Your Health Benefit Options. Retirees CECIL COUNTY PUBLIC SCHOOLS. Cecil County Public Schools Your Health Benefit Options Retirees C1

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1 Your Health Benefit Options CECIL COUNTY PUBLIC SCHOOLS Retirees Cecil County Public Schools Your Health Benefit Options Retirees C1

2 Table of Contents Welcome... 1 How the Preferred Provider BlueCard Program Works... 2 PPO Benefits Summary... 4 Medi-Comp Benefits for Retirees... 7 Medi-Comp Benefits Summary... 8 CareFirst Medi-Comp Medical Program... 9 My Account Health + Wellness Where to Call With Questions

3 Welcome We know how important prevention, healthy living, early detection and early treatment are to you. It s one of the many advantages of having CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. (collectively, CareFirst) as your health insurance plan. We will work with you to help you maintain a healthy lifestyle, prevent illness and seek care when you need it. CareFirst BlueCross BlueShield (CareFirst) is a member of the Blue Cross and Blue Shield Association for 70 years the most trusted name in health care. This health care is available to you and your family for the September 1, 2015 through December 31, If you are under age 65 you may enroll in the Preferred Provider Network also known as PPO BlueCard. If you are over 65 and eligible for Medicare you may enroll in the Medi-Comp Program. You and your dependents are eligible for coverage without restrictions or waiting periods, regardless of past medical history. Once you have enrolled during this open enrollment season, your choice will remain in effect until the next open enrollment period. The only time you can make a change in your benefits is if you have a Lifestyle Event. The changes must be made within 31 days and be consistent with that event, as outlined by IRS regulations. Such events include marriage, divorce, death, birth or certain changes to your spouse s or your employment status. Claims are edited against the enrollment information you have provided CareFirst via your membership application. To prevent claims from being rejected or delayed, always update your application whenever there is a change in information for you or your dependents. To the extent that this health care benefits plan is completely self-funded by the sponsor, CareFirst provides administrative services only and does not assume any financial risk or obligation with respect to health care benefit claims for the selfinsured portion of the contract. CareFirst is compensated for these services as a percentage of the total amount of claims it processes and pays on behalf of the sponsor s health care benefits. Cecil County Public Schools Your Health Benefit Options Retirees 1

4 How the Preferred Provider BlueCard Program Works For Retirees Under Age 65 Choosing a doctor is an important, personal decision. By selecting CareFirst s Preferred Provider Organization (PPO) plan, you are ensuring your freedom to choose your own doctor or specialist, every time you need care. PPO BlueCard: for retirees under age 65 Depending on the physician you choose for your care, CareFirst s PPO offers lower copayments while providing you financial incentives for seeking your health care from our large Preferred Provider network. And best of all, with CareFirst s PPO, there s no need to select a Primary Care Physician (PCP) or to seek a referral before receiving outpatient care. Large provider network CareFirst s PPO offers one of the largest provider networks in Maryland (over 18,000 doctors, specialists and hospitals). And, if your doctor isn t in the PPO network, your plan allows you to go out of network in order to ensure that you receive the coverage that you deserve. Coverage that travels with you The BlueCard Program gives you access to doctors and hospitals almost everywhere, giving you the peace of mind that you ll always find the care you need. As a Blue Plan member, you have more freedom to choose the doctors and hospitals that best suit you and your family. Your membership gives you a world of choices. More than 85% of all doctors and hospitals throughout the U.S. contract with Blue Cross and Blue Shield Plans. Outside the U.S., you have access to doctors and hospitals in more than 200 countries. 2 Cecil County Public Schools Your Health Benefit Options Retirees

