MISSOURI HEALTH INSURANCE POOL

Transcription

1 MISSOURI HEALTH INSURANCE POOL Certificate A guide to your benefits and rights (Revised Jan. 1, 2013) Welcome to the Missouri Health Insurance Pool (MHIP). MHIP is a nonprofit entity created to provide quality health insurance for Missourians who are unable to purchase affordable, comprehensive health coverage due to a medical condition, or who are otherwise unable to obtain health insurance coverage in the standard market. This certificate is designed to outline and explain your health insurance benefits. MHIP has developed some excellent options to fill this important coverage need. MHIP was established in 1991 through a statute enacted by the Missouri General Assembly. It continues to operate according to Sections of the Missouri Revised Statutes. In 2008, legislation was passed that enables this plan to qualify as the HIPAA alternative for federally defined eligible individuals, and for those individuals eligible for the federal Health Coverage Tax Credit under the Trade Act of MHIP has contracted with Anthem Blue Cross and Blue Shield of Missouri (Anthem BCBS) and Blue Cross and Blue Shield of Kansas City (BCBSKC) to administer this health insurance program. Please take a few minutes to review your MHIP coverage and become familiar with how your plan works. Thank you for enrolling in the Missouri Health Insurance Pool.

2 TABLE OF CONTENTS Contact Information...5 Plan Overview...6 How The Program Works...6 MHIP Certificate...6 Identification Card (ID Card)... 6 Choosing Doctors And Hospitals...6 Services Outside Missouri... 6 Non Network Care...7 Explanation of Benefits... 7 Managed Care Requirements...7 Nurse Assist Line Wellness Tools...8 Enrollee Surveys...8 How to Use This Certificate...8 Eligibility...9 Adding Newborn Children Enrollment Enrolling in the Program Premiums and Your Cost Refund Policy Refund Policy for Termination of Coverage Changes in Coverage Termination of Coverage Health Insurance Portability and Accountability Act of 1996 (HIPAA) Managed Care Utilization Management Using Network Providers Using Non-Network Providers Calling for Precertification Calling for Recertification Adverse Determinations Filing a Grievance Procedures Requiring Utilization Management Prior Authorization for Non-Network Care Disease Management Maternity Individual Medical Case Management Cost-Effective Alternatives Appeals Medical Benefits Summary of PPO Enrollee Responsibilities Summary of PPO Medical Benefits...20 Summary of HDHP Enrollee Responsibilities Summary of HDHP Medical Benefits...22 Detailed Benefit Description...23 Deductibles...23 Coinsurance...23 Out-of-Pocket Maximum...23 Maximum Lifetime Benefits...23 Maximum Benefits...23 High Deductible Health Plan...23 Covered Services and Care Prescription Drug Benefits Participating Network Pharmacies Non-Participating Pharmacies Prescription Deductibles Coinsurance Generic Incentive Program Out-of-Pocket Maximum Mail-Order Services Clinical Guidelines Summary Of Enrollee Prescription Drug Costs Administering Carrier Prescription Plans Frequently Asked Questions Inclusions and Exclusions...34 Therapeutic/Drug Inclusions Therapeutic/Drug Exclusions...36 Pre-Existing Condition Limitations...37 Waiver of Pre-existing Condition Limitation Limitations and Exclusions...38 General Rules...38 Charges Not Covered...38 Limitations on Care...38 Specific Exclusions...38 Limitations and Exclusions Integration with Other Insurance Plans Coordination of Benefits...42 Other Types of Insurance Coverage and Protection...42 Third-Party Liability - Subrogation Claims Process Filing Your Own Claim...44 How to File...44 Appeals & Grievances...45 How to File a Grievance...45 What is a Grievance? First-Level Grievance Review...45 Second-Level Grievance...45 Grievance Review by MHIP Board Contacting Missouri DIFP...45 Glossary Miscellaneous Provisions Frequently Asked Questions TABLE OF CONTENTS STATE POOL

3 contact INFORMATION Anthem Blue Cross and Blue Shield Address PO Box Louisville, KY Blue CROSS AND BLUE SHIELD OF KANSAS CITY PO Box Kansas City, MO Application Assistance Enrollee Services Premiums Precertification Network Provider Information Disease Management Prenatal Programs Postpartum Programs Grievances Anthem Blue Cross and Blue Shield Grievance Unit Attn: Grievance Advisory PO Box Louisville, KY Nurse Assist Line Out-of-State Service Out-of-Country Service Missouri Department of Insurance, Financial Institutions and Professional Registration Catamaran (call collect) Consumer Complaints PO Box 690 Jefferson City, MO MHIP PO Box Jefferson City, MO Blue Cross and Blue Shield of Kansas City State Programs Attn: Complaints Analyst PO Box Kansas City, MO STATE POOL contact information 5

4 PLAN OVERVIEW How the Program Works MHIP is a managed health care program for residents of Missouri. It is designed to protect you from the high cost of medical expenses by promoting healthy practices and by providing comprehensive coverage. Five plan options, including a High Deductible Health Plan (HDHP) with a Health Savings Account (HSA), are available and vary by premium and deductible. One of the primary advantages of this managed care program is the large network of providers referred to as a PPO (Preferred Provider Organization). This PPO is composed of a network of physicians, hospitals and other providers of care. Although the plan allows you to use non-network provider care, you will find that network provider care has significant financial and administrative advantages. MHIP Certificate Read this certificate carefully and keep it as a reference. It will be your guide to the benefits available to you. The certificate also includes the limitations on your coverage and services not covered. Contact Blue Cross customer service for your area if you have questions about your coverage or the services described in this document. Identification Card (ID card) Once you enroll in the plan, you will receive an ID card to identify you as an MHIP enrollee. Use the card when you receive medical care or when filling a prescription. Choosing Doctors and Hospitals As a member of MHIP, you have the flexibility to choose any licensed physician, hospital or other health care provider for covered services. Since this is a PPO, you will have a higher level of coverage if you receive services from a network provider. The coverage under the PPO is higher because providers have agreed to discount their fees for patients who have coverage under the plan. If you choose a network provider, the plan will pay the provider directly for covered services and supplies. These providers agree to accept the negotiated fee for covered services. For covered services, you pay only the deductible and coinsurance, and charges that exceed maximum annual or lifetime benefit limits. There are currently more than 16,000 physicians and 130 hospitals participating in the MHIP PPO. It is your responsibility to check the provider network status before receiving any non-emergency care. Ask your providers whether they participate in the Blue Cross and Blue Shield PPO network. Another way to check network participation or provider information is to call or check online. In eastern, southern and central Missouri, call Anthem BCBS at or visit If you live in western Missouri, call or visit Services Outside Missouri The Missouri Health Insurance Pool s health care benefits are available only in the state of Missouri. White Area: Blue Cross and Blue Shield of Kansas City Shaded Area: Anthem Blue Cross and Blue Shield If you receive health care services outside Missouri, these services will be covered by the MHIP program only if the administrator determines that they were emergency services or that the care is medically necessary but not available in Missouri and the cost of the care is similar to what the care would cost in Missouri. 6 plan overview STATE POOL

5 Medical treatment received out of Missouri may result in higher outof-pocket costs. Your expenses can be reduced by seeking treatment from providers who participate with other Blue Cross and Blue Shield organizations outside Missouri. Other Blue Cross and Blue Shield organizations throughout the country have agreed to provide discounted fees, honor PPO level benefits, and handle claim processing for MHIP members requiring treatment outside Missouri. This is service is referred to as Blue Card. For information on out-of-state BCBS providers, please refer to the Contact Information Section. Non Network Care Treatment from non-network providers providers physically located in Missouri that do not have a contract with an MHIP carrier will result in higher out-of-pocket costs due to a higher deductible and coinsurance, and fees that may exceed the covered allowances. Nonnetwork providers have no obligation to assist in filing claims. If you choose a non-network provider, the plan will pay benefits based on the allowable covered charges for the services provided. You will be responsible for all charges exceeding the allowable covered charges, regardless of MHIP s maximum benefit allowance or the amount of MHIP s payment to you. MHIP will not pay for benefits if a medical provider waives the applicable coinsurance responsibility for an MHIP enrollee. In situations where precertification of benefits is required, you will be responsible for contacting Anthem BCBS at or BCBSKC at Explanation of Benefits You will be notified of the action taken when a claim has been received and processed on your behalf. This notification, called an Explanation of Benefits (EOB), includes information such as the health care provider, type of care and the charge amount. It will help you to be sure that the services billed are the services you received. The notice also shows the maximum the plan will pay for the procedure performed. The amount applied toward your deductible, the coinsurance amount and the actual benefit payment will be shown on the EOB. The benefit payment will be sent directly to the health care provider, if he or she is a network provider. You will receive an EOB notifying you of any deductible or coinsurance amount that is your responsibility. If you receive services from a nonnetwork provider, you may assign the benefits to the non-network provider in lieu of full payment at the time services are rendered. If the provider will not accept the assignment, you must submit a claim form to your carrier (Anthem BCBS or BCBSKC) with copies of all bills supporting the claim. You may call the customer service number on your ID card to have a claim form mailed to you. An EOB and any benefit payment will be sent directly to you. Managed Care Requirements MHIP includes several requirements and features that safeguard your health and save you money. Certain medical services must be preauthorized and monitored for appropriate care and length of service. Specific requirements precertification, recertification and retrospective review are described in greater detail in the Managed Care Section. If you receive care from a network provider, the provider will be responsible for contacting your carrier. Before proceeding with non-network surgery or admission to a non-network facility, you must notify your carrier to start the precertification process. Your carrier will review your case and may suggest alternatives or a network provider in your area. Nurse Assist Line All MHIP enrollees can obtain health care information by phone at no charge. Call the Nurse Assist Line and talk privately with an experienced registered nurse about symptoms or specific health questions. The nurse will help you learn about your condition and how to take care of yourself. If you call about surgery or a medical test, the nurse can help you understand what will be done, how it should help and possible complications. You can also call the Nurse Assist Line to listen to recorded messages on health care topics. The 24-hour Nurse Assist Line makes help available when you need it. Call for more information. STATE POOL plan overview 7

6 THIS IS NOT AN EMERGENCY HOT LINE. If you have an emergency, call 911. Wellness Tools MHIP wants its enrollees to enjoy good health. In addition to seeing medical providers for illnesses before they become serious, MHIP wants you to take steps to improve your health. MHIP s carriers have user-friendly websites and with health and wellness information, including general and specific suggestions to help you improve your health. The available information includes resources with tools to help you manage health issues, and assessments that can help identify your health risks. MHIP encourages you to complete these assessments to help improve your health and lifestyle. You will be asked questions about your family history and your habits, as well as questions about your health conditions and treatments. The information you send will be confidential, and the data will generate a profile of your health, with some specific recommendations for you to consider. You must log in or register to take these assessments. Health Education Materials MHIP s program emphasizes the importance of health education and healthy lifestyles. MHIP encourages all enrollees to take charge of their health and become educated health care consumers. Well-informed patients help ensure appropriate care and help control costs. MHIP may send health education materials to you from time to time, and MHIP hopes you will take the time to read the materials. Enrollee Surveys You may also be asked to give feedback on MHIP through telephone or mail surveys. These surveys utilize your information to evaluate the plan and identify areas that need improvement. All information collected from these surveys is confidential. How to Use This Certificate This MHIP Certificate is part of the legal agreement between you the enrollee and MHIP the plan sponsor. Anthem BCBS and BCBSKC are contracted with MHIP to perform services pursuant to their agreement with MHIP. The legal agreement includes the following documents: y Certificate and any amendments made to it y Application and any later applications you may make y ID card MHIP was established by statute in This document, in accordance with , contains all the terms of the legal agreement between you and MHIP, and supersedes all other statements and contracts, oral or in writing, with respect to the subject matter of the MHIP Plan. No change or modification to your agreement with MHIP will be valid unless it is in writing and signed by an authorized representative of MHIP. Anthem BCBS or BCBSKC will record the coverage you have in MHIP s enrollment records. When you change your coverage, the change will be reflected on your bill. This certificate is designed to make it easy for you to understand how you qualify, enroll, access providers, and determine benefits and requirements. When you have questions about any aspect of MHIP that cannot be answered by your carrier, please contact: Missouri Health Insurance Pool (MHIP) PO Box Jefferson City, MO plan overview STATE POOL

7 ELIGIBILITY All Missouri residents are eligible to enroll in MHIP if: y They can provide evidence of: A notice of rejection or refusal to issue substantially similar health insurance for health reasons by two insurers; OR A refusal by an insurer to issue substantially similiar health insurance, except at a rate exceeding the standard plan rate for similar health insurance y They are a federally defined eligible individual who has not experienced a break in coverage of 63 consecutive days. Refer to the Enrollment Section for more information y A trade act eligible individual. Refer to Trade Act Adjustment- TAA in the Glossary y A resident dependent of a person who is eligible for plan coverage y Any person who can be claimed as a dependent of a trade act eligible on the individual s tax filing y Any person whose health insurance coverage is involuntarily terminated for any reason, other than non-payment of premium or fraud, and who is not otherwise ineligible due to his or her MHIP claims in excess of $1 million, can be eligible. If application is made within 63 days after the involuntary termination, the effective date shall be on the date of termination of the previous coverage y Any person whose premium for health insurance coverage has increased to 150 percent to 200 percent of the rates established by the MHIP board y Any person currently insured who would have qualified as a federally defined eligible individual or a trade act eligible individual between the effective date of the federal Health Insurance Portability and Accountability Act of 1996, and 2008 People who are not eligible for MHIP are: y Persons who have, or can obtain, coverage similar to or more comprehensive than the MHIP options. This limitation does not apply to the following individuals: HIPAA eligible and/or TAA eligible or federally defined individuals A person who has coverage at a premium that is more than 150 percent of rates established as standard applicable rates A person may maintain other coverage for the period the person is satisfying any preexisting condition limitation waiting period under MHIP A person may maintain MHIP coverage for the period of time the person is satisfying a pre-existing condition waiting period under another health policy intended to replace MHIP coverage y Any person who at the time of pool application is receiving health care benefits under RSMo Section (MO HealthNet) y Any person having terminated MHIP coverage, unless 12 months have elapsed, unless the person is federally defined eligible y Persons eligible for Medicare y Persons for whom MHIP has paid $1 million in benefits y Persons eligible for public programs or inmates of public institutions, unless such a person is a federally defined eligible individual y Persons who are ineligible for other health insurance coverage due to alcohol abuse, substance abuse, or a self-inflicted injury, unless that person is a federally defined eligible individual or a trade act eligible individual y Persons eligible for COBRA, continuation of group health coverage under state law, or group health conversion coverage, except for people whose premiums are 150 percent or more of the standard insurance rates established by the board Adding Newborn Children A newborn child will be covered automatically until the child is 32 days old. Coverage during the first 31-day period will not be subject to a separate deductible from the enrollee, but will be subject to separate coinsurance and annual out-of-pocket limits based on the enrollee s plan. To cover the child after the first 31 days of life, you must notify the plan, submit a completed application and agree to pay premiums for the newborn child beginning on the child s 32nd day of life. If the newborn is enrolled in the plan, any care received after the 32nd day will be subject to the deductible and coinsurance applicable to the plan chosen for the newborn child. All charges for services rendered from STATE POOL eligibility 9

8 the date of birth will count towards the annual out-of-pocket maximum and lifetime maximum of the newborn child s plan. An adopted child can be added to coverage any time within 31 days of birth or 31 days of placement. The coverage established for the newborn child for this 31-day period includes coverage of all medically necessary care and treatment of medically diagnosed congenital defects and birth abnormalities, notwithstanding certificate limitations and exclusions applicable to other conditions or procedures covered by the plan. 10 eligibility State POOL

