Plan features

If you use the HealthChoice medical or pharmacy provider networks, you are responsible for:

• Calendar year deductibles.

• Coinsurance.

• Calendar year out-of-pocket maximum.

First dollar coverage

For each enrolled member, this is the initial amount that HealthChoice pays towards allowable amounts for network and/or non-network covered services before anything is owed by you. This includes, but is not limited to, amounts for office visits, lab work, X-rays, surgical procedures, hospital admissions, etc. Expenses for non-covered services and any expense over the allowable amount for non-network services do not qualify for first dollar coverage. Once your first dollar coverage limit is reached, you will be responsible for meeting your deductible.

Basic Plan	Basic Alternative Plan
First dollar coverage $500	First dollar coverage $250

Calendar year deductible

After your first dollar coverage has been met, network and/or non-network allowable amounts for covered services go toward your deductible. No member must contribute more than the individual deductible. Once the individual deductible is met, the member shares the cost of services with HealthChoice by paying coinsurance. A family deductible applies when two or more family members are covered and can be met by any combination of the family members. Once the family deductible is met, coinsurance will begin for everyone.

Basic Plan	Basic Alternative Plan
Individual deductible $1,000	Individual deductible $1,250
Family deductible $1,500	Family deductible $1,750

Copayments

You have no network copays on the Basic and Basic Alternative plans. You only have one non- network copay of $300, which is for a non-network hospital/facility inpatient admission.

Coinsurance

You must meet the deductible before coinsurance applies. You are responsible for the cost of all non-covered services regardless of your provider’s network or non-network status.

COINSURANCE	Network	Non-Network
Member pays	50% of allowable amount	50% of allowable amount*
HealthChoice pays	50% of allowable amount	50% of allowable amount

*Plus, you pay the difference between the amount billed by the provider and the allowable amount.

Calendar year out-of-pocket maximum

No member contributes more than the individual maximum. Once the individual maximum is met, HealthChoice then pays 100% of the allowed amount for that person. A family maximum applies when three or more family members are covered and can be met by any combination of the family members. HealthChoice then pays 100% of the allowable amounts for covered services for everyone on the plan.

Basic Plan	Basic Alternative Plan
Individual deductible $1,000	Individual deductible $1,250
Family deductible $1,500	Family deductible $1,750

Charges that do not count toward the out-of-pocket maximum

The following charges do not count toward meeting the out-of-pocket maximum and do not qualify for 100% payment after the out-of-pocket maximum is met:

• Amounts above HealthChoice allowable amounts.
  
• Non-network copays.
  
• Non-covered services or charges.
  
• Amounts above maximum benefit limitations.

**Some services have an annual cap on the dollar amount or the total number of visits that will be covered. After the annual limit is reached, you must pay all associated health care costs for the remainder of the calendar year.No lifetime maximum per member.

Plan features

If you use the HealthChoice medical and pharmacy provider networks, you are responsible for:

• Calendar year deductible.
  
• Office visit copays.
  
• Coinsurance.
  
• Calendar year out-of-pocket maximum.
  

Calendar year deductible

Both pharmacy and medical expenses apply toward the combined deductible in the HDHP only. There is not a separate pharmacy deductible with HDHP as there is in the High and Basic Option plans.For families of two or more, the family deductible must be met before benefits for any member will be paid by the plan. The deductible can be met by one individual or any combination of covered family members. Once the family deductible is met by any combination of covered family members, coinsurance and copayments will begin for everyone.

Individual	Family
Deductible $1,750	Deductible $3,500

CopaymentsThis is the fixed amount you pay for certain services, and most copays only apply after you meet your deductible.

 

Service	Copay
General physician office visit (network general practitioners, internal medicine physicians, OB/GYNs, pediatricians, physician assistants and nurse practitioners)	$30*
Urgent care (urgent care visits at a network urgent care facility)	$30*
Specialist office visit (network specialist providers)	$50*
Emergency department (network or non-network visit; waived if the patient is admitted to the hospital or if death occurs prior to admission)	$200
Non-network inpatient admission (non-network hospital/facility admissions; patient is subject to balance billing)	$300
Preventive services (qualified preventive care office visits and services)	$0

*Applies after deductible is met.

Coinsurance

You must meet the deductible before coinsurance applies. You are responsible for the cost of all non-covered services regardless of your provider’s network or non-network status.

Coinsurance	Network	Non-Network
Member pays	20% of allowable amount	50% of allowable amount*
HealthChoice pays	80% of allowable amount	50% of allowable amount

*Plus, you pay the difference between the amount billed by the provider and the allowable amount.

Calendar year out-of-pocket network maximum

No member contributes more than the individual maximum. Once the individual maximum is met, HealthChoice then pays 100% of the allowed amount for that person. A family maximum applies when two or more family members are covered and can be met by any combination of the family members. HealthChoice then pays 100% of the allowable amounts for covered services for everyone on the plan.

Network Individual	Network Family
$6,000 calendar year maximum	$12,000 calendar year maximum

Charges that do not count toward the out-of-pocket maximum

The following charges do not count toward meeting the out-of-pocket maximum and do not qualify for 100% payment by HealthChoice after the out-of-pocket maximum is met:

All non-network expenses, including:

• Non-network covered services up to the allowable amount.
• Non-network expenses above the HealthChoice allowable amount.
• Non-network pharmacy charges.
• Non-network pharmacy expenses.
  
• Non-covered services or charges.
• Amounts above maximum benefit limitations.

**Some services have an annual cap on the dollar amount or the total number of visits that will be covered. After the annual limit is reached, you must pay all associated health care costs for the remainder of the calendar year.

No lifetime maximum per member

 

 

 

Covered services, supplies and equipment are based on use of network or non-network providers and are subject to plan provisions and criteria for coverage. Covered services through a non-network provider are subject to balance billing. Some services are covered only through network providers. Refer to HealthChoice High and High Alternative Plans, HealthChoice Basic and Basic Alternative Plans or HealthChoice High Deductible Health Plan.

This is not a comprehensive list. Some services may have limited coverage and/or require certification of medical necessity for coverage; refer to Plan Exclusions or Certification for additional information. For questions or information benefits or coverage, contact HealthChoice Customer Care. Refer to HealthChoice Plan Contact Information.

Acupuncture

• Covered only as alternative to anesthesia for surgery.
  

Allergy serum, treatment and testing

• Limited to one battery of 60 tests every 24 months; excludes testing of the home environment.

Ambulance

• Air and ground services.
  
• Refer to Emergency Care Coverage for additional information.
  

Anesthesia

• Eligible services for covered illness or surgery.
  

Autism spectrum disorders

• Screening and diagnosis services provided by a licensed physician or a licensed doctoral-level psychologist.
  
• Specific to applied behavior analysis:
  • Treatment services provided by a Board Certified Behavior Analyst (BCBA), a licensed physician or psychologist, Board Certified Assistant Behavior Analyst (BCaBA) or a Registered Behavior Technician who is under the direction and close supervision of the BCBA, BCaBA, physician or psychologist for up to eight years.
  • Proposed treatment plan with script is required upon receipt of the first claim each rolling year from a medical doctor or clinical psychologist.○Services are limited to 25 hours per week and no more than $25,000 per calendar year.
  • Other calendar year benefit limitations do not apply for treatment (e.g., limits of 60 per calendar year); other plan provisions apply.
• Refer to Preventive Services for additional information.

Bariatric surgery

• Must be age 18 or older and HealthChoice must be patient’s primary insurance.
• Must be covered by HealthChoice for 12 consecutive months prior to surgery
• Must be performed at a network bariatric facility.
  

Birthing center

• Must be associated with an inpatient obstetrical and neonatal facility.
  

Blood and blood products

• Processing, storage and administration of blood and blood products in inpatient and outpatient settings, including collection and storage of autologous blood.
  

Breast pumps

• Refer to Preventive Services for additional information.
  

Chelation therapy

• Covered only for heavy metal poisoning.
  

Chemotherapy

• Home, outpatient or inpatient services when medically necessary.
  
