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Services

Network

Non-Network

Services

Network

Non-Network

Preventive Services

Network
MCHCP pays 100%

Non-Network
40% coinsurance

MCHCP pays 100%

40% coinsurance

Deductible
  Individual
  Family

Network
Individual: $1,250
Family: $2,500

Non-Network
Individual: $2,500
Family: $5,000


$1,250
$2,500


$2,500
$5,000

Medical OOP Maximum
  Individual
  Family

Network
Individual: $3,750
Family: $7,500

Non-Network
Individual: $7,500
Family: $15,000


$3,750
$7,500


$7,500
$15,000

Prescription OOP Maximum
  Individual
  Family

Network
Individual: $4,150
Family: $8,300

Non-Network
No Maximum


$4,150
$8,300


No Maximum

Office Visit

Network
Primary Care or Mental Health: $25 copayment
Chiropractor: $20 copayment
Specialist: $40 copayment

Non-Network
40% coinsurance

Primary Care or Mental Health: $25 copayment
Chiropractor: $20 copayment
Specialist: $40 copayment

40% coinsurance

Urgent Care

Network
$50 copayment

Non-Network
Network Benefit

$50 copayment

Network Benefit

Emergency Room

Network
$250 copayment plus 20% coinsurance

Non-Network
Network Benefit

$250 copayment plus 20% coinsurance

Network Benefit

Inpatient

Network
$200 copayment plus 20% coinsurance

Non-Network
$200 copayment plus 40% coinsurance

$200 copayment plus 20% coinsurance

$200 copayment plus 40% coinsurance

Other Medical Services

Network
20% coinsurance

Non-Network
40% coinsurance

20% coinsurance

40% coinsurance


Copayments
Members will pay a copayment for office visits and urgent care. Members may pay a $250 copayment for Emergency Room services in addition to deductible and coinsurance. The Emergency Room copayment is waived if the member is admitted to the hospital or the services are considered by the medical plan to be a “true emergency.” Even if the copayment is waived, the member will still have to pay any deductible or coinsurance owed for the Emergency Room service.

Members also have a $200 copayment for inpatient services in addition to coinsurance.

Copayments apply to the out-of-pocket maximum, but not the deductible.



How the PPO 1250 Plan Works

  1. When visiting a health care provider, the member will pay a copayment for each visit. The member will also pay for other medical expenses out of their pocket until the annual deductible is met see Copayments section above).
  2. The office visit copayments cover the visit only. Any lab, X-ray or other services associated with the visit will apply to the deductible and coinsurance.
  3. Chiropractor copayment may be less than $20 if it is more than 50 percent of the total cost of the service.
  4. Once the deductible is met, members will continue to pay copayments. However, members will now pay coinsurance on covered expenses until their out-of-pocket maximum is reached. At that time, the plan will begin paying 100 percent of covered services (see Family Coverage section below).
  5. Active employees with a health care Flexible Spending Account (FSA) may receive reimbursement for qualified medical expenses by submitting a claim and providing necessary documentation to MOCafe (see HSA vs FSA).

Family Coverage
If two or more family members are covered in a PPO plan and one family member reaches the individual deductible or out-of-pocket maximum, the medical plan begins paying claims for the individual. If one or more additional family members meet the individual deductible or out-of-pocket maximum, the medical plan begins paying claims for the entire family.

Two married active state employees who cover children may combine medical deductibles by participating in Family Roll Up.


See Prescription Drug Plans for information on the prescription drug coverage and coinsurance/copayments.


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