Updater State Health Benefit Plan [Spring 2000]

This UPDATER constitutes official notification to State Health Benefit Plan (SHBP) members of Plan changes and, as such, supersedes any previously published information that conflicts with the material included in this UPDATER. It will be used--in conjunction with the SHBP Booklet dated November 1, 1995, the HMO Member Handbook dated March 1998, plus any UPDATER published after November 1, 1995-- to administer the Plan until new booklets are published. If you are disabled and need this information in an alternative format, write the State Health Benefit Plan at P.O. Box 38342, Atlanta, GA 30334 or for TDD Relay Service only, call (800) 255-0056 (text telephone) or (800) 255-0135 (voice).

STATE HEALTH BENEFIT PLAN
UPDATER

GEORGIA DEPARTMENT OF COMMUNITY HEALTH

Spring, 2000

SIGNIFICANT PLAN CHANGES EFFECTIVE JULY 1, 2000

This UPDATER describes material changes to the State Health Benefit Plan (SHBP). Plan members are encouraged to read the entire document to be informed about all Plan options. Plan changes indicated herein are effective July 1, 2000. This UPDATER is for active employees covered under the SHBP. If you are a retired member, please refer to the special retiree Spring 2000 UPDATER.
As you review the changes, it may be helpful to refer to the Glossary on page 18 for a description of terms.
RISING MEDICAL COSTS LEAD TO SHBP PLAN CHANGES
In the face of rising medical costs, the Georgia Department of Community Health made significant changes to keep the SHBP financially sound. Overall medical costs are increasing 12.5 to 17% a year and premiums for SHBP members have not kept pace. The increase in medical costs without a corresponding increase in premiums has led to a serious budget shortfall.
Double-digit medical cost increases have affected benefit plans across the country, so it's not surprising that most employers turned to managed care several years ago to contain costs. In fact, very few employers continue to offer indemnity plans and only 13% of employees nationwide are enrolled in indemnity plans like the Standard and High Options. On the other hand, almost 75% of SHBP members are enrolled in one of these two options. To remain financially sound, combat increasing costs, and provide SHBP members access to quality care with an increased emphasis on preventive care, the SHBP had to make changes and expand Plan options.
The 20002001 SHBP design is based on the goals the Georgia Department of Community Health was charged with when it began operating on July 1, 1999:
1. Maximize the state's purchasing power and administrative efficiency; 2. Allow the state to develop a more responsive health care delivery system; and 3. Focus more attention on wellness.
Continued on page 2.
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AN OVERVIEW OF MAJOR CHANGES
A Preferred Provider Organizaton (PPO) Option replaces the Standard Option. A PPO is a network of preferred doctors, hospitals, and other providers that have agreed to offer quality medical care and services at discounted rates. Members of the PPO can choose to use this network of participating providers for a higher level of benefit coverage, or they can see any licensed provider they wish for a lower level of benefit coverage. See page 5 for more information on the new PPO Option and how it compares to the Standard Option it replaces.
Premiums for the High Option have increased. See your personnel/payroll office for your new monthly premium rate. There also have been a few High Option benefit changes. Refer to page 15 for a review of the benefit changes.
As a result of a new state law, both the PPO and the HMOs will offer Consumer Choice options. These options allow members to nominate nonnetwork providers to render care for you or your eligible dependents on an in-network basis for a slightly higher premium. See page 4 for more information on Consumer Choice options.
A REVIEW OF YOUR ENROLLMENT CHOICES
Your enrollment choices include the following:
These options are available statewide and in selected areas outside of Georgia near the border: The Standard PPO Option. Current Standard
Option members who do not make another choice will automatically continue coverage in the Standard PPO Option;
The PPO Choice Option. Other than the ability to nominate providers to be paid as network providers, benefits are identical to the Standard PPO Option.
See page 14 for PPO service area information.
The High Option is available to anyone eligible for SHBP coverage.
The following HMO options are available if you live or work within the HMO's service area: Aetna US Healthcare;
Aetna US Healthcare Consumer Choice Option; *
BlueChoice;
BlueChoice Consumer Choice Option; *
Kaiser Permanente; and

Kaiser Permanente Consumer Choice Option. *
* Note: Other than the ability to nominate providers, an HMO's Consumer Choice Option benefits are identical to the regular HMO option. Also, Consumer Choice Option premiums are higher than their respective HMO premium.
A CLOSER LOOK AT THE STATE HEALTH BENEFIT PLAN OPTIONS
THE NEW PPO OPTIONS COMBINE COST SAVINGS AND CHOICE
PPO Network Offers Broad Physician and Hospital Choices The most significant change to your benefits is the replacement of the Standard Option with the new Standard PPO Option. The new Standard PPO Option represents a commitment to controlling rising costs without sacrificing quality or the freedom to choose doctors and hospitals. The PPO network is actually a combination of two provider networks that joined to offer comprehensive provider access across the state and in selected areas near Georgia's border. The combined network, called MRN/Georgia 1st includes more than 8,500 physicians, 151 hospitals, and a comprehensive ancillary and chiropractic network.
This large number of physicians includes 94% of the doctors currently providing services to Standard and High Option members. That means that many Standard and High Option members will find their current physicians included in the PPO network. In addition, over 90% of the hospitals in the state of Georgia are included in the network. The PPO network also includes hospitals and doctors near the Georgia border in Florida, Tennessee, Alabama, and South Carolina.
PPO Provider Directories are available at your personnel/payroll office or on the Internet at www.communityhealth.state.ga.us.
The Standard PPO Option The Standard PPO Option provides many of the advantages of indemnity-type plans, like the High and former Standard Options. When you need care, you make the decision to see a PPO network provider or to see any licensed provider outside the PPO network. It's your choice at the time you receive care, but your level

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of benefit coverage will be reduced if you see a nonnetwork provider, and you may have to file claims. If you use in-network providers, they will file claims for you.
PPO Choice Option In addition to the Standard PPO Option, you also have the option of joining the PPO Choice Option. The eligibility rules and benefits are identical to the Standard PPO Option, but you have the ability to nominate providers with a valid Georgia license who are not in the PPO network. For more information on Consumer Choice, see page 4.
Who Can Join the PPO Although you must use a network provider to receive the highest level of benefit coverage, the PPO is available to anyone eligible for SHBP coverage who lives or works in Georgia or in selected areas near the Georgia border. See page 14 for the PPO's service area.
You Can Choose to See Any Provider Within the PPO Network The doctors, hospitals, and other providers included in the PPO network are located throughout the state and in selected areas near the Georgia border. Within this network, you can see any physician or other provider you wish. You do not have to choose a primary care physician (PCP) to direct your care or to refer you to specialists.
In-Network Copayments, Deductibles, and Coinsurance You pay a fixed $20 copayment for office visits. Other than for preventive care and illness/injury office visits, you must meet a yearly general deductible of $300 per person ($900 family maximum) before benefits are payable. In network, the Plan generally pays 90% of the network rate and you pay 10% of the network rate. You are not subject to balance billing when you see in-network providers. (See Glossary for balance billing definition.) When you use in-network providers, your providers will file all claim forms for you. When claims are paid, you will continue to receive an explanation of benefits (EOB) showing what portion of your claim the Plan paid and other useful information.
In-Network Preventive Care Coverage You're covered for a wide variety of preventive care services--such as annual check-ups, well-baby care, and immunizations--and best of all, no deductibles apply. Lab work and tests associated with preventive care office visits are covered too--at 100% up to $500 per person per year. This includes coverage for mammograms, pap smears, PSA tests, and other preventive care tests.