• Refer to Pharmacy Benefits for medication coverage.
  

Chiropractic therapy

• Limited to 20 visits per calendar year without certification; maximum of 60 visits per year.
  
• Includes manipulative therapy.
  

Clinical trials

• Must be registered with the U.S. National Library of Medicine at clinicaltrials.gov or with the National Cancer Institute at cancer.gov.
• Routine medical care services required for the provision of the item or service associated with the clinical trial.○Includes standard lab work, MRI, CT and PET scans.
  

Cochlear implant device

• Analysis, implant and related services/supplies

• Covered as durable medical equipment/supplies.
  
• Unit covered as rent-to-purchase once every five years when medically necessary.
• Unit supplies limited to once every 90 days, no more than four times per calendar year.
  

• Implantable contraceptives (e.g., Implanon).
  
• Diaphragm or cervical cap.
  
• Depo Provera injections.
  
• Elective sterilization – tubal ligation, vasectomy.
• IUD insertion, surgical removal and equipment.
  
• Refer to Preventive Services and Pharmacy Benefits for additional information.
  

• Eyeglasses one time following cataract surgery.
  
• Contact lenses for the diagnosis of keratoconus when medically necessary, limited to one set per calendar year.
  

• Medically necessary treatment for the repair of traumatic injury to sound natural teeth or gums, provided the accident and treatment occur while the individual is a member under the health plan and the treatment is performed within 12 months following the date of the accident.

• Equipment and supplies covered as durable medical equipment/supplies.
  • Continuous glucose monitor.
    
  • Insulin pumps and related supplies.
    
• Education services limited to 10 visits per calendar year.
  
• Refer to Pharmacy Benefits for additional information.
  

• Purchase, rental, repair and/or replacement when medically necessary.
  

• Refer to Emergency Care Coverage.
  

• Covered as durable medical equipment/supplies with a diagnosis of diabetes.
  
• Limit of one pair of therapeutic shoes and three inserts per foot per calendar year.

• Coverage includes diabetes, glaucoma and macular degeneration.
  

• Routine and diagnostic services.
• Refer to Preventive Services for additional information.

• Limit of one per impaired ear every 48 months up to the age of 18 when medically necessary.
  
• Limit of four additional ear molds per calendar year for children up to age of 2.
  
• Must be prescribed, filled and dispensed by a licensed audiologist.
  

• Limit of one hearing screening and one hearing test per calendar year.
• Refer to Preventive Services for additional information.
  

• Limited to 100 visits per calendar year when medically necessary.
  
  • Home visit/nursing care.
    
  • Home health aide.
  • Administration of medication and injections.
    
  • Occupational, physical and speech therapy.
    

• Inpatient services when medically necessary.
  
• Hospice services in the home or in a long-term care facility when medically necessary.
  
  • Requires a physician’s statement of life expectancy of six months or less.
    

• Inpatient – Requires admission to a health care facility (i.e., hospitals, skilled or long- term acute care facilities).
  
  • Includes observation stays 48 hours or more.
    
• Outpatient – Does not require admission to a health care facility (i.e., hospitals or surgical centers).
  • Includes observation stays less than 48 hours.

• Diagnostic testing – Includes hysteroscopy, lab tests, ultrasounds and hysterosalpingograms.
  
• Treatment is limited to prescription coverage only.

• Home services when medically necessary.
  
  • ○Not subject to home health care limitations.
    
• Outpatient or inpatient services when medically necessary.
  

• Routine and diagnostic services.
  
• Refer to Preventive Services for additional information.
  

• Prenatal and postnatal care; including office visits, lab work and ultrasound.
  
• Hospital facility and physician services for delivery.
  
• One skilled nurse home health visit if the delivery is at home or in a birthing center.
  
• Refer to Preventive Services for additional information.
  

• Inpatient, outpatient, intensive outpatient, residential and partial hospital services when medically necessary.
  
• Outpatient services limited to 20 visits per calendar year without certification; maximum 60 visits per calendar year.
• Refer to Autism spectrum disorder in this section for specific coverage details and ABA services.
  
• Refer to Preventive Services for additional information.
  

• Provider must be a certified nurse midwife and licensed by the state in which services are provided.
  

• Home, inpatient and outpatient services.
• Outpatient services limited to 20 visits per calendar year without certification; maximum 60 visits per calendar year.
  

• Routine and diagnostic.
  
• Refer to Preventive Services for additional information.
  

• Inpatient and outpatient services when medically necessary.
  
• Includes removal of tumors or cysts, osteotomies, arthroplasties and mandibular/ maxillary reconstruction

• Non-experimental transplant of (human origin) bone marrow, peripheral stem cells, cornea and the following solid organs: kidney, liver, pancreas, kidney/pancreas, heart, lung, heart/lung and/or intestine when medically necessary.
  
• Procurement and harvesting.
  
  • Donor charges covered if recipient is covered by HealthChoice; limited to 90 days following transplant.
    

• Supplies covered as durable medical equipment/supplies.
  
• Education services are limited to three visits per calendar year.
  
• Refer to Pharmacy Benefits for additional information.

• Covered as durable medical equipment/supplies.
  

• Home, inpatient and outpatient services.
  
• Outpatient services limited to 20 visits per calendar year without certification; maximum 60 visits per calendar year.
  
• Includes manipulative therapy services.
  

• Refer to Preventive Services.
  

• Covered as durable medical equipment/supplies.
  

• Routine and diagnostic.
  
• Includes X-rays, ultrasounds, mammograms, imaging scans (MRI, CT, PET).
• Refer to Preventive Services for routine coverage information.
  

• Inpatient and outpatient services when medically necessary.
• Refer to Physical therapy/physical medicine, Occupational therapy, Speech therapy and Mental health treatment.
  

• Limit of 100 days per calendar year when medically necessary.

• Home, inpatient and outpatient services.
  
• Outpatient services limited to 60 visits per calendar year.
  
• For members under 18 years of age, coverage is limited to restoring existing speech loss due to disease or injury when medically necessary.
  • Therapy must be expected to restore the level of speech the member had before the disease or injury.
    

• Surgeon, assistant surgeon, perfusionist and anesthesiologist, when medically necessary and in attendance during the surgery.
  
• Standby services must be documented in the patient’s medical record and include time in attendance.
  

• Inpatient, outpatient, intensive outpatient, residential and partial hospital services when medically necessary.
  

• Refer to Telemedicine/Telehealth Services.
  

• Routine and diagnostic services.
  

• Covered only for psoriasis.
  

• Covered in accordance with the current Centers for Disease Control and Prevention guidelines.
  
• Refer to Preventive Services for additional information.
  

• Covered as durable medical equipment/supplies.
• Limited to one wig or one scalp prosthesis per calendar year for individuals who experience hair loss due to radiation or chemotherapy treatment resulting from a covered medical condition.
  
• Must be obtained from a licensed cosmetologist or durable medical equipment provider.

Certification is a review process used to determine if services are medically necessary according to HealthChoice guidelines. Certification is also referred to as prior authorization, precertification or preauthorization. All HealthChoice plans require certification for coverage of specified services. Certification approval does not guarantee benefits. Clinical editing and other plan policies, provisions and criteria apply.

Guidelines

Providers are responsible for obtaining certification. To request certification, your provider must contact Customer Care or go online to healthchoiceconnect.com to complete the online request form. For non-urgent services, certification requests must be initiated within three working days prior to the scheduled service. For urgent services, certification must be initiated within one day following the service. Services rendered in an emergency department and/or ambulance are not subject to certification requirements. For more information on the difference between emergency and urgent services, refer to Plan Definitions.

If certification approval is not obtained for services that require it and/or if certification is denied either before or after the services are provided, claims for those services will be denied. For certifications approved after services are provided, a 10% penalty deduction on the allowable amounts may be applied. Network providers are not allowed to impose certification penalties on members or their covered dependents. If you use a non-network provider, you should ensure that the provider obtains certification prior to receiving services. Otherwise, you may be held responsible for paying the full amount (if certification is denied) or the 10% penalty (if applied because of late certification), as well as any billed amounts over allowable amounts (balance billing).For more detailed information on certification, contact Customer Care. Refer to HealthChoice Plan Contact Information.

