{"response":{"docs":[{"id":"dlg_ggpd_y-ga-bc900-pe4-bs1-bn4-b2013-belec-p-btext","title":"New enrollee decision guide for plan year 2013","collection_id":"dlg_ggpd","collection_title":"Georgia Government Publications","dcterms_contributor":["Georgia. Department of Community Health."],"dcterms_spatial":["United States, Georgia, 32.75042, -83.50018"],"dcterms_creator":["Georgia. Department of Community Health"],"dc_date":["2013"],"dcterms_description":["Title from cover"],"dc_format":["application/pdf"],"dcterms_identifier":null,"dcterms_language":["eng"],"dcterms_publisher":["Atlanta, Ga. : Georgia Dept. of Community Health, Division of Public Employee Health Benefits, 2012"],"dc_relation":null,"dc_right":["http://rightsstatements.org/vocab/InC/1.0/"],"dcterms_is_part_of":null,"dcterms_subject":["Government employees' health insurance--Georgia"],"dcterms_title":["New enrollee decision guide for plan year 2013"],"dcterms_type":["Text"],"dcterms_provenance":["University of Georgia. Map and Government Information Library"],"edm_is_shown_by":["https://dlg.galileo.usg.edu/do:dlg_ggpd_y-ga-bc900-pe4-bs1-bn4-b2013-belec-p-btext"],"edm_is_shown_at":["https://dlg.galileo.usg.edu/id:dlg_ggpd_y-ga-bc900-pe4-bs1-bn4-b2013-belec-p-btext"],"dcterms_temporal":null,"dcterms_rights_holder":null,"dcterms_bibliographic_citation":null,"dlg_local_right":null,"dcterms_medium":["state government records"],"dcterms_extent":null,"dlg_subject_personal":null,"iiif_manifest_url_ss":null,"dcterms_subject_fast":null,"fulltext":"New Enrollee \nDecision Guide \nfor Plan Year 2013 \n \n Additional Help/Contact Information \nState Health Benefit Plan (SHBP): \n \nVendor \nCIGNA HRA, HMO, HDHP 24 hours a day / 7 days a week \nUnitedHealthcare HRA HMO, HDHP hours 8 a.m.  8 p.m. local time zone; Monday  Friday, TTY 711 \n \nMember Services \n800-633-8519 TTY 711 \n800-396-6515 877-246-4189 \n \nSHBP Eligibility \nAdditional Information \nTRICARE Supplemental Plan hours 8:30 a.m.  5 p.m. local time zone; Monday  Friday \nPeachCare for Kids \n \n800-610-1863 Member Services \n866-637-9911 \n877-427-3224 \n \nWebsite www.mycigna.com/shbp \nwww.welcometouhc.com/shbp www.welcometouhc.com/shbp \nwww.dch.georgia.gov/shbp Website \nwww.asicorporation.com/ga_shbp \nwww.peachcare.org \n \nListed below are common health care acronyms that are used throughout this Decision Guide. \n \nCDHP \u003e Consumer-Driven Health Plan CMS \u003e Centers for Medicare and Medicaid Services COB \u003e Coordination of Benefits DCH \u003e Georgia Department of Community Health FSA \u003e Flexible Spending Account \nHDHP \u003e High Deductible Health Plan HMO \u003e Health Maintenance Organization HRA \u003e Health Reimbursement Arrangement HSA \u003e Health Savings Account \n \nMA (PPO) \u003e Medicare Advantage Preferred \nProvider Organization \nOE \u003e Open Enrollment PCF \u003e Personalized Change Form PCP \u003e Primary Care Physician ROCP \u003e Retiree Option Change Period SHBP \u003e State Health Benefit Plan SPC \u003e Specialist SPD \u003e Summary Plan Description UHC \u003e UnitedHealthcare \n \n Table of Contents \n\u003e Additional Help/Contact Information \nInside Front Cover \n\u003e General Information \npage 3 \n\u003e SHBP Eligibility Information \npage 4 \n\u003e Enrolling in SHBP Coverage \npage 7 \n\u003e Understanding Your Plan Options \npage 12 \n\u003e If You Are Retiring \npage 23 \n\u003e Legal Notices \npage 24 \n1 New Enrollee Decision Guide 2013 \n \n David A. Cook, Commissioner \n \nNathan Deal, Governor \n \n2 Peachtree Street, NW Atlanta, GA 30303-3159 www.dch.georgia.gov \n \nNovember 1, 2012 \n \nDear New State Health Benefit Plan Member: \n \nYour State Health Benefit Plan (SHBP) holds opportunities for you to become more engaged with your health care. In keeping with Gov. Deal's Strategic Goals for the state, our SHBP increases personal responsibility in health care by encouraging members to adopt healthy behaviors. \n \nNew enrollees may choose between two consumer-driven health options offered by both Cigna and UnitedHealthcare (UHC), our health plan vendors. These plans are: \n \nCigna Standard HDHP Standard HRA \n \nUnitedHealthcare Standard HDHP Standard HRA \n \nEach plan's design is similar to that of a Preferred Provider Organization Plan (PPO) with in-network and out-of-network benefits, 100 percent unlimited coverage for wellness care based on national age and gender guidelines, and other enhanced benefits exclusive to these plans. \n \nIf you choose the HRA option, you will have the extra benefit of the SHBP contributing dollars to your HRA on an annual basis for payment of medical and pharmacy expenses. The HDHP has a lower monthly premium and allows members to start a Health Savings Account (HSA) to set aside tax-free dollars to pay for eligible health care expenses and offset the higher deductible. \n \nIn keeping with Gov. Deal's initiative, we also encourage new enrollees to complete the online health assessment, complete a biometric screening, and participate in your plan's online health modules and other tools designed to educate and engage members in healthier behaviors. Wellness care is included in your plans; we urge you to take advantage of this benefit. \n \nThe Georgia Department of Community Health, which administers the SHBP, is committed to providing you with choices in your options while keeping costs down. Be assured that we will continue to provide you with tools to help you make the right health care choices for you and your family members. \n \nSincerely, \n \nDavid A. Cook Commissioner \n \n2 New Enrollee Decision Guide 2013 \n \n General IPnlfaonrmChaationnges \nThis guide will provide you with a brief explanation of each Plan Option. \nWhile CIGNA and UnitedHealthcare's basic plan design is the same for each option, each vendor has nuances in benefits and services that are unique to each option. It is important that you read the Decision Guide so you will understand what these differences are and how they may affect you. \nState Health Benefit Plan \nThe Georgia Department of Community Health (DCH), which administers the State Health Benefit Plan (SHBP), continually seeks to offer high-quality, affordable health coverage. Keep in mind, however, that you are the manager of your health care needs, and in turn, must take the time to understand your Plan benefit choices in order to make the best decisions for you and your family. \nLet's start by talking about how the SHBP works. It is a self-funded plan, which means that all expenses are paid by employee premiums and employer funds. Approximately 75 percent of the cost is funded by your employer, with you paying approximately 25 percent. \nPeople who do not understand their health coverage pay more, according to the American Medical Association. To help you better understand your Plan and save your health care dollars, we have prepared a few points for you to consider. \nWhat Can You Do to Help Manage Your Health Care Costs? \nUnderstand Your Options  Compare all Plan Options, considering both the premiums and out-of-pocket costs that you may incur. Web sites and phone numbers are listed on the inside of the front cover of the Decision Guide if you need more information. \nBecome a More Proactive Consumer of Health Care  Most people do not realize how much their treatments, medicines and tests cost. Steps you can take include:  Keep a list of all medications you take.  Shop in-network providers and pharmacies.  Find out what your drugstore charges for a drug.  Make sure all procedures are pre-certified, if required.  Make sure you get the results of any test or procedure.  Understand what will happen if you need surgery.  Check your Explanation of Benefits (if provided under your plan option) and if you have questions, ask your provider \nabout it. \nThese and other steps you take will help manage healthcare expenses, reduce your out-of-pocket costs and those of the Plan. In addition, these steps will help in keeping premium costs down. \n3 New Enrollee Decision Guide 2013 \n \n SHBP Eligibility Information \nAll SHBP options have the same eligibility requirements. A summary is listed below. \nSHBP Eligibility for You \nYou are eligible to enroll yourself and your eligible dependents for coverage if you are:  A full-time employee of the state of Georgia, the Georgia General Assembly, or an agency, board, commission, \ndepartment, county administration or contracting employer that participates in the SHBP, as long as: --You work at least 30 hours a week consistently, and --Your employment is expected to last at least nine months. \nNot eligible: Student employees or seasonal, part-time or short-term employees.  A certified public school teacher or library employee who works half-time or more, but not less than 17.5 hours a week \nNot eligible: Temporary or emergency employees  A non-certified service employee of a local school system who is eligible to participate in the Teachers Retirement \nSystem or its local equivalent. You must also work at least 60 percent of a standard schedule for your position, but not less than 20 hours a week  An employee who is eligible to participate in the Public School Employees' Retirement System as defined by Paragraph 20 of Section 47-4-2 of the Official Code of Georgia, Annotated. You must also work at least 60 percent of a standard schedule for your position, but not less than 15 hours a week  A retired employee of one of these listed groups who was enrolled in the Plan at retirement and is eligible to receive an annuity benefit from a state-sponsored or state-related retirement system. See the Summary Plan Description (SPD) for more information  An employee in other groups as defined by law. 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. \n4 New Enrollee Decision Guide 2013 \n \n Eligible Dependents Are: \n1. 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. \n2. Dependent Child  An eligible Dependent child of an Enrolled Member must meet one of the following definitions: \n 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). \n 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). \n 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. \n 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). \n 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 and depends primarily on the Enrolled Member for support and maintenance. See the Summary Plan Description at www.dch.georgia.gov/shbp or call 800-610-1863 for more information. \n \nWhat Should I Do Before Making My Election? \n 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/shbp. 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. \n Verify your provider(s) will be participating in the option you choose by going to the vendors' websites or calling the vendors. \n Check the distance you will have to drive to see your provider(s). \n Check the Preferred Drug Lists of each vendor to see if your prescriptions are covered and at what co-payment or co-insurance level. \n \nWho Should I Contact if I Have Questions? \n \nBenefit Questions: \n \nEligibility Questions: \n \n CIGNA for HRA, HMO or HDHP Options  800-633-8519  UHC HRA  800-396-6515  UHC HMO, HDHP  877-246-4189 \n \n SHBP Call Center  800-610-1863  SHBP E-Mail  shbpnoreply@dch.ga.gov \n \n5 New Enrollee Decision Guide 2013 \n \n How Do I Decide Which Plan is Best for Me? \nThis 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 \nconsider 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. \nThe premiums are lower than the HMO and the co-insurance 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.  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 health care vendor and you may want to consider using the Mail Order Program which should lower your prescription drug costs. \nYour Responsibilities as a SHBP Member \n Notify SHBP whenever you have a change in covered dependents within the time limits set by the SHBP  Read and make sure you understand the materials provided to you  Check your payroll deduction to verify the correct health deduction is made  Update any change in address by making the correction online at www.myshbp.ga.gov during Open Enrollment \nor by completing and submitting a Miscellaneous Change Form posted at www.dch.georgia.gov/shbp  Review all communications from the SHBP and take the required actions \n6 New Enrollee Decision Guide 2013 \n \n Enrolling in SHBP coverage \nBefore You Enroll \nYou should:  Read this Decision Guide and Summary Plan Description to understand your Health Plan Options prior to making \nyour health election.  Read and understand the SHBP Tobacco Surcharge Policy on page 9 and answer the question regarding this \nsurcharge. If you fail to answer the question, the surcharge will apply for the 2013 Plan Year unless you experience a qualifying event or you complete the applicable steps to remove the surcharge.  Gather eligibility verification documents for all dependents for whom coverage has been requested to submit within the required time frame as described on page 22.  Understand the election you make will be valid for the 2013 Plan Year unless you experience a qualifying event. Qualifying events are described on page 21.  Additional options may be available to you during the Fall Open Enrollment for coverage effective January 1, 2014. \nHealth Benefit Cost Estimators \nChoosing the right health plan is an important decision and CIGNA and UHC each provide a Plan Cost Estimator (PCE) tool to assist you. The PCEs offer you a simple way to help determine which option is best for you and your family. These online tools let you compare how your out-of-pocket expenses may vary under the different health plan options available to you. You can use the PCE to review cost information for prescriptions, anticipated tests and procedures. \nHow to Enroll \nIf you're eligible to participate in the SHBP, you become a member by enrolling either:  As a new hire, within 31 days of your hire date. If you join the SHBP during that first 31-day enrollment opportunity, your cover- \nage will go into effect on the first day of the month after you complete one full calendar month of employment. See your personnel/payroll office for instructions on how to enroll or if you have benefit questions, you may call the vendor directly at the telephone numbers listed on the inside of the front cover of the Decision Guide.  As a result of a qualifying event. See Making Changes When You Have a Qualifying Event, page 21 of this guide for more details. \n7 New Enrollee Decision Guide 2013 \n \n  If you terminate employment and are re-hired by any employer eligible for the SHBP during the same Plan year, you must enroll in the same Plan option and tier (even if there is a gap in coverage) provided you are eligible for that option and have not had a qualifying event since coverage ended. \n If the termination is in one year and you are hired in the following year with a gap in coverage, you are restricted to the consumer driven health plan options: the Health Reimbursement Arrangement (HRA), High Deductible Health Plan (HDHP) Standard Options and TRICARE Supplement with the new employer. \n If you decline coverage under SHBP when you first become eligible and later decide to enroll due to a qualifying event or at a future Open Enrollment period, your options will be limited to the HRA, HDHP Standard Plans and TRICARE supplement (if eligible) for your first Plan Year of coverage. \n \nIf You Decide to Become a SHBP Member, You Will Have Two Major Choices to Make: \n1. Your health care vendor and coverage option: CIGNA Healthcare \n Standard Health Reimbursement Arrangement (HRA)  Standard High Deductible Health Plan (HDHP) \n \nUnitedHealthcare  Standard Health Reimbursement Arrangement (HRA)  Standard High Deductible Health Plan (HDHP) \n \n2. Which eligible dependents would you like to have covered by SHBP? For a list of eligible dependents, refer to pages 5.  SHBP is required to obtain the Social Security Number of each covered dependent. \n \n3. Which coverage tier? Select the coverage tier you desire for the dependents that you choose to cover. You will be locked into the tier for the 2013 Plan Year unless you experience a qualifying event. \n \n You \n \n You + Child(ren) \n \n You + Spouse \n \n You + Family* \n \n SHBP requires you to submit documentation confirming eligibility of your dependents (see page 22). \n \n*You + Family = You + Spouse + Child(ren) \n \nNOTE: Additional options may be available to you during the Fall Open Enrollment period for the following Plan Year. \n \nWhat Happens if I Have Other Insurance? \nYou or your covered dependents may have medical coverage under more than one plan. In this case, coordination of benefits (COB) provisions apply. \nIMPORTANTNOTE \n \nWhen you have other group or Medicare coverage and SHBP coverage, the benefit under SHBP will be no greater than it would have been if there was no coverage other than that of SHBP. This also applies to state on state coverage. Non-covered services or items, penalties and amounts balance billed are not part of the allowed amount and are the member's responsibility. \nIt is important that you notify the health insurance vendor you selected if you have other group coverage to prevent incorrect processing of any claims. For further information about COB rules, refer to the SPD or contact your health care vendor directly. \n \n8 New Enrollee Decision Guide 2013 \n \n What if I Am Working and Am Eligible for Medicare? \nFederal Law requires SHBP to pay primary benefits for active employees and their dependents. Active members or their covered dependents may choose to delay Medicare enrollment. Termination of active employment is a qualifying event for enrolling in Medicare without penalty as our plans are creditable. \nTobacco Surcharge Policy \nYou should be aware that SHBP charges a Tobacco Surcharge. A $80 Tobacco Surcharge will be added to your monthly premium if you or any of your covered dependents have used tobacco products in the previous 60 days. SHBP provides 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. You will automatically be charged the Tobacco Surcharge if you fail to answer the Tobacco question. The surcharge will apply to your premium until the next Plan Year unless you take steps to have the surcharge removed. \nMaking Changes When You Have a Qualifying Event \nIf 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. Please refer to page 21 for a complete description of qualifying events or see your Summary Plan Description (SPD) available online at www.dch.georgia.gov/shbp. You may also contact the Eligibility Call Center for assistance at 800-610-1863. \nIMPORTANTNOTE \nIf you change options or vendors during the year, any amounts applied toward your deductible or out-of-pocket are not transferred to the new option. \n9 New Enrollee Decision Guide 2013 \n \n 2014 Incentives and Requirements \nIn 2014, SHBP will be moving from \"promise-based\" incentives to \" action-based\" incentives. As part of this progression, SHBP will reward members (For all options except the TRICARE Supplement) with HRA incentive fund contributions for their completion of certain required health actions. \nThe SHBP member and spouse (if covered) are each eligible to earn a $240 HRA incentive fund contribution for 2014 if either take the following three actions: \n1.Complete their vendor's (Cigna or UnitedHealthcare) online Health Assessment through www.mycigna.com or www.myuhc.com between January 1, 2013, and May 31, 2013 and print a copy of the Confirmation of Completion; \n2.Complete a biometric screening if one was not completed and submitted in 2012, (including body mass index (BMI), blood pressure, cholesterol, and glucose) at a physician's office between July 1, 2012, and May 31, 2013, with the completed and signed physician screening form showing the test results faxed to the number shown on the form between November 1, 2012, and May 31, 2013; and \n3.Complete a health education module through the new SHBP Member Education Portal at www.AHealthierSHBP.com between January 1, 2013, and May 31, 2013. \nNote: ALL required actions must be completed by the member and spouse (if covered) by May 31, 2013, 4:30 p.m. EST in order to earn HRA incentive fund contributions for 2014. Those members and spouses (if covered) who complete all required actions by the dates stated above will each be awarded the $240 HRA incentive fund contribution on January 1, 2014, and may be eligible for additional benefits as determined by SHBP in its sole discretion. \nPreventive Care \nTreatment properly coded as preventive care is covered at 100% under all Plan Options. In accordance with the Patient Protection and Affordable Care Act, certain women's health care services are now considered preventive care when properly coded. These services include contraceptive products and services, routine prenatal screenings and breastfeeding equipment and supplies. Contact the vendor's pre-enrollment website, Cigna, at www.mycigna.com/shbp and UnitedHealthcare at www.welcometouhc.com/shbp. \nHealth Coaching \nSHBP members who obtain biometric screenings may have individual health issues identified. It is recommended that members follow up with their Primary Care Physician (PCP) to discuss their results and develop individual health and wellness plans. \nAll SHBP members, whether in the Wellness Plan or Standard Plan Options, are encouraged to participate in a telephonic or online wellness coaching programs. Wellness coaching programs such as weight management, exercise, stress management, heart health, diabetes and nutrition are currently available. Check with your vendor (Cigna or UnitedHealthcare) to learn more about their programs. \n10 New Enrollee Decision Guide 2013 \n \n If your biometric screening results were outside of the target ranges, a nurse or health coach may reach out to you directly. A health coach is able to assist you in establishing your health goals and then help you in reaching them. Your coach will help you track your weekly progress. Keeping track of your progress will help you as you strive to reach your goals. \n \nNote: Please be sure to keep your contact information current including your phone number, address and email to ensure that you receive all of the health coaching services and communications that are available to you. \nBiometric Targets as Recommended by National Guidelines \n \nBiometric Screening Cholesterol Glucose Blood Pressure Body Mass Index (BMI) \n \nTarget Range \nLDL less than 130 Fasting Blood Sugar less than 100 or A1c less than 5.7 \nLess than 140/90 Less than 30 \n \nChildhood Obesity \nAccording to the Centers for Disease Control (CDC), childhood obesity has more than tripled in the past 30 years. Obese youth are more likely to have risk factors for cardiovascular disease and more likely to have pre-diabetes. They are also at a greater risk for bone and joint problems, sleep apnea and social and psychological problems such as stigmatization and poor self-esteem. \nIn support of the State of Georgia's strategic goals, SHBP is now offering comprehensive health benefits to children for the treatment of childhood obesity. SHBP provides coverage for four visits with a primary care physician and four visits with a registered dietician for children between the ages of 3 and 18 who qualify as determined by their physician. These healthcare professionals work with children and their families to establish and maintain a healthy lifestyle through in-depth nutritional counseling that can be instrumental in changing their diet and physical activity patterns. \nSHBP supports adults who wish to combat their own weight issues. Both vendors provide online and telephonic weight management coaching. In addition, both vendors offer discounts for weight loss programs and for gym memberships. \nAll SHBP members and spouses (if covered) are eligible for three consultations with a registered dietician when diet is a part of the medical management of a documented disease. Contact Cigna or UnitedHealthcare for details about this benefit. \nAdditional Wellness Resources \nFor Cigna go to: www.cigna.com/shbp For UnitedHealthcare go to: www.welcometouhc.com/shbp \n \n11 New Enrollee Decision Guide 2013 \n \n 2U0n1d3erstanding YPloaunr CPlhaannOgepstions \nBelow you will find a brief description of each option offered. CIGNA and UnitedHealthcare are your health care vendors and each offer an HRA and HDHP option. NOTE: If you are enrolling in coverage for the first time or if you were not covered by SHBP in 2012, your options are the Standard HRA, Standard HDHP and TRICARE Supplement for your first Plan Year. During the next Open Enrollment Period, you may have additional options for the next Plan Year. \nEach Plan provides 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 (SPC). In addition, there are no lifetime maximums and all preventive care benefits are covered at 100% when you use in-network providers only and when filed with appropriate wellness codes. \nPlease keep in mind, if you change options or vendors (Cigna or UHC) during the year, any amounts applied toward your deductible or out-of-pocket are not transferred to the new Option. \nHealth Reimbursement Arrangement (HRA) \nThe 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. HRA dollars reduce the amount you pay towards the deductible and out-of-pocket maximum and can be used to pay any co-insurance you may owe for certain covered services. You pay co-insurance after the deductible is satisfied rather than set dollar co-payments for medical expenses and prescription drugs until the out-of-pocket maximum is met. \nTo 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 Standard Plan Option with family coverage, the money funded by SHBP can help cover the first $1,600 of your deductible. This will lower your family deductible of $4,000 to $3,500. 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%. \nAny 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 OE or due to a qualifying event. \n12 New Enrollee Decision Guide 2013 \n \n High Deductible Health Plan (HDHP) \nThe 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 in-network and out-of-network out-of-pocket maximum. The deductible applies to all eligible health care expenses including pharmacy before benefits are paid. 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 20 to compare benefits under the HDHP to other Plan Options. Go to www.irs.gov/publications/p969 for more information. \nHealth Savings Account (HSA)  Information Only \nAn 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. \nYou 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 $3,250 single, $6,450 family as long as you are enrolled in the HDHP. These limits are set by \nfederal 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 \nSHBP coverage  HSA dollars can be used to pay for health care expenses (medical, dental, vision and over-the-counter medications \nwhen a doctor states they are medically necessary) that the IRS considers tax-deductible and 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) \n13 New Enrollee Decision Guide 2013 \n \n TRICARE Supplement for Eligible Military Members \nThe TRICARE Supplement Plan is an alternative to SHBP coverage that is offered to employees and dependents who are eligible for SHBP coverage and enrolled in TRICARE. 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 (AMRA) and is administered by the Association \u0026 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/ga_shbp. You may also find information at www.dch.georgia.gov/shbp. \nThe 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). \nIMPORTANTINFORMATION \n 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 \n Employers are prohibited by law from paying any portion of the cost of TRICARE Supplement Coverage  You will need to file an appeal and select a health care vendor and Option. If the appeal is approved, this \nchange will be retroactive to the beginning of the current Plan Year and you will need to pay the difference in premiums. \nPoints to Consider if You Elect TRICARE Supplement Plan Coverage \n 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 \n--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 \n--Unmarried children under the age of 21 or 23 if a full-time 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 \n Tobacco Surcharge will not apply  COBRA rights will not apply \n14 New Enrollee Decision Guide 2013 \n \n  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 \u0026 Society Insurance Corporation (ASI), administrator of TRICARE Supplement \n 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 \n 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 re-enroll in an SHBP coverage option \n 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 during the ROCP \nQuestions about eligibility or benefits should be addressed to ASI at www.asicorporation.com/ga_shbp or call 866-637-9911. \nPEACHCARE FOR KIDS \nAs state or public school employees, you could be eligible to enroll your children in PeachCare for Kids if your child(ren) have been without coverage for six months. You can save more than $2,000 per year by enrolling your children in highquality PeachCare for Kids instead of the State Health Benefit Plan. \nPeachCare for Kids provides great coverage, including vision, dental, check-ups, prescription medicine and more. Your premiums may be lower and there are no deductibles. The current monthly cost for PeachCare for Kids for one child ranges from $10 to $35 with a maximum of $70 for two or more children living in the same household. There are no premiums for children under age 6. \n \nMonthly Premiums (Based on HMO example) One child \nChildren under age 6 \n \nPeachCare for Kids \n \nCurrent SHBP Options (Approximate monthly premium for child/children) \n$171 to $205 (1 child or more) \n$171 to $205 \n \nPeachCare for Kids (Approximate monthly \npremium) \n$10 to $35 ($70 maximum for 2 or more children) \nFREE! \n \nAnnual Savings with PeachCare for Kids \n$1,932 to $2,040 \n$2,052 to $2,460 \n \n15 New Enrollee Decision Guide 2013 \n \n Eligibility depends on household income. A family of three earning $44,868 annually or a family of four earning $54,180 may qualify. PeachCare for Kids will have an income calculator to help you determine if your children are eligible for this program. \nPeachCare for Kids Benefits for Families \n PeachCare for Kids is high-quality, low-cost health care for kids ages 0 to 19  State and public school employees can apply for PeachCare for Kids  Significantly reduce your out-of-pocket costs by switching your child's, or children's health care benefits from the State \nHealth Benefit Plan to PeachCare for Kids  PeachCare for Kids has low or no co-payments  PeachCare for Kids has no deductibles  For an eligible single parent, PeachCare for Kids may save more than $200 per month  PeachCare for Kids includes free dental and vision care  PeachCare for Kids includes free mental health services  Children under age 6 are free (no premiums)  Children ages 6 to 19 have low premiums ($35 for one child; maximum of $70 total for two or more children)  All major medical, including hospitalization, is covered by PeachCare for Kids  Your physician may already be a PeachCare for Kids provider \nIf your children are eligible and you enroll them in PeachCare for Kids, SHBP will be notified of the enrollment effective date and will change your premiums (if your enrollment tier will change) and terminate your child's SHBP coverage because children cannot be covered under both SHBP and PeachCare for Kids. Once children are approved for PeachCare, employees should verify that the correct SHBP deduction is being taken. \nIf your child loses PeachCare for Kids coverage, you have 60 days from the loss of coverage to enroll your child in SHBP. It is not a qualifying event to enroll your children in SHBP if PeachCare for Kids denies enrollment or if coverage under PeachCare ends because of failure to pay the monthly premiums. Do not discontinue your child's coverage in SHBP until you receive confirmation that PeachCare for Kids has approved his/her enrollment. \nThe PeachCare for Kids enrollment process can take up to four weeks -- so apply now so coverage will go into effect once approved. \nVisit www.peachcare.org or call 1-877-427-3224 for more information. \n16 New Enrollee Decision Guide 2013 \n \n 2013 Plan Options \n \nBenefits Comparison: HRA--HDHP Plans \nSchedule of Benefits for You and Your Dependents for January 1, 2013  December 31, 2013 \n \nStandard HRA Option \n \nIn-Network Out-of-Network \n \nCovered Services \n \nDeductible/Co-Payments  You  You + Spouse  You + Child(ren)  You + Family \n \n$1,600* $2,800* $2,800* $4,000* \n \nOut-of-Pocket Maximum  You  You + Spouse  You + Child(ren)  You + Family \n \n*HRA credits will reduce this amount $4,500* $7,000* $7,000* $9,500* \n \n*HRA credits will reduce this amount \n \nHRA Credits  You  You + Spouse  You + Child(ren)  You + Family \nPhysicians' Services \n \n$150 $300 $300 $500 The Plan Pays \n \nPrimary Care Physician or Specialist Office or Clinic Visits Treatment of illness or injury \nMaternity Care (prenatal, delivery and postpartum) \nPrimary Care Physician or Specialist Office or Clinic Visits for the Following:  Wellness care/preventive health care  Annual gynecological exams (these \nservices are not subject to the deductible)  Prenatal care coded as preventative \n \n85% coverage; subject to deductible 100% \ncoverage;not subject to \ndeductible \n \n60% coverage; subject to deductible \nNot covered \n \nPhysician Services Furnished in a Hospital  Visits; surgery in general, including charges \nby surgeon, anesthesiologist, pathologist and radiologist \nPhysician Services for Emergency Care \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n85% coverage; subject to deductible \n \nStandard HDHP Option In-Network Out-of-Network \n \n$2,000 $4,000 $4,000 $4,000 \n \n$4,000 $8,000 $8,000 $8,000 \n \n$4,500 $9,000 $9,000 $9,000 \n \n$9,000 $18,000 $18,000 $18,000 \n \nNone \n \nThe Plan Pays \n \n80% coverage; subject to de- \nductible \n \n60% coverage; subject to deductible \n \n100% coverage;not sub- \nject to deductible \n \nNot covered \n \n80% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n80% coverage; subject to in-network deductible \n \nAllergy Shots and Serum \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n80% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n17 New Enrollee Decision Guide 2013 \n \n Benefits Comparison: HRA--HDHP Plans \nSchedule of Benefits for You and Your Dependents for January 1, 2013  December 31, 2013 \n \nStandard HRA Option \n \nIn-Network Out-of-Network \n \nPhysicians' Services \nOutpatient Surgery  When billed as office visit \n \nThe Plan Pays \n \n85% coverage; \n \n60% coverage; \n \nsubject to deductible subject to deductible \n \nOutpatient Surgery  When billed as outpatient \nsurgery at a facility \n \n85% coverage; \n \n60% coverage; \n \nsubject to deductible subject to deductible \n \nHospital Services \nInpatient Services  Inpatient care, delivery and inpatient short-term acute rehabilitation services \nInpatient Services  Well-newborn care \n \nThe Plan Pays \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nOutpatient Surgery Hospital/facility \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nEmergency Care--Hospital  Treatment of an emergency medical condition or injury \n \n85% coverage; subject to deductible \n \nOutpatient Testing, Lab, etc. \n \nThe Plan Pays \n \nNon Routine laboratory; X-Rays; Diagnostic Tests; Injections  Including medications covered under medical benefits--for the treatment of an illness or injury \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nStandard HDHP Option \n \nIn-Network \n \nOut-of-Network \n \nThe Plan Pays \n \n80% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n80% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nThe Plan Pays \n \n80% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n80% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n80% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n80% coverage; subject to in-network deductible \n \nThe Plan Pays \n \n80% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n18 New Enrollee Decision Guide 2013 \n \n 2013 Plan Options \n \nBenefits Comparison: HRA--HDHP Plans \nSchedule of Benefits for You and Your Dependents for January 1, 2013  December 31, 2013 \n \nBehavioral Health \nMental Health and Substance Abuse Inpatient Facility and Partial Day Hospitalization \nMental Health and Substance Abuse Outpatient Visits and Intensive Outpatient \n \nStandard HRA Option \n \nIn-Network \n \nOut-of-Network \n \nStandard HDHP Option \n \nIn-Network \n \nOut-of-Network \n \nThe Plan Pays \n \nThe Plan Pays \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n80% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nContact vendor regarding prior authorization \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n80% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nContact vendor regarding prior authorization \n \nOther Coverage \n \nThe Plan Pays \n \nThe Plan Pays \n \nOutpatient Acute Short-Term Rehabilitation Services  Physical Therapy  Speech Therapy  Occupational Therapy  Other short term \nrehabilitative services \n \n85% coverage; subject to deductible; up to 40 visits per therapy per Plan Year (not to exceed a total of 40 visits combined, \nincluding any out-of-network visits) \n \n60% coverage; subject to deductible; up to 40 visits per therapy per Plan Year \n(not to exceed a total of 40 visits combined, \nincluding any in-network visits) \n \n80% coverage up to 40 visits per therapy per Plan Year; subject to deductible \n(not to exceed a total of 40 visits combined, \nincluding any outof-network visits) \n \n60% coverage up to 40 visits per therapy per \nPlan Year; subject to deductible (not to exceed \na total of 40 visits combined, including any \nin-network visits) \n \nChiropractic Care NOTE: UHC Coverage up to a maximum of 20 visits; CIGNA  up to a maximum of 20 days, per Plan Year \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n80% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nHearing Services Routine hearing exam \n \n85% coverage for routine exam and fitting; subject to deductible. $1,500 hearing aid allowance every 5 years; not subject to the deductible \n \nUrgent Care Services NOTE: All subject to deductible except HMO \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nPharmacy - You Pay \n \n80% coverage for routine exam and fitting; subject to deductible. $1,500 hearing aid allowance every \n5 years; subject to the deductible \n \n80% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nTier 1 Co-payment \nTier 2 Co-payment Preferred Brand \nTier 3 Co-payment Non-Preferred Brand \n \n15% ($20 min/$50 max) not subject to deductible \n \n40% coverage; not subject to deductible* \n \n25% ($50 min/$80 max) \n \n40% coverage; \n \nnot subject to deductible not subject to deductible* \n \n25% ($80 min/$125 max) \n \n40% coverage; \n \nnot subject to deductible not subject to deductible* \n \n20% coverage; subject to deductible $10 min/ \n$100 max 20% coverage; subject to deductible $10 min/ \n$100 max 20% coverage; subject to deductible $10 min/ \n$100 max \n \nNot covered Not covered Not covered \n \n90-Day Voluntary Mail Order \n \nTier 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 \n \n20% ($25 min/$250 max) No non-network coverage \n \n19 New Enrollee Decision Guide 2013 \n \n Benefits Comparison: HRA--HDHP Plans \nSchedule of Benefits for You and Your Dependents for January 1, 2013  December 31, 2013 \n \nStandard HRA Option \n \nStandard HDHP Option \n \nIn-Network \n \nOut-of-Network \n \nIn-Network \n \nOut-of-Network \n \nOther Coverage \n \nThe Plan Pays \n \nThe Plan Pays \n \nHome Health Care Services NOTE: Prior approval required \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n80% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nSkilled Nursing Facility Services NOTE: Prior approval required \n \n85% coverage; up to 120 days per Plan Year; subject to deductible \n \nNot covered \n \n80% coverage up to 120 days per Plan Year; subject to deductible \n \nNot covered \n \nHospice Care NOTE: Prior approval required \nDurable Medical Equipment (DME)--Rental or purchase NOTE: Prior approval required for certain DME \nFoot Care NOTE: Covered only for neurological or vascular diseases \nTransplant Services NOTE: Prior approval required \n \n85% coverage; subject to deductible \n85% coverage; subject to deductible \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n60% coverage; subject to deductible \n \n80% coverage; subject to deductible \n80% coverage; subject to deductible \n \n60% coverage; subject to deductible \n60% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n80% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nContact vendor for coverage details \n \n20 New Enrollee Decision Guide 2013 \n \n Making Changes When You Have a Qualifying Event \nIf 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 days for Medicaid or State Children's Health Insurance Program (SCHIP or Medicare) or 90 days (for a newly eligible dependent child) as 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. \nQualifying events include, but are not limited to: \n Birth or adoption of a child, or placement for adoption  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 \nIMPORTANTNOTE \n If you have single coverage and are having a baby, in order for the baby's charges to be covered, you must change tiers to include the baby at birth. \n You will need to add your newborn within the first of the month of his or her birth. A newborn's charges will not be covered if the effective date occurs the month after the birth. Since SHBP premiums are paid one month in advance of the coverage, retroactive deductions may apply. \nIMPORTANTINFORMATION \n Change requests should not be held waiting on additional information, such as Social Security Number, marriage or birth certificate. \n 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. \n 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 \ndependents to your record. Do not send originals as they will not be returned. \n21 New Enrollee Decision Guide 2013 \n \n Documentation Confirming Eligibility for Your Spouse or Dependents \nSHBP 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) \nincluding 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 certified 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. \nCOBRA Rights  Dependents \nThe 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.dch.georgia.gov/shbp. \n22 New Enrollee Decision Guide 2013 \n \n If You Are Retiring \nIf You Are Retiring \n In order to continue your SHBP Plan as a retiree, you and any dependents you want covered must be enrolled in the Plan at the time you retire. If you are not enrolled in the SHBP coverage and wish to carry coverage as a retiree, you will need to enroll in the Plan during the Open Enrollment the year prior to your retirement. \n If you are under 65, your Options are the same as for active employees and the Tobacco Surcharge will apply.  Once retired, you will have an annual Retiree Option Change Period (ROCP) that allows you to change your Plan \nOption only.  You may add dependents only if you have a qualifying event.  Please refer to the Retiree Decision Guide for complete details regarding your SHBP coverage and Options as a retiree. \n23 New Enrollee Decision Guide 2013 \n \n Legal \nNotices \n \nAbout the Following Notice \nThe notice on the following pages is required by the Centers for Medicaid \u0026 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. \n \nThis notice states that prescription drug coverage under all SHBP coverage options are considered Medicare Part D \"creditable coverage.\" This means generally that the prescription drug coverage under the SHBP HMO, HRA and HDHP Standard Options are all \"as good or better than\" the prescription drug coverage offered through Medicare Part D plans that are sold to individuals. \n \nYour SHBP Option SHBP Medicare Advantage PPO Standard or SHBP Medicare Advantage PPO Premium Plan \nHRA /HMO/HDHP \n \nWhat happens if you buy an individual Medicare Part D Plan \nYour 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 \nYour 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 pay a Medicare \"late enrollment\" penalty unless the reason you didn't enroll in Medicare Part D when you first became eligible is because you were still working \n \n24 New Enrollee Decision Guide 2013 \n \n Important Notice from the State Health Benefit Plan About Your 2013 Prescription Drug Coverage under the HDHP, HRA and HMO Options (either Standard or Wellness) offered by Cigna or UnitedHealthcare and Medicare \nFor Plan Year: January 1  December 31, 2013 \nPlease 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. \nThis 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. \nThere are two important things you need to know about your current coverage and Medicare's prescription drug coverage: \n1. 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. \n2. The SHBP has determined that the prescription drug coverage offered under the HMO, HRA and HDHP Standard and Wellness Plans offered by Cigna and UnitedHealthcare under SHBP are, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and are, 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. \nWhen 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. \nWhat 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 benefits with the 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 30301-1990. \nImportant: If you are a retiree and terminate your SHBP coverage, you will not be able to get this SHBP coverage back. \n25 New Enrollee Decision Guide 2013 \n \n 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. \nIf 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. \nIn addition, if you don't join within 63 continuous days after your current coverage ends, you may have to wait until the following October to join. \nFor More Information About This Notice Or Your Current Prescription Drug Coverage... Contact the SHBP Call Center at 1-800-610-1863. 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. \nFor 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 \u0026 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. \nFor 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 \u0026 You\" \nhandbook for their telephone number) for personalized help  Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. \nIf 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). \nRemember: 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). \nFrom: January 1, 2013 To: January 1, 2014 Date: October 1, 2012 Name of Entity/Sender: State Health Benefit Plan Contact: Call Center Address: 2 Peachtree Street, Atlanta, GA 30334 Phone Number: 1-800 - 610-1863 \n26 New Enrollee Decision Guide 2013 \n \n STATEHEALTH BENEFITPLANANNUALLEGALNOTICES \nWomen's Health and Cancer Rights Act The Plan complies with the Women's Health and Cancer Rights Act of 1998. Mastectomy, including reconstructive surgery, is covered the same as other surgery under your Plan option. Following cancer surgery, the SHBP covers: \n All stages of reconstruction of the breast on which the mastectomy has been performed  Reconstruction of the other breast to achieve symmetrical appearance  Prosthesis and mastectomy bras  Treatment of physical complications of mastectomy, including lymphedema Note: Reconstructive surgery requires prior approval, and all inpatient admissions require prior notification. For more detailed information on the mastectomy-related benefits available under the Plan, you can contact the member Services unit for your coverage option. Telephone numbers are on the inside front cover of the Decisions Guide. \nNewborns' and Mothers' Health Protection Act The Plan complies with the Newborns' and Mothers' Protection Act of 1996. Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn to less than 48 hours following a vaginal delivery, or les than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother of the newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). \nHealth Insurance Portability and Accountability Act The Plan complies with the Health Insurance Portability and Accountability Act of 1996 (\"HIPAA\"). The HIPAA Privacy Notice is attached as Exhibit A. The Notice of Exemptions Letter is attached as Exhibit B. \nExhibit A Revised October 1, 2012. \nThis notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Questions? Call 404-656-6322 (Atlanta) or 800-610-1863 (outside of Atlanta). \nThe DCH and the State Health Benefit Plan Are Committed to Your Privacy. The Georgia Department of Community Health (DCH) sponsors and runs the State Health Benefit Plan (the Plan). We understand that your information is personal and private. Some DCH employees and companies hired by DCH collect your information to run the Plan. The information is called \"Protected Health Information\" or \"PHI.\" This notice tells how your PHI is used and shared. We follow the information privacy rules of the Health Insurance Portability and Accountability Act of 1996, (\"HIPAA\"). \n27 New Enrollee Decision Guide 2013 \n \n Only Summary Information is Used When Developing and Changing the Plan. The Board of Community Health and the Commissioner of the DCH make decisions about the Plan. When making decisions, they review reports that explain costs, problems, and needs of the Plan. These reports never include information that identifies any person. If your employer is allowed to leave the Plan entirely, or stop offering the Plan to a portion of its workforce, DHC will provide Summary Health Information (as defined by federal law) for the applicable portion of the workforce. This Summary Health Information does not contain names, dates of birth, or other identifiers, and may only be used by your employer in order to obtain health insurance quotes from other sources and make decision about whether to continue to offer the Plan. \nPlan Enrollment Information and Claims Information is Used in Order to Run the Plan. PHI includes two kinds of information. \"Enrollment Information\" includes 1) your name, address, and Social Security number; 2) your enrollment choices; 3) how much you have paid in premiums; and 4) other insurance you may have. This Enrollment Information is the only kind of PHI your employer is allowed to see. \"Claims Information\" includes information your health care providers send to the Plan. For example, it may include bills, diagnoses, statements, X-rays or lab test results. It also includes information you send to the Plan. For example, it may include your health questionnaires, enrollment forms, leave forms, letters and recorded telephone calls. Lastly, it includes information about you that is created by the Plan. For example, it includes payment statements and checks to your health care providers. \nYour PHI is Protected by Law. Employees of the DCH and employees of outside companies hired by DCH to run the Plan are \"Plan Representatives.\" They must protect your PHI. They may only use it as allowed by HIPAA. \nThe DCH Must Make Sure the Plan Complies with HIPAA. As Plan sponsor, the DCH must make sure the Plan complies with HIPAA. We must give you this notice. We must follow its terms. We must update it as needed. The DCH is the employer of some Plan Members. The DCH must name the DCH employees who are Plan Representatives. No DCH employee is ever allowed to use PHI for employment decisions. \nPlan Representatives Regularly Use and Share your PHI in Order to Pay Claims and Run the Plan. Plan Representatives use and share your PHI for payment purposes and to run the Plan. For example, they make sure you are allowed to be in the Plan. They decide how much the Plan should pay your health care provider. They also use PHI to help set premiums for the Plan and manage costs, but they are never allowed to use genetic information for these purposes. Some Plan Representatives work for outside companies. By law, these companies must protect your PHI. They also must sign \"Business Associate\" agreements with the Plan. Here are some examples of what they do: \nClaims Administrators: Process all medical and drug claims; communicate with Members and their health care providers; and give extra (assistance) to Members with some health conditions. \nData Analysis, Actuarial Companies: Keep health information in computer systems, study it, and create reports from it. \nAttorney General's Office, Auditing Companies, Outside Law Firms: Provide legal and auditing help to the Plan. \nInformation Technology Companies: Help improve and check on the DCH information systems used to run the Plan. \nSome Plan Representatives work for the DCH. By law, all employees of the DCH must protect PHI. They also must get special privacy training. They only use the information they need to do their work. Plan Representatives in the SHBP Division work fulltime running the Plan. They use and share PHI with each other and with Business Associates in order to help pay claims and run the Plan. In general, they can see your Enrollment Information and the information you give the Plan. A few can see Claims Information. DCH employees outside of the SHBP Division do not see Enrollment Information on a daily basis. They may use Claims Information for payment purposes and to run the Plan. \n28 New Enrollee Decision Guide 2013 \n \n Plan Representatives May Make Special Uses or Disclosures Permitted by Law. HIPAA has a list of special times when the Plan may use or share your PHI without your authorization. At these times, the Plan must keep track of the use or disclosure. To Comply with a Law, or to Prevent Serious Threats to Health or Safety: The Plan may use or share your PHI in order to comply with a law, or to prevent a serious threat to health and safety. For Public Health Activities: The Plan may give PHI to government agencies that perform public health activities. For Research Purposes: Your PHI may be given to researchers for a research project approved by a review board. The review board must review the research project and its rules to ensure the privacy of your information. Plan Representatives Share Some Payment Information with the Employee. Except as described in this notice, Plan Representatives are allowed to share your PHI only with you, and with your legal personal representative. However, the Plan may inform the employee family member about whether the Plan paid or denied a claim for another family member. \nYou May Authorize Other Uses of Your PHI. You may give a written authorization for the Plan to use or share your PHI for a reason not listed in this notice. If you do, you may take away the authorization later by writing to the contact below. The old authorization will not be valid after the date you take it away. \nYou Have Privacy Rights Related to Plan Enrollment Information and Claims Information that Identifies You. Right to See and Get a Copy your Information, Right to Ask for a Correction: Except for some reasons listed in HIPAA, you have the right to see and get a copy of information used to make decisions about you. If you think it is incorrect or incomplete, you may ask the Plan to correct it. Right to Ask for a List of Special Uses and Disclosures: You have the right to ask for a list of special uses and disclosures that were made after April 2003. \nRight to Ask for a Restriction of Uses and Disclosures, or for Special Communications: You have the right to ask for added restrictions on uses and disclosures. You also may ask the Plan to communicate with you in a special way. \nRight to a Paper Copy of this Notice, Right to File a Complaint without Getting in Trouble: You have the right to a paper copy of this notice. Please contact the SHBP HIPAA Privacy Unit or print it from www.dch.georgia.gov. If you think your privacy rights have been violated, you may file a complaint. You may file the complaint with the Plan and/or the Department of Health and Human Services. You will not get in trouble with the Plan or your employer for filing a complaint. \nAddresses for Complaints: SHBP HIPAA Privacy Unit P.O. Box 1990, Atlanta, Georgia 30301 404-656-6322 (Atlanta) or 800-610-1863 (outside Atlanta) U.S. Department of Health \u0026 Human Services, Office for Civil Rights Region IV Atlanta Federal Center 61 Forsyth Street SW, Suite 3B70 Atlanta, GA 30303-8909 \n29 New Enrollee Decision Guide 2013 \n \n Exhibit B Election to be Exempt from Certain Requirements of HIPAA October 1, 2012 TO: All Members of the State Health Benefit Plan who are not Enrolled in a Medicare Advantage Option Under a Federal law known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, as amended, group health plans must comply with a number of requirements. Under HIPAA, state health plans that are \"selffunded\" may \"opt out\" of some of these requirements by making a yearly election to be exempt. Your plan option is self-funded because the Department of Community Health pays all claims directly instead of buying a health insurance policy. Temporary rules implementing the Mental Health Parity and Addiction Equity Act apply January 1, 2013, unless the Department of Community Health again elects to be exempted from this law's requirements. The temporary rules generated more than 4,000 comments; no final rules addressing these comments have been issued. The Department of Community Health has determined to exempt your State Health Benefit Plan (\"SHBP\") option from the Mental Health Parity and Addiction Equity Act, and the temporary rules' requirements, for the 2013 calendar year. \nParity in the application of certain limits to mental health benefits. Group health plans (of employers that employ more than 50 employees) that provide both medical and surgical benefits and mental health or substance use disorder benefits must ensure that financial requirements and treatment limitations applicable to mental health or substance use disorder benefits are no more restrictive than the predominant financial requirements and treatment limitations applicable to substantially all medical and surgical benefits covered by the plan. The exemption from these federal requirements will be in effect for the plan year starting January 1, 2013, and ending December 31, 2013. The election may be renewed for subsequent plan years. HIPAA also requires the SHBP to provide covered employees and dependents with a \"certificate of creditable coverage\" when they cease to be covered under the SHBP. There is no exemption from this requirement. The certificate provides evidence that you were covered under the SHBP, because if you can establish your prior coverage, you may be entitled to certain rights to reduce or eliminate a preexisting condition exclusion if you join another employer's health plan, or if you wish to purchase an individual health insurance policy. \n30 New Enrollee Decision Guide 2013 \n \n Penalties for Misrepresentation \nIf 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. \nIn 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. \nThe material in this booklet is for information purposes only and is not a contract. It is intended only to highlight principal benefits of the health plan Options. 