Open Enrollment Checklist

Transcription

1 Open 2006 Enrollment For Non-Medicare Eligible Retirees and COBRA Members October 10 to October 27 Open Enrollment Checklist This is your annual opportunity to elect a new health plan. All Open Enrollment changes are effective January 1, Here is a checklist to help you decide if a plan change is right for you: Inside 2 Open Enrollment Choices 3 Chiropractic Care 4 Consumer Driven Health Plan 8 Health Plans Across the State Health Plan Options at a Glance 14 How Do I Select a New Plan Option? 14 Preventive Benefits New Pediatric Immunizations 15 Open Enrollment Health Fairs 16 Health Plans Take a look at the plans available in your county of residence Compare the health plan options see pages 11 and 12 for summary comparisons Take a look at what the Consumer Driven Health Plan has to offer Comprehensive Major Medical Option Members: Consider another option to reduce out-of-pocket costs Considering chiropractic care: See page 3 for the benefit under all options Please consider your options carefully. You may want to elect a different medical plan for If you would like to change medical plans at this time, complete the enclosed 2006 PEBTF Open Enrollment Form for REHP Members and mail it in the enclosed postage-paid envelope to the State Employees Retirement System (SERS). SERS must receive your completed form by Friday, October 27. If you do not have the postage paid envelope, mail your completed enrollment form to: Enrollment Retiree Health Benefits, State Employees Retirement System, 30 North Third Street, Suite 150, Harrisburg, PA Your coverage under your new plan will become effective January 1, See How Do I Select a New Plan Option on page 14 for enrollment information. You will find valuable information about your choices in this newsletter. You may also log on to the PEBTF web site at for additional Open Enrollment information. Please take the time to review your options. Attend an Open Enrollment Health Fair or contact the PEBTF with any questions you may have.

2 Open Enrollment Choices (depending on date of retirement) Retirement Date Prior to 7/1/04: Basic Option - Blue Cross coverage (hospital/surgicalmedical) - PEBTF Major Medical $100 PPO Option (also available to out-of-state residents) - $15 copayment for PCP and Specialist office visits - $25 ER copayment (waived if admitted) - Out of Network: $250 annual Deductible ($500 per family); plan pays 80% of next $5,000; 100% excess of $5,000 HMO Option (requires residency in plan coverage area) - $15 copayment for PCP and Specialist office visits - $25 ER copayment (waived if admitted) - Medical Reimbursement Plan Retirement Date On or After 7/1/04: Same Benefits as Active Employees PPO Option (also available to out-of-state residents) - $15 copayment for PCP office visits and outpatient therapy visits - $25 copayment Specialist office visits - $50 ER copayment (waived if admitted) - Out of Network: $400 annual Deductible; plan pays 70% of next $5,000; 100% excess of $5,000 HMO Option (requires residency in plan coverage area) - $15 copayment for PCP office visits and outpatient therapy visits - $25 copayment for Specialist office visits - $50 ER copayment (waived if admitted) Consumer Driven Health Plan - There are two parts to the Consumer Driven Health Plan: 1) Health Reimbursement Account (HRA) funded by the REHP and 2) Medical benefit plan same benefits as a PPO - HRA is account used to pay for medical expenses you normally would pay for out of your pocket - Annual is $1,500 (single)/ $3,000 (family) but the REHP credits your Health Reimbursement Account (HRA) with $1,000 (single)/$2,000 (family) maximum out-ofpocket expense is $500 (single)/$1,000 (family) 2

