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Chapter 1: Enrollment and Eligibility Information · Chapter 1: Enrollment and Eligibility...

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Page 1: Chapter 1: Enrollment and Eligibility Information · Chapter 1: Enrollment and Eligibility Information ... Chapter 1: Enrollment and Eligibility Information ... the ‘Life Insurance
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Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Your Responsibilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Chapter 1: Enrollment and Eligibility InformationEligibility Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Enrollment Periods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Qualifying Changes in Status Chart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Documentation Requirements – Adding Dependent Coverage Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Documentation Requirements – Terminating Dependent Coverage Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Documentation Time Limits Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Opt Out and Waiver of Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Premium Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21COBRA Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

COBRA Qualifying Events Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25COBRA Second Qualifying Events Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Chapter 2: Health, Dental, Vision and Life Coverage InformationHealth Plan Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Managed Care Health Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Quality Care Health Plan (QCHP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Medical Benefits Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Prescription Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Behavioral Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Dental Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Vision Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Life Insurance Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Chapter 3: MiscellaneousSmoking Cessation Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Coordination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58Subrogation and Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Claim Filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Claim Appeal Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Chapter 4: ReferenceGlossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Table of Contents

Retiree Benefits HandbookMyBenefits.illinois.gov

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Your Group Insurance BenefitsAnnuitants, retirees and survivors who are receiving pensionbenefits from any of the five State retirement systems may beeligible to participate in the State Employees Group InsuranceProgram (Program). The five retirement systems with theircontact information are listed below:State Employees’ Retirement System2101 South Veterans ParkwayP.O. Box 19255Springfield, IL 62794-9255Phone: 217-785-7444TDD: 217-785-7218state.il.us/srs

State Universities Retirement System1901 Fox DriveP.O. Box 2710Champaign, IL 61825-2710Phone: 800-275-7877TDD: 800-526-0844surs.org

Teachers’ Retirement System2815 West WashingtonP.O. Box 19253Springfield, IL 62794-9253Phone: 800-877-7896TDD: 866-326-0087trs.illinois.gov

Judges’ Retirement System2101 South Veterans ParkwayP.O. Box 19255Springfield, IL 62794-9255Phone: 217-782-8500TDD: 217-785-7218state.il.us/srs

General Assembly Retirement System2101 South Veterans ParkwayP.O. Box 19255Springfield, IL 62794-9255Phone: 217-782-8500TDD: 217-785-7218state.il.us/srs

Please read this handbook carefully as it contains vitalinformation about your benefits.

The Bureau of Benefits within the Department of CentralManagement Services (Department) is the bureau thatadministers the Program as set forth in the State EmployeesGroup Insurance Act of 1971 (Act). You have the opportunityto review your choices and change your coverage for eachplan year during the annual Benefit Choice Period. If aqualifying change in status occurs, you may be allowed to makea change to your coverage that is consistent with the qualifyingevent. See the section ‘Enrollment Periods’ for moreinformation.

MyBenefits Service Center (MBSC)The MyBenefits Service Center (MBSC) is a custom benefitssolution service provider for the Department. The MBSC willmanage the detailed enrollment process of member benefitsthrough online technical support via theMyBenefits.illinois.gov website and telephonic support viathe MyBenefits Service Center 844-251-1777. The MBSC isnow the member's primary contact for answering generalquestions you may have about your eligibility for coverageand to assist you in enrolling or changing the benefits youhave selected.

Group InsuranceRepresentative (GIR)A Group Insurance Representative (GIR) is your retirementsystem's liaison to the Department. Each retirement systemalso has Group Insurance Preparers (GIP) who may assist theGIR with your enrollment needs. GIRs and GIPs continue to bevaluable resources concerning policies and rules set forth byCMS regarding members' benefits and eligibility as well asensuring the successful enrollment process of the member.

Introduction

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Where To GetAdditional InformationIf you have questions after reviewing this book,please refer to the following:F The MBSC website contains the most up-to-date

information regarding benefits and links to planadministrators’ websites. Visit MyBenefits.illinois.gov forinformation.

F Annual Benefit Choice Options booklet. This bookletcontains the most current information regarding changesfor the plan year. Visit MyBenefits.illinois.gov to view thebooklet.

F Each individual plan administrator can provide you withspecific information regarding plan coverageinclusions/exclusions.

F The MyBenefits Service Center (MBSC) can answergeneral benefits questions or refer you to theappropriate resource for assistance. MBSC can bereached at:

MyBenefits Service Center134 N. LaSalle Street, Suite 2200Chicago, IL 60602844-251-1777 or TDD/TTY: 844-251-1778MyBenefits.illinois.gov

F The Department will continue to assist members eligiblefor Medicare, with questions regarding eligibility policiesand rules as well as answer your benefit questions or referyou to the appropriate resource for assistance. The GroupInsurance Division can be reached at:

CMS Group Insurance Division801 S. 7th StreetP.O. Box 19208Springfield, IL 62794-9208800-442-1300 or 217-782-2548TDD/TTY: 800-526-0844

ID CardsThe plan administrators produce ID cards at the time ofenrollment. Cards are mailed to the current address on filewith the Bureau of Benefits. To obtain additional cards,contact the plan administrator. Links to the planadministrators’ websites can be found atMyBenefits.illinois.gov.

Health Insurance Portability andAccountability Act (HIPAA)Title II of the federally enacted Health Insurance Portabilityand Accountability Act of 1996, commonly referred to asHIPAA, was designed to protect the confidentiality and security ofhealth information and to improve efficiency in healthcaredelivery. HIPAA standards protect the confidentiality ofmedical records and other personal health information, limitthe use and release of private health information, and restrictdisclosure of health information to the minimum necessary.If you are enrolled in the Program, a copy of the Notice ofPrivacy Practices will be sent to you on an annual basis.Additional copies are available on the MyBenefits.illinois.govwebsite.

MyBenefits.illinois.gov Retiree Benefits Handbook3

Introduction (cont.)

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It is your responsibility to know your benefits,including coverage limitations and exclusions,and to review the information in this publication.Referral and/or approval for treatment by a physiciandoes not ensure coverage under the plan.

You must notify the MyBenefits Service Center (MBSC), oryour Group Insurance Representative (GIR) at your retirementsystem if:

F You and/or your dependents experience a change ofaddress. When you move, you must provide writtennotification to the GIR at your retirement system. Whenyour dependent(s) move, you must utilize the Self-ServiceTools online at MyBenefits.illinois.gov to report yourdependent's new address. Changing your address doesnot automatically change your health plan to a plan in thatgeographic area.

F Your dependent loses eligibility. Dependents that are nolonger eligible under the Program (including divorcedspouses or partners of a dissolved civil union or domesticpartnership) must be reported immediately by completingthe online process using the Self-Service Tools atMyBenefits.illinois.gov. Failure to report an ineligibledependent is considered a fraudulent act. Any premiumpayments you make on behalf of the ineligibledependent which result in an overpayment will not berefunded. Additionally, the ineligible dependent maylose any rights to COBRA continuation coverage.

F You get married or enter into a civil union, or yourmarriage, domestic partnership or civil unionpartnership is dissolved.

F You have a baby or adopt a child.

F Your dependent’s employment status changes.

F You have or gain other coverage. If you have groupcoverage provided by a plan other than the Program, or ifyou or your dependents gain other coverage during theplan year, you must provide that information immediatelyby completing the online process using the Self-ServiceTools at MyBenefits.illinois.gov.

Contact MBSC or your GIR if you are uncertain whether ornot a life-changing event needs to be reported. See the‘Enrollment Periods’ section in this chapter for a completelisting of qualifying changes in status.

If you and/or your dependent experience a change inMedicare status or become eligible for Medicare benefits, acopy of the Medicare card must be provided to the State ofIllinois Medicare Coordination of Benefits (COB) Unit. Failureto notify the Medicare COB Unit of you and/or yourdependent’s Medicare eligibility may result in substantialfinancial liabilities. Refer to the ‘Medicare Section’ for theMedicare COB Unit’s contact information.

Retirees, annuitants and survivors should periodically reviewthe following to ensure all benefit information is accurate:

F Insurance Deductions. It is your responsibility to ensuredeductions are accurate for the insurance coverage youhave selected/enrolled. If your annuity check isinsufficient to cover your premiums, you will be billed forthe cost of your current coverage and the Department willexercise its right under the State Comptroller’s Act tocollect delinquent group insurance premiums throughinvoluntary withholding.

F Beneficiary Designations. You should periodicallyreview all beneficiary designations and make theappropriate updates. Remember, you may have deathbenefits through various State-sponsored programs, eachhaving a separate beneficiary form:

• State of Illinois life insurance• Retirement benefits• Deferred Compensation

If You Live or SpendTime Outside IllinoisRetirees, annuitants and survivors who move outside of Illinoisor the country will most likely need to enroll in the Quality CareHealth Plan (QCHP). For those in certain areas contiguous to theState of Illinois, some managed care health plan options may beavailable. Refer to MyBenefits.illinois.gov and login to youraccount to view your available options, or contact the managedcare health plan directly for information on plans available.Changing your address does not automatically change yourhealth plan.

Your Responsibilities

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5

Dependents Who Live Apart fromthe Retiree, Annuitant or Survivor Eligible dependents who are enrolled in an HMO plan andlive apart from the retiree, annuitant or survivor’s residenceand are out of the plan’s service area for any part of a planyear will be limited to coverage for emergency services only.It is crucial that employees who have an out-of-areadependent (such as a college student) contact the managedcare plan to understand the plan’s guidelines on this type ofcoverage.

Power of AttorneyRetirees, annuitants and survivors may want to considerhaving a financial power of attorney on file with both theretirement system and the health plan to allow arepresentative to act on their behalf. For purposes of groupinsurance, a financial or property power of attorney isnecessary; a healthcare power of attorney does not permitchanges to health insurance coverage.

Penalty for FraudFalsifying information/documentation or failing to provide in-formation/documentation in order to obtain/continue cover-age under the Program is considered a fraudulent act. TheState of Illinois will impose a financial penalty, including,but not limited to, repayment of all premiums the State madeon behalf of the retiree, annuitant or survivor and/or the de-pendent, as well as expenses incurred by the Program.

Your Responsibilities (cont.)

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Chapter 1Chapter 1: Enrollment and Eligibility InformationEligibility Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Enrollment Periods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Qualifying Changes in Status Chart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Documentation Requirements – Adding Dependent Coverage Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Documentation Requirements – Terminating Dependent Coverage Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Documentation Time Limits Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Opt Out and Waiver of Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Premium Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21COBRA Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

COBRA Qualifying Events Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25COBRA Second Qualifying Events Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

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Eligibility for the Group Insurance Program (Program) isdefined by the applicable federal statutes or the StateEmployees Group Insurance Act of 1971 (5 ILCS 375/1 et seq.)or as hereafter amended (Act), and by such policies, rules andregulations as shall be promulgated there under. Eligibility for Basic Life and Optional Life insurance varies; seethe ‘Life Insurance Coverage’ section in Chapter 2 for details.

Eligible CategoriesThe following groups are eligible to participate in theProgram.

F Retirees

• State Retirees are individuals who began receivingpension benefits from one of the State’s five retirementsystems prior to January 1, 1966.

• University of Illinois Federal Retirees (SURS retireesonly) are former employees of the U of I CooperativeExtension Service of Urbana.

F Annuitants

An annuitant is an individual who began receivingpension benefits on or after January 1, 1966, from one ofthe State’s five retirement systems. All annuitants mustmeet the minimum vesting requirements of theappropriate retirement system based solely on prior Stateemployment. Insurance coverage becomes effective uponcommencement of the retirement or annuity benefits, orthe first of the month of the application for retirement,whichever is later.Annuitants are referred to as either an immediateannuitant or a deferred annuitant depending on whenthe individual began receiving their State pension. Animmediate annuitant is someone whose pension beginswithin one year of terminating State employment. Adeferred annuitant is someone whose pension beginsone year or more after terminating State employment.Annuitants should contact their retirement system prior toactual retirement to confirm whether they will be eligiblefor group insurance coverage.

F Alternative Retirement Cancellation Payment (ARCP)Recipients

Alternative Retirement Cancellation Payment (ARCP)recipients are former State employees who were vestedunder the State Employees’ Retirement System andelected the Alternative Retirement Cancellation Payment(ARCP) option per Public Act 93-0839 (between August16, 2004, and October 31, 2004), Public Act 94-0109(between July 1, 2005, and September 30, 2005) orPublic Act 93-0839 (between June 6, 2006, and August31, 2006).ARCP recipients are considered annuitants for groupinsurance purposes and are referred to as annuitants inthis handbook. Specifically, an ARCP recipient who wouldhave otherwise qualified for an annuity within one year ofleaving State service is considered an immediateannuitant. An ARCP recipient who would have otherwisequalified for an annuity more than one year from the dateof leaving State service is considered a deferredannuitant. ARCP recipients should direct any benefitquestions to the Department.

F Survivors

A survivor is a spouse, civil union partner, unmarriedchild under age 18 (under age 22 if a full-time student),unmarried child over age 18 if disabled prior to age 18 ordependent parent who is certified as eligible to receive anannuity from one of the five State retirement systems as aresult of the death of a State employee, retiree orannuitant.

F Retired Judges

Retired State judges who become federal judges havespousal insurance options available. Contact the Judges’Retirement System for the specific options available.

F General Assembly

Vested members of the General Assembly who leave theGeneral Assembly before they are eligible to retire, butallow their contribution to remain with the GeneralAssembly Retirement System, may continue groupinsurance coverage until they begin receiving theirpension.

Eligibility Requirements

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Dependent EligibilityEligible dependents of a retiree, annuitant or survivor mayparticipate in the Program. Dependent coverage is anadditional cost for all members. Eligible dependents include:F Spouse (does not include ex-spouses, common-law

spouses, persons not legally married or the new spouseof a survivor).

F Same-Sex Domestic Partner (enrolled prior to June 1,2011).

F Civil Union Partner (enrolled on or after June 1, 2011).

F Child from birth to age 26, limited to:

– Natural child. – Adopted child.– Stepchild or child of a civil union partner.– Child for whom the retiree, annuitant or survivor has

permanent legal guardianship.– Adjudicated child for whom a U.S. court decree has

established a member’s financial responsibility for thechild’s medical, dental or other healthcare.

F Child age 26 and older, limited to:

– Adult Veteran Child. Unmarried adult child age 26 upto, but not including, age 30, an Illinois resident, hasserved as a member of the active or reservecomponents of any of the branches of the U.S. ArmedForces and received a release or discharge otherthan a dishonorable discharge.

– Other. (1) Recipient of an organ transplant after June 30,2000, and eligible to be claimed as a dependent forincome tax purposes by the retiree, annuitant orsurvivor, except for a dependent child who need only beeligible to be claimed for tax years in which the child isage 27 or above, or (2) an unmarried individualcontinuously enrolled as a dependent of the retiree,annuitant or survivor in the State Insurance Program (orCNA for university staff) since 2/11/83 with no break incoverage and eligible to be claimed as a dependent forincome tax purposes by the retiree, annuitant orsurvivor. The period of time the dependent was

enrolled with Golden Rule Insurance Company (prior toApril 1, 1988) does not count toward the requirementof continuous enrollment.

– Disabled. Child age 26 or older who is continuouslydisabled from a cause originating prior to age 26. Inaddition, for tax years in which the child is age 27 orabove, eligible to be claimed as a dependent forincome tax purposes by the retiree, annuitant orsurvivor.

NOTE: Survivors may add a dependent only if thatdependent was eligible for coverage as a dependent underthe original member.

Certification ofDependent CoverageIn addition to the following certification periods, theDepartment may ask the member to certify their dependenteither randomly or during an audit anytime during the year.Birth Date Certification. Retirees, annuitants and survivorsmust verify continued eligibility for dependents turning ages26 and 30. Members with dependents turning ages 26 and30 will receive a letter from the Department several weeksprior to the birth month that contains information regardingcontinuation of coverage requirements and options. Themember must provide the required documentation prior tothe dependent’s birth date. Failure to certify the dependent’seligibility will result in the dependent’s coverage beingterminated effective the end of the birth month.Annual Certification. Members are required to certify all IRSdependents in the following categories on an annual basis:Domestic Partner, Civil Union Partner, Civil Union PartnerChildren, Disabled, Other and Adult Veteran Child (age 26and older).Reinstatement of Dependent Coverage. If coverage for adependent is terminated for failure to certify and themember provides the required documentation within 30 daysfrom the date the termination was processed, coverage will bereinstated retroactive to the date of termination. After 30 days the coverage will be reinstated only with aqualifying change in status (see qualifying change in statusreasons in the ‘Enrollment Periods’ section later in this chapter).Termination of coverage for failure to certify is not a

Eligibility Requirements (cont.)

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qualifying change in status. Nonretroactive reinstatement willcause a break in coverage which would prevent adependent from qualifying for continued coverage in theOther category.NOTE: Dependents with life insurance coverage only, aswell as dependents of COBRA participants, must also certifyeligibility for coverage.

Contact the MyBenefits Service Center (MBSC) forquestions regarding certification of a dependent.

Eligibility Requirements (cont.)

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Retirees, annuitants and survivors may enroll, optout or change benefit selections with supportingdocumentation during the following periods (see the‘Documentation Requirements’ chart in this chapter):

F Initial Enrollment (upon application for annuity benefits)F Annual Benefit Choice PeriodF Qualifying Change in Status

Initial EnrollmentRetirees, annuitants and survivors are eligible to participatein the health, dental and vision plans under the Program.Life insurance coverage options and eligibility vary;therefore, retirees, annuitants and survivors should refer tothe ‘Life Insurance Coverage’ section in Chapter 2 forspecific available options. Active or inactive employees who notify the retirementsystem of their intent to retire will be sent a retirementpacket prior to their retirement date. The Pension Packetcan be found on your retirement system website and willinclude an instructional sheet regarding the MyBenefits siteand call center and a required form to be completed andsent with the pension application and other requireddocuments. The form is used by the retirement system toupdate the member’s insurance record. The MyBenefitsService Center will receive the member's updatedinformation which will allow the member to enroll or makechanges online on the MyBenefits portal to their currentbenefits within 60 days of the retirement effective date. If theactive employee is satisfied with the benefits they have inplace at the time of retirement, there will be no need to goonline to the MyBenefits portal as benefits in place at thetime of retirement will continue.NOTE: Spouses who are both eligible for coveragemust be enrolled as a member in their own right unlessthey qualify for the Annuitant Waiver option (see the‘Opt Out and Waiver’ section for qualifications).Annuitants who wish to make changes to their coverage but donot complete the online process by using the Self-Service Toolsat MyBenefits.illinois.gov within the 60-day period must waituntil a subsequent Benefit Choice Period or until theyexperience a qualifying change in status to elect the health,dental and vision coverage; however, they will continue to beenrolled with Basic Life coverage only.All retirees, annuitants and survivors must provide theirsocial security number (SSN) to be enrolled in the Program.

Upon becoming eligible for an annuity, retirees,annuitants and survivors have the followinginsurance options:F Elect a health plan (includes prescription, behavioral

health and vision coverage).F Elect not to participate in the health plan by electing to

opt out or waive coverage. See the ‘Opt Out and Waiverof Coverage’ section in this chapter for details.

F Elect to participate or not to participate in the dentalplan (enrollment in the health plan is required if electingthe dental coverage).

F Enroll eligible dependents. Refer to the ‘Qualifiying Changein Status’ section for effective dates and the 'DependentCoverage' section for documentation requirements.

F Life-eligible annuitants and certain survivors (see the ‘LifeInsurance Coverage’ section for eligibility criteria) may– add, increase, decrease or terminate MemberOptional Life insurance coverage;

– add or drop Spouse Life or Child Life coverage.An approved statement of health is required to increaseor add coverage. AD&D and Child Life coverage maybe added or dropped at any time without a statement ofhealth application. Newly eligible dependents andsurvivors do not need to provide statement of healthapproval as long as the coverage is requested within 60days of initial enrollment.

Effective Date of Coverage Due to Initial Enrollment:Coverage for annuitants will remain the same as when themember was employed unless different coverage was elected.The elected change in coverage will becomes effective on thedate of commencement of the retirement/annuity benefit, thefirst of the month that the application for required retirementdocuments was were received or the first day of the monththat the group insurance enrollment form was receivedMyBenefits Service Center was notified of the member’schange in elections, whichever is later.

Survivor coverage becomes effective (1) the day after themember’s death if the survivor is currently a dependent ofthe deceased annuitant, or (2) the first day of the monthfollowing the member’s death if the survivor is not adependent at the time of the member’s death.Dependents may be added to the member's coveragewithin 60 days. Refer to the ‘Dependent Coverage,Enrolling Dependents’ in this section for more information.

Enrollment Periods

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Annual Benefit Choice PeriodThe Benefit Choice Period is normally held annually May 1stthrough May 31st. During this 31-day period, employees maychange their coverage elections. Coverage elected during theannual Benefit Choice Period becomes effective July 1st. Electedcoverage remains in effect throughout the entire plan year,unless the employee experiences a qualifying change in statusor the Department institutes a special enrollment period whichwould allow the member to change their coverage elections.Retirees, annuitants and survivors may make thefollowing changes during the annual Benefit ChoicePeriod:F Change health plans.F Re-enroll in the Program following an opt out or

waiver of coverage.F Elect not to participate in the health plan. See the ‘Opt Out

and Waiver of Coverage’ section in this chapter for details. F Add or drop dental coverage (enrollment in the health plan

is required if electing the dental coverage).F Add or drop dependent coverage. Social security numbers

are required to add dependent coverage. Refer to the'Dependent Coverage' section for documentationrequirements.

F Life-eligible annuitants and survivors (see the ‘LifeInsurance Coverage’ section for eligibility criteria) may– add, increase, decrease or terminate Member Optional

Life insurance coverage;– add or drop Spouse Life or Child Life coverage. An approved statement of health is required to increaseor add coverage. AD&D and Child Life coverage may beadded or dropped at any time without a statement ofhealth application. Newly eligible dependents andsurvivors do not need to provide statement of healthapproval as long as the coverage is requested within 60days of initial enrollment.

Effective Date of Coverage Due to the AnnualBenefit Choice Period:All Benefit Choice health, dental and dependent coverage changesbecome effective July 1st. Life insurance coverage changesrequiring a statement of health become effective July 1st if theapproval date from the life insurance plan administrator is on orbefore July 1st. If the approval date is after July 1st, the effectivedate will be the statement of health approval date.

Qualifying Change in StatusThe Department’s administrative policy prohibits changes inretiree, annuitant and survivor elections during the plan yearunless there is a qualifying change in status. See the‘Qualifying Change in Status’ chart for allowable electionchanges consistent with the event. Any request to change anelection mid-year must be consistent with the qualifying eventthe retiree, annuitant or survivor has experienced.Qualifying change in status events may include, butare not limited to: F Events that change a retiree, annuitant or survivor’s legal

relationship status, including marriage, civil unionpartnership, death of spouse or civil union partner, divorce,legal separation, civil union dissolution or annulment.

