City of Baltimore

[Pages:36]City of Baltimore

2017 Retiree Benefits Booklet

Rajesh Gulhar, Chief, Employee Benefits Division

Mary H. Talley, Director & Chief Human Capital Officer

Note: This Comparison Is To Be Used As A Guide Only. Actual Benefits Will Be Governed by The Terms and Conditions of the Master Contract.

Revised 9/12/2016

Page 1

Table of Contents

Section

Section 1

Section 2 Section 3

Section 4 Section 5 Section 6

Contents

Cover Page Table of Contents Important Information Contacts Information About Your 2017 Benefits Alex Family Status Change Two Step Process Dependent Eligibility /Required Documentation

Medicare Information Medicare Sunset Letter Important Information About Medicare 2017 Retiree Premium Contributions 50% Retiree Contribution (15 or More Years of Service) 80% Retiree Contribution (10-14 Years of Service) 100% Retiree Contribution (5-9 Years of Service) Rx Premium Rx Premium Key Retiree without Medicare Benefits Retiree with Medicare Benefits Rx, Vision & Life Benefits Rx Copays Vision Benefits Basic Life Benefits Basic Life Beneficiary form Back Cover

Page

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 21 27 31 32 33 34 35 36

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Page 2

Section 1

Important Information

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Page 3

Retiree Contacts

Phone Numbers & Websites

Phone

Provider

Number

Insurance Companies

CareFirst PPN

1-800-535-2292

CareFirst Medicare Supplemental Beacon Health Options

Mental Health/Substance Abuse (CareFirst Non-Medicare Benefits Only)

Kaiser Permanente HMO

1-800-535-2292

1-866-468-5633 1-866-248-0715

Express Scripts Prescription Plan (Non-Medicare) Express Scripts Prescription Plan (Medicare) CareFirst Select Vision

1-800-354-8123 1-877-577-0459 1-800-535-2292

Securian Life (Life and AD&D)

1-888-658-0193

Retirement Agencies

Baltimore City Retirement System

1-877-273-7136

Fire & Police Retirement Maryland State Retirement (Pension Information)

1-888-410-1600 1-800-492-5909

Employee Benefits Division

Baltimore City Medicare Rx Plan (Medicare Part D)

410-396-1780

Employee Benefits Division (TTY)

TTY 711 (Maryland)

Website



baltimore express- express-

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baltimorecity. baltimorecity.

Revised 9/12/2016

Page 4

Information About Your Benefits for 2017

Please read the information provided in this benefit book.

CareFirst Medicare Supplemental Plan

No coverage for Erectile Dysfunction Medication Dental Coverage

Effective January 1, 2017, the City's CareFirst Medicare Supplemental plan will no longer pay 100 % after Medicare. The City will reduce the Medicare eligible retiree's supplemental plan reimbursements paid by the plan from 100% to 80% of the Medicare allowed charges. The retiree must pay the remaining balance. Reminder: The City of Baltimore no longer covers erectile dysfunction medication for City of Baltimore Retirees and their dependents. This change was effective January 1, 2016.

Dental Benefits for all enrolled retirees is provided through their health plan. Reminder: Retirees enrolled in the CareFirst Medicare Supplemental Plan do not receive dental benefits.

Jelly Vision - Meet Alex

Dependent Eligibility

Summary Benefits and Coverage (SBC)

Prescription Coverage

The City of Baltimore will provide Jelly Vision to active employees and retirees without Medicare during Open Enrollment as well as Ongoing Enrollment starting October 21, 2016. Employees and retirees without Medicare will have an opportunity to interact online with Alex the virtual interactive benefits counselor. You can find Alex on the City's Health Benefits Enrollment System under the Main Menu. Alex will help you make smarter healthcare decisions that may save you time and money by answering a series of health related questions.

Administrative Information Dependent children are eligible for benefits until the end of the calendar year they reach age 26, regardless of student status.

The Patient Protection and Affordable Care Act (PPACA) require health plans and health insurance issuers to provide a Summary of Benefits and Coverage (SBC) to applicants and enrollees. The SBC is a concise document providing simple and consistent informat ion about health plan benefits and coverage. Its purpose is to help health plan consumers better understand the coverage they have and to help them make easy comparisons of different options when shopping for new coverage. The City of Baltimore will post this document on its enrollment website: baltimorecity. under its own drop down menu labeled Summary of Benefits and Coverage.