5 How the Preferred Provider BlueCard Program Works With the BlueCard Program, you can locate doctors and hospitals quickly and easily. Have your Blue Cross and Blue Shield Plan ID card handy, and do one of the following: Maryland providers: Visit the CareFirst website, to locate doctors and hospitals along with maps and directions to find them. Select Search Providers Select Find a Provider U n d e r Provider Type, select the type of provider you are looking for Under Plan, select BlueCross BlueShield Preferred Follow instructions to select providers. Or call member service at (877) National and international providers: Visit the BlueCard Doctor and Hospital Finder web site at or to locate doctors and hospitals along with maps and directions to find them. You can also link to this site via Or call BlueCard Access at (800) 810-BLUE. How the plan works The amount of coverage you receive is determined each time you choose care, depending on whether you choose to go in or out-of-network. This also determines the outof-pocket expenses you will have to pay. It s your choice. In-network benefits In-network Benefits provide the highest level of plan coverage. This means you have the most coverage at the lowest cost when you choose a doctor who participates in the CareFirst PPO network. Many in-network services are paid at 100% after meeting a deductible and a per visit copay. When you visit a PPO doctor or hospital, you should have no claim forms to file and no billing hassles. Depending on the plan you choose, in-network services will be reimbursed at a coinsurance (100% or 90%) and after meeting a deductible. Please refer to the PPO Benefits Summary for additional information. Out-of-network benefits Out-of-network benefits provide a lower level of coverage in exchange for the freedom to seek care from any doctor you choose. This means you share in more of the cost of your health care in return for greater flexibility. Depending on the plan you choose, most outof-network services will be reimbursed at a coinsurance (80% or 70%) subject to a deductible. Non-participating providers You have the same coverage when you go out-ofnetwork, but your out-of-pocket costs are highest when seeing non-participating providers. You pay a greater share of the costs because the provider may bill you for the difference between CareFirst s allowed benefit and the actual charge. You may be responsible for submitting the claim to CareFirst. Cecil County Public Schools Your Health Benefit Options Retirees 3

6 PPO Benefits Summary Side-by-side Comparison Chart Type of Service In-Network Core Plan Out-of-Network In-Network (PPO Providers) Plus Plan BENEFIT PERIOD CALENDAR YEAR CALENDAR YEAR DEDUCTIBLE $500 Individual $1,500 Family $1,000 Individual $3,000 Family $300 Individual $900 Family Out-of-Network (Participating or Non- Participating Providers) $900 Individual $2,700 Family OUT-OF-POCKET LIMIT $2,500 Individual / $5,000 Family $2,500 Individual / $5,000 Family COINSURANCE (FOR MOST SERVICES) IN-NETWORK COPAYMENTS AFTER DEDUCTIBLE (FOR CERTAIN SERVICES) CareFirst pays 90% of the allowed benefit after the deductible is met Office Visit: $20 per visit Specialist: $20 per visit Emergency Room: $100 per visit Urgent Care and Hospital Facility: $35 per visit Practitioner (at the hospital): $25 per visit CareFirst pays 70% of the allowed benefit after the deductible is met Your are responsible for deductible & coinsurance amounts for services rendered by participating providers** LIFETIME MAXIMUM Unlimited Unlimited CareFirst pays 100% of the preferred provider allowed benefit after the deductible is met Office Visit: $15 per visit (Family or General Practitioner; Internist; Pediatrician) Specialist: $25 per visit Emergency Room: $75 per visit Urgent Care and Hospital Facility: $35 per visit Practitioner (at the hospital): $25 per visit TYPE OF SERVICE PLAN PAYMENT PLAN PAYMENT HOSPITAL INPATIENT* Semi-private room or intensive care unit Operating room/special treatment room All medically necessary services Includes Medical, Surgical, Rehabilitation, Maternity, Extended Care Facility, Psychiatric and Substance abuse Admissions Precertification is required (UCP+) PHYSICIAN SERVICES Office visits (home visits) Inpatient Care (hospital visits) Surgeon (in-hospital visits) Assistant Surgeon, Anesthesiologist 90% of AB deductible, then $20 copay Patient admitted as result of urgent care paid as in-network 90% of AB 90% of AB 90% of AB Paid at CareFirst pays 80% of the allowed benefit after the deductible is met Your are responsible for deductible & coinsurance amounts for services rendered by participating providers** 100% of AB deductible, then $15 or $25 per visit copay Patient admitted as result of urgent care paid as in-network 100% of AB 100% of AB 100% of AB Paid at in-network benefit ** AB = Allowed Benefit * Hospital precertification required for all elective admissions. Benefits reduced by $500 if precertification is not obtained. Certain outpatient services require approval to begin or continue outpatient treatment. ** Non-Participating providers can bill you up to total charges. *** Non-participating providers paid up to charges. This chart is for comparison purposes only. The group contract between Cecil County Board of Education and CareFirst BlueCross BlueShield will prevail. 4 Cecil County Public Schools Your Health Benefit Options Retirees

