Retiree decision guide 2012

Plan chanGes

RetiRee Decision GuiDe 2012
Are you engaged in your health?
RETIREE OPTION CHANGE PERIOD OCTOBER 11 NOVEMBER 10, 2011 www.myshbp.ga.gov
1

aDDitional helP/contact inFoRMation
State Health Benefit Plan (SHBP): www.myshbp.ga.gov

Vendor
CIGNA HRA, HMO, HDHP hours 8 a.m. 8 p.m. local time zone; Monday Friday
Humana Group Medicare PPO Plan (An Alliance with CIGNA) Retiree Help Line hours 8 a.m. 8 p.m. local time zone; Monday Friday
UnitedHealthcare Retiree Help Line HRA HMO, HDHP hours 8 a.m. 8 p.m. local time zone; 7 days a week, TTY 711
SHBP Eligibility
Additional Information
Centers for Medicare & Medicaid (CMS) 24 hours a day / 7 days a week
Social Security Administration

Member Services
800-633-8519 TTY 711
800-942-6724 TDD 711
877-246-4190 800-396-6515 877-246-4189
800-610-1863 Member Services
800-633-4227 TTY 877-486-2048
800-772-1213

Website www.mycigna.com/shbp
www.humana.com/stateofga www.mycigna.com/shbp
www.uhcretiree.com/shbp
www.myshbp.ga.gov Website
www.medicare.gov www.ssa.gov

Listed below are common health care acronyms that are used throughout this decision guide.

CDHP Consumer-Driven Health Plan CMS Centers for Medicare and Medicaid Services COB Coordination of Benefits 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

MA (PPO) Medicare Advantage Preferred Provider Organization OE Open Enrollment PCF Personalized Change Form PCP Primary Care Physician ROCP Retiree Option Change Period SHBP State Health Benefit Plan SPC Specialist SPD Summary Plan Description UHC UnitedHealthcare

Retiree Decision Guide 2012

David A. Cook, Commissioner

Nathan Deal, Governor

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

September 26, 2011
Dear State Health Benefit Plan (SHBP) Retiree:
It is my pleasure, as Commissioner of the Department of Community Health (DCH), to welcome you to the 2012 Retiree Option Change Period (ROCP). The dates for this year's ROCP are October 11November 10, 2011. Retirees will make their election for 2012 at the new website, www.myshbp.ga.gov, or by returning their enclosed Personalized Change Form to SHBP no later than November 10, 2011.
Like other states, we in Georgia face a number of fiscal and regulatory challenges that have had an impact on our State Health Benefit Plan. We are committed to finding innovative solutions to address these challenges in a way that keeps premiums down, preserves the fiscal integrity of the plan for the future, promotes the health and wellness of our members and offers SHBP members a choice. You will see that this year we have made a number of changes consistent with this approach.
Medicare-eligible retirees may continue to choose between the Humana or UnitedHealthcare Medicare Advantage PPO Standard or Premiums Plans. We are pleased to offer a new TRICARE supplement plan option for those members eligible through their military service.
In addition, we are pleased to announce the introduction of new Standard and voluntary Wellness Plan options. The Wellness plan options offer a discount on premiums to those members who choose to actively engage in wellness activities. Our new Standard Plans do not require our members to engage in wellness activities but will have higher premiums and out-of-pocket costs than the new Wellness Plan options.
Please take the time to learn more about these and other plan changes before making your 2012 Plan year election. This Decision Guide, along with the other plan materials and tools, is designed to help you choose the plan that is best for you and your family. All of this information is available online at www.myshbp.ga.gov.
All of us at DCH are committed to doing the best job possible to meet the current and future needs of our members. Because your feedback is important to us, we have included a survey for you to complete after you have made your online 2012 Plan election. Please take the time to complete the survey to help us better serve you.
Sincerely,

David A. Cook Commissioner

Retiree Decision Guide 2012

WelcoMe to the RetiRee oPtion chanGe PeRioD (RocP)
Website available October 11, at 4a.m. November 10, 4:30p.m. FOR PLAN COVERAGE JANUARY 1, 2012 DECEMBER 31, 2012
In this guide, you will find what's changing for the 2012 Plan Year, a brief explanation of each health insurance option, a list of things to consider before making your decision and a benefit comparison chart. See the Table of Contents below to review the sections that apply to your situation.
TabLe of ConTenTs Additional Help/Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inside Front Cover Plan Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Making Your Health Elections for 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Benefits When Not Eligible for Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Benefits When Medicare-Eligible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 SHBP Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Legal Notices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
The material in this booklet is for informational purposes only 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 federal or state law changes or as approved by the Board of the Department of Community Health.
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2012 Plan chanGes

annoUnCInG neW PLan oPTIons
SHBP is excited to announce new Wellness and Standard plan offerings through CIGNA and UnitedHealthcare (UHC). You will be able to select coverage from the following options during ROCP:

CIGNA Wellness HRA

CIGNA Standard HRA

CIGNA Wellness HDHP

CIGNA Standard HDHP

CIGNA Wellness HMO

CIGNA Standard HMO

UHC Wellness HRA

UHC Standard HRA

UHC Wellness HDHP

UHC Standard HDHP

UHC Wellness HMO

UHC Standard HMO

TRICARE Supplement

The Wellness Options are designed to help you (and your spouse, if covered) become a more active participant in your health and require you to take additional steps in engaging in better health. If you do not wish to participate in the Wellness Options, the Standard Options are available to you. With these new Plan Options, all members will need to make a new election this year. Please go to page 3 for more information.

The new TRICARE Supplement option is available to active and retired military enrolled in TRICARE. Please see page 11 for more information.

neW Web PoRTaL - www.myshbp.ga.gov
SHBP has a new website for you to make your election during the ROCP for the 2012 Plan Year and to obtain information about benefits, premiums, etc. Just go to www.myshbp.ga.gov. You can also access this site after ROCP closes and view the election you made for the 2012 Plan Year. See page 3 for more information.

TobaCCo CessaTIon MeDICaTIon
SHBP will now provide limited coverage of tobacco cessation medications. To find out how to qualify for coverage of these medications, contact your health care vendor (CIGNA or UHC) for details. For removal of the Tobacco Surcharge, see the Tobacco Surcharge policy online at www.myshbp.ga.gov.

HRa PResCRIPTIon DRUG benefITs
Prescription drugs will change to a three (3) tier structure with a minimum and maximum co-insurance amount paid by the member. You no longer have to satisfy a deductible before pharmacy benefits are paid. In addition, you may continue to use your HRA credits to pay for your new pharmacy co-insurance amounts but any monies credited for pharmacy expenses will no longer be combined with your medical benefits to satisfy your deductible and out-of-pocket maximum. In other words, only your medical expenses will count toward your deductible and out-of-pocket max. Once all your HRA credits have been exhausted, you will continue to pay only your co-insurance amounts without having to satisfy your deductible and out-of-pocket max. The benefits are the same for the Wellness and Standard Plans.

Note: UnitedHealthcare members will need to present their new Pharmacy Health Care Spending Card (PHCSC) and medical ID card to access their HRA credits. Once your information is on file with your pharmacy you only need to present your PHCSC to pay for your covered medications. The PHCSC must be activated 1 business day before presenting it at the pharmacy. No separate card is required for CIGNA.

HRa PHaRMaCY InfoRMaTIon

Coverage Tier

Wellness and Standard HRA Plans

Retail Pharmacy Tier 1 15% ($20 min/$50 max) Tier 2 25% ($50 min/$80 max) Tier 3 25% ($80 min/$125 max)

90-Day Retail Pharmacy

Tier 1 15% ($60 min/$150 max) Tier 2 25% ($150 min/$240 max) Tier 3 25% ($240 min/$375 max)

90-Day Voluntary Mail Pharmacy

Tier 1 15% ($50 min/$125 max) Tier 2 25% ($125 min/$200 max) Tier 3 25% ($200 min/$312.50 max)

PeaCHCaRe foR KIDs enRoLLMenT
Federal law has changed and now allows the PeachCare for Kids program to enroll children of members covered under SHBP. See page 6 for more information.
baRIaTRIC sURGeRY CoVeRaGe
Bariatric surgery will no longer be covered under any plan option.

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Plan chanGes

VIsIon HaRDWaRe/Lens CoVeRaGe
The $200 Vision hardware/lens benefit will no longer be available under either of the HMO options.
InCRease In PReMIUMs
All SHBP members will have an increase in health premiums for 2012. The amount of the increase varies based on the plan option selected. Please refer to the rates posted online and on your personalized change form. Rates are also posted on www.myshbp.ga.gov.
sPoUsaL sURCHaRGe VeRIfICaTIon
Members covering their spouses are required to pay the Spousal Surcharge if their spouse is eligible for health insurance under their own employer and does not enroll in that coverage. SHBP will be requesting from you documentation or an affidavit from your spouse's employer verifying the spouse is not eligible for health insurance. Therefore, it is important that you answer the Spousal Surcharge questions accurately to avoid disruption of coverage. You do not need to take any additional action until documentation is requested.
eLIGIbILITY CHanGes
SHBP will now allow 90 days from the date of birth to add a newborn. You must have you + child(ren) or family coverage at time of birth for newborn charges to be covered
SHBP will now allow 90 days for the surviving spouse to notify us of the death of the SHBP member to request to continue coverage
eLeCTIon eRRoR RePoRTInG
It is important to verify the accuracy of your election, that you received the correct insurance card and, if having premiums deducted from an annuity, the correct amount is deducted from your check. If you discover that a mistake was made, you have until December 31, 2011 to notify SHBP to correct the mistake. You can view your coverage election even if made online at www.myshbp.ga.gov after ROCP closes and see the amount that will be deducted from your check. A letter is sent to all retirees prior to the new Plan Year advising the new health premium amount for 2012. Please verify for accuracy.

