1. Healthcare

Baltimore County
Public Schools
Retiree Benefits Guide
an option for retirees
Effective January 1, 2015
October 2014
Re: Retiree Benefit plans
Dear Retiree,
The 2015 Retiree benefit guide provides 2015 benefit information. Any requests for changes to your benefit plans
must be received in the Benefit office by November 10, 2014 for benefits effective January 1, 2015. Cigna and Kaiser
continue to provide our medical plans for 2015. Please review the benefit guide for additional information and the new
premiums for 2015.
We continue to strive to offer an attractive package of benefits to meet your needs and to support the vision of Blueprint 2.0.
Important Reminders
For retirees under 65
Plans are being offered by CIGNA and Kaiser Permanente for 2015.
■■ CIGNA plans include the – Open Access Plus – in network (OAPIN) and a Preferred Provider Organization (PPO) type
plan - Open Access Plus – in/out of network (OAP)
■■ Kaiser Permanente offers a HMO plan.
■■ For 2015, several provisions of the Affordable Care Act will go into effect. For retirees under 65, you may be eligible to
enroll in benefits available through the State of Maryland Health Care Exchange. The Office of Benefits, Leaves and
Retirement will provide information to retirees as it becomes available.
■■
Please review the details and cost of these plans.
For all retirees
No action is required if you wish to maintain your current Medical and Prescription coverage for 2015.
There are no changes to BCPS Dental Plans. CareFirst PPO and CareFirst Traditional plans and the CIGNA Dental
DHMO will remain in effect for 2015. No action is required if you wish to maintain your current Dental Coverage for
2015.
■■ CareFirst – Davis Vision remains the BCPS Vision provider. No action is required if you wish to maintain your current
Vision coverage for 2015.
■■
■■
If you have any questions, please refer to the contact listings in the back of this Enrollment Guide, call the Office of
Employee Benefits and Retirement at (410) 887-8943, or email at [email protected]. We hope you continue to be
pleased with these programs as we endeavor to maintain a competitive benefits package for you and your family.
Sincerely,
S. Dallas Dance, Ph.D.
Superintendent
What’s New for This Plan Year..............................................................................................2–4
BCPS 2015 Benefit Plan Choices.............................................................................................5
Monthly Contribution for Medical Benefits......................................................................... 6–13
Monthly Rates for Dental and Vision Benefits for Retirees..................................................... 14
Benefits Enrollment...........................................................................................................15–19
Non-Medicare Medical Options — Highlights...................................................................20–30
Non-Medicare Medical Options — At-a-Glance Chart........................................................ 31–45
Federally Required Information About Your Health Plan.........................................................46
Dental Options — Highlights..................................................................................................47
Dental Options — At-a-Glance Chart.......................................................................................48
Vision Insurance...............................................................................................................49–50
Life Insurance................................................................................................................... 51–53
Medicare...........................................................................................................................54–70
Important Things to Remember.............................................................................................. 71
HIPAA......................................................................................................................................72
Notice of Privacy Policy and Practices...............................................................................73–76
Important Resources.........................................................................................................77–79
Important Notice............................................................................................................... 80–81
Health Care Reform Impact.....................................................................................................82
Health Insurance Marketplace Coverage...........................................................................83–87
Affordable Care Act – Frequently Asked Questions........................................................... 88–91
Retiree Benefits Enrollment/Change Application....................................................................93
The purpose of this Retiree Benefits Guide is to provide information about your benefit options and how to enroll
for coverage or make changes to existing coverage. This Guide is only a summary of your choices and does not
fully describe each benefit option. Please refer to your carrier Guide or Certificate of Coverage for information
about the plans.
Every effort has been made to ensure that the information in this Guide is accurate; however, the provisions of the
actual contracts for each plan will govern in the event of any discrepancy. Copies of the Employee Benefit Guides, plan
contracts, and other plan materials are available upon request from the Office of Benefits, Leaves and Retirement at our
website, www.bcps.org/offices/benefits/forms, or from the insurance carriers.
Baltimore County ­Public Schools
Retiree Benefits Guide
1
2
What’s New for This Plan Year
What’s New For This Plan Year n 2015
At-a-Glance
All Open Enrollment information is available from the
BCPS website at http://www.bcps.org/offices/benefits/.
Here is a Look at What’s New for 2015
■■
■■
■■
■■
■■
igna will continue to administer the Medicare
C
Supplement Plan. The Plan is called Cigna Medicare
Surround Indemnity Plan.
or Non-Medicare retirees, Cigna Open Access
F
Plus in-network (OAPIN) is available for 2015. This
plan includes an Open Access Plan that requires
an in-network use of doctors. This is similar to an
HMO but the use of a Primary Care Physician and
referrals are not required. Cigna maintains a world
wide network.
or Non-Medicare retirees, Cigna Open Access
F
Plus (OAP) is available for 2015. This plan allows
for in-network or out-of-network use of doctors.
This plan is similar to a PPO plan. A Primary Care
Physician and referrals are not required.
Here’s What’s Not Changing
CareFirst PPO and traditional dental plans remain in
effect for 2015.
■■
■■ Cigna Dental DHMO Plan remains in effect for
2015.
■■ CareFirst Davis Vision plan remains in effect for
2015.
Prescription plans remain with Express Scripts.
Co-pays remain the same with ESI for 2015. Please
note that Walgreens Pharmacy is not part of the
ESI network with BCPS.
■■
■■
etirees who are currently enrolled in the Cigna
R
OAPIN, Cigna OAP, Kaiser HMO, Cigna Medicare
Surround Plan or Kaiser Medicare Plus Plan who
wish to maintain their current benefit choices do
not need to complete a benefit enrollment form.
Your selections will be established for 2015.
ependents may be covered until the end of the
D
month they turn age 26 for all benefit programs.
Premium costs have changed for 2015.
Baltimore County ­Public Schools
Retiree Benefits Guide
3
Know what’s important to you
Programs and services that help you make the most of
your Cigna health plan and support your well-being.
Mycigna.com – your secure portal for benefit
information and resources
Nothing is more important than understanding your
benefits and your good health. That’s why there’s www.
myCigna.com – your online home for assessment tools,
provider search engine, explanation of benefits paid,
medical updates and much more.
So get ready to click with a site that clicks with you.
How to register:
■■
Step 1 – Enter www.myCigna.com in the web
address line on your browser.
■■
Step 2 – Click on the Register Now button.
■■
Step 3 – Enter personal details.
■■
■■
Your Member ID number is printed on your
ID card. Upon entering personal information
a Confirmation Page should then appear. Click
“Accept” if all information is accurate.
Step 4 – Complete your Demographic and Security
Information data. Click “Continue”.
■■
Step 5 – Confirm your identity.
■■
Step 6 – Review and submit.
24 Health Information Line – 24-hour guidance on
medical treatment
Dial the toll-free number on your Cigna ID card and
you’ll be connected directly to a nurse who is ready to
help answer your health questions. Nurses can offer
detailed answers to your health questions, and help you
decide where and when to seek medical attention. You
can also listen to hundreds of our latest podcasts in
English and Spanish to help you stay informed.
Healthy Rewards – complimentary discounts
If you have Cigna coverage, the choice to use Healthy
Rewards is entirely yours. The program is separate from
your coverage, so the services don’t apply to your plan’s
copays or coinsurance. No doctor’s referral is required
Baltimore County ­Public Schools
– and no claim forms, either. Set the appointments
yourself, show your ID card when you pay for services
and enjoy the savings.
Health Assessment – personalized report about your
health
The health assessment can give you an idea of the current
state of your health. Based on your responses, you’ll also
learn if you are at any risk for certain conditions like
diabetes or high blood pressure. It will also help you
understand what you can do to maintain and improve
your health.
To start. Go to www.myCigna.com and select Take
my health assessment and follow the registration
instructions until you reach my health & wellness center.
Select Take my health assessment now and follow the
steps through the questionnaire.
When taking the health assessment, know the following:
your blood pressure, total cholesterol, HDL cholesterol,
height, weight, and waist circumference. If you don’t
know these, you can answer, “I’m not sure”, but
answering all questions produces the best results.
We’ll help you get what you need for your chronic
health condition
If you have a chronic health condition, we know there
are times when you need extra help. That’s why we’re
here. Take advantage of our free health coaching and
then, when you’re ready to go it alone, say the word.
We’ll guide you to self service resources and be there
when you need us. It’s up to you.
A health advocate, nurse, health educator or behavioral
health specialist – may be calling you to get things
started, or you can call us at any time. We can help you:
■■
■■
■■
■■
■■
■■
■■
Manage a chronic health condition.
Create a personal care plan.
Understand medications or your doctor’s orders.
Identify health risks that affect your condition.
Make educated decisions on your treatment
options.
Know what to expect if you need to spend time in
the hospital.
Improve your lifestyle by coping with stress,
quitting tobacco use, maintaining good eating
habits, and managing or losing weight.
Retiree Benefits Guide
What’s New for This Plan Year
What’s New For This Plan Year n 2015
4
What’s New for This Plan Year
What’s New For This Plan Year n 2015
Benefits Available to All Cigna
Participants
YOU’VE GOT A GOAL. AND YOU’VE GOT WHAT IT
TAKES TO REACH IT.
Whether your goal is to lose weight, quit tobacco or
lower your stress levels, you have the power to make
it happen. Cigna Lifestyle Management Programs can
help – and all at no cost to you. Each program is easy
to use and available where and when you need it. And,
you can use each program online or over the phone –
or both.
Weight Management
Reach your goal of maintaining a healthy weight – all
without the fad diets. Create a personal healthy-living
plan that will help you build your confidence, be more
active and eat healthier. And, you’ll get the support you
need to stick with it.
Tobacco
Get the help you need to finally quit tobacco. Create a
personal quit plan with a realistic quit date. And, get the
support you need to kick the habit for good. You’ll even
get free over-the-counter nicotine replacement therapy
(patch or gum).
My Health Assistant - Your way to achieve BIG
health changes
My Health Assistant online coaching is a fun,
interactive program to help you achieve big health and
wellness goals in just a few small steps.
Here’s how it works for you.
■■ Visit myCigna.com, click on Manage My Health
and select My Health Assistant
■■ Online Coaching
■■ You select the activities you like and the goals you
want to achieve
■■ My Health Assistant creates a personal coaching
program just for you
■■ You check in regularly to track your success
■■ My Health Assistant lets you add or change
activities and goals at any timeSmall steps are a
great way to make big change possible. Especially
when it comes to your health.
Get started now.
You’ll be happy that you did – and on your way to
better health. Powered by WebMD®
Stress Management
Lower your stress levels and raise your happiness levels.
Learn what causes you stress in your life and develop a
personal stress management plan. And, get the support
you need to help you cope with stressful situations –
both on and off the job.
Over the phone
■■ One-on-one wellness coaching
■■ Convenient evening and weekend hours
■■ Program workbook and toolkit
Online
■■ Secure, convenient support
■■ Self-paced program
■■ Educational materials, interactive tools and
resources
Take the first step. Call 855-246-1873 or visit
myCigna.com
Baltimore County ­Public Schools
Retiree Benefits Guide
5
Medical Plans (Under age 65)
Kaiser Permanente HMO
Dental Plans
CareFirst Regional Dental PPO
Cigna OAPIN
Cigna OAP
(including Express Scripts
prescription drug plan)
CareFirst Regional Dental
Traditional
Vision Plans
CareFirst Davis Vision Plan
Cigna DHMO
Medical Plans
(Medicare Eligible*)
Cigna Medicare Surround
(including Express Scripts
prescription drug plan)
Kaiser Permanente
Medicare Plus
Dental Plans
CareFirst Regional Dental PPO
Vision Plans
CareFirst Davis Vision Plan
CareFirst Regional Dental
Traditional
Cigna DHMO
*BCPS retirees must enroll in Medicare Parts A & B when first eligible. Retirees DO NOT need to enroll in a Medicare Part D plan.
Summary of Retiree Benefits
Medical Plans
Dental and Vision Plans
BCPS requires that as soon as a retiree, spouse or
dependent of a retiree is eligible for Medicare that they
accept Medicare as their primary health carrier.
Retirees may continue their dental and vision coverage.
The retiree is responsible for the full cost of dental and
vision coverage for him/herself or any eligible dependents
at the COBRA equivalent rate.
n
n
n
ou must obtain Part A (hospital) and Part B
Y
(medical) of Medicare.
art B will require a monthly premium deduction
P
from your Social Security check.
ou do not need to enroll in a Part D Medicare
Y
Prescription plan.
Life Insurance
Retirees who immediately receive a pension check upon
retirement, and were enrolled in life insurance while
employed can continue some coverage into retirement.
An employee who retires under the age of 65, who is not
on Medicare, may elect any of the health insurance plans
available to active employees at the time they retire.
Baltimore County ­Public Schools
Retiree Benefits Guide
BCPS 2013 Benefit Plan Choices
BCPS 2015 Benefit Plan Choices
6
Monthly Contribution for Medical Benefits
Monthly Contribution for Non-Medicare Benefits
Retired On or Before December 31, 2012 • Effective January 1, 2015 through December 31, 2015
A retiree’s monthly premium for selected medical insurance coverage depends on four factors:
1. BCPS years of service at the time of retirement (Total number of years employed by BCPS. Not total amount
of years in retirement system.) Eligible Military service may be added to your BCPS years. BCPS years do not
include contractual, temporary or substitute assignments.
2. The medical option chosen
3. The level of coverage selected (ex. Individual, Family)
4. The total monthly premium cost for each level of coverage
The following charts show the monthly premium for each of the medical insurance options. The full cost for the
dental and vision coverage is also shown. Premiums will be deducted directly from your pension check or billed
quarterly, if necessary.
MEDICAL INSURANCE FOR
NON-MEDICARE (UNDER 65)
OAPIN, OAP, and Kaiser **
Your
Monthly
Total Monthly
Share with
Premium or
30 or more
Equivalent
Years of
Service at
CIGNA OAPIN (In Network)
Your
Your
Your
Monthly
Monthly
Monthly
Share with
Share with Share with
20-29 Years 10-19 Years 0-9 Years of
of Service at of Service at Service at
10.0%
25.0%
50.0%
100.0%
Individual
$583.09
$58.31
$145.77
$291.55
$583.09
Parent/Child
1,155.27
115.53
288.82
577.64
1,155.27
Two Adults
1,391.46
139.15
347.87
695.73
1,391.46
Family
1,568.83
156.88
392.21
784.42
1,568.83
Individual
$658.27
$65.83
$164.57
$329.14
$658.27
Parent/Child
1,304.20
130.42
326.05
652.10
1,304.20
Two Adults
1,570.84
157.08
392.71
785.42
1,570.84
Family
1,771.06
177.11
442.77
885.53
1,771.06
Individual
$622.87
$62.29
$155.72
$311.44
$622.87
Parent/Child(ren)
1,234.04
123.40
308.51
617.02
1,234.04
Two Adults
1,486.37
148.64
371.59
743.19
1,486.37
Family
1,675.84
167.58
418.96
837.92
1,675.84
CIGNA OAP (In/Out Network)
Kaiser Permanente HMO
**Domestic Partner benefits may be subject to imputed income
Baltimore County ­Public Schools
Retiree Benefits Guide
7
Retired January 1 – December 31, 2013 • Effective January 1, 2015 through December 31, 2015
MEDICAL INSURANCE FOR
NON-MEDICARE (UNDER 65)
OAPIN and Kaiser **
Total
Monthly
Premium or
Equivalent
CIGNA OAPIN (In Network)
Your
Monthly
Share with
30 or more
Years of
Service at
Your
Monthly
Share with
29 Years of
Service at
Your
Monthly
Share with
28 Years of
Service at
Your
Monthly
Share with
27 Years of
Service at
11.0%
20.0%
23.0%
25.0%
Individual
$583.09
$64.14
$116.62
$134.11
$145.77
Parent/Child
1,155.27
127.08
231.05
265.71
288.82
Two Adults
1,391.46
153.06
278.29
320.04
347.87
Family
1,568.83
172.57
313.77
360.83
392.21
Individual
$622.87
$68.52
$124.57
$143.26
$155.72
Parent/Child(ren)
1,234.04
135.74
246.81
283.83
308.51
Two Adults
1,486.37
163.50
297.27
341.87
371.59
Family
1,675.84
184.34
335.17
385.44
418.96
Kaiser Permanente HMO
MEDICAL INSURANCE FOR
NON-MEDICARE (UNDER 65)
OAP **
Your Monthly Your Monthly Your Monthly Your Monthly
Total Monthly
Share with 30 Share with
Share with
Share with
Premium or
or more Years 29 Years of
28 Years of
27 Years of
Equivalent
of Service at
Service at
Service at
Service at
12.0%
CIGNA OAP (In/Out Network)
23.5%
26.8%
26.8%
Individual
$658.27
$78.99
$154.69
$176.42
$176.42
Parent/Child
1,304.20
156.50
306.49
349.53
349.53
Two Adults
1,570.84
188.50
369.15
420.99
420.99
Family
1,771.06
212.53
416.20
474.64
474.64
**Domestic Partner benefits may be subject to imputed income
(continued on next page)
Baltimore County ­Public Schools
Retiree Benefits Guide
Monthly Contribution for Medical Benefits
Monthly Contribution for Non-Medicare Benefits
8
Monthly Contribution for Medical Benefits
Monthly Contribution for Non-Medicare Benefits
Retired January 1 – December 31, 2013 • Effective January 1, 2015 through December 31, 2015
Your
Monthly
Share with
20-26 Years
of Service at
Your
Monthly
Share with
19 Years of
Service at
Your
Monthly
Share with
10-18 Years
of Service at
Your
Monthly
Share with
0-9 Years of
Service at
CIGNA OAPIN (In Network)
26.8%
52.5%
55.0%
100.0%
Individual
$156.27
$306.12
$320.70
$583.09
Parent/Child
309.61
606.52
635.40
1,155.27
Two Adults
372.91
730.52
765.30
1,391.46
Family
420.45
823.64
862.86
1,568.83
$166.93
$327.01
$342.58
$622.87
Parent/Child(ren)
330.72
647.87
678.72
1,234.04
Two Adults
398.35
780.34
817.50
1,486.37
Family
449.13
879.82
921.71
1,675.84
MEDICAL INSURANCE FOR
NON-MEDICARE (UNDER 65)
OAPIN and Kaiser **
Kaiser Permanente HMO
Individual
MEDICAL INSURANCE FOR
NON-MEDICARE (UNDER 65)
OAP **
Your Monthly Your Monthly Your Monthly Your Monthly
Share with
Share with
Share with
Share with
20-26 Years of 19 Years of 10-18 Years of 0-9 Years of
Service at
Service at
Service at
Service at
CIGNA OAP (In/Out Network)
26.8%
52.5%
55.0%
100.0%
Individual
$176.42
$345.59
$362.05
$658.27
Parent/Child
349.53
684.71
717.31
1,304.20
Two Adults
420.99
824.69
863.96
1,570.84
Family
474.64
929.81
974.08
1,771.06
**Domestic Partner benefits may be subject to imputed income
Baltimore County ­Public Schools
Retiree Benefits Guide
9
Retired January 1 – December 31, 2014 • Effective January 1, 2015 through December 31, 2015
MEDICAL INSURANCE
FOR NON-MEDICARE
(UNDER 65) OAPIN and
Kaiser **
Your
Total
Monthly
Monthly
Share with
Premium or 30 or more
Equivalent
Years of
Service at
CIGNA OAPIN (In Network)
Your
Your
Your
Your
Monthly
Monthly
Monthly
Monthly
Share with Share with Share with Share with
29 Years of 28 Years of 27 Years of 20-26 Years
Service at
Service at Service at of Service at
12.0%
20.0%
24.0%
26.0%
31.4%
Individual
$583.09
$69.97
$116.62
$139.94
$151.60
$183.09
Parent/Child
1,155.27
138.63
231.05
277.26
300.37
362.75
Two Adults
1,391.46
166.98
278.29
333.95
361.78
436.92
Family
1,568.83
188.26
313.77
376.52
407.90
492.61
Individual
$622.87
$74.74
$124.57
$149.49
$161.95
$195.58
Parent/Child(ren)
1,234.04
148.08
246.81
296.17
320.85
387.49
Two Adults
1,486.37
178.36
297.27
356.73
386.46
466.72
Family
1,675.84
201.10
335.17
402.20
435.72
526.21
Kaiser Permanente HMO
Your
Total
Monthly
Monthly
Share with
Premium
or
30 or more
MEDICAL INSURANCE FOR
Equivalent
Years of
NON-MEDICARE (UNDER
Service at
Your
Your
Your
Your
Monthly
Monthly
Monthly
Monthly
Share with Share with Share with Share with
29 Years of 28 Years of 27 Years of 20-26 Years
Service at
Service at Service at of Service at
65) OAP **
CIGNA OAP (In/Out Network)
15.0%
23.5%
26.8%
30.1%
33.4%
Individual
$658.27
$98.74
$154.69
$176.42
$198.14
$219.86
Parent/Child
1,304.20
195.63
306.49
349.53
392.56
435.60
Two Adults
1,570.84
235.63
369.15
420.99
472.82
524.66
Family
1,771.06
265.66
416.20
474.64
533.09
591.53
**Domestic Partner benefits may be subject to imputed income
(continued on next page)
Baltimore County ­Public Schools
Retiree Benefits Guide
Monthly Contribution for Medical Benefits
Monthly Contribution for Non-Medicare Benefits
10
Monthly Contribution for Medical Benefits
Monthly Contribution for Non-Medicare Benefits
Retired January 1 – December 31, 2014 • Effective January 1, 2015 through December 31, 2015
MEDICAL INSURANCE
FOR NON-MEDICARE
(UNDER 65) OAPIN and
Kaiser **
Your Monthly Your Monthly Your Monthly Your Monthly Your Monthly
Share with
Share with
Share with
Share with
Share with
19 Years of
18 Years of
17 Years of 10-16 Years of 0-9 Years of
Service at
Service at
Service at
Service at
Service at
52.5%
55.0%
57.5%
60.0%
100.0%
$306.12
$320.70
$335.28
$349.85
$583.09
Parent/Child
606.52
635.40
664.28
693.16
1,155.27
Two Adults
730.52
765.30
800.09
834.88
1,391.46
Family
823.64
862.86
902.08
941.30
1,568.83
$327.01
$342.58
$358.15
$373.72
$622.87
Parent/Child(ren)
647.87
678.72
709.57
740.42
1,234.04
Two Adults
780.34
817.50
854.66
891.82
1,486.37
Family
879.82
921.71
963.61
1,005.50
1,675.84
CIGNA OAPIN (In Network)
Individual
Kaiser Permanente HMO
Individual
Your Monthly Your Monthly Your Monthly Your Monthly Your Monthly
Share with
Share with
Share with
Share with
Share with
19
Years
of
18
Years
of
17
Years
of
10-16
Years
of
0-9
Years of
MEDICAL INSURANCE FOR
Service at
Service at
Service at
Service at
Service at
NON-MEDICARE (UNDER
65) OAP **
52.5%
55.0%
57.5%
60.0%
100.0%
$345.59
$362.05
$378.51
$394.96
$658.27
Parent/Child
684.71
717.31
749.92
782.52
1,304.20
Two Adults
824.69
863.96
903.23
942.50
1,570.84
Family
929.81
974.08
1,018.36
1,062.64
1,771.06
CIGNA OAP (In/Out Network)
Individual
**Domestic Partner benefits may be subject to imputed income
Baltimore County ­Public Schools
Retiree Benefits Guide
11
Retired January 1 – December 31, 2015 • Effective January 1, 2015 through December 31, 2015
MEDICAL INSURANCE FOR
NON-MEDICARE (UNDER 65)
OAPIN and Kaiser **
Your Monthly Your Monthly Your Monthly Your Monthly
Total Monthly
Share with 30 Share with
Share with
Share with
Premium or
or more Years 29 Years of
28 Years of
27 Years of
Equivalent
of Service at
Service at
Service at
Service at
13.0%
CIGNA OAPIN (In Network)
20.0%
24.8%
28.1%
Individual
$583.09
$75.80
$116.62
$144.61
$163.85
Parent/Child
1,155.27
150.19
231.05
286.51
324.63
Two Adults
1,391.46
180.89
278.29
345.08
391.00
Family
1,568.83
203.95
313.77
389.07
440.84
Individual
$622.87
$80.97
$124.57
$154.47
$175.03
Parent/Child(ren)
1,234.04
160.43
246.81
306.04
346.77
Two Adults
1,486.37
193.23
297.27
368.62
417.67
Family
1,675.84
217.86
335.17
415.61
470.91
Kaiser Permanente HMO
MEDICAL INSURANCE FOR
NON-MEDICARE (UNDER 65)
OAP **
Your Monthly Your Monthly Your Monthly Your Monthly
Total Monthly
Share with 30 Share with
Share with
Share with
Premium or
or more Years 29 Years of
28 Years of
27 Years of
Equivalent
of Service at
Service at
Service at
Service at
CIGNA OAP (In/Out Network)
17.0%
23.5%
26.8%
30.1%
Individual
$658.27
$111.91
$154.69
$176.42
$198.14
Parent/Child
1,304.20
221.71
306.49
349.53
392.56
Two Adults
1,570.84
267.04
369.15
420.99
472.82
Family
1,771.06
301.08
416.20
474.64
533.09
**Domestic Partner benefits may be subject to imputed income
(continued on next page)
Baltimore County ­Public Schools
Retiree Benefits Guide
Monthly Contribution for Medical Benefits
Monthly Contribution for Non-Medicare Benefits
12
Monthly Contribution for Medical Benefits
Monthly Contribution for Non-Medicare Benefits
Retired January 1 – December 31, 2015 • Effective January 1, 2015 through December 31, 2015
MEDICAL INSURANCE FOR
NON-MEDICARE (UNDER 65)
OAPIN and Kaiser **
Your Monthly Your Monthly Your Monthly Your Monthly Your Monthly
Share with
Share with
Share with
Share with
Share with
26 Years of
25 Years of 20-24 Years of 19 Years of
18 Years of
Service at
Service at
Service at
Service at
Service at
CIGNA OAPIN (In Network)
31.4%
34.7%
38.0%
52.5%
55.0%
Individual
$183.09
$202.33
$221.57
$306.12
$320.70
Parent/Child
362.75
400.88
439.00
606.52
635.40
Two Adults
436.92
482.84
528.75
730.52
765.30
Family
492.61
544.38
596.16
823.64
862.86
$195.58
$216.14
$236.69
$327.01
$342.58
Parent/Child(ren)
387.49
428.21
468.94
647.87
678.72
Two Adults
466.72
515.77
564.82
780.34
817.50
Family
526.21
581.52
636.82
879.82
921.71
Kaiser Permanente HMO
Individual
MEDICAL INSURANCE FOR
NON-MEDICARE (UNDER 65)
OAP **
Your Monthly Your Monthly Your Monthly Your Monthly Your Monthly
Share with
Share with
Share with
Share with
Share with
26 Years of
25 Years of 20-24 Years of 19 Years of
18 Years of
Service at
Service at
Service at
Service at
Service at
CIGNA OAP (In/Out Network)
33.4%
36.7%
40.0%
52.5%
55.0%
Individual
$219.86
$241.59
$263.31
$345.59
$362.05
Parent/Child
435.60
478.64
521.68
684.71
717.31
Two Adults
524.66
576.50
628.34
824.69
863.96
Family
591.53
649.98
708.42
929.81
974.08
**Domestic Partner benefits may be subject to imputed income
Baltimore County ­Public Schools
Retiree Benefits Guide
13
Retired January 1 – December 31, 2015 • Effective January 1, 2015 through December 31, 2015
MEDICAL INSURANCE FOR
NON-MEDICARE (UNDER 65)
OAPIN and Kaiser **
Your Monthly Your Monthly Your Monthly Your Monthly Your Monthly
Share with
Share with
Share with
Share with
Share with
17 Years of
16 Years of
15 Years of 10-14 Years of 0-9 Years of
Service at
Service at
Service at
Service at
Service at
CIGNA OAPIN (In Network)
57.5%
60.0%
62.5%
65.0%
100.0%
Individual
$335.28
$349.85
$364.43
$379.01
$583.09
Parent/Child
664.28
693.16
722.04
750.93
1,155.27
Two Adults
800.09
834.88
869.66
904.45
1,391.46
Family
902.08
941.30
980.52
1,019.74
1,568.83
$358.15
$373.72
$389.29
$404.87
$622.87
Parent/Child(ren)
709.57
740.42
771.28
802.13
1,234.04
Two Adults
854.66
891.82
928.98
966.14
1,486.37
Family
963.61
1,005.50
1,047.40
1,089.30
1,675.84
Kaiser Permanente HMO
Individual
MEDICAL INSURANCE FOR
NON-MEDICARE (UNDER 65)
OAP **
Your Monthly Your Monthly Your Monthly Your Monthly Your Monthly
Share with
Share with
Share with
Share with
Share with
17 Years of
16 Years of
15 Years of 10-14 Years of 0-9 Years of
Service at
Service at
Service at
Service at
Service at
CIGNA OAP (In/Out Network)
57.5%
60.0%
62.5%
65.0%
100.0%
Individual
$378.51
$394.96
$411.42
$427.88
$658.27
Parent/Child
749.92
782.52
815.13
847.73
1,304.20
Two Adults
903.23
942.50
981.78
1,021.05
1,570.84
1,018.36
1,062.64
1,106.91
1,151.19
1,771.06
Family
**Domestic Partner benefits may be subject to imputed income
Baltimore County ­Public Schools
Retiree Benefits Guide
Monthly Contribution for Medical Benefits
Monthly Contribution for Non-Medicare Benefits
14
Monthly Rates for Dental and Vision Benefits for Retirees
Monthly Contribution for Medicare, Dental and Vision Benefits
Effective January 1, 2015 through December 31, 2015
Medicare Insurance **
CIGNA Medicare Surround
Individual
Two Adults over 65
Your Monthly Your Monthly Your Monthly Your Monthly
Total Monthly
Share with 30
Share with
Share with
Share with 0-9
Premium or
or more Years 20-29 Years of 10-19 Years of Years of Service
Equivalent
of Service at
Service at
Service at
at
16.0%
$586.40
1,172.80
34.0%
$93.82
187.65
64.0%
$199.38
398.75
$375.30
750.59
100.0%
$586.40
1,172.80
Your Monthly Your Monthly Your Monthly Your Monthly
Total Monthly
Share with 30 Share with
Share with
Share with
Premium or
or more Years 20-29 Years of 10-19 Years of 0-9 Years of
Equivalent
of Service at
Service at
Service at
Service at
Kaiser Medicare Plus
Individual
Two Adults over 65
$323.65
647.30
$-
Dental Insurance
Total Monthly
Premium or
Equivalent
Your Monthly
Share at
CareFirst Regional Dental PPO
Individual
Parent/Child or Two Adults
Family
CareFirst Regional Dental
Traditional
Individual
Parent/Child or Two Adults
Family
CIGNA Dental DHMO
Individual
Parent/Child(ren) or Two
Adults
Family
Vision Insurance
CareFirst Davis Vision
Individual
Family, Parent/Child and Two
Adults
0.0%
0.0%
32.0%
$-
$103.57
207.14
100.0%
$323.65
647.30
100.0%
$24.70
53.52
81.14
$24.70
53.52
81.14
$27.99
58.69
98.58
$27.99
58.69
98.58
$39.99
$39.99
76.66
115.26
76.66
115.26
Total Monthly
Premium or
Equivalent
Your Monthly
Share at
100.0%
$2.31
$2.31
8.87
8.87
**Domestic Partner benefits may be subject to imputed income
Baltimore County ­Public Schools
Retiree Benefits Guide
15
Each year you have an opportunity to review and change your benefit elections. The benefit elections you make will take
effect on January 1st.
