How does CHAND work?
To better understand how the CHAND health benefit plan works, it will help to take a closer look at the basic cost sharing elements and limits of the plan.
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Deductible. A deductible is the specific amount you must pay before the benefit plan begins paying for covered services (see chart below). The deductible amount renews on January 1 of each year.
Coinsurance. Once the deductible has been met, you will be responsible to pay a certain percentage of your covered services. This percentage, called coinsurance, is 20 percent of the allowed charge and applies to most covered services under CHAND. The remaining 80 percent of the allowed charge is paid by the benefit plan.
Coinsurance Maximum. A limit has been set on the total coinsurance amount you are responsible to pay during the calendar year. This is called the coinsurance maximum (see chart below).
Out-of-Pocket Maximum. The deductible amount added to the coinsurance maximum is called the out-of-pocket maximum. Once the out-of-pocket maximum has been met, the benefit amount for covered services is 100 percent of the allowed charge for the remainder of the calendar year (see chart below).
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| CHAND coverage has a lifetime maximum of $1,000,000. |
It's easy with a participating provider.
More than 95 percent of all doctors, hospitals and other health care providers throughout North Dakota participate with the lead carrier for CHAND. They have entered into agreements with the Lead Carrier to accept established negotiated rates (less cost sharing amounts) as payment in full for covered services. This negotiated rate is called the allowed charge.
When you need medical services, you won't have to worry about whether you've made all the proper phone calls to your insurance company for approval. This process is done by your participating provider, who has agreed to handle any preauthorization and other requirements on your behalf. They also will file your claims for you.
If you seek covered services from a nonparticipating provider, you must notify the lead carrier prior to receiving certain services. Before receiving these services, you must either have the provider submit a preauthorization form to our office, or call the lead carrier for authorization. If you do not obtain preauthorization for services received from a nonparticipating provider, benefits will be reduced or denied.
If you receive a covered service from a nonparticipating provider, and the charges exceed our allowed charge, you will be responsible to pay the difference between the allowed charge and the amount you are billed. If services are received in North Dakota from a nonparticipating provider, your benefits will be reduced an additional 20 percent.
Managing your premium dollars on your behalf
Managed Benefits is another part of CHAND which ensures that the health care you receive is delivered in the most appropriate and cost-effective manner. Preauthorization, prior approval and concurrent review are all components of this program. Their purpose is to help you make informed decisions about the necessity of any hospitalization or service. Your responsibilities and guidelines for this program are outlined in your CHAND benefit plan.
Prenatal Plus program.
Prenatal Plus is a pregnancy screening program to help identify and periodically monitor women at risk for complications such as premature birth and low birth weight infants.
You may participate in this voluntary program by calling the lead carrier immediately following your first prenatal visit. After you complete a Preterm Labor Risk Assessment Questionnaire, you'll receive a packet of information concerning pregnancy and prenatal care.
Emergency services.
Benefits are available for emergency services. Preauthorization is not required. Please refer to the benefit plan for details.
Chiropractic services are optional.
If you choose to add benefits for services provided by a chiropractor, this optional endorsement can be added to your coverage for an additional charge (see CHIROPRACTIC SERVICES).