Health Options Program Option Selection Period FAQs

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1 Health Options Program Option Selection Period FAQs The Health Options Program Q What is a Qualifying Event? A A Qualifying Event is what makes you eligible for enrollment in the Health Options Program. You experience a qualifying event when: o You retire or lose health care coverage under your school employer s health plan. o Coverage under your school employer s health plan includes any COBRA continuation coverage you may elect under that school employer s plan. o You involuntarily lose health care coverage under a non-school employer s health plan, including any COBRA continuation coverage you may elect under that nonschool employer s health plan. o You or your spouse reach age 65 or become eligible for Medicare. o There is a change in your family status for example, divorce, the death of a spouse, addition of a dependent through birth, adoption, or marriage, or a dependent loses eligibility. Note: The death of a retiree is not a Qualifying Event unless the spouse or dependent will receive a pension from PSERS following the retiree's death. o You become eligible for Premium Assistance due to a change in legislation. o A plan approved for Premium Assistance terminates or you move out of a plan s service area. Q Can I apply online. A At this time, online applications are not available. If you want to make a change for 2017, you must complete an application by November 15. Q What is Premium Assistance? A PSERS provides Premium Assistance to help eligible retirees pay for health coverage through the Health Options Program. If you are eligible for Premium Assistance and enroll in either a Medicare Supplement plan or a Medicare Advantage plan, PSERS will pay up to $100 per month toward your monthly premium. Q How do I know if I m eligible for Premium Assistance? Is there something I have to do to get it or is it automatically applied? A Retirees are eligible for Premium Assistance if they had 24 ½ years of service, retired with a disability retirement or retired after the age of 62 with at least 15 years of service. There is nothing you have to do. A Premium Assistance election form is automatically 1

2 mailed to eligible members when they first retire. If you are not sure if you are receiving Premium Assistance, refer to the check change letters mailed to you from PSERS or call Q What if I don t want to make any changes for 2017? A No changes are required if you want to keep your current plan as updated for You don t need to submit an application or other paperwork. Q Will I get a new ID card? A If you don t make any changes, you will NOT get a new ID card for Continue to use the one you have. If you change your coverage for 2017, you will get a new ID after December 19, 2016 for use starting January 1. Q If I enroll in a Highmark plan, can I continue to use UPMC facilities in 2017? A At one point in time, there was some discussion between these companies that members who are enrolled in a Highmark Medicare Advantage plan may no longer be allowed to use UPMC facilities. However, the Commonwealth recognizes this is an important benefit for members so we stepped in and ask that this be reconsidered. I m happy to report that both organizations worked together and have agreed to continue their relationship. This means that members of the Health Options Program who are enrolled in a Highmark plan will be able to continue to use UPMC facilities throughout Q Where can I go for more information? A Visit our website at The resources page has links to important documents for Look on the home page for a link to all 2017 plan information. If you are new to the Health Options Program, the video on the home page provides an introduction to how the program works with Medicare. You can always call the HOP Administration Unit with your specific questions. The telephone number for the HOP Administration Unit is Q Do my spouse and I have to enroll in the same plan? A As a rule, you and your dependents must be covered under the same type of plan. For example, if you elect the HOP Medical Plan, your spouse must elect the HOP Medical Plan if he or she is eligible for Medicare or the HOP Pre-65 Medical Plan if he or she is not eligible for Medicare. The exception to this rule is if you and your spouse are both PSERS annuitants. In this case, you may elect different options. 2

3 Medical Plans Q If I enroll in the Value Medical Plan, do I have to pay the deductible before the Plan pays benefits? A Yes, that s correct. When you have medical expenses, you pay Medicare s annual deductible first and then you and the Plan share in the remaining cost according to how each service is covered. For reference, Medicare s annual deductible for 2016 is $166. Q Are gym memberships or discounts included with the medical plan options? A If you enroll in the HOP Medical Plan, you have SilverSneakers Fitness at no additional cost. SilverSneakers offers treadmills, weights, heated pools and fitness classes all included with your basic fitness membership. The Value Medical Plan does not include a SilverSneakers membership. Q How is the Value Medical Plan different from the HOP Medical Plan? A With the Value Medical Plan, you pay a lower monthly premium. However, with the Value Medical Plan, you must first pay a deductible before the Plan pays benefits. Q How much are my monthly premiums? A Your personalized statement list what options are available to you and the monthly costs for each. If you have questions, you can also call the HOP Administration Unit at Q Where can I find detailed information about the Medicare Advantage plans? A You can call the HOP Administration Unit at They will send you the enrollment forms and required information to be mailed to you for the plan you want. Due to the volume of these materials, they could not be included with your Personalized Statement. Q Do I need a referral for a specialist? A You do not need a referral if you are enrolled in the HOP Medical Plan or the Value Medical Plan. If you are enrolled in a Medicare Advantage plan, the rules may be different. Check with the plan to confirm if referrals are needed. Prescription Drug Plans Q Where can I find a list of local participating pharmacies? A Your OSP materials included a customized list of pharmacies within a 20-mile range of your home address. You can also go online to our website at and click on the Find a Pharmacy on the home page. 3

