DECISION GUIDE. State and Higher Education Active Employees and COBRA Participants

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2014

GUIDE

DECISION

Open Enrollment / Annual Enrollment

Transfer Period

October 1 – November 1, 2013

State and Higher Education

Active Employees and COBRA Participants

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BENEFITS CONTACT PHONE WEBSITE

Plan Administrator Benefi ts Administration 800.253.9981 tn.gov/fi nance/ins partnersforhealthtn.gov

Email: benefi ts.administration@tn.gov

Health Insurance BlueCross BlueShield of Tennessee Cigna

800.558.6213 800.997.1617

bcbst.com/members/tn_state cigna.com/stateoftn

Pharmacy Benefi ts Caremark 877.522.8679 caremark.com

Mental Health, Substance Abuse and Employee Assistance Program

Magellan 855.HERE4TN

(855.437.3486)

here4TN.com

Wellness and Nurse Advice Line Healthways 888.741.3390 partnersforhealthtn.gov (wellness tab)

Dental Insurance Assurant Employee Benefi ts Delta Dental

800.443.2995 800.223.3104

assurantemployeebenefi ts.com/stoftn deltadentaltn.com/statetn

Vision Insurance EyeMed Vision Care 855.779.5046 eyemedvisioncare.com/stoftn

Basic Term Life and Accidental Death Optional Accidental Death Insurance

see the ParTNers for Health website (other benefi ts, life insurance)

partnersforhealthtn.gov

Optional Term Life Insurance Minnesota Life 866.881.0631 lifebenefi ts.com/stateoftn

Long-Term Care Insurance MedAmerica 866.615.5824 ltc-tn.com

OTHER PROGRAMS

Edison TN Department of Finance & Administration password reset for higher education 800.253.9981, option 3; state call Edison help desk at 866.376.0104

https://www.edison.tn.gov

Flexible Benefi ts

(state employees only)

TN Department of Treasury 615.741.3131 treasury.tn.gov/fl ex

Employee Sick Leave Bank

(state employees only)

TN Department of Human Resources 615.741.5431 tn.gov/dohr

If you need help…

Contact your agency benefi ts coordinator. Your agency benefi ts coordinator has received special training in our insurance programs. For additional information about a specifi c benefi t or program, refer to the chart below.

Online resources…

ParTNers for Health — partnersforhealthtn.gov

Find information about the beneﬁ ts described in this guide, deﬁ nitions of insurance terms and answers to common questions from members.

Beneﬁ ts Administration — tn.gov/ﬁ nance/ins

Find handbooks and forms referenced in this guide (also available from your agency beneﬁ ts coordinator).

Follow us on social media…

Facebook: ParTNers For Health Twitter: @ParTNerHealthTN

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ENROLLMENT PERIOD

October 1 — November 1, 2013

This year is diﬀ erent. From now on, the Annual Enrollment Transfer Period (AETP) will be an Open Enrollment for most programs. All eligible employees and dependents can enroll in health insurance each fall. There will no longer be a monthly late applicant fee.

During this time, you can:

Change health options — switch between the Partnership and Standard PPOs, subject to eligibility* Change health insurance carriers — select BlueCross BlueShield of Tennessee or Cigna

Enroll in or cancel health insurance for yourself or your eligible dependents

Enroll in, cancel or transfer between dental options Enroll in, cancel or transfer between vision options Enroll in or cancel optional accidental death coverage

Apply for optional term life coverage, or increase or decrease optional life coverage amounts (if eligible)

*If you enrolled in the Partnership PPO for 2013 and you or your spouse did not fulﬁ ll the Partnership Promise, you are not eligible to continue in this option during 2014.

> > > > > > >

Members currently enrolled in the Standard PPO may switch to the lower cost Partnership PPO for 2014. However, you must use employee self service (ESS) in Edison to make this change.

What’s Changing for 2014

To provide additional ﬁ nancial protection for members, copays for emergency room, chiropractic and urgent care in-network visits will now count towards the out-of-pocket copay maximum (see page 6)

A pharmacy out-of-pocket copay maximum of $3,750 per individual will apply in-network (see page 6)

Premiums will increase by 5.5% in the Partnership and Standard PPOs (see pages 8 and 9)

Every Partnership PPO member must complete the online Well-Being Assessment and get a biometric screening at their doctor’s oﬃ ce or at a worksite location (see page 4)

The lower cost Cigna LocalPlus network will be available to members in middle Tennessee (see page 3) > > > > >

If you DO NOT want to make changes

No action is required if you are happy with your current beneﬁ t selections.

If you choose to stay in the Partnership PPO, you (and your covered spouse) are automatically agreeing to fulﬁ ll the 2014 Partnership Promise (see page 4).

If you DO want to make changes

You must do so online using employee self service (ESS) in Edison. Paper forms are not accepted for health, dental or vision changes (see page 2).

The options you choose during the enrollment period are eﬀ ective January 1–December 31, 2014, unless you lose eligibility or have a qualifying event or family status change during the year.

>

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You Must Do So Using ESS in Edison

Log into Edison at https://www.edison.tn.gov

Click “Beneﬁ ts Enrollment” under “My Beneﬁ ts” on the left of the page.

On the “Beneﬁ ts Enrollment” page, under “Open Beneﬁ t Events” click “Select.”

Click “Edit” next to the plan (medical, dental, vision or optional AD&D) that you want to add or change. State employees will also see ﬂ ex beneﬁ ts.

