PHIP Member Handbook and Benefit Guide. January 1, 2016 to December 31, 2016

Transcription

1 PHIP Member Handbook and Benefit Guide January 1, 2016 to December 31,

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3 Contents Medicare Basics... 5 Your Health Plan Options... 8 General Eligibility Enrollment Opportunities Premium Subsidies How to Enroll After Enrollment Coverage Outside Service Areas Benefit Changes, Health Plan Service Areas & Plan Features 25 Changes to Plans Health Plan Enrollment Service Areas Moda Health and Delta Dental Kaiser Permanente PacificSource Providence Health Plans PHIP Prescription Drug Benefit Plan Benefit & Rate Comparisons Medicare Benefit Comparison Medicare Rates Comparison Core Value Non-Medicare Rates Comparison Select Value Non-Medicare Rates Comparison Core Value Non-Medicare Benefit Comparison Select Value Non-Medicare Benefit Comparison Dental Benefit and Rate Comparison Required Notices Definitions Acronyms and Abbreviations PHIP Enrollment Request Form 63

4 The 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 to you to determine your best option. Mission statement 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: y Maintain stability of premiums y Maintain stability of coverage y Maintain stability of carriers 4

5 Medicare Basics Medicare 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 group 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. Medicare is health insurance available to: y people who are 65 years of age or older y who are under 65 but have been receiving Social Security Disability Insurance for more than 24 months; or y who have End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS). Medicare is administered by the Centers for Medicare and Medicaid Services (CMS) 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 12 of this handbook. 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 25th month after your Social Security benefits began. If you receive your Social Security benefit 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 65th birthday or when you become eligible for Medicare because of disability. 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 65th birthday and apply for Medicare Parts A and/or B. Medicare Basics 5

6 Original Medicare benefits Medicare Parts A and B y Part A covers inpatient hospital, such as room and board, skilled nursing care, and hospice expenses. In most cases, you pay no premium to maintain this coverage. y 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. Premiums for Medicare Part A (if applicable) and Part B are automatically deducted from your Social Security benefit check; or if you do not yet receive a benefit, you will be billed quarterly by Social Security. You must continue to pay your Medicare premiums to remain eligible for all PHIP Medicare plans. For Medicare Parts A and B enrollment, contact the Social Security Administration. You can find contact information on the back cover of this handbook. 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. Medicare Part D (Prescription Drug Plan) y Part D covers Medicare-approved prescription medications. Premiums for Medicare Part D plans are in addition to your Medicare Parts A and B premiums. If you are enrolled in a Medicare Advantage Plan, such as the PHIP plans offered, Medicare Part D premiums are typically included in the monthly premium you pay. 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 one (1) percent per month penalty for the months you did not have creditable coverage. Part D Late Enrollment Penalty The Late Enrollment Penalty (LEP) is an amount added to your Medicare Part D premium. You may owe a Late Enrollment Penalty if, at any time after your initial enrollment period (IEP) is over, there s a period of 63 or more days in a row when you do not have Medicare Part D or other creditable prescription drug coverage. If you are required to pay the LEP, Medicare will notify PHIP of that amount and it will be added to your monthly premium. 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. 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 have ESRD, coverage is available through Original Medicare (Supplement Plan). You can only join a Medicare Advantage Plan in certain situations. Please contact either Medicare or the Social Security Administration as referenced on the back cover of this handbook for more information. 6 Medicare Basics

7 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 Medicare Part D plan. Social Security will notify and bill you if you are required to pay this additional premium. The amount you pay can change each year. To be eligible for PHIP coverage, you must pay your Part D-IRMAA assessment, 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 questions about Part D-IRMAA, please contact either Medicare or the Social Security Administration as referenced on the back cover of this handbook. Medicare Basics 7