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. For all Options other than Medicare Advantage Option, the Plan documents include the SHBP regulations, Summary Plan Descriptions and reimbursement guidelines of the vendors. The Plan documents for Medicare Advantage is the insurance certificates. It is the responsibility of each member, active or retired, to read the Plan documents in order to fully understand how that Option pays benefits. 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. Premiums for SHBP Options are established by the DCH Board and may be changed at any time by the Board resolutions subject to advance notice. \n31 New Enrollee Decision Guide 2013 \n \n  "},{"id":"dlg_ggpd_y-ga-bc900-pe4-bs1-bn4-b2012-belec-p-btext","title":"New enrollee decision guide 2012","collection_id":"dlg_ggpd","collection_title":"Georgia Government Publications","dcterms_contributor":["Georgia. Department of Community Health."],"dcterms_spatial":["United States, Georgia, 32.75042, -83.50018"],"dcterms_creator":["Georgia. 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Map and Government Information Library"],"edm_is_shown_by":["https://dlg.galileo.usg.edu/do:dlg_ggpd_y-ga-bc900-pe4-bs1-bn4-b2012-belec-p-btext"],"edm_is_shown_at":["https://dlg.galileo.usg.edu/id:dlg_ggpd_y-ga-bc900-pe4-bs1-bn4-b2012-belec-p-btext"],"dcterms_temporal":null,"dcterms_rights_holder":null,"dcterms_bibliographic_citation":null,"dlg_local_right":null,"dcterms_medium":["state government records"],"dcterms_extent":null,"dlg_subject_personal":null,"iiif_manifest_url_ss":null,"dcterms_subject_fast":null,"fulltext":"PLAN CHANGES \n \nNEW ENROLLEE \nDECISION GUIDE 2012 \nAre you engaged in your health? \nPlan Year January 1 -- December 31, 2012 www.myshbp.ga.gov \n1 \n \n ADDITIONAL HELP/CONTACT INFORMATION \nState Health Bene t Plan (SHBP): www.myshbp.ga.gov \n \nVendor CIGNA \nHRA, HDHP hours 24/7 \nUnitedHealthcare HRA HDHP hours 8 a.m.  8 p.m. local time zone; 7 days a week, TTY 711 \nPeachCare for Kids TRICARESupplement \nSHBP Eligibility \n \nMember Services \n800-633-8519 TDD 800-576-1314 \n800-396-6515 877-246-4189 \n \nWebsite www.mycigna.com/shbp www.welcometouhc.com/shbp \n \n877-427-3224 866-637-9911 800-610-1863 \n \nwww.peachcare.org www.asicorporation.com \nwww.myshbp.ga.gov \n \nPENALTIES FOR MISREPRESENTATION \nIf an SHBP participant misrepresents eligibility information when applying for coverage, during change of coverage or when filing for benefits, the SHBP may take adverse action against the participant, including but not limited to terminating coverage (for the participant and his or her 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. \nNew Enrollee Decision Guide 2012 \n \n David A. Cook, Commissioner \n \nNathan Deal, Governor \n \n2 Peachtree Street, NW Atlanta, GA 30303-3159 www.dch.georgia.gov \n \nDear State Health Benefit Plan (SHBP) Member: \nWelcome to the State Health Benefit Plan (SHBP). The SHBP is committed to providing highquality health benefits at an affordable price to its members. SHBP's goal is to assure that all members receive the best possible health care insurance coverage at affordable costs while keeping members as healthy as possible by encouraging them to lead a healthy lifestyle. \nUpon joining SHBP, new enrollees have the opportunity to choose between two consumer-driven health options, each offered by CIGNA Healthcare and UnitedHealthcare. These plans are: \n Standard HDHP  Standard HRA \nFor those members enrolled in TRICARE, the TRICARE supplement plan option is also available. \nThe HDHP has a lower monthly premium and allows members to start a Health Savings Account (HSA) to set aside tax-free dollars to pay for eligible health care expenses that offsets the higher deductible. \nIf you choose to take advantage of the HRA, you will have the extra benefit of the SHBP contributing dollars to your HRA on an annual basis for treatment of medical and pharmacy expenses. \nPlease read the New Enrollee Decision Guide carefully to learn about the plans available to you. Additional information and tools are available at www.myshbp.ga.gov. \nThe Georgia Department of Community Health, which administers the SHBP, is committed to providing you with meaningful and affordable options as well as the tools to help you and your family members stay healthy. \nSincerely, \nDavid A. Cook Commissioner \n \nNew Enrollee Decision Guide 2012 \n \n TABLE OF CONTENTS \nAdditional Help/Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inside Front Cover General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 SHBP Eligibility Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Enrolling in SHBP Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Understanding Your Plan Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Legal Notices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 \n \nListed below are common health care acronyms that are used throughout this decision guide. \n \nCDHP  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 \n \nOE  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 \n \nThe 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. \n \n1 New Enrollee Decision Guide 2012 \n \n GENERAL INFORMATION \n \nGENERAL INFORMATION \n \nThis guide will provide you with a brief explanation of each Plan Option. \nWhile CIGNA and UnitedHealthcare's basic plan design is the same for each option, each vendor has nuances in benefits and services that are unique to each option. It is important that you read the Decision Guide so you will understand what these differences are and how they may affect you. \nSTATE HEALTH BENEFIT PLAN \nThe Georgia Department of Community Health (DCH), which administers the State Health Benefit Plan (SHBP), continually seeks to offer high-quality, affordable health coverage. Keep in mind, however, that you are the manager of your health care needs, and in turn, must take the time to understand your Plan benefit choices in order to make the best decisions for you and your family. \nLet's start by talking about how the SHBP works. It is a self-funded plan, which means that all expenses are paid by employee premiums and employer funds. Approximately 75 percent of the cost is funded by your employer, with you paying approximately 25 percent. \nPeople who do not understand their health coverage pay more, according to the American Medical Association. To help you better understand your Plan and save your health care dollars, we have prepared a few points for you to consider. \nWHAT CAN YOU DO TO HELP MANAGE YOUR HEALTH CARE COSTS? \nUnderstand Your Options  Compare all Plan Options, considering both the premiums and out-of-pocket costs that you may incur. Web sites and phone numbers are listed on the inside of the front cover of the Decision Guide if you need more information. \n \nConsider Enrolling in a Flexible Spending Account (FSA)  A FSA (also referred to as a health care spending account) helps you save tax dollars, approximately 2645 percent depending on your tax situation. By electing to use a FSA, you may set aside up to $5,040 annually to cover health-related treatments for yourself and your dependents. Eligible expenses include deductibles, co-insurance and costs for certain procedures not covered under your health plan. The benefit of this account is that you are able to pay for these out-of-pocket costs with tax-free dollars! Contact your Benefit Coordinator for more information. \nBecome a More Proactive Consumer of Health Care  Most people do not realize how much their treatments, medicines and tests cost. \nSteps you can take include:  Keep a list of all medications you take.  Shop in-network providers and pharmacies.  Find out what your drugstore charges for a drug.  Make sure all procedures are pre-certified, if \nrequired.  Make sure you get the results of any test or \nprocedure.  Understand what will happen if you need surgery.  Check your Explanation of Benefits (if provided under \nyour plan option) and if you have questions, ask your provider about it. \nThese and other steps you take will help manage healthcare expenses, reduce your out-of-pocket costs and those of the Plan. In addition, these steps will help in keeping premium costs down. \n \nNew Enrollee Decision Guide 2012 \n \n2 \n \n GENERAL INFORMATION \n \nGEORGIA STATISTICS SHOW HOW OUR CHOICES MAY BE AFFECTING OUR HEALTH \n 27% of adults are obese, which increases the risk of cardiovascular disease. \n Cardiovascular Disease (CVD) accounted for one third (32%) - 21,389 CVD deaths in 2007. \n Adults with high blood pressure has increased from 21% in 1997 to 30% in 2007. \n Adults with high cholesterol has increased from 24% in 1997 to 37% in 2007. \n Adults reported having diabetes increased from 6% in 1998 to 10% in 2008. \n The majority (75%) of adults did not consume the recommended five or more servings of fruits and vegetables per day in 2007. \n \nWhat 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 \ninformation 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. \nTo learn more about these and other helpful tools and resources go to www.mycigna.com and www.welcometouhc.com/shbp. \n \nTAKE STEPS TO GET HEALTHY Online and Telephonic Coaching Programs and Resources Available to You Through the Vendors \n \nBiometric Screening \nCholesterol Blood Sugar Blood Pressure Body Mass Index (BMI) \n \nWeight Management \nX X X \n \nExercise X X \n \nStress X \n \nHeart Health X \nX X \n \nDiabetes X X \n \nNutrition X X \nX \n \n3 New Enrollee Decision Guide 2012 \n \n SHBP ELIGIBILITY \n \nSHBP ELIGIBILITY INFORMATION \n \nAll SHBP options have the same eligibility requirements. A summary is listed below. \nSHBP ELIGIBILITY FOR YOU \nYou are eligible to enroll yourself and your eligible dependents for coverage if you are: \n A full-time employee of the state of Georgia, the Georgia General Assembly, or an agency, board, commission, department, county administration or contracting employer that participates in the SHBP, as long as: \n You work at least 30 hours a week consistently, and \n Your employment is expected to last at least nine months. \nNot eligible: Student employees or seasonal, part-time or short-term employees.  A certified public school teacher or library employee who works half-time or more, but not less than 17.5 hours a week \nNot eligible: Temporary or emergency employees  A non-certified service employee of a local school \nsystem who is eligible to participate in the Teachers Retirement System or its local equivalent. You must also work at least 60 percent of a standard schedule for your position, but not less than 20 hours a week  An employee who is eligible to participate in the Public School Employees' Retirement System as defined by Paragraph 20 of Section 47-4-2 of the Official Code of Georgia, Annotated. You must also work at least 60 percent of a standard schedule for your position, but not less than 15 hours a week  A retired employee of one of these listed groups who was enrolled in the Plan at retirement and is eligible to receive an annuity benefit from a state-sponsored or state-related retirement system. See the Summary Plan Description (SPD) for more information  An employee in other groups as defined by law \nSHBP ELIGIBILITY FOR YOUR DEPENDENTS \nThe 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. \n \nEligible Dependents Are: 1. Spouse  Individual who is not legally separated, who \nis 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 natu- \nral 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. \n \nNew Enrollee Decision Guide 2012 \n \n4 \n \n SHBP ELIGIBILITY \n \nDOCUMENTATION CONFIRMING ELIGIBILITY FOR YOUR SPOUSE OR DEPENDENTS \nSHBP requires documentation concerning eligibility of dependents covered under the plan. No health claims will be paid until the documentation is received and approved by SHBP. Please write your Social Security Number on each document. Do not send originals as they will not be returned. Please give the documentation to your employer.  Spouse  Certified copy of marriage license or copy \nof 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. \n 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 certified 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. \n 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. \n 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. \n \nMAKING CHANGES WHEN YOU HAVE A QUALIFYING EVENT \nIf 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. \nQualifying Events Include, But are Not Limited to:  Birth or adoption of a child, or placement for adoption. \n Change in residence by you or your spouse that results in ineligibility for coverage in your selected option because of location. \n Death of a spouse or child, if the only dependent enrolled. \n Your spouse's or dependent's loss of eligibility for other group health coverage. \n Marriage or divorce. \n Medicare eligibility. \nH AV I N G A B A B Y \nYou will need to add your newborn within the first of the month of his or her birth. A newborn's charges will not be covered if the effective date occurs the month after the birth. Since SHBP premiums are paid one month in advance of the coverage, retroactive deductions may apply. \n \n5 New Enrollee Decision Guide 2012 \n \n SHBP ELIGIBILITY \n \nIMPORTANT INFORMATION \n 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. \n Change requests should not be held waiting on additional information, such as Social Security Number, marriage or birth certificate. \n 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. \n No health claims will be paid until the documentation is received and approved by SHBP. \n 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. \nCOBRA RIGHTS  DEPENDENTS \nThe 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.gov. \n \nNew Enrollee Decision Guide 2012 \n \n6 \n \n ENROLLING IN SHBP COVERAGE \n \nENROLLING IN SHBP COVERAGE \n \nBEFORE YOU ENROLL \nYou should:  Read this Decision Guide and Summary Plan Descrip- \ntion to understand your Health Plan Options prior to making your health election. \n Read and understand the SHBP Tobacco and Spousal Surcharge Policies on pages 8 and 9, and answer all questions regarding these surcharges. If you fail to answer the questions, the surcharge(s) will apply for the 2012 Plan Year unless you experience a qualifying event or you complete the applicable steps to remove the surcharges as outlined on page 9. \n Gather eligibility verification documents for all dependents for whom coverage has been requested to submit within the required time frame. \n Understand the election you make will be valid for the 2012 Plan Year unless you experience a qualifying event. \n Additional options may be available to you during the Fall Open Enrollment for coverage effective January 1, 2013. \nHEALTH BENEFIT COST ESTIMATORS \nChoosing the right health plan is an important decision and CIGNA and UHC each provide a Plan Cost Estimator (PCE) tool to assist you. The PCEs offer you a simple way to help determine which option is best for you and your family. These online tools let you compare how your out-ofpocket expenses may vary under the different health plan options available to you. \nYou can use the PCE to review cost information for prescriptions, anticipated tests and procedures. \nHOW TO ENROLL \nIf you're eligible to participate in the SHBP, you become a member by enrolling either:  As a new hire, within 31 days of your hire date. If you join \nthe SHBP during that first 31-day enrollment opportunity, your coverage will go into effect on the first day of the month after you complete one full calendar month of employment. See your personnel/payroll office for instructions on how to enroll or if you have benefit questions, you may call the vendor directly at the telephone numbers listed on the inside of the front cover of the Decision Guide. \n \n If you decline coverage under SHBP when you first become eligible and later decide to enroll due to a qualifying event or at a future Open Enrollment period, your options will be limited to the HRA, HDHP and TRICARE supplement for your first Plan year of coverage. \n As a result of a qualifying event. See Making Changes When You Have a Qualifying Event, page 5 of this guide for more details. \n If you terminate employment and are re-hired by any employer eligible for the SHBP during the same Plan year, you must enroll in the same Plan option and tier (even if there is a gap in coverage) provided you are eligible for that option and have not had a qualifying event since coverage ended. \n If the termination is in one year and you are hired in the following year with a gap in coverage, you are restricted to the consumer driven health plan options: the Health Reimbursement Arrangement (HRA), High Deductible Health Plan (HDHP) and TRICARE Supplement with the new employer. \nIF YOU DECIDE TO BECOME A SHBP MEMBER,YOU WILL HAVE TWO MAJOR CHOICES TO MAKE: \n1.Your coverage options: CIGNA Healthcare  Standard Health Reimbursement Arrangement (HRA) \n Standard High Deductible Health Plan (HDHP)* UnitedHealthcare  Standard Health Reimbursement Arrangement \n(HRA) \n Standard High Deductible Health Plan (HDHP)* \n* These options allow you to set up a Health Savings Account. See page 12 for more information. \n2. Which eligible dependents would you like to have covered by SHBP? For a list of eligible dependents, refer to pages 4 and 5. \n SHBP is required to obtain the Social Security Number of each covered dependent. \n \n7 New Enrollee Decision Guide 2012 \n \n ENROLLING IN SHBP COVERAGE \n \n3. Which coverage tier? Select the coverage tier you desire for the dependents that you choose to cover. You will be locked into the tier for the 2012 Plan Year unless you experience a qualifying event. \n \n You \n \n You+ Child(ren) \n \n You + Spouse  You + Family* *You+ Family = You + Spouse + Child(ren) \n \nNOTE: Additional options may be available to you during the Fall Open Enrollment period for the following plan year. \nWHAT HAPPENS IF I HAVE OTHER INSURANCE? \nYou or your covered dependents may have medical coverage under more than one plan. In this case, coordination of benefits (COB) provisions apply. \n \nWhen you have other group or Medicare coverage and SHBP coverage, the benefit under SHBP will be no greater than it would have been if there was no coverage other than that of SHBP. Non-covered services or items, penalties and amounts balance billed are not part of the allowed amount and are the member's responsibility. \nIt is important that you notify the health insurance vendor you selected if you have other group coverage to prevent incorrect processing of any claims. For further information about COB rules, refer to the SPD or contact your health care vendor directly. \nWHAT IF I AM WORKING AND AM ELIGIBLE FOR MEDICARE? \nFederal Law requires SHBP to pay primary benefits for active employees and their dependents. Active members or their covered dependents may choose to delay Medicare enrollment. Termination of active employment is a qualifying event for enrolling in Medicare without penalty if your plan is creditable. Remember the HDHP plan is NOT creditable. To avoid the penalty, you should enroll in a creditable plan at Open Enrollment if someone under your coverage will turn 65 during the plan year and they will not be enrolling in Medicare due to your active employment. \n \nIMPORTANT NOTE \n Dual coverage (more commonly referred to as State on State coverage) is when two members are eligible for coverage both as an employee and spouse under SHBP. For example: a member is eligible for SHBP coverage through his/her employment and his/her spouse is also eligible for SHBP coverage as an employee. \n If both members are eligible for coverage as employees, it may not be cost effective to cover each other as dependents. This is because regardless of the other coverage (SHBP or another group policy) you will still be responsible for co-payments, deductibles and non-covered or ineligible charges. \nSURCHARGE POLICY \nYou should be aware that SHBP charges a Tobacco and Spousal Surcharge. A $80 Tobacco Surcharge will be added to your monthly premium if you or any of your covered dependents have used tobacco products in the previous 12 months. SHBP provides 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. \nA $50 Spousal Surcharge will be added to your monthly premium if you have elected to cover your spouse and your spouse is eligible for coverage through his/her employment but chose not to take it. If your spouse is eligible for coverage with SHBP through his/her employment, the spousal surcharge will be waived. \nYou will automatically be charged the applicable surcharges if you fail to answer all questions concerning the surcharges. The surcharges will apply to your premium until the next Plan Year unless you take steps to have the surcharges removed. See next page for details. \n \nNew Enrollee Decision Guide 2012 \n \n8 \n \n ENROLLING IN SHBP COVERAGE \n \nSPOUSAL SURCHARGE VERIFICATION \nSHBP 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. \nHOW TO REMOVE SURCHARGES \nTobacco You may have the Tobacco Surcharge removed if you contact your health care vendor and follow their instructions. See the inside cover for vendor contact information. \nSpousal SHBP charges a Spousal Surcharge for SHBP members who cover their spouses when the spouse declines health coverage through their employer. You may have the Spousal Surcharge removed:  If your spouse becomes covered by his/her employer's \nhealth benefit plan; and \n If you make the request and provide proof within 31 days of the effective date of the other coverage. \nNo refund in premiums will be made for previous health deductions that included the surcharge amounts. Additional information is available at www.dch.georgia.gov/shbp. \nWHO SHOULD I CONTACT IF I HAVE QUESTIONS? \nBene t Questions:  CIGNA for HRA or HDHP Options  800-633-8519 \n UHC HRA  800-396-6515 \n UHC HDHP  877-246-4189 Eligibility Questions:  SHBP Call Center  800-610-1863 \n SHBP E-Mail  shbpnoreply@dch.ga.gov \n \nHOW DO I DECIDE WHICH PLAN IS BEST FOR ME? \nThis can be a difficult decision but listed below are some things you may want to consider when making your decision. \n Under the HRA Plan, SHBP contributes dollars for your first dollar coverage for eligible health care and pharmacy expenses. \n Your prescription drug costs apply to the deductible and out-of-pocket maximum under the HDHP Option. \n 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 may lower your prescription drug costs. \nIMPORTANT INFORMATION \nIf you change options or vendors during the year, any amounts applied toward your deductible or out-of-pocket are not transferred to the new option. \n \n9 New Enrollee Decision Guide 2012 \n \n New Enrollee Decision Guide 2012 \n \nENROLLING IN SHBP COVERAGE \n \n10 \n \n UNDERSTANDING YOUR PLAN OPTIONS \n \nUNDERSTANDING YOUR PLAN OPTIONS \n \nBelow you will find a brief description of each option offered. CIGNA and UnitedHealthcare are your healthcare vendors and each offer an HRA and HDHP option. \nNOTE: If you are enrolling in coverage for the first time or if you were not covered by SHBP in 2011, your options are the Standard HRA, Standard HDHP and TRICARE Supplement for your first Plan Year. During the next Open Enrollment Period, you may have additional options for the next Plan Year. \nEach plan provides 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. \nSTANDARD HEALTH REIMBURSEMENT ARRANGEMENT (HRA) \nThe 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. The amount funded by SHBP into your HRA reduces your deductible and out-of-pocket maximum for covered medical expenses. These dollars 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. \n \nPrescription drugs have a three (3) tier structure with a minimum and maximum co-insurance amount you will pay. You may use your HRA credits to pay for your pharmacy co-insurance amounts but any monies credited for pharmacy expenses will not be used to satisfy your deductible and out-of-pocket maximum. In other words, only your medical expenses will count toward your deductible and out-ofpocket max. Once all your HRA credits have been exhausted, you will to pay your co-insurance minimum or maximum based on the tier for your prescription drugs and will not have to satisfy your deductible. \nIMPORTANT INFORMATION \nUnitedHealthcare members will need to present their Pharmacy Health Care Spending Card (PHCSC) for prescription drugs only 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 card to use HRA dollars to pay for your covered medications. The PHCSC must be activated one business day before presenting it at the pharmacy. No separate card is required for CIGNA. \nAny 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 OE or due to a qualifying event. \nIf you have a flexible spending account, HRA dollars must be used first before using dollars from your flex account. \n \n11 New Enrollee Decision Guide 2012 \n \n UNDERSTANDING YOUR PLAN OPTIONS \n \nSTANDARD HIGH DEDUCTIBLE HEALTH PLAN (HDHP) \nThe 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. 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 15 to compare benefits under the HDHP to other Plan Options. Go to www.irs.gov/publications/p969 for more information. \nIMPORTANT INFORMATION \nPrescription drug coverage under the HDHP Plan is not creditable. That means if you are enrolled in the HDHP Plan at the time you or your spouse turn 65 and don't sign up for Medicare Part D Plan or a SHBP Medicare Advantage Plan, even if you or your spouse are still actively working, you may be charged a late enrollment penalty. See the legal notice for more information. \n \nHEALTH SAVINGS ACCOUNT (HSA)  INFORMATION ONLY \nAn 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. \nYou 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. \n 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. \n HSA dollars can be used for eligible health care expenses even if you are no longer enrolled in the HDHP or any SHBP coverage. \n 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). \n You can contribute an additional $1,000 if you are 55 or older (see IRS Publication 969 at www.irs.gov). \n \nNew Enrollee Decision Guide 2012 \n \n12 \n \n UNDERSTANDING YOUR PLAN OPTIONS \n \nTRICARE SUPPLEMENT FOR ELIGIBLE MILITARY MEMBERS \nThe 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 TRICARE. 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 \u0026 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. \nThe 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). \nPoints to Consider if You Elect TRICARE Supplement Plan Coverage  TRICARE will become your primary coverage. \n TRICARE Supplement Plan will become the secondary coverage. \n The eligibility rules and benefits described in the TRICARE Supplement Plan will apply. \n TRICARE covers unmarried dependent children under the age of 21 or 23 if a full-time student. \n Unmarried adult children under the age of 26 who are no longer eligible for regular TRICARE must be enrolled in TYA through TRICARE before enrolling in the TRICARE Supplement Plan offered by SHBP. \n Tobacco and Spousal Surcharges will not apply. \n \n COBRA rights will not apply.  If you or your dependents lose eligibility for SHBP \ncoverage while you are enrolled in the TRICARE Supplement Plan, you will be offered a portability feature by the Association \u0026 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.  Attainment of age 65 and eligibility for Medicare causes a loss of eligibility for TRICARE Supplement Plan coverage. This is a qualifying event and you must make a request within 31 days in order to re-enroll in an SHBP coverage option. \nIMPORTANT INFORMATION \n 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 \n Employers are prohibited by law from paying any portion of the cost of TRICARE Supplement Coverage \nQuestions about eligibility or benefits should be addressed to ASI at www.asicorporation.com or call 866-637-9911. \n \n13 New Enrollee Decision Guide 2012 \n \n UNDERSTANDING YOUR PLAN OPTIONS \n \nPEACHCARE FOR KIDS \nIf you are eligible for SHBP coverage you may enroll your 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. \nThe PeachCare for Kids website has 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 \n \nhave 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. \nIf 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. \nPlease contact PeachCare for Kids directly regarding any questions about this program. The website address is www.peachcare.org; phone 1-877-427-3224/ 1-877-GA PEACH. \n \nCOMPARISON OF THE MOST COMMON BENEFITS UNDER SHBP AND EACH PEACHCARE PROGRAM  CO-PAYS, DEDUCTIBLES UNDER EACH PLAN \n \nDeductible Emergency Room \n \nSHBP Plans \n \nPeachCare \n \nMinimum of $1,300 to maximum of $7,000 No Deductible, No co-pays \n \nMinimum of 10% or $150 copay \n \nNo Deductible, No co-pays \n \nHospital Services (inpatient/outpatient) \n \nMinimum of 15% or 40% after satisfying the No Deductible, No co-pays deductible \n \nPhysician Office Services (illness/injury) \n \nMinimum of 15% after satisfying the deductible or $35 - $55 copay 85%/60% \n \nNo Deductible, No co-pays \n \nMental Health/Substance Abuse (inpatient). Prior notification required. Visits unlimited \n \nYou will pay a minimum of 10% to 20% \n \nNo Deductible, No co-pays \n \nin-network and 40% if going out-of-network. \n \nPharmacy (Up to a 31 day supply) \n \nMinimum of $10 with maximum of $125 \n \nNo Deductible, No co-pays \n \nDental Coverage - Repair of sound natural teeth or tissue when damaged by traumatic injury. \n \nTreatment covered only for repair of natural teeth due to a traumatic injury. You will pay at least 5% or $45-$55 after satisfying the deductible. \n \nNo Deductible, No co-pays \n \nVision Benefits \n \n100% coverage for routine eye exam every No Deductible, No co-pays 2 years. \n \nOral Maxillofacial Surgery \n \nNo benefit \n \nNo Deductible, No co-pays \n \nNote: You will have greater out-of-pocket expenses under SHBP Plans. Consider this when deciding about applying for coverage for your child(dren) under PeachCare for Kids. \n \nNew Enrollee Decision Guide 2012 \n \n14 \n \n Bene ts Comparison: Standard HRA  HDHP \nSchedule of Bene ts for You and Your Dependents for January 1, 2012  December 31, 2012 \n \nCovered Services \nDeductible/Co-Payments  You  You + Spouse  You + Child(ren)  You + Family \n \nStandard HRA Option \n \nIn-Network \n \nOut-of-Network \n \nStandard HDHP Option \n \nIn-Network \n \nOut-of-Network \n \n$1,300* $2,250* $2,250* $3,250* \n \n$1,750 $3,500 $3,500 $3,500 \n \n$3,500 $7,000 $7,000 $7,000 \n \nOut-of-Pocket Maximum  You  You + Spouse  You + Child(ren)  You + Family \n \n*HRA credits will reduce this amount \n$3,000* $5,000* $5,000* $7,000* \n \n$2,650 $4,600 $4,600 $4,600 \n \n$5,800 $10,800 $10,800 $10,800 \n \n*HRA credits will reduce this amount \n \nHRA Credits  You  You + Spouse  You + Child(ren)  You + Family \nPhysicians' Services \nPrimary Care Physician or Specialist Office or Clinic Visits Treatment of illness or injury \n \n$375 $650 $650 $1,000 \nThe Plan Pays \n \n85% coverage; \n \n60% coverage; \n \nsubject to deductible subject to deductible \n \nNone \n \nThe Plan Pays \n \n80% coverage;sub- \n \n60% coverage; \n \nject to deductible subject to deductible \n \nPrimary Care Physician or Specialist Office or Clinic Visits for the Following:  Wellness care/preventive \nhealth care  Annual gynecological \nexams(these services are not subject to the deductible) \nMaternity Care (prenatal, delivery and postpartum) \nPhysician Services Furnished in a Hospital  Visits; surgery in general, \nincluding charges by surgeon, anesthesiologist, pathologist and radiologist \n \n100% coverage; not subject to deductible \n85% coverage; subject to deductible \n85% coverage; subject to deductible \n \nNot covered \n60% coverage; subject to deductible \n60% coverage; subject to deductible \n \n100% coverage; not subject to deductible \n80% coverage; subject to deductible \n80% coverage; subject to deductible \n \nNot covered \n60% coverage; subject to deductible \n60% coverage; subject to deductible \n \n15 New Enrollee Decision Guide 2012 \n \n Bene ts Comparison: Standard HRA  HDHP \nSchedule of Bene ts for You and Your Dependents for January 1, 2012  December 31, 2012 \n \nPhysicians' Services Physician Services for Emergency Care \nOutpatient Surgery  When billed as office visit \nOutpatient Surgery  When billed as outpatient \nsurgery at a facility \nAllergy Shots and Serum \n \nStandard HRA Option \n \nIn-Network \n \nOut-of-Network \n \nThe Plan Pays \n \n85% coverage; subject to in-network deductible \n \nStandard HDHP Option \n \nIn-Network \n \nOut-of-Network \n \nThe Plan Pays \n \n80% coverage; subject to in-network deductible \n \n85% coverage; \n \n60% coverage; \n \n80% coverage; sub- \n \n60% coverage; \n \nsubject to deductible subject to deductible ject to deductible subject to deductible \n \n85% coverage; \n \n60% coverage; \n \n80% coverage; \n \n60% coverage; \n \nsubject to deductible subject to deductible subject to deductible subject to deductible \n \n85% coverage; \n \n60% coverage; \n \n80% coverage; \n \n60% coverage; \n \nsubject to deductible subject to deductible subject to deductible subject to deductible \n \nHospital Services Inpatient Services  Inpatient care, delivery and \ninpatient short-term acute rehabilitation services \nInpatient Services  Well-newborn care \n \nThe Plan Pays \n \n85% coverage; \n \n60% coverage; \n \nsubject to deductible subject to deductible \n \nThe Plan Pays \n \n80% coverage; \n \n60% coverage; \n \nsubject to deductible subject to deductible \n \n85% coverage; \n \n60% coverage; \n \n80% coverage; \n \n60% coverage; \n \nsubject to deductible subject to deductible subject to deductible subject to deductible \n \nOutpatient Surgery Hospital/facility \n \n85% coverage; \n \n60% coverage; \n \n80% coverage; \n \n60% coverage; \n \nsubject to deductible subject to deductible subject to deductible subject to deductible \n \nEmergency Care--Hospital  Treatment of an emergency medical condition or injury \n \n85% coverage; subject to deductible \n \n80% coverage; subject to in-network deductible \n \nOutpatient Testing, Lab, etc. \nNon Routine laboratory; X-Rays; Diagnostic Tests; Injections--including medications covered under medical benefits--for the treatment of an illness or injury \n \nThe Plan Pays \n \nThe Plan Pays \n \n85% coverage; \n \n60% coverage; \n \n80% coverage; \n \n60% coverage; \n \nsubject to deductible subject to deductible subject to deductible subject to deductible \n \nNew Enrollee Decision Guide 2012 \n \n16 \n \n Bene ts Comparison: Standard HRA  HDHP \nSchedule of Bene ts for You and Your Dependents for January 1, 2012  December 31, 2012 \n \nStandard HRA Option \n \nIn-Network \n \nOut-of-Network \n \nBehavioral Health \n \nThe Plan Pays \n \nMental Health and Substance Abuse Inpatient Facility and Partial Day Hospitalization \nNOTE: Contact vendor \nregarding prior authorization \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nStandard HDHP Option \n \nIn-Network \n \nOut-of-Network \n \nThe Plan Pays \n \n80% coverage; \n \n60% coverage; \n \nsubject to deductible subject to deductible \n \nMental Health and Substance Abuse Outpatient Visits and Intensive Outpatient \nNOTE: Contact vendor \nregarding prior authorization \n \n85% coverage; \n \n60% coverage; \n \n80% coverage; \n \n60% coverage; \n \nsubject to deductible subject to deductible subject to deductible subject to deductible \n \nDental \n \nThe Plan Pays \n \nThe Plan Pays \n \nDental 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 \n \n85% coverage; \n \n60% coverage; \n \n80% coverage; \n \n60% coverage; \n \nsubject to deductible subject to deductible subject to deductible subject to deductible \n \nNOTE: Notification required for all UHC options. \n \nTemporomandibular Joint Syndrome (TMJ) NOTE: Coverage for diagnostic testing and non-surgical treatment up to $1,100 per person lifetime maximum benefit. \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n80% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nVision \nRoutine Eye Exam NOTE: Limited to one eye exam every 24 months \n \nThe Plan Pays \n \n100% coverage; not subject to deductible \n \nEye exam not covered \n \nThe Plan Pays \n \n100% coverage; not subject to deductible \n \nEye exam not covered \n \nOther Coverage Hearing Services Routine hearing exam \nAmbulance Services for Emergency Care NOTE: \"Land or air ambulance\" to nearest facility to treat the condition \n \nThe Plan Pays \n85% coverage for routine exam and fitting; subject to deductible. $1,500 hearing aid allowance every 5 years; not subject to the deductible \n85% coverage; subject to deductible \n \nThe Plan Pays \n80% coverage for routine exam and fitting; subject to deductible. $1,500 hearing aid allowance every 5 years; subject to the deductible \n80% coverage; subject to in-network deductible \n \nUrgent Care Services NOTE: All subject to deductible \n \n85% coverage; \n \n60% coverage; \n \n80% coverage; \n \n60% coverage; \n \nsubject to deductible subject to deductible subject to deductible subject to deductible \n \n17 New Enrollee Decision Guide 2012 \n \n Bene ts Comparison: Standard HRA  HDHP \nSchedule of Bene ts for You and Your Dependents for January 1, 2012  December 31, 2012 \n \nStandard HRA Option \n \nStandard HDHP Option \n \nOther Coverage Home Health Care Services NOTE: Prior approval required \n \nIn-Network \n \nOut-of-Network \n \nThe Plan Pays \n \n85% coverage; \n \n60% coverage; \n \nsubject to deductible subject to deductible \n \nIn-Network \n \nOut-of-Network \n \nThe Plan Pays \n \n80% coverage; \n \n60% coverage; \n \nsubject to deductible subject to deductible \n \nSkilled Nursing Facility Services NOTE: Prior approval required \nHospice Care NOTE: Prior approval required \n \n85% coverage; up to 120 days per Plan year; subject to deductible \n85% coverage; subject to deductible \n \nNot covered \n60% coverage; subject to deductible \n \n80% coverage up to 120 days per Plan \nYear; subject to deductible \n80% coverage; subject to deductible \n \nNot covered \n60% coverage; subject to deductible \n \nDurable Medical Equipment (DME)--Rental or purchase NOTE: Prior approval required for certain DME \nOutpatient Acute Short-Term Rehabilitation Services  Physical Therapy  Speech Therapy  Occupational Therapy  Other short term \nrehabilitative services \n \n85% coverage; \n \n60% coverage; \n \n80% coverage; \n \n60% coverage; \n \nsubject to deductible subject to deductible subject to deductible subject to deductible \n \n85% coverage; \n \n60% coverage; 80% coverage up to 40 60% coverage up \n \nsubject to \n \nsubject to deductible; visits per therapy per to 40 visits per therapy \n \ndeductible; up to 40 vis- up to 40 visits per ther- Plan year; subject to per Plan year; subject \n \nits per therapy per Plan apy per Plan year deductible (not to ex- to deductible (not to \n \nyear (not to exceed a (not to exceed a total of ceed a total of 40 visits exceed a total of \n \ntotal of 40 visits com- 40 visits combined, in- combined, including 40 visits combined, \n \nbined, including any cluding any in-network \n \nany out-of- \n \nincluding any \n \nout-of-network visits) \n \nvisits) \n \nnetwork visits) \n \nin-network visits) \n \nChiropractic Care NOTE: UHC Coverage up to a maximum of 20 visits; CIGNA  up to a maximum of 20 days, per plan year \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n80% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nFoot Care \n \n85% coverage; \n \nNOTE: Covered only for neurological or subject to deductible \n \nvascular diseases \n \n60% coverage; subject to deductible \n \n80% coverage; subject to deductible \n \nTransplant Services NOTE: Prior approval required \n \nContact vendor for coverage details \n \nPharmacy - You Pay \n \nTier 1 Co-payment \n \n15% ($20 min/$50 max) 40% coverage; not 20% coverage; subject \n \nnot subject to \n \nsubject to deductible* to deductible $10 \n \ndeductible \n \nmin/$100 max \n \nTier 2 Co-payment Preferred Brand \n \n25% ($50 min/$80 max) 40% coverage; not \n \nnot subject to \n \nsubject to deductible* \n \ndeductible \n \n20% coverage; subject to deductible $10 min/$100 max \n \n60% coverage; subject to deductible \nNot covered Not covered \n \nTier 3 Co-payment Non-Preferred Brand \n90-Day Voluntary Mail Order \n \n25% ($80 min/$125 max) 40% coverage; not \n \nnot subject to \n \nsubject to deductible* \n \ndeductible \n \n20% coverage; subject to deductible $10 min/$100 max \n \nNot covered \n \nTier 115% ($50 min/$125 max) Tier 225% ($125 min/$200 max) Tier 325% ($200 min/$312.50 max) \nDoes not apply to deductible or out-of-pocket max \n \n20% ($25 min/$250 max) No non-network coverage \n \nNew Enrollee Decision Guide 2012 \n \n18 \n \n LEGAL NOTICES \n \nLEGAL NOTICES \n \nThis section includes Legal Notices that outline your rights under the Women's Health and Cancer Rights Act, Newborns' and Mothers' Health Protection Act, Health Insurance Portability and Accountability Act, the Department of Community Health's use of your protected health insurance and Notice about the early Retiree Reinsurance Program. \nAlso the information below and on pages 20-23 provide you information about your prescription drug coverage. \n \nThese 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. \n \nThe notices on the following pages are required by the Centers for Medicaid \u0026 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. \n \nYour SHBP Option SHBP Medicare Advantage PPO Standard or SHBP Medicare Advantage PPO Premium Plan HRA \nHDHP (High Deductible) \n \nWhat happens if you buy an individual Medicare Part D Plan \nYour 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. \nYour 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 \nYou 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\" \n \n19 New Enrollee Decision Guide 2012 \n \n LPELGANALCNHOATNICGES \n \nIMPORTANT NOTICE FROM THE SHBP ABOUT YOUR CREDITABLE PRESCRIPTION DRUG COVERAGE UNDER ANY OF THE FOLLOWING OPTIONS AND MEDICARE: \nCIGNA STANDARD HRA , CIGNA STANDARD HMO AND UNITEDHEALTHCARE STANDARD HRA AND UNITEDHEALTHCARE STANDARD HMO \nFor Plan Year: January 1  December 31, 2012 \nThis 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. \nPlease 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. \nThere are two important things you need to know about your current coverage and Medicare's prescription drug coverage: \n1 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. \n2 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. \nWhen 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. \n \nNew Enrollee Decision Guide 2012 \n \n20 \n \n LEGAL NOTICES \n \nImportant: 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. \nIf 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. \nFor 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. \nFor 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 \u0026 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. \nFor 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 \u0026 \nYou\" handbook for their telephone number) for personalized help  Call 1-800-MEDICARE (800-633-4227). TTY users should call 1-877-486-2048. \nIf 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). \nRemember: 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). \nDate: 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 \n21 New Enrollee Decision Guide 2012 \n \n PLELGANALCNHOATNICGES \n \nIMPORTANT NOTICE FROM THE SHBP ABOUT YOUR NON-CREDITABLE PRESCRIPTION DRUG COVERAGE UNDER ANY OF THE FOLLOWING OPTIONS AND MEDICARE: \nCIGNA STANDARD HDHP AND UNITEDHEALTHCARE STANDARD HDHP \nFor Plan Year: January 1  December 31, 2012 \nThis notice only applies if you are covered under the CIGNA Standard or Wellness HDHP or the UnitedHealthcare Standard or Wellness HDHP. \nPlease 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. \nThere are three important things you need to know about your current coverage and Medicare's prescription drug coverage: \n1 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. \n2 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. \n3 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. \nWhen 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. \n \nNew Enrollee Decision Guide 2012 \n \n22 \n \n PLELGANALCNHOATNICGES \n \nHowever, 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. \nWhen 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. \nWhat 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. \nImportant: If you are a retiree and terminate your SHBP coverage, you will not be able to rejoin the SHBP in the future. \nFor 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. \nFor 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 \u0026 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: \n Visit www.medicare.gov  Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the \"Medicare \n\u0026 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. \nIf 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). \nDate: 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 \n23 New Enrollee Decision Guide 2012 \n \n PLELGANALCNHOATNICGES \n \nThis notice was prepared by the United States Department of Health and Human Services. By law, the Department of Community Health is required to provide you this notice. \nNOTICE ABOUT THE EARLY RETIREE REINSURANCE PROGRAM \nSeptember 25, 2011 \nYou are a plan participant, or are being offered the opportunity to enroll as a plan participant, in an employment-based health plan that is certified for participation in the Early Retiree Reinsurance Program. The Early Retiree Reinsurance Program is a Federal program that was established under the Affordable Care Act. Under the Early Retiree Reinsurance Program, the Federal government reimburses a plan sponsor of an employment-based health plan for some of the costs of health care benefits paid on behalf of, or by, early retirees and certain family members of early retirees participating in the employment-based plan. By law, the program expires on January 1, 2014. \nUnder the Early Retiree Reinsurance Program, your plan sponsor may choose to use any reimbursements it receives from this program to reduce or offset increases in plan participants' premium contributions, co-payments, deductibles, co-insurance, or other out-of-pocket costs. If the plan sponsor chooses to use the Early Retiree Reinsurance Program reimbursements in this way, you, as a plan participant, may experience changes that may be advantageous to you, in your health plan coverage terms and conditions, for so long as the reimbursements under this program are available and this plan sponsor chooses to use the reimbursements for this purpose. A plan sponsor may also use the Early Retiree Reinsurance Program reimbursements to reduce or offset increases in its own costs for maintaining your health benefits coverage, which may increase the likelihood that it will continue to offer health benefits coverage to its retirees and employees and their families. \nIf you have received this notice by email, you are responsible for providing a copy of this notice to your family members who are participants in this plan. \n \nNew Enrollee Decision Guide 2012 \n \n24 \n \n LEGAL NOTICES \n \nSTATE HEALTH BENEFIT PLAN ANNUAL LEGAL NOTICES \nWomen's Health and Cancer Rights Act \nThe Plan complies with the Women's Health and Cancer Rights Act of 1998. Mastectomy, including reconstructive surgery, is covered the same as other surgery under your Plan option. Following cancer surgery, the SHBP covers: \n All stages of reconstruction of the breast on which the mastectomy has been performed  Reconstruction of the other breast to achieve a symmetrical appearance  Prostheses and mastectomy bras  Treatment of physical complications of mastectomy, including lymphedema Note: Reconstructive surgery requires prior approval, and all inpatient admissions require prior notification. For more detailed information on the mastectomy-related benefits available under the Plan, you can contact the Member Services unit for your coverage option. Telephone numbers are on the inside front cover of the Decision Guide. \nNewborns' and Mothers' Health Protection Act \nThe Plan complies with the Newborns' and Mothers' Health Protection Act of 1996. Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). \nHealth Insurance Portability and Accountability Act \nThe Plan complies with the Health Insurance Portability and Accountability Act of 1996 (\"HIPAA\"). The HIPAA Privacy Notice is attached as Exhibit A. The Notice of Exemption Letter is attached as Exhibit B. \nExhibit A Revised March 23, 2010. \nThis notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Questions? Call 404-656-6322 (Atlanta) or 800-610-1863 (outside of Atlanta). \nThe DCH and the State Health Benefit Plan Are Committed to Your Privacy. The Georgia Department of Community Health (DCH) sponsors and runs the State Health Benefit Plan (the Plan). We understand that your information is personal and private. Some DCH employees and companies hired by DCH collect your information to run the Plan. The information is called \"Protected Health Information\" or \"PHI.\" This notice tells how your PHI is used and shared. We follow the information privacy rules of the Health Insurance Portability and Accountability Act of 1996, (\"HIPAA\"). \n25 Retiree Decision Guide 2012 \n \n LEGAL NOTICES \n \nOnly Summary Information is Used When Developing and Changing the Plan. The Board of Community Health and the Commissioner of the DCH make decisions about the Plan. When making decisions, they review reports that explain costs, problems, and needs of the Plan. These reports never include information that identifies any person. If your employer is allowed to leave the Plan, your employer may also get summary reports. \nPlan Enrollment Information and Claims Information is Used in Order to Run the Plan. PHI includes two kinds of information. \"Enrollment Information\" includes 1) your name, address, and Social Security number; 2) your enrollment choices; 3) how much you have paid in premiums; and 4) other insurance you may have. This Enrollment Information is the only kind of PHI your employer is allowed to see. \"Claims Information\" includes information your health care providers send to the Plan. For example, it may include bills, diagnoses, statements, X-rays or lab test results. It also includes information you send to the Plan. For example, it may include your health questionnaires, enrollment forms, leave forms, letters and recorded telephone calls. Lastly, it includes information about you that is created by the Plan. For example, it includes payment statements and checks to your health care providers. \nYour PHI is Protected by Law. Employees of the DCH and employees of outside companies hired by DCH to run the Plan are \"Plan Representatives.