Minnesota Health Insurance | Blue Cross HealthPartners Medica Business Family Temporary Insurance Plans

MCHA - Minnesota Comprehensive Health Association

MCHA MN HDHP

Available as of 1/1/2010

MCHA HIGH DEDUCTIBLE HEALTH PLAN

SUMMARY OF BENEFITS

Administered by Medica

Contact info

Download MCHA Application

MCHA Rates

Partial Listing of

Covered Services

In-Network Benefits

These benefits apply when services are provided by network providers or are authorized in advance by MCHA.

Out-Of-Network Benefits**

These benefits apply when services are provided by non-network providers.

MCHA Lifetime Maximum Benefit

$5,000,000

Out-of-Pocket

Individual

Estimated at $3000, or higher, per calendar year for 2010

Maximum

Family

Estimated at $6000, or higher, per calendar year for 2010

Deductible

Individual

Estimated at $3000, or higher, per calendar year for 2010

Family

Estimated at $6000, or higher, per calendar year for 2010

When you receive covered services after the deductible has been satisfied, MCHA pays:

When you receive covered services after deductible has been satisfied, MCHA pays:

Preventive Care Received in

the Physician’s Office or Hospital

· Routine Physical Exams

· Immunizations

· Well Child Care

· Mammograms

· Pap Smears

· Routine Eye Exams

· Allergy Shots

100%

100% The deductible does not apply.

100%

100%*

100%* The deductible does not apply.

100%*

Services Received in the

Physician’s Office

· Office visits for illness or injury

· Lab and X-ray

· Surgical Services

100%

100%*

Services Received in a Hospital

or Surgicenter

· Inpatient Hospital

Facility

Physician

· Outpatient Hospital

Facility

Physician

· Outpatient Lab and X-ray

Facility

Physician

100%

100%*

Urgent or Emergency Care

· Urgent Care Center

· Hospital Emergency Room

· Emergency Ambulance

100%

Emergency Services from

Non-Preferred Providers

100%

Maternity Care Received in the

Physician’s Office or Hospital

· Prenatal Services

· Delivery Services

Physician

Hospital

· Postnatal Services

100% The deductible does not apply.

100%

100%* The deductible does not apply.

100%*

* Coverage is limited to the non-network provider reimbursement amount (as defined in your Policy) after deductible is met.

** If you decide to utilize your Out-of-Network Benefits, you may pay more than you would for In-Network Benefits. The amount you pay could include a deductible amount. In addition, if the amount that your non-network provider bills you is more than the non-network provider reimbursement amount (as defined in your Policy), you are responsible for paying the difference, and such difference will not be applied toward the Out-of-Pocket Maximum.

Partial Listing of

Covered Services

In-Network Benefits

These benefits apply when services are provided by network providers or are authorized in advance by MCHA.

Out-Of-Network Benefits**

These benefits apply when services are provided by non-network providers.

When you receive covered services after the deductible has been satisfied, MCHA pays:

Prescription Medications

Received at a Pharmacy

Up to a 34-day supply per prescription.

Preferred: 100% per prescription unit or refill.

Mental Health Care

· Outpatient Services

· Inpatient Services

Care must be provided by a MCHA-designated mental health provider. You must receive authorization from MCHA's designated mental health provider prior to receiving services.

100%

100%*

Substance Abuse Care

· Outpatient Services

· Inpatient Services

Care must be provided by a MCHA-designated substance abuse provider. You must receive authorization from MCHA's designated substance abuse provider prior to receiving services.

100%

100%*

Rehabilitative Therapy Received

in the Provider’s Office or Hospital

· Physical Therapy

· Occupational Therapy

· Speech Therapy

100%

100%*

Durable Medical Equipment and Prosthetics

100%

100%*

Home Health Care

100%

Chiropractic Care

100%

100%*

Exclusions and Limitations

to Coverage

The following is a list of some of the services and supplies that are excluded from coverage. When you enroll, the Policy you receive will provide a more detailed list of exclusions. Please refer to your Policy for specific information about excluded services or supplies.

Cosmetic services.

Reversal of voluntary sterilization, in vitro fertilization, sperm banking and adoption.

Exams for employment, insurance, administrative proceedings, research or licensure.

Personal convenience items and some non-durable supplies.

A drug, device or medical treatment or procedure that is investigative.

Health services that are not medically necessary.

Custodial supportive care and self-care or self-help training.

Educational classes, programs or seminars.

Services for mental disorders not listed in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders.

Services by persons who are family or of the same legal residence.

Dental procedures, except accident-related dental.

Services prohibited by law or regulation.

Autopsies.

Injuries that occur while on military duty.

Internal feedings except to treat PKU.

Services that are the primary responsibility of a different carrier (including but not limited to worker’s compensation, auto insurance and employer’s liability insurance) shall be subject to coordination of benefits.

Travel, transportation or living expenses.

Recreational therapy.

Vocational and job rehabilitation.

*Coverage is limited to the non-network provider reimbursement amount (as defined in your Policy) after deductible is met.

** If you decide to utilize your Out of-Network Benefits, you may pay more than you would for In-Network Benefits. The amount you pay could include a percentage coinsurance, a fixed dollar copayment and/or deductible amounts. In addition, if the amount that your non-network provider bills you is more than the non-network provider reimbursement amount (as defined in your Policy), you are responsible for paying the difference, and such difference will not be applied toward the Out-of-Pocket Maximum.

Note: This health care plan may not cover all your health care expenses; read your Policy carefully to determine which expenses are covered. This is a benefit summary only, and does not outline all of your benefits. When you enroll with MCHA, you will receive a Policy of Coverage. If there is a discrepancy between information in this summary and your Policy of Coverage, the Policy of Coverage will take precedence in determining your benefits. Contact Customer Service at 1-866-894-8053, 952-992-3190 (Mpls./St. Paul metro area individuals with hearing impairments), or 1-800-841-6753 (outside of Mpls./St. Paul metro area individuals with hearing impairments) for more information or answers to specific questions.

877.800.7340 local 612.991.3546

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