Benefits & Rights Prescribed by Law

MCHCP medical plans comply with state and federally mandated benefits.

Take a peek at these benefits and rights:

1. Approved Cancer Screenings
2. Scalp Hair Prosthesis
3. Women's Health Law
4. Newborn Screenings
5. Dental Care
6. Referrals
7. Second Opinions
8. Patient's Rights Under Missouri Law
9. Subrogation

Approved Cancer Screenings

Some of the benefits provided through MCHCP for cancer screenings are listed below. These guidelines are based on the recommendations made by the American Cancer Society and may be age specific. (Contact the American Cancer Society at 800.227.2345 for age specific guidelines.)

• Pelvic examination and pap smear for any woman without symptoms
• Prostate examination and laboratory tests for any man without symptoms
• Colorectal cancer examination and laboratory tests for any person without symptoms
• Annual mammogram for any woman without symptoms

Additional mammograms are covered, if recommended by a physician, for any woman with a history of breast cancer or whose mother or sister has prior history of breast cancer.


Scalp Hair Prosthesis

Missouri law requires coverage for members 18 years of age or younger with expenses for scalp hair prosthesis worn for hair loss suffered as a result of alopecia areata or alopecia totalis. There is a maximum benefit of $200/calendar year, not to exceed a lifetime maximum benefit of $3,200 for persons who select a more permanent scalp hair prosthesis. A one-time expenditure of up to $3,200 may be requested, and benefits expire when a total of $3,200 has been spent or the member reaches 19 years of age.


Clinical Cancer Trials

Missouri law requires coverage for routine patient care costs incurred as the result of phase II, III or IV of a clinical trial that is approved by an appropriate entity and is undertaken for the purposes of the prevention, early detection or treatment of cancer. Coverage includes routine patient care costs incurred for drugs and devices that have been approved for sale by the Food and Drug Administration (FDA), regardless of whether approved by the FDA for use in treating the patient’s particular condition. Coverage includes reasonable and medically necessary services needed to administer the drug or use the device under evaluation in the clinical trial.

The following limitations apply to phase II coverage:

1. Routine patient care costs are limited to those incurred within the plan’s provider network; and
2. The member must be enrolled in the clinical trial. Coverage is not available to those merely following the protocol of phase II clinical trial.

See section 376.429, Revised Statutes of Missouri for further information.


Women’s Health Law

Missouri laws require:

• Direct access to a network obstetrician, gynecologist or OB/GYN for obstetrical or gynecological diagnosis, treatment or referral.
• Coverage for the diagnosis, treatment and appropriate management of osteoporosis, which may include bone mass measurement when medically indicated. Coverage is the same as for any other test and/or office visit.
• Coverage for all prescription drugs and devices approved by the FDA for use as a contraceptive. Coverage is not required for those drugs and devices that are intended to induce an abortion.

There is no timeframe on reconstructive surgery or prosthetic devices following a mastectomy. If an individual had a mastectomy and changes medical plans, the new plan shall provide coverage consistent with the federal Women’s Health and Cancer Rights Act.


Newborn Screenings

Missouri law requires coverage for:

• Newborn hearing screenings.
• Necessary rescreenings.
• Audiological assessment.
• Follow-up and initial amplification.

Dental Care: Anesthesia & Hospital Charges

Missouri law requires health insurers and similar entities to cover the administration of general anesthesia and hospital charges for dental care to children under age five, the severely disabled, or a person with a medical or behavioral condition that requires hospitalization. It mandates coverage of general anesthesia when dental care is provided in a participating or non-participating hospital or surgical center. Prior authorization may be required by the health carrier.

Referrals

Referrals to non-participating specialists and facilities are covered subject to the same copayment amounts as participating providers if the health plan determines that its network does not contain a provider with appropriate training, experience or specialty.

Second Opinions

Physician visits to seek second opinions are covered at the same copayment cost as initial visits.

Patient’s Rights Under Missouri Law

The plans offered through MCHCP may use the following managed care processes. If you participate in one of MCHCP’s fully-insured plans and, at any time during the process, do not agree with the initial determination, concurrent review, retrospective review or adverse determination, you may contact the Missouri Department of Insurance, Financial Institutions & Professional Registration (DIFP) at 800.726.7390 for assistance.

Utilization Review
For certain hospitalizations, surgical procedures and tests, it is necessary for the medical plans to pre-authorize or evaluate the necessity, appropriateness and efficiency of the use of medical services, procedures and facilities on a prospective, concurrent or retrospective basis.

Initial Determination
In the case of proposed hospital admissions and procedures or services requiring review, the medical plan is required to notify the provider within two working days of obtaining the necessary information. The medical plan confirms to you and the provider by written or electronic confirmation within two working days of making the initial certification.

Concurrent Review Determinations
In the case of certifying an extended stay or additional services, the medical plan is required to notify the provider by telephone within one working day of the certification. Written or electronic confirmation of the telephone call is required within one working day of making the certification.

Retrospective Review Determinations
Determination must be made by the health care plan within 30 working days of receiving the necessary information. You should receive written notice within ten working days of the plan making the determination.

Adverse determinations
When the procedure, hospitalization and/or test is denied, reduced or terminated, it is called adverse determination. The medical plan is required to notify the provider by telephone within 24 hours of making the adverse determination and to furnish you and the provider with a written or electronic confirmation within one working day of the telephone call.

Reconsideration of Adverse Determination
The provider of a service may request reconsideration of adverse determination on your behalf. Reconsideration must be made within one day of receipt of the request between the provider and the reviewer who denied the request or a clinical peer of the reviewer. If the difference is not resolved, you or the provider on your behalf, have the right to appeal.

Prior Authorization
Prior authorization does not verify eligibility for coverage or payment, nor does it assure coverage is provided if any of the following apply:

• Such authorization is based on a material misrepresentation or omission about the person’s health condition or the cause of the condition.
• The health benefit plan terminates before the healthcare services are provided.
• The covered person’s coverage under the plan terminates before the healthcare services are provided.

Self-insured plans are subject to subrogation. Subrogation enables the insurer to rights belonging to the subscriber against a third party.
For example: MCHCP paid a medical claim due to your automobile accident when your automobile insurer should have covered the claim. Subrogation allows MCHCP to stand in your place and recover the money from the automobile insurer.

Right of Recovery
If the amount of the payment made by the Plan, including the reasonable cash value of any benefits provided in the form of services, is more than it should have paid under the terms of the Agreement, the Plan may recover the excess payments from one (1) or more of :

The persons it has paid, for whom it has paid,
insurance companies, or other organizations.