State Health Benefit Plan, July 1, 2004 - June 30, 2005, health plan decision guide for retirees

STATE HEALTH BENEFIT PLAN
JULY 1, 2004 JUNE 30, 2005
HEALTH PLAN DECISION GUIDE
FOR RETIREES
A SHARED SOLUTION
RETIREE OPTION CHANGE PERIOD: April 15-May 14, 2004

GEORGIA DEPARTMENT OF COMMUNITY HEALTH
RETIREE OPTION CHANGE PERIOD FOR 2004 2005 APRIL 15 MAY 14, 2004

Check www.statehealth.org to make coverage changes online during the Retiree Option Change Period or complete and return your Personalized Change Form (PCF) postmarked by May 14, 2004.

PHONE NUMBERS AND CONTACTS FOR BENEFIT AND PROVIDER INFORMATION

PPO, PPO CHOICE OPTIONS (BASIC, PREMIER), INDEMNITY OPTIONS (BASIC, PREMIER)
u For rate and benefit coverage information, call the Retiree Help Line at (800) 586-9288
TDD line for the hearing impaired: (800) 269-4719 (outside Atlanta), (404) 842-8073 (in Atlanta)
During the Retiree Option Change Period, call volume for these numbers is expected to be very high, and you may experience time on hold.
You can get both National and Georgia PPO provider information online at: www.healthygeorgia.com

HMOS BlueChoice Healthcare Plan (800) 464-1367 Online provider information: www.bcbsga.com
CIGNA HealthCare of Georgia (800) 564-7642 Online provider information: www.cigna.com
Kaiser Permanente (404) 261-2590 or (800) 611-1811 Online provider information: www.kaiserpermanente.org.
Kaiser Permanente Medicare + Choice (404) 233-3700 or (800) 956-1358

BEHAVORIAL HEALTH SERVICES
Contact Magellan for provider and referral information. 24 hours per day, 7 days per week. (800) 631-9943 www.magellanhealth.com
TDD line for hearing impaired: (678) 319-3860 or (800) 201-8316

UnitedHealthcare of Georgia (866) 527-9599 Online provider information: www.provider.uhc.com/gdch
ADDITIONAL INFORMATION Medicare or Medicare + Choice www.medicare.gov

PRESCRIPTION DRUG PROGRAM INFORMATION
All Options except HMOs Contact the Pharmacy Benefits Manager, Express Scripts, at (877) 650-9342
TDD line for the hearing impaired: (800) 842-5754

Centers for Medicare and Medicaid Services (CMS) www.cms.gov
Social Security Administration (800) 772-1213 www.ssa.gov

Information on page 8 of this guide contains a notice of upcoming Plan changes effective on July 1, 2004. Prior to the start of the 2004 2005 Plan year, the Plan will distribute an Updater, which is your official notice of Plan changes effective on July 1, 2004. If you do not receive a copy of the Updater by July 1, 2004, contact the State Health Benefit Plan at (404) 656-6322 or (800) 610-1863 (outside Atlanta). Please keep your Summary Plan Description (SPD) and Updater for future reference. If you are disabled and need this information in an alternative format, call the TDD Relay Service at (800) 255-0056 (text telephone) or (800) 255-0135 (voice) or write the SHBP at P.O. Box 38342,Atlanta, GA 30334.

REMEMBER THIS DEADLINE
For changing your coverage during the Retiree Option Change Period -- April 15 through May 14 -- you can enter your changes on the Web site below or complete and return the Personalized Change Form.
u www.statehealth.org Midnight (April 14) to midnight (May 14) 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.

CONTENTS

PHONE NUMBERS AND CONTACTS FOR BENEFIT AND PROVIDER INFORMATION . . . . . . . . . . . . . . . . . . . . . . . INSIDE FRONT COVER

YOU ARE PART OF THE SOLUTION! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

BASIC PLAN INFORMATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

MAKING ENROLLMENT DECISIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

WHAT'S CHANGING FOR 2004 2005 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

UNDERSTANDING PROVIDER NETWORKS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 u INDEMNITY OPTIONS BASIC AND PREMIER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 u PPO OPTIONS BASIC AND PREMIER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 u PPO CHOICE OPTIONS BASIC AND PREMIER . . . . . . . . . . . . . . . . . . . . . . . . . . 11 u HMO OPTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 u HMO CHOICE OPTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 u MEDICARE+CHOICE HMO OPTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Q+A ON MEDICARE+CHOICE HMO AND REGULAR HMOS . . . . . . . . . . . . . . . . . 15

BENEFITS COMPARISON: PPO, INDEMNITY AND HMO OPTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

SERVICE AREAS FOR YOUR HEALTH PLAN OPTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) ANNUAL NOTICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

DEPARTMENT OF COMMUNITY HEALTH PRIVACY NOTICE . . . . . . . . . . . . . . . . . . . . . . . . 34

WOMEN'S HEALTH AND CANCER RIGHTS ACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

PENALTIES FOR MISREPRESENTATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

1

YOU ARE PART OF
THE SOLUTION!

Each Retiree Option Change Period, members express concern about the rising costs of healthcare benefits. Monthly premiums continue to increase and benefits are modified.This is true of State Health Benefit Plan (SHBP) members as well as employees and retirees nationally.
The American Medical Association reports that people who do not understand their health coverage pay more.To help you understand your plan and help you save your healthcare dollars, we have prepared a few points for you to consider.

The SHBP is a self-funded plan.That means that employee/ retiree premiums and employer funds (i.e., the State of Georgia, local school systems and other employers) pay all expenses.There are costs associated with administering the plan but that amounts to 5% of the total plan cost.The other 95% of the premium you pay goes directly to pay member healthcare claims. Premiums are based on an average of active members and retirees.This is a considerable benefit to retirees. If retiree premiums were based only on retiree costs, they would increase by more that 50%!

