2014-health-program-guideHealth Program Guide An informational guide to your CalPERS health benefits
About This Publication The Health Program Guide describes CalPERS Basic health plan eligibility, enrollment, and choices. It provides an overview of CalPERS health plan types and tells you how and when you can make changes to your plan (including what forms and documenta-tion you will need). It also describes how life changes or changes in your employment status can affect your benefits and eligibility.This publication is one resource CalPERS offers to help you choose and use your health plan. Others include: •Health Benefit Summary Provides valuable informa-tion to help you make an informed choice about your health plan; compares benefits, covered services, and co-payment information for all CalPERS health plans •CalPERS Medicare Enrollment Guide Provides information about how Medicare works with your CalPERS health benefits You can obtain the above publications, required forms, and other information about your CalPERS health benefits through CalPERS On-Line at www.calpers.ca.gov or by calling CalPERS at 888 CalPERS (or 888 -225-7377).About CalPERS CalPERS is the largest purchaser of public employee health benefits in California, and the second largest public purchaser in the nation after the federal government. Our program provides benefits to more than 1.3 million public employees, retirees, and their families.Depending on where you reside or work, CalPERS offers active employees and retirees one or more types of health plans, which may include: •Health Maintenance Organization (HMO) •Preferred Provider Organization (PPO) •Exclusive Provider Organization (EPO) (for members in certain California counties)The CalPERS Board of Administration annu-ally determines health plan availability, covered benefits, health premiums, and co-payments.Whether you are working or retired, your employer or former employer makes monthly contributions toward your health premiums. The amount of this contribution varies. Your cost may depend on your employer or former employer’s contribution to your premium, the length of your employment, and the health plan you choose. For monthly contribution amounts, active employees should contact their employer, State retirees should contact CalPERS, and contracting agency retirees should contact their former employer. CalPERS Health Program Vision Statement CalPERS will lead in the promotion of health and wellness of our members through best-in-class, data-driven, cost-effective, quality, and sustainable health benefit options for our members and employers.We will engage our members, employers, and other stakeholders as active partners in this pursuit and be a leader for health care reform both in California and nationally.
Contents Eligibility and Enrollment . . . . . . . . . . . . .2 Who Is Eligible for the CalPERS Health Program? . . .2 Who Is Not Eligible for the CalPERS Health Program? . 3 Enrollin g Yourself and Eligible Family Members . . . . 4 Additional Enrollment Opportunities . . . . . . . 7 Circumstances That Can Affect Your Health Benefits . . . . . . . . . . . . . . . 8 Life Changes . . . . . . . . . . . . . . . . 8 Changes i n Employment Status . . . . . . . . 10 Losing You r Coverage . . . . . . . . . . . . .11 When Can You Change Your Health Plan? . . . . 12 Health Plan Options . . . . . . . . . . . . . . 13 Choosing a Health Plan . . . . . . . . . . . .13 CalPERS Basic Health Plans . . . . . . . . . . 14 CalPERS Me dicare Health Plans . . . . . . . . 15 Information for Members Who Are Retiring or Retired . . . . . . . . . . 16 How Retirement Affects Your Health Benefits . . . 16 Where to Get Help Once You Are Retired . . . . . 16 Your Separ ation Date and Your Retirement Date . . 17 State Vesting Requirements . . . . . . . . . . 18 Contract ing Agency Vesting Requirements . . . . 18 Enrolling in a CalPERS Medicare Health Plan . . . . 19 Certifyi ng Your Medicare Status . . . . . . . . 19 Qualifying Information . . . . . . . . . . . 20 Enrollment Forms and Supporting Documentation . . . . . . . . . . . . . . . 21 Getting the Information You Need . . . . . . . 21 Required Documentation for Enrollment Change . . 23 Resources . . . . . . . . . . . . . . . . . . . 24 Getting Assistance with Your Health Benefits . . . 24 Contact ing Your Health Plan . . . . . . . . . 25 Resolvi ng Problems with Your Health Plan . . . . 25 Patient B ill of Rights . . . . . . . . . . . . . 26 CalPERS N otice of Privacy Practices . . . . . . . 28 Definition of Terms . . . . . . . . . . . . . . .32
2 | Health Program Guide Who Is Eligible for the CalPERS Health Program?Note : Beginning in 2014, The Affordable Care Act has new provisions which expand eligibility criteria for certain varia ble-hour employees. For additional information please contact you employer.Retirees You are eligible to enroll in a CalPERS health plan if you meet all of the following criteria: •Your retirement date is within 120 days of separation from employment •You were eligible for health benefits upon separation •You receive a monthly retirement allowance •You retire from the State, California State University (CSU), or an agency that currently contracts with CalPERS for health benefits Family Members The terms “family member” and “dependent” are used interchangeably. Eligible family members include: •Spouse •Registered domestic partner •Children (natural, adopted, domestic partner’s, or step) up to age 26 •Children, up to age 26, if the employee or annuitant has assumed a parent-child relationship and is considered the primary care parent •Certified disabled dependent children age 26 and older Empl oyees and annuitants of the State of California (“State”) and contracting agencies may enroll in the CalPERS Health Program. Annuitants are eligible retirees or their surviving family member. To enroll in the program, you must meet certain eligibility requirements.Employees Eligibility is based on tenure and time base of your qualify-ing appointment. You must work at least half-time and have a permanent appointment or a “limited term” appointment with a duration of more than six months. State Permanent-Intermittent (PI) Employees If you are a State Permanent-Intermittent (PI) employee, you may enroll if you have credit for a minimum of 480 paid hours at the end of a “control period.” A control period is the six months from January 1 to June 30 or July 1 to December 31. You cannot become eligible in the middle of a control period even if the minimum hours are met. To continue to qualify for coverage, you must be credited with at least 480 paid hours at the end of each control period or at least 960 hours in two consecutive periods. Checkpoints to determine whether the hours have been met are June 30 and December 31. Note for Contracting Agency Employees: Check with your Health Benefits Officer for any health plan enrollment eligibility exceptions.Eligibility and Enrollment
Health Program Guide | 3 Where to Get Help With Your Health Benefits Enrollment If you are an active employee, contact your Health Benefits Officer to make all health benefit enrollment changes. Your Health Benefits Officer is usually located in your personnel office or human resources department.Once you retire, CalPERS becomes your Health Benefits Officer. As a retiree, you may make changes to your health plan in any of the following ways: •Online through my|CalPERS at my.calpers.ca.gov during Open Enrollment •By writing to us at P.O. Box 942715, Sacramento, CA 94229-2715 •By calling us toll free at 888 CalPERS (or 888 -225-7377).For general information about health benefits, go to CalPERS On-Line at www.calpers.ca.gov .The chart on pages 24–25 indicates the forms and supporting documentation needed for most changes.Who Is Not Eligible for the CalPERS Health Program?Certain State or contracting agency employees and family members are not eligible for CalPERS health benefits.Ineligible Employees •Those working less than half time (except for certain California State University and contracting agency employees whose contracts provide health benefits for less than half time work) •Those whose appointment lasts less than six months •Those whose job classification is “Limited-Term Intermittent” (seasonal or temporary) •Those classified as “Permanent-Intermittent” who do not meet the hour requirements within the control period •Those whose employer does not have a contract or has terminated its contract with CalPERS Ineligible Family Members •Former spouses/former registered domestic partners •Children age 26 and older •Disabled children over age 26 who were never enrolled or who were deleted from coverage •Children of a former spouse/former registered domestic partner •Grandparents •Parents Do Not Enroll Ineligible Family Members It is against the law to enroll ineligible family members. If you do so, you may have to pay all costs incurred by the ineligible person from the date the coverage began.
