Active employee decision guide for plan year 2014

Resources/Contact Information State Health Benefit Plan (SHBP)

Vendor Medical - Blue Cross Blue Shield of Georgia
Customer Service Hours: 8:00 a.m. 8:00 p.m. ET; Monday Friday
Wellness - Healthways Customer Service* Hours: 8:00 a.m. 8:00 p.m. ET; Monday Friday *Customer Service Center not available until 12/16/2013
Pharmacy - Express Scripts Customer Service Hours: 24 hours a day / 7 days a week
SHBP Call Center Hours: 8:30 a.m. 5:00 p.m. ET; Monday Friday
Additional Information Centers for Medicare & Medicaid (CMS)
24 hours a day / 7 days a week TRICARE Supplement PeachCare for Kids

Member Services 1-855-641-4862 (TTY 711) 1-888-616-6411

Website www.bcbsga.com/shbp
www.BeWellSHBP.com

1-877-841-5227

www.express-scripts.com/GeorgiaSHBP

1-800-610-1863 Member Services
1-800-633-4227 TTY 877-486-2048 1-866-637-9911 1-877-427-3224

www.mySHBPga.adp.com Website
www.medicare.gov
www.asicorporation.com/ga_shbp www.peachcare.org

Listed below are common health care acronyms that are used throughout this Decision Guide.

BCBSGa > Blue Cross Blue Shield of Georgia CMS > Centers for Medicare & Medicaid Services DCH > Georgia Department of Community Health FSA > Flexible Spending Account HRA > Health Reimbursement Arrangement

PCP > Primary Care Physician OE > Open Enrollment SHBP > State Health Benefit Plan SPC > Specialist SPD > Summary Plan Description

1 Active Decision Guide 2014

Welcome to the Annual Open Enrollment (OE)
Welcome to the Georgia Department of Community Health (DCH), State Health Benefit Plan (SHBP) 2014 Annual Open Enrollment (OE). During October 21 through November 8, 2013, over 680,000 eligible employees, retirees, and their families will have the opportunity to enroll and/or continue access to quality health insurance benefits offered through SHBP. On behalf of Governor Nathan Deal, Commissioner Clyde Reese, the Board of Community Health and the entire SHBP team, I encourage you to explore the plan changes, including the Affordable Care Act (ACA) requirements, and plan options that are available to you for 2014. Please take a moment to carefully review this Active Employee Decision Guide, as it has been created especially for you to help you make an informed decision during the Annual OE. After you carefully review the Active Employee Decision Guide, follow the enrollment instructions through our online enrollment web portal www.mySHBPga.adp.com and choose the coverage option that you believe offers the best choice for you and/or your family. This Active Employee Decision Guide outlines specific benefit changes that will become effective January 2014 and continue in effect through December 31, 2014. In addition to this guide, you may visit www.dch.georgia.gov/shbp for other helpful tools, Summary Plan Description, premium costs, in-network provider information, qualifying event definitions and more. Thank you for the opportunity to serve you by offering quality, cost-effective health care coverage which aligns with our mission to promote health and wellness for all of our SHBP members. Warmest regards,
Lurline Craig-Burke Chief, State Health Benefit Plan
2 Active Decision Guide 2014

Table of Contents
Contents
> Resources/Contact Information
Inside Front Cover
> Commissioner's Welcome Letter
page 1
> Welcome to the Annual Open Enrollment (OE)
page 2
> Table of Contents
page 3
> OE and Your Responsibilities
page 4
> Making Your Health Benefit Elections for 2014
page 5
> New Hires
page 7
> 2014 Plan Changes
page 8
> Transition to 2014
page 9
> Understanding Your Plan Options for 2014
page 10
> Wellness in 2014
page 11
> Benefits Comparison: Gold HRA, Silver HRA and Bronze HRA Plans
page 12
> Flexible Benefits Program
page 16
> Alternative Coverage
page 17
> If You Are Retiring
page 18
> Legal Notices
page 19
> Terms and Conditions for 2014
page 20
3 Active Decision Guide 2014

Open Enrollment (OE) anPldanYCohuarnRgeesponsibilities
October 21 November 8, 2013 for January 1 December 31, 2014 www.mySHBPga.adp.com
Your Responsibilities as a SHBP Member
Make your elections online at www.mySHBPga.adp.com no later than November 8, 2013 by 5:00 p.m. ET
Notify SHBP whenever you have a change in covered dependents (within 31 days of Qualifying Event) Read and make sure you understand the plan materials posted at www.dch.georgia.gov/shbp Check your payroll deduction to verify the correct deduction amount is made Notify your employer of any change in address Review all communications from the SHBP and your employer and take the required actions Notify SHBP when you or a covered spouse or dependent gain Medicare coverage within the time limits set by SHBP,
including gaining coverage as a result of End Stage Renal Disease
During the Annual OE, You May:
Change to any option for which you are eligible Enroll in a new plan option Drop covered dependents Discontinue SHBP coverage Enroll eligible dependents Decrease/increase coverage tier
IMPORTANT NOTE
Dual coverage (more commonly referred to as State on State coverage) is when two members are eligible for coverage both as an employee and spouse under SHBP. For example: a member is eligible for SHBP coverage through his/her employment and his/her spouse is also eligible for SHBP coverage as an employee.
If both members are eligible for coverage as employees, it may not be cost effective to cover each other as dependents. This is because regardless of the other coverage (SHBP or another group policy) you will still be responsible for deductibles and non-covered or ineligible charges.
4 Active Decision Guide 2014

