2012 Insurance Benefits Guide www.eip.sc.gov Employee Insurance Program 251
Insurance Benefits Guide 2012 A B C Academic Employee 137 Transfers 13 Accidental Death/Dismemberment 117, 120, 132 Active Employee 9 Active Employment 20 Active Group Benefits Refusal Form 194 Actively at Work 119, 122 Active Work Requirement Basic 138 Supplemental 142 Activities of Daily Living 152 Added Value Discount Programs 66, 86 Adding Children See also Newborns Health, dental 26 131 Advanced Practice Registered Nurse 58 Advanced Radiology Preauthorization 51 Age Category () 123 Allowed Amount Balance billing 48 Defined 2 Dental coverage 99, 100, 101 42 Alternative Treatment Plans 58 Ambulance 58, 81 Annual Deductible Applied to Savings Plan drugs 68 BlueChoice HealthPlan HMO 78 42 Annual Enrollment 23, 193 Any Occupation Disability 139, 145 Appeals BlueChoice HealthPlan HMO 89 CIGNA HMO 94 Dental 106 Eligibility 33 Long Term Care 156 140, 147 MoneyPlu$ 179 77 State Vision Plan 114 Audits See Dependent Eligibility Audits Authorized Representative 5 Autism Spectrum Disorders 58, 81, 88, 92 Autopsies 133 Balance Billing 48 Basic Program 117 Conversion at retirement 190 Basic (BLTD) 137 140, 194, 208 Basic Salary 120 Beneficiary 124 Health Savings Account 179 Medical Spending Account 178 Update with MyBenefits 24 Benefit Credit CIGNA and Medicare 218 Benefits Administrator In retirement 193 Benefits at a Glance BlueChoice HealthPlan HMO 78 CIGNA HMO 90 Dental 100 Savings Plan/ 41 State Vision Plan 109 Benefits ID Number (BIN) 21 Benefit Waiting/Elimination Period Long Term Care 153 Benefit Waiting Period Basic 137 Supplemental 141 BlueCard Worldwide BlueChoice HealthPlan HMO 83 Retirement 215 46 BlueChoice HealthPlan HMO Comparison charts 198 200, 220 223 Exclusions 86 Plan summary 78 Prescriptions 84 Retirement 193 Website 89 BlueCross BlueShield of South Carolina 106 See also Savings Plan; See also Appeals, 77 Dental Plus card 193 Discount programs, 66 Medicare Supplemental Plan Claims 214 Paper claims Dental 240 Health 239 Medicare claims 217 Braces, Dental See Orthodontics (Orthodontia) Break in Coverage See Significant Break in Coverage Carve-out Method of Claims Payment 216 Case Management 53, 55, 56 Certificate, Basic 137 Certificate, Supplemental Long Term Disability 142 Change in Status (MoneyPlu$) 172, 178 Changing Coverage 24, 193 Checklists New Employee 34 Retiree 35 Survivor 36 Checkups (Well Child) 65 Child See also Adding Children Eligibility 10 Incapacitated 11 Newborns 26, 50 Child and Dependent Care Tax Credit 162 Children s Health Insurance Program (CHIP) 28 Chiropractic 76, 81 Chronic Disease Workshops 29 CIGNA HMO 90 Comparison charts 198 200, 220 223 Exclusions 93 Tobacco treatment program 93 With Medicare 218 Claims 104 CIGNA HMO 91 With Medicare 219 Dental 101 Basic 118 Dependent 132 Optional 127 Basic 137 Supplemental 142 Medicare Supplemental Plan 213 Paper Dental 240 Health, mental health 239 Prescription drugs 240 With Medicare 216 Out-of-network 239 State Vision Plan Out-of-network 113 COBRA 30 And Medicare 31, 209 Initial COBRA Notice 245 250 Medical Spending Account Retiree 191 When benefits run out 32 Coinsurance 252 Employee Insurance Program www.eip.sc.gov
