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Medical benefit plan design options coupled with multiple deductible selections enable Member Groups to customize their plan(s) to their employees’ needs. MACoHCT offers the following medical benefit plans:

• Revised Major Medical Plan (RM) • Comprehensive Major Medical Plan (CM) • High Deductible Health Plan (HD) - Health Savings Account Qualified • Basic Medical Plan (BP)

MACoHCT requires each member group to enroll at least 75% of all eligible employees and eligible county elected officials, excluding those waiving coverage because they are insured under another group health plan.

MACoHCT and Express Scripts contract to provide members with the convenience and cost savings of the Express Scripts purchasing network and the ease of purchasing prescription drugs with the MACoHCT ID card at participating pharmacies. Express Scripts offers mail-order prescriptions and all local pharmacies within its network provide 90-day prescriptions at mail order prices.

Dental and Vision benefits are available to employees, spouses and dependent children. Enrollment in a medical plan is not necessary. Dental and Vision Coverage may be voluntarily canceled ONLY during the annual open enrollment period. If coverage is voluntarily canceled, there is a two-year waiting period before coverage can be reinstated.

MACoHCT and Blue Cross Medicare AdvantageSM have partnered to offer a Group Medicare Advantage Plan to retired Health Care Trust members over the age of 65 years. The plan includes enhanced Medicare benefits, prescription drug coverage, a large network of medical providers, no medical deductibles, simple co-pays, wellness benefits and incentives, world-wide coverage for emergent care, gym membership, preventive and comprehensive dental, vision exams and eyewear allowance, hearing exams and hearing aid allowance.

A Basic Life Insurance and Accidental Death & Dismemberment (AD&D) benefit of $25,000 is provided at no cost to all active employees and active county elected officials enrolled in a MACoHCT medical plan.

In addition to the Basic Life Insurance and AD&D benefit provided by MACoHCT at no cost, member groups may elect to enhance the Basic Life Insurance and AD&D benefit through UNUM for eligible active employees and eligible county elected officials. Active eligible employees and active county elected officials may also elect to purchase Voluntary Life Insurance and AD&D coverage.

• Additional Basic Life Insurance and AD&D Employers may elect any amount in increments of $10,000, to a maximum of $150,000 - late enrollee rules apply. Employers may also elect to purchase spouse and dependent child(ren) Life Insurance and AD&D coverage in the amount of $10,000 for a flat monthly rate.

• Voluntary Life Insurance and AD&D

Active eligible employees and county elected officials may elect coverage in increments of $10,000 to the lesser of $500,000 or 4 times annual earnings. Guaranteed issue amount of up to $100,000 - late enrollee rules apply. Coverage for spouses in increments of $10,000 can also be purchased up to the amount of coverage purchased by the employee or elected official with a guarantee issue of $30,000 - late enrollee rules apply. Dependent child(ren) Life Insurance and AD&D in the amount of $10,000 can be purchased for a flat monthly rate.

Life Insurance and AD&D coverage provided by UNUM through MACoHCT also includes Life Planning Financial & Legal Resources, Interest Bearing Retained Asset Accounts, Education Benefits, Seat Belt Benefits, Air Bag Benefits and Worldwide Emergency Travel Assistance Services.

The Health Advocate Employee Assistance Program through UNUM provides personal, confidential advice at no cost for employees and county elected officials enrolled in a MACoHCT medical plan and/or for those with Employer Paid UNUM Life Insurance. To access this free, confidential service 24 hours a day, 7 days a week call 800-854-1446 or visit www.unum.com/life balance

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MACoHCT is compliant with PPACA preventive benefit requirements as mandated by Federal Health Care Reform. Here’s just some of the numerous preventive benefits covered by all MACoHCT medical plans:

• Well-child care following the American Academy of Pediatrics recommended schedule

• CDC recommended immunizations

• Preventive annual pap test

• Preventive annual mammogram

• Preventive colon cancer screenings including fecal occult blood test, sigmoidoscopy and colonoscopy

