Get documents about "Monthly Premiums Effective SDCERS Home
Document Sample
RETIREE HEALTH INSURANCE
Benefit Information
&
Resource Guide
MAJOR PLAN CHANGES
FOR FY 2008
See page 5 for details
FY 2008
Open Enrollment Period
June 4 – July 3, 2007
CONTENTS
Who To Call If You Have Questions………………………………………………. 1
Instructions …………………………………………………………………………… 2
General Information …………………………………………………………………. 3
Major Plan Changes for FY2008 …………………………………………………… 5
Making Changes Between Plans ………………………………………………….. 5
City of San Diego – Sponsored Health Insurance Plans …………………….. 9
Kaiser Permanente HMO ………………………………………………………... 10
Kaiser Permanente Senior Advantage …………………………………………. 12
PacifiCare HMO …………………………………………………………………… 14
PacifiCare PPO …………………………………………………………………… 16
PacifiCare Secure Horizons …………………………………………………….. 18
PacifiCare Senior Supplement …………………………………………………. 20
Union – Sponsored Health Insurance Plans …………………………………... 23
L127 – CIGNA …………………………………………………………………….. 24
MEA – Sharp HMO ………………………………………………………………. 26
City of San Diego - Dental & Vision Plans …………………………………….. 29
Concordia Dental PPO ………………………………………………………….. 30
PacifiCare Vision …………………………………………………………………. 31
Reimbursement Benefit …………………………………………………………… 33
Eligibility & Coverage ……………………………………………………………… 34
o Health Eligible Retiree Reimbursement …………………………….. 34
o Non Health Eligible Retiree Reimbursement ..……………………… 34
o Medicare Part B Reimbursement ……………………………………. 35
o Death in the line of Duty Widow Reimbursement ………………….. 35
Medicare Information ……………………………………………………………….. 36
Forms …………………………………………………………………………………. 39
Health Insurance Reimbursement ……………………………………………….. 39
Medicare Part B Reimbursement ……………………………………………….. 41
Public Safety Officer (PSO) Affidavit ……………………………………………. 43
CareCounsel ………………………………………………………………………….. 45
WHO TO CALL IF YOU HAVE QUESTIONS
Depending on the information you need, there are several organizations you may contact.
For City of San Diego sponsored health, dental and vision plans, please contact the
SDCERS Open Enrollment Help Desk; For union sponsored plans, please call MEA or
Local 127 directly. For general questions about health insurance or help understanding your
benefits, CareCounsel is available to answer questions and to help you work through issues
with your insurance plan or healthcare providers.
CITY SPONSORED HEALTH, DENTAL & VISION PLANS
SDCERS health benefit representatives are available Monday through Friday 8:00am
to 5:00pm PDT, to answer questions and provide plan information for the following
City-sponsored health, dental and vision insurance plans only.
• PacifiCare HMO • Kaiser HMO
• PacifiCare PPO • Kaiser Senior Advantage
• PacifiCare Secure Horizons • Concordia Dental PPO
• PacifiCare Senior Supplement • PacifiCare Vision
SDCERS’ Open Enrollment Help Desk
(619) 525-3664 or (800) 774-4977
Forms and a copy of this booklet can be viewed and downloaded from the SDCERS
website at: www.sdcers.org. If you don’t have access to our website please call us at
(619) 525-3664 or (800) 774-4977 to request forms and information.
UNION SPONSORED HEALTH PLANS
All inquires regarding the MEA Sharp HMO and Local 127 Cigna plans should be
directed to the respective unions:
Local 127 (AFL-CIO) …………………………………………………. (619) 640-4939
CIGNA PPO
Municipal Employees’ Association (MEA) ………………………. (619) 264-6632
SHARP HMO (888) 950-6632
CARECOUNSEL
For confidential healthcare assistance, SDCERS contracts with CareCounsel to
provide retirees with healthcare education, information, advocacy and coaching.
CareCounsel does not provide medical advice or treatment but serves as an
advocate to help Members work through billing and coverage issues. CareCounsel
can be reached M-F 8:30am to 5:00pm PST at (888)227-3334.
MEDICARE
Website: www.medicare.gov ………………………............................1-800-MEDICARE
1
INSTRUCTIONS
This year’s open enrollment period is from June 4 – July 3, 2007. During this period, you
may make any of the following changes or additions to your health insurance coverage:
► Enroll in a Plan ► Change Carriers ► Add Dependents*
* New dependents can be added anytime during the year, within 30 days of a birth, adoption, marriage,
loss of COBRA coverage, or registration of a domestic partnership in the state of California.
WHAT DO YOU WANT TO DO?
► KEEP YOUR CURRENT HEALTH INSURANCE PLAN:
Confirm that your plan has not been eliminated for the coming coverage period
(see Major Plan Changes on page 5). If it is still being offered then no further action
by you is necessary. Your coverage will continue with any plan coverage or premium
changes made automatically for you effective 8/1/07.
► SIGN UP FOR A NEW PLAN BECAUSE YOUR OLD PLAN HAS BEEN ELIMINATED:
Complete an enrollment form for the new plan of your choice. Submit all forms and
attachments to SDCERS no later than 5:00 pm, July 3, 2007.
► ADD OR CHANGE DEPENDENT COVERAGE:
Complete an enrollment form for your dependent(s). Submit all forms and attachments
to SDCERS no later than 5:00 pm, July 3, 2007.
► CHANGE BETWEEN EXISTING PLANS:
Complete a termination form for your current plan and an enrollment form for the plan
in which you wish to enroll. Submit all forms and attachments to SDCERS no later
than July 3, 2007. If you are changing health insurance carriers and you are enrolled
in Medicare, please include a copy of your Medicare card when you return your
enrollment form.
Deadline to Submit all Health Insurance Forms to SDCERS:
TUESDAY - JULY 3, 2007
Return all forms to:
San Diego City Employees’ Retirement System (SDCERS)
401 B Street, Suite 400 ♦ San Diego, CA 92101 ♦ Fax (619) 595-0513
IMPORTANT! Forms received by SDCERS after July 3, 2007, will not be processed.
2
GENERAL INFORMATION
ELIGIBILITY COVERAGE AMOUNT
HEALTH ELIGIBLE The maximum coverage/reimbursement
amount of premiums for Health Eligible retirees
Retirees who: for FY2008 (7/1/07 through 6/30/08) is $694.44
per month for non-Medicare eligible retirees
• Are eligible for and receive a retirement
and $654.00 per month for Medicare eligible
allowance from SDCERS;
retirees, or the Member’s actual premium cost,
• Were on the active payroll of the City of whichever is less. Medicare Part B premiums
San Diego on or after October 5, 1980; (currently $93.50 per month) will continue to be
and reimbursed in addition to reimbursement for
health insurance premiums incurred. Retirees
• Were retired on or after October 6, 1980
must be properly enrolled in Medicare to be
from the City of San Diego.
eligible to receive the Medicare
reimbursement.
NON-HEALTH ELIGIBLE The maximum reimbursement amount for Non-
Health Eligible retirees is $1,200 ($100
Retirees who: maximum per month) for FY2008 (July 1, 2007
– June 30, 2008). Reimbursements cover
• Are eligible for and receive a retirement
medical expenses and Medicare Part B
allowance from SDCERS;
premiums incurred during FY2008.
• Retired or terminated City employment
before October 6, 1980, from City of San
Diego employment.
Pension Deduction Changes
Changes in pension deductions, due to rate changes and requests received during the
FY2008 open enrollment period, will be reflected on retiree pension checks dated July 31,
2007.
Are You Moving Out of San Diego County or California
Most health plans have a limited provider service area and you may find that your current
health plan does not provide coverage if you move out of San Diego County or California.
Please contact your health plan directly 6-8 weeks prior to moving in order to determine if
your new residence will be out of their service area. If you determine that your new
residence is outside of their service area, immediately contact SDCERS to obtain forms to
make the necessary changes.
*Plan changes due to a permanent move out of the provider’s service area can be made at any time
during the year including the Open Enrollment period.
3
Pension Protection Act of 2006 Retired Public Safety Officer Tax Benefit
The Pension Protection Act (PPA) of 2006 permits eligible retired Public Safety Officers
(PSO) to exclude up to $3,000 of distributions from their SDCERS retirement benefit for
direct payment of health care premiums. These excluded distributions will be used by
SDCERS for direct payment of qualified health insurance premiums for the qualified
Member, their spouse, and/or dependents. This Internal Revenue Service (IRS) tax benefit
became effective January 1, 2007.
A “Public Safety Officer,” as defined by the PPA is “an individual serving a public agency in
an official capacity, with or without compensation, as a law enforcement officer, as a
firefighter, as a chaplain, or as a member of a rescue squad or ambulance crew.” Omnibus
Crime Control Act of 1968, 42 U.S.C 3796b(9)(A).
