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MACoHCT Questions & Answers


This information is intended to provide general guidance for members’ common questions about MACoHCT. The Summary Plan Description document, related amendments, and Schedule of Medical Benefits may supersede this general information for specific eligibility and benefit questions.

 

Questions:  Select a Topic

Eligibility & Enrollment Questions

1.   What is the deadline for enrolling?

2.   I am a new employee. When does my coverage begin?

3.   What should I do if I need to see a doctor and haven’t yet received my MACoHCT identification card?

4.   I lost my ID card. Can I get a new one?

5.   Can my children who are away at college get their own ID cards?

6.   My employer offers more than one MACoHCT health plan. Can I switch to a different plan?

7.   What is a “special enrollment” period?

8.   When do my deductible and maximum out-of-pocket amounts start accumulating?

9.   I am currently enrolled in MACoHCT and will soon take a job with a different county that also offers MACoHCT health benefits.  Will I get credit for deductible and out-of-pocket expenses I had already satisfied in my old county?

10. I have a pre-existing medical condition. Will the MACoHCT plan impose any restrictions because of this?

11. Is pregnancy considered a pre-existing condition?

12. Am I required to participate in case management?

13. Can my spouse stay on my insurance if we get divorced or legally separated?

14. Is my newborn automatically eligible under my coverage?

15. What are the eligibility rules for dependent children?

16. If I drop my dental or vision coverage, can I re-enroll later?

17. Does the vision plan pay for both glasses and contacts in the same year?

18. Are retirees eligible for MACoHCT coverage?

19. I am a retiree turning 65. How will my claims be paid if I choose not to enroll in Medicare Part B?

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20. What is a Health Savings Account (HSA)?

21.  Who can have an HSA?

22. How does the HSA-qualifying High Deductible Health Plan (HDHP) compare to other MACoHCT plans?

23. Does MACoHCT control the Health Savings Account (HSA)?

24. Who funds the HSA? What is the employer's role in this?

25. How much money can be put into the HSA?

26. How do HSA account holders access their money?

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27. Do all MACoHCT plans have a pharmacy benefit?

28. Is there a separate ID card for the pharmacy benefit?

29. What should I do if I need to fill a prescription and haven’t yet received my MACoHCT card?

30. Can I really save money by filling a 90-day prescription?

31. Do I have to use a mail-order service to get a 90-day supply?

32. What should I do if my pharmacist doesn’t bill insurance?

33. I have dual pharmacy benefits under both my own policy and my spouse’s policy. How does that work?

34. Can I drop only the prescription drug part of my MACoHCT benefits?

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35. Who processes my claims?

36. Do I have to submit my own medical claims?

37. Can I view my claims information online?

38. What number should I call if I have a question about a claim?

39. I called the Claims Administration office, but I need additional help understanding how my claim was processed. What should I do?

40. How do I appeal a claim determination?

41. Can I see any doctor I want?

42. Can I see providers outside the U.S.?

43. What does UCR stand for?

44. My claim for a preventive visit was not processed correctly. Why?

45. Does MACoHCT reimburse for mileage to my health care provider?

46. I have other coverage in addition to MACoHCT. How does MACoHCT determine which plan pays first?

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Answers:  Select a Topic

1.   What is the deadline for enrolling?

All completed enrollment forms must be received in the MACoHCT administration office within 60 days of becoming eligible. Refer to the Summary Plan Description for details.

2.   I am a new employee. When does my coverage begin?

This will depend on the eligibility rules that your employer has established. They may stipulate, for example, that you are eligible on your date of hire, or on the first day of the following month. Newly acquired / newly eligible dependents can be added the day they become eligible.

Note:  Activation of coverage depends on timely receipt of completed enrollment forms in the MACoHCT office within 60 days.

3.   What should I do if I need to see a doctor and haven’t yet received my MACoHCT identification card?

Call the MACoHCT administration office (866-669-6428) to verify that your enrollment forms have been received and processed. If they have, MACoHCT can provide you with a temporary identification card to use until your permanent card is received in the mail.

