retiree book-state of ga - georgia department of community ...the georgia department of community...

Phone Numbers and Contacts for Benefit and Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Inside Front Cover

Making Informed Health Plan Coverage Decisions . . . . . . . . . . . . . . . . . . . . . . . . . .2

What You Need to Do . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

What’s Changing for 2003 – 2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

If You Do Not Make Any Changes During the Retiree Option Change Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

If You Want to Change Your Option During the Retiree Option Change Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Basic Plan Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Eligible Dependents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Documentation Upon Request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Making Changes When You Have Qualifying Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Overview of How Each Health Plan Option Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Important Terms to Understand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

PPO Option . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

PPO Choice Option . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Indemnity Option (Formerly Named High Option) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

HMO Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

HMO Choice Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Medicare+Choice HMO Option (M+C HMO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Comparing Benefits Within Health Plan Options . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Comparison of Benefits: PPO Option and Indemnity Option . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Comparison of Benefits: HMO Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

Service Areas for Your Health Plan Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

Health Insurance Portability and Accountability Act (HIPAA) Annual Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

Department of Community Health Privacy Notice . . . . . . . . . . . . . . . . . . . . . . . . . .42

Women’s Health and Cancer Rights Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

Penalties for Misrepresentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

C O N T E N T S

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S TAT E H E A L T H B E N E F I T P L A N 2 0 0 3 / 2 0 0 4

Making Informed HealthPlan Coverage Decisions

The Georgia Department of Community Health,which administers the State Health Benefit Plan(SHBP), continually seeks to bring you high-quality,affordable health coverage. Keep in mind, how-ever, that you are the manager of your health careneeds, and in turn, must take the time to under-stand your Plan benefit choices in order to makethe best decisions for you and your family. Duringthe Retiree Option Change Period, it is importantthat you carefully review the coverage optioninformation provided in this Retiree Health PlanDecision Guide. You should evaluate your healthcare needs and, if necessary, those of your depend-ents, as well as the premiums and out-of-pocketcosts related to these different options beforemaking your decision. Once you make your cover-age decision, you may not make changes to yourcoverage outside the Retiree Option ChangePeriod unless you have a qualifying event. Seepage 8 for details.

If after reading this Guide you want more informa-tion before making a coverage decision, you canrefer to your Summary Plan Description (SPD)booklet and Updaters or call the Retiree Help Lineat (800) 586-9288. Note that a new SPD andUpdater will be mailed to your home addressprior to the start of the new Plan year.

Making informed decisions about your health care includes other considerations as well. Patientsafety is a critical mission for the SHBP. Therefore,we offer these five steps to safer health care:

1. Speak up if you have questions or concerns.Choose a physician whom you feel comfortabletalking to about your health and treatment.Takea relative or friend with you if this will helpyou ask questions and understand the answers.It’s okay to ask questions and to expectanswers you can understand.

• If you are considering PPO coverage,providerdirectories are available to help you choosephysicians who have been credentialed intheir specialties.Visit the 1st Medical Network

(formerly MRN/Georgia 1st) Web site atwww.healthygeorgia.com for the most up-to-date listing of over 14,000physicians and 166 hospitals in Georgia anda link to national PPO provider informationfor national access to 385,000 physiciansand 3,300 hospitals. Printed directories areavailable by calling the Retiree Help Lineduring the Retiree Option Change Period.

• If you are considering HMO coverage,see the inside front cover for HMO Web sites that include provider information.Youalso can contact the individual HMO directlyto request a provider directory.

However, the provider listings are subject tochange without notice. Before selecting yourphysician, call the physician’s office to make sure that physician is accepting new patientsand that he/she is still a participating provider.

2. Keep a list of all the medicines you take.Tell your physician and pharmacist about themedicines that you take, including over-the-counter medicines such as aspirin, ibuprofenand dietary supplements like vitamins andherbals. Tell them about any drug allergies youhave. Ask the pharmacist about side effects andwhat foods or other things to avoid while tak-ing the medicine.When you get your medicine,read the label, including warnings. Make sure itis what your physician ordered, and you knowhow to use it. If the medicine looks differentthan you expected, ask the pharmacist about it.

3. Make sure you get the results of any test or procedure.Ask your physician or nurse when and howyou will get the results of tests or procedures.If you do not get them when expected—in person, on the phone or in the mail—don’tassume the results are fine. Call your physicianand ask for them. Ask what the results mean for your care.

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4. Talk with your physician and health care team about your options if you need hospital care.If you have more than one hospital to choosefrom, ask your physician which one has thebest care and results for your condition.Hospitals do a good job of treating a widerange of problems. However, for some procedures (such as heart bypass surgery),research shows results often are better at hospitals doing a lot of these procedures.Also, before you leave the hospital, be sure toask about follow-up care, and be sure youunderstand the instructions.

5. Make sure you understand what will happenif you need surgery.Ask your physician and surgeon:“Who will takecharge of my care while I’m in the hospital?Exactly what will you be doing? How long willit take? What will happen after the surgery?How can I expect to feel during recovery?” Tellthe surgeon, anesthesiologist and nurses if youhave allergies or have ever had a bad reactionto anesthesia. Make sure you, your physicianand your surgeon all agree on exactly what willbe done during the operation.

For PPO providers

Visit the 1st Medical Network Web site at www. healthygeorgia.com for the most up-to-date listing of Georgia PPO providers.This Website also has a link to a listing of National PPO (Beech Street) providers located across theUnited States.You also can call the Retiree Help Line at (800) 586-9288 to request printedprovider directories.

For HMO providers

Check the HMO's Web site for current providersor call to request a current HMO directory. Note: Ifyou sign up for one of the HMO options, receipt ofyour HMO card could be delayed if a primary carephysician selection is not received by the HMO. Besure to select a primary care physician if youenroll online, or indicate your selection on yourPersonalized Change Form if you are mailing theinformation to the Health Plan. Note: If you selectUnitedHealthcare HMO, you do not need to selecta primary care physician.

P R O V I D E R D I R E C T O R I E S :

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What You Need to Do

R E V I E W T H E M A T E R I A L S I N

Y O U R P A C K A G E

Review this Guide and your PersonalizedChange Form (PCF). Keep your PCF, whichhas your mailing address on the back. Besure to read the What’s Changing for 2003 –2004 section on page 5 and 6 for importantinformation about Plan changes.

If you need to correct your address, you can do this by indicating your new addresson your PCF. If there are other correctionsneeded, call the Plan’s Eligibility Unit at(800) 610-1863, or in the Atlanta area(404) 656-6322.

I F N O C H A N G E S A R E N E E D E D

To continue your current coverage for 2003 – 2004:

PPO and Indemnity Options (FormerlyNamed Standard PPO and High Options)You do not need to take any action.Your coverage will be continued at the new costsshown on your Personalized Change Form.This also applies to any currently covered family members.

HMO and Medicare+Choice HMO OptionsRefer to the HMO Options charts starting onpage 37 of this Guide to see if your currentHMO is still available in your area. If so, andyou do nothing, your current coverage willbe continued automatically. If the HMO is nolonger available, and you do nothing, yourcoverage will be transferred automatically to the PPO Option.

T O C H A N G E Y O U R C O V E R A G E

• Online: Go to www.statehealth.org andaccess your information using your per-sonal security code (PIN) from the upperright corner of your PCF. Instructions areon the Web site.

• By mail:Complete your PCF and mail itback to the Health Plan postmarked by thedeadline,using the envelope provided inyour package.Keep a copy for your records.

If you want to continue coverage for yourdependents, check the appropriate box.Remember, if you check "no," you won't beable to reenroll the dependent in the futureunless you have a qualifying event. Note,however, that you cannot change fromFamily to Single coverage online.

In most cases, you and any covered familymembers must each select a primary carephysician.You may indicate PCP selectionsonline or on your PCF.

O P T I O N A L — A T T E N D A B E N E F I T

F A I R I N Y O U R A R E A

Check the list enclosed in your package for a benefit fair scheduled in your area.

Confirmation of Your Change

If you make changes to your current coverage,you will receive a new ID card by mail beforeJuly 1, 2003.

If you change your coverage online, you can printa confirmation of your option change directlyfrom the Web site or write the confirmation num-ber that you will see on the computer screen inthe space provided on your PCF for your records.

If you choose "No Coverage" for 2003 – 2004,you will not be able to reenroll in an SHBPoption at any time in the future, unless youreturn to active employment with the State in abenefits-eligible position.

I M P O R T A N T N O T E :

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What’s Changing for 2003 – 2004Effective July 1, 2003, changes to your Plan options include:

• For PPO and Indemnity Option members:

Deductibles and co-payments will change as indicated in the chart below.

BENEFITPPO OPTION INDEMNITY OPTION

CURRENTEFFECTIVE

JULY 1, 2003CURRENT

EFFECTIVEJULY 1, 2003

DEDUCTIBLES

CO-PAYMENTS

NOTE

Hospital Deductible per Admission,Excluding BHS and Transplant Benefits

General Deductibles

Individual Deductible per Plan Year

$0

Family Maximum Deductible per PlanYear

Physician Office Visit Co-payment perVisit

Emergency Room Co-payment per VisitNote: The co-payment effective July 1,2003 will be reduced to $80 if the member is referred by NurseCall 24before receiving emergency room services.

Urgent Care Center Co-payment perVisit at Approved Centers

Prescription Drug Co-PaymentsNote: Co-payments effective July 1, 2003will be prorated if the amount dispensedis less than the standard supply. See p.6

Generic Drugs

Preferred Brand-name Drugs

Non-Preferred Brand-name Drugs

$250

$300 $400

$400 $500

$900 $1,200

$1,200 $1,500

$60 $100

$35 $45

$10 $15

$20 $25

$100 $400

$400

$60 $100

$10 $15

$20 $25

In-Network/Georgia

In-Network/Out-of-State and Out-of-Network (Combined Deductibles)

In-Network/Georgia

In-Network/Out-of-State and Out-of-Network (Combined Deductibles)

$20 $30

$35 minimumto a $75

maximum andis calculated

based on 20%of the network

price of thedrug

$35 minimumto a $100

maximum andis calculated

based on 20%of the network

price of thedrug

$35 minimum to a $75

maximum and is calculated

based on 20% of the network

price of thedrug

$35 minimum to a $100

maximum and is calculated

based on 20% of the network

price of thedrug

$300

$900 $1,200

Not Applicable Not Applicable

Not Applicable Not Applicable

Current Plan rules, limitations, exclusions and co-insurance applicable to these benefits will remain in effectfor the Plan Year beginning on July 1, 2003.

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What’s Changing for 2003 – 2004 (Continued)

Effective July 1, 2003, changes to your Plan options include:

• For Indemnity and PPO Option members:

The monthly out-of-pocket spending limitfor generic and preferred brand name pre-scription drugs will become a quarterly(three-calendar month) out-of-pocket spend-ing limit with new maximums as describedbelow:

> If your individual combined co-paymentsfor generic drugs and preferred brandname drugs in any quarter reaches $300,you will not be charged additional co-payments for generic and preferred brandname drugs for the rest of that quarter.

> If you have family coverage and your family’s combined co-payments for generic drugs and preferred brand namedrugs in any quarter reaches $600, youand your dependents will not be chargedadditional co-payments for generic andpreferred brand name drugs for the rest of that quarter.

Notes:1) Co-payments for non-preferred brand

name medications do not count towardthe quarterly out-of-pocket limit.

2) If you choose a preferred brand namedrug when a generic is available, only the$15 generic co-payment will be appliedtoward the quarterly out-of-pocket limit.

3) Quarters coincide with the State’s fiscalyear, which begins every July 1.

Prescription drug co-payments that are effec-tive July 1, 2003 will be prorated accordingto the amount of the drug dispensed if theamount dispensed is less than the “standardsupply” for the prescription. The standardsupply is the quantity of the prescriptionthe Health Plan covers for one co-payment,which could be based on a specific numberof days, pills, vials, inhalers, packages, etc.For example, if your pharmacist dispenses a10-day supply of a generic drug and the

standard supply for the drug is 30 days, thenyour co-payment will be one-third of $15, or$5.00. Also, when you return to the phar-macy to receive the balance of your pre-scription you would pay another $10.00.

Coverage of specific osseous surgeries forthe treatment of periodontal disease will bediscontinued. Refer to your dental plan documents for information on available coverage for the treatment of periodontaldisease.Also, if offered by your employer,consider using your Health Care SpendingAccount to offset any out-of-pocket expenseyou may incur for these services.

• For HMO Option members:

The CIGNA and UnitedHealthcare serviceareas will change. See pages 31-34 for a list of specific counties in the approvedservice area.

If you currently have HMO coverage thatwill not be available in your area for thenew Plan year, you must select another available option. If you do not select another option, your current coverage willbe transferred automatically to the PPOOption effective July 1, 2003.

The BlueChoice HMO co-payment for urgentcare is changing. See the covered serviceschart for specific information.

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If You Do Not Make Any ChangesDuring the Retiree OptionChange Period

If you do not want to make any changes, your current coverage option and type continues intothe new Plan year, unless otherwise noted (seepage 6 under the “For HMO Option members”section).

It is not necessary to submit any paperworkif you do not want to make any changes.

