State Health Benefit Plan decision guide 2007: retiree

Phone Numbers/Contact Information

State Health Benefit Plan (SHBP): www.dch.georgia.gov/shbp_plans

PPO, PPO CCO, Indemnity:

Retiree Help Line Member Services
To View Benefit Video

877-246-4190 877-246-4189 TDD 800-955-8770
www.myuhc.com/groups/gdch

Pharmacy Information

877-650-9342 TDD 800-842-5754

HDHP:

Member Services and Pharmacy

HMOs:

BlueChoice

800-464-1367 TDD 404-842-8073

Cigna

800-564-7642

Kaiser Permanente

800-611-1811 TDD 800-255-0056

United Healthcare

866-527-9599 TDD 800-955-8770

877-246-4195 TDD 800-842-5754
www.bcbsga.com
www.cigna.com www.kaiserpermanente.org
www.myuhc.com/groups/gdch

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

Center for Medicare and Medicaid (CMS)

Social Security Administration

800-772-1213

www.medicare.gov www.cms.gov www.ssa.gov

Page 4 of this Guide contains Plan changes effective January 1, 2007. Prior to the start of the 2007 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/shbp_ plans. This SPD is your official notification of Plan Changes effective January 1, 2007. You may print or request a paper copy by calling the Customer Service number on the back of your ID card. 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.

Welcome

Welcome to the Retiree Option Change Period (ROCP) for the State Health Benefit Plan for Coverage effective January 1, 2007 December 31, 2007
This guide will provide you with a brief explanation of each Plan Option, steps on how to make your election, information about the Health & Wellness features available through the health plan options and a comparison of benefits chart. The Decision Guide for Retirees can be found at www.dch.georgia.gov/shbp_ plans or www.oe2007ga.gov.
Table of Contents

Contact Information for Benefits and Providers Welcome to ROCP Online ROCP What's Changing for 2007? SHBP Eligibility SHBP Medicare Policy SHBP Health & Wellness Information Understanding Your Plan Options Benefits Comparison Chart Important Plan Considerations Legal Notices

Inside Front Cover Page 1 Pages 2-3 Page 4 Page 5-6 Page 7-8 Pages 8-11 Pages 12-17 Pages 18-25 Pages 26-28 Pages 29-37

SHBP Plan Options
High Deductible Health Plan PPO (HDHP) BlueChoice HMO Indemnity Plan CIGNA HMO UHC Preferred Provider Organization (PPO) Kaiser HMO Kaiser Senior Advantage TRICARE Supplement (see page 16 for eligibility rules) United Healthcare Choice HMO
Consumer Choice Options (CCO): For a higher premium, the PPO, HMO and High Deductible Health Plan options allow a member to nominate a Georgia out-of-network provider. If approved, the member may receive services from the provider at the in-network benefit level.
Am I Eligible to Participate in Each of the Above Options?
All retirees are eligible to participate in the HDHP, Indemnity and PPO options. You may participate in the Kaiser HMO or Kaiser Senior Advantage only if you live in the metro Atlanta area. You may participate in the other HMOs if the HMO is offered in the county where you live or you are willing to drive to a county where the HMO is offered. You may participate in the TRICARE Supplement only if you are eligible for TRICARE and have a Defense Enrollment Eligibility Reporting System (DEERS) number.

Welcome to ROCP

Online ROCP
What Should I Do before I Make My 2007 Benefit Election?
If you want to continue with the same coverage you currently have, you don't have to do anything.
If you want to change your health coverage options or discontinue coverage, you need to take action during this Retiree Option Change Period (ROCP). If you discontinue coverage, you will not be able to enroll later.
If you or your covered spouse are turning age 65, please be sure to carefully read the Medicare information on page 7. You should carefully review the Retiree Decision Guide. You should read the Summary Plan Description (SPD) available at
www.dch.georgia.gov/shbp_plans to determine which option may best suit your healthcare needs. You may contact the Retiree Helpline at 877-246-4190 to obtain rates. Call each Plan Option or go to the vendor website to see in which Options your physician or provider participates. Check which Tier 1, 2 and 3 co-payments will apply to your prescription drugs on each Plan Option. You may make your elections online. See page 3 for instructions OR you may complete your Personalized Change Form (PCF) and mail the form in the enclosed envelope to State Health Benefit Plan, P. O. Box 347069, Atlanta, GA 30334. Note your envelope must be postmarked by November 9, 2006 for your SHBP election to be valid. Any forms postmarked after November 9, 2006 will not be processed (note: no exceptions). DO NOT RETURN THIS FORM IF YOU MAKE YOUR ELECTION ONLINE OR DO NOT CHANGE YOUR BENEFIT ELECTION.
Reminders You should submit eligibility verification documents timely for all dependents
when requested by SHBP. You should verify that the correct health deduction is taken from each
retirement check if you receive an annuity. Be sure that your address is kept current. All retiree communications from
SHBP are through U.S. mail. If you are enrolled in Medicare and have not submitted a copy of your card or
cards to SHBP, please do so immediately.
Online ROCP

Follow these Steps to Make Your On-line ROCP Selections:
1. Go to www.oe2007.ga.gov. You will have to "Register" the first time you logon. Click on Register and enter your Policy Number and Date of Birth. Select a Password and enter the Password, re-enter the Password to confirm, select a security question and answer your security answer. You then click on "Register". This will take you to the "Login" screen. Here you will enter your Policy Number, Password and then click on "Login". This will take you to the Terms of Use. After you scroll to the bottom, click and agree to the authorization...then click on agree, your current health benefit election will appear. If you have technical difficulty in logging in, contact the Help Desk toll free at 1-866-676-0009.
2. Your 2006 Health Benefit election and covered dependents will be listed. Make any necessary changes.
3. Prior to confirming your benefits, review to make sure your benefit election and covered dependents are correct. If your selection is not correct, go back and make changes. You may return to the website as often as you wish during the Retiree Option Change Period to make changes.
4. Print your confirmation notice or write down the confirmation number to confirm your enrollment. Each time you login the system and confirm your choices, you will receive a new unique confirmation number which you should print or write down and keep. The benefit selected and confirmed as of 4:00 p.m. November 9, 2006 will be your benefit selection for the 2007 Plan Year.
What Happens if I don't Go On-line or Return the PCH to SBHP?
You will retain the same coverage option and tier (single or family) you currently have.
health tip:
Kick the smoking habit. Many serious health risks are associated with smoking, including heart disease and elevated blood pressure.
Consider a tobacco use cessation program.
Online ROCP

What's Changing for 2007?

