B S ENEFIT

MACo Health Care Trust
BENEFIT SUMMARY
Effecve July 1, 2013
HEALTH CARE TRUST ADMINISTRATION
2717 Skyway Drive, Suite D
Helena, MT 59602
1-866-669-6428
HEALTH CARE TRUST MARKETING
P.O. Box 3663
Lewistown, MT 59457
1-406-366-6893
HEALTH CARE TRUST CLAIMS
P.O. Box 1966
Missoula, MT 59806
1-888-883-3233
IT’S ALL ABOUT TRUST
MACo Health Care Trust | 2717 Skyway Drive, Suite D | Helena, MT 59602
(Ph) 406-443-8102 | (F) 406-443-8103 | www.mtcounes.org/hct
The mission of MACoHCT is to provide quality group health benefits for Montana Counties. We
accomplish this through member directed leadership, outstanding member service, excellent
benefit plans including preventive care and wellness, premium rate stability through shared risk
pooling, and responsible transparent financial management.
Medical Benefits
Medical benefit plan design options coupled with multiple deductible selections enable Member Groups to customize their plan(s) to their
employees’ needs. MACoHCT offers the following medical benefit plans:
• Revised Major Medical Plan (RM)
• Comprehensive Major Medical Plan (CM)
• High Deductible Health Plan (HD) - qualifies for Health Savings Account
• Catastrophic Medical Plan (CM)
• Basic Medical Plan (BP)
MACoHCT requires each member group to enroll at least 75% of all eligible employees and eligible county elected officials, excluding
those waiving coverage because they are insured under another group health plan.
Prescription Benefits
MACoHCT and Caremark contract to provide members with the convenience and cost savings of the Caremark purchasing network and
the ease of purchasing prescription drugs with the MACoHCT ID card at participating pharmacies. Caremark offers mail-order
prescriptions and approximately 225 local pharmacies within its network that provide 90-day prescriptions at near mail-order prices.
Dental & Vision Benefits
Dental and Vision benefits are available for employees and dependents. Enrollment in a medical plan is not necessary.
NEW
MACo Health Care Trust Medicare Retiree Plan
MACoHCT and New West Medicare have partnered to offer a Group Medicare Advantage Plan to retired
Health Care Trust members over the age of 65 years old. The plan includes enhanced Medicare benefits, prescription
drug coverage, a large network of medical providers, no medical deductibles, simple co-pays, wellness benefits, world-wide coverage for
emergent care, gym membership, dental benefits, annual eyewear allowance, hearing aid coverage and excellent Montana based
Customer Care Service. 888-873-8049
Life Insurance Benefits
The Basic Life Insurance and Accidental Death & Dismemberment benefit of $20,000 is provided at no cost to all active employees and
active county elected officials enrolled in a MACoHCT medical benefit plan.
In addition to the Basic Life Insurance provided by MACoHCT at no cost, Member Groups may elect to enhance the life insurance benefit
through Standard Life Insurance Company for eligible active employees and eligible county elected officials.
•
Option 1: Employer Paid Additional Life and AD&D Policy
Employers may elect any amount in increments of $10,000, to a maximum of $150,000, not to exceed $100,000 for
member groups with fewer than 10 eligible employee. Late enrollee rules apply.
Employers may also elect to offer Dependent life insurance - $10,000 spouse and $10,000 per child.
•
Option 2: Employee Paid Additional Life Insurance and AD&D Policy
Active eligible employees and active eligible county elected officials can elect any amount in increments of $10,000 to the
lesser of $500,000 or 4 times annual earnings. Guaranteed issue amount of up to $50,000 (in most cases) without
submitting evidence of insurability. Late enrollee rules apply. The Employer can elect to pay a portion of the premium if
desired .
Employees and county elected officials may also elect to purchase Dependent life insurance - $10,000 spouse and
$10,000 per child.
MEDEX® Travel Assist
MEDEX Travel Assist helps MACoHCT members and their families cope with emergencies when traveling more than 100 miles from
home or internationally for trips up to 180 days. MEDEX Travel Assist can also help with non-emergencies, such as pre-trip planning.
