Benefits Summary
Summary of Fringe Benefits
Related Links
Updated January, 2008
- Retirement
- Life Insurance
- Health Insurance Options
- Dental
- AFLAC
- IRS Section 125
- Flexible Spending Accounts
- Long Term Disability (LTD)-ITT Hartford Life Insurance Co.
- Credit Union
- Direct Deposit
- Tax Sheltered Annuities (TSA) - 403b
- Notes
- Employee Assistance Program
- Tuition Assistance Program
- Policy for Continuing Insurance Benefits
Retirement
TEACHERS RETIREMENT SYSTEM OF GEORGIA:
All regular staff employees who work one-half time or more are required to participate in the Teachers Retirement System (TRS) of Georgia plan. Employees contribute 5% of their salary on a federal and state tax-deferred basis. The current university contribution matching rate is 9.28%.
If you leave our employ and request a refund of your contributions, you will be subject to
federal and state taxes plus a 10% penalty if under age 59 ½. You may avoid this penalty if you roll over your contributions within 60 days of receipt of your refund to another qualified retirement account or an IRA.Your retirement account is considered a “vested” account when you have at least 10 years of credible service. Vesting means that you have a right to a retirement benefit at age 60.
The Teachers Retirement System of Georgia web site can be accessed at http://www.trsga.com/. The TRS Member’s Guide can be accessed and printed from this site (Publications Link).
OPTIONAL RETIREMENT PLAN OF THE UNIVERSITY SYSTEM OF GEORGIA:Regular faculty members and administrative officers may elect to participate in the Optional Retirement Plan (ORP) of the University System of Georgia in lieu of active membership in the TRS of Georgia. Selection of a retirement plan must be made within 60 days of date of hire for faculty members and eligible administrative officers.
Members contribute 5% of their salary to the ORP retirement plan. The current university contribution matching rate is 8.15%.
For additional information, please see the Optional Retirement Plan handout, available from Human Resources. The individual ORP companies may be accessed at www.usg.edu/employment/benefits/retirement/index.phtml.
DEFINITION OF A UNIVERSITY SYSTEM OF GEORGIA RETIREE/ELIGIBILITY FOR RETIREMENT:
Effective November 1, 2002, to be eligible for retirement from the University System of Georgia, an employee must meet one of the following four conditions at the time of his/her separation from employment, regardless of the retirement plan elected by the employee:
An employee must have been employed by the University System of Georgia for
the last 10 years in a regular, benefited position and have attained age 60;
OR
An employee must have at least 25 total years of benefited service established with a State of Georgia sponsored retirement plan, of which the last 5 years of employment must have been continuous and with the University System of Georgia. An early pension benefit penalty will apply to an individual who elects to participate in the Teachers Retirement System of Georgia if he/she decides to retire with between 25 and 30 years of benefited service, prior to attaining age 60;
OR
An employee must have at least 30 total years of benefited service established with a State of Georgia sponsored retirement plan, of which the last 5 years must have been continuous and with the University System of Georgia;
OR
An employee must be deemed to be totally and permanently disabled, as documented through the receipt of disability benefits from Social Security or from the Teachers Retirement System of Georgia, following 9.5 years of continuous service to the University System of Georgia in a regular, benefited position.An individual who has retired from another State of Georgia sponsored retirement plan may not count such retirement service toward meeting the eligibility criteria for retirement from the University System of Georgia.
Note: Employees should consult their professional financial planners, retirement counselors, tax advisors, etc., for retirement planning advice and services. Staff members of the University of West Georgia are not to be considered as professional retirement consultants or tax advisors. No official retirement records are maintained at the University of West Georgia. Official retirement records for members of the Teachers Retirement System of Georgia (TRS) are maintained at the TRS Office, Two Northside 75, Suite 400, Atlanta, GA 30318, phone no. 1-800-352-0650. The TRS web site can be accessed at http://www.trsga.com/. Official retirement records for Optional Retirement Plan (ORP) members are maintained by the individual ORP company, and information may be obtained from representatives of the individual ORP company.
