retiree state health benefit plan updater · this updater describes material changes to the state...

S TAT E H E A LT H B E N E F I T P L A N

UPDATERGEORGIA DEPARTMENT OF COMMUNITY HEALTH Spring, 2000

UPDATER 1

This UPDATER describes material changes to the State Health BenefitPlan (SHBP) for Retirees. Plan members are encouraged to read theentire document to be informed about all Plan options. Plan changesindicated herein are effective July 1, 2000. This UPDATER is forretired employees covered under the SHBP. If you are an active mem-ber, please refer to the Spring 2000 UPDATER for active members.

As you review the changes, it may be helpful to refer to the Glossaryon page 25 for a description of terms.

If you have questions or need help, call the Retiree Help Line at (800)230-2291. The Retiree Help Line is available specifically to answerquestions during the Retiree Option Change Period, April 17through May 16, 2000. Representatives are available Monday—Friday, 8 a.m. to 6 p.m., beginning April 3, 2000.

RISING MEDICAL COSTS LEAD TO SHBP PLAN CHANGES In the face of rising medical costs, the Georgia Department ofCommunity Health made significant changes to keep the SHBPfinancially sound. Overall medical costs are increasing 12.5 to 17 percent a year and premiums for SHBP members have not kept pace.The increase in medical costs without a corresponding increase inpremiums has led to a serious budget shortfall.

Double-digit medical cost increases have affected benefit plansacross the country, so it’s not surprising that most employers turnedto managed care several years ago to contain costs. In fact, very fewemployers continue to offer indemnity plans and only 13 percent ofemployees nationwide are enrolled in indemnity plans like theStandard and High Options. On the other hand, almost 75 percent ofSHBP members are enrolled in one of these two options. To remainfinancially sound, combat increasing costs, and provide SHBPmembers access to quality care with an increased emphasis onpreventive care, the SHBP had to make changes and expand planoptions.

This UPDATERconstitutes officialnotification to StateHealth Benefit Plan(SHBP) members ofPlan changes and, assuch, supersedes anypreviously publishedinformation that conflicts with thematerial included inthis UPDATER. Itwill be used—in conjunction with theSHBP Booklet datedNovember 1, 1995,the HMO MemberHandbook datedMarch 1998, plusany UPDATER published afterNovember 1, 1995—to administer thePlan until new book-lets are published. Ifyou are disabled andneed this informationin an alternative format, write theState Health BenefitPlan at P.O. Box38342, Atlanta, GA30334 or for TDDRelay Service only,call (800) 255-0056(text telephone) or(800) 255-0135 (voice).

SIGNIFICANT PLAN CHANGES EFFECTIVE JULY 1, 2000

RETIREE

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As these changes were made, your voiceshave been influential in helping the Plan toidentify critical needs and concerns aboutyour retiree medical insurance coverage.

In focus groups conducted among retireesthroughout Georgia, we heard you say youwanted things like continuing high quality,fair premiums, less paperwork, faster claimsprocessing, enhanced vision coverage, betterprescription drug benefits, and a chance tochange your coverage options.

The information you provided has helped theSHBP to develop a better benefit plan forretirees. We are excited about the changes andnew coverage options available to you.

AN OVERVIEW OF MAJOR CHANGES• You can change your coverage during the

first annual Retiree Option ChangePeriod (ROCP). In the past, the SHBP didnot allow you to change health coverageoptions after retirement, unless you hadspecial qualifying events. Now, for the firsttime, SHBP retirees have the opportunityto change their health coverage during theRetiree Option Change Period. The ROCPwill occur annually in conjunction with the Open Enrollment Period for activemembers—mid-April to mid-May.

• For the first time, Medicare-enrolledretirees can enroll in Medicare+Choice(M+C) HMOs. Each of the three HMOshas a Medicare+Choice Option. If you areentitled to Medicare Part A and enrolled inMedicare Part B and live in certain coun-ties, you should carefully consider theMedicare+Choice Options. These optionsoffer additional benefits and lower premi-ums than the regular HMOs. The M+COptions include prescription drug benefitsthat offer the same prescription drug cover-age as for active employees. M+C optionsalso have additional enhancements like anallowance for hearing aids/exams, and

vision care. (See page 6 and the accompa-nying Health Plan Guide for Retirees for moredetails on your new Medicare+ChoiceOptions.)

• A Preferred Provider Organization (PPO)Option replaces the Standard Option. APPO is a network of doctors, hospitals, andother providers that have agreed to offerquality medical care and services at dis-counted rates. Members of the PPO canchoose to use this network for a higherlevel of coverage, or they can see anylicensed provider they wish for a lowerlevel of coverage. See pages 10-14 for moreinformation on the new PPO Option andhow it compares to the Standard Option itreplaces.

• Premiums for the High Option haveincreased. Review the enclosed RateWorksheet for your new monthly pre-mium. There have also been a few HighOption benefit changes. Refer to page 21for a review of the benefit changes.

• As a result of a new state law, both thePPO and the HMOs will offer ConsumerChoice Options. These options allow mem-bers to nominate non-network providers toprovide care on an in-network basis. Seepage 9 for more information on theConsumer Choice Options.

THE FIRST RETIREE OPTION CHANGEPERIOD—APRIL 17 THROUGH MAY 16, 2000During this first annual Retiree OptionChange Period, you have the opportunity toselect from several different coverage optionsas long as they are available in your county ofresidence. You can change from any coverageoption to any other option for which you arecurrently eligible. This change period allowsall retirees to change their health coverageoption—including surviving spouses of members, and direct pay members who arecurrently covered. However, you cannotenroll for coverage or change from single tofamily coverage.

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The decision you make (for yourself and yourfamily) during this period will become effec-tive on July 1, 2000 and remain in effectthrough June 30, 2001 (except as provided forM+C selections as referenced on page 5).

For More Information About the ChangesIf you have questions or need help at anypoint during the change period, call theRetiree Help Line at (800) 230-2291. TheRetiree Help Line is available specifically toanswer questions during the Retiree OptionChange Period. Representatives are availableMonday—Friday, 8 a.m. to 6 p.m., beginningApril 3, 2000 through May 16, 2000.

A REVIEW OF YOUR ENROLLMENTCHOICESThese new Medicare+Choice (M+C) optionsare available to you if you are entitled toMedicare Part A, are enrolled in MedicarePart B and live in certain counties—

• Aetna US Healthcare Medicare+Choice; • BlueChoice Medicare+Choice; and• Kaiser Permanente Medicare+Choice.

The service area and benefits for these optionsdiffer from the service area for the respectiveregular HMO and HMO Consumer Choiceoptions.

These options are available if you live in theHMO’s approved service area—

• Aetna US Healthcare HMO;• Aetna US Healthcare Consumer Choice

Option;* • BlueChoice HMO;• BlueChoice Consumer Choice Option;* • Kaiser Permanente HMO; and • Kaiser Permanente Consumer Choice

Option.*

*Other than the ability to nominate providers, benefits are identical to the regular HMO option.

Special Notice: As reported in the January 2000issue of UPDATER, Prudential coverage under the SHBP will not be available as of July 1, 2000.Members currently in the Prudential HMO willhave the opportunity to select any other availableoption during this ROCP (for coverage effective on July 1, 2000). Please note that if you do not choosea new option during the ROCP, your coverage will automatically continue under the StandardPPO Option.

These options are available statewide and inselected areas outside of Georgia near the border—

• The Standard PPO Option. CurrentStandard Option members who do notmake another choice will automaticallycontinue coverage in the Standard PPOOption. If you are a current StandardOption member living outside the PPO service area, you will automatically betransferred into High Option effective July1, 2000, unless you elect to discontinue cov-erage during the open enrollment period;

• The PPO Choice Option. Other than theability to nominate providers to be paid asnetwork providers, benefits are identical tothe Standard PPO Option.

See page 20 for PPO service area information.

The High Option is available to anyone eligible for SHBP coverage.

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What You Need to Do to Change Your CoverageIn most cases, to change your coverage, you’ll need to fill out a Personalized Change Form(PCF). However, in certain cases, no action may be necessary. For example, if you are currently aStandard Option member, you want to continue coverage in the Standard PPO Option, and youlive in the PPO service area, your coverage will continue automatically. The chart below showswhat actions you need to take based on your enrollment choices.

