Retiree Benefits Enrollment Guide

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Retiree Benefits Enrollment Guide

County of Riverside Human Resources

Benefits Beyond Your Expectations

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H T T P : / / B E N E F I T S . R C - H R . C O M

Table of

What’s New For

2015?

Don’t miss your chance to enroll! You have from

October 6 through October 24, 2014.

Here are some important changes to be aware of before you enroll:

• Effective January 1, 2015, UnitedHealthcare (UHC) will replace Health Net as our HMO, PPO, and Medicare plan provider.If you’re currently enrolled in a Health Net medical plan and you do not actively enroll for medical coverage for 2015, you will be automatically enrolled in the plan most similar to your current plan at your current coverage level (e.g., retiree only, retiree plus spouse).

The coverage under the Early Retiree HMO, PPO, and Retiree Medicare plans will remain the same, with minor changes to a few benefits, including the addition of chiropractic coverage to our Early Retiree HMO and Medicare Advantage plan

Your

County of Riverside

Benefits

County of Riverside

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Y O U R M E D I C A L B E N E F I T C H O I C E S

The County medical plans available to you vary based on your age, your eligibility for Medicare, and where you live. To help you with your choices, we have color-coded the pages where your medical choices are displayed:

nnnnnn For retirees who are not eligible for Medicare

nnnnnn For Medicare-eligible retirees

If you are enrolling dependents whose Medicare eligibility is different from yours, you need to make sure you enroll in a plan that’s appropriate for everyone. Please see page 12 for more

information.

offerings. Refer to pages 12 for details about your medical plan options. Note: The Health Net Seniority Plus HMO has been replaced with the UnitedHealthcare Medicare Advantage plan.

Important:If you enroll in the HMO or the Medicare Advantage plan, you’ll be asked to provide a 10-digit Primary Care Physician (PCP) ID number which can be found within the provider search at www.uhcwest.com or

www.uhcretiree.com. If you don’t designate a PCP when you enroll, a PCP will be auto-assigned.

• The Health Net Seniority Plus plan is being replaced with the UnitedHealthcare Medicare Advantage plan.If you’re currently enrolled in the Seniority Plus plan, you’ll be automatically enrolled in the new plan unless you return an opt-out form you received in early October. If you need another copy, call the Benefits Information Line at (951) 955-4981, option 1.

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E L I G I B L E F O R M E D I C A R E ?

A D D I T I O N A L P L A N - S P E C I F I C

F O R M S R E Q U I R E D !

If you or your dependent is eligible for Medicare, you must also complete a Medicare enrollment form for the specific medical plan you elect (Kaiser Senior Advantage High Option or Low Option, UnitedHealthcare Medicare Advantage Plan, or SCAN HMO), and you must send us a copy of your Medicare ID card. Please contact the Benefits Information Line at (951) 955-4981 to request the correct form. If you terminate coverage for yourself or a dependent who is currently enrolled in one of these plans, Medicare rules require that you complete a disenrollment form. If you do not complete the required Medicare enrollment forms or disenrollment forms, the County will not be able to make the election changes you request.

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2 0 1 5 B E N E F I T S E N R O L L M E N T — I M P O RTA N T D AT E S

• Annual Enrollment for County plans: The County’s Annual Enrollment period for retirees is October 6 through October 24, 2014.

This includes enrollment in County medical, dental, and vision plans.

• County plan rate changes will be effective January 1, 2015.You will see rate changes for medical, dental, and vision plans on your January CalPERS warrant. Contributions are collected from your retiree warrant to pay for the current month of coverage. For example, the deductions from your January retiree warrant are used to pay for January coverage. If your retiree warrant is insufficient to pay premiums for the coverage you elect, the County’s Benefits Division will send an invoice directly to you for the premiums due. If your premiums exceed your CalPERS allowance, you

will be responsible for paying your premiums directly to the County of Riverside. Your premiums must bereceived on or before the 25th day of the month preceding coverage. For example: Your premiums for January are due on or before December 25. Please make sure your premiums are paid on time to avoid a lapse or termination in your coverage.

• CalPERS health plan enrollment (for retirees who retired from DDAA, LEMU, or RSA Public Safety):The CalPERS Annual Enrollment period was September 15 through October 10, 2014. If you dropped your

CalPERS plan coverage so that you could enroll in one of the County’s Exclusive Care plans, now is the time to make your Exclusive Care plan election for 2015. To enroll in an Exclusive Care plan, or a County-sponsored dental or vision plan, you must complete the enclosed Retiree Benefit Election Form.

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Complete the 2015 Retiree Benefit Election Formand return it to the County of Riverside Benefits Division no later than October 24, 2014. Please consider your elections carefully, and submit your form one time only.

Remember to make a copy for your records and include any supporting forms or documents that are required. If you are enrolling a spouse, registered domestic partner, or dependent children, you will need to enroll your dependent(s) on the form AND provide supporting documentation. You must submit your documentation with the Retiree Benefit Election Formto the County of Riverside Benefits Division no later than October 24, 2014. Your enrollment form cannot be processed without the supporting documentation. See “Required Proof of Eligibility” on page 9 for requirements.

During Annual Enrollment, you can... • Do nothing, and your current health care

coverage will continue as long as you remain eligible, unless you are enrolled in a Health Net plan. If so, you must elect new medical plan for 2015.

• Choose a different plan or cancel your medical, dental, or vision plan

• Add or delete coverage for an eligible dependent

M A K I N G Y O U R A N N U A L E N R O L L M E N T D E C I S I O N S

This enrollment guide provides basic information about your County-sponsored medical, dental, and vision care plans, including resources that you may need to evaluate your options.

Enrolling

in Your Benefits

3 H T T P : / / B E N E F I T S . R C - H R . C O M Enrolling

D O I N E E D T O TA K E

A C T I O N D U R I N G O P E N

E N R O L L M E N T ?

If you do not wish to change your elections for 2015, you do not need to do anything. Please DO NOT send a Retiree Benefit Election Form.You only need to take action during Annual Enrollment if you want to: • Elect a different medical plan if you’re currently

enrolled in a Health Net medical plan.

• Consider the new Low Option plan offered by Kaiser. • Change or elect your medical, dental, vision

plan elections

• Add or delete dependent coverage

• Consider the new UnitedHealthcare plan options.

Step 1:Read all the information contained in your personalized enrollment letter. This letter shows your current coverage and the coverage options available to you in 2015.

Note:If you are eligible for or enrolled in a medical plan through CalPERS, this election will not be indicated in your County of Riverside personalized enrollment letter (because your coverage is

maintained by CalPERS). You will receive a

confirmation statement from CalPERS about your medical plan.

