2024-2025 Choices Actives Workbook

Active Employee Benefits 2024-2025
Montana University System

MUS Annual Enrollment - April 24, 2024 - May 15, 2024

Visit the MUS Choices home page and click on the applicable campus login button to make your 2024-2025 Choices Annual Enrollment benefit elections in the Benefitsolver online enrollment system.

•      If  you  do  not  complete  the  online  Annual  Enrollment  process  between April 24 – May 15, 2024, you and your covered dependents will automatically be re-enrolled in your current benefit plan(s) and coverage levels.

•      To add an eligible dependent child not currently on your plan during Annual Enrollment, you must make an active election in the Benefitsolver online enrollment system.

•      You must complete the online Annual Enrollment process if you wish to re-elect a: 
                  •      Health Care or Limited Purpose Flexible Spending Account
                  •      Dependent Care (Day Care) Flexible Spending Account
                  •      FSA participants must re-enroll in a HCFSA or LPFSA for any unused FSA contribution amounts in rollover into the next Plan Year ("use it - or - lose it") or they will be forfeited.

Table of Contents

Campus Human Resources/Benefit Office Contacts

How Choices Works

• Choices Enrollment for an Employee
• Who’s Eligible
• How to Enroll

Mandatory Benefits (must choose)

• Medical Plan
• Medical Plan Rates
• Schedule of Medical Plan Benefits
• Preventive Services
• Prescription Drug Plan
• Dental Plans
• Basic Life/Accidental Death & Dismemberment (AD&D) & Long Term Disability Insurance (LTD)

Optional Benefits (voluntary)  

• Vision Hardware Plan
• MUS Wellness Programs
• Employee Assistance Program (EAP)
• Flexible Spending Accounts (FSA)
• Supplemental  Life Insurance
• Supplemental Accidental Death & Dismemberment (AD&D)

Additional Benefit Plan Information

• Dependent Premium Hardship Waiver & Self Audit Award Program
• Summary Plan Description (SPD)
• Summary of Benefits & Coverage (SBC) & HIPAA
• Glossary
• Benefits Worksheet (printable PDF)
• Enrollment Instructions
• Insurance Card Examples
• Resources

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Questions?

If you have questions about your benefits or enrolling in the Benefitsolver online enrollment system, please review enrollment instructions or contact your campus Benefits Representative directly.

Campus Human Resources/Benefits Office Contacts

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Choices Enrollment for an Employee

Benefit Plan Year July 1 - June 30

This workbook is your guide to Choices – the Montana University System’s employee benefits program (MUS Plan) that lets you match your benefits to your individual and family situation. To get the most out of this opportunity to design your own benefits package, you need to consider your benefit needs, compare them to the options available under Choices, and enroll for the benefits you have chosen. Please read the information in this workbook carefully. This enrollment workbook is not a guarantee of benefits.

Who’s Eligible:

1. Permanent faculty or professional staff members regularly scheduled to work at least 20 hours per week
   or 40 hours over two weeks for a continuous period of more than six months in a 12-month period.
2. Temporary faculty or professional staff members scheduled to work at least 20 hours per week or 40
   hours over two weeks for a continuous period of more than six months in a 12-month period, or who do so regardless of schedule.
3. Seasonal faculty or professional staff members regularly scheduled to work at least 20 hours per week
   or 40 hours over two weeks for a continuous period of more than six months in a 12-month period, or who do so regardless of schedule.
4. Academic or professional employees with an individual contract under the authority of the Board of Regents which provides for eligibility under one of the above requirements.

Note:  Student employees who occupy positions designated as student positions by a campus are not eligible to join the MUS Group Benefits Plan.

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Waiver of Coverage:

You have the option to waive benefits coverage with the MUS Group Benefits Plan. To waive coverage, you must actively elect to waive coverage in the online enrollment system by your enrollment deadline, verifying you are waiving coverage. If you do not actively elect to waive coverage, current coverages will continue (existing employees) or you will be defaulted into coverage (new employees) as outlined below. The cost of default coverage will be within the employer contribution amount.

Please note, there is no continuing or default coverage for Flexible Spending Accounts (FSAs), as these accounts must be actively elected each benefit Plan Year.

If you waive coverage, all of the following will apply:

• You waive coverage for yourself and all eligible dependents.
• You waive all mandatory and optional Choices coverages, including Medical, Dental, Rx, Vision Hardware, Basic Life/Accidental Death and Dismemberment (AD&D), Long Term Disability (LTD), supplemental Life/AD&D, and Flexible Spending Accounts.
• You forfeit the monthly employer contribution toward benefits coverage.
• Your eligible dependent children cannot enroll unless they have a qualifying event or until the next Annual Enrollment period.
• Your legal spouse cannot be enrolled in the Medical or Dental Plans unless they have a qualifying event.
• If you are enrolling after previously waiving coverage, you will only be allowed to enroll in the lowest
  benefit plan options available.

If you default coverage, your coverage will be defaulted to Employee only coverage and will consist of: 

• Employee Only – Medical Plan 
• Employee Only – Basic Dental Plan 
• Basic Life/AD&D – Option 1 ($15,000) 
• Long Term Disability (LTD) - Option 1 (60% of pay/180-day waiting period)

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How to Enroll:

1. New benefits eligible employees have the option of enrolling themselves and any eligible dependents, or waiving all coverages, during a 30-day initial enrollment period, that begins the day following the date of hire or the date of benefits eligibility under the Plan. 
2. Employees may make benefit changes from among the benefit plan options during Annual Enrollment each benefit Plan Year or within 63 days of a qualifying event (30 days for a death or divorce qualifying event) based on Plan rules.
3. Each benefit option in Choices has a monthly cost associated with it.  These costs are shown in the online benefits enrollment system and in the Medical Plan section below.
   
   

   Mandatory (must choose or waive):

   • Medical Plan
   • Prescription Drug Plan (included in Medical)
   • Dental Plans
   • Basic Life and AD&D Insurance
   • Long Term Disability

   Optional (voluntary):

   • Vision Hardware Plan
   • Flexible Spending Accounts
   • Supplemental Life Insurance
   • Supplemental AD&D Insurance
4. Employees make their benefit elections online in the Benefitsolver online enrollment system.  The online benefits enrollment system will step you through your coverage options and monthly costs.  For more information, view Instructions on how to log in and navigate the online Benefitsolver enrollment system.
5. Select the applicable campus login button to enroll.  
   Company Key:  musbenefits
   
   

   If the benefits you choose cost . . .

   • The same or less than the employer contribution, you will not see any change in your paycheck.
   • More than the employer contribution, you will pay the difference through automatic payroll deductions.

Your annual Choicesbenefit elections remain in effect for the entire benefit Plan Year (July 1 – June 30) following enrollment or unless you have a change in status (qualifying event). 

Enrolling Family Members:

MUS has Closed Enrollment for a legal spouse, unless there is a qualifying event.