And youwant toenroll in:

High Option

Standard PPOOption

ConsumerChoice PPO

Aetna USHealthcareHMO

Aetna USHealthcareConsumerChoice HMO

Aetna USHealthcareMedicare+Choice

BlueChoiceHMO

BlueChoiceConsumerChoice HMO

BlueChoiceMedicare+Choice

KaiserPermanenteHMO

KaiserPermanenteConsumerChoice HMO

KaiserPermanenteMedicare+Choice HMO

High Option

No action necessary

Complete a PCF

StandardOption

No action necessary

Aetna USHealthcare

HMO

No action necessary

BlueChoiceHMO

No action necessary

KaiserPermanente

HMO

No action necessary

PrudentialHMO

No action necessary

What to do if:

You’re currently enrolled in:

Complete a PCF

Complete a PCF

Complete a PCF

Complete a PCF

Complete a PCF

Complete a PCF

Complete a PCF

Complete a PCF

Complete a PCF

Complete a PCF

Complete a PCF

Complete a PCF

Complete a PCF and Medicare+Choice FormSee Health Plan Guide for Instructions



To change your option on line, visit www.statehealth.org between april 17, 2000 and May 16, 2000.

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How to Get Confirmation of YourOption Change • If you make changes to your current cover-

age by mail, you will receive a new ID cardby mail around July 1, 2000 confirmingyour election for Plan year 2000-2001.

• If you make changes to your current cover-age online using the SHBP Web site, youcan print a confirmation of your optionchange directly from the Web site. If aprinter is not available to you, simply writethe confirmation number you’ll see on yourcomputer screen in the space provided onyour PCF.

• In each case, review your PCF as soon asyou get it to make sure it’s right. If youraddress is incorrect, mark though theaddress on the form and “write in” the correct address. If you see other errors onthe form, contact the Retiree Help Line at(800) 230-2291.

Important Note: If you have medical coverageunder another plan, like your spouse’s medicalplan, you may decide not to choose medicalcoverage with the SHBP. However, if youchoose “No Coverage” for Plan year 2000-2001, you will not be able to reenroll in anSHBP option at any time in the future, unlessyou return to active employment in a benefitseligible position.

MAKING MIDYEAR CHANGESIn addition to the annual Retiree OptionChange Period, you can also make changesduring the year under the following circum-stances:• You have a qualifying event during the

Plan year. Qualifying events include mar-riage, divorce, a new dependent, yourspouse loses or gains coverage through hisor her employment, death, attainment ofMedicare eligibility, or moving out of an

HMO or the PPO service area. If you needto change your election because of a changein family status, your new election must befiled with the SHBP within 31 days of thequalifying event. (Refer to the SHBP booklettitled State Health Benefit Plan, November 1,1995 and subsequent UPDATERS for a com-plete description of qualifying events.)

• You decide the Medicare+Choice HMOoption you’ve chosen is not right for you.You are encouraged to consider enrolling inthe Medicare+Choice HMO option. Becausethe Plan recognizes that an enrollment in anM+C option may be a big change for you,the Plan is giving you a trial period thisfirst year. If you are dissatisfied with yourchoice, you can reverse your decision foreffective dates of October 1, 2000,November 1, 2000, December 1, 2000, orJanuary 1, 2001. You must file the request toreverse your decision to enroll in an M+CHMO at least 30 days before the effectivedate and no later than December 1, 2000.Or, rather, than reverse your decision, youcan choose the Standard PPO.

• If you choose the Medicare+Choice HMOand you decide to reverse your decision,coordination with Medicare is critical.Please contact the eligibility section of theSHBP at (800) 610-1863 or in Atlanta, (404)656-6322 for assistance with reversing your decision.

• The Medicare+Choice trial period is onlyfor the Retiree Option Change Period forPlan year 2000–2001. If you miss theDecember 1, 2000 deadline, you will havean opportunity to make an option changeduring the next annual Retiree OptionChange Period. The effective date of thatchange would be July 1, 2001.

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A CLOSER LOOK AT THE STATE HEALTH BENEFIT PLAN OPTIONSNEW HMO OPTIONS CAN SAVE YOU MONEYFor detailed information about these HMOOptions, refer to the accompanying HealthPlan Guide for Retirees.

Who Can JoinYou must live in the approved HMO servicearea to join the regular HMOs and theConsumer Choice HMOs. Before making your enrollment decisions, you should refer to the Service Area charts in the accompanyingHealth Plan Guide for Retirees to make sure youare eligible.

Physicians and Other ProvidersYou receive coverage when in-networkproviders are used for covered services.Generally, except for emergency care, servicesare not covered outside of the HMO’sprovider network. You are required to select aPrimary Care Physician and, in most cases,referrals are required to see specialists.

Copayments, Deductibles, andCoinsuranceGenerally there are no deductibles to pay.Instead, you pay an in-network office visitcopayment each time you see a physician inhis or her office and when you obtain a pre-scription. Hospitalization and other servicesare usually covered at 100%.

Preventive Care CoverageAlthough benefits vary by HMO, HMOs gen-erally offer very broad preventive carecoverage as long network providers are seen.

Introducing the Medicare+Choice HMO OptionsEach of the HMO options has aMedicare+Choice option connected with it.M+C HMOs provide comprehensive coveragefor medical services for Medicare+Choiceenrolled persons at lower premiums than theregular HMOs. As long as you continue pay-ing your Part B premiums, your benefits as anM+C member will be greater than traditional

HMO benefits. If you choose an M+C HMOfor medical coverage, all care must bearranged by the M+C HMO providers for youto receive benefits—except for emergency oracute care. To be eligible to choose an M+Coption, you must live in an M+C service area.

Note: Currently, M+C HMOs are available inMetro Atlanta service areas only.

How Medicare+Choice Can Affect YourCurrent Medicare CoverageIf you choose an M+C Option, your new cov-erage will replace your traditional Medicarecoverage. Your claim forms will no longer befiled with Medicare and the SHBP. All of yourservices and payments would be coordinatedthrough the M+C HMO.

Although Medicare+Choice HMO benefitsvary by HMO, most include some benefitsnot covered by Medicare, including prescrip-tion drugs, vision care, hearing aids, andexpanded preventive care, including annualphysical examinations.

If you enroll in a Medicare+Choice option,you will continue to pay the Medicare Part Bpremium, usually deducted from yourmonthly Social Security benefit checks. Yourcoverage will be based on the rules of theM+C option, which can offer you the advan-tages of low out-of-pocket costs, reducedpaperwork, and low premiums. Medicarepays a portion of your premium directly to theHMO. In addition to the Part B premium, youpay an SHBP premium, however it will belower than regular HMO option coverages.

Introducing HMO Consumer Choice OptionsIn addition to the Medicare+Choice Option,each of the three HMO Options have a respec-tive Consumer Choice Option. Eligibility rules and benefits are identical to the regularHMO Option. The difference is the ability tonominate providers to provide care on an in-network basis. Consumer Choice Options arenot available for Medicare+Choice Plans. For more information on Consumer Choice,see page 9.

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THE NEW PPO OPTIONS COMBINECOST SAVINGS AND CHOICE

PPO Network Offers Broad Physicianand Hospital Choices Another significant change to your benefits is the replacement of the Standard Optionwith the new Standard PPO Option. The newStandard PPO Option represents a commit-ment to controlling rising costs withoutsacrificing quality or freedom to choose doctors and hospitals. The PPO network isactually a combination of two provider networks that joined to offer comprehensiveprovider access across the state and in selectedareas near Georgia’s border. The combinednetwork includes more than 8,500 physicians,151 hospitals, and a comprehensive ancillaryand chiropractic network.

This large number of physicians includes 94%of the doctors currently providing services toStandard and High Option members. Thatmeans that many Standard and High Optionmembers will find their current physiciansincluded in the PPO network. In addition,over 90% of the hospitals in the state ofGeorgia are included in the network. The PPOnetwork also includes hospitals and doctorsnear the Georgia border in Florida, Tennessee,Alabama, and South Carolina.

The enclosed PPO Provider Directory includes the doctors, hospitals, and otherproviders in the PPO network. You can also find the directory on the internet atwww.communityhealth.state.ga.us.

The Standard PPO Option The Standard PPO Option provides many ofthe advantages of indemnity-type plans, likethe High and former Standard Options. Whenyou need care, you make the decision to see aPPO network provider or to see any licensedprovider outside the PPO network. It’s yourchoice at the time you receive care, but yourlevel of benefit coverage will be reduced ifyou see a non-network provider, and you mayhave to file claims. If you use in-networkproviders, they will file claims for you.