PER RETIREE PER MONTH COST

Monthly Retiree Contribution Monthly State Contribution Monthly Total Cost

$400

STATE HEALTH BENEFIT PLAN PPO SINGLE

$350 $300 $250 $200

$273.04 $227.94

$289.00 $243.90

$303.45 $255.27

$304.65 $255.27

$150

$100 $50

$45.10

$45.10

$48.18

$49.38

$0 FISCAL YEAR 2000

FISCAL YEAR 2001

FISCAL YEAR 2002

FISCAL YEAR 2003

$345.68 $286.62
$59.06 FISCAL YEAR 2004

$800

STATE HEALTH BENEFIT PLAN PPO FAMILY

PER RETIREE PER MONTH COST

$700 $600 $500 $400

$505.06 $373.34

$535.00 $403.28

$561.75 $414.65

$565.43 $414.65

$641.58 $461.30

$300 $200 $100

$131.72

$131.72

$147.10

$150.78

$180.28

$0

2

FISCAL YEAR 2000

FISCAL YEAR 2001

FISCAL YEAR 2002

FISCAL YEAR 2003

FISCAL YEAR 2004

GENERAL INFORMATION

GENERAL INFORMATION

Employee/retiree premiums cover only a portion of SHBP's total healthcare costs.The remaining costs are paid by the State.The graphs to the left provide you with an idea of how the costs of your healthcare are allocated between employees/ retirees and the State of Georgia.
So what can you do to help manage your healthcare costs and keep down the increase in premiums?
UNDERSTAND YOUR OPTIONS
Review all your plan options, taking into account both the premium costs and out-ofpocket costs that you may incur. As part of your responsibility, it is extremely important that you read the Decision Guide, Pharmacy Benefit Comparison brochure and Summary Plan Description carefully. Web sites and phone numbers are listed on the inside front cover of the Decision Guide if you need more information.
BECOME A MORE PROACTIVE
CONSUMER OF HEALTHCARE
Most people do not realize how much their treatments, medicines and tests cost.The illustration below is one example of the savings from choosing a generic drug instead of a brand-name drug.

Steps You Can Take Include:
u Shop in-network providers and pharmacies. Find out what your drugstore charges for a drug, not just the co-payment.
u Use generic medicines whenever possible.
u Make sure all procedures are precertified, if required.
u Talk to your provider. For example, ask your doctor if tests are necessary or if there are other forms of treatment.
u Check your Explanation of Benefits (if provided under your plan option) and if something does not make sense or seems to cost too much, ask your provider about it.
These and other steps you take to help manage healthcare expenses, reduce your out-of-pocket costs and those of the Plan. In addition, these steps will help in keeping premium costs down. As an informed consumer of healthcare, you can have an impact on what you have to pay for premiums and be part of the solution.

PRESCRIPTION BRAND NAME GENERIC S AV I N G S

MEMBER C O - PAY M E N T
$25
$10
to you $15

TOTAL PRESCRIPTION COST
$90
$42


COST TO THE SHBP
$65
$32
to SHBP $33

3

BASIC PLAN
INFORMATION
ELIGIBLE DEPENDENTS
A dependent is defined as:
u Your spouse, if you are legally married; u 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.

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:
u A copy of your certified marriage license to cover spouses;
u A copy of a certified birth certificate to cover a natural child;
u 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;
u 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);
u Disability paperwork for disabled dependents 19 and over; this documentation must be received by the Plan before the child's 19th birthday; or
u A certification letter for full-time student dependents from the registrar's office of your child's school.

GENERAL INFORMATION

4

GENERAL INFORMATION

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 2004 2005 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:
u Marriage or divorce;
u Birth or adoption of a child or placement for adoption;
u Death of a spouse or child, if only dependent enrolled;
u Your spouse's or dependent's eligibility for or loss of eligibility for other group health coverage;
u 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
u 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.

5

MAKING
ENROLLMENT DECISIONS

You have the opportunity to make benefit plan selections during this Retiree Option Change Period. Selections requested during this period will become effective on July 1, 2004. Refer to the Benefits Comparison section on pages 16-27 of this guide for an overview of the medical services covered by each option.

CONSIDERATIONS Before choosing a new option, carefully review the benefits offered and network providers participating in the various options. Phone numbers and Web site addresses are listed on the inside of the front cover to assist you.

u PPO Premier, PPO Choice Premier and Indemnity Premier -- These options offer a more extensive level of prescription coverage and a maximum out-of-pocket feature.You pay a higher monthly premium than with the Basic option.

PPO, PPO CHOICE AND INDEMNITY OPTIONS
Effective July 1, 2004, the current Indemnity, PPO and PPO Choice Options are no longer available.You will be offered new PPO and Indemnity Options.The new options will be known as PPO Basic, PPO Premier, PPO Choice Basic, PPO Choice Premier, Indemnity Basic and Indemnity Premier.The medical benefits in these new Plan options are the same as offered in the 20032004 Plan year; however, there are significant changes to the pharmacy benefits.

Carefully review the Pharmacy Benefit Comparison brochure for specific information about the changes in the pharmacy benefits.

u PPO Basic, PPO Choice Basic and Indemnity Basic -- These options offer a basic level of prescription coverage. The Basic pharmacy benefit does not offer a maximum out-of-pocket feature. You will pay a lower monthly premium than with the Premier option.

ENROLLMENT INFORMATION

6

ENROLLMENT INFORMATION

HMO OPTIONS After reviewing the benefit comparison, if you wish to continue with your current HMO coverage, no action is required. If you select 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. Please contact the HMO Customer Service Department directly to make your PCP selection. Note: UnitedHealthcare does not require the selection of a PCP.
NOTE: If you do not submit a new election by May 14, 2004, your current Health Plan option under the PPO or PPO Choice plans will default to the PPO Basic or PPO Choice Basic Option. The current Indemnity Plan Option will default to the Indemnity Basic Option. This will result in a change from your current pharmacy benefit.
7

WHAT'S CHANGING
FOR 2004 2005

ID Card Changes: Effective July1, 2004, state law prohibits the printing of Social Security numbers on health benefit identification cards. New PPO Basic, PPO Premier, Indemnity Basic and Indemnity Premier cards will be issued in late June.The number that will be listed in lieu of the Social Security number has been randomly assigned. Please present your providers with a copy of your new card when receiving services.
For Indemnity, PPO and PPO Choice Option members: The current PPO and Indemnity Options will not be offered effective July 1, 2004.You will be offered new PPO and Indemnity Plan Options.The new options will be known as PPO Basic, PPO

Premier, PPO Choice Basic, PPO Choice Premier, Indemnity Basic and Indemnity Premier.The medical benefits in these options are the same as offered in the 20032004 Plan year. However, the new plans offer different choices in pharmacy benefits. Please refer to the Pharmacy Benefit Comparison brochure for specific information about the changes in the pharmacy benefits.

For HMO Option members:

BENEFIT

BLUECHOICE

CIGNA

KAISER PERMANENTE

UNITEDHEALTHCARE

Home Healthcare Services (require prior approval PA)

None

None

100% with PA; 120 visits max per Plan year (formerly 120 days)

None

HMO Service Area Changes

None

None

None

Yes

See pages 29-32 for a list of specific counties in the approved service area.

