Retirees Benefits Guide

Transcription

1 Retirees 2016 Benefits Guide Open Enrollment October 12-30, 2015

2 2016 OPEN ENROLLMENT MEETINGS FOR RETIREES SESSION DATE TIME LOCATION* Pre-65 Retiree Medical Plan Friday, October AM Medicare Eligible Medical Plan Friday, October AM Pre-65 Retiree Medical Plan Friday, October PM SAWS -Tower II Room 145 SAWS -Tower II Room 145 SAWS -Tower II Room 145 Medicare Eligible Medical Plan Friday, October PM SAWS -Tower II Room 145 Pre-65 Retiree Medical Plan Friday, October AM SAWS -Tower II Room 145 Medicare Eligible Medical Plan Friday, October AM SAWS -Tower II Room 145 Pre-65 Retiree Medical Plan Friday, October AM SAWS -Tower II Room 145 Medicare Eligible Medical Plan Friday, October AM SAWS -Tower II Room 145 Pre-65 Retiree Medical Plan Friday, October PM SAWS -Tower II Room 145 Medicare Eligible Medical Plan Friday, October PM SAWS -Tower II Room 145 *NOTE: All retiree Open Enrollment meetings will be held at SAWS Headquarters Tower II located at 2800 U.S. Hwy 281 North, San Antonio, Texas 78212

3 2016 Benefits Guide for Retirees The SAWS 2016 Open Enrollment is October 12 through October 30, This guide is designed to provide information regarding the available medical plans for eligible retirees in If you need further information regarding your plans, please contact the Human Resources Benefits Office at or attend one of the scheduled open enrollment meetings. Pre-65 Retirees Plan Highlights Medicare Eligible Retiree Plans SAWS will continue to offer the United Healthcare Medicare Advantage Plans in 2016, the PPO Plan and the PPO Plus Plan. There will be no change in plan designs for 2016 same copays, deductibles, coinsurance and out-of-pocket as the 2015 plans. In order to keep the same level of benefits, there will be a slight increase in the Medicare Advantage Plan premiums for both SAWS and retirees in Pre-65 retirees will continue to have a choice in 2016 between the PPO Economy and PPO Plus Plans, administered by United Healthcare (UHC). Medicare Advantage Plan enrollment is individual; if your spouse/dependent is not Medicare eligible, they must enroll in one of the pre-65 plans. Express Scripts, Inc. will remain the Pharmacy Benefit Manager. There are no changes in medical plan designs same copays, deductibles, coinsurance and out-of-pocket as 2015 plans. Your prescription copays will also remain the same, with the exception of specialty generic prescriptions. Those copays will increase from $50 to $80 for a 30-day supply. There will be changes to the prescription drug list (formulary), as these are usually reviewed annually to help manage prescription costs. Medical and Rx claim costs continue to rise. To keep the same level of benefits, medical premiums will increase for both SAWS and retirees. Table of Contents 2016 Highlights... 1 Important Contacts Enrollment... 3 Opting out of Coverage... 3 Dependent Coverage... 3 Surviving Dependent Benefits... 3 Medicare Eligible Retirees... 4 Are You Turning Medicare Advantage Plan Premiums... 5 Pre-65 Retiree Health Plan Options... 6 Pre-65 Retiree Pharmacy Plan... 7 Pre-65 Health Plan Premiums... 8 Tools to Manage Medical Costs Health Plan Terminology Required Legal Notices

4 IMPORTANT CONTACT INFORMATION ORGANIZATION NAME PHONE WEBSITE/ ADDRESS SAWS Human Resources - Benefits Office United HealthCare (UHC) UHC Customer Service Nurseline Mental Health Providers SAWS Onsite UHC Service Account Manager amanda_davila@uhc.com SAWS Onsite UHC Wellness Coordinator taryn_bechtol@uhc.com Express Scripts - Pharmacy Benefit Manager Accredo - Specialty Pharmacy Group # SAWATER United HealthCare Medicare Advantage Plans Nurseline OTHER HELPFUL NUMBERS Texas Municipal Retirement System (TMRS) SAWS Retirement Plan - Principal ICMA-RC 457 Plan - Group # Nationwide 457 Plan - Group #

