Retiree decision guide 2009

STATE HEALTH BENEFIT PLAN
Retiree Decision Guide 2009
Steps to Maintain Good Health: Select the Best Health Care Option Seek Preventative Care Complete Your Health Assessment Participate in Health Coaching Take Charge of Your Health
RETIREE OPTION CHANGE PERIOD
October 10November 10, 2008

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

Vendor

Member Services Pharmacy

UnitedHealthcare

Retiree Help Line

877-246-4190

Definity HRA

800-396-6515

PPO Choice HMO HDHP

877-246-4189 TDD 800-955-8770 800-372-5802
866-527-9599 TDD 800-955-8770
877-246-4195 TDD 800-842-5754 800-372-5802

CIGNA Healthcare

Retiree Help Line

800-942-6724

HRA, PPO, HMO, HDHP

800-633-8519 TDD 800-576-1314 800-633-8519

Kaiser Permanente

800-611-1811 800-255-0056

Pharmacy Contact your respective vendor

All Options: Eligibility

404-656-6322 800-610-1863

Web Site
www.myuhc.com/groups/gdch www.myuhc.com/groups/gdch
www.myuhc.com/groups/gdch www.myuhc.com/groups/gdch
www.cigna.com/shbp www.kaiserpermanente.org www.dch.georgia.gov/shbp_plans www.dch.georgia.gov/shbp_plans

Additional Information

Medicare

800-633-4227

Centers for Medicare and Medicaid (CMS)

Social Security Administration

800-772-1213

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

Page 2 of this guide contains Plan changes effective January 1, 2009. Prior to the start of the 2009 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, 2009. 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

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



October 1, 2008

Dear State Health Benefit Plan (SHBP) Member:

Welcome to the 2009 Retiree Option Change Period (ROCP). This year the ROCP dates will be October 10 November 10, 2008. Retirees will again make their health election on the Web at www.oe2009.ga.gov.

SHBP is committed to providing a comprehensive benefit program with multiple choices while keeping prices affordable for all members. We have also heard your feedback and ideas for improving your benefit program and we are happy to announce some exciting changes that will be offered January 1, 2009:

To streamline administrative costs and improve network access, SHBP conducted a competitive procurement earlier this year and awarded statewide contracts to CIGNA Healthcare and UnitedHealthcare (effective January 1, 2009). These two vendors offer the broadest access to providers across the state and proven quality care. Each vendor will offer a Health Reimbursement Arrangement (HRA), High Deductible Health Plan (HDHP), Preferred Provider Organization (PPO), Health Maintenance Organization (HMO) and Medicare Advantage Private Fee-for-Service with Prescription Drugs (MA PFFS-PD) options

SHBP is excited to offer retirees and/or their eligible dependent(s) who are enrolled in Medicare Parts A and B the opportunity to enroll in one of two Medicare MA PFFS-PD options

The MA PFFS-PD options are Medicare approved plans that have been structured to offer enhanced benefits while reducing/limiting retirees' out-of-pocket expenses

For the HRA option, members will see new incentives for wellness/preventative care by completing health assessments and obtaining an annual physical

Mental health benefits have also been expanded to more closely match those of the medical benefits with unlimited days for inpatient and outpatient treatment

The Georgia Department of Community Health, which administers SHBP, is committed

to providing you with meaningful choices in your options, while keeping costs down. Be

assured that we will continue to seek to provide you with these options, low premiums

and tools to help you make the best decisions for you and your family members.





Sincerely,





Rhonda M. Medows, M.D.



Commissioner

Equal Opportunity Employer

WHAT'S CHANGING FOR 2009?

Contents

Phone Numbers, Contacts and Provider Information
Inside Front Cover

Retiree Option Change Period (ROCP)
Page 2

What's Changing for 2009? Page 2

Enhancements and Changes
Page 4

Transition of Care Page 6

ROCP Benefit Election Page 6

Health & Wellness Page 9

Understanding Your Plan Options
Page 10

Eligibility, Qualifying Events, COBRA
Page 15

Benefits Comparison: PPO, HRA, HDHP, HMO and MA PFFS-PD Options
Page 18

SHBP Medicare Policy Page 26

HRA and HSA Considerations

Page 28

Important Notices Page 29

Welcome to the Retiree Option Change Period (ROCP) for the State Health Benefit Plan for Coverage Effective January 1, 2009 December 31, 2009
The ROCP dates are October 10 through November 10, 2008. 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 health 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.oe2009.ga.gov.
Retirees who wish to make a change will make their health election at www.oe2009.ga.gov and the Web site will be open beginning 12:01 a.m. on October 10 and will close at 4:30 p.m. on November 10, 2008.
What's Changing for 2009?
New Offerings
Through a comprehensive and competitive procurement process, CIGNA Healthcare and UnitedHealthcare were chosen to provide your medical and pharmacy benefit plans effective January 1, 2009. Strong statewide and national access to physicians and hospitals as well as documented clinical excellence were the two most critical factors in the award. CIGNA Healthcare and UnitedHealthcare also both demonstrate expertise and innovation in wellness and consumerism, two important areas of focus for SHBP.
New Plan Option Offerings
CIGNA Healthcare and UnitedHealthcare will each offer the following options:
Health Reimbursement Arrangement (HRA) High Deductible Health Plan (HDHP) Preferred Provider Organization (PPO) Health Maintenance Organization (HMO) Medicare Advantage Private Fee for Service Plan with Prescription Drugs
(MA PFFS-PD) Plan (retirees age 65 and older)

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WHAT'S CHANGING FOR 2009?
No Longer Offered
The Indemnity Option The BlueCross BlueShield of Ga BlueChoice HMO and Lumenos plan options The Consumer Choice Option (CCO) The Kaiser Permanente Option will be frozen and will be offered only to
individuals currently enrolled in this option
Premiums
Overall cost increase on average to employees and retirees: 7.5 percent The HRA and HDHP options will receive a lower rate increase (0 to 3
percent); non-Consumer Driven Health Plans will receive a larger increase (2 to 10 percent)
Eligibility Changes
Surviving Spouse Coverage
If a surviving spouse becomes eligible for coverage as an active employee, he/she must be covered under SHBP as an active employee through his/her employer and NOT as a surviving spouse
When surviving spouse leaves active employment, he/she must notify SHBP within 31 days to regain coverage as a surviving spouse
SHBP Acronyms
CDHP Consumer Driven Health Plan DCH Georgia Department of Community Health FSA Flexible Spending Account HDHP High Deductible Health Plan HMO Health Maintenance Organization HRA Health Reimbursement Arrangement HSA Health Savings Account PPO Preferred Provider Organization MA PFFS-PD Medicare Advantage Private Fee-forService with Prescription Drugs SHBP State Health Benefit Plan SPD Summary Plan Description UHC UnitedHealthcare
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decision guide 2009

