2015/16 MCC Staff
Medical Plans
Frequently Asked Questions
and Terminology
Plans Developed by the 2015 Health Benefits Task Force
9/30/2015
FREQUENTLY ASKED QUESTIONS
The Health Benefits Task Force (HBTF) included representatives from the Administrative
Support, Maintenance & Operations, Professional-Technical, Supervisory-Managerial,
Exempt and Public Safety employee groups. The mission of the HBTF was to
recommend modifications to our current health plan to reduce costs while maintaining
quality coverage. One aspect was to design a plan that would engage employees in the
use of their own health care. The HBTF concluded with recommending three (3) BCBS
PPO plan options to employees.
1. Q: What drives the cost of Health Care?
A: The cost of Health Care is driven by many factors including demographics, size of
group covered, experience (previous claims data) and level of plan coverage.
2. Q: Why is there so much focus on Health Insurance now?
A: Public Act 152 (PA 152) is legislation passed in 2011 that limits the amount an
employer can pay for health insurance. A public employer must limit its
contributions (including reimbursement of co-pays, deductibles, or payments in
Health Savings Accounts, Flexible Spending Accounts, or similar accounts used
for health care costs). There are two (2) options:

80/20- A public employer shall not pay more than 80% of the total
annual costs of all of the medical benefit plans it offers or contributes to
for its employees.

Hard Cap- For 2015, a public employer may not pay more than the sum
of $5,992.30 times the number of employees with single person
coverage, plus $12,531.75 times the number of employees with twoperson coverage, plus $16,342.66 times the number of employees with
family coverage.
3. Q: Which PA152 calculation does the College use?
A: The HBTF has recommended using the Hard Cap calculation.
4. Q: What are the plans being offered effective 7/1/15?
A: There are three (3) options (see MCC Staff Medical Plan Comparison sheet on
the HR Open Enrollment website for more information.):
 1 PPO Conventional plan
 2 PPO plans with High Deductibles and Health Savings Accounts (HSA’s)
 Cash-in-Lieu (will continue to be an option if it is currently offered to you)
5. Q: What will my premium (payroll deduction) be for each plan?
A: For the breakdown of premium (payroll deduction) see the MCC Staff Medical
Plan Comparison sheet on the HR Open Enrollment website.
6. Q: What types of dependents are included under “Two Person” coverage?
A: Two-Person coverage includes employee + spouse or employee + 1 child
(dependent).
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7. Q: What is a PPO plan?
A: PPOs are Preferred Provider Organizations that offer a larger choice of innetwork physicians. Under a PPO benefit plan, covered individuals can see innetwork specialists without a referral from their primary care physician and
retain the freedom of choice of providers and are given financial incentives (i.e.,
lower out-of-pocket costs) to use the preferred provider network.
8. Q: Why aren’t there any HMO plans being offered effective 7/1/15?
A: Vendors, including BCBS either didn’t offer HMO plans, would not co-exist with
other vendors offering HMO plans or would not guarantee rates if co-existing
with another vendors with HMO plans.
9. Q: What is important to know about “In-Network” vs “Out-of-Network” as it
relates to all of the PPO plans?
A: Although a PPO plan allows employees to go to any doctor or facility they
choose, there can be a significant increase in an employee’s out of pocket costs
if they go to an out-of-network doctor or facility. In-Network doctors, clinics,
hospitals and other providers agree to accept the fees they are reimbursed by
the insurance companies as payment in full. Typically, employees have fewer
out-of-pocket costs when they use in-network providers. Out-of-Network
doctors, hospitals and medical practitioners do not have an agreement with the
health insurance company and therefore employees will pay more to use such
providers.
10. Q: How do I determine if my doctor is in the BCBS network or find a doctor?
A: To find a BCBS doctor, go to the BCBS website at https://bcbsm.eproviderdirectory.com/.
Select PPO Plans – Group Enrollees under “Please select your plan”.
11. Q: Comparing the 3 plans, what are the key features?
A: See the Benefit Summaries for all 3 plans on the HR Open Enrollment website for
more information.
12. Q: Will cash-in-lieu continue to be an option if I opt out of health insurance
through MCC?
A: Yes. Cash-in-lieu will continue to be an option if it is currently offered to you. If
you currently have health insurance through MCC and decide to opt out and
receive cash in lieu, you will be required to provide proof of other health
insurance coverage. This has been our standard practice.
13. Q: What are Deductibles?
A: A deductible is the annual amount a member is required to pay for services
before the health insurance company begins paying for health care services.
There are deductible amounts for individual coverage and a different amount
for two person/family coverage.