• Diabetic screening and education Free Annual Wellness Screenings, Education, Challenges and Participation Incentives

MACoHCT medical plan members are eligible for the free and confidential services of Maternity Management, a pro-active benefit for expectant mothers. Maternity Management registered nurses provide answers to member’s questions, pregnancy wellness information, support services to complement the provider’s care, and assistance with special needs. 877-792-7827

MACoHCT works in partnership with Allegiance Care Management to provide free and confidential Case Management services to identify and assist with plan members’ immediate and ongoing medical issues. Case Management Nurse Managers work with members families, caregivers and payers to arrange the most appropriate and cost-effective treatment possible. 877-792-7827

Allegiance Care Management specialized nurses also provide free and confidential Disease Management services which include guidance and education to manage chronic conditions such as: Asthma, Diabetes, Chronic Kidney Disease, Coronary Artery Disease, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease (COPD), Hyperlipidemia, Hypertension and Chronic Pain due to Osteoarthritis, RA and Lower Back Pain. 866-458-0474

Pre-notification with Allegiance Care Management is recommended before admission on all scheduled outpatient procedures and inpatient hospital stays. Emergency admissions should be reported within 72 hours. Pre-notification is not a guarantee of benefits. 800-342-6510

A pre-treatment review is strongly recommended before incurring expenses for any outpatient or inpatient service, medication, supply or on-going treatment for: bariatric surgery, commercial or private transportation, outpatient rehabilitative care, surgery that could be considered cosmetic, any procedure or service that could be considered experimental or investigational, surgical treatment of TMJ, rental or purchase of durable medical equipment, home health care services and organ or tissue transplant. 888-883-3233

A Pre-Determination of Benefits Review request can be submitted to the MACoHCT Claims Department by a member or provider prior to any medical procedure. A Pre-Determination of Benefits Review estimate outlines charges that are eligible and excluded by the MACoHCT plan. A Pre-Determination of Benefits Review is strongly encouraged whenever medical necessity is in question, but it is not required. 888-883-3233

MACoHCT members enrolled in a medical plan have free access to Healthcare Bluebook. This on-line and mobile application allows members to shop for care, compare facilities, view quality ratings and save money on healthcare services. To access this tool, go to mtcounties.org/hct and click on the ‘Access Healthcare Bluebook’ link. Select ‘Cost Transparency’ then enter your group number and participant number found on your MACoHCT ID Card.

MACoHCT is fully compliant with the privacy provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

MACoHCT administers COBRA, the Consolidated Omnibus Reconciliation Act of 1985 (temporary health insurance continuation) for all of our member groups.

PLUS

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All benefits payable are subject to the applicable plan exclusions, procedure based maximum expense (PBME), plan maximum limits and medical necessity.

MEDICAL BENEFITS REVISED MAJOR MEDICAL PLAN

(RM)

COMPREHENSIVE MAJOR MEDICAL PLAN (CM)

Maximum Lifetime Limit None None

Deductible - Individual $500 $1000 $1500 $2000 $3000 $200 $1000

Deductible - Family $1000 $2000 $3000 $4000 $6000 $400 $2000

Out-of-Pocket Max - Individual $1500 $3000 $3000 $4000 $5000 $1200 $3000

Out-of-Pocket Max - Family $3000 $6000 $6000 $8000 $10000 $2400 $6000

Co-Insurance 80/20% 80/20% 80/20% 80/20% 80/20% 90/10% 80/20%

First Dollar Medical Benefit N/A N/A

Life Insurance $25,000 $25,000

Accident Benefit

Deductible Waived/100% Deductible Waived/100%

Maximum Benefit per Accident $500 within 90 days of accident $500 within 90 days of accident

