CONTENTS Phone Numbers and Contacts for Benefit and Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Inside Front Cover Making Informed Health Plan Coverage Decisions . . . . . . . . . . . . . . . . . . . . . . . . . .2 What You Need to Do . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 What's Changing for 2003 2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 If You Do Not Make Any Changes During the Retiree Option Change Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 If You Want to Change Your Option During the Retiree Option Change Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Basic Plan Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Eligible Dependents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Documentation Upon Request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Making Changes When You Have Qualifying Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Overview of How Each Health Plan Option Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Important Terms to Understand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 PPO Option . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 PPO Choice Option . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Indemnity Option (Formerly Named High Option) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 HMO Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 HMO Choice Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Medicare+Choice HMO Option (M+C HMO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Comparing Benefits Within Health Plan Options . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Comparison of Benefits: PPO Option and Indemnity Option . . . . . . . . . . . . . . . . . . . . . . . . . . .20 Comparison of Benefits: HMO Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 Service Areas for Your Health Plan Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 Health Insurance Portability and Accountability Act (HIPAA) Annual Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 Department of Community Health Privacy Notice . . . . . . . . . . . . . . . . . . . . . . . . . .42 Women's Health and Cancer Rights Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 Penalties for Misrepresentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 1 STATE HEALTH BENEFIT PLAN 2003/2004 Making Informed Health Plan Coverage Decisions The Georgia Department of Community Health, which administers the State Health Benefit Plan (SHBP), continually seeks to bring you high-quality, affordable health coverage. Keep in mind, however, that you are the manager of your health care needs, and in turn, must take the time to understand your Plan benefit choices in order to make the best decisions for you and your family. During the Retiree Option Change Period, it is important that you carefully review the coverage option information provided in this Retiree Health Plan Decision Guide. You should evaluate your health care needs and, if necessary, those of your dependents, as well as the premiums and out-of-pocket costs related to these different options before making your decision. Once you make your coverage decision, you may not make changes to your coverage outside the Retiree Option Change Period unless you have a qualifying event. See page 8 for details. If after reading this Guide you want more information before making a coverage decision, you can refer to your Summary Plan Description (SPD) booklet and Updaters or call the Retiree Help Line at (800) 586-9288. Note that a new SPD and Updater will be mailed to your home address prior to the start of the new Plan year. Making informed decisions about your health care includes other considerations as well. Patient safety is a critical mission for the SHBP. Therefore, we offer these five steps to safer health care: 1. Speak up if you have questions or concerns. Choose a physician whom you feel comfortable talking to about your health and treatment.Take a relative or friend with you if this will help you ask questions and understand the answers. It's okay to ask questions and to expect answers you can understand. If you are considering PPO coverage, provider directories are available to help you choose physicians who have been credentialed in their specialties.Visit the 1st Medical Network (formerly MRN/Georgia 1st) Web site at www.healthygeorgia.com for the most up-to-date listing of over 14,000 physicians and 166 hospitals in Georgia and a link to national PPO provider information for national access to 385,000 physicians and 3,300 hospitals. Printed directories are available by calling the Retiree Help Line during the Retiree Option Change Period. If you are considering HMO coverage, see the inside front cover for HMO Web sites that include provider information.You also can contact the individual HMO directly to request a provider directory. However, the provider listings are subject to change without notice. Before selecting your physician, call the physician's office to make sure that physician is accepting new patients and that he/she is still a participating provider. 2. Keep a list of all the medicines you take. Tell your physician and pharmacist about the medicines that you take, including over-thecounter medicines such as aspirin, ibuprofen and dietary supplements like vitamins and herbals. Tell them about any drug allergies you have. Ask the pharmacist about side effects and what foods or other things to avoid while taking the medicine.When you get your medicine, read the label, including warnings. Make sure it is what your physician ordered, and you know how to use it. If the medicine looks different than you expected, ask the pharmacist about it. 3. Make sure you get the results of any test or procedure. Ask your physician or nurse when and how you will get the results of tests or procedures. If you do not get them when expected--in person, on the phone or in the mail--don't assume the results are fine. Call your physician and ask for them. Ask what the results mean for your care. 2 STATE HEALTH BENEFIT PLAN 2003/2004 4. Talk with your physician and health care team about your options if you need hospital care. If you have more than one hospital to choose from, ask your physician which one has the best care and results for your condition. Hospitals do a good job of treating a wide range of problems. However, for some procedures (such as heart bypass surgery), research shows results often are better at hospitals doing a lot of these procedures. Also, before you leave the hospital, be sure to ask about follow-up care, and be sure you understand the instructions. 5. Make sure you understand what will happen if you need surgery. Ask your physician and surgeon: "Who will take charge of my care while I'm in the hospital? Exactly what will you be doing? How long will it take? What will happen after the surgery? How can I expect to feel during recovery?" Tell the surgeon, anesthesiologist and nurses if you have allergies or have ever had a bad reaction to anesthesia. Make sure you, your physician and your surgeon all agree on exactly what will be done during the operation. PROVIDER DIRECTORIES: For PPO providers Visit the 1st Medical Network Web site at www. healthygeorgia.com for the most up-todate listing of Georgia PPO providers.This Web site also has a link to a listing of National PPO (Beech Street) providers located across the United States.You also can call the Retiree Help Line at (800) 586-9288 to request printed provider directories. For HMO providers Check the HMO's Web site for current providers or call to request a current HMO directory. Note: If you sign up for one of the HMO options, receipt of your HMO card could be delayed if a primary care physician selection is not received by the HMO. Be sure to select a primary care physician if you enroll online, or indicate your selection on your Personalized Change Form if you are mailing the information to the Health Plan. Note: If you select UnitedHealthcare HMO, you do not need to select a primary care physician. 3 STATE HEALTH BENEFIT PLAN 2003/2004 What You Need to Do 1 REVIEW THE MATERIALS IN YOUR PACKAGE Review this Guide and your Personalized Change Form (PCF). Keep your PCF, which has your mailing address on the back. Be sure to read the What's Changing for 2003 2004 section on page 5 and 6 for important information about Plan changes. If you need to correct your address, you can do this by indicating your new address on your PCF. If there are other corrections needed, call the Plan's Eligibility Unit at (800) 610-1863, or in the Atlanta area (404) 656-6322. 2 IF NO CHANGES ARE NEEDED To continue your current coverage for 2003 2004: PPO and Indemnity Options (Formerly Named Standard PPO and High Options) You do not need to take any action.Your coverage will be continued at the new costs shown on your Personalized Change Form. This also applies to any currently covered family members. HMO and Medicare+Choice HMO Options Refer to the HMO Options charts starting on page 37 of this Guide to see if your current HMO is still available in your area. If so, and you do nothing, your current coverage will be continued automatically. If the HMO is no longer available, and you do nothing, your coverage will be transferred automatically to the PPO Option. 3 TO CHANGE YOUR COVERAGE Online: Go to www.statehealth.org and access your information using your personal security code (PIN) from the upper right corner of your PCF. Instructions are on the Web site. By mail: Complete your PCF and mail it back to the Health Plan postmarked by the deadline, using the envelope provided in your package. Keep a copy for your records. If you want to continue coverage for your dependents, check the appropriate box. Remember, if you check "no," you won't be able to reenroll the dependent in the future unless you have a qualifying event. Note, however, that you cannot change from Family to Single coverage online. In most cases, you and any covered family members must each select a primary care physician.You may indicate PCP selections online or on your PCF. 4 OPTIONAL--ATTEND A BENEFIT FAIR IN YOUR AREA Check the list enclosed in your package for a benefit fair scheduled in your area. Confirmation of Your Change If you make changes to your current coverage, you will receive a new ID card by mail before July 1, 2003. If you change your coverage online, you can print a confirmation of your option change directly from the Web site or write the confirmation number that you will see on the computer screen in the space provided on your PCF for your records. IMPORTANT NOTE: If you choose "No Coverage" for 2003 2004, you will not be able to reenroll in an SHBP option at any time in the future, unless you return to active employment with the State in a benefits-eligible position. 4 What's Changing for 2003 2004 Effective July 1, 2003, changes to your Plan options include: For PPO and Indemnity Option members: Deductibles and co-payments will change as indicated in the chart below. BENEFIT DEDUCTIBLES Hospital Deductible per Admission, Excluding BHS and Transplant Benefits PPO OPTION CURRENT EFFECTIVE JULY 1, 2003 $0 $250 INDEMNITY OPTION CURRENT EFFECTIVE JULY 1, 2003 $100 $400 General Deductibles Individual Deductible per Plan Year In-Network/Georgia Family Maximum Deductible per Plan Year CO-PAYMENTS Physician Office Visit Co-payment per Visit $300 $400 In-Network/Out-of-State and Out-ofNetwork (Combined Deductibles) $400 $500 In-Network/Georgia $900 $1,200 In-Network/Out-of-State and Out-ofNetwork (Combined Deductibles) $1,200 $1,500 $300 $900 $20 $30 Not Applicable $400 $1,200 Not Applicable Emergency Room Co-payment per Visit Note: The co-payment effective July 1, 2003 will be reduced to $80 if the member is referred by NurseCall 24 $60 before receiving emergency room services. Urgent Care Center Co-payment per Visit at Approved Centers $35 Prescription Drug Co-Payments Note: Co-payments effective July 1, 2003 will be prorated if the amount dispensed is less than the standard supply. See p.6 $100 $60 $100 $45 Not Applicable Not Applicable Generic Drugs $10 $15 $10 $15 Preferred Brand-name Drugs $20 $25 $20 $25 Non-Preferred Brand-name Drugs $35 minimum $35 minimum $35 minimum to a $75 to a $100 to a $75 maximum and maximum and maximum and is calculated is calculated is calculated based on 20% based on 20% based on 20% of the network of the network of the network price of the price of the price of the drug drug drug $35 minimum to a $100 maximum and is calculated based on 20% of the network price of the drug NOTE Current Plan rules, limitations, exclusions and co-insurance applicable to these benefits will remain in effect for the Plan Year beginning on July 1, 2003. 