4 | Health Program Guide Enrolling Yourself and Eligible Family Members This section provides you information about enrollment timeframes and effective dates for enrolling yourself and family members. If your initial timeframe expires, you may enroll during the next Open Enrollment period, or use a special or late enrollment opportunity. (See “Additional Enrollment Opportunities” on page 8 for more information.)All health plan changes made during Open Enrollment will be effective January 1 following the Open Enrollment period. The chart on pages 24–25 helps you identify the forms and supporting documentation required to enroll eligible family members. Employees You have 60 days from the date of your initial appoint -ment to enroll, or decline to enroll, yourself or yourself and all eligible family members in a health plan (Permanent Intermittent employees have 60 days from the end of the qualifying control period to enroll). The effective date is the first day of the month following the date your Health Benefits Officer receives the Health Benefits Plan Enrollment form.When you enroll, you must enroll yourself or yourself and all eligible family members, unless the family member is: •Covered under another health plan •A spouse not living in your household •A child who has attained the age of 18 •A member of the armed forces You must complete the Declaration of Health Coverage form during your initial eligibility period, whether you elect to enroll or decline health coverage.If you or your eligible family members decline to enroll during the initial enrollment period, enrollment can occur at a later date. (See “Split Enrollments” on page 7 and “Additional Enrollment Opportunities” on page 8.) Note : Beginning in 2014, The Affordable Care Act has new provisions which expand eligibility criteria for certain variable-hour employees. For additional information please contact you employer. Annuitants An annuitant is an individual who has retired within 120 days of separation from employment and who receives a retirement allowance. An annuitant can also be a surviving family member who receives the retirement allowance in place of the deceased, or a survivor of a deceased employee entitled to special death benefits and survivor allowance under certain laws. Retirees As an eligible retiree you may enroll yourself and all eligi -ble family members in a health plan within 60 days of your retirement date. The effective date is the first day of the month following the date CalPERS receives the Health Benefits Plan Enrollment form. You may also enroll during any future Open Enrollment period. If you are enrolled in a CalPERS health plan at separa -tion from employment and want to continue your enrollment into retirement, your coverage will automati -cally continue as long as your separation and retirement dates are within 30 days of each other. (See the section “Information for Members Who are Retiring or Retired” beginning on page 18 for more details.) If you do not wish to continue your CalPERS health coverage, contact your Health Benefits Officer (CalPERS, if already retired) to cancel your coverage.Note: As you transition from employment to retirement, be sure to inform CalPERS if you or your dependents have Medicare coverage.Survivors You may enroll in a health plan as a survivor if you were eligible for enrollment as a dependent on the date of death of a CalPERS retiree and receive a monthly survivor check. If you meet eligibility requirements, you may enroll in a health plan within 60 days of the employee or annui -tant’s death. The effective date of enrollment is the first day of the month following the date CalPERS receives your request. Exceptions may apply for certain contracting agency survivors who do not receive a monthly survivor check. Contact your (or your spouse’s) former employer for additional information.
Health Program Guide | 5 If you are enrolled in a CalPERS health plan as a dependent on the date of death of the retiree, CalPERS will automatically enroll you as a survivor once your first monthly survivor check is released. A survivor can only enroll dependents who were eligible for CalPERS health benefits at the time of the retiree’s death.For more information regarding health coverage options for survivors, see the section on “Life Changes” on page 9.Spouse You may add your spouse to your health plan within 60 days of your marriage. You are required to provide a copy of the marriage certificate and the spouse’s Social Security Number and Medicare card (if applicable). Your spouse’s coverage will become effective the first day of the month following the date your Health Benefits Officer receives the Health Benefits Plan Enrollment form. Registered Domestic Partner You may add your registered domestic partner to your health plan within 60 days of registration of the domestic partnership. The coverage will become effective the first day of the month following the date your Health Benefits Officer receives the Health Benefits Plan Enrollment form.To add a domestic partner to your health plan, you must register your domestic partnership through the California Secretary of State’s Office. Upon registration, that office will provide you with a Declaration of Domestic Partnership. CalPERS requires that you submit a copy of the approved Declaration of Domestic Partnership, the domestic partner’s Social Security number, and a copy of their Medicare card (if applicable).Same sex domestic partnerships between persons who are both at least age 18 and certain opposite sex domestic partnerships (one partner must be 62 years of age or older and the other partner at least 18 years of age) are eligible to register with the Secretary of State. For more informa -tion about domestic partnership registration, visit the Secretary of State’s website at www.sos.ca.gov.Children Natural-born, adopted, domestic partners, and stepchil -dren who are under age 26 may be added to your health plan, as outlined below: •Newborn children should be added within 60 days of birth. Coverage is effective from the date of birth. •Newly adopted children should be added within 60 days of physical custody. Coverage is effective from the date physical custody is obtained. •Stepchildren or a domestic partner’s children under age 26 can be added within 60 days after the date of your marriage or registration of your domestic partnership. The coverage will become effective the first day of the month following the date your Health Benefits Officer receives the Health Benefits Plan Enrollment form. Disabled Children Over Age 26 A child age 26 and over who is incapable of self-support because of a mental or physical condition may be eligible for enrollment. The disability must have existed prior to reaching age 26 and continuously since age 26, as certi -fied by a licensed physician. You are required to complete and submit the Member Questionnaire for the CalPERS Disabled Dependent Benefit form, and the physician must complete and submit a Medical Report for the CalPERS Disabled Dependent Benefit form for CalPERS approval. The initial certification of the Disabled Dependent must occur during one of the following two eligibility periods (whichever applies): •Within 60 days before and ending 60 days after the child’s 26 th birthday (member and dependent currently enrolled), or •Within 60 days of a newly eligible employee’s initial enrollment in the CalPERS Health Program Upon certification of eligibility, the dependent’s cover -age must be continuous and without lapse. You will be required to submit an updated questionnaire and medical report for re-certification periodically, upon request.Note: If the disabled child has a Social Security- approved disability, you must provide CalPERS with a copy of his or her Medicare card.
6 | Health Program Guide Dependents in a Parent-Child Relationship A child other than an adopted, step, or recognized natural child up to age 26 may be added to your health plan if both of the following criteria are met: •You have assumed a parent-child relationship •You are considered the primary care parent You have 60 days from the date you obtained custody of the child to enroll him or her on your health plan. Prior to enrollment of a dependent who is in a parent-child rela -tionship, you must complete and submit an Affidavit of Parent-Child Relationship. You may be asked to provide supporting documentation such as court records, school records, tax returns, or additional proof that a parent-child relationship exists. A parent-child relationship must be certified at the time of enrollment for each child and annu -ally thereafter up to age 26. Coverage will become effective the first day of the month following the date your Health Benefits Officer receives the Health Benefits Plan Enrollment form. Split Enrollments When two active or retired members are married to each other or in a domestic partnership, each member can enroll separately. However, when these individuals enroll in a CalPERS health plan in their own right, one parent must carry all dependents on one health plan. Parents cannot split enrollment of dependents. CalPERS will retroactively cancel split enrollments. You may be responsible for all costs incurred from the date the split enrollment began.Enrolling in Two CalPERS Health Plans Dual CalPERS coverage occurs when you are enrolled in a CalPERS health plan as both a member and a dependent or as a dependent on two enrollments. This duplication of coverage is against the law. When dual CalPERS coverage is discovered, the enrollment that caused the dual coverage will be retroactively canceled. You may be responsible for all costs incurred from the date the dual coverage began. Members may enroll in both a CalPERS health plan and a health plan provided through another employer. For example, a spouse may enroll in a CalPERS plan and in the plan from his or her private employer. In this case, the two plans may coordinate benefits. Identification Cards You will need your health plan identification card when you seek medical care. Identification cards are issued by each health plan, not by CalPERS. Contact your health plan directly if: •You do not receive your card by the effective date of your initial enrollment •You need care before your card arrives •You need additional cards Check Your Health Plan Premium Deduction When you change health plans, enroll for the first time, or add/delete dependents, carefully check the “Statement of Earnings and Deductions” section of your pay warrant to verify that the health premium is being paid to the correct health plan in the correct amount.If you change health plans during Open Enrollment but your January pay warrant does not reflect your new plan’s premium payment, do not continue to use the prior health plan’s services after the first of the year. The premium payment will be adjusted during the subsequent pay period. If your Open Enrollment health plan change is not reflected on your next pay warrant, contact your employ -er’s Health Benefits Officer (or CalPERS, if retired).A $0.00 deduction for your health plan showing on your pay warrant means that your employer (or former employer) is paying the entire premium on your behalf. If you change health plans, you should check to make sure the new plan name is listed.
Health Program Guide | 7 Additional Enrollment Opportunities You have new family members: When you enroll, you must enroll yourself or yourself and all eligible family members. If you later have a new dependent as a result of marriage, domestic partnership registration, birth, change of custody, adoption, or placement for adoption, you may enroll yourself and all eligible dependents within 60 days of that event.The effective date for a Special Enrollment is the first day of the month following the date your Health Benefits Officer receives the Health Benefits Plan Enrollment form.Late Enrollment If you decline or cancel enrollment for yourself or your dependents and the Special Enrollment exceptions do not apply, your right to enroll (or add dependents) will be limited. You will either have to wait for a 90-day period or until the next CalPERS Open Enrollment period. The earliest effective date of enrollment will be the first of the month following the 90-day waiting period or the January 1 following the Open Enrollment period. New employees and their dependents may initially enroll in a CalPERS health plan as indicated in the previous sections. Additional enrollment options and guidelines are described below.In 1996, Congress enacted the Health Insurance Portability and Accountability Act (HIPAA) to improve portability and continuity of health insurance coverage in the group insurance markets. HIPAA requirements for CalPERS took effect in 1998. HIPAA offers two provisions for employees and family members to enroll in CalPERS health plans outside of the initial enrollment period and the Open Enrollment period. Special Enrollment Special Enrollment refers to certain types of enrollment after your initial enrollment, but outside of the Open Enrollment period. You may need Special Enrollment under the following circumstances:You lose other health coverage: If you initially declined (or canceled) enrollment for yourself or your dependents (including your spouse) because you had other private or CalPERS health coverage at that time, you may be able to enroll in a CalPERS health plan if the other coverage invol -untarily ends. To qualify, you will need to request enrollment within 60 days after the other coverage ends and provide proof that the other coverage has ended.