3 Chiropractic Benefit Under all Health Plan Options For members considering chiropractic care (spinal manipulations), the following highlights the benefit under all plan options. PPO OPTION HMO OPTION BASIC CDHP OPTION COMP. MAJOR MED. Six medically-necessary visits per year, then a treatment plan must be submitted for additional visits $15 copayment for network chiropractic care Non-network care subject to annual, then reimbursed at 80% (retired prior to 7/1/04)/70% (retired on or after 7/1/04) of allowed charge; you may be balance billed For network chiropractic: Members within the Capital Blue Cross 21-county area, refer to the Capital Blue Cross Provider Directory Members outside of the 21-county area, contact ASH Networks at or visit their website at Under the HMO, all outpatient therapies have a combined maximum of 60 visits per year therapies subject to the maximum including chiropractic/spinal manipulation, as well as physical, occupational, speech due to a medical diagnosis and not developmental), cardiac rehabilitation, pulmonary rehabilitation and respiratory Each HMO has its own review procedures, but it is important to remember the spinal manipulation benefit does not cover visits or treatment for the maintenance of a condition. Some of the HMOs may only allow two weeks of treatment for an acute condition Benefits are payable only if you use an HMO-network chiropractor; some plans may require a referral from your PCP Fifteen medically-necessary visits per year, then a treatment plan must be submitted for additional visits If you visit a non-participating chiropractor, you will be balance billed for costs above the plan allowance To find a participating chiropractor: Contact ASH Networks at or visit their website at Six medically-necessary visits per year, then a treatment plan must be submitted for additional visits Twenty medically-necessary visits per year, a treatment plan is required after the initial 15 visits Visits are subject to your annual and coinsurance and you may be balance billed if you visit a non-ash Networks chiropractor To find a participating chiropractor: Contact ASH Networks at or visit their website at ASH Network of Chiropractors Members enrolled in the PPO or Basic Option can choose from a large network of chiropractors. The ASH Network includes 1,374 chiropractors in Pennsylvania and 429 chiropractors in the states surrounding Pennsylvania. Since January 2006, ASH Networks has added 259 Pennsylvania chiropractors and 121 chiropractors in the states surrounding Pennsylvania. PPO & Basic Option Members To find an ASH Networks chiropractor in your county: Call Or Log on to - Choose Providers at the top of the home page - Then, click on Find a Provider on the left - You may search by zip code, state/city, clinic name or provider name Remember, within the 21-county Capital Blue Cross area, the ASH Networks chiropractors are part of the Capital Blue Cross Network. To nominate a chiropractor for the ASH Networks: Call PEBTF Open Enrollment: October 10 - October 27,

4 Consumer Driven Health Plan Continues for 2007 For Non-Medicare Eligible Members who Retired on or After 7/1/04 The UnitedHealthcare Consumer Driven Health Plan (CDHP) continues for 2007 the second year that the REHP is offering this new type of plan. The CDHP: Combines the flexibility of a medical benefit plan with an REHPfunded account. The CDHP product name is UnitedHealthcare s Definity Health Reimbursement Account. The plan is designed to encourage you to seek and obtain the most appropriate and cost-effective health care. It combines a medical benefit plan that provides coverage for medical services like office visits, tests, hospitalization, etc., and protects you against excessive medical costs while the funds in the Health Reimbursement Account help pay your. The medical benefit works like the PPO with both an in-network and out-of-network benefit. The CDHP covers, generally speaking, the medical services and supplies as outlined in the REHP Plan of Benefits. Consumer Driven Health Plan (CDHP) Examine closely before selecting this option. Attend a CDHP Seminar if one is held in your area Protects you from high medical costs Plan pays at 100% in network and 70% for out-of-network services Out-of-pocket maximums are in place - Single in-network = $1,500; Single out-of-network = $4,500 HRA reduces amount by = $1,000 - Family in-network = $3,000 Family out-of-network = $9,000 HRA reduces amount by = $2,000 Your money Defined limits Reduced in future years by HRA rollover Total Deductible = HRA + Member Responsiblity Health Coverage 100% Member Responsibility $500 Single $1,000 Family Health Reimbursement Account (HRA) $1,000 Single $2,000 Family Preventive Care 100% UnitedHealthcare Resources & Tools Available via phone Cost/Quality comparisons Preventive care covered at 100% ($500 single/$1,000 family per year) Provided 100% by REHP Pays a portion of your, including nonpreventative services. Rollover to next year 4

5 What are Some Advantages to the Consumer Driven Health Plan? You make the decisions about your health care UnitedHealthcare supports you with education, personalized information and cutting-edge Internet-based tools While it is a high- plan, you have the Health Reimbursement Account to help meet most of your annual Preventive benefits are covered up to $500 for an individual and $1,000 for a family each year, and are not subject to the or deducted from the HRA Unused HRA funds may roll over from one year to the next big advantage for the member Health Reimbursement Account funds can be used to pay for qualified medical expenses and IRS Section Consumer Driven Health Plan Benefit Design Benefit Annual Deductible Single Annual Deductible Family HRA Single (PEBTF Contribution) * HRA Family (PEBTF Contribution) * Out-of-Pocket Maximum Single Out-of-Pocket Maximum Family Physician Office Visits Preventive Care Including wellwoman and well-child care Not subject to Annual Deductible Emergency Room Services Inpatient & Outpatient Hospital Services Home Health Care Chiropractic (6 medically-necessary visits, then treatment plan submitted; not for maintenance of a condition) Lifetime Maximum In-Network Out-of-Network $1,500 $1,500 $3,000 $3,000 $1,000 $2,000 $1,500 ($1,000 $4,500 HRA reduces this to $500 member share) $3,000 ($2,000 $9,000 HRA reduces this to $1,000 family share) 100% after 70% after 100% ($500 Not Covered single/$1,000/family annual maximum) 100% after 70% after 100% after 70% after 100% after 70% after 100% after 70% after Unlimited $1,000, d expenses (see page 13 for a list) The plan works together with UnitedHealthcare s extensive network and discount programs There is no copayment at the time of an office visit with a network physician the doctor s office will submit a claim to UnitedHealthcare first and UnitedHealthcare will automatically apply the network discount to each claim *Your HRA can be used to reimburse you for s and other out-of-pocket medical costs. In addition to any 2006 carry-overs, the 2007 HRA credit is $1,000 single/$2,000 family) PEBTF Open Enrollment: October 10 - October 27,

