Plans and Services

MESSA MEDICAL HEALTH INSURANCE PLANS

Essentials by MESSA Plan Coverage Booklet

IMPORTANT INFORMATION FOR ALL MESSA MEDICAL PLANS

WHAT YOU SHOULD KNOW ABOUT REFERRALS

MEDICAL CARE WHILE TRAVELING IN THE U.S.

COMPARE PLANS & ESTIMATE OUT OF POCKET COSTS

PLAN COMPARISON TOOL

DENTAL COVERAGE – DELTA DENTAL

MESSA dental benefit plan year change

Starting Jan. 1, 2023, the MESSA dental benefit plan year will change to a calendar year, or Jan. 1 to Dec. 31. MESSA is making the change to make it easier for members to monitor their coverage once all MESSA benefits and deductibles reset on Jan. 1 each year. Also, the dental benefit plan will coincide with the calendar year matching the MESSA medical benefits format.
The change will happen automatically so members won’t have to take any action. Meanwhile, members will continue to receive the same unmatched personal service from MESSA that they expect and deserve.

Since 1968, MESSA has offered dental coverage to supplement its health plans. Because good dental care is an essential component to a person’s overall health, MESSA dental plans fill an important need. MESSA’s dental plans are underwritten and administered by Delta Dental of Michigan, a non-profit dental care corporation known for its high-quality dental programs.

Delta Dental contracts with dentists throughout Michigan to provide high-quality care at a reasonable cost. More than 90 percent of Michigan dentists participate with Delta Dental. When you seek services from a dentist who participates with Delta Dental, the dentist will bill Delta Dental directly and your out-of-pocket costs will be limited to the deductible and co-payment for covered charges as specified in your plan. If you choose to see a non-participating dentist, you may have higher out-of-pocket costs and the dentist may not bill Delta Dental directly. For specific details on your benefits, please refer to your Delta Dental plan coverage booklet or access your Delta Dental Subscriber Page.

If you have any questions, please contact our Member Service Center at 800-336-0013 or your local field representative at 800-292-4910. We are here for you.

LIFE AND DISABILITY BENEFITS

Basic Life Group Insurance for School Employees (PDF)

Life and accident insurance options (PDF)

Long term disability insurance options (PDF)

Short term disability insurance options (PDF)

COMMONLY ASKED QUESTIONS ABOUT DISABILITY BENEFITS

MESSA Group Negotiated Long Term Disability (LTD)

MESSA Optional Long Term Disability (LTD)

MESSA Optional Short Term Disability (STD)

MESSA gives you options

MESSA MEMBER FORMS

As a service to our members, we have made many of our most frequently requested forms available here for easy download.

These forms are in Adobe portable document format (PDF). In order to view and print these documents, you will need to have Adobe Acrobat Reader installed on your computer. Log in to MyMESSA® for access to all member forms and specific information about your coverage including, deductible progress, benefits, claims and account management.

Member Claims

- Sample Claim Form

A standardized Health Insurance Claim Form can be completed and mailed with provider receipt(s) for benefit reimbursements.

- Claims Reimbursement Form

This form should be completed by the member and mailed with provider receipt(s) for benefit reimbursements.

- International Claim Form

This form should be completed by the member when costs are incurred during international travel, and mailed to MESSA with provider receipt(s) for benefit reimbursements.

- OptumRx Home Delivery Form
- OptumRx Home Delivery Form Español

This form should be completed by the member and mailed with the prescription to OptumRx for home delivery.

- OptumRx New Prescription Physician Fax Form

This form should be completed by the member and their health care provider, and faxed to OptumRx from the prescribing provider’s office on Dec. 14, 2021, or later.

- PPO Referral Form

This completed form should be submitted and approved prior to services being rendered at a non-PPO physician, hospital, or laboratory. The highlighted fields on the form are required in order to process the referral.

- Express Scripts Medicare Part D Reimbursement Form

This form should be completed by the member and mailed or faxed to Express Scripts for prescription claim reimbursement.

Member Appeal Form

Chiropractic Treatment Plan Form

Accident Claim Form for MESSA supplemental plan

Hospital Claim Form for MESSA supplemental plan

Critical Illness Claim Form for MESSA supplemental plan

Disability Claims

- Employer Statement for STD and LTD Income Benefits

This form must be completed by your employer when you apply for STD or LTD income benefits.

- Member Report for STD and LTD Income Benefits

This form must be completed to apply for STD or LTD income benefits.

- Physician/Psychologist Report For Disability Benefits

This form must be completed by your disabling provider when applying for disability benefits.

- Disability Direct Deposit Authorization

This form must be completed to authorize electronic fund transfer for disability benefits.

OptionALL Forms

OptionALL Medical / Dependent Care Flexible Spending Account

OptionALL Medical Reimbursement Flexible Spending Account (FSA) Withdrawal Request

OptionALL Dependent Care Spending Account Plan Withdrawal Request

OptionALL Health Savings Account (HSA) Contribution Program

Premium Contribution or Cash in Lieu Election and Authorization

OptionALL Employment Status Change

Privacy Forms

- Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed by entities covered under the HIPAA privacy rules.

- - Authorization to Use and Disclose Protected Health Information (PHI)

Members should use this form to provide MESSA with written authorization to use, discuss or disclose their PHI with a third party.

- - Authorization to Use or Disclose Psychotherapy Notes

Similar to the written authorization form, this form is required for specific authorization to use or disclose psychotherapy notes to MESSA or from MESSA.

- - Protected Health Information (PHI) Disclosure Accounting Request

Members should use this form to request a summary of disclosures (with a six year maximum) by MESSA of their PHI.

- - Request to Amend Protected Health Information (PHI)

This form is for members to request an amendment to the PHI MESSA maintains.

- - Request to Inspect or Obtain Designated Records Containing Your PHI

This form is for members to request a review of the records MESSA maintains containing their PHI.

- - Request to Restrict MESSA’s Use or Disclosure of Protected Health Information (PHI)

Members may request that MESSA further restrict the disclosure of their PHI beyond what is authorized by the HIPAA law, but MESSA is not compelled to agree. This form is used to submit the request to MESSA.