STRS OHIO HEALTH CARE. Program Guide. Effective Jan. 1, 2018

Transcription

1 STRS OHIO HEALTH CARE Program Guide 2018 Effective Jan. 1, 2018

2 Aetna Basic Who to Contact WEBSITE MAILING ADDRESS CUSTOMER SERVICE Claims Address: P.O. Box El Paso, Texas Aetna Medicare Plan (toll-free) Hours: Weekdays, 8 a.m. 6 p.m. Claims Address: P.O. Box El Paso, TX (toll-free) Hours: Weekdays, 8 a.m. 6 p.m. AultCare PPO Mailing Address: P.O. Box 6910 Canton, OH Canton area: All other areas: (toll-free) Hours: Weekdays, 7:30 a.m. 5 p.m. Express Scripts Medical Mutual Basic Claims Address Non-Medicare enrollees: Commercial Claims P.O. Box Lexington, KY Medicare enrollees: Medicare Part D Claims P.O. Box Lexington, KY Non-Medicare enrollees: (toll-free) Medicare enrollees: (toll-free) Hours: 7 days a week, 24 hours a day Claims Address: P.O. Box 6018 Cleveland, OH (toll-free) Hours: Monday Thursday, 7:30 a.m. 7:30 p.m. Hours: Friday, 7:30 a.m. 6 p.m. Hours: Saturday, 9 a.m. 1 p.m. Medicare (toll-free) Hours: 7 days a week, 24 hours a day Paramount HMOs Mailing Address: P.O. Box 928 Toledo, OH (toll-free) Hours: Weekdays, 8 a.m. 5 p.m. Social Security Administration (toll-free) Hours: Weekdays, 7 a.m. 7 p.m. STRS Ohio Mailing Address: Health Care Services Department 275 E. Broad St. Columbus, OH (toll-free) Hours: Weekdays, 8 a.m. 5 p.m. 2

3 Welcome Thank you for your interest in the STRS Ohio Health Care Program. We understand access to quality health insurance in retirement is important to you. This is why all STRS Ohio medical plans include hospital, medical and prescription drug coverage. Separate dental and vision insurance is also available. Coverage is currently offered to eligible benefit recipients with 15 or more years of service who participate in the Defined Benefit Plan or Combined Plan. Eligible dependents may also enroll in a plan if the benefit recipient is enrolled. Members who retire on or after Aug. 1, 2023, will need at least 20 years of qualifying service to participate in the STRS Ohio Health Care Program. STRS Ohio currently makes medical plan premiums more affordable for eligible service retirement and disability benefit recipients by paying a portion of the monthly costs. Once you enroll in a plan, monthly premiums will be deducted from your STRS Ohio benefit payment. The plans available to you depend on the location of your permanent residence and your Medicare status on file with STRS Ohio and Medicare. Enrollment in Medicare Parts A & B or Part B-only is required for all plan participants who are age 65 or older, or otherwise eligible for Medicare. To find out which plans are available to you, review the personalized list of plan options you may have received with this guide. If you do not have a personalized list, please call STRS Ohio or register for an STRS Ohio Online Personal Account. Knowing your plan options will help you focus on the information that applies to you. If you have questions after reviewing this guide, please call STRS Ohio. To stay up to date on health care program news throughout the year, sign up for STRS Ohio s news service by sending an to contactus@strsoh.org. STRS Ohio Member Services Center STRS Ohio website... STRS Ohio ...contactus@strsoh.org The STRS Ohio Health Care Program is authorized by Chapter 3307 of the Revised Code, which may be amended at any time by the Ohio General Assembly. Furthermore, coverage under the program may be modified or eliminated at any time by the State Teachers Retirement Board. Health care coverage is not guaranteed. STRS Ohio may change or discontinue all or part of the program for all or a class of eligible benefit recipients and covered dependents at any time. Premiums, copayments/coinsurance, deductibles and all other charges or fees paid by an enrollee may change from year to year. This guide is an overview of the STRS Ohio Health Care Program. It is not a legal document. Your plan will send you a comprehensive description of your coverage after enrollment is confirmed STRS Ohio Health Care Program Guide 1

4 What s Inside Section 1: Eligibility and Enrollment... 3 Who Is Eligible for Coverage?... 3 Premium Subsidy and Financial Assistance... 5 Enrolling as a New Benefit Recipient... 6 Enrolling After Monthly Benefits Begin... 6 Coverage Considerations... 7 Section 2: Understanding Your Plan Options...9 Which Plans Are Available to You?... 9 Plan Features to Consider Key Terms to Understand Types of Plans Offered Prescription Drug Coverage Section 3: Plans and Premiums Without Medicare Prescription Drug Plan Features Without Medicare Plan Features for 2018 Without Medicare Monthly Premiums for 2018 Without Medicare Section 4: Medicare Enrollment Understanding Medicare Enrolling in Medicare Selecting Your New STRS Ohio Plan After You Enroll in Medicare Section 5: Plans and Premiums With Medicare Prescription Drug Plan Features With Medicare Plan Features for 2018 With Medicare Monthly Premiums for 2018 With Medicare Section 6: Additional Information Quality Standards Release of Information and Confidentiality Statement Affordable Care Act and Your STRS Ohio Medical Plan Notice of Privacy Practices General Notice of COBRA Continuation Coverage Rights Notice of Medicare Part D Creditable Coverage Section 1557 Notice of Nondiscrimination

5 Section 1: Eligibility and Enrollment Who Is Eligible for Coverage? BENEFIT RECIPIENTS Service retirement A Defined Benefit Plan or Combined Plan member with 15 or more years of qualifying service credit who is granted service retirement with an effective date of Jan. 1, 2004, or later is eligible for coverage. In addition, a Defined Benefit Plan or Combined Plan member who was granted service retirement with an effective date before Jan. 1, 2004, is also eligible for coverage; however, the member pays 100% of the health care premium if the member has less than 15 years of service credit. Disability A disability recipient is eligible for coverage. If a disability recipient later applies for service retirement, the following applies: If the disability effective date was before Jan. 1, 2004, the recipient qualifies for access to health care coverage under the service retirement account as long as there was no break in benefits between the disability benefit and the service retirement benefit. However, if the recipient has less than 15 years of qualifying service credit, the recipient pays the full cost of the coverage. If the disability effective date is on or after Jan. 1, 2004, the recipient must have 15 or more years of qualifying service credit to have access to health care coverage if the recipient later applies for service retirement. Note: Members who retire Aug. 1, 2023, or later, will need 20 or more years of qualifying service to be eligible for health care coverage. EMPLOYED NON-MEDICARE ENROLLEES Coverage under the STRS Ohio Health Care Program is limited for non-medicare enrollees employed in public or private positions. Employed enrollees are eligible only for secondary coverage through STRS Ohio s Basic Plan if they: (1) are eligible for medical and prescription drug coverage through their employer, or (2) hold a position for which similarly situated employees are eligible for medical and prescription drug coverage at the same cost as full-time employees. The rule applies to all employed enrollees who are not eligible for Medicare, regardless of hire date or type of employment. STRS Ohio requires non-medicare enrollees to verify their employment status and access to employer health coverage annually. To provide verification, log in to your STRS Ohio Online Personal Account or submit a Verification of Employment and Employer Health Care Access form (available on our website or upon request). If you prefer to opt out of secondary coverage by canceling your STRS Ohio plan enrollment, contact STRS Ohio STRS Ohio Health Care Program Guide 3

6 ELIGIBLE DEPENDENTS Once the benefit recipient enrolls, a spouse, child and/ or disabled adult child may be eligible for coverage. You must notify STRS Ohio when a dependent no longer meets eligibility requirements and indicate the day, month and year your dependent is no longer eligible. Premium deductions from your monthly STRS Ohio benefit payment do not guarantee coverage if your dependent no longer meets eligibility requirements. Spouse A person married to a service retirement benefit recipient, disability benefit recipient or active member at the time of the member s death. Child A child of a service retirement benefit recipient, disability benefit recipient or active member at the time of the member s death. The child must be under age 26 and be a: Biological child; or Lawfully adopted child or a stepchild; or A child for whom the benefit recipient or member is legally appointed as guardian. Disabled Adult Child A person age 26 or older who meets the following requirements: Has never been married; and Is a biological child, legally adopted child prior to age 18 or a stepchild of a living or deceased primary benefit recipient or member; or a child for whom a primary benefit recipient has been legally appointed as guardian prior to the child attaining age 18; and Continuously meets the requirements for physical or mental incompetency as set forth in Administrative Code Rule 3307:1-8-01; and Either was adjudged physically or mentally incompetent by a court prior to age 22; or was continuously physically or mentally incompetent and continuously unable to earn a living where both conditions occurred prior to age 22. BENEFICIARIES AND SURVIVORS Beneficiaries of Service Retirement Benefit Recipients A spouse, child or disabled adult child receiving benefits under a Joint and Survivor Annuity or Annuity Certain plan of payment who was an eligible dependent of the service retirement benefit recipient at the time of the benefit recipient s death. The service retirement benefit recipient must have been eligible for coverage at the time of death for a beneficiary to qualify for coverage. (See Benefit Recipients on Page 3 for eligibility criteria.) Survivors of Active Members or Disability Benefit Recipients A spouse, child or disabled adult child who is granted survivor benefits under division (C)(2) of Section , Revised Code, and who was an eligible dependent at the time of the active member s or disability benefit recipient s death. For survivors of active members, if the effective date of survivor benefits is Jan. 1, 2004, or later, 15 or more years of service at the time of the member s death may be required depending on the type of survivor benefit selected. 4