Plan Deductibles
Plan 1 - $500/$1,000*
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Plan 2 - $1,300/$2,600
Plan 3 - $1,300/$2,600
*For 2-Person/Family coverage, one a single member meets the “individual” deductible amount of
$500, BCBS will begin paying for services for that member.
14. Q: What is a High Deductible Plan?
A: A high deductible health plan (HDHP) is a health insurance plan with lower
premiums and higher deductibles than a traditional health plan. Being covered
by an HDHP is also a requirement for having a health savings account. The
current guidelines for HDHP require a minimum deductible of at least $1,300 for
individual and $2,600 for two-person or family. The deductible must be met
before the insurance company will pay for benefits such as: Prescriptions, Office
visits (non-preventive care visits), Hospital care, etc. Preventive services are
covered at 100% and are not subject to the deductible.
15. Q: What is a Health Savings Account (HSA)?
A: An HSA is a tax-advantaged medical savings account. Unlike a Flexible Savings
Account (FSA), the money in an HSA rolls over from year to year and is yours,
even if you leave the employer. Employees can direct via payroll deduction, pretax dollars in an HSA to be used for the payment of qualified medical expenses,
such as anything that accrues towards your deductible or coinsurance. HSAs can
also be used in retirement. Qualified High Deductible Health Plans can be
aligned with a Health Savings Account (HSA) to help pay for the deductible and
coinsurance. You can contribute to both an HSA and FSA at the same time, but
if you have an HSA, you cannot use your FSA for medical related expenses. (See
Question #21 for more information).
Plans Eligible for an HSA
 Plan 2
 Plan 3*
*Because the Single Coverage rate under this plan is less than the Hard Cap limitations, this
plan will automatically come with an HSA partially funded by MCC. The difference between
the hard cap limitation and the premium amount will be placed in an HSA for the employee.
The employee can opt to contribute their own dollars as well.
16. Q: How much will the College automatically be contributing towards an HSA for
Plan 3 – Single Coverage?
A: The College will automatically contribute the following one-time contribution for
each employee that enrolls in the following plan:
Plan 3
Single
$523.64
17. Q: When will the College’s one-time contribution under Plan 3 single coverage
be deposited into the HSA?
A: July 1, 2015.
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18. Q: Are there limits to how much I can contribute to my Health Savings Account
(HSA) each year?
A: Yes, there are dollar limits to how much you can contribute during a benefit
period.


Individual
Two person/family
$3,350*
$6,750*
*These limits are subject to change by the IRS and are based on a calendar year (not fiscal).
19. Q: What bank will be administering the Health Savings Accounts?
A: HSA Bank will be the administrator for the Health Savings Accounts. (For more
information on HSA Bank see the Health Savings Account section of the HR Open
Enrollment Website).
20. Q: Can I choose my own bank to administer my Health Savings Account?
A: No. At this time the College will be utilizing only one vendor, just as we do for
the Flexible Spending Account.
21. Q: What if I am currently contributing to a Flexible Spending Account (FSA) and
want to utilize a Health Savings Account (HSA) beginning July 1, 2015?
A: If you open an HSA and you currently have an FSA, your FSA would then become
a Limited Purpose FSA. You can continue to participate in the FSA on a limited
basis, meaning that your FSA funds could continue to be used for dental and
vision expenses, as well as for dependent care (if you signed up for dependent
care). You cannot use FSA funds for medical expenses if you are contributing to
a health savings account (HSA).
22. Q: What happens to any leftover dollars in my current medical Flexible Spending
Account at the end of the year?
A: $500 maximum may be rolled over into the new fiscal year. IRS rules however,
require that you forfeit any money you have remaining in the account at the end
of the plan year (06/30/16) after the rollover and all qualified healthcare and/or
dependent care expenses have been submitted/reimbursed.
NOTE: If you have roll-over dollars to the next fiscal year, you CANNOT
contribute to an HSA, nor can the College contribute to an HSA on your behalf in
the new fiscal year beginning 7/1/15.
23. Q: What are post-deductible maximums?
A: Post-deductible maximums refer to the maximum out-of-pocket amount that an
employee will have to pay in copays once the deductible has been met. There
are maximum amounts for individual coverage and two person/family coverage.
Plans with Post-Deductible Maximums
Plan 1 - $5,850/$11,700
Plan 2 - $950/$1,900
Plan 3 - $950/$1,900
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24. Q: What are copays?
A: A fixed amount (for example, $30) you pay for a covered health care service,
usually when you receive the service. The amount can vary by the type of
covered health care service.
Some copays are not required until after a deductible is met. Once the
deductible is met the copays must be paid by the employee up to the postdeductible maximum.
