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Public Entity Members

Medical Plans

Overview | HSA Plan | PPO 600 | PPO 1000

Overview

Selecting the right medical plan is an important decision; one that can impact your finances. It’s important to consider how the plans are similar, where they differ in cost, and which one is the right fit for you.

Network

Benefit Health Savings Account (HSA) Plan PPO 600 PPO 1000
Coinsurance and/or Copayments Health Savings Account (HSA) Plan
20% coinsurance after deductible for most services

Separate coinsurance applies to prescriptions

See plan tab for details
PPO 600
10% coinsurance after deductible for most services

Copayments apply to Emergency Room and prescriptions

See plan tab for details
PPO 1000
10% coinsurance after deductible for most services

Copayments apply to Emergency Room, office visits and prescriptions

See plan tab for details
Deductible
Individual
Family
Health Savings Account (HSA) Plan
Individual:  $1,650
Family:  $3,300
PPO 600
Individual:  $600
Family:  $1,200
PPO 1000
Individual:  $1,000
Family:  $3,000
Medical Out-of-Pocket Maximum
Individual
Family
Health Savings Account (HSA) Plan
Individual:  $3,300
Family:  $6,600
PPO 600
Individual:  $1,500
Family:  $3,000
PPO 1000
Individual:  $4,500
Family:  $9,000
Prescription Out-of-Pocket Maximum
Individual
Family
Health Savings Account (HSA) Plan
Combined with medical
PPO 600
Individual:  $5,100
Family:  $10,200
PPO 1000
Individual:  $2,100
Family:  $4,200

Non-Network

Benefit Health Savings Account (HSA) Plan PPO 600 PPO 1000
Coinsurance and/or Copayments Health Savings Account (HSA) Plan
40% coinsurance after deductible for most services

Separate coinsurance applies to prescriptions

See plan tab for details
PPO 600
30% coinsurance after deductible for most services.

Copayments apply to Emergency Room and prescriptions

See plan tab for details
PPO 1000
30% coinsurance after deductible for most services

Copayments apply to Emergency Room, office visits and prescriptions

See plan tab for details
Deductible
Individual
Family
Health Savings Account (HSA) Plan
Individual:  $4,000
Family:  $8,000
PPO 600
Individual:  $1,200
Family:  $2,400
PPO 1000
Individual:  $2,000
Family:  $6,000
Medical Out-of-Pocket Maximum
Individual
Family
Health Savings Account (HSA) Plan
Individual:  $5,000
Family:  $10,000
PPO 600
Individual:  $3,000
Family:  $6,000
PPO 1000
Individual:  $10,000
Family:  $30,000
Prescription Out-of-Pocket Maximum
Individual
Family
Health Savings Account (HSA) Plan
Combined with medical
PPO 600
No Maximum
PPO 1000
No Maximum

All three of MCHCP’s medical plans offer the same, basic coverage, such as:

  • Preventive care — such as annual wellness exams, vaccinations and age-specific screenings — covered 100 percent, when received from a network provider.
  • Freedom to choose care from a nationwide network of primary care providers, specialists, pharmacies and hospitals, usually at a lower negotiated group discount.
  • The same covered benefits for both medical and pharmacy.

However, while the benefits are the same in all three plans, other aspects differ — such as the premium, deductible and out-of-pocket (OOP) costs.

The member pays the deductible, copayments and coinsurance amounts until the OOP maximum is reached. There are separate deductibles and OOP maximums for network and non-network services.

  1. Covered at 100 percent for PPO members or 100 percent after deductible is met for HSA Plan members, when received through a network provider. Visits must be ordered by a provider.

HSA Plan

The HSA Plan is a qualified high-deductible plan. Members receive health coverage at a lower premium, when compared to other MCHCP medical plans.

Network and Non-Network

Services Network Non-Network
Preventive Services Network
MCHCP pays 100%
Non-Network
40% coinsurance
Deductible
Individual
Family
Network
Individual:
$1,650
Family: $3,300
Non-Network
Individual:
$4,000
Family: $8,000
Medical OOP Maximum
Individual
Family
Network
Individual:
$3,300
Family: $6,600
Non-Network
Individual:
$5,000
Family: $10,000
Prescription OOP Maximum Network
Combined with medical
Non-Network
Combined with medical
Urgent Care Network
20% coinsurance
Non-Network
20% coinsurance
Emergency Room Network
20% coinsurance
Non-Network
20% coinsurance
Other Medical Services Network
20% coinsurance
Non-Network
40% coinsurance
Prescription Drugs* Network
Generic: 10% coinsurance
Preferred: 20% coinsurance
Non-Preferred: 40% coinsurance
Non-Network
Generic: 40% coinsurance
Preferred: 40% coinsurance
Non-Preferred: 50% coinsurance

* Reduced coinsurance/copayments for certain diabetic medications and supplies. See Prescription Drug Plan for more information.

