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3500 Detailed Summary of Benefits

Montana Unified School Trust: 3500 0% 3500 HDHP Embedded Plan

Coverage Period: 09/01/2021 - 08/31/2022

Coverage for: Individual + Family | Plan Type: HDHP

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services.3500 Detailed Summary

NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-855-322-4953 or visit www.MUSTbenefits.org. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.

Important Questions
Important Questions Answers Why This Matters:
What is the overall deductible? $3,500 individual / $7,000 family In-Network
$3,500 individual / $7,000 family Out-of-Network		 Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
Are there services covered before you meet your deductible? Yes. Diabetic education, initial accident care, breast pumps, mammograms, and preventive health & well-child are covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services.
What is the out-of-pocket limit for this plan?

$3,500 individual / $7,000 family In-Network
$3,500 individual / $7,000 family Out-of-Network

 The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in the out-of-pocket limit? Premiums, balance-billing charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Will you pay less if you use a network provider? Yes. See www.bcbsmt.com or call 1-855-322-4953 for a list of participating providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral.

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Services
Common Medical Event Services You May Need What You Will Pay
In-Network Provider
(You will pay the least)

What You Will Pay
Out-of-Network Provider
(You will pay the most)

 Limitations, Exceptions, & Other Important Information
If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness No Charge after deductible No Charge after deductible Virtual visits available through MDLIVE: No Charge after deductible.
  Specialist visit No Charge after deductible No Charge after deductible None
  Preventive care/screening/immunization No Charge; deductible does not apply No Charge after deductible You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Coverage for a pap test limited to 1 per plan year. Coverage for colonoscopy limited to 1 every 10 years beginning at age 50.
If you have a test Diagnostic test (x-ray, blood work) No Charge after deductible No Charge after deductible None
  Imaging (CT/PET scans, MRIs) No Charge after deductible No Charge after deductible None
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.MUSTbenefits.org Preferred generic drugs No Charge after deductible No Charge after deductible Covers up to a 30-day supply (retail prescription); 90-day supply (mail order prescription at a plan approved mail order pharmacy); 90-day supply (retail extended supply network pharmacy). Specialty drugs covered up to a 30-day supply.
  Non-preferred generic drugs No Charge after deductible No Charge after deductible Covers up to a 30-day supply (retail prescription); 90-day supply (mail order prescription at a plan approved mail order pharmacy); 90-day supply (retail extended supply network pharmacy). Specialty drugs covered up to a 30-day supply.
  Preferred brand drugs No Charge after deductible No Charge after deductible Covers up to a 30-day supply (retail prescription); 90-day supply (mail order prescription at a plan approved mail order pharmacy); 90-day supply (retail extended supply network pharmacy). Specialty drugs covered up to a 30-day supply.
  Non-preferred brand drugs No Charge after deductible No Charge after deductible Covers up to a 30-day supply (retail prescription); 90-day supply (mail order prescription at a plan approved mail order pharmacy); 90-day supply (retail extended supply network pharmacy). Specialty drugs covered up to a 30-day supply.
  Preferred specialty drugs No Charge after deductible No Charge after deductible Covers up to a 30-day supply (retail prescription); 90-day supply (mail order prescription at a plan approved mail order pharmacy); 90-day supply (retail extended supply network pharmacy). Specialty drugs covered up to a 30-day supply.
  Non-preferred specialty drugs No Charge after deductible No Charge after deductible Covers up to a 30-day supply (retail prescription); 90-day supply (mail order prescription at a plan approved mail order pharmacy); 90-day supply (retail extended supply network pharmacy). Specialty drugs covered up to a 30-day supply.
If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge after deductible No Charge after deductible Preauthorization required.
  Physician/surgeon fees No Charge after deductible No Charge after deductible None
If you need immediate medical attention Emergency room care No Charge after deductible No Charge after deductible The plan pays the first $500 of eligible expenses for accident injuries; deductible waived.
  Emergency medical transportation No Charge after deductible No Charge after deductible None
  Urgent care No Charge after deductible No Charge after deductible None
If you have a hospital stay Facility fee (e.g., hospital room) No Charge after deductible No Charge after deductible Preauthorization required.
  Physician/surgeon fees No Charge after deductible No Charge after deductible None
If you need mental health, behavioral health, or substance abuse services Outpatient services No Charge after deductible No Charge after deductible None.
  Inpatient services No Charge after deductible No Charge after deductible Preauthorization required.
If you are pregnant Childbirth/delivery professional services No Charge after deductible No Charge after deductible Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
  Childbirth/delivery professional services No Charge after deductible No Charge after deductible Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
  Childbirth/delivery facility services No Charge after deductible No Charge after deductible Preauthorization required.
If you need help recovering or have other special health needs Home health care No Charge after deductible No Charge after deductible 180 day combined maximum for home health care and hospice. Preauthorization required.
  Rehabilitation services No Charge after deductible No Charge after deductible Outpatient physical, occupational, speech, and cardiac therapies have a combined 50 visit maximum per benefit period. Inpatient physical, occupational, speech, and cardiac therapies have a combined 60 day maximum per benefit period. Preauthorization required for inpatient therapies.
  Habilitation services No Charge after deductible No Charge after deductible None
  Skilled nursing care No Charge after deductible No Charge after deductible 60 days maximum per benefit period. Preauthorization required.
  Durable medical equipment No Charge after deductible No Charge after deductible None
  Hospice services No Charge after deductible No Charge after deductible 180 day combined maximum for home health care and hospice. Preauthorization required.
If your child needs dental or eye care Children’s eye exam No Charge; deductible does not apply No Charge; deductible does not apply Limited to 1 exam per benefit plan year.
  Children’s glasses Not Covered Not Covered None
  Children’s dental check-up Not Covered Not Covered None