DIsease ManaGeMenT PHaRMaCY Co-PaYMenT/Co-InsURanCe WaIVeR PRoGRaM
This program will only be available for members enrolled in the Wellness HMO and Wellness HRA Plan Options. Contact CIGNA or UnitedHealthcare for details.
neW PLan oPTIons
The HRA, HDHP and HMO Options will be replaced by the Wellness and Standard HRA, HDHP and HMO Options offered by CIGNA and UnitedHealthcare.
neW WeLLness PLan oPTIons
The Wellness Plan Options are part of a multi-year Wellness Program. Each year, a member electing one of the Wellness Plans promises to take additional steps toward better health than members who enroll in a Standard Plan. Once enrolled in a Wellness Plan, members must complete those additional steps to retain eligibility for a Wellness Plan the following year. Enrollment in a Wellness Plan is voluntary. Members who do not wish to participate in a Wellness Plan may elect one of the Standard Plans and will not be required to take any additional steps.
Year one Wellness Plan Requirements When you enroll in a Wellness Option, you will complete a Wellness Promise to take the following two actions:
1) You and your spouse (if covered) will complete your Plan's (CIGNA or UnitedHealthcare) online Health Assessment through www.mycigna.com or www.myuhc.com between January 1 June 30, 2012; and
2) You and your spouse (if covered) will obtain a biometric screening between July 1, 2011 and June 30, 2012. The required screening must include the following four measurements: blood pressure, body mass index (BMI) cholesterol and glucose.
These screenings are considered preventive and are covered at 100%. The Promise applies only to the SHBP member and spouse (if covered).
Screenings may be obtained at your in-network physician's office. Your physician must complete the "physician screening form" and securely fax the form to your health care

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vendor. The physician screening form will be available on January 1, 2012 at www.mycigna.com, www.myuhc.com and www.myshbp.ga.gov.
If you do not take the Health Assessment, complete and have your physician submit the results of the required screening that includes all four measurements by the June 30, 2012 deadline, you will not be eligible to enroll in any of the Wellness Plan Options the following year.
Your reward for making the Wellness Promise and enrolling in one of the Wellness Plans is lower premiums and lower out-of-pocket expenses than in the Standard Plans. There are also slight differences between the Wellness and Standard Plan designs that are outlined in the charts on pages 13-20.
Year Two Wellness Plans Requirements During year two of the program, you and your spouse (if covered) will be required to complete the health assessment and complete the screenings again. In addition to these two requirements, those members whose screening results are not within normal limits for any biometric target, must demonstrate that they are attempting to reach these targets. The requirement is for the member to engage by taking action, regardless of whether the target is actually achieved or not. Members who can not attempt to achieve the targets due to a medical condition must have their doctor submit a form that will be available through their health care vendor. Information regarding the required actions for year two will be available by next year's open enrollment. Requirements may change for the program each year so make sure you carefully read the information about the Wellness program each year.
If you decide not to participate in a Wellness Option in year one, you will have the opportunity to participate in year two, if you wish.

YoUR HeaLTH & WeLLness
After completing your biometric screening you should follow up with your Primary Care Physician (PCP) to discuss your test results and to develop an individual health and wellness plan. If you don't have a PCP, each vendor has an online tool to assist you in finding a physician. Just sign on to the vendor's website and click on the Find a Doctor/Physician link. Developing an ongoing relationship with one physician who knows you and your medical history can lead to better overall outcomes and lower health care costs.
If your biometric results are out-of-range, both vendors have telephonic and online wellness coaching programs and resources available to help you on your road to a healthier you. These programs are free for covered members. The chart at the bottom of the page suggests programs you may want to consider.
What else Can I Do for My Health and Wellness? Utilize the Preventive Health and Wellness Services Use the Nurse Advice Line Use Vendor Online Tools -There is a wealth of
information available at your fingertips online --You can compare prescription drug costs --You can access health coaching programs --You can locate a premier doctor if you are having
surgery --You can locate a doctor in the network --You can review the status of claims and review
benefits --You can track your balances in the HRA --Order an ID card
To learn more about these and other helpful tools and resources go to www.mycigna.com and www.welcometouhc.com

TaKe sTePs To GeT HeaLTHY online and Telephonic Coaching Programs and Resources available to You Through the Vendors

Biometric Screening Cholesterol Blood Sugar Blood Pressure Body Mass Index (BMI)

Weight Management
X X X

Exercise X X

Stress X

Heart Health X
X X

Diabetes X X

Nutrition X X
X

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Plan chanGes

Georgia statistics show How our Choices May be affecting our Health 27% of adults are obese, which increases the risk of
cardiovascular disease
Cardiovascular Disease (CVD) accounted for one third (32%) - 21,389 CVD deaths in 2007
Adults with high blood pressure has increased from 21% in 1997 to 30% in 2007
Adults with high cholesterol has increased from 24% in 1997 to 37% in 2007
Adults reported having diabetes increased from 6% in 1998 to 10% in 2008
The majority (75%) of adults did not consume the recommended five or more servings of fruits and vegetables per day in 2007
sTanDaRD PLan oPTIons
SHBP will also offer HRA, HMO and HDHP Standard Plans. Under these Plans, you will not have to make a promise or take steps to improve your health. The same services will be covered under these Plans but you will have higher premiums, co-payments, deductibles, coinsurance and out-of-pocket maximums.
HRA Plan you will not be able to earn the $125 for obtaining your annual physical and taking your online health assessment
Disease Management Program Waiver will not apply to the Standard Plans
You should carefully compare the benefits under each plan on page 13 - 20.

Wellness and standard Plan Differences

HRa PLan

Coverage Tier

Wellness HRA Contribution

Standard HRA Contribution

You You + Spouse You + Child(ren)

$500 $1,000 $1,000

$375 $650 $650

You + Family

$1,500

$1,000

HDHP PLan

Deductible (In/Out-of-Network)

Wellness HDHP

Standard HDHP

You

$1,500/$3,000 $1,750/$3,500

You + Spouse

$3,000/$6,000 $3,500/$7,000

You + Child(ren)

$3,000/$6,000 $3,500/$7,000

You + Family

$3,000/$6,000 $3,500/$7,000

Out-of-Pocket Maximum (In/Out-of-Network)

You

$2,400/$5,300 $2,650/$5,800

You + Spouse

$4,100/$9,800 $4,600/$10,800

You + Child(ren)

$4,100/$9,800 $4,600/$10,800

You + Family

$4,100/$9,800 $4,600/$10,800

Co-insurance (In/Out-of-Network)

Co-insurance

90% / 60%

80% / 60%

Mail Order

90-Day Mail Order

80% ($25 min/$250 max) No non-network coverage

HMo PLan

Type of Service

Wellness HMO Standard HMO Co-Payment Co-Payment

Primary Care Physician

$35

$45

Specialist

$45

$55

90-Day Mail Order

Tier 1--$50 Tier 2--$125 Tier 3--$225

IMPORTANT REMINDERS
SHBP introduced the voluntary mail pharmacy benefit program on July 1, 2011. Please refer to the chart on pages 19-20 for this benefit.

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PeaCHCaRe foR KIDs
We are happy to announce that effective January 1, 2012 employees eligible for SHBP coverage may now enroll their children in the PeachCare for Kids Program if they meet PeachCare requirements. Program information is available at www.peachcare.org. PeachCare provides the same coverage as private programs- including check-ups, prescription medicine, dental and vision care. Some additional benefits of PeachCare are low premiums and no deductibles. Currently, the monthly premium for PeachCare coverage is $10 to $35 for one child and a maximum of $70 for two or more children living in the same household, depending on household income.
The PeachCare for Kids website will have an income calculator available to help you determine if your children are potentially eligible for this program. If you enroll your children, and they are accepted into the program, you have 60 days to notify SHBP of the enrollment so SHBP can remove the children from SHBP coverage and change your premiums (if your tier will change). Children cannot be covered under both SHBP and PeachCare. If you child loses PeachCare coverage in the future, you have 60 days from the date of the loss of PeachCare coverage to enroll your children in SHBP. It is not considered a qualifying event to enroll your children in SHBP coverage if PeachCare denies enrollment. Therefore, you should not discontinue coverage for your child until you receive confirmation that PeachCare has approved their enrollment.
Please contact PeachCare for Kids directly regarding any questions about this program. The web-site address is www.peachcare.org; phone 1-877-427-3224/ 1-877-GA PEACH.
Retiree Decision Guide 2012 6