Step 2:Use this guide to learn more about the benefit options available to you. If you have questions, be sure to get them answered before you select benefits and complete your Retiree Benefit Election Form.

Forms are available online at http://benefits.rc-hr.com/Homeor from the Benefits Information Line at (951) 955-4981.

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Step 3:Consider your health and financial needs carefully. Ask yourself these questions:

• Does your current benefit coverage meet your needs?

• Are your current prescription drugs covered under the plan?

• Is your CalPERS warrant sufficient to cover your premium?

• Are you or your dependent(s) newly eligible for Medicare, or will you become eligible this year?

• Do the plan’s premium costs fit your budget?

• Have your health care needs changed?

• Has your marital status changed?

• Have your eligible dependents changed?

Step 4:If you would like to change your elections, mark your County benefit choices on the Retiree Benefit Election Form that you received with this package. DO NOT submit a new election form if you are not making changes to your current coverage.

Step 5:Complete any additional enrollment forms required by the plan you’ve selected. These additional forms are generally required if you or your dependent is over 65 and/or eligible for Medicare and you are enrolling in or disenrolling from one of the following plans: UnitedHealthcare Medicare Advantage or Coordination of Benefits (COB) Plan, Kaiser Senior Advantage High Option or Low Option, or the SCAN HMO.We will not be able to process your

medical plan enrollment without these

completed forms. You must also provide a copy of the Medicare card that verifies enrollment in Parts A and B.

Step 6:Once you have chosen your benefits, add up all of your costs. Your benefit costs will continue to be deducted monthly, whenever possible, from your CalPERS pension warrant for 2015. Remember, we will reduce the cost of your medical premium by applying your County contribution (see page 39) or your CalPERS warrant.

Step 7:Be sure to provide your current dependent information.

Step 8:Sign and date each of your completed forms.

Step 9:Attach copies of documentation that verifies the eligibility of your dependents. See pages 9–10 for documentation requirements.

Step 10:Make a copy of your form(s) and any documentation for your records.

Step 11:Submit your benefit forms to the County of Riverside Benefits Division no later than October 24, 2014.

Note: Please consider your options carefully— and review the total cost of your coverage— before submitting your Retiree Benefit Election Form, to make sure you are enrolling in the benefits you want and can afford.

Remember: If you do not wish to change your benefit elections, you do not need to complete aRetiree Benefit Election Form for the 2015 plan year, if you are not enrolled in a Health Net plan.

A D D I N G O R D E L E T I N G D E P E N D E N T S

You can add or delete eligible dependents from County-sponsored medical, dental, and vision plans during Annual Enrollment by completing the enclosed Retiree Benefit Election Form.

To Add Dependents and/or a Registered Domestic Partner

1. Complete the dependent section of your Retiree Benefit Election Form. Be sure to provide complete information for each dependent and choose a primary care physician and/or primary care dentist, if required by the plan. Note:You must 4

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list ALL of your eligible dependents (even if they are currently enrolled). Make sure you clearly indicate the coverage options (medical, dental, and vision) you want for EACH dependent.

2. Provide required dependent documentation.

See pages 9–10 for details. Attach the required documentation with your Retiree Benefit Election Form.

3. Submityour completed forms to the County of Riverside Benefits Division no later than October 24, 2014.Remember to make a copy and keep it for your records.

To Delete Spouse/Registered Domestic Partner and/or Dependents

1. Completethe enclosed Retiree Benefit Election Form. List all dependents you want enrolled, but leave off the dependent whose coverage you wish to delete. Any dependents not listed will not be covered for the new plan year.

2. Submityour completed election form to the County of Riverside Benefits Division no later than October 24, 2014.Remember to make a copy and keep it for your records.

If you are electing or terminating a Medicare Advantage plan, you must complete a plan-specific enrollment or disenrollment form.

W H E N C O V E R A G E B E G I N S

If you are enrolling for coverage or making changes to your current benefit elections during the Annual Enrollment period, your new coverage will be effective January 1, 2015, and will continue through December 31, 2015, or until you cease to be eligible for coverage, if earlier. Your deductions for coverage are taken beginning with your first CalPERS retiree warrant in January for coverages beginning

January 1, 2015.

If you are enrolling for coverage as a new retiree or making mid-year election changes, your new coverage will generally be effective the first of the month following receipt of your completed Retiree Benefit Election Formand appropriate supporting documentation, unless another effective date is required to comply with the special enrollment rights under the Health Insurance Portability and Accountability Act (HIPAA) or to coordinate your coverage with Medicare.

HEALTH INSURANCE PORTABILITY

AND ACCOUNTABILITY—SPECIAL

ENROLLMENT RIGHTS

If you are waiving enrollment for yourself or your dependents (including your spouse/registered domestic partner) because of other health insurance coverage, in the future you may be able to enroll yourself and/or your dependents in a plan, provided that you request enrollment within 60 days after your other coverage ends. 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 60 days after the event occurs.

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M A K I N G M I D - Y E A R C H A N G E S

Each year, during the Annual Enrollment period, you have an opportunity to change your benefit plan elections for the following plan year. Generally, the benefit elections you make during Annual

Enrollment will stay in effect from January 1 through December 31, if you remain eligible for benefits. However, if you incur a qualified change of status, please notify the County’s Benefits Division to make the appropriate change. Qualified status changes include:

• Marriage or registration of a registered domestic partnership

• Divorce or separation from a registered domestic partner

• Birth or adoption of a child

• Death of a spouse/registered domestic partner or a child

• Change in your spouse’s/registered domestic partner’s employment

• Significant changes in your spouse’s/registered domestic partner’s employer’s medical coverage

• Child’s loss of eligibility due to age

• Full-time/part-time employment status change that results in an insurance eligibility change

• You, your spouse, or your dependent child becomes eligible for Medicare, Medicaid, or Medi-Cal

• A judgment, decree, or court order requires a coverage change

Most status changes are easy to manage. Simply complete a Retiree Benefit Election Formand return it to the County of Riverside Benefits Division within 60 days of the event that caused the status change. You must include documentation of the event (such as a certified birth certificate or certified marriage certificate). Most changes are made prospectively from the date that the County of Riverside Benefits Division receives a properly completed and signed Retiree Benefit Election orCancellation Form.

Exceptions are made for birth or adoption to comply with the special enrollment rights defined under the Health Insurance Portability and Accountability Act (HIPAA), and to coordinate your Medicare

eligibility.

Please keep in mind that any changes to your

coverage must be consistent with the qualified status change. For example, if you get married, you can enroll your new spouse in the benefit plans—but you cannot make unrelated changes, such as switching from one medical plan to another.

