PHONE NUMBERS/CONTACT INFORMATION State Health Benefit Plan (SBHP): www.dch.georgia.gov PPO, PPO CCO, Indemnity: Retiree Help Line Member Services Pharmacy Information (ESI) 877-246-4190 877-246-4189 TDD 800-545-6751 877-650-9342 TDD 800-842-5754 www.myuhc.com/groups/gdch HDHP: Member Services and Pharmacy 877-246-4195 HMOs: BlueChoice 800-464-1367 www.bcbsga.com TDD 404-842-8073 Cigna 800-564-7642 www.cigna.com Kaiser Permanente 800-611-1811 www.kaiserpermanente.org TDD 800-255-0056 Medicare Advantage 404-233-3700 or 800-956-1358 United Healthcare 866-527-9599 www.myuhc.com TDD 800-955-8770 TRICARE Supplement 800-638-2610 ext. 255 www.asitrisuppga.com All Options: Eligibility 404-656-6322 or 800-610-1863 Additional Information: Medicare 800-633-4227 Centers for Medicare and Medicaid Services (CMS) Social Security Administration 800-772-1213 www.medicare.gov www.cms.gov www.ssa.gov Pages 3 through 6 of this Guide contain Plan changes effective January 1, 2006. Prior to the start of the 2006 Plan Year, the Plan will post a new Summary Plan Description (SPD) for each Plan Option to the DCH Web site, www.dch.georgia.gov. This SPD is your official notification of Plan Changes effective January 1, 2006. You will receive a copy at your home in January 2006. Please keep your Summary Plan Description (SPD) 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. Photos on the cover are courtesy of the Georgia Department of Economic Development. RETIREE RESPONSIBILITIES After carefully reviewing the Plan changes, you have the opportunity to decide which option may best suit your healthcare needs during this Retiree Option Change Period (ROCP) October 17November 8, 2005 for coverage effective January 1 through December 31, 2006. 1 Review the information from Medicare Part D to determine if you should enroll in one of the prescription drug programs offered by Center for Medicare and Medicaid Services (CMS) prior to making a decision about your benefits under the State Health Benefit Plan (SHBP). See page 13. 2 If you are covered under the PPO, Indemnity or HDHP Options, you will be required to obtain the necessary prior notification or prior approval for certain covered services under the Plans. You should contact the specific health Plan regarding notification requirements. 3 If you are enrolled in Medicare and have not submitted a copy of your card to SHBP, please do so immediately. 4 You may make your elections online. See page 2 for instructions. OR, 5 You may complete your Personalized Change Form (PCF) and mail the form in the enclosed post marked envelope by November 8, 2005 to: State Health Benefit Plan P.O. Box 347069 Atlanta, GA 30334 Please do not return this form if you make your decision online or do not change your benefit election. 6 If you do not wish to make a change in your coverage, your health benefits will default to the coverage you had last year and it is not necessary to return the Personalized Change Form. 7 You should submit eligibility verification documents timely for all dependents when requested by SHBP. 8 You should verify that the correct health deduction is taken from each retirement check. 9 Be sure that your address is kept current. All retiree communications from SHBP are through U.S. mail. Notify the Plan of any fraudulent activity regarding Plan members, providers, payment of benefits, etc. Call 1-877-878-3360 or 404-260-9514. ! PLEASE READ! If you have Medicare, a new Federal law gives you more choices about your prescription drug coverage, starting in 2006. Please see pages 1417 for more details. ! Tobacco surcharges may apply to retirees at some future date. ! Retiree Help Line: 1-877-246-4190. Contents: Phone Numbers and Contacts for Benefit and Provider Information - Inside Front Cover Retiree Responsibilities - Page 1 Online Enrollment - Page 2 SHBP Plan Changes Effective January 1, 2006 - Pages 3-6 Eligibility - Pages 7-8 Understanding Your Plan Options - Pages 9-12 Information Concerning Medicare Part D - Page 13 Prescription Drug Coverage and Medicare - Pages 14-17 Benefits Comparison: PPO, Indemnity, HDHP, and HMO Options - Pages 18-25 Important Plan Considerations - Pages 26-27 HIPAA and other legal notices - Pages 28-32 1 Retiree Responsibilities ONLINE ENROLLMENT/CHANGES ! Retiree Option Change Period (ROCP) dates are October 17 November 8, 2005 and the Web site will be available beginning 12:01 a.m. October 17 and will close at 4:00 p.m. Eastern Standard Time on November 8, 2005. ! After the close of the Retiree Option Change Period, no changes in coverage option or tier will be allowed unless you experience a qualifying event. How to Make Your Online Enrollment/ Changes 1 Go to www.shbp.org and login. You will use your Policy number which is your Social Security number and birth date to log in. Please call 404-818-6600 or 866-351-0001 if you have trouble with the login process. 2 Once you have signed on, your 2005 benefit information and enrolled dependents will appear. Please review to make sure this information is correct and make any corrections to the basic data, i.e. address. 3 Review your current health insurance option and make any desired changes. You may change your options as many times as you wish during the ROCP. 4 Review your election to make sure all information is correct. If any of this information is not correct, go back into the Web site prior to the close of the ROCP and make your corrections. 5 Print your confirmation notice and keep a copy for your records. The confirmation statement with the latest date prior to the close of the ROCP confirms your benefit selection for the 2006 Plan Year. ! During the Retiree Option Change Period, call volume for contact numbers is expected to be very high and you may experience time on hold. New Tool Assists You in Making Your ROCP Selection Choosing the right health plan is an important decision and the SHBP is providing a Plan Cost Estimator (PCE) tool to assist you. The PCE offers you a simple way to help determine which option is best for you and your family. This online tool lets you compare how your out-of-pocket expenses may vary under the different health plan options available to you. You can use the PCE to review cost information for prescriptions, anticipated tests and procedures. The information provided by PCE is not meant to be an endorsement of any particular health plan. The service is offered only to help you compare your estimated expenses across each health plan option. Access the link to the PCE tool at the DCH Web site www.dch.georgia.gov and click on the Find Information about the Open Enrollment under "How Do I?" Online Enrollment/Changes 2 2 SHBP PLAN CHANGES EFFECTIVE JANUARY 1, 2006 New UnitedHealthcare (UHC) PPO The new PPO will be administered by UnitedHealthcare (UHC) effective January 1, 2006. There are some key advantages of the UHC PPO that will benefit you and your dependents. Following is a list of the program enhancements available to you through the UHC PPO. For any changes to the Summary of Benefits, please be sure to review the chart on pages 18 thru 25. National PPO Provider Network with Strong Statewide Coverage UHC's national PPO network includes over 470,000 physicians and other health care professionals, and 4,500 hospitals across 50 states. Currently in Georgia, UHC has over 10,000 physicians and 133 hospitals under contract. While they currently have a strong statewide PPO network, they are aggressively pursuing contracts with providers who are not in their network. Any provider interested in becoming a part of the network should contact UHC directly. Because UHC provides a national network, you will no longer have to pay a higher coinsurance when using providers outside of Georgia. With UHC's PPO program, you receive the same network level of benefits whether you use contracted providers in Georgia or anywhere else in the United States. Commitment to Your Total Health and Well-being UHC is committed to helping you improve your total health and wellbeing. Through their UnitedHealth WellnessSM program, they offer both on-site and online wellness programs and services. The