LIFE INSURANCE
CONNECTICUT GENERAL LIFE INSURANCE COMPANY (CIGNA)
Basic: The University provides each employee with a $25,000 life insurance policy. This is a double indemnity policy. Supplemental: Employees have the option to elect supplemental life insurance based on 1, 2, or 3 times your benefits base (annual salary) rounded to the next higher thousand. The premiums are based on your age. The supplemental life insurance is also a double indemnity policy. Dependent: Employees may elect dependent life insurance which covers all eligible dependents for $10,000 at a cost of $4.70 per month. Children age two weeks but less than six months in age are insured for $2,000. Application for enrollment in supplemental and dependent life insurance after the first 31 days of employment requires evidence of insurability. The life insurance plan booklet may be accessed at www.usg.edu/employment/benefits/life/index.phtml
HEALTH INSURANCE OPTIONS
Currently, there are four health plan choices offered to benefits eligible employees and their legal dependents. Blue Cross/Blue Shield of Georgia administers claims for the plans. Employees have the option of enrolling in the Indemnity Health Plan, the Preferred Provider Plan (PPO), the High Deductible Plan (HDHP/HSA), or the Blue Choice Plan (HMO). Highlights of the plans are illustrated below. For more detailed information refer to plan booklets, available from the Human Resources Office.
The healthcare premium contribution for active, eligible employees will be paid with pre-tax dollars. Employees must enroll during the first 31 days of employment or during the annual open enrollment period. Open enrollment is generally held in the fall of each calendar year. A University System of Georgia open enrollment period covers a 30 calendar year time frame. Healthcare plan elections made during an open enrollment period will become effective at the beginning of the new plan year. The plan year is currently a calendar year (January 1 – December 31). During an open enrollment period, an active and eligible employee may elect to: (1) enroll in a healthcare plan; (2) drop healthcare coverage; (3) participate in a different healthcare plan option; and/or (4) change his/her level of coverage (i.e., single, employee + child, employee + spouse, or family).
Because your share of the cost for healthcare plan premiums is paid with pre-tax dollars, the Internal Revenue Service rules state that the choices made by a covered member during an annual open enrollment period must remain in effect for the entire plan year. The only exception permitted is when a covered member has a qualifying event. If you have a qualifying event, you may add, change, or discontinue healthcare coverage within 31 days of the qualifying event. Appropriate documentation must be presented to the Human Resources Office before a change in healthcare coverage can be granted. Some examples of qualifying events include: the birth or adoption of a child, death of a dependent, change in employment status of a covered member, his/her spouse, or his/her covered dependent, the loss of eligibility status by a covered dependent, member or spouse being called to full-time active military duty, losing or gaining healthcare coverage eligibility under Medicare or Medicaid, or a change in residence to a location outside of a healthcare plan’s service area. A failure to complete a change form within 31 days of a qualifying event will prohibit you from making such changes until the next University System open enrollment period.
ELIGIBLE DEPENDENT: Spouse and unmarried children up to age 19, or up to age 26, if they are full time students. Full time students are defined as those enrolled three out of four quarters, or 2 out of 3 semesters. Students enrolled in a co-op program are considered full time for that term.
RELATED HEALTHCARE WEBSITES:
Health Insurance University System of GA www.usg.edu/employment/benefits/health/index.phtml.
This BOR site includes the Health Benefits Comparison Charts, a link to Blue Cross/Blue Shield provider directory info, BC/BS claim forms, and resource links such as Express Scripts.PPO Provider Directories www.healthygeorgia.com/
Provides on-line information regarding networks of Georgia PPO providers (1st Medical Network) and the National PPO providers (Beech Street).
Express Scripts www.express-scripts.com/ga/regents/
The pharmacy benefit program provider has established a web site for University
System of Georgia plan participants. Helpful information regarding pharmacy benefits under the Indemnity and PPO plans is available at this site.
INDEMNITY HEALTH PLAN
(Self Insured Plan through the Board of Regents, University System of Georgia; claims administered by Blue Cross/Blue Shield of Georgia.)
