State Employees Group Insurance Program

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STATE OF ILLINOISDepartment of Central Management ServicesBureau of BenefitsFY 2023State Employees GroupInsurance ProgramBenefit Choice Period May 1 - May 31, 2022Effective July 1, 2022

Table of ContentsBenefit Choice PeriodWhat is Available in Your Area . . . . . 1Monthly Contributions . . . . . . . . . . . 2Dependent Monthly Contributions . 2Adding a Dependent . . . . . . . . . . . . . 3Opt-Out . . . . . . . . . . . . . . . . . . . . . . . 3Transition of Care after . . . . . . . . . . . 3Medicare Requirements . . . . . . . . 3Health PlansHMO Benefits . . . . . . . . . . . . . . . . . . 4Open Access Plan (OAP) Benefits . . 5Quality Care Health Plan(QCHP) Benefits . . . . . . . . . . . . . . . 6Consumer Driven Health Plan(CDHP) Benefits . . . . . . . . . . . . . . . 7Health Savings Accounts (HSA) andFlexible Spending Accounts (FSA)MCAP . . . . . . . . . . . . . . . . . . . . . . . . . 8DCAP . . . . . . . . . . . . . . . . . . . . . . . . . 8HSA . . . . . . . . . . . . . . . . . . . . . . . . . . 8Vision . . . . . . . . . . . . . . . . . . . . . . . . . 9Dental . . . . . . . . . . . . . . . . . . . . . . . . . 9Life . . . . . . . . . . . . . . . . . . . . . . . . . . 10Contacts . . . . . . . . . . . . . . . . . . . . . . 11Federally Required Notices . . . . . . . 12ONLINE ENROLLMENT PLATFORMMaking benefit elections is simple through the MyBenefits website.Follow these steps:1. Go to MyBenefits.illinois.gov.2. In the top right corner of the home page, click Login.3. If you are logging in for the first time, click Register in the bottomright corner of the login box and follow the prompts. You will needto provide your name as printed on the Benefit Choice materialsmailed to your home.4. Enter your login ID and password. After logging in and landing onthe welcome page, explore your benefit options by clicking on thebenefit tiles.5. After exploring your benefit options and determining whichbenefits you would like to elect, click on the Benefit Choice Event,located on the Welcome page.Need Help?AVA, the interactive digital assistant, is available online atMyBenefits.illinois.govOrContact MyBenefits Service Center (toll-free)844-251-1777, or 844-251-1778 (TDD/TTY) with inquiries.Representatives are availableMonday – Friday, 8:00 AM - 6:00 PM CT.WHAT YOU NEED TO DO1. Go to MyBenefits.illinois.gov to review your benefit options.2. Choose the benefits you’d like to elect at MyBenefits.illinois.govbetween May 1-May 31, 2022.3. Consider going paperless. Provide, or update your emailaddress at MyBenefits.illinois.gov to receive quick responses andnotifications through electronic communications.4. Take advantage of your new benefits which will become effectiveJuly 1, 2022.Note: If you are not currently enrolled in benefits due to previousnonpayment of premiums, contact the Premium Collection Unit todiscuss your enrollment options 217-558-4783.DISCLAIMERMonthly health insurance contributions are based on yourMarch 1st salary, or initial salary for new hires. Your monthlycontribution amount reflected within this site is based on the salaryreported on your paycheck for the first pay period in March, and willbe adjusted as necessary, if updated information is provided.