What's Changing for 2007?

There will be no increase in health premiums and no changes in benefits. As in prior years, premiums are subject to change when you become eligible for Medicare. See page 7 for more information.
Vendor Updates and Eligibility Changes for 2007
Kaiser Permanente will be adding a new medical center in West Cobb at the East/ West Connector in early 2007.
Kaiser Senior Advantage has added Barrow, Bartow, Butts, Hall, Newton, Rockdale, Spalding, Walton and all of Paulding County. (This option is offered to retirees with Medicare Parts A and B and who reside in one of the counties listed on page 17 only).
BlueChoice has added Catoosa, Chattahoochee, Habersham, Heard, Jasper, Murray, Putnam, Rabun, Stewart, Towns, Washington, and Whitfield counties to their service area and removed Taliaferro.
United Healthcare has added all acute care hospitals in the State of Georgia in the PPO network.
When you add a dependent and the Plan requests dependent verification documentation, you must submit the documentation requested by the Plan in order to cover the dependent. If you fail to provide dependent verification documentation on a timely basis, the dependent will not be eligible for coverage unless a Qualifying Event occurs.
When all covered dependents lose eligibility for coverage, the SHBP will automatically decrease the coverage tier to Employee Only under the member's current health benefit option. Loss of all covered dependents may be through divorce, death, legal separation, an only covered dependent exceeding the maximum age of eligibility, an only covered dependent no longer meeting fulltime student requirements, marriage of an only covered dependent child, or a Qualified Medical Child Support Order (QMCSO) requiring a former spouse to provide health coverage for all covered natural children.
Full-time students whose verification documentation is not submitted timely will not be eligible for coverage unless a Qualifying Event occurs. This means that you will need to submit full-time student verification before coverage ends at age 19 and each subsequent year to keep the student's eligibility active. If you allow the student's coverage to lapse because verification documentation is submitted late, you will not be able to add the student to your coverage. Recertification must be received before the coverage expiration date.
Qualifying Event to request the addition of an eligible dependent, submission of the request to SHBP must be made within 31 days prior to or after the Qualifying Event. (i.e. newborns, marriage, etc.)
Documentation you have 31 days from the date of the Qualifying Event or the date of the request for coverage, whichever is later, to provide Qualifying Event documentation and/or dependent verification documentation.
Member contributions not remitted to the Plan by the due date may result in suspension and/or termination of coverage.
SHBP will provide members with additional information on these eligibility changes prior to implementation.

State Health Benefit Plan (SHBP) Eligibility

All SHBP Options have the same eligibility requirements except the TRICARE Supplement. See page 16, 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 Full-time 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 have 31 days prior to or after a Qualifying Event to make a request. 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. You will have 31 days from the Qualifying Event or the date of the request for coverage, whichever is later, to provide Qualifying Event documentation and/ or dependent verification. 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.
* T RICARE 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.

health tip:
Keep your body moving. Exercise is important for a healthy heart. Aerobic exercise such as walking, bicycling or swimming is great for your heart.

SHBP Eligibility

Making Changes When You Have a Qualifying Event
The option choice you make during the ROCP will stay in effect through December 31, 2007, 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 the change 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. 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.
COBRA and the TRICARE Supplement
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.
SHBP Eligibility

State Health Benefit Plan Medicare Policy
Georgia law requires that SHBP pay benefits after Medicare has paid.
SHBP will calculate premiums and claim payments based upon Medicare enrollment for retirees over 65 or those eligible for Medicare due to disability.
Premiums will be based on the Parts of Medicare (A, B, or D) that you have. There will be no adjustments in premiums because you have other coverage such as TRICARE, VA or other group coverage since SHBP may have potential primary liability.
SHBP will coordinate benefits for members who are enrolled in Medicare A, B or D.
SHBP will pay primary benefits on members not eligible or not enrolled in Medicare, but you will pay a higher premium.
If you enroll in Medicare (A, B, or D), please send a copy of your Medicare cards by the first of the month in which you are eligible for Medicare. Premiums cannot be reduced until copies of your Medicare cards are received and the change in premium is processed by the retirement system. Delay in submission of Medicare information does not qualify for a refund of the difference in premiums.
Medicare information is available at:
www.cms.hhs.gov/medicarereform
www.medicare.gov
www.ssa.gov
1-800-669-8387 (Georgia Cares)
1-800-633-4227 (Medicare)
Medicare Part D Information
If you are not enrolled in Medicare Part D, you may enroll during the Medicare annual open enrollment, November 15 December 31, 2006. This open enrollment is held by the Centers for Medicare and Medicaid (CMS) and not by SHBP. In many cases, you do not need the enhanced prescription drug plan. Your individual pharmacy needs will indicate the level of coverage that is best for you.
Coordination of Pharmacy Benefits between your PDP and SHBP Each time you go to the pharmacy, present both your Medicare Part D and
SHBP identification cards.
When Medicare coordination of benefits occurs, you should not be responsible for more than your SHBP co-payment for eligible charges.
When you reach the PDP coverage gap, you should still present both identification cards and you will pay your SHBP co-payment.
Example: Drug costs $100 and the PDP has a $250 deductible. The PDP will apply the $100 toward your Medicare Part D deductible. The $100 will then be filed with SHBP as a Tier 2 drug with a $30 co-payment. The SHBP will consider their contracted rate of $100 and subtract what Medicare has paid