In addition to meeting the PPA definition of PSO, an individual must:
• Have separated from City of San Diego employment as a PSO,
• Have a taxable SDCERS retirement allowance,
• Have health insurance premiums deducted directly from their SDCERS retirement
allowance for coverage of the Member, their spouse or dependents,
• Have attained the normal retirement age at retirement, or retired by reason of disability.
Substantiating eligibility as a PSO is the responsibility of the Member. If you believe
you retired from the City of San Diego in a position that is qualified as a PSO and are
eligible for this tax benefit, please submit to SDCERS a completed Public Safety Officer
(PSO) Affidavit form located on page 43 of this booklet. SDCERS does not advise on tax
issues of any kind. For additional questions on this or other tax issues relating to your
retirement benefits, please consult with a qualified tax professional.
DON’T FORGET!
All Health Insurance Forms Must be Submitted to SDCERS
No later than:
TUESDAY - JULY 3, 2007*
*Forms received by SDCERS after July 3, 2007, will not be processed.
Return Your Forms to:
San Diego City Employees’ Retirement System (SDCERS)
401 B Street, Suite 400 ♦ San Diego, CA 92101 ♦ Fax (619) 595-0513
4
MAJOR PLAN CHANGES FOR FY 2008
IMPORTANT NOTICE!
♦ The following union-sponsored health insurance plans have
been eliminated for FY2008:
• Local 145 - HealthNet HMO
• Local 145 - HealthNet PPO
• SDPOA - HealthNet HMO
• SDPOA - HealthNet PPO
♦ If you are currently enrolled in one of these plans, your coverage
will terminate on 7/31/07
If you wish to maintain health insurance coverage, you must enroll in
a new plan. To enroll in a City-sponsored plan, simply complete an
enrollment form for the plan you would like to participate in and submit it to
SDCERS no later than July 3, 2007.
Please note that all current participants in the above plans will receive
information directly from PacifiCare regarding comparable plans.
DENTAL & VISION INSURANCE
For FY2008, the City of San Diego is offering Concordia Dental PPO and PacifiCare
Vision insurance to its retirees. While the City is making these plans available to retirees,
they will not be paying for any part of the premiums or deductibles. If you enroll in one of the
following plans, SDCERS will deduct the premium amount from your monthly retirement
allowance. For more information about City-offered dental and vision insurance plans,
please see page 29.
MAKING CHANGES BETWEEN PLANS
Please follow the instructions on the following two pages when making changes between
plans. Read the information under both your existing plan and the plan you want to enroll in
for FY2008. If you are changing health insurance carriers and you are enrolled in Medicare,
please include a copy of your Medicare card when returning your enrollment form. Note that
any changes between Medicare eligible plans must be made during the open
enrollment period. If you have additional questions, please call the SDCERS Help Desk at
(619) 525-3664 or (800) 774-4977 to speak with a representative.
5
KAISER PERMANENTE
HMO PLAN (Non-Medicare Eligible)
• If you are currently enrolled in this plan, have recently reached age 65, are eligible
for Medicare A and B, and wish to stay with Kaiser Permanente, you must enroll in
the Senior Advantage plan.
• Those individuals who are 65 or older and are not eligible for Medicare A and B,
may remain in the HMO plan but must submit written proof of ineligibility to
SDCERS.
• If you are currently enrolled in this plan and want to change to any of the available
PacifiCare plans, you must submit a Kaiser Permanente disenrollment form and
an enrollment form for the PacifiCare plan of your choice. If you are enrolling in a
Medicare eligible plan, you must submit an election form assigning Medicare A
and B to that plan.
SENIOR ADVANTAGE PLAN (Medicare Eligible)
• You must be over age 65 to be eligible for this plan.
• You must have Medicare A and B to be eligible for this plan.
• You must complete an election form assigning Medicare A and B to this plan.
• If you are currently enrolled in this plan and wish to change to PacifiCare’s Secure
Horizon’s or Senior Supplement plans for FY2008, please submit a Kaiser
Permanente and Senior Advantage disenrollment form, and an enrollment form for
the PacifiCare plan you are choosing.
PACIFICARE
HMO PLAN (Non-Medicare Eligible)
• If you are currently enrolled in this plan, have reached age 65, are eligible for
Medicare A and B, and wish to stay with PacifiCare, you must enroll in the Secure
Horizons plan. Please complete a Secure Horizon’s enrollment form assigning
Medicare to the Secure Horizon’s plan.
• Those individuals who are 65 or older, but not eligible for Medicare A and B, may
remain in the HMO plan but must submit written proof of ineligibility to SDCERS.
• If you are currently enrolled in this plan and want to change to any of the Kaiser
Permanente plans, you must submit a PacifiCare disenrollment form and a Kaiser
Permanente enrollment form. If you are enrolling in a Medicare eligible plan, you
must submit an election form assigning Medicare A and B to that plan.
6
PPO PLAN (Non-Medicare Eligible)
• If you are currently enrolled in this plan and are eligible for Medicare A and B, and
wish to stay with PacifiCare, you must enroll in the Senior Supplement plan.
• Those individuals who are 65 or older, but not eligible for Medicare A and B, may
remain in the PPO plan but must submit written proof of ineligibility to SDCERS.
• If you are currently enrolled in this plan and need to change to PacifiCare’s Senior
Supplement plan, you must complete a Senior Supplement enrollment form
assigning Medicare A & B to the Senior Supplement plan.
• If you are currently enrolled in this plan and want to change to any of the Kaiser
Permanente plans, you must submit a PacifiCare disenrollment form and a Kaiser
Permanente enrollment form. If you are enrolling in a Medicare eligible plan, you
must submit an election form assigning Medicare A and B to that plan.
SECURE HORIZONS (Medicare Eligible)
• You must be over age 65 to be eligible for this plan.
• You must have Medicare A and B to be eligible for this plan.
• You must complete an election form assigning Medicare A and B to this plan.
• If you are currently enrolled in Secure Horizons and wish to change to Senior
Supplement, please submit a Senior Supplement enrollment form and an election
form assigning Medicare A & B to the Senior Supplement plan.
• If you are currently enrolled in Secure Horizons and wish to change to Kaiser
Permanente’s Senior Advantage plan for FY2008, please submit a PacifiCare
disenrollment form, a Senior Advantage enrollment form, and an election form
assigning Medicare A & B to the Senior Advantage plan.
SENIOR SUPPLEMENT (Medicare Eligible)
• You must have Medicare A and B to be eligible for this plan.
• You must complete a Senior Supplement enrollment form.
• If you are currently enrolled in Senior Supplement and wish to change to Secure
Horizons, please submit a PacifiCare disenrollment form and a Secure Horizons
enrollment form assigning Medicare A & B to the Secure Horizons plan.
• If you are currently enrolled in Senior Supplement and wish to change to Kaiser
Permanente’s Senior Advantage plan for FY2008, please submit a PacifiCare
disenrollment form, a Kaiser enrollment form and a Senior Advantage form
assigning Medicare A & B.
7
This Page Intentionally Left Blank.
8
City-Sponsored
Retiree Health Insurance Plans
The following information is a summary of the benefits and premiums for City of San Diego
sponsored health insurance plans for FY2008 including:
• Kaiser HMO (non-Medicare Plan)
• Kaiser Senior Advantage (Medicare Plan)
• PacifiCare HMO (non-Medicare Plan)
• PacifiCare PPO (non-Medicare Plan)
• PacifiCare Secure Horizons (Medicare Plan)
• PacifiCare Senior Supplement (Medicare Plan)
If you have questions about the following City sponsored plans or would like to have
additional information sent to you, please contact the SDCERS Open Enrollment Help Desk
at (619) 525-3664.
9
SUMMARY OF HEALTH PLAN
City of San Diego Sponsored
KAISER PERMANENTE
HMO (Non-Medicare Plan)
Customer Service: Choice of Physician and Hospital:
• 1-800-464-4000 • Assignment of Primary Care Provider
• Group # 104303 within the Kaiser Permanente of
California Network
Website: Prescription Orders:
www.kp.org • Call the phone number on your current
prescription or contact Customer Service
for the nearest pharmacy
• Request refills or check status on
www.kp.org
Monthly Premiums Effective 8/1/07 – 7/31/08
Monthly out of
Total Monthly pocket cost to
COVERAGE Health Eligible*
Premium
Retiree
Subscriber Only $568.91 $0
Subscriber + One Dependent With
$864.95 $ 296.04
Medicare
Subscriber + One Dependent
$1,137.82 $ 568.91
Without Medicare
Subscriber + One Dependent With
Medicare and Additional $1,433.86 $ 864.95
Dependent(s) Without Medicare
Subscriber + Two or More
$1,706.73 $ 1,137.82
Dependents Without Medicare
* See page 3 for Health Eligible Retiree definition
10
COVERED HEALTH SERVICES COVERAGE
PLAN YEAR DEDUCTIBLES No deductible
PLAN YEAR OUT-OF-POCKET MAXIMUM $1,500/$3,000 per calendar year
Generic: $10 co-pay for 100 day supply
PRESCRIPTION DRUGS
Brand: $20 co-pay for 100 day supply
$50 co-payment per visit
EMERGENCY ROOM Waived if admitted to hospital - hospital visit co-payment would
apply instead
OFFICE VISITS, ROUTINE CHECK-UPS &
$10 co-payment per visit
PHYSICIAN VISITS
HOSPITAL $100 co-payment per admission
INTENSIVE CARE UNIT $100 co-payment per admission
SKILLED NURSING FACILITY (SNF) No charge
INPATIENT SURGERY Covered under Hospital admission fee
OUT PATIENT SURGERY $50 co-payment per procedure
PHYSICAL THERAPY $10 co-payment per visit
INPATIENT REHABILITATION $100 co-payment per admission
ALLERGY TREATMENT No charge
PSYCHIATRIC CARE INPATIENT $100 co-payment per admission
$10 co-payment per individual visit
PSYCHIATRIC CARE OUTPATIENT
$5 co-payment per group therapy visit
HOME HEALTH CARE No charge
HOSPICE CARE No charge
ACUPUNCTURE Not covered
CHIROPRACTOR $10 per office visit-40 visits per year
HEARING AIDS $500 allowance per aid
Office Co-payment: $10
VISION
Glasses: Not covered
For additional information on services, please review the health plan coverage packet
available through SDCERS. Contact your selected health plan prior to service
regarding access to services & receiving prior authorization.