Or, You Can Choose to See Providers Not in the PPO Network When you need care, you also can decide to see providers who are not in the PPO network. For example, you might stay in-network and see a family practice physician, and go out-of-network to see a specialist. When you do go out-of-network, your expenses are eligible for reimbursement but you're responsible for more of the costs and the benefits will be reduced to the out-of-network level. You are subject to balance billing when you see out-of-network providers.
Note: When a member elects to use both in-network and out-of-network providers, payments made toward deductibles and stop-loss amounts will be applied separately to either the in-network or out-of-network amounts as appropriate. The amounts are different.
Out-of-Network Copayments, Deductibles, and Coinsurance Deductibles and coinsurance generally apply. The Plan generally pays 60% of the allowed amount after you meet the deductible. You pay 40% of the allowed amount plus you may be required to pay 100% of any amount greater than the usual, customary, or reasonable (UCR) rate or DRG allowed amount--after you meet the deductible. (See terms in Glossary.)
Preventive Care Coverage Out-of-Network is not Available.
An overview showing the new PPO Option benefits and how they compare to the former Standard Option benefits is included on pages 5-9.
THE HIGH OPTION PROVIDES CHOICE--BUT AT A HIGHER COST
Who Can Join The High Option continues to be available to anyone eligible for SHBP coverage.
Physicians and Other Providers You are not required to select a primary care physician and you do not need a referral to see specialists. Except for behavioral care and transplants, benefit levels are not based on a provider's network participation. However, when you use a physician who is not in the Participating Physician Program (PPP) (See Glossary) or when you go to a hospital that does not have a direct contract with the SHBP, you are subject to balance billing.
Copayments, Deductibles, and Coinsurance In most cases, you must meet deductibles before benefits are payable. Most charges are subject to coinsurance. In most cases, the Plan pays 90% of the

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allowed amount and you pay 10% of the allowed amount after meeting the deductible(s) plus 100% of any charge over the allowed amount from a non-PPP physician or from a hospital that does not have a direct contract with the SHBP.
Preventive Care Coverage Preventive care is covered up to $100 per person per year for specific tests and immunizations only. There is an additional $75 of coverage for mammograms. No deductible applies. Office visit charges for routine care are excluded from coverage.
HMOS CAN SAVE YOU MONEY, BUT RESTRICT PROVIDER CHOICE
Who Can Join You must live or work in the approved HMO service area to be eligible for their coverage. (Please refer to the Health Plan Decision Guide for detailed service area information.)
There are six HMO options--Aetna US Healthcare; Aetna US Healthcare Consumer Choice; BlueChoice; BlueChoice Consumer Choice; Kaiser Permanente; and Kaiser Permanente Consumer Choice.
Physicians and Other Providers You receive coverage when in-network providers are used for covered services. Generally, except for emergency care, services are not covered outside of the HMO's provider network. You are required to select a primary care physician and in most cases referrals are required to see specialists.
HMO Consumer Choice Options Each of the three regular HMO Options has a respective HMO Consumer Choice Option. Eligibility rules are identical to the regular HMO Option. Within the respective HMO, benefits are identical to regular HMO benefits. The difference is that the member has the ability to nominate providers to deliver your care on an in-network basis. For more information on Consumer Choice, see the following article.
Copayments, Deductibles, and Coinsurance Generally there are no deductibles to pay. Instead, you pay an in-network office visit copayment each time you see a physician in his or her office and you also pay a copayment when you obtain a prescription drug.

Preventive Care Coverage Although benefits vary by HMO, HMOs generally offer broad preventive care benefits when network providers are seen. If you live or work in an HMO service area, contact your personnel/payroll office to request a Health Plan Decision Guide. This guide provides additional information on HMO's offered through the SHBP.
MORE INFORMATION ABOUT CONSUMER CHOICE
The PPO Choice Option and the three HMO Consumer Choice Options are the result of a new Georgia law called the Consumer Choice Option Law. This law is effective for SHBP members on July 1, 2000. The law states that if a member joins the Consumer Choice version of an HMO or PPO option, the member can request that an out-of-network provider licensed in Georgia be approved to deliver the member's care on an in-network basis. (Only providers with a valid Georgia license may be nominated under the Consumer Choice Option Law, including behavioral health and transplant providers.)
To request that a provider be paid as an in-network provider, the member "nominates" the provider by filling out a form. (Forms are available by calling the PPO or HMOs.) Providers are not actually added to the network, but the cost to you is the same as seeing an in-network provider. The PPO or HMO must approve the nomination application as long as the provider has appropriate Georgia licensing, agrees to the PPO or HMO terms and conditions for network providers, and accepts the network reimbursement rate.
After the nomination is accepted, the provider can deliver your care and be paid on a network basis for the remainder of the Plan year. For example, if your provider is accepted in August 2000, the nomination is in effect until June 30, 2001. You would then need to renominate them for the July 1, 2001 Plan year.
The premiums for the Consumer Choice Options of the PPO and HMOs are higher than the Standard PPO or regular HMO options, but the benefits, other than the ability to nominate a provider, are identical. You should be aware that if the nominated provider is not accepted by the HMO or PPO or chooses not to agree to your nomination, you cannot change out of the Consumer Choice Option until the following open enrollment period unless you have a qualifying event.
A note of caution: A nomination must be completed and approved before care is received. Otherwise, the service is covered at an out-of-network benefit level for PPO members and is not covered for HMO members.

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HOW THE PPO OPTIONS COMPARE TO THE FORMER STANDARD OPTION

The following chart is a summary description comparing the major benefits and services of the new PPO Options to the former Standard Option. If you live or work in an HMO service area, be sure to refer to the Health Plan Decision Guide to compare the various HMO option benefits.

Standard PPO Option (Replaces the Standard Option effective July 1, 2000. The following benefits also apply to the PPO Choice Option.)

In-Network

Out-of-Network

What's Better/Important to Know About the New PPO Option Compared to the Former Standard Option?

Description of Plan Providers of Service

A network of doctors and hospitals that have agreed to offer quality medical care and services at discounted rates with no balance billing.

You can go out-of-network for a lower level of benefit coverage and see any qualified provider. You are subject to balance billing.

For the highest benefit,

Any lawfully operated

network providers must be hospital, physician, or

used. Prescription drugs other provider of services

may be obtained at any covered under the Plan.

pharmacy. Referrals to spe-

cialists are not required.

If you use PPO network providers, benefit levels are generally higher than under the former Standard Option.

Maximum Lifetime Benefit

The Plan Pays: $2 million

The Plan Pays: $2 million

Benefit is $1,000,000 more than the former Standard Option.

Pre-Existing Conditions $1,000 (1st year in Plan, subject to HIPAA)

$1,000

Benefit is the same as the former Standard Option.