PPO Choice OptionIn addition to the Standard PPO Option, youalso have the option of joining the PPO ChoiceOption. The eligibility rules and benefits areidentical to the Standard PPO Option, but youhave the ability to nominate providers with avalid Georgia license who are not in the PPOnetwork. For more information on ConsumerChoice, see page 9.

Who Can Join the PPOAlthough you must use a network provider toreceive the highest level of benefit coverage,the PPO is available to anyone eligible forSHBP coverage who lives or works in Georgiaor in selected areas near the Georgia border.See page 20 for the PPO’s service area.

Special Note: If you are a current StandardOption member not eligible to join the PPO,you will automatically be transferred intoHigh Option effective July 1, 2000, unless youelect to discontinue coverage during theROCP.

Coordinating Benefits Between theNew PPO Options and MedicareFor Medicare-enrolled retirees, benefits arecoordinated with Medicare. The SHBP is con-sidered secondary and Medicare is consideredyour primary coverage. That means thatMedicare pays for your coverage first andwhat Medicare doesn’t pay, your SHBP benefitplan often will. For example, when you’re ill,you’ll generally receive 100% of the hospitaland physician allowed amount after you meetthe general deductible—from the combinationof Medicare and the SHBP payments. Underthe new PPO, prescription drugs will alwaysbe paid at 90% rather than 100% of the phar-macy network rate.

If you are enrolled in Medicare Parts A and B,the PPO Options will continue to provide pay-ment at the secondary amount for in-networkand out-of-network services. In cases whereyou use an out-of-network provider, the out-of-network deductible must be met before thesecondary payment will be made. If you useboth in-network and out-of-network providers,the secondary payment will depend onwhether the specific deductible has been met.

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You Can Choose to See Any ProvidersWithin the PPO NetworkThe doctors, hospitals, and other providersincluded in the PPO network are locatedthroughout the state and in selected areas nearthe Georgia border. Within this network, youcan see any physician or other provider youwish. You do not have to choose a primarycare physician (PCP) to direct your care or torefer you to specialists.

In-Network Copayments, Deductibles, and CoinsuranceYou pay a fixed $20 copayment for office vis-its. Other than for preventive care andillness/injury office visits, you must meet ayearly general deductible of $300 per person($900 family maximum) before benefits arepayable. In network, the Plan generally pays90% of the network rate and you pay 10% ofthe network rate. You are not subject to bal-ance billing when you see in-networkproviders. (See Glossary for balance billingdefinition.) When you use in-networkproviders, your providers will file all claimforms for you. When claims are paid, you willcontinue to receive an explanation of benefits(EOB) showing what portion of your claim thePlan paid and other useful information.

In-Network Preventive Care CoverageYou’re covered for a wide variety of preven-tive care services—such as annual check-ups,well-baby care, and immunizations—and bestof all, no deductibles apply. Lab work andtests associated with preventive care office vis-its are covered too—at 100% up to $500 perperson per year. This includes coverage formammograms, Pap smears, PSA tests andother preventive care tests.

Or, You Can Choose to See ProvidersOutside the PPO Network When you need care, you also can decide tosee providers who are not in the PPO network.For example, you might stay in-network andsee a family practice physician, and go out-of-network to see a specialist. When you do goout-of-network, your expenses are eligible forreimbursement but you’re responsible formore of the costs and the benefits will bereduced to the out-of-network level. You aresubject to balance billing when you see out-of-network providers.

Note: When a member elects to use both in-network and out-of-network providers,payments made toward deductibles and stop-loss amounts will be applied separately toeither the in-network or out-of-networkamounts as appropriate. The amounts are different.

Out-of-Network Copayments, Deductibles,and CoinsuranceDeductibles and coinsurance generally apply.The Plan generally pays 60% of the allowedamount after you meet the deductible. Youpay 40% of the allowed amount plus you may be required to pay 100% of any amountgreater than the usual, customary, or reason-able (UCR) rate or DRG allowed amount—after you meet the deductible.

Preventive Care Coverage Out-of-Network isnot available.

An overview showing the new PPO Optionbenefits and how they compare to the formerStandard Option benefits is included on pages 10-14.

THE HIGH OPTION PROVIDESCHOICE—BUT AT A HIGHER COST Who Can Join The High Option continues to be available toanyone eligible for SHBP coverage.

Physicians and Other ProvidersYou are not required to select a primary carephysician and you do not need a referral tosee specialists. Except for behavioral care andtransplants, benefit levels are not based on aprovider’s network participation. However,when you use a physician who is not in theParticipating Physician Program (PPP) (seeGlossary) or when you go to a hospital thatdoes not have a direct contract with the SHBP,you are subject to balance billing.

Copayments, Deductibles, andCoinsuranceIn most cases, you must meet deductiblesbefore benefits are payable. Most charges aresubject to coinsurance. In most cases, the Planpays 90% of the allowed amount and you pay10% of the allowed amount after meeting thedeductible(s) plus 100% of any charge over theallowed amount from a non-PPP physician orfrom a hospital that does not have a directcontract with the SHBP.

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Preventive Care CoveragePreventive care is covered up to $100 per person per year for specific tests and immu-nizations only. There is an additional $75 ofcoverage for mammograms. No deductibleapplies. Office visit charges for routine careare excluded from coverage.

MORE INFORMATIONABOUT CONSUMER CHOICE The PPO Choice Option and the three HMOConsumer Choice Options are the result of anew Georgia law called the Consumer ChoiceOption Law. This law is effective for SHBPmembers on July 1, 2000. The law states that if a member joins the Consumer Choice ver-sion of an HMO or PPO option, the membercan request that an out-of-network providerlicensed in Georgia be approved to deliver themember’s care on an in-network basis. (Onlyproviders with a valid Georgia medical licensemay be nominated under the ConsumerChoice Option Law, including behavioralhealth and transplant providers.)

To request that a provider be paid as an in-network provider, the member ‘nominates’ theprovider by filling out a form. (Forms areavailable by calling the PPO or HMOs.)Providers are not actually added to the net-work, but the cost to you is the same as seeingan in-network provider. The PPO or HMOmust approve the nomination application aslong as the provider has appropriate Georgialicensing, agrees to the PPO or HMO termsand conditions for network providers, andaccepts the network reimbursement rate.

After the nomination is accepted, the providercan deliver your care and be paid on a net-work basis for the remainder of the Plan year.For example, if your provider is accepted inAugust 2000, the nomination is in effect untilJune 30, 2001. You would then need to renominate them for the July 1, 2001 Plan year.

The premiums for the Consumer ChoiceOptions of the PPO and HMOs are higherthan the Standard PPO or regular HMOoptions, but the benefits, other than the abilityto nominate a provider, are identical. Youshould be aware that if the nominatedprovider is not accepted by the HMO or PPOor chooses not to agree to your nomination,you cannot change out of the ConsumerChoice Option until the following ROCPperiod unless you have a qualifying event.

A note of caution: A nomination must be completedand approved before care is received. Otherwise, the service is covered at an out-of-network benefitlevel for PPO members and is not covered for HMO members.

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Standard PPO Option (Replaces the Standard Option effective July 1, 2000. The following benefits also apply to the PPO Choice Option.)

Description of Plan

Providers of Service

Maximum LifetimeBenefit

Pre-Existing Conditions(1st year in Plan, subject toHIPAA)

Lifetime Benefit forTreatment of:

Temporomandibular JointDysfunction

Substance Abuse

Organ and TissueTransplants

Home Hyperalimentation

Deductibles/Copayments:

Deductible

Individual FamilyMaximum

In-Network

A network of doctors andhospitals that have agreedto offer quality medicalcare and services at dis-counted rates with nobalance billing.

For the highest benefit,network providers must beused. Prescription drugsmay be obtained at anypharmacy. Referrals to spe-cialists are not required.

The Plan Pays:$2 million

$1,000

$1,100

3 episodes

$500,000

$500,000

General Deductible

$300

$900

Out-of-Network

You can go out-of-networkfor a lower level of benefitcoverage and see any qualified provider. You aresubject to balance billing.

Any lawfully operatedhospital, physician, orother provider of servicescovered under the plan.

The Plan Pays:$2 million

$1,000

$1,100

3 episodes

$500,000

$500,000

Out-of-NetworkPPO Deductible

$400

$1,200

What’s Better/Importantto Know About the New PPO OptionCompared to the FormerStandard Option?

If you use PPO networkproviders, benefit levels are generally higher thanunder the former StandardOption.