FEATURE
INDEMNITY PLAN
Pre-Existing Condition None Maximum Lifetime Benefit
$2 million
Maximum Annual Deductible
$300 individual
$900 familyMaximum Annual Out-of-Pocket
$2,000 individual
$4,000 familyPhysician Office Visit 80% of UCR charges for non-surgical svcs Wellness Care/Preventive Health Care
$750 per person per plan year; not subject to deductible
Laboratory Services provided in Physicians office (exclusive of Wellness Care/Preventive Health Care)
80% of UCR charges
Maternity Care-Physician Svcs/In-Office (Prenatal, Delivery and Post Natal)
90% of UCR charges
Outpatient Surgery
90% of UCR charges
Second Surgical Opinions
100% of UCR charges; not subject to deductible
Treatment of TMJ 80% of UCR charges; maximum $1,000 lifetime Allergy testing 80% of UCR charges Allergy Shots & Serum 80% of UCR charges In-Patient Hospital Services for Physician Care/Surgery 90% of UCR charges for surgeon;80% of UCR charges for anesthesiologist, pathologuist, or radiologist services/consulatations. Hospital Services Other than Emergency Room Care
90% of contracted DRG rate for In-State Hospitals;90% of UCR charges for service area in Out-of-State hospitals
Maternity Care-Inpatient Hospital (Delivery) 90% of contracted DRG rate Inpatient-Hospital Lab Services 90% of UCR charges Inpatient Hospice Care 90% of UCR charges Inpatient Treatment of TMJ 90% of UCR charges Outpatient Hospital Svcs for Physician Care/Surgery
90% of UCR charges for surgeon;80% of UCR charges for anesthesiologist, pathologist, or radiologist svcs/consultations.
Outpatient Facility Selected by Treating Physician 90% of UCR charges in a Plan approved facility Outpatient Hospital/Facility Laboratory Services 80% of UCR changes Care in a Hospital Emergency Room
( treatment of an emergency medical condition or injury)Surgical Services: 90% of UCR charges if referred by Medcall; 80% of UCR charges if not referred by Medcall.
Non-Surgical Services: 80% of UCR charges if referred by Medcall; 70% if not referred by Medcall
Urgent Care Services
80% of UCR changes Home Nursing Care 90% of UCR charges Extended Care Facility 90% of UCR charges Home Hyperalimentation 90% of UCR charges Ambulance Services 80% of UCR charges Outpatient Hospice Care 90% of UCR charges Cochlear Implants 90% of UCR charges Durable Medical Equipment 80% of UCR changes Outpatient Short Term Rehabilitation Svcs 80% of UCR charges;physical, speech, cardiac, & occupational therapies are limited to 40 visits per incident type per plan year. Chiropractic Care Not covered Surgical Extraction of Impacted Teeth
(medical benefits are not available for partially erupted teeth)
90% of UCR surgeon charges Disease State Management Training & Edu. Svcs.
(Diabetes, Oncology, Congestive Heath Failure, Asthma, and Cardiovascular Disease with Stroke Overlay Program)
100% of vendor negotiated rate; no deductible; pre-certification by UNICARE required. To receive plan benefits coverage, participation in the appropriate DSM program is required.
Mental Health/Substance Abuse Facility Charges for Inpatient: 90% of UCR charges; maximum benefit coverage of 60 days per person per plan year; 90 days per person lifetime.
Provider Charges for Inpatient: 90% of UCR charges.
Provider Charges for Outpatient: 80% of UCR charges; maximum of 20 visits per person per plan year; UNICARE may approve up to 50 visits per year under the following conditions: 1) in lieu of inpatient treatment; or 2) immediately following hospital confinement for the same condition.
Dental/Oral Care Not covered; other than accidental injury to natural teeth which is covered at 80% of UCR charges. Organ & Transplant Program(Prior approval required by UNICARE)
90% of vendor network rate at a UNICARE contracted transplant center. Lifetime benefit limit for expenses related to the donor search using a UNICARE contracted transplant center is $10,000. Pharmacy Program
Prescription DrugsPrescription Drugs
3-Tier Co-payment Structure
(Vendor: Express Scripts)(1) Generic: $10 co-payment per 30-day supply
(2) Preferred Brand Name: $25 co-payment per 30-day supply
(3) Non-Preferred Brand Name: 20% co-payment of drug cost, with minimum co-payment of $40 &maximum member co-payment of $100, for up to a 30-day supply.Quarterly Out-of-Pocket Maximum for generic and preferred brand name prescriptions:
Employee $ 450/quarter
Employee + Child $ 900/quarter
Employee + Spouse $ 900/quarter
Family $1,350/quarter
If the usual and customary charge for a generic or preferred brand name drug is less that the co-payment amount, the member will pay the lesser of the two. If a physician indicates “Brand Necessary” on a prescription, then only a preferred or non-preferred brand name medication can be dispensed. The member will be responsible for the preferred/non-preferred brand name medication co-payment . If a physician does not indicate “Brand Necessary” and the member chooses a preferred/non-preferred brand name medication over its available generic equivalent, the member will be required to pay the generic co-payment. In addition to paying the generic co-payment, the member will also be responsible for paying the difference in the cost between the generic and the preferred/non-preferred brand name drug. This difference in member cost is sometimes referred to as an ancillary charge.