Lifetime Benefit for Treatment of:

Temporomandibular Joint $1,100 Dysfunction

$1,100

Substance Abuse
Organ and Tissue Transplants

3 episodes $500,000

3 episodes $500,000

Benefit is the same as the former Standard Option.

Home Hyperalimentation $500,000

$500,000

Deductibles/ Copayments:
Deductible
Individual Family Maximum

General Deductible
$300 $900

Out-of-Network PPO Deductible
$400
$1,200

The in-network deductibles are the same as the former Standard Option. Out-ofNetwork deductibles are higher than the former Standard Option.

Continued on page 6 UPDATER 5

Standard PPO Option

Deductibles/ Copayments (Cont.):

In-Network

Hospital Deductible per No separate hospital admission--excluding BHS deductible. and Transplant Program

BHS and Transplant Program--Hospital Deductible per Admission
Emergency Room (ER) Copayment

$100
$60; $40 if referred by NurseCall 24; waived if admitted within 24 hours.

Urgent Care Center

$35

Copayment

Annual Stop-Loss Limits
Individual (you or one of your dependents)
Family (you and your dependents)

$1,000 $2,000

BHS Program (per patient; only applies to BHSreferred care)
Covered Services
Primary Care Physician or Specialist Office or Clinic Visits: Treatment of illness or
injury Preventive care

$2,500
100% after a per visit copayment of $20. Not subject to general deductible.

Out-of-Network No separate hospital deductible.
$100

What's Better/Important to Know About the New PPO Option Compared to the Former Standard Option?
There was an additional $100 per admission deductible in the former Standard Option.
Benefit is the same as the former Standard Option.

$60; $40 if referred by NurseCall 24; waived if admitted within 24 hours.

The copayment is $10 higher than the former Standard Option. The copayment is no longer waived if referred by NurseCall 24 or personal physician, or if outpatient surgery is performed.

Copayment not applicable. There was no Urgent Care

80% of allowed amount. Center copayment in the for-

Subject to deductible.

mer Standard Option.

Copayment is less than ER

Copayment.

$2,000

In-network stop-loss is $1,000 less than former Standard Option.

$4,000 $2,500

In-network stop-loss is $2,000 less than former Standard Option.
Maximums are the same as they were under the former Standard Option.

60% of UCR for treatment of illness or injury, subject to deductible. Preventive care office visits are not covered.

Your costs are lower in-network because coinsurance and deductibles do not apply and preventive care office visits are now covered. Out-of-network, your costs are higher.

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Continued on page 7

Standard PPO Option

Covered Services Cont.: In-Network

Lab work and tests done in 100% of network rate with

conjunction with preven- no copayment for associ-

tive care visits including: ated lab work and test

Well-newborn exam charges with a "v" (routine)

Well-child exams and code, up to a maximum of

immunizations

$500 per year per person (at

Annual physicals

network rate.) Not subject

Annual gynecological to general deductible.

exams

Covered according to age

schedules and medical

history. Look up age

schedules online at

www.healthygeorgia.com

or call member services line

at (800) 483-6983 (outside

Atlanta) or (404) 233-4479

(inside Atlanta).

Lab work and tests done in conjunction with treatment of illness or injury including (precertification may be required):
x-ray allergy testing injectible medications

90% of network rate. Subject to general deductible.

Maternity Treatment (prenatal, delivery, and postnatal)

90% of network rate after an initial visit copayment of $20. No copayments for subsequent visits. Not subject to general deductible.

Outpatient surgery in an office setting

90% of network rate. Subject to general deductible.

Allergy Shots and Serum
Physician Services Furnished in a Hospital Surgery (including
charges by Surgeon, Anesthesiologist, Pathologist, Radiologist, and consultation)

100% for shots and serum. (If physician is seen, visit is treated as an office visit subject to the per visit copayment of $20.) Not subject to the general deductible.
90% of network rate. Subject to general deductible.

Out-of-Network Not covered. Charges do not apply to deductible or annual stop-loss limits.
60% of UCR. Subject to deductible.
60% of UCR. Subject to deductible.
60% of UCR. Subject to deductible.
60% of UCR. Subject to deductible
60% of UCR. Subject to deductible.

What's Better/Important to Know About the New PPO Option Compared to the Former Standard Option? In-network benefits are significantly richer than in the former Standard Option-- office visit charges are covered and you receive up to $400 more benefit coverage for lab work and tests.
Your benefit level is 10% higher in-network than under the former Standard Option.
Your benefit level is 10% higher in-network than under the former Standard Option.
Your benefit level is 10% higher in-network than the former Standard Option. Charges are subject to general deductibles. Your out-of-pocket costs are lower in-network because coinsurance and deductibles do not apply.
Your benefit level is 10% higher in-network than under the former Standard Option. Charges are now subject to general deductible.
Continued on page 8

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Standard PPO Option

Covered Services (Cont.):

In-Network

Out-of-Network

What's Better/Important to Know About the New PPO Option Compared to the Former Standard Option?

Well-Newborn Care

100% of network rate.

Not covered.

Not covered under the former Standard Option.

Outpatient Surgery Facility Hospital or Ambulatory Surgical Center

90% of network rate. Subject to general deductible.

60% of UCR. Subject to deductible.

Your benefit level is 10% lower in-network than it was under the former Standard Option. Charges are now subject to general deductible.

Hospital Services Other Than Those for Emergency Room Care and Outpatient Surgery Inpatient Care (including
inpatient short-term rehabilitation services.) Precertification required.

90% of network rate. Subject to general deductible.

60% of UCR. Subject to deductible.

Your benefit level is 10% higher in-network than under the former Standard Option.

Outpatient Services

90% of network rate. Subject to general deductible.

60% of UCR. Subject to deductible.

Your benefit level is 10% lower in-network than under the former Standard Option.

Care in a Hospital Emergency Room Treatment of an Emergency Medical Condition or Injury

90% of network rate after a 60% of allowed amount Your benefit level is 10%

per visit copayment of $60. after a per visit copayment higher in-network than the

The copayment is reduced of $60. The copayment is former Standard Option. If

to $40 if referred by

reduced to $40 if referred admitted, you no longer

NurseCall 24. The copay- by NurseCall 24. The

have to pay a separate hos-

ment is not charged if

copayment is not charged if pital deductible. The

admitted within 24 hours. admitted within 24 hours. emergency room copayment

General deductible applies. Deductible applies.

is waived only if admitted.

Urgent Care Centers (In an approved urgent-care center; see PPO Provider Directory)

100% of network rate after a per visit copayment of $35. Not subject to a general deductible.

80% of UCR. Subject to deductible.

Your out-of-pocket costs are lower in-network because coinsurance and deductibles do not apply.

X-rays and Laboratory Services (From an approved provider)

90% of network rate. Subject to general deductible.

60% of UCR. Subject to general deductible.

Your benefit level is 10% higher in-network than under the former Standard Option.

Skilled Nursing Facility Services

Not covered.

Not covered.

Benefit is the same as the former Standard Option.

Home Nursing Care (Limited to $7,500 per year; Plan-approved Letter of Medical Necessity required. If in lieu of hospitalization, additional benefits may be approved.)

