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State and Public School's Health Insurance Plan
Administered by Blue Cross Blue Shield of Mississippi
Post Office Box 23071
Jackson, MS 39225-3071
1-800-709-7881
AHS State Network
The State Employees’ Health Insurance Plan is provided for employees who are employed as a full-time or part-time employee and who work assignments are one-half time or more. The Plan is self-funded by the State of Mississippi which means claims are payable from the actual premiums received from other University or state agencies. The Claims Administrator, Blue Cross Blue Shield, processes all medical claims. The AHS State Network contracts with physicians, hospitals, and other health care providers to provided negotiated discounts in a defined geographic area. The Pharmacy Benefit Manger, Catalyst Rx, processes retail pharmacy claims and provides a pharmacy mail order service. The Utilization Review Manager, CareAllies, determines medical necessity for inpatient admissions and certain outpatient services, as well as provides case management services.
The University bears 100% of the premium for each covered employee, and the employee pays the total premium of dependent coverage through payroll deduction.
Employees electing coverage within the first 31 days of hire are covered as of their date of employment. If you waive coverage or do not enroll your eligible dependents at the time of your initial enrollment, you may later enroll yourself or add dependents during a regular open enrollment, generally in October, or special enrollment period. A special enrollment period arises when you or an eligible dependent lose coverage under another health plan or when you gain a new eligible dependent (marriage, birth, adoption, legal guardianship, Qualified Medical Child Support Order, and/or Dependent returning to full-time student status). To enroll yourself or your new dependent for coverage under these circumstances, you must submit an Application for Coverage form within 60 days and make the proper premium payments. You may be required to provide proof of the qualifying event. Assuming these requirements are met, coverage under the Plan will take effect immediately as of the date of the qualifying event.
Please note that all new employees and their dependents that initially applied for coverage are subject to a 12-month pre-existing condition exclusion period. Those that enroll during a regular open enrollment will be subject to an 18-month pre-existing condition exclusion period. The number of prior creditable health coverage may reduce this period. You will receive credit for prior creditable coverage that occurred without a break in coverage of 63 days or more. Any coverage occurring to a break in coverage of 63 days or more would not be credited against an exclusion period.
The Plan provides for in-network and out-of-network coverage for both you and your covered dependents, whether you live within the State of Mississippi or outside of its boundaries. Using providers that are in-network ensures you receive the maximum benefits available through the Plan.
The AHS State Network helps you manage your overall health care needs through a network of physicians, hospitals, and other health care providers. Providers included in the Network must agree to accept pre-negotiated fees set by the Network. When you visit in-network doctors and facilities, you will receive maximum benefits available under the Plan.
There are two types of plans to choose from: Select Coverage and Base Coverage.
SELECT PLAN
|
Premium Class |
Monthly Rates |
||
|
Active
|
University Portion
|
Employee Portion
(Employees hired before January 1, 2006) |
Employee Portion
(Employees hired after January 1, 2006) |
|
Employee |
$361 |
-0- |
$18 |
|
Employee + Spouse |
$361/343 |
$385 |
$403 |
|
Employee + Spouse + |
$361/343 |
$563 |
$581 |
|
Employee + Child |
$361/343 |
$135 |
$153 |
|
Employee + Children |
$361/343 |
$271 |
$289 |
Participants may choose any covered participating or non-participating provider, primary care or specialist; however, using providers that participate in the Network provides participants the maximum benefits available through the Plan. Participants choosing to use providers that do not participate in the Network are responsible for paying any fees charged over the allowable charge, in addition to paying a higher annual deductible and coinsurance.
To find a participating provider, participants can access the AHS Network directory through the Plan’s web site at knowyourbenefits.dfa.state.ms.us or may call the Network at 1-800-294-6307.
Select Plan Health Insurance Deductible and Co-Insurance/Co-payment Amounts
Individual Calendar Year Medical Deductible
The calendar year medical deductible is the amount of medical costs you must pay each year out of your own pocket before the Plan begins to pay its share of medical costs. Once the calendar year deductible is met, the Plan pays a percentage of the allowable charge for covered medical services.
The initial $500 of covered medical expense will apply to both the in and out-of-network deductible. After the initial $500 has been applied, only services rendered by a non-participating provider will be applied to the additional $500 out-of-network deductible.