4.   I lost my ID card. Can I get a new one?

Yes; call the MACoHCT administration office at 866-669-6428.

5.   Can my children who are away at college get their own ID cards?

Yes; call the MACoHCT administration office at 866-669-6428.

6.   My employer offers more than one MACoHCT health plan. Can I switch to a different plan?

You have an opportunity to switch plans each year, during your group’s annual open enrollment period.  You also may be able to switch midyear if you qualify for a “special enrollment” period (see below).

7.   What is a “special enrollment” period?

Employees and/or certain eligible dependents may enroll (or switch plans) after certain qualifying events. These events include marriage, birth or adoption of a child, involuntary loss of other coverage, and change in employment status. (Refer to the Summary Plan Description for details.)

To be eligible for special enrollment, the participant or employer must notify the MACoHCT administration office within 30 days of the qualifying event, and appropriate paperwork (Enrollment & Change form) must be received by MACoHCT within 60 days of the event.

8.   When do my deductible and maximum out-of-pocket amounts start accumulating?

With MACoHCT, your deductibles and out-of-pocket amounts accumulate according to your group’s benefit year, not the calendar year.  For example, if the annual renewal date for your group's plan is July 1, your deductibles and maximum out-of-pocket amounts start over on July 1 every year.

9.   I am currently enrolled in MACoHCT and will soon take a job with a different county that also offers MACoHCT.  Will I get credit for deductible and out-of-pocket expenses I had already satisfied in my old county?

No.  Plan options, premiums, deductibles, and out-of-pocket maximums are established separately for each member group. Credit cannot be given for the deductibles and out-of-pocket expenses that a new participant had incurred while enrolled in a previous employer’s group.

10. I have a pre-existing medical condition. Will the MACoHCT plan impose any restrictions because of this?

The MACoHCT Plan does not impose any pre-existing medical condition restrictions on any individuals for any reason.

11. Is pregnancy considered a pre-existing condition?

Pregnancy is never subject to pre-existing condition exclusions. A pregnant woman can enroll under the same eligibility rules as any other person. However, becoming pregnant does not create “special enrollment” rights.

12. Am I required to participate in case management?

Participation in case management is voluntary. However, declining to participate or declining to continue participating in case management services will result in a penalty. Upon notification from StarPoint Case Management of a member who has chosen to not participate or has declined continued participation, all claims will be processed according to the plan, subject to an additional $2,500 medical plan deductible.

Questions and appeals regarding case management determinations must be submitted in writing to the Plan Administrator at 2717 Skyway Drive, Suite D; Helena MT 59602.

13. Can my spouse stay on my insurance if we get divorced or legally separated?

No; the spouse must be dropped from the participant’s coverage, and this must be reported to MACoHCT within 60 days of the divorce or legal separation. The terminated spouse will be offered COBRA continuation coverage (refer to the Summary Plan Description for details).

14. Is my newborn automatically eligible under my coverage?

No; you (or your human resources department) must notify the MACoHCT administration office within 30 days of the birth that you wish to enroll your baby. Then, a completed Enrollment & Change Form must be received in the MACoHCT administration office within 60 days of the birth. Otherwise, you will need to wait until your group’s next open enrollment period to add your baby as a dependent child.

15. What are the eligibility rules for dependent children?

To be eligible for coverage, the child must be:

- The participant’s natural child, stepchild, legally adopted child, a child who has been placed with the participant  for adoption, or a child for whom the participant has been appointed the legal guardian prior to the child attaining nineteen (19) years of age and;

- Is less than twenty-six (26) years of age. This requirement is waived if the child is mentally handicapped/challenged or physically handicapped/challenged, provided that the child is incapable of self-supporting employment and is chiefly dependent upon the participant for support and maintenance and;

- Is not eligible to enroll in an employer-sponsored health plan of the dependent child's employer.