7 PPO Benefits Summary Side-by-side Comparison Chart Type of Service In-Network Core Plan Out-of-Network In-Network (PPO Providers) Plus Plan BENEFIT PERIOD CALENDAR YEAR CALENDAR YEAR MATERNITY (Outpatient) Physician & medical services Birthing Centers Invitro Fertilization/ Artificial Insemination* (limitations apply) 90% of AB URGENT CARE (Emergency accident or Medical Emergency; Initial visit only if rendered within 72 hours) Ambulance Service 100% of AB Paid at * Physician in Office Physician in ER or Urgent Care Center Emergency Room; Outpatient Facility Services Urgent Care Center deductible, then $20 copay Paid at 100% of AB Paid at * deductible, then $100 copay deductible, then $35 copay Paid at Paid at Admitted as Inpatient 90% of AB Paid at Care Outside 72 Hours or Follow-up Care OUTPATIENT SURGERY Outpatient Facility Services Physician Care in Outpatient Department Practitioner in Office HOSPITAL OUTPATIENT (Non-Surgical) Outpatient Facility Services Physician Care in Outpatient Department OUTPATIENT DIAGNOSTIC/LAB Physician Office/ Independent Lab Outpatient (Facility) Outpatient Professional Component billing (charge for reading) CT Scans and MRIs Paid the same as other covered services deductible, then $35 copay deductible, then $25 copay deductible, then $20 copay deductible, then $35 copay deductible, then $25 copay deductible, then $15 copay deductible, then $15 copay Paid the same as other covered services Paid at 90% of AB Paid at deductible, then $75 copay Out-of-Network (Participating or Non- Participating Providers) 100% of AB 100% of AB Paid at * 100% of AB Paid at 100% of AB Paid at * deductible, then $75 copay deductible, then $35 copay Paid at Paid at 100% of AB Paid at Paid the same as other covered services deductible, then $35 copay deductible, then $25 copay deductible, then $15 or $25 per visit copay deductible, then $35 copay deductible, then $25 copay deductible, then $15 copay deductible, then $15 copay Paid the same as other covered services Paid at in-network benefit ** 100% of AB Paid at in-network benefit ** deductible, then $75 copay AB = Allowed Benefit * Hospital precertification required for all elective admissions. Benefits reduced by $500 if precertification is not obtained. Certain outpatient services require approval to begin or continue outpatient treatment. ** Non-Participating providers can bill you up to total charges. *** Non-participating providers paid up to charges. This chart is for comparison purposes only. The group contract between Cecil County Board of Education and CareFirst BlueCross BlueShield will prevail. Cecil County Public Schools Your Health Benefit Options Retirees 5

8 PPO Benefits Summary Side-by-side Comparison Chart Type of Service In-Network Core Plan Out-of-Network In-Network (PPO Providers) Plus Plan BENEFIT PERIOD CALENDAR YEAR CALENDAR YEAR WELL CARE Adult Routine Physical Exam (1/CY) Routine GYN Exam (1/CY) Well Child Visits (guidelines apply) Mammogram Screening (guidelines apply) 100% of AB no deductible 100% of AB no deductible 100% of AB no deductible PHYSICAL THERAPY (100 Visits per Calendar Year) Facility Billed Practitioner in Facility Practitioner in Office OCCUPATIONAL AND SPEECH THERAPY Facility Billed Practitioner in Facility Practitioner in Office no deductible Out-of-Network (Participating or Non- Participating Providers) 100% of AB 100% of AB 100% of AB no deductible 100% of AB 100% of AB $35 member copay $25 member copay deductible, then $20 copay $35 member copay $25 member copay deductible, then $20 copay RADIATION THERAPY, CHEMOTHERAPY & RENAL DIALYSIS Facility Billed Practitioner in Facility Practitioner in Office 100% AB, then $35 member copay 100% AB, then $25 member copay 100% AB, then $20 member copay OUTPATIENT PSYCHIATRIC & SUBSTANCE ABUSE Halfway House/Partial Hospitalization Outpatient Visits $35 member copay $25 member copay deductible, then $25 per visit copay $35 member copay $25 member copay deductible, then $25 per visit copay deductible, then $35 member copay deductible, then $25 member copay deductible, then appropriate copay Benefits are available to the same extent as benefits provided for other illnesses. AB = Allowed Benefit * Hospital precertification required for all elective admissions. Benefits reduced by $500 if precertification is not obtained. Certain outpatient services require approval to begin or continue outpatient treatment. ** Non-Participating providers can bill you up to total charges. *** Non-participating providers paid up to charges. This chart is for comparison purposes only. The group contract between Cecil County Board of Education and CareFirst BlueCross BlueShield will prevail. 6 Cecil County Public Schools Your Health Benefit Options Retirees