5 2016 Enrollment Annual Enrollment will be passive, meaning that retirees who do not wish to make any benefit election changes do not have to participate; your 2015 current plan will roll over into the new plan year. A 2016 enrollment form is included in your packet. Should you decide to change plans, please complete the 2016 enrollment form and return it to the SAWS HR Benefits Office at the following address no later than October 30, Remember, you can only change plans during an annual open enrollment period and no new dependents may be added. Physical Address: San Antonio Water System 2800 U.S. Hwy. 281, North Tower II San Antonio, TX Mailing Address: San Antonio Water System Human Resources Department P.O. Box 2449 San Antonio, TX Enrollment deadline October 30, Opting Out of Coverage Do you have other coverage? SAWS allows you or your spouse/children a one-time opt out opportunity if you have coverage through another health plan. If that coverage ends, all you need to do is provide proof of continuous coverage within 31 days of it ending to re-enroll in the SAWS plans. Returning children must continue to meet the age eligibility requirements under the Health Care Reform, currently age 26. Verification of Personal Information To receive your identification cards promptly, make sure that the SAWS Human Resources Benefit Office has your correct contact information on file. You may call the Benefits Office at (210) to report an address change or other corrections or send your correction to the SAWS address provided under 2016 Enrollment. Retiree Dependent Coverage An eligible retiree who elects coverage under the Plan may also elect to cover any dependents (including a spouse) who were covered under the Plan at the time of the employee's retirement (referred to as "eligible dependents"). New dependents may not be enrolled after an eligible retiree's retirement. An eligible retiree may enroll eligible dependents at the time of his or her initial election for retiree coverage or upon subsequent election for retiree coverage following a period of deferral. Once enrolled in the Plan, an eligible dependent's coverage will terminate upon the earliest of the following events: Ceasing to meet the applicable definition of "dependent" in the Plan Document; Termination of eligible retiree's coverage under the Plan for any reason other than death; and Decision by the eligible retiree to terminate the eligible dependent's coverage. Remember, if your dependent currently has coverage through another heath plan, you can opt out of SAWS and re-enroll later with proof of continuous coverage. Surviving Dependent Coverage Upon the death of a retiree, a spouse who is covered by the Plan may continue to participate for the remainder of his or her lifetime with no SAWS subsidy towards the premium. Likewise, dependent children may continue to participate as long as they meet the applicable definition of dependent in the Plan Document with no SAWS subsidy towards the premium. 3

6 MEDICARE ELIGIBLE RETIREES POST-65 RETIREES SAWS provides Medicare eligible retirees the option of selecting between two United HealthCare Medicare Advantage Plans, the PPO Plan and PPO Plus Plan. During the annual open enrollment, you have the option of switching between the two plans. However, no action is required from you if you would like to keep your existing plan. Medicare Eligible Requirements A retiree or retiree spouse/dependent eligible for Medicare due to age must enroll in Medicare Parts A and B, prior to enrolling in the Medicare Advantage Plans and continuing coverage through SAWS. Are You Turning Age 65? If you are turning age 65 now or during 2016, you will need to enroll in Medicare Parts A and B to continue retiree medical coverage through SAWS. Be sure to complete the following steps to ensure there is no break in coverage: 1. Enroll in Medicare Parts A and B. Retirees and/ or their covered spouses must enroll in Medicare Parts A and B at age 65 as a requirement of medical coverage through the SAWS benefit programs. Three months before you turn age 65, contact your local Social Security Administration Office to enroll in Medicare Parts A and B or you can apply online at Retirees must pay the full cost of the monthly premium for Medicare Part B. Medicare may charge a penalty to retirees who delay enrollment in Medicare Part B at the time of initial eligibility. 2. Notify the SAWS Benefits Office within 30 days of your 65th birthday. At least 30 days prior to reaching 65, you and/or your covered spouse must report the change in age to the Benefits Office and complete a Medicare Advantage enrollment form. A copy of your Medicare Card will need to accompany your enrollment form. Help and Information from Medicare You can obtain information from Medicare through the following: Call MEDICARE ( ), 24 hours a day, 7 days a week. Telephone Typewriter (TTY) users should call Visit the Medicare website ( Read the Medicare & You 2016 Handbook. Every year in October, this booklet is mailed to people with Medicare. It has a summary of Medicare benefits, rights and protections, and answers to the most frequently asked questions about Medicare. If you don t have a copy of this booklet, you can get it at the Medicare website ( or by calling MEDI-CARE ( ). TTY users should call