UnitedHealth Wellness program is available through unitedhealthwellness.com and will provide you and your family access to discounted programs and services to improve your health, save money and keep your life in balance. In addition to these online and self-service wellness tools, UHC also provides 24 hour access to experienced registered nurses through their toll-free NurseLine feature. Nurses are always available to answer your questions and clarify important medical decisions you can even contact them through their convenient online nurse chat function available on the United member Web site. 3 Plan Changes Some of the features of UnitedHealth Wellness include: myRenewellSM helps you find health and wellness services and discounts on products and programs. UnitedHealth AlliesSM provides savings of up to 50 percent on certain health care products and services that are not covered by your medical, dental or vision plan. Health Assessment an online, confidential survey helps assess your overall current status of health. Online Health Improvement Programs let you choose from a variety of six-week programs like losing weight, gaining energy or improving overall health. Online Personal Health Manager lets you manage your health information all in one place! Through the Care Coordination program, UHC will assist you with coordinating your hospitalizations, disease management needs and chronic health care issues. UHC provides confidential support for your behavioral health needs through the United Behavioral Health program. Comprehensive Retiree Service Support UHC understands your concerns with a change in health care providers and will provide experienced member services support during the ROCP and after to answer important questions about network access, benefits and transition of care. If you or a family member need continued care with a non-participating provider after January 1, a transition of care application is available and can be requested through Retiree Services. The transition of care benefit allows you to receive network benefits while transitioning your care from a non-participating provider to a contracted physician in the UHC PPO network. Examples of eligible transition of care patients are a pregnant member in their third trimester, a member with complex and chronic medical needs and patients hospitalized during the transition to UHC. In addition to the toll-free Retiree services number, UHC provides a comprehensive Web site, myuhc.com. Through this member Web site, you will have online access to benefits information, your eligibility and medical claims history and be able to search the directories of physicians and other health care professionals by location, specialty and language. You can also order replacement ID cards as well as print a temporary ID card. In addition, the site allows participants to search a wide variety of health care topics and participate in live health forums. 4 4 Plan Changes Points to Know About the Transition to United Healthcare (UHC) Members will receive a new PPO or Indemnity ID card that includes the UHC logo and address. Be sure to show the card to your physician or hospital so that they will know how to submit your claim. You will receive your ID cards through the mail. Express Scripts will remain the Pharmacy Benefit Manager for the PPO and Indemnity Plan Options. You will receive a separate pharmacy ID card from Express Scripts through the mail. If you file a paper medical claim for services on or before December 31, 2005, the claim must be received by Blue Cross Blue Shield of Georgia (BCBSGA) at P.O. Box 38151, Atlanta, GA 30334, no later than March 31, 2006. This requirement also applies to any claim adjustments. Claims received by BCBSGA after March 31, 2006 will not be paid if the services were received in the year 2005. ! Paper claims for services received after January 1, 2006 are subject to the normal 12-month timely filing requirement and should be filed with UHC. HMO Live or Work Rule Effective January 1, 2006, the live or work rule will no longer be based on the county in which you live or work to obtain HMO coverage. You and your eligible dependents may join an HMO of your choice if the HMO is offered in your area or surrounding counties. This does not apply to partial year residency in another state. You will need to contact the particular HMO of interest directly to determine if that HMO is offered in your area. Out-of-State Coverage: If you are living outside the state of Georgia you may not have all options available to you. You will need to inquire with the HMO if services are available in your area before making your selection. Plan Changes 5 ! See page 26 for more detail on the new HDHP and the opportunity it provides to enroll in a Health Savings Account. See the Benefits Comparison that starts on page 18 for more about how the Plan covers specific expenses. ! NOTE! If you are covered by Medicare, you cannot contribute to a Health Savings Account. ! SHBP will notify you by letter of any change in your health benefit premiums. High Deductible Health Plan A High Deductible Health Plan (HDHP) will be offered to all retirees effective January 1, 2006. This Option offers you a new way to manage your healthcare dollars. When you enroll: Your monthly insurance premiums are lower. You may qualify to start a Health Savings Account (HSA) for yourself, through a bank or other financial organization acting as an HSA custodian/administrator, and set aside tax-free dollars to pay for eligible healthcare expenses now or in the future. HSAs typically earn interest and may even offer investment options. You may start an HSA when you enroll in the HDHP as long as you do not have other medical coverage and are not medicare eligible. You will be responsible for selecting your HSA vendor, setting up your account, and making contributions. In return for the lower premiums and the potential tax advantages of a Health Savings Account, you take on more responsibility for your healthcare needs when you enroll in the HDHP. You: Have a higher deductible, with benefits payable only after you meet the deductible (except for preventive care coverage). Pay coinsurance after you have satisfied the deductible rather than set dollar co-payments for network office visits and prescription drugs. State Health Benefit Plan Medicare Policy Effective January 1, 2006, the SHBP will implement a new Medicare policy. SHBP will calculate premiums and claims payment based upon Medicare enrollment for retirees age 65 or older and those eligible for Medicare due to disability. As in the past, SHBP will coordinate benefits for members who are enrolled for Medicare Part A and/or B. Additionally, coordination will also begin for retirees who enroll in the Medicare Part D Prescription Drug Plan (PDP). Premiums will be reduced for each part of Medicare for which the retiree enrolls. SHBP will pay primary benefits for non-enrolled Medicare eligible retirees as well as retirees who are not entitled to Medicare because they did not participate in Social Security or pay Medicare taxes. The premiums for these primary payments will be increased the month in which the retiree (or dependent spouse) becomes 65 or becomes eligible for Medicare due to disability. Plan Changes Additional information can be 6 found at www.dch.georgia.gov. 6 ELIGIBILITY INFORMATION All SHBP options have the same eligibility requirements except the TRICARE Supplement. See page 11, TRICARE Supplement for Eligible Military Members. Eligible Dependents A dependent is defined as: Your legally married spouse, as defined by Georgia Law. Your never-married dependent children who are: 1 Natural or legally adopted children 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 who are physically or mentally disabled and who depend on you for primary support may continue their existing Plan coverage past age 19. 