 

Excluded Services & Other Covered Services

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

  • Bariatric Surgery
  • Cosmetic Surgery
  • Dental Care (Adult)
  • Hearing Aids
  • Infertility Treatment
  • Long term care
  • Non-emergency care when traveling outside the U.S.
  • Private-duty nursing
  • Routine foot care

Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)

  • Acupuncture
  • Chiropractic Care
  • Most coverage provided outside the United States. See www.bcbsmt.com.
  • Routine eye care (Adult)
  • Weight loss programs

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the plan at 1-855-322-4953, U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, or Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Does this plan provide Minimum Essential Coverage? Yes
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan meet the Minimum Value Standards? Yes
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-855-322-4953.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-855-322-4953.
Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-855-322-4953.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-855-322-4953.

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Examples of how this plan might cover medical care
Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery)   Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well-controlled condition)   Mia’s Simple Fracture (in-network emergency room visit and follow up care)  
  • The plan’s overall deductible $3,500
  • Specialist copayment 0%
  • Hospital (facility) coinsurance 0%
  • Other coinsurance 0%

This EXAMPLE event includes services like:
Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)

  
  • The plan’s overall deductible $1,500
  • Specialist copayment 0%
  • Hospital (facility) coinsurance 0%
  • Other coinsurance 0%

This EXAMPLE event includes services like:
Primary care physician office visits (including disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)

  
  • The plan’s overall deductible $3,500
  • Specialist copayment 0%
  • Hospital (facility) coinsurance 0%
  • Other coinsurance 0%

This EXAMPLE event includes services like:
Emergency room care (including medical supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)

  
Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800
In this example, Peg would pay:   In this example, Joe would pay:   In this example, Mia would pay:  
Cost Sharing   Cost Sharing   Cost Sharing  
Deductibles $3,500 Deductibles $3,500 Deductibles $2,800
Copayments $0 Copayments $0 Copayments $0
Coinsurance $0 Coinsurance $0 Coinsurance $0
What isn’t covered   What isn’t covered   What isn’t covered  
Limits or exclusions $60 Limits or exclusions $20 Limits or exclusions $0
The total Peg would pay is $3,560 The total Joe would pay is $3,520 The total Mia would pay is

$2,800

 

If you, or someone you are helping, have questions, you have the right to get help and information in your language at no cost. To speak to an interpreter, call the customer service number on the back of your member card. If you are not a member, or don't have a card, call 855-710-6984.

  • (This information is unable to be converted to an ADA compliant version from the original file any further, please review original document if you would like to read this information in another language, other than English.)

Health care coverage is important for everyone.

We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability.

To receive language or communication assistance free of charge, please call us at 855-710-6984.

If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.

Office of Civil Rights Coordinator
300 E. Randolph St.
35th Floor
Chicago, Illinois 60601
Phone: 855-664-7270 (voicemail)
TTY/TDD: 855-661-6965
Fax: 855-661-6960
Email: CivilRightsCoordinator@hcsc.net

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at:

U.S. Dept. of Health & Human Services
200 Independence Avenue SW
Room 509F, HHH Building 1019
Washington, DC 20201
Phone: 800-368-1019
TTY/TDD: 800-537-7697
Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html