Slides - Missouri Consolidated Health Care Plan

PPO 300 Plan
Plan Year 2016
Understanding your Benefits Plan
The PPO 300
PPO 300
Copayment, Coinsurance, Out-of-Pocket
Maximum, Deductible
What do all these terms mean?
PPO 300
Premium: The fixed amount you will pay
for your insurance.
PPO 300
Deductible
Copayment
Coinsurance
OOP Maximum
The Amount you pay
before your insurance
plan pays
A Fixed Amount
you pay for covered
services
Cost Sharing between
your medical plan and
you
Out Of Pocket
Maximum is the total
amount you pay for
services in a plan year
PPO 300
Deductible
The Amount you pay
before your insurance
plan pays
The amount you owe for health services before your
health insurance begins to pay.
For Example: Your Deductible is $300, so you are responsible for the
first $300 of medical services in addition to office copayments.
Copayments do not count towards your deductible.
Preventive care is covered at 100% and is not subject to deductible.
PPO 300
Copayment
A Fixed Amount
you pay for covered
services
A fixed amount owed for a covered health service
upon receipt of service.
Office copayments on PPO 300:
$25 Primary Care and mental health
$40 Specialist
$20 Chiropractor or 50% of total cost
$50 Urgent Care
$100 Emergency Room (possible to be waived)
Additional charges apply to deductible, coinsurance
and out-of-pocket maximum.
Copayments do apply to out-of-pocket maximum, but not
to the deductible.
PPO 300
Coinsurance
Percentage of costs that member owes for covered health services.
Member has 10% coinsurance after deductible.
Cost Sharing between
your medical plan and
you
Example: $300 deductible is met
Visit family doctor for sore throat with $50 lab
Member responsible for $25 office copayment plus
$5 for lab
PPO 300
The maximum amount member pays before plan pays 100%
of covered services
Out-of-Pocket Maximum on PPO 300 is $1500.
OOP Maximum
Out Of Pocket
Maximum is the total
amount you pay for
services in a plan year
This amount includes deductible, office copayments
and coinsurance.
Example: January 1 visit Urgent Care with stomach pain
Member responsible for $50 copayment
Doctor admits to hospital for appendectomy
Hospital and surgery bill is $11,800
Member owes $1450
Covered at 100% remainder of year
PPO 300
Preventive
Preventive care is covered at 100%
Examples of Preventive Care: Annual physical exams, Immunizations, and
Age-specific screenings
What do these terms mean to my wallet?
Individual Plan
Co-Payment
Co-Insurance
+
Annual Premium
$840
Deductible
Out of Pocket
Individual Plan
Co-Payment
varies
Co-Insurance
10%
+
Annual Premium
$840
Out of Pocket
$1500
Deductible
$300
Network Service Benefits
Include Premium Incentives such as Tobacco Free Promise, Quit Tobacco Promise, and Partnership Incentive
Family Plan
Co-Payment
varies
Co-Insurance
10%
+
Annual Premium
$4728
Out of Pocket
$3000
Deductible
$1200
Network Service Benefits
Include Premium Incentives such as Tobacco Free Promise, Quit Tobacco Promise, and Partnership Incentive
How does this all work together?
Feel Sick
Provider Visit
Office
Copayment
Explanation of Benefits (EOB)
Explanation of Benefits (EOB)
The EOB details the service received, the amount covered by the plan,
and amount the provider may bill you.
The EOB allows member to track annual out-of-pocket expenses.
Your Payment
The Bill
Up to $300 – which is your
Prescription Benefits
Prescription Drug Copayments apply when filled at a Network Pharmacy
Prescription Benefits
Brand Name
1-31 Days
Generic
$8
Non-Formulary
$35
$100
32-60 Days
$16
$70
$200
61-90 Days (Retail)
$24
$105
$300
Prescription Benefits
Home Delivery
61-90 Days
Generic
Brand Name
Non-Formulary
$20
$87.50
$250
To Learn more about your Prescription Drug Benefits –
Please view the Prescription Drug Presentation
available on MCHCP.org
What if I went to the Emergency Room?
If it is a true emergency, you would be responsible
for your deductible, coinsurance and out of pocket maximum
But what if it wasn’t a true emergency?
If plan determines visit was not true emergency,
Member owes $100 copayment plus additional cost of services
that are subject to deductible, coinsurance and
out-of-pocket maximum.
Let’s look at a hospital visit
• The doctor orders test: $150
• Overnight Stay: $700
• Pain Reliever: $50
Total: $900
• The doctor orders test: $150
• Overnight Stay: $700
• Pain Reliever: $50
Total: $900
+
Deductible is $300
=
Coinsurance is 10%
Member Owes
How long do I pay copayment and coinsurance?
Until you reach your Out-of-Pocket Maximum
PPO 300
How much is my Out-of-Pocket Maximum?
Out-of-Pocket Maximum
Individual Plan
PPO 300
How much is my Out-of-Pocket Maximum?
Out-of-Pocket Maximum
Family Plan
PPO 300
What defines a Family Plan?
PPO 300
Family Plan
Family Plan becomes effective
when three or more people are on the medical plan
PPO 300
Family Plan
Miriam and Bertrand are participating
in the Family Plan with Bernice and Milton
PPO 300
Family Plan
They now have a Family Deductible of $600
and a Out of Pocket Maximum of $3000
PPO 300
How do they meet the Family Deductible?
PPO 300
I’m glad you asked that…
Let’s say Bertrand gets hurt.
Bertrand incurs $600 of expenses
The Family will then pay his Deductible of $300
Copayment of $25 and his Coinsurance of 10%
Copayments will continue. However, Bertrand will now begin
paying 10% Coinsurance for his remaining medical expenses.
Now let’s say Bernice also gets hurt.
Bernice incurs $600 of expenses
The Family will then also pay her Deductible of $300
Copayment of $25 and her Coinsurance of 10%
The Family has now met the Family Deductible
So now, if Miriam and Milton get sick, the family only pays
their Copayments and the Coinsurance of 10% for their medical
needs until the family reaches the Out of Pocket Maximum
Two family members must contribute to the family deductible.
One family member cannot meet the entire family deductible.
What if the Family also paid up to $3000 for Bertrand and Bernice’s illnesses?
The Family would meet their out-of-pocket maximum
and be covered at 100% for the rest of the year
That’s how you would utilize the Family Plan
800-487-0771
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Thank You!
Missouri Consolidated Health Care Plan
www.mchcp.org
800-487-0771
Contact MCHCP for:
Eligibility/Enrollment, premiums, change of address, name change, or general benefit questions.
Plan contact information can be found on our website or in your Benefit Guide.