period

morecosts

morecosts

Jane reaches her $5,000out-of-pocket limitJane has seen the doctor often and paid $5,000 in total. Her plan pays the full cost of her covered health care services for the rest of the year.

Office visit costs: $125 Jane pays: $0 Her plan pays: $125

Jane pays 0%

Her plan pays 100%

28 Member Information

Women’s Health andCancer Rights NoticeIf you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA).

For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

• All stages of reconstruction of the breast on which the mastectomy was performed;

• Surgery and reconstruction of the other breast to produce a symmetrical appearance;

• Prostheses; and• Treatment of physical complications

of the mastectomy, including lymphedema

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan.

If you would like more information on WHCRA benefits, call UMR at 888-200-1167 or Aetna at 800-245-0618.

29State Members

Notice of Privacy PracticesThis notice describes how medical information about you may be used and disclosed

and how you can get access to this information. Please review it carefully.

If you have any questions about this notice, please contact Missouri Consolidated Health Care Plan’s Privacy Officer at 832 Weathered Rock Court, PO Box 104355, Jefferson City, MO 65110, or by calling 573-751-8881 or toll free 800-701-8881.

This notice describes the information privacy practices followed by workforce members of Missouri Consolidated Health Care Plan. For purposes of this notice, the pronouns “we”, “us” and “our” and the acronym “MCHCP” refer to Missouri Consolidated Health Care Plan.

This notice applies to the information and records we have about your health care and the services you receive. We are required by law to maintain the privacy of your protected health information and to notify you if there has been a breach of your protected health information. We are also required by law to give you this notice. It will tell you about the ways in which we may use and disclose health information about

you and describes your rights and our obligations regarding the use and disclosure of that information.

How We May Use and Disclose Health Information About You

For TreatmentWe may use or disclose protected health information about you to assist in providing you with medical treatment or services. For example, we may use and disclose protected health information with your providers (pharmacies, physicians, hospitals, etc.) to assist in your treatment.

For PaymentWe may use and disclose protected health information about you so that the treatment and services you receive will be paid. For example, we may use or disclose protected health information in order for your claims to be processed, coordinate your benefits, review health care services provided to you and evaluate medical necessity or appropriateness of care or charges. We may also use or disclose your protected health

information to determine whether a treatment is a covered benefit under the health plan. We may use and disclose your protected health information to determine eligibility for coverage, in order to obtain pretax payment of your premiums from your employer or sponsoring entity, and for determining wellness premium incentives. We may use and disclose your protected health information for underwriting purposes, but, if we do, we are prohibited from using your genetic information for such purposes.

For Health Care OperationsWe may use and disclose protected health information for our health care operations. For example, we may use and disclose your protected health information to address or resolve complaints or appeals regarding your medical benefits. We may use or disclose protected health information with our wellness or disease management programs in which you participate. We may use your protected health information

to conduct audits, for purposes of rate-making, as well as for purposes of risk management. We may also disclose your protected health information to our attorneys, accountants and other consultants who assist us in performing our functions. We may disclose your protected health information to health care providers or entities for certain health care operations activities, such as quality assessment and improvement activities, case management and care coordination. In this case, we will only disclose your protected health information to these entities if they have or have had a relationship with you and your protected health information pertains to that relationship, such as with other health plans or insurance carriers in order to coordinate benefits, if you or your family members have coverage through another health plan.

Disclosures to EmployerWe may also use and disclose protected health information with your employer as necessary to

Effective September 1, 2013


perform administrative functions. Employers who receive this type of information are required by law to have safeguards in place to protect against inappropriate use or disclosure of your information.

Disclosures to Family Members or OthersWe may disclose health information about you to your family members or friends if we obtain your written authorization to do so. Also, unless you object, we may disclose relevant portions of your protected health information to a family member, friend, or other person you indicate is involved in your health care or in helping you receive payment for your health care. For example, we may assume you agree to our disclosure of your personal health information to your spouse when you bring your spouse with you to a meeting or have your spouse on the telephone while such information is discussed. We may also disclose claim and payment information of family members to the subscriber in a family plan.

If you are not capable of agreeing or objecting to these disclosures because of, for instance, an emergency situation, we will disclose protected health information (as we determine) in your best interest. After the emergency, we will give you

the opportunity to object to future disclosures to family and friends.

Disclosures to Business AssociatesWe contract with individuals and entities (business associates) to perform various functions on our behalf or provide certain types of services. To perform these functions or provide these services, our business associates will receive, create, maintain, use or disclose protected health information. We require the business associates to agree in writing to contract terms to safeguard your information, consistent with federal and state law. For example, we may disclose your protected health information to a business associate to administer claims or provide service support, utilization management, subrogation or pharmacy benefit management.