You and your dependents must be enrolled in a City of Baltimore medical plan in order to enroll in a prescription drug plan.

Duplicate Coverage Information

Medicare Secondary Payer (MSP)

Mandatory Reporting

If you and your spouse are City employees/retirees, you cannot enroll each other or the same eligible dependents on your City medical, dental, vision and prescription plans during any coverage period. You will be notified to adjust duplicate coverage, if applicable.

Under the Medicare Secondary Payer (MSP) Mandatory Reporting, federal law requires the mandatory collection and reporting of social security numbers for all covered participants including employees, retirees and their dependents through employer group health benefits. Noncompliance may result in the loss of coverage for participants with invalid or missing social security numbers.

Change of Address

You must notify your retirement agency, in writing, about your change of address the Employee Benefits Division cannot change your address.

Enrollment Website & Logon Information

baltimorecity. To log on to the website, you will need your social security number and your four -digit PIN number, which is provided on your worksheet.

New membership ID cards will only be issued for new enrollments and coverage level New Membership ID Cards changes.

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Page 7

Required Documentation For Newly Added Dependents & Family Status Changes

Instructions: Documentation is required for newly added dependents and family status changes. Attach all required documentation to this form and return to the Employee Benefits Division, 201 E. Baltimore Street, Suite 500, Baltimore, MD 21202 within 60 days of your initial enrollment period or qualifying event. Please complete the section below.

Name: _________________________________ Social Security Number: _____________________________ Address: __________________________________________________________________ ( ) Employee ( ) Retiree Date of Birth: __________________ Daytime Telephone No.: _____________________ Cell No.: ____________________

Eligible Dependent Relationships To Employee/Retiree Legal Spouse

Children Birth Adoption Stepchild Permanent

Guardianship Grandchild Medical Child

Support Order Disabled Child (At

Age 26 as of December 31)

Newly Added Dependents

Dependent

Documentation

Eligibility

For Verification of Relationship

Criteria

(Provide Copy Of)

Legally married as recognized Official Court-Certified State Marriage Certificate (must be certified and by the laws of the State of dated by the appropriate state or County official, such as the Clerk of Court):

Maryland or in a jurisdiction

From the court in the County or City in which the marriage took

where such marriage is legal

place; or

From the Maryland Division of Vital Records; or

From the Department of Health and Mental Hygiene (DHMH)

website dhmh. (click Online Services) or



Under age 26 as of December Birth: Official Sate Birth Certificate with name of employee/retiree as

31

child's parent

Required to reside in your

Adoption: Official Court Documents & Official State Birth Certificate

home

Stepchild: Official Court-Certified State Marriage Certificate & Official

May be married or unmarried

State Birth Certificate with name of spouse of employee/retiree as

Provide 100% economic

child's parent

support

Permanent Guardianship: Official Court Documents signed by a judge

Covered until the end of the

& Official State Birth Certificate

year they reach age 26

Grandchild: Official State Birth Certificate of your child and grandchild

Over age 26 and incapable of self-support due to mental or

showing line of relationship, recent Income Tax Return claiming grandchild and the "Certification of Economic Support For

physical incapacity incurred

Grandchildren Form" (Posted on website under FORMS LIBRARY)

prior to age 26

Medical Child Support Order: Official Medical Child Support Order

requiring employee/retiree to provide health coverage signed by the

child support officer or judge

Disabled Child: Original Disability Questionnaire Form (Posted on

website under FORMS LIBRARY)

Termination of Covered Dependents Due To A Family Status Change

Termination of Dependents Due To Family Status Change

Copy of Required Documentation

Death of Spouse or Child

Death Certificate

Divorce

Divorce Decree

Gain Other Coverage (Employee, Retiree, Spouse or Child)

Letter from Employer or Medical Plan

Marriage of Dependent Child

Official State Marriage Certificate

Enrollment Due To A Family Status Change

Enrollment Due To Family Status Change

Copy of Required Documentation

Loss of Coverage (Employee, Retiree, Spouse or Child)

Letter from Employer or Medical Plan

Reminder: If you do not submit the required documentation to Employee Benefits Division within 60 days of your initial enrollment period or

qualifying event, your dependents will not be added to your coverage and/or your enrollment change will not be processed. You will be required to

wait until the next annual open enrollment period to enroll new dependents or make any changes to your enrollment.

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