PHIP Member Handbook & Benefit Guide. January 1, 2015, to December 31, 2015

Transcription

1 PHIP Member Handbook & Benefit Guide January 1, 2015, to December 31, 2015

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3 Table of contents Introduction 5 Your health plan options 8 Other important information 10 Plan change 10 Exclusions and limitations 10 Eligibility 12 Enrollment opportunities 14 How to enroll 18 After enrollment 19 Premium subsidies 20 Continuation of coverage 23 Coverage outside the service areas 24 Benefit changes, health plan service areas and plan features 27 Changes to plans 28 Health plan service areas 30 Moda Health Plans/ODS 32 Kaiser Permanente 34 PacificSource Health Plans 36 Providence Health Plan 38 Prescription drug benefit 40 Plan benefit and rate comparisons Medicare benefit comparison Medicare rate comparison Core Value non-medicare rate comparison Select Value non-medicare rate comparison Core Value non-medicare benefit comparison Select Value non-medicare benefit comparison Dental benefit comparison 54 Definitions 56 Acronyms and abbreviations 59 Notes 60 Please refer to the back of this handbook for important phone numbers and website addresses.

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5 Introduction Mission statement The PERS Health Insurance Program (PHIP) provides PERS retirees with high-quality, comprehensive coverage (or benefits) at the most cost-effective rates possible to meet retiree benefit needs. Our core values are: Maintain stability of premiums Maintain stability of coverage Maintain stability of carriers PERS Health Insurance Program PHIP offers health insurance coverage for all retirees, their spouses and dependents who meet the eligibility requirements. When planning your retirement, review all health coverage options available through your or your spouse s employer to determine the best option for you. PHIP website On the PHIP website (pershealth.com), you can download the forms necessary to make changes to your account or health plan, view the latest Member Handbook or look at past issues of the quarterly HealthWise newsletter. The website is one way PHIP communicates important information to members throughout the year. Medicare basics Medicare is health insurance available to people who are 65 years of age or older, who are under 65 but receiving Social Security Disability Insurance for more than 24 months or who have end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS). Medicare is administered by the Centers for Medicare and Medicaid Services (CMS). To enroll, PHIP requires all Medicare-eligible members and eligible Medicare dependents to be enrolled and retain both Parts A and B of Medicare. If you turn down Part B when first eligible and request to enroll at a later date, you may be penalized by Medicare. In addition, if you do not have Part B in place when you lose employer-sponsored coverage, you cannot enroll in a PHIP plan and may miss your enrollment opportunity altogether. If you stop paying your Part B premium, you will lose your ability to continue any of the PHIP plans. In most circumstances, if you do not enroll in PHIP when you are first eligible for Medicare Parts A and B, you will forfeit any future opportunity to enroll in a PHIP medical plan. Refer to enrollment opportunities on page 14 of this handbook. Enrollment in a PHIP Medicare plan includes automatic enrollment in a Medicare Part D prescription plan. 5

6 Medicare enrollment You will become eligible for Medicare at age 65, regardless of whether you are receiving a Social Security benefit at the time. You are entitled to Medicare the first day of the calendar month during which you turn 65. If your birthday falls on the first day of the month, you are entitled to Medicare the first day of the prior month. Medicare eligibility could occur earlier than age 65 if you are awarded Social Security Disability Insurance. Medicare eligibility because of disability would become effective the first day of the 25 th month after your Social Security benefits began. If you receive Social Security benefits prior to age 65, you will automatically be enrolled in Medicare. You should receive your Medicare information, including your Medicare Parts A and B card, approximately three months prior to your 65 th birthday or when you become eligible for Medicare because of disability. Medicare due to end-stage renal disease End-stage renal disease (ESRD) is the stage of kidney impairment that appears irreversible and permanent, which requires a regular course of dialysis or a kidney transplant to maintain life. If you currently have ESRD, your ability to enroll in a Medicare Advantage plan through PHIP may be limited. However, the Moda Health Medicare Supplement Plan is available to you. Please contact PHIP for more information. Please review your health coverage options through your employer-sponsored health plans if you become Medicare eligible because of ESRD. If you are enrolled in another health plan in addition to PHIP, please provide that information for correct coordination of benefits. If you do not receive your Social Security benefit prior to age 65, you will need to contact the Social Security Administration or visit your local Social Security office approximately three months prior to your 65 th birthday and apply for Medicare Parts A and/or B. 6

