PERS Health Insurance Program (PHIP) Member Guide

completed application. You must keep bothMedicare Part A and Part B to be enrolledin a PHIP Medicare plan. Any EnrollmentRequest Forms received after 90 days of initialMedicare eligibility is considered outside of theenrollment opportunity and will be ineligible.Medicare DisabilityYour eligibility to enroll in Medicare Part Aand Part B due to Social Security Disability,becomes effective the first day of the 25thmonth after your Social Security Disabilitybenefits began. In this case, becomingMedicare-eligible due to disability isconsidered your initial Medicare eligibility.You will be able to enroll within 90 days ofMedicare eligibility. If you miss this opportunity,becoming Medicare-eligible at age 65 willnot be a new opportunity to enroll in a PHIPhealth plan, unless you have had 24 monthsof continuous employer-sponsored coverageimmediately before enrollment in PHIP.If you are currently enrolled in a PHIPnon-Medicare plan, you must completeand submit an Enrollment Request Form 30days before becoming Medicare-eligible.If you do not submit a new EnrollmentRequest Form for Medicare coverage,your PHIP coverage will end.Dependent EnrollmentYou may enroll an eligible spouseor dependent during any enrollmentopportunity available to retirees.A Medicare eligible spouse can enroll in a PHIPMedicare health plan before the retiree does,as long as the spouse is enrolled in MedicarePart A and Part B. This is also contingenton the PERS retiree enrolling in PHIP upontheir final enrollment opportunity. If the PERSretiree does not enroll in PHIP during theirfinal enrollment opportunity, the spouse willno longer be eligible for PHIP coverage.You must enroll your new spouse ordependent within 30 days of the familystatus change (e.g., birth, marriage). If yourspouse has a different last name, PHIP willrequire a copy of the marriage certificate.To add a new spouse and/or dependent,please complete and submit a PHIPEnrollment Request Form.Coverage will begin the first of themonth after we receive the completedPHIP Enrollment Request Form includingadditional documentation (e.g., birthcertificate, marriage certificate).Death Notification of PERSRetiree or SpouseIf you are the PERS retiree:If your spouse passes away, your PHIP coveragewill continue as usual. To end your spouse’scoverage, please contact PHIP member servicesand mail a photocopy of the death certificate toPHIP and separately to the PERS Pension office.If you are the surviving spouse ordependent child of a PERS retiree:If the PERS retiree passes away, yourPHIP coverage will continue automatically.You will need to mail a copy of theretiree’s death certificate to PHIP and alsoseparately to the PERS Pension office.If you would like to end your coverage,please send PHIP a Disenrollment Form.Enrollment upon death of the PERS retireeIf the surviving spouse is not enrolled at thetime of the PERS retiree’s death, the spousemay enroll within 90 days of the date of death,or by meeting other enrollment opportunities.However, if the spouse remarries, coveragecannot be extended to the new spouse.Once disenrollment or termination occurs,you cannot re-enroll in PHIP unless youhave a new enrollment opportunity.Dental Plan EnrollmentTo enroll in a PHIP dental plan, you mustenroll in a PHIP medical plan during thesame enrollment opportunities as the PHIPmedical plan. Dependents’ dental coveragemust be with the same contracted dentalplan as the retiree. However, the retireecan choose dental and medical plans fromdifferent Contracted Health Plans (CHP).For Kaiser Permanente dental, youmust live in the Kaiser Permanentedental plan service area.Enrollment Opportunities 7