11
SUMMARY OF HEALTH PLAN
City of San Diego Sponsored
KAISER PERMANENTE
Senior Advantage (Medicare Plan)
Customer Service: Choice of Physician and Hospital:
• 1-800-443-0815 • Assignment of Primary Care Provider
• Group # 104303 within the Kaiser Permanente of
California Network
Prescription Orders:
Website: • Call the phone number on your current
www.kp.org prescription or contact Customer Service
for the nearest pharmacy
• Request refills or check status on
www.kp.org
Monthly Premiums Effective 8/1/07 – 7/31/08
Monthly out of
Total Monthly pocket cost to
COVERAGE Health Eligible*
Premium
Retiree
Subscriber Only with Medicare (ME) $296.04 $0
Subscriber ME + One Dependent
$592.08 $ 296.04
With Medicare
Subscriber ME + One Dependent
$864.95 $ 568.91
Without Medicare
Subscriber ME + One Dependent
With Medicare and Additional $ 1,160.99 $ 864.95
Dependent(s) Without Medicare
Subscriber ME + Two or More
$ 1,433.86 $ 1,137.82
Dependents Without Medicare
* See page 3 for Health Eligible Retiree definition
12
COVERED HEALTH SERVICES COVERAGE
PLAN YEAR DEDUCTIBLES No deductible
PLAN YEAR OUT-OF-POCKET MAXIMUM $1,500/$3,000 per calendar year
Generic: $10 co-pay for 100 day supply
PRESCRIPTION DRUGS
Brand: $20 co-pay for 100 day supply
$50 co-payment per visit
EMERGENCY ROOM Waived if admitted to hospital - hospital visit co-payment would
apply instead
OFFICE VISITS, ROUTINE CHECK-UPS &
$10 co-payment per visit
PHYSICIAN VISITS
HOSPITAL $100 co-payment per admission
INTENSIVE CARE UNIT $100 co-payment per admission
SKILLED NURSING FACILITY (SNF) No charge
INPATIENT SURGERY Covered under Hospital admission fee
OUT PATIENT SURGERY $50 co-payment per procedure
PHYSICAL THERAPY $10 co-payment per visit
INPATIENT REHABILITATION $100 co-payment per admission
ALLERGY TREATMENT No charge
PSYCHIATRIC CARE INPATIENT $100 co-payment per admission
$10 co-payment per individual visit
PSYCHIATRIC CARE OUTPATIENT
$5 co-payment per group therapy visit
HOME HEALTH CARE No charge
HOSPICE CARE $100 co-payment per admission
ACUPUNCTURE Not covered
CHIROPRACTOR $10 per office visit-40 visits per year
HEARING AIDS $500 allowance per aid
Office Co-payment: $ 10 per exam
VISION
Glasses: $150 allowance / every 24 months
For additional information on services, please review the health plan coverage packet
available through SDCERS. Contact your selected health plan prior to service
regarding access to services & receiving prior authorization.
13
SUMMARY OF HEALTH PLAN
City of San Diego Sponsored
PACIFICARE
HMO (Non-Medicare Plan)
Customer Service: Choice of Physician and Hospital:
• Phone: 1-800-624-8822 • Assignment of Primary Care
• Group # 145923 Provider within the PacifiCare of
California HMO Network
Website: Prescription Mail Order Provider:
www.PacifiCare.com • Prescription Solutions
• Phone: 1-800-562 6223
• www.rxsolutions.com
Monthly Premiums Effective 8/1/07 – 7/31/08
Monthly out of
Total Monthly pocket cost to
COVERAGE Health Eligible*
Premium
Retiree
Subscriber Only $596.99 $0
Subscriber + One Dependent With
$820.41 $ 223.42
Medicare
Subscriber + One Dependent
$1,195.67 $ 598.68
Without Medicare
Subscriber + One Dependent With
Medicare and Additional $1,419.09 $ 822.10
Dependent(s) Without Medicare
Subscriber + Two or More
$1,792.63 $ 1,195.64
Dependents Without Medicare
* See page 3 for Health Eligible Retiree definition
14
COVERED HEALTH SERVICES COVERAGE
PLAN YEAR DEDUCTIBLES No deductible
PLAN YEAR OUT-OF-POCKET MAXIMUM $1,500 individual / $3,000 family per calendar year
Generic: $10 co-pay for 30 day supply
PRESCRIPTION DRUGS Brand: $20 co-pay for 30 day supply
Mail Order: 2 co-payments for 90 day supply
EMERGENCY ROOM $50 co-payment per visit. Waived if admitted to hospital
OFFICE VISITS, ROUTINE CHECK-UPS &
$10 co-payment per visit
PHYSICIAN VISITS
HOSPITAL Paid in Full
INTENSIVE CARE UNIT Paid in Full
SKILLED NURSING FACILITY (SNF) Paid in Full
INPATIENT SURGERY Paid in Full
OUT PATIENT SURGERY $50 co-payment per procedure
PHYSICAL THERAPY $10 co-payment per visit
INPATIENT REHABILITATION $Paid in Full
ALLERGY TREATMENT $10 Co-payment (Serum included)
PSYCHIATRIC CARE INPATIENT Covered in Full (up to 30 days per plan year)
PSYCHIATRIC CARE OUTPATIENT $10 co-payment (Up to 30 visits per plan year)
HOME HEALTH CARE Paid in Full
HOSPICE CARE Paid in Full (Prognosis of life expectancy of one year or less)
$10 co-payment (40 visits per year combined for Acupuncture &
ACUPUNCTURE
Chiropractic)
$10 co-payment (40 visits per year combined for Acupuncture &
CHIROPRACTOR
Chiropractic) Provider Network: ACN
HEARING AIDS $500 allowance / 36 months
VISION Not covered
For additional information on services, please review the health plan coverage packet
available through SDCERS. Contact your selected health plan prior to service
regarding access to services & receiving prior authorization.
15
SUMMARY OF HEALTH PLAN
City of San Diego Sponsored
PACIFICARE
PPO (Non-Medicare Plan)
Customer Service: Choice of Physician and Hospital:
• Phone # 866-316-9776 • For a directory of Network providers
• Group # 10086 in Southern CA, contact SDCERS
• For a directory of Network providers
in other areas contact PacifiCare
Customer Service
Website:
www.pacificare.com Prescription Mail Order Provider:
• Prescription Solutions
• Phone # 800-562-6223
• www.rxsolutions.com
Monthly Premiums Effective 8/1/07 – 7/31/08
Monthly out of
Total Monthly pocket cost to
COVERAGE Health Eligible*
Premium
Retiree
Subscriber Only $596.62 $0
Subscriber + One Dependent With
$1,030.78 $ 434.16
Medicare
Subscriber + One Dependent
$1,193.25 $ 596.63
Without Medicare
Subscriber + One Dependent With
Medicare and Additional $1,627.40 $ 1,030.78
Dependent(s) Without Medicare
Subscriber + Two or More
$1,789.87 $ 1,193.25
Dependents Without Medicare
* See page 3 for Health Eligible Retiree definition
16
COVERED HEALTH NON-PARTICIPATING
PARTICIPATING PROVIDER
SERVICES PROVIDER
PLAN YEAR
$250 individual / $500 family
DEDUCTIBLES
PLAN YEAR OUT-OF-
$2000 individual / /$4,000 family per plan year
POCKET MAXIMUM
Generic: $10 co-pay for 30 day supply
PRESCRIPTION DRUGS Brand: $20 co-pay for 30 day supply
Mail Order 90-day supply: 2 co-payments
$50 co-payment per visit
EMERGENCY ROOM
Waived if admitted to hospital - hospital visit co-payment would apply.