F Events that change a retiree, annuitant or survivor’snumber of dependents, including birth, death, adoption,placement for adoption or termination of a domesticpartner relationship.

F Events that change the employment status of themember's spouse, civil union partner or dependent.Events include termination or commencement ofemployment, strike or lockout, commencement of, or returnfrom, an unpaid leave of absence or change in worksite.

F Events that cause a dependent to satisfy or cease to satisfyeligibility requirements for coverage.

F A change of residential county for the retiree, annuitantor survivor, or the retiree, annuitant or survivor’s spouse,civil union partner or dependent or, a move to a foreigncountry by an eligible dependent.

Retirees, annuitants and survivors experiencing a qualifyingchange in status have 60 days to change certain benefitselections. Members are required to notify the State of anyqualifying changes by completing the online process using theSelf-Service Tools at MyBenefits.illinois.gov. Members mustalso submit proper supporting documentation to MBSC withinthe 60-day period in order for the change to become effective.See ‘Effective Date of Coverage Due to a Qualifying Change inStatus’ later in this section.See the ‘Qualifying Changes in Status’ chart in this chapterfor a complete list of qualifying change in status events andcorresponding options.

Effective Date of Coverage Due to a QualifyingChange in Status:Coverage election changes made due to a qualifying eventare effective the later of:

F The date the request for change was received by MBSC, orF The date the event occurred.

Enrollment Periods (cont.)

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Qualifying Change in Status Effective Date Exceptions:F Newborns, natural or adopted. A child is considered a

newborn if they are within 60 days of birth. If the requestto add the child is made within 60 days of the birth,coverage may be retroactive to the date of birth.

F Adopted children, other than newborn. Requests to addan adopted child who is 60 days old or older will beeffective the date of the placement of the child, the filing ofthe adoption petition or the entry of the adoption orderprovided that the request is received within 60 days of theplacement of the child, filing of the adoption petition or theentry of the adoption order.

Other Allowable Mid-year ChangesThere are some coverage options that can be changed anytime during the plan year. These include:F Changes in Member Optional Life insurance coverage. An

approved statement of health is required to add orincrease coverage.

F Changes to Spouse Life coverage. An approved statementof health is required to add coverage, unless the spouse orcivil union partner is newly acquired.

F Changes to Accidental Death and Dismemberment (AD&D)and Child Life coverage. A statement of health is not requiredto add or increase AD&D and/or Child Life coverage.

F Changes to (adding or dropping) dependent coverage aslong as the retiree, annuitant or survivor’s dependentmonthly contribution category remains ‘Two or MoreDependents’.

Effective Date of Coverage for Other Allowable Mid-year Changes:The effective date for adding or dropping dependent coveragewhen the retiree, annuitant or survivor is in the ‘Two or MoreDependents’ monthly contribution category is the date the requestfor change is received by the MyBenefits Service Center or atMyBenefits.illinois.gov, or 844-251-1777.The effective date of coverage when adding or increasingMember Optional Life, or when adding Spouse Life, will bethe statement of health approval date. The life planadministrator will send a copy of the statement of healthapproval/denial letter to the individual who requested thechange.When adding or increasing AD&D and/or Child Life coverage theeffective date is the date the request was received.When terminating or decreasing any Optional Life coverageoutside the Benefit Choice Period, the effective date will be thedate of the request.

Dependent CoverageEnrolling DependentsEligible dependents will be added to the member's coverageas long as the request and required documentation is receivedwithin 60 days of the mailing of group insurance enrollmentinformation or qualifying event, whichever is later. Dependentcoverage will be effective the date the request was received bythe retirement system as long as it is received within the 60-day qualifying window. To add an eligible dependent,complete the online process by using the Self-Service Tools atMyBenefits.illinois.gov or contact the MyBenefits ServiceCenter. If dependents are added to the member’s coverage, thedependents will be enrolled in the same health and dentalplans as the retiree, annuitant or survivor. Members electingto opt out or waive the health and dental plan coverage maystill enroll their dependents with Child Life and/or Spouse Lifecoverage only.When both parents* are members, either member may electto cover the dependents; however, the same dependentcannot be enrolled under both members for the same type ofcoverage. For example, eligible dependents may be enrolledunder one parent for health and dental coverage and enrolledunder the other for life coverage. NOTE: Dependents whosecoverage was terminated for nonpayment of premium underone parent cannot be enrolled under the other until allpremiums due for that dependent are paid.

* The term 'parent' includes a stepparent or a civil unionpartner of the child's parent.

Documentation RequirementsDocumentation, including the dependent’s social securitynumber (SSN), is always required to enroll dependents.Failure to provide the required documentation in the allottedtime period will result in denial of dependent coverage. Ifdenied, the eligible dependent may be added during the nextBenefit Choice Period or upon the member experiencing aqualifying change in status, as long as the documentation isprovided in a timely manner.A time period of 90 days is allotted to provide the SSN ofnewborns and adopted children; however, the election timeframes still apply to request the addition of the dependentcoverage. If the SSN is not provided within 90 days of thedependent’s date of birth or adoption date, coverage will beterminated. Refer to the ‘Documentation Requirements –Adding Dependent Coverage’ chart later in this chapter forspecific documentation requirements.

Enrollment Periods (cont.)

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The State of Illinois health plans are administered in accordance with qualifying change in status rules. The chart below indicates thosechanges that members are allowed to make which are consistent with a qualifying change in status.

Qualifying Changes in Status

MEMBER – Qualifying Changes in StatusCorresponding HEALTH & DENTAL Options

Changes affecting the Member Opt Out of Enroll or Add Newly Add Add Terminate Terminate Change WaiveHealth & Re-Enroll Acquired Existing Spouse Dependent Spouse or Health Health &Dental in the Child Child or Civil Coverage Civil Union Carrier Dental

Coverage Program Union Partner CoveragePartner Coverage

Adjudicated Child: X*Member financially responsibleAdoption (or placement for adoption) X X* X XBirth X X* X XCustody awarded and requires X X* Xdependent coverage (court ordered)Custody loss (court ordered)/Court XOrder expiresDivorce/Legal Separation/Annulment/ X X X XDissolution of Civil UnionEligibility: Member becomes eligible O Pfor non-State group insurance coverageEligibility: Member loses eligibility of

X X Xnon-State group insurance coverage(for other than nonpayment of premium)

Marriage or Civil Union Partnership O X X* X X** P

Medicaid or Medicare eligibility gained O X X P

Medicaid or Medicare eligibility loss X X XPremium increase 30% or greater: X X XMember’s non-State health insurancePremium increase 30% or greater: X X PMember’s STATE health insuranceResidence location: XMember’s county changes***

X = Eligible changes for all members.P = Eligible changes for annuitants and survivors responsible for a portion of the State contribution.O = Eligible changes for retirees, annuitants and survivors with 20 or more years of state service.Newly Acquired Child = A child for which the member gained custody within the previous 60-day period, such as a new stepchild, child of a civil union partner, adopted

child, adjudicated child or a child for which the member gained court-ordered guardianship.Existing Child = A child for which the member had custody prior to the previous 60-day period, such as a natural or adopted child, adjudicated child, stepchild, child of a

civil union partner or a child for which the member is guardian.

* For Survivors only: Survivors may add a dependent only if that dependent was eligible for coverage as a dependent under the original member.** For Survivors only: Survivors may not add a new spouse, nor may they add a civil union partner or their children.*** Change allowed if health carrier unavailable in new location.

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Qualifying Changes in Status(Whenever the term 'Spouse' is indicated on this page it also includes a Civil Union Partner.)

SPOUSE – Qualifying Changes in StatusCorresponding HEALTH & DENTAL Options

Changes affecting the Spouse Member Member Add Newly Add Add Terminate Terminate Change WaiveMay Opt may Acquired Existing Spouse Dependent Spouse Health Health/

Out of Enroll or Child Child Coverage Coverage Carrier DentalProgram Re-Enroll Coverage

in the Program

Coordination of spouse’s O X X X X X Popen enrollment period *Death of spouse X X XEligibility: Spouse loses eligibility X X Xfor group insurance coverageEligibility: Spouse now provided O X X Pwith group insurance coverageEmployment Status: O X X PSpouse gains employmentEmployment Status: X X XSpouse loses employmentLOA: Spouse enters nonpay status X XLOA: Spouse returns to work fromnonpay status X X

Medicare eligibility: Spouse gains XMedicare eligibility: Spouse loses XPremium of spouse’s employer increases

X X X30% or greater, or spouse’s employersignificantly decreases coverage Residence/Work location: XSpouse’s county changes**

DEPENDENT (other than Spouse) – Qualifying Changes in StatusCorresponding HEALTH & DENTAL Options

Changes affecting a Dependent Member Member Add Newly Add Add Terminate Terminate Change Waive

(other than a Spouse) May Opt may Acquired Existing Spouse Dependent Spouse Health Health/Out of Enroll or Child Child Coverage Coverage Carrier Dental

Program Re-Enroll Coveragein the

Program

Death of Dependent XEligibility: Dependent becomes Xeligible for State group coverageEligibility: Dependent loses eligibility Xfor non-State group coverageEligibility: Dependent now eligible for Xnon-State group coverageLOA: Dependent enters nonpay status XLOA: Dependent returns to work fromnonpay status X

Medicare eligibility: Dependent gains XMedicare eligibility: Dependent loses XResidence/Work location: XDependent’s county changes*

* The member’s request to change coverage must be consistent with, and on account of, the spouse’s election change.** Change allowed if health carrier unavailable in new location.

X = Eligible changes for all members. P = Eligible changes for annuitants and survivors responsible for a portion of the State contribution.O = Eligible changes for retirees, annuitants and survivors with 20 or more years of state service.Existing Child = A child for which the member had custody prior to the previous 60-day period, such as a natural or adopted child, adjudicated child, stepchild, child of a civil union

partner or a child for which the member is guardian. * Change allowed if health carrier unavailable in new location.

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Type of DependentAdjudicated ChildBirth up to, but not including, age 26

Adoption or Placement for AdoptionBirth up to, but not including, age 26

Adult Veteran ChildChild age 26 up to, but not including, age 30

Disabled Child age 26 and older(onset of disability must have occurred prior to age 26)

Legal GuardianshipBirth up to, but not including, age 26Natural ChildBirth up to, but not including, age 26OtherOrgan transplant recipient

Spouse or Civil Union Partner

Stepchild or Child of Civil Union PartnerBirth up to, but not including, age 26

Supporting Documentation Required• Judicial Support Order from a judge; or• Copy of DHFS Qualified Medical Support Order with the page that indicates the

member must provide health insurance through the retirement system• Adoption Decree/Order with judge’s signature and the circuit clerk’s file stamp,

or a• Petition for adoption with the circuit clerk’s file stamp• Birth Certificate required, and • Proof of Illinois residency, and • Veterans’ Affairs Release form DD-214 (or equivalent), and a• Copy of the tax return

• Birth Certificate required, and a• Statement from the Social Security Administration with the Social Security disability

determination or a Court Order, and a• Copy of the tax return

• Court Order with judge’s signature and circuit clerk’s file stamp

• Birth Certificate required

• Birth Certificate required, and • Proof of organ transplant performed after June 30, 2000, and a • Copy of the tax return for dependents 26 and older

• Marriage Certificate or tax return• Civil Union Partnership Certificate. A tax return is also required if claiming the civil

union partner as a dependent.• Birth Certificate required, and • Marriage or Civil Union Partnership Certificate indicating the member is married to,

or the partner of, the child’s parent. A tax return is also required if claiming the civilunion partner’s child as a dependent.

Note: Birth Certificate from either the State or admitting hospital which indicates the member is the parent is acceptable.

* A valid social security number (SSN) is required to add dependent coverage. If the SSN has not yet been issued for a newborn or adopted child, the child will be added tothe member’s coverage upon receipt of the birth certificate or adoption order without the SSN. The member must provide the SSN within 90 days of the date the coveragewas requested in order to continue the dependent's coverage.

Documentation Requirements – Adding Dependent Coverage*

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Qualifying Event

Divorce, Dissolution of Civil Union Partnership or Annulment

Legal Separation

Loss of Court-Ordered Custody

Supporting Documentation Required

Divorce Decree or Judgment of Dissolution or Annulment filed in a U.S. Court – firstand last pages with judge’s signature with circuit clerk’s file stamp.

Court Order with judge’s signature with circuit clerk’s file stamp.

Court Order indicating the member no longer has custody of the dependent. Theorder must have judge’s signature with circuit clerk’s file stamp.

Documentation Requirements – Terminating Dependent Coverage

When adding Dependent coverage due to or during the:

Initial Enrollment Period

Annual Benefit Choice Period(Normally held May 1 – May 31 each year)

Qualifying Change in Status (Exception for birth or adoption – noted below)

Birth of Child (Natural or Adopted)

Adopted Children (Other than newborn)

If the coverage is requested…

Day 1 – 60 from the benefit begin date

During the Benefit Choice Period

Before, or the day of, theevent

Day 1 – 60 after eventFrom birth up to 60 days after the birthWithin 60 days of theevent

And if the documentation is provided…Day 1 – 60 from the benefit begin date

Within 10 days of theBenefit Choice Periodending

1 – 60 days after theevent

From birth to 60 daysafter the birthWithin 60 days of theevent

Dependent coveragewill be effective…

The date the request wasreceived by the retirementsystem

July 1st

Date of the event

Date the request was received bythe retirement system

Date of birth

Date of placement of the child,filing of the petition or the entryof the adoption order

Documentation Time LimitsDependent health, dental and vision coverage may be added with the corresponding effective date when documentation is provided to theMyBenefits.illinois.gov or the MyBenefits Service Center within the allowable time frame as indicated below. If documentation is providedoutside the time frames, adding dependent coverage will not be allowed until the next annual Benefit Choice Period or until the memberexperiences a qualifying change in status. Refer to the ‘Life Insurance Coverage’ section for effective dates of life coverage.

Penalty for FraudFalsifying information/documentation or failing to provide information/documentation in order to obtain/continue coverageunder the Program is considered a fraudulent act. The State of Illinois will impose a financial penalty, including, but not lim-ited to, repayment of all premiums the State made on behalf of the retiree, annuitant, survivor and/or the dependent, as well asexpenses incurred by the Program.

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Retirees, annuitants and survivors may opt out orwaive coverage during certain enrollment periods.The election to opt-out or waive coverage will terminatehealth, dental and vision coverage for the member and anyenrolled dependents. Annuitants and survivors who areeligible for Basic Life will continue, and/or be enrolled in, theBasic Life coverage regardless of their election to opt out orwaive the health, dental and vision coverage. The member’selected Optional Life coverage will also continue to be inforce. Annuitants and survivors should refer to the ‘LifeInsurance Coverage’ section for Basic and Optional Lifeeligibility requirements.Annuitants and survivors who have opted out/waived mayelect to enroll/re-enroll in the health, dental and visioncoverage during a subsequent Benefit Choice Period or uponexperiencing a qualifying change in status. Retirees, annuitants and survivors who opt out of the Programor waive coverage will not be eligible for the following:F Free influenza immunizations offered annually F COBRA continuation of coverage F Smoking Cessation Program

Opting Out of CoverageApplies to all Retirees, Annuitants and SurvivorsIn accordance with Public Act 92-0600, retirees, annuitants andsurvivors may elect to opt out of the State’s coverage during theannual Benefit Choice Period or upon experiencing a qualifyingchange in status. Annuitant and survivors electing to opt out of health coverage(which includes the termination of vision and prescriptioncoverage) will remain enrolled in the dental and life insurancecoverage. Members who opt out of the health coverage and donot want the dental coverage may only elect to opt out of thedental coverage during the annual Benefit Choice Period. Members choosing this opt-out election cannot be enrolled asa dependent in any other plan administered by theDepartment and must provide proof of other major medicalinsurance by an entity other than the Department. Proof ofother coverage must accompany the Opt Out ElectionCertificate available on the MyBenefits.illinois.gov website.NOTE: An application for other health coverage is notacceptable proof of other coverage.

Opt Out with Financial IncentiveApplies only to Annuitants not eligible for Medicare(includes annuitants with less than 20 years ofservice) – Survivors are not eligible for the incentiveIn accordance with Public Act 98-0019, effective July 1, 2013,annuitants who have other comprehensive medical coverageand meet the following criteria may elect to OPT OUT of theProgram and receive a financial incentive of $150 per month(annuitants with less than 20 years of state service) or $500per month (annuitants with 20 years or more of state service),less applicable withholding. In order to be eligible to receivethe incentive, the annuitant must be receiving a retirementannuity from one of the five state retirement systems and beenrolled in the State Employees Health Insurance Program,and be ineligible for Medicare. Proof of other coverage willbe required on an annual basis in order to continue receivingthe incentive. The Department will send a notice each yearrequesting proof of other coverage. The Opt Out with FinancialIncentive selection option is available online atMyBenefits.illinois.gov.

Annuitant WaiverApplies to Annuitants who have been a Dependentfor One Year or MorePublic Act 93-553 changed the State Employees GroupInsurance Act to allow an annuitant who is currently enrolledas a dependent of their State-covered spouse or civil unionpartner to remain a dependent and waive coverage in theirown right. To qualify for this waiver, the annuitant must beenrolled as a dependent under their State-covered spouse orcivil union partner for a year or more. The annuitant must indicate the election to continue as adependent by completing the online process using the Self-Service Tools at MyBenefits.illinois.gov or by calling theMBSC Annuitants who do not complete the online processusing the Self-Service Tools at MyBenefits.illinois.gov withinthe required timeframe will have their coverage as adependent of their spouse/civil union partner terminated.The spouse/civil union partner cannot carry Spouse Life on theannuitant; instead, the annuitant will have Basic Life coverageas a member.

Opt Out and Waiver of Coverage

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Waiver OptionAt the time an annuitant or survivor files an annuity applicationthey will receive a Participation Election Form from theretirement system, in addition to other documentation.Annuitants who would like to waive the health, dental and visioncoverage must select the applicable box on the election formindicating the desire to waive the coverage. Retirees, annuitants and survivors who are currently enrolledin the health, dental and vision coverage but wish to waivethe coverage must wait until either the annual Benefit ChoicePeriod or until they experience a qualifying change in status.Waivers requested due to a qualifying change in status will beeffective the later of either the date of the receipt of therequest or the date of the qualifying event. Waiversrequested during the annual Benefit Choice Period will beeffective July 1st.

Opt Out and Waiver of Coverage (cont.)

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The State covers the majority of the cost of health anddental insurance coverage for retirees, annuitants andsurvivors, and all of the cost for vision and Basic Lifeinsurance coverage. The amount a retiree, annuitant orsurvivor contributes each month is based upon thecoverage elections in effect on the 1st of the month.Premiums will not be prorated when a member changestheir coverage elections or terminates from the Program ona day other than the 1st. Annuitants and survivors whoseannuity check is insufficient to have premiums deductedwill be direct billed. Additional information about member-paid premiums isoutlined below. It is your responsibility to verify theaccuracy of premiums paid, whether deducted from theannuity or direct billed, and to notify your GIR of any errors.

Retiree, Annuitantand Survivor ContributionsMember Coverage Contributions

Contribution amounts for retirees, annuitants and survivorsare based on years of service. While some members may beresponsible for a contribution for their health coverage, othersreceive premium-free coverage. Refer to the ‘StateContribution’ section for specific criteria requirements.Optional coverage options, including dependent, dental andoptional life coverage requires a member contribution. Optional Coverage Contributions

All retirees, annuitants and survivors are responsible for aportion of the cost of elective dental and dependentcoverage, as well as the full cost of any Optional Lifecoverage. Premiums for optional coverage are establishedannually and reflected in the Benefit Choice Options booklet.These contributions/premiums are subject to change eachplan year. Special provisions apply for the following types ofdependents if they cannot be claimed as a dependent underthe IRS tax code: adult veteran children age 26 through age29, domestic partners, civil union partners and children ofcivil union partners. F The premium for a non-IRS domestic partner, a non-IRS

civil union partner or the non-IRS child(ren) of a civilunion partner, is the ‘One Dependent’ or ‘Two or MoreDependent’ rate depending on the number of non-IRS

dependents in these categories being covered.F The premium for a non-IRS adult veteran child ages 26

through 29 is 100% of the cost of coverage (member’sportion plus the State contribution).

The value of the coverage for a domestic partner, civil unionpartner and any children of the civil union partner isconsidered “imputed income” and will be reported as incomeat the end of each calendar year. The premiums for thesedependents and imputed income amounts are indicated inthe Domestic Partner/Civil Union Partner FAQ located on theMyBenefits.illinois.gov website.

Reciprocal Service CreditRetirees, annuitants and survivors under certaincircumstances use creditable service established in the fiveretirement systems to qualify for or reduce their cost of healthbenefits. Contact the retirement system for more informationregarding reciprocal service credit.

State ContributionRetirees, annuitants and survivors with 20 or more years ofcreditable service receive premium-free coverage.Contributions are required for individuals who have less than20 years of service. Specifically, the State will contribute 5percent of the cost of coverage toward an individual’s healthplan election for every eligible year of service worked up to a100 percent contribution. The following annuitants andsurvivors who have less than 20 years of service are requiredto pay 5 percent of the cost of coverage for each year ofservice less than 20 years upon which their annuity is based:SERS

F SERS annuitants who retire on or after January 1, 1998, andhave between 8 and 20 years of creditable service.

F ARCP recipients who had between 8 and 20 years ofcreditable service at the time they elected the ARCPoption.

F Survivors of a deceased annuitant in one of the abovecategories.

F Survivors of a deceased employee who would have beeneligible for one of the above categories on the date ofdeath.

Premium Payment

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SURS

F SURS annuitants who retired on or after January 1, 1998,and have between 5 and 20 years of creditable service.

F Survivors of a deceased annuitant in one of the abovecategories.

F Survivors of a deceased employee who would have beeneligible for one of the above categories on the date ofdeath.

TRS *

F TRS annuitants who retired on or after July 1, 1999, andhave between 5 and 20 years of creditable service.

F Survivors of a deceased annuitant in one of the abovecategories.

F Survivors of a deceased employee who would have beeneligible for one of the above categories on the date ofdeath.

The following individuals are required to pay an additional12.5% of the cost of coverage for each year of service lessthan 8 years of creditable service they served as a regionalsuperintendent or an assistant regional superintendent:

TRS

F TRS regional superintendent annuitants who retire underTRS on or after July 1, 1998, and have less than 8 years ofcreditable service.

The following individuals are eligible for coverage but arerequired to pay 100% of the cost:

GARS

F Former members of the General Assembly who havevested and allowed their contributions to remain with theGeneral Assembly Retirement System, but are notreceiving an annuity.