Under “Select an Option,” click your plan choice. Under “Enroll Your

Dependents,” check the boxes next to the dependent’s name to cover him/her.

Click “Continue” to conﬁ rm your option. If you select the Partnership PPO, read the Partnership Promise and click “OK.”

You will see a summary of the options you selected. To make changes, click “Discard Changes.” If no changes, click “Update Elections.”

Once you have made all of your changes, click “Submit” on the “Beneﬁ ts Enrollment” page.

If adding dependents, upload any documents that you need to submit, then click the “Finished Uploading, Continue to Next Step” link.

You must choose if you want your conﬁ rmation by mail or email. Make any changes needed. Click “Submit.”

> > > 1. 2. 3. 4. 5. > > >

To Add Dependents

You may add dependents in the medical, dental and vision sections. Look for the “Enroll Your Dependents” section. Click “Add/Review Dependents” to add a dependent.

Add the dependent’s personal information and click “Save,” then “OK” on the next screen.

To add additional dependents, click “Add a Dependent“ on the Enrollment Dependent/

Beneﬁ ciary Summary page. When done, click “Return to Event Selection.”

Click the “Enroll” boxes under “Enroll Your Dependents.” Then click “Update Elections.”

To add a dependent to dental or vision, click on the “Enroll” boxes under “Enroll Your Dependents.” You will see an “Action Needed” page. Click “Update Elections” to add dependent veriﬁ cation.

You can upload your dependent documentation into ESS. Scan your document and click “Upload Documents.” Click “Browse,” ﬁ nd the ﬁ le and upload. You can upload as many documents as needed. When complete, click “Finished Uploading, Continue to the Next Step.”

If faxing hard copies, send to 615.741.8196 and include your name and employee ID (found on the front of your Caremark card) on each page. Click “Finished Uploading, Continue to Next Step.” 1. 2. 3. 4. 5. 6. 7. 8.

You may also add dependents to your plan. Follow the instructions in the To Add Dependents section.

For higher education employees, your User ID and a temporary password will be mailed to your home address. If you did not receive this or are having trouble logging in, please call Beneﬁ ts Administration at 800.253.9981, option 3. For state employees, if you do not know your password or have trouble logging in to Edison, call the Edison help desk at 866.376.0104.

•

All dependent veriﬁ cation documents must be received by November 1.

!

Don’t Wait — Enroll early! You can make changes throughout AETP. Changes must be submitted by 11:59 p.m. (Central) November 1.

If you choose to make a change…

!

There is a link to a list of acceptable documentation on the ESS “Upload

Dependent Veriﬁ cation Documents” page and the Beneﬁ ts Administration website.

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HEALTH BENEFITS

Your Health Insurance Options

You will always pay less for services if you are enrolled in the Partnership PPO.

Both PPOs cover the same services and treatments. 2

Free in-network preventive health services are covered by both PPOs (see page 6).

1

Choose between two preferred provider organizations (subject to eligibility) 1

Partnership PPO Standard PPO

> >

Each carrier has its own network of health care providers. Doctors and facilities move in and out of networks from time to time. Check the networks carefully for your preferred doctor or hospital when making your selection. See inside front cover for website information.

Network Options

BlueCross BlueShield of Tennessee (BCBST) and Cigna both have PPO networks available throughout Tennessee. Both BlueCross and Cigna have made signiﬁ cant changes to their networks for 2014.

Choose an insurance carrier

BlueCross BlueShield of Tennessee Cigna > >

2 Available Networks

BCBST: Network S

Cigna: Open Access Plus (statewide) or LocalPlus (middle Tennessee only)

> >

New in 2014: Cigna will oﬀ er an additional network called Cigna LocalPlus as a two-year pilot program in the middle Tennessee region.

!

Additional $20 per month for employee only coverage Additional $40 per month for all other tiers

> >

1_{If you enrolled in the Partnership PPO for 2013 and you or your spouse}

did not fulﬁ ll the Partnership Promise, you are not eligible to continue in this option during 2014.

2_{For some procedures, diﬀ erent medical criteria may apply based on}

the carrier you select.

Depending on where you live, BlueCross BlueShield and Cigna have a $20/$40 network carrier surcharge because the providers have diﬀ erent costs in each region.

What You Should Know about Cigna LocalPlus:

This is a narrower network than the Cigna Open Access Plus network.

The network includes primarily HCA-aﬃ liated hospitals and Vanderbilt Medical Center, among others.

The St. Thomas Hospitals (Baptist, St. Thomas, Middle Tennessee Medical), Williamson Medical Center, among others, are NOT included.

The $20/$40 network carrier surcharge will NOT apply. The Cigna LocalPlus network will cost the same as BlueCross in Middle Tennessee.

The larger Cigna Open Access Plus network is still available in middle Tennessee and the network carrier surcharge will apply.

> > > > > >

Less Costly Carrier

More Costly Carrier

CIGNA WEST BCBST and CIGNA LOCALPLUS MIDDLE BCBST EAST BCBST + $20 or + $40 CIGNA + $20 or + $40

CIGNA OPEN ACCESS

+ $20 or + $40

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PARTNERSHIP PROMISE

Take Action. Save Money.

If you enroll in the Partnership PPO, you will pay much lower premiums and get great discounts on services and procedures. But to keep this beneﬁ t, you must complete the Partnership Promise each year. When you maintain or improve your health, you help lower health care costs for you, your family and all insurance plan members. This savings means we can oﬀ er you the most comprehensive insurance plan at the lowest cost. Without your active participation in the Partnership Promise, everyone could pay higher costs.