8 | Health Program Guide Circumstances That Can Affect Your Health Benefits Life Changes The following changes must be reported to CalPERS so we can make the appropriate change to your health cover -age. If you are an active employee, contact your Health Benefits Officer. If you are a retiree, contact CalPERS toll free at 888 CalPERS (or 888 -225-7377).Marital Status or Registered Domestic Partnership Changes in marital status as a result of marriage, divorce, or death may affect your health plan enrollment. Establishing or terminating a registered domestic partner -ship may also result in changes. When you divorce or terminate a registered domestic partnership, your former spouse or registered domestic partner is no longer eligible to receive CalPERS health benefits under your coverage. The coverage terminates on the first day of the month following the date the divorce decree or termination of registered domestic partnership is granted. A copy of the final Divorce Decree or Termination of Domestic Partnership is required when you delete a former spouse or registered domestic partner from your health plan. You are responsible for ensuring that the health enroll -ment information about you and your family members is accurate, and for reporting any changes in a timely manner. If you fail to maintain current and accurate health enrollment information, you may be liable for the reimbursement of health premiums or health care services incurred during the entire ineligibility period.State law limits the health premium reimbursement period to six months for certain life-changing events. For example, if your divorce or dissolution occurred in 2010, yet you did not report it until 2013, your former spouse or registered domestic partner will be retroactively canceled from coverage effective the first of the month following the divorce or dissolution. The health premiums will be adjusted for a period of no more than six months from the date your Health Benefits Officer receives copies of supporting documentation.Disenroll Ineligible Family Members Immediately It is against the law to continue enrollment of an ineligible family member. If you do so, you may have to pay all costs incurred by the ineligible person during the ineligibility period.
Health Program Guide | 9 Medicare Eligibility If you are retired and you, your spouse, or a dependent becomes Medicare eligible due to age or disability, notify CalPERS immediately so that you are enrolled in a CalPERS Medicare health plan. If the Social Security Administration determines that you are no longer eligible for Medicare because of changes to your disability status, or because you moved outside of the United States, notify CalPERS immediately. You will need to enroll in a non-Medicare health plan. If you later become eligible for Medicare or return to the United States, you must enroll in Medicare Part A and B and transition to a CalPERS Medicare health plan.Change of Residence or Work Address When you move or change employers, you must update your address so that the correct ZIP Code is used to estab -lish your eligibility in a health plan. You cannot use a P.O. Box to establish eligibility for health plan enrollment. If you use a P.O. Box as your mailing address, you must also provide your residential address. If you are an active employee, contact your employer to update your address and determine availability of health plans in your residence or work service area. If you are a retiree, contact CalPERS. You must change health plans if you move out of your health plan’s service area.Death of a Spouse, Registered Domestic Partner, or Dependent You must report the death of a spouse, registered domes -tic partner, or dependent to your Health Benefits Officer (if active) or CalPERS (if retired) as soon as possible.Death of an Employee or Retiree When a member dies, the surviving spouse, registered domestic partner, or a family member must notify CalPERS at 888 CalPERS (or 888-225-7377). Death of an Employee Upon the death of an employee while in State service, the law requires the State employer to continue to pay contri -butions for all enrolled dependents’ health coverage for up to 120 days after the death.If a member was eligible to retire on the date of death, the surviving family members will be eligible for continua -tion of health benefits provided they were eligible at the time of death and qualify for a monthly survivor check.Surviving family members who do not meet the above qualifications may be eligible for Consolidated Omnibus Budget Reconciliation Act (COBRA) Continuation Coverage. (See page 11 for more information about COBRA.) Death of a Retiree Surviving family members will be eligible for continued health benefit coverage provided they qualify for a monthly survivor check, were eligible dependents at the time of the annuitant’s death, and continue to qualify as eligible family members.Surviving family members who do not meet the above qualifications may be eligible for Consolidated Omnibus Budget Reconciliation Act (COBRA) Continuation Coverage. (See page 11 for more information about COBRA.)
10 | Health Program Guide As your employment status changes, so can your eligibil -ity for CalPERS health benefits. Following are examples of some of those changes and information on how you can maintain your health coverage eligibility. Off-Pay Status/Temporary Leave You may continue your coverage during off-pay status or while on temporary leave by paying the entire monthly health premium directly to your health plan. You are eligi -ble for direct payment if you: •Take a leave of absence without pay •Take temporary disability leave and do not use sick leave or vacation time •Are waiting for approval of disability retirement or “regular” service retirement •Are waiting for approval of Non-Industrial Disability Insurance benefits •Are suspended from your job •Institute legal proceedings appealing a dismissal from your job •Are a State Permanent-Intermittent employee eligible for health benefits, but are on non-pay status (Direct pay may only be elected through the end of the qualify -ing control period.)To initiate direct payment, contact your Health Benefits Officer for a Direct Payment Authorization form. You must submit requests for the direct payment option to your employer prior to the beginning of your leave, but no later than the last day of the month of coverage. If you do not elect the direct payment option during off-pay status, you must cancel your coverage. You can re-enroll when you return to pay status if your earnings are sufficient to cover your share of the monthly premium.Military Duty When you take a leave of absence for military duty, you may continue coverage by paying the monthly health premium directly to your health plan. When you direct pay, there are no administrative costs and your employer does not contribute to your health premium. Your CalPERS health coverage will resume the day you return to pay status. To initiate direct payment, contact your Health Benefits Officer for a Direct Payment Authorization form. You also have the option to cancel coverage, and may re-enroll upon returning from military duty.Note for Contracting Agency Employees: Check with your Health Benefits Officer to coordinate continuation of coverage when your employment status changes.Leaving Your Job If you leave your job for reasons other than retirement, you are covered until the first day of the second month follow -ing the last date you were employed. This is subject to you having sufficient earnings to cover your share of the health premium.If you elect to cancel your coverage before you leave your job, your benefits will not continue, and you will not be eligible for COBRA Continuation Coverage.Changes in Employment Status
Health Program Guide | 11 Disabled Employees If you qualify for Social Security Disability or the Supplemental Security Income program, you may continue coverage for up to 29 months. The cost to you cannot exceed 102 percent of the monthly group premium for the first 18 months, and 150 percent of the monthly group premium for months 19 to 29. This COBRA coverage applies to you and any dependents currently enrolled under your eligibility.Dependents Dependents may also enroll in COBRA for up to 36 months as a result of any of the following: •Death of the member under which they were depen -dents. Eligibility applies whether the member was working or retired at the time of death (dependent must have been enrolled in the health plan at the time of member’s death) •Divorce, termination of registered domestic partnership, or legal separation •Enrolled child reaches age 26 Cancellation of COBRA Coverage COBRA coverage for you or your dependents remains in effect until one of the following events occurs: •You fail to pay the premium •You receive coverage through another group health plan •You become entitled to Medicare •Your coverage time limit ends •You request cancellation If you lose your CalPERS coverage, you have two options to continue your health benefits: COBRA Continuation Coverage or an Individual Conversion Policy.COBRA Continuation Coverage COBRA allows you and your dependents to continue health coverage for a limited time under certain circumstances such as job loss (for reasons other than gross miscon -duct), reduction in hours worked, death, divorce, and other life events. Your cost under COBRA may include an addi -tional fee, but your total generally will not exceed 102 percent of the monthly group premium rate.If you or your dependents are eligible for COBRA, you will be notified by your employer (or by CalPERS if retired). You must complete and return a Group Continuation Coverage form within 60 days of notification. Return the form to the employer (or CalPERS, if retired). Coverage must be continuous from the date your CalPERS coverage ends. You must make your premium payments directly to the health plan. Guidelines for COBRA Continuation Coverage are as follows:Active Employees You may continue COBRA coverage for 18 months if either of the following applies: •You separate from employment for reasons other than dismissal due to gross misconduct •You have a reduction in work hours to less than half-time (or less than 480 hours in a control period for State Permanent-Intermittent employees) Coverage for either of the above reasons applies to you and any dependents currently enrolled under your eligibility.Losing Your Coverage
12 | Health Program Guide Extension of COBRA Coverage Under certain conditions, California law permits an exten -sion of COBRA benefits. This extension does not apply to out-of-state COBRA enrollees.If you exhaust your federal COBRA benefit, and have had less than 36 months of COBRA coverage, Cal-COBRA may extend the benefit up to a total of 36 months. This Cal-COBRA extension premium cannot exceed 110 percent of the current group rate. You may change your health plan at the following times: If you move: You must change plans if you move out of your health plan’s service area. Until you make the change, your previous health plan may limit coverage to emer -gency or urgent care only. When you move or change employment, you may submit your health plan change up to 60 days after the move. The effective date of the change will be the first of the month following the date your Health Benefits Officer receives your request. When you retire: You may change health plans within 60 days of your retirement date. You may select any health plan available in your residential ZIP Code area. If you are a working retiree, you can use the ZIP Code of a current employer for eligibility purposes. The effective date of the change will be the first of the month following the date your Health Benefits Officer receives your request. If you are a working retiree enrolled in a Medicare Advantage plan, you must use your residential address for eligibility. You cannot use your work address or a P.O. Box to enroll. When you qualify for Medicare: As a retiree, when you first become eligible for Medicare, you must request a change from a CalPERS Basic health plan to a CalPERS Medicare health plan. You may also change health plans within 60 days from the effective date of your Medicare enrollment. The effective date of the change will be the first of the month following the date your Health Benefits Officer receives your request. During the CalPERS Open Enrollment period: Open Enrollment is held each fall, and changes become effective the following January 1. Additionally, if you did not include eligible family members in your initial health plan enroll -ment or add them within the applicable 60-day eligibility period, you may enroll them during the Open Enrollment period. To make changes during Open Enrollment, active members should contact their Health Benefits Officer. Retirees should contact CalPERS. Individual Conversion Policy An Individual Conversion Policy is an alternative to COBRA or can follow COBRA coverage. If you lose your CalPERS health benefits or COBRA coverage, you can request an Individual Conversion Policy through your prior health plan. You must request this new policy within 30 days of losing coverage. All CalPERS health plans offer this Individual Conversion Policy option, but your cost and benefits will differ from your previous coverage. When Can You Change Your Health Plan?
