State Health Benefit Plan decision guide 2008: retiree

RETIREE
State Health Benefit Plan
Decision Guide 2008
RETIREE OPTION CHANGE PERIOD October 10 November 9, 2007

Phone Numbers/Contact Information
State Health Benefit Plan (SHBP): www.dch.georgia.gov/shbp_plans

Vendor
Retiree Help Line UnitedHealthcare
Definity HRA PPO and Indemnity
Choice HMO
HDHP
Blue Cross Blue Shield of GA Lumenos HRA HMO
Kaiser Permanente
Pharmacy

Member Services
877-246-4190
800-396-6515 877-246-4189 TDD 800-955-8770 866-527-9599 TDD 800-955-8770 877-246-4195 TDD 800-842-5754
866-835-6863 800-464-1367 800-611-1811 TDD 800-255-0056

All Options: Eligibility Plan Cost Estimator

404 656-6322 800 610-1863

Pharmacy

Web Site

877-650-9342 877-246-4195

www.myuhc.com/groups/gdch www.myuhc.com/groups/gdch www.myuhc.com/groups/gdch www.myuhc.com/groups/gdch

www.info.lumenos.com www.bcbsga.com

www.kaiserpermanente.org

Contact your

www.dch.georgia.gov/shbp_plans

respective vendor

www.dch.georgia.gov/shbp_plans

www.dch.georgia.gov/shbp_plans

Additional Information
Medicare
Centers for Medicare and Medicaid (CMS)
Social Security Administration

800-633-4227 800-772-1213

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

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. Availability of SHBP options may change based on changes in federal or state law.
Page 2 of this guide contains Plan changes effective January 1, 2008. Prior to the start of the 2008 Plan Year, or shortly thereafter, 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, 2008. 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.

Rhonda M. Medows, MD, Commissioner

Sonny Perdue, Governor

October 1, 2007

2 Peachtree Street, NW Atlanta, GA 30303-3159 www.dch.georgia.gov

Dear SHBP Member:
Welcome to 2008 Retiree Option Change Period (ROCP). The ROCP dates will be October 10 November 9, 2007. Retirees will again make their health election on the Web at www.oe2008.ga.gov.
The State Health Benefit Plan (SHBP) strives to bring the best value to its members. We have heard your feedback and ideas for improvement and are happy to announce two exciting new options that will be offered January 1, 2008.
These options are based on the idea that you should have greater control over how you spend your health care dollars using tools that help you make informed decisions. These new options address two of the largest challenges in our health care system: improving access to affordable, high-quality care and controlling costs.
These consumer driven health plan options with a Health Reimbursement Account (HRA) will be offered by UnitedHealthcare Definity and BlueCross BlueShield of Georgia Lumenos. Each year SHBP will contribute dollars to your HRA for treatment of medical expenses. In 2008, this amount is $500 for single coverage and $1,000 for family coverage. If you use up the credits in your HRA account, there is a deductible to meet, and then the plan works very similar to the PPO with co-insurance and in-network and out-of-network benefits. If you have money in your account left over at the end of the year, this is then rolled over to the next year and combined with SHBP's new deposit.
Each plan also provides 100 percent unlimited coverage for wellness care subject to age and gender guidelines. Your wellness expenses are not charged to your HRA.
The Georgia Department of Community Health, which administers the SHBP, is committed to providing you with meaningful choices in your options and keeping costs down. Be assured that we will continue to seek to provide you with the meaningful options, low premiums and tools to help you make the best decisions for you and your family members.
Sincerely,
Rhonda M. Medows, M.D.

Equal Opportunity Employer

decision guide 2008

2 what's changing for 2008?

Table of Contents

Phone Numbers, Contacts and Provider Information Welcome to Retiree Option Change Period (ROCP) What's Changing for 2008? Understanding Your Plan Options Eligibility, Qualifying Events Benefits Comparison: PPO, HRA, HDHP, and HMO Options Health Care Accounts SHBP Medicare Policy Important Notices

Inside Front Cover Page 2 Page 2 Page 6 Page 12 Page 14 Page 22 Page 23 Page 24

SHBP Acronyms
BCBSGa BlueCross BlueShield of Georgia
CCO Consumer Choice Option DCH Georgia Department of
Community Health
FSA Flexible Spending Account HDHP High Deductible
Health Plan
HMO Health Maintenance Organization
HRA Health Reimbursement Account
HSA Health Savings Account PPO Preferred Provider
Organization
SHBP State Health Benefit Plan SPD Summary Plan Description UHC UnitedHealthcare

Welcome to the Retiree Option Change Period (ROCP) for the State Health Benefit Plan for Coverage Effective January 1, 2008 December 31, 2008
The ROCP dates are Wednesday, October 10 through Friday, November 9, 2007. This guide will provide you with a brief explanation of each Plan option, important changes in your SHBP options, steps on how to make your ROCP election, information about the health and wellness features available through the health plan options and a comparison of benefits chart. This guide, the Retiree Decision Guide, can also be found at www.dch.georgia.gov/shbp_plans or www.oe2008.ga.gov.
Retirees will make their health election at www.oe2008.ga.gov and the Web site will be open beginning 12:01 a.m. on October 10 and will close at 4 p.m. on November 9, 2007.
What's Changing for 2008?
New Offerings
The SHBP will be offering two new consumer driven health plan options statewide through UnitedHealthcare Definity HRA and BlueCross BlueShield of Georgia Lumenos HRA. Advantages of these options are: Ui>,iLiiVV,v`i`L- *>`iv`>
coverage for Single Coverage ($500) and Family Coverage ($1,000) UiVii`iiLiivL>i`>>>}i>`}i`i}`ii