90% of network rate. (Two hours of care in a 24-hour day.) Subject to general deductible. Expenses do not apply to annual stoploss limit.

60% of UCR. (Two hours of care in a 24-hour day.) Subject to general deductible. Expenses do not apply to annual stop-loss limit.

Your benefit level is 10% higher in-network than the former Standard Option.

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Continued on page 9

Standard PPO Option

Covered Services (Cont.):

In-Network

Home hyperalimentation (Must be precertified; lifetime benefit limit of $500,000)

90% of network rate. Subject to general deductible.

Hospice Care (Precertification required; if in lieu of hospitalization, additional benefits may be approved.)

100% of network rate. Subject to general deductible.

Ambulance Services

90% of network rate. Subject to general deductible. Medically necessary emergency transportation only.

Durable Medical Equipment (May require Plan-approved Letter of Medical Necessity)

90% of network rate. Subject to general deductible.

Outpatient SelfManagement Training and Educational Services for Diabetes, Oncology, Congestive Heart Failure, and Asthma

100% of negotiated rate. Not subject to general deductible. Covered only when participating in approved disease state management program.

Outpatient Short-Term Rehabilitation Services (Physical, Speech, Cardiac, and Occupational therapies are each limited to 40 visits per year.)

90% of network rate. Subject to general deductible.

Treatment of TMJ Diagnostic testing and non-surgical treatment limited to $1,100 lifetime maximum

90% of network rate. Subject to general deductible.

Chiropractic Care

90% of network rate.

(Limited to 40 visits per year) Subject to general

deductible.

Out-of-Network 60% of UCR. Subject to deductible.
60% of UCR. Subject to deductible.

What's Better/Important to Know About the New PPO Option Compared to the Former Standard Option?
Your benefit level is 10% higher in-network than the former Standard Option.
Your benefit level is 10% higher in-network than the former Standard Option.

60% of UCR if medically necessary, non-emergency transportation, or if not MCP approved. Subject to deductible.
60% of allowed amount. Subject to deductible.

Your benefit level is 10% higher in-network than the former Standard Option.

Not applicable. Covered only when participating in approved disease state management program.

Benefit is the same as the former Standard Option.

60% of UCR. Subject to deductible.

60% of UCR. Subject to general deductible.
60% of allowed amount. Subject to deductible.

Your benefit level is 10% higher in-network than under the former Standard Option. Annual visit limitations and lifetime TMJ benefits are the same as the former Standard Option.

Important Note: Payments for covered services from an in-network PPO provider will apply only to the in-network deductible and stop-loss amounts. When a member uses both in-network and out-of-network providers, payments made toward deductibles and stop-loss amounts will be applied separately to the appropriate in-network or out-of-network amounts. Annual dollar and visit limitations are based on a July 1 to June 30 fiscal year.
Note: See pages 12-13 for information on prescription drug, BHS, and transplant benefits.

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HOW THE PPO OPTIONS COMPARE TO THE HIGH OPTION
Following are some of the major points to consider between the new Standard PPO Option and PPO Choice Option and the High Option. Before making a decision, you should carefully compare the benefits and costs of all the
available options.

Benefits and Services Premiums Deductibles and Coinsurance
Stop-Loss Limits Preventive Care
Office Visits for an Illness or Injury

What's Better/Important to Know About the New PPO Options?
Premiums for the PPO Choice Option are lower than for the High Option. Premiums for the Standard PPO Option are significantly lower than for the High Option.
The general deductible is the same in both the PPO options and the High Option. The out-of-network PPO deductible is $100 more per person and $300 more per family. Under the PPO Options you do not have to meet a separate hospital deductible.
Coinsurance for the Standard PPO and PPO Choice Options in-network is generally 10%--the same as coinsurance for the High Option. Out-of-network, PPO Option coinsurance is 40%.
Under the PPO Options, your in-network stop-loss limits are $500 less for individuals and $500 less for families than they are under the High Option.
Preventive care benefits are much richer under the PPO Options, in-network, than under the High Option. -- In-network under the PPO Options, you pay a $20 copayment for office visits
and receive a 100% benefit for associated lab work and tests up to a maximum of $500 per person per benefit year. Preventive care is not covered out-of-network. -- Under the High Option, your maximum preventive care benefit is $100 per person per year for certain tests and immunizations and an additional $75 per year for routine mammograms. Office visits for preventive care are not covered.
Your costs for illness or injury office visits are generally much lower in-network under the PPO Options than under the High Option. --When you get care in the PPO network, you pay a $20 copayment for physician or
clinic visits, no deductible applies and you are not subject to balance billing. For associated lab work and tests, you pay 10% coinsurance, subject to the general deductible. Out-of-network, you pay 40% of allowed charges after meeting a $400 deductible, and you are subject to balance billing. --In the High Option, generally you pay 10% of allowed charges after meeting a $300 deductible and if you do not use a PPP physician, you are subject to balance billing.

HOW YOUR OUT-OF-POCKET COSTS COMPARE
Following are some common situations when care is needed along with comparisons of your out-of-pocket costs when you get care in one of the PPO Options, in the High Option, and in the former Standard Option.
As described in the examples below, your level of benefit coverage under the PPO Options in-network is generally 10% higher than under the former Standard Option and the same as the High Option. But the PPO saves you even more money because no deductibles or coinsurance apply to office visits when you see participating network providers. You only pay a $20 copayment for the office visit. (Associated lab work and tests for an illness or injury are covered at 90%, subject to the general deductible.)

Also, in-network under the PPO, lab work and tests done in conjunction with a preventive care office visit are covered at 100%, up to a maximum per person per year benefit of $500, and no deductible applies. That's $400 more than the level of preventive care benefit coverage in either the former Standard Option or in the High Option.
Finally, even though your in-network PPO general deductible is the same as it is in High Option and in the former Standard Option, there is no additional per admission hospital deductible in the PPO Option (except for BHS and transplant admissions). However, you should be aware that there are separate deductibles in-network and out-of-network and that deductibles and coinsurance payments accumulate separately for in-network and out-of-network care.

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COMMON CARE SITUATIONS
1. You're ill and visit a physician in the office. Under the Standard PPO Option and PPO Choice
Option, you pay a $20 copayment for in-network care. And that's all. You are protected from balance billing and you do not have to meet a deductible first. Out-of-network, you pay 40% coinsurance after meeting the $400 deductible.* Under the former Standard Option, you paid 20% coinsurance after you met the $300 general deductible. Under the High Option, you pay 10% coinsurance after you meet the $300 general deductible.*
2. Your child needs an immunization or lab work in conjunction with a preventive care office visit.
Under the Standard PPO Option and PPO Choice Option, you pay nothing when you see a participating network provider--up to a maximum benefit of $500 per year for associated lab and test charges. Preventive care is covered according to age schedules and medical history. Office visits are covered with a copayment. Out-of-network, immunizations and lab work for preventive care are not covered.
Under the former Standard Option, you paid nothing up to a maximum benefit of only $100 per year and the cost of the office visit was not covered.
Under the High Option, you pay nothing up to a maximum benefit of only $100 per year and the cost of the office visit is not covered.
3. You're admitted to a hospital. In network, under the Standard PPO Option and
PPO Choice Option, you pay 10% of the allowed amount after you meet the $300 general deductible and you are protected from balance billing. Out-ofnetwork, you pay 40% of the allowed amount after you meet the $400 deductible.* There is no additional hospital deductible. Under the former Standard Option, you paid 20% of the allowed amount of the institutional charge after meeting the $100 per admission deductible. Under the High Option, you pay 10% of the allowed amount of the institutional charges after meeting the $100 per admission deductible.*
4. You get a prescription filled. Under the Standard PPO Option and PPO Choice
Option you pay 10% of the allowed amount after you meet the $300 general deductible. (You are subject to balance billing if you use a non-network pharmacy.) Under the former Standard Option, you paid 20% of the allowed amount after meeting the $300 general deductible.

