PLAN BENEFIT AND PROCEDURAL CHANGES
BENEFIT CHANGES
Preventive Services - Non-Medicare subscribers and non-Medicare enrolled spouses in the PPO Plan will be eligible to receive up to $300 annually for preventive medical services. This is an increase for active employees and a new benefit for all other non-Medicare subscribers. (Effective January 1, 2005)
Lifetime Maximums - Lifetime maximum benefits for covered services for both PPO and Open Access III Plans will be unlimited. (The lifetime maximum was $1,000,000 per participant.) (Effective January 1, 2005)
Emergency Ambulance Services - Benefits will be paid for emergency air or land ambulance services at the highest level of in-network benefits provided by the plan in which the subscriber is enrolled even if the ambulance service is not a participating provider. (Reference Section 6.01 (g), effective January 1, 2005).
Speech Therapy Services - Speech therapy services were modified as follows: “Treatment by a qualified speech therapist for the correction of a speech impairment resulting from disease, surgery, injury, congenital and developmental anomalies, or previous therapeutic processes. Therapy is limited to 30 visits per calendar year. A $25 co-payment will apply to each visit, the balance of approved charges will be allowed according to plan guidelines subject to applicable deductibles and coinsurance.” (Effective July 1, 2004)
Chemical Dependency Coverage - PPO and OAIII Plans - No annual or lifetime maximums for medical services related to chemical dependence. These services will be paid as other covered services in the plan, applicable to deductible(s), copayment(s) and/or coinsurance. (Effective January 1, 2005)
Immunization Schedule - This schedule has been revised to reflect the latest edition of the “Recommended Childhood and Adolescent Immunization Schedule. (Reference Page 45.)
Well-Baby and Well-Child Checks – The language was clarified that these services are covered at 100% in-network only. Out-of-network services will apply to your deductible(s) and coinsurance.
Change in Dental Coverage - A dental examination prescribed by a physician prior to joint replacement, valve replacement or transplant surgery to verify an infection/bacteria is not present, which could jeopardize the success of the surgery. The coverage will not include any dental services required as a result of the check-up. Proof of surgery will be required from your physician. See other dental coverage outlined in Sections 6.01 (i) and exclusions under Section 6.02 (a). (Effective January 1, 2005.)
State Paid Life Insurance - Employees approved for work-related disability after July 1, 2004, are eligible to continue their State Paid Life; however, they will not receive the state contribution and will have to pay the entire premium. (Effective July 1, 2004)
Optional Life Insurance - Employees approved for work-related disability benefits after July 1, 2004, can retain the amount of insurance coverage in force on the date he ceased to be an active full-time, permanent part-time or seasonal employee eligible for benefits. Upon retirement they have the same options offered to retirees. (Effective July 1, 2004)
PROCEDURAL CHANGES
New Employee Open Enrollment Period - New employees have 31 days from date of hire to enroll themselves and any eligible dependents in the medical plan. (Effective January 1, 2005.) This is a change from the current 60-day period allowed.
Continuation of Coverage Rights (COBRA) - Additional clarification has been provided in Article XI.
Subrogation - Reference Article XIV concerning the subrogation rights of the plan. A new law was passed effective August 28, 2004 reinstating our rights to subrogate.
Change in Plan Status – No change in a subscriber’s plan group or change in status of a person who may be covered under the Plan shall take effect until the first day of the next calendar month after receipt of application by the Employee Benefits Division at the Central Office.
(Example: Application for change is received February 1 the effective date of coverage will be March 1.)
Optional Life Insurance/Active Military Service – Please refer to section for a change in the Optional Group Life Insurance for individuals (both active employees and retirees) called up for active military duty.
Member HIPAA Notification
MODOT/MSHP Medical and Life Insurance Plan
In 1996 Congress passed the Health Insurance Portability and Accountability Act (HIPAA). This legislation affects many aspects of group health insurance plans, mandating measures that must be taken to protect the privacy of members. Compliance with the privacy rules of HIPAA was established by April 14, 2003.
You have the right to see and obtain copies of your health care records, and to request amendments to those records. You also have the right to issue a complaint about suspected HIPAA violations by our Plan. In order to do any of these things, you may contact the designated privacy officer. The privacy officer for our Plan is Jeff Padgett, Manager of Employee Benefits, MoDOT, P.O. Box 270, Jefferson City, MO 65102.
