Understanding Your Health Plan

Links 

Covered Topics 

Words and Phrases

  • Glossary

$500 Deductible Plan

  • Master Schedule
$1,000 Deductible Plan
  • Master Schedule

$1,800 Deductible Plan

  • Master Schedule

South Dakota State Employee Health Plan Comparison Chart

  • Plan Comparison Chart
  • Selecting Coverage
  • When Coverage Becomes Effective
  • Option Not to Elect Coverage (Opt-Out)
  • Re-Enrolling in the Plan
  • Dual Coverage
  • Family Status Change
  • Special Enrollment Period
  • Late Entrants

Major Medical Benefits

  • Medical Out-Of-Pocket Limit
  • Obtaining Health Services
  • Medically Necessary Treatment
  • Usual, Customary, and Reasonable Charges (UCR) and/or Maximum Allowable Charges (MAC)
  • Covered Charges
  • Benefit Exclusions
  • Set Payments for CT/MRI/PET
  • Out of Country Coverage
  • Continuous Period of Illness or Injury

Managed Care Program

  • Pre-authorization Services In-State
  • Pre-authorization Out-of-State
  • Failure to Pre-authorize Hospital and Medical Services
  • Services Requiring Pre-authorization
  • Second Opinions
  • Services Requiring Second Opinions
  • Utilization Review Services
  • Medical Case Management
  • Intensive Medical Case Management

Prescription Drug Plan

  • Copayments
  • Pharmacy Deductible Per Person Per Plan Year
  • Pharmacy Out-of-Pocket Maximum
  • Special Rules for the $2,000 Deductible Plan (HSA Compatible)
  • Generics Policy
  • Covered Drugs
  • Limits to Benefits
  • Refills and Maintenance Drugs
  • Early Refill Policy
  • Drugs Requiring Pre-authorization
  • Step Therapy Programs
  • Prescription Drug Plan Exclusions
  • Submitting Claims

Latitude Wellness and Prevention

  • Health Screenings
  • Health Assessment
  • Latitude Programs
  • Asthma Condition Management Program
  • Chronic Pain Condition Management Program
  • Diabetes Condition Management Program
  • Cardiovascular Condition Management Program
  • Cancer Screening Procedures
  • Maternity Care
  • Our Healthy Baby
  • Well Child Care
  • Overview of Immunizations and Vaccinations (Chart)

Tobacco User Status

  • Identification of Tobacco User Status
  • Change to Tobacco User
  • Change to Non-Tobacco User
  • Verification of Tobacco User
  • Flowchart

Claims Payment Process

  • One-Stop Claim Processing
  • Automatic Claim Process
  • Processing Exceptions
  • Benefit Payments
  • Physical Exams, Autopsy, Second Opinions, and Release of Information
  • Claims Administrator's Right to Investigate Claims
  • Billing and Processing Error Incentive Program

When Coverage Ends and Continuation of Coverage

  • Approved Leave of Absense Without Pay
  • Retiree Coverage
  • Option to Continue Coverage (COBRA)
  • Electing Continuation Coverage (COBRA)
  • Continuation Coverage Ends
  • Healthcare Certification
  • Conversion of Coverage

Claims Action

  • Appealing a Denied Claim
  • Legal Action
  • Subrogation
  • Benefits Subject to this Provision
  • Definitions
  • Effect on Benefits
  • Medical Coverage for Senior Employees
  • Medical Coverage for Senior Dependent
  • Medical Coverage for Retired Employees
  • Medical Coverage for Certain Employees and Dependents

Plan Administration and Operations

  • Right to Release and Obtain Necessary Information
  • Facility of Payment
  • Right to Recovery
  • Assignment
  • Plan Modification and Amendment
  • Severability
  • Plan Termination