Pharmacy

See Pharmacy

See Pharmacy

See Pharmacy

Benefit Comparison Benefit Comparison Benefit Comparison

brochure

brochure

brochure

See Pharmacy Benefit Comparison
brochure

ENROLLMENT INFORMATION

8

OVERVIEW OF PLAN OPTIONS

UNDERSTANDING
PROVIDER NETWORKS

The State Health Benefit Plan has contracted with healthcare organizations that have been carefully reviewed and selected to provide the highest level of provider accessibility and quality of care.When selecting your health plan option during the Retiree Option Change Period, it is extremely critical that you fully understand how the provider network functions for the various health plan options:

INDEMNITY OPTIONS BASIC AND PREMIER
The Indemnity Option is a traditional fee-forservice plan that generally provides the same benefit coverage level no matter which qualified medical provider you use.The Plan reimburses up to the Plan's allowed amounts for covered services.The Indemnity Option also uses contracted healthcare 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' billed charges are considerably higher than the Plan's allowed amounts. Hospital stays (even for emergencies) outside of Georgia can result in significant balance billing amounts. In some cases, this can be well in excess of $10,000.

Points to Consider
u You may access any provider.
u You may pay most healthcare bills up to the deductible amount before the Plan starts paying benefits.
u You continue to pay co-insurance for covered services after meeting the deductible (up to the out-of-pocket maximum).
u When using a non-participating provider, including out-of-state hospitals, you are subject to balance billing for charges over the allowed amounts.These amounts do not apply to the out-of-pocket maximum.
u See the Pharmacy Benefit Comparison brochure to compare the Basic and Premier Pharmacy Options.
u You must call the Medical Certification Program (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.

NOTE: The State Health Benefit Plan does not have the legal authority to intervene when non-participating providers balance bill you; therefore, the State Health Benefit Plan cannot reduce or eliminate amounts balance billed. In addition, the Health Plan cannot make additional payments above the allowed amounts when you are balance billed by non-participating providers.

9

PPO OPTIONS BASIC AND PREMIER
The PPO Options offer you a network of over 14,000 Georgia participating physicians and 166 Georgia hospitals managed by 1st Medical Network in the Georgia service area.You also have the added benefit of access to a national network of participating providers and hospitals across the United States, which is managed by the Beech Street Corporation.The PPO Options offer you the choice and flexibility of using in-network or out-of-network providers. In order to receive the highest level of benefit coverage and avoid filing claims and balance billing, you will need to use an in-network provider. If you choose to use an out-of-network provider, the reimbursement will be at a lower level of benefit coverage. Note, the Transplant and Behavioral Health Services (BHS) networks are separate from the 1st Medical Network.
To view the list of PPO providers online, visit www.healthygeorgia.com. If you do not have Internet access, call the Retiree Help Line for provider information at (800) 586-9288.
It is ultimately your responsibility to verify if a provider participates in the PPO network prior to receiving services. Providers may enter or leave the network at any time.

Points to Consider
u You do not need to select a primary care physician (PCP) or obtain referrals to see specialists.
u No balance billing when using participating PPO providers.
u You pay only a minimal co-payment for in-network PPO physician visits and other covered services (subject to deductibles).
u You 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.
u 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 (National PPO network).
u Some physicians affiliated with our PPO networks may not accept new patients at certain times during the year or may drop out during the year. Please check with the physician of your choice before you enroll in one of the PPO options.
u See the Pharmacy Benefit Comparison brochure to compare the Basic and Premier Pharmacy Options.
u In-network hospitals may contract with out-of-network physicians or labs.You may be subject to balance billing by these providers.

OVERVIEW OF PLAN OPTIONS

10

OVERVIEW OF PLAN OPTIONS

PPO CHOICE OPTIONS BASIC AND PREMIER
Benefits under the PPO Choice Options are the same as in the PPO Basic and PPO Premier Options. However, PPO Choice Options premiums are higher. In return for a higher premium, you can request that an out-of-network Georgia provider be reimbursed as an in-network provider.This request is known as a "nomination." If the out-of-network provider accepts your nomination, agrees to the PPO fees, and is approved by the PPO, you will receive in-network benefits for that provider.The in-network relationship between you and the provider remains in effect until you or the provider terminates the agreement.You may nominate as many eligible providers as you wish at any time during the Plan year.

Points to Consider
u The PPO must approve your provider nomination before you receive services.
u If your provider does not accept your nomination, does not accept the network fees, or is not approved by the PPO Network Administrator, then services from that provider are covered at the lower, out-of-network benefit level. SHBP rules do not allow a member to change options when a nominated provider or the PPO rejects a nomination.
u Only providers located and licensed in Georgia can be nominated, 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.
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).

11

HMO OPTIONS
HMO Options are available only to SHBPeligible retirees who live in an approved HMO's service area in Georgia. Please review the approved HMO service area list on pages 29-32 of this guide to determine if you are eligible for an HMO. If your residence circumstances change during the Plan year and you no longer live in an approved HMO service area, you will be required to change to another plan option.
HMOs provide prepaid benefits for most healthcare needs, with no bills or claim forms.You are responsible for selecting a primary care physician (PCP) from a list of participating providers. *(See footnote.) 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 your PCP referral, there is no coverage even if the physician or facility is in the HMO network.
Points to Consider
u You must access physicians, specialists and hospitals offered through the HMO's network to receive benefits, except for emergencies as defined by the HMO.
u You choose a PCP to serve as your first point of contact for most healthcare services. *(See footnote.) Your covered family members must also select a PCP. The PCP is responsible for coordinating your healthcare services (specialists, ancillary providers, hospitals).
u Providers may drop out of the network at any time during the year and this is not a qualifying event to change coverage.

u See the Pharmacy Benefit Comparison brochure to compare the pharmacy programs.
u You pay only a minimal co-payment for HMO in-network physician visits, prescription drugs and some other covered services.
u You pay the full cost for non-referred services and for services received outside the HMO's participating network, except for emergencies.
u You have coordinated care through a network of HMO participating providers.
u In most cases, HMOs do not have a deductible to meet, so your out-of-pocket cost may be lower.
u There are no pre-existing condition limitations.
u 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.
u All services received outside the State of Georgia must be coordinated through the HMO.
(*) Note: UnitedHealthcare HMO does not require you to select a PCP or obtain referrals to see specialists.

