Quality Care Health Plan (QCHP)

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Quality Care Health Plan (QCHP)

QCHP (administered by CIGNA) is the medical plan that offers a comprehensive range of benefits. Under the QCHP, plan participants can choose any physician or hospital for medical services; however, plan participants receive enhanced benefits, resulting in lower out-of-pocket costs, when receiving services from a QCHP network provider.

The QCHP has a nationwide network that consists of physicans, hospitals, and ancillary providers. Notification to Intracorp, the QCHP notification administrator, is required for certain medical services in order to avoid penalties. Contact Intracorp at (800)962-0051 for direction

QCHP utilizes Magellan for behavioral health benefits and the Express Scripts/Medco retail pharmacy network for prescription benefits. Plan participants can access plan benefit and particpating QCHP network information, Explanation of Benefits (EOB) statement and other valuable health information online at: www.cigna.com

Maximums and Deductibles

PLAN YEAR MAXIMUMS & DEDUCTIBLES

FY2015

FY2014

Plan Year and Lifetime Maximum

Unlimited

Unlimited

Employee's Annual Salary (based on each Employee’s annual salary as of April 1st)

Member Plan Year Deductible

Family Plan Year Deductible

Member Plan Year Deductible

Family Plan Year Deductible Cap

$60,700 - or less

$375

$937.50

$350

$875

$60,701 - $75,900

$475

$1,187.50

$450

$1,125

$75,901 and above

$525

$1,312.50

$500

$1,250

Retiree/Annuitant/Survivor

$375

$937.50

$350

$875

Dependent

$375

N/A

$350

N/A

Additional Deductibles

Emergency Room

$450

$425

QCHP Hospital Admission

$100

$75

Non-QCHP Hospital Admission

$500

$400

Out of Pocket Maximums

In-Network Out-of-Network
FY2015 FY2014 FY2015 FY2014
$1,500 Individual $1,500 Individual $6,000 Individual $6,000 Individual
$3,750 Family $3,750 Family $12,000 Family $12,000 Family

Deductibles and eligible coinsurance payments accumulate toward the annual out-of-pocket maximum. There are two separate out-of-pocket maximums; In network & Out-of-Network.  Coinsurance and deductibles apply to one or the other, but not both. After the out-of-pocket maximum has been met, coinsurance amounts are no longer required and the plan pays 100% of eligible charges for the remainder of the plan year. It is important to note that certain charges are always the member's responsibility and do not count toward the out-of-pocket maximum, nor are they covered after the out-of-pocket maximum has been met. Charges ineligible for payment by the plan include prescription deducible and copayments, amounts over U&C, charges for noncovered services, charges for services deemed to be not medically necessary and penalties for failing to precertify/provide notification. For QCHP, $50 of the Medicare Part A deductible is also the member's responsibility.


QCHP - MEDICAL PLAN COVERAGE

FY2015 Hospital Services

Service In Network Out-of-Network
Inpatient services 85% after the annual plan deductible and a $100 hospital admission deductible per admission 60% of U&C after the annual plan deductible and a $500 hospital admission deductible per admission
Mental Health and Substance Abuse Inpatient Facility and Partial Day Hospitalization 85% after the annual plan deductible and a $100 hospital admission deductible per admission 60% of U&C after the annual plan deductible and a $500 hospital admission deductible per admission
FY2015 Outpatient Services

Emergency Care - Hospital

Facility charges for treatment of emergency medical condition or injury. Note: Professional fees may be billed separately.

 85% after the annual plan deductible and a $450 emergency room deductible per visit 60% of U&C after the annual plan deductible and a $450 emergency room deductible per visit

Physician or Specialist Office Visit

  • Treatment of Illness or injury
  • Behavioral health
 85% after the annual plan deductible 60% of U&C after the annual plan deductible

Physician or Specialist Office Visits

Wellness care/Preventive healthcare (including womens' healthcare) are not subject to the health plan year deductible.		 100% 60% of U&C after the annual plan deductible

Outpatient Surgery

When billed as an office visit

 85% after annual plan deductible 60% of U&C after the annual plan deductible

Outpatient/Facility Surgery

When billed as outpaitient surgery at a facility

 85% after annual plan deductible 60% of U&C after the annual plan deductible
Imaging & Diagnostic Tests 85% after annual plan deductible 60% of U&C after the annual plan deductible
Hearing Services

Exam: up to $150 every three plan years

Hearing Aids: Up to $600 every three plan years

Exam: up to $150 every three plan years

Hearing Aids: Up to $600 every three plan years

Chiropractic Services

Note: Chiropractic care for maintenance is not covered.