7 Medicare parts A, B and D description Medicare consists of several parts. Part A covers inpatient hospital expenses. In most cases, you pay no premium to maintain this coverage. Part B covers outpatient (medical) expenses, such as doctor visits, lab work and diagnostic services. You pay a premium each month to maintain this coverage. This premium is deducted from your Social Security benefit check, or if you do not yet receive a benefit, you will be billed by Social Security quarterly. You must continue to pay your Part B premium to remain eligible for all PHIP Medicare plans. For more information, contact your health plan customer service for clarification about which Part B drugs and supplies are covered by contracted or network providers. For Medicare Parts A and B enrollment, contact the Social Security Administration. You can find contact information on the back cover of this handbook. Part D covers approved prescription medications. You must pay a premium for this coverage; however, it is included in the premium you pay for coverage through PHIP. The PHIP Medicare Part D plan does not have an up-front deductible or coverage gap (doughnut hole) like some individual Medicare Part D plans sold on the commercial market. See pages for benefit information. Medicare part D creditable coverage If you or your dependent are already Medicare-eligible when you enroll in a PHIP health plan, you may be required to show proof from your prior employer or health plan that the prior plan s prescription drug coverage was equal to or exceeded that of the basic Medicare Part D prescription drug benefit. If the coverage was not creditable, Medicare could impose a 1 percent per month penalty for the months you did not have creditable coverage. You will be automatically terminated from all PHIP coverage if you enroll in a second Medicare Part D prescription plan or Medicare Advantage plan. Once termination has occurred, you cannot re-enroll in PHIP, unless you experience a new enrollment opportunity. Part D-IRMAA Part D Income Related Monthly Adjustment Amount (Part D-IRMAA) is an assessment required by Medicare for individuals whose income is above the Medicare-defined income threshold and who are enrolled in a Part D plan. Under PHIP, you will have a Part D prescription plan. Social Security will notify and bill you if you are required to pay this additional premium. To be eligible for PHIP coverage, you must pay your Part D-IRMAA, or Medicare will notify your plan and you will be terminated from PHIP entirely. Do not contact PHIP or the health plans regarding this mandate. For additional information, see the PHIP website for a Medicare Q&A at For questions about Part D-IRMAA, please contact either Medicare or the Social Security Administration as referenced on the back cover of this handbook. 7

8 Your health plan options Below are descriptions of the various types of health plans available through PHIP. You can find additional planspecific information in the benefit comparisons, premium rates and definition sections in this handbook. Medicare Supplement The Medicare Supplement plan allows you to choose any physician who is a Medicare participating provider. You can live anywhere in the United States or travel outside the U.S. and still maintain coverage as referred to on pages You must meet your annual deductible first; then, Medicare pays its portion, and the plan pays the balance of the Medicare-allowed benefits. Medicare Supplement Moda Health Managed care plans Managed care plans contract with hospitals and physicians to provide care for enrollees. With managed care plans, you usually pay a modest fixed charge, called a "copay, at the time you receive care. Generally, you have no claim forms to file for managed care doctors, hospitals and other healthcare providers who contract with these health plans. When you join a managed care plan, you must use the providers (hospitals and physicians) that are part of the plan. You must live in a certain geographic area, known as a service area, to be eligible for benefits. You also must select a primary care physician and be referred by that physician for most specialist care. Exceptions in Medicare Advantage plans are described later in this handbook. Managed care plans for Medicare-eligible participants are called Medicare Advantage (MA) plans. When you enroll in any MA plan, that plan becomes the administrator of your Medicare Parts A and B benefits and you are locked into the managed care plan you have chosen until the plan change period or you move out of the plan s service area. PHIP offers health maintenance organization (HMO), point-of-service (POS) and Preferred Provider Organization (PPO) Medicare Advantage plans to its Medicare participants. 8

9 You can be enrolled in only one Medicare Advantage plan at a time. By enrolling in a PHIP Medicare Advantage plan, any prior Medicare Advantage coverage will be terminated. Medicare Advantage managed care HMO plans: y PacificSource Medicare y Kaiser Permanente y Providence Medicare Advantage plans (Providence Medicare Align Group Plan(HMO)) Medicare Advantage managed care HMO-POS plan: y Providence Medicare Advantage Plans (Providence Medicare Flex Group Plan (HMO-POS)) Medicare Advantage PPO plan: y PERS Moda Health PPORX (PPO) Non-Medicare plans Participants may select either a $500 deductible Core Value plan option or a $1,000 deductible Select Value plan option. Kaiser Permanente offers a traditional HMO plan as a Core Value plan and a $1,000 deductible plan as a Select Value plan option. Refer to pages for more information. PHIP offers HMO, POS and PPO plans for non-medicare participants: Core Value Traditional HMO plan: Kaiser Permanente Select Value HMO plan with Deductible: Kaiser Permanente Core Value and Select Value POS plans: PacificSource Health Plans Core Value and Select Value PPO plans: Moda Health and Providence Health Plan If you are eligible for Medicare Parts A and/ or B, you will not be eligible to enroll in any of the PHIP non-medicare plans. Once enrolled under the Select Value plan ($1,000 deductible), you will not be able to move back to the Core Value plan ($500 deductible/kaiser HMO). You will be able to move within the Select Value plans ($1,000 deductible) offered by another provider within your service area during plan change. You will not be able to change to the Core Value plan midyear, even if you experience a family status change or new enrollment opportunity. Dental options PHIP offers two dental plans: Kaiser Permanente ODS You can enroll in either dental plan regardless of your medical plan selection. However, for Kaiser Permanente dental, you must reside in the Kaiser Permanente dental plan service area. Please refer to pages for a description of dental services. For additional information on dental enrollment, refer to page 16. 9