decision guide 2008

what's changing for 2008? 3
Wellness Enhancement Expansion
In 2008, SHBP is enhancing its focus on wellness and consumerism. Each retiree and family member is encouraged to take a personal health assessment under the plan option of your choice to evaluate your health risk for certain medical conditions. The SHBP wants you to become a more knowledgeable consumer about your health and well-being. Medical statistics show better outcomes for early detection of identified health issues that are treated before they become more serious. In addition, support tools are available to help you make informed decisions about how you spend your health care dollars.
U/i**"iiLiivVi>}vfxf]iVii```> based on national age and gender guidelines
U/i *iiLiivVi>}vfxiVii`Vi>}i per covered individual based on national age and gender guidelines
No Longer Offered
U/i`i"Livvii`only to individuals currently enrolled in this option
U/i
"no longer be offered. If you do not elect a new option, you and your dependents' coverage will be automatically enrolled in the PPO Option for the 2008 Plan Year. If you file a paper medical claim for services on or before December 31, 2007, the claim must be received by CIGNA at P.O. Box 182223, Chattanooga, TN 37422-7223 no later than March 31, 2008. This requirement also applies to any claim adjustments or appeals. Claims received by CIGNA after March 31, 2008, will not be paid if the services were received in the year 2007 or before. Contact your new vendor for any transition of care issues.
U/i/,
, -iino longer be offered. If you do not elect a new option, you and your dependents' coverage will be automatically enrolled in the PPO Option for the 2008 Plan Year. Retiree premiums are based on Medicare coverage at age 65. Please read page 23 for important information
Network Changes
U i
Vi"Li>``}}] >`i] `}i]`]>VV]-ii] Walker and Webster counties to their service area
U>i*i>iiLi>``}
>] >]>>]i>`]>>]iii] Pickens and Pike counties to their service area (does not apply to Senior Advantage)
Premiums
For the last 18 months, SHBP members have enjoyed the benefit of a stable premium. However, for the new 2008 Plan Year, premiums will increase by 10 percent. Most large employers have increases of 10 percent or more each year. The SHBP is self-funded, which means that our costs increase as a direct result of our increased claims expenses. While health care costs continue to rise, the SHBP still pays approximately 75 percent of the total cost of your health care benefits.
Eligibility Changes
Services will not be covered for any dependents that have not been verified by SHBP. If you have not yet verified a dependent you wish to cover, SHBP will request documentation verifying the eligibility of your dependent. Failure to submit the documents within 31 days from SHBP's request will result in the dependent being ineligible for coverage, unless a qualifying event occurs. See page 12 for the definition and more information about qualifying events.

4 retiree option change period

decision guide 2008

ROCP

SHBP Plan Options

BlueCross BlueShield of Georgia



UNew Lumenos with HRA

UBlueChoice HMO

UnitedHealthcare



UNew Definity with HRA

UHigh Deductible Health Plan (HDHP)*

UPreferred Provider Organization (PPO)

UUnitedHealthcare Choice HMO

UIndemnity (if currently enrolled only)

*This option allows you to set up a Health Savings Account. See page 8 for more information.

Kaiser Permanente



UHMO



USenior Advantage

Each Plan offers a Consumer Choice Option (CCO), which allows you to nominate a provider who is not participating in the network so that benefits may be paid at the in-network rate. See page 11 for more information.

What Should I Do before I Make My 2008 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 option 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 23.
U9`V>iviii,iii iV`i`iiiV option may best suit your healthcare needs.
U9>V>Vi,iiiii>n{{L>>i
U
>i>V*>"}ii`iLiiiV your physician or provider participates.
U
iVV/i]>`V>i>iV`} on each Plan Option.
U9>>iiiVi-ii>}ixvV",> 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.
U iiiiLi>i`L iLi]v- * election to be valid. Any forms postmarked after November 9, 2007 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
U9`Li}LivV>`Viiv>`ii`i when requested by SHBP.

retiree option change period 5

decision guide 2008

U9`iv>iViVi>`i`V>ivi>V retirement check if you receive an annuity.
U ii>>``iiViiiiVV>v SHBP are through U.S. mail.
Uv>iii`i`V>i] ]>` >`>iLi`>Vv your card or cards to SHBP, please do so immediately.

Follow These Steps to Make Your ROCP election
1) Go to www.oe2008.ga.gov
a) Register the first time you logon, by clicking on "Register"
b) Enter your policy number and date of birth
c) Select, enter and re-enter the password to confirm
d) Select a security question and answer it
e) Complete by clicking "Register"
2. Now you are on the "login" screen. Re-enter your policy number, password and then click on "Login"
3. After reading the "Terms of Use" text, scroll to the end of the text, click on the "Agree" box, and click "Accept"
4. Your name, address and current coverage tier, and Medicare information will display. If needed, make any changes
5. The dependents screen will appear. Indicate `Yes' or `No' for each dependent to be covered. If you mark "No" next to all your dependants, you will be changed to single
6. Select your health benefit coverage option
7. Review your health benefit election, listed dependents on the Pre-confirmation page. If your election is not correct, make any corrections through the edit function. Click `Confirm' to finalize your election
8. Click `Printer Friendly' to produce an easy to print version of your confirmation page, which will include a confirmation number. This reflects your 2008 benefit election. You may also save your confirmation on your computer or to a disk by saving the printer friendly confirmation as a pdf file. Each time you login to the system and confirm your choices, you will receive a unique confirmation number, which you should print or save. The benefits elected and confirmed as of 4 p.m. on November 9, 2007 will be your benefit election for the 2008 Plan Year. NOTE: If a confirmation number does not show, you have not completed the process. You must click "Confirm" to complete your election. If you are unable to print or save this page, copy the confirmation number and keep it in a safe place
9. Do not wait until the last minute to go online to make your election for 2008 as Web traffic may be heavy and exceptions will not be allowed if you were unable to complete your 2008 election. REMINDER: the Web site will close at 4 p.m. EST on November 9, 2007

health tip:
Eat a diet rich in vegetables, fruits, whole grains and fiber. Limit your salt intake.

decision guide 2008

6 understanding your plan options
What Happens if I Don't Go Online or return the PCF to SHBP?
You will retain the same coverage option and tier (single or family) you currently have unless you are enrolled in the CIGNA, CIGNA CCO, or the TRICARE Supplement. If you do not go online or complete the PCF to make a new health election, you will automatically be enrolled in the PPO Option effective January 1, 2008.
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 health care needs. Please refer to your health Plan option for details on programs offered. U*i>i>ii each vendor has a personal health assessment
questionnaire available on their Web site 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 Ui>>>}ii-iVi each vendor offers assistance with health care services such as disease management, case management and behavioral health. Please refer to your health plan option for additional details on programs offered
U i`Vii 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
Understanding Your Plan Options
To maximize your health benefits, it is important to fully understand how each SHBP option works. This brief overview will help you determine which option best fits your health care needs. Keep in mind that failure to use in-network providers could cost you more.
Consumer Driven Health Plan Options
Health Reimbursement Account (HRA)
The HRA is a consumer driven health care option whose plan design offers you a different approach for managing your health care needs. It is similar to that of the PPO with an in-network and out-of-network benefit, except the SHBP funds $500 for single coverage and $1,000 for family coverage to a HRA that can be used to provide first dollar coverage for eligible health care expenses including pharmacy. The amount in your HRA helps offset the deductible (bridge). The Plan also offers unlimited wellness benefits based on age and gender national guidelines when seeing in-network providers only. You will pay co-insurance after you have satisfied the deductible rather than co-payments for medical expenses and prescription drugs.