MaKinG YouR health election FoR 2012

MaKinG YouR health election FoR 2012

WHaT sHoULD I Do befoRe MaKInG MY eLeCTIon?
Evaluate your health care needs and compare the benefits under each option in relation to the premiums by going to www.mycigna.com or www.welcometomyuhc.com. These sites explain the differences in the plans and have cost estimator tools to help you determine which plan costs are less along with other valuable tools
Verify your provider(s) will be participating in the option you choose by going to the vendors' websites or calling the vendors
Check the distance you will have to drive to see your provider(s)
Check the Preferred Drug Lists of each vendor for each option to see if your prescriptions are covered and at what co-payment or co-insurance level
If you fail to answer the surcharge questions, surcharges will apply. Steps for removal of surcharges can be found at www.myshbp.ga.gov
WHo sHoULD I ConTaCT If I HaVe QUesTIons?
benefit Questions: Contact CIGNA for HRA, HMO or HDHP Options
800-633-8519
Contact Humana for questions about the MA PO Plan 800-942-6724
UnitedHealthcare Line 877-246-4190
eligibility Questions: SHBP Call Center 800-610-1863
SHBP E-Mail shbpnoreply@dch.ga.gov
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 dependents) 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.
IMPORTANT NOTES
Medicare Advantage: If you don't make an election and are in a MA PPO Option, SHBP will default your coverage to your current health plan and vendor
Split Option: If you do not make an election, your coverage will default to the Standard of the HRA, HMO or HDOP Option with your current tier and vendor with no surcharges and the person in the MA PPO will default to the current MA PPO Option
HRA, HMO, HDHP: If you do not make an election and are in the HRA, HMO or HDHP Plan, your coverage will default to the Standard HRA, HMO or HDHP Option with your current tier and vendor and any applicable surcharges will apply
State on State Coverage there is no benefit in being covered by two SHBP plans
If you have the HRA Option and elect another option, any unused HRA dollars will be forfeited
HoW Do I DeCIDe WHICH PLan Is besT foR Me?
This can be a difficult decision but listed below are some things you may want to consider when making your decision.
Are you able to afford your prescription drugs if you have to satisfy a deductible? If the answer is "No" then you should consider enrolling in the HRA or HMO Option
If you have very low or very high medical expenses, you may want to consider enrollment in the HRA or HDHP Plans. The premiums are lower than the HMO and the coinsurance applies to your out-of-pocket limit (except for prescription drugs under the HRA). With high medical expenses, the out-of-pocket limit is reached more quickly and expenses are then paid at 100% after the limit is reached.

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MaKinG YouR health election FoR 2012

If you have very low expenses, the premium is lower in the HRA and you have 100% coverage for covered services until your HRA dollars are exhausted. Also, if you don't use all of your HRA dollars, they will roll to the next year provided you are in a HRA Option.
If you take a number of prescriptions, compare costs for your prescriptions under each plan and you may want to consider using the Mail Order Program which should lower your prescription drug costs.
MaKInG MY 2012 eLeCTIon
Online Online at www.myshbp.ga.gov;
4 a.m. October 11 4:30 p.m. November 10
You must register before you can log in to the website
If you are unable to access the site, contact SHBP for assistance at 800-610-1863
Make sure you select the correct option and tier you wish to have for the 2012 Plan Year
Answer the surcharge questions if they are presented (non MA PPO or Split Plans only)
Verify your dependents
Verify your home address
Remember to click CONFIRM to finalize your election
You may go online multiple times; however, the last option selected and confirmed at the close of ROCP will be your option for 2012 unless you experience a qualifying event that allows you to make a change
Remember a confirmation number will be shown once your election has been processed. You should copy this number or print the confirmation page and keep it
Your election must be confirmed by the end of the ROCP at 4:30 p.m. on November 10, 2011
Do not wait until the last minute to make your election as web traffic and SHBP phone volumes are unusually heavy near the end of ROCP
Paper Your Personalized Change Form (PCF) is on the
reverse side of the insert showing your address
Check the option and tier that you choose for the 2012 Plan Year

Verify your dependents
Verify your home address
Verify you have correctly answered the Tobacco and Spousal Surcharge questions if presented
Sign and date your Personalized Change Form
Envelope must be postmarked by November 10, 2011 in order for your election to be valid
IMPORTANT REMINDERS
If you complete both online and paper enrollment, if the elections are different in any way, it may result in you being placed in an incorrect option. Please do one or the other-not both
If you are eligible for Medicare due to age and are not enrolling in one of the MA PPO Options, you will not be able to make your election online. You will need to complete the Personalized Change Form. The form will be in your Retiree Option Change Packet.
Remember you only have 31 days before or after a qualifying event to add a dependent (90 days for a newborn)
Remember to keep your address current. Only you or your authorized designee can change your address
RoCP eLeCTIon eRRoRs
Confirmation of web elections will be available on the website by December 1. You will also receive a letter notifying you of a change in your health insurance premium. This should be reviewed prior to December 31, 2011 to identify any possible election error made during ROCP. If you are a COBRA or DIRECT PAY member, you must verify your election by the amount shown on your billing statement is correct by December 31, 2011
You must notify SHBP by December 31, 2011 if you feel you made an error in making your election
You should fax any correction of an ROCP mistake to 866-828-4796 or mail to P.O. Box 1990, Atlanta, GA 30301-1990. Requests for correction must be received by December 31, 2011

Retiree Decision Guide 2012 8

BeneFits When not eliGiBle FoR MeDicaRe

BeneFits When not eliGiBle FoR MeDicaRe

UnDeRsTanDInG YoUR PLan oPTIons
Whether you are enrolled in one of the Wellness or Standard Plan Options, the plans provide a statewide and national network of providers across the United States. None of the plan options require the selection of a primary care physician (PCP) or referrals to a specialist. In addition, there are no lifetime maximums and all preventive care benefits are covered at 100% at no cost to you when you use in-network providers only.
Please keep in mind, if you change options or vendors (CIGNA or UnitedHealthcare) during the year, any amounts applied toward your deductible or out-of-pocket are not transferred to the new option.
HeaLTH MaInTenanCe oRGanIzaTIon (HMo)
A HMO provides major medical, treatment of illness including pharmacy coverage only when using in-network providers (except in cases of emergencies). This Plan features certain services that are subject to a deductible and co-insurance which count toward your out-of-pocket maximum. However, co-payments do not count toward your deductible or out-of-pocket maximum. Although you are not required to obtain a referral to a specialist (SPC), you are encouraged to select a PCP to help coordinate your care. See pages 13-20 for more information.

HeaLTH ReIMbURseMenT aRRanGeMenT (HRa)
The HRA is a Consumer-Driven Health Plan Option (CDHP) that includes a SHBP funded health reimbursement account that provides first dollar coverage for eligible health care and pharmacy expenses. Because this Plan has a deductible that must be satisfied and co-insurance amounts used to meet your out-of-pocket maximum, the amount funded by SHBP into your HRA is used to help offset some of your initial upfront costs. Pharmacy claims are not applied to the deductible or out-of-pocket maximum including any amounts paid out of your HRAfund for pharmacy expenses.
To illustrate how this works, the following is an example of how your HRA fund can help lower some of your medical out-of-pocket expenses. In the new Wellness Plan Option with family coverage, the money funded by SHBP can help cover the first $1,500 of your out-of-pocket expenses. This will lower your family deductible of $3,250 to $1,750. Once the remainder of the deductible has been satisfied, the Plan pays 85% of your in-network expenses or 60% of your out-of-network expenses until you reach your out-of-pocket maximum. Once your out-of-pocket maximum has been met, the Plan pays at 100%.
Any unused dollars in your HRA roll over to the next Plan Year if you are still participating in this Option, but will be forfeited if you change options during the ROCP or due to a qualifying event.

One special benefit for enrolling in the Wellness HMO or Wellness HRA Plans is that certain drug costs are waived if SHBP is primary and you participate and remain compliant in one of the Disease State Management (DSM) Programs for Diabetes, Asthma and/or Coronary Artery Disease.

Please remember if you enroll in this Plan after the 1st of the year, your HRA dollars are pro-rated but the deductibles are not.

9 Retiree Decision Guide 2012

BeneFits When not eliGiBle FoR MeDicaRe

HIGH DeDUCTIbLe HeaLTH PLan (HDHP)
The HDHP Option offers in-network and out-of-network benefits and provides access to a network of providers on a statewide and national basis across the United States. This Plan has a low monthly premium but you must satisfy a separate in-network and out-of-network deductible and out-of-pocket maximum. The deductible applies to all health care expenses including pharmacy before benefits are paid. However, preventive care is covered at 100% when seeing an in-network provider and you do not have to satisfy the deductible. If you cover dependents, you must meet the ENTIRE deductible before benefits are payable for any covered member. You pay co-insurance after you have satisfied the deductible rather than set dollar co-payments for medical expenses and prescription drugs until the out-of-pocket maximum is met. 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 13 to compare benefits under the HDHP to other Plan Options. Go to www.irs.gov/publications/p969 for more information.
IMPORTANT INFORMATION
Prescription drug coverage under the HDHP Plan is not creditable. That means if you don't sign up for Medicare Part D plan if still working or the MA Plan when you first become eligible, you may be charged a late enrollment penalty. See the legal notice for more information.