10 Other important information Plan change PHIP offers an annual plan change period from October 1 to November 15. Plan information and rates for the coming year are posted to the PHIP website in September. During the plan change period, you can change your medical and/or dental plan to another plan available within your residing area. This annual plan change period is not an opportunity to add dental coverage or dependents. Plan changes made during this period become effective January 1. If you are enrolled and do not want to change plans, no paperwork is required. Exclusions and limitations All available plans have some limitations and exclusions. Please contact the specific health plan administrator for more information. The plan benefit handbook you receive from your chosen health plan after enrollment will include complete information on the exclusions and limitations for the plan. Information also will be available on your health plan s website. Please refer to the back of this handbook for phone numbers and website addresses. If you want to make a change, you must fill out a Disenrollment Form for the plan you are ending as well as an Enrollment Request Form for the new coverage. Submit both forms to PHIP before the November 15 deadline. Forms can be found at pershealth.com or by calling PHIP customer service. If you do not submit a change during this period, you will be unable to change your enrollment midyear, unless you experience a family status change or new enrollment opportunity. 10

11 Power of Attorney/Authorization to Disclose Information PHIP requires that a Power of Attorney or Authorization to Disclose Information be on file with the program office for anyone acting on a member s behalf. PHIP is unable to release information to anyone who is not authorized by the PHIP member. To disclose or change information after the death of a member, please provide one of the following: executor, letter of probate or trustee documentation, or Last Will and Testament. Change of address You must submit all address changes through PHIP to ensure coordination of billing and effective dates with your health plans. PHIP will notify the appropriate health plans for you. Failure to notify PHIP within 30 days of moving outside a service area can result in involuntary termination of coverage if you are enrolled in a managed care plan. Address changes must be submitted in writing by the member or authorized party. Complete, sign, date and submit a Change of Address Form to PHIP. Address changes may be sent via mail or fax. ( requests will not be accepted.) You are also required to submit your change of address in writing to the PERS Pension Office at the address listed on the back cover of this handbook. PHIP Snow Bird option For members who are enrolled in PacificSource, Providence Medicare Align Group Plan (HMO) or Kaiser Permanente, and who reside inside Oregon part of the year and outside Oregon part of the year, PHIP offers a Snow Bird option. The Snow Bird option allows members to change their health plan to Moda Health while living outside their managed care plan s service area. Members must plan on living outside the service area for more than 60 days for this option to apply. Before leaving, members should contact PHIP to request an application and Disenrollment Form to change to either the Moda Health Medicare Supplement Plan or the PERS Moda Health PPORX (PPO) Plan for the time spent living outside the managed care service area. Upon returning to Oregon, members will be eligible to change back to their managed care plan. For non-medicare members who are enrolled in Kaiser Permanente, PacificSource, or Providence plan, and who reside inside Oregon part of the year and outside Oregon part of the year, PHIP offers a Snow Bird option. You must fill out a Disenrollment Form for the plan you are ending and an Enrollment Request Form for the new coverage when leaving the area and when returning. Please contact PHIP for more information about this option. You must maintain a primary residence within the United States to be eligible for PHIP. If you reside in another country, you are not eligible to retain PHIP coverage. 11

12 Eligibility The information in this section is a summary of the Oregon Administrative Rule (OAR ) for enrolling in PHIP health plans. If you have any questions about your eligibility for enrollment or contributions to your Retirement Health Insurance Account (RHIA) or Retiree Health Insurance Premium Account (RHIPA) (see pages 21 22), or if you would like a copy of the complete OAR eligibility rules, please call PHIP at or visit arcweb.sos. state.or.us/banners/rules.html. Who s eligible? An eligible person includes an eligible PERS retiree, a spouse, a dependent domestic partner, a dependent, or a surviving spouse or dependent. PHIP reviews eligibility upon receiving enrollment forms. The categories of eligible persons are as follows: An eligible spouse is the spouse of an eligible retiree. A marriage certificate is required if the spouse has a different last name than the retiree. An IRS-eligible, dependent domestic partner, as defined by IRS Code 26 USC 105(b), refers to a person who has had a relationship with and resided with a PERS retiree for at least 12 months immediately preceding enrollment into PHIP. In addition, the PERS retiree must be providing more than one-half the financial support for the person and must have claimed that person on his or her most recent federal tax return. 12