decision guide 2008

understanding your plan options 7
The BlueCross BlueShield of Georgia Lumenos with Health Reimbursement Account (HRA) offers a network of more than 700,000 participating physicians through the BlueCross BlueShield BlueCard PPO Network. The BCBSGa Lumenos HRA Plan requires that after using all HRA dollar credits, you satisfy the entire family deductible before any benefits are paid. This does not apply to wellness. You do not have to pay the provider at the time of service except for pharmacy. See pages 1421 for a benefits comparison. The UnitedHealthcare (UHC) Definity with Health Reimbursement Account (HRA) offers a network of more than 520,000 participating physicians through the UHC PPO Network. The UHC Definity HRA Plan offers a debit card that can be used when seeing in-network providers or when purchasing prescription drugs from an in-network pharmacy. See pages 1421 for a benefits comparison. Considerations: U1i``>,>VViii*>9i>v>i
participating in this option U,`>Vi`V>Lii`i," Uvi`}ii>],`>Vi`Li>i`L>i`i
number of months remaining in the Plan Year (which is calendar) UviiiVi>>v}ii>`V>}iiv}iv>Vi>}i]
your new HRA dollar credits will be pro-rated based on the number of months remaining in the Plan Year UviiiVi>>v}ii>`V>}iivv>}iVi>}i] your HRA dollar credits will not be reduced U1i``>i,>VVLivvii`vV>}i`}i Retiree Option Change Period or qualifying event or terminate employment, even if you re-enroll in a subsequent Plan Year U/ii>i>>i`i`VLi>`V>Vivvi
health tip:
Experts agree that exercise is the best predictor of longterm weight control. Rapid weight loss can lower your metabolism because the body thinks it is starving and makes it harder to lose weight.

decision guide 2008

8 understanding your plan options

High Deductible Health Plan (HDHP) with a Health Savings Account (HSA)

The High Deductible Health Plan (HDHP) is a consumer driven health care option whose plan design is very similar to that of the PPO with an in-network and outof-network benefit. The HDHP offers you the use of the UHC PPO network. This option offers 100 percent unlimited wellness benefits based on national age and gender guidelines. In return for a low monthly premium, you must satisfy a higher deductible that applies to all health care expenses except preventive care. If you have family coverage, you must meet the family deductible before benefits are payable for any family member. You pay co-insurance after you have satisfied the deductible rather than set dollar co-payments for medical expenses and prescription drugs. Also, you may qualify to start a Health Savings Account (HSA) for yourself and set aside tax-free dollars to pay for eligible health care expenses now or in the future. HSAs typically earn interest and may even offer investment options. See the benefits comparison chart that starts on page 14 to compare benefits under the HDHP to other Plan options.

HDHP Considerations: U9>v>i>>ii>`vi`i`VLi U9>viv>`i`VLiLiviLiiv>i>>Liv>iLi U9>V>Vi>viii}iv>`i`VLiv>i`V>iii

Health Savings Account (HSA)

health tip:
No more than 30 percent of your daily calories should be from fat.

An HSA is like a personal savings account with investment options for health care, except it's all tax-free. You may still open an HSA with an independent HSA administrator/ custodian and may locate HSA Administrators at www.hsafinder.com/sitemap.shtml.
You may open an HSA if you enroll in the SHBP HDHP and do not have other coverage through: 1) Your spouse's employer's plan 2) Medicare 3) Medicaid 4) Health Care Spending Account (HCSA) or any other non-qualified medical plan.
U9V>>iVL>-iii`i *>>>Vi member (employee or retiree)
U9V>VLifn}i]fxnv>>}>>iii`i HDHP. Limits are set by federal law. Unused money in your account carries forward to the next Plan Year and earns interest
U-`>V>Lii`vi}Lii>V>iiiiiiv>i}i enrolled in the HDHP
U-`>V>Lii`>vi>V>iiiii`V>]`i>]]i the-counter medications) that the IRS considers tax-deductible that are NOT covered by any health care plan (see IRS Publication 502 at www.irs.gov)
U9V>VLi>``>`>v>ixx`iii,-*LV>> www.irs.gov)

PPO Option
A Preferred Provider Organization (PPO) allows you to receive benefits from participating in-network and out-of-network providers. In order to receive the highest level of benefit coverage and avoid filing claims and balance billing, you should use an in-network provider. If you choose to use an out-of-network provider, the reimbursement will be at a lower

decision guide 2008

understanding your plan options 9
level of benefit coverage. No election of a primary care physician or referral to specialists is required. This option requires you to satisfy a deductible with coinsurance and has an out-of-pocket maximum. When you meet the maximum, the PPO pays your covered services at 100 percent. The PPO option offers you access to a network of more than 13,000 participating physicians and access to every acute care Georgia hospital through the UnitedHealthcare PPO network. You also have the added benefit of access to a national network of participating providers and hospitals across the United States.
Considerations:
U"viLiiv>i>`>iViL>>ViL} U
>i`>>``i`VLivVi>i
otherwise noted
U9>v>i>>ii>`vi`i`VLi>`i>>i of-pocket maximum
Indemnity Option
If you are currently participating in this option, you may continue to do so in 2008, but this Plan option is not accepting new members. You will receive a benefits comparison chart in the mail prior to Retiree Option Change Period.
HMO Options
A Health Maintenance Organization (HMO) allows you to receive benefits from participating providers in the HMO. The SHBP offers BlueCross BlueShield of Georgia
iVVi"]1i`i>V>i
Vi"]>`>i*i>ii" These options are available to SHBP eligible employees who live or work in the county or surrounding counties in which an HMO is offered. You are responsible for selecting a Primary Care Physician (PCP) from a list of participating providers unless you participate in the UnitedHealthcare Choice Option. Your PCP must provide a referral before you see another provider, including specialists, for your expenses to be covered (except in 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.
HMOs provide 100 percent benefit coverage for preventive health care needs after paying applicable co-payments. Certain services are subject to a deductible and co-insurance amount. See page 14 for more information.
Considerations:
U6iv`i>V>LiviiiV}>"" U
i>}i>>>Lii}i`iiViV>iv
emergencies)
U >}Vi}>`>LiViivi`>`ii`i>`}>`>LvvVi V>i`i>iv>Vi>iLiV`i`VLi>`V>Vi

10 understanding your plan options

decision guide 2008

Medicare Advantage Plan with Part D (MAPD) Option

/i>ivii`V>i"vvii`L>i*i>ii-i Advantage.