 Plan 2
 Plan 3
25. Q: What is the Step Therapy for Prescription Drugs?
A: Step Therapy means “first step” medication is required before coverage of
“second step” drugs are covered. Generic drugs are usually in the “first step” so
that treatment starts with safe, effective and affordable drugs. If needed, more
expensive brand drugs are usually in the “second step”. BCBS will work with your
doctor to determine whether you have met Step Therapy requirements for
prescription drugs that require them.
26. Q: Will I have to go through Step Therapy if I’m currently on a brand name drug?
A: If you have already gone through step therapy with BCBS, you can continue to
take the drug and will not be required to go through Step Therapy again.
27. Q: Can I do mail-order for my prescriptions?
A: Yes. All you need to do is call BCBS’s mail order company, Express Scripts at
1-800-903-8346.
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HEALTH CARE TERMINOLOGY
BENEFIT PERIOD: A consecutive 12 month period during which the terms and
provisions of the coverage apply. Here at MCC, the Benefit Period is 7/1 through 6/30.
COPAYMENT: Copayment (Copay) means the amount each member must pay per visit
to a treating provider for certain covered services.
COVERED SERVICES: The services, treatments, or supplies identified as payable in your
insurance certificate of coverage. Covered services must be medically necessary to be
payable, unless stated otherwise.
DEDUCTIBLE: Deductible is the amount you pay out of pocket for health care services
before your health insurance plan begins to pay. For example, if your deductible is
$1,000, your plan won’t pay anything until you’ve met your $1,000 deductible.
EFFECTIVE DATE: The day your insurance coverage begins under your contract. Here at
MCC, for new hires, the effective date is the first of the month following your hire date.
For the current Open Enrollment Period it will be 7/1/14.
ELIGIBLE DEPENDENT: A dependent of a covered employee who meets the
requirements specified in the group contract to qualify for coverage. Under Health
Care Reform legislation, effective January 1, 2011, employers are required to make
available medical dependent coverage to children of employees until age 26, married or
unmarried. To be eligible for dependent coverage, a child is no longer required to be a
student, a tax dependent or live with the parents. If elected, coverage will continue
through December 31st of the year the child reaches 26 years of age.
EMERGENCY CARE: Medical care given at a Hospital Emergency Room for a serious
medical condition resulting from injury, sickness, or mental illness that arises suddenly
and requires immediate care.
EMPLOYEE CONTRIBUTION:
employee.
The portion of the insurance premium paid by the
FLEXIBLE SPENDING ACCOUNT (FSA): A Flexible Spending Account is designed to cover
specific out-of-pocket healthcare and dependent care (daycare) expenses you
anticipate during the course of the Benefit Period. The Flexible Spending Account allows
you to use pretax dollars to pay for healthcare expenses not covered by insurance and
dependent care.
Healthcare Dollars:
The total dollars you designate for Healthcare
reimbursement for the entire year are made available to you from day one of
the Benefit Period.
Dependent Care Dollars: The dollars are not made available to you until they
have been deducted from your paycheck.
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GENERIC DRUG: A chemically equivalent copy designed from a brand-name drug
whose patent has expired. Typically less expensive and sold under the common name
for the drug, not the brand name.
HEALTH SAVINGS ACCOUNT (HSA):
An HSA is a tax-advantaged medical savings
account. Contributions to an HSA can only be made when covered under a tax qualified
high deductible health plan. Other contributions and distribution prohibitions apply.
Unlike a Flexible Spending Account, the money in an HSA rolls over from year to year
and is yours, even if you leave the employer. Money in an HSA is used to pay for
qualified medical expenses, such as anything that accrues towards your deductible.
HSAs can also be used in retirement. High Deductible Health Plan’s often coexist with a
Health Savings Account (HSA). See High Deductible Health Plans for more information.
HIGH DEDUCTIBLE HEALTH PLANS (HDHP): Tax qualifying high deductible health plans
are defined by the Internal Revenue Service, have higher deductibles than typical health
plans and have maximum amounts that the subscriber can be required to pay out of
pocket under the plan. Current IRS minimum deductibles for tax qualified high
deductible health plans are $1,200 for individual and $2,400 for two-person or family
coverage. A HDHP operates on a network (HMO or PPO). A high deductible is set in
exchange for a lower premium. The deductible must be met before the insurance
company will pay for most benefits such as: Prescriptions, Office visits (non-preventive
care visits), Hospital care, etc. HDHP often coexist with an HSA.
IN-NETWORK: Doctors, clinics, hospitals and other providers with whom the health
insurance plan has an agreement and negotiated rates for services to care for its
members. Typically, members have fewer out-of-pocket costs when they use innetwork providers.