Benefits Enrollment – A Quick Overview
Retirees do not need to re-enroll for medical, dental and/or vision benefits. If you cancel your participation in the dental
and/or vision plans, special re-enrollment rules apply.
Important Dates
October, 2014
October 7 – November 10, 2014
November 10 – 4:45 p.m.
January Pension Check
January 1, 2015 –
December 31, 2015
Baltimore County ­Public Schools
Enrollment Activity
Enrollment materials mailed
to retirees
Enrollment Period
Retirees may change plans
by completing the enclosed
enrollment form. Retirees are
NOT required to re-enroll. If you
do nothing your coverage will
remain the same.
Initial Deadline for receipt by
the Office of Benefits, Leaves
and Retirement for enrollment
applications to ensure a January
1st effective date.
Pension Check Deduction for
January 2015 plan costs in
effect.
New Benefits Plan elections
take effect. Changes may be
made during the Plan Year.
Contact the Office of Benefits,
Leaves and Retirement via
e-mail at [email protected] or
call (410) 887-8943.
Retiree Benefits Guide
Benefits Enrollment
Welcome to Benefits Enrollment
16
Benefits Enrollment
Eligible Retiree
Eligible Dependents
For a retiree to be considered eligible for benefits, the retiree
must have started collecting their Baltimore County Public
Schools sponsored pension immediately upon retirement
from Baltimore County Public Schools.
Eligible family members include your:
Rehired Retirees
n
Domestic Partner, which is defined as:
Employees seeking re-employment with Baltimore County
Public Schools following retirement from Baltimore
County Public Schools or Baltimore County Government
should contact the Department of HR for information
regarding the availability of positions. Prior to accepting
any employment (with BCPS or elsewhere), a retiree should
contact his/her pension plan to determine what effect, if
any, the employment will have on the amount of his/her
pension. These rules apply to all permanent, temporary,
and contractual positions.
nSame
nBoth
nNot
nWho
nReside together continuously for at least 12 months
n
Have
nNot legally married to anyone else or in a registered
As a retiree you can only enroll in the retiree benefit programs
offered. You may not enroll in benefits as a new employee.
For Maryland State Retirement Pension System (MSRPS)
retirees rehired into non-MSRPS-eligible positions
Retirees are eligible for rehire and may be eligible to
participate in the ERS pension plan.
For MSRPS retirees rehired into MSRPS-eligible positions
Retirees are eligible for rehire subject to an earnings
limitation (cap). This information is sent to you by MSRPS
at retirement. There may be some exceptions to this cap
therefore, please direct questions to MSRPS.
For ERS retirees rehired into non-ERS-eligible positions
ERS retirement benefits will continue, provided the new
position is MSRPS-eligible.
For ERS retirees rehired into ERS-eligible positions –
restrictions apply
ERS retirees are eligible for rehire in one category only
– temporary status. The individual may be hired as a
temporary employee one time only for a maximum of six
months, regardless of the number of hours worked. The
six-month period begins on the first day worked and ends
six months later. There is one exception to this rule; ERS
retirees who retired with a service retirement may work as
a school bus driver without an earnings restriction.
n
Legal spouse
n Domestic
partner
or opposite gender
18 years or older and
related by blood
share financial obligations
agreed to be jointly responsible for each
other’s welfare, and
domestic partnership with anyone else
To cover your domestic partner, your partnership MUST
be registered with BCPS. You can find more information
about domestic partner registration on the benefits Website
at www.bcps.org/offices/benefits/forms.
n Dependent
children
n
Children include the retiree’s:
nNatural
nStepchildren
nLegally
nA
n
Children
children
adopted children
child for whom you have legal guardianship
including grandchildren
of your Registered Domestic Partner
who depend on you for financial support
Dependent children are covered through the end of the
month they turn age 26. Student certifications are no
longer required. The retiree must be legally responsible
for providing the dependent’s health coverage through a
divorce decree, court order, or Qualified Medical Child
Support Order (QMCSO).
If a person is receiving a pension from MSRPS, they can
not participate in MSRPS while employed at BCPS.
Baltimore County ­Public Schools
Retiree Benefits Guide
17
When Your Dependent Loses
Eligibility for Coverage
If you and your spouse (or domestic partner) are both
retirees of BCPS, you may each enroll as an individual
or one of you can elect two-person or family health care
coverage. If you elect coverage separately, you cannot
claim each other as a dependent. Your eligible dependent
child(ren) may only be covered by one of you.
Any ineligible dependents should be removed from your
coverage as soon as they become ineligible. You must
notify the Office of Benefits, Leaves and Retirement at
410-887-8943 or email [email protected] within thirty (30)
days of any qualifying event (e.g. marriage, birth of a child,
divorce, etc.) affecting your eligibility or the eligibility of
your dependents. You should contact the Benefits Office,
in advance, so that the dependent can be removed from
coverage at the appropriate time. There are no refunds of
monthly deductions or quarterly payments taken during
the period of ineligibility. When coverage ends for a
dependent, he or she may choose to continue coverage
under COBRA for a maximum of 36 months, as long as you
have notified the Office of Benefits, Leaves and Retirement
within thirty (30) days of the loss of eligibility.
Important Domestic Partner Tax Note
Internal Revenue Service regulations require different tax
treatment for group insurance costs associated with samesex domestic partner coverage in cases where the partner
does not qualify as a tax dependent under the IRS Code.
(In determining the tax effect of same-sex domestic partner
coverage, Baltimore County Public Schools requires a
completed Declaration of Tax Status Form.)
The Federal and State tax consequences of benefits coverage
are different for a same-sex domestic partnership than
for a husband and wife. Under Federal law, Baltimore
County Public School’s contribution toward the cost of
health care coverage for a domestic partner and his or her
dependent(s) is considered taxable income to the retiree. It
should be noted that retirees are billed quarterly to cover a
domestic partner and dependent(s) on an after-tax basis.
The employee should consult with a tax advisor for a full
understanding of the tax consequences.
BCPS shall have the right to determine the eligibility of a
spouse and dependents consistent with the provisions of
the Plan.
Reminder: We have included a few examples of
INELIGIBLE dependents:
n
Anyone who is not your legal spouse (ex-spouse, etc.)
n
Dependents no longer covered by a court order
n
n
hildren of live-in partners, if the domestic partner
C
is not covered
Stepchildren following divorce from natural parent
Surviving Spouse Benefit
Upon retiree's death, if the spouse and dependent have
been covered under a BCPS health care plan, he or she will
have the option to continue coverage. The Board pays the
contribution in effect for one year after the retiree's death.
After one year, coverage may continue without any Board
contribution unless the spouse has been an employee of
BCPS. The Board contribution for premiums shown above
would continue as long as the surviving spouse elects
to continue coverage. A surviving spouse may not add
dependents.
Baltimore County ­Public Schools
Retiree Benefits Guide
Benefits Enrollment
Spouse or Domestic Partner Coverage
if Individual is Also a BCPS Employee
18
Benefits Enrollment
How to Enroll in or Change Benefits
n
n
n
Complete the Benefits Enrollment Form.
enrolling in Kaiser Permanente Select HMO, you
If
will have to select a Kaiser Primary Care Physician
or Kaiser Center. To find a participating center’s
location go to the Kaiser Permanente Website:
www.kaiserpermanente.org.
S ign and date your Benefits Enrollment Form and
return to the Benefits Office. The address is on the
form.
Enrollment Deadline
If you want to switch to a different plan, you must complete
a change form by the 10th of any month for coverage to be
effective the first day of the following month.
Baltimore County ­Public Schools
When Coverage Terminates
Retiree – Retiree coverage shall immediately terminate
upon the earliest of the following dates:
n
n
e date this Plan is terminated (if continuation of
Th
coverage is not available).
e period for which the retiree fails to make any
Th
required Plan contribution or quarterly payment.
Dependent – Dependent coverage shall immediately
terminate upon the earliest of the following dates, unless
the Retiree or the covered dependent elects continuation
of coverage:
n
n
n
n
n
last day of the month in which the Dependent
The
ceases to be an eligible Dependent as defined in
the Plan.
last day of the month in which the Retiree’s
The
coverage under the Plan is terminated.
Until
the last day of the month in which the child
reaches age 26.
period for which the Retiree fails to make
The
any required Plan contribution on behalf of the
Dependent.
date the Plan is terminated (if continuation of
The
coverage is not available).
Retiree Benefits Guide
19
Benefits Enrollment
Enrollment Deadline
Retiree applications must be received by the Office of
Benefits, Leaves and Retirement by November 10, 2014 at
4:45 p.m. for changes to be effective January 1, 2015.
The Office of Benefits, Leaves and Retirement is located at:
6901 North Charles St., Bldg. B
Towson, MD 21204
It is very important that enrollment material is complete
and received by the November 10 deadline. This allows us
time to send enrollment information to all of our benefit
plan administrators.
Information on the Web
Additional information can be found on the BCPS internet
Website at http://www.bcps.org/offices/benefits/retiree_ben/
You can email the Office of Benefits, Leaves and Retirement
at [email protected]. Responses are usually completed
within 24 hours.
Our benefit plan administrators maintain online Websites
for you to access information about their providers and
other programs they offer – plan Website addresses are
found in this guide.
Baltimore County ­Public Schools
Retiree Benefits Guide
20
Non-Medicare Medical Options – Highlights
Non-Medicare Medical Options — Highlights
Prior to enrolling in Medicare, retirees and their eligible
dependents can enroll in any medical plan offered to
active employees at the time of their retirement.
If BCPS changes the benefit plans and/or the costs of the
plans available to active employees, those same changes
will affect retirees. Changes are announced annually and
take effect January 1st of each year.
BCPS offers eligible retirees the choice of the following
medical plan options:
n
Kaiser Permanente HMO
n
Cigna Open Access Plus In Network - OAPIN
n
Cigna Open Access Plus - OAP
About Our Medical Plan Options
The medical plans offered through BCPS’ flexible benefits
program have different ways of delivering health care.
BCPS gives you the choice of one Health Maintenance
Organization (HMO) plan, one Open Access in-network
plan, and one Open Access in- or out-of-network plan.
The differences between the HMO plan and the Open
Access plans are the levels of coverage and the selection
of providers. An HMO and Open Access Plus in network
plan offers only one level of coverage and you must use
the network of participating providers. The Open Access
Plus allows for both in- and out-of-network providers.
The flexibility to seek care outside the network translates
into a higher price tag from your paycheck. You decide
which plan works best for you
What is a “Primary Care Physician (PCP)”?
The HMO option requires the selection of a Primary
Care Physician (PCP) to obtain the highest level of
coverage. A PCP is typically a general practitioner, a
family practitioner, an internist, or a pediatrician. You
and each covered member of your family must choose a
PCP from the plan’s provider directory. The most current
provider directory information is available from each
plan’s Website, from Member Services, or you may call the
Office of Benefits, Leaves and Retirement to obtain a paper
copy of the directory. The Open Access Plus in-network
and the Open Access Plus plans do not require a PCP but
it is recommended that a PCP be used to coordinate care.
Your PCP provides your medical care or refers you to a
specialist, as necessary. Your PCP will get to know your
medical history and your individual health care needs.
Primary Care Physicians make sure that you are not
receiving unnecessary medical treatment and that the
medications that you are taking are safe and effective.
There are generally no claim forms to complete or
submit. Call the Member Services number on your
medical plan identification card for information on
changing your PCP.
Important Note: This enrollment guide is neither a
contract nor a summary description of your health plan
choices. If you have specific questions about a particular
plan before enrolling in it, call the Office of Benefits, Leaves
and Retirement to obtain enrollment brochures and a copy
of the applicable Benefit Guide or Certificate of Coverage.
Baltimore County ­Public Schools
Retiree Benefits Guide
21
■■
24/7 service.
Whenever you need us, customer service
representatives are available to take your calls. You
can also speak with a health care professional over
the phone, any time, day or night.
■■
Access to myCigna.com.
Use a personalized website to:
Cigna’s Open Access Plus plan gives you important
choices. Each time you need care, you can choose the
doctors and other health professionals and facilities that
work best for you.
Enroll in the Open Access Plus plan and
you’ll get:
Options for accessing quality health care.
■■
■■
■■
Primary Care Physician (PCP).
You decide if you want to choose a PCP as your
personal doctor to help coordinate care and act as a
personal health advocate. It’s recommended but not
required.
In-network.
Choose to see doctors or other health professionals
who participate in the Cigna network to keep your
costs lower and eliminate paperwork.
No-referral specialist care.
If you need to see a specialist, you do not need a
referral to see a doctor who participates in the Cigna
network – just make the appointment and go! Precertification may be necessary for hospitalizations
and some types of outpatient care, but there is no
paperwork for you.
■■
Out-of-network.
You also have the freedom to visit doctors or use
facilities that are not part of the Cigna network, but
your costs will be higher and you may need to file a
claim.
■■
Emergency and urgent care.
When you need care, you’re covered, 24 hours a
day, worldwide.
Baltimore County ­Public Schools
■■
■■
■■
■■
Learn more about your plan and the coverage and
programs available to you.
iew claim history and account transactions; print
V
claim forms when you need them.
ind information and estimate costs for medical
F
procedures and treatments.
Learn how hospitals rank by number of procedures
performed, patients’ average length of stay and cost.
Questions and Answers
Do I have to choose a Primary Care Physician (PCP)?
No. However, a PCP gives you and your covered family
members a valuable resource and can be a personal
health advocate.
What if my doctor isn’t on your list?
That means your PCP does not participate in the
Cigna network. To receive your maximum coverage,
you should select a doctor from the Cigna list of
participating doctors and other health care professionals.
You can continue seeing your current doctor, even if he
or she is not in Cigna’s network. However, in that case,
you will pay higher out-of-pocket costs, and your care
will be covered at the out-of-network coverage level.
Retiree Benefits Guide
Non-Medicare Medical Options – Highlights
Cigna Open Access Plus
22
Non-Medicare Medical Options – Highlights
Do I need a referral to see a specialist?
Though you may want your personal doctor’s advice
and assistance in arranging care with a specialist in the
network, you do not need a referral to see a participating
specialist. If you choose an out-of-network specialist, your
care will be covered at the out-of-network coverage level.
What is the difference between in-network coverage
and out-of-network coverage?
Each time you seek medical care, you can choose your
doctor – either a doctor who participates in the Cigna
network or someone who does not participate. When
you visit a participating doctor, you receive “in-network
coverage” and will have lower out-of-pocket costs. That’s
because our participating health care professionals have
agreed to charge lower fees, and your plan covers a larger
share of the charges. If you choose to visit a doctor outside
of the network, your out-of-pocket costs will be higher.
What if I need to be admitted to the hospital?
In an emergency, your care is covered. Requests for
non-emergency hospital stays other than maternity stays
must be approved in advance or “pre-certified.” This
enables Cigna HealthCare to determine if the services are
covered.
Pre-certification is not required for maternity stays of
48 hours for vaginal deliveries or 96 hours for cesarean
sections. Depending on your plan, you may be eligible for
additional coverage. Any hospital stay beyond the initial
48 or 96 hours must be approved.
Who is responsible for obtaining pre-certification?
Your doctor will help you decide which procedures
require hospital care and which can be handled on an
outpatient basis. If your doctor participates in the Cigna
network, he or she will arrange for pre-certification. If
you use an out-of-network doctor, you are responsible
for making the arrangements. Your plan materials will
identify which procedures require pre-certification.
What is Case Management?
Case management is a program that assists customers
with the hardships of an illness. A nurse Case Manager
will help to coordinate the most appropriate care and
works with you, your family and your physicians for the
best results.
How do I find out if my doctor is in the Cigna network
before I enroll?
Our dedicated Enrollment Information Line is available
24/7 to help you learn about the benefits and advantages
of Cigna. Call today and a knowledgeable Enrollment
Specialist will provide you with assistance in identifying
participating physicians and related service providers.
Call us at 1.800.896.0948
Or go to the online provider directory found on
www.cigna.com
Click on “Find a Doctor”
Select a Directory
■■ Choose between “Doctor, Dentist, or Hospital,
Pharmacy, Facility”
■■ Enter a “Location” (City and State OR Zip Code)
■■ Click “Select a Plan”
■■ Click “Open Access Plus, OA Plus, ChoiceFund OA
Plus”
■■ Click “Choose”
■■ Click “A-Z” (for specialized doctors or search by
name (optional)
■■ Click “Search”
■■
■■
Print and email options are available to save your results.
After the plan effective date use www.mycigna.com,
which recognizes the plan you are in, and what health care
professionals are in your plan or simply call Customer
Support for assistance.
What if I go to an out-of-network physician who sends
me to a network hospital? Will I pay in-network or outof-network charges for my hospitalization?
Cigna HealthCare will cover authorized medical services
provided by an Open Access Plus participating hospital
at your in-network benefits level – whether you were sent
there by an in- or out-of-network doctor.
What is Transition of Care?
Transition of care coverage allows you to continue to receive
services for specified medical and behavioral conditions for a
defined period of time with health care professionals who do
not participate in the Cigna network until the safe transfer of
care to a participating doctor or facility can be arranged. You
must apply for Transition of Care at enrollment, or change
in Cigna medical plan, but no later than 30 days after the
effective date of your coverage.
For behavioral health related services please contact Cigna
Behavioral Health by calling the Customer Services phone
number on the back of your ID card.
Baltimore County ­Public Schools
Retiree Benefits Guide
23
■■
24/7 service.
Whenever you need us, customer service
representatives are available to take your calls. You
can also speak with a health care professional over
the phone, any time, day or night.
■■
Access to myCigna.com.
Use a personalized website to:
Cigna’s Open Access Plus In-Network plan gives you
important choices. Each time you need care, you can
choose the doctors and other health professionals and
facilities that work best for you.
Enroll in the Open Access Plus In-Network plan
and you’ll get:
Options for accessing quality health care.
■■
■■
■■
Primary Care Physician (PCP).
You decide if you want to choose a PCP as your
personal doctor to help coordinate care and act as a
personal health advocate. It’s recommended but not
required.
In-network.
For your health care to be covered by the plan, you
must choose a health care professional who is part
of the Cigna® network.
No-referral specialist care.
If you need to see a specialist, you do not need
a referral to see a doctor who participates in the
Cigna network – just make the appointment
and go! Pre-certification may be necessary for
hospitalizations and some types of outpatient care,
but there is no paperwork for you.
■■
Out-of-network.