Due to the CalPERS processing deadlines, you may experience a delay in when the deductions from your PERS warrant start or stop. In these cases, you will be billed for the premium difference or given a refund for any premium you overpaid.

Important: You must notify the County of Riverside Benefits Division within 60 days of a change in status. Failure to notify the County of Riverside Benefits Division will result in the County’s inability to correct and/or refund premium deductions.

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R E T I R E E E L I G I B I L I T Y

To be eligible for enrollment, all of the following conditions must be met:

• You must retire within 120 days from the date you separate from employment with the County of Riverside;

• You must receive a retirement allowance from CalPERS; and

• You must have been eligible for enrollment on the date of separation from the County of Riverside. The surviving dependent of a retiree may also be eligible.

Medical, Dental, and Vision Coverage County medical plans.All County retirees who were previously represented by LIUNA and SEIU, elected officials, and those in Management,

Confidential, and Unrepresented units are eligible.

CalPERS medical plans. County retirees who were represented by DDAA, LEMU, and RSA Public Safety Unit are eligible. Participants eligible for CalPERS plans are also eligible to enroll in the County’s Exclusive Care plans. Any election changes must be coordinated with the CalPERS enrollment period, which was September 15 through October 10, 2014. Even if you choose not to enroll in a medical plan when you retire, if you meet all of the criteria listed above, you are eligible to enroll in a medical plan at any subsequent Annual Enrollment period. In addition, you are eligible to enroll in a medical plan if you experience a loss of eligibility for other coverage due to a qualifying event and you request enrollment within 60 days of the event that caused the loss of coverage.

County dental plans. You can enroll in a County dental plan even if you do not currently have coverage.

Eligibility

for Coverage

Once you or your dependent reaches age 65 or becomes eligible for Medicare, your plan options and rates change. Refer to page 12 for a description of how Medicare eligibility affects your benefit choices. The County’s monthly retiree contribution toward your medical coverage is the same for all medical plans.

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County vision plan.All retirees who meet the general eligibility criteria can enroll in the vision plan. Even if you choose not to enroll in the vision plan at the time you retire, you can enroll at any subsequent Annual Enrollment period. Before enrolling in the vision plan, it’s a good idea to see what kind of vision benefits your medical plan covers, to avoid duplication of benefits.

D E P E N D E N T E L I G I B I L I T Y

You can enroll your eligible dependents in your medical, dental, and vision coverage. Eligible dependents include your:

• Legal spouse.

• Registered domestic partner, if you and your domestic partner meet all of the criteria listed below. A domestic partnership is defined as two people who both:

--- Are at least 18 years of age, unmarried, and not a blood relative close enough to bar marriage in the State of California;

--- Live in a mutually exclusive relationship in which you are jointly responsible for each other’s welfare and financial obligations;

--- Live in the same principal residence and intend to do so indefinitely; and

--- Have registered with the State of California by completing a Declaration of Domestic

Partnership, having both partners’ signatures notarized, submitting the form (with the appropriate fee) to the Secretary of State, and receive documentation from the State with proof of filing.

Based on state law (AB26 and AB25), the following partners are eligible to register with the state: --- Specified same-sex domestic partnerships

between persons who are both at least 18 years of age; or

--- Specified opposite-sex domestic partnerships in which one or both partners are age 62 or older.

• Children. Your child must be under age 26. Eligible children include your or your spouse’s/registered domestic partner’s:

--- Natural child. --- Stepchild.

--- Adopted child who is adopted by you or placed in your physical custody for adoption prior to age 18. “Placed for adoption” means that you have assumed a legal obligation for total or partial support of the child in anticipation of adopting the child. The child must be available for adoption and the legal process must have begun.

--- Child for whom you have legal custody or guardianship.

--- Child for whom you are required to provide coverage due to a qualified medical child support order(QMCSO). A QMCSO includes a judgment, decree, or other order issued by a court of competent jurisdiction or through an administrative process established under state law. Coverage cannot be discontinued for any child who is enrolled to comply with a QMCSO unless you submit written evidence that the order is no longer in effect.

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--- Disabled child over age 26 (who, except for age, meets the above eligibility requirements), if he or she is incapable of self-support because of a mental or physical disability that existed before age 26 (and continuously since age 26). The child must be dependent on you or your spouse/registered domestic partner for support and claimed as your dependent for federal income tax purposes. Coverage for a disabled child beyond age 26 can only be established when you first enroll for benefits or as a continuation of coverage in a County-sponsored plan.

The following are examples of individuals who

are notconsidered eligible dependents:

• Your spouse following final decree of dissolution, divorce, or legal separation.

• Someone else’s child (such as your grandchildren, nieces, or nephews), unless you have been awarded legal custody or guardianship.

• Parents or grandparents, regardless of their IRS dependent status.

• Your child’s spouse.

Important News About Dependent Eligibility

During Annual Enrollment, you MUST review your dependent elections and certify that each enrolled dependent continues to meet our eligibility rules. You also must be prepared to provide appropriate documentation to confirm your dependent’s eligibility if you are selected for a dependent audit. If you’re enrolling a dependent for the first time, you are required to provide documentation before the end of Annual Enrollment.

Please keep the following rules in mind:

1. It is against the law to enroll ineligible family members. If you do, you may have to pay for all costs incurred by the ineligible dependent from the date the coverage began.

2. If you do not add newly eligible family members to your health plan within the 60-day period of eligibility, you will have to wait until the next Annual Enrollment period before you can enroll them.

3. Your former spouse/registered domestic partner, parents, parents-in-law, other relatives, and non-disabled children age 26 and over are not eligible for coverage under your health care plans.

4. You must drop coverage for your enrolled dependent when he or she loses eligibility (for example, if you and your spouse divorce or your child reaches age 26).

R E Q U I R E D P R O O F O F E L I G I B I L I T Y

You will need to provide proof of eligibility the first time you request that a dependent be added to your medical, dental, or vision plan (and periodically to comply with a benefits audit process). Once you have completed your Retiree Benefit Election Form, submit all of the necessary documentation to the County of Riverside Benefits Division. If you are doing so during Annual Enrollment, you must submit the documentation no later than October 24, 2014. Please remember to keep a copy of all documentation for your records.

Eligibility

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Legal Spouse

A copy of your certificate of marriage and your spouse’s Social Security number must be submitted at the time your spouse is enrolled.

Domestic Partner

You must provide a copy of the Declaration of Domestic Partnershipregistered with the Secretary of State and your partner’s Social Security number.

Children

For a natural child or stepchild, provide a copy of the child’s birth certificate. For an adopted child or a child for whom you have legal custody or

guardianship, you must provide a copy of the child’s birth certificate anda copy of the judgment or decree. You must also provide the child’s Social Security number.