You have the right to grant consent authorizing another person to access your protected health information (PHI). This will allow your designated representative to discuss your PHI with parties that are involved with your health care. You may have to complete more than one of these authorizations depending upon the number of entities involved in the delivery of and payment for your health care services. Except in the case of a minor child, PHI can only be shared with the patient. PHI cannot be shared with spouses, children or other parties unless notarized authorization(s) have been completed and filed with the entities involved.
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
TO:WESTPORT BENEFITS AND:MODOT
120 S. Central, Suite 160Employee Benefits
St. Louis, MO 63105P.O. Box 270
Jefferson City, MO 65102
Patient:[Patient's Name]
[Patient's Address]
[City, State and Zip]
Social Security Number:[Social Security Number]
Date of Birth:[DOB]
I, ______, do hereby request that you release to the person(s) or entity listed below, information related to 1) my past, present or future physical or mental health or condition, 2) information related to the provision of my health care; and 3) information related to the past, present or future payment for the provision of my health care. In addition, I authorize MODOT to disclose my social security number to the person(s) or entity listed below. The information is to be provided only to the following person(s) or entity:
[Person receiving information]
[Title]
[Company]
[Address]
[City, State, Zip]
I may revoke this authorization at any time by sending written notice of the revocation to Westport Benefits at the above address. Such revocation shall not be effective until received by Westport Benefits, and shall not apply to any disclosures made in reliance on this authorization prior to receipt of the revocation.
I acknowledge and understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient, and any such redisclosure will not be protected by the Standards for Privacy of Individually Identifiable Health Information. (See 45 CFR §160.101 et seq.)
This Authorization shall expire on ______.
IN WITNESS WHEREOF, I have hereunto set my hand this ______day of ______, 200____.
______
Signature of Patient, Parent, Legal Guardian or Personal Representative of the Patient
______
Relationship to Patient
State of ______)
) ss.
County of ______)
On this ____ day of ______, 200___, personally appeared before me, personally known to me to be the same person described in and who executed the foregoing instrument, who acknowledged to me that the same was executed as his/her free act and deed.
______
Notary Public
My Commission Expires: ______
1
THE MISSOURI DEPARTMENT OF TRANSPORTATION
AND
MISSOURI STATE HIGHWAY PATROL
MEDICAL AND LIFE INSURANCE PLAN
Effective January 1, 2005, the Missouri Highway and Transportation Commission acting by and through the Board of Trustees of the Missouri Department of Transportation (MoDOT) and the Missouri State Highway Patrol (MSHP) Medical and Life Insurance Plan (the “Board of Trustees”), hereby adopts the amended and restated Missouri Department of Transportation and Missouri State Highway Patrol Medical and Life Insurance Plan, (herein after called Plan). This amended and restated Plan is the basis for calculating benefits for medical care services and supplies received.
The purpose of the Plan is to provide hospital, surgical, medical, and life insurance coverage for certain individuals and dependents who are eligible in accordance with the terms and conditions of the Plan.
NOTE: Precertification is required as stated in Article IX. You, your physician, or facility must call the utilization review organization for preapproval. Ultimately, it is the subscriber’s responsibility to assure precertification has been obtained. Failure to obtain PreAdmission Certification will result in a 20 percent reduction (not to exceed $1,000) in the total allowed amount before plan benefits are determined. Costs incurred for admissions or services that are not medically necessary are not allowed amounts and 100 percent of such costs will be deducted before plan benefits are determined.
First Printing January 1, 1991
Second Printing January 1, 1997
Third Printing – May 1, 1999
Fourth Printing – January 1, 2001
Fifth Printing – January 1, 2003
Sixth Printing – January 1, 2005
IF YOU NEED INFORMATION
To ensure that you receive accurate information regarding your medical and life insurance benefits you should direct your questions ONLY to the sources listed below. NO ONE ELSE is authorized to give you information.
For information about your medical benefits or claims, call the tollfree number of the claims administrator listed on the back of your medical insurance identification card or prescription drug card.
For information regarding enrollment in the medical and life insurance plans, contact Employee Benefits or the insurance representative at your district, division or troop assignment as follows:
Employee Benefits Contacts -
Toll-free ...... 1-877-863-9406
Senior Benefits Specialist...... (573) 751-5704
Senior Benefits Specialist...... (573) 751-2861
Senior Benefits Specialist...... (573) 522-8121
MoDOT Districts: Contact your district insurance representative.