ENHANCEMENTS AND CHANGES
Enhancements and Changes
Enhanced Mental Health and Substance Abuse Benefits
Day limitations no longer apply to the following:
Inpatient Facility Inpatient Professional Charges Outpatient Visits Partial Day Hospitalization/Intensive Outpatient
NOTE: Number of days and/or visits authorized remain subject to health plan approval
Medicare Advantage Private Fee-for-Service with Prescription Drugs (MA PFFS-PD)
A Medicare Advantage Private Fee-for-Service with Prescription Drugs (MA PFFS-PD) is an approved plan by the Centers for Medicare and Medicaid Services (CMS) or often called a Medicare Part C Plan. This plan is for retirees and their eligible dependent(s) who are enrolled in Medicare Parts A and B. This option takes the place of your original Medicare (Part A Hospital and Part B Medical Insurance benefits.)
These options have enriched benefits and are structured to reduce/limit retirees' out-of-pocket expenses and include Part D prescription drug coverage. If you are currently enrolled in a Medicare Part D plan, CMS will automatically disenroll you from your Part D coverage once your enrollment in a MA PFFS-PD is approved. 100% coverage for covered medical expenses once your low, fixed out-of-pocket
maximum of $1,000 has been met for the Plan year. This is important if you are faced with an expensive medical procedure No more coordination of benefits with Medicare as this is an all-inclusive plan in place of `traditional' Medicare SHBP has expanded the drugs offered to include coverage on some drugs that are normally not covered by the MA PFFS-PD. This gives you covered drugs beyond the Medicare Part D drug coverage To receive covered services, you'll simply need to verify your provider will accept the terms of payment and show your CIGNA or UnitedHealthcare ID card at every visit
HRA and HDHP Enhancements
Retiree and Spouse can each earn an additional $125 in their HRA account by taking an annual physical and completing a health assessment (HRA only)
No cost for certain asthma, diabetes and cardiac prescriptions for members enrolled and compliant with the disease state management program (HRA only)
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ENHANCEMENTS AND CHANGES

Treatment of Morbid Obesity at approved Centers of Excellence for members who meet the medical guidelines and complete specified requirements (available on HDHP also)
Allowance for hearing aids up to $1500 every 5 years (available on HDHP also)
HRA credits and deductibles will be adjusted as follows:

Tier
Single Family

HRA Deductible and Out-of-Pocket Limit January 1, 2009

2008 HRA Credits

2009 HRA Credits

2008

2009

Deductibles Deductibles

2008 Maximum In & Out-ofNetwork Outof-Pocket Limit

2009 Maximum In & Out-of-
Network Out-ofPocket Limit*

$500 $1,000

$500 $1,500

$1,000 $2,000

$1,000 $2,500

$2,000 $4,000

$2,000 $4,500

*These deductibles will be reduced by the HRA dollar credits.

Tier
Single Family

2008 Deductibles
$1,100 $2,200

HDHP Deductibles January 1, 2009

2009 Deductibles

2008 Out-of-Network Deductibles

2009 Out-of-Network Deductibles

$1,150 $2,300

$2,200 $4,400

$2,300 $4,600

PPO Changes

SHBP PPO Out-of-Pocket Limit January 1, 2009

Tier

2008 Out-of-

2009 Out-of-

2008 Out-of-Network 2009 Out-of-Network

Pocket Maximum Pocket Maximum Out-of-Pocket Maximum Out-of-Pocket Maximum

Single $1,100 + co-pays $1,500 + co-pays Family $2,200 + co-pays $3,000 + co-pays

$2,200 + co-pays $4,400 + co-pays

$3,000 + co-pays $6,000 + co-pays

HMO Changes

The deductible and maximum out-of-pocket limits are changing

HMO Office co-pays are increasing to $30 for primary care and specialists

HMO co-pays are increasing for preferred prescription drugs from $25 to $30 and non-preferred prescription drugs from $50 to $75

HMO Deductibles and Out-of-Pocket Limits January 1, 2009

Tier

2008

2009

Deductibles Deductibles

2008 Out-of-Pocket Maximum

2009 Out-of-Pocket Maximum

Single Family

$200 $400

$400 $800

$1,000 + co-pays $2,000 + co-pays

$1,500 + co-pays $3,000 + co-pays

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decision guide 2009

decision guide 2009

TRANSITION OF CARE 6

Transition of Care
Transition of Care for BlueChoice HMO and Lumenos members and UnitedHealthcare Indemnity and CCO members Transition of care may be provided for if treatment is needed after the end of
December. To request transition of care, call the Customer Service number shown on your new ID card by December 31, 2008 If you have any medical or pharmacy claims for services on or before December 31, 2008, these claims must be received by BlueChoice, Lumenos or UnitedHealthcare no later than March 31, 2009. This requirement also applies to any requests for appeals and adjustments. All claims and requests for appeals and adjustments received after March 31, 2009 will be denied. Please contact your 2008 healthcare vendor to obtain the address
SHBP Plan Options
CIGNA Healthcare and UnitedHealthcare Each Offer:
Health Reimbursement Arrangement (HRA) High Deductible Health Plan (HDHP) with Health Savings Account (HSA) Preferred Provider Organization (PPO) Health Maintenance Organization (HMO) Medicare Advantage Private Fee-for-Service with Prescription Drugs (MA PFFS-PD)
What Should I Do Before I Make My 2009 Benefit Election?
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. Evaluate your health care needs BlueChoice HMO, Lumenos, Consumer Choice and UnitedHealthcare
Indemnity members must make a selection for a NEW option If you want to continue with the same coverage you currently have (if offered),
you don't have to do anything Carefully read this Retiree Decision Guide for important information about Plan
changes Verify that your provider(s) will be participating in the option you choose by
calling the Plan option or go to the vendor Web site Check the distance you will have to drive to see your provider(s) Check Preferred Drug Lists co-payments or co-insurance If you have questions about the options, you may call the Retiree Helpline at:
CIGNA Healthcare (800) 942-6724 or UnitedHealthcare (877) 246-4190

ROCP BENEFIT ELECTION

If you or your covered spouse are turning age 65, please be sure to carefully read the Medicare information on page 30
You may make your election online. See below 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
Your envelope must be postmarked by November 10, 2008 for your election to be valid. Any forms postmarked after November 10, 2008, will not be processed (NO EXCEPTIONS)
DO NOT RETURN THE ENCLOSED PCF IF YOU MAKE YOUR ELECTION ONLINE OR CHOOSE NOT TO CHANGE YOUR BENEFIT ELECTION.