7 Premium Subsidy and Financial Assistance PREMIUM SUBSIDY FOR BENEFIT RECIPIENTS STRS Ohio currently makes medical plan premiums more affordable for eligible service retirement and disability benefit recipients by paying a portion of the monthly costs. Covered dependents do not receive a premium subsidy. As a benefit recipient, if you participate in the Defined Benefit or Combined Plan and have 15 or more years of qualifying service credit, STRS Ohio will subsidize your individual monthly medical plan premium. The 2018 premium subsidy rates are: 1.9% for non-medicare enrollees, up to a maximum of 57%; and 2.1% for Medicare enrollees, up to a maximum of 63%. HEALTH CARE ASSISTANCE PROGRAM The Health Care Assistance Program (HCAP) is designed to help qualified benefit recipients who need financial assistance to pay for their STRS Ohio medical plan. The assistance program currently includes a $0 monthly premium for the benefit recipient and often lower out-ofpocket costs for all enrollees in the plan. Although covered family members may receive the same plan of coverage as the qualifying benefit recipient, they are not eligible for the $0 premium and must pay the full cost of their coverage. The assistance program is currently available to: Service retirement benefit recipients with 25 or more years of qualifying service credit; Disability benefit recipients receiving STRS Ohio benefits; and Beneficiaries and survivors who are otherwise eligible for subsidized premiums. New applicants must be eligible for a subsidy under the STRS Ohio Health Care Program to qualify for HCAP enrollment. Benefit recipients, beneficiaries and survivors who were enrolled in HCAP as of Dec. 31, 2015, are not subject to the subsidy requirement as long as they continue to meet all other HCAP requirements and remain continuously enrolled in the program. Depending on Medicare status, approved individuals may enroll in the Medical Mutual Health Care Assistance Plan or the Aetna Medicare Plan. Medicare-eligible participants must maintain their Medicare Parts A & B or Part B-only enrollment to remain eligible for HCAP. To be eligible for the program: Your total annual family gross income (including any annual pension benefits and cost-of-living adjustments) must be at or below $23,800 for you, your spouse and any dependent children; and Liquid assets or funds readily available to your family, such as cash, savings, money market and checking accounts, trust funds, publicly traded securities and other investment vehicles, must not exceed $23,800 per calendar year. (A home is not considered a liquid asset.) To apply for the program, you must submit a completed application to STRS Ohio, a copy of the previous year s federal tax return and a copy of your Medicare card if applicable. Applications must be received no later than the 15th of the month to be considered for approval for an effective date starting the next month. STRS Ohio will requalify participants annually. For more information about the program, please call STRS Ohio or visit our website for an application. How STRS Ohio Health Care Is Funded The laws that govern STRS Ohio do not guarantee or fund health care. In 1983, the State Teachers Retirement Board established the Health Care Fund to help support the health care program. With no dedicated revenue source for health care, funding comes from: premiums paid by enrollees in the health care program, annually determined employer contributions (currently 0%), investment earnings on the Health Care Fund, federal subsidies and pharmaceutical reimbursements for prescription drugs. Due to increasing claims costs and no additional funding beyond the current Health Care Fund balance, STRS Ohio faces significant health care funding challenges. As the Retirement Board explores viable funding options, we will use our website, newsletters, news service and social media channels to keep you informed STRS Ohio Health Care Program Guide 5

8 Enrolling as a New Benefit Recipient Before you begin receiving service retirement or disability benefits, you must complete a pension benefit application. A section of this application asks whether you want to enroll in an STRS Ohio health care plan. If you indicate you want to enroll but do not select a plan, health care information will be mailed to you after your benefit application has been processed. Review the coverage available to you and the monthly premiums charged for coverage. If you did not previously select a plan on your application, you must call STRS Ohio to select your plan. If you do not specify a plan or submit required Medicare information, you will be enrolled in the Basic Plan. The date health care coverage begins for you and your eligible dependents will be determined as follows: Service retirement recipients For recipients who elect coverage within 31 days of their benefit effective date, coverage begins on their benefit effective date. For recipients with a retroactive benefit effective date who elect coverage within 31 days of the first of the month following receipt of the retirement application, coverage begins the first of the month following the date the retirement application is received. Disability recipients For recipients who elect coverage within 31 days from the end of the month when disability benefits are granted, coverage is effective the first of the month following the date the Retirement Board grants disability benefits. Survivor and service retirement beneficiary recipients For recipients who elect coverage when benefits are granted or within three months from the end of the month of the member s date of death, coverage begins the first of the month following the member s date of death. For a service retirement beneficiary recipient who was enrolled as a dependent of a member at the time of the member s death, coverage will continue at the same level on the first of the month following the member s date of death. Determining your effective date of coverage Be sure to verify the date your employer-sponsored coverage will end. Knowing this information will help you determine an accurate start date of STRS Ohio coverage. Keep in mind: The effective date of STRS Ohio coverage cannot be changed after premium deductions and coverage have begun. The health care coverage you had through your employer is separate from your STRS Ohio coverage. Any amounts you have accumulated toward an annual deductible or out-of-pocket maximum do not transfer to your STRS Ohio plan from your employer plan. Paying your monthly premium Your monthly premium for coverage will be deducted from your STRS Ohio benefit payment. If your monthly premium exceeds your benefit payment, the remainder of your premium must be paid in full through the establishment of a direct debit account with your financial institution and STRS Ohio. (A direct debit account allows premium payments to be automatically withdrawn from your checking or savings account.) If payment is not received by the first business day of the month the premium is due, your coverage may be canceled. Enrolling After Monthly Benefits Begin Opportunities to join an STRS Ohio plan are limited after monthly benefits begin. Eligible benefit recipients who do not enroll in a plan when monthly benefits begin may later request enrollment under the following circumstances. An eligible dependent may also request enrollment under the following circumstances but only if the benefit recipient is enrolled in the plan. The following qualifying events apply to each individual requesting enrollment. Family enrollments will not be accepted after monthly benefits begin unless each individual experiences a qualifying event. An enrollment application is required and must be received within 31 days of the qualifying event, unless otherwise specified. Proof documentation may also be required. Loss of other coverage An eligible individual may enroll upon loss of other coverage. Coverage becomes effective the first of the month in which other coverage is lost. Required documentation may include a Certificate of Creditable Coverage from your group health care plan; or a letter signed by your current or former employer or plan sponsor on company letterhead verifying the type of coverage and the date coverage terminated. The certificate or letter must also include the names of any covered dependents, types of coverage and dates of termination. Medicare enrollment An eligible individual may enroll upon initial eligibility for and enrollment in Medicare Parts A & B or Part B-only. Coverage will be effective the first of the month Medicare coverage begins. 6

9 Open enrollment An eligible individual may enroll during open enrollment. Open enrollment is offered in November each year for medical plans and once every two years for dental and vision plans. Enrollment applications are accepted Nov. 1 through the Tuesday before Thanksgiving. Coverage will be effective Jan. 1 following open enrollment. Marriage Service retirement or disability recipients may enroll a spouse upon marriage. Coverage will be effective the first of the month following the date of marriage. If the marriage occurs on the first of the month, coverage is effective on that date. Birth, legal adoption or legal guardianship Benefit recipients may enroll an eligible child for coverage beginning the first of the month of the date of birth, legal adoption or legal guardianship. Coverage Considerations CHANGES IN ELIGIBILITY Eligible dependents Notify STRS Ohio by phone or in writing before the end of the month when an enrolled dependent no longer meets eligibility requirements. Please indicate the date your dependent is no longer eligible. Note: If your dependent is enrolled in the Aetna Medicare Plan or Paramount Elite and you notify us at the end of the month, your cancellation request may not be fulfilled until the end of the following month due to insufficient time to relay the request to your plan administrator and Medicare under their termination requirements. STRS Ohio must receive all cancellation requests by the 15th of the month to stop the next month s premium deduction from your STRS Ohio benefit payment. Premium deductions from your monthly benefit payment do not guarantee coverage if your dependent no longer meets eligibility requirements. Employed non-medicare enrollees You must notify STRS Ohio if you are employed in a public or private position. Coverage under the STRS Ohio Health Care Program may be limited for employed enrollees who are not eligible for Medicare. See Page 3 for additional information. Moving to a new residence If you are moving, call STRS Ohio as soon as you know your new address. STRS Ohio will inform you over the phone if your medical plan options will change as a result of your new address. COVERAGE UNDER MORE THAN ONE STRS OHIO ACCOUNT If you are eligible for health care coverage under more than one STRS Ohio account, you are limited to coverage under only one account. For example, you cannot be covered as both a benefit recipient and a survivor of a benefit recipient. Your monthly premium cost may be significantly different under each account. Be sure to compare premium rates for each type of account, taking into consideration such factors as years of service and Medicare eligibility. It is your responsibility to contact STRS Ohio each year to indicate from which account your monthly premium should be deducted. COVERAGE UNDER MORE THAN ONE OHIO PUBLIC RETIREMENT SYSTEM If you are eligible for health care coverage through more than one Ohio public retirement system, guidelines determine which system is responsible for your coverage. Contact STRS Ohio for details. Also, if you are eligible for partial Medicare Part B premium reimbursement through more than one Ohio public retirement system, specific guidelines apply. It is your responsibility to contact STRS Ohio to determine which system is responsible for providing your reimbursement. Please note, STRS Ohio Medicare Part B premium reimbursements will be discontinued effective Jan. 1, FOREIGN TRAVEL OR LIVING ABROAD Before traveling or moving to a foreign country, check with your medical and prescription drug plan administrators to learn how your coverage will be affected while you are abroad STRS Ohio Health Care Program Guide 7

