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

27 Moda Health Medicare Supplement y No benefit changes for the 2016 plan year. PERS Moda Health PPORX (PPO) Medicare Advantage y No benefit changes for the 2016 plan year. Non-Medicare Core Value Plan y Tobacco cessation treatment is covered at no cost share in-network and 40% out-of-network. y The requirement for an originating site has been removed from Telemedical Health Services. y Kidney dialysis is covered at 100% of the Maximum Plan Allowance (MPA) for in-network and out-of-network services once the deductible has been met. y Coverage for End-Stage Renal Disease (ESRD) facilities is the contracted amount for in-network and 125% of the Medicare allowable amount for out-of-network. y Maximum Plan Allowance (MPA) for medical devices, including implanted devices, and for durable medical equipment is the contracted amount or the lesser of 100% of the Medicare allowable amount or the acquisition cost of the device plus 10% if there is no contracted amount. y Self-administered medications purchased through a retail pharmacy are now covered and subject to the pharmacy plan benefit. y Self-administered medications supplied by a physician s office, facility or clinic are excluded from the medical plan benefits. Non-Medicare Select Value Plan y In-network out-of-pocket maximum is now $3,000 + deductible per individual; out-of-network out-of-pocket maximum is now $9,000 + deductible per individual. y In-network coinsurance is now 30%; out-of-network coinsurance is now 50%. y In-network physician office visit and urgent care copay is $25. y In-network specialist copay is $35. y Ambulance coinsurance in-and out-of-network is now 30%. y Tobacco cessation treatment is covered at no cost share in-network and 40% out-of-network. y The requirement for an originating site has been removed from Telemedical Health Services. y Kidney dialysis is covered at 100% of the Maximum Plan Allowance (MPA) for in-network and out-of-network services once the deductible has been met. y Coverage for End-Stage Renal Disease (ESRD) facilities is the contracted amount for in-network and 125% of the Medicare allowable amount for out-of-network. y Maximum Plan Allowance (MPA) for medical devices, including implanted devices, and for durable medical equipment is the contracted amount, or the lesser of 100% of the Medicare allowable amount or the acquisition cost of the device plus 10% if there is no contracted amount. y Self-administered medications purchased through a retail pharmacy are now covered and subject to the pharmacy plan benefit. y Self-administered medications supplied by a physician s office, facility or clinic are excluded from the medical plan benefits. Changes to Plans 27

28 PacificSource PacificSource Prescription Drug Program applies to all Medicare and non-medicare enrollees y Prescription drug coverage for PacificSource members is now provided through PacificSource. You will receive a new PacificSource ID card that reflects pharmacy coverage. The PacificSource formulary applies. If you were prescribed and are currently taking a specific medication under the Moda Prescription Drug plan on December 31, 2015, you may continue that medication without interruption or prior authorization, unless required by law or if there is a change to the script dosage or frequency. Some new medications may require prior authorization. Medicare y Lung cancer screening coverage for high risk members has been added. y GlobalFit is no longer a contracted PacificSource vendor. y Silver & Fit is the new contracted fitness vendor with PacificSource. Non-Medicare Core Value Plan y GlobalFit is no longer a contracted PacificSource vendor. y No benefit changes for the 2016 plan year. Non-Medicare Select Value Plan y Individual and family deductible now applies to both the in- and out-of-network benefits. y In-network out-of-pocket maximum is now $3,000 + deductible per individual and $9,000 + deductible for families; out-of-network out-of-pocket maximum is now $9,000 + deductible per individual. The family out-of-pocket maximum has been removed. y In-network coinsurance is now 30%; out-of-network coinsurance is now 50%. y In-network specialist copay is $35. y Ambulance coinsurance in- and out-of-network is now 30%. y GlobalFit is no longer a contracted PacificSource vendor. Providence Health Plans Providence Prescription Drug Program applies to all Medicare and non-medicare enrollees y Prescription drug coverage for Providence members is now provided through Providence. You will receive a new Providence ID card that reflects pharmacy coverage. The Providence formulary applies. If you were prescribed and are currently taking a specific medication under the Moda Prescription Drug plan on December 31, 2015, you may continue that medication without interruption or prior authorization, unless required by law or if there is a change to the script dosage or frequency. Some medications may require prior authorization. 28 Changes to Plans

29 Medicare Align Plan y Routine eye exams and hardware allowance are available through VSP and the VSP Choice Network. Vision services received outside of this network will not be covered. y Telemedical services are now available through Providence Health express. Members may now video conference with a provider through a personal computer, tablet or smartphone. Medicare Flex Plan y Out-of-network cardiac outpatient rehab copay is now $30. y Out-of-network outpatient substance abuse copay is now $30. y Out-of-network Medicare covered hearing exams is now 20%. y Routine eye exams and hardware allowance are available through VSP and the VSP Choice Network. Vision services received outside of this network will be covered at the out-of-network benefit level. y Telemedical services are now available through Providence Health express. Members may now video conference with a provider through a personal computer, tablet or smartphone. Non-Medicare Core Value Plan y Colonoscopies are covered in full when billed with a preventive diagnosis. y Telemedical services are now available through Providence Health express. Members may now video conference with a provider through a personal computer, tablet or smartphone. y Provider network name has changed from Exclusive Provider Organization (EPO) to Providence Signature Network (PPO). Non-Medicare Select Value Plan y In-network out-of-pocket maximum is now $3,000 + deductible per individual and $9,000 + deductible for families; out-of-network out-of-pocket maximum is now $9,000 + deductible per individual. The family maximum has been removed. y In-network coinsurance is now 30%; out-of-network coinsurance is now 50%. y In-network physician office visit and urgent care copay is $25. y In-network specialist copay is $35. y Ambulance coinsurance in- and out-of-network is now 30%. y Colonoscopies are covered in full when billed with a preventive diagnosis. y Telemedical services are now available through Providence Health express. Members may now video conference with a provider through a personal computer, tablet or smartphone. y Provider network name has changed from Exclusive Provider Organization (EPO) to Providence Signature Network (PPO). Changes to Plans 29

30 Health Plan Enrollment Service Areas For PHIP Medicare and non-medicare plans Moda Health y Moda Health Medicare Supplement Plan and Moda Health non-medicare PPO ypers Moda Health PPORX (PPO) Kaiser Permanente Oregon Benton: 97330, 97331, 97333, 97339, 97370; Clackamas (excluding 97028); Columbia; Hood River: 97014, Linn: 97321, 97322, 97335, 97355, 97358, 97360, 97374, 97389; Marion (excluding 97350); Multnomah; Polk; Washington; Yamhill Washington Clark; Cowlitz; Lewis: 98591, 98593, 98596; Skamania: 98639, 98648; Wahkiakum: 98612, PERS retirees who live in California and are interested in enrollment in a Kaiser Permanente Health Plan located in their area should call PHIP for more information. Premium rates and benefits will differ from those noted in this handbook. 30 Health Plan Enrollment Service Areas

31 In selecting a PHIP health plan, your primary residence (not mailing address) must be within the United States and the health plan s service area. PacificSource Coos; Crook; Curry; Deschutes; Grant; Hood River; Jefferson; Klamath: 97731, 97733, 97737, 97739; Lake: 97638, 97641, 97735, 97739; Lane; Sherman; Wasco; Wheeler Providence Health Plans Oregon Benton, Clackamas, Columbia, Crook, Deschutes, Hood River, Jefferson, Lane, Linn, Marion, Multnomah, Polk, Washington, Wheeler and Yamhill Washington Clark County Health Plan Enrollment Service Areas 31

32 Moda Health and Delta Dental Rooted in the Pacific Northwest, we are a company dedicated to partnering with and caring for our members. We re proud to provide you with evidence-based plans, diverse provider networks, innovative member programs and exceptional customer service. PERS Moda Health PPORX (PPO) Members can receive services from any provider in the Moda Health Medicare Advantage statewide network or any out-of-network Medicare provider. You are not required to select a primary care provider, and you can seek care from a specialist without a referral. Moda Health Medicare Supplement Plan This is a traditional Medicare Supplement insurance program that pays secondary to Medicare. Members can receive services from any Medicare provider. Members also can live anywhere in the United States. 32 Moda Health and Delta Dental

