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BEGIN ENROLLMENTClick Start Here and follow the instructions to make your benefit elections or waivecoverage by the deadline shown on the calendar. If you miss the deadline, you will not beable to make any changes to your benefit elections until the next annual enrollment period.MAKE YOUR ELECTIONSUsing Next, Looks Good, and Back to navigate, review your benefit options as you movethrough the enrollment process.Click Select on the benefit option(s) you would like to choose and which dependent(s) youwould like to cover.Track your benefit elections and costs on each page.REVIEW AND CONFIRM YOUR ELECTIONSReview and edit your personal information, benefit elections, dependent(s), and beneficiary(ies)and Approve your enrollment.Your benefit elections are not complete until you click Approve.To finalize your enrollment, click I Agree.-5-

FINALIZEWhen your enrollment is complete, you will receive a confirmation number and you canalso Print Benefit Summary.Your To Do list will notify you if you have any additional actions needed to complete yourenrollment.REVIEW YOUR BENEFITSClick Benefit Summary on the Home page to review your current benefits elections.CHANGE YOUR BENEFITSOnce approved, your benefit elections will remain in effect until the end of the benefit plan year,unless you have a qualifying life event, such as marriage, divorce, or birth of a child.1. Click Change My Benefits.2. Select Life Event and the event type.3. Review your benefit options and follow the instructions previously outlined to complete yourchanges.**IMPORTANT: You must make changes and provide the required documentation for verificationwithin 63 days of the qualifying life event.CHANGE YOUR BENEFICIARY(IES)1. Click on Change My Benefits2. Select Basic Info and Change of Beneficiary.3. Follow the prompts to complete your change.MyChoiceSM MOBILE APP1. Visit your device’s app store and download the MyChoice Mobileby Businessolver App.2. Visit the Benefitsolver Home page to Get Access Code.3. Activate the app with your access code.(You must use the access code within 20 minutes, or you will need togenerate a new code.)4. Follow the instructions within the mobile app to access to your benefits.-6-

How the Choices Medical Plan WorksWhen a Plan member receives medical servicesfrom an In-Network Provider, the provider willsubmit a claim to the Plan claims administrator forthe member. The Plan claims administrator willprocess the claim and send an Explanation ofBenefits (EOB) to the member and the provider,showing the member’s payment responsibilities(deductible, copayments, and/or coinsurancecosts). The Plan then pays the remaining allowedamount. The provider will not balance bill themember the difference between the billed chargeand the allowed amount.Out-of-Network Providers - Providers whodo not have a contract with the Plan claimsadministrator. You pay 35% of the allowed amount(after a separate deductible) for services receivedfrom an Out-of-Network Provider. Out-of-NetworkProviders may balance bill you for any differencebetween their billed charge and the allowedamount.Emergency Services - Emergency services arecovered everywhere; however, Out-of-NetworkProviders may balance bill the difference betweenthe allowed amount and the billed charge.When a Plan member receives medical servicesfrom an Out-of-Network Provider, the membermust verify if the provider will submit the claimto the Plan claims administrator or if themember must submit the claim. The Plan claimsadministrator will process the claim and sendan EOB to the member showing the member’spayment responsibilities (deductible, coinsurance,and any difference between the allowed amount(balance billing)). The Plan pays the remainingallowed amount. The Out-of-Network Provider maybalance bill the member the difference between thebilled charge and the allowed amount.Deductible - The amount you pay each benefitPlan Year before the Plan begins to pay.Copayment - A fixed dollar amount you pay fora covered service that a member is responsiblefor paying. The Medical Plan pays the remainingallowed amount.Coinsurance - A percentage of the allowed amountfor covered charges you pay, after paying anyapplicable deductible.Out-of-Pocket Maximum - The maximum amount youpay toward the cost of covered health care services.Out-of-Pocket expenses include deductibles,copayments, and coinsurance.Members may self-refer to any health careprovider, however, there is a cost savings formedical services received by an In-NetworkProvider.Definition of TermsIn-Network Providers – Providers who havecontracted with the Plan claims administrator tomanage and deliver care at agreed upon allowedamounts. You pay a 25 copayment for Primary CarePhysician (PCP) office visits and a 40 copaymentfor Specialty provider office visits to In-NetworkProviders (no deductible) and 25% coinsurance (afterdeductible) for most In-Network outpatient/inpatientservices.ImportantVerify the networkstatus of your providers. Thisis an integral cost savingscomponent of each of your planchoices.-7-