7 Medicare Advantage Participants Benefits Information Important to Remember: POST-65 RETIREES The Centers of Medicare and Medicaid (CMS) require United Healthcare Medicare Advantage Plans to provide participants specific information regarding their medical plans each year. You will be receiving the following information in the mail during the month of October: 2016 Annual Notice of Change 2016 Evidence of Coverage Summary detailed benefit information 2016 Formulary Drug Prescription List 2016 Bonus Drug List Directory Insert The documents listed above will require no action on your part because you are already enrolled. MEDICARE ADVANTAGE PLAN You must keep Medicare Parts A and B and continue to pay your Medicare Part B premium. You can only be in one Medicare Advantage plan at a time, including Medicare supplemental plans. Enrolling in another plan will automatically disenroll you from the SAWS Medicare Advantage Plan. You do not need to show your Medicare card when receiving service. Your United Healthcare card should be provided as identification for medical and prescription Rx services. Need help finding a provider or pharmacy near you? 2016 MONTHLY PREMIUMS Retiree Pays SAWS Pays Total Cost PPO RETIREE 65+ Retiree Only $45.30 $98.98 $ Spouse $68.28 $76.00 $ Dependent $68.28 $76.00 $ Retiree <2002 $0.00 $ $ Spouse <2002 $0.00 $ $ Dependent <2002 $0.00 $ $ PPO PLUS RETIREE 65+ Retiree Only $51.26 $ $ Spouse $77.25 $85.99 $ Dependent $77.25 $85.99 $ Retiree <2002 $0.00 $ $ Spouse <2002 $0.00 $ $ Dependent <2002 $0.00 $ $ Visit to find providers and pharmacies near you. Sign in, then click on the Provider Search or Pharmacy Locator link. If you are a new user, click Register Now to create an account. 2. Call Customer Service toll-free at , TTY 711, 8 a.m. to 8 p.m. local time, Monday through Friday. They can help you over the phone, or you can ask them to send you a printed copy of the Provider or Pharmacy Directory. You should get your directory 7 to 10 days after UHC receives your request. 5

8 PRE-65 RETIREES SAWS 2016 PRE-65 RETIREE HEALTH PLAN OPTIONS PPO ECONOMY AND PPO PLUS PLANS To determine which plan is best for you and your family, consider both the coverage you get when you use the plan (below) and the premiums you have to pay each month. PLAN BENEFIT PPO ECONOMY PPO PLUS In-Network Out-of-Network In-Network Out-of-Network Deductible $1,000 Individual $1,500 Individual $500 Individual $1,000 Individual $3,000 Family $4,500 Family $1,500 Family $2,500 Family Coinsurance 80% after deductible 60% after deductible 80% after deductible 60% after deductible Out-of-Pocket* $4,100 Individual $6,150 Individual $3,600 Individual $5,400 Individual $8,200 Family $13,180 Family $7,200 Family $10,800 Family Office Visit PCP/SCP $40/$60 60% after deductible $25/$40 60% after deductible Preventive Care 100% 60% after deductible 100% 60% after deductible Urgent Care $40 60% after deductible $40 60% after deductible Emergency Room $150 per visit co-pay, plus deductible and coinsurance Hospital Inpatient 80% after deductible 60% after deductible 80% after deductible $150 per visit co-pay, plus deductible and coinsurance 60% after the Per $100 Occurrence Deductible and Annual Deductible *Note: Out-of-pocket maximums for both the PPO Economy and PPO Plus include medical and prescription copay, deductible, and coinsurance amounts. For all of the Coverage details, see the official Plan Documents on SAWS.org or contact HR Benefits Office at How It All Works Together You Pay: The monthly premium and the full cost of certain medical expenses until you reach your deductible. Items with copays are covered without needing to meet deductible, i.e. doctor visits, Rx. Preventive services are covered at 100% without meeting deductible. 6 SAWS/UHC Pays: A portion of expenses once you meet your deductible. You will continue to pay your coinsurance (%) amount until you reach your maximum out -of-pocket (OOP). SAWS/UHC Pays: Once you meet your Out-of-Pocket maximum, SAWS/UHC pays 100% of your eligible expenses for the remainder of the calendar year.