Health Program Guide | 13 Health Plan Options Choosing a Health Plan If you need help selecting a health plan, visit www.calpers.ca.gov to access the following tools and resources: •The Health Plan Chooser tool lets you compare and rank health plans and search for specific doctors. •The Health Benefit Summary provides a side-by-side comparison of health plans and benefits, covered services, and co-payment information to help you make an informed choice about your health plan.While CalPERS provides a variety of health plans, only you can decide which is best for yourself and your family. Although cost is a key factor in choosing a health plan, as with other major purchases, you will want to consider other factors, such as the available doctors and hospitals in your area, the location of care facilities, and how the plan works with other health plans like Medicare. When you choose a health plan, be sure to review the plan’s covered and non-covered services and the restrictions on your choice of providers. The right health plan for you will be the one that best fits your specific situation. Health Plan Availability In general, if you are an active employee or a working CalPERS retiree, you may enroll in a health plan using either your residential or work ZIP Code. You cannot use a P.O. Box to establish eligi -bility, but may use it for mailing purposes. To enroll in a Medicare Advantage plan, you must use your residential address. If you are a retired CalPERS member, you may select any health plan in your residential ZIP Code area. If you are a working retiree, you may use the ZIP Code of your current employer for health plan eligibility.If you use your residential ZIP Code, all enrolled dependents must reside in the health plan’s service area. When you use your work ZIP Code, all enrolled dependents must receive all covered services (except emergency and urgent care) within the health plan’s service area, even if they do not reside in that service area. To determine if the health plan you are consid -ering provides service where you reside or work, contact the plan before you enroll. You may also use our online service, the Health Plan Search by ZIP Code, available at www.calpers.ca.gov and on my|CalPERS at my.calpers.ca.gov.
14 | Health Program Guide to a traditional “fee-for-service” health plan, but you must use doctors in the PPO network or pay higher co-insurance (percentage of charges). In a PPO health plan, you must meet an annual deductible before some benefits apply. You are responsible for a certain co-insurance amount, and the health plan pays the balance up to the allowable amount.When you use a non-participating provider you are responsible for any charges above the amount allowed. Exclusive Provider Organization (EPO) Health Plan The EPOs serve only Colusa, Mendocino, Monterey, and Sierra counties. The health plans offer the same covered services as the provider’s HMO health plan, but members seek services from the EPO network of preferred providers. Members are not required to select a personal primary care physician.Out-of-State Health Plan Choices Basic and Medicare-eligible members living outside of California may select a PPO plan, or in some areas, an HMO. Depending on where you reside or work, one or more of the following Basic health plan types may be available to you. (For a full listing of health plan options, refer to the Health Benefit Summary .) Health Maintenance Organization (HMO) Basic Health Plans HMOs offer members a range of health benefits, including preventive care. The HMO will give you a list of doctors from which you select a primary care provider (PCP). Your PCP coordinates your care, including referrals to special -ists. Other than applicable co-payments, you pay no additional costs when you receive pre-authorized services from the HMO’s contracted providers. Except for emergency and urgent care, if you obtain care outside the HMO’s provider network without a refer -ral from the health plan, you will be responsible for the total cost of services.Preferred Provider Organization (PPO) Basic Health Plans Unlike an HMO, where a primary care physician directs all your care, a PPO allows you to select a primary care provider and specialists without referral. A PPO is similar CalPERS Basic Health Plans
Health Program Guide | 15 CalPERS Medicare Health Plans For more information about how the CalPERS Health Program works with Medicare, please refer to the CalPERS Medicare Enrollment Guide . You can obtain this publication on CalPERS On-Line at www.calpers.ca.gov or by calling CalPERS toll free at 888 CalPERS (or 888 -225-7377). Depending on where you reside or work, one or more of the following Medicare health plan types may be available to you. (For a full listing of health plan options, refer to the Health Benefit Summary .)PPO Supplement to Medicare Plans With a PPO Supplement to Medicare plan, your provider bills Medicare for most services and your health plan pays for some services not covered by Medicare. If your provid -ers participate in Medicare, your health plan will pay most bills for Medicare-approved services. If any of your provid -ers do not accept Medicare payments, you will have to pay a larger portion of your health care bills. You can find out if you will have to pay more by asking your providers. EPO Supplement to Medicare Plan Similar to the Basic EPO, this plan is like an HMO but you are not required to select a PCP. The health plan’s providers bill Medicare for each visit or service, and the health plan reimburses providers for approved services not covered by Medicare. Just as with an HMO Supplement health plan, you may use your Medicare card to obtain services outside your EPO plan’s network. When you use non-participating providers, you are responsible for co-payments or deductibles not covered by Medicare.Important Reminder Once you or your family members enroll in a CalPERS Medicare health plan, you may not change back to a CalPERS Basic health plan. This rule does not apply if the Social Security Administration cancels your Medicare benefits (for a reason other than non-payment), you permanently move outside the United States, or you return to work and are eligible for employer group health coverage.HMO Supplement to Medicare Plans With an HMO Supplement to Medicare health plan, bene -fits are similar to those in a Basic HMO. The health plan reimburses providers for some services not covered by Medicare. You may use your Medicare card to obtain services outside of your HMO network. However, when you use non-participating providers, you are responsible for any co-payments or deductibles not covered by Medicare (except for emergency or out-of-area urgent care services). HMO Medicare Managed Care Plans (Medicare Advantage Plans) Under a Medicare Advantage plan, you work closely with your PCP to receive care, similar to a Basic HMO. Medicare Advantage plans are approved by the Medicare program and receive a monthly premium directly from Medicare to provide your Medicare benefits. Therefore, you must elect to have the health plan administer your Medicare benefits by completing the plan’s Medicare Advantage Election form. To obtain this form, contact your health plan. After you assign your Medicare benefits to your Medicare Advantage plan, your CalPERS health benefits will be coordinated, including payment for autho -rized services. To enroll in a Medicare Advantage plan, you must reside within the health plan’s service area.