An eligible dependent does not include a spouse of the dependent child or a child of the dependent child.

Important Note:

The definition of a "dependent" for Montana health insurance purposes is changed and is no longer tied to or the same as the definition of a "dependent" under IRS code. If you take advantage of this new law and keep or add coverage for a non IRS Section 152 dependent child, there may be tax consequence

MACoHCT strongly encourages counties, member groups and plan participants to contact a qualified tax consultant with questions relating to possible tax consequences.

16. If I drop my dental or vision coverage, can I re-enroll later?

Members are only permitted to voluntarily drop dental and/or vision coverage during the annual open enrollment period.  If a member voluntarily drops dental and/or vision coverage there is a 2-year waiting period before he/she can re-enroll.

17. Does the vision plan pay for both glasses and contacts in the same year?

No. The plan allows for either contacts or glasses in the same 12-month period, but not both. Members may also choose Rx sunglasses in-lieu of glasses or contacts.

18. Are retirees eligible for coverage under MACoHCT?

Employees, supervisors, and elected County officials who are enrolled in a MACoHCT plan prior to the retirement date can continue their health coverage as a retiree. Their enrolled dependents may also remain enrolled. The retiree may also continue any employee-paid life insurance on a self-pay, age-rated basis.

Documentation certifying retirement eligibility may be required, along with a MACoHCT Enrollment & Change Form requesting the change from Active to Retiree status.

19. I am a retiree turning 65. How will that affect my MACoHCT coverage?

MACoHCT retirees that are eligible for Medicare will be transitioned over to MACoHCT’s Group Medicare Advantage Plan administered by New West. Although MACo Health Care Trust Medicare eligible retirees will not have the option to stay on, or return to, the traditional MACo Health Care Trust Plan, the MACo Health Care Trust is confident that our Medicare eligible retiree members will receive excellent benefits and have less out-of-pocket costs in the long run.

Medicare eligible retirees must be eligible for Part A and enrolled in Part B to take advantage of the MACo Health Care Trust Group Medicare Advantage Plan. 

Participation in the MACo Health Care Trust Group Medicare Advantage Plan is available if the Medicare Retiree member’s permanent residence is located in Montana and absence from Montana does not exceed more than six months at a time. Just like the traditional MACo Health Care Plan, there is coverage when outside of Montana and abroad.

If a Medicare Retiree currently has coverage for their spouse who is less than 65 years of age, the spouse will be eligible to remain on the traditional MACo Health Care Trust plan until they reach 65 year of age. Once the spouse reaches 65 years of age they will be eligible to transition over to the Medicare Retiree Plan.

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20. What is a Health Savings Account (HSA)?

The Health Savings Account, or HSA, is a tax-favored way to put aside money for health expenses. Like a Flexible Spending Account (FSA), the employee can spend the funds on a wide variety of qualifying medical expenses as defined by the IRS. However, unlike the FSA, the employee does not lose any unspent funds. In fact, the money in the account always belongs to the participant, even if he/she leaves employment.

There are several investment options that can provide tax-free growth for funds in the HSA. In this way, an HSA is similar to an IRA or 401(k) retirement plan, except that the participant does not have to wait until retirement to spend it. He or she can choose to spend the money today, or can let the account build for future medical emergencies. The money is never taxed as income if spent on qualifying medical expenses. If HSA funds are spent on non-qualifying expenses, the participant must pay income tax on the amount, and if he or she is under age 65, a 10% penalty will also apply.

21. Who can have an HSA?

To open an HSA, the participant must be enrolled in a qualifying High Deductible Health Plan and cannot be enrolled in other medical coverage (including Medicare). The High Deductible Health Plan must meet federal guidelines, and therefore not every health plan that has a high deductible is considered an HSA-qualified plan.  MACoHCT has developed two HSA-qualified High Deductible Health Plans that meet the federal criteria.

Please note that IRS rules generally prohibit having both a Flexible Spending Account (FSA) and an HSA, unless the Flexible Spending Account can only be used for a limited purpose, such as dental, vision, or child care.