If you or your covered spouse fail to fulﬁ ll any

requirement of the 2014 Partnership Promise, you will both be transferred to the Standard PPO in 2015.

2014 Partnership Promise Requirements

Members and covered spouses must: 1

Complete the online Healthways Well-Being Assessment™ (WBA) by March 15 Complete a biometric health screening

by July 15

Update your contact information with your employer if it changes

Engage in the tobacco cessation program if you are a tobacco user Participate in health coaching and/or case management if identiﬁ ed

Online Well-Being Assessment

The online Well-Being Assessment (WBA) summarizes your overall health and off ers steps you can take to improve. By completing the confi dential assessment, you will learn more about your physical, emotional and social health and how your lifestyle habits aff ect your overall well-being.

The Well-Being Assessment must be completed between January 1 and March 15, 2014.

To complete the assessment, visit

partnersforhealthtn.gov and click on the “My Wellness Login” button.

Biometric Health Screening

In 2014, all Partnership PPO members must get a biometric screening by July 15. There are two ways:

At a worksite screening. Screening sites will be available across the state. You can see a complete list of worksite screening locations on the ParTNers for Health website in January 2014.

From your health care provider. Healthways will accept screening results from a doctor’s visit between July 16, 2013, and July 15, 2014. Visit the Quick Links box on the ParTNers for Health website to print a Physician Screening Form. Fax it to your doctor’s oﬃ ce or take it with you when you visit. The doctor will need to complete the form and send it to Healthways by the July 15 deadline.

Health Coaching

Members who are identiﬁ ed by Healthways must participate in health coaching during 2014. The ParTNers for Health wellness staﬀ will identify members based on medical conditions and lifestyle behaviors that may cause current or future health issues. These are determined using information from health insurance claims, your Well-Being Assessment results and past health screening results. 1.

2.

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Health coaching programs include: Lifestyle management

Disease management

Health coaches include licensed registered nurses, licensed dieticians, licensed clinical social workers, certiﬁ ed health educators and those with degrees in physiology, exercise science and health promotion. All conversations with your health coach are conﬁ dential and cannot be shared with the state.

When you participate in coaching, your frequency of calls will be tailored to your individual plan of care.

Case Management is managed by BlueCross

BlueShield, Cigna and Magellan. You must participate in case management if you are contacted by one of these carriers. This program provides coordination of care for members with complicated medical needs, chronic conditions and catastrophic illnesses or injuries.

Tobacco Cessation

Partnership PPO members who use tobacco must participate in Healthways tobacco cessation program and work toward becoming tobacco free.

A tobacco user is someone who uses any tobacco product, including cigarettes, cigars or smokeless tobacco. Someone who smokes an occasional cigar (up to one a month) will not be considered a tobacco user. 2

When you conﬁ rm that you are a tobacco user, Healthways will reach out to you to enroll you in a tobacco cessation program.

You will not be required to stop using tobacco by the end of 2014, but you must complete the tobacco cessation program and make an eﬀ ort to quit.

Updating Contact Information

Make sure that your phone number, mailing address and email address, if you have one, are current with your employer. If your information changes during the year, you must update your record.

State employees: Change your contact information yourself in Edison or by contacting your agency’s human resources oﬃ ce.

> > > > > >

Higher Education employees: Change your contact information yourself in Edison, or by contacting your agency beneﬁ ts coordinator or by calling the Beneﬁ ts Administration Service Center at 800.253.9981 and selecting option 6.

New employees (as of 1/1/14) who enroll in the Partnership PPO must complete the online Well-Being Assessment and biometric screening within 120 days of their insurance coverage eﬀ ective date.

Healthways administers the Partnership Promise. >

ParTNers for Health

Wellness Program

888.741.3390

Healthways Call Center Hours

Monday – Friday 7:30 a.m. – 9:30 p.m. Central Time Saturday 8:00 a.m. – 6:30 p.m. Central Time

partnersforhealthtn.gov

(Wellness Tab)

1_{The beneﬁ ts of the Partnership Promise are open to all plan members.}

If you think you might be unable to fulﬁ ll the Partnership Promise, call our ParTNers for Health Wellness Program at 888.741.3390, and they will work with you and/or your physician, if you wish, to ﬁ nd an alternate way for you to meet the Promise.

2_{Based on similar guidelines from life insurance companies that allow}

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Services that Require Copays

Services in this table ARE NOT subject to a deductible and costs DO APPLY to the annual out-of-pocket copay maximum.