16 | Health Program Guide Information for Members Who Are Retiring or Retired How Retirement Affects Your Health Benefits If you are nearing retirement, this section provides general information about how retirement will affect your health benefits. You can find more details about how Medicare and CalPERS work together to provide you with health coverage in the CalPERS Medicare Enrollment Guide . This Where to Get Help Once You Are Retired Once you retire, CalPERS becomes your Health Benefits Officer. You can make most changes to your health enroll -ment when you log into my|CalPERS. The Member Self Service function allows you to change plans during Open Enrollment, add a newly acquired dependent, or delete a dependent for certain qualifying life events. You may also request changes by email, by fax (800) 959-6545, by publication is available on CalPERS On-Line at www.calpers.ca.gov . You can request a printed copy by calling CalPERS at 888 CalPERS (or 888 -225-7377). If you are still an active employee, refer any questions about your health benefits to your Health Benefits Officer. calling 888 CalPERS (or 888 -225-7377), or by requesting a change in writing and mailing the request to: CalPERS Health Account Services P.O. Box 942715 Sacramento, CA 94229-2715
Health Program Guide | 17 Your Separation Date and Your Retirement Date As retirement approaches, two dates are particularly important: your separation date (last day of employment) and your retirement date. If you are not sure when these dates occur, talk to your Health Benefits Officer. If you anticipate a delay in processing your retirement, you can avoid having your coverage suspended between your last day of work and your retirement date by paying the full monthly premium directly to your health plan. Contact the Health Benefits Officer where you worked and ask for a Direct Payment Authorization form. For more information on retiree eligibility, see page 2 of this booklet. The chart below explains how your separation date and your retirement date affect your health plan enrollment: If your separation and retirement date are…and…then your health coverage…Note within 30 days of each other you are enrolled in a CalPERS health plan at the time of separation will continue into retirement without a break.If you do not want your health benefits to continue, contact your Health Benefits Officer (if still working) or decline coverage in Section 7 of CalPERS Retirement Election Application.between 31 and 120 days of each other you are enrolled in a CalPERS health plan at the time of separation will not automatically continue. You may re-enroll within 60 days of your retirement date or during Open Enrollment.When your health coverage lapses, you may be eligible for COBRA.within 120 days of each other you are eligible for — but not enrolled in — a CalPERS health plan at the time of separation eligibility remains valid.You may enroll within 60 days of your retirement date or during Open Enrollment.more than 120 days apart regardless of whether you are enrolled in a CalPERS health plan at the time of separation cannot be reinstated. You are no longer eligible for CalPERS health benefits.There are some exceptions to the rule. Contact CalPERS directly.
18 | Health Program Guide State Vesting Requirements For State employees, “vesting” refers to the amount of time you must be employed by the State to be eligible to receive employer contributions toward the cost of the monthly health premium during retirement. Bargaining unit negotiations may affect the State’s vesting require -ments. State vesting requirements do not apply to California State University retirees, employees of the Legislature, contracting agency retirees, or those on disability retirement.The amount the State contributes toward your health coverage depends on whether you are vested. The contri -bution amount is determined by a formula set by law and the date you were first hired by the State. •First hired by the State prior to January 1, 1985: You are eligible to receive 100 percent of the State’s contribution toward your health premium upon your retirement. •First hired by the State between January 1, 1985 and January 1, 1989: You are subject to vesting require -ments, as follows: −10 years of credited State service: You are fully vested and qualify for 100 percent of the State’s contribution toward your health premium. −Less than 10 years of credited State service: You are eligible for health coverage; however, the State’s contribution will be reduced by 10 percent for each year of service under 10 years. You will be respon -sible for the difference.Note: Employees of the Judicial Branch are subject to the 10 years’ vesting requirement regardless of hire date. •First hired by the State after January 1, 1989: The percentage of the State’s contribution is based on your completed years of State service as follows:Years of State Agency Service State Contribution Fewer than 10 0%10 50%10-19 50%, plus 5% added for each year after the 10 th year 20 or more 100% •First hired by the state after January 1, 2011: Employees in bargaining unit 12 have a 25-year vesting schedule. Once you reach 25 years of credited State service, you are fully vested and qualify for 100 percent of the State’s contribution toward your health premium. Contracting Agency Vesting Requirements Contracting agency employees may be subject to vesting requirements. Some contracting agencies elect to partici -pate in vesting requirements for their employees upon retirement. Vesting schedules apply only to employees hired on or after the effective date of the contract or memorandum of understanding that incorporates vesting. Contact your employer directly to determine if you are affected by vesting requirements and the amount your employer will contribute for your health benefits once you retire.
Health Program Guide | 19 Enrolling in a CalPERS Medicare Health Plan Medicare is a federal health insurance program that covers individuals age 65 and older. In some cases, Medicare can also cover individuals under age 65 with certain disabilities and individuals with End-Stage Renal Disease. The parts of Medicare are: Part A – Hospital insurance Part B – Outpatient medical insurance Part C – Medicare Advantage health plans Part D – Prescription drug coverage The Social Security Administration (SSA) is the federal agency responsible for Medicare eligibility determination, enrollment, and premiums. To obtain additional informa -tion about Medicare contact the SSA at (800) 772-1213 or TTY (800) 325-0778, or visit their website at www.ssa.gov.The Centers for Medicare & Medicaid Services (CMS) regulates the Medicare program. The CMS publishes a handbook titled Medicare & You, which provides general information and explains the parts of Medicare. You can view or download this publication at www.medicare.gov. For information on Medicare, contact the CMS at (800) 633-4227 or visit their website at www.medicare.gov.For additional information about how the parts of Medicare work with the CalPERS Health Program, refer to the CalPERS Medicare Enrollment Guide available on CalPERS On-Line at www.calpers.ca.gov . Certifying Your Medicare Status You will receive a notice from CalPERS four months prior to the month you turn 65. This notice informs you of CalPERS requirements to continue your health coverage. If you are retired or have initiated the process of retiring from active employment, you will also receive a Certification of Medicare Status form along with this notice. CalPERS requires that you complete this form and provide proof of your Medicare status. You must certify your Medicare status in order to continue your CalPERS health coverage. You will need to complete the Certification of Medicare Status form and return it to CalPERS with the proper docu -mentation certifying one of the following choices: •Enrollment in Medicare Parts A and B (submit a copy of Medicare card or SSA documentation) •Ineligible for Medicare either in your own right and/or through the work history of a current, former, or deceased spouse (submit SSA documentation) •Deferred enrollment in Medicare Part B due to your (or your spouse’s) employment (submit proof of active group health insurance through the current employer) If you are retired, and you do not return the Certification of Medicare Status form and/or copies of your supporting documentation to CalPERS by the beginning of your birth month, you will receive a notice of cancellation informing you that health coverage for you and all enrolled depen -dents will be automatically canceled the first day of the month after you turn 65. If you need assistance completing the form, contact CalPERS toll free at 888 CalPERS (or 888 -225-7377). Note: Your CalPERS Medicare health plan will become effective on your Medicare effective date or the first day of the month following CalPERS receipt of the Certification of Medicare Status form, whichever is later.
20 | Health Program Guide Qualifying Information Checklist for Enrolling in a CalPERS Medicare Health Plan ✓ A pply for Medicare. Three months before you turn 65, apply for Medicare by contacting the SSA toll free at (800) 772-1213 or TTY (800) 325-0778. Be prepared to provide your and your spouse’s Social Security numbers. ✓ I f you are retired and qualify for Medicare Part A at no cost, you must enroll in Part B when first eligible. ✓ C omplete and return to CalPERS the Certification of Medicare Status form along with a copy of your Medicare card. ✓ C hange from a CalPERS Basic health plan to a CalPERS Medicare health plan. −Your CalPERS Medicare health plan will become effective on your Medicare effective date or the first day of the month following CalPERS receipt of the Certification of Medicare Status form, whichever is later. −Enrollment by you or your family members in a CalPERS Medicare health plan will not affect other family members who are enrolled in a CalPERS Basic health plan. Unless they are Medicare-eligible, they will continue their enrollment in a CalPERS Basic health plan.Generally, your work status will determine if you or your dependents are eligible to enroll in a CalPERS Basic or Medicare health plan. If you are a CalPERS retiree who qualifies for Medicare Part A at no cost – either on your own or through a current, former, or deceased spouse – you must enroll in Part B when you first become eligible. You must then enroll in a CalPERS Medicare health plan. If you are retired and you (or your dependents) have a Social Security-qualified disability, you (or your depen -dents) may be eligible to enroll in a CalPERS Medicare health plan once the 24-month Social Security coordina -tion period has been completed. Note: Whether retired or active, if you or a dependent has End-Stage Renal Disease and the 30-month Social Security coordination period has been completed, you are eligible to enroll in a CalPERS Medicare health plan. You must have Medicare Part B to continue your enroll -ment in a CalPERS Medicare health plan. If you cancel your Part B coverage, you will lose your CalPERS health coverage. If the SSA cancels your Part B benefits for any reason, please inform CalPERS immediately.If you certify that you are ineligible for Medicare or defer enrollment because you are working and have other employer group health coverage, you will remain in a CalPERS Basic health plan. Once you retire or lose your other employer group health coverage, you must enroll in Medicare Parts A and B and transition to a CalPERS Medicare health plan.For more information about how the CalPERS Health Program interacts with Medicare, please refer to the CalPERS Medicare Enrollment Guide. This publication is available at CalPERS On-Line at www.calpers.ca.gov . You can also request a copy by calling CalPERS at 888 CalPERS (or 888 -225-7377).