33 Non-Medicare PPO plan Moda Health offers a Preferred Provider Organization (PPO) plan for non-medicare retirees and dependents. Four networks are available to members. The state in which you reside will determine the PPO network as follows: Connexus Network This network includes Legacy Health System, Oregon Health & Science University (OHSU), Providence Health & Services and Adventist Health. The Connexus Network provides access to providers, hospitals and pharmacies in Oregon, Idaho, Southern Washington and Northern California. First Choice Health Network This network is available to members who reside in Washington state and do not live in Benton, Clark, Cowlitz, Klickitat, Pacific, Skamania, Wahkiakum or Walla Walla counties. PHCS Network This network is available to members who reside in a state other than Oregon, Washington or Idaho. Moda Health additional Medicare benefits Silver&Fit The Silver&Fit program will empower you to get active and stay fit, regardless of your fitness level. Your membership includes access to a participating fitness facility, or if you prefer to work out at home, you can order up to two Silver&Fit Home Fitness kits. In addition, all enrolled Silver&Fit members will receive Healthy Aging educational materials available online or, if requested, by mail. Members can also track their exercise through more than 70 wearable fitness devices using the Silver Fit Connected!, program, sign up for the Silver Slate newsletter, which provides useful information about health and fitness, and access Silver&Fit is a federally registered trademark of American Specialty Health Incorporated and used with permission herein. Moda Health value-added services mymoda This personalized website is designed to help you manage your health. With mymoda, you can: y View your ID card, benefits, claim information, eligibility and history y Access health tools y Find a physician, dentist, pharmacist or clinic y Access Dental Optimizer y View our prescription price check tool (pharmacy members only) Be Better tools Access tools and get individualized support to help you improve your health. Available through mymoda, Be Better tools include: y Health coaching for PERS Moda Health PPORX (PPO) enrollees only y Care coordination and case management for PERS Moda Health PPORX (PPO) only y Registered Nurse Advice Line call any time of the day or night y Vision hardware discounts available when ordering through your participating Moda vision provider Delta Dental of Oregon The Delta Dental of Oregon dental plan gives you access to the Delta Dental Premier Network, one of the largest dental networks available in Oregon and across the nation. Oral Health, Total Health Oral health research has shown a strong link between oral health and overall health. Delta Dental believes that when Moda Health and Delta Dental 33

34 you see a dentist regularly and maintain a healthy mouth, it can help keep the rest of your body healthy too. Through our Oral Health, Total Health program, Delta Dental offers additional preventive benefits to members with diabetes and pregnant women in their third trimester. Passport Dental No matter where in the world you roam, Passport Dental gives you access to great care through your Delta Dental plan. PHIP prescription drug benefit for Moda Health Moda Health has a comprehensive national network with more than 71,000 participating pharmacies around the United States. This includes most of the large national chains as well as many neighborhood pharmacies. Mail order prescription drugs Mail order prescriptions can be obtained through any mail order company listed in the 2016 Moda Health PPORX (PPO) Pharmacy Directory. Payless Drug Special Service Pharmacy To ensure prescription drug adherence, we offer a mail-order program through Payless Drug Special Service Pharmacy. The program helps members take their medications at the right time throughout the day: y Your pills are put in easy-to-use cards, set up on a 28-day cycle, grouped together into days and times they need to be taken y We mail your cards directly to you each month automatically no more standing in line at the pharmacy y We help you keep track of when you ve taken your pills, so you don t miss a day or take them twice y We work with your doctors to coordinate your prescriptions Ardon Health Specialty Pharmacy We provide pharmacy services, plus a caring team of professionals dedicated to your well-being. Together, we connect you with the resources you need to feel better. Our pharmacists and patient care associates help you understand your health condition, access medications, bill your insurance plan and find copay assistance. Count on us, every step of the way. For more information about your prescription medications and all specialty and mail order pharmacies, please refer to the 2016 Moda Health PPORX (PPO) Pharmacy Directory or call the Moda PHIP Pharmacy Program at the phone number listed on the back cover of this book. Prescriptions for Moda Health members residing in long-term care facilities Patients residing in nursing homes or other long-term care facilities will pay 40 percent of the prescription charge at the time of dispensing or upon receiving a bill from the institutional pharmacy servicing the facility. 34 Moda Health and Delta Dental

35 Kaiser Permanente Proudly serving the Northwest for 70 years, Kaiser Permanente offers comprehensive care that s convenient, connected, and designed to provide the prevention, wellness and healthcare resources you need to live well. Senior Advantage Get more. More control, convenience and quality with a plan that goes beyond Original Medicare. With care under one roof, online health management tools, worldwide emergency coverage and comprehensive care that builds in wellness programs and supportive services to promote your total health, Kaiser Permanente s Medicare Advantage plan offers comprehensive care and coverage. Non-Medicare plans Core Value Traditional Plan With a Kaiser Permanente Traditional Plan, you don t have to keep track of Kaiser Permanente 35

36 deductibles or worry about paperwork for the services you receive. When you come in for care, you ll just pay a copay for most services covered by your plan. Let us help you get easy access to a wide range of care and support to help you stay healthy and get the most out of life. Select Value plan with deductible With a Kaiser Permanente deductible plan, you receive a wide range of care and support to help you stay healthy. Most preventative care services, such as routine physical exams, routine mammograms and cholesterol screenings are covered at little or no additional cost to you, even before you reach your deductible. For most other covered services, you ll pay just a copay or coinsurance after you reach your deductible. Everything under one roof You have access to 53 offices (medical and dental) from Salem-Keizer to Longview; with pharmacy, lab, X-ray, dental and vision services so you can do more and drive less. Same-day appointments and after-hours urgent care are available for life s unexpected moments. Online access Save time by using your smartphone, computer or mobile device to your doctor s office, schedule routine and some specialty appointments, view lab test results, refill prescriptions and more. Kaiser Permanente additional benefits 24-hour advice nurse benefit Contact a Kaiser Permanente advice nurse for quick, around-the-clock help with your needs. Call in Portland or from elsewhere. Health fitness benefit We offer the Silver&Fit program as part of your Senior Advantage (HMO) Plan. You can choose to become a member at a contracted fitness club or exercise facility, or you can choose the Silver&Fit Home Fitness program. Dental plan The Kaiser Permanente dental plan offers 17 dental offices in the Northwest region. Members with Chronic Medical Conditions Utilizing our Oral Health Status (OHS) data, we identify patients with certain chronic medical conditions who are overdue for a dental appointment. This is important because we know that certain medical conditions can trigger oral health issues, making regular oral health exams and receipt of any necessary treatment an important component of your total health. Kaiser Permanente healthy extras* Kaiser Permanente offers health resources and discounts* on alternative care, wellness classes and a variety of other activities. Comfort Keepers * Members who live in the Northwest are eligible for a 5 percent discount on services from Comfort Keepers, a leader in nonmedical, in-home services. LifeStation medical alert* Members who permanently live in the Northwest qualify for a discounted rate on 24/7 medical alert services from LifeStation, one of the nation s largest and most trusted medical alert service providers. Call for more information. *The products and services described above are neither offered nor guaranteed under our contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes related to these products and services may be subject to the Kaiser Permanente grievance process. 36 Kaiser Permanente

37 Mom s Meals NourishCare Kaiser Permanente members receive a reduced rate on fresh, ready-to-eat meals delivered right to your home. Recovering from an illness? Have special dietary needs? Simply too busy to cook? Call (888) for more information. Complementary Health Plans (CHP) Active & Healthy Bring a healthy balance to your life (and your bank account). With CHP Active and Healthy, you ll save money on local entertainment, fitness and complementary care offerings, including chiropractic care, acupuncture, movie and sports event tickets and more. Prescriptions for members residing in longterm care facilities Patients residing in nursing homes or other long-term care facilities will pay 40 percent of the prescription charge for Part D covered drugs, up to a maximum of $150 per prescription for up to a 31-day supply. Specialty packaging costs are not covered. Health coaching Get free one-on-one help setting health goals and developing a wellness plan. Go to kp.org to learn more about Kaiser Permanente. PHIP prescription drug benefit for Kaiser Permanente Members enrolled with Kaiser Permanente through PHIP are covered under the Kaiser prescription drug benefit. Kaiser Permanente members must use Kaiser facilities and pharmacies to obtain prescription drugs. Kaiser Permanente Mail Delivery Kaiser Permanente Mail Delivery Pharmacy can save you a trip to the medical office. The service is free, easy-to-use and fast. Orders arrive within 7 to 10 days. Members can order prescription refills by phone, via the website or by mail. For covered Part D maintenance drugs*, you can order up to a 90-day supply for 40 percent of the prescription charge with a maximum limit of $300 per prescription. *See page 58 for a definition of maintenance drug. Kaiser Permanente 37

38 PacificSource PacificSource offers Medicare Advantage plans under the name PacificSource Medicare. It is part of the PacificSource family of companies, which has an 82-year history and reputation for taking great care of people. PacificSource employs 700 people, and serves more than 275,000 members with individual, employer, Medicare and Medicaid plans throughout the Northwest. Our parent company, PacificSource Health Plans, is an independent not-for-profit community health plan founded by a group of physicians in Oregon with the goal of improving healthcare quality and access in the community. Our Medicare Advantage plans The PacificSource Medicare Essentials Rx 803 plan is a Medicare Advantage plan. Members use in-network providers for most services. You can see any Medicare-approved provider in the PacificSource Medicare 38 PacificSource

39 network. You can choose your own primary care provider, and you have the freedom to see specialists without a referral. Our Medicare Advantage plan covers more than Medicare alone. PacificSource Medicare additional benefits The following additional benefits are available to PacificSource Medicare members at no additional cost. Gym benefits through Silver&Fit Exercise & Healthy Aging Program y Access to more than 10,000 participating fitness facilities and exercise centers. y Home fitness kit option y Group classes made for older adults, where offered y Online classes and resources Health screenings, events and immunization programs You can get free health screenings, educational events, immunization programs and health risk assessments to help you manage chronic conditions and live the life you want. Hearing benefits y Routine hearing exams: $15 copay y Hearing aids: $250 reimbursement every two calendar years Non-Medicare Point-of- Service (POS) plans PacificSource Core Value and Select Value POS plans give you the freedom to see either in-network or out-of-network providers for covered services. You will generally pay less for services from providers in the PacificSource network. And you have the freedom to see specialists without a referral. Extra benefits for both Medicare and non-medicare members Free medication review by a pharmacist y One-on-one consultation with a licensed pharmacist y Opportunity to ask personalized questions y We will work with you and your doctor to help identify possible lower-cost alternatives y Reduce your risk of side effects and complications 24-Hour NurseLine You can call the 24-Hour NurseLine any time of the night or day from the comfort of your home to receive trusted health information and advice. Call , or TTY Care programs If you have a chronic health condition such as diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure or asthma, you can get personal help to improve your health, overcome barriers and coordinate your care. Online resources Our secure website for members, InTouch, gives you 24-hour access to plan materials and authorizations. Click InTouch Login at the top of our website to register once you re a member. PHIP prescription drug benefit for PacificSource Members enrolled with PacificSource through PHIP are covered under the PacificSource prescription drug benefit. If you are Medicare eligible, you are automatically enrolled in the PacificSource Part D prescription drug plan. PacificSource 39

