retiree book-state of ga - georgia department of community ...the georgia department of community...
TRANSCRIPT
Phone Numbers and Contacts for Benefit and Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Inside Front Cover
Making Informed Health Plan Coverage Decisions . . . . . . . . . . . . . . . . . . . . . . . . . .2
What You Need to Do . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
What’s Changing for 2003 – 2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
If You Do Not Make Any Changes During the Retiree Option Change Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
If You Want to Change Your Option During the Retiree Option Change Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Basic Plan Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Eligible Dependents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Documentation Upon Request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Making Changes When You Have Qualifying Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Overview of How Each Health Plan Option Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Important Terms to Understand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
PPO Option . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
PPO Choice Option . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
Indemnity Option (Formerly Named High Option) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
HMO Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
HMO Choice Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
Medicare+Choice HMO Option (M+C HMO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Comparing Benefits Within Health Plan Options . . . . . . . . . . . . . . . . . . . . . . . . . . .19
Comparison of Benefits: PPO Option and Indemnity Option . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Comparison of Benefits: HMO Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
Service Areas for Your Health Plan Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
Health Insurance Portability and Accountability Act (HIPAA) Annual Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
Department of Community Health Privacy Notice . . . . . . . . . . . . . . . . . . . . . . . . . .42
Women’s Health and Cancer Rights Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44
Penalties for Misrepresentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44
C O N T E N T S
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Making Informed HealthPlan Coverage Decisions
The Georgia Department of Community Health,which administers the State Health Benefit Plan(SHBP), continually seeks to bring you high-quality,affordable health coverage. Keep in mind, how-ever, that you are the manager of your health careneeds, and in turn, must take the time to under-stand your Plan benefit choices in order to makethe best decisions for you and your family. Duringthe Retiree Option Change Period, it is importantthat you carefully review the coverage optioninformation provided in this Retiree Health PlanDecision Guide. You should evaluate your healthcare needs and, if necessary, those of your depend-ents, as well as the premiums and out-of-pocketcosts related to these different options beforemaking your decision. Once you make your cover-age decision, you may not make changes to yourcoverage outside the Retiree Option ChangePeriod unless you have a qualifying event. Seepage 8 for details.
If after reading this Guide you want more informa-tion before making a coverage decision, you canrefer to your Summary Plan Description (SPD)booklet and Updaters or call the Retiree Help Lineat (800) 586-9288. Note that a new SPD andUpdater will be mailed to your home addressprior to the start of the new Plan year.
Making informed decisions about your health care includes other considerations as well. Patientsafety is a critical mission for the SHBP. Therefore,we offer these five steps to safer health care:
1. Speak up if you have questions or concerns.Choose a physician whom you feel comfortabletalking to about your health and treatment.Takea relative or friend with you if this will helpyou ask questions and understand the answers.It’s okay to ask questions and to expectanswers you can understand.
• If you are considering PPO coverage,providerdirectories are available to help you choosephysicians who have been credentialed intheir specialties.Visit the 1st Medical Network
(formerly MRN/Georgia 1st) Web site atwww.healthygeorgia.com for the most up-to-date listing of over 14,000physicians and 166 hospitals in Georgia anda link to national PPO provider informationfor national access to 385,000 physiciansand 3,300 hospitals. Printed directories areavailable by calling the Retiree Help Lineduring the Retiree Option Change Period.
• If you are considering HMO coverage,see the inside front cover for HMO Web sites that include provider information.Youalso can contact the individual HMO directlyto request a provider directory.
However, the provider listings are subject tochange without notice. Before selecting yourphysician, call the physician’s office to make sure that physician is accepting new patientsand that he/she is still a participating provider.
2. Keep a list of all the medicines you take.Tell your physician and pharmacist about themedicines that you take, including over-the-counter medicines such as aspirin, ibuprofenand dietary supplements like vitamins andherbals. Tell them about any drug allergies youhave. Ask the pharmacist about side effects andwhat foods or other things to avoid while tak-ing the medicine.When you get your medicine,read the label, including warnings. Make sure itis what your physician ordered, and you knowhow to use it. If the medicine looks differentthan you expected, ask the pharmacist about it.
3. Make sure you get the results of any test or procedure.Ask your physician or nurse when and howyou will get the results of tests or procedures.If you do not get them when expected—in person, on the phone or in the mail—don’tassume the results are fine. Call your physicianand ask for them. Ask what the results mean for your care.
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4. Talk with your physician and health care team about your options if you need hospital care.If you have more than one hospital to choosefrom, ask your physician which one has thebest care and results for your condition.Hospitals do a good job of treating a widerange of problems. However, for some procedures (such as heart bypass surgery),research shows results often are better at hospitals doing a lot of these procedures.Also, before you leave the hospital, be sure toask about follow-up care, and be sure youunderstand the instructions.
5. Make sure you understand what will happenif you need surgery.Ask your physician and surgeon:“Who will takecharge of my care while I’m in the hospital?Exactly what will you be doing? How long willit take? What will happen after the surgery?How can I expect to feel during recovery?” Tellthe surgeon, anesthesiologist and nurses if youhave allergies or have ever had a bad reactionto anesthesia. Make sure you, your physicianand your surgeon all agree on exactly what willbe done during the operation.
For PPO providers
Visit the 1st Medical Network Web site at www. healthygeorgia.com for the most up-to-date listing of Georgia PPO providers.This Website also has a link to a listing of National PPO (Beech Street) providers located across theUnited States.You also can call the Retiree Help Line at (800) 586-9288 to request printedprovider directories.
For HMO providers
Check the HMO's Web site for current providersor call to request a current HMO directory. Note: Ifyou sign up for one of the HMO options, receipt ofyour HMO card could be delayed if a primary carephysician selection is not received by the HMO. Besure to select a primary care physician if youenroll online, or indicate your selection on yourPersonalized Change Form if you are mailing theinformation to the Health Plan. Note: If you selectUnitedHealthcare HMO, you do not need to selecta primary care physician.
P R O V I D E R D I R E C T O R I E S :
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What You Need to Do
R E V I E W T H E M A T E R I A L S I N
Y O U R P A C K A G E
Review this Guide and your PersonalizedChange Form (PCF). Keep your PCF, whichhas your mailing address on the back. Besure to read the What’s Changing for 2003 –2004 section on page 5 and 6 for importantinformation about Plan changes.
If you need to correct your address, you can do this by indicating your new addresson your PCF. If there are other correctionsneeded, call the Plan’s Eligibility Unit at(800) 610-1863, or in the Atlanta area(404) 656-6322.
I F N O C H A N G E S A R E N E E D E D
To continue your current coverage for 2003 – 2004:
PPO and Indemnity Options (FormerlyNamed Standard PPO and High Options)You do not need to take any action.Your coverage will be continued at the new costsshown on your Personalized Change Form.This also applies to any currently covered family members.
HMO and Medicare+Choice HMO OptionsRefer to the HMO Options charts starting onpage 37 of this Guide to see if your currentHMO is still available in your area. If so, andyou do nothing, your current coverage willbe continued automatically. If the HMO is nolonger available, and you do nothing, yourcoverage will be transferred automatically to the PPO Option.
T O C H A N G E Y O U R C O V E R A G E
• Online: Go to www.statehealth.org andaccess your information using your per-sonal security code (PIN) from the upperright corner of your PCF. Instructions areon the Web site.
• By mail:Complete your PCF and mail itback to the Health Plan postmarked by thedeadline,using the envelope provided inyour package.Keep a copy for your records.
If you want to continue coverage for yourdependents, check the appropriate box.Remember, if you check "no," you won't beable to reenroll the dependent in the futureunless you have a qualifying event. Note,however, that you cannot change fromFamily to Single coverage online.
In most cases, you and any covered familymembers must each select a primary carephysician.You may indicate PCP selectionsonline or on your PCF.
O P T I O N A L — A T T E N D A B E N E F I T
F A I R I N Y O U R A R E A
Check the list enclosed in your package for a benefit fair scheduled in your area.
Confirmation of Your Change
If you make changes to your current coverage,you will receive a new ID card by mail beforeJuly 1, 2003.
If you change your coverage online, you can printa confirmation of your option change directlyfrom the Web site or write the confirmation num-ber that you will see on the computer screen inthe space provided on your PCF for your records.
If you choose "No Coverage" for 2003 – 2004,you will not be able to reenroll in an SHBPoption at any time in the future, unless youreturn to active employment with the State in abenefits-eligible position.
I M P O R T A N T N O T E :
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What’s Changing for 2003 – 2004Effective July 1, 2003, changes to your Plan options include:
• For PPO and Indemnity Option members:
Deductibles and co-payments will change as indicated in the chart below.
BENEFITPPO OPTION INDEMNITY OPTION
CURRENTEFFECTIVE
JULY 1, 2003CURRENT
EFFECTIVEJULY 1, 2003
DEDUCTIBLES
CO-PAYMENTS
NOTE
Hospital Deductible per Admission,Excluding BHS and Transplant Benefits
General Deductibles
Individual Deductible per Plan Year
$0
Family Maximum Deductible per PlanYear
Physician Office Visit Co-payment perVisit
Emergency Room Co-payment per VisitNote: The co-payment effective July 1,2003 will be reduced to $80 if the member is referred by NurseCall 24before receiving emergency room services.
Urgent Care Center Co-payment perVisit at Approved Centers
Prescription Drug Co-PaymentsNote: Co-payments effective July 1, 2003will be prorated if the amount dispensedis less than the standard supply. See p.6
Generic Drugs
Preferred Brand-name Drugs
Non-Preferred Brand-name Drugs
$250
$300 $400
$400 $500
$900 $1,200
$1,200 $1,500
$60 $100
$35 $45
$10 $15
$20 $25
$100 $400
$400
$60 $100
$10 $15
$20 $25
In-Network/Georgia
In-Network/Out-of-State and Out-of-Network (Combined Deductibles)
In-Network/Georgia
In-Network/Out-of-State and Out-of-Network (Combined Deductibles)
$20 $30
$35 minimumto a $75
maximum andis calculated
based on 20%of the network
price of thedrug
$35 minimumto a $100
maximum andis calculated
based on 20%of the network
price of thedrug
$35 minimum to a $75
maximum and is calculated
based on 20% of the network
price of thedrug
$35 minimum to a $100
maximum and is calculated
based on 20% of the network
price of thedrug
$300
$900 $1,200
Not Applicable Not Applicable
Not Applicable Not Applicable
Current Plan rules, limitations, exclusions and co-insurance applicable to these benefits will remain in effectfor the Plan Year beginning on July 1, 2003.
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What’s Changing for 2003 – 2004 (Continued)
Effective July 1, 2003, changes to your Plan options include:
• For Indemnity and PPO Option members:
The monthly out-of-pocket spending limitfor generic and preferred brand name pre-scription drugs will become a quarterly(three-calendar month) out-of-pocket spend-ing limit with new maximums as describedbelow:
> If your individual combined co-paymentsfor generic drugs and preferred brandname drugs in any quarter reaches $300,you will not be charged additional co-payments for generic and preferred brandname drugs for the rest of that quarter.
> If you have family coverage and your family’s combined co-payments for generic drugs and preferred brand namedrugs in any quarter reaches $600, youand your dependents will not be chargedadditional co-payments for generic andpreferred brand name drugs for the rest of that quarter.
Notes:1) Co-payments for non-preferred brand
name medications do not count towardthe quarterly out-of-pocket limit.
2) If you choose a preferred brand namedrug when a generic is available, only the$15 generic co-payment will be appliedtoward the quarterly out-of-pocket limit.
3) Quarters coincide with the State’s fiscalyear, which begins every July 1.
Prescription drug co-payments that are effec-tive July 1, 2003 will be prorated accordingto the amount of the drug dispensed if theamount dispensed is less than the “standardsupply” for the prescription. The standardsupply is the quantity of the prescriptionthe Health Plan covers for one co-payment,which could be based on a specific numberof days, pills, vials, inhalers, packages, etc.For example, if your pharmacist dispenses a10-day supply of a generic drug and the
standard supply for the drug is 30 days, thenyour co-payment will be one-third of $15, or$5.00. Also, when you return to the phar-macy to receive the balance of your pre-scription you would pay another $10.00.
Coverage of specific osseous surgeries forthe treatment of periodontal disease will bediscontinued. Refer to your dental plan documents for information on available coverage for the treatment of periodontaldisease.Also, if offered by your employer,consider using your Health Care SpendingAccount to offset any out-of-pocket expenseyou may incur for these services.
• For HMO Option members:
The CIGNA and UnitedHealthcare serviceareas will change. See pages 31-34 for a list of specific counties in the approvedservice area.
If you currently have HMO coverage thatwill not be available in your area for thenew Plan year, you must select another available option. If you do not select another option, your current coverage willbe transferred automatically to the PPOOption effective July 1, 2003.
The BlueChoice HMO co-payment for urgentcare is changing. See the covered serviceschart for specific information.
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If You Do Not Make Any ChangesDuring the Retiree OptionChange Period
If you do not want to make any changes, your current coverage option and type continues intothe new Plan year, unless otherwise noted (seepage 6 under the “For HMO Option members”section).
It is not necessary to submit any paperworkif you do not want to make any changes.
If You Want to Change YourOption During the Retiree Option Change Period
The Comparing Benefits Within Health PlanOptions section starting on page 19 of this Guide provides an overview of what services are coveredby each option. Before choosing a new option,you’ll probably want to look at the benefits offeredand at physicians, hospitals and other providersparticipating in the networks of the variousoptions. For your reference, phone numbers forrequesting provider directories and specific benefitinformation are listed on the inside front coveralong with Web site addresses.
Knowing what your benefits cover can help preventunexpected out-of-pocket expenses during the Planyear. Before you schedule a physician’s appointment,for example, make sure you understand what services your new option covers. If you’ve chosenan option that offers a network of preferredproviders, consider the difference between seeingin-network providers and out-of-network providers.Most out-of-network services will cost you more and are subject to balance billing.
Using the security access code on yourPersonalized Change Form you received in yourpackage, you can:
• Change your address
• Change your coverage option
• Delete dependents (but you cannot changefrom Family to Single coverage online)
• Add or change primary care physicians forHMO Option selections
• Discontinue coverage*
* If you choose to discontinue at any time, youwill not be able to reenroll in any SHBPoption in the future, unless you return toactive employment in a benefits-eligible position.