\" They must protect your PHI. They may only use it as allowed by HIPAA. \nThe DCH Must Make Sure the Plan Complies with HIPAA. As Plan sponsor, the DCH must make sure the Plan complies with HIPAA. We must give you this notice. We must follow its terms. We must update it as needed. The DCH is the employer of some Plan Members. The DCH must name the DCH employees who are Plan Representatives. No DCH employee is ever allowed to use PHI for employment decisions. \nPlan Representatives Regularly Use and Share your PHI in Order to Pay Claims and Run the Plan. Plan Representatives use and share your PHI for payment purposes and to run the Plan. For example, they make sure you are allowed to be in the Plan. They decide how much the Plan should pay your health care provider. They also use PHI to help set premiums for the Plan and manage costs, but they are never allowed to use genetic information for these purposes. Some Plan Representatives work for outside companies. By law, these companies must protect your PHI. They also must sign \"Business Associate\" agreements with the Plan. Here are some examples of what they do: \nClaims Administrators: Process all medical and drug claims; communicate with Members and their health care providers; and give extra (assistance) to Members with some health conditions. \nData Analysis, Actuarial Companies: Keep health information in computer systems, study it, and create reports from it. \nAttorney General's Office, Auditing Companies, Outside Law Firms: Provide legal and auditing help to the Plan. \nInformation Technology Companies: Help improve and check on the DCH information systems used to run the Plan. \nSome Plan Representatives work for the DCH. By law, all employees of the DCH must protect PHI. They also must get special privacy training. They only use the information they need to do their work. Plan Representatives in the SHBP Division work full-time running the Plan. They use and share PHI with each other and with Business Associates in order to help pay claims and run the Plan. In general, they can see your Enrollment Information and the information you give the Plan. A few can see Claims Information. DCH employees outside of the SHBP Division do not see Enrollment Information on a daily basis. They may use Claims Information for payment purposes and to run the Plan. \n \nNew Enrollee Decision Guide 2012 \n \n26 \n \n LEGAL NOTICES \n \nPlan Representatives May Make Special Uses or Disclosures Permitted by Law. HIPAA has a list of special times when the Plan may use or share your PHI without your authorization. At these times, the Plan must keep track of the use or disclosure. \nTo Comply with a Law, or to Prevent Serious Threats to Health or Safety: The Plan may use or share your PHI in order to comply with a law, or to prevent a serious threat to health and safety. \nFor Public Health Activities: The Plan may give PHI to government agencies that perform public health activities. For example, the Plan may give PHI to DCH employees in the Department of Public Health who need it to do their jobs. \nFor Research Purposes: Your PHI may be given to researchers for a research project approved by a review board. The review board must review the research project and its rules to ensure the privacy of your information. \nPlan Representatives Share Some Payment Information with the Employee. Except as described in this notice, Plan Representatives are allowed to share your PHI only with you, and with your legal personal representative. However, the Plan may inform the employee family member about whether the Plan paid or denied a claim for another family member. \nYou May Authorize Other Uses of Your PHI. You may give a written authorization for the Plan to use or share your PHI for a reason not listed in this notice. If you do, you may take away the authorization later by writing to the contact below. The old authorization will not be valid after the date you take it away. \nYou Have Privacy Rights Related to Plan Enrollment Information and Claims Information that Identifies You. Right to See and Get a Copy your Information, Right to Ask for a Correction: Except for some reasons listed in HIPAA, you have the right to see and get a copy of information used to make decisions about you. If you think it is incorrect or incomplete, you may ask the Plan to correct it. \nRight to Ask for a List of Special Uses and Disclosures: You have the right to ask for a list of special uses and disclosures that were made after April 2003. \nRight to Ask for a Restriction of Uses and Disclosures, or for Special Communications: You have the right to ask for added restrictions on uses and disclosures. You also may ask the Plan to communicate with you in a special way. Right to a Paper Copy of this Notice, Right to File a Complaint without Getting in Trouble: You have the right to a paper copy of this notice. Please contact the SHBP HIPAA Privacy Unit or print it from www.dch.ga.gov. If you think your privacy rights have been violated, you may file a complaint. You may file the complaint with the Plan and/or the Department of Health and Human Services. You will not get in trouble with the Plan or your employer for filing a complaint. Addresses for Complaints: SHBP HIPAA Privacy Unit P.O. Box 1990 Atlanta, Georgia 30301 404-656-6322 (Atlanta) or 800-610-1863 (outside Atlanta) U.S. Department of Health \u0026 Human Services, Office for Civil Rights Region IV Atlanta Federal Center 61 Forsyth Street SW, Suite 3B70 Atlanta, GA 30303-8909 \n27 Retiree Decision Guide 2012 \n \n LEGAL NOTICES \n \nExhibit B \nELECTION TO BE EXEMPT FROM CERTAIN REQUIREMENTS OF HIPAA \nAugust 15, 2011 \nTO: All Members of the State Health Benefit Plan who are not Enrolled in a Medicare Advantage Option \nUnder a Federal law known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, as amended, group health plans must comply with a number of requirements. Under HIPAA, state health plans that are \"self-funded\" may \"opt out\" of some of these requirements by making a yearly election to be exempt. Your plan option is self-funded because the Department of Community Health pays all claims directly instead of buying a health insurance policy. \nTemporary rules implementing the Mental Health Parity and Addiction Equity Act apply January 1, 2012, unless the Department of Community Health again elects to be exempted from this law's requirements. The temporary rules generated more than 4,000 comments; no final rules addressing these comments have been issued. The Department of Community Health has determined to exempt your State Health Benefit Plan (\"SHBP\") option from the Mental Health Parity and Addiction Equity Act, and the temporary rules' requirements, for the 2012 calendar year. \nParity in the application of certain limits to mental health benefits. Group health plans (of employers that employ more than 50 employees) that provide both medical and surgical benefits and mental health or substance use disorder benefits must ensure that financial requirements and treatment limitations applicable to mental health or substance use disorder benefits are no more restrictive than the predominant financial requirements and treatment limitations applicable to substantially all medical and surgical benefits covered by the plan. \nThe exemption from these federal requirements will be in effect for the plan year starting January 1, 2012, and ending December 31, 2012. The election may be renewed for subsequent plan years. \nHIPAA also requires the SHBP to provide covered employees and dependents with a \"certificate of creditable coverage\" when they cease to be covered under the SHBP. There is no exemption from this requirement. The certificate provides evidence that you were covered under the SHBP, because if you can establish your prior coverage, you may be entitled to certain rights to reduce or eliminate a preexisting condition exclusion if you join another employer's health plan, or if you wish to purchase an individual health insurance policy. \n \nNew Enrollee Decision Guide 2012 \n \n28 \n \n  "},{"id":"dlg_ggpd_y-ga-bc900-pe4-bs1-bn4-b2010-belec-p-btext","title":"New enrollee decision guide for 2010","collection_id":"dlg_ggpd","collection_title":"Georgia Government Publications","dcterms_contributor":["Georgia. Department of Community Health."],"dcterms_spatial":["United States, Georgia, 32.75042, -83.50018"],"dcterms_creator":["Georgia. Department of Community Health"],"dc_date":["2010"],"dcterms_description":["Title from cover"],"dc_format":["application/pdf"],"dcterms_identifier":null,"dcterms_language":["eng"],"dcterms_publisher":["Atlanta, Ga. : Georgia Dept. of Community Health, Division of Public Employee Health Benefits, 2010"],"dc_relation":null,"dc_right":["http://rightsstatements.org/vocab/InC/1.0/"],"dcterms_is_part_of":null,"dcterms_subject":["Government employees' health insurance--Georgia"],"dcterms_title":["New enrollee decision guide for 2010"],"dcterms_type":["Text"],"dcterms_provenance":["University of Georgia. Map and Government Information Library"],"edm_is_shown_by":["https://dlg.galileo.usg.edu/do:dlg_ggpd_y-ga-bc900-pe4-bs1-bn4-b2010-belec-p-btext"],"edm_is_shown_at":["https://dlg.galileo.usg.edu/id:dlg_ggpd_y-ga-bc900-pe4-bs1-bn4-b2010-belec-p-btext"],"dcterms_temporal":null,"dcterms_rights_holder":null,"dcterms_bibliographic_citation":null,"dlg_local_right":null,"dcterms_medium":["state government records"],"dcterms_extent":null,"dlg_subject_personal":null,"iiif_manifest_url_ss":null,"dcterms_subject_fast":null,"fulltext":" Phone Numbers/Contact Information \nState Health Benefit Plan (SHBP): www.dch.georgia.gov/shbp_plans \n \nVendor \nUnitedHealthcare HRA HDHP      \nCIGNA HRA, HDHP \nPharmacy SHBP Eligibility \n \nMember Services Web Site \n \n800-396-6515 \n877-246-4189 TDD 800-255-0056 \n \nwww.myuhc.com/shbp www.myuhc.com/shbp \n \n800-633-8519 TDD 800-576-1314 \n \nwww.mycigna.com/shbp \n \nCall vendor listed above \n \n404-656-6322 800-610-1863 \n \nwww.dch.georgia.gov/shbp_plans \n \nNotify the Plan of any fraudulent activity regarding Plan members, providers, payment of benefits, etc. Call 1-877-878-3360 or 404-463-7590. \nDisclaimer: The material in this booklet is for informational purposes and is not a contract. It is intended only to highlight principal benefits of the medical plans. Every effort has been made to be as accurate as possible; however, should there be a difference between this information and the Plan documents, the Plan documents govern. It is the responsibility of each member, active or retired, to read all Plan materials provided in order to fully understand the provisions of the option chosen. Availability of SHBP options may change based on changes in federal or state law. \nThe Summary Plan Description (SPD) for each Plan option is posted on the Department of Community Health Web site, www.dch.georgia.gov/shbp_plans. You may print or request a paper copy by calling the Customer Service number on the back of your ID card. Please keep your SPD for future reference. If you are disabled and need this information in an alternative format, call the TDD Relay Service at (800) 255-0056 (text telephone) or (800) 255-0135 (voice) or write the SHBP at P.O. Box 1990, Atlanta, GA 30301. \n \n Rhonda M. Medows, MD, Commissioner Sonny Perdue, Governor \n \n2 Peachtree Street, NW Atlanta, GA 30303-3159 www.dch.georgia.gov \n \nDecember 1, 2009 \n \nDear New State Health Benefit Plan Member: \n \nWelcome to the State Health Benefit Plan (SHBP). The SHBP is committed to providing high quality health benefits at an affordable price to its members. Upon joining SHBP, new enrollees have the opportunity to choose between two consumer driven health options each offered by CIGNA Healthcare and UnitedHealthcare (UHC). The High Deductible Health Plan (HDHP) and the Health Reimbursement Arrangement (HRA) offered by CIGNA HealthCare and UHC provide health care consumers with low monthly premiums, extensive provider networks, and 100 percent unlimited coverage for wellness care based on national age and gender guidelines. \n \nIf you chose to take advantage of the HRA, you will have the extra benefit of the SHBP contributing dollars to your HRA on an annual basis for treatment of medical expenses. In 2009, this amount is: $500 for an employee only plan, $1,000 for an employee plus spouse, $1,000 for an employee plus child(ren), and $1,500 for an employee plus spouse and child(ren). \n \nHDHP has the lowest monthly premium and it allows members to start a Health Savings Account (HSA) to set aside tax-free dollars to pay for eligible health care expenses which offsets the higher deductible. \n \nEach plan's design is similar to that of an Open Access Plan (OAP) with in-network and out-ofnetwork benefits, wellness benefits, and other enhanced benefits exclusive to the HRA and HDHP plans. \n \nSHBP offers an annual open enrollment period for all employees. You will be able to select from the consumer driven health options in addition to the options that are offered to active members, which at this time are two OAP and two Health Maintenance Organization (HMO) options during the 2010 open enrollment period. You can access information about these options at www.dch.georgia.gov/shbp. \n \nThe Georgia Department of Community Health, which administers the SHBP, is committed to providing you with meaningful choices in your options while keeping costs down. Be assured that we will continue to seek to provide you with meaningful options, low premiums and tools to help you make the right healthcare choices for you and your family members. \n \nSincerely, \n \nRhonda M. Medows, M.D. \n \nEqual Opportunity Employer \n \n WELCOME \n \nContents \nPhone Numbers, Contacts \u0026 Provider Information About the State Health Benefit Plan (SHBP) Eligibility \u0026 Qualifying Events General Information and Enrollment SHBP Surcharge Information Understanding Your Plan Options Health \u0026 Wellness Benefits Comparison HRA \u0026 HDHP Important Notices \n \nInside Front Cover Page 3 Page 4 Page 6 Page 8 Page 10 Page 13 Page 14 Page 18 \n \nCommon Acronyms \nCDHP  Consumer Driven Health Plan CMS  Centers for Medicare \u0026 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 \n \nIRS  Internal Revenue Service MAPD PFFS  Medicare Advantage with Prescription Drugs Private Fee-for-Service OAP  Open Access Plan (Choice Plus-UHC and Open Access Plus-CIGNA) OE  Open Enrollment PCP  Primary Care Physician SHBP  State Health Benefit Plan SPD  Summary Plan Description UHC  UnitedHealthcare \n \nnew enrollee decision guide 2010 \n \n2 \n \n State Health Benefit Plan \nThe Georgia Department of Community Health (DCH), which administers the State Health Benefit Plan (SHBP), continually seeks to offer high-quality, affordable health coverage. Keep in mind, however, that you are the manager of your health care needs, and in turn, must take the time to understand your Plan benefit choices in order to make the best decisions for you and your family. \nLet's start by talking about how the SHBP works. It is a self-funded plan, which means that all expenses are paid by employee premiums and employer funds. Approximately 75 percent of the cost is funded by your employer, with you paying approximately 25 percent. \nPeople who do not understand their health coverage pay more, according to the American Medical Association. To help you better understand your Plan and save your health care dollars, we have prepared a few points for you to consider. \nWhat can you do to help manage your health care costs? \nUnderstand Your Options  Compare all Plan Options, considering both the premiums and out-of-pocket costs that you may incur. Web sites and phone numbers are listed on the inside of the front cover of the Decision Guide if you need more information. \nConsider Enrolling in a Flexible Spending Account (FSA)  A FSA (also referred to as a health care spending account) helps you save tax dollars, approximately 2645 percent depending on your tax situation. By electing to use a FSA, you may set aside up to $5,040 annually to cover health-related treatments for yourself and your dependents. Eligible expenses include deductibles, co-insurance, over-the-counter items for medical purposes and costs for certain procedures not covered under your health plan. The benefit of this account is that you are able to pay for these out-of-pocket costs with tax-free dollars! Contact your Benefit Coordinator for more information. \nBecome a More Proactive Consumer of Health Care  Most people do not realize how much their treatments, medicines and tests cost. \nSteps you can take include: \n Keep a list of all medications you take \n Shop in-network providers and pharmacies \n Find out what your drugstore charges for a drug \n Make sure all procedures are pre-certified, if required \n Make sure you get the results of any test or procedure \n Understand what will happen if you need surgery \n Check your Explanation of Benefits (if provided under your plan option) and if you have questions, ask your provider about it \nThese and other steps you take will help manage healthcare expenses, reduce your out-ofpocket costs and those of the Plan. In addition, these steps will help in keeping premium costs down. \n \nABOUT SHBP 3 \n \nnew enrollee decision guide 2010 \n \n ELIGIBILITY AND QUALIFYING EVENTS \nEligibility Information \nAll SHBP options have the same eligibility requirements. A summary is listed below. \nFor You \nYou are eligible to enroll yourself and your eligible dependents for coverage if you are:  A full-time employee of the state of Georgia, the Georgia General Assembly, or an agency, board, commission, department, county administration or contracting employer that participates in the SHBP, as long as:  You work at least 30 hours a week consistently, and  Your employment is expected to last at least nine months. Not eligible: Student employees or seasonal, part-time or short-term employees.  A certified public school teacher or library employee who works half-time or more, but not less than 17.5 hours a week Not eligible: Temporary or emergency employees  A non-certified service employee of a local school system who is eligible to participate in the Teachers Retirement System or its local equivalent. You must also work at least 60 percent of a standard schedule for your position, but not less than 20 hours a week  An employee who is eligible to participate in the Public School Employees' Retirement System as defined by Paragraph 20 of Section 47-4-2 of the Official Code of Georgia, Annotated. You must also work at least 60 percent of a standard schedule for your position, but not less than 15 hours a week  A retired employee of one of these listed groups who was enrolled in the Plan at retirement and is eligible to receive an annuity benefit from a state-sponsored or state-related retirement system. See the Summary Plan Description (SPD) for more information  An employee in other groups as defined by law \nFor Your Dependents \nThe SHBP covers dependents who meet SHBP guidelines and requires eligibility documentation before SHBP can send dependents' notification of coverage to the health plans. \nEligible dependents are: \n Your legally married spouse, as defined by Georgia Law \n Your never-married dependent children who are: \n1. Natural or legally adopted children under age 19, unless they are eligible for coverage as employees. Children that are legally adopted through the judicial courts become eligible only after they are placed in your physical custody \n2. Stepchildren under age 19 who live with you at least 180 days per year and for whom you can provide documentation satisfactory to the Plan that they are your dependents \n3. Other children under age 19 if they live with you permanently and legally depend on you for financial support  as long as you have a court order, judgment or other satisfactory proof from a court of competent jurisdiction \n4 \n \nnew enrollee decision guide 2010 \n \n ELIGIBILITY AND QUALIFYING EVENTS \n4. Your natural children, legally adopted children or stepchildren, who are physically or mentally disabled prior to reaching age 26 and who depend on you for primary support \n5. Your natural children, legally adopted children or stepchildren or other children ages 19 through 25 from categories 1, 2, or 3 above who are registered full-time students at accredited secondary schools, colleges, universities or nurse training institutions and, if employed, who are not eligible for a medical benefit plan from their employer. The number of credit hours required for full-time student status is defined by the school in which the child is enrolled. \nDocumentation Confirming Eligibility for Your Spouse or Dependents \nSHBP requires documentation verifying the eligibility of dependents covered under the plan. You must submit the documentation requested by the Plan in order to cover the dependent. No health claims will be paid until the documentation is received and approved by SHBP. However, do not delay submission of your enrollment form if the required documentation is not readily available as the enrollment form must be submitted to your personnel/benefit coordinator within 31 days of hire or a qualifying event. \nAcceptable documentation: \n Spouse: A copy of your certified marriage certificate or a copy of your most recent Federal tax Return (filed jointly with spouse) including legible signatures for you and your spouse with financial information blacked out. Spouse's Social Security number must be on documentation \n Natural child: A copy of the certified birth certificate listing the parents by name or a letter of confirmation of birth for newborns. Birth cards without the parents' names are not acceptable. Submit Social Security number upon receipt from Social Security \n Stepchild: 1) A copy of the certified birth certificate showing your spouse is the natural parent; 2) A copy of the certified marriage certificate showing the natural parent is your spouse; and 3) A notarized statement that the dependent lives in your home at least 180 days per year. Stepchild's Social Security number must be on the documentation \n Other children: 1) A court order, judgment, adoption papers, or other satisfactory proof from a court of competent jurisdiction, or as prescribed by law, and 2) An affidavit that the dependent depends on you for support and lives in your home at least 180 days per year. Submit Social Security number upon receipt from Social Security \nFor dependents under age two, SHBP will provide coverage without the social security number upon receipt and approval of the above acceptable documentation. \nIn addition to the above documentation, SHBP requires further documentation to verify the eligibility if the child is age 19 or older. \n Student: For students age 19 through 25, a certification letter from the school's registrar. This letter must include: 1) Enrollment date(s) for both current and previous quarters or semesters, 2) Number of credit hours taken each quarter or semester, and 3) Enrollment status (full-time or part-time) for each quarter or semester. Letters of acceptance can be submitted to temporarily extend coverage for students who graduate from high school in May and plan to attend college for the Fall semester or students transferring between colleges \n Disabled dependent: Medical documentation of your child's disability must be received and approved by SHBP prior to coverage being granted 5 \n \nnew enrollee decision guide 2010 \n \n GENERAL INFORMATION AND ENROLLMENT \nPlease note:  The employee's Social Security Number must be written on each document so we can \nmatch your dependents to your record. Don't forget to include dependent's Social Security number on their documentation  Do not send original documents as no documents will be returned to you  SHBP will allow members to submit verification of their dependent's eligibility any time during the Plan Year; however, no claims will be paid until the documentation is received and approved by SHBP. Coverage will be effective the date of the qualifying event or the first day of the Plan Year, whichever is later \nMaking Changes When You Have a Qualifying Event \nIf you experience a qualifying event, you may be able to make changes for yourself and your dependents, provided you make the request to SHBP within 31 days of the qualifying event. Also, your requested change must correspond to the qualifying event. For a complete description of qualifying events, see your SPD. You can contact the Eligibility Unit for assistance at 800-610-1863 or in the Atlanta area at 404-656-6322. \nQualifying events include, but are not limited to: \n Birth or adoption of a child or placement for adoption  Change in residence by you, your spouse or dependents that results in ineligibility for \ncoverage 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 \nGeneral Information and Enrollment \nBefore You Enroll \nYou should:  Read the current Decision Guide and SPD to understand your Health Plan Options \nprior to making your health election  Contact your employer or payroll location Benefit Coordinator for assistance if you \nhave benefit questions or you may go to www.dch.georgia.gov/shbp  Read and understand the SHBP Tobacco and Spousal Surcharge Policies, and answer \nall questions regarding these surcharges. If you fail to answer the questions, the surcharge(s) will apply for the 2010 Plan Year unless you experience a qualifying event  Gather eligibility verification documents for all dependents for whom coverage has been requested to submit within the required time frame  Understand the election you make will be valid for the 2010 Plan Year unless you experience a qualifying event  Additional options may be available to you during the Fall Open Enrollment for coverage effective January 1, 2011 \n6 \n \nnew enrollee decision guide 2010 \n \n GENERAL INFORMATION AND ENROLLMENT \nHealth Benefit Cost Estimators \nChoosing the right health plan is an important decision and CIGNA and UHC each provide a Plan Cost Estimator (PCE) tool to assist you. The PCEs offer you a simple way to help determine which option is best for you and your family. These online tools let you compare how your out-of-pocket expenses may vary under the different health plan options available to you. \nYou can use the PCE to review cost information for prescriptions, anticipated tests and procedures. The information provided by PCE is not meant to be an endorsement of any particular health plan. The service is offered only to help you compare your estimated expenses across each health plan option. \nYou may access the links to the PCE tools at the DCH Web site, www.dch.georgia.gov/shbp, or by going directly to the vendor Web sites. \nHow to Enroll \nIf you're eligible to participate in the SHBP, you become a member by enrolling either:  As a new hire, within 31 days of your hire date. If you join the SHBP during that first \n31-day enrollment opportunity, your coverage will go into effect on the first day of the month after you complete one full calendar month of employment. See your personnel/ payroll office for instructions on how to enroll or if you have benefit questions, you may call the vendor directly at the telephone numbers listed on the inside of the front cover.  If you decline coverage under SHBP when you first become eligible and later decide to enroll due to a qualifying event or at a future Open Enrollment period, your options will be limited to the HRA and HDHP for your first Plan year of coverage.  As a result of a qualifying event. See Making Changes When You Have a Qualifying Event, page 6 of this guide for more details. \nIf you decide to become a SHBP member, you will have two major choices to make: \n1. Your coverage options: CIGNA Healthcare  Health Reimbursement Arrangement (HRA)  High Deductible Health Plan (HDHP)* UnitedHealthcare  Health Reimbursement Arrangement (HRA)  High Deductible Health Plan (HDHP)* *These options allow you to set up a Health Savings Account. See page 12 for more information. \n2. Which eligible dependents would you like to have covered by SHBP? For a list of eligible dependents, refer to pages 4, 5 and 6.  SHBP is now required to obtain the Social Security Number of each covered dependent \n7 \n \nnew enrollee decision guide 2010 \n \n SHBP SURCHARGE INFORMATION \n \n3. Which coverage tier? Select the coverage tier you desire for the dependents that you choose to cover. You will be locked into the tier for the 2010 Plan Year unless you experience a qualifying event. \n \n EE = Employee \n \n EC = Employee + Child(ren) \n \n ES = Employee + Spouse \n \n EF = Employee + Spouse + Child \n \nNOTE: Additional options may be available to you during the Fall Open Enrollment period for coverage effective January 1, 2011. \n \nWhat Happens if I Have Other Insurance? \nYou or your covered dependents may have medical coverage under more than one plan. In this case, coordination of benefits (COB) provisions apply. \nWhen you have other group or Medicare coverage and SHBP coverage, the benefit under SHBP will be no greater than it would have been if there was no coverage other than that of SHBP. Non-covered services or items, penalties and amounts balance billed are not part of the allowed amount and are the member's responsibility. \nIt is important that you notify the health insurance vendor you selected if you have other group coverage to prevent incorrect processing of any claims. For further information about COB rules, refer to the SPD or contact your vendor directly. \n \nCOBRA Rights \nThe Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986 requires that the Plan offer you, 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 you, or one of your dependents, may continue the coverage is based on the qualifying event. For further information, please refer to your SPD. \n \nSurcharge Policy \n \nYou should be aware that SHBP charges a Tobacco and Spousal Surcharge. A $60 tobacco surcharge will be added to your monthly premium if you or any of your covered dependents have used tobacco products in the previous 12 months. A $40 spousal surcharge will be added to your monthly premium if you have elected to cover your spouse and your spouse is eligible for coverage through his/her employment but chose not to take it. If your spouse is eligible for coverage with SHBP through his/her employment, the spousal surcharge will be waived. \nYou will automatically be charged the applicable surcharges if you fail to answer all questions concerning the surcharges. The surcharges will apply to your premium until the next Plan Year. See page 9 for ways to have the surcharges removed. \nPlease note the SHBP may audit any member covering a spouse who does not pay the spousal surcharge. \nIntentional misrepresentation in response to surcharge questions will have significant consequences. You will automatically lose SHBP coverage for 12 months beginning on the date that your false response is discovered. \n \n8 \n \nnew enrollee decision guide 2010 \n \n SHBP SURCHARGE INFORMATION \nHow to Remove Surcharges \nTobacco \nYou may have the tobacco surcharge removed if:  You quit using tobacco products and attend a tobacco cessation program sponsored \nby the American Cancer Society, the American Lung Association, or other approved programs listed on the DCH Web site, www.dch.georgia.gov/shbp  You will receive an attendance certification form. You and the representative should both sign this form  Complete and submit the appropriate Tobacco Affidavit Form and attendance certification form to your payroll location benefit coordinator to complete the required deduction information. The Affidavit Form is available at www.dch.georgia.gov/shbp \nSpousal \nSHBP charges a spousal surcharge for SHBP members who cover their spouses. You may have the spousal surcharge removed:  If your spouse becomes covered by his/her employer's health benefit plan; and  If you make the request and provide proof within 31 days of the effective date of the \nother coverage. No refund in premiums will be made for previous health deductions that included the surcharge amounts. \nState Health Benefit Plan Medicare Policy and Retirement \nFederal Law requires SHBP to pay primary benefits for active employees and their dependents. Active members or their covered dependents may choose to delay Medicare enrollment. Termination of active employment is a qualifying event for enrolling in Medicare without penalty (except HDHP, see page 21). If you want to have health insurance under SHBP when you retire, you must enroll for coverage for you and eligible dependents during the OE period prior to your retirement. Once retired, you will have an annual Retiree Option Change Period that allows you to change your Plan option only. You may add dependents only if you experience a qualifying event and request the change within 31 days and provide the documentation required by SHBP. For more information, refer to the DCH Web site at www.dch.georgia.gov/shbp. \n9 \n \nnew enrollee decision guide 2010 \n \n UNDERSTANDING YOUR PLAN OPTIONS \nUnderstanding Your Plan Options \nOn the following pages, you will find a brief description of each option and important considerations to help you select the best option for you. To help you understand the information in this section, a few key terms are defined below. \nImportant Terms to Understand \nAllowed Amount  A dollar amount the Plan uses to calculate benefits payable. Balance Billing  A dollar amount charged by the provider that is over the Plan's allowed amount for the care received. You are subject to balance billing when you receive services from non-participating providers, including emergency services. Co-insurance Amount  The percentage of the Plan's allowed amount paid by a Plan member. The SHBP generally pays 90 percent to 60 percent of the Plan's allowed amount for covered services, so your co-insurance is between 10 percent and 40 percent. Covered Services  Services for medically necessary care that are eligible for reimbursement under the Plan. Deductible  A specified dollar amount, which varies by Plan option, for specified covered services that you must pay out-of-pocket each Plan Year before the option pays a benefit. Depending on your coverage option, the deductible may not apply to some services. Emergency Care  Care provided when a sudden, severe and unexpected illness or injury happens that could be life threatening or result in permanent impairment of bodily functions if not treated immediately. Lifetime Maximum  The dollar amount that each Plan member may receive in benefits from the SHBP during his or her lifetime. Out-of-Pocket Limits  The maximum amount you would have to pay out of your pocket each Plan Year for covered services. Once you meet your out-of-pocket limit for the Plan Year, the Plan pays 100 percent of the allowed amounts for most covered services for the rest of the Plan Year. Your out-of-pocket costs for premiums and noncovered charges are not applied to the limit. The deductible and co-insurance are applied to your annual out-of-pocket limit. Participating Provider  Any physician, hospital or other health-service professional or facility that offers covered services and that has joined the network of a HRA or HDHP Plan Option. Participating providers may not balance bill Plan members for covered services. \nContact the Member Services unit for each option if you need more detail. Telephone numbers are on the inside front cover. You also may access an SPD online at: www.dch.georgia.gov/shbp. \n10 \n \nnew enrollee decision guide 2010 \n \n UNDERSTANDING YOUR PLAN OPTIONS \nHealth Reimbursement Arrangement (HRA) \nThe HRA is a Consumer Driven Health Plan option (CDHP) whose plan design offers you a different approach for managing your health care needs. It is similar to that of the Open Access Plan (OAP) with an in-network and out-of-network benefit, except SHBP funds dollar credits to your HRA each year to provide first dollar coverage for eligible health care and pharmacy expenses. Unused dollars in your HRA account roll over the next Plan year if you are still participating in this option, but will be forfeited if you change options during Open Enrollment or due to a qualifying event. \nPlan Features \n The plan offers unlimited wellness benefits based on age and gender national guidelines when seeing in-network providers only \n If you enroll during the year, or change tiers from single to family, your HRA dollar credits will be pro-rated based on the number of months remaining in the Plan Year. The deductible and out-of-pocket maximum are not adjusted \n HRA dollar credits are part of this option only and can only be used with the HRA option  The amount in your HRA is used to reduce the deductible and maximum out-of-pocket \nand any unused dollars in your account roll over to the next Plan Year if you are still participating in the Plan  There is not a separate deductible and out-of-pocket maximum for out-of-network expenses  After satisfying your deductible, you will pay your co-insurance amount until you reach your out-of-pocket maximum  Certain drug costs are waived if SHBP is primary and you participate in one of the Disease State Management Programs (DSM) for Diabetes, Asthma and/or Coronary Artery Disease \nHigh Deductible Health Plan (HDHP) \nThe HDHP design is very similar to that of the OAP with an in-network and out-ofnetwork benefit. \nIn return for a low monthly premium, you must satisfy a high deductible that applies to all health care expenses except preventive care. If you have family coverage, you must meet the ENTIRE family deductible before benefits are payable for any family member. You pay co-insurance after you have satisfied the deductible rather than set dollar co-payments for medical expenses and prescription drugs. Also, you may qualify to start a Health Savings Account (HSA) to set aside tax-free dollars to pay for eligible health care expenses now or in the future. HSAs typically earn interest and may even offer investment options. See the benefits comparison chart that starts on page 14 to compare benefits under the HDHP to other Plan options. \nPlan Features: \n This option offers 100 percent unlimited wellness benefits based on national age and gender guidelines \n You must satisfy a separate in-network and out-of-network deductible and out-of-pocket maximum \n You pay co-insurance after meeting the entire family deductible for all medical expenses and prescriptions \n This plan is not creditable so if you don't sign up for Medicare when you first become eligible; you may be charged a late enrollment penalty 11 \n \nnew enrollee decision guide 2010 \n \n UNDERSTANDING YOUR PLAN OPTIONS \n \nHealth Savings Account (HSA)  For Information Only \nAn 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. \nYou may open an HSA if you enroll in the SHBP HDHP and do not have other coverage through: 1) Your spouse's employer's plan 2) Medicare 3) Medicaid 4) General Purpose Health Care Spending Account (GPHCSA) or any other non-qualified medical plan. \n You can contribute up to $3,050 single, $6,150 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 \n HSA dollars can be used for eligible health care expenses even if you are no longer enrolled in the HDHP or any SHBP coverage \n HSA dollars can be used to pay for health care expenses (medical, dental, vision, overthe-counter medications) that the IRS considers tax-deductible that are NOT covered by any health plan (see IRS Publication 502 at www.irs.gov) \n You can contribute an additional $1,000 if you are 55 or older (see IRS Publication 502 at www.irs.gov) \n \nOverview \n \nHRA \nA tax-exempt account that reimburses retirees and dependents for qualified medical expenses. Can be funded by employer only. \n \nHSA \nA tax-exempt custodial account that exclusively pays for qualified medical expenses of the employee and his or her dependents. Can be funded by retiree, employer, or other party. \n \nWho is eligible? \n \nAvailable to SHBP members enrolled in an HRA. See benefits chart for amounts funded by SHBP. \n \nAvailable to SHBP members who elect HDHP and may enroll in an HSA of your choice. \n \nCan I have other coverage and take advantage of this benefit? \nWho owns the money in these accounts? \n \nYes. \nSHBP. Money reverts back to SHBP upon loss of SHBP HRA coverage. \n \nNo other general medical insurance coverage permitted. You cannot be enrolled in Medicare Parts A or Part B. \nThe member. \n \nCan these dollars be rolled over each year? \nIs there a monthly service charge? \nIf I terminate my SHBP coverage or change options... \n \nYes. \nNo. \nUnused amounts can be distributed until depleted to pay for claims incurred before termination. \n \nYes. \nCheck with your HSA administrator. \nFund disbursement is not tied to individual's employment. Unused amounts can be distributed tax-free for qualified medical expenses. Subject to income and excise tax for non-qualified expenses. \n \nnew enrollee decision guide 2010 \n \n12 \n \n Health \u0026 Wellness \nDid You Know? \n Cardiovascular disease is the leading cause of death in Georgia \n Diabetes in Georgia is 8% higher than the nation as a whole \n Asthma has been diagnosed in approximately 210,000 children in Georgia between the ages of 017 years old \n Certain drug costs are waived for HRA members who participate in the Disease State Management (DSM) Programs for cardiovascular disease, diabetes or asthma \nWhat Can You Do About Your Health? \nTake a Personal Health Assessment at least once a year to assist you in learning about potential health risks related to your lifestyle and family history. Each vendor has a health assessment questionnaire available on their Web site that you can complete. After completing the health assessment you will get a customized report that identifies health risks and provides recommendations on ways to help you reduce health risks and suggestions on how to make better lifestyle choices. Members who complete the health assessment may be contacted by the vendor's registered nurses or health coaches regarding steps they can take to control or eliminate these risks. Participant data is completely confidential and individual results are not shared with your employer or SHBP. \nUtilize the Preventive Health and Wellness Services: One of the best ways to stay healthy is to take advantage of preventive health care. Check with the vendor regarding the plan option you choose to confirm which preventive services are covered. In addition, each vendor offers health coaching and wellness programs such as weight loss, nutrition, and stress management. Contact the vendors to learn more about the programs they offer or visit their Web site to view available services. \nEngage in the Health Management Services: Each vendor offers assistance with health care services including disease management, case management and behavioral health. Please contact the vendor of choice for additional details on programs offered such as the DSM Program that waives prescription drug co-payments/costs on certain medications for members who have cardiovascular disease, diabetes and/or asthma and remain compliant with the DSM Program requirements. \nCall the Nurse Advice Line: Each vendor has a 24-hour, seven days a week (including holidays) nurse advice line that is available to assist you in making informed decisions about your health. Check with your health plan option for the telephone number. \nGood health is priceless. When you live a healthy lifestyle, you can feel better, live easier and save money on health care expenses! \n \nHEALTH \u0026 WELLNESS \n \nnew enrollee decision guide 2010 \n \n13 \n \n BENEFITS COMPARISON \n \nBenefits Comparison \n \nSchedule of Benefits for You and Your Dependents for January 1, 2010  \n \nDecember 31, 2010 HIGH DEDUCTIBLE OPTION (HDHP) \n \nHRA OPTION \n \nIn-Network \n \nOut-of-Network In-Network Out-of-Network \n \nCovered Services \nMaximum Lifetime Benefit (combined for all SHBP Options) \nPre-Existing Conditions (first year in Plan only, subject to HIPAA) \nLifetime Benefit Limit for Treatment of: (combined for Open Access Option and HDHP)  Temporomandibular joint \ndysfunction (TMJ) \nDeductibles/Co-Payments: EE = Employee ES = Employee + Spouse EC = Employee + Child(ren) EF = Employee + Spouse + \nChild(ren)  Hospital deductible per admission \nOut-of-Pocket Maximum: EE = Employee ES = Employee + Spouse EC = Employee + Child(ren) EF = Employee + Spouse + \nChild(ren) \nHRA Credits: EE = Employee ES = Employee + Spouse EC = Employee + Child(ren) EF = Employee + Spouse + \nChild(ren) \nPhysicians' Services \nPrimary Care Physician or Specialist Office or Clinic Visits: Treatment of illness or injury \n \nThe Plan Pays: $2 million \nNot applicable \n \n$1,100 \n \n$1,200 $2,400 $2,400 $2,400 \n \n$2,400 $4,800 $4,800 $4,800 \nNot applicable \n \n$1,800 $3,100 $3,100 $3,100 \n \n$4,000 $7,400 $7,400 $7,400 \n \nNone \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nThe Plan Pays: $2 million \nNot applicable \n \n$1,100 \n$1,100* $1,900* $1,900* $2,750* *HRA credits will reduce this amount. Not applicable \n$2,500* $4,100* $4,100* $5,700* *HRA credits will reduce this amount. \n$500 $1,000 $1,000 $1,500 \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nnew enrollee decision guide 2010 \n \nPrimary Care Physician or Specialist Office or Clinic Visits for the Following:  Wellness care/preventive \nhealth care  Annual gynecological exams \n(these services are not subject to the deductible) \n \n100% coverage; not subject to deductible \n \nNot covered; Charges do not apply to deductible or annual out-ofpocket limits \n \n100% coverage; not subject to deductible \n \nNot covered. Charges do not apply to deductible or annual out-ofpocket limits \n \n14 \n \n BENEFITS COMPARISON \n \nDollar amounts, visit limitations, deductibles and out-of-pocket limits are based on a January 1December 31, 2010 Plan Year. NOTE: Coverage is defined as allowed eligible expenses. Exclusions and limitations vary among Plan options. Contact your specific Plan option for more information. \n \nHIGH DEDUCTIBLE OPTION (HDHP) \n \nIn-Network \n \nOut-of-Network \n \nHRA OPTION \nIn-Network Out-of-Network \n \nPhysicians' Services Maternity Care (prenatal, delivery and postpartum) \nPhysician Services Furnished in a Hospital  Visits; surgery in general, \nincluding charges by surgeon, anesthesiologist, pathologist and radiologist \nPhysician Services for Emergency Care Non-emergency use of the emergency room not covered \nOutpatient Surgery  When billed as office visit \n When billed as outpatient surgery at a facility \nAllergy Shots and Serum \nHospital Services \nInpatient Services  Inpatient care, delivery and \ninpatient short-term acute rehabilitation services \n \nThe Plan Pays: \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n90% coverage; subject to in-network deductible \n \n90% coverage; subject to deductible \n90% coverage; subject to deductible \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n60% coverage; subject to deductible \n60% coverage; subject to deductible \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nThe Plan Pays: \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n85% coverage; subject to deductible \n \n85% coverage; subject to deductible \n85% coverage; subject to deductible \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n60% coverage; subject to deductible \n60% coverage; subject to deductible \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n Well-newborn care \nOutpatient Surgery-- Hospital/facility \nEmergency Care--Hospital  Treatment of an emergency \nmedical condition or injury  Non-emergency use of the \nemergency room not covered \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n90% coverage; subject to in-network deductible \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n85% coverage; subject to deductible \n \nnew enrollee decision guide 2010 \n \nChart continued pg. 16 \n \n15 \n \n BENEFITS COMPARISON \n \nHIGH DEDUCTIBLE OPTION (HDHP) \n \nIn-Network \n \nOut-of-Network \n \nHRA OPTION \nIn-Network Out-of-Network \n \nOutpatient Testing, Lab, etc. \n \nThe Plan Pays: \n \nNon Routine Laboratory; X-Rays; Diagnostic Tests; Injections--including medications covered under medical benefits--for the treatment of an illness or injury \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nBehavioral Health \nMental Health and Substance Abuse Inpatient Facility and Partial Day Hospitalization NOTE: Contact vendor regarding prior authorization. \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nMental Health and Substance Abuse Outpatient Visits and Intensive Outpatient NOTE: All services require prior authorization. \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nThe Plan Pays: \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nDental \nDental 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. \nTemporomandibular Joint Syndrome (TMJ) NOTE: Coverage for diagnostic testing and non-surgical treatment up to $1,100 per person lifetime maximum benefit. \nVision \nRoutine Eye Exam NOTE: Limited to one eye exam every 24 months. \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nNOTE: Notification required for all UHC options. \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n100% coverage; not subject to deductible \n \nEye exam not covered \n \n100% coverage; Eye exam not not subject to covered deductible \n \nnew enrollee decision guide 2010 \n \nOther Coverage Hearing Services Routine hearing exam \nAmbulance Services for Emergency Care NOTE: \"Land or air ambulance\" to nearest facility to treat the condition. \nUrgent Care Services \n \n90% coverage for route exam and fitting; subject to deductible. $1,500 hearing aid allowance every 5 years; not \nsubject to the deductible \n90% coverage; subject to in-network deductible \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n16 \n \n85% coverage for routine exam and fitting; subject to deductible. $1,500 hearing aid allowance every 5 years; \nnot subject to the deductible \n85% coverage; subject to deductible \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n HIGH DEDUCTIBLE OPTION (HDHP) \n \nIn-Network \n \nOut-of-Network \n \nBENEFITS COMPARISON \nHRA OPTION \nIn-Network Out-of-Network \n \nOther Coverage Home Health Care Services \nNOTE: Prior approval required. \nSkilled Nursing Facility Services NOTE: Prior approval required. \nHospice Care NOTE: Prior approval required. \nDurable Medical Equipment (DME)--Rental or purchase NOTE: Prior approval required for certain DME. \nOutpatient Acute Short-Term Rehabilitation Services \n Physical therapy  Speech therapy  Occupational therapy  Other short term \nrehabilitative services \n \nThe Plan Pays: \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n90% coverage up to 120 days per Plan Year; subject to deductible \n \nNot covered \n \n90% coverage; subject to deductible \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n60% coverage; subject to deductible \n \n90% coverage up to 40 visits per therapy per Plan Year; subject to deductible (not to exceed a total of 40 visits combined, including any outof-network visits) \n \n60% coverage up to 40 visits per therapy per Plan Year; subject to deductible (not to exceed a total of 40 visits combined, including any in-network visits) \n \nThe Plan Pays: \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n85% coverage; up to 120 days per Plan Year; subject to deductible \n \nNot covered \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n85% 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-network visits) \n \n60% 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) \n \nChiropractic Care NOTE: Coverage for up to a maximum of 20 visits per Plan Year. \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nTransplant Services NOTE: Prior approval required. \nPharmacy  You Pay Pharmacy Co-insurance \n \n90% coverage at contracted transplant facility; subject to deductible \n \nNot covered \n \n20% coverage; subject to deductible; $10 min.; $100 max. \n \nNot covered \n \n85% coverage; subject to deductible \n85% coverage; subject to deductible \n \n60% coverage; subject to deductible \n60% coverage; subject to deductible \n \n15% generic; 25% brand; subject to deductible \n \n40% generic; 40% brand; subject to deductible* \n \n*Member must pay full charges at point of sale and submit a paper claim. Members will be reimbursed at the pharmacy network rate less the required co-insurance for covered drugs. Member is responsible for charges that exceed the pharmacy network rate. \n \nnew enrollee decision guide 2010 \n \n17 \n \n IMPORTANT NOTICE \n \nAbout the Following Notices \nThe notices on the following pages are required by the Center for Medicaid \u0026 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. \n \nYOUR SHBP OPTION \nSHBP Medicare Advantage Standard or SHBP Medicare Advantage Premium Plan Open Access Plan/HRA HMO \nHDHP (High Deductible) \n \nWHAT HAPPENS IF YOU BUY AN INDIVIDUAL MEDICARE PART D PLAN \nYou will permanently lose SHBP coverage if you purchase a Part D Plan once enrolled in a SHBP Medicare Advantage Plan. You will not pay a Medicare \"late enrollment\" penalty. \nYour 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. \nYou 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.\" \n \nThese 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 SHBP MA Standard, SHBP MA Premium, OAP, 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. \n \nnew enrollee decision guide 2010 \n \nWARNING! Buying any individual Medicare insurance product outside of the Medicare Advantage plans 18 offered through SHBP could AUTOMATICALLY and PERMANENTLY END your SHBP Coverage. \n \n IMPORTANT NOTICE \n \nTwo Peachtree Street  Atlanta, GA 30303 (404) 656-6322  (800) 610-1863 \n \nOctober 1, 2009 \n \nAbout Your Prescription Drug Coverage with CIGNA and UnitedHealthcare OAP, HMO, HRA and Medicare \nFor Plan Year: January 1December 31, 2010 \nPlease 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 cost 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. \nThere are two important things you need to learn about your current coverage and Medicare's prescription drug coverage. \n1. 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. \n2. The SHBP has determined that the prescription drug coverage offered by the CIGNA and UnitedHealthcare OAP, HMO and HRA offered under SHBP is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is considered Creditable Coverage. Because your existing coverage is 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. \nWhen Can You Join a Medicare Drug Plan? \nYou can join a Medicare drug plan when you first become eligible for Medicare and each year from November 15th through December 31st. 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. \nWhat Happens to Your Current Coverage if You Do Join a Medicare Drug Plan? \nIf you decide to join a Medicare drug plan, your SHBP coverage will be affected. You can keep your SHBP coverage if you elect Part D and SHBP will coordinate with Part D coverage the month following receipt of enrollment notice. Your premiums will also be reduced by each Part of Medicare you have. You should send a copy of your Medicare cards to SHBP at P. O. Box 1990, Atlanta, GA 30301. \nIf you do decide to join a Medicare drug plan and drop your coverage with the State Health Benefit Plan, be aware that you and your dependents can not get this coverage back if you are a retiree. \nWhen Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan? \nYou should also know that if you drop or lose your coverage with SHBP and don't join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. \n \nnew enrollee decision guide 2010 \n \nWARNING! Buying any individual Medicare insurance product outside of the Medicare Advantage plans offered through SHBP could AUTOMATICALLY and PERMANENTLY END your SHBP Coverage. 19 \n \n IMPORTANT NOTICE \nIf you go 63 continuous days or longer without credible prescription drug coverage that's at least as good as Medicare's prescription drug coverage, your monthly premium may go up by at least 1% of the 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 November to join. \nFor More Information about this Notice or Your SHBP Current Prescription Drug Coverage... \nContact the SHBP Eligibility Unit at (404) 656-6322 or (800) 610-1863. NOTE: You'll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through the State Health Benefit Plan changes. You also may request a copy of this notice at any time. \nFor More Information about Your Options under Medicare Prescription Drug Coverage... \nMore detailed information about Medicare plans that offer prescription drug coverage is in the Medicare \u0026 You handbook. You will get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. \nFor 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 \u0026 You \nhandbook for their telephone number) for personalized help  Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048 \nIf 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). \nRemember: 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). \nDate: October 1, 2010 Name of Sender: State Health Benefit Plan Office: Call Center Address: P. O. Box 1990, Atlanta, GA 30301 Phone Number: (404) 656-6322 or (800) 610-1863 \n \nnew enrollee decision guide 2010 \n \nWARNING! Buying any individual Medicare insurance product outside of the Medicare Advantage plans \n \n20 \n \noffered through SHBP could AUTOMATICALLY and PERMANENTLY END your SHBP Coverage. \n \n IMPORTANT NOTICE \n \nTwo Peachtree Street  Atlanta, GA 30303 (404) 656-6322  (800) 610-1863 \n \nOctober 1, 2009 \n \nImportant Notice from the SHBP about Your Prescription Drug Coverage and Medicare \nAbout Your Prescription Drug Coverage with the CIGNA and UnitedHealthcare High Deductible Health Plan (HDHP) and Medicare \nFor Plan Year: January 1December 31, 2010 \nPlease 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. \nThere are three important things you need to know about your current coverage and Medicare's prescription drug coverage: \n1. 