This information is intended to provide general guidance for members’ common questions about MUST. The Summary Plan Description document, related amendments, and Schedule of Medical Benefits may supersede this general information for specific eligibility and benefit questions.

What is the deadline for enrolling?

All completed enrollment forms must be received in the MUST office within 30 days of becoming eligible. Refer to the Summary Plan Description for details.

I am a new employee. When does my coverage begin?

This will depend on the bargaining agreement under which you were hired. The agreement may stipulate that you are eligible on your date of hire, or on the first day of the following month.  Newly acquired / newly eligible dependents can be added the day they become eligible. Note:  Activation of coverage depends on timely receipt of completed enrollment forms in the MUST office (30 days).

What should I do if I need to see a doctor and haven’t yet received my MUST identification card?

Call MUST Customer Service (1-800-845-7283) to verify that your enrollment forms have been received and processed. If they have, you will be given your group plan number verbally. The provider’s office will usually accept this, but if not, ask them to call the number above to verify your eligibility.

I lost my ID card. Can I get a new one?

Yes; call MUST Customer Service at 1-800-845-7283.

Can my children who are away at college get their own ID cards?

Yes; call 1-800-845-7283 to request their cards.

My employer offers more than one MUST health plan. Can I switch to a different plan?

You have an opportunity to switch plans each year, during your group’s annual open enrollment period.  You also may be able to switch mid-year if you qualify for a “special enrollment” period (see below).

What is a “special enrollment” period?

Employees and/or certain eligible dependents may enroll (or switch plans) after certain qualifying events. These events include marriage, birth or adoption of a child, involuntary loss of other coverage, and change in employment status. (Refer to the Summary Plan Description for details.)

To be eligible for special enrollment, the participant or district clerk must notify the MUST administration office within 30 days of the qualifying event and the appropriate paperwork (enrollment or change form) must be received by MUST within 60 days of the event.

When do my deductible and maximum out-of-pocket amounts start accumulating?

With MUST, your deductibles and out-of-pocket amounts accumulate according to your group’s benefit year, not the calendar year. This means your deductibles and maximum out-of-pocket amounts start over on either July 1 or September 1 every year, depending on your group’s renewal date.

I am currently enrolled in MUST and will soon take a job with a different school district (member group) that also offers MUST.  Will I get credit for deductible and out-of-pocket expenses I had already satisfied in my old district?

No.  Plan options, premiums, deductibles, and out-of-pocket maximums are established separately for each employer group. Credit cannot be given for the deductibles and out-of-pocket expenses that a new participant had incurred while enrolled in a previous employer’s group.

I have a pre-existing medical condition. Will the MUST plan impose any restrictions because of this?

It depends on when you enroll and whether you have had previous health coverage.  If you enroll as soon as you become eligible for coverage (such as upon hire), there is never a pre-existing condition exclusion period for you or your dependents who enroll with you.

However, if you waive coverage when first eligible but decide to enroll at a later date (such as during the annual open enrollment period), a pre-existing condition exclusion period of 18 months may be imposed. This exclusion period for pre-existing conditions is waived if there is creditable coverage from a prior health plan.

However, there is no such exclusion or limitation period for dependent children under the age of 19. 

What is creditable coverage?

The portability provisions of the HIPAA laws allow you to get credit for the time you were enrolled in another health plan.This helps ensure that you don’t have to start over in satisfying any pre-existing condition exclusion period. If you had prior health coverage for at least 18 months and had no more than a 63-day break in coverage, no exclusion for pre-existing conditions can be imposed.

When you leave one health plan, the carrier is required to provide you a Certificate of Creditable Coverage showing who was covered and for how long. Give this certificate to your new insurance carrier so that your pre-existing condition exclusion period can be reduced by the length of time you were covered on the prior plan. For example, if your new plan normally would impose an 18-month exclusion period but you were covered on a prior plan for 12 months, the exclusion period would be shortened to six months based on your creditable coverage.

Is pregnancy considered a pre-existing condition?

