The MADA Insurance Trust is committed to providing quality benefits while ... claims to EBMS on your behalf and agree to limit what they will charge for.
MTADA Insurance Trust
2021 Member Guide
The MADA Insurance Trust is committed to providing quality benefits while managing costs through innovative solutions. Countrywide, healthcare costs continue to trend upward and currently account for over 20% of U.S. Gross Domestic Product. Inflation in healthcare costs, coupled with the lack of competition and transparency in Montana's healthcare industry, is a continual struggle for all health plans in Montana. While only 10% of the total number of claims submitted to MADA Insurance Trust are for payments to hospitals or care facilities, these payments amount to 60% of the total dollars the Trust spends. To combat these problems, the Trust has put into effect the following cost-control solutions:
1. Direct contracts and partnerships with Montana hospitals and surgery centers. 2. Access to most Montana physicians through the InterWest Practioner-only Network
(https://interwesthealth.com/providers/). 3. Balance bill protection for out-of-network services from ELAP (1-800-977-7381). 4. Patient advocacy services and second opinions from VezaHealth (1-800-970-6571).
Montana Hospital Partners
The Trust has partnered with the following hospitals and surgery centers listed to the right. These healthcare providers will accept and submit claims to EBMS on your behalf and agree to limit what they will charge for services based on agreed to allowable limits. By going to these providers you will avoid the risk of balance billing.
Montana Hospital Partners are fully executed at:
Anaconda, MT Community Hospital of Anaconda Billings, MT St. Vincent Healthcare Billings, MT - Yellowstone Surgery Center Butte, MT St. James Healthcare Forsyth, MT Rosebud Health Care Center Glendive, MT Glendive Medical Center Great Falls, MT Benefis Health System Great Falls, MT Great Falls Clinic Helena, MT St. Peter's Hospital Lewistown, MT Central Montana Medical Center Miles City, MT Holy Rosary Healthcare Missoula, MT Community Medical Center Whitefish, MT North Valley Hospital
IMPORTANT
Some out-of-network providers may ask that you pay in advance of receiving services and/or required to complete a self-
pay form. If you are asked to pay in advance of receiving services or complete a self-pay form, please contact EBMS at
866.894.1499 and they will assist you. If you are asked to sign any form detailing the estimated cost for your services, or if
you are not sure what to do when asked to sign anything, please contact EBMS at 866.894.1499 immediately. Out-of-
network practitioner claims will be processed by EBMS at 90% of UCR (usual, customary and reasonable charge) to set the
allowable payment limit. Most providers will accept 90% UCR as payment in full, however for those that don't, you
could be balance billed for the difference between their billed charge and the Plan's 90% UCR allowable payment
limit.
MTADA Insurance Trust Member Guide | Page 2
InterWest Practitioner-only Network
For care outside of the hospital (care from a physician's office), this Plan contains provisions under which you may receive more benefits by using InterWest's physicians. ("Preferred Providers" or "PPO Providers"). PPO Providers are individuals and entities that have contracted with the Plan to provide services to our members at pre-negotiated rates. The Preferred Provider list can change; therefore, it is important you verify with the provider that they are in InterWest's Practitioner-only network before receiving services. You are responsible for determining a provider's participation in InterWest. To access a list of Preferred Providers, visit https://interwesthealth.com/providers/ and select Practitioner-only Network. Physicians associated with Billings Clinic and Kalispell Regional Medical Center do not participate in the Preferred Provider Organization (PPO).
Balance Bills
On January 1, 2015, the MADA Insurance Trust began reimbursing hospitals and other non-physician facilities based on a model designed to ensure these providers earn a reasonable profit while also allowing the Plan to avoid paying excessive and unreasonable charges that bear no relation to the value of services received. The Trust contracts with ELAP Services, LLC, which audits all Non-Network facility claims to determine an allowable payment limit equal to the greater of Medicare's allowable payment plus 20%, or the actual cost of the service plus 12%. The facility or air ambulance carrier could bill you for the difference between the allowable payment limit, referred to as the Eligible Amount shown on your EBMS Explanation of Benefits, and the Facility's actual charge after your deductible and coinsurance has been applied as shown on your EBMS Explanation of Benefits in the Ineligible Amount column is called balance billing. If you are balance billed, contact ELAP immediately, and their attorneys will defend your balance bill at no cost to you.
ELAP is not available for balance bill defense of practitioner claims. Since some claims could be processed as both a practitioner and a facility claim (e.g. doctor visit with lab work), we suggest that you contact EBMS at (866) 894-1499 for assistance as they can tell you if your claim was sent as a practitioner claim, a facility claim, or both, and if your claim is eligible for balance bill defense in the event you are balance billed.
ELAP Balance Bill Department Contact Information: Call: (800) 977-7381 Live call center available 9:00am 7:00pm ET Off hours messaging system available to receive a next day call back
Email: balancebills@elapservices.com
Fax: (888) 560-2447
Also, DO NOT PAY UPFRONT FOR FACILITY SERVICES as you may pay more than what you may be required to pay under your health plan through ELAP audit. If you pay more than you are required, it is very likely you will not receive the additional amount back from the facility. If a facility is requiring you pay upfront or agree to a payment plan, please call EBMS right away at (866) 894-1499 for guidance.