SHBP Medicare

$0. The SHBP member will pay their $30 co-payment and SHBP will pay the $70 balance. Your $30 out of pocket expense will be applied to your Medicare TROOP.
Kaiser Permanente offers a Medicare Advantage Plan with Part D (MAPD Plan). This option is offered only to retirees who are enrolled in Medicare Part A and or B and who live in the Kaiser Permanente service area. If you choose the Senior Advantage Plan, you do not have to enroll in a stand-alone Medicare Prescription Drug Plan. If you currently have an existing Part D Plan and enroll in the Senior Advantage, Medicare will automatically cancel your existing Part D Plan. Senior Advantage is a MAPD Plan, which will fulfill your Part D obligation with SHBP. Your prescription coverage (PDP) will be creditable with flat co-pays. See the benefit design on page 17.
Note if you are eligible for TRICARE, you may enroll in the Tricare Supplement. If you choose the Tricare Supplement, you do not have to enroll in a Medicare PDP to avoid an increase in your premiums.
Health & Wellness
The Health Plans offer education on healthy living initiatives. The goal is to provide enhanced information, tools, and support to promote your healthy lifestyle and meet your healthcare needs. Please refer to your Health Plan Option for details on programs offered. Personal Health Assessments each vendor has a Personal Health Assessment
Questionnaire available on their website that you can complete. This information is kept confidential and will indicate potential health risks. The vendor may contact you regarding steps you can take to control or eliminate this risk or tests you may want to consider. Health Management Services each vendor offers assistance with healthcare services such as disease management, case management and behavioral health. Please refer to your Health Plan Option for additional details on programs offered. Nurse Advice Line each vendor has a 24-hour, seven days a week (including holidays) Nurse Advice Line that is available to assist you in making informed decisions about your health. You can call for professional medical advice regarding medical situations. Check with your Health Plan Option for the telephone number.
SHBP Wellness Information

Wellness Tips

BlueChoice HMO
Our 360 Health program surrounds you and your family with personalized support to help you achieve and maintain your highest potential for good health. The following are descriptions of some of the programs available to you. Find out more about the programs available to you through 360 Health, by accessing www.bcbsga.com or contacting the customer service at (800) 464-1367.
Discounts on wellness products, vision services, alternative practitioners and fitness clubs.
Healthy Living, powered by webMD, a vast resource center that allows you to take part in online programs and access news and health information.
BlueChoice On-Call your toll free, 24/7 connection to a registered nurse as well as to recorded information on over 400 health-related topics
Baby Connection includes nurses to guide expectant mothers through their pregnancy.
Condition Management, a coordinated system that provides tailored assistance for individuals who have or are at risk for a specific chronic illness or medical conditions like asthma, diabetes, chronic obstructive pulmonary disease, coronary artery disease and heart failure. Highly personalized to address your specific health needs and lifestyle challenges.

CIGNA
CIGNA HealthCare's Healthy Rewards program can save members up to 60 percent on a range of complementary and alternative care services and products. The discounts apply whenever you use Healthy Rewards participating providers. No referral. No claim. No catch.
Some of the rewards you can enjoy include: Acupuncture Chiropractic Care Online Health & Beauty Products Fitness Club Memberships Hearing Care Laser Vision Correction Massage Therapy Natural Supplements Tobacco Cessation Weight Management Vision Care
If good health is its own reward, consider Healthy Rewards a well-deserved bonus.

health tip:
Caring for your mind, as well as your body is good for overall health and key to your success at home, at work and at school.

SHBP Wellness Information

health tip:
If you have diabetes, it is important to take care of yourself every day by taking your medications as prescribed and following a dietary and exercise plan outlined by your doctor.

Kaiser Permanente
Kaiser Permanente members have access to a wide variety of programs, classes, discounts, online tools, and other resources to help them stay healthy and take an active role in their own health mind, body, and spirit.* Some of these include: Health coaches at no cost 24-hours a day, 7 days a week through Healthy
Solutions.
Discounts on health clubs, Weight Watchers, 10,000 Steps Walking Program, complementary health products, and more.
Discounts on vision care, LASIK, chiropractic care, acupuncture, acupressure, and massage therapy.
Free or low-cost health classes including yoga, tai chi, stress reduction, nutrition, and many others.
Free online Total Health Assessment program that gives an in-depth health evaluation and a completely personalized action plan.
Customized online programs to help lose weight, eat healthy, reduce stress, or quit smoking.
Online health and drug encyclopedias, featured health topics, and other selfhelp resources.
Secure 24-hour access to parts of their health record online at kp.org, including the ability to e-mail a Kaiser doctor's office, view certain lab results, review past office visit information, monitor their ongoing health conditions, and more.**
Online message boards to discuss health topics and get support.
Free HealthWise Handbook self-help guide for many common health problems.
To learn more, visit members.kp.org or call (404) 261-2590.
* Available to Kaiser Permanente members and their families. Discounts and services are provided on a fee-for-service basis, do not replace and cannot be combined with any existing benefit, and are not covered benefits. Kaiser Permanente assumes no responsibility for the arrangement, nature, quality, or outcome of the services. **Available to members receiving care at Kaiser Permanente Medical Centers.