Annual Contribution Limits



2017

2017

Contributions
Subscriber Only Subscriber/Spouse
Subscriber/Child(ren)
Subscriber/Family
IRS Contribution Limit Subscriber Only: $3,400 Subscriber/Spouse, Subscriber/Child(ren), Subscriber/Family: $6,750
IRS Contribution Limit
(age 55 and older)
Subscriber Only: $4,400 Subscriber/Spouse, Subscriber/Child(ren), Subscriber/Family: $7,750

2018

2018

Contributions
Subscriber Only Subscriber/Spouse
Subscriber/Child(ren)
Subscriber/Family
IRS Contribution Limit Subscriber Only: $3,450 Subscriber/Spouse, Subscriber/Child(ren), Subscriber/Family: $6,900
IRS Contribution Limit
(age 55 and older)
Subscriber Only: $4,450 Subscriber/Spouse, Subscriber/Child(ren), Subscriber/Family: $7,900

Contribution rules for HSAs are complex. Members should consult a tax advisor about individual circumstances and the maximum annual contribution. MCHCP does not provide individual tax advice.

 The HSA Offers Several Key Advantages

The HSA Offers Several Key Advantages

  • Control: HSA funds accumulate to pay for IRS-qualified medical expenses, such as doctor and chiropractor fees, dental treatments, hospital bills, prescriptions and more. You decide how to spend it based on your health care needs and budget. Plus, HSA funds roll over from year to year, there is no "use-it-or-lose-it" policy.
  • Flexibility: You can deposit (as long as you remain eligible) or withdraw money any time. There is a yearly maximum amount for how much you can put in your account.
  • Portability: You own the HSA funds and may keep them — even if you later change plans, leave your job or retire.
  • Tax Savings: There are triple tax savings with an HSA
    1. You can put away money for qualified medical expenses before taxes are taken out. This means you set aside income-tax-free dollars in an HSA to pay for qualified medical expenses.
    2. Savings in your HSA grow tax-free.
    3. You pay no taxes when you use HSA funds to pay for qualified medical expenses.

Qualified expenses include doctor and chiropractor fees, dental treatments, hospital bills and prescriptions. A complete list of qualified expenses can be found on the IRS website. HSA funds may also be used toward the qualified medical expenses of the subscriber's spouse and eligible dependents (as defined by the IRS).

 Eligibility

Eligibility

To participate in an HSA Plan, subscribers cannot:

  • Be claimed as a dependent on someone else's tax return.
  • Be enrolled in another medical plan, including Medicare and TRICARE.
    • If the subscriber is an active employee and Medicare eligible, they must defer Medicare to participate.
    • If the subscriber is retired and they or a covered dependent will be Medicare primary in the upcoming plan year, they cannot enroll in the HSA Plan during Open Enrollment.
    • Exception: A member may be enrolled in another qualified high deductible health plan, dental and/or vision plan.
  • Be a retiree with a Medicare-eligible dependent.
  • Have a health care flexible spending account (FSA) [excludes premium-only, Dental/Vision Health Care and dependent care portions] or a health reimbursement account (HRA).
  • Have received medical benefits from the Department of Veterans Affairs (VA) at any time during the previous three (3) months, unless the medical benefits received consist solely of disregarded coverage or preventive care.

 How the HSA Plan Works

How the HSA Plan Works

  1. Active employee opens an HSA through a bank of their choice. The bank will send a debit card, along with detailed information about the account.
  2. Members may contribute to their HSA any time. Members are encouraged to fund their account up to the annual limit set by the IRS (see Annual Contribution Limits).
  3. Members may monitor their account through their bank’s website and/or monthly activity statements.
  4. When visiting any health care provider or pharmacy, the member may pay for their expenses using the HSA debit card. No claim forms are required.
  5. There are no copayments with the HSA Plan. Members will pay all of their medical and prescription expenses, using their HSA funds or out of their pocket, until the annual deductible is met. The HSA may be used at any time for qualified expenses, as long as sufficient funds are available in the account.
  6. Once the deductible is met, members will pay coinsurance on covered expenses until their out-of-pocket maximum is reached. At that time, the plan will begin paying 100 percent of covered services.

When a subscriber enrolls in Medicare and is no longer eligible to participate in the HSA Plan, remaining HSA funds may still be used for qualified medical expenses.

  • Members under 65 can use the account to pay deductibles, copayments and coinsurance. If the funds are used for non-qualified medical expenses, the member will be required to pay taxes on those funds, as well as an associated penalty.
  • Members 65 or older can use the account to pay Medicare or MCHCP premiums, deductibles, copayments and coinsurance. The account cannot be used to pay for Medicare Supplement insurance or a "Medigap" policy.

 Family Coverage

Family Coverage

If two or more family members are covered in the HSA Plan, the family deductible must be met before the member begins paying applicable coinsurance. One covered family member's expenses may meet the entire family deductible.

See Prescription Drug Plan for information on the prescription drug coverage and copayments.

PPO 600 Plan

The 600 Plan offers health coverage at a higher premium, when compared to other MCHCP medical plans.