Under the High Option, you pay 10% of the allowed amount after meeting the $300 general deductible, the same as you pay under the PPO Options. However, your monthly premium is much higher than the PPO Options.
*Note: You are subject to balance billing if charges exceed the Plan's allowed amounts.
HOW THE PPO NETWORK PROVIDER WAS SELECTED
The Georgia Department of Community Health selected the combined resources of The Medical Resource Network, LLC (MRN) and Georgia 1st, Inc. to provide network management services for the PPO Option. The selection was based on overall quality, access, and to a lesser extent, cost. This joint venture includes more than 8,500 physicians, 151 hospitals, and a comprehensive chiropractic and ancillary network (ancillary providers include durable medical equipment vendors, independent labs, home health agencies and others.)
The PPO network was required to meet the following qualifications: The PPO network must continuously monitor the
quality of care provided by participating physicians, hospitals, and other providers; The PPO network must require and verify the existence and maintenance of credentials, licenses, certificates, and insurance of all the providers. The credentials must be verified every two years; and Each PPO network physician must possess and maintain admitting privileges at a minimum of one PPO hospital unless the PPO has requested in writing that the PPO physician does not maintain admitting privileges.
WHAT'S NOT CHANGING
Many existing health care relationships are not changing. Administrative functions and requirements that were common to the Standard and High Options will continue under the PPO Options. For example:
Medical Certification Program (MCP)--The MCP program is not changing. The program is designed to help members and the Plan save money by preventing unnecessary care. To avoid a reduction in benefits, you must comply with the MCP requirements outlined in the Plan booklet. Although procedures have not changed, there are some changes to the list of outpatient procedures that require precertification. See page 16 for more information on these changes.
Claims Processing--The SHBP uses the same claims processor as was used for both the High and former Standard Options. The claims procedures for the PPO Options are the same as they were under the High and former Standard Options.

UPDATER 11

NurseCall 24 Program--This program will continue to be available 7-days a week, 24-hours a day to answer health-related questions, to mail you literature, and to assist PPO and High Option members in determining the most appropriate level of care when medical attention is requested. If you are referred to an emergency room by NurseCall 24, your ER copayment is reduced from $60 to $40.
Participating Physician Program (PPP)--The PPP will continue to protect High Option members against balance billing. The PPP is a contractual arrangement between the Plan's claims administrator and medical doctors in Georgia. Each participating physician agrees to accept the Plan's allowed amount for his or her services and may not balance bill members for charges other than the coinsurance and non-covered services amounts. PPO members also are protected from balance billing when they use providers in the PPO network
Appeals Process--The appeals process under the PPO Options is the same as it was under the High Option and the former Standard Option.
Exclusions--No new exclusions have been added. The exclusions under the PPO Options are the same as they were under the former Standard Option and are under the High Option.
A Special Note on Separate Provider Networks The network of participating PPO providers does not include pharmacies, BHS providers, or transplant providers. A separate network of providers is in place for each benefit program. PPO Option and High Option members will continue to have access to these same networks without change. The following is a brief description of how each benefit program will continue to work under the PPO and High Options. See the chart on page 13 for more information on these special benefit programs.
Prescription Drug Program--The new PPO network does not change how you use the existing pharmacy network. You may continue to use the same pharmacies as in the past with your prescriptions covered at 90% of the network rate, regardless of whether you are a PPO or High Option member. (For former Standard Option members this is a 10% higher level of benefit coverage.) All the major pharmacy chains and most independent pharmacies throughout the state are participating in the pharmacy network. Although you still receive a 90% benefit if you use a non-network pharmacy, you are subject to balance billing for any prescription charges that exceed the pharmacy network rate.
You also should be aware that the penalty for brand-

name drugs will remain in effect. For a brand-name drug (if a generic equivalent is available and if neither the physician nor the pharmacist has specified a brand name), the benefit is either the average networkreimbursable generic amount or half of the networkreimbursable brand-name amount--whichever is more.
Behavioral Health Services (BHS) Program--The new PPO network does not change how you use the existing network of BHS providers or the level of benefit coverage that you receive under the BHS Program, regardless of whether you are a PPO or High Option member. BHS will provide mental health and substance abuse referrals for PPO and High Option members. The level of benefit you receive is based on whether or not you receive a BHS referral for care. To receive the highest level of benefit coverage, PPO and High option members must receive a referral form from the BHS program prior to receiving services.
Transplant Program--The new PPO network does not change how you use the existing network of contracted transplant centers. You continue to have access to contracted transplant centers as in the past with MCPapproved transplants covered at 90% of the network rate, regardless of whether you are a PPO or High Option member. (For former Standard Option members this is a 10% higher level of benefit coverage.) The MCP will provide prior approvals for transplants for PPO and High Option members. The level of benefit you receive is based on whether you use a contracted or non-contracted transplant center. To receive the highest level of benefit coverage, PPO and High option members must receive prior approval through the MCP and use a contracted transplant center.

12 UPDATER

HOW SPECIAL BENEFIT PROGRAMS WILL WORK
Note that the information contained in the following table is a summary to give you an overview only of how your coverage works in the special cases where benefit programs have their own separate network of participating providers. Benefit limitations, precertification requirements, and other details are not listed in the table. Please
refer to your SHBP booklet dated November 1, 1995 and to subsequent UPDATERs for additional details.

PPO/High Option Benefit Program Prescription Drug Program
BHS Program
Transplant Program

What determines whether I receive the higher or lower level of benefit coverage? Benefit coverage is a fixed percentage.
Whether or not your care is referred by BHS. BHS referred care has a higher level of benefit coverage.
Whether or not you receive care at a contracting transplant center. Care received at a contracting center has a higher level of benefit coverage. (Contact the MCP prior to any transplant care.)

What is the higher level of benefit coverage?

What is the lower level of benefit coverage?

How are my out-of-pocket expenses applied to deductibles and stop-loss limits?

Although the level of benefit coverage is fixed at 90% of the network rate, you are not subject to balance billing if you use a participating network pharmacy.

If you use a non-network pharmacy and are charged more than 90% of the network rate, you are responsible for the 10% coinsurance amount and the amount charged over the network rate.

To the $300 general deductible; and
To the $1,000 stoploss limit under the PPO options; or
To the $1,500 stoploss limit under the High Option

90% of the network rate for facility charges.
80% of the network rate for professional charges.