HeaLTH saVInGs aCCoUnT (Hsa) InfoRMaTIon onLY
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 a bank or an independent HSA administrator/custodian.
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; or 4) General Purpose Health Care Spending Account (GPHCSA) or any other non-qualified medical plan. SHBP does not offer an HSA account.
You can contribute up to $3,100 single, $6,250 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, and over-the-counter medications when a doctor states they are medically necessary) 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 an additional $1,000 if you are 55 or older (see IRS Publication 969 at www.irs.gov)

Retiree Decision Guide 2012 10

BeneFits When not eliGiBle FoR MeDicaRe

TRICaRe sUPPLeMenT foR eLIGIbLe MILITaRY MeMbeRs
The TRICARE Supplement Plan is an alternative to SHBP coverage that will be offered to employees and dependents who are eligible for SHBP coverage and are also eligible for the TRICARE Supplement Plan. The TRICARE Supplement Plan is not sponsored by the SHBP, the Department of Community Health or any employer. The TRICARE Supplement Plan is sponsored by the American Military Retirees Association and is administered by the Association & Society Insurance Corporation. In general, to be eligible, the employee and dependents must each be under age 65, ineligible for Medicare and registered in the Defense Enrollment Eligibility Reporting System (DEERS). For complete information about eligibility and benefits, contact 866-637-9911 or visit www.asicorporation.com. You may also find information at www.myshbp.ga.gov.
The TRICARE Supplement Plan works with TRICARE to pay the balance of covered medical expenses after TRICARE pays. The TRICARE Supplement Plan helps to pay 100% of members' TRICARE outpatient deductible, cost share, co-payments plus 100% of covered excess charges. Members have flexibility and freedom of choice in selecting civilian providers (physicians, specialists, hospitals and pharmacies).

Points to Consider if You elect TRICaRe supplement Plan Coverage Effective January 1, 2012, TRICARE will become
your primary coverage
TRICARE Supplement Plan will become the secondary coverage
The eligibility rules and benefits described in the TRICARE Supplement Plan will apply
Unmarried adult children under the age of 26 who are no longer eligible for regular TRICARE must be enrolled in TRICARE Young Adult (TYA) through TRICARE before enrolling in the TRICARE Supplement Plan
Unmarried children under the age of 21 or 23 if a fulltime student who are no longer eligible for regular TRICARE must be enrolled in TRICARE Young Adult (TYA) through TRICARE before enrolling in the TRICARE Supplement Plan
Tobacco and Spousal Surcharges will not apply
COBRA rights will not apply
If you or your dependents lose eligibility for SHBP coverage while you are enrolled in the TRICARE Supplement Plan, you will be offered a portability feature by the Association & Society Insurance Corporation (ASI), administrator of TRICARE Supplement
Loss of eligibility for the TRICARE Supplement Plan is a qualifying event. If you continue to be eligible for coverage under the SHBP, you may enroll in an SHBP Option outside of the Open Enrollment period if you make a request within 31 days of losing eligibility for the TRICARE Supplement Plan

11 Retiree Decision Guide 2012

BeneFits When not eliGiBle FoR MeDicaRe

Attainment of age 65 and eligibility for Medicare causes a loss of eligibility for TRICARE Supplement Plan coverage. This is a qualifying event and retirees must make a request within 31 days in order to reenroll in an SHBP coverage option
Retirees who elect TRICARE Supplement Plan coverage may discontinue TRICARE Supplement Plan coverage and re-enroll in SHBP coverage in the future as long as they maintain continuous coverage with either the TRICARE Supplement Plan or SHBP coverage and properly submit the required change forms to SHBP durning the ROCP
IMPORTANT INFORMATION
Neither SHBP or ASI can verify eligibility for TRICARE or register you or your dependents in DEERS. Only the employee, spouse or dependent child age 18 or older can verify eligibility and register in DEERS. To verify eligibility and register in DEERS, contact DEERS at 800-538-9552
Employers are prohibited by law from paying any portion of the cost of TRICARE Supplement Coverage
Questions about eligibility or benefits should be address to ASI at www.asicorporation.com or call 866-637-9911.
Retiree Decision Guide 2012 12

Benefits comparison: Wellness hRa hDhP hMo Plans
schedule of benefits for You and Your Dependents for January 1, 2012 December 31, 2012

Covered Services
Deductible/Co-Payments You You + Spouse You + Child(ren) You + Family

Wellness HRA Option

Wellness HDHP Option

Wellness HMO Option

In-Network Out-of-Network In-Network Out-of-Network

In-Network

$1,300* $2,250* $2,250* $3,250*

$1,500 $3,000 $3,000 $3,000

$3,000 $6,000 $6,000 $6,000

$1,000 $1,500 $1,500 $2,000

*HRA credits will reduce this amount

Out-of-Pocket Maximum You You + Spouse You + Child(ren) You + Family

$3,000* $5,000* $5,000* $7,000*

$2,400 $4,100 $4,100 $4,100

$5,300 $9,800 $9,800 $9,800

$3,000 $4,500 $4,500 $6,000

*HRA credits will reduce this amount

HRA Credits You You + Spouse You + Child(ren) You + Family
Physicians' Services
Primary Care Physician or Specialist Office or Clinic Visits Treatment of illness or injury

$500 $1,000 $1,000 $1,500

The Plan Pays

85% coverage; subject to deductible

60% coverage; subject to deductible

None

The Plan Pays

90% coverage;
subject to deductible

60% coverage; subject to deductible

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)

100% coverage; not subject to deductible

Not covered

100% coverage; not subject to deductible

Not covered

None
The Plan Pays 100% after a $35 PCP or
$45 SPC per office visit co-payment
100% coverage; not subject to deductible

Maternity Care (prenatal, delivery and postpartum)
Physician Services Furnished in a Hospital Visits; surgery in general,
including charges by surgeon, anesthesiologist, pathologist and radiologist

85% coverage; subject to deductible
85% coverage; subject to deductible

60% 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

100% after initial $35 co-payment
80% coverage; subject to deductible

13 Retiree Decision Guide 2012

Benefits comparison: standard hRa hDhP hMo Plans
schedule of benefits for You and Your Dependents for January 1, 2012 December 31, 2012

Covered Services
Deductible/Co-Payments You You + Spouse You + Child(ren) You + Family

Standard HRA Option

Standard HDHP Option

Standard HMO Option

In-Network Out-of-Network In-Network Out-of-Network

In-Network

$1,300* $2,250* $2,250* $3,250* *HRA credits will reduce this amount

$1,750 $3,500 $3,500 $3,500

$3,500 $7,000 $7,000 $7,000

$1,000 $1,500 $1,500 $2,000

Out-of-Pocket Maximum You You + Spouse You + Child(ren) You + Family

$3,000* $5,000* $5,000* $7,000*

$2,650 $4,600 $4,600 $4,600

$5,800 $10,800 $10,800 $10,800

$3,000 $4,500 $4,500 $6,000

*HRA credits will reduce this amount

HRA Credits You You + Spouse You + Child(ren) You + Family
Physicians' Services
Primary Care Physician or Specialist Office or Clinic Visits Treatment of illness or injury

$375 $650 $650 $1,000

The Plan Pays

85% coverage; subject to deductible

60% coverage; subject to de-
ductible

None

The Plan Pays

80% coverage;subject to
deductible

60% coverage; subject to de-
ductible

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)

100% coverage; not subject to deductible

Not covered

100% coverage; not subject to deductible

Not covered

None
The Plan Pays 100% after a $45 PCP or
$55 SPC per office visit co-payment
100% coverage; not subject to deductible

Maternity Care (prenatal, delivery and postpartum)
Physician Services Furnished in a Hospital Visits; surgery in general,
including charges by surgeon, anesthesiologist, pathologist and radiologist

85% coverage; subject to deductible
85% coverage; subject to deductible

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

80% coverage; subject to deductible
80% coverage; subject to deductible

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

100% after initial $45 co-payment
80% coverage; subject to deductible

Retiree Decision Guide 2012 14

Benefits comparison: Wellness hRa hDhP hMo Plans
schedule of benefits for You and Your Dependents for January 1, 2012 December 31, 2012

Physicians' Services
Physician Services for Emergency Care

Wellness HRA Option

Wellness HDHP Option

In-Network Out-of-Network In-Network Out-of-Network

The Plan Pays
85% coverage; subject to deductible

The Plan Pays
90% coverage; subject to in-network deductible

Wellness HMO Option
In-Network
The Plan Pays
100% ($150 co-payment applies to facility expenses)

Outpatient Surgery When billed as office visit

85% coverage; 60% coverage; 90% coverage; 60% coverage;

subject to

subject to

subject to

subject to

deductible

deductible

deductible

deductible

Outpatient Surgery When billed as outpatient
surgery at a facility
Allergy Shots and Serum

85% coverage; subject to deductible
85% coverage; subject to deductible

60% 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

Hospital Services
Inpatient Services Inpatient care, delivery and inpatient short-term acute rehabilitation services

The Plan Pays

85% coverage; 60% coverage;

subject to

subject to

deductible

deductible

The Plan Pays

90% coverage; subject to deductible

60% coverage; subject to deductible

Inpatient Services Well-newborn care

85% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

Outpatient Surgery Hospital/facility

85% coverage; 60% coverage;

subject to

subject to

deductible

deductible

Emergency Care--
Hospital Treatment of an emergency medical condition or injury

85% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to in-network deductible

100% ($35 PCP or $45 SPC
co-payment if billed as office visit)
80% coverage; subject to deductible
100% for shots and serum after a $35 PCP or $45 SPC per visit co-payment; no co-payment if office visit not billed
The Plan Pays
80% coverage; subject to deductible
100% coverage; not subject to deductible
80% coverage; subject to deductible
100% after a $150 per visit co-payment; if admitted,
co-payment waived; 80% coverage; subject
to deductible

Outpatient Testing, Lab, etc.
Non Routine laboratory; X-Rays; Diagnostic Tests; Injections--including medications covered under medical benefits--for the treatment of an illness or injury

The Plan Pays

The Plan Pays

85% coverage; 60% coverage; 90% coverage; 60% coverage;

subject to

subject to

subject to

subject to

deductible

deductible

deductible

deductible

The Plan Pays
80% coverage; subject to deductible

15 Retiree Decision Guide 2012

Benefits comparison: standard hRa hDhP hMo Plans
schedule of benefits for You and Your Dependents for January 1, 2012 December 31, 2012