If You Want to Change YourOption During the Retiree Option Change Period

The Comparing Benefits Within Health PlanOptions section starting on page 19 of this Guide provides an overview of what services are coveredby each option. Before choosing a new option,you’ll probably want to look at the benefits offeredand at physicians, hospitals and other providersparticipating in the networks of the variousoptions. For your reference, phone numbers forrequesting provider directories and specific benefitinformation are listed on the inside front coveralong with Web site addresses.

Knowing what your benefits cover can help preventunexpected out-of-pocket expenses during the Planyear. Before you schedule a physician’s appointment,for example, make sure you understand what services your new option covers. If you’ve chosenan option that offers a network of preferredproviders, consider the difference between seeingin-network providers and out-of-network providers.Most out-of-network services will cost you more and are subject to balance billing.

Using the security access code on yourPersonalized Change Form you received in yourpackage, you can:

• Change your address

• Change your coverage option

• Delete dependents (but you cannot changefrom Family to Single coverage online)

• Add or change primary care physicians forHMO Option selections

• Discontinue coverage*

* If you choose to discontinue at any time, youwill not be able to reenroll in any SHBPoption in the future, unless you return toactive employment in a benefits-eligible position.

If you do not have Internet access, complete andreturn your Personalized Change Form to:

State Health Benefit PlanP.O. Box 347069Atlanta, GA 30334

The envelope must be postmarked no later thanMay 15, 2003. A pre-addressed return envelope isinside your package.

Note: If you sign up for one of the HMO Options,receipt of your HMO card could be delayed if the HMO does not receive your primary carephysician (PCP) selection. If you selectUnitedHealthcare HMO, you do not need to select a PCP or complete the enrollment supplement form.

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If you do not need basic information on

participating in the Plan, including infor-

mation on who is eligible to participate,

proceed to page 19 for a comparison

of benefits.

Basic Plan Information

Eligible Dependents

A dependent is defined as:

• Your spouse, if you are legally married;

• Your never-married dependent children who are:

1. Natural or legally adopted children andunder age 19;

2. Stepchildren under age 19 who live withyou at least 180 days per year;

3. Other children under age 19 if they livewith you permanently and legally dependon you for financial support;

4. Your natural children, legally adopted children or stepchildren who were coveredunder the SHBP before age 19 and who are physically or mentally disabled anddependent on you for primary support (they may continue their existing Plan coveragepast age 19); and

5. Your children from categories 1, 2 or 3above who are registered full-time studentsat fully accredited schools, are not employedfull-time and are between the ages of 19 and 25.

For changing your coverage during the RetireeOption Change Period — May 1 through May 15 — you can enter your changes on theWeb site below, or complete and return thePersonalized Change Form.

• www.statehealth.org8 a.m. (May 1) to 6 p.m. (May 15)Available 24 hours a day, 7 days a week

After sending your changes online, be sure toobtain a confirmation number. The confir-mation number is your documentation thatan online transaction occurred. Please keepthis confirmation number in a safe place.

R E M E M B E R T H I S D E A D L I N E :

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Documentation Upon Request

In order to cover a spouse or dependent underthe Plan, you must provide documentation uponrequest from the Plan. The Plan requires:

• A copy of your certified marriage license tocover spouses;

• A copy of a certified birth certificate to cover anatural child;

• A copy of a stepchild’s certified birth certifi-cate, showing your legal spouse as the naturalparent of the child, and a letter documentingthat your stepchild lives in your home on a permanent basis in a parent-child relationshipfor at least 180 days per year;

• Adoption papers, guardian or court orders forother children who live with you permanentlyand legally depend on you for financial support. (The SHBP will recognize and honor a Qualified Medical Child Support Order(QMCSO) for eligible dependents. See your SPD for more information);

• Disability paperwork for disabled dependents19 and over; this documentation must bereceived by the Plan before the child’s 19th

birthday; or

• A certification letter for full-time studentdependents from the registrar’s office of yourchild’s school.

In any of these situations, you may be required to provide documents to verify your dependentrelationships during the Retiree Option ChangePeriod or at various periods throughout the Plan year.

If eligibility verification cannot be made after arequest from the Plan, the dependent’s coveragewill be terminated retroactively to his or her cover-age effective date.The Plan will make every effortallowable under the law to recover from the sub-scriber (i.e., retired employee) any and all pay-ments made by the Plan on behalf of an ineligibledependent.

Making Changes When You HaveQualifying Events

The option choice you make during the RetireeOption Change Period will stay in effect for theduration of the 2003 – 2004 Plan year unless youhave a qualifying event. Some qualifying eventsmay allow a change to Family coverage.A changeto Single coverage is allowed at any time.

Qualifying events include, but are not limited to:

• Marriage or divorce;

• Birth or adoption of a child or placement for adoption;

• Death of a spouse or child, if only dependentenrolled;

• Your spouse’s or dependent’s eligibility for or loss of eligibility for other group health coverage;

• A change in residence by you, your spouse ordependents that makes you or a covereddependent ineligible for coverage in yourselected option; and

• Medicare eligibility.

If you experience a qualifying event, you may beable to make changes for yourself and your dependents, provided you request those changeswithin 31 days of the qualifying event.Also, yourrequested change must correspond to the qualify-ing event. For a complete description of qualifyingevents, see your SPD and Updaters.You can contactthe Eligibility Unit for assistance at (800) 610-1863,or in the Atlanta area (404) 656-6322.

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Overview of How Each HealthPlan Option Works

On the following pages, you will find a briefdescription of each option and important consid-erations to help you select the best option for you.A comparison of specific benefits within eachoption is in the next section.

Contact the Retiree Help Line or HMO if youneed more detail. Telephone numbers are onthe inside front cover. You also may refer toyour SPD and Updaters to obtain more detailson benefits and Plan participation.

To help you understand the information in thissection, a few key terms are defined below:

Important Terms to UnderstandAllowed Amount—A dollar amount the Plan usesto calculate benefits payable.The Plan uses the following allowed amounts:

1. Network Rate—for in-network PPO services;

2. Out-of-Network Rate—for out-of-network PPO services; and

3. Indemnity Rate—for Indemnity Option services.

Balance Billing—A dollar amount charged by aprovider that is over the Plan’s allowed amount forthe care received. You are subject to balancebilling when you receive services from non-partici-pating providers, including emergency services.

Co-insurance Amount—The percentage of thePlan’s allowed amount paid by a Plan member inthe PPO or Indemnity Option. Depending on theoption selected, the SHBP generally pays 90% to60%, so your co-insurance is between 10% and 40%.

Co-payment—A set dollar amount that you pay atthe time you receive services or items. For exam-ple, you pay a $20 co-payment for an in-networkPPO physician’s office visit while you are at thephysician’s office. Co-payments do not apply toPlan year deductibles or out-of-pocket limits unless otherwise noted.

Covered Services—Services for medically necessary care that are eligible for reimbursementunder the Plan.

Deductible—A specified dollar amount, whichvaries by Plan option, for specified coveredservices that you must pay out-of-pocket each Planyear before the PPO Option or Indemnity Optionpays a benefit. Depending on your coverageoption, the deductible may not apply to someservices. For example, the deductible does notapply to in-network physician office visits underthe PPO Option. HMO Options do not havedeductible.

Emergency Care—Care provided when a sudden,severe and unexpected illness or injury happensthat could be life-threatening or result in perma-nent impairment of bodily functions if not treatedimmediately.

Lifetime Maximum—The maximum dollaramount that each Plan member may receive inbenefits from the SHBP during his or her lifetime.

Medical Certification Program (MCP)—A featureof the PPO and Indemnity Options that helps you and the Plan save money by preventingunnecessary care. To receive full benefits, youmust comply with the MCP requirements outlinedin the SPD and Updaters.

Out-of-Pocket Limit—A maximum amount youwould have to pay out of your pocket each Planyear for covered services. Once you meet yourout-of-pocket limit for the Plan year, the Plan pays100% of the allowed amounts for most coveredservices for the rest of the Plan year. Your out-of-pocket costs for premiums, co-payments and non-covered charges are not applied to the limit.The deductible is applied to your annual out-of-pocket limit.

Participating Provider—Any physician, hospital orother health-service professional or facility thatoffers covered services and that has joined thePPO network, the Indemnity network or HMO network for the Plan option. Providers nominatedand accepted under a Choice Option also are considered participating providers for the personmaking the nomination. Participating providersmay not balance bill Plan members for coveredservices.

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PPO Option

Anyone eligible for SHBP coverage may select thePPO Option.

The PPO Option consists of a network of over14,000 Georgia participating physicians and 166Georgia hospitals, over 385,000 physicians and3,300 hospitals across the United States, and hundreds of ancillary providers that have agreedto provide quality medical care and services at discounted rates. You have the choice of using in-network or out-of-network providers. If you usein-network providers, you’ll receive the highestlevel of benefits and avoid filing claims.To viewthe list of Georgia PPO providers online, visitwww.healthygeorgia.com.

If you choose the PPO Option, you . . .

• Can access providers in the Plan’s network of over 14,000 Georgia physicians and 166 hospitals to receive a higher level of benefitcoverage.

• Do not need to select a primary care physician(PCP) or obtain referrals to see specialists.

• Pay less than the Indemnity Option.

• Have no balance billing when using participat-ing PPO providers.

• Pay only a minimal co-payment for in-networkPPO physician visits, prescription drugs andsome other covered services.

• May access any licensed out-of-network physician, specialist or hospital at any time.However, you will generally pay more for out-of-network services and charges are subjectto balance billing.

• Have maximum in-network coverage for mostage-appropriate preventive care, including cov-erage for office visits.

• Have coordinated care through a vast networkof providers who will assist you in receivingthe maximum level of benefits.

• May reduce or eliminate the pre-existing condition limitation period if you can provecreditable coverage. See the HIPAA AnnualNotice on page 41 of this Guide.

National PPO Network

As a PPO Option member, you have the addedbenefit of access to a national network of partici-pating providers, which is managed by the BeechStreet Corporation.

You can take advantage of this national network if:

• You or a dependent lives outside of Georgia;

• You have a dependent going to school inanother state;

• You are traveling in another state; or

• You want to use an out-of-state provider.

The network consists of over 385,000 physiciansand 3,300 hospitals across the United States.Whenyou access Beech Street national providers outsidethe Georgia service area (see page 36), you areprotected from balance billing. Your level of benefit coverage is generally different when usingthe national network and you are subject to separate deductibles and out-of-pocket maximums.To view the list of national providers online, visitwww.healthygeorgia.com. If you do not haveInternet access, call Member Services for providerinformation.

Other Points to Consider• You must call the Medical Certification

Program (MCP) to precertify inpatient stays andspecified outpatient procedures when you areusing out-of-network providers or Beech Streetproviders.

• Some physicians affiliated with a PPO may notaccept new patients at some times during theyear. Check with the physician of your choicebefore you enroll in the PPO.

See Comparison of Benefits: PPO Option andIndemnity Option starting on page 20 for benefitdetails.

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PPO Choice Option

Anyone eligible for SHBP coverage may select thePPO Choice Option.

PPO Choice Option benefits are the same as in thePPO Option. However, PPO Choice Option premi-ums are higher. In return for a higher premium,you can request that an out-of-network providerbe reimbursed as an in-network provider. Thisrequest is known as a “nomination.” If the out-of-network provider accepts your nomination, agreesto the PPO fees, and is approved by the PPO, youwill receive in-network benefits from thatprovider. The in-network relationship between youand the provider remains in effect until either youor the provider terminates the agreement. Youmay nominate as many eligible providers as youwish at any time during the Plan year.

If your provider does not accept your nomination,does not accept the network fees, or is notapproved by the PPO, then services from thatprovider are covered at the lower, out-of-network benefit level. SHBP rules do not permit a member to change options when a nominatedprovider or the PPO rejects a nomination.

Note that you may nominate only providerslocated and licensed in Georgia, even if you live out of state. After the PPO receives yournomination, the PPO has three business days to either reject or approve the nomination. ThePPO must approve your provider nominationbefore you receive services.

For further details regarding the nominationprocess and to obtain the necessary paperwork,please contact the Retiree Help Line.

Note: The Behavioral Health Services (BHS) and transplant provider networks are separate from the PPO provider network.To nominate a BHS provider, contact the BHS Program at (800) 631-9943. For nominations of transplantproviders, call (800) 828-6518 (outside Atlanta) or (770) 438-9770 (inside Atlanta).

Indemnity Option (Formerly Named High Option)

Anyone eligible for SHBP coverage may select theIndemnity Option.

Important Note: The Indemnity Option is a traditional fee-for-service plan that also uses contracted health careproviders who have agreed to discounted rateswithout balance billing for charges over theallowed amount.As long as you use a participatingprovider, you may not be balance billed for cov-ered services. However, not all Georgia providersparticipate in these special arrangements andthere are no participating Indemnity Networkproviders outside of Georgia. In most instances,non-participating providers charge amounts thatare considerably higher than the Plan’s allowedamounts. When a non-participating providercharges you over the allowed amount, you areresponsible for the entire amount of the over-age (i.e., balance billing), which could be thou-sands of dollars. For example, during 2002,Indemnity Option members hospitalized outsideof Georgia paid an average out-of-pocket amountof over $20,000 per admission.

Note that the State Health Benefit Plan does nothave the legal authority to intervene when non-participating providers balance bill you; therefore,the State Health Benefit Plan cannot reduce oreliminate amounts balance billed.Also, the HealthPlan cannot make additional payments above theallowed amounts when you are balance billed bynon-participating providers.