9 SAWS 2016 PHARMACY BENEFIT PRE-65 RETIREES The following pharmacy benefit is included in both the Pre-65 Retiree PPO Economy Plan and the PPO Plus Plan. The pharmacy benefit manager is Express Scripts, Inc. Pharmacy Benefit Retail Home Delivery (30 Day Supply) (90 Day Supply) Diabetic Generic $0 $0 Other Generic $10 $25 Preferred Brand 30%, $25 Min / $50 Max $62.50 Non-preferred Brand 45%, $40 Min / $75 Max $100 Specialty (Generic and Brand) $80 $150 Pharmacies Locate Express Scripts network pharmacies at or call Express Scripts has over 55,000 independent and chain pharmacies nationwide. Resources Find Helpful resources at Express-Scripts.com, including the ability to order refills and renewals; check order status; compare medication costs to find potential lower-cost options under your plan; receive timely medication-related safety alerts; check claims, balances and make payments; obtain forms, and much more. Mobile App Stay on track with the help of the Express Scripts Mobile App by downloading it from your mobile app store for free. From anywhere, anytime, you can check order status, refill and renew orders, locate a pharmacy and get directions, check drug interactions, set up medication alerts, access your virtual member ID card, and much more. Mail Order or Home Delivery Receive up to a 90-day supply of long-term medication delivered directly to you for one home delivery copayment. A long-term medication is one that is taken to treat an ongoing condition, such as high blood pressure, high cholesterol, or diabetes. To enroll in the Home Delivery Program, visit Express-Scripts.com, sign in and choose which of your current maintenance medications you d like to receive through home delivery. Or you can call Express Scripts at the toll-free number on your ID card or Specialty Medications Due to the high cost of specialty medications, these medications must be ordered through Express Scripts specialty pharmacy, Accredo. If you have any questions or need help filling a prescription for one of these medications, call Accredo s toll-free number, , Monday through Friday, 7 a.m. to 8 p.m. and Saturday 8 a.m. to 12 noon CST. Specialty medications treat complex conditions such as hepatitis C, multiple sclerosis, cancer, rheumatoid arthritis, etc., and often require special handling, storage and administration. Prior Authorization Some medications require that you obtain approval through a coverage review before the medication can be covered under the plan. The coverage review process for prior authorization will allow Express Scripts to obtain more information about your treatment (information that is not available on your original prescription) in determining whether a given medication qualifies for coverage under your plan. Only your physician can provide the additional information. 7

10 PRE-65 RETIREES PRE-65 MEDICAL PLAN PREMIUMS Cost of Coverage The San Antonio Water System continues to strive to achieve a 2/3 1/3 cost share with retirees. As the cost of healthcare continues to rise, SAWS makes gradual changes to the premiums to achieve this goal. The 2016 premiums for the Pre-65 retirees and dependents who do not have Medicare are illustrated in the following table. Your premium depends on the Plan you select, the family members you choose to enroll, and your years of services with SAWS NON-MEDICARE MONTHLY PREMIUMS Years of Service 30+ and Pre Retiree Pays SAWS Pays Retiree Pays SAWS Pays Retiree Pays SAWS Pays Retiree Pays SAWS Pays Retiree Pays SAWS Pays 2016 PPO ECONOMY PRE-65 RETIREES Retiree Only $16.38 $ $22.88 $ $31.20 $ $58.57 $ $76.25 $ Retiree + Spouse Retiree + Child(ren) Retiree + Family $68.80 $1, $81.12 $1, $97.76 $1, $ $1, $ $1, $61.15 $ $71.76 $ $93.60 $ $ $ $ $ $ $1, $ $1, $ $1, $ $1, $ $1, PPO PLUS PRE-65 RETIREES Retiree Only $84.52 $ $ $ $ $ $ $ $ $ Retiree + Spouse Retiree + Child(ren) Retiree + Family $ $1, $ $1, $ $1, $ $1, $ $1, $ $1, $ $1, $ $1, $ $ $ $ $ $1, $ $1, $ $1, $ $1, $ $1, Premium Payments SAWS will continue to coordinate with Principal to have your monthly premiums automatically deducted from your monthly SAWS Retirement Plan annuity payment administered by Principal Financial Group. If you do not receive a monthly benefit from Principal, you may set up a monthly bank draft for payment of your premium. Contact the Benefits Office at for the appropriate bank draft form. Note: If premiums are not paid when due, coverage will be terminated. 8

11 TOOLS TO MANAGE YOUR MEDICAL COSTS PRE-65 RETIREES Website The UHC website is full of helpful information. Using the website you can: Understand your coverage Find a doctor in your area Manage your claims Organize your health information Estimate costs of future treatments Read articles to help improve your health Managing your benefits and your personal health is easier with this powerful tool. Registration is quick and simple. How to Register Visit myuhc.com and select Register Now Enter your health plan ID card information or your Social Security # and birth date Enter your address or sign up for a free account and check to receive important s Choose a username and password, then get started 9