60% of the network rate for facility charges.
50% of the network rate for professional charges.

To the $300 general deductible for professional charges and, if in High Option, to the $100 deductible for hospital charges; and

For BHS referred care, to the separate $2,500 stop-loss limit; there is no limit for non-referred care.

90% of the network rate.

60% of the network rate.

To the $300 general deductible for professional charges and, if in High Option, to the $100 deductible for hospital charges; and

To the $1,000 stoploss limit under the PPO options; or

To the $1,500 stoploss limit under the High Option.

UPDATER 13

PPO SERVICE AREA
You must live or work in the following zip codes to be eligible for the PPO Options.

Alabama

35901 35903 35904 35959 35960 35961 35967 35973 35983 36262 36263 36264 36269 36272 36273 36274 36275 36301 36302 36303 36304 36305 36312 36313 36319 36320 36321 36322 36345 36349 36350 36352 36353 36370 36371 36375 36376 36804 36851 36854

36855 36856 36859 36863 36867 36868 36869 36870 36872 36874 36875 36877

32004 32009 32011 32030 32034 32035 32041 32046 32050 32065 32067 32068 32073 32082 32095 32097 32099 32200 32201 32202 32203 32204 32205 32206 32207 32208 32209 32210 32211 32212 32214 32215 32216 32217 32218 32219 32220 32221 32222 32223

Florida

32224 32225 32226 32227 32228 32229 32230 32231 32232 32233 32234 32235 32236 32237 32238 32239 32240 32241 32244 32245 32246 32247 32250 32254 32255 32256 32257 32258 32259 32260 32266 32267 32276 32277 32294 32296 32297 32301 32302 32303

32304 32306 32307 32308 32309 32310 32311 32312 32313 32314 32315 32316 32317 32324 32330 32332 32333 32337 32343 32344 32345 32350 32351 32352 32353 32361 32362 32395 32399 32423 32426 32432 32440 32442 32443 32447 32448 32460 33900

Georgia
The PPO Options are available in all Georgia zip codes.

South Carolina

29003 29042 29081 29105 29113 29129 29137 29138 29146 29166 29621 29622 29623 29624 29625 29626 29628 29639 29643 29655 29656 29658 29659 29664 29665 29666 29672 29675 29677 29678 29679 29684 29686 29689 29691 29693 29696 29801 29802 29803

29804 29805 29808 29809 29810 29812 29813 29814 29816 29817 29821 29822 29824 29826 29827 29828 29829 29831 29832 29834 29836 29838 29839 29841 29842 29843 29844 29845 29846 29847 29849 29850 29851 29853 29856 29860 29861 29901 29902 29903

29904 29905 29906 29910 29915 29918 29920 29922 29925 29926 29927 29928 29931 29934 29935 29938 29939 29940 29943 29948

Tennessee

37302 37304 37307 37308 37309 37310 37311 37312 37315 37316 37320 37323 37325 37336 37338 37340 37341 37343 37347 37350 37351 37353 37361 37362 37363 37364 37369 37370 37373 37377 37379 37384 37396 37397 37400 37401 37402 37403 37404 37405

37406 37407 37408 37409 37410 37411 37412 37414 37415 37416 37419 37421 37422 37424 37450 37499

HIGH OPTION SERVICE AREA
Unrestricted. Anyone eligible for SHBP coverage may enroll.
HMO SERVICE AREAS
See the Health Plan Decision Guide available at your personnel/payroll office.

14 UPDATER

A REVIEW OF HIGH OPTION BENEFIT CHANGES
In addition to a premium increase, there are High Option benefit changes. This chart summarizes those changes.

High Option Benefit Changes

Benefit Lifetime Maximum Benefit Emergency Room Services
Home Nursing Care
Stop-Loss Limits
Surgery Physician services Outpatient facility or
ambulatory surgical center charges Out-of-state hospitals

High Option Benefits Effective July 1, 2000
$2,000,000
$60 copayment; $40 copayment if referred by NurseCall 24. Fully waived if admitted.
Two hours of home care per day by RN or LPN, if medically necessary and ordered by a physician-- up to $7,500 per year--are covered at 90% of the UCR after the general deductible is met.
Stop-loss protection limits the deductibles and coinsurance to $1,500 of eligible out-of-pocket expenses per person, or $2,500 per family per Plan year
Professional fees are subject to the general deductible.
90% of allowed amount, subject to general deductible.
90% of DRG allowed amount after meeting the $100 deductible. Subject to balance billing.

High Option Benefits Prior to July 1, 2000
$1,000,000
$50 copayment; fully waived if admitted or referred by NurseCall 24 or physician or if outpatient surgery was performed.
Two hours of home care per day by RN or LPN, if medically necessary and ordered by a physician-- up to $7,500 per year-- were covered at 80% of the UCR after the general deductible was met.
Stop-loss protection limited the deductibles and coinsurance to $1,000 of eligible out-of-pocket expenses per person or $2,000 per family, per Plan year.
Payment for professional fees was not subject to the general deductible.
100% of allowed amount, and not subject to deductible.
90% of charge after meeting the $100 deductible. Not subject to balance billing.

What's Different? Maximum benefit increased by $1,000,000. Emergency room copayment increased by $10. Fully waived only if admitted. $20 copayment reduction if referred by NurseCall 24. Your level of benefit coverage increased by 10%.
You pay up to $500 more for both individual and family coverage before your stop-loss protection limits apply.
Professional fees now subject to the general deductible. Benefit level is now 10% lower and subject to general deductible. Charges now subject to DRG maximums and to balance billing.

For premium information, see your personnel/payroll office.

UPDATER 15

WOMEN'S HEALTH AND CANCER MCP OUTPATIENT

RIGHTS ACT OF 1998

PRECERTIFICATION CHANGES

Each year, the Georgia Department of Community Health is required to notify you of the federal law known as the Women's Health and Cancer Rights Act of 1998. The Act generally requires those group health plans and insurance companies that provide mastectomy-related benefits or services to provide specific coverages to Plan participants or beneficiaries.
The Act provides a group health plan participant or beneficiary who is receiving benefits in connection with a mastectomy, and who elects breast reconstruction in connection with the mastectomy, with coverage for the following: 1. Reconstruction of the breast on which the mastec-
tomy has been performed; 2. Surgery and reconstruction of the other breast to
produce a symmetrical appearance; and 3. Prostheses and treatment of physical complications
at all stages of mastectomy, including lymphedemas.
Coverage for these benefits or services will be provided in a manner determined in consultation with the attending physician and the patient.
Coverage for the mastectomy-related services or benefits provided under the Act will be subject to the same deductibles and coinsurance provisions that apply to other medical or surgical benefits provided under the SHBP.
High Option For the High Option, the medical care services generally require a $100 inpatient hospital deductible (per confinement), and 10% coinsurance on hospital charges, up to the member's stop-loss limit.
PPO Option For the PPO Option, in-network medical care services typically require a 10% coinsurance after the general deductible of $300 per person/$900 per family is met. Out of the PPO network, a 40% coinsurance and $400 per person/$1,200 per family deductible apply.
If you are a covered member or qualified dependent under the SHBP, and you require a mastectomy, the Plan's coverage includes all treatments for which coverage is required under the Women's Health and Cancer Rights Act.

