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Where Water Matters 2016 Retiree Open Enrollment Important Information About Your Benefits For 2016 Beyond. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Highlights Of Plan Changes For 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Benefits Open Enrollment Schedule. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 2016 Medical Dental and Vision Plan Rates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Open Enrollment Timeline. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Important Things To Remember. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Summary Of Services Disclaimer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Insurance Coverage For Dependents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Change Of Life Events. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 NON-MEDICARE-ELIGIBLE RETIREE MEDICAL PRESCRIPTION 2016 Calendar Year Medical Summary Of Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 911 CVScaremark Personal Prescription Benefit Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 CVScaremark Maintenance Choice For Long-Term Medications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Kaiser Permanente Prescription Benefits At-A-Glance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 National Vision Administrators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Delta Dental Plan Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1617 MEDICARE-ELIGIBLE RETIREE MEDICAL PRESCRIPTION Medicare Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Medicare Frequently Asked Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Medicare-Eligible Summary of Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 SilverScript Prescription Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2123 Certificate Of Creditable Coverage for Medicare Part D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2425 Legislative Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2627 HIPAA Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2831 Glossary Of Insurance Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3234 MetLife Basic Life Insurance Beneficiary Change Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Customer Service Contacts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inside Back Cover Table of Contents Dear Retiree We are pleased to provide you with your 2016 Open Enrollment Booklet which contains important information about your benefits for 2016. Open Enrollment begins Monday October 5th and closes Friday October 30th. This is your annual opportunity to Modify your benefit plan elections Change your dependent coverage This booklet contains important information about your benefits including Important information about your benefits for 2016 and beyond Highlights of Plan Changes for 2016 Legislative updates Key Contact Information WSSC continually strives to offer employees a strong benefit package with access to some of the best plan options available. Please take time to read this booklet before completing your 2016 WSSC Retiree Benefit Request Form and then refer to it throughout the year. The best way to get additional information or to have your questions answered is to attend one of our Open Enrollment Information Sessions at a WSSC site closest to you the schedule of which is contained in this booklet. If you are not able to attend one of the sessions and have questions please email us at openenrollmentwsscwater.com or call us at 301-206-7034. Respectfully L. Todd Allen SPHR CEBS SHRM-SCP Human Resources Director 2 Last year we informed you that we had undertaken a multi-year strategy to manage benefit costs to ensure continuation of a strong benefit package for our employees retirees and dependents. We implemented incremental changes in our plan design and cost share arrangements. In addition we encouraged our members to become educated consumers while taking advantage of wellness programs available to them with our health insurance carriers and WSSC. We appreciate your feedback about this approach and the changes that were made. While change is not an easy path to navigate we heard that your benefits are important to you and understanding them is the key to being an educated user of the services. Throughout this past year we continued to monitor the usage of our benefit plans and discussed possible strategies to ad- dress the projected increase in future benefit costs. The primary cost factors driving the increased spending in health care were high-cost claimants specialty pharmacy benefits and overall medical inflation. Historically we have had a very com- prehensive benefit plan compared to other public utilities. With the rising cost of health care a growing number of retirees under the age of 65 and evolving federal requirements we anticipate our costs will continue to increase if we do not take proactive steps on a regular basis. Earlier this year we officially implemented our new wellness program MyLife Wellbeing. This program offers employees the opportunity to participate in workshops and events and utilize resources to improve their overall health. This fall we will expand access to new health care tools programs i.e. tobacco cessation screenings and additional resources coaching and self-service decision-making tools to help members to become better health care consumers. For 2016 we will continue to implement incremental changes to our health and pharmacy plan design. Some examples include increasing health and pharmacy copays adding pharmacy adherence programs and moving the Medicare-eligible retiree pharmacy benefits from CVScaremark to SilverScript. We will however maintain the 2015 employerretiree cost share arrangement for another year. We encourage you to read this booklet to learn more about your benefits and take an active role in managing your health. Important Information about your Benefits for 2016 and Beyond 1 Take full advantage of the resources your health pharmacy and dental plans have to offer check out their websites for detailed information use their nurse line services and benefit from free preventive services and wellness visits. 2 Take time to evaluate your health plan options This is the perfect time to determine if you should remain in the plan you are enrolled in now or make a change. For example If you are enrolled in UnitedHealthcares POS plan compare the benefits you get from this higher premium plan to the UnitedHealthcare EPO plan you may find that your providers is in the EPO plan and by changing from the POS to the EPO you will save a substantial amount of money each year in your premium. 3 If you need to see a doctor and it is after hours or you cannot get an appointment right away you have a few options 4 Save money on medications. If you take a brand name medication ask your doctor if you are a good candidate for a generic substitute you will realize the savings when you pay your copay and still receive the treatment your doctor is prescribing. Also take advantage of the mail order program for maintenance medications. See page 13 for more details. 5 Ask questions For many of us it is uncomfortable to ask the doctor questions and to trust what heshe is telling us to do. We encourage you to be your own advocate Write down your questions before your doctors appointment take a family member or friend with you as a second set of ears to hear what the doctor is saying and be sure to get answers to all of your questions before the appointment ends. We recognize that change can be difficult however we all must take responsibility to control our rising costs make educated decisions about how we access our health care services and ultimately manage our health and lifestyle appropriately. Contact Carole Silberhorn at carole.silberhornwsscwater.com or Regina Rodriguez at regina.rodriguezwsscwater.com with your questions. Note Copay depends on which plan you are enrolled in. See Summary of Services for more details. What can you do to become an educated consumer Use For Average price Copay per visit Walk in clinic Vaccines ailments that are bothersome but not life-threatening 60 2025 Urgent Care Urgent but not severe problems that would warrant a trip to the hospital 131 2025 ER Situations that involve serious trauma or other life threatening conditions 1044 100 3 The Primary Care Physician PCP copay will increase to 25. The Specialist copay will increase to 30. The copay for Mental Health services outpatient will increase to 20. The out-of-pocket maximum for in-network services will be increased to 2500 per individual and 5000 per family. The out-of-pocket maximum for out-of-network services will be increased to 2500 per individual and 5000 per family. The out-of pocket maximum will be increased to 2000 per individual and 4500 per family. Effective January 1 2016 Medicare-eligible retirees andor their Medicare-eligible dependents who are enrolled in UnitedHealthcare will have their prescription drug coverage provided under the SilverScript Prescription Drug Plan PDP. Please see pages _____ for more information on this change. Kaiser members and non-Medi- care-eligible UnitedHealthcare members will not be affected by this change. The copay for non-preferred brand name drugs will increase to 45 for a 30-day supply and 85 for a 90-day supply. The Primary Care Physician PCP copay will increase to 20. The Specialist copay will increase to 25. The copay for Mental Health services outpatient will increase to 20 for individual and 10 for group therapy. In the past WSSC has deducted medical and dental premiums from your paycheck one month in advance. For example in September we deduct your premiums for the month of October. This schedule will be changed for calendar year 2016. Rather than deduct the premiums one month in advance we will deduct them the month of. For example in January we will deduct your January premiums. In order to change to the new deduction schedule there will be a skip on medical and dental deductions in December. Your new deductions as reflected on the 2016 rates on page 5 will start coming out of your January 1 2016 paycheck. We are pleased to announce that in 2016 we will be offering a voluntary vision plan through National Vision Administrators. Retirees must be enrolled in the medical plan to elect this benefit. It is 100 retiree paid there is no employer contribution. Complete details on the plan can be found on page 15 and the rates are on page 5. Highlights of Plan Changes for 2016 UnitedHealthcare POS UnitedHealthcare EPO Prescription Coverage for Medicare-eligible UnitedHealthcare Members- SilverScript CVScaremark Kaiser Deductions for Medical and Dental Vision 4 Anacostia Depot Multi-Purpose Room 301-206-4295 3500 Kenilworth Ave. Hyattsville MD 20781 October 14 2015 730 a.m.900 a.m. Gaithersburg Depot Multi-Purpose Room 301-206-7350 111 West Diamond Ave. Gaithersburg MD 20877 October 7 2015 700 a.m.830 a.m. Lyttonsville Depot Multi-Purpose Room 301-206-4086 2501 Lyttonsville Rd. Silver Spring MD 20910 October 28 2015 700 a.m.830 a.m. Richard G. Hocevar Building LK 120 121 301-206-8696 14501 Sweitzer Lane Laurel MD 20707 October 6 2015 800 a.m.100 p.m. Temple Hills Depot Multi-Purpose Room 301-206-7300 8444 Temple Hill Rd. Temple Hills MD 20748 October 21 2015 700 a.m.830 a.m. Brighton Dam 301-206-7485 2 Brighton Dam Road Brookeville MD 20833 October 8 2015 1130 a.m.1230 p.m. Consolidated Laboratory Conference Room behind Lobby 301-206-75757580 12245 Tech Road Silver Spring MD 20904 October 15 2015 1130 a.m.1230 p.m. Piscataway WWTP Conference Room 301-206-7420 11 Farmington Road West Accokeek MD 20708 October 21 2015 1245 p.m.300 p.m. Potomac WFP Multi-Purpose Room 301-206-7390 12200 River Road Potomac MD 20854 October 27 2015 700 a.m.800 a.m. Richard G. Hocevar Building LK 120 121 301-206-8696 14501 Sweitzer Lane Laurel MD 20707 October 22 2015 1100 a.m.200 p.m. Seneca WFP Multi-Purpose Room 301-206-7900 12600 Great Seneca Hwy. Germantown MD 20874 October 14 2015 700 a.m.800 a.m. Western Branch WWTP Conference Room 301-206-7550 6600 Crain Hwy. Upper Marlboro MD 20772 October 21 2015 700 a.m.830 a.m. Benefits Open Enrollment Schedule HR Outside Vendors HR Representatives Only October 2015 MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY 1 2 5 6 7 8 9 12 13 14 15 16 19 20 21 22 23 26 27 28 29 30 OPEN ENROLLMENT starts INFO SESSION RGH Open Enrollment Wellbeing Fair 800AM100PM INFO SESSION gaithersburg 700-830AM INFO SESSION brighton dam 700800aM HOLIDAY Columbus Day RGH Closed INFO SESSIONs anacostia 730900AM seneca 700800AM INFO SESSION lab 1130am1230pM temple hills 700830 AM western branch 700830 AM piscataway 1245300PM INFO SESSION RGH 1100 AM200PM INFO SESSION potomac 700800AM INFO SESSION lyttonsville 700830AM last day of OPEN ENROLLMENT INFO SESSIONs 5 For the 2016 plan year WSSC contributes 77 of the monthly premium towards the UnitedHealthcare Choice Plus POS plan and 79 of the monthly premium for all other health plans. There is no WSSC contribution to the Dental plans or Vision plan. Rates may vary based on years of service andor retirement status. If you were hired after April 1 1994 and have less than 20 years of service or you are a deferred retiree with less than 20 years of service you are subject to a higher perceptage of cost sharing than what is shown in this chart. Please contact HR for more details. Once you become eligible for Medicare Part B you must enroll. Your plan with WSSC will coordinate with Medicare to pay your medical bills. Please see pages 1824 in this booklet for more information. 