Family Calendar Year Medical Deductible
Once a family has paid the family medical deductible in a calendar year, all covered participants in that family will be considered to have satisfied their individual medical deductibles for that calendar year. The family deductible amount is twice the calendar year deductible for one individual The family medical deductible also applies when both husband and wife are covered separately as enrollees and both are enrolled in Select Coverage. No individual family may contribute more than $500 to the in-network family medical deductible or more than $1,000 to the out-of-network family medical deductible. The initial $1,000 of covered expense will apply to both the in and out-of-network family medical deductible. After the initial $1,000 has been applied, only services rendered by a non-participating provider will be applied to the additional $1,000 out-of-network family medical deductible.
Coinsurance
Once a participant has me the calendar year medical deductible, the Plan pays a portion of the allowable charge for covered medical expense. The participant pays the remainder in the form of coinsurance. Any fees charged by a non-participating provider that are above the allowable charge are not part of the coinsurance amount. The Plan will not pay any portion of these charges.
Individual Medical Coinsurance Maximum
The out-of-pocket maximum is the maximum amount that you and your family have to pay out of your own pocket for eligible medical expenses in a calendar year. However, what you pay toward meeting the calendar year deductible does not count toward satisfying the out-of-pocket maximum. You must meet the deductibles and out-of-pocket maximum separately. Essentially, the out-of-pocket maximum protects you from having to pay extraordinary medical bills in a given year. Once your out-of-pocket maximum costs meet the annual out-of-pocket maximum, the Plan covers 100% of the allowable charge of your eligible medical expenses for the remainder of that calendar year. Please refer the Summary Plan Description for a complete listing of expenses that will and will not count towards the out-of-pocket maximum (page 7).
Below is a summary of the deductibles and insurance payments for both in- and out-of-area participants.
*Most medical services are paid at 80% once the calendar year deductible is met. Please refer to the Summary Plan Description for information regarding specific medical benefits. The following expenses do not count towards the calendar year medical deductible:
- Prescription drug deductible
- Expenses in excess of the allowable charge
- Expenses in excess of Plan maximum limits
- Services not considered medically necessary
- Emergency room co-payment
- Prescription drug co-payments
- Utilization review penalties
- Private room co-payment
- Services not covered by the Plan
Individual Prescription Drug Deductible
Before the Plan will pay any of the cost for prescription drugs, each participant must first satisfy a $50 prescription drug deductible each calendar year. The prescription drug deductible and co-payment amounts will not apply toward satisfying the medical calendar year deductible or co-insurance maximum. Prescription drug benefits paid by the Plan will apply towards the participant’s $1,000,000 lifetime maximum.
BASE PLAN
|
Premium Class
|
Monthly Rates
|
||
|
Active
|
Total Premium
|
University Portion
|
Employee Portion
|
|
Employee
|
$322
|
-0-
|
-0-
|
|
Employee + Spouse
|
$640
|
$322
|
$318
|
|
Employee + Spouse +
Child(ren) |
$808
|
$322
|
$486
|
|
Employee + Child
|
$406
|
$322
|
$84
|
|
Employee + Children
|
$533
|
$322
|
$211
|
Base Coverage meets the federal government’s criteria of a qualifying highdeductible health plan (HDHP) under Section 201 of the Medicare Prescription Drug Improvement and Modernization Act of 2003. Participants enrolled in the HDHP may establish a Health Savings Account (HSA). HSAs are portable, interest bearing, funded accounts to provide for tax-free savings for medical expenses. HSAs allow individuals to pay for current health expenses and save for future qualified medical and retiree health expenses on a tax-free basis. HSAs must be funded through a trust or custodial account. Permissible trustees and custodians include banks, insurers, or any entity that has been approved by the IRS to be a trustee of an individual retirement account or Archer MSA.
The following is a summary of the benefits for the HDHP.