District 1...... St. Joseph(816) 3872405
District 2...... Macon(660) 3858252
District 3...... Hannibal(573) 2482456
District 4...... Kansas City(816) 6226305
District 5...... Jefferson City(573) 5265139
District 6...... Chesterfield(314) 3404216
District 7...... Joplin(417) 6293303
District 8...... Springfield(417) 8957614
District 9...... Willow Springs(417) 4696222
District 10...... Sikeston(573) 4725368
MSHP Contact – Contact the insurance representative:
GHQ – Jefferson City...... (573) 526-6136 or (573) 526-6356
MSHP Troops: Contact your troop insurance representative.
Troop A Lee’s Summit...... (816) 6220800, ext. 242
Troop B Macon...... (660) 3852132, ext. 220
Troop C...... St. Louis(314) 3404059
Troop D...... Springfield(417) 8956767, ext. 228
Troop E...... Poplar Bluff(573) 8409500, ext. 219
Troop F...... Jefferson City(573) 526-6329, ext. 221
Troop G...... Willow Springs(417) 4693121, ext. 226
Troop H...... St. Joseph(816) 3872345, ext. 220
Troop I...... Rolla(573) 3682345
The plan document is also available on the MoDOT/MSHP Employee Benefits website:
MISSOURI DEPARTMENT OF TRANSPORTATION
NOTE TO INSURANCE REPRESENTATIVES
For quick reference, we are providing you with selected telephone numbers, websites and addresses as follow:
Westport Benefits
PO Box
St. Louis, MO 63105
Benefits or Claim Information...... 18883066681
website:
Mailing Address:Westport Benefits
P.O. Box 66743
St. Louis, MO 63166-6743
HealthLink/Preferred Care
Utilization Management Program (Pre-certification)...1-877-284-0102
Provider Locator: or call...... 1-888-724-9395
Mailing Address:HealthLink/Freedom Network
P.O. Box 419104
St. Louis, MO 63141-1640
EHS
Retail/Mail Order Pharmacy Questions ...... 1-888-414-3141
website:
Express Pharmacy Services
Mailing Address:Express Pharmacy Services
P.O. Box 270
Pittsburg, PA 15230-9949
THE MISSOURI DEPARTMENT OF TRANSPORTATION
AND MISSOURI STATE HIGHWAY PATROL
MEDICAL AND LIFE INSURANCE PLAN
TABLE OF CONTENTS
MEDICAL PLAN
Article IDEFINITIONS PAGE
Section
1.01Allowed Amount...... 9
1.02Ambulatory Care Facility...... 9
1.03Benefit...... 9
1.04Benefit Acceleration Point...... 9
1.05Board of Trustees...... 9
1.06Claims Administrator...... 10
1.07Clinical Psychologist...... 10
1.08Code...... 10
1.09CommonLaw Spouse...... 10
1.10Coinsurance...... 10
1.11Co-payment ...... 10
1.12Coverage Date...... 10
1.13Covered Service...... 10
1.14Custodial Care...... 10
1.15Deductible(s)…...... 10
1.16Dependent…...... 11
1.17Diagnostic Admission...... 11
1.18Diagnostic Service...... 11
1.19Election Period...... 12
1.20Emergency Care...... 12
1.21Employee…...... 12
1.22Employer…...... 12
1.23Employer or State Contribution...... 12
1.24Experimental/Investigative...... 12
1.25Freestanding Renal Dialysis Facility...... 12
1.26FullTime Student...... 12
1.27HMO………...... 12
1.28Hospital……...... 12
1.29Inpatient…...... 13
1.30Intensive Care Unit...... 13
1.31LongTerm Disability Recipient...... 13
1.32Medically Necessary...... 13
1.33Medicare Member...... 13
1.34Mental Health...... 13
1.35NonParticipating Provider...... 14
1.36Open Access III...... 14
1.37Out-of-Network...... 14
1.38Outpatient…...... 14
1.39Participant…...... 14
1.40Physician……...... 14
1.41Plan...... 14
1.42 Plan Sponsor...... 14
1.43Preferred Provider Organization (PPO)...... 14
Article IDEFINITIONS PAGE
Section
1.44Provider……...... 14
1.45Psychiatric Facility...... 15
1.46Retiree…...... 15
1.47Skilled Nursing Facility...... 15
1.48Special Enrollment Period……………………………………………………15
1.49State………...... 15
1.50Subscriber…...... 15
1.51Subscriber Contribution...... 15
1.52Therapy Service...... 15
1.53Usual, Customary and Reasonable...... 16
1.54Utilization Review Organization...... 17
1.55Vested Member...... 17
1.56Work-Related Disability Recipient...... 17
Article IIELIGIBILITY
Section
2.01Employee Eligibility...... 18
2.02Dependent Eligibility...... 18
2.03Retiree Eligibility...... 18
2.04Application for Coverage...... 18
2.05Change of Employment Status...... 18
2.06Employee Leave of Absence Without Pay...... 18
