Download Benefit Summary effective 7/1/2015

Benefit Summary
2015
2016
1
MUST BENEFITS
MUST is proud to offer a variety
of plan designs, which enables
educational communities to tailor
benefits to fit local needs.
MUST offers the following benefits
and includes group life insurance and
long-term disability insurance with
group medical plans, including the
Revised Major Medical Plan (RM),
Comprehensive Major Medical Plan
(CM), High Deductible Health Plan
(HDHP), and Basic Medical Plan (BP).
MUST requires a member group to
enroll at least 75% of all eligible
employees, excluding eligible
employees waiving coverage because
they are covered under a spouse’s plan.
Prescription Drug Benefits
MUST uses the URx pharmacy plan
for all members. Unlike traditional
pharmacy plans, which have no
mechanism for determining the value of
a medication, URx uses a 5-tier system
to “grade” prescription medications
based on their cost and clinical efficacy.
Wellness Program
Higher-value medications, which are
those that are equally or more effective
with the same or lower cost, get higher
grades and cost the member less. See
details on page eight.
MUST offers the Healthy Futures
Wellness Program to all groups. The
wellness program includes a blood
screening and health risk assessment
to help identify eligible participants’
health risks. More details can be found
on page five.
Dental and Vision Benefits
Maternity Program
Employees and dependents enrolled in
the medical plan are eligible for dental
and vision coverage in districts offering
those benefits. See page nine for
additional details.
MUST medical participants are eligible
for a free, confidential prenatal
education and high-risk-pregnancy
identification program to help mothers
carry their babies to term. The result
is an increased number of healthy,
full-term deliveries and a decrease in
costly, long-term hospital stays.
Preventive Benefits
All MUST plans include a rich menu
of preventive benefits. This benefit
now includes a vision exam and
contraceptive coverage for all groups.
See page four for more details.
2
Case Management
MUST contracts with case-management
professionals who identify immediate
Accidental Death and Dismemberment
(AD&D) benefit of $10,000 is provided
to all active employees enrolled in
a MUST health-benefit plan (unless
waived by the group).
About Our Networks
Optional Life and AD&D benefits are
available for an additional premium.
Member groups may enhance this
benefit for eligible employees, schoolboard trustees, and retirees.
MUST members will experience the
lowest out-of-pocket costs when
utilizing network providers. Though
members are free to see non-network
providers, there are many advantages
to using network providers.
Dependent Life Insurance is also
available for an additional premium.
The benefit is $5,000 for a spouse and
$5,000 per child. See page 10.
Long-Term Disability
MUST provides basic Long Term
Disability (LTD) coverage to eligible
employees of participating member
groups (unless waived by the group)
at no additional cost to the member
group or the employee. Member groups
may enhance this LTD coverage for
employees by electing the LTD buy-up.
See page 10.
and ongoing participant needs and plan
courses-of-care with measurable goals
and objectives.
Case managers work with participants,
families, providers, caregivers, and
payers to arrange the most appropriate,
effective, and cost-efficient treatment
possible.  
Disease Management
Members with conditions such as
asthma, chronic obstructive pulmonary
disease, coronary artery disease,
diabetes, and heart failure have access
to a confidential disease management
program through Blue Cross and Blue
Shield of Montana that helps them take
control of such medical conditions and
maintain good health.
Life Insurance
COBRA Administration
MUST administers COBRA provisions for
continuation of coverage.
Privacy
MUST is fully compliant with the privacy
and security provisions of the Health
Insurance Portability and Accountability
Act of 1996 (HIPAA).
MUST utilizes Blue Cross and Blue
Shield of Montana’s extensive
nationwide provider networks.
Network providers agree to accept
pre-determined allowable amounts
as payment in full. This means
members are not subject to charges
beyond MUST’s allowable limits (often
referred to as balance billing). Network
providers also agree to submit claims
on members’ behalf and MUST, through
BCBSMT, will make payments directly to
those providers.