Annuitants and SurvivorsDirect BilledBilling Procedure and Time Frames

Annuitants and survivors whose annuity check is not sufficientto deduct premiums will be direct billed. When this occurs, abill will be generated for the premium amount due. Bills aregenerated and mailed the first week of each month. Paymentmust be made by the final due date to ensure continuation ofcoverage.

Nonpayment of PremiumIf payment is not received by the final due date, coverage willbe terminated effective the last day of the current month. TheDepartment will exercise its right under the StateComptroller’s Act to collect delinquent group insurancepremiums through involuntary withholding.A member who retires but still owes outstanding premiums toCMS will not be eligible for coverage upon retirement, norwill they be eligible for coverage at any time in the future,under the State group insurance plan.Annuitants, survivors and their dependents who wereterminated for nonpayment of premium are not eligible to re-enroll in the Program, be covered under another member, norare they eligible for continuation of coverage through COBRA.

Premium Payment (cont.)

Penalty for FraudFalsifying information/documentation or failing to provide information/documentation in order to obtain/continue coverageunder the Program is considered a fraudulent act. The State of Illinois will impose a financial penalty, including, but not lim-ited to, repayment of all premiums the State made on behalf of the retiree, annuitant, survivor and/or the dependent, as well asexpenses incurred by the Program.

* This information applies only to TRS retirees that have qualifying state service. Most retired teachers are covered under the terms of theTeachers’ Retirement Insurance Program (TRIP) and should reference the TRIP Benefits Handbook. Please contact TRS for furtherinformation.

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COBRA ParticipantsWhile a plan participant is on COBRA, a monthly bill isgenerated by the Department for the premium amount due.Bills are mailed the first week of each month and must be paidby the due date to ensure continuation of coverage. Planparticipants who do not receive a bill should contact theDepartment for assistance. Failure to submit payment willresult in termination of coverage retroactive to midnight thelast day of the month for which full payment was received.

Premium RefundsPremium refunds based on corrections to a retiree, annuitantor survivor’s insurance elections may be processedretroactively up to six months. Members who fail to notify theMyBenefits Service Center within 60 days of a dependent’sineligibility will not receive a premium refund.

Premium UnderpaymentsUnderpaid premiums are the responsibility of the annuitantor survivor and must be paid in full, regardless of the timeperiod for which the underpayment occurred.

Premium Payment (cont.)

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The coverage of a retiree, annuitant or survivor will onlyterminate upon the benefit ceasing, the member’s death orcoverage being terminated for nonpayment of premium.When a dependent experiences an event which terminatestheir coverage, such as a member's death, the dependent’shealth, dental and vision coverage, in most cases, can becontinued under the Consolidated Omnibus BudgetReconciliation Act (COBRA). See the 'COBRA Coverage'section for more information.

Termination of Retiree,Annuitant and Survivor CoverageRetiree, annuitant and survivor coverage terminates atmidnight:

F On the date of member's death.

F On the last day of the month for which payment is notreceived following the issuance of a final notice ofpremium due from the Department (member and alldependents will be ineligible for COBRA).

F On the last day of the month in which the annuity orsurvivor benefit ceases.

Termination ofDependent CoverageAn enrolled dependent’s coverage terminates at midnight:

F Simultaneous with termination of the retiree, annuitant orsurvivor’s coverage.

F On the last day of the month in which a dependent loseseligibility.

F On June 30th for dependents who are voluntarilyterminated during the Benefit Choice Period (thesedependents will be ineligible for COBRA).

F On the requested date of a voluntary termination of adependent (these dependents will be ineligible forCOBRA).

F On the date of dependent's death.

F On the last day of the month in which the retiree,annuitant or survivor fails to certify continued eligibility forcoverage of the dependent child.

F On the day preceding the dependent's:

– enrollment in the Program as a member.

– divorce or civil union partnership dissolution from theretiree, annuitant or survivor. The divorce or civil unionpartnership dissolution terminates the coverage for thespouse or civil union partner and all applicablestepchildren or children of the civil union partner.

NOTE: Retirees, annuitants and survivors who fail to notifythe MyBenefits Service Center (MBSC) within 60 days of thedependent’s ineligibility will not receive a premium refund,nor will the dependent be eligible for COBRA.

Termination

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OverviewThe Consolidated Omnibus Budget Reconciliation Act of 1985(COBRA) and Sections 367.2, 367e and 367e.1 of theIllinois Insurance Code provides eligible covered membersand their eligible dependents the opportunity to temporarilyextend their health coverage when coverage under the healthplan would otherwise end due to certain qualifying events.COBRA rights are restricted to certain conditions under whichcoverage is lost. The election to continue coverage must bemade within a specified election period. If elected, coveragewill be reinstated retroactive to the date following terminationof coverage.

An initial notice is provided to all new members uponenrollment in the Program. This notice is to acquaintindividuals with COBRA law, notification obligations andpossible rights to COBRA coverage if loss of group healthcoverage should occur. If an initial notice is not received,members should contact the MyBenefits Service Center(MBSC).

EligibilityCovered members and dependents who lose coverage due tocertain qualifying events (see the ‘COBRA Qualifying Events’chart at the end of this section) are considered qualifiedbeneficiaries and may be allowed to continue coverage underthe provisions of COBRA. A qualified beneficiary is an individual(including the member, spouse, civil union partner, domesticpartner or child) who loses employer-provided group healthcoverage and is entitled to elect COBRA coverage. The individualmust have been covered by the plan on the day before thequalifying event occurred and enrolled in COBRA effective thefirst day of eligibility or be a newborn or newly adopted child ofthe covered member. Any voluntary termination of coveragewill render the member and any dependents ineligible forCOBRA coverage.

Coverage available under COBRA for qualified beneficiaries isidentical to the health, dental and vision insurance coverageprovided to employees. Individuals converting to COBRA whoelected not to participate in the dental plan prior to becomingeligible for COBRA may not enroll in the dental plan until theannual Benefit Choice Period. The life insurance coverage in forceon the date of termination is not available through COBRA;however, the member and/or dependent may be eligible toconvert or port their life insurance coverage. See the LifeInsurance Coverage Certificate for details.

Covered dependents retain COBRA eligibility rights even ifthe member chooses not to enroll. Qualified beneficiarieselecting continuation of coverage under COBRA will beenrolled as a member. NOTE: If the member’s spouse, civilunion partner, domestic partner or dependent child(ren)live at another address, you must immediately completethe online process using the Self-Service Tools atMyBenefits.illinois.gov so that notification can be sent tothe proper address(es).

Retirees, annuitants and survivors who have opted out orwaived health, dental and vision insurance coverage, andtheir dependents, are not eligible to participate in COBRA.

Notification of COBRA EligibilityThe MyBenefits Service Center (MBSC) will send a letter to thequalified beneficiary regarding COBRA rights within 14 days ofreceiving notification from MBSC of the termination. Includedwith the letter will be an enrollment form, premium paymentinformation and important deadlines. If a letter is not receivedwithin 30 days and you completed notification to MBSC withinthe 60-day period, you should contact the MBSC Service Centerimmediately for information.

COBRA EnrollmentIndividuals have 60 days from the date of the COBRA eligibilityletter to elect enrollment in COBRA and 45 days from the date ofelection to pay all premiums. Failure to complete and return theenrollment form or to submit payment by the due dates willterminate COBRA rights. If the enrollment form and all requiredpayments are received by the due dates, coverage will bereinstated retroactive to the date of the qualifying event.

Medicare or Other GroupCoverage - Impact on COBRAQualified beneficiaries who become eligible for Medicare orobtain other group insurance coverage (which does notimpose preexisting condition limitations or exclusions) afterenrolling in COBRA are required to notify MBSC bycompleteing the online process using the Self-Service Tools atMyBenefits.illinois.gov their Medicare eligibility or othergroup coverage. These individuals are ineligible to continueCOBRA coverage and will be terminated from the COBRAprogram.

COBRA Coverage

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The Department reserves the right to retroactively terminateCOBRA coverage if an individual is deemed ineligible.Premiums will not be refunded for coverage terminatedretroactively due to ineligibility.

COBRA ExtensionsF Disability Extension

Qualified beneficiaries covered under COBRA who havebeen determined to be disabled by the Social SecurityAdministration (SSA) may be eligible to extend coveragefrom 18 months to 29 months at an increased cost.Enrolled nondisabled family members are also eligible forthe extension. See ‘Premium Payment under COBRA’ later inthis section for premium information.

To be eligible for the extension, the qualified beneficiarymust either (1) become disabled during the first 60 days ofCOBRA continuation coverage or (2) be determined disabledprior to the date of COBRA eligibility. In either case, thedetermination must have been made by the Social SecurityAdministration (SSA) and a copy of the SSA determinationletter must be submitted to the Department within 60days of the date of the SSA determination letter or the firstday of COBRA coverage, whichever is later.

The affected qualified beneficiary must also notify theDepartment of any SSA final determination of loss ofdisability status. This notification must be providedwithin 30 days of the SSA determination letter.

F Second Qualifying Event ExtensionIf a member who experienced a qualifying event thatresulted in an 18-month maximum continuation periodexperiences a second qualifying event before the end ofthe original 18-month COBRA coverage period, thespouse, civil union partner, domestic partner and/ordependent child (must be a qualified beneficiary) mayextend coverage an additional 18 months for a maximumof 36 months.

Waiver of COBRA Rights andRevocation of that WaiverA qualified beneficiary may waive rights to COBRA coverageduring the 60-day election period and can revoke the waiver atany time before the end of the 60-day period. Coverage willbe retroactive to the qualifying event.

Premium Payment under COBRAThe qualified beneficiary has 45 days from the date coverageis elected to pay all premiums. Individuals electing COBRAare considered members and will be charged the memberrate. A divorced or widowed spouse (including a former civilunion partner) who has a dependent child on their coveragewould be considered the member and charged the memberrate, with the child being charged the applicable dependentrate. If only a dependent child elects COBRA, then each childwould be considered a member and charged the memberrate.

Once the COBRA enrollment form is received and thepremium is paid, coverage will be reinstated retroactive to thedate coverage was terminated. Monthly billing statementswill be mailed to the member’s address on file on or aboutthe 5th of each month. Bills for the current month are due bythe 25th of the same month. Final notice bills (those with abalance from a previous month) are due by the 20th of thesame month. Failure to pay the premium by the final duedate will result in termination of coverage retroactive to thelast day of the month in which premiums were paid.

It is the member’s responsibility to promptly notify theDepartment in writing of any address change or billingproblem.

The State does not contribute to the premium for COBRAcoverage. Most COBRA members must pay the applicablepremium plus a 2% administrative fee for participation.COBRA members who extend coverage for 29 months due toSSA’s determination of disability must pay the applicablepremium plus a 50% administrative fee for all monthscovered beyond the initial 18 months.

COBRA Coverage (cont.)

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Adding Dependents - SecondQualifying Event LimitationsNewly-acquired dependents, including spouses, civil unionpartners, children of civil union partners and stepchildren,may be added to existing COBRA coverage. Even thoughthese dependents are eligible for COBRA coverage, unlessthey are a newborn child or newly adopted child, they are notconsidered “qualified beneficiaries” and therefore would beineligible for an extension if a second qualifying event wouldoccur.

Existing dependents who are not enrolled on the first day themember becomes eligible for COBRA continuation coverageare not considered qualified beneficiaries. These dependentsmay only be added during the annual Benefit Choice Periodand are also not eligible for second qualifying eventextensions.

Documentation requirements must be met to add dependents.See the ‘Documentation Requirements – Adding DependentCoverage’ chart in this chapter for details.

Termination of Coverage underCOBRACOBRA coverage terminates when the earliest of thefollowing occurs:

F Maximum continuation period ends.

F Failure to make timely payment of premium.

F Covered member or dependent becomes a participant inanother group health plan which does not impose apreexisting condition exclusion or limitation (for example,through employment or marriage).

F Covered member or dependent becomes entitled toMedicare. Special rules apply for End-Stage Renal Disease.Contact the Department for more information.

F Covered member or dependent reaches the qualifying agefor Medicare.

F Covered dependent gets divorced from COBRA member(includes when the COBRA member's civil unionpartnership with the covered dependent is dissolved).

F Covered dependent child or domestic partner loseseligibility.

F Upon the member’s death for any dependent notconsidered a qualified beneficiary.

Refer to the ‘COBRA Qualifying Events’ chart in this chapter formore information.

Conversion Privilege for HealthCoverageWhen COBRA coverage terminates, members may have theright to convert to an individual health plan. Members areeligible for this conversion unless group health coverageended because:

F the required premium was not paid, or

F the coverage was replaced by another group health plan,including Medicare, or

F the COBRA coverage was voluntarily terminated.

Approximately two months before COBRA coverage ends, theDepartment will send a letter providing instructions on how toapply for conversion. To be eligible for conversion, membersmust have been covered by the current COBRA health plan forat least 3 months and requested conversion within 31 days ofexhaustion of COBRA coverage. The converted coverage, ifissued, will become effective the day after COBRA coverageended. Contact the appropriate health plan administratorfor information regarding conversion. The Department isnot involved in the administration or premium ratestructure of coverage obtained through conversion.

COBRA Coverage (cont.)

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COBRA Coverage (cont.)

Qualifying EventsMEMBERMember’s loss of eligibilityDEPENDENTMember’s termination of benefitsLegal separation from member*Loss of eligibility as a dependent child or domestic partnerMember’s death

• Spouse under age 55• Spouse age 55 or older if already enrolled in Medicare• Spouse age 55 or older

• Dependent child • Domestic partner

Dissolution of Marriage or Civil Union Partnership*• Ex-Spouse under age 55• Ex-Spouse age 55 or older if already enrolled in Medicare• Ex-Spouse age 55 or older

• Stepchild or Child of a Civil Union Partner

Maximum Eligibility Period

18 months

18 months36 months36 months

36 months36 months Until obtains Medicare or reaches the qualifying age for Medicare36 months36 months

36 months36 monthsUntil obtains Medicare or reaches the qualifying age for Medicare36 months

COBRA QUALIFYING EVENTSA COBRA qualifying event is any of the events shown below that result in a loss of coverage.

The term 'Spouse' in this chart includes civil union partners; 'Ex-spouse' includes civil union partnerswhose partnership has been dissolved.

* Dropping a spouse’s coverage during the annual Benefit Choice Period in anticipation of a divorce, civil union partnership dissolution orlegal separation will result in the spouse losing coverage effective July 1st. The spouse will be eligible for COBRA only once the divorce,dissolution or legal separation actually occurs. Spouses whose coverage was terminated due to a divorce, dissolution or legal separationmust contact our office within 30 days of the event in order to be offered COBRA coverage.

Falsifying information/documentation or failing to provide information/documentation in order to obtain/continue coverage under

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COBRA Coverage (cont.)

* Dropping a spouse’s coverage during the annual Benefit Choice Period in anticipation of a divorce, civil union partnership dissolution orlegal separation will result in the spouse losing coverage effective July 1st. The spouse will be eligible for COBRA only once the divorce,dissolution or legal separation actually occurs. Spouses whose coverage was terminated due to a divorce, dissolution or legal separationmust contact our office within 30 days of the event in order to be offered COBRA coverage.

Qualifying EventsCOBRA MEMBER

SSA disability determination within the first 60 days of COBRA

COBRA DEPENDENT

Loss of eligibility as a dependent child or domestic partner

Legal separation from COBRA member*COBRA member’s death

• Spouse under age 55• Spouse age 55 or older if already enrolled in Medicare

• Spouse age 55 or older

• Dependent child • Domestic partner

Divorce from/Dissolution of civil union partnership with COBRA member*• Ex-Spouse under age 55• Ex-Spouse age 55 or older if already enrolled in Medicare

• Ex-Spouse age 55 or older

• Stepchild or Child of Civil Union Partner

Maximum Eligibility Period

Additional 11 months for a maximum of 29 months

Additional 18 months for amaximum of 36 months

Additional 18 months for amaximum of 36 months

Until obtains Medicare or reaches the qualifying age for Medicare

Additional 18 months for amaximum of 36 months

Until obtains Medicare or reaches the qualifying age for MedicareAdditional 18 months for amaximum of 36 months

SECOND QUALIFYING EVENTSThe events shown below will extend coverage for a qualified beneficiary

if it occurs during the original 18-month COBRA period.The term 'Spouse' in this chart includes civil union partners; 'Ex-spouse' includes civil union partners

whose partnership has been dissolved.

Falsifying information/documentation or failing to provide information/documentation in order to obtain/continue coverage underCOBRA is considered a fraudulent act. Premiums paid will not be refunded for coverage terminated retroactively due to ineligibility.

A qualified beneficiary is an individual (including the member, spouse, civil union partner, domestic partner or child) who losesemployer-provided group health coverage and is entitled to elect COBRA coverage. The individual must have been covered by theplan on the day before the qualifying event occurred and enrolled in COBRA effective the first day of eligibility or be a newborn ornewly adopted child of the covered member.

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Chapter 2Chapter 2: Health, Dental, Vision and Life Coverage InformationHealth Plan Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Managed Care Health Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Quality Care Health Plan (QCHP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Medical Benefits Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Prescription Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Behavioral Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Dental Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Vision Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Life Insurance Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

MyBenefits.illinois.govRetiree Benefits Handbook 28

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OverviewThe State offers a variety of health plans from which to choose.Each plan provides health, behavioral health and prescriptiondrug benefits; however, the benefit levels, exclusions andlimitations may differ. When making choices, members shouldconsider health status, coverage needs and service preferences.Dependents will have the same health and dental plan as themember under whom they are enrolled.The MyBenefits.illinois.gov website provides a listing of thehealth plans available and the Illinois counties in which theyprovide coverage.

Types of Health PlansThe types of health plans available are:F Managed Care Plans

• Health Maintenance Organizations (HMOs)• Open Access Plans (OAPs)

F Quality Care Health Plan (QCHP)Annuitants, retirees and survivors who change their healthplan outside the Benefit Choice Period, regardless of the basisfor the change, will be responsible for any deductiblesrequired by the new plan (including prescription deductibles),even if the plan participant met all deductibles while coveredby the previous health plan.

Disease Management Programsand Wellness OfferingsDisease management programs are utilized by the healthplans as a way to improve the health of plan participants.Plan participants may be contacted by their health plan toparticipate in these programs.Wellness options and preventive measures are offered andencouraged by the health plans. Offerings range from healthrisk assessments to educational materials and, in some cases,discounts on items such as gym memberships and weight lossprograms. These offerings are available to plan participantsand are provided to help plan participants take control of theirpersonal health and well-being. Information about the variousofferings is available on the plan administrators’ websites.

Managed Care Health Plans Managed care is a method of delivering healthcare through asystem of network providers. Managed care plans providecomprehensive health benefits at lower out-of-pocket costs byutilizing network providers. Managed care health planscoordinate all aspects of a plan participant’s healthcareincluding medical, prescription drug and behavioral healthservices.There are two types of managed care plans, healthmaintenance organizations (HMOs) and open access plans(OAPs). Members who enroll in an HMO must select a primarycare physician (PCP) from the health plan’s provider directory,which can be found on the plan’s website. Plan participantsshould contact the physician’s office or the HMO planadministrator to find out if the PCP is accepting new patients.Plan participants are required to use network physicians andhospitals for maximum benefits. Annuitants, retirees andsurvivors enrolled in an OAP do not need to select a PCP. Forcomplete information on specific plan coverage or providernetworks, contact the managed care health plan and reviewthe Summary Plan Document (SPD).Like any health plan, managed care plans have planlimitations including geographic availability and limitedprovider networks. Managed care coverage is offered incertain counties called service areas. Ordinarily, managed careplans only cover members within the State; however, plansthat have networks outside the State of Illinois may providecoverage. Members should contact the managed care planadministrator to ascertain if coverage is available outside theirgeographic area. Eligible dependents that live apart from themember’s residence for any part of a plan year may be subjectto limited service coverage. It is critical that members whohave an out-of-area dependent (such as a college student)contact the managed care plan to understand the plan’sguidelines on out-of-area coverage.The open access health plans are self insured, meaning all claimsare paid by the State of Illinois even though managed care healthplan benefits apply. These plans are not regulated by the IllinoisDepartment of Insurance and are not governed by the EmployeesRetirement Income Security Act (ERISA).In order to have the most detailed information regarding aparticular managed care health plan, members should ask theplan administrator for its summary plan document (SPD)which describes the covered services, benefit levels, andexclusions and limitations of the plan’s coverage. The SPDmay also be referred to as a certificate of coverage or asummary plan document.

Health Plan Options

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Members should pay particular attention to the managedcare plan’s exclusions and limitations. It is important thatplan participants understand which services are not coveredunder the plan. Members deciding to enroll in a managedcare health plan should read the SPD before seekingmedical attention. It is the plan participant’s responsibilityto become familiar with all of the specific requirements ofthe health plan.

Most managed care health plans impose benefit limitations ona plan year basis (July 1 through June 30); however, somemanaged care health plans impose benefit limitations on acalendar year basis (January 1 through December 31). Refer to the annual Benefit Choice Options booklet for planadministrator information.

Health Maintenance Organization (HMO)HMO members must choose a primary care physician/ provider(PCP) who will coordinate the healthcare, hospitalizations andreferrals for specialty care. In most cases a referral for specialtycare will be restricted to those services and providers authorizedby the designated PCP. Additionally, referrals may also requireprior authorization from the HMO. To receive the maximumhospital benefit, your PCP or specialist must have admittingprivileges to a network hospital. Like any health plan, HMOs have plan limitations includinggeographic availability and participating provider networks.HMO coverage is offered in certain counties called serviceareas. There is no coverage outside these service areas unlesspreapproved by the HMO. When traveling outside of thehealth plan’s service area, coverage is limited to life-threatening emergency services. For specific informationregarding out-of-area services or emergencies, call the planadministrator. NOTE: When an HMO plan is the secondaryplan and the plan participant does not utilize the HMOnetwork of providers or does not obtain the required referral,the HMO plan is not required to pay for services. Refer to theplan’s description of coverage for additional information.Preventive care is paid at 100 percent when services areobtained through a network provider. HMO providernetworks are subject to change. Annuitants, retirees andsurvivors will be notified in writing by the plan administratorwhen a PCP network change occurs. If the designated PCPleaves the HMO network, you must choose another PCPwithin that plan.When an HMO member’s primary care physician (PCP) leavesthe plan’s network, the member will only be allowed tochange health plans if the HMO network experienced asignificant change in the number of medical providersoffered, as determined by CMS.

HMO Out-of-Pocket Maximums After the out-of-pocket maximum has been satisfied, the planwill pay 100 percent of covered expenses for the remainder ofthe plan year for eligible medical, behavioral health andprescription drug charges. Charges that apply toward the out-of-pocket maximum for HMOs are:F Annual prescription plan year deductibleF Medical and prescription copaymentsF Medical coinsurance.