Disabled Children (Age 26 or Over)

You must submit a copy of your most recent federal income tax return indicating that the child is a qualified tax dependent, provide the child’s Social Security number, and complete a Member Questionnairefor the Disabled Dependent Formand a Medical Report Form.These forms must be received within 60 days of your initial enrollment or the child’s 26th birthday. The forms must be approved by the insurance carrier upon enrollment and updated upon request.

Eligibility 10

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Riverside County offers a number of medical, dental, and vision plan options. While the dental and vision plans are available to all bargaining and employee units, your specific medical plan options depend on your bargaining or employee unit at retirement, your age, Medicare eligibility, and where you live (see the charts on the following pages). Before making your health care elections, think about how you use your health care plans, the required premiums for each

plan, and what’s important to you and your family. You can use the County’s medical and dental

comparison charts in this guide to help you evaluate each plan’s features.

M E D I C A L P L A N E L I G I B I L I T Y

Riverside County is pleased to offer you a choice of medical plan options.

MEDICAL PLAN ELIGIBILITY

Eligible for County Medical Plans Eligible for CalPERS or Exclusive Care Medical Plans

Elected Officials DDAA Represented Employees

SEIU Represented Employees LEMU Represented Employees LIUNA Represented Employees RSA Public Safety Employees

Management Employees Contact CalPERS directly for information about their plans. Confidential Employees

Unrepresented Employees

Your

Health Care

Options

For CalPERS medical plan features, refer to the CalPERS Benefit Summary and Program Guide. You can obtain these materials by contacting CalPERS directly. (See “Contact Information” on the back cover.) These elections are not reflected on your County benefit forms.

Health Care

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If you and/or your dependents ARE ELIGIBLE for Medicare, you can enroll in these plans: If you live in the plan’s service area… If you live outside the plan’s service area…

• Exclusive Care Select Medicare Coordination Plan • Exclusive Care Select Medicare Coordination Plan • Exclusive Care Select Medicare Supplement Plan • Exclusive Care Select Medicare Supplement Plan

• Kaiser Senior Advantage HMO – High Option and • UnitedHealthcare Medicare Indemnity Coordination Plan—

Low Option available only outside California

• UnitedHealthcare EPO Coordination of Benefits Plan • UnitedHealthcare PPO Coordination of Benefits Plan • UnitedHealthcare Medicare Advantage HMO Plan • SCAN HMO

Choose one of these plans if you—or one or more of your dependents—are eligible for Medicare. Family members who are not Medicare-eligible will be enrolled in the non-Medicare version of the plan. For example, if you are Medicare-eligible and choose a Kaiser Senior Advantage plan, your dependents who are not eligible for Medicare will be enrolled in the

Kaiser Permanente HMO plan. (Keep in mind that you and your dependents may be enrolled in plans with different copayments for this reason.) The one exception is the SCAN plan, which is open to Medicare-eligible members only and has no non-Medicare counterpart. If you are eligible for Medicare but your dependents are not, you cannot enroll in the SCAN plan.

Rates for common plan combinations are shown on page 40.

If you are under age 65 and ARE NOT ELIGIBLE for Medicare, you can enroll in these plans: If you live in the plan’s service area… If you live outside the plan’s service area… • Exclusive Care EPO • UnitedHealthcare PPO

• UnitedHealthcare PPO

• UnitedHealthcare Signature Value HMO • Kaiser Permanente HMO

Family members who are Medicare-eligible will be enrolled in the Medicare version of the plan you elect. For example, if you are not Medicare-eligible and choose the Exclusive Care EPO plan, your spouse who is eligible for Medicare will be enrolled in the Exclusive Care Select Medicare Supplement Plan. If your dependent is over age 65 but not enrolled in Medicare Parts A and B, your premium will be higher. Please contact the Benefits Information Line for options and costs.

H O W Y O U R M E D I C A R E E L I G I B I L I T Y A F F E C T S Y O U R C H O I C E O F P L A N S

The County medical plans available to you depend on your age, your eligibility for Medicare, and where you live. If you are enrolling dependents, you must also consider their ages, eligibility, and residence to make sure that you enroll in a plan that is appropriate for you and your eligible dependents.

F O R R E T I R E E S W H O A R E N O T E L I G I B L E F O R M E D I C A R E Health Care

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If you or your dependents are age 65 or older and are NOT eligible for Medicare, the UnitedHealthcare Signature Value HMO, Kaiser HMO, Exclusive Care EPO and UnitedHealthcare PPO remain available to you, generally at the same cost as an early retiree. Please contact the Benefits Information Line for assistance with your eligibility, enrollment, and premiums.

Following are brief descriptions of the types of plans offered to pre-Medicare-eligible retirees in 2015. Key features and benefits of these plans are shown in the comparison charts on pages 18–20 (early retirees) and pages 25–30 (Medicare-eligible retirees).

I M P O RTA N T N O T E A B O U T L I V I N G I N Y O U R P L A N ’ S S E R V I C E A R E A

Some of the medical plan options offer coverage only to members who live in their service area. The guidelines for determining whether you live in a plan’s service area are shown below. Remember to contact the County of Riverside Benefits Division team if you move out of your plan’s service area.

• UnitedHealthcare Signature Value HMO, UnitedHealthcare EPO Coordination of Benefits Plan, or UnitedHealthcare Medicare Adantage Plan:You must live or work within the plan’s service area. You will be covered only for urgent care and emergency services when temporarily outside the service area. If you move outside the plan’s service area, your coverage will be terminated, and you’ll have to elect another plan.

• Exclusive Care EPO Plan:You must have a permanent address within 30 miles of the border of Riverside County and reside at that address 12 months out of the year.

Out-of-area/out-of-network care is covered only in the case of an emergency during travel. If you live somewhere else part of the year, you should enroll in the UniteHealthCare PPO Plan for greater flexibility in choosing cost-effective care.

• Kaiser Senior Advantage HMO (High Option and Low Option):You must have a permanent home address in the plan’s service area; a post office box or rental mailbox cannot be used to determine whether you meet the residence eligibility. If you permanently move outside the Kaiser service area, or you are temporarily absent from the service area for a period of more than six months in a row, you must notify Kaiser. You will not be able to continue your Senior Advantage membership under this plan.

• SCAN HMO:You must live within the plan’s service area for more than six months of the year to be eligible. Your membership will end if you move out of the service area or stay out of the service area for more than six consecutive months. Coverage for services provided outside the network is limited to emergency care only.