NETWORK: A defined group of providers typically linked through contractual
arrangements, which supply a full range of primary and acute health care services at
negotiated rates.
OPEN ENROLLMENT: The period of time, once a year, when employees have the
opportunity to enroll, drop or make changes to their benefit election for the upcoming
benefit period.
OUT OF NETWORK: Doctors, hospitals and medical practitioners other than those with
whom the health plan has an agreement; the employee pays more to use such
providers.
OUT-OF-POCKET COSTS: Out-of-pocket costs means all costs that a member must pay
including: copays, coinsurance and deductibles.
OUT-OF-POCKET MAXIMUM: Out-of-pocket maximum means the total amount of out
of pocket costs you must pay for covered services during each benefit period.
PARTICIPATING PROVIDER: A provider who has signed an agreement with the
insurance company to accept its payment for covered services as payment in full, less
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any deductible or copayment that applies.
These providers are considered “innetwork” and have negotiated rates for services.
POST-DEDUCTIBLE MAXIMUM: Post-deductible maximums refer to the maximum outof-pocket amount that an employee will have to pay in copays once the deductible has
been met. There are often differing maximum amounts for individual and two
person/family coverage.
PREADMISSION CERTIFICATION: The practice of reviewing claims for hospital
admission before the patient actually enters the hospital. This cost-control mechanism
is intended to eliminate unnecessary hospital expenses by denying medically
unnecessary admissions.
PREFERRED PROVIDERS: Physicians, hospitals, and other health care providers who
contract to provide health services to persons covered by a particular health plan.
PREFERRED PROVIDER ORGANIZATION (PPO): PPOs are managed care organizations
that offer integrated delivery systems (i.e., networks of providers) that are available
through a vast array of health plans and are readily accountable to purchasers for cost,
quality, access, and services associated with their networks. Under a PPO benefit plan,
covered individuals retain the freedom of choice of providers but are given financial
incentives (i.e., lower out-of-pocket costs) to use the preferred provider network
because providers in a preferred network have negotiated rates with the health
insurance plan for services.
PREMIUM: The cost of a health plan. This cost is typically shared between the
employer and the employee.
PREVENTIVE SERVICES: Those services aimed at prevention, early detection and early
treatment of health conditions. This includes routine physical examinations, routine
gynecological services, immunizations, preventive diagnostic screenings and well person
care. Under Health Care Reform legislation these preventive services are required with
no employee cost-sharing.
PRIMARY CARE PHYSICIAN: First contact, first-level professional care. Usually provided
by a general practitioner, internist, pediatrician, and physician but may also be provided
by a physician assistant, pediatric nurse-practitioner, etc.
PRIOR AUTHORIZATION: Prior authorization for certain medically necessary services
are often required in PPO Plans. Your physician is responsible for submitting prior
authorization requests for medically necessary services such as MRI’s, durable medical
equipment, certain inpatient care and certain outpatient services prior to receiving
these services.
PROVIDER: Any supplier of health care services, i.e., physician, pharmacist, case
management firm, etc.
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QUALIFYING STATUS CHANGES: Events that allow you to start, stop, or change your
benefit election at a time other than open enrollment. These events are defined by law
and include: change in marital status, change in the number of dependents, loss of
coverage elsewhere and legal judgments, decrees or orders.
REASONABLE AND CUSTOMARY: Fee-for-service payment to physicians based on the
usual and customary fee for the same service in the area where the practice is located
or on some other judgment of reasonableness.
SPECIALISTS:
Providers whose practices are limited to a specific disease
(rheumatologist); part of the body (ear, nose, and throat); age group (pediatrician); or
procedure (oral surgery). Specialists may be Board-certified, Board-eligible, or
otherwise specially trained through post-graduate residencies, etc., or merely selfstyled.
STEP THERAPY: A prescription protocol used insurance companies to utilize the most
cost-effective drug therapy for selective diagnoses. If the patient does not respond
satisfactorily, progressively more advanced therapy is prescribed as needed.
SUBSCRIBER: The person who signed and submitted the application for insurance
coverage. All communications from the carrier are addressed to the subscriber.
URGENT CARE CENTER: A medical facility where ambulatory patients can be treated on
a walk-in basis, without an appointment, and receive immediate, non-emergency care.
The urgent care center may be open 24 hours a day; patients calling an HMO afterhours with urgent, but not emergent clinical problems are often referred to these
facilities. Generally the copay for an Urgent Care visit is less than the copay for an
Emergency Room visit.
WELLNESS: A health care process that fosters awareness and attitudes toward healthy
lifestyles so that individuals can make informed choices to achieve optimum physical
and mental health.
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