13 An Affidavit of Dependent Domestic Partnership and a copy of your most recent federal tax return will be required. An eligible dependent is a dependent child who is less than 26 years old and meets one of the following requirements (the retiree must provide legal documentation of birth or adoption): ya natural child ya legally adopted child or a child placed in the home pending adoption (legal custody and guardianship do not apply) ya step-child who resides in the household of the step-parent who is an eligible retired member ya grandchild, provided at the time of birth at least one of the grandchild s parents was covered under a PHIP plan as a dependent child and resides in the household of an eligible retired member An eligible dependent also can be someone who is 26 or older and has either been continuously dependent upon the retiree since childhood because of a disability or physical handicap, or has been covered under a healthcare insurance plan as the retiree s dependent for at least 24 consecutive months immediately before enrollment in a PHIP plan. In either case, the following additional requirements must be satisfied: ythe child is not able to achieve self-support through work because of a developmental disability, mental retardation or a physical handicap as verified by a physician and accepted by the carrier. ythe incapacity is continuous and began before the date the child would otherwise have ceased to be an eligible dependent. An eligible surviving spouse or dependent refers to: ythe surviving spouse or dependent of a deceased retired PERS member ythe surviving spouse or dependent of a deceased PERS member who was not retired but was eligible to retire at the time of death In no event shall an eligible person as defined in this rule be entitled to coverage as both a retiree and as a spouse or dependent. Members and their dependents must reside in the United States to receive coverage. Upon reaching age 65 or becoming Medicare-eligible because of a disability, a retiree and/or dependents must be enrolled in and maintain Parts A and B of Medicare to be eligible for PHIP coverage. Part B premiums must be paid to Medicare. If you drop your Part B coverage through Medicare, you will no longer be eligible for coverage through PHIP. Enrollment in a PHIP Medicare plan includes enrollment in a PHIP Medicare Part D plan. PHIP enrollment appeals If you disagree with any determination related to your enrollment or eligibility in PHIP, you may submit an appeal in writing within 60 days of a determination to PERS, Attn: Appeals, SW 68th Parkway, Tigard, OR Health plan appeals Appeals related to claim and benefit payments, or Medicare plan enrollment or disenrollment issues, should be directed to the health insurance carrier of the plan in which you are enrolled. Contact information for all health plans may be found on the back of this handbook. 13

14 Enrollment opportunities The PHIP milestones, as defined in OAR , mark the only enrollment opportunities available. Eligible retirees and their spouses or dependents who do not choose to enroll in a PHIP health plan during one of these enrollment periods will lose their opportunity to enroll in PHIP. Enrollment periods New retiree New retirees can enroll up to 90 days after the effective date of their retirement. Coverage will be effective on your retirement date (if you apply before your retirement date or the date of your PERS disability approval letter) or on the first day of the month after your application is received (if you apply within 90 days of your retirement date or the date of your PERS disability approval letter). Verify your prior employer s coverage end date to ensure that your PHIP plan does not overlap other employer-sponsored coverage. Working past Medicare eligibility If you are not drawing a Social Security benefit check and are still working and covered by an employer-sponsored plan when you turn 65, you will need to contact the Social Security Administration to sign up for Medicare Part A. Part A is free for most people. Because Medicare Part B has a premium, you may want to wait until three months before your retirement date or loss of employer-sponsored coverage to contact the Social Security Administration to sign up for Part B. The Medicare enrollment period is anytime during the active group coverage or anytime during the eight months after the active coverage ends. If you do not have Part B in place when you lose your employer coverage, you cannot enroll in a PHIP plan. Medicare eligibility PERS retirees can enroll up to 90 days after the date of their initial Medicare eligibility if they are enrolled in both Medicare Parts A and B. Enrollment in a PHIP medical plan includes enrollment in a PHIP Medicare Part D plan. PHIP coverage will take effect on the date your Medicare coverage becomes effective if you enroll before the date of your Medicare eligibility. 14

15 PHIP coverage will take effect on the first day of the month after your application is received if you apply after the date of your Medicare eligibility. If you are currently enrolled in a PHIP non-medicare plan, you will be required to fill out the Enrollment Request Form 30 days before becoming Medicare-eligible. Failure to submit a new Enrollment Request Form for Medicare coverage will result in cancellation of your non-medicare health plan coverage under PHIP upon Medicare eligibility with the possibility of no future opportunities to enroll. Medicare disability Your eligibility to enroll in Medicare Parts A and B, due to Social Security Disability, becomes effective the first day of the 25th month after your Social Security Disability benefits began. You are required to retain both Medicare Parts A and B to be enrolled in a PHIP Medicare plan. The 90-day Medicare eligibility enrollment opportunity also applies in these circumstances. If you miss this opportunity, becoming Medicare-eligible at age 65 will not be a new opportunity to enroll in a PHIP health plan unless you have had 24 months of continuous employer-sponsored coverage immediately preceding enrollment in PHIP. If you are currently enrolled in a PHIP non-medicare plan, you must fill out the Enrollment Request Form 30 days before becoming Medicare-eligible. Failure to submit a new Enrollment Request Form for the Medicare coverage will result in cancellation of your non-medicare health plan coverage under PHIP upon Medicare eligibility with the possibility of no future opportunities to enroll. Continuous employer-sponsored coverage PERS retirees can enroll at any time if they have been covered under another employer-sponsored group health plan for 24 consecutive months immediately preceding enrollment in PHIP and within 30 days of losing prior employer-sponsored coverage. Employer-sponsored group coverage can be: Coverage you had as an active or retired employee that is terminating Coverage you had under an eligible spouse s active employment or as a retired employee that is terminating Coverage continued through COBRA following termination of employment ycobra coverage is secondary to Medicare, except when the Medicare beneficiary has ESRD. ycobra coverage is primary to Medicare during the 30-month ESRD coordination period. For the purposes of PHIP, healthcare coverage under worker s compensation, Medicare or any other government entitlement program (including foreign healthcare) does not qualify as employer-sponsored health coverage. PHIP coverage will be effective the first of the month after employer-sponsored coverage ends, if loss of coverage is the reason for enrolling. If the PHIP enrollment form is received after the loss of coverage and within the 30-day time line, the effective date will be the first of the month after the enrollment form is received, and your Enrollment Request Form is received prior to loss of coverage. Verify your coverage end date with your employer to ensure that you enroll with PHIP on the correct effective date. Changes to the 15