10 SHBP Wellness Information

United Healthcare
With United Healthcare, you will enjoy the benefits of the United Healthwellness package of wellness programs, services and valuable health and well-being discounts. These programs and services are designed to complement your medical benefits plan by giving you more options to improve your and your family's total health and well-being, all at no additional cost to you! United Healthwellness provides you with a multitude of options to improve your health including: The Health Assessment Survey, this online health survey helps individuals
assess their overall current state of health. After completion of the health assessment, individuals receive an immediate personalized report with their results and health improvement suggestions. Online Health Improvement Programs, this health improvement tool includes 10 six-week interactive online programs to help individuals make lifestyle changes and achieve health objectives in key targeted areas, including fitness, weight loss, nutrition, stress, smoking cessation, and more. The Total Well-Being Program, this online program helps individuals achieve a healthy and balanced lifestyle, addressing the five areas of total well-being: Physical, Intellectual, Social, Spiritual and Emotional. This is accomplished with online, personalized wellness tools, educational materials, and discounted wellness products including fitness club and weight loss center discounts. The Health Value Program, this discount program provides 10-50 percent savings on many healthcare services not covered under an individual's medical, dental or vision plan. Healthy Pregnancy Program, this program is designed to provide personal support through all stages of pregnancy and delivery. The program includes two assessments to identify special needs and identification of risk factors, a 24hour toll-free line to experienced maternity nurses, and customized newsletters and educational materials. Personal Health Manager, this flexible, confidential online program designed to help individuals manage their health information, such as conditions, medical contacts, and doctor visits.
SHBP Wellness Information 11

Understanding Your Plan Options
To maximize your health benefits, it is important to fully understand how each of the SHBP options work. 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.
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.
PPO Options
The PPO options offer you a network of more than 13,000 Georgia participating physicians and all acute care Georgia hospitals through United Healthcare PPO network. 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. All benefit appeals should be directed to United Healthcare. A PPO Consumer Choice Option (CCO) is also available (see page 13 for more details). To view the list of PPO providers and benefit video, visit www.myuhc.com/ groups/gdch, or call 1-877-246-4189.
HMO Options
HMO options are available to SHBP-eligible retirees who live in the county or surrounding counties in which an HMO is offered. You may be required to drive some distance if you select a provider practicing in another county.
HMOs provide 100% benefit coverage for preventive health care needs after paying applicable co-payments. 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%. Co-payment amounts are excluded from the annual out-of-pocket maximum.
Diagnostic testing and lab services performed at independent radiology and lab offices located in the Kaiser facilities are subject to deductible and co-insurance.
12 Understanding Your Plan Options

In most HMOs, you are responsible for selecting a Primary Care Physician (PCP) from a list of participating providers (see note). When you use a provider other than your PCP, your PCP must provide a referral for your expenses to be covered (except in life threatening emergencies and other limited cases). If you receive care from a provider other than your PCP, without your PCP's referral, there is no coverage even if the physician or facility is in the HMO network. Note: United Healthcare Choice HMO does not require you to select a PCP or obtain referrals to see specialists. All benefit appeals should be directed to your HMO Option. An HMO Consumer Choice Option (CCO) is also available.
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.
Understanding Your Plan Options 13

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 non-participating 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. All benefit appeals should be directed to United Healthcare.
High Deductible Health Plan
The High Deductible Health Plan (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 has the following differences from the other plan options: Your monthly insurance premiums are lower You have a higher deductible that applies to everything except the first
$500 in preventive care expenses. If you have family coverage, you must meet the family deductible before benefits are payable for any family member. You pay coinsurance after you have satisfied the deductible rather than set dollar co-payments for network office visits and prescription drugs. If you are not enrolled in Medicare, you may qualify to start a Health Savings Account (HSA) for yourself 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.
14 Understanding Your Plan Options

Your Health Savings Account (HSA) Opportunity
An HSA is like a personal savings account for healthcare, except it's all tax-free. You can open an HSA with an independent HSA administrator/custodian.
You may only open an HSA if you enroll in the SHBP HDHP and do not have other coverage through your spouse's employer's plan, Medicare, Medicaid, an Health Care Spending Account (HCSA) or any other non-qualified medical plan.
HSA Highlights

What you can contribute each year
What happens at the end of the year What happens if you don't enroll in an HDHP next year
When is money available

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 an HDHP (Note these amounts may be indexed based on federal cost of living factors.)
Unused money in your account carries forward and continues to earn interest.
You can no longer contribute to your HSA, but you keep the account and can continue to use the balance for eligible healthcare expenses
Money is available only if actually in your account

While funds in the HSA are not subject to forfeitures and can be carried over from year to year, the HSA may not be right for all retirees in a HDHP. Please read the HSA information carefully so that you understand the benefits as well as the limitations.
See pages 26 and 27 for more detail on the HDHP and the opportunity it provides to enroll in an HSA. See the Benefits Comparison chart that starts on page 18 for more information about how the plan covers specific expenses.

health tip:
Did you know that no single fruit or vegetable provides all of the nutrients needed to be healthy? The key lies in choosing a colorful variety of fruits and vegetables.

Understanding Your Plan Options 15

TRICARE Supplement for Eligible Military Members
The TRICARE Supplement Insurance is offered to retirees 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.
If you decide you prefer another option, you can change during future Retiree Option Change Periods.
If you enroll in the 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, 2007.
You do not have to enroll in Medicare Part D if you are enrolled in the TRICARE Supplement.
Dependents
To cover a child past age 19, your child must be a full-time student.
You may cover your full-time student from age 19-23 under the TRICARE Supplement.
To cover your full-time student from age 23-26, you must select another SHBP option during the ROCP prior to your child reaching age 23.
Your child must meet State Health Benefit Plan and TRICARE eligibility requirements. Contact TRICARE for their eligibility requirements.
See page 6 for COBRA information.
What Happens at Age 65
When you and/or your spouse are ineligible for Medicare, the 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 the TRICARE Supplement.
When you and/or your spouse are eligible for Medicare, Medicare will be your primary insurance, TRICARE for Life secondary, and the 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 SHBP option during the ROCP 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.
16 Understanding Your Plan Options

Medicare Advantage Plan with Part D (MAPD) Option

The name of the Medicare Option offered by Kaiser Permanente is Senior Advantage.