Physicians' Services
Physician Services for Emergency Care

Standard HRA Option
In-Network Out-of-Network
The Plan Pays 85% coverage; subject to
deductible

Standard HDHP Option
In-Network Out-of-Network
The Plan Pays 80% coverage; subject to
in-network deductible

Standard HMO Option
In-Network
The Plan Pays
100% ($150 co-payment applies to facility expenses)

Outpatient Surgery When billed as office visit
Outpatient Surgery When billed as outpatient
surgery at a facility Allergy Shots and Serum

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; 60% coverage;

subject to

subject to

deductible

deductible

85% coverage; subject to deductible
85% coverage; subject to deductible

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

80% coverage; subject to deductible
80% coverage; subject to deductible

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

100% ($45 PCP or $55 SPC
co-payment if billed as office visit)
80% coverage; subject to deductible
100% for shots and serum after a $45 PCP or $55 SPC per visit co-payment; no co-payment if office visit not billed

Hospital Services

The Plan Pays

Inpatient Services Inpatient care, delivery and inpatient short-term acute rehabilitation services

85% coverage; subject to deductible

60% coverage; subject to deductible

Inpatient Services Well-newborn care

85% coverage; subject to deductible

60% coverage; subject to deductible

Outpatient Surgery Hospital/facility

85% coverage; subject to deductible

60% coverage; subject to deductible

Emergency Care--
Hospital Treatment of an emergency medical condition or injury

85% coverage; subject to deductible

The Plan Pays

80% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to in-network deductible

The Plan Pays
80% coverage; subject to deductible
100% coverage; not subject to deductible
80% coverage; subject to deductible
100% after a $150 per visit co-payment; if admitted,
co-payment waived; 80% coverage subject
to deductible

Outpatient Testing, Lab, etc.
Non Routine laboratory; X-Rays; Diagnostic Tests; Injections--including medications covered under medical benefits--for the treatment of an illness or injury

The Plan Pays

85% coverage; subject to deductible

60% coverage; subject to deductible

The Plan Pays

80% coverage; 60% coverage;

subject to

subject to

deductible

deductible

The Plan Pays
80% coverage; subject to deductible

Retiree Decision Guide 2012 16

Benefits comparison: Wellness hRa hDhP hMo Plans
schedule of benefits for You and Your Dependents for January 1, 2012 December 31, 2012

Wellness HRA Option

Wellness HDHP Option

Wellness HMO Option

In-Network Out-of-Network In-Network Out-of-Network

In-Network

Behavioral Health

The Plan Pays

The Plan Pays

The Plan Pays

Mental Health and Substance Abuse Inpatient Facility and Partial Day Hospitalization NOTE: Contact vendor regarding prior authorization

85% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

Mental Health and Substance Abuse Outpatient Visits and Intensive Outpatient NOTE: Contact vendor regarding prior authorization

85% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

100% after $45 SPC per visit co-payment. $10 co-payment for group therapy

Dental

The Plan Pays

The Plan Pays

The Plan Pays

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

85% coverage; subject to
deductible

60% coverage; subject to deductible

90% coverage;
subject to deductible

60% coverage; subject to deductible

100% after $45 SPC per visit co-payment; if inpatient/ outpatient facility, 80% subject to deductible

NOTE: Notification required for all UHC options.

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

85% coverage; subject to
deductible

60% coverage; subject to deductible

90% coverage;
subject to deductible

60% coverage; subject to deductible

100% after $45 SPC co-payment for
related surgery and diagnostic services; excludes appliances and orthodontic treatment; if inpatient/ outpatient facility 80% subject to
deductible

Vision
Routine Eye Exam NOTE: Limited to one eye exam every 24 months

The Plan Pays

100% coverage; not subject to deductible

Eye exam not covered

The Plan Pays

100% coverage; not subject to deductible

Eye exam not covered

The Plan Pays
100% coverage not subject to deductible

Other Coverage

The Plan Pays

The Plan Pays

The Plan Pays

Hearing Services Routine hearing exam
Ambulance Services for Emergency Care NOTE: "Land or air ambulance" to nearest facility to treat the condition

85% coverage for routine exam and fitting; subject to deductible.
$1,500 hearing aid allowance every 5 years; not subject to
the deductible
85% coverage; subject to deductible

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

Not covered
100% coverage; not subject to deductible

Urgent Care Services NOTE: All subject to deductible except HMO

85% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

100% after $35 co-payment

17 Retiree Decision Guide 2012

Benefits comparison: standard hRa hDhP hMo Plans
schedule of benefits for You and Your Dependents for January 1, 2012 December 31, 2012

Standard HRA Option

Standard HDHP Option

Standard HMO Option

In-Network Out-of-Network In-Network Out-of-Network

In-Network

Behavioral Health

The Plan Pays

The Plan Pays

The Plan Pays

Mental Health and Substance Abuse Inpatient Facility and Partial Day Hospitalization NOTE: Contact vendor regarding prior authorization

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

Mental Health and Substance Abuse Outpatient Visits and Intensive Outpatient NOTE: Contact vendor regarding prior authorization

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

100% after $55 SPC per visit co-payment. $10 co-payment for group therapy

Dental

The Plan Pays

The Plan Pays

The Plan Pays

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

85% coverage; subject to
deductible

60% coverage; subject to de-
ductible

80% coverage; subject to deductible

60% coverage; subject to deductible

100% after $55 SPC per visit co-payment; if inpatient/ outpatient facility, 80% subject to deductible

NOTE: Notification required for all UHC options.

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

85% coverage; subject to
deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

Vision
Routine Eye Exam NOTE: Limited to one eye exam every 24 months

The Plan Pays

100% coverage; not subject to deductible

Eye exam not covered

The Plan Pays

100% coverage; not subject to deductible

Eye exam not covered

100% after $55 SPC co-payment for
related surgery and diagnostic services; excludes appliances and orthodontic treatment; if inpatient/ outpatient facility 80% subject to
deductible
The Plan Pays
100% coverage not subject to deductible

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

The Plan Pays
85% coverage for routine exam and fitting; subject to deductible. $1,500 hearing aid allowance every 5 years; not subject to the deductible

The Plan Pays
80% coverage for route exam and fitting; subject to deductible. $1,500 hearing aid allowance every 5 years; subject to the deductible

85% coverage; subject to deductible

90% coverage; subject to in-network deductible

The Plan Pays Not covered
100% coverage; not subject to deductible

Urgent Care Services NOTE: All subject to deductible except HMO

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

100% after $35 co-payment

Retiree Decision Guide 2012 18

Benefits comparison: Wellness hRa hDhP hMo Plans
schedule of benefits for You and Your Dependents for January 1, 2012 December 31, 2012

Wellness HRA Option

Wellness HDHP Option

Wellness HMO Option

In-Network Out-of-Network In-Network Out-of-Network

In-Network

Other Coverage

The Plan Pays

The Plan Pays

The Plan Pays

Home Health Care Services NOTE: Prior approval required

85% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

100% coverage; UHC up to 120 visits; CIGNA up to 120 days
per Plan year

Skilled Nursing Facility Services NOTE: Prior approval required

85% coverage; up to 120 days per
Plan year; subject to deductible

Not covered

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

Not covered

80% coverage; up to 120 days per Plan year; subject to deductible

Hospice Care NOTE: Prior approval required

85% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

100% coverage; subject to deductible

Durable Medical Equipment (DME)--Rental or purchase NOTE: Prior approval required for certain DME

85% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

100% coverage when medically necessary

Outpatient Acute Short-Term Rehabilitation Services Physical Therapy Speech Therapy Occupational Therapy Other short term
rehabilitative services

85% coverage; subject to
deductible; up to 40 visits per therapy per Plan year (not to exceed a total of 40 visits combined, including any out-of-net-
work visits)

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

90% coverage up 60% coverage up

to 40 visits per to 40 visits per

therapy per Plan therapy per Plan

year; subject to year; subject to

deductible (not to deductible (not to

exceed a total of exceed a total of

40 visits com- 40 visits combined,

bined, including including any

any out-of-

in-network visits)

network visits)

100% coverage after $25 per visit co-payment; up to 40 visits per therapy per
Plan year

Chiropractic Care NOTE: UHC Coverage up to a maximum of 20 visits; CIGNA up to a maximum of 20 days, per plan year
Foot Care NOTE: Covered only for neurological or vascular diseases

85% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

85% coverage; subject to deductible

60% coverage; subject to deductible

90% coverage; subject to deductible

60% coverage; subject to deductible

100% coverage after $45 SPC
co-payment per visit
100% coverage after $35 PCP or $45 SPC copayment per visit

Transplant Services NOTE: Prior approval required

Contact vendor for coverage details

Pharmacy - You Pay

Tier 1 Co-payment

15% ($20 min/ $50 max)
not subject to deductible

40% coverage; not subject to deductible*

Tier 2 Co-payment Preferred Brand

25% ($50 min/ $80 max)
not subject to deductible

40% coverage; not subject to deductible*

Tier 3 Co-payment Non-Preferred Brand

25% ($80 min/ $125 max)
not subject to deductible

40% coverage; not subject to deductible*

90-Day Voluntary Mail Order

Tier 115% ($50 min/$125 max) Tier 225% ($125 min/$200 max) Tier 325% ($200 min/$312.50 max)
Does not apply to deductible or out-of-pocket max

