Effective Jan. 1, STRS Ohio Health Care Program Guide

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1 Effective Jan. 1, STRS Ohio Health Care Program Guide

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3 Welcome Thank you for your interest in the STRS Ohio Health Care Program. We understand choosing a health care plan is an important decision for you and your family. This is why we re dedicated to making your selection process as easy as possible. When you choose the STRS Ohio Health Care Program, you re selecting a program that is provided by one of the largest public retirement systems in the country. In 1974, STRS Ohio established itself as one of the nation s leaders by offering health care coverage to retired Ohio educators. Today, we continue our dedication to meeting your retirement needs by offering access to health care plans that include hospital, medical and prescription drug coverage. We also offer health management programs and dental and vision plans to supplement your hospital, medical and prescription drug coverage. In addition, we offer a subsidy based on years of service to eligible benefit recipients to help pay the cost of their monthly STRS Ohio health care premiums. Although access to health care is not guaranteed under Ohio law, STRS Ohio understands quality health care in retirement is important to you. To find out which health care plans are available to you, please review your personalized list of plan options you may have received with this publication. If you do not have a personalized list and would like to know which plans are available to you along with monthly premiums, please call STRS Ohio or register for a personal account on our website. Knowing your plan options will help you focus on the information in this publication that applies to you. If you have questions after reviewing the information in this publication, please call STRS Ohio. To stay up to date on health care program news throughout the year, sign up for STRS Ohio s news service by sending an to webmaster@strsoh.org. For enrollment and eligibility questions STRS Ohio Member Services Center STRS Ohio website... The STRS Ohio Health Care Program is authorized by Chapter 3307 of the Revised Code, which may be amended at any time by the Ohio General Assembly. Furthermore, coverage under the program may be modified or eliminated at any time by the State Teachers Retirement Board. Health care coverage is not guaranteed. STRS Ohio may change or discontinue all or part of the program for all or a class of eligible benefit recipients and covered dependents at any time. Premiums, copayments/coinsurance, deductibles and all other charges or fees paid by an enrollee may change from year to year. This guidebook is an overview of the STRS Ohio Health Care Program. It is not a legal document. Your plan will send you a comprehensive description of your coverage after enrollment is confirmed STRS Ohio Health Care Program Guide 1

4 What s Inside Section 1: Selecting Your Plan... 3 Why Choose STRS Ohio for Your Health Care Needs?... 4 How STRS Ohio Health Care Is Funded... 4 Partners in Health... 5 STRS Ohio s Role... 5 Your Role... 5 Who Is Eligible for Coverage?... 5 Benefit Recipients... 5 Employed Enrollees... 6 Eligible Dependents... 6 Beneficiaries and Survivors... 6 Premium Subsidy and Health Care Assistance Program... 7 Subsidy Rate... 7 Health Care Assistance Program... 7 Understanding Your Plans and Coverage Features... 7 Plan Features to Consider... 8 Key Terms to Understand... 8 Types of Plans Offered... 8 Prescription Drug Coverage... 9 Enrolling in a Health Care Plan... 9 Enrolling as a New Benefit Recipient... 9 Enrolling After Monthly Benefits Begin Adding Eligible Dependents to Your Coverage Coverage Considerations...11 Changes in Eligibility...11 Foreign Travel...11 Coverage Under More Than One STRS Ohio Account...11 Coverage Under More Than One Ohio Public Retirement System...11 Changing Plans After Enrollment...11 Terminating Coverage...12 Section 2: Plans and Premiums Without Medicare Prescription Drug Reference Guide...13 Plan Features for 2016 Without Medicare Monthly Premiums for 2016 Without Medicare Section 3: Medicare Enrollment Understanding Medicare What Is Medicare? Medicare Parts What Parts Does STRS Ohio Require? How Medicare Works With Your STRS Ohio Coverage...24 Why You Need to Enroll in Medicare Parts A & B...24 What Happens With Your STRS Ohio Coverage if You Don t Enroll/Remain Enrolled in Medicare?...24 Can You Delay Your Medicare Enrollment if You re Still Employed?...24 Medicare Prior to Age Enrolling in Medicare When to Enroll in Medicare How to Enroll in Medicare Selecting Your New STRS Ohio Plan Your Plan Options Will Change Evaluating Your Plans Selecting Your Plan as a Medicare Enrollee After You Enroll in Medicare Paying Your Medicare Part B Premiums Understanding Your Medicare Part D Prescription Drug Coverage Medicare Late Enrollment Penalties Medicare Surcharges for Higher Incomes Partial Medicare Part B Premium Reimbursement Medicare Part B-Covered Drugs and Supplies Qualifying for Extra Help With Prescription Drug Costs Confused? We Can Help Section 4: Plans and Premiums With Medicare Prescription Drug Reference Guide Plan Features for 2016 With Medicare Monthly Premiums for 2016 With Medicare Section 5: Additional Information About Our Program Quality Standards Release of Information and Confidentiality Statement Affordable Care Act and Your STRS Ohio Health Care Plan Notice of Privacy Practices General Notice of COBRA Continuation Coverage Rights Notice of Medicare Part D Creditable Coverage Getting More Information

5 Section 1: Selecting Your Plan This section provides an overview of the STRS Ohio Health Care Program. Inside you ll learn about: The advantages of enrolling in our program; Who is eligible to enroll in a plan; Premium subsidy and the Health Care Assistance Program; Which types of plans are offered; and How to enroll STRS Ohio Health Care Program Guide 3