PARTNERSHIP PPO STANDARD PPO

COVERED SERVICES IN-NETWORK OUT-OF-NETWORK [1] _IN-NETWORK _{OUT-OF-NETWORK}[1]

Preventive Care

Offi ce Visits

Well-baby, well-child visits as recommended by the Centers for Disease Control and Prevention (CDC) Adult annual physical exam

Annual well-woman exam

Immunizations as recommended by CDC Annual hearing and non-refractive vision screening Screenings including colonoscopy, mammogram and colorectal, Pap smears, labs, bone density scans, nutritional guidance, tobacco cessation counseling and other services as recommended by the US Preventive Services Task Force

• • • • • •

No charge $45 copay No charge $50 copay

Outpatient Services

Primary Care Offi ce Visit *

Family practice, general practice, internal medicine, OB/GYN and pediatrics

Nurse practitioners, physician assistants and nurse midwives (licensed healthcare facility only) working under the supervision of a primary care provider Including surgery in offi ce setting and initial maternity visit

• •

•

$25 copay $45 copay $30 copay $50 copay

Specialist Offi ce Visit *

Including surgery in offi ce setting •

$45 copay $70 copay $50 copay $75 copay

Mental Health and Substance Abuse * [2] _{$25 copay} _{$45 copay} _{$30 copay} _{$50 copay}

X-Ray, Lab and Diagnostics

Including reading, interpretation and results (not including advanced x-rays, scans and imaging) •

100% covered after offi ce copay, if applicable

100% covered up to MAC after offi ce copay, if

applicable

100% covered after offi ce copay, if applicable

100% covered up to MAC after offi ce copay, if

applicable

Allergy Injection 100% covered 100% covered up to MAC 100% covered 100% covered up to MAC

Allergy Injection with Offi ce Visit * $25 copay primary; $45 copay specialist $45 copay primary; $70 copay specialist $30 copay primary; $50 copay specialist $50 copay primary; $75 copay specialist

Chiropractors * Visits 1-20: $25 copay Visits 21 and up: $45 copay

Visits 1-20: $45 copay Visits 21 and up: $70 copay

Pharmacy

Out-of-Pocket Maximum (per individual) $3,750 none $3,750 none

30-Day Supply *** $5 copay generic;

$35 copay preferred brand; $85 copay non-preferred brand

Copay plus amount exceeding MAC

$10 copay generic; $45 copay preferred brand;

$95 copay non-preferred brand

90-Day Supply (90-day network pharmacy or mail order)

90-Day Supply (certain maintenance medications from 90-day network pharmacy or mail order)[4]

$160 copay non-preferred

$180 copay non-preferred

Urgent Care

Convenience Clinic or Urgent Care Facility * $30 copay $35 copay

Emergency Room

Emergency Room Visit (waived if admitted) * AND_** _{$125 copay} _{$145 copay}

* Out-of-Pocket Copay Maximum — per individual (applies to in-network oﬃ ce visits for primary care, specialist care, emergency room, chiropractors, urgent care and mental health and substance abuse treatment); $900 Partnership PPO; $1,100 Standard PPO.

** Services subject to coinsurance may be extra.

*** Members who are taking a preferred brand human growth hormone will be required to try a preferred brand before the plan will cover a non-preferred brand. This is referred to as “step therapy.”

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PARTNERSHIP PPO STANDARD PPO

COVERED SERVICES IN-NETWORK OUT-OF-NETWORK [1] _IN-NETWORK _{OUT-OF-NETWORK}[1]

Hospital/Facility Services

Inpatient care [3]

Outpatient surgery [3]

Inpatient mental health and substance abuse [2] [3]

• • •

10% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance

Maternity

Global billing for labor and delivery and routine services beyond the initial offi ce visit

•

Home Care [3]

Home health Home infusion therapy •

•

Rehabilitation and Therapy Services

Inpatient [3]_{; outpatient}

Skilled nursing facility [3]

• •

Ambulance

Air and ground •

10% coinsurance 20% coinsurance

Hospice Care [3]

Through an approved program •

100% covered up to MAC (even if deductible has not been met)

Equipment and Supplies [3]

Durable medical equipment and external prosthetics Other supplies (i.e., ostomy, bandages, dressings) •

•

Dental

Certain limited benefi ts (extraction of impacted wisdom teeth, excision of solid-based oral tumors, accidental injury, orthodontic treatment for facial hemiatrophy or congenital birth defect)

• 10% coinsurance for oral surgeons 40% coinsurance for oral surgeons 20% coinsurance for oral surgeons 40% coinsurance for oral surgeons 10% coinsurance non-contracted providers

(i.e., dentists, orthodontists)

20% coinsurance non-contracted providers (i.e., dentists, orthodontists)

Advanced X-Ray, Scans and Imaging

Including MRI, MRA, MRS, CT, CTA, PET and nuclear cardiac imaging studies [3]

•

Reading and interpretation

• 100% covered 100% covered up to MAC 100% covered 100% covered up to MAC

Out-of-Country Charges

Non-emergency and non-urgent care •

N/A - no network 40% coinsurance N/A - no network 40% coinsurance

Services that Require Coinsurance — Deductibles and Out-of-Pocket Coinsurance Maximums

Services in this table ARE subject to a deductible and eligible expenses CAN BE APPLIED to the annual out-of-pocket coinsurance maximum.

Deductible

Employee Only $450 $800 $800 $1,500

Employee + Child(ren) $700 $1,250 $1,250 $2,350

Employee + Spouse $900 $1,600 $1,600 $3,000

Employee + Spouse + Child(ren) $1,150 $2,050 $2,050 $3,850

Out-of-Pocket Coinsurance Maximum

Employee Only $1,550 $2,900 $1,900 $3,600

Employee + Child(ren) $2,450 $4,600 $3,100 $5,900

Employee + Spouse $3,100 $5,800 $3,800 $7,200

Employee + Spouse + Child(ren) $4,000 $7,500 $5,000 $9,500

No single family member will be subject to a deductible or out-of-pocket maximum greater than the “employee only” amount. Once two or more family members (depending on premium level) have met the total deductible and/or out-of-pocket coinsurance maximum, it will be met by all covered family members. Only eligible expenses will apply toward the deductible and out-of-pocket maximum. Charges for non-covered services and amounts exceeding the maximum allowable charge will not be counted.