Effective July 1, 2000, the outpatient precertification list last published in the Spring/Summer 1998 UPDATER will be replaced with the list given below. Esophageal surgery is a new category requiring precertification. There also are a number of laparoscopy CPT codes that are added or deleted. All new procedure codes are shown in bold italics. Changed codes are in italics.
CAT or CT Scans (except for brain and spine): 70480 through 70492; 71250 through 71270; 72192 through 72194; 73200 through 73202; 73700 through 73702; 74150 through 74170; 76375; 76380.
Colonoscopies: 45378 through 45385.
Endoscopies: 43234; 43235; 43239.
Esophageal Surgeries: 43280; 43289; 43324; 43325.
Laparoscopies and/or Peritoneoscopies: 47562; 47563; 47564; 49320; 49321; 49322; 49329; 58550; 58551; 58578; 58579; 58660; 58661; 58662; 58679.
MRAs: 70541; 71555; 72159; 72198; 73225; 73725; 74185.
MRIs: 70336; 70540; 70551 through 70553; 71550; 72141 through 72158; 72196; 73220; 73221; 73720; 73721; 74181; 75552 through 75556; 76093; 76094; 76400.
Nasal Surgeries: 30130; 30140; 30400 through 30520; 30620; 30801; 30802; 30930.
Sleep Studies: 95805; 95806; 95807; 95808; 95810; 95811.
Uvulopalatopharyngoplasties: 42120; 42140; 42145; 42299; 42950.
You may want to share this list with your physician. If either you or a covered dependent plans to undergo one of the listed procedures, call the Medical Certification Program in advance for precertification. The toll-free number outside of the Atlanta area is (800) 762-4535, and the number in the Atlanta area is (770) 438-9770.

16 UPDATER

SHBP BALANCE BILLING POLICY
AND RELATED ISSUES
EFFECTIVE JULY 1, 2000--
High Option Out-of-state hospital charges under the High Option will be subject to balance billing. After meeting your $100 deductible, the High Option will pay 90% of a DRG allowed amount. You will be responsible for the 10% coinsurance amount plus all charges that exceed the DRG allowed amount, if any.
You will continue to be subject to balance billing from out-of-state and non-PPP providers.
PPO Options If you use participating network providers, you are protected from balance billing. Also note that the PPO network includes participating network providers in selected out-of-state areas, including areas near the Georgia border in Alabama, Florida, South Carolina, and Tennessee. (Please refer to the PPO Provider Directory available from your personnel/payroll office or by accessing the provider directory online at www.communityhealth.state.ga.us.)
Out-of-network hospital charges for routine or planned care under the PPO options are subject to balance billing. After meeting your $400 deductible, the PPO options pay 60% of a DRG allowed amount. You are responsible for the 40% coinsurance amount plus all charges that exceed the DRG allowed amount, if any. However, for emergency or acute care out-of-network, the PPO pays 90% of the DRG amount after meeting the $300 general deductible, subject to the possibility of balance billing. (See the Glossary for emergency and acute care definitions.)
Out-of-network professional charges for routine or planned care under the PPO options are subject to balance billing. After meeting your $400 deductible, the PPO options pay 60% of a UCR allowed amount. You are responsible for the 40% coinsurance amount plus all charges that exceed the UCR allowed amount, if any. However, for emergency or acute care out-of-network, the PPO options pay 90% of the UCR amount after meeting the $300 general deductible, subject to the possibility of balance billing.
Stop-Loss Limits Charges that exceed the Plan's allowed amounts are not applied toward deductibles or stop-loss limits, regardless of your coverage option.

VISION DISCOUNT PROGRAM
(See the Spring/Summer 1997 UPDATER for program information.)
The BlueChoice Vision discount program will be a feature of the new Standard PPO and PPO Choice Options.
If you are a High Option member, the discount program will remain in effect until further notice.
PRUDENTIAL HMO OPTION MEMBERS
As indicated in the January 1, 2000 issue of the UPDATER, Prudential HMO was purchased by Aetna US Healthcare. Prudential HMO coverage under the SHBP will not be available on or after July 1, 2000. Members currently in Prudential HMO will have the opportunity to select any other available option during the upcoming open enrollment period (for coverage effective on July 1, 2000). Please note that if you do not choose a new option during open enrollment, the Plan will automatically place you (and any covered dependents) in the Standard PPO Option.
HIPAA ANNUAL NOTICE
Each year the Plan is required to notify you of certain rights available to you under the Health Insurance Portability and Accountability Act.
The PPO and High options contain a preexisting conditions limitation. Specifically, the Health Plan will not pay charges that are over $1,000 for the treatment of any pre-existing condition (see Glossary) during the first 12 months of a patient's coverage, unless the patient gives satisfactory documentation that he or she has been free of treatment for at least six consecutive calendar months.
In certain situations, SHBP members and dependents can reduce the 12-month pre-existing condition (PEC) limitation period. The reduction is possible by using what is called "creditable coverage." Creditable coverage generally includes the health coverage you or a family member had immediately prior to joining the SHBP. Most group health plans, including individual health policies and governmental health programs qualify as creditable coverage.

UPDATER 17

For Individuals Gaining SHBP Coverage The (PEC) limitation period can be reduced by the length of time that creditable coverage existed, under the following conditions:
When the Plan member provides the SHBP with a certificate of creditable coverage from one or more former health plans that states when coverage started and ended for each covered person under that plan who now desires SHBP coverage; and
For Members When the time between losing coverage under the
most recent former health plan and the later of either your hire date (with the state or school system) or the first day of the waiting period prior to SHBP coverage does not exceed 63 days.
For Eligible Dependents (including spouses) When the time between the day your dependent
becomes covered under the SHBP and the last day your dependent had coverage from any former health plan does not exceed 63 days.
Note: If you or a dependent (including a spouse) had any break in former coverage lasting more than 63 days, you or your dependent will receive coverage only for the period of time after the break ended.
You have the right to obtain a letter of creditable coverage from your former employer(s) to offset the PEC limitation period under the SHBP. If you require assistance in obtaining a letter from a former employer, contact the Plan's eligibility unit at (404) 656-6322 in the Atlanta area or at (800) 610-1863 outside the Atlanta area.
GLOSSARY
Acute Care Care provided when such services are medically necessary and immediately required as a result of a sudden onset of illness or injury.
Allowed Amount A dollar figure the Plan uses to calculate benefits payable. In many cases, the allowed amount equals a usual, customary, or reasonable (UCR) amount (see UCR definition). In the case of hospitals, the allowed amount is based on a patient's diagnosis. See DRG definition. Plan members using non-network providers (PPO Option) or non-participating providers (High Option) are responsible for paying any amount charged over the allowed amount. PPO members using network providers are charged only up to the allowable amount and will not be subject to additional payments for that service.