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. \n2. 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 is also 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. \n3. You can keep your current coverage in a CIGNA or UnitedHealthcare HDHP offered by the 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 as it explains your options. \nWhen Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan? \nSince 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 credible 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 credible 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 November to join. \n \nnew enrollee decision guide 2010 \n \nWARNING! Buying any individual Medicare insurance product outside of the Medicare Advantage plans offered through SHBP could AUTOMATICALLY and PERMANENTLY END your SHBP Coverage. 21 \n \n IMPORTANT NOTICE \nWhen Can You Join a Medicare Drug Plan? \nYou can join a Medicare drug plan when you first become eligible for Medicare and each year from November 15th through December 31st. However, if you decide to drop your current coverage under SHBP, since it is an employer sponsored group plan, 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 Credible Coverage under SHBP. \nWhat Happens to Your Current Coverage if You Decide to Join a Medicare Drug Plan? \nIf you decide to join a Medicare drug plan, your HDHP coverage under SHBP will be affected. If you enroll in Medicare Part D when you become eligible for Medicare Part D, you can keep your HDHP coverage and the HDHP will coordinate benefits with the Part D coverage. If you do decide to join a Medicare drug plan and drop your HDHP coverage under SHBP, be aware that you and your dependents will not be able to get your SHBP coverage back if you are a retiree. You should also know that if you drop or lose your HDHP coverage with SHBP and don't join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. \nFor More Information about this Notice or Your Current Prescription Drug Coverage... \nContact the SHBP Call Center at (404) 656-6322 or (800) 610-1863 for further information. NOTE: You will get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage though SHBP changes. You also may request a copy of this notice at any time. \nFor More Information about Your Options under Medicare Prescription Drug Coverage... \nMore detailed information about Medicare plans that offer prescription drug coverage is in the Medicare \u0026 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 \u0026 \nYou 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). \nDate: October 1, 2010 Name of Sender: State Health Benefit Plan Office: Call Center Address: P. O. Box 1990, Atlanta, GA 30301 Phone Number: (404) 656-6322 or (800) 610-1863 \nWARNING! Buying any individual Medicare insurance product outside of the Medicare Advantage plans 22 offered through SHBP could AUTOMATICALLY and PERMANENTLY END your SHBP Coverage. \n \nnew enrollee decision guide 2010 \n \n IMPORTANT NOTICE \n \nRhonda M. Medows, MD, Commissioner Sonny Perdue, Governor \nOctober 1, 2009 \n \n2 Peachtree Street, NW Atlanta, GA 30303-3159 www.dch.georgia.gov \n \nState Health Benefit Plan Annual Legal Notices \nWomen's Health and Cancer Rights Act \nThe Plan complies with the Women's Health and Cancer Rights Act of 1998. Mastectomy, including reconstructive surgery, is covered the same as other surgery under your Plan option. Following cancer surgery, the SHBP covers: \n All stages of reconstruction of the breast on which the mastectomy has been performed \n Reconstruction of the other breast to achieve a symmetrical appearance \n Prostheses and mastectomy bras \n Treatment of physical complications of mastectomy, including lymph edema \nNote: Reconstructive surgery requires prior approval, and all inpatient admissions require prior notification. \nFor more detailed information on the mastectomy-related benefits available under the Plan, you can contact the Member Services unit for your coverage option. Telephone numbers are on the inside front cover. \nNewborns' and Mothers' Health Protection Act \nThe Plan complies with the Newborns' and Mothers' Health Protection Act of 1996. Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the Plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). \nHealth Insurance and Accountability Act (HIPPA) Annual Notice \nThis section describes certain rights available to you under the Health Insurance Portability and Accountability Act (HIPAA) when you add a dependent to your State Health Benefit Plan (SHBP) coverage. \nThe OAP Option contains a pre-existing condition (PEC) limitation. Specifically, the Health Plan will not pay charges that are over $1,000 for the treatment of any pre-existing condition during the first 12 months of a patient's coverage, unless the patient gives satisfactory documentation that he or she has been free of treatment of medication for that condition for at least six consecutive calendar months. However, a PEC limitation does not apply to converge for: \n Pregnancy; or \n Newborns or children under age 18 who are adopted or placed for adoption, if the child becomes covered within 31 days after birth, adoption or placement for adoption \n \nnew enrollee decision guide 2010 \n \n23 \n \n IMPORTANT NOTICE \nIn certain situations, SHBP members and dependents can reduce the 12-month PEC limitation period. The reduction is possible by using what is called \"creditable coverage\" to offset a PEC period. Creditable coverage generally includes the health coverage you or a family member had immediately prior to joining the SHBP. Coverage under most group health plans, as well as coverage under individual health policies and governmental health programs, qualifies as creditable coverage. To reduce the PEC limitation period for your own coverage, you must provide the SHBP with a certificate of creditable coverage from one or more former health plans or insurers that states when your prior coverage started and ended. Any period of prior coverage will reduce the 12-month limitation period if the time between losing coverage and the first day of your SHBP coverage does not exceed 63 days. If you are enrolling as a new hire, the 63-day period is measured from your last day of prior coverage up to your date of hire. To reduce the PEC limitation period for your dependents (including your spouse), you must provide the SHBP with a certificate of creditable coverage stating when coverage started and ended for each dependent that you want to cover. Any period of prior coverage for that dependent will reduce the 12-month limitation period if no more than 63 days have elapsed between the dependent's loss of prior coverage and the first day of coverage under the SHBP (or your date of hire, if you are enrolling as a new hire). If you or your dependent (including a spouse) had any break in coverage lasting more than 63 days, you or your dependent will receive creditable coverage only for the period of time after the break ended. Within two years after your former coverage terminated, you have the right to obtain a certificate of creditable coverage from your employer(s) to offset the pre-existing condition limitation period under the SHBP. The SHBP will evaluate the certificate of creditable coverage or other documentation to determine whether any of the preexisting condition limitation period will be reduced or eliminated. After completing the evaluation, the SHBP will notify you as to how the pre-existing condition limitation period will be reduced or eliminated. Please submit the certificate of creditable coverage to the Plan with your enrollment paperwork. If you require assistance in obtaining a letter from a former employer, contact your personnel/payroll office. \n24 \n \nnew enrollee decision guide 2010 \n \n IMPORTANT NOTICE \n \nTwo Peachtree Street  Atlanta, GA 30303 (404) 656-6322  (800) 610-1863 \n \nSeptember 15, 2009 \n \nTo: All Members of the State Health Benefit Plan Who Are Not Enrolled in a Medicare Advantage Option \nUnder a Federal law known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, as amended, group health plans must comply with a number of requirements. Under HIPAA, state health plans that are \"self-funded\" may \"opt out\" of these requirements by making a yearly election to be exempt. Your plan option is self-funded because the Department of Community Health pays all claims directly instead of buying a health insurance policy. The Department of Community Health is renewing its yearly election to exempt your State Health Benefit Plan (\"SHBP\") option from the following two HIPAA requirements. \nThe Department of Health and Human Services considers tobacco use to be a health status-related factor. Therefore, the Department of Community Health will exempt the SHBP from the following requirement in order to apply the tobacco surcharge. \nProhibitions against discriminating against individual participants and beneficiaries based on health status. A group health plan may not discriminate in enrollment rules or in the amount of premiums or contributions it requires an individual to pay based on certain health status-related factors. \nThe Department of Community Health will exempt the SHBP from the following requirement in order to apply a 31 day period for making any enrollment change as a result of a qualifying event. \nSpecial enrollment periods. Group health plans are required to provide special enrollment periods for individuals who do not enroll in the plan because they have other coverage, but subsequently lose that coverage. Also, if a plan provides dependent coverage, the plan must provide a special enrollment period for new dependents (and the employee if not already enrolled) within 30 days after a marriage, birth, adoption or placement for adoption. A 60-day special enrollment period applies to eligible individuals who lose eligibility for Medicaid coverage or coverage under a State child health plan, or becomes eligible under Medicaid or a State child health plan for group health plan premium assistance. \nThe exemption from these federal requirements will be in effect for the plan year starting January 1, 2010 and ending December 31, 2010. The election may be renewed for subsequent plan years. \nHIPAA also requires the SHBP to provide covered employees and dependents with a \"certificate of creditable coverage\" when they cease to be covered under the SHBP. There is no exemption from this requirement. The certificate provides evidence that you were covered under the SHBP, because if you can establish your prior coverage, you may be entitled to certain rights to reduce or eliminate a preexisting condition exclusion if you join another employer's health plan, or if you wish to purchase an individual health insurance policy. \n \nnew enrollee decision guide 2010 \n \n25 \n \n IMPORTANT NOTICE \n \nTwo Peachtree Street  Atlanta, GA 30303 (404) 656-6322  (800) 610-1863 \n \nRevised August 1, 2009. \n \nState Health Benefit Plan Information Privacy Notice \nThis notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. \nQuestions? Call 404-656-6322 (Atlanta) or 800-610-1863 (outside of Atlanta). \nThe DCH and the State Health Benefit Plan Are Committed to Your Privacy. The Georgia Department of Community Health (DCH) sponsors and runs the State Health Benefit Plan (the Plan). We understand that your information is personal and private. Some DCH employees and companies hired by DCH collect your information to run the Plan. The information is called \"Protected Health Information\" or \"PHI.\" This notice tells how your PHI is used and shared. We follow the information privacy rules of the Health Insurance Portability and Accountability Act of 1996, (\"HIPAA\"). \nOnly Summary Information is Used When Developing and Changing the Plan. The Board of Community Health and the Commissioner of the DCH make decisions about the Plan. When making decisions, they review reports. These reports explain costs, problems, and needs of the Plan. These reports never include information that identifies any person. If your employer is allowed to leave the Plan, your employer may also get summary reports. \nPlan Enrollment Information and Claims Information is Used in Order to Run the Plan. PHI includes two kinds of information. \"Enrollment Information\" includes: 1) your name, address, and social security number; 2) your enrollment choices; 3) how much you have paid in premiums; and 4) other insurance you have. This Enrollment Information is the only kind of PHI your employer is allowed to see. \"Claims Information\" includes information your health care providers send to the Plan. For example, it may include bills, diagnoses, statements, x-rays or lab test results. It also includes information you send to the Plan. For example, it may include your health questionnaires, enrollment forms, leave forms, letters and telephone calls. Lastly, it includes information about you that is created by the Plan. For example, it includes payment statements and checks to your health care providers. \nYour PHI is Protected by Law. Employees of the DCH and employees of outside companies hired by DCH to run the Plan are \"Plan Representatives.\" They must protect your PHI. They may only use it as allowed by HIPAA. \nThe DCH Must Make Sure the Plan Complies with HIPAA. As Plan sponsor, the DCH must make sure the Plan complies with HIPAA. We must give you this notice. We must follow its terms. We must update it as needed. The DCH is the employer of some Plan Members. The DCH must name the DCH employees who are Plan Representatives. No DCH employee is ever allowed to use PHI for employment decisions. \nPlan Representatives Regularly Use and Share your PHI in Order to Pay Claims and Run the Plan. Plan Representatives use and share your PHI for payment purposes and to run the Plan. For example, they make sure you are allowed to be in the Plan. They decide how much the Plan should pay your health care provider. They set premiums and manage costs. Some Plan Representatives work for outside companies. By law, these companies must protect your PHI. They also must sign \"Business Associate\" agreements with the Plan. Here are some examples what they do. \n \nnew enrollee decision guide 2010 \n \n26 \n \n IMPORTANT NOTICE \nClaims Administrators: Process all medical and drug claims; communicate with Members and their health care providers; and give extra help to Members with some health conditions. Data Analysis, Actuarial Companies: Keep health information in computer systems, study it, and create reports from it. Attorney General's Office, Auditing Companies, Outside Law Firms: Provide legal and auditing help to the Plan. Information Technology Companies: Help improve and check on the DCH information systems used to run the Plan. Some Plan Representatives work for the DCH. By law, all employees of the DCH must protect PHI. They also must get special privacy training. They only use the information they need to do their work. Plan Representatives in the SHBP Division work full-time running the Plan. They use and share PHI with each other and with Business Associates in order to help pay claims and run the Plan. In general, they can see your Enrollment Information and the information you give the Plan. A few can see Claims Information. DCH employees outside of the SHBP Division do not see Enrollment Information on a daily basis. They may use Claims Information for payment purposes and to run the Plan. \nPlan Representatives May Make Special Uses or Disclosures Permitted by Law. HIPAA has a list of special times when the Plan may use or share your PHI without your authorization. At these times, the Plan must keep track of the use or disclosure. \nTo Comply with a Law, or to Prevent Serious Threats to Health or Safety: The Plan may use or share your PHI in order to comply with a law, or to prevent a serious threat. \nFor Public Health Activities: The Plan may give PHI to government agencies that perform public health activities. For example, the Plan may give PHI to DCH employees in the Public Health Division who need it to do their jobs. \nFor Research Purposes: Your PHI may be given to researchers for a research project approved by a review board. The review board must review the research project and its rules to ensure the privacy of your information. \nPlan Representatives Share Some Payment Information with the Employee. Except as described in this notice, Plan Representatives are allowed to share your PHI only with you, and with your legal personal representative. However, the Plan may inform the employee family member about whether the Plan paid or denied a claim for another family member. \nYou May Authorize Other Uses of Your PHI. You may give a written authorization for the Plan to use or share your PHI for a reason not listed in this notice. If you do, you may take away the authorization later by writing to the contact below. The old authorization will not be valid after the date you take it away. \nYou Have Privacy Rights Related to Plan Enrollment Information and Claims Information that Identifies You. \nRight to See and Get a Copy your Information, Right to Ask for a Correction: Except for some reasons listed in HIPAA, you have the right to see and get a copy of information used to make decisions about you. If you think it is incorrect or incomplete, you may ask the Plan to correct it. \nRight to Ask for a List of Special Uses and Disclosures: You have the right to ask for a list of special uses and disclosures that were made after April, 2003. \nRight to Ask for a Restriction of Uses and Disclosures, or for Special Communications: You have the right to ask for added restrictions on uses and disclosures. You also may ask the Plan to communicate with you in a special way. \n27 \n \nnew enrollee decision guide 2010 \n \n IMPORTANT NOTICE \nRight to a Paper Copy of this Notice, Right to File a Complaint Without Getting in Trouble: You have the right to a paper copy of this notice. Please contact the SHBP HIPAA Privacy Unit or print it from www.dch.ga.gov. If you think your privacy rights have been violated, you may file a complaint. You may file the complaint with the Plan and/or the Department of Health and Human Services. You will not get in trouble with the Plan or your employer for filing a complaint. \nAddress for Complaints: \nHBP HIPAA Privacy Unit P.O. Box 1990, Atlanta, Georgia 30301 404-656-6322 (Atlanta) or 800-610-1863 (outside Atlanta) U.S. Department of Health \u0026 Human Services, Office for Civil Rights Region IV Atlanta Federal Center 61 Forsyth Street SW, Suite 3B70 Atlanta, GA 30303-8909 \n28 \n \nnew enrollee decision guide 2010 \n \n Notify the Plan of any fraudulent activity regarding Plan members, providers, payment of benefits, etc. Call 1-877-878-3360 or 404-463-7590. \nPenalties for Misrepresentation \nIf an SHBP participant misrepresents eligibility information when applying for coverage, during change of coverage or when filing for benefits, the SHBP may take adverse action against the participants, including but not limited to terminating coverage (for the participant and his or her dependent(s) or imposing liability to the SHBP for fraud or indemnification (requiring payment for benefits to which the participant or his or her beneficiaries were not entitled). Penalties may include a lawsuit, which may result in payment of charges to the Plan or criminal prosecution in a court of law. \nIn 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. \n \n  "},{"id":"dlg_ggpd_y-ga-bc900-pe4-bs1-bn4-b2009-belec-p-btext","title":"New employee decision guide 2009","collection_id":"dlg_ggpd","collection_title":"Georgia Government Publications","dcterms_contributor":["Georgia. Department of Community Health."],"dcterms_spatial":["United States, Georgia, 32.75042, -83.50018"],"dcterms_creator":["Georgia. Department of Community Health"],"dc_date":["2009"],"dcterms_description":["Title from cover"],"dc_format":["application/pdf"],"dcterms_identifier":null,"dcterms_language":["eng"],"dcterms_publisher":["Atlanta, Ga. : Georgia Dept. of Community Health, Division of Public Employee Health Benefits, 2009"],"dc_relation":null,"dc_right":["http://rightsstatements.org/vocab/InC/1.0/"],"dcterms_is_part_of":null,"dcterms_subject":["Government employees' health insurance--Georgia"],"dcterms_title":["New employee decision guide 2009"],"dcterms_type":["Text"],"dcterms_provenance":["University of Georgia. Map and Government Information Library"],"edm_is_shown_by":["https://dlg.galileo.usg.edu/do:dlg_ggpd_y-ga-bc900-pe4-bs1-bn4-b2009-belec-p-btext"],"edm_is_shown_at":["https://dlg.galileo.usg.edu/id:dlg_ggpd_y-ga-bc900-pe4-bs1-bn4-b2009-belec-p-btext"],"dcterms_temporal":null,"dcterms_rights_holder":null,"dcterms_bibliographic_citation":null,"dlg_local_right":null,"dcterms_medium":["state government records"],"dcterms_extent":null,"dlg_subject_personal":null,"iiif_manifest_url_ss":null,"dcterms_subject_fast":null,"fulltext":"STATE HEALTH BENEFIT PLAN \nNew Employee Decision Guide 2009 \nSteps to Maintain Good Health:  Select the Best Health Care Option  Seek Preventive Care  Complete Your Health Assessment  Participate in Health Coaching  Take Charge of Your Health \n \n Phone Numbers/Contact Information \nState Health Benefit Plan (SHBP): www.dch.georgia.gov/shbp_plans \n \nVendor \n \nMember Services Pharmacy \n \nWeb Site \n \nUnitedHealthcare \n \nDefinity HRA \n \n800-396-6515 \n \nwww.myuhc.com/groups/gdch \n \nHDHP \n \n877-246-4195 \n \nTDD 800-842-5754 800-372-5802 www.myuhc.com/groups/gdch \n \nCIGNA Healthcare \n \nHRA, HDHP \n \n800-633-8519 TDD 800-576-1314 800-633-8519 \n \nPharmacyContact your respective vendor \n \nAll Options: Eligibility \n \n404-656-6322 800-610-1863 \n \nwww.cigna.com/shbp www.dch.georgia.gov/shbp_plans www.dch.georgia.gov/shbp_plans \n \nNotify the Plan of any fraudulent activity regarding Plan members, providers, payment of benefits, etc. Call 1 877-878-3360 or 404-463-7590. \nDisclaimer: This material is for informational purposes and is not a contract. It is intended only to highlight principal benefits of the medical plans. Every effort has been made to be as accurate as possible; however, should there be a difference between this information and the Plan documents, the Plan documents govern. It is the responsibility of each member, active or retired, to read all Plan materials provided in order to fully understand the provisions of the option chosen. Availability of SHBP options may change based on changes in federal or state law. \nThe Summary Plan Description (SPD) for each Plan option is posted on the DCH Web site, www.dch.georgia.gov/shbp_plans. You may print or request a paper copy by calling the Customer Service number on the back of your ID card. Please keep your Summary Plan Description (SPD) for future reference. If you are disabled and need this information in an alternative format, call the TDD Relay Service at (800) 255-0056 (text telephone) or (800) 255-0135 (voice) or write the SHBP at P.O. Box 38342, Atlanta, GA 30334. \n \n Rhonda M. Medows, MD, Commissioner \n \nSonny Perdue, Governor \n \nDecember 1, 2008 \n \n2 Peachtree Street, NW Atlanta, GA 30303-3159 www.dch.georgia.gov \n \nDear New State Health Benefit Plan Member: \nWelcome to the State Health Benefit Plan (SHBP). The SHBP is committed to providing high quality health benefits at an affordable price to its members. Upon joining SHBP, new employees have the opportunity to choose between two consumer driven health options each offered by CIGNA Healthcare and UnitedHealthcare (UHC). The High Deductible Health Plan (HDHP) and the Health Reimbursement Arrangement (HRA) offered by CIGNA HealthCare and UHC provide health care consumers with low monthly premiums, extensive provider networks, and 100 percent unlimited coverage for wellness care based on national age and gender guidelines. \nIf you chose to take advantage of the HRA, you will have the extra benefit of the SHBP contributing dollars to your HRA on an annual basis for treatment of medical expenses. In 2009, this amount is: $500 for an employee only plan, $1,000 for an employee plus spouse, $1,000 for an employee plus child(ren), and $1,500 for an employee plus spouse and child(ren). \nHDHP has the lowest monthly premium and it allows members to start a Health Savings Account (HSA) to set aside tax-free dollars to pay for eligible health care expenses which offsets the higher deductible. \nEach plan's design is similar to that of a PPO with in-network and out-of-network benefits, wellness benefits, and other enhanced benefits exclusive to the HRA and HDHP plans. \nSHBP offers an annual open enrollment period for all employees. You will be able to select from the consumer driven health options in addition to two Preferred Participating Organization (PPO) options, and two Health Maintenance Organization (HMO) options during the 2009 open enrollment period. You can access information about these options at www.dch.georgia.gov/shbp_plans. \nThe Georgia Department of Community Health, which administers the SHBP, is committed to providing you with meaningful choices in your options while keeping costs down. Be assured that we will continue to seek to provide you with meaningful options, low premiums and tools to help you make the right healthcare choices for you and your family members. \n \n \n \nSincerely, \n \nRhonda M. Medows, M.D. \n \n \n \n \n \nEqual Opportunity Employer \n \n HEALTH \u0026 WELLNESS \nSH BP  Acronyms \nDCH  Georgia Department of Community Health \nCDHP  Consumer Driven Health Plan \nFSA  Flexible Spending Account HDHP  High Deductible  \nHealth Plan HMO  Health Maintenance \nOrganization HRA  Health Reimbursement \nArrangement HSA  Health Savings Account PPO  Preferred Provider \nOrganization SHBP  State Health Benefit Plan SPD  Summary Plan Description UHC  UnitedHealthcare EE  Employee ES  Employee + Spouse EC  employee + Child(ren) EF  Employee + Child(ren) + \nSpouse \n \nTable of Contents \nPhone Numbers, Contacts and Provider Information Health \u0026 Wellness About the State Health Benefit Plan Eligibility and Qualifying Events General Information and Enrollment Understanding Your Plan Options Benefits Comparison: HRA and HDHP Options Health Care Accounts Important Notices \n \nInside Front Cover Page 2 Page 3 Pages 46 Pages 69 Page 10 Page 13 Page 17 Page 18 \n \nHealth \u0026 Wellness \nThe health options offer education on healthy living initiatives. The goal is to provide enhanced information, tools, and support to promote a healthy lifestyle and meet your health care needs. Please refer to your health plan option for details on programs offered. \n Health Assessments  each SHBP vendor has a health assessment questionnaire available on their Web site that you can complete. This information is kept confidential and will indicate potential health risks. The vendor may contact you regarding steps you can take to control or eliminate your risk or tests you may want to consider \n Health Management Services  each vendor offers assistance with health care services such as disease management, case management and behavioral health. Please refer to your Plan option for additional details on programs offered \n Nurse Advice Line  each vendor has a 24-hour, seven days a week (including holidays) nurse advice line that is available to assist you in making informed decisions about your health. You can call for professional medical advice regarding medical situations. Check with your health plan option for the telephone number \n \ndecision guide 2009 \n \n2 \n \n State Health Benefit Plan \nThe Georgia Department of Community Health (DCH), which administers the State Health Benefit Plan (SHBP), continually seeks to offer high-quality, affordable health coverage. Keep in mind, however, that you are the manager of your health care needs, and in turn, must take the time to understand your Plan benefit choices in order to make the best decisions for you and your family. \nLet's start by talking about how the SHBP works. It is a self-funded plan, which means that all expenses are paid by employee premiums and employer funds. Approximately 75 percent of the cost is funded by your employer, with you paying approximately 25 percent. \nPeople who do not understand their health coverage pay more, according to the American Medical Association. To help you better understand your Plan and save your health care dollars, we have prepared a few points for you to consider. \nWhat can you do to help manage your health care costs? \nUnderstand Your Options  Compare all Plan Options, considering both the premium and out-of-pocket costs that you may incur. Web sites and phone numbers are listed on the inside of the front cover of the Decision Guide if you need more information. \nConsider Enrolling in a Flexible Spending Account (FSA)  A FSA (also referred to as a health care spending account) helps you save tax dollars, approximately 2645 percent depending on your tax situation. By electing to use a FSA, you may set aside up to $5,040 annually to cover health-related treatments for yourself and your dependents. Eligible expenses include deductibles, co-insurance, over-the-counter items for medical purposes and costs for certain procedures not covered under your health plan. The benefit of this account is that you are able to pay for these out-of-pocket costs with tax-free dollars! Contact your Benefit Coordinator for more information. \nBecome a More Proactive Consumer of Health Care  Most people do not realize how much their treatments, medicines and tests cost. \nSteps you can take include: \n Keep a list of all medications you take \n Shop in-network providers and pharmacies \n Find out what your drugstore charges for a drug \n Make sure all procedures are pre-certified, if required \n Make sure you get the results of any test or procedure \n Understand what will happen if you need surgery \n Check your Explanation of Benefits (if provided under your plan option) and if something does not make sense or seems to cost too much, ask your provider about it \nThese and other steps you take will help manage healthcare expenses, reduce your out-of-pocket costs and those of the Plan. In addition, these steps will help in keeping premium costs down. \n \nABOUT SHBP 3 \n \ndecision guide 2009 \n \n decision guide 2009 \n \nELIGIBILITY INFORMATION 4 \n \nEligibility Information \nAll SHBP options have the same eligibility requirements. A summary is listed below. \nFor You \nYou are eligible to enroll yourself and your eligible dependents for coverage if you are:  A full-time employee of the state of Georgia, the Georgia General Assembly, or \nan agency, board, commission, department, county administration or contracting employer that participates in the SHBP, as long as:  You work at least 30 hours a week consistently, and  Your employment is expected to last at least nine months. Not Eligible: Student employees or seasonal, part-time or short-term employees.  A certified public school teacher or library employee who works half-time or more, but not less than 17.5 hours a week  Not Eligible: Temporary or emergency employees  A non-certified service employee of a local school system who is eligible to participate in the Teachers Retirement System or its local equivalent. You must also work at least 60 percent of a standard schedule for your position, but not less than 20 hours a week  An employee who is eligible to participate in the Public School Employees' Retirement System as defined by Paragraph 20 of Section 47-4-2 of the Official Code of Georgia, Annotated. You must also work at least 60 percent of a standard schedule for your position, but not less than 15 hours a week  A retired employee of one of these listed groups who was enrolled in the Plan at retirement and is eligible to receive an annuity benefit from a state-sponsored or staterelated retirement system. See the SPD for more information  An employee in other groups as defined by law \nFor Your Dependents \nThe SHBP covers dependents who meet SHBP guidelines and requires eligibility documentation before SHBP can send dependents' notification of coverage to the health plans. \nEligible dependents are: \n Your legally married spouse, as defined by Georgia Law \n Your never-married dependent children who are: \n1. Natural or legally adopted children under age 19, unless they are eligible for coverage as employees. Children that are legally adopted through the judicial courts become eligible only after they are placed in your physical custody \n2. Stepchildren under age 19 who live with you at least 180 days per year and for whom you can provide documentation satisfactory to the Plan that they are your dependents \n3. Other children under age 19 if they live with you permanently and legally depend on you for financial support  as long as you have a court order, judgment or other satisfactory proof from a court of competent jurisdiction \n \n ELIGIBILITY INFORMATION \n \n4. Your natural children, legally adopted children or stepchildren, who are physically or mentally disabled prior to reaching age 26 and who depend on you for primary support \n5. Your natural children, legally adopted children or stepchildren or other children ages 19 through 25 from categories 1, 2, or 3 above who are registered full-time students at accredited secondary schools, colleges, universities or nurse training institutions and, if employed, who are not eligible for a medical benefit plan from their employer. The number of credit hours required for full-time student status is defined by the school in which the child is enrolled. \nDocumentation Confirming Eligibility for Your Spouse or Dependents \nSHBP requires documentation verifying the eligibility of dependents covered under the plan. You must submit the documentation requested by the Plan in order to cover the dependent. No health claims will be paid until the documentation is received and approved by SHBP. However, do not delay submission of your enrollment form if the required documentation is not readily available as the enrollment form must be submitted to your personnel/benefit coordinator within 31 days of hire or a qualifying event. \nAcceptable documentation: \n Spouse: A copy of your certified marriage certificate or a copy of your most recent Federal tax Return (filed jointly with spouse) including legible signatures for you and your spouse with financial information blacked out \n Natural child: A copy of the certified birth certificate listing the parents by name or a letter of confirmation of birth for newborns. Birth cards without the parents' names are not acceptable \n Stepchild: 1) A copy of the certified birth certificate showing your spouse is the natural parent; 2) A copy of the certified marriage certificate showing the natural parent is your spouse; and 3) A notarized statement that the dependent lives in your home at least 180 days per year \n Other children: 1) A court order, judgment, adoption papers, or other satisfactory proof from a court of competent jurisdiction, or as prescribed by law, and 2) An affidavit that the dependent depends on you for support and lives in your home at least 180 days per year \nIn addition to the above documentation, SHBP requires further documentation to verify the eligibility if the child is age 19 or older. \n Student: For students age 19 through 25, a certification letter from the school's registrar. This letter must include: 1) Enrollment date(s) for both current and previous quarters or semesters, 2) Number of credit hours taken each quarter or semester, and 3) Enrollment status (full-time or part-time) for each quarter or semester. Letters of acceptance can be submitted to temporarily extend coverage for students who graduate from high school in May and plan to attend college for the Fall semester or students transferring between colleges \n Disabled dependent: Medical documentation of your child's disability must be received and approved by SHBP prior to coverage being granted \n \nhealth tip: \nIf your child is turning 19 and is a full-time student or disabled, you may be able to continue his/her coverage, provided you submit the proper documentation. \n \ndecision guide 2009 \n \n5 \n \n ELIGIBILITY INFORMATION \nPlease note:  The employee's Social Security Number must be written on each document so we can \nmatch your dependents to your record  Do not send original documents as no documents will be returned to you  SHBP will allow members to submit verification of their dependent's eligibility any \ntime during the Plan Year; however, no claims will be paid until the documentation is received and approved by SHBP \nMaking Changes When You Have a Qualifying Event \nIf you experience a qualifying event, you may be able to make changes for yourself and your dependents, provided you request the change prior to or within 31 days after the qualifying event. Also, your requested change must correspond to the qualifying event. For a complete description of qualifying events, see your SPD. You can contact the Eligibility Unit for assistance at 800-610-1863 or in the Atlanta area at 404-656-6322. \nQualifying events include, but are not limited to: \n Birth or adoption of a child or placement for adoption  Change in residence by you, your spouse or dependents that results in ineligibility for \ncoverage 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 \nGeneral Information and Enrollment \nBefore You Enroll \nYou should:  Read the current Decision Guide and SPD to understand your Health Plan Options \nprior to making your health election  Contact your employer or payroll location Benefit Coordinator for assistance if you have \nbenefit questions or you may go to www.dch.georgia.gov/shbp_plans  Read and understand the SHBP Tobacco and Spousal Surcharge Policies, and answer \nall questions regarding these surcharges. If you fail to answer the questions, the surcharge(s) will apply for the 2009 Plan Year unless you experience a qualifying event  Gather eligibility verification documents for all dependents for whom coverage has been requested to submit within the required time frame  Understand the election you make will be valid for the 2009 Plan Year unless you experience a qualifying event  Additional options will be available to you during the Fall Open Enrollment for coverage effective January 1, 2010 \n6 \n \ndecision guide 2009 \n \n GENERAL INFORMATION \n \nHealth Benefit Cost Estimators \nChoosing the right health plan is an important decision and CIGNA and UHC each provide a Plan Cost Estimator (PCE) tool to assist you. The PCEs offer you a simple way to help determine which option is best for you and your family. These online tools let you compare how your out-of-pocket expenses may vary under the different health plan options available to you. \nYou can use the PCE to review cost information for prescriptions, anticipated tests and procedures. The information provided by PCE is not meant to be an endorsement of any particular health plan. The service is offered only to help you compare your estimated expenses across each health plan option. \nAccess the links to the PCE tools at the DCH Web site, www.dch.georgia.gov/shbp_plans. \n \nHow to Enroll \n \nIf you're eligible to participate in the SHBP, you become a member by enrolling either: \n As a new hire, within 31 days of your hire date. If you join the SHBP during that first 31-day enrollment opportunity, your coverage will go into effect on the first day of the month after you complete one full calendar month of employment. See your personnel/payroll office for instructions on how to enroll or if you have benefit questions, you may call the vendor directly at the telephone numbers listed on the inside of the front cover. \n As a result of a qualifying event. See Making Changes When You Have a Qualifying Event, page 6 of this guide for more details. \n \nIf you decide to become a SHBP member, you will have two major choices to make: \n1. Your coverage options: CIGNA Healthcare  CIGNA Choice Fund (HRA)  High Deductible Health Plan (HDHP)* UnitedHealthcare  Definity (HRA)  High Deductible Health Plan (HDHP)*  *These options allow you to set up a Health Savings Account. See page 12 for more information. \n \n2. Which eligible dependents would you like to have covered by SHBP? For a list of eligible dependents, refer to pages 4 and 5. \n \n3. Which coverage tier? Select the coverage tier you desire for the dependents that you choose to cover. You will be locked into the tier for the 2009 Plan Year unless you experience a qualifying event. \n \n EE = Employee \n \n EC = Employee + Child(ren) \n \n ES = Employee + Spouse \n \n EF = Employee + Child(ren) + Spouse \n \nNOTE: Additional options will be available to you during the Fall Open Enrollment period for coverage effective January 1, 2010. \n \nhaving a baby? adopting a child? getting \nmarried or divorced? \nRemember you only have 31 days from the qualifying event to add or delete dependents. Don't miss the deadline waiting \nfor documentation. \n7 \n \ndecision guide 2009 \n \n GENERAL INFORMATION \n \nhealth tip: \nRegular exercise can help direct your attention away from daily stress and may contribute to a feeling of mental wellbeing. \n \nWhat Happens if I Have Other Insurance? \nYou or your covered dependents may have medical coverage under more than one plan. In this case, coordination of benefits (COB) provisions apply. \nWhen SHBP benefits are coordinated, the SHBP does not pay more than 100 percent of the allowed amount. Non-covered services or items, penalties and amounts balance billed are not part of the allowed amount and are the member's responsibility. \nIt is important that you notify the health insurance vendor you selected if you have other group coverage to prevent incorrect processing of any claims. For further information about COB rules, refer to the SPD or contact your vendor directly. \nCOBRA Rights \nThe Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986 requires that the Plan offer you, 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 you, or one of your dependents, may continue the coverage is based on the qualifying event. For further information, please refer to your SPD. \nSurcharge Policy \nYou should be aware that SHBP charges a Tobacco and Spousal Surcharge. A $40 tobacco surcharge will be added to your monthly premium if you or any of your covered dependents have used tobacco products in the previous 12 months. A $30 spousal surcharge will be added to your monthly premium if you have elected to cover your spouse and your spouse is eligible for coverage through his/her employment but chose not to take it. If your spouse is eligible for coverage with SHBP through his/her employment, the spousal surcharge will be waived. \nYou will automatically be charged the applicable surcharges if you fail to answer all questions concerning the surcharges. The surcharges will apply to your premium until the next Plan Year. \n \ndecision guide 2009 \n \n8 \n \n GENERAL INFORMATION \n \nHow to Remove Surcharges \nTobacco \nYou may have the tobacco surcharge removed if: \n You quit using tobacco products and attend a tobacco cessation program sponsored by the American Cancer Society, the American Lung Association, or other approved programs listed on the DCH Web site. Check the DCH Web site for any updates at www.dch.georgia.gov/shbp_plans \n You will receive an attendance certification form. You and the representative should both sign this form \n Complete and submit the appropriate Tobacco Affidavit Form and attendance certification form to your payroll location Benefit Coordinator to complete the required deduction information. The Affidavit Form is available at www.dch.georgia.gov/shbp_plans \nSpousal \nSHBP charges a spousal surcharge for SHBP members who cover their spouses. You may have the spousal surcharge removed: \n If your spouse becomes covered by his/her employer's health benefit plan; and \n If you make the request and provide proof within 31 days of the effective date of the other coverage. \nNo refund in premiums will be made for previous health deductions that included the surcharge amounts. \nState Health Benefit Plan Medicare Policy and Retirement \nFederal Law requires SHBP to pay primary benefits for active employees and their dependents. Active members or their covered dependents may choose to delay Medicare enrollment. Termination of active employment is a qualifying event for enrolling in Medicare without penalty (except HDHP, see page 18). \nIf you want to have health insurance under SHBP when you retire, you must enroll for coverage for you and eligible dependents during the OE period prior to your retirement. \nOnce retired, you will have an annual Retiree Option Change Period that allows you to change your Plan option only. You may add dependents only if you experience a qualifying event and request the change within 31 days and provide the documentation required by SHBP. \nFor more information, refer to the DCH Web site at www.dch.georgia.gov/shbp_plans \n \nhealth tip: \nEating a low-fat, lowsugar diet with plenty of fruits and vegetables can boost your physical \nand mental health. \n \ndecision guide 2009 \n \n9 \n \n UNDERSTANDING YOUR PLAN OPTIONS \n \nshbp tip: \nBe on the watch for prize drawings in 2009 for completing your health assessment. \n \nUnderstanding Your Plan Options \nOn the following pages, you will find a brief description of each option and important considerations to help you select the best option for you. To help you understand the information in this section, a few key terms are defined below. \nImportant Terms to Understand \nAllowed Amount  A dollar amount the Plan uses to calculate benefits payable. \nBalance Billing  A dollar amount charged by the provider that is over the Plan's allowed amount for the care received. You are subject to balance billing when you receive services from non-participating providers, including emergency services. \nCo-insurance Amount  The percentage of the Plan's allowed amount paid by a Plan member. The SHBP generally pays 90 percent to 60 percent of the Plan's allowed amount for covered services, so your co-insurance is between 10 percent and 40 percent. \nCovered Services  Services for medically necessary care that are eligible for reimbursement under the Plan. \nDeductible  A specified dollar amount, which varies by Plan option, for specified covered services that you must pay out-of-pocket each Plan Year before the option pays a benefit. Depending on your coverage option, the deductible may not apply to some services. \nEmergency Care  Care provided when a sudden, severe and unexpected illness or injury happens that could be life threatening or result in permanent impairment of bodily functions if not treated immediately. \nLifetime Maximum  The dollar amount that each Plan member may receive in benefits from the SHBP during his or her lifetime. \nOut-of-Pocket Limits  The maximum amount you would have to pay out of your pocket each Plan Year for covered services. Once you meet your out-of-pocket limit for the Plan Year, the Plan pays 100 percent of the allowed amounts for most covered services for the rest of the Plan Year. Your out-of-pocket costs for premiums and noncovered charges are not applied to the limit. The deductible and co-insurance are applied to your annual out-of-pocket limit. \nParticipating Provider  Any physician, hospital or other health-service professional or facility that offers covered services and that has joined the network of a HRA or HDHP Plan Option. Participating providers may not balance bill Plan members for covered services. \nContact the Member Services unit for each option if you need more detail. Telephone numbers are on the inside front cover. You also may access an SPD online at: www.dch.georgia.gov/shbp_plans. \n \ndecision guide 2009 \n \n10 \n \n UNDERSTANDING YOUR PLAN OPTIONS \n \nTo maximize your health benefits, it is more important to understand how each SHBP option works. This brief overview will help you determine which option best fits your health care needs. Keep in mind, you will have a total of four choices. You must select either an option offered by CIGNA Healthcare or UnitedHealthcare. During next Open Enrollment, you may have additional options available. Information is available at www.dch.ga.gov/shbp_plans \nConsumer Driven Health Plan Options \nThe Health Reimbursement Arrangement (HRA) and the High Deductible Health Plan (HDHP) are consumer driven health plan options. These options are structured to provide lower out-of-pocket expenses for many participants and are explained below. Participation in these options impacts your eligibility and the amount you can contribute to a FSA. Additional information to assist you with understanding the rules and differences can be found on page 17 of this Decision Guide. \nHealth Reimbursement Arrangement (HRA) \nThe HRA is a consumer driven health care option whose plan design offers you a different approach for managing your health care needs. It is similar to that of a PPO with an in-network and out-of-network benefit, except SHBP funds dollar credits to your HRA each year to provide first dollar coverage for eligible health care and pharmacy expenses. The amount in your HRA is used to reduce the deductible and maximum outof-pocket. After satisfying your deductible, you will pay your coinsurance amount until you reach your out-of-pocket maximum, at which time SHBP will pay 100 percent of eligible expenses for the remainder of the Plan Year. \nConsiderations: \n The plan offers unlimited wellness benefits based on age and gender national guidelines when seeing in-network providers only \n There is not a separate deductible and co-insurance for out-of-network expenses \n Unused dollars in your HRA account roll over to the next Plan Year if you are still participating in this option \n HRA dollar credits are part of this option only and can only be used with the HRA option \n Unused dollars in the HRA account will be forfeited if you change to a non HRA option during the Open Enrollment, a qualifying event occurs, or you terminate employment; even if you re-enroll in a subsequent Plan Year \n If you enroll during the year, your HRA dollar credits will be pro-rated based on the number of months remaining in the Plan Year (which is calendar) \n If you experience a qualifying event and change tiers, your new HRA dollar credits only will be pro-rated based on the number of months remaining in the Plan Year; the deductible and out-of-pocket maximum are not adjusted \n If you experience a qualifying event and change tiers from family to another tier, your HRA dollars will not be reduced \n Certain drug costs are waived if you participate in one of the Disease State Management Programs (DSM) for Diabetes, Asthma and Coronary Artery Disease \n \nshbp tip: \nTo save money, try overthe-counter brands. \nAn HRA member with itchy eyes received a doctor's prescription \nfor drops that cost $82. Her pharmacist helped find \n$12 over-the-counter drops that did the same thing. Savings to her HRA  $70. \n \ndecision guide 2009 \n \n11 \n \n UNDERSTANDING YOUR PLAN OPTIONS \nHigh Deductible Health Plan with a Health Savings Account \nThe High Deductible Health Plan (HDHP) design is very similar to that of a PPO with an in-network and out-of-network benefit. \nIn return for a low monthly premium, you must satisfy a high deductible that applies to all health care expenses except preventive care. If you have family coverage, you must meet the ENTIRE family deductible before benefits are payable for any family member. You pay co-insurance after you have satisfied the deductible rather than set dollar co-payments for medical expenses and prescription drugs. Also, you may qualify to start a Health Savings Account (HSA) to set aside tax-free dollars to pay for eligible health care expenses now or in the future. HSAs typically earn interest and may even offer investment options. See the benefits comparison chart that starts on page 13 to compare benefits under the HDHP to other Plan options. \nConsiderations: \n This option offers 100 percent unlimited wellness benefits based on national age and gender guidelines \n You must satisfy a separate in-network and out-of-network deductible and out-ofpocket maximum \n You pay co-insurance after meeting the entire family deductible for all medical expenses and prescriptions \nHealth Savings Account \nAn HSA is like a personal savings account with investment options for health care, except it's all tax-free. You may be eligible to participate in an HSA that is offered through the State of Georgia Flexible Benefits Program or by your employer. Participation through payroll deductions allows your contributions to be pre-tax. If your employer does not offer an HSA, you may still open an HSA with an independent HSA administrator/custodian. You may locate HSA Administrators at www.healthsavingsinfo.com/finding.htm \nYou may open an HSA if you enroll in the SHBP HDHP and do not have other coverage through: 1) Your spouse's employer's plan 2) Medicare 3) Medicaid 4) FSA also known as the General Purpose Flexible Spending Account (GPFSA), or a General Purpose Health Care Spending Account or 5) any other non-qualified medical plan.  