5 STATE HEALTH BENEFIT PLAN 2003/2004 What's Changing for 2003 2004 (Continued) Effective July 1, 2003, changes to your Plan options include: For Indemnity and PPO Option members: The monthly out-of-pocket spending limit for generic and preferred brand name prescription drugs will become a quarterly (three-calendar month) out-of-pocket spending limit with new maximums as described below: > If your individual combined co-payments for generic drugs and preferred brand name drugs in any quarter reaches $300, you will not be charged additional copayments for generic and preferred brand name drugs for the rest of that quarter. > If you have family coverage and your family's combined co-payments for generic drugs and preferred brand name drugs in any quarter reaches $600, you and your dependents will not be charged additional co-payments for generic and preferred brand name drugs for the rest of that quarter. Notes: 1) Co-payments for non-preferred brand name medications do not count toward the quarterly out-of-pocket limit. 2) If you choose a preferred brand name drug when a generic is available, only the $15 generic co-payment will be applied toward the quarterly out-of-pocket limit. 3) Quarters coincide with the State's fiscal year, which begins every July 1. Prescription drug co-payments that are effective July 1, 2003 will be prorated according to the amount of the drug dispensed if the amount dispensed is less than the "standard supply" for the prescription. The standard supply is the quantity of the prescription the Health Plan covers for one co-payment, which could be based on a specific number of days, pills, vials, inhalers, packages, etc. For example, if your pharmacist dispenses a 10-day supply of a generic drug and the standard supply for the drug is 30 days, then your co-payment will be one-third of $15, or $5.00. Also, when you return to the pharmacy to receive the balance of your prescription you would pay another $10.00. Coverage of specific osseous surgeries for the treatment of periodontal disease will be discontinued. Refer to your dental plan documents for information on available coverage for the treatment of periodontal disease.Also, if offered by your employer, consider using your Health Care Spending Account to offset any out-of-pocket expense you may incur for these services. For HMO Option members: The CIGNA and UnitedHealthcare service areas will change. See pages 31-34 for a list of specific counties in the approved service area. If you currently have HMO coverage that will not be available in your area for the new Plan year, you must select another available option. If you do not select another option, your current coverage will be transferred automatically to the PPO Option effective July 1, 2003. The BlueChoice HMO co-payment for urgent care is changing. See the covered services chart for specific information. 6 STATE HEALTH BENEFIT PLAN 2003/2004 If You Do Not Make Any Changes During the Retiree Option Change Period If you do not want to make any changes, your current coverage option and type continues into the new Plan year, unless otherwise noted (see page 6 under the "For HMO Option members" section). It is not necessary to submit any paperwork if you do not want to make any changes. If You Want to Change Your Option During the Retiree Option Change Period The Comparing Benefits Within Health Plan Options section starting on page 19 of this Guide provides an overview of what services are covered by each option. Before choosing a new option, you'll probably want to look at the benefits offered and at physicians, hospitals and other providers participating in the networks of the various options. For your reference, phone numbers for requesting provider directories and specific benefit information are listed on the inside front cover along with Web site addresses. Knowing what your benefits cover can help prevent unexpected out-of-pocket expenses during the Plan year. Before you schedule a physician's appointment, for example, make sure you understand what services your new option covers. If you've chosen an option that offers a network of preferred providers, consider the difference between seeing in-network providers and out-of-network providers. Most out-of-network services will cost you more and are subject to balance billing. Using the security access code on your Personalized Change Form you received in your package, you can: Change your address Change your coverage option Delete dependents (but you cannot change from Family to Single coverage online) Add or change primary care physicians for HMO Option selections Discontinue coverage* * If you choose to discontinue at any time, you will not be able to reenroll in any SHBP option in the future, unless you return to active employment in a benefitseligible position. If you do not have Internet access, complete and return your Personalized Change Form to: State Health Benefit Plan P.O. Box 347069 Atlanta, GA 30334 The envelope must be postmarked no later than May 15, 2003. A pre-addressed return envelope is inside your package. Note: If you sign up for one of the HMO Options, receipt of your HMO card could be delayed if the HMO does not receive your primary care physician (PCP) selection. If you select UnitedHealthcare HMO, you do not need to select a PCP or complete the enrollment supplement form. 7 STATE HEALTH BENEFIT PLAN 2003/2004 REMEMBER THIS DEADLINE: For changing your coverage during the Retiree Option Change Period -- May 1 through May 15 -- you can enter your changes on the Web site below, or complete and return the Personalized Change Form. www.statehealth.org 8 a.m. (May 1) to 6 p.m. (May 15) Available 24 hours a day, 7 days a week After sending your changes online, be sure to obtain a confirmation number. The confirmation number is your documentation that an online transaction occurred. Please keep this confirmation number in a safe place. If you do not need basic information on participating in the Plan, including information on who is eligible to participate, proceed to page 19 for a comparison of benefits. Basic Plan Information Eligible Dependents A dependent is defined as: Your spouse, if you are legally married; Your never-married dependent children who are: 1. Natural or legally adopted children and under age 19; 2. Stepchildren under age 19 who live with you at least 180 days per year; 3. Other children under age 19 if they live with you permanently and legally depend on you for financial support; 4. Your natural children, legally adopted children or stepchildren who were covered under the SHBP before age 19 and who are physically or mentally disabled and dependent on you for primary support (they may continue their existing Plan coverage past age 19); and 5. Your children from categories 1, 2 or 3 above who are registered full-time students at fully accredited schools, are not employed full-time and are between the ages of 19 and 25. 8 STATE HEALTH BENEFIT PLAN 2003/2004 Documentation Upon Request In order to cover a spouse or dependent under the Plan, you must provide documentation upon request from the Plan. The Plan requires: A copy of your certified marriage license to cover spouses; A copy of a certified birth certificate to cover a natural child; A copy of a stepchild's certified birth certificate, showing your legal spouse as the natural parent of the child, and a letter documenting that your stepchild lives in your home on a permanent basis in a parent-child relationship for at least 180 days per year; Adoption papers, guardian or court orders for other children who live with you permanently and legally depend on you for financial support. (The SHBP will recognize and honor a Qualified Medical Child Support Order (QMCSO) for eligible dependents. See your SPD for more information); Disability paperwork for disabled dependents 19 and over; this documentation must be received by the Plan before the child's 19th birthday; or A certification letter for full-time student dependents from the registrar's office of your child's school. In any of these situations, you may be required to provide documents to verify your dependent relationships during the Retiree Option Change Period or at various periods throughout the Plan year. If eligibility verification cannot be made after a request from the Plan, the dependent's coverage will be terminated retroactively to his or her coverage effective date.The Plan will make every effort allowable under the law to recover from the subscriber (i.e., retired employee) any and all payments made by the Plan on behalf of an ineligible dependent. Making Changes When You Have Qualifying Events The option choice you make during the Retiree Option Change Period will stay in effect for the duration of the 2003 2004 Plan year unless you have a qualifying event. Some qualifying events may allow a change to Family coverage.A change to Single coverage is allowed at any time. Qualifying events include, but are not limited to: Marriage or divorce; Birth or adoption of a child or placement for adoption; Death of a spouse or child, if only dependent enrolled; Your spouse's or dependent's eligibility for or loss of eligibility for other group health coverage; A change in residence by you, your spouse or dependents that makes you or a covered dependent ineligible for coverage in your selected option; and Medicare eligibility. If you experience a qualifying event, you may be able to make changes for yourself and your dependents, provided you request those changes within 31 days of the qualifying event.Also, your requested change must correspond to the qualifying event. For a complete description of qualifying events, see your SPD and Updaters.You can contact the Eligibility Unit for assistance at (800) 610-1863, or in the Atlanta area (404) 656-6322. 