If you do not have Internet access, complete andreturn your Personalized Change Form to:
State Health Benefit PlanP.O. Box 347069Atlanta, GA 30334
The envelope must be postmarked no later thanMay 15, 2003. A pre-addressed return envelope isinside your package.
Note: If you sign up for one of the HMO Options,receipt of your HMO card could be delayed if the HMO does not receive your primary carephysician (PCP) selection. If you selectUnitedHealthcare HMO, you do not need to select a PCP or complete the enrollment supplement form.
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If you do not need basic information on
participating in the Plan, including infor-
mation on who is eligible to participate,
proceed to page 19 for a comparison
of benefits.
Basic Plan Information
Eligible Dependents
A dependent is defined as:
• Your spouse, if you are legally married;
• Your never-married dependent children who are:
1. Natural or legally adopted children andunder age 19;
2. Stepchildren under age 19 who live withyou at least 180 days per year;
3. Other children under age 19 if they livewith you permanently and legally dependon you for financial support;
4. Your natural children, legally adopted children or stepchildren who were coveredunder the SHBP before age 19 and who are physically or mentally disabled anddependent on you for primary support (they may continue their existing Plan coveragepast age 19); and
5. Your children from categories 1, 2 or 3above who are registered full-time studentsat fully accredited schools, are not employedfull-time and are between the ages of 19 and 25.
For changing your coverage during the RetireeOption Change Period — May 1 through May 15 — you can enter your changes on theWeb site below, or complete and return thePersonalized Change Form.
• www.statehealth.org8 a.m. (May 1) to 6 p.m. (May 15)Available 24 hours a day, 7 days a week
After sending your changes online, be sure toobtain a confirmation number. The confir-mation number is your documentation thatan online transaction occurred. Please keepthis confirmation number in a safe place.
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Documentation Upon Request
In order to cover a spouse or dependent underthe Plan, you must provide documentation uponrequest from the Plan. The Plan requires:
• A copy of your certified marriage license tocover spouses;
• A copy of a certified birth certificate to cover anatural child;
• A copy of a stepchild’s certified birth certifi-cate, showing your legal spouse as the naturalparent of the child, and a letter documentingthat your stepchild lives in your home on a permanent basis in a parent-child relationshipfor at least 180 days per year;
• Adoption papers, guardian or court orders forother children who live with you permanentlyand legally depend on you for financial support. (The SHBP will recognize and honor a Qualified Medical Child Support Order(QMCSO) for eligible dependents. See your SPD for more information);
• Disability paperwork for disabled dependents19 and over; this documentation must bereceived by the Plan before the child’s 19th
birthday; or
• A certification letter for full-time studentdependents from the registrar’s office of yourchild’s school.
In any of these situations, you may be required to provide documents to verify your dependentrelationships during the Retiree Option ChangePeriod or at various periods throughout the Plan year.
If eligibility verification cannot be made after arequest from the Plan, the dependent’s coveragewill be terminated retroactively to his or her cover-age effective date.The Plan will make every effortallowable under the law to recover from the sub-scriber (i.e., retired employee) any and all pay-ments made by the Plan on behalf of an ineligibledependent.
Making Changes When You HaveQualifying Events
The option choice you make during the RetireeOption Change Period will stay in effect for theduration of the 2003 – 2004 Plan year unless youhave a qualifying event. Some qualifying eventsmay allow a change to Family coverage.A changeto Single coverage is allowed at any time.
Qualifying events include, but are not limited to:
• Marriage or divorce;
• Birth or adoption of a child or placement for adoption;
• Death of a spouse or child, if only dependentenrolled;
• Your spouse’s or dependent’s eligibility for or loss of eligibility for other group health coverage;
• A change in residence by you, your spouse ordependents that makes you or a covereddependent ineligible for coverage in yourselected option; and
• Medicare eligibility.
If you experience a qualifying event, you may beable to make changes for yourself and your dependents, provided you request those changeswithin 31 days of the qualifying event.Also, yourrequested change must correspond to the qualify-ing event. For a complete description of qualifyingevents, see your SPD and Updaters.You can contactthe Eligibility Unit for assistance at (800) 610-1863,or in the Atlanta area (404) 656-6322.
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Overview of How Each HealthPlan Option Works
On the following pages, you will find a briefdescription of each option and important consid-erations to help you select the best option for you.A comparison of specific benefits within eachoption is in the next section.
Contact the Retiree Help Line or HMO if youneed more detail. Telephone numbers are onthe inside front cover. You also may refer toyour SPD and Updaters to obtain more detailson benefits and Plan participation.
To help you understand the information in thissection, a few key terms are defined below:
Important Terms to UnderstandAllowed Amount—A dollar amount the Plan usesto calculate benefits payable.The Plan uses the following allowed amounts:
1. Network Rate—for in-network PPO services;
2. Out-of-Network Rate—for out-of-network PPO services; and
3. Indemnity Rate—for Indemnity Option services.
Balance Billing—A dollar amount charged by aprovider that is over the Plan’s allowed amount forthe care received. You are subject to balancebilling when you receive services from non-partici-pating providers, including emergency services.
Co-insurance Amount—The percentage of thePlan’s allowed amount paid by a Plan member inthe PPO or Indemnity Option. Depending on theoption selected, the SHBP generally pays 90% to60%, so your co-insurance is between 10% and 40%.
Co-payment—A set dollar amount that you pay atthe time you receive services or items. For exam-ple, you pay a $20 co-payment for an in-networkPPO physician’s office visit while you are at thephysician’s office. Co-payments do not apply toPlan year deductibles or out-of-pocket limits unless otherwise noted.
Covered Services—Services for medically necessary care that are eligible for reimbursementunder the Plan.
Deductible—A specified dollar amount, whichvaries by Plan option, for specified coveredservices that you must pay out-of-pocket each Planyear before the PPO Option or Indemnity Optionpays a benefit. Depending on your coverageoption, the deductible may not apply to someservices. For example, the deductible does notapply to in-network physician office visits underthe PPO Option. HMO Options do not havedeductible.
Emergency Care—Care provided when a sudden,severe and unexpected illness or injury happensthat could be life-threatening or result in perma-nent impairment of bodily functions if not treatedimmediately.
Lifetime Maximum—The maximum dollaramount that each Plan member may receive inbenefits from the SHBP during his or her lifetime.
Medical Certification Program (MCP)—A featureof the PPO and Indemnity Options that helps you and the Plan save money by preventingunnecessary care. To receive full benefits, youmust comply with the MCP requirements outlinedin the SPD and Updaters.
Out-of-Pocket Limit—A maximum amount youwould have to pay out of your pocket each Planyear for covered services. Once you meet yourout-of-pocket limit for the Plan year, the Plan pays100% of the allowed amounts for most coveredservices for the rest of the Plan year. Your out-of-pocket costs for premiums, co-payments and non-covered charges are not applied to the limit.The deductible is applied to your annual out-of-pocket limit.
Participating Provider—Any physician, hospital orother health-service professional or facility thatoffers covered services and that has joined thePPO network, the Indemnity network or HMO network for the Plan option. Providers nominatedand accepted under a Choice Option also are considered participating providers for the personmaking the nomination. Participating providersmay not balance bill Plan members for coveredservices.
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PPO Option
Anyone eligible for SHBP coverage may select thePPO Option.
The PPO Option consists of a network of over14,000 Georgia participating physicians and 166Georgia hospitals, over 385,000 physicians and3,300 hospitals across the United States, and hundreds of ancillary providers that have agreedto provide quality medical care and services at discounted rates. You have the choice of using in-network or out-of-network providers. If you usein-network providers, you’ll receive the highestlevel of benefits and avoid filing claims.To viewthe list of Georgia PPO providers online, visitwww.healthygeorgia.com.
If you choose the PPO Option, you . . .
• Can access providers in the Plan’s network of over 14,000 Georgia physicians and 166 hospitals to receive a higher level of benefitcoverage.
• Do not need to select a primary care physician(PCP) or obtain referrals to see specialists.
• Pay less than the Indemnity Option.
• Have no balance billing when using participat-ing PPO providers.
• Pay only a minimal co-payment for in-networkPPO physician visits, prescription drugs andsome other covered services.
• May access any licensed out-of-network physician, specialist or hospital at any time.However, you will generally pay more for out-of-network services and charges are subjectto balance billing.
• Have maximum in-network coverage for mostage-appropriate preventive care, including cov-erage for office visits.
• Have coordinated care through a vast networkof providers who will assist you in receivingthe maximum level of benefits.
• May reduce or eliminate the pre-existing condition limitation period if you can provecreditable coverage. See the HIPAA AnnualNotice on page 41 of this Guide.
National PPO Network
As a PPO Option member, you have the addedbenefit of access to a national network of partici-pating providers, which is managed by the BeechStreet Corporation.
You can take advantage of this national network if:
• You or a dependent lives outside of Georgia;
• You have a dependent going to school inanother state;
• You are traveling in another state; or
• You want to use an out-of-state provider.
The network consists of over 385,000 physiciansand 3,300 hospitals across the United States.Whenyou access Beech Street national providers outsidethe Georgia service area (see page 36), you areprotected from balance billing. Your level of benefit coverage is generally different when usingthe national network and you are subject to separate deductibles and out-of-pocket maximums.To view the list of national providers online, visitwww.healthygeorgia.com. If you do not haveInternet access, call Member Services for providerinformation.
Other Points to Consider• You must call the Medical Certification
Program (MCP) to precertify inpatient stays andspecified outpatient procedures when you areusing out-of-network providers or Beech Streetproviders.
• Some physicians affiliated with a PPO may notaccept new patients at some times during theyear. Check with the physician of your choicebefore you enroll in the PPO.
See Comparison of Benefits: PPO Option andIndemnity Option starting on page 20 for benefitdetails.
12
S TAT E H E A L T H B E N E F I T P L A N 2 0 0 3 / 2 0 0 4
PPO Choice Option
Anyone eligible for SHBP coverage may select thePPO Choice Option.
PPO Choice Option benefits are the same as in thePPO Option. However, PPO Choice Option premi-ums are higher. In return for a higher premium,you can request that an out-of-network providerbe reimbursed as an in-network provider. Thisrequest is known as a “nomination.” If the out-of-network provider accepts your nomination, agreesto the PPO fees, and is approved by the PPO, youwill receive in-network benefits from thatprovider. The in-network relationship between youand the provider remains in effect until either youor the provider terminates the agreement. Youmay nominate as many eligible providers as youwish at any time during the Plan year.
If your provider does not accept your nomination,does not accept the network fees, or is notapproved by the PPO, then services from thatprovider are covered at the lower, out-of-network benefit level. SHBP rules do not permit a member to change options when a nominatedprovider or the PPO rejects a nomination.
Note that you may nominate only providerslocated and licensed in Georgia, even if you live out of state. After the PPO receives yournomination, the PPO has three business days to either reject or approve the nomination. ThePPO must approve your provider nominationbefore you receive services.
For further details regarding the nominationprocess and to obtain the necessary paperwork,please contact the Retiree Help Line.
Note: The Behavioral Health Services (BHS) and transplant provider networks are separate from the PPO provider network.To nominate a BHS provider, contact the BHS Program at (800) 631-9943. For nominations of transplantproviders, call (800) 828-6518 (outside Atlanta) or (770) 438-9770 (inside Atlanta).
Indemnity Option (Formerly Named High Option)
Anyone eligible for SHBP coverage may select theIndemnity Option.
Important Note: The Indemnity Option is a traditional fee-for-service plan that also uses contracted health careproviders who have agreed to discounted rateswithout balance billing for charges over theallowed amount.As long as you use a participatingprovider, you may not be balance billed for cov-ered services. However, not all Georgia providersparticipate in these special arrangements andthere are no participating Indemnity Networkproviders outside of Georgia. In most instances,non-participating providers charge amounts thatare considerably higher than the Plan’s allowedamounts. When a non-participating providercharges you over the allowed amount, you areresponsible for the entire amount of the over-age (i.e., balance billing), which could be thou-sands of dollars. For example, during 2002,Indemnity Option members hospitalized outsideof Georgia paid an average out-of-pocket amountof over $20,000 per admission.
Note that the State Health Benefit Plan does nothave the legal authority to intervene when non-participating providers balance bill you; therefore,the State Health Benefit Plan cannot reduce oreliminate amounts balance billed.Also, the HealthPlan cannot make additional payments above theallowed amounts when you are balance billed bynon-participating providers.
The Indemnity Option generally provides the samecoverage level no matter which qualified medicalprovider you use.The Plan reimburses you for covered services, subject to the Plan’s allowedamounts for covered services. Therefore, it is themost expensive Plan option.
The Indemnity Option has similar coverage levels when compared to in-network PPO benefits, but it has:
• A higher premium;
• Less coverage for preventive care; and
• No provider network outside of Georgia.
13
S TAT E H E A L T H B E N E F I T P L A N 2 0 0 3 / 2 0 0 4
Indemnity Option (continued)
If you choose the Indemnity Option, you . . .• Access any provider.
• Receive the same level of benefit coveragewhether or not your provider is in theIndemnity network.
• Pay most health care bills up to the deductibleamount before the Plan starts paying benefits.
• Continue to pay a percentage of the cost of cov-ered expenses—co-insurance—after meeting thedeductible (up to the out-of-pocket maximum)plus any non-covered costs or penalties.
• Are subject to balance billing from all out-of-state hospitals.
• Receive the same level of coverage as offeredin the PPO Option for prescription drug,behavioral and transplant benefits. TheIndemnity Option and PPO Option utilize thesame provider networks for prescription drug,behavioral and transplant benefits.
• Are not required to select a primary care physi-cian (PCP) to get referrals to see specialists.
• May reduce or eliminate the pre-existing limita-tion period if you can prove creditable cover-age. See the HIPAA Annual Notice on page 41
of this Guide.
Other Points to Consider• The Indemnity Option is the most
expensive option.
• The Indemnity Option does not include anational network of providers.
• Deductible for office visits, medical care andhospitalization must be met before benefits arepayable.
• Coverage is available for specified preventivelab work and tests, subject to allowed amountsand annual maximums. Office visits for preven-tive care are covered, subject to the deductibleand co-insurance. A co-payment-only benefitdoes not apply.