9 Medi-Comp Benefits for Retirees Over Age 65 with Medicare Parts A & B After receiving medical services, all physicians must file claims to Medicare for you. If your provider indicates your Medi-Comp information on the Medicare claim form, you will not have to file claims to CareFirst. Claims for your remaining benefits will automatically come to CareFirst from Medicare. Medi-Comp determines coverage amounts by coordinating benefits after Medicare makes payment. Medi-Comp does this by first determining what CareFirst would have paid for services had Medicare not been responsible. Secondly, Medi-Comp will compare this amount against the balance after Medicare payment and reimburse the lesser of the two amounts. Questions before you sign up? If you have any questions about coverage through CareFirst s Medi-Comp coverage, please call us at (877) If your physician is accepting Medicare s allowed amount as payment in full, CareFirst will reimburse the physician directly for services and calculate benefits using Medicare s allowed amount. If your physician is not accepting assignment, we reimburse you and calculate benefits using Medicare s limiting charge. Medicare developed limiting charges as protection from high charges for Medicare beneficiaries as the most a physician can charge for services. In 1993 and future years it is 115% of Medicare s allowed amount. Cecil County Public Schools Your Health Benefit Options Retirees 7

10 Medi-Comp Benefits Summary Type/Place of Service BENEFIT PERIOD DEDUCTIBLE OUT-OF-POCKET LIMIT LIFETIME MAXIMUM Comprehensive Program Calendar Year $300 Individual $1,500 Individual Unlimited COINSURANCE (for most services) Plan pays, Member pays 20% HOSPITAL INPATIENT Semi-private room or intensive care unit Operating room/special treatment room All medically necessary services Includes Medical, Surgical, Rehabilitation, Maternity, Extended Care Facility, Psychiatric and Substance Abuse Admissions URGENT CARE EMERGENCY ACCIDENT OR MEDICAL EMERGENCY (initial visit only if rendered within 72 hours) Physician s office Emergency Room Follow-up Care HOSPITAL OUTPATIENT PHYSICIAN SERVICES Office visits, home visits, Inpatient Care Second Surgical Opinion Inpatient Care Surgery, Assistant Surgeon, Anesthesiologist WELL CARE Adult Routine Physical Exam (1/CY) Routine GYN Exam (1/CY) Mammogram Screening (guidelines apply) OUTPATIENT DIAGNOSTIC LAB/X-RAY RADIATION THERAPY, CHEMOTHERAPY & RENAL DIALYSIS PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY HOME CARE & HOSPICE SERVICES - AGENCY SERVICES TRANSPLANTS Kidney, Cornea, Bone Marrow Liver, Heart, Pancreas, Lung ADDITIONAL BENEFITS DURABLE MEDICAL EQUIPMENT, PROSTHESES, MEDICAL & OSTOMY SUPPLIES, AMBULANCE, ORTHOTICS & BRACES, CHIROPRACTIC SERVICES OUTPATIENT PSYCHIATRIC & SUBSTANCE ABUSE Halfway House/Partial Hospitalization Outpatient Visits 100% of AB, no deductible 100% of AB, no deductible Regular Medical Benefit,,,, 100% of AB, no deductible 100% of AB, no deductible 100% of AB, no deductible, no deductible,,, no deductible Covered as surgical procedure 100% of AB, no deductible,,, AB= Allowed Benefit This summary is for comparison purposes only and does not create rights not given through the benefits contract. 8 Cecil County Public Schools Your Health Benefit Options Retirees