Health Plan OptionsWhen you pick a health or dental plan,your permanent residence (not mailingaddress) must be within the United Statesand the health plan’s service area.Learn more about PHIP plans byreviewing the benefit outline and rateinformation at pershealth.com.down Part B when first eligible and requestto enroll at a later date, Medicare may chargeyou a penalty. If you stop paying your Part Bpremium, you will lose your ability to continueany of the PHIP Medicare health plans.In addition, if you do not have Part B inplace when you lose employer-sponsoredgroup coverage, you cannot enroll ina PHIP plan. This may cause you tolose your enrollment opportunity.Medicare OptionsPHIP offers Supplement, HMO, HMO-POSand PPO plan options for Medicare retirees.All Medicare eligible members, spouses anddependents must be enrolled and retain bothPart A and Part B of Medicare. If you turnWhen the retiree and spouse/dependenthave Medicare, the coverage must bewith the same contracted health plan.PHIP Medicare Advantage Plans — All Plans Include Medicare Part D Prescription Drug CoverageContracted Health PlanHMOKaiser FoundationHealth Plan of the NWKaiser PermanenteSenior AdvantagePacificSource MedicareProvidence MedicareAdvantage PlansHMO-POSPPOPacificSource MedicareEssentials RX 803Providence MedicareAlign Group Plan RXProvidence MedicareFlex Group Plan RXUnitedHealthcare Group MedicareAdvantage (PPO)UnitedHealthcare PHIP Medicare Supplement Plan — Includes Medicare Part D Prescription Drug CoverageContracted Health PlanMedicare Supplement PlanModa Health Plan, Inc.Moda Health Supplement PlanYou can find additional information on Medicare and PHIP in the PERS Health InsuranceProgram (PHIP) Medicare Enrollment Guide.8 Health Plan Options

Non-Medicare OptionsHealth Savings Account (HSA) BasicsPHIP offers a traditional HMO and PPOplan, as well as qualified High DeductibleHealth Plans (HDHP) for non-Medicareretirees. Once you become eligible forMedicare, you will not be eligible to enrollin a PHIP non-Medicare plan. If you areenrolled in a PHIP non-Medicare plan, whenyou become eligible for Medicare, yournon-Medicare coverage will be terminated.An HSA is a special savings account thatyou contribute money to, then withdrawfunds to be used for qualified medical,pharmacy, dental and vision expenses.HSAs are funded by individual contributionsand have annual contribution limits set bythe IRS. Additionally, HSAs allow you tocarry over your balance from year-to-year.Contributions cannot be directly depositedto your HSA from your pension benefit.When the retiree and spouse/dependents are enrolling in non-Medicarecoverage, the coverage must be withthe same Contracted Health Plan.The PHIP qualified High DeductibleHealth Plan (HDHP) can be used with aHealth Saving Account (HSA). If you haveother health insurance coverage suchas Medicare, or private health insurance,you are not eligible for this type ofplan. You are also not eligible if you areclaimed on someone else’s tax return.Once enrolled in the Qualified HDHP plan,you cannot switch to the Core Value plan atany time in the future.If you are 55 or older an additional annualcatch-up contribution may be available.If you change plans or become Medicareeligible you can keep the HSA accountand the money in it, which you cancontinue to use for qualified expenses.You are responsible for setting up yourHSA through a financial institution.HSA and MedicareOnce you become eligible for Medicareyou can no longer contribute to yourHSA, but you can still cover some medicalexpenses with existing HSA funds. Theseexpenses include Medicare premiums andpremiums for long-term care insurance.PHIP Non-Medicare Health Plans — All Plans Include Prescription Drug CoverageContracted Health PlanHMOKaiser FoundationHealth Plan of the NWKaiser PermanenteTraditionalCore Value(no deductible)UnitedHealthcare PPOHDHP*Kaiser PermanenteQualified HDHP( 3000 deductible)UnitedHealthcareChoice PlusCore Value( 1000 deductible)UnitedHealthcareChoice PlusQualified HDHP( 3000 deductible)*HSA Qualified; Contact a tax advisor for specific rules regarding a Health Savings Account.Health Plan Options 9

Dental Plan OptionsYou can enroll in either dental plan. However, for Kaiser Permanente dental, you must live in theKaiser Permanente service area.Contracted Health PlanPlan TypeKaiser FoundationHealth Plan of the NWDental Maintenance Organization (DMO)Delta Dental of OregonIndemnityExclusions and LimitationsAll available health and dental plans have some exclusions and limitations. You can find thisinformation in the Evidence of Coverage (EOC) or member benefit handbook you receive from yourhealth or dental plan after enrollment.10 Health Plan Options