Health Program Guide | 21 Enrollment Forms and Supporting Documentation Getting the Information You Need life events. You may also request changes by e-mail, by fax to (800) 959-6545, by calling 888 CalPERS (or 888 -225-7377), or by mailing the request with any necessary documentation to:CalPERS Health Account Services P.O. Box 942715 Sacramento, CA 94229-2715 Note: The Declaration of Health Coverage form must be completed by all active employees within 60 days of your initial qualifying appointment. This form must also be completed each time you make a change to your health benefits enrollment. The form declares that you have been offered health insurance and either chose to enroll or declined benefits. You can obtain the health benefit forms and publications you need from your employer or by contacting CalPERS toll free at 888 CalPERS (or 888 -225-7377). You may also obtain publications on CalPERS On-Line at www.calpers.ca.gov .The chart on the following pages can assist you in determining the forms and supporting documentation CalPERS needs to make various types of enrollment changes. If you are an active employee, submit all enrollment requests and copies of supporting documentation to your Health Benefits Officer.If you are a Retiree, you can make most changes to your health enrollment when you log into my|CalPERS. The Member Self Service function allows you to change plans during Open Enrollment, add a newly acquired dependent, or delete a dependent for certain qualifying
22 | Health Program Guide Required Documentation for Enrollment Change Enrollment type Copies of Supporting Documentation *CalPERS Forms Active employee – new enrollment N/A Health Benefits Plan Enrollment form (active)Declaration of Health Coverage (active only)Adding a registered domestic partner Declaration of Domestic Partnership from the California Secretary of State’s Office Medicare card (if applicable)Health Benefits Plan Enrollment form (active)Declaration of Health Coverage (active only)Health Benefits Plan Enrollment for Retirees form Adding a spouse Marriage Certificate Medicare card (if applicable)Health Benefits Plan Enrollment form (active)Declaration of Health Coverage (active only)Health Benefits Plan Enrollment for Retirees form Adding a dependent who is in a parent-child relationship Employer and/or CalPERS reserves the right to request any supporting documentation Affidavit of Parent-Child Relationship Health Benefits Plan Enrollment form (active)Declaration of Health Coverage (active only)Health Benefits Plan Enrollment for Retirees form Adding/deleting a dependent child Medicare card (if applicable)Reason for add/delete Birth Certificate Health Benefits Plan Enrollment form (active)Declaration of Health Coverage (active only)Health Benefits Plan Enrollment for Retirees form Changing plans due to address change Include both old and new addresses Health Benefits Plan Enrollment form (active)Declaration of Health Coverage (active only)Health Benefits Plan Enrollment for Retirees form
Health Program Guide | 23 Required Documentation for Enrollment Change Enrollment type Copies of Supporting Documentation *CalPERS Forms Active employee – new enrollment N/A Health Benefits Plan Enrollment form (active)Declaration of Health Coverage (active only)Adding a registered domestic partner Declaration of Domestic Partnership from the California Secretary of State’s Office Medicare card (if applicable)Health Benefits Plan Enrollment form (active)Declaration of Health Coverage (active only)Health Benefits Plan Enrollment for Retirees form Adding a spouse Marriage Certificate Medicare card (if applicable)Health Benefits Plan Enrollment form (active)Declaration of Health Coverage (active only)Health Benefits Plan Enrollment for Retirees form Adding a dependent who is in a parent-child relationship Employer and/or CalPERS reserves the right to request any supporting documentation Affidavit of Parent-Child Relationship Health Benefits Plan Enrollment form (active)Declaration of Health Coverage (active only)Health Benefits Plan Enrollment for Retirees form Adding/deleting a dependent child Medicare card (if applicable)Reason for add/delete Birth Certificate Health Benefits Plan Enrollment form (active)Declaration of Health Coverage (active only)Health Benefits Plan Enrollment for Retirees form Changing plans due to address change Include both old and new addresses Health Benefits Plan Enrollment form (active)Declaration of Health Coverage (active only)Health Benefits Plan Enrollment for Retirees form Enrollment type Copies of Supporting Documentation *CalPERS Forms Medicare certification (to validate eligibility, ineligibility, or deferment)Medicare card (reflecting Parts A and B enrollment) or SSA documentation Certification of Medicare Status form Death of employee, retiree, or family member Death Certificate N/A Deleting a registered domestic partner due to termination of partnership Termination of Domestic Partnership submitted to the California Secretary of State’s Office Health Benefits Plan Enrollment form (active)Health Benefits Plan Enrollment for Retirees form Deleting a spouse due to divorce Divorce Decree Health Benefits Plan Enrollment form (active)Health Benefits Plan Enrollment for Retirees form Disabled child over age 26 – certification N/A Member Questionnaire for the CalPERS Disabled Dependent Benefit form Medical Report for the CalPERS Disabled Dependent Benefit form Enrolling self or dependents due to loss of other health coverage Certificate of Creditable Coverage, or other proof of loss of coverage Medicare card (if applicable)Birth Certificate (child)Marriage Certificate (spouse)Declaration of Domestic Partnership (domestic partner)Health Benefits Plan Enrollment form (active)Declaration of Health Coverage (active only)Health Benefits Plan Enrollment for Retirees form Retiree – new enrollment Medicare card (if applicable)Marriage Certificate (if applicable)Health Benefits Plan Enrollment for Retirees form Off-Pay Status – continue coverage Off-Pay Status – cancel coverage N/A Direct Payment Authorization form Health Benefits Plan Enrollment form (active)*Note : Do not submit original documents as your documentation will not be returned.
24 | Health Program Guide Resources Getting Assistance with Your Health Benefits If you have questions about your CalPERS health benefits and you are an active member, contact your employer’s Health Benefits Officer. If you are a retiree, contact CalPERS.Online For more information on health benefits and programs, visit CalPERS On-Line at www.calpers.ca.gov . To view your current health plan information, go to my|CalPERS at my.calpers.ca.gov. By Phone Call CalPERS toll free at 888 CalPERS (or 888 -225-7377)Monday through Friday, 8:00 a.m. to 5:00 p.m.TTY (877) 249-7442 (for speech and hearing impaired)By Mail or Fax CalPERS Health Account Services P.O. Box 942715 Sacramento, CA 94229-2715 Fax (800) 959-6545 In Person You can visit a Regional Office at the following locations:Fresno Regional Office 10 River Park Place East, Suite 230 Fresno, CA 93720 Glendale Regional Office 655 North Central Avenue, Suite 1400 Glendale, CA 91203 Orange Regional Office 500 North State College Boulevard, Suite 750 Orange, CA 92868 Sacramento Regional Office 400 Q Street, Room 1820 Sacramento, CA 95811 San Bernardino Regional Office 650 East Hospitality Lane, Suite 330 San Bernardino, CA 92408 San Diego Regional Office 7676 Hazard Center Drive, Suite 350 San Diego, CA 92108 San Jose Regional Office 181 Metro Drive, Suite 520 San Jose, CA 95110 Walnut Creek Regional Office 1340 Treat Boulevard, Suite 200 Walnut Creek, CA 94597
Health Program Guide | 25 Contacting Your Health Plan To obtain up-to-date contact information for the health plans, please refer to the Health Benefit Summary or go to CalPERS On-Line at www.calpers.ca.gov . Contact your health plan with questions about: identification cards, veri -fication of provider participation, service area boundaries Resolving Problems with Your Health Plan Your health plan and CalPERS work together to ensure timely delivery of services for you and your family; however, disagreements may occur. To resolve an issue, you should first contact your health plan. If they are unable to help you, contact CalPERS for assistance. Following is information about specific ways your health plan and CalPERS can help.Cancellation of Your Coverage and CalPERS Administrative Review Process If CalPERS cancels your CalPERS health coverage, you can request an Administrative Review. The Administrative Review process helps us decide if your coverage should be reinstated. You must ask for an Administrative Review within 90 days of losing coverage by writing to:CalPERS Health Account Services P.O. Box 942715 Sacramento, CA 94229-2715 Once we have all your information, we will review your request. We will tell you within 60 days if your coverage will be reinstated. If your coverage is not reinstated, we will tell you why.Filing a Grievance If you feel your health plan has not helped you appropri -ately, you have a legal right to file a written grievance with them to resolve an issue, complaint, or disagreement. Refer to your health plan’s Evidence of Coverage booklet for more information about your plan’s grievance process. Contact your health plan for a copy of the Evidence of Coverage booklet.Appealing a Decision If you receive a written response about a grievance you have filed and you are not satisfied with the decision, you may also appeal your plan’s decision as follows: Members in a Health Maintenance Organization (HMO) and Exclusive Provider Organization (EPO) Plan The California Department of Managed Health Care (DMHC) regulates all HMOs in California. If you are an HMO or EPO health plan enrollee, and you have filed a grievance and are dissatisfied with your HMO or EPO’s final decision, you should contact the DMHC HMO Consumer Help Center at (888) 466-2219 or TTY (877) 688-9891 to register your complaint. You also should request assistance through DMHC’s website at www.dmhc.ca.gov. You may contact DMHC if the matter is not resolved within 30 days from the time your grievance was received by your health plan. Contact them immediately if the matter is urgent. If you have filed a grievance and are dissatisfied with your HMO or EPO’s final decision regarding your eligibility for health benefits or limits of coverage under the plan, you may contact CalPERS for assistance. Members in a Preferred Provider Organization (PPO) Plan If you are a PPO health plan enrollee, and you have filed a grievance and are dissatisfied with your PPO’s final decision, you may contact CalPERS at 888 CalPERS (or 888 -225-7377) for assistance. (covered ZIP Codes), or Individual Conversion Policies. Your plan benefits, deductibles, limitations, and exclusions are outlined in detail in your health plan’s Evidence of Coverage booklet. You can obtain the Evidence of Coverage by contacting your health plan directly.