11 CareFirst Medi-Comp Medical Program How it Works with Medicare Example 1 Medicare Payments HOSPITAL DOCTOR Total Allowed Charges $1,000 $1,000 Less Medicare Deductible 1, (-100) 845 x 80% Medicare s Payments $ 0 $ 676 Mrs. Smith s Liability after Medicare $ 1,000 $ 324 Mrs. Smith, a retiree with Medicare, has inpatient surgery. In this example, Mrs. Smith s surgery results in $1,000 in hospital bills and $1,000 in doctor charges allowed by Medicare. CareFirst Payment Calculation HOSPITAL DOCTOR Total Allowed Charges $1,000 $1,000 Less Deductible 300 met x 80% x 80% Maximum Normal Plan Payment $ 1,000 $ 324 Payment calculation will be determined by first establishing how the claim would normally be paid (without Medicare payment considered). CareFirst Payment Calculation HOSPITAL DOCTOR Mrs. Smith s Liability after Medicare $1,000 $ 324 Less Plan Payment Mrs. Smith s Final Liability $ 440 $ 0 CareFirst will pay the Normal Plan Payment or the patient s actual liability, whichever is lower. Cecil County Public Schools Your Health Benefit Options Retirees 9

12 CareFirst Medi-Comp Medical Program How it Works with Medicare Example 2 Medicare Payments HOSPITAL DOCTOR Total Allowed Charges $10,000 $7,000 Less Medicare Deductible 1, $ 8,900 $ 6,845 x 80% Medicare s Payments $ 8,900 $ 5,476 Mrs. Jones Liability after Medicare $ 1,100 $ 1,524 Mrs. Jones, a retiree with Medicare, has to undergo treatment for breast cancer. In this example, Mrs. Jones treatment results in $10,000 in hospital bills and $7,000 in doctor charges allowed by Medicare. CareFirst Payment Calculation HOSPITAL DOCTOR Total Allowed Charges $10,000 $7,000 Less Deductible 300 met $ 9,700 $ 7,000 x 80% x 80% Maximum Normal Plan Payment $ 7,760 $ 5,600 Payment calculation will be determined by first establishing how the claim would normally be paid (without Medicare payment considered). CareFirst Payment Calculation HOSPITAL DOCTOR Mrs. Jones Liability after Medicare $1,100 $ 1,524 Less Plan Payment 1,000 1,524 Mrs. Jones Final Liability $ 0 $ 0 CareFirst will pay the Normal Plan Payment or the patient s actual liability, whichever is lower. 10 Cecil County Public Schools Your Health Benefit Options Retirees

13 CareFirst Medi-Comp Medical Program How it Works with Medicare Example 3 Mrs. Green s Out-of-Pocket Costs MONTH APPLIED TO MEDICARE DEDUCTIBLE 80% MEDICARE PAYMENT APPLIED TO COMPREHENSIVE DEDUCTIBLE COMPREHENSIVE PAYMENT SUBSCRIBER LIABILITY January $ $ 0.00 $ $ 0.00 $ February March April May June July August September October November December TOTALS $ $ $ $ $ Mrs. Green s hypertension requires she visit her doctor once a month. Her doctor charges $40 per office visit which Medicare allows as reasonable. The chart below outlines Mrs. Green s out-ofpocket costs for an entire year of office visits. Entire year of office visits 12 Office Visits at $65.00 each = $ Medicare Payments = Comprehensive Payments = Subscriber Liability = Cecil County Public Schools Your Health Benefit Options Retirees 11