6 Why Choose STRS Ohio for Your Health Care Needs? All STRS Ohio health care plans meet the minimum essential coverage requirement under the Patient Protection and Affordable Care Act. See Page 39 for details. Premium subsidy for benefit recipients STRS Ohio currently makes health care premiums more affordable for eligible service retirement and disability benefit recipients by paying a portion of the monthly costs. As a benefit recipient, if you participate in the Defined Benefit or Combined Plan and have 15 or more years of qualifying service credit, STRS Ohio will subsidize your individual monthly health care premium. The 2016 subsidy rate is 2.1% for each year of service credit, up to a maximum of 63%. For example, if you have 30 years of service credit, STRS Ohio will pay 63% of your individual monthly premium cost. STRS Ohio also offers a Health Care Assistance Program to qualified benefit recipients. See Page 7 for details. Access for you and your family We offer you and your family your spouse and other eligible dependents access to quality health care coverage. Broad coverage All of the health care plans we offer include hospital, medical and prescription drug coverage. No need for additional Medicare Part D coverage When you re covered under an STRS Ohio health care plan, you should not purchase additional Medicare Part D prescription drug coverage. All of the health care plans we offer to enrollees with Medicare Parts A & B, Part A-only or Part B-only include Medicare Part D prescription drug coverage. Set annual premiums When you enroll in a plan, your monthly premium is fixed for the calendar year (unless your Medicare status changes or you change plans). This means your premium will not increase if a serious health issue arises or simply because you get older. Quality To be offered as an STRS Ohio health care plan option, a plan must adhere to and maintain quality standards. Our plans also offer special programs to help you better manage your health. Personalized planning and convenience We offer personal counseling before retirement to help you coordinate your pension benefit and health care coverage during retirement. We also make it easy for you to pay your and your family s monthly health care premiums by automatically deducting the amounts from your STRS Ohio benefit payment. How STRS Ohio Health Care Is Funded The State Teachers Retirement Board established the Health Care Fund in 1983 to help support the STRS Ohio Health Care Program. With no dedicated revenue source to finance health care for STRS Ohio retirees, funding comes from: premiums paid by enrollees in the health care program; annually determined employer contributions; investment earnings on the health care fund; federal subsidies; and pharmaceutical reimbursements for prescription drugs. The Retirement Board is working to ensure the stability of the pension plan and the health care program. You can keep up to date on health care funding through your STRS Ohio newsletters, the STRS Ohio website ( and STRS Ohio s news service. To register for the news service, send an to webmaster@strsoh.org. 4

7 Partners in Health When you enroll in the STRS Ohio Health Care Program, you gain a partner in health. To benefit from this partnership, it s important to understand STRS Ohio s role and your role in the health care program. STRS OHIO S ROLE Financial As your health partner, STRS Ohio provides you and your eligible family members access to health care coverage for a monthly premium. We also provide partial Medicare Part B premium reimbursement to eligible benefit recipients who enroll in an STRS Ohio health care plan and provide proof of Medicare Part B enrollment. Premium assistance to low-income enrollees who meet the program s eligibility requirements is also available. In addition, prescription drug coverage is included in all of the health care plans we offer. This means you don t need to purchase additional prescription drug coverage. Managing Your Health All STRS Ohio health care plans include hospital, medical and prescription drug coverage so you can access the services you need to manage your health. In addition, prescription drug coverage includes convenient retail and home delivery programs. Disease management programs are available at no additional cost to plan enrollees to help those with chronic conditions manage and improve their health. Some of these conditions include congestive heart failure, diabetes, coronary artery disease, chronic obstructive pulmonary disease, and other chronic conditions such as end-stage renal disease, multiple sclerosis and rheumatoid arthritis. (See Page 38 for details about the release of enrollee information for disease management and wellness programs.) YOUR ROLE Financial As a health partner, you pay a monthly premium for health care coverage. You also pay other out-of-pocket expenses for hospital care, medical services and prescription drugs. These expenses may include an annual deductible, coinsurance and copayments. As a health care consumer, you can reduce your out-of-pocket expenses by using network providers, network pharmacies and generic drugs whenever possible. You can also save money by using the home delivery pharmacy for maintenance medications. In addition, you can lower your monthly STRS Ohio health care premium by signing up for Medicare when you turn age 65 or whenever you become eligible. Managing Your Health You can reduce your need for health care services by maintaining and improving your health. By using covered preventive services, your doctor can detect health problems earlier. In addition, proper diet and physical activity are key to overall good health. If you already have a chronic health condition, disease management programs can help you maintain and improve your health. Many STRS Ohio health care plans also offer wellness resources to assist you. Other steps you can take to manage your health include not smoking, limiting alcohol intake, maintaining a healthy weight, reducing stress levels and taking prescribed medications as indicated by your physician. By managing and improving your health, you may be able to reduce your visits to the doctor and your need for multiple prescription drugs. This will save you money and help you enjoy a healthier retirement. Who Is Eligible for Coverage? If you have questions about eligibility, please call STRS Ohio s Member Services Center toll-free at BENEFIT RECIPIENTS Service Retirement A Defined Benefit Plan or Combined Plan member with 15 or more years of qualifying service credit who is granted service retirement with an effective date of Jan. 1, 2004, or later is eligible for coverage. In addition, a Defined Benefit Plan or Combined Plan member who is granted service retirement with an effective date before Jan. 1, 2004, is also eligible for coverage; however, they pay 100% of their health care premium if they have less than 15 years of service credit. Disability A disability recipient is eligible for coverage. If a disability recipient later applies for service retirement, the following applies: If the disability effective date was before Jan. 1, 2004, the recipient qualifies for access to health care coverage under the service retirement account as long as there was no break in benefits between the disability benefit and the service retirement benefit. However, if the recipient has less than 15 years of qualifying service credit, the recipient pays the full cost of their coverage. If the disability effective date is on or after Jan. 1, 2004, the recipient must have 15 or more years of qualifying service credit to have access to health care coverage if the recipient later applies for service retirement. Note: Members who retire Aug. 1, 2023, or later, will need 20 or more years of qualifying service to be eligible for health care coverage STRS Ohio Health Care Program Guide 5