Medical Plan (mandatory)FY2023Administered by BlueCross BlueShield of Montana 1-800-820-1674 or 447-8747, bcbsmt.comChoices offers a Medical Plan for Employees and their eligible dependents.Medical Plan Monthly RatesEmployee/Survivor Only 748Employee & SpouseEmployee & Child(ren)/Survivor & Childr(ren 1,075Employee & Family 1,327Sample Medical card 994The employer contribution for FY2023 is 1,054 per month foreligible active employees (applies to pre-tax benefits only).Schedule of Medical BenefitsFY2023Medical Plan CostsDeductibleApplies to all covered services, unless otherwise noted orcopayment is indicated.Copayment (outpatient office visits)Primary Care Physician Visit (PCP)Specialty Provider VisitIn-NetworkOut-of-Network * 750/Person 1,500/FamilySeparate 750/PersonSeparate 1,750/Family 25 copay 40 copayN/AN/A25%35% 4,000/Person 8,000/FamilySeparate 6,000/PersonSeparate 12,000/FamilyCoinsurance Percentage(% of allowed charges member pays)Out-of-Pocket Maximum(Maximum amount paid by member in a Plan Year for coveredservices; includes deductibles, copays and coinsurance)from an Out-of-Network Provider have separate deductibles, % coinsurance, and Out-of-Pocket maximums. An Out-of* ServicesNetwork Provider may balance bill the difference between their billed charge and the allowed amount.-8-

Examples of Medical Costs to Plan and Member - Primary Care Physician Visit(In-Network) Jack’s Plan deductible is 750, coinsurance is 25%, and out-of-pocket max is 4,000.July 1Beginning Plan YearJack pays 25 officevisit copay and100% of allowedamount for lab chargesmore costsPlan paysremainder ofoffice visitJack has not reached his deductibleyet and he visits the doctor and haslab work. He pays 25 for the officevisit and 100% of the allowed amount forcovered lab charges. For example, Jack’sdoctor visit totals 1,000. The office visitis 150 and lab work is 850. The Planallows 100 for the office visit and 400for the lab work. Jack pays 25 for theoffice visit and 400 for the lab work.The Plan pays 75 for the office visitand 0 for the lab work. The In-NetworkProvider writes off 500.June 30End of Plan Yearmore costsPlan paysremainder of officevisit and 75% ofallowed amountJack pays 25office visit copayand 25% of allowedamount for labchargesJack has seen the doctor several times andreaches his 750 deductible. He pays 25for the office visit and 25% of the allowedamount for lab work and the Plan pays theremainder of the office visit 75% of theallowed amount.For example, Jack’sdoctor visit totals 1,000. The office visit is 150 and lab work is 850. The Plan allows 100 for the office visit and 400 for the labwork. Jack pays 25 for the office visit and 100 for the lab work. The Plan pays 75 forthe office visit and 300 for the lab work. TheIn-Network Provider writes off 500.Jack pays0%Plan pays100% allowedamountJack reaches his 4,000 out-ofpocket maximum. Jack has seen his doctoroften and paid 4,000 total (deductible coinsurance copays).The Planpays 100% of the allowed amount forcovered charges for the remainder of thePlan Year. For example, Jack’s doctorvisit totals 1,000. The office visit is 150and lab work is 850. The Plan allows 100 for the office visit and 400 for thelab work. Jack pays 0 and the Plan pays 500. The In-Network Provider writes off 500.(Out-of-Network) Jack’s Plan deductible is 750, coinsurance is 35%, and out-of-pocket max is 6,000.July 1Beginning Plan YearJack pays100%Plan pays0%Jack hasn’t reached his deductibleyet and he visits the doctor. He pays100% of the provider charge. Onlyallowed amounts apply to hisdeductible.For example, theprovider charges 1,000. The Planallowed amount is 500. 500 appliesto Jack’s Out-of-Network deductible.Jack must pay the provider the full 1,000.more costsmore costsJack pays 35% anydifference betweenprovider charge andplan allowed amount.Plan pays65% of allowableJack has seen the doctor several times andreaches his 750 Out-of-Network deductible. Hisplan pays some of the costs of his next visit. He pays35% of the allowed amount and any differencebetween the provider charge and the Planallowed amount. The Plan pays 65% of theallowed amount. For example, the providercharges 1,000. The Plan allowed amount is 500. Jack pays 35% of the allowed amount( 175) the difference between the providercharge and the Plan allowed amount ( 500).Jack’s total responsibility is 675. The Plan pays65% of the allowed amount ( 325).-9-June 30End of Plan YearJack pays anydifference betweenprovider charge andplan allowed amount(balance bill)Plan pays100% ofallowedamountJack reaches his 6,000 out-ofpocket maximum. Jack has seen his doctoroften and paid 6,000 total (deductible coinsurance). The Plan pays 100% ofthe allowed amount for covered chargesfor the remainder of the Plan Year.Jack pays the difference between theprovider charge and the allowed amount.For example, the provider charges 1,000. The Plan allowed amount is 500.Jack pays 500 and the Plan pays 500.