Reminders
You should verify that the correct health deduction is taken from each retirement check if you receive any 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 A, B, and D and have not submitted a copy of your card or cards to SHBP, please do so immediately so you can pay the lowest premium
Follow These Steps to Make Your ROCP Election Online
1) Go to www.oe2009.ga.gov
a) Register the first time you logon, by clicking on "Register"
b) Enter your policy number and date of birth
c) Create, enter and re-enter the password to confirm (please note what your password is for future reference)
d) Select a security question and answer it
e) Complete by clicking "Register"
f) You are now logged in. If you exit the system, you will be directed to the "login" screen to enter your policy number and the password you chose above.
2. After reading the "Terms, Conditions and Instructions" text, scroll to the end of the text, click on the "I Agree" button
3. Your name and address will display. If needed, make any changes. Place a `check' in the check box to confirm that you have validated your address
4. The dependents screen will appear. Indicate `Yes' or `No' for each dependent to be covered. If you mark "No" next to all your dependents, you will be changed to single coverage
5. Review your Medicare information (if available) on the Coverage Selection page. Select your health benefit coverage option

Having a baby? adopting a child? getting
married or divorced?
Remember you only have 31 days from the qualifying event to add or delete dependents. Don't miss the deadline waiting
for documentation.

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decision guide 2009

ROCP BENEFIT ELECTION

health tip:
Regular exercise can help direct your attention away from daily stress and may contribute to a feeling of mental wellbeing.

6. A considerations page will be displayed. Please read this page carefully as it is designed to assist you with items you may wish to consider before confirming your election. If you wish to change your election after reviewing this page, click on the "Return" button to go back to the Coverage Selection page. If you are satisfied with your election, click on the "Confirm" button
7. A Pre-Confirmation page will be displayed. Review your health benefit election, listed dependents and check your answers to the surcharge questions. If your election is not correct, make any corrections through the edit function. Click `Confirm' to finalize your election
8. This is your confirmation page, which reflects your 2009 benefit election. Click `Printer Friendly' to produce an easy to print version of your confirmation page, which will include a confirmation number. You may also save your confirmation on your computer or to a disk by saving the printer friendly confirmation as a pdf file. This confirmation page is your record of your election. 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 4:30 p.m. on November 10, 2008 will be your benefit election for the 2009 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. Click on "Logout" to exit
10. Do not wait until the last minute to go online to make your election for 2009 as Web traffic may be heavy and exceptions will not be allowed if you were unable to complete your 2009 election. REMINDER: the Web site will close at 4:30 p.m. EST on November 10, 2008
If you are unable to access www.oe2009.ga.gov to make your ROCP election, contact SHBP for assistance at (800) 610-1863 or (404) 656-6322 prior to the close of ROCP.
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 Bluechoice HMO, Bluechoice HMO CCO, Lumenos, Lumenos CCO, or Indemnity options. If you do not go online or complete the PCF to make a new health selection, you will automatically be enrolled in the UnitedHealthcare HRA Option effective January 1, 2009
If you are enrolled in the Kaiser or UHC Consumer Choice Options (CCO), your coverage will roll over without the Consumer Choice Option
If you are enrolled in a Kaiser or UHC option, your coverage will roll over to your existing coverage

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8

Health & Wellness
Did You Know?
Georgia ranks 14th in the U.S. for adult obesity
Georgia has the 13th highest inactivity rate at 25.9 percent
Approximately 10 percent (6,700) of Georgians die from obesity each year
Georgia is in the top 15 states for the highest obesity rates for youths ages 10 through 17
Approximately 10 percent of adult Georgians have diabetes
Top three causes of death in Georgia cardiovascular disease, cancer and stroke
What Can You Do About Your Health?
Take a Personal Health Assessment to assist you in learning about potential
health risks related to your lifestyle and family history. Each vendor has a health assessment questionnaire available on their Web site that you can complete. After completing the health assessment you will get a customized report that identifies health risks and provides recommendations on ways to help you reduce health risks and suggestions on how to make better lifestyle choices. Personal behaviors that can negatively affect your health can be modified or changed to prevent or reduce the risk of getting certain health conditions/diseases. Members who complete the health assessment may be contacted by the vendor regarding steps you can take to control or eliminate these risks or advise you of tests you may want to consider. You will also be educated on other health coaching services available. Participant data is completely confidential and individual results are not shared with your employer or SHBP. Combined results of all the assessments are used to support and enhance employee health and wellness programs.
Utilize the Preventive Health and Wellness Services One of the best
ways to stay healthy is to take advantage of preventive healthcare. Each vendor offers preventive care services. Preventive care is typically defined as periodic health evaluations, such as annual physicals and well-child care, child and adult immunization and screening services, and are subject to national age and gender guidelines; check with the vendor regarding the plan option you choose to confirm which preventive services are covered. Preventive care generally does not include services intended to treat an existing illness, injury or condition or for diagnostic purposes. Each vendor offers health coaching and wellness programs such as weight loss, nutrition and stress management. Contact the vendors to learn more about the programs they offer. You may also use your local health department to receive benefit coverage for eligible immunizations/vaccinations.
Engage in the Health Management Services Each vendor offers
assistance with health care services such as disease management, case management and behavioral health. Please refer to your health plan options for additional details on programs offered.
Call the Nurse Advice Line Each vendor has a 24-hour, seven days a week
(including holidays) nurse advice line 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.

HEALTH & WELLNESS
shbp tip:
Good health is priceless. When you live a healthy
lifestyle, you can feel better, live easier and save money on health
care expenses!
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decision guide 2009

UNDERSTANDING YOUR PLAN OPTIONS

shbp tip:
Be on the watch for prize drawings in 2009 for getting your annual physical and completing your health assessment.