Benefit is $1,000,000 morethan the former StandardOption.

Benefit is the same as theformer Standard Option.


The in-network deductiblesare the same as the formerStandard Option. Out-of-Network deductibles arehigher than the formerStandard Option.

Continued on page 11

HOW THE PPO OPTIONS COMPARE TO THE FORMER STANDARD OPTIONThe following chart is a summary description comparing the major benefits and services of thenew PPO Options to the former Standard Option. If you live in an HMO service area, be sure torefer to the Health Plan Guide for Retirees to compare the various HMO option benefits.

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Deductibles/Copayments (Cont.):

Hospital Deductible peradmission—excluding BHSand Transplant Program

BHS and TransplantProgram—HospitalDeductible per admission

Emergency Room (ER)Copayment

Urgent Care CenterCopayment

Annual Stop-LossLimits

Individual (you or one ofyour dependents)

Family (you and yourdependents)

BHS Program (per patient;only applies to BHS-referred care)

Covered Services

Primary Care Physician orSpecialist Office or ClinicVisits:• Treatment of illness or

injury• Preventive care

In-Network

No separate hospitaldeductible.

$100

$60; $40 if referred byNurseCall 24; waived ifadmitted within 24 hours.

$35

$1,000

$2,000

$2,500

100% after a per visitcopayment of $20. Notsubject to generaldeductible.

Out-of-Network

No separate hospitaldeductible.

$100

$60; $40 if referred byNurseCall 24; waived ifadmitted within 24 hours.

Copayment not applicable.80% of allowed amount.Subject to deductible.

$2,000

$4,000

$2,500

60% of UCR for treatmentof illness or injury, subjectto deductible. Preventivecare office visits are notcovered.


There was an additional$100 per admissiondeductible in the formerStandard Option.


The copayment is $10 higherthan the former StandardOption. The copayment isno longer waived if referredby NurseCall 24 or personalphysician, or if outpatientsurgery is performed.

There was no Urgent CareCenter copayment in the for-mer Standard Option.Copayment is less than ERCopayment.

In-network stop-loss is$1,000 less than formerStandard Option.

In-network stop-loss is$2,000 less than formerStandard Option.

Maximums are the same as they were under the former Standard Option.

Your costs are lower in-net-work because coinsuranceand deductibles do notapply and preventive careoffice visits are now cov-ered. Out-of-network, yourcosts are higher.


Standard PPO Option

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Covered Services (Cont.):

Lab work and tests done inconjunction with preven-tive care visits including:

– Well-newborn exam– Well-child exams and

immunizations– Annual physicals– Annual gynecological

exams

Lab work and tests done in conjunction with treat-ment of illness or injuryincluding (pre-certificationmay be required):

– x-ray – allergy testing – injectible medications

Maternity Treatment (prenatal, delivery, andpostnatal)

Outpatient Surgery in anoffice setting

Allergy Shots and Serum

Physician ServicesFurnished in a Hospital •Surgery (including charges

by Surgeon, Anesthesiologist, Pathologist, Radiologist, and consultation)

In-Network

100% of network rate withno copayment for associ-ated lab work and testcharges with a “v” (routine)code, up to a maximum of$500 per year per person (atnetwork rate.) Not subjectto general deductible.Covered according to ageschedules and medical history. Look up age schedules online at www.healthygeorgia.comor call member services lineat 800-483-6983 (outsideAtlanta) or 404-233-4479(inside Atlanta).

90% of network rate.Subject to generaldeductible.

90% of network rate afteran initial visit copayment of$20. No copayments forsubsequent visits. Not sub-ject to general deductible.


100% for shots and serum.(If physician is seen, visit istreated as an office visitsubject to the per visitcopayment of $20.) Notsubject to the generaldeductible.


Out-of-Network

Not covered. Charges donot apply to deductible orannual stop-loss limits.

60% of UCR. Subject todeductible.



60% of UCR. Subject todeductible



In-network benefits are sig-nificantly richer than in theformer Standard Option—office visit charges arecovered and you receive upto $400 more benefit cover-age for lab work and tests.

Your benefit level is 10%higher in-network thanunder the former StandardOption.


Your benefit level is 10%higher in-network than theformer Standard Option.Charges are subject to gen-eral deductibles.

Your out-of-pocket costs arelower in-network becausecoinsurance and deductiblesdo not apply.

Your benefit level is 10%higher in-network thanunder the former StandardOption. Charges are now subject to generaldeductible.


Standard PPO Option

UPDATER 13


• Well-newborn care

Outpatient SurgeryFacilityHospital or AmbulatorySurgical Center

Hospital Services OtherThan Those forEmergency Room Careand Outpatient Surgery• Inpatient Care (including

inpatient short-termrehabilitation services.)Precertification required.

• Outpatient Services

Care in a HospitalEmergency Room forTreatment of anEmergency MedicalCondition or Injury

Urgent Care Centers(In an approved urgent-carecenter; see PPO ProviderDirectory)

X-rays and LaboratoryServices(From an approved provider)

Skilled Nursing FacilityServices

Home Nursing Care(Limited to $7,500 per year;Plan-approved Letter ofMedical Necessity required. Ifin lieu of hospitalization,additional benefits may beapproved.)

In-Network

100% of network rate.




90% of network rate after aper visit copayment of $60.The copayment is reducedto $40 if referred byNurseCall 24. The copay-ment is not charged ifadmitted within 24 hours.General deductible applies.

100% of network rate aftera per visit copayment of$35. Not subject to a gen-eral deductible.


Not covered.

90% of network rate. (Twohours of care in a 24-hourday.) Subject to generaldeductible. Expenses donot apply to annual stop-loss limit.

Out-of-Network

Not covered.




60% of allowed amountafter a per visit copaymentof $60. The copayment isreduced to $40 if referredby NurseCall 24. Thecopayment is not charged ifadmitted within 24 hours.Deductible applies.


60% of UCR. Subject togeneral deductible.

Not covered.

60% of UCR. (Two hours of care in a 24-hour day.)Subject to generaldeductible. Expenses donot apply to annual stop-loss limit.


Not covered under the former Standard Option.

Your benefit level is 10%lower in-network than it wasunder the former StandardOption. Charges are nowsubject to generaldeductible.


Your benefit level is 10%lower in-network than under the former StandardOption.

Your benefit level is 10%higher in-network than theformer Standard Option. Ifadmitted, you no longerhave to pay a separate hos-pital deductible. Theemergency room copaymentis waived only if admitted.

Your out-of-pocket costs arelower in-network becausecoinsurance and deductiblesdo not apply.



Your benefit level is 10%higher in-network than theformer Standard Option.


Standard PPO Option

14 UPDATER


• Home hyperalimentation(Must be precertified;lifetime benefit limit of$500,000)

Hospice Care(Precertification required; ifin lieu of hospitalization,additional benefits may beapproved.)

Ambulance Services

Durable MedicalEquipment(May Require Plan-approvedLetter of Medical Necessity)

Outpatient Short-TermRehabilitation Services(Physical, Speech, Cardiac,and Occupational thera-pies are each limited to 40visits per year)

Treatment of TMJDiagnostic testing andnon-surgical treatment lim-ited to $1,100 lifetimemaximum

Chiropractic Care(Limited to 40 visits per year)

In-Network



90% of network rate.Subject to generaldeductible. Medically nec-essary emergencytransportation only.





Out-of-Network



60% of UCR if medicallynecessary, non-emergencytransportation, or if notMCP approved. Subject todeductible.

60% of allowed amount.Subject to deductible.


60% of UCR. Subject togeneral deductible.

60% of allowed amount.Subject to deductible.





Your benefit level is 10%higher in-network thanunder the former StandardOption. Annual visit limita-tions and lifetime TMJbenefits are the same as theformer Standard Option.

Standard PPO Option

Important Note: Payments for covered services from an in-network PPO provider will apply only to the in-net-work deductible and stop-loss amounts. When a member uses both in-network and out-of-network providers,payments made toward deductibles and stop-loss amounts will be applied separately to the appropriate in-net-work or out-of-network amounts. Annual dollar and visit limitations are based on a July 1 to June 30 fiscal year.

Note: See page 17–19 for information on prescription drug, BHS, and transplant benefits.

UPDATER 15

HOW THE PPO OPTIONS COMPARE TO THE HIGH OPTIONFollowing are some of the major points to consider between the new Standard PPO Option andPPO Choice Option and the High Option. Before making a decision, you should carefully com-pare the benefits and costs of all the available options.