Days Supply
A member will be charged one co-payment per 30 day retail supply of a prescription drug. Maintenance medications are those prescription drugs that a member may obtain for a period of up to 90 days. The member will be charged one co-payment per 30-day supply.
Other Coverage Rules
For specific prescribed drugs, the plan may impose certain requirements. Those requirements may include prior medical authorization, limits on the day supply amount of the prescribed medication, and/or limits on the number of approved units/labels of medication per prescription.
Progressive Drug Management Program (PDMP)
In partnership with physicians and pharmacists, Express Scripts has developed a Progressive Drug Management Program. The PDMP is a prescriptions drug protocol management resource that promotes the appropriate utilization of first line medications and/or therapeutic categories. PDMP is a clinically justified program that assists your physician in prescribing the most appropriate and cost-efficient therapeutic treatment strategy for you and/or your family. Under this program, your physician will usually prescribe a proven, less expensive medication that is known to be safe and effective, as an initial treatment strategy.
PREFERRED PROVIDER OPTION HEALTH PLAN (PPO)
On-line provider directories for the PPO plan can be accessed at http://www.healthygeorgia.com/, or by calling 1-800-675-6492 for providers within the state of Georgia, or by calling 1-800-424-8950 for national providers.
FEATURE
PPO PLAN, Georgia In-Network
PPO PLAN, National In-Network PPO PLAN, Out-of-Network
Pre-Existing Conditions None None None Maximum Lifetime Benefit
$2 million
$2 million $2 million
Maximum Annual Deductible
$300 individual
$900 family$ 400 individual
$1200 family
$400 individual
$1,200 familyMaximum Annual Out-of-Pocket
(Stop Loss)$1,000 individual
$2,000 family
$2000 individual
$4000 family
$2,000 individual
$4,000 family
Physician Ofc Visit $100% of network rate after $20 co-payment per visit-applies to ofc visit only(non-surgical svcs) 100% of network rate after $20 co-payment per visit-applies to ofc visit only(non-surgical svcs) 60% of network rate for non-surgical svcs. Wellness Care/Preventive Care $750/ person per plan year paid at 100%; not subject to deductible; $20 co-payment per ofc visit. $750/ person per plan year paid at 100%; not subject to deductible; $20 co-payment per ofc visit. Not covered. Charges do not apply to annual deductible or annual-out of pocket maximum. Lab Svcs provided in Physician's Ofc (exclusive of wellness/preventive care 90% of network rate; subject to deductible. 80% of network rate; subject to deductible. 60% of network rate; subject to deductible and balance billing. Maternity Care (prenatal, delivery, postnatal) 90% of network rate after an initial visit co-payment of $20. 80% of network rate after an initial visit co-payment of $20. 60% of network rate; subject to deductible and balance billing. Outpatient Surgery 90% of network rate 80% of network rate 60% of network rate; subject to deductible and balance billing. Second Surgical Opinions 100% of network rate after a $20 co-payment per visit; not subject to deductible. 100% of network rate after a $20 co-payment per visit, not subject to deductible 60% of network rate; subject to deductible and balance billing. Treatment of TMJ 90% of network rate.
Lifetime benefit limit of $1,100.
