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Benefit Plan Options

All five MHIP plans are comprehensive major medical-type plans that include a preferred provider organization feature. Enrollees must receive care from a PPO network provider in order to receive the maximum level of benefits.

Program Options

Deductibles. MHIP plans offer the choice of four calendar year deductibles which apply to benefits for care from a PPO network provider: $500, $1,000, $2,500 or $5,000. The deductible is doubled for care received from a non-network provider. The deductible must be met each calendar year before benefits for most types of care will be payable.

Preferred Provider Network. The MHIP's plan of benefits feature a group of hospitals and physicians who have agreed to participate in preferred provider networks operated by the MHIP's administering carriers. The plan pays a higher level of benefits for care delivered by PPO network providers. In addition, the cost of care received by a provider out of network is subject to twice the normal annual deductible, and the out-of-pocket maximum never applies to payments for such care. The MHIP provider directory contains a list of all PPO network providers. You can identify and locate a participating provider by clicking on Find a Provider.

Coinsurance: After the deductible is met, the plan will pay:

80% for covered services received from network providers, for network or non-network emergency room care or ambulance services or for medically necessary care that is unavailable in Missouri and approved in advance by the administrator, up to coinsurance maximum.

50% for covered services received from non-network providers within the network service area. The higher deductible applies, and there is no coinsurance maximum for these services. You must always pay 50% of the covered charges for care you receive outside Missouri if we determine it was urgent or emergency care (other than an emergency room or ambulance services).

Coinsurance Maximums. If you choose Option I ($500 deductible), you or your provider will be reimbursed at 80% of the first $12,500 in eligible expenses and 100% for the remainder of all eligible expenses incurred after the $500 deductible is met for that calendar year. In this example the most coinsurance you would pay in one year is $2500. The annual coinsurance maximum is $5000 or 80% of $25,000 for other deductible options.

If you use a non-PPO medical provider, the coinsurance percentage is reduced to 50% and there is no out-of-pocket coinsurance maximum. As a result, although an enrollee can obtain medical care from any Missouri medical provider, use of a non-PPO provider can result in the enrollee incurring significantly greater personal expense.

Option I: $500 Deductible Option

After your $500 deductible is met, if you go to a PPO provider, the Plan pays 80% of the next $12,500 of eligible expenses, then 100% for the remainder of the calendar year. Total PPO out-of-pocket expense to you is $3,000 ($500 deductible + $2,500 coinsurance).

Option II: $1,000 Deductible Option

After your $1,000 deductible is met, if you go to a PPO provider, the Plan pays 80% of the next $25,000 of eligible expenses, then 100% for the remainder of the calendar year. Total PPO out-of-pocket expense to you is $6,000 ($1,000 deductible + $5,000 coinsurance).

Option III: $2,500 Deductible Option

After your $2,500 deductible is met, if you go to a PPO provider, the Plan pays 80% of the next $25,000 of eligible expenses, then 100% for the remainder of the calendar year. Total PPO out-of-pocket expense to you is $7,500 ($2,500 deductible + $5,000 coinsurance).

Option IV: $5,000 Deductible Option

After your $5,000 deductible is met, if you go to a PPO provider, the Plan pays 80% of the next $25,000 of eligible expenses, then 100% for the remainder of the calendar year. Total PPO out-of-pocket expense to you is $10,000 ($5,000 deductible + $5,000 coinsurance).

Option V: $2,500 High Deductible Health Plan (HDHP)/Health Savings Account (HSA) Option

After your $2,500 deductible is met, if you go to a PPO provider, the Plan pays 80% of the next $12,500 of eligible expenses, then 100% for the remainder of the calendar year. Total PPO out-of-pocket expense to you is $5,000 ($2,500 deductible + $2,500 coinsurance). This Plan has a $2,500 deductible and is used to access your HSA account. You are responsible to establish and manage your health savings account. Please contact the administering carrier customer service office for additional information and assistance in establishing your health savings account.

Lifetime Maximum Benefit. The MHIP will not pay more than $1 million in benefits for any enrollee. When total benefits paid to or on behalf of an enrollee reach $1 million, the enrollee's MHIP coverage will end, and he or she won't be eligible to re-enroll.

Prescription Drug Benefit. MHIP coverage includes a prescription drug card benefit administered by Catalyst Rx. The coinsurance for both generic and brand medications at retail and mail pharmacies is 30% of the total cost of the medication. Note: If generic is available and you are receiving a brand drug, you are responsible for paying the cost difference.

"Prescription drug costs are 100% your responsibility up to your individual deductible. Please see the plan's amounts listed below to determine your annual deductible amount. After meeting the deductible, you are responsible for the copayments as shown below. Your out of pocket maximum is also listed below and is per individual per calendar year. After you reach your out of pocket maximum, the plan will pay 100% on all claims for the remainder of the calendar year. Your deductibles are as follows:

For each prescription filled for you, your co-payment is:

Access Catalyst Rx directories that provide a more detailed description of the Prescription Drug Plan on the Forms Page.

Preventative Care Benefits (not subject to deductible)

Managed Care. All inpatient hospitalizations must be pre-certified. Either you or the PPO hospital must contact the pre-certification telephone number on your identification card. Significant benefit reductions and penalties may be imposed if your hospitalization is not pre-certified. The MHIP Administering Carriers have a case management staff that is available to assist you with your medical care needs.

Pre-existing Condition Exclusion. A pre-existing condition is a condition for which medical advice, diagnosis, care or treatment (including medications), of the condition was recommended or received during the six month period prior to your MHIP effective date.

The MHIP plan excludes coverage for 12 months for any medical condition that is determined to be "pre-existing". This exclusion applies only to the medical plan. If you have a pre-existing condition, you can receive prescription drug coverage for that condition effective immediately upon your MHIP coverage effective date.

You may qualify for a pre-existing condition waiver if the following situations exist: