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.

What is the deadline for enrolling?

All completed enrollment forms must be received in the MACoHCT administration office within 30 days of becoming eligible. Refer to the Summary Plan Description for details.

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 (30 days).

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

Call MACoHCT Customer Service (866-669-6428) to verify that your enrollment forms have been received and processed. If they have, you will be given your group plan number verbally. The provider’s office will usually accept this, but if not, ask them to call the number above to verify your eligibility.

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

Yes; call MACoHCT Customer Service at 866-669-6428.

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

Yes; call 866-669-6428 to request their cards.

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).

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 district clerk must notify the MACoHCT administration office within 30 days of the qualifying event, and appropriate paperwork (enrollment or change form) must be received by MACoHCT within 60 days of the event.

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.

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 employer 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.

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

It depends on when you enroll, and sometimes on whether you have had previous health coverage.  If you enroll when you are first eligible for coverage (such as upon hire), there is never a pre-existing condition exclusion period for you or any dependents who enroll with you.

However, if you or your dependents waive coverage when first eligible but decide to enroll at a later date (such as during the annual open enrollment period), a pre-existing condition exclusion period of 18 months may be imposed. This exclusion period for pre-existing conditions is waived if there is creditable coverage from a prior health plan.

Even if an exclusion period is imposed, this will affect only conditions that were pre-existing. Other conditions will be covered according to the terms and conditions of the Plan.

What is creditable coverage?

If you had prior health coverage for at least 18 months and had no more than a 63-day break in coverage, no exclusion for pre-existing conditions can be imposed. The portability provisions of the HIPAA laws allow you to get credit for the time you were enrolled in another health plan.This helps ensure that you don’t have to start over in satisfying any pre-existing condition exclusion period.

When you leave one health plan, the carrier is required to provide you a Certificate of Creditable Coverage showing who was covered and for how long. Give this certificate to your new insurance carrier so that your pre-existing condition exclusion period can be reduced by the length of time you were covered on the prior plan. For example, if your new plan normally would impose an 18-month exclusion period but you were covered on a prior plan for 12 months, the exclusion period would be shortened to 6 months based on your creditable coverage.

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.

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 30 days of the divorce or legal separation. The terminated spouse will be offered COBRA continuation coverage (refer to the Summary Plan Description for details).

Is my newborn automatically eligible under my coverage?

Any newly acquired dependents (including newborns) are automatically eligible to be added to your coverage, but will not be covered unless you request to enroll them within 30 days of the birth. You (or your county clerk and recorder) must notify the MACoHCT administration office within 30 days of the birth that you wish to enroll the child. Then, a completed 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 the baby as a dependent.

What are the eligibility rules for children under 19?

To be eligible for coverage, the child must be:

• The participant’s natural child, stepchild, or adopted child; or a child for whom the participant has been appointed the legal guardian,
• Unmarried
• In the physical custody of and financially dependent upon the participant. (This requirement is waived if the participant is required to provide coverage as part of a court order or divorce decree.)

What are the eligibility rules for children 19 and older?

The 2007 Montana State Legislature passed Senate Bill 419 which makes it possible for plan participants to cover their adult, unmarried children on their family health insurance plan up to age 25 regardless of whether or not they are in college, financially dependent or a volunteer. 

The new law becomes effective as of the member group’s effective date or next annual renewal concurrent with or after January 1, 2008. 

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 a non IRS Section 152 dependent child to the Plan, the “fair market amount” of the benefit (whether or not there is any increase in premium) may be included as income for the plan participant on their W-2’s and the ”fair market amount” is taxable.

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

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

If you voluntarily drop your dental or vision coverage, you cannot re-enroll at the next annual open enrollment, but you could enroll the second year.

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.

Are retirees eligible for coverage under MACoHCT?

Employees, supervisors, and elected 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 retiree status from PERS or TRS is required, along with a MACoHCT change form requesting the change from Active to Retiree status.

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

We encourage all Medicare eligible participants to enroll in Medicare Part B. If you are eligible for Medicare Part B and choose to not enroll, MACoHCT will estimate the amount that Medicare Part B would have paid for a covered service and will consider only the remaining balance for payment.

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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.

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.

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. 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. In the HDHP, members can collect pharmacy receipts and submit them so that these costs 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.

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. MACoHCT has partnered with Wells Fargo Bank and Valley Bank of Helena to simplify the process, but an employee can choose any qualified financial institution of their choice. For more information click on the Health Saving Account Website Quick Link on the left-hand side of the home page.

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 regulation 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.

 

An employee can also make after-tax deposits into the HSA and save Federal and Montana income tax as they complete their individual tax returns. This is accomplished with an “above-the-line” reduction to their adjusted gross income. The taxpayer is not required to itemize deductions, but must complete IRS Form 8889 for HSA contributions and distributions. This form can be found on the U.S. Treasury website.