40 Pharmacy network You can access your PacificSource prescription drug benefit at retail pharmacies, through mail order or through Long Term Care (LTC) pharmacies. Our retail pharmacy network has over 68,000 pharmacies throughout the United States. This includes well-known national and regional chain pharmacies and independent pharmacies as well. Most retail pharmacies in our network allow you to get a long-term supply (up to 93 days) of maintenance drugs. Mail order prescription drugs Having your prescriptions delivered to you by mail can save you a trip to the pharmacy each month. The service is free, easy-to-use and fast. You can order your prescription refills by phone, on the web or by mail. Our mail order prescription service is provided by CVS or WellPartner. Prescriptions for members residing in a long-term care facility Patients residing in a nursing home or other long-term care facilities will pay 40 percent of the prescription charge for Part D covered drugs up to a maximum of $150 per prescription for up to a 31-day supply. Specialty packaging costs are not covered. Specialty pharmacy PacificSource does not limit or restrict which in-network Specialty pharmacy you choose to use. Specialty drugs are limited to a 31-day supply. 40 PacificSource

41 Providence Health Plans Providence Health Plans is part of one of the largest healthcare systems in the Pacific Northwest, Providence Health & Services. Providence Medicare Advantage plans We offer two different plans to meet your needs. The chart on the next page illustrates highlights of each plan offering. Non-Medicare plans Providence offers a Preferred Provider Organization (PPO) plan that provides inand out-of-network benefits to non-medicare beneficiaries and their dependents. Providence additional Medicare benefits and value-added services No-cost fitness membership through Silver&Fit Exercise and Health Aging Program With the Silver&Fit Exercise and Healthy Aging Program, you have access to: y Fitness facilities or exercise centers y Home fitness kits y Materials on healthy aging and member newsletters Providence Health Plans 41

42 Providence Medicare Align Group HMO Providence Medicare Flex Group HMO-POS Benefits and premium Richer benefits Lower premium Provider access In-network only In-network and out-of-network Primary care physician Required Required Referrals Required Optional Travel benefits (non-urgent/emergency care) Worldwide urgent care, emergency care and ambulance $1,000 allowance Included Covered at the out-of-network benefit Included For more information, or to find participating gyms, visit silverandfit.com. Providence RN Free medical advice 24 hours a day, seven days a week at or Exclusive discounts Discounts on recreational activities, apparel and more through the LifeBalance Program. Health and wellness discounts y 25 percent off at participating chiropractors, acupuncturists, massage therapists and dietitians y Health and fitness classes y Vision services and hardware y Hearing aids and hearing-aid batteries y Lifeline life alert system Providence Healthcare Services Providence Care Management registered nurses offer personalized support to members with complex health issues or chronic conditions: y Diabetes y Asthma y Chronic Obstructive Pulmonary Disease (COPD) y Congestive heart failure y Coronary artery disease y Post-hospital follow-up care y Support of family and loved ones For more information, visit the Providence PHIP web page at providencehealthplan.com/phip. PHIP prescription drug benefit for Providence Health Plans Members enrolled with Providence Health Plans through PHIP are covered under the Providence Health Plans prescription drug benefit. If you are Medicare eligible, you are automatically enrolled in the Providence Part D prescription drug plan. For a general summary of benefits for this plan, refer to page 44. For more specific questions regarding the Providence Health Plans prescription drug benefit, please contact us directly at the phone number listed on the back cover of this handbook. Pharmacy network Providence Health Plans has approximately 25,000 participating pharmacies available for use nationwide. 42 Providence Health Plans

43 Preferred pharmacies Some of our network pharmacies have preferred cost-sharing, and member responsibility may be less when using these preferred cost-sharing pharmacies. Members may also be eligible to obtain a 93-day supply of medication through these pharmacies. Our network of preferred pharmacies includes but is not limited to: Albertsons/Sav-On, Bartell Drugs, Bi-Mart, Costco, Fred Meyer, Haggen, QFC, Safeway and Walgreens. Mail-order prescription drugs Mail-order prescriptions can be obtained through any mail order company that is not associated with another insurance carrier. Our preferred mail-order pharmacy options are Postal Prescription Services, Walgreens and Wellpartner. Prescriptions for Providence Health Plans members residing in long-term care facilities Patients residing in nursing homes or other long-term care facilities will pay 40 percent of the prescription charge for Part D covered drugs, up to a maximum of $150 per prescription for up to a 31-day supply. Specialty packaging costs are not covered. Specialty pharmacy Our preferred Specialty Pharmacy option is Credena Health, formerly known as Providence Specialty Pharmacy. Credena Health provides maintenance medication services that require specialized delivery and administration. Available medications range from self-injectable products that require refrigeration to oncology oral products. Credena Health s pharmacists specialize in medications for a wide variety of chronic diseases. Visit the Credena Health website online at for additional information. Providence Health Plans 43

44 PHIP Prescription Drug Benefit PHIP plans, including the prescription drug benefit, are among the most cost-effective benefit plans available to retirees. Each of the health plans available through PHIP includes a comprehensive prescription drug benefit plan. PHIP prescription drug benefit for all health plans In an effort to provide stable, comprehensive prescription benefits, PHIP established a uniform prescription drug benefit design. y No annual deductible y $4,850 out-of-pocket maximum per member, per year y 40 percent of the prescription charge, up to a maximum of $150 for each prescription filled (brand and generic)* y Access to retail and mail order pharmacies** Claims for foreign mail-order pharmacies are not covered. PHIP does not cover medications imported from foreign countries because this practice is in violation of the Federal Food, Drug and Cosmetic Act. Medications obtained from foreign sources that are represented as U.S.-approved prescription drugs may be of unknown origin and quality and may create a potential safety risk to individuals. Medicare Part D If you are Medicare-eligible, you are automatically enrolled in the PHIP Part D prescription drug plan. You cannot be enrolled in two Medicare Part D prescription drug plans at the same time. If you terminate your Medicare Part D prescription drug coverage directly through Medicare or enroll in another Part D prescription drug plan, this will dis-enroll you completely from PHIP, including your medical and optional dental coverage. Prescriptions for members residing in long-term care facilities Patients residing in nursing homes or other long-term care facilities will pay 40 percent of the prescription charge for Part D covered drugs, up to a maximum of $150 per prescription for up to a 31-day supply. Additional pharmacy information can be found within each of the health plan s feature pages. * Each health plan has their own prescription formulary, or list of covered medications. Some medications may require prior authorization. ** PHIP promotes the use of generic drugs whenever medically appropriate. When generics are used, additional cost savings may occur when ordering a 90-day supply for some Part D covered drugs. 44 PHIP Prescription Drug Benefit

45 Plan Benefits & Rate Comparisons Benefit changes, health plan service areas and plan features section 45

46 2016 Medicare Benefit Comparison Supplement Plan Moda Health Medicare Supplement Plan 1 PERS Moda Health PPORX (PPO) In-network 3 Out-of-network 4 Service area Refer to page 30 Refer to page 30 Eligible providers Any licensed Medicare provider Advantage network providers Any licensed Medicare provider MEMBER pays: MEMBER pays: Calendar year deductible $147 per individual 5 None Calendar year medical out-of-pocket maximum Inpatient Care y Inpatient hospital care y Skilled nursing facility Outpatient Care y Physician office visits y Specialist office visits y Outpatient surgery y Ambulance y Emergency services y Urgent care y DME y Lab test y X-Ray y Diagnostic procedures (CT/MRI) y Physical therapy Preventive Care y Annual wellness exam y Women s preventive y Prostate cancer screening y Immunizations Other Services y Chiropractic care 9 y Vision routine eye exam y Vision hardware None y Discounts available, contact Moda Health y$100 copay per day; $300 max per admit ycovered in full y$15 copay y$20 copay y$125 copay y$50 copay (one way) y$65 copay y$20 copay y10% 6 ycovered in full y10% y10% y$20 copay ycovered in full ycovered in full ycovered in full ycovered in full y$20 copay y$20 copay ydiscounts available, contact Moda Health $2,500 per individual y$100 copay per day; $300 max per admit ycovered in full y$15 copay y$20 copay y$125 copay y$50 copay (one way) y$65 copay y$20 copay y10% 6 ycovered in full y10% y10% y$20 copay ycovered in full ycovered in full ycovered in full ycovered in full y$20 copay y$20 copay ydiscounts available, contact Moda Health Prescription Drugs Retail and mail order y Brand and generic y Rx out-of-pocket max y40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y$4,850 out-of-pocket maximum per member per calendar year, no deductible 46 Medicare Benefit Comparison