>i*i>iivvi>i`V>i`>>}i*>*> * *> This option is offered only to retirees who are enrolled in Medicare Part A or
>`ii>i*i>iiiVi>i>vVii-i 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 14. See chart below for a listing of counties serviced by i>i*i>ii-i`>>}i

Points to Consider
U9>>- *i]LLii>ii}> HMO Option premiums. See your Personalized Change Form for premium information.
U9>ii>`>>}ivivViV>`i`Vi` >iiVi>`>iLiV`>i`}>i Permanente.
U/iLiiv>>>Li}i>i*i>ii-i`>>}i*> are similar to that of the regular HMO.
U9i`ii>i*i>ii-i`>>}ii /i>vv>i``ii`vvivii}>"]L>>i Permanente facilities are covered under both plans.
U/i>i*i>ii-i`>>}i]Viii >i*i>ii-i`>>}i
-ii>V>v*i>i V>>i*i>ii>{{nxxnL> ii>i>]Vii>`>L>V>i
U
iVi>i*i>ii-i`>>}ii>i` change form and return to SHBP during the ROCP.

Kaiser Permanente Senior Advantage Coverage by County

/iv}i}>Vi>iVii`L>i*i>ii-i Advantage Plan:

U > U
> U i>L

U

U i

U > U
LL

U }>

Ui U*>`}

U

U
i> U>ii

U>

U,V`>i

U
iii U
i> U

Ui

U->`}









U7>

understanding your plan options 11

decision guide 2008

Consumer Choice Options (CCO)
This plan option applies to all SHBP options (except Indemnity) and allows you to nominate (request) a Georgia out-of network provider to be reimbursed as an in-network provider. This in-network relationship between you and the provider exists only for you and the provider. The out-of-network provider must be licensed and located in Georgia and accept the nomination, fees and conditions of the network and be approved by the network BEFORE you receive any services from that provider. You must also follow this process for each dependent wishing to see an out-of-network provider. For further details and to obtain the necessary paperwork, please call the selected plan option member services department.
Considerations:
U/ii}>>ii>i`i>i>VVi nomination or be approved by the network
U->ii]ViVi

"]V>V>}i the following ROCP unless you experience a qualifying event
U/i

"`i`ii>Vi`Liiv
U"`iV>i`>`Vii`i}>>ii}Liv>
U*`i>i>ii>V>>>i`}i*>9i>
Considerations that Apply to All SHBP Options:
U>`>>`>]`i`VLi>`vVii`}>i based on the Plan Year, January 1, 2008 to December 31, 2008
UviiLiiv>>iVLi`>>}i**"],]`i] HDHP and HMO Options
UiVii`iVi>ii`i`VLi>`vVi limit
UV>}ii`ii>>v}ii>`iiLi> change Plan options during the Plan Year
U
>}iv>V>}`i>iLiVL>>ViL}/iiV>}i are the member's responsibility and do not count toward deductibles or out-of-pocket spending limits
U
>i`>>``i`VLivVivi Indemnity, PPO and HMO options
U"viVii`iVi>ivi`i`VLi>`v pocket limit for the PPO and HDHP. In HMOs, there is no out-of-network coverage, except in limited cases
U-iiVi>ii>>LiVii`]iiVi> have limitations not contained in this summary
U >V*>vvi>
i
Vi"

"See above for details
U
>Vi>V>i``iVvi`i>i}>`}Vii`iVi]iV and limitations. Telephone numbers can be found on the inside cover of this guide

health tip:
To lose weight, burn more calories than you consume each day. Take the stairs instead of the elevator. Instead of watching TV on the weekend, take a walk or ride your bicycle.

decision guide 2008

12
SHBP Eligibility
The SHBP covers dependents who meet SHBP guidelines and requires eligibility documentation before SHBP sends dependents' notification of coverage to the health plans.
Eligible dependents are:
UYour legally married spouse, as defined by Georgia Law
U9ii>i``ii`iV`i>i\
1. Natural or legally adopted children under age 19, unless they are eligible for coverage as employees. Children that are legally adopted through the judicial courts become eligible only after they are placed in your physical custody
2. Stepchildren under age 19 who live with you at least 180 days per year and for whom you can provide documentation satisfactory to the Plan that they are your dependents
3. Other children under age 19 if they live with you permanently and legally depend on you for financial support as long as you have a court order, judgment or other satisfactory proof from a court of competent jurisdiction
4. Your natural children, legally adopted children or stepchildren who were covered under the SHBP before age 19 from categories 1 and 2 above who are physically or mentally disabled prior to reaching age 19 and who depend on you for primary support may continue their existing Plan coverage past age 19
5. Your natural children, legally adopted children, stepchildren or other children ages 19 through 25 from categories 1, 2, or 3 above who are registered fulltime students at fully accredited schools, colleges, universities or nurse training institutions and, if employed, who are not eligible for a medical benefit plan from their employer. The number of credit hours required for full-time student status is defined by the school in which the child is enrolled
UV>}i}iVi>}i>i`>>i
U ViVi>}i>>i>i>i
Making Changes When You Have a Qualifying Event
The option choice you make during the ROCP will stay in effect through December 31, 2008 unless you experience a qualifying event. You must 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 SHBP Call Center for assistance at 800-610-1863 or in the Atlanta area at 404-656-6322.
Qualifying events include, but are not limited to: U >`v>V`>Viiv>` U
>}ii`iViL]i`ii`i>ii}Lv
coverage in your selected option because of location U i>v>iV`]vi`ii`iii` U9i`ii`ivi}Lvi}i>Vi>}i U>>}i`Vi Ui`V>ii}L

Documentation Confirming Eligibility for Your Spouse or Dependents
USpouse: A copy of your certified marriage certificate or a copy of your most recent Federal Tax Return (filed jointly with spouse) including legible signatures for you and your spouse with financial information blacked out
UNatural or student child: A copy of the certified birth certificate listing the parents by name or a letter of confirmation of birth for newborns. Birth cards without the parents' names are not acceptable
U`i>}i}>}ix]- *iiiV`LVivV>i>` documentation from the school's registrar's office verifying full-time student status
U-iV`\
VviVivi`LVivV>i}ii>>>i
2. A copy of the certified marriage certificate showing the natural parent is your i>`
3. A notarized statement that the dependent lives in your home at least 180 days per year
You have 31 days from the date of the qualifying event or the day of the request for coverage, whichever is later, to provide the qualifying event documentation and/or dependent verification documentation.
The member's social security number MUST be written on each document so we can match your dependents to your record. Do not send originals as originals will not be returned.
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.

eligibility and verification 13

decision guide 2008

health tip:
As much as 25 percent of any weight loss may come from muscle. Weight lifting will build muscle increasing your metabolism. Muscle keeps your metabolism revved up burning calories, fat and sugar.