Health Coverage While TravelingAll PHIP health plans provide coverage for urgent and emergent care when you travel anywherein the world. When you travel outside of your health plan’s service area, your coverage is limited.Some plan’s travel benefits have limits and exclusions. Before you travel, contact your health planto determine how your travel benefits will work if you need services while you are away.Kaiser PermanenteMembers temporarily visiting otherKaiser Permanente regions mayreceive visiting member care fromdesignated providers in those areas.This also includes a travel benefit fornecessary follow-up care from any Medicareprovider outside the plan service area. Planpays 80 percent and the member pays 20percent, up to a combined 1,000 annual limit.Travel vaccines are prescribed through theKaiser travel clinic after itinerary review.Moda Health Plan, Inc.Under the Moda Health MedicareSupplement plan, you have coveragethroughout the entire United States,including the U.S. territories. When travelingoutside the United States, Original Medicareusually does not provide any coverage.This is where your Moda Health MedicareSupplement plan comes in. If you findyourself in need of urgent care, emergencyor ambulance services when you areoutside of the United States, Moda Healthwill pay 80% and you will be responsiblefor 20%. Coverage outside of the UnitedStates is limited to 50,000 per lifetime.PacificSource MedicarePacificSource members have coveragefor emergency and urgent careservices worldwide. These services donot require a prior authorization.outside the plan service area. Plan pays 80percent and the member pays 20 percent,up to a combined 1,000 annual limit.Providence Medicare Flex Group Plan Rx (HMO-POS) is a Point-of-Service(POS) benefit that allows you to see anyMedicare-approved provider. There is noannual limit on what Providence will payfor approved out-of-network services.UnitedHealthcareMedicareWhile traveling abroad, as a memberof UnitedHealthcare you are coveredfor emergency care and urgentlyneeded services. This includes urgentcare, emergency room and ambulanceservices to the nearest facility foryour condition. It does not includetransportation back to the United States.Non-MedicareWhile traveling abroad, as a member ofUnitedHealthcare you are covered foremergency care and ambulance servicesto the nearest facility. Transportation backto the United States is not covered.If you do need services whiletraveling outside of your plan servicearea or in a foreign country, it islikely that you will need to pay out ofpocket for those services and submita claim for reimbursement fromyour health plan when you return.Providence Medicare Advantage PlansProvidence Medicare Align Group Plan RX(HMO) includes a travel benefit for necessaryfollow-up care from any Medicare providerHealth Coverage While Traveling 11

Health PlansEnrollment andService AreasChanges to Plans 12

Kaiser FoundationHealth Plan of the NWMedicare Service AreaOregon Counties — Benton: 97330, 97331, 97333,97339, 97370; Clackamas; Columbia; Hood River;Lane; Linn: 97321, 97322, 97335, 97355, 97358,97360, 97374, 97389; Marion; Multnomah; Polk;Washington; YamhillWashington Counties — Clark; Cowlitz; Skamania;Wahkiakum: 98612, 98647Non-Medicare Service AreaOregon Counties — Benton: 97330, 97331, 97333,97339, 97370, 97456; Clackamas; Columbia; HoodRiver: 97014; Lane; Linn: 97321, 97322, 97335,97348, 97355, 97358, 97360, 97374, 97377, 97389,97446; Marion; Multnomah; Polk; Washington;YamhillWashington Counties — Clark; Cowlitz; Skamania:98639, 98648; Wahkiakum: 98612, 98647Dental Service AreaOregon Counties — Benton: 97330, 97331, 97333, 97339, 97370, 97456; Clackamas; Columbia;Hood River: 97014; Lane: 97401, 97402, 97403, 97404, 97405, 97408, 97409, 97419, 97424, 97426,97431, 97437, 97438, 97440, 97448, 97451, 97452, 97454, 97455, 97461, 97475, 97477, 97478,97487, 97489; Linn: 97321, 97322, 97335, 97348, 97355, 97358, 97360, 97374, 97377, 97389,97446; Marion; Multnomah; Polk; Washington; YamhillWashington Counties — Clark; Cowlitz; Skamania: 98639, 98648; Wahkiakum: 98612, 98647Kaiser Permanente 13