Open Access Plans (OAPs) Open access plans combine similar benefits of an HMO withthe same type of coverage benefits as a traditional healthplan. Members who elect an OAP will have three tiers ofproviders from which to choose to obtain services. The benefitlevel is determined by the tier in which the healthcareprovider is contracted. Members enrolled in an OAP can mixand match providers and tiers.F Tier I offers a managed care network which provide

enhanced benefits and require copayments which mirrorHMO copayments, but do not require a plan yeardeductible.

F Tier II offers another managed care network, in addition tothe managed care network offered in Tier I, and alsoprovides enhanced benefits. Tier II requires copayments,coinsurance and is subject to an annual plan yeardeductible.

F Tier III covers all providers which are not in the managedcare network of Tiers I or II (i.e., out of network providers).Using Tier III can offer members flexibility in selectinghealthcare providers, but involve higher out-of pocket costs.Tier III has a higher plan year deductible and has a highercoinsurance amount than Tier II services. In addition,certain services, such as preventive/wellness care, are notcovered when obtained under Tier III. Furthermore, planparticipants who use out-of-network providers will beresponsible for any amount that is over and above thecharges allowed by the plan for services (i.e., allowablecharges, Usual and Customary charges (U&C), MaximumReimbursable Charges (MRC), Maximum AllowableCharges (MAC)). which could result in much higher out-of-pocket costs. When using out-of-network providers, it isrecommended that the participant obtain apreauthorization of benefits to ensure that medicalservices/stays will meet medical necessity criteria and beeligible for benefit coverage.

Health Plan Options

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Members who use providers in Tiers II and III will beresponsible for the plan year deductible. In accordance withthe Affordable Care Act, these deductibles will accumulateseparately from each other and will not ‘cross accumulate.'This means that amounts paid toward the deductible in onetier will not apply toward the deductible in the other tier.Preventive care is paid at 100 percent without having to meetthe annual deductible when services are obtained through aTier I or Tier II network provider.

OAP Out-of-Pocket Maximums Eligible medical, behavioral health and prescription drugcharges will be covered at 100 percent for the remainder ofthe plan year after the plan’s out-of-pocket maximum hasbeen satisfied. Charges that apply toward the out-of-pocketmaximum for an OAP plan (only applies to Tier I and Tier IIproviders) are:F Annual medical plan year deductible (Tier II)F Annual prescription plan year deductibleF Medical and prescription copaymentsF Medical coinsurance. Eligible charges from Tiers I and II will be added togetherwhen calculating the out-of-pocket maximum. Tier III doesnot have an out-of-pocket maximum.

Quality Care Health Plan (QCHP) The Quality Care Health Plan (QCHP) is the State’s self-insuredhealth plan offering a comprehensive range of benefits. Allclaims and costs are paid by the State through a third-partyadministrator. For complete information regarding specificplan coverage and the provider’s network, refer to the summaryplan document on the MyBenefits.illinois.gov website. Benefitenhancements are available by utilizing the:

F Nationwide QCHP physician, hospital, ancillary servicesand transplant network.

F Pharmacy network.F Behavioral health network.Each of these three components is discussed separately in thissection. Each component has its own plan administrator.

Member Responsibilities F The member is always responsible for:

– Any amount required to meet plan year deductibles,additional deductibles and coinsurance amounts.

– Any amount over the allowable charges.– Any penalties for failure to comply with the notification

requirements.– Any charges NOT covered by the plan or determined by

the plan administrator to be not medically necessaryservices.

NOTE: Specific dollar amounts and percentages that apply todeductibles, “additional deductibles” and coinsurance areupdated each year on the MyBenefits.illinois.gov website

Plan Requirements Plan Year DeductibleThe plan year deductible requirement applies to all medicaland behavioral health services, except preventive services.The plan year deductible for retirees, annuitants and survivorsis a set amount that may change each plan year. To verify theretiree, annuitant, survivor plan year deductible or thefamily plan year deductible, review theMyBenefits.illinois.gov website. The plan year runs from July1 through June 30.

Each family member’s plan year deductible will accumulatetoward a family plan year deductible. Once the family as aunit has satisfied the family plan year deductible, no furtherplan deductibles for any family member will be required foreligible charges incurred for the remainder of that plan year.The member plan year deductible and/or the family plan yeardeductible accumulate toward the annual out-of-pocketmaximum.

Additional DeductiblesBesides the plan year deductible, plan participants must payadditional deductibles for the following: F Each emergency room visit that does not result in a

hospital admissionF QCHP hospital admissionF Non-QCHP hospital admissionF Transplant hospital admission

Health Plan Options

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Health Plan Options Even though these additional deductibles do not applytoward the plan year deductible, they do accumulate towardthe annual out-of-pocket maximum.

CoinsuranceCoinsurance is the percentage of eligible charges that planparticipants must pay after the annual plan year deductiblehas been met. Eligible charges are charges for coveredservices and supplies which are medically necessary.

QCHP Out-of-Pocket Maximum Plan year deductibles, “additional deductibles” and eligiblecoinsurance payments accumulate toward the annual outof-pocket maximum. There are two separate out-of-pocketmaximums: in-network and out-of-network. After the out-of-pocket maximum has been met, deductibles and coinsuranceamounts are no longer required and the plan pays 100% ofeligible charges for the remainder of the plan year.Coinsurance and deductibles apply to one or the other, butnot both. Eligible medical, behavioral health and prescriptiondrug charges will be covered at 100 percent for the remainderof the plan year after the plan’s out-of-pocket maximum hasbeen satisfied. Charges that apply toward the out-of-pocketmaximum for the QCHP plan are:

F Annual medical plan year deductibleF Annual prescription plan year deductibleF Prescription copaymentsF Medical coinsuranceF QCHP additional medical deductiblesThe following do not apply toward out-of-pocketmaximums:

F Notification penalties.F Ineligible charges (i.e., amounts over the allowable

charge, charges for noncovered services and charges forservices deemed not to be medically necessary).

F The portion of the Medicare Part A deductible the planparticipant is responsible to pay.

Medical NecessityF QCHP covers charges for services and supplies that are

medically necessary. Medically necessary services andsupplies are those which are:

– provided by a hospital, medical facility or prescribed by a

physician or other provider and are required to identifyand/or treat an illness or injury.

– consistent with the symptoms or diagnosis andtreatment of the condition (including pregnancy),disease, ailment or accidental injury.

– generally accepted in medical practice as necessary andmeeting the standards for good medical practice for thediagnosis or treatment of the patient’s condition.

– the most appropriate supply or level of service which canbe safely provided to the patient.

– not solely for the convenience of the patient, physician,hospital or other provider.

– repeated only as indicated as medically appropriate.– not redundant when combined with other treatment

being rendered.Predetermination of BenefitsPredetermination of benefits ensures that medicalservices/stays will meet medical necessity criteria and beeligible for benefit coverage. The plan participant’s physicianmust submit written detailed medical information to themedical plan administrator. For questions regarding apredetermination of benefits, contact the plan administrator.

Benefits are based on the plan participant’s eligibility andplan provisions in effect at the time services are rendered.Precise claim payment amounts can only be determined uponreceipt of the itemized bill and are subject to standard claimpayment policies including, but not limited to, multiple andincidental procedure reductions, allowable charges and claimbundling and unbundling of procedures.

Allowable ChargesThe maximum amount the plan will pay an out-of-networkhealthcare professional for billed services is referred to asallowable charges. The amount that is over the allowablecharges amount is not considered eligible for payment by theplan and therefore cannot be applied to the plan yeardeductible nor the out-of-pocket maximum. The planparticipant will be responsible for the entire amount that isover and above the allowable charges amount. Allowablecharges are usually applied when using out-of-networkproviders.

When processing any given claim, the plan administratortakes the following into account:

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F Complexity of the services.F Any unusual circumstances or complications that require

additional skill, time or experience.F Prevailing charge level in the geographic area where the

provider is located and other geographic areas havingsimilar medical-cost experience.

Allowable charges applies to medical services, proceduresand/or supplies. Allowable charges may also be referred to asUsual and Customary charges (U&C), MaximumReimbursable Charges (MRC) or Maximum AllowableCharges (MAC).

IMPORTANT: The amount of the claim that will be paid isbased on the allowable charges amount or the actual chargemade by the provider, whichever is less, for out-of-networkservices.

Quality Care Health Plan (QCHP) Network The Quality Care Health Plan (QCHP) network includeshospitals, physicians and ancillary providers throughoutIllinois, as well as nationwide. The network provides qualityinpatient and outpatient care at negotiated rates, which resultin savings to plan participants. The network is subject tochange any time during the plan year. Medical Case Management The Medical Case Management (MCM) Program is designed toassist plan participants requiring complex care in times ofserious or prolonged illness. There is no additional cost to theplan participant for this service.

The referral to the MCM Program is made through either theMCM administrator, the QCHP plan administrator or byrequest from a plan participant. Once referred, the planparticipant is assigned a case manager who serves as a liaisonand facilitator between the patient, family, physician andother healthcare providers. The case manager is a registerednurse or other healthcare professional with extensive clinicalbackground. The case manager can effectively minimize thefragmentation of care.

Upon completing the MCM review, the case manager willmake a recommendation regarding the treatment setting,intensity of services and appropriate alternatives of care. Toreach the MCM plan administrator, call the toll-free numberlisted in the plan administrator section of theMyBenefits.illinois.gov website.

Notification Requirements

Notification is the telephone call to the notification administratorinforming them of an upcoming admission to a facility suchas a hospital or skilled nursing facility or for an outpatientprocedure, therapy service or supply. If using a QCHPnetwork provider, the medical provider is responsible forcontacting the notification administrator on behalf of the planparticipant. If using a non-QCHP provider, the plan participant mayrequest that their non-QCHP medical provider contact thenotification administrator to provide specific medicalinformation, setting and anticipated length of stay to determinemedical appropriateness. The plan participant may also makenotification, after which a medically qualified reviewer willcontact the plan participant’s physician or provider to obtainspecific medical information.Regardless of where services are rendered, it is the planparticipant’s responsibility to ensure that notification hasoccurred. Failure to contact the notification administrator priorto having a service performed may result in a financialpenalty and risk incurring noncovered charges. Notification isrequired for all plan participants including those with Medicareor other insurance as primary payer.

Contact information for the notification administrator can befound in the plan administrator section of theMyBenefits.illinois.gov website. The toll-free number is alsoprinted on your identification card. You can call seven days aweek, twenty-four hours a day.F Notification is required for the following:

(Contact the notification administrator for the most up-to-date list of procedures requiring notification).

– Outpatient Surgery, Procedures, Therapies andSupplies/Equipment. Outpatient surgery andprocedures include, but are not limited to, items such asimaging (MRI, PET, SPECT and CAT scan), physical,occupational or speech therapy, foot orthotics, durablemedical equipment (DME) supplies, infertility surgery,cardiac or pulmonary rehabilitation, skin removal orenhancement (lipectomy, select injectable drug treatmentfor varicose veins, etc.).

– Any Elective Inpatient Surgery or Non-EmergencyAdmission. Notification must be made at least seven daysbefore admission. The admission and length of stay mustbe authorized before entering the facility.

Health Plan Options

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– Skilled Nursing Facility, Extended Care Facility orNursing Home Admission. Notification must be madeat least seven days before admission. A review of thecare being rendered will be conducted to determine ifthe services are skilled in nature.

– Emergency or Urgent Admission. Notification must bemade within two business days after the admission.

– Hospice Admission. Notification must be made prior tothe admission.

– Potential Transplants. Notification must be made priorto beginning evaluation services. Benefits are onlyavailable through the QCHP transplant network ofhospitals/facilities.

F Notification is Not:– A final determination of medical necessity. If the

notification administrator should determine that thesetting and/or anticipated length of stay are no longermedically necessary and NOT eligible for coverage, thephysician will be informed immediately. The planparticipant will also receive written confirmation of thisdetermination.

– A guarantee of benefits. Regardless of notification of aprocedure or admission, there will be no benefitpayment if the plan participant is ineligible for coverage onthe date services were rendered or if the charges aredeemed ineligible.

– Enrollment of a newborn for coverage. Complete theonline process using the Self-Service Tools atMyBenefits.illinois.gov to enroll a newborn within 60days of birth.

– A determination of the amount which will be paid for acovered service. Benefits are based upon the planparticipant’s eligibility status and the plan provisions ineffect at the time the services are provided.

NOTE: For authorization procedures and time limits forbehavioral health services, see the ‘Behavioral Health’ sectionlater in this chapter.Benefits for Services Received While Outside theUnited States

The plan covers eligible charges incurred outside of the UnitedStates for services that are generally accepted as medicallynecessary within the United States. All plan benefits are

subject to plan provisions and deductibles. The benefit forfacility and professional charges is paid at the non-QCHP rate.Notification is not required for medically necessary servicesrendered outside of the United States; however, medicalnecessity must be established prior to reimbursement.Payment for the services will most likely be required fromthe member at the time the services are rendered.

Plan participants must file a claim with the plan administratorfor reimbursement. When filing a claim, enclose the itemizedbill with a description of the services translated to English andthe total amount of billed charges, along with the name of thepatient, date of service, diagnosis, procedure code and theprovider’s name, address and telephone number.Reimbursement in American dollars will be based on theconversion rate of the billed currency on the date services wererendered.Generally, Medicare will not pay for healthcare obtainedoutside the United States and its territories. When Medicaredoes not pay, QCHP becomes the primary payer and standardbenefit levels will apply.Hospital Bill Audit Program

The Hospital Bill Audit Program applies to QCHP and non-QCHP hospital charges. Under the program, a member ordependent who discovers an error or overcharge on a hospitalbill and obtains a corrected bill is eligible for 50% of theresulting savings. There is no cap on the savings amount.Related nonhospital charges, such as radiologists andsurgeons are not eligible charges under this program. Thisprogram applies only when QCHP is the primary payer.Reimbursement documentation required:

– Original incorrect bill,– Corrected copy of the bill, and– Member’s name, telephone number and last four digits

of the SSN.Submit Documentation to:

Hospital Bill Audit ProgramCMS Group Insurance Division801 S. 7th StreetP.O. Box 19208Springfield, IL 62794-9208

Health Plan Options

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AcupunctureF Charges for treatment of diagnosed chronic pain with a

written referral from a physician or dentist. Coverage issubject to frequency limitations. Note: Chronic pain isdefined as pain that persists longer than the amount oftime normally expected for healing.

Ambulance (See Exclusion #5 and #42)

F Transportation charges to the nearest hospital/facility foremergency medically necessary services for a patientwhose condition warrants such service. The planadministrator should be notified as soon as possible for adetermination of coverage. Medically necessarytransportation charges (emergency ground or airambulance) will be paid at the 85% benefit level after theannual plan year deductible has been met. Services thatare determined not to be medically necessary will not becovered.

F Transportation services eligible for coverage: – From the site of the disabling illness, injury, accident or

trauma to the nearest hospital qualified to providetreatment (includes air ambulance when medicallynecessary).

– From a remote area, by air, land or water (inside oroutside the United States), to the nearest hospitalqualified to provide emergency medical treatment.

– From a facility which is not equipped to treat the patient’sspecific injury, trauma or illness to the nearest hospitalequipped to treat the injury, trauma or illness.

Behavioral HealthIn an emergency or a life-threatening situation, call 911, or goto the nearest hospital emergency room. Plan participantsmust call the behavioral health plan administrator within 48

hours to avoid a financial penalty. Authorizationrequirements still apply when plan participants have othercoverage, such as Medicare.F Inpatient services must be authorized prior to admission

or within 48 hours of an emergency admission to receivein-network or out-of-network benefits. Authorization isrequired with each new admission. Failure to notify thebehavioral health plan administrator of an admission to aninpatient facility within 48 hours will result in a financialpenalty and risk incurring noncovered charges.

F Partial hospitalization and intensive outpatienttreatment must be authorized prior to admission toreceive in-network or out-of-network benefits.Authorization is required before beginning each treatmentprogram. Failure to notify the behavioral health planadministrator of a partial hospitalization or intensiveoutpatient program will result in a financial penalty andrisk incurring noncovered charges.

F Outpatient services received at the in-network benefitlevel must be provided by a QCHP network provider.Most routine outpatient services (such as therapysessions and medication management) will be coveredwithout the need for prior authorization. Authorizationrequirements for certain specialty outpatient servicesare noted below. Outpatient services that are notconsistent with usual treatment practice for a planparticipant’s condition will be subject to a medicalnecessity review. The behavioral health administratorwill contact the plan participant’s provider to discuss thetreatment if a review will be applied. Outpatientservices received at the out-of-network benefit levelmust be provided by a licensed professional includinglicensed clinical social worker (LCSW), registered nurse,clinical nurse specialist (RN CNS), licensed clinicalprofessional counselor (LCPC), licensed marriage andfamily therapist (LMFT), psychologist or psychiatrist tobe eligible for coverage.

Quality Care Health Plan – Medical Benefits SummaryIn-Network Benefit: Preventive services are paid at 100%. Unless otherwise indicated, a 85% benefit level will be applied to all other eligible services, supplies and therapies.Out-of-Network Benefit: Unless otherwise indicated, all eligible services, supplies and therapies, includingpreventive services, are paid at 60% of allowable charges after the plan year deductible has been met.

This document contains a brief overview of some of the benefits available under the Quality Care Health Plan (QCHP). Contact the planadministrator for more information or coverage requirements and/or limitations. In order for any service, therapy or supply to beconsidered eligible for coverage, it must be medically necessary as determined by the plan administrator. The information belowindicates the requirements and benefit levels of the covered services, supplies and therapies for the standard benefit level (60% ofallowable charges). There is a 85% enhanced benefit level for utilizing network providers.

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F Electroconvulsive therapy, psychological testing andapplied behavioral analysis must be authorized to receivein-network or out-of-network benefits. Failure to obtainauthorization will result in the risk of incurring noncoveredcharges.

F Residential services must be authorized prior toadmission to receive in-network or out-of-networkbenefits. Authorization is required with each newresidential admission. Failure to notify the behavioralhealth plan administrator of an admission to a residentialfacility will result in a financial penalty and risk incurringnoncovered charges.

Breast Reconstruction FollowingMastectomyF The plan provides coverage, subject to and consistent with

all other plan provisions, for services following amastectomy, including: – Reconstruction of the breast (including implants) on

which the mastectomy was performed.– Surgery and reconstruction on the other breast

(including implants) to produce a symmetricalappearance.

– Prosthesis and treatment for any physical complicationsat any stage of mastectomy, including post-surgicallymphedema (swelling associated with the removal oflymph nodes) rendered by a provider covered underthe plan.

– Mastectomy bras are covered following surgery or achange in prosthesis.

Cardiac RehabilitationF Phase I and Phase II when ordered by a physician.

Chiropractic ServicesF Maximum of thirty (30) visits per plan year will be covered.F No coverage for chiropractic services considered to be

maintenance in nature, in that medical information does notdocument progress in the improvement of the condition.

Christian Science PractitionerF Coverage for the services of a Christian Science Nurse or

Practitioner. – A Christian Science Nurse is a nurse who is listed in a

Christian Science Journal at the time services are given

and who: (a) has completed nurses’ training at aChristian Science Benevolent Association Sanitarium; or(b) is a graduate of another School of Nursing; or (c) hadthree consecutive years of Christian Science Nursing,including two years of training.

– A Christian Science Practitioner is an individual who islisted as such in the Christian Science Journal at thetime the medical services are provided and whoprovides appropriate treatment in lieu of treatment by amedical doctor.

CircumcisionF Charges for professional services. F Charges for circumcision are considered to be covered

services when billed as a separate claim for the newbornas long as the newborn is enrolled in the plan and thesurgery is performed within the first thirty (30) daysfollowing birth.

Dental Services (See Exclusion #14 and # 15)

F Accidental Injury:

– Coverage for professional services necessary as a resultof an accidental injury to sound natural teeth caused byan external force. Care must be rendered within threemonths of original accidental injury. The appropriatefacility benefit applies.

F Nonaccidental: Coverage limited to: – Anesthesia and facility charges for dependent children

age six and under. – A medical condition that requires anesthesia and facility

charges for dental care (not anxiety or behavioralrelated conditions). Professional services are notcovered under the medical plan.

Diabetic CoverageF Charges for dietitian services and consultation when

diagnosed with diabetes. No coverage unless ordered inconjunction with a diagnosis of diabetes.

F Charges for routine foot care by a physician whendiagnosed with diabetes.

F Charges for insulin pumps and related supplies whendeemed medically necessary.

Dialysis F Charges for hemodialysis and peritoneal dialysis.

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Durable Medical Equipment(DME) (See Exclusion #5)

F Short-term Rental:

– Rental fees up to the purchase price for items thattemporarily assist an impaired person during recovery.Examples include canes, crutches, walkers, hospitalbeds and wheelchairs.

F Purchase:

– Charges to purchase the equipment. Equipmentshould be purchased only if it is expected that therental costs will exceed the purchase price.

F DME exclusions include, but are not limited to: – Repairs or replacements due to negligence or loss of

the item. – Newer or more efficient models.

F DME is eligible for coverage when provided as the mostappropriate and lowest cost alternative as required by theperson’s condition.

NOTE: See Prosthetic Appliances for permanentreplacement of a body part.

Emergency ServicesThe facility in which emergency treatment is rendered and thelevel of care determines the benefit level (hospital, urgentcare center, physician office). For emergency transportationservices, refer to the ‘Ambulance’ section.F Emergency Room:

– 85% of allowable charges at a QCHP or non-QCHPfacility. The special deductible applies to each visit toan emergency room which does not result in aninpatient admission.

F Physician’s Office:

– 85% of allowable charges; no special emergency roomdeductible applies. Treatment must be rendered within 72hours of an injury or illness and meet the definition ofemergency services presented above. Nonemergencymedically necessary care is covered at 60% of allowablecharges.

F Urgent Care or Similar Facility:

– 85% of allowable charges; no special emergency roomdeductible applies. Treatment must be rendered within72 hours of an injury or illness and meet the definition ofemergency services presented above. This benefitapplies to professional fees only. Facility charges not

covered when services are performed in a physician’soffice or urgent care center. Nonemergency medicallynecessary care is considered at 60% of allowable charges.

Eye Care (See Exclusion #11 and #26)

F Charges for treatment of injury or illness to eye.

Foot Orthotics Notification is required. Refer to ‘Notification Requirements’in the ‘Quality Care Health Plan’ section of the BenefitsHandbook for more information. F Must be custom molded or fitted to the foot and ordered

by a physician or podiatrist.

Hearing Services F Diagnostic hearing exams performed by an audiologist

are covered up to $150 and hearing aids are covered upto $600 every three plan years.

F Professional service charges for the hearing examassociated with the care and treatment of an injury or anillness.