If you choose to see a doctor who is not in the
network, your care will not be covered except in
emergencies.
■■
Emergency and urgent care.
When you need care, you’re covered, 24 hours a
day, worldwide.
Baltimore County ­Public Schools
■■
■■
■■
■■
Learn more about your plan and the coverage and
programs available to you.
iew claim history and account transactions; print
V
claim forms when you need them.
ind information and estimate costs for medical
F
procedures and treatments.
earn how hospitals rank by number of procedures
L
performed, patients’ average length of stay and
cost.
Questions and Answers
Do I have to choose a Primary Care Physician (PCP)?
No. However, a PCP gives you and your covered family
members a valuable resource and can be a personal
health advocate.
What if my doctor isn’t on your list?
That means your PCP does not participate in the Cigna
network. To receive coverage from your health plan, you
must select a doctor from the Cigna list of participating
doctors and other health care professionals. If you decide
to continue seeing your current doctor, your care will
not be covered by your plan.
Retiree Benefits Guide
Non-Medicare Medical Options – Highlights
Cigna Open Access Plus In-Network
24
Non-Medicare Medical Options – Highlights
Do I need a referral to see a specialist?
Though you may want your personal doctor’s advice and
assistance in arranging care with a specialist, you do not
need a referral to see a participating specialist. If you
choose an out-of-network specialist, your care will not be
covered by your plan.
How does my plan cover my care?
When you visit a doctor who participates in the Cigna
network, you receive in-network coverage and will
have lower out-of-pocket costs. That’s because our
participating health care professionals have agreed to
charge lower fees, and your plan covers a larger share of
the charges. If you choose to visit a doctor outside of the
network, your care will not be covered by your plan.
What if I need to be admitted to the hospital?
In an emergency, your care is covered. Requests for nonemergency hospital stays other than maternity stays must
be approved in advance or “pre-certified.” This enables
Cigna HealthCare® to determine if the services are
covered. Pre-certification is not required for maternity
stays of 48 hours for vaginal deliveries or 96 hours for
caesarean sections. Depending on your plan, you may be
eligible for additional coverage. Any hospital stay beyond
the initial 48 or 96 hours must be approved.
Who is responsible for obtaining pre-certification?
Your doctor will help you decide which procedures
require hospital care and which can be handled on an
outpatient basis. If your doctor participates in the Cigna
network, he or she will arrange for pre-certification. If
you use an out-of-network doctor, you are responsible
for making the arrangements and your care will not
be covered. Your plan materials will identify which
procedures require pre-certification.
What is Case Management?
Case management is a program that assists customers
with the hardships of an illness. A nurse Case Manager
will help to coordinate the most appropriate care and
works with you, your family and your physicians for the
best results.
Baltimore County ­Public Schools
How do I find out if my doctor is in the Cigna network
before I enroll?
Our dedicated Enrollment Information Line is available
24/7 to help you learn about the benefits and advantages
of Cigna. Call today and a knowledgeable Enrollment
Specialist will provide you with assistance in identifying
participating physicians and related service providers.
Call us at 1.800.896.0948
Or go to the online provider directory found on www.
cigna.com
Click on “Find a Doctor”
Select a Directory
■■ Choose between “Doctor, Dentist, or Hospital,
Pharmacy, Facility”
■■ Enter a “Location” (City and State OR Zip Code)
■■ Click “Select a Plan”
■■ Click “Open Access Plus, OA Plus, ChoiceFund OA
Plus”
■■ Click “Choose”
■■ Click “A-Z” (for specialized doctors or search by
name (optional)
■■ Click “Search”
■■
■■
Print and email options are available to save your
results. After the plan effective date use www.mycigna.
com, which recognizes the plan you are in, and what
health care professionals are in your plan or simply call
Customer Support for assistance.
What is Transition of Care?
Transition of care coverage allows you to continue to
receive services for specified medical and behavioral
conditions for a defined period of time with health
care professionals who do not participate in the Cigna
network until the safe transfer of care to a participating
doctor or facility can be arranged. You must apply for
Transition of Care at enrollment, or change in Cigna
medical plan, but no later than 30 days after the effective
date of your coverage.
For behavioral health related services please contact
Cigna Behavioral Health by calling the Customer
Services phone number on the back of your ID card.
Retiree Benefits Guide
25
How are Prescriptions Covered?
n See the prescription drug services section on the
Medical Options At-a-Glance chart that follows
for details.
n The use of generic drugs, if available, is mandatory.
If you obtain a brand name drug when a generic
is available, regardless of the circumstances, you
will pay more.
Baltimore County ­Public Schools
Is a Mail Order Program Offered?
Yes. The ESI mail order program provides you with
the convenience of receiving up to a 90-day supply of
prescription maintenance medications at your home. You
can order refills using ESI’s automated touch-tone refill
system or by using their Website at www.express-scripts.
com. Your medications will be delivered by the U.S. Postal
Service or UPS within seven business days of receipt at ESI.
To obtain further information about the mail order program,
call ESI at (877) 852-4061. Order forms are available from
the Office of Benefits, Leaves and Retirement.
Note: If you change your address, contact the Office of
Benefits, Leaves and Retirement. All address information
is provided to each vendor with the exception of Express
Scripts mail order. You must contact the mail order
number directly to change your mailing address.
Retiree Benefits Guide
Non-Medicare Medical Options – Highlights
Prescription Drug Coverage for Cigna Members
Prescription drug coverage is provided through Express
Scripts (ESI). A separate identification card will be
mailed directly to your home for use at participating
pharmacies throughout the country. To obtain the name
of a pharmacy that is conveniently located in your area,
visit their Website at www.express-scripts.com or call
Member Services.
26
About Kaiser Permanente
It’s one neat package
At Kaiser Permanente, we combine health plans, facilities, and practitioners in one
neat package—making your membership convenient and easy to use. Our members
have relied on this all-in-one model of health care for more than 65 years, and it’s
something we continue to perfect.
Your health plan
made simple
Where you go for
personalized care
A care team
focused on you
Your health plan is the key to
the care you need and so much
more, including:
Every Kaiser Permanente facility
in our area is connected to your
electronic health record, which
keeps your care team informed
and ready to give you the right
care at the right time.
With Kaiser Permanente, you get
a choice of personal physicians for
you and your family. To find one
that’s right for you, just go online
to kp.org/doctor. All of our Kaiser
Permanente physicians work
closely together to help you get
well and stay well. This teamwork
is part of our focus on prevention
and our commitment to providing
you with personalized care.
u
Freedom to email your doctor’s
office, anytime, day or night.
u
Online tools that let you make
appointments, order most
prescription refills, and read
most lab test results (and so
much more).
u
Urgent care clinics open on
evenings and weekends to suit
your needs.
u
Health and wellness programs,
both online and off, to help you
stay well.
Baltimore County ­Public Schools
Our medical centers combine
state-of-the-art technology and
expert physicians in convenient
medical centers. Most include
pharmacy, lab, and X-ray services
on site so you can spend more
time on things you enjoy.
See page 24 for a quick-reference guide with phone numbers, addresses, and other resources.
Retiree Benefits Guide
1
27
Getting started
Good health begins with
your doctor
Your experience with the total
health approach of Kaiser
Permanente begins with your
selection of your primary care
physician (PCP) who takes an
interest in your well-being,
ultimately promoting a healthier
life for you. You and your PCP will
review your medical background
together and discuss your health
goals (such as reducing stress,
quitting smoking, lowering your
cholesterol, or lowering your
blood sugar).
You have access to the almost
1,000 physicians in the MidAtlantic Permanente Medical
Group, P.C., along with network
physicians who do not practice
in our medical centers but are in
private practice.
Looking for the best?
When you search for the best of
anything, you don’t begin with a
field of thousands. You start with a
pre-screened set of trusted, highquality options, often verified by
third parties. That’s what you get
with the Mid-Atlantic Permanente
Medical Group, P.C.—a group
of physicians whose credentials,
education, and training are
certain, and who practice
evidence-based medicine and
preventive care.
Before any physician begins
practicing with Kaiser Permanente,
he or she must first undergo a
screening process. Physicians
are board certified or become
board certified within five years
of being hired or joining the
medical group. This means they
have had additional training in
their specialty and successfully
completed a medical specialty
exam. In addition, all physicians
and surgeons go through a review
process every two to three years
to verify that their credentials,
including license and board
certification, are up-to-date. When
you choose a Kaiser Permanente
physician, you’re assured that
we have already reviewed and
confirmed his or her credentials.
It’s tough to become one of our doctors
Only 1 in 10 who applies is accepted as a Kaiser Permanente doctor.
kaiser Permanente physicians promote a healthy lifestyle, disease prevention, education,
and open communication. improving patient health using these approaches, combined with
management of chronic diseases, is a cornerstone of kaiser Permanente medicine.
Baltimore County ­Public Schools
Retiree Benefits Guide
5
28
Your primary care
physician (PCP)
The Kaiser Permanente
team advantage
It’s our goal to help you create
the healthiest life possible for
you and your family. That begins
by establishing a relationship
with a PCP and seeing him or her
regularly so you get consistent
and personalized care. Your
PCP is your personal physician
who will care for your total wellbeing—helping you stay healthy,
as well as treating you if you get
sick. This doctor is responsible
for coordinating your health care
needs, including hospital and
specialty care, if needed.
Small teams of physicians
practice in the same office
with a group of nurses and
other professionals. This team
approach helps maintain the
continuity of your care and,
when your doctor is unavailable,
provides you with a doctor
on the same team to see. As
necessary, your PCP or Ob/Gyn
also consults with any number
of physician specialists or other
health care professionals, such
as nutritionists or physical
therapists, who practice at the
same medical center or at other
Kaiser Permanente locations.
Each family member may select
his or her own PCP. Adults should
select a doctor who specializes
in internal medicine or family
practice. For members under age
18, physicians in pediatrics are
available. You may also choose a
family practitioner who cares for
your entire family.
If you choose a doctor in the
network, talk with that physician
about how his or her health care
team is organized to support
your care.
Choose your physician
Your obstetrician/
gynecologist (Ob/Gyn)
Women will choose an Ob/Gyn
in addition to their PCP. Your
relationship with your Ob/Gyn
is a special one that’s important
throughout your life. As with your
PCP, your Ob/Gyn is your personal
physician and will coordinate
your Ob/Gyn–related health care
needs while communicating with
your PCP, providing you with
consistent, personalized care. You
may make appointments directly
with your Ob/Gyn.
6
Baltimore County ­Public Schools
Each Kaiser Permanente PCP and
Ob/Gyn has a panel (roster) of
patients composed of members
who have either selected or
been assigned to that physician.
Occasionally, it is necessary to
temporarily close a physician’s
panel because of high demand
by patients to see that particular
physician. If you are told the
physician you have selected
is not accepting new patients,
we will try to offer you another
physician who is a member
of your originally requested
physician’s health care team.
1. Learn about the doctors
u
Browse individual physician
Web pages at kp.org/doctor.
u
Review a list of physicians in the
printed physician directory.
u
Contact Member Services
for assistance.
2. Choose your PCP
If you don’t choose a PCP when
you enroll, we’ll send you a letter
asking you to make a selection. If
you still do not choose one, we’ll
make a selection for you, based
on where you live, and notify
you in writing. Of course, you can
change your PCP any time you like.
3. Choose your Ob/Gyn
Women choose an Ob/Gyn in
addition to the PCP (your
Ob/Gyn cannot be your PCP). We
recommend that you make your
selection when you enroll. If you
do not make your selection within
the first month of becoming a
member, we will select one for
you. Of course, you can change
your Ob/Gyn any time you like.
4. Tell us your choices. You can:
u
Choose your physician by
registering at kp.org and
visiting kp.org/doctor, or by
calling Member Services.
u
Use the selection form included
in the physician directory.
u
Indicate your selections on the
form provided by your employer.
See page 24 for a quick-reference guide with phone numbers, addresses, and other resources.
Retiree Benefits Guide
29
How to change your
PCP or Ob/Gyn
You may choose a different
physician at any time for any
reason. Simply:
u
Visit kp.org/doctor, or
u
Call Member Services
You’ll receive a letter
acknowledging the change. If
you must change from a Kaiser
Permanente physician who
practices in one of our medical
centers to a network physician
who does not practice at a
medical center (or vice versa),
you will need to request that
your medical records be sent to
your new doctor’s location.
If you choose a network
physician
If you select a network PCP or
Ob/Gyn who practices in the
community, you may use the
services (such as the pharmacy
and lab) in Kaiser Permanente
medical centers. Keep in mind
that when you use a network
physician, you will not have the
benefit of:
1. The connectivity between
Kaiser Permanente physicians
and other caregivers made
possible by our electronic
medical record,
2. The convenience of having
many services in one
building, and
Baltimore County ­Public Schools
3. Functions available to
registered users of
My Health Manager at
kp.org/myhealthmanager,
such as:
u
u
u
u
Emailing your doctor’s
office,
Managing appointments
online,
Requesting most
prescription refills,
Viewing most lab test
results, and more.
location and you would like to
continue seeing him or her at
the new location, you may.
If you select a network physician,
we will notify you of changes in his
or her status as we are informed of
them by the doctor.
As always, you may change your
PCP or Ob/Gyn at any time for
any reason.
New member orientation
We will notify you about
physician changes
If your PCP or Ob/Gyn leaves
Kaiser Permanente (or changes
office location), we will mail
you a letter explaining the
change and when the change
is effective. If a new physician is
not named to take your doctor’s
patients, you will be asked to
select another physician. If a
replacement is named, you will
receive a letter about the new
physician. Of course, if your
physician is changing to another
Kaiser Permanente medical center
Talk directly with our staff at a
new member orientation about a
range of topics such as choosing
a PCP, where to call for medical
care, how to take advantage
of our self-care and preventive
care classes, what to do in an
emergency, and more. Call
Member Services for information
on when and where new
member orientation meetings
will be held.
KP.ORG/DOCTOR
Read about Kaiser Permanente physicians on their personal
Web pages. You’ll find information about their education
and credentials, and a link to email the doctor’s office. Some
physicians include details about their special professional
interests and personal hobbies and provide general medical
information for their patients.
Retiree Benefits Guide
7
30
What’s new in your area
With medical centers close to
where you live and work, health
care has never been more
convenient. To find a location
near you, visit kp.org/facilities
or download a free app for your
Maryland
Virginia
1
1 Annapolis
Annapolis Medical
Medical Center
Center
19 Ashburn
EXPANDED
Ashburn
19
Medical
Center
Medical Center
20 Burke Medical Center
20 Burke Medical Center
21 Fair Oaks Medical Center
21 Fair Oaks Medical Center
22 Falls Church Medical Center
22 Falls Church Medical Center
23 Kaiser Permanente
23 Fredericksburg
Kaiser Permanente
Medical Center†
Fredericksburg Medical Center†
24 Manassas Medical Center
24 Manassas Medical Center
25 MOVING Penderbrook Medical
25 Center
MOVING Penderbrook
Medical Center
26 Reston Medical Center
26 Reston Medical Center
27 Springfield Medical Center
27 Springfield Medical Center
28 Tysons Corner Medical Center
28 NEW Tysons Corner
29 Woodbridge Medical Center
Medical Center
2 Camp
2
Camp Springs
Springs Medical
Medical Center
Center
3 City
City Plaza
Plaza Medical
Medical Center
Center
4 Columbia
Columbia Gateway
Gateway Medical
Medical
Center
Center
5 Kaiser
Kaiser Permanente
Permanente Frederick
Frederick
Medical
Medical Center
Center
Gaithersburg
6 NEW
Gaithersburg
Medical Center
Medical Center
7 Kensington Medical Center
7 Kensington Medical Center
8 EXPANDING Largo Medical
8 EXPANDING
Largo
Center
Medical Center
9 Marlow Heights Medical Center
9 Marlow Heights Medical Center
10 Prince George’s Medical Center
10 Prince George’s Medical Center
11 Severna Park Medical Center
11 Severna Park Medical Center
12 Shady Grove Medical Center
12 Shady Grove Medical Center
13 Silver Spring Medical Center
13 Silver Spring Medical Center
14 South Baltimore County Medical
Center – Open
24/7/365
Days
14 COMING
SOON
South Baltimore
County Medical Center
15 Summit Behavioral Health
Center Behavioral Health Center
15 Summit
smartphone or mobile device
from the App Store or from
Google Play.
Washington, D.C.
30 Kaiser
Kaiser Permanente
Permanente Capitol
Capitol Hill
Hill
30
Medical
Center
Medical Center
31 Northwest
NEW Northwest
D.C. Medical
31
D.C. Medical
Office
Office
Building
Building
29 Woodbridge Medical Center
16 Towson
Towson Medical
Medical Center
Center
17 White
White Marsh
Marsh Medical
Medical Center
Center
17
18 Woodlawn
Medical Center
Center
18
Woodlawn Medical
For information about the services all our medical centers provide, visit kp.org/facilities.
Baltimore County ­Public Schools
Retiree Benefits Guide
21
31
Medical Options At-a-Glance
Baltimore County ­Public Schools
Retiree Benefits Guide
32 Medical Options At-a-Glance Chart
Non-Medicare Medical Options At-a-Glance Chart
(Summary Plan Document Prevails; visit www.bcps.org/offices/benefits for full details)
Plan Name
Cigna OAPIN
Member Services
Cigna (Medical)
800-896-0948
Express Scripts (Prescription)
877-852-4061
Cigna (Mental Health)
800-274-7603
Group Number
3216080
Plan Facts
Benefit Levels
Calendar Year Deductible (Jan 1 - Dec 31)
- Individual
- Family
Individual $0
Family $0
Coinsurance
You pay 0%
Plan pays 100%
Calendar Year Out-of-Pocket Maximum
- Individual
- Family
Medical:
Individual $1,100
Family $3,600
Lifetime Maximum
Unlimited
Prescription:
Individual $5,500
Family $9,600
PROFESSIONAL SERVICES
Office Visits
- PCP
- Specialist
Primary Care Physician
You pay $15 per visit
Specialist
You pay $20 per visit
Physical/Speech/Occupational
Therapy Office Visit
You pay $20 per visit
40 days for each therapy per calendar year
Chiropractic Office Visit
You pay $20 per visit
Limited to 40 days per calendar year
Diagnostic Laboratory Tests, X-Rays
Physician’s Office
You pay 0%
Plan pays 100%
Associated PCP or Specialist visit copay may apply.
Allergy Shots/Other Covered Injections
You pay 0%
Plan pays 100%
Allergy Serum
You pay 0%
Plan pays 100%
Allergy Testing
You pay 0%
Plan pays 100%
Baltimore County ­Public Schools
Retiree Benefits Guide
January 1, 2015 to December 31, 2015 33
In-Network
Kaiser Permanente
Out-of-Network
Cigna (Medical)
800-896-0948
Express Scripts (Prescription)
877-852-4061
Cigna (Mental Health)
800-274-7603
Cigna (Medical)
800-896-0948
Express Scripts (Prescription)
877-852-4061
Cigna (Mental Health)
800-274-7603
3216080
3216080
800-777-7902
Kaiser (Mental Health)
866-530-8778
7434-6
HMO
Individual $200
Family $400
Individual $300
Family $600
None
None
You pay 15%
Plan pays 85%
after the deductible is met
You pay 25%
Plan pays 75%
after the deductible is met
N/A
Medical:
Individual $1,000
Family $2,000
Individual $1,500
Family $3,000
Prescription:
Individual $5,600
Family $11,200
Prescription:
Individual $5,600
Family $11,200
Individual $3,500
Family $9,400
Unlimited
Unlimited
Unlimited
Primary Care Physician
You pay $20 per visit
Specialist
You pay $30 per visit
You pay 25%
Plan pays 75%
after the deductible is met
100% after $5 copay
100% after $5 copay (referral required)
You pay $30 per visit
100 days all therapies combined
per calendar year
(In-network and Out-of-network)
You pay 25%
Plan pays 75%
after the deductible is met
100 days all therapies combined per
calendar year
(In-network and Out-of-network)
100% after $5 copay (maximum 30 visits
or 90 days per contract year)
You pay $30 per visit
Unlimited days per calendar year
You pay 25%
Plan pays 75% after the deductible is met
Unlimited days per calendar year
Discounts available- no referral
Physician’s Office
You pay 0%
Plan pays 100%
Associated PCP or Specialist visit copay
may apply.
You pay 25%
Plan pays 75%
after deductible is met
100%
You pay 0%
Plan pays 100%
no deductible
You pay 25%
Plan pays 75%
after the deductible is met
100% after $5 copay
You pay 0%
Plan pays 100%
no deductible
You pay 25%
Plan pays 75%
after the deductible is met
100%
You pay 15%
Plan pays 85%
after the deductible is met
You pay 25%
Plan pays 75%
after the deductible is met
100% after $5 copay
Baltimore County ­Public Schools
Retiree Benefits Guide
Non-Medicare Medical Options At-a-Glance Chart
Cigna OAP
34 Medical Options At-a-Glance Chart (continued)
Non-Medicare Medical Options At-a-Glance Chart
(Summary Plan Document Prevails; visit www.bcps.org/offices/benefits for full details)
Plan Name
Cigna OAPIN
Member Services
Cigna (Medical)
800-896-0948
Express Scripts (Prescription)
877-852-4061
Cigna (Mental Health)
800-274-7603
Plan Facts
Group Number
3216080
Benefit Levels
PREVENTIVE CARE
Well Child Visit/Immunization
You pay 0%
Plan pays 100%
Routine Gynecological Exam
(no referral required)
You pay 0%
Plan pays 100%
Routine Pap Smear (no referral required)
You pay 0%
Plan pays 100%
Routine Mammogram (once per 12 months)
You pay 0%
Plan pays 100%
Routine Adult Physical
You pay 0%
Plan pays 100%
PSA Testing
You pay 0%
Plan pays 100%
HOSPITAL SERVICES (Inpatient & Outpatient)
Semi-Private Room and Board
$100 copay per admission, then
You pay 0%
Plan pays 100%
Lab Tests and X-Rays
(Outpatient)
Physician’s Office
You pay 0%
Plan pays 100%
Associated PCP or Specialist visit copay may apply.
Home Health Care
You pay 0%
Plan pays 100%
Unlimited days per calendar year
Skilled Nursing Facility/Rehab Facility Care
You pay 0%
Plan pays 100%
100 days per calendar year
Baltimore County ­Public Schools
Retiree Benefits Guide
January 1, 2015 to December 31, 2015 35
Kaiser Permanente
In-Network
Out-of-Network
Cigna (Medical)
800-896-0948
Express Scripts (Prescription)
877-852-4061
Cigna (Mental Health)
800-274-7603
Cigna (Medical)
800-896-0948
Express Scripts (Prescription)
877-852-4061
Cigna (Mental Health)
800-274-7603
3216080
3216080
800-777-7902
Kaiser (Mental Health)
866-530-8778
7434-6
HMO
You pay 0%
Plan pays 100%
no deductible
You pay 25%
Plan pays 75%
after the deductible is met
100%
You pay 0%
Plan pays 100%
no deductible
You pay 25%
Plan pays 75%
after the deductible is met
100%
You pay 0%
Plan pays 100%
no deductible
You pay 0%
Plan pays 100%
no deductible
100%
You pay 0%
Plan pays 100%
no deductible
You pay 0%
Plan pays 100%
no deductible
100%
You pay 0%
Plan pays 100%
no deductible
You pay 25%
Plan pays 75%
after the deductible is met
100%
(once per calendar year)
You pay 0%
Plan pays 100%
no deductible
You pay 0%
Plan pays 100%
no deductible
100%
You pay 15%
Plan pays 85%
after the deductible is met
You pay 25%
Plan pays 75%
after the deductible is met
100%
Physician’s Office
You pay 0%
Plan pays 100%
Associated PCP or Specialist visit copay
may apply.
You pay 25%
Plan pays 75%
after deductible is met
100%
You pay 0%
Plan pays 100%
no deductible
130 days per calendar year
(In-network and Out-of-network)
You pay 25%
Plan pays 75%
after the deductible is met
130 days per calendar year
(In-network and Out-of-network)
100%
You pay 15%
Plan pays 85%
after the deductible is met
120 days per calendar year
(In-network and Out-of-network)
You pay 25%
Plan pays 75%
after the deductible is met
120 days per calendar year
(In-network and Out-of-network)
100% (maximum of 100 days per plan year)
Baltimore County ­Public Schools
Retiree Benefits Guide
Non-Medicare Medical Options At-a-Glance Chart
Cigna OAP
36 Medical Options At-a-Glance Chart (continued)
Non-Medicare Medical Options At-a-Glance Chart
(Summary Plan Document Prevails; visit www.bcps.org/offices/benefits for full details)
Plan Name
Cigna OAPIN
Member Services
Cigna (Medical)
800-896-0948
Express Scripts (Prescription)
877-852-4061
Cigna (Mental Health)
800-274-7603
Plan Facts
Group Number
3216080
Benefit Levels
HOSPITAL SERVICES
(Inpatient & Outpatient) (CONT.)