6 Example 1 Single Coverage Annual Deductible: $1,500 HRA Funds (paid by the REHP): $1,000 Member s Potential Deductible Responsibility: $ 500 Preventive Care Benefit (not subject to annual ): $ 500 In-Network Benefit: 100% after 6 How Does the CDHP Work? The following are two illustrations to help you better understand how the CDHP works: Jim, is a single person who enrolled in the UnitedHealthcare CDHP effective January 1, He had a good year, but he did have a bout with the flu in early February. Let s see how the CDHP worked for Jim: Plan Year 2006 Service Cost Paid Paid by Out-of- Remaining Deductible from Benefit Pocket HRA to be HRA Plan Expenses Balances Satisfied Preventive care visit* $100 N/A $100 None $1,000 $1,500 In-network office visit flu $60 $60 $0 None $940 $1,440 In-network follow up office visit flu $60 $60 $0 None $880 $1,380 Year Total $220 $120 $100 None $880 N/A * The preventive care services at network providers are at no charge to the member up to $500 each year. In 2006, Jim only had two office visits that totaled $120. These office visits were paid by the HRA funds and Jim had no out-of-pocket expenses. Plus, he has $880 remaining in his HRA which will roll over to 2007 and be added to the HRA funds of $1,000 for the new plan year for a total of $1,880. Now, let s look at the coming year. Jim decided to have surgery for an old football injury. He has $1,880 in his HRA to begin the year. Plan Year 2007 Service Cost Paid Paid by Out-of- Remaining Deductible from Benefit Pocket HRA to be HRA Plan Expenses Balances Satisfied Knee surgery $9,000 $1,500 $7,500 $0 $380* $0 (Network facility & network doctor) In-network office visit Bronchitis $60 $0 $60 $0 $380 $0 Year Total $9,060 $1,500 $7,560 $0 $380 $0 * Jim s out-of-pocket expenses for the year were $0 because he had $1,880 in his HRA and the annual is $1,500. Jim has $380 in his HRA at the end of the year to be carried-over to For More Information about the CDHP Attend a CDHP seminar at the Open Enrollment Health Fairs. See page 15 for a schedule of meetings. All CDHP members, age 18 and older have a personal, private website that provides a variety of helpful tools: View your current account balances Find cost and quality information Research a variety of health information The CDHP website: After you enroll in the CDHP and you receive your ID card, you will be able to register at Just click the Register Now button and follow the instructions. Pre-Member Website: For PEBTF members considering the UnitedHealthcare CDHP, you may visit the Pre-Member website at You can search for a provider from the Pre-Member web site and get some additional information about the plan.