26 | Health Program Guide Binding Arbitration Binding arbitration is a method used by some health plans to resolve conflicts. It requires you to agree in advance that any claims or disagreements will be settled through a neutral, legally binding resolution, replacing court or jury trials. In some instances, you can choose to appeal to CalPERS rather than go through binding arbitration. If your plan requires binding arbitration, the process will be described in your plan’s Evidence of Coverage booklet, which you can obtain from your health plan.The California Patient’s Guide The California Patient’s Guide: Your Health Care Rights and Remedies informs you of your rights to receive quality health care and what steps you can take if you encounter problems. The full text of the guide is available at www.calpatientguide.org, or you can request a copy by calling the DMHC HMO Consumer Help Center at (888) 466-2219.Patient Bill of Rights CalPERS Notice of Agreement for Arbitration Enrolling in certain health benefit plans consti -tutes your agreement that any dispute(s) you have with the plan, including medical malpractice, that is, whether any medical services rendered under this contract were unnecessary or unau -thorized or were improperly, negligently, or incompetently rendered, as well as any dispute(s) relating to the delivery of service under the plan will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceed -ings. By enrolling in one of these plans, you are giving up your constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitra -tion. Please refer to the health plan’s Evidence of Coverage for details. As a member of the CalPERS Health Program, you have important rights. These rights protect your privacy, your access to quality health care, and your right to participate fully in medical decisions affecting you and your family.How and Where to Get Help If you have a concern about your rights and health care services, we urge you to first discuss it with your physi -cian, hospital, or other provider, as appropriate. Many complaints can be resolved at this level because your health plan wants satisfied customers. If you still have concerns, you may have the right to appeal the health plan’s decision directly to CalPERS or, in many health plans, through the grievance process. Consult your Evidence of Coverage booklet for information on the benefits covered or your appeal rights. You can contact CalPERS at 888 CalPERS (or 888 -225-7377) for further information.
Health Program Guide | 27 As a patient and a CalPERS member, you have the right to: •Be treated with courtesy and respect •Receive health care without discrimination •Have confidential communication about your health •Have your medical record or information about your health disclosed only with your written permission •Access and copy your medical record •Have no restrictions placed on your doctor’s ability to inform you about your health status and all treatment options •Be given sufficient information to make an informed decision about any medical treatment or procedure, including its risks and benefits •Refuse any treatment •Designate a surrogate to make your health care decisions if you are incapacitated •Access quality medical care, including specialist and urgent care services, when medically necessary and covered by your health plan •Access emergency services when you, as a “prudent layperson,” could expect the absence of immediate medical attention would result in serious jeopardy to you •Participate in an independent, external medical review when covered health care services are denied, delayed, or limited on the basis that the service was not medically necessary or appropriate, after the health plan’s internal grievance process has been exhausted •Discuss the costs of your care in advance with your provider •Get a detailed, written explanation if payment or services are denied or reduced •Have your complaints resolved in a fair and timely manner and have them expedited when a medical condition requires treatment You can help protect your rights by doing the following: •Express your health care needs clearly •Build mutual trust and cooperation with your providers •Give relevant information to your health care provider about your health history, condition, and all medications you use •Contact your providers promptly when health problems occur •Ask questions if you don’t understand a medical condition or treatment •Be on time for appointments •Notify providers in advance if you can’t keep your health care appointment •Adopt a healthy lifestyle and use preventive medicine, including appropriate screenings and immunizations •Familiarize yourself with your health benefits and any exclusions, deductibles, co-payments, and treatment costs •Understand that cost controls, when reasonable, help keep good health care affordable
28 | Health Program Guide Effective Date: April 14, 2011 This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions about this notice, please contact the Health Insurance Portability and Accountability Act (HIPAA) Administrator at 888 CalPERS (or 888 -225-7377).Why We Ask for Information About You The Information Practices Act of 1977 and the Federal Privacy Act require CalPERS to provide the following infor -mation to individuals who are asked to supply information. The information requested is collected pursuant to the Government Code (Section 20000, et seq.) and will be used for administration of the Board’s duties under the Public Employees’ Retirement Law, the Social Security Act, and the Public Employees’ Medical and Hospital Care Act, as the case may be. Submission of the requested informa -tion is mandatory. Failure to supply the information may result in CalPERS being unable to perform its functions regarding your status. Portions of this information may be transferred to other governmental agencies (such as your employer), physicians, and insurance carriers, but only in strict accordance with current statutes regarding confidentiality.You have the right to review your CalPERS membership file. For questions concerning your rights under the Information Practices Act of 1977, please contact the CalPERS Customer Contact Center at 888 CalPERS (or 888 -225-7377).How We Use Your Social Security Number Section 7(b) of the Privacy Act of 1974 (Public Law 93-579) requires that any federal, State, or local govern -mental agency which requests an individual to disclose a Social Security number shall inform that individual whether that disclosure is mandatory or voluntary, by which statutory or other authority such number is solic -ited, and what uses will be made of it.Section 111 of Public Law 101-173 requires group health plans to collect and provide member Social Security numbers for the coordination of federal and State benefits. Furthermore, the CalPERS Health Program requires each enrollee’s Social Security number for identification purposes and to verify eligibility for benefits.The CalPERS Health Program uses Social Security numbers for the following purposes: •Enrollee identification for eligibility processing and verification •Payroll deduction and State contribution for State employees •Billing of public agencies for employee and employer contributions •Reports to CalPERS and other State agencies •Coordination of benefits among health plans •Resolution of member appeals/complaints/grievances with health plans How We Safeguard Your Protected Health Information We understand that protected health information about you is personal and CalPERS is committed to safeguarding protected health information, which is in our possession. This notice applies to all of the records of your health plan participation generated by CalPERS. The participating health plan in which you are enrolled may have different policies or notices regarding its use and disclosure of your protected health information. The remainder of this notice will tell you about the ways in which we may use and disclose protected health information about you. We also describe your rights and certain obligations we have regarding the use and disclo -sure of protected health information.The Federal Health Insurance Portability and Accountability Act Privacy Regulations (Title 45, Code of Federal Regulations, sections 164.500, et seq.) require us to: •Make sure protected health information that identifies you is kept private; CalPERS Notice of Privacy Practices
Health Program Guide | 29 •Give you this notice of our legal duties and privacy practices with respect to your protected health information; and •Follow the terms of the notice that is currently in effect.How We May Use and Disclose Your Protected Health Information The following categories describe different ways that we may use and disclose protected health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. •Health Care Operations. We may use and disclose protected health information about you for CalPERS health benefits operations. These uses and disclosures are necessary to run the CalPERS health benefits program and make sure that all of our enrollees receive quality care. For example, we may use and disclose protected health information about you to confirm your eligibility and to enroll you in the participating health plan that you select, to evaluate the performance of the health plan in which you are enrolled, for coordination of benefits among health plans, or to resolve an appeal, complaint, or grievance with the health plan. We may also combine protected health information about many CalPERS health benefits enrollees to evaluate health plan performance, to assist in rate setting, to measure quality of care provided or for other health care opera -tions. In some cases, we may obtain protected health information about you from a participating health plan, provider, or third-party administrator for certain health care operations. If the protected health information received from others is part of our health care opera -tions, the uses and disclosures would be in accordance with this guideline. •Health-Related Benefits and Services. We may use and disclose protected health information to tell you about health-related benefits or services, such as treatment alternatives, disease management or wellness programs that may be of interest to you. •Named Insured. If you are enrolled in the CalPERS health benefit program as a dependent, we may release protected health information about you to the named insured. •As Required By Law. We will disclose protected health information about you when required to do so by federal, state, or local law or regulation. •To Avert a Serious Threat to Health or Safety. We may use and disclose protected health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.Special Situations •Workers’ Compensation. We may release protected health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness. •Health Oversight Activities. We may disclose protected health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, govern -ment programs, and compliance with civil rights laws. •Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose protected health information about you in response to a court or administrative order. We may also disclose protected health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if you have been given proper notice and an opportunity to object. •Law Enforcement. We may release protected health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons, or similar process. •National Security and Intelligence Activities. We may release protected health information about you to authorized federal officials for intelligence, counterintel -ligence, and other national security activities authorized by law.