9 STATE HEALTH BENEFIT PLAN 2003/2004 Overview of How Each Health Plan Option Works On the following pages, you will find a brief description of each option and important considerations to help you select the best option for you. A comparison of specific benefits within each option is in the next section. Contact the Retiree Help Line or HMO if you need more detail. Telephone numbers are on the inside front cover. You also may refer to your SPD and Updaters to obtain more details on benefits and Plan participation. To help you understand the information in this section, a few key terms are defined below: Important Terms to Understand Allowed Amount--A dollar amount the Plan uses to calculate benefits payable.The Plan uses the following allowed amounts: 1. Network Rate--for in-network PPO services; 2. Out-of-Network Rate--for out-of-network PPO services; and 3. Indemnity Rate--for Indemnity Option services. Balance Billing--A dollar amount charged by a provider that is over the Plan's allowed amount for the care received. You are subject to balance billing when you receive services from non-participating providers, including emergency services. Co-insurance Amount--The percentage of the Plan's allowed amount paid by a Plan member in the PPO or Indemnity Option. Depending on the option selected, the SHBP generally pays 90% to 60%, so your co-insurance is between 10% and 40%. Co-payment--A set dollar amount that you pay at the time you receive services or items. For example, you pay a $20 co-payment for an in-network PPO physician's office visit while you are at the physician's office. Co-payments do not apply to Plan year deductibles or out-of-pocket limits unless otherwise noted. Covered Services--Services for medically necessary care that are eligible for reimbursement under the Plan. Deductible--A specified dollar amount, which varies by Plan option, for specified covered services that you must pay out-of-pocket each Plan year before the PPO Option or Indemnity Option pays a benefit. Depending on your coverage option, the deductible may not apply to some services. For example, the deductible does not apply to in-network physician office visits under the PPO Option. HMO Options do not have deductible. Emergency Care--Care provided when a sudden, severe and unexpected illness or injury happens that could be life-threatening or result in permanent impairment of bodily functions if not treated immediately. Lifetime Maximum--The maximum dollar amount that each Plan member may receive in benefits from the SHBP during his or her lifetime. Medical Certification Program (MCP)--A feature of the PPO and Indemnity Options that helps you and the Plan save money by preventing unnecessary care. To receive full benefits, you must comply with the MCP requirements outlined in the SPD and Updaters. Out-of-Pocket Limit--A maximum amount you would have to pay out of your pocket each Plan year for covered services. Once you meet your out-of-pocket limit for the Plan year, the Plan pays 100% of the allowed amounts for most covered services for the rest of the Plan year. Your out-ofpocket costs for premiums, co-payments and noncovered charges are not applied to the limit. The deductible is applied to your annual out-ofpocket limit. Participating Provider--Any physician, hospital or other health-service professional or facility that offers covered services and that has joined the PPO network, the Indemnity network or HMO network for the Plan option. Providers nominated and accepted under a Choice Option also are considered participating providers for the person making the nomination. Participating providers may not balance bill Plan members for covered services. 10 STATE HEALTH BENEFIT PLAN 2003/2004 PPO Option Anyone eligible for SHBP coverage may select the PPO Option. The PPO Option consists of a network of over 14,000 Georgia participating physicians and 166 Georgia hospitals, over 385,000 physicians and 3,300 hospitals across the United States, and hundreds of ancillary providers that have agreed to provide quality medical care and services at discounted rates. You have the choice of using in-network or out-of-network providers. If you use in-network providers, you'll receive the highest level of benefits and avoid filing claims.To view the list of Georgia PPO providers online, visit www.healthygeorgia.com. If you choose the PPO Option, you . . . Can access providers in the Plan's network of over 14,000 Georgia physicians and 166 hospitals to receive a higher level of benefit coverage. Do not need to select a primary care physician (PCP) or obtain referrals to see specialists. Pay less than the Indemnity Option. Have no balance billing when using participating PPO providers. Pay only a minimal co-payment for in-network PPO physician visits, prescription drugs and some other covered services. May access any licensed out-of-network physician, specialist or hospital at any time. However, you will generally pay more for out-of-network services and charges are subject to balance billing. Have maximum in-network coverage for most age-appropriate preventive care, including coverage for office visits. Have coordinated care through a vast network of providers who will assist you in receiving the maximum level of benefits. May reduce or eliminate the pre-existing condition limitation period if you can prove creditable coverage. See the HIPAA Annual Notice on page 41 of this Guide. National PPO Network As a PPO Option member, you have the added benefit of access to a national network of participating providers, which is managed by the Beech Street Corporation. You can take advantage of this national network if: You or a dependent lives outside of Georgia; You have a dependent going to school in another state; You are traveling in another state; or You want to use an out-of-state provider. The network consists of over 385,000 physicians and 3,300 hospitals across the United States.When you access Beech Street national providers outside the Georgia service area (see page 36), you are protected from balance billing. Your level of benefit coverage is generally different when using the national network and you are subject to separate deductibles and out-of-pocket maximums. To view the list of national providers online, visit www.healthygeorgia.com. If you do not have Internet access, call Member Services for provider information. Other Points to Consider You must call the Medical Certification Program (MCP) to precertify inpatient stays and specified outpatient procedures when you are using out-of-network providers or Beech Street providers. Some physicians affiliated with a PPO may not accept new patients at some times during the year. Check with the physician of your choice before you enroll in the PPO. See Comparison of Benefits: PPO Option and Indemnity Option starting on page 20 for benefit details. 11 STATE HEALTH BENEFIT PLAN 2003/2004 PPO Choice Option Anyone eligible for SHBP coverage may select the PPO Choice Option. PPO Choice Option benefits are the same as in the PPO Option. However, PPO Choice Option premiums are higher. In return for a higher premium, you can request that an out-of-network provider be reimbursed as an in-network provider. This request is known as a "nomination." If the out-ofnetwork provider accepts your nomination, agrees to the PPO fees, and is approved by the PPO, you will receive in-network benefits from that provider. The in-network relationship between you and the provider remains in effect until either you or the provider terminates the agreement. You may nominate as many eligible providers as you wish at any time during the Plan year. If your provider does not accept your nomination, does not accept the network fees, or is not approved by the PPO, then services from that provider are covered at the lower, out-ofnetwork benefit level. SHBP rules do not permit a member to change options when a nominated provider or the PPO rejects a nomination. Note that you may nominate only providers located and licensed in Georgia, even if you live out of state. After the PPO receives your nomination, the PPO has three business days to either reject or approve the nomination. The PPO must approve your provider nomination before you receive services. For further details regarding the nomination process and to obtain the necessary paperwork, please contact the Retiree Help Line. Note: The Behavioral Health Services (BHS) and transplant provider networks are separate from the PPO provider network.To nominate a BHS provider, contact the BHS Program at (800) 631-9943. For nominations of transplant providers, call (800) 828-6518 (outside Atlanta) or (770) 438-9770 (inside Atlanta). Indemnity Option (Formerly Named High Option) Anyone eligible for SHBP coverage may select the Indemnity Option. Important Note: The Indemnity Option is a traditional fee-forservice plan that also uses contracted health care providers who have agreed to discounted rates without balance billing for charges over the allowed amount.As long as you use a participating provider, you may not be balance billed for covered services. However, not all Georgia providers participate in these special arrangements and there are no participating Indemnity Network providers outside of Georgia. In most instances, non-participating providers charge amounts that are considerably higher than the Plan's allowed amounts. When a non-participating provider charges you over the allowed amount, you are responsible for the entire amount of the overage (i.e., balance billing), which could be thousands of dollars. For example, during 2002, Indemnity Option members hospitalized outside of Georgia paid an average out-of-pocket amount of over $20,000 per admission. Note that the State Health Benefit Plan does not have the legal authority to intervene when nonparticipating providers balance bill you; therefore, the State Health Benefit Plan cannot reduce or eliminate amounts balance billed.Also, the Health Plan cannot make additional payments above the allowed amounts when you are balance billed by non-participating providers. The Indemnity Option generally provides the same coverage level no matter which qualified medical provider you use.The Plan reimburses you for covered services, subject to the Plan's allowed amounts for covered services. Therefore, it is the most expensive Plan option. The Indemnity Option has similar coverage levels when compared to in-network PPO benefits, but it has: A higher premium; Less coverage for preventive care; and No provider network outside of Georgia. 12 STATE HEALTH BENEFIT PLAN 2003/2004 Indemnity Option (continued) If you choose the Indemnity Option, you . . . Access any provider. Receive the same level of benefit coverage whether or not your provider is in the Indemnity network. Pay most health care bills up to the deductible amount before the Plan starts paying benefits. Continue to pay a percentage of the cost of covered expenses--co-insurance--after meeting the deductible (up to the out-of-pocket maximum) plus any non-covered costs or penalties. Are subject to balance billing from all out-ofstate hospitals. Receive the same level of coverage as offered in the PPO Option for prescription drug, behavioral and transplant benefits. The Indemnity Option and PPO Option utilize the same provider networks for prescription drug, behavioral and transplant benefits. Are not required to select a primary care physician (PCP) to get referrals to see specialists. May reduce or eliminate the pre-existing limitation period if you can prove creditable coverage. See the HIPAA Annual Notice on page 41 of this Guide. Other Points to Consider The Indemnity Option is the most expensive option. The Indemnity Option does not include a national network of providers. Deductible for office visits, medical care and hospitalization must be met before benefits are payable. Coverage is available for specified preventive lab work and tests, subject to allowed amounts and annual maximums. Office visits for preventive care are covered, subject to the deductible and co-insurance. A co-payment-only benefit does not apply. Members must call the MCP to precertify inpatient stays at non-participating hospitals and members must precertify certain outpatient tests and procedures. Financial penalties apply if precertification rules are not followed. HMO Options HMO Options are available only to SHBP-eligible retirees who live in an HMO's approved service area. To see if you are eligible for an HMO, check pages 37 40 in this Guide. For the 2003 2004 Plan year, you may be eligible for up to five different HMO Options. HMOs provide prepaid benefits for most health care needs, with no bills or claim forms. You choose a primary care physician (PCP) from a list of providers.