Helping you get there. Healthcare Resource Guide

Transcription

1 Helping you get there Healthcare Resource Guide Published November, 2009

2 Table of Contents Introduction... 3 Medical Benefit Summaries Blue Shield Low Option EPO... 4 Blue Shield High Option EPO... 7 Blue Shield PPO Option...10 Blue Shield HDHP Option...13 Kaiser Low Option HMO...16 Kaiser High Option HMO...18 Kaiser Low Option HMO Medicare Advantage...20 Kaiser High Option HMO Medicare Advantage...22 SecureHorizons Low & High Options...24 Additional Information Regarding Your Benefits...26 Prescription Drug Coverage and Medicare...27 Retiree Healthcare 401(h) Medical Trust Plan Benefits...28 Rules for Dependent Eligibility...30 Glossary...31 Contact Information

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4 EPO LOW OPTION, page 1 4

5 EPO LOW OPTION, page 2 5

6 EPO LOW OPTION, page 3 1 Deductible and copayments marked with a (1) do not accrue to calendar-year copayment maximum. Copayments and charges for services not accruing to the member s calendar-year copayment maximum continue to be the member s responsibility after the calendar-year copayment maximum is reached. Deductible does not apply toward the calendar-year maximum. Please refer to the Plan Contract for exact terms and conditions of coverage. 2 Member is responsible for copayment in addition to any charges above allowable amounts. The copayment percentage indicated is a percentage of allowable amounts. Preferred providers accept Blue Shield s allowable amount as full payment for covered services. 3 Participating ambulatory surgery centers may not be available in all areas. Regardless of their availability, you can obtain outpatient surgery services from a hospital, or an ambulatory surgery affiliated with a hospital with payment according to your health plan s hospital services benefits. 4 Home health care, home infusion and hospice services require prior authorization. 5 Bariatric surgery is covered when pre-authorized by Blue Shield. However, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura Counties ( Designated Counties ), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons; coverage is not available for bariatric services from any other preferred provider and there is no coverage for bariatric services from non-preferred Providers. In addition, if prior authorized by Blue Shield of California, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Plan Contract for further benefit details. 6 Services may require prior authorization by Blue Shield. 7 Mental health services are accessed through Blue Shield using Blue Shield s participating providers. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Plan Contract. 8 Copayment shown is for physician s services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. 9 Inpatient services for acute detoxification are covered under the medical benefit; see hospitalization services for benefit details. Services for medical acute detoxification are accessed through Blue Shield s preferred providers. Plan designs may be modified to ensure compliance with state and federal requirements (11/09) ASO_RDB Opl ME103009l 6

7 EPO HIGH OPTION, page 1 7

8 EPO HIGH OPTION, page 2 8

9 EPO HIGH OPTION, page 3 1 Deductible and copayments marked with a (1) do not accrue to calendar-year copayment maximum. Copayments and charges for services not accruing to the member s calendar-year copayment maximum continue to be the member s responsibility after the calendar-year copayment maximum is reached. Deductible does not apply toward the calendar-year maximum. Please refer to the Plan Contract for exact terms and conditions of coverage. 2 Member is responsible for copayment in addition to any charges above allowable amounts. The copayment percentage indicated is a percentage of allowable amounts. Preferred providers accept Blue Shield s allowable amount as full payment for covered services. 3 Participating ambulatory surgery centers may not be available in all areas. Regardless of their availability, you can obtain outpatient surgery services from a hospital, or an ambulatory surgery affiliated with a hospital with payment according to your health plan s hospital services benefits. 4 Home health care, home infusion and hospice services require prior authorization. 5 Bariatric surgery is covered when pre-authorized by Blue Shield. However, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura Counties ( Designated Counties ), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons; coverage is not available for bariatric services from any other preferred provider and there is no coverage for bariatric services from non-preferred Providers. In addition, if prior authorized by Blue Shield of California, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Plan Contract for further benefit details. 6 Services may require prior authorization by Blue Shield. 7 Mental health services are accessed through Blue Shield using Blue Shield s participating providers. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Plan Contract. 8 Copayment shown is for physician s services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. 9 Inpatient services for acute detoxification are covered under the medical benefit; see hospitalization services for benefit details. Services for medical acute detoxification are accessed through Blue Shield s preferred providers. Plan designs may be modified to ensure compliance with state and federal requirements (11/09) ASO_RDB ME103009l 9