22. How does the HSA-qualifying High Deductible Health Plan (HDHP) compare to other MACoHCT plans?

These plans provide coverage similar to other MACoHCT plans, including preventive care paid at 100% care. Higher deductibles generally equate to lower premiums, so the premium for the HDHP is usually lower than the premium would be for another MACoHCT plan that has a smaller deductible.

Due to the federal HDHP criteria, there are two important differences between the HDHP and other MACoHCT plans. First, the “single” deductible is irrelevant when the employee has elected family HDHP coverage. In other words, the entire family deductible must be met before the plan will pay covered services on an 80/20% basis. However, unlike other MACoHCT plans, the family deductible can be met by one family member.

Second, the guidelines state that all covered benefits (except for preventive care) must count toward the deductible, including prescription drugs. In most of the other MACoHCT plans, there is a separate pharmacy benefit with its own deductible and out-of-pocket maximum limit. In the HDHP, members can collect prescription receipts and submit them to the MACoHCT Claims Department so that they can accumulate toward the medical deductible. This can be beneficial for people with high prescription costs.

When an employer group joins or renews with MACoHCT, they may elect to include an HDHP option among their benefit offerings. There are no minimum participation requirements regarding the number of people who must enroll in the plan. As HSAs become more well-known, enrollment in the qualifying health plans is likely to increase.

23. Does MACoHCT control the Health Savings Account (HSA)?

No. MACoHCT only administers the health plans that qualify a person to open an HSA.

If an employer decides to offer one of these qualifying HDHP options to its employees, it's the employees' decision whether – and where – to open a Health Savings Account. An employee can choose any qualified financial institution of their choice to open an Health Saving Account. For more information click on this link to view Health Saving Account websites.

24. Who funds the HSA, and what is the employer's role in this?

The HSA is usually funded by the employee, but the employer could also choose to contribute to the account on a pre-tax basis. Employers who choose to make contributions are obligated by regulations to treat similarly situated employees (i.e., all employees enrolled in the High Deductible Health Plan) the same. Employees can fund their account on a pre-tax basis only if the employer has a Section 125 (“flex” or “cafeteria”) plan.

NOTE:  Employers should amend their cafeteria plan to accommodate HSA contributions. They are encouraged to consult their tax advisor or human resources manager to ensure pre-tax HSA contributions are managed correctly.

More information about HSA contribution and tax implications can be found on the U.S. Treasury website.

25. How much money can be put into the HSA?

HSA maximum contribution amounts are adjusted by the IRS annually for inflation. For the current tax-year, you'll want to consult a financial institution that provides Health Savings Accounts, your tax advisor, or visit the U.S. Treasury website.

26. How do HSA account holders access their money?

Most financial institutions (including Wells Fargo and Valley Bank) provide the HSA account holder with a special debit card. As with any debit card, funds cannot be spent unless they are present in the account.

The participant can use the debit card in the doctor’s office or pharmacy to pay any costs that would apply toward the HDHP deductible. Or, the participant can choose to pay the bill by cash, check, or credit card, and then can either withdraw funds from the HSA to reimburse him/herself, or can leave the money in the HSA to grow for the future.

One important advantage is that the account holder can use the HSA funds to pay for qualifying medical expenses for anyone in their immediate family, even if those family members are not enrolled in the HDHP. Also, the list of qualifying medical expenses is not limited to services that are covered under the HDHP. According to IRS rules, the HSA funds can be used to cover your out-of-pocket medical, dental, or vision costs, including some over-the-counter drugs.

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27. Do all MACoHCT plans have a pharmacy benefit?

Yes, all MACoHCT medical plans have a pharmacy benefit.

If you are enrolled in the Basic Plan or an HSA-qualified High Deductible Health Plan, you pay for your prescriptions until your medical deductible is met, and then prescriptions are covered the same as any other medical service. 