20% coverage; subject to
deductible $10 min/$100 max

Not covered

20% coverage; subject to
deductible $10 min/$100 max

Not covered

20% coverage; subject to
deductible $10 min/$100 max

Not covered

20% ($25 min/$250 max)

No non-network coverage

$20
$50
$90
Tier 1$50 Tier 2$125 Tier 3$225

19 Retiree Decision Guide 2012

Benefits comparison: standard hRa hDhP hMo Plans
schedule of benefits for You and Your Dependents for January 1, 2012 December 31, 2012

Standard HRA Option

Standard HDHP Option

Standard HMO Option

In-Network Out-of-Network In-Network Out-of-Network

In-Network

Other Coverage

The Plan Pays

The Plan Pays

The Plan Pays

Home Health Care Services NOTE: Prior approval required

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

100% coverage; UHC up to 120 visits; CIGNA up to 120 days
per Plan year

Skilled Nursing Facility Services NOTE: Prior approval required

85% coverage; up to 120 days per
Plan year; subject to deductible

Not covered

80% coverage up to 120 days per Plan Year; subject
to deductible

Not covered

80% coverage; up to 120 days per Plan year;
subject to deductible

Hospice Care NOTE: Prior approval required

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

100% coverage; subject to deductible

Durable Medical Equipment (DME)--Rental or purchase NOTE: Prior approval required for certain DME

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

100% coverage when medically necessary

Outpatient Acute Short-Term Rehabilitation Services Physical Therapy Speech Therapy Occupational Therapy Other short term
rehabilitative services

85% coverage; subject to
deductible; up to 40 visits per therapy per Plan year (not to exceed a total of 40 visits combined, including any out-of-net-
work visits)

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

80% coverage up 60% coverage up

to 40 visits per to 40 visits per

therapy per Plan therapy per Plan

year; subject to year; subject to

deductible (not to deductible (not to

exceed a total of exceed a total of

40 visits com- 40 visits combined,

bined, including including any

any out-of-

in-network visits)

network visits)

100% coverage after $25 per visit
co-payment; up to 40 visits per therapy per
Plan year

Chiropractic Care NOTE: UHC Coverage up to a maximum of 20 visits; CIGNA up to a maximum of 20 days, per plan year
Foot Care NOTE: Covered only for neurological or vascular diseases

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

100% coverage after $55 SPC
co-payment per visit
100% coverage after $45 PCP
or $55 SPC co-payment per visit

Transplant Services NOTE: Prior approval required

Contact vendor for coverage details

Pharmacy - You Pay

Tier 1 Co-payment

15% ($20 min/ $50 max)
not subject to deductible

40% coverage; not subject to deductible*

Tier 2 Co-payment Preferred Brand

25% ($50 min/ $80 max)
not subject to deductible

40% coverage; not subject to deductible*

Tier 3 Co-payment Non-Preferred Brand

25% ($80 min/ $125 max)
not subject to deductible

40% coverage; not subject to deductible*

90-Day Voluntary Mail Order Tier 115% ($50 min/$125 max) Tier 225% ($125 min/$200 max) Tier 325% ($200 min/$312.50 max)
Does not apply to deductible or out-of-pocket max

20% coverage; subject to
deductible $10 min/$100 max

Not covered

20% coverage; subject to
deductible $10 min/$100 max

Not covered

20% coverage; subject to
deductible $10 min/$100 max

Not covered

20% ($25 min/$250 max) No non-network coverage

$20
$50
$90
Tier 1$50 Tier 2$125 Tier 3$225

Retiree Decision Guide 2012 20

RetiRee BeneFits When MeDicaRe eliGiBle

RetiRee BeneFits When MeDicaRe eliGiBle

CHanGes
The changes to the Medicare Advantage PPO Plans are outlined below.

Out-of-Pocket Primary Physician Specialist Outpatient Specialized Scans

2011 PLAN YeAR

Standard $2,000

Premium $1,000

$20

$10

$25

$20

$0

$0

Foot Care Ambulance Inpatient Hospital
Preferred/Generic/Preferred Brand/Non-Preferred Specialty Mail Order (90 day)

$20 PCP, $25 SPC $0
$190 per day (1-6) $0 days 7 and beyond $10/$40/$80/$80

$10 PCP, $20 SPC $0
$100 per day (1-5) $0 days 6 and beyond $10/$30/$60/$60

$20/$80/$160/$160 $20/$60/$120/$120

2012 PLAN YeAR

Standard $3,500

Premium $2,500

$25 $30 $35 plus office visit co-payment $25 PCP, $30 SPC $50

$15 $25 $35 plus office visit co-payment $15 PCP, $25 SPC $50

20% co-insurance

15% co-insurance

$15/$45/$85/$85

$15/$45/$85/$85

$37.50/$112.50/ $212.50/$212.50

$37.50/$112.50/ $212.50/$212.50

GeneRaL MeDICaRe InfoRMaTIon anD sHbP MeDICaRe PoLICY
Medicare is the country's health care system for individuals at age 65 or those with certain disabilities. When you or your dependent become eligible for Medicare because of reaching age 65 or disability, you should enroll in Medicare. Medicare includes Parts A - hospitalization, B - provider services and D - prescription drug coverage. You should enroll in Part A (if no cost to you) and Part B (monthly premium applies).
You should enroll for Medicare when you first become eligible and should mail a copy of your Medicare card or approval form from Social Security to SHBP, P.O. Box 1990, Atlanta, GA 30301 or fax to a secure fax line at 866-828-4796. You must submit this information by the first of the month prior to the month you turn age 65 to allow time for processing and to avoid paying higher premiums
Members and/or their dependents eligible due to disability will be responsible for notifying SHBP of their Medicare enrollment as soon as they are eligible
SHBP does not refund the difference in premiums for non-timely submission of Medicare information
SHBP will pay primary benefits on members not enrolled in Medicare, but you will pay 100% of the cost of your SHBP premiums. Premiums may range from $600 to $3,000 per month

You should enroll in Part D only if you do not enroll in a MA PPO Plan
WILL MY oPTIons CHanGe?
Options are the same as for active employees but you will also have the choice of two Medicare Advantage PPO plans
When you or any of your eligible dependents (including dependent children) enroll in Medicare (because of reaching 65) the SHBP will automatically transfer the person (retiree or dependent) to the MA Standard Plan of your current health care vendor, if SHBP has the Medicare Part B information on file
Members age 65 or over who choose not to enroll in one of the SHBP MA PPO Plans will pay the entire cost of their health care premiums
WILL MY PReMIUMs CHanGe?
Yes, premiums and options change when you or a covered dependent become eligible for Medicare
Please refer to the SHBP rate sheets for premiums You will pay a monthly premium for Medicare Part B
AND will pay a premium for your SHBP coverage You should carefully read the next section for detailed information about the impact Medicare will have on your coverage and plan options.

21 Retiree Decision Guide 2012

RetiRee BeneFits When MeDicaRe eliGiBle

WHaT aRe MY 2012 sHbP PLan oPTIons If I WanT THe sTaTe To ConTRIbUTe To MY PReMIUMs?
Humana Group Medicare PPO Plan Standard
Humana Group Medicare PPO Plan Premium
UnitedHealthcare Group Medicare Advantage PPO Standard
UnitedHealthcare Group Medicare Advantage PPO Premium
MeDICaRe aDVanTaGe PPo PLan
The Medicare Advantage Preferred Provider Organization (MA PPO) Plan is an approved plan by the Centers for Medicare & Medicaid (CMS); sometimes called a Part C Plan. This Plan takes the place of your original Medicare Part A Hospital, B Medical and includes Medicare Part D, a prescription drug benefit. This Plan is very similar to a traditional PPO plan. You may receive benefits from in-network and out-of-network providers as long as the provider accepts Medicare. The MA PPO also provides a contracted network on a statewide and national basis across the United States. You will have the choice of a MA PPO Standard or Premium Plan. Plus, you can see non-contracted providers as long as they accept Medicare.
You do not have to select a primary care physician (PCP) or obtain a referral to see a specialist
Co-payments apply toward the out-of-pocket maximum (except for prescription drugs)
Unlike traditional PPO plans, there is no difference in your co-payment/co-insurance levels if you see providers who are contracted (in-network) or providers who are not contracted (out-of-network). So, you are not penalized for going to a non-contracted provider
There will be no coverage if you see a provider who does not accept Medicare
Enrollment in the MA PPO plans is subject to CMS approval
CMS requires a street address and full Medicare number with alpha letter at the end before approving MA PPO coverage

Once approved, CMS will notify SHBP of the effective date of your coverage
You will receive a new insurance card that you will show (in place of your Medicare card) when receiving service
When everyone you cover is not eligible to participate in the MA PPO Option, it is called split eligibility. This means that the individual with Medicare enrolls in the MA PPO option and any family members that are not eligible for Medicare because of age or disability, can enroll in one of the other options offered by SHBP with the same vendor as the retiree.
Prescription Drug Coverage Under the Medicare advantage Plan The Plan includes Medicare Part D coverage
Once you reach the out-of-pocket costs of $4,700, you will pay the greater of 5% co-insurance of the cost of the drug or $2.60 for generic drugs or a drug that is treated like a generic, or a $6.50 co-payment for all other drugs

What if I Have end stage Renal Disease (esRD) ?
If you have Medicare due to End Stage Renal Disease (ESRD), please send SHBP a copy of the notification from Social Security of your start date to P.O. Box 1990, Atlanta, GA 30301-1990. If you are under 65, eligible for Medicare due to ESRD, in your 30-month coordination period and wish to enroll in a Medicare Advantage Option you must select the Humana Option offered by SHBP through the CIGNA/Humana alliance. After the 30-month coordination period ends for ESRD, both vendors can offer Medicare Advantage.

