"Health Benefit Summary" - California

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Health Benefit Summary is a legal document that was released by the California Public Employees' Retirement System - a government authority operating within California.

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California Public Employees’ Retirement System
Office of Public Affairs
P.O. Box 942701
Sacramento, California 94229-2701
888 CalPERS (or 888-225-7377)
www.calpers.ca.gov
HBD–110: Supplemental Information
Appends the 2016 CalPERS Health Benefit Summary, CalPERS Publication HBD-110
(version dated September 2015.09.1)
There is an error in the 2016 Health Benefit Summary booklet. Refer to page 17 of the CalPERS Health Plan Benefit
Comparison – Basic Plans section. For the PORAC (Association Plan) PPO Basic Plan, the amounts reflected in the
Maximum Calendar Year Co-pay for an individual ($3,300) and family ($6,600) are incorrect. The accurate
amounts are $4,500 for an individual and $9,000 for a family.
See chart below with corrected rates highlighted in bold.
PPO Basic Plans
CAHP
PERS Select
PERS Choice
PERSCare
PORAC
(Association Plan)
(Association Plan)
BENEFITS
PPO
Non-PPO
PPO
Non-PPO
PPO
Non-PPO
PPO
Non-PPO
PPO
Non-PPO
Calendar Year Deductible
Individual
$500
$500
$500
N/A
$300
$600
(not transferable
(not transferable
(not transferable
between plans)
between plans)
between plans)
Family
$1,000
$1,000
$1,000
N/A
$900
$1,800
(not transferable
(not transferable
(not transferable
between plans)
between plans)
between plans)
Maximum Calendar Year Co-pay/Co-insurance (excluding pharmacy)
Individual
$2,000
$3,000
$3,000
$2,000
$4,500
N/A
N/A
N/A
N/A
N/A
(co-
(co-
(co-
(co-
insurance)
insurance)
insurance)
insurance)
Family
$4,000
$6,000
$6,000
$4,000
N/A
N/A
N/A
N/A
$9,000
N/A
(co-
(co-
(co-
(co-
insurance)
insurance)
insurance)
insurance)
Hospital (including Mental Health and Substance Abuse)
Deductible
N/A
N/A
N/A
$250
N/A
(per admission)
Inpatient
20–30%
10%
Varies
40%
20%
40%
10%
40%
10%
(hospital
tiers)
September 2015 | HBD-110
California Public Employees’ Retirement System
Office of Public Affairs
P.O. Box 942701
Sacramento, California 94229-2701
888 CalPERS (or 888-225-7377)
www.calpers.ca.gov
HBD–110: Supplemental Information
Appends the 2016 CalPERS Health Benefit Summary, CalPERS Publication HBD-110
(version dated September 2015.09.1)
There is an error in the 2016 Health Benefit Summary booklet. Refer to page 17 of the CalPERS Health Plan Benefit
Comparison – Basic Plans section. For the PORAC (Association Plan) PPO Basic Plan, the amounts reflected in the
Maximum Calendar Year Co-pay for an individual ($3,300) and family ($6,600) are incorrect. The accurate
amounts are $4,500 for an individual and $9,000 for a family.
See chart below with corrected rates highlighted in bold.