Hospice F Written notification of the terminal condition is required

from the attending physician. F Inpatient hospice requires notification. Refer to ‘Notification

Requirements’ in the ‘Quality Care Health Plan’ section of theBenefits Handbook for more information.

Inpatient Hospital/Facility Services(See Exclusions #3, #6, #8, #32)F Hospital/facility charges. QCHP

– In-network - 85% of allowable charges after the specialdeductible at a QCHP facility. the special deductible appliesto each hospital stay.

– Out-of-network - 60% of allowable charges after the specialdeductible at a non-QCHP facility. The special deductibleapplies to each hospital stay.

NOTE: Failure to provide notification of an upcomingadmission or surgery will result in a financial penalty anddenial of coverage for services not deemed medicallynecessary. Refer to ‘Notification Requirements’ in the ‘Quality

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Care Health Plan’ section of the Benefits Handbook for moreinformation.

Infertility Treatment Benefits are provided for the diagnosis and treatment ofinfertility. Infertility is defined as the inability to conceiveafter one year of unprotected sexual intercourse, the inabilityto conceive after one year of attempts to produce conception,the inability to conceive after an individual is diagnosed witha condition affecting fertility, or the inability to sustain asuccessful pregnancy. A woman shall be considered infertilewithout having to engage in one year of unprotected sexualintercourse if a physician determines that: 1) a medicalcondition exists that renders conception impossible throughunprotected sexual intercourse; or 2) efforts to conceive as aresult of one year of medically based and supervisedmethods of conception, including artificial insemination,have failed and are not likely to lead to a successfulpregnancy. F Predetermination of Benefits:

– A written predetermination of benefits must beobtained from the health plan administrator prior tobeginning infertility treatment to ensure optimumbenefits. Documentation required from the physicianincludes the patient’s reproductive history includingtest results, information pertaining to conservativeattempts to achieve pregnancy and the proposed planof treatment with physicians’ current proceduralterminology (CPT) codes.

F Infertility Benefits: – Coverage is provided only if the plan participant has

been unable to sustain a successful pregnancy throughreasonable, less costly, medically appropriate infertilitytreatment for which coverage is available under thisplan.

F Coverage for assisted reproductive procedures includes,but is not limited to: – Artificial insemination, in vitro fertilization (IVF) and

similar procedures which include but are not limited to:gamete intrafallopian tube transfer (GIFT), low tubeovum transfer (LTOT), zygote intrafallopian tube transfer(ZIFT), and uterine embryo lavage with a maximum offour (4) procedures per lifetime;

– A maximum of three (3) artificial inseminationprocedures per menstrual cycle for a total of eight (8)cycles per lifetime;

– If a live birth results from an in vitro procedure, two

additional procedures are eligible for coverage;– Eligible medical costs associated with sperm or egg

donation by a person covered under the plan mayinclude, but are not limited to, monitoring the cycle of adonor and retrieval of an egg for the purpose ofdonating to a covered individual.

F Infertility treatment exclusions include, but are not limitedto:– Nonmedical expenses of a sperm or egg donor

otherwise covered under the plan such astransportation, shipping or mailing, administrative feessuch as donor processing, search for a donor orprofiling a donor, cost of sperm or egg purchased froma donor bank, cryopreservation and storage of sperm orembryo or fees payable to a donor;

– Infertility treatment deemed experimental or unprovenin nature;

– Reversal of voluntary sterilization;– Payment for medical services rendered to a surrogate

for purposes of attempting or achieving pregnancy;– Pre-implantation genetic testing.

Lab and Radiology F Outpatient:

– Charges at a physician’s office, hospital, clinic or urgentcare center.

F Inpatient: – If billed by a hospital as part of a hospital confinement,

paid at the appropriate hospital benefit level.F Professional charges:

– Professional charges associated with the interpretationof the lab or radiology procedures.

Medical Supplies (See Exclusions #3, #5, #19)

F Medical supplies include, but are not limited to ostomysupplies, surgical dressings and surgical stockings.

Morbid Obesity Treatment (See Exclusion #12)

F Charges for professional services.F Obesity surgery is eligible for covered dependents with a

showing of medical necessity and predetermination ofbenefits.

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Newborn Care (See Exclusion #40)

F Charges for professional services in an office or hospitalsetting.

F Benefits are available for newborn care only if the dependentis enrolled no later than 60 days following the birth.

Occupational Therapy/PhysicalTherapy (See Exclusion #10)

Notification is required. Refer to ‘Notification Requirements’in the ‘Quality Care Health Plan’ section of the BenefitsHandbook for more information.F Covered if administered under the supervision of and

billed by a licensed or registered occupational therapist,physical therapist or physician.

Outpatient Hospital/FacilityServices, including Surgery(See Exclusions #3, #4, #6)

F Covered if performed at a hospital/facility.F Covered if performed at an ambulatory surgical treatment

center which is licensed by the Department of PublicHealth, or the equivalent agency in other states, toperform outpatient surgery.

Physician ServicesF Charges for medical treatment of an injury or illness.

Physician Services – Surgical(See Exclusions #12, #13, #16)

F Inpatient Surgery:– Follow-up care by the surgeon is considered part of the

cost of the surgical procedure and is NOT covered as aseparate charge.

F Outpatient Surgery: – If surgery is performed in a physician’s office, the

following will be considered as part of the fee: – Surgical tray and supplies. – Local anesthesia administered by the physician.– Medically necessary follow-up visits.

F Plastic and reconstructive surgery is limited for thefollowing:

– An accidental injury. – Congenital deformities evident at infancy. – Reconstructive mammoplasty following a mastectomy.

F Assistant surgeon:– A payable assistant surgeon is a physician who assists

the surgeon, subject to medical necessity. – Up to 20% of allowable charges of eligible charges.

F Multiple surgical procedures: – Standard plan guidelines are used in processing claims

when multiple surgical procedures are performedduring the same operative session.

– Charges for the most inclusive (comprehensive)procedure. Additional procedures are paid at a lesserlevel. Contact the plan administrator for apredetermination of benefits.

Podiatry Services (See Exclusion #9)

Notification is required. Refer to ‘Notification Requirements’in the ‘Quality Care Health Plan’ section of the BenefitsHandbook for more information.

Prescription DrugsF Drug charges if billed by a physician’s office and not

obtained at a pharmacy. F Prescription drugs obtained as part of a skilled care facility

stay are payable by the health plan administrator.F Prescription drugs obtained as part of a hospital stay are

payable at the appropriate facility benefit level. F Prescription drugs billed by a skilled nursing facility,

extended care facility or a nursing home must besubmitted to the prescription drug plan administrator.

Preventive ServicesRoutine preventive care services which do NOT require adiagnosis or treatment are covered at 100% when utilizing anetwork provider. Out-of-network preventive care is covered atthe out-of-network benefit level. Your doctor will determine thetests and frequency that are right for you based on your age,gender and family history. In-network preventive services arenot subject to the plan year deductible. NOTE: Claims which indicate a diagnosis are notconsidered preventive and are subject to the plan yeardeductible and coinsurance.

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Prosthetic AppliancesA prosthetic appliance is one which replaces a body part.Examples are artificial limbs and artificial eyes.F Charges for:

– The original prosthetic appliance.– Replacement of a prosthetic appliance due to growth or a

change in the person’s medical condition.– Repair of a prosthetic appliance due to normal wear and

usage rendering the appliance no longer functional.F No payment will be made if the appliance is damaged or

lost due to negligence. F Prosthetic appliances exclusions include, but are not

limited to: – Appliances not recommended or approved by a

physician.– Appliances to overcome sexual dysfunction, except when

the dysfunction is related to an injury or illness.– Items considered cosmetic in nature such as artificial

fingernails, toenails, eyelashes, wigs, toupees or breastimplants.

– Experimental or investigational appliances.

Skilled Nursing Service –Home SettingF Contact the Notification/Medical Case Management plan

administrator for a determination of benefits. F The benefit for skilled nursing service will be limited to

the lesser of the cost for care in a home setting or theaverage cost in a skilled nursing facility, extended carefacility or nursing home within the same geographicregion.

F The continued coverage for skilled nursing service will bedetermined by the review of medical records and nursingnotes.

Skilled Nursing – In a SkilledNursing Facility, ExtendedCare Facility or Nursing Home(See Exclusions #3, #4, #6)

F Benefits are subject to skilled care criteria and will beallowed for the most cost-effective setting or the level ofcare required as determined by the Notification/MedicalCase Management plan administrator.

F Must be a licensed healthcare facility primarily engaged inproviding skilled care.

F Notification is required at least seven days prior toadmission or at time of transfer from an inpatient hospitalstay.

F Benefits are limited to the average cost of availablefacilities within the same geographic region.

F The service must be medically necessary.F The continued coverage for skilled nursing service will be

determined by the review of medical records and nursingnotes.

F Prescription drug charges must be submitted to the healthplan administrator.

NOTE: Extended care facilities are sometimes referred to asnursing homes. Most care in nursing homes is NOT skilledcare and therefore is NOT covered. Many people purchaselong-term care insurance policies to cover those nursinghome services which are NOT covered by medical insuranceor Medicare.

Speech TherapyNotification is required. Refer to ‘Notification Requirements’in the ‘Quality Care Health Plan’ section of the BenefitsHandbook for more information.F Charges for medically necessary speech therapy ordered

by a physician. F Treatment must be for a speech disorder resulting from

injury or illness serious enough to significantly interferewith the ability to communicate at the appropriate agelevel.

F The therapy must be restorative in nature with the abilityto improve communication.

F The person must have the potential for communication.

Transplant Services In order for any organ, tissue or bone marrow transplant tobe covered under the plan, one of the designatedprocedure specific transplant hospitals must be utilized.The transplant candidate must contact theNotification/Medical Case Management plan administratorof the potential transplant. Once notification occurs, theMedical Case Manager (MCM) will coordinate all treatmentsand further notification is not required. Those refusing toparticipate in the MCM program will be notified thatcoverage may be terminated under the plan for treatment ofthe condition.

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The transplant benefit includes all diagnostic treatment andrelated services necessary to assess and evaluate thetransplant candidate. All related transplant chargessubmitted by the transplant hospital are covered at 85% ofthe contracted rate. In some cases, transplants may be considered nonviable forsome candidates, as determined by the MCM planadministrator in coordination with the transplant hospital. F Transplant exclusions include, but are not limited to:

– Investigational drugs, devices or experimentalprocedures.

– Charges related to the search for an unrelated bonemarrow donor.

– A corneal transplant is not part of the transplant hospitalbenefit; however, standard benefits apply under themedical portion of the coverage.

Transplant Coordinationof Donor/Recipient BenefitsF When both the donor and the recipient are covered under

the plan, both are entitled to benefits under the plan,under separate claims.

F When only the recipient is covered, the donor’s chargesare covered as part of the recipient’s claim if the donordoes not have insurance coverage, or if the donor’sinsurance denies coverage for medical expenses incurred.

F When only the recipient is covered and the donor’sinsurance provides coverage, the plan will coordinate withthe donor’s plan.

F When only the donor is covered, only the donor’s chargeswill be covered under the plan.

F When both donor and recipient are members of the samefamily and are both covered by the plan, no deductible orcoinsurance shall apply.

The transplant hospital network is subject to changethroughout the year. Call the Notification/Medical CaseManagement plan administrator for current transplanthospitals.

Transplant– Transportation/Lodging BenefitF The maximum expense reimbursement is $2,400 per

case. Automobile mileage reimbursement is limited tothe mileage reimbursement schedule established by theGovernor’s Travel Control Board. Lodging per diem islimited to $70. There is no reimbursement for meals.

F The plan will also cover transportation and lodgingexpenses for the patient and one immediate familymember or support person prior to the transplant and forup to one year following the transplant. This benefit isavailable only to those plan participants who have beenaccepted as a candidate for transplant services.

F Requests for reimbursement for transportation andlodging with accompanying receipts should be forwardedto:

Organ Transplant ReimbursementCMS Group Insurance Division801 S. 7th StreetP.O. Box 19208Springfield, IL 62794-9208

F The plan participant has twelve months from the dateexpenses were incurred to submit eligible charges forreimbursement. Requests submitted after the twelve-month limit will not be considered for reimbursement.

Urgent Care ServicesUrgent care is care for an unexpected illness or injury thatrequires prompt attention, but is less serious thanemergency care. Treatment may be rendered in facilitiessuch as a physician’s office, urgent care facility or prompt carefacility. This benefit applies to professional fees only. If afacility fee is billed, the emergency room deductible applies.NOTE: See Emergency Services for medically necessaryemergency care.

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1. For services or care not recommended, approved andprovided by a person who is licensed under the IllinoisMedical Practices Act or other similar laws of Illinois,other states, countries or by a nurse midwife who hascompleted an organized program of study recognized bythe American College of Nurse Midwives or by aChristian Science Practitioner.

2. For services and supplies not related to the care andtreatment of an injury or illness, unless specificallystated in this document to be a covered service in effectat the time the service was rendered. Excluded servicesand supplies include, but are not limited to: sports-related health checkups, employer-required checkups,wigs and hairpieces.

3. For care, treatment, services or supplies which are notmedically necessary for the diagnosed injury or illness,or for any charges for care, treatment, services orsupplies which are deemed unreasonable by the plan.

4. For charges for the services, room and board or suppliesthat exceed allowable charges.

5. For personal convenience items, including but notlimited to: telephone charges, television rental, guestmeals, wheelchair/van lifts, nonhospital type adjustablebeds, exercise equipment, special toilet seats, grab bars,ramps, transportation services or any other services oritems determined by the plan to be for personalconvenience.

6. For rest, convalescence, custodial care or education,institutional or in-home nursing services which areprovided for a person due to age, mental or physicalcondition mainly to aid the person in daily living such ashome delivered meals, child care, transportation orhomemaker services.

7. For extended care and/or hospital room and boardcharges for days when the bed has not been occupied bythe covered person (holding charges).

8. For private room charges which are not medicallynecessary as determined by the plan administrator.

9. For routine foot care, including removal in whole or inpart of corns, calluses, hyperplasia, hypertrophy and the

cutting, trimming or partial removal of toenails, exceptfor patients with the diagnosis of diabetes.

10. For chiropractic services, occupational therapy andphysical therapy considered to be maintenance innature, in that medical documentation indicates thatmaximum medical improvement has been achieved.

11. For keratotomy or other refractive surgeries.

12. For the diagnosis or treatment of obesity, except servicesfor morbid obesity, as approved by the planadministrator.

13. For sexual dysfunction, except when related to an injuryor illness.

14. For services relating to the diagnosis, treatment, orappliance for temporomandibular joint disorders orsyndromes (TMJ), myofunctional disorders or otherorthodontic therapy.

15. For an internal accidental injury to the mouth caused bybiting on a foreign object and outpatient services forroutine dental care.

16. For the expense of obtaining an abortion, inducedmiscarriage or induced premature birth, unless it is aphysician’s opinion that such procedures are necessaryfor the preservation of the life of the woman seekingsuch treatment, or except in an induced premature birthintended to produce a live viable child and suchprocedure is necessary for the health of the woman orher unborn child.

17. For cosmetic surgery or therapies, except for the repair ofaccidental injury, for congenital deformities evident ininfancy or for reconstructive mammoplasty after partialor total mastectomy when medically indicated.

18. For services rendered by a healthcare providerspecializing in behavioral health services who is acandidate in training.

19. For services and supplies which do not meet acceptedstandards of medical or dental practice at the time theservices are rendered.

Quality Care Health Plan (QCHP) Exclusions and LimitationsNo benefits are available:

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20. For treatment or services which are investigational,experimental or unproven in nature including, but notlimited to, procedures and/or services: which areperformed in special settings for research purposes or ina controlled environment; which are being studied forsafety, efficacy and effectiveness; which are awaitingendorsement by the appropriate national medicalspecialty organization; which medical literature does notaccept as a reasonable alternative to existing treatments;or, that do not yet meet medical standards of care.

21. For services due to bodily injury or illness arising out ofor in the course of a plan participant’s employment,which is compensable under any Workers’Compensation or Occupational Disease Act or law.

22. For court mandated services if not a covered serviceunder this plan or not considered to be medicallynecessary by the appropriate plan administrator.

23. For services or supplies for which a charge would nothave been made in the absence of coverage or forservices or supplies for which a plan participant is notrequired to pay.

24. For services arising out of war or an act of war, declaredor undeclared, or from participation in a riot, or incurredduring or as a result of a plan participant’s commissionor attempted commission of a felony.

25. For services related to the reversal of sterilization.26. For lenses (eye glasses or removable contact lenses)

except initial pair following cataract surgery.27. For expenses associated with obtaining, copying or

completing any medical or dental reports/records.28. For services rendered while confined within any federal

hospital, except for charges a covered person is legallyrequired to pay, without regard to existing coverage.

29. For charges imposed by immediate relatives of the patientor members of the plan participant’s household as definedby the Centers for Medicare and Medicaid Services.

30. For services rendered prior to the effective date ofcoverage under the plan or subsequent to the datecoverage is terminated.

31. For private duty nursing, skilled or unskilled, in ahospital or facility where nursing services are normallyprovided by staff.

32. For services or care provided by an employer-sponsoredhealth clinic or program.

33. For travel time and related expenses required by aprovider.

34. For facility charges when services are performed in aphysician’s office.

35. For residential treatment for behavioral health servicesincurred prior to July 1, 2014.

36. For the treatment of educational disorders relating tolearning, motor skills, communication and pervasivedevelopment conditions.

37. For nonmedical counseling or ancillary services,including but not limited to custodial services,education, training, vocational rehabilitation, behavioraltraining, biofeedback, neuro feedback, hypnosis, sleeptherapy, employment counseling, back-to-school, returnto work services, work hardening programs, drivingsafety and services, training, educational therapy ornonmedical ancillary services for learning disabilities,developmental delays, autism (except as provided undercovered expenses) or intellectual disability.

38. For telephone, email and internet consultations andtelemedicine.

39. For expenses associated with legal fees.

40. For medical and hospital care and cost for the infantchild of a dependent, unless this infant is otherwiseeligible under the plan.

42. For transportation between healthcare facilities becauseof patient’s choice; transportation of patients who haveno other available means of transportation;transportation that is not medically necessary; orMedicar or similar type of transportation when used forpatient’s convenience.

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OverviewPlan participants enrolled in any State health plan haveprescription drug benefits included in the coverage.Regardless of the plan chosen, a prescription deductibleapplies to each plan participant each plan year. An annualprescription deductible must be satisfied before theprescription copayments apply; however, if the cost of theprescription is less than the plan’s prescription copayment,the plan participant will pay the cost of the prescription. Oncethe prescription deductible has been satisfied, the participantwill pay the copayment of the prescription. However, if a planparticipant elects a brand name drug and a generic isavailable, the plan participant must pay the cost differencebetween the brand product and the generic product, inaddition to the brand copayment.Members who change health plans outside the annualBenefit Choice Period will be responsible for satisfying theprescription deductible of the new health plan even if theypreviously met the prescription deductible of their previoushealth plan. Prior authorization may be required for a select group ofmedications. If a prescription is presented for one of thesemedications, the pharmacist will indicate that a priorauthorization is needed before the prescription can be filled.To receive a prior authorization, the prescribing physicianmust provide medical information including a diagnosis tothe prescription drug plan administrator for review. Once aprior authorization is in place, the prescriptions may be filleduntil the authorization expires, usually one year.Plan participants who have additional prescription drug coverage,including Medicare, should contact their prescription planadministrator for coordination of benefits (COB) information.

Formulary ListAll prescription medications are compiled on a formulary list(i.e., drug list) maintained by each health plan's prescriptionbenefit manager (PBM). Formulary lists categorize drugs intolevels: Each level requires a different copayment amount.Formulary lists are subject to change any time during the planyear. To compare formulary lists, cost-savings programs and toobtain a list of network pharmacies that participate in the varioushealth plans, plan participants should visit the website of theirhealth plan or PBM. Certain health plans or the PBM notify planparticipants by mail when a prescribed medication they arecurrently taking is reclassified into a different formulary category.If a formulary change occurs, plan participants should consultwith their physician to determine if a change in prescription isappropriate.

Health Maintenance Organizations(HMOs)Health maintenance organizations (HMOs) use a separateprescription benefit manager (PBM) to administer theirprescription drug benefits. Members who elect one ofthese health plans must utilize a pharmacy participating inthe plan’s pharmacy network or the full retail cost of themedication will be charged. If the member uses anonparticipating pharmacy, partial reimbursement may beprovided if the plan participant files a claim with thehealth plan. It should be noted that most plans do notcover over-the-counter drugs or drugs prescribed bymedical professionals (including dentists), other than theplan participant’s primary care physician (PCP) or anyspecialist the plan participant was referred to by their PCP.Members should direct prescription benefit questions tothe respective health plan administrator. Refer to theannual Benefit Choice Options booklet for specificinformation regarding deductible and copaymentamounts.

Open Access Managed Care Plansand the Quality Care Health Plan(QCHP) Open access managed care plans and the Quality Care HealthPlan (QCHP) have prescription drug benefits administeredthrough the self-insurance plans’ prescription benefitmanager (PBM). Prescription drug benefits are independentof other medical services and are not subject to the medicalplan year deductible. Most drugs purchased with aprescription from a physician or a dentist are covered;however, most over-the-counter drugs are not covered, even ifpurchased with a prescription. Prescription Drug Step Therapy (PDST) is required formembers who have their prescription drug benefitsadministered through QCHP or one of the open accessmanaged care plans. PDST requires the member to first tryone or more specified drugs to treat a particular conditionbefore the plan will cover another (usually more expensive)drug that their doctor may have prescribed. PDST is intendedto reduce costs to both the member and the plan byencouraging the use of medications that are less expensivebut still treat the member’s condition effectively.

Prescription Coverage

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Prescription Coverage (cont.)Members taking a brand medication that requires PDST,which has not received prior authorization approval, willreceive a rejection at a retail or mail order pharmacy as theplan requires a generic in that drug class be tried first. If thephysician believes the original brand medication is needed,he/she may request a review to override the step therapyrequirement.