10 CHANGING PLANS AFTER ENROLLMENT Once you enroll in an STRS Ohio medical plan, you will remain in the plan you select for the calendar year, unless you experience a qualifying event. The qualifying events listed below allow enrollees to change plans during the calendar year. This means enrollees can switch to any STRS Ohio medical plan for which they are eligible. Plan changes may apply to both the benefit recipient and any covered dependents. Enrollee experiences one of the following events and requests to change plans within 31 days of the event: (1) marriage, divorce, dissolution or legal separation; (2) birth, adoption or legal guardianship of a child; (3) death; or (4) full loss of premium subsidy. Enrollee becomes eligible for and enrolls in Medicare Parts A & B or Part B-only. Enrollee must request to change plans within three months following the effective date of Medicare. Note: If you are enrolled in the Basic Plan, you will be enrolled in the Aetna Medicare Plan, if eligible, unless you specify a different plan when you submit proof of Medicare enrollment to STRS Ohio. Enrollee is a new retiree. The new enrollee must request to change plans within 31 days of receiving the first monthly benefit payment. A PPO or an HMO enrollee experiences the loss of a key provider from the network. An enrollee permanently moves to another service area, which results in different plan options being available. Furthermore: An Aetna Medicare Plan enrollee may cancel coverage at the end of any month and enroll in the Medical Mutual Basic Plan or a regional plan if available. The request to cancel coverage must be received by STRS Ohio before the effective termination date and by the 15th of the month to stop the next month s premium deduction from the STRS Ohio benefit payment. The request to enroll in another STRS Ohio plan must be received by STRS Ohio within 31 days of the termination effective date. A Paramount Elite HMO enrollee may cancel coverage at any time and enroll in the Aetna Medicare Plan or Medical Mutual Basic Plan. The request to cancel coverage must be received by STRS Ohio before the effective termination date and by the 15th of the month to stop the next month s premium deduction from the STRS Ohio benefit payment. The request to enroll in another STRS Ohio plan must be received by STRS Ohio within 31 days of the termination effective date. CANCELING COVERAGE Canceling coverage at any time You may cancel your or your dependent s STRS Ohio medical coverage at any time. All cancellation requests must be received by the 15th of the month to stop the next month s premium deduction from your STRS Ohio benefit payment. Aetna, AultCare and Medical Mutual enrollees may cancel coverage by calling STRS Ohio. Paramount enrollees may cancel coverage by sending a written request to STRS Ohio. The letter must be signed by the benefit recipient and any other covered enrollees on the account. Please note, there are limited opportunities to reenroll in an STRS Ohio plan after you cancel coverage. See Page 6 for details. Canceling your dependent s coverage due to loss of eligibility Spouse In the event of a divorce, your spouse s coverage ends the first of the month following finalization of the divorce. The cancellation request must be received by the 15th of the month to stop the next month s premium deduction from your STRS Ohio benefit payment. Your spouse may be eligible for COBRA continuation coverage. Call STRS Ohio for more information. Please note that some plans do not allow retroactive cancellations. It is the benefit recipient s responsibility to notify STRS Ohio when a divorce is finalized. Child In the event a covered child loses access to STRS Ohio coverage because a parent dies, parents become divorced or the child stops being eligible for coverage, the child may be eligible for COBRA continuation coverage. Call STRS Ohio for more information. After death of benefit recipient (Single Life Annuity) If you selected a Single Life Annuity at the time of retirement and have dependents enrolled in an STRS Ohio plan at the time of your death, dependent coverage will be discontinued at the end of the month in which your death occurred. Your dependents may be eligible for COBRA continuation coverage. Contact STRS Ohio for more information. Note: If you experience a qualifying event during the calendar year and choose to change plan administrators, your medical deductible and out-of-pocket maximums will transfer to the new plan administrator only if you move between an Aetna plan and a Medical Mutual plan. 8

11 Section 2: Understanding Your Plan Options All STRS Ohio medical plans include hospital, medical and prescription drug coverage. Separate dental and vision insurance is also available. Please contact STRS Ohio if you are interested in supplemental dental and vision coverage. Which Plans Are Available to You? The plans available to you depend on the geographic location of your permanent residence and your Medicare status on file with STRS Ohio and Medicare. As a result, you may find some plans may not be available to you or your family. To find out the specific plans available to you, review your personalized list of options you may have received with this guide. If you do not have a personalized list, call STRS Ohio or register for an STRS Ohio Online Personal Account. Then see Section 3 and/or Section 5 for the coverage features and monthly premiums of your plan options based on Medicare status. You and your family must enroll in a plan offered by the same plan administrator unless you have Medicare and non-medicare enrollees on your account. In this case, Medicare-eligible individuals may choose the Aetna Medicare Plan while other non-medicare family members choose the Basic Plan. Enrollment in separate plans is only permitted when all Medicare enrollees on the account select the Aetna Medicare Plan. If the Aetna plan is not selected, all members on the account must choose the Basic Plan or a regional plan if available. Eligibility for indemnity and PPO plans is determined individually based on where you live and your Medicare status. This means, for example, it s possible for you to be enrolled in a PPO plan and an eligible dependent to be enrolled in an indemnity plan offered by the same plan administrator. Keep in mind, prescription drug coverage is included in all STRS Ohio medical plans. This means you do not need to purchase additional prescription drug coverage. This is especially important for Medicare enrollees, who must not enroll in any other Medicare Part D plan if they want to remain enrolled in an STRS Ohio plan STRS Ohio Health Care Program Guide 9

12 Plan Features to Consider Features to consider when selecting your plan include: Services Look at the services offered by each plan. Are any services limited or not covered? Is there a good match between what is provided and what you think you will need? Choice Which doctors, hospitals and other medical providers can you use? Do you need approval from the plan before going into the hospital or getting specialty care? Location Where will you go for care? Are these places conveniently located? How does the plan cover services when you re away from home? Costs How much will you pay for your monthly premiums, including Medicare Part B (if applicable) and other out-of-pocket expenses? If a plan does not cover certain services, how much will you have to pay? Although you may not know in advance what your health care needs will be for the coming year, you can think about the services you or your family might need. This will help you estimate what your total costs might be for services under each plan. Key Terms to Understand When reviewing plans, it s important to understand the following terms: Annual deductible For medical plans, this is the amount you must pay before the plan pays a portion of your hospital/medical costs. There is a seperate annual deductible for prescription drugs. For prescription drug coverage, this is the amount you must pay for drugs classified as covered brand-name, including specialty, before the plan begins paying a portion of the costs for these drugs. Generic drug costs and non-preferred pharmacy fees do not apply to the deductible. Allowed/noncontracting provider amounts The predetermined amount a plan will pay a provider for medically necessary services as established by the plan administrator. Coinsurance The percentage of covered charges you must pay after you have met your annual deductible, such as 20% for a physician office visit or 13% for specialty drugs. Copayment The fixed amount you pay for a specific service, such as $15 for a primary care physician office visit or $10 for generic drugs at retail. Covered brand-name Brand-name medications available for a copayment after the deductible is met. Enrollee s maximum annual expense This is the maximum annual amount you will pay for prescription drugs. Once the maximum annual expense limit is met, you pay nothing for covered drugs for the remainder of the year. Non-preferred pharmacy fees do not apply to the maximum annual expense. Generic Generic medications available for the lowest copayment. Home Delivery Pharmacy The Express Scripts mail-order pharmacy that fills prescriptions for a copayment/coinsurance. Monthly premium The fixed amount you pay monthly for coverage under the plan. This amount must be paid even if you don t use any of the services. Non-preferred pharmacy A network retail pharmacy where you can purchase prescription drugs for a copayment/coinsurance, plus a $10 fee per fill. This fee does not apply to the annual deductible or the enrollee s maximum annual expense. Out-of-pocket maximum The amount you must pay in a calendar year before the plan pays 100% of remaining expenses for covered hospital/medical services that year. This amount does not include prescription drug coverage costs and any charges exceeding allowed/ noncontracting provider amounts set by the plan administrator, unless otherwise noted. Preferred pharmacy A network retail pharmacy where you can purchase prescription drugs for a copayment/ coinsurance. This type of pharmacy offers the highest level of coverage. Specialty Specialty medications available for a 13% coinsurance up to a maximum cost of $550 per fill (after the deductible is met, if applicable). These high-cost medications typically include infused, injectable and oral drugs that are used to treat chronic and life-threatening diseases; are often difficult to administer; may cause adverse reactions; may require temperature control or other special handling; and/or may have restrictions as determined by the Food and Drug Administration. 10