8 Your Health Plan Options PHIP contracts with four different health plan carriers and two dental carriers. All health plans include prescription drug coverage. In selecting a health or dental plan, your primary residence (not mailing address) must be within the United States and the plan s service area; see pages for more details. You can find additional plan-specific information in the health plan feature pages, benefit comparisons, premium rates and definition sections in this handbook. Medicare Supplement Medicare Supplement plans allow 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. You must meet your annual deductible first; then, Medicare pays its portion, and the plan pays the balance of the Medicare-allowed benefits. y Medicare Supplement Moda Health Medicare Advantage plans (Part C) Medicare Advantage (MA) plans contract with hospitals and physicians to provide care for enrollees. With Medicare Advantage plans, you usually pay a fixed charge, called a copay, at the time you receive care. Generally, you have no claim forms to file for MA doctors, hospitals and other healthcare providers who contract with these health plans. When you join a MA 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 may be required to select a primary care physician (PCP) and be referred by that physician for most specialist care. All available plans have some limitations and exclusions. When you enroll in any MA plan, that plan becomes the administrator of your Medicare Parts A and B benefits and you are then locked into the MA plan you have chosen until the plan change period or until you move out of the plan s service area. PHIP offers Health Maintenance Organization (HMO), Point-of-Service (POS) and Preferred Provider Organization (PPO) MA plans to its Medicare participants. You can be enrolled in only one MA plan at a time. By enrolling in a PHIP Medicare Advantage plan, any prior MA coverage will be terminated. y PHIP Medicare Advantage HMO plans: PacificSource Medicare Essentials RX 803 Kaiser Permanente Senior Advantage (HMO) Providence Medicare Align Group Plan (HMO) y PHIP Medicare Advantage managed care HMO-POS plan: Providence Medicare Flex Group Plan (HMO-POS) y PHIP Medicare Advantage PPO plan: PERS Moda Health PPORX (PPO) Non-Medicare plans PHIP offers HMO, POS and PPO plans for non-medicare participants. Retirees may select either the $500 deductible Core Value plan or the $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 about each of the health plans and their PHIP plan offerings. 8 Your Health Plan Options

9 y Core Value Traditional plan: Kaiser Permanente y Select Value plan with Deductible: Kaiser Permanente y Core Value and Select Value POS plans: PacificSource y Core Value and Select Value PPO plans: Moda Health and Providence Health Plans If you are eligible for Medicare, you will not be eligible to enroll in any of the PHIP non-medicare plans. If you are enrolled in a PHIP non-medicare plan, upon Medicare eligibility, your non-medicare coverage will be terminated. Exclusions and limitations All available plans have some limitations and exclusions. 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. Please contact the specific health plan for more information. Information is also available on your health plan s website. Please refer to the back cover of this handbook for phone numbers and website addresses. Dental options PHIP offers two dental plans: y Kaiser Permanente y Delta Dental of Oregon (formerly 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 14. Due to significant changes made to some of the $1,000 deductible Select Value plans in 2016, PHIP will allow members to move to a Core Value plan ($500 deductible/kaiser HMO) during the 2015 (2016 plan year) plan change only. If you choose to remain on a $1,000 deductible Select Value plan, please be aware that you will not be able to move back to the Core Value plan ($500 deductible/kaiser HMO) at any time, for any reason. Your Health Plan Options 9

10 General 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, or if you would like a copy of the complete OAR eligibility rules, please call PHIP at or visit 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: y 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. y 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 of the financial support for the person and must have claimed that person on his or her most recent federal tax return. An Affidavit of Domestic Partnership and a copy of your most recent federal tax return will be required. y 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): A natural child A legally adopted child or a child placed in the home pending adoption (legal custody and guardianship do not apply) A step-child who resides in the household of the step-parent who is an eligible retired member A grandchild, provided at the time of birth at least one of the grandchild s parents were covered under a PHIP plan as a dependent child and resides in the household of an eligible retired member y An eligible dependent also can be someone who is age 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: The 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 The incapacity is continuous and began before the date the child would otherwise have ceased to be an eligible dependent 10 General Eligibility

11 y An eligible surviving spouse or dependent refers to: The surviving spouse or dependent of a deceased retired PERS member; or The surviving spouse or dependent of a deceased PERS member who was not retired but was eligible to retire at the time of death y 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 y Members and their dependents must reside in the United States to receive coverage Who s ineligible? y If a spouse is enrolled in a PHIP health plan at the time of divorce, the spouse will become ineligible for PHIP, even if receiving a PERS benefit check. COBRA continuation rights apply. See page 56. y The new spouse of a surviving spouse who is not a PERS retiree. 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. General Eligibility 11