Making Your Health Benefit Election
for 2014
Before you finalize your selection, we urge you to review the plans described in this guide, discuss them with your family and choose a program that is best for you and your individual circumstance. Only you can decide which plan meets your needs.
How to Make Your 2014 Election New Web Portal www.mySHBPga.adp.com Go online today!
Annual OE: October 21, 2013, 12:01 a.m. ET to November 8, 2013, 5:00 p.m. ET You must first register using the registration code SHBP-GA and set up a
password before making your 2014 election You must have a valid email address to access the web portal Once registered you should:
--Verify your address --Verify your coverage tier (you only, you & spouse, you & child(ren) or you & family) --Verify your dependents --Answer the Tobacco Surcharge question --Make sure your election is made and confirmed by clicking CONFIRM by 5:00 p.m. ET, November 8, 2013 --Make sure you print and save your confirmation code, write down the confirmation code, or save the code to your
computer's hard drive
What if I Do Not Take Any Action?
If SHBP does not receive an election from you through the website, you have made a decision to take the default coverage below: If you are enrolled in a UnitedHealthcare or Cigna HMO, HRA or HDHP option in 2013 you will be defaulted to
the Bronze HRA option for 2014 and will continue to pay any Tobacco Surcharge you were paying in 2013. This is the option with the lowest premium, but it also has the highest deductible, the highest co-insurance and the smallest base HRA dollars. You should expect to pay out-of-pocket expenses for all medical treatment (other than covered treatment properly coded as "preventive care") that costs more than $100. If you are enrolled in the TRICARE Supplement in 2013, you will be enrolled in the TRICARE Supplement for 2014.
Note: If you paid a Tobacco Surcharge in 2013, it will continue to apply. If you did not pay a Tobacco Surcharge in 2013, you will not pay one if you choose the default coverage election above. Remember, it is your obligation to notify the SHBP immediately if you no longer qualify for the Tobacco Surcharge waiver.
5 Active Decision Guide 2014

PMlakninCghaYnoguersHealth Benefit Election for 2014
IMPORTANT NOTE
The election made during the 2014 Annual OE will be the coverage you have for the entire 2014 Plan Year unless you have a Qualifying Event that allows a change in coverage.
Enrolling or discontinuing coverage from individual coverage such as coverage offered through the Health Insurance Marketplace is not a Qualifying Event. See Qualifying Events below for more information.
Making Changes During the Year
Consider your benefit needs carefully and make the appropriate selections. Your selection will remain in effect for the entire calendar year. You will not have an opportunity to change your selection until the next Annual OE unless you experience a Qualifying Event during the Plan Year. For a complete description of Qualifying Events, see your Summary Plan Description (SPD) available online at www.dch.georgia.gov/shbp. You may also contact the SHBP Call Center for assistance at 1-800-610-1863.
Qualifying Events include, but are not limited to:
Birth, or adoption of a child, or placement for adoption Death of a spouse or child, only if the dependent is currently enrolled Your spouse's or dependent's loss of eligibility for other group health coverage Marriage or divorce (once divorced, your ex-spouse is not eligible for coverage under SHBP) Medicare eligibility
Eligible Dependents
The SHBP covers dependents who meet SHBP guidelines. Eligibility documentation must be submitted before SHBP can send notification of a dependent's coverage to BCBSGa.
Eligible Dependents Include: 1. Spouse 2. Dependent Child Natural child Adopted child Stepchild Guardianship Totally disabled child
For a complete description of eligibility, see your SPD available online at www.dch.georgia.gov/shbp.
IMPORTANT NOTE
If you have single coverage and are having a baby, in order for the baby's charges to be covered, you must change tiers to include the baby at birth.
Remember you only have 31 days before or after a Qualifying Event to add a dependent (90 days for a newborn).
6 Active Decision Guide 2014

New Hires
Coverage Effective Date for New Hires
SHBP uses a "calendar month" instead of the hire date for the effective date of coverage. The effective date of coverage is the first of the month following one full calendar month of employment, unless the hire date is concurrent with the first of the month. If the hire date is concurrent with the first of the month, then coverage is effective the first month following the hire date. Examples: If hired on 10/15/2013, one full calendar month
following October is 11/15/2013. Coverage would begin the first of the month following November and is effective 12/1/2013 If hired on 11/1/2013, since the hire date is concurrent with the first of the month, coverage would begin the first of the month following the hire date: 12/1/2013 If hired on 1/31/2014, one full calendar month following January is February, and coverage would begin the first month following February and is effective 3/1/2014
7 Active Decision Guide 2014