Eligible children under the age of 26 may be added during the Annual Enrollment period or if there is a qualifying event.

If you are a new employee, you may enroll your eligible dependents for benefits, including Medical, Dental, Vision Hardware, and supplemental life/AD&D insurance coverage.

Eligible family members include your:

Legal spouse:  Legally married or certified common-law married spouses, as defined under Montana law, will be eligible for enrollment as a dependent on the MUS Plan.  Only legally married or common-law spouses with a certified affidavit of common-law marriage will be eligible for enrollment on the Plan during the employee’s initial enrollment period or within 63 days of a qualifying event.

Eligible dependent children under age 26*:  Children include your natural children, step-children, and children placed in your home for adoption before age 18 or for whom you have court-ordered legal custody or court-ordered legal guardianship.

*Coverage may continue past age 26 for an eligible unmarried dependent child who is mentally or physically disabled and incapable of self-support and is currently covered on the MUS Plan.  Eligibility is subject to review each benefit Plan Year.

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Qualifying Events*

• Marriage
• Birth or adoption of a child
• Death or Divorce
• Loss of eligibility for other health insurance coverage - voluntarily canceling other health insurance does not constitute loss of eligibility

Documentation to support the change is required.

Qualifying events may allow limited benefit changes.

Questions?  If you have questions about enrolling in the Benefitsolver online benefits enrollment system, please contact your campus Benefits Representative.  If you have specific questions about qualifying events, please contact your campus Benefits Representative or consult the Summary Plan Description (SPD).

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How the Choices Medical Plan Works

When a Plan member receives covered medical services from an In-Network Provider, the provider will submit a claim to the Plan claims administrator for the member. The Plan claims administrator will process the claim and send an Explanation of Benefits (EOB) to the member and the provider, showing the member’s payment responsibility (deductible, copayments, and/or coinsurance costs). The Plan then pays the remaining allowed amount for covered services. The provider will not balance bill the member the difference between the billed charge and the allowed amount for covered services.

When a Plan member receives covered medical services from an Out-of-Network Provider, the member must verify if the provider will submit the claim to the Plan claims administrator or if the member must submit the claim. The Plan claims administrator will process the claim and send an EOB to the member showing the member’s payment responsibility (deductible, coinsurance, and any difference between the allowed amount (balance billing)). The Plan pays the remaining allowed amount for covered services. The Out-of-Network Provider may balance bill the member the difference between the billed charge and the allowed amount.

Members may self-refer to any health care provider, however, there is a cost savings for covered medical services received by an In-Network Provider.

Definition of Terms

In-Network Providers – Providers who have contracted with the Plan claims administrator to manage and deliver care at agreed upon allowed amounts. You pay a $25 copayment for Primary Care Physician (PCP) office visits and a $40 copayment for Specialist office visits to In-Network Providers (no deductible) and 25% coinsurance (after deductible) for covered In-Network outpatient/inpatient services.

Out-of-Network Providers - Providers who do not have a contract with the Plan claims administrator. You pay 35% of the allowed amount (after a separate deductible) for covered services received from an Out-of-Network Provider. Out-of-Network Providers may balance bill you for any difference between their billed charge and the allowed amount for covered services.

Emergency Services –  Emergency services are covered everywhere; however, Out-of-Network Providers may balance bill the difference between the allowed amount and the billed charge for covered services.

Deductible – The amount you pay each benefit Plan Year before the Plan begins to pay for covered services.

Copayment  - A fixed dollar amount the member pays for a covered service, usually at the time the member receives the service.  The Plan pays the remaining allowed amount for covered services.  

Coinsurance – A percentage of the allowed amount for covered services you pay, after paying any applicable deductible.

Out-of-Pocket Maximum - The maximum amount you pay toward the cost of covered services. Out-of-Pocket expenses for covered services include deductibles, copayments, and coinsurance.

Important:  Verify the network status of your providers.  This is an integral cost savings component of each of your plan choices.

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Medical Plan (mandatory)

Administered by

BlueCross BlueShield of Montana

1-800-820-1674 or 1-406-447-8747

Choices offers a Medical Plan for Employees and their eligible dependents.

The employer contribution for FY2025 is $1,054 per month for benefits eligible employees (applies to pre-tax benefits only).

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Schedule of Medical Benefits

*Services from an Out-of-Network Provider have separate deductibles, % coinsurance, and Out-of-Pocket maximums.

An Out-of-Network Provider may balance bill the difference between their billed charge and the allowed amount for covered services.

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Examples of Medical Costs to Plan and Member - Primary Care Physician Visit

Benefit Plan Year July 1 – June 30

(In-Network)

Jack’s Plan deductible is $750, coinsurance is 25%, and out-of-pocket max is $4,000.

Jack has not reached his deductible yet and he visits the doctor and has lab work. He pays $25 for the office visit and 100% of the allowed amount for covered lab charges. For example, Jack’s doctor 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 lab work. Jack pays $25 for the office visit and $400 for the lab work. The Plan pays $75 for the office visit and $0 for the lab work. The In-Network Provider writes off $500.

Jack has seen the doctor several times and reaches his $750 deductible. He pays $25 for the office visit and 25% of the allowed amount for lab work and the Plan pays the remainder of the office visit + 75% of the allowed amount. For example, Jack’s doctor 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 lab work. Jack pays $25 for the office visit and $100 for the lab work. The Plan pays $75 for the office visit and $300 for the lab work. The In-Network Provider writes off $500.

Jack reaches his $4,000 out-of-pocket maximum. Jack has seen his doctor often and paid $4,000 total (deductible + coinsurance + copays). The Plan pays 100% of the allowed amount for covered service for the remainder of the Plan Year. For example, Jack’s doctor 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 lab 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.

Jack hasn’t reached his deductible yet and he visits the doctor.  He pays 100% of the provider charge.  Only allowed amounts apply to his deductible.  For example, the provider charges $1,000.  The Plan allowed amount is $500.  $500 applies to Jack’s Out-of-Network deductible.  Jack must pay the provider the full $1,000.

Jack has seen the doctor several times and reaches his $750 Out-of-Network deductible.  His plan pays some of the costs of his next visit.  He pays 35% of the allowed amount and any difference between the provider charge and the Plan allowed amount.  The Plan pays 65% of the allowed amount.  For example, the provider charges $1,000.  The Plan allowed amount is $500.  Jack pays 35% of the allowed amount ($175) + the difference between the provider charge and the Plan allowed amount ($500).  Jack’s total responsibility is $675.  The Plan pays 65% of the allowed amount ($325).

Jack reaches his $6,000 out-of-pocket maximum.  Jack has seen his doctor often and paid $6,000 total (deductible + coinsurance).  The Plan pays 100% of the allowed amount for covered services for the remainder of the Plan Year.  Jack pays the difference between the provider 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.

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Reminder:
Deductible applies to all covered services unless otherwise indicated or a copay applies.  Out-of-Network Providers may balance bill the difference between their billed charge and the allowed amount for covered services.    