2016 Medical Dental Vision Plan Rates for Retirees Plan Coverage Level Monthly Rate WSSC Monthly Contribution Retiree Monthly Deduction United Healthcare ChoicePlus POS Individual 1085.00 835.45 249.55 2-Person 2143.00 1650.11 492.89 Family 2710.00 2086.70 623.30 United Healthcare Medicare Supplement Individual Medicare 597.00 471.63 125.37 2-Person Medicare 1198.00 946.42 251.58 United Healthcare Select EPO Individual 745.00 588.55 156.45 2-Person 1491.00 1177.89 313.11 Family 2169.00 1713.51 455.49 Kaiser Permanente HMO Individual 537.00 424.23 112.77 2-Person 1073.00 847.67 225.33 Family 1626.00 1284.54 341.46 Individual Medicare 233.00 184.07 48.93 2-Person Medicare 466.00 368.14 97.86 Delta Dental PPO Individual 40.00 - 40.00 2-Person 67.00 - 67.00 Family 99.00 - 99.00 Delta Dental HMO Individual 21.00 - 21.00 2-Person 34.00 - 34.00 Family 50.00 - 50.00 National Vision Administrators Individual 3.49 - 3.49 Family 12.23 - 12.23 NOTE Must be enrolled in Retiree medical to participate in the vision plan. NOTES For the 2015 plan year WSSC contributes 77 of the monthly premium towards the United Healthcare Choice Plus POS plan and 79 of the monthly premium for all other health plans. 2016 Medical Dental Vision Plan Rates for WSSC Retirees There is no contribution to the dental plans or Vision plan. Rates may vary based on years of service andor retirement status. If you were hired after April 1 1994 and have less than 20 years of service or you are a deferred retiree with less than 20 years of service you are subject to a higher perceptage of cost sharing than what is shown in this chart. Please contact HR for more details. 6 Open Enrollment Activity Dates Open Enrollment begins October 5 2015 Open Enrollment information sessions See calendar on page 4 Open Enrollment ends October 30 2015 New Medical Dental and Vision deductions begin January 1 2016 Benefit plan elections take effect January 1 2016 Open Enrollment Timeline The purpose of this Open Enrollment Guide is to give you basic information about your benefit options and how to enroll for coverage or make changes to existing coverage. This guide is only a summary of your choices and does not fully describe each benefit option. For a more detailed description of benefits please refer to the plans benefit booklet brochure summary plan description SPD summary of benefits and coverage SBC or evidence of cover- age EOC. You may also call the plan using the customer service phone number on the last page of this booklet. Please note that plans will not cover a service if it is not considered medically necessary. Additionally if your physician or facility discontinues participation in a plan you will not be allowed to change plans outside the window of Open Enrollment as this is NOT considered a qualifying life event for you or your dependents. Every effort has been made to make the information contained in this booklet accurate however if there are discrepancies between this document and the contract with the carrier the contract will govern. Open Enrollment Period is October 5 October 30 2015. During Open Enrollment you have the following options Elect vision coverage if currently enrolled in medical. Change to a different health andor dental plan. Change coverage levels by adding or deleting dependents. Waive health andor dental coverage for the 2016 Plan Year. Update beneficiary information for Basic and Supplemental Life Insurance if applicable. Continue decrease or waive Supplemental Life Insurance if applicable. All changes become effective January 1 2016. If you are enrolling a dependent age 1926 for the first time you are required to complete an affidavit. Please see page 7 for information on dependent coverage. Medical Dental and Vision selections will be done on the Benefits Request Form that is enclosed with your open enrollment book. In order to validate your enrollment for 2016 the Benefit Request Form must be completed even if you arent making changes. Check to make sure both sides are completed and the request form is signed. Mail the completed form back to WSSC HR using the enclosed postage paid envelope. If you are changing plans you should receive your new ID cards no later than January 1 2016. Otherwise you will not receive a new card. Once Open Enrollment closes your selections are bind- ing and cannot be changed modified or canceled unless you have a qualified change of life event. See Change of Life Event section on page 8 for further details. Important Things To Remember PLEASE NOTE Any benefits change to add or delete dependents requires legal documentation before benefits will be available. See Insurance Coverage for Dependents section on page 7. 7 Eligible Dependents are a. A spouse husband or wife of the opposite or same sex with whom you are legally married b. An unmarriedmarried dependent child regardless of student status until the end of the birth month in which he or she reaches age 26 c. An unmarriedmarried dependent child who is incapable of self-support because of a mental and or physical disability and who depends on you for support. Ineligible dependents are domestic partners and civil union partners both same sex or opposite sex. The term Dependent child means any of the following a. Biological children b. Legally adopted children or children placed in the employees home pending final adoption c. Stepchildren d. Foster children e. Children who are under the legal guardianship of the employee f. Children for whom the employee is required to pro- vide health care coverage under a recognized Quali- fied Medical Child Support Order Coverage Effective Date for Newly Enrolled Dependents Coverage is effective on January 1 2016 for eligible newly enrolled dependents. Dependent Eligibility Verification In order to provide coverage for your newly enrolled dependents you must submit proper legal documentation to Human Resources no later than October 30 2015. Spouse marriage certificate Dependent child birth certificate Stepchild birth certificate AND marriage certificate. Foster child adopted child or child whom you have legal guardianship birth certificate AND legal docu- ments from the court. Any NEWLY ENROLLED dependent child between the ages of 19-26 Documents listed above AND a completed AND notarized affidavit. See below. Age Limits Dependent children may be covered through the end of the birth month in which they turn 26. Prior to January 1 2015 WSSC required a completed and notarized affidavit to cov- er any dependent children between the ages of 19-26. Now we will only require submission of an affidavit for newly enrolled dependents between the ages of 19-26. You will not need to submit an affidavit if your overage dependent child is already enrolled on our plans. The affidavit is in Human Resources and on the Intranet. Insurance Coverage for Dependents WHAT IF I HAVE QUESTIONS OR NEED ADDITIONAL INFO Contact the Benefits Team in Human Resources at hr_benefitswsscwater.com or call 301 206-7034. 8 According to the Internal Revenue Service IRS regulations that govern flexible benefit plans the optional Benefits you elect during enrollment must remain in effect throughout the calendar year unless you experience a qualified change of life event. If you decide to change your elections as the result of one of the events listed below you must do so within 30 days after the qualifying event. If you do NOT notify the Human Resources Office within 30 days after the event you cannot change your elections until the next annual open enrollment. You must provide the Human Resources Office with veri- fication of all change of life events. Change of Life Events Event Qualified Status Change How to begin If you experience a life change such as marriage legal separation divorce birth or adoption of a child or death If you your spouse or eligible dependent child experiences a change in employment status If you experience a loss of coverage due to relocation out of the Plans coverage area If your physician or facility discontinues participation in plan. Yes you have 30 days to notify Human Resources. Yes you have 30 days to notify Human Resources. Yes you have 30 days to notify Human Resources. No you must wait until the next open enrollment to change plans. Contact the Benefits Team in Human Resources and make a request to add or dropdelete dependents. Provide HR with certified docu- mentation such as a marriage license birth certificate divorce decree or other legal document. Contact the Benefits Team in Human Resources and make a request to add dependents to your existing plan. Provide HR with proof of previous coverage from the family members insurance carrier andor former employer. Contact the Benefits Team in Hu- man Resources and make a request to enroll in another health andor dental plan. Provide HR with proof of your new residence. You must wait until the next open enrollment to change plans. NOTE This chart applies only if you currently have coverage. 9 Copays PCP Specialists Deductibles Out-of-Pocket Maximum Child Preventive Visits Adult Preventive Visits Physician Office Visit PCP Sickness and Injury Specialist Office Visit Sickness and Injury Routine Gynecological Exam Mammogram Screening Cancer Screenings Prostate PAP Colorectal Allergy Office Visit Allergy Testing Allergy Injections Inpatient Hospital Facility Hospital Services Skilled Nursing Facility Inpatient Professional ServicesMedical Physician Services Surgery Anesthesia Diagnostic Radiology Pathology Physical Therapist Services Plan Benefits 25 30 NA 2500 Individual 5000 Family Covered at 100. Covered at 100. Covered at 100 after PCP copay. Covered at 100 after Special- ist copay non-routine care. Covered at 100. Covered at 100 for routine screenings. Covered at 100 for routine screenings. Diagnostic Lab covered at 100. Covered at 100 after applicable PCP or Specialist copay. Covered at 100 after applicable PCP or Specialist copay. Covered at 100 after applicable PCP or Specialist copay. Covered at 100. Covered at 100 Limited to 60 combined days per benefit year. Covered at 100. Covered at 100. Covered at 100. Please see Outpatient Rehabilitation Services. UnitedHealthcare Choice Plus POS In-Network NA 300 Individual 600 Family 2500 Individual 5000 Family Covered at 70 of Plan Allowance through age 18. Not subject to deductible. Covered at 70 of Plan Allowance after deductible. Covered at 70 of Plan Allowance after deductible. Covered at 70 of Plan Allowance after deductible. Covered at 70 of Plan Allowance after deductible. Covered at 70 of Plan Allowance. Not Subject to deductible. Covered at 70 of Plan Allowance after deductible. Covered at 70 of Plan Allowance after deductible. Covered at 70 of Plan Allowance after deductible. Covered at 70 of Plan Allowance after deductible. Covered at 70 of Plan Allowance after deductible. Covered at 70 of Plan Allowance after deductible Limited to 60 combined days per benefit year. Covered at 70 of Plan Allowance after deductible. Covered at 70 of Plan Allowance after deductible. Covered at 70 of Plan Allowance after deductible. Please see Outpatient Rehabilitation Services. UnitedHealthcare Choice Plus POS Out-of-Network 20 25 NA 2000 Individual 4500 Family Covered at 100. Covered at 100. Covered at 100 after PCP copay. Covered at 100 after Special- ist copay non-routine care. Covered at 100. Covered at 100 for routine screenings. Covered at 100 for rou- tine screenings. Diagnostic Lab covered at 100. Covered at 100 after applicable PCP or Specialist copay. Covered at 100 after applicable PCP or Specialist copay. Covered at 100 after applicable PCP or Specialist copay. Covered at 100. Covered at 100 Limited to 60 days per benefit year. Covered at 100. Covered at 100. Covered at 100. Please see Outpatient Rehabilitation Services. UnitedHealthcare Select EPO In-Network Only 20 25 Requires PCP referrals. NA 3500 Individual 9400 Family 0 Well Child Exams Immunizations. 