• Members must call the MCP to precertify in-patient stays at non-participating hospitals andmembers must precertify certain outpatienttests and procedures. Financial penalties applyif precertification rules are not followed.
HMO Options
HMO Options are available only to SHBP-eligibleretirees who live in an HMO’s approved servicearea. To see if you are eligible for an HMO, checkpages 37 – 40 in this Guide. For the 2003 – 2004Plan year, you may be eligible for up to five different HMO Options.
HMOs provide prepaid benefits for most healthcare needs, with no bills or claim forms. Youchoose a primary care physician (PCP) from a listof providers.* You must receive care from yourPCP or from a physician or facility referred byyour PCP for your expenses to be covered, exceptin cases of emergency and in other limited cases.If you receive care from a physician other thanyour PCP, or without being referred by your PCP,you won’t receive any benefit coverage even if thephysician or facility is in the HMO network.
If you choose an HMO Option, you . . .
• Must access physicians, specialists and hospitalsoffered through the HMO’s network to receivebenefits, except for emergencies.
• Choose a primary care physician (PCP) to serveas your first point of contact for most healthcare services.* Your covered family membersalso must select a PCP. PCPs refer you to network providers for specialty care.
• Pay only a minimal co-payment for HMO in-network physician visits, prescription drugsand some other covered services.
• Have coordinated care through a network ofHMO participating providers.
• Have low-cost access to the many services theHMO offers in preventive health care—well-baby and well-child care, physical exams andimmunizations.
* Note: UnitedHealthcare HMO does not require you to
select a PCP or obtain referrals to specialists.
14
S TAT E H E A L T H B E N E F I T P L A N 2 0 0 3 / 2 0 0 4
Other Points to Consider• Generally, you don’t have to file claims.
• You pay the full cost for most non-referredservices and for services received outside theHMO’s network, except for emergencies.
• In most cases, HMOs do not have a deductibleto meet—so your out-of-pocket costs may be lower.
• There are no pre-existing condition limitations.
• You may be required to follow the HMO’s standardized treatment plan for your condition.For example, you may be required to receivetreatment from your primary care physician for a specified period before being referred to a specialist.
HMO Choice Options
If you are eligible for an HMO Option, you also areeligible for that HMO’s Choice Option.
HMO Choice Option benefits are the same as therespective regular HMO Option benefits. However,the Choice Option premiums are higher. In returnfor a higher premium, the HMO Choice Optiongives members the opportunity to request that an out-of-network provider be treated as an HMOnetwork provider. This request is known as a“nomination.” You may nominate providers if theyare located and licensed in Georgia and offer services the HMO covers. Also, you may nominateas many eligible providers as you wish at any timeduring the Plan year.
If the out-of-network provider accepts your nomination, accepts the HMO’s fees and isapproved by the HMO, you may receive in-net-work benefits from that provider. If your providerdoes not accept your nomination, does not acceptthe HMO’s fees, or does not get approved by theHMO, then services from that provider are notcovered. SHBP rules do not permit a member tochange options when a nominated provider or theHMO rejects a nomination.
Please contact the respective HMO directly to findout more about the required procedures andpaperwork necessary to nominate a provider.
15
S TAT E H E A L T H B E N E F I T P L A N 2 0 0 3 / 2 0 0 4
Medicare+Choice HMO Option(M+C HMO)
The Medicare+Choice HMO Option is availableonly to those retirees who are enrolled in Part Aand Part B Medicare coverage and live in the M+CHMO service area (metro Atlanta). Check page 40in this Guide to find a listing of counties servicedby the M+C HMO.
If you choose the Kaiser M+C HMO, your newcoverage will replace your Medicare coverage.Your claim forms would not be filed withMedicare and the SHBP. All your services and payments would be coordinated through theKaiser M+C HMO.
If you choose the M+C HMO Option, you . . .
• Should refer to the information under the regular HMO Option on page 14 but also note that:
— The Kaiser M+C provider network is different from the regular Kaiser HMOprovider network.
— If your spouse and/or dependents are not Medicare-eligible, they would automaticallybe enrolled in the regular Kaiser HMO.Thebenefits and providers available throughthe regular HMO are different from theM+C HMO.
• Must use providers in the Kaiser M+C HMOnetwork in order to receive coverage. If you gooutside the network, there are usually no bene-fits, except in the case of an emergency.
• Should return the separate form that the HMOsupplies to you to ensure that you are in com-pliance with Medicare requirements.
• Would have coverage for prescription drugs,vision care, and preventive care not covered by Medicare.
Other Points to Consider• You will continue to pay the Medicare Part B
premium, usually deducted from your monthlySocial Security benefit checks.Your coveragewill be based on the rules of the M+C HMOOption, which can offer you the advantages of lower out-of-pocket costs and reducedpaperwork. Medicare pays a portion of yourpremium directly to the M+C HMO.
• You also will pay an SHBP premium, but it willbe lower than regular HMO Option premiums.See your Personalized Change Form for premium information.
• If you select the Kaiser Medicare+Choice HMO,you will receive a temporary ID card or letterto use until Medicare approves your applicationand you receive your permanent ID card.
If you want additional details on your Medicare bene-fits, contact the Social Security Administration.Thephone number and Web site are listed on the insidefront cover of this Guide. If you want additionaldetails on your M+C benefits, see page 28 of thisGuide and/or call the Kaiser Permanente M+C HMOat (800) 956-1358 or (404) 233-3700 in Atlanta.
16
S TAT E H E A L T H B E N E F I T P L A N 2 0 0 3 / 2 0 0 4
How Medicare+Choice Affects Your Current Medicare CoverageIt's important to note that your benefit levels will be greater than those of regular HMOs as long as youcontinue to pay your Medicare Part B premiums.
Your Choice
If you choose traditionalMedicare (Part A and Part B)
If you choose the Kaiser M+C HMO Option
How Medicare Works
. . . then traditional Medicarebecomes your primary plan andpays your medical benefits first
. . . then traditional Medicare nolonger processes your claims.Your Medicare coverage will pay a portion of the M+C HMOpremium.
How SHBP Benefits Work
. . . and your SHBP benefits pay sec-ondary benefits up to the allowedamount for Medicare Part A and PartB coverages.
When Medicare is coordinated with the SHBP, you have 100% coverage on allowed amounts afterthe deductible for eligible services.
. . . and your SHBP benefits will payan additional portion of your M+CHMO premium, making coveragegenerally less expensive than othercoverage options.
17
S TAT E H E A L T H B E N E F I T P L A N 2 0 0 3 / 2 0 0 4
Q&A on Medicare+Choice HMO and Regular HMOs
Q: What if I temporarily live outside myMedicare+Choice or regular HMO service area?
A: If you live in a different area of the country for an extended period, the M+C HMO maynot be the best choice for you. Remember that services are available only within theHMO's service area, except for emergency andacute care, follow-up care, and renal-dialysiscare. Call the HMO directly to request moreinformation if needed.
Q: Can I be denied enrollment in aMedicare+Choice HMO?
A: The Centers for Medicare and MedicaidServices (CMS), responsible for the administra-tion of Medicare, may deny your enrollmentunder these conditions:
• You do not reside in the service area of theM+C HMO.
• You are not entitled to Medicare Part A orare not enrolled in Medicare Part B.
• You have been diagnosed with end-stagerenal disease (ESRD) or received a kidneytransplant within the past 36 months(except for current HMO members). ESRDis kidney failure that requires dialysis or atransplant. However, ESRD beneficiaries cur-rently enrolled in an HMO will be able toenroll in the M+C HMO Option. Note: If youare converting from HMO to M+C HMO cov-erage, you and any dependents must convertinto the same HMO's M+C plan.
• If you are not approved for theMedicare+Choice HMO Option by CMS,you will be placed in the respective regularHMO Option.Your premiums will be adjusted to the regular HMO Option rates.
Q: What happens if I’m out of the HMO service area and need health care?
A: In emergencies, you should first seek treatment.Then contact your PCP as soon as practical.HMOs cover emergency care as if you were intheir network. Routine (non-emergency) careor services that could have been anticipatedare generally not covered outside of yourHMO service area. Refer to the HMO's enroll-ment materials for procedures to follow.
Q: What if I’m unhappy with my primary care physician?
A: If you are unhappy, you can change to anotherprimary care physician.The procedure will varyby HMO, so contact your HMO for assistance.
18
S TAT E H E A L T H B E N E F I T P L A N 2 0 0 3 / 2 0 0 4
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19
S TAT E H E A L T H B E N E F I T P L A N 2 0 0 3 / 2 0 0 4
Comparing Benefits Within Health Plan Options
This section includes two charts, one that
compares specific benefits within the PPO and Indemnity Options and one
that compares HMO Option benefits. Benefit changes for the new Plan year are
in bold type. For more specific information on covered services, call the
Member Services numbers listed on the inside front cover.
To make it easier to view information on the PPO and Indemnity Options, the
chart is formatted in a “landscape” view.
SCH
ED
ULE
OF B
EN
EFIT
S FO
R Y
OU
AN
D Y
OU
R D
EP
EN
DE
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ly 1
,200
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Co
mp
ar
iso
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en
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rgia
Th
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IND
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PT
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Th
e P
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Max
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m L
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efit
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20
An
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Th
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Dru
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Purc
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Ex
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Pu
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-Ray
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-pay
men
to
f $30
;no
t su
bje
ct t
od
edu
ctib
le
90%
of
NR
;su
bje
ct t
o d
edu
ctib
le
100%
of
NR
;no
t su
bje
ctto
th
e d
edu
ctib
le.I
fp
hys
icia
n i
s se
en,v
isit
is
trea
ted
as
an o
ffic
e vi
sit
sub
ject
to
th
e p
er v
isit
co-p
aym
ent
of
$30
.
90%
of
NR
;su
bje
ct t
o d
edu
ctib
le
80%
of
NR
aft
er a
n
init
ial
visi
t co
-pay
men
to
f $30
;no
t su
bje
ct t
od
edu
ctib
le
80%
of
NR
;su
bje
ct t
o d
edu
ctib
le
100%
of
NR
;no
t su
bje
ctto
th
e d
edu
ctib
le.I
fp
hys
icia
n i
s se
en,v
isit
is
trea
ted
as
an o
ffic
e vi
sit
sub
ject
to
th
e p
er v
isit
co-p
aym
ent
of
$30
.
80%
of
NR
;su
bje
ct t
o d
edu
ctib
le
60%
of
OO
NR
;su
bje
ct t
o d
edu
ctib
le
60%
of
OO
NR
;su
bje
ct t
o d
edu
ctib
le
60%
of
OO
NR
;su
bje
ct t
o d
edu
ctib
le
60%
of
OO
NR
;su
bje
ct t
o d
edu
ctib
le
22
CO
MP
AR
ISO
N O
F P
PO
AN
D I
ND
EM
NIT
Y O
PT
ION
S
$15
co-p
aym
ent
for
gen
eric
dru
gs;$
25
co-p
aym
ent
for
pre
ferr
ed b
ran
d n
ame
dru
gs;c
o-p
aym
ent
for
non
-p
refe
rred
bra
nd
nam
e dr
ugs
ran
ges
from
a $
35 m
inim
um
to
a $100
max
imu
m a
nd
is c
alcu
late
d b
ased
on
20%
of
the
net
wor
k p
rice
of
the
dru
g.C
o-p
aym
ents
for
gen
eric
an
d p
refe
rred
bra
nd
nam
e dr
ugs
are
app
lied
to a
qu
arte
rly o
ut-
of-
po
cket
lim
it o
f $300 p
er p
erso
n a
nd
$600 p
er f
amil
y.
Wh
en a
mem
ber
ch
oo
ses
a p
refe
rred
bra
nd
nam
e o
r n
on
-pre
ferr
ed b
ran
d n
ame
dru
g o
ver
its
gen
eric
equ
ival
ent,
the
mem
ber
may
be
resp
on
sib
le f
or
a h
igh
er c
o-p
aym
ent
than
lis
ted
her
ein
.Co
-pay
men
tsar
e b
ased
up
on
su
pp
lies
of
up
to
30
day
s;so
me
dru
gs a
re l
imit
ed t
o a
sta
nd
ard
su
pp
ly o
f le
ss t
han
30
day
s.Se
e th
e SP
D a
nd
Upda
ters
for
det
ails
.
Mem
ber
mu
st p
ay f
ull
char
ges
at p
oin
t o
f sa
le a
nd
su
bm
it a
pap
er c
laim
.Mem
ber
s w
ill b
e re
imb
urs
edat
th
e p
har
mac
y n
etw
ork
rat
e le
ss t
he
req
uir
ed c
o-p
aym
ent
for
cove
red
dru
gs.C
har
ges
are
sub
ject
to
ba
lan
ce b
illi
ng
.Co
vera
ge p
rovi
sio
ns
liste
d a
bo
ve a
lso
ap
ply
.
No
te:
Co
-pay
men
ts a
re p
rora
ted
acco
rdin
g to
th
e am
ou
nt
of
the
dru
gd
isp
ense
d i
f th
e am
ou
nt
dis
pen
sed
is
less
th
an t
he
stan
dar
d s
up
ply
fo
r th
ep
resc
rip
tio
n. Se
e p
age
6.
Ph
ysi
cian
Ser
vice
s Fu
rnis
hed
in
a H
osp
ital
•Su
rger
y in
gen
eral
,in
clu
din
g ch
arge
sb
y su
rgeo
n,a
nes
thes
iolo
gist
,p
ath
olo
gist
an
d r
adio
logi
st
•In
pat
ien
t w
ell-n
ewb
orn
ex
ams
Ph
ysi
cian
Ser
vice
s T
hat
Are
fo
rE
mer
gen
cy C
are
Ou
tpat
ien
t Su
rger
y—
Ph
ysi
cian
’s O
ffic
e
Ou
tpat
ien
t Su
rger
y—
Ho
spit
al/F
acil
ity
Ho
spit
al S
ervi
ces
Oth
er T
han
Th
ose
Th
at A
re f
or
Em
erge
ncy
Car
e
•In
pat
ien
t ca
re,i
ncl
ud
ing
inp
atie
nt
sho
rt-t
erm
acu
te r
ehab
ilita
tio
n s
ervi
ces
•O
utp
atie
nt
serv
ices
— N
on
-em
erge
ncy
use
of
emer
gen
cy r
oo
m—
Oth
er
•W
ell-n
ewb
orn
car
e
90%
of
IR;
sub
ject
to
ded
uct
ible
No
t co
vere
d
90%
of
IR;s
ub
ject
to
ded
uct
ible
an
d t
o b
al-
an
ce b
illi
ng
fro
m n
on
-p
arti
cip
atin
g p
rovi
der
s
90%
of
IR;
sub
ject
to
ded
uct
ible
90%
of
IR;
sub
ject
to
ded
uct
ible
90%
of
IR;s
ub
ject
to
ap
er a
dm
issi
on
ded
uct
ible
of
$400
90%
of
IR;
sub
ject
to
ded
uct
ible
.If
ser
vice
s ar
e in
co
nju
nct
ion
wit
h n
on
-em
erge
ncy
use
of
emer
gen
cy r
oo
m,
ben
efit
als
o s
ub
ject
to
$100
/vis
it c
o-p
aym
ent.