12 Enrollment Opportunities The PHIP milestones, as defined in OAR , mark the only enrollment opportunities available. Eligible retirees and their spouses or dependents that do not choose to enroll in a PHIP health plan during one of these enrollment periods will lose their opportunity to enroll in PHIP. If you have any questions about your enrollment opportunities, or if you would like a copy of the complete OAR enrollment rules, please call PHIP at or visit 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). You must 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 active employer-sponsored plan when you turn 65, you will need to contact the Social Security Administration to sign up for Medicare. Medicare Part A is free for most people; Medicare Part B has a premium and therefore you may want defer enrollment into Medicare Part B while under active employer-sponsored group health coverage. When your active employer-sponsored group coverage ends, you are allotted a Special Enrollment Period (SEP) by Medicare to enroll in your Medicare Part B. Three months before your retirement date or loss of active employer-sponsored group coverage contact the Social Security Administration to sign up for Medicare Part B. Your Medicare Part B effective date should be the first of the month after your active employer-sponsored group coverage ends. The Medicare Initial Enrollment Period (IEP) 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. NOTE: If your IEP is concurrent with your SEP, the IEP enrollment timelines prevail. 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 the PHIP Medicare Part D prescription plan. PHIP coverage will take effect on the date your Medicare coverage becomes effective if you enroll before the date of your Medicare eligibility. 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 an 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. 12 Enrollment Opportunities

13 Medicare disability Your eligibility to enroll in Medicare Part A and Part 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 an 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 employersponsored 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 group coverage. Employer-sponsored group coverage can be: y Coverage you had as an active or retired employee that is terminating y Coverage you had under an eligible spouse s active employment or as a retired employee that is terminating y Coverage continued through COBRA following termination of employment COBRA coverage is secondary to Medicare, except when the Medicare beneficiary has ESRD COBRA 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 group health coverage. To ensure you are selecting the correct PHIP effective date, verify your current health plan coverage end date with your employer. To avoid a gap in coverage, select the first of the month after your employer-sponsored group coverage ends as the PHIP effective date. To enroll, submit your PHIP Enrollment Request Form 30 days prior to your employer-sponsored group coverage ending to prevent a gap in coverage. PHIP allows up to 30 days to enroll after loss of employer-sponsored group coverage ends, however if the Enrollment Request Form is received after your group coverage ends, your PHIP effective date will be the first of the month after receipt of your Enrollment Request Form. Any application received after 30 days of loss of employer group coverage is considered outside of the enrollment opportunity and will be ineligible. Changes to the original PHIP effective date will not be allowed once the requested effective date has passed. Enrollment Opportunities 13

14 Dependent enrollment Dependents can enroll during any of the enrollment periods available to retirees, as described on pages If a spouse or dependent has an enrollment opportunity after the retiree is enrolled, he or she will be eligible to enroll under the retiree s account. A Medicare eligible spouse or dependent can enroll in a PHIP Medicare health plan prior to the retiree, provided the spouse or dependent is enrolled in Medicare Parts A and B and contingent on the PERS retiree enrolling in PHIP upon his or her final enrollment opportunity. If the PERS retiree does not enroll in PHIP upon his or her final enrollment opportunity, the spouse or dependents will no longer be eligible for PHIP coverage and will be disenrolled. New dependents must be enrolled within 30 days of the family status change (e.g., birth, marriage). If the spouse has a different last name than the retiree, a copy of the marriage certificate will be required. If the retiree has Medicare coverage and the dependent has non-medicare coverage, the dependent s coverage will be with the same health plan as the retiree. Notice: Effective date of coverage will be the first of the month after receipt of the PHIP Enrollment Request Form. Surviving spouses 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 from the date of death or by meeting other enrollment opportunities (see pages 12 14). However, in the event of remarriage, coverage cannot be extended to the new spouse. Dental plan enrollment The PHIP dental plan is only available if you are enrolled in a PHIP medical plan. If anyone in your family chooses dental coverage, everyone who is enrolled in a PHIP medical plan also must be enrolled in a PHIP dental plan. Dependents must enroll in the same dental plan as the retiree. You can enroll in either dental plan regardless of your medical plan selection. For Kaiser Permanente dental, you must reside in the Kaiser Permanente dental plan service area. Enrollment in a PHIP dental plan must be made under the same enrollment conditions as the PHIP medical plan. 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. Please refer to pages for a description of dental services. 14 Enrollment Opportunities