80% of network rate. Lifetime benefit limit of $1,100. 60% of network rate; subject to deductible and balance billing. Lifetime benefit limit of $1,100. Allergy Testing 90% of network rate 80% of network rate 60% of network rate; subject to deductible and balance billing. Allergy Shots & Serum 100% for allergy shots & serum; not subject to deductible. 100% for allergy shots & serum; not subject to deductible. 60% of network rate; subject to deductible and balance billing. In-Patient Hospital Physician Care/Surgery 90% of network rate subject to deductible and balance billing 80% of network rate subject to deductible and balance billing 60% of network rate; subject to deductible and balance billing. In-patient Hospital Svcs Other than for Emergency Room Care 90% of network rate 80% of network rate 60% of contracted State Georgia DRG rate; subject to deductible and balance billing. Maternity Care In-Hospital (Delivery) 90% of contracted DRG rate 80% of network rate 60% of contracted State of Georgia rate; subject to deductible and balance billing. In-patient Hospital Lab Svcs 90% of network rate 80% of network rate 60% of contracted State of Georgia DRG rate; subject to deductible and balance billing. Inpatient Hospice Care 100% of network rate 100% of network rate 60% of network rate; subject to deductible and balance billing. Outpatient Physician Care/Surgery Physician Svcs 90% of network rate 80% of network rate 60% of network rate; subject to deductible and balance billing Care in Hospital Emergency Room 90% of network rate after a $75 co-payment per visit; co-payment is reduced to $50 if referred by MedCall. Co-payment is waived, if admitted within 24 hrs. 90% of network rate after a $75 co-payment per visit;co-payment is reduced to $50 if referred by MedCall. Co-payment is waived if admitted within 24 hrs. 90% of network rate after a $75 co-payment per visit; co-payment is reduced to $50 is referred by MedCall. Co-payment is waived if admitted within 24 hrs. Outpatient Lab Svcs 90% of network rate 80% of network rate 60% of network rate; subject to deductible and balance billing. Urgent Care Svcs 90% of network rate after $20 co-payment per visit. 80% of network rate after $20 co-payment per visit. 60% of network rate; subject to deductible and balance billing Home Nursing Care 90% of network rate; limited to 2 hours of care in a 24-hour day. 80% of network rate; limited to 2 hours of care in a 24-hour day 60% of network rate; limited to 2 hours of care in a 24-hour day; subject to deductible and balance billing Outpatient Hospice Care 100% of network rate 100% of network rate 60% of network rate; subject to deductible and balance billing. Extended Care Facility Not available Not available Not available Home Hyperalimentation 90% of network rate; lifetime limit of $500,000 80% of network ratelifetime limit of $500,000 60% of network rate; subject to deductible and balance billing. Ambulance Svcs 90% of network rate 90% of network rate 90% of network rate; subject to the MRN/GA First in-network deductible; subject to balance billing. Cochlear Implants 90% of network rate 80% of network rate 60% of network rate; subject to deductible and balance billing. Durable Medical Equipment 90% of network rate 80% of network rate 60% of network rate; subject to deductible and balance billing. Outpatient Short Term Rehabilitation Svcs 90% of network rate; Physical, speech, cardiac and occupational therapies are limited to 40 visits per incident type per plan year 80% of network rate; Physical, speech, cardiac and occupational therapies are limited to 40 visits per incident type per plan year. 60% of network rate; subject to deductible and balance billing; Physical, speech, cardiac, and occupational therapies are limited to 40 visits per incident type per plan year. Chiropractic Care
90% of network rate;limited to 40 visits per member per plan year.
80% of network rate; limited to 40 visits per member per plan year. 60% of network rate; subject to deductible and balance billing; limited to 40 visits per member per plan year.
Surgical Extraction of Impacted Teeth
(Medical benefits are not available for partially erupted teeth)
90% of network rate 80% of network rate 60% of network rate Dental/Oral Care
(Not covered other than accidental injury to natural teeth)
90% of network rate 80% of network rate 60% of network rate Disease State Management Program
(Diabetes, Oncology, Congestive Heart Failure, Asthma, and Cardiovascular Disease with Stroke Overlay Program)
100% of vendor negotiated rates; not subject to deductible. (To receive plan benefits coverage, participation in the appropriate DSM program is required)
80% of vendor negotiated rates; not subject to deductible. (To receive plan benefits coverage, participation in the appropriate DSM program is required)
Not applicable Mental Health/Substance Abuse Facility Charges for Inpatient In-network: 90% of network rate; subject to deductible and to a separate $100 hospital deductible; maximum benefit of 60 combined mental health and substance abuse days per person per plan year; substance abuse coverage limited to 3 episodes per lifetime. Provider Charges for Inpatient In-Network: 80% of network rate; maximum of 60 visits per person per plan year. For outpatient: 80% of network rate with authorization from Magellan.
Facility Charges for Inpatient In-Network: 90% of network rate; subject to deductible and to a separate $100 hospital deductible; maximum benefits of 60 combined mental health and substance abuse days per person per plan year; substance abuse coverage limited to 3 episodes per lifetime. Provider Charges for Inpatient In-Network: 80% of network rate; maximum of 60 visits per person per plan year. For outpatient: 80% of network rate with authorization from Magellan.
Not applicable Prescription Drugs
Prescription Drugs
3-Tier Co-payment Structure (Vendor: Express Scripts)
Pharmacy Program
Cont'd1) Generic: $10 co-payment for up to a 30-day supply
2) Preferred Brand Name: $25 co-payment for up to a 30-day supply
3) Non-Preferred Brand Name: 20% co-payment of drug cost, with a minimum co-payment of $40/maximum co-payment of $100, for up to a 30-day supply.