2012 Insurance Benefits Guide BlueChoice HealthPlan HMO 81 CIGNA HMO 91 Medicare 211 43 Carve-out method 216 Coinsurance Maximum 198 CIGNA HMO 91 Comparison charts 220 Drugs 68 Drugs 68 With Medicare 216 41 Penalties for not calling Medi-Call 50 Colonoscopies 58 Common Law Marriage 20, 25 Companion Benefit Alternatives 42, 73 Appeals 77 Medicare Supplemental Plan 211 Provider Network 47 Medicare 214 Comparison charts 15 Retirees with Medicare 221 Retirees without Medicare 198 Complex Care Management 55 Compound Prescriptions 70 Confidentiality Policies 4, 5 See also Health Insurance Accountability and Portability Act of 1996 (HIPAA) Contributions Health Savings Account Availability 176 Limits 175 Conversion Basic 118 Dependent 133 Optional 129 Supplemental 146 Coordination of Benefits (COB) 12 Dental 104 Long Term Care 155 45 Drugs 72 Coordination period End-stage renal disease 207 Copayment 68, 81, 91 Creditable Coverage 13, 25 Custodial Agreement 179 D Daily Benefit Maximum 151, 153 Day Care Benefit 126 Death Benefits Accidental 117, 125 117, 123, 124, 132 Long Term Care 154 Supplemental 147 Effect on MoneyPlu$ accounts 178 Retiree 195 Subscriber or covered dependent 32 Decreasing Coverage 23 In retirement 193 Deductible BlueChoice HealthPlan HMO 80 Dental 99 Medicare 211 Medicare Supplemental Plan Private Duty Nursing 212 Annual 42 Carve-out method 216 Per-occurrence 43 Deductible Income Basic 140 Supplemental 146 Deferred Effective Date Defined 120 Dependents 132 Optional 123 Dental Adding or dropping coverage 23 Dental/Dental Plus premiums 227 229 Orthodontics (Orthodontia) 100, 104 Procedures 100 Services not covered 102 Dental Claim 240 Dental Plus 99 In retirement 189 Pretax deduction of premiums 159, 161 Dependent Care Spending Account 159 164 How leaving job affects it 173 Dependent Child See Child Dependent Documentation Initial enrollment 20 Dependent Eligibility Audits 11 Dependent Program 130 134 Child, age 19-24 10 Child, premiums 233 May convert at retirement 191 Spouse coverage 132 Spouse, premiums 231 Dependent Spouse See Spouse Direct Deposit MoneyPlu$ 168 Disability Defined 145 Eligibility for retiree coverage 183 Medicare before 65 206 Disclosure of Health Information See Health Insurance Portability and Accountability Act of 1996 (HIPAA) Divorce 25 Doctor Visits BlueChoice HealthPlan HMO 59 59 Documentation At enrollment 20 Dependent Eligibility Audits 11 Durable Medical Equipment 59 E Earned Income Tax Credit 162 Education Benefit (Life insurance) 126 EIP Direct 29 Eligibility Active employee 9 Appeals 33 Basic 117 Conversion 129 Dependent 130 Long Term Care 152 Basic 137 Supplemental 141 Medicare 205 MoneyPlu$ Dependent Care Spending Account 163 Health Savings Account 174 Limited-use Medical Spending Account 171 Medical Spending Account 166 Pretax Group Insurance Premium Feature 161 Retiree insurance 183 Spouse and children 10 Survivor 11 Eligible Expenses Dependent Care Spending Account 164 Limited-use Medical Spending Account 167 Medical Spending Account 167 Eligible Retiree See Eligibility Emergency Care BlueChoice HealthPlan HMO 82 Comparison charts 198 Dental 102 41 Medi-Call 50 Outpatient services 61 End of Coverage 30 129, 133 Basic 140 Supplemental 147 www.eip.sc.gov Employee Insurance Program 253
