Quality Care Health Plan (QCHP)
The QCHP is a medical plan that offers a comprehensive range of benefits. The basic concept underlying this traditional approach to group health insurance is freedom of choice. You have the option to choose any physician or hospital for general or specialty medical services, and receive enhanced benefits by using QCHP hospitals, network pharmacies for prescription drugs and behavioral health network providers. As a member of the QCHP, you are responsible for plan year deductibles, special deductibles, and coinsurance amounts.
The QCHP benefit levels for the plan year (July 1, 2015 through June 30, 2016) are indicated in this FY16 chart. The QCHP benefit levels beginning July 1, 2016 are indicated in this FY17 chart. The QCHP is comprised of three independent components:
- Prescription drugs
- Behavioral health services
Prescription drug deductibles and copayments you pay apply to your out-of-pocket maximum; therefore, when you reach your out-of-pocket maximum, eligible medical, behavioral health and prescription drug charges will be covered at 100 percent for the remainder of the plan year.
Points to consider in making this choice:
- The freedom to choose any doctor or treatment site also means you may change your choice of doctor or treatment site at any time.
- Coverage is provided for some preventive and well-care services.
- An annual deductible and coinsurance apply to most medical services.
- An annual prescription deductible applies to each member.
- An out-of-network provider is generally paid at 60% of the Maximum Reimbursable Charge (MRC) based on Medicare rates in a geographical location, after the plan year deductible.
- The following do not apply toward out-of-pocket maximums: deductibles or co-payments; pre-certification penalties; ineligible charges (amounts over the maximum allowable charge, charges for non-covered services, and charges for services deemed not medically necessary).
- A mandatory pre-certification provision applies to hospital admissions, inpatient or outpatient surgical procedures, extended-care facility admissions and organ & tissue transplants.
- You may receive additional benefits and/or reductions in cost by using QCHP network providers for inpatient stays, hospital outpatient services, prescription drugs, and behavioral health services.
- You, or your provider, are required to submit claim forms for payment of benefits. The claims administrator is CIGNA.
FY 2017 Benefit Choice Options booklet (As of July 1, 2016)
FY 2016 Benefit Choice Options booklet (July 1, 2015 through June 30, 2016)
CMS QCHP Overview