Non-network providers are under
no obligation to submit claims for
members. If the non-network provider
chooses to submit the claim on the
member’s behalf, any payment will be
made directly to the provider. However,
if the provider chooses not to submit
the claim on the member’s behalf, the
member is responsible for submitting
the claim himself or herself. In such
instances, claim payments are directed
to the member and the member is
responsible for paying the provider.
Balance-bill amounts do not accrue
toward member deductibles and out-ofpocket maximums.
Important Note: This summary is intended to be an
easy-to-use reference for members and others interested in
MUST Health Benefits. The Summary Plan Description and
other materials specific to your plan supersede this general
information with regard to individual participants’ eligibility and
benefits.
A Basic Group Life Insurance and
3
PREVENTIVE BENEFITS
The preventive services payable by this plan
are designed to comply with terms of the Patient
Protection and Affordable Care Act (PPACA), the
current recommendations of the United States
Preventive Services Task Force, the Health Resources
and Services Administration, and the Centers for
Disease Control and Prevention.
The benefit levels in the table to the right apply
when provided by a network provider. If non-network
providers are used, the member is subject to
deductible, co-insurance, and any charges beyond
MUST’s allowable limits.
Charges beyond MUST’s allowable limits (often
referred to as balance billing) do not apply to
member deductibles and out-of-pocket maximums.
When preventive services and diagnostic or
therapeutic services occur during the same visit,
the member pays deductibles and co-insurance for
diagnostic or therapeutic services but not for the
preventive services.
Claims submitted outside the recommended
frequency limits will be subject to deductible and
co-insurance.
Preventive MEDICAL Benefit
Immunizations
Deductible, benefit percentage
Well-child care
Deductible, benefit percentage
Diabetic Education
Waived, 100%
Waived, 100%
Waived, 100% (subject to
deductible on HDHP)
Maximum
Five visits per benefit period
Vision Exam (with or without refraction)
Deductible, benefit percentage
Waived, 100%
Maximum
One per year
Deductible, benefit percentage
Women’s Health
Preventive mammogram
Deductible, benefit percentage
Maximum
Preventive Pap smear
Deductible, benefit percentage
Maximum
Birth control*
Deductible, benefit percentage
Maximum
Waived, 100%
One per benefit period
Waived, 100%
One per benefit period
Waived, 100%
No maximum
Colon Cancer Screening (age 50 and over)
Fecal occult blood test
Deductible, benefit percentage
Maximum
Sigmoidoscopy
Deductible, benefit percentage
Maximum
Colonoscopy
Deductible, benefit percentage
Maximum
Waived, 100%
One per benefit period
Waived, 100%
One every five years
Waived, 100%
One every 10 years
Virtual colonoscopy
Deductible, benefit percentage
Waived, 100%
Maximum
One every five years
* Women on all MUST plans have access to generic oral
contraceptives, diaphragms, and cervical caps, sterilization
procedures and patient education and counseling. Over-thecounter female contraceptives are covered when prescribed
by a provider.
4
WELLNESs
welcome to Healthy futures!
ELIGIBLE MEMBERS and THEIR SPOUSES* on must plans
have a great way to track their health and put valuable health information
where it will do the most good: in their doctor’s hands.
Participating in the Healthy Futures Wellness Program is a win-win because
eligible parties get to improve their health and receive a $50 Mastercard
gift card for doing it!
The process is fairly simple and the program comes at no additional cost. But there
are a couple of important requirements: (1) the health screening process and (2)
the online follow-up.
1
Health screening and form submission
— Download a Blue Cross and Blue Shield of Montana Total Health
Management Assessment Form at mustbenefits.org/forms and take the
form with you to your primary care physician
— Have your provider conduct the tests described on the form and/
or review those tests if they were conducted by another provider
during that benefit period
— Have your provider fill out the form and sign it
— Fax or email the completed form to Blue Cross and Blue
Shield of Montana for processing
2
Online follow-up
Complete a Health Assessment at wellontarget.com. If you
are already registered for Blue Access for Members, you
can use the same login information. If not, just follow the
directions, complete the assessment and wait for your gift
card to arrive in the mail.