Pregnancy is never subject to pre-existing condition exclusions. A pregnant woman can enroll under the same eligibility rules as any other person. However, becoming pregnant does not create “special enrollment” rights.

Can my spouse stay on my insurance if we get divorced or legally separated?

No; the spouse must be dropped from the participant’s coverage and this must be reported to MUST within 30 days of the divorce or legal separation. The terminated spouse will be offered COBRA continuation coverage (refer to the Summary Plan Description for details).

Is my newborn automatically eligible under my coverage?

Yes, and newborns are also automatically covered for their first 31 days. However, if you wish to officially enroll your new child as a dependent under your plan, you, your district clerk, or benefit manager must notify the MUST administration office within 30 days after the birth. A completed Change Form then must be received in the MUST office within 60 days of the birth. Otherwise, you will need to wait until your group’s next open enrollment period to add the baby as a dependent.

What are the eligibility rules for children under 19?

To be eligible for coverage, the child must be all of the following:

• The participant’s natural child, stepchild, or adopted child; or a child for whom the participant has been appointed the legal guardian
• Unmarried
• In the physical custody of and financially dependent upon the participant. (This requirement is waived if the participant is required to provide coverage as part of a court order or divorce decree.)

What are the eligibility rules for children 19 and older?

Your unmarried child remains eligible until age 26 regardless of student status.

If I drop my dental or vision coverage, can I re-enroll later?

If you voluntarily drop your dental or vision coverage, you cannot re-enroll at the next annual open enrollment, but you could enroll two years later.

Does the vision plan pay for both glasses and contacts in the same year?

No. The plan allows for either contacts or glasses in the same 12-month period, but not both.

Are retirees eligible for MUST coverage?

Yes, retired employees and trustees are usually eligible if they were enrolled in a MUST plan prior to their retirement date. ( Retired trustees are eligible if they served two terms.) Retirees may also continue their employee-paid life insurance (if any) on a self-pay basis and at age-banded rates.

Documentation certifying retiree status from TRS or PERS is required, along with a MUST change form requesting the change from Active to Retiree status. For more information, see the Retiree Brochure on the Forms & Publications page.

I am a retiree turning 65. How will my claims be paid if I choose not to enroll in Medicare Part B?

We encourage all Medicare eligible participants to enroll in Medicare Part B. If you are eligible for Medicare Part B and choose to not enroll, MUST will estimate the amount that Medicare Part B would have paid for a covered service and will consider only the remaining balance for payment.

I am the District Clerk and I handle MUST enrollment for our employees. Is there a handbook or list of procedures available?

Yes. A Benefit Administration Handbook has been developed for your convenience. It is available from the Forms & Publications page of this Web site.

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What is a Health Savings Account (HSA)?

The Health Savings Account, or HSA, is a tax-favored way to put aside money for health expenses. Like a Flexible Spending Account (FSA), the employee can spend the funds on a wide variety of qualifying medical expenses as defined by the IRS. However, unlike the FSA, the employee does not lose any unspent funds. In fact, the money in the account always belongs to the participant, even if he/she leaves employment. 

There are several investment options that can provide tax-free growth for funds in the HSA. In this way, an HSA is similar to an IRA or 401(k) retirement plan, except that the participant does not have to wait until retirement to spend it. He or she can choose to spend the money today, or can let the account build for future medical emergencies. The money is never taxed as income if spent on qualifying medical expenses. If HSA funds are spent on non-qualifying expenses, the participant must pay income tax on the amount and if he/ she is under age 65 a 10% penalty will also apply.

To open an HSA, the participant must be enrolled in a qualifying plan (e.g., MUST's HM or HE plans) and cannot be enrolled in other medical coverage (including Medicare). The plan must meet federal guidelines and, therefore, not every health plan that has a high deductible is considered an HSA-qualified plan.  MUST has developed a variety of HSA-qualified health plans that meet the federal criteria.

Who can have an HSA?

To open an HSA, the participant must be enrolled in a qualifying health plan (HM or HE) and cannot be enrolled in other medical coverage (including Medicare). The plan must meet federal guidelines and, therefore, not every health plan that has a high deductible is considered an HSA-qualified plan.  MUST has developed a variety of HSA-qualified health plans that meet the federal criteria.