Compound drugs are covered under the prescription drugplan. If the compound drug contains an ingredient not coveredby the plan, the entire compound drug will be denied.Injectable and intravenous medications may be obtainedthrough a retail network pharmacy or through the prescriptiondrug plan administrator’s mail order pharmacy.If a network pharmacy does not stock a particular drug orsupply and is unable to obtain it, call the prescription drugplan administrator for further direction.Prepackaged prescriptions – A copayment is based on a 1 to30-day supply as prescribed by the physician. Sincemanufacturers sometimes prepackage products in amountsthat may be more or less than a 30-day supply as prescribed,more than one copayment may be required.Prescribed medical supplies are supplies necessary for theadministration of prescription drugs such as coveredhypodermic needles and syringes. Copayments may apply.Diabetic supplies and insulin that are purchased with aprescription are covered through the plan and are subject tothe appropriate copayment. Some diabetic supplies are also covered under Medicare PartB. If the plan participant is not Medicare Part B primary, theappropriate copayment must be paid at the time of purchaseat a network pharmacy. If Medicare Part B is primary, the planparticipant is responsible for the Medicare coinsurance at thetime of purchase. The claim must first be submitted toMedicare for reimbursement. Upon receipt of the MedicareSummary Notice (MSN), a claim may be filed with theprescription drug plan administrator for any secondary benefitdue. If the diabetic supplies are billed by a physician ormedical supplier, the supplies would be paid by the healthplan administrator. Insulin pumps and their related supplies are not covered underthe prescription drug plan. In order to receive coverage for theseitems, contact the health plan administrator listed on theMyBenefits.illinois.gov website.

Nonmaintenance MedicationIn-Network PharmacyRetail pharmacies that contract with the prescription benefitmanager (PBM) and accept the copayment amount formedications are referred to as in-network pharmacies. Planparticipants who use an in-network pharmacy must present theirprescription ID card/number or they will be required to pay thefull retail cost. If, for any reason, the pharmacy cannot verifyeligibility when they submit the claim electronically, the planparticipant will need to submit a claim form to the planadministrator. The maximum supply of nonmaintenance medicationallowed at one fill is 60 days. Two copayments will be chargedfor any 31-60 day supply. A list of in-network pharmacies, aswell as claim forms, is available on theMyBenefits.illinois.gov website.Out-of-Network PharmacyPharmacies that do not contract with the plan administratorare referred to as out-of-network pharmacies. In most cases,prescription drug costs will be higher when an out-of-networkpharmacy is used. If a medication is purchased at an out-of-network pharmacy, the plan participant must pay the full retailcost at the time the medication is dispensed. Reimbursementof eligible charges may be obtained by submitting a paperclaim and the original prescription receipt to the PBM.Reimbursement will be provided at the applicable brand orgeneric in-network price minus the appropriate in-networkcopayment. Prescription claim forms are available atMyBenefits.illinois.gov website or contacting the MyBenefitsService Center at 844-251-1777.

Maintenance MedicationThe Maintenance Medication Program (MMP) wasdeveloped to provide an enhanced benefit to planparticipants who use maintenance medications. The MMP iscomprised of a Maintenance Pharmacy Network and a MailOrder Pharmacy. When plan participants use a MaintenanceNetwork pharmacy or the Mail Order Pharmacy for theirmaintenance medications, they will receive a 90-day supplyof medication (equivalent to 3 fills) for only two and a halfcopayments. A maintenance medication is medication that istaken on a regular basis for conditions such as high bloodpressure and high cholesterol. To determine whether amedication is considered a maintenance medication, contacta maintenance network pharmacy or the PBM.

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Maintenance Pharmacy NetworkThe Maintenance Pharmacy Network is a network of retailpharmacies that contract with the PBM to accept thecopayment amount for maintenance medication. When planparticipants use the Maintenance Pharmacy Network formaintenance medications they will receive a 90-day supply ofmedication (equivalent to 3 fills) for only two and a halfcopayments. Pharmacies in this network may also be an in-network retail pharmacy as described in the‘Non-Maintenance Medication’ section. Participants will becharged a penalty in an amount equal to double theprescription copayment if they obtain a maintenancemedication from a non-maintenance network pharmacy or aprescription for a maintenance medication that is writtenfor a 30-day supply instead of a 90-day supply. The penaltywill be forgiven only for the first two 30-day fills (or first 60-day fill), but will apply thereafter. A list of pharmaciesparticipating in the Maintenance Pharmacy Network isavailable on the MyBenefits.illinois.gov website.

Mail Order PharmacyThe Mail Order Pharmacy provides participants the opportunityto receive medications directly from the PBM. Bothmaintenance and nonmaintenance medications may beobtained through the mail order process. When planparticipants use the Mail Order Pharmacy for maintenancemedications they will receive a 90-day supply of medication(equivalent to 3 fills) for only two and a half copayments. Toutilize the Mail Order Pharmacy, plan participants must submitan original prescription from the attending physician. Formaintenance medication, the prescription should be written fora 90-day supply and include up to three 90-day refills totalingone year of medication. The original prescription must beattached to a completed Mail Order form and sent to theaddress indicated on the form. Order forms can be obtained bycontacting the PBM or by accessing theMyBenefits.illinois.gov website.

Special Note Regarding Medications forNursing Home/Extended Care Facility PatientsDue to the large amounts of medication generally administeredat nursing homes and extended care facilities, many of thesetypes of facilities cannot maintain more than a 30-day supplyof prescriptions per patient. In order to avoid being charged adouble copayment for a 30-day supply, the patient or personwho is responsible for the patient’s healthcare (such as aspouse, civil union partner, power of attorney or guardian)should submit a letter requesting an ‘exception’ to the double

copayment for their medication. The effective date of theexception is the receipt date of the request. NOTE: Since eachrequest is based on a specific list of medications, any newlyprescribed medication(s) must be sent as another request.

Request RequirementsF Must be in the form of a letter.F Must include the patient’s name, a list of all medications

the patient is taking and the dosage of each medication.

Submit Documentation to:CMS Group Insurance DivisionMember Services Unit801 S. 7th StreetP.O. Box 19208Springfield, IL 62794-9208

Coordination of BenefitsThis Program coordinates with Medicare and other groupplans. The appropriate copayment will be applied for eachprescription filled.

Exclusions and LimitationsThe Program reserves the right to exclude or limit coverage ofspecific prescription drugs or supplies.

Prescription Coverage (cont.)

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OverviewBehavioral health services are for the diagnosis and treatment ofmental health and/or substance abuse disorders. Eligiblecharges are for those covered services deemed medicallynecessary by the plan administrator. The coverage ofbehavioral health services (mental health and substanceabuse) complies with the federal Mental Health Parity andAddiction Equity Act of 2008. This federal law requires healthplans to cover behavioral health services at benefit levelsequal to those of the plan’s medical benefits. Coverage for behavioral health services is provided under allof the State plans. There are no restrictions regarding thenumber of visits and hospital days allowed per plan year. Thecharges for behavioral health services are included in a planparticipant’s annual plan deductible if applicable and annualout-of-pocket maximum. Covered services for behavioralhealth must still meet the managed care plan administrator’smedical necessity criteria and will be paid in accordance withthe managed care benefit schedule. Please contact themanaged care plan for specific benefit information.

Quality CareHealth Plan (QCHP)Covered services for behavioral health which meet the planadministrator’s medical necessity criteria are paid inaccordance with the Quality Care Health Plan (QCHP) benefitschedule for in-network and out-of-network providers. Pleasecontact the behavioral health plan administrator for specificbenefit information and for a listing of in-network hospitalfacilities and participating providers. Authorization Requirements for Behavioral Health ServicesIn an emergency or a life-threatening situation, call 911, or goto the nearest hospital emergency room. Plan participants mustcall the behavioral health plan administrator within 48 hours toavoid a financial penalty. Authorization requirements still applywhen plan participants have other coverage, such as Medicare.F Inpatient services must be authorized prior to admission or

within 48 hours of an emergency admission to receivein-network or out-of-network benefits. Authorization isrequired with each new admission. Failure to notify thebehavioral health plan administrator of an admission to an

inpatient facility within 48 hours will result in a financialpenalty and risk incurring noncovered charges.

F Partial hospitalization and intensive outpatienttreatment must be authorized prior to admission toreceive in-network or out-of-network benefits.Authorization is required before beginning each treatmentprogram. Failure to notify the behavioral health planadministrator of a partial hospitalization or intensiveoutpatient program will result in a financial penalty andrisk incurring noncovered charges.

F Outpatient services received at the in-network benefitlevel must be provided by a QCHP network provider. Mostroutine outpatient services (such as therapy sessions andmedication management) will be covered without theneed for prior authorization. Authorization requirementsfor certain specialty outpatient services are noted below.Outpatient services that are not consistent with usualtreatment practice for a plan participant’s condition will besubject to a medical necessity review. The behavioralhealth administrator will contact the plan participant’sprovider to discuss the treatment if a review will beapplied. Outpatient services received at the out-of-network benefit level must be provided by a licensedprofessional including licensed clinical social worker(LCSW), registered nurse, clinical nurse specialist (RNCNS), licensed clinical professional counselor (LCPC),licensed marriage and family therapist (LMFT),psychologist or psychiatrist to be eligible for coverage.

F Electroconvulsive therapy, psychological testing andapplied behavioral analysis must be authorized to receivein-network or out-of-network benefits. Failure to obtainauthorization will result in the risk of incurring noncoveredcharges.

F Residential services must be authorized prior toadmission to receive in-network or out-of-networkbenefits. Authorization is required with each newresidential admission. Failure to notify the behavioralhealth plan administrator of an admission to a residentialfacility will result in a financial penalty and risk incurringnoncovered charges.

Behavioral Health

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OverviewThe Quality Care Dental Plan (QCDP) is designed to offer planparticipants coverage for basic dental services regardless ofthe health plan chosen.  Retirees, annuitants and survivorswho opt out of the health plan are not eligible for dentalcoverage.  Each plan participant is subject to an annual dental plandeductible for all dental services, except those listed in theDental Schedule of Benefits as ‘Diagnostic’ or ‘Preventive’.Once the deductible has been met, the plan participant issubject to a maximum annual dental benefit.  See theMyBenefits.illinois.gov website for the amount of themaximum benefit.F Plan participants may go to any dentist.F The maximum benefit amount paid for eligible services is

listed in the Dental Schedule of Benefits.  Dentalprocedure codes that are not listed in the Dental Schedule ofBenefits are not covered by the plan and are not eligiblefor payment.  Members are responsible for all chargesover the scheduled amount and/or over the annualmaximum benefit.  The Dental Schedule of Benefits isavailable at MyBenefits.illinois.gov. 

F Plan participants may obtain dental identification cardsfrom the dental plan administrator.

Retirees, annuitants and survivors may enroll in the dentalplan at the time of initial enrollment, upon opting into thehealth plan or during the annual Benefit Choice Period. Amonthly premium will apply for dental coverage.  Members may opt out of the dental plan at the time of initialenrollment or during the annual Benefit Choice Period.  Theelection to drop coverage will remain in effect the entire planyear, without exception. 

Choosing a Provider With QCDP, plan participants can choose any dental provider forservices; however, plan participants will receive enhancedbenefits, resulting in lower out-of-pocket costs, when theyreceive services from a network provider. There are twoseparate networks of providers that a plan participant mayutilize for dental services: the PPO network and the Premiernetwork.

• PPO Network: If you receive services from a PPO dentist,your out-of-pocket expenses will often be less becausethese providers accept a reduced PPO fee (less anydeductible). If the PPO fee is higher than the amount listedon the Schedule of Benefits, you will be required to pay thedifference.

• Premier Network: If you receive services from a Premierdentist, your out-of-pocket expenses may be less becausePremier providers accept the allowed Premier fee (less anydeductible). If the allowed fee is higher than the amountlisted on the Schedule of Benefits, you will be required topay the difference.

Out-of-Network ServicesIf you receive services from a dentist who does not participatein either the PPO or Premier network, , the amount paid by theplan will be in accordance with the Schedule of Benefits.

Preventive and Diagnostic ServicesPreventive and diagnostic services are not subject to theannual deductible and include, but are not limited to:

• Two periodic oral examinations per person per plan year. • Two adult or child prophylaxis (scaling and polishing of

teeth) per person per plan year. • Two bitewing radiographs per person per plan year. • One full mouth radiograph per person every three plan

years.

Prosthodontics Prosthodontics, which include implants, crowns, bridges anddentures, are subject to the following limitations:

• Prosthodontics to replace missing teeth are covered onlyfor teeth that are lost while the person is coveredunder this plan.

• Immediate dentures are covered only if five or moreteeth are extracted on the same day.

• Permanent dentures to replace immediate dentures arecovered only if placed in the person’s mouth within twoyears from the placement of the immediate denture.

Dental Coverage

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• Replacement dentures are covered only under one of thefollowing circumstances:

– Existing denture is at least 5 years old, or – Structural changes in the person's mouth require

new dentures.• Replacement crowns are covered only when the existing

crown is at least 5 years old. • Replacement bridges are covered only when the existing

bridge is at least 5 years old.

Child OrthodonticsThe child orthodontia benefit is available only to children whobegin treatment prior to the age of 19.  A maximum lifetimebenefit for child orthodontia applies regardless of the numberof courses of treatment. The annual plan year deductible willneed to be satisfied unless it was previously satisfied for otherdental services incurred during the plan year.The maximum lifetime benefit amount applies to each planparticipant and does not start over with each course oftreatment.  A course of treatment can be for any orthodonticservices, not only the placement of braces.  For example, achild may have a retaining device when they are 8 years oldand then have braces installed when they are 15.  The benefitamount for the retainer plus the benefit amount for thebraces can not exceed the maximum lifetime benefit amountallowed.The benefit amount that will be paid for orthodontic treatmentdepends on the length of treatment plan as determined by theorthodontist. The length of treatment time frames and theasociated benefit amount allowed is listed on theMyBenefits.illinois.gov website.Twenty-five percent (25%) of the applicable orthodontiabenefit, based on the length of treatment, will be reimbursedafter the initial banding.  The remaining benefit will beprorated over the remaining length of treatment period.

Provider PaymentIf you use a network dentist, you will not have to pay thedentist at the time of service (with the exception of applicabledeductibles, charges for noncovered services, charges overthe amount listed on the Schedule of Benefits and/oramounts over the annual maximum benefit). Networkdentists will automatically file the dental claim for theirpatients. Employees who use a network provider and do nothave any out-of-pocket costs for their visit will not receive anexplanation of benefits (EOB). The employee may, however,view their EOB on the dental plan administrator’s website. Participants who use an out-of-network dentist may have topay the entire bill at the time of service and/or file their ownclaim form depending on the payment arrangements theplan participant has with their dentist. Out-of-networkdentists can elect to accept assignment from the plan or mayrequire other payment terms. Coordination of benefitsapplies to any other dental coverage.

Pretreatment EstimateFor both prosthodontics and orthodontics, although notrequired, a pretreatment estimate is strongly encouraged toassist plan participants in determining the benefits available.To obtain a pretreatment estimate plan participants shouldcontact their dental provider.

Benefits for Services ReceivedWhile Outside the United StatesThe plan covers eligible charges incurred for services receivedoutside of the United States. All plan benefits are subject toplan provisions and deductibles. Payment for the services may be required at the time serviceis provided and a paper claim must be filed with the dentalplan administrator. When filing the claim, enclose the itemizedbill with a description of the service translated to English andconverted to U.S. currency along with the name of the patient,date of service, diagnosis, procedure code and the provider’sname, address and telephone number.

Dental Coverage (cont.)

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Dental Exclusions and LimitationsNo benefits shall be payable for:1. Dental services covered under the health plan.2. Services rendered prior to the plan participant’s effective

date of coverage or subsequent to the date of termination ofcoverage.

3. Services not listed in this plan description or for servicesrendered prior to the date a service or procedure became acovered benefit as indicated in this plan description.

4. Services performed to correct congenital and /ordevelopmental conditions including but not limited tomalformations, retention of deciduous (baby) teeth,impaction or absence of permanent teeth, cleft palate,mandibular prognathism or retrognathism, enamelhypoplasia, amelogenesis imperfecta, fluorosis, andanodontia (i.e., the absence of teeth) are excluded fromcoverage.

5. Dental services relating to the diagnosis or treatment,including appliances, for temporomandibular jointdisorders (TMJ) and myofunctional disorders,craniofacial pain disorders and orthognathic surgery.However, occlusal guards are covered.

6. Services not necessary or not consistent with the diagnosis ortreatment of a dental condition, as determined by thedental plan administrator.

7. Orthodontia of deciduous (baby) teeth or adult orthodontia.8. Services compensable under the Workers’ Compensation Act

or Employer’s Liability Law.9. Procedures or surgeries undertaken for primarily cosmetic

reasons.10. Construction of duplicate dentures.11. Replacement of a fixed or removable prosthesis for

which benefits were paid under this plan for the sametooth/teeth, if the replacement occurs within five yearsfrom the date the expense was incurred, unless:– The replacement is made necessary by the initial

placement of an opposing full prosthesis or theextraction of natural teeth;

– The prosthesis is a stayplate or a similar temporaryprosthesis and is being replaced by a permanentprosthesis; or

– The prosthesis, while in the oral cavity, has beendamaged beyond repair, as a result of injury whileeligible under the plan.

12. Customization of dental prosthesis, including personalized,elaborate dentures or specialized techniques.

13. Expenses associated with obtaining, copying orcompleting any dental or medical reports.

14. Charges for procedures considered experimental innature.

15. Service or care performed by a family member or otherperson normally residing with the participant.

16. Services provided or paid for by a governmental agency orunder any governmental program or law, except forcharges which the person is legally obligated to pay. Thisexception extends to any benefits provided under the U.S.Social Security Act and its amendments.

17. General anesthesia, conscious sedation or intravenoussedation services (with the exception of children underage 6) unless medically necessary. Supportingdocumentation from a physician will be reviewed by thedental plan administrator.

18. Fixed or removable prosthodontics for a patient underage 18.

19. Sealants for adults over age 18.20. Amalgam and resin-based composite fillings more than

once per surface in a 12-month interval.

Dental Coverage (cont.)

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OverviewThe vision plan is designed to assist with the costs of well-vision care and to encourage the maintenance of visionthrough regular eye exams. Periodic eye exams can detectand prevent ailments not only in the eyes, but throughoutthe body. The plan provides coverage when glasses orcontacts are required. For more information, contact thevision plan administrator.

EligibilityAll plan participants covered by any of the health plansoffered by the State Employees Group Insurance Program areeligible for vision care benefits. Benefit levels are publishedon the MyBenefits.illinois.gov website.

Frequency of BenefitsEach service component is available once every 24 monthsfrom the last time the benefit component was used, except forthe eye examination, spectacle lenses and contact lens benefitwhich are available once every 12 months from the last timeused. Each service component is independent and may beobtained at separate times from separate providers. Forexample, a plan participant may receive an eye examinationfrom one provider and purchase frames/lenses from adifferent provider.

Provider ServicesMaterials and services obtained from a network provider arepaid at the network provider coverage benefit level. Applicablecopayments and additional charges must be paid at the timeof service. Eligible services or materials may be obtained fromany licensed optometrist, ophthalmologist or optician. Adirectory of network providers can be found on the planadministrator’s website.If an out-of-network provider is used, the plan participantmust pay the provider in full and request reimbursement fromthe vision plan administrator. To request reimbursement, sendan itemized receipt and a claim form requestingreimbursement to the vision plan administrator.Reimbursement will be paid up to the maximum allowanceamount as detailed in the schedule of benefits, out-of-network provider coverage chart on theMyBenefits.illinois.gov website. Out-of-network providerbenefits are paid directly to the covered member. Claimforms are available on the MyBenefits.illinois.gov websiteand through the plan administrator.

Vision Coverage

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OverviewThere are two types of life coverage available: Basic Life andOptional Life. Life insurance options change uponretirement. For more information regarding life insurancecoverage and benefits, consult the State of Illinois GroupTerm Life Certificate of Insurance or contact the lifeinsurance plan administrator.

Basic and Optional Life CoverageBasic term life insurance coverage is provided automaticallyat no cost to immediate and deferred annuitants and eligiblesurvivors through the State Employees Group InsuranceProgram. Immediate annuitants and certain survivors maypurchase Optional Life insurance coverage. All premiums forOptional Life insurance coverage are at the member’sexpense. Rates are published each year in the Benefit ChoiceOptions booklet.F Basic Life. Term coverage amounts vary – see eligibility in

this section.F Member Optional Life. Options vary – see eligibility in

this section. Any amount requested above four times theBasic Life amount will require satisfactory evidence ofinsurability.

F Accidental Death and Dismemberment (AD&D).Accidental Death and Dismemberment (AD&D) isavailable to members in either (1) an amount equal totheir Basic Life amount, or (2) the combined amount oftheir Basic and Member Optional Life, subject to a totalmaximum of five times the Basic Life insurance amount or$3,000,000, whichever is less.

F Spouse Life. Term coverage amounts vary – see eligibilityin this section. Spouse Life applies to civil union partners,but does not apply to domestic partners.

F Child Life. Term coverage of $10,000 per child. Once amember elects Child Life coverage for one child, alleligible, MBSC-reported, dependent children age 25 andunder will have Guaranteed Issue Child Life coverage,except individuals enrolled in the Other category. Childrenin the Disabled category are eligible for life coverage aslong as they continue to meet eligibility requirements.

Eligibility for retirees and annuitants is below:Retirees (prior to 1/1/1966) and their survivors:F Basic Life coverage is not provided.

F Not eligible for Member Optional Life, AD&D, Child Life orSpouse Life coverage.

Deferred Annuitants (on or after 1/1/1966):F Basic Life

• Under age 60 – Annuitants are insured for an amountequal to their annual basic salary as of the last day ofemployment.

• Upon turning age 60 – Basic Life coverage reduces to$5,000.

F Not eligible for Member Optional Life, AD&D, Child Life orSpouse Life coverage.

Immediate Annuitants (on or after 1/1/1966):F Basic Life

• Under age 60 – Annuitants are insured for an amountequal to their basic annual salary as of the last day ofemployment.

• Upon turning age 60 – Basic Life coverage reduces to$5,000.

F Member Optional Life• Under age 60 - Annuitants may elect up to eight times

their basic amount.• Upon turning age 60 – Member Optional Life ($5,000

increments) in excess of four times the basic amountterminates.

F AD&D - Basic or Combined.F Child Life - $10,000 per child.F Spouse Life

• Under age 60 – Spouse Life is $10,000.• Upon turning age 60 – Spouse Life coverage reduces to

$5,000.

Eligibility for survivors is below:Survivors of Immediate Annuitants and of DeceasedEmployees:F Individuals who became a survivor prior to 09/22/79:

• Basic Life coverage is $2,000.• Member Optional Life - May elect up to four times their

basic amount of $2,000.• AD&D - Basic or Combined• Child Life - $2,000 per child.• Spouse Life - $5,000.

Life Insurance Coverage

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Eligibility for survivors continued:F Individuals who became a survivor on or after 09/22/79:

• Basic Life coverage is not provided.• Member Optional Life is $5,000.• Not eligible for AD&D, Spouse Life or Child Life

coverage.

Survivors of Deferred Annuitants:F Individuals who became a survivor prior to 09/22/79:

• Basic Life coverage is $2,000.• Not eligible for Member Optional Life, AD&D, Child Life

or Spouse Life coverage.F Individuals who became a survivor on or after 09/22/79:

• Basic Life coverage is not provided.• Not eligible for Member Optional Life, AD&D, Child Life

or Spouse Life coverage.