47 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. Kaiser Permanente Medicare Advantage Plans PacificSource Medicare Essentials RX 803 Providence Medicare Align Group Providence Medicare Flex Group 2 In-network Refer to page 30 Refer to page 31 Refer to page 31 Refer to page 31 Kaiser Permanente and The Portland Clinic physicians and hospitals Plan physicians and hospitals Plan physicians and hospitals Plan physicians and hospitals MEMBER pays: MEMBER pays: MEMBER pays: MEMBER pays: Out-of-network Any licensed Medicare provider None None None None None $1,000 per individual $3,400 per individual $1,500 per individual $3,000 per individual y $200 copay per admit y $15 copay y $15 copay y $15 copay y $50 copay y $50 copay y $15 copay y 20% 6 y $125 copay per day (days 1-4 only); $500 max per admit y $10 copay y $15 copay y $125 copay y $50 copay y $50 copay y $15 copay 6 y $100 copay per day; $500 max per admit y $15 copay y $15 copay y $75 copay y $50 copay (one way) y $50 copay y $25 copay y 10% 6 y $125 copay per day; $500 max per admit y $20 copay y $20 copay 7 y $150 copay y $50 copay (one way) y $65 copay y $25 copay y 10% 6 y 10% y 10% y 20% y 20% y $30 copay y $30 copay y 20% y $50 copay (one way) y $65 copay y $25 copay y 20% 6 y 20% y 20% y 20% 1. Medicare covered services only. 2. Member must select a Primary Care Physician (PCP) from network in order to receive in-network benefits. Certain out-of-network services may require prior-authorization. If services received from out-of-network provider, excess charges may apply if the provider does not accept Medicare assignment. 3. Prior Authorization required for hospital inpatient services, skilled nursing, home health care, outpatient surgery, chiropractic, outpatient rehab, DME, prosthetic services and diagnostic procedures. 4. Out-of-network Medicare providers are paid up to the Medicare limiting charge. 5. Part B deductible, required by Medicare, listed in above comparison is the 2015 Part B deductible; 2016 Part B deductible was not available when this handbook went to print. Please refer to your 2016 Medicare & You handbook, when available, for the new Part B deductible. Deductible and coinsurance applies to all Medicare Part B approved services only. 6. Applies to Medicare approved supplies/equipment only and may require Pre-Authorization. Some diabetic supplies are covered in full. 7. If no referral is in place when seeing an in-network specialist, $30 copay applies. 8. An office visit copayment may apply if non-preventive issues and services are managed during a scheduled preventive visit. 9. Medicare covered chiropractic services only. 10. Must use VSP Choice Network providers in order to receive benefits. y $15 copay y $15 copay y $15 copay y $20 copay y $30 copay y $15 copay y $15 copay y $100 credit every 2 years for lenses, frames and/or contacts y 40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y $4,850 out-of-pocket maximum per member per calendar year, no deductible y $15 copay y $15 copay y $100 credit every 24 months for lenses, frames and/or contacts y 40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y $4,850 out-of-pocket maximum per member per calendar year, no deductible y $15 copay y $15 copay 10 y $100 credit every 2 years for lenses, frames and/or contacts 10 y $20 copay y $20 copay 10 y $100 credit every 2 years for lenses, frames and/or contacts 10 y $30 copay y $20 copay or up to a $45 allowance y $100 credit every 2 years for lenses, frames and/or contacts y 40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y $4,850 out-of-pocket maximum per member per calendar year, no deductible Medicare Benefit Comparison 47

48 2016 Medicare Rates Medical & prescription drug monthly premium rate comparison Retirement Health Insurance Account (RHIA) Contribution Premium Rates (applies to all health plans) The monthly premiums shown below are AFTER the $60 Retirement Health Insurance Account contribution. More information on the Retirement Health Insurance Account (RHIA) contribution and eligibility can be found on page 15 of this handbook. Retiree with Medicare Retiree with Medicare, family with Medicare Retiree with Medicare, family without Medicare (Core Value) Retiree with Medicare, family without Medicare (Select Value) Moda Health Medicare Supplement Plan PERS Moda Health PPORX (PPO) Kaiser Permanente Senior Advantage PacificSource Medicare Essentials RX 803 Providence Medicare Align Group Providence Medicare Flex Group $ $ $ $ $ $ $ $ $ $ $ $ $1, $1, $1, $1, $1, $1, $1, $1, $ $1, $ $ Non-Contribution Premium Rates (applies to all health plans) The monthly premiums shown below are WITHOUT contribution from RHIA. More information on RHIA contributions and eligibility can be found on page 15 of this handbook Core Value non-medicare Rates Medical & prescription drug monthly premium rate comparison Non-Contribution Premium Rates (applies to all health plans) The monthly premiums shown below are WITHOUT contributions from the Retiree Health Insurance Premium Account (RHIPA). More information on RHIPA contributions and eligibility can be found on pages Moda Health PPO Plans Kaiser Permanente PacificSource Choice POS Providence Health Plans Retiree without Medicare $1, $ $ $ Retiree without Medicare, family* without Medicare Retiree without Medicare, family* with Medicare Retiree without Medicare, family* with Medicare (Moda Health Medicare Supplement Plan) Retiree without Medicare, family* with Medicare (PERS Moda Health PPORX (PPO) Retiree without Medicare, family* with Medicare (PHP Medicare Align) Retiree without Medicare, family* with Medicare (PHP Medicare Flex) $1, $1, $1, $1, N/A $1, $1, N/A $1, N/A N/A N/A $1, N/A N/A N/A N/A N/A N/A $1, N/A N/A N/A $1, Retiree with Medicare Retiree with Medicare, family with Medicare Retiree with Medicare, family without Medicare (Core Value) Retiree with Medicare, family without Medicare (Select Value) Moda Health Medicare Supplement Plan PERS Moda Health PPORX (PPO) Kaiser Permanente Senior Advantage PacificSource Medicare Essentials RX 803 Providence Medicare Align Group Providence Medicare Flex Group $ $ $ $ $ $ $ $ $ $ $ $ $1, $1, $1, $1, $1, $1, $1, $1, $ $1, $1, $1, 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. 48 Medicare Rates & Core Value non-medicare Rates

49 2016 Select Value non-medicare Rates Medical & prescription drug monthly premium rate comparison Non-Contribution Premium Rates (applies to all health plans) The monthly premiums shown below are WITHOUT contributions from the Retiree Health Insurance Premium Account (RHIPA). More information on RHIPA contributions and eligibility can be found on pages Moda Health PPO Plans Kaiser Permanente PacificSource Choice POS Providence Health Plans Retiree without Medicare $ $ $ $ Retiree without Medicare, family* without Medicare Retiree without Medicare, family* with Medicare Retiree without Medicare, family* with Medicare (Moda Health Medicare Supplement Plan) Retiree without Medicare, family* with Medicare (PERS Moda Health PPORX (PPO) Retiree without Medicare, family* with Medicare (PHP Medicare Align) Retiree without Medicare, family* with Medicare (PHP Medicare Flex) $1, $1, $1, $1, N/A $ $1, N/A $1, N/A N/A N/A $1, N/A N/A N/A N/A N/A N/A $ N/A N/A N/A $ 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. Select Value non-medicare Rates 49

50 2016 Core Value non-medicare Benefit Comparison In-plan Moda Health Out-of-plan Kaiser Permanente Service area Refer to page 30 Refer to page 30 Eligible providers Preferred physicians and providers MEMBER pays: Any licensed physician or facility Kaiser Permanente and The Portland Clinic physicians and hospitals MEMBER pays: Calendar year deductible $500 per individual None Calendar year medical out-of-pocket maximum $2,000 + deductible per individual $6,000 + deductible per individual $2,000 per individual; $4,000 per family Inpatient Care y Inpatient hospital care y Skilled nursing facility Outpatient Care y Physician office visits y Specialist office visits y Outpatient surgery y Ambulance y Emergency services y Urgent care y DME y Lab test y X-Ray y Diagnostic procedures (CT/MRI) y Physical therapy Preventive Care y Preventive physical exam 5 y Women s preventive y Prostate cancer screening y Immunizations Other Services y Alternative care y Vision routine eye exam y Vision hardware Prescription Drugs Retail and mail order y Brand and generic y Rx out-of-pocket max y20% after deductible y20% after deductible y$20 copay, no deductible y$20 copay, no deductible y20% after deductible y20% after deductible y$200 copay, then 20% y$20 copay, no deductible y20% after deductible y20% after deductible y20% after deductible y20% after deductible y20% after deductible 4 ycovered in full ycovered in full y$20 copay, no deductible ycovered in full y$25 copay, no deductible 7 ydiscounts available, contact Moda Health y40% after deductible y40% after deductible y40% after deductible y40% after deductible y40% after deductible y20% after deductible y$200 copay, then 20% y40% after deductible y40% after deductible y40% after deductible y40% after deductible y40% after deductible y40% after deductible 4 y40% after deductible y40% after deductible y40% after deductible y40% after deductible y40% after deductible 7 ydiscounts available, contact Moda Health y40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y$4,850 out-of-pocket maximum per member per calendar year, no deductible y $200 copay per day; $1,000 max per admit y $30 copay y $40 copay y $200 copay y $100 copay y $200 copay y $30 copay y 20% y $30 copay per visit y $30 copay per visit y 20% y $40 copay 2 y $25 copay 7 y $30 copay y Not covered y 40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y $4,850 out-of-pocket maximum per member per calendar year, no deductible 1. Member must select a Primary Care Physician (PCP). 2. Benefit is limited to 20 visits per calendar year. 3. Urgent/Immediate Care ancillary charges billed separately will be subject to the applicable cost share. The deductible will apply to diagnostics (lab, x-rays, etc) received during the visit. 4. Limited to 30 visits per calendar year; this 30-visit limitation encompasses all therapy modalities combined. 5. Preventive services 50 Core Value non-medicare Benefit Comparison