Benefits and Services

Premiums

Deductibles andCoinsurance

Stop-Loss Limits

Preventive Care

Office Visits for Illness or Injury

What’s Better/Important to Know About the New PPO Options?

Premiums for the PPO Choice Option are lower than for the High Option. Premiumsfor the Standard PPO Option are significantly lower than for the High Option.

The general deductible is the same in both the PPO options and the High Option. Theout-of-network PPO deductible is $100 more per person and $300 more per family.Under the PPO Options, you do not have to meet a separate hospital deductible.

Coinsurance for the Standard PPO and PPO Choice Options in-network is generally10%—the same as coinsurance for the High Option. Out-of-network, PPO Optioncoinsurance is 40%.

Under the PPO Options, your in-network stop-loss limits are $500 less for individuals and $500 less for families than they are under the High Option.

Preventive care benefits are much richer under the PPO Options, in-network, thanunder the High Option. — In-network under the PPO Options, you pay a $20 copayment for office visits and

receive a 100% benefit for associated lab work and tests up to a maximum of $500per person per benefit year. Preventive care is not covered out-of-network.

— Under the High Option, your maximum preventive care benefit is $100 per personper year for certain tests and immunizations and an additional $75 per year forroutine mammograms. Office visits for preventive care are not covered.

Your costs for illness or injury office visits are generally much lower in-networkunder the PPO Options than under the High Option. — When you get care in the PPO network, you pay a $20 copayment for physician or

clinic visits , no deductible applies, and you are not subject to balance billing. Forassociated lab work and tests, you pay 10% coinsurance, subject to the generaldeductible. Out-of-network, you pay 40% of allowed charges after meeting a $400deductible, and you are subject to balance billing.

— In the High Option, generally you pay 10% of allowed charges after meeting a$300 deductible and if you do not use a PPP physician, you are subject to balance billing.

HOW YOUR OUT-OF-POCKET COSTS COMPAREFollowing are some common situations whencare is needed along with comparisons ofyour out-of-pocket costs when you get care inone of the PPO Options, in the High Option,and in the former Standard Option.

As described in the examples below, yourlevel of benefit coverage under the PPOOptions in-network is generally 10% higherthan under the former Standard Option andthe same as the High Option. But the PPOsaves you even more money because nodeductibles or coinsurance apply to office

visits when you see participating networkproviders. You only pay a $20 copayment forthe office visit. (Associated lab work and testsfor an illness or injury are covered at 90%,subject to the general deductible.)

Also, in-network under the PPO, lab workand tests done in conjunction with a preven-tive care office are covered at 100% up to amaximum per person per year benefit of $500and no deductible applies. That’s $400 morethan the level of preventive care benefit cover-age in either the former Standard Option or inthe High Option.

16 UPDATER

Finally, even though your in-network PPOgeneral deductible is the same as it is in HighOption and in the former Standard Option,there is no additional per admission hospitaldeductible in the PPO Option (except for BHSand transplant admissions). However, youshould be aware that there are separatedeductibles in-network and out-of-networkand that deductibles and coinsurance pay-ments accumulate separately for in-networkand out-of-network care.

COMMON CARE SITUATIONS1. You’re ill and visit a physician in the

office.• Under the Standard PPO Option and PPO

Choice Option, you pay a $20 copaymentfor in-network care. And that’s all. You areprotected from balance billing and you donot have to meet a deductible first. Out-of-network, you pay 40% coinsurance aftermeeting the $400 deductible.*

• Under the former Standard Option, youpaid 20% coinsurance after you met the$300 general deductible.

• Under the High Option, you pay 10% coin-surance after you meet the $300 generaldeductible.*

2. You need an immunization or lab work in conjunction with a preven-tive care office visit.

• Under the Standard PPO Option and PPOChoice Option, you pay nothing when yousee a participating network provider—up toa maximum benefit of $500 per year forassociated lab and test charges. Preventivecare is covered according to age schedulesand medical history. Office visits are cov-ered with a copayment. Out-of-network,immunizations and lab work for preventivecare are not covered.

• Under the former Standard Option, youpaid nothing up to a maximum benefit ofonly $100 per year and the cost of the officevisit was not covered.

• Under the High Option, you pay nothingup to a maximum benefit of only $100 peryear and the cost of the office visit is notcovered.

3. You’re admitted to a hospital.• In network, under the Standard PPO

Option and PPO Choice Option, you pay10% of the allowed amount after you meetthe $300 general deductible and you areprotected from balance billing. Out-of-net-work, you pay 40% of the allowed amountafter you meet the $400 deductible.* Thereis no additional hospital deductible.

• Under the former Standard Option, youpaid 20% of the allowed amount of theinstitutional charge after meeting the $100per admission deductible.

• Under the High Option, you pay 10% of theallowed amount of the institutional chargesafter meeting the $100 per admissiondeductible.*

4. You get a prescription filled. • Under the Standard PPO Option and PPO

Choice Option you pay 10% of the allowedamount after you meet the $300 generaldeductible. (You are subject to balancebilling if you use a non-network pharmacy.)

• Under the former Standard Option, youpaid 20% of the allowed amount after meet-ing the $300 general deductible.

• Under the High Option, you pay 10% of theallowed amount after meeting the $300 gen-eral deductible, the same as you pay underthe PPO Options. However, your monthlypremium is much higher than the PPOOptions.

*Note: You are subject to balance billing if chargesexceed the Plan’s allowed amounts.

HOW THE PPO NETWORK PROVIDERWAS SELECTEDThe Georgia Department of CommunityHealth selected the combined resources of TheMedical Resource Network, LLC (MRN) andGeorgia 1st, Inc. to provide network manage-ment services for the PPO Option. Theselection was based on overall quality, access,

UPDATER 17

and to a lesser extent, cost. This joint ventureincludes more than 8,500 physicians, 151 hos-pitals, and a comprehensive chiropractic andancillary network (ancillary providers includedurable medical equipment vendors, indepen-dent labs, home health agencies, and others.)

The PPO network was required to meet the following qualifications: • The PPO network must continuously

monitor the quality of care provided byparticipating physicians, hospitals, andother providers;

• The PPO network must require and verifythe existence and maintenance of creden-tials, licenses, certificates, and insurance ofall the providers. The credentials must beverified every two years; and

• Each PPO network physician must possessand maintain admitting privileges at a min-imum of one PPO hospital unless the PPOhas requested in writing that the PPOphysician does not maintain admittingprivileges.

WHAT’S NOT CHANGING Many existing health care relationships are notchanging. Administrative functions andrequirements that were common to theStandard and High Options will continueunder the PPO Options. For example:

Medical Certification Program (MCP)—TheMCP program is not changing. The program isdesigned to help members and the Plan savemoney by preventing unnecessary care. Toavoid a reduction in benefits, you must com-ply with the MCP requirements outlined inthe Plan booklet. Although procedures havenot changed, there are some changes to the listof outpatient procedures that require precerti-fication. See pages 22-23 for more informationon these changes.

Claims Processing—The SHBP uses the sameclaims processor used for both the High andformer Standard Options. The claims proce-dures for the PPO Options are the same asthey were under the High and formerStandard Options.

NurseCall 24 Program—This program willcontinue to be available 7 days a week, 24hours a day to answer health-related questions,to mail you literature, and assist PPO and HighOption members in determining the mostappropriate level of care when medical atten-tion is requested. If you are referred to anemergency room by NurseCall 24, your ERcopayment is reduced from $60 to $40.

Participating Physician Program (PPP)—ThePPP will continue to protect High Optionmembers against balance billing. The PPP is acontractual arrangement between the Plan’sclaims administrator and medical doctors inGeorgia. Each participating physician agreesto accept the Plan’s allowed amount for his orher services and may not balance bill mem-bers for charges other than the coinsuranceand non-covered services amounts. PPOmembers also are protected from balancebilling when they use providers in the PPOnetwork.

Appeals Process—The appeals process underthe PPO Options is the same as it was underthe High Option and the former StandardOption.

Exclusions—No new exclusions have beenadded. The exclusions under the PPO Optionsare the same as they were under the formerStandard Option and are under the HighOption.

A Special Note on Separate ProviderNetworksThe network of participating PPO providersdoes not include pharmacies, BHS providers, ortransplant providers. A separate network ofproviders is in place for each benefit program.PPO Option and High Option members willcontinue to have access to these same networkswithout change. The following is a briefdescription of how each benefit program willcontinue to work under the PPO and HighOptions. See the chart on page 19 for moreinformation on these special benefit programs.