5 Your children from categories 1, 2, or 3 who are registered Fulltime Students* at fully accredited schools, are not employed full time and are between the ages of 19 and 25. When you enroll or add dependents, you will be required to provide copies of certified documents such as a marriage license, birth certificate, adoption contract or judge-signed court order to verify your dependent relationship. The Plan has the right to determine whether or not the documentation satisfies Plan requirements. If verification cannot be made, 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, any and all payments made by the Plan on behalf of an ineligible dependent. * TRICARE covers Full-time Students to age 23. To cover your Full-time Student after age 23 to age 26, you must select another SHBP option during the ROCP prior to your dependent reaching age 23. A Full-time Student reaching age 23 is not a qualifying event to change options. Note: Ineligible dependent determination does NOT allow a refund of a premium. Dependent eligibility cannot be determined until the subscriber presents proper documentation to SHBP. Please review eligibility requirements before selecting family coverage. 7 Eligibility Information Making Changes When You Have a Qualifying Event The option choice you make during the ROCP will stay in effect through December 31, 2006, 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 at 404-656-6322. COBRA Rights Dependents of Retirees The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986 requires that the Plan offer your spouse or an eligible dependent the opportunity to continue health coverage if Plan coverage is lost due to a qualifying event. The length of time one of your dependents may continue the coverage is based on the qualifying event. For further information refer to your SPD. If you are enrolled in the Indemnity Option and have Medicare Parts A and B, you should consider if the benefits offered balance the cost. 8 8 Eligibility Information UNDERSTANDING YOUR PLAN OPTIONS To maximize your health benefits, it is important to fully understand how each of the SHBP options works. This brief overview will help you determine which option best fits your health care needs. Keep in mind that failure to use network providers could result in a financial impact to you. PPO Options The PPO Options offer you a network of more than 10,000 Georgia participating physicians and 133 Georgia hospitals. You also have the added benefit of access to a national network of participating providers and hospitals across the United States. 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. A PPO CCO is also available. See page 10 for more details. To view the list of PPO providers, visit www.myuhc.com/groups/gdch, or call 1-877-246-4190. ! It is ultimately your responsibility to verify that a provider is in the PPO or HMO network prior to receiving services. Providers may enter or leave the network at any time. HMO Options HMO Options are available to SHBP-eligible retirees who live in the county or surrounding counties in which an HMO is offered. HMOs provide 100 percent benefit coverage for preventive health care needs after paying applicable co-payments. There are no bills or claim forms. Certain services are subject to a deductible and co-insurance amount (i.e., inpatient and outpatient hospital facility, inpatient professional charges, etc.). These deductibles and co-insurance amounts have an annual out-of pocket maximum. When you meet this maximum, the HMO pays your covered services at 100 percent. Copayment amounts are excluded from the annual out-of-pocket maximum. In HMOs, you are responsible for selecting a Primary Care Physician (PCP) from a list of participating providers (see note). You must be referred to a network provider by your participating physician or facility for your expenses to be covered, except in emergencies and in other limited cases. If you receive care from a provider other than your PCP, or without your PCP's referral, there is no coverage even if the physician or facility is in the HMO network. An HMO CCO is also available. See page 10 for more details. ! NOTE: UnitedHealthcare HMO does not require you to select a PCP or obtain referrals to see specialists. ! Diagnostic testing and lab services performed at independent radiology and lab offices located in the Kaiser facilities are subject to deductible and co-insurance. Understanding Your Plan Options 9 PPO, HMO and High Deductible Health Plan Consumer Choice Options (CCO) Selection of any CCO option does not provide enhanced benefits. The CCO premiums are higher than the corresponding Option. For the increased cost, you can request that a Georgia out-of network provider be reimbursed as an in-network provider. This is referred to as a nomination. The out-of-network provider must accept the fees and conditions of the network and be approved by the network BEFORE you receive any services from that provider. This in-network relationship between you and the provider exists only for you and the provider. Other family members who wish to receive in-network benefits from that provider must complete a provider nomination form. You may nominate as many providers as you wish. SHBP rules do not allow you to change your coverage option if the provider you would like to nominate rejects the nomination. Only providers located and licensed in Georgia are eligible for nomination. For further details and to obtain the necessary paperwork, please call the selected plan option member services department. Indemnity Option The Indemnity Option is a traditional fee-for-service 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 see a participating provider, you may not be balance billed for covered services. However, not all providers participate in these special arrangements. In most instances, non-participating providers' billed charges are considerably higher than the Plan's allowed amounts. The SHBP does not have the legal authority to intervene when nonparticipating providers balance bill you. As a result, the SHBP cannot reduce or eliminate amounts balance billed. The SHBP cannot make additional payments above the allowed amounts when you are balance billed by non-participating providers. 10 10 Understanding Your Plan Options TRICARE Supplement for Eligible Military Members The TRICARE Supplemental Insurance is offered to employees and dependents who are eligible for TRICARE and who have a Defense Enrollment Eligibility Reporting System (DEERS) number.* Considerations TRICARE will become your primary insurance. TRICARE Supplement will become your secondary coverage. TRICARE covers Full-time students only to age 23. You must select another SHBP option during the ROCP period prior to your child reaching age 23 to cover a Full-time student from age 23 to 26. (Reaching age 23 as a Full-time Student is not a qualifying event). COBRA legislation requires SHBP to offer continuation of coverage when coverage is lost. If you elect COBRA and the premiums are paid, there is NO break in SHBP coverage. If you elect coverage through the Association and Society Insurance Corporation's (ASI) portability feature instead of COBRA, you will no longer be covered by SHBP. What Happens at Age 65 When you and/or your spouse are ineligible for Medicare, TRICARE Supplement continues with submission of disallowance by Social Security. When you and/or your spouse are entitled to Medicare Part A and enrolled in Medicare Part B, your coverage will continue through TRICARE Supplement. When you and/or your spouse are eligible for Medicare, Medicare will be your primary insurance; TRICARE for Life secondary and TRICARE Supplement Tertiary. When you or your spouse are eligible for Medicare, if you wish to cover your spouse through SHBP, you need to select another Option during the ROCP Period prior to you or your spouse reaching age 65. Attainment of age 65 and eligibility for Medicare is a qualifying event and will allow you to change to another Plan option. When you and/or your spouse reach age 65 and reside overseas, your coverage will continue through the TRICARE Supplement if you are entitled to Medicare Part A and are enrolled in Medicare Part B. ! *TRICARE covers dependents to age 23 even if they are not a full-time student. However, SHBP only covers dependents who are not Full-time students to age 19. You