13 Types of Plans Offered STRS Ohio offers four types of plans. Each plan includes prescription drug coverage. 1. Indemnity (administered by Aetna and Medical Mutual) An indemnity plan is traditional health care coverage in which reimbursement is made either to you or directly to your provider, up to an allowed dollar amount or coverage limit determined by the plan administrator. You are responsible for any charges exceeding this amount or limit. As an enrollee, you can use any health care provider. 2. PPO (administered by Aetna, AultCare and Medical Mutual) A preferred provider organization (PPO) is a group of selected health care providers who have agreed to offer comprehensive services at contractually determined reimbursement levels. These providers including physicians, hospitals and other health care providers are referred to as in-network providers. As an enrollee, you can use out-of-network providers, but your out-of-pocket expenses will be higher. 3. Medicare Advantage (administered by Aetna and Paramount) A Medicare Advantage plan is a health care plan approved by Medicare in which the federal government reimburses a private company to provide the enrollee with basic Medicare coverage and other services. These plans, which are sometimes referred to as Medicare Part C plans or MA plans, can be PPO plans, HMO plans, private fee-for-service plans or Medicare special needs plans. A Medicare Advantage plan covers all of the services that Medicare Parts A & B cover and may provide additional coverage for services not typically covered by Medicare, such as preventive services, and vision and hearing services. When you enroll in a Medicare Advantage plan, your Medicare Parts A & B benefits are assumed by the Medicare Advantage plan. You must remain enrolled in Medicare Part B and pay your monthly Part B premium to Medicare when enrolled in a Medicare Advantage plan. 4. HMO(administered by Paramount) A health maintenance organization (HMO) is a health plan in which physicians, hospitals and other health care providers either contract with or are employed directly by the HMO to provide services. Prescription Drug Coverage Prescription drug coverage is included in all STRS Ohio plans. Express Scripts administers two plans for STRS Ohio enrollees: Express Scripts Prescription Drug Plan for enrollees without Medicare (see Page 12) and Express Scripts Medicare Part D Prescription Drug Plan for enrollees with Medicare (see Page 23). The deductible, copayments/ coinsurance and maximum annual expense are the same for both plans. Other coverage features may vary. It is important to understand enrollees with Medicare Parts A & B, Part A-only or Part B-only are covered by a Medicare Part D plan administered by Express Scripts. Medicare does not allow enrollment in more than one Medicare Part D plan. If you enroll in any other Medicare Part D plan or fail to pay any income-related surcharge required by Medicare, your STRS Ohio medical and prescription drug coverage will be canceled. Contact STRS Ohio before making any changes to your Medicare Part D coverage. You can purchase covered prescription medications for a copayment/coinsurance through Express Scripts network retail pharmacies or the Express Scripts Home Delivery Pharmacy, which offers a convenient mail-order option. No claim form is needed when you use a network retail pharmacy or home delivery. Network There are two types of network retail pharmacies: preferred and non-preferred. You can use either type of network pharmacy; however, if you use a non-preferred pharmacy, you will pay a $10 fee per fill in addition to the applicable copayment/coinsurance. (This fee does not apply to the annual deductible or maximum annual expense.) Contact Express Scripts to check the network status of your pharmacy. Out-of-Network If you use an out-of-network pharmacy, you must pay the full cost of the prescription at time of purchase and then submit a claim form to Express Scripts. If the drug is covered, you will be reimbursed the amount STRS Ohio would have paid at a preferred network pharmacy, less the applicable copayment/coinsurance. If an out-of-network pharmacy charges more than this amount, you are responsible for excess charges STRS Ohio Health Care Program Guide 11

14 Section 3: Plans and Premiums Without Medicare Please review this section for the features and premiums of the plans for enrollees without Medicare. If you have Medicareeligible family members, also review Section 5 (Page 23) for the features and premiums of the plan options for enrollees with Medicare. Be aware coverage features under the same plan could differ based on Medicare status. Premiums also differ. Prescription Drug Plan Features Without Medicare Annual Brand-Name Deductible per Enrollee (Generic drug costs and non-preferred pharmacy fees do not apply to the deductible.) Express Scripts Prescription Drug Plan $250 for covered brand-name drugs, including specialty Standard (Network) Retail/Nursing Home Pharmacy Copayments/Coinsurance per 31-day Supply (If the cost of the drug is less than the copayment, the enrollee pays the cost of the drug.) Preferred Pharmacies Generic: Enrollee pays $10 Covered brand-name: Enrollee pays $30 after deductible is met Specialty: Enrollee pays 13% up to a maximum of $550 per fill (after deductible is met, if applicable) Non-Preferred Pharmacies Enrollee pays the copayment/ coinsurance charged at a preferred pharmacy, plus a $10 fee per fill Maximum Day Supply Retail: 31 days Home delivery: 90 days Home Delivery Copayments/Coinsurance (If the cost of the drug is less than the copayment, the enrollee pays the cost of the drug.) Enrollee s Maximum Annual Expense (Non-preferred pharmacy fees do not apply to the maximum annual expense.) Low-Cost Generic Drug Program medications: Enrollee pays $9 Generic: Enrollee pays $25 Covered brand-name: Enrollee pays $75 after deductible is met Specialty: Enrollee pays 13% up to a maximum of $550 per fill (after deductible is met, if applicable) If an enrollee pays a total of $5,000 out of pocket in copayments/coinsurance/deductible for generic, covered brand-name and specialty medications, that enrollee pays nothing for covered medications for the remainder of the year. 12

15 Plan Features for 2018 WITHOUT MEDICARE You may be eligible for these plans if you are not yet eligible for Medicare. PLAN FEATURES Medical Mutual Basic (Indemnity or PPO) Aetna Basic (Indemnity or PPO) AultCare PPO In-Network and Indemnity 1 Out-of-Network 1 In-Network Out-of-Network 1 Paramount Health Care (HMO) Enrollee Eligibility Medical Mutual: Available in any location in Ohio Aetna: Available in any location except Ohio Available in select northeastern Ohio area ZIP codes Available in select northwestern Ohio and southern Michigan area ZIP codes Annual Deductible per Enrollee 2 $2,500 $5,000 $2,500 $5,000 $2,000 Out-of-Pocket Maximum 2 (Excludes prescription drug costs. Amounts included are noted for each plan.) Lifetime Benefits Maximum per Enrollee $6,500 per enrollee (includes deductible, coinsurance and primary care physician copayments) $13,000 per enrollee (includes deductible and coinsurance) $6,500 per enrollee (includes deductible, coinsurance and primary care physician copayments) $13,000 per enrollee (includes deductible and coinsurance) $4,000 per enrollee (includes deductible, copayments and coinsurance) Unlimited Unlimited Unlimited Health Provider Access Use network provider (PPO); use any covered provider (indemnity) Use any covered provider Use network provider PHYSICIAN, HOSPITAL, SKILLED NURSING AND HOME HEALTH CARE Primary Care Physician Office Visit Specialist Physician Office Visit Enrollee pays $20 per visit for first two visits per year (no deductible); 20% thereafter (after deductible) Enrollee pays 50% after deductible Enrollee pays $20 per visit for first two visits per year (no deductible); 20% thereafter (after deductible) Use any covered provider Use HMO network provider Enrollee pays 50% Enrollee pays $10 Enrollee pays 20% Enrollee pays 50% Enrollee pays 20% Enrollee pays 50% Enrollee pays $20 Urgent Care Enrollee pays $40 Enrollee pays $40 Enrollee pays $40 Hospital Services (Inpatient and Outpatient) Hospital Charges for Outpatient Surgery and Preadmission Testing Enrollee pays 20% Enrollee pays 50% Enrollee pays 20% Enrollee pays 50% Enrollee pays 20% Enrollee pays 20% Enrollee pays 50% Enrollee pays 20% Enrollee pays 50% Enrollee pays 20% Emergency Room Care Enrollee pays $150; waived if admitted Enrollee pays $150; waived if admitted Enrollee pays $150; waived if admitted Skilled Nursing Facility (Benefit period varies by plan administrator.) Inpatient Mental Health Enrollee pays 20% (90 days per benefit period); after 90 days, enrollee pays 100% Enrollee pays 20%; no limit on days Enrollee pays 50% (90 days per benefit period); after 90 days, enrollee pays 100% Enrollee pays 50%; no limit on days Enrollee pays 20% (90 days per illness); after 90 days, enrollee pays 100% Enrollee pays 20%; no limit on days Enrollee pays 50% (90 days per illness); after 90 days, enrollee pays 100% Enrollee pays 50%; no limit on days Enrollee pays 20% after deductible Enrollee pays 20%; no limit on days Home Health Care Enrollee pays 20%; no visit limit Enrollee pays 50%; no visit limit Enrollee pays 20%; no visit limit Enrollee pays 50%; no visit limit Enrollee pays 20%; no visit limit 1 Indemnity and out-of-network payments are based on allowed/noncontracting provider amounts for medically necessary services as established by the plan administrator. If nonparticipating 1 providers charge in excess of these amounts, the enrollee is responsible for the excess charges. 2 Annual deductible must be met before plan begins making payments, unless otherwise noted. In-network and out-of-network accumulations are separate STRS Ohio Health Care Program Guide 13

