QCHP 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 and any pharmacy for prescription drugs. Plan participants receive enhanced benefits resulting in lower out-of-pocket amounts when receiving services from a QCHP network provider. The QCHP has a nationwide network that consists of physicians, hospitals, ancillary providers, pharmacies and behavioral health services.
- QCHP comprises three independent components:
- Prescription drugs.
- Behavioral Health Services.
The coverage for prescription drugs and behavioral health services operates independently of medical benefits. It is not necessary to satisfy the medical plan year deductible in order to start receiving benefits for prescription drugs or behavioral health services; however, the prescription plan year deductible must be satisfied prior to receiving prescription benefits. An annual prescription deductible is applied for each individual covered on the plan each plan year. The prescription drugs and behavioral health services are not subject to out-of-pocket maximums and have their own plan administrator.
- The Member is always responsible for:
Plan year Deductible
The plan year deductible must first be satisfied before benefits begin, unless the family cap has been met. This deductible requirement applies to all services unless otherwise noted in this section. The plan year deductible also applies toward satisfying the out-of-pocket maximums.
An employee's plan year deductible is based on the employee’s annual salary as of the first of each April preceding the beginning of the plan year. The plan year deductible for an annuitant, retiree or survivor is not based on the member's annuity. To verify the plan year deductible or family cap, review the current Benefit Choice Options booklet or contact your agency group insurance representative (GIR). The plan year begins on July 1.
An employee's salary-based deductibles stay in force for the entire plan year, regardless of any change in salary. The annual deductible in force at the time of termination of eligibility under the Program remains in force for those who elect continuation of coverage under COBRA.
If a member retires, accepts a voluntary reduction in pay or returns to State employment at a different salary, the deductible is reassessed. Should the deductible requirement be reduced, only the lower deductible must be met; however, no reimbursements will be made if the lower deductible has been exceeded.
All family members’ plan year deductibles will be accumulated toward a family cap. Once the family as a unit has satisfied the family cap, no further plan deductibles will be taken for eligible charges incurred for the remainder of that plan year.
In addition to the plan year deductible, plan participants must pay an “additional” deductible for each emergency room visit that does not result in a hospital admission. An additional deductible will also apply for each admission to a non-QCHP hospital. Additional deductibles are waived for admission to a QCHP hospital or for medically necessary transfers.
Additional deductibles accumulate toward the annual out-of-pocket maximum, but do not apply to the plan year deductible.
After the annual plan year deductible has been met, the Plan generally pays most of the cost of services or supplies; but plan participants must pay a percentage, called coinsurance, of eligible charges.
If a member reaches the out-of-pocket maximum for their expenses, the plan pays 100% of all eligible charges. This out-of-pocket maximum protects plan participants from catastrophic medical expenses.
Annual Out-of-Pocket Maximum Expenses
The amounts paid toward deductibles and eligible coinsurance accumulates toward satisfying the annual out-of-pocket maximum.
After the 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.
There are two separate out-of-pocket maximums: an In-Network maximum and an Out-of-Network maximum. Coinsurance and deductibles apply toward one or the other, but not both.
- QCHP provides benefits for eligible charges for those covered services and supplies which are:
- Medically necessary.
- Based on U&C charges.
- QCHP covers charges for services and supplies that are medically necessary. Medically necessary services or supplies are those which are:
- Provided by a hospital, medical facility or prescribed by a physician or other provider and are required to identify and/or treat an illness or injury.
- Consistent with the symptoms or diagnosis and treatment of the condition (including pregnancy), disease, ailment or accidental injury.
- Generally accepted in medical practice as necessary and meeting the standards for good medical practice for the diagnosis or treatment of the patient’s condition.
- The most appropriate supply or level of service which can be safely provided to the patient.
- Not solely for the convenience of the patient, physician, hospital or other provider.
- Repeated only as indicated as medically appropriate.
- Not redundant when combined with other treatment being rendered.
Predetermination of Benefits
Predetermination is a method to ensure that medical services/stays will meet medical necessity criteria and be eligible for benefit coverage.
The plan participant’s physician must submit written detailed medical information to the medical plan administrator. For questions regarding a predetermination of benefits, contact the plan administrator.
Precise claim payment amounts can only be determined upon receipt of the itemized bill. Benefits are based on the plan participant’s eligibility and plan provisions in effect at the time services are rendered. Standard claim payment policies include, but are not limited to, multiple procedure reductions and U&C charges. Claim bundling/unbundling procedures will be applied to only services eligible for coverage under the Plan.
Usual and Customary (U&C) Charges
U&C is an amount determined by the plan administrator not to exceed the general level of amounts charged by providers in the locality where the charge is incurred when furnishing like or similar services, treatment or supplies for a similar medical condition.