OVERVIEW OF PLAN OPTIONS

12

OVERVIEW OF PLAN OPTIONS

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 an out-of-network Georgia provider to be treated as an in-network provider. This request is known as a "nomination."You may nominate providers if they are located and licensed in Georgia and offer services covered by the HMO. In addition, you may nominate as many eligible providers as you wish at any time during the Plan year.
Points to Consider
u The HMO must approve your out-of-network provider before you receive medical services.
u 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.
u If your provider does not accept your nomination, does not accept the HMO's fees, or is not approved by the HMO, services from that provider are not covered.
u SHBP rules do not permit a member to change options when a nominated provider or HMO rejects a nomination.
Please contact the Member Services Department of the respective HMO directly to find out more about the required procedures and paperwork necessary to nominate a provider. Telephone numbers are listed on the inside of the front cover.

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 32 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 12 but also note that:
u The Kaiser M+C provider network is different from the regular Kaiser HMO provider network.
u 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.
You 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.
You should return the separate form that the HMO supplies to you to ensure that you are in compliance with Medicare requirements.
You would have coverage for prescription drugs, vision care, and preventive care not covered by Medicare.

13

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 . . . then traditional Medicare becomes your primary plan and pays your medical benefits first
. . . then traditional Medicare no longer processes your claims.Your Medicare coverage will pay a portion of the M+C HMO premium.

HOW SHBP BENEFITS WORK
. . . 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.
. . . and your SHBP benefits will pay an additional portion of your M+C HMO premium, making coverage generally less expensive than other coverage options.

OTHER POINTS TO CONSIDER u 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.
u 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.
u 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 16 of this guide and/or call the Kaiser Permanente M+C HMO at (800) 956-1358 or (404) 233-3700 in Atlanta.

OVERVIEW OF PLAN OPTIONS

14

OVERVIEW OF PLAN OPTIONS

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:
u You do not reside in the service area of the M+C HMO.
u You are not entitled to Medicare Part A or are not enrolled in Medicare Part B.
u 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.
u 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 HEALTHCARE?
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.

YOU ARE PART OF THE SOLUTION!
UNDERSTANDING YOUR HEALTH PLAN OPTIONS
This section compares specific benefits within the PPO, Indemnity and HMO Options. For more specific information on covered services, call the Member Services numbers listed on the inside front cover.
15

BENEFITS COMPARISON: PPO, INDEMNITY AND HMO OPTIONS
SCHEDULE OF BENEFITS FOR YOU AND YOUR DEPENDENTS -- JULY 1, 2004

COVERED SERVICES
Maximum Lifetime Benefit (combined for all SHBP Options)
Pre-Existing Conditions (1st year in Plan only, subject to HIPAA)
Lifetime Benefit Limit for Treatment of: (combined for PPO Option and Indemnity) u Temporomandibular joint
dysfunction (TMJ) u Substance abuse u Organ and tissue transplants u Home hyperalimentation
Deductibles/Co-Payments: u Deductible--individual u Deductible--family maximum
u Hospital deductible/admission-- excluding BHS and transplants
u Hospital deductible/admission-- BHS and transplants
u Hospital co-payment
Annual Out-of-Pocket Limits: u Individual (you or one of your
dependents) u Family (you and your dependents)

PPO OPTIONS -- BASIC AND PREMIER

PPO OPTIONS In-Network/Georgia

PPO OPTIONS In-Network/Out-of-State

PPO OPTIONS Out-of-Network

The Plan Pays:

The Plan Pays:

The Plan Pays:

$2 million

$1,000

$400 $1,200 $250 $100 None
$1,000 $2,000

$1,100

3 episodes $500,000 $500,000

In-Network/Out-of-State & Out-of-Network amounts combined $500 $1,500

$250

$250

$100

$100

None

None

In-Network/Out-of-State & Out-of-Network amounts combined $2,000

$4,000

u BHS program (per patient); BHS authorized care only
PHYSICIANS' SERVICES
Primary Care Physician and/or Referral Required
Primary Care Physician or Specialist Office or Clinic Visits: u Treatment of illness or injury

$2,500

No

No

100% NR* after a per visit co-payment of $30;
not subject to deductible

100% NR* after a per visit co-payment of $30;
not subject to deductible

No
60% of OONR*; subject to deductible

* See legend on page 26 for definitions of NR, OONR and IR. 16

INDEMNITY OPTIONS BASIC AND PREMIER The Plan Pays: $2 million
$1,000

BLUECHOICE The Plan Pays:
$2 million None

HMO OPTIONS

CIGNA

KAISER PERMANENTE KAISER PERMANENTE M+C

The Plan Pays:

The Plan Pays:

UNITEDHEALTHCARE The Plan Pays:

$2 million

No lifetime benefit maximums

$2 million

None

None

None

$1,100 3 episodes $500,000 $500,000
$400 $1,200 $400 $100 None
$2,000 $4,000
$2,500

No separate lifetime No separate lifetime No separate lifetime No separate lifetime

benefit limit

benefit limit

benefit limit

benefit limit

Not applicable Not applicable Not applicable
$200
Not applicable
Not applicable

Not applicable

Not applicable

Not applicable

Not applicable Not applicable
$200
Not applicable
Not applicable

Not applicable
Not applicable
$200
Not Applicable Kaiser Permanente M+C
$1,500 individual $4,500 family per Plan year
Not applicable

Not applicable Not applicable
$200
Not applicable
Not applicable

No

Yes

Yes

Yes

No

90% of IR*; subject to deductible

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

Chart continued pg.18

17

COVERED SERVICES

PPO OPTIONS -- BASIC AND PREMIER

PPO OPTIONS In-Network/Georgia

PPO OPTIONS In-Network/Out-of-State

PPO OPTIONS Out-of-Network

The Plan Pays:

The Plan Pays:

The Plan Pays:

Primary Care Physician or Specialist Office or Clinic Visits for the Following: u Wellness care/preventive
healthcare u Well-newborn exam u Well-child exams and
immunizations u Annual physicals u Annual gynecological exams

100% of NR after

100% of NR after

$30 co-payment per office $30 co-payment per office

visit. 100% of NR with

visit. 100% of NR with

no co-payment for associated no co-payment for associated

tests and immunizations.

tests and immunizations.

Maximum of $500 payable Maximum of $500 payable

per person per Plan year

per person per Plan year

for all preventive services. for all preventive services.

Maximum combined with Maximum combined with

In-Network/Out-of-State benefit. In-Network/Georgia benefit.

Not covered. Charges do not apply to deductible or annual out-of-pocket limits.

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).