What is Available in Your Area in FY23Review the following map and charts to identify plans available in your county. Then, review yourmonthly contribution and plan benefits to determine which plan is best for you.BlueAdvantage HMOHMO IllinoisAetna OAPBlue Cross Blue Shield OAP Tiers I, II & IIIHealthLink OAP Tiers I, II & IIIConsumer Driven Health Plan (CDHP)Quality Care Health Plan (QCHP)Aetna HMOHealth Alliance HMOAetna OAPBlue Cross Blue Shield OAP Tiers I, II & IIIHealthLink OAP Tiers I, II & III (Except Ford County)Consumer Driven Health Plan (CDHP)Quality Care Health Plan (QCHP)Aetna HMOHealth Alliance HMOAetna OAP (Gallatin County has Tiers II & III Only)Blue Cross Blue Shield OAP Tiers II & III OnlyHealthLink OAP Tiers I, II & IIIConsumer Driven Health Plan (CDHP)Quality Care Health Plan (QCHP)Aetna HMOHealth Alliance HMOAetna OAPBlue Cross Blue Shield OAP Tiers II & III OnlyConsumer Driven Health Plan (CDHP)Quality Care Health Plan (QCHP)Aetna HMOBlueAdvantage HMOHealth Alliance HMOHMO IllinoisAetna OAPBlue Cross Blue Shield OAP Tiers I, II & IIIHealthLink OAP Tiers I, II & III (Except Scott County)Consumer Driven Health Plan (CDHP)Quality Care Health Plan (QCHP)* Aetna HMOBlueAdvantage HMOHealth Alliance HMOHMO IllinoisAetna OAPBlue Cross Blue Shield OAP Tiers II & III OnlyHealthLink OAP Tiers I, II & III (Except Stark County)Consumer Driven Health Plan (CDHP)Quality Care Health Plan (QCHP)*Aetna HMOBlueAdvantage HMOHealth Alliance HMOHMO IllinoisAetna OAPBlue Cross Blue Shield OAP Tiers II & III OnlyHealthLink OAP Tiers II & III OnlyConsumer Driven Health Plan (CDHP)Quality Care Health Plan (QCHP)* Please be aware that some counties in the green and striped purple areasdo not have provider coverage for either HMO Illinois or BlueAdvantage HMO;members in these counties may have access to the aforementioned health planproviders in a neighboring county. Please check with your provider for details.MyBenefits.illinois.govSEGIP1

Monthly ContributionsThe State shares the cost of health coverage with you. While the State covers most of the cost, you must makemonthly contributions determined by your annual salary. The following charts outline monthly contribution ratesfor full-time members. Part-time members are required to pay a percentage of the State’s portion of the monthlycontribution in addition to their own. Special rules apply for non-IRS dependents (see MyBenefits.illinois.gov formore information).EmployeeAnnual Salary 30,200 & below 30,201 - 45,600 45,601 - 60,700 60,701 - 75,900 75,901 - 100,000 100,001 - 125,000 125,000 - and overAetnaBlueHealthHMO Advantage AllianceIllinois 120 94 120 139 113 139 158 132 158 176 150 176 195 169 195 249 223 249 282 256 282HMO Aetna BCBSIL* HealthLink CDHP** QCHP***Illinois OAPOAPOAP 98 117 136 154 173 227 260 114 133 152 170 189 243 276 114 133 152 170 189 243 276 128 147 166 184 203 257 290 95 114 133 151 170 224 257 134 153 171 190 209 263 296Members who retire, accept a salary reduction, or return to State employment at a different salary may have their monthly contributionadjusted based upon the new salary. This applies to members who return to work after having a 10-day or greater break in State serviceafter terminating employment. This does not apply to members who have a break in coverage due to a leave of absence.Dependent Monthly Health Plan ContributionsIn addition to monthly contributions for their own health coverage, members must make additional monthlycontributions for dependents they cover. Dependents must be enrolled in the same plan as the member. TheMedicare dependent monthly contribution applies only if Medicare is primary for both Parts A and B.Number ofDependentsAetnaBlueHealth HMO Aetna BCBSIL* HealthLink CDHP** QCHP***HMO Advantage Alliance Illinois OAPOAPOAPIllinois1 Dependent 195 158 195 162 186 186 204 169 2912 Dependents 240 194 241 201 231 231 257 213 3291 Medicare A & BPrimary Dependent 172 137 171 141 163 163 180 146 1842 Medicare A & BPrimary Dependents 214 172 215 178 205 205 227 187 245DISCLAIMERRetiree, annuitant, and survivor contributions for all health plan options will be in accordance with the levels set forth above in FY23.For future years, the State reserves the right to designate the plan options which constitute the basic program of health benefits and torequire additional contributions in accordance with the law for any optional coverage elected by an annuitant, retiree, or survivor.* BCBSIL OAP Blue Cross Blue Shield of Illinois** CDHP Consumer Driven Health Plan*** QCHP Quality Care Health Plan2FY2023 Benefit Choice Options