10 PPO OPTION, page 1 10

11 PPO OPTION, page 2 11

12 PPO OPTION, page 3 Care Outside of Plan Service Area Benefits provided through BlueCard Program, for out-of-state emergency and non-emergency care, are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider. Within US: BlueCard Program See Applicable Benefit See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit See Applicable Benefit 1 Deductible and copayments marked with a (1) do not accrue to calendar-year copayment maximum. Copayments and charges for services not accruing to the member s calendar-year copayment maximum continue to be the member s responsibility after the calendar-year copayment maximum is reached. Deductible does not apply toward the calendaryear maximum. Please refer to the Plan Contract for exact terms and conditions of coverage. 2 Member is responsible for copayment in addition to any charges above allowable amounts. The copayment percentage indicated is a percentage of allowable amounts. Preferred providers accept Blue Shield s allowable amount as full payment for covered services. Non-preferred providers can charge more than these amounts. When members use nonpreferred providers, they must pay the applicable copayment plus any amount that exceeds Blue Shield s allowable amount. Charges above the allowable amount do not count toward the calendar-year deductible or copayment maximum. 3 Participating ambulatory surgery centers may not be available in all areas. Regardless of their availability, you can obtain outpatient surgery services from a hospital, or an ambulatory surgery affiliated with a hospital, with payment according to your health plan s hospital services benefits. 4 The maximum allowed charges for non-emergency hospital services received from a non-preferred hospital is $600 per day. Members are responsible for 40 percent of this $600 per day, plus all charges in excess of $ Bariatric surgery is covered when pre-authorized by Blue Shield. 6 Services may require prior authorization by Blue Shield. When these services are prior authorized, members pay the preferred or participating provider amount. 7 Mental health services are accessed through Blue Shield - using Blue Shield s participating and non-participating providers. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Plan Contract. 8 All outpatient chiropractic, rehabilitation and acupuncture visits accrue to the calendar-year maximum regardless of whether the plan deductible has been met. 9 Inpatient services for acute detoxification are covered under the medical benefit; see hospitalization services for benefit details. Services for medical acute detoxification are accessed through Blue Shield s preferred providers or nonpreferred providers. 10Out of network home health care, home infusion and hospice services are not covered unless pre-authorized. When these services are pre-authorized, the member pays the Preferred Provider copayment. 11Copayment shown is for physician s services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. Plan designs may be modified to ensure compliance with state and federal requirements A17268 (11/09)ME_ASO

13 HDHP OPTION, page 1 13

14 HDHP OPTION, page 2 14

15 HDHP OPTION, page 3 15

16 KAISER LOW OPTION HMO - NON-MEDICARE, Page 1 16

17 KAISER LOW OPTION HMO - NON-MEDICARE, Page 2 17

18 KAISER HIGH OPTION HMO - NON-MEDICARE, Page 1 18

19 KAISER HIGH OPTION HMO - NON-MEDICARE, Page 2 19

20 KAISER LOW OPTION HMO - MEDICARE ADVANTAGE, Page 1 20

21 KAISER LOW OPTION HMO - MEDICARE ADVANTAGE, Page 2 21

22 KAISER HIGH OPTION HMO - MEDICARE ADVANTAGE, Page 1 22

23 KAISER HIGH OPTION HMO - MEDICARE ADVANTAGE, Page 2 23

24 SECUREHORIZONS LOW & HIGH OPTION HMO-Page 1 24

25 SECUREHORIZONS LOW & HIGH OPTION HMO-Page 2 25

26 Additional Information Regarding Your Benefits HIPAA Health Insurance Portability & Accountability Act The Group Health Plan you are enrolling in (may) impose a pre-existing condition limitation or exclusion on new enrollees for a period of 12 months from the start of your waiting period. The federal Health Insurance Portability and Accountability Act of 1996 ( HIPAA ) requires that we periodically remind you of your right to receive a copy of HIPAA Privacy Notice. You can request a copy of the Privacy Notice by contacting Santa Barbara County Human Resources. HIPAA Privacy Notices that pertain to other health plans may be obtained by contacting your insurance carrier directly, at the address provided in the Evidence of Coverage booklets. Women s Health and Cancer Rights Act Your health plan, as required by the Women's Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy (including lymphedema). Call your health plan's Member Services for more information. Newborns and Mothers Health Protection Act Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean delivery. However, Federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). 26