In-NetworkMedical Plan ServicesOut-of-NetworkHospital Inpatient Services Pre-Certification of non-emergency inpatient hospitalization is strongly recommendedRoom and Board Charges25%35%Ancillary Services25%35%Surgical Services25%35%25%25%35%35% 25 copay/visit35%(See Summary Plan Description forsurgeries requiring prior authorization)Hospital Outpatient ServicesOutpatient ServicesOutpatient Surgery Center ServicesPhysician/Professional Provider Services (not listed elsewhere)Primary Care Physician (PCP) Office Visit- Includes Telemedicine and Naturopathic visitsNote: Naturopathic visits are processed In-Network,however, the member may be balance billed the differencebetween the billed charge and the allowed amountSpecialty Provider Office Visit- Includes Telemedicine visits(for office visit only - lab, x-ray &other procedures are subject todeductible/coinsurance) 40 copay/visit(for office visit only - lab, x-ray &other procedures are subject Outpatient Physician ServicesLab/Ancillary/Misc. ChargesEye Exam0%one/Plan Year(preventive or medical)35%one/Plan Year0%/visitSecond Surgical Opinion(for office visit only - lab, x-ray &other procedures are subject todeductible/coinsurance)35% 200 copay/transport 200 copay/transport 250 copay/visit 250 copay/visit25%25% 75 copay/visit 75 copay/visit25%25%Emergency ServicesAmbulance Services forMedical EmergencyEmergency Room Charges(for room charges only - lab, x-ray (for room charges only - lab, x-ray& other procedures are subject to & other procedures are subject todeductible/coinsurance (waived if deductible/coinsurance (waived ifimmediately admitted to hospital)) immediately admitted to hospital))Professional Provider ServicesUrgent Care ServicesFacility/Professional Services(for room charges only - lab, x-ray (for room charges only - lab, x-ray& other procedures are subject to & other procedures are subject b & Diagnostic ServicesReminder:Deductible applies to all covered services unless otherwise indicated or a copay applies. Out-of-Network providerscan balance bill the difference between their billed charge and the allowed amount.- 10 -

Schedule of Medical BenefitsFY2023Medical Plan ServicesIn-NetworkOut-of-Network25%35%Maternity ServicesHospital ServicesPhysician Services(delivery & inpatient)Prenatal Office Visit25%(waived if enrolled in WellBabyProgram within first trimester) 25 copay/visit(waived if enrolled in WellBabyProgram within first trimester)35%35%Preventive ServicesPreventive screenings/immunizations(adult & Well-Child care)Refer to pgs 14 & 15 for listing of In-NetworkPreventive Services covered at 100% of the allowedamount and age recommendations0%(limited to services listed onpgs 14 & 15. Other preventiveservices subject to deductible andcoinsurance)35%25%35%First 4 visits 0 copaythen 25 copay/visit35%Mental Health/Chemical Dependency ServicesInpatient Services(Pre-Certification is recommended)Outpatient Visit(this is a combined max of 4 visits at 0 copay formental health and chemical dependency services)-Includes Telemedicine VisitsRehabilitative Services Physical, Occupational, Speech, Cardiac, Respiratory, Pulmonary, and Massage Therapies;Acupuncture and ChiropracticInpatient Services(Pre-Certification is recommended)25%Max: 30 days/Plan Year35%Max: 30 days/Plan YearOutpatient Services(this is a combined max of 60 visits for all outpatientrehabilitative services)- Includes Telemedicine visits 25 copay/visitMax: 60 visits/Plan Year35%Max: 60 visits/Plan YearNote: Acupuncture & Massage Therapy visits areprocessed In-Network, however, the member may bebalance billed the difference between the billed chargeand the allowed amount.Reminder:Deductible applies to all covered services unless otherwise indicated or a copay applies. Out-of-Network Providersmay balance bill the difference between their billed charge and the allowed amount.- 11-