18 UPDATER

Prescription Drug Program—The new PPOnetwork does not change how you use theexisting pharmacy network. You may continueto use the same pharmacies as in the past withyour prescriptions covered at 90% of the net-work rate, regardless of whether you are a PPOor High Option member. (For former StandardOption members this is a 10% higher level ofbenefit coverage.) All the major pharmacychains and most independent pharmaciesthroughout the state are participating in thepharmacy network. Although you still receivea 90% benefit if you use a non-network phar-macy, you are subject to balance billing for anyprescription charges that exceed the pharmacynetwork rate.

You also should be aware that the penalty forbrand-name drugs will remain in effect. For abrand-name drug (if a generic equivalent isavailable and if neither the physician nor thepharmacist has specified a brand name), thebenefit is either the average network-reimbursable generic amount or half of thenetwork-reimbursable brand-name amount—whichever is more.

Behavioral Health Services (BHS) Program—The new PPO network does not change howyou use the existing network of BHSproviders or the level of benefit coverage thatyou receive under the BHS Program, regard-less of whether you are a PPO or High Optionmember. BHS will provide mental health andsubstance abuse referrals for PPO and HighOption members. The level of benefit youreceive is based on whether or not you receivea BHS referral for care. To receive the highestlevel of benefit coverage, PPO and Highoption members must receive a referral fromthe BHS program prior to receiving services.

Transplant Program—The new PPO networkdoes not change how you use the existing network of contracted transplant centers. You continue to have access to contractedtransplant centers as in the past with MCP-approved transplants covered at 90% of thenetwork rate, regardless of whether you are aPPO or High Option member. (For formerStandard Option members this is a 10% higherlevel of benefit coverage.) The MCP will pro-vide prior approvals for transplants for PPOand High Option members. The level of bene-fit you receive is based on whether you use acontracted or non-contracted transplant center.To receive the highest level of benefit cover-age, PPO and High option members mustreceive prior approval through the MCP anduse a contracted transplant center.

UPDATER 19

HOW SPECIAL BENEFIT PROGRAMS WILL WORKNote that the information contained in the following table is a summary to give you anoverview only of how your coverage works in the special cases where benefit programs havetheir own separate network of participating providers. Benefit limitations, precertificationrequirements, and other details are not listed in the table. Please refer to your SHBP bookletdated November 1, 1995 and to subsequent UPDATERs for additional details.

PPO/High OptionBenefit Program

Prescription DrugProgram

BHS Program

Transplant Program

What determineswhether I receivethe higher orlower level ofbenefit coverage?

Benefit coverage is afixed percentage.

Whether or not yourcare is referred byBHS. BHS referredcare has a higherlevel of benefit coverage.

Whether or not youreceive care at a con-tracted transplantcenter. Care receivedat a contracted centerhas a higher level ofbenefit coverage.(Contact the MCPprior to any trans-plant care.)

What is thehigher level ofbenefit coverage?

Although the level ofbenefit coverage isfixed at 90% of thenetwork rate, youare not subject to bal-ance billing if youuse a participatingnetwork pharmacy.

90% of the networkrate for facilitycharges.

80% of the networkrate for professionalcharges.

90% of the networkrate.

What is the lowerlevel of benefitcoverage?

If you use a non-net-work pharmacy andare charged morethan 90% of the net-work rate, you areresponsible for the10% coinsuranceamount and theamount charged overthe network rate.

60% of the networkrate for facilitycharges.

50% of the networkrate for professionalcharges.

60% of the networkrate.

How are my out-of-pocketexpenses appliedto deductiblesand stop-loss limits?

To the $300 generaldeductible; and

To the $1,000 stop-loss limit under thePPO options; or

To the $1,500 stop-loss limit under theHigh Option

To the $300 generaldeductible for profes-sional charges and, if in HighOption, to the $100deductible for hospital charges; and

For BHS referredcare, to the separate$2,500 stop-loss limit;there is no stop-losslimit for non-referredcare.

To the $300 generaldeductible for pro-fessional charges and, if in HighOption, to the $100deductible for hospital charges; and

To the $1,000 stop-loss limit under thePPO options; or

To the $1,500 stop-loss limit under theHigh Option.

20 UPDATER

PPO SERVICE AREAYou must live or work in the following zip codes to be eligible for the PPO Options.

Alabama Florida Georgia South Carolina Tennessee

35901359033590435959359603596135967359733598336262362633626436269362723627336274362753630136302363033630436305363123631336319363203632136322363453634936350363523635336370363713637536376368043685136854

368553685636859368633686736868368693687036872368743687536877

The PPO Optionsare available in allGeorgia zip codes.

29003290422908129105291132912929137291382914629166296212962229623296242962529626296282963929643296552965629658296592966429665296662967229675296772967829679296842968629689296912969329696298012980229803

29804298052980829809298102981229813298142981629817298212982229824298262982729828298292983129832298342983629838298392984129842298432984429845298462984729849298502985129853298562986029861299012990229903

2990429905299062991029915299182992029922299252992629927299282993129934299352993829939299402994329948

37302373043730737308373093731037311373123731537316373203732337325373363733837340373413734337347373503735137353373613736237363373643736937370373733737737379373843739637397374003740137402374033740437405

37406374073740837409374103741137412374143741537416374193742137422374243745037499

32004320093201132030320343203532041320463205032065320673206832073320823209532097320993220032201322023220332204322053220632207322083220932210322113221232214322153221632217322183221932220322213222232223

32224322253222632227322283222932230322313223232233322343223532236322373223832239322403224132244322453224632247322503225432255322563225732258322593226032266322673227632277322943229632297323013230232303

323043230632307323083230932310323113231232313323143231532316323173232432330323323233332337323433234432345323503235132352323533236132362323953239932423324263243232440324423244332447324483246033900

HIGH OPTION SERVICE AREAUnrestricted. Anyone eligible for SHBP coverage may enroll.

HMO SERVICE AREASSee the Health Plan Decision Guide for Retirees included in this package.

UPDATER 21

A REVIEW OF HIGH OPTION BENEFIT CHANGESIn addition to a premium increase, there are High Option benefit changes. This chart summarizes those changes.

Benefit

Lifetime MaximumBenefit

Emergency Room Services

Home Nursing Care

Stop-Loss Limits

Surgery• Physician services

• Outpatient facility orambulatory surgical center charges

Out-of-state hospitals

High Option BenefitsEffective July 1, 2000

$2,000,000

$60 copayment; $40 copay-ment if referred byNurseCall 24. Fully waivedif admitted.

Two hours of home careper day by RN or LPN, ifmedically necessary andordered by a physician— up to $7,500 per year—arecovered at 90% of the UCR after the generaldeductible is met.

Stop-loss protection limitsthe deductibles and coin-surance to $1,500 ofeligible out-of-pocketexpenses per person, or$2,500 per family per Planyear

Professional fees are subject to the generaldeductible.

90% of allowed amount,subject to generaldeductible.

90% of DRG allowedamount after meeting the$100 deductible. Subject tobalance billing.

High Option Benefits Prior to July 1, 2000

$1,000,000

$50 copayment; fullywaived if admitted orreferred by NurseCall 24or physician or if outpatient surgery wasperformed.

Two hours of home careper day by RN or LPN, ifmedically necessary andordered by a physician— up to $7,500 per year—were covered at 80% of theUCR after the generaldeductible was met.

Stop-loss protection lim-ited the deductibles andcoinsurance to $1,000 ofeligible out-of-pocketexpenses per person or$2,000 per family, per Plan year.

Payment for professionalfees was not subject to the general deductible.

100% of allowed amount,and not subject todeductible.

90% of charge after meet-ing the $100 deductible.Not subject to balancebilling.

What’s Different?

Maximum benefitincreased by $1,000,000.

Emergency room copay-ment increased by $10.Fully waived only ifadmitted. $20 copaymentreduction if referred byNurseCall 24.

Your level of benefit coverage increased by 10%.

You pay up to $500 morefor both individual andfamily coverage beforeyour stop-loss protectionlimits apply.

Professional fees now subject to the generaldeductible.

Benefit level is now 10% lower and subject togeneral deductible.

Charges now subject toDRG maximums and to balance billing.

High Option Benefit Changes

For premium information, see the enclosed Rate Worksheet.

