M ississippi State and School Employees Life and …

1 Mississippi State and School Employees '. life and health insurance Plan PLAN DOCUMENT. Revised January 2017. B enefits KNOW. YOUR. Required federal notices are included in the back of this Plan Document. Important Vendor Addresses and Telephone Numbers Blue Cross & Blue Shield of Mississippi (BCBSMS). 3545 Lakeland Drive MEDICAL CLAIMS ADMINISTRATION. Flowood, MS 39232. (800) 709-7881. AHS State Network (AHS). P. O. Box 23070. MEDICAL PROVIDER NETWORK. Jackson, MS 39225-3070. (800) 294-6307. ActiveHealth Management, Inc. (ActiveHealth). MEDICAL/DISEASE MANAGEMENT 4582 Ulster Street Parkway health AND WELLNESS PROMOTION Denver, CO 80327. (866) 939-4721. Prime Therapeutics LLC (Prime). Box 21870. PHARMACY BENEFIT MANAGEMENT. Lehigh Valley, PA 18002-1870. (855) 457-0408. PrimeMail PHARMACY MAIL ORDER PROGRAM Box 650041. Dallas, TX 75265. Prime Specialty Pharmacy SPECIALTY PHARMACY NETWORK.

2 (877) 627-6337. Minnesota life insurance Company, an affiliate of Securian Financial Group 400 Robert Street North life insurance COMPANY. St. Paul, MN 55101-2098. (877) 348-9217. State and School Employees health insurance Management Board c/o Department of Finance and Administration Office of insurance P. O. Box 24208. PLAN SPONSOR Jackson, MS 39225-4208. (601) 359-3411. (866) 586-2781. Plan Tax ID: 64-6000749. Vendor websites can be accessed through: Services of legal process may be made on the agent listed below or the Plan Sponsor. Office of the Attorney General, State of Mississippi P. O. Box 220. Jackson, MS 39205. Table of Contents How the Plan Provider 2. Base Calendar Year Deductible Individual Base 5. Calendar Year Deductible Family Base 6. Coinsurance Base 6. Coinsurance Maximum Individual Base 6. Coinsurance Maximum Family Base 6. Out-of-Pocket Limit Individual Base 7.

3 Out-of-Pocket Limit Family Base 7. Preventive 8. Select Calendar Year Medical Deductible - Individual Select 10. Calendar Year Medical Deductible Family Select 10. Coinsurance - Select 11. Coinsurance Maximum Individual Select 11. Out-of-Pocket Limit - Individual Select 12. Out-of-Pocket Limit Family Select 12. Primary Care Physician (PCP) Office Visit Copayment Select 12. Individual Prescription Drug 12. Prescription Drug Prime Customer 13. 13. Coordination of Benefits .. 13. Formulary / Preferred Drug List (PDL).. 13. Non-formulary/ Non-preferred 14. Generic 14. Vaccine 14. Home Delivery 14. Prior 15. Step 15. Quantity 15. Early 15. Prime Specialty Drug Management 15. Limited Distribution 16. Pseudoephedrine 16. Mississippi State and School Employees ' life and health insurance Plan | Plan Document Page i Covered Ambulance .. 17. Ambulatory Surgical 17. Bariatric Surgical 17.

4 Breastfeeding Support, Supplies and 19. Cardiac Rehabilitation - 19. Chiropractic 19. 19. Dental 19. Diabetic Management 20. Diabetic Self-Management 20. Diagnostic Services - X-rays and Laboratory 20. Dietitian 20. Durable Medical Equipment .. 20. Emergency 21. Emergency Room 21. Home Infusion 21. Hospice 21. Hospital 21. Long Term Acute Care 22. 22. 22. Maternity Management 23. Medical 23. Mental health 23. Nursing Services - Private Duty and Home 23. Occupational 23. Out-of-Network Review 23. Physical 24. Physician 24. Multiple Surgery 24. Prosthetic or Orthotic 24. Pulmonary Rehabilitation 24. Residential Treatment 24. Skilled Nursing 24. Sleep 24. Speech 25. Mississippi State and School Employees ' life and health insurance Plan | Plan Document Page ii Sterilization 25. Substance 25. 25. Temporomandibular Joint Syndrome (TMJ).. 25. Tobacco 25. Transplants.

5 26. Organ Acquisition 26. Travel Expenses Related to Transplant .. 26. Living Donor Coverage .. 26. Travel Outside the United 26. Weight Management 27. Well-Child Care .. 27. Wellness/Preventive Coverage for 27. Wound Vacuum Assisted 27. Limitations and Drugs and medical items not covered under the prescription drug program:.. 31. health insurance Eligibility and Enrollee 32. Dependent 32. Initial Enrollment for New 33. Legacy 33. Horizon 33. Disabled 33. Right to Request 33. Paying for 33. Special Rules When Family Members Are Also 34. Active employee Eligibility and Open Enrollment for Active 35. Open Enrollment for COBRA 35. Special Enrollment Periods Resulting from Loss of 35. Special Enrollment Period as a Result of Gaining a New 35. Transferring Within the 36. Address 36. When Coverage 36. Terminating Dependent 36. Retiree Eligibility and Retiree 37.