Kaiser's Senior Advantage Option is available only to those retirees who are enrolled in Medicare Part A or Part B and who live in the Kaiser Permanente service area. See chart below for a listing of counties serviced by the Kaiser Permanente Senior Advantage.

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.
The benefits available through the Kaiser Permanente Senior Advantage Plan are similar to that of the regular HMO.
You must use providers in the Kaiser Permanente Senior Advantage 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 Senior Advantage, you must complete the Kaiser Permanente Senior Advantage CMS enrollment application form. Please call Kaiser Permanente at 404-233-3700 or 800-956-1358 to obtain your enrollment materials, complete and mail back to Kaiser.
Check the Kaiser Permanente Senior Advantage option on your personalized change form and return to SHBP during the ROCP.

Kaiser Permanente Senior Advantage Coverage by County

The following Georgia counties are covered by Kaiser Permanente Senior Advantage Plan:

Barrow

DeKalb

Henry

Bartow Butts Cherokee

Douglas Fayette Forsyth

Newton Paulding Rockdale

Clayton

Fulton

Spalding

Cobb Coweta

Gwinnett Hall

Walton

Understanding Your Plan Options 17

Benefits Comparison: PPO, Indemnity, HDHP and HMO Options

Schedule of Benefits for You and Your Dependents for January 1, 2007 December 31, 2007
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

Dollar amounts, visit limitations, deductibles and out-of-pocket limits are based on a January 1December 31, 2007 Plan Year.

NOTE: Coverage is defined as allowed eligible expenses.

PPO OPTION

In-Network

Out-of-Network

INDEMNITY

The Plan Pays:

The Plan Pays:

$2 million

$2 million

$1,000

$1,000

$1,100 3 episodes

$1,100 3 episodes

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

$500 $1,500
$1,100 $2,200

$600 $1,800
$250
$2,200 $4,400

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

60% of coverage; subject to deductible

$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)
Maternity Care (prenatal, delivery and postpartum)
18 Benefits Comparison

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.

90% of coverage; not

60% of coverage;

subject to deductible after subject to deductible

initial $30 co-payment

90% of coverage; subject to deductible

Don't forget the TRICARE Supplement Option (see page 16 for more information)

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, UnitedHealthcare
The Plan Pays:
$2 million

HMO Plan Differences
Kaiser Permanente SA unlimited

None

$1,100 3 episodes

$1,100 $2,200*

$2,200 $4,400*

*You must meet the family deductible before benefits are payable for any family member.

Not applicable

$1,700 $2,900

$3,800 $7,000

No separate lifetime benefit limit
$200 $400
Not applicable
$1,000 $2,000

Kaiser Permanente SA $1,000 individual, $2,000 per 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.

60% of coverage; subject to deductible
Not covered, charges do not apply to deductible or annual out-ofpocket limits.

100% after a per visit copayment** of $20 for primary care and $25 for specialty care
100% after a per visit copayment of $20 for primary care and $25 for specialty care. No co-payment for immunizations and mammograms.

**Includes lab and x-rays done in the physician's office. Kaiser: lab and x-rays may be subject to deductible

90% of coverage; subject to deductible

60% of coverage; subject to deductible

100% after initial $25 co-payment

Chart continued pg. 20
Benefits Comparison 19

Physicians' Services
Physician Services Furnished in a Hospital
Surgery in general, including charges by surgeon, anesthesiologist, pathologist and radiologist
Physician Services for Emergency Care Non-emergency use of the emergency room not covered.
Outpatient Surgery-- When billed as office visit

PPO 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; subject to deductible

90% of coverage; subject to in-network deductible
60% of coverage; subject to deductible

When billed as outpatient surgery at a facility
Allergy Shots and Serum
Hospital Services Inpatient Services Inpatient care, delivery and
inpatient short-term acute rehabilitation services Well-newborn care

90% of coverage; subject to deductible
100% for shots and serum; $30 per visit co-payment not subject to deductible (no copayment if office visit not billed)
90% of coverage; subject to a $250 per admission deductible
100% of coverage; not subject to deductible

Outpatient Surgery-- Hospital/Facility

90% of coverage; subject to deductible

Emergency Care-- Hospital/Facility
Treatment of an emergency medical condition or injury
Non-emergency use of the emergency room not covered.

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 deductible
60% of coverage; subject to deductible
60% of coverage; subject to a $250 per admission deductible
60% of coverage; subject to a $250 per admission deductible 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

INDEMNITY
The Plan Pays:
90% 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 deductible
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

20 Benefits Comparison

Don't forget the TRICARE Supplement Option (see page 16 for more information)

HIGH DEDUCTIBLE OPTION

In-Network

Out-of-Network

The Plan Pays:

90% of coverage; subject to deductible

60% of coverage; subject to deductible

HMO OPTIONS
BlueChoice, CIGNA, Kaiser Permanente, UnitedHealthcare
The Plan Pays:

HMO Plan Differences

90% 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 deductible
90% of coverage; subject to deductible

60% 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. Applies to all plan options.
Kaiser Permanente 90% of coverage; subject to deductible
Kaiser Permanente $5 for shots and $50 for a six-month supply of serum. United Healthcare no co-pay if office visit not billed.

90% 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
90% of coverage; subject to deductible
90% 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. Applies to all plan options.

90% of coverage; subject to deductible

60% of coverage; subject to deductible

90% of coverage; subject to deductible

Kaiser Permanente lab and x-rays may be subject to deductible. United Healthcare independent lab/x-ray are payable at 100%.
Chart continued pg. 22
Benefits Comparison 21

Behavioral Health
Mental Health and Substance Abuse Inpatient Facility NOTE: All services require prior authorization.

PPO OPTION

In-Network

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

INDEMNITY
The Plan Pays: 90% of coverage; subject to deductible limited to 45 days combined per Plan Year

Partial Day Hospitalization and Intensive Outpatient NOTE: Notification Required.