12 PRE-65 RETIREES HOW TO MANAGE YOUR MEDICAL COSTS Stay In Network There are several things you can do to help keep your cost down. The most important of these is to choose United Healthcare network providers. What is a network? A network is a group of doctors, hospitals and other providers and facilities that have a contract with United-Healthcare. As part of their contract they have agreed to follow our guidelines and provide health care services to you at lower prices. Why is this important? You can save money. In-network providers are contracted with UnitedHealthcare and cannot bill you above the contracted rate. Out of Network Providers do not have a contract with UnitedHealthcare and can bill you above the reasonable and customary rates. Visit the UnitedHealthcare website myuhc.com to help you verify if your provider is in network or call and an Advocate4me representative will help you verify and locate an in network provider. Premium Program To help people make more informed about their health UHC created the UnitedHealth Premium Program. The Premium program doctors who meet standards for quality and cost UHC uses medicine and national industry guidelines to quality. The cost efficiency standards rely on market benchmarks for the use of in providing care. 10

13 TOOLS TO MANAGE YOUR MEDICAL COSTS PRE-65 RETIREES Cost Tool When you enroll in a SAWS medical plan you will want to know how much a medical service or medication will cost before you pay for it. UnitedHealthcare offers the cost estimator tool which will allow you to estimate the cost of services at different providers before you decide to seek care. Since you are responsible for all or part of the charges you can choose the provider that works best for your needs and budget. To use the UnitedHealthcare Cost Estimator tool login to myuhc.com, click on Estimate Healthcare Costs, enter your zip code and follow the prompts. Understanding health care costs before you see the doctor is easy just remember the 4Ps. Procedure Learn more about a procedure and compare treatment options Provider Select a provider for a procedure Price Quickly estimate out-of-pocket costs for specific procedures Place Locate providers based on geographic search criteria, view maps and print directions Mobile App UnitedHealthcare Health4Me, is a free smart phone app that provides instant to your important health information anytime and anywhere. Get information to help you stay connected to your care management. View and share health plan ID cards via or fax Check account balances and benefit amounts Collect, track and share past and current Personal Health Records View and manage claims Pay providers for out-of-pocket expenses Estimate costs of common procedures and conditions up front Find nearby providers, hospitals and quick care facilities Connect with helpful professionals 24/7 11

14 PRE-65 RETIREES TOOLS TO MANAGE YOUR MEDICAL COSTS MyNurseLine The UnitedHealthcare mynurseline gives you access to a registered nurse that can assist in guiding you through your medical issue anytime, day or night. For example, a registered nurse can help you determine if your child needs to be taken to an urgent clinic in a hospital in the middle of the night or they can explain treatment options for serious conditions. For assistance call hours a day, 7 days a week. When you call, a registered nurse can help you: Discuss your options for the right medical care. Understand a wide range of symptoms. Determine what type of care may be right for your needs. Find a doctor or hospital Find doctors or hospitals that meet your needs and preferences. Locate an urgent care center and other health resources in your area. Understand treatment options Learn more about a diagnosis. Explore the risks, benefits and possible results of your treatment options. Develop a healthy lifestyle Get tips on how nutrition and exercise can help you maintain a healthy weight. Learn about important health screenings and immunizations. Ask medication questions Explore how to save money on prescriptions. Learn how to take medication safely and avoid interactions. 12