9 enrollment Enrolling in the Program Submit applications for MHIP coverage to the carrier for the area in which you live. The application is available online at If you don t have Internet access, call Anthem BCBS at or BCBSKC at to receive an application by mail. After you have completed and signed the application, send it to the carrier. Make sure you have included all required documentation. Incomplete documentation will delay the processing of your application. Once the application and accompanying documentation are reviewed, you will receive written confirmation that you have been accepted into MHIP. You will also be notified if MHIP s pre-existing condition exlusion applies or if you qualify for a waiver of the exclusion. Your coverage will go into effect the first day of the month after your application is approved. If you want your MHIP coverage to begin sooner to prevent a gap in coverage, MHIP will begin your coverage effective the day after the termination of your previous health coverage. If your MHIP eligibility is based on HIPAA rights, you will be able to choose between the date MHIP received your completed application or your COBRA termination date, whichever is later; or the effective date as outlined above. Premiums and Your Cost The required premiums are determined and established by MHIP and statutory requirements governing MHIP. The MHIP Board of Directors may change premiums: y If there are changes in federal and/or state law y After giving you 30 days written notice, changes can be made only if the same change is made for all enrollees of the same classification If your premium is paid beyond the effective date of the change, the plan may require you to pay an additional premium or accept a refund, whichever is necessary. Your first premium must be paid on or before the date coverage begins under this certificate. You will not be covered until MHIP receives the first payment. After the first payment, your premium will be payable by the end of the coverage month. Premiums may be paid through Electronic Funds Transfer (EFT). You may contact your carrier for any forms required to establish the EFT. It is your responsibility to pay premiums to your carrier in a timely manner. If your premiums are not paid by the end of the coverage month, your coverage will automatically terminate. The cancellation will be effective the last day of the period for which the premium was paid. The plan will not pay for any services you received after the date of cancellation. If services are cancelled for nonpayment of premiums, you must wait 12 months before you may be considered for re-enrollment. Refund Policy After reading this certificate, if you are not satisfied for any reason, you may return it to MHIP within 30 days from the date of receipt. All premiums you paid within that 30-day period will be refunded. However, any benefit payments made for any claims within that 30-day period will become your responsibility. No other refund of premiums will be made. Refund Policy for Termination of Coverage If it is determined that you were or have become ineligible for coverage on or after your effective date, MHIP may refund any or all premiums collected and terminate coverage retroactively to the date of your ineligibility, up to a maximum of 12 months. MHIP reserves the right to recover any amounts paid on your behalf under the plan. Changes in Coverage You may change your plan deductible only during the annual Open Enrollment period. For other coverage changes, including change of address, contact customer service for a change form. Please contact MHIP if you have any questions. Termination of Coverage Coverage Period An enrollee s coverage under the program shall be on a month-tomonth basis. Termination of Coverage An enrollee s coverage under the program shall automatically terminate as follows: y If an enrollee has engaged in fraud or made an intentional State Pool enrollment 11

10 misrepresentation of material fact with his or her application, the enrollee s coverage will terminate, without notice, retroactive to the effective date of such coverage y If the enrollee fails to pay the premiums required when such premiums are due or within the applicable 31-day grace period, the coverage will terminate, without notice, as of 11:59 p.m. on the last day of the period for which premiums were received (excluding any grace period) y If the enrollee ceases to reside in the state of Missouri, the coverage will terminate as of the date on which the enrollee fails to maintain Missouri residency. This limitation does not apply to HIPAA eligible, trade act eligible or federally defined individuals y If the enrollee obtains health insurance or an insurance arrangement or becomes eligible for continuation/ conversion coverage (provided the premium for such health insurance, insurance arrangement or continuation/conversion coverage does not meet the 300 percent threshold), the enrollee s coverage will terminate at the end of the coverage period in which the enrollee obtained such health insurance or insurance arrangement or became eligible for such continuation/conversion coverage y If it is determined the enrollee was eligible for MO HealthNet benefits at the time of enrollment in MHIP, coverage will terminate retroactive to the effective date of coverage y If the enrollee becomes an inmate of a public institution or becomes eligible for public programs, the enrollee s coverage will terminate, without notice, at 11:59 p.m. on the last day of the month in which the enrollee became an inmate of a public institution or became eligible for public programs y If the enrollee becomes eligible for Medicare, the enrollee s coverage will terminate, without notice, at 11:59 p.m. on the last day of the month in which the enrollee became a Medicare recipient y If the enrollee does not respond to a place of residence inquiry from MHIP or the enrollee s carrier within 31 days after the enrollee is notified in writing, the enrollee s coverage will terminate, without further notice, at 11:59 p.m. on the last day of such 31-day period y If the enrollee dies, the enrollee s coverage shall terminate, without notice, at 11:59 p.m. on the date of enrollee s death y If the enrollee notifies MHIP or his or her carrier, in writing, that the enrollee desires to terminate his or her coverage, the enrollee s coverage will terminate at 11:59 p.m. on the last day of the month in which such notice was given y The enrollee s coverage will terminate, without notice, on the date the program s aggregate payments on behalf of such enrollee reach $1 million Each enrollee is required to notify MHIP or his or her carrier, in writing, of the occurrence of any event that would result in the termination of the enrollee s coverage under the program. If, as a result of the enrollee s failure to notify MHIP or his or her carrier of the occurrence of a terminating event with respect to such enrollee, or if, despite such notice, MHIP or the enrollee s carrier fails to terminate the enrollee s coverage at the appropriate time as specified above, the enrollee shall be responsible to refund to the plan any payments that the carrier made for health care services received by the enrollee after the applicable termination date. MHIP will refund to the enrollee any premiums paid by the enrollee for coverage under the program for periods of time after the applicable termination date, up to 12 months. Health Insurance Portability and Accountability Act of 1996 (HIPAA) Federal legislation, known as HIPAA, establishes certain federal standards for the portability of health insurance coverage and the uses and disclosures of your personal health information (PHI). Portability Under this federal law, certain rights must be extended to any person applying for health insurance, if that person meets specific criteria. If they meet these criteria, they are federally defined eligible and must be offered guaranteed-issue coverage, without pre-existing condition limitations, through MHIP or similar options available in all states. These criteria include the following; y That person must have 18 months of creditable coverage, the most recent of which was under an employer, government or church group plan y Have no gaps in coverage of 63 or more full days within or after the 18 months of creditable coverage. y Have accepted and exhausted all available coverage under COBRA or a similar state continuation 12 enrollment STATE POOL

11 program y Must not be eligible for another group plan, Medicare or MO HealthNet y May not have other health coverage, with some exceptions (Contact carrier or MHIP for exceptions) y May not have had prior coverage cancelled for fraud or nonpayment of premium Your Right to a Certificate of Creditable Health Coverage You have the right to receive a certificate of creditable health coverage from MHIP. Your carrier will automatically issue a certificate of creditable coverage to you when coverage under MHIP ends. You may also request a copy at any time for purposes of documenting current MHIP coverage or within 24 months after your coverage terminates. You may request a certificate of creditable health coverage by contacting MHIP s carriers: Anthem Blue Cross and Blue Shield 1831 Chestnut St. St. Louis, MO Blue Cross and Blue Shield of Kansas City PO Box Kansas City, MO The certificate of creditable health coverage contains all the necessary information another health plan will need to determine whether you had prior continuous coverage that should be credited toward any pre-existing condition limitation period. State Pool enrollment 13

12 managed care Utilization Management Precertification, recertification, retrospective review and prior authorization These managed care provisions are an integral part of MHIP, and you must follow these provisions. These provisions help you use your benefits appropriately and efficiently. They help to keep costs affordable by curbing unnecessary hospitalizations and inappropriate procedures. Using Network Providers You don t need to call your carrier for precertification or recertification when you go to network providers. Network providers will handle that for you. Using Non-Network Providers If you go to a non-network provider for non-emergency care, follow the procedures described below to avoid a reduction in your benefits: y Call for precertification if you are to receive inpatient care at a non-network hospital, residential treatment facility or skilled nursing facility. This does not apply to an admission for childbirth y Call for precertification if you are to have outpatient surgery in a non-network facility. Outpatient surgery is performed on an outpatient basis in a hospital or free-standing facility y Call for precertification if you are to receive home health care or durable medical equipment from a non-network provider y Call for recertification if you are receiving care from a nonnetwork home health care agency and you need approval for more visits than initially approved y Call for recertification if you are an inpatient in a non-network facility and need to stay beyond the days initially approved y For maternity care, call for certification if you stay in the hospital for more than 48 hours after a vaginal delivery or 96 hours after cesarean delivery Call Anthem BCBS at or ; or BCBSKC at or If you do not obtain precertification or recertification when required, and your carrier later determines the care was not medically necessary, you will be responsible for all charges. If you do obtain precertification or recertification when required, and it turns out the care was not medically necessary, you will not be penalized for care approved by your carrier. Calling for Precertification When a call is received for certification of care you have not yet received, your carrier will make a determination about the care within two working days after obtaining all necessary information for consideration. The carrier will notify your physician or health care provider by phone within 24 hours. Precertification only applies to care that is directly related to the diagnosis and/or procedure and that is described in the patient s treatment plan. If care is certified, the carrier will send written confirmation to you and your health care provider within two working days after making the decision. If care is not approved, you and your health care provider will receive written confirmation within one working day after making the decision. When care is not approved, this is called an adverse determination. Precertification is not required before you go to the emergency room. However, if you are admitted as an inpatient from the emergency room, your carrier must be called within 48 hours or as soon as possible. You, your doctor or the hospital should call the appropriate certification center. Your carrier will notify you whether the inpatient setting is approved and, if approved, the number of days considered medically necessary. By calling your carrier, you may avoid financial responsibility for any inpatient care that is determined not to be medically necessary under your plan. You may be responsible for 100 percent of the charges if the care is not deemed medically necessary. Calling for Recertification When a request is received for additional inpatient days or additional services, your carrier will make a decision within one working day after receiving all necessary information. Your carrier will notify your health care provider by phone within one working day of making the decision. Then, within one working day of the call, the carrier will provide written confirmation to you and your health care provider. The written confirmation will include the number of extended days or the next review date, and the date of admission or start of services. 14 managed care STATE POOL

13 If care is NOT approved, your carrier will notify your health care provider by phone within 24 hours of making the adverse determination. The carrier will then provide you and your health care provider with written confirmation within one working day. Before a decision can be made about a precertification or recertification request, your carrier must have all the necessary information. If you or your health care provider does not provide the information, the request will be denied. Approval depends on whether the care is deemed medically necessary and delivered in the most appropriate setting. This is determined based on nationally recognized clinical criteria. If the care does not meet your carrier s criteria, the request will be reviewed by a health care provider. If the provider agrees with the carrier, the request will be denied, and benefits will not be provided for the care. If a request for precertification or recertification is denied, your health care provider may request reconsideration. If reconsideration does not resolve the matter, you may send a written letter of complaint, called a grievance. Your health care provider or your representative may file a grievance for you. You are not required to request reconsideration before you file a grievance. For more information, refer to How to File a Grievance in the Appeals and Grievances Section. If a request for recertification is denied, coverage for your care will continue until you are notified of the denial. The denial notice will give the reason for the denial. It will also explain how to request a written explanation of the clinical rationale and clinical review criteria used to make the decision. If you disagree with any managed care decision, you can file a grievance. Certification does not guarantee benefits. MHIP will not provide benefits if any of the following is true: The certification was based on material misrepresentation or omission of information about your health condition or the cause of your health condition Your health plan terminated before the services were provided Your coverage terminated before services were provided Certification for Care Already Received If you received care that was not precertified, your carrier will decide whether to cover the care within 30 days of receiving all the necessary information. The carrier will then notify you, your physician or your representative of its decision within 10 working days. If you are in a hospital or a skilled nursing facility and you no longer need inpatient care, you will be notified in writing. If you remain in the hospital or skilled nursing facility, benefits will not be provided after the date specified in the notice. Retrospective Review Your carrier will perform a retrospective review on the following types of care: y Care not subject to the precertification/recertification requirements described above y Care subject to the precertification/recertification requirements described above, but only if the network provider or enrollee fails to obtain such precertification/recertification The retrospective review will be performed within 30 days after such care is delivered. The enrollee and provider will be notified in writing of the results of the retrospective review within 10 days after the review is completed. The retrospective review will consider whether the care: 1. Was covered by the plan; AND 2. Was medically necessary. If the outcome for either requirement is NO, MHIP shall not be financially responsible for the care. Your carrier will look to the terms of the plan to determine whether the care is medically necessary. The carrier will base its determination on nationally recognized criteria mutually agreeable to the carrier and MHIP. If your carrier determines the care in question is not medically necessary, the carrier will have the decision reviewed by a provider selected by the carrier with experience related to the care in question. If the provider agrees with the carrier s determination, the carrier s decision will be binding, and the program will not be responsible to pay for such care. If the provider disagrees, your carrier s determination may be reversed, and the program may pay for such care. STATE POOL managed care 15

14 A decision by your carrier that the care in question is not covered by the program or not medically necessary will be considered an adverse determination, and may be appealed by the enrollee or the applicable provider pursuant to MHIP s grievance procedure. Adverse Determinations If your carrier makes an adverse determination, your physician has the right to ask for reconsideration. For more information, see What is an adverse determination? in the Appeals and Grievances Section. Your physician may discuss the decision with the reviewer who made the adverse determination. If that physician is not available, your physician may talk with another physician of the same or similar specialty that would typically manage the medical condition, procedure or treatment plan under review. The reconsideration will be done within one working day. If you are not satisfied with the reconsideration decision, you may file a grievance. You are not required to have your physician file for reconsideration before filing a grievance. Your health care provider or your representative may file for you. Filing a Grievance To file a grievance, including an adverse determination, call customer service to obtain a MHIP Member Grievance Form, or send a letter explaining your disagreement, including medical records and any information you believe supports your grievance. Send your letter or form with pertinent records to: Anthem Blue Cross and Blue Shield of Missouri Managed Care Grievance Unit PO Box St. Louis, MO Blue Cross and Blue Shield of Kansas City Attn: State Programs Complaint Analyst PO Box Kansas City, MO If you do not agree with MHIP s response to your grievance, you may file a second-level grievance. Also, if you believe the normal time frame for resolving a grievance would seriously jeopardize your life or health, you may request an expedited review. For more information, see How to File a Grievance in the Appeals and Grievances Section. Procedures Requiring Utilization Management Services requiring precertification include: y All inpatient admissions y Outpatient admissions y Outpatient surgery/procedures (including MRIs, CT scans and other imaging) y Skilled nursing facility or home health care y Residential treatment facility y Transplants Prior authorization for non-network care In the event an enrollee wishes to receive covered care from a nonnetwork provider based on the ACTION Precertification obtained Precertification or recertification not obtained, services determined to be medically necessary Precertification or recertification not obtained, services determined NOT to be medicallly necessary enrollee s belief that the provider offers care not available from a network provider, the enrollee may request that his or her carrier authorize the enrollee to obtain such care from the designated provider. To make the request, the enrollee must contact his or her carrier by telephone at the number in the Contact Information Section. Provide the carrier with all information requested regarding the care in question and the designated provider. Your carrier will make its decision within 30 days after receipt of both: y Request for service(s) y All information requested to make determination The carrier will notify the enrollee of its decision by telephone within 24 hours after it makes the decision, and will confirm such decision in writing within two working days after it makes the decision. The carrier will make its determination regarding the authorization based on its good-faith assessment of the relative capabilities of the designated provider and the available network providers. If the carrier decides not to authorize the enrollee to receive such covered care from the designated provider, your carrier will have the determination reviewed by a provider selected by the carrier with experience relevant to the care in question. RESULT Maximum benefits allowed No assurance that maximum benefit will be allowed No benefits 16 managed care STATE POOL