16 Plan Features for 2018 WITHOUT MEDICARE You may be eligible for these plans if you are not yet eligible for Medicare. PREVENTIVE SERVICES Medical Mutual Basic (Indemnity or PPO) Aetna Basic (Indemnity or PPO) AultCare PPO In-Network and Indemnity 1 Out-of-Network 1 In-Network Out-of-Network 1 Paramount Health Care (HMO) Services such as a routine physical exam, bone density screening, mammogram, routine prostatic specific antigen (PSA), colorectal cancer screening, Pap smear and immunizations/ inoculations may be covered. Contact the plan administrator for details. Enrollee pays 0% (no deductible); limit one per calendar year (colorectal cancer screening limit one per 24 months if high risk or one per 10 years if not high risk) Enrollee pays 0% (no deductible); limited designated services; frequency/age/gender limitations apply Enrollee pays 0%; limited designated services; frequency/age/gender limitations apply OUTPATIENT SERVICES Diagnostic X-ray and Lab Testing Enrollee pays 20% Enrollee pays 50% Enrollee pays 20% Enrollee pays 50% Enrollee pays 20% Outpatient Mental Health Enrollee pays 20%; no visit limit Enrollee pays 50%; no visit limit Enrollee pays 20%; no visit limit Enrollee pays 50%; no visit limit Enrollee pays $20; no visit limit ADDITIONAL SERVICES Dental Care No coverage No coverage No coverage Vision Care No coverage No coverage Enrollee pays $20 for annual eye exam at participating providers 1 Indemnity and out-of-network payments are based on allowed/noncontracting provider amounts for medically necessary services as established by the plan administrator. If nonparticipating 1 providers charge in excess of these amounts, the enrollee is responsible for the excess charges. 14

17 Monthly Premiums for 2018 WITHOUT MEDICARE You may be eligible for these plans if you are not yet eligible for Medicare. Medical Mutual Basic (Indemnity or PPO) Aetna Basic (Indemnity or PPO) AultCare PPO Paramount Health Care (HMO) ELIGIBILITY GROUP TOTAL COST: $927 TOTAL COST: $847 TOTAL COST: $816 Medical Mutual: Available in any location in Ohio Aetna: Available in any location except Ohio Available in select northeastern Ohio area ZIP codes Available in select northwestern Ohio and southern Michigan area ZIP codes BENEFIT RECIPIENT ELIGIBLE FOR SUBSIDY YEARS OF SERVICE STRS OHIO PAYS YOU PAY STRS OHIO PAYS YOU PAY STRS OHIO PAYS Benefit Recipient Not Eligible for Subsidy YOU PAY Spouse Per Child Disabled Adult Child (Sponsored Dependent) Members who retired before Jan. 1, 2004, with less than 15 years of service credit have access to the STRS Ohio Health Care Program but pay the full cost of their premium. Members who retire on or after Jan. 1, 2004, and before Aug. 1, 2023, must have at least 15 years of qualifying service credit to access coverage. Members who retire on or after Aug. 1, 2023, must have at least 20 years of qualifying service credit to access coverage STRS Ohio Health Care Program Guide 15

18 Section 4: Medicare Enrollment If you are age 65 or will be turning age 65, please read this important information about Medicare. STRS Ohio requires all medical plan participants to enroll in Medicare at age 65 or whenever eligible. Enrollment in Medicare Parts A & B will determine your eligibility for plans offered by STRS Ohio. You will also pay a lower monthly premium for STRS Ohio coverage. Understanding Medicare WHAT IS MEDICARE? Medicare is a federal health insurance program for people age 65 and older, some people with disabilities under age 65 and people with end-stage renal disease or amyotrophic lateral sclerosis (ALS). A common misconception is that Ohio educators do not qualify for Medicare because they did not contribute to Social Security. However, you are eligible for Medicare when you turn age 65 even if you are not eligible for Social Security retirement benefits. MEDICARE PARTS Part A (hospital insurance) Most U.S. citizens or permanent residents age 65 or older qualify for premium-free Medicare Part A (hospital insurance) based on their own employment history. You are eligible for premium-free Part A at age 65 if you paid Medicare taxes for at least 40 quarters while working in a federal, state or local government job (including public education). This applies to most STRS Ohio members. You also qualify for premium-free Part A coverage if you receive Social Security or Railroad Retirement benefits or you are eligible to receive these benefits but haven t filed for them yet. If you do not qualify for premium-free Medicare Part A based on your own employment history, you may qualify based on your current or former spouse s work history if: You are currently married for at least one year and your spouse is age 62 or older. You are divorced and currently single, and you were married for at least 10 years. You are widowed and currently single, and you were married for at least nine months before your spouse died. Please note, your spouse does not need to apply for Social Security benefits for you to be eligible for premium-free Medicare Part A based on his or her employment history. Important: If you are not eligible for premium-free Medicare Part A at age 65 but you later become eligible through your spouse, you must contact Social Security to sign up for Medicare Part A at no cost. Prior to age 65, you may qualify for Medicare Part A if you have a qualifying disability, end-stage renal disease or ALS. If you believe you are not eligible for premium-free Medicare Part A, STRS Ohio will require a letter from your local Social Security Administration office confirming ineligibility. 16

19 Part B (medical insurance) Almost every U.S. citizen or permanent resident who is age 65 or older (or under age 65 but eligible for Medicare Part A) can enroll in Medicare Part B. A monthly premium is required. If you believe you are not eligible for Medicare Part B, STRS Ohio will require a letter from your local Social Security Administration office confirming ineligibility. Part C (Medicare Advantage plans) In addition to Parts A & B, Medicare offers Part C (Medicare Advantage plans). Medicare Advantage plans are approved by Medicare and administered by private companies. You do not need to enroll in Part C enrollment in Parts A & B or Part B-only qualifies you for coverage under our group Medicare Advantage plans. Part D (prescription drug insurance) Medicare also offers Part D (prescription drug plans). If you want to remain enrolled in an STRS Ohio plan, you should not enroll in any other Part D plan all of the medical plans we offer for enrollees with Medicare Parts A & B, Part A-only or Part B-only already include Medicare Part D prescription drug coverage. Enrollment in any other Part D plan will cancel your STRS Ohio plan enrollment. See Page 21 for details. Medicare Enrollment Requirements You qualify for Medicare at age 65 even if you did not contribute to Social Security. Coverage type Am I required to enroll? What happens if I do not fulfill the requirement? Part A (hospital) Yes You must enroll if premium-free coverage is available from Medicare. No Do not enroll if you must pay a premium to Medicare. If premium-free Part A is available and you do not enroll, you may not be eligible for an STRS Ohio medical plan. If you must pay a Part A premium to Medicare, you do not need to enroll. However, if you later become eligible for premium-free Medicare Part A through your current or former spouse, you must sign up for Part A at no cost. Part B (medical) Yes You must enroll and pay a monthly premium to Medicare. If you do not enroll in Part B or you stop paying your monthly Part B premium to Medicare, you may not be eligible for an STRS Ohio medical plan. STRS Ohio requires proof of Medicare enrollment. Send us a copy of your Medicare card or submit your Medicare information through your STRS Ohio Online Personal Account. Part C (Medicare Advantage) No Enrollment in Parts A & B or Part B-only qualifies you for coverage under STRS Ohio s Medicare Advantage plans. You must not enroll in any other Medicare Advantage plan if you want to keep your coverage under the Medicare Advantage plans administered by Aetna and Paramount. Part D (prescription) No Part D prescription drug coverage is included in your STRS Ohio medical plan. You must not enroll in any other Part D plan. If you do, your STRS Ohio coverage will be canceled STRS Ohio Health Care Program Guide 17

20 HOW MEDICARE WORKS WITH YOUR STRS OHIO COVERAGE Medicare Parts A & B do not replace your STRS Ohio coverage. Instead, Medicare works with your STRS Ohio plan to provide maximum hospital and medical coverage. In general, when you enroll in Medicare Parts A & B, Medicare becomes the primary payer of your hospital and medical expenses; STRS Ohio becomes the secondary payer. If you enroll in a Medicare Advantage plan, such as the Aetna Medicare Plan or Paramount Elite, the plan assumes responsibility for paying for covered services and receives payment from Medicare. After you enroll in Medicare, you must pay two separate monthly premiums: a premium for STRS Ohio coverage (paid to STRS Ohio) and a premium for Medicare Part B coverage (paid to Medicare). CAN YOU DELAY MEDICARE ENROLLMENT IF YOU ARE STILL EMPLOYED? If you or your spouse is still employed and covered by a group health plan through the employer, you may choose to delay your enrollment in Medicare. However, if you delay your enrollment, you should be aware of the following: You will have an eight-month special enrollment period in which to sign up for Medicare after the employer health coverage ends or employment ends (whichever comes first). See Page 19 for details. You will not be subject to a late enrollment penalty if you sign up during this special enrollment period. If the employer has more than 20 employees, your employer health plan will be the primary payer of covered hospital and medical expenses. Your STRS Ohio plan will be the secondary payer. If you discontinue the employer health coverage and fail to enroll in Medicare, you may not be eligible for an STRS Ohio medical plan. MEDICARE PRIOR TO AGE 65 Some people under age 65 qualify for Medicare due to a qualifying disability benefit through the Social Security Administration, end-stage renal disease (permanent kidney failure requiring dialysis or kidney transplant) or ALS (a progressive neurodegenerative disease often referred to as Lou Gehrig s disease). If you enroll in Medicare prior to age 65, you must send STRS Ohio proof of Medicare Parts A & B enrollment. Note: If you are under age 65 and qualify for Medicare because of end-stage renal disease, there is a 30-month coordination period during which the Centers for Medicare & Medicaid Services requires the STRS Ohio plan to be the primary payer of your hospital and medical expenses and Medicare to be the secondary payer. During this 30-month coordination period, you will be charged the monthly premium for enrollees without Medicare. See Page 15 for these monthly premiums. Enrolling in Medicare WHEN TO ENROLL IN MEDICARE Initial enrollment period You have a seven-month initial enrollment period in which to sign up for Medicare. This period begins three months before you turn age 65, includes the month you turn age 65 and ends three months after the month of your birthday. For coverage to be effective the month you turn age 65, you must sign up during the first three months of the initial enrollment period (one to three months before the month of your birthday). If you wait to sign up during the last four months of the period, your effective date of Medicare will be delayed. General enrollment period If you miss the initial enrollment period, you can enroll during a general enrollment period from Jan. 1 through March 31 each year. However, Medicare coverage is not effective until July 1 and a lifetime Medicare late enrollment penalty will apply. See Page 22 for details. Initial Enrollment Period for Medicare Begins three months before and ends three months after the month you turn age 65 You will have NO DELAY in coverage if you enroll: Three months before you turn 65 The month you turn 65 Coverage begins one month after the month you enroll Two months before you turn 65 Coverage begins the month you turn 65 (If your birthday is the first of the month, coverage begins the first day of the previous month.) One month before you turn 65 You will have a DELAY in coverage if you enroll: One month after you turn 65 Coverage begins two months after the month you enroll Two months after you turn 65 Coverage begins three months after the month you enroll Three months after you turn 65 Coverage begins three months after the month you enroll 18