Quarterly Out-of-Pocket Maximum for generic and preferred brand name prescriptions:
Employee:$450/quarter
Employee + Child: $900/quarter
Employee + Spouse: $900/quarter
Family: $1,350/quarter
1) Generic: $10 co-payment for up to a 30-day supply
2) Preferred Brand Name: $25 co-payment for up to a 30-day supply
3) Non-Preferred Brand Name: 20% co-payment of drug cost, with a minimum co-payment of $40/maximum co-payment of $100, for up to a 30-day supply.
Quarterly Out-of-Pocket Maximum for generic and preferred brand name prescriptions:
Employee: $450/quarter
Employee + Child: $900/quarter
Employee + Spouse: $900/quarter
Family: $1,350/quarter
1) Generic: $10 co-payment for up to a 30-day supply
2) Preferred Brand Name: $25 co-payment for up to a 30-day supply
3) Non-Preferred Brand Name: 20% co-payment of drug cost, with a minimum co-payment of $40/maximum co-payment of $100, for up to a 30-day supply.
Quarterly Out-of-Pocket Maximum for generic and preferred brand name prescriptions: Employee: $450/quarter
Employee + Child: $900/quarter
Employee + Spouse: $900/quarter
Family: $1,350/quarter
If the usual and customary charge for a generic or preferred brand name drug is less that the co-payment amount, the member will pay the lesser of the two. If a physician indicates "Brand Necessary" on a prescription, then only a preferred or non-preferred brand name medication can be dispensed. The member will be responsible for the preferred/non-preferred brand name medication co-payment . If a physician does not indicate "Brand Necessary" and the member chooses a preferred/non-preferred brand name medication over its available generic equivalent, the member will be required to pay the generic co-payment. In addition to paying the generic co-payment, the member will also be responsible for paying the difference in the cost between the generic and the preferred/non-preferred brand name drug. This difference in member cost is sometimes referred to as an ancillary charge.Days Supply
A member will be charged one co-payment per 30 day retail supply of a prescription drug. Maintenance medications are those prescription drugs that a member may obtain for a period of up to 90 days. The member will be charged one co-payment per 30-day supply.Other Coverage Rules
For specific prescribed drugs, the plan may impose certain requirements. Those requirements may include prior medical authorization, limits on the day supply amount of the prescribed medication, and/or limits on the number of approved units/labels of medication per prescription.Progressive Drug Management Program (PDMP)
In partnership with physicians and pharmacists, Express Scripts has developed a Progressive Drug Management Program. The PDMP is a prescriptions drug protocol management resource that promotes the appropriate utilization of first line medications and/or therapeutic categories. PDMP is a clinically justified program that assists your physician in prescribing the most appropriate and cost-efficient therapeutic treatment strategy for you and/or your family. Under this program, your physician will usually prescribe a proven, less expensive medication that is known to be safe and effective, as an initial treatment strategy.HIGH DEDUCTIBLE HEALTH PLAN (HDHP/HSA)
This plan is administered by Blue Cross/Blue of Georgia, and provides major medical coverage including diagnosis and/or treatment of illness, injury or medical conditions. Benefits include physician, hospital, surgical, disease state management, mental health/substance abuse and transplant services.
The High Deductible Health Plan is Health Savings Account (HSA) qualified. The University System nor Blue Cross/Blue Shield of Georgia administrate the HSA. If you enroll in the High Deductible Health Plan and wish to establish a Health Savings Account (HSA), you may do so at a bank or financial institution that offers the HSA. IRS guidelines do not allow both a Health Savings Account (HSA) and a Flexible Health Spending Account. If you are considering opening an HSA, you are advised to consult with a qualified tax advisor.
FEATURE HIGH DEDUCTIBLE PLAN /HSA Pre-Existing Conditions
None
Max. Lifetime Benefit
$2 million
Max. Annual Deductible
$1500 Individual (In-Network)
$3000Family (In-Network)(entire family deductible must be met for those enrolled in options other than employee only, before plan starts to pay its percentage)
Max. Annual Out-of-Pocket
$3000 Individual (In-Network)
$6000 Family (In-Network)$6000 (Out-of-Network)
$12,000 (Out-of-Network)Physician Office Visit
90% of UCR, in-network
70% of UCR, out-of-networkWellness Care/Preventive Care
$750 per person, paid at 100% in network; paid at 70% out of network; not subject to deductible.