7 The Smith Family enrolled in the UnitedHealthcare CDHP effective January 1, Mr. & Mrs. Smith have two children, Lilly and Frasier. The family is healthy except for the occasional colds and flu. Let s take a look at how the CDHP worked for the Smiths: Plan Year 2006 Service Cost Paid Paid by Out-of- Remaining Deductible from Benefit Pocket HRA to be HRA Plan Expenses Balances Satisfied Preventive care visit Mr. Smith* $100 N/A $100 None $2,000 $3,000 Preventive care visit Mrs. Smith* $250 N/A $250 None $2,000 $3,000 (annual OB-Gyn visit, Pap Smear & Mammogram) Lilly s well-child visit & immunization* $120 N/A $120 None $2,000 $3,000 Frasier s well-child visit & immunization* $120 N/A $120 None $2,000 $3,000 Four in-network office visits for colds & flu $240 $240 $0 None $1,760 $2,760 Year Total $830 $240 $590 None $1,760 N/A * The preventive services at in-network providers are at no charge to the family up to $1,000 each year. The Smith s had a good year. They took advantage of the preventive care benefit which is at no cost to them. The family only had $240 in office expenses for colds and flu. These office visits were paid by the HRA funds and the Smiths had no out-of-pocket expenses. Plus, they have $1,760 remaining in their HRA which will roll over to 2007 and be added to the HRA funds of $2,000 for the new plan year for a total of $3,760. Now, let s look at the coming year. Plan Year 2007 Service Cost Paid Paid by Out-of- Remaining Deductible from Benefit Pocket HRA to be HRA Plan Expenses Balances Satisfied Preventive care visit Mr. Smith* $100 N/A $100 None $3,760 $3,000 Preventive care visit Mrs. Smith* $250 N/A $250 None $3,760 $3,000 (annual OB-Gyn visit, Pap Smear & Mammogram) Lilly s well-child visit & immunization* $120 N/A $120 None $3,760 $3,000 Frasier s well-child visit & immunization* $120 N/A $120 None $3,760 $3,000 Eight in-network office visits $480 $480 $0 None $3,280 $2,520 for minor illnesses One in-network orthopedic dr. office $250 $250 $0 None $3,030 $2,270 visit for Frasier sprained ankle Lasik Eye Surgery $5,000 $3,030 $0 $1,970 $0 $2,270 In-network doctor s office visit for $60 $0 $0 $60 $0 $2,210 Frasier s poison ivy Year Total $6,380 $3,760 $590 $2,030 $3,030 N/A Example 2 Family Coverage Annual Deductible: $3,000 HRA Funds (paid by the REHP): $2,000 Member s Potential Deductible Responsibility: $1,000 Preventive Care Benefit (not subject to annual ): $1,000 In-Network Benefit: 100% after * The preventive services at in-network providers are at no charge to the family up to $1,000 each year. HRA funds were used for the Lasik Eye Surgery, which is not covered by the medical plan. However, amounts in your HRA can be used to reimburse you for IRS-allowed medical expenses even if otherwise excluded under your plan. Fees for services that are not covered under your medical plan (IRS allowed expenses) do not count toward the medical plan. See page 13 for a complete list of IRS allowed expenses. For 2008, the Smiths will have no HRA funds to roll over because the funds were used to pay Lasik Eye Surgery. The family will begin year 2008 with the new HRA contribution of $2,000. Continued on page 10 PEBTF Open Enrollment: October 10 - October 27,

8 Region 1 Western Pennsylvania Allegheny, Armstrong, Beaver, Butler, Fayette, Greene, Washington and Westmoreland Counties Health Plans Offered UnitedHealthcare Consumer Driven Health Plan HealthAmerica HMO Keystone Health Plan West HMO UPMC HMO Health Plans A Region 4 Central Pen Blair, Centre, Clearfield, Northumberland, Snyder Health Plans Offered UnitedHealthcare Consum Geisinger HMO Keystone Health Plan Cen Blair and Clearfield Coun Region 2 Northwestern Pennsylvania Cameron, Clarion, Crawford, Elk, Erie, Forest, Jefferson, Lawrence, McKean, Mercer, Venango and Warren Counties Region 2 R Health Plans Offered UnitedHealthcare Consumer Driven Health Plan HealthAmerica HMO Keystone Health Plan West HMO Region 3 Laurel Highlands Bedford, Cambria, Indiana and Somerset Counties Health Plans Offered UnitedHealthcare Consumer Driven Health Plan Keystone Health Plan West HMO UPMC HMO Region 4 Region 1 Region Reg 3 Region 5 Southcentra Adams, Cumberland, Dau Lancaster, Lebanon, Perr Health Plans Offered UnitedHealthcare Consum HealthAmerica HMO (No Keystone Health Plan Ce Refer to the individual plans listed below to see if the plan is offered in your county of residence. Offered in all Pennsylvania counties Consumer Driven Health Plan UnitedHealthcare Consumer Driven Health Plan offered in all Pennsylvania counties 8 HMO Plans Aetna HMO Berks Bucks Carbon Chester Delaware Lehigh Montgomery Northampton Philadelphia Schuylkill Blue Care HMO (formerly First Priority Health HMO) Bradford Clinton Lackawanna Luzerne Lycoming Monroe Pike Sullivan Susquehanna Tioga Wayne Wyoming Geisinger Health Plan HMO Berks Blair Bradford Carbon Centre Clearfield Clinton Columbia Lackawanna Lehigh Luzerne Lycoming Mifflin Monroe Montour Northampton Northumberland Pike Potter Schuylkill Snyder Sullivan Susquehanna Tioga Union Wayne Wyoming HealthAmerica HMO Adams Allegheny Armstrong Beaver Butler Cameron Clarion Crawford Cumberland Dauphin Elk Erie Fayette Forest Franklin Greene Huntingdon Jefferson Juniata Lancaster Lawrence Lebanon McKean Mercer Perry Venango Warren Washington Westmoreland York