Adding a DependentIf you add a dependent for the first time, or re-enroll a dependent during open enrollment, you mustprovide the required documentation to complete enrollment no later than June 10, 2022. Failure to provideadequate documentation by this deadline, will result in dependents not being added to your plan. Note: Anydocumentation received after May 31, 2022, may result in a delay of ID cards.Opt-OutFull-time employees, retirees, annuitants, and survivors have the option to opt-out of health coverage if theyhave other comprehensive coverage provided by an entity other than the Department of Central ManagementServices. Be advised that if you have previously opted-out, or waived benefits, you can re-enroll during theBenefit Choice Period or if you experience a Qualifying Change in Status.Transition of Care after Health Plan ChangeMembers and their dependents who elect to change health plans and are then hospitalized prior to July 1 anddischarged on or after July 1, are involved in an ongoing course of treatment, or have entered the third trimesterof pregnancy, should contact their new plan administrator before July 1 to coordinate the transition of services.State Employees Group Insurance ProgramMedicare RequirementsRetirees and survivors must apply for Medicare benefits upon turning age 65. If the SSA determines that themember and/or dependent is eligible for Medicare Part A and/or Part B, the member and/or dependent isrequired by the State to enroll in Medicare Parts A and B. Those on a disability leave are also required to applyfor Medicare Part A and B. Once enrolled in Medicare, the member and/or dependent is required to fax oremail the front-side copy of the Medicare identification card to the State of Illinois Medicare COB Unit (contactinformation below).If the SSA determines that a member and/or dependent is not eligible for premium-free Medicare Part A basedon their own work history or the work history of a spouse (current, ex-spouse or deceased) at least 62 years ofage, the member must request a written statement of the Medicare ineligibility from the SSA. Upon receipt, thewritten statement must be forwarded to the State of Illinois Medicare COB Unit to avoid a financial penalty.State of Illinois Medicare COB UnitPO Box 19208Springfield, Illinois 62794-9208CMS.Ben.MedicareCOB@illinois.govFax: 217-557-3973MyBenefits.illinois.govSEGIP3

HMO BenefitsHealth Maintenance Organization (HMO) members are required to stay within the health plan provider network.No out-of-network services are available, other than listed below. Members will need to select a primary carephysician (PCP) from a network of participating providers. The PCP will direct all healthcare services and makereferrals to specialists and hospitalization. Benefits are outlined in each plan’s Summary Plan Document (SPD).It is the member’s responsibility to know and follow the specific requirements of the HMO plan selected. For acopy of the SPD, contact the plan administrator (see page 11).HMO Plan DesignPlan Year Out-of-Pocket Maximum 3,000 Individual 6,000 FamilyHospital ServicesIn-NetworkOut-of-NetworkEmergency Room Services 275 copayment per visit 275 copayment per visitInpatient Hospitalization 425 copayment per admissionNot coveredInpatient Alcohol and Substance Abuse 425 copayment per admissionNot coveredInpatient Psychiatric Admission 425 copayment per admissionNot coveredOutpatient Surgery 300 copayment per visitNot coveredSkilled Nursing Facility100% coveredNot coveredDiagnostic Lab and X-ray100% coveredNot coveredComplex Imaging (CT/Pet Scans/MRIs) 30 copaymentNot coveredTransplant Services 375 copay limited to network transplant facilities as determined by the medical plan administrator.To assure coverage, the transplant candidate must contact your plan provider prior to beginningevaluation services.Organ and TissueTransplantsProfessional and Other ServicesIn-NetworkOut-of-NetworkPreventive Care/Well-Baby/Immunizations100% coveredNot coveredPhysician Office Visit 30 copayment per visitNot coveredSpecialist Office Visit 35 copayment per visitNot coveredTelemedicine 10 copaymentNot coveredOutpatient Psychiatric and SubstanceAbuse 30 or 35 copayment per visitNot coveredDurable Medical Equipment80% coveredNot coveredHome Health Care 35 copayment per visitNot coveredComplex Imaging (CT/Pet Scans/MRIs) 30 copaymentNot coveredPrescription DrugsPlan Year Pharmacy Deductible – 150 per enrolleePreventive Prescription Drugs – 0Reduced Tier I *Tier ITier IITier IIICopayments (30-day supply) 4.00 16.00 33.00 57.00Copayments (90-day supply) 10.00 40.00 82.50 142.50* Applies to specific medications as defined by plan.Some HMOs may have benefit limitations based on a calendar year.4FY2023 Benefit Choice Options