IF UNDeR 65 WITH MeDICARe

Options Wellness and Standard HRA, HMO, HDHP and MA: Standard and Premium

If not enrolled in MA

Pay active rate Subject to surcharges
No discount for any parts of Medicare that you have

Retiree Decision Guide 2012 22

RetiRee BeneFits When MeDicaRe eliGiBle

CHanGInG To Ma PPo oPTIon fRoM HRa
If you have a balance of $100 or more in your HRA at the time you move to the MA PPO, an individual HRA account will be set up by your health care vendor
After a six-month run-out period, to allow for prior year's claims, the funds will be available for use
In July or August, UHC will pay the member monies in the HRA in the amount for any co-payments, deductible or co-insurance to the maximum balance in the HRA that you may have paid. If you are a CIGNA Humana member, you will need to submit a claim for the co-payments, deductible or co-insurance in July or August for which you have paid. The claim form is available at www.myshbp.ga.gov

IMPORTANT INFORMATION

If 65 or older with Medicare

Then...

Stop Paying Part B Your MA coverage under SHBP will

Enroll in a non-

be terminated and we will move you

SHBP MA Plan,

to the Standard option and vendor

Medicare Supple- you had before MA PPO and you will

mental Plan or Part pay 100% of the premium. If the op-

D Prescription Plan tion is not offered, you will be placed

in the Standard HMO of the vendor

you had before the MA PPO

If 65 with no Medicare Part B

Keep current option and pay 100% of cost

If you or your covered dependent(s) have Part A but do not have Part B, you should contact Social Security for information on enrolling during the general enrollment period of January 1 through March 31 each year.

23 Retiree Decision Guide 2012

Benefits comparison: shBP Medicare advantage with Prescription Drugs PPo standard and Premium Plans
schedule of benefits for You and Your Dependents for January 1, 2012 December 31, 2012

Covered Services
Lifetime Benefit Limit for Treatment of Temporomandibular joint dysfunction (TMJ)
Deductibles
Out-of-Pocket Maximum Per Member
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 Annual routine physical exam (non-Medicare covered)
Annual Screenings

Standard SHBP MA PPO Humana, UnitedHealthcare
You Pay Contact plans for details
Not applicable
$3,500 per member You Pay
PCP--$25 per office visit co-payment; SPC--$30 per office visit co-payment
$0 co-payment
$0 co-payment; (mammograms, pap smears, prostate cancer screening,
colorectal cancer screening)

Inpatient Hospital Services
Outpatient Hospital Services (includes observation, medical and surgical care)
Outpatient Standard (X-rays, Lab and Diagnostic Tests)

20% co-insurance $95 co-payment per surgery
$0 co-payment

PReMIUM SHBP MA PPO Humana, UnitedHealthcare
You Pay Contact plans for details
Not applicable
$2,500 per member You Pay
PCP--$15 per office visit co-payment; SPC--$25 per office visit co-payment $0 co-payment
$0 co-payment; (mammograms, pap smears, prostate cancer screening,
colorectal cancer screening) 15% co-insurance
$50 co-payment per surgery
$0 co-payment

Retiree Decision Guide 2012 24

Benefits comparison: shBP Medicare advantage with Prescription Drugs PPo standard and Premium Plans
schedule of benefits for You and Your Dependents for January 1, 2012 December 31, 2012

Behavioral Health Mental Health and Substance Abuse Inpatient Facility and Partial Day Hospitalization NOTE: Mental Health lifetime max does not apply when admitted to a psychiatric unit of a general hospital Mental Health and Substance Abuse Outpatient Visits Dental Dental and Oral Care Medicare covered Vision Routine Eye Exam NOTE: Limited to one eye exam every 12 months
Other Coverage Routine Hearing Services
Ambulance Services for Emergency Care NOTE: "Land or air ambulance" to nearest facility to treat the condition
Urgent Care Services
Other Coverage Home Health Care Services

Standard SHBP MA PPO Humana, UnitedHealthcare
You Pay 190 day lifetime maximum when admitted to a psychiatric hospital; $60 co-payment per
day for partial hospitalization
PCP$25 per office visit co-payment; SPC$30 per office visit co-payment
You Pay $30 per office visit co-payment for Medicare
covered dental services You Pay
$30 co-payment per office visit--limited to 1 annual eye exam; $125 eyewear
(glasses/frames or contact lenses) allowance every 24 months You Pay
$30 co-payment limited to one test every 12 months; $1,000 hearing aid allowance
every 48 months $50 co-payment
$25 co-payment waived if admitted to hospital within 24 hours for the
same condition You Pay
$0 co-payment per visit

PReMIUM SHBP MA PPO Humana, UnitedHealthcare
You Pay 190 day lifetime maximum when admitted to a psychiatric hospital; $50 co-payment per
day for partial hospitalization
PCP$15 per office visit co-payment; SPC$25 per office visit co-payment
You Pay $25 per office visit co-payment for Medicare covered dental services
You Pay $25 co-payment per office visit--limited to 1 annual eye exam; $125 eyewear
(glasses/frames or contact lenses) allowance every 24 months You Pay
$25 co-payment limited to one test every 12 months; $1,000 hearing aid allowance
every 48 months $50 co-payment
$20 co-payment waived if admitted to hospital within 24 hours for the
same condition You Pay
$0 co-payment per visit

Emergency Care

$50 co-payment waived if admitted to hospital $50 co-payment waived if admitted to hospital

within 24 hours for the same condition

within 24 hours for the same condition

25 Retiree Decision Guide 2012

Benefits comparison: shBP Medicare advantage with Prescription Drugs PPo standard and Premium Plans
schedule of benefits for You and Your Dependents for January 1, 2012 December 31, 2012

Other Coverage Skilled Nursing Facility Services
Hospice Care
Durable Medical Equipment (DME) Outpatient Acute Short-Term Rehabilitation Services Physical Therapy Speech Therapy Occupational Therapy Other short term
rehabilitative services Chiropractic Care
Foot Care
Transplant Services NOTE: Prior approval required Pharmacy Tier 1 Co-payment Tier 2 Co-payment Tier 3 Co-payment Tier 4 Co-payment NOTE: UHC includes specialty
Tier 5 Co-payment (Humana only) Specialty Drugs

Standard SHBP MA PPO
Humana, UnitedHealthcare
You Pay
$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 hospital stay required)
100% coverage; (must receive care from a Medicare covered hospice facility; no prior approval required)
20% coverage for Medicare covered items (no prior approval required)
$25 co-payment per office visit for Medicare covered services; no limit on number of visits

PReMIUM SHBP MA PPO
Humana, UnitedHealthcare
You Pay
$0 co-payment per day for days 110; $25 co-payment per day for days 11100
for up to 100 days per benefit period (no prior hospital stay required)
100% coverage; (must receive care from a Medicare covered hospice facility; no prior approval required)
15% coverage for Medicare covered items (no prior approval required)
$10 co-payment per office visit for Medicare covered services; no limit on number of visits

Medicare Covered Humana-$25; UnitedHealthcare-$18 co-payment per office visit;
Routine Non-Medicare CoveredHumana/UnitedHealthcare $30 co-payment per
office visit; limit of 20 visits per year

Medicare Covered Humana-$20; UnitedHealthcare-$18 co-payment per
office visit; Routine Non-Medicare Covered and Humana/UnitedHealthcare-
$25 co-payment per office visit; limit of 20 visits per year

$25 PCP-$30 SPC per office visit co-payment; Routine Non-Medicare covered-$30
co-payment, limit of 6 visits per year
20% coinsurance

$15 PCP-$25 SPC per office visit co-payment; Routine Non-Medicare covered-
$25 co-payment; limit of 6 visits per year
15% coinsurance

You Pay *$15 retail; $37.50 mail order--90-day supply *$45 retail; $112.50 mail order--90-day supply

You Pay *$15 retail; $37.50 mail order--90-day supply $45 retail; $112.50 mail order--90-day supply

*$85 retail; $212.50 mail order--90- day supply $85 retail; $212.50 mail order--90-day supply

*$85 retail; $212.50 mail order-- 90-day supply; Medicare Part B Covered Drugs-- 20% coverage

$85 retail; $212.50 mail order--90-day supply Medicare Part B covered drugs 15% coverage

Contact Humana

Contact Humana

*After your yearly out-of-pocket cost reaches $4,700, you will pay the greater of $2.60 for the generic or a preferred brand drug that is a multi-source drug and $6.50 for all other drugs, or 5% co-insurance.