Please note that IRS rules generally prohibit having both a Flexible Spending Account (FSA) and an HSA, unless the Flexible Spending Account can only be used for a limited purpose, such as dental, vision, or child care.

How do HSA-qualifying plans compare to other MUST plans?

These plans provide coverage similar to other MUST plans, including preventive care. Higher deductibles generally equate to lower premiums, so the premium for the HM or HE plans are usually lower than they would be for another MUST plan with a smaller deductible.

With one version of the HSA-Qualifying Plan (HM), the individual deductible is irrelevant when the employee has elected coverage on two or more family members. In other words, the entire family deductible must be met before the plan will begin sharing costs. However, unlike other MUST plans, the family deductible can be met by one family member. 

With the other version (HE), MUST begins to share costs on claims for a member with a family plan once the member meets the individual-deductible level embedded within the given family plan.

Federal guidelines state that all covered benefits (except for preventive care) must count toward the deductible, including prescription drugs. In most of the other MUST plans, there is a separate pharmacy benefit with its own deductible and out-of-pocket maximum. With HSA-qualifying plans, members can collect pharmacy receipts and submit them for reimbursement so that these costs accumulate toward the medical deductible. This can be beneficial for people with high prescription costs.

Does MUST control the Health Savings Account (HSA)?

No. MUST only administers the health plans that qualify a person to open an HSA.

 

If a district decides to offer one of these HSA-qualifying options to its employees, the employee decides whether – and where – to open a Health Savings Account. MUST has partnered with Wells Fargo Bank to simplify the process, but the employee could choose a different qualified financial institution. More information is available on the Wells Fargo HSA Web site.

Who funds the HSA, and what is the school district’s role in this?

The HSA is usually funded by the employee, but the school district could also choose to contribute to the account on a pre-tax basis. Employers who choose to make contributions are obligated by regulation to treat similarly situated employees (i.e., all employees enrolled in the High Deductible Health Plan) the same. Employees can fund their account on a pre-tax basis only if the school district has a Section 125 (“flex” or “cafeteria”) plan.

NOTE:  School districts should amend their cafeteria plan to accommodate HSA contributions. They are encouraged to consult their tax advisor or human resources manager to ensure pre-tax HSA contributions are managed correctly.

 

An employee can also make after-tax deposits into the HSA and save Federal and Montana income tax as they complete their individual tax returns. This is accomplished with an “above-the-line” reduction to their adjusted gross income. The taxpayer is not required to itemize deductions, but must complete IRS Form 8889 for HSA contributions and distributions. This form can be found on the U.S. Treasury Web site.

How much money can be put into the HSA?

For the tax year 2006 (and earlier), IRS regulations generally stated that the annual HSA contribution could not exceed the deductible for the HSA-qualifying plan). And, if the person was not eligible for an HSA for the entire year, only a prorated amount could be put into the account.

Beginning in 2007:  Congress passed legislation that eliminates some of these restrictions and increases the potential tax advantages of opening an HSA. The maximum HSA contribution amount is no longer limited by the CDHP deductible. For the 2007 tax year, an account holder can contribute up to $2,850 (for single coverage) or $5,650 (for family coverage), even if their deductible is less. He/she can also contribute this amount if only eligible for part of the year. (These amounts are adjusted annually for inflation.)

The new law also allows participants to do a one-time transfer from an IRA (individual retirement account) or FSA (flexible spending account) to fund their HSA initially.  More information can be found on the U.S. Treasury's HSA Web site and other sources; interested persons should consult their tax advisor for specific guidance.

How do HSA account holders access their money?

Most financial institutions (including Wells Fargo) provide the HSA account holder with a special debit card. As with any debit card, funds cannot be spent unless they are present in the account.

 

The participant can use the debit card in the doctor’s office or pharmacy to pay any costs that would apply toward the deductible. Or the participant can choose to pay the bill by cash, check, or credit card, and then can either withdraw funds from the HSA to reimburse him/herself or leave the money in the HSA to grow for the future.