14

decision guide 2008

Benefits Comparison

Schedule of Benefits for You and Your Dependents for January 1, 2008

December 31, 2008

PPO OPTION

HRA OPTION

In-network

Out-of-network

In-network

Out-of-network

Definity or Lumenos Definity or Lumenos

Covered Services

The Plan Pays:

The Plan Pays:

Maximum Lifetime Benefit (combined for all SHBP Options)

$2 million

$2 million

Pre-Existing Conditions (First year in Plan only, subject to HIPAA)

$1,000

None

Lifetime Benefit Limit for Treatment of: (combined for PPO Option and HDHP) U/i>`L>
dysfunction (TMJ) U-L>Vi>Li

$1,100 3 episodes

$1,100 3 episodes

Deductibles/Co-Payments: U i`VLip``> U i`VLipv>>

$500 $1,500

$600 $1,800

U>`i`VLii admission
Annual Out-of-pocket Limits: U``> U>

$1,100 $2,200

$250
$2,200 $4,400

HRA Credits: U``> U>VLi`
Physicians' Services
Primary Care Physician or Specialist Office or Clinic Visits: Treatment of illness or injury
Primary Care Physician or Specialist Office or Clinic Visits for the Following: U7iiV>iiii
health care U>}iV}V>i>
(these services are not subject to the deductible)
Maternity Care (prenatal, delivery and postpartum)

None

100% after a $30 per office visit V>inot subject to deductible

Vi>}i subject to deductible

100% after $30 copayment per office visit. No co-payment for associated tests and immunizations. Maximum of $1000 per person per Plan Year.

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

Vi>}i subject to deductible after initial $30 copayment

Vi>}i subject to deductible

$1,000* $2,000* *HRA credits will reduce this amount.

Not applicable
$2,000* $4,000* *HRA credits will reduce this amount.
$500 $1000 *un-used credits roll to next plan year.

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i not subject to deductible

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

Vi>}i subject to deductible

Vi>}i subject to deductible

benefits comparison 15

decision guide 2008

Dollar amounts, visit limitations, deductibles and out-of-pocket limits are based on a January 1 December 31, 2008 Plan Year. NOTE: Coverage is defined as allowed eligible expenses. 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

HMO OPTIONS
i
Vi]>i*i>ii] UnitedHealthcare The Plan Pays:
$2 million

HMO Plan Differences:
>i*i>ii- unlimited

None

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

None

No separate lifetime benefit limit
$200 $400
Not applicable $1,000 $2,000
None

>i*i>ii- $1,000 individual, $2,000 per family per Plan Year

Vi>}i subject to deductible
Vi>}i not subject to deductible

Vi>}i 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

**Includes lab and x-rays done
in the physician's office. >iq>L>`>> be subject to deductible.

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

No primary care physician designation or specialist referral for UHC.

Vi>}i subject to deductible

Vi>}i subject to deductible

100% after initial $25 co-payment

Chart continued pg. 16

decision guide 2008

16 benefits comparison
Physicians' Services Physician Services Furnished in a Hospital U6}i}ii>]
including charges by surgeon, anesthesiologist, pathologist and radiologist Physician Services for Emergency Care Non-emergency use of the emergency room not covered
Outpatient Surgery-- U7iLi`>vvVi
U7iLi`>>i surgery at a facility
Allergy Shots and Serum
Hospital Services Inpatient Services U>iV>i]`ii>`
inpatient short-term acute rehabilitation services U7iiLV>i

PPO OPTION

In-network

Out-of-network

The Plan Pays:

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to in-network deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

100% for shots and ifi co-payment not subject to deductible (no co-payment if office visit not billed)

Vi>}i subject to deductible

90% coverage after `i`VLi>` subject to a $250 per admission deductible
Vi>}i not subject to deductible

60% coverage after `i`VLi>` subject to a $250 per admission deductible
Vi>}i not subject to deductible

HRA OPTION

In-network

Out-of-network

Definity or Lumenos Definity or Lumenos

The Plan Pays:

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible
Vi>}i subject to deductible
Vi>}i subject to deductible

Vi>}i subject to deductible
Vi>}i subject to deductible
Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i not subject to deductible

Vi>}i not subject to deductible

Outpatient Surgery-- Hospital/facility

Vi>}i subject to deductible

Vi>}i subject to deductible

Emergency Care--Hospital U/i>iv>ii}iV
medical condition or injury U ii}iVivi
emergency room not covered

90% coverage after a $100 per visit V>iV payment waived if >`i`LiV to in-network deductible

Outpatient Testing, Lab, etc.

Laboratory; X-Rays; Diagnostic Tests; Injections-- including medications covered `ii`V>Liivpvi treatment of an illness or injury

Vi>}i subject to deductible

90% coverage after a $100 per visit V>iV payment waived if >`i`LiV to in-network deductible
Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

HIGH DEDUCTIBLE OPTION

In-network

Out-of-network

The Plan Pays:

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible
Vi>}i subject to deductible
Vi>}i subject to deductible

Vi>}i subject to deductible
6Vi>}i subject to deductible
Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible
Vi>}i subject to deductible

Vi>}i subject to deductible
Vi>}i subject to deductible

decision guide 2008

HMO OPTIONS
i
Vi]>i*i>ii] UnitedHealthcare
The Plan Pays:

benefits comparison 17 HMO Plan Differences:

Vi>}iLiV to deductible

100% ($100 co-pay applies to facility expenses)
100% after $20 co-payment for PCP, $25 for specialist, if billed as office visit
Vi>}iLiV to deductible

Non-emergency use of the emergency room not covered. Applies to all plan options.
>i*i>ii qVi>}i subject to deductible

100% for shots and serum after a $25 per visit copayment

>i*i>iiq $5 for shots and $50 for a three-month supply of serum. UnitedHealthcare no copay if office visit not billed.