For other MACoHCT plans (Comprehensive Major Medical and Revised Major Medical), the pharmacy plan has a separate deductible and maximum-out-of-pocket amount, and prescriptions therefore do not count toward the medical deductible and out-of-pocket amounts.

28. Is there a separate ID card for the pharmacy benefit?

No; your MACoHCT card has all the information that the pharmacist will need.

29. What should I do if I need to fill a prescription and haven’t yet received my MACoHCT card?

Call the MACoHCT administration office (866-669-6428) to verify that your enrollment forms have been received and processed. If they have, MACoHCT can provide you with a temporary identification card to use until your permanent card is received in the mail.

30. Can I really save money by filling a 90-day prescription?

Yes; your copayment is usually lower than if you purchased three 30-day prescriptions. Ask your doctor if a 90-day prescription is appropriate for the medications you take.

31. Do I have to use a mail-order service to get a 90-day supply?

No; there are several Montana retail pharmacies that have agreements in place for 90-day fills, including most major chains. A list of pharmacies in your area is available on the Pharmacy Benefit Plan’s website (see the “Quick Links” box on the MACoHCT website home page) or call the MACoHCT administration office at 866-669-6428 for a list of 90-day network retail pharmacies in your area.

32. What should I do if my pharmacist doesn’t bill insurance?

If your pharmacist won’t bill insurance or doesn’t belong to a Network Pharmacy, he or she will require full payment at the time of purchase. You can submit a pharmacy claim yourself using this form. Be sure to follow all instructions on the form.

33. I have dual pharmacy benefits under both my own policy and my spouse’s policy. How does that work?

With MACoHCT, coordination of benefits for pharmacy claims is handled the same way as coordination of benefits for medical claims. In general, MACoHCT as the secondary plan pays a reduced amount so that the combined amount paid by both plans does not exceed 100% of the allowable charge. Deductibles and copayments under each plan will also affect your out-of-pocket cost at the pharmacy.

Important note: The pharmacy benefit manager Caremark can process pharmacy claims under the primary coverage only. Therefore, the Caremark Pharmacy Reimbursement Form cannot be used to process pharmacy claims under the secondary plan. See the Pharmacy Benefit section of the Summary Plan Description document, under “Primary Coverage Under Another Plan.” This section provides instructions for submitting secondary pharmacy claims to the MACoHCT Claims Department for processing.

Tip:  Pharmacy receipts sometimes do not show the full retail cost of the drug. This can create problems when processing the claim under the secondary plan. Be sure that the pharmacy provides you a receipt that shows the full retail cost, not just the copay amount that was charged under the primary plan.

34. Can I drop only the prescription drug part of my MACoHCT benefits?

No; the prescription drug benefit is integrated with your MACoHCT medical plan.

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35. Who processes my claims?

MACoHCT medical, dental and vision claims are processed by Allegiance Benefit Management in Missoula.

MACoHCT prescription claims are processed by CVS/Caremark.

36. Do I have to submit my own medical claims?

Most medical providers will submit claims for you. However, if the provider requires you to submit your own claim, his or her office should supply you with a copy of an itemized bill which can be submitted to the MACoHCT Claims Department. The following information is required:

- The date of service,
- The participant’s name,
-The name and birth date of the patient receiving the treatment or service and his/her relationship to the participant,
-The diagnosis code of the condition being treated,
-The code for the treatment or service performed,
-The amount charged by the provider for the treatment or service, and
-Notes or documentation supporting the medical necessity of the treatment or service.

The address for submitting medical, dental, and vision claims is:

MACoHCT Claims
PO Box 1966
Missoula, MT 59806-1966

Claims must be submitted to MACoHCT within 1 year after the date of service to be eligible for processing and payment.

37. Can I view my claims information online?

Yes. On the MACoHCT website home page, look in the "Quick Links” box for a link to the Claims website. You will need a password to access your information. If you have never accessed the Claims website before, click the Register New User icon on the login page.