Proudly serving the Northwest for over 70 years,Kaiser Permanente offers comprehensive carethat is convenient, connected, and designedto provide the prevention, wellness, andhealthcare resources you need to live well. Youhave access to 55 offices (medical and dental)from Eugene-Springfield* to Longview; withpharmacy, lab, X-ray, dental, and vision servicesso you can do more and drive less. Same-dayappointments and after-hours urgent careare available for life’s unexpected moments.Kaiser Permanente MedicareSenior AdvantageGet more. More control, convenience,and quality with a plan that goes beyondOriginal Medicare. With care under oneroof, online health management tools,worldwide emergency coverage, andcomprehensive care that builds in wellnessprograms and supportive services to promoteyour total health, Kaiser Permanente’sMedicare Senior Advantage plan offerscomprehensive care and coverage.Qualified High Deductible Health Plan(HDHP, 3,000 deductible)With a Kaiser Permanente qualifiedHDHP plan, you have a lower premiumand preventive care is not subject to thedeductible. Most other services are subjectto the deductible and then 20% coinsurance.To learn more about how the HSA pairswith the qualified HDHP refer to page 9**.PHIP prescription drug benefitfor Kaiser PermanenteMembers enrolled with Kaiser Permanentethrough PHIP are covered under theKaiser prescription drug benefit. KaiserPermanente members must use Kaiserpharmacies to obtain prescription drugs(except in Eugene-Springfield service area).Dental planThe Kaiser Permanente dental plan offers21 dental offices in the Northwest region.Kaiser Non-Medicare plansTraditional Core Value(HMO plan, no deductible)With a Kaiser Permanente Traditional CoreValue plan, you don’t have to keep trackof deductibles or worry about paperworkfor the services you receive. When youcome in for care, you’ll just pay a copayfor most services covered by your plan.* Salem to Longview for Medicare only.** Contact a tax advisor for specific rules regarding Health Savings Accounts (HSA).14 Kaiser Permanente

Moda Health Plan, Inc. andDelta Dental of OregonMedicare and Dental Service AreaNationwideRooted in the Pacific Northwest since 1955,Moda Health and Delta Dental of Oregon isdedicated to partnering with you to help youlive a healthier life. We are proud to provideyou with enhanced benefits, innovativeprograms and exceptional customer service.Moda Health MedicareSupplement PlanFor nearly 30 years, Moda Health hasbeen offering the Medicare Supplementplan to PERS members. This is a MedicareSupplement insurance program that payssecondary to Medicare. Members havethe freedom to receive services from anyMedicare provider nationwide and canlive anywhere within the United States.With this plan, there are no referralsrequired, no PCP requirements, and youpay nothing for Medicare covered servicesafter your Medicare Part B deductiblehas been met. This plan also includesadditional value-added services anddiscounts beyond what Medicare covers.PHIP prescription drug benefitfor Moda HealthMembers in the Moda Health MedicareSupplement plan are covered under theModa Health Part D prescription drugplan. Moda Health has a comprehensivenational network with more than 66,000participating pharmacies throughout theUnited States. This includes most well-known,large national and regional chains as wellas many neighborhood pharmacies.Delta Dental of OregonDelta Dental of Oregon, a local company,gives you access to the Delta DentalPremier and PPO national networks, thecountry’s largest dental networks. Withmore than 157,000 participating dentists tochoose from nationwide, you can get thedental care you need wherever you are.Moda Health and Delta Dental 15

PacificSource MedicareMedicare Service AreaOregon Counties — Clackamas; Coos;Crook; Curry; Deschutes; Grant; HoodRiver; Jefferson; Klamath: 97731, 97733,97737, 97739; Lake: 97638, 97641, 97735,97739; Lane; Multnomah; Sherman; Wasco;Washington; WheelerWashington County — ClarkPacificSource offers Medicare Advantageplans under the name PacificSource Medicare.They employ 1,500 people and serve morethan 300,000 members throughout theNorthwest. PacificSource is a not-for-profitcommunity health plan founded in 1933 bya group of physicians in Oregon to improvehealthcare quality and access. They areknown for their customer service; whetheryou call, email, or stop by, expect friendly,knowledgeable, real people, ready to help you.PacificSource Medicare Advantage PlanThe PacificSource Medicare Essentials Rx 803plan is a Medicare Advantage plan. Membersuse in-network providers for most services.You can see any Medicare-approved providerin the PacificSource Medicare network. Youcan choose your own primary care provider,and you have the freedom to see specialistswithout a referral. Our Medicare Advantageplan covers more than Medicare alone.16 PacificSource MedicarePHIP prescription drug benefitfor PacificSource MedicareMembers enrolled with PacificSourceMedicare through PHIP are covered underthe PacificSource Medicare prescription drugbenefit. If you are Medicare eligible, you areautomatically enrolled in the PacificSourceMedicare Part D prescription drug plan. Youcan access your PacificSource Medicareprescription drug benefit at retail pharmacies,through mail order or through long termcare (LTC) pharmacies. Our retail pharmacynetwork has over 68,000 pharmaciesthroughout the United States. This includeswell-known national and regional chainpharmacies and independent pharmaciesas well. Most retail pharmacies in ournetwork allow you to get a long-term supply(up to 93 days) of maintenance drugs.