15 Allowed Amount Maximum - The amount on which payment is based for covered health care services. This may be called eligible expense, payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.) Annual Deductible (or Deductible) - The amount you must pay for Covered Health Services in a calendar year before the Plan will begin paying Benefits in that calendar year. Balance Billing - When a provider bills you for the difference between the provider s charge and the allowed amount. For example, if the provider s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services. Coinsurance - The charge, stated as a percentage of Eligible Expenses, that you are required to pay for certain Covered Health Services Copayment (or Copay) - The charge, stated as a set dollar amount, that you are required to pay for certain Covered Health Services. Emergency Medical Condition - An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm. In-network Co-insurance - The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance. In-network Co-payment - A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments. Network - The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services. Non-Preferred Provider - A provider who doesn t have a contract with your health insurer or plan to provide services to you. You ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a tiered network and you must pay extra to see some providers. Out-of-network Co-insurance - The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out-of-network co-insurance usually costs. Out-of-Pocket Maximum - The maximum amount you pay every calendar year. Preferred Provider - A provider who has a contract with your health insurer or plan to provide services to you at a discount. Primary Physician - A Physician who has a majority of his or her practice in general pediatrics, internal medicine, obstetrics/ gynecology, family practice or general medicine. Specialist Physician - A Physician who has a majority of his or her practice in areas other than general pediatrics, internal medicine, obstetrics/gynecology, family practice or general medicine. UnitedHealth Premium Program - A program that identifies Network Physicians or facilities that have been designated as a UnitedHealth Premium Program Physician or facility for certain medical conditions. To be designated as a UnitedHealth Premium provider, Physicians and facilities must meet program criteria. The fact that a Physician or facility is a Network Physician or facility does not mean that it is a UnitedHealth Premium Program Physician or facility Urgent Care - Treatment of an unexpected Sickness or Injury that is not life-threatening but requires outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering, such as high fever, a skin rash, or an ear infection. Urgent Care Center - A facility that provides Urgent Care services, as previously defined in this section. In general, Urgent Care Centers: Do not require an appointment. Are open outside of normal business hours, so you can get medical attention for minor illnesses that occur at night or on weekends. Provide an alternative if you need immediate medical attention, but your Physician cannot see you right away. 13

16 REQUIRED LEGAL NOTICES Summary of Benefits and Coverage (SBC) and Uniform Glossary of Terms Under the law, insurance companies and group health plans must provide consumers with a concise document detailing, in plain language, simple and consistent information about health plan benefits and coverage. This summary will help consumers better understand the coverage they have and allow them to easily compare different coverage options. It summarizes the key features of the plan and coverage limitations and exceptions. For a copy of the SBC of the SAWS medical plans go to EZLink/Human Resources/Benefits Corner or contact the HR Benefits Office at for a copy. Under the Patient Protection and Affordable Care Act (Health Reform), consumers will also have a resource to help them understand some of the most common but confusing jargon used in health insurance. Employees can access the Uniform Glossary of Terms online at EZLink/Human Resources/Benefits Corner or contact the HR Benefits Office at for a copy. Governing Plan This guide is intended to provide summary information about the benefit plans offered to the employees of the San Antonio Water System. Complete plan details are included in the Plan Documents available on EZLink/Human Resources/Benefits Corner or contact the Human Resources Benefits Office at for a copy. In the event of any discrepancy between this document and the official Plan Document, the Plan Document shall govern. COBRA The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, is a federal law that requires employers to offer qualified beneficiaries the opportunity to continue medical coverage, vision coverage, dental coverage, and/or participation in the SAWS Health Care Flexible Spending Account at their own cost in the case of certain qualifying events. COBRA Notice Requirements. Each employee or qualified beneficiary is required to notify the Human Resources Benefits Office within 60 days of a divorce, legal separation, a child no longer meeting the definition of dependent, or entitlement to Medicare benefits. United Healthcare, the SAWS COBRA administrator, will then notify all qualified beneficiaries of their rights to enroll in COBRA coverage. Notice to a qualified beneficiary who is the spouse or former spouse of the covered employee is considered proper notification to all other qualified beneficiaries residing with the spouse or former spouse at the time the notification is made. HIPAA Privacy Policy The Health Insurance Portability and Accountability Act (HIPAA) details the rules the San Antonio Water System will follow to safeguard the confidentiality of medical information obtained through the course of enrollment and administration of our health plans. For detailed information, visit hhs.gov/ocr/privacy or EZLink/Human Resources/Benefits Corner. Patient Protection and Affordable Care Act ("PPACA") - Patient Protection Notices The Claims Administrator generally allows the designation of a primary care provider. You have the right to designate any primary care provider who participates in the Claims Administrator's network and who is available to accept you or your family members. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact the Claims Administrator at the number on the back of your ID card. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from the Claims Administrator or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the Claims Administrator's network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the Claims Administrator at the number on the back of your ID card. 14