16 original PHIP effective date will not be made once the requested effective date has passed, which can affect the premiums you pay. Dependent enrollment Dependents can enroll during any of the enrollment periods available to retirees. These include the retiree s date of retirement or Medicare eligibility and after the retiree has had at least 24 consecutive months of coverage under another employer-sponsored health plan. If a dependent has an enrollment opportunity after the retiree is enrolled, he or she will be eligible to enroll under the retiree s account. New dependents can be enrolled within 30 days of becoming a dependent through marriage. If the spouse has a different last name than the retiree, a copy of the marriage certificate will be required. Dependents must enroll in the same plan as the retiree. If the retiree has Medicare coverage and the dependent has non-medicare coverage, the dependent s coverage must be with the same health plan. As long as the retiree has applied for and received PERS retirement, a spouse or dependent can enroll in a PHIP health plan up to 90 days after his or her initial Medicare eligibility in both Medicare Parts A and B, even though the retiree remains enrolled in the employer-sponsored group plan. Enrollment in a PHIP Medicare plan includes enrollment in Medicare Part D. A spouse or dependent can enroll in a PHIP Medicare health plan when the retiree enrolls at a later time, provided the spouse or dependent also is enrolled in Medicare Parts A and B. If the retiree does not enroll in PHIP upon his or her final enrollment opportunity, dependent(s) will not be eligible for PHIP coverage. Divorced spouses of PERS retirees are not eligible for a PHIP health plan, even if receiving a PERS benefit check. If a spouse is enrolled in a PHIP health plan at the time of divorce, COBRA continuation applies. The retiree or spouse must send a copy of the divorce decree to PHIP within 60 days of the dissolution of marriage for the spouse to be eligible to continue coverage. The surviving spouse and/or dependents of a PERS member may continue enrollment as described on page 13. If the surviving spouse or dependent is not enrolled at the time of the PERS retiree s death, the spouse or dependent may enroll within 90 days of the death or by meeting other enrollment opportunities (see pages 14 16). However, in the event of remarriage, coverage cannot be extended to the new spouse. Dental plan enrollment You are eligible to enroll in a PHIP dental plan only if you also have PHIP medical coverage. If anyone in your family wants dental coverage, everyone who is enrolled in a PHIP medical plan also must be enrolled in a PHIP dental plan. Enrollment in a PHIP dental plan is limited to when you first enroll in a PHIP medical plan. You must apply for dental coverage at your initial enrollment opportunity or you will not be able to get PHIP dental coverage. The only exception is for members who have continuous dental coverage through an employer-sponsored health plan immediately preceding enrollment in PHIP. There are no other dental enrollment periods. There may be a 12-month waiting period for some services if you have not had 12 months of continuous employer-sponsored dental coverage immediately preceding enrollment into a PHIP dental plan. (See page 55 for more information.) PHIP offers two dental plans: Kaiser Permanente and ODS. You can enroll in either dental plan regardless of your medical plan selection. However, for Kaiser Permanente dental, you must reside in the Kaiser Permanente dental plan service area. Please refer to pages for a description of dental services. 16

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18 How to enroll Your coverage will start on the date described in the Enrollment Opportunities section on pages During peak enrollment times (i.e., plan change, peak retirement periods, end of month), delays may occur. Please allow time for PHIP to process your application and notify your health carrier. In the event you need immediate access to your health plan information, please contact PHIP at the customer service number listed on the back of this handbook. To enroll in any PHIP health plan, you must: Meet one of the PHIP enrollment opportunities described on pages Complete the Enrollment Request Form in its entirety. Be sure to include your personal information. Include spouse or dependent information only if they are enrolling in PHIP. Indicate your reason for applying for PHIP coverage and select a medical and/or dental plan. If you are enrolled in a PHIP non-medicare plan, you must submit a new Enrollment Request Form upon Medicare eligibility. Complete the Medicare card section for all Medicare-eligible individuals. Make photocopies of either the Medicare card or a Letter of Entitlement showing Medicare effective dates for Parts A and B for each Medicare-eligible individual applying. Send the copy with the Enrollment Request Form. Complete the payment option section. Select only one option. The PERS pension holder must sign this section if choosing pension deduction. (See Making monthly premium payments on page 19.) Answer all questions in the section related to coordination of benefits for all enrollees. Missing information can delay your enrollment. Sign and date the Enrollment Request Form. Both the retiree and spouse must sign if both are enrolling. Enrollments must be signed and received prior to the month in which coverage is to begin. Additional documentation may be required based on your enrollment opportunity. This may include a dependent s birth certificate, adoption paperwork, PERS disability retirement approval letter, Affidavit of Dependent Domestic Partnership, or marriage license. Submit documentation with your Enrollment Request Form. However, do not delay submitting your Enrollment Request Form because you do not have the necessary documents. Enrollment will be pended until your documents are received. A Disenrollment Form is required if you are changing from one health plan to another. Submit the form to the PHIP office. The address is listed on the back cover of this handbook. You can be enrolled in only one Medicare Advantage and Medicare Part D prescription drug plan at a time. Terminating your Medicare Part D prescription coverage or enrolling in another Medicare Advantage or Medicare Part D prescription plan will automatically terminate all coverage. Once termination has occurred, you may not reenroll in PHIP, unless you experience a new enrollment opportunity. When enrolling in a PHIP Medicare plan, you will automatically be enrolled in a Part D prescription plan. 18