should not elect the TRICARE Supplement if you wish to cover a child who is between the ages of 19 and 23 and is not a Fulltime student. ! If you enroll in TRICARE Supplement and are not eligible, you will be enrolled in the PPO Option. You will be required to pay the PPO premiums retroactive to your date of ineligibility or your coverage will be terminated effective January 1, 2006. Do not enroll for the TRICARE Supplement if you are not enrolled in TRICARE. Understanding Your Plan Options 11 Medicare+Choice HMO Option (MA HMO) The name of the Medicare+Choice Option offered by Kaiser Permanente is the Medicare Advantage (MA) HMO. Kaiser's MA Option is available only to those retirees who are enrolled in Part A, Part B and Part D Medicare coverage and live in the MA service area. See chart below for a listing of counties serviced by the Kaiser MA HMO. Points to Consider You will pay an SHBP premium, but it will be lower than the regular HMO Option premiums. See your Personalized Change Form for premium information. You will have the advantage of lower out-of-pocket costs and reduced paperwork. All your services and payments will be coordinated through Kaiser Permanente MA. The benefits available through the Kaiser Permanente MA are similar to that of the regular HMO. You must use providers in the Kaiser Permanente MA network. The affiliated provider network differs from the regular HMO, but all Kaiser Permanente facilities are covered under both plans. To enroll in Kaiser Permanente MA, you must complete the Kaiser Permanente MA form. Please call Kaiser Permanente at (404) 233-3700 or (800) 956-1358 to obtain your enrollment materials. Kaiser Permanente Medicare Advantage Coverage by County The following Georgia counties are covered by Kaiser Permanente MA HMO: Cherokee DeKalb Fulton Clayton Douglas Gwinnett Cobb Fayette Henry Coweta Forsyth Paulding (only in areas with a 30127 or 30141 zip code) Understanding Your Plan Options 12 12 ADDITIONAL INFORMATION CONCERNING MEDICARE PART D Medicare Part D will offer a standard and enhanced prescription drug plan effective January 1, 2006. The initial enrollment period is November 15, 2005 May 15, 2006. If you are considering enrolling in a Part D plan, SHBP suggests that you enroll in a standard plan. The standard plan and the coordination of benefits with SHBP should meet your coverage needs. Please note that certain medications have specific quantity level limits and some require Prior Authorization. The SHBP will still apply these requirements and limits to your prescription drug coverage. Kaiser Medicare Advantage Plan If you are enrolled in the Kaiser Medicare Advantage (MA) option, you do not need to join a Medicare Part D Plan. You will automatically be enrolled in the Medicare Advantage Prescription Drug Plan (MA-PD). However, if you elect to enroll in another Medicare Part D Plan, your coverage in the MA-PD will end and you will no longer be covered by the Kaiser Medicare Advantage Plan. Your coverage will change to the regular Kaiser Plan for Medicare Parts, A, B and D. If you are enrolling in Medicare Advantage during this Retiree Option Change Period (ROCP), you must make your election on the Personalized Change Form and submit to SHBP. Kaiser will mail you a Medicare Advantage application that you will need to complete. You should also check the Medicare Part D box on this application. By checking this box, you are agreeing to have Part D Prescription Coverage administered by Kaiser. To Get a Prescription Filled You will present your Medicare Part D and SHBP identification cards. Medicare Part D is primary and the SHBP coordinates benefits. You will pay your SHBP co-payment. The pharmacist will file your prescription drug claim with Medicare Part D first and the SHBP second. You are responsible for your SHBP co-payment. In order for the SHBP to coordinate benefits with Part D starting January 1, 2006, you must join a Part D plan by December 31, 2005. The SHBP is encouraging all members that are eligible for Medicare Part D and who want to join, to enroll as soon as possible. Retirees who enroll in Part D should provide a copy of their card to the SHBP immediately upon receipt. Premiums cannot be reduced until a copy of your card is received and the change in premium is processed by the retirement system. Delay in submission of the card does not qualify for a refund of the difference in premium. Remember, if you are eligible for Part D and you enroll after December 31, 2005, your monthly premium will be higher for your SHBP coverage until you enroll in Part D and submit a copy of your card to SHBP. You may contact the customer service numbers provided on the inside front cover if you have additional questions concerning Part D and coordination of benefits with Medicare. SHBP will notify you by letter of any change in your health benefit premium. 13 Medicare Part D Information IMPORTANT NOTICE ABOUT YOUR PRESCRIPTION DRUG COVERAGE AND MEDICARE ! Because your existing coverage with one of the following SHBP Options: PPO, Indemnity, CIGNA, United Healthcare HMO, Kaiser Permanente, BlueChoice, and TRICARE Supplement is on average at least as good as the standard Medicare prescription drug coverage, you can keep this coverage and not pay extra if you later decide to enroll in Medicare coverage. PPO, Indemnity, CIGNA, United Healthcare HMO, Kaiser Permanente, BlueChoice and TRICARE Supplement Plan Options Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with the State Health Benefit Plan (SHBP) and the new prescription drug coverage available soon for people with Medicare. 1 Starting January 1, 2006, new Medicare prescription drug coverage will be available to everyone with Medicare. 2 DCH has determined that the prescription drug coverage offered by the SHBP is, on average for all plan participants, expected to pay out as much as the standard Medicare prescription drug coverage will pay. 3 Read this notice carefully it explains the options you have under Medicare prescription drug coverage, and can help you decide whether or not you want to enroll. Starting January 1, 2006, prescription drug coverage will be available to everyone with Medicare through Medicare prescription drug plans. All Medicare prescription drug plans will provide at least a standard level of coverage set by Medicare. Some plans might also offer more coverage for a higher monthly premium. People with Medicare can enroll in a Medicare prescription drug plan from November 15, 2005 through May 15, 2006. Each year after that, you will have the opportunity to enroll in a Medicare prescription drug plan between November 15 and December 31. You should compare your current coverage, including which drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. In addition, your current coverage pays for other health expenses, in addition to prescription drugs, and you will still be eligible to receive all of your current health and prescription drug benefits if you choose to enroll in a Medicare prescription drug plan. Prescription Drug Coverage and Medicare 14 14 You should also know that if you drop or lose your coverage with SHBP and don't enroll in Medicare prescription drug coverage after your current coverage ends, you may pay more to enroll in Medicare prescription drug coverage later. If after May 15, 2006, you go 63 days or longer without prescription drug coverage that's at least as good as Medicare's prescription drug coverage; your monthly premium will go up at least 1 percent per month for every month after May 15, 2006, that you did not have that coverage. For example, if you go 19 months without coverage, your premium will always be at least 19 percent higher than what most other people pay. You'll have to pay this higher premium as long as you have Medicare coverage. In addition, you may have to wait until next November to enroll. For more information about this notice or your current prescription drug coverage...contact your Pharmacy Benefit Manager at the number on your identification card or call the State Health Benefit Plan at 404-651-6142 or 800-610-1863. NOTE: You may receive this