|
|
In-Network
|
Out-of-Network
|
|
Employee Only Calendar Year Deductible
|
$1,100
|
|
|
Employee Plus Dependents
Calendar Year Deductible |
$2,200
|
|
|
Employee Only Out-Of-Pocket
Maximum |
$2,450
|
$3,950
|
|
Employee Plus Dependents
Out-of-Pocket |
$4,900
|
$7,900
|
|
Co-Insurance for In-Area
Participant |
80%
|
60%
|
|
Co-Insurance for Out-of-Area
Participant |
80%
|
75%
|
Base Plan Health Insurance Deductible and Co-Insurance/Co-payment Amounts
Calendar Year Deductible – Individual Coverage
The calendar year deductible is the amount of covered expense a participant must pay each year before the Plan begins to pay its share of covered expense. All expenses, medical and pharmacy, apply toward the calendar year deductible. Once the calendar year deductible has been met, the Plan pays its portion of the allowable charge for covered expenses, and the participant pays prescription drug co-payments of the allowable charge for covered medical expenses
Coinsurance/Co-payment Maximum – Individual Coverage
The coinsurance maximum is the maximum amount that an enrollee with individual coverage has to pay in coinsurance and co-payments for covered expenses in a calendar year before benefits will be paid at 100%. The amount paid toward meeting the calendar year deductible does not count toward satisfying the coinsurance/co-payment maximum. The initial $2,450 of coinsurance is applied to both the in and out-of-network coinsurance/co-payment maximum. After the initial $2,450 has been met, only the coinsurance amount for services rendered by non-participating providers will be applied to the additional $1,500 out-of-network coinsurance. Once the annual coinsurance/co-payment maximum is met, the Plan pays 100% of the allowable charge for covered medical expenses and prescription drugs for the remainder of that calendar year, except as otherwise specified.
Calendar Year Deductible – Family Coverage
If an employee has family coverage, there is no separate deductible for each individual in the family. Benefits will not be paid until the Family Deductible for all participants under that ID number has been satisfied. The family deductible also applies when both husband and wife are covered separately as enrollees, one of the enrollees has dependent coverage, and both are enrolled in the Base Coverage.
If both husband and wife are covered employees, one carries dependent coverage, and only on of them elects Base Coverage, calendar year deductibles and coinsurance/co-payments amounts are not shared.
If both husband and wife are covered employees with employee only coverage, and both elect the Base Coverage, the calendar year deductible and coinsurance-co-payments amounts are not shared.
The following expenses do not count towards the calendar year deductible for Individual or Family Coverage:
- Expenses in excess of the allowable charge
- Utilization review penalties
- Expenses in excess of Plan maximum limits
- Services not considered medically necessary
- Services not covered by the Plan including those found in Medical Limitations and Exclusions section.
Coinsurance Maximum – Family Coverage
The coinsurance/co-payment maximum is the maximum amount that an enrollee with family coverage has to pay in coinsurance and co-payments for covered expenses in a calendar year before benefits will be paid at 100%. If an enrollee has family coverage, there is no separate coinsurance/co-payment maximum for each individual. The family coinsurance/co-payment maximum also applies when both husband and wife are covered separately as enrollees, one of the enrollees has family coverage, and both are enrolled in the Base Coverage. The amount paid toward meeting the calendar year deductible does not count toward satisfying the coinsurance/co-payment maximum.
The coinsurance/co-payment maximum is the maximum amount that an enrollee with family coverage has to pay in coinsurance and co-payments for covered expenses in a calendar year before benefits will be paid at 100%. If an enrollee has family coverage, there is no separate coinsurance/co-payment maximum for each individual. The family coinsurance/co-payment maximum also applies when both husband and wife are covered separately as enrollees, one of the enrollees has family coverage, and both are enrolled in the Base Coverage. The amount paid toward meeting the calendar year deductible does not count toward satisfying the coinsurance/co-payment maximum.
The initial $4,900 of coinsurance and co-payments is applied to both the in and out-of-network coinsurance/co-payment maximum. After the initial $4,900 has been applied, only the coinsurance amount for services rendered by non-participating providers will be applied to the additional $3,000 out-of-network coinsurance/co-payments maximum. Once the annual coinsurance/co-payment maximum is met, the Plan pays 100% of the allowable charge for covered medical expenses and prescription drugs for the remainder of that calendar year, except as otherwise specified.
The Plan will never pay 100% for those expenses that do not apply toward satisfying the coinsurance/co-payment maximum.
SELECT AND BASE PLAN BENEFIT HIGHLIGHTS
Lifetime Maximum
The maximum benefit you can receive from the Plan during your lifetime is $1,000,000. This lifetime maximum benefit of $1,000,000 applies to each covered employee or dependent under the Plan. This maximum applies to your entire lifetime, regardless of whether you’re an active employee, retiree, COBRA participate, surviving spouse, or dependent. This maximum also applies regardless of any break in coverage or service.