21 Special enrollment period If you delay enrollment at age 65 because you or your spouse is still employed and covered by a group health plan through the employer, you can enroll in Medicare during a special enrollment period. Special enrollment allows you to enroll without paying a late enrollment penalty during either of the following time frames: At any time while you have employer health coverage (your own or through your spouse); or During the eight-month period that begins the month employer health coverage ends or the month employment ends (whichever comes first). If you do not enroll by the end of the eighth month, general enrollment guidelines apply. See Page 18 for additional information about delaying Medicare enrollment while employed. HOW TO ENROLL IN MEDICARE Enrolling in Medicare is an easy two-step process. However, it may take more than one month for the entire application process to be completed, so be sure to start the process before your 65th birthday. Step 1 Sign up for Medicare. To enroll in Medicare, visit your local Social Security Administration office or call Social Security toll-free at If you are eligible for both Medicare Parts A & B, you can also enroll online at (Medicare Part B-only applicants must visit or call Social Security to enroll.) If you visit your local office, find out which documents to bring with you to your appointment. Be sure to apply for Medicare before your 65th birthday so there is no delay in Medicare coverage. Step 2 Send proof of Medicare enrollment to STRS Ohio. Once you enroll in Medicare, you must submit proof of Medicare enrollment to STRS Ohio by sending us a copy of your Medicare card or a copy of a letter from Social Security confirming Medicare enrollment. You can also submit your Medicare information through your STRS Ohio Online Personal Account Sample card beginning April 2018 If you do not have a Medicare card or a letter from Social Security, you can send STRS Ohio a copy of any of the following Social Security Administration forms: Retirement, Survivors and Disability Insurance Notice of Award; Report of Confidential Social Security Benefit Information; or Notice of Health Insurance Entitlement. These are the only documents STRS Ohio can accept in lieu of a copy of your Medicare card or enrollment confirmation letter. STRS Ohio will not accept a letter acknowledging Medicare s receipt of your enrollment application. Also, please check all information on your Medicare card for accuracy. If it is incorrect, contact Medicare to request a new card with the correct information. The information you send to STRS Ohio must include your Medicare effective date and your Medicare number. Write your STRS Ohio account number on any documents you submit. (If you re unsure of your account number, call STRS Ohio.) STRS Ohio must receive proof of Medicare enrollment by the 15th of the month to begin your participation in the Aetna Medicare Plan the first of the following month STRS Ohio Health Care Program Guide 19

22 q q q q YOUR MEDICARE ENROLLMENT CHECKLIST Call your local Social Security Administration office three months before your 65th birthday to schedule an appointment to enroll in Medicare. If you re unable to locate the nearest office, call Social Security toll-free at If you are eligible for both Medicare Parts A & B, you can also complete your Medicare application online at (Medicare Part B-only applicants must visit or call Social Security to enroll.) You must pay the Part B premium to Medicare each month. If your Part B premium is not deducted automatically from a federal retirement payment, sign up for the Medicare Easy Pay plan. This free electronic payment option offered by Medicare will ensure your premium payment is never late. You can sign up when you enroll in Medicare or call Medicare toll-free at Remember, your Medicare Part B premium is not included in your monthly STRS Ohio medical plan premium. It is a separate premium that must be paid to Medicare. Watch your mail for enrollment confirmation from Medicare, including your Medicare card. Check all information on your Medicare card for accuracy. If it is incorrect, contact Medicare to request a new card with the correct information. q q q q Submit your Medicare information to STRS Ohio through your Online Personal Account or send us a copy of your Medicare card showing the Medicare effective dates. If you send a copy of your card, write your STRS Ohio account number on the copy you submit. Currently, service retirement and disability benefit recipients who submit proof of Medicare Part B enrollment to STRS Ohio may receive partial reimbursement to offset the standard monthly premium charged by Medicare for Part B coverage. Enrollment in an STRS Ohio medical plan is required to receive the reimbursement. Medicare Part B partial premium reimbursement will be discontinued effective Jan. 1, Review the coverage features and premiums of the plan options available to you as a Medicare enrollee. You can also log in to your STRS Ohio Online Personal Account to view your plan options and premiums. Select an STRS Ohio plan up to three months after your 65th birthday. Attention Basic Plan enrollees: If you qualify for the Aetna Medicare Plan, you will be enrolled in the plan after STRS Ohio receives proof of Medicare enrollment and Medicare approves your Aetna enrollment request. STRS Ohio must receive proof of Medicare enrollment by the 15th of the month to begin your participation in the Aetna Medicare Plan the first of the following month. If you do not want the Aetna Medicare Plan, you may opt out and select the Medical Mutual Basic Plan or a regional plan if available. To opt out of the Aetna Medicare Plan, select AMA Opt Out when you submit your Medicare information through your STRS Ohio Online Personal Account, or submit your request in writing or call STRS Ohio. Selecting Your New STRS Ohio Plan YOUR PLAN OPTIONS WILL CHANGE After you enroll in Medicare, the STRS Ohio plans available to you will change. Call STRS Ohio toll-free at to learn about your new plan options and premiums. You can also review this information in your STRS Ohio Online Personal Account. Important: If you do not submit proof of Medicare enrollment, you may not be eligible for an STRS Ohio medical plan. EVALUATING YOUR PLANS Your plan options as a Medicare enrollee are based on your Medicare status and the location of your permanent residence. Plans for Medicare enrollees include the Aetna Medicare Plan, the Medical Mutual Basic Plan or a regional plan if available in your area. If you reside outside the United States, your STRS Ohio plan options are limited to the Medical Mutual Basic Plan. Medicare generally does not cover health care items and services furnished or delivered outside the United States. As a result, you will be responsible for submitting all claims to your plan administrator and for paying 80% of all claims expenses that would have been covered by Medicare. 20

23 SELECTING YOUR PLAN AS A MEDICARE ENROLLEE To select a plan, call STRS Ohio toll-free at You may select a new plan up to three months after your 65th birthday. The effective date of coverage under your new plan will be the first of the month following notification to STRS Ohio, if received by the 15th of the month. There will be no interruption in your STRS Ohio coverage. Be aware, your plan selection cannot be processed until STRS Ohio receives proof of Medicare enrollment. This applies even if you are selecting a plan offered by your current plan administrator. STRS Ohio must receive proof of Medicare enrollment by the 15th of the month. Any delay in submitting this proof will delay your enrollment in the plan you select as a Medicare enrollee. If you are a Basic Plan enrollee who is eligible for the Aetna Medicare Plan, you will be enrolled in the Aetna Medicare plan after STRS Ohio receives proof of Medicare enrollment and Medicare approves your enrollment request. If you do not want the Aetna Medicare Plan, you must submit your request to be enrolled in the Medical Mutual Basic Plan (or a regional plan if available) when you submit proof of Medicare enrollment to STRS Ohio. If you are a Paramount Health Care enrollee, you will be enrolled in Paramount Elite after STRS Ohio receives proof of Medicare enrollment and Medicare approves your enrollment request. If you do not want Paramount Elite, you must submit your request to be enrolled in the Aetna Medicare Plan or Medical Mutual Basic Plan when you submit proof of Medicare enrollment to STRS Ohio. If you are selecting a Medicare Advantage plan, such as the Aetna Medicare Plan or Paramount Elite, you will not be officially enrolled in the plan until Medicare approves your enrollment request. Additionally, once enrolled, you must not subsequently sign up for another Medicare Advantage plan. If you do, your STRS Ohio coverage will be canceled. Note: If you change plan administrators, your medical deductible and out-of-pocket maximums will transfer to the new plan administrator only if you move between an Aetna plan and a Medical Mutual plan. After You Enroll in Medicare PAYING YOUR MEDICARE PART B PREMIUMS Your Medicare Part B premium is not included in your monthly STRS Ohio medical plan premium. It is a separate premium that must be paid to Medicare, not to STRS Ohio. If you receive a monthly Social Security, Railroad Retirement or Civil Service Retirement payment, your Medicare Part B premium will be deducted automatically from this payment. Otherwise, Medicare will send you a bill for your Part B premium. Another payment option is to have your Part B premium automatically deducted through Medicare Easy Pay. This is a free, electronic payment option offered by Medicare. Through Medicare Easy Pay, Medicare automatically deducts the premium payment from your savings or checking account. To sign up for Medicare Easy Pay, call Medicare toll-free at Remember, you must pay your monthly Medicare Part B premium before the due date to avoid cancellation of your Medicare Part B coverage. If your Part B coverage is canceled, you may not be eligible for an STRS Ohio medical plan. UNDERSTANDING YOUR MEDICARE PART D PRESCRIPTION DRUG COVERAGE After you enroll in Medicare, the prescription drug coverage included in your STRS Ohio medical plan will be provided under a Medicare Part D prescription drug plan administered by Express Scripts. To be eligible, you must be enrolled in Medicare Parts A & B, Part A-only or Part B-only. Do not enroll in any other Medicare Part D plan. Medicare does not allow enrollment in more than one Medicare Part D plan. If you enroll in another Medicare Part D plan, your STRS Ohio medical and prescription drug coverage will be canceled. Also, if you decline coverage under the Medicare Part D plan included in your STRS Ohio plan, your STRS Ohio medical coverage will be canceled. Before making any changes to your Medicare Part D prescription drug plan coverage, call STRS Ohio to find out how your STRS Ohio coverage will be affected STRS Ohio Health Care Program Guide 21