8 EMPLOYED ENROLLEES Coverage under the STRS Ohio Health Care Program is limited for non-medicare enrollees employed in public or private positions. Employed enrollees are eligible for only secondary health care coverage through STRS Ohio s Medical Mutual Basic Plan if they: (1) are eligible for health care coverage through their employer, or (2) hold a position for which similarly situated employees are eligible for health care coverage at the same cost as full-time employees. The rule applies to all employed enrollees who are not eligible for Medicare, regardless of hire date or type of employment. If you are employed and not eligible for Medicare, it is your responsibility to notify STRS Ohio by completing a Verification of Employment and Employer Health Care Access form (available in the Health Care section of our website or upon request). If you prefer to opt out of secondary coverage by terminating your STRS Ohio health care plan enrollment, contact STRS Ohio. ELIGIBLE DEPENDENTS Once the benefit recipient enrolls, a spouse, child and/or sponsored dependent may be eligible for coverage. You must notify STRS Ohio in writing when a dependent no longer meets eligibility requirements and indicate the day, month and year your dependent is no longer eligible. Premium deductions from your monthly STRS Ohio benefit payment do not guarantee coverage if your dependent no longer meets eligibility requirements. Spouse A spouse means a husband or wife of a primary service retirement benefit recipient, disability benefit recipient or active member at the time of the member s death. Child A child means a child of a primary service retirement benefit recipient, disability benefit recipient or active member at the time of the member s death. The child must be under age 26 and be a: Biological child; or Lawfully adopted child or a stepchild; or A child for whom the benefit recipient or member is legally appointed as guardian. Sponsored Dependent Category 1 One person age 26 or older who is permanently living in the home (or has moved temporarily to a convalescent center or any other type of institution that retains a person temporarily) of an unmarried primary service retirement benefit recipient, an unmarried disability benefit recipient or an unmarried member at the time of the member s death. Category 2 (Disabled Adult Child) A person age 26 or older who is permanently and totally disabled and: Is a biological child, child lawfully adopted before age 18 or stepchild of a primary service retirement benefit recipient, disability benefit recipient or active member at the time of the member s death; or a child for whom the primary service retirement benefit recipient, disability benefit recipient or deceased active member was legally appointed as guardian before the child attained age 18; and Meets the following requirements: Person has never been married and has been adjudged physically or mentally incompetent by a court before age 18 or age 22 if attending school on at least twothirds-of-a-full-time basis and has been continuously disabled; or Person has never been married and has been unable to earn a living because of a mental or physical condition that was disabling before age 18 or age 22 if attending school on at least two-thirds-of-a-full-time basis and has been continuously disabled. (This means the person is incapable of earning 150% of the federal minimum wage multiplied by 2,080 hours and rounded to the nearest $1,000 as of Jan. 1 of the prior year, as well as the current year and for each year thereafter. Currently this amount is $23,000.) BENEFICIARIES AND SURVIVORS Beneficiaries of Service Retirement Benefit Recipients A beneficiary means a spouse, child or sponsored dependent receiving benefits under a Joint and Survivor Annuity or Annuity Certain plan of payment who was eligible for coverage as a dependent of the primary service retirement benefit recipient at the time of the benefit recipient s death. The service retirement benefit recipient must have been eligible for coverage at the time of death for a beneficiary to qualify for coverage. (See Benefit Recipients on Page 5 for eligibility criteria.) Survivors of Active Members or Disability Benefit Recipients A survivor means a spouse, child or sponsored dependent who is granted survivor benefits under division (C)(2) of Section , Revised Code, and who was an eligible dependent at the time of the active member s or disability benefit recipient s death. For survivors of active members, if the effective date of survivor benefits is Jan. 1, 2004, or later, 15 or more years of service at the time of the member s death may be required depending on the type of survivor benefit selected. 6

9 Premium Subsidy and Health Care Assistance Program SUBSIDY RATE STRS Ohio subsidizes individual monthly health care premiums for eligible service retirement and disability benefit recipients. The premium subsidy rate for 2016 is 2.1% for each year of service credit, up to a maximum of 63%. Covered dependents do not receive a premium subsidy. HEALTH CARE ASSISTANCE PROGRAM The Health Care Assistance Program (HCAP) is designed to help low-income benefit recipients pay for their STRS Ohio health care plan. The assistance program currently includes a $0 monthly premium for the benefit recipient and often lower out-of-pocket costs for all enrollees in the plan.* Although covered family members may receive the same plan of coverage as the qualifying benefit recipient, they are not eligible for the $0 premium and must pay the full cost of their coverage. Beginning Jan. 1, 2016, the assistance program is available to: Service retirement benefit recipients with 25 or more years of qualifying service credit; Disability benefit recipients receiving STRS Ohio benefits; and Beneficiaries and survivors who are otherwise eligible for subsidized premiums. New applicants must be eligible for a subsidy under the STRS Ohio Health Care Program to qualify for HCAP enrollment. Benefit recipients, beneficiaries and survivors who were enrolled in HCAP as of Dec. 31, 2015, are not subject to the subsidy requirement as long as they continue to meet all other HCAP requirements and remain continuously enrolled in the program. Depending on Medicare status, approved individuals may enroll in the Medical Mutual Health Care Assistance Plan or the Aetna Medicare Plan. Medicare-eligible participants must maintain their Medicare Parts A & B or Part B-only enrollment to remain eligible for HCAP. To be eligible for the program: Your total annual family gross income (including any costof-living adjustments) must fall at or below $23,800 for you, your spouse and any dependent children; and Liquid assets or funds readily available to your family, such as cash, savings, money market and checking accounts, trust funds, publicly traded securities and other investment vehicles, must not exceed $23,800. (A home is not considered a liquid asset.) To apply for the program, you must submit a completed application to STRS Ohio along with a copy of the previous year s federal tax return. Applications must be received no later than the 15th of the month to be considered for approval for an effective date starting the next month. STRS Ohio will requalify participants annually. For more information about the program, please call STRS Ohio or visit our website for an application. * The Retirement Board is reviewing the possibility of charging an HCAP monthly premium beginning in HCAP coverage changes may also be implemented in the future. Understanding Your Plans and Coverage Features All STRS Ohio health plans include hospital, medical and prescription drug coverage. Separate dental and vision insurance is also available. The plans available to you depend on the geographic location of your permanent residence and your Medicare status on file with STRS Ohio and Medicare. As a result, you may find that some plans may not be available to you or your family. To find out the specific plans available to you, review your personalized list of options you may have received with this publication. If you do not have a personalized list, please call STRS Ohio for your plan options or register for a personal account on our website. Then see Section 2 and/or Section 4 for the coverage features and monthly premiums of your plan options based on Medicare status. You and your family must enroll in a plan offered by the same plan administrator unless you have Medicare and non- Medicare enrollees on your account. In this case, Medicareeligible individuals may choose the Aetna Medicare Plan while other non-medicare family members choose the Medical Mutual Basic Plan. Enrollment in separate plans is only permitted when all Medicare enrollees on the account select the Aetna Medicare Plan. If the Aetna plan is not selected, all members on the account must choose the Medical Mutual Basic Plan or a regional plan if available. Eligibility for indemnity and PPO plans is determined individually based on where you live and your Medicare status. This means, for example, it s possible for you to be enrolled in a PPO plan and an eligible dependent to be enrolled in an indemnity plan offered by the same plan administrator. Keep in mind, prescription drug coverage is included in all of the health care plans we offer. This means you do not need to purchase additional prescription drug coverage. This is especially important for Medicare enrollees, who must not enroll in any other Medicare Part D plan if they want to remain enrolled in an STRS Ohio health care plan STRS Ohio Health Care Program Guide 7