0 copay for exam Immunizations. PCP copay waived for children under age 5. Specialist copay. Covered at 100. Covered at 100. Covered at 100. 20 copay PCP 25 copay Specialist. 20 copay PCP 25 copay Specialist. 20 copay. Covered at 100. Covered at 100 when deemed medically neces- sary Limited to 100 days per contract year. Covered at 100. Covered at 100. Covered at 100. Covered at 100. Kaiser Permanente HMO In-Network Only 2016 Medical Summary of Services This is a summary of health care benefits. In the event of a difference between this summary and the plan brochure the plan brochure will govern. Please Note Copay copayment charges are Per Visit unless specified otherwise. This chart does not apply to Medicare Eligible members. Please see pages 1823 for Medicare Supplement Plan details. No PCP or referrals required. 10 Outpatient Hospital FacilityDiagnostic Services Pre-admission testing Outpatient Professional Services Labs and X-Ray Surgery Maternity Benefits Hospitalization Birthing Center Professional Pre Postnatal Care Newborn Pediatric Inpatient Care Infertility Services Infertility Counseling and Testing Artificial Insemination In Vitro Fertilization Mental Health Substance Abuse Benefits-Inpatient Professional Mental Health Substance Abuse Benefits-Outpatient Professional Emergency Urgent CareIn Area In Office Urgent Care Center Plan Affiliated Emergency Room Ambulance Ground and Air Plan Benefits Covered at 100. Diagnostic Lab and X-Ray covered at 100. Profes- sional services covered at 100. Outpatient hospital covered at 100. Professional services covered at 100. Covered at 100. Covered at 100. Covered at 100 after the first visit to applicable PCP. Nursery care covered at 100. Covered at 100. Covered at 100 after applicable PCP or specialist copay limit of 3 attempts per live birth not to exceed lifetime limit 100000. Covered at 100. Covered at 100 after 20 copay. Covered at 100 after 25 copay. 100 copay for ER waived if admitted. Covered at 100 for emergencies and some non-emergency situations. UnitedHealthcare Choice Plus POS In-Network Covered at 100. Diagnostic Lab and X-Ray covered at 100. Profes- sional services covered at 100. Outpatient hospital covered at 100. Professional services covered at 100. Covered at 100. Covered at 100. Covered at 100 after the first visit to applicable PCP. Nursery care covered at 100. Covered at 100 after 50 coinsurance. 50 coinsurance limit of 3 attempts per live birth not to exceed lifetime limit 100000. Covered at 100. Covered at 100 after 20 copay. Covered at 100 after 20 copay. 100 copay for ER waived if admitted. Covered at 100 for emergencies and some non-emergency situations. UnitedHealthcare Select EPO In-Network Only Covered at 100. Covered at 100. Outpatient Specialty Imaging 50 copay 25 copay. Covered at 100. Covered at 100 if Kaiser authorized. 25 copay for initial visit then covered at 100. Covered at 100. 50 of allowable charges. 50 of allowable charges for up to 3 attempts per live birth. Not to exceed lifetime limit of 100000. Covered at 100. Copays 20 Individual and 10 group therapy. 25 copay. 100 copay for emergency room waived if admitted. 50 copay. Kaiser Permanente HMO In-Network Only 2016 Medical Summary of Services This is a summary of health care benefits. In the event of a difference between this summary and the plan brochure the plan brochure will govern. Please Note Copay copayment charges are Per Visit unless specified otherwise. This chart does not apply to Medicare Eligible members. Please see pages 1823 for Medicare Supplement Plan details. Covered at 70 of Plan Allowance after deductible. Covered at 70 of Plan Allowance after deductible. Covered at 70 of Plan Allowance after deductible. Covered at 70 of Plan Allowance after deductible. Covered at 70 of Plan Allowance after deductible. Covered at 70 of Plan Allowance after deductible. Covered at 70 of Plan Allowance after deductible. Covered at 70 of Plan Allowance after deductible. Covered at 70 of Plan Allowance after deductible Limit of 3 attempts per live birth not to exceed lifetime limit 100000. Covered at 70 of Plan Allowance after deductible. Covered at 70 of Plan Allowance after deductible. Covered at 100 after 20 copay. Covered at the network level. Covered at 100 for emergencies and some non-emergency situations. UnitedHealthcare Choice Plus POS Out-of-Network 11 Emergency Urgent CareIn Area In Office Continued Emergency Urgent CareOut of Area Out of Network Emergency Room or Urgent Care Center Outpatient Rehabilitative Services Physical Occupational and Speech Therapy Chiropractic Services Acupuncture Home Health Care Hospice Care Durable Medical Equipment Orthopedics Hearing Aids Audiometric Exam Evaluation Test Purchase and Fitting Vision Services Glasses Contacts Prescription Benefit Plan Benefits Covered at 100 after 100 copay waived if admitted. Non-emergency use no coverage. 25 copay for Urgent Care if participating facility. Covered at 100 after 30 copay short term non chronic conditions 60 visits per therapy per benefit year combined with non-net- work benefits. Covered at 100 after 30 copay up to 36 combined visits per benefit year. Covered at 100 after 30 copay up to 12 combined visits per benefit year. Covered at 100 120 com- bined visits per benefit year. Covered at 100 180 day combined lifetime maximum. Covered at 100. Shoe Orthotics limited to two pair every benefit year combined with non-net- work benefits. Covered at 80 limited to 1200 combined maximum every 3 benefit years. No dollar limit applies to children under the age of 26. Specialist copay for eye refractive exam every benefit year. Discounts on lenses and frames at participating providers. See full description of the CVScaremark Prescription Benefit on page 12. UnitedHealthcare Choice Plus POS In-Network Covered at the network level. Covered at 70 of Plan Allowance after deductible 60 visits per therapy per benefit year combined with network benefits. Covered at 70 of Plan Allowance after deductible up to 36 combined visits per benefit year. Covered at 70 of Plan Allowance after deductible up to 12 combined visits per benefit year. Covered at 70 of Plan Allowance after deductible 120 combined visits per benefit year. Covered at 70 of Plan Allowance after deductible 180 day combined lifetime maximum. Covered at 70 of Plan Allowance after deductible. Shoe Orthotics limited to two pair every benefit year combined with network benefits. Covered at 70 of Plan Allowance after deductible limited to 1200 combined maximum every 3 benefit years. No dollar limit applies to children under the age of 26. Covered at 70 after deductible one eye exam every benefit year. NA See full description of the CVScaremark Prescription Benefit on page 12. UnitedHealthcare Choice Plus POS Out-of-Network Covered at 100 after 100 copay waived if admitted. Non-emergency use no coverage. 20 copay for Urgent Care if participating facility. Covered at 100 after 25 copay Short term non chronic conditions 60 visits per benefit year. Covered at 100 after 25 copay up to 36 combined visits per benefit year. Covered at 100 after 25 copay up to 12 visits per benefit year. Covered at 100. Covered at 100. Covered at 100. Shoe Orthotics limited to two pair every benefit year. Covered at 80 limited to 1200 every 3 benefit years. No dollar limit applies to children under the age of 26. Specialist copay for eye re- fractive exam every benefit year. Discounts on lenses and frames at participating providers. See full description of the CVScaremark Prescription Benefit on page 12. UnitedHealthcare Select EPO In-Network Only 100 copay for emergency room waived if admitted 25 for urgent care. 25 copay limit 30 visits. 90 day limit for speech and occupational therapy. 25 copay 20 visits per calendar year. 25 copay 20 visits per calendar year. Covered at 100. Covered at 100. Covered at 100 when deemed medically necessary. Covered at 100 per each hearing impaired ear every 36 months for children up to age 26. 25 copay. 25 discount on eyeglasses and 15 initial fitting and purchase discount on contact lenses when pur- chased from plan providers. See Kaiser Pharmacy description on page 14. Kaiser Permanente HMO In-Network Only 2016 Medical Summary of Services This is a summary of health care benefits. In the event of a difference between this summary and the plan brochure the plan brochure will govern. Please Note Copay copayment charges are Per Visit unless specified otherwise. This chart does not apply to Medicare Eligible members. Please see pages 1823 for Medicare Supplement Plan details. 12 13 14 Prescription Benefits Prescription Benefits At-A-Glance For Non-Medicare prescription drug coverage When to Use Your Benefit Where Cost to You Web Services Kaiser Permanente Medical Center Preferred For immediate or short term prescriptions Prescriptions can be filled at a Kaiser Permanente Medical Center. Please Note Copays are lower when filled at a Kaiser Permanente Medical Center vs. a community network pharmacy. Up to a 30-day supply 10 for generic. 20 for brand name drugs. 40 for non-preferred drugs. Up to a 90-day supply 20 for generic. 40 for brand name drugs. 80 for non-preferred drugs. Community Based Network Pharmacy For immediate or short term prescriptions Prescriptions can also be filled at community pharmacies such as Giant Safeway Rite Aid Target Wal-Mart and K-Mart. Please Note Copays are higher when filled at a community network pharmacy. Up to a 30-day supply 20 for generic. 35 for brand name drugs. 50 for non-preferred drugs. Up to a 90-day supply 40 for generic. 70 for brand name drugs. 100 for non-preferred drugs. Mail Order Program Preferred For short term maintenance and long term prescriptions You can have prescriptions mailed right to your home through the Kaiser Permanente Mail order program. Up to a 90 day supply 20 for generic. 40 for brand name drugs. 