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Mississippi State and School Employees’Life and Health Insurance PlanPLAN DOCUMENTRevised January 2017B enefitsKNOWYOURRequired federal notices are included in the back of this Plan Document.
Important Vendor Addresses and Telephone NumbersBlue Cross & Blue Shield of Mississippi (BCBSMS)3545 Lakeland DriveMEDICAL CLAIMS ADMINISTRATIONFlowood, MS 39232(800) 709-7881AHS State Network (AHS)P. O. Box 23070MEDICAL PROVIDER NETWORKJackson, MS 39225-3070(800) 294-6307ActiveHealth Management, Inc. (ActiveHealth)MEDICAL/DISEASE MANAGEMENT4582 Ulster Street ParkwayHEALTH AND WELLNESS PROMOTION Denver, CO 80327(866) 939-4721Prime Therapeutics LLC (Prime)P.O. Box 21870PHARMACY BENEFIT MANAGEMENTLehigh Valley, PA 18002-1870(855) 457-0408PrimeMailPHARMACY MAIL ORDER PROGRAM P.O. Box 650041Dallas, TX 75265Prime Specialty PharmacySPECIALTY PHARMACY NETWORK(877) 627-6337Minnesota Life Insurance Company, an affiliate of Securian Financial Group400 Robert Street NorthLIFE INSURANCE COMPANYSt. Paul, MN 55101-2098(877) 348-9217State and School Employees Health Insurance Management Boardc/o Department of Finance and AdministrationOffice of InsuranceP. O. Box 24208PLAN SPONSORJackson, MS 39225-4208(601) 359-3411(866) 586-2781Plan Tax ID: 64-6000749Vendor websites can be accessed through: http://KnowYourBenefits.dfa.ms.govServices of legal process may be made on the agent listed below or the Plan Sponsor.Office of the Attorney General, State of MississippiP. O. Box 220Jackson, MS 39205
Table of ContentsIntroduction.1How the Plan Works.2Provider Networks. 2Base Coverage.4Calendar Year Deductible – Individual Base Coverage. 5Calendar Year Deductible – Family Base Coverage. 6Coinsurance – Base Coverage. 6Coinsurance Maximum – Individual Base Coverage. 6Coinsurance Maximum – Family Base Coverage. 6Out-of-Pocket Limit – Individual Base Coverage. 7Out-of-Pocket Limit – Family Base Coverage. 7Preventive Medications. 8Select Coverage.9Calendar Year Medical Deductible - Individual Select Coverage. 10Calendar Year Medical Deductible – Family Select Coverage. 10Coinsurance - Select Coverage. 11Coinsurance Maximum – Individual Select Coverage. 11Out-of-Pocket Limit - Individual Select Coverage. 12Out-of-Pocket Limit – Family Select Coverage. 12Primary Care Physician (PCP) Office Visit Copayment–Select Coverage. 12Individual Prescription Drug Deductible. 12Prescription Drug Program.13Prime Customer Service. 13Copayments. 13Coordination of Benefits . 13Formulary / Preferred Drug List (PDL). 13Non-formulary/ Non-preferred Drugs. 14Generic Drugs. 14Vaccine Program. 14Home Delivery Service. 14Prior Authorization. 15Step Therapy. 15Quantity Limits. 15Early Refills. 15Prime Specialty Drug Management Program. 15Limited Distribution Drugs. 16Pseudoephedrine Medications. 16Mississippi State and School Employees' Life and Health Insurance Plan Plan DocumentPage i
Covered Services.17Ambulance . 17Ambulatory Surgical Facility. 17Bariatric Surgical Services. 17Breastfeeding Support, Supplies and Counseling. 19Cardiac Rehabilitation - Outpatient. 19Chiropractic Services. 19Contraceptives. 19Dental Services. 19Diabetic Management Program. 20Diabetic Self-Management Training/Education. 20Diagnostic Services - X-rays and Laboratory Services. 20Dietitian Services. 20Durable Medical Equipment . 20Emergency Care. 21Emergency Room Services. 21Home Infusion Therapy. 21Hospice Care. 21Hospital Services. 21Long Term Acute Care Facility. 22Mastectomy. 22Maternity. 22Maternity Management Program. 23Medical Supplies. 23Mental Health Services. 23Nursing Services - Private Duty and Home Health. 23Occupational Therapy. 23Out-of-Network Review Services. 23Physical Therapy. 24Physician Services. 24Multiple Surgery Procedures. 24Prosthetic or Orthotic Devices. 24Pulmonary Rehabilitation Programs. 24Residential Treatment Facility. 24Skilled Nursing Facility. 24Sleep Disorders. 24Speech Therapy. 25Mississippi State and School Employees' Life and Health Insurance Plan Plan DocumentPage ii