How much money can be put into the HSA?

For the tax year 2006 (and earlier), IRS regulations generally stated that the annual HSA contribution could not exceed the deductible for the High Deductible Health Plan (HDHP). And, if the person was not eligible for an HSA for the entire year, only a prorated amount could be put into the account.

NEW for 2007:  Congress has passed new legislation that eliminates some of these restrictions and increases the potential tax advantages of opening an HSA. The maximum HSA contribution amount is no longer limited by the HDHP deductible. For the 2007 tax year, an account holder can contribute up to $2,850 (for single coverage) or $5,650 (for family coverage), even if their HDHP deductible is less. They can also contribute this amount if they were only eligible for part of the year. (These amounts are adjusted annually for inflation.)

The new law also allows participants to do a one-time transfer from an IRA (individual retirement account) or FSA (flexible spending account) to fund their HSA initially.  More information can be found on the U.S. Treasury website and other sources; interested persons should consult their tax advisor for specific guidance.

How do HSA account holders access their money?

Most financial institutions (including Wells Fargo) 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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Do all MACoHCT plans have a pharmacy benefit?

All plans except the Basic plan and the HSA-qualified High Deductible Health Plan (HDHP) have a prescription (pharmacy) benefit.  Please note:

• If you are enrolled in the Basic plan:  You pay for your own prescriptions. There is no coverage for prescriptions under the Basic plan; however, you might receive discounted prices at the pharmacy as a MACoHCT member (be sure to show the pharmacist your MACoHCT identification card).
• If you are enrolled in the HSA-qualified High Deductible Health Plan: You pay for your own prescriptions and submit the receipts to the plan. If your medical deductible has not yet been satisfied, they will count toward that deductible. If your medical deductible is satisfied, they will be covered according to the same copayment percentages as any other medical services.

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.

Is there a separate ID card for the pharmacy benefit?

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

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

Call MACoHCT Customer Service (866-669-6428) to verify that your enrollment forms have been received and processed. If they have, you will be given your group plan number verbally. The pharmacist will usually accept this, but if not, ask them to call the number above to verify your eligibility.

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 drugs that you take.

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

No; there are several 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 MACoHCT at 866-669-6428 for a list of 90-day network pharmacies in your area.

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

If your pharmacist won’t bill insurance or doesn’t belong to the pharmacy benefit plan’s network, he or she will require full payment at the time of purchase. If your MACoHCT coverage includes a pharmacy benefit plan, you can submit a claim yourself using this form. Be sure to follow all instructions on the form.

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 pharmacy claims to the MACoHCT claims office for processing under the secondary MACoHCT plan.

 

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.

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

No; the prescription drug benefit (if applicable) is integrated with your MACoHCT health plan.

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Who processes my claims?

MACoHCT claims are administered by Allegiance Benefit Management in Missoula.

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 claims office. 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 claims is:

MACoHCT Claims

PO Box 1966

Missoula, MT 59806-1966

 

Generally, claims must be submitted to MACoHCT within 12 months after the date of service. However, if the employer group has terminated its MACoHCT coverage, claims must be submitted within three months of the termination date.

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.

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

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

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 (866-669-6428). A Customer Service representative will be happy to help you understand your benefits or to help explore any claims questions you may have.

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 understand 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 Plan Supervisor will research the information initially received and determine if the initial determination was appropriate based on the terms and conditions of the Plan and other relevant information. Notice of the decision will be sent to the participant within 60 days after receiving the request. If the denial is upheld, the participant may request a second review; refer to the Summary Plan Description for details.

Can I see any doctor I want?

You can see any licensed provider you wish. However, Allegiance (the MACoHCT claims administrator) has agreements in place with a number of different provider networks in Montana and other parts of the United States. Logos for these networks appear on your MACoHCT identification 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 using the Providers button on the main menu, or you can call 888-883-3233 for assistance with questions about providers and networks.

Can I see providers outside the U.S.?

If you plan to travel outside the U.S., contact the Claims Administration office (888-883-3233) before you leave. They will provide 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 review.

What does UCR stand for?

This stands for “Usual, Customary, and Reasonable” charges. When you obtain services from an out-of-network provider, MACoHCT pays claims according to established UCR allowable charges. See the Providers section of this website for more information.

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 benefit rather than the preventive benefit. 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.

 

If the service was submitted with a preventive code but was denied, it may have exceeded the limits of the plan’s preventive benefit, such as receiving the same test twice within the same benefit year.  Call the Claims Administration office at 888-883-3233 if you have questions.

Does MACoHCT reimburse for mileage to my health care provider?

No; travel expenses are specifically excluded under the plan.

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, 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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