notice at other times in the future such as before the next period you can enroll in Medicare prescription drug coverage, and if this coverage changes. You also may request a copy. More information about your options under Medicare prescription drug coverage...will be available in October 2005 in the "Medicare & You 2006" handbook. You'll get a copy of the handbook in the mail from Medicare. You may also be contacted directly by Medicare prescription drug plans. You can also get more information about Medicare prescription drug plans from these places: Visit www.medicare.gov for personalized help. Call your State Health Insurance Assistance Program (see your copy of the Medicare & You handbook for their telephone number). Call 1-800 MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Please contact the Social Security Administration (SSA) at 1-800-772-1213 (TTY 1-800-325-0778) or visit their Web site at www.socialsecurity.gov for more information about this extra help. ! REMEMBER TO KEEP THIS NOTICE. If you enroll in one of the new plans approved by Medicare which offer prescription drug coverage after May 15, 2006, you may need to give a copy of this notice when you join to show that you are not required to pay a higher premium amount. Prescription Drug Coverage and Medicare 15 IMPORTANT NOTICE ABOUT YOUR HDHP PRESCRIPTION DRUG COVERAGE AND MEDICARE High Deductible Health Plan Option Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with the State Health Benefit Plan (SHBP) and new prescription drug coverage available soon for people with Medicare. 1 Starting January 1, 2006, new Medicare prescription drug coverage will be available to everyone with Medicare. 2 DCH has determined that the prescription drug coverage under the High Deductible Health Plan Option offered by the SHBP is, on average for all plan participants, NOT expected to pay as much as the standard Medicare prescription drug coverage will pay. This is important, because for most people, enrolling in Medicare prescription drug coverage before May 15, 2006, means you will get more assistance with drug costs. 3 You have decisions to make about Medicare prescription drug coverage that may affect how much you pay for that coverage, depending on if and when you enroll. Read this information carefully it explains your options. Starting January 1, 2006, prescription drug coverage will be available to everyone with Medicare through Medicare prescription drug plans. All Medicare prescription drug coverage will provide at least a standard level of coverage set by Medicare. Some plans might also offer more coverage for a higher monthly premium. Because the coverage you have with the State Health Benefit Plan is on average for all plan participants in the High Deductible Health Plan Option, NOT expected to pay out as much as the standard Medicare prescription drug coverage will pay, you might want to consider enrolling in a Medicare prescription drug plan. You can first join between November 15, 2005 and May 15, 2006. This is important, because if you do not get Medicare prescription drug coverage (or equivalent coverage) before May 15, 2006, you may have to pay a higher premium if you join later. You will pay that higher premium as long as you have Medicare prescription drug coverage. Prescription Drug Coverage and Medicare If you don't enroll in Medicare prescription drug coverage by May 15, 2006, you may pay more. If you enroll after May 15, 2006, your monthly premium for a Medicare prescription drug plan could be much higher. If after May 15, 2006, you go 63 days or longer without prescription drug coverage that is at least as good as Medicare's prescription drug coverage; your premium will go up at least 1 percent per month for every month after May 15, 2006, that you did not have that coverage. You will have to pay this higher premium as long as you have Medicare prescription drug coverage. For example, if you go 19 months without coverage, your premium will always be at least 19 16 percent higher than what most other people pay. 16 If you don't enroll in a Medicare prescription drug plan by May 15, 2006, you may also have to wait to enroll. Generally, after May 15, 2006, you can only join a Medicare prescription drug plan between November 15 and December 31 of any year. This may mean the number of months you have to wait for coverage will be longer, which could make your premium higher. In addition, your current coverage pays for other health expenses, in addition to prescription drugs. You will still be eligible to receive all of your current health and prescription drug benefits if you choose to enroll in a Medicare prescription drug plan. You need to make a decision. When you make your decision, you should compare your current coverage, including which drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. For more information about this information or your current prescription drug coverage...contact your Pharmacy Benefit Manager at the number on your identification card or call the State Health Benefit Plan at 404-651-6142 or 1-800-610-1863. NOTE: You may receive this notice at other times in the future such as before the next period you can enroll in Medicare prescription drug coverage, and if this coverage changes. You also may request a copy. For more information about your options under Medicare prescription drug coverage...more detailed information about Medicare plans that offer prescription drug coverage will be available in October 2005 in the "Medicare & You 2006" handbook from Medicare you will receive in the mail. You may also be contacted directly by Medicare-approved prescription drug plans. You can also get more information about Medicare prescription drug plans from these places: Visit www.medicare.gov for personalized help. Call your State Health Insurance Assistance Program (see your copy of the Medicare & You handbook for their telephone number). Call 1-800MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information about this extra help is available from the Social Security Administration (SSA). For more information about this extra help, visit SSA online at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). 17 Prescription Drug Coverage and Medicare BENEFITS COMPARISON: PPO, INDEMNITY, HDHP AND HMO OPTIONS Schedule of Benefits for You and Your Dependents for January 1, 2006 December 31, 2006 Dollar amounts, visit limitations, deductibles and out-of-pocket limits are based on a January 1December 31, 2006 Plan Year. NOTE: Coverage is defined as allowed eligible expenses. PPO OPTION In-Network/Georgia Out-of-Network INDEMNITY 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, Indemnity and HDHP ) Temporomandibular joint dysfunction (TMJ) Substance abuse Deductibles/Co-Payments: Deductible--individual Deductible--family maximum Hospital deductible per admission Annual Out-of-Pocket Limits: Individual Family Physicians' Services Primary Care Physician or Specialist Office or Clinic Visits: Treatment of illness or injury The Plan Pays: $2 million $1,000 $500 $1,500 $1,100 $2,200 $1,100 3 episodes $600 $1,800 $250 $2,200 $4,400 100% after a $30 per visit co-payment; not subject to deductible 60% of coverage; subject to deductible The Plan Pays: $2 million $1,000 $1,100 3 episodes $500 $1,500 $400 $2,200 $4,400 90% of coverage; subject to deductible Primary Care Physician or Specialist Office or Clinic Visits for the Following: Wellness care/preventive healthcare Annual gynecological exams (these services are not subject to the deductible) 100% after $30 copayment per office visit. No co-payment for associated tests and immunizations. Maximum of $500 per person per Plan Year. Not covered. Charges do not apply to deductible or annual out-of-pocket limits. 90% per office visit after deductible. 