* You must receive care from your PCP or from a physician or facility referred by your PCP for your expenses to be covered, except in cases of emergency and in other limited cases. If you receive care from a physician other than your PCP, or without being referred by your PCP, you won't receive any benefit coverage even if the physician or facility is in the HMO network. If you choose an HMO Option, you . . . Must access physicians, specialists and hospitals offered through the HMO's network to receive benefits, except for emergencies. Choose a primary care physician (PCP) to serve as your first point of contact for most health care services.* Your covered family members also must select a PCP. PCPs refer you to network providers for specialty care. Pay only a minimal co-payment for HMO innetwork physician visits, prescription drugs and some other covered services. Have coordinated care through a network of HMO participating providers. Have low-cost access to the many services the HMO offers in preventive health care--wellbaby and well-child care, physical exams and immunizations. * Note: UnitedHealthcare HMO does not require you to select a PCP or obtain referrals to specialists. 13 STATE HEALTH BENEFIT PLAN 2003/2004 Other Points to Consider Generally, you don't have to file claims. You pay the full cost for most non-referred services and for services received outside the HMO's network, except for emergencies. In most cases, HMOs do not have a deductible to meet--so your out-of-pocket costs may be lower. There are no pre-existing condition limitations. You may be required to follow the HMO's standardized treatment plan for your condition. For example, you may be required to receive treatment from your primary care physician for a specified period before being referred to a specialist. HMO Choice Options If you are eligible for an HMO Option, you also are eligible for that HMO's Choice Option. HMO Choice Option benefits are the same as the respective regular HMO Option benefits. However, the Choice Option premiums are higher. In return for a higher premium, the HMO Choice Option gives members the opportunity to request that an out-of-network provider be treated as an HMO network provider. This request is known as a "nomination." You may nominate providers if they are located and licensed in Georgia and offer services the HMO covers. Also, you may nominate as many eligible providers as you wish at any time during the Plan year. If the out-of-network provider accepts your nomination, accepts the HMO's fees and is approved by the HMO, you may receive in-network benefits from that provider. If your provider does not accept your nomination, does not accept the HMO's fees, or does not get approved by the HMO, then services from that provider are not covered. SHBP rules do not permit a member to change options when a nominated provider or the HMO rejects a nomination. Please contact the respective HMO directly to find out more about the required procedures and paperwork necessary to nominate a provider. 14 STATE HEALTH BENEFIT PLAN 2003/2004 Medicare+Choice HMO Option (M+C HMO) The Medicare+Choice HMO Option is available only to those retirees who are enrolled in Part A and Part B Medicare coverage and live in the M+C HMO service area (metro Atlanta). Check page 40 in this Guide to find a listing of counties serviced by the M+C HMO. If you choose the Kaiser M+C HMO, your new coverage will replace your Medicare coverage. Your claim forms would not be filed with Medicare and the SHBP. All your services and payments would be coordinated through the Kaiser M+C HMO. If you choose the M+C HMO Option, you . . . Should refer to the information under the regular HMO Option on page 14 but also note that: -- The Kaiser M+C provider network is different from the regular Kaiser HMO provider network. -- If your spouse and/or dependents are not Medicare-eligible, they would automatically be enrolled in the regular Kaiser HMO.The benefits and providers available through the regular HMO are different from the M+C HMO. Must use providers in the Kaiser M+C HMO network in order to receive coverage. If you go outside the network, there are usually no benefits, except in the case of an emergency. Should return the separate form that the HMO supplies to you to ensure that you are in compliance with Medicare requirements. Would have coverage for prescription drugs, vision care, and preventive care not covered by Medicare. Other Points to Consider You will continue to pay the Medicare Part B premium, usually deducted from your monthly Social Security benefit checks.Your coverage will be based on the rules of the M+C HMO Option, which can offer you the advantages of lower out-of-pocket costs and reduced paperwork. Medicare pays a portion of your premium directly to the M+C HMO. You also will pay an SHBP premium, but it will be lower than regular HMO Option premiums. See your Personalized Change Form for premium information. If you select the Kaiser Medicare+Choice HMO, you will receive a temporary ID card or letter to use until Medicare approves your application and you receive your permanent ID card. If you want additional details on your Medicare benefits, contact the Social Security Administration.The phone number and Web site are listed on the inside front cover of this Guide. If you want additional details on your M+C benefits, see page 28 of this Guide and/or call the Kaiser Permanente M+C HMO at (800) 956-1358 or (404) 233-3700 in Atlanta. 15 STATE HEALTH BENEFIT PLAN 2003/2004 How Medicare+Choice Affects Your Current Medicare Coverage It's important to note that your benefit levels will be greater than those of regular HMOs as long as you continue to pay your Medicare Part B premiums. Your Choice If you choose traditional Medicare (Part A and Part B) If you choose the Kaiser M+C HMO Option How Medicare Works How SHBP Benefits Work . . . then traditional Medicare becomes your primary plan and pays your medical benefits first . . . and your SHBP benefits pay secondary benefits up to the allowed amount for Medicare Part A and Part B coverages. When Medicare is coordinated with the SHBP, you have 100% coverage on allowed amounts after the deductible for eligible services. . . . then traditional Medicare no longer processes your claims. Your Medicare coverage will pay a portion of the M+C HMO premium. . . . and your SHBP benefits will pay an additional portion of your M+C HMO premium, making coverage generally less expensive than other coverage options. 16 STATE HEALTH BENEFIT PLAN 2003/2004 Q&A on Medicare+Choice HMO and Regular HMOs Q: What if I temporarily live outside my Medicare+Choice or regular HMO service area? A: If you live in a different area of the country for an extended period, the M+C HMO may not be the best choice for you. Remember that services are available only within the HMO's service area, except for emergency and acute care, follow-up care, and renal-dialysis care. Call the HMO directly to request more information if needed. Q: Can I be denied enrollment in a Medicare+Choice HMO? A: The Centers for Medicare and Medicaid Services (CMS), responsible for the administration of Medicare, may deny your enrollment under these conditions: You do not reside in the service area of the M+C HMO. You are not entitled to Medicare Part A or are not enrolled in Medicare Part B. You have been diagnosed with end-stage renal disease (ESRD) or received a kidney transplant within the past 36 months (except for current HMO members). ESRD is kidney failure that requires dialysis or a transplant. However, ESRD beneficiaries currently enrolled in an HMO will be able to enroll in the M+C HMO Option. Note: If you are converting from HMO to M+C HMO coverage, you and any dependents must convert into the same HMO's M+C plan. If you are not approved for the Medicare+Choice HMO Option by CMS, you will be placed in the respective regular HMO Option.Your premiums will be adjusted to the regular HMO Option rates. Q: What happens if I'm out of the HMO service area and need health care? A: In emergencies, you should first seek treatment. Then contact your PCP as soon as practical. HMOs cover emergency care as if you were in their network. Routine (non-emergency) care or services that could have been anticipated are generally not covered outside of your HMO service area. Refer to the HMO's enrollment materials for procedures to follow. Q: What if I'm unhappy with my primary care physician? A: If you are unhappy, you can change to another primary care physician.The procedure will vary by HMO, so contact your HMO for assistance. 17 STATE HEALTH BENEFIT PLAN 2003/2004 This page intentionally left blank. 18 STATE HEALTH BENEFIT PLAN 2003/2004 Comparing Benefits Within Health Plan Options This section includes two charts, one that compares specific benefits within the PPO and Indemnity Options and one that compares HMO Option benefits. Benefit changes for the new Plan year are in bold type. For more specific information on covered services, call the Member Services numbers listed on the inside front cover. To make it easier to view information on the PPO and Indemnity Options, the chart is formatted in a "landscape" view. 19 Comparison of Benefits: PPO Option and Indemnity Option 20 SCHEDULE OF BENEFITS FOR YOU AND YOUR DEPENDENTS July 1, 2003 COVERED SERVICES INDEMNITY OPTION The Plan Pays: PPO OPTION In-Network/Georgia The Plan Pays: PPO OPTION In-Network/Out-of-State The Plan Pays: PPO OPTION Out-of-Network The Plan Pays: Maximum Lifetime Benefit (combined for all SHBP Options) $2 million $2 million Pre-existing Conditions (1st year in Plan only, subject to HIPAA) $1,000 $1,000 Lifetime Benefit Limit for Treatment of: (combined for Indemnity and PPO Option) Temporomandibular joint dysfunction (TMJ) Substance abuse Organ and tissue transplants Home hyperalimentation $1,100 3 episodes $500,000 $500,000 $1,100 3 episodes $500,000 $500,000 Deductibles/Co-payments: Deductible--individual Deductible--family maximum Hospital deductible/admission-- excluding BHS and transplants Hospital deductible/admission-- BHS and transplants Emergency room co-payment Urgent care center co-payment $400 $1,200 $400 $100 $100 Not applicable $400 $1,200 $250 $100 $100 $45 In-Network/Out-of-State and Out-of-Network amounts combined $500 $1,500 $250 $250 $100 $100 $100 $45 $100 Not applicable Annual Out-of-Pocket Limits: In-Network/Out-of-State and Out-of-Network amounts combined Individual (you or one of your dependents) Family (you and your dependents) $2,000 $4,000 $1,000 $2,000 $2,000 $4,000 BHS program (per patient); BHS authorized care only $2,500 $2,500 Primary Care Physician or Specialist Office or Clinic Visits: Treatment of illness or injury 90% of Indemnity Rate (IR); subject to deductible 100% of Network Rate (NR) after a per visit co-payment of $30; not subject to deductible 100% of Network Rate (NR) after a per visit co-payment of $30; not subject to deductible 60% of Out-of-Network Rate (OONR); subject to deductible 21 Primary Care Physician or Specialist Office or Clinic Visits for the following: Wellness care/preventive health care Well-newborn exam Well-child exams and immunizations Annual physicals Annual gynecological exams Notes: Lab and test charges include such services as mammograms, prostate screenings/PSAs, and pap tests. Covered according to preventive care age schedules. Covered care schedules are online at www.healthygeorgia.com or call Member Services at (800) 483-6983 (outside Atlanta) or (404) 233-4479 (inside Atlanta). 90% of IR for office visit after deductible. 100% of IR with no deductible for associated lab and test charges, up to a maximum of $200 per person per Plan year; additional $125 benefit for screening mammogram. 100% of NR after $30 co-payment for office visit. 