2014 Plan Changes
Members will experience a number of positive enhancements as a result of the new SHBP plan options. The 2014 plan options (listed below) are designed to provide members affordable premiums and their choice of plan options that best meet their needs.
Health Reimbursement Arrangement (HRA) Plan Options: Gold HRA Silver HRA Bronze HRA All plan options are consumer-driven, HRA plan options that offer medical, wellness and pharmacy benefits. Prescription benefits are the same in each HRA plan option. All members get a starting balance of spending dollars in an HRA
account. All HRA plan options are now wellness options. HMO and HDHP will no longer be available through SHBP. The TRICARE Supplement will continue to be available for those members enrolled in TRICARE. PeachCare for Kids will continue to be available for those members enrolled in PeachCare for Kids. See page 17 for additional information. Please read the Benefits Comparison table in this guide carefully and look at your medical and prescription expenses to make sure you understand the out-of-pocket costs under each option. In addition, you can find premium rates online at www.dch.georgia.gov/shbp.
8 Active Decision Guide 2014

Transition to 2014
The new plan administrators BCBSGa, Express Scripts, Inc. and Healthways, will administer the 2014 plan options. Effective January 1, 2014, Cigna and UnitedHealthcare will no longer administer the SHBP plan options.
2013 Claims
1. Medical and pharmacy claims for services rendered on or before December 31, 2013, need to be filed with UnitedHealthcare or Cigna no later than March 31, 2014.
2. Any request for appeals and claim adjustments for 2013 claims must be submitted by April 30, 2014.
3. UnitedHealthcare and Cigna will process all claims for services rendered on or before December 31, 2013.
BCBSGa Open Access POS Network
1. Be sure to check that your current provider is in-network with BCBSGa. SHBP is utilizing BCBSGa's Open Access POS network of providers for the HRA plan options.
2. If your current provider is not in-network with BCBSGa, you can search for a new provider online at www.bcbsga.com/shbp or by calling BCBSGa at 1-855-641-4862 and a customer service representative will assist you in locating an in-network provider.
3. You may also nominate a provider to join the network. Instructions are available at www.bcbsga.com/shbp. 4. If you are traveling outside of Georgia you can access the BlueCard National PPO Network. For network providers,
call 1-855-641-4862 or go online at www.bcbsga.com/shbp.
Transition Assistance Program for Continuation of Care
1. Transition assistance is a process that allows for continued care for SHBP members when their treating provider is not a part of the BCBSGa Open Access POS participating provider program.
2. Continuation of care may be received if treatment is needed for certain conditions after December 31, 2013. 3. You may request Continuation of Care if:
a. You are in an active course of treatment for an acute medical condition or serious chronic condition; b. You are in an active course of treatment for any behavioral health condition; c. You are pregnant, regardless of trimester; d. You have a terminal illness; Hospice care or e. You have a surgery or other procedure scheduled that has been authorized by the previous plan. 4. If you require ongoing care for any chronic condition and you are not in an active phase of your illness, you should select an in-network provider to meet your ongoing health care needs.
For more information regarding Continuation of Care, visit www.bcbsga.com/shbp or call BCBSGa Customer Service at 1-855-641-4862.
9 Active Decision Guide 2014

PUlanndChearnsgteas nding Your Plan Options for 2014
SHBP members who elect an HRA plan option can select from one of the following for 2014: Gold HRA Silver HRA Bronze HRA
How the HRA plan options work for medical benefits

HRA
Every year, SHBP contributes money to your HRA account.
These dollars are used to help pay for your covered medical expenses, like office visits, lab work and tests. It's important to note that when you go to the doctor, you don't pay a co-pay. Instead, you pay the contracted or discounted rate for service, even if the provider typically charges more. You can use the Blue Cross Blue Shield online tools to have a better idea of what those costs will be.
If you don't use all of the money in your HRA account, it rolls over from year to year, as long as you remain enrolled in the HRA plan.

Annual deductibles

Co-insurance

You are responsible for paying annual After you meet your annual deductible,

deductibles before the plan begins to

you pay a percentage of the cost of your

pay a percentage of your covered ex-

covered expenses, called co-insurance.

penses.

If you still have money in your HRA

The money in your HRA account is used account after you've met your annual

to help meet your deductibles. And if

deductible, you can use the funds to pay

you've been enrolled in the plan for more your share of co-insurance.

than one year, you may have enough saved to pay for your entire deductible.

Once you reach your annual co-insurance maximum, the plan pays 100 percent of

any of your remaining covered expenses

for the rest of the year.