15 If the selected provider agrees with your carrier s determination, the requested authorization will be denied. If, however, the selected provider disagrees with the carrier s determination, the requested authorization will be granted. In the event the carrier authorizes the enrollee to receive covered care from the designated provider, the designated provider will be deemed a network provider with respect to such care for purposes of applying the annual medical deductible, coinsurance, and annual out-ofpocket maximum. Such care will still be subject to the precertification/ recertification requirements set forth in this section. In the event the carrier does not authorize the enrollee to receive covered care from such designated provider, the carrier s decision is considered an adverse determination and may be appealed by the enrollee pursuant to the procedures in the Appeals and Grievances Section. Disease Management MHIP, in conjunction with Anthem BCBS and BCBSKC, also offers a voluntary disease management program called Complex Care. Enrollees with chronic conditions such as asthma, congestive heart failure, diabetes, depression, cancer, and cardiovascular and musculoskeletal disease will be encouraged to participate in these customized programs. With a plan of care created just for you, you will learn behaviors to help you stay healthy between doctor visits. Call Anthem BCBS at or BCBSKC at for more information about these programs. Maternity Your coverage also includes maternity care programs. Anthem BCBS offers Baby Connection, and BCBSKC offers Little Stars. These programs provide proactive coaching for pregnant enrollees through obstetrics-trained registered nurses with experience in prenatal care. The program is supported by a team that includes physical and respiratory therapists, pharmacists and dietitians. This team is specifically trained to help enrollees set individual goals and will guide enrollees through behavior changes often required during pregnancy to help maintain the health of the expectant mother and baby. This approach also enables the team to address as many of the enrollee s health needs as possible. For more information, call Anthem BCBS at or BCBSKC at , extension There also is support for enrollees who may experience postpartum depression. Call Anthem BCBS at or BCBSKC s New Directions Behavioral Health at for more information about this service. Individual Medical Case Management The Individual Medical Case Management Program s purpose is to identify enrollees who would benefit from a case management program, to involve consultant resources, and to assist enrollees in utilizing appropriate community health services to maximize their medical benefits. Enrollees who would benefit from Individual Medical Case Management are typically those with chronic medical conditions that require ongoing medical care or those with extremely severe illnesses. The plan uses a screening process to identify enrollees who would benefit from Individual Medical Case Management. Participants could be identified by: y Certain diagnoses on claims y High-cost claims, including organ transplants y Long-term inpatient stay recommended y Certain types of care or prescriptions y High-risk pregnancy y High-risk newborn Participants will be notified that they have been selected for Individual Medical Case Management. An enrollee or someone acting on the enrollee s behalf can request a referral. A plan of action, developed with the enrollee s provider and the enrollee, may be required before a final determination is made on enrollment in Individual Medical Case Management. Any determination regarding enrollment in Individual Medical Case Management must include the enrollee s consent, and a finding that Individual Medical Case Management is necessary and effective. The carriers provide Individual Medical Case Management services only when and for so long as it determines that Individual Medical Case Management is necessary and effective. Payment for all care provided under Individual Medical Case Management will be subject to the annual medical deductible and coinsurance. STATE POOL managed care 17

16 The carrier may provide extra contractual benefits (such as care not normally covered by the plan) in connection with Individual Medical Case Management when and for so long as the carrier determines the extra contractual benefits are necessary and effective. Appeals You may appeal a benefit determination for the above programs by following the procedure outlined in the Appeals and Grievances Section. Such extra contractual benefits will be deemed covered care for purposes of the program and will be subject to the same annual medical deductible and coinsurance as other covered care. The decision to provide Individual Medical Case Management and/ or extra contractual benefits in one instance will not obligate the carrier to provide the same or similar benefits for another enrollee in any other instance, nor will it be construed as a waiver of the carrier s right to administer the program in all other respects in strict accordance with the express terms of this description. Cost-effective Alternatives The plan may use prudent business judgment by making limited exceptions to the terms of MHIP. When the cost of equivalent services from different providers or suppliers varies significantly, the plan may consider these variations when determining benefits. Such decisions will be made only after establishing the costeffectiveness of a medically necessary service and with the understanding of the affected enrollee. Any such decisions will not, however, prevent the plan and its carrier from administering the plan in strict accordance with its terms in other situations. 18 managed care STATE POOL

17 medical benefits This section illustrates the services, supplies and procedures covered under MHIP. The benefits are only for services, supplies and procedures that are medically necessary and consistent with evidence-based medical practices. It is important to understand that some care may be necessary but not covered, or limited according to MHIP guidelines. The following summaries include: y Benefits and services paid by MHIP s traditional PPO plans. Most of these services are subject to an applicable deductible, coinsurance and limitations y Your costs for each PPO plan y Benefits and services paid by MHIP s High Deductible Health Plan (HDHP), which qualifies for a Health Savings Account (HSA) y Your costs for the HDHP y Details on all plans, including limitations and conditions for treatment, and covered procedures Annual Deductible Plan I Plan II Plan III Plan IV Coinsurance Applies after deductible is met Out-of-Pocket Maximum (Deductible + Coinsurance) Plan I Plan II Plan III Plan IV SUMMARY OF PPO ENROLLEE RESPONSIBILITIES $500 $1,000 $2,500 $5,000 Network Care received from network providers Non-Network Care received from non-network, licensed doctor or facility $1,000 $2,000 $5,000 $10,000 20% 50% $3,000 $6,000 $7,500 $10,000 No limit Maximum Lifetime Benefit $1 million Preventive Care 20% of cost (no deductible) 50% of cost (no deductible) Physician Fees 20% of cost after deductible 50% of cost after deductible Urgent Care 20% of cost after deductible 20% of cost after deductible (in emergency) Specialist Fees 20% of cost after deductible 50% of cost after deductible Ambulance Services 20% of cost after deductible 20% of cost after deductible (in emergency) Hospital Services 20% of cost after deductible 50% of cost after deductible Skilled Nursing Care Limited to 90 days per year Hospice Care Limited to 100 days 20% of cost after deductible 50% of cost after deductible 20% of cost after deductible 50% of cost after deductible Emergency Room 20% of cost after deductible 20% of cost after deductible (in emergency) STATE POOL medical benefits 19

18 Preventive Care Not subject to deductible Medical Services Subject to deductible, coinsurance and maximum SUMMARY OF PPO MEDICAL BENEFITS Cancer screenings Annual pelvic exam and Pap smear Colorectal screening and related lab tests Prostate exam and related lab tests Mammogram and manual breast exam Immunizations Lead poisoning tests Newborn hearing screenings Osteoporosis screenings Prenatal HIV testing and other mandated newborn screenings Ambulance service Emergency room care Chiropractic care Maintenance care excluded Home health care, respiratory and infusion therapy care Limited to 90 days per year Hospice Limited to 100 days Hospital Services Includes physician services Surgery and Related Services Physician office Outpatient hospital Inpatient hospital Inpatient hospital care Maternity care Physician office Hospital or other facility (inpatient or outpatient) Mental health (inpatient) Limited to 180 days per year Outpatient hospital care Chemotherapy Radiation therapy Dialysis treatment Cardiac and pulmonary rehabilitation (for certain diagnoses; subject to limitations) Substance Abuse Treatment Outpatient Limited to 30 one-hour sessions Inpatient Limited to 21 days Day treatment Limited to 30 days Medical and social detoxification Limited to six days Physical Therapy Maintenance care excluded Limited to 20 visits per calendar year for most therapy Occupational therapy unlimited Speech therapy unlimited 20 medical benefits STATE POOL

19 SUMMARY OF HDHP ENROLLEE RESPONSIBILITIES Network Care received from network providers Non-Network Care received from non-network doctor or facility Annual Deductible $2,500 Combined with network deductible Coinsurance Applied after deductible is met Out-of-Pocket Maximum Deductible + coinsurance Maximum Lifetime Benefit 20% 50% $5,000 $10,000 $1 million Preventive Care 20% of cost (no deductible) 50% of cost (no deductible) Physician Fees 20% of cost after deductible 50% of cost after deductible Urgent Care 20% of cost after deductible 20% of cost after deductible (in emergency) Specialist Fees 20% of cost after deductible 50% of cost after deductible Ambulance Services 20% of cost after deductible 20% of cost after deductible (in emergency) Hospital Services 20% of cost after deductible 50% of cost after deductible Skilled Nursing Care Limited to 100 days per year Hospice Care Limited to 100 days 20% of cost after deductible 50% of cost after deductible 20% of cost after deductible 50% of cost after deductible Emergency Room 20% of cost after deductible 20% of cost after deductible (in emergency) Prescription Drugs 30% of cost after deductible (BCBSKC) 20% of cost after deductible (Anthem) 30% of cost after deductible (BCBSKC) 50% of cost after deductible (Anthem) STATE POOL medical benefits 21

20 Preventive Care Not subject to deductible Medical Services Subject to deductible, coinsurance and maximum Hospital Services Includes physician services Surgery and Related Services Substance Abuse Treatment 10 episode maximum Physical Therapy Maintenance care excluded SUMMARY OF HDHP MEDICAL BENEFITS Routine wellness visit Cancer screenings Annual pelvic exam and Pap smear Colorectal screening and related lab tests Prostate exam and related lab tests Mammogram and manual breast exam Immunizations Lead poisoning tests Newborn hearing screenings Osteoporosis screenings Prenatal HIV testing and other mandated newborn screenings Ambulance service Emergency room care Chiropractic care Maintenance care excluded Home health care, respiratory and infusion therapy care Limited to 100 visits per year Hospice Limited to 100 days Inpatient hospital care Maternity care Physician office Hospital or other facility (inpatient or outpatient) Mental health (inpatient) Limited to 180 days per year Outpatient hospital care Chemotherapy Radiation therapy Dialysis treatment Cardiac and pulmonary rehabilitation (for certain diagnoses; subject to limitations) Physician office Outpatient hospital Inpatient hospital Outpatient Limited to 30 one-hour sessions Inpatient Limited to 21 days Day treatment Limited to 30 days Medical and social detoxification Limited to six days Limited to 20 visits per calendar year for most therapy Occupational therapy unlimited Speech therapy unlimited 22 medical benefits STATE POOL

21 Detailed Benefit Description In addition to deductibles and coinsurance, many of the benefits and services listed in this section are subject to requirements in the Managed Care, Pre-existing Condition Limitations, and Exclusions and Limitations Sections. MHIP has the authority to determine your eligibility for benefits and all terms in your Certificate. Benefits may be amended from time to time. Deductibles The deductible represents the calendar year first-dollar cost sharing for the enrollee. Most benefits are subject to the deductible before any benefits are covered. Certain preventive care tests and services are not subject to the annual deductible. The prescription drug plan, through Catamaran, has a separate annual deductible. The exception to a separate prescription deductible is the HDHP, which has a combined annual deductible. Coinsurance After you meet the required deductible, you and the plan will share the cost for covered expenses during each calendar year at either 80 percent for network care or 50 percent for non-network care. Exceptions to the coinsurance are: y Medical emergencies that are treated by non-network providers will be paid at the network coinsurance level if these services are considered medically necessary and meet the definition of Emergency Medical Condition in the Glossary y Urgent care visits that are treated by non-network providers will be paid at the network coinsurance level if these services are considered medically necessary and meet the definition of Urgent Care in the Glossary y Consideration for covered special care that is not available innetwork. These will be paid by MHIP at the network coinsurance level. This situation will require prior authorization by the administering carrier before the treatment or procedure is performed. Out-of-Pocket Maximum The sum of the deductible and the coinsurance is limited for covered network services. This maximum excludes non-network care. The PPO plan maximum does not include prescription copayments, which have separate limits. Separate rules apply for the HDHP, which has a combined deductible and a $10,000 out-of-pocket maximum for non-network care. Maximum Lifetime Benefits The maximum lifetime payment allowance for all covered services, including prescriptions, is $1 million per enrollee. Maximum Benefits Certain benefits under the Certificate are subject to maximum annual benefit limits (such as days of inpatient care and home infusion therapy care), or lifetime benefit limits (such as mental illness and substance abuse treatment). High Deductible Health Plan The benefits of the High Deductible Health Plan (HDHP) are similar to the PPO plan benefits, with the following exceptions: y Prescriptions are subject to the same deductible as medical care y HDHP enrollees may establish and contribute to a Health Savings Account (HSA). These contributions are limited to $3,050 per year for enrollees up to age 55 and $4,050 for those 55 and older y The funds may be used for noncovered medical expenses such as deductibles, or other services or supplies covered under Section 26U S.C., Section 223 of the IRS code y Unspent funds may remain in the HSA to be used for future health expenses. More HSA information is available from the carriers y If funds are not used for qualified medical expenses, they are subject to income taxes and a 20 percent IRS penalty STATE POOL medical benefits 23

22 Benefit Allergy Diagnosis and Treatment Provided in physician s office Ambulance Services When enrollee cannot be safely transported by other means, the plan will cover reasonable charges for the following ground ambulance services: Transportation to the closest hospital with appropriate facilities or from one hospital to another for medically necessary inpatient care. Applies to transfers for further emergency care or for further inpatient care Transportation to the closest hospital with appropriate facilities for medically necessary outpatient care for an injury or illness resulting from an accident or medical emergency Anesthesia Services Professional care rendered in connnection with surgery or other care that is covered by the plan Continuous epidural anesthesia is covered when used for control of chronic, intractable pain due to terminal cancer or when used for control of acute post-operative pain Autism Spectrum Disorder Treatment for autism spectrum disorder including, but not limited to: Psychiatric care Psychological care Habilitative or rehabilitative care, including applied behavior analysis therapy Therapeutic care Pharmacy care COVERED SERVICES AND CARE Limitations and Exclusions Limited to office visits and medically necessary testing, injections and allergy antigens MHIP will only pay benefits when evidence clearly shows the hospital to which a patient is transported is the closest one with the appropriate specialized tratement facilities, equipment or staff physicians The plan may adjust maximum payments without notice Air ambulance is a benefit only when terrain, distance or the enrollee s condition requires an air ambulance. The plan s medical consultants determine on a case-by-case basis when transport by air ambulance is a benefit The plan will not pay for other transportation services not specifically covered, such as private automobile, aviation, commercial or public transportation, or wheelchair ambulance If the enrollee could have been transported by automobile, commercial or public transportation without endangering the enrollee s health or safety, an ambulance trip will not be covered. The plan will not pay for such ambulance services even if other means of transportation were not available When performed and/or billed by the operating or delivering physician, only the following are covered: Epidural anesthesia Spinal anesthesia Local anesthesia General anesthesia The anesthesiologist or anesthetist must be present during the entire surgical procedure. The procedure must be medically necessary, and the enrollee s condition must warrant anesthesia attendance Not available in connection with non-covered care Only covered in connection with dental care for the following: Enrollees through age 4 Enrollees who are severely disabled Enrollees who have severe medical or behavioral conditions that require hospitalization or general anesthesia when dental care is provided Coverage is limited to medically necessary treatment that is ordered by the insured s treating licensed physician or licensed psychologist in accordance with a treatment plan The treatment plan shall include all elements necessary for MHIP to pay claims. Such elements include, but are not limited to, a diagnosis, proposed treatment by type, frequency and duration of treatment, and goals MHIP has the right to review the treatment plan not more than once every six months, unless MHIP and the individual s treating physician or psychologist agree that a more frequent review is necessary $41,263 annual limit. The maximum may be exceeded, upon prior authorization, if services beyond the maximum limit are medically necessary 24 medical benefits STATE POOL