100% of NR with no co-payment for associated lab and test charges, up to a maximum of $500 per person per Plan year, including office visit charges (less the co-payment); maximum combined with In-Network/Out-of-State benefit. 100% of NR after $30 co-payment for office visit. 100% of NR with no co-payment for associated lab and test charges, up to a maximum of $500 per person per Plan year, including office visit charges (less the co-payment); maximum combined with In-Network/Georgia benefit. Not covered. Charges do not apply to deductible or annual out-of-pocket limits. COMPARISON OF PPO AND INDEMNITY OPTIONS COVERED SERVICES INDEMNITY OPTION The Plan Pays: Prescription Drugs PPO OPTION In-Network/Georgia The Plan Pays: PPO OPTION In-Network/Out-of-State The Plan Pays: PPO OPTION Out-of-Network The Plan Pays: Purchased at an Express Scripts network pharmacy, regardless of Health Plan option Note: Co-payments are prorated according to the amount of the drug dispensed if the amount dispensed is less than the standard supply for the prescription. See page 6. $15 co-payment for generic drugs; $25 co-payment for preferred brand name drugs; co-payment for nonpreferred brand name drugs ranges from a $35 minimum to a $100 maximum and is calculated based on 20% of the network price of the drug. Co-payments for generic and preferred brand name drugs are applied to a quarterly out-of-pocket limit of $300 per person and $600 per family. When a member chooses a preferred brand name or non-preferred brand name drug over its generic equivalent, the member may be responsible for a higher co-payment than listed herein. Co-payments are based upon supplies of up to 30 days; some drugs are limited to a standard supply of less than 30 days. See the SPD and Updaters for details. Purchased at an out-of-network pharmacy, regardless of Health Plan option Member must pay full charges at point of sale and submit a paper claim. Members will be reimbursed at the pharmacy network rate less the required co-payment for covered drugs. Charges are subject to balance billing. Coverage provisions listed above also apply. 22 Maternity Treatment (pre-natal and post-natal) 90% of IR; subject to deductible 90% of NR after an initial visit co-payment of $30; not subject to deductible 80% of NR after an initial visit co-payment of $30; not subject to deductible 60% of OONR; subject to deductible Laboratory; X-Rays; Diagnostic Tests; Injections, including Medications Covered Under Medical Benefits--for the Treatment of an Illness or Injury 90% of IR; subject to deductible 90% of NR; subject to deductible 80% of NR; subject to deductible 60% of OONR; subject to deductible Allergy Shots and Serum 90% of IR; subject to deductible 100% of NR; not subject to the deductible. If physician is seen, visit is treated as an office visit subject to the per visit co-payment of $30. 100% of NR; not subject to the deductible. If physician is seen, visit is treated as an office visit subject to the per visit co-payment of $30. 60% of OONR; subject to deductible Allergy Testing 90% of IR; subject to deductible 90% of NR; subject to deductible 80% of NR; subject to deductible 60% of OONR; subject to deductible Physician Services Furnished in a Hospital Surgery in general, including charges by surgeon, anesthesiologist, pathologist and radiologist 90% of IR; subject to deductible 90% of NR; subject to deductible 80% of NR; subject to deductible 60% of OONR; subject to deductible Inpatient well-newborn exams Not covered 100% of NR; not subject 100% of NR; not subject to deductible to deductible Not covered Physician Services That Are for Emergency Care 90% of IR; subject to deductible and to balance billing from nonparticipating providers 90% of NR; subject to deductible 90% of NR; subject to In-Network/Georgia deductible 90% of NR; subject to In-Network/Georgia deductible and to balance billing Outpatient Surgery-- Physician's Office 90% of IR; subject to deductible 90% of NR; subject to deductible 80% of NR; subject to deductible 60% of OONR; subject to deductible 23 Outpatient Surgery--Hospital/Facility 90% of IR; subject to deductible 90% of NR; subject to deductible 80% of NR; subject to deductible 60% of OONR; subject to deductible Hospital Services Other Than Those That Are for Emergency Care Inpatient care, including inpatient short-term acute rehabilitation services 90% of IR; subject to a per admission deductible of $400 90% of NR; subject to a per admission deductible of $250 80% of NR; subject to a per admission deductible of $250 60% of OONR; subject to a per admission deductible of $250 Outpatient services -- Non-emergency use of emergency room -- Other 90% of IR; subject to deductible. If services are in conjunction with non- emergency use of emergency room, benefit also subject to $100/visit co-payment. 90% of NR; subject to deductible. If services are in conjunction with non- emergency use of emergency room, benefit also subject to $100/visit co-payment. 80% of NR; subject to deductible. If services are in conjunction with non- emergency use of emergency room, benefit also subject to $100/visit co-payment. 60% of OONR; subject to deductible. If services are in conjunction with non- emergency use of emergency room, benefit also subject to $100/visit co-payment. Well-newborn care 90% of IR; not subject to deductible 100% of NR; not subject to deductible 100% of NR; not subject to deductible 60% of OONR; not subject to deductible COMPARISON OF PPO AND INDEMNITY OPTIONS COVERED SERVICES INDEMNITY OPTION The Plan Pays: PPO OPTION In-Network/Georgia The Plan Pays: PPO OPTION In-Network/Out-of-State The Plan Pays: PPO OPTION Out-of-Network The Plan Pays: Hospital Services That Are for Emergency Care Treatment of an emergency medical condition or injury Notes: The $100 co-payment is reduced to $80 if referred by NurseCall 24 before receiving emergency room services. 90% of IR after a per visit co-payment of $100; co-insurance and hospital deductible, if admitted, apply. Subject to balance billing from non-participating providers. 90% of NR after a per 90% of NR after a visit co-payment of $100; per visit co-payment co-insurance and of $100; co-insurance hospital deductible, if and hospital deductible, admitted, apply if admitted, apply 90% of OONR after a per visit co-payment of $100; co-insurance and hospital deductible, if admitted, apply. Subject to balance billing. Ambulance Services for Emergency Care Notes: Limited to transportation for emergencies and benefits subject to balance billing from non-participating providers of ambulance services. 90% of IR; subject to deductible 90% of NR; subject to deductible 90% of NR; subject to In-Network/Georgia deductible 90% of OONR; subject to In-Network/Georgia deductible 24 Urgent Care Services in an Approved Urgent Care Center 90% of IR; subject to deductible 90% of NR after a per 90% of NR after a per visit co-payment of $45; visit co-payment of $45; subject to deductible subject to deductible Not applicable Home Nursing Care Approved in Advance by the MCP Notes: Home nursing care not reviewed by the MCP Covers two hours of medically necessary skilled home care per day by RN or LPN if ordered by a physician; limited to $7,500 per Plan year. $7,500 limit is a combined total in PPO Options. Member's share of cost is not applied to Plan year out-of-pocket limits. 90% of IR; subject to deductible 90% of NR; subject to deductible 80% of NR; subject to deductible 60% of OONR; subject to deductible Skilled Nursing Facility Services Not covered Not covered Not covered Not covered Hospice Care 100% of IR, up to Medicare's approved lifetime maximum; subject to deductible and to hospital deductible, if in lieu of hospitalization 100% of NR; subject to deductible and to hospital deductible, if in lieu of hospitalization 100% of NR; subject to deductible and to hospital deductible, if in lieu of hospitalization 60% of OONR; subject to deductible and to hospital deductible, if in lieu of hospitalization Durable Medical Equipment (DME)-- Rental or Purchase 90% of IR; subject to deductible 90% of NR; subject to deductible 80% of NR; subject to deductible 60% of OONR; subject to deductible Outpatient Acute Short-Term Rehabilitation Services Notes: Coverage for up to 40 visits per Plan year when conditions are met for physical, speech and occupational therapies and for cardiac rehabilitation. 90% of IR; subject to deductible 90% of NR; subject to 80% of NR; subject to deductible and $20/visit deductible and $20/visit co-payment co-payment 60% of OONR; subject to deductible 25 Dental and Oral Care-- Limited Coverage Coverage in general Notes: Coverage for most procedures for the prompt repair of sound natural teeth or tissue for the correction of damage caused by traumatic injury. 90% of IR; subject to deductible and, if admitted, to hospital deductible 90% of NR; subject to deductible and, if admitted, to hospital deductible. Network providers may not be available for all covered services; charges are paid at 90% of NR, subject to balance billing. 80% of NR; subject to deductible and, if admitted, to hospital deductible. Network providers may not be available for all covered services; charges are paid at 80% of NR, subject to balance billing. 60% of OONR; subject to deductible and, if admitted, to hospital deductible Coverage of specific osseous surgeries for the treatment of periodontal disease Not covered Not covered Not covered Not covered Temporomandibular joint syndrome (TMJ) 90% of IR; subject to deductible 90% of NR; subject to deductible 80% of NR; subject to deductible 60% of OONR; subject to deductible Notes: Coverage only for diagnostic testing and non-surgical treatment of TMJ, up to $1,100 per person lifetime maximum benefit. COMPARISON OF PPO AND INDEMNITY OPTIONS COVERED SERVICES INDEMNITY OPTION The Plan Pays: PPO OPTION In-Network/Georgia The Plan Pays: PPO OPTION In-Network/Out-of-State The Plan Pays: PPO OPTION Out-of-Network The Plan Pays: Chiropractic Care Notes: Coverage for up to a maximum of 40 visits per Plan year. 90% of IR; subject to deductible 90% of NR; subject to 80% of NR; subject to deductible and $20/visit deductible and $20/visit co-payment co-payment 60% of OONR; subject to deductible Behavioral Health Care With BHS authorization, regardless of Health Plan option Inpatient hospital services for mental health and substance abuse are covered at 90% of network rate for up to a combined total of 60 days per person, per Plan year; associated professional fees are covered at 80% of network rate for up to 60 visits. Partial hospitalization program (PHP) and intensive outpatient (IOP) charges are covered at 90% of the network rate with BHS authorization (limited to 30 combined PHP and IOP visits/days per Plan year); no benefit without BHS authorization. Outpatient professional services for mental health and substance abuse are covered at 80% of network rate for up to 50 visits per Plan year. Visit limitation includes up to three brief situational counseling sessions covered at 100% without deductible. All eligible charges are subject to deductibles ($300 PPO in-network/Georgia; $300 Indemnity Option deductible and $100 per confinement hospital deductible) and to a separate out-ofpocket limit of $2,500 per person, per Plan year. No inpatient benefit is available without a BHS authorization. See the SPD and Updaters for full details on coverage provisions and exclusions. 