OFFICE VISITS, ROUTINE
80% of Covered Expense after 70% of Covered Expense after
CHECK-UPS & PHYSICIAN
VISITS reaching deductible reaching deductible
80% of Covered Expense after 70% of Covered Expense after
HOSPITAL
reaching deductible reaching deductible
80% of Covered Expense after 70% of Covered Expense after
INTENSIVE CARE UNIT
reaching deductible reaching deductible
SKILLED NURSING 80% of Covered Expense after 70% of Covered Expense after
FACILITY (SNF) reaching deductible reaching deductible
80% of Covered Expense after 70% of Covered Expense after
INPATIENT SURGERY
reaching deductible reaching deductible
80% of Covered Expense after 70% of Covered Expense after
OUT PATIENT SURGERY
reaching deductible reaching deductible
80% of Covered Expense after 70% of Covered Expense after
PHYSICAL THERAPY
reaching deductible reaching deductible
INPATIENT 80% of Covered Expense after 70% of Covered Expense after
REHABILITATION reaching deductible reaching deductible
80% of Covered Expense after 70% of Covered Expense after
ALLERGY TREATMENT
reaching deductible reaching deductible
PSYCHIATRIC CARE 80% of Covered Expense after 60% of Covered Expense after
INPATIENT reaching deductible reaching deductible
PSYCHIATRIC CARE 80% of Covered Expense after 60% of Covered Expense after
OUTPATIENT reaching deductible reaching deductible
80% of Covered Expense after 70% of Covered Expense after
HOME HEALTH CARE
reaching deductible reaching deductible
80% of Covered Expense after 70% of Covered Expense after
HOSPICE CARE
reaching deductible reaching deductible
80% of Covered Expense after 70% of Covered Expense after
ACUPUNCTURE reaching deductible 12 visits per reaching deductible 12 visits per
plan year plan year
80% of Covered Expense after 70% of Covered Expense after
reaching deductible $1000 reaching deductible $1000
CHIROPRACTOR
maximum maximum
Provider Network: ACN Provider Network: ACN
HEARING AIDS $1,000 maximum every 24 months $1,000 maximum every 24 months
VISION Not Covered Not Covered
For additional information on services, please review the health plan coverage
packet available through SDCERS. Contact your selected health plan prior to
service regarding access to services & receiving prior authorization.
17
SUMMARY OF HEALTH PLAN
City of San Diego Sponsored
PACIFICARE
Secure Horizons (Medicare Plan)
Customer Service: Choice of Physician and Hospital:
• Phone: 1-888-622 8055 • Assignment of Primary Care
• Group # 145903 Provider within the Secure
Horizons of California Network
Prescription Mail Order Provider:
Website:
www.securehorizons.com • Rx Solutions
• Phone: 1-800-955 8098
• www.rxsolutions.com
Monthly Premiums Effective 8/1/07 – 7/31/08
Monthly out of
Total Monthly pocket cost to
COVERAGE Health Eligible*
Premium
Retiree
Subscriber Only with Medicare (ME) $223.42 $0
Subscriber ME + One Dependent
$446.84 $ 223.42
With Medicare
Subscriber ME + One Dependent
$820.41 $ 596.99
Without Medicare
Subscriber ME + One Dependent
With Medicare and Additional $1,043.83 $ 820.41
Dependent(s) Without Medicare
Subscriber ME + Two or More
$1,419.09 $ 1,195.67
Dependents Without Medicare
* See page 3 for Health Eligible Retiree definition
18
COVERED HEALTH SERVICES COVERAGE
PLAN YEAR DEDUCTIBLES No deductible
PLAN YEAR OUT-OF-POCKET MAXIMUM No Maximum
Generic: $10 co-pay for 30 day supply
PRESCRIPTION DRUGS Brand: $20 co-pay for 30 day supply
Mail Order: 2 co-payments for 90 day supply
$50 co-payment per visit. Waived if admitted to hospital -
EMERGENCY ROOM hospital visit co-payment would apply.
$20 co-payment for out of area Urgent Care
OFFICE VISITS, ROUTINE CHECK-UPS &
$10 co-payment per visit
PHYSICIAN VISITS
HOSPITAL Paid in Full
INTENSIVE CARE UNIT Paid in Full
SKILLED NURSING FACILITY (SNF) Paid in Full (up to 120 days)
INPATIENT SURGERY Paid in Full
OUT PATIENT SURGERY $50 co-payment per procedure
PHYSICAL THERAPY Paid in Full
INPATIENT REHABILITATION Paid in Full
ALLERGY TREATMENT No charge
PSYCHIATRIC CARE INPATIENT Paid in Full (190 days lifetime maximum)
$10 co-payment per individual visit (Unlimited visits – subject to
PSYCHIATRIC CARE OUTPATIENT
review for medical necessity)
HOME HEALTH CARE Paid in Full
HOSPICE CARE Paid in Full by Medicare / per CMS guidelines
ACUPUNCTURE Not covered
$10 co-payment (up to 30 visits per year)
CHIROPRACTOR
Provider Network: ACN
HEARING AIDS $500 maximum / 36 months
Office Co-payment: $ 10
VISION
Glasses: $75 allowance every 24 months
For additional information on services, please review the health plan coverage packet
available through SDCERS. Contact your selected health plan prior to service
regarding access to services & receiving prior authorization.
19
SUMMARY OF HEALTH PLAN
City of San Diego Sponsored
PACIFICARE
Senior Supplement (Medicare Supplement)
Customer Service: Choice of Physician and Hospital:
• Phone: 1-800-851 3802 • Any Physician or Hospital that accepts
• Group # 10864sd01 Medicare. Choosing a provider that
accepts Medicare assignment will assure
the lowest out-of-pocket expenses. To
find a Medicare provider call 1-800-
Website: MEDICARE or visit www.medicare.gov
www.securehorizons.com Prescription Mail Order Provider:
• UnitedHealth Rx
• Phone: 1-888-556 6648
• www.UnitedHealthRxforGroups.com
Monthly Premiums Effective 8/1/07 – 7/31/08
Monthly out of
Total Monthly pocket cost to
COVERAGE Health Eligible*
Premium
Retiree
Subscriber Only with Medicare (ME) $434.16 $0
Subscriber ME + One Dependent
$868.32 $ 434.16
With Medicare
Subscriber ME + One Dependent
$1,030.78 $ 596.62
Without Medicare
Subscriber ME + One Dependent
With Medicare and Additional $1,464.94 $ 1,030.78
Dependent(s) Without Medicare
Subscriber ME + Two or More
$1,627.40 $ 1,193.24
Dependents Without Medicare
* See page 3 for Health Eligible Retiree definition
20
All Benefits are subject to Medicare approved amounts and coverage limits. Please note that Medicare
deductibles and coinsurance amounts are for year 2007 and are subject to change for 2008
PACIFICARE
COVERED HEALTH SERVICE MEDICARE PAYS YOU PAY
PAYS
PLAN YEAR OUT-OF-POCKET
None
MAXIMUM
$10 Generic/$20 Brand 30 day
PRESCRIPTION DRUGS
$20 Generic/$40 Brand 90 days
HOSPITALIZATION: Semi-private room & board, general nursing & miscellaneous services & supplies
$992 (Part A
Part A Hospital – first 60 days All but $992 $0
Deductible)
Part A Hospital – days 61-90 All but $248 per day $248 per day $0
Part A Hospital – days 91 and
after:
-While using 60 lifetime All but $496 per day $496 per day $0
reserve days
After 60 lifetime reserve days are 100% of $0
used: Medicare Eligible
~ 365 Lifetime additional days $0 Expenses
~ Beyond 365 lifetime additional
days $0 $0 All costs
SKILLED NURSING FACILITY CARE: You must meet Medicare’s requirements, including having
been hospitalized for at least 3 days & entering the Medicare approved facility within 30 days of leaving
the hospital.
Days 1-20 All approved amounts $0 $0
Up to $124 per
Days 21-100 All but $124 per day $0
day
Days 101 and after $0 $0 All costs
HOSPICE CARE: All but very limited
Available as long as your doctor coinsurance for
$0 Balance
certifies you are terminally ill and outpatient drugs and
you elect to receive these services inpatient respite care
DURABLE MEDICAL
EQUIPMENT: $131 (Part B
$0 $0
First $124 of Medicare Approved Deductible)
Amounts
Remainder of Medicare Approved 80% of approved 20% of approved
$0
Amounts amounts amounts
MEDICAL SERVICES: Includes services such as Physician services, inpatient and outpatient medical,
surgical and chiropractic services and supplies, physical and speech therapy and diagnostic tests.
First $124 of Medicare Approved
$0 $131 $0
Amounts
Remainder of Medicare Approved
Generally 80% Generally 20% $0
Amounts
Part B Excess Charges (above
$0 $0 All costs
Medicare Approved Amounts)
For additional information on services, please review the health plan coverage packet
available through SDCERS. Contact your selected health plan prior to service regarding
access to services & receiving prior authorization.