[1] Subject to maximum allowable charge (MAC). The MAC is the most a plan will pay for a service from an in-network provider. For non-emergent care from an out-of-network provider who charges more than the MAC, you will pay the copay or coinsurance PLUS diﬀ erence between MAC and actual charge. [2] The following behavioral health services are treated as “inpatient” for the purpose of determining member cost-sharing: residential treatment, partial

hospitalization and intensive outpatient therapy. Prior authorization (PA) is required for psychological testing and electroconvulsive therapy.

[3] Prior authorization (PA) required. When using out-of-network providers, beneﬁ ts for medically necessary services will be reduced by half if PA is required but not obtained, subject to the maximum allowable charge. If services are not medically necessary, no beneﬁ ts will be provided. (For DME, PA only applies to more expensive items.)

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EAST WEST

BCBST _{OPEN ACCESS}CIGNA EMPLOYER _SHARE BCBST _{OPEN ACCESS}CIGNA EMPLOYER _SHARE

PARTNERSHIP PPO

Employee Only $114.49 $134.49 $521.55 $134.49 $114.49 $521.55

Employee + Child(ren) $171.73 $211.73 $782.34 $211.73 $171.73 $782.34 Employee + Spouse $240.42 $280.42 $1,095.26 $280.42 $240.42 $1,095.26 Employee + Spouse + Child(ren) $297.67 $337.67 $1,356.04 $337.67 $297.67 $1,356.04

STANDARD PPO

Employee Only $139.49 $159.49 $521.55 $159.49 $139.49 $521.55

Employee + Child(ren) $196.73 $236.73 $782.34 $236.73 $196.73 $782.34 Employee + Spouse $290.42 $330.42 $1,095.26 $330.42 $290.42 $1,095.26 Employee + Spouse + Child(ren) $347.67 $387.67 $1,356.04 $387.67 $347.67 $1,356.04

Monthly Premiums for State Plan Active Employees

MIDDLE

BCBST _{LOCAL PLUS}CIGNA _{OPEN ACCESS}CIGNA EMPLOYER SHARE

PARTNERSHIP PPO

Employee Only $114.49 $114.49 $134.49 $521.55

Employee + Child(ren) $171.73 $171.73 $211.73 $782.34

Employee + Spouse $240.42 $240.42 $280.42 $1,095.26

Employee + Spouse + Child(ren) $297.67 $297.67 $337.67 $1,356.04

STANDARD PPO

Employee Only $139.49 $139.49 $159.49 $521.55

Employee + Child(ren) $196.73 $196.73 $236.73 $782.34

Employee + Spouse $290.42 $290.42 $330.42 $1,095.26

Employee + Spouse + Child(ren) $347.67 $347.67 $387.67 $1,356.04

You will always pay less in the Partnership PPO

BlueCross BlueShield costs $20/$40 more per month in West TN

Cigna Open Access Plus costs $20/$40 more per month in East and Middle TN Cigna LocalPlus costs the same as BlueCross BlueShield in Middle TN

> > >

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EAST WEST

BCBST _{OPEN ACCESS}CIGNA BCBST _{OPEN ACCESS}CIGNA

PARTNERSHIP PPO

Employee Only $648.76 $669.16 $669.16 $648.76

Employee + Child(ren) $973.15 $1,013.95 $1,013.95 $973.15

Employee + Spouse $1,362.40 $1,403.20 $1,403.20 $1,362.40

Employee + Spouse + Child(ren) $1,686.79 $1,727.59 $1,727.59 $1,686.79

STANDARD PPO

Employee Only $674.26 $694.66 $694.66 $674.26

Employee + Child(ren) $998.65 $1,039.45 $1,039.45 $998.65

Employee + Spouse $1,413.40 $1,454.20 $1,454.20 $1,413.40

Employee + Spouse + Child(ren) $1,737.79 $1,778.59 $1,778.59 $1,737.79

Monthly Premiums for State Plan COBRA Participants

MIDDLE

BCBST _{LOCAL PLUS}CIGNA _{OPEN ACCESS}CIGNA

PARTNERSHIP PPO

Employee Only $648.76 $648.76 $669.16

Employee + Child(ren) $973.15 $973.15 $1,013.95

Employee + Spouse $1,362.40 $1,362.40 $1,403.20

Employee + Spouse + Child(ren) $1,686.79 $1,686.79 $1,727.59

STANDARD PPO

Employee Only $674.26 $674.26 $694.66

Employee + Child(ren) $998.65 $998.65 $1,039.45

Employee + Spouse $1,413.40 $1,413.40 $1,454.20

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DENTAL BENEFITS

PREPAID PLAN PDO PLAN

Employee Only $9.92 $21.07

Employee + Child(ren) $20.60 $48.44

Employee + Spouse $17.58 $39.85

Employee + Spouse + Child(ren) $24.17 $77.98

Monthly Premiums for Active Members

PREPAID PLAN PDO PLAN

Employee Only $10.12 $21.49

Monthly Premiums for COBRA Participants

Your Dental Insurance Options

During the enrollment period, eligible employees can enroll in or transfer between these two options.

If you don’t change your current dental carrier or cancel coverage using ESS in Edison, you will keep your current coverage.