2.07Medicare Eligibility...... 19
2.08Termination of Coverage for Subscriber……………………………………. 19
2.09Termination of Coverage for Retirees, Vested, Long-Term Disability or
Surviving Lawful Spouse…………………………………………………….19
2.10Termination of Coverage for Dependents...... 19
Article IIIELECTION AND EFFECTIVE DATE OF COVERAGE
Section
3.01Election of Coverage...... 21
3.02Special Enrollment Period...... 22
3.03Effective Date of Coverage...... 23
3.04Change of Plan Election……………………………………………………...24
Article IVSCHEDULE OF BENEFITS
Section
4.01Plan Summary of Benefits...... 25
4.02Medicare Member Benefits...... 25
4.03Co-payment...... 25
4.04Coverage for OutofCountry Service...... 25
4.05Coverage for OutofState Service...... 25
4.06Coverage for Veterans Administration (VA) Facilities...... 25
4.07Prescription Drug Card Program...... 25
Article VSPECIAL INCENTIVE BENEFITSPAGE
Section
5.01General Information...... 31
5.02PreAdmission Testing...... 31
5.03Large Case Management...... 31
Article VICOVERED SERVICES AND EXCLUSIONS
Section
6.01Covered Services...... 32
6.02Exclusions…...... 41
Article VIIHUMAN ORGAN TRANSPLANT INSURANCE
Section
7.01Human Organ Transplant Coverage...... 46
Article VIIIMEDICARE MEMBER PROVISIONS
Section
8.01Eligibility...... 47
8.02Deductible(s)…...... 47
8.03Benefits...... 47
8.04Coordination of Benefits...... 48
8.05Services by NonMedicare Provider...... 48
8.06Coverage for OutofCountry Service...... 48
8.07Coverage for Veterans Administration (VA) Facilities...... 48
8.08Coverage for Medicare Denied Claims...... 48
Article IXCOST CONTAINMENT
Section
9.01General Information...... 49
9.02PreAdmission Certification and Concurrent Review Requirements 49
9.03Admission Review...... 50
Article XCOORDINATION OF BENEFITS
Section
10.01Applicability...... 51
10.02Definitions...... 51
10.03Order of Benefit Determination Rules...... 52
10.04Effect on Benefits of the Plan...... 53
10.05Right to Receive and Release Needed Information...... 54
10.06Facility of Payment...... 54
10.07Right of Recovery...... 54
Article XICOBRA CONTINUATION COVERAGE RIGHTS PAGE
Section
11.01General Information...... 55
11.02Qualified Beneficiary...... 55
11.03Qualifying Event...... 55
11.04Vested Status vs. COBRA...... 56
11.05Applicable Premium...... 56
11.06COBRA Election Period...... 56
11.07Maximum Coverage Period...... 56
11.08Terminating Events...... 57
11.09Rights and Privileges during Continuation Period...... 57
11.10Premium Requirements...... 57
11.11Notice Requirements...... 57
Article XII CLAIM PROCEDURE AND ARBITRATION RIGHTS
Section
12.01Claim for Benefits...... 59
12.02Payment of Benefits...... 59
12.03Arbitration Rights...... 59
12.04Legal Action...... 60
12.05Misstatements...... 60
Article XIIIFUNDING POLICY
Section
13.01General Information...... 61
13.02State Contributions...... 61
13.03Subscriber Contribution Amount...... 61
13.04Payment of Subscriber Contributions...... 62
13.05Grace Period on Subscriber Contributions...... 62
13.06Reimbursement of Contributions...... 62
Article XIVSUBROGATION
Section
14.01Subrogation for Third Party Liability...... 63
Article XVADMINISTRATION
Section
15.01Plan Administration...... 64
15.02Examination of Records...... 64
Article XVIAMENDMENT OR TERMINATION OF PLAN
Section
16.01Amendment...... 65
16.02Termination...... 65
Article XVII MISCELLANEOUSPAGE
Section
17.01Plan Interpretation...... 66
17.02Conversion Privilege...... 66
17.03NonAlienation of Benefits...... 66
17.04Limitation on Employee Rights...... 66
17.05Governing Law...... 66
17.06Severability...... 66
17.07Captions...... 66
17.08NonGender Clause...... 67
STATE PAID LIFE INSURANCE PLAN...... 68
OPTIONAL GROUP LIFE INSURANCE PLAN...... 70
ARTICLE I
DEFINITIONS
1.01Allowed Amount means the charge for covered services provided to a participant for which benefits may be payable, as determined reasonable by the Plan. In the case of a physician or other professional provider, the allowed amount is the usual, customary and reasonable charge or the charge determined by other specified methods.