27 Important Notice from the County of Santa Barbara About Your Prescription Drug Coverage and Medicare The County of Santa Barbara has determined that the prescription drug coverage offered by the County of Santa Barbara s medical plans are, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. You should also know that if you drop or lose your coverage with the County of Santa Barbara and don t enroll in Medicare prescription drug coverage after your current coverage ends, you may pay more (a penalty) to enroll in Medicare prescription drug coverage later. If you go 63 days or longer without prescription drug coverage that s at least as good as Medicare s prescription drug coverage, your monthly premium will go up at least 1% per month for every month that you did not have that coverage. For example, if you go nineteen months without coverage, your premium will always be at least 19% higher than what many other people pay. You ll have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to enroll. For more information about this notice or your current prescription drug coverage You will receive this notice annually and at other times in the future such as before the next period you can enroll in Medicare prescription drug coverage, and if this coverage through the County of Santa Barbara changes. You also may request a copy. For more information about your options under Medicare prescription drug coverage More detailed information about Medicare plans that offer prescription drug coverage is in the Medicare & You handbook. You ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare prescription drug plans. For more information about Medicare prescription drug plans: Visit Call your State Health Insurance Assistance Program (see your copy of the Medicare & You handbook for their telephone number) for personalized help Call MEDICARE ( ). TTY users should call For people with limited income and resources, extra help paying for Medicare prescription drug coverage is available. Information about this extra help is available from the Social Security Administration (SSA) online at or you call them at (TTY ). Remember: Keep this notice. If you enroll in one of the new plans approved by Medicare which offer prescription drug coverage, you may be required to provide a copy of this notice when you join to show that you are not required to pay a higher premium amount. For more information about this notice or your current prescription drug coverage, please contact our office at 3916 State Street, Suite 210, Santa Barbara, CA, or call or

28 Retiree Healthcare 401(h) Medical Trust Plan How does the County help retirees with Healthcare costs? On September 16, 2008 the Santa Barbara County Board of Supervisors passed a resolution adopting regulations and an administrative agreement to establish an account for the provision of retiree medical benefits to be funded by the County and other Plan Sponsors and administered by SBCERS, in accordance with 401(h) of the Internal Revenue Code. What are the benefits? Insurance Premium Subsidy As a result of this agreement, SBCERS retirees are eligible to receive a monthly medical allowance based on $15 per year of service to help pay health premiums. If the monthly premium for the health plan selected is less than $15 times the member s years of service, the subsidy is limited to the entire premium. The health plans include coverage for eligible spouses and dependents. If a member is eligible for a disability retirement benefit, the member can receive a monthly health plan subsidy of $187 per month or $15 per year of service, whichever is greater. After the member s death, a surviving spouse is eligible to continue health plan coverage. The subsidy benefit will be equal to $15 per year of service times the survivor continuation percentage applicable for pension benefits. Healthcare Reimbursement Arrangement (HRA) Retirees who choose not to participate in a County sponsored health plan receive a cash allowance benefit of $4.00 per month per year of service. When you decline or drop all health insurance coverage, you are automatically enrolled in the HRA program. The HRA account balance accumulates from month-to-month and from year-to-year. The balance is available for up to 12 months after the date of death of the retiree. If there is a surviving spouse, the balance will transfer to the survivor s account and continue to grow at the survivor s percentage of the original benefit. Upon the death of the survivor, the survivor s balance is available for up to 12 months after the date of death for healthcare reimbursements. This cash allowance reimburses qualified health care expense. In order to receive reimbursement, you are required to submit a claim form with proof of payment of qualified expenses (e.g., Medicare statements, pharmacy receipts, physician office receipts, etc.). The HRA program is administered by a third party administrator, WageWorks. WageWorks administers all aspects of the HRA accounts, providing balances and information to SBCERS retirees, receiving the claims for reimbursement and issuing monthly reimbursement payments for eligible expenses. The payments are issued as direct deposits into the same bank account used for your monthly SBCERS allowance. 28