Prepaid Plan — Assurant Employee Benefi ts

Administered by Assurant Employee Beneﬁ ts. Provides services at predetermined copay amounts (reduced fees) for dental treatments.

No deductibles to meet, no claims to ﬁ le, no waiting periods for covered members, no annual dollar maximum and pre-existing conditions are covered. Referrals are not required.

To receive beneﬁ ts, you must select a dentist from the Prepaid Plan list and notify Assurant of your selection. There are some areas in the state where network dentists are not available. Depending on where you live, the Prepaid Plan may not be the best option for you. Be sure to carefully review the provider directory. The network is DentiCare. Some oﬃ ces may be closed to new enrollment. See inside front cover for website information.

Premiums will increase by 3 percent in 2014.

> > > > > > >

Choose between two dental options

Prepaid Plan provides services at predetermined copay amounts from a limited network of participating dentists and specialists.

Preferred Dental Organization (PDO) allows members to choose any dentist.

>

PDO — Delta Dental

Administered by Delta Dental.

Choose any dentist (receive maximum beneﬁ ts when visiting an in-network Delta Dental PPO provider). You pay coinsurance for covered services.

Deductible applies for out-of-network dental care only.

Referrals are not required.

You or your dentist will ﬁ le claims for covered services. Some services require waiting periods and limitations and exclusions apply.

Premiums will increase by 3 percent in 2014.

> > > > > > > >

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ASSURANT PREPAID OPTION DELTA PDO OPTION

COVERED SERVICES GENERAL DENTIST SPECIALIST DENTIST IN-NETWORK OUT-OF-NETWORK

Annual Deductible None None $100 single; $300 family,

per policy year [5]

Annual Maximum Benefi t None $1,500 per person, per policy year

Pre-existing Conditions Covered Some exclusions

Offi ce Visit $10 copay [3] _{No charge} _{20% of MAC}

Periodic Oral Evaluation No charge No charge 20% of MAC

Routine Cleaning No charge No charge 20% of MAC

X-ray — Intraoral, Complete Series No charge $5 copay 20% of MAC 40% of MAC

Amalgam (silver) Filling — 2 Surfaces Permanent

$8 copay $10 copay 20% of MAC 40% of MAC

Endodontics — Root Canal Therapy Molar

(excluding fi nal restoration)

$250 copay $600 copay 50% of MAC

Major Restorations — Crowns

(porcelain fused to high noble metal)

$275 copay, plus lab fees [1] _{50% of MAC}[4]

Extraction of Erupted Tooth (minor oral surgery) $15 copay $70 copay 20% of MAC 40% of MAC

Removal of Impacted Tooth — Complete Bony

(complex oral surgery)

$100 copay $120 copay 50% of MAC

Dentures — Complete Upper $310 copay, plus lab fees[1] _{50% of MAC}[4]

Orthodontics 25% off participating orthodontist’s usual fees 50% of MAC [4]

• Annual Deductible None None

• Lifetime Maximum None $1,250 (including any benefi ts received

under a prior dental plan )[2]

• Waiting Period None 12 months

• Age Limit None Up to age 19

MAC—Maximum Allowable Charge

The beneﬁ ts listed are a sample of the most frequently utilized dental treatments. Refer to vendor materials for complete information on coverage, limitations and exclusions.

[1] Members are responsible for additional lab fees for these services.

[2] If an individual had coverage through another dental plan, they may also have had a lifetime maximum for orthodontia. The orthodontia maximum is a lifetime benefi t, which means if an individual enrolls under the PDO, the benefi t amount will not start over again. The benefi ts for orthodontia under the PDO would be adjusted based on the benefi ts a member may have received previously through another dental plan.

[3] A charge of $20 may apply for a missed appointment when the member does not cancel at least 24 hours prior to the scheduled appointment. [4] A 12-month waiting period applies.

[5] Does not apply to diagnostic and preventive beneﬁ ts such as periodic oral evaluation, cleaning and x-ray.

Covered Dental Services

Here is a comparison of deductibles, copays and your share of coinsurance under the dental options. Costs represent what the member pays.

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VISION BENEFITS

BASIC EXPANDED

Monthly Premiums for Active Members

BASIC EXPANDED

Monthly Premiums for COBRA Participants

Your Vision Insurance Options

Optional vision coverage is available to all state and higher education employees and dependents.

Both plans oﬀ er the same services, including: Annual routine eye exam

Frames Eyeglass lenses Contact lenses

Discount on Lasik/refractive surgery

The basic and expanded plans are both administered by EyeMed Vision Care. In-network and out-of-network beneﬁ ts are available. See the ParTNers for Health website for a list of limitations and exclusions.

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Choose between two vision options

Basic Plan oﬀ ers discounted rates and allowances for services.

Expanded Plan provides services with a combination of copays, allowances and discounted rates.

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You will receive the maximum beneﬁ t when visiting a provider in EyeMed’s Select network.

Tennessee Board of Regents Vision Plans

The Tennessee Board of Regents (TBR) off ers both the TBR — VSP plan and the State EyeMed Plan. You can fi nd benefi t and premium information about the TBR — VSP Vision Plan at tbrvision.com.

Employees Currently Enrolled in the TBR — VSP Vision Plan:

To switch to the State’s vision plan, you must enroll using the State’s Employee Self Service (ESS) in Edison, even if you do not make changes to your health or dental plans. You must contact your campus HR department to cancel coverage under the TBR — VSP vision plan.