Medical services that require certification

• Bariatric surgery (eligibility criteria also required).
  
• Chiropractic therapy.
  
  • Required only after initial 20 visits per calendar year.
    
  • Visits are limited to 60 total per calendar year (some exceptions apply).
    
• Drugs and medical injectables (some exceptions apply).
  
  • Required for specified medications covered under the HealthChoice medical benefit; this is not inclusive of requirements under the HealthChoice pharmacy benefit.
    
  • Required for Botox Injections that are non-cosmetic and rendered in the physician’s office.
    
• Durable medical equipment.
  
• Enteral feeding.
• Foot orthotics.
• Genetic testing.
• Glucose monitors: continuous.
• Hearing aids.
• Home health care (visits limited to 100 per calendar year).
  • Home intravenous therapy (not subject to home health care limits).
• Hyperbaric oxygen therapy (outpatient).
• Inpatient admissions.
• Maternity care.
  • Required if patient and baby are not discharged within 48 hours of vaginal delivery or within 96 hours of C-section delivery.
• Mental health treatment.
  • Inpatient, residential and partial hospitalization.
  • Required for outpatient services after initial 20 visits per calendar year.
  • Required initially for intensive outpatient therapy services.
  • Required initially for transcranial magnetic stimulation treatment.
  • Required initially for esketamine.
  • Required initially for Applied Behavioral Analysis services.
• Myocardial PET scan.
• Observation stays 48 hours or longer.
• Occupational therapy (outpatient).
  • Required after initial 20 visits per calendar year.
• Oral splints and appliances (some exceptions apply).
• Oral surgery (inpatient/outpatient).
• Outpatient surgical procedures:
  • Blepharoplasty.
  • Mammoplasty (including reduction, removal of implants and symmetry).
  • Correction of lid retraction.
  • Panniculectomy.
  • Rhinoplasty.
  • Septoplasty.
  • Varicose vein surgeries and procedures.
    • ▪Including sclerotherapy.
  • Sleep apnea related surgeries, limited to:
    • Radiofrequency ablation (coblation, somnoplasty).
    • Uvulopalatopharyngoplasty, including laser-assisted procedure.
• Organ transplants.
• Oxygen.
• Physical medicine/physical therapy (outpatient).
  • ○Required only after initial 20 visits per calendar year.
  • ○Visits are limited to 60 total per calendar year (some exceptions apply).
• Prophylactic and gynecomastia mastectomies.
• Prostheses and orthopedic appliances (some exceptions apply).
• Proton beam radiation therapy.
• Skilled nursing facility.
• Speech therapy.
  • Required only for age 17 years and younger.
  • Visits limited to 60 total per calendar year (some exceptions apply)
• Spinal cord stimulator placement and revision.
• Spinal surgical procedures
  • Cervical
  • Lumbar.
  • Thoracic.
• Substance use disorder treatment.
  • Inpatient, residential and partial hospitalization.
  • Outpatient services after initial 20 visits per calendar year.
  • Intensive outpatient treatment.
• Unlisted and not otherwise specified – required for specified codes.

The term emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. This is in accordance with section 1867(e)(1)(A) of the Social Security Act (42 U.S.C. § 1395dd(e)(1)(A).

• All related facility and professional emergency department claims, and all ambulance transport claims are processed in accordance with your network benefits, regardless of network status. This includes your plan provisions for copays, deductible and coinsurance.
  • You are still responsible for any charges for non-covered services.
  • If you receive services from a non-network provider, you are responsible for charges above the allowable amount if you are billed by the provider (balance billing).
  • There is a $200 emergency room copay for each emergency department visit under the High Option plans and the HDHP. The Basic Option plans do not require a $200 emergency room copay.
    
    • This copay is waived if the patient is admitted or death occurs prior to admission.
    • Certification is required for the inpatient admission. Refer to Certification.
      
    • If emergency treatment cannot be provided, and the patient is referred to another emergency room for treatment, the emergency room copay is waived on the emergency room that could not provide treatment.

HealthChoice offers additional assistance and coverage for out-of-state emergency services. To request assistance or additional benefits, call Customer Care. Refer to HealthChoice Plan Contact Information.

These are covered services provided for overall health maintenance — such as routine health/ wellness exams and tests, vaccinations, well-baby care and well-child care. Health screenings and wellness exams can discover problems you may not know you have. The earlier problems are found, the greater the opportunity for treatment.

HealthChoice covers qualifying preventive care services at 100% of allowable amounts when rendered by a participating network provider. Qualifying coverage may be determined by age, gender or other factors. There may be exceptions, limitations or clinical criteria to qualify for these services at no cost. If you receive services during a preventive care visit other than for qualifying preventive care, you may have to pay for those services.In addition to Affordable Care Act specific requirements, HealthChoice follows the recommendations of the United States Preventive Services Task Force and The American Academy of Pediatrics Bright Futures recommendations for the basis of coverage and criteria.

For more details on qualifying preventive care services and coverage criteria, you can visit healthchoiceconnect.com or contact Customer Care and a member advocate will be happy to assist you. Refer to HealthChoice Plan Contact Information.

Preventive services

This is not an all-inclusive list. Qualifying coverage criteria may apply.

• Abdominal aortic aneurysm screening.
  
• Alcohol misuse: screening and counseling.
  
• Blood pressure screenings.
  
• BRCA screening/assessment.
  
• Breast cancer screening.
  
• Breastfeeding supply and services.
  
• Cervical cancer screening.
  
• Colorectal cancer screening.
  
• Depression screening.
  
• Diabetes Prevention Program (CDC recognized).
• Diabetes screening.
  
• Gonorrhea screening.
  
• Newborn screening and medication.
  
• Hepatitis B screening.
  
• Hepatitis C screening.
• HIV screening.
  
• Intimate partner violence screening.
  
• Lung cancer screening.
• Obesity screening.
• Osteoporosis screening.
• Prenatal screenings, services and tests.
• Sexually transmitted infection screening.
• Tobacco use counseling.
• Tuberculosis screening.
• Vaccinations.
• Vision screening (children).
  
  

Vaccinations for adults and children

Vaccinations, including the vaccine and its administration, are covered under both medical and pharmacy benefits. Qualifying preventive vaccinations are covered at 100% by the plan when using a network pharmacy or medical provider, such as a physician or health department.

HealthChoice covers all CDC-recommended vaccinations through a network pharmacy or provider, such as for shingles, under the preventive services benefits. There may be limitations or qualification criteria for coverage. When using a non-network provider, you are subject to non-network benefits and can be balance billed for amounts above the allowable amounts.

Please note that free-standing ambulatory care clinics located inside pharmacies, grocery stores or supercenters may not be participating network providers, and your services may not be covered at these locations. Always verify network provider status by visiting the HealthChoice website or calling Customer Care. Refer to HealthChoice Plan Contact Information.

The following vaccinations are covered under medical or pharmacy benefits:

• Anthrax.
  
• Flu.
  
• Haemophilus influenzae.
  
• Hepatitis A.
  
• Hepatitis B.
  
• Human papillomavirus.
  
• Influenza A.
• Influenza HD.
• Japanese encephalitis.
  
• Measles.
  
• Meningococcal.
• Mumps.
  
• Pneumococcal.
  
• Poliomyelitis.
  
• Rabies (human diploid).
• Rabies (purified chick embryo cell vaccine).
• Rotavirus.
  
• Rubella.
  
• Shingrix (shingles).
  
• Smallpox (vaccinia) vaccine.
  
• Tetanus booster.
  
• Tetanus, diphtheria, pertussis.
  
• Typhoid.
  
• Varicella.
  
• Yellow fever.
  
• Zoster (shingles).
  

This list is not all-inclusive.Due to the rapidly changing conditions of COVID-19, refer to healthchoiceconnect.com for updated COVID-19 preventive service coverage.