17 Women's Health and Cancer Rights Act of 1998 As required by the Women's Health and Cancer Rights Act of 1998, the Plan provides Benefits under the Plan for mastectomy, including reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy (including lymphedema). If you are receiving Benefits in connection with a mastectomy, Benefits are also provided for the following Covered Health Services, as you determine appropriate with your attending Physician: All stages of reconstruction of the breast on which the mastectomy was performed. Surgery and reconstruction of the other breast to produce a symmetrical appearance. Prostheses and treatment of physical complications of the mastectomy, including lymphedema. The amount you must pay for such Covered Health Services (including Copayments and any Annual Deductible) are the same as are required for any other Covered Health Service. Limitations on Benefits are the same as for any other Covered Health Service. Statement of Rights under the Newborns' and Mothers' Health Protection Act Under Federal law, group health Plans and health insurance issuers offering group health insurance coverage generally may not restrict Benefits for any Hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean section. However, the Plan or issuer may pay for a shorter stay if the attending provider (e.g., your physician, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn earlier. Also, under Federal law, plans and issuers may not set the level of Benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, a plan or issuer may not, under Federal law, require that a physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain prior authorization or notify the Claims Administrator. For information on notification or prior authorization, contact your issuer. Medicare Part D Creditable Coverage Notice Entities that provide prescription drug coverage to Medicare Part D eligible individuals must notify these individuals whether the drug coverage they have is creditable or non-creditable. SAWS has determined that the prescription drug coverage offered by SAWS through Express Scripts is, on the average for all plan participants, expected to pay out as much as, or more than, what the standard Medicare prescription drug coverage will pay and is considered Creditable Coverage under Medicare. For a copy of the SAWS Creditable Disclosure Notice please see pages 16 and 17 of this benefit guide or contact the HR Benefits Office at for a copy. 15

18 SAWS Retirees and Dependents Important Notice from the San Antonio Water System About Your Prescription Drug Coverage and Medicare Prescription Drug Coverage Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with the San Antonio Water System ( SAWS ) through a non-medicare plan and information about prescription drug coverage for people with Medicare. It also tells you where to find more information to help you make decisions about your prescription drug coverage and can help you decide whether you want to enroll in Medicare prescription drug coverage. 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare through Medicare prescription drug plans and Medicare Advantage Plans that offer prescription drug coverage. This coverage is sometimes referred to as Medicare Part D prescription drug coverage. Generally speaking, Medicare Part D provides coverage for prescription drugs not covered by Medicare Parts A and B. All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare. Some Medicare plans may also offer more coverage for a higher monthly premium. 2. SAWS has determined that the prescription drug coverage offered by SAWS through Express Scripts, Inc. is, on the average for all plan participants, expected to pay out as much as, or more than, what the standard Medicare prescription drug coverage will pay and is considered Creditable Coverage under Medicare. There is a penalty for late enrollment in a Medicare prescription plan. However, because your existing coverage from SAWS is, on the average, better than the standard Medicare prescription drug coverage, you can keep the SAWS coverage and not pay extra for Medicare prescription drug coverage. When Can You Join A Medicare Drug Plan? People with Medicare can enroll in a Medicare prescription drug plan when they first become eligible for Medicare and each year from October 15th through December 7th. Participants leaving employer coverage may be eligible for a Special Enrollment Period to sign up for a Medicare prescription drug plan. However, because you have existing prescription drug coverage that, on the average for all plan participants, is as good as or better than Medicare coverage, you can choose to join a Medicare prescription drug plan later and without penalty. You should compare your current coverage, including which drugs are covered, with coverage of the plans offering Medicare prescription drug coverage in your area. Most SAWS retirees and their dependents will choose to have only SAWS prescription coverage to avoid additional costs in Medicare Part D. It is important to make an informed and deliberate decision, based on your individual situation. Do not enroll in Medicare Part D just in case. What Are Your Prescription Coverage Options? Under the SAWS Group Health Plan, you have the following three options concerning prescription drug coverage: 1. You may stay with the SAWS prescription drug coverage and not enroll in Medicare prescription drug coverage at this time. You will be able to enroll in the Medicare prescription drug coverage at a later date without penalty, either (1) during a Medicare open enrollment period; or (2) if you drop your coverage under the SAWS prescription drug plan. 2. You may stay in the SAWS Group Health Plan, including SAWS Prescription Drug Coverage, and also enroll in Medicare Part D prescription drug coverage. Your current coverage under the SAWS Plan, which pays for other health benefits as well as prescription drugs, will not change if you choose to enroll in Medicare Part D prescription drug coverage. The Medicare Part D prescription drug coverage will be the primary payer and the SAWS Group Health Plan will pay prescription drug benefits as the secondary payer. (Please note that once you have Medicare Parts A & B, you must enroll in the Medicare Advantage Plan with SAWS). When you enroll in SAWS Medicare Advantage Plan, you will need to cancel your Medicare Part D plan. 3. You may reject all coverage under the SAWS Group Health Plan and choose coverage under Medicare as your primary and only payer for all medical and prescription drug expenses. SAWS allows you or your dependents a one-time opt out opportunity if you have coverage through another plan. If that coverage ends, you will need to provide proof of continuous coverage within 31 days of it ending to re-enroll in the SAWS plans. Here is some information to help you compare the benefits under the SAWS Prescription Drug Plan and Medicare prescription drug plan. In doing this comparison, you also should compare the premiums charged for each plan. The SAWS Prescription Drug Plan with Express Scripts, Inc. has the following features: Standard retail pharmacy prescription co-pays (up to 30 day supply) of: Convenient mail order prescription drugs (up to 90 day supply) of: No Annual Deductible No Cost Generic Diabetic Medications $10.00 Other Generic 30% ($25.00 min, $50.00 max) Preferred Brand 45% ($40.00 min, $75.00 max) Non-Preferred Brand $80.00 Specialty 4 th Tier No Annual Deductible No Cost Generic Diabetic Medications $25.00 Other Generic $62.50 Preferred Brand $ Non-Preferred Brand $ Specialty 4 th Tier 16