The Indemnity Option generally provides the samecoverage level no matter which qualified medicalprovider you use.The Plan reimburses you for covered services, subject to the Plan’s allowedamounts for covered services. Therefore, it is themost expensive Plan option.

The Indemnity Option has similar coverage levels when compared to in-network PPO benefits, but it has:

• A higher premium;

• Less coverage for preventive care; and

• No provider network outside of Georgia.

13


Indemnity Option (continued)

If you choose the Indemnity Option, you . . .• Access any provider.

• Receive the same level of benefit coveragewhether or not your provider is in theIndemnity network.

• Pay most health care bills up to the deductibleamount before the Plan starts paying benefits.

• Continue to pay a percentage of the cost of cov-ered expenses—co-insurance—after meeting thedeductible (up to the out-of-pocket maximum)plus any non-covered costs or penalties.

• Are subject to balance billing from all out-of-state hospitals.

• Receive the same level of coverage as offeredin the PPO Option for prescription drug,behavioral and transplant benefits. TheIndemnity Option and PPO Option utilize thesame provider networks for prescription drug,behavioral and transplant benefits.

• Are not required to select a primary care physi-cian (PCP) to get referrals to see specialists.

• May reduce or eliminate the pre-existing limita-tion period if you can prove creditable cover-age. See the HIPAA Annual Notice on page 41

of this Guide.

Other Points to Consider• The Indemnity Option is the most

expensive option.

• The Indemnity Option does not include anational network of providers.

• Deductible for office visits, medical care andhospitalization must be met before benefits arepayable.

• Coverage is available for specified preventivelab work and tests, subject to allowed amountsand annual maximums. Office visits for preven-tive care are covered, subject to the deductibleand co-insurance. A co-payment-only benefitdoes not apply.

• Members must call the MCP to precertify in-patient stays at non-participating hospitals andmembers must precertify certain outpatienttests and procedures. Financial penalties applyif precertification rules are not followed.

HMO Options

HMO Options are available only to SHBP-eligibleretirees who live in an HMO’s approved servicearea. To see if you are eligible for an HMO, checkpages 37 – 40 in this Guide. For the 2003 – 2004Plan year, you may be eligible for up to five different HMO Options.

HMOs provide prepaid benefits for most healthcare needs, with no bills or claim forms. Youchoose a primary care physician (PCP) from a listof providers.* You must receive care from yourPCP or from a physician or facility referred byyour PCP for your expenses to be covered, exceptin cases of emergency and in other limited cases.If you receive care from a physician other thanyour PCP, or without being referred by your PCP,you won’t receive any benefit coverage even if thephysician or facility is in the HMO network.

If you choose an HMO Option, you . . .

• Must access physicians, specialists and hospitalsoffered through the HMO’s network to receivebenefits, except for emergencies.

• Choose a primary care physician (PCP) to serveas your first point of contact for most healthcare services.* Your covered family membersalso must select a PCP. PCPs refer you to network providers for specialty care.

• Pay only a minimal co-payment for HMO in-network physician visits, prescription drugsand some other covered services.

• Have coordinated care through a network ofHMO participating providers.

• Have low-cost access to the many services theHMO offers in preventive health care—well-baby and well-child care, physical exams andimmunizations.

* Note: UnitedHealthcare HMO does not require you to

select a PCP or obtain referrals to specialists.

14


Other Points to Consider• Generally, you don’t have to file claims.

• You pay the full cost for most non-referredservices and for services received outside theHMO’s network, except for emergencies.

• In most cases, HMOs do not have a deductibleto meet—so your out-of-pocket costs may be lower.

• There are no pre-existing condition limitations.

• You may be required to follow the HMO’s standardized treatment plan for your condition.For example, you may be required to receivetreatment from your primary care physician for a specified period before being referred to a specialist.

HMO Choice Options

If you are eligible for an HMO Option, you also areeligible for that HMO’s Choice Option.

HMO Choice Option benefits are the same as therespective regular HMO Option benefits. However,the Choice Option premiums are higher. In returnfor a higher premium, the HMO Choice Optiongives members the opportunity to request that an out-of-network provider be treated as an HMOnetwork provider. This request is known as a“nomination.” You may nominate providers if theyare located and licensed in Georgia and offer services the HMO covers. Also, you may nominateas many eligible providers as you wish at any timeduring the Plan year.

If the out-of-network provider accepts your nomination, accepts the HMO’s fees and isapproved by the HMO, you may receive in-net-work benefits from that provider. If your providerdoes not accept your nomination, does not acceptthe HMO’s fees, or does not get approved by theHMO, then services from that provider are notcovered. SHBP rules do not permit a member tochange options when a nominated provider or theHMO rejects a nomination.

Please contact the respective HMO directly to findout more about the required procedures andpaperwork necessary to nominate a provider.

15


Medicare+Choice HMO Option(M+C HMO)

The Medicare+Choice HMO Option is availableonly to those retirees who are enrolled in Part Aand Part B Medicare coverage and live in the M+CHMO service area (metro Atlanta). Check page 40in this Guide to find a listing of counties servicedby the M+C HMO.

If you choose the Kaiser M+C HMO, your newcoverage will replace your Medicare coverage.Your claim forms would not be filed withMedicare and the SHBP. All your services and payments would be coordinated through theKaiser M+C HMO.

If you choose the M+C HMO Option, you . . .

• Should refer to the information under the regular HMO Option on page 14 but also note that:

— The Kaiser M+C provider network is different from the regular Kaiser HMOprovider network.

— If your spouse and/or dependents are not Medicare-eligible, they would automaticallybe enrolled in the regular Kaiser HMO.Thebenefits and providers available throughthe regular HMO are different from theM+C HMO.

• Must use providers in the Kaiser M+C HMOnetwork in order to receive coverage. If you gooutside the network, there are usually no bene-fits, except in the case of an emergency.

• Should return the separate form that the HMOsupplies to you to ensure that you are in com-pliance with Medicare requirements.

• Would have coverage for prescription drugs,vision care, and preventive care not covered by Medicare.

Other Points to Consider• You will continue to pay the Medicare Part B

premium, usually deducted from your monthlySocial Security benefit checks.Your coveragewill be based on the rules of the M+C HMOOption, which can offer you the advantages of lower out-of-pocket costs and reducedpaperwork. Medicare pays a portion of yourpremium directly to the M+C HMO.

• You also will pay an SHBP premium, but it willbe lower than regular HMO Option premiums.See your Personalized Change Form for premium information.

• If you select the Kaiser Medicare+Choice HMO,you will receive a temporary ID card or letterto use until Medicare approves your applicationand you receive your permanent ID card.

If you want additional details on your Medicare bene-fits, contact the Social Security Administration.Thephone number and Web site are listed on the insidefront cover of this Guide. If you want additionaldetails on your M+C benefits, see page 28 of thisGuide and/or call the Kaiser Permanente M+C HMOat (800) 956-1358 or (404) 233-3700 in Atlanta.

16


How Medicare+Choice Affects Your Current Medicare CoverageIt's important to note that your benefit levels will be greater than those of regular HMOs as long as youcontinue to pay your Medicare Part B premiums.

Your Choice

If you choose traditionalMedicare (Part A and Part B)

If you choose the Kaiser M+C HMO Option

How Medicare Works

. . . then traditional Medicarebecomes your primary plan andpays your medical benefits first

. . . then traditional Medicare nolonger processes your claims.Your Medicare coverage will pay a portion of the M+C HMOpremium.

How SHBP Benefits Work

. . . and your SHBP benefits pay sec-ondary benefits up to the allowedamount for Medicare Part A and PartB coverages.

When Medicare is coordinated with the SHBP, you have 100% coverage on allowed amounts afterthe deductible for eligible services.

. . . and your SHBP benefits will payan additional portion of your M+CHMO premium, making coveragegenerally less expensive than othercoverage options.

17


Q&A on Medicare+Choice HMO and Regular HMOs

Q: What if I temporarily live outside myMedicare+Choice or regular HMO service area?

A: If you live in a different area of the country for an extended period, the M+C HMO maynot be the best choice for you. Remember that services are available only within theHMO's service area, except for emergency andacute care, follow-up care, and renal-dialysiscare. Call the HMO directly to request moreinformation if needed.

Q: Can I be denied enrollment in aMedicare+Choice HMO?

A: The Centers for Medicare and MedicaidServices (CMS), responsible for the administra-tion of Medicare, may deny your enrollmentunder these conditions:

• You do not reside in the service area of theM+C HMO.

• You are not entitled to Medicare Part A orare not enrolled in Medicare Part B.

• You have been diagnosed with end-stagerenal disease (ESRD) or received a kidneytransplant within the past 36 months(except for current HMO members). ESRDis kidney failure that requires dialysis or atransplant. However, ESRD beneficiaries cur-rently enrolled in an HMO will be able toenroll in the M+C HMO Option. Note: If youare converting from HMO to M+C HMO cov-erage, you and any dependents must convertinto the same HMO's M+C plan.

• If you are not approved for theMedicare+Choice HMO Option by CMS,you will be placed in the respective regularHMO Option.Your premiums will be adjusted to the regular HMO Option rates.

Q: What happens if I’m out of the HMO service area and need health care?

A: In emergencies, you should first seek treatment.Then contact your PCP as soon as practical.HMOs cover emergency care as if you were intheir network. Routine (non-emergency) careor services that could have been anticipatedare generally not covered outside of yourHMO service area. Refer to the HMO's enroll-ment materials for procedures to follow.

Q: What if I’m unhappy with my primary care physician?

A: If you are unhappy, you can change to anotherprimary care physician.The procedure will varyby HMO, so contact your HMO for assistance.

18


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19


Comparing Benefits Within Health Plan Options

This section includes two charts, one that

compares specific benefits within the PPO and Indemnity Options and one

that compares HMO Option benefits. Benefit changes for the new Plan year are

in bold type. For more specific information on covered services, call the

Member Services numbers listed on the inside front cover.

To make it easier to view information on the PPO and Indemnity Options, the

chart is formatted in a “landscape” view.

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er v

isit

co-p

aym

ent

of

$30

.

80%

of

NR

;su

bje

ct t

o d

edu

ctib

le

60%

of

OO

NR

;su

bje

ct t

o d

edu

ctib

le

60%

of

OO

NR

;su

bje

ct t

o d

edu

ctib

le

60%

of

OO

NR

;su

bje

ct t

o d

edu

ctib

le

60%

of

OO

NR

;su

bje

ct t

o d

edu

ctib

le

22

CO

MP

AR

ISO

N O

F P

PO

AN

D I

ND

EM

NIT

Y O

PT

ION

S

$15

co-p

aym

ent

for

gen

eric

dru

gs;$

25

co-p

aym

ent

for

pre

ferr

ed b

ran

d n

ame

dru

gs;c

o-p

aym

ent

for

non

-p

refe

rred

bra

nd

nam

e dr

ugs

ran

ges

from

a $

35 m

inim

um

to

a $100

max

imu

m a

nd

is c

alcu

late

d b

ased

on

20%

of

the

net

wor

k p

rice

of

the

dru

g.C

o-p

aym

ents

for

gen

eric

an

d p

refe

rred

bra

nd

nam

e dr

ugs

are

app

lied

to a

qu

arte

rly o

ut-

of-

po

cket

lim

it o

f $300 p

er p

erso

n a

nd

$600 p

er f

amil

y.

Wh

en a

mem

ber

ch

oo

ses

a p

refe

rred

bra

nd

nam

e o

r n

on

-pre

ferr

ed b

ran

d n

ame

dru

g o

ver

its

gen

eric

equ

ival

ent,

the

mem

ber

may

be

resp

on

sib

le f

or

a h

igh

er c

o-p

aym

ent

than

lis

ted

her

ein

.Co

-pay

men

tsar

e b

ased

up

on

su

pp

lies

of

up

to

30

day

s;so

me

dru

gs a

re l

imit

ed t

o a

sta

nd

ard

su

pp

ly o

f le

ss t

han

30

day

s.Se

e th

e SP

D a

nd

Upda

ters

for

det

ails

.

Mem

ber

mu

st p

ay f

ull

char

ges

at p

oin

t o

f sa

le a

nd

su

bm

it a

pap

er c

laim

.Mem

ber

s w

ill b

e re

imb

urs

edat

th

e p

har

mac

y n

etw

ork

rat

e le

ss t

he

req

uir

ed c

o-p

aym

ent

for

cove

red

dru

gs.C

har

ges

are

sub

ject

to

ba

lan

ce b

illi

ng

.Co

vera

ge p

rovi

sio

ns

liste

d a

bo

ve a

lso

ap

ply

.

No

te:

Co

-pay

men

ts a

re p

rora

ted

acco

rdin

g to

th

e am

ou

nt

of

the

dru

gd

isp

ense

d i

f th

e am

ou

nt

dis

pen

sed

is

less

th

an t

he

stan

dar

d s

up

ply

fo

r th

ep

resc

rip

tio

n. Se

e p

age

6.