51 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. PacificSource Health Plans 1 Providence Health Plans In-plan Out-of-plan In-plan Out-of-plan Refer to page 31 Refer to page 31 Plan physicians and hospitals Any licensed physician or facility Plan physicians and hospitals Any licensed physician or facility $500 per individual; $1,500 per family $2,000 + deductible per individual; $6,000 + deductible per family MEMBER pays: $1,000 per individual; $3,000 per family $6,000 + deductible per individual; $18,000 + deductible per family MEMBER pays: $500 per individual; $1,500 per family (3 or more) $2,000 + deductible per individual; $6,000 + deductible per family (3 or more) $6,000 + deductible per individual; $18,000 + deductible per family (3 or more) y 20% after deductible y 40% after deductible y 20% after deductible y 40% after deductible y 20% after deductible y 40% after deductible y 20% after deductible y 40% after deductible y $20 copay, no deductible y $20 copay, no deductible y 20% after deductible y 20%, no deductible y $200 copay, then 20% y $20 copay, no deductible y 20% after deductible y 20% after deductible y 20% after deductible y 20% after deductible y 40% after deductible y 40% after deductible y 40% after deductible y 20%, no deductible y $200 copay, then 20% y 40%, no deductible y 40% after deductible y 40% after deductible y 40% after deductible y 40% after deductible y $20 copay, no deductible y $20 copay, no deductible y 20% after deductible y 20% after deductible y $200 copay, then 20% y $20 copay, no deductible 3 y 20% after deductible y 20% after deductible y 20% after deductible y 20% after deductible y 40%, no deductible y 40%, no deductible y 40% after deductible y 20% after deductible y $200 copay, then 20% y 40%, no deductible 3 y 40% after deductible y 40% after deductible y 40% after deductible y 40% after deductible y $20 copay, no deductible 4 y 40% after deductible 4 y 20% after deductible 4 y 40% after deductible 4 y 40%, no deductible y 40% after deductible y 40% after deductible y 40%, no deductible y $20 copay, no deductible 6 y 40% after deductible y 40% after deductible y 40% after deductible y 40%, no deductible y $25 copay, no deductible 7 y Not covered y Not covered y 40% after deductible 7 y Not covered y Not covered y $25 copay 7 y Discounts available, contact Providence Health Plans y Not covered y Discounts available, contact Providence Health Plans y 40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y $4,850 out-of-pocket maximum per member per calendar year, no deductible y 40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y $4,850 out-of-pocket maximum per member per calendar year, no deductible will be covered in accordance with ACA guidelines. This applies to Kaiser and in-network services under Moda Health, PacificSource, and Providence. 6. Prostate cancer screening lab work is subject to the lab benefit. 7. Chiropractic/spinal manipulation and acupuncture office visits are limited to 12 combined visits per calendar year. Coverage for naturopaths is included, no visit limitations. No massage therapy coverage. Core Value non-medicare Benefit Comparison 51

52 2016 Select Value non-medicare Benefit Comparison In-plan Moda Health Out-of-plan Kaiser Permanente Service area Refer to page 30 Refer to page 30 Eligible providers Calendar year deductible Calendar year medical out-of-pocket maximum InpatientCare y Inpatient hospital care y Skilled nursing facility Outpatient Care y Physician office visits y Specialist office visits y Outpatient surgery y Ambulance y Emergency services y Urgent care y DME y Lab test y X-Ray y Diagnostic procedures (CT/MRI) y Physical therapy Preventive Care y Preventive physical exam 5 y Women s preventive y Prostate cancer screening y Immunizations Other Services y Alternative care y Vision routine eye exam y Vision hardware Prescription Drugs Retail and mail order y Brand and generic y Rx out-of-pocket max Preferred physicians and providers $3,000 + deductible per individual y30% after deductible y30% after deductible MEMBER pays: $1,000 per individual y$25 copay, no deductible y$35 copay, no deductible y30% after deductible y30% after deductible y$200 copay, then 20% y$25 copay, no deductible y30% after deductible y30% after deductible y30% after deductible y30% after deductible y$25 copay, no deductible 4 ycovered in full ycovered in full y$25 copay, no deductible ycovered in full y$25 copay, no deductible 7 ydiscounts available, contact Moda Health Any licensed physician or facility $9,000 + deductible per individual y50% after deductible y50% after deductible y50% after deductible y50% after deductible y50% after deductible y30% after deductible y$200 copay, then 20% y50% after deductible y50% after deductible y50% after deductible y50% after deductible y50% after deductible y50% after deductible 4 y50% after deductible y50% after deductible y50% after deductible y50% after deductible y50% after deductible 7 ydiscounts available, contact Moda Health y40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y$4,850 out-of-pocket maximum per member per calendar year, no deductible Kaiser Permanente and The Portland Clinic physicians and hospitals MEMBER pays: $1,000 per individual; $3,000 per family $3,000 + deductible per individual; $9,000 + deductible per family y 30% after deductible y 30% after deductible y $25 copay, no deductible y $35 copay, no deductible y 30% after deductible y 30% after deductible y 30% after deductible y $25 copay, no deductible y 30% after deductible y 30% after deductible y 30% after deductible y 30% after deductible y $35 copay after deductible 2 y $25 copay, no deductible y $25 copay, no deductible y Not covered y 40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y $4,850 out-of-pocket maximum per member per calendar year, no deductible 1. Member must select a Primary Care Physician (PCP). 2. Benefit is limited to 20 visits per calendar year. 3. Urgent/Immediate Care ancillary charges billed separately will be subject to the applicable cost share. The deductible will apply to diagnostics (lab, x-rays, etc) received during the visit. 4. Limited to 30 visits per calendar year; this 30-visit limitation encompasses all therapy modalities combined. 5. Preventive services 52 Select Value non-medicare Benefit Comparison

53 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. PacificSource Health Plans 1 Providence Health Plans In-plan Out-of-plan In-plan Out-of-plan Refer to page 31 Refer to page 31 Plan physicians and hospitals Any licensed physician or facility Plan physicians and hospitals Any licensed physician or facility MEMBER pays: MEMBER pays: $1,000 per individual; $3,000 per family $1,000 per individual; $3,000 per family (3 or more) $3,000 + deductible per individual; $9,000 + deductible per family $9,000 + deductible per individual; no family maximum $3,000 + deductible per individual; $9,000 + deductible per family $9,000 + deductible per individual; no family maximum y 30% after deductible y 30% after deductible y 50% after deductible y 50% after deductible y 30% after deductible y 30% after deductible y 50% after deductible y 50% after deductible y $25 copay, no deductible y $35 copay, no deductible y 30% after deductible y 30%, no deductible y $200 copay, then 20% y $25 copay, no deductible y 30% after deductible y 30% after deductible y 30% after deductible y 30% after deductible y 50% after deductible y 50% after deductible y 50% after deductible y 30%, no deductible y $200 copay, then 20% y 50%, no deductible y 50% after deductible y 50% after deductible y 50% after deductible y 50% after deductible y $25 copay, no deductible y $35 copay, no deductible y 30% after deductible y 30% after deductible y $200 copay, then 20% y $25 copay, no deductible y 30% after deductible 3 y 30% after deductible y 30% after deductible y 30% after deductible y 50%, no deductible y 50%, no deductible y 50% after deductible y 30% after deductible y $200 copay, then 20% y 50%, no deductible 3 y 50% after deductible y 50% after deductible y 50% after deductible y 50% after deductible y $25 copay, no deductible 4 y 50% after deductible 4 y $25 copay, no deductible y 50% after deductible 4 y 50%, no deductible y 50% after deductible y 50% after deductible y 50%, no deductible y $25 copay, no deductible 6 y 50% after deductible y 50% after deductible y 50% after deductible y 50%, no deductible y $25 copay, no deductible 7 y Not covered y Not covered y 50% after deductible 7 y Not covered y Not covered y $25 copay, no deductible 7 y Discounts available, contact Providence Health Plans y Not covered y Discounts available, contact Providence Health Plans y 40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y $4,850 out-of-pocket maximum per member per calendar year, no deductible y 40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y $4,850 out-of-pocket maximum per member per calendar year, no deductible will be covered in accordance with ACA guidelines. This applies to Kaiser and in-network services under Moda Health, PacificSource, and Providence. 6. Prostate cancer screening lab work is subject to the lab benefit. 7. Chiropractic/spinal manipulation and acupuncture limited to 12 combined visits per calendar year. Coverage for naturopaths is included, no visit limitation. No massage therapy coverage. Select Value non-medicare Benefit Comparison 53

