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How the Plan Works

Medical Plan Choices The Plan provides two types of coverage from which active employees, COBRA participants, non- Medicare eligible retirees, and non-Medicare eligible surviving spouses can choose: Base Coverage and Select Coverage. These coverage types are explained in this section.

The Plan includes a separate coverage level for Medicare eligible retirees, Medicare eligible surviving spouses, and Medicare eligible dependents of retirees and surviving spouses. Refer to the Retiree Eligibility and Medical Coverage section for more information.

The Provider Network The AHS State Network (Network) is a network of physicians, hospitals, and other health care providers. The Network Administrator is responsible for recruiting, credentialing, and communicating with providers. Providers participating in the Network agree to accept the allowable charge fees set by the Network and agree to file claims for Plan participants.

Participants may choose any covered participating or non-participating provider, primary care or specialist; however, using providers that participate in the Network provides participants the maximum benefits available through the Plan. Participants choosing to use providers that do not participate in the Network are responsible for paying any fees charged over the allowable charge, in addition to paying a higher annual deductible (for those participants under Select Coverage) and higher coinsurance amounts.

To find a participating provider, participants can access the Network directory through the Plan’s web site at http://knowyourbenefits.dfa.state.ms.us or may call the Network at the telephone number listed in this Plan Document. Provider participation in the Network may change from time to time. It is important for participants to verify provider participation prior to receiving services.

Out-of-Area Participants An out-of-area participant is a participant whose principal/primary residence is located outside the State of Mississippi. The enrollee’s address on file with Blue Cross & Blue Shield will determine whether the enrollee and their covered dependents are out-of-area participants. Any covered dependent of an enrollee whose principal/primary residence is located outside the geographic boundaries of the State of Mississippi is an out-of-area participant. The Plan reserves the right to require proof of residence for any participant. Coverage levels for out-of-area participants are in the Summaries of Medical Benefits.

Dependents who are full-time students between the ages of 19 and 25 are not out-of-area participants. Covered medical expenses for full-time students are paid at the higher in-network level, even though the student is in school away from home.


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