Ph

ysi

cian

Ser

vice

s Fu

rnis

hed

in

a H

osp

ital

•Su

rger

y in

gen

eral

,in

clu

din

g ch

arge

sb

y su

rgeo

n,a

nes

thes

iolo

gist

,p

ath

olo

gist

an

d r

adio

logi

st

•In

pat

ien

t w

ell-n

ewb

orn

ex

ams

Ph

ysi

cian

Ser

vice

s T

hat

Are

fo

rE

mer

gen

cy C

are

Ou

tpat

ien

t Su

rger

y—

Ph

ysi

cian

’s O

ffic

e

Ou

tpat

ien

t Su

rger

y—

Ho

spit

al/F

acil

ity

Ho

spit

al S

ervi

ces

Oth

er T

han

Th

ose

Th

at A

re f

or

Em

erge

ncy

Car

e

•In

pat

ien

t ca

re,i

ncl

ud

ing

inp

atie

nt

sho

rt-t

erm

acu

te r

ehab

ilita

tio

n s

ervi

ces

•O

utp

atie

nt

serv

ices

— N

on

-em

erge

ncy

use

of

emer

gen

cy r

oo

m—

Oth

er

•W

ell-n

ewb

orn

car

e

90%

of

IR;

sub

ject

to

ded

uct

ible

No

t co

vere

d

90%

of

IR;s

ub

ject

to

ded

uct

ible

an

d t

o b

al-

an

ce b

illi

ng

fro

m n

on

-p

arti

cip

atin

g p

rovi

der

s

90%

of

IR;

sub

ject

to

ded

uct

ible

90%

of

IR;

sub

ject

to

ded

uct

ible

90%

of

IR;s

ub

ject

to

ap

er a

dm

issi

on

ded

uct

ible

of

$400

90%

of

IR;

sub

ject

to

ded

uct

ible

.If

ser

vice

s ar

e in

co

nju

nct

ion

wit

h n

on

-em

erge

ncy

use

of

emer

gen

cy r

oo

m,

ben

efit

als

o s

ub

ject

to

$100

/vis

it c

o-p

aym

ent.

90%

of

IR;n

ot

sub

ject

to d

edu

ctib

le

90%

of

NR

;su

bje

ct t

o d

edu

ctib

le

100%

of

NR

;no

t su

bje

ctto

ded

uct

ible

90%

of

NR

;su

bje

ct t

o d

edu

ctib

le

90%

of

NR

;su

bje

ct t

o d

edu

ctib

le

90%

of

NR

;su

bje

ct t

o d

edu

ctib

le

90%

of

NR

;su

bje

ct t

o a

per

ad

mis

sio

n d

edu

ctib

le

of

$250

90%

of

NR

;su

bje

ct t

o d

edu

ctib

le.

If s

ervi

ces

are

in

con

jun

ctio

n w

ith

no

n-

emer

gen

cy u

se o

f em

erge

ncy

ro

om

,b

enef

it a

lso

su

bje

ct t

o$100

/vis

it c

o-p

aym

ent.

100%

of

NR

;no

t su

bje

ct t

o d

edu

ctib

le

80%

of

NR

;su

bje

ct t

o d

edu

ctib

le

100%

of

NR

;no

t su

bje

ctto

ded

uct

ible

90%

of

NR

;su

bje

ct t

oIn

-Net

wo

rk/G

eorg

iad

edu

ctib

le

80%

of

NR

;su

bje

ct t

o d

edu

ctib

le

80%

of

NR

;su

bje

ct t

o d

edu

ctib

le

80%

of

NR

;su

bje

ct t

o a

per

ad

mis

sio

n d

edu

ctib

le

of

$250

80%

of

NR

;su

bje

ct t

o d

edu

ctib

le.

If s

ervi

ces

are

in

con

jun

ctio

n w

ith

no

n-

emer

gen

cy u

se o

f em

erge

ncy

ro

om

,b

enef

it a

lso

su

bje

ct t

o$100

/vis

it c

o-p

aym

ent.

100%

of

NR

;no

t su

bje

ct t

o d

edu

ctib

le

60%

of

OO

NR

;su

bje

ct t

o d

edu

ctib

le

No

t co

vere

d

90%

of

NR

;su

bje

ct t

oIn

-Net

wo

rk/G

eorg

iad

edu

ctib

le a

nd

to

ba

lan

ce b

illi

ng

60%

of

OO

NR

;su

bje

ct t

o d

edu

ctib

le

60%

of

OO

NR

;su

bje

ct t

o d

edu

ctib

le

60%

of

OO

NR

;su

bje

ct t

o a

per

ad

mis

sio

n d

edu

ctib

le

of

$250

60%

of

OO

NR

;su

bje

ct t

o d

edu

ctib

le.

If s

ervi

ces

are

in

con

jun

ctio

n w

ith

no

n-

emer

gen

cy u

se o

f em

erge

ncy

ro

om

,b

enef

it a

lso

su

bje

ct t

o$100

/vis

it c

o-p

aym

ent.

60%

of

OO

NR

;no

tsu

bje

ct t

o d

edu

ctib

le

23

CO

VE

RE

D S

ER

VIC

ES

PP

O O

PT

ION

Ou

t-o

f-Net

wo

rk

Th

e P

lan

Pays

:

PP

O O

PT

ION

In-N

etw

ork

/Ou

t-o

f-Sta

te

Th

e P

lan

Pays

:

PP

O O

PT

ION

In-N

etw

ork

/Geo

rgia

Th

e P

lan

Pays

:

IND

EM

NIT

Y O

PT

ION

Th

e P

lan

Pays

:

Ho

spit

al S

ervi

ces

Th

at A

re f

or

Em

erge

ncy

Car

e •

Trea

tmen

t o

f an

em

erge

ncy

med

ical

con

dit

ion

or

inju

ry

Not

es:

Th

e $1

00co

-pay

men

t is

red

uced

to

$80

if r

efer

red

by

Nur

seC

all 2

4 b

efor

ere

ceiv

ing

emer

gen

cy r

oom

ser

vice

s.

Am

bu

lan

ce S

ervi

ces

for

Em

erge

ncy

Car

e

No

tes:

Lim

ited

to

tra

nsp

ort

atio

n f

or

emer

-ge

nci

es a

nd

ben

efit

s su

bje

ct t

o b

ala

nce

bil

lin

gfr

om

no

n-p

arti

cip

atin

g p

rovi

der

so

f am

bu

lan

ce s

ervi

ces.

Urg

ent

Car

e Se

rvic

es i

n a

n A

pp

rove

dU

rgen

t C

are

Cen

ter

Ho

me

Nu

rsin

g C

are

Ap

pro

ved

in

Ad

van

ce b

y t

he

MC

P

No

tes:

Ho

me

nu

rsin

g ca

re n

ot

revi

ewed

by

the

MC

P –

Co

vers

tw

o h

ou

rs o

f m

ed-

ical

ly n

eces

sary

ski

lled

ho

me

care

per

day

by

RN

or

LPN

if

ord

ered

by

a p

hys

icia

n;

limit

ed t

o $

7,50

0 p

er P

lan

yea

r.$7

,500

limit

is

a co

mb

ined

to

tal

in P

PO

Op

tio

ns.

Mem

ber

’s s

har

e o

f co

st i

s n

ot

app

lied

to

Pla

n y

ear

ou

t-o

f-po

cket

lim

its.

Skil

led

Nu

rsin

g Fac

ilit

y S

ervi

ces

90%

of

IR a

fter

a p

ervi

sit

co-p

aym

ent

of $

100

;co

-insu

ran

ce a

nd

h

osp

ital

ded

uct

ible

,if

adm

itte

d,a

pp

ly.S

ub

ject

to b

ala

nce

bil

lin

gfr

om

no

n-p

arti

cip

atin

gp

rovi

der

s.

90%

of

IR;

sub

ject

to

ded

uct

ible

90%

of

IR;

sub

ject

to

ded

uct

ible

90%

of

IR;

sub

ject

to

ded

uct

ible

No

t co

vere

d

90%

of

NR

aft

er a

per

visi

t co

-pay

men

t of

$100

;co

-insu

ran

ce a

nd

h

osp

ital

ded

uct

ible

, if

adm

itte

d,

app

ly

90%

of

NR

;su

bje

ct t

o d

edu

ctib

le

90%

of

NR

aft

er a

per

visi

t co

-pay

men

t o

f $45

;su

bje

ct t

o d

edu

ctib

le

90%

of

NR

;su

bje

ct t

o d

edu

ctib

le

No

t co

vere

d

90%

of

NR

aft

er a

p

er v

isit

co

-pay

men

t o

f $100

;co

-insu

ran

ce

and

ho

spit

al d

edu

ctib

le,

if a

dm

itte

d, a

pp

ly

90%

of

NR

;su

bje

ct t

oIn

-Net

wo

rk/G

eorg

iad

edu

ctib

le

90%

of

NR

aft

er a

per

visi

t co

-pay

men

t o

f $45

;su

bje

ct t

o d

edu

ctib

le

80%

of

NR

;su

bje

ct t

o d

edu

ctib

le

No

t co

vere

d

90%

of

OO

NR

aft

er a

per

vis

it c

o-p

aym

ent

of

$100

;co

-insu

ran

ce a

nd

ho

spit

al d

edu

ctib

le,

if a

dm

itte

d,

app

ly.

Sub

ject

to

ba

lan

cebil

lin

g.

90%

of

OO

NR

;su

bje

ctto

In

-Net

wo

rk/G

eorg

iad

edu

ctib

le

No

t ap

plic

able

60%

of

OO

NR

;su

bje

ct t

o d

edu

ctib

le

No

t co

vere

d

24

CO

MP

AR

ISO

N O

F P

PO

AN

D I

ND

EM

NIT

Y O

PT

ION

S

Ho

spic

e C

are

Du

rab

le M

edic

al E

qu

ipm

ent

(DM

E)—

Ren

tal

or

Pu

rch

ase

Ou

tpat

ien

t A

cute

Sh

ort

-Ter

mR

ehab

ilit

atio

n S

ervi

ces

Not

es:C

over

age

for

up t

o 40

vis

its

per

Pla

nye

ar w

hen

con

diti

ons

are

met

for

phy

sica

l,sp

eech

an

d oc

cup

atio

nal

th

erap

ies

and

for

card

iac

reh

abili

tati

on.

Den

tal

and

Ora

l C

are—

Lim

ited

Co

vera

ge

•C

ove

rage

in

gen

eral

No

tes:

Co

vera

ge f

or

mo

st p

roce

du

res

for

the

pro

mp

t re

pai

r o

f so

un

d n

atu

ral

teet

ho

r ti

ssu

e fo

r th

e co

rrec

tio

n o

f d

amag

eca

use

d b

y tr

aum

atic

in

jury

.

•C

over

age

of

spec

ific

oss

eou

s su

rger

ies

for

the

trea

tmen

t o

f p

erio

do

nta

l d

isea

se

•Te

mp

oro

man

dib

ula

r jo

int

syn

dro

me

(TM

J)

Not

es:C

over

age

only

for

dia

gnos

tic

test

ing

and

no

n-s

urg

ical

tre

atm

ent

of T

MJ,

up

to

$1,1

00 p

er p

erso

n l

ifet

ime

max

imu

m

ben

efit

.

100%

of

IR,u

p t

oM

edic

are’

s ap

pro

ved

lifet

ime

max

imu

m;s

ub

-je

ct t

o d

edu

ctib

le a

nd

to h

osp

ital

ded

uct

ible

,if

in l

ieu

of

ho

spit

aliz

atio

n

90%

of

IR;

sub

ject

to

ded

uct

ible

90%

of

IR;s

ub

ject

to

ded

uct

ible

90%

of

IR;

sub

ject

to

ded

uct

ible

and

,if

adm

itte

d,t

o

ho

spit

al d

edu

ctib

le

No

t co

vere

d

90%

of

IR;

sub

ject

to

ded

uct

ible

100%

of

NR

;su

bje

ct t

o d

edu

ctib

lean

d t

o h

osp

ital

ded

uct

ible

, if

in

lie

uo

f h

osp

ital

izat

ion

90%

of

NR

;su

bje

ct t

o d

edu

ctib

le

90%

of

NR

;su

bje

ct t

od

edu

ctib

le a

nd

$20

/vis

itco

-pay

men

t

90%

of

NR

;sub

ject

to

dedu

ctib

le a

nd

, if

ad

mit

ted

, to

ho

spit

ald

edu

ctib

le.N

etw

ork

pro

vide

rs m

ay n

ot b

eav

aila

ble

for

all c

over

edse

rvic

es;c

har

ges

are

pai

dat

90%

of

NR

,sub

ject

to

bala

nce

bil

lin

g.

No

t co

vere

d

90%

of

NR

;su

bje

ct t

o d

edu

ctib

le

100%

of

NR

;su

bje

ct t

o d

edu

ctib

lean

d t

o h

osp

ital

ded

uct

ible

, if

in

lie

uo

f h

osp

ital

izat

ion

80%

of

NR

;su

bje

ct t

o d

edu

ctib

le

80%

of

NR

;su

bje

ct t

od

edu

ctib

le a

nd

$20

/vis

itco

-pay

men

t

80%

of

NR

;sub

ject

to

dedu

ctib

le a

nd

, if

ad

mit

ted

, to

ho

spit

ald

edu

ctib

le.N

etw

ork

pro

vide

rs m

ay n

ot b

eav

aila

ble

for

all c

over

edse

rvic

es;c

har

ges

are

pai

dat

80%

of

NR

,sub

ject

to

bala

nce

bil

lin

g.