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. Benefits Comparison Maternity Care (prenatal, delivery and postpartum) 18 18 90% of coverage; not subject to deductible after initial $30 copayment 60% of coverage; subject to deductible 90% of coverage; subject to deductible Exclusions and limitations vary among Plan options. Contact your specific Plan option for more information. HIGH DEDUCTIBLE OPTION (HDHP) In-Network Out-of-Network The Plan Pays: $2 million None HMO OPTIONS BlueChoice, CIGNA, Kaiser Permanente, Kaiser Permanente MA, UnitedHealthcare The Plan Pays: HMO Plan Differences $2 million Kaiser Permanente MA; unlimited None $1,100 $2,200 $1,700 $2,900 $1,100 3 episodes $2,200 $4,400 Not applicable $3,800 $7,000 No separate lifetime benefit limit $200 $400 Not applicable $1,000 $2,000 Kaiser Permanente MA; $1000 individual; $2000 family per Plan Year 90% of coverage; subject to deductible 100% coverage up to a maximum of $500 per person per plan year. Not subject to deductible. 90% of coverage; subject to deductible 60% of coverage; subject to deductible Not covered, charges do not apply to deductible or annual out-ofpocket limits. 60% of coverage; subject to deductible 100% after a per visit copayment** of $20 for primary care and $25 for specialty care ** Includes lab and x-rays done in the physician's office. Kaiser: Subject to deductible for independent labs/radiology offices at Kaiser facilities. 100% after a per visit copayment of $20 for primary care and $25 for specialty care. No co-payment for immunizations and mammograms. 100% after initial $25 co-payment Chart continued pg. 20 19 Benefits Comparison Physicians' Services Physician Services Furnished in a Hospital Surgery in general, including charges by surgeon, anesthesiologist, pathologist and radiologist Physician Services for Emergency Care Outpatient Surgery-- When billed as office visit PPO OPTION In-Network/Georgia Out-of-Network The Plan Pays: INDEMNITY The Plan Pays: 90% of coverage; subject to deductible 60% of coverage; subject to deductible 90% of coverage; subject to deductible 90% of coverage; subject to deductible 90% of coverage; subject to deductible 90% of coverage; subject to in-network deductible 60% of coverage; subject to deductible 90% of coverage; subject to deductible 90% of coverage; subject to deductible When billed as outpatient surgery at a facility Allergy Shots and Serum 90% of coverage; subject to deductible 100% for shots and serum after $30 per visit co-payment not subject to deductible 60% of coverage; subject to deductible 60% of coverage; subject to deductible 90% of coverage; subject to deductible 90% of coverage; subject to deductible Hospital Services Inpatient Services Inpatient care, delivery and inpatient short-term acute rehabilitation services Well-newborn care Covered Services Outpatient Surgery-- Hospital/Facility 90% of coverage; subject to a $250 per admission deductible 100% of coverage; not subject to deductible 90% of coverage; subject to deductible Emergency Care Treatment of an emergency medical condition or injury 90% of coverage after a $100 per visit copayment; co-payment waived if admitted; subject to deductible 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 coverage; subject to deductible 60% of coverage; subject to a $250 per admission deductible Not covered 60% of coverage; subject to deductible 90% of coverage after a $100 per visit copayment; co-payment waived if admitted; subject to deductible 60% of coverage; subject to deductible Benefits Comparison 20 20 90% of coverage; subject to a $400 per admission deductible 90% of coverage; not subject to deductible 90% of coverage; subject to deductible 90% of coverage after a $100 per visit copayment; co-payment waived if admitted; subject to deductible 90% of coverage; subject to deductible HIGH DEDUCTIBLE OPTION In-Network Out-of-Network The Plan Pays: HMO OPTIONS BlueChoice, CIGNA, Kaiser Permanente, Kaiser Permanente MA, UnitedHealthcare The Plan Pays: HMO Plan Differences 90% of coverage; subject to deductible 60% of coverage; subject to deductible 90% of coverage; subject to deductible 90% of coverage; subject to deductible 90% of coverage; subject to deductible 60% of coverage; subject to deductible 60% of coverage; subject to deductible 90% of coverage; subject to deductible 90% of coverage; subject to deductible 60% of coverage; subject to deductible 60% of coverage; subject to deductible 90% of coverage; subject to deductible 60% of coverage; subject to deductible 100% after $100 co-payment 100% after $25 co-payment if billed as office visit 90% of coverage; subject to deductible 100% for shots and serum after a $25 per visit copayment Non-emergency use of the emergency room not covered. Kaiser Permanente 90% of coverage; subject to deductible Kaiser Permanente $5 for shots and $50 for a three-month supply of serum; Kaiser Permanente MA $10 shots and no serum charge 90% of coverage; subject to deductible 90% of coverage; subject to deductible 60% of coverage; subject to deductible 90% of coverage; subject to deductible 90% of coverage; subject to deductible 60% of coverage; subject to deductible 60% of coverage; subject to deductible 100% of coverage not subject to deductible 90% of coverage; subject to deductible 100% after a $100 per visit co-payment; co-payment waived if admitted No Non-emergency use of the emergency room not covered. 90% of coverage; subject to deductible 60% of coverage; subject to deductible 90% of coverage; subject to deductible Benefits Comparison Chart continued pg. 22 21 Behavioral Health Mental Health and Substance Abuse Inpatient Facility NOTE: All services require prior authorization. Partial Day Hospitalization and Intensive Outpatient NOTE: Notification Required. Professional Charges Inpatient PPO OPTION In-Network/Georgia Out-of-Network The Plan Pays: 90% of coverage; subject to deductible limited to 45 days combined per Plan Year 60% of coverage; subject to deductible limited to 45 days combined per Plan Year 90% of coverage; subject to deductible limited to 60 days combined per Plan Year No benefit 90% of coverage; subject to deductible; limited to 1 visit per authorized day combined per Plan Year 60% of coverage; subject to deductible; limited to 1 visit per authorized day combined per Plan Year INDEMNITY The Plan Pays: 90% of coverage; subject to deductible limited to 45 days combined per Plan Year 90% of coverage; subject to deductible limited to 60 days combined per Plan Year 90% of coverage; subject to deductible; limited to 1 visit per authorized day combined per Plan Year Mental Health and Substance Abuse Outpatient Visits NOTE: Notification Required. Dental Dental and Oral Care NOTE: 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 coverage; subject to deductible, limited to 50 visits combined per Plan Year 60% of coverage; subject to deductible; limited to 25 visits combined per Plan Year 90% of coverage; subject to deductible 60% of coverage; subject to deductible 90% of coverage; subject to deductible; limited to 50 visits combined per Plan Year 90% of coverage; subject to deductible Temporomandibular Joint Syndrome (TMJ) NOTE: Coverage for diagnostic testing and non-surgical treatment up to $1,100 per person lifetime maximum benefit. This does not apply to the HMO Vision Benefits Comparison Other Coverage Ambulance Services for Emergency Care NOTE: "Land or air ambulance" to 22 nearest facility to treat the condition. 