90% of coverage; subject to deductible limited to 60 days combined per Plan Year

No benefit

90% of coverage; subject to deductible limited to 60 days combined per Plan Year

Professional Charges Inpatient

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 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.
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
Other Coverage Ambulance Services for Emergency Care
NOTE: "Land or air ambulance" to nearest facility to treat the condition.

90% of coverage; subject to deductible, limited to 50 visits per Plan Year (the 50 visit limit includes any outof-network visits)

60% of coverage; subject to deductible; limited to 25 visits per Plan Year (not to exceed a total of 50 visits combined)

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

90% of coverage; subject to deductible

90% of coverage; subject to deductible; limited to 50 visits per Plan Year
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

22 Benefits Comparison

Don't forget the TRICARE Supplement Option (see page 16 for more information)

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

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

HMO OPTIONS
BlueChoice, CIGNA, Kaiser Permanente, 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
Kaiser Permanente SA 90% of coverage; subject to deductible and unlimited days for mental health, substance abuse and detoxification.

90% of coverage; not subject to deductible

Kaiser Permanente 90% of coverage; subject to deductible

100% after $25 per visit co-payment; limited to 25 visits combined per Plan Year

Kaiser Permanente $25 copayment, 100% coverage, unlimited visits, Mental Health and Detoxification; limited to 25 visits for substance abuse
Kaiser Permanente SA 100% after $25 co-payment. Unlimited visits for mental health, substance abuse and detoxification.

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.

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

100% after applicable copayment for related surgery and diagnostic services; excludes appliances and orthodontic treatment; if inpatient/outpatient facility, 90% subject to deductible

KaiseNr oPermanente 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
Benefits Comparison 23

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

PPO OPTION

In-Network

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 @ 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

90% of coverage; subject to deductible

60% of coverage; subject to deductible

Outpatient Acute Short-Term Rehabilitation Services
Chiropractic Care NOTE: Coverage for up to a maximum of 20 visits per Plan Year

90% of coverage; subject to deductible and $20 per visit co-payment up to 40 visits per Plan Year (not to exceed a total of 40 visits combined, including any out-ofnetwork visits)

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

90% of coverage; after a $30 per visit co-payment; not subject to deductible

60% of coverage; subject to deductible

Transplant Services NOTE: Prior approval required
Pharmacy Tier 1 Co-payment

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

Tier 2 Co-payment

$30

$30*

$30

Tier 3 Co-payment

$100

$100*

$100

*Member must pay full charges at point of sale and submit a paper claim. Members will be reimbursed at the pharmacy network rate less the required co-payment for covered drugs. Member is responsible for charges that exceed the pharmacy network rate.

24 Benefits Comparison

Don't forget the TRICARE Supplement Option (see page 16 for more information)

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

60% of coverage; subject to deductible

90% of coverage up to 40 visits per Plan Year; subject to deductible

60% of coverage up to 40 visits per Plan Year; subject to deductible

HMO OPTIONS
BlueChoice, CIGNA, Kaiser Permanente, 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

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 SA up to 100 days per Plan Year; subject to deductible.
CIGNA 90% of coverage; subject to deductible; outpatient 100% not subject to deductible
United Healthcare notification required for items over $1,000
Kaiser Permanente SA unlimited visits

90% of coverage; subject to deductible
90% of coverage; subject to deductible at contracted transplant facility
80% of coverage; subject to deductible $10 min./$100 max.
80% of coverage; subject to deductible $10 min./$100 max.
80% of coverage; subject to deductible $10 min./$100 max.

60% of coverage; subject to deductible Not covered
Not covered Not covered Not covered

100% of coverage after $25 co-payment per visit
No
90% of coverage; subject to deductible

$10

Kaiser Permanente

Kaiser facility: $10

Network Pharmacies: $16

$25

Kaiser Permanente

Kaiser facility: $25

Network Pharmacies: $31

$50

Kaiser Permanente

N/A

Benefits Comparison 25

Important Plan Considerations

Important PPO and Indemnity Considerations
See the Summary Plan Description for coverage details, including limitations and exclusions.
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.
A change to the provider network is not a qualifying event and the member may not change Plan options.
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 innetwork 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.

If you should go to the pharmacy and are told that your prescription cannot be filled because it requires prior authorization, please have your doctor call the pharmacy benefit manager with your clinical information.

health tip: High Deductible Health Plan/HSA Considerations

Are there specific factors that contribute to
your health? Are they hereditary? Are they controllable? You can find out by taking a Health Risk Assessment (information will be kept confidential) on your Health Option's website. Through the assessment, you will learn what to do to gain better control of your health and
well-being.

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 also reflects the importance of preventive care, with a $500 annual benefit with no deductible.
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.
Deductibles:
The deductible applies to everything except the first $500 in preventive care expenses. If you have family coverage, you must meet the family deductible before benefits are payable for any family member.
With the HDHP, you pay coinsurance after the deductible for in-network office visits and prescription drugs.
See the Summary Plan Description on the web, www.dch.georgia.gov/shbp_plans for coverage details, including limitations and exclusions.
In return for lower monthly health premiums, you have a higher deductible and if you have family coverage, you must meet the family deductible before benefits are payable for any family member.
You pay coinsurance after the deductible for in-network office visits and prescription drugs.