The HRA plan options offer access to a quality provider network, and all plan options pay 100% of covered services provided by innetwork providers that are properly coded as "preventive care" within the meaning of the Affordable Care Act (ACA).
Under the pharmacy benefits, the member pays no cost for certain types of drugs identified by the ACA as "preventive care" such as select oral contraceptives. A member actively complying with the requirements of the disease management co-insurance waiver program pays no cost for certain maintenance medications. There is no deductible and no out-of-pocket maximum for pharmacy benefits. Instead, the member pays a percentage of costs for a prescription, subject to a per-prescription minimum and maximum. These member costs are paid with available HRA dollars.

IMPORTANT NOTE
Any unused dollars in your HRA account under Cigna or UnitedHealthcare in 2013 will rollover to the 2014 Plan Year. HRA dollars remaining from 2013 will rollover by April 2014. This allows 2013 HRA dollars to be used to pay your out-of-pocket expenses for 2013 claims filed no later than January 31, 2014.
Members and/or spouses (if covered) who met the 2013 Wellness Requirements (in either the 2013 Wellness or Standard options) will each have $240 credited to the member's HRA account on January 1, 2014.

10 Active Decision Guide 2014

Wellness in 2014

SHBP is excited to announce the addition of the new wellness partner, Healthways, to provide members with comprehen-

sive well-being resources and incentive programs. Healthways will also administer the 2014 action-based HRA incentives

that will allow SHBP members and covered spouses to earn additional dollars for their HRA account. To earn these HRA

dollars, complete the following requirements any time between January 1 December 31, 2014:

What to DO

What you EARN

1 Assess Your Health
Complete your Healthways Well-Being Assessment (WBA), a confidential, online questionnaire that will take about 20 minutes.
2 Know Your Numbers
Complete a biometric screening and submit results (body mass index, blood pressure, cholesterol, glucose). The biometric screening must be completed at an SHBP-sponsored screening event or by your physician or other providers identified by SHBP in published materials and your results submitted appropriately.

Complete both and earn $240 for your HRA account
(WBA must be completed before HRA dollars can
be earned)

3 Take Action
It's your choice! Complete the coaching pathway, online pathway or a combination of both.
Coaching Pathway
Create your Well-Being Plan. Actively engage in telephonic coaching.
Online Pathway
Create your Well-Being Plan. Record 5 online well-being activities using the same tracker within 4 consecutive weeks and earn $40 into your HRA account. You can earn these HRA dollars ($40) up to 6 times. Sample activities: track exercise five times, record daily steps five times, track food five times.

Earn up to $240 for your HRA account
(WBA must be completed before HRA dollars can
be earned)

By completing the incentive actions, you are investing in your health and increasing the amount in your HRA account as outlined in the chart below. This will reduce the amount you will have to pay in deductibles and co-insurance.

Tier

Gold

Gold HRA after Silver

Silver HRA after Bronze Bronze HRA after

HRA

completion of all HRA

completion of all HRA

completion of all

Dollars 2014 incentive Dollars 2014 incentive Dollars 2014 incentive

actions (initial

actions (initial

actions (initial

HRA $ + earned

HRA $ + earned

HRA $ + earned

HRA $)

HRA $)

HRA $)

You You + Child(ren) You + Spouse You + Family

$400 $600 $600 $800

$880 $1,080 $1,560 $1,760

$200 $300 $300 $400

$680 $780 $1,260 $1,360

$100 $150 $150 $200

$580 $630 $1,110 $1,160

SHBP members will have access to a variety of Healthways' tools, activities and services. To learn more, visit BeWellSHBP.com beginning January 1, 2014.

11 Active Decision Guide 2014

PHlRaAn CPlhaannOgepstions

Benefits Comparison: Gold, Silver and Bronze HRA Plans
January 1, 2014 December 31, 2014

Covered Services Deductible You You + Spouse You + Child(ren) You + Family
Out-of-Pocket Maximum You You + Spouse You + Child(ren) You + Family
HRA HRA Credits You You + Spouse You + Child(ren) You + Family Physicians' Services Primary Care Physician or Specialist Office or Clinic Visits Treatment of illness or injury Maternity Care (non-routine, prenatal, delivery and postpartum) Primary Care Physician or Specialist Office or Clinic Visits for the Following: Wellness care/preventive
health care Annual gynecological exams
(these services are not subject to the deductible) Prenatal care coded as preventative Physician Services Furnished in a Hospital Visits; surgery in general, including charges by surgeon, anesthesiologist, pathologist and radiologist Physician Services for Emergency Care Allergy Shots and Serum

