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State Members

Medical Plans

Overview | HSA Plan | PPO 600 | PPO 300

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 300
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 300
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 300
Individual: $300
Family: $600
Medical OOP Maximum
Individual
Family
Health Savings Account (HSA) Plan
Individual: $3,300
Family: $6,600
PPO 600
Individual: $1,500
Family: $3,000
PPO 300
Individual: $1,500
Family: $3,000
Prescription OOP Maximum
Individual
Family
Health Savings Account (HSA) Plan
Combined with medical
PPO 600
Individual: $5,100
Family: $10,200
PPO 300
Individual: $5,100
Family: $10,200

Non-Network

Benefit Health Savings Account (HSA) Plan PPO 600 PPO 300
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 300
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 300
Individual: $600
Family: $1,200
Medical OOP Maximum
Individual
Family
Health Savings Account (HSA) Plan
Individual: $5,000
Family: $10,000
PPO 600
Individual: $3,000
Family: $6,000
PPO 300
Individual: $3,000
Family: $6,000
Prescription OOP Maximum
Individual
Family
Health Savings Account (HSA) Plan
Combined with medical
PPO 600
No Maximum
PPO 300
No Maximum

Family Roll Up

Two married active state employees who cover children may combine medical deductibles by participating in Family Roll Up. This offering allows subscribers to combine their deductibles into one family deductible. For example, one spouse covers themselves and their children on a family plan, while the other spouse covers only themselves on an individual plan. With a Family Roll Up, this family would only have to meet one family deductible, instead of a family deductible plus a separate individual deductible.

To participate, each spouse must enroll in the same medical plan through the same carrier. Each spouse must report they are married to an active state employee eligible for MCHCP medical benefits and provide the spouse’s Social Security number (SSN) during the Open Enrollment process, or by completing section 5 on the Enroll/Change/Cancel form.

When using Family Roll Up:

  • The spouse who covers the dependent children is considered the subscriber (policy holder) for the entire family
  • The spouse not covering the children is considered a dependent on the policy and is listed as a dependent on the ID cards
  • When contacting the medical plan’s customer service department, the dependent spouse should provide the subscribing spouse’s SSN or other identifying information in order to receive coverage and claim information
  • The dependent spouse should present the correct ID card to providers for proper claims submission under the correct policy. If the correct ID card is not used, it could delay claim submission and/or processing.

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.

HSA Plan

The HSA Plan is a qualified high-deductible plan. Members receive health coverage at a lower or no-cost 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 Plans for more information.

HSA vs FSA

Active employees are encouraged to fund their medical expenses by setting up either a Health Savings Account (HSA) or a health care Flexible Spending Account (FSA). Both accounts allow members to deposit and withdraw money tax-free for qualified medical expenses.

Question Health Savings Account (HSA) Plan Flexible Spending Account (FSA)
Which plan must a subscriber enroll in to have this account? HSA Plan - HSA Plan Flexible Spending Account (FSA) - PPO 600 or PPO 300
Who contributes? HSA Plan - Subscriber and MCHCP FSA - Subscriber
What is MCHCP's contribution? HSA Plan - (Active Employees Only)
Subscriber Only: $300
All Other Levels: $600
FSA - $0
What are the maximum annual contribution limits for 2017? HSA Plan - Subscriber Only: $3,400
All Other Levels: $6,750
FSA - $2,550 per subscriber
What happens at the end of the year? HSA Plan - Unused balance rolls over. FSA - Subscriber can incur expenses up to March 15 the following year. Any balance remaining at the end of this grace period is forfeited; budget conservatively.
What happens if a subscriber leaves their job? HSA Plan - Subscriber keeps their account and may continue to use the funds for qualified expenses. FSA - Subscriber may submit expenses for reimbursement until April 15 of the following year. Expenses must have been incurred during time of employment.
What is the reimbursement process? HSA Plan - Use HSA debit card for qualified expenses. FSA - Submit a claim form and provide documentation to MOCafe. Claims may be submitted via mail, fax, mobile app or online.
What are the tax benefits? HSA Plan - Contributions are tax-deductible.
Interest is tax-free. Withdrawals for qualified medical expenses are tax-free.
FSA - Contributions are taken from paycheck on a pre-tax basis (before taxes are withheld). Claim reimbursements for qualified medical expenses are tax-free.

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.

