"Health Benefit Summary" - California

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2019 | Health Benefit Summary
Helping you make an informed decision about your health plan
2019 | Health Benefit Summary
Helping you make an informed decision about your health plan
About CalPERS
About This Publication
CalPERS is the largest purchaser of public
The 2019 Health Benefit Summary provides valuable
employee health benefits in California, and the
information to help you make an informed choice about
second largest public purchaser in the nation
your health plan and health care providers. This publication
after the federal government. Our program
compares covered services, co-payments, and benefits for
provides benefits to more than 1.4 million
each CalPERS health plan. It also provides information
public employees, retirees, and their families.
about plan availability by county and a chart summarizing
Depending on where you reside or work,
important differences among health plan types.
CalPERS offers active employees and retirees
You can use this information to determine which health
one or more types of health plans, which may
plan offers the services you need at the cost that works for you.
include:
The 2019 health plan premiums are available at the CalPERS
• Health Maintenance Organization (HMO)
website at www.calpers.ca.gov. Check with your employer
• Preferred Provider Organization (PPO)
to find out how much they contribute toward your premium.
• Exclusive Provider Organization (EPO)
The 2019 Health Benefit Summary provides only a general
(for members in certain California counties)
overview of certain benefits. It does not include details of
all covered expenses or exclusions and limitations. Please
The CalPERS Board of Administration annu-
refer to each health plan’s Evidence of Coverage (EOC)
ally determines health plan availability, covered
booklet for the exact terms and conditions of coverage.
benefits, health premiums, and co-payments.
Health plans mail EOCs to new members at the beginning
Whether you are working or retired, your
of the year, and to existing members upon request. In case
employer or former employer makes monthly
of a conflict between this summary and your health plan’s
contributions toward your health premiums.
EOC, the EOC establishes the benefits that will be provided.
The amount of this contribution varies. Your
We recommend that you only use this publication in
cost may depend on your employer or former
conjunction with the current year’s health premium rate
employer’s contribution to your premium, the
schedule and EOCs. To obtain a copy of the health premium
length of your employment, and the health plan
rate schedule for any health plan, please go to the CalPERS
you choose. For monthly contribution amounts,
website at www.calpers.ca.gov or contact CalPERS at
active employees should contact their employer,
888 CalPERS (or 888–225–7377).
State retirees should contact CalPERS, and
Other Health Publications
contracting agency retirees should contact
their former employer.
This publication is one of many resources CalPERS offers to
help you choose and use your health plan. Others include:
• Health Program Guide: Describes Basic and Medicare
Health Care Affordability
Transform health care purchasing and delivery
health plan eligibility, enrollment, and choices
• CalPERS Medicare Enrollment Guide: Provides information
to achieve affordability
We aspire to transform health care
about how Medicare works with your CalPERS health
purchasing and delivery, to make it affordable
benefits
while providing the best value in health care to
our members. We seek to understand rising
You can obtain the above publications and other
health care costs and the impact of wellness
information about your CalPERS health benefits through
on those costs.
my|CalPERS at my.calpers.ca.gov or by calling CalPERS
at 888 CalPERS (or 888–225–7377).
Contents
Considering Your Health Plan Choices
. . . . . . . 2
Additional Resources. . . . . . . . . . . . . . . . 14
Understanding How CalPERS Health Plans Work . . . 3
Health Plan Directory . . . . . . . . . . . . 14
CalPERS Health Plan Choices . . . . . . . . . . 4
Obtaining Health Care Quality Information . . . .
15
Choosing Your Doctor and Hospital . . . . . . . . 5
Enrolling in a Health Plan Using Your Residential
CalPERS Health Plan Benefit Comparison
or Work ZIP Code . . . . . . . . . . . . . 5
Basic Plans. . . . . . . . . . . . . . . . . . . . 16
Health Plan Availability
Medicare Plans. . . . . . . . . . . . . . . . . .24
Basic Plans . . . . . . . . . . . . . . . . 6
Medicare Plans . . . . . . . . . . . . . . 8
Tools to Help You Choose Your Health Plan . . . . . 10
Accessing Health Plan Information
with my|CalPERS . . . . . . . . . . . . . 10
my|CalPERS Health Plan Comparison Feature . . . 10
Comparing Your Options: Find a Medical Plan . . . . 11
Comparing Your Options: Health Plan Choice
Worksheet . . . . . . . . . . . . . . . . 11
Health Plan Choice Worksheet. . . . . . . . .