15 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 $60 monthly contribution toward the cost of healthcare coverage for some PERS retirees. This contribution is applied automatically, if you are eligible. PHIP will determine eligibility by verifying your pension service records. The contribution is reflected in the monthly premium you pay. If you have any questions about premium subsidies, or if you would like a copy of the complete rules, please call PHIP at or visit To have RHIA contributions applied toward PHIP premiums, retired members must meet the following requirements: y Be enrolled in Parts A and B of Medicare and also meet one of these requirements: 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; or 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 y Be a surviving spouse or dependent of a deceased eligible Tier 1 or Tier 2 retired member, as described on page 14, who is enrolled in Medicare Parts A and B and who also meets these requirements: Is receiving a retirement allowance or benefit from PERS; or Was covered under an eligible retiree member s PHIP health plan at the time of the retiree s death and the deceased member retired on or before May 1, 1991 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. RHIPA (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 directly 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. PHIP will determine eligibility by verifying your qualifying Premium Subsidies 15

16 state service time. The monthly premium amount you pay will reflect the subsidy, following verification. If you have any questions about premium subsidies, or if you would like a copy of the complete rules, please call PHIP at or visit To have RHIPA contributions applied toward PHIP premiums, retired state of Oregon employees enrolled in a PHIP health plan must meet the following requirements: y Be a Tier 1 or Tier 2 retiree who is a state of Oregon employee at the time of retirement and is not eligible for Medicare, and who also meets one of these requirements: 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); or 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 premium 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 RHIPA eligible members to the PHIP office. 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 y Be a surviving spouse or dependent of a deceased eligible Tier 1 or Tier 2 retired state of Oregon employee, as described on page 14, who is not eligible for Medicare and who meets one of these requirements: Is receiving a retirement allowance or benefit from PERS; or Was covered under an eligible retiree member s PHIP health plan at the time of the retiree s death and the eligible retired state employee retired on or after September 29, 1991 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. 16 Premium Subsidies

17 How to Enroll During peak enrollment times, 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 cover of this handbook. Your coverage will start on the date described in the Enrollment Opportunities section on pages To enroll in any PHIP health plan, you must: y Meet one of the PHIP enrollment opportunities described on pages y Complete the Enrollment Request Form in its entirety. Include spouse or dependent information only if they are enrolling in PHIP. Missing information can delay your enrollment. Indicate your reason for applying for PHIP coverage and select a medical and dental plan (dental plan optional). If you are enrolled in a PHIP non-medicare plan, you must submit a new Enrollment Request Form upon Medicare eligibility. y All Medicare-eligible individuals must complete the Medicare card section. Submit a photocopy of either the Medicare card or a Letter of Entitlement (Letters of Eligibility are not accepted) showing Medicare effective dates for Parts A and B for each Medicare-eligible individual applying. y 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. y 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. You will have 30 days from the requested effective date to submit any additional paperwork. If necessary documentation is not received within 30 days from requested effective date, you may be required to submit a new Enrollment Request Form. y Submit all documents to the PHIP office. The address is listed on the back cover of this handbook. Retain a copy of the Enrollment Request Form for your records. 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 PHIP coverage. Once termination has occurred, you may not re-enroll in PHIP, unless you experience a new enrollment opportunity. When enrolling in a PHIP Medicare plan, you will automatically be enrolled in a Medicare Part D prescription plan. How to Enroll 17

18 After Enrollment Plan change PHIP offers an annual plan change period from October 1 to November 15. 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. 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 plan 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. Snow bird For members who are enrolled in any PHIP Medicare Advantage plan, and who reside inside Oregon part of the year and outside Oregon part of the year, PHIP offers the Snow Bird option. The Snow Bird option allows members to change their health plan to Moda Health Medicare Supplement Plan while living outside their Medicare Advantage 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 the service area, members should contact PHIP to request an Enrollment Request Form and Disenrollment Form to change to the Moda Health Medicare Supplement Plan for the time spent living outside the Medicare Advantage service area. Upon returning to Oregon, members will be eligible to change back to their prior Medicare Advantage plan. The Snow Bird option also applies to non-medicare members who are enrolled in Kaiser Permanente, PacificSource, or Providence Health Plans, and who reside inside Oregon part of the year and outside Oregon part of the year. You have the option to change to the Moda non-medicare plan in the same Value tier. 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. Change of address 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.) PHIP will notify the appropriate health plan, however they will not update your address with the PERS pension office. To update your address with the PERS pension office, contact PERS directly at the address listed on the back cover of this handbook. Failure to notify PHIP within 30 days of moving outside a service area can result in involuntary termination of coverage. 18 After Enrollment