Physician/Surgical Services
You pay 0%
Plan pays 100%
Anesthesia Services
You pay 0%
Plan pays 100%
Medical Consultations
Outpatient - Primary Care Physician
You pay $15 per visit
Specialist
You pay $20 per visit
Inpatient - You pay 0%
Plan pays 100%
ICU/CCU
$100 copay per admission, then
You pay 0%
Plan pays 100%
Hospice Care
You pay 0%
Plan pays 100%
Dialysis/Radiation/Chemotherapy
(Inpatient)
$100 copay per admission then
You pay 0%
Plan pays 100%
Dialysis/Radiation/Chemotherapy
(Outpatient)
You pay 0%
Plan pays 100%
Physical/Speech/Occupational Therapy
(Inpatient)
$100 copay per admission then
You pay 0%
Plan pays 100%
Physical/Speech/Occupational Therapy
(Outpatient)
You pay $20 per visit, 40 days for each therapy per calendar year
Outpatient Diagnostic Services
You pay 0%
Plan pays 100%
SUPPLIES
Durable Medical Equipment
You pay 0%, plan pays 100%,(unlimited maximum)
Hearing aids for adult and children:
Unlimited dollar amount, 2 hearing aids every three years
Baltimore County ­Public Schools
Retiree Benefits Guide
January 1, 2015 to December 31, 2015 37
Kaiser Permanente
In-Network
Out-of-Network
Cigna (Medical)
800-896-0948
Express Scripts (Prescription)
877-852-4061
Cigna (Mental Health)
800-274-7603
Cigna (Medical)
800-896-0948
Express Scripts (Prescription)
877-852-4061
Cigna (Mental Health)
800-274-7603
3216080
3216080
800-777-7902
Kaiser (Mental Health)
866-530-8778
7434-6
HMO
You pay 15%
Plan pays 85%
after the deductible is met
You pay 25%
Plan pays 75% per visit
after the deductible is met
100%
You pay 15%
Plan pays 85%
after the deductible is met
You pay 25%
Plan pays 75% after the deductible is met
100%
Outpatient - Primary Care Physician
You pay $20 per visit
Specialist
You pay $30 per visit
Inpatient - You pay 15%
Plan pays 85%
after the deductible is met
Outpatient and Inpatient
You pay 25%
Plan pays 75%
after the deductible is met
100%
You pay 15%
Plan pays 85%
after the deductible is met
You pay 25%
Plan pays 75%
after the deductible is met
100%
You pay 0%
Plan pays 100%
no deductible
You pay 0%
Plan pays 100%
no deductible
100%
You pay 15%
Plan pays 85%
after the deductible is met
You pay 25%
Plan pays 75%
after the deductible is met
100%
You pay 0%
Plan pays 100%
no deductible
You pay 25%
Plan pays 75%
after the deductible is met
100% after $5 copay
You pay 15%
Plan pays 85%
after the deductible is met
100 days per calendar year
(In-network and Out-of-network)
You pay 25%
Plan pays 75%
after the deductible is met
100 days per calendar year
(In-network and Out-of-network)
100%
You pay $30 per visit
100 days per calendar year
(In-network and Out-of-network)
You pay 25%
Plan pays 75%
after the deductible is met
100 days per calendar year
(In-network and Out-of-network)
100% after $5 copay
You pay 0%
Plan pays 100%
You pay 25%
Plan pays 75%
after the deductible is met
100%
You pay 0%, plan pays 100%,(unlimited
maximum)
You pay 0%, plan pays 100%,(unlimited
maximum)
Hearing aids for adult and children:
Unlimited dollar amount, 2 hearing aids
every three years
Hearing aids for adult and children:
Unlimited dollar amount, 2 hearing aids
every three years
100% of allowed benefit for basic DME;
Hearing aids for adults and children 1 per ear
every 36 months to $1,000 max per ear for
adults; $1,400 max per ear for children.
Baltimore County ­Public Schools
Retiree Benefits Guide
Non-Medicare Medical Options At-a-Glance Chart
Cigna OAP
38 Medical Options At-a-Glance Chart (continued)
Non-Medicare Medical Options At-a-Glance Chart
(Summary Plan Document Prevails; visit www.bcps.org/offices/benefits for full details)
Plan Name
Cigna OAPIN
Member Services
Cigna (Medical)
800-896-0948
Express Scripts (Prescription)
877-852-4061
Cigna (Mental Health)
800-274-7603
Plan Facts
Group Number
3216080
Benefit Levels
SUPPLIES
Prosthetic Devices and Orthopedic Braces
You pay 0%
Plan pays 100%
Unlimited Maximum
per Calendar Year
Diabetic Supplies
You pay 0%
Plan pays 100%
EMERGENCY SERVICES
Emergency Room
if admitted
if discharged
Urgent Care
Ambulance
(Air Ambulance if medically necessary)
You pay $50 per visit
(copay waived if admitted)
Copay waived if admitted, You pay $25 per visit, no deductible
You pay 0%
Plan pays 100%
MATERNITY/INFERTILITY SERVICES2
Pre- and Postnatal Care and Delivery
Initial Visit to confirm pregnancy
Primary Care Physician
You pay $15 per visit
Specialist
You pay $20 per visit
Global Maternity Professional Fees
You pay 0%
Plan pays 100%
Inpatient Facility
$100 copay per admission, then
You pay 0%
Plan pays 100%
Sterilization/Reverse Sterilization
Physician’s Office
Primary Care Physician
You pay $15 per visit
Specialist
You pay $20 per visit
Inpatient Facility
$100 copay per admission, then
You pay 0%
Plan pays 100%
Outpatient Facility
You pay 0%
Plan pays 100%
Excludes reversal of sterilization
Baltimore County ­Public Schools
Retiree Benefits Guide
January 1, 2015 to December 31, 2015 39
Kaiser Permanente
In-Network
Out-of-Network
Cigna (Medical)
800-896-0948
Express Scripts (Prescription)
877-852-4061
Cigna (Mental Health)
800-274-7603
Cigna (Medical)
800-896-0948
Express Scripts (Prescription)
877-852-4061
Cigna (Mental Health)
800-274-7603
3216080
3216080
800-777-7902
Kaiser (Mental Health)
866-530-8778
7434-6
HMO
You pay 0%
Plan pays 100%
no deductible
Unlimited Maximum per Calendar Year
You pay 25%
Plan pays 75%
after deductible is met
Unlimited Maximum per
Calendar Year
100% of allowed benefit
You pay 0%
Plan pays 100%
no deductible
You pay 25%
Plan pays 75%
after deductible is met
80% of allowed benefit
You pay $70 per visit
no deductible
(copay waived if admitted)
Copay waived if admitted, You pay $30
per visit, no deductible
You pay $70 per visit
no deductible
(copay waived if admitted)
Copay waived if admitted, You pay $30 per
visit, no deductible
100%
100% after $35 copay
You pay 0%
Plan pays 100%
no deductible
You pay 0%
Plan pays 100%
no deductible
100% if medically necessary
Initial Visit to confirm pregnancy
Primary Care Physician
You pay $20 per visit
Specialist
You pay $30 per visit
Global Maternity Professional Fees
You pay 5%
Plan pays 95%
after the deductible is met
Inpatient Facility, Outpatient Facility
You pay 15%
Plan pays 85%
after the deductible is met
You pay 25%
Plan pays 75%
after the deductible is met
100%
Primary Care Physician
You pay $20 per visit
Specialist
You pay $30 per visit
Inpatient Facility, Outpatient Facility,
Physician’s services
You pay 15%
Plan pays 85%
after the deductible is met
Excludes reversal of sterilization
You pay 25%
Plan pays 75%
after the deductible is met
Excludes reversal of sterilization
Applicable cost share based upon place of
service. Reverse sterilization not covered.
Baltimore County ­Public Schools
Retiree Benefits Guide
Non-Medicare Medical Options At-a-Glance Chart
Cigna OAP
40 Medical Options At-a-Glance Chart (continued)
Non-Medicare Medical Options At-a-Glance Chart
(Summary Plan Document Prevails; visit www.bcps.org/offices/benefits for full details)
Plan Name
Cigna OAPIN
Member Services
Plan Facts
Cigna (Medical)
800-896-0948
Express Scripts (Prescription)
877-852-4061
Cigna (Mental Health)
800-274-7603
Group Number
3216080
Benefit Levels
MATERNITY/INFERTILITY SERVICES2
Elective Abortions in Inpatient and
Outpatient Facility
Primary Care Physician
You pay $15 per visit
Specialist
You pay $20 per visit
Inpatient Facility
$100 copay per admission, then
You pay 0%
Plan pays 100%
Outpatient Facility;
Physician’s Services
You pay 0%
Plan pays 100%
Artificial Insemination
(requires pre-authorization)
Primary Care Physician
You pay $15 per visit
Specialist
You pay $20 per visit
Inpatient Facility
$100 copay per admission, then
You pay 0%
Plan pays 100%
Outpatient Facility;
Physician’s Services
You pay 0%
Plan pays 100%
Unlimited dollar maximum
InVitro Fertilization
(requires pre-authorization)
Primary Care Physician
You pay $15 per visit
Specialist
You pay $20 per visit
Inpatient Facility
$100 copay per admission, then
You pay 0%
Plan pays 100%
Outpatient Facility;
Physician’s Services
You pay 0%
Plan pays 100%
Unlimited dollar maximum
MENTAL HEALTH AND SUBSTANCE ABUSE
3
Max (10) EAP visits with Cigna Behavioral
or BCPS – Call 410-887-5414 or
Cigna 888-431-4334
Pre-authorization Required
Mental Health
Inpatient Services
Baltimore County ­Public Schools
Yes
$100 copay per admission, then
You pay 0%
Plan pays 100%
Retiree Benefits Guide
January 1, 2015 to December 31, 2015 41
Kaiser Permanente
In-Network
Out-of-Network
Cigna (Medical)
800-896-0948
Express Scripts (Prescription)
877-852-4061
Cigna (Mental Health)
800-274-7603
Cigna (Medical)
800-896-0948
Express Scripts (Prescription)
877-852-4061
Cigna (Mental Health)
800-274-7603
3216080
3216080
800-777-7902
Kaiser (Mental Health)
866-530-8778
7434-6
HMO
Primary Care Physician
You pay $20 per visit
Specialist
You pay $30 per visit
You pay 25%
Plan pays 75%
after deductible is met
Applicable cost share based upon place of
service
You pay 25%
Plan pays 75%
after deductible is met
Applicable cost share based upon place of
service
Inpatient Facility, Outpatient Facility,
Physician’s services
You pay 15%
Plan pays 85%
after the deductible is met
Primary Care Physician
You pay $20 per visit
Specialist
You pay $30 per visit
$100,000 lifetime maximum
Inpatient Facility, Outpatient Facility,
Physician’s services
You pay 15%
Plan pays 85%
after the deductible is met
Unlimited dollar maximum
Primary Care Physician
You pay $20 per visit
Specialist
You pay $30 per visit
You pay 25%
Plan pays 75%
after deductible is met
50% of allowed benefit lifetime maximum
of $100,000 per member
$100,000 lifetime maximum
Inpatient Facility, Outpatient Facility,
Physician’s services
You pay 15%
Plan pays 85%
after the deductible is met
Unlimited dollar maximum
Max (10) EAP visits with Cigna Behavioral
or BCPS – Call 410-887-5414 or
Cigna 888-431-4334
Max (10) EAP visits with Cigna Behavioral
or BCPS – Call 410-887-5414 or
Cigna 888-431-4334
Yes
Yes
You pay 15%
Plan pays 85%
after the deductible is met
Baltimore County ­Public Schools
You pay 25%
Plan pays 75%
after the deductible is met
Max (10) EAP visits with Cigna Behavioral
or BCPS – Call 410-887-5414 or
Cigna 888-431-4334
Yes
100%
Retiree Benefits Guide
Non-Medicare Medical Options At-a-Glance Chart
Cigna OAP
42 Medical Options At-a-Glance Chart (continued)
Non-Medicare Medical Options At-a-Glance Chart
(Summary Plan Document Prevails; visit www.bcps.org/offices/benefits for full details)
Plan Name
Cigna OAPIN
Member Services
Plan Facts
Cigna (Medical)
800-896-0948
Express Scripts (Prescription)
877-852-4061
Cigna (Mental Health)
800-274-7603
Group Number
3216080
Benefit Levels
MENTAL HEALTH AND SUBSTANCE ABUSE
3
Mental Health
Outpatient Services
Office Visit
You pay $20 per visit
Outpatient Facility
You pay 0%
Plan pays 100%
Substance Abuse
Inpatient Services
$100 copay per admission, then
You pay 0%
Plan pays 100%
Substance Abuse
Outpatient Services
Office Visit
You pay $20 per visit
Outpatient Facility
You pay 0%
Plan pays 100%
OTHER SERVICES
Kidney, Cornea, Bone Marrow Transplants
Primary Care Physician
You pay $15 per visit
Specialist
You pay $20 per visit
Inpatient Facility
$100 copay per admission, then
You pay 0%
Plan pays 100%
Outpatient Facility; Physician Services
You pay 0%
Plan pays 100%
Heart, Heart-Lung, Lung, Pancreas, Liver Transplants (requires preauthorization)
Primary Care Physician
You pay $15 per visit
Specialist
You pay $20 per visit
Inpatient Facility
$100 copay per admission, then
You pay 0%
Plan pays 100%
Outpatient Facility; Professional Fees
You pay 0%
Plan pays 100%
Baltimore County ­Public Schools
Retiree Benefits Guide
January 1, 2015 to December 31, 2015 43
Kaiser Permanente
In-Network
Out-of-Network
Cigna (Medical)
800-896-0948
Express Scripts (Prescription)
877-852-4061
Cigna (Mental Health)
800-274-7603
Cigna (Medical)
800-896-0948
Express Scripts (Prescription)
877-852-4061
Cigna (Mental Health)
800-274-7603
3216080
3216080
800-777-7902
Kaiser (Mental Health)
866-530-8778
7434-6
HMO
Office Visit
You pay $30 per visit
You pay 25%
Plan pays 75%
after the deductible is met
100% after $5 copay for individual visits;
$5 copay for group therapy visits.
You pay 15%
Plan pays 85%
after the deductible is met
You pay 25%
Plan pays 75%
after the deductible is met
100%
Office Visit
You pay $30 per visit
You pay 25%
Plan pays 75%
after the deductible is met
100% after $5 copay for individual visits;
$5 copay for group therapy visits.
You pay 25%
Plan pays 75%
after deductible is met
100%
Outpatient Facility
You pay 0%
Plan pays 100%
after the deductible is met
Outpatient Facility
You pay 0%
Plan pays 100%
after the deductible is met
Primary Care Physician
You pay $20 per visit
Specialist
You pay $30 per visit
Inpatient Facility, Outpatient Facility,
Physician’s services
You pay 15%
Plan pays 85%
after the deductible is met
(covered at 100% at LifeSource
Center)
Primary Care Physician
You pay $20 per visit
Specialist
You pay $30 per visit
You pay 25%
Plan pays 75%
after deductible is met
100%
Inpatient Facility, Outpatient Facility,
Physician’s services
You pay 15%
Plan pays 85 %
after the deductible is met
(covered at 100% at LifeSource
Center)
Baltimore County ­Public Schools
Retiree Benefits Guide
Non-Medicare Medical Options At-a-Glance Chart
Cigna OAP
44 Medical Options At-a-Glance Chart (continued)
Non-Medicare Medical Options At-a-Glance Chart
(Summary Plan Document Prevails; visit www.bcps.org/offices/benefits for full details)
Plan Name
Cigna OAPIN
Member Services
Cigna (Medical)
800-896-0948
Express Scripts (Prescription)
877-852-4061
Cigna (Mental Health)
800-274-7603
Plan Facts
Group Number
3216080
Benefit Levels
OTHER SERVICES (continued)
Organ Transplant Procurement
Organ Transplant Travel
Unlimited
Travel maximum $10,000 per transplant (only available if using
Lifesource Facility)
Cardiac Rehabilitation
You pay $20 per visit
40 days per calendar year
PRESCRIPTION DRUG SERVICES
Prescription services provided through Express Scripts. Copays
are per fill at participating pharmacies up to a 30-day supply.
Patients may purchase up to 90 day supply at retail, however (3)
copays will apply for 90 day supply.
Retail
Mandatory generic – $10
Formulary brand – $20
Non-formulary brand – $35
Mail Order
Prescription services provided through Express Scripts.
Copays are per fill up to a 90-day supply.
Mandatory generic $20
Formulary brand - $40
Non-formulary brand - $70
VISION
Routine vision services
not covered
DENTAL
Routine dental services
not covered
COMMENTS
• Chiropractic care, Acupuncture & massage therapy discount available.
No referral required. www.mycigna.com
Baltimore County ­Public Schools
Retiree Benefits Guide
January 1, 2015 to December 31, 2015 45
Kaiser Permanente
In-Network
Out-of-Network
Cigna (Medical)
800-896-0948
Express Scripts (Prescription)
877-852-4061
Cigna (Mental Health)
800-274-7603
Cigna (Medical)
800-896-0948
Express Scripts (Prescription)
877-852-4061
Cigna (Mental Health)
800-274-7603
3216080
3216080
800-777-7902
Kaiser (Mental Health)
866-530-8778
7434-6
HMO
Unlimited
Unlimited
100% covered if recipient is the member
Travel maximum $10,000 per transplant
(only available if using Lifesource
Facility)
Not Applicable
Limited benefit
You pay $30 per visit
Unlimited days per calendar year
You pay 25%
Plan pays 75%
after the deductible is met
Unlimited days per calendar year
100% after $5 copay
Prescription services provided through
Express Scripts. Copays are per fill at
participating pharmacies up to a 30-day
supply. Patients may purchase up to 90
day supply at retail, however (3) copays
will apply for 90 day supply.
Prescription services provided through
Express Scripts. Copays are per fill at
participating pharmacies up to a 30-day
supply. Patients may purchase up to 90
day supply at retail, however (3) copays will
apply for 90 day supply.
Copays are per fill up to a 60-day supply.
Mandatory generic – $5
Brand – $5
At a participating community pharmacy:
Mandatory generic – $15
Brand – $15
Mandatory generic – $10
Formulary brand – $20
Non-formulary brand – $35
Mandatory generic – $10
Formulary brand – $20
Non-formulary brand – $35
Prescription services provided through
Express Scripts.
Copays are per fill up to a 90-day supply.
Prescription services provided through
Express Scripts.
Copays are per fill up to a 90-day supply.
Mandatory generic $20
Formulary brand - $40
Non-formulary brand - $70
Mandatory generic $20
Formulary brand - $40
Non-formulary brand - $70
Routine vision services
not covered
Routine vision services
not covered
$5 copayment for routine exam; discount
on lenses & frames available
Routine dental services
not covered
Routine dental services
not covered
None
• Chiropractic care, Acupuncture &
massage therapy discount available. No
referral required. www.mycigna.com
• Chiropractic care, Acupuncture & massage
therapy discount available. No referral required.
www.mycigna.com
•C
hiropractic care, acupuncture & massage
therapy discount available. No referral
required. my.kp.org/mida/bcps or
www.kp.org
Baltimore County ­Public Schools
Copays are per fill for maintenance
prescriptions up to a 90-day supply.
Mandatory generic – $5
Brand – $5
Retiree Benefits Guide
Non-Medicare Medical Options At-a-Glance Chart
Cigna OAP
46
Federally Required Information About Your Health Plan
Federally Required Information About Your Health Plan
Federally Required Information on Mastectomy
Services for All Medical Plans
Under all the medical plans, coverage is provided for
a person receiving benefits for a medically necessary
mastectomy who elects breast reconstruction after the
mastectomy, for:
n
n
n
n
econstruction of the breast on which the
R
mastectomy has been performed
S urgery and reconstruction of the other breast to
produce a symmetrical appearance
Prostheses
reatment of physical complications for all stages
T
of a mastectomy, including lymphedemas (swelling
associated with the removal of lymph nodes)
This coverage is provided in consultation with the
attending physician and patient. These benefits are subject
to the same deductibles and coinsurance amounts that
apply to other benefits provided under your medical plan.
Important Notice About Maternity Coverage and
Newborn Length of Stay
Under federal law, group health plans and health insurance
issuers offering group insurance coverage generally may
not restrict benefits for any hospital length of stay in
connection with childbirth for the mother or newborn
child to:
n
n
ess than 48 hours following a normal vaginal
L
delivery or
Less than 96 hours following a cesarean section
However, the plan or health insurance issuer may pay for a
shorter stay if the attending provider (e.g., your physician,
nurse midwife, or physician assistant), after consultation with
the mother, discharges the mother or the newborn earlier.
In addition, under federal law, plans and issuers may not
set the level of benefits or out-of-pocket costs so that any
later portion of the 48-hour (or 96-hour) stay is treated in a
manner less favorable to the mother or the newborn than
any earlier portion of the stay.
In addition, a plan or issuer may not, under federal law,
require that a physician or other health care provider
obtain authorization for prescribing a length of stay up to
48 hours (or 96 hours). However, to use certain providers
or facilities, or to reduce your out-of-pocket costs, you may
be required to obtain precertification. Please contact your
health plan’s member services unit.
Baltimore County ­Public Schools
Retiree Benefits Guide
47
The Board of Education sponsors three dental plans for
retirees. There are two CareFirst BlueCross BlueShield
dental insurance plans and one Cigna DHMO plan.
You may enroll in one of these plans at any time. If we
receive your enrollment application by the 10th of the
month, then coverage will be effective the first of the month
following the date your application was received.
The retiree is responsible for the full cost of dental coverage
at the COBRA equivalent rate. Once elected, the premium
will be deducted from your Maryland State or Baltimore
County pension check. If the pension check does not cover
the cost of the benefits, then you will be billed quarterly
by the Board. If you and your spouse are both retirees of
Baltimore County Public Schools, you may each enroll as
an individual to lessen your costs.
Regional Dental PPO
The CareFirst Dental PPO Program offers two levels of
benefits in one plan. When you need dental care, you
may see the dentist of your choice. Benefit levels and
out‑of‑pocket expenses are determined based upon
whether you receive dental care from a preferred dentist.
In-Network Benefits
When you use a Preferred Provider, you receive the highest
level of coverage with the least amount of out-of-pocket
expense. In order to choose a preferred dentist, please refer to
the Preferred Dental Provider directory or contact Member
Services at (866) 891-2802.
Out-of-Network Benefits
You may choose to use dentists outside of the network, but
your costs may be higher. There are two types of out-ofnetwork dentists:
n
n
articipating dentists are not preferred dentists,
P
but they have agreed to bill only up to the allowed
benefit amount by CareFirst BlueCross BlueShield,
thus limiting your out-of-pocket expense.
Non-participating dentists have no agreement
with CareFirst BlueCross BlueShield and may bill
you up to their charges, which may increase your
out-of-pocket expense. Members who receive care
from non-participating dentists must pay for their
services at the time the services are rendered and
must file a claim for reimbursement directly from
CareFirst BlueCross BlueShield.
Plan Highlights
n Each enrolled family member receives up to $1,000
in paid benefits per calendar year.
n Flexibility to choose any dentist.
Baltimore County ­Public Schools
n
n
areFirst Preferred and Participating Providers
C
will file claims for you and cannot balance bill you.
Preventive care is available with no out-of-pocket
expense if a CareFirst Preferred Provider is used.
Regional Dental Traditional
The CareFirst Traditional Dental Program allows you
the freedom to choose any dentist. If you seek care from a
CareFirst participating provider, the dentist cannot bill you
the difference between their charge and the allowed amount.
You are only responsible for deductibles and coinsurance.
A non-participating provider will bill for any amount over
CareFirst’s allowed benefit.
Plan Highlights
n Each enrolled family member receives up to $750 in
paid benefits per calendar year.
n Flexibility to choose any dentist.
n CareFirst’s Participating Providers will file claims
for you and cannot balance bill.
Cigna Dental Care
Cigna Dental Care is a dental health maintenance
organization (DHMO). You must select and seek
services from your DHMO facility. No benefits
are available if non-participating dentists are
used. For the most current information regarding
participating dentists in your area, you may obtain a
personalized provider directory by calling Cigna at
(800) 896-0948. You may also visit Cigna’s Website at
www.cigna.com/dental. Both resources are available
24 hours a day. You may change your primary dentist
selection by calling Member Services. In most cases, the
change will take effect on the first day of the following
month.
Plan Highlights
n There is no deductible.
n There are no annual dollar maximums.
n There are no claim forms for you to file.
n All preventive care and some restorative care is
available with zero copayments from you.
n Complex procedures are available for low, pre-set
patient charges that are published in the Patient
Charge Schedule.
An informational package is available from the Office of
Benefits, Leaves and Retirement which contains the Cigna
provider directory and the patient schedule of copayments
for all covered dental services.