26 Care received outside of BHS network or without BHS authorization, regardless of Health Plan option Inpatient hospital services for mental health and substance abuse are covered at 60% of the average network per diem rate when BHS-authorized for up to a combined total of 60 days per Plan year; associated professional fees are covered at 50% of the network rate for up to 25 visits per Plan year. No inpatient benefit is available without a BHS authorization. Outpatient professional (MD/PhD) services for mental health and substance abuse are covered at 50% of the network rate for up to 25 visits per Plan year. All eligible charges are subject to deductibles and do not accumulate toward any out-of-pocket limit. Balance billing may apply. See the SPD and Updaters for full details on coverage provisions and exclusions. Transplant Services The level of benefit coverage is based on whether or not you select a contracted transplant center, regardless of your Health Plan option. At contracted centers, the level of benefit coverage is 90% of the network rate for covered services. At non-contracted centers, the level of benefit coverage is 60% of the network rate for covered services. Subject to hospital deductible of $100 per admission. IMPORTANT CONSIDERATIONS Charges from non-participating providers are subject to balance billing. Amounts balance billed by non-participating providers are the member's responsibility and do not count toward deductibles or out-of-pocket spending limits. Services covered under the PPO from an In-Network/Georgia provider will apply only to the In-Network/Georgia deductible and out-of-pocket limit. Services covered under the PPO from in-network/out-of-state and out-of-network providers apply to the same deductible and out-of-pocket limit. Lifetime benefit maximums are combined totals among the PPO Options, Indemnity Option and HMO Options (except for Kaiser Permanente). Some PPO annual maximums and limitations are combined totals. Annual dollar and visit limitations, deductibles and out-of-pocket spending limits are based on a July 1 to June 30 Plan year. Some services may require MCP precertification, prior approval or letters of medical necessity before such services are covered by the Plan. Co-payments do not apply toward deductibles or out-of-pocket limits unless otherwise noted. Co-payments for a prescription drug may change at any time during the Plan year due to a change in the status of the drug on the Plan's preferred drug list. For instance, if a preferred brand is reclassified as a generic, your co-payment would decrease. Also, if a preferred brand is reclassified as a non-preferred brand, your co-payment would increase. PPO and Indemnity Options include a discount program for vision screenings and eyewear. Contact the BlueChoice Vision Program at (800) 377-6436 or visit www.bcbsga.com for more information.Vision program availability is subject to change during the Plan year. See the SPD and Updaters for coverage details, including limitations and exclusions. 27 Comparison of Benefits: HMO Options 28 The following chart summarizes the benefits offered by the HMOs--BlueChoice, CIGNA, Kaiser Permanente, Kaiser Permanente Medicare+Choice and UnitedHealthcare. Most covered services are the same for each HMO. If you are trying to choose among HMOs, you should: Check the service area covered by each HMO to see if you live in an approved county. Check which physicians, specialists and hospitals are offered through the HMOs' networks.Would you have to switch physicians if you selected a new HMO? Are physicians' offices located near you? Phone numbers and Web sites for the HMOs are listed on the inside front cover. Compare covered services and what your premium would be for each. To help you compare all SHBP options, this HMO chart follows the same format as the PPO and Indemnity Option comparison of benefits. The Kaiser Permanente and Kaiser Permanente Medicare+Choice benefits are the same, except where noted. HMO COVERED SERVICES COVERED SERVICES BLUECHOICE The Plan Pays: CIGNA The Plan Pays: KAISER PERMANENTE and KAISER PERMANENTE MEDICARE+CHOICE (M+C) The Plan Pays: UNITEDHEALTHCARE The Plan Pays: Maximum Lifetime Benefit $2 million (all SHBP limits combined) $2 million (all SHBP limits combined) No lifetime benefit maximums $2 million (all SHBP limits combined) Pre-existing Conditions (1st year in Plan only, subject to HIPAA) None None None None Lifetime Benefit Limit for Treatment of: Temporomandibular joint dysfunction (TMJ) Substance abuse Organ and tissue transplants Home hyperalimentation No separate lifetime benefit limit No separate lifetime benefit limit No lifetime benefit maximums No separate lifetime benefit limit Deductibles/Co-payments: Deductible--individual Deductible--family maximum Not applicable Not applicable Not applicable Not applicable continued... Hospital co-payment/admission Emergency room co-payment Urgent care center co-payment $200 $200 $200 $200 $50 (waived if admitted) $50 (waived if admitted) $50 (waived if admitted) $50 (waived if admitted) $25 (referral required) $25 $30 $25 Annual Out-of-Pocket Limits: Individual (you or one of your dependents) Family (you and your dependents) Not applicable Not applicable Not applicable Kaiser Permanente M+C: $1,500 per individual, $4,500 per family, per Plan Year Not applicable Primary Care Physician or Specialist Office or Clinic Visits: Treatment of illness or injury 100% after a per visit co-payment of $15 for primary care and $20 for specialty care 100% after a per visit co-payment of $15 for primary care and $20 for specialty care 100% after a per visit co-payment of $15 for primary care and $20 for specialty care 100% after a per visit co-payment of $15 for primary care and $20 for specialty care 29 Primary Care Physician or Specialist Office or Clinic Visits for the following: Wellness care/preventive health care Well-newborn exam Well-child exams and immunizations Annual physicals Annual gynecological exams 100% after a per visit co-payment of $15 for primary care and $20 for specialty care 100% after a per visit co-payment of $15 for primary care and $20 for specialty care. No co-payment for immunizations and mammograms. 100% after a per visit copayment of $15 for primary care and $20 for specialty care. No co-payment for immunizations and mammograms. 100% after a per visit co-payment of $15 for primary care and $20 for specialty care. No co-payment for immunizations and mammograms. 30 HMO COVERED SERVICES COVERED SERVICES Prescription Drugs Generic Preferred brand name Non-preferred brand name Generic Preferred brand name Non-preferred brand name Maintenance medications Notes: Covers only prescriptions filled at participating local pharmacy or HMO medical center. Maternity Treatment -- Physician Services (pre-natal and post-natal) Laboratory; X-Rays; Diagnostic Tests; Injections, including Medications Covered Under Medical Benefits--for the Treatment of an Illness or Injury BLUECHOICE The Plan Pays: CIGNA The Plan Pays: KAISER PERMANENTE and KAISER PERMANENTE UNITEDHEALTHCARE MEDICARE+CHOICE (M+C) The Plan Pays: The Plan Pays: 100% after your per prescription co-payment $10 $20 $35 100% after your per prescription co-payment $10 $20 $35 100% after your per prescription co-payment At Kaiser pharmacy At Eckerd's $10 $16 $20 $26 Not Not applicable applicable 100% after your per prescription co-payment $10 $20 $35 Kaiser Permanente M+C: $10 $16 $15 $21 Not Not applicable applicable 90-day supply covered 90-day supply covered after two co-payments after two co-payments Up to 90-day supply; co-payment is per 30-day supply; applies to Kaiser and Kaiser M+C. 90-day supply covered after two co-payments 100% after an initial co-payment of $20 100% after an initial co-payment of $20 100% after an initial co-payment of $20 100% after an initial co-payment of $20 Kaiser Permanente M+C: 100% coverage 100% 100% 100% 100% Allergy Shots and Serum 100% for shots and serum after a co-payment of $20 per visit 100% for shots and serum after a co-payment of $20 per visit $5 for shots and $50 for six-month supply of serum Kaiser Permanente M+C: $5 for shots, no charge for serum 100% for shots and serum after a co-payment of $20 per visit Allergy Testing 100% after per visit co-payment of $20 100% after per visit co-payment of $20 100% after per visit co-payment of $20 100% after per visit co-payment of $20 Physician Services Furnished in a Hospital Surgery in general, including charges by surgeon, anesthesiologist, pathologist and radiologist 100% 100% 100% 100% Inpatient well-newborn exams 100% 100% 100% 100% 31 Physician Services That Are for Emergency Care 100% after applicable co-payment 100% after applicable co-payment 100% after applicable co-payment 100% after applicable co-payment Outpatient Surgery-- Physician's Office 100% after $20 100% after $20 100% after $20 100% after $20 co-payment if billed as co-payment if billed as co-payment if billed as co-payment if billed as office visit; 100% after office visit; 100% after office visit; 100% after office visit; 100% after $100 co-payment if billed $100 co-payment if billed $100 co-payment if billed $100 co-payment if billed as outpatient surgery as outpatient surgery as outpatient surgery as outpatient surgery Outpatient Surgery--Hospital/Facility 100% after $100 per confinement co-payment 100% after $100 per confinement co-payment 100% after $100 per confinement co-payment 100% after $100 per confinement co-payment Hospital Services Other Than Those That Are for Emergency Care Inpatient care, including inpatient short-term acute rehabilitation services 100% after $200 per confinement co-payment 100% after $200 per confinement co-payment 100% after $200 per confinement co-payment 100% after $200 per confinement co-payment HMO COVERED SERVICES COVERED SERVICES BLUECHOICE The Plan Pays: CIGNA The Plan Pays: KAISER PERMANENTE and KAISER PERMANENTE UNITEDHEALTHCARE MEDICARE+CHOICE (M+C) The Plan Pays: The Plan Pays: Hospital Services Other Than Those That Are for Emergency Care (continued) Outpatient services -- Non-emergency use of emergency room Requires prior Requires prior Requires prior Requires prior authorization from PCP, authorization from PCP, authorization from PCP, authorization from HMO, otherwise not covered otherwise not covered otherwise not covered otherwise not covered Well-newborn care 100% 100% 100% 100% Hospital Services That Are for Emergency Care Treatment of an emergency medical condition or injury 100% after a per visit co-payment of $50 (co-payment waived if admitted) 100% after a per visit co-payment of $50 (co-payment waived if admitted) 100% after a per visit co-payment of $50 (co-payment waived if admitted) 100% after a per visit co-payment of $50 (co-payment waived if admitted) 32 Ambulance Services for Emergency Care 100% 100% 100% after a $50 copayment per trip when medically necessary 100% Urgent Care Services in an Approved 100% after a $25 co- Urgent Care Center payment, referral required 100% after a $25 co-payment 100% after a $30 co-payment 100% after a $25 co-payment Home Nursing Care Skilled Nursing Facility Services 100%; up to 120 days per Plan year 100%; up to 120 days per Plan year 100%; up to 120 days 100%; up to 120 days per per Plan year Plan year Kaiser Permanente M+C: 100%; no day limit 100%; prior approval 100%; prior approval 100%; prior approval 100%; prior approval is is required; 45-day maxi- is required; 45-day max- is required; up to 45-day required; 120-day mum per Plan year imum per Plan year maximum per Plan year maximum per Plan year Hospice Care 100%; prior approval is required 100%; prior approval is required 100%; prior approval is required 100%; prior approval is required Durable Medical Equipment (DME)-- Rental or Purchase 100% when medically 100% when medically 100% when medically necessary necessary necessary 100% when medically necessary Outpatient Acute Short-term Rehabilitation Services 100% after a $20 co-payment per visit; up to 40 visits per Plan year 100% after a $20 co-payment per visit; up to 40 visits per Plan year 100% after a $20 co-payment per visit; up to 40 visits per Plan year or up to two consecutive months per condition, whichever is more 100% after a $20 