You can make contributions to a State of Georgia HSA only when enrolled in the SHBP \nHDHP  You can contribute up to $3,000 single, $5,950 family as long as you are enrolled in \nthe HDHP. These limits are set by federal law. Unused money in your account carries forward to the next Plan Year and earns interest  HSA dollars can be used for eligible health care expenses even if you are no longer enrolled in the HDHP or any SHBP coverage  HSA dollars can be used to pay for health care expenses (medical, dental, vision, over-thecounter medications) that the IRS considers tax-deductible that are NOT covered by any health plan (see IRS Publication 502 at www.irs.gov)  HSA accounts cannot be combined with a FSA also known as a General Purpose Healthcare Spending Account (GPHCSA), but can be combined with a limited purpose flexible spending account. Contact the State Personnel Administration or your employer  You can contribute additional dollars if you are 55 or older (see IRS Publication 502 at www.irs.gov) \n12 \n \ndecision guide 2009 \n \n BENEFITS COMPARISON \n \nBenefits Comparison \n \nSchedule of Benefits for You and Your Dependents for January 1, 2009  \n \nDecember 31, 2009* \n \nHIGH DEDUCTIBLE OPTION \n \nIn-network CIGNA Healthcare, UnitedHealthcare \n \nOut-of-network CIGNA Healthcare, UnitedHealthcare \n \nHRA OPTION \n \nIn-network \n \nOut-of-network \n \nCIGNA Healthcare, CIGNA Healthcare, \n \nUnitedHealthcare UnitedHealthcare \n \nCovered Services \n \nThe Plan Pays: \n \nThe Plan Pays: \n \nDeductibles: EE = Employee ES = Employee + Spouse EC = Employee + Child(ren) EF = ECmhipldlo(ryeene) + Spouse + \n \n$1,150 $2,300 $2,300 $2,300 \n \n$2,300 $4,600 $4,600 $4,600 \n \n$1,000* $1,750* $1,750* $2,500* *HRA credits will reduce this amount. \n \nOut-of-Pocket Maximum: EE = Employee ES = Employee + Spouse EC = Employee + Child(ren) EF = ECmhipldlo(ryeene) + Spouse + \n \n$1,700 $2,900 $2,900 $2,900 \n \n$3,800 $7,000 $7,000 $7,000 \n \n$2,000* $3,250* $3,250* $4,500* *HRA credits will reduce this amount. \n \nHRA Credits: EE = Employee ES = Employee + Spouse EC = Employee + Child(ren) EF = ECmhipldlo(ryeene) + Spouse + \nMaximum Lifetime Benefit (combined for all SHBP Options) \nPre-Existing Conditions, Limitations or Exclusions (First year in Plan only, subject to HIPAA) \n \nNone $2 million \nNone \n \n$500 $1,000 $1,000 $1,500 \n$2 million \nNone \n \nLifetime Benefit Limit for Treatment of: (combined for PPO Option and HDHP)  Temporomandibular joint \ndysfunction (TMJ) \nPhysicians' Services \nPrimary Care Physician or Specialist Office or Clinic Visits: Treatment of illness or injury \n \n$1,100 \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n$1,100 \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nPrimary Care Physician or Specialist Office or Clinic Visits for the Following:  Wellness care/preventive \nhealth care  Annual gynecological exams \n(these services are not subject to the deductible) \n \n100% coverage; not subject to deductible \n \nNot covered; Charges do not apply to deductible or annual out-ofpocket limits \n \n100% coverage; not subject to deductible \n \nNot covered; Charges do not apply to deductible or annual out-ofpocket limits \n \ndecision guide 2009 \n \n*HMO and PPO options will be available at the next Open Enrollment period. \n \n13 \n \n BENEFITS COMPARISON \nPhysicians' Services Maternity Care (prenatal, delivery and postpartum) \nPhysician Services Furnished in a Hospital  Visits; surgery in general, \nincluding charges by surgeon, anesthesiologist, pathologist and radiologist \n \nHIGH DEDUCTIBLE OPTION \n \nIn-network CIGNA Healthcare, UnitedHealthcare \n \nOut-of-network CIGNA Healthcare, UnitedHealthcare \n \nThe Plan Pays: \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nHRA OPTION \n \nIn-network \n \nOut-of-network \n \nCIGNA Healthcare, CIGNA Healthcare, \n \nUnitedHealthcare UnitedHealthcare \n \nThe Plan Pays: \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nPhysician Services for Emergency Care Non-emergency use of the emergency room not covered \nOutpatient Surgery--  When billed as office visit \n When billed as outpatient surgery at a facility \nAllergy Shots and Serum \n \n90% coverage; subject to in-network deductible \n \n90% coverage; subject to deductible \n90% coverage; subject to deductible \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n60% coverage; subject to deductible \n60% coverage; subject to deductible \n \n90% coverage; subject to deductible \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n90% coverage; subject to deductible \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n60% coverage; subject to deductible \n \nHospital Services \nInpatient Services  Inpatient care, delivery and \ninpatient short-term acute rehabilitation services \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \ndecision guide 2009 \n \n Well-newborn care \nOutpatient Surgery-- Hospital/facility \nEmergency Care--Hospital  Treatment of an emergency \nmedical condition or injury  Non-emergency use of the \nemergency room not covered 14 \n \n90% coverage; subject to deductible \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n60% coverage; subject to deductible \n \n90% coverage; subject to in-network deductible \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n90% coverage; subject to deductible \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n60% coverage; subject to deductible \n \n90% coverage; subject to deductible \n \n HIGH DEDUCTIBLE OPTION \n \nIn-network CIGNA Healthcare, UnitedHealthcare \n \nOut-of-network CIGNA Healthcare, UnitedHealthcare \n \nOutpatient Testing, Lab, etc. \n \nThe Plan Pays: \n \nLaboratory; X-Rays; Diagnostic Tests; Injections-- including medications covered under medical benefits--for the treatment of an illness or injury \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nBehavioral Health \nMental Health and Substance Abuse Inpatient Facility and Partial Day Hospitalization NOTE: All services require prior authorization. \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nBENEFITS COMPARISON \n \nHRA OPTION \n \nIn-network \n \nOut-of-network \n \nCIGNA Healthcare, CIGNA Healthcare, \n \nUnitedHealthcare UnitedHealthcare \n \nThe Plan Pays: \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nMental Health and Substance Abuse Outpatient Visits and Intensive Outpatient NOTE: All services require prior authorization \nDental \nDental 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. \nTemporomandibular Joint Syndrome (TMJ) NOTE: Coverage for diagnostic testing and non-surgical treatment up to $1,100 per person lifetime maximum benefit. \n \n90% coverage; subject to deductible \n90% coverage; subject to deductible \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n60% coverage; subject to deductible \n60% coverage; subject to deductible \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nVision \nRoutine Eye Exam NOTE: Limited to one eye exam every 24 months \nOther Coverage \nAmbulance Services for Emergency Care NOTE: \"Land or air ambulance\" to nearest facility to treat the condition. \nUrgent Care Services \n \n90% coverage; not subject to deductible \n \nEye exam not covered \n \n90% coverage; subject to in-network deductible \n \n90% overage; subject to deductible \n \n60% coverage; subject to deductible \n \n100% coverage; not subject to deductible \n \nEye exam not covered \n \n90% coverage; subject to deductible \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \ndecision guide 2009 \n \nHome Health Care Services NOTE: Prior approval required \n \n90% overage; subject to deductible \n \n60% coverage; subject to deductible \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n15 \n \n BENEFITS COMPARISON \nOther Coverage Skilled Nursing Facility Services \nNOTE: Prior approval required \n \nHIGH DEDUCTIBLE OPTION \n \nIn-network CIGNA Healthcare, UnitedHealthcare \n \nOut-of-network CIGNA Healthcare, UnitedHealthcare \n \nThe Plan Pays: \n \n90% coverage up to 120 days per Plan Year; subject to deductible \n \nNot covered \n \nHospice Care NOTE: Prior approval required \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nDurable Medical Equipment (DME)--Rental or purchase \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \ndecision guide 2009 \n \nOutpatient Acute Short-Term Rehabilitation Services \n Physical Therapy  Speech Therapy  Occupational Therapy  Other short term \nrehabilitative services \nChiropractic Care NOTE: Coverage for up to a maximum of 20 visits per Plan Year. Transplant Services NOTE: Prior approval required. \nPharmacy Tier 1 Co-payment \nNOTE: No Tiers in HRA Option \nTier 2 Co-payment \nTier 3 Co-payment \n16 \n \n90% coverage up to 40 visits per therapy per Plan Year; subject to deductible (not to exceed a total of 40 visits combined, including any out-of-network visits) \n \n60% coverage up to 40 visits per therapy per Plan Year; subject to deductible (not to exceed a total of 40 visits combined, including any in-network visits) \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nUHC  90% coverage at a designated transplant facility; Subject to deductible \n \nNot covered \n \nCIGNA  100% at Lifesource Centers otherwise 90%; subject to deductible \n \nCIGNA  No coverage \n \n80% coverage; subject to deductible $10 min. /$100 max. \n \nNot covered \n \n80% coverage; subject to deductible $10 min. /$100 max. \n \nNot covered \n \n80% coverage; subject to deductible $10 min. /$100 max. \n \nNot covered \n \nHRA OPTION \n \nIn-network \n \nOut-of-network \n \nCIGNA Healthcare, CIGNA Healthcare, \n \nUnitedHealthcare UnitedHealthcare \n \nThe Plan Pays: \n \n90% coverage; up to 120 days per Plan Year; subject to deductible \n \nNot covered \n \n90% coverage; subject to deductible \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n60% coverage; subject to deductible \n \n90% coverage; subject to deductible; up to 40 visits per Plan Year (not to exceed a total of 40 visits combined, including any out-of-network visits) \n \n60% coverage; subject to deductible; up to 40 visits per Plan Year (not to exceed a total of 40 visits combined, including any in-network visits) \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \nUHC  90% coverage at a designated transplant facility; Not subject to deductible \n \n60% coverage; subject to deductible \n \nCIGNA  100% at Lifesource Centers otherwise 90%; not subject to deductible \n \nCIGNA  No coverage \n \n90% coverage; subject to deductible \n \n60% coverage; subject to deductible \n \n HEALTH CARE ACCOUNTS \n \nHRA, HSA and Flexible Spending Account (FSA) Considerations \n \nHRA and HSA participation impacts your eligibility and amount of dollars you can contribute to a FSA, also known as a Healthcare Spending Account. This chart highlights the rules and differences. \n \nHRA \n \nHSA \n \nOverview \n \nA tax-exempt account that is funded for qualified medical expenses. Can be funded by employer only. \n \nA tax-exempt custodial account that exclusively pays for qualified medical expenses of the employee and his or her dependents. Can be funded by employee, employer, or other party. \n \nCan I have other coverage and take advantage of this benefit? \n \nAvailable to SHBP members enrolled in an HRA. The benefits chart for amounts funded by SHBP. \nYes. \n \nAvailable to SHBP members who elect HDHP. An HSA is available under the Flexible Benefits Program, offered through the State Personnel Administration, your employer, or you may participate as an individual. SHBP does not fund these amounts. \nNo other general medical insurance coverage permitted. You cannot be enrolled in Medicare Part A or Part B. \n \nCan I participate in a Flexible Spending Account? \n \nYou may enroll in a General Purpose Flexible Spending Account. You may use a FSA for uncovered or unreimbursed portions of qualified medical costs. \n \nYou may enroll in a Limited Purpose FSA covering dental and vision if you are enrolled in a Health Savings Account. \n \nWho owns the money in these accounts? \n \nSHBP. Money reverts back to SHBP upon loss of SHBP HRA coverage. \n \nThe employee. \n \nCan these dollars be rolled \n \nYes. \n \nYes. \n \nover each year? \n \nIs there a monthly service \n \nNo. \n \ncharge? \n \nYes, $3.00 per account per month with the SPA Flexible Benefits Program. For other HSA accounts check with your HSA administrator. \n \nWhat is the order in using these accounts? \nCan I take it with me? \n \nHRA must be used before using the FSA.* \nUnused amounts can be distributed until depleted to pay for claims incurred before termination. \n \nCan only use Limited Purpose FSA with the HSA, but it doesn't matter which is used first. \nFund disbursement is not tied to individual's employment. Unused amounts can be distributed taxfree for qualified medical expenses. Subject to income and excise tax for non-qualified expenses. \n \ndecision guide 2009 \n \n*When determining how much money to set aside in an FSA, employees should consider the first $500 (employee) or $1,000 {employee + spouse OR employee + child(ren) OR $1,500 (employee + spouse + child(ren)} of qualified medical expenses will be covered by the HRA. \n17 \n \n IMPORTANT NOTICE \nTwo Peachtree Street Atlanta, GA 30303 (404) 656-6322  (800) 610-1863 \n \nOctober 1, 2008 \n \nAbout Your Prescription Drug Coverage with PPO, United Healthcare HMO, UnitedHealthcare Definity, Kaiser Permanente, CIGNA Healthcare Open Access Plus PPO, CIGNA Healthcare Open Access Plus In-Network HMO, CIGNA Healthcare Choice Fund HRA and Medicare \nFor Plan Year: January 1December 31, 2009 \nPlease 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. \n1. 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. \n2. The State Health Benefit Plan has determined that the prescription drug coverage offered by the UnitedHealthcare PPO, United Healthcare HMO, UnitedHealthcare Definity, Kaiser Permanente, CIGNA Healthcare Open Access Plus PPO, CIGNA Healthcare Open Access Plus In-Network HMO, CIGNA Healthcare Choice Fund HRA offered under SHBP is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is considered Creditable Coverage. \nBecause your existing coverage is, on average, at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. \nYou can join a Medicare drug plan when you first become eligible for Medicare and each year from November 15th through December 31st. This may mean that you may have to wait to join a Medicare drug plan and that you may pay a higher premium (a penalty) if you join later. You may pay that higher premium (a penalty) as long as you have Medicare prescription drug coverage. However, if you lose creditable prescription drug coverage, through no fault of your own, you will be eligible for a sixty (60) day Special Enrollment Period (SEP) because you lost creditable coverage to join a Part D plan. \nIn addition, if you lose SHBP coverage voluntarily, you will be eligible to join a Part D plan at that time using an Employer Group Special Enrollment Period. You should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. \nIf you decide to join a Medicare drug plan, your State Health Benefit Plan coverage will be affected. See below for more information about what happens to your current coverage if you join a Medicare drug plan. You can keep your SHBP coverage if you elect Part D and SHBP will coordinate with Part D coverage. Your premiums will also be reduced by each Part of Medicare you have. You should send a copy of your Medicare cards to SHBP at P. O. Box 38342, Atlanta, GA 30334. \n18 \n \ndecision guide 2009 \n \n IMPORTANT NOTICE \nIf you do decide to join a Medicare drug plan and drop your coverage with the State Health Benefit Plan, be aware that you and your dependents can not get this coverage back if you are a retiree. \nYou should also know that if you drop or lose your coverage with SHBP and don't join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. \nIf you go 63 continuous days or longer without prescription drug coverage that's at least as good as Medicare's prescription drug coverage, your monthly premium may go up by at least 1% of the base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without coverage, your premium may consistently be at least 19% higher than the base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to join. \nFor More Information about this Notice or Your SHBP Current Prescription Drug Coverage... \nContact the SHBP Eligibility Unit at (404) 656-6322 or (800) 610-1863. NOTE: You'll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through the State Health Benefit Plan changes. You also may request a cop \nFor More Information about Your Options under Medicare Prescription Drug Coverage... \nMore detailed information about Medicare plans that offer prescription drug coverage is in the Medicare \u0026 You handbook. You will get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. \nFor 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 \nMedicare \u0026 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 \nIf 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). \nRemember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and whether or not you are required to pay a higher premium (a penalty). \nDate: October 1, 2008 Name of Sender: State Health Benefit Plan Office: Call Center Address: P. O. Box 38342, Atlanta, GA 30334 Phone Number: (404) 656-6322 or (800) 610-1863 \n19 \n \ndecision guide 2009 \n \n IMPORTANT NOTICE \nOctober 1, 2008 \nTwo Peachtree Street Atlanta, GA 30303 (404) 656-6322  (800) 610-1863 \nImportant Notice from the SHBP about Your Prescription Drug Coverage and Medicare \nAbout Your Prescription Drug Coverage with the CIGNA Healthcare Open Access Plus and UnitedHealthcare High Deductible Health Plan and Medicare \nFor Plan Year: January 1December 31, 2009 \nPlease read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with the State Health Benefit Plan (SHBP) and about your options under Medicare's prescription drug coverage. This information can help you decide whether you want to join a Medicare drug plan. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. \n1. 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. \n2. The State Health Benefit Plan (SHBP) has determined that the prescription drug coverage under the High Deductible Health Plan (HDHP) Option, is on average for all plan participants, NOT expected to pay out as much as standard Medicare prescription drug coverage pays and is considered Non-Creditable Coverage. This is important, because most likely, you will get more help with your drug costs if you join a Medicare drug plan, than if you only have prescription drug coverage through the HDHP offered by SHBP. \n3. You have decisions to make about Medicare prescription drug coverage that may affect how much you pay for that coverage, depending on if and when you join. Read this notice carefully as it explains your options. \nConsider joining a Medicare drug plan. You can keep your HDHP coverage offered by the SHBP. You can keep the coverage regardless of whether it is good as Medicare drug plan. However, because your existing coverage is, on average, NOT at least as good as standard Medicare prescription drug coverage, you may pay a higher premium ( a penalty) if you later decide to join a Medicare drug plan. \nYou can join a Medicare drug plan when you first become eligible for Medicare and each year from November 15th through December 31st. This may mean that you may have to wait to join a Medicare drug plan and that you may pay a higher premium (a penalty) if you join later. You may pay that higher premium (a penalty) as long as you have Medicare prescription drug coverage. However, if you lose your HDHP coverage under SHBP; you will be eligible to join a Part D plan at that time using an Employer Group Special Enrollment Period. \nYou Need to Make a Decision \nWhen you make your decision, you should compare your current coverage, including which drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. \nIf you decide to join a Medicare drug plan, your HDHP coverage under SHBP will be affected. See below for more information about what happens to your current coverage if you join a Medicare drug plan. \n20 \n \ndecision guide 2009 \n \n IMPORTANT NOTICE \nIf you enroll in Medicare Part D when you become eligible for Medicare Part D, you can keep your HDHP coverage even if you elect Part D and the HDHP will coordinate benefits with the Part D coverage. \nIf you do decide to join a Medicare drug plan and drop your HDHP coverage under SHBP, be aware that you and your dependents will not be able to get your SHBP coverage back if you are a retiree. \nYou should also know that if you drop or lose your HDHP coverage with SHBP and don't join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. \nIf you go 63 continuous days or longer without prescription drug coverage that's at least as good as Medicare's prescription drug coverage, your monthly premium may go up by at least 1 percent of the base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without coverage, your premium may consistently be at least 19 percent higher than the base beneficiary premium. You may have to pay this higher premium (penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to join. \nFor More Information about this Notice or Your Current Prescription Drug Coverage... \nContact the SHBP Call Center at (404) 656-6322 or (800) 610-1863 for further information. NOTE: You will get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if your SHBP coverage changes. You also may request a copy. \nFor More Information about Your Options under Medicare Prescription Drug Coverage... \nMore detailed information about Medicare plans that offer prescription drug coverage is in the \"Medicare \u0026 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 \n\"Medicare \u0026 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 \nIf 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). \nDate: October 1, 2008 Name of Sender: State Health Benefit Plan Office: Call Center Address: P. O. Box 38342, Atlanta, GA 30334 Phone Number: (404) 656-6322 or (800) 610-1863 \n21 \n \ndecision guide 2009 \n \n IMPORTANT NOTICE \n \nRhonda M. Medows, MD, Commissioner \n \nSonny Perdue, Governor \n \n2 Peachtree Street, NW Atlanta, GA 30303-3159 www.dch.georgia.gov \n \nAnnual Legal Notices (No Action Required) \nWomen's Health and Cancer Rights Act \nThe Plan complies with the Women's Health and Cancer Rights Act of 1998. Mastectomy, including reconstructive surgery, is covered the same as other surgery under your Plan option. \nFollowing cancer surgery, the SHBP covers:  All stages of reconstruction of the breast on which the mastectomy has been performed  Reconstruction of the other breast to achieve a symmetrical appearance  Prostheses and mastectomy bras  Treatment of physical complications of mastectomy, including lymphedema \nNote: Reconstructive surgery requires prior approval, and all inpatient admissions require prior notification. \nFor more detailed information on the mastectomy-related benefits available under the Plan, you can contact the Member Services unit for your coverage option. Telephone numbers are on the inside front cover. \nStatement of Rights under the Newborns' and Mothers' Health Protection Act \nSHBP complies with the Statement of Rights under the Newborns' and Mothers' Health Protection Act. \nGroup health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). \n \ndecision guide 2009 \n \n22 \n \n IMPORTANT NOTICE \nHealth Insurance Portability and Accountability Act (HIPAA) Annual Notice \nThis section describes certain rights available to you under the Health Insurance Portability and Accountability Act (HIPAA) when you add a dependent to your State Health Benefit Plan (SHBP) coverage. \nThe PPO Option contains a pre-existing condition (PEC) limitation. Specifically, the Health Plan will not pay charges that are over $1,000 for the treatment of any pre-existing condition during the first 12 months of a patient's coverage, unless the patient gives satisfactory documentation that he or she has been free of treatment or medication for that condition for at least six consecutive calendar months. However, a PEC limitation does not apply to coverage for:  Pregnancy; or  Newborns or children under age 18 who are adopted or placed for adoption, if the child becomes \ncovered within 31 days after birth, adoption or placement for adoption \nIn certain situations, SHBP members and dependents can reduce the 12-month PEC limitation period. The reduction is possible by using what is called \"creditable coverage\" to offset a PEC period. Creditable coverage generally includes the health coverage you or a family member had immediately prior to joining the SHBP. Coverage under most group health plans, as well as coverage under individual health policies and governmental health programs, qualifies as creditable coverage. \nTo reduce the PEC limitation period for your own coverage, you must provide the SHBP with a certificate of creditable coverage from one or more former health plans or insurers that states when your prior coverage started and ended. Any period of prior coverage will reduce the 12-month limitation period if the time between losing coverage and the first day of your SHBP coverage does not exceed 63 days. If you are enrolling as a new hire, the 63-day period is measured from your last day of prior coverage up to your date of hire. \nTo reduce the PEC limitation period for your dependents (including your spouse), you must provide the SHBP with a certificate of creditable coverage stating when coverage started and ended for each dependent that you want to cover. Any period of prior coverage for that dependent will reduce the 12-month limitation period if no more than 63 days have elapsed between the dependent's loss of prior coverage and the first day of coverage under the SHBP (or your date of hire, if you are enrolling as a new hire). \nIf you or your dependent (including a spouse) had any break in coverage lasting more than 63 days, you or your dependent will receive creditable coverage only for the period of time after the break ended. \nWithin two years after your former coverage terminated, you have the right to obtain a certificate of creditable coverage from your employer(s) to offset the pre-existing condition limitation period under the SHBP. The SHBP will evaluate the certificate of creditable coverage or other documentation to determine whether any of the pre-existing condition limitation period will be reduced or eliminated. After completing the evaluation, the SHBP will notify you as to how the pre-existing condition limitation period will be reduced or eliminated. Please submit the certificate of creditable coverage to the Plan with your enrollment paperwork. If you require assistance in obtaining a letter from a former employer, contact your personnel/payroll office. \n23 \n \ndecision guide 2009 \n \n IMPORTANT NOTICE \n \nRhonda M. Medows, MD, Commissioner \n \nSonny Perdue, Governor \n \n2 Peachtree Street, NW Atlanta, GA 30303-3159 www.dch.georgia.gov \n \nNovember 1, 2008 \nTO: All Members of the State Health Benefit Plan \nUnder a federal law known as the Health Insurance Portability and Accountability Act of 1996 (\"HIPAA\"), certain notices must be provided to you. This letter will serve as notice to you related to the surcharge for tobacco use that the Plan will charge for coverage January 1, 2009. This memo will also serve as notice to you that the State Health Benefit Plan, (\"SHBP\") has elected to exempt SHBP from the Special enrollment periods. \nUnder HIPAA, group health plans may not discriminate on the basis of \"health status.\" However, the law also permits state and local government employers that sponsor health plans to elect to exempt a plan from this requirement for any plan that is \"self-funded\" by the employer, rather than provided through a private health insurance policy. The Department of Health and Human Resources considers tobacco use to be a \"health status.\" Therefore, the self-funded options under the SHBP have opted out of this requirement for the plan year January 1, 2009 through December 31, 2009. The election may be renewed for subsequent plan years. The purpose of this exemption is to enable the SHBP to comply with federal law in applying the tobacco use surcharge. \nTherefore, this notice informs all members of the self-funded options of the SHBP of the Plan's election to be exempt from the following provision: \nProhibitions against discriminating against individual participants and beneficiaries based upon health status. A group health plan may not discriminate in enrollment rules or in the amount of premiums or contributions; it requires an individual to pay based on certain health status-related factors: health status, medical condition (physical and mental illnesses), claims experience, receipt of health care, medical history, genetic information, evidence of insurability, and disability. \nThe exemption and this notice to not change your eligibility, your benefits, or your premiums, other than to apply the surcharge for tobacco use, if applicable. \nHIPAA also requires the Plan to provide covered employees and dependents with a \"certificate of creditable coverage\" when they cease to be covered under the Plan. There is no exemption from this requirement. The certificate provides evidence that you were covered under this Plan because you may be entitled to certain rights to reduce or eliminate a preexisting condition exclusion if you join another employer's health plan, or if you wish to purchase an individual health insurance policy. You may obtain the certificate of creditable coverage upon request. \nThe SHBP elects to be exempt from Special enrollment periods. Group health plans are required to provide special enrollment periods for individuals who do not enroll in the plan because they have other coverage, but subsequently lose that coverage. Also, if a plan provides dependent coverage, the plan must provide a special enrollment for new dependents (and the employee is not already enrolled) within 30 days after a marriage birth, adoption or placement for adoption. As a self-funded non-federal governmental group health plan, the SHBP of the Georgia Department of Community Health (\"DCH\") elects to opt-out of this option. \nIf you have any questions about this notice, you may contact: State Health Benefit Plan Attn: Surcharge P. O. Box 38342 Atlanta, GA 30334 \n24 \n \ndecision guide 2009 \n \n IMPORTANT NOTICE \n \nTwo Peachtree Street Atlanta, GA 30303 (404) 656-6322  (800) 610-1863 \n \nOctober 1, 2008 \n \nDepartment of Community Health Privacy Notice \n \nThis notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. \nThe Plan's Privacy Commitment to You \nThe Georgia Department of Community Health (DCH) understands that information about you and your family is personal. DCH is committed to protecting your information. This notice tells you how DCH uses and discloses information about you. It tells you your rights and the Plan's requirements about your information. \nUnderstanding the Type of Information that the Plan Has \nYour employer (state agency, school system authority, etc.) sent information about you to DCH. This information included your name, address, birth date, phone number, Social Security Number, gender and other health insurance policies that you may have. It may also have included health information. When your health care providers send claims to the Plan's claims administrator for payment, the claims include your diagnoses and the medical treatments you received. For some medical treatments, your health care providers send additional medical information to the Plan such as doctor's statements, x-rays or lab test results. \nYour Health Information Rights \nYou have the following rights regarding the health information that DCH has about you: \n You have the right to see and obtain a copy of your health information. An exception is psychotherapy notes. Another exception is information that is needed for a legal action relating to DCH \n You have the right to ask DCH to change health information that is incorrect or incomplete. DCH may deny your request under certain circumstances \n You have the right to request a list of the disclosures that DCH has made of your health information beginning in April 2003 \n You have the right to request a restriction on certain uses or disclosures of your health information. DCH is not required to agree with your request \n You have the right to request that DCH communicates with you about your health in a way or at a location that will help you keep your information confidential \n You have the right to receive a paper copy of this notice. You may ask DCH staff to give you another copy of this notice, or you may obtain a copy from DCH's Web site, www.dch.georgia.gov. Click on HIPAA Privacy Notices \n \ndecision guide 2009 \n \n25 \n \n IMPORTANT NOTICE \nPrivacy Law's Requirements \nDCH is required by law to:  Maintain the privacy of your information  Give you this notice of DCH's legal duties and privacy practices regarding the information that DCH \nhas about you  Follow the terms of this notice  Not use or disclose any information about you without your written permission, except for the \nreasons given in this notice. You may take away your permission at any time, in writing, except for the information that DCH disclosed before you stopped your permission. If you cannot give your permission due to an emergency, DCH may release the information if it is in your best interest. DCH must notify you as soon as possible after releasing the information \nIn the future, DCH may change its privacy practices. If its privacy practices change significantly, DCH will provide a new notice to you. DCH will post the new notice on its Web site at www.dch.georgia.gov. Click on HIPAA Privacy Notices. This notice is effective April 14, 2003. \nHow DCH Uses and Discloses Health Care Information \nThere are some services the Plan provides through contracts with private companies. For example, a health insurance company pays most medical claims to your healthcare providers. When services are contracted, the Plan may disclose some or all of your information to the company so that they can perform the job the Plan has asked them to do. To protect your information, the Plan requires the company to safeguard your information in accordance with the law. \nThe following categories describe different ways that the Plan uses and discloses your health information. For each category, we will explain what we mean and give an example. \nFor Payment \nThe Plan may use and disclose information about you so that it can authorize payment for the health services that you received. For example, when you receive a service covered by the Plan, your healthcare provider sends a claim for payment to the claims administrator. The claim includes information that identifies you, as well as your diagnoses and treatments. \nFor Medical Treatment \nThe Plan may use or disclose information about you to ensure that you receive necessary medical treatment and services. For example, if you participate in a Disease State Management Program, the Plan may send you information about your condition. \nTo Operate Various Plan Programs \nThe Plan may use or disclose information about you to run various Plan programs and ensure that you receive quality care. For example, the Plan may contract with a company that reviews hospital records to check on the quality of care that you received and the outcome of your care. \nTo Other Government Agencies Providing Benefits or Services \nThe Plan may give information about you to other government agencies that are giving you benefits or services. The information must be necessary for you to receive those benefits or services and will be authorized by you or by law. \n26 \n \ndecision guide 2009 \n \n To Keep You Informed \nThe Plan may mail you information about your health and well-being. Examples are information about managing a disease that you have, information about your managed care choices, and information about prescription drugs you are taking. \nFor Overseeing Health Care Providers \nThe Plan may disclose information about you to the government agencies that license and inspect medical facilities, such as hospitals, as required by law. \nFor Research \nThe Plan may disclose information about you for a research project that has been approved by a review board. The review board must review the research project and its rules to ensure the privacy of your information. The research must be for the purpose of helping the Plan. \nAs Required by Law \nThe Plan will disclose information about you as required by law. \nUnder the HIPAA Privacy Law, you may authorize the Plan to release your Personal Health Information (PHI) to another individual. If you have authorized the release of PHI to another individual, the personal representative form authorizing the release of your PHI is not transferred between options. This is for the protection of your privacy. If you wish to continue to designate another individual after changing health options, you may be asked to complete a new personal representative form. \nFor More Information or to Report a Problem \nIf you have questions and would like additional information, you may contact the SHBP at 404-656-6322 (Atlanta calling area) or 800-610-1863 (outside of Atlanta calling area). \nIf You Believe Your Privacy Rights Have Been Violated \n You can file a complaint with the Plan by calling the SHBP at 404-656-6322 (Atlanta calling area) or 800-6101863 (outside of Atlanta calling area), or by writing to: SHBPHPU, P.O. Box 38342, Atlanta, GA 30334 \n You can file a complaint with the Health and Human Services Office for Civil Rights by writing to: U.S. Department of Health and Human Services Office for Civil Rights, Region IV, Atlanta Federal Center, 61 Forsyth Street SW, Suite 3B70, Atlanta, GA 30303-8909. Phone 404-562-7886; Fax 404-562-7881; TDD 404-562-7884, www.hhs.gov/ocr \nThere will be no retaliation for filing a complaint. \nPenalties for Misrepresentation \nIf an SHBP participant misrepresents eligibility information when applying for coverage, during change of coverage or when filing for benefits, the SHBP may take adverse action against the participants, including but not limited to terminating coverage (for the participant and his or her dependent[s]) or imposing liability to the SHBP for fraud or indemnification (requiring payment for benefits to which the participant or his or her beneficiaries were not entitled). Penalties may include a lawsuit, which may result in payment of charges to the Plan or criminal prosecution in a court of law. \nIn 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. \n27 \n \ndecision guide 2009 \n \n Notes \n28 \n \ndecision guide 2009 \n \n  Thanks to all of you who participated in the State Health Benefit Plan's \"Georgia's Nuts About Health\" wellness initiative. It's never too late to be healthy! www.nutsabouthealth.ga.gov \n \n "},{"id":"dlg_ggpd_y-ga-bc900-pe4-bs1-bn4-b2006-belec-p-btext","title":"State health benefit decision guide for January 1, 2006 - December 31, 2006: new employee","collection_id":"dlg_ggpd","collection_title":"Georgia Government Publications","dcterms_contributor":["Georgia. 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Map and Government Information Library"],"edm_is_shown_by":["https://dlg.galileo.usg.edu/do:dlg_ggpd_y-ga-bc900-pe4-bs1-bn4-b2006-belec-p-btext"],"edm_is_shown_at":["https://dlg.galileo.usg.edu/id:dlg_ggpd_y-ga-bc900-pe4-bs1-bn4-b2006-belec-p-btext"],"dcterms_temporal":null,"dcterms_rights_holder":null,"dcterms_bibliographic_citation":null,"dlg_local_right":null,"dcterms_medium":["state government records"],"dcterms_extent":null,"dlg_subject_personal":null,"iiif_manifest_url_ss":null,"dcterms_subject_fast":null,"fulltext":"NEW EMPLOYEE \nState Health Benefit \nDecision Guide for January 1, 2006  December 31, 2006 \nImportant Information Please Read \n \n PHONE NUMBERS/CONTACT INFORMATION \n \nState Health Benefit Plan (SHBP): www.dch.georgia.gov \n \nPPO, PPO CCO, Indemnity: \nMember Services \nPharmacy Information (ESI) \nHDHP: \nMember Services and Pharmacy \nHMOs: \n \n877-246-4189 TDD 800-545-6751 www.myuhc.com/groups/gdch 877-650-9342 TDD 800-842-5754 \n877-246-4195 \n \nBlueChoice \nCigna Kaiser Permanente United Healthcare \nTRICARE Supplement: All Options: Eligibility \n \n800-464-1367 TDD 404-842-8073 \n \nwww.bcbsga.com \n \n800-564-7642 \n \nwww.cigna.com \n \n800-611-1811 \n \nwww.kaiserpermanente.org \n \n866-527-9599 TDD 800-955-8770 \n \nwww.myuhc.com \n \n800-638-2610 ext. 255 \n \nwww.asitrisuppga.com \n \n404-656-6322 or 800-610-1863 \n \nIf you enroll for health insurance coverage under the State Health Benefit Plan (SHBP), you should receive a Summary Plan Description (SPD) from your Human Resources Department. This SPD reflects Plan benefits as of January 1, 2006. Please keep your Summary Plan Description (SPD) for future reference. If you are disabled and need this information in an alternative format, call the TDD Relay Service at (800) 255-0056 (text telephone) or (800) 255-0135 (voice) or write the SHBP at P.O. Box 38342, Atlanta, GA 30334. \nPhotos on the cover courtesy of the Georgia Department of Economic Development. \n \n STATE BENEFIT HEALTH PLAN \n \nThe Georgia Department of Community Health, which administers the State Health Benefit Plan, (SHBP), continually seeks to offer highquality, affordable health coverage. Keep in mind, however, that you are the manager of your healthcare needs, and in turn, must take the time to understand your Plan benefit choices in order to make the best decisions for you and your family. \nLet's start by talking about how the SHBP works. It is a self-funded plan, which means that all expenses are paid by employee premiums and employer funds. Approximately 95% of the premium goes directly to pay healthcare claims and 5% goes toward administering the Plan. \nWhat can you do to help manage your healthcare costs? \nUnderstand Your Options  compare all Plan Options, considering both the premium and out-of-pocket costs that you may incur. Web site and phone numbers are listed on the inside of the front cover of the Decision Guide if you need more information. \nConsider Enrolling in a Healthcare Spending Account (HCSA)  A HCSA helps you save tax dollars, approximately 2645% depending on your tax situation. By electing to use a HCSA, you may set aside up to $5,040 annually to cover health-related treatment for yourself and your dependents. Eligible expenses include deductibles, co-payments, over-the-counter items for medical purposes and costs for certain procedures not covered under your health plan. The benefit of this account is that you are able to pay for these out-of-pocket costs with tax-free dollars! Contact your Benefit Coordinator for more information. \nBecome a More Proactive Consumer of Healthcare  Most people do not realize how much their treatments, medicines and tests cost. \nSteps you can take include: \n Keep a list of all medications you take \n Shop in-network providers and pharmacies \n Find out what your drugstore charges for a drug, not just the co-payment \n Use generic medicines whenever possible \n Make sure all procedures are pre-certified, if required \n Make sure you get the results of any test or procedure \n Understand what will happen if you need surgery \n Check your Explanation of Benefits (if provided under your plan option) and if something does not make sense or seems to cost too much, ask your provider about it. \nThese and other steps you take will help manage healthcare expenses, reduce your out-of-pocket costs and those of the Plan. In addition, these steps will help in keeping premium costs down. \n \n! People who do not understand their health coverage pay more, according to the American Medical Association. To help you better understand your Plan and save your healthcare dollars, we have prepared a few points for you to consider. \nContents: \nPhone Numbers and Contacts Inside Front Cover Eligibility Information - Pages 3-4 General Information - Pages 5-8 Employee Responsibilities Page 8 Understanding Your Plan Options - Pages 9-13 Benefits Comparison: PPO, Indemnity, HDHP, and HMO Options - Pages 14-21 Important Plan Considerations Pages 22-23 If You Are Retiring: What You Need to Know - Page 24 Prescription Drug Coverage and Medicare - Pages 25-28 Legal Notices - Pages 29-33 \n1 \n \nState Benefit Health Plan \n \n Tim Burgess, Commissioner \n \nSonny Perdue, Governor \n \n2 Peachtree Street, NW Atlanta, GA 30303-3159 www.communityhealth.state.ga.us \n \nM E MO R A N D U M \n \nNovember 7, 2005 \n \nTO: All Members of the State Health Benefit Plan \n \nUnder a federal law known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA), certain notices must be provided to you. This memo will serve as notice to you related to the surcharge for tobacco use that the Plan will charge for coverage beginning January 1, 2006. \nUnder HIPAA, group health plans may not discriminate on the basis of \"health status.\" However, the law also permits state and local government employers that sponsor health plans to elect to exempt a plan from this requirement for any plan that is \"self-funded\" by the employer, rather than provided through a private health insurance policy. The Department of Health and Human Services considers tobacco use to be a \"health status.\" Therefore, the self-funded options under the SHBP have opted out of this requirement for the plan year January 1, 2006, through December 31, 2006. The election may be renewed for subsequent plan years. The purpose of this exemption is to enable the SHBP to comply with federal law in applying the tobacco use surcharge. \nTherefore, this notice informs all members of the self-funded options of the State Health Benefit Plan of the Plan's election to be exempt from the following provision: \nProhibitions against discriminating against individual participants and beneficiaries based upon health status. A group health plan may not discriminate in enrollment rules or in the amount of premiums or contributions it requires an individual to pay based on certain health status-related factors: health status, medical condition (physical and mental illnesses), claims experience, receipt of health care, medical history, genetic information, evidence of insurability, and disability. \nThe exemption and this notice do not change your eligibility, your benefits, or your premiums, other than to apply the surcharge for tobacco use if applicable. \nHIPAA also requires the Plan to provide covered employees and dependents with a \"certificate of creditable coverage\" when they cease to be covered under the Plan. There is no exemption from this requirement. The certificate provides evidence that you were covered under this Plan because you may be entitled to certain rights to reduce or eliminate a preexisting condition exclusion if you join another employer's health plan, or if you wish to purchase an individual health insurance policy. You may obtain the certificate of creditable coverage upon request. \nIf you have any questions about this notice, you may contact: \nState Health Benefit Plan Attn: Surcharge P. O. Box 38342 Atlanta, Georgia 30334 \nEqual Opportunity Employer \n2 \n \nHIPAA Memorandum \n \n ELIGIBILITY INFORMATION \nAll SHBP options have the same eligibility requirements except the TRICARE Supplement (see page 13). A summary is listed below. \nFor You \nYou are eligible to enroll yourself and your eligible dependents for coverage if you are:  A full-time employee of the State of Georgia, the General \nAssembly, or an agency, board, commission, department, county administration or contracting employer that participates in the SHBP, as long as: You work at least 30 hours a week consistently, and Your employment is expected to last at least nine months. Not Eligible: Student employees or seasonal, part-time or short-term employees.  A certified public school teacher or library employee who works half-time or more, but not less than 17.5 hours a week. Not Eligible: Temporary or emergency employees.  A non-certified service employee of a local school system who is eligible to participate in the Teachers Retirement System or its local equivalent. You must also work at least 60% of a standard schedule for your position, but not less than 20 hours a week.  An employee who is eligible to participate in the Public School Employees' Retirement System as defined by Paragraph 20 of Section 47-4-2 of the Official Code of Georgia, Annotated. You must also work at least 60% of a standard schedule for your position, but not less than 15 hours a week.  A retired employee of one of these listed groups who was enrolled in the Plan at retirement and is eligible to receive an annuity benefit from a state-sponsored or state-related retirement system. See the SPD for more information.  An employee in other groups as defined by law. \n3 \n \nEligibility Information \n \n ! *TRICARE covers full-time students to age 23. To cover your full-time student after age 23 to age 26, you must select another SHBP option during the Open Enrollment Period prior to your dependent reaching age 23. A full-time student reaching age 23 is not a qualifying event to change options. \n! NOTE: Ineligible dependent determination does NOT allow a refund of premium or a change to single coverage. Dependent eligibility cannot be determined until the subscriber presents proper documentation to SHBP. Please review eligibility requirements before selecting family coverage. \n! The member's social security number MUST be written on each document. \n \nFor Your Dependents \nEligible dependents are: \n Your legally married spouse, as defined by Georgia Law. \n Your never-married dependent children who are: \n1 Natural or legally adopted children under age 19, unless they are eligible for coverage as employees. Children that are legally adopted through the judicial courts become eligible only after they are placed in your physical custody. \n2 Stepchildren under age 19 who live with you at least 180 days per year and for whom you can provide documentation satisfactory to the Plan that they are your dependents. \n3 Other children under age 19 if they live with you permanently and legally depend on you for financial support--as long as you have a court order, judgment or other satisfactory proof from a court of competent jurisdiction. \n4 Your natural children, legally adopted children or stepchildren who were covered under the SHBP before age 19 from categories 1 and 2 above who are physically or mentally disabled prior to reaching age 19 and who depend on you for primary support may continue their existing Plan coverage past age 19. \n5 Your natural children, legally adopted children, stepchildren or other children ages 19 through 25 from categories 1, 2, or 3 above who are registered Full-time Students* at fully accredited schools, colleges, universities or nurse training institutions and, if employed, who are not eligible for a medical benefit plan from their employer. The number of credit hours required for Full-time Student status is defined by the school in which the child is enrolled. \nIn order to cover a spouse or dependent under the Plan, you must provide documentation. The Plan requires: \n Spouse: A copy of your certified marriage certificate or a copy of your most recent Federal Tax Return (filed jointly with spouse) including legible signatures for you and your spouse with financial information blacked out. \n Natural or Student Child: A copy of the certified birth certificate listing the parents by name. Birth cards without the parents' names are not acceptable. \n Stepchild: \n1 A copy of the certified birth certificate showing your spouse is the natural parent; and \n2 A copy of the certified marriage certificate showing the natural parent is your spouse; and \n3 A notarized statement that the dependent lives in your home at least 180 days per year. \n \nEligibility Information \n \n4 \n \n GENERAL INFORMATION \nHow to Enroll \nIf you're eligible to participate in the SHBP, you become a member by enrolling either:  As a new hire, within 31 days of your hire date. If you join the \nSHBP during that first 31-day enrollment opportunity, your coverage will go into effect on the first day of the month after you complete one full calendar month of employment. See your personnel/payroll office for instructions on how to enroll.  As a result of a qualifying event. See When Are Changes Allowed? on page 7 of this guide for more details. If you elect to decline SHBP coverage, you must complete a Declination Form, available from you personnel/payroll office, and file it within 31 days of your hire date. Before making your selection, you should be aware that SHBP charges a Tobacco and Spousal Surcharge. A $40 tobacco surcharge will be added to your monthly premium if you or any of your covered dependents have used tobacco products in the previous twelve months. A $30 spousal surcharge will be added to your monthly premium if you have elected to cover your spouse and your spouse is eligible for coverage through his/her employment but chose not to take it. If your spouse is eligible for coverage with SHBP through his/ her employment, the spousal surcharge will be waived. You will automatically be charged the surcharge if you fail to answer all questions concerning the surcharges. The surcharge will apply to your premium until the next Plan year. If you decide to become a SHBP member, you will have two major choices to make:  Your coverage option  PPO, PPO CCO, Indemnity, HMO or HMO CCO, HDHP, HDHP CCO, or TRICARE Supplement; and  Your coverage type  Single or Family coverage. For details on Single and Family coverage, see your SPD. \n5 \n \nGeneral Information \n \n ! VERY IMPORTANT: DEPENDENTS MUST BE VERIFIED PRIOR TO THEIR COVERAGE EXPIRATION DATE \nContinued Coverage for Students, Disabled Children and Legal Children  Recertification must be received \nbefore coverage expiration date.  The dependent will not be eligible \nafter the expiration date, if the documentation is not received before this coverage expires. You may add the dependent during the next Open Enrollment period. \n! It is important that you notify us if you have other group coverage to prevent incorrect processing of any claims. For futher information about COB rules, refer to the SPD. \n! A new employee's PEC limitation period begins the first day of the month he/she was hired. \n \nHealth Benefit Cost Estimator \nChoosing the right health plan is an important decision and the SHBP is providing a Plan Cost Estimator (PCE) tool to assist you. The PCE offers you a simple way to help determine which option is best for you and your family. This online tool lets you compare how your out-of-pocket expenses may vary under the different health plan options available to you. \nYou can use the PCE to review cost information for prescriptions, anticipated tests and procedures and, if offered, determine how much to contribute to your Flexible Spending Account (FSA). The information provided by PCE is not meant to be an endorsement of any particular health plan. The service is offered only to help you compare your estimated expenses across each health plan option. \nAccess the link to the PCE tool at the DCH Web site www.dch.georgia.gov and click on \"How Do I?\" and then click on \"Find Health Benefit Information as a New Hire or Transfer\". \nWhat Happens if I Have Other Insurance? \nYou or your covered dependents may have medical coverage under more than one plan. In this case, the Plan's coordination of benefits (COB) provisions apply. \nWhen SHBP benefits are coordinated, the Plan does not pay more than 100% of the Plan's allowed amount. Non-covered services or items, penalties and amounts balance billed are not part of the allowed amount and are the subscriber's responsibility. \nPre-existing Conditions and Coverage Limits \nNew SHBP members in the PPO or Indemnity options have a 12-month pre-existing condition (PEC) coverage limitation period. Each PEC is limited to $1,000. \nA PEC is any sickness, injury, or other condition for which medical advice, diagnosis, care, or treatment, including prescription medication, was recommended or received within six months immediately preceding a member's coverage effective date under the Plan. \nSHBP members may reduce or eliminate the 12-month PEC limitation period by documenting \"creditable coverage.