21
This Page Intentionally Left Blank.
22
Union-Sponsored
Retiree Health Insurance Plans
The following information is a summary of the benefits and premiums for health insurance
plans offered through the Local 127 and Municipal Employees Association (MEA) unions for
FY 2008.
• Local 127 – Cigna PPO / OAP Local 127 - 619-640-4939
• MEA – Sharp HMO MEA - 619-264-6632
For information regarding coverage, costs and prescriptions drug formularies, please
contact the sponsoring union or health plan directly.
23
SUMMARY OF HEALTH PLAN
AFSCME Local 127 Sponsored
LOCAL 127 - CIGNA
PPO /OAP
Customer Service: Choice of Physician and Hospital:
• 1-800-CIGNA-24 • Choose ANY Provider within the
• Group # 108652 CIGNA Network (not an HMO)
Website: Prescription Mail Order Provider:
www.cigna.com • CIGNA Tel Drug
• 1–800–TEL-DRUG
• www.MyCIGNA.com
Monthly Premiums Effective 8/1/07 – 7/31/08
Monthly out of
Total Monthly pocket cost to
COVERAGE Health Eligible*
Premium
Retiree
Subscriber Only $399.12 $0
Subscriber + Spouse $957.90 $ 558.78
Subscriber + Children $766.32 $ 367.20
Subscriber + Family $1,297.12 $ 898.00
For additional rate & Medicare information please contact:
Local 127 at (619) 640 4939 or 800-883-0902 for group administrator
* See page 3 for Health Eligible Retiree definition
24
COVERED HEALTH SERVICES COVERAGE
PLAN YEAR DEDUCTIBLES $150 single / $450 Family
PLAN YEAR OUT-OF-POCKET
$1,000 / $2,000 per calendar year
MAXIMUM
Generic: $7 co-pay for 30 day supply (no deductible)
PRESCRIPTION DRUGS Brand: $15 co-pay for 30 day supply (no deductible)
Non Preferred: $35 co-pay for 30 day supply (no deductible)
$50 co-payment per visit
EMERGENCY ROOM Waived if admitted to hospital - hospital visit co-payment would
apply instead
OFFICE VISITS, ROUTINE CHECK-UPS
$10 co-payment per visit (deductible waived)
& PHYSICIAN VISITS
HOSPITAL 10% of discounted rates
INTENSIVE CARE UNIT 10% of discounted rates
SKILLED NURSING FACILITY (SNF) 10% of discounted rates
INPATIENT SURGERY 10% of discounted rates
OUT PATIENT SURGERY 10% of discounted rates
PHYSICAL THERAPY $10 co-payment per visit (deductible waived)
INPATIENT REHABILITATION 10% of discounted rates
ALLERGY TREATMENT $10 co-payment per visit (deductible waived)
PSYCHIATRIC CARE INPATIENT 10% of discounted rates
$20 co-payment per individual visit (deductible waived)
PSYCHIATRIC CARE OUTPATIENT
$20 co-payment per group therapy visit (deductible waived)
HOME HEALTH CARE 10% of discounted rates10% of discounted rates
HOSPICE CARE 10% of discounted rates10% of discounted rates
ACUPUNCTURE Not covered
CHIROPRACTOR 10% of discounted rates
HEARING AIDS Not Covered
VISION Not Covered
For additional information on services, review the health plan coverage packet
available through your union representative. Contact your selected health plan prior to
service regarding access to services & receiving prior authorization.
25
SUMMARY OF HEALTH PLAN
Municipal Employees Association (MEA) Sponsored
M E A - SHARP
HMO
Customer Service: Choice of Physician and Hospital:
• 1-888-840 4747 • Assignment of Primary Care
• Group # 79173 Provider within the Sharp Network
Website: Prescription Mail Order Provider:
www.Sharphealthplan.com • Precision Rx
www.SDMEA.org • Phone: 1-866-302 7154
• www.precisionrx.com
Monthly Premiums Effective 8/1/07 – 7/31/08
Monthly out of
Total Monthly pocket cost to
COVERAGE Health Eligible*
Premium
Retiree
Subscriber Only No Medicare (NME) $469.91 $0
Subscriber NME + Dependent NME $935.96 $466.05
Subscriber NME + Dependent ME $798.15 $328.24
Subscriber NME + Family $1,501.51 $1,031.60
Subscriber Only with Medicare (ME) $297.15 $0
Subscriber ME + Dependent NME $719.17 $422.02
Subscriber ME + Dependent ME $593.31 $296.16
Subscriber ME + Family $1,126.39 $829.24
For additional rate & Medicare information please contact:
MEA at (619) 264 6632 or 888-950-6632
* See page 3 for Health Eligible Retiree definition
26
COVERED HEALTH
COVERAGE
SERVICES
PLAN YEAR DEDUCTIBLES No deductible
PLAN YEAR OUT-OF-POCKET
$3,000 individual / $5000 family
MAXIMUM
Generic: $10 co-payment for 30 day supply
PRESCRIPTION DRUGS Brand Formulary: $20 co-payment for 30 day supply
Non-formulary: $40 co-payment for 30 day supply
$50 co-payment per visit. Waived if admitted to hospital - hospital visit
EMERGENCY ROOM co-payment would apply.
Urgent Care: $15 co-payment
OFFICE VISITS, ROUTINE CHECK-
$15 co-payment per visit
UPS & PHYSICIAN VISITS
HOSPITAL $100 co-payment per admission
INTENSIVE CARE UNIT Paid in Full upon admittance
Paid in Full with prior authorization. Limited to acute care up to 100
SKILLED NURSING FACILITY (SNF)
consecutive days
INPATIENT SURGERY Paid in Full with prior authorization
OUT PATIENT SURGERY Paid in Full with prior authorization
PHYSICAL THERAPY $15 co-payment per visit
INPATIENT REHABILITATION $150 co-payment per admission (30 day maximum)
Testing: $15 co-payment per visit
ALLERGY TREATMENT
Injection: $3 per visit
PSYCHIATRIC CARE INPATIENT $100 co-payment per admission
PSYCHIATRIC CARE OUTPATIENT $15 co-payment per individual visit
HOME HEALTH CARE Paid in Full with prior authorization
HOSPICE CARE Paid in Full upon admittance
$15 co-payment (40 visits per year combined for Acupuncture &
ACUPUNCTURE
Chiropractic)
$15 co-payment (40 visits per year combined for Acupuncture &
CHIROPRACTOR
Chiropractic)
HEARING AIDS $1000 allowance / 36 months
Discount towards complete set of frames and lenses. Limited discount
VISION
towards contact lenses and Laser vision correction
For additional information on services, review the health plan coverage packet
available through your union representative. Contact your selected health plan prior to
service regarding access to services & receiving prior authorization.
27
This Page Intentionally Left Blank.
28
City of San Diego
Retiree Dental & Vision Plans*
The following information is a summary of the coverage and premiums offered through City
of San Diego dental and vision insurance plans for FY 2008.
• Concordia Dental PPO
• PacifiCare Vision
If you have questions about the following plans or would like to have additional information
sent to you, please contact the SDCERS Open Enrollment Help Desk at (619) 525-3664.
* Dental & vision insurance premiums are not paid for or reimbursed by the City of San
Diego. Retirees choosing to participate in the dental and vision plans offered by the City will
have the full monthly premium deducted from their retirement allowance each month.
29
SUMMARY OF HEALTH PLAN
City of San Diego
CONCORDIA DENTAL PPO
Customer Service: 1-866-215-2358 Website: www.ucci.com
NOTE: Dental insurance premiums are not paid for by the City of San Diego.
MONTHLY PREMIUM
COVERAGE
Effective 8/1/07 – 7/31/08
Subscriber Only $ 23.20
Subscriber + Dependent $ 46.40
Subscriber + 2 or more Dependents $ 65.50
COVERED SERVICES IN-NETWORK OUT-OF-NETWORK
DIAGNOSTIC / PREVENTIVE SERVICES
Exams
Bitewing X-rays
Cleanings 100 % 100 %
Fluoride Treatments
Sealants
BASIC SERVICES
Basic Restorative
X-rays (all others)
Palliative Treatment
Space Maintainers 70 % 70 %
Repairs of Crowns, Inlays, Onlays, Bridges
& Dentures
Simple Extractions
MAJOR SERVICES
Inlays, Onlays, Crowns
Prosthetics
Endodontics Member pays reduced fee
Member pays the dentist’s
Non-Surgical / Surgical Periodontics (MAC) directly to the
full charge
Complex Oral Surgery participating dentist
General Anesthesia and/or IV Sedation
Cosmetics, Implants, Veneers, Bleaching
ORTHODONTICS (TO AGE 19)
Member pays reduced fee
Member pays the dentist’s
Diagnostics, Active, Retention Treatment (MAC) directly to the
full charge
participating dentist
PROGRAM MAXIMUMS & DEDUCTIBLES
Lifetime Orthodontic Maximum (to age 19) None None
Annual Program Maximum (per member) $1,000 $1,000
$50 per member $50 per member
Annual Program Deductible
$150 per family $150 per family
30
SUMMARY OF HEALTH PLAN
City of San Diego
PACIFICARE VISION
Customer Service: 1-800-228-3384 Website: www.pacificare-vision.com
Group Number: 107602
NOTE: Vision insurance premiums are not paid for by the City of San Diego.