9 cross the State nsylvania Columbia, Mifflin, Montour, and Union Counties er Driven Health Plan tral HMO (Not available in ties) egion 6 Region 7 ion 5 Region 8 l Pennsylvania phin, Franklin, Fulton, Huntingdon, Juniata, y and York Counties er Driven Health Plan t available in Fulton County) ntral HMO (Not available in Huntingdon County) Keystone Health Plan Central HMO Adams Berks Centre Columbia Cumberland Dauphin Franklin Fulton Juniata Lancaster Lebanon Lehigh Mifflin Montour Northampton Northumberland Perry Schuylkill Snyder Union York Keystone Health Plan East HMO Bucks Chester Delaware Montgomery Philadelphia Keystone Health Plan West HMO Allegheny Armstrong Beaver Bedford Butler Cambria Cameron Clarion Crawford Elk Erie Fayette Forest Region 6 Northeastern Pennsylvania Bradford, Clinton, Lackawanna, Luzerne, Lycoming, Monroe, Pike, Potter, Sullivan, Susquehanna, Tioga, Wayne and Wyoming Counties Health Plans Offered UnitedHealthcare Consumer Driven Health Plan BlueCare HMO (formerly First Priority Health HMO) Geisinger HMO Region 7 Eastern Pennsylvania Berks, Carbon, Lehigh, Northampton and Schuylkill Counties Health Plans Offered UnitedHealthcare Consumer Driven Health Plan Aetna HMO Geisinger HMO Keystone Health Plan Central HMO (Not available in Carbon County) Region 8 Southeastern Pennsylvania Bucks, Chester, Delaware, Montgomery and Philadelphia Counties Health Plans Offered UnitedHealthcare Consumer Driven Health Plan Aetna HMO Keystone Health Plan East HMO Greene Indiana Jefferson Lawrence McKean Mercer Somerset Venango Warren Washington Westmoreland UPMC Health Plan HMO Allegheny Armstrong Beaver Bedford Butler Cambria Fayette Greene Indiana Somerset Washington Westmoreland To be eligible for a plan you must reside in the county in which the plan is offered. Options for Out-of-State Members Basic Option Basic Option is available to those who retired before 7/1/04 in all states Available in all out-of-state areas. an option to out-of-state members who retired prior to 7/1/04. Members who retired after 7/1/04 and who reside in counties bordering Pennsylvania must elect this plan or enroll in one of the HMOs that are offered. Keystone East HMO Available in certain New Jersey Counties (contact the PEBTF for specific counties) Keystone Health Plan West HMO Available in certain Ohio counties (Contact the PEBTF for specific information) Aetna HMO Available in certain Delaware, Maryland & New Jersey Counties (Contact the PEBTF for specific counties) BlueCare HMO New York residents who live within 20 miles/20 minutes of Pennsylvania may join BlueCare HMO but must use Pennsylvania network providers HealthAmerica HMO Available in certain Ohio and West Virginia Counties (contact the PEBTF for specific counties) Contact SERS or the PEBTF for more information on outof-state areas. PEBTF Open Enrollment: October 10 - October 27,

10 Continued from page 7 Advantages of the UnitedHealthcare Consumer Driven Health Plan Preventive care services are covered at 100 percent in network up to $500 a year ($1,000 for family) Amounts credited to your Health Reimbursement Account (HRA) that are not used can be rolled over to the next year and used for additional medical expenses at a later date Money remaining in your HRA can be used for expenses such as s, copayments and charges for health-related services even if not otherwise covered under your REHP Plan of Benefits see list of IRS-allowed medical expenses on page 13 Your HRA is your money to spend on qualified medical expenses as long as you remain in the plan You become a better health care consumer Disadvantages of the UnitedHealthcare Consumer Driven Health Plan After applying the initial amount deposited in your HRA, you may have out-of-pocket costs of $500 (individual) or $1,000 (family) per year You could have greater out-of-pocket expenses than you would have under a PPO or HMO, unless and until you can accumulate amounts in your HRA to pay those expenses It may not be the best option for members with high medical expenses, because high expenses prevent you from accumulating amounts in your HRA The UnitedHealthcare network may lack providers in some areas of Pennsylvania Innovative phone-based and online tools offered by UnitedHealthcare How Does the CDHP Work When I Visit my Doctor s Office? In order to get the most out of the CDHP and avoid unnecessary costs, you should visit doctors and other health care professionals who participate in the UnitedHealthcare network. 1. Make sure your doctor is in UnitedHealthcare s network. CDHP Members may check the online directory at or call United s Customer Care at the number found on the back of their medical ID card. If you are not yet enrolled in the CDHP, you may visit the pre-member website at If you visit network providers, you ll receive care at United s negotiated rates. 2. Show your UnitedHealthcare medical ID card when you arrive at your doctor s office. 3. The doctor s office should submit a claim to UnitedHealthcare first. UnitedHealthcare will automatically apply the network discount to each claim. The office visit cost will be deleted from your HRA. If you exhaust the HRA, you will be responsible for the office visit and your doctor will send you a bill. If you visit a non-network doctor, you may have to submit your claim directly to United- Healthcare. Remember that you will not get the advantage of the UnitedHealthcare discount for these services. 4. You will receive a Monthly Health Statement from UnitedHealthcare that reflects services rendered under the health plan and activity on your Definity HRA Account. You may also view the statements online at myuhc.com 10