22 UPDATER

WOMEN’S HEALTH AND CANCERRIGHTS ACT OF 1998

Each year, the Georgia Department ofCommunity Health is required to notify youof the federal law known as the Women’sHealth and Cancer Rights Act of 1998. The Actgenerally requires those group health plansand insurance companies that provide mastec-tomy-related benefits or services to providespecific coverages to Plan participants or ben-eficiaries.

The Act provides a group health plan partici-pant or beneficiary who is receiving benefitsin connection with a mastectomy, and whoelects breast reconstruction in connection withthe mastectomy, with coverage for the following:1. Reconstruction of the breast on which the

mastectomy has been performed;2. Surgery and reconstruction of the other

breast to produce a symmetrical appear-ance; and

3. Prostheses and treatment of physical com-plications at all stages of mastectomy,including lymphedemas.

Coverage for these benefits or services will beprovided in a manner determined in consulta-tion with the attending physician and thepatient.

Coverage for the mastectomy-related servicesor benefits provided under the Act will besubject to the same deductibles and coinsur-ance provisions that apply to other medical orsurgical benefits provided under the SHBP.

High Option For the High Option, medical care servicesgenerally require a $100 inpatient hospitaldeductible (per confinement), and 10% coin-surance on hospital charges, up to themember’s stop-loss limit.

PPO OptionFor the PPO Option, in-network, medical careservices typically require a 10% coinsuranceafter the general deductible of $300 per per-son/$900 per family is met. Out of the PPOnetwork, a 40% coinsurance and $400 per per-son/$1,200 per family deductible apply.

If you are a covered member or qualifieddependent under the SHBP, and you require a mastectomy, the Plan’s coverage includes all treatments for which coverage is requiredunder the Women’s Health and Cancer Rights Act.

MCP OUTPATIENT PRECERTIFICATION CHANGES

Effective July 1, 2000, the outpatient precertifi-cation list last published in theSpring/Summer 1998 UPDATER will bereplaced with the list given below. Esophagealsurgery is a new category requiring precertifi-cation. There also are a number of laparoscopyCPT codes that are added or deleted. All newprocedure codes are shown in bold italics.Changed codes are in italics.

CAT or CT Scans (except for brain andspine):70480 through 70492; 71250 through 71270;72192 through 72194; 73200 through 73202;73700 through 73702; 74150 through 74170;76375; 76380.

Colonoscopies:45378 through 45385.

Endoscopies:43234; 43235; 43239.

Esophageal Surgeries:43280; 43289; 43324; 43325.

Laparoscopies and/or Peritoneoscopies:47562; 47563; 47564; 49320; 49321; 49322;49329; 58550; 58551; 58578; 58579; 58660;58661; 58662; 58679.

UPDATER 23

MRAs:70541; 71555; 72159; 72198; 73225; 73725;74185.

MRIs:70336; 70540; 70551 through 70553; 71550;72141 through 72158; 72196; 73220; 73221;73720; 73721; 74181; 75552 through 75556;76093; 76094; 76400.

Nasal Surgeries:30130; 30140; 30400 through 30520; 30620;30801; 30802; 30930.

Sleep Studies:95805; 95806; 95807; 95808; 95810; 95811.

Uvulopalatopharyngoplasties:42120; 42140; 42145; 42299; 42950.

You may want to share this list with yourphysician. If either you or a covered dependentplans to undergo one of the listed procedures,call the Medical Certification Program inadvance for precertification. The toll-free num-ber outside of the Atlanta area is (800) 762-4535,and the number in the Atlanta area is (770) 438-9770.

SHBP BALANCE BILLING POLICYAND RELATED ISSUESEFFECTIVE JULY 1, 2000—High OptionOut-of-state hospital charges under the HighOption will be subject to balance billing. Aftermeeting your $100 deductible, the HighOption will pay 90% of a DRG allowedamount. You will be responsible for the 10% coinsurance amount plus all charges thatexceed the DRG allowed amount, if any.

You will continue to be subject to balance billingfrom out-of-state and non-PPP providers.

PPO OptionsIf you use participating network providers,you are protected from balance billing. Alsonote that the PPO network includes participat-ing network providers in selected out-of-stateareas, including areas near the Georgia border

in Alabama, Florida, South Carolina, andTennessee. (Please refer to the enclosed PPOProvider Directory. You can also access the PPO Provider Directory online at www.communityhealth.state.ga.us.)

Out-of-network hospital charges for routine orplanned care under the PPO options are sub-ject to balance billing. After meeting your $400deductible, the PPO options pay 60% of aDRG allowed amount. You are responsible forthe 40% coinsurance amount plus all chargesthat exceed the DRG allowed amount, if any.However, for emergency or acute care out-of-network, the PPO pays 90% of the DRG amountafter meeting the $300 general deductible, sub-ject to the possibility of balance billing. (See the Glossary for emergency and acute care definitions.)

Out-of-network professional charges for rou-tine or planned care under the PPO optionsare subject to balance billing. After meetingyour $400 deductible, the PPO options pay60% of a UCR allowed amount. You areresponsible for the 40% coinsurance amountplus all charges that exceed the UCR allowedamount, if any. However, for emergency oracute care out-of-network, the PPO optionspay 90% of the UCR amount after meeting the$300 general deductible, subject to the possi-bility of balance billing.

Stop-Loss LimitsCharges that exceed the Plan’s allowedamounts are not applied toward deductibles orstop-loss limits, regardless of your coverageoption.

VISION DISCOUNT PROGRAM

(See the Spring/Summer 1997 UPDATER for program information.)

The BlueChoice Vision discount program willbe a feature of the new Standard PPO andPPO Choice Options.

If you are a High Option member, the discount program will remain in effect until furthernotice.

HIPAA ANNUAL NOTICE

Each year the Plan is required to notify you ofcertain rights available to you under the HealthInsurance Portability and Accountability Act.

The PPO and High options contain a pre-existing conditions limitation. Specifically, theHealth Plan will not pay charges that are over$1,000 for the treatment of any pre-existingcondition (see Glossary) during the first 12months of a patient’s coverage, unless thepatient gives satisfactory documentation thathe or she has been free of treatment for at leastsix consecutive calendar months.

In certain situations, SHBP members anddependents can reduce the 12-month pre-existing condition (PEC) limitation period.The reduction is possible by using what iscalled “creditable coverage.” Creditable cov-erage generally includes the health coverageyou or a family member had immediatelyprior to joining the SHBP. Most group healthplans, including individual health policies andgovernmental health programs qualify ascreditable coverage.For Individuals Gaining SHBP CoverageThe PEC limitation period can be reduced by the length of time that creditable coverageexisted, under the following conditions:

• When the Plan member provides the SHBPwith a certificate of creditable coverage fromone or more former health plans that states

when coverage started and ended for eachcovered person under that plan who nowdesires SHBP coverage; and

For Members• When the time between losing coverage

under the most recent former health planand the later of either your hire date (withthe state or school system) or the first day ofthe waiting period prior to SHBP coveragedoes not exceed 63 days.

For Eligible Dependents (including spouses)• When the time between the day your depen-

dent becomes covered under the SHBP andthe last day your dependent had coveragefrom any former health plan does not exceed63 days.

Note: If you or a dependent (including a spouse)had any break in former coverage lasting morethan 63 days, you or your dependent will receive coverage only for the period of time after thebreak ended.

You have the right to obtain a letter of cred-itable coverage from your former employer(s)to offset the PEC limitation period under theSHBP. If you require assistance in obtaining aletter from a former employer, contact thePlan’s eligibility unit at 404-656-6322 in theAtlanta area or at 800-610-1863 outside theAtlanta area.

24 UPDATER

UPDATER 25

CoinsuranceA percentage of the provider’s charge or thePlan’s allowed amount that must be paid bythe member, generally 10% to 40%.

CopaymentA fixed dollar amount that must be paid bythe member for a particular service or item,for example, $10 or $20 for office visits.

DeductibleA fixed dollar amount that must be paid out-of-pocket by the patient before any benefit ispayable by the patient’s health care plan. Paideach Plan year and, in some cases, paid perhospital admission, depending on your cover-age option.

DRGDiagnostic related group. For charges from in-state hospitals that contract directly withthe State Health Benefit Plan (SHBP), the Planpays a fixed amount based on the patient’sdiagnosis. The actual diagnosis is convertedinto a DRG that is used to calculate the hospi-tal’s reimbursement. Contracting hospitalsagree to accept the DRG amount as theallowed amount.