Retiree Benefits Guide
Dental Options – Highlights
Dental Options – Highlights
48
Dental Options At-a-Glance Chart
Dental Options At-a-Glance Chart
Dental Plans
CareFirst BlueCross BlueShield
Regional Dental
PPO
Group# 7 91
Covered Service
Deductible
per Calendar Year**
In-Network
(Preferred)
$10 per person
$20 per family
Maximum Benefit
per Calendar Year**
Out-of-Network
(Participating or
non-participating*)
$25 per person
$50 per family
$1,000 per person
CareFirst BlueCross BlueShield
Regional Dental
Traditional
Group# 7 91
Participating or
non-participating*
Cigna Dental
DHMO
Group# 10013509
In-Network Only
$10 per person
$25 per family
$-0-
$750 per person
Unlimited
PLAN PAYS:
Preventive Care
Exams, Cleanings,
X-rays, Fluoride
100%
80%
100% when using a Participating 100%
Provider
(Non-Participating Providers can
balance bill)
Restorative Care
Fillings, Crowns,
Root Canals
80% after
deductible
60% after
deductible
80% after deductible*
Most fillings and root
canals: no out-of-pocket
expense; copayments for
other covered procedures
range from $0 to $220
Periodontic
Services
80%
for limited
services after
deductible
60%
for limited
services after
deductible
80% for limited
services after deductible
Copayments for covered
procedures range
from $15 to $335; no
deductible
Prosthetic
Services,
Dentures,
Bridgework
50% after
deductible
30% after
deductible
50% after deductible
Copayments for covered
procedures range from
$15 to $335; no
deductible
Emergency Care
Orthodontia
Services
$0 ($54 after regularly
scheduled hours)
50% after
deductible
($1,500 lifetime
maximum)
50% after
50% after deductible
deductible ($1,000 ($1,000 lifetime maximum)
lifetime maximum)
(for dependent children only)
Copayments vary from
case to case. Maximum
benefit of 24 months. See
patient charge schedule
for details
(for dependent children only)
*CareFirst payments based on allowed benefits. Non-participating providers can bill any amount over the CareFirst BlueCross
BlueShield allowed benefit.
**Calendar Year means January 1 through December 31.
Baltimore County ­Public Schools
Retiree Benefits Guide
49
Davis Vision, one of the nation’s leading managed vision
care companies, will continue to provide vision benefits.
Davis Vision has a provider network consisting of 22,000
private practitioners, independent optometrists and
ophthalmologists, opticians, and retailers nationwide.
Collection of covered frames
If you select a frame from the Davis Vision Tower
Collection, available at independent providers, you will
not have a copay. If you select a non-Tower frame, you will
be given up to $130 towards the retail cost.
Expanded network
Many national and regional retail stores are now
in‑network, including Wal-Mart, Target Optical, Sears
Optical, Pearle Vision, and Doctor’s Visionworks! To find
a vision provider, please visit www.carefirst.com and click
on “Find a Doctor” or call Davis Vision at 888-336-7125.
Who is eligible
The Board of Education offers a retiree vision plan through
CareFirst's partner, Davis Vision. To elect vision benefits,
a completed application must be returned to the Office of
Benefits, Leaves and Retirement. The cost of this benefit
will be deducted from your pension check.
Benefit
From Davis Vision Provider
From Out-Of-Network Provider*
Examination
(every 12 months1)
$20 Copay
Covered up to $35
Spectacle Lenses
(every 24 months2)
$20 Copay
Covered up to $25/single vision
Covered up to $40/bifocal
Covered up to $55/trifocal
Covered up to $80/lenticular
Frames
(every 24 months)
Tower Collection
Non-Tower Frames
Covered in full
Covered up to $130
Contact Lenses3
(every 24 months2)
• Elective (in lieu of frames & lenses)
• Medically Necessary**
Covered up to $130
$20 Copay
Covered up to $130
Covered up to $210
Laser Vision Correction
Discounted services
None
Covered up to $35
1 Based on your last date of service.
2 Basic single vision, lined bifocal or lined trifocal lenses.
3 Patients choosing contacts use their eligibility for a frame and
lenses. Fitting is included if Davis Vision Collection contact lenses
are prescribed. You are responsible for all charges after the allowed
amount for non-Davis Vison Collection contact lenses.
* You are responsible for all charges for services received out-of-network
and must file a claim for reimbursement up to the plan benefit. Claims
must be submitted within twelve months of the date of service.
** Medically Necessary – Contact lenses prescribed for conditions where
visual acuity cannot be adequately corrected with eyeglasses but can
be corrected by contact lenses. Preapproval required.
In-Network Providers
All in-network or participating Davis Vision providers will offer the following services at no additional cost.
• One year breakage warranty on plan eyeglasses
• Plastic or glass lenses
• Oversized lenses
Before selecting your eyewear, ask your doctor what is fully covered by your vision plan through Baltimore
County Public Schools. To find a provider near you, please visit www.carefirst.com and click on “Find a Doctor” or call
CareFirst Davis Vision at 888-336-7125.
Baltimore County ­Public Schools
Retiree Benefits Guide
Vision Insurance
Vision Insurance
50
Vision Insurance
Vision Insurance
Out-of-Network Providers
Should you choose to visit an eye care professional not in
the Davis Vision network, you will still receive coverage;
however, your out-of-pocket costs will be higher than if
you had visited a network provider.
Note: Please be aware that non-Davis Vision providers
will expect the entire payment up-front. You may then
seek reimbursement by submitting a claim form to
CareFirst Davis Vision. You will be reimbursed up to your
allowed amounts.
Discounted Rates on Special Services
In addition to your standard eye glass coverage, you
will also be offered discounts or pre-negotiated fees for
additional options.
n Laser
Vision correction – when using a provider in the
Davis Vision Laser Vision network, you are entitled
Example
Costs for
(Lenses
& Frames)usual and
to a discount
of Glasses
up to 25%
off providers
You
can save acharge
significant
of money from
if you use
customary
or amount
a 5% discount
the aLaser
Davis Vision Provider as shown below.
center’s advertised special.
You Pay:
Example 1
123Spectacle
Mail Order
Contact Lens
• $20 for lenses
Single vision
lenses Replacement
Program
– allowsFrames
significant• Frames
savingscovered
of up to
50% on
in full
with
Tower Collection
from
a
Davis
Vision
Provider
replacement contact lenses. Lens 123 will guarantee
n Lens
the lowest
call 1-800-LENS123
You Pay:
Example
2 price. You would simply
for lenses contacts or
Single
Spectacle
lenses for• $20
withvision
a valid
prescription
replacement
• Frames covered up to $130
with Non‑Tower Collection
additional boxes.
retail; you pay the balance
Frames from a Davis Vision
nProvider
20% courtesy discount at most Davis Vision
participating
offices towardsYou
thePay:
purchase of items not
Example
3
•
Lenses:
Balance after $25
Single
vision
Spectacle
lenses
covered, such as a second pair of glasses.
Allowance
and Frames from an out‑of‑
• Frames: Balance after $35
network providerChanges
Prescription
Allowance
If your lens prescription changes before you are
Total $60
eligible for new lenses and that prescription meets at
least one of the following criteria, lenses and frames
will be replaced at a 12-month frequency:
a. a new
prescription differs from the original by
Special
Services
at
least
.50 diopter sphere
Tinting
$0 or cylinder;
b.
an
axis
change
of
15
degrees
or more;
Standard Progressive Lenses $50
c. a .5 prism diopter change in at least
one ™eye.
™
Premium Progressive Lenses
For more information
$90 (Varilux , Kodak ,
Rodenstock™)
Scratch Resistant Coating
$20
Call
Davis Vision’s dedicated
Baltimore County
Glare
Resistant
Treatment
$35
Customer Service Department
at 888-336-7125,
)
Plastic
Photosensitive
Lenses
$65
(Transitions
Mon. – Fri., 8 a.m. – 11 p.m., Sat. 9 a.m. – 4 p.m.,™Sun.
noon – 4
p.m.,
Eastern time.
Polycarbonate
Lenses
$30
(Polycarbonate lenses
To access the Davis Vision website,
visit www.carefirst.com
covered
in full for dependentand
click on “Find a Doctor” in the Solution
Then
click on
children, Center.
monocular
patients
patients with prescription
“Vision” under Search by Providerand
Type.
≥ +/‑ 6.00 diopter.)
Example Costs for Glasses (Lenses & Frames)
Examp
You can save a significant amount of money if you use a
Davis Vision Provider as shown below.
You can
Davis V
Example 1
Single vision Spectacle lenses
with Tower Collection Frames
from a Davis Vision Provider
You Pay:
• $20 for lenses
• Frames covered in full
Exampl
Elective
the Dav
Example 2
Single vision Spectacle lenses
with Non‑Tower Collection
Frames from a Davis Vision
Provider
You Pay:
• $20 for lenses
• Frames covered up to $130
retail; you pay the balance
Exampl
Other E
(Non‑Da
You Pay:
• Lenses: Balance after $25
Allowance
• Frames: Balance after $35
Allowance
Total $60
Example Costs for Glasses (Lenses & Frames)
Example 3
Single vision Spectacle lenses
and Frames from an out‑of‑
network provider
Examp
You can save a significant amount of money if you use a
You can
Davis V
You
can save
of Pay:
money if you use a
Example
1 a significant amountYou
Special Services
Davis
shown below.
• $20 for lenses
SingleVision
vision Provider
Spectacleaslenses
Tinting
• Frames
with
Tower
Pay: covered in full
Example
1 Collection Frames $0You
Exampl
For
m
Elective
Example
Costs
for Contact
Davis Vision
Provider
as shownLenses
below.
from
a Davis
Vision
Provider
Elective
Contact
Lenses
from
Standard
Progressive
Lenses
the
Davis2Vision Collection
Example
Premium Progressive Lenses
Single vision Spectacle lenses
with Non‑Tower
Collection
Example
2
Scratch Resistant Coating
FramesElective
from a Contact
Davis Vision
Other
Lenses
Glare Resistant
Treatment
Provider
(Non‑Davis
Vision
Collection)
• $0 Fitting
$50
•You
Contact
™
Pay: Lenses:
, Kodak™,
$90
(Varilux
covered
in full
™
• $20 for lenses
Rodenstock
)
• Frames
You
Pay: covered up to $130
$20
you pay the charge
balance
• retail;
Fitting‑Provider’s
$35
• Contact Lenses: balance
after
$130 allowance
™
)
Plastic Photosensitive
Lenses $65
(Transitions
You
Pay:
Example
3
•
Lenses:
Balance
after $25
Single
vision
Spectacle
lenses
You
Pay:
Example
3
Polycarbonate Lenses
$30
Allowance lensescharge
and Frames
from an out‑of‑
• Fitting‑Provider’s
Medically
Necessary
Contact
(Polycarbonate
Frames:
Balance
after
$35
network provider
• Contact
Lenses‑$20
copay
Lenses
covered
in full
for dependent
Allowance
from
in‑network
provider
children, monocular patients
• Contact
balance
Total
$60
and
patientsLenses:
with prescription
allowance from
≥ +/‑after
6.00$210
diopter.)
out‑of‑network provider
Tinting
Call
the Dav
Dav
Service D
Exampl
Sat.
9 a.
Other E
(Non‑Da
To
acces
and click
Exampl
click
on
Medical
Lenses
For m
Special Services
$0
For
more information
Standard Progressive Lenses $50
Call Davis Vision’s dedicated Baltimore County
Customer
Premium Progressive Lenses $90 (Varilux™, Kodak™,
Service Department at 888-336-7125,
Mon. – Fri.,
™
Rodenstock
) 8 a.m. – 11 p.m.,
Sat.
9
a.m.
–
4
p.m.,
Sun.
noon
–
4
p.m.,
Eastern
time.
Scratch Resistant Coating
$20
Call Dav
Service D
Sat. 9 a.
To acces
and click
click on
Resistant
Treatment
$35 visit www.carefirst.com
ToGlare
access
the Davis
Vision website,
™
)
Plastic
Lenses in
$65
(Transitions
and
clickPhotosensitive
on “Find a Doctor”
the
Solution Center.
Then
10455
Mill Run Circle
Polycarbonate
Lenses
click
on “Vision”
under Search $30
by Provider Type.
(Polycarbonate lensesOwings Mills, MD 21117
covered in full for dependent
www.carefirst.com
children, monocular patients
and patients with prescription
≥ +/‑ 6.00 diopter.)
CareFirst BlueCross BlueShield is the business name of Group Hospitalization and Medical Services, Inc. C
licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue
CST1043-1P (9/11)
Baltimore County ­Public Schools
Exampl
Medical
Lenses
Retiree Benefits Guide
51
Life Insurance Benefits & Costs
Benefit Amount
Effective September 1, 2009, the basic term life insurance
and optional life insurance carrier changed from MetLife
to Prudential Insurance Company of America (Prudential).
Continuation of life insurance is optional upon retirement,
but cannot be elected any time after retirement. If elected, a
retiree’s amount of life insurance coverage can be no more
than $50,000, including the $15,000 of basic insurance
and $35,000 of optional coverage. The optional coverage
immediately reduces by 10% on the date of retirement; for
example, $35,000 of optional coverage becomes $31,500
of optional coverage on the date of retirement. Therefore,
the maximum life insurance coverage on your actual
retirement date is $46,500.
Life insurance can only be continued for those retirees
immediately eligible to draw a pension from Baltimore
County Public Schools (e.g. if you retire at age 45 but are
not eligible to receive a retirement check until age 55, you
will not be allowed to enroll in life insurance benefits once
you are receiving your retirement check.)
Reminder: All retirees should be sure they have
updated their beneficiary designation and notify the
insurance company if there is a change. Call MetLife at
(888) 280-6083 if you received paid-up life insurance in
December, 2004. For changes after September 1, 2009, call
Prudential at (800) 778-3827, Monday-Friday, 8:00am –
8:00pm EST.
Benefit Reduction
Following the original deduction of 10% on the date of
retirement, an additional 10% of the original amount
of insurance will be deducted on each of the next four
anniversaries of the date of retirement.
Enrolling in Coverage
Upon notice of your retirement by the Office of Personnel,
the Office of Benefits, Leaves and Retirement will prepare
a personalized life insurance election form. This must be
completed and returned within thirty (30) days of the
effective date of your retirement.
Date
Value of Optional
Coverage
Value of Basic
Coverage
Total Life Insurance
Coverage
Pre-Retirement
6–30–14
$65,000
$15,000
$80,000
Retirement
7–1–14
$31,500
$15,000
$46,500
1st Anniversary
7–1–15
$28,000
$15,000
$43,000
2nd Anniversary
7–1–16
$24,500
$15,000
$39,500
3rd Anniversary
7–1–17
$21,000
$15,000
$36,000
4th Anniversary (final 7–1–18
reduction)
$17,500
$15,000
$32,500
Example: The retiring employee HAD a total amount of life insurance of $80,000 consisting of $15,000 basic and $65,000
optional coverage. Upon retirement, the coverage would immediately be reduced to an allowable maximum of $50,000
($15,000 basic plus $35,000 optional coverage). On the actual retirement date, the optional coverage amount is further
reduced by $3,500 to $31,500 (90% of $35,000) for a total amount of basic and optional insurance of $46,500. In this
example, the amount of optional insurance continues to reduce by $3,500 through the fourth retirement anniversary.
After the fourth retirement anniversary, the retiree would have a total of $32,500 of life insurance, consisting of $15,000
of basic coverage and $17,500 of optional coverage. There would be no further reductions.
Baltimore County ­Public Schools
Retiree Benefits Guide
Life Insurance
Life Insurance
52
Life Insurance
Waiver of Premium
Prior to retirement, an employee may apply for a waiver of
premium for life insurance by completing forms available
from the Office of Benefits, Leaves and Retirement. The
waiver of premium must be approved by the life insurance
company. The waiver of premium will expire on the retiree’s
65th birthday.
Change in Beneficiary – Prudential
(effective 9/1/09)
You may designate or update your life insurance beneficiary
information quickly and easily at:
www.giselfservice.prudential.com.
If you have any questions about Prudential’s Website,
your user profile or need additional assistance, contact
Prudential’s Customer Service at (800) 778-3827, MondayFriday, 8:00am-8:00pm EST.
Change in Beneficiary – MetLife
If you retired prior to 1/1/2005 you may also have a
paid-up MetLife policy. For information or to obtain
the beneficiary designation form by mail, call MetLife at
(888) 280-6083.
2 4-hour pre-departure information (weather,
currency, holidays)
n
n
Urgent message transmission
n
Political evacuation
AXA Travel Assistance Program can be contacted at
(800) 565-9320.
Cost of Insurance
The cost of life insurance is paid entirely by the retiree.
Premiums are deducted from your pension check or
are billed quarterly by the Office of Benefits, Leaves and
Retirement. Payments must be made by the due date.
Coverage terminated for non-payment of premiums cannot
be reinstated.
For employees who retired prior to January 1, 2005,
Baltimore County Public Schools purchased paid up
coverage in the amount of $2,620 of the retiree’s basic
amount. (Refer to the life insurance certificate of coverage
for more information.)
Coverage Details
The benefit is underwritten by Prudential. The group policy
number is 49143.
Travel Assistance Services
As part of the Basic Life insurance, Prudential offers a
Travel Assistance Benefit. This program, offered through
AXA Travel Assistance Program, is a travel assistance
service provided to insureds and their dependents while
traveling internationally or domestically over 100 miles
from home. The program provides medical, travel, legal
and financial assistance, 24 hours a day, 365 days a year,
including the following services:
eneral travel information about visa, passport,
G
inoculation requirements and local customs
n
n
n
n
Lost document and luggage assistance
n
Emergency cash/bail assistance
Legal referrals
ssistance with pet friendly hotel accommodations,
A
boarding facilities and travel for pets
Baltimore County ­Public Schools
Retiree Benefits Guide
53
Retiree’s Age
Cost per $1,000 of Life Insurance
Basic (Retired Prior to 1/1/2005)
N/A
$2.88 (for $7,380 of coverage)
Basic
N/A
$5.85 (for $15,000 of coverage)
Retiree’s Age Monthly Cost per $1,000 of Life Insurance
2011
2012
2013
2014
2015
2016
Less than 25
$0.050
$0.050
$0.050
$0.050
$0.050
$0.050
25–29
$0.060
$0.060
$0.060
$0.060
$0.060
$0.060
30–34
$0.070
$0.070
$0.070
$0.070
$0.070
$0.070
35–39
$0.090
$0.090
$0.090
$0.090
$0.090
$0.090
40–44
$0.100
$0.100
$0.100
$0.100
$0.100
$0.100
45–49
$0.190
$0.150
$0.150
$0.150
$0.150
$0.150
50–54
$0.245
$0.245
$0.230
$0.230
$0.230
$0.230
55–59
$0.455
$0.440
$0.430
$0.430
$0.430
$0.430
60–64
$0.575
$0.633
$0.660
$0.660
$0.660
$0.660
65–69
$0.992
$1.091
$1.200
$1.270
$1.270
$1.270
70+
$0.992
$1.091
$1.200
$1.320
$1.452
$1.597
Other Available Plans
Catastrophic Insurance
Retiree dental, vision, and long term care insurance plans
are also available to purchase through the Maryland
Retired School Personnel Association (MRSPA). Contact
the MRSPA at (410) 551-1517 or online at www.mrspa.org
for more details about eligibility guidelines and costs for
these plans.
This insurance coverage has been billed directly by
CareFirst BlueCross BlueShield for several years. Any
billing or coverage questions should be addressed to
CareFirst BlueCross BlueShield. The phone number to call
for questions about this coverage is (410) 581-3404.
Cancer Insurance
Premiums for this coverage are deducted from pension
checks in combination with the cost of health insurance.
Thus, a retiree with cancer insurance and health insurance
will see a deduction from the pension check which
combines the cost of both programs. Retirees wishing to
cancel this insurance must notify the Office of Benefits,
Leaves and Retirement in writing. If a retiree cancels this
coverage, it will not be possible to reinstate it at a later date.
Accidental Death & Dismemberment
Insurance
This insurance may be continued into retirement
by converting it to an individual policy. Contact
Cigna at (800) 441-1832 for more details. Effective
September 1, 2009 the new insurance carrier will be
Prudential. You may contact Prudential after September 1
at (800) 778-3827.
Widow and Widower Benefits
If you are a BCPS retiree who gets remarried, the new
spouse is eligible for coverage under a Baltimore County
Public School’s sponsored health plan. A surviving spouse
of a deceased retiree may not add a new spouse to the plan,
if they get remarried. However, they can keep their own
insurance coverage.
Baltimore County ­Public Schools
Retiree Benefits Guide
Life Insurance
Type of Insurance Coverage
54
Medicare
Medicare
Baltimore County Public Schools requires Medicare
enrollment as soon as a retiree, spouse or dependent of
a retiree is eligible for Medicare. Parts A & B MUST be
elected.
Medicare Overview
There are three parts to Medicare:
n
n
n
ospital Insurance (also called “Part A” Medicare.
H
Your enrollment is automatic upon turning age 65.
edical Insurance (also called “Part B” Medicare),
M
which is partly financed by monthly premiums
paid by individuals who choose to enroll. You
MUST enroll, if you are eligible.
rescription Drug Insurance (also called “Part
P
D: Medicare). Do NOT enroll unless you qualify
for financial assistance for retirees on limited
incomes. If you meet the limited income criteria,
please contact the Office of Benefits, Leaves and
Retirement.
An individual is automatically enrolled in Part B when he/
she becomes entitled to Part A, if receiving social security
benefits due to either age or disability. However, because
an individual must pay a monthly premium for Part B
coverage, he/she has the option of refusing the coverage.
Note: If you deny coverage you will not be permitted to
continue participation in a BCPS sponsored plan.
If you are no longer actively employed and do not enroll in
Part B within three months after reaching age 65 you must
wait until the next general enrollment period (January 1
through March 31) to sign up. Coverage would begin the
following July. There is a 10% monthly premium penalty
for each twelve-month period that you were eligible for
Part B, but did not enroll. (Note: You are covered under
a spouse’s group health plan, enrollment in Part B may
be delayed. You will not be required to wait for a general
enrollment period or pay the 10% premium surcharge for
late enrollment.) Three months prior to becoming Medicare
eligible, you will be sent a letter instructing you of the steps
necessary to insure you will not be penalized.
Baltimore County ­Public Schools
Once eligible for Medicare, you, your spouse or dependent,
will be eligible to enroll in a Medicare Supplemental Plan
through Baltimore County Public Schools. As soon as
you are enrolled in Medicare, please notify the Office of
Benefits, Leaves and Retirement, so we can insure that
your records are updated and that no claim problems will
result.
For additional information about Medicare benefits,
please contact them directly at 1-800-MEDICARE
(1‑800‑633‑4227) or online at www.medicare.gov.
It is Important to Read the Annual Notice of Change
Announcement Each Year. Retirees are notified each year,
by mail, of the enrollment dates and plan offerings for the
next year. Rates for the upcoming year are also included in
that packet. This is the only way Baltimore County Public
Schools routinely notifies you of plan and/or rate changes.
Medicare Part D Prescription Plans
Federal legislation created prescription drug benefits for
Medicare enrollees that took effect on January 1, 2006. The
new benefits are called Medicare Part D plans. Retirees
who choose to enroll in a Medicare Part D plan will pay a
monthly premium for their prescription coverage. They will
be required to pay the deductibles and coinsurance amounts
required by the plan they selected. Standard Medicare Part
D plans have a provision called “the doughnut hole” that
allows the plan to stop paying toward prescription drugs
for an enrollee after they have incurred annual prescription
drug costs of $2,960. The plans resume paying when the
prescription expenses reach $4,700 for calendar year 2015.
These amounts are adjusted annually by CMS (Center for
Medicaid & Medicare Services).
Employers who offered prescription benefits for their
Medicare retirees had a number of options once the new
program was in place. Baltimore County Public Schools
chose to continue BCPS prescription benefits for Medicare
retirees. The benefits provided under the plans are at least as
good as those provided under the standard Medicare Part
D plan and do not contain a “doughnut hole” provision.
Retiree Benefits Guide
55
Required Disclosures to Medicare
Beneficiaries
Baltimore County Public Schools must provide a notice
of creditable prescription drug coverage to Medicare
beneficiaries who are covered by, or who apply for,
prescription drug coverage under any of the Baltimore
County Public Schools plans.
For a copy of this notice, please visit our Website at:
www.bcps.org/offices/benefits_enrollment/ or
www.bcps.org/offices/benefits/retiree_ben/.
If you chose the Kaiser Medicare Plus plan, you will
continue to have prescription coverage through Kaiser for
a small copay amount.
*The “doughnut hole” refers to the gap in many Medicare Prescription Drug Programs (Part D) during which the
consumer must pay 100 percent out-of-pocket for drug purchase costs.
Baltimore County ­Public Schools
Retiree Benefits Guide
Medicare
For retirees/spouses who chose Cigna Medicare Surround
Plan, prescription coverage is included. It is administered
by Express Scripts, Inc. (ESI). The member pays 20%
for brand or generic drugs at a retail pharmacy or a $20
copay for generic, $40 copay for brand drugs at mail order.
Your share of the cost is paid directly to the pharmacy.
The remainder of the cost is paid by BCPS. There is no
“doughnut hole” or deductibles in BCPS’ prescription
coverage plan.* ESI participating pharmacies maintain
records of the costs for your medications. ESI also offers the
convenience of mail-order service for your maintenance
medications.