Gold HRA Option In-Network Out-of-Network
You Pay

$1,500* $2,250* $2,250* $3,000*

$3,000* $4,500* $4,500* $6,000*

*HRA credits will reduce this amount

$4,000* $6,000* $6,000* $8,000*

$8,000* $12,000* $12,000* $16,000*

*HRA credits will reduce this amount

The Plan Pays

$400 $600 $600 $800

The Plan Pays

85% coverage; subject to deductible

60% coverage; subject to deductible

100% coverage; not subject
to deductible

Not covered

85% coverage; subject to deductible

60% coverage; subject to deductible

85% coverage; subject to in-network deductible

85% coverage; subject to deductible

60% coverage; subject to deductible

Silver HRA Option In-Network Out-of-Network
You Pay

$2,000* $3,000* $3,000* $4,000*

$4,000* $6,000* $6,000* $8,000*

*HRA credits will reduce this amount

$5,000* $7,500* $7,500* $10,000*

$10,000* $15,000* $15,000* $20,000*

*HRA credits will reduce this amount

The Plan Pays

$200 $300 $300 $400

The Plan Pays

80% coverage; subject to deductible

60% coverage; subject to deductible

100% coverage; not subject to deductible

Not covered

80% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to in-network deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

Bronze HRA Option In-Network Out-of-Network
You Pay

$2,500* $3,750* $3,750* $5,000*

$5,000* $7,500* $7,500* $10,000*

*HRA credits will reduce this amount

$6,000* $9,000* $9,000* $12,000*

$12,000* $18,000* $18,000* $24,000*

*HRA credits will reduce this amount

The Plan Pays

$100 $150 $150 $200

The Plan Pays

75% coverage; subject to deductible

60% coverage; subject to deductible

100% coverage; not subject to deductible

Not covered

75% coverage; subject to deductible

60% coverage; subject to deductible

75% coverage; subject to in-network deductible

75% coverage; subject to deductible

60% coverage; subject to deductible

12 Active Decision Guide 2014

HRA Plan Options

Benefits Comparison: Gold, Silver and Bronze HRA Plans
January 1, 2014 December 31, 2014

Gold HRA Option

Silver HRA Option

Bronze HRA Option

Physicians' Services Outpatient Surgery When billed as office visit
Outpatient Surgery When billed as outpatient
surgery at a facility

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

The Plan Pays

85% coverage; subject to deductible

60% coverage; subject to deductible

85% coverage; subject to deductible

60% coverage; subject to deductible

The Plan Pays

80% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

The Plan Pays

75% coverage; subject to deductible

60% coverage; subject to deductible

75% coverage; subject to deductible

60% coverage; subject to deductible

Hospital Services Inpatient Services Inpatient care, delivery and
inpatient short-term acute rehabilitation services Inpatient Services Well-newborn care
Outpatient Surgery Hospital/facility
Emergency Care--Hospital Treatment of an emergency
medical condition or injury

The Plan Pays

The Plan Pays

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

85% coverage; subject to deductible
85% coverage; subject to deductible

60% coverage; subject to deductible
60% coverage; subject to de-
ductible

80% coverage; subject to deductible
80% coverage; subject to deductible

60% coverage; subject to deductible
60% coverage; subject to deductible

85% coverage;

80% coverage;

subject to in-network deductible subject to in-network deductible

The Plan Pays

75% coverage; subject to deductible

60% coverage; subject to deductible

75% coverage; subject to deductible

60% coverage; subject to deductible

75% coverage; subject to deductible

60% coverage; subject to deductible

75% coverage; subject to in-network deductible

Outpatient Testing, Lab, etc. Non Routine laboratory; X-Rays; Diagnostic Tests; Injections Including medications
covered under medical benefits--for the treatment of an illness or injury

The Plan Pays

The Plan Pays

The Plan Pays

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

75% coverage; subject to deductible

60% coverage; subject to deductible

13 Active Decision Guide 2014

HPlRaAn PClhaannOgepstions

Benefits Comparison: Gold, Silver and Bronze HRA Plans
January 1, 2014 December 31, 2014

Gold HRA Option

Silver HRA Option

Bronze HRA Option

Behavioral Health

In-Network Out-of-Network The Plan Pays

In-Network Out-of-Network The Plan Pays

In-Network Out-of-Network The Plan Pays

Mental Health and Substance Abuse Inpatient Facility and Partial Day Hospitalization*

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; 75% cover- 60% coverage;

subject to

age; subject to

subject to

deductible

deductible

deductible

Mental Health and Substance Abuse Outpatient Visits and Intensive Outpatient* Other Coverage

85% coverage; subject to deductible

60% coverage; subject to deductible

The Plan Pays

80% coverage; subject to deductible

60% coverage; subject to deductible

The Plan Pays

75% cover- 60% coverage;

age; subject to

subject to

deductible

deductible

The Plan Pays

Outpatient Acute Short-Term Rehabilitation Services Physical Therapy Speech Therapy Occupational Therapy Other short term
rehabilitative services

85% coverage; subject to deductible; up to 40 visits per
therapy per Plan Year (not
to exceed a total of 40 visits combined, including any out-of-network
visits)