Sterilization Procedures. 25Substance Abuse. 25Telemedicine. 25Temporomandibular Joint Syndrome (TMJ). 25Tobacco Cessation. 25Transplants . 26Organ Acquisition Coverage. 26Travel Expenses Related to Transplant . 26Living Donor Coverage . 26Travel Outside the United States. 26Weight Management Program. 27Well-Child Care . 27Wellness/Preventive Coverage for Adults. 27Wound Vacuum Assisted Closure. 27Limitations and Exclusions.28Drugs and medical items not covered under the prescription drug program:. 31Health Insurance Eligibility and Enrollment.32Enrollee Eligibility. 32Dependent Eligibility. 32Initial Enrollment for New Employees. 33Legacy Employee. 33Horizon Employee. 33Disabled Dependent. 33Right to Request Documentation. 33Paying for Coverage. 33Special Rules When Family Members Are Also Employees. 34Active Employee Eligibility and Coverage.35Open Enrollment for Active Employees. 35Open Enrollment for COBRA Participants. 35Special Enrollment Periods Resulting from Loss of Coverage. 35Special Enrollment Period as a Result of Gaining a New Dependent. 35Transferring Within the Plan. 36Address Changes. 36When Coverage Ends. 36Terminating Dependent Coverage. 36Retiree Eligibility and Coverage.37Retiree Eligibility. 37Mississippi State and School Employees' Life and Health Insurance Plan Plan DocumentPage iii
Retiree Enrollment . 37Surviving Spouse Eligibility. 37Surviving Spouse Enrollment. 37Cost of Retiree/Surviving Spouse Coverage. 38Open Enrollment . 38Address Changes. 38Special Enrollment Periods Resulting from Loss of Coverage. 38Special Enrollment Period as a Result of Gaining a New Dependent. 38Right to Request Documentation. 39Transferring Dependent Coverage. 39Retiree Re-employment. 39Changes in Enrollment Status. 39Medical Coverage: Non-Medicare Eligible Retirees, Surviving Spouses and Dependents. 39Medical Coverage: Medicare Retirees, Surviving Spouses and Dependents . 39Prescription Drug Program - Medicare. 40Limitations and Exclusions. 40Canceling Coverage. 40Continuing Coverage Under the Plan.41Active Military Duty. 41What are COBRA Benefits?. 41Who is a Qualified Beneficiary?. 41What is a Qualifying Event?. 41Disability Extension. 43Cost for COBRA Continuation Coverage. 43COBRA Continuation Coverage Checklist. 43COBRA Benefits and Premium Changes. 43Dependent Coverage for COBRA Participants. 43Coordination of Benefits.44Medicare Coordination. 45Medicare Coordination – End-Stage Renal Disease. 45Medical Management and Utilization Review.46Notification Requirements. 46Certifying a Hospital Admission. 46Certifying Maternity Hospitalization. 46Certifying an Emergency Hospital Admission. 47Notification Requirements for Inpatient Hospital Admissions. 47Inpatient Financial Penalties. 47Mississippi State and School Employees' Life and Health Insurance Plan Plan DocumentPage iv
Notification Requirements for Outpatient Diagnostic Tests. 47Outpatient Financial Penalty. 47Noncertification of Medical Necessity. 47Retrospective Review. 48Medical Case Management. 48Disease Management Program. 48Clinical Decision Support Program. 48Pre-Admission and Post-Discharge Call Services. 48Solid Organ and Bone Marrow/Stem Cell Transplant Services. 49Claims Administration.50Verifying Coverage of a Service. 50How to File a Medical Claim. 50How to File a Prescription Drug Claim. 50Time Limit for Claims Filing. 50A Special Note about Medical Claims. 51Patient Audit Program. 51General Claims Process Information. 51Appeals.53Medical Appeals. 53Prescription Drug Appeals. 53Utilization Review Appeals. 54Out-of-Network Review Appeals. 54Other Complaints. 54General Internal Appeals Process Information. 54Refund of Overpayments and Subrogation.56Refund to the Plan of Overpayment of Benefits. 56Subrogation–Third Party Liability. 56Subrogation–Work Related. 56General Conditions.58Breach or Default. 58Covered Expense. 58Disclosure. 58Formulary. 58Liability. 58Notices. 58Network Agreements. 58Proof of Loss. 58Terms. 58Mississippi State and School Employees' Life and Health Insurance Plan Plan DocumentPage v
Privacy of Protected Health Information.59Security of Electronic Protected Health Information. 60Glossary.61Group Term Life Insurance.69Who Is Eligible?. 70Enrolling in Life Insurance.
Minnesota Life Insurance Company, an affiliate of Securian Financial Group 400 Robert Street North St. Paul, MN 55101-2098 (877) 348-9217 PLAN SPONSOR State and School Employees Health Insurance Management Board c/o Department of Finance and Administration Office of Insurance P. O. Box 24208 Jackson, MS 39225-4208 (601) 359-3411 (866) 586-2781