SwiftMD offers medical consults from board certified physicians via telephone or teleconference 24/7 for eligible members. Services include many common and minor illnesses or injuries such as allergies, rashes, fever, flu, pink eye, sinusitis and sore throat. SwiftMD is easy to use and helps prevent unnecessary emergency department/urgent care visits or long waits for doctor appointments. All SwiftMD physicians have a minimum of 10 years of practice experience.

SwiftMD is available to HealthChoice members who are 3 or older. For HealthChoice High and Basic Option Plan members, there is $0 cost per visit with no limitations. For HDHP members, refer to your HealthChoice member materials. SwiftMD is available toll-free 833-980-1442 or by visiting SwiftMD.com. Be sure to activate your SwiftMD membership online before calling for an appointment.

HealthChoice also offers telehealth coverage for select services. Standard plan provisions apply including copays, deductible and coinsurance.

Note: Refer to healthchoiceconnect.com for any temporary COVID-19 expanded benefits in 2021.

The pharmacy benefits of the HealthChoice High, High Alternative, Basic and Basic Alternative Plans and High Deductible Health Plan include the following features:

• Electronic point-of-sale claims processing.
  
• An extensive pharmacy network.
  
• Coverage of up to a 90-day supply of medication at mail and retail for the applicable copay.
  
• Coverage of certain tobacco cessation medications for $0 copay.
  

Note: Specific therapeutic categories, medications and/or dosage forms may have more restrictive quantity and/or duration of therapy limitations. Pharmacy benefits are subject to and limited by your physician’s orders. Refer to Medications Limited in Quantity in this section.HealthChoice pharmacy benefits include the following provisions:

• Generic medications are preferred medications. If no generic exists, then a preferred brand-name medication is usually the next least expensive choice.
  
• If you choose a non-preferred medication instead of a preferred medication, you are responsible for the higher non-preferred copay.
  
• If you choose a brand-name medication when a generic is available, you are responsible for the difference in cost, plus the copay.
  
• The cost difference between generic and brand-name medications, medications purchased at non-network pharmacies and excluded medications do not count toward your pharmacy out-of-pocket maximum.
  
• Certain medications require prior authorization for coverage. Refer to Pharmacy Prior Authorization in this section.
  
• Ostomy bags and wafers are covered under both medical and pharmacy benefits.
  
• Diabetic supplies, including insulin syringes with needles, testing strips, lancet devices and glucometers are covered under pharmacy benefits; quantity limitations apply.

HealthChoice pharmacy network

In Oklahoma, there are more than 930 pharmacies that participate in the HealthChoice pharmacy network. Nationwide, there are nearly 68,000 participating pharmacies. To locate a HealthChoice network pharmacy, go to healthchoiceconnect.com or contact the pharmacy benefit manager. Refer to HealthChoice Plan Contact Information.

Network pharmacy benefits

Pharmacy deductible – Before benefits are available for HealthChoice High, High Alternative, Basic and Basic Alternative plan members, the separate pharmacy deductible of $100 per individual/$300 maximum per family must be met, and for HDHP members, the combined medical and pharmacy deductible of $1,750 individual/$3,500 per family must be met.

Note: Medications on the HealthChoice Preventive Medication List are not subject to the deductible. Copays apply to the pharmacy out-of-pocket maximum, but they do not apply to the deductible.

 

Medication Type	Up to a 30-Day Supply of a Medication	31- to 90-Day Supply of a Medication
Generic	Up to $10 copay	Up to $25 copay
Preferred	Up to $45 copay	Up to $90 copay
Non-Preferred	Up to $75 copay	Up to $150 copay
Specialty	Generic – $10 copay Preferred –$100 copay Non-preferred – $200 copay	Specialty medications are covered only for up to a 30-day supply

*All plan provisions apply. Only copays for preferred medications purchased at network pharmacies apply to the pharmacy out-of-pocket maximums for each plan. Some medications are subject to prior authorization and/or quantity limitations. When a generic is available, and you choose a brand-name medication for any reason, you will pay the cost difference between the brand-name medication and the generic plus the brand-name copay.

Non-network pharmacy benefits

Preferred Medication	Non-Preferred Medication
50% of the cost of the medication, plus the dispensing fee.	75% of the cost of the medication, plus the dispensing fee.

*All plan provisions apply. Only copays for preferred medications purchased at network pharmacies apply to the pharmacy out-of-pocket maximums for each plan.

When you use a non-network pharmacy, you pay the full amount and submit your claim to the pharmacy benefit manager for reimbursement. Refer to the Claims Procedures section for more information.

Calendar year out-of-pocket maximum

High Option and Basic Option plans network pharmacy	HDHP network pharmacy (combined medical and pharmacy)
$2,500 individual/$4,000 family	$6,000 individual/$12,000 family

 

After meeting the out-of-pocket maximum, the plan pays 100% of the cost of preferred medications purchased at network pharmacies for the remainder of the calendar year.Note: When a generic is available and you choose a brand-name medication for any reason, you will pay the difference between the brand-name medication and the generic plus the brand-name copay. The brand-generic cost difference does not count toward your pharmacy out-of-pocket maximum and is always your responsibility even after your out-of-pocket maximum is met.

The following charges do not count toward your pharmacy out-of-pocket maximum and do not qualify for 100% payment after your out-of-pocket maximum is met:

• Non-network pharmacy purchases.
  
• Cost differences between generic and brand-name medications.
  
• Non-covered medications.
  
• Amounts paid by copay assistance programs, manufacturer copay cards or other third parties do not apply toward deductibles or out-of-pocket maximums.

HealthChoice Formulary

The HealthChoice Formulary is a list of medications covered by the plan. To find out how your medications are covered, contact the pharmacy benefit manager. Refer to HealthChoice Plan Contact Information. You can also go to healthchoiceconnect.com. Here you can also find lists of commonly prescribed medications, excluded medications with preferred alternatives, and specialty medications.Your share of the cost of a medication is subject to:

• The cost of the medication.
  
• Network copays.
  
• Pharmacy deductible.
  
• Non-network coinsurance.
• The cost difference between a brand-name and generic medication if a brand-name is purchased when a generic is available.
  
• Medication quantity limits per copay.

• Ask your physician to prescribe a preferred medication you can receive at the preferred pharmacy copay.
  
• Continue with your current non-preferred medication and pay the non-preferred copay.
  
• Obtain a medical necessity exception if you have specific health problems that require a non-preferred medication. To be considered for this exception, specific criteria must be met and detailed documentation from your physician must justify your request for an exception. The steps to request a medical necessity exception are the same as the steps to request a prior authorization. Refer to Pharmacy Prior Authorization in this section.

• Are high cost.
  
• Are specialty medications.
  
• Are limited in quantity.
  
• Have lower cost preferred alternatives.
  

• Have your physician’s office call the pharmacy benefit manager. Refer to HealthChoice Plan Contact Information.
  
• The pharmacy benefit manager will assist your physician’s office with completing a prior authorization form.
  
• If your prior authorization is approved, your physician’s office is notified of the approval within 24 to 48 hours. You are also notified in writing.
• If your prior authorization is denied, your physician’s office is notified of the denial within 24 to 48 hours. You are also notified in writing.
  

• Bupropion 150 mg SR/SA tabs.
  
• Chantix.
• Nicotrol inhaler system.
• Nicotrol NS nasal spray.
  

The plan does not pay benefits for any of the following services, treatments, items or supplies, except as specifically provided for under Covered Services, Supplies and Equipment.

Exclusions are not covered even if they are prescribed by your physician or if they are the only available treatment for your condition. Some services may be medically necessary but not covered by the plan.

A. Alternative treatments

1. Acupressure.
   
2. Biofeedback.
   
3. Kinesiology (movement therapy).
   
4. Rolf technique (Rolfing).
   
5. Art therapy, music therapy, dance therapy, equine therapy; and other forms of alternative treatment as defined by the National Center for Complementary and Integrative Health of the National Institutes of Health.