* Employee and covered spouse qualify for the program, but not other dependents.
Retirees who are not yet eligible for Medicare qualify for the program, as do their
covered spouses. However, Medicare-eligible retirees and their spouses do not qualify.
Get a $50 Mastercard gift card
for completing the healthy
futures wellness program!
5
BENEFITS
RM
Revised major
medical plan
CM
comprehensive major
medical plan
MUST offers plans with a number of different deductible and out-of-pocket maximums that cannot be
detailed fully below. Ask your MUST representative about packages available to your group.
Deductible – individual
From $200 to $4,000
From $200 to $4,000
Deductible – family
From $400 to $8,000
From $400 to $8,000
Out-of-pocket maximum – individual
From $1,200 to $4,950
From $1,200 to $4,950
Out-of-pocket maximum – family
From $2,400 to $9,900
From $2,400 to $9,900
Benefit percentages available
80/20% or 70/30%
80/20% or 70/30%
Non-preventive first-dollar benefit
N/A
N/A
Waived
Applies
Office Visits (physician/chemical dependency/mental illness)
Deductible
Benefit percentage
First-dollar benefit (chemical dependency/mental illness
only)
In network: $25 or $35 co-pay
Out of network: 80/20% or 70/30%
80/20% or 70/30%
First three visits paid at 100%
First three visits paid at 100%
Deductible, benefit percentage
Waived, 100%
Waived, 100%
Maximum benefit per accident
$500 within 90 days of accident
$500 within 90 days of accident
Applies, 80/20% or 70/30%
Applies, 80/20% or 70/30%
Applies, 80/20% or 70/30%
Applies, 80/20% or 70/30%
Deductible, benefit percentage
Waived, 100%
Applies, 100%
Maximum visits per benefit period (combined)
10
6
Applies, 80/20% or 70/30%
Applies, 80/20% or 70/30%
Applies, 80/20% or 70/30%
Applies, 80/20% or 70/30%
Deductible, benefit percentage
Applies, 80/20% or 70/30%
Applies, 80/20% or 70/30%
Maximum visits per benefit period (combined)
180
180
Applies, 80/20% or 70/30%
Applies, 80/20% or 70/30%
Applies, 80/20% or 70/30%
Applies, 80/20% or 70/30%
Applies, 80/20% or 70/30%
Applies, 80/20% or 70/30%
Deductible, benefit percentage
Applies, 80/20% or 70/30%
Applies, 80/20% or 70/30%
Maximum benefit period (outpatient/inpatient)
50 visits/60 days
50 visits/60 days
Deductible, benefit percentage
Applies, 80/20% or 70/30%
Applies, 80/20% or 70/30%
Maximum days per benefit period
60
60
Deductible, benefit percentage
Applies, 80/20% or 70/30%
Applies, 80/20% or 70/30%
Lifetime maximum
N/A
N/A
Pharmacy
See pharmacy benefits on page 8.
See pharmacy benefits on page 8.
Accident
Autism Spectrum Disorders
Deductible, benefit percentage
Chemical Dependency (inpatient)
Deductible, benefit percentage
Chiropractic/Acupuncture Visits
Chiropractic X-Rays
Deductible, benefit percentage
Diagnostic X-Ray
Deductible, benefit percentage
Home Health/Hospice Care
Hospital Services
Deductible, benefit percentage
Lab work
Deductible, benefit percentage
Mental Illness (inpatient)
Deductible, benefit percentage
Rehabilitation Services
Skilled Nursing Facility
Transplants
6
BP
basic plan
HDHP
high deductible
health plan
$2,000
From $1,500 to $5,000
$4,000
From $3,000 to $10,000
$4,000
From $1,500 to $5,000
$8,000
From $3,000 to $10,000
70/30%
100/0%
$300
N/A
Applies
Applies
70/30%
100%
First three visits paid at 100%
N/A
Waived, 100%
Applies, 100%
$300 within 90 days of accident
N/A
Applies, 70/30%
Applies, 100%
Applies, 70/30%
Applies, 100%
N/A
Applies, 100%
N/A
10
N/A
Applies, 100%
Applies, 70/30%
Applies, 100%
Applies, 70/30%
Applies, 100%
90
180
Applies, 70/30%
Applies, 100%
Applies, 70/30%
Applies, 100%
Applies, 70/30%
Applies, 100%
Applies, 70/30%
Applies, 100%
20 visits/30 days
50 visits/60 days
Applies, 70/30%
Applies, 100%
60
60
Applies, 70/30%
Applies, 100%
70/30% on first $25,000; 10/90% on
subsequent charges above $25,000
N/A
No Rx coverage, but discounts available.