Open Access Plan (OAP) BenefitsOpen Access Plan (OAP) members will have three tiers of providers from which to choose to obtain services. Tier I offers a managed care network which provides enhanced benefits and operates similar to an HMO. Tier II offers an expanded network of providers and is a hybrid plan operating like an HMO and PPO. Tier III covers all providers which are not in the managed care networks of Tiers I or II (out-of-networkproviders). It is the member’s responsibility to know and follow the specific requirements of the OAP.Benefits are outlined in each plan's Summary Plan Document (SPD), contact the plan administrator(see page 11).BenefitTier IPlan Year Out-of-Pocket Maximum Per Individual Per FamilyTier II 3,000 (includes eligible charges from Tier I and Tier II combined) 6,000 (includes eligible charges from Tier I and Tier II combined)Plan Year Deductible (must besatisfied for all services) 300 per enrollee* 0Tier III (Out-of-Network)**Not Applicable 400 per enrollee*Hospital Services (Percentages listed represent how much is covered by the plan)Emergency Room ServicesInpatient Hospitalization 275 copayment per visit 275 copayment per visitof network charges after 425 copayment per admission 90% 475 copayment per admission*of network charges after 425 copayment per admission 90% 475 copayment per admission* 275 copayment per visit60% of allowable charges after 575 copayment per admission*60% of allowable charges after 575 copayment per admission*Outpatient Surgeryof network charges after 425 copayment per admission 90% 475 copayment per admission*90% of network charges after 300 copayment per visit 300 copayment*60% of allowable charges after 575 copayment per admission*60% of allowable charges after 300 copayment*Skilled Nursing Facility100% covered90% of network charges*Not coveredDiagnostic Lab and X-ray100% covered90% of network charges*60% of allowable charges*Complex Imaging (CT/Pet Scans/MRIs) 30 copayment90% of network charges*60% of allowable charges*Inpatient Alcohol andSubstance AbuseInpatient Psychiatric AdmissionTransplant ServicesTier I: 100% covered. Tier II: 90% of network charges. Tier III: Not covered. To assure coverage, thetransplant candidate must contact your plan provider prior to beginning evaluation services.Organ and TissueTransplantsPreventive Care/Well-Baby/ImmunizationsPhysician Office VisitsSpecialist Office VisitsTelemedicineOutpatient Psychiatric andSubstance AbuseDurable Medical EquipmentHome Health CareProfessional and Other Services100% covered100% coveredNot covered 30 copayment 35 copayment 10 copayment90% of network charges*90% of network charges*Not covered60% of allowable charges*60% of allowable charges*Not covered 30 or 35 copayment90% of network charges*60% of allowable charges*80% of network charges 35 copayment80% of network charges*90% of network charges*60% of allowable charges*Not coveredPrescription DrugsPlan Year Pharmacy Deductible – 150 per enrolleeCopayments (30-day supply)Copayments (90-day supply)***Maintenance Choice (90-day supply)****Tier I 16.00 40.00 20.00Preventive Prescription Drugs – 0Tier II 33.00 82.50 41.25Tier III 57.00 142.50 71.25* A plan year deductible must be met before Tier II and Tier III plan benefits apply. Benefit limits are measured on a plan year basis.** Using out-of-network services may significantly increase your out-of-pocket expense. Amounts over the plan’s allowable charges do not counttoward your plan year out-of-pocket maximum; this varies by plan and geographic region.*** If a member or dependent elects a higher Tier drug where a lower Tier drug is available, the member or dependent is responsible for the highercopayment plus the difference in cost between the drugs.**** Medications received at CVS Caremark Retail Pharmacy or through CVS Caremark Mail Service Pharmacy.MyBenefits.illinois.govSEGIP5