24 EXTRA FEES FOR LATE ENROLLMENTS AND HIGHER INCOMES Medicare charges late enrollment penalties if you delay enrollment in Medicare Part B or go 63 days or more without Medicare Part D or creditable prescription drug coverage. This additional cost will be charged as long as you have Medicare coverage. Also, Medicare Part B and Part D enrollees with higher annual incomes are subject to monthly Medicare surcharges. Surcharges vary by income levels set by Medicare (currently $85,000+ for individuals; $170,000+ for married couples.) Failure to pay surcharges will result in cancellation of your STRS Ohio medical coverage. Visit for more information. PARTIAL MEDICARE PART B PREMIUM REIMBURSEMENT Currently, service retirement and disability benefit recipients who are enrolled in an STRS Ohio medical plan and provide proof of Medicare Part B enrollment may receive partial reimbursement to offset the standard monthly premium charged by Medicare for Part B coverage. Effective Jan. 1, 2019, STRS Ohio Medicare Part B premium reimbursements will be discontinued. If STRS Ohio receives proof of your Medicare Part B enrollment by the 15th of the month, partial reimbursement of the benefit recipient s future standard Medicare Part B premium cost will begin the first of the following month. If verification is received after the 15th of the month, partial premium reimbursement will begin the first day of the second following month. Partial reimbursement is not retroactive. If you are eligible to receive a Medicare Part B premium reimbursement through more than one Ohio public retirement system, specific guidelines apply. It is your responsibility to contact STRS Ohio to determine which system is responsible for providing your reimbursement; you may not receive more than one Part B premium reimbursement. Please call STRS Ohio for Medicare Part B premium reimbursement guidelines. MEDICARE PART B-COVERED DRUGS AND SUPPLIES Medicare Part B covers a limited number of drugs/supplies as determined by the Centers for Medicare & Medicaid Services. Following are examples of drugs/supplies covered by Medicare Part B: Diabetic supplies such as blood sugar testing monitors, test strips, lancets and lancet devices, and blood sugar control solutions. Injections administered in a doctor s office. Certain oral cancer drugs. Drugs used with some types of durable medical equipment, such as a nebulizer or external infusion pump. Under limited circumstances, certain drugs administered in a hospital outpatient setting. If you are enrolled in a plan administered by Aetna or Medical Mutual, the STRS Ohio Health Care Program will pay your portion of costs for Medicare Part B-covered drugs/supplies that are coordinated with Medicare. When a claim for a covered drug or supply is coordinated with Medicare Part B, the claim is submitted to Medicare first for primary payment and then to the medical plan for secondary payment, leaving you with no copayment for drugs/supplies dispensed by a participating Medicare retail pharmacy. QUALIFYING FOR EXTRA HELP WITH PRESCRIPTION DRUG COSTS Medicare offers a low-income subsidy program to qualified participants in a Medicare Part D prescription drug plan. Under the program (also called Extra Help), participants may pay a lower deductible and lower copayment amounts for covered prescription drugs. Medicare, not STRS Ohio, determines if participants qualify for the subsidy program. Medicare works directly with Express Scripts to determine if you qualify for assistance. If you qualify, your prescription drug plan administrator will send you a letter informing you about the program. If you receive a letter from Express Scripts, you will be enrolled automatically in the subsidy program offered by Medicare. If you do not receive a letter and believe you may qualify for assistance, you can call Medicare directly for more information or to request an application. CONFUSED? WE CAN HELP Understanding Medicare and its requirements can sometimes be confusing. That s why we offer the webinar, Medicare Enrollment and STRS Ohio. We ll guide you through the Medicare enrollment process, provide information specific to new Medicare enrollees and address any questions you submit during the live presentation. To register for this free webinar visit the Counseling & Seminars section of our website at

25 Section 5: Plans and Premiums With Medicare Please review this section for the features and premiums of the plans for enrollees with Medicare. If you have family members on your account without Medicare, also review Section 3 (Page 12) for features and premiums of the plan options for non-medicare enrollees. Be aware, coverage features under the same plan could differ based on Medicare status. Premiums also differ. Prescription Drug Plan Features With Medicare Annual Brand-Name Deductible per Enrollee (Generic drug costs and non-preferred pharmacy fees do not apply to the deductible.) Express Scripts Medicare Part D Plan $250 for covered brand-name drugs, including specialty Standard (Network) Retail/Nursing Home Pharmacy Copayments/Coinsurance per 31-day Supply (If the cost of the drug is less than the copayment, the enrollee pays the cost of the drug.) Preferred Pharmacies Generic: Enrollee pays $10 Covered brand-name: Enrollee pays $30 after deductible is met Specialty: Enrollee pays 13% up to a maximum of $550 per fill (after deductible is met, if applicable) Non-Preferred Pharmacies Enrollee pays the copayment/ coinsurance charged at a preferred pharmacy, plus a $10 fee per fill Maximum Day Supply Retail: Up to 90* Home delivery: 90 days *Prior to acceptance in Express Scripts Medicare Part D plan, maximum retail supply is 31 days Home Delivery Copayments/Coinsurance (If the cost of the drug is less than the copayment, the enrollee pays the cost of the drug.) Enrollee s Maximum Annual Expense (Non-preferred pharmacy fees do not apply to the maximum annual expense.) Low-Cost Generic Drug Program medications: Enrollee pays $9 Generic: Enrollee pays $25 Covered brand-name: Enrollee pays $75 after deductible is met Specialty: Enrollee pays 13% up to a maximum of $550 per fill (after deductible is met, if applicable) If an enrollee pays a total of $5,000 out of pocket in copayments/coinsurance/ deductible for generic, covered brand-name and specialty medications, that enrollee pays nothing for covered medications for the remainder of the year STRS Ohio Health Care Program Guide 23

26 Plan Features for 2018 WITH MEDICARE You may be eligible for these plans if you are enrolled in Medicare. If you have Medicare Part A-only, your only option is Medical Mutual Basic. A disabled adult child with Medicare Part B-only may enroll only in the Aetna Medicare Plan or Medical Mutual Basic. PLAN FEATURES Aetna Medicare Plan 1 (Medicare Advantage PPO) In-Network (PPO) or Extended Service Area (ESA PPO) Out-of-Network (PPO) Medical Mutual Basic (Indemnity or PPO) In-Network and Indemnity 2,4 Out-of-Network 2,4 Enrollee Eligibility Available in any location in the United States Available in any location Annual Deductible per Enrollee 3 $150 $500 $2,500 $5,000 Out-of-Pocket Maximum 3 (Excludes prescription drug costs. Amounts included are noted for each plan.) $1,500 per enrollee (includes deductible, copayments and coinsurance) $2,500 per enrollee (includes deductible, copayments and coinsurance) $6,500 per enrollee (includes deductible, coinsurance and primary care physician copayments) Lifetime Benefits Maximum per Enrollee Unlimited Unlimited Health Provider Access Use network provider (PPO); use any provider that accepts Medicare and the Aetna plan (ESA PPO) PHYSICIAN, HOSPITAL, SKILLED NURSING AND HOME HEALTH CARE Primary Care Physician Office Visit Specialist Physician Office Visit Enrollee pays $15 (no deductible) Enrollee pays $25 (no deductible) Use any provider that accepts Medicare Enrollee pays $40 after deductible Enrollee pays $55 after deductible Use network provider (PPO); use any covered provider (indemnity) $13,000 per enrollee (includes deductible and coinsurance) Use any covered provider Enrollee pays $20 per visit for first two visits per year (no deductible); 20% thereafter (after deductible) Enrollee pays 20% Urgent Care Enrollee pays $40 (no deductible) Enrollee pays $40 Hospital Services (Inpatient and Outpatient) Enrollee pays 4% Enrollee pays 8% Enrollee pays 20% 5 Enrollee pays 50% 5 Hospital Charges for Outpatient Surgery Enrollee pays 4% Enrollee pays 8% Enrollee pays 20% and Preadmission Testing Enrollee pays $75 (no deductible); Emergency Room Care Enrollee pays $150; waived if admitted waived if admitted Skilled Nursing Facility (Benefit period varies by plan administrator.) Enrollee pays 0% for up to 100 days per benefit period after deductible; after 100 days, enrollee pays 100% Enrollee pays 8% for up to 100 days per benefit period after deductible; after 100 days, enrollee pays 100% Inpatient Mental Health Enrollee pays 4% Enrollee pays 8% Enrollee pays 20% (90 days per benefit period); after 90 days, enrollee pays 100% Enrollee pays 20%; no limit on days Enrollee pays 50% (90 days per benefit period); after 90 days, enrollee pays 100% Enrollee pays 50%; no limit on days Home Health Care Enrollee pays 0% after deductible; no visit limit Enrollee pays 8% after deductible; no visit limit Enrollee pays 20%; no visit limit 1 If providers do not accept Medicare assignment or charge in excess of Medicare payments, the enrollee is responsible for the excess charges. 2 Indemnity and out-of-network payments are based on allowed/noncontracting provider amounts for medically necessary services as established by the plan administrator. If nonparticipating 1 providers or providers that do not accept Medicare assignment charge in excess of these amounts, the enrollee is responsible for the excess charges. 3 Annual deductible must be met before plan begins making payments, unless otherwise noted. In-network and out-of-network accumulations are separate, except for the Aetna Medicare Plan. 4 Benefits are payable after Medicare payments. 5 Enrollees with Medicare Part B-only must use in-network providers for hospital services to receive maximum claims payment. 24