56
Medicare
Medicare Supplemental Plan
Medicare Supplemental Plan
The Cigna Medicare Surround Plan offered through
Baltimore County Public Schools is health care coverage
which will pay after Medicare. This plan requires you to
have Medicare Part A & B in order to receive supplemental
benefits. When treated in a doctor’s office or a hospital,
always present your Medicare card and your Cigna card.
When seeking medical care, you will have the least out-ofpocket costs when you are seen by a physician who accepts
Medicare assignment. Please note that all physicians must
submit your claims to Medicare; however, not all physicians
have to accept assignment. In other words, the physician
who does not accept Medicare assignment may charge you
up to 15% above the Medicare allowed amount for services,
also defined as the limiting amount. You may be asked to
pay the bill in full at the time of service.
Once you have been seen by the physician, the claim will
be submitted to Medicare. After the claim is paid, you will
receive a Medicare explanation of benefits. Since Cigna is
your supplemental or secondary insurance plan, the claim
is then filed with us. Cigna also sends an Explanation of
Health Care Benefits (EOHB) which states the amount the
provider may bill if he accepts assignment. (See “How to
file claims” that follows for more details.) The benefit chart
within this booklet will show you the type of service, and
how it is paid by Medicare and Cigna.
As a member of Cigna Medicare Surround Plan, you are
covered for services in Maryland, in the United States,
and even outside the U.S. You are also eligible to seek
alternative therapies and wellness services at a discount rate
through the Cigna Healthy Rewards Program. For more
information about the providers and services, you may call
Cigna's Member Services toll free number (800) 896-0948
or by visiting the online directory on Cigna's Website www.
mycigna.com.
Note: When seeking medical care, please show both
your Medicare card and your Cigna card.
Baltimore County ­Public Schools
Baltimore County Public Schools also offers a prescription
plan through Express Scripts, Inc. (ESI). You will be
enrolled in the prescription plan once you enroll in the
Cigna Medicare Surround Plan.
Retiree Benefits Guide
57
Medicare
Prescription Drugs
Coverage for Prescription Drugs
The Cigna Medicare Surround Plan does provide coverage
for outpatient prescription drugs. The prescription plan
is administered through Express Scripts, Inc. (ESI). This
Plan is an approved Medicare Part D Plan. The Plan has
been deemed creditable and is equal to or better than the
Medicare Part D Plan. Therefore, Baltimore County
Public School retirees in the Cigna Medicare Surround
Plan do not need to enroll in an Independent Medicare
Part D prescription plans. Because you have employersponsored prescription benefits, late enrollment penalties
will not apply if you need a Medicare prescription plan in
the future.
The plan covers federal legend drugs prescribed for FDA
and Manufacturer approved diagnoses. Diabetic supplies
are also covered under the prescription plan.
Drugs that are excluded from coverage include over-thecounter medications, diet drugs, cosmetic drugs and drugs
prescribed for a condition not approved by the FDA as
appropriate for that condition.
Medical devices are not included in prescription coverage
– those claims should be submitted to Medicare and then
to Cigna for payment. Allergy serum claims should be
submitted directly to Cigna for coverage under your health
benefits.
Certain medications require that an appropriate diagnosis
be submitted to ESI before they can be filled. Your
physician can fax a request for prior authorization for
these medications to ESI at (800) 357-9577. You and your
physician can also contact ESI by phone or using the
internet for a current listing of medications requiring prior
authorization.
Your Share of the Cost of Outpatient
Prescriptions:
There is no deductible or “doughnut hole coverage gap”
that applies to this prescription plan.
n
n
n
ocal Pharmacy – 20% coinsurance per
L
prescription
ESI also provides a convenient mail-order service for
maintenance medications. These are medications you are
using, in the same strength, for greater than a three month
period. Contact Express Scripts at (866) 344-2922 or go to
www.express-scripts.com for more information on mail
order service, for order forms, and for a determination of
what your medication(s) will cost using mail order.
What is Step Therapy?
Step therapy is a program which encourages the use of
lower cost generic medications for treatment of medical
conditions which require regular use of medications.
Some examples of medical conditions that step therapy
focuses on are high blood pressure, high cholesterol, and
gastrointestinal conditions. It helps you get an effective
medication to treat your condition while keeping your
costs as low as possible.
The next time your doctor writes a prescription for you, ask
your doctor if a generic medication listed by your plan as a
“front-line drug”1 is right for you. It makes good sense to ask
for these drugs because, for most everyone, they work as well
as brand-name drugs – and they almost always cost less.
If you’ve already tried a front-line drug, or your doctor
decides one of these drugs isn’t appropriate for you, then your
doctor can prescribe a “back-up drug.”2 Ask your doctor if
one of the lower-cost brands (Step 2 drugs) listed by your
plan is appropriate. In some cases, you may be required to
try more than one first line drug. Remember, you can always
get a higher-cost brand-name drug at a higher copayment
if the front-line or Step 2 back-up drugs aren’t right for you.
For a “Step Therapy Criteria Chart,” go to http://www.bcps.
org/benefits/pdf/Express-Scripts_Front-Line-Drugs_
Retirees.pdf.
The first step – are generic drugs proven to be safe, effective and
affordable. These drugs should be tried first because they can provide the
same health benefit as more expensive drugs, at a lower cost.
1
2 Step 2 and 3 drugs – are brand-name drugs. There are lower-cost brand
drugs (Step 2) and higher-cost brand drugs (Step 3). Back-up drugs
typically cost more than front-line drugs.
ail Order – $20 copay for generic drugs;
M
$40 copay for any brand-name drug
rior Authorization or Step Therapy applies in
P
some cases
Baltimore County ­Public Schools
Retiree Benefits Guide
58
Medicare
Health Benefits Summary
Medicare Pays:
Inpatient Hospital/Facility Services
Room & Board
(ICU/CCU (other special care units), and Ancillary Services (incl. nursery
charges)
100% of the Medicare approved amount after inpatient deductible
Extended Care Facility/Skilled Nursing Care
Days 1–20: 100% of the Medicare approved amount;
Days 21–100: 100% of the Medicare approved amount after per day
deductible
Inpatient Professional/Practitioner Services
Physician Surgical Services
80% of the Medicare approved amount after annual deductible
Anesthesia, Assistant Surgeon
80% of the Medicare approved amount after annual deductible
Consultation (including follow-visits) & Physician Visits (Includes ECF)
80% of the Medicare approved amount after annual deductible
Radiation Therapy, Chemotherapy, and Renal Dialysis
80% of the Medicare approved amount after annual deductible
Outpatient Hospital/Facility Services
Minor/All Surgery (includes hospital based and freestanding surgical centers)
80% of the Medicare approved amount after annual deductible
Preadmission Testing
80% of the Medicare approved amount after annual deductible
Radiation Therapy, Chemotherapy, and Renal Dialysis
80% of the Medicare approved amount after annual deductible
Physical & Speech Therapy
80% of the Medicare approved amount after annual deductible
Occupational Therapy
80% of the Medicare approved amount after annual deductible
Diagnostic Tests
80% of the Medicare approved amount after annual deductible.
Note: Medicare pays 100% of the Medicare approved amount for
clinical laboratory services.
Outpatient/Office Professional Services
Minor/All Surgery
80% of the Medicare approved amount after annual deductible
Anesthesia, Assistant Surgeon
80% of the Medicare approved amount after annual deductible
Diagnostic Tests
80% of the Medicare approved amount after annual deductible.
Note: Medicare pays 100% of the Medicare approved amount for
clinical laboratory services.
Office Visit for Illness, Injury or consultation
80% of the Medicare approved amount after annual deductible
Allergy Tests
80% of the Medicare approved amount after annual deductible
Allergy and Other Covered Injections – administration of injections
80% of the Medicare approved amount after annual deductible
Physical therapy & Acupuncture
80% of the Medicare approved amount after annual deductible
Speech & Occupational Therapy
Speech therapy: 80% of the Medicare approved amount after
annual deductible. Note: Occupational therapy limited to $1,920
per year.
Speech & physical therapy limited to $1,920 per year.
Preventive/Well Care (Routine)
Annual Adult Physicals, Immunizations and Diagnostic Tests: age 18 & older
100% of the Medicare approved amount. One "Welcome" visit
within 12 months of becoming eligible for Medicare – A & B
deductibles and coinsurance apply.
Annual GYN Services (includes pap smear) rendered in the office
100% of the Medicare approved amount after annual deductible.
Note: Limited to one every two years and pap smear is not subject
to annual deductible.
Mammography Screening (provider must be American College of Radiology
[ACR] approved)
100% of the Medicare approved amount. Note: Limited to one
screening annually after age 40.
Prostate Cancer Screening (including PSA test)
100% of the Medicare approved amount after annual deductible.
Note: Limited to one exam annually after age 50 and PSA is not
subject to coinsurance or deductible.
Baltimore County ­Public Schools
Retiree Benefits Guide
59
100% of inpatient deductible day 1-60; The benefit will reduce to 80% after day 61 unless a new benefit period begins
Day 1-20: Medicare covers at 100% - no Cigna payment is necessary;
Day 21 – 100: 100% of the per day deductible;
Days 101-120: 100% of the allowed benefit
100% of the balance due after Medicare including the Medicare deductible
100% of the balance due after Medicare including the Medicare deductible
100% of the balance due after Medicare including the Medicare deductible
100% of the balance due after Medicare including the Medicare deductible
100% of the balance due after Medicare including the Medicare deductible
100% of the balance due after Medicare including the Medicare deductible
100% of the balance due after Medicare including the Medicare deductible
100% of the balance due after Medicare including the Medicare deductible
100% of the balance due after Medicare including the Medicare deductible
100% of the balance due after Medicare including the Medicare deductible
100% of the balance due after Medicare including the Medicare deductible
100% of the balance due after Medicare including the Medicare deductible
100% of the balance due after Medicare including the Medicare deductible
80% of the balance due after Medicare including the Medicare deductible
80% of the balance due after Medicare including the Medicare deductible
80% of the balance due after Medicare including the Medicare deductible
80% of the balance due after Medicare including the Medicare deductible
80% of the balance due after Medicare including the Medicare deductible
100% of the balance due after Medicare including the Medicare deductible
100% of the balance due after Medicare including the Medicare deductible
100% of the balance due after Medicare including the Medicare deductible
100% of the balance due after Medicare including the Medicare deductible
Baltimore County ­Public Schools
Retiree Benefits Guide
Medicare
Baltimore County Public Schools Cigna Medicare Surround Plan Pays:
60
Medicare
Health Benefits Summary
Medicare Pays:
Emergency Care
Accidental Injury/First Aid Medical Emergency or Life Threatening Event
80% of the Medicare approved amount after annual deductible
Follow-Up Visits to an Accidental Injury or Medical Emergency
80% of the Medicare approved amount after annual deductible
Ambulance
Ground (public or private)
80% of the Medicare approved amount after annual deductible
Mental Health
Inpatient Hospital/Facility and Professional Services
100% of the Medicare approved amount after inpatient deductible
Note: Coverage limited to 190 lifetime days.
Outpatient Facility, Professional Services
80% of the Medicare approved amount after annual deductible
Prosthetic Devices & Orthopedic Braces
Purchase, repair or replacement
80% of the Medicare approved amount after annual deductible
Durable Medical Equipment
Medical Supplies
80% of the Medicare approved amount after annual deductible
Hearing Aids
Not covered
80% of the Medicare approved amount after annual deductible
Home Health Care
Facility/Agency
100% of the Medicare approved amount
Outpatient Private Duty Nursing
(Non-custodial; pre-authorization required)
Hospice Care (Inpatient or At Home)
100% of the Medicare approved amount
Cardiac Rehabilitation
Organ Transplants
80% of the Medicare approved amount after annual deductible
Kidney, Cornea, Bone Marrow
80% of the Medicare approved amount after annual deductible
Heart, Heart-Lung, Single or Double Lung, Pancreas, and Liver
80% of the Medicare approved amount after annual deductible
100% of the Medicare approved amount except $5 per outpatient
prescription and 5% of inpatient respite care
Prescription Drugs
Outpatient Prescription Drugs
Not covered
Drugs dispensed by medical provider in office
80% of the Medicare approved amount after annual deductible
Routine Vision
Dental
Additional Information
Not covered
Deductible (Part A, Part B)
Verify with Medicare. Deductibles change yearly.
Out-of-Pocket Maximum
Not applicable
Lifetime Maximum
Not applicable
Not covered
Note: This benefit matrix is intended for comparison/informational purposes and is not meant to be a binding contract. Specific benefit inquiries or quotes for benefits should be directed to the appropriate customer service department. Baltimore County ­Public Schools
Retiree Benefits Guide
61
100% of the balance due after Medicare including the Medicare deductible
80% of the balance due after Medicare including the Medicare deductible
80% of the balance due after Medicare including the Medicare deductible
100% of the balance due after Medicare including the Medicare deductible
80% of the balance due after Medicare including the Medicare deductible
100% of the balance due after Medicare including the Medicare deductible
80% of the balance due after Medicare including the Medicare deductible
80% of the balance due after Medicare including the Medicare deductible
100% up to $2800 every three years
Medicare covers 100% of the Medicare allowed amount - no Cigna payment necessary
Medicare covers 100% of the Medicare allowed amount - no Cigna payment necessary
Medicare covers 100% of the Medicare allowed amount - no Cigna payment necessary
80% of the balance due after Medicare including the Medicare deductible
100% of the balance due after Medicare including the Medicare deductible
100% of the balance due after Medicare including the Medicare deductible
Coverage through Express Scripts (ESI)
80% of the balance due after Medicare including the Medicare deductible
Not covered
Not covered
Not applicable
$650
$300,000 (applies to Part B expenses)
Note: Cigna will pay up to the Medicare approved amount if the provider accepts Medicare assignment.
Cigna will not pay above the limiting amount if the doctor does not accept Medicare assignment.
Baltimore County ­Public Schools
Retiree Benefits Guide
Medicare
Baltimore County Public Schools Cigna Medicare Surround Plan Pays:
62
Medicare
How to File Medical Claims
Care Rendered in or outside of Maryland
Provider will file claim
to Medicare Part A or B
for processing
Claim is automatically
forwarded to Cigna for eligible
supplemental payments
Baltimore County ­Public Schools
■
If the provider accepts Medicare assignment,
Medicare and Cigna payments are sent directly
to the provider.
■
If provider does NOT accept Medicare
assignment, the Medicare and Cigna payments
are sent directly to you.
■
You will receive:
1) Medicare Explanation of Benefits
2) Cigna Explanation of Health Care Benefits
To find doctors who accept Medicare, or to learn
more about Medicare benefits and services, visit
www.medicare.gov or call 1-800-MEDICARE
(1-800-633-4227) 24 hours a day, 7 days a week.
TTY/TDD users call 1-877-486-2048.
Retiree Benefits Guide
63
This is an Explanation of Benefits
for a resident of Maryland.
You
May Be
Billed
You May Be Billed:
This amount represents your
deductible or coinsurance under
Medicare. Do not pay this amount
to the provider at the time you
receive this notice. When you
receive care in Maryland the claim
will automatically be filed to Cigna
for review and payment of eligible
supplemental plan benefits.
Medicare
Approved
Medicare Approved:
The amount medicare approves for a certain
service or supply. A provider who accepts Medicare
assignment will accept this amount as payment
in full. A provider who does not accept Medicare
assignment can bill an additional 15% over
this amount.
Baltimore County ­Public Schools
Medicare
Paid
Provider
Medicare Paid Provider:
The amount of the payment made by Medicare
directly to the provider of care.
Retiree Benefits Guide
Medicare
Understanding Your Medicare Explanation of Benefits
64
Medicare
Kaiser Permanente Medicare Plus
Summary of Benefits
This plan is offered by the Kaiser Foundation Health
Plan of the Mid-Atlantic States. This summary outlines
some of the Plan features. It does not list every service
that is covered or every limitation of coverage. For a
comprehensive description of benefits contact Kaiser and
request an “Evidence of Coverage” booklet. This contact
number is (800) 777-7902. Hours are Monday through
Friday from 7:30 a.m. to 5:30 p.m.
Where is Kaiser Medicare Plus Plan Available?
You can enroll in this plan if you live in the following areas:
n
n
District of Columbia
Maryland: Baltimore City, Anne Arundel County,
Baltimore County, Carroll County, Harford County,
Howard County, Montgomery County, Prince
Georges County, Calvert County*, Charles County*,
Frederick County*
n Virginia: Alexandria, Arlington, Fairfax City, Fairfax,
Falls Church, Loudon, Manassas City, Manassas Park
City and Prince William County
Physician and Hospital Choices
In-Network
You must go to network doctors, specialists and hospitals.
You’ll need a referral from your Primary Care Provider for
specialist visits and for hospital-based care.
Non-Emergency Out of Network Care
If you have Medicare Parts A & B, your Coverage will
be the same as the Original Medicare Plan. You will be
responsible for Medicare deductibles and coinsurance
amounts.
Inpatient Hospital Care
You have 100% coverage for approved Inpatient care. The
numbers of days covered is unlimited.
Emergency Care
You pay $50 for each Medicare covered Emergency room
visit. The copay is waived if you are admitted to the hospital
for the same condition.
Dental and Vision Services
Your copay is $30 for a preventive care dental visit every six
months. You pay $5 for a routine eye exam and receive a
25% discount on the cost of glasses.
Outpatient Prescription Drugs
The Kaiser plan uses a formulary, which is preferred list of
drugs selected to meet patient needs at a lower cost. If the
formulary changes, you will be notified in writing before
the change. To view the plan’s formulary, go to www.
kaiserpermanente.org on the web.
Your Out-of-Pocket Costs
You will not have a deductible with the Kaiser plan. Before
your out-of-pocket drug costs reach $4,350, you pay:
Kaiser Permanente Mail Delivery Services:
Generic or Brand: $3.00 (up to a 60-day supply for most
meds, up to a 90 day supply for maintenance medications
may be dispensed with a prorated copayment)
Kaiser Permanente Medical Center Pharmacy:
Generic or Brand: $5.00 (up to a 60-day supply); $7.50 (up
to a 90-day supply)
Kaiser Permanente Affiliated Network Pharmacy:
Generic or Brand: $10.00 (up to a 60-day supply); $15.00 (up
to a 90-day supply)
Out-of-Network Pharmacy:
Generic or Brand: $5.00 (up to a 30-day supply) plus the
amount over the in-network Kaiser Permanente Affiliated
Network Pharmacy.
After your yearly out-of-pocket drug costs reach $4,350, you pay:
Doctor Office Visits
You pay $5 for each visit to your Primary Care Provider.
You also pay $5 for approved Specialist Visits.
Kaiser Permanente Mail Deliver, Medical Center, or
Affiliated Network Pharmacy:
Generic: $1.00
Brand: $2.50
Diagnostic Tests, X-rays, Lab Services
There is no copay for Medicare covered x-rays and
diagnostic lab services. There is a $5 copay for each
Medicare Covered radiation therapy service.
Please note that certain prescription drugs will have
maximum quantity limit.
*Partial coverage in these counties.
Baltimore County ­Public Schools
Retiree Benefits Guide
65
Out-of-Network Pharmacies
Kaiser Permanente will cover prescriptions that are filled
at an out-of-network pharmacy if the prescriptions are
related to care for a medical emergency or urgently needed
care. In this situation, you will have to pay the full cost
(rather than paying just your copayment) when you fill
your prescription.
You can ask us to reimburse you for our share of the
cost by submitting a paper claim form. To learn how
to submit a paper claim, please refer to the paper claims
process described in the Evidence of Coverage. You will
be responsible for paying applicable cost-shares and all
amounts over and above the amount Kaiser Permanente
would have paid to an in-network non-preferred pharmacy
(Kaiser Permanente Affiliated Network Pharmacy).
Inpatient Hospital/Facility Services
Room & Board
ICU/CCU (other special care units), and Ancillary Services
(including nursery charges)
100% Covered
Extended Care Facility/Skilled Nursing Care (medically
necessary care—non-custodial)
100% Covered (100 days per benefit period)
Inpatient Professional/Practitioner Services
Physician Surgical Services
100% Covered
Anesthesia, Assistant Surgeon
100% Covered
Consultations (including follow-up visits) & Physician Visits
(includes ECF)
100% Covered
Radiation Therapy, Chemotherapy and Renal Dialysis
100% Covered
Outpatient Hospital/Facility Services
Minor/All Surgery (includes hospital based and freestanding $5 Copay
surgical centers)
Preadmission Testing
$5 Copay
Radiation Therapy, Chemotherapy and Renal Dialysis
$5 Copay
Physical & Speech Therapy
$5 Copay
Occupational Therapy
$5 Copay
Diagnostic Tests
100% Covered
Outpatient/Office Professional Services
Minor/All Surgery
$5 Copay
Anesthesia, Assistant Surgeon
$5 Copay
Diagnostic Tests
100% Covered
Office Visit for Illness, Injury or Consultation
$5 Copay
Allergy Tests
$5 Copay
Allergy and Other Covered Injections—administration of
injection
$5 Copay
Physical Therapy & Acupuncture
$5 Copay
Speech & Occupational Therapy
$5 Copay
Preventive/Well Care (Routine)
Annual Adult Physicals, Immunizations and
Diagnostic Tests: Ages 18 and older
Baltimore County ­Public Schools
$5 Copay
Retiree Benefits Guide
Medicare
Kaiser Permanente Medicare Plus
66
Medicare
Kaiser Permanente Medicare Plus
Preventive/Well Care (Routine) continued
GYN Services (including pap smear) rendered in the office
covered once every 24 months
100% Covered
Mammography Screening (Provider must be American
College of Radiology (ACR) approved)
100% Covered
Prostate Cancer Screening (including PSA test)
100% Covered
Emergency Care
Accidental Injury/First Aid and Medical Emergency or
Life Threatening Event
$50 Emergency Copay; waived if admitted
Follow-up Visits to an American Injury or Medical Emergency $5 Office Visit Copay
Ambulance
Ground (public and private)
Covered in full
Mental Health
Inpatient Hospital/Facility and Professional Services
Covered in full up to 190 days in psychiatric hospital
(Medicare Guidelines)
Outpatient Facility, Professional Services
$5 Copay
Prosthetic Devices & Orthopedic Braces
Purchase, repair or replacement
100% Covered (Medicare Guidelines)
Durable Medical Equipment
100% Covered (Medicare Guidelines)
Medical Supplies
100% Covered (Medicare Guidelines)
Home Health Care
Facility/Agency
100% Covered (Medicare Guidelines)
Outpatient Private Duty Nursing (non-custodial; preauthorization required)
Special limitations apply
Hospice Care (inpatient or at home; pre-authorization
required)
100% Covered (Medicare Certified Hospice)
Cardiac Rehabilitation
$5 Office Visit Copay
Organ Transplants
Kidney, Cornea, Bone Marrow
100% Covered (Medicare Guidelines)
Heart, Heart-Lung, Single or Double Lung, Pancreas and
Liver
100% Covered (Medicare Guidelines)
Prescription Drugs
Outpatient prescription drugs
60 day supply; $3 mail order, $5 Kaiser Center, $10 Kaiser
network pharmacy
Drugs dispensed by medical provider in office
Included in office visit
Routine Vision
Discounts at participating providers
Dental
Discounts at participating providers
Note: All services through Kaiser Permanente require coordination or authorization from the Plan or the member’s Primary Care Physician.
This benefit matrix is intended for comparison/informational purposes and is not meant to be a binding contract. Specific benefit inquires or quotes
should be directed to the appropriate customer service department at (800) 777-7902 or by consulting your Evidence of Coverage.
Baltimore County ­Public Schools
Retiree Benefits Guide
67
What do I need to know about Kaiser
Permanente Medicare Plus
(a Medicare HMO)?
Can I only see the Kaiser Permanente doctors at the
Kaiser Medical Centers?
If you wish to go to the doctor and pay only the $5
copayment, you must see the doctors either at the Kaiser
Permanente centers or the specialists that they refer you
to. Sometimes the specialists may be doctors in your
neighborhood or doctors you already use, but you must see
your Kaiser Permanente Primary doctor first. You may, at
any time, use your red, white and blue Medicare card to
see any Medicare participating doctor, but you will pay the
Medicare deductibles and coinsurance, and be responsible
for making the claim yourself or through the doctor.
Will I need to change all my doctors if I switch to
Kaiser Permanente?
Not necessarily. Kaiser Permanente and Medicare Plus
contract with many independent specialists in the
Baltimore metropolitan area. It is possible that some of your
doctors are already participating with Kaiser Permanente.
But in order to see these doctors for only the $5 copayment,
you will need to get a referral from your Primary Care
doctor at Kaiser Permanente.
What is it like at a Kaiser Permanente Medical
Center?
Kaiser Permanente Medical Centers offer many medical
services under one roof. There will always be Primary Care,
a pharmacy and a laboratory in the building. Each center
may also offer specialty care, such as Allergy, Orthopedics,
Dermatology or Urology. They may also have Urgent
Care hours, Outpatient Surgery, X-rays or other imaging
services available. Except for Urgent Care, these services
will require an appointment. You can call or stop by and
request a tour at one of the centers at any time during
regular business hours.