Quality Care Health Plan (QCHP) BenefitsQuality Care Health Plan (QCHP) members may choose any physician or hospital for medical services; however,members receive enhanced benefits, resulting in lower out-of-pocket costs, when receiving services from aQCHP in-network provider. QCHP has a nationwide network of providers through Aetna PPO. Benefits areoutlined in the plan’s Summary Plan Document (SPD). It is the member’s responsibility to know and follow thespecific requirements of the QCHP. For a copy of the SPD, contact the plan administrator (see page 11).Plan Year Maximums and DeductiblesEmployee’s Annual Salary (based on eachemployee’s annual salary as of March 1st) 60,700 or less 60,701 - 75,900 75,901 and moreRetiree/Annuitant/SurvivorDependentsIndividual PlanYear Deductible 425 525 575 425 425Family Plan YearDeductible Cap 1,000 1,250 1,375 1,000N/AOut-of-Pocket Maximum LimitsIn-Network Individual 1,750In-Network Family 4,375Out-of-Network Individual 7,000Out-of-Network Family 13,500Hospital Services (Percentages listed represent how much is covered by the plan)In-NetworkEmergency Room Services 450 per visit; Deductible applies85% of network charges; Deductible appliesInpatient Hospitalizationafter 200 per admissionof network charges; Deductible appliesInpatient Alcohol and Substance Abuse 85%after 200 per admission85% of network charges; Deductible appliesInpatient Psychiatric Admissionafter 200 per admissionOutpatient Surgery85% of network charges; Deductible appliesSkilled Nursing Facility85% of network charges; Deductible appliesDiagnostic Lab and X-ray85% of network charges; Deductible appliesOut-of-Network* 450 per visit; Deductible applies60% of allowable charges; Deductible appliesafter 800 per admission60% of allowable charges; Deductible appliesafter 800 per admission60% of allowable charges; Deductible appliesafter 800 per admission60% of allowable charges; Deductible applies60% of allowable charges; Deductible applies60% of allowable charges; Deductible appliesComplex Imaging (CT/Pet Scans/MRIs)60% of allowable charges; Deductible applies85% of network charges; Deductible appliesTransplant ServicesOrgan and TissueTransplants85% after 200 transplant deductible, limited to network transplant facilities as determined bythe medical plan administrator. Benefits are not available unless approved by the NotificationAdministrator. To assure coverage, contact Aetna prior to beginning evaluation services.Professional and Other ServicesIn-NetworkPreventive Care/Well-Baby/Immunizations 100% coveredPhysician Office Visit85% of network charges; Deductible appliesSpecialist Office Visit85% of network charges; Deductible appliesTelemedicine85% of network charges; Deductible appliesOutpatient Psychiatric and Substance Abuse 85% of network charges; Deductible appliesDurable Medical Equipment85% of network charges; Deductible appliesHome Health Care85% of network charges; Deductible appliesOut-of-Network*60% of allowable charges; Deductible applies60% of allowable charges; Deductible applies60% of allowable charges; Deductible appliesDoes Not Apply60% of allowable charges; Deductible applies60% of allowable charges; Deductible applies60% of allowable charges; Deductible appliesPrescription DrugsPlan Year Pharmacy Deductible – 175 per enrolleeCopayments (30-day supply)Copayments (90-day supply)Maintenance Choice (90-day supply)**Tier I 18.00 45.00 22.50Preventive Prescription Drugs – 0Tier II 38.00 95.00 47.50Tier III 60.00 150.00 75.00* Using out-of-network services may significantly increase your out-of-pocket expense. Amounts over the plan’s allowable charges donot count toward your plan year out-of-pocket maximum; this varies by plan and geographic region.** Medications received at CVS Caremark Retail Pharmacy or through CVS Caremark Mail Service Pharmacy.6FY2023 Benefit Choice Options