No

t co

vere

d

80%

of

NR

;su

bje

ct t

o d

edu

ctib

le

60%

of

OO

NR

;su

bje

ct t

o d

edu

ctib

le

and

to

ho

spit

ald

edu

ctib

le,

if i

n l

ieu

of

ho

spit

aliz

atio

n

60%

of

OO

NR

;su

bje

ct t

o d

edu

ctib

le

60%

of

OO

NR

;su

bje

ct t

o d

edu

ctib

le

60%

of

OO

NR

;su

bje

ct t

o d

edu

ctib

lean

d,

if a

dm

itte

d,

toh

osp

ital

ded

uct

ible

No

t co

vere

d

60%

of

OO

NR

;su

bje

ct t

o d

edu

ctib

le

25

CO

VE

RE

D S

ER

VIC

ES

PP

O O

PT

ION

Ou

t-o

f-Net

wo

rk

Th

e P

lan

Pays

:

PP

O O

PT

ION

In-N

etw

ork

/Ou

t-o

f-Sta

te

Th

e P

lan

Pays

:

PP

O O

PT

ION

In-N

etw

ork

/Geo

rgia

Th

e P

lan

Pays

:

IND

EM

NIT

Y O

PT

ION

Th

e P

lan

Pays

:

Ch

iro

pra

ctic

Car

e

No

tes:

Co

vera

ge f

or

up

to

a m

axim

um

of

40 v

isit

s p

er P

lan

yea

r.

Beh

avio

ral

Hea

lth

Car

eW

ith

BH

S au

tho

riza

tio

n,r

egar

dle

ss o

fH

ealt

h P

lan

op

tio

n

Car

e re

ceiv

ed o

uts

ide

of

BH

S n

etw

ork

or

wit

ho

ut

BH

S au

tho

riza

tio

n,r

egar

dle

ss o

fH

ealt

h P

lan

op

tio

n

Tra

nsp

lan

t Se

rvic

es

90%

of

IR;s

ub

ject

to

ded

uct

ible

90

% o

f N

R;s

ub

ject

to

ded

uct

ible

an

d $

20/v

isit

co-p

aym

ent

80%

of

NR

;su

bje

ct t

od

edu

ctib

le a

nd

$20

/vis

itco

-pay

men

t

60%

of

OO

NR

;su

bje

ct t

o d

edu

ctib

le

26

CO

MP

AR

ISO

N O

F P

PO

AN

D I

ND

EM

NIT

Y O

PT

ION

S

Inp

atie

nt

ho

spit

al s

ervi

ces

for

men

tal

hea

lth

an

d s

ub

stan

ce a

bu

se a

re c

over

ed a

t 90

% o

f n

etw

ork

rat

e fo

ru

p t

o a

co

mb

ined

to

tal

of

60 d

ays

per

per

son

,per

Pla

n y

ear;

asso

ciat

ed p

rofe

ssio

nal

fee

s ar

e co

vere

dat

80%

of

net

wo

rk r

ate

for

up

to

60

visi

ts.P

arti

al h

osp

ital

izat

ion

pro

gram

(P

HP

) an

d i

nte

nsi

ve o

utp

atie

nt

(IO

P)

char

ges

are

cove

red

at

90%

of

the

net

wo

rk r

ate

wit

h B

HS

auth

ori

zati

on

(lim

ited

to

30

com

bin

edP

HP

an

d I

OP

vis

its/

day

s p

er P

lan

yea

r);n

o b

enef

it w

ith

ou

t B

HS

auth

ori

zati

on

.Ou

tpat

ien

t p

rofe

ssio

nal

serv

ices

fo

r m

enta

l h

ealt

h a

nd

su

bst

ance

ab

use

are

co

vere

d a

t 80

% o

f n

etw

ork

rat

e fo

r u

p t

o 5

0 vi

sits

per

Pla

n y

ear.

Vis

it l

imit

atio

n i

ncl

ud

es u

p t

o t

hre

e b

rief

sit

uat

ion

al c

ou

nse

ling

sess

ion

s co

vere

d a

t 10

0%w

ith

ou

t d

edu

ctib

le.A

ll el

igib

le c

har

ges

are

sub

ject

to

ded

uct

ible

s ($

300

PP

O i

n-n

etw

ork

/Geo

rgia

;$30

0In

dem

nit

y O

pti

on

ded

uct

ible

an

d $

100

per

co

nfi

nem

ent

ho

spit

al d

edu

ctib

le)

and

to

a s

epar

ate

ou

t-o

f-p

ock

et l

imit

of

$2,5

00 p

er p

erso

n,p

er P

lan

yea

r.N

o i

np

atie

nt

ben

efit

is

avai

lab

le w

ith

ou

t a

BH

Sau

tho

riza

tio

n.S

ee t

he

SPD

an

d U

pda

ters

for

full

det

ails

on

co

vera

ge p

rovi

sio

ns

and

ex

clu

sio

ns.

Inp

atie

nt

ho

spit

al s

ervi

ces

for

men

tal

hea

lth

an

d s

ub

stan

ce a

bu

se a

re c

ove

red

at

60%

of

the

aver

age

net

wo

rk p

er d

iem

rat

e w

hen

BH

S-au

tho

rize

d f

or

up

to

a c

om

bin

ed t

ota

l o

f 60

day

s p

er P

lan

yea

r;as

soci

ated

pro

fess

ion

al f

ees

are

cove

red

at

50%

of

the

net

wo

rk r

ate

for

up

to

25

visi

ts p

er P

lan

yea

r.N

oin

pat

ien

t b

enef

it i

s av

aila

ble

wit

ho

ut

a B

HS

auth

ori

zati

on

.Ou

tpat

ien

t p

rofe

ssio

nal

(M

D/P

hD

) se

rvic

esfo

r m

enta

l h

ealt

h a

nd

su

bst

ance

ab

use

are

co

vere

d a

t 50

% o

f th

e n

etw

ork

rat

e fo

r u

p t

o 2

5 vi

sits

per

Pla

n y

ear.

All

elig

ible

ch

arge

s ar

e su

bje

ct t

o d

edu

ctib

les

and

do

no

t ac

cum

ula

te t

ow

ard

an

y o

ut-

of-p

ock

-et

lim

it.B

ala

nce

bil

lin

gm

ay a

pp

ly.S

ee t

he

SPD

an

d U

pda

ters

for

full

det

ails

on

co

vera

ge p

rovi

sio

ns

and

ex

clu

sio

ns.

Th

e le

vel

of

ben

efit

co

vera

ge i

s b

ased

on

wh

eth

er o

r n

ot

you

sel

ect

a co

ntr

acte

d t

ran

spla

nt

cen

ter,

rega

rdle

ss o

f yo

ur

Hea

lth

Pla

n o

pti

on

.At

con

trac

ted

cen

ters

,th

e le

vel

of

ben

efit

co

vera

ge i

s 90

% o

f th

en

etw

ork

rat

e fo

r co

vere

d s

ervi

ces.

At

no

n-c

on

trac

ted

cen

ters

,th

e le

vel

of

ben

efit

co

vera

ge i

s 60

% o

fth

e n

etw

ork

rat

e fo

r co

vere

d s

ervi

ces.

Sub

ject

to

ho

spit

al d

edu

ctib

le o

f $1

00 p

er a

dm

issi

on

.

IMP

OR

TAN

T C

ON

SID

ER

AT

ION

S

•C

har

ges

fro

m n

on

-par

tici

pat

ing

pro

vid

ers

are

sub

ject

to

bal

ance

bil

lin

g.A

mo

un

ts b

alan

ce b

illed

by

no

n-p

arti

cip

atin

g p

rovi

der

s ar

e th

em

emb

er’s

res

po

nsi

bili

ty a

nd

do

no

t co

un

t to

war

d d

edu

ctib

les

or

ou

t-o

f-po

cket

sp

end

ing

limit

s.

•Se

rvic

es c

ove

red

un

der

th

e P

PO

fro

m a

n I

n-N

etw

ork

/Geo

rgia

pro

vid

er w

ill a

pp

ly o

nly

to

th

e In

-Net

wo

rk/G

eorg

ia d

edu

ctib

le a

nd

o

ut-

of-p

ock

et l

imit

.

•Se

rvic

es c

ove

red

un

der

th

e P

PO

fro

m i

n-n

etw

ork

/ou

t-o

f-sta

te a

nd

ou

t-o

f-net

wo

rk p

rovi

der

s ap

ply

to

th

e sa

me

ded

uct

ible

an

d o

ut-

of-p

ock

et l

imit

.

•Li

feti

me

ben

efit

max

imu

ms

are

com

bin

ed t

ota

ls a

mo

ng

the

PP

O O

pti

on

s,In

dem

nit

y O

pti

on

an

d H

MO

Op

tio

ns

(ex

cep

t fo

r K

aise

r Pe

rman

ente

).

•So

me

PP

O a

nn

ual

max

imu

ms

and

lim

itat

ion

s ar

e co

mb

ined

to

tals

.

•A

nn

ual

do

llar

and

vis

it l

imit

atio

ns,

ded

uct

ible

s an

d o

ut-

of-p

ock

et s

pen

din

g lim

its

are

bas

ed o

n a

Ju

ly 1

to

Ju

ne

30 P

lan

yea

r.

•So

me

serv

ices

may

req

uir

e M

CP

pre

cert

ific

atio

n,p

rio

r ap

pro

val

or

lett

ers

of

med

ical

nec

essi

ty b

efo

re s

uch

ser

vice

s ar

e co

vere

d b

y th

e P

lan

.

•C

o-p

aym

ents

do

no

t ap

ply

to

war

d d

edu

ctib

les

or

ou

t-o

f-po

cket

lim

its

un

less

oth

erw

ise

no

ted

.

•C

o-p

aym

ents

fo

r a

pre

scri

pti

on

dru

g m

ay c

han

ge a

t an

y ti

me

du

rin

g th

e P

lan

yea

r d

ue

to a

ch

ange

in

th

e st

atu

s o

f th

e d

rug

on

th

e P

lan

’s

pre

ferr

ed d

rug

list.

For

inst

ance

,if

a p

refe

rred

bra

nd

is

recl

assi

fied

as

a ge

ner

ic,y

ou

r co

-pay

men

t w

ou

ld d

ecre

ase.

Als

o,i

f a

pre

ferr

ed b

ran

d i

sre

clas

sifi

ed a

s a

no

n-p

refe

rred

bra

nd

,yo

ur

co-p

aym

ent

wo

uld

in

crea

se.

•P

PO

an

d I

nd

emn

ity

Op

tio

ns

incl

ud

e a

dis

cou

nt

pro

gram

fo

r vi

sio

n s

cree

nin

gs a

nd

eye

wea

r.C

on

tact

th

e B

lueC

ho

ice

Vis

ion

Pro

gram

at

(800

) 37

7-64

36 o

r vi

sit

ww

w.b

cbsg

a.co

mfo

r m

ore

in

form

atio

n.V

isio

n p

rogr

am a

vaila

bili

ty i

s su

bje

ct t

o c

han

ge d

uri

ng

the

Pla

n y

ear.

•Se

e th

e SP

D a

nd

Upda

ters

for

cove

rage

det

ails

,in

clu

din

g lim

itat

ion

s an

d e

xcl

usi

on

s.

27

CO

VE

RE

D S

ER

VIC

ES

UN

ITE

DH

EA

LTH

CA

RE

Th

e P

lan

Pays

:

KA

ISE

R P

ER

MA

NE

NT

E

and

KA

ISE

R P

ER

MA

NE

NT

EM

ED

ICA

RE

+CH

OIC

E (

M+

C)

The

Pla

n P

ays

:

CIG

NA

Th

e P

lan

Pays

:B

LUE

CH

OIC

ETh

e P

lan

Pays

:

Max

imu

m L

ifet

ime

Ben

efit

Pre

-ex

isti

ng

Co

nd

itio

ns

(1st

yea

r in

Pla

n o

nly

,su

bje

ct t

o H

IPA

A)

Life

tim

e B

enef

it L

imit

fo

r T

reat

men

t o

f:

•Te

mp

oro

man

dib

ula

r jo

int

dysf

un

ctio

n (

TM

J)•

Sub

stan

ce a

bu

se•

Org

an a

nd

tis

sue

tran

spla

nts

•H

om

e h

yper

alim

enta

tio

n

Ded

uct

ible

s/C

o-p

aym

ents

:

•D

edu

ctib

le—

ind

ivid

ual

•D

edu

ctib

le—

fam

ily m

axim

um

$2 m

illio

n

(all

SHB

P l

imit

s co

mb

ined

)

No

ne

No

sep

arat

e lif

etim

eb

enef

it l

imit

No

t ap

plic

able

$2 m

illio

n(a

ll SH

BP

lim

its

com

bin

ed)

No

ne

No

sep

arat

e lif

etim

eb

enef

it l

imit

No

t ap

plic

able

No

lif

etim

e b

enef

it

max

imu

ms

No

ne

No

lif

etim

e b

enef

it

max

imu

ms

No

t ap

plic

able

$2 m

illio

n

(all

SHB

P l

imit

s co

mb

ined

)

No

ne

No

sep

arat

e lif

etim

eb

enef

it l

imit

No

t ap

plic

able

HM

O C

OV

ER

ED

SE

RV

ICE

S

28

Th

e fo

llow

ing

char

t su

mm

ariz

es t

he

ben

efit

s o

ffer

ed b

y th

e H

MO

s—B

lueC

ho

ice,

CIG

NA

,Kai

ser

Perm

anen

te,K

aise

r Pe

rman

ente

Med

icar

e+C

ho

ice

and

Un

ited

Hea

lth

care

.Mo

st c

ove

red

ser

vice

s ar

e th

e sa

me

for

each

HM

O.I

f yo

u a

re t

ryin

g to

ch

oo

se a

mo

ng

HM

Os,

you

sh

ou

ld:

•C

hec

k th

e se

rvic

e ar

ea c

ove

red

by

each

HM

O t

o s

ee i

f yo

u l

ive

in a

n a

pp

rove

d c

ou

nty

.