 85% after annual plan deductible, maximum 30 visits per plan year 60% of U&C after the annual plan deductible, maximum 30 visitis per plan year
Ambulance Service for Emergency Care 85% after annual plan deductible 60% of U&C after the annual plan deductible

Skilled Nursing Facility Services

Note: Prior approval required

 85% after annual plan deductible 60% of U&C after the annual plan deductible

Durable Medical Equipment (DME) - Rental or purchase

Note: Prior approval required for certain DME

 85% after annual plan deductible 60% of U&C after the annual plan deductible

Outpatient Rehabilitation Services

  • Physical Therapy
  • Speech Therapy
  • Occupantional Therapy
 85% after annual plan deductible 60% of U&C after the annual plan deductible

Transplant Services

Note: Prior approval required

 85% after the annual plan deductible and a $100 transplant deductible, limied to network transplant facilities as determined by the medical lan administrator. Cover in-network only

FY2015 Pharmacy Services

Service Coverage
Plan Year Pharmacy Deductible $125
Generic $10
Preferred Brand $30
Nonpreferred Brand $60

FY2014 Hospital Services

Service Coverage
QCHP Hospital $75 deductible per hospital admission 90% after annual plan deductible
Non-QCHP Hospitals $400 deductible per hospital admission. 60% of allowable charges after annual plan deductible

FY2014 Outpatient Services

Service Coverage

Preventibe Services, including immunizations

 100%

Diagnostic Lax/X-ray

 90% in-network, 60% of allowable charges out-of-network, after annual plan deductible

Approved Durable Medical Equipment (DME) and Prosthetics

Liscensed Ambulatory Surgical Treatment Centers

FY2014 Professional and Other Services

Service Coverage

Services inclued in the QCHP Network

 90% after the annual plan deductible
Services not included in teh QCHP Network 60% of allowable charges after the annual plan deductible
Hearing Services

Exam: up to $150 every three plan years. Hearing Aids: Up to $600 every three plan years

Chiropractic Services

Note: Chiropractic care for maintenance is not covered.

 90% in-network, 60% of allowable charges out-of-network after the annual plan deductible

Organ & Tissue Transplants

Note: Prior approval required

 90% after $100 transplant deductible, limited to network transplant facilities as determined by the medical plan administrator. Benefits are not available unless approved by the Notification Administrator, Cigna.

FY2014 Pharmacy Services

Service Coverage
Plan Year Pharmacy Deductible $100
Copayment (30 day supply) Generic $10
Preferred Brand $30
Non-Preferred Brand $60

QCHP Notification Requirement, Penalties and Pre-Determination of Benefits:

Network providers are subject to change throughout the plan year. Always call the respective plan administrator to verify participation of a specific provider.

Notification is the telephone call to the health plan notification administrator, Intracorp, informing them of an upcoming admission to a facility such as a hospital or skilled nursing facility, or for an outpatient procedure/therapy. Notification is the plan partipant's responsibility and is a method to avoid monetary penalties and maximize benefits. Notification is required for all plan participants including those who may have benefits available from other primary payer insurance or Medicare. Intracorp can be reached by calling (800) 962-0051.

Failure to pre-certify with Intracorp (the medical pre-certification administrator) within specific time limits, will result in a $800 non-compliance penalty and the risk of incurring non-covered charges for services not deemed to be medically necessary.  A "reference number" will be assigned and should be maintained by the plan participant should there be any questions regarding notification; however, it is not a guarantee of benefits.

It is the member's responsibility to pre-certify prior to anticipated outpatient surgery or an inpatient hospital admission.  In the case of an emergency hospital admission, notification is required within 48 hours of your admission. 
If you have questions about whether a service needs to be pre-certified, call: 1-800-962-0051.

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