Insurance Benefits Guide 2012 Retiree insurance 195 End-Stage Renal Disease 56 Enrollment Dependent Care Spending Account 163 Initial 20 Basic 117 Dependent 130 Optional 122 Long Term Care 152 Supplemental 141 Medical Spending Account 166 Enrollment Periods 23 Estate Resolution Services 124 Exclusions BlueChoice HealthPlan HMO 86 CIGNA HMO 93 Dental 102 Drugs, Savings Plan 62 118 Long Term Care 156 138, 143 Pre-existing condition 12 74 76 State Vision Plan 113 Extended Care 64, 211, 214 Extension of Benefits Basic 118 Optional 128 EyeMed Vision Care 109 F Failure to Pay Premiums 30, 40 Family and Medical Leave Act (FMLA) 28 Felonious Assault Benefit 127 Filing Your Own Claims Dental 240 Medco prescription drugs 240 239 Flexible Spending Account See Dependent Care Spending Account; See Medical Spending Account Flu Shot 66, 67 Fraud Prevention Hotline 5 Frequency of Benefits State Vision Plan 111 Fringe Benefits Management Company, a Division of WageWorks, Inc., (FB-WW) See MoneyPlu$ Full-time Employment 9, 120 Supplemental 145 Full-time Students 11 Dependent 130 Funded Retirees 185, 186 G Gaining Coverage 27 Generic Drugs BlueChoice HealthPlan HMO 84 70 Great Expectations for health BlueChoice HealthPlan HMO 85 H Health Information Rights 243 Health Insurance Portability and Accountability Act of 1996 (HIPAA) 5, 32 Disclosure of Health Information 241 Notice of Privacy Practices 241 Health Maintenance Organizations (HMO) 78 In retirement 217 Not eligible for Medicare 188 Pretax Group Insurance Premium Feature 159, 161 Health Management Program 54 Health Savings Account (HSA) 41, 173 177 Custodial agreement 176 Defined 159 Fees 177 Limited-use Medical Spending Account 167 Owner s death 179 HIPAA See Health Insurance Portability and Accountability Act of 1996 (HIPAA) Home Healthcare Medicare Supplemental Plan 212 59 Hospice Care BlueChoice HealthPlan HMO 83 60 Hospital BlueChoice HealthPlan HMO 83 Medicare Supplemental Plan 211 Retiree comparison charts 200, 220, 222 In retirement 214, 215 Inpatient care 60 Medi-Call 50 I Immunizations 65 Incapacitated Child 11 Incentive Program See Wellness Incentive Program Ineligible Expenses Dependent Care Spending Accounts 164 Medical Spending Accounts 167 Infertility BlueChoice HealthPlan HMO exclusion 87 CIGNA HMO exclusions 93 60 Exclusion 75 Initial Enrollment 20 Injury Medicare Supplemental Plan 212 Inpatient Care 50, 60 See also Hospital Insurance Advantage 23 Insurance Benefits Guide (IBG) 2 Insurance Cards 21 See also Benefits ID Number (BIN) IRS Guidelines for Flexible Spending Accounts 161 L Late Entrants 24 Dependents 132 Optional 122, 123 Retiree coverage 187 Leave of Absence 128 Leave Without Pay 28 115 134 Basic Life 117 119 Eligibility 117 Dependent Life 130 134 Eligibility 130 In retirement 190 Optional Life 119 129 Lifetime Maximum 151 Long Term Care 153 Retiree comparison charts 198, 220 41, 45 Lifetime Security Benefit 146 Limited-use Medical Spending Account 159 How much to contribute 161 Using it 171 With a Health Savings Account 175 Local Subdivision BA in retirement 35 Defined 9 Retiree insurance funding 184 Retiree premiums 188 Long Term Care Insurance (LTC) 151 156 Eligibility 152 In retirement 192 Premiums 234 235 137 148 At retirement 192 Eligibility 137, 141 Supplemental (SLTD) 141 147 Loss of Coverage 27, 131 See also COBRA 254 Employee Insurance Program www.eip.sc.gov