19 After enrollment Making monthly premium payments Premium payment options: Deduction from your monthly PERS pension check. This option ensures timely premium payment and prevents a lapse in coverage. If you choose pension deduction, the PERS pension holder s signature is required any time an Enrollment Request Form is submitted. Electronic funds transfer from your bank account. This also ensures timely payment and prevents a lapse in coverage. Only one payment option is allowed per PHIP account. Late payments Premium payments are due on or before the first of each month, with no grace period. If payment is not received by the first day of the month, the account is considered delinquent. If you do not pay your premium upon notification, your health plan coverage will be canceled. If your coverage is terminated because of a delinquent payment, you may be responsible for all claims incurred on or after that termination date, except to the extent that those claims are covered under Original Medicare. Voluntary disenrollment PHIP and Medicare guidelines require a written request for voluntary disenrollment from PHIP health insurance coverage. Disenrollment will occur the first of the month following receipt of your completed PHIP Disenrollment Form unless a later date is requested. Both the member and spouse must sign the written request for termination. If one member of your family wishes to terminate their dental coverage, the whole family loses dental coverage. Please submit a PHIP Disenrollment Form, which you can find on the PHIP website or through customer service. The PHIP address and fax number are listed on the back of this handbook. OAR (3) if payment is by check or money order, the check or money order must be physically received by the Third Party Administrator on or before the due date. (4) Failure to make the payment by the due date shall result in termination of a person's PERS-sponsored health insurance coverage. Once disenrollment or termination occurs, you cannot re-enroll in PHIP unless you experience a new enrollment opportunity. Death notification As a PERS retiree: Upon the death of your spouse, your PHIP coverage will continue as usual. To terminate your spouse s coverage, mail a photocopy of the death certificate to PHIP AND the PERS Pension office. As a surviving spouse or dependent of a PERS retiree: Your PHIP coverage will continue automatically. You must mail a copy of the retiree s death certificate to PHIP AND the PERS Pension office for your account to remain active. If you would like to terminate your coverage, a written request is required. If the surviving spouse is not enrolled at the time of the PERS retiree s death, the spouse may enroll within 90 days of the death or by meeting other enrollment opportunities. 19

20 Premium subsidies RHIA (Medicare) subsidy Oregon Revised Statute (ORS) established a trust fund called the Retirement Health Insurance Account (RHIA). The information presented in this section is a summary of OAR RHIA pays a monthly contribution toward the cost of healthcare coverage for some PERS retirees. This contribution is applied automatically, if you are eligible, by verifying your pension service records. It is reflected in the monthly premium you pay. To have RHIA contributions applied toward PHIP premiums, retired members must meet the following requirements: Be enrolled in Parts A and B of Medicare and also meet one of these requirements: y Receive a PERS service or disability retirement allowance under Tier 1 or Tier 2 and have had eight or more years of qualifying service at the time of retirement y Receive a PERS disability retirement allowance computed as if the retiree had eight or more years of creditable service and was a Tier 1 or Tier 2 retiree Be a surviving spouse or dependent of a deceased eligible Tier 1 or Tier 2 retired member, as described on page 13, who is enrolled in Medicare Parts A and B and who also meets these requirements: y Receives a retirement allowance or benefit from PERS ywas covered under an eligible retiree member s PHIP health plan and the deceased member retired before May 1, 1991 Premium payment information Because verification is based on final pension calculations, the retiree could be invoiced the full premium amount until eligibility for the RHIA subsidy is verified. Upon verification, if the retiree is due a refund, it will be calculated and sent automatically. If you are a surviving spouse or are no longer eligible for an ongoing pension benefit, you may no longer be eligible for the RHIA subsidy. If you received a subsidy while not eligible, you will have to repay any funds you received while not eligible. 20