Enrollment is automatic and all services provided by MEDEX are available 24 hours a day, every day. 800-527-0218
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Preventive Benefits - included in every plan!
MACoHCT is compliant with PPACA preventive benefit requirements as mandated by Federal Health Care Reform. Here’s just some of
the numerous preventive benefits covered by all MACoHCT medical plans:
• Well-child care following the American Academy of Pediatrics recommended schedule
• CDC recommended immunizations
• Preventive annual pap test
• Preventive annual mammogram
• Preventive colon cancer screenings including fecal occult blood test, sigmoidoscopy and colonoscopy
• Diabetic screening and education
PLUS
Free Annual Wellness Screenings and Follow-up
StarBaby Maternity Management Program for Expectant Mothers
MACoHCT medical plan members are eligible for the free and confidential services of StarBaby, a pro-active benefit for expectant
mothers. StarBaby’s registered nurses provide answers to member’s questions, pregnancy wellness information, support services to
complement the provider’s care, and assistance with special needs. 877-792-7827
Case Management
MACoHCT works in partnership with StarPoint to provide free and confidential Case Management services to identify and assist with plan
members’ immediate and ongoing medical issues. StarPoint Nurse Managers work with members families, caregivers and payers to
arrange the most appropriate and cost-effective treatment possible. 877-792-7827
Disease Management
StarPoint specialized nurses also provides free and confidential Disease Management services which include guidance and education to
manage chronic conditions such as: Asthma, Diabetes, Coronary Artery Disease, Congestive Heart Failure, Chronic Obstructive
Pulmonary Disease (COPD), Hyperlipidemia, Hypertension and Chronic Pain due to Osteoarthritis, RA and Lower Back Pain.
As an added benefit, members with select chronic conditions who actively participate in Disease Management are eligible for FREE
generic medications. 866-458-0474
Admission Pre-Notification
Pre-notification with StarPoint is recommended before admission on all scheduled outpatient procedures and inpatient hospital stays.
Emergency admissions should be reported within 72 hours. Pre-notification is not a guarantee of benefits. 800-342-6510
Pre-Treatment Review
A pre-treatment review is strongly recommended before incurring expenses for any outpatient or inpatient service, medication, supply or
on-going treatment for: bariatric surgery, commercial or private transportation, outpatient rehabilitative care, surgery that could be
considered cosmetic, any procedure or service that could be considered experimental or investigational, surgical treatment of TMJ, rental
or purchase of durable medical equipment, home health care services and organ or tissue transplant. 888-883-3233
Pre-Determination of Benefits Review
A Pre-Determination of Benefits Review request can be submitted to the MACoHCT Claims Department by a member or provider prior to
any medical procedure. A Pre-Determination of Benefits Review estimate outlines charges that are eligible and excluded by the
MACoHCT plan. A Pre-Determination of Benefits Review is strongly encouraged whenever medical necessity is in question, but it is not
required. 888-883-3233
HIPAA Privacy Information
MACoHCT is fully compliant with the privacy provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
COBRA Administration
MACoHCT administers COBRA, the Consolidated Omnibus Reconciliation Act of 1985 (temporary health insurance continuation) for all of
our member groups.
CVS Caremark ExtraCare® Health Card
BONUS
MACoHCT members are provided with two ExtraCare Health Cards that can be used at any CVS/pharmacy store or online
at www.cvs.com. Just present the card during check-out to save 20% off thousands of CVS/pharmacy brand health
related items.