co-payment per visit; up to 40 visits per Plan year Kaiser Permanente M+C: Physical, occupational and speech therapy: 100% coverage after $20 co-payment; unlimited visits per Plan year 33 Dental and Oral Care-- Limited Coverage Coverage in general 100% after applicable co-payment for oral surgery and dental services associated with an accidental injury to sound teeth 100% after applicable co-payment for oral surgery and dental services associated with an accidental injury to sound teeth Services and appliances for accidental injury to sound and natural teeth: 50% coverage for first $1,000, then 100% thereafter 100% after applicable co-payment for oral surgery and dental services associated with an accidental injury to sound teeth Coverage of specific osseous surgeries for the treatment of periodontal disease Not covered Not covered Not covered Not covered Temporomandibular joint syndrome (TMJ) 100% after applicable co-payment, subject to limitations 100% after applicable co-payment, subject to limitations 50% for non-surgical treatment 100% after applicable co-payment, subject to limitations Chiropractic Care 100% after $20 co-payment per visit; limited to 20 visits per Plan year 100% after $20 co-payment per visit; limited to 20 visits per Plan year 100% after $20 co-payment per visit; limited to 20 visits per Plan year 100% after $20 co-payment per visit; limited to 20 visits per Plan year 34 HMO COVERED SERVICES COVERED SERVICES Behavioral Health Care (Mental health and substance abuse care) Transplant Services BLUECHOICE The Plan Pays: CIGNA The Plan Pays: KAISER PERMANENTE and KAISER PERMANENTE MEDICARE+CHOICE (M+C) UNITEDHEALTHCARE The Plan Pays: The Plan Pays: For inpatient care: 100% after $50 co-payment per confinement; limited to 30 days per Plan year. For outpatient care: 100% after $20 co-payment per visit; limited to 25 visits per Plan year. For inpatient care: 100% after $50 co-payment per confinement; limited to 30 days per Plan year. For outpatient care: 100% after $20 co-payment per visit; limited to 25 visits per Plan year. Mental health: Inpatient services are covered at 100% after a $50 copayment per admission; unlimited days. Outpatient services covered at 100% after $20 co-payment per visit; unlimited visits. Substance abuse: Inpatient services covered at 100% after a $50 co-payment per admission; up to 30 days per Plan year. Kaiser Permanente M+C unlimited days per Plan year. For inpatient care: 100% after $50 co-payment per confinement; limited to 30 days per Plan year. For outpatient care: 100% after $20 co-payment per visit; limited to 25 visits per Plan year. Outpatient services covered at 100% after $20 co-payment per visit; up to 25 visits per Plan year. Kaiser Permanente M+C unlimited visits per Plan year. Detoxification: Co-payments same as above. No coverage limits on number of episodes, inpatient days or outpatient visits. 100% 100% 100% 100% IMPORTANT CONSIDERATIONS Annual dollar and visit limitations are based on a July 1 to June 30 Plan year. Some services may require prior authorization by the HMO before such services are covered. Also, some services may have limitations not contained in this summary. Most HMOs require the selection of a primary care physician (PCP) to manage your care. Failure to specify a PCP could delay receipt of your ID card. However, in some instances, the HMO assigns you a PCP located near your residence if a PCP is not specified. Note: UnitedHealthcare does not require the selection of a PCP. Most HMOs require you to obtain referrals to see most specialists. Failure to obtain a referral could result in a denial of your claim. Note: UnitedHealthcare does not require referrals for coverage of specialist services. Each HMO Option may offer vision care discounts or benefits. Contact the HMO directly for more information. Contact the HMO directly for more details regarding covered services, exclusions and limitations. 35 STATE HEALTH BENEFIT PLAN 2003/2004 Service Areas for Your Health Plan Options Service Areas Service areas are State-approved geographic areas, such as counties or zip codes, where providers participate in the network offered by the Plan option in which you have enrolled. PPO and PPO Choice Option Georgia Service Area The Georgia service area includes the state of Georgia and the border communities of the Chattanooga,Tennessee area, including Bradley County; and Phenix City, Alabama. The zip code area in which you receive a service is used to determine whether or not you are in the Georgia service area. If you receive covered services from a 1st Medical Network provider located in one of the zip codes below, you receive the highest level of coverage available in the PPO options. Out-of-State/National Service Area The out-of-state service area includes all national locations outside of the Georgia service area described to the left. By using Beech Street providers outside of the Georgia service area, you are protected against being charged more than what the Plan allows. However, use of Beech Street providers inside the Georgia service area is considered out-of-network care with lower levels of benefit coverage and a separate deductible and out-of-pocket maximum, unless the provider also is a 1st Medical Network participant. Georgia: All counties; all zip codes Alabama: Russell County (Phenix City area): 36851, 36856, 36858, 36859, 36860, 36867, 36868, 36869, 36870, 36871 and 36875. Tennessee: Bradley County (Cleveland area): 37310, 37311, 37312, 37320, 37323, 37353 and 37364. Hamilton County (Chattanooga area): 37302, 37304, 37308, 37315, 37341, 37343, 37350, 37351, 37363, 37373, 37377, 37379, 37384, 37401, 37402, 37403, 37404, 37405, 37406, 37407, 37408, 37409, 37410, 37411, 37412, 37414, 37415, 37416, 37419, 37421, 37422, 37424 and 37450. 36 STATE HEALTH BENEFIT PLAN 2003/2004 HMO Options You must live in the HMO's approved service area to be eligible for coverage under that option. Below are the regular HMO Option service areas by county. If you live or work in a county marked "Yes" under any of the HMOs listed, you may enroll in that HMO. If the county where you live is not listed below, you are not eligible for regular HMO coverage. Service area changes for the 2003-2004 Plan year are in bold type. County of Residence Appling Bacon Baldwin Banks Barrow Bartow Ben Hill Berrien Bibb Bleckley Brooks Bryan Bulloch Burke Butts Candler Carroll Catoosa Chatham Chattahoochee Chattooga Cherokee Clarke Clayton Cobb Colquitt Columbia Coweta Crawford Dade Dawson Decatur BlueChoice Not Available Not Available Not Available Yes Yes Yes Not Available Not Available Yes Yes Not Available Yes Yes Yes Yes Not Available Yes Not Available Yes Yes Yes Yes Yes Yes Yes Not Available Yes Yes Yes Not Available Yes Not Available CIGNA Yes Yes Not Available Not Available Yes Yes Not Available Not Available Yes Yes Not Available Yes Yes Yes Yes Yes Not Available Yes Yes Not Available Yes Yes Yes Yes Yes Not Available Yes Yes Not Available Yes Not Available Not Available Kaiser Permanente UnitedHealthcare Not Available Not Available Not Available Not Available Yes Yes Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Yes Not Available Not Available Not Available Not Available Not Available Not Available Yes Not Available Yes Yes Not Available Not Available Yes Not Available Not Available Not Available Not Available Not Available Yes Not Available Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Not Available 37 County of Residence DeKalb Dodge Douglas Early Effingham Elbert Emanuel Evans Fannin Fayette Floyd Forsyth Franklin Fulton Gilmer Glascock Gordon Grady Greene Gwinnett Habersham Hall Harris Hart Heard Henry Houston Jackson Jasper Jefferson Jenkins Johnson Jones Lamar Lanier Laurens Liberty STATE HEALTH BENEFIT PLAN 2003/2004 BlueChoice Yes Not Available Yes Not Available Yes Yes Yes Not Available Not Available Yes Yes Yes Yes Yes Yes Yes Yes Not Available Yes Yes Not Available Yes Yes Yes Yes Yes Yes Yes Not Available Yes Yes Yes Yes Not Available Not Available Not Available Yes CIGNA Yes Not Available Yes Not Available Yes Yes Yes Yes Not Available Yes Yes Yes Yes Yes Not Available Not Available Yes Not Available Yes Yes Not Available Yes Yes Not Available Not Available Yes Not Available Yes Not Available Yes Not Available Not Available Yes Yes Not Available Yes Yes Kaiser Permanente UnitedHealthcare Yes Not Available Yes Not Available Not Available Not Available Not Available Not Available Not Available Yes Not Available Yes Not Available Yes Not Available Not Available Not Available Not Available Not Available Yes Not Available Yes Not Available Not Available Not Available Yes Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Yes Not Available Yes Yes Yes Not Available Yes Yes Not Available Yes Yes Yes Not Available Yes Not Available Yes Yes Yes Yes Yes Yes Yes Yes Not Available Not Available Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Not Available Yes 38 County of Residence Lincoln Long Lowndes Lumpkin Madison Marion McDuffie Meriwether Mitchell Monroe Morgan Muscogee Newton Oconee Oglethorpe Paulding Peach Pickens Pike Polk Pulaski Putnam Richmond Rockdale Screven Seminole Spalding Stewart Sumter Talbot Taliaferro Tattnall Taylor Thomas Tift Toombs Twiggs STATE HEALTH BENEFIT PLAN 2003/2004 BlueChoice Yes Not Available Not Available Yes Yes Yes Yes Yes Not Available Yes Yes Yes Yes Yes Yes Yes Yes Yes Not Available Yes Yes Not Available Yes Yes Not Available Not Available Yes Yes Not Available Yes Not Available Not Available Not Available Not Available Not Available Not Available Yes CIGNA Yes Yes Not Available Not Available Yes Yes Yes Not Available Not Available Yes Not Available Yes Yes Yes Yes Yes Not Available Not Available Yes Yes Not Available Not Available Yes Yes Yes Not Available Yes Not Available Not Available Not Available Not Available Yes Yes Not Available Not Available Not Available Not Available Kaiser Permanente UnitedHealthcare Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Yes Not Available Not Available Yes Not Available Not Available Not Available Not Available Not Available Not Available Not Available Yes Not Available Not Available Yes Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Yes Yes Yes Yes Yes Not Available Yes Yes Yes Yes Yes Yes Yes Not Available Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Not Available Yes Yes Yes Yes Yes Yes Yes Yes 39 STATE HEALTH BENEFIT PLAN 2003/2004 County of Residence Upson Walker Walton Ware Warren Washington Wayne White Whitfield Wilkes Wilkinson Worth BlueChoice Not Available Not Available Yes Not Available Yes Yes Not Available Yes Not Available Yes Yes Not Available CIGNA Not Available Yes Yes Not Available Not Available Not Available Not Available Not Available Yes Yes Yes Not Available Kaiser Permanente UnitedHealthcare Not Available Not Available Yes Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Yes Yes Yes Yes Yes Not Available Yes Yes Not Available Yes Yes Yes Medicare+Choice HMO Option County of Residence Cherokee Clayton Cobb Coweta DeKalb Douglas Fayette Forsyth Fulton Gwinnett Henry Paulding Kaiser Permanente M+C HMO Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes, only if you live in zip code 30127, 30134 or 30141 40 STATE HEALTH BENEFIT PLAN 2003/2004 Health Insurance Portability and Accountability Act (HIPAA) Annual Notice This section describes certain rights available to you under the Health Insurance Portability and Accountability Act (HIPAA) when you add a dependent to your SHBP coverage. The PPO and Indemnity Options contain a preexisting condition (PEC) limitation. Specifically, the Health Plan will not pay charges that are over $1,000 for the treatment of any pre-existing condition 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 or medication for