29 401(h) Medical Trust Plan - continued How do I calculate the benefits? Insurance Premium Subsidy Example If a retiree has service credit of years, he is eligible to receive $ per month ( x $15.00 = $376.85) toward the cost of health insurance premiums for himself and his covered family. Any remaining premium is automatically deducted from the gross monthly retirement allowance. Surviving spouses and other beneficiaries receive an amount proportionate to their continuance percentage. A beneficiary receiving a 60% continuance benefit receives 60% of the $15 subsidy amount (or $9 per year of service) and a beneficiary receiving 60% of a disability retirement receives $ (60% of $187) or $9 per year of service, whichever is greater. Subsidy Calculation Example Subsidy Application Example Retirement Benefit type: Service Retirement Years of Service: Monthly Insurance Premiums $ Subsidy: x $15.00 Health Insurance Subsidy Monthly Subsidy: $ Member s Share of Premium $ Healthcare Reimbursement Arrangement (HRA) Example If a retiree has service credit of years, he is eligible to receive $ per month ( x $4.00 = $100.49). Surviving spouses and other beneficiaries receive an amount proportionate to their continuance percentage. A beneficiary receiving a 60% continuance benefit receives 60% of the $4 HRA amount (or $2.40 per year of service). HRA Calculation Example HRA Application Example Retirement Benefit type: Service Retirement Years of Service: Monthly Award $ Cash Allowance: x $4.00 Claims / Receipts Submitted Monthly Cash Allowance: $ Balance will carry forward $9.20 If you do not know the total years of service credit that are used to calculate your Subsidy or HRA, you can find it on your Retirement Agreement. If you do not have a copy of your Retirement Agreement, you may contact the retirement office for the information. It is recommended that you record your service credit total for future calculation. 29

30 Rules for Dependent Eligibility Dependent Eligibility Your legal spouse Your legally registered domestic partner Your natural children, stepchildren, foster children and adopted children of which the employee is the legal guardian. In addition, such children must be: - Unmarried - Up to Age 23 - Not be a qualifying child of another individual (as defined in the Internal Revenue Code) - Be supported by you over 50% and reported to the IRS (except for Special Rule for Divorce/ Separation) Your eligible physically or mentally handicapped children who depend on you for support, regardless of age. A child of a covered domestic partner who satisfies the same conditions as listed above for natural children, stepchildren, or adopted children, and in addition is not a qualifying child (as that term is defined in the Internal Revenue Code) of another individual. Rules for Benefit Changes During the Year You will not be allowed to change your plan selections or add dependents until the next benefit year (January 1, 2011) unless you a have a qualified change in status. The request for enrollment must be made within 31 days of the qualifying event. The events that qualify for this special enrollment are: Marriage, legal separation, divorce or death Birth, adoption or placement for adoption of a child A dependent child s loss of eligibility due to age or marital status Termination of employment or new employment of a spouse Change in employment from full-time to part-time or vice versa for you or your spouse Change in medical coverage by your spouse s employer Change in an individual s eligibility for Medicare or Medicaid Change in place of residence or worksite Any change must be consistent with the Qualifying Event 30

31 GLOSSARY Balance Billing - Balance billing is a medical billing practice increasingly instituted by health care providers to cover the cost of services rendered. If your doctor uses balance billing, she would bill you for any amount not covered by your insurance. So if her bill was for $1,000, and your insurance only covered $600, with balance billing, you would be responsible for the other $400. Balance billing may arise when you use services of out-of-network providers under a PPO or HDHP arrangement. It is illegal for health care providers affiliated with Medicare to practice balance billing. It is also illegal in most states for providers who are "in-network" to engage in balance billing, regardless of which insurance company they are affiliated with. Outof-network providers, however, are usually permitted to do so. BlueCard Network - The Blue Cross and Blue Shield Association (BCBSA) program that provides access to health care services from participating providers throughout the United States to members of any Blue Plan while traveling or residing outside of California. Your level of coverage depends on your plan. Brand-Name Formulary - Prescription drugs marketed with a specific brand name by the company that manufactures it, usually the company which develops and patents it. When patents run out, generic versions of many popular drugs are marketed at lower cost by other companies. California State Association of Counties - Excess Insurance Authority (CSAC - EIA) - Is a member directed joint powers authority (JPA) comprised of California public agencies dedicated to controlling losses and providing risk management and employee benefit solutions. Members own and run the program. Participants includes city, county and special district membership with over 200 employees. Co-Insurance - The percentage of covered expenses an insured individual shares with the carrier, (i.e., for an 80/20 plan the health plan member s co-insurance is 20%.) If applicable, co-insurance applies after the insured pays the deductible. Co-Pay - A flat fee for specified medical services (required by some insurers) that a subscriber must pay out-of-pocket at the time the service is rendered. For example, you pay a $30 copayment for a doctor visit or a $500 copayment for a hospital stay. Deductible - The amount you must pay each year for your medical expenses before your insurance policy starts paying. Dependent - Spouse, Domestic Partner and/or unmarried children (whether natural, adopted or step) of an insured. Effective Date - The date your insurance is to actually begin. You are not covered until the policies effective date Explanation of Benefits (EOB) - The insurance company's written explanation to a claim, showing what they paid and what the client must pay. Sometimes accompanied by a benefits check. Exclusive Provider Organization (EPO) - A healthcare benefit arrangement that is similar to a Preferred Provider Organization (PPO) in administration, structure, and operation, but which does not cover out-of-network care. An EPO includes insurance carriers contracted PPO providers. In an EPO, no Primary Care Physician referral is required to visit a specialist. 31