To remain in the TBR — VSP vision plan requires no action on your part. If you make changes to your health and dental plans, simply “decline or waive” the State’s vision coverage in Edison.

Employees NOT Currently Enrolled in the TBR — VSP Vision

Plan:

To enroll in the State’s vision plan, you must enroll using the State’s Employee Self Service (ESS) in Edison, even if you do not make changes to your health or dental plans.

To enroll in the TBR — VSP vision plan, visit tbrvision.com and complete the online enrollment process. If you are currently enrolled in the State’s vision plan, simply “decline or waive” the State’s vision coverage in Edison.

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Covered Vision Services — State Plan EyeMed Vision Care

Here is a comparison of discounts, copays and allowed amounts under the vision options. Copays represent what the member pays. Allowances and percentage discounts represent the cost the carrier will cover.

BASIC PLAN EXPANDED PLAN

Routine Eye Exam $0 copay $10 copay

Retinal Imaging Benefi t none up to $39 copay

Frames $50 allowance;

20% discount off balance above the allowance

$115 allowance;

20% discount off balance above the allowance

Eyeglass Lenses (includes plastic or glass)

• Single, Bifocal, Trifocal, Lenticular

• Standard Progressive Lens

• Premium Progressive Lens

$50 allowance; 20% off balance over $50

$15 copay $55 copay $81–$93 [3}

Eyeglass Lens Options (upgrades)

• Anti-refl ective

• Polycarbonate

• Photochromic

• Scratch resistance coating

• UV coating

• Tints

• Polarized

• Premium Anti-Refl ective

• All other eyeglass lens options

20% discount off all options maximum copayments: $45 copay

$30 copay; $0 for children 18 and under $70 copay

$15 copay $10 copay $25 copay 20% off retail price

$57–$68 20% discount

Exam for Contact Lenses (fi tting and evaluation) 15% discount off retail price up to $60 copay

Contact Lenses [1]

• Elective

• Conventional

• Disposable

• Medically Necessary [2]

$50 allowance; 15% off balance over $50 $50 allowance

$150 allowance

$130 allowance; 15% off balance over $130 $130 allowance

covered at 100%

Lasik/Refractive Surgery (for select providers) 15% discount off usual and customary fees 15% discount off usual and customary fees

Out-of-Network Benefi ts • All Eye Exams

• Frames

• Eyeglass Lenses

• Single Vision

• Lined Bifocal

• Lined Trifocal

• Elective Contacts (conventional or disposable)

• Medically Necessary Contacts [2]

up to $30 allowance

up to $50 allowance (frames and lenses combined)

$25 allowance $75 allowance up to $45 allowance up to $70 allowance up to $30 allowance up to $50 allowance up to $65 allowance up to $50 allowance up to $100 allowance Frequency • Eye Exam

• Eyeglass Lenses and Contacts

• Frames

Once every calendar year per person Once every calendar year per person Once every two calendar years per person

Once every calendar year per person Once every calendar year per person Once every two calendar years per person [1] Instead of eyeglass lenses

[2] If medically necessary as ﬁ rst contact lenses following cataract surgery or multiple pairs of rigid contact lenses for treatment of keratoconus [3] Copays for premium progressive lens are subject to change

EyeMed off ers some additional discounts which include:

40% off on additional pairs of eyeglasses at any network location, after the vision benefi t has been used 15% off conventional contact lenses after the benefi t has been used

20% oﬀ non-covered items such as lens cleaner, accessories and non-prescription sunglasses

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OTHER BENEFITS

Employee Assistance Program (EAP)

The Employee Assistance Program (EAP) is a support tool that helps you and your family deal with both workplace and personal issues.

All services are conﬁ dential, and available at no cost to members.

You can easily access services by calling Magellan at 855.437.3486 — available 24 hours a day, 365 days a year.

You and your eligible dependents may use up to ﬁ ve, no cost counseling sessions per problem episode, per year.

Your EAP also off ers work-life services, fi nancial and legal services, assistance fi nding eldercare and dependent care services and much more.

Learn more by visiting here4TN.com.

Basic Term Life and Accidental Death Insurance *

The state provides a basic term life insurance ($20,000) and accidental death and dismemberment insurance ($40,000) to all employees.

If you are enrolled in health insurance as the head of contract, your coverage automatically increases with your salary — to a maximum of $50,000 for basic term life insurance and $100,000 for accidental death insurance.

Optional Accidental Death Insurance *

If you would like additional accident protection, you may enroll in optional accidental death and dismemberment insurance for yourself and your dependents during open enrollment.

Coverage is available at low group rates — no questions asked.

Premiums vary by salary.

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The maximum beneﬁ t available for employees is $60,000.

The enrollment form is available on the Beneﬁ ts Administration website at tn.gov/ﬁ nance/ins.

*The State is in the process of signing a contract with the company that will provide these benefi ts for the next fi ve years. The benefi ts will not change. For more information go to partnersforhealthtn.gov.

Optional Term Life Insurance

If you qualify, you can purchase optional coverage from Minnesota Life for yourself and your dependent spouse and children. You can apply for up to seven times your annual base salary (to a maximum of $500,000) for yourself and up to a maximum of $30,000 for your spouse ($15,000 for ages 55 and older). You can also apply for coverage for your children equal to $5,000 or $10,000. If you are currently enrolled and are eligible for a guaranteed issue increase, information will be mailed to you.