21 RHIPA (state of Oregon non-medicare) subsidy ORS established a trust fund called the Retiree Health Insurance Premium Account (RHIPA). The information in this section is a summary of OAR RHIPA pays a monthly contribution toward the cost of healthcare coverage for some state of Oregon retirees who are not eligible for Medicare. This contribution applies only to PERS retirees who retire from a state agency, such as the Oregon Department of Transportation (ODOT), the Oregon Department of Fish and Wildlife, or any other agency of state government, and whose PERS effective retirement date is the first of the month following termination from state employment. The contribution will be applied automatically, if you are eligible, by verifying your qualifying state service time. The monthly premium amount you pay will reflect the subsidy, following verification. To have RHIPA contributions applied toward PHIP premiums, retired state employees enrolled in a PHIP health plan must meet the following requirements: Be a Tier 1 or Tier 2 retiree who is a state employee at the time of retirement and is not eligible for Medicare, and who also meets one of these requirements: y Receives a PERS service or disability retirement allowance or benefit and has had eight or more years of qualifying state service at the time of retirement (only STATE service time applies toward RHIPA subsidy) y Receives a PERS disability retirement allowance computed as if the retiree had eight or more years of creditable state service and had attained the earliest service retirement age Be a surviving spouse or dependent of a deceased eligible Tier 1 or Tier 2 retired state employee, as described on page 12, who is not eligible for Medicare and who meets one of these requirements: yis receiving a retirement allowance or benefit from PERS ywas covered under a PHIP health plan at the time of the retiree s death and the eligible retired state employee retired on or after September 29, 1991 Premium payment information Because verification is based on final pension calculations, the retiree will be sent premium notices reflecting the full premium amount until eligibility for the RHIPA subsidy is verified. Upon verification, any refunds due will be sent automatically RHIPA subsidy rates will become available in November Updated information will be sent to all participating RHIPA members. Please direct questions about health plan premium rates applicable to RHIPAeligible members to the PHIP office. If you are a surviving spouse and are no longer eligible for an ongoing pension benefit, you may no longer be eligible for the RHIPA subsidy. If you received a subsidy while not eligible, you will have to repay any funds you received while not eligible. 21

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23 COBRA continuation of coverage In accordance with federal and state of Oregon guidelines, PHIP provides opportunities for the continuation of coverage through COBRA following specific qualifying events. If you experience one of the qualifying events listed below, please contact PHIP for additional information. A qualifying event will occur if eligibility for coverage is lost because of: Cancellation of PERS retirement status The divorce or legal separation of a retiree s covered spouse. PHIP must be notified within 60 days from the signed Dissolution of Marriage document. A spouse or dependent no longer meeting eligibility requirements (e.g., a child reaches the maximum age limit, or a spouse loses coverage because the retiree does not enroll in PHIP upon the last enrollment opportunity) Once COBRA has been secured, timely payment of premiums is essential. Timely COBRA premium payments The initial premium must be paid within 45 days of the date COBRA is elected. Thereafter, premiums are due the first day of each month for that month s coverage. If payment is not postmarked or received on or before the 45th day (for the initial premium) or the 30th day following the monthly due date, coverage will be terminated and cannot be reinstated. 23

24 Coverage outside service areas You must maintain a residence within a plan s service area and reside in the United States in order to participate in PHIP. Moda Health Moda Health PPORX (PPO) plan Members can travel for up to 12 months anywhere in the U.S. with the PERS Moda Health PPORX (PPO) plan. The travel benefit provides members the flexibility of using an in-network provider in Oregon or any out-of-network Medicare provider while paying the same copayment or coinsurance. For members enrolled in the PERS Moda Health PPORX (PPO) plan and traveling outside the U.S., emergency care is covered worldwide Moda Health Medicare Supplement Plan Coverage is limited to eligible emergency medical care expenses incurred outside the U.S. These are emergency room, urgent care and ambulance services. Non-Medicare plan Members traveling outside of the primary service area may receive the in-network benefit level by using a Travel Network provider. The in-network benefit level applies to a Travel Network provider only if members are outside the primary service area and the travel is not for the purpose of receiving treatment or benefits. Treatment of emergency medical conditions is covered worldwide. All emergency services will be reimbursed at the in-network benefit level. However, benefits are subject to our contracted rates for in-network physicians and providers. Members may be responsible for any amounts above the maximum plan allowance. Emergency/Travel Benefits for Medicare Plans Emergency room (ER) (worldwide) Urgent care (worldwide) Ambulance (worldwide; air/ground) Moda Health Supplement MEMBER pays: Covered in full (inside U.S. only) PERS Moda Health PPORX (PPO) MEMBER pays: $65 copay $20 copay $50 copay Outside service area travel (in U.S.) Covers ER, urgent care & ambulance Out-of-network copay applies Outside service area travel (outside U.S.) Covers ER, urgent care & ambulance at 80% coinsurance. Coverage limited to $50,000 lifetime per member. Covers ER, urgent care & ambulance at out-of-network copay 24