60% coverage; subject to
deductible; up to 40 visits per therapy per Plan Year (not to exceed a total of 40 visits combined, including any in- network
visits)

80% coverage up to 40 visits
per therapy per Plan Year; subject to deductible (not
to exceed a total of 40 visits combined, including any
out-of- network visits)

60% coverage up to 40 visits per therapy per Plan Year; subject to deductible (not to exceed a total of 40 visits combined, including any innetwork visits)

75% coverage; subject to deductible; up to 40 visits per
therapy per Plan Year (not
to exceed a total of 40 visits combined, including any out-of-network
visits)

60% coverage; subject to deductible; up to 40 visits per therapy per Plan Year (not to exceed a total of 40 visits combined, including any in- network
visits)

Chiropractic Care Coverage up to a maximum of 20 visits, per Plan Year; Up to a maximum of 20 days, per Plan Year

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; 75% cover- 60% coverage;

subject to

age; subject to

subject to

deductible

deductible

deductible

Hearing Services Routine hearing exam Urgent Care Services Pharmacy - You Pay

85% coverage for routine exam and fitting; subject to deductible.
$1,500 hearing aid allowance every 5 years; not subject to the
deductible

85% cover- 60% coverage;

age;subject to subject to

deductible

deductible

You Pay

80% coverage for routine exam and fitting; subject to deductible.
$1,500 hearing aid allowance every 5 years; not subject to the
deductible

80% coverage; 60% coverage;

subject to

subject to

deductible

deductible

You Pay

75% coverage for routine exam and fitting; subject to deductible.
$1,500 hearing aid allowance every 5 years; not subject to
the deductible

75% coverage; 60% coverage;

subject to

subject to

deductible

deductible

You Pay

Tier 1 Co-insurance**1

15% ($20 min/$50 max) not subject to deductible

15% ($20 min/$50 max) not subject to deductible

15% ($20 min/$50 max) not subject to deductible

Tier 2 Co-insurance Preferred Brand**1 Tier 3 Co-insurance Non-Preferred Brand**1 90-Day Voluntary Mail Order OR Retail 90-Day Network

25% ($50 min/$80 max) not subject to deductible
25% ($80 min/$125 max) not subject to deductible
Tier 115% ($50 min/$125 max) Tier 225% ($125 min/$200 max) Tier 325% ($200 min/$312.50 max) (Does not apply to deductible or out-of-pocket max)

25% ($50 min/$80 max) not subject to deductible

25% ($50 min/$80 max) not subject to deductible

25% ($80 min/$125 max) not subject to deductible

25% ($80 min/$125 max) not subject to deductible

Tier 115% ($50 min/$125 max) Tier 225% ($125 min/$200 max)
Tier 325% ($200 min/$312.50 max)
(Does not apply to deductible
or out-of-pocket max)

Tier 115% ($50 min/$125 max) Tier 225% ($125 min/$200 max)
Tier 325% ($200 min/$312.50 max)
(Does not apply to deductible or
out-of-pocket max)

14 Active Decision Guide 2014

*Contact vendor regarding prior authorization **Not subject to out-of-pocket max 1. 31-day supply

HRA Plan Options

Benefits Comparison: Gold, Silver and Bronze HRA Plans
January 1, 2014 December 31, 2014

Other Coverage Home Health Care Services NOTE: Prior approval required
Skilled Nursing Facility Services NOTE: Prior approval required

Gold HRA Option

Silver HRA Option

In-Network Out-of-Network In-Network Out-of-Network

The Plan Pays

85% coverage; subject to deductible

60% coverage; subject to deductible

85% coverage; up to 120 days per Plan Year; subject to deductible

Not covered

The Plan Pays

80% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; up to 120 days per Plan Year; subject to deductible

Not covered

Bronze HRA Option

In-Network Out-of-Network

The Plan Pays

75% coverage; subject to deductible

60% coverage; subject to deductible

75% coverage; up to 120 days per Plan Year;
subject to deductible

Not covered

Hospice Care NOTE: Prior approval required

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

75% coverage; subject to deductible

60% coverage; subject to deductible

Durable Medical Equipment (DME)--Rental or purchase NOTE: Prior approval required for certain DME

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

75% coverage; subject to deductible

60% coverage; subject to deductible

Foot Care NOTE: Covered only for neurological or vascular diseases Transplant Services NOTE: Prior approval required

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

75% coverage; subject to deductible

Contact vendor for coverage details

60% coverage; subject to deductible

* The Plan pays a percent of eligible expenses for out-of-network providers; eligible expenses are usually 110% of the Medicare rate for the treatment. Deductibles and out-of-pocket maximums are based only on these eligible expenses, and do not include amounts you pay when out-of-network providers balance bill for the difference. You cannot use HRA funds to pay for amounts balance billed.
Note: For out-of-network providers, the plan does not accept assignment of benefits. You will receive a payment of benefits and it will be your responsibility to pay that to the provider.