Health Care

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Health Maintenance Organization (HMO) Plans

The County offers two HMO plans for early retirees under age 65 who do not have Medicare:

• UnitedHealthcare Signature Value HMO

• Kaiser Permanente HMO

UnitedHealthcare Signature Value HMO.If you enroll in the UnitedHealthcareHMO plan, you (and each enrolled member of your family) will choose a

primary care physician (PCP)who is part of the HMO provider network. Your PCP will coordinate all of your health care. If you need specialty care, your PCPwill refer you to a network specialist or hospital within the same participating group. You have no annual deductibles or claim forms to

complete, and you pay only an affordable copayment each time you go to the doctor.

If you need a provider directory, visit

UnitedHealthcare online at www.uhcwest.com, contact the UnitedHealthcare Member Services Department toll-free at (800) 624-8822, or call the Benefits Information Line at (951) 955-4981.

Kaiser Permanente HMO. This plan is available to you if you are under age 65 and not eligible for Medicare. If you enroll in the Kaiser Permanente HMO, you must go to Kaiser Permanente doctors, hospitals, and other Kaiser health care facilities whenever you need medical care. You pay no annual deductible under this plan and will generally receive 100% coverage after a copayment for office visits. In a life-threatening emergency, you are covered wherever you seek services. If you need a listing of Kaiser Permanente facilities, visit www.kp.org, contact the plan’s Member Services, at

(800) 464-4000or contact the Benefits Information Line at (951) 955-4981. Please note that the Kaiser Permanente plan is available only to retirees who live within the plan’s Southern California service area. 14

Medical Plans for Retirees Who Are

Not Eligible for Medicare

Health Care

I M P O R TA N T I N F O R M AT I O N

A B O U T U H C P R O V I D E R S

If you enroll in the UnitedHealthcare Signature Value HMO plan, you’ll be asked to designate a primary care physician (PCP). To locate a PCP in your area, visit www.uhcwest.com.

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Health Care

Exclusive Provider Organization (EPO) Plan Exclusive Care is the County of Riverside’s self-administered EPO plan. Both County and CalPERS eligible retirees can enroll in the Exclusive Care EPO.

The Exclusive Care EPO is available to all early retirees and eligible dependents who live or work in the plan’s local service area. Exclusive Care’s local service area includes all of Riverside County, as well as areas immediately adjacent to Riverside County whose zip codes are within 30 miles of the Riverside County border. Eligible dependents who live outside of the Exclusive Care service area will receive benefits under Exclusive Care’s out-of-area indemnity plan feature.

Exclusive Care provides coverage through contracted health care providers. Unlike other managed health care plans, Exclusive Care’s primary care providers are not paid a fixed amount per month. All providers are paid for each treatment, no matter how

frequently the patient is seen.

Exclusive Care was created by the County of Riverside as a high-value health plan option whose members pay substantially less than other health plans in premiums and copayments. The savings in premiums alone often enables the retiree to purchase two-party or family coverage versus individual coverage.

How the EPO Plan Works.If you enroll in this plan, you (and each enrolled family member) will choose a primary care physician(PCP) from the Exclusive Care network. Your chosen PCP will coordinate all of your non-emergency health care needs. This PCP can be a family practitioner,

internist, pediatrician, or general practitioner. If you need specialty care, your PCP will refer you to a network specialist or hospital. Through your PCP, you will have access to full-service medical care within the network and in some circumstances outside the network. Initial visits to OB/GYNs and chiropractors can be made without a referral from your PCP.

You pay no annual deductible under this plan and will generally receive 100% coverage with a small copayment for office visits, prescription drugs, and other services. There is a maximum out-of-pocket limit of $3,000 per member each calendar year. In a life-threatening emergency, you are covered wherever you seek services, even if outside the network. If an enrolled dependent lives outside of the plan’s service area, please contact Exclusive Care for more

information about their out-of-area benefits. For additional information or a provider directory, visit Exclusive Care at www.exclusivecare.com

or contact Exclusive Care Member Services at

(800) 962-1133. You can also learn more about Exclusive Care by contacting the Benefits Information Line at (951) 955-4981.

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UnitedHealthcare Select Plus PPO Medical Plan

A Preferred Provider Organization (PPO) gives you the freedom to receive medical services from any licensed provider you choose, with lower

copayments when you use UnitedHealthcare Select Plus PPO network providers. The County offers a PPO plan through UnitedHealthcare.

How the PPO Plan Works.A PPO is a network of doctors and health care facilities that provide

services to plan members at special discounted rates. The PPO plan gives you the freedom to go to any provider you choose—but it pays higher benefits when you go to a doctor or health care facility in the UnitedHealthcare PPO Select Plus network.

You must pay a portion of most covered medical expenses each year before the plan will pay benefits. This amount is called your “deductible.” After the deductible is paid, you will pay a percentage of your covered medical expenses; this percentage is called your “coinsurance.” If your share of the medical expenses reaches an amount called the “out-of-pocket maximum,” you will not have to pay any more coinsurance for the rest of the calendar year (as long as you continue to use network providers).

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In the PPO Network. When you go to a PPO provider, your coinsurance will be lower—and you can take advantage of the PPO provider’s discounted rates. Also, there are no claim forms to complete when you go to an in-network provider.

Outside the PPO Network. If you go to a doctor or health care facility that does not belong to the UnitedHealthcare PPO network, your out-of-pocket costs will be higher. Also, the plan will pay benefits only up to the “allowed amount,” which is based on a limited fee schedule. You will have to pay any charges above the allowed amount (in addition to your regular coinsurance). If you need a provider directory, visit UnitedHealthcare online at

www.myuhc.com,or contact

UnitedHealthcare Member Services at

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Please refer to the individual medical plan booklets for a summary of plan benefits. If there are any discrepancies between these booklets and the official plan documents, the official plan documents will prevail. Medical plan booklets are available on the benefits website at http://benefits.rc-hr.com or by contacting the Benefits Information Line at (951) 955-4981. For information about CalPERS medical plans, refer to your CalPERS enrollment materials.

PLEASE USE THE FOLLOWING FOOTNOTE REFERENCES WITH COUNTY MEDICAL PLANS COMPARISON

CHARTS ON PAGES 18 THROUGH 20.

1. You will pay any amount charged by an out-of-network provider that is in excess of the plan’s fee schedules. 2. Benefits are not subject to a deductible.

3. Deductibles and copayments do not count toward the out-of-pocket maximum.

4. Women's preventive care services include: screening for gestational diabetes; human papillomavirus (HPV) DNA testing for women 30 years and older; sexually transmitted infection counseling; human immunodeficiency virus (HIV screening and counseling; family planning; FDA-approved contraception methods and contraceptive counseling; breastfeeding support, supplies, and counseling; domestic violence screening and counseling; and preventive

sterilizations. The applicable cost sharing for preventive care will apply to these services.