that condition for at least six consecutive calendar months. However, a pre-existing condition limitation does not apply to coverage for: Pregnancy; or Newborns or children under age 18 who are adopted or placed for adoption, if the child becomes covered within 31 days after birth, adoption or placement for adoption. In certain situations, SHBP dependents can reduce the 12-month pre-existing condition limitation period. The reduction is possible by using what is called "creditable coverage" to offset a pre-existing condition period. Creditable coverage generally includes the health coverage a family member had immediately prior to joining the SHBP. Coverage under most group health plans, as well as coverage under individual health policies and governmental health programs, qualifies as creditable coverage. To reduce the pre-existing condition limitation period for your dependents (including your spouse), you must provide the SHBP with a certificate of creditable coverage stating when coverage started and ended for each dependent that you want to cover. Any period of prior coverage for that dependent will reduce the 12-month limitation period if no more than 63 days have elapsed between the dependent's loss of prior coverage and the first day of coverage under the SHBP. If your dependent (including a spouse) had any break in coverage lasting more than 63 days, your dependent will receive creditable coverage only for the period of time after the break ended. Within two years after your dependent's former coverage terminated, he/she has the right to obtain a certificate of creditable coverage from his/her former employer(s) to offset the pre-existing condition limitation period under the SHBP. The SHBP will evaluate the certificate of creditable coverage or other documentation to determine whether any of the pre-existing condition limitation period will be reduced or eliminated. After completing the evaluation, the SHBP will notify you as to how the pre-existing condition limitation period will be reduced or eliminated. Please submit the certificate of creditable coverage to the Plan with your dependent's enrollment paperwork. 41 STATE HEALTH BENEFIT PLAN 2003/2004 Department of Community Health Privacy Notice This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The Plan's Privacy Commitment to You The Georgia Department of Community Health (DCH) understands that information about you and your family is personal. DCH is committed to protecting your information.This notice tells you how DCH uses and discloses information about you. It tells you your rights and the Plan's requirements about your information. Understanding the Type of Information That the Plan Has Your employer (state agency, school system, authority, etc.) sent information about you to DCH.This information included your name, address, birth date, phone number, Social Security Number and other health insurance policies that you may have. It may also have included health information.When your health care providers send claims to the Plan's claim administrator for payment, the claims include your diagnoses and the medical treatments you received. For some medical treatments, your health care providers send additional medical information to the Plan such as doctor's statements, x-rays or lab test results. Your Health Information Rights You have the following rights regarding the health information that DCH has about you. You have the right to see and obtain a copy of your health information.An exception is psychotherapy notes.Another exception is information that is needed for a legal action relating to DCH. You have the right to ask DCH to change health information that is incorrect or incomplete. DCH may deny your request under certain circumstances. You have the right to request a list of the disclosures that DCH has made of your health information beginning in April 2003. You have the right to request a restriction on certain uses or disclosures of your health information. DCH is not required to agree with your request. You have the right to request that DCH communicates with you about your health in a way or at a location that will help you keep your information confidential. You have the right to receive a paper copy of this notice.You may ask DCH staff to give you another copy of this notice, or you may obtain a copy from DCH's Web site, www.dch.state.ga.us (click on "Privacy"). Privacy Law's Requirements DCH is required by law to: Maintain the privacy of your information. Give you this notice of DCH's legal duties and privacy practices regarding the information that DCH has about you. Follow the terms of this notice. Not use or disclose any information about you without your written permission, except for the reasons given in this notice.You may take away your permission at any time, in writing, except for the information that DCH disclosed before you stopped your permission. If you cannot give your permission due to an emergency, DCH may release the information if it is in your best interest. DCH must notify you as soon as possible after releasing the information. In the future, DCH may change its privacy practices. If its privacy practices change significantly, DCH will provide a new notice to you. DCH will post the new notice on its Web site at www.dch.state.ga.us (click on "Privacy").This notice is effective April 14, 2003. 42 STATE HEALTH BENEFIT PLAN 2003/2004 How DCH Uses and Discloses Health Care Information There are some services the Plan provides through contracts with private companies. For example, Blue Cross and Blue Shield of Georgia pays most medical claims to your health care providers.When services are contracted, the Plan may disclose some or all of your information to the company so that they can perform the job the Plan has asked them to do.To protect your information, the Plan requires the company to safeguard your information in accordance with the law. The following categories describe different ways that the Plan uses and discloses your health information. For each category, we will explain what we mean and give an example. For Payment: The Plan may use and disclose information about you so that it can authorize payment for the health services that you received. For example, when you receive a service covered by the Plan, your health care provider sends a claim for payment to the claims administrator.The claim includes information that identifies you, as well as your diagnoses and treatments. For Medical Treatment: The Plan may use or disclose information about you to ensure that you receive necessary medical treatment and services. For example, if you participate in a Disease State Management Program, the Plan may send you information about your condition. To Operate Various Plan Programs: The Plan may use or disclose information about you to run various Plan programs and ensure that you receive quality care. For example, the Plan may contract with a company that reviews hospital records to check on the quality of care that you received and the outcome of your care. To Other Government Agencies Providing Benefits or Services: The Plan may give information about you to other government agencies that are giving you benefits or services.The information must be necessary for you to receive those benefits or services and will be authorized by you or by law. To Keep You Informed: The Plan may mail you information about your health and well-being. Examples are information about managing a disease that you have, information about your managed care choices, and information about prescription drugs you are taking. For Overseeing Health Care Providers: The Plan may disclose information about you to the government agencies that license and inspect medical facilities, such as hospitals, as required by law. For Research: The Plan may disclose information about you for a research project that has been approved by a review board.The review board must review the research project and its rules to ensure the privacy of your information.The research must be for the purpose of helping the Plan. As Required by Law: The Plan will disclose information about you as required by law. For More Information and to Report a Problem If you have questions and would like additional information, you may contact the SHBP at 404656-6322 (Atlanta calling area) or 800-610-1863 (outside of Atlanta calling area). If you believe your privacy rights have been violated: You can file a complaint with the Plan by calling the SHBP at 404-656-6322 (Atlanta calling area) or 800-610-1863 (outside of Atlanta calling area), or by writing to: SHBP HPU, P.O. Box 38342,Atlanta, GA 30334. You can file a complaint with the Health and Human Services' Office for Civil Rights by writing to: U.S. Department of Health and Human Services Office for Civil Rights, Region IV, Atlanta Federal Center, 61 Forsyth Street SW, Suite 3B70,Atlanta, GA 30303-8909. Phone (404) 562-7886; Fax (404) 562-7881;TDD (404) 331-2867 You also may contact the HHS' Office for Civil Rights by calling 866-OCR-PRIV (866-627-7748) or 886-788-4989 TTY. There will be no retaliation for filing a complaint. 43 STATE HEALTH BENEFIT PLAN 2003/2004 Women's Health and Cancer Rights Act The Plan complies with the Women's Health and Cancer Rights Act of 1998. Mastectomy, including reconstructive surgery, is covered the same as other surgery under your Plan option. Following cancer surgery, the SHBP covers: All stages of reconstruction of the breast on which the mastectomy has been performed; Reconstruction of the other breast to achieve a symmetrical appearance; Prostheses and mastectomy bras; and Treatment of physical complications of mastectomy, including lymphedema. Note: Reconstructive surgery requires prior approval and all inpatient admissions require MCP precertification. For more detailed information on the mastectomyrelated benefits available under the Plan, you can contact the Member Services unit for your coverage option.Telephone numbers are on the inside front cover. Penalties for Misrepresentation If any SHBP participant misrepresents the facts when applying for dependent coverage, change of coverage, or benefits, the SHBP may terminate the person's participation (and that of his or her dependents) and seek legal recovery of any money paid out by the SHBP as a result of the misrepresentation. 44 STATE HEALTH BENEFIT PLAN 2003/2004 Disclaimer This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of Plan or program benefits and does not constitute a contract or any part of one. For a complete description of the benefits available to you, including procedures, exclusions and limitations, refer to your specific Plan documents, which may include the State Health Benefit Plan Summary Plan Description, Summary of Material Modification (Updater), Schedule of Benefits, Certificate of Coverage, Group Agreement, Group Insurance Certificate, Group Insurance Policy and any applicable riders to your Plan. All the terms and conditions of your Plan or program are subject to and governed by applicable contracts, laws, regulations and policies. Certain services, including but not limited to non-emergency inpatient hospital care, require precertification. All benefits are subject to coordination of benefits unless noted otherwise. In case of a conflict between your Plan documents and this information, the Plan documents will govern. Medicare is a program of the federal government. The information in this Guide is intended only to be a helpful summary of Medicare and not a complete explanation of the program. For more detailed information, contact your local Medicare office. In the event of a conflict between this summary and the Medicare program, Medicare's provisions govern. Copyright: The Georgia Department of Community Health, April 2003 45