22 90% of coverage; subject to deductible 60% of coverage; subject to deductible 90% of coverage; not subject to deductible; limited to one eye exam every 24 months Eye exam not covered 90% of coverage; subject to deductible 90% of coverage; subject to deductible 90% of coverage; subject to deductible 90% of coverage; not subject to deductible; limited to one eye exam every 24 months 90% of coverage; subject to deductible HIGH DEDUCTIBLE OPTION In-Network Out-of-Network The Plan Pays: 90% of coverage; subject to deductible limited to 30 days combined per Plan Year 60% of coverage; subject to deductible limited to 30 days combined per Plan Year 90% of coverage; subject to deductible limited to 60 days combined per Plan Year 60% of coverage; subject to deductible limited to 30 days combined per Plan Year HMO OPTIONS BlueChoice, CIGNA, Kaiser Permanente, Kaiser Permanente MA, UnitedHealthcare The Plan Pays: 90% of coverage; not subject to deductible and limited to 30 days combined per Plan Year Each HMO may or may not offer this benefit; contact the HMO for more information HMO Plan Differences Kaiser Permanente 90% of coverage; subject to deductible and unlimited days for mental health and detoxification; 30-day limit for substance abuse Medicare Advantage 90% of coverage subject to deductible and unlimited days for mental health, substance abuse and detoxification 90% of coverage; subject to deductible limited to 1 visit per authorized day combined per Plan Year 60% of coverage; subject to deductible limited to 1 visit per authorized day combined per Plan Year 90% of coverage; subject to deductible limited to 50 visits combined per Plan Year 60% of coverage; subject to deductible limited to 25 visits combined per Plan Year 90% of coverage; not subject to deductible 100% after $25 per visit co-payment; limited to 25 visits combined per Plan Year Kaiser Permanente 90% of coverage; subject to deductible Kaiser $25 co-payment, 100% coverage, unlimited visits, Mental Health and Detoxification; limited to 25 visits for substance abuse Medicare Advantage 100% after $25 visit co-payment; unlimited visits for mental health, substance abuse and detoxification 90% of coverage; subject to deductible 60% of coverage; subject to deductible 90% of coverage; subject to deductible 60% of coverage; subject to deductible 90% of coverage; not subject to deductible; limited to one eye exam every 24 months Eye exam not covered 90% of coverage; subject to deductible 60% of coverage; subject to deductible 100% after applicable co-payment, if inpatient/ outpatient facility; subject to deductible Kaiser Permanente 50% coverage on first $1,000, if inpatient/outpatient facility; subject to deductible 100% after applicable copayment for related surgery and diagnostic services; excludes appliances and orthodontic treatment; if inpatient/outpatient facility, 90% subject to deductible No Kaiser Permanente 50% for non-surgical treatment; excludes appliances and orthodontic treatment; if inpatient/outpatient facility; 90% subject to deductible Contact HMO directly for more information 100% Kaiser Permanente 100% after a $50 per trip co-payment when medically necessary Chart continued pg. 24 23 Benefits Comparison Other Coverage Urgent Care Services Home Healthcare Services NOTE: Prior approval required Skilled Nursing Facility Services NOTE: Prior approval required PPO OPTION In-Network/Georgia Out-of-Network The Plan Pays: 90% of coverage after a $45 per visit copayment; subject to deductible 60% of coverage; subject to deductible 90% of coverage; subject to deductible 60% of coverage; subject to deductible 90% of coverage; up to 45 days per Plan Year; subject to a $250 per admission deductible Not covered INDEMNITY The Plan Pays: 90% of coverage; subject to deductible 90% of coverage; subject to deductible 90% of coverage; up to 45 days per Plan Year; subject to a $400 per admission deductible at contracted facility Hospice Care NOTE: Prior approval required 100% of coverage; subject to deductible 60% of coverage; subject to deductible 100% of coverage; subject to deductible Durable Medical Equipment (DME)--Rental or Purchase Outpatient Acute Short-Term Rehabilitation Services Chiropractic Care NOTE: Coverage for up to a maximum of 20 visits per Plan Year Transplant Services NOTE: Prior approval required Pharmacy Generic Co-payment 90% of coverage; subject to deductible 90% of coverage; subject to deductible and $20 per visit copayment up to 40 visits per Plan Year 60% of coverage; subject to deductible 60% of coverage; subject to deductible and $20 per visit copayment up to 40 visits per Plan Year 90% of coverage; after a $30 per visit copayment; not subject to deductible 60% of coverage; subject to deductible 90% of coverage; subject to deductible at contracted transplant facility Not covered $10 $10 90% of coverage; subject to deductible 90% of coverage; subject to deductible and $20 per visit co-payment up to 40 visits per Plan Year 90% of coverage; subject to deductible 90% of coverage; subject to deductible at contracted transplant facility $10 Benefits Comparison Preferred Brand Co-payment Non-Preferred Brand Co-payment 24 24 $30 $100 $30 $100 $30 $100 HIGH DEDUCTIBLE OPTION In-Network Out-of-Network The Plan Pays: 90% of coverage; subject to deductible 60% of coverage; subject to deductible 90% of coverage; subject to deductible 90% of coverage up to 45 days per Plan Year; subject to deductible 60% of coverage; subject to deductible Not covered 90% of coverage; subject to deductible 60% of coverage; subject to deductible 90% of coverage; subject to deductible 90% of coverage up to 40 visits per Plan Year; subject to deductible 60% of coverage; subject to deductible 60% of coverage up to 40 visits per Plan Year; subject to deductible HMO OPTIONS BlueChoice, CIGNA, Kaiser Permanente, Kaiser Permanente MA, UnitedHealthcare The Plan Pays: 100% after $25 co-payment HMO Plan Differences BlueChoice referral required. Kaiser Permanente 100% after $30 co-payment 100% of coverage; up to 120 visits per Plan Year Kaiser Permanente MA 100%; No day limit 90% of coverage; up to 45 days per Plan Year; subject to deductible 100% of coverage; subject to deductible 100% of coverage when medically necessary 100% of coverage after $25 per visit co-payment; up to 40 visits per Plan Year United Healthcare 90% of coverage, up to 120 days per Plan Year; subject to deductible. Kaiser Permanente MA up to 100 days per Plan Year; subject to deductible CIGNA 90% of coverage; subject to deductible; outpatient 100% not subject to deductible Kaiser Permanente MA unlimited visits 90% of coverage; subject to deductible 60% of coverage; subject to deductible 100% of coverage after $25 co-payment per visit No 90% of coverage; subject to deductible at contracted transplant facility Not covered 90% of coverage; subject to deductible 80% of coverage; Not covered $10 subject to deductible $10 min./$100 max. 80% of coverage; Not covered $25 subject to deductible $10 min./$100 max. 80% of coverage; Not covered $50 subject to deductible $10 min./$100 max. Kaiser Permanente Kaiser facility: $10 Eckerd Drugs: $16 Kaiser Permanente Kaiser facility $25 Eckerd Drugs: $31 Kaiser Permanente N/A 25 Benefits Comparison IMPORTANT PLAN CONSIDERATIONS Important PPO, Indemnity Considerations See the Summary Plan Description and Updaters for coverage details, including limitations and exclusions. ! If you are covered under the PPO, Indemnity, High Deductible Health Plan or CCO option, for Choice option you are required to obtain the necessary prior notification or prior approval for all inpatient admissions and certain covered services under the Plan. You should contact member services regarding notification requirements and verification of covered services. Some services may require prior approval before such services are covered. Prior notification is the member's responsibility to obtain. Also, some services may have limitations not contained in this summary. 