Laboratory Services
(exclusive of wellness/preventative care)90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkMaternity Care
(Prenatal, Delivery and Postnatal)90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkOutpatient Surgery
90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkSecond Surgical Opinions
90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkAllergy Testing
90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkAllergy Shots & Serum
90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkTreatment of TMJ
90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkInpatient Hospital Services for Physician Care/Surgery
90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkHospital Services Other than those for Emergency Room Care
90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkMaternity Care-Inpatient Hospital (Delivery)
90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkInpatient-Hospital Lab Services
90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkInpatient Hospice Care
90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkInpatient Treatment of TMJ
90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkOutpatient Hospital Svcs for Physician Care/Surgery
90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkOutpatient Facility Selected by Treating Physician
90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkCare in a Hospital Emergency Room
(treatment of an emergency medical condition or injury)90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkOutpatient Hospital/ Facility Laboratory Services
90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkUrgent Care Services
90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkHome Nursing Care
90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkExtended Care Facility
90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkHome Hyperalimentation
90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkOutpatient Hospice Care
90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkCochlear Implants
90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkAmbulance Services
90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkDurable Medical Equipment
90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkOutpatient Short Term Rehabilitation Svcs
90% of UCR charges, In-Network
70% of UCR charges, Out-of-Network
Limited to 20 visitsChiropractic Care
90% of UCR charges, In-Network
70% of UCR charges, Out-of-Network; limited to 20 visits per plan year.Surgical Extraction of Impacted Teeth
(medical benefits are not available for partially erupted teeth)90% of UCR charges, In-Network
70% of UCR charges, Out-of-NetworkDisease State Management Training & Edu. Svcs.
(Diabetes, Oncology, Congestive Heath Failure, Asthma, and Cardiovascular Disease with Stroke Overlay Program and Obesity/Eating Disorder Program)100% of vendor negotiated rates; not subject to deductible.
Dental/Oral Care
Not covered; other than accidental injury to natural teeth which is covered at 90% of UCR charges, In-Network; 70% of UCR charges, Out-of-Network
Mental Health/Substance Abuse
Inpatient:
90% of UCR charges, maximum benefit coverage of 30 days per plan year; 90 days per person per lifetime.
Outpatient:
90% of UCR charges, maximum of 20 visits per person per plan year.Organ & Transplant Program
(Prior approval required by UNICARE)90% of vendor network rate at a UNICARE contracted transplant center. Lifetime benefit limit for expenses related to the donor search using a UNICARE contracted transplant center is $10,000. Lifetime benefit limit of $500,000.
Pharmacy Benefits
90%; subject to deductible
BLUE CHOICE HEALTH PLAN
HEALTH MAINTENANCE ORGANIZATION (HMO)
This is a healthcare program that offers employees an alternative healthcare plan. Members in this plan must use the Blue Choice HMO network providers. The closest participating physicians to Carrollton currently are in Villa Rica. This is an in-network benefit level plan; there is no coverage for out-of-network in the Blue Choice HMO Plan. Participants must declare a primary care physician from the HMO network at the time of enrollment. On-line provider directory information can be obtained at http://www.bcbsga.com/, or by calling their customer service line at 1-800-424-8950.
BLUE CHOICE (HMO)
PLAN DESIGN FEATURES Max. Lifetime Benefit $2 million Annual Medical Deductible None Annual Pharmacy Deductible None Maximum Annual Out-of-Pocket (Stop Loss) Individual-No annual maximum ; Family-No annual maximum Pre-Existing Conditions None
PHYSICIAN SERVICES IN OFFICE SETTING COPAYS Office visits: Preventive Care Well-child care, immunization $15 Co-payment per visit Physical Examinations $15 Copayment per visit Annual gynecology examination (No PCP referral
Required-Must use network provider)
$15 Copayment per visit Routine Eye Exams Not Covered Routine Hearing Exams Not Covered Illness or Injury Primary Care Physician (PSP) office visit includes
Lab, radiology and office surger)
$15 Copayment Specialty care physician office visit (PCP referral
Required)
$15 Copayment per visit Maternity Services (prenatal, delivery and post-
partum
All related physician care services are covered by $15 copayment at first office visit Allergy care (primary care physician office visit,
Specialty care, allergy shots, serum and testing)
$15 Copayment per visit Vision care services provided by network
Ophthalmologist or optometrist for the treatment
Of acute conditions (No PCP referral required)
$15 Copayment Covered Services provided by a network dermatologist
(No PCP referral required)
$15 Copayment Dental Care Not covered except for accidental injury to natural teeth or extraction of impacted teeth100% covered for x-ray services EMERGENCY ROOM SERVICES Life Threatening illness, serious accidental
Injury or with a PCP referral
$75 Copayment; waived if admitted Non-emergency use of the emergency room Not covered INPATIENT HOSPITAL SERVICES COPAYS Daily room, board and general nursing care at
Semi-private room rate, ICU/CCU charges;
Other medically necessary hospital charges such
Diagnostic x-ray and lab services; newborn
Nursery care.