80 for non-preferred drugs. Members are able to order prescription refills online or check the status of a prescription refill for yourself or another member and review a list of covered drugs though the members only section of the Kaiser Permanente web site www.kp.org. 15 National Vision Administrators L.L.C. Your NVA Vision Benefit Summary Schedule of Vision Benefits 16 Delta Dental PPO Plan Description Delta Dental offers fee-for-service dental benefits coupled with the cost management features of managed care. Subscribers have freedom of choice among dentists. Delta Dental has two networks of participating dentists Delta Dental Premier and Delta Dental PPOSM. Participating dentists complete and submit claim forms and participating dentists have agreed to accept Delta Dentals applicable Maximum Plan Allowances or their actual charge whichever is less the Allowed Amount as payment in full for covered services. The maximum benefit per person per year for services provided by PPO dentists is 1500. The maximum benefit per person per year for services provided by Premier or non-participating dentists is 1250. There is a separate 1500 lifetime maximum per person for orthodontic services covered for enrollees spouses and dependents to the end of the month of the 26th birthday. Subscribers who use non-participating dentists may need to file claim forms for reimbursement. Plan payments will be based on Delta Dentals applicable Maximum Plan Allowances or the dentists actual charge whichever is less the Allowed Amount. Diagnostic Preventive Services These services are covered at 100 if applicable. Allowed Amount with no deductible includes up to three oral exams per calendar year up to three bitewing x-rays in a calendar year one set of full mouth x-rays in a three- year period up to three prophylaxes teeth cleanings in a calendar year up to three fluoride treatments to age 19 in a calendar year sealants to age 14 once in any 36-month period on unfilled permanent first and second molars and space maintainers to age 14. Diagnostic Preventive Maximum Waiver Diagnostic and Preventive care will not count against your plan year maximum. Enhanced Benefits for Pregnancy Includes additional oral exam and choice of additional cleaning additional periodontal scalingroot planning or additional periodontal maintenance procedure. Percentage Paid by Delta Dental following 50 annual deductible for selected dental services not to exceed 150 for family level coverage Basic Restorative Silver white fillings Oral Surgery Extractions Endodontics Root canal therapy Crown Bridge Recementation Denture Repair Night Guards Injectable antibiotics Periodontics Treatment of gum disorders Major Restorative Crowns inlays onlays Prosthodontics Dentures bridges implants Orthodontics No Deductible 90 80 80 80 80 80 80 60 60 60 50 Refer to the plan brochure for complete list 17 Deltacare USA DHMO Plan Description Deltacare USA promotes great dental health for you and your family with quality dental benefits at an affordable cost. Deltacare USA plans are designed to encourage you and your family to visit the dentist regularly to main- tain your dental health. Today over 1.2 million enrollees are covered by Deltacare USA plans. When you enroll you select a primary contract dentist to provide services. The Deltacare USA network consists of private practice dental facilities that have been carefully screened for quality. Deltacare USA DHMO Enrollment Option Your chosen primary contract dentist will take care of the dental needs for each enrolled family member. If you require treatment from a specialist your primary dentist will handle the referral for you. A family may elect up to 3 dentists. After you have enrolled you will receive a membership packet that includes an identification card and an Evidence of Coverage that fully describes the benefits of your plan. Also included in this packet is the name address and phone number of your primary dentist. Under the Deltacare USA program many services are covered at no cost while others have copayments amount you pay your primary dentist for certain benefits. Please note Dental services that are not performed by your chosen primary dentist or are not covered under provisions for emergency care must be preauthorized by the Administrator to be covered by your Deltacare USA program. Please see complete fee schedule available at open enrollment meetings or by visiting Human Resources. NOTE Deltacare USA DHMO is available across the United States with the exception of MA MN ND. If you reside in MA MN or ND and wish to know more about your benefits please call Human Resources. PATIENT PAY Periodic oral exam D0120 No Charge Bitewing x-ray single film D0270 No Charge Prophylaxis cleaning adult D1110 5.00 Amalgam restoration single surface D2140 8.00 Crown porcelain fused to metal D2750 395.00 Root canal anterior 125.00 Complete denture maxillary D5110 365.00 18 WSSC requires that its retirees enroll for Medicare part B when eligible. Most people become eligible at age 65 but you could be- come eligible sooner if disabled. You should receive information from the Social Security Administration when you become eligi- ble for Medicare Part B however if you do not it is your responsibility to contact them. Failure to enroll in Medicare Part B could compromise your eligibility for WSSC medical and prescription benefits andor subject you to permanent premium penalties. Once you are enrolled in Medicare Parts A B you must send a copy of your Medicare ID card to the WSSC HR Department so that we can ensure that you are enrolled in the proper medical and prescription plans. UnitedHealthcare members are then moved into the UnitedHealthcare Medicare Supplement Plan and the SilverScript Prescription Drug Plan PDP. Please refer to pages 2123 to learn more about SilverScript. Kaiser members transition into the Kaiser Medicare Plus plan but they must also complete the Kaiser Medicare Plus application and return it directly to Kaiser. You should not enroll in an individual Medicare Part D program if you are enrolled in one of the WSSC health insurance plans because Medicare does not allow you to enroll in two Part D plans. Enrolling in an individual plan could compromise your eligibility for WSSC sponsored medical and prescription coverage. Medicare-Eligible Retirees and Dependents Medicare is a national health insurance program covering individuals age 65 and older younger people with disabilities and people with end stage renal disease kidney failure. Medicare Part A Hospital Insurance helps cover inpatient care in hospitals including critical access hospitals inpatient rehabilitation facilities and long-term care hospitals inpatient care in a skilled nursing facility not custodial or long-term care hospice care services home health care services and inpatient care in a Religious Nonmedical Health Care Institution. Certain conditions must be met to get these benefits. Medicare Part B Medical Insurance helps cover medically necessary services like physician services outpatient care home health care services and other medical services. Medicare Part B also covers some preventive services. Medicare Part D offers coverage for prescription drugs. Medicare doesnt cover everything. If you need services that Medicare doesnt cover you will have to pay out of pocket un- less you have other insurance such as a Medicare Supplement Plan to cover the costs. Even if Medicare covers a service or item you generally have to pay deductibles coinsurance and copayments. To find out if Medicare covers a service you need visit www.medicare.gov and select Find Out What Medicare Covers or call 1-800-MEDICARE 1-800-633-4227. Once youre enrolled in Medicare Parts A B your coverage will be changed to the Medicare Supplement Plan. The Medicare Supplement Plan is designed to work in conjunction with your Medicare plan to supplement benefits that Medicare does not offer. When you change to a Medicare Supplement plan offered through WSSC you are still considered a member of that health plan and may still be governed by the health plans rules on physician and hospital selection referrals to a specialist and places where you can receive diagnostic testing or have prescriptions filled. Listed below are some services that are not covered or paid in full by Medicare Part A andor Part B but would be covered or paid in full by your Medicare Supplement plan. Medicare Summary Medicare Parts A B Medicare Supplement Plan Deductible on your first hospital admission for each benefit period Daily copayment on hospital days 61-90 Daily coinsurance for days 21-100 in each benefit period for skilled nursing care Deductible for medical services covered under Part B Routine eye exams or eyeglasses Hearing aids or routine hearing loss exams Pays for the hospital deductible Pays for the hospital copayment Pays the daily coinsurance for skilled nursing care Pays the deductible Covers routine eye exams and offer discounts on eyeglass frames lenses Most of the Medicare Supplement plans offer a hearing exam as part of the annual physical. Hearing aids are not covered 19 n IM TURNING 65 THIS YEAR HOW DOES MEDICARE WORK WITH MY INSURANCE You must enroll in Medicare Parts A B when eligible. WSSCs insurance carriers will coordinate your benefits with Medicare once HR receives a copy of your Medicare ID card. If you are enrolled in Kaiser you will transition to the Kaiser Medicare Plus Plan. If you are enrolled in UnitedHealthcare you will transition from the UnitedHealthcare EPO or POS plan to the UnitedHealthcare Medicare Supplement plan. Medicare will cover approximately 80 of your medical expenses and your WSSC plan will cover the remaining 20. You may still have a copay depending on which plan you select. nWHAT IF IM NOT 65 BUT HAVE MEDICARE PARTS A B DUE TO A DISABILITY You must submit a copy of your Medicare ID card to the WSSC HR department so that WSSCs insur- ance carriers can coordinate your benefits with Medicare. Medicare will cover approximately 80 of your medical expenses and your WSSC plan will cover the remaining 20. You may still have a copay depending on which plan you select. nWhat happens to my prescription coverage when I am eligible for Medicare Parts A B If you are enrolled in Kaiser you will transition to the Kaiser Medicare Plus Plan and your prescription benefit will continue to be administered by Kaiser. You may refer to the chart on page 20 for the copays for Kaiser Medicare Plus members. If you are enrolled in UnitedHealthcare you will transition from the UnitedHealthcare EPO or POS plan to the UnitedHealthcare Medicare Supplement plan. Currently CVScaremark administers the prescrip- tion benefits for all UnitedHealthcare members. Effective January 1 2016 members who are enrolled in UnitedHealthcare and are Medicare-eligible will transition from CVScaremark to SilverScript. Please refer to pages 2123 for more information about the SilverScript PDP and page 12 for the copays. nIF MEDICARE DOES NOT PAY A MEDICAL BILL BECAUSE A SERVICE IS NOT COVERED WILL MY SUPPLEMENTAL PLAN PAY THE BILL No. Your doctor must accept Medicare in order for your WSSC plan to pay up to the 20. This is the same for medical services they must be Medicare approved for your WSSC coverage to pay their por- tion of the bill. Make sure to check with your physician or visit www.medicare.gov or call 1-800-MEDI- CARE before you have any tests surgeries etc. to make sure it is covered by Medicare. nWHAT IF MY SPOUSE TURNS 65 BEFORE ME or I TURN 65 BEFORE MY SPOUSE When one member is enrolling in Medicare your WSSC insurance enrollment is modified from a two-person or family plan to a split plan. The Medicare-eligible enrollee will have the Medicare Supplement Plan while the other member who is not eligible for Medicare will continue with their cur- rent plan. You will see separate deductions for these plans on your pension check. n WHAT HAPPENS TO MY MONTHLY BENEFIT DEDUCTION Once the Benefits Team has a copy of your Medicare ID card to verify you have successfully enrolled in Medicare Parts A B your monthly deductions will be updated. Each carrier has different premiums for their Medicare Supplement plan. Please refer to the rates on page 5 of this booklet. n WHAT IF I HAVE QUESTIONS OR NEED ADDITIONAL FORMS You may contact the Open Enrollment phone line at 301-206-7034 or email openenrollment wsscwater.com. Please leave your full name I.D. number home address and phone number. Medicare Frequently Asked Questions 20 Plan Benefits UnitedHealthcare PPO Kaiser Permanente Medicare Supplement Medicare Plus Doctor and Hospital Choice Annual Physical Inpatient Hospital Care Doctors Office Visits Diagnostic Tests X-rays Lab Services Emergency Room Services Prescriptions Durable Medical Equipment Vision Services Primary Insurance Secondary Insurance You may choose any doctor or hospital that accepts Medicare Covered at 100 Plan pays 100 of covered charges remaining after Medicare Plan pays 100 of covered charges remaining after Medicare Plan pays 100 of covered charges remaining after Medicare Plan pays 100 of covered charges remaining after Medicare See Caremark on page 12. Copays for SilverScript are the same as the CVS caremark commercial plan. Plan pays 100 of covered charges remaining after Medicare. Prior notification required. Plan pays 100 after 25 copay for a refractive eye examination every calendar year at participating providers discounts on frames and