\" Creditable coverage generally includes health coverage you or your family member had immediately before enrolling in the SHBP. Coverage under most group health insurance plans, individual health policies, and some governmental health programs qualify as creditable coverage. See the SPD for more details. \n \nGeneral Information \n \nCOBRA Rights \nThe Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986 requires that the Plan offer you, 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 you, or one of your dependents, may continue the coverage is based on the qualifying event. For further information, please refer to your SPD. \n6 \n \n When Are Changes Allowed? \n \nThe benefit choices you make as a new hire will stay in effect for the duration of the 2006 Plan year  January 1, 2006 through December 31, 2006, unless you experience certain changes in status as defined by federal law. Section 125 of the Internal Revenue Code, which governs the SHBP, does not permit canceling or otherwise changing your coverage during the Plan year unless you have a qualifying event. \nQualifying events include, but are not limited to: \n Marriage or divorce; \n Birth or adoption of a child or placement for adoption; \n Death of a spouse or child, if only dependent enrolled; \n Your spouse's or dependent's eligibility for or loss of eligibility for other group health coverage; \n A change in residence by you, your spouse or dependents that makes you or a covered dependent ineligible for coverage in your selected option; and \n A change in employment status that leads to a loss or gain of eligibility under the Plan. \nIf you declined enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may, in the future, be able to enroll yourself or your dependents in the Plan, provided that you request enrollment within 31 days of when your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your dependents provided that you request enrollment within 31 days of the marriage, birth, adoption or placement for adoption, and provide the required documentation. \nHow to Remove Surcharges \n \n! For additional information about qualifying events, see your SPD available from you personnel office or online at: www.dch.georgia.gov. \n! Keep in mind that once you enroll or decline, you cannot change your coverage until the next Open Enrollment Period unless you experience a qualifying event that would permit a corresponding change. \n \nTobacco Surcharge \n You must attend a tobacco cessation program sponsored by Kaiser or the American Cancer Society. Additional programs may be approved in the future. Please check the DCH Web site for any updates at www.dch.georgia.gov. \n You will receive an attendance certification form. You and the representative should both sign this form. \n You should complete the appropriate Tobacco Affidavit Form available from SHBP at www.dch.georgia.gov. \n Give both forms to your employer's Benefit Coordinator to complete the required deduction information. \nThe change in premiums will be effective based on the payroll schedule of your employer. No refund in premium will be made for previous health deductions that included the surcharge amounts. IRS rules do not allow premium changes to be made retroactively. \n \n! SPOUSAL SURCHARGE If your spouse becomes covered by his/her employer's health benefit plan, the surcharge can be removed if you make the request and provide proof within 31 days of the effective date of the other coverage. \n \nGeneral Information \n \n7 \n \n State Health Benefit Plan Medicare Policy \nFederal Law requires SHBP to pay primary benefits for active employees and their dependents as long as active employment continues. Active members or their covered dependents may choose to delay Medicare enrollment. Termination of active employment is a qualifying event for enrolling in Medicare without penalty. \nYou must enroll for coverage for you and any eligible dependents during the Open Enrollment period prior to your retirement if you want to have health insurance under SHBP when you retire, (if you are not already enrolled). Members who are enrolled in Medicare due to End Stage Renal Disease (ESRD) will need to contact the Social Security Administration to determine when Medicare becomes primary. \nOnce retired, during the annual Retiree Option Change Period, you are allowed to change your Plan option only. You may add dependents only if you experience a qualifying event, request the change within 31 days and provide documentation required by SHBP. \n \nEMPLOYEE RESPONSIBILITIES \n \n! If you have Medicare or will become eligible for Medicare in the next 12 months, a new Federal law gives you more choices about your prescription drug coverage, starting in 2006. Please see pages 2428 for more details. \n \nThis booklet contains a brief explanation of each Plan Option, for January 1  December 31, 2006 and a benefits comparison chart. \n Read the current Decision Guide and SPD to understand your Health Plan Options prior to making your health election. \n Contact your employer or payroll location Benefit Coordinator for assistance if you have benefit questions or, you may go to www.dch. georgia.gov and click on \"How Do I\" and then click on \"Find Health Benefit Information as a New Hire or Transfer\". \n You will automatically be charged the surcharge(s) if you fail to answer all questions concerning the surcharges. The surcharge(s) will apply for the 2006 plan year unless you experience a qualifying event. \n Eligibility verification documents for all dependents for whom coverage has been requested should be submitted within the required time frame. \n A new SHBP member should provide a Certificate of Creditable Coverage from prior health insurance to reduce or eliminate any pre-existing condition limitation for the PPO or Indemnity Options. \nNotify the Plan of any fraudulent activity regarding Plan members, providers, payment of benefits, etc. Call 1-877-878-3360, or 404-206-9514. \n \n8 \n \nGeneral Information \n \n UNDERSTANDING YOUR PLAN OPTIONS \n \nOn the following pages, you will find a brief description of each option and important considerations to help you select the best option for you. To help you understand the information in this section, a few key terms are defined below. \nImportant Terms to Understand \n \n! Contact the Member Services unit for each option if you need more detail. Telephone numbers are on the inside front cover. You also may access an SPD online at: www.dch.georgia.gov. \n \nAllowed Amount  A dollar amount the Plan uses to calculate benefits payable. \n \nBalance Billing  A dollar amount charged by the provider that is over the Plan's allowed amount for the care received. You are subject to balance billing when you receive services from non-participating providers, including emergency services. \n \nCo-insurance Amount  The percentage of the Plan's allowed amount paid by a Plan member. The SHBP generally pays 90% to 60% of the Plan's allowed amount for covered services, so your co-insurance is between 10% and 40%. \n \nCo-payment  A set dollar amount that you pay at the time you receive services or items. For example, you pay a $30 co-payment for an innetwork PPO physician's office visit while you are at the physician's office. Co-payments do not apply to Plan year deductibles or out-ofpocket limits unless otherwise noted. \n \nCovered Services  Services for medically necessary care that are eligible for reimbursement under the plan. \n \nDeductible  A specified dollar amount, which varies by Plan option, for specified covered services that you must pay out-of-pocket each Plan year before the option pays a benefit. Depending on your coverage option, the deductible may not apply to some services. For example, the deductible does not apply to in-network physician office visits under the PPO Option. \n \nEmergency Care  Care provided when a sudden, severe and unexpected illness or injury happens that could be life threatening or result in permanent impairment of bodily functions if not treated immediately. \n \nLifetime Maximum  The dollar amount that each Plan member may receive in benefits from the SHBP during his or her lifetime. \n \nOut-of-Pocket Limits  The maximum amount you would have to pay out of your pocket each Plan year for covered services. Once you meet your out-of-pocket limit for the Plan year, the Plan pays 100% of the allowed amounts for most covered services for the rest of the Plan year. Your out-of-pocket costs for premiums, co-payments and non-covered charges are not applied to the limit. The deductible is applied to your annual out-of-pocket limit. \n \nParticipating Provider  Any physician, hospital or other health-service professional or facility that offers covered services and that has joined the PPO network, the Indemnity network, the High Deductible Health Plan network or HMO network for the Plan option. Providers nominated and accepted under a CCO are also considered participating providers for the person making the nomination. Participating providers may not balance bill Plan members for covered services. \n \n9 \n \nUnderstanding Your Plan Options \n \n To maximize your health benefits, it is important to fully understand how each of the SHBP options works. This brief overview will help you determine which option best fits your health care needs. Keep in mind that failure to use network providers could result in a financial impact to you. \n \n! It is ultimately your responsibility to verify that a provider is in the PPO, HDHP or HMO network prior to receiving services. Providers may enter or leave the network at any time. \n \nPPO Options \nThe PPO Options offer you a network of more than 12,500 Georgia participating physicians and 150 Georgia hospitals. \nYou also have the added benefit of access to a national network of participating providers and hospitals across the United States. \nIn order to receive the highest level of benefit coverage and avoid filing claims and balance billing, you will need to use an in-network provider. If you choose to use an out-of-network provider, the reimbursement will be at a lower level of benefit coverage. \nA PPO CCO is also available. See page 12 for more details. \nTo view the list of PPO providers, visit www.myuhc.com/groups/gdch, or call 1-877-246-4189. \n \n! NOTE: UnitedHealthcare HMO does not require you to select a PCP or obtain referrals to see specialists. \n! Diagnostic testing and lab services performed at independent radiology and lab offices located in the Kaiser facilities are subject to deductible and coinsurance. \n \nHMO Options \nHMO Options are available to SHBP eligible employees if the HMO is offered in your area or surrounding counties. \nHMOs provide 100% benefit coverage for preventive health care needs after paying applicable co-payments. There are no bills or claim forms. Certain services are subject to a deductible and co-insurance amount (i.e., inpatient and outpatient hospital facility, inpatient professional charges, etc.). These deductibles and co-insurance amounts have an annual out-of pocket maximum. When you meet this maximum, the HMO pays your covered services at 100%. Co-payment amounts are excluded from the annual out-of-pocket maximum. \nIn HMOs, you are responsible for selecting a Primary Care Physician (PCP) from a list of participating providers (see note). You must be referred to a network provider by your participating physician or facility for your expenses to be covered, except in emergencies and in other limited cases. If you receive care from a provider other than your PCP, or without your PCP's referral, there is no coverage even if the physician or facility is in the HMO network. \nAn HMO CCO is also available. See page 12 for more details. \n \nUnderstanding Your Plan Options \n \n10 \n \n High Deductible Health Plan \nA High Deductible Health Plan (HDHP) will be offered to all employees effective January 1, 2006. This Option offers you a new way to manage your healthcare dollars. When you enroll: \n Your monthly insurance premiums are lower. \n You may qualify to start a Health Savings Account (HSA) for yourself, through a bank or other financial organization acting as an HSA custodian/administrator, and set aside tax-free dollars to pay for eligible healthcare expenses now or in the future. HSAs typically earn interest and may even offer investment options. \nYou may start an HSA when you enroll in the HDHP as long as you do not have other medical coverage. You will be responsible for selecting your HSA vendor, setting up your account, and making contributions. \nIn return for the lower premiums and the potential tax advantages of a Health Savings Account, you take on more responsibility for your healthcare needs when you enroll in the HDHP. You: \n Have a higher deductible, with benefits payable only after you meet the deductible (except for preventive care coverage) \n Pay coinsurance after you have satisfied the deductible rather than set dollar co-payments for network office visits and prescription drugs. \n Another tax savings option you may want to consider is a Health Care Spending Account (HCSA), if it is offered through your employer's cafeteria program. A HCSA helps you save tax dollars, approximately 26-45%, depending on your tax situation. By electing to use a HCSA, you may set aside up to $5,040 annually to cover health-related treatment expenses for yourself and your dependents. If you contribute to a HCSA, it is your responsibility to make sure your contributions do not violate any HSA rules. \n \n! See page 22 for more details on the new HDHP and the opportunity it provides to enroll in a Health Savings Account. \nSee the Benefits Comparison that starts on page 14 for more about how the Plan covers specific expenses. \n \nUnderstanding Your Plan Options \n \n11 \n \n ! For further details and to obtain the necessary nomination paperwork, please call the selected plan option member services department. \n \nPPO, HMO and High Deductible Health Plan Consumer Choice Options (CCO) \nSelection of any CCO option does not provide enhanced benefits. \nThe CCO premiums are higher than the corresponding Option. For the increased cost, you can request that a Georgia out-of network provider be reimbursed as an in-network provider. This is referred to as a nomination. \nThe out-of-network provider must accept the fees and conditions of the network and be approved by the network BEFORE you receive any services from that provider. \nThis in-network relationship between you and the provider exists only for you and the provider. Other family members who wish to receive innetwork benefits from that provider must complete a provider nomination form. You may nominate as many providers as you wish. \nSHBP rules do not allow you to change your coverage option if the provider you would like to nominate rejects the nomination. \nOnly providers located and licensed in Georgia are eligible for nomination. \n \nIndemnity Option \nThe Indemnity Option is a traditional fee-for-service plan that generally provides the same benefit coverage level no matter which qualified medical provider you use. The Plan reimburses up to the Plan's allowed amounts for covered services. The Indemnity Option also uses contracted healthcare providers who have agreed to discounted rates without balance billing for charges over the allowed amount. As long as you see a participating provider, you may not be balance billed for covered services. However, not all providers participate in these special arrangements. In most instances, non-participating providers' billed charges are considerably higher than the Plan's allowed amounts. \nThe SHBP does not have the legal authority to intervene when nonparticipating providers balance bill you. As a result, the SHBP cannot reduce or eliminate amounts balance billed. The SHBP cannot make additional payments above the allowed amounts when you are balance billed by non-participating providers. \n \nUnderstanding Your Plan Options \n \n12 \n \n TRICARE Supplement for Eligible Military Members \nThe TRICARE Supplemental Insurance is offered to employees and dependents who are eligible for TRICARE and who have a Defense Enrollment Eligibility Reporting System (DEERS) number.* \nConsiderations \n TRICARE will become your primary insurance. \n TRICARE Supplement will become your secondary coverage. \n TRICARE covers full-time students only to age 23. You must select another SHBP option during the Open Enrollment period prior to your child reaching age 23 to cover a full-time student from age 23 to 26. (Reaching age 23 as a full-time Student is not a qualifying event). \n Tobacco and spousal surcharges do not apply. \n COBRA legislation requires SHBP to offer continuation of coverage when coverage is lost. If you elect COBRA and the premiums are paid, there is NO break in SHBP coverage. If you elect coverage through the Association and Society Insurance Corporation's (ASI) portability feature instead of COBRA, you will no longer be covered by SHBP. \nWhat Happens at Age 65 \n When you and/or your spouse are ineligible for Medicare, TRICARE Supplement continues with submission of disallowance by Social Security. \n When you and/or your spouse are entitled to Medicare Part A and enrolled in Medicare Part B, your coverage will continue through TRICARE Supplement. \n When you and/or your spouse are eligible for Medicare, Medicare will be your primary insurance TRICARE for Life  secondary and TRICARE Supplement  Tertiary. \n When you or your spouse are eligible for Medicare, if you wish to cover your spouse through SHBP, you need to select another Option during the Open Enrollment Period prior to you or your spouse reaching age 65. \n Attainment of age 65 and eligibility for Medicare is a qualifying event and will allow you to change to another Plan option. \n When you and/or your spouse reach age 65 and reside overseas, your coverage will continue through the TRICARE Supplement if you are entitled to Medicare Part A and are enrolled in Medicare Part B. \n \n! *TRICARE covers dependents to age 23 even if they are not a full-time student. However, SHBP only covers dependents who are not full-time students to age 19. You should not elect the TRICARE Supplement if you wish to cover a child who is between the ages of 19 and 23 and is not a full-time student. \n! If you enroll in TRICARE Supplement and are not eligible, you will be enrolled in the PPO Option which includes the spousal and tobacco surcharges. You will be required to pay the PPO premiums retroactive to your date of ineligibility or your coverage will be terminated effective January 1, 2006. \n \nUnderstanding Your Plan Options \n \n13 \n \n BENEFITS COMPARISON: PPO, INDEMNITY, HDHP AND HMO OPTIONS \n \nSchedule of Benefits for You and Your Dependents for January 1, 2006 December 31, 2006 \nCovered Services \nMaximum Lifetime Benefit (combined for all SHBP Options) \nPre-Existing Conditions (1st year in Plan only, subject to HIPAA) \nLifetime Benefit Limit for Treatment of: (combined for PPO Option, Indemnity and HDHP )  Temporomandibular joint \ndysfunction (TMJ)  Substance abuse \nDeductibles  Deductible--individual  Deductible--family maximum \n Hospital deductible per admission \nAnnual Out-of-Pocket Limits:  Individual  Family \nPhysicians' Services \nPrimary Care Physician or Specialist Office or Clinic Visits: Treatment of illness or injury \nPrimary Care Physician or Specialist Office or Clinic Visits for the Following:  Wellness care/preventive \nhealthcare  Annual gynecological exams (these services are not subject to the deductible) \nMaternity Care (prenatal, delivery and postpartum) \n \nDollar amounts, visit limitations, deductibles and out-of-pocket limits are based on a January 1December 31, 2006 Plan Year. \n \nNOTE: Coverage is defined as allowed eligible expenses. \n \nPPO OPTION \n \nINDEMNITY \n \nIn-Network \n \nOut-of-Network \n \nThe Plan Pays: \n \nThe Plan Pays: \n \n$2 million \n \n$2 million \n \n$1,000 \n \n$1,000 \n \n$500 $1,500 \n$1,100 $2,200 \n \n$1,100 3 episodes \n$600 $1,800 \n$250 \n$2,200 $4,400 \n \n$1,100 3 episodes \n$500 $1,500 \n$400 \n$2,200 $4,400 \n \n100% after a $30 per visit co-payment; not subject to deductible \n \n60% of coverage; subject to deductible \n \n100% after $30 copayment per office visit. No co-payment for associated tests and immunizations. Maximum of $500 per person per Plan Year. \n \nNot covered. Charges do not apply to deductible or annual out-of-pocket limits. \n \n90% of coverage; not subject to deductible after initial $30 copayment \n \n60% of coverage; subject to deductible \n \n90% of coverage; subject to deductible \n90% per office visit after deductible. No deductible for associated lab and test charges, up to a maximum of $200 per person per Plan Year; additional $125 benefit for screening mammogram. \n90% of coverage; subject to deductible \n \nBenefits Comparison \n \n14 \n \n Exclusions and limitations vary among Plan options. Contact your specific Plan option for more information. \n \nHIGH DEDUCTIBLE OPTION (HDHP) \n \nIn-Network \n \nOut-of-Network \n \nThe Plan Pays: \n \n$2 million \n \nNone \n \nHMO OPTIONS \nBlueChoice, CIGNA, Kaiser Permanente, UnitedHealthcare \nThe Plan Pays: \n \nHMO Plan Differences \n \n$2 million \n \nNone \n \n$1,100 $2,200 \n$1,700 $2,900 \n \n$1,100 3 episodes \n$2,200 $4,400 \nNot applicable \n$3,800 $7,000 \n \nNo separate lifetime benefit limit \n$200 $400 \nNot applicable \n$1,000 $2,000 \n \n90% of coverage; subject to deductible \n100% coverage up to a maximum of $500 per person per plan year. Not subject to deductible. \n \n60% of coverage; subject to deductible \nNot covered, charges do not apply to deductible or annual out-ofpocket limits. \n \n100% after a per visit copayment** of $20 for primary care and $25 for specialty care \n100% after a per visit copayment of $20 for primary care and $25 for specialty care. No co-payment for immunizations and mammograms. \n \n** Includes lab and x-rays done in the physician's office. \nNo \n \n90% of coverage; subject to deductible \n \n60% of coverage; subject to deductible \n \n100% after initial $25 co-payment \n \nChart continued pg. 16 15 \n \nBenefits Comparison \n \n Physicians' Services \nPhysician Services Furnished in a Hospital \nSurgery in general, including charges by surgeon, anesthesiologist, pathologist and radiologist \nPhysician Services for Emergency Care \nOutpatient Surgery--  When billed as office visit \n \nPPO OPTION \n \nIn-Network \n \nOut-of-Network \n \nThe Plan Pays: \n \nINDEMNITY \nThe Plan Pays: \n \n90% of coverage; subject to deductible \n \n60% of coverage; subject to deductible \n \n90% of coverage; subject to deductible \n \n90% of coverage; subject to deductible \n90% of coverage; subject to deductible \n \n90% of coverage; subject to in-network deductible \n60% of coverage; subject to deductible \n \n90% of coverage; subject to deductible \n90% of coverage; subject to deductible \n \n When billed as outpatient surgery at a facility \n \n90% of coverage; subject to deductible \n \nAllergy Shots and Serum \nHospital Services Inpatient Services  Inpatient care, delivery and \ninpatient short-term acute rehabilitation services  Well-newborn care \nCovered Services \n \n100% for shots and serum after $30 per visit co-payment not subject to deductible \n90% of coverage; subject to a $250 per admission deductible \n100% of coverage; not subject to deductible \n \nOutpatient Surgery-- Hospital/Facility \n \n90% of coverage; subject to deductible \n \nEmergency Care Treatment of an emergency medical condition or injury \n \n90% of coverage after a $100 per visit copayment; co-payment waived if admitted; subject to deductible \n \nOutpatient Testing, Lab, etc. \n \nLaboratory; X-Rays; Diagnostic Tests; Injections, including Medications Covered Under Medical Benefits--for the Treatment of an Illness or Injury \n \n90% of coverage; subject to deductible \n \n60% of coverage; subject to deductible 60% of coverage; subject to deductible \n60% of coverage; subject to a $250 per admission deductible Not covered \n60% of coverage; subject to deductible \n90% of coverage after a $100 per visit copayment; co-payment waived if admitted; subject to deductible \n60% of coverage; subject to deductible \n \n90% of coverage; subject to deductible \n90% of coverage; subject to deductible \n90% of coverage; subject to a $400 per admission deductible 90% of coverage; not subject to deductible \n90% of coverage; subject to deductible \n90% of coverage after a $100 per visit copayment; co-payment waived if admitted; subject to deductible \n90% of coverage; subject to deductible \n \nBenefits Comparison \n \n16 \n \n HIGH DEDUCTIBLE OPTION \n \nIn-Network \n \nOut-of-Network \n \nThe Plan Pays: \n \nHMO OPTIONS \nBlueChoice, CIGNA, Kaiser Permanente, UnitedHealthcare \nThe Plan Pays: \n \nHMO Plan Differences \n \n90% of coverage; subject to deductible \n \n60% of coverage; subject to deductible \n \n90% of coverage; subject to deductible \n \n90% of coverage; subject to deductible \n90% of coverage; subject to deductible \n \n60% of coverage; subject to deductible \n60% of coverage; subject to deductible \n \n90% of coverage; subject to deductible \n90% of coverage; subject to deductible \n \n60% of coverage; subject to deductible \n60% of coverage; subject to deductible \n \n100% after $100 co-payment \n100% after $25 co-payment if billed as office visit \n90% of coverage; subject to deductible \n100% for shots and serum after a $25 per visit copayment \n \nNon-emergency use of the emergency room not covered. \nKaiser Permanente  90% of coverage; subject to deductible \nKaiser Permanente  $5 for shots and $50 for a three-month supply of serum \n \n90% of coverage; subject to deductible \n90% of coverage; subject to deductible \n \n60% of coverage; subject to deductible \n60% of coverage; subject to deductible \n \n90% of coverage; subject to deductible \n100% of coverage not subject to deductible \n \n90% of coverage; subject to deductible \n90% of coverage; subject to deductible \n \n60% of coverage; subject to deductible \n60% of coverage; subject to deductible \n \n90% of coverage; subject to deductible \n \n60% of coverage; subject to deductible \n \n90% of coverage; subject to deductible \n100% after a $100 per visit co-payment; co-payment waived if admitted \n90% of coverage; subject to deductible \n \nNo \nNon-emergency use of the emergency room not covered. \n \nBenefits Comparison \n \nChart continued pg. 18 17 \n \n Behavioral Health \nMental Health and Substance Abuse Inpatient Facility NOTE: All services require prior authorization. \nPartial Day Hospitalization and Intensive Outpatient NOTE: Notification Required. \nProfessional Charges Inpatient \n \nPPO OPTION \n \nIn-Network \n \nOut-of-Network \n \nThe Plan Pays: \n \n90% of coverage; subject to deductible limited to 45 days combined per Plan Year \n90% of coverage; subject to deductible limited to 60 days combined per Plan Year \n \n60% of coverage; subject to deductible limited to 45 days combined per Plan Year \nNo benefit \n \n90% of coverage; subject to deductible; limited to 1 visit per authorized day combined per Plan Year \n \n60% of coverage; subject to deductible; limited to 1 visit per authorized day combined per Plan Year \n \nINDEMNITY \nThe Plan Pays: \n90% of coverage; subject to deductible limited to 45 days combined per Plan Year \n90% of coverage; subject to deductible limited to 60 days combined per Plan Year \n90% of coverage; subject to deductible; limited to 1 visit per authorized day combined per Plan Year \n \nMental Health and Substance Abuse Outpatient Visits NOTE: Notification Required. \nDental \nDental 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. \n \n90% of coverage; subject to deductible, limited to 50 visits combined per Plan Year \n \n60% of coverage; subject to deductible; limited to 25 visits combined per Plan Year \n \n90% of coverage; subject to deductible \n \n60% of coverage; subject to deductible \n \n90% of coverage; subject to deductible; limited to 50 visits combined per Plan Year \n90% of coverage; subject to deductible \n \nTemporomandibular Joint Syndrome (TMJ) NOTE: Coverage for diagnostic testing and non-surgical treatment up to $1,100 per person lifetime maximum benefit. This does not apply to the HMO \nVision \nOther Coverage \nAmbulance Services for Emergency Care NOTE: \"Land or air ambulance\" to nearest facility to treat the condition. \n18 \n \n90% of coverage; subject to deductible \n \n60% of coverage; subject to deductible \n \n90% of coverage; not subject to deductible; limited to one eye exam every 24 months \n \nEye exam not covered \n \n90% of coverage; subject to deductible \n \n90% of coverage; subject to deductible \n \n90% of coverage; subject to deductible \n90% of coverage; not subject to deductible; limited to one eye exam every 24 months \n90% of coverage; subject to deductible \n \nBenefits Comparison \n \n HIGH DEDUCTIBLE OPTION \n \nIn-Network \n \nOut-of-Network \n \nThe Plan Pays: \n \n90% of coverage; subject to deductible limited to 30 days combined per Plan Year \n \n60% of coverage; subject to deductible limited to 30 days combined per Plan Year \n \n90% of coverage; subject to deductible limited to 60 days combined per Plan Year \n \n60% of coverage; subject to deductible limited to 30 days combined per Plan Year \n \nHMO OPTIONS \nBlueChoice, CIGNA, Kaiser Permanente, UnitedHealthcare \nThe Plan Pays: \n90% of coverage; not subject to deductible and limited to 30 days combined per Plan Year \nEach HMO may or may not offer this benefit; contact the HMO for more information \n \nHMO Plan Differences \nKaiser Permanente  90% of coverage; subject to deductible and unlimited days for mental health; 30-day limit for substance abuse \n \n90% of coverage; subject to deductible limited to 1 visit per authorized day combined per Plan Year \n \n60% of coverage; subject to deductible limited to 1 visit per authorized day combined per Plan Year \n \n90% of coverage; not subject to deductible \n \nKaiser Permanente  90% of coverage; subject to deductible \n \n90% of coverage; subject to deductible limited to 50 visits combined per Plan Year \n \n60% of coverage; subject to deductible limited to 25 visits combined per Plan Year \n \n100% after $25 per visit co-payment; limited to 25 visits combined per Plan Year \n \n90% of coverage; subject to deductible \n \n60% of coverage; subject to deductible \n \n90% of coverage; subject to deductible \n \n60% of coverage; subject to deductible \n \n90% of coverage; not subject to deductible; limited to one eye exam every 24 months \n \nEye exam not covered \n \n90% of coverage; subject to deductible \n \n60% of coverage; subject to deductible \n \n100% after applicable co-payment, if inpatient/ outpatient facility; subject to deductible \n \nKaiser Permanente  50% coverage on first $1,000, if inpatient/ outpatient facility; subject to deductible \n \n100% after applicable copayment for related surgery and diagnostic services; excludes appliances and orthodontic treatment; if inpatient/outpatient facility, 90% subject to deductible \n \nNo Kaiser Permanente  50% for non-surgical treatment; excludes appliances and orthodontic treatment; if inpatient/outpatient facility; 90% subject to deductible \n \nContact HMO directly for more information \n \n100% \n \nKaiser Permanente  100% after a $50 per trip co-payment when medically necessary. \nChart continued pg. 20 19 \n \nBenefits Comparison \n \n Other Coverage Urgent Care Services \nHome Healthcare Services NOTE: Prior approval required \nSkilled Nursing Facility Services NOTE: Prior approval required \nHospice Care NOTE: Prior approval required \n \nPPO OPTION \n \nIn-Network \n \nOut-of-Network \n \nThe Plan Pays: \n \n90% of coverage after a $45 per visit copayment; subject to deductible \n \n60% of coverage; subject to deductible \n \n90% of coverage; subject to deductible \n \n60% of coverage; subject to deductible \n \n90% of coverage; up to 45 days per Plan Year; subject to a $250 per admission deductible \n100% of coverage; subject to deductible \n \nNot covered \n60% of coverage; subject to deductible \n \nINDEMNITY \nThe Plan Pays: 90% of coverage; subject to deductible \n90% of coverage; subject to deductible \n90% of coverage; up to 45 days per Plan Year; subject to a $400 per admission deductible @ contracted facility 100% of coverage; subject to deductible \n \nDurable Medical Equipment (DME)--Rental or Purchase Outpatient Acute Short-Term Rehabilitation Services \nChiropractic Care NOTE: Coverage for up to a maximum of 20 visits per Plan Year \nTransplant Services NOTE: Prior approval required \nPharmacy Generic Co-payment \n \n90% of coverage; subject to deductible \n90% of coverage; subject to deductible and $20 per visit copayment up to 40 visits per Plan Year \n \n60% of coverage; subject to deductible \n60% of coverage; subject to deductible and $20 per visit copayment up to 40 visits per Plan Year \n \n90% of coverage; after a $30 per visit copayment; not subject to deductible \n \n60% of coverage; subject to deductible \n \n90% of coverage; subject to deductible at contracted transplant facility \n \nNot covered \n \n$10 \n \n$10 \n \n90% of coverage; subject to deductible \n90% of coverage; subject to deductible and $20 per visit co-payment up to 40 visits per Plan Year \n90% of coverage; subject to deductible \n90% of coverage; subject to deductible at contracted transplant facility \n$10 \n \nPreferred Brand Co-payment \nNon-Preferred Brand Co-payment \n \n$30 $100 \n \n$30 $100 \n \n$30 $100 \n \nBenefits Comparison \n \n20 \n \n HIGH DEDUCTIBLE OPTION \n \nIn-Network \n \nOut-of-Network \n \nThe Plan Pays: \n \n90% of coverage; subject to deductible \n \n60% of coverage; subject to deductible \n \n90% of coverage; subject to deductible \n90% of coverage up to 45 days per Plan Year; subject to deductible \n90% of coverage; subject to deductible \n \n60% of coverage; subject to deductible \nNot covered \n60% of coverage; subject to deductible \n \n90% of coverage; subject to deductible \n \n60% of coverage; subject to deductible \n \n90% of coverage up to 40 visits per Plan Year; subject to deductible \n \n60% of coverage up to 40 visits per Plan Year; subject to deductible \n \nHMO OPTIONS \nBlueChoice, CIGNA, Kaiser Permanente, UnitedHealthcare \nThe Plan Pays: \n100% after $25 co-payment \n \nHMO Plan Differences \nBlueChoice  referral required. Kaiser Permanente  100% after $30 co-payment \n \n100% of coverage; up to 120 visits per Plan Year \n90% of coverage; up to 45 days per Plan Year; subject to deductible \n100% of coverage; subject to deductible \n100% of coverage when medically necessary \n100% of coverage after $25 per visit co-payment; up to 40 visits per Plan Year \n \nUnited Healthcare  90% of coverage, up to 120 days per Plan Year; subject to deductible \nCIGNA  90% of coverage; subject to deductible; outpatient 100% not subject to deductible \n \n90% of coverage; subject to deductible \n \n60% of coverage; subject to deductible \n \n90% of coverage; subject to deductible at contracted transplant facility \n \nNot covered \n \n80% of coverage; subject to deductible $10 min./$100 max. \n80% of coverage; subject to deductible $10 min./$100 max. \n80% of coverage; subject to deductible $10 min./$100 max. \n \nNot covered Not covered Not covered \n \n100% of coverage after $25 co-payment per visit \n \n90% of coverage; subject to \n \nNo \n \ndeductible \n \n$10 \n \nKaiser Permanente \n \n Kaiser facility: $10 \n \nEckerd Drugs: $16 \n \n$25 \n \nKaiser Permanente \n \n Kaiser facility $25 \n \nEckerd Drugs: $31 \n \n$50 \n \nKaiser Permanente  \n \nN/A \n \nBenefits Comparison \n \n21 \n \n IMPORTANT PLAN CONSIDERATIONS \n \n! If you are covered under the PPO, Indemnity, High Deductible Health Plan or CCO option, for these options, you are required to obtain the necessary prior notification or prior approval for all inpatient admissions and certain covered services under the Plan. You should contact member services regarding notification requirements and verification of covered services. \nPPO and Indemnity Progressive Drug Management Program (PDMP) \nThis program assists your doctor in finding the most appropriate drug for you. The first step is usually a proven, less expensive treatment known to be safe and effective. If the drug does not work for you, your doctor may progress to another drug. A prior authorization may be required as the next step in the program. \nNote: If you should go to the pharmacy and are told that your prescription cannot be filled because it requires prior authorization, please have your doctor call Express Scripts with your clinical information. \n \nImportant PPO, Indemnity Considerations \nSee the Summary Plan Description for coverage details, including limitations and exclusions.  Some services may require prior approval before such services are covered. \nPrior notification is the member's responsibility to obtain. Also, some services may have limitations not contained in this summary.  Charges from non-participating providers are subject to balance billing. These charges are the member's responsibility and do not count toward deductibles or out-of-pocket spending limits.  Services covered under the PPO from in-network providers will apply to the in-network deductible and out-of-pocket limit.  Services covered under the PPO from out-of-network providers apply to the out-of-network deductible and out-of-pocket limit.  Co-payments do not apply toward deductibles or out-of-pocket limits unless otherwise noted. \nHigh Deductible Health Plan Considerations \nThe HDHP covers the same services and supplies as the SHBP's PPO Option, and includes the same network of participating physicians and hospitals  here in Georgia and across the United States. The HDHP also reflects the importance of preventive care, with a $500 annual benefit with no deductible. \nDeductibles:  The deductible applies to everything except the first $500 in preventive care \nexpenses. If you have family coverage, you must meet the family deductible before benefits are payable for any family member.  With the HDHP, you pay coinsurance after the deductible for in-network office visits and prescription drugs. \nYour Health Savings Account (HSA) Opportunity \nAn HSA is like a personal savings account for healthcare, except it's all tax-free. When you enroll in the HDHP, you may be eligible to open a HSA with an independent HSA administrator/custodian. You will need to contact a local bank or other financial organization to set-up your HSA Account. \nYou may open a HSA if you enroll in the HDHP and do not have other coverage  through your spouse's employer's plan, Medicare, Medicaid, a full unrestricted HCSA  or any other medical plan. \n \nHSA Highlights What you can contribute each year \nHow you contribute \n \nUp to HDHP deductible amount: \n $1,100 if you have individual coverage  $2,200 if you have family coverage \nas long as you continue to be enrolled in the HDHP. \nIf you are 55 or older, you may contribute additional dollars  up to $700/year  as \"catch-up\" contributions \nThrough deposits you make directly to the HSA administrator you select...either in a lump sum or in installments throughout the year. Payroll deductions may be available through your employer. \n \n22 \n \nImportant Plan Considerations \n \n HSA Highlights continued \n \nWhat you can use your HSA to pay \n \nHealthcare expenses (medical, dental, vision, overthe-counter medications) the IRS considers taxdeductible that aren't covered by any healthcare plan...see IRS Publication 502 at www.irs.gov. \n \nHow claims are paid \nWhat happens at the end of the year \n \nVaries based on HSA administrator, but generally you can pay expenses directly from your account (using a debit card or convenience checks), so there's no claim paperwork to submit \nUnused money in your account carries forward and continues to earn interest \n \nWhat happens if you don't enroll in the HDHP next year or leave your employer \n \nYou can no longer contribute to your HSA, but you keep the account and can continue to use the balance for eligible healthcare expenses \n \nPoints to Consider when selecting your HSA Administrator/Custodian \n The organization's credentials: As you look at an insurance company, a bank or other HSA custodian, check out its reputation for service, quality, licensing and financial stability. \n Investment options: How much interest will your HSA earn? Money market accounts typically earn 0.5% to 3.0% interest. Will you have a choice of investment options? Some HSA administrators require that your account balance reaches a certain threshold before you have investment choices. \n Claim payment: Many administrators offer a debit card that can be used at the doctor's office or pharmacy to pay your share of the cost of care, or even at an ATM to reimburse yourself for qualified expenses you have paid. Most offer checks, sometimes for an extra fee. \n Account fees: HSA administrators (typically) charge a set-up fee and a monthly maintenance fee. Sometimes there are additional transaction fees. \nImportant HMO Considerations \n Some services may require prior authorization by the HMO before such services are covered. Also, some services may have limitations not contained in this summary. \n Most HMOs require the selection of a primary care physician (PCP) to manage your care. Failure to specify a PCP could delay receipt of your ID card. However, in some instances the HMO assigns you a PCP located near your residence if a PCP is not specified. Note: UnitedHealthcare does not require the selection of a PCP. \n Most HMOs require you to obtain referrals to see most specialists. Failure to obtain a referral could result in denial of your claim. Note: UnitedHealthcare does not require a referral for coverage of specialist services. \n \n! NOTES APPLY TO ALL OPTIONS:  Preferred Drug Lists for SHBP members are subject to change. Prior to purchasing your medication(s), PPO and Indemnity members may view the drug lists at www.dch.georgia.gov or contact Express Scripts at 1-877-650-9342 or TDD 1-800-842-5754. HMO members may contact the HMO plan in which they are enrolled. \n Many drugs listed as non-preferred have a generic or a preferred brand name alternative. Preferred drug alternatives are therapeutically equivalent while being more cost effective. \n If the drug cost is less than the copayment, you do not have to pay the co-payment but the actual cost of the drug. \n Co-payments for drugs covered under the SHBP will not be changed or overridden on an individual basis. \n The SHBP defines maintenance drugs as medications for specified chronic conditions. PPO, PPO CCO, Indemnity and Kaiser members may obtain up to a 90-day supply of maintenance prescription(s) at one time for three co-payments. BlueChoice, CIGNA, and UnitedHealthcare members may receive a 90-day supply of maintenance prescriptions for two co-payments. Your co-payments are based on supplies of up to 30 days as this is the industry standard. However, some drugs are limited to a standard other than the 30-day supply for one co-payment. \n Lifetime benefit maximums are combined totals among the PPO Options, Indemnity, HDHP Option and HMO Options. \n Annual dollar and visit limitations, deductibles and out-of-pocket spending limits are based on January 1, 2006 to December 31, 2006. \n Contact each plan directly for more details regarding covered services, exclusions and limitations. \n \nImportant Plan Considerations \n \n23 \n \n IF YOU ARE RETIRING...WHAT YOU NEED TO KNOW \n \n! If you want to have health insurance under SHBP when you retire, you must enroll for coverage for you and any eligible dependents during the Open Enrollment period prior to your retirement. \nOnce retired, during the annual Retiree Option Change Period, you are allowed to change your Plan option only. You may add dependents only if you experience a qualifying event and request the change within 31 days. \n \nThe following information and \"Important Notices about your Prescription Drug Coverage and Medicare\" are provided to assist you with Retirement Planning. \n1 SHBP will pay primary benefits for non-enrolled Medicare eligible retirees as well as retirees who are not entitled to Medicare because they did not participate in Social Security or pay Medicare taxes. The premiums for these primary payments will be increased the month in which the retiree (or dependent spouse) becomes 65 or becomes eligible for Medicare due to disability. \n2 Effective January 1, 2006, the SHBP will implement a new Medicare policy. SHBP will calculate premiums and claims payment based upon Medicare enrollment for retirees over age 65 or those eligible for Medicare due to disability. As in the past, SHBP will coordinate benefits for members who are enrolled for Medicare Part A and/or B. Additionally, coordination will also begin for retirees who enroll in the Medicare Part D Prescription Drug Plan (PDP). Premiums will be reduced for each part of Medicare for which the retiree enrolls. \nAdditional Information Concerning Medicare Part D \nMedicare Part D will offer a standard and enhanced prescription drug plan if you are eligible for Part A and/or enrolled in Part B, you are eligible for Part D. If you are considering enrolling in a Part D plan, SHBP suggests that you enroll in a standard plan. The standard plan and the coordination of benefits with SHBP should meet your coverage needs. Please note that certain medications have specific Quantity Level Limits and some require Prior Authorization. The SHBP will still apply these requirements and limits to your prescription drug coverage. \nIf you will be retiring and are considering enrolling in the Kaiser Medicare Advantage (MA) option, you must make your election on the Membership Worksheet and submit to SHBP. Kaiser will mail you a Senior Advantage application that you will need to complete. You should also check Medicare Part D on this application. By checking this box, you are agreeing to have Part D Prescription Drug Coverage administered by Kaiser. \n \nIf You Are Retiring... \n \n24 \n \n IMPORTANT NOTICE ABOUT YOUR PRESCRIPTION DRUG COVERAGE AND MEDICARE \n \nPPO, Indemnity, CIGNA, United Healthcare HMO, Kaiser Permanente, BlueChoice and TRICARE Supplement Plan Options \nPlease read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with the State Health Benefit Plan (SHBP) and the new prescription drug coverage available soon for people with Medicare. \n1 Starting January 1, 2006, new Medicare prescription drug coverage will \nbe available to everyone with Medicare. \n2 DCH has determined that the prescription drug coverage offered by \nthe SHBP is, on average for all plan participants, expected to pay out as much as the standard Medicare prescription drug coverage will pay. \n3 Read this notice carefully  it explains the options you have under \nMedicare prescription drug coverage, and can help you decide whether or not you want to enroll. \nStarting January 1, 2006, prescription drug coverage will be available to everyone with Medicare through Medicare prescription drug plans. All Medicare prescription drug plans will provide at least a standard level of coverage set by Medicare. Some plans might also offer more coverage for a higher monthly premium. \nPeople with Medicare can enroll in a Medicare prescription drug plan from November 15, 2005 through May 15, 2006. Each year after that, you will have the opportunity to enroll in a Medicare prescription drug plan between November 15 through December 31. \nYou should compare your current coverage, including which drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. \nIn addition, your current coverage pays for other health expenses, in addition to prescription drugs, and you will still be eligible to receive all of your current health and prescription drug benefits if you choose to enroll in a Medicare prescription drug plan. \n \n! Because your existing coverage with one of the following SHBP Options: PPO, Indemnity, CIGNA, United Healthcare HMO, Kaiser Permanente, BlueChoice, and TRICARE Supplement is on average at least as good as the standard Medicare prescription drug coverage, you can keep this coverage and not pay extra if you later decide to enroll in Medicare coverage. \n! If you do decide to enroll in a Medicare prescription drug plan and drop your coverage with the SHBP, be aware that your next opportunity to enroll with the SHBP will be during the 2006 Open Enrollment for calendar year, January 1, 2007 through December 31, 2007, or if there is a qualifying event. \n \nPrescription Drug Coverage \n \n25 \n \n ! REMEMBER TO KEEP THIS NOTICE. If you enroll in one of the new plans approved by Medicare which offer prescription drug coverage after May 15, 2006, you may need to give a copy of this notice when you join to show that you are not required to pay a higher premium amount. \n \nYou should also know that if you drop or lose your coverage with SHBP and don't enroll in Medicare prescription drug coverage after your current coverage ends, you may pay more to enroll in Medicare prescription drug coverage later. If after May 15, 2006, you go 63 days or longer without prescription drug coverage that's at least as good as Medicare's prescription drug coverage; your monthly premium will go up at least 1 percent per month for every month after May 15, 2006, that you did not have that coverage. For example, if you go 19 months without coverage, your premium will always be at least 19 percent higher than what most other people pay. You'll have to pay this higher premium as long as you have Medicare coverage. In addition, you may have to wait until next November to enroll. \nFor more information about this notice or your current prescription drug coverage...contact your Pharmacy Benefit \nManager at the number on your identification card or call the State Health Benefit Plan at 404-651-6142 or 800-610-1863. NOTE: You may receive this notice at other times in the future such as before the next period you can enroll in Medicare prescription drug coverage, and if this coverage changes. You also may request a copy. \nMore information about your options under Medicare prescription drug coverage...will be available in October 2005 \nin the \"Medicare \u0026 You 2006\" handbook. You'll get a copy of the handbook in the mail from Medicare. You may also be contacted directly by Medicare prescription drug plans. You can also get more information about Medicare prescription drug plans from these places: \n Visit www.medicare.gov for personalized help. \n Call your State Health Insurance Assistance Program (see your copy of the Medicare \u0026 You handbook for their telephone number). \n Call 1-800 MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. \nFor people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Please contact the Social Security Administration (SSA) at 1-800-772-1213 (TTY 1-800-3250778) or visit their Web site at www.socialsecurity.gov for more information about this extra help. \n \nPrescription Drug Coverage \n \n26 \n \n IMPORTANT NOTICE ABOUT YOUR HDHP PRESCRIPTION DRUG COVERAGE AND MEDICARE \nHigh Deductible Health Plan Option \nPlease read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with the State Health Benefit Plan (SHBP) and new prescription drug coverage available soon for people with Medicare. \n1 Starting January 1, 2006, new Medicare prescription drug coverage \nwill be available to everyone with Medicare. \n2 DCH has determined that the prescription drug coverage under \nthe High Deductible Health Plan Option offered by the SHBP is, on average for all plan participants, NOT expected to pay as much as the standard Medicare prescription drug coverage will pay. This is important, because for most people, enrolling in Medicare prescription drug coverage before May 15, 2006, means you will get more assistance with drug costs. \n3 You have decisions to make about Medicare prescription drug \ncoverage that may affect how much you pay for that coverage, depending on if and when you enroll. Read this information carefully  it explains your options. \nStarting January 1, 2006, prescription drug coverage will be available to everyone with Medicare through Medicare prescription drug plans. All Medicare prescription drug coverage will provide at least a standard level of coverage set by Medicare. Some plans might also offer more coverage for a higher monthly premium. \nBecause the coverage you have with the State Health Benefit Plan is on average for all plan participants in the High Deductible Health Plan Option, NOT expected to pay out as much as the standard Medicare prescription drug coverage will pay, you might want to consider enrolling in a Medicare prescription drug plan. You can first join between November 15, 2005 and May 15, 2006. This is important, because if you do not get Medicare prescription drug coverage (or equivalent coverage) before May 15, 2006, you may have to pay a higher premium if you join later. You will pay that higher premium as long as you have Medicare prescription drug coverage. \nIf you don't enroll in Medicare prescription drug coverage by May 15, 2006, you may pay more. If you \nenroll after May 15, 2006, your monthly premium for a Medicare prescription drug plan could be much higher. If after May 15, 2006, you go 63 days or longer without prescription drug coverage that is at least as good as Medicare's prescription drug coverage; your premium will go up at least 1 percent per month for every month after May 15, 2006, that you did not have that coverage. You will have to pay this higher premium as long as you have Medicare prescription drug coverage. For example, if you go nineteen months without coverage, your premium will always be at least 19 percent higher than what most other people pay. \n27 \n \nPrescription Drug Coverage \n \n If you don't enroll in a Medicare prescription drug plan by May 15, 2006, you may also have to wait to enroll. Generally, after May 15, 2006, you can only join a Medicare \nprescription drug plan between November 15 and December 31 of any year. This may mean the number of months you have to wait for coverage will be longer, which could make your premium higher. \nIn addition, your current coverage pays for other health expenses, in addition to prescription drugs. You will still be eligible to receive all of your current health and prescription drug benefits if you choose to enroll in a Medicare prescription drug plan. \nYou need to make a decision. When you make your decision, \nyou should compare your current coverage, including which drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. \nFor more information about this information or your current prescription drug coverage...contact your Pharmacy \nBenefit Manager at the number on your identification card or call the State Health Benefit Plan at 404-651-6142 or 1-800-610-1863. NOTE: You may receive this notice at other times in the future such as before the next period you can enroll in Medicare prescription drug coverage, and if this coverage changes. You also may request a copy. \nFor more information about your options under Medicare prescription drug coverage...more detailed \ninformation about Medicare plans that offer prescription drug coverage will be available in October 2005 in the \"Medicare \u0026 You 2006\" handbook from Medicare you will receive in the mail. You may also be contacted directly by Medicare-approved prescription drug plans. You can also get more information about Medicare prescription drug plans from these places: \n Visit www.medicare.gov for personalized help. \n Call your State Health Insurance Assistance Program (see your copy of the \"Medicare \u0026 You\" handbook for their telephone number). \n Call 1-800 MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. \nFor people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information about this extra help is available from the Social Security Administration (SSA). For more information about this extra help, visit SSA online at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). \n28 \n \nPrescription Drug Coverage \n \n HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) ANNUAL NOTICE \n \nThis section describes certain rights available to you under the Health Insurance Portability and Accountability Act (HIPAA) when you enroll in the SHBP. \n \nThe PPO, PPO CCO and Indemnity Options contain a pre-existing condition (PEC) limitation. Specifically, the Health Plan will not pay charges that are over $1,000 for the treatment of any pre-existing condition during the first 12 months of a patient's coverage, unless the patient gives satisfactory documentation that he or she has been free of treatment or medication for that condition for at least six consecutive calendar months. If you are enrolling as a new hire, this 12-month period begins on your hire date. However, a pre-existing condition limitation does not apply to coverage for: \n Pregnancy; or \n Newborns or children under age 18 who are adopted or placed for adoption, if the child becomes covered within 31 days after birth, adoption or placement for adoption. \nIn certain situations, SHBP members and dependents can reduce the 12-month pre-existing condition limitation period. The reduction is possible by using what is called \"creditable coverage\" to offset a preexisting condition period. Creditable coverage generally includes the health coverage you or a family member had immediately prior to joining the SHBP. Coverage under most group health plans, as well as coverage under individual health policies and governmental health programs, qualifies as creditable coverage. \n \n! If you or a dependent (including a spouse) had any break in coverage lasting more than 63 days, you or your dependent will receive creditable coverage only for the period of time after the break ended. \n \nTo reduce the pre-existing condition limitation period for your own coverage, you must provide the SHBP with a certificate of creditable coverage from one or more former health plans or insurers that states when your prior coverage started and ended. Any period of prior coverage