Plan pays 100% after a $200 copay Physician Services (surgery, anesthesia, radiology,
pathology, etc.)
Plan pays 100% after a $200 copay OUTPATIENT SERVICES In-Network Benefits Level (no coverage for out-of network) Facility/hospital charges (including diagnostic
x-ray and lab services)
Play pays 100% Physician Services (surgery, anesthesia, radiology,
Pathology, etc)
Plan pays 100%, after a $50 copay Therapy Services
-Speech Therapy
-Physical, Occupational Therapy
-Respiratory Therapy
-Radiation Therapy, Chemotherapy
-Chiropractic Care (No referral required)
$15 Copayment
$15 Copayment; 40 visit calendar year maximum
Plan pays 100%; 40 visit calendar year maximum
Plan pays 100%
$15 Copayment; 20 visit calendar year maximum
Behavioral Health/Substance Abuse Services
Provided through Magellan Behavioral Health)
No PCP referral required. Services must be authorized by Magellan Health at 1-800-292-2879 Inpatient (facility and physician fee) Plan pays 100% after a $200 copay; 30-day calendar year maximum Outpatient $25 copayment; 20-visit calendar year maximum Inpatient alcohol substance abuse detoxification Plan pays 100%; 6-day calendar year maximum (combined with other inpatient behavioral health and substance abuse benefits) OTHER SERVICES Skilled Nursing Facility Plan pays 100%; 30-day calendar year maximum Home Health Care Plan pays 100%; 120-visit calendar year maximum Hospice Care Plan pays 100%; $10,000 lifetime maximum Ambulance Plan pays 100% when medically necessary PRESCRIPTION DRUGS Prescription must be written by a network physician or an emergency room physician Blue Choice participating pharmacies include: CVS,Eckerd, Kmart, Kroger, Publix, Walgreens, Wal-Mart, and many independent pharmacies $10 Co-payment for Generic (up to 30 day supply)
$25 Co-payment for Name Brand (up to 30 day
Supply)
CONSUMER CHOICE OPTION:
If you select the Consumer Choice Option for the PPO or HMO plans, and your personal physician or hospital is not a member of the respective PPO or HMO networks, the Georgia Consumer Choice statute permits you to nominate a provider to render medical care at in-network levels of benefit coverage. A physician or hospital must have the appropriate licensing; must agree to the PPO's or HMO's contractual terms and conditions for network providers; and must accept the plan's reimbursement rates. However, a physician or a hospital that has been nominated by a member may decline to participate in the PPO or HMO network. If you select a Consumer Choice option, you will be required to continue under that healthcare plan choice for the remainder of the plan year. While the premium for Consumer Choice is higher, the benefit will be identical to the in-network coverage.
MONTHLY PREMIUM RATES FOR HEALTH PLAN YEAR 2008
PLAN EMPLOYEE ONLY EMPLOYEE+CHILD EMPLOYEE+SPOUSE SELF+FAMILY BOR Traditional Indemnity Plan BOR Preferred Provider Organization(PPO) BOR Preferred Provider Organization(PPO) Consumer Choice* Blue Choice HMO
Blue Choice HMO
Consumer Choice*
High Deductible Health Plan/HSA (HDHP/HSA) $ 22.70
*Consumer Choice Option: This coverage allows you to nominate an out-of-network provider to function as an in-network provider for you, subject to plan and provider approval. This election is irrevocable during the plan year.
The dental plan is a self-insured indemnity plan through the Board of Regents of the University System of Georgia. Blue Cross/Blue Shield of Georgia administers the plan and payment of claims. Enrollment in the dental plan is only offered to employees during their first 31 days of employment. There are no open enrollment periods for the dental plan.
According to the indemnity dental plan design, a member may elect dental coverage only at the time of initial eligibility (within first 31 days of employment). A qualifying even