12
CalPERS Health Plan Member Survey Results . . . .13
1
2019 Health Benefit Summary | 
Considering Your Health Plan Choices
Selecting a health plan for you and your family is one
features, and costs can be complicated. This section
of the most important decisions you will make. This deci-
provides information that can simplify your decision-
sion involves balancing the cost of each plan, along with
making process. As you begin that process, the following
other features, such as access to doctors and hospitals,
are some questions you should ask:
• Do you prefer to receive your health care from an
pharmacy services, and special programs for managing
specific medical conditions. Choosing the right plan
HMO or PPO? Your preference will impact the plans
ensures that you receive the health benefits and services
available to you, your access to health care providers,
that matter to you.
and how much you pay for certain services. See the
If you are a new CalPERS member or you are consider-
chart on the next page for a summary of the differences
ing changing your health plan during Open Enrollment,
among plan types.
1
• What are the costs (premiums, co-payments, deduct-
you will need to make two related decisions:
• Which health plan is best for you and your family?
ibles, and coinsurance)? Beginning on page 16
• Which doctors and hospitals do you want to provide
of this booklet, you will find information about benefits,
your care?
co-payments, and covered services. Visit the CalPERS
The combination of health plan and providers that is
website at www.calpers.ca.gov to find out what the
right for you depends on a variety of factors, such as
premiums are for the various plans.
• Does the plan provide access to the doctors and hospi-
whether you prefer a Health Maintenance Organization
(HMO) or Preferred Provider Organization (PPO); your
tals you want? Contact health plans directly for this
premium and out-of-pocket costs; and whether you want
information. See the “Health Plan Directory” on page 14
to have access to specific doctors and hospitals.
of this booklet for health plan contact information.
We realize that comparing health plan benefits,
Note that in a few counties where access to HMOs is limited,
1
a third option, Exclusive Provider Organization (EPO), is
available. An EPO provides benefits similar to an HMO with
some PPO features.
2
 | 2019 Health Benefit Summary
Understanding How CalPERS Health Plans Work
The following chart will help you understand some important differences among health plan types.
HMO
PPO
EPO
Features
Accessing
Contracts with providers
Gives you access to a network of
Gives you access to the EPO
health care
(doctors, medical groups,
health care providers (doctors,
network of health care
providers
hospitals, labs, pharmacies,
hospitals, labs, pharmacies, etc.)
providers (doctors, hospitals,
etc.) to provide you services
known as preferred providers
labs, pharmacies, etc.)
at a fixed price
Selecting a
Most HMOs require you to
Does not require you to select
Does not require you to
primary care
select a PCP who will work
a PCP
select a PCP
physician
with you to manage your
(PCP)
health care needs 
1
Seeing a
Requires advance approval
Allows you access to many types
Allows you access to many
specialist
from the medical group or
of services without receiving a
types of services without
health plan for some services,
referral or advance approval
receiving a referral or advance
such as treatment by a specialist
approval
or certain types of tests
Obtaining care
Generally requires you to obtain
Encourages you to seek services
Requires you to obtain care
care from providers who are a
from preferred providers to ensure
from providers who are a part
part of the plan network
your coinsurance and co-payments
of the plan network
are counted toward your calendar
Requires you to pay the total
Requires you to pay the total
year out-of-pocket maximums 
2
cost of services if you obtain
cost of services if you obtain
care outside the HMO’s
Allows you the option of seeing
care outside the EPO’s
provider network without a
non-preferred providers, but
provider network without a
referral from the health plan
requires you to pay a higher
referral from the health plan
(except for emergency and
percentage of the bill 
(except for emergency and
3
urgent care services)
urgent care services)
Paying for
Requires you to make a small
Limits the amount preferred provid-
Requires you to make a
services
co-payment for most services
ers can charge you for services
small co-payment for most
services
Considers the PPO plan payment
plus any deductibles and
co-payments you make as payment
in full for services rendered by a
preferred provider
Your PCP may be part of a medical group that has contracted with the health plan to perform some functions, including treatment authorization, referrals to
1
specialists, and initial grievance processing.
Once you meet your annual deductible and co-insurance, the plan
Non-preferred providers have not contracted with the health plan;
2
3
pays 100 percent of medical claims for the remainder of the calendar
therefore, you will be responsible for paying any applicable member
year; however, you will continue to be responsible for co-payments
deductibles or coinsurance, plus any amount in excess of the
for physician office visits, pharmacy, and other services, up to the
allowed amount.
annual out-of-pocket maximum.
3
2019 Health Benefit Summary |