The plan participant is responsible for the portion of the expense that is above U&C. Amounts in excess of U&C are not eligible charges and are not applicable to plan year deductible or out-of-pocket maximum.
IMPORTANT: The percentage of the claim that will be paid is always based on the U&C amount or the actual charge made by the provider, whichever is less.
The QCHP network includes hospitals and physicians throughout Illinois as well as nationwide. The network is subject to change. QCHP network hospitals provide quality inpatient and outpatient care at reduced rates, which result in savings to plan participants. Costs can be significantly reduced by using a QCHP Network hospital.
Medical Case Management
QCHP has a benefit called the Medical Case Management (MCM) Program. MCM is designed to assist the plan participant requiring complex care in times of serious or prolonged illness.
If a plan participant is confronted with such an illness, a case manager will help find appropriate treatment to ensure optimum benefits under the plan. Participation in MCM has proven to enhance benefits based on an evaluation of the individual’s needs. MCM is part of the benefits under QCHP. There is no cost to the plan participant for this service.
The referral to the MCM Program is made through either the MCM Administrator, the QCHP Plan Administrator or by request from a plan participant. The case manager serves as a liaison and facilitator between the patient, family, physician and other healthcare providers. This case manager is a registered nurse or other health care professional with extensive clinical background. The case manager can effectively minimize the fragmentation of care so often encountered within the health care delivery system in response to complex cases.
Upon completing the MCM review, the case manager will make a recommendation regarding the treatment setting, intensity of services and appropriate alternatives of care.
To reach the MCM Administrator, call the toll-free number listed in the plan administrator section of the current Benefit Choice Options booklet.
Notification is the telephone call to the notification administrator informing them of upcoming behavioral health services, surgery, outpatient procedure/therapy/service/supply or admission to a facility such as a skilled nursing facility.
If using a QCHP network provider, the medical provider is responsible for contacting the notification administrator on behalf of the plan participant.
If using a non-QCHP provider, the plan participant must direct their non-QCHP medical provider to contact the notification administrator to provide specific medical information, setting and anticipated length of stay to determine medical appropriateness.
Notification is required for all plan participants including those with Medicare or other insurance as primary payer. Failure to notify the plan within the required time limits will result in a financial penalty and the risk of incurring non-covered charges for services not deemed to be medically necessary.
Benefits for Services Received While Outside the United States
The plan covers eligible charges incurred outside of the United States for generally accepted medically necessary services usually rendered within the United States.
All plan benefits are subject to plan provisions and deductibles. The benefit for facility and professional charges is paid at the non-QCHP rate. Notification is not required for medically necessary services rendered outside of the United States.
Payment for the services will most likely be required from the Member at the time of services. Plan participants must file a claim with the plan administrator for reimbursement. When filing a claim, enclose the itemized bill with a description of the services translated to English and the dollar amount converted to U.S. currency, along with the name of the patient, date of service, diagnosis, procedure code and the provider’s name, address and telephone number.
In general, Medicare will not pay for health care obtained outside the United States and its territories. If Medicare is primary, include the Explanation of Medicare Benefits (EOMB) denying payment, along with the claim form and send to the plan administrator.
QCHP - Claim Filing Deadlines and Procedures
The following procedures and deadlines pertain to the QCHP, Prescription Drug Plan and Behavioral Health Services. Utilization of network providers usually eliminates the need to file paper claims; however, if an out-of-network provider is utilized the procedures and deadlines must be followed. Contact the appropriate plan administrator with any questions about covered services, benefit levels or claim payments.
Claim Filing Deadlines
- All Claims should be filed promptly. The plans require that all claims be filed no later than one year from the ending date of the plan year in which the charge was incurred.
Claim Filing Procedures
All communication to the plan administrators must include the Member’s Social Security Number (SSN) or Alternate Member Identifier (AMI) and appropriate group number as listed on the identification card. This information must be included on every page of correspondence.
Complete the claim form obtained from the appropriate plan administrator.
- Attach the itemized bill from the provider of services to the claim form. The itemized bill must include name of patient, date of service, diagnosis, procedure code and the provider’s name, address and telephone number.
- If the person for whom the claim is being submitted has primary coverage under another group plan or Medicare, the Explanation of Benefits (EOB) from the other plan must also be attached to the claim.
- The plan administrators may communicate directly with the Plan Participant or the provider of services regarding any additional information that may be needed to process a claim.
- The benefit check will be sent and made payable to the Member (not to any dependents), unless benefits have been assigned directly to the provider of service.
- If benefits are assigned, the benefit check is made payable to the provider of service and mailed directly to the provider. An EOB is sent to the plan participant to verify the benefit determination.
- Claims are adjudicated using industry standard claim processing software and criteria. Claims are reviewed for possible bundling and unbundling of services and charges. Providers may occasionally bill for services that are not allowed by the claim review process.