B. Dental

1. Dental expenses that are covered under the dental plan.
   

C. Devices, appliances, prosthetics and supplies

1. Devices that attach to a building (walls, ceilings, floors, etc.).
   
2. Medical devices covered under pharmacy benefits are not covered, with the exception of diabetic testing supplies, ostomy supplies and products required by ACA.
   
3. Over-the-counter disposable medical supplies such as bandages, tape, gauze pads, alcohol, iodine, peroxide, saline, etc. that are purchased from any retail store, including online retail sites.
   
4. Devices, appliances, prosthetics and/or supplies, over-the-counter or otherwise, that are not primarily medical in nature and/or not considered medically necessary by the plan. Examples include, but are not limited to: braces, compression garments, room humidifiers, air purifiers, pulse oximeters, blood pressure cuffs, exercise equipment, swimming pools, Jacuzzi pumps, saunas, hot tubs, automobiles or adaptive equipment for automobiles, sun lamps, augmentative communication devices, patient lifts, adaptive bathroom and self-care equipment, assistive devices, and cold/ cryotherapy devices.
   
5. Equipment that exceeds lifetime or maximum benefits (e.g., one walker per lifetime, one breast pump per pregnancy, one CPAP every five years).
   
6. Mattresses not specifically designed for the prevention or treatment of skin breakdown or healing, or any other bedding purchased for any other reason.
7. Lost, stolen or damaged (e.g., mold, insect, etc.) equipment or devices.
8. Any device not FDA approved for general use or sale in the United States.
9. Breast pumps provided by non-network suppliers/providers.
10. Any covered items or services not used exclusively by the member or a covered dependent.

D. Drugs

1. Products marketed with 510(k) clearance (FDA cleared).
   
2. Prescription scar treatments.
3. Off-label use of drugs (use of a drug for the treatment of conditions that are not indicated on the drug’s label).
   
4. Over-the-counter drugs and vitamins (e.g., cough and cold drugs) except as required by ACA under pharmacy benefits.
   
5. Drugs under investigation in approved clinical trials.
6. Lost, stolen or damaged drugs.
   
7. Any drug not FDA approved for general use or sale in the United States.
   
8. Impotency drugs, unless following prostatectomy surgery.
   

E. Experimental/investigational services

1. Any treatment, appliance/device, drug or procedure, including any particular aspect of a treatment, deemed or considered experimental or investigational by the plan.
2. Items and services provided solely to satisfy data collection and analysis needs, including any service(s) not necessary for routine care such as specialized lab tests or drugs.
   

F. Personal care, comfort or convenience

1. Items which are furnished primarily for personal comfort or convenience and/or are not primarily medical in nature.
   1. a. Includes but is not limited to exercise equipment, air purifiers, air conditioners, humidifiers, spas, elevators, telephones, tablets, computers, software applications, watches, televisions, cervical pillows, protective clothing or shoes, and supplies for hygiene or beautification.
2. Exercise programs/fees/classes.
3. Weight management/loss programs such as Weight Watchers, Jenny Craig, Diet Center, Zone diet or similar programs including any over-the-counter food or nutritional supplements (e.g., amino acid supplements, Optifast liquid protein meals, NutriSystem pre-packaged foods, Medifast foods or phytotherapy).
4. Appetite suppressants.

1. Treatment of alopecia.
2. Cosmetic or elective surgical procedures, treatments or drugs not necessary as the result of an accident with continuous coverage from the date of the accident to the date of corrective surgery.
   
   1. a.Complications from any such procedure not originally covered by HealthChoice.
3. Breast reconstruction or implants not covered under the Women’s Health and Cancer Rights Act of 1998 and/or the Oklahoma Breast Cancer Patient Protection Act of 1998.
   
4. Custodial care.
   
5. Dyslexia testing.
6. Electromyography without needle.
7. Any routine hygienic foot/hand care, including trimming nails, and any other service rendered in the absence of localized illness, injury or symptoms involving the feet or hands.
   
8. Home dialysis training.
9. Home uterine monitoring.
10. Marriage counseling.
    
11. Medical services or treatments not generally accepted as the standard of care by the medical community.
    
12. Weight-loss (bariatric) surgery that involves any procedure performed outside of a network MSBSA-QIP certified comprehensive center of excellence.
    
13. Tobacco cessation counseling outside preventive service benefit coverage.
14. Venipuncture by a physician when also billing for lab charges.
    
15. Preoperative or postoperative care generally rendered by the operating surgeon, unless the surgeon itemizes his charges and the total amount charged is no more than the total allowable amounts for the surgery.
    
16. Services provided in a school or daycare setting.
    
17. Manipulative and physical therapy for palliative care (treatment for only the relief of pain), elective care (care designed to relieve recurring subjective symptoms), or prolonged care (treatment that does not move toward resolution as documented in the evaluation or re-evaluation goals).
    
18. Any confinement, medical care or treatment not recommended by a duly qualified practitioner.
    
19. Medical and/or mental health treatment of any kind, including hospital care, medications and medical care or medical equipment, which is excessive or where medical necessity has not been proven.
    
20. Ultraviolet treatment – actinotherapy in the home (tanning beds).
    
21. Cord blood banking, collection and storage.
    
22. Speech therapy for learning disabilities or birth defects.

1. Services supplied by a provider who is a relative by blood or marriage of the patient or one who normally lives with the patient.
   
2. Services supplied by an athletic trainer.
   

1. Infertility treatment, including artificial insemination, embryo transplant, in vitro fertilization, surrogate parenting, ovum transplant, donor semen, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), and reversal of voluntary sterilization.
   
2. Sex transformation surgeries.
   
3. Treatment for sexual dysfunction including implants of any nature except following a prostatectomy subject to state law.
   
4. Surrogate mother expenses for non-covered participants.
   

1. Injury or sickness which is covered under an Extended Benefits provision of previous health coverage, until such time as such individual has exhausted all extended benefits available thereunder.
2. Expenses to the extent the insured person is reimbursed or is entitled to reimbursement, or is in any way indemnified for such expenses by or through any public program, state or federal, or any such program of medical benefits sponsored and paid for by the federal government or any agency or subdivision thereof.
3. Bodily injury or illness arising out of or in the course of any employment not specifically excluded by 85A O.S. 2013, § 2 of the Workers’ Compensation Code.
   
4. Any services required by state or federal law to be supplied by a public school system or school district.

1. Eye examinations for the fitting of corrective lenses or any charges related to such examinations, orthoptics, visual training for any diagnosis other than mild strabismus, eyeglasses, except for the first lens(es) used as a prosthetic replacement after the removal of the natural lens, other corrective lenses, or radial keratotomy or LASIK (exceptions may apply to eye exams, refer to Preventive Services).
2. Hearing aids and examinations for fitting or prescription.
   
3. Batteries for hearing aids.
   

1. Charges for missed or canceled appointments, mileage, penalties, finance charges, separate charges for maintenance, record keeping or case management services.
   
2. Fees or retainers paid to concierge medicine providers.
3. Claims submitted later than 365 days from the date of service.
4. Medical care and supplies for which no charge is made or no payment would be requested if the insured individual did not have this coverage.
5. Expenses incurred prior to the effective date of an individual’s coverage, or for expenses incurred during a period of confinement which had its inception prior to the effective date of an individual’s coverage.
6. Hospitalization or other medical treatment furnished to the insured or dependent that begins after coverage has terminated.
7. Complications from any non-covered or excluded treatments, items or procedures.
8. Illness, injury or death as a result of committing or attempting to commit an assault or felony, including participation in a riot or insurrection as an aggressor.
9. Intentionally self-inflicted injuries or illness, except when the injury (a) resulted from being the victim of an act of domestic violence or (b) resulted from a documented medical condition (including both physical and mental health conditions) that is covered under the health plan.
10. Amounts billed for medical and surgical services and supplies in excess of the fee schedule for such services and supplies.
11. Wrongful act or negligence of another when an employee or dependent has released the responsible party, unless subrogation has been waived or reduced in writing in an individual case, solely at EGID’s option, and only for good cause.
12. Travel cost related to organ transplants.
13. Charges for injuries resulting from war or act of war (whether declared or undeclared) while serving in the military or an auxiliary unit attached to the military or working in an area of war whether voluntarily or as required by an employer.