90%
of
IR;n
ot
sub
ject
to d
edu
ctib
le
90%
of
NR
;su
bje
ct t
o d
edu
ctib
le
100%
of
NR
;no
t su
bje
ctto
ded
uct
ible
90%
of
NR
;su
bje
ct t
o d
edu
ctib
le
90%
of
NR
;su
bje
ct t
o d
edu
ctib
le
90%
of
NR
;su
bje
ct t
o d
edu
ctib
le
90%
of
NR
;su
bje
ct t
o a
per
ad
mis
sio
n d
edu
ctib
le
of
$250
90%
of
NR
;su
bje
ct t
o d
edu
ctib
le.
If s
ervi
ces
are
in
con
jun
ctio
n w
ith
no
n-
emer
gen
cy u
se o
f em
erge
ncy
ro
om
,b
enef
it a
lso
su
bje
ct t
o$100
/vis
it c
o-p
aym
ent.
100%
of
NR
;no
t su
bje
ct t
o d
edu
ctib
le
80%
of
NR
;su
bje
ct t
o d
edu
ctib
le
100%
of
NR
;no
t su
bje
ctto
ded
uct
ible
90%
of
NR
;su
bje
ct t
oIn
-Net
wo
rk/G
eorg
iad
edu
ctib
le
80%
of
NR
;su
bje
ct t
o d
edu
ctib
le
80%
of
NR
;su
bje
ct t
o d
edu
ctib
le
80%
of
NR
;su
bje
ct t
o a
per
ad
mis
sio
n d
edu
ctib
le
of
$250
80%
of
NR
;su
bje
ct t
o d
edu
ctib
le.
If s
ervi
ces
are
in
con
jun
ctio
n w
ith
no
n-
emer
gen
cy u
se o
f em
erge
ncy
ro
om
,b
enef
it a
lso
su
bje
ct t
o$100
/vis
it c
o-p
aym
ent.
100%
of
NR
;no
t su
bje
ct t
o d
edu
ctib
le
60%
of
OO
NR
;su
bje
ct t
o d
edu
ctib
le
No
t co
vere
d
90%
of
NR
;su
bje
ct t
oIn
-Net
wo
rk/G
eorg
iad
edu
ctib
le a
nd
to
ba
lan
ce b
illi
ng
60%
of
OO
NR
;su
bje
ct t
o d
edu
ctib
le
60%
of
OO
NR
;su
bje
ct t
o d
edu
ctib
le
60%
of
OO
NR
;su
bje
ct t
o a
per
ad
mis
sio
n d
edu
ctib
le
of
$250
60%
of
OO
NR
;su
bje
ct t
o d
edu
ctib
le.
If s
ervi
ces
are
in
con
jun
ctio
n w
ith
no
n-
emer
gen
cy u
se o
f em
erge
ncy
ro
om
,b
enef
it a
lso
su
bje
ct t
o$100
/vis
it c
o-p
aym
ent.
60%
of
OO
NR
;no
tsu
bje
ct t
o d
edu
ctib
le
23
CO
VE
RE
D S
ER
VIC
ES
PP
O O
PT
ION
Ou
t-o
f-Net
wo
rk
Th
e P
lan
Pays
:
PP
O O
PT
ION
In-N
etw
ork
/Ou
t-o
f-Sta
te
Th
e P
lan
Pays
:
PP
O O
PT
ION
In-N
etw
ork
/Geo
rgia
Th
e P
lan
Pays
:
IND
EM
NIT
Y O
PT
ION
Th
e P
lan
Pays
:
Ho
spit
al S
ervi
ces
Th
at A
re f
or
Em
erge
ncy
Car
e •
Trea
tmen
t o
f an
em
erge
ncy
med
ical
con
dit
ion
or
inju
ry
Not
es:
Th
e $1
00co
-pay
men
t is
red
uced
to
$80
if r
efer
red
by
Nur
seC
all 2
4 b
efor
ere
ceiv
ing
emer
gen
cy r
oom
ser
vice
s.
Am
bu
lan
ce S
ervi
ces
for
Em
erge
ncy
Car
e
No
tes:
Lim
ited
to
tra
nsp
ort
atio
n f
or
emer
-ge
nci
es a
nd
ben
efit
s su
bje
ct t
o b
ala
nce
bil
lin
gfr
om
no
n-p
arti
cip
atin
g p
rovi
der
so
f am
bu
lan
ce s
ervi
ces.
Urg
ent
Car
e Se
rvic
es i
n a
n A
pp
rove
dU
rgen
t C
are
Cen
ter
Ho
me
Nu
rsin
g C
are
Ap
pro
ved
in
Ad
van
ce b
y t
he
MC
P
No
tes:
Ho
me
nu
rsin
g ca
re n
ot
revi
ewed
by
the
MC
P –
Co
vers
tw
o h
ou
rs o
f m
ed-
ical
ly n
eces
sary
ski
lled
ho
me
care
per
day
by
RN
or
LPN
if
ord
ered
by
a p
hys
icia
n;
limit
ed t
o $
7,50
0 p
er P
lan
yea
r.$7
,500
limit
is
a co
mb
ined
to
tal
in P
PO
Op
tio
ns.
Mem
ber
’s s
har
e o
f co
st i
s n
ot
app
lied
to
Pla
n y
ear
ou
t-o
f-po
cket
lim
its.
Skil
led
Nu
rsin
g Fac
ilit
y S
ervi
ces
90%
of
IR a
fter
a p
ervi
sit
co-p
aym
ent
of $
100
;co
-insu
ran
ce a
nd
h
osp
ital
ded
uct
ible
,if
adm
itte
d,a
pp
ly.S
ub
ject
to b
ala
nce
bil
lin
gfr
om
no
n-p
arti
cip
atin
gp
rovi
der
s.
90%
of
IR;
sub
ject
to
ded
uct
ible
90%
of
IR;
sub
ject
to
ded
uct
ible
90%
of
IR;
sub
ject
to
ded
uct
ible
No
t co
vere
d
90%
of
NR
aft
er a
per
visi
t co
-pay
men
t of
$100
;co
-insu
ran
ce a
nd
h
osp
ital
ded
uct
ible
, if
adm
itte
d,
app
ly
90%
of
NR
;su
bje
ct t
o d
edu
ctib
le
90%
of
NR
aft
er a
per
visi
t co
-pay
men
t o
f $45
;su
bje
ct t
o d
edu
ctib
le
90%
of
NR
;su
bje
ct t
o d
edu
ctib
le
No
t co
vere
d
90%
of
NR
aft
er a
p
er v
isit
co
-pay
men
t o
f $100
;co
-insu
ran
ce
and
ho
spit
al d
edu
ctib
le,
if a
dm
itte
d, a
pp
ly
90%
of
NR
;su
bje
ct t
oIn
-Net
wo
rk/G
eorg
iad
edu
ctib
le
90%
of
NR
aft
er a
per
visi
t co
-pay
men
t o
f $45
;su
bje
ct t
o d
edu
ctib
le
80%
of
NR
;su
bje
ct t
o d
edu
ctib
le
No
t co
vere
d
90%
of
OO
NR
aft
er a
per
vis
it c
o-p
aym
ent
of
$100
;co
-insu
ran
ce a
nd
ho
spit
al d
edu
ctib
le,
if a
dm
itte
d,
app
ly.
Sub
ject
to
ba
lan
cebil
lin
g.
90%
of
OO
NR
;su
bje
ctto
In
-Net
wo
rk/G
eorg
iad
edu
ctib
le
No
t ap
plic
able
60%
of
OO
NR
;su
bje
ct t
o d
edu
ctib
le
No
t co
vere
d
24
CO
MP
AR
ISO
N O
F P
PO
AN
D I
ND
EM
NIT
Y O
PT
ION
S
Ho
spic
e C
are
Du
rab
le M
edic
al E
qu
ipm
ent
(DM
E)—
Ren
tal
or
Pu
rch
ase
Ou
tpat
ien
t A
cute
Sh
ort
-Ter
mR
ehab
ilit
atio
n S
ervi
ces
Not
es:C
over
age
for
up t
o 40
vis
its
per
Pla
nye
ar w
hen
con
diti
ons
are
met
for
phy
sica
l,sp
eech
an
d oc
cup
atio
nal
th
erap
ies
and
for
card
iac
reh
abili
tati
on.
Den
tal
and
Ora
l C
are—
Lim
ited
Co
vera
ge
•C
ove
rage
in
gen
eral
No
tes:
Co
vera
ge f
or
mo
st p
roce
du
res
for
the
pro
mp
t re
pai
r o
f so
un
d n
atu
ral
teet
ho
r ti
ssu
e fo
r th
e co
rrec
tio
n o
f d
amag
eca
use
d b
y tr
aum
atic
in
jury
.
•C
over
age
of
spec
ific
oss
eou
s su
rger
ies
for
the
trea
tmen
t o
f p
erio
do
nta
l d
isea
se
•Te
mp
oro
man
dib
ula
r jo
int
syn
dro
me
(TM
J)
Not
es:C
over
age
only
for
dia
gnos
tic
test
ing
and
no
n-s
urg
ical
tre
atm
ent
of T
MJ,
up
to
$1,1
00 p
er p
erso
n l
ifet
ime
max
imu
m
ben
efit
.
100%
of
IR,u
p t
oM
edic
are’
s ap
pro
ved
lifet
ime
max
imu
m;s
ub
-je
ct t
o d
edu
ctib
le a
nd
to h
osp
ital
ded
uct
ible
,if
in l
ieu
of
ho
spit
aliz
atio
n
90%
of
IR;
sub
ject
to
ded
uct
ible
90%
of
IR;s
ub
ject
to
ded
uct
ible
90%
of
IR;
sub
ject
to
ded
uct
ible
and
,if
adm
itte
d,t
o
ho
spit
al d
edu
ctib
le
No
t co
vere
d
90%
of
IR;
sub
ject
to
ded
uct
ible
100%
of
NR
;su
bje
ct t
o d
edu
ctib
lean
d t
o h
osp
ital
ded
uct
ible
, if
in
lie
uo
f h
osp
ital
izat
ion
90%
of
NR
;su
bje
ct t
o d
edu
ctib
le
90%
of
NR
;su
bje
ct t
od
edu
ctib
le a
nd
$20
/vis
itco
-pay
men
t
90%
of
NR
;sub
ject
to
dedu
ctib
le a
nd
, if
ad
mit
ted
, to
ho
spit
ald
edu
ctib
le.N
etw
ork
pro
vide
rs m
ay n
ot b
eav
aila
ble
for
all c
over
edse
rvic
es;c
har
ges
are
pai
dat
90%
of
NR
,sub
ject
to
bala
nce
bil
lin
g.
No
t co
vere
d
90%
of
NR
;su
bje
ct t
o d
edu
ctib
le
100%
of
NR
;su
bje
ct t
o d
edu
ctib
lean
d t
o h
osp
ital
ded
uct
ible
, if
in
lie
uo
f h
osp
ital
izat
ion
80%
of
NR
;su
bje
ct t
o d
edu
ctib
le
80%
of
NR
;su
bje
ct t
od
edu
ctib
le a
nd
$20
/vis
itco
-pay
men
t
80%
of
NR
;sub
ject
to
dedu
ctib
le a
nd
, if
ad
mit
ted
, to
ho
spit
ald
edu
ctib
le.N
etw
ork
pro
vide
rs m
ay n
ot b
eav
aila
ble
for
all c
over
edse
rvic
es;c
har
ges
are
pai
dat
80%
of
NR
,sub
ject
to
bala
nce
bil
lin
g.
No
t co
vere
d
80%
of
NR
;su
bje
ct t
o d
edu
ctib
le
60%
of
OO
NR
;su
bje
ct t
o d
edu
ctib
le
and
to
ho
spit
ald
edu
ctib
le,
if i
n l
ieu
of
ho
spit
aliz
atio
n
60%
of
OO
NR
;su
bje
ct t
o d
edu
ctib
le
60%
of
OO
NR
;su
bje
ct t
o d
edu
ctib
le
60%
of
OO
NR
;su
bje
ct t
o d
edu
ctib
lean
d,
if a
dm
itte
d,
toh
osp
ital
ded
uct
ible
No
t co
vere
d
60%
of
OO
NR
;su
bje
ct t
o d
edu
ctib
le
25
CO
VE
RE
D S
ER
VIC
ES
PP
O O
PT
ION
Ou
t-o
f-Net
wo
rk
Th
e P
lan
Pays
:
PP
O O
PT
ION
In-N
etw
ork
/Ou
t-o
f-Sta
te
Th
e P
lan
Pays
:
PP
O O
PT
ION
In-N
etw
ork
/Geo
rgia
Th
e P
lan
Pays
:
IND
EM
NIT
Y O
PT
ION
Th
e P
lan
Pays
:
Ch
iro
pra
ctic
Car
e
No
tes:
Co
vera
ge f
or
up
to
a m
axim
um
of
40 v
isit
s p
er P
lan
yea
r.