If you and/or your dependent spouse are not presently enrolled, you will be required to present evidence of insurability through a health questionnaire. Enroll through the Minnesota Life website at

lifebeneﬁ ts.com/stateoftn.

Long-Term Care Insurance

Qualiﬁ ed employees, their eligible dependents (spouse and children ages 18 through 25), retirees, parents and parents-in-law are eligible to enroll in long-term care coverage with MedAmerica.

Covers certain services required by individuals who are no longer able to care for themselves without the assistance of others.

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Apply at any time, subject to medical underwriting. Call MedAmerica or refer to their website at ltc-tn.com for enrollment information.

Covered services include nursing home care, assisted living, home health care, home care and adult day care.

Benefi ts are available through diff erent options based on a daily benefi t amount ($100, $150 or $200) for either a three-year or fi ve-year coverage period. Benefi ts are also available with or without infl ation protection, which protects the value of the coverage you buy today to off set future increases in the costs for long-term care.

You pay 100 percent of the premium.

Premiums are based on age at the time of enrollment. The younger you are when you apply, the lower your monthly premium will be. You can ﬁ nd premium rates on the Beneﬁ ts Administration website.

Flexible Benefi ts — State employees only

State employees (excludes higher education and off -line agencies) have access to a fl exible benefi ts plan. This program is administered by the Department of Treasury and is designed to help employees reduce taxes. It allows you to be reimbursed for certain expenses from your pre-tax income by enrolling in one of the following reimbursement accounts.

Medical

Dependent daycare Parking

Transportation

If you want a medical and/or dependent day care reimbursement account in 2014, you must sign up between October 1 – November 1, 2013 — even if you are already participating. You must enroll online using ESS in Edison.

You can enroll in a parking and/or transportation reimbursement account at any time and you are not required to re-enroll annually.

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Paper enrollment forms will not be accepted this year and no enrollments can be made after November 1. The amount you can contribute to a ﬂ ex beneﬁ ts account is set by the IRS and the limits are subject to change yearly. Please visit IRS.gov to determine contribution limits for 2014.

Higher Education employees have access to their own ﬂ exible spending accounts. Please contact your agency beneﬁ ts coordinator for additional information.

Employee Sick Leave Bank — State employees only

The Employee Sick Leave Bank (SLB) provides sick leave to qualifying members who are medically unable to perform the duties of their jobs.

Administered by the Tennessee Department of Human Resources.

Members may receive a maximum of 90 days from the Bank as a result of a personal illness, injury, accident, disability, medical condition, or quarantine or a condition related to, resulting from, or recurring from a previously diagnosed condition for which the Bank granted sick leave.

Open enrollment is August 1 – October 31 each year. You must be a full-time state employee for 12 consecutive months and have at least six days of sick leave by November 1 of your enrollment year. New members must contribute four sick leave days to enroll. If you are already enrolled, you do not need to take any action.

This information is a summary only. See the SLB Guidelines, eligibility requirements, FAQs and enroll online on the SLB website (tn.gov/dohr) — click on the “For Employees” link.

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HIPAA Privacy Rules

Privacy rules, part of the Health Insurance Portability and Accountability Act (HIPAA) passed by Congress in 1996, became eﬀ ective for most health entities on April 14, 2003. HIPAA privacy rules apply to those who provide medical services such as hospitals and doctors, and to insurance companies and health plans. These rules are intended to protect your personal information from being inappropriately disclosed. They also give you additional rights concerning your health care information. Your privacy is important to us. If you would like a copy of our complete HIPAA privacy policy, please visit tn.gov/ﬁ nance/ins—just click on the “Publications and Forms” link and select Publications.

Beneﬁ ts Administration does not support any practice that excludes participation in programs or denies the beneﬁ ts of such programs on the basis of race, color or national origin. If you have a complaint regarding discrimination, please call 1.866.576.0029 or 615.741.4517.

The information contained in this decision guide is a brief, general overview of some of the benefi ts available to you through the State of Tennessee. More complete and specifi c information is contained within the formal plan documents. If there is any discrepancy between the information in this guide and the formal plan documents, the plan documents will govern in all cases. You can fi nd a copy on the Benefi ts Administration website.

Required Notices — Aff ordable Care Act (ACA) “Health Reform”

In addition to this Decision Guide, all employees will receive two other mailings around the same time. The Federal Aﬀ ordable Care Act (ACA) (also known as Health Reform) requires that these two documents be mailed to you.

1. Notice of Coverage Options. This is a letter that includes information on:

The new Health Insurance Marketplace (Exchange);

Eligibility for a premium tax credit if buying a qualiﬁ ed health plan through the Marketplace;

Possible loss of employer contribution if buying a qualiﬁ ed health plan through the Marketplace; and Tax consequences

2. Summary of Benefi ts & Coverage (SBC) notifi cation. This is a postcard that:

Provides information about how to get a copy of the SBC, which is similar to the health insurance beneﬁ t charts contained in this decision guide

For more information about the ACA, see FAQs at partnersforhealthtn.gov.

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ST A T E OF TENNESSEE BENEFIT S ADMINISTRA TION DEP AR TMENT OF FINANCE AND ADMINISTRA TION 19 T H F LO O R , 312 ROSA L . P ARKS A VENUE WILLIAM R . SNODGRASS TENNESSEE T OWER NASHVILLE , TENNESSEE 37243 1102 PRESOR TED ST AND ARD U .S . POST A G E P AID NASHVILLE , TN PERMIT NO . 9 3 6