10 PLAN FEATURES TO CONSIDER Features to consider when selecting your plan include: Services Look at the services offered by each plan. Are any services limited or not covered? Is there a good match between what is provided and what you think you will need? Choice Which doctors, hospitals and other medical providers can you use? Do you need approval from the plan before going into the hospital or getting specialty care? Location Where will you go for care? Are these places conveniently located? How does the plan cover services when you re away from home? Costs How much will you pay for your monthly health care premiums, including Medicare Part B (if applicable) and other out-of-pocket expenses? If a plan does not cover certain services, how much will you have to pay? Although you may not know in advance what your health care needs will be for the coming year, you can think about the services you or your family might need. This will help you estimate what your total costs might be for services under each plan. KEY TERMS TO UNDERSTAND When reviewing plan types, it s important to understand the following key terms: Annual deductible This is the dollar amount you must pay before the plan pays a portion of your hospital/medical and/or prescription drug costs. Coinsurance This is the percentage of covered charges you must pay after you have met your annual deductible, such as 20% for a physician office visit or 10% for a specialty drug. Copayment This is the fixed amount you pay for a specific service, such as $15 for a primary care physician office visit or $10 for a generic drug at retail. Enrollee s maximum annual expense This is the maximum annual amount an enrollee will pay for prescription drugs. Once the maximum annual expense limit is met, the enrollee pays nothing for covered drugs for the remainder of the year. Monthly premium This is the fixed amount you pay monthly for health care coverage under the plan. This amount must be paid even if you don t use any of the services. Out-of-pocket maximum This is the amount you must pay in a calendar year before the plan pays 100% of remaining expenses for covered hospital/medical services that year. This amount does not include prescription drug coverage costs and any charges exceeding allowed/ noncontracting provider amounts set by the health care plan administrator, unless otherwise noted. Allowed/noncontracting provider amounts This is the predetermined amount a plan will pay a provider for medically necessary services as established by the health care plan administrator. TYPES OF PLANS OFFERED Five types of plans are offered under the STRS Ohio Health Care Program. Each plan includes prescription drug coverage. See Prescription Drug Coverage on Page 9 for details. 1. Indemnity (administered by Medical Mutual) An indemnity plan is traditional health care coverage in which reimbursement is made either to you or directly to your provider, up to an allowed dollar amount or coverage limit determined by the plan administrator. You are responsible for any charges exceeding this amount or limit. As an enrollee, you can use any health care provider. 2. PPO (administered by AultCare and Medical Mutual) A preferred provider organization (PPO) is a group of selected health care providers who have agreed to offer comprehensive services at contractually determined reimbursement levels. These providers including physicians, hospitals and other health care providers are referred to as in-network providers. As an enrollee, you can use out-of-network providers, but your out-ofpocket expenses will be higher. 3. Medicare Advantage (administered by Aetna and Paramount) A Medicare Advantage plan is a health care plan approved by Medicare in which the federal government reimburses a private company to provide the enrollee with basic Medicare coverage and other services. These plans, which are sometimes referred to as Medicare Part C plans or MA plans, can be PPO plans, HMO plans, private fee-for-service plans or Medicare special needs plans. A Medicare Advantage plan covers all of the services that Medicare Parts A & B cover and may provide additional coverage for services not typically covered by Medicare, such as preventive services, and vision and hearing services. When you enroll in a Medicare Advantage plan, your Medicare Parts A & B benefits are assumed by the Medicare Advantage plan. You must remain enrolled in Medicare Part B and pay your monthly Part B premium to Medicare when enrolled in a Medicare Advantage plan. 4. HMO(administered by HealthSpan and Paramount) A health maintenance organization (HMO) is a health plan in which physicians, hospitals and other health care providers either contract with or are employed directly by the HMO to provide services. 5. Medicare HMO (administered by HealthSpan) A Medicare health maintenance organization (HMO) is a health care plan in which the federal government reimburses the HMO to provide the enrollee with basic Medicare coverage and other services. This type of plan covers all of the services that Medicare Parts A & B cover and may provide additional coverage for services not typically covered by Medicare, such as preventive services, 8