5. Infertility services, supplies, injections, and medications are limited to a lifetime maximum benefit of $2,000 (combined PPO network and out-of-network).

6. Infertility benefit is limited to physician services and diagnostic testing only.

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PAT I E N T P R O T E C T I O N N O T I C E The UnitedHealthcare Signature Value HMO, Kaiser Permanente HMO, and Exclusive Care EPO plans generally require the designation of a primary care provider. You have the right to designate any primary care provider who participates in the plan’s network and who is available to accept you or your family

members. For children, you can designate a pediatrician as the primary care provider. You do not need prior authorization from UnitedHealthcare, Kaiser, or Exclusive Care, or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the plan’s network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a preapproved treatment plan, or following procedures for making referrals.

For information about how to select a primary care provider, and for a list of the participating primary care providers— including a list of participating health care professionals who specialize in obstetrics and gynecology—contact your health plan.

Contact information for each plan is listed on the back cover of this guide.

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FOR RETIREES AND DEPENDENTS UNDER AGE 65 AND/OR WHO ARE NOT MEDICARE-ELIGIBLE

These benefit summaries only highlight your benefits. They are not Summary Plan Descriptions (SPDs). If any discrepancy exists between these benefit summaries and the official plan documents, the official plan documents will prevail.

UHC Select Plus PPO

PPO Network Out-of-Network1

Choice of physician Any network provider Any licensed provider

Deductible $500/person; $1,000/family

Calendar year out-of-pocket maximum3 _{$3,000/person; $6,000/family}

Lifetime maximum benefit Unlimited

Pre-existing condition limitation 6-month waiting period applies for adults

Office Visit Benefits

Physician office visits 100% after $20 copay2 _{40% after deductible has been met} Diagnostic X-ray and lab 100%; deductible does not apply 40% after deductible has been met

Adult preventive care (includes mammography, 100%2 _{100%; copayments and deductibles do not apply} Pap smear, sigmoidoscopy, and prostate exam)

Well-baby care 100% after $20 copay2 _{100% after deductible}

Well-woman care 100% after $20 copay2 _{100% after deductible}

Vision exams (preventive) 100% 100% after deductible

Vision exams (refractive)

- Children 100% after $20 copay Not covered

- Adults 100% after $20 copay 40% after deductible

Prescription Drugs

Network retail pharmacies Generic: $5 copay2 _{Generic: $5 copay}

(up to a 30-day supply) Preferred brand: $15 copay2 _{Preferred brand: $15 copay} Nonpreferred brand: $45 copay2 _{Nonpreferred brand: $45 copay}

Plus 50% of average wholesale price

Network mail order Generic: $10 copay2 _{Not covered}

(up to a 90-day supply) Preferred brand: $30 copay2 Nonpreferred brand: $90 copay2

Hospital and Emergency Room Services

Inpatient hospital services 20% after deductible 40% after deductible; benefits limited to $600 per day

Physician hospital visits 20% after deductible 40% after deductible

Ambulatory surgical center 20% after deductible 40% after deductible

Ambulance (medically necessary) 20% after deductible 20% after deductible

Hospital emergency room 20% after deductible; a separate $50 40% after deductible; a separate $50 copayment deductible applies if not admitted applies if not admitted

Urgent care facility 20% after deductible; a separate $20 40% after deductible deductible applies if not admitted

Mental Health Treatment

Inpatient services 20% after deductible 40% after deductible

Outpatient services 100% after $20 copay2 _{40% after deductible}

Substance Abuse Treatmen

Inpatient program 20% after deductible 40% after deductible

Outpatient office visits 100% after $20 copay2 _{40% after deductible}

Other Benefits

Chiropractic 20% after deductible 40% after deductible (15 visit maximum)

Durable medical equipment 20% after deductible 40% after deductible

Benefits limited to $2,000 per calendar year

Home health care 20% after deductible 40% after deductible

Benefits limited to 100 visit/calendar year (combined PPO network and out-of-network)

Hospice services 20% after deductible 40% after deductible (15 visit maximum)

Rehabilitation therapy (includes outpatient physical, 100% after you pay $20 copayment per visit 40% after deductible speech, occupational, respiratory, and cardiac therapy)

Skilled nursing facility 20% after deductible 40% after deductible; benefits limited to 60 days/calendar year

Family Planning Services(professional services only)

Contraceptive methods (includes intrauterine device 100%2, 4 _{100% after deductible} (IUD) and injectable or implantable contraceptives)

Infertility services (includes professional services, 20% after deductible5 _{40% after deductible}5 inpatient and outpatient care, treatment by injection,

and prescription drugs; excludes coverage of artificial insemination)

Sterilization of females 100%2 _{100% after deductible}

Sterilization of males 20% after deductible 40% after deductible

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Exclusive Care EPO Kaiser HMO UHC Signature Value HMO

Network Only Network Only Network Only

Choice of physician Any Exclusive Care Any Kaiser physician and/or facility All care must be coordinated

network physician by your PCP

Calendar year deductible None None None

Calendar year out-of-pocket maximum $1,500/person $1,500/person $1,500/person

$3,000/family $3,000/family $3,000/family

Lifetime maximum benefit Unlimited Unlimited Unlimited

Pre-existing condition limitation Fully covered Fully covered Fully covered

OFFICE VISIT BENEFITS W H A T T H E P L A N P A Y S

Diagnostic X-ray and lab 100% 100% 100%

Immunizations 100% 100% 100% (you pay 20% coinsurance for

foreign travel immunizations)

Maternity care 100% after $5 copay 100% after $15 copay 100%

Periodic health evaluations/physicals 100% 100% 100%

Physician office visits 100% after $5 copay 100% after $15 copay 100% after $15 copay Vision exams 100% for screening and refraction 100% after $15 copay 100% for screening;

$15 copayment for refraction

Well-baby care 100% 100% 100%

Well-woman care 100% 100% 100%

PRESCRIPTION DRUGS W H A T T H E P L A N P A Y S

Network retail pharmacies Generic: 100% after $5 copay Generic: 100% after $10 copay Generic: 100% after $10 copay (30- to 34-day supply) Brand formulary: 100% after $15 copay (100-day supply) Brand* formulary: 100% after $25 copay

Brand nonformulary: 100% Brand formulary: 100% after $25 copay Brand* nonformulary: 100%

after $35 copay (100-day supply) after $50 copay

Network mail order Generic: 100% after $10 copay Generic: 100% after $10 copay Generic: 100% after $20 copay (90-day supply) Brand formulary: 100% after $30 copay (100-day supply) Brand formulary: 100% after $50 copay