54 2016 Dental Benefit Comparison 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 service area. Please refer to pages for information regarding the Kaiser service plan area (Kaiser s medical and dental plan service areas are the same). Medical plan enrollment Providers Delta Dental of Oregon 1 PacificSource, Kaiser Permanente, Moda Health, Providence Health Plans Any licensed dentist, hygienist and certified denturist working within the scope of their license Kaiser Permanente Kaiser Permanente, Moda Health, Providence Health Plans Kaiser Permanente Dental Associates Calendar year deductible $25 per individual None Calendar year benefit maximum (plan pays) Preventive Care y Exams y Cleanings y Diagnostic Basic Services y Restorative y Oral surgery (extractions) y Endodontic/periodontic Major Services y Crowns y Cast restorations y Dentures/bridge work y Implants $1,500 per individual 2 $1,500 per individual 2 MEMBER pays: Available twice in a calendar year ycovered in full 2 ycovered in full 2 ycovered in full 2,3 y20% after deductible 4 y20% after deductible 4 y20% after deductible 4 y50% after deductible 4 y50% after deductible 4 y50% after deductible 4 y50% after deductible 4 MEMBER pays: Limit of two cleanings per year y $10 copay per visit 2 y $10 copay per visit 2 y $10 copay per visit 2 y $10 copay, then 20% y $10 copay, then 20% y $10 copay, then 20% y $10 copay, then 50% y $10 copay, then 50% y $10 copay, then 50% y Not covered Orthodontic services Not covered Not covered Out-of-area coverage Exclusions and limitations Rates y Retiree only y Retiree and family Worldwide for emergency services only Some services are limited or not covered at all, including congenital or developmental malformations, cosmetic services and experimental procedures. Also, there may be limitations for procedures for which you might receive payment from other insurance or government programs. y$65.76 y$ Kaiser Permanente allows a benefit of up to $100 of reimbursement on an approved out-of-area emergency claim Certain services are limited or not covered at all. Some exclusions include congenital or developmental malformations, dental implants, cosmetic services and experimental procedures. Also, there may be limitations for procedures for which you might receive payment from other insurance or government programs. y $63.33 y $ Dental Benefit Comparison

55 1. A higher level of benefits are paid to providers who participate in the Delta Dental Premier Network. As the Delta Dental Plan of Oregon, members who live or travel outside Oregon have access to more than 151,000 dental professionals nationwide through the Delta Dental Network. Services provided by licensed dentist and certified denturists not participating with Delta Dental are paid at the out-of-network fee. 2. Charges for preventive services do not apply to the calendar year benefit maximum. 3. Some limitations may apply month waiting period for basic and major services following enrollment unless member has had continuous employer-sponsored dental coverage for the previous 12 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. 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. Dental Benefit Comparison 55

56 Required Notices Women s Health and Cancer Rights Act Beginning in 1999, federal law requires group health plans to provide coverage for the following services to an individual receiving plan benefits in connection with a mastectomy: y Reconstruction on the breast on which the mastectomy has been performed; y Surgery and reconstruction of the other breast to produce a symmetrical appearance; and y Prostheses and coverage for physical complications for all stages of a mastectomy, including lymphedemas (swelling associated with the removal of lymph nodes). The health plan must determine the manner of coverage in consultation with the attending physician and patient. Coverage for breast reconstruction and related services will be subject to deductibles, coinsurance amounts and copayments that are consistent with those that apply to other benefits under the plan. Power of Attorney/Authorization to Disclose Information PHIP requires that a Power of Attorney or Authorization to Disclose Information be on file with the program office for anyone acting on a member s behalf. PHIP is unable to release information to anyone who is not authorized by the PHIP member. To disclose or change information after the death of a member, please provide one of the following: executor, letter of probate or trustee documentation, or Last Will and Testament. COBRA continuation of coverage In accordance with federal and state of Oregon guidelines, PHIP provides opportunities for the continuation of coverage through COBRA following specific qualifying events. If you experience one of the qualifying events listed below, please contact PHIP for additional information. A qualifying event will occur if eligibility for coverage is lost because of: y Cancellation of PERS retirement status y The divorce or legal separation of a retiree s covered spouse; PHIP must be notified within 60 days from the signed Dissolution of Marriage document y A spouse or dependent no longer meeting eligibility requirements (e.g., a child reaches the maximum age limit, or a spouse loses coverage because the retiree does not enroll in PHIP upon the last enrollment opportunity) Once COBRA has been secured, timely payment of premiums is essential. In accordance with federal and state of Oregon guidelines, PHIP provides opportunities for the continuation of coverage through COBRA following specific qualifying events. Timely COBRA premium payments The initial premium must be paid within 45 days of the date COBRA is elected. Thereafter, premiums are due the first day of each month for that month s coverage. If payment is not postmarked or received on or before the 45th day (for the initial premium) or the 30th day following the monthly due date, coverage will be terminated and cannot be reinstated. 56 Required Notices

57 Required Notices 57

58 Definitions Care management Sometimes also called case management or disease state management, these services help ensure the best possible care and coordination of care for people who have either chronic or catastrophic conditions. Coinsurance Other than the deductible, coinsurance, which is usually expressed as a percentage, is the portion of cost that the member will pay for healthcare services. Community plans Commercial Medicare plans offered to the general public. Copay/copayment A fixed amount that the member pays at the time of service. Generally the copayment is the only cost the member will have for a particular service. Cost share Amount that the member pays for coverage. Deductible Generally applied on a calendar-year basis, the deductible is the amount of money each year that members pay out of their own pocket before the benefit plan begins to pay. Usually expressed as a per-person amount. Durable medical equipment (DME) Medicare-approved, medically necessary durable medical equipment is reusable medical equipment such as walkers, wheelchairs, hospital beds, etc. Employer-sponsored group health plan A plan sponsored by an employer, or by an employer in partnership with a union, that provides medical and/or dental care to two or more employees. Grandfathered prescriptions If you were prescribed and are currently taking a specific medication under the Moda Prescription Drug plan on December 31, 2015, you may continue that medication without interruption or prior authorization, unless required by law or if there is change to the script dosage or frequency. Health Maintenance Organization (HMO) Covers only care rendered by those doctors and other professionals who have agreed to treat patients in accordance with the HMO s guidelines and restrictions. Most HMOs require members to select a primary care physician (PCP). Late enrollment penalty An amount added to your Medicare Part D monthly premium if you go without Part D or creditable prescription drug coverage for any continuous period of 63 days or more after your Initial Enrollment Period is over. Limiting charge See Medicare limiting charge. Low income subsidy Assistance from Medicare to pay the costs of Medicare prescription drug coverage if you meet certain income and resource limits. Maintenance drug A drug that is appropriate for chronic use as prescribed and is supported by evidence that it is safe and effective when used for a chronic condition. For example, certain drugs for high blood pressure or diabetes are considered maintenance drugs. 58 Definitions

59 Maximum allowable cost Limits the amount a carrier will pay for a specific service. This designation is generally used in the absence of participating or preferred contracts. In the case of most carriers, a national data clearinghouse is used. The clearinghouse collects fee data by ZIP code and procedure and then publishes the information. Fees are usually updated every six months. Maximum out-of-pocket This is the maximum amount of money that a member is responsible for paying in any one calendar year, when a member uses only PPO or participating providers (depending on the contract). Medicare-approved amount In the original Medicare Supplement plan, this is the Medicare payment amount for an item or service. This is the amount a doctor or supplier is paid by Medicare, your supplement plan and/or you for a service or supply. It may be less than the actual amount charged by the doctor or supplier. Medicare assignment A method of payment under Medicare Part B. The doctor agrees to accept the amount of the Medicare-approved charge as full payment. Medicare limiting charge Doctors and providers who do not accept Medicare assignment may charge you more than the Medicare-approved amount. The limit on the amount over the Medicare-approved amount these providers can charge is 15 percent. The limiting charge applies only to certain services and doesn t apply to supplies and equipment. In addition, you may have to pay the entire charge at the time of service. Medicare participating provider A provider who accepts Medicare patients; this provider may or may not accept Medicare assignment. Medigap Medicare Supplement insurance that conforms to one of the 10 Medicare-approved plans. Medsupp Medicare Supplement insurance. Modified adjusted gross income The figure used to determine eligibility for lower costs in Medicare and prescription drug coverage. Generally, modified adjusted gross income is your adjusted gross income plus any tax-exempt Social Security, interest, or foreign income you have. Nonpar Nonparticipating provider. Participating provider Providers that are contracted to provide services for specific fees. The fees may or may not be discounted, but the providers are bound to not charge the member for anything above the contracted fee even if they would generally charge someone with other coverage more. This is often referred to as hold harmless because the member is not required to pay for charges over the contracted fee. Point-of-service (POS) plan A type of benefit design that requires members to choose a primary care physician to receive in-network benefits. This type of plan also offers lower benefits (or the same benefits, depending on the contract) to members who receive benefits out-of-network. Definitions 59

60 Preferred Provider Organization (PPO) provider Preferred Provider Organization (PPO) providers sign contracts with insurance companies and cannot charge members more than the contracted fee. These providers agree to discount their charges. PPO plan A type of benefit design that includes different levels of benefits depending on whether or not services are received from a preferred provider. Prior Authorization Prior Authorization is a request to determine and approve if a service or supply is medically necessary and/or covered under the Plan. Not all services and supplies require Prior Authorization. Prior Authorization is not guarantee coverage. If a Prior Authorization is not obtained within a specific timeframe, a penalty may be applied. 60 Definitions