MONTHLY PREMIUM
COVERAGE
Effective 8/1/07 – 7/31/08
Subscriber Only $ 8.69
Subscriber + 1 Dependent $ 17.38
Subscriber + Family $ 26.05
NON-PARTICIPATING
COVERED SERVICES PARTICIPATING PROVIDER
PROVIDER
COMPREHENSIVE EYE One exam during any 12- One exam during any 12-
EXAMINATION month period month period
$55 Covered Person
Exam No Charge to Covered Person
Allowance
One pair of any type lenses One pair of any type lenses
SPECTACLE LENSES
during any 12-month period. during any 12-month period.
$35 Covered Person
Single Vision No Charge to Covered Person
Allowance
$50 Covered Person
Bifocal No Charge to Covered Person
Allowance
$75 Covered Person
Trifocal No Charge to Covered Person
Allowance
One set of frames during any One set of frames during any
FRAMES
24-month period 24-month period
$90 Covered Person $50 Covered Person
Retail Frames
Allowance Allowance
One pair of contact lenses One pair of contact lenses
CONTACT LENSES during any 12-month period during any 12-month period
(Materials & Fitting) when provided in lieu of other when provided in lieu of other
eyewear eyewear
$200 Covered Person
Medically Necessary No Charge to Covered Person
Allowance
$100 Covered Person $90 Covered Person
For Cosmetic Purposes
Allowance allowance
LENS OPTIONS
Glass Tints, Solid Color: Pink or Rose Member pays all costs above
No Charge to Covered Person
#1 or #2 the plan lens allowance
Member pays all costs above
All Other Lens Options 20% retail discount
the plan lens allowance
MATERIAL DEDUCTIBLE
$0 $0
(Per Covered Person)
31
This Page Intentionally Left Blank.
32
Health Insurance Reimbursement Benefit
The health insurance premium reimbursement benefit is available to all City of San Diego
Health Eligible retired members who enroll in a private health insurance plan not sponsored
by the City or unions.
If you enroll in a plan offered by another employer, insurance company, the military or any
other group including coverage through a COBRA election, you may request a
reimbursement for all or a portion of your individual plan(s) premium(s) up to your monthly
maximum. The maximum monthly health insurance allowance for Fiscal Year 2008 is
$694.44 for Non-Medicare Eligible and $654.00 for Medicare Eligible retirees. (Please see
page 3 to determine your eligibility status.)
You will be required to submit additional documentation verifying the plan premium,
coverage, and proof of payment. After review and approval of the required documentation,
SDCERS will reimburse you up to the cost of your plan(s) premium(s) or up to the amount of
the maximum monthly health insurance allowance, whichever is less. The reimbursement
may not be used toward the cost of dependent coverage, nor may it be used toward the cost
of annual deductibles, co-payments, prescriptions, co-insurance, specialty insurance (ex.
Cancer insurance), Medicare Part D premiums, or long-term custodial care. The
reimbursement may only be used toward the cost of your individual medical plan
premium(s).
Reimbursement of Medicare Part B premiums is separate from the health insurance
premium reimbursement. If you or your dependent(s) have recently become eligible for
Medicare coverage you must notify SDCERS by submitting a Medicare Part B
Reimbursement Form (page 41). Note: Dependents do not receive reimbursement for
Medicare Part B, however, having Medicare Part B coverage may lower the dependents
premiums.
Non-Health Eligible retirees may receive up to $1,200 in FY2008 for medical expenses and
Medicare Part B premiums.
Dental & vision insurance premiums are not eligible for reimbursement.
To ensure timely payment in any given month, documents providing proof for
reimbursement must be received no later than the 10th of the month. Documentation
received after the 10th of the month will be processed the following month.
The reimbursement is effective the first day of the month following your retirement date and
can be paid retroactively. The allowable amount will be included in your monthly retirement
payment as a non taxable adjustment.
If your coverage or plan premium changes at any time, you must notify SDCERS by
completing a new Health Insurance Reimbursement form and attaching all required
documentation. For additional information regarding the required documentation please
reference section five of the application instructions.
33
Reimbursement Eligibility and Coverage
Health Eligible Retiree Reimbursement
Health Eligible retirees are those who:
• Are eligible for and receive a retirement allowance from SDCERS; and
• Were on the active payroll of the City of San Diego on or after October 5, 1980; and
• Were retired on or after October 6, 1980 from the City of San Diego.
The reimbursement amount for these retirees for the next fiscal year (7/1/07 through 6/30/08)
will be:
• Up to $694.44 per month for non-Medicare eligible retirees or the actual premium cost
(whichever is less).
• Up to $654.00 per month for Medicare eligible retirees, or the actual premium cost
(whichever is less).
To request reimbursement, please submit a Health Insurance Reimbursement form (page 39)
along with supporting documentation to SDCERS.
Non-Health Eligible Retiree Reimbursement
Non-Health Eligible retirees are those who:
• Are eligible for and receive a retirement allowance from SDCERS; and
• Retired before October 6, 1980, from City of San Diego employment.
The reimbursement amount for these retirees will remain at $1,200 ($100 maximum per month)
for the next fiscal year (July 1, 2007 – June 30, 2008) for medical expenses and Medicare Part
B premiums incurred during FY2008.
To submit for reimbursement, mail copies of receipts along with a cover letter to SDCERS. You
may request reimbursement for medical expenses, including:
• Health insurance premiums
• Medicare Part B premiums:
• Doctor’s co-payments
• Prescription drug costs
• Medicare deductibles
Non-Health Eligible retirees enrolled in a City or union sponsored health insurance plan,
do not need to submit for reimbursement. An adjustment of $100 will be added to the
monthly retirement allowance & will remain in effect until the City or Union Sponsored coverage
is terminated.
34
Medicare Part B Reimbursement
• Health Eligible Retirees are eligible for Medicare Part B Reimbursement in addition to the
Health Eligible Retiree Reimbursement.
• Non Health Eligible Retirees are eligible for Medicare Part B Reimbursement as a part of the
$1,200 annual reimbursement.
The standard Medicare Part B premium is $93.50 for calendar year 2007. If you are receiving a
monthly reimbursement from SDCERS the amount will be updated each year in January
according to the new standard Medicare Part B premium as published by the Centers for
Medicare and Medicaid Services (CMS) on the Medicare website at www.Medicare.gov.
If you are charged an amount higher than the standard amount, please submit proof of the
higher amount to the SDCERS Reimbursement Desk.
To start Medicare Part B reimbursement, submit a Medicare Part B Reimbursement form (page
41) along with a copy of your Medicare card to SDCERS.
Death in the Line of Duty Widow / Widower Reimbursement
Retiree health benefits are offered to the spouses or dependents under age 21 of a City
employee Member killed in the line of duty by (1) external violence or physical force or (2) as a
result of an accident or injury caused by external violence or physical force.
Death in the Line of Duty Widows/Widowers and their dependent children are eligible to enroll in
a City-sponsored health plan. They will receive payment for health insurance premiums and
Medicare Part B premiums up to the annual flexible dollar amount in effect for active City of San
Diego employees.
To request reimbursement please submit a Health Insurance Reimbursement form (pages 39)
along with supporting documentation to SDCERS.
If enrolled in a City or Union Sponsored health insurance plan, Death in the Line of Duty
Widows/ Widowers do not need to submit for reimbursement. Each year your eligible
reimbursement will be calculated by SDCERS and you will be mailed a breakdown of your cost
and reimbursement. A monthly adjustment will be added to your retirement allowance and will
remain in effect until the City or Union Sponsored coverage is terminated.
NOTE: Dental & vision insurance premiums are not paid for or reimbursed by the
City of San Diego. Retirees choosing to participate in the dental and vision plans
offered by the City will have the full monthly premium deducted from their
retirement allowance each month.
35
MEDICARE INFORMATION
If you are turning age 65 this year, your health insurance provider and SDCERS will be
sending you information approximately three months before your birthday about how to
enroll in Medicare and what plan changes are required by your provider. If your dependent
is turning age 65 this year, please contact SDCERS three months prior to his/her 65th
birthday.
If you are changing health insurance carriers during open enrollment and you are enrolled in
Medicare, please include a copy of your Medicare card when you return your enrollment
form. Please note that any changes between Medicare eligible plans must be made during
the open enrollment period.
Medicare Part B - Medical Coverage
• City Retirees and their dependents attaining age 65 are encouraged to apply for
Medicare Part B and enroll if eligible. Obtaining Medicare Part B & Medicare Supplement
coverage, you may reduce your City or union sponsored health insurance premium.