27 AultCare PPO In-Network 4 Out-of-Network 2,4 Paramount Elite HMO (Medicare Advantage) Available in select northeastern Ohio area ZIP codes Available in select northwestern Ohio and southern Michigan area ZIP codes $150 $500 $150 $1,500 per enrollee (includes deductible, copayments and coinsurance) $2,500 per enrollee (includes deductible, copayments and coinsurance) $1,500 per enrollee (includes deductible, copayments and coinsurance) Unlimited Unlimited Use network provider Use any covered provider Use HMO network provider Enrollee pays $15 (no deductible) Enrollee pays $40 (no deductible) Enrollee pays $15 Enrollee pays $25 (no deductible) Enrollee pays $55 (no deductible) Enrollee pays $25 Enrollee pays $40 (no deductible) Enrollee pays $40 Enrollee pays 4% 5 Enrollee pays 8% 5 Enrollee pays 4% Enrollee pays 4% Enrollee pays 8% Enrollee pays 4% Enrollee pays $75 (no deductible); waived if admitted Enrollee pays $75; waived if admitted Enrollee pays 0% (100 days per illness); after 100 days, enrollee pays 100% Enrollee pays 4%; no limit on days Enrollee pays 0% (no deductible) Enrollee pays 8% (100 days per illness); after 100 days, enrollee pays 100% Enrollee pays 8% Enrollee pays 8% after deductible; no visit limit Enrollee pays 0% for up to 100 days per benefit period; after 100 days, enrollee pays 100% Enrollee pays 4%; no limit on days Enrollee pays 0%; no visit limit 2018 STRS Ohio Health Care Program Guide 25

28 Plan Features for 2018 WITH MEDICARE You may be eligible for these plans if you are enrolled in Medicare. If you have Medicare Part A-only, your only option is Medical Mutual Basic. A disabled adult child with Medicare Part B-only may enroll only in the Aetna Medicare Plan or Medical Mutual Basic. PREVENTIVE SERVICES Services such as a routine physical exam, bone density screening, mammogram, routine prostatic specific antigen (PSA), colorectal cancer screening, Pap smear and immunizations/inoculations may be covered. Contact the plan administrator for details. OUTPATIENT SERVICES Aetna Medicare Plan 1 (Medicare Advantage PPO) In-Network (PPO) or Extended Service Area (ESA PPO) Out-of-Network (PPO) Enrollee pays 0% (no deductible); some limitations may apply Medical Mutual Basic (Indemnity or PPO) In-Network and Indemnity 2,3 Out-of-Network 2,3 Enrollee pays 0% (no deductible); limit one per calendar year (colorectal cancer screening limit one per 24 months if high risk or one per 10 years if not high risk) Diagnostic X-ray and Lab Testing Enrollee pays 4% for diagnostic X-ray after deductible; 0% for lab testing (no deductible) Enrollee pays 8% for diagnostic X-ray after deductible; 0% for lab testing after deductible Enrollee pays 20% Outpatient Mental Health Enrollee pays $25 (no deductible); no visit limit Enrollee pays $55 after deductible; no visit limit Enrollee pays 20%; no visit limit ADDITIONAL SERVICES Dental Care No coverage No coverage Vision Care Enrollee pays 0% for annual eye exam; eyewear discounts available at participating providers No coverage 1 If providers do not accept Medicare assignment or charge in excess of Medicare payments, the enrollee is responsible for the excess charges. 2 Indemnity and out-of-network payments are based on allowed/noncontracting provider amounts for medically necessary services as established by the plan 1 administrator. If nonparticipating providers or providers that do not accept Medicare assignment charge in excess of these amounts, the enrollee is responsible for the excess charges. 3 Benefits are payable after Medicare payments. 26

29 AultCare PPO In-Network 3 Out-of-Network 2,3 Paramount Elite HMO (Medicare Advantage) Enrollee pays 0% (no deductible); limited designated services; frequency/age/gender limitations apply Enrollee pays 0%; limited designated services; frequency/age/gender limitations apply Enrollee pays 4% for diagnostic X-ray after deductible; 0% for lab testing (no deductible) Enrollee pays 8% for diagnostic X-ray after deductible; 0% for lab testing after deductible Enrollee pays 4% after deductible Enrollee pays 4%; no visit limit Enrollee pays 8%; no visit limit Enrollee pays $20; no visit limit Enrollee pays $25 for annual Medicareapproved dental exam Enrollee pays $25 for annual Medicareapproved eye exam Enrollee pays $55 for annual Medicareapproved dental exam Enrollee pays $55 for annual Medicareapproved eye exam No coverage Enrollee pays $25 for annual eye exam at participating providers 2018 STRS Ohio Health Care Program Guide 27

30 Monthly Premiums for 2018 WITH MEDICARE You may be eligible for these plans if you are enrolled in Medicare. If you have Medicare Part A-only, your only option is Medical Mutual Basic. A disabled adult child with Medicare Part B-only may enroll only in the Aetna Medicare Plan or Medical Mutual Basic. ELIGIBILITY GROUP BENEFIT RECIPIENT ELIGIBLE FOR SUBSIDY YEARS OF SERVICE Aetna Medicare Plan (Medicare Advantage PPO) TOTAL COST: $342 Available in any location in the United States STRS OHIO PAYS YOU PAY Medical Mutual Basic (Indemnity or PPO) TOTAL COST: $300 Available in any location STRS OHIO PAYS YOU PAY AultCare PPO TOTAL COST: $464 Available in select northeastern Ohio area ZIP codes STRS OHIO PAYS YOU PAY Paramount Elite HMO (Medicare Advantage) TOTAL COST: $350 Available in select northwestern Ohio and southern Michigan area ZIP codes STRS OHIO PAYS Benefit Recipient Not Eligible for Subsidy YOU PAY Spouse Per Child Disabled Adult Child (Sponsored Dependent) Members who retired before Jan. 1, 2004, with less than 15 years of service credit have access to the STRS Ohio Health Care Program but pay the full cost of their premium. Members who retire on or after Jan. 1, 2004, and before Aug. 1, 2023, must have at least 15 years of qualifying service credit to access coverage. Members who retire on or after Aug. 1, 2023, must have at least 20 years of qualifying service credit to access coverage.

31 Section 6: Additional Information Quality Standards To be offered as an STRS Ohio health care plan option, a plan must meet the following quality standards: 1. Adhere to performance standards related to enrollees access to medical providers, claims payment accuracy, processing time and the quality of service provided by the plan s customer service department. 2. Allow medical providers to talk with plan enrollees about reasonable care options, including those not covered by the plan, and about how services are reimbursed. 3. Support surveys of enrollees to assess satisfaction with the plan. Use survey results to improve customer service and the quality of health care provided. 4. Provide a coverage-appeal process for enrollees that includes, as a final level of appeal, deliberation by an independent health care professional(s). 5. Show a commitment to improving the health of the plan s older adult enrollees. 6. Have business associate agreements that require safeguarding protected health information and are in compliance with the Health Insurance Portability and Accountability Act (HIPAA) regulations. In addition, HMO and PPO plans are encouraged to have or be pursuing accreditation by the National Committee for Quality Assurance (NCQA) or the American Accreditation Health Care Commission (URAC), or have programs in place to ensure the delivery of quality care to enrollees. NCQA and URAC use nationally recognized standards to measure plan performance in the areas of quality of care, access to care, utilization management and consumer satisfaction. Release of Information and Confidentiality Statement By accepting coverage under an STRS Ohio health care plan, all enrollees, including any enrolled dependents, shall: 1. Furnish STRS Ohio or its designees any and all information STRS Ohio may reasonably require pertaining to health care coverage and the operations of its health care plan. 2. Enroll in premium-free Medicare Part A (if available) and Medicare Part B at age 65 or whenever eligible, and submit proof of Medicare enrollment to STRS Ohio. 3. Authorize and direct any physician or other health care provider, health plan, pharmacy, pharmacy benefits manager or program administrator to furnish STRS Ohio or its designees any and all information and records (or copies of records) relating to care or services provided directly to the enrollee or services provided indirectly to the enrollee related to the administration of the health care program STRS Ohio Health Care Program Guide 29