Brand nonformulary: 100% after Brand formulary: 100% after $25 copay Brand nonformulary: 100% after

$70 copay (100-day supply) $100 copay

Mail order is MANDATORY for maintenance medications after a 30-day trial

HOSPITAL AND EMERGENCY ROOM SERVICE W H A T T H E P L A N P A Y S

Ambulance (medically necessary) 100% 100% 100%

Ambulatory surgical center 100% 100% after $15 copay 100%

Physician hospital visits 100% after $5 copay 100% after $100 copay per admission 100%

Inpatient hospital 100% at network facility only; $250 100% after $100 copay per admission 100% after $100 copay per

per day for emergency services admission

only at non-network facility

Outpatient hospital 100% 100%; $15 copay/procedure for 100%

outpatient surgery

Hospital emergency room 100% after $100 copay at 100% after $50 copay 100% after $100 copay; network facility; 100% after (waived if admitted) waived if admitted $250 copay at non-network

facility (waived if admitted)

Urgent care 100% after $20 copay at 100% after $15 copay $35 copay

network facility; 100% after $50 copay at non-network facility

* If you have a prescription filled with a brand-name drug when a generic equivalent is available, you will pay the copayment PLUS the cost difference between that drug and the generic (unless your physician indicates that the brand-name drug must be dispensed as written). Some medications require prior authorization from Health Net.

Refer to footnotes on page 17.

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Exclusive Care EPO Kaiser HMO UHC Signature Value HMO

Network Only Network Only Network Only

MENTAL HEALTH TREATMENT W H A T T H E P L A N P A Y S

Inpatient benefit 100%; unlimited admissions 100%; unlimited admissions $100 copay per admission (unlimited admissions) Outpatient benefit $5 copay/visit (unlimited visits) $15 copay/private visit; $15 copay/visit (unlimited visits)

$7 copay/group visit (unlimited visits)

SUBSTANCE ABUSE TREATMENT W H A T T H E P L A N P A Y S

Inpatient detoxification 100%; unlimited admissions $100 copay per day, as medically $100 copay per admission necessary (detox only) (unlimited admissions) Outpatient detoxification $5 copay/visit (unlimited visits) $15 copay/private visit; $15 copay/visit (unlimited visits)

$7 copay/group visit (unlimited visits)

OTHER BENEFITS W H A T T H E P L A N P A Y S

Allergy testing and treatment 100% after $5 copay 100% after $15 copay/visit for testing; 100% after $15 copay 100% after $3 copay/visit for injections

Chiropractic 100% after $15 copay; 100% after $15 copay/visit; 100% after $15 copayment for up to 12 visits/calendar year up to 20 visits/calendar year chiropractic and acupuncture;

up to 20 visits combined annual maximum

Durable medical equipment 50% 100% 100%

Family planning

- Elective pregnancy termination 100% after $50 copay for 1st trimester; 100% after $15 copay 100% after $125 copayment for 1st $100 for 2nd trimester; 3rd trimester trimester; $200 for 2nd trimester; 3rd not covered unless life-threatening trimester (after 20 wks) not covered

unless life threatening

- Infertility services 50% of costs up to a lifetime maximum benefit 50% of costs6 _{50% of cost copayment (see plan}

of $10,000 rider for additional information)

- Tubal ligation 100% 100% after $15 copay 100%

- Vasectomy 100% 100% after $15 copay $50 copayment

Home health care 100% 100% 100% after $15 copay, up to 100

visits per calendar year

Hospice (routine home and 100% 100% 100%

inpatient respite care)

Hospice (24-hour continuous 100% 100% 100% (prognosis of life expectancy

home care and general inpatient care) of one year or less); after a $100

copayment per admit Physical therapy $5 copay/visit; up to 30 visits/disability 100% after $15 copay 100%

(within 90-day period)

Skilled nursing facility 100%, up to 100 days/disability 100% up to 100 days/calendar year 100% after $100 copay, up to 100 days/benefit period Refer to footnotes on page 17.

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Health Maintenance Organization (HMO) Plans

The County offers four HMO plans for retirees and their eligible family members who have Medicare:

• UnitedHealthcare Medicare Advantage Plan

• Kaiser Senior Advantage High Option and Low Option

• SCAN HMO

These plans are Medicare Advantage plans under Medicare Part C.

If you enroll in one of these plans, you must be enrolled in—and maintain enrollment in—Medicare Parts A and B. You will then “assign” your Medicare benefits to the plan and receive all of your medical care within the plan’s HMO network. You will receive benefits at least as good as, and often better than, what you would have received with Medicare alone. Because of your Medicare assignment, Medicare will pay a portion of your medical plan premium in lieu of paying your medical benefit. Therefore, your monthly premium will be lower with one of these plans. The premium you pay will be the amount required over and above what Medicare will pay on your behalf. Also, since your Medicare benefits will be assigned to the HMO plan, you will not be allowed to go outside of the HMO network for care (except in the case of an emergency).

SCAN Independent Living Power.SCAN offers unique in-home services, known as Independent Living Power, to help keep people on Medicare healthy and independent. These services can help you during recovery from a hospital stay or provide support during an acute episode of long-term illness.

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Medical Plans for

Medicare-Eligible Retirees

If you do not enroll in Medicare when you first become eligible, you may not be eligible for some plans—or your costs may be higher. Here are a few important things to keep in mind as you consider your enrollment decisions:

• In order to avoid penalties, you should elect Medicare when you first become eligible. Check with Medicare to learn more about these penalties and how to avoid them. There are some reasons you may delay Medicare enrollment without a penalty. One example is if you are covered by your spouse’s employer-based coverage.

• You should NOT enroll in a separate Medicare Part D plan.You will get your prescription drug coverage through your County of Riverside medical plan, so you do not need other Medicare Part D coverage. If you enroll in another

Medicare Part D plan, you and your dependents will not be eligible to receive all of your health and prescription drug benefits and will be disenrolled from the plan.

• If you enroll in the Kaiser Senior Advantage High Option or Low Option, the UnitedHealthcare Medicare Advantage Plan, or the SCAN medical plan, you will automatically be enrolled in Medicare Part D and assign your benefits to the plan. This enrollment will be done for you when you join one of these plans, and you will NOT be required to pay any additional monthly premium. Do not sign up for a Medicare Part D plan on your own.

Please note that if you decide to switch from the Kaiser, UnitedHealthcare Medicare Advantage Plan, or SCAN plan to one of the other plans, it will take up to 30 days for Medicare to disenroll you from Medicare Part D coverage or change your assignment of Medicare benefits.

