Frequently Asked Questions - General

Q. What is the difference between a subscriber and a member?

A. The subscriber is the employee or individual who elects coverage under the plan. The member is any person covered under an employee benefit plan as either a subscriber or a dependent.

Q. What is a medical emergency?

A. A medical emergency is any medical condition leading a prudent layperson to seek immediate medical attention. Examples of medical emergencies include, but are not limited to, conditions placing a person’s health in significant jeopardy; serious impairment to a bodily function; serious dysfunction of any bodily organ or part; inadequately controlled pain or situations when the health of a pregnant woman or her unborn child are threatened. You must notify your medical plan within 48 hours or as soon as possible after seeking emergency care.

Q. What is a preventive service?

A. Preventive services are those that are concerned with preventing disease or early detection. Examples of preventive services include annual exams, mammograms, pap smears, well-child care, etc. HMO & Copay Plan Benefits offers a more detailed list of services.

Q. I had a hearing test done during my annual exam. Should I be charged a copayment?

A. Preventive services such as well exams are covered at 100%. However, if a hearing test is done during the annual physical, you may be responsible for an office visit copayment.

Q. When should I call my medical plan?

A. Whether you are participating in the HMO or Copay Plan, call your plan first when you have questions regarding claims, service issues, pre-certification and case management.

Q. What should I do if a claim for a covered benefit has been rejected by the medical plan?

A. Contact your medical plan to verify the claim was received.

• If the claim was received, ask the plan to provide the reason for denial of the claim.
• If the claim was not received, ask the provider to resubmit the claim.
• If the claim was rejected due to incorrect coding, ask the provider to resubmit the claim.
• If the claim was not filed within 12 months, the claim was correctly rejected for failure to timely file the claim.
• If you have contacted the medical plan and the provider and received no response, you can request assistance from MCHCP.

Q. How long can I keep medical coverage through MCHCP as a surviving spouse?

A. You may keep the coverage as long as you pay the required premium on time.

Q. Will Medicare become my primary insurance if I am age 65 and still working?

A. No. MCHCP remains your primary carrier until you retire. Once you retire, Medicare becomes primary, and your MCHCP plan becomes your secondary plan. If your spouse is covered as your dependent and is also eligible for Medicare, this rule also applies to him/her.

Q. What happens if I maintain a primary residence in two different regions?

A. You must decide the region in which you wish to obtain your medical care and use that address for your records with MCHCP.

Q. How long can children be covered under MCHCP?

A. Dependent children can be covered up to the age of 25. Exceptions and additional information can be found under Eligibility.

Q. My child lost coverage under my spouse’s plan since he/she no longer meets the dependent criteria for that plan. May I enroll him/her in my MCHCP plan at this time?

A. YES. You can apply for late entrant coverage for that dependent child as long as the child meets dependent eligibility requirements, and you apply within 60 days of the event.

Q. What medical options do I have if I move out-of-state?

A. The Copay Plan is the option available to an out-of-state subscriber.

Q. If I am enrolled in an HMO plan, will I have pre-existing condition limitations imposed if I change to the Copay Plan during Open Enrollment?

A. NO, as long as you had medical coverage for six months prior to enrolling in the Copay Plan, the pre-existing condition limitation does not apply.

Q. If my dependent has a child, can the newborn be covered?

A. YES, as long as your dependent is covered and the newborn is enrolled within 31 days of the birth. If you do not elect to enroll the newborn at this time, you cannot enroll the child at a later date. The child can only be covered as long as your dependent is also covered. Once your dependent loses coverage or is no longer eligible for coverage, his/her dependent would no longer be eligible for coverage through MCHCP.

Q. Am I required to enroll in a medical plan in order to elect dental or vision coverage?

A. As an active employee, you may elect dental and/or vision coverage for yourself and/or your dependent(s) without enrolling in a medical plan.

As a retired subscriber, you must be enrolled in a medical plan to have dental and/or vision coverage.