3
Medical Benefits
Revised Major Medical Plan (RM)
$1000
$2000
$3000
$6000
None
$1500
$3000
$3000
$6000
$2000
$4000
$4000
$8000
80/20% 80/20%
80/20%
80/20% 80/20%
Maximum Lifetime Limit
Deductible - Individual
Deductible - Family
Out-of-Pocket Max - Individual
Out-of-Pocket Max - Family
Co-payment
First Dollar Benefit
Life Insurance
Accident Benefit
Maximum Benefit per Accident
$500
$1000
$1500
$3000
Comprehensive Major Medical Plan (CM)
None
$3000
$6000
$6000
$12000
$200
$400
$1200
$2400
$1000
$2000
$3000
$6000
90/10%
80/20%
N/A
$20,000
N/A
$20,000
Deductible Waived, 100%
$500 within 90 days of accident
Deductible Waived, 100%
$500 within 90 days of accident
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Waived, Co-pay Applies
Deductible Applies, Co-pay Applies
First $600 Waived, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Waived, 100%
$30
25
Deductible Applies, 100%
$30
25
Deductible Waived, Co-pay Applies
$100
Deductible Applies, Co-pay Applies
$100
First 3 outpatient visits paid at 100%
Deductible Waived, Co-pay Applies
Deductible Applies, Co-pay Applies
First 3 outpatient visits paid at 100%
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
First 3 outpatient visits paid at 100%
Deductible Waived, Co-pay Applies
Deductible Applies, Co-pay Applies
First 3 outpatient visits paid at 100%
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Inpatient Hospital Services
Physician Office Visit
Diagnostic X-ray & Labs
Chiropractic Office Visit
Maximum Payment/Visit
Maximum Visits/Year
Chiropractic X-rays
Maximum Benefit Per Benefit Period
Chemical Dependency
Outpatient
Inpatient
Mental Illness
Outpatient
Inpatient
Autism Spectrum Disorder
Rehabilitation/Cardiac Therapy
Home Health/Hospice Care
Skilled Nursing Facility
All benefits payable under this plan are subject to the applicable plan exclusions, maximum eligible expense
limits, plan maximum limits and medical necessity.
4
High Deductible Health Plan (HD)
Single Deductible
Family Deductible*
Single OOP Max
Family OOP Max*
Catastrophic Medical Plan (CM)
Basic Medical Plan (BP)
None
$1400
$2800
$3600
$7200
$3000
$6000
$5000
$10000
None
$5000
$10000
$6500
$13000
None
$2000
$4000
$4000
$8000
80/20%
80/20%
80/20%
70/30%
N/A
$20,000
$300
$20,000
N/A
$20,000
Deductible Applies, 100%
$500 within 90 days of accident
HSA
Qualifying
Plans
Deductible Waived, 100%
$500 within 90 days of accident
Deductible Waived, 100%
$300 within 90 days of accident
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, 100%
$30
25
Deductible Applies, 100%
$30
25
No Benefit
N/A
N/A
Deductible Applies, Co-pay Applies
$100
Deductible Applies, Co-pay Applies
$100
No Benefit
N/A
Deductible Applies and Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
First 3 outpatient visits paid at 100%
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
First 3 outpatient visits paid at 100%
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies and Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
First 3 outpatient visits paid at 100%
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
First 3 outpatient visits paid at 100%
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
*High Deductible Health Plans —Family limits apply to Two-Party, Parent/Child(ren) and Family coverage.
The Family deductible must be met by a single participant or a combination of participants before the co-payment applies.
5
Medical Benefits
Revised Major Medical Plan
Comprehensive Major Medical Plan
Organ and Tissue Transplants
Maximum Procedure Benefit
Deductible Applies, Co-pay Applies
See Schedule of Medical Benefits
Deductible Applies, Co-pay Applies
See Schedule of Medical Benefits
Deductible Applies, Co-pay Applies
See Schedule of Medical Benefits
Deductible Applies, Co-pay Applies
See Schedule of Medical Benefits
Surgical Implants and Devices
Maximum Procedure Benefit
Non-Ambulance Travel
For the patient and one companion to travel to a contracted Center of Excellence. Pre-Treatment Review is strongly encouraged.
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Maximum Lifetime Benefit $5,000
$5,000
CPAP Machines & Supplies
Deductible Waived, Co-pay Applies
Deductible Waived, Co-pay Applies
Deductible Waived, Co-pay Applies
Deductible Waived, Co-pay Applies
Deductible Waived, Co-pay Applies
Deductible Waived, Co-pay Applies
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Diabetic Insulin Pumps & Supplies
Diabetic Blood Glucose Monitors
Mammogram
Colonoscopy
Prescription Contraceptives
Smoking Cessation
Morbid Obesity Treatment
Treatment must be pre-authorized by the plan. Specific conditions apply.