19 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. Premium payments Making monthly premium payments Premium payment options: y 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. y Electronic Funds Transfer (EFT) from your bank account. This also ensures timely payment and prevents a lapse in coverage. Only one payment option is allowed per PHIP account. Premium rates are subject to change mid-year due to Medicare requirements such as Medicare Part D Late Enrollment Penalty or Low Income Subsidy (Extra Help) notifications. PHIP is required to adjust premiums to account for these changes. For questions regarding premium changes due to Medicare programs, contact Medicare directly. 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. 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. Disenrollment 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 request through customer service. The PHIP address and fax number are listed on the back cover of this handbook. Involuntary termination In some instances, PHIP may be required to terminate your coverage. Examples of when you may lose your coverage are: y Loss of Medicare Parts A and/or B y Enrolling in another non-phip Medicare Advantage or Medicare Part D Prescription Drug Plan After Enrollment 19

20 y Loss of program eligibility due to failure to adhere to premium payment guidelines y Loss of retirement status (returning to work) If your PHIP coverage is terminated by the plan, you may not re-enroll in PHIP unless you experience a new enrollment opportunity, provided you meet the eligibility requirements as described on pages You will be required to bring your account current in the event you have any outstanding balance. Death notification y 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. y 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. Once disenrollment or termination occurs, you cannot re-enroll in PHIP unless you experience a new enrollment opportunity. PHIP appeals Pursuant to Oregon Administrative Rule (OAR) , if you receive a letter denying PHIP eligibility (program or subsidy) or enrollment and you disagree with that determination, you may request a review by writing to the PERS Director within 60 days after the date of the letter. Your request must include the following information: 1. A description of the determination you want reviewed. 2. A short statement describing how and why you think the determination is wrong. 3. A statement of facts that you believe show the determination is wrong. 4. A list of any statutes, rules, or court decisions that you believe support your position. 5. A statement of the action you seek. 6. A request for review. Oregon Revised Statutes are available from the Office of Legislative Counsel, or can be located on the Internet at Oregon Administrative Rules are available from the Oregon State Archives Mail appeal to: Public Employees Retirement System. Attn: Appeals, SW 68th Pkwy. Tigard, OR When the Director receives your request, he may ask a Division Administrator to act on it. Your request for a review may be denied if it does not contain the required information listed above. You will be mailed a response letter within 45 days after we receive your request. Health plan appeals Appeals related to claim and benefit payments, 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 cover of this handbook. 20 After Enrollment

21 After Enrollment 21

22 Coverage Outside Service Areas Moda Health Moda Health PPORX (PPO) plan Members may stay enrolled on the Moda Health PPORX (PPO) plan for up to 12 months when traveling outside of the state of Oregon. This travel benefit allows members to receive services from out-of-state Medicare providers. 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. Coverage for emergency and urgent services outside of the United States is limited to $50,000 lifetime per member. 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. Medicare Plans Only Emergency/Travel Benefits Urgent care (worldwide) Emergency room (ER) (worldwide) Ambulance (worldwide; air/ground) Outside service area travel (in U.S.) Outside service area travel (outside U.S.) Moda Health Supplement MEMBER pays: Covered in full (inside U.S. only) Covers ER, urgent care & ambulance Covers ER, urgent care & ambulance at 80% coinsurance. Coverage limited to $50,000 lifetime per member. PERS Moda Health PPORX (PPO) MEMBER pays: $20 copay $65 copay $50 copay Out-of-network provider copay for ER, urgent care and ambulance applies. Providers are paid up to the Medicare limiting charge. Out-of-network provider copay for ER, urgent care and ambulance applies. Providers are paid up to the Medicare limiting charge. Time frame 6 months* 12 months* *Per CMS guidelines for travel within and outside U.S. 22 Coverage Outside Service Areas