Transitioning from an FSA to an HSA
Subscribers cannot be in a health care FSA and be eligible for an HSA at the same time. Subscribers may, however, participate in the HSA and a Dental/Vision Health Care FSA.

In order to receive HSA contributions from MCHCP, a subscriber’s health care FSA must first have a zero balance. Subscribers with a remaining balance in their FSA on December 31 will wait longer to receive their HSA contribution the following year. Subscribers have until April 15 (the following year) to claim expenses through their FSA. MCHCP will make its annual contribution to the HSA in April rather than in January. If a subscriber does not have an outstanding balance in their health care FSA on December 31, MCHCP will make its annual contribution in January.

Deadlines to remember
Date Description
December 31 FSA must have a zero balance in order to receive the MCHCP HSA contribution in January
January MCHCP contribution will be deposited into HSA if FSA has a zero balance on December 31
March 15 Date of service deadline for any FSA remaining funds to be used for qualified expenses. Funds that are not used by this date will be forfeited
April MCHCP contribution will be deposited into HSA if there were remaining FSA funds on December 31
April 15 Deadline to submit claims for remaining FSA funds used by March 15th. Funds that are not claimed by this date will be forfeited

Annual Contribution Limits


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
MCHCP Contribution
(active employee subscribers only)
Subscriber Only: $300 Subscriber/Spouse, Subscriber/Child(ren), Subscriber/Family: $600
Active subscribers may contribute Subscriber Only: $3,100 Subscriber/Spouse, Subscriber/Child(ren), Subscriber/Family: $6,150
Active subscribers may contribute
(age 55 and older)
Subscriber Only: $4,100 Subscriber/Spouse, Subscriber/Child(ren), Subscriber/Family: $7,150

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.
  • MCHCP Contribution: MCHCP will contribute to the HSAs of active employees — $300 for individual coverage and $600 for family coverage.

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 Central Bank. The bank will send a debit card, along with detailed information about the account.
  2. Members may contribute to their HSA any time. MCHCP will make an annual contribution to each active employee’s HSA. Members are also encouraged to fund their account up to the annual limit set by the IRS (see Annual Contribution Limits). Active employees may contribute through voluntary payroll deductions. Retirees may contribute by making deposits directly with Central Bank.
  3. Members may monitor their account through Central 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.

Two married active state employees who cover children may combine medical deductibles by participating in Family Roll UpFamily Roll Up.

The maximum annual MCHCP contribution for married state employees who cover children when both are enrolled in the HSA Plan is $600. Each spouse will receive $300 into their individual health savings account.

View Your Financial Safety Net for more HSA information.

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

PPO 600 Plan

The 600 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:
$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.
  3. Active employees with a health care Flexible Spending Account (FSA) may receive reimbursement for qualified medical expenses by submitting a claim and providing necessary documentation to MOCafe (view HSA vs FSA on the HSA Plan HSA Plan tab).

See Prescription Drug Plans 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.

Two married active state employees who cover children may combine medical deductibles by participating in Family Roll UpFamily Roll Up.

PPO 300 Plan

The 300 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:
$300
Family: $600
Non-Network
Individual:
$600
Family: $1,200
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
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 300 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.
  3. Active employees with a health care Flexible Spending Account (FSA) may receive reimbursement for qualified medical expenses by submitting a claim and providing necessary documentation to MOCafe (view HSA vs FSA on the HSA Plan HSA Plan tab).

See Prescription Drug Plans 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.

Two married active state employees who cover children may combine medical deductibles by participating in Family Roll UpFamily Roll Up.

TRICARE Supplement Plan (Military Members Only)

Military members can choose the TRICARE Supplement Plan, administered by Selman & Company, instead of MCHCP medical and pharmacy benefits. The TRICARE Supplement Plan works with TRICARE, the Department of Defense’s health benefit program for the military community.

To be eligible, the member must be a non-Medicare active state employee, retiree, terminated vested subscriber or survivor and have TRICARE.

Features include:

  • Fully employee paid by pre-tax dollars through payroll deduction
  • No deductibles
  • No pre-existing condition limitations
  • No copayments or coinsurance
  • Ability to use civilian physicians

A copy of subscriber's military ID is required to enroll in the TRICARE Supplement Plan. Enrolled subscribers may enroll eligible dependents in the plan. Dependent military IDs must also be submitted, if issued.

For more information about the plan and to determine eligibility, contact Selman & Company.

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