PPO Basic Plans
CAHP
PERS Select
PERS Choice
PERSCare
PORAC
(Association Plan)
(Association Plan)
BENEFITS
PPO
Non-PPO
PPO
Non-PPO
PPO
Non-PPO
PPO
Non-PPO
PPO
Non-PPO
Calendar Year Deductible
Individual
$500
$500
$500
N/A
$300
$600
(not transferable
(not transferable
(not transferable
between plans)
between plans)
between plans)
Family
$1,000
$1,000
$1,000
N/A
$900
$1,800
(not transferable
(not transferable
(not transferable
between plans)
between plans)
between plans)
Maximum Calendar Year Co-pay/Co-insurance (excluding pharmacy)
Individual
$2,000
$3,000
$3,000
$2,000
$4,500
N/A
N/A
N/A
N/A
N/A
(co-
(co-
(co-
(co-
insurance)
insurance)
insurance)
insurance)
Family
$4,000
$6,000
$6,000
$4,000
N/A
N/A
N/A
N/A
$9,000
N/A
(co-
(co-
(co-
(co-
insurance)
insurance)
insurance)
insurance)
Hospital (including Mental Health and Substance Abuse)
Deductible
N/A
N/A
N/A
$250
N/A
(per admission)
Inpatient
20–30%
10%
Varies
40%
20%
40%
10%
40%
10%
(hospital
tiers)
September 2015 | HBD-110
2016 Health Benefit Summary
Helping you make an informed choice
about your health plan
About CalPERS
About This Publication
CalPERS is the largest purchaser of public
The 2016 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 2016 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 2016 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 rate schedule and EOCs.
employer’s contribution to your premium, the
To obtain a copy of the rate schedule for any health plan,
length of your employment, and the health plan
please go to the CalPERS website at www.calpers.ca.gov
you choose. For monthly contribution amounts,
or contact CalPERS at 888 CalPERS (or 888–225–7377).
active employees should contact their employer,
Other Health Publications
State retirees should contact CalPERS, and
contracting agency retirees should contact
This publication is one of many resources CalPERS offers to
their former employer.
help you choose and use your health plan. Others include:
• Health Program Guide: Describes Basic and Medicare
CalPERS Health Program Vision Statement
health plan eligibility, enrollment, and choices
CalPERS will lead in the promotion of health
• CalPERS Medicare Enrollment Guide: Provides information
and wellness of our members through
about how Medicare works with your CalPERS health
best-in-class, data-driven, cost-effective,
benefits
quality, and sustainable health benefit
options for our members and employers.
You can obtain the above publications and other
We will engage our members, employers,
information about your CalPERS health benefits through
and other stakeholders as active partners in
my|CalPERS at my.calpers.ca.gov or by calling CalPERS
this pursuit and be a leader for health care
at 888 CalPERS (or 888–225–7377).
reform both in California and nationally.
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 or
CalPERS Health Plan Benefit Comparison
Work ZIP Code . . . . . . . . . . . . . . 5
Basic Plans. . . . . . . . . . . . . . . . . . . . 16
Health Plan Availability by County:
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
Comparing Your Options: Health Plan Chooser . . . 10
How to Use the Health Plan Chooser . . . . . . . 11
Comparing Your Options: Health Plan Choice
Worksheet . . . . . . . . . . . . . . .
12
Health Plan Choice Worksheet. . . . . . . . . .13
1
2016 Health Benefit Summary | 
Considering Your Health Plan Choices
Selecting a health plan for yourself and your family is one
We realize that comparing health plan benefits,
of the most important decisions you will make. This deci-
features, and costs can be complicated. This section
sion involves balancing the cost of each plan, along with
provides information that can simplify your decision-
other features, such as access to doctors and hospitals,
making process. As you begin that process, the following
pharmacy services, and special programs for managing
are some questions you should ask:
specific medical conditions. Choosing the right plan
• Do you prefer to receive your health care from an
ensures that you receive the health benefits and services
HMO or PPO? Your preference will impact the plans
that matter to you.
available to you, your access to health care providers,
If you are a new CalPERS member or you are consider-
and how much you pay for certain services. See the
ing changing your health plan during Open Enrollment,
chart on the next page for a summary of the differences
you will need to make two related decisions:
among plan types.
1
• Which health plan is best for you and your family?
• What are the costs (premiums, co-payments, deduct-
• Which doctors and hospitals do you want to provide
ibles, and coinsurance)? Beginning on page 16
your care?
of this booklet, you will find information about benefits,
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.
whether you prefer a Health Maintenance Organization
• Does the plan provide access to the doctors and hospi-
(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.
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
 | 2016 Health Benefit Summary
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