61 Acronyms and Abbreviations ACA Affordable Care Act CMS Centers for Medicare and Medicaid Services COB Coordination of benefits COBRA Consolidated Omnibus Budget Reconciliation Act (federal act) DME Durable medical equipment EFT Electronic funds transfer EOB Explanation of benefits ESRD End-Stage Renal Disease FFS Fee for service HIPAA Health Insurance Portability and Accountability Act (federal act and state law) HMO Health Maintenance Organization IRMAA Income Related Monthly Adjustment Amount LEP Late Enrollment Penalty LIS Low income subsidy MA Medicare Advantage MAGI Modified Adjusted Gross Income OOA Out-of-area OOP Out-of-pocket PA Prior Authorization PCP Primary care physician (provider) PDL Preferred drug list PDP Prescription drug plan PHI Protected health information PHIP PERS Health Insurance Program POS Point-of-Service PPO Preferred provider organization Rx Prescription drug SNF Skilled nursing facility Acronyms and Abbreviations 61

62 PHIP Enrollment Request Form

63 PHIP Enrollment Request Form The PHIP Enrollment Request Form must be submitted when you are initially enrolling, adding a dependent or making a change to your PHIP coverage either at plan change or due to a family status change. If you are changing your PHIP coverage, a PHIP Disenrollment Form must also be submitted in order to cancel the original plan(s). In order to enroll in PHIP or make a change to your account you must submit a new PHIP Enrollment Request Form within an enrollment opportunity as described in your Member Handbook and Benefit Guide. The effective date of coverage will be the first of the month, if received in advance of the enrollment opportunity, or the first of the month after receipt of a completed PHIP Enrollment Request Form. If your Enrollment Request Form is missing information or additional documentation, your application will be considered incomplete. You will have 30 days to provide the requested information and/or documentation. If you are unable to provide the necessary information and/or documentation prior to your requested effective date, your effective date will change to the first of the next month. In order to avoid a gap in coverage or forfeiting your enrollment opportunity, please submit all requested information/documentation with the completed Enrollment Request Form 30 prior to your requested effective date. Upon receiving an Enrollment Request Form, PHIP will confirm all individuals for eligibility into the program. Please retain a copy for your records and mail any attachments along with the original Enrollment Request Form to: PERS Health Insurance Program PO Box 40187, Portland, Oregon The Portland-area FAX is or toll-free In the Portland-area, call or toll-free TTY users call 711. PHIP Enrollment Request Form 63

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65 Checklist Please complete pages 2 8 of the Enrollment Request Form. Page 9 is optional. Section A Did you include your requested enrollment date? This is the date you want your PHIP coverage to start. During peak enrollment times (i.e., plan change, peak retirement periods, end of month), delays may occur. Please allow time for PHIP to process your application and notify your health plan. In the event you need immediate access to your health plan information, please contact PHIP. A Did you complete all retiree information? A Did you list only family members that you want enrolled? (Please include dependents already enrolled.) A birth certificate or adoption notice for all dependents under 26 is required. An Affidavit of Dependent Domestic Partnership is required for all dependent domestic partners (DDP). A marriage certificate is required if the spouse has a different last name from the retiree. A Did you complete the Reason for this Enrollment in PHIP? If the reason is Group Coverage Ending, proof of 24 months of employer-sponsored coverage is required. A Did you request and complete a termination form if you are changing a plan? These forms are available at pershealth.com. B Did you complete the Medicare Information? You must complete for each enrolling member with Medicare and provide a copy of the Medicare cards or letter of Entitlement for processing to be complete. C Did you check the box to choose your medical plan? Please note: Once enrolled in a Select Value plan, you may not change to a Core Value plan, even during plan change. D Do you wish to enroll in dental coverage? D If you enrolled in a dental plan, did you answer the continuous employer-sponsored dental coverage question for each enrollee? If you answered Yes, did you include the name of the prior dental plan? E Did you complete the Payment Options section? If you chose pension deduct, the pension holder s signature is required. If you chose EFT, did you attach a voided check? F Did you answer the important questions on page 5? You must answer for each enrolling member. F Did you answer the coordination of benefits/other insurance coverage questions number 4 and 5? G Did you read the Release Of Information on page 6? H Did you read the Lock-In and the important statements on page 6? I Did you read the I Agree To The Following section on page 7? J Did you and your spouse (if enrolling) sign and date the Enrollment Request Form? Did you check to see if your Requested Enrollment Date is after your signature date? Your signature date must be before the requested effective date, but not earlier than 90 days prior. K Did you wish to complete the Authorization To Disclose Protected Health Information form on page 9? (Optional) PHIP Enrollment Request Form 1/9

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67 OFFICE USE ONLY PERS Approved Effective date: Member ID#: Effective Date of Coverage: ICEP/IEP: AEP: SEP (type): PBP: Tran. Code: Not eligible: Plan #: Premiums: Group#: Section A Information about you Your Requested Enrollment Date: PERS Retiree Last name First MI Social Security No. Date of birth Gender M F Medicare eligible Yes No Individuals enrolling Retiree only Retiree & family Spouse only Surviving spouse Dependent DDP Spouse/DDP Last name First MI Social Security No. Date of birth Gender M F Medicare eligible Yes No Dependent Child Last name First MI Social Security No. Date of birth Gender M F Medicare eligible Yes No Spouse is currently enrolled in PHIP If other dependents, please attach a separate sheet Spouse/DDP is a PERS retiree I am a Tier 1 or Tier 2 EWEB Retiree Reasons for this Enrollment Plan change only: New PERS Retiree New dependent Other: Medical & Dental Plan Change Medicare Eligible Moving out of area Snowbird Option Medical Only Plan Change Group Coverage Ending Dental Only Plan Change Date: Insurance Company Name: Rx Health ID#: Phone number: Permanent resident address (not a P.O. Box) City State ZIP County address Home phone number Alternate phone number Mailing address (if different) City State ZIP PHIP Enrollment Request Form 2/9

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69 Section B Medicare information Please fill in the blanks to match your Medicare card and attach a copy of your Medicare Card or a letter of Entitlement from the Social Security Administration or Railroad Retirement Board (RRB). YOU MUST HAVE Medicare Part A and Part B to enroll in a PHIP Medicare Plan. Retiree Spouse/Dependent SAMPLE ONLY SAMPLE ONLY Section C Choose your medical plan Medicare and non-medicare family members must enroll under the same Health Insurance Plan. Kaiser Permanente Moda Health PacificSource Providence Health Plans Medicare plans Includes Medicare Part D Prescription Program Kaiser Permanente Senior Advantage (HMO)* with Kaiser Rx** PERS Moda Health PPORX (PPO)* with PERS Moda Health Rx (PDP)** Moda Health Medicare Supplement Plan with PERS Moda Health Rx (PDP)** PacificSource Medicare Essentials RX 803* with PERS PacificSource Rx (PDP)** Providence Medicare Align Group Plan (HMO)* with PERS Providence Rx (PDP)** Providence Medicare Flex Group Plan (HMO-POS)* with PERS Providence Rx (PDP)** Non-Medicare plans Once enrolled in a Select Value plan ($1,000 deductible), you may not change to a Core Value plan at a later date. All plans include prescription coverage. Kaiser Permanente Core Value Kaiser Permanente Select Value ($1,000) Moda Health Core Value ($500) Moda Health Select Value ($1,000) PacificSource Core Value ($500) PacificSource Select Value ($1,000) Providence Core Value ($500) Providence Select Value ($1,000) *A Health Plan with a Medicare contract **A Medicare approved Part D sponsor Please contact your Health Insurance Plan if you need information in a language other than English or in another format. PHIP Enrollment Request Form 3/9

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71 Section D Choose your dental plan Select only one plan. Kaiser Permanente Dental Delta Dental of Oregon I do not want dental coverage. Have you and/or dependents had continuous employer-sponsored dental coverage for the last 12-months? Retiree: Yes No Spouse/DDP: Yes No Dependents: Yes No Name of previous dental plan: ID#: Phone number: Section E Payment options (Select only one payment option) Payment selection will remain in effect until PHIP has received written notification to update. Option 1: Pension deduction Health insurance premium is automatically deducted from the PERS retiree s monthly pension check. If the retiree s monthly pension check is not sufficient to cover the entire monthly premium, you may not select this option. By selecting this option and signing this application, I hereby authorize PHIP to deduct my monthly premium for medical and/or dental insurance from my monthly PERS pension check. I also understand that it may take up to 90 days for the premiums to begin deducting and that I will be invoiced until the deduction begins in order for my health insurance to be kept current. Pension holder s signature X SSN Signature date Option 2: Electronic Funds Transfer (EFT) Please attach a voided check Health insurance premium is electronically deducted from your bank checking or savings account at the beginning of each month. I also understand that it may take up to 90 days for the premiums to begin deducting from my financial institution and that I will be invoiced until the EFT begins in order for my health insurance to be kept current. Bank name Routing No. Account No. 9-digit routing no. Account no. PHIP Enrollment Request Form 4/9