Beh
avio
ral
Hea
lth
Car
eW
ith
BH
S au
tho
riza
tio
n,r
egar
dle
ss o
fH
ealt
h P
lan
op
tio
n
Car
e re
ceiv
ed o
uts
ide
of
BH
S n
etw
ork
or
wit
ho
ut
BH
S au
tho
riza
tio
n,r
egar
dle
ss o
fH
ealt
h P
lan
op
tio
n
Tra
nsp
lan
t Se
rvic
es
90%
of
IR;s
ub
ject
to
ded
uct
ible
90
% o
f N
R;s
ub
ject
to
ded
uct
ible
an
d $
20/v
isit
co-p
aym
ent
80%
of
NR
;su
bje
ct t
od
edu
ctib
le a
nd
$20
/vis
itco
-pay
men
t
60%
of
OO
NR
;su
bje
ct t
o d
edu
ctib
le
26
CO
MP
AR
ISO
N O
F P
PO
AN
D I
ND
EM
NIT
Y O
PT
ION
S
Inp
atie
nt
ho
spit
al s
ervi
ces
for
men
tal
hea
lth
an
d s
ub
stan
ce a
bu
se a
re c
over
ed a
t 90
% o
f n
etw
ork
rat
e fo
ru
p t
o a
co
mb
ined
to
tal
of
60 d
ays
per
per
son
,per
Pla
n y
ear;
asso
ciat
ed p
rofe
ssio
nal
fee
s ar
e co
vere
dat
80%
of
net
wo
rk r
ate
for
up
to
60
visi
ts.P
arti
al h
osp
ital
izat
ion
pro
gram
(P
HP
) an
d i
nte
nsi
ve o
utp
atie
nt
(IO
P)
char
ges
are
cove
red
at
90%
of
the
net
wo
rk r
ate
wit
h B
HS
auth
ori
zati
on
(lim
ited
to
30
com
bin
edP
HP
an
d I
OP
vis
its/
day
s p
er P
lan
yea
r);n
o b
enef
it w
ith
ou
t B
HS
auth
ori
zati
on
.Ou
tpat
ien
t p
rofe
ssio
nal
serv
ices
fo
r m
enta
l h
ealt
h a
nd
su
bst
ance
ab
use
are
co
vere
d a
t 80
% o
f n
etw
ork
rat
e fo
r u
p t
o 5
0 vi
sits
per
Pla
n y
ear.
Vis
it l
imit
atio
n i
ncl
ud
es u
p t
o t
hre
e b
rief
sit
uat
ion
al c
ou
nse
ling
sess
ion
s co
vere
d a
t 10
0%w
ith
ou
t d
edu
ctib
le.A
ll el
igib
le c
har
ges
are
sub
ject
to
ded
uct
ible
s ($
300
PP
O i
n-n
etw
ork
/Geo
rgia
;$30
0In
dem
nit
y O
pti
on
ded
uct
ible
an
d $
100
per
co
nfi
nem
ent
ho
spit
al d
edu
ctib
le)
and
to
a s
epar
ate
ou
t-o
f-p
ock
et l
imit
of
$2,5
00 p
er p
erso
n,p
er P
lan
yea
r.N
o i
np
atie
nt
ben
efit
is
avai
lab
le w
ith
ou
t a
BH
Sau
tho
riza
tio
n.S
ee t
he
SPD
an
d U
pda
ters
for
full
det
ails
on
co
vera
ge p
rovi
sio
ns
and
ex
clu
sio
ns.
Inp
atie
nt
ho
spit
al s
ervi
ces
for
men
tal
hea
lth
an
d s
ub
stan
ce a
bu
se a
re c
ove
red
at
60%
of
the
aver
age
net
wo
rk p
er d
iem
rat
e w
hen
BH
S-au
tho
rize
d f
or
up
to
a c
om
bin
ed t
ota
l o
f 60
day
s p
er P
lan
yea
r;as
soci
ated
pro
fess
ion
al f
ees
are
cove
red
at
50%
of
the
net
wo
rk r
ate
for
up
to
25
visi
ts p
er P
lan
yea
r.N
oin
pat
ien
t b
enef
it i
s av
aila
ble
wit
ho
ut
a B
HS
auth
ori
zati
on
.Ou
tpat
ien
t p
rofe
ssio
nal
(M
D/P
hD
) se
rvic
esfo
r m
enta
l h
ealt
h a
nd
su
bst
ance
ab
use
are
co
vere
d a
t 50
% o
f th
e n
etw
ork
rat
e fo
r u
p t
o 2
5 vi
sits
per
Pla
n y
ear.
All
elig
ible
ch
arge
s ar
e su
bje
ct t
o d
edu
ctib
les
and
do
no
t ac
cum
ula
te t
ow
ard
an
y o
ut-
of-p
ock
-et
lim
it.B
ala
nce
bil
lin
gm
ay a
pp
ly.S
ee t
he
SPD
an
d U
pda
ters
for
full
det
ails
on
co
vera
ge p
rovi
sio
ns
and
ex
clu
sio
ns.
Th
e le
vel
of
ben
efit
co
vera
ge i
s b
ased
on
wh
eth
er o
r n
ot
you
sel
ect
a co
ntr
acte
d t
ran
spla
nt
cen
ter,
rega
rdle
ss o
f yo
ur
Hea
lth
Pla
n o
pti
on
.At
con
trac
ted
cen
ters
,th
e le
vel
of
ben
efit
co
vera
ge i
s 90
% o
f th
en
etw
ork
rat
e fo
r co
vere
d s
ervi
ces.
At
no
n-c
on
trac
ted
cen
ters
,th
e le
vel
of
ben
efit
co
vera
ge i
s 60
% o
fth
e n
etw
ork
rat
e fo
r co
vere
d s
ervi
ces.
Sub
ject
to
ho
spit
al d
edu
ctib
le o
f $1
00 p
er a
dm
issi
on
.
IMP
OR
TAN
T C
ON
SID
ER
AT
ION
S
•C
har
ges
fro
m n
on
-par
tici
pat
ing
pro
vid
ers
are
sub
ject
to
bal
ance
bil
lin
g.A
mo
un
ts b
alan
ce b
illed
by
no
n-p
arti
cip
atin
g p
rovi
der
s ar
e th
em
emb
er’s
res
po
nsi
bili
ty a
nd
do
no
t co
un
t to
war
d d
edu
ctib
les
or
ou
t-o
f-po
cket
sp
end
ing
limit
s.
•Se
rvic
es c
ove
red
un
der
th
e P
PO
fro
m a
n I
n-N
etw
ork
/Geo
rgia
pro
vid
er w
ill a
pp
ly o
nly
to
th
e In
-Net
wo
rk/G
eorg
ia d
edu
ctib
le a
nd
o
ut-
of-p
ock
et l
imit
.
•Se
rvic
es c
ove
red
un
der
th
e P
PO
fro
m i
n-n
etw
ork
/ou
t-o
f-sta
te a
nd
ou
t-o
f-net
wo
rk p
rovi
der
s ap
ply
to
th
e sa
me
ded
uct
ible
an
d o
ut-
of-p
ock
et l
imit
.
•Li
feti
me
ben
efit
max
imu
ms
are
com
bin
ed t
ota
ls a
mo
ng
the
PP
O O
pti
on
s,In
dem
nit
y O
pti
on
an
d H
MO
Op
tio
ns
(ex
cep
t fo
r K
aise
r Pe
rman
ente
).
•So
me
PP
O a
nn
ual
max
imu
ms
and
lim
itat
ion
s ar
e co
mb
ined
to
tals
.
•A
nn
ual
do
llar
and
vis
it l
imit
atio
ns,
ded
uct
ible
s an
d o
ut-
of-p
ock
et s
pen
din
g lim
its
are
bas
ed o
n a
Ju
ly 1
to
Ju
ne
30 P
lan
yea
r.
•So
me
serv
ices
may
req
uir
e M
CP
pre
cert
ific
atio
n,p
rio
r ap
pro
val
or
lett
ers
of
med
ical
nec
essi
ty b
efo
re s
uch
ser
vice
s ar
e co
vere
d b
y th
e P
lan
.
•C
o-p
aym
ents
do
no
t ap
ply
to
war
d d
edu
ctib
les
or
ou
t-o
f-po
cket
lim
its
un
less
oth
erw
ise
no
ted
.
•C
o-p
aym
ents
fo
r a
pre
scri
pti
on
dru
g m
ay c
han
ge a
t an
y ti
me
du
rin
g th
e P
lan
yea
r d
ue
to a
ch
ange
in
th
e st
atu
s o
f th
e d
rug
on
th
e P
lan
’s
pre
ferr
ed d
rug
list.
For
inst
ance
,if
a p
refe
rred
bra
nd
is
recl
assi
fied
as
a ge
ner
ic,y
ou
r co
-pay
men
t w
ou
ld d
ecre
ase.
Als
o,i
f a
pre
ferr
ed b
ran
d i
sre
clas
sifi
ed a
s a
no
n-p
refe
rred
bra
nd
,yo
ur
co-p
aym
ent
wo
uld
in
crea
se.
•P
PO
an
d I
nd
emn
ity
Op
tio
ns
incl
ud
e a
dis
cou
nt
pro
gram
fo
r vi
sio
n s
cree
nin
gs a
nd
eye
wea
r.C
on
tact
th
e B
lueC
ho
ice
Vis
ion
Pro
gram
at
(800
) 37
7-64
36 o
r vi
sit
ww
w.b
cbsg
a.co
mfo
r m
ore
in
form
atio
n.V
isio
n p
rogr
am a
vaila
bili
ty i
s su
bje
ct t
o c
han
ge d
uri
ng
the
Pla
n y
ear.
•Se
e th
e SP
D a
nd
Upda
ters
for
cove
rage
det
ails
,in
clu
din
g lim
itat
ion
s an
d e
xcl
usi
on
s.
27
CO
VE
RE
D S
ER
VIC
ES
UN
ITE
DH
EA
LTH
CA
RE
Th
e P
lan
Pays
:
KA
ISE
R P
ER
MA
NE
NT
E
and
KA
ISE
R P
ER
MA
NE
NT
EM
ED
ICA
RE
+CH
OIC
E (
M+
C)
The
Pla
n P
ays
:
CIG
NA
Th
e P
lan
Pays
:B
LUE
CH
OIC
ETh
e P
lan
Pays
:
Max
imu
m L
ifet
ime
Ben
efit
Pre
-ex
isti
ng
Co
nd
itio
ns
(1st
yea
r in
Pla
n o
nly
,su
bje
ct t
o H
IPA
A)
Life
tim
e B
enef
it L
imit
fo
r T
reat
men
t o
f:
•Te
mp
oro
man
dib
ula
r jo
int
dysf
un
ctio
n (
TM
J)•
Sub
stan
ce a
bu
se•
Org
an a
nd
tis
sue
tran
spla
nts
•H
om
e h
yper
alim
enta
tio
n
Ded
uct
ible
s/C
o-p
aym
ents
:
•D
edu
ctib
le—
ind
ivid
ual
•D
edu
ctib
le—
fam
ily m
axim
um
$2 m
illio
n
(all
SHB
P l
imit
s co
mb
ined
)
No
ne
No
sep
arat
e lif
etim
eb
enef
it l
imit
No
t ap
plic
able
$2 m
illio
n(a
ll SH
BP
lim
its
com
bin
ed)
No
ne
No
sep
arat
e lif
etim
eb
enef
it l
imit
No
t ap
plic
able
No
lif
etim
e b
enef
it
max
imu
ms
No
ne
No
lif
etim
e b
enef
it
max
imu
ms
No
t ap
plic
able
$2 m
illio
n
(all
SHB
P l
imit
s co
mb
ined
)
No
ne
No
sep
arat
e lif
etim
eb
enef
it l
imit
No
t ap
plic
able
HM
O C
OV
ER
ED
SE
RV
ICE
S
28
Th
e fo
llow
ing
char
t su
mm
ariz
es t
he
ben
efit
s o
ffer
ed b
y th
e H
MO
s—B
lueC
ho
ice,
CIG
NA
,Kai
ser
Perm
anen
te,K
aise
r Pe
rman
ente
Med
icar
e+C
ho
ice
and
Un
ited
Hea
lth
care
.Mo
st c
ove
red
ser
vice
s ar
e th
e sa
me
for
each
HM
O.I
f yo
u a
re t
ryin
g to
ch
oo
se a
mo
ng
HM
Os,
you
sh
ou
ld:
•C
hec
k th
e se
rvic
e ar
ea c
ove
red
by
each
HM
O t
o s
ee i
f yo
u l
ive
in a
n a
pp
rove
d c
ou
nty
.
•C
hec
k w
hic
h p
hys
icia
ns,
spec
ialis
ts a
nd
ho
spit
als
are
off
ered
th
rou
gh t
he
HM
Os’
net
wo
rks.
Wo
uld
yo
u h
ave
to s
wit
ch p
hys
icia
ns
if y
ou
sel
ecte
d a
new
HM
O?
Are
ph
ysic
ian
s' o
ffic
es l
oca
ted
nea
r yo
u?
Ph
on
e n
um
ber
s an
d W
eb s
ites
fo
r th
e H
MO
s ar
e lis
ted
on
th
e in
sid
e fr
on
t co
ver.
•C
om
par
e co
vere
d s
ervi
ces
and
wh
at y
ou
r p
rem
ium
wo
uld
be
for
each
.
To h
elp
yo
u c
om
par
e al
l SH
BP
op
tio
ns,
this
HM
O c
har
t fo
llow
s th
e sa
me
form
at a
s th
e P
PO
an
d I
nd
emn
ity
Op
tio
n c
om
par
iso
n o
f b
enef
its.
Th
e K
aise
rPe
rman
ente
an
d K
aise
r Pe
rman
ente
Med
icar
e+C
ho
ice
ben
efit
s ar
e th
e sa
me,
exce
pt
wh
ere
no
ted
.