Out-of-Network Review
If you need specialty services that are not available from an in-network provider, you will need to contact CareAllies and request that they review the availability of the services you need. This is called an out-of-network review and must be requested prior to receiving a medical service not available in the network. If CareAllies certifies that the service you need is not available within the network, that service will be covered at the in-network benefit level, even it if is provided by an out-of-network provider. Although approval to use an out-of-network provider may be granted, you will still be responsible for amounts charged by the out-of-network provider that exceed the Plan’s allowable charge.
Health Insurance Benefits
Out-of-Network Review
If you need specialty services that are not available from an in-network provider, you will need to contact CareAllies and request that they review the availability of the services you need. This is called an out-of-network review and must be requested prior to receiving a medical service not available in the network. If CareAllies certifies that the service you need is not available within the network, that service will be covered at the in-network benefit level, even it if is provided by an out-of-network provider. Although approval to use an out-of-network provider may be granted, you will still be responsible for amounts charged by the out-of-network provider that exceed the Plan’s allowable charge.
Health Insurance Benefits
(A) Hospital Benefits: Inpatient benefits are provided for covered hospital services and supplies subject to the calendar year deductible and the private room co-payment of $20 per day. All inpatient hospitalizations are subject to certification of medical necessity by the Plan’s Utilization Review Program. See the Summary Plan Description for a complete listing of hospital and physician services covered under the Plan (page 27). The private room co-payment will not be charged after a participant in Base Coverage has met the coinsurance/co-payment maximum. Once a participant has me the calendar year deductible, the Plan pays a portion of the allowable charge for covered medical expense. The participant pays the remainder in the form of coinsurance. Any fees charged by a non-participating provider that are above the allowable charge are not part of the coinsurance amount. The Plan will not pay any portion of these charges.
(B) Emergency Care: Benefits are provided for treatment in a hospital emergency room. The State Health Insurance Plan will pay a $50 Emergency Room co-payment per visit after the first visit in any calendar year. The $50 Emergency Room co-payment will not apply to the calendar year deductible or the out-of-pocket maximum (page 26). The emergency room co-payment will not be charged after a participant in Base Coverage has met the coinsurance/co-payment maximum.
(C) Maternity Benefits: The Plan provides maternity benefits to covered employees or to a covered spouse of a male employee. Other female dependents are not eligible for maternity benefits. The attending physician will be reimbursed for covered routine prenatal care and delivery at 100% all the allowable charge (90% for out-of-network physician), not subject to the calendar year deductible. Benefits for prenatal laboratory and diagnostic procedures will be provider at 100% of the allowable charge (90% for out-of-network physician), not subject to the calendar year deductible. Regular Plan benefits will be provided for other prenatal laboratory and diagnostic procedures, inpatient hospital delivery, and other covered services. See the Summary Plan Description for a complete listing of eligible services (page 28).
Plan participants should contact CareAllies within the first four months of pregnancy to participate in the voluntary maternity management program. This program is an educating and monitoring service that identifies risk factors in early pregnancy, including high-risk screening processes, pregnancy education and support. As part of the program you will receive an educational book and other brochures on pregnancy and childbirth. Participants who do not notify Intracorp/CareAllies will be responsible for certifying their hospital admission for delivery. Participants must notify CareAllies within 48 hours of admission for delivery, and should the newborn require additional hospital stays beyond the mother’s length of stay, CareAllies should be notified.
(D) Well Child Care: Benefits are provided for well-child services for covered dependents up to age 18. All benefits are subject to the individual calendar year deductible for Select Coverage and family calendar year deductible for BaseCoverage. Benefits are only provided when a participating provider renders services.
Well-newborn nursery care while a newborn is hospital-confined after birth is covered at 100%. Well-newborn nursery care includes room, board, and other normal care provided for which a participating hospital or physician makes a charge. Also, well-child physician office visits and certain diagnostic tests are covered at 100%. Immunizations are covered at 80%.
A list of covered wellness/preventive services can be found at the Plan's web site, http://knowyourbenefits.dfa.state.ms.us or can be obtained by calling Blue Cross & Blue Shield of MS.
(E) Wellness/Preventive Coverage for Adults: Wellness/preventive services for participants, ages 18 and older, are limited to a maximum benefit of $250 annually. If a participant completes a Health Risk Assessment (HRA) on or after January 1, 2007, he will be eligible for an additional $50 to be applied toward wellness/preventive services. The HRA can be found at the Plan's web site. Benefits will be provided 100% of the allowable charge, for office visits and certain diagnostic tests as defined by the Plan. The diagnostic tests are based on age and gender. These services are not subject to the calendar year deductible.