Claims filing and payment

Network

Network providers file your claims for you and payment is automatically made to your provider.

Non-network

Non-network providers are not required to submit claims on your behalf. Ask if the provider will submit the claim on your behalf using the appropriate form or if they can provide you with a completed form so that you can file the claim yourself. Physician services must be billed on a CMS 1500 claim form, and hospital and outpatient facility services must be billed on a UB-04 claim form. If the non-network provider will not file the claim on your behalf, you will have to file your claims personally. A member self-submission medical claim form is available by logging on to healthchoiceconnect.com or by contacting Customer Care. Refer to HealthChoice Plan Contact Information.

Non-network claims are usually paid to you; however, you can choose to assign benefits to be paid directly to your provider. When a valid assignment of benefits to the provider is submitted with your claim, payment is made to the provider. When there is no valid assignment of benefits, payment is made to you, and you are responsible for paying your provider.

For HealthChoice to process a member self-submission claim, the following information is required.

• Member information: Name, Date of Birth, Member ID, and Address.
  
• Patient name.
  
• Billing CPT/HCPCS code(s).
• Diagnosis code(s).
  
• Provider’s information: Name, Tax-ID number (TIN), and NPI number.
  
• Date(s) of service.
  
• Total billed amount.Your provider will need to provide you with the CPT/HCPCS code(s), diagnosis code(s), and the required provider information. Completed claim forms should be submitted to the address listed on the back of your HealthChoice ID card. For questions on how to complete or submit a member claim form contact Customer Care. Refer to HealthChoice Plan Contact Information.
  

Claims filing deadline

Claims must be submitted to HealthChoice no later than 365 days following the date of service or date the supply was received. For example, if the date of service is Feb. 1, 2021, the claim is accepted through Feb. 1, 2022.

Claims for services outside the United States

If you receive medical treatment, services, supplies or prescription drugs outside the United States, follow these claim procedures:

• Make arrangements to pay for the services or supplies.
  
• Submit an itemized statement for reimbursement.
  
• Have claims translated into English with U.S. dollar amounts before you file your claim.
  
• Convert charges to U.S. dollars using the exchange rates applicable for the date of service.
• File the original claim along with the translation; the plan does not pay any costs for translating claims or medical records.Itemized bills should be sent to:HealthChoiceP.O. Box 99011Lubbock, TX 79490-9011Allowable amounts are paid in accordance with your plan’s non-network benefits. You are responsible for amounts above the allowable amounts.

Coordination of benefits

You are required to annually verify if you or any of your covered dependents have other medical or pharmacy coverage. You should also notify us anytime you or your covered dependent(s) adds or drops other health insurance. You may complete your verification by registering at healthchoiceconnect.com or by calling Customer Care at 800-323-4314. You can also do this when completing the annual Tobacco-Free Attestation. Failure to verify other insurance coverage will result in denial of claims until verification is completed.

This process establishes which insurance plan is primary when two plans must work together to pay claims for the same person. Coordinating benefits ensures that the two plans do not pay more than the total amount of the claim, thereby helping to reduce the cost of insurance premiums.

If you have questions about how your pharmacy benefits will be affected by coordination of benefits, contact the pharmacy benefit manager. Refer to HealthChoice Plan Contact Information.

Explanation of benefits

Each time a claim is processed, Customer Care creates an explanation of benefits that explains how your benefits are applied. Your EOB includes:

• Amount allowed.
  
• Amount not covered.
  
• Coinsurance.
• Copay.
• Date of service.
• Deductible.
• Explanation code.
• Provider write-off.
• Provider.
• Total benefits.
• Total billed amount.
  

Your EOBs are available through HealthChoice Connect at healthchoiceconnect.com. If you have difficulty accessing your EOB online, contact Customer Care. Refer to HealthChoice Plan Contact Information.

Claims requiring additional information

If your medical claim requires additional information for processing, your EOB identifies the specific information needed. In some instances, a letter is also sent that explains what information is required to complete claim processing. Your claim is closed until this information is received.Please be sure to include your member ID number and claim number when returning the requested information. Once the information is provided to Customer Care, your claim is automatically processed. You do not need to resubmit your claim.

Disputed claims procedure

If your claim is denied in whole or in part for any reason, either you or your authorized representative can request that the claim be reviewed by submitting a written request to the HealthChoice Appeals Unit at the address listed below within 180 days of your receipt of a denial.

HealthChoice Appeals Unit
P.O. Box 3897
Little Rock, AR 72203

Please follow the steps below to make sure that your appeal at any level is processed in a timely manner:

• If applicable, send a copy of any letter regarding a decision of your appeal.
• Send a copy of the EOB with any relevant additional information (e.g., benefit documents, medical records) that could help to determine if your claim is covered under the plan.
• Provide a letter summarizing the request for reconsideration that includes your name, the claim or transaction number, HealthChoice member ID number, the name of the patient and their relationship to member.
• Include Attention: Appeals Unit on all supporting documents. Be certain the member ID appears on each document.
• If you choose to designate an authorized representative, you must provide this designation to us in writing.
• If your situation is medically urgent, you may request an expedited appeal, which is generally conducted within 72 hours. If you believe your situation is urgent, follow the instructions above for filing an internal appeal and also call Customer Care to request a simultaneous external review.

Your HealthChoice plan’s internal appeals process includes two internal review levels. If you are not satisfied with the final internal review determination due to denial of payment, coverage or service requested, you may be able to ask for an independent, external review of our decision by either an independent review organization or a grievance panel. The entity that performs the external review depends on the nature of your appeal.

When considering complaints by insured members, the three-member grievance panel shall determine by a preponderance of the evidence whether EGID has followed its statutes, rules, plan documents, policies and internal procedures. The grievance panel shall not expand upon or override any EGID statutes, rules, plan documents, policies and internal procedures.To request access to and copies of all documents, records and other information about your claim, free of charge, contact Customer Care. Refer to HealthChoice Plan Identification.

Subrogation

Subrogation is the process through which HealthChoice has the right to recover any benefit payments made to you or your dependents by a third party or an insurer because of an injury or illness caused by the third party. Third party means another person or organization.

Subrogation applies when you are sick or injured as a result of the negligent act or omission of another person or party. If you or your covered dependents receive HealthChoice benefits and have a right to recover damages, the plan has the right to recover any benefits paid on your behalf. All payments from a third party, whether by lawsuit, settlement or otherwise, must be used to repay HealthChoice. The Make Whole and Common Fund Doctrines do not apply.

Example: While in your vehicle, you are hit by another driver who is at fault. In the accident, you have injuries that require medical attention. HealthChoice processes your medical claims, and when the auto insurance claim is settled, the other driver’s insurance (third party) or your uninsured/underinsured/med pay motorist policy repays HealthChoice the amounts it paid for your accident-related medical claims. If the third party or an insurer pays you or your dependent directly, you are responsible for repaying HealthChoice.

If you are asked to provide information about the injury or accident to the HealthChoice subrogation administrator at the law firm of McAfee & Taft, any related claims are pended until you have supplied the necessary information. Failure to provide the required information in a timely manner may result in your claim being denied.

Refer to HealthChoice Plan Contact Information.

Provider-patient relationship

You can choose any provider or practitioner who is licensed or certified under the laws of the state in which they practice, and who is recognized by the plan. Each provider offering healthcare services and/or supplies is an independent contractor. Providers retain the provider- patient relationship with you and are solely responsible to you for any medical advice and treatment or subsequent liability resulting from that advice or treatment.Although a provider recommends or prescribes a service or supply, this does not necessarily mean it is covered by the plan.

For information on the types of providers recognized by the plan, contact Customer Care. You can also search for a HealthChoice network provider at healthchoiceconnect.com.

Intentional misrepresentation

Coverage obtained by means of intentional misrepresentation of material fact is canceled retroactive to the effective date, and premiums you paid for coverage are refunded. Refunded premiums are reduced by any claims paid by HealthChoice.