2012 Insurance Benefits Guide M Mail-Order Pharmacy BlueChoice HealthPlan HMO 84 71 Mammograms BlueChoice HealthPlan HMO 78 With Medicare 215 64 Marriage 24 Mastectomy 62 Maternity Management 52 Maximum Benefit Period 139, 140, 144 Maximum Yearly Benefit Dental 99 Coordination of benefits 105 Medco Appeals, SHP 77 Paper claims 240 67 Mail-order pharmacy 71 Medicaid 28 Medical Cost Estimator 54 Medical Evidence of Good Health 120, 122, 132 Long Term Care 153 Medi-Call Retiree coverage 211, 212, 214, 215, 220 After mastectomy 62 Hospice care 60 Preauthorization 50 Pregnancy 50 Second opinions 63 Skilled nursing facilities 63 Medically Necessary 57 58 Medicare Supplemental Plan Home healthcare 212 Medical Spending Account (MSA) 165 168 Defined 159 Effect of leaving your job 173 Eligible expenses 167 Grace period 161 Reimbursement 165 41 Vs. claiming expenses on federal tax return 163 With myfbmc Card 167 168 Medicare Comparison charts 220 223 Deductibles, coinsurance 211 Eligibility 189, 207 Enroll in Part B 205 Failure to enroll 208 Notify EIP of enrollment 189, 207 Retiree health plan choices 188 64 Wellness checkup 206 When traveling 215 With COBRA coverage 31 With 214 217 Medicare Advantage Plans 210 Medicare Assignment 210, 213, 216 Medicare At 65 If retired 207 Medicare Before Age 65 Disability retirees 206 Medicare Part A 205 Medicare Part B 195, 205 Medicare Part C 210 Medicare Part D 206, 220 Medicare Supplemental Plan 210 214 Automatic enrollment 209 Comparison chart 220 223 Deductibles, coinsurance 211 Medicare assignment 213 Outside U.S. 213 Mental Health and Substance Abuse Benefits BlueChoice HealthPlan HMO 81 72 Out-of-network benefits 48 Preauthorization 51, 72 Provider networks 47 Military Leave of Absence 128 MoneyPlu$ 119, 122, 159 178 Administrative fees 160 Claim form 164, 168, 169 Flexible Spending Accounts 161 Eligibility 163 Health Savings Account 173 178 Pretax Group Insurance Feature 161 Retirement, not available 191 MyBenefits 23, 188 MyFBMC Card 168 170 Activating the card 169 Documentation 170 MSA grace period 165 MSA reimbursements 167 Re-enrollment 166 My Rx Choices 69 N National Imaging Associates (NIA) 51 Natural Blue 66 NBSC 175 See also Health Savings Account Network Providers See Provider Networks Newborns 26, 50 Notice of Election (NOE) Form 20 121 Adding children 131 Applying for 119 Dependent 131 Late entrant 122 142 Pretax Group Insurance Premium Feature 161 Retiree 186, 193 Notice of Privacy Practices 5, 241 O Obesity Surgery Exclusion BlueChoice HealthPlan HMO 88 CIGNA HMO 93 75 Online Enrollment System 23 Open Enrollment 23, 193 Optional Employer Group 32 See also Local Subdivision Optional Life, Dependent Life-Spouse Premiums 231 234 Optional 119 128 Contract terms 119 Disability waiver 128 Initial enrollment 122 Pretax premiums 121, 159, 161 Retirement, continuing 190 Organ Transplants BlueChoice HealthPlan HMO 83 Retirees 215 60 Orthodontics (Orthodontia) MSA eligibility 167 Out-of-Network BlueChoice HealthPlan HMO, CIGNA HMO 78 48, 61 State Vision Plan 112 Out-of-Network Differential 41 Defined 49 Outpatient Facility Services 61, 215 Outpatient Services 41, 61, 198 Outside South Carolina Medicare 214, 215, 217 Outside the United States BlueCard Worldwide 47 Long Term Care 156 Medicare rules 213 Retirees HMOs 217 Medicare 215 Over-the-Counter Medicines MSA eligibility 167 Own Occupation Disability 139, 145 P Pap Tests Medicare Supplemental Plan 213 www.eip.sc.gov Employee Insurance Program 255