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Preventive Services

1. What Services are Preventive?

The MUS Medical Plan provides preventive care coverage that complies with the federal health care reform law, the Patient Protection and Affordable Care Act (PPACA). Services designated as preventive care include:

• covered periodic wellness visits,
• covered certain designated screenings for symptom-free or disease-free individuals, and
• covered designated routine immunizations.  

Note: When covered preventive care services are provided by In-Network Providers, the services are reimbursed at 100% of the allowed amount, without application of deductible, coinsurance, or copay. Preventive care services provided by an Out-of-Network Provider have a separate deductible, 35% coinsurance, and Out-of-Pocket maximum. An Out-of-Network Provider may balance bill the difference between their billed charge and the allowed amount.

The PPACA has used specific resources to identify the preventive services that require coverage:  U.S. Preventive Services Task Force (USPSTF) A and B recommendations and the Advisory Committee on Immunization Practices (ACIP) recommendations adopted by the Centers for Disease Control (CDC).  Guidelines for preventive care for infants, 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 of the Secretary’s Advisory Committee on Heritable Disorders in Newborns and Children.

U.S. Preventive Services Task Force

Advisory Committee  on Immunization Practices (ACIP)

CDC

Bright Futures

Secretary Advisory Committee

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2. Important Tips

1. Accurate coding for preventive services by your health care provider is the key to accurate reimbursement by the Medical Plan.  All standard correct medical coding practices should be observed.
2. Also of importance is the difference between a “screening” test and a diagnostic, monitoring, or surveillance test.  A “screening” test done on an asymptomatic person is a preventive service and is considered preventive even if the test results are positive for disease, but future tests would be diagnostic, for monitoring the disease or the risk factors for the disease.  A test done because symptoms of disease are present is not a preventive screening and is considered diagnostic.
3. Ancillary services directly associated with a “screening” colonoscopy are also considered preventive services. Therefore, the evaluation office visit with the doctor performing the colonoscopy, the colonoscopy procedure, the ambulatory facility fee, anesthesiology (if necessary), and pathology will be reimbursed as preventive, provided they are submitted with accurate preventive coding.

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Covered Preventive Services

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Prescription Drug Plan (included in Medical Plan)

Administered by Navitus Health Solutions.

Who is eligible?

All MUS Medical Plan enrollees and their eligible dependents will automatically be enrolled in the Navitus Health Solutions Prescription Drug Plan (PDP) Commercial Plan coverage. There is no separate premium and no deductible for prescription drugs.

How do I access my PDP information?

To access more information about the Navitus PDPs, including the MUS-specific participating network pharmacy directory and the complete prescription drug formulary (preferred drug list), you will need to register on the Navitus Member Portal. If you have questions regarding the drug formulary or pharmacy directory, contact Navitus Customer Care.

To determine your MUS PDP drug tier level and copay amount before going to the pharmacy, consult the Drug Schedule of Benefits, log into the Navitus Member Portal, or contact Navitus Customer Care.

How do I fill my prescriptions?

Prescription drugs may be obtained through the Plan at either a local retail pharmacy (up to a 34 or 90-day supply) or through a mail order pharmacy (90-day supply). Members who use maintenance medications can experience a significant cost-savings when filling their prescriptions for a 90-day supply.

Retail Pharmacy Network

NOTE: CVS/ Target pharmacies are not part of the MUS PDP participating pharmacy network. If you choose to use these pharmacies, you will be responsible for all charges.

Mail Order Pharmacies

Ridgeway and Costco Pharmacies administer the mail order pharmacy program.

Specialty Pharmacy

The preferred Specialty Pharmacy is Lumicera Health Services.  Lumicera helps members who are taking prescription drugs that require special handling and/or administration to treat certain chronic illnesses or complex conditions by providing services that offer convenience and support.  Ordering prescriptions with the specialty pharmacy is simple, contact Patient Customer Care.

You can access the Lumicera specialty pharmacy Frequently Asked Questions (FAQs).

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Questions:

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Dental Plan (mandatory)

Administered by

Delta Dental
1-866-579-5717

Choices offers Employees and their eligible dependents two Dental plan options to choose from: Basic Plan or Select Plan.

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Select Plan Benefit Highlights:

Diagnostic & Preventive Services

The Choices Select Plan allows MUS Plan members to obtain diagnostic & preventive services without those costs applying to the annual $2,000 maximum.

Orthodontic Benefits

The Choices Select Plan provides a $1,500 lifetime orthodontic benefit per covered individual.  Benefits are paid at 50% of the allowed amount for covered services.  Treatment plans usually include an initial down payment and ongoing monthly fees.  If an initial down payment is required, the Plan will pay up to 50% of the initial payment, up to 1/3 of the total treatment charge.  In addition, Delta Dental will establish a monthly reimbursement based on your provider’s monthly fee and your prescribed treatment plan.

Dental Fee Schedule

MUS dental claims are reimbursed based on a fixed dental fee schedule.  The following subsets of the Select Plan and Basic Plan fee schedules include the most common used procedure codes.  Please note the Basic Plan provides coverage for a limited range of services, including diagnostic and preventive treatment.

The fee schedule’s fixed dollar amount is the maximum reimbursement amount paid by the Plan for the specified procedure code, regardless of provider network. Covered Dental Plan enrollees are responsible for the difference (if any) between the provider’s billed charge and the fee schedule‘s reimbursement amount.  Blue shaded codes are for the Basic Plan ONLY.  All Codes (shaded and non-shaded) are for the Select Plan.

Dental Plan enrollees have the freedom of choice to visit any licensed dentist, however, Out-of-Pocket costs may be reduced if seeing a Delta Dental Premier or PPO network dentist.

The dental procedure codes and nomenclature are copyright of the American Dental Association. The procedures described and maximum reimbursement amounts indicated in the fee schedule are subject to the terms of the MUS-Delta Dental contract and Delta Dental processing policies. These allowances may be further reduced due to maximums, limitations, and exclusions.

Please refer to the SPD for complete benefit and fee schedule information.

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Basic Life/AD&D Insurance & Long Term Disability (mandatory)

Administered by
Standard Life Insurance
1-800-759-8702

Basic Life/AD&D Insurance:

This is an Employee only benefit.

Basic life insurance coverage under Choices  helps provide financial protection by paying benefits to your in the event of your death while coverage is in effect.  Accidental Death & Dismemberment (AD&D) insurance coverage under Choices provides protection by paying benefits to you and your beneficiaries in the event of your death or dismemberment as the result of an accident. Choices offers three Basic Life/AD&D plan options to choose from.

No evidence of insurability is required.

Basic Life/AD&D Options & Monthly Rates

Option 1       $15,000          $1.28 for both

Option 2       $30,000          $2.56 for both

Option 3       $48,000          $4.08  for both

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Long Term Disability:

This is an Employee only benefit.