4 Q What prescription drug plans are available through the Health Options Program? A The Health Options Program offers three Medicare prescription drug plans the Enhanced Medicare Rx Option, the Basic Medicare Rx Option and the Value Medicare Rx Option. Your monthly premium for the Value Medicare Rx Option is lower than for either the Enhanced or Basic Medicare Rx Option, but you have to satisfy Medicare s annual deductible before the Value Medicare Rx Option pays any portion of your prescription drug expenses. MetLife Dental Plan Q Do I need an ID Card to access dental services? A Members will not receive ID cards for the dental plan. They are not required to show an ID card to their dentist as proof of coverage. Just tell your dentist s office that MetLife is your dental carrier when you schedule an appointment. Q What are differences between in-network and out-of-network benefits? And, do I have to go to an in-network dentist? A You can go to any dentist you want, but you ll get the most benefit from the plan if you use a MetLife in-network dentist. In-network dentists have agreed to accept discounted rates, which could be as much as 45% less than what they normally charge. Also, if you use an in-network dentist, you can get free preventive dental care no deductible, no copayment for things like twice-a-year exams and cleanings, or once-ayear bitewing x-rays. If you need more substantial services, you ll pay 30% or 40% of the cost depending on the type of service. If you go to an out-of-network dentist, you ll pay more. Q How do I know if my dentist is in the MetLife network? A You can find a list of MetLife dentists online by visiting the HOPbenefits.com site, selecting the MetLife Dental Plan along the left-side navigation and using the MetLife website link in the Find a Dentist Section. You can search by zip code or use the advanced search function for more specific search options. Q Do I have to submit a claim or will my dentist submit the claim? A In most cases, the dentist will submit claims for the member. However, if they need to submit a claim for example, for out-of-network services they can request a claim form by calling All claim forms should be mailed to the MetLife Dental Claims address that s on the claim form. Members can track their claims online and even receive alerts when a claim has been processed. 4

5 Q Is there a waiting period before I can use my dental benefits? A There is no waiting period before you can use your dental benefits. If you enroll during this Option Selection Period, your coverage will be effective January 1, Q Does the dental coverage have any pre-existing exclusions? A The plan has a missing tooth exclusion. This means MetLife will not cover initial placement of a bridge, implant or denture if the tooth is lost prior to your coverage effective date. MetLife may pay benefits toward the replacement of a bridge, implant or denture as long as you had the prosthesis for at least 84-months prior to it needing to be replaced. Q What if I just want to add dental coverage only? A You must complete an application and submit it by November 15. To add dental only, check the MetLife Dental Plan box on the application. Q If I m enrolled in the dental plan does my wife also need to be enrolled? A If your wife is not a PSERS retiree, she must enroll in the same plan as you. If both you and your wife are PSERS retirees, you can enroll in different plans. For more information, visit or call the HOP Administration Unit at TTY Users should call Effective January 1,

6 Pennsylvania Public School Employees Retirement System (PSERS) Notice of Nondiscrimination The Pennsylvania Public School Employees Retirement System (PSERS) Health Options Program complies with applicable Federal civil rights laws and does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The PSERS Health Options Program: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact Joseph E. Wasiak Jr., Assistant Executive Director. If you believe that the PSERS Health Options Program has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Joseph E. Wasiak Jr., Assistant Executive Director Public School Employees Retirement System 5 N 5th Street Harrisburg, PA Phone: (888) ; Fax: (717) ; jowasiak@pa.gov You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Joseph Wasiak is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD). Complaint forms are available at 6

7 Attention: Free Language Assistance This chart displays, in various languages, the phone number to call for free language assistance services for individuals with limited English proficiency. 7