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73 Section F Please read and answer these important questions Medicare only 1. Are you enrolled in your State Medicaid program? Retiree: Yes No Spouse/DDP: Yes No Dependent: Yes No If YES, please provide your Medicaid number: 2. Do you have End Stage Renal Disease (ESRD)? Retiree: Yes No Spouse/DDP: Yes No Dependent: Yes No If you have had a successful kidney transplant and/or you don t need regular dialysis anymore, please attach a note or records from your doctor showing you have had a successful kidney transplant or you don t need dialysis, otherwise we may contact you to obtain additional information. Medicare and non-medicare 3. Are you a resident of a long term care facility, such as a nursing home? Retiree: Yes No Spouse/DDP: Yes No Dependent: Yes No If YES, name of the facility: Phone number: Address: City: State: ZIP: Date of admission: / / 4. Are you/spouse/ddp actively working for an employer with 20 or more employees who provides employee group health insurance coverage for you? Yes No Retirement date: If NO, is the PERS-eligible member retired? Yes No Last PERS Employer: 5. Will you (or your enrolling spouse/ddp/dependent) have other health or prescription drug coverage in addition to your PHIP medical coverage including any Medicare Supplemental coverage? Prescription drug plan? Yes No Medical plan? Yes No If YES, please list your other coverage and your identification (ID) number(s) for this coverage: Retiree Name of other coverage: Spouse/DDP/Dependent Name of other coverage: ID# for this coverage: ID# for this coverage: Optional Retiree Primary Care Provider (First and last name): Established patient? Yes No Spouse/DDP/Dependent Primary Care Provider (First and last name): Established patient? Yes No PHIP Enrollment Request Form 5/9

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75 Section G Release of information By joining this Medicare or the non-medicare health plan, I acknowledge that the Medicare or Non-Medicare health plan will release my information to Medicare or other plans as is necessary for treatment, payment and health care operations. Section H Lock-in I understand that beginning on the date my Kaiser Permanente Senior Advantage, Kaiser Permanente non-medicare, PacificSource Medicare Essentials Rx 803 Plan or Providence Medicare Align (HMO) plan begins, all enrolled members will receive all of their health care from, or have authorized their plan s contracted providers, with the exception of emergency or urgently needed services or out-of-area dialysis services. (Refer to your health plan to determine coverage for emergency and urgently needed services, out of area dialysis services, and travel benefits.) I understand that the PERS Moda Health PPORX (PPO), Moda Health Medicare Supplement, Moda Health non-medicare Core Value/Select Value PPO plans, PacificSource Choice Core Value/Select Value non-medicare plans, Providence Medicare Flex Group Plan+Rx (HMO-POS) or the Providence non-medicare Core Value/Select Value plans allows me to see any provider of my choice. (Excess charges may apply when using Medicare providers outside of the network.) PHIP Enrollment Request Form 6/9

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77 Section I I agree to the following By completing this enrollment application, I agree to the following: Medicare only 1. I will keep my Medicare Part A and Part B coverage. 2. I can only be in one Medicare Advantage and/or one Part D prescription drug plan at a time. I understand that my enrollment in the PHIP plan will automatically end my enrollment in another Medicare Advantage or another Part D prescription drug plan. 3. It is my responsibility to inform PHIP of any other health or prescription drug coverage that I have or may get in the future. 4. I will read the Evidence of Coverage or member handbook for my plan when I receive it to know the rules I must follow in order to receive coverage. I understand that Medicare beneficiaries are generally not covered under Medicare while out of the country except for limited coverage near the U.S. border (Exception - the PHIP plans offer Emergency and Urgent Care worldwide). Medicare and non-medicare 1. Enrollment in this plan is generally for the entire calendar year. 2. I may disenroll from this plan only at certain times of the year, or under certain circumstances, by sending a written request to PHIP. 3. If I move out of my plan s service area, I will notify PHIP within 30 days, so I can disenroll and find a new plan in my new service area. 4. I have the right to appeal my plan decisions about benefit payment or services. 5. I understand that if I currently have health insurance coverage from another employer or union plan, joining a PHIP plan could affect my current employer or union health benefits. Contact your current group benefit administrator for questions about how your current coverage might be affected. 6. If you are assessed a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA), you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium in order to maintain PHIP coverage. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or RRB. DO NOT pay PHIP the Part D-IRMAA. 7. I understand premium rates are subject to change, at any time as required by Medicare due to Medicare imposed penalties or assessments, such as Medicare Part D Late Enrollment Penalty or Low Income Subsidy (Extra Help) notifications. 8. I understand it is my responsibility to review the Member Handbook and Benefit Guide and understand my obligation as a PHIP participant. PHIP Enrollment Request Form 7/9

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79 Section J Sign here Signature Required By All Enrollees (Retiree and/or Spouse) I understand that my signature (or the signature of the person authorized to act on behalf of the enrollee under the laws of the state where the enrollee resides) on this enrollment form certifies that I have read and understand the contents of this form. Previously enrolled medical and/or dental plans with PHIP will be terminated in accordance with any medical and/or dental plan changes associated with this enrollment form upon the PHIP approved effective date. Medicare members agree to keep their Medicare Part A and Part B coverage current and to inform PHIP of any other health or prescription drug coverage that they have or may get in the future. Medicare members agree that they can only be enrolled in one Medicare Advantage or Medicare prescription drug plan at a time. I also acknowledge that PHIP will release my eligibility and health-care information, including my prescription drug event data to Medicare or other plans, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. Retiree signature X Spouse/DDP signature X Date Date If signed by an authorized individual (as described above) this signature certifies that: 1. This person is a parent or guardian for dependent child(ren); 2. This person is authorized under state law to complete this enrollment; and 3. Documentation of this authority is available upon request by the Health Insurance Plan, PHIP or Medicare. Please complete the following information and attach proof of Legal Guardian, Durable Power of Attorney for Health Care (DPAHC), or proof of authorization by state law. Forms completed by (name) Relationship to Enrollee Signature X Address Phone no. Date PHIP Enrollment Request Form 8/9

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81 Section K Authorization to disclose protected health information (optional) Purpose: This Authorization allows the PERS Health Insurance Program (PHIP) and/or your health plan to discuss your retirement date and years of PERS pension service, health plan enrollment, date of enrollment, disenrollment with your health plan, billing and premium information with the individual identified below. Each person enrolled who wants to share this information must complete a separate Authorization. Additional Authorization forms may be found on the PHIP website ( All fields must be completed for this Authorization to be valid. I authorize: Representatives of the PERS Health Insurance Program and health plan: Moda Health Plans PacificSource Health Plans Kaiser Permanente Providence Health Plans PHI form will be included in your new member packet provided by Providence. to obtain and disclose my Protected Health Information to: Name: Relationship: Address: Phone #: For: The information disclosed may include any of the following elements: Verification of retirement date and years of PERS pension service, health plan enrolled in, date of enrollment/dis-enrollment with health plan, Billing and Premium information. Information obtained or disclosed with this Authorization for the purpose defined above will be limited to the minimum information to achieve the purpose. I have the right to revoke this Authorization in writing at any time. If I revoke this Authorization, the information described above will no longer be disclosed for the reasons covered by this written Authorization except to the extent action has been taken with reliance on this Authorization. Any uses or disclosures already made with my permission cannot be taken back. I understand that information used or disclosed pursuant to this Authorization may be subject to redisclosure and no longer protected under federal law. This Authorization shall be in force and in effect until the following date: Not to exceed 24-months from the signature date. If the date field is left blank, the Authorization will expire 24-months from the signature date. I have reviewed and understand this Authorization: PHIP Member name SSN Signature X OR PHIP Member s Representative name Date Address Phone # Signature X Date Relationship to member: Parent Legal Guardian Hold Power of Attorney* *Please attach legal documentation if you are the legal guardian or Holder of Power of Attorney. To revoke this Authorization, please send a written statement to: Attention PHIP, PO box 40187, Portland, Oregon PHIP Enrollment Request Form 9/9

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84 Contact Information PERS Health Insurance Program (PHIP) In Portland: Toll-free: Fax: or Mailing address: P.O. Box 40187, Portland, OR PERS Pension Office Pension questions only In Portland: Toll-free: Mailing address: P.O. Box 23700, Tigard, OR Moda Health Medical questions: (Medicare supplement and non-medicare PPO) In Portland: Toll-free: PERS Moda Health PPORX (PPO) (Medicare): In Portland: Toll-free: TTY: 711 Delta Dental of Oregon questions: In Portland: Toll-free: Moda Health Pharmacy Program: In Portland: Toll-free: Medicare Centers for Medicare and Medicaid Services Toll-free: 800-Medicare ( ) Social Security Administration Toll-free: Other websites noted within banners/rules.htm Kaiser Permanente my.kp.org/pers In Portland: Toll-free: TTY: Medicare members: Mail-order pharmacy: In Portland: Toll-free: Pacificsource Health Plans Non-Medicare plans: pacificsource.com/pers In Oregon: Toll-free: Medicare plans: medicare.pacificsource.com/or/ Member/2015/MA/Essentials803.aspx In Oregon: Toll-free: TTY: PacificSource Pharmacy Program: Medicare members: Toll-free: Non-Medicare members: Toll-free: Medicare and non-medicare TTY: Providence Health Plans Prospective members: In Portland: Toll-free: Enrolled Medicare members: In Portland: Toll-free: Enrolled non-medicare members: In Portland: Toll-free: TTY: 711 Providence Pharmacy Program In-Portland: Toll-free: (8/15)