26 Important Plan Considerations

If you are 55 or older, you may contribute additional dollars up to $700 a year as "catch-up" contributions.
Contributions can be made through deposits you or someone else make directly to the HSA.
HSA dollars can be used to pay for healthcare expenses (medical, dental, vision, over-the-counter medications) the IRS considers tax-deductible that are not covered by any healthcare plan (see IRS Publication 502 at www.irs.gov).
Claims payments vary 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
At year-end, unused money in your account carries forward and continues to earn interest.
HSA administrators typically charge a monthly maintenance fee and sometimes, additional transaction fees.
HSAs typically earn interest and there are investment options once a pre-defined threshold is reached.
HSA accounts can not be combined with a general purpose spending account. HSA accounts can be combined with a limited purpose spending account, if offered. HSA dollars are not available unless the money is in your account. If covered by Medicare, you are not eligible to contribute to an HSA.
Important HMO Considerations
Distance to the nearest physician's office or hospital (If you enroll in an HMO offered in another county, you may have to drive a distance to see your doctor or to go to a participating hospital).
A change in the provider network is not a qualifying event and the member may not change Plan options.
To be covered, you must see an in-network provider unless there is a life threatening emergency.
Verify provider participation before selecting an HMO Option. Some services may require prior authorization by the HMO to be 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. If you do not select a PCP, the HMO will assign you a PCP located near your residence. 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.
Important Plan Considerations 27

Notes Apply to All Options:

health tip:
Did you know that regular visits to the dentist may do more than brighten your smile? Research has linked periodontal (gum) disease to complications such as stroke, diabetes, pre-term birth and other health issues.

Pharmacy:
Pharmacy Benefit Drug Co-payments are based on a three (3) Tier system. Tier One (1) represents the lowest co-payment, Tier Two (2) the middle copayment, and Tier Three (3) the highest co-payment. The HDHP drug benefit is subject to co-insurance.
The Tier your drug is in is subject to change. Prior to purchasing your medication(s), PPO and Indemnity members may view the drug lists at www.dch.georgia.gov/shbp_plans or contact the pharmacy benefit manager at 1877-650-9342 or TDD 1-800-842-5754.
HMO members may contact the HMO option in which they are enrolled for information about covered drugs.
Many drugs listed as Tier 3 have a Tier 1 or a Tier 2 alternative.Tier 1 & 2 drug alternatives are therapeutically equivalent while being more cost effective.
If the drug cost is less than the co-payment, you do not have to pay the copayment 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 Choice HMO members may receive a 90-day supply of maintenance prescriptions for two copayments. HDHP members may obtain up to a 90-day supply by paying the 60-day co-insurance amount. 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. HDHP members may receive a 31-day supply by paying 20% after satisfying the $1,100 deductible with a $10 minimum/$100 maximum per prescription.
Other:
Annual dollar and visit limitations, deductibles and out-of-pocket spending limits are based on January 1, 2007 to December 31, 2007.
Lifetime benefit maximums are combined totals among the PPO Options, Indemnity, HDHP Option and HMO Options.
Contact each plan directly for more details regarding covered services, exclusions and limitations.

28 Important Plan Considerations

Two Peachtree Street Atlanta, GA 30303 (404) 656-6322 (800) 610-1863
Important Notice from the SHBP

October 1, 2006

About Your Prescription Drug Coverage with PPO, Indemnity, CIGNA, United Healthcare Choice HMO, Kaiser Permanente, BlueChoice, TRICARE Supplement Plan and Medicare
For Plan Year: January 1 December 31, 2007
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 prescription drug coverage available for people with Medicare. It also explains the options you have under Medicare prescription drug coverage and can help you decide whether or not you want to enroll. At the end of this notice is information about where you can get help to make decisions about your prescription drug coverage.
1 Medicare prescription drug coverage became available in 2006 to everyone with Medicare
through Medicare prescription drug plans and Medicare Advantage Plans that offer prescription drug coverage. All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.
2 The State Health Benefit Plan (SHBP) 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 and is considered Creditable Coverage.
Because your existing coverage is on average at least as good as the standard Medicare prescription drug coverage, you can keep your SHBP coverage and not pay extra for Part D (if you later decide) to enroll in Medicare prescription drug coverage.
Individuals can enroll in a Medicare prescription drug plan when they first become eligible for Medicare and each year from November 15th through December 31st. Beneficiaries losing their SHBP coverage may be eligible for a Special Enrollment Period to sign up for a Medicare prescription drug plan.
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.
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 benefits if you choose to enroll in a Medicare prescription drug plan. If you keep your SHBP coverage and elect Part D, SHBP will coordinate with Part D coverage. If you do decide to enroll in a Medicare prescription drug plan and drop your coverage with the State Health Benefit Plan, be aware that you and your dependents will not be able to get this coverage back if you are a retiree.

Prescription Drug Coverage and Medicare 29

Please contact us for more information about what happens to your coverage if you enroll in a Medicare prescription drug plan.
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 (a penalty) to enroll in Medicare prescription drug coverage later.
If you go 63 days or longer without prescription drug coverage that's at least as good as Medicare's prescription drug coverage, your Medicare Part D monthly premium will go up at least 1% per month for every month that you did not have that coverage. For example, if you go nineteen months without coverage, your premium will always be at least 19% higher than what many other people pay. You'll have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to enroll.
For more information about this notice or your current prescription drug coverage...
Contact our office for further information; call SHBP Eligibility Unit at (404) 656-6322 or (800) 610-1863. NOTE: You will receive this notice annually and at other times in the future such as before the next period you can enroll in Medicare prescription drug coverage, and if this coverage through SHBP 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 is in the "Medicare & You" handbook. You'll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare prescription drug plans. For more information about Medicare prescription drug plans:
Visit www.medicare.gov
Call your State Health Insurance Assistance Program (see your copy of the Medicare & You handbook for their telephone number) for personalized help, or
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 Medicare prescription drug coverage is available. Information about this extra help is available from the Social Security Administration (SSA) online at www.socialsecurity.gov, or you call them at 1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this notice. If you enroll in one of the new plans approved by Medicare which offer prescription drug coverage, you may be required to provide a copy of this notice when you join to show that you are not required to pay a higher premium amount.
Date: October 1, 2006 Name of Entity/Sender: State Health Benefit Plan Contact: Eligibility Unit Address: Two Peachtree Street,
Atlanta, GA 30303 Phone Number: (404) 656-6322 or (800) 610-1863
30 Prescription Drug Coverage and Medicare