Vi>}i subject to deductible

100% coverage not subject to deductible

Vi>}i subject to deductible
100% after a $100 iV>i co-payment waived v>`i`LiV deductible

Non-emergency use of the emergency room not covered. Applies to all plan options.

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

>i*i>ii lab and x-rays may be subject to deductible. UnitedHealthcare independent lab/x-ray are payable at 100%.
Chart continued pg. 18

decision guide 2008

18 benefits comparison
Behavioral Health
Mental Health and Substance Abuse Inpatient Facility NOTE: All services require prior authorization. Combined days include in-network and out-ofnetwork visits.
Partial Day Hospitalization and Intensive Outpatient NOTE: Notification required. (Mental Health and Substance Abuse) Combined days include in-network and out-of-network visits. Professional Charges Inpatient (Mental Health and Substance Abuse) Combined visits include in-network and out-ofnetwork visits.
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 limit does not apply to the HMO. Vision Routine Eye Exam
Other Coverage Ambulance Services for Emergency Care
NOTE: "Land or air ambulance" to nearest facility to treat the condition.

PPO OPTION

In-network

Out-of-network

The Plan Pays:

HRA OPTION

In-network

Out-of-network

Definity or Lumenos Definity or Lumenos

The Plan Pays:

Vi>}iLiV`i`VLi limited to 45 days
combined per Plan
Year

Vi>}i subject to deductLii`{x days combined per Plan Year

Vi>}iLiV`i`VLi limited to 60 days combined per Plan Year (includes partial day and intensive outpatient)

No benefit

Vi>}iLiV`i`VLi limited to 1 visit per authorized day combined per Plan Year

Vi>}iLiV`i`VLi limited to 1 visit per authorized day combined per Plan Year

Vi>}i subject to deductible limited to 30 days combined per Plan Year

Vi>}i subject to deductible limited to 30 days combined per Plan Year

Vi>}i Vi>}i

subject to

subject to

`i`VLi

`i`VLi

limited to 30 days limited to 30

combined per

days combined

Plan Year

per Plan Year

Vi>}i subject to deductLii` 30 visits per authorized day combined per Plan Year

Vi>}i subject to deductLii` 30 visits per authorized day combined per Plan Year

Vi>}i

Vi>}i

LiV`i`VLi subject to

limited to 50 visits `i`VLii`

per Plan Year

to 25 visits per Plan

(the 50 visit limit Year (not to exceed

includes any out-of- a total of 50 visits

network visits)

combined)

Vi>}i subject to `i`VLi limited to 30 visits
per Plan Year (includes any outof-network visits)

Vi>}i subject to `i`VLi limited to 30 visits per Plan Year (includes any in-network visits)

Vi>}i subject to deductible

Vi>}i subject to deductible

NOTE: Notification required for all UHC options.

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i not subject to `i`VLii` to one eye exam every 24 months

Eye exam not covered

Vi>}i subject to deductible

Vi>}i subject to deductible

Contact HRA vendor directly for more information

Vi>}i subject to deductible

Vi>}i subject to deductible

HIGH DEDUCTIBLE OPTION

In-network

Out-of-network

The Plan Pays:

Vi>}iLiV to deductible limited to 30 days combined per Plan Year

Vi>}iLiV to deductible limited to 30 days combined per Plan Year

Vi>}iLiV to deductible limited to 60 days combined per Plan Year

Vi>}iLiV to deductible limited to 30 days combined per Plan Year

benefits comparison 19

decision guide 2008

HMO OPTIONS
i
Vi]>i*i>ii] UnitedHealthcare

The Plan Pays:
Vi>}iLiV to deductible and limited to 30 days combined per Plan Year
Each HMO may or may vviLiiv contact the HMO for more information

HMO Plan Differences:
>i*i>iiqv Vi>}iLiV`i`VLi>` unlimited days for mental health and detoxification`>v substance abuse
>i*i>ii- 90% of Vi>}iLiV`i`VLi>` unlimited days for mental health, substance abuse and detoxification.

Vi>}iLiV to deductible limited to 1 visit per authorized day combined per Plan Year

Vi>}iLiV to deductible limited to 1 visit per authorized day combined per Plan Year

Vi>}iLiV to deductible

>i*i>iiq Vi>}iLiV to deductible

Vi>}iLiV to deductible limited to 50 visits combined per Plan Year (includes any out-of-network visits)

Vi>}iLiV to deductible limited to 25 visits combined per Plan Year (includes any out-of-network visits)

Vi>}iLiV to deductible

Vi>}iLiV to deductible

100% after $25 per V>i limited to 25 visits per Plan Year
100% after applicable co-payment, if inpatient/ >iv>VLiV to deductible

>i*i>ii $25 co-payment, 100% coverage, unlimited visits, Mental Health >` ivV>i`x visits for substance abuse
>i*i>ii- 100% after $25 co-payment. Unlimited visits for mental health, substance abuse and detoxification.
Contact the respective vendor

Vi>}iLiV to deductible

Vi>}iLiV to deductible

Vi>}i LiV`i`VLi limited to one eye exam
every 24 months

Eye exam not covered

100% after applicable copayment for related surgery >``>}ViVi excludes appliances and `Vi>iv inpatient/outpatient facility, 90% subject to deductible

>i*i>iiq 50% for non-surgical i>iiV`i appliances and orthodontic i>iv>i >iv>V subject to deductible

Contact HMO directly for more information

UHC includes $200 benefit for glasses and contacts

Vi>}iLiV to deductible

Vi>}iLiV to deductible

100%

>i*i>iiq 100% after a $50 per trip co-payment when medically necessary.
Chart continued pg. 20

decision guide 2008

20 benefits comparison
Other Coverage Urgent Care Services
Home Health Care Services NOTE: Prior approval required Skilled Nursing Facility Services NOTE: Prior approval required
Hospice Care NOTE: Prior approval required

PPO OPTION

In-network

Out-of-network

The Plan Pays:
90% coverage after Vi>}i a $45 per visit co- subject to >iLiV deductible deductible

Vi>}i subject to deductible
90% coverage after `i`VLi 120 days per Plan 9i>LiV> $250 per admission deductible
Vi>}i subject to deductible