32 Glossary - continued Formulary - A list of prescription drugs approved for coverage under a prescription drug plan. Generic Drug - A "twin" to a "brand name drug" once the brand name company's patent has run out and other drug companies are allowed to sell a duplicate of the original. The dispensing of a drug that is the generic equivalent of a drug listed on a pharmacy benefit management plan's formulary. In most cases, generic substitution can be performed without physician approval. Generic drugs are cheaper, and most prescription and health plans reward clients for choosing generics. High Deductible Health Plan (HDHP) - This plan has a higher deductible which gives the member a lower premium rate, but just as regular PPO plans, once the deductible is met the policy benefits start paying as noted on the plan summary. The Health Insurance Portability and Accountability Act (HIPAA) - passed by the U.S. Congress in 1996, offers people rights and protections regarding their health care plans. Because of HI- PAA, there are limits on preexisting condition exclusions, people cannot be discriminated because of health factors, there are special enrollment requirements for people who lose other group plans or have new dependents, small employers are guaranteed group health plan availability, and all group plans have guaranteed renewal if the employer wishes to renew. In summary these rights and protections include: Portability. This is the ability for a person to get new health insurance if a change is desired or needed. Availability. This refers to whether or not health insurance must be offered to a person and his or her dependents. Renewability. This refers to whether or not a person is able to renew his or her health plan. Health Maintenance Organization (HMO) - Health Maintenance Organizations represent "pre-paid" or "capitated" insurance plans in which individuals or their employers pay a fixed monthly fee for services, instead of a separate charge for each visit or service. The monthly fees remain the same, regardless of types or levels of services provided, Services are provided by physicians who are employed by, or under contract with, the HMO. HMOs vary in design. HMO Plan - In an HMO plan, members choose a primary care physician (PCP) who coordinates each assigned member s care. The PCP refers patients to specialists and provider services as needed. HMO plans often require members receive a referral from their PCP before seeing a specialist. Health Insurance Subsidy - Established to help defray the cost of health, dental and vision insurance coverage, this is an account funded by Santa Barbara County s 401(h) program for Retirees who are enrolled in the County-sponsored health insurances. Each month, an amount equal to $15 per year of service is deducted from the total amount of your health, dental and vision premiums. Health Reimbursement Arrangement (HRA) - Similar in function to a Health Savings Account, this account is funded by Santa Barbara County s 401(h) program to help those Retirees who chose not to enroll in the Countysponsored health insurances. SBC funds your HRA account with a set monthly amount ($4 per year of service). You can use this cash supplement to pay your out-of-pocket medical expenses, such as co-pays or coinsurance for office visits, prescription drugs, and other services. You must submit eligible receipts in order to receive the cash supplement. This benefit is administered by a third-party administrator, WageWorks (formerly Creative Benefits). 32

33 In-Network - Providers or health care facilities which are part of a health plan's network of providers with which it has negotiated a discount. Insured individuals usually pay less when using an in-network provider because normally the plan will pay more of the benefit when using a contracted provider, and secondly the contracted provider cannot bill the member for any amount above the contracted rate. Providers not contracted with the carrier can balance bill the members, which in turn cost the member much more. Inpatient - Treatment that is provided to a patient who must be admitted for an overnight stay in a hospital or other inpatient facility. Glossary - continued Medicare Part C is another way to get your Medicare benefits. It combines Part A, Part B, and sometimes Part D (prescription drug) coverage. Medicare Advantage Plans are managed by private insurance companies approved by Medicare. Medicare Part D - Medicare-approved plans that you purchase to provide additional coverage for prescription drugs. SBCERS Medicare plans include an enhanced Pharmacy benefit approved by Medicare. If you are enrolled in one of SBCERS Medicare plans, you have prescription coverage and there is no need to purchase additional Medicare Part D pharmacy coverage from another insurer. Independent or Individual Practice Association (IPA) An organization which contracts with individual providers or groups of providers to arrange for the provision of their professional services to enrollees of a Health Maintenance Organization (HMO). Lifetime Maximum - The maximum amount a health plan will cover for an insured individual during his or her lifetime (for example, $5 million). Medicare - A federal government hospital expense and medical expense insurance plan primarily for elderly, disabled persons and those who have end-stage renal disease (permanent kidney failure). Medicare Part A - Covers basic hospitalization services automatically for most eligible persons Medicare Part B - Covers physician visits and other outpatient expenses that Medicare Part A does not cover. Medicare Part B is voluntary. You have to enroll in Part B and pay a monthly premium. Medicare Part C - Also known as Medicare Advantage Plans or Medicare+ Choice plans. Medicare Coordination of Benefits (COB) - If you have Medicare and SBCERS health insurance coverage, each type of coverage is called a payer. When there is more than one payer, there are coordination of benefits rules that decide which one pays first. The primary payer pays what it owes on your bills, and then sends them to the secondary payer to pay. In some cases, there may be a third payer. Whether Medicare pays first depends on a number of things. Be sure to tell your doctor and other providers that you have health insurance coverage in addition to Medicare. This will help them send your bills to the correct payer to avoid delays. If you have questions about who pays first or if your insurance changes, call the Medicare Coordination of Benefits Contractor (COBC) at TTY users should call Medicare Eligible - The first day of the month in which you turn 65 years old (exceptions apply for disabled persons). Non-Formulary - Drugs that are not on your plan s formulary drug list. 33