Confirmation statements and corrections to benefits elections

When a change is made to your coverage, you are mailed a confirmation statement, which lists your coverage and the effective date and premium amount for your coverage. It is provided so you can review changes and identify errors as soon as possible.

If you find errors your coverage and the effective date and premium amount for your coverage. It is provided so you can review changes and identify errors as soon as possible.If you find errors to your benefits elections, you should submit corrections within 60 days. Current employees must submit corrections to their insurance/benefits coordinator, and former employees must submit corrections directly to EGID. Corrections reported after 60 days are effective the first of the month following notification.

Member Audit Program

Despite your provider’s best efforts, the complexity of arranging for your care and treatment may result in inaccurate billing, so it is important to check your bill carefully. If you discover certain mistakes in your bill, you can share in the savings through the Member Audit Program. You can receive up to 50% of any savings resulting from a billing error you find, limited to a maximum reimbursement of $200 per incident/$500 per year, per member or family. Please note that the error must have impacted the actual benefit amount paid by at least $50.

Eligible errors include charges for services not provided or charges that are billed incorrectly. Billing mistakes such as transposed numbers, addition mistakes and misplaced decimals are not eligible for the program. Only charges for services covered by the plan are eligible. 

Inpatient hospital and ambulatory surgery center charges are not eligible since billing is not based on individual items.

If you find an error on a medical bill and you wish to participate in the Member Audit Program, you can call the EGID toll-free hotline at 866-381-3815, email egid.antifraud@omes.ok.gov, or send a report in writing to:

EGID Compliance Officer
2401 N. Lincoln Blvd., Ste. 300
Oklahoma City, OK 73105

Note: No incentives will be provided for pre-deductible expenses for HDHP members unless the service is preventive.

Right of recovery

HealthChoice retains the right to recover any payments made by the plans in excess of the maximum allowable amounts. HealthChoice has the right to recover such payments, to the extent of excess, from one or more of the following:

• Any persons to, or for, or with respect to whom such payments were made.
  
• Any other insurers.
  
• Service plans or any other organizations.

You are eligible to participate in the HealthChoice plans if you work for a participating employer and are:

• A current education employee eligible to participate in the Oklahoma Teachers’ Retirement System and working a minimum of four hours per day or 20 hours per week.
  
• A current State of Oklahoma, local government, or certain nonprofit employee regularly scheduled to work at least 1,000 hours a year and not classified as a temporary or seasonal employee.
  
• A person elected by popular vote, e.g., board members for education and elected officials of state and local government, state employees, rural water district board members, county election board secretaries, and any employee otherwise eligible who is on approved leave without pay, not to exceed 24 months.
  
• A new employee.

As a new employee, your coverage is effective the first day of the month following your employment date or the date you become eligible with your employer. If you want to make changes to the coverage you initially elected, you have a 30-day window following your eligibility date to make benefits changes. These changes are effective the first day of the month following the date the changes are made.

Dependent coverage

You must be enrolled in one of the health plans in order to enroll your dependents. If dependent coverage is selected, all of your eligible dependents must be covered. Note: Exceptions may apply for COBRA participants and surviving dependents. Refer to Excluding Dependents from Coverage in this section for exceptions to this rule.If you are enrolled in one of the health plans and have a new dependent as a result of marriage, birth, adoption or placement for adoption, you can enroll your dependent provided you request enrollment within 30 days following the marriage, birth, adoption or placement for adoption. All other enrollments must be made during the annual Option Period.

Former employees can make changes only within 30 days of a qualifying event. Dependents or new benefit plans, other than vision, cannot be added during the annual Option Period.

If your spouse is also a primary member of a HealthChoice health plan through their employer, dependent children can be covered under either parent’s health plan, provided the parent is also enrolled. Dependent children cannot be covered under both parents’ plans.

Eligible dependents

Eligible dependents include:

• Your legal spouse (refer to the paragraph on common-law marriages in this section).
  
• Your daughter, son, stepdaughter, stepson, eligible foster child, adopted child, child for whom you have been granted legal guardianship or child legally placed with you for adoption, up to age 26, whether married or unmarried. Note: Plan coverage that terminates upon the dependent’s 26th birthday will terminate at the end of the month in which the birthday occurs.
• Your dependent, regardless of age, who is incapable of self-support due to a disability that was diagnosed prior to age 26; subject to medical review and approval of the Disabled Dependent Assessment form, which must be received at least 30 days prior to the dependent’s 26th birthday.
• Other unmarried children up to age 26 who live with you and for whom you are primarily responsible. This requires completion of an acceptable Application for Coverage for Other Dependent Children. A tax return showing dependency can be provided in lieu of the application.

Common-law marriages are recognized by the plan. A new employee can add a common-law spouse at the time of enrollment. A current employee can request coverage on a common-law spouse during the annual Option Period or in the event the common-law spouse loses other health coverage.* To enroll a common-law spouse, the employee and spouse must sign and submit an enrollment or change form.

Note: A former employee can add a common-law spouse only if the common-law spouse loses other health coverage.*

*Other health coverage cannot be an excepted benefit. Refer to Excepted Benefits in Plan Definitions.

Adding a newborn to coverage:

• Newborns must be added the first of the month of the child’s birth. You have 30 days from the date of birth to enroll a newborn in coverage. An Insurance Change Form must be completed and submitted to your insurance/benefits coordinator or EGID.
• Premiums must be paid for the full month of the child’s birth.
  
• When one or more eligible dependents are currently covered, a newborn must be added to the same coverage, unless there is proof of other health coverage.
  
• When a newborn is added to coverage, all other eligible dependents must be enrolled in coverage if they are not already enrolled; however, you can elect to exclude your spouse from health coverage.
  
• You can request coverage for a newborn grandchild by completing an Application for Coverage for Other Dependent Children. Coverage for a newborn grandchild is retroactive to the first of the month of birth following the receipt and approval of an application and payment of premiums. After 30 days, a retired member cannot add a newborn to coverage without a qualifying event.
• A Social Security number for the newborn is not required at the time of initial enrollment but must be provided when it is received from the Social Security Administration. Current employees must provide the number to their insurance/benefits coordinator. Former employees must provide it to EGID.
  

Newborn Limited Benefit

A newborn has limited coverage for a routine birth for the first 48 hours following a vaginal delivery or for the first 96 hours following a C-section delivery without an additional premium. There are no benefits for services in addition to a routine hospital stay unless the newborn is enrolled in coverage and premiums are paid for the month of the birth.

Utilizing the Newborn Limited Benefit (NOT adding a newborn to coverage):

• There is no additional premium for the Newborn Limited Benefit.
• The Newborn Limited Benefit is subject to the annual deductible, coinsurance and plan limitations.
• You are responsible for any charges over and above the Newborn Limited Benefit regardless of the facility’s network or non-network status.
• Enrollment of other eligible dependents is not required.
• The Newborn Limited Benefit applies only if the mother or father of the newborn is covered under a HealthChoice health plan.Declining the Newborn Limited Benefit (NOT recommended):
• A Newborn Limited Benefit Waiver must be completed and returned to EGID to exclude a newborn from the Newborn Limited Benefit. To obtain a waiver, current employees should contact their insurance/benefits coordinator and former employees should contact EGID Member Services. Refer to HealthChoice Plan Contact Information.

Coverage for other eligible dependents

When you have not been granted custody, adoption or guardianship by a court and the dependent is not your natural child or stepchild, you can request coverage for other unmarried dependents up to age 26 by submitting an enrollment or change form and a copy of the portion of your most recent income tax return listing the children as dependents for income tax deduction purposes. Current employees must submit the form and tax return to their insurance/ benefits coordinator, and former employees must submit these documents to EGID.

In the absence of a federal income tax return listing the children as dependents, you must provide and have approved an Application for Coverage for Other Dependent Children as specified by the plan.

Coverage for other eligible dependents begins on the first day of the month following the date you obtain physical custody or date the Application for Coverage for Other Dependent Children is approved and never applies retroactively, except in the case of a newborn. Coverage for a newborn is effective the first day of the month of birth.