Retiree Decision Guide 2012 26

shBP eliGiBilitY

shBP eliGiBilitY

The SHBP covers dependents who meet SHBP guidelines. Eligibility documentation must be submitted before SHBP can send notification of a dependent's coverage to the health care vendors.
eLIGIbLe DePenDenTs aRe:
1. Spouse Individual who is not legally separated, who is of the opposite sex of the Enrolled Member and who is legally married or who submits satisfactory evidence to the Administrator of common law marriage to the Employee or Retiree entered into prior to January 1, 1997 and is not legally separated.
2. Dependent Child An eligible Dependent child of an Enrolled Member must meet one of the following definitions:
Natural child A natural child for whom the natural guardian has not relinquished all guardianship rights through a judicial decree. Eligibility begins at birth and ends at the end of the month in which the child reaches age twenty-six (26).
Adopted child Eligibility begins on the date of legal placement for adoption and ends at the end of the month in which the child reaches age twenty-six (26).
Stepchild Eligibility begins on the date of marriage to the natural parent. Eligibility ends at the end of the month in which the child reaches age twenty-six (26), or at the end of the month in which the stepchild loses his or her status as stepchild of the Enrolled Member, whichever is earlier.
Guardianship A child for whom the Enrolled Member is the legal guardian. Eligibility begins on the date the legal guardianship is established. Eligibility ends at the end of the month in which the child reaches age twenty-six (26), or at the end of the month in which the legal guardianship terminates, whichever is earlier. Certification documentation requirements are at the discretion of the Administrator. However, a judicial decree from a court of competent jurisdiction is required unless the Administrator concludes that documentation is satisfactory to establish legal guardianship and that other legal papers present undue hardship on the Member or living natural parent(s).

Totally Disabled Child A natural child, legally adopted child or stepchild age twenty-six (26) or older, if the child was physically or mentally disabled before age twenty-six (26), continues to be physically or mentally disabled, lives with the Enrolled Member or is institutionalized, and depends primarily on the Enrolled Member for support and maintenance.
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 if you make the request within the required time period of the qualifying event which in most cases is 31 days. In some cases, the time period may be extended to 60 or 90 days based on state and federal law or SHBP regulations. The requested change must correspond to the qualifying event. For a complete description of qualifying events, see your Summary Plan Description available online at www.myshbp.ga.gov. You may also contact the Eligibility Call Center for assistance at 800-610-1863.
Qualifying events include, but are not limited to: Birth or adoption of a child, or placement for adoption
Change in residence by you or your spouse 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

27 Retiree Decision Guide 2012

shBP eliGiBilitY

IMPORTANT INFORMATION
Please submit your change request within the required time period, which is usually 31 days. In some cases the time period may be extended to 60 or 90 days based on state and federal law or SHBP regulations.
Change requests should not be held waiting on additional information, such as Social Security Number, marriage or birth certificate
SHBP will accept dependent verification at anytime during the Plan Year and coverage will be retroactive to the qualifying event date or first of the Plan Year, whichever is later
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 SHBP receives so we can match your dependents to your record. Do not send originals as they will not be returned
DoCUMenTaTIon ConfIRMInG eLIGIbILITY foR YoUR sPoUse oR DePenDenTs
SHBP requires documentation concerning eligibility of dependents covered under the plan. Spouse Certified copy of marriage license or 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. The spouse's Social Security Number is also required
Natural or adopted child Certified copy of birth certificate or birth card issued by hospital which lists parents by name are accepted for new births and certi-

fied copy of court documents establishing adoption and stating date of adoption, or, if adoption is not finalized, certified or notarized legal documents establishing the date of placement for adoption. If a certified copy of the birth certificate is not available for an adopted child, other proof of the child's date of birth is required. The Social Security Number is required for all children two and older
Stepchild Certified copy of birth certificate showing your spouse is the natural parent of the child AND certified copy of marriage license showing the natural parent of the child is your spouse 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. The Social Security Number is required for all children age two and older
Legal Guardianship Certified copy of court documents establishing the legal guardianship and stating the dates on which the guardianship begins and ends and a certified copy of the birth certificate or other proof of the child's date of birth. The Social Security Number is required for all children age two and older
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 available at www.myshbp.ga.doc.

Retiree Decision Guide 2012 28

leGal notices

leGal notices
aboUT THe foLLoWInG noTICes
The notices on the following pages are required by the Centers for Medicaid & Medicare Services (CMS) to explain what happens if you buy an individual Medicare Prescription Drug (Part D) Plan. The chart below explains what happens if you buy an individual Medicare Part D Plan.

Your SHBP Option

What happens if you buy an individual Medicare Part D Plan

SHBP Medicare Advantage PPO Standard or SHBP Medicare Advantage PPO Premium Plan

Your MA coverage under SHBP will be terminated and we will move you to the Standard option and vendor you had before MA PPO and you will pay 100% of the premium. If the option is not offered, you will be placed in the Standard HMO of the vendor you had before the MA PPO

HRA /HMO
HDHP (High Deductible)

Your Medicare Part D Plan will be primary for your prescription drugs unless you are in the deductible or doughnut hole and then SHBP will provide benefits. If you reach the Out-of-pocket Limit, SHBP will coordinate benefits with your Medicare Part D Plan. You will not pay a Medicare "late enrollment" penalty
You will have to pay a Medicare "late enrollment" penalty if you miss the initial enrollment period because the HDHP option is not considered "creditable coverage"

These notices state that prescription drug coverage under all SHBP coverage options except for the HDHP (High Deductible) option is considered Medicare Part D "creditable coverage." This means generally that the prescription drug coverage under the SHBP MA Standard, SHBP MA Premium, HMO and HRA are all "as good or better than" the prescription drug coverage offered through Medicare Part D plans that are sold to individuals.

29 Retiree Decision Guide 2012

leGal notices

Important Notice from the SHBP About Your Creditable Prescription Drug Coverage under any of the following Options and Medicare:
CIGNA Standard or Wellness HMO, CIGNA Standard or Wellness HRA, UnitedHealthcare Standard or Wellness HMO, UnitedHealthcare Standard or Wellness HRA
For Plan Year: January 1 December 31, 2012
This notice only applies if you are covered under the CIGNA Standard or Wellness HMO or HRA or the UnitedHealthcare Standard or Wellness HMO or HRA.
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. If you are considering joining, 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. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and Medicare's prescription drug coverage:
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 CIGNA Standard HMO, CIGNA Standard HRA, CIGNA Wellness HMO, CIGNA Wellness HRA, UnitedHealthcare Standard HMO, UnitedHealthcare Standard HRA, UnitedHealthcare Wellness HMO and UnitedHealthcare Wellness HRA is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can you Join a Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current SHBP coverage will be affected. If you join a Medicare drug plan and do not terminate your SHBP coverage, SHBP will coordinate with Medicare drug plan coverage the month following receipt of notice. You should send a copy of your Medicare cards to SHBP at P.O. Box 1990, Atlanta, GA 30301.
Retiree Decision Guide 2012 30

LEGAL NOTICES

Important : If you are a retiree and terminate your SHBP coverage, you will not be able to rejoin the SHBP in the future. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current 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 creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare 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 October to join.
For More Information About This Notice Or Your Current Prescription Drug Coverage... Contact the SHBP Eligibility Unit at (404) 656-6322 or (800) 610-1863. NOTE: You will receive 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 SHBP changes. You also may request a copy of this notice at any time.
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 (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, therefore, whether or not you are required to pay a higher premium (a penalty).
Date: October 1, 2011 Name of Entity/Sender: State Health Benefit Plan ContactPosition/Office: Call Center Address: 2 Peachtree Street, Atlanta, GA 30334 Phone Number: (800) 610-1863
31 Retiree Decision Guide 2012

leGal notices

Important Notice from the SHBP About Your Non-Creditable Prescription Drug Coverage under any of the following Options and Medicare: CIGNA Standard or Wellness HDHP, UnitedHealthcare Standard or Wellness HDHP
For Plan Year: January 1 December 31, 2012
This notice only applies if you are covered under the CIGNA Standard or Wellness HDHP or the UnitedHealthcare Standard or Wellness HDHP.
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.
There are three important things you need to know about your current coverage and Medicare's prescription drug coverage:
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 the HDHP option is, on average for all plan participants, NOT expected to pay out as much as standard Medicare prescription drug coverage pays. Therefore, your coverage 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 from the HDHP offered by SHBP. This also is important because it may mean that you may pay a higher premium (a penalty) if you do not join a Medicare drug plan when you first become eligible.
3 You can keep your current coverage from SHBP. However, because your coverage is non-creditable, 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 a drug plan. When you make your decision, you should compare your current coverage, including what drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. Read this notice carefully - it explains your options.
When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.
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However, if you decide to drop your current coverage with the SHBP, since it is employer sponsored group coverage, you will be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan; however you also may pay a higher premium (a penalty) because you did not have creditable coverage under SHBP.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? Since the HDHP coverage under SHBP is not creditable, depending on how long you go without creditable prescription drug coverage you may pay a penalty to join a Medicare drug plan. Starting with the end of the last month that you were first eligible to join a Medicare drug plan but didn't join, if you go 63 continuous days or longer without prescription drug coverage that's creditable, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare 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 October to join.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current HDHP coverage under SHBP will be affected. If you enroll in Medicare Part D when you become eligible for Medicare Part D and do not terminate your HDHP coverage, you can keep your HDHP coverage and the HDHP will coordinate benefits with the Part D coverage. SHBP will coordinate with Part D coverage the month following receipt of notice. You should send a copy of your Medicare cards to SHBP at P.O. Box 1990, Atlanta, GA 30301.
Important: If you are a retiree and terminate your SHBP coverage, you will not be able to rejoin the SHBP in the future.
For More Information About This Notice Or Your 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 SHBP changes. You also may request a copy of this notice at any time.
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, 2011 Name of Entity/Sender: State Health Benefit Plan ContactPosition/Office: Call Center Address: 2 Peachtree Street, Atlanta, GA 30334 Phone Number: (800) 610-1863
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