Baltimore County ­Public Schools
How do I get referral to see my specialists?
Once you and your Primary Care Physician know each
other, your doctor may send you to your specialist for a
one time evaluation, or for an entire treatment plan. The
referral is something you will discuss with your doctor and
depends on the nature of your condition. If you are already
seeing a specialist, you might ask their office if they can
help you to choose a Primary Care Physician from Kaiser
Permanente with whom they are familiar.
Are the doctors at Kaiser Permanente good?
Ninety-three percent of the physicians at Kaiser
Permanente are board certified. This means they have
taken exams in their area of specialty and continued their
medical education to remain current. Only one in eight
doctors who apply to work at the Mid-Atlantic Permanente
Medical Group is accepted to become part of the group.
What independent sources monitor the quality of
care people receive at Kaiser Permanente?
The Maryland Health Care Commission is a public
regulatory commission appointed by the Governor of the
State of Maryland that evaluates and publishes findings
on the quality and performance of managed care plans
that operate in the state. You can read the 2008 report at
http://mhcc.maryland.gov/hmo/compreport.pdf. Kaiser
Permanente has been the top rated plan for five years
straight.
Kaiser Permanente of the Mid-Atlantic States is the highest
ranking plan in member satisfaction in the 2009 J.D. Power
and Associates National Health Insurance Plan Study for
the Virginia-Maryland region.
The National Committee on Quality Assurance (NCQA)
evaluates the quality of the processes and the key systems
that define health care organizations. Kaiser Permanente
of the Mid-Atlantic States has received the highest possible
rating, Excellent. Kaiser Permanente Medicare Plus also
received recognition in the U.S. News and World Report
“Best Health Plans of 2008.”
Retiree Benefits Guide
Medicare
Kaiser Permanente Medicare Plus
68
Medicare
Kaiser Permanente Medicare Plus
What makes an HMO different from how I get my
healthcare now? What is “managed care”?
Kaiser Permanente health plans stress routine screenings
and preventive care, as well as specialized disease
management programs. The goal is to keep the patient
healthy and active instead of waiting until there is an
illness to treat. Having a Primary Care Physician means all
of your specialists, treatments and prescriptions are being
monitored and coordinated in one place. These doctors
can also easily consult and collaborate with each other,
since they are all on the same team. Kaiser’s doctors are
paid salaries, not based on each procedure they perform.
Kaiser Permanente is also recognized worldwide for its use
of the “Automated Medical Record.” This system, “Health
Connect”, makes your records immediately available to all
of the doctors and hospitals of Kaiser Permanente via the
secure Kaiser Permanente computer system.
I like my doctors, but I am finding the paperwork for
healthcare expenses to be overwhelming.
Managed care members rarely need to complete any
paperwork for payment of their healthcare. Ordinarily one
shows their identification card and pays a copayment at the
time of service. There are no deductibles or complicated
forms for reimbursement when they visit participating
physicians. Rare cases for needing to complete a form
would be when seeing a doctor who does not file to
Medicare, or for an emergency outside of the home area.
Can an HMO help me budget for my healthcare?
Many people find traditional insurance makes it hard
to plan a budget. You may have deductibles to meet
before benefits will start, and/or you are required to pay
a percentage of charges that you cannot possibly know in
advance. Also, many doctors charge more than the “Usual
and Customary” rates, which further adds to your out-ofpocket expenses.
Baltimore County ­Public Schools
With flat copayments, HMOs make it easier to budget for
your healthcare. If you can guess how many times you
might need to go to the doctor, and what prescriptions you
take, you can easily forecast how much you will need to set
aside for medical expenses.
Why do the Kaiser Permanente Medicare Plus plan
rates change in January?
The Kaiser Permanente Medicare Plus plan is an HMO
with a Medicare Cost contract. The Medicare Plus Plan
offered by Baltimore County Public Schools also includes
Medicare Part D benefits. Medicare contracts always run
on a calendar year. The laws also require the HMO to
offer at least what Medicare would cover, and to follow the
pricing rules set by CMS (the Centers for Medicare and
Medicaid Services), that also follow the calendar year.
If Medicare Plus has Medicare Part D coverage,
what am I going to do about the deductible and the
coverage gap? Aren’t there special rules about when
I can sign up for Part D?
Baltimore County Public Schools has purchased an
upgraded Medicare Part D benefit for its retirees. There
are no deductibles and there is no coverage gap. For Kaiser
Permanente Medicare Plus members, all prescriptions are
$3, $5 or $10 (or less in some cases) depending on where
you get it filled.
People who join a Part D plan through an employer
group can come in at any time allowed by the employer.
Baltimore County Public Schools has set plan rules for
open enrollment periods and “events” that allow for
plan changes. These rules apply equally to the Kaiser
Permanente Medicare Plus plan and other plans.
Retiree Benefits Guide
69
Medicare
When might it NOT be a good idea to enroll in a
Medicare Managed Care Plan or HMO such as Kaiser
Permanente Medicare Plus?
Do you live far from the central major metropolitan
area (more than 20 miles away)?
HMOs can only operate in areas approved by the federal
government. These service areas are defined by zip code. The
rule says you must “Live or Work” within the plan’s approved
service area. You should always check the service area of a
plan before applying for coverage. The plan will be notified
if the address on your application does not match your
address on record with Medicare or Social Security, and your
application may be denied.
Kaiser Permanente Medicare Plus cannot enroll people who
live outside of the Baltimore/Washington Metropolitan
areas (such as Pennsylvania or Delaware). They can enroll
people in the City of Baltimore, Baltimore, Anne Arundel,
Carroll, Harford, Howard, Montgomery and Prince Georges
Counties, and portions of Calvert, Charles, and Frederick
counties. The District of Columbia and Northern Virginia
are also included.
You may also wish to check the plan descriptions for the
nearest participating hospital. HMO’s will pay for you to go
the nearest emergency room, but for care that can be planned
or scheduled, they will use hospitals that they have contracts
with. You want to be sure these are convenient to you,
especially if driving is difficult for you or family members.
This means that in an emergency, you will be stabilized at the
closest facility, even if they do not participate. After you are
stable, you may be transferred to a participating hospital, or
will need to follow up with your regular Kaiser Permanente
doctors.
Baltimore County ­Public Schools
Are you using doctors or hospitals to whom you are
very attached and will never want to change?
If so, check with their office manager to see whether or not
they will take referrals from the plan you are considering. It
is possible that they might participate with the plan, but if
they do not, you (or the doctor) will need to file claims to
Medicare and be reimbursed after the Medicare deductible
and coinsurance. This is possible to do when a Kaiser
member, but really is not the best way to get value from the
Kaiser Permanente Medicare Plus Plan.
Do you often leave your home area for more than three
months (90 consecutive days) at a time?
Medicare managed care plans are funded based upon a
member’s permanent address. If you are out of the service area
for more than 90 consecutive days, Medicare would prefer
you select a plan in the area to which you have relocated. If
you go away for more than three months at a time often, you
should check with your employer that they will let you change
plans if necessary.
How do I enroll?
Obtain a Kaiser Permanente Medicare Plus enrollment
form and mail the form directly to Kaiser. BCPS will start
deductions when notified of enrollment by Kaiser.
How do I cancel?
Submit written notification for each covered member directly
to Kaiser.
Retiree Benefits Guide
70
Medicare
Kaiser Permanente Medicare Plus
Are you required to provide healthcare for someone
(for example, a child or spouse), who does not live in
your home area?
If you have an obligation to provide healthcare for someone
else, you should check with your employer to make sure
they are also eligible for this plan, or if another plan is
available. Some employers allow family members to have
different health plans if they live in different areas.
For dependent children who are away at college/university,
HMOs will cover them while out of town only for urgent or
emergency care. For care that can be planned or scheduled,
(if there is time to make an appointment), the patient will be
expected to return home to their Primary Care Physician.
Baltimore County ­Public Schools
Retiree Benefits Guide
71
When You Must Contact BCPS Office
of Benefits, Leaves & Retirement
It is your responsibility to notify the Office of Benefits,
Leaves and Retirement each time you have a change in
you or your dependents’ benefit status. You must contact
the Office of Benefits, Leaves and Retirement within 30
days, of a change in family status, to make a change to
your benefits enrollment. Our health plan administrators
cannot make retroactive changes to coverage further back
than the first of the month in which a change is requested.
Examples of a change in family status include:
n
n
n
n
n
irth or adoption of a new child – children must
B
be added to your coverage within 30 days of the
birth or adoption even if you already have family
coverage.
ivorce – the former spouse must be removed
D
from your coverage within 31 days of the divorce
decree.
ou obtain other health plan coverage (including
Y
eligibility for Medicare) not identified on your
health plan application.
ou or your spouse lose other benefits plan
Y
coverage due to a change in employment status
(i.e. changing from full-time to part-time status).
You must provide proof of the change requested
(i.e. – a copy of the divorce decree to remove a spouse
from coverage, or copy of birth certificate to add
newborn). Changes to benefits will only be effective the
1st of the following month if the change request and
documentation are received by the 10th of the month.
Including your dependent(s) on BCPS benefit plans
when they do not meet BCPS eligibility requirements is
fraudulent and subject to prosecution.
Continuing Coverage upon
Retirement
In order to qualify for BCPS health insurance coverage
when you retire, two basic requirements must be met:
n
n
etirees must begin receiving their pension benefit
R
immediately upon leaving employment with BCPS;
and
etirees and/or their eligible beneficiaries must
R
have been eligible for benefits while employed with
BCPS.
The amount you will pay for benefit plan participation
is based on the number of years of creditable service
with BCPS, the date of your retirement, and the type of
retirement (service or disability).
ou move to a new residence outside Maryland
Y
that is not included in your current health plan’s
coverage area.
Baltimore County ­Public Schools
Retiree Benefits Guide
Important Things to Remember
Important Things to Remember
72
HIPPA
Health Insurance Portability Accountability Act (HIPAA)
The Health Insurance Portability and Accountability Act
(HIPAA) places limitations on a group health plan’s ability
to impose pre-existing condition exclusions, provides
special enrollment rights for certain individuals, and
prohibits discrimination in group health plans based on
health status. HIPAA also safeguards your protected health
information (PHI).
BCPS electronically transmits data to the vendors
for eligibility purposes. The vendors and BCPS are in
compliance with the HIPAA requirements. No personally
identifiable information may be released to a third party.
For more detailed information, please go to our Website,
http:/www.bcps.org/offices/benefits/hipaa.
Special Enrollment Rights
If you decline enrollment for yourself or your dependents
(including your spouse) because of other health insurance
coverage, you may in the future be able to enroll yourself
or your dependents in this plan.
An enrollment request must be made within 30 days of
your other coverage ending. In addition, if you have a
new dependent (as a result of marriage, birth, adoption,
or placement for adoption), you may be able to enroll
yourself and your dependents provided that you request
enrollment within 30 days of the qualifying event.
For more information about your rights,
including COBRA, the Health Insurance
Portability and Accountability Act (HIPAA), and
other laws affecting group health plans, contact
the nearest Regional or District Office of the
U.S. Department of Labor’s Employee Benefits
Security Administration (EBSA) in your area or
visit the EBSA Website at www.dol.gov/ebsa.
New Special Enrollment Rights
that the employee notified the employer within 30 days of
the occurrence of any following events:
n
n
n
oss of health coverage under another employer
L
plan (including exhaustion of COBRA coverage).
Acquiring a spouse through marriage.
cquiring a dependent child through birth, adoption,
A
placement for adoption or foster care placement.
Effective April 1, 2009, the Children’s Health Insurance
Program Reauthorization Act of 2009 creates two new
special enrollment rights for employees and their dependents.
In addition to the special enrollment rights set forth above,
all group health plans must also permit eligible employees
and their dependent(s) to enroll in an employer plan if the
employee requests enrollment under the group health plan
within 60 days of the occurrence of following events:
n
n
oss of coverage under Medicaid or a state child health
L
plan: If you or your dependent(s) lose coverage under
Medicaid or a state child health plan, you may request to
enroll yourself and/or dependent(s) in our group health
plan not later than 60 days after the date coverage ends
under Medicaid or the state child health plan.
aining eligibility for coverage under Medicaid or a
G
state child health plan: If you and/or your dependent(s)
become eligible for financial assistance from Medicaid
or a state child health plan, you may request to enroll
yourself and/or your child(ren) under our group
health plan, provided that your request is made no
later than 60 days after the date that Medicaid or the
state child health plan determines that you and/or your
dependent(s) are eligible for such financial assistance.
If you and/or your dependent(s) are currently enrolled
in our group health plan, you have the option of
terminating your and/or your child(ren)’s enrollment
in our group health plan and enroll in Medicaid or
a state child health plan. Please note that once you
terminate your enrollment in our group health plan,
your children’s enrollment will be also terminated.
This notice is being provided so that you understand your
right to apply for group health insurance coverage outside
of Baltimore County Public School’s open enrollment
period. You should read this notice regardless of whether
or not you are currently covered under the Baltimore
County Public School’s Group Health Plan.
Failure to notify us of your loss or gain of eligibility for
coverage under Medicaid or a state children’s health
plan within 60 days, will prevent you from enrolling in
our plans and/or making any changes to your coverage
elections until our next open enrollment period.
HIPAA requires that employees be allowed to enroll
themselves and/or their dependent(s) in an employer’s
Group Health Plan under certain circumstances, provided
To request special enrollment, or if you have questions
regarding special enrollment rights, please contact the Office
of Benefits, Leaves and Retirement at (410) 887-8943.
Baltimore County ­Public Schools
Retiree Benefits Guide
73
BALTIMORE COUNTY PUBLIC
SCHOOLS NOTICE OF PRIVACY
POLICY AND PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED IF YOU ARE COVERED BY BALTIMORE
COUNTY PUBLIC SCHOOLS HEALTH BENEFIT
PLANS. PLEASE REVIEW IT CAREFULLY.
This Notice applies to the following Benefit Plans sponsored
by Baltimore County Public Schools:
Medical Benefit Plans
n
igna OAPIN, Cigna OAP, and Medicare Surround
C
Plans, Health Maintenance Organization
n Prescription Drug Benefits included with
Medical Plans
n
Dental and Vision Plans
n
EAP and Managed Mental Health Plans
n
Health Care Flexible Spending Accounts (FSAs)
These plans are treated as a single plan for purposes of this
Notice and the privacy rules that require it. For purposes
of this Notice, we will refer to these plans as a single
“Plan”. Please note that Baltimore County Public Schools
provides personal and demographic information required
to establish your eligibility in these plans and provides
the funding for the plans. In instances where the use or
disclosure of your medical information is required for
purposes of treatment, payment or operation of our health
plans, Baltimore County Public Schools has assigned those
responsibilities to Plan Administrators.
The Plans covered by this notice may share information
with each other when required and as permitted under law.
The amount of health information used or disclosed will be
limited to the Minimum Necessary to provide or pay for
medical care. The Plans may also contact you to provide
appointment reminders or other health-related services.
Baltimore County ­Public Schools
The Plan’s Duty to Safeguard Your
Protected Health Information
Individually identifiable information about your past, present,
or future health or condition, the provision of health care to
you, or payment for the health care is considered “Protected
Health Information” (“PHI”). The Plan is required to extend
certain privacy protections to your PHI under HIPAA. This
Notice serves to explain how, when, and why the Plan may use
and/or disclose your PHI. The Plan is required to follow the
privacy practices described in this Notice, though it reserves
the right to change those practices and the terms of this
Notice at any time. If it does so, and the change is material,
you will receive a revised version of this Notice either by hand
delivery, mail delivery to your last known address, or some
other fashion. This Notice, and any material revisions of it,
will also be provided to you in writing upon your request,
and will be posted on http://www.bcps.org/offices/benefits/
pdf/Notice-of-Privacy-Practices_HIPAA_0403.pdf.
You may also receive one or more other privacy notices, from
insurance companies that provide benefits under the Plan.
Those notices will describe how the insurance companies use
and disclose PHI, and your rights with respect to the PHI they
maintain.
How the Plan May Use and Disclose
Your Protected Health Information
The Plan uses and discloses PHI for a variety of reasons. For
routine internal uses and disclosures, it does not require
your authorization. However, for other uses and disclosures,
your authorization or the authorization of your personal
representative (e.g., a person who is your custodian, guardian,
or has your power of attorney) may be required. The following
offers further description and examples of the Plan’s uses and
disclosures of your PHI.
Retiree Benefits Guide
Notice of Privacy Policy and Practices
Notice of Privacy Policy and Practices
74
Notice of Privacy Policy and Practices
Uses and Disclosures Relating to
Treatment, Payment or Health Care
Operations.
n
n
n
reatment: Generally, and as you would expect,
T
the Plan Administrators are permitted to disclose
your PHI for purposes of your medical treatment.
Thus, they may disclose your PHI to doctors,
nurses, hospitals, emergency medical technicians,
pharmacists and other health care professionals
where the disclosure is for your medical treatment.
For example, if you are injured in an accident, and
it is important for your treatment team to know
your blood type, the Plan Administrators could
disclose that PHI in order to allow you to receive
effective treatment.
ayment: Of course, the Plan’s most important
P
function is that it pays for all or some of the
medical care you receive (provided the care is
covered by the Plan). In the course of its payment
operations, the Plan Administrators receive a
substantial amount of PHI about you. The doctors,
hospitals and pharmacies that provide you care
send the Plan Administrators detailed information
about the care they provided, so that they can be
paid for their services.
e Plan Administrators may also share your PHI
Th
with other plans, in certain cases. As an example, if
you are covered by more than one health care plan
(e.g. you are covered by this Plan and your spouse’s
plan or covered by plans from your father and
mother); they may share your PHI with the other
plans to coordinate payment of your claims.
ealth care operations: The Plan Administrators
H
may use and disclose your PHI in the course of its
“health care operations.” For example, it may use
your PHI in evaluating the quality of services you
received, or disclose your PHI to an accountant or
attorney for audit purposes. In some cases, the Plan
may disclose your PHI to insurance companies for
purposes of obtaining insurance coverage.
Baltimore County ­Public Schools
Other Uses and Disclosures of Your
PHI Not Requiring Authorization
The law provides that the Plan may use and disclose your
PHI to insurance companies for purposes of obtaining
insurance coverage.
o the Plan Sponsor: The Plan Administrators
T
may disclose PHI to Baltimore County Public
Schools, who is the Plan sponsor, and maintains
the benefit plans offered to its employees, retirees
and dependents. However, the PHI may only be
used for limited purposes. It may not be used
for purposes of employment-related actions
or decisions or in connection with any other
benefit or employee benefit plan of the employers.
Additionally, PHI may be disclosed to:
n
nBaltimore
nPayroll
nTechnology
nFinance
n
n
County Public School’s Office of
Benefits, Leaves and Retirement for purposes
of enrollment and disenrollment, census, claim
resolutions, and other matters related to Plan
administration.
Department for purposes of ensuring
appropriate payroll deductions and other
payments by covered persons for their coverage.
Department, as needed for
preparation of data compilations and reports
related to Plan administration.
Department for purposes of reconciling
appropriate payments of premium to and benefits
from the Plan, and other matters related to Plan
administration; Internal legal counsel to assist
with resolution of claim, coverage, and other
disputes related to the Plan’s provision of benefits.
equired by law: The Plan may disclose PHI when
R
a law requires that it report information about
suspected abuse, neglect or domestic violence,
or relating to suspected criminal activity, or in
response to a court order. It must also disclose PHI
to authorities who monitor compliance with these
privacy requirements.
orkers’ Compensation: We may release medical
W
information about you for workers’ compensation
or for similar programs that provide benefits for
work-related injuries or illness.
Retiree Benefits Guide
75
n
n
n
n
n
n
or public health activities: The Plan may disclose
F
PHI when required to collect information about
disease or injury, or to report vital statistics to the
public health authority.
or health oversight activities: The Plan may disclose
F
PHI to agencies or departments responsible for
monitoring the health care system for such purposes
as reporting or investigation of unusual incidents.
elating to descendants: The Plan may disclose
R
PHI relating to an individual’s death to coroners,
medical examiners or funeral directors, and to organ
procurement organizations relating to organ, eye, or
tissue donations or transplants.
or research purposes: In certain circumstances, and
F
under strict supervision of a privacy board, the Plan
may disclose PHI to assist medical and psychiatric
research.
your location, general condition, or death. However, the Plan
may disclose your PHI only if you are informed about the
disclosure in advance and you do not object. (However, if
there is an emergency situation and you cannot be given your
opportunity to object, disclosure may be made if it is consistent
with any prior expressed wishes and/or if disclosure is
determined to be in your best interests. You must be informed
and given an opportunity to object to further disclosure as
soon as you capable).
Your Rights Regarding Your
Protected Health Information
You have the following rights relating to your protected health
information:
n
n
n
o avert threat to health or safety: In order to avoid
T
a serious threat to health or safety, the Plan may
disclose PHI as necessary to law enforcement or other
persons who can reasonably prevent or lessen the
threat of harm.
or specific government functions: In certain
F
situations, The Plan may disclose PHI of military
personnel and veterans, to correctional facilities,
to government programs relating to eligibility and
enrollment, and for national security reasons.
Uses and Disclosures Requiring
Authorization
For uses and disclosures beyond treatment, payment and
operations purposes, and for reasons not included in one of
the exceptions described above, the Plan is required to have
your written authorization. Your authorizations can be
revoked at any time to stop future uses and disclosures, except
to the extent that the Plan has already undertaken an action in
reliance upon your authorization.
Uses and Disclosures Requiring You
to have an Opportunity to Object
The Plan may share PHI with your family, friend or other
person involved in your care, or payment for your care. We
may also share PHI with these people to notify them about
Baltimore County ­Public Schools
o request restrictions on uses and disclosures:
T
You have the right to ask that the Plan (or Plan
Administrator) limit how it uses or discloses your
PHI. The Plan will consider your request, but is not
legally bound to agree to the restriction. To the extent
that it agrees to any restriction on its use or disclosure
of your PHI, it will put the agreement in writing and
abide by it except for in emergency situations. The
Plan cannot agree to limit uses or disclosures that are
required by law.
o choose how the Plan contacts you: You have the
T
right to ask that the Plan (or Plan Administrator) send
you information at an alternative address or by an
alternative means. The Plan (or Plan Administrator)
must agree to your request as long as it is reasonably
able to accommodate the request.
o inspect and copy your PHI: Unless your access
T
is restricted for clear and documented treatment
reasons, you have a right to see your PHI in the
possession of the Plan or its Administrators. Your
request MUST be in writing. The Plan, or someone
on behalf of the Plan, will respond to your request,
normally within 30 days. If your request is denied,
you will receive written reasons for the denial and an
explanation of any right to have the denial reviewed.
If you want copies of your PHI, a copying fee may
be imposed. This fee may be waived at the Plan’s
discretion. You have a right to choose which portions
of your information you want copied. Upon request,
you may receive prior notice of the cost of copying.
Retiree Benefits Guide
Notice of Privacy Policy and Practices
76
Notice of Privacy Policy and Practices
n
n
o request amendment of your PHI: If you believe
T
that there is a mistake or missing information
in a record of your PHI held by one of the Plan
Administrators, you may request in writing, that
the record be corrected or supplemented. The Plan
or Plan Administrators will respond, normally
within 60 days of receiving your request. The Plan
may deny the request if it is determined that the
PHI is: (1) correct and complete; (2) not created
by the Plan or its Administrator and/or not part
of the Plan’s or Administrator’s records; (3) not
permitted to be disclosed. Any denial will state the
reasons for denial and explain your rights to have
the request and denial, along with any statement
in response that you provide, appended to your
PHI. If the request for amendment is approved, the
Plan or Plan Administrator will change the PHI.
They will inform you and others that need to know
about the change in the PHI.
o find out what disclosures have been made:
T
For actions that occur on and after June 1, 2009,
you have a right to request a list of when, to
whom, for what purpose, and what portion of
your PHI has been released by the Plan and/or
its Plan Administrators, other than instances of
disclosure for which you gave authorizations, or
instances where the disclosure was made to you
or your family. In addition, the disclosure list will
not include disclosures for treatment, payment, or
health care operations. The list also will not include
any disclosures for national security purposes, to
law enforcement officials, or correctional facilities,
or before the date federal privacy rules applied
to the Plan. You will receive a response to your
written request for such a list within 60 days after
you make the request. You may make one (1)
request in any 12-month period at no cost to you.
There may be a charge for more frequent requests.
How to Complain about the Plan’s
Privacy Practices:
If you think the Plan or one of its Plan Administrators
may have violated your privacy rights, or if you disagree
with a decision made by the Plan or a Plan Administrator
about access to your PHI, you may file a complaint with the
person listed in the section immediately below. You also
may file a written complaint with the Secretary of the U.S.
Department of Health and Human Services. The law does
not permit anyone to take retaliatory action against you if
you make such complaints.