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Many seniors find that these services provide the extra assistance necessary to stay out of a nursing home. Members who qualify for Independent Living Power are eligible for up to $500 per month in additional benefits, such as free home-delivered meals and a range of home health care and homemaking services for only a $15 copayment. Independent Living Power is available only to members who live in approved zip codes within Los Angeles, Orange, Riverside, and San Bernardino counties. For more information, please contact SCAN at (877) 212-7654or the Benefits Information Line at (951) 955-4981.

Plans for Family Members Who Are Not Eligible for Medicare.One of the advantages of the

County’s group plans is that Exclusive Care Select Medicare Supplement, Exclusive Care Medicare Coordination, UnitedHealthcare Medicare Advantage, UnitedHealthcare EPO Coordination Plan, UnitedHealthcare PPO Coordination Plan,

UnitedHealthcare Indemnity Coordination Plan, and the Kaiser Senior Advantage High Option and Low Option plans will allow you to enroll you and your dependents in the appropriate type of coverage if someone in your family is under 65 and not eligible for Medicare. For example, if you are Medicare-eligible but your spouse is not, you would be

enrolled in the Kaiser Senior Advantage High Option or Low Option plan and your spouse would be enrolled in the Kaiser HMO plan offered to non-Medicare-eligible retirees. You will pay one premium rate for your entire family, but each family member will have access to a health plan based on his or her age and eligibility for Medicare.

Please note the SCAN plan does not offer coverage to dependents who are not eligible for Medicare. If your dependent is not eligible for Medicare, you must select another plan for both yourself and your dependents.

W A R N I N G ! D O N O T R I S K L O S I N G

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

J O I N I N G A P R I VAT E M E D I C A R E

A D VA N TA G E P L A N !

You may receive offers or advertisements for “free” private Medicare Advantage plans. If you enroll in one of these plans, your Medicare benefits or other Medicare plan will be assigned to the new plan, and you will lose your County medical coverage.Please do not enroll in one of these plans without studying the benefits closely. These plans

typically have higher out-of-pocket costs when you receive care and may have no coverage or minimal coverage for prescription drugs. If you have any questions about how your County medical benefits compare with plans on the private market, please call the Benefits Information Line at (951) 955-4981.

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Medicare Coordination Plans

The County offers several medical plans that coordinate your benefits with your Medicare coverage. Medicare-eligible retirees and family members can choose from the following coordination of benefits (COB) plans:

• Exclusive Care Select Medicare Coordination Plan

• UnitedHealthcare EPO COB Plan

• UnitedHealthcare PPO COB Plan

• UnitedHealthcare Indemnity Medicare COB Plan—members outside California only

Exclusive Care Select Medicare Coordination Plan.Under this plan, you can seek care from any provider who accepts Medicare assignment. Medicare will pay benefits first, with the Exclusive Care Select Medicare Coordination Plan providing secondary coverage up to the plan limits. The plan will pay Tier 1 benefits for Exclusive Care providers and Tier 2 benefits for other providers who accept Medicare assignment (subject to the plan’s benefit limits and reasonable and customary amounts). You must be enrolled in—and maintain enrollment in— Medicare Part A and/or Part B to sign up for the Exclusive Care Select Medicare Coordination Plan.

Exclusive Care Centers of Excellence

Members must obtain prior authorization from Exclusive Care for services in cardiac care, complex and rare cancer treatments, transplant services, joint replacement surgery, mental health care, and other highly specialized complex care programs. Exclusive

Care’s Medical Director has designated and approved access to medical facilities across the nation that have demonstrated expertise in delivering quality health care for these treatments. The Center of Excellence designation is based on rigorous, evidence-based, objective selection criteria established in

collaboration with expert physicians’ and medical organizations’ recommendations. Exclusive Care members with these special treatment needs will be evaluated through prior authorization and other medical management programs to improve the overall quality and delivery of health care and to support better overall health outcomes for members. The Exclusive Care Select Plan will pay benefits at the Tier 1 level for all allowable charges approved under this program. If you do not get prior authorization and go to the designated Center of Excellence, benefits will be paid at the out-of-network level.

UnitedHealthcare EPO Coordination of Benefits (COB) Plans.UnitedHealthcare’s Medicare COB plans work just like traditional EPO or PPO plans, but they coordinate the cost of care with Medicare as the primary payer. You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare COB plan. You must show your Medicare card in addition to your UnitedHealthcare identification card when obtaining services. If you choose the EPO COB plan, you also must live within the

UnitedHealthcare EPO service area.

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• PPO COB Plan. Medicare PPO coverage is designed to give you a greater level of choice. Every time you seek care, you have the option of using in-network or out-of-network care. When you use this plan, your Medicare deductibles and coinsurance are 100% covered. For in-network care, simply make an appointment with any contracted PPO doctor. There’s no referral or authorization required. UnitedHealthcare’s PPO network has more than 72,000 physicians. For out-of-network care, make an appointment with any licensed physician you wish to see. You will generally have higher copayments and coinsurance if you seek care or treatment from an out-of-network PPO provider. Certain services may require claim forms to be submitted to UnitedHealthcare for reimbursement.

Under the Medicare COB plans, Medicare is the primary plan and UnitedHealthcare is the secondary plan. Claims are first submitted by your provider to the Medicare intermediary for determination and payment of allowable amounts. The Medicare intermediary then sends a Medicare Summary Notice to the provider of service, who will then submit the claim to UnitedHealthcare. The Medicare Summary Notice is a summary of benefits paid on your behalf by Medicare. You will also receive a copy of the Medicare Summary Notice.

Please note:Some secondary claims are sent electronically to UnitedHealthcare by Medicare and do not require that the provider of service submit the claim. UnitedHealthcare and/or your medical provider is responsible for paying the difference between the amount Medicare paid and the amount of the covered service.

Medicare Supplement Plan

The Exclusive Care Select Medicare Supplement Plan works with your Medicare benefits to pay 100% of all Medicare-approved amounts when you receive services from a provider who accepts Medicare assignment. The plan pays your Medicare Part A deductible; it also includes prescription drug coverage. You must pay the Medicare Part B deductible each year before the plan pays its share. Under the Medicare Supplement Plan, you can go to any licensed provider you choose—but your out-of-pocket expenses will be lower if you go to a provider who accepts Medicare. When you receive covered medical services, Medicare is billed first for the total cost of the services. After Medicare pays, this plan will pay the applicable amount of allowable charges, subject to any limitations, copayments, or deductibles. If you go to a provider who does not accept Medicare, you will be responsible for the difference between the Medicare-approved amount and the billed charges.

Retiree Benefits Enrollment Guide

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