You must request coverage within 30 days of the date of initial placement, otherwise:

• Current employees cannot add dependents to coverage until the next annual Option Period.
• Former employees cannot add dependents to coverage at any future date.

Note: You must meet all eligibility requirements, cover all eligible dependents and pay all premiums.

The plan has the right to verify the dependent status of children, request copies of the portion of your most recent income tax return listing the children as dependents, and discontinue coverage for dependents who are deemed ineligible for coverage.

Legal adoption

An adopted dependent is eligible for coverage the first of the month you obtain physical custody of your child. You must submit an enrollment or change form, including a copy of your adoption papers. Current employees must submit the paperwork to their insurance/benefits coordinator and former employees must submit their paperwork directly to EGID. In the absence of adoption papers or other court records, someone involved in the adoption process, such as your attorney or a representative of the adoption agency, must provide proof of the date you actually received custody of your child pending the final adoption hearing.

You must request coverage within 30 days of the date of the initial placement for adoption, otherwise:

• Current employees cannot add dependents to coverage until the next annual Option Period.
  
• Former employees cannot add dependents to coverage at any future date.
  

Legal guardianship

Legal guardianship follows the same guidelines as an adoption. Refer to Legal Adoption in this section.

Excluding dependents from coverage

Any of your eligible dependents can be excluded from coverage if they have other qualified health coverage or are eligible for Indian Health Services or military health benefits. Excepted benefits do not qualify as other coverage. You can exclude your eligible dependent children who do not reside with you, are married, or are not financially dependent on you for support.

You can also exclude your spouse from health coverage. If you exclude your spouse and cover other eligible dependents, your spouse must sign the Spouse Exclusion Certification section of your enrollment or change form.

Changes to coverage after initial enrollment/HIPAA special enrollment rights

If you are a current employee and declined enrollment in a health plan because you had other individual* or group health insurance coverage, Indian Health Services or military health benefits, you can enroll:

• Within 30 days of the date you lose other coverage.
  
• During the annual Option Period

*To qualify, the individual coverage cannot be an excepted benefit. Excepted benefits include:

• Benefits that are generally not health coverage.
  
• Limited scope vision or dental benefits.
  
• Benefits for long-term care, nursing home care, home health care, or community-based care.
  
• Coverage for only a specified disease or illness, such as a cancer-only policy, and hospital indemnity or other fixed indemnity insurance.
  
• Coverage supplemental to Medicare, the Civilian Health and Medical Program of the Department of Veterans Affairs, or TRICARE, or similar coverage that is supplemental to coverage provided under a group health plan.
  
• Coverage provided under a separate policy, certificate or contract of insurance.
  

Certain qualifying events allow a midyear benefits change; however, an enrollment or change form must be completed within 30 days of the qualifying event. Examples of midyear qualifying events include:

• A change in your legal marital status, such as marriage, divorce or death of your spouse.
  
• A change in the number of your dependents, such as the birth of a child.
  
• A change in employment status that affects your eligibility or that of your spouse or dependent.
  
• An event that causes your dependent to meet, or fail to meet, eligibility requirements.
  
• Commencement or termination of adoption proceedings.
  
• Judgments, decrees or orders (your employer may allow changes only to health and dental).
  
• Medicare eligibility for you or a dependent.
  
• Medicaid eligibility for you or a dependent; only two changes are allowed per plan year, once out and once back in or vice versa.
  
• Changes in the coverage of your spouse or dependent under another employer’s plan.
  
• Eligibility for leave under the Family and Medical Leave Act.
  
• The Uniformed Services Employment and Reemployment Rights Act of 1994.
  

To request special enrollment or obtain more information, current employees contact your insurance/ benefits coordinator. Former employees contact EGID member services. Refer to HealthChoice Plan Contact Information.

Current employees

You can make changes to coverage only within 30 days of a qualifying event or during the annual Option Period.All changes to coverage must be in compliance with the rules of your employer’s Section 125 plan, or if no 125 plan is offered, in compliance with allowed midyear coverage changes as defined by Title 26, Section 125, of the Internal Revenue Codes (as amended) and pertinent regulations. Current employees must contact their insurance/benefits coordinator and complete an enrollment or change form.

Former employees and surviving dependents

You can make changes to coverage only within 30 days of a qualifying event. Dependents or new benefits plans, other than vision, cannot be added during the annual Option Period.Former employees and surviving dependents must submit a written request for changes in coverage to:

EGID
P.O. Box 58010
Oklahoma City, OK 73157-8010

Requests for changes can also be faxed to 405-717-8939. Verbal requests for changes in coverage are not accepted.

Note: Oklahoma law prohibits dropping your spouse/dependents if you are in the process of a divorce or legal separation at any time. If you are in the process of separation or divorce, it is important that you contact your legal counsel for advice before making any changes to your coverage.

Options for current employees called to active military service

Under USERRA, coverage can be continued for up to 24 months. USERRA provides certain rights and protections for all employees called to serve our nation. All branches of the military, all military reserve units and all National Guard units come under USERRA.

In addition to health care provided by the military, you have the following four choices regarding your current coverage:

• Retain all coverage. Your current employer is responsible for collecting and forwarding all premiums to EGID.
• Discontinue member coverage but retain dependent coverage. This is the COBRA option and dependents are billed directly at 102% of premiums, the COBRA rate, for health, dental and/or vision coverage. Under COBRA rules, life insurance cannot be retained.
• Discontinue all coverage except life insurance. You are billed directly.
• Discontinue all member and dependent coverage.

Each month, you must pay the full premium for the coverage you selected. Failure to pay premiums timely can result in the termination of coverage at the end of the month for which the last full premium was received. There is no penalty for renewing coverage upon discharge from active duty if coverage is elected within 30 days of your return to the same employment.

Regardless of whether you receive written or verbal military orders, EGID staff and/or your insurance/ benefits coordinator will assist you in making any benefits arrangements. If you are a member of a military reserve unit or the National Guard and anticipate being called to active service, notify your insurance/benefits coordinator at work.

Leave without pay – current employees

If you are on approved leave without pay through your employer, you can continue coverage for up to 24 months from the day you begin leave without pay status. You must make timely premium payments in full each month to your insurance/benefits coordinator.If your coverage terminates for failure to pay premiums on time, you can re-enroll upon returning to work.If you take leave under the Family and Medical Leave Act, please make premium payment arrangements with your employer before you take leave.

Special rules for those eligible for Medicare

If you are a current employee and you or your covered dependents become eligible for Medicare, either as a result of age or because of disability, your employer’s group plan remains primary and Medicare is your secondary coverage.You can accept or reject coverage under your employer’s group health plan. If you reject your employer’s plan, Medicare becomes the primary payer for Medicare-covered health services. Additionally, your employer cannot provide you with a plan that pays supplemental benefits for Medicare-covered services or subsidize such coverage. Upon termination of employment, Medicare coverage becomes your primary insurance carrier.

If you are a former employee and you or your covered dependent is under age 65 and eligible for Medicare, you must notify EGID and provide the Medicare number as it appears on the beneficiary’s Medicare Health Insurance card. Medicare supplement coverage is effective the date you become eligible for Medicare, or the first day of the month following notice to EGID, whichever is later. Late notice does not allow for a refund of excess premiums paid.

For further information regarding Medicare enrollment, call Social Security toll free at 800- 772-1213. TTY users call toll free 800-325-0778. You can also access information regarding Medicare enrollment at Medicare.gov or call Medicare toll free at 800-633-4227. TTY users call toll free 877-486-2048.

Proof of creditable prescription drug coverage

All of the HealthChoice health plans provide creditable prescription drug coverage. This means the prescription drug coverage offered through HealthChoice is at least as good as the standard Medicare Part D prescription drug coverage and meets the benefits guidelines set by Medicare.

If you or your spouse leave the employment that allows you to participate in HealthChoice coverage, you have the option to continue coverage through the HealthChoice Medicare supplement plans, which includes either Medicare Part D prescription drug coverage or creditable prescription drug coverage.