Montana Unified School Trust: 6000 0% 6000 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.
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 | Answers | Why This Matters: |
|---|---|---|
| What is the overall deductible? | $6,000 individual / $12,000 family In-Network $6,000 individual / $12,000 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? | $6,000 individual / $12,000 family In-Network $6,000 individual / $12,000 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 Event | Services You May Need | What You Will Pay In-Network Provider (You will pay the least) |
What You Will Pay |
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 and coinsurance 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 | First 3 visits per plan year not subject to deductible and coinsurance. Subsequent visits $25 copay per visit. |
| 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.
| 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) | |||
|---|---|---|---|---|---|
This EXAMPLE event includes services like: |
This EXAMPLE event includes services like: |
This EXAMPLE event includes services like: |
|||
| 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 | $6,000 | Deductibles | $900 | Deductibles | $1,500 |
| 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 | $6,060 | The total Joe would pay is | $5,420 | 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