11 as well as vision and hearing services. When you enroll in a Medicare HMO, your Medicare Parts A & B benefits are assumed by the Medicare HMO plan. You must remain enrolled in Medicare Part B and pay your monthly Part B premium to Medicare when enrolled in a Medicare HMO. PRESCRIPTION DRUG COVERAGE Enrollees Without Medicare Express Scripts administers prescription drug coverage for Medical Mutual, AultCare and Paramount enrollees without Medicare. HealthSpan administers coverage for its enrollees. Enrollees With Medicare If you re enrolled in Medicare Parts A & B, Part A-only or Part B-only, the prescription drug coverage included in your STRS Ohio health care plan is provided under a Medicare Part D plan. A Medicare Part D plan is a prescription drug plan approved by Medicare in which the federal government reimburses a private company to provide the enrollee with prescription drug coverage. Express Scripts administers Medicare Part D prescription drug coverage for Aetna, Medical Mutual, AultCare and Paramount enrollees. HealthSpan administers coverage for its enrollees. Do not enroll in any other Medicare Part D plan. Medicare does not allow enrollment in more than one Medicare Part D plan. If you enroll in any other Medicare Part D plan, your STRS Ohio medical and prescription drug coverage will be canceled. In addition, if you decline or lose coverage under the Medicare Part D plan included in your STRS Ohio health care plan, your STRS Ohio medical coverage will be canceled. Enrolling in a Health Care Plan ENROLLING AS A NEW BENEFIT RECIPIENT Before you begin receiving service retirement or disability benefits, you must complete a pension benefit application. A section of this application asks whether you want to enroll in an STRS Ohio health care plan. If you indicate you want to enroll but do not select a plan, health care information will be mailed to you after your benefit application has been processed. Review the coverage available to you and the monthly premiums charged for coverage. If you did not previously select a plan in writing or in your online application, you must call STRS Ohio to select your plan. If you do not specify a plan, submit required HMO applications or submit required Medicare information, you will be enrolled in the Medical Mutual Basic Plan. The date health care coverage begins for you and your eligible dependents will be determined as follows: Service retirement recipients For recipients who elect coverage within 31 days of their benefit effective date, coverage begins on their benefit effective date. For recipients with a retroactive benefit effective date who elect coverage within 31 days of the first of the month following receipt of the retirement application, coverage begins the first of the month following the date the retirement application is received. Disability recipients For recipients who elect coverage within 31 days from the end of the month when disability benefits are granted, coverage is effective the first of the month following the date the retirement board grants disability benefits. Survivor and service retirement beneficiary recipients For recipients who elect coverage when benefits are granted or within three months from the end of the month of the member s date of death, coverage begins the first of the month following the member s date of death. For a service retirement beneficiary recipient who was enrolled as a dependent of a member at the time of the member s death, coverage will continue at the same level on the first of the month following the member s date of death. Determining your effective date of coverage Be sure to verify the date your employer-sponsored coverage will end. Knowing this information will help you determine an accurate start date of STRS Ohio coverage. Keep in mind: The effective date of STRS Ohio coverage cannot be changed after premium deductions and coverage have begun. The health care coverage you had through your employer is separate from your coverage through STRS Ohio. Any amounts you have accumulated toward an annual deductible or out-of-pocket maximum do not transfer to your STRS Ohio plan from your employer plan. Paying your health care premium Your monthly health care premium will be deducted from your STRS Ohio benefit payment. It s important to understand: If your monthly premium exceeds your benefit payment, the remainder of your premium must be paid in full through the establishment of a direct debit account with your financial institution and STRS Ohio. (A direct debit account allows premium payments to be automatically withdrawn from your checking or savings account.) If payment is not received by the first business day of the month the premium is due, your health care coverage may be canceled STRS Ohio Health Care Program Guide 9

12 ENROLLING AFTER MONTHLY BENEFITS BEGIN If you do not enroll in an STRS Ohio health care plan when monthly benefits begin, you may request enrollment for yourself under the following circumstances by submitting an enrollment application to STRS Ohio. Loss of other coverage You may enroll yourself upon loss of other coverage. Coverage becomes effective the first of the month in which other coverage is lost if STRS Ohio receives the enrollment application and required documentation within 31 days of the date your other coverage ended. Required documentation may include a Certificate of Creditable Coverage from your group health care plan; or a letter signed by your current or former employer or plan sponsor on company letterhead verifying the date health care coverage terminated. The certificate or letter should also include the names of any covered dependents and the dates their coverage terminated. If applicable, you must submit proof of Medicare enrollment to STRS Ohio. If you are selecting a Paramount plan, you must also submit an HMO enrollment application to Paramount. Medicare enrollment You may enroll yourself upon initial eligibility for and enrollment in Medicare Parts A & B or Part B-only. Coverage will be effective the first of the month Medicare coverage begins. See Section 3 for information about Medicare enrollment. Open enrollment STRS Ohio currently offers an openenrollment period each year from Nov. 1 through the Tuesday before Thanksgiving. During this time, benefit recipients can change their health care plan or enroll for the first time. Coverage will be effective Jan. 1 following open enrollment. ADDING ELIGIBLE DEPENDENTS TO YOUR COVERAGE To enroll an eligible dependent, the benefit recipient must also be enrolled. An enrollment application is required for dependents and must be received within 31 days of the qualifying events listed below. Proof documentation may also be required. To request an application, call STRS Ohio or visit our website to print the form. See Page 6 for dependent eligibility guidelines. Marriage Service retirement or disability recipients may enroll a spouse upon marriage. Coverage will be effective the first of the month following the date of marriage. If the marriage occurs on the first of the month, coverage is effective on that date. Loss of other coverage Benefit recipients may enroll an eligible dependent who has lost other coverage. Coverage will be effective the first of the month in which other coverage is lost. Required documentation includes a Certificate of Creditable Coverage from the group health care plan; or a letter signed by the current or former employer or plan sponsor on company letterhead verifying the date the dependent s health care coverage terminated. Medicare enrollment Benefit recipients may enroll an eligible dependent upon the dependent s enrollment in Medicare Parts A & B or Part B-only. Coverage will be effective the first of the month Medicare coverage begins. See Section 3 for information about Medicare enrollment. Birth, legal adoption or legal guardianship Benefit recipients may enroll a child for coverage beginning the first of the month of the date of birth, legal adoption or legal guardianship. Open enrollment Benefit recipients may enroll an eligible dependent during open enrollment. STRS Ohio currently offers an open-enrollment period each year from Nov. 1 through the Tuesday before Thanksgiving. Coverage will be effective Jan. 1 following open enrollment. 10