Insurance Benefits Guide 2012 64, retirees 215 Partial Disability 139, 146 Participating Group Defined 20 Participating Providers See Provider Networks Pay-the-Difference Policy Drugs 69 Permanent, Part-Time Teachers 9, 10 Premiums 230 Per-occurrence Deductible 41 Defined 43 With Medicare 220 Personal Health Assessment 57 Personal Health Record 56 Physical Exam See also Checkups BlueChoice HealthPlan HMO 80 142 Medicare 220 Savings Plan 67 Plan Administrators 45 Portability Health Savings Account 178 Long Term Care 152 PPO (Preferred Provider Organization) 45 Preauthorization BlueChoice HealthPlan HMO Behavioral Health Benefits 81 Dental See Pretreatment Estimates Appeals 77 Drugs 70 Medical services See Advanced Radiology Preauthorization; See Medi-Call Mental Health/substance abuse 73 Predisability Earnings 145 Pre-existing Condition 12 138, 142, 143 Preferred Brand Drugs BlueChoice HealthPlan HMO 79 Comparison charts 198 199, 220 221 Preferred Drug Step Therapy 69 Preferred Provider Organization (PPO) 45 Pregnancy 50 See also Medi-Call; See also Maternity Management Premiums COBRA 228 Dependent Life-Child 233 Employer contributions 227 Health, denta1, vision Non-funded retirees 228 Health, dental, vision Active employees 227 132 How determined 122 Long Term Care 151, 234 235 Retiree 192 MoneyPlu$ 160 See also Pretax Group Insurance Premium Feature Optional Life, Dependent Life-Spouse 231 234 Permanent, part-time teachers 230 Retiree 188 Supplemental 144 Survivor 229 Premium Waiver 32 Long Term Care 155 Prescription Drug Claims Medco Paper 240 Prescription Drugs BlueChoice HealthPlan HMO 84 Comparison chart With Medicare 220 221 HMOs, retirees 217 Provider networks 47 Savings Plan 41 Exclusions 76 Mail order 71 41, 43 Benefits 62, 67 69 Compound prescriptions 70 Contraceptives 59 Coordination of benefits 72 Infertility 60 Medicare Supplemental Plan 213, retirees 215 Without Medicare 198 Pretax Group Insurance Premium Feature 121 122, 159, 161 Not required for Flexible Spending Accounts 163 Pretreatment Estimates Dental 102 Prevention Partners 29 Worksite screening See Preventive Workplace Screening Preventive Benefits Savings Plan 67 64 Preventive Workplace Screening 29, 40 Primary Care Physician 78, 80, 91 Comparison chart 198 Privacy 5 See also Health Insurance Portability and Accountability Act of 1996 (HIPAA) Private Duty Nursing Medicare Supplemental Plan 212 Prosthetics BlueChoice HealthPlan HMO 85 Prosthodontics 100, 104 Provider Networks BlueChoice HealthPlan HMO 80 Dental Plus 99 HMOs With Medicare 217 Internet access 29 Savings Plan Physicals 67 45 Drugs 48, 71 Mental health 47, 72 Out-of-network providers 49 Transplant network 60 State Vision Plan 112 Prudential 151 156 Q Qualifying Event 2 See also Special Eligibility Situations COBRA 30 Divorce 26 Quit For Life 74 BlueChoice HealthPlan HMO 86 74 R Rates See Premiums Reconstructive Surgery After Mastectomy 62 Rehabilitation 62, 84 Reimbursement See also MyFBMC Card Dependent Care Spending Account 164 Medical Spending Account 167 State Vision Plan 109, 109 110, 112, 113 Repatriation Benefit 127 Retail Maintenance Network, SHP 71 Retail Pharmacy 71, 198, 220 Retiree Funding Funded 185, 186 Non-funded 185, 186 Partial 186 Retirees 183 Checklist 35, 183 184 Enrollment 186 Health plan choices 188 Information sent to 193 Insurance funding rules 185 Continuing coverage 129 Return to work 194 Retirement, Employment After See Employment After Retirement Savings Plan See also State Health Plan; See also Health Savings Account Additional exclusions 76 Benefits chart 41 Drug coverage 68 Mail order 71 S 256 Employee Insurance Program www.eip.sc.gov