Understanding Your Plan Options
To maximize your health benefits, it is more important to 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 this year, you will have two choices for each option listed below. You must select either an option offered by CIGNA Healthcare or UnitedHealthcare.
Consumer Driven Health Plan Options
The Health Reimbursement Arrangement (HRA) and the High Deductible Health Plan (HDHP) are consumer driven health plan options. These options are structured to provide lower out-of-pocket expenses for many participants and are explained below.
Health Reimbursement Arrangement (HRA)
The HRA is a consumer driven health plan option (CDHP) 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 SHBP funds dollar credits to your HRA each year to provide first dollar coverage for eligible health care and pharmacy expenses. The amount in your HRA is used to reduce the deductible and maximum out-of-pocket. After satisfying your deductible, you will pay your coinsurance amount until you reach your out-ofpocket maximum.
Considerations:
The plan offers unlimited wellness benefits based on age and gender national guidelines when seeing in-network providers only
There is not a separate deductible and out-of-pocket maximum for out-ofnetwork expenses
Unused dollars in your HRA account roll over to the next Plan Year if you are still participating in this option
HRA dollar credits are part of this option only and can only be used with the HRA option
Unused dollars in the HRA account will be forfeited if you change options during the ROCP or due to a qualifying event
If you experience a qualifying event and change tiers, your new HRA dollar credits only will be pro-rated based on the number of months remaining in the Plan Year; the deductible and out-of-pocket maximum are not adjusted
If you experience a qualifying event and change tiers from family to single coverage, your HRA dollars will not be reduced
Certain drug costs are waived if SHBP is primary and you participate in one of the Disease State Management Programs (DSM) for Diabetes, Asthma and Coronary Artery Disease

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UNDERSTANDING YOUR PLAN OPTIONS

High Deductible Health Plan (HDHP) with a Health Savings Account (HSA)
The High Deductible Health Plan (HDHP) design is very similar to that of the PPO with an in-network and out-of-network benefit.
In return for a low monthly premium, you must satisfy a high deductible that applies to all health care expenses except preventive care. If you have family coverage, you must meet the ENTIRE 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) to 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 18 to compare benefits under the HDHP to other Plan options.
Considerations:
This option offers 100 percent unlimited wellness benefits based on national age and gender guidelines
You must satisfy a separate in-network and out-of-network deductible and outof-pocket maximum
You pay co-insurance after meeting the entire family deductible for all medical expenses and prescriptions
Health Savings Account (HSA)
An HSA is like a personal savings account with investment options for health care, except it's all tax-free. You may open an HSA with an independent HSA administrator/custodian. Locate HSA Administrators at www.healthsavingsinfo. com/finding.htm.
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) General Purpose Health Care Spending Account (GPHCSA) or any other nonqualified medical plan.
You can contribute up to $3,000 single, $5,950 family as long as you are enrolled in the HDHP. These limits are set by federal law. Unused money in your account carries forward to the next Plan Year and earns interest
HSA dollars can be used for eligible health care expenses even if you are no longer enrolled in the HDHP or any SHBP coverage
HSA dollars can be used to pay for health care expenses (medical, dental, vision, over-the-counter medications) that the IRS considers tax-deductible that are NOT covered by any health plan (see IRS Publication 502 at www.irs.gov)
You can contribute additional dollars if you are 55 or older (see IRS Publication 502 at www.irs.gov)

shbp tip:
To save money, try over-the-counter brands.
An HRA member with itchy eyes received a doctor's prescription
for drops that cost $82. Her pharmacist helped find $12 over-
the-counter eye drops that did the same thing.
Savings to her HRA $82. (over-the-counter medications
are not covered under an HRA.)
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UNDERSTANDING YOUR PLAN OPTIONS
Medicare Advantage Private Fee-for-Service with Prescription Drugs (MA PFFS-PD)
A Medicare Advantage Private-Fee-for-Service (MA PFFS) product is an approved plan by the Centers for Medicare and Medicaid Services (CMS) and sometimes called a Medicare Part C Plan. This plan is for retirees and their eligible dependents enrolled in Medicare Parts A and B. This option takes the place of your original Medicare (Part A Hospital and Part B Medical Insurance benefits).
This option offers nationwide coverage where members may see any provider willing to accept the Plan's (CIGNA Healthcare or UnitedHealthcare) payment terms, conditions and payment rates. This option provides great flexibility in terms of accessibility to medical providers. Prescription drug coverage is also offered through the Plan's national pharmacy networks.
The MA PFFS-PD option offered by SHBP is a custom option with enriched benefits and is structured to reduce/limit retirees' out-of-pocket expenses.
How does the MA PFFS-PD Option Work (Medical)?
You can choose any Deemed Provider (a provider who is eligible to receive payment from Medicare and who agrees to the CIGNA Medicare Access Plus Rx or UnitedHealthcare Medicare Direct terms, conditions and payment rate)
What is a Deemed Provider and what does it have to do with receiving care?
Your doctor must be eligible to receive payment from Medicare and agree to accept the terms, conditions and payment rate of the plan you are enrolled in. He/she will then be considered a Deemed Provider
If your doctor or hospital does not agree to be a Deemed Provider, any services received will not be covered under the MA PFFS-PD options
If your doctor wants to become a Deemed Provider, you or your physician can contact CIGNA Heathcare or UnitedHealthcare directly
How does the MA PFFS-PD Option Work (Prescription Drugs)?
Most Medicare Part D plans have a deductible and what's called a coverage gap commonly referred to as the "doughnut hole." SHBP has waived the deductible and will provide benefits through the coverage gap for you. You will only pay your co-pay amount until you reach the plan's predetermined limit of $4350.00
Once you reach the limit you will pay the greater of 5 percent coinsurance or reduced co-pays for generics and brand drugs ($2.40$6.00) for the remainder of the calendar year
Will the MA PFFS-PD cover all of my prescription drugs?
If you are taking a medication that may require a change (for instance it is not on the approved CIGNA or United Healthcare's drug list), you will receive a letter after you receive your first supply of that medication. The letter will tell you what to do and the time period that you have to make a change. After that date, you will be required to change to an alternative medication or complete the necessary steps with your doctor to continue your current medication
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UNDERSTANDING YOUR PLAN OPTIONS
You should talk to your doctor and discuss if you should switch to a drug that is covered under your Plan option or request an exception so that the drug you take will be covered
What if I have Medicare Part A and B and my spouse doesn't?
You can enroll in one of the MA PFFSPD options and your spouse will automatically be enrolled in the corresponding HRA option of the vendor you select. You will need to enroll with family coverage in the MA PFFS-PD option
What if my spouse has Medicare Parts A and B and I don't?
You can enroll your spouse in one of the MA PFFS-PD options and you will automatically be enrolled in the corresponding HRA option by the vendor you select. You will need to enroll with family coverage in the MA PFFS-PD option. The vendor you selected will contact you regarding enrollment in a MA PFFS-PD option once you become eligible
What if I or my spouse are 65 and have Medicare Part A but aren't enrolled in Medicare Part B?
You may enroll for Medicare Part B during the Medicare annual enrollment period of January 1 March 31, 2009
Part B Coverage will then become effective on July 1 of the same year
Isn't there a penalty if I didn't enroll for Part B when I first became eligible?
Yes. However, the SHBP will pay the penalties on your behalf
Can I enroll in the MA PFFS-PD plan now if I or my spouse doesn't have Medicare Part B?
No, but you can when you obtain Medicare Part B coverage
Considerations:
Must have Medicare Parts A and B To enroll in the MA PFFS-PD you must make your electon online or via paper
and submit to SHBP. The MA PFFS-PD will mail you an application you will need to complete Prescription drugs are included; you do not need to purchase a separate Part D plan If you have purchased Part D on your own, it will automatically be cancelled if you enroll in an SHBP sponsored MA PFFS-PD If you are covered by the SHBP MA PFFS-PD option and elect to enroll in a Medicare Part D plan, your coverage in the MA PFFS-PD option will end Low out-of-pocket expenses Must seek services from a Deemed Provider that accepts UnitedHealthcare or CIGNA Healthcare's terms, conditions and payment rates No filing of claims with Medicare or coordination of benefits
13