See page 8 for more details.
Rx charges apply to medical deductible and co-insurance. See page 8 for more details.
7
Pharmacy
The pharmacy benefits detailed
below are included in all MUST plans
except the Basic Plan. Prescription
charges for High Deductible Health
Plans apply to the medical deductible; once met, remaining charges are
reimbursed according to the tiers listed
below. Members on the Basic Plan can
use the MUST ID card for certain pharmacy discounts.
MUST’s pharmacy plan is called URx.
Unlike traditional pharmacy plans,
which have no mechanism for determining the value of a medication, URx uses
a 5-tier system to “grade” prescription
medications based on their cost and
clinical efficacy.
Higher-value medications, which are
those that are equally or more effective
with the same or lower cost, get higher
grades and cost the member less.
Lower value medications, those that
are more costly and/or clinically less
effective, get lower grades and cost the
member more.
Members always have the option of
choosing a medication with a lower
grade; it will simply be more expensive.
The URx plan design aligns the member’s cost with the actual value of the
medication.
By putting this control in the members’
hands, URx helps groups manage the
spiraling costs of prescription
medications.
Questions about which tier your
prescriptions falls under? Just call
URx Customer Service at
1-888-648-6764.
URx Medication Classification
(Based on medical evidence of impact to
health and overall net cost)
Medication
Class
Deductible
30-day RX
at retail
90-day RX
(mail order
or at retail)
Excellent level of value based on best medical evidence, best opportunity for improved health outcomes via disease management,
and best overall net cost. This tier includes both generic and brand
name medications.
Tier A
(HDHP only)*
$0 Copay
$0 Copay
High level of value based on medical evidence of outcomes and
lower overall net cost savings. Includes both generic and brand
medications compared to higher cost brand name counterparts.
Tier B
(HDHP only)*
$15 Copay
$30 Copay
Good level of value based on fair medical evidence grading, but
displaying higher overall net cost relative to generic counterparts
and less expensive brand name drug or clinical alternatives.
Tier C
(HDHP only)*
$40 Copay
$80 Copay
Lower level of value based on evidence of outcomes relative to
other clinical alternatives. Generally have much higher overall net
costs. [Coinsurance is calculated on the discounted cost of the
medication. Discounts have been negotiated for most medications
purchased through URx.]
Tier D
(HDHP only)*
50%**
Coinsurance
(You pay half of the
discounted price)
50%**
Coinsurance
(You pay half of the
discounted price)
These medications have the lowest level of value (based on
clinical evidence) or the highest overall net cost in relation to generic or other brand alternatives. [Coinsurance is calculated on the
discounted cost of the medication. Discounts have been negotiated for most drugs purchased through URx.]
Tier F
(HDHP only)*
100%**
Coinsurance
(You pay 100% of the
discounted price)
100%**
Coinsurance
(You pay 100% of the
discounted price)
Specialty Pharmacy Program. Specialty drugs are defined as
high cost prescription medications that may require special handling and/or administration to treat chronic, complex conditions.
These medications may be taken orally but often are injectables
with a complex manufacturing process or may have a limited distribution status. This specialty program includes medications to treat
Hemophilia, Hepatitis C, Arthritis, Multiple Sclerosis, etc.
Tier S
(HDHP only)*
$50 copay / $200
copay
Not Covered
*Members on High Deductible Health Plans (HDHPs) will pay 100% of the cost of their medications until their medical plan deductible is met.
