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Once payment of the deductible is met, coverage is provided at 80% of the allowed amount for eligible services received from In-Network providers. Payment of the remaining 20% charges is a coinsurance and the responsibility of the insured. Once $3,000 of eligible out-of-pocket expenses has been satisfied in a calendar year (for the $5,000 and $10,000 deductible plans, the deductible amount serves as the out-of-pocket maximum), MCHA pays 100% of the allowed amount for eligible services to the end of the calendar year, to a lifetime maximum benefit of $5,000,000 (effective May 22, 2007).
You have the option to utilize Out-of-Network providers, however, the benefit and payment percentage will generally be less than stated above.
Benefits generally include charges for eligible services when ordered by a physician. Eligible services include:
- Professional Service
- Prescription Drugs and Pharmacy Services
- Mail Service Prescription Drug Program
- Hospital Services
- Ambulance Services
- Home Health Care
- Outpatient Rehabilitation
- Mental Health
- Substance Abuse
- Durable Medical Equipment and Prosthetics
- Miscellaneous Medical supplies
- Organ and Bone Marrow Transplant Services
- Infertility Services
- Reconstructive and Restorative Surgery
- Skilled Nursing Facility Services
- Hospice Services
- Temporomandibular Joint Disorder (TMJ)
- Medical-Related Dental Services
- Emergency Services
This is only a summary of eligible services. If you have specific questions about whether a specific service is covered, please contact Customer Service at the telephone numbers listed below.
High Deductible Health Plan (HDHP)
This is a federally qualified high deductible health plan that allows you to open a health savings account (HSA) if certain HSA eligibility requirements are met. Individual and family annual deductible and out-of pocket amounts are variable, adjusted each January 1st, and are tied to the Federal annual maximum amount allowed for contribution to a Health Savings Account (HSA).
Once the annual deductible has been met, coverage is provided at 100% of the allowed amount for eligible services. Eligible services are described above.
Differences
The following information outlines the major differences in coverage and benefits between the MCHA deductible plans and the HDHP:
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Deductible Plans
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HDHP
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Deductible is split between pharmacy and medical services
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Total deductible must be met before coverage is available
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Individual only deductible
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Individual and family deductible
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Coverage for both formulary and non-formulary drugs
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Coverage only for formulary drugs
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Medicare Supplement Plan:
- Basic Medicare Supplement (no Rx coverage, optional riders available)
For the Basic Medicare Supplement plan (providing the care is Medicare eligible and the member has met his/her Medicare deductibles) MCHA pays the 20% not covered by Medicare up to the allowed amount. The insured is responsible for any amount in excess of the allowed amount and for any ineligible service. Optional additional riders are available.
This is only a summary of eligible services. If you have specific questions about whether a specific service is covered, please contact Customer Service at the telephone numbers listed below.
Important Information on Pre-existing Conditions:
For all MCHA policies, no benefits are payable during the first six months of coverage for expenses for any preexisting condition, injury, illness or other physical or mental condition that was diagnosed, treated or evaluated during the 90 days preceding the effective date of coverage. However, Minnesota State law does provide some exceptions to the preexisting condition limitation. In order to determine if you may be eligible for a waiver, you must requests a waiver of the preexisting condition limitation by completing the applicable section of the MCHA application.
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