decision guide 2009

UNDERSTANDING YOUR PLAN OPTIONS

shbp tip:
While not required, we strongly encourage you to select a PCP to assist in the overall coordination of care.

Preferred Provider Organization (PPO)
A Preferred Provider Organization (PPO) allows you to receive benefits from in-network and out-of-network providers, and provides access on a statewide and national basis across the United States. To receive the highest level of benefit coverage and to avoid filing claims and balance billing, you should use an in-network provider. If you use an out-of-network provider, the reimbursement will be lower and you will be subject to balance billing from your provider. No election of a primary care physician or referral to a specialist is required. This option requires that you satisfy a deductible with coinsurance and has an out-of-pocket maximum (OOP). When you meet the maximum, the PPO pays your covered services at 100 percent of the allowed amount; however, you will continue to pay your co-pays.
Considerations:
Out-of-network benefits are paid at 60 percent with balance billing (the amount above the negotiated rate approved by the vendor)
Co-payments do not apply toward deductibles or out-of-pocket maximum unless otherwise noted
You must satisfy a separate in-network and out-of-network deductible and separate out-of-pocket maximum
Health Maintenance Organization (HMO)
A Health Maintenance Organization (HMO) allows you to receive benefits from participating providers only and does not require you to select a Primary Care Physician (PCP). 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. See page 18 for more information.
Considerations:
Verify provider participation before selecting an HMO Option
Coverage is available only when using in-network providers (except in cases of emergencies)
Co-payments do not count toward your deductible or out-of-pocket maximum
Both CIGNA Healthcare and UnitedHealthcare HMO options provide a national network and services are paid at the same benefit levels when using network providers outside of Georgia
Maintenance medications require only two co-pays for a 90-day supply when received at a retail pharmacy

decision guide 2009

14

ELIGIBILITY

SHBP Eligibility

The SHBP covers dependents who meet SHBP guidelines and requires eligibility documentation before SHBP can send dependents' notification of coverage to the health plans.
Eligible dependents are:
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, 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 are physically or mentally disabled prior to reaching age 26 and who depend on you for primary support
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 full-time students at accredited secondary 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
SHBP requires documentation annually from the college or university your student attends verifying he/she is a full-time student.
A change to single coverage is allowed at any time. You may discontinue coverage at any time, but you MAY NOT ENROLL LATER.

health tip:
If your child is turning 19 and is a full-time student or disabled, you may be able to continue his/her coverage,
provided you submit the proper documentation.

decision guide 2009

15

ELIGIBILITY

Making Changes When You Have a Qualifying Event
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.
Qualifying events include, but are not limited to:
Birth or adoption of a child or placement for adoption
Change in residence by you, your spouse or dependents that results in ineligibility for coverage in your selected option because of location
Death of a spouse or child, if the only dependent enrolled
Your spouse's or dependent's loss of eligibility for other group health coverage
Marriage or divorce
Medicare eligibility
Please submit your request, within 31 days of the event to your personnel/benefit coordinator. Requests should not be held waiting on additional information, such as Social Security Number, marriage or birth certificate.
Documentation Confirming Eligibility for Your Spouse or Dependents
SHBP requires documentation concerning eligibility of dependents covered under the plan.
Spouse: 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
Natural 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

decision guide 2009

16

For students age 19 through age 25, SHBP requires the child's birth certificate and documentation from the school's registrar's office verifying fulltime student status and a completed and signed student status form
Stepchild:
1. A copy of the certified birth certificate showing your spouse is the natural parent;
2. A copy of the certified marriage certificate showing the natural parent is your spouse; and
3. A notarized statement that the dependent lives in your home at least 180 days per year.
NOTE: No health claims will be paid until the documentation is received and approved by SHBP.
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

health tip:
Eating a low-fat, lowsugar diet with plenty of fruits and vegetables can boost your physical
and mental health.

decision guide 2009

17

BENEFITS COMPARISON
Benefits Comparison
Schedule of Benefits for You and Your Dependents for January 1, 2009 December 31, 2009

Covered Services
Maximum Lifetime Benefit (combined for all SHBP Options)

PPO OPTION

In-network CIGNA Healthcare, UnitedHealthcare

Out-of-network CIGNA Healthcare, UnitedHealthcare

The Plan Pays:

$2 million

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

$1,000

Lifetime Benefit Limit for Treatment of: (combined for PPO Option and HDHP) Temporomandibular joint
dysfunction (TMJ)

$1,100

Deductibles/Co-Payments: Employee Employee + Spouse +
Child(ren) Hospital deductible per
admission for Medical and Behavioral Health

$500 $1,500

$250

$1,000 $3,000

Out-of-Pocket Maximum: Retiree Family

$1,500 + co-pays $3,000 + co-pays

$3,000 + co-pays $6,000 + co-pays

HRA Credits: Retiree Family

None

HRA OPTION

In-network

Out-of-network

CIGNA Healthcare, CIGNA Healthcare,

UnitedHealthcare UnitedHealthcare

The Plan Pays:

$2 million

Not applicable

$1,100

$1,000* $2,500* *HRA credits will reduce this amount. Not applicable
$2,000* $4,500* HRA credits will reduce this amount.
$500 $1,500

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: Wellness care/preventive
health care Annual gynecological exams
(these services are not subject to the deductible)

$30 per office visit co-payment; subject to deductible for associated lab and x-ray
$30 co-payment per office visit; No co-payment for associated tests and immunizations. Maximum of $1,000 per person per Plan Year

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

decision guide 2009

18

90% coverage; subject to deductible

60% coverage; subject to deductible

100% coverage; not subject to deductible

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

BENEFITS COMPARISON

Dollar amounts, visit limitations, deductibles and out-of-pocket limits are based on a January 1 December 31, 2009 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 CIGNA Healthcare, UnitedHealthcare