11 Health Plan Options at a Glance Members Who Retired before 7/1/04 HMO PPO Basic Copayments $15 PCP $15 PCP Member pays for all office $15 Specialist $15 Specialist visits and then submits a $25 ER (waived $25 ER (waived claim to PEBTF Major if admitted) if admitted) Medical for payment consideration Network Network benefit In Network & You can seek care from only Non-Network any provider benefit (participating providers will accept plan allowance). If you visit a nonparticipating provider, you will be balance billed Specialist Some HMOs No No Referral require PCP Needed referral Deductible Out-of- Pocket Maximum $250 per person $1,000 per person ($2,000 per family), plus the Non- Network No non-network N/A Benefits: benefits Out-of- Network 80%; Member Plan pays 20% Payment Preventive Network benefit Network & Adult annual physical Benefits* only with copay Non-Network not covered Wellness Programs Vary by plan Vary by plan N/A Disease Yes Yes Yes Management Program *See the Summer 2006 Retiree Review for covered preventive benefits. Note: Payment percentages above refer to a percentage of expenses not in excess of Usual, Customary and Reasonable (UCR) charges as determined by the medical plan. Amounts in excess of UCR charges are the member s sole responsibility. PEBTF Open Enrollment: October 10 - October 27,

12 Health Plan Options at a Glance Members Who Retired on or After 7/1/04 HMO PPO Consumer Driven CMM Health Plan (no new enrollment) Copayments $15 PCP $15 PCP REHP credits Member pays 100% of $25 Specialist $25 Specialist $1,000 (single), all medical expenses up $50 ER (waived $50 ER (waived $2,000 (family) to the $500 ; if admitted) if admitted) in your Health Plan then pays 80% of Reimbursement Account Member pays 100% of all medical expenses up to applicable but can use Health Reimbursement Account to reimburse the. Deductible is $1,500 (single)/$3,000 (family), thereafter the plan pays at 100% for in-network services; 70% for non-network services the next $15,000 eligible expenses Your maximum out-ofpocket could be $3,000 + $500 or $9,000 per family + $1,500 Network Network benefit Network & Network & You can seek care from only Non-Network Non-Network any provider benefit benefit (participating providers will accept plan allowance). If you visit a nonparticipating provider, you will be balance billed Specialist Some HMOs No No No Referral require PCP Needed referral No non-network benefits Deductible $400 per person Out-of- Pocket Maximum $1,500 per person ($3,000 per family), plus the $4,500 per person ($9,000 per family), plus the (see Copayments above) if you visit nonnetwork providers Non- Network Benefits: Out-of- Network 70%; Member 70%; Member Plan pays 30% pays 30% Payment Preventive Network benefit Network & Covered up to Not Covered Benefits* only with copay Non-Network $500 (single coverage) and $1,000 (family coverage) per year you do not have to use funds from your Health Reimbursement Account Wellness Programs Vary by plan Vary by plan Yes N/A Disease Yes Yes Yes Yes Management Program * See the Summer 2006 Retiree Review for covered preventive benefits Note: Payment percentages above refer to a percentage of expenses not in excess of Usual, Customary and Reasonable (UCR) charges as determined by the medical plan. Amounts in excess of UCR charges are the member s sole responsibility. 12