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. Services covered under the PPO from in-network providers will apply to the in-network deductible and out-of-pocket limit. Services covered under the PPO from out-of-network providers apply to the out-of-network deductible and out-of-pocket limit. Co-payments do not apply toward deductibles or out-of-pocket limits unless otherwise noted. High Deductible Health Plan (HDHP) Considerations The HDHP covers the same services and supplies as the SHBP's PPO Option, and includes the same network of participating physicians and hospitals here in Georgia and across the United States. The HDHP PPO and Indemnity also reflects the importance of preventive care, with a $500 annual benefit with no deductible. Progressive Drug Management Program (PDMP) This program assists your doctor Deductibles: The deductible applies to everything except the first $500 in preventive care expenses. If you have family coverage, you must meet the family in finding the most appropriate deductible before benefits are payable for any family member. drug for you. The first step is usually a proven, less expensive With the HDHP, you pay coinsurance after the deductible for in-network office visits and prescription drugs. treatment known to be safe and effective. If the drug does not work for you, your doctor may progress to another drug. A prior authorization may be required as the next step in the program. Your Health Savings Account (HSA) Opportunity An HSA is like a personal savings account for healthcare, except it's all taxfree. When you enroll in the HDHP, you may be eligible to open a HSA with an independent HSA administrator/custodian. You will need to contact a local bank or other financial organization to set-up your HSA Account. You may open a HSA if you enroll in the HDHP and do not have other Note: If you should go to the pharmacy and are told that coverage through your spouse's employer's plan, Medicare, Medicaid, a full unrestricted HCSA or any other medical plan. your prescription cannot be Important Plan Considerations filled because it requires prior HSA Highlights authorization, please have your doctor call Express Scripts with your clinical information. What you can contribute each year Up to HDHP deductible amount: $1,100 if you have individual coverage $2,200 if you have family coverage as long as you continue to be enrolled in the HDHP. If you are 55 or older, you may contribute additional dollars up to $700/year as "catch-up" 26 contributions. 26 HSA Highlights continued How you contribute Through deposits you make directly to the HSA administrator you select...either in a lump sum or in installments throughout the year. Payroll deductions may be available through your employer. What you can use your HSA to pay Healthcare expenses (medical, dental, vision, overthe-counter medications) the IRS considers taxdeductible that aren't covered by any healthcare plan...see IRS Publication 502 at www.irs.gov. How claims are paid Varies based on HSA administrator, but generally you can pay expenses directly from your account (using a debit card or convenience checks), so there's no claim paperwork to submit. What happens at Unused money in your account carries forward the end of the year and continues to earn interest. What happens if you don't enroll in the HDHP next year or leave your employer You can no longer contribute to your HSA, but you keep the account and can continue to use the balance for eligible healthcare expenses Points to Consider when selecting your HSA Administrator/Custodian The organization's credentials: As you look at an insurance company, a bank or other HSA custodian, check out its reputation for service, quality, licensing and financial stability. Investment options: How much interest will your HSA earn? Money market accounts typically earn 0.5% to 3.0% interest. Will you have a choice of investment options? Some HSA administrators require that your account balance reaches a certain threshold before you have investment choices. Claim payment: Many administrators offer a debit card that can be used at the doctor's office or pharmacy to pay your share of the cost of care, or even at an ATM to reimburse yourself for qualified expenses you have paid. Most offer checks, sometimes for an extra fee. Account fees: HSA administrators (typically) charge a set-up fee and a monthly maintenance fee. Sometimes there are additional transaction fees. Important HMO Considerations 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 denial of your claim. Note: UnitedHealthcare does not require a referral for coverage of specialist services. ! NOTES APPLY TO ALL OPTIONS Preferred Drug Lists for SHBP members are subject to change. Prior to purchasing your medication(s), PPO and Indemnity members may view the drug lists at www.dch. georgia.gov or contact Express Scripts at 1-877-650-9342 or TDD 1800-842-5754. HMO members may contact the HMO plan in which they are enrolled. Many drugs listed as non-preferred have a generic or a preferred brand name alternative. Preferred drug alternatives are therapeutically equivalent while being more cost effective. If the drug cost is less than the copayment, you do not have to pay the co-payment but the actual cost of the drug. Co-payments for drugs covered under the SHBP will not be changed or overridden on an individual basis. The SHBP defines maintenance drugs as medications for specified chronic conditions. PPO, PPO CCO, Indemnity and Kaiser members may obtain up to a 90-day supply of maintenance prescription(s) at one time for three co-payments. BlueChoice, CIGNA, and UnitedHealthcare members may receive a 90-day supply of maintenance prescriptions for two co-payments. Your co-payments are based on supplies of up to 30 days as this is the industry standard. However, some drugs are limited to a standard other than the 30-day supply for one co-payment. Lifetime benefit maximums are combined totals among the PPO Options, Indemnity, HDHP Option and HMO Options. Annual dollar and visit limitations, deductibles and out-of-pocket spending limits are based on January 1, 2006 to December 31, 2006. Contact each plan directly for more details regarding covered services, exclusions and limitations. Important Plan Considerations 27 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 CCO and Indemnity Options 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: 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 preexisting 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 or she has the right to obtain a certificate of creditable coverage from his or 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. HIPAA Annual Notice Please submit the certificate of creditable coverage to the Plan with your 28 dependent's enrollment paperwork. 28 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 SHBP records indicate that you have previously provided information to us. This information included your name, address, birth date, phone number, Social Security Number, gender and Medicare information, if applicable. When your healthcare providers send claims to the Plan's claims 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: 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"). 29 Privacy Notice Privacy Notice ! 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. 30 30 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. How DCH Uses and Discloses Healthcare Information There are some services the Plan provides through contracts with private companies. For example, United Healthcare 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. 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 or 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: 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: SHBPHPU, 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 404562-7886; Fax 404-562-7881; TDD 404-562-7884. You also may contact the HHS Office for Civil Rights by calling 866-OCR-PRIV 866-627-7748 or e-mailing the OCR at OCRComplaint@hhs.gov. There will be no retaliation for filing a complaint. ! Under the HIPAA Privacy Law, you may authorize the Plan to release your Personal Health Information (PHI) to another individual. If you have authorized the release of PHI to another individual, the personal representative form authorizing the release of your PHI is not transferred between options. This is for the protection of your privacy. If you wish to continue to designate another individual after changing health options, you may be asked to complete a new personal representative form. Privacy Notice 31 ! 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. 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. Treatment of physical complications of mastectomy, including lymphedema. Note: Reconstructive surgery requires prior approval, and all inpatient admissions require prior notification. For more detailed information on the mastectomy-related 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 an SHBP participant misrepresents eligibility information when applying for coverage, during change of coverage or when filing for benefits, the SHBP may take adverse action against the 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. Legal Notices 32 32