Balance Billing A dollar amount charged by a provider that is over the Plan's allowed amount for the care or treatment received. Amounts balance billed are the member's responsibility and do not apply to the Plan's stop-loss limits. PPO providers do not bill for amounts over the allowed amount and thus members will not be subject to balance billing when using a network PPO provider.
Behavioral Health Services (BHS) The BHS program is part of the PPO and High Options. It is a managed care program for mental health and substance abuse benefits. The program is designed to provide wide access to necessary care while balancing choice of provider, enhanced benefits within the network, and overall cost effectiveness. In order to receive full benefits, members must contact BHS prior to receiving behavioral health services.
Coinsurance A percentage of the provider's charge or the Plan's allowed amount that must be paid by the member, generally 10% to 40%.
Copayment A fixed dollar amount that must be paid by the member for a particular service or item, for example, $10 or $20 for office visits.
Deductible A fixed dollar amount that must be paid out-of-pocket by the patient before any benefit is payable by the patient's health-care plan. Paid each Plan year and, in some cases, paid per hospital admission, depending on your coverage option.
DRG Diagnostic related group. For charges from in-state hospitals that contract directly with the State Health Benefit Plan (SHBP), the Plan pays a fixed amount based on the patient's diagnosis. The actual diagnosis is converted into a DRG that is used to calculate the hospital's reimbursement. Contracting hospitals agree to accept the DRG amount as the allowed amount.
Emergency Care Care provided in the event of a sudden, severe and unexpected illness or injury which, if not treated immediately, could be life-threatening or result in permanent impairment of bodily functions.
Indemnity Plan A health plan model allowing members freedom to select providers and to direct their own care. The High Option is an indemnity-type plan.

18 UPDATER

Medical Certification Program (MCP) The MCP is a part of the PPO and High Options. It is designed to help members and the Plan save money by preventing unnecessary care. To avoid a reduction in benefits, you must comply with the MCP requirements outlined in the Plan booklet.
Participating Physician Program (PPP) A contractual arrangement between the Plan's claims administrator, Blue Cross Blue Shield of Georgia, Inc., and medical doctors who practice in Georgia. Each participating physician agrees to accept the Plan's allowed amount for his or her services and may not balance bill members. PPP applies to the High Option. (Participating PPO providers also agree to accept the Plan's allowed amount and may not balance bill members.)
Plan Year July 1st through June 30th of the following year.
Pre-Existing Condition (PEC) Existence of a condition or symptoms which would cause an ordinarily prudent person to seek diagnosis, care, or treatment; or of a condition for which medical advice or treatment (including medication) had been recommended by or received from any health care provider before SHBP coverage began. The period subject to review for PECs is six months, beginning from the later of either your hire date or the first day of the waiting period prior to coverage under the Plan.
Preferred Provider Organization (PPO) The PPO is a comprehensive network of doctors, ancillary providers, and hospitals that have agreed to offer quality medical care and services at discounted rates. You must use a network provider to receive the highest level of coverage. If you choose a PPO, you have the flexibility to go out-of-network for your health care services but you will receive a reduced level of benefit. With out-of-network benefits, you can see any qualified provider of medical services. You pay a greater percentage of the charges for covered services if you go out-of-network and you are subject to balance billing for charges above the Plan's allowed amount.
Primary Care Physician (PCP) A doctor who has the primary responsibility for providing, arranging, and coordinating every aspect of a patient's health care. An HMO member must select a PCP. A member of a PPO may choose to have a PCP, but it is not required. Generally, PCPs are either internists, family practitioners, pediatricians, or OB/GYNs.
Provider Licensed medical doctors, hospitals, and other healthcare providers through whom the Plan offers coverage.

Self-Insured Benefit Plan A program of medical care reimbursement in which an employer and its employees pay all costs of employee health care; no outside insurance company underwrites the risk or makes a profit. The High Option and PPO Options are self-insured benefit plans.
Service Area A service area consists of approved counties or zip codes in which in-network services are available.
Stop-Loss Limit A maximum annual dollar amount that a Plan member would have to pay out-of-pocket for covered expenses. Once the stop-loss limit is reached, covered expenses for the remainder of the Plan Year are reimbursed at 100%. Stop-loss limits apply per person and per family.
Usual, Customary, and Reasonable (UCR) UCR fees apply to High Option members and to PPO Option members who choose to go out-of-network. PPO members who choose to go in-network are subject to a maximum allowed amount, not to a UCR fee. Participating PPO providers do not bill for amounts over the discounted rate. The UCR fee may be defined in three parts:
--Usual Fee The fee a physician most frequently received as reimbursement for the procedure performed.
--Customary Fee The fee based on a competitive profile of the usual fees received as reimbursement by similar physicians in a given geographic area for the procedure performed, according to third-party administrator's records.
--Reasonable Fee The fee different from a usual or customary fee because of unusual circumstances involving complications requiring additional time, skill, and experience.
The Plan pays up to the usual fee, not to exceed the customary fee, unless special circumstances or complications occur, in which case the Plan may consider the reasonable fee.

UPDATER 19

FOR MORE INFORMATION
PPO Options Benefit and Rate Information and PPO Provider Directory: Contact your Personnel/Payroll Representative
If your Personnel/Payroll Representative is not available, benefit information is available by calling: (800) 483-6983 (outside Atlanta) or (404) 233-4479 (inside Atlanta).
During the open enrollment period, call volume for these numbers is expected to be very high, and you may experience time on hold or be asked to dial another number.
TDD line for the hearing impaired: (404) 842-8073
New Patient Availability and Status of Pending Participating Network Providers Information: (800) 675-6492
On-Line PPO Provider Directory: www.communityhealth.state.ga.us
For on-line viewing of preventive care health standards, visit the MRN/GA 1st web site at www.healthygeorgia.com (schedule applies to PPO Option members using in-network providers.)
For PPO Choice Option members Only providers with a valid Georgia license may be nominated under the Consumer Choice Option Law.
Nomination of PPO Provider Information: (800) 675-6492
Nomination of BHS Provider information: (800) 631-9943 (404) 842-8073 (TDD Line for the hearing impaired)
Nomination of Transplant Provider Information: (770) 438-9770 (Atlanta area) (800) 762-4535 (outside Atlanta) (800) 453-9776 (TDD Line for the hearing impaired)
High Option Contact your Personnel/Payroll Representative If a representative is not available, call phone numbers given above for benefit information.
TDD Line for the hearing impaired: (404) 842-8073

For PPO and High Option members For emergency room referrals and for medical information from registered nurses 24-hours a day, seven days a week, call NurseCall 24: (800) 524-7130
HMO Options If you are eligible for HMO option coverage, benefit information is in the Health Plan Decision Guide (available from your personnel/payroll office) or by calling the HMO directly.
- Aetna U.S. Healthcare Regular Option: (800) 444-0759 Consumer Choice Option: (800) 443-6917 On-Line Provider Information: www.aetnaushc.com
- BlueChoice (800) 464-1367 On-Line Provider Information: www.bcbsga.com
- Kaiser Permanente (404) 261-2590 On-Line Provider Information: www.kp.org/ga
Note for most School System Personnel New for this open enrollment, most school system personnel have on-line access to a web site for open enrollment. See your personnel/payroll office or refer to your Membership Change Worksheet.

20 UPDATER