Co
mp
ar
iso
n o
f B
en
ef
its
: H
MO
Op
tio
ns
con
tin
ued
...•
Ho
spit
al c
o-p
aym
ent/
adm
issi
on
•Em
erge
ncy
ro
om
co
-pay
men
t•
Urg
ent
care
cen
ter
co-p
aym
ent
An
nu
al O
ut-
of-
Po
cket
Lim
its:
•In
div
idu
al (
you
or
on
e o
f yo
ur
dep
end
ents
) •
Fam
ily (
you
an
d y
ou
r d
epen
den
ts)
Pri
mar
y C
are
Ph
ysi
cian
or
Spec
iali
stO
ffic
e o
r C
lin
ic V
isit
s:
•Tr
eatm
ent
of
illn
ess
or
inju
ry
Pri
mar
y C
are
Ph
ysic
ian
or
Spec
iali
stO
ffic
e o
r C
lin
ic V
isit
s fo
r th
e fo
llo
win
g:•
Wel
lnes
s ca
re/p
reve
nti
ve h
ealt
h c
are
•W
ell-n
ewb
orn
ex
am•
Wel
l-ch
ild e
xam
s an
d i
mm
un
izat
ion
s•
An
nu
al p
hys
ical
s•
An
nu
al g
ynec
olo
gica
l ex
ams
$200
$50
(wai
ved
if a
dmit
ted)
$25
(ref
erra
l re
qu
ired
)
No
t ap
plic
able
100%
aft
er a
per
vis
itco
-pay
men
t o
f $1
5 fo
rp
rim
ary
care
an
d $
20fo
r sp
ecia
lty
care
100%
aft
er a
per
vis
itco
-pay
men
t o
f $1
5 fo
rp
rim
ary
care
an
d $
20fo
r sp
ecia
lty
care
$200
$50
(wai
ved
if a
dmit
ted)
$25
No
t ap
plic
able
100%
aft
er a
per
vis
itco
-pay
men
t o
f $1
5 fo
rp
rim
ary
care
an
d $
20fo
r sp
ecia
lty
care
100%
aft
er a
per
vis
itco
-pay
men
t o
f $1
5 fo
rp
rim
ary
care
an
d $
20fo
r sp
ecia
lty
care
.N
o c
o-p
aym
ent
for
imm
un
izat
ion
s an
dm
amm
ogr
ams.
$200
$50
(wai
ved
if a
dmit
ted)
$30
No
t ap
plic
able
Kai
ser
Perm
anen
te M
+C
:$1
,500
per
in
div
idu
al,
$4,5
00 p
er f
amily
,per
Pla
n Y
ear
100%
aft
er a
per
vis
it
co-p
aym
ent
of
$15
for
pri
mar
y ca
re a
nd
$20
fo
rsp
ecia
lty
care
100%
aft
er a
per
vis
it c
o-
pay
men
t o
f $1
5 fo
r p
ri-
mar
y ca
re a
nd
$20
fo
rsp
ecia
lty
care
.N
o c
o-p
aym
ent
for
imm
un
izat
ion
s an
d
mam
mo
gram
s.
$200
$50
(wai
ved
if a
dmit
ted)
$25
No
t ap
plic
able
100%
aft
er a
per
vis
itco
-pay
men
t o
f $1
5 fo
rp
rim
ary
care
an
d $
20fo
r sp
ecia
lty
care
100%
aft
er a
per
vis
itco
-pay
men
t o
f $1
5 fo
rp
rim
ary
care
an
d $
20fo
r sp
ecia
lty
care
.N
o c
o-p
aym
ent
for
imm
un
izat
ion
s an
d
mam
mo
gram
s.
29
CO
VE
RE
D S
ER
VIC
ES
UN
ITE
DH
EA
LTH
CA
RE
Th
e P
lan
Pays
:C
IGN
ATh
e P
lan
Pays
:B
LUE
CH
OIC
ETh
e P
lan
Pays
:
Pre
scri
pti
on
Dru
gs
•G
ener
ic•
Pref
erre
d b
ran
d n
ame
•N
on-p
refe
rred
bra
nd
nam
e
•G
ener
ic•
Pref
erre
d b
ran
d n
ame
•N
on-p
refe
rred
bra
nd
nam
e
•M
ain
ten
ance
med
icat
ion
s
Not
es:C
over
s on
ly p
resc
rip
tion
s fi
lled
at
par
tici
pat
ing
loca
l ph
arm
acy
or H
MO
m
edic
al c
ente
r.
Mat
ern
ity T
reat
men
t —
Ph
ysi
cian
Ser
vice
s (p
re-n
atal
an
d p
ost
-nat
al)
Lab
ora
tory
; X
-Ray
s; D
iagn
ost
ic T
ests
;In
ject
ion
s, i
ncl
ud
ing
Med
icat
ion
s C
ove
red
Un
der
Med
ical
Ben
efit
s—fo
rth
e T
reat
men
t o
f an
Ill
nes
s o
r In
jury
100%
aft
er y
ou
r p
er
pre
scri
pti
on
co
-pay
men
t
•$1
0•
$20
•$3
5
90-d
ay s
up
ply
co
vere
daf
ter
two
co
-pay
men
ts
100%
aft
er a
n i
nit
ial
co-p
aym
ent
of
$20
100%
100%
aft
er y
ou
r p
erp
resc
rip
tio
n
co-p
aym
ent
•$1
0•
$20
•$3
5
90-d
ay s
up
ply
co
vere
daf
ter
two
co
-pay
men
ts
100%
aft
er a
n i
nit
ial
co-p
aym
ent
of
$20
100%
100%
aft
er y
ou
r p
er
pre
scri
pti
on
co
-pay
men
t
At
Kai
ser
ph
arm
acy
At
Ecke
rd’s
•$1
0•
$16
•$2
0•
$26
•N
ot
•N
ot
app
licab
le
ap
plic
able
Kai
ser
Perm
anen
te M
+C
:•
$10
•$1
6•
$15
•$2
1•
No
t•
No
t ap
plic
able
a
pp
licab
le
100%
aft
er a
n i
nit
ial
co-p
aym
ent
of
$20
Kai
ser
Perm
anen
te M
+C
:10
0% c
ove
rage
100%
100%
aft
er y
ou
r p
erp
resc
rip
tio
n
co-p
aym
ent
•$1
0•
$20
•$3
5
90-d
ay s
up
ply
co
vere
daf
ter
two
co
-pay
men
ts
100%
aft
er a
n i
nit
ial
co-p
aym
ent
of
$20
100%
HM
O C
OV
ER
ED
SE
RV
ICE
S
30
KA
ISE
R P
ER
MA
NE
NT
E
and
KA
ISE
R P
ER
MA
NE
NT
EM
ED
ICA
RE
+CH
OIC
E (
M+
C)
The
Pla
n P
ays
:
Up
to
90-d
ay s
up
ply
;co
-pay
men
t is
per
30
-day
su
pp
ly;a
pp
lies
to K
aise
r an
d K
aise
r M
+C
.
All
ergy
Sh
ots
an
d S
eru
m
All
ergy
Tes
tin
g
Ph
ysi
cian
Ser
vice
s Fu
rnis
hed
in
a H
osp
ital
•Su
rger
y in
gen
eral
,in
clu
din
g ch
arge
sb
y su
rgeo
n,a
nes
thes
iolo
gist
,pat
ho
lo-
gist
an
d r
adio
logi
st
•In
pat
ien
t w
ell-n
ewb
orn
ex
ams
Ph
ysi
cian
Ser
vice
s T
hat
Are
fo
rE
mer
gen
cy C
are
Ou
tpat
ien
t Su
rger
y—
Ph
ysi
cian
’s O
ffic
e
Ou
tpat
ien
t Su
rger
y—
Ho
spit
al/F
acil
ity
Ho
spit
al S
ervi
ces
Oth
er T
han
Th
ose
Th
at A
re f
or
Em
erge
ncy
Car
e
•In
pat
ien
t ca
re,i
ncl
ud
ing
inp
atie
nt
sho
rt-t
erm
acu
te r
ehab
ilita
tio
n s
ervi
ces
100%
fo
r sh
ots
an
dse
rum
aft
er a
co
-pay
men
t o
f $2
0 p
er v
isit
100%
aft
er p
er v
isit
co-p
aym
ent
of
$20
100%
100%
100%
aft
er a
pp
licab
le
co-p
aym
ent
100%
aft
er $
20
co-p
aym
ent
if b
illed
as
offi
ce v
isit
;100
% a
fter
$100
co-
pay
men
t if
bill
edas
ou
tpat
ien
t su
rger
y
100%
aft
er $
100
per
co
nfi
nem
ent
co-p
aym
ent
100%
aft
er $
200
per
co
nfi
nem
ent
co-p
aym
ent
100%
fo
r sh
ots
an
dse
rum
aft
er a
co
-pay
men
t o
f $2
0 p
er v
isit
100%
aft
er p
er v
isit
co-p
aym
ent
of
$20
100%
100%
100%
aft
er a
pp
licab
le
co-p
aym
ent
100%
aft
er $
20
co-p
aym
ent
if b
illed
as
offi
ce v
isit
;100
% a
fter
$100
co-
pay
men
t if
bill
edas
out
pat
ien
t su
rger
y
100%
aft
er $
100
per
co
nfi
nem
ent
co-p
aym
ent
100%
aft
er $
200
per
co
nfi
nem
ent
co-p
aym
ent
$5 f
or
sho
ts a
nd
$50
fo
r si
x-m
on
th s
up
ply
o
f se
rum
Kai
ser
Perm
anen
te M
+C
:$5
fo
r sh
ots
,no
ch
arge
for
seru
m
100%
aft
er p
er v
isit
co-p
aym
ent
of
$20
100%
100%
100%
aft
er a
pp
licab
le
co-p
aym
ent
100%
aft
er $
20
co-p
aym
ent
if b
illed
as
offi
ce v
isit
;100
% a
fter
$100
co-
pay
men
t if
bill
edas
ou
tpat
ien
t su
rger
y
100%
aft
er $
100
per
co
nfi
nem
ent
co-p
aym
ent
100%
aft
er $
200
per
co
nfi
nem
ent
co-p
aym
ent
100%
fo
r sh
ots
an
dse
rum
aft
er a
co
-pay
men
t o
f $2
0 p
er v
isit
100%
aft
er p
er v
isit
co-p
aym
ent
of
$20
100%
100%
100%
aft
er a
pp
licab
leco
-pay
men
t
100%
aft
er $
20
co-p
aym
ent
if b
illed
as
offi
ce v
isit
;100
% a
fter
$100
co-
pay
men
t if
bill
edas
ou
tpat
ien
t su
rger
y
100%
aft
er $
100
per
co
nfi
nem
ent
co-p
aym
ent
100%
aft
er $
200
per
con
fin
emen
t co
-pay
men
t
31
CO
VE
RE
D S
ER
VIC
ES
UN
ITE
DH
EA
LTH
CA
RE
Th
e P
lan
Pays
:C
IGN
ATh
e P
lan
Pays
:B
LUE
CH
OIC
ETh
e P
lan
Pays
:
Ho
spit
al S
ervi
ces
Oth
er T
han
Th
ose
Th
at A
re f
or
Em
erge
ncy
Car
e (c
on
tin
ued
)•
Ou
tpat
ien
t se
rvic
es —
N
on
-em
erge
ncy
use
of
emer
gen
cyro
om
•W
ell-n
ewb
orn
car
e
Ho
spit
al S
ervi
ces
Th
at A
re f
or
Em
erge
ncy
Car
e •
Trea
tmen
t o
f an
em
erge
ncy
med
ical
con
dit
ion
or
inju
ry
Am
bu
lan
ce S
ervi
ces
for
Em
erge
ncy
Car
e
Urg
ent
Car
e Se
rvic
es i
n a
n A
pp
rove
dU
rgen
t C
are
Cen
ter
Ho
me
Nu
rsin
g C
are
Skil
led
Nu
rsin
g Fac
ilit
y S
ervi
ces
Ho
spic
e C
are
Req
uir
es p
rio
r au
tho
riza
tio
n f
rom
PC
P,o
ther
wis
e n
ot
cove
red
100%
100%
aft
er a
per
vis
it
co-p
aym
ent
of
$50
(co
-pay
men
t w
aive
d i
f ad
mit
ted
)
100%
100%
aft
er a
$25
co-
pay
men
t,re
ferr
al r
equi
red
100%
;up
to
120
day
sp
er P
lan
yea
r
100%
;pri
or
app
rova
l is
req
uir
ed;4
5-d
ay m
axi-
mu
m p
er P
lan
yea
r
100%
;pri
or
app
rova
l is
req
uir
ed
Req
uir
es p
rio
r au
tho
riza
tio
n f
rom
PC
P,o
ther
wis
e n
ot
cove
red
100%
100%
aft
er a
per
vis
itco
-pay
men
t o
f $5
0 (c
o-p
aym
ent
wai
ved
if
adm
itte
d)
100%
100%
aft
er a
$25
co
-pay
men
t
100%
;up
to
120
day
sp
er P
lan
yea
r
100%
;pri
or
app
rova
l is
req
uir
ed;4
5-d
ay m
ax-
imu
m p
er P
lan
yea
r
100%
;pri
or
app
rova
l is
req
uir
ed
Req
uir
es p
rio
r au
tho
riza
tio
n f
rom
PC
P,o
ther
wis
e n
ot
cove
red
100%
100%
aft
er a
per
vis
itco
-pay
men
t o
f $5
0 (c
o-p
aym
ent
wai
ved
if
adm
itte
d)
100%
aft
er a
$50
co
-p
aym
ent
per
tri
p w
hen
med
ical
ly n
eces
sary
100%
aft
er a
$30
co-p
aym
ent
100%
;up
to
120
day
sp
er P
lan
yea
r
Kai
ser
Perm
anen
te M
+C
:10
0%;n
o d
ay l
imit
100%
;pri
or
app
rova
l is
req
uir
ed;u
p t
o 4
5-d
aym
axim
um
per
Pla
n y
ear
100%
;pri
or
app
rova
l is
req
uir
ed
Req
uire
s p
rior
au
thor
izat
ion
from
HM
O,
oth
erw
ise
no
t co
vere
d
100%
100%
aft
er a
per
vis
it
co-p
aym
ent
of
$50
(co
-pay
men
t w
aive
d i
fad