19 SAWS does not charge a separate premium for its prescription drug plan. You will pay the same premium to participate in the SAWS group health plan whether or not you elect to receive prescription drug coverage through Express Scripts, Inc. The standard Medicare prescription drug plan has the following features. The threshold amounts are subject to annual adjustments by the Centers for Medicare and Medicaid Services. The thresholds for 2016 are shown below.: Annual Deductible of $360. After you have met the annual deductible, Medicare pays 75% of the next $2,950 and you will be responsible for paying 25% coinsurance. After you have incurred $3,310 in prescription drug costs, Medicare will pay approximately 42% of the cost of generic medications and you will pay approximately 58% of the cost of generic medications and Medicare will pay approximately 5% of the cost of brand name medications and you will pay 45% of the cost of brand name medications, until your prescription costs for the year reach $7,515. All brand name medications will be offered at a 50% discount, but the pre-discount price will be taken into account for the purpose of determining when the $7,515 threshold is met. After you have reached the $7,515 threshold, Medicare pays approximately 95% of your costs for drugs covered by the plan and you pay 5%. Premiums are expected to be approximately $30-$40 per month for standard Medicare prescription drug plans. You should consult the Medicare prescription drug plan for the exact premium amounts. Although SAWS cannot state that in all cases the SAWS prescription drug coverage will be more advantageous than the Medicare prescription drug coverage, in most cases you will have better and less expensive prescription drug coverage under the SAWS prescription drug coverage. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your coverage with SAWS and don t enroll in Medicare prescription drug coverage after your current coverage ends, you may pay more to enroll in Medicare prescription drug coverage later. If you go 63 days or longer without prescription drug coverage that s at least as good as Medicare s prescription drug coverage, your monthly premium will go up at least 1% per month for every month that you did not have that coverage. For example, if you go nineteen months without coverage, your premium will always be at least 19% higher than what most other people pay. You ll have to pay this higher premium for as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to enroll. For More Information About This Notice Or Your Current Prescription Drug Coverage: Contact our office for further information at (210) NOTE: You may receive this notice annually and at other times in the future, such as before the next period you can enroll in Medicare prescription drug coverage, and if this coverage changes. You also may request a copy. For More Information About Your Options Under Medicare Prescription Drug Coverage: More detailed information about Medicare plans that offer prescription drug coverage is available in the Medicare & You handbook (available at You ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare prescription drug plans. For more information about Medicare prescription drug plans: Visit Call your State Health Insurance Assistance Program (see your copy of the Medicare & You handbook for their telephone number) Call MEDICARE ( ). TTY users should call For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information about this extra help is available from the Social Security Administration (SSA). For more information about this extra help, visit SSA online at or call them at (TTY ). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Date: October 12, 2015 Name of Entity/Sender: San Antonio Water System Contact Person/Office: Dianne Flores/Human Resources Address: 2800 U.S. Hwy 281 North San Antonio, TX Phone Number: (210)

20 2800 U.S. Hwy 281 North P.O. Box 2449 San Antonio, Texas SAWS (7297)