Inpatient Hospital Services

Deductible Applies/Co-Insurance Applies Deductible Applies/Co-Insurance Applies

Physician Office Visit

Deductible Waived/Co-Insurance Applies Deductible Applies/Co-Insurance Applies

Diagnostic X-ray & Labs

First $600 Waived/Co-Insurance Applies Deductible Applies/Co-Insurance Applies

Chiropractic Office Visit

Deductible Waived/100% Deductible Applies/100%

Maximum Payment/Visit $30 $30

Maximum Visits/Year 25 25

Chiropractic X-rays

Deductible Waived/Co-Insurance Applies Deductible Applies/Co-Insurance Applies

Maximum Benefit Per Benefit Period $100 $100

Chemical Dependency

Outpatient First 3 outpatient visits paid at 100% First 3 outpatient visits paid at 100%

Deductible Waived/Co-Insurance Applies Deductible Applies/Co-Insurance Applies

Inpatient & Residential Deductible Applies/Co-Insurance Applies Deductible Applies/Co-Insurance Applies

Mental Illness

First 3 outpatient visits paid at 100% First 3 outpatient visits paid at 100% Outpatient

Deductible Waived/Co-Insurance Applies Deductible Applies/Co-Insurance Applies

Inpatient & Residential Deductible Applies/Co-Insurance Applies Deductible Applies/Co-Insurance Applies

Autism Spectrum Disorder

Deductible Applies/Co-Insurance Applies Deductible Applies/Co-Insurance Applies

Rehabilitation/Cardiac Therapy

Deductible Applies/Co-Insurance Applies Deductible Applies/Co-Insurance Applies

Home Health/Hospice Care

Deductible Applies/Co-Insurance Applies Deductible Applies/Co-Insurance Applies

Skilled Nursing Facility

Deductible Applies/Co-Insurance Applies Deductible Applies/Co-Insurance Applies

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HIGH DEDUCTIBLE HEALTH PLAN (HD)

BASIC MEDICAL PLAN (BP)

None None

$3000 $4000 $5000 $6000 $2000

$6000 $8000 $10000 $12000 $4000

$3000 $4000 $5000 $6000 $4000

$6000 $8000 $10000 $12000 $8000

100% 100% 100% 70/30% 100%

N/A $300

$25,000 $25,000

Deductible Applies/100% Deductible Waived/100%

$500 within 90 days of accident $300 within 90 days of accident

Deductible Applies Deductible Applies/Co-Insurance Applies

Deductible Applies Deductible Applies/Co-Insurance Applies

Deductible Applies Deductible Applies/Co-Insurance Applies

Deductible Applies/100% No Benefit

$30 N/A

25 N/A

Deductible Applies No Benefit

$100 N/A

Deductible Applies First 3 outpatient visits paid at 100%

Deductible Applies Deductible Applies/Co-Insurance Applies

Deductible Applies Deductible Applies/Co-Insurance Applies

Deductible Applies First 3 outpatient visits paid at 100%

Deductible Applies Deductible Applies/Co-Insurance Applies

Deductible Applies Deductible Applies/Co-Insurance Applies

Deductible Applies Deductible Applies/Co-Insurance Applies

Deductible Applies Deductible Applies/Co-Insurance Applies

Deductible Applies Deductible Applies/Co-Insurance Applies

Deductible Applies Deductible Applies/Co-Insurance Applies

HSA Qualifying Plans

All benefits payable are subject to the applicable plan exclusions, procedure based maximum expense (PBME), plan maximum limits and medical necessity.

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MEDICAL BENEFITS REVISED MAJOR MEDICAL

(RM)

COMPREHENSIVE MAJOR MEDICAL (CM)

Organ & Tissue Transplants

Deductible Applies/Co-Insurance Applies Deductible Applies/Co-Insurance Applies

Maximum Procedure Benefit See Schedule of Medical Benefits See Schedule of Medical Benefits

Surgical Implants & Devices

Deductible Applies/Co-Insurance Applies Deductible Applies/Co-Insurance Applies

Maximum Procedure Benefit See Schedule of Medical Benefits See Schedule of Medical Benefits

Non-Ambulance Travel

For the patient and one companion to travel to a contracted Center of Excellence. Pre-Treatment Review is strongly encouraged.