13 Your HRA Can be Used to Reimburse Non-Covered Medical Expenses An added benefit of the CDHP is that your HRA dollars can also be used for medical expenses not covered under the health plan. The IRS allows the expenses listed below to be reimbursed from your HRA. But, it is recommended that you wait until you build up funds in your HRA before you use it to pay for the following expenses. Fees for services that are not covered under the medical plan (IRS allowed services) do not count toward the medical plan, even if those fees are reimbursed from the funds in the HRA. For example, you may use your HRA funds to help pay for Lasik eye surgery. You would be responsible for any costs above the amount you have in your HRA. The medical plan would not pay for any of these IRS allowed expenses. And, because you exhausted your HRA funds, you would have to pay for any medical services such as doctor visits incurred after you exhausted your HRA funds. The following expenses may be reimbursed from your HRA: Alcoholics Anonymous, transportation costs to and from meetings Acupuncture Amounts over usual and customary Amounts in excess of any health coverage plan limits Braille books and magazines, the difference in cost compared to a regular printed edition Christian Science practitioners Contact lenses Eyeglasses Optometrists/ophthalmologists (does not include Laser Eye services) Contact lens solution Contraception (oral contraceptives and contraceptive services such as IUDs, Norplant, Depo-Provera injections) Dental treatment (does not include dental treatment which is for cosmetic purposes, i.e. teeth whitening) Dentures Diaper service needed to relieve the effects of a certain disease Difference between brand and generic prescription drugs (not variable) Experimental/investigational treatments (services that do not meet the plan s experimental definition in the health coverage) Full body scans Guide dog or other animal used by a visually or hearing-impaired person Hearing aids and hearing aid batteries Heart scan (EBCT) Home construction needed for the installation of special, medically necessary equipment Premiums for individual medical insurance plans Infertility treatments Laser eye surgery Lead-based paint removal to prevent a child from contracting lead poisoning Legal fees needed to authorize treatment for mental illness Lodging and meals while receiving medical care up to $50 per night Massage therapy, when determined to be medically necessary by a physician Medical information plans Modification of a car for use by a disabled dependent Nursing home expenses for medical reasons Prescription drugs not covered under the health coverage Smoking cessation programs and prescription drugs Special home for a mentally disabled dependent Special schools and education for mentally impaired or physically disabled person Special telephones or televisions for hearing impaired individuals Reversal of sterilization Transportation needed to obtain medical care; this may include bus or taxi fare, cost of gas, tolls, parking, etc. Tuition fees for dependents with learning disabilities, when recommended by a physician Admission and transportation to a medical conference which concerns the chronic illness of a member Tutoring fees for members with learning disabilities, when recommended by a physician Vision therapy Weight loss program when recommended by a physician to treat an existing disease, such as heart disease PEBTF Open Enrollment: October 10 - October 27,

14 How Do I Select a New Option? The 2006 Open Enrollment is your annual opportunity to change to another health plan option. Follow these easy steps to make a change: 1. Review the health plans offered in your county of residence. You can find a list of health plans beginning on page 8 of this newsletter. You may also log on to the PEBTF web site for more information about Open Enrollment. If you are considering an HMO, PPO, or CDHP, contact the health plans offered in your county of residence to request a provider directory. The plan telephone numbers appear on page 16 of this newsletter. Or you can log onto the health plan s web site to find a provider. COBRA Members: Please review the enclosed rate information to help in making a decision. 2. Plan on attending an Open Enrollment Health Fair if one is held in your area. Representatives from UnitedHealthcare will be there to present additional information about the Consumer Driven Health Plan. Members who retired on or after 7/1/04 may elect this option. 3. If you would like to change medical plans at this time, complete the enclosed 2006 PEBTF Open Enrollment Form for REHP Members and mail it in the enclosed postage-paid envelope to the State Employees Retirement System (SERS). You must complete the enclosed Open Enrollment form in its entirety and include all information about your dependents that have REHP coverage. SERS must receive your completed form by Friday, October 27. If you do not have the postage paid envelope, mail your completed enrollment form to: Enrollment Retiree Health Benefits, State Employees Retirement System, 30 North Third Street, Suite 150, Harrisburg, PA, COBRA Members: Complete the enclosed COBRA Member Enrollment Form and submit (postmark) the form to the PEBTF by Friday, October 27. Preventive Benefits New Pediatric Immunizations Added The following pediatric immunizations (under age 21) are covered by the REHP effective September 1, 2006: Hepatitis A Pneumococcal (PCV) Meningococcal (MCV4) Routine physical exams Up to age 18 The following chart includes childhood preventive benefits covered under the REHP s Plan of Benefits. Service Recommended Ages Newborn, 2 4 weeks, 1 month, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 24 months 3 years, 4 years, 5 years, 6 years, 8 years, 10 years years annually REHP Coverage See schedule as outlined under Recommended Ages Immunizations (covered up to age 21) Polio (IVP) Diphtheria-Tetanus-Pertussis (DTaP) Tetanus/Diphtheria (Td) Measles/Mumps/Rubella (MMR) Hemophilus influenza type b (Hib) Chickenpox (Varicella) Hepatitis B Hepatitis A (effective 9/1/06) Pneumococcal (PCV) (effective 9/1/06) Meningococcal (MCV4) (effective 9/1/06) Recommended Ages Contact your child s pediatrician for recommended ages when immunizations are given. REHP Coverage Covered 14