Vi>}i subject to deductible Not covered
Vi>}i subject to deductible

HRA OPTION

In-network

Out-of-network

Definity or Lumenos Definity or Lumenos

The Plan Pays:

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible
Vi>}i up to 120 days i*>9i> subject to deductible
Vi>}i subject to deductible

Vi>}i subject to deductible Not covered
Vi>}i subject to deductible

Durable Medical Equipment (DME)--Rental or purchase

Vi>}i

Vi>}i

subject to deductible subject to deductible

(UHC options require notification over $1000)

Outpatient Acute Short-Term Rehabilitation Services
U *V>/i> U -iiV/i> U "VV>>/i> U "ii
rehabilitative services

Vi>}i subject to `i`VLifi visit co-payment up to 40 visits per Plan Year (not to exceed a total of 40 visits combined, including any outof-network visits)

Vi>}i subject to `i`VLi 40 visits per Plan Year (not to exceed a total of 40 visits, including any innetwork visits)

Chiropractic Care NOTE: Coverage for up to a maximum of 20 visits per Plan Year.

Vi>}i after a $30 per V>i not subject to deductible

Vi>}i subject to deductible

Transplant Services NOTE: Prior approval required. Lumenos lifetime benefit maximum $500,000 (except for kidney or cornea).

90% coverage at

Not covered

contracted transplant

v>VLiV

deductible and $250 per

admission deductible

Pharmacy

Tier 1 Co-payment

$10

NOTE: No Tiers in HRA Option

$10*

Tier 2 Co-payment

$30

$30*

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to `i`VLi up to 40 visits per Plan Year (not to exceed a total of 40 visits combined, including any outof-network visits)

Vi>}i subject to `i`VLi up to 40 visits per Plan Year (not to exceed a total of 40 visits combined, including any innetwork visits)

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

Vi>}i subject to deductible

Tier 3 Co-payment

$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.

HIGH DEDUCTIBLE OPTION

In-network

Out-of-network

The Plan Pays:

i>}iLiV Vi>}iLiV

deductible

to deductible

Vi>}iLiV to deductible

Vi>}iLiV to deductible

90% coverage up to `>i*>9i> subject to deductible

Not covered

Vi>}iLiV to deductible

Vi>}iLiV to deductible

benefits comparison 21

decision guide 2008

HMO OPTIONS
i
Vi]>i*i>ii] UnitedHealthcare
The Plan Pays:
100% after $25 co-payment

HMO Plan Differences
BlueChoice referral ii`>i Permanente 100% after $30 co-payment

Vi>}i visits per Plan Year

Vi>}i `>i*>9i>LiV to deductible
Vi>}iLiV deductible

>i*i>iiq`> i*>9i>LiV deductible >i*i>ii-q `>i*>9i>LiV
deductible

Vi>}iLiV to deductible

Vi>}iLiV to deductible

90% coverage up to {i*>9i> subject to deductible (not to exceed a total of 40 visits combined, including any out-ofnetwork visits)

60% coverage up to {i*>9i> subject to deductible (not to exceed a total of 40 visits combined, including any innetwork visits)

100% coverage when medically necessary
100% coverage after $25 iV>i 40 visits per Plan Year

UnitedHealthcare notification required for items over $1,000
>i*i>ii-q unlimited visits

Vi>}iLiV to deductible

Vi>}iLiV to deductible

100% coverage after $25 co-payment per visit

90% coverage at contracted transplant v>VLiV deductible

Not covered

nVi>}i subject to deductible $10 min./$100 max.
nVi>}i subject to deductible $10 min./$100 max.
nVi>}i subject to deductible $10 min./$100 max.

Vi>}i subject to deductible $10 min./$100 max.
Vi>}i subject to deductible $10 min./$100 max.
Vi>}i subject to deductible $10 min./$100 max.

Vi>}iLiV deductible

$10

>i*i>ii

q>iv>V\f

Network Pharmacies: $16

$25

>i*i>ii

q>iv>V\fx

Network Pharmacies: $31

$50

>i*i>iiq

N/A

22 health care accounts
HRA and HSA Considerations

decision guide 2008

Overview Who is eligible?

HRA
A tax-exempt account that reimburses employees or retirees and dependents for qualified medical expenses. Funded by SHBP only.
------------------------------------------
Available to SHBP members enrolled in the BCBS Lumenos or UHC DeFinity Options

HSA
A tax-exempt custodial account that exclusively pays for qualified medical expenses of the employee or retiree and his or her dependents. Can be funded by employee, retiree, employer, or other party.
------------------------------------------
Available to SHBP members who elect HDHP.

Can I have other coverage and

Yes.

take advantage of this benefit?

No other general medical insurance coverage permitted. You cannot be enrolled in Medicare Part A or Part B.

Who owns the money in these accounts?

SHBP. Money reverts back to SHBP upon loss of SHBP HRA coverage.

Can these dollars be rolled

Yes.

over each year?

The employee or retiree. Yes.

Is there a monthly service

No.

charge?

Check with your HSA administrator.

If I terminate my SHBP coverage or change options

Unused amounts can be distributed until depleted to pay for claims incurred before termination or change of coverage.

Fund disbursement is not tied to individual's employment. Unused amounts can be distributed taxfree for qualified medical expenses. Subject to income and excise tax for non-qualified expenses.

decision guide 2008

23
State Health Benefit Plan Medicare Policy
Ui}>>ii>- *>Liiv>vii`V>i>>` U- *V>V>ii>`V>>iL>i`i`V>iiiviiii
65 or those eligible for Medicare due to disability. U*iLiL>i`i*>vi`V>i] ] >>i/iiLi
>`iiLiV>i>iiVi>}iV>/,
, ]6i} coverage since SHBP may have potential primary liability. U- *V`>iLiivviLi>iii`i`V>i] U- *>>LiiviLii}Liii`i`V>i]L> a higher premium. Uvii`V>i] ] ]i>ii`>Vvi`V>iV>`Livvi 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: UV} Ui`V>i} U>} Unnni}>
>i Un{i`V>i
Medicare Part D Information
If you are not enrolled in Medicare Part D, you may enroll during the Medicare annual open enrollment i` iLixq iViLi]/iiii`Li
iivi`V>i and Medicaid (CMS) and not by SHBP. In many cases, you do not need the Medicare Part D enhanced prescription drug plan (PDP). Your individual pharmacy needs will indicate the level of coverage that is best for you.
Coordination of Pharmacy Benefits between your PDP and SHBP U >Vi}i>>V]iiLi`V>i*> >`- *`ivV>V>` U 7ii>Vi* *Vi>}i}>]`iiL`ivV>V>`>`
pay your SHBP co-payment. U v>>VV>LLi`V>i*> >`- *]>ivi>>iV>
with the SHBP vendor or change drug stores. U
iVii`i}>`}L>>iV>