Maternity Care

90% of NR;

80% of NR;

(prenatal, delivery and postpartum) not subject to deductible not subject to deductible

after initial $30 co-payment after initial $30 co-payment

60% of OONR; subject to deductible and
to balance billing

Physician Services Furnished in a Hospital u Surgery in general, including charges
by surgeon, anesthesiologist, pathologist and radiologist
u Inpatient well-newborn exams

90% of NR; subject to deductible
100% of NR; not subject to deductible

80% of NR; subject to deductible
100% of NR; not subject to deductible

60% of OONR; subject to deductible
Not covered

Physician Services for Emergency Care

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 u When billed as office visit

90% of NR; subject to deductible

80% of NR; subject to deductible

60% of OONR; subject to deductible

u When billed as outpatient surgery at a facility
HOSPITAL SERVICES
Inpatient Services u Inpatient care, delivery and
inpatient short-term acute rehabilitation services
u Outpatient services u Non-emergency use of the emergency room u Other

90% of NR; subject to deductible
90% of NR; subject to a per admission
deductible of $250
90% of NR; subject to deductible; Subject to $100/visit
co-payment

80% of NR; subject to deductible
80% of NR; subject to a per admission
deductible of $250
80% of NR; subject to deductible; Subject to $100/visit
co-payment

60% of OONR; subject to deductible
60% of OONR; subject to a per admission
deductible of $250
60% of OONR; subject to deductible; Subject to $100/visit
co-payment

u Well-newborn care 18

100% of NR; not subject to deductible

100% of NR; not subject to deductible

Not covered

INDEMNITY OPTIONS
BASIC AND PREMIER
The Plan Pays:
90% of IR per 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.

BLUECHOICE The Plan Pays:

HMO OPTIONS

CIGNA

KAISER PERMANENTE KAISER PERMANENTE M+C

The Plan Pays:

The Plan Pays:

UNITEDHEALTHCARE The Plan Pays:

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 co-payment 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.

100% after a per visit co-payment of $15 for primary care and $20
for specialty care. No co-payment for immunizations and
mammograms.

Note: PPO notes to the left also apply here.

90% of IR; subject to deductible

100% after initial $20 co-payment

100% after initial $20 co-payment

100% after initial $20 co-payment. Kaiser M+C:
100% coverage

100% after initial $20 co-payment

90% of IR; subject to deductible

100%

100%

100%

100%

Not covered

100%

100%

100%

100%

90% of IR; subject to deductible and to balance billing from non-participating providers

100% after applicable 100% after applicable 100% after applicable 100% after applicable

co-payment

co-payment

co-payment

co-payment

90% of IR; subject to deductible
90% of IR; subject to deductible

100% after $20 co-payment if billed as office visit

100% after $20 co-payment if billed as office visit

100% after $20 co-payment if billed as office visit

100% after $20 co-payment if billed as office visit

$100 co-payment for $100 co-payment for $100 co-payment for $100 co-payment for

outpatient surgery

outpatient surgery

outpatient surgery

outpatient surgery

90% of IR; subject to a per admission
deductible of $400
90% of IR; subject to deductible. If services are in conjunction with non-emergency use of the emergency room, benefit also subject to
$100/visit co-payment
90% of IR; not subject to deductible

100% after

100% after

100% after

100% after

$200 per confinement $200 per confinement $200 per confinement $200 per confinement

co-payment

co-payment

co-payment

co-payment

PCP prior

PCP prior

PCP prior

authorization required authorization required authorization required

for coverage

for coverage

for coverage

Requires prior authorization
from HMO

100%

100%

100%
Chart continued pg.20

100% 19

COVERED SERVICES
Outpatient Surgery Hospital/Facility
Emergency Care u Treatment of an emergency
medical condition or injury

PPO OPTIONS -- BASIC AND PREMIER

PPO OPTIONS In-Network/Georgia

PPO OPTIONS In-Network/Out-of-State

PPO OPTIONS Out-of-Network

The Plan Pays:

The Plan Pays:

The Plan Pays:

90% of NR; subject to deductible

80% of NR; subject to deductible

60% of OONR; subject to deductible

90% NR after a per visit

90% NR after a per visit 90% OONR after a per visit

co-payment of $100;

co-payment of $100;

co-payment of $100;

co-insurance and hospital co-insurance and hospital co-insurance and hospital

deductible apply, if admitted deductible apply, if admitted deductible apply, if admitted.

Subject to balance billing.

Note: $100 co-payments are reduced to $80 if referred by NurseCall 24 before receiving emergency room services

OUTPATIENT TESTING, LAB, ETC.

Laboratory; X-Rays; Diagnostic Tests; Injections, including Medications Covered Under Medical Benefits - for the Treatment of an Illness or Injury

90% of NR; subject to deductible

80% of NR; subject to deductible

Allergy Shots and Serum

100% of NR; not subject to the 100% of NR; not subject to the

deductible. If physician is seen, deductible. If physician is seen,

visit is treated as an office visit visit is treated as an office visit

subject to the per visit

subject to the per visit

copayment of $30

copayment of $30

60% of OONR; subject to deductible
60% of OONR; subject to deductible

Allergy Testing

90% of NR; subject to deductible

80% of NR; subject to deductible

60% of OONR; subject to deductible

BEHAVIORAL HEALTH
Mental Health and Substance Abuse Inpatient Facility

90% of NR; subject to deductible and separate hospital deductible,
if admitted when authorized by BHS

90% of NR; subject to deductible and separate hospital deductible,
if admitted when authorized by BHS

60% of NR; subject to deductible and separate hospital deductible,
if admitted when authorized by BHS

Note: 1.All services require prior authorization. 2. Inpatient facility charges (limited to 60 combined mental health
and substance abuse days per person per Plan year). 3. Substance Abuse coverage limited to three episodes per lifetime.

20

INDEMNITY OPTIONS BASIC AND PREMIER
The Plan Pays: 90% of IR;
subject to deductible

BLUECHOICE The Plan Pays:

HMO OPTIONS

CIGNA

KAISER PERMANENTE KAISER PERMANENTE M+C

The Plan Pays:

The Plan Pays:

UNITEDHEALTHCARE The Plan Pays:

100% after $100 per 100% after $100 per 100% after $100 per 100% after $100 per confinement co-payment confinement co-payment confinement co-payment confinement co-payment

90% 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.
Note: PPO note to the left also applies here.

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)

90% of IR; subject to deductible

100%

100%

100%

100%

90% of IR; subject to deductible
90% of IR; subject to deductible

100% for shots and serum after a $20 co-payment
per visit
100% after a $20 per visit co-payment

100% for shots and serum after a $20 co-payment
per visit
100% after a $20 per visit co-payment

$5 for shots and $50 for a six-month
supply of serum Kaiser M+C: $5 shots and no serum charge
100% after a $20 per visit co-payment

100% for shots and serum after a $20 co-payment
per visit
100% after a $20 per visit co-payment

90% of IR; subject to deductible
if admitted when authorized by BHS
Note: PPO notes to the left also apply here.