23 You must maintain a residence within a plan s service area and reside in the United States in order to participate in PHIP. 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. Delta Dental of Oregon Dental plan The Delta Dental dental plan gives you the freedom to choose any licensed dentist. Delta Dental Premier Network is the largest dental network in the country; you can visit any of the 151,000 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 Kaiser Permanente Senior Advantage (HMO) PacificSource Medicare Essentials RX 803 Providence Medicare Align Group Providence Medicare Flex Group MEMBER pays: MEMBER pays: MEMBER pays: MEMBER pays: $15 copay $15 copay $25 copay $25 copay $50 copay $50 copay $50 copay $50 copay $50 copay $50 copay $50 copay $50 copay Covers routine, preventive and follow-up care outside Kaiser network at 20% coinsurance as part of $1,000 annual worldwide travel benefit maximum. 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 and ambulance at copays listed above Covers ER, urgent care and ambulance at copays listed above 20% to maximum allowance of $1,000 for follow-up services Covers ER, urgent care and ambulance at copays listed above 20% coinsurance Covers ER, urgent care and ambulance at copays listed above 6 months* 6 months* 6 months* 6 months* This is a summary of benefits only, for general comparison. Any errors or omissions are purely unintentional. Should any discrepancies be found between this guide and the plan document, the information in the plan document shall prevail. Coverage Outside Service Areas 23

24 who are out of the service area for six consecutive months or more must disenroll from their Kaiser 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. 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 Rx 803 plan provides worldwide coverage for the following four services: y Emergency services y Urgently needed services y Medically necessary ground or air ambulance services y 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. Travelers have the added protection of worldwide coverage for: y Emergency services y Urgently needed services y Medically necessary ground or air ambulance services y Out-of-area dialysis services These services do not require prior authorization. Providence Health Plans All plans offer worldwide coverage for urgent and emergency care and include ambulance coverage (air and ground). Providence Medicare Align Group plan (HMO) + Rx Group plan Includes a travel benefit for necessary follow-up care from any Medicare provider outside the plan service area. Providence pays 80% and the member pays 20%, up to a combined $1,000 annual limit. Providence Medicare Flex Group plan (HMO-POS) + Rx Group plan The Providence Medicare Flex Group Plan out-of-network benefit allows you to see any Medicare-approved provider. Non-Medicare PPO plan Providence Health Plans gives members access to nearly one million providers nationwide. 24 Coverage Outside Service Areas

25 Benefit Changes, Health Plan Service Areas & Plan Features Benefit changes, health plan service areas and plan features section 25

26 Changes to Plans Effective January 1, 2016 Important notice for the 2016 plan year Effective January 1, 2016, prescription drug coverage for PacificSource and Providence members will be provided through your medical health plan. Refer to the appropriate health plan s feature page for more information. Prescription drug program Applies to all Medicare and non-medicare enrollees: y The prescription drug out-of-pocket maximum per person per calendar year will now be $4,850. Dental ODS y ODS is now doing business as Delta Dental of Oregon. y Revised the Maximum Plan Allowance (MPA) to a fee schedule for non-participating providers in Oregon. y Members with periodontal disease may receive up to a total of 4 (four) periodontal cleanings per year. Kaiser Permanente y No benefit changes for the 2016 plan year. Medical Non-Medicare plans For the 2016 plan year only, due to significant changes made to some of the $1,000 deductible Select Value plan options, we will allow members to move to a Core Value plan (lower deductible/ Kaiser HMO) during plan change only. If you choose to remain on a $1,000 deductible Select Value plan, please be aware that you will not be able to move back to the Core Value plan (lower deductible/kaiser HMO) at any time, for any reason, even with a different health plan provider. Kaiser Permanente Medicare y No benefit changes for the 2016 plan year. y The student out-of-area benefit does not apply under Medicare. Non-Medicare Core Value and Select Value Plans y Healthy diet, obesity and weight management counseling have been added. y External Prosthetic devices and Orthotic devices have been added to the list of items requiring prior authorization. y Telemedical services are covered at the appropriate cost share. y The student out-of-area coverage is now: 10 office visits, 10 x-ray and lab visits, and 10 prescriptions all covered at 20% member coinsurance. 26 Changes to Plans