13 Coverage Considerations CHANGES IN ELIGIBILITY Eligible dependents Notify STRS Ohio by phone or in writing before the end of the month when an enrolled dependent no longer meets eligibility requirements. Please indicate the date your dependent is no longer eligible. Note: If your dependent is enrolled in the Aetna Medicare Plan or a Medicare HMO and you notify us at the end of the month, your termination request may not be fulfilled until the end of the following month due to insufficient time to relay the request to your plan administrator and Medicare under their termination requirements. STRS Ohio must receive all termination requests by the 15th of the month to stop the next month s premium deduction from your STRS Ohio benefit payment. Premium deductions from your monthly benefit payment do not guarantee coverage if your dependent no longer meets eligibility requirements. Employed enrollees You must notify STRS Ohio if you are employed in a public or private position. Coverage under the STRS Ohio Health Care Program may be limited for employed enrollees who are not eligible for Medicare. See Page 6 for additional information. Moving to a new residence If you are moving, call STRS Ohio as soon as you know your new address. STRS Ohio will inform you over the phone if your health care plan options will change as a result of your new address. FOREIGN TRAVEL Before traveling to a foreign country, check with your medical and prescription drug plan administrators to learn about emergency coverage while you are abroad. COVERAGE UNDER MORE THAN ONE STRS OHIO ACCOUNT If you are eligible for health care coverage under more than one STRS Ohio account, you are limited to coverage under only one account. For example, you cannot be covered as both a benefit recipient and a survivor of a benefit recipient. Your monthly premium cost may be significantly different under each account. Be sure to compare premium rates for each type of account, taking into consideration such factors as years of service and Medicare eligibility. It is your responsibility to contact STRS Ohio each year to indicate from which account your monthly premium should be deducted. COVERAGE UNDER MORE THAN ONE OHIO PUBLIC RETIREMENT SYSTEM If you are eligible for health care coverage through more than one Ohio public retirement system, guidelines determine which system is responsible for your health care coverage. Contact STRS Ohio for details. Note: If you are eligible for partial Medicare Part B premium reimbursement through more than one Ohio public retirement system, specific guidelines apply. It is your responsibility to contact STRS Ohio to determine which system is responsible for providing your reimbursement. CHANGING PLANS AFTER ENROLLMENT Once you enroll in an STRS Ohio health care plan, you will remain in the health care plan you select for the calendar year, unless you experience a qualifying event. The qualifying events listed below allow enrollees to change plans during the calendar year. This means enrollees can switch to any STRS Ohio health care plan for which they are eligible. Plan changes may apply to both the benefit recipient and any covered dependents. Enrollee experiences one of the following events and requests to change plans within 31 days of the event: (1) marriage, divorce, dissolution or legal separation; (2) birth, adoption, placement for adoption or legal guardianship of a child; (3) death; or (4) full loss of premium subsidy. Enrollee becomes eligible for and enrolls in Medicare Parts A & B or Part B-only. Enrollee must request to change plans within three months following the effective date of Medicare. Note: If you are enrolled in the Medical Mutual Basic Plan, you will be enrolled in the Aetna Medicare Plan, if eligible, unless you specify a different plan when you submit proof of Medicare enrollment to STRS Ohio. Enrollee is a new retiree. The new enrollee must request to change plans within 31 days of receiving the first monthly benefit payment. A PPO or an HMO enrollee experiences the loss of a key provider from the network. An enrollee permanently moves to another service area, which results in different plan options being available. Furthermore: An Aetna Medicare Plan enrollee may terminate coverage at the end of any month and enroll in the Medical Mutual Basic Plan or a regional plan if available. The request to terminate coverage must be received by STRS Ohio before the effective termination date and by the 15th of the month to stop the next month s premium deduction from the STRS Ohio benefit payment. The request to enroll in another STRS Ohio plan must be received by STRS Ohio within 31 days of the termination effective date. A HealthSpan Medicare Plus or Paramount Elite HMO enrollee may terminate coverage at any time and enroll in the Aetna Medicare Plan or Medical Mutual Basic Plan. A written request to terminate coverage must be sent to STRS Ohio before the termination date becomes effective. As required by the Centers for Medicare & Medicaid 2016 STRS Ohio Health Care Program Guide 11

14 Services, the letter must be signed by the benefit recipient and any other covered Medicare enrollees on the account. The request to enroll in another STRS Ohio plan must be received by STRS Ohio within 31 days of the termination effective date. Note: If you experience a qualifying event during the calendar year and choose to change plan administrators, your medical deductible and out-of-pocket maximums will transfer to the new plan administrator only if you move between the Aetna Medicare Plan and the Medical Mutual Basic Plan. TERMINATING COVERAGE Terminating coverage at any time You may terminate your or your dependent s STRS Ohio health care coverage at any time. All termination requests must be received by the 15th of the month to stop the next month s premium deduction from your STRS Ohio benefit payment. Aetna, AultCare and Medical Mutual enrollees may terminate coverage by calling STRS Ohio. HealthSpan and Paramount enrollees may terminate coverage by sending a written request to STRS Ohio. The letter must be signed by the benefit recipient and any other covered enrollees on the account. If applicable, Medicare coverage assumed by the plan will be reinstated effective immediately so there is no gap in health care coverage. Please note, there are limited opportunities to reenroll in an STRS Ohio health care plan after you terminate coverage. See Page 10 for details. Terminating your dependent s coverage due to loss of eligibility Spouse In the event of a divorce, your spouse s health care coverage terminates the first of the month following finalization of the divorce. The termination request must be received by the 15th of the month to stop the next month s premium deduction from your STRS Ohio benefit payment. Your spouse may be eligible for COBRA continuation coverage. Call STRS Ohio for more information. Please note that some plans do not allow retroactive terminations. It is the benefit recipient s responsibility to notify STRS Ohio when a divorce is finalized. Child In the event a covered child loses access to STRS Ohio health care coverage because a parent dies, parents become divorced or the child stops being eligible for coverage, the child may be eligible for COBRA continuation coverage. Call STRS Ohio for more information. After death of benefit recipient (Single Life Annuity) If you selected a Single Life Annuity at the time of retirement and have dependents enrolled in an STRS Ohio health care plan at the time of your death, dependent health care coverage will terminate at the end of the month in which your death occurred. Your dependents should contact STRS Ohio for information about COBRA continuation coverage. 12