100% after $50 co-payment per confinement; limited to 30 days
per Plan year

100% after $50 co-payment per confinement; limited to 30 days
per Plan year

100% after $50 co-payment per confinement; unlimited days for mental health; 30-day limit for
substance abuse

100% after $50 co-payment per confinement; limited to 30 days
per Plan year

Outpatient Care:

Outpatient Care:

Outpatient Care:

Outpatient Care:

100% after $20 per visit 100% after $20 per visit 100% after $20 per visit 100% after $20 per visit

co-payment; limited to co-payment; limited to co-payment; unlimited co-payment; limited to

25 visits per Plan year 25 visits per Plan year visits for mental health; 25 visits per Plan year

limited to 25 visits for

substance abuse per

Plan year

Kaiser Permanente M+C unlimited days 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%

Chart continued pg.22

21

COVERED SERVICES
Partial Day Hospitalization and Intensive Outpatient

PPO OPTIONS In-Network/Georgia
The Plan Pays:

PPO OPTIONS
PPO OPTIONS In-Network/Out-of-State
The Plan Pays:

90% of NR;

90% of NR;

subject to deductible and subject to deductible and

separate hospital deductible, separate hospital deductible,

if admitted when

if admitted when

authorized by BHS

authorized by BHS

PPO OPTIONS Out-of-Network The Plan Pays:
No benefit

Note: 1. Maximum benefit of 30 combined PHP/IOP visits/days per person per Plan year. 2. Benefit coverage is only available when using an in-network Magellan provider
for partial/day hospitalization and intensive outpatient charges.

23 Hour Observation Room (requires prior authorization to receive coverage.)

90% of NR;

90% of NR;

subject to $100 deductible subject to $100 deductible

No benefit

Professional Charges Inpatient (combined total for substance abuse and mental health)

80% of NR; subject to

80% of NR; subject to

50% of NR; subject to

deductible. Maximum 1 visit deductible. Maximum 1 visit deductible and balance billing.

per authorized day when per authorized day when Maximum of 25 professional

authorized by BHS

authorized by BHS

visits per person per Plan year.

Outpatient (Pre-certification required to receive coverage.)

80% of NR; subject to

80% of NR; subject to

50% of NR; subject to

deductible when authorized deductible when authorized deductible (without authori-

by BHS, limited to 50 visits by BHS, limited to 50 visits zation) and balance billing.

per Plan year.

per Plan year.

Maximum 25 combined

mental health, substance

abuse and brief therapy visits

per person per Plan year.

Limited to services rendered

by a Psychiatrist (M.D.) or

a psychologist (Ph.D.)

Note: In-network maximum coverage of 50-combined mental health, substance abuse, and brief therapy visits per person per Plan year. Limit includes 25 out-of-network counseling sessions and 3 brief visits.

Brief-Visit Therapy (limit - 3 visits per Plan Year; requires BHS prior authorization.)

100%; not subject to deductible

90%; not subject to deductible

No benefit

Note:Visits are included in the 50-visit limit of outpatient care.

DENTAL

Dental and Oral Care 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 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% 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% NR, subject to balance billing

60% of OONR; subject to deductible
and, if admitted, to hospital deductible

22

INDEMNITY OPTIONS BASIC AND PREMIER
The Plan Pays:
90% of IR; subject to deductible and separate hospital deductible,
if admitted

BLUECHOICE The Plan Pays: Not applicable

Note: PPO notes to the left also apply here.
90% of IR; subject to $100 deductible
80% of IR; subject to deductible and balance billing.
PPO benefits apply when authorized by BHS
80% of IR; subject to deductible when authorized by BHS, limited to 50 visits
per Plan year.

Not applicable Not applicable Not applicable

HMO OPTIONS

CIGNA

KAISER PERMANENTE KAISER PERMANENTE M+C

The Plan Pays:

The Plan Pays:

UNITEDHEALTHCARE The Plan Pays:

Not applicable

Not applicable

Not applicable

Not applicable Not applicable

Not applicable Not applicable

Not applicable Not applicable

Not applicable

Not applicable

Not applicable

Note: PPO notes to the left also apply here.
100%; not subject to deductible
Note: PPO note to the left also applies here.

Not applicable

Not applicable

Not applicable

Not applicable

90% of IR; subject to deductible
and, if admitted, to hospital deductible.

100% after

100% after

Services/appliances

100% after

applicable oral surgery applicable oral surgery for accidental injury to applicable oral surgery

co-payment and dental co-payment and dental sound and natural teeth: co-payment and dental

services for accidental services for accidental

50% coverage

services for accidental

injury to sound teeth injury to sound teeth

on first $1,000,

injury to sound teeth

100% thereafter

Chart continued pg.24

23

COVERED SERVICES
DENTAL CONT.
Coverage of specific osseous surgeries for the treatment of periodontal disease
Temporomandibular joint syndrome (TMJ) Note: Coverage for diagnostic testing and non-surgical treatment of TMJ, up to $1,100 per person lifetime maximum benefit.This does not apply to the HMOs.

PPO OPTIONS In-Network/Georgia
The Plan Pays:
Not covered
90% of NR; subject to deductible

PPO OPTIONS PPO OPTIONS
In-Network/Out-of-State The Plan Pays:
Not covered
80% of NR; subject to deductible

PPO OPTIONS Out-of-Network The Plan Pays:
Not covered
60% of OONR; subject to deductible

VISION
OTHER COVERAGE Ambulance Services for Emergency Care Note:"Land or air Ambulance" to nearest facility to treat the condition. Note: Limited to transportation for emergencies and benefits subject to balance billing for non-participating providers of ambulance services. Urgent Care Services in an Approved Urgent Care Center
Home Healthcare Services Approved in Advance by the MCP

Note: PPO Options include a discount program for vision screenings and eyewear. Contact 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.

90% of NR; subject to deductible

90% of NR; subject to In-Network/Georgia
deductible

90% of OONR; subject to In-Network/Georgia deductible

90% of NR after a per visit co-payment of $45;
subject to deductible
90% of NR; subject to deductible

90% of NR after a per visit co-payment of $45;
subject to deductible
80% of NR; subject to deductible

Not applicable
60% of OONR; subject to deductible

Skilled Nursing Facility Services

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; $7,500 per Plan year limit is a combined total in PPO Options. Member's share of cost is not applied to Plan year out-of-pocket limits.