• If you are not eligible for Medicare Part B, you must provide proof of ineligibility to
SDCERS. If you do not provide proof or if you discontinue your Medicare Part B
coverage, it may adversely affect your health benefit. Potential consequences include:
additional cost to you for City or union sponsored health premiums, discontinuation of
Medicare Part B reimbursement & increased future premiums for Medicare Part B and/or
Medicare supplement plans including Medicare prescription drug plans.
• Health eligible retirees are reimbursed for their Medicare Part B premium on a monthly
basis. Reimbursement is added to the monthly retirement allowance.
Medicare Part D - Prescription Drug Coverage
• City and union sponsored health plans include Medicare Part D prescription drug
coverage. Members are not allowed to opt out of the prescription portion of their City or
union sponsored health plan. Coverage with a City or union plan is all or nothing.
• Federal guidelines allow you to enroll in only one Medicare Part D prescription
drug plan. If you enroll in another health plan that includes Medicare Part D prescription
drug coverage, your City or union sponsored plan will be terminated in its entirety.
For information on enrolling in Medicare please contact CMS at 1-800-MEDICARE or visit them
at www.medicare.gov. You may also contact your local Social Security Administration office.
36
ANNUAL NOTICE REGARDING MEDICARE PART D
AS COMPILED BY THE CITY OF SAN DIEGO
Important Notice from the City of San Diego About Your
Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has
information about your current prescription drug coverage with the City of San Diego and
prescription drug coverage available for people with Medicare. It also explains the
options you have under Medicare prescription drug coverage and can help you decide
whether or not you want to enroll. At the end of this notice is information about where
you can get help to make decisions about your prescription drug coverage.
1. Medicare prescription drug coverage became available in 2006 to everyone with
Medicare through Medicare prescription drug plans and Medicare Advantage plans
that offer prescription drug coverage. All Medicare prescription drug plans provide at
least a standard level of coverage set by Medicare. Some plans may also offer more
coverage for a higher monthly premium.
2. The City of San Diego has determined that the prescription drug coverage offered by
PacifiCare, Kaiser, HealthNet and/or Sharp Health plans is, on average for all plan
participants, expected to pay out as much as the standard Medicare prescription drug
coverage will pay and is considered Creditable Coverage. Any retiree enrolled in one
of these plans is enrolled in a Part D plan through the health plan and should not
enroll for a separate Medicare prescription drug plan. If you do you will be disenrolled
from the City sponsored health coverage.
_______________________________________________________________________
Because your existing coverage is, on average, at least as good as standard Medicare
prescription drug coverage, you can keep this coverage and not pay extra if you later
decide to enroll in another Medicare prescription drug coverage.
Individuals can enroll in a Medicare prescription drug plan when they first become eligible for
Medicare and each year from November 15th through December 31st. Beneficiary’s leaving
employer/union coverage may be eligible for a Special Enrollment Period to sign up for a
Medicare prescription drug plan.
You should compare your current coverage, including which drugs are covered, with the
coverage and cost of the plans offering Medicare prescription drug coverage in your area.
If you decide to enroll in a Medicare prescription drug plan outside of the City
health plan you are enrolled in, you will be dropped from the City’s health plan.
You should also know that if you drop or lose your coverage with the City of San Diego and
don’t enroll in Medicare prescription drug coverage after your current coverage ends, you may
pay more (a penalty) to enroll in Medicare prescription drug coverage later.
37
If you go 63 days or longer without prescription drug coverage that’s at least as good as
Medicare’s prescription drug coverage, your monthly premium will go up at least 1% per month
for every month that you did not have that coverage. For example, if you go nineteen months
without coverage, your premium will always be at least 19% higher than what many other
people pay. You’ll have to pay this higher premium as long as you have Medicare prescription
drug coverage. In addition, you may have to wait until the following November to enroll.
For more information about this notice or your current prescription drug coverage please
contact CareCounsel at 1-888-227-3334 Monday – Friday, 8:30 a.m. to 5:00 p.m. PST.
NOTE: You will receive this notice annually and at other times in the future such as
before the next period you can enroll in Medicare prescription drug coverage, and if this
coverage through the City of San Diego changes. You also may request a copy of this
notice.
For more information about your options under Medicare prescription drug coverage:
More detailed information about Medicare plans that offer prescription drug coverage is in the
“Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from
Medicare. You may also be contacted directly by Medicare prescription drug plans. For more
information about Medicare prescription drug plans:
• Visit www.medicare.gov
• Call your State Health Insurance Assistance Program (see your copy of the Medicare &
You handbook for their telephone number) for personalized help,
• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
For people with limited income and resources, extra help paying for Medicare prescription drug
coverage is available. Information about this extra help is available from the Social Security
Administration (SSA) online at www.socialsecurity.gov, or you call them at 1-800-772-1213 (TTY
1-800-325-0778).
Remember: Keep this notice. If you enroll in one of the new plans approved by Medicare
which offer prescription drug coverage, you may be required to provide a copy of this
notice when you join to show that you are not required to pay a higher premium amount.
Date: November 21, 2006
Name of Entity/Sender: The City of San Diego
Contact--Position/Office: Valerie VanDeweghe/Benefits Manager
Address: 1200 3rd Avenue, Ste 1000, San Diego,CA 92101
Phone Number: 619-236-7300
38
Health Insurance Reimbursement
401 B Street, Suite 400 ♦ San Diego, CA 92101-4298 ♦ 619-525-3600 ♦ 619-595-0513 Fax
As a City of San Diego Health Eligible retiree you may request reimbursement of your individual medical
insurance plan premium up to a monthly maximum set by the City of San Diego. You are required to
complete this application and attach additional documentation based on your coverage.
INITIAL REQUEST CHANGE REQUEST
SECTION 1 - E VENT T YPE Check this box if you are requesting a
st
Check this box if you are making a change to health
( MAKE ONLY ONE SELECTION ) reimbursement for the 1 time. plan or premium amount.
SECTION 2 - M EMBER I NFORMATION : PLEASE COMPLETE ALL BOXES BELOW
Last First Last 4 Digits
Name Name of SSN xxx-xx-
Address City
Day Evening
State Zip Code ( ) ( )
Phone Phone
SECTION 3 – M EDICAL P LAN I NFORMATION : PLEASE COMPLETE ALL BOXES BELOW
Medical Plan Name _ __________________________________________________________ (i.e. Tricare, Kaiser, Secure Horizons)
Are you the policy Policy Holder
Effective date of # of people (including yourself)
holder or
policy or change ___ _________ covered by this plan? ______ ________
dependent? Dependent
SECTION 4: P LAN P REMIUM INFORMATION :
Many insurance plans cover more than one person. By completing this section SDCERS will be able to accurately distinguish between the actual
costs you pay for your own coverage vs. the total cost you pay if your plan covers dependents. Fill in the total monthly premium cost you pay for
yourself and, if applicable, your dependents. If your employer pays a portion of your health premium, please indicate if the contribution is coming
from a flexible spending account or allowance. The amounts you enter in this section should equal the total monthly premium.
Is 100% of the monthly premium paid by you? Yes If no please explain:
No _______ _________________________________
Total monthly premium breakdown: Section 5: DOCUMENTATION REQUIREMENTS:
If you are submitting an initial request or change request, you are required to
Member only cost/premium: $
provide documentation verifying proof of Plan premium, proof of coverage, and
proof of payment. All others submissions proof of payment only.
Dependent cost/premium: + $ PLAN PREMIUM PROOF: Must include details of the premium rates separately
from the dependents costs (if applicable). Examples of acceptable documentation
Employer Contribution: + $ include: 1) Most recent premium breakdown from your carrier or employer; 2) a
signed letter from your insurance company or employer.
Dental cost/premium : + $ PROOF OF COVERAGE: Examples are: 1) Most recent invoice or billing statement
showing your name, amount and the effective date of coverage; 2) A signed letter
Vision cost/premium: + $ from your insurance company or employer.
PROOF OF PAYMENT: Examples are: 1) Recent pay stub, check; 2) Recent bank
Other cost/premium: + $ or credit card statement showing automatic deduction circled; 3) a signed letter
from your insurance company or employer verifying payment.
Check this box indicating that you are including the proper
Total monthly premium : = $ documentation. Any application sent without supporting documentation
will not be processed.
SECTION 6 : A UTHORIZATION – P LEASE BE SURE TO READ ALL INFORMATION ON REVERSE SIDE OF THIS FORM
I have read, agree, and understand both sides of this form. I elect coverage as I have indicated above and agree to notify SDCERS immediately of
any plan or premium changes.
Signature: Date:
OE – FY08 – Health Ins Reimb
39
Program information:
The health insurance premium reimbursement benefit is available to all City of San Diego Health Eligible retired
members who enroll in a private health insurance plan not sponsored by the City or Unions. Health Eligible
Members have a retirement date on or after 10/06/1980, please Refer to the Municipal code sections 24.0103 and
24.1201 for additional information regarding the definition of a Health Eligible Retiree.