6 Mississippi State and School Employees ' life and health insurance Plan | Plan Document Page iii Retiree Enrollment .. 37. Surviving Spouse 37. Surviving Spouse 37. Cost of Retiree/Surviving Spouse 38. Open Enrollment .. 38. Address 38. Special Enrollment Periods Resulting from Loss of 38. Special Enrollment Period as a Result of Gaining a New 38. Right to Request 39. Transferring Dependent 39. Retiree 39. Changes in Enrollment 39. Medical Coverage: Non-Medicare Eligible Retirees, Surviving Spouses and 39. Medical Coverage: Medicare Retirees, Surviving Spouses and Dependents .. 39. Prescription Drug Program - 40. Limitations and 40. Canceling 40. Continuing Coverage Under the Active Military 41. What are COBRA Benefits?.. 41. Who is a Qualified Beneficiary?.. 41. What is a Qualifying Event?.. 41. Disability 43. Cost for COBRA Continuation 43. COBRA Continuation Coverage 43.

7 COBRA Benefits and Premium 43. Dependent Coverage for COBRA 43. Coordination of Medicare 45. Medicare Coordination End-Stage Renal 45. Medical Management and Utilization Notification 46. Certifying a Hospital 46. Certifying Maternity 46. Certifying an Emergency Hospital 47. Notification Requirements for Inpatient Hospital 47. Inpatient Financial 47. Mississippi State and School Employees ' life and health insurance Plan | Plan Document Page iv Notification Requirements for Outpatient Diagnostic 47. Outpatient Financial 47. Noncertification of Medical 47. Retrospective 48. Medical Case 48. Disease Management 48. Clinical Decision Support 48. Pre-Admission and Post-Discharge Call 48. Solid Organ and Bone Marrow/Stem Cell Transplant 49. Claims Verifying Coverage of a 50. How to File a Medical 50. How to File a Prescription Drug 50. Time Limit for Claims 50. A Special Note about Medical 51.

8 Patient Audit 51. General Claims Process 51. Medical 53. Prescription Drug 53. Utilization Review 54. Out-of-Network Review 54. Other 54. General Internal Appeals Process 54. Refund of Overpayments and Refund to the Plan of Overpayment of 56. Subrogation Third Party 56. Subrogation Work 56. General Breach or 58. Covered 58. 58. 58. 58. 58. Network 58. Proof of 58. 58. Mississippi State and School Employees ' life and health insurance Plan | Plan Document Page v Privacy of Protected health Security of Electronic Protected health 60. Group Term life Who Is Eligible?.. 70. Enrolling in life 71. Late 71. How Much Coverage Can An employee Have?.. 71. Cost of Coverage for 71. Accidental Death and Dismemberment 71. Retiring 71. Cost of Coverage for Retired 72. Totally Disabled 72. Naming a 72. Termination of life insurance 73. Portability to a Term life 73. Converting to a Whole life 73.

9 Applying for Benefits During the Conversion 73. Filing a 74. Other State -Sponsored (Alternative) life insurance 74. Who to 75. Required Federal Notice of Election of Exemption from Certain Requirements of the health insurance Portability and Accountability Act (HIPAA)..77. Summary of Benefits - Base Summary of Benefits - Select health insurance Portability and Accountability Act (HIPAA) Notice of Privacy Prescription Drug Coverage and Mississippi State and School Employees ' life and health insurance Plan | Plan Document Page vi Introduction This Plan Document contains the official rules and regulations of the State and School Employees ' life and health insurance Plan (Plan). This Plan Document replaces and supersedes all previously issued Plan Documents, Plan Document Amendments, Summary Plan Descriptions and Master Plan Documents. When there are changes in benefits, a notice explaining the details of the changes will be issued.

10 Notices of changes to the health and life insurance coverage may be included in the Plan's Know Your Benefits newsletter. This Plan Document is a reference guide for questions on life and health benefits. No verbal statements of any person will modify or otherwise affect the benefits or limitations and exclusions of the Plan, nor shall any such statements convey or void any coverage, or increase or reduce any benefits under the Plan. This Plan Document does not create, nor is it intended to provide an employment contract between the State of Mississippi and any employee . Note: Whenever a personal pronoun in the masculine gender is used, it will be deemed to include the feminine unless the context clearly indicates the contrary. As provided by Mississippi law, the State and School Employees health insurance Management Board (Board). is the Plan Sponsor. The Board has the sole legal authority to promulgate rules and regulations governing the operations of the Plan within the confines of the law governing the Plan.