30 | Health Program Guide •Protective Services for the President and Others. We may disclose protected health information about you to authorized federal or state officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations. •Inmates. If you are an inmate of a correctional institu -tion or under the custody of a law enforcement official, we may release protected health information about you to the correctional institution or law enforcement offi -cial. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.Rights Regarding Your Protected Health Information You have the following rights regarding protected health information we maintain about you: •Right to Inspect and Copy. You have the right to inspect and copy protected health information about you that is maintained by the CalPERS Health Program. In most cases, this consists solely of information concerning your health plan enrollment. In some cases, it may also include information that you have provided to CalPERS to assist with coordination of benefits among health plans or to resolve an appeal, complaint, or grievance against the health plan in which you are enrolled.To inspect and copy protected health information about you that is maintained by the CalPERS Health Program, you must submit your request in writing to the HIPAA Administrator at P.O. Box 942715, Sacramento, CA 94229-2715. If you request a copy of the informa -tion, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request.We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to the protected health information, you may request that the denial be reviewed. A licensed health care professional chosen by CalPERS will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review. •Right to Amend. If you feel the protected health infor -mation we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the infor -mation is kept by or for the CalPERS Health Program.To request an amendment, your request must be made in writing and submitted to the HIPAA Administrator at P.O. Box 942715, Sacramento, CA 94229-2715. In addition, you must provide a reason that supports your request.We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: −Was not created by us, unless the person or entity that created the information is no longer available to make the amendment; −Is not part of the protected health information kept by or for CalPERS; −Is not part of the information which you would be permitted to inspect and copy; or −Is accurate and complete. •Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of the protected health information about you.To request this list or accounting of disclosures, you must submit your request in writing to the HIPAA Administrator at P.O. Box 942715, Sacramento, CA 94229-2715. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the costs involved and you may choose to withdraw or modify your request at that time before any costs are incurred. •Right to Request Restrictions. You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment, or health care operations. You also
Health Program Guide | 31 have the right to request a limit on the protected health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.We are not required to agree to your request. If we do agree, we will comply with your request unless the infor -mation is needed to provide you emergency treatment.To request restrictions, you must make your request in writing to the HIPAA Administrator at P.O. Box 942715, Sacramento, CA 94229-2715. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclo -sure, or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse. •Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail to a specific address.To request confidential communications, you must make your request in writing to the HIPAA Administrator at P.O. Box 942715, Sacramento, CA 94229-2715. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. •Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.To obtain a paper copy of this notice contact the HIPAA Administrator at 888 CalPERS (or 888 -225-7377).Changes to This Notice We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for protected health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at CalPERS and on the CalPERS website at www.calpers.ca.gov . The notice will contain on the first page, in the top right-hand corner, the effective date. Complaints If you believe your privacy rights have been violated, you may file a complaint with CalPERS or with the Secretary of the California Health and Human Services Agency. To file a complaint with CalPERS, contact the HIPAA Administrator at 888 CalPERS (or 888 -225-7377). All complaints must be submitted in writing.You will not be retaliated against for filing a complaint.Other Uses of Protected Health Information Other uses and disclosures of protected health informa -tion not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose protected health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose protected health information about you for the reasons covered by your written authori -zation. You understand that we are unable to take back any disclosures we have already made with your permis -sion, and that we are required to retain our records of your participation in the CalPERS health benefits program.
32 | Health Program Guide Definition of Terms Annuitant A person who has retired within 120 days of separation from employment and who receives a retirement allow -ance from the retirement system provided by the employer, or a surviving family member who receives the retirement allowance in place of the deceased, or a survi -vor of a deceased employee entitled to special death benefits and survivor allowance under Section 21541, 21546, 21547, or 21547.7 of the Public Employees’ Retirement Law, or similar provisions of any other state retirement system.CalPERS Basic Health Plan A CalPERS Basic health plan provides health benefits coverage to members who are under age 65 or who are over age 65 and still working. Members who are 65 years of age or older and not eligible for Medicare Part A may also be eligible to enroll in a Basic health plan.CalPERS Medicare Health Plan A CalPERS Medicare health plan requires Medicare to assume the role as primary payer for health care costs. This coordination of benefits between Medicare and your CalPERS Medicare health plan lowers the costs of your health premiums and provides some coverage beyond Medicare.The Consolidated Omnibus Budget Reconciliation Act (COBRA)The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986 provides for continuation of group health coverage that otherwise might be terminated. COBRA provides certain former employees, retirees, spouses, former spouses, and dependent children the right to temporary continuation of health coverage at group rates. This coverage is only available when coverage is lost due to certain events. Co-insurance The amount you may be required to pay for service after you pay the deductible.Co-payment The amount you pay for a doctor visit or for receiving a covered service or prescription.Deductible The amount you must pay for health care before the health plan starts to pay. Dependent A family member who meets the specific eligibility criteria for coverage in the CalPERS Health Program. Employer Contribution The amount your current or former employer contributes towards the cost of your health premium.
Health Program Guide | 33 Emergency Services Medical services to treat an injury or illness that could result in serious harm if you don’t get care right away.Health Insurance Portability & Accountability Act (HIPAA)This federal law protects health insurance coverage for workers and their families when they change or lose their jobs. It also includes provisions for national standards to protect the privacy of personal health information. Non-Participating Provider Non-preferred providers that have not contracted with the health plan.Out-of-Pocket Costs Generally refers to the actual costs individuals pay to receive health care. These costs are the total of the premium (minus any employer contribution) plus any additional costs such as co-payments and deductibles.Open Enrollment Period A specific period of time, as determined by the CalPERS Board of Administration, when you can enroll in or change health plans or add eligible family members who are not currently enrolled in the CalPERS Health Program. Preferred Provider This is a provider that participates in a preferred provider network. You will pay less to visit a preferred provider.Premium The monthly amount a health plan charges to provide health benefits coverage. Primary Care Provider (PCP)The doctor who works with you and other doctors to provide, prescribe, approve, and coordinate all your medical care and treatment (also referred to by some health plans as “Personal Physician”).Retiree A person who has retired within 120 days of separation from employment with the State or a contracting agency and who receives a retirement allowance from the retire -ment system provided by the employer.Service Area The geographic area in which your health plan provides coverage. You must reside or work in the health plan’s service area to enroll in and remain enrolled in a plan. For some plans, the Medicare service area may not be identi -cal to the Basic service area. Specialist A doctor who has special training in a specific kind of medical care, for example, cardiology (heart), neurology (nervous system), or oncology (cancer).Urgently Needed Services A non-emergency situation when you need to see a doctor, but are away from your health plan’s service area. See your health plan’s Evidence of Coverage booklet for more details.
CalPERS Health Benefits Program P.O. Box 942715 Sacramento, CA 94229-2715 888 CalPERS (or 888 -225-7377) www.calpers.ca.gov HBD–120 Produced by CalPERS External Affairs Branch Office of Public Affairs August 2014.08.1