Changes to CoverageChanges to life insurance coverage may be made at any timeduring the plan year.

Statement of Health ApprovalWhen an immediate annuitant or eligible survivor requests toincrease Member Optional Life, or requests to add Spouse Lifecoverage, evidence of insurability (an approved statement ofhealth application) is required. If approved, coverage will beeffective the date of approval by the life insurance planadministrator.A statement of health is not required for Child Life coverage,for newborns added within 60 days of birth or for newly-acquired dependents including a (spouse, civil union partner,child of the civil union partner, adopted child, stepchild orchild for whom the annuitant or survivor has obtained legalguardianship) added within 60 days of the qualifying event.Statement of health applications are available on theMyBenefits.illinois.gov website.

Effective Date of Life Coverage ChangeWhen increasing Member Optional Life, or when addingMember Optional Life or Spouse Life, the effective date of thecoverage will be the statement of health approval date. Thelife plan administrator will send a letter to the member andthe MyBenefits Service Center (MBSC) that indicates whether

the statement of health application was approved or denied.When adding or increasing AD&D and/or Child Lifecoverage the effective date will be the date the request wasreceived by the MBSC. When terminating or decreasing any Optional Lifecoverage outside the Benefit Choice Period, the effectivedate will be the date the request. Requests made during the Benefit Choice Period to add,increase, decrease or terminate any Optional Life coveragewill be effective July 1st.

Accelerated BenefitsLife insurance benefits may be paid prior to death undercertain circumstances. Accelerated benefits offer accessto a portion of life insurance benefits if the member isdiagnosed with a terminal illness and has a lifeexpectancy of 24 months or less. Contact the lifeinsurance plan administrator for more information.

Beneficiary FormA life insurance beneficiary form must be completed andupdated periodically. It is the member’s responsibility tocontact the life insurance plan administrator with any changes tothe beneficiary designation and/or beneficiary address.

Continuing Optional Life Coverageupon Turning 60Upon turning age 60, Basic Life and Member Optional Lifecoverage drops to $5,000 each per unit. The combinedamount of Basic Life and Member Optional Life insurance thathas been terminated may be continued by converting to anindividual whole life insurance policy. Member Optional Lifeinsurance coverage may be ported in lieu of converting. In order to continue life coverage, the annuitant must contact thelife insurance plan administrator within 31 days of the date theyattain the age of 60. Should the annuitant choose to continuecoverage through one of the available insurance products, thefull premium must be paid by the annuitant directly to the planadministrator. Once the annuitant makes the selection, theProgram is no longer involved in the administration or premiumrate structure of these insurance products. Contact the lifeinsurance plan administrator for additional informationregarding conversion and portability options.

Life Insurance Coverage (cont.)

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Chapter 3Chapter 3: MiscellaneousSmoking Cessation Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Coordination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58Subrogation and Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Claim Filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Claim Appeal Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

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OverviewEligible plan participants are entitled to receive a rebatetowards the cost of a smoking cessation program. Themaximum rebate is $200, limited to one per plan year andavailable only upon completion of a smoking cessationprogram. Please note that many managed care plans offersmoking cessation programs separate from the Department'sSmoking Cessation Program. Members who utilize a smokingcessation program through their managed care plan are noteligible for a Smoking Cessation Program benefit through theDepartment. Contact the managed care plan for moreinformation regarding their smoking cessation programoptions and limitations.

EligibilityThe Smoking Cessation Program is available to all retirees,annuitants and survivors who are eligible for benefits underthe State Employees Group Insurance Program and theirenrolled dependents. Members who opt out or waive healthcoverage under the Program are not eligible for the SmokingCessation Program.

Ineligible for ReimbursementThe following therapies are not eligible for reimbursementunless they are an integral part of a smoking cessationprogram. F Hypnosis (even if an integral part, will not be reimbursed

unless performed by a medical doctor); F Acupuncture;F Prescription drug therapy;F Nonprescription drug therapy; F Aricular therapy.

Reimbursement Documentation RequirementsF Receipt indicating payment for a smoking cessation

program.F Program certificate verifying the number of sessions and

date of completion of a smoking cessation program.F Member’s name, address, agency name and agency

telephone number.

Submit Documentation to:Smoking Cessation ProgramCMS Group Insurance Division801 S. 7th StreetP.O. Box 19208Springfield, IL 62794-9208

For More InformationThe Department of Central Management Services(Department) is the administrator of the SmokingCessation Program. Questions regarding the SmokingCessation Program should be directed to the Departmentat 800-442-1300.

Smoking Cessation Program

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If a plan participant enrolled in the Program is entitled to primarybenefits under another group plan, the amount of benefitspayable under the Program may be reduced. The reduction maybe to the extent that the total payment provided by all plans doesnot exceed the total allowable expense incurred for the service.Allowable expense is defined as a medically necessary service forwhich part of the cost is eligible for payment by this plan oranother plan(s). Under coordination of benefits (COB) rules, the Department’splan first calculates what the benefit would have been for theclaim if there was no other plan involved. The Department’s planthen considers the amount paid by the primary plan and paysthe claim up to 100% of the allowable expense. NOTE: When a managed care health plan is thesecondary plan and the plan participant does not utilize themanaged care health plan’s network of providers or doesnot obtain the required referrals, the managed care healthplan is not required to pay. Refer to the managed careplan’s summary plan document for additionalinformation.

The State of Illinois coordinates benefits with the following:F Any group insurance plan. F Medicare.F Any Veterans’ Administration (VA) plan.F Any “no-fault” motor vehicle plan. This term means a

motor vehicle plan which is required by law and providesmedical or dental care payments which are made, in wholeor in part, without regard to fault. A person who has notcomplied with the law will be deemed to have received thebenefits required by the law.

The State of Illinois does not coordinate benefits with thefollowing:F Private individual insurance plans.F Any student insurance policy (elementary, high school

and college).F Medicaid or any other State-sponsored health insurance

program.F TRICARE. It is the member’s responsibility to provide other insuranceinformation (including Medicare) to the Department'sMedicare COB Unit. Any changes to other insurancecoverage must be reported promptly to the Department'sMedicare COB Unit (contact information located in theMedicare section).

Order of Benefit DeterminationThe Department’s medical and dental plans follow the NationalAssociation of Insurance Commissioners (NAIC) modelregulations. These regulations dictate the order of benefitdetermination, except for members who are eligible forMedicare due to End-Stage Renal Disease (ESRD). Refer to the‘Medicare’ section for details regarding coordination of benefitsfor plan participants eligible for Medicare. The rules below areapplied in sequence. If the first rule does not apply, thesequence is followed until the appropriate rule that applies isfound. Special rules apply for adult children and children ofcivil union partners. Contact the Department for moreinformation.

MemberThe plan that covers the plan participant as an active memberis primary:

1. over the plan that covers the plan participant as adependent.

2. over the plan that covers the plan participant as aretiree.

3. over the plan that covers the plan participant underCOBRA.

4. if it has been in effect the longest, back to the originaleffective date under the employer group, whether or notthe insurance company has changed over the course ofcoverage.

Dependent Children of Parents Not Separated orDivorcedThe following “Birthday Rule” is used if a child is covered bymore than one group plan. The plans must pay in thefollowing order:

1. The plan covering the parent whose birthday* falls earlierin the calendar year is the primary plan.

2. If both parents have the same birthday, the plan that hasprovided coverage longer is the primary plan.

* Birthday refers only to the month and day in a calendaryear, not the year in which the person was born.

NOTE: Some plans not covered by state law may follow theGender Rule for dependent children. This rule states that thefather’s coverage is the primary carrier. In the event of adisagreement between two plans, the Gender Rule applies.

Coordination of Benefits

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Dependent Children of Separated or DivorcedParentsIf a child is covered by more than one group plan and theparents are separated or divorced, the plans must pay in thefollowing order:

1. The plan of the parent with custody of the child; 2. The plan of the spouse of the parent with custody of the

child; 3. The plan of the parent not having custody of the child.

NOTE: If the terms of a court order state that one parent isresponsible for the healthcare expenses of the child and thehealth plan has been advised of the responsibility, that plan isprimary payer over the plan of the other parent.

Dependent Children of Parents with Joint CustodyThe Birthday Rule applies to dependent children of parentswith joint custody.

Coordination of Benefits (cont.)

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OverviewMedicare is a federal health insurance program for individualsage 65 and older, individuals under age 65 with certaindisabilities and individuals of any age with End-Stage RenalDisease (ESRD).

The Social Security Administration (SSA) or the RailroadRetirement Board (RRB)** determines Medicare eligibility uponapplication and enrolls eligible plan participants into theMedicare Program. The Medicare Program is administered bythe Centers for Medicare and Medicaid Services (also known asthe federal CMS).

Medicare has the following parts:F Part A is insurance that helps pay for inpatient hospital

facility charges, skilled nursing facility charges, hospicecare and some home healthcare services. Medicare Part Adoes not require a monthly premium contribution fromplan participants with enough earned work credits. Planparticipants without enough earned work credits have theoption to enroll in Medicare Part A and pay a monthlypremium contribution.

F Part B is insurance that helps pay for outpatient servicesincluding physician office visits, labs, x-rays and somemedical supplies. Medicare Part B requires a monthlypremium contribution.

F Part C (also known as Medicare Advantage) is insurance thathelps pay for a combination of the coverage provided inMedicare Parts A, B and sometimes D. An individual mustalready be enrolled in Medicare Parts A and B in order toenroll in a Medicare Part C plan. Medicare Part C requires amonthly premium contribution.

F Part D is insurance that helps pay for prescription drugs.Generally, Medicare Part D requires a monthly premiumcontribution.

Medicare Due to AgePlan Participants Age 65 and olderThe State Employees Group Insurance Programrequires all plan participants to contact the SSA andapply for Medicare benefits three months prior toturning age 65.

Medicare Part AEligibility for premium-free Medicare Part A occurs when anindividual is age 65 or older and has earned at least 40 workcredits from paying into Medicare through Social Security. Anindividual who is not eligible for premium-free Medicare PartA benefits based on his/her own work credits may qualify forpremium-free Medicare Part A benefits based on the workhistory of a current, former or deceased spouse. All planparticipants that are determined to be ineligible for MedicarePart A based on their own work history are required to applyfor premium-free Medicare Part A on the basis of a spouse(when applicable).

If the SSA determines that a plan participant is eligible forpremium-free Medicare Part A, the State Employees GroupInsurance Program requires that the plan participant acceptthe Medicare Part A coverage and submit a copy of theMedicare identification card to the Department's MedicareCOB Unit upon receipt.

If the SSA determines that a plan participant is not eligible forMedicare Part A benefits at a premium-free rate, the StateEmployees Group Insurance Program does not require theplan participant to purchase Medicare Part A coverage;however, the State does require the plan participant toprovide a written statement from the SSA advising of his/herMedicare Part A ineligibility. The plan participant is requiredto submit a copy of the SSA statement to the Department'sMedicare COB Unit.

Medicare Part B Most plan participants are eligible for Medicare Part B uponturning the age of 65.

Medicare

In order to apply for Medicare benefits, plan participants should contact the local Social SecurityAdministration (SSA) office or call the SSA at 800-772-1213. Plan participants may enroll in Medicareon the SSA website at ssa.gov/Medicare.** Railroad Retirement Board (RRB) participants should contact their local RRB office or call theRRB at 877-772-5772 to apply for Medicare.

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The State Employees Group Insurance Program requiresplan participants to enroll in Medicare Part B if they areeligible for Medicare Part A benefits at a premium-free rate.Refer to the 'Failure to Enroll in Medicare' section for moreinformation.

Medicare Due to DisabilityPlan Participants Age 64 and UnderPlan participants are automatically eligible forMedicare (Parts A and B) disability insurance afterreceiving Social Security disability payments for aperiod of 24 months.

Medicare Part A

Plan participants who become eligible for Medicare disabilitybenefits are required to accept the Medicare Part A coverageand submit a copy of the Medicare identification card to theDepartment's Medicare COB Unit upon receipt.

Medicare Part B

Plan participants who become eligible for Medicare disabilitybenefits are required to accept the Medicare Part B coverage.Refer to the 'Failure to Enroll in Medicare' section for moreinformation.

Medicare Due to End-Stage RenalDisease (ESRD)All State Employees Group Insurance Program planparticipants who are receiving regular dialysis treatments orwho have had a kidney transplant on the basis of ESRD arerequired to apply for Medicare benefits.

Plan participants must contact the Department's MedicareCoordination of Benefits (COB) Unit at 800-442-1300. TheDepartment's Medicare COB Unit calculates the 30-monthcoordination period in order for plan participants to sign upfor Medicare benefits on time to avoid additional out-of-pocket expenditures.

Medicare Part A

Plan participants who become eligible for Medicare benefitson the basis of ESRD are required to accept the Medicare Part A

coverage and submit a copy of the Medicare identification cardto the Department's Medicare COB Unit upon receipt.

Medicare Part B

The State Employees Group Insurance Program requiresplan participants to enroll in Medicare Part B if they areeligible for Medicare Part A benefits at a premium-free rate.Plan participants who become eligible for Medicare on thebasis of ESRD are required to accept the Medicare Part Bcoverage when Medicare is determined to be the primarypayer. Refer to the 'Failure to Enroll in Medicare' section formore information.

Medicare Coordination with theQuality Care Health Plan (QCHP)When Medicare is the primary payer, QCHP will coordinatebenefits with Medicare as follows:

Medicare Part A - Hospital Insurance

In-Network Provider: After Medicare Part A pays, QCHP pays85% of the Medicare Part A deductible after the QCHP annualplan deductible has been met.

Out-of-Network Provider: After Medicare Part A pays, QCHPpays 60% of the Medicare Part A deductible after the QCHPannual plan deductible has been met.

Medicare Part B - Medical Insurance

In-Network Provider: After Medicare Part B pays, QCHP pays85% of the balance after the QCHP annual plan deductiblehas been met.

Out-of-Network Provider: After Medicare Part B pays, QCHPpays 60% of the balance after the QCHP annual plandeductible has been met.

Failure to Enroll in Medicare(Medicare Parts A and B Reduction)Plan participants who do not enroll in Medicare Parts A andB, are responsible for the portion of your healthcare coststhat Medicare would have covered. Failure to enroll orremain enrolled in Medicare when Medicare is determined

Medicare (cont.)

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to be the primary payer will result in a reduction of eligiblebenefit payments.

Services and Supplies Not Coveredby MedicareServices and supplies that are not covered by Medicare will bepaid in the same manner (i.e., same benefit levels anddeductibles) as if the plan participant did not have Medicare(provided the services and supplies meet medical necessityand benefit criteria and would normally be eligible forcoverage).

Medicare Crossover –QCHP MembersMedicare Crossover is an electronic transmittal of claim datafrom Medicare (after Medicare has processed their portion ofthe claim) to the QCHP plan administrator for secondarybenefit determination.

In order to set up Medicare Crossover, plan participants mustcontact the QCHP plan administrator and provide theMedicare Health Insurance Claim Number (HICN) located onthe front side of the Medicare identification card.

Private Contracts with Providerswho Opt Out of MedicareSome healthcare providers choose to opt out of the Medicareprogram. When a plan participant has medical servicesrendered by a provider who has opted out of the Medicareprogram, a private contract is usually signed explaining that theplan participant is responsible for the cost of the medicalservices rendered. Neither providers nor plan participants areallowed to bill Medicare. Therefore, Medicare will not pay for theservice (even if it would normally qualify as being Medicareeligible) or provide a Medicare Summary Notice to the planparticipant. If the service(s) would have normally been coveredby Medicare, the plan administrator will estimate the portion ofthe claim that Medicare would have paid. The planadministrator will then subtract that amount from the totalcharge and adjudicate the claim for any eligible secondaryreimbursement. The difference between the total charge andthe eligible reimbursement amount is the plan participant'sresponsibility.

Medicare (cont.)

Medicare COB Unit Contact InformationDepartment of Central Management ServicesMedicare Coordination of Benefits Unit801 S. 7th Street, P.O. Box 19208Springfield, Illinois 62794-9208Phone: 800-442-1300 or 217-782-7007Fax: 217-557-3973

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Subrogation and Reimbursement OverviewDepartment plans will not pay for expenses incurred forinjuries received as the result of an accident or incident forwhich a third party is liable. These plans also do not providebenefits to the extent that there is other coverage undernongroup medical payments (including automobile liability)or medical expense type coverage to the extent of thatcoverage. However, the plans will provide benefits otherwise payableunder one of these plans, to or on behalf of its coveredpersons, but only on the following terms and conditions:F In the event of any payment under one of these plans, the

plan shall be subrogated to all of the covered person’s rightsof recovery against any person or entity. The coveredperson shall execute and deliver instruments anddocuments and do whatever else is necessary to securesuch rights. The covered person shall do nothing after lossto prejudice such rights. The covered person shallcooperate with the plan and/or any representatives of theplan in completing such documents and in providing suchinformation relating to any accident as the plan by itsrepresentatives may deem necessary to fully investigatethe incident. The plan reserves the right to withhold ordelay payment of any benefits otherwise payable until allexecuted documents required by this provision have beenreceived from the covered person.

F The plan is also granted a right of reimbursement fromthe proceeds of any settlement, judgment or otherpayment obtained by or on behalf of the covered person.This right of reimbursement is cumulative with and notexclusive of the subrogation right granted in the precedingparagraph, but only to the extent of the benefits paid bythe plan.

F The plan, by payment of any proceeds to a coveredperson, is thereby granted a lien on the proceeds of anysettlement, judgment or other payment intended for,payable to or received by or on behalf of the coveredperson or a representative. The covered person inconsideration for such payment of proceeds, consents tosaid lien and shall take whatever steps are necessary tohelp the plan secure said lien.

F The subrogation and reimbursement rights and liensapply to any recoveries made by or on behalf of thecovered person as a result of the injuries sustained,including but not limited to the following:

• Payments made directly by a third party tortfeasoror any insurance company on behalf of a thirdparty tortfeasor or any other payments on behalf ofa third party tortfeasor.

• Any payments or settlements or judgments orarbitration awards paid by any insurance companyunder an uninsured or underinsured motoristcoverage, whether on behalf of a covered personor other person.

• Any other payments from any source designed orintended to compensate a covered person forinjuries sustained as the result of negligence oralleged negligence of a third party.

• Any Workers’ Compensation award or settlement.F The parents of any minor covered person understand and

agree that the State’s plan does not pay for expensesincurred for injuries received as a result of an accident orincident for which a third party is liable. Any benefits paidon behalf of a minor covered person are conditional uponthe plan’s express right of reimbursement. No adultcovered person hereunder may assign any rights that suchperson may have to recover medical expenses from anytortfeasor or other person or entity to any minor child orchildren of the adult covered person without the expressprior written consent of the plan. In the event any minorcovered child is injured as a result of the acts or omissionsof any third party, the adult covered persons/parentsagree to promptly notify the plan of the existence of anyclaim on behalf of the minor child against the third partytortfeasor responsible for the injuries. Further, the adultcovered persons/parents agree, prior to thecommencement of any claim against the third partytortfeasors responsible for the injuries to the minor child,to either assign any right to collect medical expenses fromany tortfeasor or other person or entity to the plan, or attheir election, to prosecute a claim for medical expenseson behalf of the plan.

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Subrogation and Reimbursement (cont.)In default of any obligation hereunder by the adult coveredpersons/parents, the plan is entitled to recover the conditionalbenefits advanced plus costs (including reasonable attorneys’fees), from the adult covered persons/parents.F No covered person shall make any settlement which

specifically excludes or attempts to exclude the benefitspaid by the plan.

F The plan’s right of recovery shall be a prior lien againstany proceeds recovered by a covered person, which rightshall not be defeated nor reduced by the application of anyso-called “Made-Whole Doctrine,” “Rimes Doctrine” or anyother such doctrine purporting to defeat the plan’srecovery rights by allocating the proceeds exclusively tononmedical expense damages.

F No covered person under the plan shall incur anyexpenses on behalf of the plan in pursuit of the plan’srights to subrogation or reimbursement, specifically, nocourt costs nor attorneys’ fees may be deducted from theplan’s recovery without the prior express written consentof the plan. This right shall not be defeated by any so-called “Fund Doctrine,” “Common Fund Doctrine” or“Attorney’s Fund Doctrine.”

F The plan shall recover the full amount of benefits paidhereunder without regard to any claim of fault on the partof any covered person, whether under comparativenegligence or otherwise.

F The benefits under this plan are secondary to anycoverage under no-fault, medical payments or similarinsurance.

F This subrogation and reimbursement provision shall begoverned by the laws of the State of Illinois.

F In the event that a covered person shall fail or refuse tohonor its obligations hereunder, the plan shall have aright to suspend the covered person’s eligibility and beentitled to offset the reimbursement obligation againstany entitlement for future medical benefits, regardless ofhow those medical benefits are incurred. The suspensionand offset shall continue until such time as the coveredperson has fully complied with his obligations hereunder.

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In general, most dental, medical and behavioral healthproviders file claims for reimbursement with the insurancecarrier. Out-of-network vision claims and pharmacy expensestypically must be filed by the member. In situations where aclaim is not filed by the provider, the member must file theclaim within a specific period of time. All claims should be filed promptly. Claim forms areavailable on the plan administrators’ website and on theMyBenefits.illinois.gov website. F In-network QCHP medical and behavioral health claims

must be filed within 90 days from the date in which thecharge was incurred.

F Out-of-network QCHP medical and behavioral healthclaims must be filed within 180 days from the date inwhich the charge was incurred.

F Out-of-network dental claims must be filed no later thanone-year from the ending date of the plan year in whichthe charge was incurred.

F Out-of-network pharmacy claims for the open accessplans (OAPs) and QCHP must be filed no later than one-year from the ending date of the plan year in which thecharge was incurred.

F Out-of-network vision claims are required to be filed nolater than 180 days (6 months) from the date of service inorder to be considered for reimbursement.

Filing deadlines for managed care plans, including behavioralhealth services offered under the managed care plan, may bedifferent. Contact the managed care plan directly fordeadlines and procedures.

Claim Filing ProceduresAll communication to the plan administrators must include theretiree, annuitant or survivor's social security number (SSN)and appropriate group number as listed on the identificationcard. This information must be included on every page ofcorrespondence.F Complete the claim form obtained from the appropriate

plan administrator.F Attach the itemized bill from the provider of services to

the claim form. The itemized bill must include name ofpatient, date of service, diagnosis, procedure code and theprovider’s name, address and telephone number.

F If the person for whom the claim is being submitted hasprimary coverage under another group plan or Medicare,the explanation of benefits (EOB) or the MedicareSummary Notice (MSN) from the other plan must also beattached to the claim.