23 Benefit Blood Administration and processing of blood Chemotherapy Includes transportation to and from facility approved to provide care for enrollee and one other individual. If enrollee is a minor, transportation covered for enrollee and two other individuals Chiropractic Services Provided by licensed chiropractor No precertification necessary Cleft Palate/Cleft Lip Correction Surgical procedures and related expenses Inpatient hospital care Necessary outpatient services, including: Speech therapy Otolaryngology treatment Audiology assessments Prosthetic treatment, such as obturators, speech appliances and feeding appliances Clinical Cancer Trials Routine patient care costs incurred as the result of a Phase II, III or IV clinical trial that is approved by an appropriate entity and is undertaken for the purposes of the prevention, early detection or treatment of cancer Dental Services Must meet all of the following criteria: Accident resulting in other injuries outside mouth or oral cavity Injury occurred while coverage in effect (applies regardless of any pre-existing condition clause or waiver thereof). This limitation does not apply to HIPAA eligible, TAA eligible or federally defined individuals Injuries to sound, natural teeth Treatment necessary to restore teeth to their condition immediately before accident Related services received within 12 months of accident Services received while coverage in effect COVERED SERVICES AND CARE Limitations and Exclusions No coverage for charges related to the procurement or storage of blood or blood products, or blood donor expenses No coverage for blood received for non-covered surgical procedure Total transportation, lodging and meal expense payment limited to $10,000 for each procedure No coverage for acupuncture, biofeedback therapy or vitamin/ supplement therapy, regardless of whether performed or prescribed by a chiropractor Precertification required Includes routine patient care costs incurred for drugs and devices that have been approved for sale by the FDA, regardless of whether they have been approved by the FDA for use in treating the patient s condition Includes reasonable and medically necessary services needed to administer the drug or use the device under evaluation in the clinical trial Written precertification required No coverage for routine dental care No coverage for injuries caused by biting or chewing Restorations limited to services, supplies and appliances determined to be appropriate in restoring mouth, teeth or jaws to condition before accident No coverage for surgical preparations for dentures No coverage for services related to non-covered dental procedures No coverage for non-covered dental procedures in connection with medically necessary hospital stay for hazardous medical conditions STATE POOL medical benefits 25

24 Benefit Durable Medical Equipment (DME) Rental or purchase, whichever is less expensive, when related to a covered condition Repair or replacement of purchased DME when necessary due to normal use Oxygen and the equipment needed to administer it (one permanent and one portable unit per enrollee) Hairpieces and Hair Implants Home Health Care Services provided under active physician and nursing management through certified agency, when medically necessary Includes professional nursing services, physical therapy, occupational therapy, respiratory and inhalation therapy, speech therapy and audiology, medical social services, home health aide services and medical supplies Home Infusion Therapy Care When prescribed by enrollee s physician and medically necessary. Includes: IV fluids IV antibiotic therapy IV analgesic therapy Enteral therapy supplies and equipment Total parenteral nutrition Growth hormone therapy for enrollees with documented growth hormone deficiencies FDA-approved chemotherapy Hospice Care Care received under active physician and nursing management through licensed agency responsible for coordinating all hospice services. Includes: Hospice day care services Routine home hospice services Professional nursing services Home health aide services Respiratory and inhalation therapy Medical social services Short-term inpatient or continuous home care Medical supplies Physician services COVERED SERVICES AND CARE Limitations and Exclusions Limited to reasonable charges in relation to condition and charges billed by most suppliers for comparable items No coverage for repair or replacement due to loss, misuse or abuse Deluxe or luxury equipment covered only when additional features are required for effective treatment or to allow enrollee to operate equipment without assistance No coverage for hospital beds, including water beds or other flotation mattresses, for chronic back pain Coverage only for wigs purchased because of hair loss due to covered radiation therapy or chemotherapy, up to a maximum of $200 per calendar year, not to exceed a lifetime maximum benefit of $3,200. Under Plan V, there is a maximum benefit of $500 per calendar year Precertification required Limited to 90 two-hour visits per year, 100 visits per year under Plan V Nursing services limited to $50,000 per year, and $100,000 lifetime maximum under Plan V No coverage for dietary services, homemaker services, maintenance care or therapy care, except as set forth in Article VII.A.1.b, transportation to and from a hospital, convalescent, custodial or domiciliary care, dialysis equipment, food, or care for mental illness or substance abuse Must be administered by home infusion therapy care provider Must be provided pursuant to a plan of treatment Limited to an aggregate of 90 days per year Does not include: Dietary services Investigational care Convalescent or custodial care Fluids for dialysis treatment (hemodialysis or peritoneal) Care not expressly specified Only for terminally ill enrollee with life expectancy of six months or less, who has voluntarily requested admission and been accepted into a hospice program Home hospice services subject to 90-day visit limit (100-visit limit under Plan V) for professional nursing services and home health aide services Prior authorization and precertification required for shortterm inpatient or continuous home care, limited to 90 days No coverage for services related to well-baby care, food services or meals other than dietary counseling, services or supplies for personal comfort or convenience (except in crisis periods or in association with respite care), pastoral care or care to prolong life The plan reserves the right to periodic review of treatment plans 26 medical benefits STATE POOL

25 Benefit Hospital Services Inpatient: Medically necessary inpatient room expenses and ancillary charges up to 180 days per year, based on semi-private room rates; subject to negotiated fee schedule limitations Outpatient: Ancillary services billed by a hospital Hemodialysis covered during medically necessary inpatient stay and as outpatient treatment Laboratory, Pathology, X-ray and Radiology Services Provided by a physician, independent pathology laboratory or independent radiology center Maternity and Newborn Care Labor, delivery, recovery, postpartum and nursery room, and covered services: Premature labor, false labor, premature rupture of membranes, placenta previa and other complications directly related to pregnancy Spontaneous termination of pregnancy prior to full term Routine newborn services Routine physician and hospital care of well newborn Newborn hearing screening, rescreening and audiological assessment Screening for potentially treatable disorders Prenatal medical care Laboratory and X-ray services related to prenatal or postnatal care Medical Care Provided by physician or licensed health care professional in accordance with negotiated fee schedule Inpatient physician charges covered for condition requiring only medical care or condition that, during admission for surgery, requires medical care not normally related to surgery performed Necessary outpatient care for treatment of illness, disease or injury, or pain management services for treatment of chronic, intractable pain when provided or managed by physician with documented experience in pain management COVERED SERVICES AND CARE Limitations and Exclusions Precertification required for prescribed inpatient hospital services Certain outpatient hospital services may be subject to precertification Private room expenses only covered if medical condition requires isolation to protect enrollee or others from exposure to dangerous bacteria or diseases When home care replaces inpatient or outpatient dialysis treatments, the plan will pay for rental or purchase of dialysis equipment (whichever is less expensive) for in-home use Physician charges for services when enrollee is an inpatient or outpatient in a hospital or other facility only covered when the facility will bill only for technical services, or the facility will not submit any charges for lab or X-ray services No coverage for services related to weight loss No coverage for services related to non-covered care 48-hour hospital stay with vaginal delivery 96-hour hospital stay with cesarean delivery Two home visits covered at 100 percent if discharge occurs earlier than the time periods listed above with at least one visit in the home, in accordance with accepted maternal and neonatal physical assessments, by a registered professional nurse with experience in maternal and child health nursing or a physician. Services provided by the registered professional nurse or physician shall include, but not be limited to, physical assessment of the newborn and mother, parent education, assistance and training in breast or bottle feeding, education and services for complete childhood immunizations, the performance of any necessary and appropriate clinical tests and submission of a metabolic specimen satisfactory to the state laboratory Inpatient benefits for one attending physician per covered hospitalization. Second physician covered in case of transfer from one physician to another for inpatient care of same condition, so long as days each physician is responsible for care are not duplicated STATE POOL medical benefits 27

26 Benefit Medical Emergency/Urgent Care Refer to Hospital Services Mental Illness/Substance Abuse Mental Illness care includes: Outpatient treatment, including partial or full-day programs Two sessions per year to diagnose or assess condition in office of licensed psychiatrist, psychologist, clinical social worker or professional counselor; preapproval or certification not required Residential treatment programs Substance abuse care includes: Non-residential and partial or full-day programs up to 30 days per year Residental treatment and inpatient care up to 21 days per year Medical or social detoxification up to six days per year Patient Education Programs Material available directly from MHIP Free online programs offered by Anthem BCBS and BCBSKC Includes diabetes self-management training Preventive Care and Diagnostic Tests Cancer screenings Annual pelvic exam and Pap smear Colorectal screening and related tests Prostate exam and related lab tests Mammogram and manual breast exam One between ages 35 and 39 Annually for women 40 and older Any woman with family history of breast cancer (mother or sister) on doctor s recommendation One well-woman, man or child exam per year Immunizations Lead poisoning test for pregnant women, and children younger than 6 Newborn hearing screenings, necessary rescreening, audiological assessment, follow-up and initial amplification Newborn screening for potentially treatable disorders Osteoporosis screening Prenatal HIV testing and other mandated newborn screenings COVERED SERVICES AND CARE Limitations and Exclusions Certification must be sought within 48 hours for hospital admissions from emergency room Emergency care from non-network provider is paid as network benefit if care meets definition of emergency care Non-network urgent care is paid as network benefit if treatment is for a condition that arises suddenly, is nonlife-threatening and requires immediate care Precertification required for mental health and substance abuse treatment in a facility Mental health inpatient care limited to 180 days per year Substance abuse coverage limited to 10 episodes of treatment during member s lifetime. Does not apply to medical detoxification in a life-threatening situation, as determined by treating physician and documented within 48 hours to the reasonable satisfaction of the carrier Provider must be certified by Missouri Department of Mental Health, accredited by nationally recognized organization or licensed by the state Covered up to $250 per year when prescribed by enrollee s attending physician Not subject to deductible Coinsurance applies to out-of-pocket maximum Immunization coverage limited to immunizations required by the Missouri Department of Health and Senior Services or recommended by the Centers for Disease Control and Prevention Services recommended by the U.S. Preventive Services Task Force (Categories A and B) 28 medical benefits STATE POOL

27 Benefit Prosthetic Devices and Orthopedic Appliances Reasonable charges for prostheses and orthopedic appliances, as well as fitting, adjustment, repair and replacement due to normal use or change in condition Artificial arms, legs or eyes Leg braces, including attached shoes Arm and back braces Maxillofacial prostheses Cervical collars Surgical implants External breast prostheses and mastectomy bras after a mastectomy Skilled Nursing Facility and Rehabilitation/Transitional Care Covered under same requirements as inpatient care, based on daily limit equal to semi-private room rate and any other eligible expenses, while enrollee is under continuous physician care and requires 24-hour nursing care and the confinement is in lieu of medically necessary hospital stay Spiritual Healing Supplements Non-prescription drugs and food, food supplements and nutritional formula Surgery Includes preoperative visits, local administration of anesthesia, follow-up care and recasting Standby anesthesia may be covered, depending on circumstances Includes mastectomies and physical complications of mastectomies, including lymphedemas, as well as breast reconstruction of the affected and unaffected sides, including internal prosthetic devices Additional procedures completed during primary surgery covered at reduced allowance, as determined by Anthem BCBS or BCBSKC COVERED SERVICES AND CARE Limitations and Exclusions As prescribed by a physician acting within the scope of his or her practice Orthopedic shoes are covered only when they are used with an attached leg brace. No coverage for orthotics and arch supports, elastic stockings and garter belts Precertification required Limited to 90 days per calendar year, 100 days per year under Plan V No coverage for services or supplies provided for personal convenience that are not related to the treatment of the enrollee s condition Covered up to $25 per session, limited to Christian Science practitioners Coverage limited to testing and nutritional formulas recommended by physician to diagnose and treat phenylketonuria (PKU) or any inherited disease of amino and organic acids. Formula must be purchased from a network durable medical equipment (DME) provider, or other approved provider at the direction of MHIP Precertification required More than one surgery performed during the course of an operative period is a multiple surgery. Benefits for multiple surgeries are reduced so that pre- and post-surgery allowances of the major surgery are not duplicated Ambulatory surgery: No coverage for inpatient room charges or other charges that would not be incurred if the enrollee could have had surgery performed in a physician s office or in the outpatient department of a hospital or other facility Written authorization required for cochlear implantation No coverage for subsequent procedures to correct injury or illness resulting from enrollee s noncompliance with prescribed medical treatment STATE POOL medical benefits 29

28 Benefit Surgical Assistants Covered when services are provided by an assistant credentialed by a hospital to provide such services Therapies Inpatient therapy covered when provided by a hospital or other facility: Physical therapy, limited to 20 visits per year Occupational therapy, limited to 20 visits Speech therapy, unlimited; services must be approved in advance Outpatient therapy covered when prescribed by physician and performed by appropriate physician or licensed health care provider: Physical therapy Occupational therapy Speech therapy, when speech is lost due to trauma or disease, regardless of enrollee s age, as well as for the development of speech in children with congenital disorders or birth abnormalities Diagnostic testing, including auditory testing, so long as it is performed by a qualified provider Eligible conditions include, but are not limited to, acute injury or illness; acute episode of chronic condition; chronic, progressive conditions, such as multiple sclerosis, arthritis, ALS and cerebral palsy; cardiac rehabilitation and pulmonary rehabilitation COVERED SERVICES AND CARE Limitations and Exclusions When the assistant surgeon also bills for other services covered by MHIP: Assistant surgery services are not a benefit when the same physician is paid for surgical services performed on the same enrollee on the same day. Only the greater of the two benefits will be allowed When the assistant surgeon also bills for medical care for the same condition that requires surgery, an allowance will be paid only for care provided up to the date of surgery When assistant surgeon bills for medical care for a condition not related to the surgery, medical care and assistant surgery services are covered Benefits available only for procedures of such complexity that they require an assistant, as determined by carrier If assistant surgery is performed by resident intern or other person paid by the hospital, the plan will not allow medical-surgical benefits for the assistant surgery No coverage for expenses of non-covered surgical procedures Limitations and Exclusions on Surgery also apply Precertification required for all therapies Precertification approval based on medical necessity as determined by medical case manager Services for children with disabilities must be provided by therapists experienced and/or trained in developmental pediatric therapies Benefits differ based on diagnosis or condition of enrollee No coverage for: Recreational, sex, primal scream, sleep and Z therapies Self-help, stress management and weight-loss programs Transactional analysis, encounter groups and transcendental meditation (TM) Sensitivity or assertiveness training Rolfing Religious or marital counseling Holistic medicine and other wellness programs Educational programs such as cardiac class or arthritis class Chelation therapy, except for acute arsenic, gold, mercury or lead poisoning 30 medical benefits STATE POOL

29 Benefit Transplants Transplant care is very specialized and uses the Centers of Excellence program. The transplant network is separate from the network for other care. If your physician indicates you need a transplant, ask your physician to contact Anthem BCBS at or BCBSKC at Covered transplants include cornea, kidney, liver, lung, pancreas, heart, small bowel, bone marrow and stem cell for certain conditions The plan will pay for inpatient room expenses and ancillary services in a designated transplant facility, subject to the limitations of the plan Outpatient services provided by a hospital or other facility are covered, subject to the limitations of the plan For the recipient, the plan will allow benefits for covered medical expenses, including follow-up expenses for covered transplants, immunosuppressant therapy and use of temporary mechanical equipment, pending the acquisition of human organs For the donor, the plan will allow benefits for testing to identify a donor, acquisition of an organ from a donor, and storage and transportation costs incurred and directly related to the donation of an organ used in a covered organ transplant procedure Unrelated donor searches: Bone marrow/stem cell transplants for covered procedure limited to $30,000 per transplant. No coinsurance for enrollee or for live donor expenses for covered procedures in Centers of Excellence HOTT program. Enrollees not participating in network responsible for 30 percent of maximum allowable amount If travel is required for approved transplant, MHIP will cover up to $10,000 in reasonable and necessary expenses for transportation, lodging and meals Vision Exams COVERED SERVICES AND CARE Limitations and Exclusions Care must be approved and coordinated in writing through Anthem BCBS or BCBSKC Surgeon must obtain written authorization for transplant benefits before date of service. MHIP or its designee is responsible for determining whether a transplant is medically necessary and standard treatment on case-bycase basis Benefit levels for transplant care may differ significantly from other types of medical care For care administered through the Human Organ Tissue and Transplants (HOTT) program using Centers of Excellence program and network, no copayment for care starting one day before the covered transplant and continuing for the applicable case rate or global time approved under the specific contracted arrangement. This time frame differs based on several variations Transplants pursued in full or partially outside the Centers of Excellence network require 30 percent copayment, with no out-of-pocket maximum. Enrollee will also be responsible for transportation and lodging Transplants for uncovered procedures will not be covered, regardless of where the procedure is performed No coverage for follow-up expenses for non-covered transplants Donor expense coverage limited to $30,000 per procedure Non-covered charges for transportation, meals and lodging include, but are not limited to, alcohol, tobacco and non-food items; child care; mileage within the transplant city; rental car or public transportation, other than what is approved; frequent-flier miles; coupons, vouchers, travel tickets, prepayments or deposits; services for an unrelated condition; telephone calls, laundry, postage and entertainment; interim visits to medical facility while waiting for transplant procedure; travel expenses for donor, companion or caregiver; or return visits for donor for treatment of condition found during evaluation No coverage for transplants using non-human animal organs or artificial organs No benefits for transplant surgery expenses when medically approved alternatives are available Services and related charges apply to lifetime maximum Limited to one per calendar year Wellness Services See Preventive Care and Diagnostic Tests benefit STATE POOL medical benefits 31