MTADA Insurance Trust Member Guide | Page 3
70/30 -- Claim Example
Sally is covered on the the Traditional 70/30 health plans. She has met her $3,000 max out-of-pocket and suffered a fall resulting in a broken leg. Sally was sent to a nearby hospital which is partnered with the MADA Insurance Trust.
EBMS processes as follows:
1. The hospital charge is considered a facility claim so EBMS sends the claim to ELAP for audit. ELAP determines that $750 is a reasonable charge for the visit and sends the audit back to EBMS who sends an Explanation of Benefits (EOB) to both the hospital and Sally showing the "Patient May Owe" $0 because Sally had met her deductible/max and the Plan pays the $750 to the hospital; the balance of $500 is considered ineligible billed charges as documented in the EOB. The hospital didn't consider the $750 payment as payment in full so they bill Sally for the remaining $500; she has just been balance billed $500. Sally contacts ELAP for balance bill defense.
2. The surgeon is not in-network so EBMS processes the claims at 90% UCR which is $450. EBMS sends an EOB to both the doctor and Sally showing the "Patient May Owe" $0 because Sally had met her deductible/max and the Plan pays $450 to the surgeon. The surgeon didn't accept $450 as payment in full and bills Sally for$50; Sally has just been balance billed $50. Because this is a practitioner claim, this claim is not eligible for ELAP balance bill defense and Sally will be responsible for the$50 but can ask the provider to write-off the balance.
Sally's responsibility under the Plan is: $0-$50 (depending on if the surgeon balance bills her or not).
VezaHealth
Are you contemplating any inpatient or outpatient medical procedures? If so, VezaHealth can help you navigate the Healthcare System! There is also a $100 incentive that goes toward your deductible and/or max out of pocket for utilizing VezaHealth.
Highest Quality Physician Access
VezaHealth partners with the nation's most respected physicians who are leaders in their specialty. We carefully select these physicians because they are skilled in the latest minimally invasive technologies, they emphasize patient education, and they provide clinical options with the best outcomes.
Domestic Medical Travel
If the second opinion demonstrates that medical travel will result in better health and financial outcomes, the VezaHealth Consultant will manage all travel logistics and provide intensive case management consistent with the high-quality physician's recommendations.
Second Opinions
Members will receive second opinions from one of our high-quality physicians and learn about all their appropriate health care options.
Cost Control
Health plans will experience savings through VezaHealth's negotiations and the reduction of health care waste.
Holistic Approach
VezaHealth takes a holistic approach when partnering with health plans by understanding their goals, membership, and other partners. Similarly, we support patients by recognizing and accounting for their lifestyle and health goals.
MTADA Insurance Trust Member Guide | Page 4
Medical Benefit - Administered by EBMS
Deductible Individual Family Maximum Out-Of-Pocket Individual Family Coinsurance Physician Office Visit
RX Pharmacy
Traditional 70/30
$1,500 $3,000
$3,000 $6,000 70/30 $35 co-pay when utilizing a professional participating provider. No Deductible
Preventive Generic Generic Brand Name Formulary Brand Name Non-formulary Specialty Maximum Rx Out-of-Pocket
$0 $15 $40 50% $100 $1,450 Single/$2,900 Family
HSA 2800
HSA 4500
$2,800 $5,600
$4,500 $9,000
$2,800 $5,600 100/0 Medical deductible applies, then paid at 100% Applies to Deductible then below copays to $1,450 OOP
$0 $15 $40 50% $100 $1,450 Single/$2,900 Family
$4,500 $9,000 100/0 Medical deductible applies, then paid at 100% Applies to Deductible then below copays to $1,450 OOP
$0 $15 $40 50% $100 $1,450 Single/$2,900 Family
A $10,000 Unum life insurance policy is included for every covered employee in the Trust. One vision exam covered at 100% is included for every employee and dependent in the Trust.
MTADA Wellness Program - A benefit everyone should utilize...
A focus of the Trust is to help individuals maintain or improve their health. In order to reduce the chances of chronic diseases such as diabetes and heart disease the Trust offers comprehensive health screenings for members. It Starts With Me Health uses state of the art technologies and employs the best health professionals in the field to assure that you have a premier and private experience.
Health Screening: The basic health screening is covered 100% through your membership in the healthcare Trust, including employees, spouses and dependents 18 years old or older. The screening includes the following features: Comprehensive Metabolic Panel, Lipid Panel, Complete Blood Count, TSH, PSA, Blood Pressure, Body Composition, Personal Health Report, and Easy-to-Read Lab Report.
Non-Participation Surcharge: In order to increase participation, a surcharge of $60.00 per month will be applied to employee and spouse members who do not participate in the Trust sponsored screenings from It Starts With Me Health. The Trust provides annual health screenings throughout the year so please make sure you attend.