mit
ted
)
100%
100%
aft
er a
$25
co
-pay
men
t
100%
;up
to
120
day
s p
erP
lan
yea
r
100%
;pri
or
app
rova
l is
req
uir
ed;1
20-d
ay
max
imu
m p
er P
lan
yea
r
100%
;pri
or
app
rova
l is
req
uir
ed
HM
O C
OV
ER
ED
SE
RV
ICE
S
32
KA
ISE
R P
ER
MA
NE
NT
E
and
KA
ISE
R P
ER
MA
NE
NT
EM
ED
ICA
RE
+CH
OIC
E (
M+
C)
The
Pla
n P
ays
:
Du
rab
le M
edic
al E
qu
ipm
ent
(DM
E)—
Ren
tal
or
Pu
rch
ase
Ou
tpat
ien
t A
cute
Sh
ort
-ter
mR
ehab
ilit
atio
n S
ervi
ces
Den
tal
and
Ora
l C
are—
Lim
ited
Co
vera
ge
•C
ove
rage
in
gen
eral
•C
over
age
of
spec
ific
oss
eou
s su
rger
ies
for
the
trea
tmen
t o
f p
erio
do
nta
l d
isea
se
•Te
mp
oro
man
dib
ula
r jo
int
syn
dro
me
(TM
J)
Ch
iro
pra
ctic
Car
e
100%
wh
en m
edic
ally
nec
essa
ry
100%
aft
er a
$20
co
-pay
men
t p
er v
isit
;u
p t
o 4
0 vi
sits
per
P
lan
yea
r
100%
aft
er a
pp
licab
leco
-pay
men
t fo
r o
ral
surg
ery
and
den
tal
serv
ices
ass
oci
ated
wit
han
acc
iden
tal
inju
ry t
oso
un
d t
eeth
No
t co
vere
d
100%
aft
er a
pp
licab
leco
-pay
men
t,su
bje
ct t
olim
itat
ion
s
100%
aft
er $
20
co-p
aym
ent
per
vis
it;
limit
edto
20
visi
ts p
erP
lan
yea
r
100%
wh
en m
edic
ally
nec
essa
ry
100%
aft
er a
$20
co
-pay
men
t p
er v
isit
;u
p t
o 4
0 vi
sits
per
P
lan
yea
r
100%
aft
er a
pp
licab
leco
-pay
men
t fo
r o
ral
surg
ery
and
den
tal
serv
ices
ass
oci
ated
wit
h a
n a
ccid
enta
lin
jury
to
so
un
d t
eeth
No
t co
vere
d
100%
aft
er a
pp
licab
leco
-pay
men
t,su
bje
ct t
olim
itat
ion
s
100%
aft
er $
20
co-p
aym
ent
per
vis
it;
limit
edto
20
visi
ts p
erP
lan
yea
r
100%
wh
en m
edic
ally
nec
essa
ry
100%
aft
er a
$20
co
-pay
men
t p
er v
isit
;u
p t
o 4
0 vi
sits
per
P
lan
yea
r o
r u
p t
o t
wo
con
secu
tive
mo
nth
s p
erco
nd
itio
n,w
hic
hev
eris
mo
re
Kai
ser
Perm
anen
te M
+C
:P
hys
ical
,occ
up
atio
nal
and
sp
eech
th
erap
y:10
0% c
ove
rage
aft
er $
20co
-pay
men
t;u
nlim
ited
visi
ts p
er P
lan
yea
r
Serv
ices
an
d a
pp
lian
ces
for
acci
den
tal
inju
ry t
oso
un
d a
nd
nat
ura
l te
eth
:50
% c
ove
rage
fo
r fi
rst
$1,0
00,t
hen
100
%
ther
eaft
er
No
t co
vere
d
50%
fo
r n
on
-su
rgic
altr
eatm
ent
100%
aft
er $
20
co-p
aym
ent
per
vis
it;
limit
edto
20
visi
ts p
erP
lan
yea
r
100%
wh
en m
edic
ally
nec
essa
ry
100%
aft
er a
$20
co
-pay
men
t p
er v
isit
;u
p t
o 4
0 vi
sits
per
P
lan
yea
r
100%
aft
er a
pp
licab
leco
-pay
men
t fo
r o
ral
surg
ery
and
den
tal
serv
ices
ass
oci
ated
wit
han
acc
iden
tal
inju
ry t
oso
un
d t
eeth
No
t co
vere
d
100%
aft
er a
pp
licab
leco
-pay
men
t,su
bje
ct t
olim
itat
ion
s
100%
aft
er $
20
co-p
aym
ent
per
vis
it;
limit
edto
20
visi
ts p
erP
lan
yea
r
33
CO
VE
RE
D S
ER
VIC
ES
UN
ITE
DH
EA
LTH
CA
RE
Th
e P
lan
Pays
:C
IGN
ATh
e P
lan
Pays
:B
LUE
CH
OIC
ETh
e P
lan
Pays
:
Beh
avio
ral
Hea
lth
Car
e(M
enta
l hea
lth a
nd s
ubst
ance
ab
use
car
e)
Tra
nsp
lan
t Se
rvic
es
For
inp
atie
nt
care
:10
0% a
fter
$50
co
-pay
men
t p
er
con
fin
emen
t;lim
ited
to
30 d
ays
per
Pla
n y
ear.
For
ou
tpat
ien
t ca
re:
100%
aft
er $
20
co-p
aym
ent
per
vis
it;
limit
ed t
o 2
5 vi
sits
per
Pla
n y
ear.
100%
For
inp
atie
nt
care
:10
0% a
fter
$50
co
-pay
men
t p
er
con
fin
emen
t;lim
ited
to
30 d
ays
per
Pla
n y
ear.
For
outp
atie
nt
care
:10
0% a
fter
$20
co
-pay
men
t p
er v
isit
;lim
ited
to
25 v
isit
s p
erP
lan
yea
r.
100%
Men
tal h
ealt
h:I
np
atie
nt
serv
ices
are
cov
ered
at
100%
aft
er a
$50
co-
pay
men
t p
er a
dmis
sion
;u
nlim
ited
day
s.O
utp
atie
nt
serv
ices
co
vere
d at
100
% a
fter
$20
co-p
aym
ent
per
vis
it;
un
limit
ed v
isit
s.
Sub
stan
ce a
bu
se:I
np
atie
nt
serv
ices
cov
ered
at
100%
afte
r a
$50
co-p
aym
ent
per
adm
issi
on;u
p t
o 30
days
per
Pla
n y
ear.
Kai
ser
Perm
anen
te M
+C
un
limit
ed d
ays
per
P
lan
yea
r.
Ou
tpat
ien
t se
rvic
es
cove
red
at 1
00%
aft
er $
20co
-pay
men
t p
er v
isit
;up
to 2
5 vi
sits
per
P
lan
yea
r.K
aise
r Pe
rman
ente
M+
Cu
nlim
ited
vis
its
per
P
lan
yea
r.
Det
ox
ific
atio
n:
Co-
pay
men
ts s
ame
asab
ove.
No
cove
rage
lim
its
on n
um
ber
of
epis
odes
,in
pat
ien
t da
ys o
rou
tpat
ien
t vi
sits
.
100%
For
inp
atie
nt
care
:10
0% a
fter
$50
co
-pay
men
t p
er
con
fin
emen
t;lim
ited
to
30 d
ays
per
Pla
n y
ear.
For
ou
tpat
ien
t ca
re:
100%
aft
er $
20
co-p
aym
ent
per
vis
it;
limit
ed t
o 2
5 vi
sits
per
Pla
n y
ear.
100%
HM
O C
OV
ER
ED
SE
RV
ICE
S
34
KA
ISE
R P
ER
MA
NE
NT
E
and
KA
ISE
R P
ER
MA
NE
NT
EM
ED
ICA
RE
+CH
OIC
E (
M+
C)
The
Pla
n P
ays
:
35
IMP
OR
TAN
T C
ON
SID
ER
AT
ION
S
•A
nn
ual
do
llar
and
vis
it l
imit
atio
ns
are
bas
ed o
n a
Ju
ly 1
to
Ju
ne
30 P
lan
yea
r.
•So
me
serv
ices
may
req
uir
e p
rio
r au
tho
riza
tio
n b
y th
e H
MO
bef
ore
su
ch s
ervi
ces
are
cove
red
.A
lso
,so
me
serv
ices
may
hav
e lim
itat
ion
s n
ot
con
tain
ed i
n t
his
su
mm
ary.
•M
ost
HM
Os
req
uir
e th
e se
lect
ion
of
a p
rim
ary
care
ph
ysic
ian
(P
CP
) to
man
age
you
r ca
re.F
ailu
re t
o s
pec
ify
a P
CP
co
uld
del
ay r
ecei
pt
of
you
rID
car
d.H
owev
er,i
n s
om
e in
stan
ces,
the
HM
O a
ssig
ns
you
a P
CP
lo
cate
d n
ear
you
r re
sid
ence
if
a P
CP
is
no
t sp
ecif
ied
.No
te:U
nit
edH
ealt
hca
red
oes
no
t re
qu
ire
the
sele
ctio
n o
f a
PC
P.
•M
ost
HM
Os
req
uir
e yo
u t
o o
bta
in r
efer
rals
to
see
mo
st s
pec
ialis
ts.F
ailu
re t
o o
bta
in a
ref
erra
l co
uld
res
ult
in
a d
enia
l o
f yo
ur
clai
m.
No
te:U
nit
edH
ealt
hca
re d
oes
no
t re
qu
ire
refe
rral
s fo
r co
vera
ge o
f sp
ecia
list
serv
ices
.
•Ea
ch H
MO
Op
tio
n m
ay o
ffer
vis
ion
car
e d
isco
un
ts o
r b
enef
its.
Co
nta
ct t
he
HM
O d
irec
tly
for
mo
re i
nfo
rmat
ion
.
•C
on
tact
th
e H
MO
dir
ectl
y fo
r m
ore
det
ails
reg
ard
ing
cove
red
ser
vice
s,ex
clu
sio
ns
and
lim
itat
ion
s.
36
S TAT E H E A L T H B E N E F I T P L A N 2 0 0 3 / 2 0 0 4
Service Areas for Your Health Plan Options
Service AreasService areas are State-approved geographic areas,such as counties or zip codes, where providersparticipate in the network offered by the Planoption in which you have enrolled.
PPO and PPO Choice OptionGeorgia Service Area
The Georgia service area includes the state ofGeorgia and the border communities of theChattanooga,Tennessee area, including BradleyCounty; and Phenix City, Alabama. The zip codearea in which you receive a service is used todetermine whether or not you are in the Georgiaservice area. If you receive covered services froma 1st Medical Network provider located in one ofthe zip codes below, you receive the highest levelof coverage available in the PPO options.
Out-of-State/National Service Area
The out-of-state service area includes all nationallocations outside of the Georgia service areadescribed to the left. By using Beech Streetproviders outside of the Georgia service area, youare protected against being charged more thanwhat the Plan allows. However, use of BeechStreet providers inside the Georgia service area is considered out-of-network care with lower levels of benefit coverage and a separatedeductible and out-of-pocket maximum, unless the provider also is a 1st Medical Network participant.
Georgia:
All counties; all zip codes
Alabama:
Russell County (Phenix City area): 36851,36856, 36858, 36859, 36860, 36867, 36868,36869, 36870, 36871 and 36875.
Tennessee:
Bradley County (Cleveland area): 37310, 37311,37312, 37320, 37323, 37353 and 37364.
Hamilton County (Chattanooga area): 37302,37304, 37308, 37315, 37341, 37343, 37350,37351, 37363, 37373, 37377, 37379, 37384,37401, 37402, 37403, 37404, 37405, 37406,37407, 37408, 37409, 37410, 37411, 37412,37414, 37415, 37416, 37419, 37421, 37422,37424 and 37450.
37
S TAT E H E A L T H B E N E F I T P L A N 2 0 0 3 / 2 0 0 4
HMO OptionsYou must live in the HMO’s approved service area to be eligible for coverage under that option. Below arethe regular HMO Option service areas by county. If you live or work in a county marked “Yes”under any ofthe HMOs listed, you may enroll in that HMO. If the county where you live is not listed below, you are noteligible for regular HMO coverage. Service area changes for the 2003-2004 Plan year are in bold type.