30 prescription drug benefits You are automatically enrolled in the MHIP prescription benefit plan when you enroll in the medical plan. MHIP has contracted with an independent prescription benefit manager (PBM), Catamaran, for prescription services for Plans I through IV. Plan V is administered through the PBMs of Anthem BCBS and BCBSKC. Participating Network Pharmacies Pharmacies have contracted with the PBMs to offer reduced prices for covered prescription drugs. Network pharmacies and the mail-order pharmacy can provide significant savings and convenience. Non-Participating Pharmacies If a covered drug is purchased from a non-participating pharmacy or from a participating pharmacy when the enrollee s ID card is not used, the enrollee must pay the entire cost of the prescription and submit the receipt to his or her PBM for reimbursement. The enrollee will be reimbursed only if the drug is covered by the plan and only for the discounted network price the PBM would have paid a participating pharmacy, minus any applicable deductible and coinsurance. This amount may be significantly lower than the retail price the enrollee actually paid. It is always best to use a network pharmacy and present your ID card. Prescription Deductibles The MHIP prescription deductibles for Plans I, II, III and IV are separate from the medical plan deductible. Plan V has one deductible for medical and prescription expenses. The deductible is the amount of covered expenses each enrollee incurs during the year before the plan pays benefits. The deductible applies to covered expenses at all network pharmacies, including retail and the mail-order pharmacy. The deductible applies to covered prescription items only. Coinsurance You are responsible for a percentage of the cost of a covered prescription. The coinsurance does not apply until the deductible is met. Generic Incentive Program Generic medications should be used when available. If a brand-name medication is requested when a generic is available, the enrollee will pay the difference between the generic price and the brand-name price in addition to the generic coinsurance. The generic incentive program is also called the Dispense as Written (DAW) penalty. Penalty amounts for prescriptions that ignore the generic incentive program do not count toward the prescription plan deductible or out-of-pocket maximum. Out-of-Pocket Maximum Once you have reached the outof-pocket maximum for your prescription drug plan, MHIP pays 100 percent of the cost of covered prescriptions. Mail-Order Services Enrollees may be able to obtain covered maintenance prescriptions for chronic or long-term health conditions through mail service options offered through MHIP. This option may be more convenient and less expensive. Those enrolled in Plans I, II, III and IV, using Catamaran, may register online or by mail using Walgreens Mail Services. Those in Plan V may access the mail-order service through Express Scripts under BCBSKC or through WellPoint NextRX under Anthem BCBS. Clinical Guidelines In an ongoing effort to effectively manage your prescription drug benefits and promote the best possible medical outcomes for MHIP enrollees, MHIP has implemented clinical guidelines as part of your prescription drug plan. MHIP PRESCRIPTION DRUG PLAN Plan I Plan II Plan III Plan IV Plan V Deductible $100 $100 $250 $500 $2,500 (combined with medical plan) Out-of-Pocket Maximum Deductible + Coinsurance $3,000 $3,000 $3,150 $3,500 $5,000 (combined with medical plan) 32 prescription drug benefits STATE POOL

31 Retail (Network) 30-day supply Retail (Non-Network) 30-day supply Mail Order (Network) 90-day supply SUMMARY OF ENROLLEE PRESCRIPTION DRUG COSTS Plan I Plan IV Generic: 30% of drug s cost, $25 max Brand: 30% of drug s cost, $75 max You will be required to pay the full cost of the drug and file a claim. You are reimbursed up to 70% of the discounted allowance Generic: 30% of drug s cost, $75 max Brand: 30% of drug s cost, $225 max Plan V (HDHP) BCBSKC: 30% of drug s cost after deductible Anthem: 20% of drug s cost after deductible You will be required to pay the full cost of the drug and file a claim. You are reimbursed based on the discounted allowance, minus the applicable coinsurance BCBSKC: 30% of drug s cost after deductible Anthem: 50% of drug s cost after deductible BCBSKC: 30% of drug s cost after deductible Anthem: 20% of drug s cost after deductible These clinical guidelines are known as first fill starter quantity, prior authorization, step therapy, and quantity limitations. The following information is intended to explain these guidelines and their purpose, and identify common medications that are managed under these guidelines. Information about these clinical guidelines is also available at www. mycatamaranrx.com, or by calling Multiple Dosage Copayments If a prescription drug is prescribed in a single dosage amount for which the particular prescription drug is not manufactured and requires dispensing the drug in a combination of different manufactured dosage amounts, MHIP shall only impose one copayment for dispensing the combination of manufactured dosages that equal the prescribed dosage. This copayment requirement does not apply to prescriptions in excess of a one-month supply. Preferred Drug Changes MHIP will notify enrollees presently taking a prescription drug electronically, or in writing, upon request of the enrollee, at least 30 days prior to any deletions, other than generic substitutions, in MHIP prescription drug formulary that affect such enrollees. Administering Carrier Prescription Plans Plan V Informational and educational programs are developed by each of the administering carriers. Prescription drug benefits for Plan V under Anthem BCBS are administered by Express Scripts, Inc. (ESI). Members enrolled in Plan V through Anthem BCBS may contact ESI at (314) or by mail at: 1 Express Way St. Louis, MO Prescription drug benefits for Plan V under BCBSKC are administered by Prescription information is available at For information on authorization status, contact BCBSKC at or , or by mail at: BCBSKC Pharmacy Services PO Box Kansas City, MO Frequently Asked Questions Why are clinical guidelines necessary? Clinical guidelines are necessary because there are certain medications that require closer review to support enrollees benefits. Medications selected for prior authorization, step therapy or quantity limits are typically newer, STATE POOL prescription drug benefits 33

32 more expensive medications that may have off-label uses (not approved by the FDA), the potential to be used inappropriately, or lesser known side effects. Prior authorization, step therapy and quantity limits affect only a small number of medications, including those on the following lists; however, clinical guidelines may be applied to newly approved medications as well. In most cases, enrollees taking one or more of the medications subject to review will not experience a delay in obtaining medicine. You may experience a delay, however, if the appropriate documentation cannot be obtained immediately. This review is in place to make sure the medications are being dispensed for the appropriate reason and to protect the integrity of the prescription drug plan. Please refer to the following lists for drugs that require clinical programs. These lists are not all-inclusive. What is first fill starter quantity? Enrollees in Plans I through IV are required to obtain coverage for a starter quantity of medication (no more than a 30-day supply) before the enrollee can obtain coverage for up to a 90-day supply, if prescribed. This process is designed to help reduce the volume of prescription drugs that may be wasted due to intolerance or failure to benefit from a new medication. A prescription is considered new if it has not been filled in the past six months, if the strength or dosage form changes, or if you have not previously taken the medication. What is prior authorization for prescriptions? Prior authorization means the PBM will conduct a clinical review of certain medications before authorizing payment under your prescription benefit plan. This review consists of two steps: 1. A medical diagnosis is obtained from the prescribing doctor (some medications may require additional information). Your pharmacist may supply the PBM with the necessary information required to perform the review if the information is provided on the prescription, or your doctor can call or fax the appropriate medical documentation to the PBM. 2. Clinical personnel at the PBM will determine whether the condition follows appropriate clinical guidelines and whether the medication in question will be covered by the prescription plan. Please refer to the following list for common medications that require prior authorization. What is step therapy? Step therapy is a process to promote the use of traditional and more proven treatments to provide needed drug therapy the safest way possible. To ensure that the more proven medication is used as the first line of treatment, step therapy requires that coverage for a select group of medications be approved only after you have tried a more traditional medication first, without success; or if you have a specific medical condition that prevents you from trying the alternatives. The pharmacist may be able to tell you whether it is covered by your prescription plan. If an enrollee follows the recommended treatment guidelines, the intended result is more effective treatment at a lower cost. Please refer to the following lists for common medications that require step therapy. What is quantity limitation? Quantity limitation means your prescription plan will only cover a certain number of pills or units (such as injections or nasal spray bottles) within a specified time period. This limitation is typically in place for medications that have an abuse potential, or for medications that have been deemed by the FDA to be safe only in limited amounts or for shortterm treatment. A quantity limitation is typically in place for only a limited number of medications. Please refer to the following lists for common medications that are subject to quantity limitation. This clinical guideline may be added to newly approved medications as well. Inclusions and Exclusions Certain medications may be covered (inclusions) or may not be covered (exclusions) under the prescription drug plan. The following chart lists therapeutic categories or drugs that are defined as included or excluded. This list is not all-inclusive. Please call Catamaran at for questions about exclusions. Separate exclusions may apply to Plan V. Call Anthem BCBS at or BCBSKC at if you have a question regarding coverage for a specific medication. 34 prescription drug benefits STATE POOL

33 THERAPEUTIC/DRUG INCLUSIONS UNDER CATAMARAN Drug Limitations Acne Medications Retin-A, Avita Covered up to age 25 Other Vitamin A Derivatives * Covered to age 25, then prior authorization required ADD/ADHD Medications* Prior authorization required after age 19 AIDS-Related Drugs Anabolic Steroids Antifungals Anti-Migraine Medications Oral Spray Injectables Chemotherapy Medications Contraceptives Oral Seasonale (91-day supply) Patches (Ortho Evra) Ring (NuvaRing) Diabetic Test Supplies Lancets Monitors Strips Other Federal Legend Growth Hormone* Hematinics Immunosuppressants Impotency Drugs Includes Viagra, Levitra, Cialis, Caverject, Muse and Edex Injectables Insulin (over the counter) Needles/Syringes - Insulin only (over the counter) Non-Insulin Syringes (over the counter) Smoking Deterrents Vitamins (Prenatal only) None None None Limited to nine per 30 days, 27 per 90 days Limited to six per 30 days, 18 per 90 days Limited to three per 30 days, nine per 90 days None Three times retail copayment per 91-day supply None None None None None Retail: Six units per 25 days Mail: 18 units per 75 days None One copayment if insulin and needles are purchased the same day None $500 lifetime maximum None *These drugs require prior authorization. STATE POOL prescription drug benefits 35

34 THERAPEUTIC/DRUG EXCLUSIONS UNDER CATAMARAN Drug Exclusions Abortifacients Acne Medications Accutane Anti-Obesity/Anorexiant Drugs Blood Sera Botox Contraceptives Injectable Contraceptive Implants and Topicals IUDs and Diaphragms Cosmetic Drugs Rogaine, Propecia Diagnostic Test Supplies Fertility Agents Fluoride Preparations Inhaler Devices Non-Legend Drugs (over the counter) Schedule V Cough Syrups Therapeutic Devices/Appliances (over the counter) Vaccines/Serums/Toxoids/Allergens Vaginal Estrogen (90-day supply only) Vitamins Other than prenatal 36 prescription drug benefits STATE POOL

35 pre-existing condition limitations MHIP s medical plans (but not its pharmacy plans) exclude charges or expenses incurred during the first 12 months after the enrollee s effective date for any pre-existing condition. A pre-existing condition is defined as any condition that manifested itself in such a manner that would cause an ordinarily prudent person to seek diagnosis, care, advice or treatment for the condition within the six months before the start of this coverage or any coverage waiting period or probationary period. A pre-existing condition will be covered after 12 months of continuous coverage under MHIP. This limitation does not apply to HIPAA eligible, trade act eligible or federally defined individuals. Waiver of Pre-existing Condition Limitation A pre-existing condition can be waived upon consideration of the following circumstances: 1. You were previously covered under another health insurance program, including Medicaid or MO HealthNet, that ended involuntarily for a reason other than your failure to pay the premium; you applied for MHIP within 63 days after the involuntarily terminated coverage ended; your coverage was effective and premiums were paid retroactive to the termination; and you had satisfied a 12-month waiting period or did not have a waiting period under your prior program. 2. The pre-existing condition waiting period will also be eliminated if the conversion program or any other valid program available to you would have cost you 150 percent of the rate considered for a standard risk person. The 150 percent qualification does not apply to federally defined eligible individuals. 3. If you are a federally defined eligible individual who has not experienced a gap in coverage of 63 days or longer. 4. If you are a trade act eligible who maintained creditable coverage for an aggregate period of three months prior to loss of employment and have not experienced a gap in coverage of 63 days or longer since that time. A child born under MHIP coverage is not subject to the pre-existing condition limitation. Application for coverage must be made within 31 days of the child s birth. Complications of pregnancy are covered during any applicable pre-existing condition limitation period. The term Complications of Pregnancy shall mean: Conditions whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy. STATE POOL pre-existing condition limitations 37

36 limitations & EXCLUSIONS General Rules In addition to any previously specified exclusions and limitations, the plan excludes the following: y Any care not expressly specified, or complications resulting from such care (except in the case of pregnancy complications, as determined by the carrier) y Any pre-existing condition and care for any condition that is caused by, contributed to, or is a consequence of a pre-existing condition. The carrier will determine whether the condition was caused by, contributed to, or is a consequence of a pre-existing condition. Refer to the Pre-existing Condition Limitations Section y Inpatient treatment that began before the effective date of the enrollee s coverage. This limitation does not apply to HIPAA eligible, trade act eligible or federally defined individuals y Any care that continues beyond the date of termination of coverage y Care not adequately reported to the administering carrier in a timely fashion, as set forth in the Claims Process Section Charges Not Covered This program does not cover: y Charges in excess of eligible expenses y Charges that exceed allowable covered charges, as determined by the administering carrier y Charges billed separately that the carrier determines should have been part of another charge y Charges that exceed the maximum number of covered services, days or visits y Charges related to court appearances, court proceedings, hearings or collection activities y Charges for care available to the enrollee without charge y Charges for failure to keep a scheduled visit y Charges for completion of a claim form y Late payment fees Limitations on Care This program does not provide coverage for: y Services that are not medically necessary y Services that are considered investigational y Obsolete care y Services that are not consistent with diagnosis and treatment of a condition requiring hospitalization y A service that is not provided, prescribed, performed or directed by a physician or other licensed health care professional (including those in training), or not legally able to provide care y A service that is covered in any way by workers compensation or other employer liability law y Services available to the enrollee through any government program, unless the program would require payment y Services rendered because of a condition suffered as a result of any act of war or while on active or reserve military duty y Services rendered as a result of an intentionally self-inflicted injury or for an injury or sickness as a result of taking part in the commission of a felony y Telephone consultations The administering carrier will determine whether such care is for treatment of a serious bodily injury or illness that requires immediate and urgent care. Specific Exclusions This section details specific medical conditions, services and medical equipment that are either excluded or limited under the plan. Medical services are limited to usual and customary charges and may also be limited in the number of days of treatment. Refer to the Medical Benefits Section for more information. Coverage of medical services provided to individuals other than to the named insured covered by the plan is excluded. This exclusion does not apply to coverage of services provided for the delivery of or initial care for newborns up to 31 days after birth. 38 limitations & EXCLUSIONS STATE POOL