A list of covered wellness/preventive services can be found at the Plan's web site, http://knowyourbenefits.dfa.state.ms.us or can be obtained by calling Blue Cross Blue Shield of MS.
Benefits are only provided when a participating provider renders services. Unused benefit amounts do not carry over into subsequent years.
(B) Emergency Care: Benefits are provided for treatment in a hospital emergency room. The State Health Insurance Plan will pay a $50 Emergency Room co-payment per visit after the first visit in any calendar year. The $50 Emergency Room co-payment will not apply to the calendar year deductible or the out-of-pocket maximum (page 26). The emergency room co-payment will not be charged after a participant in Base Coverage has met the coinsurance/co-payment maximum.
(C) Maternity Benefits: The Plan provides maternity benefits to covered employees or to a covered spouse of a male employee. Other female dependents are not eligible for maternity benefits. The attending physician will be reimbursed for covered routine prenatal care and delivery at 100% all the allowable charge (90% for out-of-network physician), not subject to the calendar year deductible. Benefits for prenatal laboratory and diagnostic procedures will be provider at 100% of the allowable charge (90% for out-of-network physician), not subject to the calendar year deductible. Regular Plan benefits will be provided for other prenatal laboratory and diagnostic procedures, inpatient hospital delivery, and other covered services. See the Summary Plan Description for a complete listing of eligible services (page 28).
Plan participants should contact CareAllies within the first four months of pregnancy to participate in the voluntary maternity management program. This program is an educating and monitoring service that identifies risk factors in early pregnancy, including high-risk screening processes, pregnancy education and support. As part of the program you will receive an educational book and other brochures on pregnancy and childbirth. Participants who do not notify Intracorp/CareAllies will be responsible for certifying their hospital admission for delivery. Participants must notify CareAllies within 48 hours of admission for delivery, and should the newborn require additional hospital stays beyond the mother’s length of stay, CareAllies should be notified.
(D) Well Child Care: Benefits are provided for well-child services for covered dependents up to age 18. All benefits are subject to the individual calendar year deductible for Select Coverage and family calendar year deductible for BaseCoverage. Benefits are only provided when a participating provider renders services.
Well-newborn nursery care while a newborn is hospital-confined after birth is covered at 100%. Well-newborn nursery care includes room, board, and other normal care provided for which a participating hospital or physician makes a charge. Also, well-child physician office visits and certain diagnostic tests are covered at 100%. Immunizations are covered at 80%.
A list of covered wellness/preventive services can be found at the Plan's web site, http://knowyourbenefits.dfa.state.ms.us or can be obtained by calling Blue Cross & Blue Shield of MS.
(E) Wellness/Preventive Coverage for Adults: Wellness/preventive services for participants, ages 18 and older, are limited to a maximum benefit of $250 annually. If a participant completes a Health Risk Assessment (HRA) on or after January 1, 2007, he will be eligible for an additional $50 to be applied toward wellness/preventive services. The HRA can be found at the Plan's web site. Benefits will be provided 100% of the allowable charge, for office visits and certain diagnostic tests as defined by the Plan. The diagnostic tests are based on age and gender. These services are not subject to the calendar year deductible.
A list of covered wellness/preventive services can be found at the Plan's web site, http://knowyourbenefits.dfa.state.ms.us or can be obtained by calling Blue Cross Blue Shield of MS.
Benefits are only provided when a participating provider renders services. Unused benefit amounts do not carry over into subsequent years.
FOR A COMPLETE LISTING OF ALL COVERED SERVICES, PLEASE REFER THE PLAN DOCUMENT, PAGES 24-34.
This page is maintained by Lisa Giger. Send questions and comments regarding this site to lgiger@deltastate.edu
|
|
In-Area Participants
|
Out-of-Area Participants
|
||||||
 |
IN-NETWORK
|
OUT-OF-NETWORK
|
IN-NETWORK
|
OUT-OF NETWORK
|
||||
|
Calendar Year Deductible
|
$500
|
80%
|
$1,000
|
60%
|
$500
|
80%
|
$1,000
|
75%
|
|
Family Deductible
|
$1,000
|
80%
|
$2,000
|
60%
|
$1,000
|
80%
|
$2,000
|
75%
|
|
Out-of-Pocket Maximum
|
$2,000
|
100%
|
$3,000
|
100%
|
$2,000
|
100%
|
$3,000
|
100%
|