34 Glossary - continued Out-of-Network - This phrase usually refers to physicians, hospitals or other health care providers who are considered nonparticipants in an insurance plan (usually an HMO or PPO). Depending on an individual's health insurance plan, expenses incurred by services provided by out-of-plan health professionals may not be covered, or covered only in part by an individual's insurance company. Out-Of-Pocket Maximum - A predetermined limited amount of money that an individual must pay before an insurance company will pay 100 percent for an individual's health care expenses. Outpatient - Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility. Pooling - The practice of underwriting a number of small groups as if they constituted one large group. Pre-Existing Condition - A medical condition that is excluded from coverage by an insurance company, because the condition was believed to exist prior to the individual obtaining a policy from the particular insurance company. An insurance company cannot apply these restrictions for more than 12 months. Prior creditable coverage may be used to decrease the time period applied to each member. Point of Service (POS) Plan - A heath plan which allows the subscriber to choose HMO, PPO or indemnity coverage at the point of service (time the services are received). Subscribers pay less for in-network care. For out-of-network care, subscribers usually pay a deductible and coinsurance. Preferred Provider Organization (PPO) - A network or panel of physicians and hospitals that agrees to discount its normal fees in exchange for a high volume of patients. PPO members usually pay more when they receive care outside the PPO network. Primary Care Physician (PCP) - An internist, pediatrician, family physician, general practitioner, or in some instances an obstetrician/ gynecologist who is responsible for monitoring an individual's overall health care needs. Typically, a PCP serves as a "quarterback" for an individual's medical care, referring the individual to more specialized physicians for specialist care. If you are enrolled in an HMO, you usually must choose a PCP from a list of participating providers. The PCP coordinates your care and makes referrals to specialists as needed. Retiree - In this publication, the term Retiree refers to any person who has retired from service or disability with the County of Santa Barbara and/or their survivors and who are currently receiving a monthly benefit from SBCERS. Preferred Provider Arrangement (PPA) - A contract between a healthcare insurer and a healthcare provider or group of providers who agree to provide services to persons covered under the contract. Examples include preferred provider organizations (PPOs) and exclusive provider organizations (EPOs). 34

35 Contact Information SBCERS Santa Barbara Office State Street, Suite 210 Santa Barbara, CA A-K Retirees Barbara Gordon: L-Z Retirees Scott Dunlap: SBCERS Santa Maria Office Professional Parkway, Suite 150 Santa Maria, CA A-K Retirees Doreen Miller: L-Z Retirees Renee Lynn: SBCERS Toll Free Number: Website: Blue Shield (including prescriptions HDHP) Member Services: Website: Medco (BSC Prescriptions, EPO and PPO) Member Services: Website: SecureHorizons Customer Service: Website: Kaiser Permanente Member Services: Senior Advantage members: Website: Golden West Dental Customer Service: Website: Vision Service Plan (VSP) Customer Service: Website: Conexis (COBRA Administrator) Customer Service: Website: CareCounsel Healthcare Assistance Customer Service: Website: WageWorks (formerly Creative Benefits) Customer Service: Website: 35

36 Santa Barbara County Employees Retirement System 3916 State Street, Suite 210 Santa Barbara, CA RETURN SERVICE REQUESTED