15 Section 2: Plans and Premiums Without Medicare If you re not eligible for Medicare, this section is for you. Inside you ll find the coverage features of the plans available to enrollees without Medicare. You ll also find monthly premiums for benefit recipients based on years of service, as well as premiums for spouses, children and sponsored dependents without Medicare. Review the personalized list of plan options you may have received with this publication to find out the specific plans available to you and your family. (If you did not receive a personalized list, please call STRS Ohio s Member Services Center for your plan options.) Keep in mind, you and your family members must enroll in the same option. If two plans are listed under an option, you and your dependents are eligible for different plans under that option based on Medicare status. Please review this section for the features and premiums of the plans for enrollees without Medicare. If you have Medicare-eligible family members, also review Section 4 (Page 29) for the features and premiums of the plan options for enrollees with Medicare. Be aware coverage features under the same plan could differ based on Medicare status. Premiums also differ. If you have specific questions about plan features, please contact the plan administrator directly (Page 45). If you have questions about monthly premiums, call STRS Ohio. PRESCRIPTION DRUG REFERENCE GUIDE Express Scripts administers the prescription drug plan for the Medical Mutual, AultCare and Paramount plans described in this section. When reviewing prescription drug coverage for these plans, it s important to understand the following key terms. KEY TERM Annual deductible Generic Covered brand-name Specialty Over-the-counter PPI DESCRIPTION The amount an enrollee must pay for drugs classified as covered brand-name, including specialty, before the plan begins paying a portion of the costs for these drugs. Generic drug costs are not subject to the deductible. Generic medications available for the lowest copayment. Brand-name medications available for a copayment after the deductible is met. Specialty medications available for a 10% coinsurance up to a maximum cost of $500 per fill (after the deductible is met if applicable). These high-cost medications typically include infused, injectable and oral drugs that are used to treat chronic and life-threatening diseases; are often difficult to administer; may cause adverse reactions; may require temperature control or other special handling; and/or may have restrictions as determined by the Food and Drug Administration. Over-the-counter proton pump inhibitor (PPI) medication, such as Prilosec OTC, which is available for the generic copayment with a prescription STRS Ohio Health Care Program Guide 13

16 Plan Features for 2016 Without Medicare You may be eligible for these plans if you are not yet eligible for Medicare. Medical Mutual Basic (Indemnity or PPO) AultCare PPO PLAN FEATURES In-network and Indemnity 1 Out-of-network 1 In-network Out-of-network 1 Enrollee Eligibility Available in any location Available in select northeastern Ohio area ZIP codes Annual Deductible per Enrollee 2 $2,500 $5,000 $2,500 $5,000 Out-of-Pocket Maximum 2 (Excludes prescription drug costs. Amounts included are noted for each plan.) Lifetime Benefits Maximum per Enrollee Health Provider Access $6,500 per enrollee (includes deductible, coinsurance and primary care physician copayments) Use network provider (PPO); use any covered provider (indemnity) Unlimited PHYSICIAN, HOSPITAL, SKILLED NURSING AND HOME HEALTH CARE Primary Care Physician Office Visit Enrollee pays $20 per visit for first two visits per year (no deductible); 20% thereafter (after deductible) $13,000 per enrollee (includes deductible and coinsurance) $6,500 per enrollee (includes deductible, coinsurance and primary care physician copayments) Unlimited $13,000 per enrollee (includes deductible and coinsurance) Use any covered provider Use network provider Use any covered provider Enrollee pays 50% after deductible Enrollee pays $20 per visit for first two visits per year (no deductible); 20% thereafter (after deductible) Enrollee pays 50% Specialist Physician Office Visit Enrollee pays 20% Enrollee pays 50% Enrollee pays 20% Enrollee pays 50% Urgent Care Enrollee pays $35 Enrollee pays $35 Hospital Inpatient Services Enrollee pays 20% Enrollee pays 50% Enrollee pays 20% Enrollee pays 50% Hospital Charges for Outpatient Surgery and Preadmission Testing Enrollee pays 20% Enrollee pays 50% Enrollee pays 20% Enrollee pays 50% Emergency Room Care Enrollee pays $150; waived if admitted Enrollee pays $150; waived if admitted Skilled Nursing Facility (Benefit period varies by plan administrator.) Inpatient Mental Health Home Health Care Enrollee pays 20% (90 days per benefit period); after 90 days, enrollee pays 100% Enrollee pays 20%; no limit on days Enrollee pays 20%; no visit limit Enrollee pays 50% (90 days per benefit period); after 90 days, enrollee pays 100% Enrollee pays 50%; no limit on days Enrollee pays 50%; no visit limit Enrollee pays 20% (90 days per illness); after 90 days, enrollee pays 100% Enrollee pays 20%; no limit on days Enrollee pays 20%; no visit limit Enrollee pays 50% (90 days per illness); after 90 days, enrollee pays 100% Enrollee pays 50%; no limit on days Enrollee pays 50%; no visit limit 1 Indemnity and out-of-network payments are based on allowed/noncontracting provider amounts for medically necessary services as established by the health care plan administrator. If nonparticipating 1 providers charge in excess of these amounts, the enrollee is responsible for the excess charges. 2 Annual deductible must be met before plan begins making payments, unless otherwise noted. In-network and out-of-network accumulations are separate. 14