Out-of-network CIGNA Healthcare, UnitedHealthcare

The Plan Pays:

$2 million

HMO OPTIONS
CIGNA Healthcare, UnitedHealthcare The Plan Pays:
$2 million

MA PFFS-PD
CIGNA Healthcare, UnitedHealthcare The Plan Pays:
Not applicable

Not applicable

Not applicable

Not applicable

$1,100

$1,150 $2,300

$2,300 $4,600
Not applicable

No separate lifetime benefit limit
$400 $800 Not applicable

Contact plans for details
Not applicable Not applicable

$1,700 $2,900

$3,800 $7,000

$1,500 + co-pays $3,000 + co-pays

$1,000 per member

None

None

None

90% coverage; subject to deductible

60% coverage; subject to deductible

100% coverage; not subject to deductible

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

$30 per office visit co-payment
100% after a per visit co-payment of $30 for primary care and specialty care; No co-payment for immunizations and mammograms

Primary--$20 per office visit co-payment; Specialist--$25 per office visit co-payment
Primary--$20 per office visit co-payment; Specialist--$25 per office visit co-payment

decision guide 2009

Chart continued pg. 20

19

decision guide 2009

BENEFITS COMPARISON
Physicians' Services Maternity Care (prenatal, delivery and postpartum)
Physician Services Furnished in a Hospital Visits; 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
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
Outpatient Surgery-- Hospital/facility
Emergency Care--Hospital Treatment of an emergency
medical condition or injury Non-emergency use of the
emergency room not covered
20

PPO OPTION

In-network CIGNA Healthcare, UnitedHealthcare

Out-of-network CIGNA Healthcare, UnitedHealthcare

The Plan Pays:

90% coverage; not subject to deductible after initial $30 co-payment

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to in-network deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

100% for shots and serum; $30 per visit co-payment not subject to deductible (no co-payment if office visit not billed)

60% coverage; subject to deductible

90% coverage after deductible; and subject to a $250 per admission deductible

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

100% coverage; not subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage after $100 per visit co-payment; co-payment waived if admitted; subject to
in-network deductible

HRA OPTION

In-network

Out-of-network

CIGNA Healthcare, CIGNA Healthcare,

UnitedHealthcare UnitedHealthcare

The Plan Pays:

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to in-network deductible

90% coverage; subject to deductible
90% coverage; subject to deductible
90% coverage; subject to deductible

60% coverage; subject to deductible
60% coverage; subject to deductible
60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible
90% coverage; subject to deductible

60% coverage; subject to deductible
60% coverage; subject to deductible

90% coverage; subject to deductible

HIGH DEDUCTIBLE OPTION (HDHP)

In-network CIGNA Healthcare, UnitedHealthcare

Out-of-network CIGNA Healthcare, UnitedHealthcare

The Plan Pays:

90% coverage; subject to deductible

60% coverage; subject to deductible

HMO OPTIONS
CIGNA Healthcare, UnitedHealthcare
The Plan Pays:
100% after initial $30 co-payment

BENEFITS COMPARISON
MA PFFS-PD
CIGNA Healthcare, UnitedHealthcare
The Plan Pays: $0 co-payment after initial Specialist co-payment of $25

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

100% coverage, hospital facility co-payment will apply

90% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to in-network deductible

100% ($100 co-pay applies to facility expenses)

100% coverage, facility copayment will apply

100% after $30 co-payment if billed as office visit
90% coverage; subject to deductible

Primary $20 per office visit co-payment; Specialist $25 per office visit co-payment
100% coverage, facility copayment will apply

100% for shots and serum after a $30 per visit co-payment; No co-pay if office visit not billed

Primary--$20 per office visit co-payment; Specialist--$25 per office visit co-payment
90% coverage of serum if billed separately

90% coverage; subject to deductible
100% coverage not subject to deductible
90% coverage; subject to deductible
100% after a $100 per visit co-payment; if admitted co-payment waived; subject to deductible

$190 per day co-payment for days 14, $0 co-payment per day for days 5 and beyond
Not covered
100% coverage after $95 co-payment
$50 co-payment (waived if admitted within 24 hours)

decision guide 2009

Chart continued pg. 22

21

BENEFITS COMPARISON

PPO OPTION

In-network CIGNA Healthcare, UnitedHealthcare

Out-of-network CIGNA Healthcare, UnitedHealthcare

Outpatient Testing, Lab, etc.

The Plan Pays:

Laboratory; X-Rays; Diagnostic Tests; Injections-- including medications covered under medical benefits--for the treatment of an illness or injury

90% coverage; subject to deductible

60% coverage; subject to deductible

Behavioral Health
Mental Health and Substance Abuse Inpatient Facility and Partial Day Hospitalization NOTE: All services require prior authorization except MA PFFS-PD

90% coverage; subject to deductible

60% coverage; subject to deductible

HRA OPTION

In-network

Out-of-network

CIGNA Healthcare, CIGNA Healthcare,

UnitedHealthcare UnitedHealthcare

The Plan Pays:

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

Mental Health and Substance Abuse Outpatient Visits and Intensive Outpatient NOTE: All services require prior authorization except MA PFFS-PD
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 NOTE: Limited to one eye exam every 24 months

90% coverage;

60% coverage;

subject to deductible; subject to

$30 co-payment for deductible

office visit

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

NOTE: Notification required for all UHC options.

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; not subject to deductible

Eye exam not covered

100% coverage; not subject to deductible

Eye exam not covered

Other Coverage Hearing Services

Not covered

90% coverage for routing exam and fitting; subject to deductible; $1,500 hearing aid allowance every 5 years

decision guide 2009

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

90% coverage; subject to in-network deductible

Urgent Care Services NOTE: All subject to deductible except HMO and MA PFFS-PD

90% coverage after a $45 per visit co-payment

60% coverage

22

90% coverage; subject to in-network deductible

90% coverage

60% coverage

HIGH DEDUCTIBLE OPTION (HDHP)

In-network CIGNA Healthcare, UnitedHealthcare

Out-of-network CIGNA Healthcare, UnitedHealthcare

The Plan Pays:

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

HMO OPTIONS
CIGNA Healthcare, UnitedHealthcare
The Plan Pays:
90% coverage; subject to deductible; office or independent lab/ x-ray 100% coverage
UHC--90% coverage; not subject to deductible. CIGNA--90% coverage subject to deductible
100% after $30 per visit co-payment. $10 co-payment for group therapy

BENEFITS COMPARISON
MA PFFS-PD
CIGNA Healthcare, UnitedHealthcare
The Plan Pays:
$0 co-payment for diagnostic test/lab services and Medicare covered standard x-rays; $25 co-payment for complex radiology services and imaging procedures
$190 co-payment per day for days 14, $0 co-payment for days 5190. 190 day lifetime maximum; $60 co-payment per day for partial hospitalization
$25 per office visit copayment; Intensive Outpatient--$60 co-payment per visit

90% coverage; subject to deductible
90% coverage; subject to deductible

60% coverage; subject to deductible

100% after $30 per visit co-payment; if inpatient/ outpatient facility, 90% subject to deductible

NOTE: Notification required for all UHC options.