**Co-insurance payments for D & F medications do not apply to the out-of-pocket maximum. Members on D & F medications will always pay a portion of
the cost.
—For members on RM and CM plans, the out-of-pocket prescription maximum is $1,650 ($3,300 family).
—For members on HDHPs, URx uses the plan’s medical out-of-pocket maximum.
8
Vision & Dental
Vision
Members may choose one set of frames and glasses or one set of contact lenses, but not both, during a given benefit period.
Exams
One vision exam per benefit period is now available to all
MUST members under the Preventive Medical Benefit. That
means the medical ID card should be presented at the time
of the exam. More details on page 4.
Materials
Per lens
Per pair
Single vision lenses
$32
$64
Bifocal lenses
$41
$82
Trifocal lenses
$54
$108
Progressive lenses
$54
$108
Lenticular lenses
$77
$154
Necessary contacts
$165
$330
Elective contacts
N/A
$110*
Frames
N/A
$85
*One pair per year or one year supply of disposable lenses up to $110.
IMPORTANT NOTE: If a participant elects
vision or dental coverage, but drops it at the end of
the year, there is a two-year waiting period before
the coverage can be reinstated. Participants may
not drop vision or dental coverage mid-year unless
they are also dropping medical coverage.
Dental
Dental Coverage
Maximum benefit/period/covered person
$1,250
(Combined type A, B, and C expenses)
Type A ─ Diagnostic/preventive
Deductible waived
No co-payment
Type B ─ Routine/basic care
Deductible waived
20% co-insurance
Type C ─ Major restorative
$25 deductible
50% co-insurance
Orthodontia Coverage (for dependents under 19)
Maximum lifetime benefit
$1,000
Orthodontia
$50 deductible
50% co-insurance
9
Life & LTD
Life Insurance
Basic Life
MUST provides $10,000 of Basic Group Life insurance at no cost to all active employees.
Additional Life Insurance is available as well. However, it is important to note that Life
coverage is not available for retirees or school-board trustees.
Additional Life Options
Employer-Paid Life. This is an Additional Life and Accidental Death & Dismemberment
(AD&D) policy paid for by the employer. Employers may elect any amount in increments of
$10,000 to a maximum of $150,000.
Voluntary buy-up. This is an Additional Life and AD&D policy paid for by the employee
(though the district can elect to pay a portion of the premium). Employees can elect any
amount in increments of $10,000 to the lesser of $500,000 or four times annual earnings. Groups can elect up to $50,000 without submitting evidence of insurability. Late
enrollment rules apply.
Long-term Disability (LTD)
MUST also provides Basic Long Term Disability (LTD) insurance. Active employees enrolled
in MUST medical coverage are automatically enrolled in the Basic LTD Plan. However, it is
important to note that LTD coverage is not available for retirees or school-board trustees.
Basic LTD Plan (paid for by MUST)
LTD benefit: Max monthly benefit:
Benefit waiting period:
50% pre-disability earnings
$5,000
180 days
Member groups (school districts) may enhance this LTD coverage for their active employees by electing an LTD buy-up. The premium for this buy-up is paid by the member group.
LTD Buy-Up
LTD benefit: Max monthly benefit:
Benefit waiting period:
60%* pre-disability earnings
$6,000
90 days
TRAVEL ASSISTANCE
MUST members are automatically enrolled at no additional cost in a great travel assistance benefit. The benefit provides emergency assistance to members and their dependents traveling more than 100 miles from home, and includes benefits such as foreign-language assistance, evacuation services, and repatriation services if needed.
10
Glossary
Allowable limits. Non-network
provider charges are sometimes greater
than MUST’s plan allowance. In such
an instance, MUST will only pay the
provider’s charges up to the allowed
amount, as determined by a calculation
system described in the Summary Plan
Description. Members are responsible
for charges beyond allowable limits.