17 Plan Features for 2016 Without Medicare HealthSpan (HMO) Closed to new enrollments Paramount Health Care (HMO) Available in select Cleveland, Ohio, area ZIP codes Available in select northwestern Ohio and southern Michigan area ZIP codes $2,000 $2,000 $4,000 per enrollee (includes deductible, copayments and coinsurance) $4,000 per enrollee (includes deductible, copayments and coinsurance) Unlimited Unlimited Use HMO network provider Use HMO network provider Enrollee pays $20 Enrollee pays $10 Enrollee pays $20 Enrollee pays $20 Enrollee pays $35 Enrollee pays $35 Enrollee pays 20% Enrollee pays 20% Enrollee pays 20% Enrollee pays 20% Enrollee pays $150; waived if admitted Enrollee pays 20% for up to 100 days per calendar year; after 100 days, enrollee pays 100% Enrollee pays 20%; no limit on days Enrollee pays 20%; no visit limit Enrollee pays $150; waived if admitted Enrollee pays 20% after deductible Enrollee pays 20%; no limit on days Enrollee pays 20%; no visit limit 2016 STRS Ohio Health Care Program Guide 15

18 Plan Features for 2016 Without Medicare You may be eligible for these plans if you are not yet eligible for Medicare. Medical Mutual Basic (Indemnity or PPO) AultCare PPO PREVENTIVE SERVICES Services such as a routine physical exam, bone density screening, mammogram, routine prostatic specific antigen (PSA), colorectal cancer screening, Pap smear and immunizations/ inoculations may be covered. Contact the plan administrator for details. In-network and Indemnity 1 Out-of-network 1 In-network Out-of-network 1 Enrollee pays 0% (no deductible); limit one per calendar year (colorectal cancer screening limit one per 24 months if high risk or one per 10 years if not high risk) Enrollee pays 0% (no deductible); limited designated services; frequency/age/gender limitations apply OUTPATIENT SERVICES Diagnostic X-ray and Lab Testing Enrollee pays 20% Enrollee pays 50% Enrollee pays 20% Enrollee pays 50% Outpatient Mental Health ADDITIONAL SERVICES Enrollee pays 20%; no visit limit Enrollee pays 50%; no visit limit Enrollee pays 20%; no visit limit Dental Care No coverage No coverage Vision Care No coverage No coverage Enrollee pays 50%; no visit limit 1 Indemnity and out-of-network payments are based on allowed/noncontracting provider amounts for medically necessary services as established by the health care plan administrator. If nonparticipating 1 providers charge in excess of these amounts, the enrollee is responsible for the excess charges. 16

19 Plan Features for 2016 Without Medicare HealthSpan (HMO) Closed to new enrollments Paramount Health Care (HMO) Enrollee pays 0%; limited designated services; frequency/age/gender limitations apply Enrollee pays 0%; limited designated services; frequency/age/gender limitations apply Enrollee pays 20% Enrollee pays 20% Enrollee pays $20; no visit limit Enrollee pays $20; no visit limit No coverage Enrollee pays $20 for annual eye exam through EyeMed providers No coverage Enrollee pays $20 for annual eye exam at participating providers 2016 STRS Ohio Health Care Program Guide 17

20 Plan Features for 2016 Without Medicare You may be eligible for these plans if you are not yet eligible for Medicare. Medical Mutual Basic (Indemnity or PPO) AultCare PPO PRESCRIPTION DRUG COVERAGE Retail Network Provider Express Scripts Express Scripts Annual Brand-name Deductible per Enrollee (Generic drug costs do not apply to deductible.) Standard (Network) Retail/Nursing Home Pharmacy Copayments/Coinsurance $225 for covered brand-name drugs, including specialty Generic: $10 (includes over-the-counter PPI with prescription) Covered brand-name: $30 after deductible is met If the cost of the drug is less than the copayment, the enrollee pays the cost of the drug. Specialty: 10% up to a maximum of $500 per fill (after deductible is met if applicable) Out-of-network pharmacies and pharmacies outside the U.S. and Puerto Rico: Reimbursed the amount STRS Ohio would have been charged at a standard (network) pharmacy, less copayment $225 for covered brand-name drugs, including specialty Generic: $10 (includes over-the-counter PPI with prescription) Covered brand-name: $30 after deductible is met If the cost of the drug is less than the copayment, the enrollee pays the cost of the drug. Specialty: 10% up to a maximum of $500 per fill (after deductible is met if applicable) Out-of-network pharmacies and pharmacies outside the U.S. and Puerto Rico: Reimbursed the amount STRS Ohio would have been charged at a standard (network) pharmacy, less copayment Maximum Day Supply Retail: 31 days; Mail: 90 days Retail: 31 days; Mail: 90 days Home Delivery Provider Express Scripts Express Scripts Home Delivery Copayments/Coinsurance Low-Cost Generic Drug Program medications: $9 Generic: $25 (includes over-the-counter PPI with prescription) Covered brand-name: $75 after deductible is met If the cost of the drug is less than the copayment, the enrollee pays the cost of the drug. Specialty: 10% up to a maximum of $500 per fill (after deductible is met if applicable) Low-Cost Generic Drug Program medications: $9 Generic: $25 (includes over-the-counter PPI with prescription) Covered brand-name: $75 after deductible is met If the cost of the drug is less than the copayment, the enrollee pays the cost of the drug. Specialty: 10% up to a maximum of $500 per fill (after deductible is met if applicable) Maximum Annual Expense per Enrollee (Excludes medical costs unless otherwise noted.) If an enrollee pays a total of $4,850 out of pocket in copayments/coinsurance/deductible for generic, covered brand-name and specialty medications, that enrollee pays nothing for covered medications for the remainder of the year. If an enrollee pays a total of $4,850 out of pocket in copayments/coinsurance/deductible for generic, covered brand-name and specialty medications, that enrollee pays nothing for covered medications for the remainder of the year. 18