Consumer Driven Health Plan (CDHP) BenefitsThis is a high-deductible health plan as defined by the IRS. Consumer Driven Health Plan (CDHP) members maychoose any physician or hospital for medical services; however, members receive enhanced benefits, resultingin lower out-of-pocket costs, when receiving services from a CDHP in-network provider. CDHP has a nationwidenetwork of providers through Aetna PPO. CDHP is available for active employees only, under the StateEmployees’ Group Insurance Program. This plan is not available to retirees. Benefits are outlined in the plan’sSummary Plan Document (SPD). It is the member’s responsibility to know and follow the specific requirementsof the CDHP. For a copy of the SPD, contact the plan administrator (see page 11).Plan Year Medical DeductiblesIn-Network Individual 1,500In-Network Family 3,000Out-of-Network Individual 1,500Out-of-Network Family 3,000Out-of-Pocket Maximum LimitsIn-Network Individual 3,000In-Network Family 6,000Out-of-Network Individual 3,000Out-of-Network Family 6,000Hospital Services (Percentages listed represent how much is covered by the plan)In-NetworkEmergency Room ServicesOut-of-Network*90% of coinsurance; Deductible applies90% of coinsurance; Deductible appliesInpatient Hospitalization90% of network charges; Deductible applies65% of allowable charges; Deductible appliesInpatient Alcohol and Substance Abuse90% of network charges; Deductible applies65% of allowable charges; Deductible appliesInpatient Psychiatric Admission90% of network charges; Deductible applies65% of allowable charges; Deductible appliesOutpatient Surgery90% of network charges; Deductible applies65% of allowable charges; Deductible appliesSkilled Nursing Facility90% of network charges; Deductible applies65% of allowable charges; Deductible appliesDiagnostic Lab and X-ray90% of network charges; Deductible applies65% of allowable charges; Deductible appliesComplex Imaging (CT/Pet Scans/MRIs)90% of network charges; Deductible applies65% of allowable charges; Deductible appliesTransplant ServicesOrgan and TissueTransplants90% after plan year deductible, limited to network transplant facilities as determined by the medicalplan administrator. Not covered out-of-network. Benefits are not available unless approved by theNotification Administrator. To assure coverage, contact Aetna prior to beginning evaluation services.Professional and Other ServicesIn-NetworkOut-of-Network*Preventive Care/Well-Baby/Immunizations100% covered65% of allowable charges; Deductible appliesPreventive Services (IRS-allowed)**90% of network charges; No Deductible65% of allowable charges; Deductible appliesPhysician Office Visit90% of network charges; Deductible applies 65% of allowable charges; Deductible appliesSpecialist Office Visit90% of network charges; Deductible applies 65% of allowable charges; Deductible appliesTelemedicine90% of network charges; Deductible applies Does Not ApplyOutpatient Psychiatric and Substance Abuse 90% of network charges; Deductible applies 65% of allowable charges; Deductible appliesDurable Medical Equipment90% of network charges; Deductible applies 65% of allowable charges; Deductible appliesComplex Imaging (CT/Pet Scans/MRIs)90% of network charges; Deductible applies 65% of allowable charges; Deductible appliesPrescription DrugsPreventive Prescription Drugs – 0 Preventive Prescription Drugs (IRS-allowed) ** - 90% covered; No DeductibleCopayments (30-day supply)Copayments (90-day supply)Maintenance Choice (90-day supply)***Tier I90%; Deductible Applies90%; Deductible Applies95%; Deductible AppliesTier II90%; Deductible Applies90%; Deductible Applies95%; Deductible AppliesTier III90%; Deductible Applies90%; Deductible Applies95%; Deductible Applies* Using out-of-network services may significantly increase your out-of-pocket expense. Amounts over the plan’s allowable charges donot count toward your plan year out-of-pocket maximum; this varies by plan and geographic region.** Contact Aetna for IRS-allowed services and prescriptions.*** Medications received at CVS Caremark Retail Pharmacy or through CVS Caremark Mail Service Pharmacy.MyBenefits.illinois.govSEGIP7