25 ODS Dental plan The ODS dental plan gives you the freedom to choose any licensed dentist. As part of the Delta Dental Plan, the largest dental network in the country, you can visit any of the 145,000 Delta Dental dentists in the U.S. and still be covered in-network. Kaiser Permanente Kaiser Permanente members temporarily outside the service area are covered for emergency care, urgent care and medically necessary ground or air ambulance service worldwide under Medicare and non-medicare plans. Medicare members also have a limited travel benefit that covers routine and follow-up care worldwide. Currently enrolled Medicare members who permanently move outside the Kaiser Permanente Northwest service area or who are out of the service area for six consecutive months or more must disenroll from their Medicare Advantage plan. Members temporarily visiting other Kaiser Permanente regions may receive visiting member care from designated providers in those areas for either Medicare or non-medicare plans. For information about service areas and facility locations in other regions, please call Membership Services. With Kaiser Permanente, health plans are available in California for PERS retirees who relocate to that area. Please call the PHIP office for more information. Premiums and benefits for those areas will differ from those noted in this handbook. Kaiser Permanente Senior Advantage PacificSource Medicare Essentials 801 Providence Medicare Align Group Providence Medicare Flex Group MEMBER pays: MEMBER pays: MEMBER pays: MEMBER pays: $50 copay $50 copay $50 copay $65 copay $15 copay $15 copay $25 copay $25 copay $50 copay $50 copay $50 copay $50 copay Care in other KP regions or Group Health Cooperative service area. Covers ER, urgent care and ambulance worldwide. Covers routine, preventive and follow-up care outside Kaiser network at 20% coinsurance as part of $1,000 annual worldwide travel benefit maximum. Covers ER, urgent care and ambulance worldwide. Covers routine, preventive and follow-up care outside Kaiser network at 20% coinsurance, up to $1,000 annual worldwide travel benefit maximum. Covers ER, urgent care & ambulance Covers ER, urgent care & ambulance 20% to maximum allowance of $1,000 for follow-up services Covers ER, urgent care & ambulance 20% Covers ER, urgent care & ambulance 25

26 If you do not use Kaiser Permanente s physicians and hospitals, neither Kaiser Permanente nor Medicare will cover your services, except for emergency and urgent care, authorized referrals, renal dialysis outside the service area per Medicare criteria and travel benefits. Kaiser Permanente Dental plan If you have a dental emergency while traveling outside the service area, you may go to the nearest dental office. You have limited coverage for qualifying emergency dental care. PacificSource Medicare plan The PacificSource Essentials 801 plan provides worldwide coverage for the following four services: Emergency services Urgently needed services Medically necessary ground or air ambulance services Out-of-area dialysis services These services do not require prior authorization. Non-Medicare plan The PacificSource plans give you the freedom to see either in-network or out-of-network providers for covered services. This includes access to in-network providers nationwide through the First Health Network. You will generally pay less for services from providers in the PacificSource network. Travelers have the added protection of worldwide coverage for: Urgently needed services Medically necessary ground or air ambulance services Out-of-area dialysis services These services do not require prior authorization. Providence Health Plan All plans offer worldwide coverage for urgent and emergency care and include ambulance coverage (air and ground). Providence Medicare Align Group Plan (HMO) Includes a travel benefit for necessary follow-up care from any Medicare provider outside the plan service area. Providence pays 80 percent and the member pays 20 percent, up to a combined $1,000 annual limit. Providence Medicare Flex Group Plan (HMO-POS) If you are a snowbird or are out of the service area, the Providence Medicare Flex Group Plan out-of-network benefit allows you to see any Medicare-approved provider. Non-Medicare PPO plan Providence Health Plan gives members access to nearly one million providers nationwide. If you are traveling and use a national network provider such as First Choice Health Network or MultiPlan/PHCS network, benefits are paid at the in-network level. If you choose an out-of-network provider, benefits are paid at the out-of-network level. 26

27 Benefit changes, health plan service areas and plan features 27

28 Changes to plans Effective January 1, 2015 Prescription drug program Applies to all enrollees Medicare and non-medicare The Prescription drug out-ofpocket maximum per person per calendar year is now $4,700. No other benefit changes for the 2015 plan year. Medical Moda Health Medicare Supplement Plan No benefit changes for the 2015 plan year. PERS Moda Health PPORX (PPO) Medicare Advantage No benefit changes for the 2015 plan year. Non-Medicare Core Value and Select Value Plans y The ambulance out-of-network coinsurance will now match the in-network level of 20%; the deductible still applies. y No other benefit changes for the 2015 plan year. Kaiser Permanente Medicare For members who had a Medicare covered transplant, post-surgical Immunosuppressive drugs used in transplant services are now subject to the applicable plan coinsurance amount. Self-administered clotting factors for the treatment of hemophilia are now subject to the applicable Part B copayment or coinsurance. Clinically administered medications in all outpatient settings, including those given in a medical office setting, are now subject to the applicable Part B copayment or coinsurance. No other benefit changes for the 2015 plan year. Non-Medicare Core Value and Select Value Plans yclinically administered medications in all outpatient settings, including those given in a medical office setting, are now subject to 10% coinsurance. ythe definition of Usual and Customary Fee has been deleted and replaced with Allowed Amount. y No other benefit changes for the 2015 plan year. PacificSource Medicare No benefit changes for the 2015 plan year. Non-Medicare Core Value and Select Value Plans ythe provider network name is changing from the Choice network to the Prime network. y No other benefit changes for the 2015 plan year. Providence Health Plan Providence will be expanding into the following Oregon counties for both Medicare and non-medicare: Crook, Deschutes, Hood River, Jefferson, and Wheeler. Medicare Choice (Flex) Plan Name of the plan is changing to Medicare Flex Plan. New ID cards will be issued. SilverSneakers has been replaced with Silver&Fit. No other benefit changes for the 2015 plan year. 28