24

important notice

decision guide 2008

October 1, 2007
Two Peachtree Street Atlanta, GA 30303 {{xUnn
Important Notice from the SHBP for Medicare
Eligible Members
About Your Prescription Drug Coverage with BlueChoice HMO, BlueCross BlueShield Lumenos HRA, Kaiser Permanente, Indemnity, PPO, UnitedHealthcare Choice HMO, UnitedHealthcare Definity HRA and Medicare
For Plan Year: January 1December 31, 2008
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 SHBP and about your options under Medicare's prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare 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 by BlueChoice HMO, i
i-i`i,]>i*i>ii]`i]**"]1i`i>V>i
Choice HMO and UnitedHealthcare Definity HRA Options under SHBP are, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is considered Creditable Coverage.
Because your existing coverage is, on average, at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
You can join a Medicare drug plan when you first become eligible for Medicare and each year from November 15th through December 31st. This may mean that you may have to wait to join a Medicare drug plan and that you may pay a higher premium (a penalty) if you join later. You may pay that higher premium (a penalty) as long as you have Medicare prescription drug coverage. However, if you lose creditable prescription drug coverage, through no fault of your own, you will be eligible for a sixty (60) day Special Enrollment Period (SEP) because you lost creditable coverage to join a Part D plan. In addition if you lose your SHBP coverage, you will be eligible to join a Part D plan at that time using an Employer Group Special Enrollment Period. You should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area.
If you decide to join a Medicare drug plan, your SHBP coverage will be affected. See below for more information about what happens to your current coverage if you join a Medicare drug plan.
If you elect Part D and keep your SHBP coverage under BlueChoice HMO, BlueCross BlueShield i,]>i*i>ii]`i]**"]1i`i>V>i
Vi">` UnitedHealthcare Definity HRA Options, these plans will coordinate with Part D coverage.

important notice

25

decision guide 2008

If you do decide to join a Medicare drug plan and drop your BlueChoice HMO, BlueCross i-i`i,]>i*i>ii]`i]**"]1i`i>V>i
Vi"
UnitedHealthcare Definity HRA coverage, be aware that you and your dependents will not be able to get your SHBP coverage back. You should also know that if you drop or lose your coverage with SHBP and don't join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without prescription drug coverage that's at least as good as Medicare's prescription drug coverage, your monthly premium may go up by at least 1% of the base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without coverage, your premium may consistently be at least 19% higher than the base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to join.
For More Information about this Notice or Your Current Prescription Drug Coverage...
Contact the SHBP Call Center at (404) 656-6322 or (800) 610-1863 for further information. NOTE: You'll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if your SHBP 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 is in the Medicare & You handbook. You will get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:
U6i`V>i}
U
>->ii>>Vi>Vi*}>iii`iL>VVivVvi Medicare & You handbook for their telephone number) for personalized help
U
>n
, n{//9i`V>n{n{n
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and whether or not you are required to pay a higher premium (a penalty).
Date: October 1, 2007 Name of Entity/Sender: State Health Benefit Plan Office: Call Center Address: P. O. Box 38342, Atlanta, GA 30334 Phone Number: (404) 656-6322 or (800) 610-1863

26

important notice

decision guide 2008

Two Peachtree Street Atlanta, GA 30303 {{xUnn

October 1, 2007

Important Notice from the SHBP for
Medicare Eligible Members
About Your Prescription Drug Coverage with the High Deductible Health Plan and Medicare
For Plan Year: January 1December 31, 2008
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 about your options under Medicare's prescription drug coverage. This information can help you decide whether you want to join a Medicare drug plan. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare 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 under the High Deductible Health Plan (HDHP) Option, is, on average for all plan participants, NOT expected to pay out as much as standard Medicare prescription drug coverage pays and is considered NonCreditable Coverage. This is important, because most likely, you will get more help with your drug costs if you join a Medicare drug plan, than if you only have prescription drug coverage through the HDHP offered by 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 join. Read this notice carefully as it explains your options
Consider joining a Medicare drug plan. You can keep your HDHP coverage offered by the SHBP. You can keep the coverage regardless of whether it is as good as Medicare drug plan. However, because your existing coverage is, on average, NOT at least as good as standard Medicare prescription drug coverage, you may pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
You can join a Medicare drug plan when you first become eligible for Medicare and each year from November 15th through December 31st. This may mean that you may have to wait to join a Medicare drug plan and that you may pay a higher premium (a penalty) if you join later. You may pay that higher premium (a penalty) as long as you have Medicare prescription drug coverage. However, if you lose *Vi>}i`ii- *Lii}Li>*> >>>i}> Employer Group Special Enrollment Period.
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. If you decide to join a Medicare drug plan, your HDHP coverage under SHBP will be affected. See below for more information about what happens to your current coverage if you join a Medicare drug plan.

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decision guide 2008

Uvii`V>i*> iLiVii}Livi`V>i*> ]V>ii your HDHP coverage even if you elect Part D and the HDHP will coordinate benefits with Part D coverage.
Uv``iV`i>i`V>i`}>>`` *Vi>}i`i- *]Li aware that you and your dependents will not be able to get your SHBP coverage back.
U9`>>v`i *Vi>}i- *>``> Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.
Uv}V`>}iiV`}Vi>}i>>i>>}`> Medicare's prescription drug coverage, your monthly premium may go up by at least 1% of the base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without coverage, your premium may consistently be at least 19% higher than the base beneficiary premium. You may have to pay this higher premium (penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to join.
For More Information about this Notice or Your Current Prescription Drug Coverage...
Contact the SHBP Call Center at (404) 656-6322 or (800) 610-1863 for further information. NOTE: You will get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if your SHBP 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 is in the Medicare & You handbook. You will get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:
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If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).
Date: October 1, 2007 Name of Entity/Sender: State Health Benefit Plan Office: Call Center Address: P. O. Box 38342, Atlanta, GA 30334 Phone Number: (404) 656-6322 or (800) 610-1863

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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:
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U iLV`i`i>}in>i>`i`>Vi`v>`]viV` 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.

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