15 Open Enrollment Health Fairs Open Enrollment Health Fairs offer you an opportunity to talk with the health plans offered in your area. Seminars on the UnitedHealthcare Consumer Driven Health Plan (CDHP) will be conducted at each location. The CDHP seminars will last an hour and the times are listed below. PEBTF representatives are also available to assist you with any benefit questions. Tuesday, October 10 AFSCME Conference Center 150 S 43rd Street Harrisburg Health Fair 9 a.m. 3 p.m. CDHP Seminars Begin at 9 a.m. Health Plans in Attendance: UnitedHealthcare CDHP HealthAmerica HMO Keystone Health Plan Central HMO United Behavioral Health (UBH) Medco Tuesday, October 10 Pittsburgh Hilton 600 Commonwealth Place Pittsburgh Health Fair 9 a.m. 3 p.m. CDHP Seminars Begin at 9 a.m. Health Plans in Attendance: UnitedHealthcare CDHP HealthAmerica HMO Keystone Health Plan West HMO UPMC HMO United Behavioral Health (UBH) Medco Wednesday, October 11 Hiram G. Andrews Center 727 Goucher Street Johnstown Health Fair 9 a.m. 3 p.m. CDHP Seminars Begin at 9 a.m. Health Plans in Attendance: UnitedHealthcare CDHP Keystone Health Plan West HMO UPMC HMO Monday, October 16 Strawberry Square Walnut Street Harrisburg Health Fair 9 a.m. 3 p.m. CDHP Seminars Begin at 9 a.m. Harrisburg Hilton & Towers One North Second Street Harrisburg Health Plans in Attendance UnitedHealthcare CDHP HealthAmerica HMO Keystone Health Plan Central HMO United Behavioral Health (UBH) Medco Tuesday, October 17 Holiday Inn, Wilkes-Barre 880 Kidder Street Wilkes-Barre (across from the Wyoming Valley Mall) Health Fair 9 a.m. 3 p.m. CDHP Seminars Begin at 9 a.m. Health Plans in Attendance: UnitedHealthcare CDHP BlueCare HMO (formerly First Priority Health HMO) Geisinger HMO Tuesday, October 17 Four Points Sheraton Allentown Jetport Hotel 3400 Airport Road Allentown Health Fair 9 a.m. 3 p.m. CDHP Seminars Begin at 9 a.m. Health Plans in Attendance UnitedHealthcare CDHP Aetna HMO Geisinger HMO Keystone Health Plan Central HMO United Behavioral Health (UBH) Monday, October 23 Sheraton Philadelphia City Center Hotel 17th & Race Streets Philadelphia Health Fair 9 a.m. 3 p.m. CDHP Seminars Begin at 9 a.m. Health Plans in Attendance: UnitedHealthcare CDHP Aetna HMO Keystone Health Plan East United Behavioral Health (UBH) Medco Tuesday, October 24 Norristown State Hospital Building #33, Auditorium 1001 Sterigere Street Norristown Health Fair 9 a.m. 3 p.m. CDHP Seminars Begin at 9 a.m. Health Plans in Attendance: UnitedHealthcare CDHP Aetna HMO Keystone Health Plan East Open Enrollment Health Fairs give you an opportunity to find out more about your important health benefits. UnitedHealthcare Consumer Driven Health Plan (CDHP) Seminars are being held at each location. The seminars begin at: 9 a.m., 10:30 a.m., Noon, and 1:30 p.m. PEBTF Open Enrollment: October 10 - October 27,

16 Health Plans To find out more information about the health plans offered in your area, attend an Open Enrollment Meeting, call or log on: HMO Plans Aetna HMO BlueCare HMO Geisinger Health Plan HMO HealthAmerica HMO HealthAmerica HMO (western region) Keystone Health Plan Central HMO Keystone Health Plan East HMO Keystone Health Plan West HMO UPMC Health Plan HMO PPO Consumer Driven Health Plan UnitedHealthcare Definity Health Reimbursement Account Pre-Member Site: Member Site: Basic Plans Capital Blue Cross Comprehensive Major Medical PLEASE FEEL FREE TO CONTACT A PEBTF BENEFIT SERVICES REPRESENTATIVE WITH ANY QUESTIONS YOU MAY HAVE Phone: (Harrisburg area) (Toll free in Pennsylvania) (Toll free out-of-state) asd