Long Term Disability (LTD) coverage can help protect your income in the event you become disabled and unable to work due to a covered illness or injury.  Choices includes three LTD plan options designed to replace a portion of your income and supplement other sources of disability income that may be available to you.  The three LTD plan options differ in the amount of your earnings they replace, when benefits become payable, and monthly premium costs.

Long Term Disability Options & Monthly Rates

Option 1      60% of pay/180 day waiting period          $5.40

Option 2      66 2/3% of pay/180 day waiting period    $10.78

Option 3      66 2/3% of pay/120 day waiting period    $13.46

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Benefit Amount:

The monthly benefit amount is the % of your pre-disability earnings option you elected, to a maximum benefit of $9,200 per month.  The minimum monthly benefit is the greater of $100 or 10% of your LTD benefit reduced by deductible income.

Benefit Duration:

If you become disabled and your claim LTD benefit is approved, LTD benefits are payable after you have been continuously disabled for the waiting period option you elected and you remain continuously disabled.  LTD benefits are not payable durin the waiting period.

Employees increasing coverage one level during Annual Enrollment or due to a qualifying event will be subject to a pre-existing condition exclusion for disabilities occuring during the first 12 months that the increase in coverage is effective.  Any coverage existing for at least 12 months prior to the increase will not be subject to the pre-existing condition exclusion.

Employees on a leave status may not be eligible for LTD coverage.  Please consult with your campus Benefits Representative.

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Do you have other Disability Income?

The level of LTD coverage you select ensures that you will continue to receive a percentage of your base pay each month if you become totally disabled.

Some of the money you receive may come from other sources, such as Social Security, Workers’ Compensation, or other group disability benefits.  Your Choices LTD benefit will be offset by any amounts you receive from these sources. The total combined income will equal the benefit level you selected.

The following applies to both Basic Life/AD&D Insurance and Long Term Disability

• A new employee may elect any coverage during initial enrollment without submitting evidence of insurability.
• If an employee previously waived all coverages, they may only enroll in coverage Option 1.
• An employee may increase coverage one level or decrease coverage to any level during Annual Enrollment.
• An employee may increase or decrease coverage one level if the change is consistent with the event (i.e., marriage, coverage can be increased one level; divorce, coverage can be decreased one level).

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Vision Hardware Plan (optional)

Administered by
BlueCross BlueShield of Montana
1-800-820-1674  or 1-406-447-8747

Choices offers a Vision Hardware Plan for Employees and their eligible dependents.

Using Your Vision Hardware Plan Benefit

Quality vision care is important to your eye wellness and overall health care.  Visiting your vision provider, purchase your hardware, and submit your claim to BlueCross BlueShield of Montana (BCBSMT) for processing. The optional Vision Hardware Plan coverage is for hardware only.  Eye Exams, whether preventive or medical, are covered under the Medical Plan (see Eye Exam (preventive & medical)).  Please refer to the SPD for complete Vision Hardware Plan benefits, limitations, and exclusions.

Monthly Vision Hardware Plan Rates
Employee/Survivor Only                          $10.70

Employee & Spouse                                 $20.20

Employee/Survivor & Child(ren)            $21.26

Employee & Family                                  $31.18

*Prescription contact lenses that are required to treat medical or abnormal visual conditions, including but not limited to eye surgery (i.e., cataract removal), when visual acuity cannot be corrected to 20/70 in the better eye with eyeglasses, and certain corneal or other eye diseases (i.e., anisometropia, high ametropia, and keratoconus).

Filing a claim: 

The Plan member may be responsible for vision hardware charges at the time of purchase.  If the Provider does not bill for vision hardware purchases, the Provider should provide the Plan member with a walk-out statement that can be submitted to BCBSMT for reimbursement, along with a BCBSMT Claim Form.

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MUS Wellness Program (optional)

The MUS Plan offers Wellness programs to covered Choices Medical Plan enrollees over the age of 18.

Wellness Health Screenings

WellChecks:  

Each campus location offers two free wellness health screenings (WellChecks) per Plan Year (July 1 - June 30). A free basic blood panel and biometric screening are provided at WellCheck, with additional optional tests available at discounted prices. MUS Wellness staff are present at most WellChecks to answer wellness related questions. Visit Wellness WellCheck for more information.

Online Registration:

Online registration is required for all participants for WellCheck appointments.  Register with It Starts With Me.

Lab Tests:

Log on to your It Starts With Me account for a complete listing of tests available at WellCheck.

Flu Shots:  

Flu shots are offered FREE in the fall, subject to national vaccine availability.  Visit Wellness WellCheck for more information.

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Healthy Lifestyle Education & Support

Quick Help Program:

If you have a quick question regarding health, fitness, or nutrition related topics, send us an email at:  wellness@montana.edu.  We will do our best to provide the information you need or point you in the right direction if we don’t have an answer ourselves!

The information given through the Quick Help Program does not provide medical advice, is intended for general educational purposes only, and does not always address individual circumstances.  

WellBaby Program:

WellBaby is a pregnancy benefit designed to help you achieve a healthier pregnancy.  Enroll during your first trimester to take advantage of all of the program benefits, including copay/coinsurance waivers.  For more information call 406-660-0082 or visit WellBaby.

Stay Connected
For education and updates visit our Blog
Visit the MUS Wellness Website

Wellness Incentive Program:

Brought to you by

VirginPulse

Employees and their legal spouses who are covered on the Choices Medical Plan are eligible to participate in the Virgin Pulse Wellness Incentive Program!

Build healthy habits, have fun with family, friends, and coworkers and experience the lifelong rewards of better wellbeing. Earn Pulse Cash by participating in wellness challenges and redeem for items in the Virgin Pulse Store.

Ready to get started?  Visit VirginPulse to join.

Already registered? Visit the VirginPulse Member page.

For more information about the MUS Wellness incentive program, contact the MUS Wellness office at 406-994-6111

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Take Control Lifestyle Management Program

Take Control is a health coaching program that believes living well is within everyone’s reach.  Take Control offers comprehensive and confidential education and support for the medical conditions listed below. Their unique and convenient telephonic delivery method allows Plan members to participate from anywhere and receive individual attention specific to each Plan member’s needs. Plan members with any of the following conditions may enroll:

Diabetes:  Type I, Type II, Pre-diabetes, or Gestational (Fasting GLUC > 125)
Weight Loss:  High Body Mass Index (BMI > 24.99)
High Blood Pressure:  (Hypertension) (Systolic > 140 or Diastolic > 90)
High Cholesterol:  (Hyperlipidemia) (CHOL > 240 or TRIG > 200 or LDL > 150 or HDL < 40M/50F)
WellBaby participants can join Take Control as part of the WellBaby program 

Services include monthly health coaching and healthy lifestyle resources.

Benefits Pre-Authorized by your Health Coach may include:

• Visit with an In-Network primary care provider ($0 copay)
• Sleep study (deductible/coinsurance waived),
• Additional counseling visits ($0 copay).
• Copay waivers for diabetic supplies.