14 My Account Online access to your claims View personalized information on your claims and out-of-pocket costs online with My Account. Simply log on to for real-time information about your plan. Features of My Account View your deductible status and out-of-pocket costs for your current and previous plan year. Review up to one year of medical claims total charges, benefits paid and costs for a specific date range Request an ID card Sign up for electronic communications and get your information faster and more securely Signing up is easy Visit click on Register Now and set up your User ID and Password. You ll just need information from your member ID card. Additional tools Depending on your specific health plan, you may have access to the following services through My Account: Download claim forms Find in-netwok providers Track your reward progress Compare costs from different doctors, hospitals and facilities with our Treatment Cost Estimator Mobile access View the most-visited information in My Account on your smartphone or tablet. Our mobile site is available from any browser-equipped mobile device. To try out the app, visit your favorite app store, search for CareFirst and install the CareFirst app on your device. Enjoy access to: Find A Provider Search for nearby urgent care and ER facilities, based on your current location (as determined by your device s GPS). Searchable claims information Who s eligible and covered under your policy View your ID cards (App users can also print and ID cards) Register for My Account and maintain your security and notification preferences. For more information on our mobile site and app, visit SUM2000-1P 12 Cecil County Public Schools Your Health Benefit Options Retirees

15 Health + Wellness Whether you re looking for health and wellness tips, discounts on health-related services, or support to manage a health condition, we have the resources to help you get on the path to good health. Online Health education Find a wide variety of health education articles, nutritious recipes and cooking videos, interactive health-related tools and more at FirstHelp Registered nurses are available 24 hours a day to answer your health care questions. Call (800) with your health questions or for help choosing the best source of care. Vitality magazine Vitality provides updates to your health care plan and a variety of health and wellness topics, including food and nutrition, physical fitness and preventive health. All issues are available online at Wellness discount program Blue365 delivers great discounts from top national and local retailers on fitness gear, gym memberships, family activities, healthy eating options and more. Visit Health news Get the latest information to help you and your family maintain a healthy lifestyle. To sign up for our monthly electronic member newsletter, visit Health and wellness programs and resources help you and your family live a healthy life. CUT7486-1P Cecil County Public Schools Your Health Benefit Options Retirees 13

16 Pedometer app Count your steps, distance traveled and calories burned for each workout with the free CareFirst Ready, Step, Go! app. The app is available for iphone, ipod Touch, or Android smartphones visit your app store and search for Ready, Step, Go! Coordinating your care Whether you re trying to get healthy or stay healthy, you need the best care. CareFirst has programs to help you take an active role in your health, address any health care issues and enjoy a healthier future. Case Management If you have a serious illness or injury, our Case Management program can help you navigate through the health care system and provide support along the way. Our Case Managers are registered nurses who will: Work closely with you and your doctors to develop a personalized treatment plan. Coordinate necessary services. Answer any of your questions. Our Case Management program is voluntary and confidential. For more information, or to enroll, call (888) Patient-Centered Medical Home (PCMH) PCMH was designed to provide your primary care provider with a more complete view of your health needs, as well as the care you receive from other providers. When you participate in this program, you are the focus of an entire health care team whose goal is to better manage and coordinate your care and improve your health. If you have a chronic condition, or are at risk for one, your PCP may: Create a care plan based on your health needs with specific follow-up activities to help you manage your health Provide access to a care coordinator, who is a registered nurse, so you have the support you need, answers to your questions and information about your care Find a participating PCMH provider in our provider directory at 14 Cecil County Public Schools Your Health Benefit Options Retirees

17 Where to Call With Questions CareFirst BlueCross BlueShield Medical claims member services (877) Service: 24 hours/day 7 day/week Holidays: 8:00 a.m. 4:00 p.m. For members enrolled in PPO coverage Case Management Hospital Preadmission Review Outpatient Pretreatment Certification Finding PPO providers BlueCard BlueCard Worldwide (800) 810-BLUE (2583) Benelogic ccps.benelogic.com Approval of inpatient admissions, Infertility Service, Home Health and Hospice Care, Private Duty Nursing and Habilitative Services (866) PREAUTH ( ) Cecil County Public Schools Your Health Benefit Options Retirees 15

18 Notes 16 Cecil County Public Schools Your Health Benefit Options Retirees

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20 CareFirst BlueCross BlueShield CareFirst BlueChoice, Inc Mill Run Circle Owings Mills, MD Health benefits administered by: CONNECT WITH US: BOK5042-1N (5/15) CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.