60% coverage; subject to deductible

100% after $30 co-payment for related surgery and diagnostic services; excludes appliances and orthodontic treatment; if inpatient/ outpatient facility, 90% subject to deductible

$25 per office visit co-payment for covered medical services
Contact plans for details

90% coverage; not subject to deductible

Eye exam not covered

100% after $30 co-payment; not subject to deductible. $200 annual benefit for glasses and contacts

$25 co-payment per office visit--limited to 1 annual eye exam; $125 eyewear (glasses, contact lenses and frames) allowance every 2 years

90% coverage for routing exam and fitting; subject to deductible; $1,500 hearing aid allowance every 5 years
90% coverage; subject to in-network deductible

90% coverage

60% coverage

Not covered
100% coverage; not subject to deductible
100% after $35 co-payment

$25 co-payment for each covered diagnostic and/or routine hearing exam; limited to 1 annual test; $1,000 hearing aid allowance every 4 years
100% coverage

decision guide 2009

$25 co-payment

Chart continued pg. 24

23

BENEFITS COMPARISON
Other Coverage 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 CIGNA Healthcare, UnitedHealthcare

Out-of-network CIGNA Healthcare, UnitedHealthcare

The Plan Pays:

90% coverage;

60% coverage;

subject to deductible subject to deductible

90% coverage after deductible; up to 120 days per Plan Year; subject to a $250 per admission deductible

Not covered

100% coverage; subject to deductible

60% coverage; subject to deductible

HRA OPTION

In-network

Out-of-network

CIGNA Healthcare, CIGNA Healthcare,

UnitedHealthcare UnitedHealthcare

The Plan Pays:

90% coverage; subject to deductible
90% coverage; up to 120 days per Plan Year; subject to deductible

60% coverage; subject to deductible
Not covered

90% coverage; subject to deductible

60% coverage; subject to deductible

Durable Medical Equipment (DME)--Rental or purchase NOTE: Prior approval required for certain DME
Outpatient Acute Short-Term Rehabilitation Services
Physical Therapy Speech Therapy Occupational Therapy Other short term
rehabilitative services
Chiropractic Care NOTE: Coverage for up to a maximum of 20 visits per Plan Year.

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; sub- 60% coverage;

ject to deductible; subject to

$20 per visit co-pay- deductible; up to

ment up to 40 visits 40 visits per Plan

per Plan Year (not to exceed a total of 40 visits combined, including any outof-network visits)

Year (not to exceed a total of 40 visits, including any in-network visits)

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

60% coverage; subject to deductible

Foot Care
Transplant Services NOTE: Prior approval required.
Pharmacy Tier 1 Co-payment
NOTE: No Tiers in HRA Option

90% coverage; after 60% coverage;

a $30 per visit

subject to

co-payment; not deductible

subject to deductible

90% coverage at

Not covered

contracted transplant

facility; subject to de-

ductible and $250 per

admission deductible

$10

$10*

Tier 2 Co-payment

$30

$30*

90% coverage; subject to deductible

60% coverage; subject to deductible

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

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

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible
90% coverage; subject to deductible

60% coverage; subject to deductible
60% coverage; subject to deductible

90% coverage; subject to deductible
Not applicable

60% coverage; subject to deductible
Not applicable

decision guide 2009

Tier 3 Co-payment

$100

$100*

Not applicable

Not applicable

Tier 4 Co-payment

Not applicable

Not applicable

Not applicable

Not applicable

*Member must pay full charges at point of sale and submit a paper claim. Members will be reimbursed at the pharmacy network 24 rate less the required co-payment for covered drugs. Member is responsible for charges that exceed the pharmacy network rate.

HIGH DEDUCTIBLE OPTION (HDHP)

In-network CIGNA Healthcare, UnitedHealthcare

Out-of-network CIGNA Healthcare, UnitedHealthcare

The Plan Pays:

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage up to 120 days per Plan Year; subject to deductible

Not covered

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage up to 40 visits per therapy per Plan Year; subject to deductible (not to exceed a total of 40 visits combined, including any out-ofnetwork visits)
90% coverage; subject to deductible

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

90% coverage; subject to deductible
90% coverage at contracted transplant facility; subject to deductible

60% coverage; subject to deductible
Not covered

HMO OPTIONS
CIGNA Healthcare, UnitedHealthcare The Plan Pays: 100% coverage; up to 120 visits per Plan Year
90% coverage; up to 120 days per Plan Year; subject to deductible
100% coverage; subject to deductible
100% coverage when medically necessary
100% coverage after $25 per visit co-payment; up to 40 visits per therapy per Plan Year

BENEFITS COMPARISON
MA PFFS-PD
CIGNA Healthcare, UnitedHealthcare
The Plan Pays:
100% coverage--unlimited (no prior approval required)
$0 co-payment per day for days 110; $50 co-payment per day for days 11100 for up to 100 days per benefit period (no prior approval required)
100% coverage (must receive care from a Medicare covered hospice facility; no prior approval required)
90% coverage for Medicare covered items (no prior approval required)
$25 co-payment per office visit; no limit on number of visits

100% coverage after $30 co-payment per visit
100% coverage after $30 co-payment per visit 90% coverage; subject to deductible

Medicare Covered--$25 copayment per office visit Routine Non Medicare Covered--United: $25 copayment per office visit; limited to 20 visits per year; CIGNA: Not covered
$25 per office visit co-payment; Routine Non Medicare Covered--limit 6 annual visits
$190 co-payment per day for days 14, $0 copayment per day for days 5 and beyond

80% coverage;

Not covered

$10

subject to deductible

$10 min./$100 max.

*$10 retail/$20 Mail order 90 day supply

80% coverage;

Not covered

$30

subject to deductible

$10 min./$100 max.

*$25 retail/$50 Mail order 90 day supply

decision guide 2009

80% coverage; subject to deductible $10 min./$100 max.
Not applicable

Not covered Not covered

$75 Not covered

*$50 retail/$100 Mail order 90 day supply
*$50 retail/$100 Mail order 90 day supply; Medicare Part B Covered Drugs--90% coverage

*Includes a Medicare approved Part D drug benefit; After total yearly out-of-pocket costs reach $4,350 you pay the greater of $2.40 for generic or

a preferred brand drug and $6 for all other drugs or 5% co-insurance.