For more information, visit MUS Take Control, contact Take Control at 1-800-746-2970 or visit Take Control MT.

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Employee Assistance Program (EAP)

The Employee Assistance Program, offered by the Montana University System, provides all MUS employees and their household members with confidential advice, counseling, support, referrals, and practical solutions to real-life issues. Deer Oaks EAP Services are available at any time and can assist with work-related concerns, personal problems, and other issues affecting your well-being.

For more information about the MUS EAP program and how to access these services for you and your household members, please visit EAP & Work-Life Services.

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Flexible Spending Accounts (optional)

Administered by
HealthEquity/WageWorks
1-877-WageWorks (1-877-924-3967)

This is an Employee only benefit.

Choices offers three Flexible Spending Accounts (FSA). These reimbursement accounts (FSAs) can work to your advantage by allowing an employee to set aside contributions out of each paycheck (pre-tax), in equal installments throughout the Plan Year (July 1 – June 30), to pay for qualified Out-of-Pocket expenses for health care and dependent care (day care).

No Automatic Enrollment: You must re-enroll each benefit Plan Year to participate in a FSA (no exceptions will be made for late enrollment).

FSA Changes for FY25 (July 1, 2024 – June 30, 2025)

• The HCFSA/LPFSA maximum contribution amount has increased to $3,200.
• HCFSA/LPFSA participants may rollover up to $640 in unused funds from FY25 (July 1, 2024 - June 30, 2025) only if an FSA is elected for FY26 (July 1, 2025 - June 30, 2026).
• FSA participants must re-enroll in a HCFSA/LPFSA for any unused FSA contribution amounts to rollover into the next Plan Year ("use it - or - lose it") or they will be forfeited.

If you enroll in an FSA during your initial enrollment, your account(s) becomes effective the first day of the month following your date of hire. If you enroll in a FSA during Annual Enrollment, your account(s) becomes effective July 1st. FSA funds may only be used for expenses incurred on or after your FSA effective date through the remaining benefit Plan Year.

When you enroll in a FSA, you are electing to participate for the entire benefit Plan Year (July 1 – June 30). No changes to your FSA election may be made during the benefit Plan Year, unless you experience a qualifying event. Changes must be consistent with the change in status or qualifying event, subject to Plan restrictions..

The amount you elect for your FSA expenses are not subject to federal, state, Social Security, or Medicare taxes. You can access tax savings FSA calculators for accurate savings estimates.

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Health Care Flexible Spending Account (HCFSA)

A HCFSA allows you to set aside contributions (pre-tax) to pay for medical, dental, vision, or Rx expenses which are not fully covered by the group health plan. The HCFSA allows you to be reimbursed for eligible expenses incurred by you and/or your dependents during the benefit Plan Year. Expenses are considered “incurred” on the date the service was rendered, not the date the expense is paid.  HCFSA expenses which are eligible for reimbursement include those defined by IRS Code, Section 213(d).

Visit HealthEquity/WageWorks for a comprehensive list of qualified HCFSA healthcare expenses, including a list of expenses that may require a letter of Medical Necessity or a prescription from your provider.

NOTE: If you or your legal spouse contribute to a Health Savings Account (HSA), you are not eligible to participate in a HCFSA; however, you may enroll in a Limited Purpose Flexible Spending Account (LPFSA) (see below).

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Limited Purpose Flexible Spending Account (LPFSA)

The LPFSA guidelines are the same as the HCFSA, with the exception of eligible expenses.  The LPFSA eligible expenses only include dental and vision expenses.

Visit HealthEquity/WageWorks for a comprehensive list of qualified LPFSA dental and vision expenses.

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HCFSA/LPFSA Rollover Funds:

The IRS permits HCFSA/LPFSAs to rollover a limited amount of unused FSA contributions from one benefit Plan Year to the next. This means that HCFSA/LPFSA balances from the current Plan Year, can be rolled over to the next benefit Plan Year, which begins July 1 and runs through June 30.

Be sure not to elect more than you will need to cover expenses incurred by you and/or your dependents during the benefit Plan Year. Any amounts over the rollover maximum not used by the end of the benefit Plan Year will be forfeited.

Under the "use it - or - lose it" rule, you must re-enroll in a HCFSA/LPFSA for any unused contribution amounts to rollover to the next Plan Year or they will be forfeited.

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Dependent Care (Day Care) Flexible Spending Account (DCFSA)

The DCFSA (day care) is not used for reimbursement of health care expenses.

The DCFSA allows you to set aside contributions (pre-tax) to pay for qualified dependent day care expenses for children under age 14, or individuals unable to care for themselves. If both you and your legal spouse work or you are a single parent, you may have dependent day care expenses. A dependent receiving day care must live in your home at least eight (8) hours per day. The day care must be necessary for you and your legal spouse to remain gainfully employed. Day care must be provided through live-in care, babysitters, licensed day care/preschool centers, and after school care. You cannot use pre-tax dollars to pay your legal spouse or one of your children under the age of nineteen (19) for providing day care. Schooling expenses at the kindergarten level and above, overnight camps, and nursing home care are not reimbursable.  Comprehensive list of eligible DCFSA expenses.

Unlike health FSAs, DCFSAs may only reimburse expenses up to the amount you have contributed at any time during the benefit Plan Year. If you submit a reimbursement request for an amount that is greater than your account balance, that amount will be pended until your next contribution is posted to your account and then any eligible amount(s) will be reimbursed to you.

Under the "use it - or - lose it" rule, any unused DCFSA (day care) contribution amounts cannot be rolled over to the next benefit Plan Year and will be forfeited.

Visit HealthEquity for a comprehensive list of non-qualified HCFSA, LPFSA, or DCFSA expenses.

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FSA Mid-Year Election Changes:

FSA election changes must be made within 63 days of a qualifying event (30 days for death or divorce). FSA changes are limited and differ for each pre-tax option. Changes must be consistent with the change in status or qualifying event. For more information about mid-year election changes, please contact your campus Benefits Representative.

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Reimbursement

Claims are usually processed within 2 – 3 business days of receipt and you should receive a check in the mail or via direct deposit (if applicable) within 5 business days after HealthEquity/WageWorks receives your claim. You may submit claims via mail (HealthEquity/WageWorks, PO Box 14053, Lexington, KY, 40512), fax (1-877-353-9236), HealthEquity/WageWorks online, or via your mobile device.

All claims incurred during the FY25 benefit Plan Year (July 1, 2024 - June 30, 2025) must be received by HealthEquity/WageWorks before September 30, 2025 to be eligible for reimbursement.

If you terminate employment during the benefit Plan Year, your participation in the FSA ends, subject to COBRA limitations.  However, you may submit claims through September 30, 2024 if the claims were incurred during your period of employment and during the benefit Plan Year.