1.02Ambulatory Care Facility means a provider with an organized staff of physicians that:
(a)has permanent facilities and equipment for the primary purpose of performing surgical and/or medical procedures on an outpatient basis;
(b)provides continuous nursing services and treatment by physicians whenever the participant is in the facility;
(c)does not provide inpatient accommodations,
(d)is not, other than incidentally, a facility used as an office or clinic for the private practice of a physician; and
(e)is licensed as an ambulatory care facility.
1.03Benefit means the Plan’s payment or reimbursement for covered services as outlined in the Schedule of Benefits set forth in Article IV.
1.04Benefit Acceleration Point (“BAP”) means the point at which the plan increases its co-insurance to 100 percent of the allowed amount for covered services. Expenses counted toward the BAP do not include:
(a)deductible(s) and copayment(s);
(b)cost of any service or supply that is not a covered service;
(c)charges in excess of the allowed amount; or
(d)amounts resulting from reductions in benefits due to the participant’s (or provider’s) failure to comply with the cost containment provisions
When the BAP is reached, the level of benefits is increased, as specified.
1.05Board of Trustees means the body established by the Missouri Highways and Transportation Commission to provide for the general administration of the Plan. The Board consists of eight members as follows:
(a)four MoDOT employees appointed by its Director;
(b)two MSHP employees appointed by its Superintendent;
(c)one retired MoDOT employee appointed by its Director; and
(d)one retired MSHP employee appointed by its Superintendent.
All appointees must be approved by the Missouri Highways and Transportation Commission prior to performing any Board duties.
1.06Claims Administrator means the person or entity duly authorized by the Board of Trustees, as contracted from time to time, to process claims.
1.07Clinical Psychologist means a person who provides clinical psychological services in connection with the diagnosis or treatment of mental, psychoneurotic or personality disorders, and who is duly licensed as a psychologist.
1.08Code means the Internal Revenue Code of 1986, as amended.
1.09CommonLaw Spouse means a spouse in a commonlaw marriage, which occurs prior to the parties residing in Missouri, in a state that recognizes commonlaw marriage. The Plan will permit the commonlaw spouse of the member to be a dependent under Section 1.16(a) as a lawful spouse. Proof of commonlaw marriage will be required by the Board.
1.10Coinsurance means the shared portion of payment between the Plan and the member where each pays a percentage of medical expenses (reference Appendix A, Page 28).
1.11Co-payment means a fixed fee required by the Plan to be paid by the patient at the time services are rendered at a participating provider (PPO/HMO); such as office visit, emergency room visit, urgent care, etc.
1.12Coverage Date means the date on which participation begins under the Plan provided all requirements and conditions for participation have been satisfied and performed.
1.13Covered Service means a service or supply specified in Article VI for which benefits will be furnished, subject to the deductible(s) and other requirements for payment by the plan, when rendered by a provider (reference Section 1.44). A charge for a covered service will be considered to have been incurred on the date the service or supply was provided to the participant. Eligibility for payment of benefits, including obstetrical benefits without limitations, will be determined on the date the service is rendered.
1.14Custodial Care means care provided primarily for the convenience of the participant or his family, maintenance of the participant, or which is designed essentially to assist the participant in meeting his activities of daily living and which is not primarily provided for its therapeutic value in the treatment of an illness, disease, bodily injury, or condition. Custodial care includes, but is not limited to:
(a)help in walking, bathing, dressing, feeding;
(b)preparation of special diets;
(c)supervision over selfadministration of medications not requiring constant attention of trained medical personnel; or
(d)acting as a companion or sitter.
Unless a participant is receiving medical, surgical, or psychiatric treatment that is intended or designed to permit him to live outside a hospital or skilled nursing facility, the care being provided will be deemed custodial care.