If you enroll in a plan offered by another employer, insurance company, the military or any other group including
coverage through a COBRA election, you may request a reimbursement to pay for all or a portion of your individual
plan(s) premium(s) up to your monthly maximum. The maximum monthly health insurance allowance for Fiscal
Year 2008 is $694.44 for Non-Medicare Eligible and $654.00 for Medicare Eligible retirees.
You will be required to submit additional documentation verifying the plan premium, coverage, and proof of
payment. After review and approval of the required documentation, SDCERS will reimburse you up to the cost of
your plan(s) premium(s) or up to the amount of the maximum monthly health insurance allowance, whichever is
less. The reimbursement may not be used toward the cost of dependent coverage, nor may it be used toward the
cost of annual deductibles, co-payments, prescriptions, co-insurance, specialty insurance (ex. Cancer insurance),
Medicare Part D premiums, or long-term custodial care. (Reimbursement of Medicare Part B premiums is separate
from the health insurance reimbursement.) The reimbursement may only be used toward the cost of your
individual medical plan premium(s).
To ensure timely payment in any given month, documents providing proof for reimbursement must be received no
later than the 10th of the month. Documentation received after the 10th of the month will be processed the
following month.
The reimbursement is effective the first day of the month following your retirement date and can be paid
retroactively. The allowable amount will be included in your monthly retirement payment as a non taxable
adjustment.
If your coverage or plan premium changes at any time, you must notify SDCERS by completing a new
Reimbursement form and attaching all required documentation. For additional information regarding the
required documentation please reference section five of the application instructions.
Authorization:
By signing the form you are stating that you have read and understand the information contained in the SDCERS
reimbursement application materials.
I understand if I choose a plan other than a City Sponsored plan, my coverage may be different than if I had
selected a City Sponsored plan. A non-City Sponsored plan may require me to prove my good health or may
exclude pre-existing conditions. My health insurance reimbursement covers only medical insurance premiums that
are paid for my individual coverage and cannot be used to purchase Medicare Part D. I further understand that my
reimbursement will not be reported to the Internal Revenue Service (IRS) on Form 1099-R as taxable income. If
the IRS requires any tax payment from the health insurance reimbursement I receive, I understand that I am
responsible for all taxes.
The coverage I have indicated on the reverse side in Section 3 is currently in effect and I agree to notify SDCERS
immediately if my plan or premium(s) cease or change. If I receive a reimbursement overpayment, I agree to
repay the full overpayment and accept repayment terms determined by SDCERS.
Please mail or fax to: Fax # (619) 595-0513
San Diego City Employees’ Retirement System (SDCERS)
401 B Street, Suite 400
San Diego, CA 92101
40
MEDICARE PART B Reimbursement
401 B Street, Suite 400 ♦ San Diego, CA 92101-4298 ♦ 619-525-3600 ♦ 619-595-0513 Fax
Use this form to notify SDCERS that you or your dependent(s) has become eligible for Medicare coverage.
Enrolling in Medicare Part A & B may reduce your health insurance premiums.
SECTION 1 - M EMBER I NFORMATION : PLEASE COMPLETE ALL BOXES BELOW
Last First Last 4 Digits
xxx-xx-
Name Name of SSN
Address City
Zip Day Evening
State ( ) ( )
Code Phone Phone
SECTION 2 – M EDICARE P ART B I NFORMATION : PLEASE COMPLETE ALL BOXES BELOW
I am eligible for Medicare Part B. (Please attaché a copy of your Medicare card or letter from Social Security
verifying the effective date of coverage for Medicare Part B. Reimbursement
will not be processed without proof of coverage.)
I am NOT eligible for Medicare Part B. (Please attaché a copy of a letter from Social Security verifying your
ineligibility for Medicare Part B. Without proof of ineligibility, SDCERS may
impose a surcharge until proof is received.)
Medicare Claim Medicare Part A Medicare Part B
Number Effective Date Effective Date
SECTION 3 : A UTHORIZATION
I have read, agree, and understand this form.
Signature: Date:
NOTE: Medicare Part B reimbursement will be included in your benefit check each month and will show
as a non-taxable adjustment. SDCERS automatically updates the amount each calendar year according
to the new premium amount published by the Centers for Medicare and Medicaid Services (CMS).
OE – FY08 - Part B Reimb
41
This Page Intentionally Left Blank.
42
PUBLIC SAFETY OFFICER (PSO) AFFIDAVIT
401 B Street, Suite 400 ♦ San Diego, CA 92101-4298 ♦ 619-525-3600 ♦ 619-595-0513 Fax
The Pension Protection Act (PPA) of 2006 permits eligible retired Public Safety Officers (PSO) to exclude up to
$3,000 of distributions from their SDCERS retirement benefit for direct payment of health care premiums. These
excluded distributions will be used by SDCERS for direct payment of qualified health insurance premiums for the
qualified PSO member, their spouse or Registered Domestic Partner and/or dependents.
SECTION 1 - M EMBER I NFORMATION : PLEASE COMPLETE ALL BOXES BELOW
Last First Last 4 Digits
Name Name of SSN xxx-xx-
Address City
Day
State Zip Code ( ) Date of Birth
Phone
TO HAVE YOUR REQUEST PROCESSED BY SDCERS YOU MUST COMPLETE ALL SECTIONS OF THIS
FORM AND MEET ALL THE REQUIREMENTS SET OUT BELOW:
I attest that I meet the definition of a Public Safety Officer (PSO) as defined under Section 845 of the
Pension Protection Act of 2006 which states in part: “an individual serving a public agency in an official
capacity, with or without compensation, as a law enforcement officer, as a firefighter, as a chaplain, or as a
member of a rescue squad or ambulance crew.” Omnibus Crime Control Act of 1968, 42 U.S.C. 3796b(9)(A).
City of San Diego positions that are known to be included in this definition are:
• Police Officer
• Firefighter
City of San Diego positions that MAY be included in this definition but need further verification by Member are:
• Deputy City Attorney (serving as a prosecutor at retirement)
• Investigator in the City Attorney’s Criminal Division
City of San Diego positions known to NOT be included in this definition include: Police Officer and Firefighter
• Police Dispatcher
• Deputy City Attorney (not serving as a prosecutor)
My position classification on my last day of work for the City of San Diego was:
I certify that I have not, and will not, request a pre-tax deduction of health insurance from another retirement plan.
I also attest that I:
• Have separated from City of San Diego employment as a PSO,
• Have a taxable SDCERS retirement allowance,
• Have health insurance premiums deducted directly from my SDCERS retirement allowance for
coverage for me, my spouse or my dependents, and
• Have attained the normal retirement age at retirement, or retired by reason of disability.
- OR -
My position is not listed above, however I have attached documentation affirming the eligibility of the position
classification that I held on my last day of work for the City of San Diego.
SECTION 6 : A UTHORIZATION – P LEASE BE SURE TO READ ALL INFORMATION ON REVERSE SIDE OF THIS FORM
I elect to participate in the Internal Revenue Service (IRS) tax benefit provided under Section 845 of the Pension Protection Act of
2006. I acknowledge it is my responsibility to substantiate my Public Safety Officer (PSO) eligibility to SDCERS and in the event of an
IRS audit. By signing below, I certify, under penalty of perjury, that all of the information I have provided is true.
Signature: Date:
OE – FY08 – PSO Affidavit
43
This Page Intentionally Left Blank.
44
CareCounsel is a healthcare assistance program providing healthcare education,
information, advocacy, and coaching. Expert CareCounselors, who are Registered
Nurses and master’s level healthcare professionals, are available by telephone to assist
retirees.
RESOURCES FOR YOUR HEALTH CARE NEEDS
Some of the areas where we can help are:
Understanding your health benefits
Serving as a liaison with your health plan or healthcare provider when you
need help
Assisting with claims payment and billing problems or service denials
Helping you make smart decisions when choosing a primary care provider,
specialist, hospital or long term care provider
Providing tools to make the most of your doctor visits
Addressing provider network access issues like getting an appointment or
referrals to specialists
Understanding drug formularies and getting the most from your healthcare
dollars
Locating community resources and support groups
Educating yourself when you or a family member has a disease or condition, so
you can form an effective partnership with your doctors
Resolving questions and concerns regarding your health insurance program.
A NOTE ABOUT OUR SERVICES
CareCounsel is different from your health plan. We do not provide medical advice or
treatment, but serve as advocates to help you get your needs met. We provide an
independent and confidential assistance.
Please call CareCounsel at 1 (888) 227-3334 for help.
*CARECOUNSEL SERVICES ARE AVAILABLE TO CITY OF SAN DIEGO RETIREES AT NO COST.
THE SERVICES ARE AVAILABLE ALL YEAR LONG, NOT JUST AT OPEN ENROLLMENT.
45
401 B Street, Suite 400
San Diego, CA 92101-4298