37 Abortion Service Acupuncture Services related to acupuncture, whether for medical or anesthesia purposes Biofeedback Services related to biofeedback Chemotherapy High-dose chemotherapy that requires bone marrow reconstitution, including stem cell reconstitution, for the treatment of malignant disease Cosmetic Procedures Surgical or non-surgical procedures, drugs or nutritional programs Custodial Care Domiciliary care or rest cures Dental Care Refer to Medical Benefits Section Equipment Air conditioners, furnaces, humidifiers, dehumidifiers and similar equipment Experimental, Investigational, Unproven, Unusual or Not Customary Treatments, Procedures, Devices or Drugs Includes, but is not limited to, orthomolecular medicine; holistic medicine; environmental medicine; chelation therapy, unless medically necessary for the treatment of metal poisoning; hair analysis; colonics; gene manipulation therapy; medications used in a non-fda-approved manner; naturopathic services; and megavitamin therapy Ear Examinations LIMITATIONS AND EXCLUSIONS Limitations and Exclusions Covered only when necessary to prevent the death of the woman upon whom the abortion is performed Covered only when such treatment is: Part of a National Cancer Institue Phase II, III or IV trial For breast cancer, and precertification has been received prior to treatment Covered only when plastic or reconstructive surgery is medically necessary to: Repair a congenital anomaly of a covered newborn Repair a functional disorder caused by disease or injury Restore breast symmetry by reduction mammoplasty or mastopexy after a mastectomy. There is no time frame on reconstructive surgery or prostheses after a mastectomy. If an individual had a mastectomy and changes medical plans, the new plan shall provide coverage consistent with the federal Women s Health and Cancer Rights Act. No coverage for breast augmentation surgery on the unaffected breast Coverage only for oral surgery for head and neck cellulites, treatment for disease of salivary glands and ducts, removal of teeth that interfere with radiation therapy, oral surgery required to correct accidental injury to the jaw, cheeks, lips, tongue, roof and floor of mouth, to treat accidental injury to mature teeth within 90 days of the accident, removal of tumors or cysts, except when associated with endodontic surgery, and surgery on the temporomandibular joint No coverage for a treatment, procedure, device or drug that is investigational, unproven, unusual or not customary. The plan shall interpret this section on experimental/ investigative procedures and make determinations on all questions arising in the administration, interpretation and application of this section, including determining what procedures, devices and/or drugs are experimental, investigational, unusual, not customary or unproven. No coverage for routine hearing examinations, other than newborn hearing screenings STATE POOL LIMITATIONS & EXCLUSIONS 39

38 Service Gender Reassignment Services or supplies related to sex-change operations, reversals of such procedures, or complications of such procedures Hearing Aids Hospital Care and Anesthesia Hospital Confinement For environmental change Hot Water Bottles, Heating Pads, Ice Packs and Personal Hygiene Items Including, but not limited to, devices and equipment used for environmental control or to enhance the environmental setting Hypnosis, Acupuncture and Acupressure Related services Infertility Treatment Including, but not limited to, artificial insemination, in vitro fertilization (test tube babies), gamete intrafallopian transfer (GIFT) procedure, zygote intrafallopian transfer (ZIFT) procedure, artificial reproductive technology (ART), other ovum transplant procedures, surrogate parentage, drug therapy for infertility and related costs of each, procedures considered experimental or investigational, costs related to donor sperm and ova, infertility services for enrollees who have undergone a voluntary sterilization procedure, salpingoplasty, and drugs and treatments Learning Deficiencies and Behavioral Problems Legal Payment Obligations Maintenance Therapy for maintaining a level of health rather than improving a condition brought on by illness or injury Music Recreational or activity therapy, remedial reading, all forms of special education, and related supplies or equipment Orthognathic (Jaw) Surgery LIMITATIONS AND EXCLUSIONS Limitations and Exclusions Coverage only for initial amplification for a newborn after a newborn hearing screening Covered only when a concurrent medical disease or illness makes such care medically necessary. Concurrent disease or illness does not include phobias, behavioral or anxiety problems No coverage for charges relating to the diagnosis and treatment of infertility or any procedure that attempts to achieve the fertilization of an ovum or initiate a pregnancy Except as described under Therapies in the Medical Benefits Section, no coverage for special education, counseling, therapy or care for learning deficiencies or behavioral problems, regardless of whether associated with a manifest mental disorder, retardation or other disturbance No coverage for services for which you have no legal obligation to pay or charges made only because benefits are available under this plan. The plan will not allow benefits for services for which the enrollee has received a professional or courtesy discount or for services provided to the enrollee by himself or herself or by a family member Covered only when required for restoration as the result of an accidental injury that occurred after the enrollee s effective date 40 limitations & EXCLUSIONS STATE POOL

39 Service Orthoptic and Pleoptic Training Technique of eye exercises designed to correct the visual axes of eyes not properly coordinated for binocular vision Personal Comfort or Convenience Services and supplies used primarily for personal comfort or convenience that are not related to treatment for a condition. Includes, but is not limited to, guest trays, beauty or barbershop services, gift shop purchases, long-distance phone calls, television, admission kits and personal laundry services Physical Fitness Equipment Hot tubs, heated spas, pools, health club memberships Podiatry Arch supports, support stockings, corrective shoes and care for the treatment of corns, bunions, calluses, toenails, flat feet/fallen arches, weak feet, chronic foot strain or other symptomatic conditions of the feet Psychoanalysis Report Preparations Charges for preparing medical reports, itemized bills or claim forms Riot Services or supplies to treat condition resulting from participation in a riot or in the commission of or attempt to commit a felony Self-Care Unit Apartment or similar facility operated by or connected with a hospital Sexual Dysfunction Care for such LIMITATIONS AND EXCLUSIONS Limitations and Exclusions No coverage except when major surgery is performed No coverage for marital counseling or counseling with relatives about an enrollee s mental illness or chemical dependency Sterilization Reversal Surgery For psychological or emotional reasons Taxes Sales, service or other taxes imposed by law that apply to benefits covered under this Certificate Weight-loss Programs Services and supplies related to weight loss STATE POOL LIMITATIONS & EXCLUSIONS 41

40 integration with other insurance plans Generally, benefits payable under MHIP shall be reduced by all amounts paid or payable by any health expense benefit, workers compensation, automobile medical payment or liability insurance, whether provided on the basis of fault or no fault. Coordination of Benefits In most cases, eligibility for MHIP is based on ineligibility for other plans. In some cases, there may be exceptions. In approved situations where other group or qualified individual health coverage is in force, MHIP will be secondary. This secondary coverage will be limited to covered allowable expenses up to the limits of MHIP s policy. Other Types of Insurance Coverage and Protection MHIP will never be primary if one of these other types of coverage applies. Workers Compensation y Services and supplies resulting from work-related illness or injury are not a benefit under MHIP. This exclusion from coverage applies to expenses resulting from occupational accidents or sickness covered under: Occupational disease laws Employer s liability Municipal, state or federal law Workers Compensation Act y To recover benefits for a workrelated illness or injury, you must pursue your rights under the Workers Compensation Act or any of the above provisions that may apply to your situation y The plan will not pay benefits for services and supplies resulting from a work-related illness or injury even if other benefits are not paid because: You fail to file a claim within the filing period allowed by the applicable law You obtain care that is not authorized by workers compensation insurance Your employer fails to carry the required workers compensation insurance. In this case, your employer becomes liable for any work-related illness or injury expenses You fail to comply with any other provisions of the law y MHIP may provide coverage for work-related injuries if you qualify under Missouri law to reject workers compensation coverage as an owner and officer of your business. MHIP reserves the right to request documentation Automobile Insurance Provisions The benefits available under this certificate apply to injuries you may suffer in an automobile accident, except to the extent of any medical payment coverage you have purchased as part of your automobile insurance policy. All benefits paid by MHIP are subject to deductible, coinsurance and network requirements. If you have purchased medical payment coverage as part of your automobile insurance policy, the medical payment benefit will be the primary coverage for any injury you suffer in an automobile accident in your insured vehicle. The benefits available under this certificate will be paid only after you have exhausted your medical payment coverage. If you have medical payment coverage under your automobile insurance policy and you fail to assert your rights under that coverage, MHIP will not pay for any medical or hospital costs that would have been covered under the medical payment coverage. Third-Party Liability Subrogation Third-party liability exists when someone else is legally responsible for your condition or injury. The plan will not pay for any services or supplies for which a third party is liable. The plan may provide benefits under these conditions: y When it is established that thirdparty liability does not exist y When you guarantee in writing to reimburse the plan if the third party later settles with you for any amount or if you recover any damages in court MHIP s Rights When Third-Party Liability Exists When a third party is or may be liable for the costs of any covered expenses payable to you or on your behalf under MHIP, the plan has subrogation rights. This means MHIP has the right, either as co-plaintiff or by direct suit, to enforce your claim against a third party for the benefits paid to you or on your behalf. When you fail to cooperate in satisfying MHIP s subrogation interest and the plan must file a 42 integration with other insurance plans STATE POOL

41 lawsuit against you or the third party to enforce its rights under this provision, the enrollee receiving benefits under this certificate shall be responsible for attorney s fees and costs incurred by MHIP. Your Obligations When Third-Party Liability Exists If a third party is or may be liable for the costs of any expenses payable to you or on your behalf under MHIP, then YOU must do the following: 1. Promptly notify the plan of your claim against the third party 2. You and your attorney must provide information about the benefits paid by the plan in any settlement with the third party or the third party s insurance carrier 3. If you receive money for the claim by suit, settlement or otherwise, you must fully reimburse the plan for the amount of benefits provided you under MHIP. You may not exclude recovery for the plan s health care benefits from any type of damages or settlement recovered. In the event settlement is made excluding MHIP s recovery, the plan reserves the right to refuse future claims until its subrogation interest is satisfied 4. Cooperate in every way necessary to help the plan enforce its subrogation rights 5. You may not take any action that might prejudice the plan s subrogation rights STATE POOL integration with other insurance plans 43

42 claims process Filing Your Own Claim It is not necessary to submit a claim form for every service you receive. If you use a network provider, the provider will automatically file the claim on your behalf. The plan will then make the appropriate payment directly to the provider and prepare an explanation of benefits (EOB) for you. If services are performed by a non-network provider who accepts assignment of benefits, show the provider your ID card and ask the provider to file for you. If the provider will not file the claim for you, be sure to obtain an itemized bill from the provider. Submit a copy of the bill along with a completed claim form. For faster processing, you should file a claim as soon as possible after you receive covered services or supplies. You must file your claim no later than the end of the calendar year after the year in which you received the services or supplies. This is true unless it was not reasonably possible to file during that time. How to File y You can use the same form to file claims for all of your benefits, with the exception of pharmacy claims for Plans I through VI. Contact Catamaran for pharmacy claim filing procedures y Upon receipt of a notice of claim, the insurer will furnish to you such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within 15 days after receiving notice, you will be deemed to have complied with the requirements of this policy as to proof of loss upon submitting, within the time fixed in the policy for filing proofs of loss, written proof covering the occurrence the character and the extent of the loss for which claim is made y You can obtain claim forms from your carrier. Call the number on your ID card to request a claim form. The back of the claim form has filing instructions. Please read the instructions before completing the form y You may submit claims for more than one person in the same envelope. However, you must complete a separate claim form for each person. Attach each person s bill to the correct form. If you do not, the claims may be returned y Complete the claim form fully and accurately. You must check yes or no for each question. If you do not answer a question, the carrier may have to return your claim to you. This is also true if you do not provide additional information required. When you write in your ID number on the claim form, be sure to include all digits y The carrier can only accept itemized bills. Each bill must show all of the following: The name of the patient The name and address of the provider A description and date for each service provided A diagnosis The charge for each service y Canceled checks and nonitemized bills are not sufficient y Include all bills for covered services not previously submitted. Be sure to include those used to meet your deductible y If you have paid the provider, mark each bill paid y In some cases, the administering carrier will pay you directly for covered services. In other cases, the provider will be paid y Keep copies of the completed claim form and itemized bills. y Send your claim to the address shown on the form Explanation of Benefits In many cases, you will receive an Explanation of Benefits (EOB) from your carrier. This document will tell you what services were covered and what services, if any, were not covered. In some instances, you may receive more than one EOB for the same claim. You may need to include a copy of the EOB if you file a grievance regarding a benefit determination. If you receive a bill from your provider for services that you believe should have been covered, call the customer service number on the back of your ID card. 44 claims process STATE POOL

43 appeals & grievances How to File a Grievance If you have a complaint about the availability, delivery or quality of your health care, or if you disagree with a claims decision, call the number on the back of your ID card to request a review. A customer service representative will investigate your complaint. If you are not satisfied with the results of the review, you may send a letter of complaint to your carrier. This process is a grievance. You may file a grievance without requesting a review. Your health care provider or your representative may file a grievance for you. What is a Grievance? A grievance is a written complaint submitted by you, or on your behalf, regarding: y The availability, delivery or quality of health care services, including a complaint regarding an adverse determination y A claims payment, handling or reimbursement for services y Matters pertaining to your contractual relationship with MHIP If your grievance involves an adverse determination on a request for precertification or recertification, see the Managed Care Section. An adverse determination is a denial, reduction or termination of benefits because the care does not meet MHIP s requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness. First-Level Grievance To file a grievance, send a letter to your carrier, or fill out a Member Grievance Form requested through customer service. Include all pertinent records and any information you believe supports your grievance. Send all documentation to your carrier: Anthem Blue Cross and Blue Shield of Missouri Attn: Grievance Advisory PO Box Louisville, KY Blue Cross and Blue Shield of Kansas City State Programs Attn: Complaint Coordinator PO Box Kansas City, MO The carrier will let you know that it has received your grievance within 10 business days. The carrier will investigate your grievance within 20 business days after receipt. If the carrier cannot complete the investigation within 20 business days, it will notify you in writing within that time. The carrier will then complete the investigation within 30 additional business days. Within five working days after the carrier completes the investigation, it will send you an explanation of the decision. The explanation will include details on your right to file a second-level grievance if you disagree with the decision. If someone other than the covered person has filed the grievance, that person will also be notified. The carrier will send the notice within 15 business days after completion of the investigation. Second-Level Grievance If you do not agree with the response to your grievance, you may file a second-level grievance. All secondlevel grievances will be submitted to a Grievance Advisory Panel. The time frames for resolving a second-level grievance are the same as a first-level grievance. Expedited Grievance Review In some cases, you may believe the normal time frame for a firstor second-level grievance could seriously jeopardize your life or health. In that case, you, your representative or your health care provider can request an expedited grievance review. This request can be made by phone or in writing. The carrier will give you a decision by phone within 72 hours after receiving the request. The carrier will then confirm the decision in writing within three business days. If you need an expedited grievance review, call the precertification phone number on the back of your ID card. Grievance Review by the MHIP Board If you are not satisfied with the results of the second-level grievance, you may file a grievance with the MHIP Board of Directors at: MHIP Board of Directors c/o Executive Director PO Box Jefferson City, MO Contacting Missouri DIFP You may contact the Missouri Department of Insurance, Financial Institutions and Professional Registration at any time at or: Missouri DIFP Consumer Complaints PO Box 690 Jefferson City, MO STATE POOL appeals & grievances 45