If you have questions you can reach It Starts With Me Health at (866) 932-6467.
MTADA Insurance Trust Member Guide | Page 5
Dental Benefit -- Insured by Delta Dental
Benefits & Covered Services
PPO Plan Pays
Diagnostic and Preventive
100%
Sealants
80%
Basic Restorative
80%
Oral Surgery
80%
Endodontics
80%
Periodontics
80%
Major Restorative
50%
Implants
50%
Orthodontics Child
50%
Orthodontics Adult
Not a benefit
TMJ Services
Not a benefit
DEDUCTIBLES PER CALENDAR YEAR
(Diagnostic, preventive and orthodontic
services are waived from deductible.)
Per enrollee
$50
Per family
$150
Benefits & Covered Services
PPO Plan Pays
MAXIMUMS
Per enrollee each Calendar Year
$1,200
Lifetime maximum for orthodontic services per enrollee WAITING PERIODS
$1,000
Major Restorative, Prosthodontics
12 months
Orthodontics Child
12 months
MONTHLY RATES
Premiums are separate from association dues and/or
fees charged to members and employees. Employee Only
$34.40
Employee & Spouse
$77.49
Employee & Child(ren)
$83.55
Employee & Family
$114.74
This program is offered per dealership. Your dealership may or may not have opted to offer this benefit.
Vision Benefit - Administered by EBMS
Benefits & Covered Services
Eye Exam, once per Calendar Year
Reimbursement Rate:
100%, no deductible
Benefit maximum per calendar year
1 exam per Calendar Year
Frames and Frame-type lenses or Contact Lenses
Reimbursement Rate:
80%, no deductible
Benefit maximum per Calendar Year
$320
This program is offered per dealership. Your dealership may or may not have opted to offer this benefit.
MTADA Insurance Trust Member Guide | Page 6
Savvy Healthcare + Benefits Tips
· Have an established Primary Care Provider. Find a local physician in the Interwest network that you like and is accessible to you. Being an active patient with a primary care provider is more important than ever. With online tools like MyChart and other telehealth solutions, you can receive support (e.g., change in prescription, minor medical support and advice) without going into the office. It's convenient and it helps you save money.
· Use online tools and telephonic services. Along with contacting your primary care provider with a web-based tool, there are other online and telephonic resources that will improve your healthcare experience.
o Ebms.com Requeset new ID cards, print off EOBs (Explanations of Benefits), view important documents (plan document, Summary of Benefits and coverages) and much more.
o Call VezaHealth (800) 970-6571 For support in seeking care outside of your community or to a receive a remote second opinion, call the nurses at VezaHealth.
o Dr. On Demand, Bridge by Benefis. Use app services like Dr. On Demand or Bridge by Benefis to replace unnecessary trips to the emergency room and urgent care facilities. Submit your receipts from these services to EBMS and they will apply it to your benefits.
· Review your EOBs and bills.
o It is critical you match any health care provider bill to the EOB you receive from EBMS. If the bill exceeds the "Amount You May Owe" noted on the EOB, call the provider and tell them you are not willing to pay the excessive, additional charge. If they are unwilling to reduce the charge, call our insurance consultant, Erin Jimison (406-696-7383).
o Review the EOB and provider bill to verify it only includes services you received. If you in fact find an erroneous or fraudulent charge you may earn 50% of the savings for your due diligence. Erin Jimison will be able to support you in this situation as well.
· Buy prescriptions wisely. Consider utilizing one of the mail order services for your prescriptions. It will save you time and money and will help the Trust continue to manage costs. There are also other coupon and cost-saving programs offered by ProAct. Simply, call the ProAct number on your ID card and see if you qualify for any of them.
MTADA Insurance Trust Member Guide | Page 7
MTADA Insurance Trust Partners
Employee Benefit Management Services (EBMS) Processing claims and customer service support. Access your benefit and claims information online (866) 894-1499 www.ebms.com
ELAP Audits facility claims (except for NRHA claims) to set allowable payment limits, checks for billing errors, and provides balance bill defense (800) 977-7381 www.elapservices.com
InterWest Primary network of practitioners (406) 542-1912 https://interwesthealth.com/providers/
ProAct Pharmacy benefit administrator (877) 635-9545 phone www.ProActRx.com
Unum Life insurance benefit (800) 854-1446
VezaHealth Second opinion and domestic travel services (800) 970-6571 www.vezahealth.com
MTADA Association executive office (406) 442-1233
www.mtada.com
Aligned Business Solutions Erin Jimison
(406) 696-7389 phone
erin@aligned-inc.com Member support and plan consulting - Call Erin with any questions or concerns regarding the benefits and programs.
DISCLAIMER: In the event there is a discrepancy between this communication and the plan documents, the plan documents will supersede any information in this guide.
MTADA Insurance Trust Member Guide | Page 8
Adobe PDF Library 15.0.4 PDF Export