Special SituationsWe may use or disclose health information about you without your permission for the following purposes, subject to all applicable legal requirements and limitations:

To Avert a Serious Threat to Health or SafetyWe may use and disclose health information about you when necessary to prevent a serious threat

to your health and safety or the health and safety of the public or another person.

Required By LawWe will disclose your health information when required to do so by federal, state or local law.

Public Health ActivitiesWe may disclose your health information to a public health authority that is authorized by law to collect or receive such information for the purpose of preventing disease or injury.

For ResearchUnder certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct research.

To a Health Oversight AgencyWe may disclose your health information to a health oversight agency for oversight activities authorized by law.

Judicial and Administrative ProceedingsWe may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal. We may disclosure your health information

in the course of any judicial or administrative proceeding in response to a subpoena, discovery request, or other lawful process if we receive satisfactory assurance that you have been given notice of the request or that there is a qualified protective order for the information.

Workers’ CompensationWe may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Law EnforcementWe may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.

For Military, National Security, or Incarceration/Law Enforcement CustodyIf you are involved with the military, national security or intelligence activities, or you are in the custody of law enforcement officials or an inmate in a correctional institution, we may release your health information to the proper authorities so they may carry out their duties under the law.

31State Members

Information Not Personally IdentifiableWe may use or disclose health information about you in a way that does not personally identify you or reveal who you are.

Other Uses & Disclosures of Health InformationWe will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written Authorization. If you give us Authorization to use or disclose health information about you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.

If we have HIV or substance abuse information about you, we cannot release that information without a special signed, written authorization from you. In order to disclose these types of records for purposes of treatment, payment or health care operations, we will have to have a special written Authorization that complies with the law governing HIV or substance abuse records.

If we have psychotherapy notes, we will not use or disclose that

information without authorization unless the use or disclosure is used to defend MCHCP in a legal action or other proceeding brought by you.

MCHCP will not use or disclose your protected health information for marketing purposes without an authorization, except if the marketing communication is in the form of a face-to-face communication made by MCHCP to you or in the form of a promotional gift of nominal value provided by MCHCP. MCHCP will not sell your protected health information without your authorization.

Your Rights Regarding Health Information About YouYou have the following rights regarding health information we maintain about you:

Right to Inspect and CopyYou have the right to inspect and copy your health information, such as enrollment, eligibility and billing records. You must submit a written request to MCHCP’s Privacy Officer in order to inspect and/or copy your health information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other associated supplies. We may deny your request to inspect and/or copy in certain limited circumstances. If you are denied access to your health information, you

may ask that the denial be reviewed. If such a review is required by law, we will select a licensed health care professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.

Right to Amend Incorrect or Incomplete PHIIf you believe health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment as long as the information is kept by this office.

To request an amendment, complete and submit a Member Record Amendment/Correction Form to MCHCP’s Privacy Officer. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

1. We did not create, unless the person or entity that created the information is no longer available to make the amendment;

2. Is not part of the health information that we keep;

3. You would not be permitted to inspect and copy; or

4. Is accurate and complete.

Right to an Accounting of Certain DisclosuresYou have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you for purposes other than treatment, payment and health care operations. To obtain this list, you must submit your request in writing to MCHCP’s Privacy Officer. It must state a time period, which may not go back more than six years from the date of the request. Your request should indicate in what form you want the list (for example, on paper or electronically). We may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request RestrictionsYou have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. For example, you could ask that we not use or disclose information about a particular health care treatment you received.


We are Not Required to Agree to Your RequestWe are not required to agree to your request for restrictions. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. If your request restricts us from using or disclosing information for purposes of treatment, payment or health care operations, we have the right to discontinue providing you with health care treatment and services.

Request RestrictionsTo request restrictions, you may complete and submit the Request for Restriction on Use/Disclosure of Health Care Information to MCHCP’s Privacy Officer.

Right to Request Confidential CommunicationsYou have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you may complete and submit the Request for Restriction on Use and Disclosure of Health Care Information and/or Confidential Communication to MCHCP’s Privacy Officer. We will not

ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This NoticeYou have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive it electronically, you are still entitled to a paper copy. To obtain such a copy, contact MCHCP’s Privacy Officer.