Benefit percentage. Once
deductibles are satisfied, members
and MUST split allowable charges up to
the member’s Maximum Out-of-Pocket
amount. The benefit percentages
listed herein are 100/0%, 80/20%,
and 70/30%. The first number refers
to MUST’s percentage and the second
to the member’s. For example, if the
benefit percentage is 80/20%, MUST
would pay 80% of allowable charges
and the member would pay 20%.
Benefit period. Also known as the
plan year, this refers to that duration of
time between renewal periods during
which members are covered for elected
services.
Co-insurance. This is the member’s
portion of the benefit percentage. For
example, if the benefit percentage is
listed as 70/30%, MUST’s portion is
70% while the member’s co-insurance
is 30%.
Co-payment. This is a flat rate that a
member pays for a given service.
Deductible. This is the amount the
member is expected to pay before the
costs of services are shared by MUST
(co-insurance) and it varies greatly
depending upon the member group’s
plan elections.
Embedded/non-embedded
deductible. When a member
holds an HSA-qualified plan with
Questions?
If you have questions about any of the offerings and
programs outlined in this Benefit Summary, make sure to
visit mustbenefits.org
an embedded deductible, any one
member of a covered family can meet
the individual deductible, at which
point the plan starts to pay its share of
claims for that member. With a nonembedded deductible, the full family
deductible amount must be reached by
an individual or a combination of family
members before MUST pays any claims.
HSA. This stands for Health Savings
Account, which is a certain kind of
narrowly defined account earmarked
specifically for pre-tax, health-related
spending. HSAs are limited for use with
qualifying high-deductible health plans.
Member Appeal. If your claim is
denied, you have the right to appeal the
denial. For information on how to file
an appeal, consult your Summary Plan
Document or contact your marketing
representative. See back cover.
Network provider. Also referred
to as a participating provider, this is a
provider who agrees to submit claims
on the member’s behalf and to accept
MUST’s allowable limit amount as
payment in full. Using network providers
ensures members the highest possible
benefit by avoiding so-called balance
billing. Balance-billed amounts do
not accrue toward the member’s
11
deductibles and out-of-pocket
maximums.
Out-of-pocket maximum. This
is the maximum financial exposure a
member is exposed to in a given benefit
period, which means that, after this
amount is met, the plan pays eligible
claims at 100% up to allowable limits.
Deductibles, co-insurance, and copayments count toward this amount.
Preventive benefit. This includes
any number of first-dollar benefits
offered to all MUST members, which
include coverage for certain screenings
and immunizations billed by healthcare
providers as preventive services.
Specialty drugs. This refers
to a narrowly defined class of
extremely high-cost, biologic drugs
that often require special handling,
administration, and careful adherence
to treatment protocols.
Third-party administrator
(TPA). MUST uses a third-party
administrator, Blue Cross and Blue
Shield of Montana, to administer day-today health plan functions. MUST’s TPA
not only brings large provider networks
to members, but also processes claims
and provides front-line customer
service.
MUST CONTACTS
MSSF/MUST
P.O. Box 4579
Helena, MT 59604
Phone:
Toll free:
Fax:
E-mail:
(406) 457-4400
(800) 845-7283
(406) 442-4161
[email protected]
Marketing TEAM
Shelly Batista (Helena)
(406) 457-4415
Deb Barrett (Helena)
(406) 457-4417
MUST Representatives
Enrollment
Tamara Crowder (Culbertson)
Office: (406) 787-5239
Cell:
(406) 461-0847
Judy Sanchez
(406) 457-4502
Greg Disney (Billings)
Office: (406) 248-9859
Cell:
(406) 366-3252
Marcia Ellermeyer (Helena)
Office: (406) 457-4416
Cell:
(406) 459-9027
Karyn Hedgecock (Columbia Falls)
Office: (406) 892-5001
cell:
(406) 270-9076
Dawn Sullivan (Choteau)
Office: (406) 466-2295
Cell:
(406) 217-1188
Lori Adams
(406) 457-4408
Project manager
Florence “Missy” Smith
(406) 457-4504
Accounting
Kelli Hargreaves
(406) 457-4404
Pam Chappell
(406) 457-4403