F The plan administrator may communicate directly withthe plan participant or the provider of services regardingany additional information that may be needed to process aclaim.

F The benefit check will be sent and made payable to themember (not to any dependents), unless otherwiseindicated by law, or benefits have been assigned directlyto the provider of service.

F If benefits are assigned, the benefit check will be madepayable to the provider of service and mailed directly tothe provider. An EOB is sent to the plan participant toverify the benefit determination.

F QCHP claims are adjudicated using industry standardclaim processing software and criteria. Claims arereviewed for possible bundling and unbundling of servicesand charges.

Claim Filing

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Under the State Employees Group Insurance Program(Program) there are formal procedures to follow in order tofile an appeal of an adverse benefit determination. Theappropriate plan administrator will provide moreinformation regarding the plan administrator’s internalappeal process.

Categories of AppealThere are two separate categories of appeals: medical andadministrative. The plan administrator determines thecategory of appeal and will send the plan participant writtennotification regarding the category of appeal, the planparticipant’s appeal rights and information regarding how toinitiate an appeal from the plan administrator.F Medical Appeals. Medical appeals pertain to benefit

determinations involving medical judgment, includingclaim denials determined by the plan administrator to bebased on lack of medical necessity, appropriateness,healthcare setting, level of care or effectiveness; denialspursuant to Section 6.4 of the State Employees GroupInsurance Act; and denials for services determined by theplan administrator to be experimental or investigational.Medical appeals also pertain to retroactive cancellations ordiscontinuations of coverage, unless the cancellation ordiscontinuation relates to a failure to pay requiredpremiums or contributions.

F Administrative Appeals. Administrative appeals pertainto benefit determinations based on plan design and/orcontractual or legal interpretations of plan terms that donot involve any use of medical judgment.

Quality Care Health Plan (QCHP)and Open Access Managed CarePlans Appeal ProcessMembers enrolled in either the QCHP or one of the openaccess managed care plans may utilize an internal appealprocess which may be followed by an external review, ifneeded. For urgent care situations, the plan participant maybypass the internal appeal process and request an expeditedexternal review (see “Expedited External Review- MedicalAppeals Only” for urgent care situations in the box).

Expedited External Review - Medical Appeals OnlyFor medical appeals involving urgent care situations, theplan participant may make a written or oral request forexpedited external review after the plan administratormakes an adverse benefit determination, even if the planadministrator’s internal appeal process has not beenexhausted. The external reviewer will review the request todetermine whether it qualifies for expedited review. If theexternal reviewer determines that the request qualifies forexpedited review, the external reviewer will provide a finalexternal review decision within 72 hours after the receipt ofthe request. If the external reviewer decides in favor of theplan participant, the decision shall be final and binding onthe plan administrator.

Step 1: Internal Appeal Process

The internal appeal process is available through the healthplan administrator. The plan administrator’s internal appealprocess must be followed before the plan participant mayseek an external review, except for urgent care situations. Forurgent care situations, the plan participant may request anexpedited external review (see “Expedited External Review-Medical Appeals Only” for urgent care situations).

First-Level Internal Appeals

First-level appeals must be initiated with the planadministrator within 180 days of the date of receipt of theinitial adverse benefit determination. All appeals will bereviewed and decided by an individual(s) who was notinvolved in the initial claim decision. Each case will bereviewed and considered on its own merits. If the appealinvolves a medical judgment, it will be reviewed andconsidered by a qualified healthcare professional. In somecases, additional information, such as test results, may berequired to determine if additional benefits are available.Once all required information has been received by the planadministrator, the plan administrator shall provide a decisionwithin the applicable time frame: 15 days for pre-serviceauthorizations, 30 days for post-service claims, or 72 hours forurgent care claims.

Claim Appeal Process

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Step 2: External Review Process

After the completion of the plan administrator’s internalappeal process, the plan participant may request an externalreview of the plan administrator’s final internal benefitdetermination. The process for external review will dependon whether the appeal is an administrative appeal or medicalappeal.

Administrative Appeals

For administrative appeals, if, after exhausting every level ofreview available through the plan administrator, the planparticipant still feels that the final benefit determination bythe plan administrator is not consistent with the publishedbenefit coverage, the plan participant may appeal the planadministrator’s decision to CMS’ Group Insurance Division.For an appeal to be considered by CMS’ Group InsuranceDivision, the plan participant must appeal in writing withinsixty (60) days of the date of receipt of the planadministrator’s final internal adverse benefit determination.All appeals must be accompanied by all documentationsupporting the request for reconsideration.

Submit Administrative Appeal Documentation to:CMS Group Insurance Division801 S. 7th StreetP.O. Box 19208Springfield, IL 62794-9208

The decision of CMS’ Group Insurance Division shall be finaland binding on all parties.

Medical AppealsExternal Review

For medical appeals, if, after exhausting every level of reviewavailable through the plan administrator, the plan participantstill feels that the final benefit determination is not consistentwith the published benefit coverage, the plan participant mayrequest an independent external review of the planadministrator’s decision. A request for an external reviewmust be filed in writing within four (4) months of the date ofreceipt of the plan administrator’s final internal adversebenefit determination. The plan administrator will providemore information regarding how to file a request for externalreview. The plan participant will be given the opportunity tosubmit additional written comments and supporting medicaldocumentation regarding the claim to the external reviewer.

The external reviewer will provide a final external reviewdecision within 45 days of the receipt of the request. If theexternal reviewer decides in favor of the plan participant, thedecision shall be final and binding.

Claim Appeal Process (cont.)

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Appeal Process for Fully-InsuredManaged Care Health PlansThe Department of Central Management Services (CMS)does not have the authority to review or process fully-insured managed care health plan appeals. Fully-insuredmanaged care health plans must comply with the ManagedCare Reform and Patient Rights Act. In order to file a formalappeal, refer to the process outlined in the managed carehealth plan’s summary plan document (SPD) or certificate ofcoverage. Specific timetables and procedures apply. Planparticipants may call the customer service number listed ontheir identification card to request a copy of suchdocuments.

Assistance with the Appeal Process For questions regarding appeal rights and/orassistance with the appeal process, a plan participantmay contact the Employee Benefits SecurityAdministration at 866-444-EBSA (3272). A consumerassistance program may also be able to assist the planparticipant. Requests for assistance from theconsumer assistance program should be sent to:

Office of Consumer Health InsuranceConsumer Services Section122 S. Michigan Ave., 19th FLChicago, IL 60603insurance.illinois.gov877-527-9431Email: [email protected]

or

Illinois Department of Insurance320 W. Washington St, 4th FloorSpringfield, IL 62727

Claim Appeal Process (cont.)

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Chapter 4Chapter 4: ReferenceGlossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

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Additional Deductible: Deductibles that are in addition tothe annual plan deductible.

Admission: Entry as an inpatient to an accredited facility,such as a hospital or skilled care facility, or entry to astructured outpatient, intensive outpatient or partialhospitalization program.

Adverse Claim Determination: A denial, reduction,termination of or failure to pay for a benefit, whether in wholeor in part. Adverse claim determinations include rescissionsof coverage.

Allowable Charges: The maximum amount the plan willpay an out-of-network healthcare professional for billedservices.

Allowable Expense: A medically necessary service for whichpart of the cost is eligible for payment by this plan or anotherplan(s).

Annuitant: A member who began receiving an annuity on orafter January 1, 1966.

Authorization: The result of a review that approves treatment asmeeting medical necessity criteria and appropriateness ofcare.

Benefit: The amount payable for services obtained by planparticipants and dependents.

Benefit Choice Period: A designated period when membersmay change benefit coverage elections, ordinarily held May 1through May 31.

Certificate of Coverage: A document containing a descriptionof benefits provided by licensed insurance plans. Also knownas a summary plan document (SPD).

Civil Union: Civil union means a legal relationship betweentwo persons, of either the same or opposite sex, establishedpursuant to the Illinois Religious Freedom Protection and CivilUnion Act.

Civil Union Partner: A party to a civil union.

Claim: A paper or electronic billing. This billing must include fulldetails of the service received, including name, age, sex,

identification number, the name and address of the provider, anitemized statement of the service rendered or furnished, the dateof service, the diagnosis and any other information which a planmay request in connection with services rendered.

Claim Payment: The benefit payment calculated by a plan,after submission of a claim, in accordance with the benefitsdescribed in this handbook.

Coinsurance: The percentage of the charges for eligibleservices for which the plan participant is responsible after anyapplicable deductible has been met.

Coordination of Benefits: A method of integrating benefitspayable under more than one group insurance plan.

Copayment: A specific dollar amount the plan participant isrequired to pay for certain services covered by a plan.

Covered Services: Services that are eligible for benefitsunder a plan.

Creditable Coverage: The amount of time a plan participanthad continuous coverage under a previous health plan.

Custodial Care: Room and board or other institutional ornursing services which are provided for a patient due to age ormental or physical condition mainly to aid in daily living; or,medical services which are given merely as care to maintainpresent state of health and which cannot be expected to improvea medical condition.

Deductible: The amount of eligible charges plan participantsmust pay before insurance payments begin.

Deferred Annuitant: Person who began receiving anannuity one year or more after terminatiing Stateemployment.

Department: The Department of Central ManagementServices, also referred to as CMS.

Dependent: A member’s spouse, civil union partner, child orother person as defined by the State Employees GroupInsurance Act of 1971, as amended (5 ILCS 375/1 et seq.). Forpurposes of the health plan only, the term dependent alsoincludes a domestic partner.

Glossary

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Diagnostic Service: Tests performed to diagnose a condition dueto symptoms or to determine the progress of an illness or injury.Examples of these types of tests are x-rays, pathology services,clinical laboratory tests, pulmonary function studies,electrocardiograms (ECG), electroencephalograms (EEG),radioisotope tests and electromyograms.

Domestic Partner: An unrelated, same-sex individual, age 19or older, who resides in the same household and has afinancial and emotional interdependence consistent with thatof a married couple for a period of not less than one year.

Eligible Charges: Charges for covered services and supplieswhich are medically necessary and based on charges asdetermined by a plan administrator.

Emergency Services: Services provided to alleviate severepain or for immediate diagnosis and/or treatment ofconditions or injuries such that in the opinion of the prudentlayperson might result in permanent disability or death if nottreated immediately.

Evidence of Insurability: Documentation that an individual’shealth condition is satisfactory for coverage. May requireproof of age or a statement of health status from thephysician. Evidence of insurability is generally required toadd Spouse Life insurance and to increase Member OptionalLife insurance.

Exclusions and Limitations: Services not covered under theState Employees Group Insurance Program, or services thatare provided only with certain qualifications, conditions orlimits.

Experimental: Medical services or supplies in which newtreatments or products are tested for safety and effect onhumans.

Explanation of Benefits (EOB): A statement from a planadministrator explaining benefit determination for servicesrendered.

Final Internal Determination: The final benefitdetermination made by a plan administrator after a planparticipant has exhausted all appeals available through theplan administrator’s formal internal appeals process.

Fiscal Year (FY): Begins on July 1 and ends on June 30.

Formulary (Prescription Drugs): A list of drugs and ancillarysupplies approved by the prescription drug planadministrator for inclusion in the prescription drug plan. Theformulary list is subject to change.

Fully Insured: All claims and costs are paid by the insurancecompany.

Generic Drug: Therapeutic equivalent of a brand name drugand must be approved by the U.S. Food and DrugAdministration for safety and effectiveness.

Group Insurance Representative (GIR): An individual whoprovides information and/or materials and processesenrollment changes related to benefits. Hospice: A program of palliative and supportive services forterminally ill patients that must be approved by a planadministrator as meeting standards including any legallicensing requirements. Hospital: A legally constituted and licensed institutionhaving on the premises organized facilities (includingorganized diagnostic and surgical facilities) for the care andtreatment of sick and injured persons by or under thesupervision of a staff of physicians and registered nurses onduty or on call at all times. Identification Card: Document identifying eligibility forbenefits under a plan.

Immediate Annuitant: Person who began receiving anannuity within one year of terminatiing State employment.Independent External Review: An external review,conducted by an independent third party of a planadministrator’s adverse claim determination or final internaldetermination. Initial Enrollment Period: The 60-day period beginning withthe benefit begin date. Injury: Damage inflicted to the body by external force. Inpatient Services: A hospital stay of 24 or more hours. Intensive Outpatient Program (Behavioral HealthServices): Services offered to address treatment of mentalhealth or substance abuse and could include individual,group or family psychotherapy and adjunctive services suchas medical monitoring.

Glossary (cont.)

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Investigational: Procedures, drugs, devices, services and/orsupplies which (a) are provided or performed in specialsettings for research purposes or under a controlledenvironment and which are being studied for safety, efficiencyand effectiveness, and/or (b) are awaiting endorsement by theappropriate National Medical Specialty College or FederalGovernment agency for general use by the medicalcommunity at the time they are rendered to a covered person,and (c) with respect to drugs, combination of drugs and/ordevices, which have not received final approval by the Foodand Drug Administration at the time used or administered tothe covered person.

Itemized Bill: A form submitted for claim purposes; musthave the name of the patient, description, diagnosis, date andcost of services provided.

Medical Documentation: Additional medical informationrequired to substantiate the necessity of proceduresperformed. This could include daily nursing and doctor notes,additional x-rays, treatment plans, operative reports, etc.

Medicare: A federally operated insurance program providingbenefits for eligible persons.

Medicare Summary Notice (MSN): A quarterly statementfrom Medicare explaining benefit determination for servicesrendered.

Member: Employee, annuitant, retired employee, survivor orCOBRA participant.

MyBenefits Service Center (MBSC): The MyBenefits ServiceCenter (MBSC) is a custom benefits solution service providerfor the Department. The MBSC will manage the detailedenrollment process of member benefits through onlinetechnical support via the MyBenefits.illinois.gov website andtelephonic support via the MyBenefits Service Center 844-251-1777. The MBSC is now the member's primary contactfor answering questions you may have about your eligibilityfor coverage and to assist you in enrolling or changing thebenefits you have selected.

Non-IRS: Any dependent who is not considered aqualifying child or a qualifying relative, as defined by theIRS, and cannot be claimed as a dependent for income taxpurposes.

Nonpreferred Brand Drug: Prescription drugs available at

the highest copayment. Many high cost specialty drugs fallunder the nonpreferred drug category.

Out-of-Pocket Maximum: The maximum dollar amount paidout of pocket for covered expenses in any given plan year.After the out-of-pocket maximum has been met the planbegins paying at the 100% of allowable charges for eligiblecovered expenses.

Outpatient Services (Behavioral Health Services): Carerendered for the treatment of mental health or substanceabuse when not confined to an inpatient hospital setting.

Outpatient Services (Medical/Surgical): Services provided in ahospital emergency room or outpatient clinic, at anambulatory surgical center or in a doctor’s office.

Partial Hospitalization (Behavioral Health Services): Servicesoffered to address treatment of mental health or substanceabuse and could include individual, group or familypsychotherapy. Services are medically supervised andessentially the same intensity as would be provided in ahospital setting except that the patient is in the program lessthan 24 hours per day.

Physician/Doctor: A person licensed to practice under theIllinois Medical Practice Act or under similar laws of Illinois orother states or countries; a Christian Science Practitioner listedin the Christian Science Journal at the time the medicalservices are provided.

Plan: A specifically designed program of benefits.

Plan Administrator: An organization, company or other entitycontracted to review and approve benefit payments, payclaims, and perform other duties related to the administrationof a specific plan.

Plan Participant: An eligible person enrolled and participating inthe Program.

Plan Year: July 1 through the following June 30.

Preferred Brand Drug: A list of drugs, biologicals and devicesapproved by the pharmacy benefit manager for inclusion in theprescription drug plan. These drugs are proven to be bothclinically and cost effective. The preferred brand drug list issubject to change.

Glossary (cont.)

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Prescription Drugs: Medications which are lawfully obtainedwith a prescription from a physician/doctor or dentist. Pretreatment Estimate (Dental): A provider’s statement,including diagnostic x-rays and laboratory reports describingplanned treatment and expected charges which is reviewed bythe dental plan administrator for verification of eligible benefits. Preventive Service: Routine services which do not require adiagnosis or treatment of an illness or injury. Primary Care Physician/Primary Care Provider (PCP): Thephysician or other medical provider a plan participant selectsunder a managed care plan to manage all healthcare needs. Professional Services: Eligible services provided by alicensed medical professional, including but not limited to aphysician, radiologist, anesthesiologist, surgeon, physicaltherapist, etc. Program: The State Employees Group Insurance Program asdefined by the State Employees Group Insurance Act of 1971,as amended (5 ILCS 375/1 et seq.). Provider: Any organization or individual which providesservices or supplies to plan participants. This may includesuch entities as hospitals, pharmacies, physicians, laboratories orhome health companies. Quality Care Health Plan (QCHP) Hospital: A hospital orfacility with which the Quality Care Health Plan plan hasnegotiated favorable rates. Qualified Beneficiary: A qualified beneficiary is an individual(including member, spouse, civil union partner, domesticpartner and child) who loses employer-provided group healthcoverage and is entitled to elect COBRA coverage. Theindividual must have been covered by the plan on the daybefore the qualifying event occurred and enrolled in COBRAeffective the first day of eligibility or be a newborn or newlyadopted child of the covered member. Retiree: A member who retired before January 1, 1966, andbegan to receive an annuity.Schedule of Benefits: A listing of specific services covered bythe Quality Care Dental Plan and the vision plan. Second Opinion: An opinion rendered by a second physicianprior to the performance of certain nonemergency, electivesurgical procedures or medical treatments.

Self Insured: All claims and costs are paid by the State ofIllinois. Self-Service Tools: Using the Self-Service tools online allowsthe member to create a life event (such as getting married,adding a child etc) online as the electronic version ofsubmitting a paper form to the Department. Skilled Nursing Service: Noncustodial professional servicesprovided by a registered nurse (RN) or licensed practical nurse(LPN) which require the technical skills and professionaltraining of such a licensed professional acting within thescope of their licensure. Spouse: A person who is legally married to the member asdefined under Illinois law and pursuant to the InternalRevenue Service Code.Spouse Life: Term life insurance coverage that covers themember's spouse or civil union partner, but does not cover adomestic partner.State Employees Group Insurance Act: The statutoryauthority for benefits offered by the Department (5 ILCS 375/1et seq.). Statement of Health: A form which a plan participantcompletes and submits to the life insurance plan administratorto have a determination made of health status for lifeinsurance coverage. Survivor: Spouse, civil union partner, dependent child(ren) ordependent parent(s) of a deceased member as determined bythe appropriate state retirement system.Surgery: The performance of any medically recognized,noninvestigational surgical procedure including specializedinstrumentation and the correction of fractures or completedislocations and any other procedures as reasonablyapproved by a plan.Urgent Care Claim: Any claim for medical care or treatmentwith respect to the application of the time periods for makingnonurgent care determinations could: 1) seriously jeopardizethe life or health of the claimant or the ability of the claimantto regain maximum function; or 2) in the opinion of thephysician with knowledge of the claimant's medicalcondition, would subject the claimant to severe pain thatcannot be adequately managed without the care or treatmentthat is the subject of the claim.

Glossary (cont.)

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72Retiree Benefits Handbook MyBenefits.illinois.gov

– A –Annual Benefit Choice Period .................................11

– B –Behavioral Health Coverage ...................................47

– C –Certification of Dependent Coverage........................8Claim Appeal Process..............................................64Claim Filing.............................................................63COBRA.....................................................................22Contributions..........................................................18Continuing Optional Life Coverage

upon Turning 60.................................................53Conversion Privilege Health Coverage ...................24Coordination of Benefits.........................................56

– D –Dependent Coverage..............................................12Dental Coverage .....................................................48Dental Exclusions....................................................50Direct Billing ...........................................................19Documentation Requirements

Adding Dependent Coverage .............................15Terminating Dependent Coverage .....................16

Documentation Time Limits....................................16

– E –Eligibility

Eligible Categories................................................7Eligible as Dependents.........................................8

Enrolling Dependents.............................................12Enrollment Periods .................................................10

– F –Formulary................................................................44

– G-H –Group Insurance Division..........................................2Group Insurance Representative...............................2Health Maintenance Organizations (HMOs)...........29Health Plan Options................................................28HIPAA ........................................................................3Hospital Bill Audit Program ....................................33

– I –ID Cards.....................................................................3Initial Enrollment....................................................10

– J-K-L –Life Insurance Coverage..........................................52

– M –Mail Order Pharmacy..............................................46Maintenance Medication........................................46Maintenance Pharmacy Network............................46Managed Care Health Plans ...................................28Medicare.................................................................58MyBenefits Service Center (MBSC) ...........................2

– N –Nonmaintenance Medication.................................45Nonpayment of Premium.......................................20

– O –Open Access Plan....................................................29Opt Out ...................................................................17Orthodontic Services (child)....................................49Other Allowable Mid-year Changes ........................12

Index

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73 Retiree Benefits HandbookMyBenefits.illinois.gov

– P –Porting Life Coverage..............................................53Premium Payment ..................................................18Premium Refunds...................................................20Premium Underpayment........................................20Prescription Coverage.............................................44Prescription Drug Step Therapy ..............................44Pretreatment Estimate (Dental) ..............................49Prior Authorization (Prescription Drugs) .................44Prosthodontics ........................................................48

– Q –Qualifying Change in Status ...................................11Qualifying Change in Status Chart .........................13Quality Care Dental Plan.........................................48Quality Care Health Plan.........................................30

Additional Deductibles .......................................30Allowable Charges..............................................31Coinsurance........................................................30Emergency Admission ........................................32Exclusions and Limitations .................................42Medical Benefit Summary..................................34Medical Case Management................................31Medical Necessity...............................................31Notification Requirements .................................32Out-of-Pocket Maximum.....................................30Plan Year Deductible ..........................................30Predetermination of Benefits .............................31QCHP Network....................................................31Transplant Notification........................................32

– R-S –Reciprocal Service Credit ........................................18Self-Service Tools.......................................................4Smoking Cessation Program ..................................55Subrogation and Reimbursement ..........................61

– T –Termination of Dependent Coverage..................... 21Termination of Retiree, Annuitant

and Survivor Coverage .......................................21Termination of Coverage under COBRA..................24

– U-V –Vision Coverage ......................................................51

– W –Waiving Coverage...................................................17

– X-Y-Z –

Index (cont.)

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The State of Illinois intends that the terms of this plan are legally enforceable and that the plan is maintained for the exclusivebenefit of Members. The State reserves the right to change any of the benefits, program requirements and contributionsdescribed in this Handbook. Changes will be communicated through addenda as needed the MyBenefits.illinois.gov websiteand the annual Benefit Choice Options Booklet. If there is a discrepancy between this Handbook or any other Departmentpublications, and state or federal law, the law will control.

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Printed by the Authority of the State of Illinois. 9/16 IOCI 17-167


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