•C

hec

k w

hic

h p

hys

icia

ns,

spec

ialis

ts a

nd

ho

spit

als

are

off

ered

th

rou

gh t

he

HM

Os’

net

wo

rks.

Wo

uld

yo

u h

ave

to s

wit

ch p

hys

icia

ns

if y

ou

sel

ecte

d a

new

HM

O?

Are

ph

ysic

ian

s' o

ffic

es l

oca

ted

nea

r yo

u?

Ph

on

e n

um

ber

s an

d W

eb s

ites

fo

r th

e H

MO

s ar

e lis

ted

on

th

e in

sid

e fr

on

t co

ver.

•C

om

par

e co

vere

d s

ervi

ces

and

wh

at y

ou

r p

rem

ium

wo

uld

be

for

each

.

To h

elp

yo

u c

om

par

e al

l SH

BP

op

tio

ns,

this

HM

O c

har

t fo

llow

s th

e sa

me

form

at a

s th

e P

PO

an

d I

nd

emn

ity

Op

tio

n c

om

par

iso

n o

f b

enef

its.

Th

e K

aise

rPe

rman

ente

an

d K

aise

r Pe

rman

ente

Med

icar

e+C

ho

ice

ben

efit

s ar

e th

e sa

me,

exce

pt

wh

ere

no

ted

.

Co

mp

ar

iso

n o

f B

en

ef

its

: H

MO

Op

tio

ns

con

tin

ued

...•

Ho

spit

al c

o-p

aym

ent/

adm

issi

on

•Em

erge

ncy

ro

om

co

-pay

men

t•

Urg

ent

care

cen

ter

co-p

aym

ent

An

nu

al O

ut-

of-

Po

cket

Lim

its:

•In

div

idu

al (

you

or

on

e o

f yo

ur

dep

end

ents

) •

Fam

ily (

you

an

d y

ou

r d

epen

den

ts)

Pri

mar

y C

are

Ph

ysi

cian

or

Spec

iali

stO

ffic

e o

r C

lin

ic V

isit

s:

•Tr

eatm

ent

of

illn

ess

or

inju

ry

Pri

mar

y C

are

Ph

ysic

ian

or

Spec

iali

stO

ffic

e o

r C

lin

ic V

isit

s fo

r th

e fo

llo

win

g:•

Wel

lnes

s ca

re/p

reve

nti

ve h

ealt

h c

are

•W

ell-n

ewb

orn

ex

am•

Wel

l-ch

ild e

xam

s an

d i

mm

un

izat

ion

s•

An

nu

al p

hys

ical

s•

An

nu

al g

ynec

olo

gica

l ex

ams

$200

$50

(wai

ved

if a

dmit

ted)

$25

(ref

erra

l re

qu

ired

)

No

t ap

plic

able

100%

aft

er a

per

vis

itco

-pay

men

t o

f $1

5 fo

rp

rim

ary

care

an

d $

20fo

r sp

ecia

lty

care

100%

aft

er a

per

vis

itco

-pay

men

t o

f $1

5 fo

rp

rim

ary

care

an

d $

20fo

r sp

ecia

lty

care

$200

$50

(wai

ved

if a

dmit

ted)

$25

No

t ap

plic

able

100%

aft

er a

per

vis

itco

-pay

men

t o

f $1

5 fo

rp

rim

ary

care

an

d $

20fo

r sp

ecia

lty

care

100%

aft

er a

per

vis

itco

-pay

men

t o

f $1

5 fo

rp

rim

ary

care

an

d $

20fo

r sp

ecia

lty

care

.N

o c

o-p

aym

ent

for

imm

un

izat

ion

s an

dm

amm

ogr

ams.

$200

$50

(wai

ved

if a

dmit

ted)

$30

No

t ap

plic

able

Kai

ser

Perm

anen

te M

+C

:$1

,500

per

in

div

idu

al,

$4,5

00 p

er f

amily

,per

Pla

n Y

ear

100%

aft

er a

per

vis

it

co-p

aym

ent

of

$15

for

pri

mar

y ca

re a

nd

$20

fo

rsp

ecia

lty

care

100%

aft

er a

per

vis

it c

o-

pay

men

t o

f $1

5 fo

r p

ri-

mar

y ca

re a

nd

$20

fo

rsp

ecia

lty

care

.N

o c

o-p

aym

ent

for

imm

un

izat

ion

s an

d

mam

mo

gram

s.

$200

$50

(wai

ved

if a

dmit

ted)

$25

No

t ap

plic

able

100%

aft

er a

per

vis

itco

-pay

men

t o

f $1

5 fo

rp

rim

ary

care

an

d $

20fo

r sp

ecia

lty

care

100%

aft

er a

per

vis

itco

-pay

men

t o

f $1

5 fo

rp

rim

ary

care

an

d $

20fo

r sp

ecia

lty

care

.N

o c

o-p

aym

ent

for

imm

un

izat

ion

s an

d

mam

mo

gram

s.

29

CO

VE

RE

D S

ER

VIC

ES

UN

ITE

DH

EA

LTH

CA

RE

Th

e P

lan

Pays

:C

IGN

ATh

e P

lan

Pays

:B

LUE

CH

OIC

ETh

e P

lan

Pays

:

Pre

scri

pti

on

Dru

gs

•G

ener

ic•

Pref

erre

d b

ran

d n

ame

•N

on-p

refe

rred

bra

nd

nam

e

•G

ener

ic•

Pref

erre

d b

ran

d n

ame

•N

on-p

refe

rred

bra

nd

nam

e

•M

ain

ten

ance

med

icat

ion

s

Not

es:C

over

s on

ly p

resc

rip

tion

s fi

lled

at

par

tici

pat

ing

loca

l ph

arm

acy

or H

MO

m

edic

al c

ente

r.

Mat

ern

ity T

reat

men

t —

Ph

ysi

cian

Ser

vice

s (p

re-n

atal

an

d p

ost

-nat

al)

Lab

ora

tory

; X

-Ray

s; D

iagn

ost

ic T

ests

;In

ject

ion

s, i

ncl

ud

ing

Med

icat

ion

s C

ove

red

Un

der

Med

ical

Ben

efit

s—fo

rth

e T

reat

men

t o

f an

Ill

nes

s o

r In

jury

100%

aft

er y

ou

r p

er

pre

scri

pti

on

co

-pay

men

t

•$1

0•

$20

•$3

5

90-d

ay s

up

ply

co

vere

daf

ter

two

co

-pay

men

ts

100%

aft

er a

n i

nit

ial

co-p

aym

ent

of

$20

100%

100%

aft

er y

ou

r p

erp

resc

rip

tio

n

co-p

aym

ent

•$1

0•

$20

•$3

5

90-d

ay s

up

ply

co

vere

daf

ter

two

co

-pay

men

ts

100%

aft

er a

n i

nit

ial

co-p

aym

ent

of

$20

100%

100%

aft

er y

ou

r p

er

pre

scri

pti

on

co

-pay

men

t

At

Kai

ser

ph

arm

acy

At

Ecke

rd’s

•$1

0•

$16

•$2

0•

$26

•N

ot

•N

ot

app

licab

le

ap

plic

able

Kai

ser

Perm

anen

te M

+C

:•

$10

•$1

6•

$15

•$2

1•

No

t•

No

t ap

plic

able

a

pp

licab

le

100%

aft

er a

n i

nit

ial

co-p

aym

ent

of

$20

Kai

ser

Perm

anen

te M

+C

:10

0% c

ove

rage

100%

100%

aft

er y

ou

r p

erp

resc

rip

tio

n

co-p

aym

ent

•$1

0•

$20

•$3

5

90-d

ay s

up

ply

co

vere

daf

ter

two

co

-pay

men

ts

100%

aft

er a

n i

nit

ial

co-p

aym

ent

of

$20

100%

HM

O C

OV

ER

ED

SE

RV

ICE

S

30

KA

ISE

R P

ER

MA

NE

NT

E

and

KA

ISE

R P

ER

MA

NE

NT

EM

ED

ICA

RE

+CH

OIC

E (

M+

C)

The

Pla

n P

ays

:

Up

to

90-d

ay s

up

ply

;co

-pay

men

t is

per

30

-day

su

pp

ly;a

pp

lies

to K

aise

r an

d K

aise

r M

+C

.

All

ergy

Sh

ots

an

d S

eru

m

All

ergy

Tes

tin

g

Ph

ysi

cian

Ser

vice

s Fu

rnis

hed

in

a H

osp

ital

•Su

rger

y in

gen

eral

,in

clu

din

g ch

arge

sb

y su

rgeo

n,a

nes

thes

iolo

gist

,pat

ho

lo-

gist

an

d r

adio

logi

st

•In

pat

ien

t w

ell-n

ewb

orn

ex

ams

Ph

ysi

cian

Ser

vice

s T

hat

Are

fo

rE

mer

gen

cy C

are

Ou

tpat

ien

t Su

rger

y—

Ph

ysi

cian

’s O

ffic

e

Ou

tpat

ien

t Su

rger

y—

Ho

spit

al/F

acil

ity

Ho

spit

al S

ervi

ces

Oth

er T

han

Th

ose

Th

at A

re f

or

Em

erge

ncy

Car

e

•In

pat

ien

t ca

re,i

ncl

ud

ing

inp

atie

nt

sho

rt-t

erm

acu

te r

ehab

ilita

tio

n s

ervi

ces

100%

fo

r sh

ots

an

dse

rum

aft

er a

co

-pay

men

t o

f $2

0 p

er v

isit

100%

aft

er p

er v

isit

co-p

aym

ent

of

$20

100%

100%

100%

aft

er a

pp

licab

le

co-p

aym

ent

100%

aft

er $

20

co-p

aym

ent

if b

illed

as

offi

ce v

isit

;100

% a

fter

$100

co-

pay

men

t if

bill

edas

ou

tpat

ien

t su

rger

y

100%

aft

er $

100

per

co

nfi

nem

ent

co-p

aym

ent

100%

aft

er $

200

per

co

nfi

nem

ent

co-p

aym

ent

100%

fo

r sh

ots

an

dse

rum

aft

er a

co

-pay

men

t o

f $2

0 p

er v

isit

100%

aft

er p

er v

isit

co-p

aym

ent

of

$20

100%

100%

100%

aft

er a

pp

licab

le

co-p

aym

ent

100%

aft

er $

20

co-p

aym

ent

if b

illed

as

offi

ce v

isit

;100

% a

fter

$100

co-

pay

men

t if

bill

edas

out

pat

ien

t su

rger

y

100%

aft

er $

100

per

co

nfi

nem

ent

co-p

aym

ent

100%

aft

er $

200

per

co

nfi

nem

ent

co-p

aym

ent

$5 f

or

sho

ts a

nd

$50

fo

r si

x-m

on

th s

up

ply

o

f se

rum

Kai

ser

Perm

anen

te M

+C

:$5

fo

r sh

ots

,no

ch

arge

for

seru

m

100%

aft

er p

er v

isit

co-p

aym

ent

of

$20

100%

100%

100%

aft

er a

pp

licab

le

co-p

aym

ent

100%

aft

er $

20

co-p

aym

ent

if b

illed

as

offi

ce v

isit

;100

% a

fter

$100

co-

pay

men

t if

bill

edas

ou

tpat

ien

t su

rger

y

100%

aft

er $

100

per

co

nfi

nem

ent

co-p

aym

ent

100%

aft

er $

200

per

co

nfi

nem

ent

co-p

aym

ent

100%

fo

r sh

ots

an

dse

rum

aft

er a

co

-pay

men

t o

f $2

0 p

er v

isit

100%

aft

er p

er v

isit

co-p

aym

ent

of

$20

100%

100%

100%

aft

er a

pp

licab

leco

-pay

men

t

100%

aft

er $

20

co-p

aym

ent

if b

illed

as

offi

ce v

isit

;100

% a

fter

$100

co-

pay

men

t if

bill

edas

ou

tpat

ien

t su

rger

y

100%

aft

er $

100

per

co

nfi

nem

ent

co-p

aym

ent

100%

aft

er $

200

per

con

fin

emen

t co

-pay

men

t

31

CO

VE

RE

D S

ER

VIC

ES

UN

ITE

DH

EA

LTH

CA

RE

Th

e P

lan

Pays

:C

IGN

ATh

e P

lan

Pays

:B

LUE

CH

OIC

ETh

e P

lan

Pays

:

Ho

spit

al S

ervi

ces

Oth

er T

han

Th

ose

Th

at A

re f

or

Em

erge

ncy

Car

e (c

on

tin

ued

)•

Ou

tpat

ien

t se

rvic

es —

N

on

-em

erge

ncy

use

of

emer

gen

cyro

om

•W

ell-n

ewb

orn

car

e

Ho

spit

al S

ervi

ces

Th

at A

re f

or

Em

erge

ncy

Car

e •

Trea

tmen

t o

f an

em

erge

ncy

med

ical

con

dit

ion

or

inju

ry

Am

bu

lan

ce S

ervi

ces

for

Em

erge

ncy

Car

e

Urg

ent

Car

e Se

rvic

es i

n a

n A

pp

rove

dU

rgen

t C

are

Cen

ter

Ho

me

Nu

rsin

g C

are

Skil

led

Nu

rsin

g Fac

ilit

y S

ervi

ces

Ho

spic

e C

are

Req

uir

es p

rio

r au

tho

riza

tio

n f

rom

PC

P,o

ther

wis

e n

ot

cove

red

100%

100%

aft

er a

per

vis

it

co-p

aym

ent

of

$50

(co

-pay

men

t w

aive

d i

f ad

mit

ted

)

100%

100%

aft

er a

$25

co-

pay

men

t,re

ferr

al r

equi

red

100%

;up

to

120

day

sp

er P

lan

yea

r

100%

;pri

or

app

rova

l is

req

uir

ed;4

5-d

ay m

axi-

mu

m p

er P

lan

yea

r

100%

;pri

or

app

rova

l is

req

uir

ed

Req

uir

es p

rio

r au

tho

riza

tio

n f

rom

PC

P,o

ther

wis

e n

ot

cove

red

100%

100%

aft

er a

per

vis

itco

-pay

men

t o

f $5

0 (c

o-p

aym

ent

wai

ved

if

adm

itte

d)

100%

100%

aft

er a

$25

co

-pay

men

t

100%

;up

to

120

day

sp

er P

lan

yea

r

100%

;pri

or

app

rova

l is

req

uir

ed;4

5-d

ay m

ax-

imu

m p

er P

lan

yea

r

100%

;pri

or

app

rova

l is

req

uir

ed

Req

uir

es p

rio

r au

tho

riza

tio

n f

rom

PC

P,o

ther

wis

e n

ot

cove

red

100%

100%

aft

er a

per

vis

itco

-pay

men

t o

f $5

0 (c

o-p

aym

ent

wai

ved

if

adm

itte

d)

100%

aft

er a

$50

co

-p

aym

ent

per

tri

p w

hen

med

ical

ly n

eces

sary

100%

aft

er a

$30

co-p

aym

ent

100%

;up

to

120

day

sp

er P

lan

yea

r

Kai

ser

Perm

anen

te M

+C

:10

0%;n

o d

ay l

imit

100%

;pri

or

app

rova

l is

req

uir

ed;u

p t

o 4

5-d

aym

axim

um

per

Pla

n y

ear

100%

;pri

or

app

rova

l is

req

uir

ed

Req

uire

s p

rior

au

thor

izat

ion

from

HM

O,

oth

erw

ise

no

t co

vere

d

100%

100%

aft

er a

per

vis

it

co-p

aym

ent

of

$50

(co

-pay

men

t w

aive

d i

fad

mit

ted

)

100%

100%

aft

er a

$25

co

-pay

men

t

100%

;up

to

120

day

s p

erP

lan

yea

r

100%

;pri

or

app

rova

l is

req

uir

ed;1

20-d

ay

max

imu

m p

er P

lan

yea

r

100%

;pri

or

app

rova

l is

req

uir

ed

HM

O C

OV

ER

ED

SE

RV

ICE

S

32

KA

ISE

R P

ER

MA

NE

NT

E

and

KA

ISE

R P

ER

MA

NE

NT

EM

ED

ICA

RE

+CH

OIC

E (

M+

C)

The

Pla

n P

ays

:

Du

rab

le M

edic

al E

qu

ipm

ent

(DM

E)—

Ren

tal

or

Pu

rch

ase

Ou

tpat

ien

t A

cute

Sh

ort

-ter

mR

ehab

ilit

atio

n S

ervi

ces

Den

tal

and

Ora

l C

are—

Lim

ited

Co

vera

ge

•C

ove

rage

in

gen

eral

•C

over

age

of

spec

ific

oss

eou

s su

rger

ies

for

the

trea

tmen

t o

f p

erio

do

nta

l d

isea

se

•Te

mp

oro

man

dib

ula

r jo

int

syn

dro

me

(TM

J)

Ch

iro

pra

ctic

Car

e

100%

wh

en m

edic

ally

nec

essa

ry

100%

aft

er a

$20

co

-pay

men

t p

er v

isit

;u

p t

o 4

0 vi

sits

per

P

lan

yea

r

100%

aft

er a

pp

licab

leco

-pay

men

t fo

r o

ral

surg

ery

and

den

tal

serv

ices

ass

oci

ated

wit

han

acc

iden

tal

inju

ry t

oso

un

d t

eeth

No

t co

vere

d

100%

aft

er a

pp

licab

leco

-pay

men

t,su

bje

ct t

olim

itat

ion

s

100%

aft

er $

20

co-p

aym

ent

per

vis

it;

limit

edto

20

visi

ts p

erP

lan

yea

r

100%

wh

en m

edic

ally

nec

essa

ry

100%

aft

er a

$20

co

-pay

men

t p

er v

isit

;u

p t

o 4

0 vi

sits

per

P

lan

yea

r

100%

aft

er a

pp

licab

leco

-pay

men

t fo

r o

ral

surg

ery

and

den

tal

serv

ices

ass

oci

ated

wit

h a

n a

ccid

enta

lin

jury

to

so

un

d t

eeth

No

t co

vere

d

100%

aft

er a

pp

licab

leco

-pay

men

t,su

bje

ct t

olim

itat

ion

s

100%

aft

er $

20

co-p

aym

ent

per

vis

it;

limit

edto

20

visi

ts p

erP

lan

yea

r

100%

wh

en m

edic

ally

nec

essa

ry

100%

aft

er a

$20

co

-pay

men

t p

er v

isit

;u

p t

o 4

0 vi

sits

per

P

lan

yea

r o

r u

p t

o t

wo

con

secu

tive

mo

nth

s p

erco

nd

itio

n,w

hic

hev

eris

mo

re

Kai

ser

Perm

anen

te M

+C

:P

hys

ical

,occ

up

atio

nal

and

sp

eech

th

erap

y:10

0% c

ove

rage

aft

er $

20co

-pay

men

t;u

nlim

ited

visi

ts p

er P

lan

yea

r

Serv

ices

an

d a

pp

lian

ces

for

acci

den

tal

inju

ry t

oso

un

d a

nd

nat

ura

l te

eth

:50

% c

ove

rage

fo

r fi

rst

$1,0

00,t

hen

100

%

ther

eaft

er

No

t co

vere

d

50%

fo

r n

on

-su

rgic

altr

eatm

ent

100%

aft

er $

20

co-p

aym

ent

per

vis

it;

limit

edto

20

visi

ts p

erP

lan

yea

r

100%

wh

en m

edic

ally

nec

essa

ry

100%

aft

er a

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co

-pay

men

t p

er v

isit

;u

p t

o 4

0 vi

sits

per

P

lan

yea

r

100%

aft

er a

pp

licab

leco

-pay

men

t fo

r o

ral

surg

ery

and

den

tal

serv

ices

ass

oci

ated

wit

han

acc

iden

tal

inju

ry t

oso

un

d t

eeth

No

t co

vere

d

100%

aft

er a

pp

licab

leco

-pay

men

t,su

bje

ct t

olim

itat

ion

s

100%

aft

er $

20

co-p

aym

ent

per

vis

it;

limit

edto

20

visi

ts p

erP

lan

yea

r

33

CO

VE

RE

D S

ER

VIC

ES

UN

ITE

DH

EA

LTH

CA

RE

Th

e P

lan

Pays

:C

IGN

ATh

e P

lan

Pays

:B

LUE

CH

OIC

ETh

e P

lan

Pays

:

Beh

avio

ral

Hea

lth

Car

e(M

enta

l hea

lth a

nd s

ubst

ance

ab

use

car

e)

Tra

nsp

lan

t Se

rvic

es

For

inp

atie

nt

care

:10

0% a

fter

$50

co

-pay

men

t p

er

con

fin

emen

t;lim

ited

to

30 d

ays

per

Pla

n y

ear.

For

ou

tpat

ien

t ca

re:

100%

aft

er $

20

co-p

aym

ent

per

vis

it;

limit

ed t

o 2

5 vi

sits

per

Pla

n y

ear.

100%

For

inp

atie

nt

care

:10

0% a

fter

$50

co

-pay

men

t p

er

con

fin

emen

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36


Service Areas for Your Health Plan Options

Service AreasService areas are State-approved geographic areas,such as counties or zip codes, where providersparticipate in the network offered by the Planoption in which you have enrolled.

PPO and PPO Choice OptionGeorgia Service Area

The Georgia service area includes the state ofGeorgia and the border communities of theChattanooga,Tennessee area, including BradleyCounty; and Phenix City, Alabama. The zip codearea in which you receive a service is used todetermine whether or not you are in the Georgiaservice area. If you receive covered services froma 1st Medical Network provider located in one ofthe zip codes below, you receive the highest levelof coverage available in the PPO options.

Out-of-State/National Service Area

The out-of-state service area includes all nationallocations outside of the Georgia service areadescribed to the left. By using Beech Streetproviders outside of the Georgia service area, youare protected against being charged more thanwhat the Plan allows. However, use of BeechStreet providers inside the Georgia service area is considered out-of-network care with lower levels of benefit coverage and a separatedeductible and out-of-pocket maximum, unless the provider also is a 1st Medical Network participant.

Georgia:

All counties; all zip codes

Alabama:

Russell County (Phenix City area): 36851,36856, 36858, 36859, 36860, 36867, 36868,36869, 36870, 36871 and 36875.

Tennessee:

Bradley County (Cleveland area): 37310, 37311,37312, 37320, 37323, 37353 and 37364.

Hamilton County (Chattanooga area): 37302,37304, 37308, 37315, 37341, 37343, 37350,37351, 37363, 37373, 37377, 37379, 37384,37401, 37402, 37403, 37404, 37405, 37406,37407, 37408, 37409, 37410, 37411, 37412,37414, 37415, 37416, 37419, 37421, 37422,37424 and 37450.

37


HMO OptionsYou must live in the HMO’s approved service area to be eligible for coverage under that option. Below arethe regular HMO Option service areas by county. If you live or work in a county marked “Yes”under any ofthe HMOs listed, you may enroll in that HMO. If the county where you live is not listed below, you are noteligible for regular HMO coverage. Service area changes for the 2003-2004 Plan year are in bold type.