No exceptions can be made on late claims submissions.

Pay Me Back or Pay My Provider: 

When filing a request for reimbursement, you may elect to have HealthEquity/WageWorks make the HCFSA/LPFSA payment directly to you (Pay Me Back) or to pay your provider directly (Pay My Provider). You may also elect to have recurring payments for DCFSA (day care) expenses or recurring medical expenses, such as orthodontia.

When submitting a Pay Me Back reimbursement request, you may elect to receive your reimbursement via check or direct deposit. Sign up online for direct deposit and your reimbursement will be electronically deposited directly into your account.

Debit Card:

The HealthEquity/WageWorks Healthcare© Card is an easy way to pay for eligible HCFSA/LPFSA expenses. You will receive a Health Equity/ WageWork VISA debit card upon enrollment in a HCFSA/LPFSA at no cost to you. You may use the debit card to pay for eligible medical, dental, vision, or Rx expenses incurred on or after the FSA effective date through the remaining benefit Plan Year. Documentation to substantiate the expense may be required, so keep all FSA receipts, Explanation of Benefits (EOB), and other supporting documentation when you use your debit card.

Debit cards cannot be used to pay for expenses that were incurred prior to the FSA effective date or current Plan Year.

If the expense is covered by your Medical, Dental, or Vision Hardware Plan, you must provide an Explanation of Benefits (EOB) as documentation to support your reimbursement request if expenses are not covered by your Medical, Dental, or Vision Hardware Plan, an itemized statement from the provider may satisfy documentation requirements.

Have FSA contributions you need to spend before the end of the benefit Plan Year?

The FSA Store has a large selection of qualified eligible HCFSA and LPFSA products. You can use your Healthcare debit card to conveniently order and pay for these products online!

Questions?

Contact your campus Benefits Representative or HeathEquity/WageWorks.  HeathEquity/WageWorks Customer Service is available 24/day, 7 days/week at 1-877-WageWorks (1-877-924-3967).

FSA administrative fees are paid by MUS

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Supplemental Life Insurance (optional)

Administered by
Standard Insurance Co.
1-800-759-8702

Supplemental Life Insurance:

This is an Employee only benefit.

If you enroll in Supplemental Life Insurance, your cost depends on your age as of July 1st and the amount of coverage you select, as shown in the following table.  The cost of this benefit is paid on an after-tax basis.

• A new employee may elect up to $300,000 in life coverage during initial enrollment without submitting evidence of insurability.
• If an employee previously waived all coverages, they may elect life coverage of $25,000 when enrolling in coverage.  If electing more than $25,000, they must submit evidence of insurability.
• If an employee is enrolling in life coverage for the first time, they elect coverage of $25,000 during Annual Enrollment.  If electing more than $25,000 they must submit evidence of insurability.
• An employee may increase life coverage one level, decrease coverage to any level, or drop coverage completely during Annual Enrollment.  If increasing more than one level during Annual Enrollment, they must submit evidence of insurability.
• An employee may elect life coverage of $25,000 due to marriage or first newborn/adopted child, if not currently enrolled.  If electing more than $25,000, they must submit evidence of insurability.
• An employee may increase or decrease lifecoverage one level if the change is consistent with the event (i.e., marriage, current coverage may be increased one level; divorce, current coverage may be decreased one level).  If increasing more than one leve, they must submit evidence of insurability.
• Evidence of insurability is required for all life elections over $300,000.

_{*The benefit election examples are only a subset of allowed benefit elections/changes and is not an all-inclusive list.  Contact your campus Benefits Representative for more information related to qualifying events, changes in family status, and allowed mid-year changes (subject to Plan restrictions).}

_{*The controlling provisions are in the group policy issued by Standard Insurance Company.  Neither the certificate nor the information presented in this booklet modifies the group policy or the insurance coverage in any way.}

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Supplemental Life Monthly Rates - Employee Benefit (based on age of Employee as of July 1)

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Supplemental Dependent Life Insurance Eligibility:

Supplemental Dependent Life Insurance for your legal spouse and unmarried dependent child(ren) (live birth to age 26) is designed to protect you against certain financial burdens (such as funeral expenses) in the event a covered dependent dies. You are automatically the beneficiary of any benefits that become payable.  Employees MAY NOT cover other MUS employed family members.  In addition, dependent children MAY NOT be insured by more than one MUS employed member. You must enroll in employee supplemental life coverage to be eligible for your legal spouse or dependent child(ren) to enroll in supplemental life coverage. The cost of this benefit is paid on an after-tax basis.

• Spouse life elections cannot exceed 100% of the employee election (i.e., employee elects $50,000 for self, spouse maximum is $50,000).
• A new employee may elect up to $50,000 in spouse life coverage during initial enrollment without submitting evidence of insurability.
• If an employee is enrolling in spouse life coverage for the first time, they may elect any coverage level during Annual Enrollment and they must submit evidence of insurability.
• If an employee increases spouse life coverage over $50,000 or more than one coverage level during Annual Enrollment, they must submit evidence of insurability.
• An employee may decrease spouse life coverage to any level or drop completely during Annual Enrollment.
• An employee may elect spouse life coverage due to marriage, first newborn/adopted child, or due to spouse losing eligibility for other insurance coverage, up to $50,000, without submitting evidence of insurability.  If electing more than $50,000, they must submit evidence of insurability.
• An employee may increase spouse life coverage one level if the change is consistent with the event (i.e., newborn child is added to coverage, current coverage may be increased one level).  If increasing more than one leve, they must submit evidence of insurability.
• Evidence of insurability is required for all spouse life elections over $50,000.

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Supplemental Life Monthly Rates - Spouse Benefit (based on age of Legal Spouse as of July 1st)

No evidence of insurability is required for dependent child coverage at any level.

• An employee must enroll in employee life coverage equal to or greater than the amount elected for child life coverage (i.e., employee elects $25,000 for self, child maximum is $25,000).
• A new employee may elect up to $30,000 in child life coverage during initial enrollment.
• If an employee is enrolling in child life coverage for the first time, they may elect coverage of $5,000 during Annual Enrollment.
• An employee may increase child life coverage one level, decrease coverage to any level, or drop coverage completely during Annual Enrollment.
• An employee may elect child life coverage in any amount if adding first newborn/adopted child to coverage and no current coverage exists.
• An employee may elect child life coverage of $5,000 due to the child losing eligibility for other insurance coverage and no current coverage exits.
• An employee may increase child life coverage one level if the change is consistent with the event (i.e., newborn child is added to coverage, current coverage may be increased one level).
• Disabled dependent children over the age of 26 who are covered on the Plan MAY NOT be covered on child life coverage.

Supplemental Life Monthly Premium - Child Benefit

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Supplemental AD&D Coverage (optional)

Administered by
Standard Insurance Co.
1-800-759-8702

Supplemental AD&D Insurance Eligibility:

This is an Employee only benefit.