Deductible Applies/Co-Insurance Applies Deductible Applies/Co-Insurance Applies

Maximum Lifetime Benefit $5,000 $5,000

CPAP Machines & Supplies

Deductible Waived/Co-Insurance Applies Deductible Waived/Co-Insurance Applies

Diabetic Insulin Pumps & Supplies

Deductible Waived/Co-Insurance Applies Deductible Waived/Co-Insurance Applies

Diabetic Blood Glucose Monitors

Deductible Waived/Co-Insurance Applies Deductible Waived/Co-Insurance Applies

Hearing Aids & Exams

Deductible Waived/Co-Insurance Applies Deductible Waived/Co-Insurance Applies

Maximum Lifetime Benefit $2,000 $2,000

Mammogram

Deductible Waived/100% Deductible Waived/100%

Colonoscopy

Deductible Waived/100% Deductible Waived/100%

Prescription Contraceptives

Deductible Waived/100% Deductible Waived/100%

Smoking Cessation

Deductible Waived/100% Deductible Waived/100%

Morbid Obesity Treatment

Treatment must be pre-authorized by the plan. Specific conditions apply.

Deductible Applies/Co-Insurance Applies Deductible Applies/Co-Insurance Applies

Bariatric Surgery

Treatment must be pre-authorized by the plan. Specific conditions apply.

Deductible Applies/Co-Insurance Applies Deductible Applies/Co-Insurance Applies

Preventive Care

Deductible Waived/100% Deductible Waived/100%

Immunizations

Deductible Waived/100% Deductible Waived/100%

Diabetic Education

Deductible Waived/100% Deductible Waived/100%

Prescription Pharmacy Benefit See Pharmacy Benefits on Back Cover See Pharmacy Benefits on Back Cover

NEW

All benefits payable are subject to the applicable plan exclusions, procedure based maximum expense (PBME), plan maximum limits and medical necessity.

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HIGH DEDUCTIBLE HEALTH (HD)

BASIC MEDICAL (BP)

Deductible Applies Deductible Applies/Co-Insurance Applies

See Schedule of Medical Benefits See Schedule of Medical Benefits

Deductible Applies Deductible Applies/Co-Insurance Applies

See Schedule of Medical Benefits See Schedule of Medical Benefits

For the patient and one companion to travel to a contracted Center of Excellence. Pre-Treatment Review is strongly encouraged.

Deductible Applies Deductible Applies/Co-Insurance Applies

$5,000 $5,000

Deductible Applies Deductible Waived/Co-Insurance Applies

Deductible Applies Deductible Waived/Co-Insurance Applies

Deductible Applies Deductible Waived/Co-Insurance Applies

Deductible Applies Deductible Waived/Co-Insurance Applies

$2,000 $2,000

Preventive: Deductible Waived/100% Deductible Waived/100%

Diagnostic: Deductible Applies

Preventive: Deductible Waived/100% Deductible Waived/100%

Diagnostic: Deductible Applies

Deductible Waived/100% Deductible Waived/100%

Deductible Waived/100% Deductible Waived/100%

Treatment must be pre-authorized by the plan. Specific conditions apply.

Deductible Applies Deductible Applies/Co-Insurance Applies

Treatment must be pre-authorized by the plan. Specific conditions apply.

Deductible Applies Deductible Applies/Co-Insurance Applies

Deductible Waived/100% Deductible Waived/100%

Deductible Waived/100% Deductible Waived/100%

Deductible Waived/100% Deductible Waived/100%

See Pharmacy Benefits on Back Cover See Pharmacy Benefits on Back Cover

All benefits payable are subject to the applicable plan exclusions, procedure based maximum expense (PBME), plan maximum limits and medical necessity.

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