Services Network Non-Network
Preventive Services Network
MCHCP pays 100%
Non-Network
30% coinsurance
Deductible
Individual
Family
Network
Individual:
$600
Family: $1,200
Non-Network
Individual:
$1,200
Family: $2,400
Medical OOP Maximum
Individual
Family
Network
Individual:
$1,500
Family: $3,000
Non-Network
Individual:
$3,000
Family: $6,000
Prescription OOP Maximum
Individual
Family
Network
Individual:
$5,100
Family: $10,200

Non-Network
No Maximum
Urgent Care Network
10% coinsurance
Non-Network
10% coinsurance
Emergency Room Network
$100 copayment plus 10% coinsurance
Medicare: 10% coinsurance
Non-Network
$100 copayment plus 10% coinsurance
Medicare: 10% coinsurance
Other Medical Services Network
10% coinsurance
Non-Network
30% coinsurance

Emergency Room Copayment
Members visiting an emergency room (ER) may pay a $100 copayment. This copayment is waived if the member is admitted to the hospital or the services are considered by the medical plan to be a "true emergency." Even if the copayment is waived, the member will still have to pay any deductible or coinsurance owed for the ER service.

Copayments apply to the out-of-pocket maximum, but not the deductible. Medicare retirees will not owe copayments; they are only charged coinsurance.

How the PPO 600 Plan Works

  1. When visiting a health care provider, the member will pay for their medical expenses out of their pocket until the annual deductible is met. Members visiting an emergency room may also pay a $100 copayment.
  2. Once the deductible is met, members will pay coinsurance on covered expenses until their out-of-pocket maximum is reached. At that time, the plan will begin paying 100 percent of covered services.

See Prescription Drug Plan for information on the prescription drug coverage and copayments.

Family Coverage
If two or more family members are covered in a PPO plan and one family member reaches the individual deductible or out-of-pocket maximum, the medical plan begins paying claims for the individual. If one or more additional family members meet the individual deductible or out-of-pocket maximum, the medical plan begins paying claims for the entire family.

PPO 1000

The 1000 Plan offers health coverage at a moderately priced premium, when compared to other MCHCP medical plans.

Services Network Non-Network
Preventive Services Network
MCHCP pays 100%
Non-Network
30% coinsurance
Deductible
Individual
Family
Network
Individual:
$1,000
Family: $3,000
Non-Network
Individual:
$2,000
Family: $6,000
Medical OOP Maximum
Individual
Family
Network
Individual:
$4,500
Family: $9,000
Non-Network
Individual:
$10,000
Family: $30,000
Prescription OOP Maximum
Individual
Family
Network
Individual:
$2,100
Family: $4,200

Non-Network
No Maximum
Office Visit1 Network
Primary Care or Mental Health: $25 copayment
Chiropractor2: $20 copayment
Specialist:
$40 copayment
Medicare: 10% coinsurance
Non-Network
30% coinsurance
Medicare: 10% coinsurance
Urgent Care Network
$50 copayment
Medicare: 10% coinsurance
Non-Network
$50 copayment
Medicare: 10% coinsurance
Emergency Room Network
$100 copayment plus 10% coinsurance
Medicare: 10% coinsurance
Non-Network
$100 copayment plus 10% coinsurance
Medicare: 10% coinsurance
Other Medical Services Network
10% coinsurance
Non-Network
30% coinsurance
  1. The office visit copayments cover the visit only. Any lab, X-ray or other services associated with the visit will apply to the deductible and coinsurance.
  2. Chiropractor copayment may be less than $20 if it is more than 50 percent of the total cost of the service.

Copayments
Members will pay a copayment for office visits, urgent care and emergency room (ER) services. The ER copayment is waived if the member is admitted to the hospital or the services are considered by the medical plan to be a "true emergency." Even if the copayment is waived, the member will still have to pay any deductible or coinsurance owed for the ER service.

Copayments apply to the out-of-pocket maximum, but not the deductible. Medicare retirees will not owe copayments; they are only charged coinsurance.

How the PPO 1000 Plan Works

  1. When visiting a health care provider, the member will pay a copayment for each visit. The member will also pay for other medical expenses out of their pocket until the annual deductible is met.
  2. Once the deductible is met, members will continue to pay copayments. However, members will now pay coinsurance on covered expenses until their out-of-pocket maximum is reached. At that time, the plan will begin paying 100 percent of covered services.

See Prescription Drug Plan for information on the prescription drug coverage and copayments.

Family Coverage
If two or more family members are covered in a PPO plan and one family member reaches the individual deductible or out-of-pocket maximum, the medical plan begins paying claims for the individual. If one or more additional family members meet the individual deductible or out-of-pocket maximum, the medical plan begins paying claims for the entire family.

Non-Contraception Benefit Option

Missouri state law, Section 191.724, RSMo, allows a person the right to decline or refuse coverage for contraception if these items or procedures are contrary to an employee’s religious beliefs or moral convictions.

While all MCHCP plans cover these services (see Contraception and Sterilization), if you have such a religious or moral conviction, MCHCP is offering a benefit plan option excluding these services. If you declare you have a religious or moral objection, your benefits will provide no coverage for contraception as either a medical or pharmacy benefit for individuals covered on your plan.

MCHCP subscribers have the option to declare a religious or moral objection and decline contraception coverage.

Members may contact their payroll representative to complete a non-contraception benefit option form. Members may also contact MCHCP Member Services at 800-487-0771 with questions or to request a non-contraception benefit option form to fill out.

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