If you enroll in Supplemental Accidental Death & Dismemberment (AD&D) Insurance, your cost depends on the amount of coverage you select, as shown in the following table.  The cost of this benefit is paid on an after-tax basis.

No evidence of insurability is required for supplemental AD&D coverage at any level.

• A new employee may elect any AD&D coverage level during initial enrollment.
• If an employee previously waived all coverages, they may elect AD&D coverage of $25,000 when enrolling in coverage.
• If an employee is enrolling in AD&D for the first time they may elect coverage of $25,000 during Annual Enrollment.
• An employee may increase AD&D coverage one level, decrease coverage to any level, or drop coverage completely during Annual Enrollment
• An employee may elect AD&D coverage of $25,000 due to marriage or first newborn/adopted child, if not currently enrolled.
• An employee may increase or decrease AD&D coverage one level if the change is consistent with the event (i.e., marriage, current coverage may be increased one level; divorce, current coverage may be decreased one level).

_{*The benefit election examples are only a subset of allowed benefit elections/changes and is not an all-inclusive list.  Contact your Benefits Representative for more information related to qualifying events, changes in family status, and allowed mid-year changes (subject to Plan restrictions).}

_{*The controlling provisions are in the group policy issued by Standard Insurance Company.  Neither the certificate nor the information presented in this booklet modifies the group policy or the insurance coverage in any way.}

Supplemental AD&D Monthly Rates - Employee Benefit

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Supplemental Dependent AD&D Insurance eligibility:

Supplemental Dependent AD&D Insurance for your legal spouse and unmarried dependent child(ren) (live birth to age 26) is designed to protect you against certain financial burdens in the event a covered dependent dies due to an accidental death. You are automatically the beneficiary of any benefits that become payable. Employees MAY NOT cover other MUS employed family members. In addition, dependent children MAY NOT be insured by more than one MUS employed member. You must enroll in employee supplemental AD&D coverage to be eligible for your legal spouse or dependent child(ren) to enroll in supplemental AD&D coverage.  The cost of this benefit is paid on an after-tax basis.

No evidence of insurability is required for spouse or dependent child coverage at any level.

• Spouse AD&D elections cannot exceed 100% of the employee election (i.e., employee elects $100,000 for self, spouse maximum is $100,000).
• A new employee may elect any spouse AD&D coverage level during initial enrollment.
• If an employee enrolling in spouse AD&D coverage for the first time, they may elect $25,000 during Annual Enrollment.
• An employee may increase spouse AD&D coverage one level, decrease coverage to any level, or drop completely during Annual Enrollment. 
• An employee may elect spouse AD&D coverage at any level due to marriage, first newborn/adopted child, or due to spouse losing eligibility for other insurance coverage.
• An employee may increase spouse AD&D coverage one level if the change is consistent with the event (i.e., newborn child is added to coverage, current coverage may be increased one level).

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Supplemental AD&D Monthly Rates - Spouse Benefit

• An employee must enroll in employee AD&D coverage equal to or greater than the amount elected for child AD&D coverage (i.e., employee elects $50,000 for self, child maximum is $30,000).
• A new employee may elect any child AD&D coverage level during initial enrollment.
• If an employee is enrolling in child AD&D coverage for the first time, they may elect coverage of $5,000 during Annual Enrollment.
• An employee may increase child AD&D coverage one level, decrease coverage to any level, or drop coverage completely during Annual Enrollment.
• An employee may elect child AD&D coverage in any amount if adding a newborn/adopted child to coverage and no current coverage exists.
• An employee may elect child AD&D coverage of $5,000 due to the child losing eligibility for other insurance coverage and no current coverage exists.
• An employee may increase child AD&D coverage one level if the change is consistent with the event (i.e., newborn child, is added to coverage, current coverage may be increased one level).
• Disabled dependent children over the age of 26 who are covered on the Plan MAY NOT be covered on child AD&D coverage.

Supplemental AD&D Monthly Premium - Child Benefit

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Additional Benefit Plan Information

Dependent Premium Hardship Waiver

The MUS Benefit Plan offers a Dependent Premium Hardship Waiver (DPHW) to assist employees with the cost of medical health care coverage for children covered on the MUS Medical Plan. The family must first apply for Healthy Montana Kids (HMK) coverage for all children under the age of 19.  If HMK denies coverage and the family has a financial hardship, a DPHW application may be submitted to the MUS Benefits office requesting the Dependent Premium Hardship Waiver.  If the total household income is not more than 125% of the HMK guidelines, covered dependent children will be eligible for the waiver for the benefit Plan Year (July 1 – June 30).  The family must re-apply for HMK coverage and the DPHW each benefit Plan Year to be eligible for the waiver. For more information, please contact your campus HR/Benefits Office or the MUS Benefits office at 1-877-501-1722.  The DPHW application is available on the Choices Forms page.

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Self-Audit Award Program

Be sure to check all medical health care provider bills and Explanation of Benefits (EOBs) from the Medical Plan claims administrator to ensure charges have not been duplicated or you have been billed for services you did not receive. When you detect billing errors that result in a claims adjustment, the Plan will share the savings with you! You may receive an award of 50% of the savings, up to a maximum of $1,000.

The Self-Audit Award Program is available to all MUS Medical Plan members who identify medical billing errors which:

• Have not already been detected by the Medical Plan’s claims administrator or reported by the health care provider.
• Include medical services which are allowable and covered by the MUS Medical Plan, and
• Total $50 or more in errant charges.

To receive the Self-Audit Award, the member must:

• Notify the Medical Plan claims administrator of the error before it is detected by the claims administrator or the health care provider.
• Contact the provider to verify the error and work out the correct billing, and
• Submit copies of the correct billing to the Medical Plan claims administrator for verification, claims adjustment and calculation of the Self-Audit Award.

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Summary Plan Description (SPD)

All MUS Plan participants have the right to obtain a current copy of the SPD.  Despite the use of “summary” in the title, this document contains the full legal description of the Plan’s medical, dental, vision hardware, and prescription drug benefits and should always be consulted when a specific question arises about the Plan.

Plan participants may request a hard copy of the SPD by contacting their campus HR/Benefits office or the MUS Benefits office at 1-877-501-1722.  The SPD is also available online on the MUS Choices website.

Eligibility and enrollment rules for coverage in the Montana University System Group Benefit Plan for participants and their dependents (who are NOT active employees within MUS), are published in the MUS Summary Plan Description in these sections: 

• Eligibility 
• Enrollment, Changes in Enrollment, and Effective Dates of Coverage
• Leave, Layoff, Coverage Termination, Re-Enrollment, Surviving Dependent, and Retirement Options
• Continuation of Coverage Rights under the Consolidated Omnibus Budget Reconciliation Act (COBRA)

Each covered employee and retiree is responsible for understanding the rights and responsibilities for themselves and their eligible dependents for maintaining enrollment in the MUS Plan.  