Medical Care Assistance Program (MCAP) - Companion to yourHMO, OAP, QCHP, or CDHP (if not enrolled in an HSA)EMPLOYEES MUST RE-ENROLL EACH YEARThe MCAP maximum contribution limit is 2,850 for the FY23 plan year period. The rollover of unused FY23funds will be capped at 570.00. Participants who do not re‐enroll for the new plan year will forfeit anyamount eligible for rollover.Dependent Care (Day Care) Assistance Program (DCAP)DCAP is an account that allows you to set aside pre‐tax contributions per pay period to pay for dependent care(Day Care) expenses, for children age 12 and under, or care for a physically or mentally disabled dependent.DCAP cannot be used for dependent medical expenses or for children for which you are not considered theprimary or custodial parent. The DCAP maximum contribution limit is 5,000 for the FY23 plan year period.Any unused DCAP funds at the end of the plan year will be forfeited.Health Savings Accounts (HSA) for Active State Employees Companion to CDHP Enrollment ONLYEMPLOYEES MUST RE-ENROLL EACH YEARAn HSA is like a 401(k) for healthcare, yet the HSA tax benefits are far greater. It is a tax‐favored, interest-bearingaccount that active State employees can use to pay for qualified medical expenses now, or in the future. ActiveState employees who qualify (see Qualifying for an HSA below), can save or invest the account funds. Paired withthe Consumer Driven Health Plan (CDHP), an HSA is a powerful financial tool that gives you more control of yourhealthcare decisions.The State will contribute a third of the deductible to an active State employee's HSA. Maximum HSAcontributions (Employer Employee) for FY23 will be:Under Age 55Age 55 and olderIndividualFamilyEmployer Contribution 500 1,000Employee Contribution 3,150Max IRS Allowed Contribution 3,650IndividualFamilyEmployer Contribution 500 1,000 6,300Employee Contribution 4,150 7,300 7,300Max IRS Allowed Contribution 4,650 8,300Contributions to your HSA can be made through pre-tax payroll deductions or post-tax direct payment. ActiveState employees can make tax‐free withdrawals to pay for qualified medical expenses, for you and your eligibledependents. HSAs are portable and all contributions rollover to the next plan year. If the employee investsHSA funds, those funds remain in the investment account. HSAs may be used for future healthcare expensesincluding out‐of‐pocket expenses after retirement, Medicare, and long‐term care (LTC) premiums, up to IRS limitsand certain LTC expenses. There are no income limitations.Qualifying for an HSATo be an eligible individual and qualify for an HSA, you must: Be covered under a high-deductible health plan Have no other health coverage (except what ispermitted under Other health S 2019 publink1000204039) Not be enrolled in Medicare. This includes Part A Not be claimed as a dependent on someoneelse’s tax returnYou cannot be enrolled in both an HSA and MCAP Flexible Spending Account.8FY2023 Benefit Choice Options

VisionVision coverage is provided at no cost to all members enrolled in a State health plan and is administered by EyeMed.All enrolled members and dependents receive the same vision coverage regardless of the health plan selected.ServiceIn-NetworkOut-of-Network**Benefit FrequencyEye Exam 30 copayment 30 allowanceOnce every 12 monthsStandard Frames 30 copayment (up to 175 retailframe cost; member responsiblefor balance over 175) 70 allowanceOnce every 24 monthsVision Lenses* (single, bifocaland trifocal) 30 copayment 50 allowance for singlevision lenses. 80 allowancefor bifocal and trifocal lensesOnce every 12 monthsContact Lenses (All contactlenses are in lieu of vision lenses) 120 allowance 120 allowanceOnce every 12 months* Vision Lenses: Member pays all optional lens enhancement charges. In-network providers may offer additional discounts on lens enhancementsand multiple pair purchases.** Out-of-network claims must be filed within one year from the date of service.DentalEmployees have the option to enroll in Dental Only coverage. However, if you enroll in health coverage andchoose dental coverage, dependents must mirror the coverage of the member.The State’s Quality Care Dental Plan (QCDP) offers a comprehensive range of benefits and is available to all membersand is administered by Delta Dental of Illinois. Visit MyBenefits.illinois.gov for a Dental Schedule of Benefits.Deductible and Plan Year MaximumPlan year deductible for preventive servicesN/APlan year deductible for all other covered services 175Plan Year Maximum Benefit (Orthodontics All Other Covered Expenses Maximum Benefit)In-network plan year maximum benefit 2,500Out-of-network plan year maximum benefit 2,000It is strongly recommended that plan members obtain a pretreatment estimate through Delta Dental for any service more than 200. Failure to obtain apretreatment estimate may result in unanticipated out-of-pocket costs.Child Orthodontia BenefitLength of Orthodontia Treatment*Maximum BenefitIn-NetworkOut-of-Network0 - 36 Months 2,000 1,5000 - 18 Months 1,820 1,3640 - 12 Months 1,040 780Member Monthly Quality Care Dental Plan (QCDP) Contributions**Member OnlyMember 1 DependentMember 2 or More Dependents 14.00 23.00 25.50* Orthodontia Treatments must start prior to age 19.** Part-time employees are required to pay a percentage of the

Quality Care Health Plan (QCHP) Aetna HMO. Health Alliance HMO. Aetna OAP Blue Cross Blue Shield OAP Tiers I, II & III HealthLink OAP Tiers I, II & III (Except Ford County) Consumer Driven Health Plan (CDHP) Quality Care Health Plan (QCHP) Aetna HMO. Health Alliance HMO. Aetna OAP (Gallatin County has Tiers II & III Only) Blue Cross Blue Shield .

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