15 Active Decision Guide 2014

Flexible Benefits Program
If you are eligible to make benefit elections under the Flexible Benefits Program, administered by the Department of Administration Services (DOAS), please visit www.GABreeze.ga.gov or call 1-877-342-7339 to make your annual enrollment benefit elections.
Board of Education or Agencies Not Participating in the DOAS Flexible Benefits Program
If your employer does not participate in the Flexible Benefits Program, contact your personnel/payroll office to obtain information regarding flexible benefits sponsored by your employer.
16 Active Decision Guide 2014

2AP0ltlea1nr4nCahatinvgeesCoverage
TRICARE Supplement for Eligible Military Members
The TRICARE Supplement Plan is an alternative to SHBP coverage that is offered to employees and dependents who are eligible for SHBP coverage and enrolled in TRICARE. The TRICARE Supplement Plan is not sponsored by the SHBP, the Department of Community Health or any employer. The TRICARE Supplement Plan is sponsored by the American Military Retirees Association (AMRA) and is administered by the Association & Society Insurance Corporation. In general, to be eligible, the employee and dependents must each be under age 65, ineligible for Medicare and registered in the Defense Enrollment Eligibility Reporting System (DEERS). For complete information about eligibility and benefits, contact 1-866-637-9911 or visit www.asicorporation.com/ga_shbp. You may also find information at www.dch.georgia.gov/shbp
PEACHCARE FOR KIDS
As state or public school employees, you could be eligible to enroll your children in PeachCare for Kids. Visit www.peachcare.org or call 1-877-427-3224 for information.
Health Insurance Marketplace
You may also qualify for a lower cost health insurance plan through the Health Insurance Marketplace under the Affordable Care Act. To find out if you qualify, visit www.healthcare.gov. Open Enrollment for the Health Insurance Marketplace begins October 1, 2013, for coverage starting as early as January 1, 2014.
17 Active Decision Guide 2014

If You Are Retiring
Planning to retire soon? Here is what you need to know:
In order to continue your SHBP plan as a retiree, you and any dependents you want covered must be enrolled in the plan at the time you retire. If you are not enrolled in the SHBP coverage and wish to carry coverage as a retiree, you will need to enroll in the plan during the Annual Open Enrollment the year prior to your retirement.
If you are under 65, your options are the same as for active employees and the Tobacco Surcharge will apply. Once retired, you will have an annual Retiree Option Change Period (ROCP) that allows you to change your
plan option only. You may add dependents only if you have a Qualifying Event. Please refer to the Retiree Decision Guide for additional information regarding your SHBP coverage and
options as a retiree. If you have a balance of $100 or more in your HRA at
the time you move to a BCBSGa Medicare Advantage (MA) PPO option, an individual HRA account will be set up by BCBSGa. After a six-month run-out period, to allow for prior year's claims, the funds will be available for use.
18 Active Decision Guide 2014

Legal
Notices
About the Following Notice
The following important legal notices are posted on the SHBP website at www.dch.georgia.gov/shbp under Plan Documents: Women's Health and Cancer Rights Act Notice describes SHBP's compliance with federal law by covering reconstructive
surgery after mastectomy Newborns' and Mothers' Health Protection Act Notice describes SHBP's compliance with federal law by covering hospital
stays following childbirth Health Insurance Portability and Accountability Act SHBP Notice of Information Privacy Practices describes how medical
information about you is used and protected in accordance with federal law Mental Health Parity and Addiction Equity Act Opt-Out Notice explains DCH's decision to opt out of certain coverage
mandates, as permitted by federal law Centers for Medicaid & Medicare Services Medicare Part D Creditable Coverage Notice informs you that prescription drug
coverage under all SHBP coverage options are considered Medicare Part D "creditable coverage" Summaries of Benefits and Coverage describe benefits under the Non-MA Plan Options in a standard form required by
the Affordable Care Act Georgia Law Section 33-30-13 Notice describes the impact of the Affordable Care Act on premiums for SHBP options
Penalties for Misrepresentation
If an SHBP participant misrepresents eligibility information when applying for coverage, during change of coverage or when filing for benefits, the SHBP may take adverse action against the participants, including but not limited to terminating coverage (for the participant and his or her dependents) or imposing liability to the SHBP for fraud or indemnification (requiring payment for benefits to which the participant or his or her beneficiaries were not entitled). Penalties may include a lawsuit, which may result in payment of charges to the Plan or criminal prosecution in a court of law. In order to avoid enforcement of the penalties, the participant must notify the SHBP immediately if a dependent is no longer eligible for coverage or if the participant has questions or reservations about the eligibility of a dependent. This policy may be enforced to the fullest extent of the law.
19 Active Decision Guide 2014