Retirees eligible for Medicare and paying Medicare Retiree premium rates, as published in the Choices Retiree Workbook, are required to be continuously enrolled in BOTH Medicare Part A and Medicare Part B as their primary coverage.

Coordination of Benefits (COB):  Persons covered by a health care plan through the MUS AND by another non-liability health care coverage plan, whether private, employer-based, governmental (including Medicare and Medicaid), are subject to coordination of benefits rules as specified in the SPD.  Rules vary from case to case by the circumstances surrounding the claim and by the active or retiree status of the member.  No more than 100% of a claim’s allowed amount will be paid by the sum of all payments from all applicable coordinated insurance coverages.

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Summary of Benefits and Coverage (SBC)

The SBC, required by PPACA, will outline what the MUS Medical Plan covers and what the cost share is for the member and the Plan for covered services.  

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Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) Notice

The MUS Plan has a duty to safeguard and protect the privacy of all plan members’ personally identifiable health information that is created, maintained, sent, or received by the Plan.

View the HIPAA Notice

The MUS Plan contracts with individuals or entities, known as Business Associates, who perform various functions on the Plan’s behalf such as claims processing and other health-related services associated with the Plan, including claims administration or to provide support services, such as medical review or pharmacy benefit management services, etc.

The MUS Plan, in administering Plan benefits, shares and receives personally identifiable medical information concerning Plan members as required by law and for routine transactions concerning eligibility, treatment, payments, wellness programs (including WellChecks and lifestyle management programs), healthcare operations, and claims processing (including review of claims payments or denials, appeals, health care fraud and abuse detection, and compliance).  Information concerning these categories may be shared, without a Plan participant’s written consent, between authorized MUS Benefits office employees and MUS Business Associates, the participant’s providers, or legally authorized governmental entities.

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Glossary

Allowed Amount:  A set dollar allowance for procedures/services that are covered by the Plan.

Balance Billing:  This amount is the difference between the provider’s billed charge and the allowed amount for covered services provided by an Out-of-Network Provider or the billed amount for a non-covered service.

Benefit Plan Year:  The period starting July 1 and ending June 30.

Certification/Pre-Certification:  A determination by the Medical Plan claims administrator that a specific service - such as an inpatient hospital stay - is medically necessary. Pre-Certification is done in advance of a non-emergency admission by contacting the Medical Plan claims administrator.

Coinsurance:  A percentage of the allowed amount for covered services that a member is responsible for paying, after paying any applicable deductible.  For example, if Jack has met his deductible for In-Network medical costs ($750), he pays 25% of the allowed amount up to the Out-of-Pocket Maximum and the Plan pays 75%.

Copayment:  A fixed dollar amount the member pays for a covered service, usually at the time the member receives the service.  The Plan pays the remaining allowed amount.

Covered Services: Services that are determined to be medically necessary and are eligible for payment under the Plan.

Deductible:  A set dollar amount that a member must pay for covered services before the Medical Plan pays. The deductible applies to the benefit Plan Year (July 1 through June 30).  For example, Jack’s deductible is $750.  Jack pays 100% of the allowed amount for covered services until his deductible has been met.

Diagnostic:  A type of service that includes tests or exams usually performed for monitoring a disease or condition which you have signs, symptoms, or a prevailing medical history.

Emergency Services:  Evaluation and treatment of a covered emergency medical condition (illness, injury, or serious condition).  Emergency Services are covered everywhere; however, Out-of-Network Providers may balance bill the difference between the billed charge and the allowed amount for covered services.

Fee Schedule:  A fee schedule is a complete listing of fees used by the Plan to reimburse providers and suppliers for providing selected covered services.  The comprehensive listing of fee maximums is used to  reimburse a provider on a fee-for-service or fixed (flat-fee) basis.

In-Network Provider:  A provider who has a participating contract with the Plan claims administrator to provide services for Plan members and to accept the allowed amount as payment in full for covered services. Also called “Preferred Provider” or “Participating Provider”. Members will pay less Out-of-Pocket expenses for covered services if they see an In-Network Provider.

Out-of-Network Provider:  A provider who provides services to a member but does not have a participating contract with the Plan claims administrator. Also called “Non-Preferred Provider” or “Non-Participating Provider”. Members will pay more Out-of-Pocket expenses for covered services if they see an Out-of-Network Provider.  Out-of-Network Providers may balance bill the difference between the billed charge and the allowed amount for covered services.

Out-of-Pocket Maximum:  The maximum amount of money a member pays toward the cost of covered services.  Out-of-Pocket expenses include deductibles, copayments, and coinsurance.  For example, Jack reaches his $4,000 Out-of-Pocket Maximum. Jack has seen his doctor often and paid $4,000 total (deductible + coinsurance + copays). The Plan pays 100% of the allowed amount for covered services for the remainder of the benefit Plan Year (July 1 through June 30).  Balance billing amounts for covered services (the difference between Out-of-Network Provider billed charges and the allowed amount) do not apply to the Out-of-Pocket Maximum.  The Out-of-Pocket Maximum applies to the benefit Plan Year (July 1 through June 30).

Plan:  Healthcare benefits coverage offered to eligible members through the employer to assist with the cost of covered services.

Preventive Services:  Routine health care, including screenings and exams, to prevent or discover illnesses, disease, or other health problems.

Prior Authorization:  A process that determines whether a proposed service, medication, supply, or ongoing treatment is considered medically necessary as a covered service.

Primary Care Physician:  A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine, nurse practitioner, clinical nurse specialist or physician assistant) who directly provides or coordinates a range of health care services for or helps access health care services for a patient.

Screening:  A type of preventive service that includes tests or exams to detect the presence of something, usually performed when you have no symptoms, signs, or a prevailing medical history of a disease or condition.

Specialist:  A physician specialist who focuses on a specific area of medicine to diagnose, manage, prevent, or treat certain types of symptoms and conditions.

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Insurance Card Examples

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RESOURCES

Montana University System Benefits Office
Office of the Commissioner of Higher Education
1-877-501-1722 * Fax (406) 449-9170

MEDICAL PLAN & VISION HARDWARE PLAN

BLUECROSS BLUESHIELD OF MONTANA
1-800-820-1674 or 1-406-447-8747

DENTAL PLANS

DELTA DENTAL
1-866-579-5717

FLEXIBLE SPENDING ACCOUNTS

HEALTHEQUITY/WAGEWORKS INC
1-877-924-3967

PRESCRIPTION DRUG PLAN
NAVITUS COMMERCIAL PLAN
1-866-333-2757

LUMICERA HEALTH SERVICES
1-855-847-3553

COSTCO MAIL ORDER PHARMACY
1-800-607-6861
Fax:  1-888-545-4615

RIDGEWAY MAIL ORDER PHARMACY
1-800-630-3214
Fax (406) 462-6050

LIFE/AD&D & LONG TERM DISABILITY PLANS

STANDARD LIFE INSURANCE
1-800-759-8702

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