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Bariatric Surgery
Treatment must be pre-authorized by the plan. Specific conditions apply.
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Preventive Care
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Immunizations
Diabetic Education
Prescription Pharmacy Benefit
See Pharmacy Benefits on Back Cover
See Pharmacy Benefits on Back Cover
All benefits payable under this plan are subject to the applicable plan exclusions, maximum eligible expense
limits, plan maximum limits and medical necessity.
6
High Deductible Health Plan
Catastrophic Medical Plan
Basic Medical Plan
Deductible Applies, Co-pay Applies
See Schedule of Medical Benefits
Deductible Applies, Co-pay Applies
See Schedule of Medical Benefits
Deductible Applies, Co-pay Applies
See Schedule of Medical Benefits
Deductible Applies, Co-pay Applies
See Schedule of Medical Benefits
Deductible Applies, Co-pay Applies
See Schedule of Medical Benefits
Deductible Applies, Co-pay Applies
See Schedule of Medical Benefits
Deductible Applies, Co-pay Applies
$5,000
Deductible Applies, Co-pay Applies
$5,000
Deductible Applies, Co-pay Applies
$5,000
Deductible Applies, Co-pay Applies
Deductible Waived, Co-pay Applies
Deductible Waived, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Waived, Co-pay Applies
Deductible Waived, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Waived, Co-pay Applies
Deductible Waived, Co-pay Applies
Preventive: Deductible Waived, 100%
Diagnostic: Deductible Applies, Co-pay Applies
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Applies, Co-pay Applies
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Deductible Waived, 100%
Preventive: Deductible Waived, 100%
Diagnostic: Deductible Applies, Co-pay Applies
See Pharmacy Benefits on Back Cover
See Pharmacy Benefits on Back Cover See Pharmacy Benefits on Back Cover
7
PHARMACY BENEFITS
STANDARD PLAN
DISCOUNT PLAN
Included in Revised Major Medical Plans (RM), Comprehensive Major
Medical Plans (CM) and Catastrophic Medical Plan (CM)
Annual Deducble per Individual
Annual Rx Out-of-Pocket Maximum per Individual
$50
$1,500
30-Day Supply
Filled at Parcipang Pharmacy
Generic
Preferred
Non-Preferred
discounted rate. Prescripon claims are then
medical plan deducble is sasfied all remaining
90-Day Supply
Filled Via Mail Order or at Parcipang Pharmacy
prescripon drug claims are subject to the medical
plan
co-pay
unl
the
medical
maximum
out-of-pocket limit is met. Once the medical
maximum out-of-pocket is sasfied, prescripon
claims are reimbursed at 100%.
Greater of 20% or $20
Greater of 30% or $40
Greater of 40% or $80
VISION BENEFITS
Annual Deducble per Individual
Exam
Hardware
Prescripons can be obtained at the Pharmacy at a
applied to the medical plan deducble. Once the
Greater of 20% or $10
Greater of 30% or $20
Greater of 40% or $40
Generic
Preferred
Non-Preferred
Included in High Deducble Health Plans (HD) and Basic Plan (BP)
DENTAL BENEFITS
$0
$70/annual allowance
$200/annual allowance
IMPORTANT NOTE
This document is intended to provide an easy-to-use
reference. The Summary Plan Descripon and other
material specific to your plan will supersede this general
informaon with regard to individual members’
eligibility and benefits.
Annual Deducble per Individual
Type A - Diagnosc/Prevenve
Type B - Roune/Basic Care
Type C - Major Restorave
Maximum Dental Benefit
per Period per Individual
(Type A, B and C Expenses)
Orthodona Benefit
(For Dependents Under Age 19)
Maximum Lifeme Orthodona Benefit
$25
100%
80/20%
50/50%
$1,500
50/50%
$1,000
`