will reduce the 12-month limitation period if the time between losing coverage and your first day of SHBP coverage does not exceed 63 days. If you are enrolling as a new hire, the 63-day period is measured from your last day of prior coverage up to your date of hire. \nTo reduce the pre-existing condition limitation period for your dependents (including your spouse), you must provide the SHBP with a certificate of creditable coverage stating when coverage started and ended for each dependent that you want to cover. Again, any period of prior coverage for that dependent will reduce the 12-month limitation period if no more than 63 days have elapsed between the dependent's loss of prior coverage and the first day of coverage under the SHBP (or your date of hire, if you are enrolling as a new hire). \n \n! Please submit your certificate of creditable coverage to the Plan with your enrollment paperwork. If you require assistance in obtaining a letter from a former employer, contact your personnel/ payroll office. \n \nHIPAA Notice \n \nWithin two years after your former coverage terminated, you have the right to obtain a certificate of creditable coverage from your former employer(s) to offset the pre-existing condition limitation period under the SHBP. The SHBP will evaluate your certificate of creditable coverage or other documentation to determine whether any of the pre-existing condition limitation period will be reduced or eliminated. After completing the evaluation, the SHBP will notify you as to how the pre-existing condition limitation period will be reduced or eliminated. \n \n29 \n \n DEPARTMENT OF COMMUNITY HEALTH PRIVACY NOTICE \nThis notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. \nThe Plan's Privacy Commitment to You \nThe Georgia Department of Community Health (DCH) understands that information about you and your family is personal. DCH is committed to protecting your information. This notice tells you how DCH uses and discloses information about you. It tells you your rights and the Plan's requirements about your information. \nUnderstanding the Type of Information That the Plan Has \nYour employer (state agency, school system, authority, etc.) sent information about you to DCH. This information included your name, address, birth date, phone number, Social Security Number and other health insurance policies that you may have. It may also have included health information. When your health care providers send claims to the Plan's claim administrator for payment, the claims include your diagnoses and the medical treatments you received. For some medical treatments, your healthcare providers send additional medical information to the Plan such as doctor's statements, x-rays or lab test results. \nYour Health Information Rights \nYou have the following rights regarding the health information that DCH has about you: \n You have the right to see and obtain a copy of your health information. An exception is psychotherapy notes. Another exception is information that is needed for a legal action relating to DCH. \n You have the right to ask DCH to change health information that is incorrect or incomplete. DCH may deny your request under certain circumstances. \n You have the right to request a list of the disclosures that DCH has made of your health information beginning in April 2003. \n You have the right to request a restriction on certain uses or disclosures of your health information. DCH is not required to agree with your request. \n You have the right to request that DCH communicates with you about your health in a way or at a location that will help you keep your information confidential. \n You have the right to receive a paper copy of this notice. You may ask DCH staff to give you another copy of this notice, or you may obtain a copy from DCH's Web site, www.dch.georgia.gov (click on \"Privacy\"). \n30 \n \nPrivacy Notice \n \n Privacy Law's Requirements \nDCH is required by law to: \n Maintain the privacy of your information. \n Give you this notice of DCH's legal duties and privacy practices regarding the information that DCH has about you. \n Follow the terms of this notice. \n Not use or disclose any information about you without your written permission, except for the reasons given in this notice. You may take away your permission at any time, in writing, except for the information that DCH disclosed before you stopped your permission. If you cannot give your permission due to an emergency, DCH may release the information if it is in your best interest. DCH must notify you as soon as possible after releasing the information. \nIn the future, DCH may change its privacy practices. If its privacy practices change significantly, DCH will provide a new notice to you. DCH will post the new notice on its Web site at www.dch.georgia.gov (click on \"Privacy\"). This notice is effective April 14, 2003. \nHow DCH Uses and Discloses Healthcare Information \nThere are some services the Plan provides through contracts with private companies. For example, UnitedHealthcare of Georgia pays most medical claims to your healthcare providers. When services are contracted, the Plan may disclose some or all of your information to the company so that they can perform the job the Plan has asked them to do. To protect your information, the Plan requires the company to safeguard your information in accordance with the law. \nThe following categories describe different ways that the Plan uses and discloses your health information. For each category, we will explain what we mean and give an example. \nFor Payment \nThe Plan may use and disclose information about you so that it can authorize payment for the health services that you received. For example, when you receive a service covered by the Plan, your healthcare provider sends a claim for payment to the claims administrator. The claim includes information that identifies you, as well as your diagnoses and treatments. \nFor Medical Treatment \nThe Plan may use or disclose information about you to ensure that you receive necessary medical treatment and services. For example, if you participate in a Disease State Management Program, the Plan may send you information about your condition. \n31 \n \nPrivacy Notice \n \n ! Under the HIPAA Privacy Law, you may authorize the Plan to release your Personal Health Information (PHI) to another individual. If you have authorized the release of PHI to another individual, the personal representative form authorizing the release of your PHI is not transferred between options. This is for the protection of your privacy. If you wish to continue to designate another individual after changing health options, you may be asked to complete a new personal representative form. \n \nTo Operate Various Plan Programs \nThe Plan may use or disclose information about you to run various Plan programs and ensure that you receive quality care. For example, the Plan may contract with a company that reviews hospital records to check on the quality of care that you received and the outcome of your care. \nTo Other Government Agencies Providing Benefits or Services \nThe Plan may give information about you to other government agencies that are giving you benefits or services. The information must be necessary for you to receive those benefits or services and will be authorized by you or by law. \nTo Keep You Informed \nThe Plan may mail you information about your health and well-being. Examples are information about managing a disease that you have, information about your managed care choices, and information about prescription drugs you are taking. \nFor Overseeing Healthcare Providers \nThe Plan may disclose information about you to the government agencies that license and inspect medical facilities, such as hospitals, as required by law. \nFor Research \nThe Plan may disclose information about you for a research project that has been approved by a review board. The review board must review the research project and its rules to ensure the privacy of your information. The research must be for the purpose of helping the Plan. \nAs Required by Law \nThe Plan will disclose information about you as required by law. \nFor More Information and to Report a Problem \nIf you have questions and would like additional information, you may contact the SHBP at 404-656-6322 (Atlanta calling area) or 1-800-610-1863 (outside of Atlanta calling area). \nIf you believe your privacy rights have been violated: \n You can file a complaint with the Plan by calling the SHBP at 404-656-6322 (Atlanta calling area) or 1-800-610-1863 (outside of Atlanta calling area), or by writing to: SHBPHPU, P.O. Box 38342, Atlanta, GA 30334. \n You can file a complaint with the Health and Human Services Office for Civil Rights by writing to: U.S. Department of Health and Human Services Office for Civil Rights, Region IV, Atlanta Federal Center, 61 Forsyth Street SW, Suite 3B70, Atlanta, GA 30303-8909. Phone 404-562-7886; Fax 404-562-7881; TDD 404-562-7884. \n You also may contact the HHS Office for Civil Rights by calling 1-866-OCR-PRIV 1-866-627-7748 or e-mail to OCR at OCRComplaint@hhs.gov. \nThere will be no retaliation for filing a complaint. \n \nPrivacy Notice \n \n32 \n \n Women's Health and Cancer Rights Act \nThe Plan complies with the Women's Health and Cancer Rights Act of 1998. Mastectomy, including reconstructive surgery, is covered the same as other surgery under your Plan option. \nFollowing cancer surgery, the SHBP covers: \n All stages of reconstruction of the breast on which the mastectomy has been performed. \n Reconstruction of the other breast to achieve a symmetrical appearance. \n Prostheses and mastectomy bras. \n Treatment of physical complications of mastectomy, including lymphedema. \nFor more detailed information on the mastectomy-related benefits available under the Plan, you can contact the Member Services unit for your coverage option. Telephone numbers are on the inside front cover. \n \n! NOTE: Reconstructive surgery requires prior approval, and all inpatient admissions require MCP precertification. \n \nPenalties for Misrepresentation \nIf an SHBP participant misrepresents eligibility information when applying for coverage, during change of coverage or when filing for benefits, the SHBP may take adverse action against the participant, including but not limited to terminating coverage (for the participant and his or her dependent[s]) or imposing liability to the SHBP for fraud or indemnification (requiring payment for benefits to which the participant or his or her beneficiaries were not entitled). Penalties may include a lawsuit, which may result in payment of charges to the Plan or criminal prosecution in a court of law. \nIn 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. \n \n! Intentional misrepresentation in response to surcharge questions will have significant consequences. You will automatically lose State Health Benefit Plan coverage for 12 months beginning on the date that your false response is discovered. \n! DISCLAIMER: This material is for informational purposes and is not a contract. It is intended only to highlight principal benefits of the medical plans. Every effort has been made to be as accurate as possible; however, should there be a difference between this information and the Plan documents, the Plan documents govern. It is the responsibility of each member, active or retired, to read all Plan materials provided in order to fully understand the provisions of the option chosen. \n \nWomen's Health/Misrepresentation \n \n33 \n \n  "},{"id":"dlg_ggpd_y-ga-bc900-pe4-bs1-bn4-b2004-h2005","title":"State Health Benefit Plan, July 1, 2004 - 2005, new employee health plan decision guide","collection_id":"dlg_ggpd","collection_title":"Georgia Government Publications","dcterms_contributor":["Georgia. Department of Community Health."],"dcterms_spatial":["United States, Georgia, 32.75042, -83.50018"],"dcterms_creator":["Georgia. 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Map and Government Information Library"],"edm_is_shown_by":["https://dlg.galileo.usg.edu/do:dlg_ggpd_y-ga-bc900-pe4-bs1-bn4-b2004-h2005"],"edm_is_shown_at":["https://dlg.galileo.usg.edu/id:dlg_ggpd_y-ga-bc900-pe4-bs1-bn4-b2004-h2005"],"dcterms_temporal":null,"dcterms_rights_holder":null,"dcterms_bibliographic_citation":null,"dlg_local_right":null,"dcterms_medium":["state government records"],"dcterms_extent":null,"dlg_subject_personal":null,"iiif_manifest_url_ss":null,"dcterms_subject_fast":null,"fulltext":"-~A \n;goo.1;4 \n$/ \nA14 2004PlXJ5 \n \nSTATE HEALTH BENEFIT PLAN JULY 1, 2004 - JUNE 30, 2005 \n \no NEW EMPLOYEE HEALTH PLAN DECISION GUIDE \n \n o GEORGIA DEPARTMENT OF COMMUNITY HEALTH \nPHONE NUMBERS AND CONTACTS FOR BENEFIT AND PROVIDER INFORMATION \n \nPPO, PPO CUOICE OPTIONS \n(BASIC, PREMIER), INDEMNITY OPTIONS (BASIC, PREMIER) \n~ For rate information, cont:tct your personnellpayroll representative \n~ For benefit COVCr'dgC information, call Member Services at: (BOO) 483-6983 (outside Atlanta), or (404) 233-4479 (in Atlanta) \nTOO Line for the hearing impaired: (800) 269-4719 (outside Atlama), (404) 842-8073 (in Atlanta) \nYou can get both National and Georgia PPO prO\\ri.der information online at: www.healthygeorgia.com \nBEHAVIORAL HEALTH SERVICES \nAll Options except HMOs \nContact Magellan for prOVider and referral information. 24 hours per day, \n7 days per week. (BOO) 631-9943 \nwww.magellanhcalth.com \nTOO line for hearing impaired: (678) 319-3860 or (BOO) 201-8316 \n \nPRESCRIPTION DRUG PROGRAM INFORMATION \nAll Options except HMOs Contact the Pharmacy Benefits Manager, Express Scripts, at (877) 650-9342 \nTOO line for the hearing impaired: (BOO) 842-5754 \nTIle Basic and Premier dnlg lists are online at www.dch.st;J.tc.ga.us \nHMOs BlueChoice HeaJlbcare Plan (BOO) 464-1367 Online provider information: www.hcbsga.com \nor QGNA HealthCare Georgia \n(800) 564-7642 Online provider information: www.cigna.com \nKaIser Permanente (404) 261-2590 (800) 6]]-18]] \nOmine provider information: www.kaiserpermaneIJte,org \nUnitedHealthcare of Georgia (866) 527-9599 Online prm'ider information: www.provider.uhc.com/gdch \n \nIf you enroll for health insurance co\\'en.ge under me Sute Hcalm Benefit Plan (SHBP), )'Ou should receive a Swnmary Plan DeSCription (SPD) from your Human Resourus Depanment.This SPD reflects Plan benefits as of April 1,2003. Eolch yC'J.r, any Plan changes are printed in an Upf/ater, which is your official nOlice of Plan changes. You may request a copy of the July 2003 and 2004 Updaters from your personnel office or you may print a copy from the OCH Web Site, www.dch.statc.ga.lIs.Please keep your Summary Plan Description (SPD) and Updaters for fut\\ltC reference. If you arc disabled and need this information in an alternative format, call the TOO Relay Service at (800) 255-0056 (text telephone) or (800) 2550135 (voice) or write the SHBP at P.O. Box 38342, Atlanta. GA 30334. \n \n PHONE NUMBERS AND CONTACTS FOR BENEFIT AND PROVIDER INFORMATION THE STATE HEALTH BENEFIT PLAN  GENERAL INFORMATION  \n \n INSIDE FRONT COVER \n .. 2  .. 4 \n \nOVERVIEW OF PLAN OPTIONS \n \n \n \n  9 \n \n~ INDEMNITY OPTIONS - BASIC AND PREMIER                              9 \n \n~ PPO AND PPO CHOICE OPTIONS - BASIC AND PREMIER  10-11 \n \n~ HMO OPTIONS.           .   \n \n  12 \n \n~ HMO CHOICE OPTIONS . 13 \n \nBENEFITS COMPARISON: PPO, PPO CHOICE, INDEMNITY AND HMO OPTIONS. PHARMACY BENEFIT OPTIONS  \nSEIlVICE AREAS FOR YOUR HEALTH PLAN OPTIONS  \n \n........ \n \n ....... 14 \n \n \n \n26 \n \n ........ 30 \n \nHEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) ANNUAL NOTICE \nDEPARTMENT OF COMMUNITY HEALTH PIlIVACY NOTICE \n \n................ 35  . 36 \n \nHow OCH USES AND DISCLOSES HEALTHCAIlE INFOIlMATION                     37 \n \nWOMEN'S HEALTH AND CANCER RIGHTS ACT  39 \n \nPENALTIES FOil: MISIlEPRESENTATlON                                      39 \n \no \n \n THE STATE HEALTH BE EFIT PLAN (SHBP) \n \nThe Georgia Department of Community Health, which administers the State Health Benefit Plan (SHBP), continuaUy seeks to offer high-quatiry, affordable health coverage. Keep in mind, however, that you are the manager of your healthcare needs, and in turn, must take the time (0 understand your Plan benefit choices in order (Q make the; beSt decisions for yOli and your family. \nYou may wonder how much your heahhcare benefits will COSt this year. Monthly premiums continue to increase and benefits arc modified. This is true for State Health Iknefit Plan (SHBP) members as well as employees and retirees nationally. Why docs this happen and how C:1O we better manage hcailhcare Costs? Actually, )IOU IlIll)1 be pari oftbe ~OllltiQIl. \n \nPeopk who do not understand thrir health eO\\'er age pay more,according (0 theArnerican Medical Association.To help you beuer understand your plan and save your healthcare dollars, we have prepared a few points for you to consider. \nlet's start by ralkjng about how the SHBP works. It is a seif-ftmtlet[ piau, which means Ih:u all expenses arc paid by employee premiums and employer funds. Approximately 95% of the premium goes dirt:ctly to pay hc;tlthcare claims and 5% goes toward adminisu:ring the Plan. \nThe g...a. phs below provide you with an idea of how the cost of your healthcarc is allocated between employees and employers. \n \n- $400 \n \n \n0 \n \n$350 \n \nv \n \n: $300 \n\"z \n0 $250 \n.-.~ \n0 $200 \n \n\u003e $150 \n0 \n\" $100 \n~ $50 \n.-0 $0 \n \n--- Monthl)' Employee Contribution \n \nMontbl)' Employer Contribution \n.e \n \nMonthl)' Total Cost \n-+- \n \nSTATE HEALTH BF.:\\f.F1T PLA:'Ii - PPO SI:\"OGLE \n \n5345.68 \n \n$303.45 \n \n$304.65 __ - - - - - . \n \n52'Z3.04 \n \n5289.00 _ __ _ ..........\"'-- - - - - - -.- _.... \n \n$286.62 \n \n~----------.... ----- \n \n5255.27 \n \n$255.27  \n \n............... $2 \n \n27. \n \n9 \n \n\" \n'I \n \n5243.90  \n \n. \n \n...545.10 \nFISCAL YEAR 2000 \n \n...$45.10 \nFISCAL YEAR 2001 \n \n..$48.18 \nFISCAL YEAR 2002 \n \n$49....38 \nFISCAL YEAR 2003 \n \n...$59,.06 \nFISCAL YEAR 2004 \n \n5505.06 \n \n-S535.00 \n \n.+ ... -----~-~- \n \n$373:34 \n \n.54032B \n \n..$1'31.72 \n \n-$S61.-=7? \n \n. - - -.- - ~~6.~~- \n \n$641.58 \n \n5461.30 5414.65 _$414.65  \n \n... SI47.10~ \n \n... $150.78 \n \n..$180.28 \n \n So wbat Call you do to belp manage your beaUbcare cos's and keep down 'be increase in premiums? \nUNDERSTAND YOUR OPTIONS \nCompare all your plan options, considering both the premium and out-of-pocket costs that you may incur. Web sites and phone numbers are listed on the inside front cover of the Decision Guide if you need more information. \nCONSIDER ENROLLING IN A HEALTHCARE SPENDING ACCOUNT (HCSA) \nA HCSA helps you save tax dollars, approximately 26-45%, depending on your tax situation. By electing to use a HCSA, you may set aside up to $5,040 aJUllIally to cover healthrdated treatment for yourself and your dependents. Eligible expenses include deductiblcs, co-paymems, over-the-counter items for medical purposes and costs for certain procedures not covered under your health plan. The benefit of this account is that you're able to pay for these out-of-pocket costs with taxfn:e dollars! Contact your HR represemative for more information. \nBECOME A MORE PROACTIVE CONSUMER Of HEAlTHCARE \nMost people do not realize how much their treatments, medicines and tests cost. The illustration below is one example of the savings from choosing a generic drug instead of a bmnd-name drug. \n \nSteps You Can Take Include: ~ Keep a list of all medications you take. ~ Shop in-network providers and pharmacies. \nEnd out what your drugstore charges for a drug, not just the co-payment. \n.. Use generic medicines whenever possible. .. Make sure all procedures are preccrtified, \nif required. .. Make sure you get the results of any test or \nprocedure. .. Talk to your prOVider. For example, ask your \ndoctor if tests are necessary or if there are other forms of treatment. \n~ Understand what will happen if you need surgery. \n~ Check your Explanation of Benefits (if provided under your plan oplion) and if something does not make sense or seems to cost too much, ask your provider about it. \nThese and other steps you take will help manage healthcare expenses, reduce your out-of-pocket costs and those of the Plan. In addition, these steps will help in keeping premium costs down. As an informed consumer of healthcare, you can have an impact on what you have to pay for premiums and be part of the solution. \nIf after reading this Guide you want more information before making a coverage decision, you can request a Summary Plan Description (SPD) booklet and Updaters from your personneVpayroll office. \n \nPRF.SCRIPTION BRAND NAME GENERIC SAVINGS \n \n- \n \n- \n \n. . \n \n. \n \n'Mi;'IBER'- \n \n \n \n~O-PAYME~T , \n \n$25 \n \n-\" ~ii-~- .TO-TAL~~...t.\"-l8~.(COSTl~ \n \n. PRESCJ!..I~.T_IO!,,!_. COST \n \n\\To I.!H~!lB \n \n$90 \n \n565 \n \n$10 \n \n542 \n \n532 \n \ntoyou-Sl5 \n \n- \n \nto SHBP - $33 \n \n o GENERAL \nINFORMATION \n \nELIGIBLE DEPENDENTS \nA dependent is defined as: \n~ Your spouse, if you are legally married as defined by the state of Georgia; \n~ Your never-married dependcnt dtildren who are: \no Natural or 1cgalJy adopted children and \nunder age 19; \ne Stepchildren under age 19 who live with \nyou al least 180 days per year; \no Olher children under age 19 if they live \nwilh you permanently and legall~' depend on you for financial supporl; \n Your natural children. legally adopred children or stl:pchilth'en who were covered under the SHBr before age 19 and who are physically or menrally disabled and dcpendelll all you f\u003clr primary support (they may continue their exisring Plan coverage past age 19): and \no Your childn::n from caregories 1,2 01':3 \nabove who arc registered hill-time students at fully accredited schools, arc not cmployed full-Lime and arc benveen rhe agl:S of 19 \nand 2;. \n \nDOCUMENTATION UPON REQUEST \nIn order to cover a SpOUSl: or dependent under the Plan, yOLl lllust provide dOClll1ll:ntation UpOIJ request frOlll tJle Plan. The Plan n:qui],l:s: \n~ A copy of your certified maniage license to cover spouses; \n~ A copy of:l certified birth certifiCate to COVCl\" a natural child: \n~ A copy of a stepdlUd's certified birth certificate, \nshowing your legal spouse as the natural parent \nof thc child, ;llld a llotarizt:d Jette]' documenting \nthat YOllr stepchild lives in your home on a pcrmanelll basis in a parentchild relationship Jor ar k;lst 180 days per year; \n~ Adopt ion papers. gu;mlian Or COurt orck]'s for other children who live with YOll perm;lllcntly and legally depend on rOll for financial support. (The SJmp wiU recognize and honor a Qualitkd Medical Child Support O]'der (QMCSO) for digiblt: ckpcndcnb. Sl:e yuu]' SPD for more inrormat ion); \n~ Disahility paperwork fix disabled dependents 19 and over; this documentation must he received by the Phn before thl: child's 19th birthday: or \n~ A c(.'nifiC:l\\ion leue]' for full-time studelll dependents from Ihe registfa],'s office of your child's school. \nSHUP conducts random audits of Plan members eligibility. Failure to provide the requested dOCurnelH'atioll within sixty days of the request, will result in the termination of the depemkllfs coverage n::r.roactively to his or her coverJ.ge effeclive date. The rccove]'y process to recover any and :111 paymenls made by thl: Plan on behalf of any ineligible dependents will begin 30 days afLer notification of cancellation. \n \n How TO ENROll \nIf rou're eligible to participate: in the SHUp, rou become a member by enrolling cith\u003c::r: \n~ As a new hire, within 31 dars of your hire date. If yOll join rhe SHBP during that first 31day enrollment opportunity, roul' coveragt: will go into efftct on the first day of the month after you completc one: full calendar month of employment. See your personnel/payroll office for instructions on how to enroll. \n~ As a result of a qualifying event. See \\Vbel1 Are \nC!Jallges Allowed? on page 6 of this Guide for \nmore demils. \nIf you elect to decline SHIW con:=rage, YOli must \ncomplete a Declination Form. available from your personnel/payroll office, and file it within 31 days of your hire date. \nIf you decide to become an SHUP member, you will have two major choiccs to make: \n~ YOUf coverage option-I'PO Basic, PPO Premier, PPO Choice Basic, PPO Choke: Premier, lmkmnily lbsic, lndemniry Pn.;mitr, HMO Option or HMO Choice Option (if you live or work in an HMO servin; an:a); and \n~ Your coverage type-Single 01' Family coverage. For dewils on Single and Family cover-lge, see your SPD and Upda/crs. \n \nWHAT HAPPENS IF I HAVE OTHER INSURANCE? \nYOli or YOLlr covered dependents may have medical coverage under morc than one plan. In this case, the Plan's coordination of benefits (COB) provisions apply. \nWhen SHUP benefits are coordinated, the Plan does not pay morc than [00% of the Plan's allowed amount. Non-covcrcd serviceS or items, penalties and amountS balance billed arc not pan of the allowed amount and are the subscrihc(s responsibility. \n11 is important that you notify us if you have mher group coverage to prevent incorrect pnxessing of :my claims. I'or further information about COB rules, n:fer to the SPO. \nCOBRA RIGHTS \nTIle Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986 requires that the Plan offer you, your spouse or an eligible dependent the opponunity to continue he\u003cllthollt covemge if Plan coverage: is lost due to a qualifying event.l1H: length of time yOll may continue the coverage is based on the qualifying event. For fl.1fther information, please refe:r to your SPD. \n \nKeep in mind that once you do enroll or decline, you cannot change your coverage voluntarily until the next Open Enrollment Period, unless you c--xperieoce a qualifying event thai would permit a corresponding change. \n \n \n \n WHfN ARf CHA GfS AUOWfO? \nTIle henefit choices you make as a new hire will Sla)' in effect for the duration of the 2004 - 2005 Plan year - Jul}' 1,2004 - June 30,2005, unless rou experience certain changes in status as defined by feder.tl law, Section 12; of the internal Revenue Code, which governs the ST-mp, does not permit canceling or othc.rwise changing your coverage during the Plan Yl.-ar unless you have a qualifying evenl. \nQualifying events include, but arc not limited to: \n.. Marriage or divorce; \n.. Ilirth or adoption of a child or placement for adoption; \n.. Death of a spouse or child, if only dependent enrolled; \n.. Your spouse's or dependent's e1igibilit}' for or loss of eligibility for other group health coverage; \n.. A change in residence by you, your spouse or dependents that makes you or a covered dependent ineligible for coverage in your selected option; and \n.. A change in employmelll status lhat leads to a loss or gain of digibility under the Plan. \n \nIf you declined enrollment for yourself or your dependents (including your spouse) bec-.msc of other health insurance covc.r.tge, you may, in the future, be able to enroll yourself or your dependents in the Plan. provided that you request enroUmem within 31 days of whcn your other co\\'erJ.ge ends, In addition, if you have a m'. W dependent as a l\"l.'Sult of marriage, binh, adoption or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 31 days of the marriage, birth, adoption or placement for adoption, and pro\\'ide the required documentation. \nFor additional information about qLmlifying events, see your SPD available from your pcrSOilllc! officc or online at www.dch.state.ga.lL..t \n \n OVERVIEW or How EACH HEALTH PLAN OPTION WOKKS \nOn lhe following pages, yOll will find a brief descriplion of each option and importanl consider:llions 10 help yOlI select the best option for you. \nCont3ct the Member Services unit for each option if you need more detail. Telephone numbers :Lre on the inside front cover. You \nalso may access an SPD and Updatel's \nonline 3t www.dch.state.ga.us. \nTo help you understand the information in this \nsection, a few key terms are defined below: \nIMPORTANT TERMS TO UNDERSTAND \nAllowed Amount-A dollar amount lhe Plan uses lO calcul:ne benefits payable. The Plan uses the following allowed amounts: \no Network Rate-for in-network PPO services; o Out-ofNetwork Rate-for out-ofnetwork \nPPO services; and \no Indemnity Rate-for Indemnity Option \nservices, \nBalance BUling-A dollar amOllJ1( charged by a provider that is over the Plan's allowed amount for the care received, YOli arc subject lO balancc billing when YOll receive services from non-partil.ipating providers, including emergeol.1' services. \nCo-lnsurnnce Amount-The percentage of the Plan's allowed amount paid b)' a 1)lan member in lhe PPO or Indemnity Option. Depending on the option selected, the SHOP generAlly pays 90% to \n60%. so )'OUr co-insur.mce is between 10% and 40%. \n \nCo-paymeol-A set doUar amount that rOll pay al lhe time yOU receive :crvices or ilems. For eX;llllple, rOll pay a 530 co-p:l)'melll for :Ill in-network I)PO phrsicians office visit while rOll arc at the physician's office. Co-paymcnts do not apply to Plan )'C:lf deducribles or Out-of-pocket limils unless otherwise noted. \nCovered Services-Services for mcdically necessary care that are eligible for reimbursemenl under the Plan, \nDeductible-A specified dollar amOlllll, which varies by Plan option, for specified cmcred services that rou must pay OUI-orpockel each Pl:m rear before the PPO Option or Indemnity Option pays a benefit. Depending on rour COVCr.lb'C option, the deductible may nm :lpply to some services. For example, the dl.-Quctible docs nOt appl)' to innetwork physician office visits under the PPO Option. R\\10 Options do not have deductibles. \nEmergency Care-Care.: provided when a sudden, se....ere and uncxjx:ctcd illness or injury h,lppcns that could be Iife-rhrc:ltcning or result in pcrmaneJlt impairment of hndily functions if not lrealed immediately. \nLifetime Maximum-The maxillllllll dollar amounl thal each Plan member may n,:cdve in benefits from the SHill' during his or her lifetime. \nMedical Certification Program (MCP)-A feamre of the I)PO and Indemnity Options that helps you and the 1)lan save money by preventing unnecessary c:trc. To receive full benefits, you must comply with the MCP requlremems outlincd in the 51)0 and U/Xla/ers. \n \n \n \n Out-of-Pocket Limlt-A maximum amount you would have to payout of your pocket each Plan year for covered services. Once you meet your out-of-pocket limit for the Plan year, the Plan pays 100% of the allowed amounts for most covered services for the rest of the Plan year. Your out-of-pocket costs for premiums, co-payments and non-covered charges are not applied to the limit.The deductible is applied to your annual out-of-pocket limit. \nParticipating Provider-Any physician, hospital or other health-service professional or bcility that ofkrs covered services and that has joined the PPO network, the Indemnity network or HMO network for the Plan option. Providers nominated and accepted under a Choice Option also are considered participating providers for the person making the nomination. PartiCipating providers may not balance bill Plan members for covered services. \nPRE-EXISTING CONDITIONS AND COVERAGE LIMITS \nA Pre-existing Condition (PEC) is any sickness, injury or other condition (except as noted below) for which medical advice, diagnosis, care or treatment, induding prescription medication, was recommended or received within SLX months immediately preceding a member's coverage effective date under the Plan. \nNew SI-IBP members who enroll in the PPO or Indenmity Option and have a PEC have a 12-momh coverage limitation period for their PECs. Coverage for each PEC is limited to $I,O\u003cXJ during the first 12 months of Plan eovemge. \nFor new employees, the l2-month coverage limitation period begins the first day of the month in which the new employee was hired. \n \nThe PEe limitation period does 110t apply to coverage for pregnancy, for a newborn, or for a ne\\vly adopted child or a child placed for adoption under the age of 18, if the child becomes covered within 31 days of birth or adoption. \nEnrollees are treated as new members, subject to the PEC limitation period, if they are enrolling in the PPO or Indemnity Option after a coverage break of four or more months. \nCREDITABLE COVERAGE \nSHBP members and dependents can reduce or eliminate the l2-mOlllh PEe limitation period by documenting \"creditable coverage.\"' Cn.:ditablc coverage generally includes the health coverage you or a family member had immediately before joining the SHBP Coverage under most group health plans, individual health policies and some governmental health progm1lls qualifies as creditable coverage. \nTo reduce or eliminate the PEC limitation period for your own coverage: \n... You must provide the SHBP with a certificate of creditable coverage from one or more former health plans or insurers that states when your prior coverage staned and ended. \n \n o OVERVIEW OF PLAN OPTIONS \n \nThe State Heahh Benefit Plan has conll':lClcd with heallhcare organiZ:ltions that have been carefully reviewed and selected to provide the highest Ieyel of provider accessibiliry and quality of care. When selecting your health plan option, it is t.'\\:t'remely critiGl1 that you fully understand how the provider network functions for the ,'acious health plan options. \n \nINDEMNITY OPTIONS - \nBASIC AND PREMIER \nTilt: Indemnity Options arc traditional fccforscovicc plans that generally provide the same benefit coverage k\"e1 no maner which qualified medical provider yOll use. These Plans reimburse up 10 the Plan's allowed amounts for con:red services,'I11c Indcnmiry Options also lise contr:lcted healthcarc providc::rs who have agreed to discounted rates without balance billing for c:..:harges over the allowed amount. As long as you lise a participating provider, you may not be balance billed for covered sen'ices. Howcwr, nOI all Georgia proViders panicip:lle in these special arr:mgemems and there are no participating Indemnity Network providers outside of Georgia. In mosl instances, non-panicipating providers' billed charges :Ire considerably higher th:1tl the Plan's allowed amounts. Hospital stays (even for emcrgcm:ies) outside of Georgia em result in signifkant balan\u003c.:e billing amounts. In some cases, this can be wdJ in excess of 510,000. \n \nI'oints to Consider \n~ You mar access an~' provider. \n~ YOli may par most heallhClre bills up 10 the deductible amount before the Plan stans paring benefits. \n~ YOli continue to pay co-insurdnce for covered sen'ices after meeting the deductible (up to lhe OUH)fpockct maximum). \n~ When using a non-participating provider, including aU out-of~slate providers, you are subject to bal:lIlce bilJing for charges ovcr the aUowed amowns.1l1csc :lmounk'\u003e do nO( apply to the ollt-of-pocket maximum. \n~ Compare lhe Basic and Premier Phamlaq- Options. \n.. You must call the I\\!'edical Cenific:nion Progr:ml 0'lCP) to prtcenify inp:uient stays at non-participating hospitals, and members must prcc:..:ertify certain outpatienl tests and procedures. Financial penalties apply if precerlific:uion rules are nOI followed. \n \nThere arc two pharmacy options under the Indemnity Plan Options.-111ese options :Ire the IJldcmnit)' \"asic and [ndemnity Premier. The medical benefits are the same under the Basic and Premier options. For additional informalion refer to page 26 of this Guide. \nNOt(: Somt contract groups thtU participau ill tilt SHE? au not tligib/~ to partieipau /11 tht IndrmnilJ Optioll. \n \nNOtE: The State Health Benefit Plan does not have the legal authority to intervene when non-participating providers balance bill; therefore, the State Health Benefit Plan cannot ..educe 0 .. elltninate amounts balance billed. In addition, the Health Plan cannot make additional payments above the allowed amounts when you are balance billed by non-participating providers. \n \no \n \n PPO AND PPO CHOICE OPTIONS BASIC AND PREMIER \nThe PPO Options offer you a network of over 14,000 Georgia participating physicians and 166 Georgia hospitals managed by 1st l\\'ledical Network in the Georgia service area. You also have the added benefit of access to a national network of panicipating providers and hospitals across Ihe United States, which is managed by the Beech Stccet Corporation.The PPO Options offer you the choice and flexibility of using in-network or out-of-network providers. In order to receive the highest level of benefit coverage and avoid filing claims and balance billing, yOll will need to use an in-network provider. If YOli choose to use an om-of-network providc:r, the reimbursement will be at a lower level of benefit coverage. NOfe:The Transplant and Bch:lvioral Health Services (B1'IS) networks arc separate from the Ist Medical Network and the Ueech Street Network. \n'10 view the list of 1'1'0 providers onhne, visit www,hcalth)'georgi'l COlD. If you do not have Internet :lccess, call Member Services for provider information. \n.It is ultimatcly your responsibility to verify if a provider participates in the PPO network prior to receiving services. Providers may entcr or leave thc network at any time. \nThere arc two pharmacy options under the PPO and PPO Choice Options - PP{) B::lsic and PPO Premier. TIle medical benefits arc the same under the PPO :ll1d PPO Choice Options. Please refer to page 26 for additional information . \n \nPoints to Consider \n.. You do not need [Q select a primary GIn: physician (I'CP) or obtain referrals to see specialists. \n.. No balance billing when using participating PPO providers. \n.. You pay a minimal co-payment for in-network PPO physician visits. Other covered services are subject to dc::ducribles and co-insurance. \n.. YOli may access any licensed out--of-network physician, specialist or hospital at any time. However. you will genernUy pay more for out-of-nerwork services and dlarges are subject to b:llance billing. \n.. You must \u003c..,111 the Medical Certification IJrogram (MCP) to precertify inpaticm stays and specified olllpatient procedufCs when you arc using olll-of-network providers or Beech Street providers (National PPO network). \n.. Some physicians affiliated with our PPO networks may not accept new patients at certain times during the year or may drop out during the year. Please check with the physician of your choice before you enroll in one of the PPO Options. \n.. Compare the pharmacy programs . \n.. In-nctwork hospitals may contract with ollt-of nctwork physicians or labs. You may be subject to balance billing by these providers. \n.. YOll have access to a mltional network of Beech Street providers. Your level of benefit coverage is gener-lIly different and you are subject LO Separate deductiblcs and out--of-pockct maximums. \n.. Physicians or hospitals leaving the network are not considered a qualifying event and do not allow you to dl,lIlge coverage. \n \n The C('Orgia Sf!rt'lce tln'ti i\"di/tI('S the slate of Georgia ClIlti the border comll1lll/ilit'S of tbe Clxl1tcmoogtl, Telllu!SS(.'t' an'CI, illClut/iIl,C: 8rt/(l/e)1 C(lIIII~\"; and pwnL, Cit); Alabama. TlJe zip axle area III which yOi/ receille a senl;ee is IISl'tI to tletermille Il'IJf!tber or nol JUll are ;1/ tbe Georgia serillee area.!iee j}(lge 30 for fllrtbe-r b/fonlultiQ1J. \n \n ADDITIONAL INFORMATION ABOUT \nPPO CHOICE - 8ASIC AND PREMIER \nlknefits under the PPO Choice Options arc the same in the PPO Et'lsic lmd PPO Premier Options. However, PPO Choice Option premiums arc higher. In return for a higher premium, rou can request that an out-of-network Georgia provider be reimbursed as an in-network provider. TIlis request is kno\\vn as a Mnomination.... lf the out-of-network provider accepts your nomination, agrees to the PPO kes, and is approved by the PPO, you will receive in-network benefits for that provider. The in-network relationship between you and the provider remains in effect until you or the provider terminales Ihe llgreemenl. You may nominate as many eligible providers as you wish al lmy time during the Plan year. \n \nPoints to Consider \n... TIle PPO muSI approve YOllr provider nomination before you receive sen'ices_ \n... If your provider docs not accept rour nomination, docs nOt accept the network fees, or is not approved by the PPO Network Administrator, then services from that provider are coyen:d at the lower, out-of-network benefit le\\'el. SHBP rules do not aUow a member to change options when a nominated provider or the PPO rejects a nomination. \n... Only proViders loc:ned and licensed in Georgia can be nominated, even if you live oul of state. After the PPO receives your nomination, the PPO has three business days to either reject or approve the nomination. \nFor further details reWlrding the nomination process and to ohl'ain the necessary paperwork, please cantllel Member Services. \nNote:Tbe lJebavloral Healtb Services (BHS) amI transpltml proVider nelworks (/I'e \nseparate from tbe PPO provider /letwo/'k in \nall PPO alld PPO Cboice 0pliollS. To nominate a JJHS provider, contact the HHS Pro,r;ram at \n(800) 63/-9943. I'o/, /'IO/lli!Ulliolis of transplant \nproviders, C(/ll (800) 828-6518 (ullt~'ide Allanla). \n \n HMO OPTIONS \nHMO Options are available only [0 SHHP-eligibk t:mployces who livt: or work in an approved HMO service area in Georgia. -(See footnote.) Ple:ISC review the approved HMO service area list on pages 31- 34 of this Guide 10 determine if rou are eligible for an HMO. If your residence circumstanccs change during the Plan rear and yOli no longer live or work in an ::lpproved HMO service area, you will be required to changt: to another Plan option. \nHMOs provide prepaid benefits for most healthcare needs, with no bills or claim torms.Yol\\ are responsible for selecting a primary care physician (PCP) from a list of participating providers. M(See footnote.) YOLI must n:ccive care from your PCP or from a physiLian or f.ICi!it}' referred by rour pcp for your expenses to tx: co\\'ered. except in C\"'dSCS of emergenc), and in other limilt:d cases. If you receive care from a physician other than your PCI~ or without your PCP rcferral, there is no covcrage even if the physician or f.lcility is in the HMO nct work. \nPoints to Consider \n.. You must ;u.:ccss physicians, specialists and hOSpitalS offered through the HMO's network to receive henefits, except for emergencies as defined b}' the HMO. \n.. You choose a pcp to serve as your first point of conmct for most he;l1th\u003c.:are seniccs. \"(See footnotc.) Your covered family members mUSt also select a pcp. TIle PCP is responsible for coordinating rour healthc:ue services (speci:llislS, ancillary providers, hospitals). \n,. Providers may drop Out of the network al any time during lhe year and this is 11m a qualifying event to change coverage. \n \n.. See the Pharmacy lkndlt Options on page 26 to compare the pharmacy programs. \n.. YOLI pay only a minimal co-paymem for liMO innetwork ph~'Sician visits. prescriptiOn drugs and somc other covered services. \n.. You pay the full cost for non-referred sen'ices and for services received out.\u003c;ide tht: H)tOs panicip:uing netWork, except for t:IJlergencies \nas defined by the HMO. \n.. YOli ha\\'e coordinatc...-d care through a network of HMO participating pro\\'iders. \n,. In most cases, HMOs do nOl have: a deductible to meet, so your outol~pocketcost may he lower. \n.. There are no pre-cxisting condition limitations. \n.. You may be required to follow the HMO's standardized treatmcnt plan for your condition. For example, you mar be required to recei\\T treatment frOI11 your primaq' care physician for a specified period befort: being referred to a specialist. \n.. All services received outside the State of Gcorgia must be: coordinated through the HMO. \nC-) Some contract groups that participate in \nthe SHBP are not eligible to participate in the HMO Options. C--) Note: UnitedHealthcare HMO does not require you to select a pcp or obtain referrals to see specialists. \n \n HMO CHOICE OPTIONS \nIf yOlL are eligible for an HMO Option, YOll also :m: eligible for th:u HMO's Choice Option. \n11110 Choice Option benefits are the samc as the 11.::tjX'cti\\e regular HMO Option bendirs. HOWe\\TC the Choice Option premiums are higher. In return for a higher premium, the HMO Choice Option gin:s llll\"mbers the opportunity to reque:tl an OUI-of-nenvork Georgia provider to be trc;ttcd as an in-network provider. This requesl is known as a \"nomination.~ You may nominatc providers if Ihey arc located ant! licensed in Georgia and offer services covt:l1::d by the HMO. In ;Iddition, you may nominate.: as many eligible providers as YOLI wish at any time during the Plan YC:lr. \n \nPoinlS 10 Consider \n~ 111e HMO !TIllSt approve your OLlt-of-nctwork provider before YOli receive medical scn'ices. \n~ If the ollt-of-lletwork provider accepts YOllr nomination. accc.:pls the 1-I.\\IOs fees and is appro\\\"t:d by the H.\\10, you may receive in-llt:twork bcnefits from that proVider. \n~ If your prm'ider does not aCCt:pt your nomination. docs not accept the.: HMO's fees, or is not approved by till' HMO, sen'ices from that providt:r are not covered. \n~ Ikferral rules apply when the nominated doctor is a specialist for the B1ueChoice, elGNA and Kaiser HMOs. \n~ SHllP rules do nOI pcrm..it a member to change options \\..\"hen a nominatcd provider or HMO rejects a nomination. \nPlcase contact thc Mcmber Services Departmcnt of the respectivc HMO directly to find out more ::lbout the rcquired procedures and paperwork necessary to nominate a provider. Telephone numbers are listed on Ihe inside front cover, \n \nYou ARE PART OF THE SOLUTION! \n \n.~U'N'DERSTA~DING Yo.u~' HEALTH \n \nTlJis secti011 complres specific bellefllS witlJill IlJe PPO, Il1dertmily alld HMO OpUOIIS. \n \nFOI' more speciJlc itifm'matioll Oil covered services, call the Member Services IllImbers \n \nlisted Oil the illside from cover, \n \n00 o \n \n o BENEFITS COMPARISON: PPO, INDEMNITY AND HMO OPTIONS \nSCIIIWULE 01' B.:NEFITS FOR You AND YOUR DEPENDENTS - JULY 1, 2004 \n \nMa.'timum Lifetime Benefit (combined for all SHBP Options) \nPre-Existing Conditions (l51 year in Plan only, subject 10 HlPAA) \nLifetime Benefit Liotit for Treatment of: (combined for PPQ Option and Indemnity) .. Temporomandibular joint \ndysfunction (fMJ) .. Substance abuse .. Organ and tissue tr:msplants ... Home hypcr:llimcnt:ttion \nDeductibleslCo-Payments: ... Deductible-individual to Deduclible-f.lmily m:lximum \n.. Hospital deductiblc/admissionexcluding B1\"IS and trJ.llsplants \n... Hospital deductible/admissionBHS and transplants \n.. Hospital co-payment \nAnnual Out-of-Pocket Limits: .. Individual (you or one of your \ndcpendents) .. Family (you and yOllr dependents) \n.. BHS program (per patient); BHS authorized care only \n \n5400 \n$1,200 $250 $100 Nonc \nS 1, 0 0 0 \nSV)(}() \n \n52 million 51,000 \n \n51,100 \n \n3 episodes 5500,000 $;00,000 \n \nlo-Nctwork/OUI-of-SI:1te \u0026 OUI-QfNctwork amounts \u003c.'()mbint:d $500 51,500 \n \n5250 \n \n5250 \n \nS100 \n \n$100 \n \nNone \n \nNone \n \nLn-NetwOl'k/Ollt-of..State \u0026 Oul-of..Network amounts combined 52,000 \n \n52,500 \n \nS4,OOO \n \nPrimary Care Physician and/or Referral Required \nPrimary Care Physician or Specialist Office or Clinic Visits: .. Treafment of illness or injury \n \nNo \n \nNo \n \n100% NR- :lfrt:r a per visit co-payment of $30; \nnot subject [0 dcductible \n \n100% NR- after :I per \\'isit co-payment of 530: \nnot subject to deductible \n \nNo \n60% of DONn-; subject to deductible \n \n- See legend on page 24 for definitions of NR, OONR and IR. \n \n $2 mmion $1,000 \n \nBWF.CtJOICf \nTbe Plan Pays $2 million None \n \nHMO OPTIOSS \n \nOGNA \n \nKAl.\"ER PERMANEI'I,'TE \n \nThe Plan Pays: $2 million \nNone \n \nThe Plan Pays. \nNo lifetime benefit maximums \nNone \n \nUNITEOHEALnlC.o\\RE \nThe P/(m Pays. 52 million None \n \n$1,100 \n3 episodes \n$,00.000 S,OO,OOO \n'400 \n$1.200 \n'400 Sloo \nNone \nS2,O\u003cXl 54,000 52500 \n \nNo separ:uc lifetime benefit limit \n \nNo separate lifetime benefit limit \n \nNo separate lifetime benefit limit \n \nNo separate lifetime benefit limit \n \nNot applicable \n \nNot applicable \n \nNot applicable \n \nNot applicable \n \n_..-..................... ......_.._..... _.......... ... _............ __ ... _.. _- . __ ._.............. _... _- \n \nNot applicable \n \nNot applicable \n \nNot applicable \n \nNot applicable \n \nNot :tpplicable \n \nNot applicable \n \nNot applicable \n \nNot applicable \n \n$200 \n \n$200 \n \n5200 \n \n$200 \n \nNot :lpplicable \n \nNot applicable \n \nNot applicable \n \nNot applicable \n \nNot applicable \n \nNot applicable \n \nNot appliC'dblc \n \nNot applicable \n \nNo \n \nYes \n \nYes \n \nYes \n \nNo \n \n9O'XJ of JR'; subject to deductible \n \n100% after a per visit co-payment of 5 I; for primary c:lre :md 520 \nfor specialt)' care \n \n100% after a per visit co-paYlllent of 5 15 for primary care and 520 \nfor specialty care \n \n100% after a per visit' co-paymem of $15 for prim:lf)' care and 520 \nfor specialty cart: \n \n100% after a per visit co-payment of 5 15 for primary care and 520 \nfor specialty care \n \na ( Chari co\"U,oucd PRIf\u003e \n \n COVERED SERVICES \n \n----'-'-\"'- \n \n \n \n- - \u003e...... \n \nPrimary Care Physician or Specialist Office or Clinic Visits for the Following: .. Wellness care/prcvt:ntivc \nhcalthcarc .. Well-newborn exam .. Well-child exam$ and \nimmunizations .. Annual physicals .. Annual gynecological exams \n \n100% of NR aCler \n \n100% of NK after \n \n$.30 co-payment per office SjO co-paymelll per offiCI: \n \nvisit.IOO%ofNI~ with \n \n\\'isit. 100% of NK with \n \nno co-payment for a$sodatctl no co-payment for associated \n \ntests and immunLwtions. \n \ntests and immunizations. \n \nMaximum of S500 payable ~bximurn of $500 payable \n \nper person per Plan year \n \npef persoll I)(:r Plan year \n \nfor aU prcn:nth'e services. fOf all preventive services. \n \nM:lximulTI combined with M:tximlllll combined with \n \nIn-Network/Oul-Qf-5tate benefit. IJl.-Nt.\"\"twork/Gcorgia benefit. \n \nNot cove~d\" Charges do not :lpply to deductible or annual out-ol:pocket limits. \n \nNOltS: Lab and ICSI charges include such services as m:unmograms. proSI':l.IC scrcenings/PSAs, and pap tesrs. Gwered according to prc\"cnrh\"e ,--a~ age schedules. \nCon:red care schedliles are online al www.hcJ.hh\\geol\\:ill.com or call ,\\Iember \nSCrvief.-'S at (ROO) 483-6983 (olllside Allama) or (404) 2334479 (insillc: Allama). \n \nMaternity Care (prenatal, delivery and postpartum) \n \n90% of Nil; not subject 10 deductible after initial 530 co-payment \n \nsow' of NR; \nnot subject 10 deductible \nafter initial 530 co-payment \n \n60% ofOONR; subject to deduetihle and \nto balance billing \n \nPhysician Services Furnished in a Hospital .. Surgery in general, including charges \nby :surgeon, anesthesiologist, pathologist and radiologist \n \n90% of NIt; SUbject to deduCliblc \n \nsow, of NR: \nsubjeci to dl--\"ductible \n \n60% of 001\\l1t; subject to deductible \n \n.. Lnpaticnt well-newbonl exams \n \n100% of NR: not subject to dcductible \n \n100% of NR; llot subjeCl 10 deductible \n \nNot covered \n \nPhysician Services for Emergency Care \n \n90% of NR: subject 10 deductible \n \n90% (If NR: subject to In-Network/Georgia \ntleductible \n \n9O'Xo of NR: subjeci to In-Network/Geargia deductible \nand la balance billing \n \nOutpatient Surgery .. When billed as office visit \n \n90% of NR: SUbjCLt to deductible \n \n80% of NR: subject to uedllctible \n \n60% arOONI{: subject 10 deductible \n \n.. When billed as outpatient surgery at a facility \nIIOSPtTAL SER\\ ICF.S \nInpatient Services .. Inpmienr care. delivery and \ninp:tticnr short-tt:rrn acutc rehabilitation services \n.. Outpatient scrvicc$ .. Nan-emergency USe of Ibe emergency room .. Other \n \n90% of NK: subject to (Jeduclible \n90% of 1\\'R: subject ta a per :ldmis.\"ion \ndetluctible of 5250 \n90% of Nit; subject to deductible; subject 10 S 100/Visit \nco-payment \n \n80'}6 of Nit: subject to deductible \n8Q%ofNIt: subject to a per admission \ndeductible of 5250 \n8(jJ(, of NR; sLlbjcl.:t to deullctible; subject to SIOO/visit \nl.:o-paymem \n \n6O'J(, of OONR: subject 10 ueductible \n6O%0fOONR; ~ubjeci to a per admission \ndcductible of $250 \n(i)'X, of OO~lt sllhject to deductible; sllbjecr 10 $1 OONis!! \nco-p:trlllent \n \n.. WeU-newbom care \n \n100% of ;'\\TR: not subjcci to deductible \n \nI()()'h, of :\\'K: not sllbjeL\"t 10 deductible \n \nNot cO\\'ercd \n \n INDf.:\\tNITY OPTIONS \nBAStC A.\"lD PRF.toIIER \n- \nTile e../~'!. ~aJ's.~..(;.~ \n9O'J' of lR per office visit after deductible. \n1~ of IR with no deductible for associated \nlab and test charges, up to a maximum of 5200 per person per 1'1:In year; additi01l:11 $125 benefit for screening mammogram. \n \nBLUECIIOICE \n \nHMO OPTIo:\\,s CIGNA \n \nUNITEDHEAL111CARE \n \n17Je Plait Pa)'s' \n \nTlJe Pfti,~ P!i)'S.' \n \nn.Jp PI,,;' p(l)'~j.Jfi ~ n.Je Plan Pays \n \n100% after a per visil co-payment of S15 \nfor primary GIre amI 520 for specialty care. \nNo co-pa}'ment for immunizations and \nmammograms. \n \n100% after a per \\'Isit co-payment of S 15 for primary care and 520 for specialty care. No co-payment for inulluniz.,1lions and \nmammograms. \n \n100% aft~r a per visit co-paymenl of 5 I; for primary care and 520 \nfor specialty care. No co-parme.-\"1lt for immul1i7~1.tions and \nm:m1mogrnIllS. \n \n100% after a per \\'isil co-parment of 5 I; for primary care and 520 \nfor specialty care. No l.'O-parment for inmlUl1i7.ations and \nm:unmogrJ.IllS. \n \nNote: PPO nOles to the lett also apply hen:. \n \n90% of lit; subjeci 10 dcductible \n \n100% after initial 520 co-payment \n \n100% after inilial 520 co-payment \n \n100% after initial 20 co-payment \n \n100% after initial $20 co-payment \n \n90'.\\ of IR: subject to dctluctihle \n \n100% \n \n100% \n \n100% \n \n100'; \n \nNot cO\\Trcd \n \n100% \n \n100% \n \n100% \n \n100% \n \n90% oflR:subrcct to deductible anu to b:llance billing from lloll1,anicipating providers \n \n100% after applicable 100% after applicable 100% after applicable 100% after applicable \n \neo-pa}'l1lcnt \n \nco-payment \n \nco-payment \n \nco-paym~nt \n \n90% of In: subjecl lO dnluLtibk \n90'X, of Ill; subject to dcductible \n \n100% after $20 co-payment if billed as office visit \n$100 co-payment for outpatient surgery \n \n100% after $20 eOpayment if billed as office visit \n$ I 00 co-payment for outpatient surgery \n \n100% aftcr $20 co-payment if billed as ofJke visit \n$ 100 co-payment for outpatient surgery \n \n100% aftcr $20 co-payment if billed as office visit \nS100 copaymcllt for outpatient surgery \n \n90% ofIR; subjecl 10 :t l\u003eer admission \ndcducliblt: of 5400 \n90% of II{; subje.