In-NetworkOut-of-Network 25 copay/visitMax: 30 visits/Plan Year35%Max: 30 visits/Plan Year25%Max: 6 months35%Max: 6 months25%Max: 30 days/Plan Year35%Max: 30 days/Plan YearMedical Plan ServicesExtended Care ServicesHome Health Care Visit(Prior Authorization is recommended)Hospice ServicesSkilled Nursing Facility Services(Prior Authorization is recommended)Miscellaneous ServicesAllergy ShotsDurable Medical Equipment,Prosthetic Appliances & Orthotics(Prior Authorization is recommended foramounts greater than 2,500)Reminder: 40 copay/visit(for office visit onlyif no office visit,deductible & coinsurance waived)25%Max: 200/Plan Year for footorthotics35%35%Max: 200/Plan Year for footorthoticsDeductible applies to all covered services unless otherwise indicated or a copay applies. Out-of-Network Providersmay balance bill the difference between their billed charge and the allowed amount.- 12 -

Schedule of Medical BenefitsMedical Plan ServicesFY2023In-NetworkOut-of-Network0% (no deductible)35%Miscellaneous Services cont.PKU Supplies(Includes treatment & medical foods)Hearing AidsPediatric- 18 years or youngerAdult- 19 years or older(See SPD for benefit details)25%25%Pediatric- 1/ear every 3 yearsAdult- 2,000/ear lifetimemaximumPediatric- 1/ear every 3 yearsAdult- 2,000/ear lifetimemaximumFirst 8 visits 0 copay, then 25 copay/visit35%Note: Hearing Aids are processed In-NetworkDietary/Nutritional Counseling Visit- Includes Telemedicine VisitsObesity Management(Prior Authorization required)TMJ Services(Prior Authorization recommended)25%(must be enrolled in TakeControl program fornon-surgical treatment)25%(surgical treatment only)Organ TransplantsTransplant Services25%(Prior Authorization required)35%35%35%Travel ReimbursementTravel reimbursement for patient only- If services are not available in local area(Prior Authorization required)0%- up to 1,500/Plan Year- up to 5,000/transplant0%- up to 1,500/Plan Year- up to 5,000/transplant(See SPD for travel reimbursement details)MUS Wellness ProgramPreventive Health ScreeningsHealthy Lifestyle Education & Supportsee pg 26WellBaby ProgramTake Control Lifestyle Management ProgramDiabetes, Weight Loss, Tobacco Use,High Cholesterol, High Blood Pressuresee pg 27Virgin Pulse Incentive ProgramReminder:Deductible applies to all covered services unless otherwise indicated or a copay applies. Out-of-Network Providersmay balance bill the difference between their billed charge and the allowed amount.- 13 -

Preventive Services1. What Services are Preventive?The MUS Medical Plan provides preventive care coverage thatcomplies with the federal health care reform law, the Patient Protectionand Affordable Care Act (PPACA). Services designated as preventivecare include: Pine Creek Lake, MTperiodic wellness visitscertain designated screenings for symptom-free or disease-free individuals, anddesignated routine immunizations.Note: When covered preventive care services are provided by In-Network Providers, the services arereimbursed at 100% of the allowed amount, without application of deductible, coinsurance, or copay. Preventivecare services provided by an Out-of-Network Provider have a 35% coinsurance and a separate deductible andOut-of-Pocket maximum. An Out-of-Network Provider may balance bill the difference between their billed chargeand the allowed amount.The PPACA has used specific resources to identify the preventive services that require coverage: U.S. PreventiveServices Task Force (USPSTF) A and B recommendations and the Advisory Committee on Immunization Practices(ACIP) recommendations adopted by the Center for Disease Control (CDC). Guidelines for preventive care forinfants, children, and adolescents, supported by the Health Resources and Services Administration (HRSA),come from two sources: Bright Futures Recommendations for Pediatric Health Care and the Uniform Panel ofthe Secretary’s Advisory Committee on Heritable Disorders in Newborns and Children.U.S. Preventive Services Task Force: uspreventiveservicestaskforce.orgAdvisory Committee on Immunization Practices (ACIP): cdc.gov/vaccines/acip/CDC: cdc.govBright Futures: brightfutures.orgSecretary Advisory Committee: hrsa.gov/about/organization/committees.html2. Important Tips1. Accurate coding for preventive services by your healthcare provider is the key t

A, Bozeman, MT 59717 406-994-3651 MSU - Billings 1500 University Dr., Billings, MT 59101 406-657-2278 MSU - Northern 300 West 11th Street, Havre, MT 59501 406-265-3568 Great Falls College - MSU 2100 16th Ave. S., Great Falls, MT 59405 406-268-3701 UM - Missoula 32 Campus Drive, Lommasson, Room 252, Missoula, MT 59812 406-243-6766