Southern Illinois University Carbondale

Human Resources

Quality Care Health Plan (QCHP)

QCHP is the State's medical indemnity 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 nationwide OCHP networks consists of physicians, hospitals, ancillary providers, pharmacies (Medco retail and maintenance pharmacy network) and behavioral health services (Magellan behavioral health network). QCHP Networks are subject to change throughout the plan year. To access online network visit the CIGNA web site

YEAR MAXIMUMS AND DEDUCTIBLES

Plan Year Maximum Benefit

Unlimited

Lifetime Maximum Benefit

Unlimited

Plan Year Deductible

The plan year deductible is based upon each employee's annual salary (see chart below) for current plan year information)

Additional Deductibles*

*These are in addition to the plan year deductible.

Each emergency room visit $400

Non-QCHP hospital admission $200

Transplant deductible $100

Note: There is no additional deductible for admission to a QCHP hospital.

PLAN YEAR DEDUCTIBLES:

Employee's
Annual Salary

Member Annual Plan Deductible

Family Deductible Cap

$59,300 or less

$300

$750

$59,301 - $74,300

$400

$1,000

$74,301 and above

$450

$1,125

Retiree/Annuitant/Survivor

$300

$750

Dependents

$300

N/A

OUT-OF-POCKET MAXIMUMS:

Deductibles and eligible coinsurance payments accumulate toward the annual out-of-pocket maximum. 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. There are two separate out-of-pocket maximums; a general one and one for non-QCHP hospital charges. Coinsurance and deductibles apply to one or the other, but not both.

General:

$1,100 per individual

$2,750 per family per plan year

Non-QCHP Hospital:

$4,400 per individual

$8,800 per family per plan year

The following do not apply toward out-of-pocket maximums:

Prescription Drug benefits or co-payments
Behavioral Health benefits, coinsurance or co-payments.
Notification penalties.
Ineligible charges (amounts over Usual and Customary (U&C) and charges for non-covered services).
The portion ($50) of the Medicare Part A deductible the plan participant is responsible to pay.

QCHP - Medical Plan Coverage

Hospital Services

QCHP Network Hospitals (formally Preferred Provider Organization (PPO) Hospitals)

90% after annual plan deductible. No admission deductible.

QCHP (formally Non-PPO Hospitals)

$200 per admission deductible.

If the member resides in Illinois or within 25 miles of a QCHP network hospital and the member chooses to use a non-QCHP and/or voluntarily travels in excess of 25 miles when a QCHP network hospital is available within the same travel distance, the plan pays 65% after the annual plan deductible.

If the member resides in Illinois and has no QCHP network hospital available within 25 miles and voluntarily chooses to travel further than the nearest QCHP network hospital, the plan pays 65% after the annual plan deductible.

If the member does not reside in Illinois or within 25 miles of a QCHP network hospital, the plan pays 80% after the annual plan deductible.

Outpatient Services

Lab/X-ray

90% of Usual & Customary (U&C) after annual plan deductible

Approved Durable Medical Equipment (DME) and Prosthetics

80% of U&C after annual plan deductible.

Licensed Ambulatory Surgical Treatment Centers

90% of negotiated fee or 80% of U&C as applicable, after plan deductible.

Professional and Other Services

QCHP Physcian Network (formally the PPO Network)

90% of negotiated fee after the annual plan deductible.

U & C charges do not apply

Physician and Surgeon Services not included in QCHP Network

80% of U&C after the annual plan deductible for inpatient, outpatient and office visits.

Chiropractic Services (limit of 30 visits per plan year)

90% of negotiated fee or 80% of U&C, as applicable, after plan deductible.

Transplant Services

Organ and Tissue Transplants

80% of negotiated fee after $100 transplant deductible. Benefits are not available unless approved by the Notification Administrator, Intracorp. To assure coverage, the transplant candidate must contact Intracorp prior to beginning evaluation services.

Behavioral Health Services

Magellan administers the QCHP Behavioral Health Services benefit. Authorization is required for all behavioral health servies. For authorization procedures, see page 81 of the Benefits Handbook or call Magellan at (800) 513-2611.

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

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.