County of KaiserResidence BlueChoice CIGNA Permanente UnitedHealthcare

Appling Not Available Yes Not Available Not Available

Bacon Not Available Yes Not Available Yes

Baldwin Not Available Not Available Not Available Not Available

Banks Yes Not Available Not Available Yes

Barrow Yes Yes Yes Yes

Bartow Yes Yes Yes Yes

Ben Hill Not Available Not Available Not Available Yes

Berrien Not Available Not Available Not Available Yes

Bibb Yes Yes Not Available Yes

Bleckley Yes Yes Not Available Yes

Brooks Not Available Not Available Not Available Yes

Bryan Yes Yes Not Available Yes

Bulloch Yes Yes Not Available Yes

Burke Yes Yes Not Available Yes

Butts Yes Yes Yes Yes

Candler Not Available Yes Not Available Yes

Carroll Yes Not Available Not Available Yes

Catoosa Not Available Yes Not Available Yes

Chatham Yes Yes Not Available Yes

Chattahoochee Yes Not Available Not Available Yes

Chattooga Yes Yes Not Available Yes

Cherokee Yes Yes Yes Yes

Clarke Yes Yes Not Available Yes

Clayton Yes Yes Yes Yes

Cobb Yes Yes Yes Yes

Colquitt Not Available Not Available Not Available Yes

Columbia Yes Yes Not Available Yes

Coweta Yes Yes Yes Yes

Crawford Yes Not Available Not Available Yes

Dade Not Available Yes Not Available Yes

Dawson Yes Not Available Not Available Yes

Decatur Not Available Not Available Not Available Not Available

38



DeKalb Yes Yes Yes Yes

Dodge Not Available Not Available Not Available Not Available

Douglas Yes Yes Yes Yes

Early Not Available Not Available Not Available Yes

Effingham Yes Yes Not Available Yes

Elbert Yes Yes Not Available Not Available

Emanuel Yes Yes Not Available Yes

Evans Not Available Yes Not Available Yes

Fannin Not Available Not Available Not Available Not Available

Fayette Yes Yes Yes Yes

Floyd Yes Yes Not Available Yes

Forsyth Yes Yes Yes Yes

Franklin Yes Yes Not Available Not Available

Fulton Yes Yes Yes Yes

Gilmer Yes Not Available Not Available Not Available

Glascock Yes Not Available Not Available Yes

Gordon Yes Yes Not Available Yes

Grady Not Available Not Available Not Available Yes

Greene Yes Yes Not Available Yes

Gwinnett Yes Yes Yes Yes

Habersham Not Available Not Available Not Available Yes

Hall Yes Yes Yes Yes

Harris Yes Yes Not Available Yes

Hart Yes Not Available Not Available Not Available

Heard Yes Not Available Not Available Not Available

Henry Yes Yes Yes Yes

Houston Yes Not Available Not Available Yes

Jackson Yes Yes Not Available Yes

Jasper Not Available Not Available Not Available Yes

Jefferson Yes Yes Not Available Yes

Jenkins Yes Not Available Not Available Yes

Johnson Yes Not Available Not Available Yes

Jones Yes Yes Not Available Yes

Lamar Not Available Yes Not Available Yes

Lanier Not Available Not Available Not Available Yes

Laurens Not Available Yes Not Available Not Available

Liberty Yes Yes Not Available Yes

39



Lincoln Yes Yes Not Available Yes

Long Not Available Yes Not Available Yes

Lowndes Not Available Not Available Not Available Yes

Lumpkin Yes Not Available Not Available Yes

Madison Yes Yes Not Available Yes

Marion Yes Yes Not Available Not Available

McDuffie Yes Yes Not Available Yes

Meriwether Yes Not Available Not Available Yes

Mitchell Not Available Not Available Not Available Yes

Monroe Yes Yes Not Available Yes

Morgan Yes Not Available Not Available Yes

Muscogee Yes Yes Not Available Yes

Newton Yes Yes Yes Yes

Oconee Yes Yes Not Available Not Available

Oglethorpe Yes Yes Not Available Yes

Paulding Yes Yes Yes Yes

Peach Yes Not Available Not Available Yes

Pickens Yes Not Available Not Available Yes

Pike Not Available Yes Not Available Yes

Polk Yes Yes Not Available Yes

Pulaski Yes Not Available Not Available Yes

Putnam Not Available Not Available Not Available Yes

Richmond Yes Yes Not Available Yes

Rockdale Yes Yes Yes Yes

Screven Not Available Yes Not Available Yes

Seminole Not Available Not Available Not Available Yes

Spalding Yes Yes Yes Yes

Stewart Yes Not Available Not Available Yes

Sumter Not Available Not Available Not Available Not Available

Talbot Yes Not Available Not Available Yes

Taliaferro Not Available Not Available Not Available Yes

Tattnall Not Available Yes Not Available Yes

Taylor Not Available Yes Not Available Yes

Thomas Not Available Not Available Not Available Yes

Tift Not Available Not Available Not Available Yes

Toombs Not Available Not Available Not Available Yes

Twiggs Yes Not Available Not Available Yes

40



Upson Not Available Not Available Not Available Yes

Walker Not Available Yes Not Available Yes

Walton Yes Yes Yes Yes

Ware Not Available Not Available Not Available Yes

Warren Yes Not Available Not Available Yes

Washington Yes Not Available Not Available Not Available

Wayne Not Available Not Available Not Available Yes

White Yes Not Available Not Available Yes

Whitfield Not Available Yes Not Available Not Available

Wilkes Yes Yes Not Available Yes

Wilkinson Yes Yes Not Available Yes

Worth Not Available Not Available Not Available Yes

County of Residence

Cherokee Yes

Clayton Yes

Cobb Yes

Coweta Yes

DeKalb Yes

Douglas Yes

Fayette Yes

Forsyth Yes

Fulton Yes

Gwinnett Yes

Henry Yes

Paulding Yes, only if you live in zip code 30127,30134 or 30141

Kaiser Permanente M+C HMO

Medicare+Choice HMO Option

41


Health Insurance Portability and Accountability Act (HIPAA)Annual Notice

This section describes certain rights available toyou under the Health Insurance Portability andAccountability Act (HIPAA) when you add adependent to your SHBP coverage.

The PPO and Indemnity Options contain a pre-existing condition (PEC) limitation. Specifically,the Health Plan will not pay charges that are over$1,000 for the treatment of any pre-existing condition during the first 12 months of a patient’scoverage, unless the patient gives satisfactory documentation that he or she has been free oftreatment or medication for that condition for atleast six consecutive calendar months. However, apre-existing condition limitation does not apply tocoverage for:

• Pregnancy; or

• Newborns or children under age 18 who areadopted or placed for adoption, if the childbecomes covered within 31 days after birth,adoption or placement for adoption.

In certain situations, SHBP dependents can reducethe 12-month pre-existing condition limitationperiod. The reduction is possible by using what iscalled “creditable coverage” to offset a pre-existingcondition period. Creditable coverage generallyincludes the health coverage a family member hadimmediately prior to joining the SHBP. Coverageunder most group health plans, as well as coverageunder individual health policies and governmentalhealth programs, qualifies as creditable coverage.

To reduce the pre-existing condition limitationperiod for your dependents (including yourspouse), you must provide the SHBP with a certificate of creditable coverage stating whencoverage started and ended for each dependentthat you want to cover. Any period of prior cover-age for that dependent will reduce the 12-monthlimitation period if no more than 63 days haveelapsed between the dependent’s loss of priorcoverage and the first day of coverage under the SHBP.

If your dependent (including a spouse) hadany break in coverage lasting more than 63 days,your dependent will receive creditable coverageonly for the period of time after the break ended.

Within two years after your dependent’s formercoverage terminated, he/she has the right toobtain a certificate of creditable coverage fromhis/her former employer(s) to offset the pre-exist-ing condition limitation period under the SHBP.The SHBP will evaluate the certificate of cred-itable coverage or other documentation to deter-mine whether any of the pre-existing conditionlimitation period will be reduced or eliminated.After completing the evaluation, the SHBP willnotify you as to how the pre-existing conditionlimitation period will be reduced or eliminated.

Please submit the certificate of creditable cover-age to the Plan with your dependent’s enrollmentpaperwork.

42


Department of CommunityHealth Privacy Notice

This notice describes how medical informationabout you may be used and disclosed and howyou can get access to this information. Pleasereview it carefully.

The Plan’s Privacy Commitment to YouThe Georgia Department of Community Health(DCH) understands that information about youand your family is personal. DCH is committed toprotecting your information.This notice tells youhow DCH uses and discloses information aboutyou. It tells you your rights and the Plan’s require-ments about your information.

Understanding the Type of InformationThat the Plan HasYour employer (state agency, school system,authority, etc.) sent information about you toDCH.This information included your name,address, birth date, phone number, Social SecurityNumber and other health insurance policies thatyou may have. It may also have included healthinformation.When your health care providers sendclaims to the Plan’s claim administrator for pay-ment, the claims include your diagnoses and themedical treatments you received. For some med-ical treatments, your health care providers sendadditional medical information to the Plan such asdoctor’s statements, x-rays or lab test results.

Your Health Information RightsYou have the following rights regarding the healthinformation that DCH has about you.

• You have the right to see and obtain a copy ofyour health information.An exception is psy-chotherapy notes.Another exception is infor-mation that is needed for a legal action relatingto DCH.

• You have the right to ask DCH to changehealth information that is incorrect or incom-plete. DCH may deny your request under certain circumstances.

• You have the right to request a list of the dis-closures that DCH has made of your healthinformation beginning in April 2003.

• You have the right to request a restriction oncertain uses or disclosures of your health infor-mation. DCH is not required to agree with yourrequest.

• You have the right to request that DCH com-municates with you about your health in a wayor at a location that will help you keep yourinformation confidential.

• You have the right to receive a paper copy ofthis notice.You may ask DCH staff to give youanother copy of this notice, or you may obtaina copy from DCH’s Web site,www.dch.state.ga.us (click on "Privacy").

Privacy Law’s RequirementsDCH is required by law to:

• Maintain the privacy of your information.

• Give you this notice of DCH’s legal duties andprivacy practices regarding the informationthat DCH has about you.

• Follow the terms of this notice.

• Not use or disclose any information about youwithout your written permission, except forthe reasons given in this notice.You may takeaway your permission at any time, in writing,except for the information that DCH disclosedbefore you stopped your permission. If you can-not give your permission due to an emergency,DCH may release the information if it is in yourbest interest. DCH must notify you as soon aspossible after releasing the information.

In the future, DCH may change its privacy prac-tices. If its privacy practices change significantly,DCH will provide a new notice to you. DCH willpost the new notice on its Web site atwww.dch.state.ga.us (click on "Privacy").Thisnotice is effective April 14, 2003.

43


How DCH Uses and Discloses HealthCare InformationThere are some services the Plan providesthrough contracts with private companies. Forexample, Blue Cross and Blue Shield of Georgiapays most medical claims to your health careproviders.When services are contracted, the Planmay disclose some or all of your information tothe company so that they can perform the job thePlan has asked them to do.To protect your infor-mation, the Plan requires the company to safe-guard your information in accordance with thelaw.

The following categories describe different waysthat the Plan uses and discloses your health infor-mation. For each category, we will explain whatwe mean and give an example.

For Payment: The Plan may use and disclose infor-mation about you so that it can authorize paymentfor the health services that you received. Forexample, when you receive a service covered bythe Plan, your health care provider sends a claimfor payment to the claims administrator.The claimincludes information that identifies you, as well asyour diagnoses and treatments.

For Medical Treatment: The Plan may use or dis-close information about you to ensure that youreceive necessary medical treatment and services.For example, if you participate in a Disease StateManagement Program, the Plan may send youinformation about your condition.

To Operate Various Plan Programs: The Planmay use or disclose information about you to runvarious Plan programs and ensure that you receivequality care. For example, the Plan may contractwith a company that reviews hospital records tocheck on the quality of care that you received andthe outcome of your care.

To Other Government Agencies ProvidingBenefits or Services: The Plan may give informa-tion about you to other government agencies thatare giving you benefits or services.The informa-tion must be necessary for you to receive thosebenefits or services and will be authorized by youor by law.

To Keep You Informed: The Plan may mail youinformation about your health and well-being.Examples are information about managing a disease that you have, information about yourmanaged care choices, and information about prescription drugs you are taking.

For Overseeing Health Care Providers: The Planmay disclose information about you to the govern-ment agencies that license and inspect medicalfacilities, such as hospitals, as required by law.

For Research: The Plan may disclose informationabout you for a research project that has beenapproved by a review board.The review boardmust review the research project and its rules toensure the privacy of your information.Theresearch must be for the purpose of helping thePlan.

As Required by Law: The Plan will disclose infor-mation about you as required by law.

For More Information and to Report aProblemIf you have questions and would like additionalinformation, you may contact the SHBP at 404-656-6322 (Atlanta calling area) or 800-610-1863(outside of Atlanta calling area).

If you believe your privacy rights have been violated:

• You can file a complaint with the Plan by calling the SHBP at 404-656-6322 (Atlanta calling area) or 800-610-1863 (outside ofAtlanta calling area), or by writing to:SHBP – HPU, P.O. Box 38342,Atlanta, GA 30334.

• You can file a complaint with the Health andHuman Services’ Office for Civil Rights by writ-ing to: U.S. Department of Health and HumanServices Office for Civil Rights, Region IV,Atlanta Federal Center, 61 Forsyth Street SW,Suite 3B70,Atlanta, GA 30303-8909. Phone(404) 562-7886; Fax (404) 562-7881;TDD (404)331-2867

• You also may contact the HHS’ Office for CivilRights by calling 866-OCR-PRIV (866-627-7748)or 886-788-4989 TTY.

There will be no retaliation for filing a complaint.

44


Women’s Health and CancerRights Act

The Plan complies with the Women’s Health andCancer Rights Act of 1998. Mastectomy, includingreconstructive surgery, is covered the same asother surgery under your Plan option.

Following cancer surgery, the SHBP covers:

• All stages of reconstruction of the breast onwhich the mastectomy has been performed;

• Reconstruction of the other breast to achieve asymmetrical appearance;

• Prostheses and mastectomy bras; and

• Treatment of physical complications of mastectomy, including lymphedema.

Note: Reconstructive surgery requires priorapproval and all inpatient admissions require MCPprecertification.

For more detailed information on the mastectomy-related benefits available under the Plan, you can contact the Member Services unit for yourcoverage option.Telephone numbers are on theinside front cover.

Penalties for Misrepresentation

If any SHBP participant misrepresents the factswhen applying for dependent coverage, change of coverage, or benefits, the SHBP may terminatethe person’s participation (and that of his or her dependents) and seek legal recovery of anymoney paid out by the SHBP as a result of the misrepresentation.

45


Disclaimer

This material is for informational purposes only and is

neither an offer of coverage nor medical advice. It contains

only a partial, general description of Plan or program

benefits and does not constitute a contract or any part of

one. For a complete description of the benefits available

to you, including procedures, exclusions and limitations,

refer to your specific Plan documents, which may

include the State Health Benefit Plan Summary Plan

Description, Summary of Material Modification

(Updater), Schedule of Benefits, Certificate of Coverage,

Group Agreement, Group Insurance Certificate, Group

Insurance Policy and any applicable riders to your Plan.

All the terms and conditions of your Plan or program

are subject to and governed by applicable contracts, laws,

regulations and policies. Certain services, including but

not limited to non-emergency inpatient hospital care,

require precertification. All benefits are subject to

coordination of benefits unless noted otherwise. In case

of a conflict between your Plan documents and this

information, the Plan documents will govern.

Medicare is a program of the federal government.The

information in this Guide is intended only to be a

helpful summary of Medicare and not a complete

explanation of the program. For more detailed informa-

tion, contact your local Medicare office. In the event of

a conflict between this summary and the Medicare

program, Medicare's provisions govern.

Copyright: The Georgia Department of Community

Health, April 2003

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