Providence Medicare Advantage PlansMedicare Service AreaOregon Counties — Benton, Clackamas,Columbia, Crook, Deschutes, Hood River,Jefferson, Lane, Linn, Marion, Multnomah,Polk, Washington, Wheeler and YamhillWashington Counties — Clark, Snohomishand SpokaneProvidence Medicare AdvantagePlans are part of Providence Health &Services. You can choose a Providenceprovider or choose from our network ofthousands of well-known provider partnersthrough Oregon and Washington.Providence Medicare Advantage PlansWith the Providence Medicare Flex GroupPlan Rx (HMO-POS) or ProvidenceMedicare Advantage Align Group Plan Rx (HMO), you get all the benefitsof traditional Medicare and more.y Choose from thousands of in-networkproviders, both in and out of theProvidence system.y Sign up for Providence Express Care Virtual(at no cost) and visit with a provider via livesecure video from your tablet, smartphoneor computer.y Get same-day treatment at a ProvidenceExpress Care Clinic.y Start or continue a healthy fitness routineand take advantage of a no-cost fitnesscenter membership benefit.y Take advantage of the routine hearingexam and hearing benefit.We're recognized as a trusted health carecompany in the Northwest, operatingnationally-recognized hospitals and providingquality medical plans. With each plan, you’llget quality health coverage and have accessto the valued resources of Providence Health& Services, with more than 160 years ofhealth care experience.PHIP prescription drugbenefit for ProvidenceMembers enrolled in a Providence MedicareAdvantage plan through PHIP are coveredunder the Providence Medicare Advantageplan Part D prescription drug benefit.Providence Medicare Advantage plan hasover 40,000 participating pharmaciesavailable for use nationwide.Most of our network pharmacies havepreferred cost-sharing, and memberresponsibility may be less when usingthese preferred cost-sharing pharmacies.Providence Medicare Advantage Plans 17

UnitedHealthcare Medicare and Non-MedicareService AreaNationwideUnitedHealthcare has been servingthe people of the Northwest for morethan 30 years.We are dedicated to helping people livehealthier lives by simplifying the health caresystem for everyone, meeting consumerhealth and wellness needs, and sustainingtrusted relationships with care providers.UnitedHealthcare MedicareAdvantage PlanThe UnitedHealthcare Group MedicareAdvantage plan is a Preferred ProviderOrganization (PPO) plan which offerscomprehensive coverage for hospital andmedical services as well as additionalprograms that go beyond Original Medicare.18 UnitedHealthcareMembers have access to our national networkof providers and the flexibility to see anyprovider (in or out-of-network) at the samecost share, as long as they accept the planand have not opted out of Medicare.UnitedHealthcare Non-Medicare plansChoice Plus PlanThe Choice Plus plan options give membersand their dependents the freedom to choosea network physician or specialist from theUnitedHealthcare Choice Plus networkwithout visiting a primary care physician(PCP) for a referral. Choice Plus includesplan coverage for out-of-network providers.You will generally pay less for services fromproviders in the UnitedHealthcare network.

Core Value( 1,000 deductible)The Choice Plus Core Value plan allows youto see any

Your Health Plan Options page 8 — Medicare Health Plans page 8 — Non-Medicare Health Plans page 9 — Dental Plans page 10 — Health Coverage While Traveling page 11 Health Plan Enrollment Service Areas page 12 — Kaiser Foundation Health Plan of the NW page 13 — Moda Health Plan, Inc. page 15 — PacificSource Medicare page 16