County of KaiserResidence BlueChoice CIGNA Permanente UnitedHealthcare
Appling Not Available Yes Not Available Not Available
Bacon Not Available Yes Not Available Yes
Baldwin Not Available Not Available Not Available Not Available
Banks Yes Not Available Not Available Yes
Barrow Yes Yes Yes Yes
Bartow Yes Yes Yes Yes
Ben Hill Not Available Not Available Not Available Yes
Berrien Not Available Not Available Not Available Yes
Bibb Yes Yes Not Available Yes
Bleckley Yes Yes Not Available Yes
Brooks Not Available Not Available Not Available Yes
Bryan Yes Yes Not Available Yes
Bulloch Yes Yes Not Available Yes
Burke Yes Yes Not Available Yes
Butts Yes Yes Yes Yes
Candler Not Available Yes Not Available Yes
Carroll Yes Not Available Not Available Yes
Catoosa Not Available Yes Not Available Yes
Chatham Yes Yes Not Available Yes
Chattahoochee Yes Not Available Not Available Yes
Chattooga Yes Yes Not Available Yes
Cherokee Yes Yes Yes Yes
Clarke Yes Yes Not Available Yes
Clayton Yes Yes Yes Yes
Cobb Yes Yes Yes Yes
Colquitt Not Available Not Available Not Available Yes
Columbia Yes Yes Not Available Yes
Coweta Yes Yes Yes Yes
Crawford Yes Not Available Not Available Yes
Dade Not Available Yes Not Available Yes
Dawson Yes Not Available Not Available Yes
Decatur Not Available Not Available Not Available Not Available
38
S TAT E H E A L T H B E N E F I T P L A N 2 0 0 3 / 2 0 0 4
County of KaiserResidence BlueChoice CIGNA Permanente UnitedHealthcare
DeKalb Yes Yes Yes Yes
Dodge Not Available Not Available Not Available Not Available
Douglas Yes Yes Yes Yes
Early Not Available Not Available Not Available Yes
Effingham Yes Yes Not Available Yes
Elbert Yes Yes Not Available Not Available
Emanuel Yes Yes Not Available Yes
Evans Not Available Yes Not Available Yes
Fannin Not Available Not Available Not Available Not Available
Fayette Yes Yes Yes Yes
Floyd Yes Yes Not Available Yes
Forsyth Yes Yes Yes Yes
Franklin Yes Yes Not Available Not Available
Fulton Yes Yes Yes Yes
Gilmer Yes Not Available Not Available Not Available
Glascock Yes Not Available Not Available Yes
Gordon Yes Yes Not Available Yes
Grady Not Available Not Available Not Available Yes
Greene Yes Yes Not Available Yes
Gwinnett Yes Yes Yes Yes
Habersham Not Available Not Available Not Available Yes
Hall Yes Yes Yes Yes
Harris Yes Yes Not Available Yes
Hart Yes Not Available Not Available Not Available
Heard Yes Not Available Not Available Not Available
Henry Yes Yes Yes Yes
Houston Yes Not Available Not Available Yes
Jackson Yes Yes Not Available Yes
Jasper Not Available Not Available Not Available Yes
Jefferson Yes Yes Not Available Yes
Jenkins Yes Not Available Not Available Yes
Johnson Yes Not Available Not Available Yes
Jones Yes Yes Not Available Yes
Lamar Not Available Yes Not Available Yes
Lanier Not Available Not Available Not Available Yes
Laurens Not Available Yes Not Available Not Available
Liberty Yes Yes Not Available Yes
39
S TAT E H E A L T H B E N E F I T P L A N 2 0 0 3 / 2 0 0 4
County of KaiserResidence BlueChoice CIGNA Permanente UnitedHealthcare
Lincoln Yes Yes Not Available Yes
Long Not Available Yes Not Available Yes
Lowndes Not Available Not Available Not Available Yes
Lumpkin Yes Not Available Not Available Yes
Madison Yes Yes Not Available Yes
Marion Yes Yes Not Available Not Available
McDuffie Yes Yes Not Available Yes
Meriwether Yes Not Available Not Available Yes
Mitchell Not Available Not Available Not Available Yes
Monroe Yes Yes Not Available Yes
Morgan Yes Not Available Not Available Yes
Muscogee Yes Yes Not Available Yes
Newton Yes Yes Yes Yes
Oconee Yes Yes Not Available Not Available
Oglethorpe Yes Yes Not Available Yes
Paulding Yes Yes Yes Yes
Peach Yes Not Available Not Available Yes
Pickens Yes Not Available Not Available Yes
Pike Not Available Yes Not Available Yes
Polk Yes Yes Not Available Yes
Pulaski Yes Not Available Not Available Yes
Putnam Not Available Not Available Not Available Yes
Richmond Yes Yes Not Available Yes
Rockdale Yes Yes Yes Yes
Screven Not Available Yes Not Available Yes
Seminole Not Available Not Available Not Available Yes
Spalding Yes Yes Yes Yes
Stewart Yes Not Available Not Available Yes
Sumter Not Available Not Available Not Available Not Available
Talbot Yes Not Available Not Available Yes
Taliaferro Not Available Not Available Not Available Yes
Tattnall Not Available Yes Not Available Yes
Taylor Not Available Yes Not Available Yes
Thomas Not Available Not Available Not Available Yes
Tift Not Available Not Available Not Available Yes
Toombs Not Available Not Available Not Available Yes
Twiggs Yes Not Available Not Available Yes
40
S TAT E H E A L T H B E N E F I T P L A N 2 0 0 3 / 2 0 0 4
County of KaiserResidence BlueChoice CIGNA Permanente UnitedHealthcare
Upson Not Available Not Available Not Available Yes
Walker Not Available Yes Not Available Yes
Walton Yes Yes Yes Yes
Ware Not Available Not Available Not Available Yes
Warren Yes Not Available Not Available Yes
Washington Yes Not Available Not Available Not Available
Wayne Not Available Not Available Not Available Yes
White Yes Not Available Not Available Yes
Whitfield Not Available Yes Not Available Not Available
Wilkes Yes Yes Not Available Yes
Wilkinson Yes Yes Not Available Yes
Worth Not Available Not Available Not Available Yes
County of Residence
Cherokee Yes
Clayton Yes
Cobb Yes
Coweta Yes
DeKalb Yes
Douglas Yes
Fayette Yes
Forsyth Yes
Fulton Yes
Gwinnett Yes
Henry Yes
Paulding Yes, only if you live in zip code 30127,30134 or 30141
Kaiser Permanente M+C HMO
Medicare+Choice HMO Option
41
S TAT E H E A L T H B E N E F I T P L A N 2 0 0 3 / 2 0 0 4
Health Insurance Portability and Accountability Act (HIPAA)Annual Notice
This section describes certain rights available toyou under the Health Insurance Portability andAccountability Act (HIPAA) when you add adependent to your SHBP coverage.
The PPO and Indemnity Options contain a pre-existing condition (PEC) limitation. Specifically,the Health Plan will not pay charges that are over$1,000 for the treatment of any pre-existing condition during the first 12 months of a patient’scoverage, unless the patient gives satisfactory documentation that he or she has been free oftreatment or medication for that condition for atleast six consecutive calendar months. However, apre-existing condition limitation does not apply tocoverage for:
• Pregnancy; or
• Newborns or children under age 18 who areadopted or placed for adoption, if the childbecomes covered within 31 days after birth,adoption or placement for adoption.
In certain situations, SHBP dependents can reducethe 12-month pre-existing condition limitationperiod. The reduction is possible by using what iscalled “creditable coverage” to offset a pre-existingcondition period. Creditable coverage generallyincludes the health coverage a family member hadimmediately prior to joining the SHBP. Coverageunder most group health plans, as well as coverageunder individual health policies and governmentalhealth programs, qualifies as creditable coverage.
To reduce the pre-existing condition limitationperiod for your dependents (including yourspouse), you must provide the SHBP with a certificate of creditable coverage stating whencoverage started and ended for each dependentthat you want to cover. Any period of prior cover-age for that dependent will reduce the 12-monthlimitation period if no more than 63 days haveelapsed between the dependent’s loss of priorcoverage and the first day of coverage under the SHBP.
If your dependent (including a spouse) hadany break in coverage lasting more than 63 days,your dependent will receive creditable coverageonly for the period of time after the break ended.
Within two years after your dependent’s formercoverage terminated, he/she has the right toobtain a certificate of creditable coverage fromhis/her former employer(s) to offset the pre-exist-ing condition limitation period under the SHBP.The SHBP will evaluate the certificate of cred-itable coverage or other documentation to deter-mine whether any of the pre-existing conditionlimitation period will be reduced or eliminated.After completing the evaluation, the SHBP willnotify you as to how the pre-existing conditionlimitation period will be reduced or eliminated.
Please submit the certificate of creditable cover-age to the Plan with your dependent’s enrollmentpaperwork.
42
S TAT E H E A L T H B E N E F I T P L A N 2 0 0 3 / 2 0 0 4
Department of CommunityHealth Privacy Notice
This notice describes how medical informationabout you may be used and disclosed and howyou can get access to this information. Pleasereview it carefully.
The Plan’s Privacy Commitment to YouThe Georgia Department of Community Health(DCH) understands that information about youand your family is personal. DCH is committed toprotecting your information.This notice tells youhow DCH uses and discloses information aboutyou. It tells you your rights and the Plan’s require-ments about your information.
Understanding the Type of InformationThat the Plan HasYour employer (state agency, school system,authority, etc.) sent information about you toDCH.This information included your name,address, birth date, phone number, Social SecurityNumber and other health insurance policies thatyou may have. It may also have included healthinformation.When your health care providers sendclaims to the Plan’s claim administrator for pay-ment, the claims include your diagnoses and themedical treatments you received. For some med-ical treatments, your health care providers sendadditional medical information to the Plan such asdoctor’s statements, x-rays or lab test results.
Your Health Information RightsYou have the following rights regarding the healthinformation that DCH has about you.
• You have the right to see and obtain a copy ofyour health information.An exception is psy-chotherapy notes.Another exception is infor-mation that is needed for a legal action relatingto DCH.
• You have the right to ask DCH to changehealth information that is incorrect or incom-plete. DCH may deny your request under certain circumstances.
• You have the right to request a list of the dis-closures that DCH has made of your healthinformation beginning in April 2003.
• You have the right to request a restriction oncertain uses or disclosures of your health infor-mation. DCH is not required to agree with yourrequest.
• You have the right to request that DCH com-municates with you about your health in a wayor at a location that will help you keep yourinformation confidential.
• You have the right to receive a paper copy ofthis notice.You may ask DCH staff to give youanother copy of this notice, or you may obtaina copy from DCH’s Web site,www.dch.state.ga.us (click on "Privacy").
Privacy Law’s RequirementsDCH is required by law to:
• Maintain the privacy of your information.
• Give you this notice of DCH’s legal duties andprivacy practices regarding the informationthat DCH has about you.
• Follow the terms of this notice.
• Not use or disclose any information about youwithout your written permission, except forthe reasons given in this notice.You may takeaway your permission at any time, in writing,except for the information that DCH disclosedbefore you stopped your permission. If you can-not give your permission due to an emergency,DCH may release the information if it is in yourbest interest. DCH must notify you as soon aspossible after releasing the information.
In the future, DCH may change its privacy prac-tices. If its privacy practices change significantly,DCH will provide a new notice to you. DCH willpost the new notice on its Web site atwww.dch.state.ga.us (click on "Privacy").Thisnotice is effective April 14, 2003.
43
S TAT E H E A L T H B E N E F I T P L A N 2 0 0 3 / 2 0 0 4
How DCH Uses and Discloses HealthCare InformationThere are some services the Plan providesthrough contracts with private companies. Forexample, Blue Cross and Blue Shield of Georgiapays most medical claims to your health careproviders.When services are contracted, the Planmay disclose some or all of your information tothe company so that they can perform the job thePlan has asked them to do.To protect your infor-mation, the Plan requires the company to safe-guard your information in accordance with thelaw.
The following categories describe different waysthat the Plan uses and discloses your health infor-mation. For each category, we will explain whatwe mean and give an example.
For Payment: The Plan may use and disclose infor-mation about you so that it can authorize paymentfor the health services that you received. Forexample, when you receive a service covered bythe Plan, your health care provider sends a claimfor payment to the claims administrator.The claimincludes information that identifies you, as well asyour diagnoses and treatments.
For Medical Treatment: The Plan may use or dis-close information about you to ensure that youreceive necessary medical treatment and services.For example, if you participate in a Disease StateManagement Program, the Plan may send youinformation about your condition.
To Operate Various Plan Programs: The Planmay use or disclose information about you to runvarious Plan programs and ensure that you receivequality care. For example, the Plan may contractwith a company that reviews hospital records tocheck on the quality of care that you received andthe outcome of your care.
To Other Government Agencies ProvidingBenefits or Services: The Plan may give informa-tion about you to other government agencies thatare giving you benefits or services.The informa-tion must be necessary for you to receive thosebenefits or services and will be authorized by youor by law.
To Keep You Informed: The Plan may mail youinformation about your health and well-being.Examples are information about managing a disease that you have, information about yourmanaged care choices, and information about prescription drugs you are taking.
For Overseeing Health Care Providers: The Planmay disclose information about you to the govern-ment agencies that license and inspect medicalfacilities, such as hospitals, as required by law.
For Research: The Plan may disclose informationabout you for a research project that has beenapproved by a review board.The review boardmust review the research project and its rules toensure the privacy of your information.Theresearch must be for the purpose of helping thePlan.
As Required by Law: The Plan will disclose infor-mation about you as required by law.
For More Information and to Report aProblemIf you have questions and would like additionalinformation, you may contact the SHBP at 404-656-6322 (Atlanta calling area) or 800-610-1863(outside of Atlanta calling area).
If you believe your privacy rights have been violated:
• You can file a complaint with the Plan by calling the SHBP at 404-656-6322 (Atlanta calling area) or 800-610-1863 (outside ofAtlanta calling area), or by writing to:SHBP – HPU, P.O. Box 38342,Atlanta, GA 30334.
• You can file a complaint with the Health andHuman Services’ Office for Civil Rights by writ-ing to: U.S. Department of Health and HumanServices Office for Civil Rights, Region IV,Atlanta Federal Center, 61 Forsyth Street SW,Suite 3B70,Atlanta, GA 30303-8909. Phone(404) 562-7886; Fax (404) 562-7881;TDD (404)331-2867
• You also may contact the HHS’ Office for CivilRights by calling 866-OCR-PRIV (866-627-7748)or 886-788-4989 TTY.
There will be no retaliation for filing a complaint.
44
S TAT E H E A L T H B E N E F I T P L A N 2 0 0 3 / 2 0 0 4
Women’s Health and CancerRights Act
The Plan complies with the Women’s Health andCancer Rights Act of 1998. Mastectomy, includingreconstructive surgery, is covered the same asother surgery under your Plan option.
Following cancer surgery, the SHBP covers:
• All stages of reconstruction of the breast onwhich the mastectomy has been performed;
• Reconstruction of the other breast to achieve asymmetrical appearance;
• Prostheses and mastectomy bras; and
• Treatment of physical complications of mastectomy, including lymphedema.
Note: Reconstructive surgery requires priorapproval and all inpatient admissions require MCPprecertification.
For more detailed information on the mastectomy-related benefits available under the Plan, you can contact the Member Services unit for yourcoverage option.Telephone numbers are on theinside front cover.
Penalties for Misrepresentation
If any SHBP participant misrepresents the factswhen applying for dependent coverage, change of coverage, or benefits, the SHBP may terminatethe person’s participation (and that of his or her dependents) and seek legal recovery of anymoney paid out by the SHBP as a result of the misrepresentation.
45
S TAT E H E A L T H B E N E F I T P L A N 2 0 0 3 / 2 0 0 4
Disclaimer
This material is for informational purposes only and is
neither an offer of coverage nor medical advice. It contains
only a partial, general description of Plan or program
benefits and does not constitute a contract or any part of
one. For a complete description of the benefits available
to you, including procedures, exclusions and limitations,
refer to your specific Plan documents, which may
include the State Health Benefit Plan Summary Plan
Description, Summary of Material Modification
(Updater), Schedule of Benefits, Certificate of Coverage,
Group Agreement, Group Insurance Certificate, Group
Insurance Policy and any applicable riders to your Plan.
All the terms and conditions of your Plan or program
are subject to and governed by applicable contracts, laws,
regulations and policies. Certain services, including but
not limited to non-emergency inpatient hospital care,
require precertification. All benefits are subject to
coordination of benefits unless noted otherwise. In case
of a conflict between your Plan documents and this
information, the Plan documents will govern.
Medicare is a program of the federal government.The
information in this Guide is intended only to be a
helpful summary of Medicare and not a complete
explanation of the program. For more detailed informa-
tion, contact your local Medicare office. In the event of
a conflict between this summary and the Medicare
program, Medicare's provisions govern.
Copyright: The Georgia Department of Community
Health, April 2003