25

SHBP MEDICARE POLICY

State Health Benefit Plan Medicare Policy
Georgia law requires that SHBP pay benefits after Medicare has paid
SHBP will calculate premiums and pay claims 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
Members who are enrolled in Medicare due to End Stage Renal Disease (ESRD) will need to contact the Social Security Administration to determine when Medicare becomes primary
Medicare information is available at:
www.cms.hhs.gov
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 period; November 15 December 31, 2008. 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 Medicare Part D enhanced prescription drug plan (PDP). Your individual pharmacy needs will indicate the level of coverage that is best for you.

decision guide 2009

26

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 you reach the PDP coverage gap, you should still present both identification cards and you will pay your SHBP co-payment
If your pharmacy can't bill both your Medicare Part D and SHBP, you will have to file a paper claim with the SHBP vendor or change drug stores
Check with the vendor regarding limits to submit a paper claim
Retirees have the same options as active employees as well as the two Medicare Advantage Private Fee-for-Service Plans for Prescription Drugs (MA PFFSPD). The MA PFFS-PD Plans have been designed to reduce the out-of-pocket expenses for retirees with Medicare Parts A and B.
If you enroll in one of the MA PFFS-PD options once retired, you do not need to join an individual Medicare Part D plan as these options include Part D.
You are not required to enroll in one of the MA PFFS-PD options; however, to pay the lowest premiums with SHBP, you may want to consider enrolling in Medicare Parts A, B and D.
If you elect to enroll in another Medicare Part D plan, your coverage in the MA PFFS option will end. To enroll in a SHBP-sponsored MA PFFS-PD, you must make your election on the Personalized Change Form and submit to SHBP. The MA PFFS option will mail you an application that you will need to complete.
If you are enrolled in Medicare Parts A or Part B, you are eligible for Part D. SHBP will provide secondary coverage to Medicare prescription drug plans. In many cases, a basic Part D plan will meet your needs as SHBP will pay benefits during any deductible and the "donut hole" that may apply under your Part D option.
Your individual pharmacy needs will determine the level of coverage that is best for you.
More detailed information can be found in this Retiree Decision Guide or at www.dch.georgia.gov/shbp_plans.

SHBP MEDICARE POLICY

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HRA AND HSA CONSIDERATIONS
HRA and HSA Considerations

Overview Who is eligible?

HRA
A tax-exempt account that reimburses retirees and dependents for qualified medical expenses. Can be funded by employer only.
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Available to SHBP members enrolled in an HRA. See benefits chart for amounts funded by SHBP.

HSA
A tax-exempt custodial account that exclusively pays for qualified medical expenses of the employee and his or her dependents. Can be funded by retiree, employer, or other party.
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Available to SHBP members who elect HDHP. SHBP does not fund these accounts.

Can I have other coverage and

Yes.

take advantage of this benefit?

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?

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

Is there a monthly service charge?
If I terminate my SHBP coverage or change options...

No.
Unused amounts can be distributed until depleted to pay for claims incurred before termination.

Check with your HSA administrator.
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.

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IMPORTANT NOTICE
October 1, 2008
Two Peachtree Street Atlanta, GA 30303 (404) 656-6322 (800) 610-1863
About Your Prescription Drug Coverage with PPO, United Healthcare HMO, UnitedHealthcare Definity, Kaiser Permanente, CIGNA Healthcare Open Access Plus PPO, CIGNA Healthcare Open Access Plus In-Network HMO, CIGNA Healthcare Choice Fund HRA and Medicare
For Plan Year: January 1December 31, 2009
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 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 State Health Benefit Plan has determined that the prescription drug coverage offered by the UnitedHealthcare PPO, United Healthcare HMO, UnitedHealthcare Definity, Kaiser Permanente, CIGNA Healthcare Open Access Plus PPO, CIGNA Healthcare Open Access Plus In-Network HMO, CIGNA Healthcare Choice Fund HRA offered under SHBP is, 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 SHBP coverage voluntarily, 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 State Health Benefit Plan coverage will be affected. See below for more information about what happens to your current coverage if you join a Medicare drug plan. You can keep your SHBP coverage if you elect Part D and SHBP will coordinate with Part D coverage. Your premiums will also be reduced by each Part of Medicare you have. You should send a copy of your Medicare cards to SHBP at P. O. Box 38342, Atlanta, GA 30334.
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decision guide 2009

IMPORTANT NOTICE
If you do decide to join a Medicare drug plan and drop your coverage with the State Health Benefit Plan, be aware that you and your dependents can not get this coverage back if you are a retiree.
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 SHBP Current Prescription Drug Coverage...
Contact the SHBP Eligibility Unit at (404) 656-6322 or (800) 610-1863. 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 this coverage through the State Health Benefit 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. 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: Visit www.medicare.gov Call your State Health Insurance Assistance Program (see the inside back cover of 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
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, 2008 Name of 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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decision guide 2009

IMPORTANT NOTICE

Two Peachtree Street Atlanta, GA 30303 (404) 656-6322 (800) 610-1863

October 1, 2008

Important Notice from the SHBP about Your Prescription Drug Coverage and Medicare
About Your Prescription Drug Coverage with the CIGNA Healthcare Open Access Plus and UnitedHealthcare High Deductible Health Plan and Medicare
For Plan Year: January 1December 31, 2009
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 Non-Creditable 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 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 good as the 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 your HDHP coverage under SHBP; you will be eligible to join a Part D plan at that time using an 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.

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31

IMPORTANT NOTICE
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.
If you enroll in Medicare Part D when you become eligible for Medicare Part D, you can keep your HDHP coverage even if you elect Part D and the HDHP will coordinate benefits with the Part D coverage.
If you do decide to join a Medicare drug plan and drop your HDHP coverage under SHBP, be aware that you and your dependents will not be able to get your SHBP coverage back if you are a retiree.
You should also know that if you drop or lose your HDHP 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 percent 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 percent 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'll 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: Visit www.medicare.gov Call your State Health Insurance Assistance Program (see the inside back cover of 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
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, 2008 Name of 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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decision guide 2009

Notify the Plan of any fraudulent activity regarding Plan members, providers, payment of benefits, etc. Call 1 877-878-3360 or 404 463-7590.
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 participants, 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: The material in this booklet 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.

Thanks to all of you who participated in the State Health Benefit Plan's "Georgia's Nuts About Health" wellness initiative. It's never too late to be healthy! www.nutsabouthealth.ga.gov