44 glossary Various terms used in this certificate are defined here. Becoming familiar with these terms can help you better understand how MHIP works for you. Acute Care: Care to treat an immediate and severe episode of an illness, to treat injuries related to an accident or other trauma, or to facilitate recovery from a surgery. Usually only needed for a short period of time. Administering Carrier: Anthem Blue Cross and Blue Shield of Missouri or Blue Cross and Blue Shield of Kansas City. Advanced Practice Nurse: A nurse who has had education beyond the basic nursing education and is certified by a nationally recognized professional organization as having a nursing specialty, or who meets criteria for advanced practice nurses established by the board of nursing. Adverse Determination: A determination by an administering carrier, or its designee, that an admission, availability of care, continued stay or other care has been reviewed and does not meet the carrier s requirements for medical necessity, and the payment for the care is therefore denied, reduced or terminated. Alcoholism or Substance Abuse Treatment Center: A detoxification and/or rehabilitation facility licensed by the state to treat alcoholism and/or substance abuse. Allowed Amount: The appropriate rate for a covered service as determined by the administering carrier. Ambulance: A specially designed and equipped vehicle used only for transporting the sick and injured. It must have customary safety and lifesaving equipment, such as firstaid supplies and oxygen equipment. The vehicle must be operated by trained personnel and licensed as an ambulance. Ambulatory Surgical Center: An establishment that has an organized medical staff of physicians, permanent facilities equipped and operated primarily for the purpose of performing surgical procedures, continuous physician service and registered professional nursing services whenever a patient is in the establishment, and does not provide services or other accommodations for enrollees to stay overnight. The establishment must be licensed by the state as an ambulatory surgical center. Ancillary Services: Services and supplies (in addition to room services) for which a facility bills and regularly makes available for the treatment of an enrollee s condition. Such services include, but are not limited to: y Use of operating room, recovery room, emergency room, treatment rooms and related equipment y Intensive and coronary care units y Prescription drugs, medicines and biologicals (medicines made from living organisms and their products) and pharmaceuticals y Dressings and supplies, sterile trays, casts and splints y Diagnostic and therapeutic services y Blood processing and transportation, blood handling, and blood, blood plasma and blood derivatives Anesthesia: Drug, gas or other modality that, when administered, causes a loss of sensation and consciousness. Automatic Payment: Arrangement in which the enrollee has premiums deducted from his or her checking account. Blood Expenses: Charges for processing, transporting, handling and administration of blood products, as well as the cost of blood, blood plasma and blood derivatives. Calendar Year: Period of one year beginning Jan. 1. Cardiac Rehabilitation: Medically supervised interventions that include exercise training, counseling and behavioral management aimed at limiting physical and other damage from heart disease, and helping the patient resume a normal life. Case Manager: Registered nurse or mental health professional who assists an enrollee in coordinating the appropriate use of MHIP benefits with the provider s plan of treatment. Certificate: The document reflecting the plan benefits and how to access them, including exclusions, limitations, rights, duties and eligibility. Certification: Determination by the administering carrier or its designee that an admission, availability of care, continued stay or other care has been reviewed and, based on the information provided, is covered by the plan and satisfies the administering carrier s requirements for medical necessity. 46 glossary STATE POOL

45 Chemotherapy: FDA-approved antineoplastic agents and their administration for the treatment of malignant disease. Chiropractic Services: Adjustment or manipulation by hand of the articulations and adjacent tissue of the human body, particularly the spinal column, and the use of procedures that facilitate and make the adjustment and manipulation more effective, including physical remedial measures, such as heat, cold, electric currents, ultrasound and ultraviolet radiation. Christian Scientist Practitioner: An individual listed as a Christian Science practitioner in the most recent issue of The Christian Science Journal. Clinical Peer: Physician or other licensed health care professional who holds an unrestricted license in a state of the United States in the same or similar specialty as typically manages the medical condition, procedure or treatment under review. Cleft Lip and/or Palate: Birth deformity in which the lip or roof of the mouth fails to close. Cochlear Implant: Device implanted in the ear to facilitate communication in the profoundly hearing impaired. Coinsurance: The portion an enrollee pays for the cost of his or her care after the deductible has been met. Cognitive Behavioral Therapy (CBT): Therapy that focuses on identifying patterns of thinking that are maladaptive or dysfunctional, and assists the enrollee in developing alternatives to those thoughts and/ or to change behavioral responses to situations. Complications of Pregnancy: Condition experienced during pregnancy that may jeopardize the health of the mother or her unborn infant. The condition may be related to the pregnancy, or may occur coincidentally and adversely affect the course of the pregnancy. Consultation: Service provided by another physician at the request of the physician in charge of an enrollee s case. The consulting physician often has specialized skills to help diagnose or treat an illness or injury. Copayment: A set dollar amount that a covered individual must pay for a specific service or supply. Custodial Care: Any care provided by a nurse or caretaker that does not meet the requirement of skilled nursing care as defined by the administering carrier. Includes, but is not limited to, help in walking, bathing, dressing or eating; preparation of special diets; services as a companion or sitter; administration of medications (unless such administration requires the skills of a licensed nurse); and services that can reasonably be taught to and performed by non-licensed personnel. Deductible: The amount the member must pay before the plan begins to pay for covered services and supplies. This amount is not reimbursable by the plan. Dental Care: Care to prevent or treat any disease, pain, deformity, deficiency or injury of teeth, gums or adjacent and supporting structures. Diagnostic Services: Procedures to diagnose a condition in response to specific symptoms, ordered or performed by a health care provider licensed to render the services. Dialysis Treatment: Hemodialysis or peritoneal dialysis for the treatment of acute renal failure or chronic, irreversible renal insufficiency. Discharge Planning: The formal process for determining, prior to discharge from a facility, the coordination and management of care that a patient receives after leaving such facility. Durable Medical Equipment (DME): Equipment that can withstand repeated use and is made to serve a medical purpose, is useless to a person who is not ill or injured, and is appropriate for use in the home. Durable Medical Equipment Supplier: An entity that supplies DME to an enrollee according to a plan prescribed and approved in writing by the enrollee s physician. Elective Abortion: Any nonspontaneous abortion for any reason other than to prevent the death of the woman upon whom the abortion is performed. Electronic Funds Transfer (EFT): Arrangement in which the enrollee may have premiums deducted from his or her checking account or billed to a credit card. Eligible Expense: The lesser of the allowed amount or the provider s actual charge. May include all or some of the taxes, surcharges and other fees incurred in connection with such services. The eligible expense is the maximum amount the carrier will STATE POOL glossary 47

46 pay for covered care, subject to the provisions of this description. Emergency Medical Condition: The sudden and unexpected onset of a condition that manifests itself by symptoms of sufficient severity that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that immediate care is required, which may include, but will not be limited to: y Placing the person s health in significant jeopardy y Serious impairment to a bodily function y Serious dysfunction of any bodily organ or part y Inadequately controlled pain y With respect to a pregnant woman who is having contractions: There is inadequate time for a safe transfer to another hospital before delivery Transfer to another hospital may pose a threat to the health or safety of the woman or unborn child Emergency Service: Care furnished or required to evaluate and treat an emergency medical condition, which may include, but will not be limited to, care provided in a licensed hospital s emergency room by an appropriate provider. Enrollee: A person participating in (MHIP). Enrollee may also be referred to as participant, member, subscriber or patient. Episode: A distinct course of medical treatment separated by at least 30 days without treatment. Evidence-Based Medicine: The judicious use of the best current evidence in making decisions about the care of the individual patient. Experimental, Investigational, Unproven, Unusual or Not Customary: A treatment, procedure, device and/or drug shall be deemed experimental, investigational, unproven, unusual or not customary if it: y Cannot be lawfully marketed without the approval of the FDA or other government agency, and such approval has not been granted at the time of its proposed use y It is the subject of a current investigational new drug or new device application on file with the FDA y It is being provided pursuant to a Phase I or Phase II clinical trial or as the experimental or research arm of a Phase III clinical trial y It is being provided pursuant to a written protocol that describes among its objectives determinations of safety, toxicity, effectiveness or effectiveness in comparison to conventional alternatives y It is being delivered or should be delivered subject to the approval and supervision of an Institutional Review Board as required and defined by federal regulations, particularly those of the FDA or the Department of Health and Human Services y The predominant opinion among experts as expressed in the published authoritative literature is that usage should be substantially confined to research settings y The predominant opinion among experts as expressed in the published authoritative literature is that further research is necessary to define safety, toxicity, effectiveness, or effectiveness compared with conventional alternatives y It is not a covered benefit under Medicare as determined by the Centers for Medicare and Medicaid Services y It is not a generally acceptable medical practice in the predominant opinion of independent experts y A majority of a representative sample of not less than three health insurance or benefit providers or administrators consider the requested treatment, procedure, device or drug to be experimental, investigational, unproven, unusual or not customary based upon criteria and standards regularly applied by the industry y It is not experimental or investigational in itself pursuant to the above, and would not be medically necessary, but for being provided in conjunction with the provision of a treatment, procedure, device or drug that is experimental, investigational, unproven, unusual or not customary Facility: An alcoholism treatment center, hospital, ambulatory surgery center or skilled nursing facility that MHIP recognizes as a health care provider. Grievance: Written complaint submitted by, or on behalf of, an enrollee regarding: y Availability, delivery or quality of care, including a complaint regarding an adverse determination made pursuant to utilization management y Claims payment, handling or reimbursement for care y Matters pertaining to the contractual relationship between 48 glossary STATE POOL

47 an enrollee and administering carrier Grievance Advisory Panel: A panel established by the administering carrier that may review, at an enrollee s request, the administering carrier s decision regarding grievances that have not been resolved to the enrollee s satisfaction. The panel is composed of other enrollees and representatives from the administering carrier and will include a majority of clinical peers when adverse determinations are reviewed. It does not include anyone involved in the original or subsequent determinations. If the grievance involves an adverse determination, the Grievance Advisory Panel will consist of a majority of persons who are appropriate clinical peers in the same or similar specialty as would typically manage the case being reviewed, who were not involved in the circumstances giving rise to the original determination or in any subsequent investigation or determination of the grievance. Growth Hormone Therapy: Treatment for short stature secondary to pituitary gland failure by the use of human growth hormone. Health Insurance: Any hospital and medical expense policy, nonprofit health care service for benefits other than through insurer, nonprofit health care service plan contract, health maintenance organization enrollee contract, preferred provider arrangement or contract, or any other similar contract or agreement for the provision of health care benefits. The term Health Insurance does not include short-term, accident, fixed indemnity, limited benefit or credit insurance, coverage issued as a supplement to liability insurance, insurance arising out of a workers compensation or similar law, automobile medical payment insurance, or insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in any liability insurance certificate or equivalent self-insurance. Hearing Aid: Electronic device worn or implanted for the purpose of amplifying sound and assisting the physiological process of hearing. Home Care: Care for a condition in the enrollee s home that includes home health care, home infusion therapy care and home respiratory therapy care. Home Health Care: Skilled nursing care and other services on a visiting basis for the continued care of a condition for which hospitalization would otherwise be required. Home Health Care Agency: Entity that provides skilled nursing and other services on a visiting basis in the enrollee s home, and is responsible for supervising the delivery of such services as prescribed and approved in writing by the enrollee s physician. Home Infusion Therapy Care Provider: Entity that provides parenteral and enteral therapy on a visiting basis in the enrollee s home, and is responsible for supervising the delivery of such services as prescribed and approved in writing by the enrollee s physician. Home Respiratory Therapy Care Provider: Entity that provides home respiratory equipment and oxygen systems in the enrollee s home, and is responsible for supervising the delivery of such services as prescribed in writing by the enrollee s physician. Hospice Agency: Hospital, home health care agency or other provider that may lawfully render hospice care. Hospice Care: Supportive and palliative services provided to an enrollee who is terminally ill and has a life expectancy of six months or less. The purpose is to provide care for the enrollee without attempting to prolong his or her life. Hospital: A place devoted primarily to the maintenance and operation of facilities for the diagnosis, treatment or care for not less than 24 hours in any week of three or more nonrelated individuals suffering from illness, disease, injury, deformity or other abnormal physical condition; or a place devoted primarily to providing medical or nursing care for three or more nonrelated individuals for not less than 24 hours in any week. The term hospital does not include convalescent, nursing, shelter or boarding homes. Services provided include: y Diagnosis and treatment of illness, injury, deformity, abnormality or pregnancy y Clinical laboratory, diagnostic X-ray and definitive medical treatment provided by an organized medical staff within the institution y Treatment facilities for emergency and surgical services either within the institution or through a contractual agreement with another licensed hospital. The services must be documented by a well-defined plan and related to community needs Hospital Accommodations: Room and board (including special diets STATE POOL glossary 49

48 and general nursing services) in the following types of accommodations in a hospital: y Private Room: Room having only one bed y Semi-Private Room: Room having two or more beds Hospital Care: Care provided and billed for by a hospital. Such care is subject to the rules and regulations of the hospital selected by the enrollee, and includes only the care acceptable to such hospital. Identification Card (ID card): Card provided to the enrollee that shows such information as the enrollee s name, number and effective date of coverage. Immediate Family: Enrollee s spouse, natural or adoptive parent, child or sibling, stepparent, stepchild, stepbrother, stepsister, father-in-law, mother-in-law, son-in-law, daughterin-law, brother-in-law, sister-in-law, grandparent or grandchild, and their spouses. Individual Medical Case Management: Management of benefits, services and equipment on an individual basis pursuant to the provider s plan of treatment, which may include: y Assessment of the enrollee s individual care needs y Formulation and modification of a comprehensive care plan y Coordination of care y Evaluation of the effectiveness of the plan of action y Negotiation of extra-contractual services, if necessary Inpatient Care: Care received when an enrollee is a registered bed patient in a hospital, skilled nursing facility, free-standing rehabilitation facility or residential treatment facility, and a room and board charge is assessed. Insurance Arrangement: Plan, program, contract or other arrangement under which one or more employers, unions or other organizations provide to their employees or enrollees, either directly or indirectly through a trust or a third-party administration, health care services or benefits other than through an insurer. Laboratory Expenses: Expenses related to testing procedures required for the diagnosis or treatment of a condition or analysis of a tissue specimen or other material that has been removed from the body, and expenses related to diagnostic medical procedures, such as electrocardiograms (EKGs) and electroencephalograms (EEGs). Licensed Health Care Professional: Physician or other professional provider licensed to render care in a profession recognized under Missouri law (not including licensed professional counselors) and that is covered by the program. Licensed Practical Nurse: Person licensed as a practical nurse by the state in which the person is engaged in the practice of nursing. Maintenance Care: Care provided to prevent regression of physical or cognitive function in an enrollee with a chronic, progressive illness or condition. Manipulation/Adjustment: Treatment of malpositioned articulations and structures of the body, provided that the adjustment, manipulation or treatment is directed toward restoring normal neuromuscular and musculoskeletal function and health. Maternity Care: All medically necessary care for a pregnancy, including services such as delivery room, pre- and post-delivery rooms, nursery care of the newborn, medical and surgical care for both the preand post-partum period, and delivery (childbirth). Does not include complications of pregnancy, which are covered the same as any other illness. Medicaid (MO HealthNet): Federal insurance or assistance as provided by Title XIX of the federal Social Security Act, as amended. Medical Case Manager: Person or persons who have contracted with the plan to review the medical needs of an enrollee and coordinate the medical care prescribed by the treating physician(s) and other providers. The medical case manager works with the treating physician(s) to determine clinically appropriate treatment for the enrollee. Medical Supplies: Expendable items required for the treatment of an illness or injury. Medically Necessary: Care that is: y Consistent with the symptoms, diagnosis or treatment of the enrollee s condition y Appropriate for the enrollee s condition according to commonly accepted standards of good medical practice y Not greater than the level or amount of care that is appropriate for enrollee s condition according to commonly accepted standards of good medical practice y Provided in the appropriate clinical setting for the enrollee s condition according to commonly 50 glossary STATE POOL

