- Any amount required to meet plan year deductible additional deductibles , and coinsurance amounts
- Any amount over the maximum reimbursable charge (MRC) charge
- Any penalties for failure to comply with the notification requirements
- Any charges NOT covered by the plan or determined by the plan administrator to be not medically necessary services.
Plan year Deductible
The plan year deductible must first be satisfied before benefits begin unless the family cap has been met. This deductible requirement applies to all services unless otherwise noted in this section. The plan year deductible also applies toward satisfying the out-of-pocket maximums .
An employee's plan year deductible is based on the employee’s annual salary as of the first of each April preceding the beginning of the plan year. The plan year deductible for an annuitant, retiree, or survivor is not based on the member's annuity. To verify the plan year deductible or family cap, review the current Benefit Choice Options booklet or contact your agency group insurance representative (GIR). The plan year begins on July 1.
An employee's salary-based deductibles stay in force for the entire plan year, regardless of any change in salary. The annual deductible in force at the time of termination of eligibility under the Program remains in force for those who elect continuation of coverage under COBRA.
If a member retires, accepts a voluntary reduction in pay, or returns to State employment at a different salary, the deductible is reassessed. Should the deductible requirement be reduced, only the lower deductible must be met; however, no reimbursements will be made if the lower deductible has been exceeded.
All family members’ plan year deductibles will be accumulated toward a family cap. Once the family as a unit has satisfied the family cap, no further plan deductibles will be taken for eligible charges incurred for the remainder of that plan year.
Additional Deductibles
In addition to the plan year deductible, plan participants must pay an “additional” deductible for each emergency room visit that does not result in hospital admission. An additional deductible will also apply for each admission to a non-QCHP hospital. Additional deductibles are waived for admission to a QCHP hospital or for medically necessary transfers.
Additional deductibles accumulate toward the annual out-of-pocket maximum but do not apply to the plan year deductible.
Coinsurance
After the annual plan year deductible has been met, the plan generally pays most of the cost of services or supplies; but plan participants must pay a percentage, called coinsurance, of eligible charges.
If a member reaches the out-of-pocket maximum for their expenses, the plan pays 100% of all eligible charges. This out-of-pocket maximum protects plan participants from catastrophic medical expenses.
Annual Out-of-Pocket Maximum Expenses
The amounts paid toward deductibles and eligible coinsurance accumulate toward satisfying the annual out-of-pocket maximum.
After the maximum has been met, coinsurance amounts are no longer required, and the plan pays 100% of eligible charges for the remainder of the plan year.
There are two separate out-of-pocket maximums: an In-Network maximum and an Out-of-Network maximum. Coinsurance and deductibles apply toward one or the other, but not both.
Eligible Charges
- QCHP provides benefits for eligible charges for those covered services and supplies which are:
- Medically necessary.
- Based on MRC charges.
Medical Necessity
- QCHP covers charges for services and supplies that are medically necessary. Medically necessary services or supplies are those which are:
- Provided by a hospital, medical facility, or prescribed by a physician or other provider and are required to identify and/or treat an illness or injury.
- Consistent with the symptoms or diagnosis and treatment of the condition (including pregnancy), disease, ailment, or accidental injury.
- Generally accepted in medical practice as necessary and meeting the standards for good medical practice for the diagnosis or treatment of the patient’s condition.
- The most appropriate supply or level of service can be safely provided to the patient.
- Not solely for the convenience of the patient, physician, hospital, or other providers.
- Repeated only as indicated as medically appropriate.
- Not redundant when combined with other treatments being rendered.
Predetermination of Benefits
Predetermination is a method to ensure that medical services/stays will meet medical necessity criteria and be eligible for benefit coverage.
The plan participant’s physician must submit written detailed medical information to the medical plan administrator. For questions regarding a predetermination of benefits, contact the plan administrator.
Precise claim payment amounts can only be determined upon receipt of the itemized bill. Benefits are based on the plan participant’s eligibility and plan provisions in effect at the time services are rendered. Standard claim payment policies include, but are not limited to, multiple procedure reductions and U&C charges. Claim bundling/unbundling procedures will be applied to only services eligible for coverage under the Plan.