Participants can review information about their own claims, deductible information, etc., as well as for covered dependents under age 18. Spouses and dependents age 18 and older must obtain their own password.

38. What number should I call if I have a question about a claim?

Call the MACoHCT Claims Department at 888-883-3233, then press 4.

39. I called the Claims Administration office, but I need additional help understanding how my claim was processed.  What should I do?

Call the MACoHCT Administration Office at 866-669-6428. MACoHCT staff will be happy to help you understand your benefits or explore any claims questions you may have.

40. How do I appeal a claim determination?

If a claim is denied in whole or in part, the participant will receive a claim Explanation of Benefits (EOB) form showing the reason for denial. If the participant does not agree with the reason for the denial and wishes to appeal the decision, he/she must submit a written request to the address below within 180 days of the denial:

MACoHCT Claims
PO Box 1966
Missoula, MT 59806-1966

The MACoHCT Claims Department will research the claim information and determine if the initial determination was appropriate based on the terms and conditions of the MACoHCT plan language. Notice of the decision will be mailed to the participant within 60-days of receipt of the request. If the denial is upheld, the participant may request a second (and possibly third) level review; refer to the Summary Plan Description for details.

41. Can I see any doctor I want?

You can see any licensed provider you wish. However, Allegiance (the MACoHCT Claims Department)) has agreements in place with a number of different provider networks in Montana and other parts of the United States. 98% of the medical providers in Montana belong to an Allegiance preferred provider network.  Logos for some of these networks appear on your MACoHCT card.

It is to your advantage to use providers who are network members, because claims payment is based on the reduced rates negotiated with the networks. If your provider happens to be out-of-network, he/she is not obligated to accept the amount that MACoHCT will pay for a given service, and may “balance-bill” you for any charge exceeding this amount (although this is rare).

More information is available in the Providers section of this website, or you can call 888-883-3233 for assistance with questions about providers and networks.

42. Can I see providers outside the U.S.?

If you plan to travel outside the U.S., contact the MACoHCT Claims Department (888-883-3233) before you leave. They will provide you with a letter that outlines the requirements for submitting and processing foreign claims (see sample letter). It is likely that you will need to pay for services at the time they are rendered and submit the claim yourself to MACoHCT for reimbursement.

43. What does MME and UCR stand for?

MME stands for ‘Maximum Eligible Expense’ which the maximum amount considered for payment by the MACoHCT Plan for any covered treatment, service or supply, subject however to all annual and lifetime maximum benefit limitations.

UCR stands for “Usual, Customary, and Reasonable” charges. In rare circumstances, an established MME may not be available for a particular treatment, service or supply which can sometimes happen when an out-of-network provider is used.  Under these circumstances, MACoHCT will process the claim according to established UCR allowable charges. See the Providers section of this website for more information.

44. My claim for a preventive visit was not processed correctly. Why?

The most common reason is that the provider’s office did not code it as a preventive visit, which means it was paid according to the medical portion of your plan benefits rather than the preventive plan benefits. You should ask your provider whether the claim will be submitted using a preventive code. However, keep in mind that the appropriate coding is your provider’s decision, based on your health status, prior test results, and other factors.

45. Does MACoHCT reimburse for mileage to my health care provider?

No; travel expenses are specifically excluded under the plan.  However, there is a special provision of the MACoHCT plan that allows for a limited amount of reimbursement of travel expenses to a contracted Center of Excellence if treatment at a contracted Center of Excellence is more cost effective than the same treatment if received from other providers. Pre-Treatment Review is strongly encouraged.

46. I have other coverage in addition to MACoHCT. How does MACoHCT determine which plan pays first?

If you are enrolled in MACoHCT as the participant/employee, then that plan is primary (i.e., pays first). If you are enrolled in another plan as a spouse or dependent, that plan is secondary. When dependent children are covered by their parents under two plans, the primary plan is determined by the parent whose birthday occurs first in the year. Other factors may come into play for dependents; see the Summary Plan Description document under “Coordination of Benefits.”

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