Not covered

Not covered

Not covered

Hospice Care
Note: IndemnityMCP may approve additional benefits in lieu of Acute Care hospitalization.

100% of NR; subject to deductible

100% of NR; subject to deductible

60% of OONR; subject to deductible

24

INDEMNITY OPTIONS BASIC AND PREMIER
The Plan Pays:

BLUECHOICE The Plan Pays:

HMO OPTIONS

CIGNA

KAISER PERMANENTE KAISER PERMANENTE M+C

The Plan Pays:

The Plan Pays:

UNITEDHEALTHCARE The Plan Pays:

Not covered
90% of IR; subject to deductible

Not covered

Not covered

Not covered

Not covered

100% after applicable co-payment for related surgery and diagnostic
services. Excludes appliances and
orthodontic treatment

100% after applicable 50% for non-surgical 100% after applicable

co-payment for related treatment; 100% after co-payment for related

surgery and diagnostic applicable co-payment surgery and diagnostic

services. Excludes for related surgery and services. Excludes appli-

appliances and

diagnostic services. ances and orthodontic

orthodontic treatment Excludes appliances and

treatment

orthodontic treatment

Note: PPO note to the left also applies here.

Each HMO Option may offer vision care discounts or benefits. Contact the HMO directly for more information.

90% of IR; subject to deductible

100%

100%

100% after a $50 per trip co-payment when medically necessary

100%

90% of IR; subject to deductible
90% of IR; subject to deductible
Note: PPO notes to the left also apply here.

100% after $25 co-payment, referral required
100%; up to 120 visits per Plan year

100% after $25 co-payment

100% after $30 co-payment

100% after $25 co-payment

100%; up to 120 visits per Plan year

100%; up to 120 visits per Plan year
Kaiser Permanente M+C 100%: No day limit

100%; up to 120 visits per Plan year

Not covered
100% of IR, up to Medicare's approved lifetime maximum;
subject to deductible

100%; prior approval required, up to 45 days per Plan year
100%; prior approval
required

100%; prior approval required, up to 45 days per Plan year
100%; prior approval
required

100%; prior approval required, up to 45 days per Plan year
100%; prior approval
required

100%; prior approval required, up to 120 days per Plan year
100%; prior approval
required

Chart continued pg.26

25

COVERED SERVICES
Durable Medical Equipment (DME) Rental or Purchase
Outpatient Acute Short-Term Rehabilitation Services

PPO OPTIONS In-Network/Georgia
The Plan Pays:
90% of NR; subject to deductible
90% of NR; subject to deductible and $20 per visit co-payment

PPO OPTIONS
PPO OPTIONS In-Network/Out-of-State
The Plan Pays:
80% of NR; subject to deductible
80% of NR; subject to deductible and $20 per visit co-payment

PPO OPTIONS Out-of-Network
The Plan Pays:
60% of OONR; subject to deductible
60% of OONR; subject to deductible

Note: Coverage for up to 40 visits per Plan year when conditions are met for physical, speech and occupational therapies and for cardiac rehabilitation.

Chiropractic Care
Note: Coverage for up to a maximum of 40 visits per Plan year.

90% of NR; subject to deductible and $20 per visit co-payment

80% of NR; subject to deductible and $20 per visit co-payment

60% of OONR; subject to deductible

Transplant Services

90% of NR; subject to deductible at Unicare contracted
network facility

90% of NR; subject to deductible at Unicare contracted
network facility

60% of NR; subject to deductible and balance billing

Note: Services provided through Unicare Centers of Excellence for PPO and Indemnity.
IMPORTANT PPO AND INDEMNITY CONSIDERATIONS

See the Summary Plan Description and Updaters for coverage details, including limitations and exclusions.
u Charges from non-participating providers are subject to balance billing.These charges are the member's responsibility and do not count toward deductibles or out-of-pocket spending limits.
u 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.
u Services covered under the PPO from In-Network/Out-of-State and Out-of-Network providers apply to the same deductible.
u Lifetime benefit maximums are combined totals among the PPO Options, Indemnity Options and HMO Options (except Kaiser Permanente).
u Some PPO annual maximums and limitations are combined totals.
u Annual dollar and visit limitations, deductibles and out-of-pocket spending limits are based on a July 1 to June 30 Plan year.
u Some services may require MCP precertification, prior approval or letters of medical necessity before such services are covered.
u Copayments do not apply toward deductibles or out-of-pocket limits unless otherwise noted.
u Exclusions and limitations vary among Plan options. Contact specific Plan option for more information.

* NR = Network Rate for in-network PPO services.

OONR = Out-of-Network Rate for out-of-network PPO services

26

IR = Indemnity Rate for Indemity Services

INDEMNITY OPTIONS BASIC AND PREMIER
The Plan Pays: 90% of IR;
subject to deductible 90% of IR;
subject to deductible
Note: PPO note to the left also applies here.
90% of IR; subject to deductible
90% of NR at contracted facility;
60% NR subject to $100 hospital deductible Note: PPO note to the left
also applies here.

BLUECHOICE The Plan Pays:

HMO OPTIONS

CIGNA

KAISER PERMANENTE KAISER PERMANENTE M+C

The Plan Pays:

The Plan Pays:

UNITEDHEALTHCARE The Plan Pays:

100% when medically necessary

100% when medically necessary

100% when medically necessary

100% when medically necessary

100% after $20 per visit co-payment; up to 40 visits per
Plan year

100% after $20 per visit co-payment; up to 40 visits per
Plan year

100% after $20 per visit co-payment; up to 40 visits per Plan year or up to two consecutive months per condition, whichever is more

100% after $20 per visit co-payment; 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

100% after

100% after

100% after

100% after

$20 co-payment per $20 co-payment per $20 co-payment per $20 co-payment per

visit; limited to 20 visits visit; limited to 20 visits visit; limited to 20 visits visit; limited to 20 visits

per Plan year

per Plan year

per Plan year

per Plan year

100%

100%

100%

100%

IMPORTANT HMO CONSIDERATIONS
u Annual dollar and visit limitations are based on a July 1 to June 30 Plan year.
u 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.
u 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.
u Most HMOs require you to obtain referrals to see most specialists. Failure to obtain a referral could result in denial of your claim. Note: UnitedHealthcare does not require referral for coverage of specialist services.
u Contact the HMO directly for more details regarding covered services, exclusions and limitations.

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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 OPTIONS BASIC AND PREMIER
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 to the right, 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 right. By using Beech Street providers outside of the Georgia service area, you are protected against balance billing (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 coverage and separate deductibles, 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.