Changes to This NoticeMCHCP is required to abide by the terms of the notice currently in effect. We reserve the right to change this notice, and to make the revised or changed notice effective for medical information we already have about you, as well as any information we receive in the future.

We will post the revised notice to our website prior to the effective date of the change, and we will distribute any amended notice or information about the change and how to obtain a revised notice in the next annual communication to members, either by mail or electronically if you have agreed to receive communications in that manner. Please note that the amended notice may be part of another mailing from MCHCP. In

addition, we will post the current notice in our office and on www.mchcp.org with its effective date directly under the heading. You are entitled to a copy of the notice currently in effect.

33State Members

Notice Regarding theStrive for Wellness® ProgramStrive for Wellness® is a voluntary program available to active Missouri state employees with Missouri Consolidated Health Care Plan (MCHCP) medical coverage. The Strive for Wellness® Program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable, among others. If you choose to participate in the wellness program you will be asked to complete a voluntary health assessment (HA) that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., diabetes, or heart disease). You are not required to complete the HA.

However, eligible subscribers who choose to participate in the wellness program will receive a premium reduction of $25 monthly for agreeing to participate in the Partnership Incentive, completing the HA and a Health Education Quiz. Although you are not required to complete the HA or the Health Education Quiz, only employees who do so will receive the Partnership Incentive of $25 a month.

Partnership Incentive participants can receive a t-shirt for completing a health-related activity such as an annual preventive exam or regularly exercising. If you are unable to participate in any of the MCHCP-approved health-related activities you may be entitled to a reasonable accommodation or an alternative standard. You may request a reasonable accommodation or an alternative standard by contacting MCHCP at 800-487-0771.

The information from your HA will be used to provide you with information to help you understand your current health and potential risks. You are encouraged to share your HA results or concerns with your health care provider.

Protections from Disclosure of Medical InformationMCHCP is required by law to maintain the privacy and security of your personally identifiable health information. Although the Strive for Wellness® Program and MCHCP may use aggregate information it collects to design a program based on identified health risks in the workplace, Strive for Wellness® will never disclose any of your personal information either publicly or to the employer, except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the Strive for Wellness® Program, or as expressly

permitted by law. Medical information that personally identifies you that is provided in connection with the Strive for Wellness® Program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment or health benefits.

Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the Strive for Wellness® Program, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the Strive for Wellness® Program or receiving the Partnership Incentive. Anyone who receives your information for purposes of providing you services as part of the Strive for Wellness®

Program will abide by the same confidentiality requirements. The


only individuals who will have access to your personally identifiable health information are MCHCP Information Technology and Clinical Staff and only if accessing your personally identifiable health information is needed to potentially provide you with services under the Strive for Wellness® Program.

In addition, all medical information obtained through the wellness program will be maintained separate from your personnel records, the identity of information stored electronically will be encrypted, and no information you provide as part of the wellness program will be used in making any employment decision. Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the wellness program, we will notify you immediately.

You may not be discriminated against in employment because of the medical information you provide as part of participating in the Strive for Wellness® Program, nor may you be subjected to retaliation if you choose not to participate.

If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact MCHCP Member Services at 800-487-0771.

35State Members

Discrimination is Against the LawMCHCP complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. MCHCP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

MCHCP:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

o Qualified sign language interpreters

o Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:

o Qualified interpreters

o Information written in other languages

If you need these services, contact Shelley Farris.

If you believe that MCHCP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Shelley FarrisDirector of Benefit Administration832 Weathered Rock CourtPO Box 104355Jefferson City, MO 65110Phone: 800-487-0771Fax: [email protected]

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Shelley Farris (Director of Benefit Administration) is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights

Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

1-800-368-1019 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html


ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-487-0771 (TTY: 1-800-735-2966).

1-800-487-0771 (TTY: 1-800-735-2966).

CHÚ Ý:

OBAVJEŠTENJE:dostupne su vam besplatno. Nazovite 1-800-487-0771 (TTY- Telefon za

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos

1-800-487-0771 (TTY: 1-800-735-2966).

800-487-0771-1 :

.800-735-2966-1

ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-800-487-0771 (ATS: 1-800-735-2966).

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-487-0771 (TTY: 1-800-735-2966).

Wann du Deitsch schwetzscht, kannscht du mitaus Koschte ebber gricke,

1-800-487-0771 (TTY: 1-800-735-2966).

KUJDES:gjuhësore, pa pagesë. Telefononi në 1-800-487-0771 (TTY: 1-800-735-2966).

1-800-487-0771

XIYYEEFFANNAA:afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-487-0771 (TTY: 1-800-735-2966).

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