49 accepted standards of good medical practice y Not primarily for the convenience of the enrollee, the enrollee s family, physician (or other licensed health care provider) or facility providing care Care will not be considered medically necessary solely because it is provided or prescribed by the enrollee s physician or other licensed health care professional. Medicare: Programs of health care for the aged and disabled established by Title XVIII of the Social Security Act of 1965, as amended. Mental Illness: Conditions classified as mental disorders in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. Negotiated Fee Schedule: The administering carrier s agreed-upon fees with network providers. Any amounts above this schedule are not charged to the enrollee. Network Provider: Providers physically located within the state of Missouri (or in Johnson or Wyandotte Counties within the state of Kansas) that have a contract with an administering carrier to participate in the program. Non-Network Provider: Providers physically located in Missouri that do not have a contract with the administering carrier to participate in the program, but are in a provider class that is eligible to participate. Nonresidential Treatment Facility: A facility that provides medical and other services for the treatment of substance abuse to individuals who do not require inpatient care and are free from acute physical and mental complications. The facility must maintain an organized program of treatment that may be limited to less than 12 hours per day, and not be available seven days a week. The facility must be certified by the Missouri Department of Mental Health for treatment of substance abuse. Nutrient Supplements: Formula and low-protein modified food products recommended by physician and limited to treatment of phenylketonuria (PKU) or any inherited disease of amino and organic acids. Obsolete Care: Care that is no longer generally accepted as standard care according to the standards of good medical practice. Occupational Therapy: Treatment of a physically or mentally disabled person by means of constructive activities designed and adapted to promote the restoration of the person s ability to satisfactorily accomplish the activities of daily living. Activities of daily living include feeding, dressing, bathing and other self-care. Orthopedic Appliance: Rigid or semi-rigid support used to eliminate, restrict or support motion in a part of the body that is diseased, injured, weak or deformed. Out-of-Pocket Maximum: The total amount an enrollee must pay in a calendar year for covered services under MHIP. The maximum is a combination of the medical deductible and coinsurance. Out-of-State Provider: Provider not physically located in the state of Missouri or in Johnson or Wyandotte counties in Kansas. Outpatient Care: Care provided to an enrollee while the enrollee is not an inpatient. Outpatient Hospital Care: Hospital care provided to an enrollee in the emergency room or outpatient department of a hospital. Participating Pharmacy: Retail pharmacy that has entered into an agreement with Catamaran to provide pharmacy benefits under the plan in accordance with the terms and conditions specified by MHIP. Patient Education Program: A program under the direction of the enrollee s attending physician that meets the following criteria: y Includes education or training provided on an inpatient or outpatient basis y Is designed to restrict, control or otherwise cause remission of the covered condition (for example, diabetes self-management training to assist an enrollee in administering insulin and educate the enrollee on the proper use of a glucometer or other blood sugar measuring device) Pharmacy Benefit Manager (PBM): Entity responsible for administrative matters relating to the pharmacy benefits under the plan. Catamaran is the PBM for MHIP. Physical Therapy: Treatment by physical means hydrotherapy, heat, physical agents and/or biomechanical and neurophysiological principles and devices to relieve pain, restore maximum bodily function or prevent disability arising from a condition. Physical therapy does not include cardiac rehabilitation programs, pulmonary rehabilitation programs or STATE POOL glossary 51

50 manipulation/adjustment. Physician: Doctor of medicine, doctor of osteopathy, optometrist, podiatrist or psychologist who is licensed by the laws of the state or jurisdiction where the services are being provided, and who is recognized by MHIP. Certain services will also be covered when provided by a doctor of dentistry practicing within the scope of his or her license. Plan: The Missouri Health Insurance Pool (MHIP). Prescription Drugs: Drugs that require a physician s written prescription for purchase and must be listed in the United States Pharmacopoeia, the National Formulary or the Homeopathic Pharmacopoeia, and must be evaluated as probably effective in the current edition of the American Medical Association s Drug Evaluations. All prescription drugs must be approved by the FDA and must not be identified as experimental or investigational. Preventive Care: Care focused on preventing the development of disease. Includes general promotion of health and specific protection, such as immunizations, as well as the early diagnosis of disease to shorten the duration and reduce the severity of illness. Prior Coverage: The health insurance, insurance arrangement or continuation/ conversion coverage that covered the enrollee s care prior to the date an enrollee s coverage under MHIP becomes effective. Professional Care: Care rendered by a physician or other licensed health care professional who is licensed under the laws of the state of Missouri. Programs: A collection of health insurance plans offered and administered through the Missouri Health Insurance Pool (MHIP) and its administering carriers. Provider: Hospital, ambulatory surgical center, home health care agency, skilled nursing facility, DME supplier, home infusion therapy care provider, home respiratory therapy care provider, physician, other licensed health care professional licensed to render care covered by the program, or other health care provider specified in this description or any authorized amendments issued for attachment to this description, in every case subject to any limitations set forth in this description, licensed where required, and performing within the scope of that license. Pulmonary Rehabilitation: Comprehensive program for the management of patients with substantial chronic lung disease, including diagnostic testing, monitored dynamic exercise and education under the direct supervision of a qualified physician. PUVA Therapy: Treatment combining the use of prescription drugs and ultraviolet light for the symptomatic control of psoriasis. Radiation Therapy: X-ray, radon, cobalt, betatron, telocobalt and radioactive isotope treatment for malignant diseases and other medical conditions. Registered Nurse: Person licensed or registered as a registered professional nurse by the state in which the person is engaged in the practice of nursing. Resident: Person who occupies a dwelling within the state of Missouri, intends to remain within the state of Missouri for an indefinite period of time, and manifests a genuineness of that intent by establishing an ongoing physical presence within the state of Missouri together with intent that his or her presence within the state of Missouri is something other than merely transitory in nature. Residential Treatment Facility: Facility that can provide medical and other services for the treatment of substance abuse to patients on an inpatient basis who are free from acute physical and mental complications. The facility must operate on a 24-hour basis, seven days a week, under an organized program, and be certified by the Missouri Department of Mental Health for treatment of substance abuse. Respiratory Therapy: Introduction of gases into the lungs for treatment purposes. Retrospective Review: Utilization management of coverage and medical necessity that is conducted after services have been provided. Does not include review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding or adjudication for payment. Shock Therapy: Electric shock treatment for mental illness. Skilled Nursing Care: Requires the education, training and skill of a registered nurse (RN) or licensed practical nurse. Services that can be safely performed by unlicensed personnel after appropriate instruction by a licensed nurse may be considered skilled nursing care during the period of initial instruction. 52 glossary STATE POOL

51 Skilled Nursing Facility: Statelicensed establishment primarily engaged in providing skilled nursing care and related services to bed patients who require 24-hour skilled nursing services, but not confinement in a hospital, and at which care is rendered by or under physician supervision. The facility is not, other than incidentally, a place that provides minimal care, custodial care, ambulatory care, part-time care, or care for mental illness or substance abuse. Special Care Unit: Part of a hospital, specifically designated as an intensive care unit, for which an additional charge is made, and which is permanently equipped and staffed to provide more extensive care for critically ill or injured patients than available in other types of hospital accommodations. Such care includes close observation by trained and qualified hospital personnel whose duties are primarily confined to this part of the hospital. Speech Therapy: Treatment for the restoration of speech when the impairment is a result of illness, disease, surgery or injury. Standby Provider: Physician or other licensed health care professional, such as a surgeon or anesthesiologist, generally requested by another provider, to be available while a procedure is being performed, but who does not actually provide care. Subrogation: If you receive plan benefits for an injury or illness caused by another person or organization, and if you receive any payment relating to such injury or illness, the plan is entitled to repayment of the plan benefits received. This is true even if the amount recovered is not described as being related to medical costs. The plan is entitled to be paid first out of any recovery. Substance Abuse: Psychological or physiological dependence upon or abuse of drugs, including alcohol, characterized by drug tolerance or withdrawal, impairment of social or occupational role functioning, or both. Surgery: Performance of generally accepted operative and cutting procedures utilizing specialized instruments; endoscopic examinations and other invasive procedures; correction of fractures and dislocations; and usual related preoperative and postoperative care, not including diagnostic services. Termination Event: A circumstance that would result in the termination of an enrollee s coverage under MHIP. Therapy: Care ordered or provided by a physician or other health care professional licensed to render care for the treatment of a condition, to promote the recovery of the enrollee. Trade Act Adjustment (TAA): The Trade Adjustment Assistance Reform Act of 2002 created a federal tax credit that subsidizes private health insurance coverage for displaced workers certified to receive certain trade adjustment assistance benefits, for older workers receiving alternative trade adjustment assistance benefits, and individuals receiving benefits from the Pension Benefit Guaranty Corporation. The tax credit is 80 percent of the amount paid by eligible individuals for qualified health insurance coverage. This credit is referred to as the Health Coverage Tax Credit (HCTC) and is administered by the IRS. Taxpayers may elect to claim the 80 percent credit on their federal tax return when filing at the end of the year, or individuals may obtain an advance credit of 80 percent, which requires the taxpayer to pay the 20 percent balance of the monthly premium. Urgent Care: Care for a medical condition caused by an illness or injury that arises suddenly. Although it may not be life-threatening, it requires immediate care. Utilization Management: Set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy or efficiency of, health care services, procedures or setting. X-ray and Radiology Services: Services that use radiology, nuclear medicine, ultrasound and other imaging techniques to obtain a visual image of internal body organs and structures and the interpretation of these images. Includes MRIs, CT scans and PET scans. STATE POOL glossary 53

52 miscellaneous provisions Assignment of Benefits All benefits are automatically assigned to the health care provider, including non-network providers. In every case, you will receive an Explanation of Benefits (EOB) detailing the amount paid to the provider and any remaining amount for which you may be responsible. Availability of Provider Services The plan makes no guarantee as to the kind of room or services that will be available at a hospital, alcoholism treatment center or other facility you choose. Neither does the plan guarantee that the services of a participating facility or provider will be available for any given service. Changes to MHIP The Missouri Health Insurance Pool (MHIP) may change coverage under this certificate or require you to enroll under a different coverage when authorized by the Board of Directors of the Missouri Health Insurance Pool (MHIP). The plan will give you at least 30 days written notice of an amendment to this Certificate or a new coverage. No employee of an MHIP carrier may change this plan by giving incomplete or incorrect information or by contradicting the terms of the plan. Any such situation will not prevent the carrier from administering the plan in strict accordance with its terms. Disclaimer of Liability Anthem BCBS, BCBSKC and MHIP have no control over any diagnosis, treatment, care or other service provided to an enrollee by any facility or provider, and the plan is not liable for any loss or injury caused by any health care provider by reason of negligence or otherwise. Disclosure of Medical Information Your medical information is considered confidential, and the plan will not disclose this information to third parties not working on behalf of MHIP for the purpose of administering this plan, unless MHIP has your written authorization or is required by law to do so. As part of its administration of the plan, MHIP and those working on its behalf may use your medical information for treatment, payment and routine health care operations. For more information, please see the MHIP Notice of Privacy Practices. Execution of Papers As a condition of coverage under MHIP, you must, upon request, execute and deliver to your carrier any documents and papers necessary to carry out the provisions of the plan, including annual mailings requesting verification of Missouri residency. Enrollee s Legal Expense Obligations You are liable for any actions that may prejudice MHIP s rights under this certificate. If Anthem BCBS, BCBSKC and/or MHIP is forced to take legal action to uphold its rights and it prevails in that action, Anthem BCBS, BCBSKC and/or MHIP will be entitled to receive, and you will be required to pay, legal expenses, including attorney s fees and court costs. Payment in Error If the plan makes an erroneous benefit payment, the plan may require you, the provider of services or the ineligible person to refund the amount paid in error. The plan reserves the right to correct payments made in error by offsetting the amount paid against new claims. The plan also reserves the right to take legal action to correct payments made in error. The plan will not request a refund against a claim more than 12 months after the claim was paid. Pilot Programs The plan may occasionally develop pilot programs to test different benefits or recognize different providers. The existence of a pilot program does not guarantee that all enrollees are eligible for pilot program benefits or that such benefits will be permanent. Research Fees The plan reserves the right to charge an administrative fee when extensive research is necessary to reconstruct information that has already been provided to you in explanations of benefits, letters or other forms. Reserve Funds No enrollee is entitled to share in any reserve or other funds that may be accumulated or established by MHIP. Sending Notices All notices are considered to be sent to and received by you when deposited in the United States mail with postage prepaid and addressed to you at the latest address appearing on MHIP enrollee records. Utilization Management Claims for covered services may be reviewed to establish that the services were medically necessary, and consistent with the condition reported and with generally accepted standards 54 miscellaneous provisions STATE POOL

53 of medical and surgical practice in the area where performed. Paragraph Headings The paragraph and section headings used throughout the MHIP certificate are for reference only. They are not to be used by themselves for interpreting the provisions of the plan. STATE POOL miscellaneous provisions 55

54 frequently asked questions What is a PPO? A Preferred Provider Organization (PPO) is a contractual arrangement between an administrator and health care providers, where the providers agree to provide patients with discounts and assistance in return for patient volume, streamlined administration and timely reimbursement from the administrator. What is a network provider? PPO network providers are those that are located in Missouri or in Johnson and Wyandotte counties in Kansas, and that accept discounted fees and agree to file claims for enrollees. What is a non-network provider? Non-network providers, also called non-participating providers, are located in Missouri or in Johnson and Wyandotte counties in Kansas, and are not part of the PPO network, and they may not accept discounted fees or handle claims responsibilities. What is an allowable covered charge? The allowable covered charge is the fee the administering carrier pays for medical procedures and services. They are generally discounted fees that the administering carrier will pay to network providers and nonnetwork providers. (Non-network providers will often bill the patient for the balance regardless of what the medical plan pays.) How is MHIP funded? The plan is funded by enrollee premiums and assessments from insurance companies doing business in Missouri. Why does MHIP have two carriers? MHIP works with Anthem BCBS and BCBSKC to offer its enrollees the broadest access to providers and the best discounts on care. MHIP utilizes the discounts and services of Blue Cross and Blue Shield organizations throughout the country using the Blue Card arrangement. What is an out-of-state participating provider? An out-of-state participating provider participates in the local Blue Cross and Blue Shield network and the national Blue Card arrangement. These providers accept MHIP s allowable covered charges and bill MHIP enrollees only for the appropriate percentage of a discounted fee. What is a non-participating provider? A non-participating provider is one that has no agreement with MHIP. These providers are not obligated to accept any discounts and may charge and collect any billed fee. What is managed care? Managed care is a broad term that applies to a plan with controls. The goal is to provide appropriate levels of care at the most reasonable cost to enrollee. What is disease management? Disease management is a program in which medical experts with experience in the care of certain conditions provide the enrollee with advice to help manage his or her health problems. It does not replace the enrollee s physician but serves to educate the enrollee. What is evidenced-based medicine? Evidenced-based medicine is medical treatment based on clinical research. If I m outside the United States and have an urgent care issue, will MHIP cover me? Yes. If you need assistance outside the country, you may make a collect call to for assistance. In many cases, you will have to pay the bill for services and be reimbursed by the plan. If I have Medicare Part A only, am I eligible for MHIP? Yes. If you have only Part A coverage, you may participate in MHIP, provided you meet other qualifications. Please compare the cost of other coverage. What is a generic drug? Generic drugs are those that meet the same standards for safety, purity, strength and effectiveness as their corresponding brand-name drugs. Generic drugs usually cost less than brand-name drugs. Where can I get materials on wellness? Your carrier s website has wellness information. If you don t have access to a computer, call your carrier or MHIP to have information sent to you. Does the plan evaluate new procedures that can help enrollees? Yes. Anthem BCBS and BCBSKC regularly evaluate new procedures and drugs. The carriers gather information from a number of sources, including nationally recognized health care research organizations. Assessments are conducted by a staff of physicians 56 frequently asked questions STATE POOL

55 and research scientists who consult with professionals in various medical specialties. The findings are reviewed by an advisory panel composed of nationally recognized experts in technology, clinical research and clinical practice who make determinations for new procedures to be covered along with the plan s board and advisors. What is the difference between Plan V and MHIP s other plans? MHIP s Plan V is a High Deductible Health Plan, which means enrollees participating in that plan are eligible to make contributions to a Health Savings Account (HSA). Plan V has a single deductible that applies to all covered services, including prescriptions. Plan V enrollees may establish an HSA with their carrier s bank or their own bank, and contributions to the HSA are exempt from federal income taxes, as long as the contributions are used to pay for qualified medical expenses, as defined by the IRS. STATE POOL frequently asked questions 57