Two Peachtree Street Atlanta, GA 30303 (404) 656-6322 (800) 610-1863
Important Notice from the SHBP

October 1, 2006

About Your High Deductible Health Plan Prescription Drug Coverage and Medicare
For Plan Year: January 1 December 31, 2007
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 prescription drug coverage available for people with Medicare. It also explains the options you have under Medicare prescription drug coverage, and can help you decide whether or not you want to enroll. At the end of this notice is information about where you can get help to make decisions about your prescription drug coverage.
1 Medicare prescription drug coverage became available to everyone with Medicare through
Medicare prescription drug plans and Medicare Advantage Plans that offer prescription drug coverage in 2006. All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.
2 The SHBP has determined that the prescription drug coverage offered under the High
Deductible Health Plan (HDHP) is, on average for all plan participants, NOT expected to pay out as much as the standard Medicare prescription drug coverage will pay and is considered Non-Creditable Coverage. This is important, because for most people enrolled in the HDHP under the SHBP enrolling in Medicare prescription drug coverage means you will get more assistance with drug costs than if you had prescription drug coverage exclusively through the HDHP under the SHBP.
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 notice carefully it explains your options.
Consider enrolling in Medicare prescription drug coverage
Because the coverage you have with the HDHP is on average for all plan participants, NOT expected to pay out as much as the standard Medicare prescription drug coverage will pay, consider enrolling in a Medicare prescription drug plan. Individual's can enroll in a Medicare prescription drug plan when they first become eligible for Medicare and each year from November 15th through December 31st. Beneficiaries losing SHBP coverage may be eligible for a Special Enrollment Period to sign up for a Medicare prescription drug plan.
This may mean that you will have to wait to enroll in Medicare prescription drug coverage and that you may pay a higher premium (a penalty) if you join Medicare Part D later, you will pay that higher premium as long as you have Medicare prescription drug coverage.

HDHP Prescription Drug Coverage and Medicare 31

If you go 63 days or longer without prescription drug coverage that is at least as good as Medicare's prescription drug coverage, your Medicare Part D premium will go up at least 1% 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 nineteen months without coverage, your premium will always be at least 19% higher than what many other people pay.

You Need to Make a Decision
When you make your decision, you should also 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.

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 benefits if you choose to enroll in a Medicare prescription drug plan. If you keep your SHBP coverage and elect Part D, SHBP will coordinate with Part D coverage. If you are a retiree and decide to enroll in a Medicare prescription drug plan and drop your coverage with the SHBP, be aware that you and your dependents will not be able to get this coverage back.

For more information about this notice or your current prescription drug coverage...
Contact our office for further information or call the SHBP Eligibility Unit at (404) 656-6322 or (800) 610-1863. NOTE: You will receive this notice annually and at other times in the future, such as before the next period you can enroll in Medicare prescription drug coverage, and if this coverage through the High Deductible Health Plan 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 is in the Medicare & You handbook from Medicare. You'll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare-approved prescription drug plans. For more information about Medicare prescription drug plans:
Visit www.medicare.gov
Call your State Health Insurance Assistance Program (see your copy of the Medicare & You handbook for their telephone number) for personalized help,
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 Medicare prescription drug coverage is available. Information about this extra help is available from the Social Security Administration (SSA) online at www.socialsecurity.gov, or you call them at 1-800-772-1213 (TTY 1-800-325-0778).



Date: October 1, 2006 Name of Entity/Sender: State Health Benefit Plan Contact: Eligibility Unit Address: Two Peachtree Street,
Atlanta, GA 30303 Phone Number: (404) 656-6322 or (800) 610-1863

32 HDHP Prescription Drug Coverage and Medicare

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 preexisting condition limitation does not apply to coverage for:
Pregnancy; or
Newborns or children under age 18 who are adopted or placed for adoption, if the child becomes covered within 31 days after birth, adoption or placement for adoption.
In certain situations, SHBP dependents can reduce the 12-month pre-existing condition limitation period. The reduction is possible by using what is called "creditable coverage" to offset a pre-existing condition period. Creditable coverage generally includes the health coverage a family member had immediately prior to joining the SHBP. Coverage under most group health plans, as well as coverage under individual health policies and governmental health programs, qualifies as creditable coverage.
To reduce the pre-existing condition limitation period for your dependents (including your spouse), you must provide the SHBP with a certificate of creditable coverage stating when coverage started and ended for each dependent that you want to cover. Any period of prior coverage for that dependent will reduce the 12-month limitation period if no more than 63 days have elapsed between the dependent's loss of prior coverage and the first day of coverage under the SHBP.
If your dependent (including a spouse) had any break in coverage lasting more than 63 days, your dependent will receive creditable coverage only for the period of time after the break ended.
Within two years after your dependent's former coverage terminated, he or she has the right to obtain a certificate of creditable coverage from his or her former employer(s) to offset the preexisting 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.
HIPAA Annual Notice 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
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. georgia.gov (click on "About Us" and then click on "Privacy").
34 DCH Privacy Notice

Privacy Law's Requirements
DCH is required by law to: Maintain the privacy of your information. Give you this notice of DCH's legal duties and privacy practices regarding the information
that DCH has about you. Follow the terms of this notice. Not use or disclose any information about you without your written permission, except for
the reasons given in this notice. You may take away your permission at any time, in writing, except for the information that DCH disclosed before you stopped your permission. If you cannot give your permission due to an emergency, DCH may release the information if it is in your best interest. DCH must notify you as soon as possible after releasing the information.
In the future, DCH may change its privacy practices. If its privacy practices change significantly, DCH will provide a new notice to you. DCH will post the new notice on its Web site at www. dch.state.ga.us (click on "Privacy"). This notice is effective April 14, 2003.
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.
DCH Privacy Notice 35

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.
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.
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 404-562-7886; 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.
36 DCH Privacy Notice

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. 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 37