Emergency CareCare provided in the event of a sudden,severe, and unexpected illness or injurywhich, if not treated immediately, could belife-threatening or result in permanent impair-ment of bodily functions.

Indemnity PlanA health plan model allowing members themost freedom to select providers and to directtheir own care. The High Option is an indem-nity-type plan.

Medical Certification Program (MCP)The MCP is a part of the PPO and HighOptions. It is designed to help members andthe Plan save money by preventing unneces-sary care. To avoid a reduction in benefits, youmust comply with the MCP requirements out-lined in the Plan booklet.

GLOSSARY

Acute CareCare provided when such services are med-ically necessary and immediately required as aresult of a sudden onset of illness or injury.

Allowed AmountA dollar figure the Plan uses to calculate bene-fits payable. In many cases, the allowedamount equals a usual, customary, or reason-able (UCR) amount (see UCR definition). Inthe case of hospitals, the allowed amount isbased on a patient’s diagnosis. See DRG defin-ition. Plan members using non-networkproviders (PPO Option) or non-participatingproviders (High Option) are responsible forpaying any amount charged over the allowedamount. PPO members using networkproviders are charged only up to the allow-able amount and will not be subject toadditional payments for that service.

Balance BillingA dollar amount charged by a provider that isover the Plan’s allowed amount for the care ortreatment received. Amounts balance billedare the member’s responsibility and do notapply to the Plan’s stop-loss limits. PPOproviders do not bill for amounts over theallowed amount and, thus, members will notbe subject to balance billing when using a net-work PPO provider.

Behavioral Health Services (BHS)The BHS program is part of the PPO and HighOptions. It is a managed care program formental health and substance abuse benefits.The program is designed to provide wideaccess to necessary care while balancingchoice of provider, enhanced benefits withinthe network, and overall cost effectiveness. Inorder to receive full benefits, members mustcontact BHS prior to receiving behavioralhealth services.

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Primary Care Physician (PCP)A doctor who has the primary responsibilityfor providing, arranging, and coordinatingevery aspect of a patient’s health care. AnHMO member must select a PCP. A member of a PPO may choose to have a PCP, but it isnot required. Generally, PCPs are eitherinternists, family practitioners, pediatricians,or OB/GYNs.

Provider Licensed medical doctors, hospitals, and otherhealth care providers through whom the Planoffers coverage.

Self-Insured Benefit PlanA program of medical care reimbursement inwhich an employer and its employees pay allcosts of employee health care; no outsideinsurance company underwrites the risk ormakes a profit. The High Option and PPOOptions are self-insured benefit plans.

Service AreaA service area consists of approved countiesor zip codes in which in-network services areavailable.

Stop-Loss LimitA maximum annual dollar amount that a Planmember would have to pay out-of-pocket forcovered expenses. Once the stop-loss limit isreached, covered expenses for the remainderof the Plan Year are reimbursed at 100%. Stop-loss limits apply per person and per family.

Usual, Customary, and Reasonable(UCR)UCR fees apply to High Option members andto PPO Option members who choose to goout-of-network. PPO members who choose togo in-network are subject to a maximumallowed amount, not to a UCR fee. ParticipatingPPO providers do not bill for amounts over thediscounted rate. The UCR fee may be definedin three parts:

—Usual FeeThe fee a physician most frequently receivedas reimbursement for the procedure performed.

Participating Physician Program (PPP)A contractual arrangement between the Plan’sclaims administrator, Blue Cross Blue Shieldof Georgia, Inc., and medical doctors whopractice in Georgia.

Each participating physician agrees to acceptthe Plan’s allowed amount for his or her ser-vices and may not balance bill members. PPPapplies to the High Option. (Participating PPOproviders also agree to accept the Plan’sallowed amount and may not balance bill members.)

Plan YearJuly 1st through June 30th of the followingyear.

Pre-Existing Condition (PEC)Existence of a condition or symptoms whichwould cause an ordinarily prudent person toseek diagnosis, care, or treatment; or of a con-dition for which medical advice or treatment(including medication) had been recom-mended by or received from any health careprovider before SHBP coverage began. Theperiod subject to review for PECs is sixmonths, beginning from the later of eitheryour hire date or the first day of the waitingperiod prior to coverage under the Plan.

Preferred Provider Organization (PPO)The PPO is a comprehensive network of doc-tors, ancillary providers, and hospitals thathave agreed to offer quality medical care andservices at discounted rates. You must use anetwork provider to receive the highest levelof coverage. If you choose a PPO, you havethe flexibility to go out-of-network for yourhealth care services but you will receive areduced level of benefit. With you out-of-network benefits, you can see any qualifiedprovider of medical services. You pay agreater percentage of the charges for coveredservices if you go out-of-network and you aresubject to balance billing for charges above thePlan’s allowed amount.

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—Customary FeeThe fee based on a competitive profile of theusual fees received as reimbursement by sim-ilar physicians in a given geographic area forthe procedure performed, according to third-party administrator’s records.

—Reasonable FeeThe fee different from a usual or customaryfee because of unusual circumstancesinvolving complications requiring addi-tional time, skill, and experience.

The Plan pays up to the usual fee, not toexceed the customary fee, unless special circumstances or complications occur, inwhich case the Plan may consider the reasonable fee.

FOR MORE INFORMATION

HMO OptionsIf you are eligible for HMO option coverage,benefit information is in the enclosed HealthPlan Benefit Guide for Retirees or by calling theHMO directly:

• Aetna US Healthcare: (800) 444-0759

• Aetna US Healthcare Consumer Choice:(800) 443-6917

• Aetna US Healthcare Medicare+Choice:1-888-217-2768

• Aetna US Healthcare Web site:www.aetnaushc.com

• BlueChoice: (800) 464-1367

• BlueChoice Consumer Choice:(800) 464-1367

• BlueChoice Medicare+Choice:(800) 652-7189

Hearing impaired: (877) 463-2187

• BlueChoice Web site: www.bcbsga.com

• Kaiser Permanente: (404) 261-2590

• Kaiser Permanente Consumer Choice:(404) 261-2590

• Kaiser Medicare+Choice: (800) 956-1358

• Kaiser Permanente Web site:www.kp.org/ga

PPO OptionsDuring the ROEP, call volume may be veryhigh, and you may experience time on hold orbe asked to dial another number.

Retiree Help Line: (800) 230-2291

TDD line for the hearing impaired: (404) 842-8073

New Patient Availability and Status of PendingParticipating Network Providers Information: (800) 675-6492

On-Line PPO Provider Directory: www.communityhealth.state.ga.us

For on-line viewing of preventive care healthstandards, visit the MRN/GA 1st web site atwww.healthygeorgia.com (schedule applies toPPO Option members using in-networkproviders.)

For PPO Choice Option membersOnly providers with a valid Georgia licensemay be nominated under the Consumer ChoiceOption Law.

Nomination of PPO Provider Information:(800) 675-6492

Nomination of BHS Provider information: (800) 631-9943(404) 842-8073 (TDD Line for the hearingimpaired)

Nomination of Transplant Provider Information:(770) 438-9770 (Atlanta area)(800) 762-4535 (outside Atlanta)(800) 453-9776 (TDD Line for the hearingimpaired)

High Option • Retiree Help Line: 1-800-230-2291 (Available

from April 3, 2000 through May 16, 2000)

• TDD line for the hearing impaired: (404) 842-8073

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For PPO and High Option membersFor emergency room referrals and for medicalinformation from registered nurses 24-hours aday, seven days a week, call NurseCall 24: (800) 524-7130

For More about Medicare or YourInsurance PremiumsTo find out more about your Medicare premi-ums, Social Security benefits, applying forMedicare or to locate the Social Security officenearest you, call:

• Social Security Administration

—Toll free: (800) 772-1213

—The Social Security Administration:www.ssa.gov

If You Have Access to the Internet, Visitthe Web Site to Change Your Option • The State Health Benefit Plan:

www.statehealth.org

—If you want to make changes to yourSHBP coverage, you can do so on line atour new Web site. If you decide tochange your health coverage option, youcan visit www.statehealth.org betweenApril 17, 2000 and May 16, 2000 to makeyour option change.

If You Have Access to the Internet, Visitthese Web Sites for More Information• Medicare or Medicare+Choice:

www.medicare.gov

• The Health Care Financing Administration:www.hcfa.gov

• The Social Security Administration:www.ssa.gov

retiree state health benefit plan updater · this updater describes material changes to the state...

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