PLAN OPTIONS' SERVICE AREAS

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PLAN OPTIONS' SERVICE AREAS

HMO OPTIONS
You must live in the HMO's approved service area to be eligible for coverage under that option. Below are the HMO Options service areas by county. If you live 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 HMO coverage. Service area changes for the 200405 Plan year are in bold type.

COUNTY OF RESIDENCE
Appling Atkinson Bacon Baldwin Banks Barrow Bartow Ben Hill Berrien Bibb Bleckley Brooks Bryan Bulloch Burke Butts Candler Carroll Catoosa Chatham Chattahoochee Chattooga Cherokee Clarke Clayton

BLUECHOICE Not Available 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

CIGNA Yes
Not Available 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

KAISER PERMANENTE
Not Available 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

UNITEDHEALTHCARE Yes Yes Yes
Not Available Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Chart continued pg.30

29

COUNTY OF RESIDENCE
Clinch Cobb Colquitt Columbia Cook Coweta Crawford Dade Dawson Decatur DeKalb Dodge Douglas Early Echols Effingham Elbert Emanuel Evans Fannin Fayette Floyd Forsyth Franklin Fulton Gilmer Glascock Gordon Grady Greene Gwinnett Habersham Hall Harris

BLUECHOICE
Not Available Yes
Not Available Yes
Not Available Yes Yes
Not Available Yes
Not Available Yes
Not Available Yes
Not Available 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

CIGNA
Not Available Yes
Not Available Yes
Not Available Yes
Not Available Yes
Not Available Not Available
Yes Not Available
Yes Not Available 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

KAISER PERMANENTE
Not Available Yes
Not Available Not Available Not Available
Yes Not Available Not Available Not Available Not Available
Yes Not Available
Yes Not Available 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

UNITEDHEALTHCARE
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Not Available Yes Yes Yes Yes Yes Yes Yes Not Available Yes Yes Yes Not Available Yes Not Available Yes Yes Yes Yes Yes Yes Yes Yes

PLAN OPTIONS' SERVICE AREAS

30

PLAN OPTIONS' SERVICE AREAS

COUNTY OF RESIDENCE Hart Heard Henry Houston Jackson Jasper Jefferson Jenkins Johnson Jones Lamar Lanier Laurens Liberty Lincoln Long Lowndes Lumpkin Madison Marion McDuffie Meriwether Mitchell Monroe Morgan Muscogee Newton Oconee Oglethorpe Paulding Peach Pickens Pierce Pike

BLUECHOICE Yes Yes Yes Yes Yes
Not Available Yes Yes Yes Yes
Not Available Not Available Not Available
Yes Yes Not Available Not Available Yes Yes Yes Yes Yes Not Available Yes Yes Yes Yes Yes Yes Yes Yes Yes Not Available Not Available

CIGNA Not Available Not Available
Yes Not Available
Yes Not Available
Yes Not Available Not Available
Yes Yes Not Available Yes Yes 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 Not Available Yes

KAISER PERMANENTE 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 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

UNITEDHEALTHCARE Not Available Not Available Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Not Available Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Chart continued pg.32
31

COUNTY OF RESIDENCE
Polk Pulaski Putnam Richmond Rockdale Screven Seminole Spalding Stephens Stewart Sumter Talbot Taliaferro Tattnall Taylor Thomas Tift Toombs Troup Turner Twiggs Upson Walker Walton Ware Warren Washington Wayne White Whitfield Wilkes Wilkinson Worth

BLUECHOICE
Yes Yes Not Available Yes Yes Not Available Not Available Yes Not Available Yes Not Available Yes Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Yes Not Available Not Available Yes Not Available Yes Yes Not Available Yes Not Available Yes Yes Not Available

MEDICARE+CHOICE HMO OPTION

CIGNA
Yes Not Available Not Available
Yes Yes Yes Not Available Yes Not Available Not Available Not Available Not Available Not Available Yes Yes Not Available Not Available Not Available Not Available Not Available Not Available Not Available Yes Yes Not Available Not Available Not Available Not Available Not Available Yes Yes Yes Not Available

KAISER PERMANENTE
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 Not Available Not Available 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

UNITEDHEALTHCARE
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Not Available Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Not Available Yes Yes Yes Yes Yes Yes

PLAN OPTIONS' SERVICE AREAS

COUNTY OF RESIDENCE
Cherokee Clayton Cobb Coweta DeKalb Douglas Fayette Forsyth Fulton Gwinnett Henry Paulding 32

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

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, PPO Choice and Indemnity Options (Basic and Premier) contain a pre-existing 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:
u Pregnancy; or
u 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.

33

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 healthcare 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.
u 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.
u You have the right to ask DCH to change health information that is incorrect or incomplete. DCH may deny your request under certain circumstances.

u You have the right to request a list of the disclosures that DCH has made of your health information beginning in April 2003.
u 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.
u 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.
u 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:
u Maintain the privacy of your information.
u Give you this notice of DCH's legal duties and privacy practices regarding the information that DCH has about you.
u Follow the terms of this notice.
u 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.

34

How DCH Uses and Discloses Healthcare 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 healthcare 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 healthcare 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 Healthcare 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 404-656-6322 (Atlanta calling area) or 800-610-1863 (outside of Atlanta calling area).
If you believe your privacy rights have been violated:
u 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.
u 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
u 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.

35

WOMEN'S HEALTH & 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: u All stages of reconstruction of the breast on
which the mastectomy has been performed. u Reconstruction of the other breast to achieve
a symmetrical appearance. u Prostheses and mastectomy bras. u 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 a SHBP participant misrepresents eligibility information when applying for coverage, during change of coverage or filing for benefits, the SHBP may take adverse action against the participant, including but not limited to terminating coverage (for the participant and his or her dependent(s)) or imposing liability to the SHBP for fraud or indemnification (requiring payment for benefits to which the participant or his or her beneficiaries were not entitled). Penalties may include a lawsuit, which may result in payment of charges to the Plan or criminal prosecution in a court of law.
In order to avoid enforcement of the penalties, the participant must notify the SHBP immediately if a dependent is no longer eligible for coverage or if the participant has questions or reservations about the eligibility of a dependent. This policy may be enforced to the fullest extent of the law.

Disclaimer
This material is for informational purposes and is not a contract. It is intended only to highlight principal benefits of the medical plans. Every effort has been made to be as accurate as possible; however, should there be a difference between this information and the Plan documents, the Plan documents govern. It is the responsibility of each member, active or retired, to read all Plan materials provided in order to fully understand the provisions of the option chosen.

36