--x.1 lO deductible. If SCf\\;ces are in conjunction with non-emcrgency lise of the emergency room, benefit also subject to \n$IOO/\\'isit co-payment \n90% of lit: subject to ptT admission deduCtible of $1 00 \n \n100% after \n \n100% after \n \n5200 per confmement 5200 per confinement \n \nco-payment \n \nco-payment \n \n100% after \n \n100% after \n \n200 per confinemem 5200 per confinemelll \n \nco-payment \n \nco-paymenl \n \nPCP prior \n \nPCP prior \n \npcp prior \n \nauthoriZ3lion required allthori7..arion reqUired authori7.ation required \n \nfor coverage \n \nfor covcrnge \n \nfor eo\\'cr:lge \n \nRequires prior authori7.at'ion \nfrom 1'1\"10 \n \n100% \n \n100% \n \n100% \na ( Cb\",., \"\"\"\"\"\",'\u003c11'1;.1101 \n \n100% \n \n Outpatient Surgery .. Hospital/Facilit}' \nEmergenf.1' Care ... Treatment of :In emergency \nmedicaJ condition or injury \n \n90% of NR; subject to deductihle \n \n80% of NR; suhject to dcduclible \n \n60% ofOONR; subject to deductible \n \n90W. NI{ after a per \\'isit co-payment of $100; \nco-insurance and hospital deductible appl}'. if admitted \n \n9()'.l(, NR after a rx:r \\'isit co-payment of $100; \nco-insurance and hospital deductible apply, if admitted \n \n90% OONR after a per visit co-payment of S 100; \nco-insurance :md hospital deductible apply. if admitted. \nSubject to balance billing. \n \nNote: S 100 co-payments arc reduced ro $SO if referred by NurscCall 24 before receiving emtrgency roOm services. The ER co-payment is waived, if admitted within 24 hours. \n \nOUTPi\\TlE:'lIT TF.STING. tAn, ETC. \n \nL1boratory; X-Rays; Diagnostic Tests; Injections, including Medications Covered Under Medical Benefits - for the Treatment of an Illness or Injury \n \n90% of NR; subjcct to deductible \n \nSO%of NR; subject to deductible \n \nAllergy Shots and Serum \n \nI(X)\"Al of NR; not subjf.'Ct to the 100.16 of NR; not subject to the \n \ndeductible. If physician is seen. deductible. If physician is seen. \n \nvisit is treated as an orfice visit visit is treateJ as :Ul offic~ visit \n \nsubject to the per visit \n \nsubtect to the per visit \n \ncopayment of S30 \n \ncopaymem of S30 \n \nAUergy Testing \n \n90% ofNR: subject to deductible \n \n80% ofNR; subject to deductible \n \n60%ofOONR; subject to deductible \n60% ofOONR; subject to deductible \n60% ofOONR; subject to deductible \n \nBEHA\\IORAL HEALTH \nMental Health and Substance Abuse Inpatient Facility \n \n90% of Nit; sllbjecl to deductible and separate hospital deductible, \nif admitted when authorized by 13115 \n \n90% of NIt; subjecl to deJlIetible and separate hospital deductible, \nif admitted when authorized by 13115 \n \n60% of NR; subject to deductible and separate hospilal deductible, \nif admitted when authorized br nHS \n \nNote: 1oA11 services require prior :lllthori7.:nion. 2. Inpatient facility charges (limited to 60 combined mental health \nand substance abuse days per person per Plan year). 5. Subst:lOceAbuse eO\\'erage limite\u003c.lto three episodes per lifetime. \n \nPartial Day Hospitalization and Intensive Outpatient \n \n9O'Xi of NI{; \n \n90'% of NI{; \n \nsubject to deductible and subject to deduclible and \n \nseparate hospital deductible, separate hospital deductible. \n \nif admined when \n \nif admitted when \n \nau(horizcd b~' BUS \n \nauthorized b~' B1-IS \n \nNo benefit \n \nNote: I. Ma.ximum Ix:nefit of 30 combined PHP/IOP \\'isits/days pl'r person per P!:In rear. 2.l3encfit co\\'cragc is only available when using an in-network i\\bgelbt1 provider for partial/day hospitalization :tnJ intensive olltp:llient charges. \n \n INDEMNITY OPTIONS BASIC AND PREl'tUER \nThe Plan Pays_ 90% of IR; \nsubject 10 deductible \n \n100% after $100 per 100% after $100 per 100% after $100 per 100% after S 100 per confinement co-paymelU confinement co-payment confinement co-payment eonlinemelll co-p:lymclll \n \n90% U{ after a per visit co-payment of 5 100; co-insurance an\u003c.l hospital deductible, if admitlcd, apply_ Subject to balance billing from non-participating providers. \nNote: PPO note 10 the left also applies here. \n \n100% after a per visit co-payment of SSO (co-payment waived \nifadmined) \n \n100% aftcr a per visit co-paymcnt of $SO (co-payment waived \nif admitted) \n \n100% after a per visit co-payment of SSO (co-payment waived \nif admiued) \n \n100% after a peT visit co-payment of 550 (co-pa)'lllem waived \nif admitted) \n \n90% of IR; subjecl to deductiblc \n \n100% \n \n100% \n \n100% \n \n100% \n \n90% of IR; subject to deductible \n90% ofIR; subject to deductible \n \n100% for shots and serum after a $20 co-payment \nper visit \n \n100% for shots and serum aftcr a $20 co-payment \nper visit \n \n$; for shots and 5;0 for :l six-month \nsupply of serum \n \n100% for shots and scnllTI after a 520 co-payment \nper visit \n \n100% after a 520 per 100% after a 520 per 100% after a 520 per 100% after a 520 per \n \nvisit co-payment \n \nvisit co-payment \n \nvisit co-payment \n \nvisit co-payment \n \n90% of II{; subject to deductible \nif admitted when authorized by BHS \nNote: PPO notes to tile left also apply heTe. \n90% of IR; subject to deductible and separat\u003c.' hospital deductiblc, \nif admitted \n \n100% after 5S0 co-payment per confinemcnt; limited to 30 days \npC:f PI;m year \n \n100% after S50 co-payment per confinement; limited to 30 days \npte Plan year \n \n100% after 5;0 cO-pa)'lllent per confinement; unlimited days for 1llent.al health; \n3()-\u003c.lay limit for subst:ll1ce abuse \n \n100% after 5;0 co-payment peT confinement; limited to 30 days \nper Plan ycar \n \nOutpatient Care: \n \nOutpatient Care: \n \nOutpatient Care: \n \nOutpatient Care: \n \n100% after S20 per visit 100% after 520 per visit 100% after $20 pef visit 100% after $20 per visit \n \nco-paymel1l; limited to co-payment; limited to co-payment; unlimited co-payment; limited to \n \n2S visits peT Plan )'car 25 visits per Plan year days for mental health; 25 visits peT Plan year \n \nlimited to 25 viSits for \n \nsubstance abuse pCT \n \nPlan )'car \n \nS50 co-p:l)'mellt per confinement; contact \nHI\\'IO for specifics \n \n$50 co-payment per confinement; contact \nHI\\'IO for specifics \n \n$50 co-paymcnt per confinemcnt.: contaCt \nHMO for specifics \n \nS50 Co-pa)'IllCllI per confincmem; contact \nHMO for specifics \n \nNote: PPO notes to the left also apply hCTe. \n \n 23 Hour Observation Room (requires prior authorization to receive coverage.) \n \n90% of Nit; \n \n90\",.{, of NR; \n \nsubject to $100 deductible subjl:l't to $100 dcductiblt' \n \nNo benefit \n \nProfessional Charges Inpatient (combined total for substance abuse lind mental health) \n \n80% (If NR: subject to \ndeductible. MaxilUUJll 1 visit \nper alithoriz-.:lIliay when \n:I\\uhorized by 11II5. \n \nRO% of Nit subj-.:ct to \n \n;0% of NR; subject to \n \n(ledw.:tible.l\\Jlaximlim I visil deduclible and balance billing. \n \npCI' :llItllorizcd day when Maximulll of 25 professional \n \n:ltlthorizcd by B1-IS. \n \nvisits per person p\u003c:r Plan year. \n \nOutpatient (Precertification required to receive coverage,) \n \n80% of NH: subject to tkductiblc when authorized by BIIS, limited to 50 visits \nper Plan year. \n \n80% of Nn; subject 10 \n \n50% of NR: subject to \n \ndedllc('ibk when aUlhoriZt.:d deductible (without authori- \n \nby 13I-1S, limited \\(l 50 visits zation) and balancc billin~. \n \nper Plan )'c:lr. \n \nMaximum 25 combincd \n \nmcntal he:llth, substance \n \nabuse and brief therapy visits \n \nper person per Plan rear. \n \nLimited 10 scrvices rendered \n \nby a Psychiatrist (M.D.) or \n \na Psychologist (ph.D.) \n \nNou:: In-network maximum covcrage of 50-\u003c:ombined mental hcalth, SUbSI:lllcc.: ahuse, :llld brief Iher-Ipy visits per pl:rsun per Plan ~car. \nLimil indudc.:s 25 out-of-nl~twork cUlUlsding sessions amJ 3 brief visils. \n \nBrief-Visit Therapy (limit - 3 visits per Plan year; requires BHS prior authorization.) \n \n100%; not subjeci to deductibk \n \n90%: not subject to dc.:dllctible \n \nNo benefit \n \nNote: Visits are includcd in Ihe 50-visit limit of outpatiCIH care. \n \nDEN1'AL \n \nI \n \nv . ;- ' ,l i.-,.........,l.~ . _ ),\u003e. -:-,-T-2-: \n \n.. ~ '''''1 \n \nDental and Oral Care \nCoverage for mOSt procedures for the \nprompt rcp:Lir of sound naturaJ teeth \nor tissue for the cOn'eclion of damage \ncaused by trnumatic injury \n \n90% of NR; subjeCl to deductible \nand, if admitted, \nto hospilal deductible. Nctwork proViders \nmay nOI be :lv;lilablc \ntill' all covE-re(1 services: \ncharges are paid at 90% NIt \nsubject to balance billing \n \n80% of NIt; subject to dcuuctible \n:1l1d, if admitted, to hospital deductible, \nNetwork pl'()vidt:rs \nmay nOI be available for all covered services: \ncharges are paid at 80% NIt suhject to b:llance billing \n \n6o'J{, of OONn; \nsubject to deductible \nand, if admitted. to hospital deductiblc \n \nCoverage of specific osseous surgeries for the treatment of pcricxlorltal disease \n \nNot covcrcd \n \nNot \u003c:overed \n \nNot covered \n \nTemporomandibular joint syndrome (TMJ) \n \n90% of NIt; subject to dcductible \n \n80% of Nit subject 10 dedUCtible \n \n60% of OONlt suhject to deductible \n \nNote: Coverage for diagnostic testing and nonsurgicallreatmcm ofT:\\'1J, \nup 10 S1,100 pcr person lifetime \nmaximum bcncfit.This docs not apply \n10 the HMOs. \n \n INDEMNITY OPTIONS BASIC At~D PREMIER \n \n90'X, of IR: subject to $100 deductible \nHO% of IR; subjt:ct to deduccih1e ant..! balance billing. \nPPO benefits apply when authorized by BHS. \nSO'X, of He subject to dedllcribJc when authorized br lUIS, limited to 50 visils \nper Plan year. \n \n100% after $50 co-payment \n[00% \n100% after $20 co-payment \n \n100% after $50 co-payment \n100% \nI(Xl% after S20 co-payment \n \n100% after $50 co-payment \n100% \n100% after $20 co-payment \n \n100% after $50 co-payment \n100% \n100% after $20 co-payment \n \nNarc: !'PO notcs 10 the left also apply here. \n[00%: not subject to deductible \nNote: PPO note to the left also applies here. \n \nContact HMO for specifics \n \nContact HMO for specifics \n \nContact HI\\Jl0 for specifics \n \nContact HMO for specifics \n \n90% of lH; subject to deductible \nand, if admillcd, to hospital deductible. \n \n100% after applicable oral surgery co-payment and dental services for accidental injury to sound teeth \n \n100% after \n \nServices/appliances \n \n100% after \n \napplicable oral surgery for accidental injury to applicable oral surgery \n \nco-payment and llental sound and natural teeth: cn-payment and dental \n \nservices for accidental \n \n50% coverage \n \nservices for accidental \n \ninjury to sound teeth \n \non first SI ,000, \n \ninjury to sound tet:th \n \n100% thereafter \n \nNot covered \n90% of [H; subject to deductible \n \nNot covered \n \nNot covered \n \nNot covered \n \nNot covered \n \n100% after applicable co-payment fnr related surgery and diagnostic \nservices. Excludes appliances and \northodontic treatment. \n \n100% after applicable co-payment for related surgery and diagnostic \nservices. Excludes appliances and \northodontic treatment. \n \n50% for non-surgical treatment: 100% after applicahle co-payment \nfor related surgery and diagnostic \nservices. Excludes appliances and \northodontic treatment. \n \nIOO'){, ;Iner applicable co-payment [or related surgery and diagnostic \nservices. Excludes appliances and \northodontic tre\u003cllment. \n \n1:1 ( c/)(,,, cOIlIi\"\",,\" jJg.22 \n \n Note: PPO Oplions include :1 diS\u003c.'ount progralTl for \\'ision screenings and eyewear. Coll[aCI BllIL\u003e(:hoice Vision Progr...m:1I (800) 377-6436 or visit u'ww.hchsg;u:om for lTlore infonnatioll. Vision prngr:lm avail:lbilir), is subject [0 change during the Plan rear. \n \nOTHER COVERAGE \nAmbulance Services for Emergency Care \nNotc:-L:J.nd or air ambulancc~to nearest fadlily to treat the condition. \n \n9O%ofNR: subject to deductible \n \n90% of NR; subject [0 In-NetWork/Georgia \ndeductible \n \n90% of OONR; subject to In-Network/Georgia deductible \n \nNote: limited [0 transportation for emergencies and benefits subject to balance billing for non-participating providers of ambulance scn'ices. \nUrgent Care Services in an Approved Urgent c.\"lre Center \n \n90% of l'\\R after :1 per visil co-payment of $45: \nsubject to deductible \n \n90% of i\\R al'lt:r a per \\'isit co,p:lyment of 4;; \nsubject In deductible \n \nl'\\ot applicable \n \nHome Healthcarc Services Approved in Advance by the MCP \n \n90% of 1\\'R \nsubject In deductible \n \n80''' of NR; subject to deductible \n \n6O%0fOONR: subject to deductible \n \n-...... --- --- --- --- .-- ......... ............................... ...........-.._--- .._......_... \nNOles: I lome nursing cart': not rev1c:wed by the i'l'ICP C-Ovcrs two hours of medically necesS:lry skilled home care per day by RN or LPN if ordered by a physician: $7500 per Plan ye:lr limit is a combined total in Pro Options. Members share of cOSt is not applied to Plan year out-of-pocket limits. \n \nSkilled Nursing FacWty Services \n \nl\\ot covered \n \nNot covt:red \n \nNot covered \n \nHospice Care \nNote: Indemnity - Mer m:!y approve \nadditional benefits in lieLl of Acute Care hospitalization. \nDurable Medical Equipment COME) - Rental or Purchase \nOutpatient Acute ShortTerm Rehabilitation Services \n \n100% of Nit; suhject to deductible \n \n100% of Nit; slIbjcct to deductible \n \n60% ofOONR: sllbjecr 10 deductible \n \n9O'Yn of NI{; subjcci 10 dcductible \n \n80% of NR; subject to deductible \n \nI \n60% of OONR; subject to {kductib1e \n \n90% of NR: \n \n80% of NR; \n \n60% of OO:\"lR; \n \nsubject to deductible and subject to dedllL1ihle and \n \nsubject [Q deductible \n \n520 pcr visit co-paymenl 520 per vi!'\u003eit co-p:tymem \n \n. ... . ... ... ... ... .. . ... ... ... ..  +  +. --- --_. _.-  \n \n  _  +  \n \nNote: Coyemge for up to 40 visits per Plan fC'oIr whell conditions are met for \n \nphrskal.spccch, occllp.1tionalthcr:ll)ics and for Clrdiac rehabilitation. \n \n INDE.'\\.I:'\u003clIfY OPTIONS BASIC AND PR:E.\\lIER \nTbe Pltm Pays: \nNote: PPO note to the left also applies heft:_ \n \nBWECHOlCE \nTbe Plan PtIJ's: \n \nliMO OPTIONS \nCIGNA \n \nThe Piau Pays: \n \nThe Plan Pays, . \n \nUNrrEDHEALUlCARE \nnJe Plall Pays, \n \nEach HMO Option m:lY offer vision care discounts or benefits. Contact the HMO directly foe more information. \n \n90% of lit suhje\u003c.:t 10 deductible \n \n100% \n \n100% \n \n100% after:1 $;0 pee trip co-pllyment when \nmedically ne\u003c.:essary \n \n100% \n \n90% of IR: suhject to deductible \n90% of IR: subject to deductible \nNote: PPO notes to Ihe left also apply heft:. \n \n100% aIler 52; co-payment, referral required \n100%; up to 120 visits \nper Plan year \n \n100% :Lftcr $25 \u003c.:o-payment \n100%; tIp to 120 visits \npCI' Plan year \n \n100% after $30 co-payment \n100%; \nup to 120 visits per Plan rear \n \n100% after 525 co-pa)'men! \n100%; \nup to 120 visits per Plan year \n \nNot co\\'(:rcd \n100% of lit liP to l\\'kdit:are's appron:d lifclime maximum; \nsubject to deductible \n \n100%; \nprior approval required, up to 4; days \nper Plan year \n \n100%: \nprior approval required, up to 45 days \nper Plan year \n \n100%; prior approval \nrequired, IIp to 45 days per Plan year \n \n100%; \nprior approval required,lIp to 120 days \nper Plan year \n \n100%; prior approval \nrequired \n \n100%; prior approv:11 \nrequired \n \n100%; \nprior approval required \n \n100%; \nprior approval required \n \n90% of IR: subje\u003c.'t to \u003c.kductible \n90% of IR; subject to deductible \nNote: PPO note to Ihe left also applies here_ \n \n100% when medically necessary \n100% after 20 per visit co-payment; lip to 40 visits per \nPlan yc..-..r \n \n100% when medically necessary \n \n100% when medically necessary \n \n100% when medically ncc\u003c.\"SSaf) \n \n100% after $20 per visit co-payment; up 10 40 visits per \nPlan rear \n \n100% after $20 per \\'isit co-pa}'rnent; up to 40 visits per Plan year or up to two consecutive months per condition, \nwhiche\\'cr is more \n \n100% after $20 per visit co-paymcnt; up to 40 visits per \nPlan year \n \na ( Ch\u003cl\"/ com/nlle,/ pl/.,:l4 \n \n PPO AND PPO CHOICE OPTIONS - BASIC AND PREMIER \nPPO OI'TION InNetwork/Olit-of-Statc \n \nChiropractic Care \nNote: Cover:tge for lip to a maximum of 40 visits per Plan year. \n \n90% of NR; \nsubjt:ct ro d\u003c.-Oucrible ami \n$20 per \\'isil co-payment \n \n80% of NR; subject to deductible and $20 per visil co-payment \n \n60%ofOONR; subject to deductible \n \nTransplant Services \n \n90% of Nit; subjecl to deductible al lJnicare contracted \nnetwork facilit y \n \n90% of NR; subject to deductible at Unican: contracted \nnctwork f.tcilit)' \n \n60% of NR; subject to deductible \nand balance billing \n \nNote: Services provid(~d through Unic.trc Centers of Excellence for PPO and Imkmnity. \n \nIMPORTANT PPO AND INDEMNITY CONSIDERATIONS \n \nSee the Summary Plan Description and Updalels for coverage details, including limitations and exclusions. \n~ Ch;trges [rom non-participating provi(krs are subject to balance billing.Thesc charges arc the member's responsibility and do not (\"Olllll toward deductiblcs or omof-pocket spending limits. \n \n~ Serviccs cov(OrC{IUlldcr the PPO fmlll;1I1 In-Network/Georgia provider will apply only to the In-Network/Georgia de\u003c.\\uclihle :1ll{1 out-or-pockct limit. \n~ Scrviccs covcrc\u003c.\\ under the PPO from In;\\knvork/Om-of-Sratc and Out-of-Network providers apply 10 tbe same deductihle. \n~ I.lfctil11e henefit maximums :trc combined totals among the PPO Options_ Indemnity Option :l1ld HMO Options (except KaisLT Pcrl11:tnente). \n \n~ Some PPO annual maximums and limitations are combined totals_ \n \n~ Annual dollar and visit Iimilations, dcdm:lihles and ollt-ol:pocket spending limits are based on a July I to June 30 Plan year. \n~ Some sen'iees may require Mep prcccrtiticatioll, prior approval or lcuers of medical necessity before such services arc covered. \n \n~ Co-payments do not apply toward deductibles or Ollt-ot~pocket limits ullkss otherwise noted, \n~ Exclusions and limitations vary :11ll0ng Plan options. Contact specitic Plan option Cor more information. \n \n* Nn \"\" N\u003c:twork Hate for in-network PPO Serviu:s DONn = OUI..()f~Netw()rk Hate for ollt-ol:nctwork PPO services IR \"\" lndcmnity I{ate for Indcmnity services \n \n BI.UECHOICE \n \nHMO OPTIONS \nCIGNA \n \nUNITEDHEALn ICARE \n \n90'X, of IR: subject to (kuuctiblc \n90% of Nit at comractl..\"d facility: \n60% NI{ subject to 5100 hospital deductible \nNote: PPO notc to the left also applies hen:. \n \n100% after \n \n100% after \n \n1000Xi after \n \n100')(, aftn \n \n$20 co-payment per $20 eo-paylllc..:nt pc..:r $20 co-payment per S20 co-payment per \n \nvisit; limited to 20 visits \\'isit: limitc..:d to 20 visits visit; limited to 20 visits visit: limited to 20 \\'isits \n \nper Plan ~'ear \n \nper Plan year \n \nper Pbn year \n \nper Plan year \n \n100% \n \n100% \n \n100% \n \n100% \n \nIMPORTA:'\u003crlT HMO CO:\\SIDERATIONS \n... Annual dollar anu \\'isit limitations arc based on a July 1 to June 30 Plan )'1.\"3r. \n... Some services may require prior atHhori....1IiOn by the 1-[\\10 before such services arc cO\\\"Crcd.AJso. some services may have limil:llions not cOlllainl.\"d in this summary. \n... Most HMOs require the selection of:l primary (\"Ire physician (PCP) to manage your Glre. Failure to specify a pcp could delay receipt of your ID card. HO\\\\'c\\Ter. in somc instances the 1iJ.\\'0 assigns YOll a PCP 10000dtC'd ncar your residcnce if a PCP is not specified. Note: UnitedHealthcarc docs not rc..:quire the selection of a PCP. \n... Most HMOs require you to obtain refcrr:lls to sec most specialists. Failure to ohtain a referral could resuh in denial of)'uur claim. Note: Unitedl-lealthcarc dues not require a referntl for cover.lge of specialist scn'ices. \n... ComaCI the HMO directly for more dct:lils reg;lf(.Iing covered sen'ices, exclusions and limimtions. \n \n D PHARMACY \nBENEFIT OPTIONS \n \n... PPO Basic ... PPO Premier ... PPO Choice Basic \n \n... PPO Choice Premier ... Indemnity Basic ... Indemnity Premier \n \nWHAT A~E THE DIFFEIHNCES BETWEEN THE BASIC AND PREMIER PHARMACY OPTIONS? \nThne are three differences between the Basic and Premier prescription benefits: \n... The 13asic Preferred Drug List (POL) is not as cxtr.:nsive as the Premier Preferred Drug List; \n... The co-payments are different (see the Pharmacy Benefit Comparison chart on the next page); and \n.. There are no Maximum Out-or-Pocket (MOP) limits for the Basic Pharmacy Options. (see the Pharmacy Benefit Comparison chart) \n \nBefore making your choice, review the 1'1'0, PPO Choice, Indemnity Plan Overviews and the Pharmacy Benefit Comparison chart. \n \nPLAN PROvISIONS FOR THE BASIC \nAND PREMIER OniONS \nProgressive Drug Mallagemellt Program (PDMP) This progro.lill has been designed to assist your doctor in finuing the most appropriate drug treatment for you and your f:l1nily.The first step in the program is usually a proven less expensive treatment known to be safe and effeclive for most people. If the drug does not work for you, your doctor may progress to another drug.A Prior Authorization may be requireu as the next step in the program to obtain the drug that is best suited for you. Progressive Drug i\\Ianagement helps to ensure that you are receiving the most appropriate and COSt effective drug for your condition. The POMP is in effect for the following therapeutic caregories:ACE Inhibitors, Brand NSAII), EliddlProtopic and Glucophage XR. Notr: This list is 5lIbjec! 10 c!Jlmge during ,he Pltln )'fllr. \n \nNote: If you should go to the pharmacy and are told that your prescription cannot be ftIled because a prior authorization is required, please have your doctor call with your clinical information to Express Scripts, lnc.'s (ES['s) prior authorization unit.The prior authorization process is a telephonic process where your doctor can give your clinical information over the phone for review. If the information provided by your uoctor does not meet the criteria for the drug requested, yOll are entitled to appeal. Your physician will nced to fax a written request to 1:.5l's appeals unit that shoulu include your medical history and all previollsly llsed drugs to treat yOllr particular condition. \nHEALTH MAINTENANCE ORGANIZATIONS (HMOs) \n'\" Generic co-payments are different from the PPO and IJl(lemllity Plan Oplions \n'\" No Maximum OLlt-ot~Pocket (MOP) limit tcature \n'\" Maintenance Drugs may be obtained for lip to a 90-day slIpply of your prescription(s) for two (2) co-payments. Note: Kaiser: one co-payment per 30day supply. \n'\" ContaCl respective HMO tor hlrther Plan provisions. See the inside cover lor telephone numbers and Web site addresses. \nALL PLAN OPTIONS \n'\" No co-payments for drugs that are covered by the SHBP will be changed or overridden on an individual basis. \n 111 addition, many dmgs listed as non-prctl.:rrcd have a generic or preferred brand-name drug alternative. Preferred drug alternatives arc therapeutically equivalent while being more cost effective. \n'\" If the drug cost is less than the co-payment, you do not pay the co-payment but the lesser of, which is the actual cost of the drug. For example, if the preferred drLl~ cost is $18.23, and the preferred drug copayment is 525.00, you will only pay SItU:'). \n \n PPO Basic PPO Choke Basic \nIndemnity Basic \nPPO Premier PPO Choice Premier \nIndemnity Premier \nHMO's - BlueChoice CIGNA UniledHealthcare Kaiser Pennanente \n \nn:LSic (Sl.\"e \n \n510 \n \npage 28 for \n \nabbreviatcd POL \n \nUasic (see \n \nSIO \n \npage 28 for \n \nabbrc\\'iated PDL \n \nPremier (see \n \n51') \n \npage 29 for \n \nabbre\\'iated POL \n \nPremier (see \n \n515 \n \npage 29 for \n \nabbreviated I\u003eOL \n \nHMO Onlg List \n \n510 \n \nS-'-, \n \nS40 \n \nDoes not apply \n \nS-'-, \n \n540 \n \nJ::k\u003ees not apply \n \n5-'-, \n \n-2()'\\, of l:ost: \n \nS450 per member, \n \nminimum 540. \n \nS 1.300 family \n \nmaximum 5100 \n \nS,--, \n \n-200(, of cost: \n \n5i50 per membt-r. \n \nminimum 540. \n \n5 LjOO r.1mily \n \nmaximum S100 \n \nS,--, \n \n540 \n \nDoes 110t apply \n \nKaiser Drug Ust \n \n, \nKaiser: Eckerd r.1.cility: Drugs \n510 : 516 \n \nKail\u003eCr f:lcility \n525 \n \nEckert! Dntgs \nSjl \n \nDoes not apply \n \nDoes not apply \n \n-Note: Tbe NOli-Preferred n,.,md Cu-PaJ'\",eut does 110/ apply 10 IlJe QI/l\".,erfy MaximulIl OUI-of-Pocket. Please COIl fact C?acb HMO regarding pharmacy lists - BlueCboice (800) 464-1367: ClGNA (ROO) 564-7642; KlIisel' Pemulllellle (800) 6/ /-/8/ I; Ullitedl/eallbcare (866) 527-9599 \n \nBASIC AND PREMIER PREFERRED DRUG LISTS \n~ Tht: pharmacy drug lists ;lre created, reviewed and COl1\\illually updated by a team of healthc;\\re professionals including physicians and pharmacists. \n~ A medication becomes a prdnrcd drug based first on dficaq', then safcty and last on cost-tlfectivcncss. \n~ Your doctor c:ln usc the list associated with your chosen option to select medications for your he;lhhcarc needs, while helping you maximize your prescription drug bendit.The choice of medications is strictly between you and your doctor. \n \n~ Preferred Drug LislS for the SHBP members are subjeel to change. Prior co purchasing your medkation(s) y011 may view the drug lists at www.dch.st:Lle.ga.usorcontact Express Scripts by phone:1( (Rn) 65()-9j42 orTDD (800) 842-5754 to gel the most current st;ltUS on any covered drug. On the following pages is an abbre\\'iau:d v(. rsion of the two drug lists for comparison. Use these lists to help rou determine what yOllr co-payments will he and to evaluate which drug benefit will beSt meet rour needs. \n \n GEORGIA BASIC PREFERRED DRUG LIST (ABBREVIATED) \nEFFECTIVE JULY 1, 2004 \nFOR STATE HEALTH BENEFIT PLAN - PPO AND INDEMNITY HEALTH PLANS All generics are considered preferred drugs (cxampks listed in each category). If at any time during the Plan year a \nbrand has a generic equivalent become available, that brand \\vill automatically be moved to the non-prd't:rrnl status. \n \nKH \nPA _ prior authorization re~uired QLl - quantity or therapy limits exist \n \nALLERGY!RESPIRATQRY ADVAIR DI$KUS, Qtt albuterol generic, Qtt \nf\\LLEGRA, -0, Qtt COMBIVENT, Qtt \nFlOVENT ROTADISK, QI.L FORArJIL, QLl INTAL, Qtt \nipratrolJium gerleric, Qtt PROV NTIL HFA, Qtt \nQVAR, QU. SEREVENT DISKUS, Qtt SINGULAIR \nANTIINFECTIVES Jcyclovir gClwric ,tnlOxicillin generic C1moxicillinldavulanic generic ,unpicillin generic AUGMENl'IN ($ AUG.'v\\NTlN XI{, QLL AV[lOX, ABC PACK cefllroxime generic cephJJcxin generic C1PRO LJnUCAN, PA doxvcycline generic erylhrofllycirl generic keloconJ7.01c gcneric nilroiurrl,llain generic penicillin generic SrORANOX, QLl. lOA TEQUIN tetracycline genl'ric lilllelhoprim generic tmp/smx gerlCric ZITHROMAX \nAUTONOMIC \u0026 CNS AMIlIEN, QLl Jmitriptyline generic CELEXA CONCERTA rlexlroamphelamine generic \nf'AJge\u003e 11 EfHXOR, -XR f1uoxeline generic IMITREX. ()LL \nLUAI-'RO MET/\\D/\\TE CD lJlelhylphenicbte generic rllirtnJpine generic pJfQxetlnc generic I-',\\XIL CR \nREMERON soltJb SONATA. QU. STRATTERA Il'mazepam generic tr\u003clzoJone generic WHLBUTRIN 5R lOMIG, -ZJ\\H. QLL \n \nGASTROINTESTINAL ASACOL cilllelidine generic faillolirline generic nizJtidine generic omepra7.0le generic QlL. PA rENtASA f'REVACID. QLL PA PREVPAC QLL r,mitidine generic suhasalazine generic \nCARDIOVASCULAR ADVICOR Jlenolol.seneric AVALlO[ AVAPRO bi,oprolol generic bisoprololw/hc1Z generic. chlorthalidone generic c!onidine generic COREG CRESTOR diltiJlem, er generic DIOVAN, HCT en,llapril generic enal~lpril w/helz generic gerllllbrOLri generiC hydrochlorothiazide generic INNOI-'Rf\\N XL LlPITOR lisinopril generic lisinopril w/hclz generic l.OTE~\"SIN IICT LOTR[L lov;151alil1 \"elleric metoprolof tJrlrJle generic mocxiprrl generiC NIASPAN niiedipine er generic NORVASC propranolol generic lerzosin generic verapJmfl generic verapJrnil. xr generic lAROXOLYN ZETlA, PA \nENDOCRINE I\\CTONEL QLL ACTOS, Ql.l AVANOAMET AVANDIA, QLl DIDRONEL EVIST/\\ FORTEO, PA F05AMAX, QLL glipizide generic \n \nglyburirle generic IIUMALOG HUMUllN LANTUS metformin generic NOVOLl,,,, NOVOlOG PR/\\NDIN pRECOSE 5TARLIX tolazJmide generic lolblilamide generic \nOBSTETRICAL/ GYNECOLOGICAL ESCLlM, QLL eSlradiol generic FEMI-IRT mearoxyprogesterone generic ORTHO EVRA. QLL ORTHO TRI-CYCI.EN LO PREMARIN PREMPIIASE PREMPRO YASMIN \n \nEAR_NOSE_THROAT ASHLIN, Ql.L FlONASE, QLL NASON EX, QlL \nUROLOGICAl. DETROl., -I.A oxybUlynin generic AVODART EDEX, QLL PA FLOMAX VIAGRA, QLL, f'A \nMUSCULOSKELETAl, diclofenac sodium generic ibuprofen generic: indomethacin generic nabumelone generic rlapmxen generic VIOXX, QLL choline mag lrisJlicylale \ngeneric dillllnisal generic satsalatc gerlCric \n \nAUEWr\u003c.',\\lIVE PRODUCT lISTI~G row NON_PUf,WUO RWM,llS \n \nNOr\u003c.'-PWlfERRED BRAND \n \nSf.lECTW AlHRNATlvr B~A\"os \n \nAccolate \n \n_. Singulair \n \nAccupril, \n \n__ lisinopril \n \nI\\ciphex \n \n. , omerrazole, Prevacid \n \nAClivelb \n \n, .. , .. , FemHRl Prempro. Pre.n:ph;l5~ \n \nAltace \n \n\" .. , .. , ... , ... , .. , .. , ... I,slIlopfil \n \nAtacanJ, \n \n__ .. _. , . _.. Avapro, DiovJrl \n \nBiaxin, -XL, \n \n__ erylhromycin, Zilhrom,lX \n \nC1arinex \n \n., \n \n, Allergra \n \nCOl,lar., ... , .. , , .. , .. , , .. , ,Avapm, DiO\\'an \n \nl-IyzaJr .. , , .. , .. , , .. , , . AV;llide. Diovan I-ICT \n \nMi\\xJlt, -MLT, _. , .. , .. , , .. , , Imilrcx, Zornig. -lMT \n \nMobic _ \n \n. generic NSAIOs \n \nNexium \n \n.. \n \n. om~lxazole, P~evi\\ciJ \n \nI-'Iendil, \n \n. , .. , , . JlI eOlplne, ~orV;lSC \n \nPmtol1ix. \" .. \".\" .. \" .. , onHo'prMole, PrevJcid \n \nPulmicort _ \n \n_____ __. Flovenl, QVAR \n \nSlIlJ( . Zocor _. \n \n. , __ . __ nifedipine l'.'orV,lSC \n. .. lovaslalin, Cresl~r, lipilor \n \nZalait, .. , .. filioxetine, paroxetine, Lexdpro, r,lxi! CR \n \nZyrtec. \n \n_. Allegra \n \nFor I'rlor Authorizat;ons (PA), Quamity l.e,-e1LJm;{s (QLL) or any questions regarding spedtle eover..ge rules or co_payment information for dn,gs 110t listed on (his document, please eontae' F_\"pn\"'s s\u003c::rlpts, Inc. at 1877(;509342. \n \nIln'i'cd April 7. 100..J I 'lJJi.~ IW i.~ SIII?/\"'-1 10 clJtIII6C 1/1 Ilw disC/rtfaJi o/I/.\u003e\u003c, n't'\" rill/('Ill of CrJIIlI!ll1!! II)' }-Jc\"IIIJ. \n \n GEORGIA PREMIER PREFERRED DRUG LIST (ABBREVIATED) \nEFI'IOCTIVE JULY 1, 2004 FOR STATE HEALTH BENEFIT PLANS - PPO AND INDEMNITY HEALTH PLANS AU j.:cncrics arc considcrt:d prdcrn:d drugs (examples listed in !.-'lell cau:gory).lf:1( any lime during the Plan year a br.uuf h:L\u003c; a generic equiv';.l!clll be...-come :n';liJahle, that brand will autOm:uically be movnl to the non-preferred status. \n \nKfY \nPA - prior authorization reljuired Qtl - quantity or therapy limits exist \n \nALJ.ERGY/RF.SPIRATORY ADVAIR OISKUS, QLI dlbulCl'ol generic, Qt.l AllEGRA, -il, Qt.l COMHtVEI\\.T, Qtl cromolyn sodium generic FLOVENT, -ROTADISK. Qll FORADll. QU. ipr~tropillm generic. QLl MAXAIR AUTO' IAI.ER, QLt mCI;Jprorcrcoolllcncric. QtL PROVENTIL HFA, Qtl PUL\\t\\ICORT RESPUL(S, QLl SINGULAIR TlLADE, Qll ZVRTEC, Qll \nANTI-INFECl'IVES 'llyclovir generic amlJxicillirl generic amoxkillin/c1,l\\Iul.lnic generic ampicillin gcncril \nAUGMENT\" ER AUG.'.IE1\\'TIN X~, Qll AVELOX \nccfuroxime gCI'IC.\u003efic CEFZll cephalexin generic CIPRO CIPRO XR, QlL DIFlUC,\\N 150...tG, QLl DIFtUCAr-., PA \ndoxycyclirw; generk. erythromyCIn genC'f1C GANTRISIN PEDIATlUC grb;cofulvin gcnl\u003efic I{eloconilzole gelll..\u003efic LAMISI1, P/\\ MACROlllD penicillin generil: SPECTRACEF SPQRANOX Qll, P,\\ lelrilcycline generiC Ifl1JYsm)( generic VALTR[)(, Qtl lITHROMAX \nAUTONOMIC \u0026 eNS ADDERALI XR, PA age \u003e2 I Jlprawlilnl generic AMIlIEN, QLL amitripTyline gCrlC'fk bupropion generic buspirooe generic CONCERTA desiPfamine generic de)(lro.lmphe!amme generic, \nPAage\u003e21 dial.('pilm generil EfFEXQR, .. XR \nfluoxclinc generic imipramine generic lMITREX, Qtt LEXAPRO IOfazcpam generic MIGRANAl, Qtt nortriplrlinc generic oxal.qJam generic paroxCline generic Irazodonc generic lriazul.lm generic \n \nWHlBUTRIN..Xl lOtOH lOMIG, -ZMT, Qtt \nGASTROINTESTINAL ASACOt AZUlFID1NE EN,TAB cimctidine generic far'lotiuine generic omeprazule generic QLL, PA PANCREASE pancrelipase generic PEr-.'iASA PREVACID QlL PA PREVPAC, Qtl PIl:QCTOFOAM-HC ranitirlinc generic ROWASA ,ucralf.lle generic UI\u003c:SO VIOKASE ZANTAC SYRUP \nCARDIOVASCULAR ADVICOR AtTACE alcnolol generic henazepnl generic ben.ll.eprililictz ger'lcric (,lploprd generic CARDIZEM lA CATAPRES-rrs, QLl chol('Slyraminc generic COREG COZAAR dil!iilzem, sa generic OIOVAN. -ITCT en,11.1pril generic furosemide generic gem/ibro?il gwerir. Fiydrochlorothaizide generic 11YZAAR LEVATOl tEXXEl lIPITOR liSlnopril generic Iislflopril wihdz generic lOTREL IOVilst,ltin generic mClOl.lzonc gerleric meloprulol generic NIASPAN nicarrlipine generic lli(edipmc. cr, xl generic NIMOTOt\u003e r-.ORVASC PI\u003c:AVACHOt prazosin generic propr,lnorol generic spironolactone generic lcrawsin gem'ric TOI'ROL Xl IOfscmirle gCrlt'lic TRrCOR vcr\u003clpamil, xr generic ZOCO!\u003c \nF.NDOCRINF. ACTOS, QLL AMARYL AVANDIA, QLt \n \nDDAVP NASAL [VISTA FOSA,\\1AX, QlL glipizirlc cr ~ic \nglybundc micronized generic \nGlYSET t-lUMAtOG HUMULIN IN,nUS \nmclformin MIACAlCIN NOVOLIN NOVOlOG PRANDIN \nPRECOSE STARLIX 10J,1Zamide generic \ntolbutamide generic \n08STETRICAL! \nGYNECOI.OGICAI. COMBlPATCH ESTRADERM PATCH, Qtl ESTRATEST, HS eslradiol patch genefic, Qtt estropipate generic ESTROSTEP FE FEMHRT \n1nc\u003clroxvprogCSlcrone gencri( MEN ESt NUVARING ORTHO EVRA. QLl ORTHO TRI-CYCLN LO PREMARIN PREMPH!\\S \n \nPI\u003c:EMPRO VIVEllE. -DOT. QLl \nEAR-:\"l'OSETHRo..n ASHLIN, Qll FtOr-.'ASE AQ, Qtt NASONEX, Qll \nUROLOGICAl. DHROt, -LA OITROPAN Xt EDEX QtL, PA FlOMAX oxybut'l'nin gcoeril: \n\"\"OSCAR VIACRA QLL, PA \nMUSCULOSKELETAL ARTHROTEC CEI.EBREX, Ql.l didolenal: generic f~rofcn generic i1urbiproicn generic indomethacin generil: \nketoproien generic \nmedofcnamale generic nilbumelonc generic nal)roxen generic piroxicam generic sul;ndac gentric lolmeTin gcneric VIOXX, QLl \n \nALTUINAllVI PRODUCT ll\u003eTING tOR NON-PREHRR(() BRANDS \n \nNON-PREfERRED BRAN!) \n \nSHlCTEO ALTERNATII/E BRANDS \n \nAceon. \n \nben,n(,'pril. lisinopril, Ahace \n \nAciphex . . . \n \n. \n \nolneprazole, Pr('Vacid \n \nAccolate . . \n \n. \n \n, .. Singulair \n \nAccupri! , , . \n \nbcnazeprit lisinopril, AllilCl' \n \nAdillclla ....... , . _ .. f'rempro, ~\u003cISC \n \nAdone! . . . . \n \n. Mam\u003clx, MiKillein \n \nAlacanrl. . \n \n. ... Cozaar, Diovan \n \nKiaxin, -Xl \n \n~1hrolnycin, Zilhromax \n \nCelexa . . \n \n, nuoxeline, paroxetine, Lcxapro. Zolo!l \n \nClarinex, . \n \n. .. . ..... \" . . Alle-rwa, Zyrtec \n \nLescoJ, -XL. \n \n. IOl/astalin, lipilor. Pral/Olchol, Zocor \n \nMal/ik. . \n \n. ..... bcnazcpril, lisinopril, Ahace \n \nMaxalt, -MLT. \n \n. .. , lmilrex, ZomiF,. -Z,\\.1T \n \nMoIlic. , ,  . . \n \n.  , , ., generic NSAIDs \n \nNexium .  . . \n \nomq\u003erazolc, PreYa\u003c:id \n \nJ Plendil. . . . . \n \n. \n \nnilf\"dipine, Norvasc \n \nProlonix  . . . \n \n. \n \nomeprazole, Prevacid \n \nPulmiOOI1., - ... \" . - . ,  ,. .. -\". Flovent \n \nScrevenl , . \n \n. \n \nFaradil \n \nSular . \n \n. nife'\u003c.1ipine. Norvasc \n \nTcvelen \n \n, .. , _Cozaar, Diol/i1n \n \nfor Prior AUlhorizalions (PA), Quantity ~cl1lmi1S (Qtl.) or .11)' queslions rq;arding spL\"Cifk CO\"Cr:\u003egc:: ruk:-!; or ro--p\")'In~m inform:,,;on for dnll!lS nOI Lisle\u003c! on tJili; document. pkase CQnl:K:t F.xpress Scrlpt-s, Inc. at 1-8776509342. \n \nRc\\iSl\"ll \"prj! -. 11111-1 I This list I,: slIlJjt'a If} ('millS\u003c' (I/ 11)\u003c' diS('Tf'II'oll of rhe IJ\u003ctH/rlll/ellt 0/ CfJllJlm/llit), Ht'{,frb. \n \n o SERVICE AREAS \nFOR YOUR HI\"\\I.TH PLAN OPTIONS \n \nSERVICE AREAS \nService areas are Sratc-:lppmvcd geographic areas, such as counties or zip codes, where providers participate in Ihe network offered by the Plan option in which yOll han: enrolled. \nPPO AND PPO CHOICE OPTIONS - \nBASIC AND PREMIER \nGeOlogia Service A\"ell The Georgia service arc;. includes the state of \nGeorgia and the border communities of the Chattanooga, Tennessee area, including Bradle}' County; and Phenix Citr.Alahama.The zip code area in which yOll receive a service is llsed 10 (klermin\u003c.~ whether or not rOll arc.: in the Georgia service area. If rOll receive con:rcd sen-ices from a lSI: Medical Nc:twork provider kx.-aled in onc of Ihe 7ip codes to the righl. yuu receive the highest level of con~r.tge .\",ailable in the PPO Options. \nOUI-o/-SllIle/NalioulI/ Service Area The out-of-state service area includes all national locations oursidc Of the Georgia service art.:a described to the right. By \\lsin~ Beech Street pro\\'iders outside of the Georgia servicl.: area, you are protected against bal:ll1ce biJling (being charged more than what tht' Plan allows). Howc'-cr, use of Beech Street pro'klers inside the Georgia service area is considered OUl-of-nelwork care with lower k\\\"e1s of coverage and separate deductibles, unlc..-ss the provider also is a 1:;1 Medical Network participant. \n \nGEORGIA: \nAll counties; all zip codes \nAtABAMA: \nRussell County (Phenix City area): 36851, 36856, 36858, 36859, 36860, 36867, 36868, 36869, 36870, 36871 and 36875. \nTENNESSEE: \nBradley County (Cleveland area): 37310, 3731 1,37312,37320,37323,37353 and 37364. \nHamilton County (Chattanooga area): \n37302,37304,37308,37315,37341, 37343,37350,37351,37363,37373, \n37377,37379,37384,37401,37402, 37403,37404,37405,37406,37407, 37408,37409,37410,37411,37412, 37414,37415,37416,37419,37421, 37422,37424 and 37450. \n \n HMO OPTIONS \nYou must live or work in the HMO's approved sen:i.cc area (Q be eligible for co\\'(~rage under th:u option. (klow are the HMO Option sc:n'ice an:;IS b)' county If you live or work in a count)' marked ~Ycs' under any of the HMOs listed, you rna)' enroll in that I-IMO. If the count)' where rOll live or work is not listed bdow, YOll are not eligible for HMO covemgc. \n \nCOUNTY OF RESlDENCE \nAppling Atkinson Bacon Ibnks Barrow Bartow Ben Hill .Berrien Bibb BIeckJe)' Brooks Bryan Bulloch Burke Buus Candle.:r Carroll Catoosa Chatham Chattahoochee Chauooga Cherokee Clarke Clayton Clinch \n \nBltlECHOICE \nNot Available Not Available Not Available \nYe, \nYes \nYe, \nNot Available Not AV'dilable \nyO' Yes Not Available Ye, Yes Ye, Yes Not Available yO' Not Available yO' Yes Yes Ye\u003e Yes Y\", Not Available \n \nCIG~A \nyO' Not Available \nYes Not Available \nYes Yes Not Available Not Amilablc \nYe, \nYes Not Available \nY\", \nYes Yes \nYe, \nYes Not Available \nYes \nYes Not Availahle \nYes Yes \nYes \nYes Not Available \n \nKAISER PER\\tA:\"iE:\"1TE \nNot Available Not Available Not Available Not Avail:lble \nYe, Ye, \nNot Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available \nYes \nNot Available NOI Available Not Available Not Available Not Available Not Available.: \nYes \nNot Avail::tble \nYe, \nNOt A\\':tilable \n \nUStTED H E,\\lTHC.4.RE \nYes \n'1'\u003c':5 \nYes Yes Yes Yes Yes Yes yO' \nY\", \nYes Yes Yes Yes Yes Yes \nY\", \nYes Yes Yes Yes Yes Yes Yes Yes \n \n COUN1Y OF RESIDENCE \nCohh Colquitt Columbia Cook Cowcta Cmwford O:lde Dawson Dee:llur OeKalb Douglas Early Echols Effingham Bbert Emanuel Evans Fayette floyd Forsyth Franklin Fulton Gilmer Glascock Gordon Grady Greene GwinnClt Habersham Hall Harris Hart Hc...-ard Hcnf)' \n \nBI.Uf.CnQICE \nYes Not Available \nYes Not Available \nYes \nYes Not Available \nYes Not Available \nYes \nYes Not Available NOI Av'.tilablc \nYes \nYes \nYes \nNot Available Yes Yes Yes Yes Yes Yes \nYes \nYc...os NOI Available \nYes \nYes NOI Availabk \nYes Yes \nYes \nYes \nYes \n \nCIGNA Yes \nNot Avail:tble Yes \nNot t\\\\\u003eailable Yes \nNot Available Yes \nNOI Av\".tilable NOt Available \nYes Yes Not Available Not A\\'\":tilablc \nY~ \nYes Yes Yes Ycs Yes Yes Ycs \nYe~ \n1\"101 Avail.1bk Not Avail:lbk \nYes 1\"101 Available \nYes \nYes \nNot Available Yes Yes \nNot A\\'ail:lble Not A\\-ailable \nYes \n \nK,\\ISER PERMANENTF. \nYcs Not Available Not Available NOI A\\-ailable \nYes Not A\\'ailable NOI A\\'ailable NOl Available NOI Available \nYes \nYes \nNot Available Not Available Not A\\':tilable Not Available NOI Availablt: Not Available \nYes \nNot Available Yes \nNot Available Yes \nNot A\\-ailable Not Available Not Available 1\"101 A\\rtilablc 1\"101 Available \nYc...\"S Not Available \nYes Not Available Not Available Not Available \nYes \n \nUNlTEDHF.ALTlICARE \nYes Yes \nYes \nYes y\"\" \nYes Yes \nYes Yes Yes Yes \nYes \nYes \nYes \nYes Yc...os Ycs Ycs Yes Yes Not Available Yes Nm Available Yes \ny~ \nYes \nYes \nYes \nYcs Yes Yes Not Available 1\"101 A\\-ailabJc Yes \n \n COUNTY OF RESIDENCE \nHOUSlOn \njackson jasper jefferson jenkins johnson jones L1mar lmlier I..:lllrellS Libelly lincoln Long Lowmk-s Lumpkin Madison Marion McDuffie Meriwcther Mitchell Monroe Morgan l\\'luscogtt Newton Oconee Oglethorpe Paulding hadl Pickens Pierce Pike Polk Pulaski Putnam \n \n8LUECnOlCl' \nYes Yes Not A\\'ailable Yes Yes Yes Yes Not Available Not Availabk Not Available Yes Yes NOI Available Not Available Yes Yes \nY\u003c~ \nYes Yes Not Available Yes Yes Yes Yes Yes Yes Yes Yes Yes Not Available Not Available Ycs Yes NmAvailablc \n \nCIGNA Not AV'::lilablc \nYes Not A\\':lilable \nYes Not A\\-ailabk Not Available \nYes Yes Not Available Yes Yes Yes Yes Not A\\\u003clilablc Not A\\'3i1abh: Y\", Yes Yes Not Available Not Available Yes Not Available Yes Yes Yes Yes y\", Not A\\~di1:lblc NO! Available Not Available Yes Yes NO( Available NO! Available \n \nKAISF.R PEKi\\lANF.Nl'f. \nNot Available Not Available Not A\\\"dilable Not A\\'ailablc Not Available Not Available Not A\\'ailablc Not Available Not Available Not Available Not Availabk Not Available Not Available Not Available Not Available Not Available NotA\\'ailablc NO[ Available Not Avail:lble Not Available Not Available Not Available Not Available \nYes Not Available Not Available \nYes Not Avail:lblc Not Available Not Available NotAvailablc Not Available Not Available Not Avaibbk \n \nUNITE(}HEALl HCARE \nYes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ye, Yes Yes Yc, Yes Yes Yes Yt;:s Yc, Yes Yes \n \n COUNTY Of ReSIDENCE \nRichmond Rockd:J1e Screven seminole Spalding Stcphens SleWart Talbot Taliaferro ';IIIn:l1l 'nlylur Thomas Tift Toombs Troup Turner Twiggs Upson Walker Walton Ware \\Varl't'n W,lshinglOn Wayne \\Vhile Whilfield Wilkes Wilkinson Wonh \n \nBLueCIlOI(.E' \nYes \nYes \nNot AV\"dilable NO! Available \nYes \nNot Available Yes Yes \nNot Available Not Available Not Available Not Available NotA\\'3i1able Not Available Not Available Not Available \nY,.. \nNot Avotilable Not Available:: \nYes Not Available \nYe, Ye, \nNot Available \nYes \nNot AV\"diJable \nYe, \nYes Not Available \n \nCIGNA \nYes Yes Yc.:s Not Available \nYes \nNot A\\\u003c-dilable Not Available NOl Available Not Available \nYes Ycs Not A\\~dilable Not Available Not Available Not Available Not A\\'OliJabk Not t\\\\\"\"dilable Not Available \nYe, \nYes Not Available Not Available Not Available Not Available Not A\\\"3ilable \nYes \nYes Yes Not Available \n \nKAISER PERMi\\NENl'E \nNot A\\\"diJablc Yes \nNot Available Not Available \nYes \nNot Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available \nYes NOl Availabk Not Available Not Available Not Available Not Available Not Available Not Available Not Av-dilable Not Available \n \n. \nUN lTEOHEAL1'IICARE \nYes Yes \nYes \nYes Yes Yes Ycs Yes Yes YeS Yes Yes Yc:.'i \nYe, \nY\u003c..\"S Yes \nYe, \nYes Ye.:s Yes Yes Yes Not Available.: Ye.:s \nY\", \nYes \nYcs \nYes Yes \n \n HEALTH I IS RANCE PORTABILITY A 0 ACCOU TABILITY ACT \n(HIPAA) ANNUAL NOTICE \n \nThis section describes certain rights available to yOli under the Health Insul\"'J.llcc Ponabiliry and Accountability Act (HIPAA) when you enroll in the SHBP. \nThe PPO, PPO Choice and Indcmnil}' Options (Basic and Premier) cOlHain a pre-existing cOlldi~ tion (PEe) limitatioll. Specifically, the Health Plan will not pay charges lhal arc over S.I ,000 for the treatmcm of any pre-exisling condilion during the first 12 months of a patient's coverage, unless the patiem gives satisfactory documentation that he or sht: has been free of treatment or medicat.ion for that condition for at I~lst six consecutive C'dlendar months. If you are enrolling as a new hire, this 12-month period begins on your hire dale. However, a I\u003ere-existing condition limitation does not apply to coverage for: \n~ Pregnancy; Of \n~ Newborns or children under age 18 who are adopted or placed for adoplion. if the child becomes covered widlin 31 days after birth, adoplion or placemem for adoption. \nIn cerlain situations, SHBP members and dependents can reduce the 12-mOlllh pre-existing condition limitation period. The reduction is possible by using what is called ~credit'able coverage\" to offset a pre-exisling condilion period, Creditable coverage generall)' includes the health coverage yOll or a f:mlily member hOld immediately prior (0 joining the SIIBP Cover:lge undc.:r most group healtll plans. as well as coverage under individual health policies and gO\\'emmelllal health programs, qualifies as creditable covernge. \nTo redu\u003c:c the pre-existing condition Iimilalion period for your own covemge, you m1lst provide the SHIlP with a certificate of credit:lble coverage from one or more former heahh pbns or insurers that states when rour prior covernge staned and \n \nendcd.Any period of prior Covcr:lge will reduce the 12-month limitation period if the limt: between losing coverage and your first da)' of SHBP covemge does nUl exceed 63 days. If you are enrolling as a new hire, the 63-day period is nH;:asured from your last day of prior cover:lge up 10 your dale of hire. \nTo reduce the prc-cxisling condition Limil\u003cllion peri\u003cX! for your dependents (including your spousc), you mUSl prO\\'ide the SHBP with a eenilil\".ate of crediL'tbk coverage stating when coverage started and ended for each dependent Ihal you wallI to COVCl'. Again, ,Illy period of prior coverage for that dependem will reduce the 12-monrh limiL:llion \nperiod if no more lhan 63 days h:I\\'c elapsed \nbetween the dependent's loss of prior covcrnge and lhe first day of Covt:r;:lge under Ihe SI-IBr (or your date of hire, if you are enrolling as \" nnv hire::). \nIf yOll or a dc.:pendel1t (including a spouse) had any hR\"ak in cO\\'erage lasting mOrt: than 63 days, yOLi or your t1epclldem will rccei\\'e creditable coverage only for the period of liml after the break ended. \nWithin twO years after your fonner con:ragc tnmin:ued, yOll have the right 10 ohtain ,I certificale of creditable co\\'er:lgc from your former cmp[oyt:r(s) to offSCi the prc-c.xisting condition limitation pcrilXi under the simp TIle $1 iUP will evalu:nl' rour cenificalc of crcdirable Co\\'(;r:lge or othcr documentation to dctermine whether any of the pre-existing condition limitation period \\v1l1 be reduced or eliminated. After eomplcling the evalualion, the SI-IUP will notify rou as lO how the pre-existing condition limit:llion period will be reduced or eliminated. \nPlease submit your certificate of creditable coverage to the Plan with your enrolJmcnt paperwork. If you rc(}uire assistance in obtaining a letter from a former employer, contact your pcrsonneJlpayroll office, \n \n o DEPARTMENT OF COMMUNITY HEAl.TH PRIVACY NOTICE \n \nThis notice describes how medical informalion about you may be used and disclosed and how you can get access (0 this information. Please review it carefully. \nTHE PLAN'S PRIVACY COMMITMENT TO You \nThe Georgia Depanmcl1t Of Community Health (DeH) understands that information about you and your tlmily is personal. OCH is committed 10 protecting your information. This IlOliCl~ tdls yOll how DCH uses and discloses information about you. It {clls )'Otl your fights and tht: Plan's requirements about your information. \nUNDERSTANDING THE TYPE Of INFORMATION THAT THE PLAN HAS \nYOllf employer (state agem.:)', schoo] system, amhority, etc.) sent information about you to DCH.This information included your name, address, birth date, phone number, Social Security Number and otlll;( health insurance policies that you may havc. It may also have included health information. When your healthcare providers send claims to the Plan's claim administr.ltor for payment, the c1aim.s include your diagnoses and the medic:ll treatments yOll received. For some medical treatments, your healthcare providers send additional medical information to the Plan such as doctor's statements, x-rays or lab lest results. \nYOUR HEALTH INFORMATION RIGHTS \nYou have the following rights regarding the health information that DCH has about you_ \n.. You have the right to SCe and obtain a copy of your health information.An exception is psychotherapy notes. Another exception is information that is needed for a legal action relating to OCH. \n.. YOll have the right ro aSk OCH to change health inform:uion that is incorrect or incomplete. DCH m:l)' dcny your request under certain circumst:mces. \n \n.. YOll have the right to request :l list of the disdosures that DCH has made of your health information beginning in April 2003. \n.. YOll have the right [Q requcst a rcstriction on certain uses or disclosurcs of your health information. DeH is not reqllin;d lO agree with your request. \n.. You have the right to request that DCH communicates with you about your health in a way or at a location that will help you keep your inform:ltioll (:onfidcIUial. \n.. YOll have the right (() receive a paper copy of this notice. YOll 1ll:IY :lsk DCH staff to give you another copy of this noticc, 01' you may obtain a copy from DeH's Web sile, www.dch.state.ga.lIs (dick on \"Privacy\"). \nPRIVACY LAW'S REQUIREMENTS \nDeli is required by law to: \n.. Maintain the priv:lCy of your infonn:ltion. \n.. Give yOll this llotice of DeII's Ieg:11 dulies :lnd privacy practices regarding the information that Dell has about yOli. \n.. Follow the terms of this Ilotice. \n.. Not use or disclose any information about you without rour wrinen permission, except for the reasons givc.:n in this notice. You may take away your permission at any time. in writing, except for the information that DeH disclosed before yOll Stopped your permission. If yOll cannot give your permission due to an emergency, DCII Illa)' release the information if it is in your best illleresl. DCB lllUSt notify you :IS soon as possible after releasing the information. \n[11 the future, DCB may change its privacy practices. If ilS privacy pr:l\u003c:tiCes change significantly. DCH will provide :t new nOli\u003c:c to yOLl. DCH will post tbe new notice on its Wcb site at www,dch.stat(,~.g:t.llS (dick on \"Privacy\"). This notice is effective April 14.200:;. \n \n How DCH USES i\\NO DISCLOSI:S \nHEAtTllCARE r:'~FORMATlON \nTIler(' are some services the Plan provides through contr.l\u003c:IS with prh'atc companies, 1;01' exampit:. Bllll' Cross and Blue Shield of Georgia pays most mediC::11 c1;lims 10 your healthcan: pro\\'iders, \\'('hen serykes arc COntrdClecL the Pl:ln ma), disclose some or all of your information 10 the compan}' so Ihat the)' f...m perform the job Ihe Pl:m has asked Ihem to do.To pmteCI yOur iitlormaiion, Ihe P\\;m requires Ihe comp:m}' to safeguard rour information in accordance with the law, \nTIn.' following cllegories descrilx different wars thai the Plan uses and discloses your health informal ion, For each f....ltcgor~f, we will explain what we llle;m and gil'e an example, \nFOR PAYMENT \n'111e Plan Ill:l}' LIS(: and disclose information about }'ou so that it C:lIl authorize payment for the hc:altll serviCes that you received. For exampfl', WhCll rou receive a service co\\'ered by the Plan, rOllr he:dthearl' provider sends a claim for paynlt::nl to tlu.: claims adruirlistr.ltor. The claim inchrdes information lll;ll idcnli.tks rOll, as wt::11 as your dia~l1oses and lreatmcnls, \n \nFOK MEDICAL TIHAHH .... T \nTht:: Plan m:l)' lise or disclose informaLion aoom rou to ensure that you receive necessary medicd! trt:::llmel1l and services. For example. if rou panicipate in a Disease St:lte ~Ianagcmcnt Program, the Plan may senti rou iJtlonnation aboul rour condiLion. \nTo OPERATE VARIOt;S PLAN PROGRAMS \nTIlC Plan ma)' use or disclose information aboUI rOll 10 run various Plan p~rams :llld ellsun: lhal rou rccci\\'e quality eire. For example,thc Plan may contract with a comp;lJ1y that rt.'views hospital records [0 check on Ihe qualily of C:lre (hat YOll rect:i\\'etl amJ Ihe outcome of YOllf care. \nTo OTHER GOVERNMENT AGENCIES PROVIDING BENEFITS OR SERVICES \nThe Pl:in may give inform:uion abollt yOll 10 othcr ~Overnlllenl agencies that arc giving YOll bend'its or services. The informatiOll must be necessary for rOll LO recdvc those bend'its or services and will be aUlhOrized b)' rou or hy law, \n \n To KEEP You INFORMED \nThe Plan may mail you information about your health and well-being. Examples arc information about managing II disease that you have, information about your managed care choices, lind inform:uion abOlit prescription drugs yOli arc t;lking. \nFOR OVERSEEING HEALTHCARE PROVIDERS \nThe Plan may disclose information about you to the government agencies that license and inspect medical facilities, such as hospitals, as required by law. \nFOR RESEARCH \nThe Pl:lIl may disclose information about you for a research project that has been :lpproved by a review boanl.The review board must review the research project :llld its rules co ensure the privacy of your information.Tile research must be for the purpose of helping the Plan. \nAs REQUIRED BY LAW The Plan will disclose information about you as required by law. \n \nFOR MORE INFORMATION AND TO REPORT A PROBLEM \nIf yotl have questions and WOuld like additional informlltioll, you may contact the SHBP at (404) 656-6322 (Atlanta calling area) or (800) 610-1863 (outside of AtJanta calling area). \nIf yOll believe your privaq' rights have been violated: \n.. You can me a complainr with the Plan by CalliJlg the SHBP at (404) 656-6322 (Atlanta calling area) or (800) 61().1863 (outside of Atlanta calling area), or by writing to: SHBP - HPU, I~O. Box 38342,ALlanta, GA 30334. \n.. YOli can file a compl;tint with the Health and Human Services' Office for Civil Rights b)' writing to: U.S. Department of Health and Human Services Office for Civil Rights, Region TV, Atlanta Federal Center,61 Forsyth Street SW, Suite 3B70,Atlama, GA 30303-8909. Phone (404) 562-7886; rax (404) 5627881; TOO (404) 331-2867. \n.. YOll also may cOntaCl the HHS Office for Civil Rights by calling (866) OCRPRJY (866) 627-7748 m (886) 788-4989TIY \nThere will be no retaliation for filing a complaint. \n \n WOME 'S HEALTH \u0026 CANCER RIGHTS ACT \nThe Plan complies with the Women's Health and Cancer Rights Act of 1998. MastccLOmy, inclmling reconstructive surgery, is covered the same as other surgery under your Plan option. \nFollowing cancn surgery, the slmp covers: ~ AU stages of reconstruction of the breast on \nwhich the mastenomy has been performed. ~ Ikconstnlction of lhe mha bre:lst 10 achieve \na symmetrical appt:'olr:mcc. \n~ Prosthescs and masleCLOmy bms. ~ Treatment of physical complications of \nmastectomy, including lymphedema. \nNotf!: Reconstructive surge')1 requil\"(!s prior appro/1t\"11 and all inpatient (Idmissions require MCP pl'ecel'tijicatio1/. \nFor more del:liled information on the mastectomyrelated benefits available under the Plan, yOli can COntact the Member Services llnit for your coverage option.Telephone numbers arc 011 the inside front cover. \n \no PENALTIES FOR MISREPRESENTATION \nIf a SHBP participant misrepresents eligibility information when appl)'ing For covcmge, during change of coverage or filing for benefits, the SHBP may lake adverse action against the participant, including but not limited to terminaling coverage (for the panicipant and his or her dcpclldem(s) or imposing liability to the SHOP for fraud or indemnification (reqUiring payment for benefits (0 whicll the participant or his or her beneficiaries were not entitled). Penallks may include a laWSuit, which may rt:slIh i.n payment of charges to the Plan or criminal prosecution in a coun of l:Iw. \nIn order to avoid enforcement of the penalties.lhe participant must notify lhe Stomp immediately if a depcndem is no longer eligible for coverage or if the participant has questions or reserv:ltions about the eligibility of a dependent.This policy may be enforced to lhe fullest extent of the law. \n \nDisclaimer \nThis material is for inforn/ational purposes and is 1I0t a contmct.1t is intended only to bigblight prinCipal benefits of tbe mediull plans. Every effort /)(IS been made to be as accurate as possible; 1.JQlvelle'; sbollid there be a difference between tbis InformaNorl and tbe PIa\" documents, the Pkm dOCU11Je1Its govem.lt Is the respmlsibifity of each member, active or retired, to read all Plan materials provided in order to fully understand {be provisions of tbe option cboselJ. \n \n  \n \n  "}],"pages":{"current_page":1,"next_page":null,"prev_page":null,"total_pages":1,"limit_value":10,"offset_value":0,"total_count":6,"first_page?":true,"last_page?":true},"facets":[{"name":"type_facet","items":[{"value":"Text","hits":6}],"options":{"sort":"count","limit":16,"offset":0,"prefix":null}},{"name":"creator_facet","items":[{"value":"Georgia. 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