Contact Person for Information, or to
Submit a Complaint:
If you want more information about Baltimore County Public
School’s privacy practices with respect to your health plans and
who is covered on your plans, contact the Employee Benefits
& Retirement Office at (410) 887-8943. If you want more
information about the privacy practices of the BCPS’s Plan
Administrators, contact them directly at the Member Services
number on your Plan ID card. Additional contact information
for Baltimore County Public School’s Plan Administrators can
be found at http://www.bcps.org/offices/benefits/.
Privacy Official
Baltimore County Public School’s
HIPAA Compliance Officer:
Employee Benefits Officer
Office of Benefits, Leaves and Retirement
6901 North Charles St., Bldg. B
Towson, MD 21204
(410) 887-8943
Effective Date
The effective date of this Notice is: 6/1/09
Baltimore County ­Public Schools
Retiree Benefits Guide
77
Office of Benefits, Leaves & Retirement
Baltimore County Public Schools
6901 North Charles St., Bldg. B
Towson, MD 21204
Phone: (410) 887-8943
Fax: (410) 887-8950
Email: [email protected]
Website: www.bcps.org/offices/benefits
Social Security Information (SSA)
Phone: (800) 772-1213
Website: www.ssa.gov
Change of address
General Medicare Part A or B eligibility or premiums
Medicare Help Line
Phone: (800) MEDICARE (633-4227)
Website: www.medicare.gov
Plan Administrator/Group Plan Name
Call us for these reasons:
n Who is eligible for BCPS health plan coverage
n General benefit questions
n Changes to life insurance beneficiaries
n Assistance with benefits election when retiring
n Continuing benefits under COBRA if you or your
dependent(s) lost BCPS benefits
n Address change
n Life status changes – i.e., marriage, divorce, birth,
adoption, death of dependents, dependent graduation/
loss of full-time student status
n Questions about your retirement
Request new ID card
Ordering Medicare publications
General Medicare information
Website
Customer Service
Express Scripts (Prescription Drugs)
Group #RB52D, Sponsor #1639
TDD
Mail Order
www.express-scripts.com
(877) 852-4061
Cigna
www.cigna.com
Under Age 65
Baltimore County ­Public Schools
(800) 899-2114
(800) 233-7139
(800) 896-0948
Retiree Benefits Guide
Important Resources
Important Resources
78
Important Resources
Important Resources – continued
Plan Administrator/Group Plan Name
Website
Customer Service
Under Age 65
Kaiser Permanente HMO
Group #7434-12
HMO
Member Services (ID Cards, verify
provider participation, claims & nurse
advice line)
www.kp.org
(800) 777-7902
Office Appointments & Doctor
Messaging Service
(800) 777-7904
Provider Service Number
(Hospital Pre-Certification/Health
Consult Service)
(800) 810-4766
Healthy Living Information Line
(Pregnancy, Diabetes Management,
Nutrition & Weight Control Programs
(800) 444-6696
TDD Line
(800) 777-7902
Network Mental Health Provider
(866) 530-8778
Mental Health TDD
(800) 828-1140
Baltimore County ­Public Schools
Retiree Benefits Guide
79
Website
Customer Service
Cigna Medicare Surround
Express Scripts (Prescription Drugs)
Group #T350D
Mail Order
Kaiser Permanente HMO
Group #7434-16
Medicare Plus
www.mycigna.com
(800) 896-0948
www.express-scripts.com
(877) 852-4061
(800) 233-7139
www.kp.org
(800) 777-7902
Plan Administrator/Group Plan Name
Website
Customer Service
www.carefirst.com
(866) 891-2802
(866) 891-2804
www.mycigna.com
(800) 367-1037
Important Resources
Plan Administrator/Group Plan Name
Medicare Eligible
Other Plans
CareFirst Dental Group #7J91
Member Services
Provider Services
Cigna DHMO Group #10013509
Member Services
Provider Services
CareFirst Davis Vision Plan
www.carefirst.com
Maryland State Retirement & Pension
System
www.sra.state.md.us
Baltimore County Employees’
Retirement System
www.baltimorecountymd.gov
Conseco
(Washington National Insurance Co)
Cancer
CareFirst BlueCross BlueShield
Catastrophic Insurance
MetLife1
Life Claims
Prudential2
Life Claims
1
2
(888) 336-7125
new cards only 877-691-5856
(800) 492-5909
(410) 625-5555
Email: [email protected]
(877) 222-3741
410-887-8246
[email protected]
(877) 372-5916
(410) 581-3404
Option 1
(888) 280-6083
(800) 778-3827
Only those retirees who had the pre-paid $2,620 life insurance should contact MetLife.
All other basic & optional life insurance is with Prudential.
Baltimore County ­Public Schools
Retiree Benefits Guide
80
IMPORTANT NOTICE
Special enrollment requirements from Cigna
This flyer contains important information you should read before you enroll in Cigna
Medicare Surround®. If you have any questions about this information, please contact
your plan sponsor.
If you are declining enrollment
If you are declining enrollment for yourself
or your dependents (including your spouse)
because of other health insurance or group
health plan coverage, you may be able to
enroll yourself and your dependents in this
plan if:
• Youoryourdependentsareeligibleunder
the plan, and
• Youoryourdependentsloseeligibilityfor
that other coverage (or if the plan sponsor
stops contributing toward your or your
dependents’ other coverage). However,
you must request enrollment within
30 days after your or your dependents’
other coverage ends (or after the plan
sponsor stops contributing toward the
other coverage). If the other coverage is
COBRA continuation coverage, you and
your dependents must complete your
entire COBRA coverage period before you
can enroll in this plan, even if your plan
sponsor stops contributions toward the
COBRA coverage.
In addition, if you have a new eligible
dependent as a result of marriage, adoption
or placement for adoption, you may be able
to enroll yourself and your dependents.
813790 e 08/13
However, you must request enrollment within
30 days after the marriage, adoption or
placement for adoption.
If you or your dependents lose eligibility for
state Medicaid or Children’s Health Insurance
Program (CHIP) coverage or become eligible
for assistance with group health plan premium
payment under a state Medicaid or CHIP
plan, you may be able to enroll yourself and
your dependents. However, you must request
enrollment within 60 days after the state
Medicaid or CHIP coverage ends or you are
determined eligible for premium assistance.
To request special enrollment or
obtain more information, contact
our customer service team at
1-800-Cigna24 (1-800-244-6224).
Other late entrants
If you decide not to enroll in this plan now,
then want to enroll later, you must qualify for
special enrollment. If you do not qualify for
special enrollment, you may have to wait until
an open enrollment period, or you may not
be able to enroll, depending on the terms and
conditions of your benefit plan. Please contact
your plan sponsor for more information.
81
Women’s Health and Cancer Rights Act (WHCRA)
• Prostheses;and
If you have had or are going to have a mastectomy,
you may be entitled to certain coverage under the
Women’s Health and Cancer Rights Act of 1998
(WHCRA). For individuals receiving mastectomyrelated coverage, it will be provided in a manner
determined in consultation with the attending
physician and the patient, for:
• Treatmentofphysicalcomplicationsofthe
mastectomy, including lymphedema.
• Allstagesofreconstructionofthebreaston
which the mastectomy was performed;
Thiscoveragewillbeprovidedsubjecttothesame
deductibles and coinsurance or copays applicable
to other medical and surgical benefits provided
underthisplanasshownintheSummaryof
Benefits. If you would like more information on
WHCRA benefits, call our customer service team
at 1-800-Cigna24 (1-800-244-6224).
• Surgeryandreconstructionoftheotherbreast
to produce a symmetrical appearance;
Protecting your confidentiality
Protection of your confidential information
At Cigna, we are committed to maintaining the
confidentiality of your health information. We have
established policies and safeguards to protect
oral, written and electronic information across
our organization.
Information about Cigna privacy practices
Our notice of privacy practices is given to everyone
enrolling in a medical insurance policy. Individuals
covered under self-insured medical plans will
receive notices from their plan sponsor and can
obtain a copy of Cigna’s notice by calling our
customer service team.
Release of confidential information
We will not use or disclose your confidential
information for any purpose other than the
purposes permitted by the HIPAA Privacy Rule
without your written authorization. For example,
we will not supply confidential information to
another company for its marketing purposes or
to a potential plan sponsor with whom you are
seeking employment unless you authorize it.
Access to your medical records
Youmayasktoinspectortoobtainacopyofyour
confidential information that is included in certain
records we maintain. We may charge you copying
and mailing costs. Under limited circumstances, we
may deny you access to a portion of your records.
Instructions on how to obtain a copy of your records
will be included in the privacy notice you receive
from Cigna or your plan sponsor after you enroll.
Information to plan sponsors
We may disclose your confidential information
to your plan sponsor or to a company acting on
your plan sponsor’s behalf so that it can monitor,
audit and otherwise administer the health plan
inwhichyouparticipate.Yourplansponsorisnot
permitted to use the confidential information we
disclose for any purpose other than administering
your health plan.
“Cigna,”“Cigna Medicare Surround,” the “Tree of Life” logo and “GO YOU” are registered service marks of Cigna Intellectual
Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided
by or through such operating subsidiaries, including Connecticut General Life Insurance Company and Cigna Health
and Life Insurance Company, and not by Cigna Corporation. Cigna Medicare Surround is not offered under a contract
with the federal government.
813790 e 08/13 NO PCL
© 2013 Cigna
82
Health Care Reform Impact
HEALTH CARE REFORM IMPACT ON BALTIMORE COUNTY PUBLIC
SCHOOLS EMPLOYEE BENEFIT PLANS
To maintain status as a grandfathered health plan, an employer benefit plan or health insurance coverage must
have had individuals enrolled in the plan on the date the Patient Protection and Affordable Care Act (PPACA)
was enacted (March 23, 2010). Accordingly, Baltimore County Public Schools believes that the Kaiser Staff Model
HMO plans meet the criteria to operate as grandfathered health plans. The new Cigna Open Access HMO (OAPIN)
and Cigna Open Access Plus PPO plan does not meet the criteria and thus will be required to comply with all the
consumer protections of the PPACA.
As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage
that was already in effect when that law was enacted. Being a grandfathered health plan means the plans that qualify
for grandfather status may not include certain consumer protections of the Affordable Care Act that apply to
other plans, for example, the requirement for the provision of preventive health services without any cost sharing.
However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care
Act, for example, coverage of adult dependent children to age 26, elimination of lifetime benefit maximums and
other provisions.
Detailed benefit charts for each of the plans sponsored by Baltimore County, Maryland are included in this benefit
guide – please review them carefully for plan coverage differences.
Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and
what might cause a plan to change from grandfathered health plan status can be directed to the Baltimore County
Public Schools Employee Benefits office at 410-887-8943. Information on grandfathered plans can also be found
online at www.dol.gov/ebsa/healthreform.
This website has a table summarizing which protections do and do not apply to grandfathered health plans.
Baltimore County ­Public Schools
Retiree Benefits Guide
83
October 2014
TO: Pre-65 non-Medicare retirees
RE: New Health Insurance Marketplace Coverage Options
Exchange Open Enrollment – November 15 – January 15, 2015
Due to the health care reform law there will be a new type of online marketplace for purchasing health insurance coverage. In Maryland, this marketplace is referred as the Maryland Health Connection (MHC). While
the new marketplace will be available to you, the law does not require you to purchase insurance coverage
through the MHC Marketplace and BCPS will continue to offer health coverage. The Marketplace offers additional options for health insurance that meets your needs and your budget.
BCPS is required to provide this information to help you understand the health insurance coverage options that
will be available starting in 2015. Beginning in November 2014, individuals not covered by employer plans,
or individuals who have to contribute more than 9.56% of their salary toward their benefit plans will be able to
find and compare health insurance plans through the MHC Marketplace and may qualify for a federal subsidy
to help pay for the premium based on income levels. Coverage through the MHC Marketplace plans may start
as early as Jan 1, 2015.
If you purchase coverage through the MHC, you may be eligible for a federal subsidy that lowers your
monthly premiums or reduces your cost sharing. Please note that in order to receive the federal subsidy, you
cannot be eligible for health plan coverage through BCPS that is affordable and provides “minimum value.”
The BCPS benefit plans do meet the minimum value standard and for most employees and pre-Medicare
retirees they also meet the affordability standard.
More information on the health care reform law and the Marketplaces in states outside Maryland is available
at www.healthcare.gov. Frequently asked questions about the Maryland Health Connection can be found at
http://marylandhealthconnection.gov or call 855-642-8572 or for TTY service 855-642-8573
Sincerely,
Office of Employee Benefits, Leaves and Retirement
Baltimore County ­Public Schools
Retiree Benefits Guide
85
Monthly Contribution for Medical Benefits
Baltimore County ­Public Schools
Retiree Benefits Guide
86
Baltimore County ­Public Schools
Retiree Benefits Guide
87
Baltimore County ­Public Schools
Retiree Benefits Guide
88
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89
Frequently Asked Questions (FAQs)
General
What is the current status of health care reform?
The health care reform law, which was signed by President
Obama in 2010, is continuing to be implemented. Many
requirements of the law have already taken effect and
additional changes will continue to be introduced over the
next several years.
How will health care reform change our
company’s medical benefits in 2015?
If you are enrolled in our medical coverage in 2015, you
have minimum essential coverage and meet the individual
mandate requirement.
Who is required to have medical coverage?
All U.S. citizens and legal residents, with a few exceptions,
are required to have minimum essential coverage.
Exceptions include individuals:
n
With religious objections
n
Not living in the United States
n
In prison
Several major requirements or provisions of the law will
take effect in 2015. BCPS meets the current requirements
of the law and offers benefits to more than 95% of our
employees. Employees who are in positions that are
classified as temporary, substitutes or contractual are not
eligible for BCPS benefits. This group of employees may
be eligible for medical benefits using the State of Maryland
Health Care Exchange. Our enrollment materials provide
additional information that explains any changes that may
affect you and your family.
n Not able to pay for coverage because it costs more than
eight percent of their household income
Individual Mandate
If a person does not have minimum essential coverage, the
Internal Revenue Service may collect a penalty from him
or her. The annual penalty is the greater of:
What is the individual mandate?
A new requirement called the individual mandate is
taking effect on January 1, 2015. All U.S. citizens and
legal residents, with a few exceptions, are required to have
“minimum essential coverage” or pay a penalty. Enrolling
in our medical coverage if you are eligible will meet this
requirement.
What is minimum essential coverage?
Coverage under one of the following types of plans qualifies
as minimum essential coverage. There are no specific
requirements about what services are covered or the level
of benefits.
n Employer
coverage
n Coverage through a government plan such as Medicare
or Medicaid
n Individual
health insurance
Baltimore County ­Public Schools
n Whose household income is below 100 percent of the
federal poverty level
n
Who have a hardship waiver
n Who are without coverage for no more than three
continuous months in a calendar year
What happens if someone doesn’t have medical
coverage?
n For 2014: $95 per uninsured adult in the household
(maximum of $285 per household) or one percent of the
household income over the income tax filing threshold
n For 2015: $325 per uninsured adult in the household
(maximum of $975 per household) or two percent of the
household income over the income tax filing threshold
n For 2016: $695 per uninsured adult in the household
(maximum of $2,085 per household) or 2.5 percent of the
household income over the income tax filing threshold
The penalty will be half of the amounts noted above for
anyone under age 18.
Penalties are determined on a monthly basis, so an
individual who had coverage for six months of the year
would pay half of the annual penalty.
Retiree Benefits Guide
Affordable Care Act – FAQs
Affordable Care Act – Health Care Reform Law
90
Affordable Care Act – FAQs
Affordable Care Act – Health Care Reform Law
Frequently Asked Questions (FAQs) (continued)
Employer Mandate
Marketplace/Exchange
What is the employer mandate?
What is the Marketplace/Exchange?
Beginning in 2015, employers with 50 or more full-time
employees, working 30 hours a week on average, or fulltime equivalents may be subject to a penalty if they do
not offer health coverage to full-time employees and their
children up to age 26. This is referred to as the employer
mandate. The coverage must be “affordable” and provide
“minimum value.”
“Affordable” means that the employee contribution for
employee-only coverage for the lowest-cost plan is no
more than 9.56% of the employee’s W-2 wages.
“Minimum value” means that the plan pays for at least
60% of allowed charges for covered services.
If I’m not eligible for employer coverage, where
can I get health insurance?
Beginning in 2015, every state will have a Health
Insurance Marketplace, also known as an Exchange,
where individuals can compare insurance policies and buy
health insurance. Depending on your household income,
you may be eligible for a subsidy to help cover part of the
cost of your coverage.
You can also purchase coverage directly from an insurance
company that sells health insurance in your area.
What if an individual has a pre-existing health
condition?
Beginning in 2015, no one can be turned down for
coverage based on a pre-existing health condition.
Health Insurance Marketplaces, or Exchanges as they are
also sometimes called, will be available starting this fall in
every state. Marketplaces are being developed as an option
for people to compare and purchase health insurance.
Federal subsidies will be available to assist low to
moderate income individuals in paying the premium
for health insurance purchased through the Health
Insurance Marketplaces. Eligibility for a subsidy is based
on income. However, individuals who are enrolled in
employer coverage or eligible for employer coverage that
is “affordable” and provides “minimum value” are not
eligible for the subsidy.
Individuals can begin enrolling in plans available through
the Marketplace on October 1, 2014, and coverage under
policies purchased through the Marketplace can begin on
January 1, 2015.
Can I go to the Marketplace and compare
coverage there with our company’s benefits?
Anyone can go to their state’s Marketplace Web site to
review the coverage options and apply for coverage. Some
people will be eligible for subsidies based on their annual
household income if they are not covered by an employer
health plan or offered employer coverage that is affordable
and provides minimum value.
Where can I get information about coverage
available through the Marketplace in my state?
Visit the website www.HealthCare.gov for more
information on the Marketplace. For Maryland residents
visit www.marylandhealthconnection.gov or call 855642-8572 or for TTY service 855-642-8573
Baltimore County ­Public Schools
Retiree Benefits Guide
91
Frequently Asked Questions (FAQs) (continued)
Will I be eligible for a subsidy to help pay for my
health insurance?
Federal subsidies will be available to assist low to moderate
income individuals in paying the premium for health
insurance purchased through the Health Insurance
Marketplaces. Eligibility for a subsidy is based on your
family size and your household income.
If you are enrolled in our BCPS medical plan or are
eligible for coverage through our medical plan that
provides “minimum value” and is “affordable,” you will
not receive a subsidy if you purchase coverage through
the Marketplace. Please note that the BCPS medical plans
provide “minimum value” and are “affordable” as defined
by the Affordable Care Act.
For employees (temporary, substitutes or contractual) who
are not eligible for BCPS benefits that meet the minimum
value and affordability requirements, you may be eligible
for a subsidy based on your household income if you
purchase coverage through the Marketplace.
Essential Health Benefits
What are Essential Health Benefits?
Starting in 2015, insured group health plans provided by
small employers with no more than 50 full-time employees
are required to cover a set of “essential health benefits.”
There are 10 general categories of essential health benefits.
Each state will determine exactly what is covered in each
of these 10 categories.
n
Ambulatory patient services
n
Emergency services
n
Hospitalization
n
Maternity and newborn care
Mental health and substance abuse disorder services,
including behavioral health treatment
n
n
Prescription drugs
n
Rehabilitative and habilitative services and devices
n
Laboratory services
Preventive and wellness services and chronic disease
management
n
n
Pediatric services, including oral and vision care
Group health plans provided by larger employers with
more than 50 full-time employees aren’t required to cover
essential health benefits. However, if there are any essential
health benefits that are covered under the plan they must
be covered without annual or lifetime dollar limits.
How will Essential Health Benefits affect our
company’s medical plan?
Any essential health benefits that are included in our
medical plan will be covered without any annual or
lifetime dollar limits.
Baltimore County ­Public Schools
Retiree Benefits Guide
Affordable Care Act – FAQs
Affordable Care Act – Health Care Reform Law
92
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BALTIMORE COUNTY PUBLIC SCHOOLS
RETIREE BENEFITS ENROLLMENT/CHANGE APPLICATION
93
PLEASE PRINT
RETURN COMPLETED FORM TO: Baltimore County Public Schools, Office of Retiree Benefits
6901 N. Charles Street, Building B, Towson, MD 21204 • Phone: (410) 887-8943 • Fax: (410) 887-8950
Scan and email to:
[email protected]
1. SUBSCRIBER INFORMATION
LAST NAME
FIRST NAME
M.I.
SOCIAL SECURITY NUMBER
___/__/____
STREET ADDRESS
APT. NO.
CITY
SEX
M
STATE
F
ZIP
DATE OF BIRTH
HOME PHONE NO.
ALTERNATIVE PHONE NO.
__/__/__
(
(
)
-
)
-
MARITAL STATUS
SINGLE
MARRIED
Date of Event
__/__/__
2. ELECTION OF BENEFITS
VISION INSURANCE:
CareFirst Davis Vision Plan
Individual
Family
I cancel/waive vision insurance
MEDICAL PLAN OPTIONS:
Check a plan and a level of coverage
Kaiser Permanente Medicare Plus
Kaiser Permanente HMO*
CIGNA OAPIN – in network only
CIGNA OAP – in/out of network
CIGNA Medicare Surround
Cancer and Intensive Care Insurance
I cancel Cancer Insurance
Individual
Parent & Child (*/children for Kaiser only)
Two Adults
Family
I cancel/waive medical coverage
DENTAL PLAN OPTIONS:
Check a plan and a level of coverage
CareFirst BlueCross BlueShield
Regional Dental PPO
CareFirst BlueCross BlueShield
Regional Dental Traditional
CIGNA Dental DHMO (you must select a
CIGNA DHMO Dentist in Section 4 below)
Individual
Parent & Child (*/children for CIGNA only)
Two Adults
Family
I cancel/waive dental coverage
3. CHANGE IN STATUS (if applicable)
If you have experienced a change in status, complete this section and attach supporting documentation (birth/adoption certificate, marriage certificate,
divorce decree etc.)
Date of Event:
Date of Event:
Reason for termination:
Add Dependent(s):
Remove dependents:
Marriage
Spouse
Death
__/__/__
__/__/__
Birth of Child
Child/children
Divorce
__/__/__
__/__/__
__/__/__
__/__/__
Adoption of Child
Child reached age limit
__/__/__
__/__/__
Other (explain) ____________________
Other (explain) ___________________
4. COVERED EMPLOYEE AND DEPENDENT(S) INFORMATION
PLEASE LIST ALL MEMBERS TO BE COVERED. If you are adding or removing coverage for a dependent, please check the appropriate box below and
complete all of the information. If Kaiser HMO indicate primary care physician or medical center.
LAST NAME
FIRST NAME
M.I.
RELATIONSHIP
SEX
DATE
of BIRTH
SOCIAL
SECURITY
NUMBER
PRIMARY CARE
PHYSICIAN (PCP) KAISER FACILITY*
EMPLOYEE/
APPLICANT
NAME:
TWO ADULTS
NAME:
ADD
REMOVE
CHILD
ADD
NAME:
REMOVE
CHILD
ADD
NAME:
REMOVE
CHILD
ADD
NAME:
REMOVE
CHILD
ADD
CIGNA DHMO
FACILITY
NUMBER
NAME:
REMOVE
If you have any questions concerning the benefits and services that are provided by or excluded under the agreement, please contact the applicable plan’s membership services representative before signing the
application form. I hereby apply for myself and any dependents listed on this application for the coverage indicated and authorize my employer to deduct from my earnings the amount required to participate in the
elected plans. I understand that the elections that I make on this form will remain in effect for the entire Plan Year, unless I am permitted to change them during the Plan Year under special rules contained in the
plan that apply only in very limited situations. If I do not complete and file a new enrollment form during the next annual enrollment period, the elections I make on this form will continue in effect indefinitely until
changed by me during an annual enrollment period or in connection with the special rules discussed above. I also understand that the elections I make on this form are subject to modification by the Employer to
insure that the Plan complies with applicable laws or to reflect increases in the cost of the elected coverage(s) that occur during the Plan Year. I hereby consent, for myself and for all individuals covered by the Plan
through me, to any investigations or inquiries into medical condition that are deemed necessary or appropriate by the Plan Administrator and to any disclosures of medical records by anyone deemed necessary or
appropriate by the Plan Administrator. I have carefully read this application and agree to its terms.
The statements are true and complete and are representations made to induce the issuance of the subscription agreement(s) for which I have applied.
RETIREE’S SIGNATURE
REVISED 9/10
REVISED 9/14
DATE
RETAIN A COPY FOR YOUR RECORDS
B
94
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The Office of Benefits, Leaves and Retirement, 6901 N. Charles Street, Building B,
Towson, MD 21204
• From I-695, take Exit 25 to Charles Street – from the West turn right onto Charles
Street. From the East – turn left on Bellona Avenue and left on Charles Street.
• Continue on Charles Street approximately 1 mile to Greenwood Road.
• Turn left on Greenwood Road.
• Proceed approximately .2 miles to entrance to parking lot on the right.
• Building B is on your right.
The Department of Human Resources
Office of Benefits, Leaves
and Retirement
6901 N. Charles Street, Building B,
Towson, MD 21204
www.bcps.org
838752 09/13