PT2la0en Cr1hm4ansgesand Conditions fPolra2n0C14hanges
Announcing NEW Plan Options
IMPORTANT: In order to make any elections or changes to SHBP coverage through the year-round web portal
(either at www.mySHBPga.adp.com or by telephone), you must accept these terms and conditions. If your election is changed to default coverage without your affirmative action, you are deemed to have accepted these Terms and Conditions. Be sure to read these carefully before making your health elections or deciding to accept default coverage.
I understand that it is my responsibility to review the most recent Active Decision Guide. It is my responsibility to review any applicable Plan documents that are available and applicable to me (including Plan documents posted electronically at http://dch.georgia.gov/shbp) at the time of my decision, and to determine the SHBP option that best meets my or my family's health care needs.
I also understand that it is my responsibility to review the following bullets and understand which of the bullets apply to my situation: I understand that providers may join and discontinue participation in a vendor's network, and this is not a Qualifying
Event that will allow me to change my election. I understand that the costs of prescription drugs may change during a Plan Year and that these changes are not a
Qualifying Event that will allow me to change my election. I understand that once I have made an election and my election window closes I will not be able to change that
election until the next Annual Open Enrollment or if I have a Qualifying Event. I understand that it is my responsibility to select the correct tier based upon the dependents I wish to cover. I understand that by electing coverage I am authorizing my employer to deduct from my monthly check the applicable
premium for the plan option and coverage tier I have selected and any applicable Tobacco Surcharge. I understand that I will have to pay premiums for the plan option and tier I select, and that coverage for any newly
added dependents will start only if I provide the required verification documentation for those dependents by the applicable deadline. Dependent coverage is retroactive to the date of the Qualifying Event if verified within the applicable deadline. I understand that it is my responsibility to verify that the correct deduction is taken and to immediately notify my employer if it is not correct. I understand that if I have chosen to add an eligible dependent(s), I will be contacted to provide dependent verification documentation and that this documentation must be provided for each pended dependent within 90 days of receiving such a request. I understand that failure to provide verification documentation of newly added dependents within this timeframe will result in the removal of the election of coverage for the dependent from the SHBP web portal and cancellation of the election request, and I will not be entitled to a refund of any deductions taken to pay for the dependent coverage.
20 Active Decision Guide 2014

Terms and Conditions
I understand that if I experience a Qualifying Event I must elect to make the change to my plan option and tier by the deadline (in most cases, within 31 days of the Qualifying Event) in order for the corresponding monthly premium to apply for the remainder of the Plan Year. I understand that the rules governing these Qualifying Events and their deadlines are provided in the Plan documents.
I understand as an active member that if I miss the deadline to add a dependent or submit verification documentation, I will not be able to add the dependent until the next Annual Open Enrollment, or until I experience a Qualifying Event that would enable me to make such a change.
I understand that I must truthfully answer the Tobacco Surcharge question. It is my responsibility to immediately notify SHBP if my answer to the Tobacco Surcharge question changes. Intentional misrepresentations in my answer to the surcharge question or my failure to notify SHBP if my answer to the surcharge question changes will have significant consequences, including loss of SHBP coverage for 12 months from the date my incorrect answer or failure to notify SHBP is discovered.
I understand that intentional misrepresentation or falsification of information (including verification documentation submitted when dependents are added) will subject me to penalties and possible legal action and, in the case of adding dependents, may result in termination of coverage retroactive to the dependent's effective date and recovery of payments made by SHBP for ineligible dependents.
I understand that by making an election either through the year-round web portal or by taking no action during the Annual Open Enrollment (if choosing default coverage), I am attesting that the information I provide (or provided in the past for default coverage) is true and correct to the best of my knowledge and that I have read and understand how my decision affects coverage for myself and my dependents. I acknowledge that I may be subject to a fine of not more than $1,000 or imprisonment for not less than one, nor more than five years, or both, if I knowingly and willfully make a false or fraudulent statement or representation to DCH pursuant to O.C.G.A. Section 16-10-20.
21 Active Decision Guide 2014

Website for the Annual Open Enrollment Available
Oct. 21, at 12:01 a.m. ET Nov. 8, 5:00 p.m ET
For Plan Coverage effective
January 1, 2014 December 31, 2014
The material in this booklet is for information purposes only and is not a contract. It is intended only to highlight principal benefits of the SHBP plan options. Every effort has been made to be as accurate as possible; however, should there be a difference between this information and the plan documents, the plan documents govern. For all plan options other than Medicare Advantage option, the plan documents include the SHBP regulations, Summary Plan Descriptions and reimbursement guidelines of the vendors. The plan documents for Medicare Advantage are the insurance certificates. It is the responsibility of each member, active or retired, to read the plan documents in order to fully understand how that option pays benefits. Availability of SHBP options may change based on federal or state law changes or as approved by the Board of the Department of Community Health (DCH). Premiums for SHBP options are established by the DCH Board and may be changed at any time by the Board resolutions subject to advance notice.
22 Active Decision Guide 2014