2012 Insurance Benefits Guide How it works 44 45 Limited-use MSA 167, 171 Out-of-network charges 49 Pretax premiums 159 Preventive benefits 64 66 Schedule of Accidental Losses and Benefits 117, 125 Schedule of Benefits 132 S.C. Retirement Systems Disability benefits 140, 146 HSA contributions 175 Seat Belt Rider 126 Second Opinion 63 Self-care Handbook Savings Plan 67 Self-Insured Plans 40 Separation 25 Significant Break in Coverage 12, 187 Skilled Nursing Facility 63 Smoking Cessation See Tobacco Treatment Program Special Eligibility Situations 24 28, 121, 193 Divorce 25, 131 Medical Spending Account 166 Retiree enrollment 187 Separation 25 Specialist Office Visit BlueChoice HealthPlan HMO 79, 80 Specialty Pharmaceuticals 84 Speech Therapy 63, 87 Spouse Divorce 25 Eligibility 10 Survivor 32 Standard Insurance Company (The Standard) 137, 140, 147 Claims 142 See also State Health Plan Benefits chart 41 Carve-out method 216 Drugs Mail order 71 Pay-the-difference policy 68 Out-of-network charges 49 Preventive benefits 64 66 Retirees 188 section 42 73 With Medicare Outside South Carolina 215 State Dental Plan/Dental Plus 99, 230 In retirement 189 Premiums 230 Pretax premiums 159 160 See also Savings Plan; See also Benefits 57 Coordination of benefits 45 Drug benefits 71 Exclusions 74 76 Drugs 72 Limits Chiropractic benefits 76 Paper claims 239 Pretax premiums 159, 161 Retirees Pap tests 215 Statement of Health Form 119, 121, 122, 131 State Vision Plan 109 114 Appeals 114 Benefits 109 110 Exclusions 113 Frequency of Benefits 111 Out-of-network benefits 112 Provider network 112 Students See Full-time Students Subrogation 40 Substance Abuse See Mental Health and Substance Abuse Benefits Suicide Exclusion 124 Supplemental (SLTD) 141 147 Surgery 63 Survivors 32, 195 Checklist 36 Supplemental 147 T TERI Enrolling after 188 With Optional Life 191 Termination of Coverage 30 Dependent 133 Term life insurance 117 Tobacco Treatment Program BlueChoice HealthPlan HMO 86 CIGNA HMO 93 74 Tobacco-Use Surcharge 40 Unable to stop for medical reason 40 Transferring Employee 13, 121 Transplants See Organ Transplants V Value Generics 84 Veterans Administration 211, 212 Vision Care In retirement 189 Vision Care Discount Program 114 W Waivers See Premium Waiver Tobacco-use surcharge 40 Websites BlueChoice HealthPlan HMO 89 CIGNA HMO 94 Companion Benefit Alternatives 77 Employee Insurance Program 29 EyeMed Vision Care 113 Fringe Benefits Management Company 171 Prudential 152 76 Medco 71 Online Health Tools 56 Weight Management BlueChoice HealthPlan HMO 85 Children 54 54 Well Child Care Benefits BlueChoice HealthPlan HMO 82 In retirement 215 65 Wellness Incentive Program 53 Will Preparation Service 124 Workers Compensation 28 Dental 103 Deductible income 140, 146 Total printing costs: $258,725; Total number of guides printed: 330,000; Unit cost: $0.78402 The cost of this guide is shared proportionately by the third-party claims processors and the Employee Insurance Program. www.eip.sc.gov Employee Insurance Program 257
Insurance Benefits Guide 2012 258 Employee Insurance Program www.eip.sc.gov