 

One important advantage is that the account holder can use the HSA funds to pay for qualifying medical expenses for anyone in their immediate family, even if those family members are not enrolled. Also, the list of qualifying medical expenses is not limited to services that are covered under the plan. According to IRS rules, HSA funds can be used to cover out-of-pocket medical, dental, or vision costs, including some over-the-counter drugs.

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Do all MUST plans have a pharmacy benefit?

All plans except the Basic plan and the Health Savings Account (HSA) qualified plan have a prescription (pharmacy) benefit. Please note:

• If you are enrolled in the Basic plan:  You pay for your own prescriptions. There is no coverage for prescriptions under the Basic plan; however, you might receive discounted prices at the pharmacy as a MUST member (be sure to show the pharmacist your MUST identification card).
• If you are enrolled under the HSA-qualified plan: You pay for your own prescriptions and submit the receipts to the plan. If your medical deductible has not yet been satisfied, they will count toward that deductible. If your medical deductible is satisfied, they will be covered according to the same co-payment percentages as any other medical services.

For other MUST plans (Catastrophic, Comprehensive Major Medical, and Revised Major Medical), the pharmacy plan has a separate deductible and maximum out-of-pocket amount and prescriptions, therefore, do not count toward the medical deductible and out-of-pocket amounts.

Is there a separate ID card for the pharmacy benefit?

No; your MUST card includes the information that the pharmacist will need.*

*NOTE: Effective July 1, 2007, Caremark replaced Express Scripts as the MUST Pharmacy Benefit Manager. (Click here for more info)

What should I do if I need to fill a prescription and haven’t yet received my MUST card?

Call MUST Customer Service (1-800-845-7283) to verify that your enrollment forms have been received and processed. If they have, you will be given your group plan number verbally. The pharmacist will usually accept this, but if not, ask him/her to call the number above to verify your eligibility.

Can I really save money by filling a 90-day prescription?

Yes; your copayment is usually lower than if you purchased three 30-day prescriptions. Ask your doctor if a 90-day prescription is appropriate for the drugs that you take.

Do I have to use a mail-order service to get a 90-day supply?

No; there are several pharmacies that have agreements in place for 90-day fills, including most major chains. A list of pharmacies in your area is available on the Caremark Web site (see the “Pharmacy Plan" link on the MUST home page, under "Quick Links").

What should I do if my pharmacist doesn’t bill insurance?

If your pharmacist won’t bill insurance or doesn’t belong to the pharmacy benefit plan’s network, he or she will require full payment at the time of purchase. If your MUST coverage includes a pharmacy benefit plan, you can submit a claim yourself using this form. Be sure to follow all instructions on the form.

I have dual pharmacy benefits under both my own policy and my spouse’s policy. How does that work?

With MUST, coordination of benefits for pharmacy claims is handled the same way as coordination of benefits for medical claims. In general, MUST as the secondary plan pays a reduced amount so that the combined amount paid by both plans does not exceed 100% of the allowable charge. Deductibles and co-payments under each plan will also affect your out-of-pocket cost at the pharmacy.

 

Important note: The Pharmacy Benefit Manager* can process pharmacy claims under the primary coverage only. Therefore, the Pharmacy Reimbursement Form cannot be used to process pharmacy claims under the secondary plan. See the Pharmacy Benefit section of the Summary Plan Description document, under “Primary Coverage Under Another Plan.” This section provides instructions for submitting pharmacy claims to the MUST claims office for processing under the secondary MUST plan.

* Effective July 1, 2007, Caremark replaced Express Scripts as the MUST Pharmacy Benefit Manager. (more info)

Tip:  Pharmacy receipts sometimes do not show the full retail cost of the drug. This can create problems when trying to process the claim under the secondary plan. Be sure that the pharmacy provides you a receipt that shows the full retail cost, not just the co-payment amount charged under the primary plan.

Can I drop only the prescription drug part of my MUST benefits?

No; the prescription drug benefit (if applicable) is integrated with your MUST health plan.

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