Maximum Reimbursable Charge (MRC)
MRC is the maximum amount Aetna will pay an out-of-network health care professional for billed services. The plan participant is responsible for the portion of the expense that is above MRC. Amounts more than MRC are not eligible charges and are not applicable to plan year deductible or out-of-pocket maximum.
IMPORTANT: The percentage of the claim that will be paid is always based on the MRC amount or the actual charge made by the provider, whichever is less.
QCHP Network
The QCHP network includes hospitals and physicians throughout Illinois as well as nationwide. The network is subject to change. QCHP network hospitals provide quality inpatient and outpatient care at reduced rates, which results in savings to plan participants. Costs can be significantly reduced by using a QCHP Network hospital.
Medical Case Management
QCHP has a benefit called the Medical Case Management (MCM) Program. MCM is designed to assist the plan participant requiring complex care in times of serious or prolonged illness.
If a plan participant is confronted with such an illness, a case manager will help find an appropriate treatment to ensure optimum benefits under the plan. Participation in MCM has proven to enhance benefits based on an evaluation of the individual’s needs. MCM is part of the benefits under QCHP. There is no cost to the plan participant for this service.
The referral to the MCM Program is made through either the MCM Administrator, the QCHP Plan Administrator, or by request from a plan participant. The case manager serves as a liaison and facilitator between the patient, family, physician, and other healthcare providers. This case manager is a registered nurse or other health care professional with an extensive clinical background. The case manager can effectively minimize the fragmentation of care so often encountered within the health care delivery system in response to complex cases.
Upon completing the MCM review, the case manager will make a recommendation regarding the treatment setting, the intensity of services, and appropriate alternatives of care.
To reach the MCM Administrator, call the toll-free number listed in the plan administrator section of the current Benefit Choice Options booklet.
Notification Requirements
Notification is the telephone call to the notification administrator informing them of upcoming behavioral health services, surgery, outpatient procedure/therapy/service/supply, or admission to a facility such as a skilled nursing facility.
If using a QCHP network provider, the medical provider is responsible for contacting the notification administrator on behalf of the plan participant.
If using a non-QCHP provider, the plan participant must direct their non-QCHP medical provider to contact the notification administrator to provide specific medical information, setting, and anticipated length of stay to determine medical appropriateness.
Notification is required for all plan participants including those with Medicare or other insurance as the primary payer. Failure to notify the plan within the required time limits will result in a financial penalty and the risk of incurring non-covered charges for services not deemed to be medically necessary.
Benefits for Services Received While Outside the United States
The plan covers eligible charges incurred outside of the United States for generally accepted medically necessary services usually rendered within the United States.
All plan benefits are subject to plan provisions and deductibles. The benefit for facility and professional charges is paid at the non-QCHP rate. Notification is not required for medically necessary services rendered outside of the United States.
Payment for the services will most likely be required from the Member at the time of services. Plan participants must file a claim with the plan administrator for reimbursement. When filing a claim, enclose the itemized bill with a description of the services translated to English and the dollar amount converted to U.S. currency, along with the name of the patient, date of service, diagnosis, procedure code, and the provider’s name, address, and telephone number.
In general, Medicare will not pay for health care obtained outside the United States and its territories. If Medicare is primary, include the Explanation of Medicare Benefits (EOMB) denying payment, along with the claim form, and send to the plan administrator.
QCHP - Claim Filing Deadlines and Procedures
The following procedures and deadlines pertain to the QCHP, Prescription Drug Plan, and Behavioral Health Services. The utilization of network providers usually eliminates the need to file paper claims; however, if an out-of-network provider is utilized the procedures and deadlines must be followed. Contact the appropriate plan administrator with any questions about covered services, benefit levels, or claim payments.
Claim Filing Deadlines
- All Claims must be filed promptly. The plans require that all in-network claims be filed within 90 days of the date in which the charge was incurred; out-of-network claims must be filed within 180 days from the date in which the charge was incurred.