lenses at participating providers. Medicare Parts A B UnitedHealthcare You may choose any Kaiser Permanente network doctor specialist and participating hospital. Specialty care may require a referral from your Primary Care Physician. Covered in full after 15 copay Unlimited days for a Medicare covered stay in a network hospital are covered in full after 100 copay 15 copay 15 copay for radiation therapy no charge for XRays lab services or diagnostic tests 50 copay copay waived if admitted 10 copay for up to a 90 day supply of mail order medicine brand or generic 15 copay for up to a 60 day supply brand or generic at Kaiser Permanente center pharmacy 25 copay for up to a 60 day supply brand or generic at participating network pharmacy. Covered in full through participating providers 15 copay for eye exam discounts on frames lenses and contact lenses Kaiser Permanente Medicare Parts A B D This is a summary of health care benefits. In the event of a difference between this summary and the plan brochure the plan brochure will govern. All WSSC sponsored health plans provide supplemental coverage for retirees with Medicare Part A and Part B. Benefits under the UnitedHealthcare and Kaiser Medicare Supplements differ from non-Medicare benefit plans and are described below. Medicare-eligible Summary of Services 21 SilverScript Prescription Drug Coverage for Medicare-eligible UnitedHealthcare Members Effective January 1 2016 Medicare-eligible Washington Suburban Sanitary Commission WSSC retirees andor their Medi- care-eligible dependents who are enrolled in UnitedHealthcare will have their prescription drug coverage provided under the SilverScript Prescription Drug Plan PDP sponsored by WSSC and administered by SilverScript Insurance Company SilverScript a CVScaremark company. Medicare-eligible Kaiser Permanente Health Plan members will not be affected by this change. About SilverScript Q. How will SilverScript work A. There will be two plan components working together as a single plan that will be administered by SilverScript 1. A component that will provide Federal government-approved standard Medicare Part D prescription benefits known as an Employer Group Waiver Plan or EGWP and 2. Asecond component often referred to as a Wrap or Wraparound that will help maintain current coverage levels. Eligibility Q. Who will be automatically enrolled in the plan for 2016 A. Individuals that Have prescription drug coverage through the CVScaremark Commercial plan and are Medicare-eligible retirees Medicare-eligible dependents of retirees or Medicare-eligible survivors and are enrolled in Medicare Parts A andor B. Note The current CVScaremark Commercial plan will continue to be offered to non-Medicare eligible plan participants. Q. Who will not be enrolled in SilverScript A. Individuals who are Active WSSC employees and their enrolled dependents WSSC retirees dependents or survivors who are not yet eligible for Medicare Medicare-eligible WSSC retirees dependents or survivors who are not enrolled in Medicare Parts A andor B Retirees dependents or survivors who do not have prescription coverage provided by WSSC or who are covered under an active WSSC employees plan Enrolled in the Kaiser Permanente Health Plan regardless of Medicare eligibility and Retirees and dependents residing outside the United States i.e. those not residing in the fifty federated states District Of Co- lumbia American Samoa Guam the Northern Mariana Islands or Puerto Rico or who are incarcerated. Q. Will only those age 65 and over be enrolled in SilverScript A. No. Enrollment is based on Medicare eligibility not age. This means that retirees and their covered dependents under age 65 who are eligible for Medicare and are enrolled in Medicare Parts A andor B will be enrolled in SilverScript. Q. My family has split coverage meaning that one or more of my covered family members are Medicare-eligible and one or more is not eligible for Medicare. Will the SilverScript plan apply to all of us or just to those who are Medicare-eligible A. SilverScript will apply only to those individuals who are eligible for Medicare and enrolled in Medicare Parts A andor B. Individuals who are not eligible for Medicare will continue to have their benefits administered by CVScaremark under the current Commercial plan. Q. I will be turning age 65 in 2016 and will become eligible for Medicare what will happen to my prescription plan coverage A. Prior to becoming eligible for Medicare you will receive information from WSSC about your benefits and how they will coordinate with Medicare. You must enroll in Medicare Parts A and B when eligible and you must provide WSSC with your Medicare ID card as soon as you receive it. At that point WSSC will begin the process of enrolling you in SilverScript. 22 What You Need to Do or Not Do Q. Do I need to do anything before during or after Open Enrollment A. If you are currently Medicare-eligible and enrolled in Medicare Parts A andor B enrolled in the CVScaremark Commercial plan with WSSC and want to keep your current benefits you do not need to do anything the change to SilverScript will be automatic. During the month of October WSSC will begin the process of enrolling you in SilverScript for a January 1 2016 effective date. Note If you are eligible for Medicare but not currently enrolled in Medicare Parts A and Part B you must enroll in both parts call 1-800-MEDICARE immediately. You must be enrolled in Medicare Parts A andor B before becoming eligible for coverage under SilverScript. Failure to enroll in Medicare could result in the loss of both WSSC sponsored Medical and Prescription Drug coverage. Important In November those who will be enrolled in SilverScript will receive a letter from SilverScript advising them that they may opt out of SilverScript and cancel coverage for 2016. This letter is one of many communications required by the Centers for Medicare and Medicaid Services CMS. PLEASE BE AWARE THAT if you opt out and cancel coverage you will have no prescrip- tion drug coverage through WSSC effective January 1 2016. If you wish to have prescription drug coverage provided by WSSC do not opt out of SilverScript. Q. I am currently covered by the CVScaremark Commercial plan with WSSC. Do I need to enroll in a Medicare Part D plan on my own or will the change to SilverScript be automatic in January 2016 A. You should not enroll in an individual Medicare Part D plan on your own if you wish to be covered by the WSSC plan. If you enroll in a Medicare Part D plan on your own your coverage through WSSC will automatically be cancelled because the Federal govern- ment does not allow coverage under two Medicare Part D plans. WSSC will take the necessary steps to enroll you in the SilverScript. The change will be automatic if you are eligible for Medicare are enrolled in Medicare Parts A andor B and have prescription coverage through WSSC excluding Kaiser. Q. Can I opt out of the SilverScript and keep my current CVScaremark Commercial plan A. No. Q. Can I cancel my WSSC coverage before 2016 and enroll in a standard Medicare Part D Prescription Drug Plan that is not offered by WSSC A. Yes but remember that the WSSC plan includes a second component that will provide benefits above and beyond the standard gov- ernment-approved Medicare Part D prescription benefits to help maintain current coverage levels i.e. the Wrap. The benefits of this second component will not be available to you if you enroll in a plan not offered through WSSC. In addition since the prescrip- tion drug coverage is linked to your health insurance election a decision to cancel your prescription drug coverage will also cancel your medical coverage. Q. Should I fill my prescriptions before the transfer to SilverScript occurs January 1 2016 A. This is recommended if in December you have prescriptions that are close to the expiration date or have no remaining refills. Q. After the transfer to SilverScript occurs January 1 2016 is there anything I will need to do differently when filling a prescription besides pre- senting my new SilverScript ID card at retail pharmacies A. If you have refills remaining as of December 31 2015 they will transfer to SilverScript for 2016. However if you have no refills re- maining you will be required to obtain a new prescription from your doctor even if you have prescriptions automatically refilled. Premiums and Subsidies Q. Is there a subsidy available for low income retirees A. Yes under certain circumstances covered members may be eligible for a Low Income Subsidy. Low income status is determined by either the Social Security Administration SSA or the State Medicaid office. Generally those eligible include individuals with income less than 150 of Federal Poverty Level 17655 for single persons in 2015 and with total resources less than 13640 for single persons in 2015. For more details visit the SSA website at www.socialsecurity.gov or call 1-800-772-1213 TTY 1-800-325-0778. Q. Can you explain the extra amount high income retirees are required to pay A. Medicare Part D requires that Part D plan participants who are determined to be high income retirees be charged an Income Related Monthly Adjustment Amount or IRMAA. This IRMAA charge will apply because SilverScript is a Medicare Part D plan. The SSA SilverScript Prescription Drug Coverage contd 23 determines who is considered a high income retiree based on tax status and yearly income as reported on IRS tax returns from two years ago. The IRMAA charge will be deducted directly from the members Social Security check. In some instances the SSA will bill affected retirees directly. To keep their coverage high income retirees in the SilverScript plan must pay this amount to SSA. In 2015 monthly IRMAA charges range from 12.30 to 70.80 per person and are based on modified adjusted gross income MAGI. 2016 IRMAA charges have not been released by CMS or the Social Security Administration SSA. Plan Benefits Q. Can I continue to use a retail pharmacy other than a CVS pharmacy A. Yes you may use one of the over 68000 participating pharmacies currently available to you such as Giant Walgreens and Walmart. Q. Will I still be able to save money by using Maintenance Choice for my maintenance medications A. For maintenance medications long-term medications taken regularly for chronic conditions such as high blood pressure high cholesterol or diabetes or long-term therapy you will still be able to fill up to a 90-day prescription at either a CVS pharmacy retail location or through CVScaremark Mail Service Pharmacy and pay only one mail order copay for a 90-day supply. In addition you may fill a 90-day prescription at a retail pharmacy other than a CVS pharmacy however your total copay will equal three 30-day copays. Q. Will there be a different formulary for SilverScript A. No. Like today you will use the CVScaremark Preferred Drug List PDL. However the Medicare Part D part of SilverScript also uses a CMS formulary you may receive CMS required mailings regarding this formulary stating that certain drugs are not covered. In most cases you may disregard these CMS letters because the wrap fea- ture will pick up coverage of those medications because it uses the same more comprehensive formulary used by the current CVS caremark Commercial plan. Q. Will my prescriptions with prior authorizations called letters of medical necessity transfer to SilverScript A. NO. If you have a prior authorization in place for a medication you must obtain a new approval from the plan. If you are taking a medication that requires a prior authorization it will be covered for a limited time period during the transition from the CVScare- mark Commercial plan to SilverScript to allow you time to get a new prior authorization approved. SilverScript ID Cards Q. Will I use the same ID card my current CVScaremark card at the retail pharmacy A. No. In November SilverScript ID cards will be mailed to all WSSC participants that are successfully enrolled in the plan. The Silver- Script ID card must be used beginning January 1 2016. Future enrollees will receive new ID cards prior to their effective date. Q. If I have split family coverage will we use different cards A. Yes. If you have split family coverage meaning that one or more of your covered family members is Medicare-eligible and one or more is not those who are Medicare-eligible will receive the new SilverScript ID card. Those who are not Medicare-eligible will continue to use the current CVScaremark card with the retirees name and ID. SilverScript Prescription Drug Coverage contd If your filing status and yearly income in 2013 was File individual tax return File joint tax return File married You pay monthly separate tax return in 2015 85000 or less 170000 or less 85000 or less your plan premium above 85000 up to 107000 above 170000 up to 214000 not applicable 12.30 your plan premium above 107000 up to 160000 above 214000 up to 320000 not applicable 31.80 your plan premium above 160000 up to 214000 above 320000 up to 428000 above 85000 up to 129000 51.30 your plan premium above 214000 above 428000 above 129000 70.80 your plan premium 24 Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with the Washington Suburban Sanitary Commission WSSC and about your options under Medicares prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining you should compare your current coverage including which drugs are covered at what cost with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicares prescription drug coverage 1.Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan like an HMO or PPO that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2.WSSC has determined that the prescription drug coverage offered by WSSCs UnitedHealthcare Medical Plans through CVS Caremark RX Services and WSSCs Kaiser Medical Plan is on average for all plan participants expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage you can keep this coverage and not pay a higher premium a penalty if you later decide to join a Medicare drug plan. n When Can You Join A Medicare Drug Plan You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th through December 7th. However if you lose your current creditable prescription drug coverage through no fault of your own you will also be eligible for a two 2 month Special Enrollment Period SEP to join a Medicare drug plan. n What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan If you decide to join a Medicare drug plan your current WSSC coverage will be affected. If you are enrolled in the UnitedHealthcare Medicare Supplement your prescription coverage is provided to you through CVS Caremark. If you elect a Medicare drug plan and you have CVS Caremark prescription coverage then you will no longer be eligible for prescription coverage under CVS Caremark. If you are enrolled in the Kaiser Medicare Plus Supplement then you do not have to elect Medicare Part D as it is automatic when enrolled in that plan. If you do decide to join a Medicare drug plan and drop your current WSSC medical coverage be aware that you and your dependents will not be able to get this coverage back. n When Will You Pay A Higher Premium Penalty To Join A Medicare Drug Plan You should also know that if you drop or lose your current coverage with your WSSCs Medical Plan and dont join a Medicare drug plan within 63 continuous days after your current coverage ends you may pay a higher premium a penalty to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage your monthly premium may go up by at least 1 of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example if you go nineteen months without creditable coverage your premium may consistently be at least 19 higher than the Medicare base beneficiary premium. You may have to pay this higher premium a penalty as long as you have Medicare prescription drug coverage. In addition you may have to wait until the following October to join. Certificate of Creditable Coverage for Medicare Part D Important Notice from WSSC About Your Prescription Drug Coverage and Medicare 25 n For More Information About This Notice Or Your Current Prescription Drug Coverage Contact our office for further information at 301-206-8696 or email openenrollmentwsscwater.com. NOTE Youll get this notice each year. You will also get it before the next period you can join a Medicare drug plan and if this coverage through WSSC changes. You also may request a copy of this notice at any time. n For More Information About Your Options Under Medicare Prescription Drug Coverage More detailed information about Medicare plans that offer prescription drug coverage is in the Medicare You handbook. Youll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. n For more information about Medicare prescription drug coverage Visit www.medicare.gov Call your State Health Insurance Assistance Program see the inside back cover of your copy of the Medicare You handbook for their telephone number for personalized help. Call 1-800-MEDICARE 1-800-633-4227. TTY users should call 1-877-486-2048. If you have limited income and resources extra help paying for Medicare prescription drug coverage is available. For information about this extra help visit Social Security on the web at www.socialsecurity.gov or call them at 1-800-772-1213 TTY 1-800-325-0778. Remember Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and therefore whether or not you are required to pay a higher premium a penalty. Certificate of Creditable Coverage for Medicare Part D Important Notice from WSSC About Your Prescription Drug Coverage and Medicare contd Date October 1 2015 Name of EntitySender Washington Suburban Sanitary Commission ContactPositionOffice Human Resources DepartmentBenefits Address 14501 Sweitzer Lane Laurel MD 20707-5902 Phone Number 301-206-8696 CMS Form 10182-CC Updated September 14 2012. 26 ANNUAL DISCLOSURE NOTICE WOMENS HEALTH AND CANCER RIGHTS ACT WHCRA If you have had or are going to have a mastectomy you may be entitled to certain benefits under the Womens Health and Cancer Rights Act of 1998 WHCRA. For individuals receiving mastectomy related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient for All stages of reconstruction of the breast on which the mastectomy was performed. Surgery and reconstruction of the other breast to produce a symmetrical appearance. Prostheses. Treatment of physical complications of the mastectomy including lymphedema. Our medical plans comply with these requirements. Benefits for these items generally are comparable to those provided under our plan for similar types of medical services and supplies. Coverage for these items may be subject to annual deductibles and coinsurance provisions as may be deemed appropriate and are consistent with those established for other benefits under the plan or coverage. Our plan neither imposes penalties for example reducing or limiting reimbursement nor provides incentives to induce providers to provide care inconsistent with these requirements. THE NEWBORNS AND MOTHERS HEALTH PROTECTION ACT NMHPA You have specific rights under the Act which protect you and your newborns. These rights include Coverage for a hospital stay of up to 48 hours for a vaginal birth and 96 hours for a cesarean section delivery without previous authorization. A plan cannot provide incentives to a mother or Provider to encourage a shorter stay. A plan cannot penalize a mother or Provider to encourage a shorter stay. A plan must provide notice of these rights with respect to the hospital lengths of stay in connection with child birth. Our Medical Plans comply with these requirements. CHILD HEALTH INSURANCE PROGRAM CHIP If you or your children are eligible for Medicaid or CHIP and youre eligible for health coverage from your employer your state may have a premium assistance program that can help pay for coverage using funds from their Medicaid or CHIP programs. If you or your children arent eligible for Medicaid or CHIP you wont be eligible for these premium as- sistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP as well as eligible under your employer plan your employer must allow you to enroll in your employer plan if you arent already enrolled. This is called a special enrollment opportunity and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA 3272. Legislative Information 27 CHIP continued If you live in one of the following states you may be eligible for assistance paying your employer health plan premi- ums. The following list of states is current as of July 31 2015. Contact your State for more information on eligibility To see if any other states have added a premium assistance program since July 31 2015 or for more information on special enrollment rights contact either U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare Medicaid Services www.dol.govebsa www.cms.hhs.gov 1-866-444-EBSA 3272 1-877-267-2323 Menu Option 4 Ext. 61565 CHILDRENS HEALTH INSURANCE PROGRAM REAUTHORIZATION ACT CHIPRA SPECIAL ENROLLMENT RIGHTS Effective April 1 2009 the Childrens Health Insurance Program Reauthorization Act CHIPRA creates two new special enrollment rights for employees and their dependents. All group health plans must permit eligible employees and their dependents to enroll in an employer plan if the employee requests enrollment under the group health plan within 60 days of the occurrence of following events 1. Loss of coverage under Medicaid or a state child health plan. 2. Gaining eligibility for coverage under Medicaid or a state child health plan The Eligible Person previously declined coverage under the Plan. 3. Event Takes Place for example a birth marriage or determination of eligibility for state subsidy. 4. Missed Initial Enrollment Period or Open Enrollment Period. Please note Once you terminate your enrollment in our group health plan your childrens enrollment will also be terminated. Failure to notify us of your loss or gain of eligibility for coverage under Medicaid or a state childrens health plan within 60 days will prevent you from enrolling in our plans andor making any changes to your coverage elections until our next open enrollment period. To request special enrollment or if you have questions regarding these disclosures please contact the Benefits Team at hr_benefitswsscwater.com. You may also find more information by visiting httpwww.dol.govebsaconsumer_info_health.html. Legislative Information FLORIDA Medicaid PENNSYLVANIA Medicaid WEST VIRGINIA Medicaid www.flmedicaidtplrecovery.com www.dpw.state.pa.ushipp www.dhhr.wv.govbms 1-877-357-3268 1-800-692-7462 1-877-598-5820 HMS 3rd Party Liability GEORGIA Medicaid VIRGINIA Medicaid and CHIP www.dch.georgia.gov Medicaid Website Phone Click on Programs then Medicaid then www.coverva.orgprograms_premium_assistance.cfm Health Insurance Premium Payment HIPP 1-800-432-5924 1-800-869-1150 CHIP Website Phone www.coverva.orgprograms_premium_assistance.cfm 1-855-242-8282 28 Washington Suburban Sanitary Commission and its affiliated entities NOTICE OF PRIVACY PRACTICES Revision Date September 23 2013 Release Date November 22 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US. The following entities owned by or affiliated with WSSC are covered by this notice This notice applies to the privacy practices of the health plans listed below. As affiliated related entities we might share your protected health information and the protected health information of others on your insurance policy as needed for payment or health care operations. UnitedHealthcare Kaiser Permanente CVScaremark Delta Dental and National Vision Administrators HIPAA Our Legal Duty This Notice describes our privacy practices which include how we might use disclose share or give out collect handle and protect our members protected health information. We are required by certain federal and state laws to maintain the privacy of your protected health information. We are also re- quired to give you this notice about our privacy practices our legal duties and your rights concerning your protected health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes ef- fect September 23 2013 and is an amendment of WSSCs prior notice of privacy practices. We reserve the right to change our privacy practices and the terms of this notice at any time as long as law permits the changes. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all protected health information that we maintain including protected health information we created or received before we made the changes. If we make a sig- nificant change in our privacy practices we will change this notice and send the new notice to our health plan subscribers within sixty days of the effective date of the change. You may request a copy of our notice at any time. For more information about our privacy practices or for additional copies of this notice please contact us using the information listed at the end of this notice. Uses and Disclosures of Medical Information Primary Uses and Disclosures of Protected Health Information We use and disclose protected health information about you for payment and health care operations. The federal health care Pri- vacy Regulations generally do not preempt or take precedence over state privacy or other applicable laws that provide individ- uals greater privacy protections. As a result to the extent state law applies the privacy laws of a particular state or other federal laws rather than the HIPAA Privacy Regulations might impose a privacy standard under which we will be required to oper- ate. For example where such laws have been enacted we will follow more stringent state privacy laws that relate to uses and disclosures of the protected health information concerning HIV or AIDS mental health substance abusechemical dependency genetic testing and reproductive rights. In addition to these state law requirements we also may use or disclose protected health information in the following situations Payment We might use and disclose your protected health information for all activities that are included within the defini- 29 tion of payment as written in the Federal Privacy Regulations. For example we might use and disclose your protected health information to pay claims for services provided to you by doctors hospitals pharmacies and others for services delivered to you that are covered by your health plan. We might also use your infor- mation to determine your eligibility for benefits to coordinate benefits to examine medical necessity to obtain premiums and to issue explanations of benefits to the person who subscribes to the health plan in which you participate. Health Care Operations We might use and disclose your protect- ed health information for all activities that are included within the definition of health care operations as defined in the Federal Privacy Regulations. For example we might use and disclose your protected health information to determine our premiums for your health plan to conduct quality assessment and improvement activities to engage in care coordination or case management and to manage our business. Business Associates In connection with our payment and health care operations activities we contract with individuals and enti- ties called business associates to perform various functions on our behalf or to provide certain types of services such as member service support utilization management subrogation or pharmacy benefit management. To perform these functions or to provide the services our business associates will receive create maintain use or disclose protected health information but only after we require the business associates to agree in writing to con- tract terms designed to appropriately safeguard your information. Other Covered Entities In addition we might use or disclose your protected health information to assist health care providers in connection with their treatment or payment activities or to assist other covered entities in connection with certain of their health care operations. For example we might disclose your protected health information to a health care provider when needed by the provider to render treatment to you and we might disclose protected health information to another covered entity to conduct health care oper- ations in the areas of quality assurance and improvement activities or accreditation certification licensing or credentialing. Other Possible Uses and Disclosures of Protected Health Infor- mation The following is a description of other possible ways in which we might and are permitted to use andor disclose your protected health information. To You or with Your Authorization We must disclose your pro- tected health information to you as described in the Individual Rights section of this notice. You may give us written authoriza- tion to use your protected health information or to disclose it to anyone for any purpose not listed on this notice. If you give us an authorization you may revoke it in writing at any time. Your revocation will not affect any use or disclosures that we made as permitted by your authorization while it was in effect. Without your written authorization we might not use or disclose your protected health information for any reason except those de- scribed in this notice. Disclosures to the Secretary of the U.S. Department of Health and Human Services We are required to disclose your protected health information to the Secretary of the U.S. Department of Health and Human Services when the Secretary is investigating or determining our compliance with the federal Privacy Regulations. To Plan Sponsors Where permitted by law we may disclose your protected health information to the plan sponsor of your group health plan to permit the plan sponsor to perform plan admin- istration functions. For example a plan sponsor may contact us seeking information to evaluate future changes to your benefit plan. We may also disclose summary health information this type of information is defined in the Federal Privacy Regulations about the enrollees in your group health plan to the plan sponsor to obtain premium bids for the health insurance coverage offered through your group health plan or to decide whether to modify amend or terminate your group health plan. To Family and Friends If you agree or if you are unavailable to agree such as in a medical emergency situation we might disclose your protected health information to a family member friend or other person to the extent necessary to help with your health care or with payment for your health care. Underwriting We might receive your protected health informa- tion for underwriting premium rating or other activities relating to the creation renewal or replacement of a contract of health in- surance or health benefits. We will not use or further disclose this protected health information received under these circumstances for any other purpose except as required by law unless and until you enter into a contract of health insurance or health benefits with us. In addition we will not use your genetic information for underwriting purposes. Health Oversight Activities We might disclose your protected health information to a health oversight agency for activities au- thorized by law such as audits investigations inspections licen- sure or disciplinary actions or civil administrative or criminal proceedings or actions. Oversight agencies seeking this informa- tion include government agencies that oversee i the health care system ii government benefit programs iii other government regulatory programs and iv compliance with civil rights laws. Abuse or Neglect We might disclose your protected health information to appropriate authorities if we reasonably believe that you might be a possible victim of abuse neglect domestic violence or other crimes. To Prevent a Serious Threat to Health or Safety Consistent with certain federal and state laws we might disclose your protected health information if we believe that the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. Coroners Medical Examiners Funeral Directors and Organ Donation We might disclose protected health information to a cor- oner or medical examiner for purposes of identifying you after you die determining your cause of death or for the coroner or medical examiner to perform other duties authorized by law. We also might disclose as authorized by law information to funeral directors so that they may carry out their duties on your behalf. Further we might disclose protected health information to organizations that handle organ eye or tissue donation and transplantation. HIPAA 30 Research We might disclose your protected health information to researchers when an institutional review board or privacy board has 1 reviewed the research proposal and established protocols to ensure the privacy of the information and 2 approved the research. Inmates If you are an inmate of a correctional institution we might disclose your protected health information to the correc- tional institution or to a law enforcement official for 1 the in- stitution to provide health care to you 2 your health and safety and the health and safety of others or 3 the safety and security of the correctional institution. Workers Compensation We might disclose your protected health information to comply with workers compensation laws and oth- er similar programs that provide benefits for work-related injuries or illnesses. Public Health and Safety We might disclose your protected health information to the extent necessary to avert a serious and imminent threat to your health or safety or the health or safety of others. Required by Law We might use or disclose your protected health information when we are required to do so by law. For example we must disclose your protected health information to the U.S. Department of Health and Human Services upon their request for purposes of determining whether we are incompliance with federal privacy laws. Legal Process and Proceedings We might disclose your protected health information in response to a court or administrative order subpoena discovery request or other lawful process under cer- tain circumstances. Under limited circumstances such as a court order warrant or grand jury subpoena we might disclose your protected health information to law enforcement officials. Law Enforcement We might disclose to law enforcement officials limited protected health information of a suspect fugitive mate- rial witness crime victim or missing person. We might disclose protected health information where necessary to assist law en- forcement officials to capture an individual who has admitted to participation in a crime or has escaped from lawful custody. Military and National Security We might disclose to military authorities the protected health information of Armed Forces per- sonnel under certain circumstances. We might disclose to federal officials protected health information required for lawful intelli- gence counterintelligence and other national security activities. OTHER USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION Other uses and disclo- sures of your protected health information that are not described above will be made only with your written authorization. For example in general and subject to specific conditions we will not use or disclose your psychiatric notes we will not use or disclose your protected health information for marketing and we will not sell your protected health information unless you give us a writ- ten authorization. If you provide us with such an authorization you may revoke the authorization in writing and this revocation will be effective for future uses and disclosures of protected health information. However the revocation will not be effective for information that we already have used or disclosed in reliance on your authorization. BREACH OF UNSECURED PROTECTED HEALTH INFOR- MATION You must be notified in the event of a breach of unse- cured protected health information. A breach is the acquisition access use or disclosure of protected health information in a manner that compromises the security or privacy of the protected health information. Protected health information is considered compromised when the breach poses a significant risk of financial harm damage to your reputation or other harm to you. This does not include good faith or inadvertent disclosures or when there is no reasonable way to retain the information. You must receive a notice of the breach as soon as possible and no later than 60 days after the discovery of the breach. HIPAA Uses and Disclosures of Medical Information contd Individual Rights Access You have the right to look at or get copies of the protect- ed health information contained in a designated record set with limited exceptions including your protected health information maintained in an electronic format. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot reasonably do so. For example if your protected health information is available in an electronic format you may request access electronically and that this be transmitted directly to someone you designate. You must make a request in writing to obtain access to your protect- ed health information. You may obtain a form to request access by using the contact information listed at the end of this notice. You may also request access by sending a letter to the address at the end of this notice. If you request copies we might charge you a reasonable fee for each page and postage if you want the copies mailed to you. If you request an alternative format we might charge a cost-based fee for providing your protected health information in that format. But any fee must be limited to the cost of labor involved in responding to your request if you requested access to an electronic health record. If you prefer we will prepare a summary or an explanation of your protected health informa- tion but we might charge a fee to do so. We might deny your request to inspect and copy your protected health information in certain limited circumstances. Under certain conditions our deni- al will not be reviewable. If this event occurs we will inform you in our denial that the decision is not reviewable. If you are denied access to your information and the denial is subject to review you may request that the denial be licensed health care professional 31 HIPAA Individual Rights contd chosen by us will review your request and the denial. The person performing this review will not be the same person who denied your initial request. Disclosure Accounting You have the right to receive a list of instances in which we or our business associates disclosed your protected health information including a disclosure involving an electronic health record for purposes other than treatment payment health care operations and certain other activities Note this exemption does not apply to electronic health records. We will provide you with the date on which we made the disclosure the name of the person or entity to which we disclosed your protected health information a description of the protected health information we disclosed the reason for the disclosure and cer- tain other information. If you request this list more than once in a 12-month period we might charge you a reasonable cost-based fee for responding to these additional requests. You may request an accounting by submitting your request in writing using the information listed at the end of this notice. Your request may be for disclosures made up to 6 years before the date of your request three years in the case of a disclosure involving an electronic health record. Restriction Requests You have the right to request that we place additional restrictions on our use or disclosure of your protected health information. We are not required to agree to these addi- tional restrictions but if we do we will abide by our agreement except in an emergency. Any agreement that we might make to a request for additional restrictions must be in writing and signed by a person authorized to make such an agreement on our behalf. We will not be liable for uses and disclosures made outside of the requested restriction unless our agreement to restrict is in writing. We are permitted to end our agreement to the requested restric- tion by notifying you in writing. You may request a restriction by writing to us using the information listed at the end of this notice. In your request tell us 1 the information of which you want to limit our use and disclosure and 2 how you want to limit our use andor disclosure of the information. Confidential Communication If you believe that a disclosure of all or part of your protected health information may endanger you you have the right to request that we communicate with you in confidence about your protected health information. This means that you may request that we send you information by alternative means or to an alternate location. We must accom- modate your request if it is reasonable specifies the alternative means or alternate location and specifies how payment issues premiums and claims will be handled. You may request a Con- fidential Communication by writing to us using the information listed at the end of this notice. Amendment You have the right to request that we amend your protected health information. Your request must be in writing and it must explain why the informa- tion should be amended. We may deny your request if we did not create the information you want amended or for certain other reasons. If we deny your request we will provide you with a writ- ten explanation. You may respond with a statement of disagree- ment to be appended to the information you wanted amended. If we accept your request to amend the information we will make reasonable efforts to inform others including people you name of the amendment and to include the changes in any future disclo- sures of that information. Electronic Notice This notice is also posted on our web site. Questions and Complaints Information WSSCs Privacy Practices If you want more information about our privacy practices or have questions or concerns please contact the member services number on the back of your card. Filing a Complaint If you are concerned that we might have violated your privacy rights or you disagree with a decision we made about your individual rights you may use the contact information listed at the end of this notice to complain to us. You also may submit a written complaint to the U.S. Department of Health and Human Services DHHS. We will provide you with the contact information for DHHS upon request. We support your right to protect the privacy of your protected health and financial informa- tion. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. HIPAA website httpwww.hhs.govocrprivacy WSSC Privacy Official Carole C. Silberhorn Human Resources Manager Benefits 14501 Sweitzer Lane Laurel MD 20707-5902 Phone 301-206-8691 Fax 301-206-8713 Email Carole.Silberhornwsscwater.com Alternate Email hr_benefitswsscwater.com 32 BENEFITS A benefit is a form of indirect compensation designed to provide employees added protection promote goodwill and reward employment. It usually takes a form other than money and are typically extended to employees as well as their immedi- ate family members. BRAND-NAME DRUG A prescription drug that has been patented and is only available through one manufacturer. Certificate of creditable coverage A written certificate issued by a group health plan or health insurance company that states the period of time you were covered by your health plan. CLAIM A request to the insurance company to pay for benefits or services rendered either by an individual or his or her health care provider. CO-INSURANCE The percentage or amount that the individual is required to pay after a deductible has been met and before the insurance company will pay. CO-PAYMENT Amount of money usually a set amount that a policyholder is required to pay for each visit to a hospital or doctors office for services. Consolidated Omnibus Budget Reconciliation Act COBRA Gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances such as voluntary or involun- tary job loss reduction in the hours worked transition between jobs death divorce and other life events. Qualified individuals may be required to pay the entire premium for coverage up to 102 percent of the cost to the plan. COORDINATION OF BENEFITS If the insured has more than one health insurance provider such as being under a spouses insurance plan along with their own the insurance company would not pay double benefits. In this case the health insurance company would coordinate benefits with the other health insurance plan. DEDUCTIBLE Refers to the amount of money that the insured would need to pay per benefit period before any claims from the health insurance company would be paid. DEFERRED COMPENSATION Payment for services under any employer-sponsored plan or arrangement that allows an employ- ee for tax related purposes to defer income to the future. Dependent Care FSA A benefit plan designed to allow employees to set aside pre-tax dollars to pay for eligible depen- dent care expenses such as daycare day camp or elder care. FSAs are strictly regulated by IRS guidelines and it is the employees responsibility to ensure that there their expenses will be eligible for reimbursement prior to enrollment. DISABLED DEPENDENT If a child who is physically or mentally incapable of self-support is covered under the benefit plan the child may continue coverage beyond the normal age limit if the disability continues the child does not have any other insurance coverage and the child remains unmarried. Medical certification of disability must accompany the carriers required documentation. DISPENSE AS WRITTEN DAW An order on a prescription commanding the pharmacist to provide the recipient with the prescription exactly as it was written. EXPLANATION OF BENEFITS EOB An EOB is not a bill it is an itemized statement that shows what action was taken on your claims. The EOB explains the services or benefits you received the doctors visited the date of service the amount paid by the insurance company and any amount you may owe. EMERGENCY CARE Care for severe pain injury sudden illness or suddenly worsening illness that you believe can cause serious danger to your health if you do not get immediate medical care. EMPLOYEE ASSISTANCE PROGRAM EAP An EAP is a free confidential program designed to help employees and their family members deal with personal problems that might adversely impact their work performance relationships health and well-being. Examples of EAP services include confidential expert counseling legal assistance stress management alcohol or drug dependency and financial services. EMPLOYEE SELF-SERVICE A trend in human resource management that allows employees to handle many job-related tasks normally conducted by HR such as benefits enrollment updating personal information and accessing company informa- tion through the use of a companys intranet specialized kiosks or other Web based applications. EVIDENCE OF COVERAGE EOC A comprehensive resource guide to your health care coverage. It explains your benefits premiums and cost-sharing conditions and limitations of cover- age and plan rules. EXCLUSIONS Specific conditions or circumstances for which the insurance policy will not provide benefits. These will be phased out over the next few years with the implementation of health care reform law. EXCLUSIVE PROVIDER ORGANIZATION EPO PLAN A plan under which employees must use providers from the specified network of physicians and hospitals to receive coverage a more restrictive type of preferred provider organization. There is no coverage for care received from a non-network provider except in an emergency situation under an EPO plan. FAMILY AND MEDICAL LEAVE ACT FMLAOF 1993 The Family and Medical Leave Act FMLA allows employees who have met minimum service requirements 12 months employed by the company with 1250 hours of service in the preceding 12 months to take up to 12 weeks of unpaid leave per year for 1 a serious health condition 2 to care for a family member with a serious health condition 3 the birth of a child or 4 the placement of a child for adoption or foster care. FAMILY STATUSLIFE EVENT CHANGE Used to define changes to an individuals existing family standing. Typically found in health care benefit plans covered by section 125 of the Internal Revenue Code. IRC 125 does not allow individuals enrolled in a covered benefit plan to make election changes to their existing benefits coverage outside of the plans annual open enrollment period unless a qualifying change in family or employment status defined by the IRS as a Qualified Family Status Change has occurred i.e. marriage divorce legal separation death birthadoption changes in employment status cessation of dependent status or a significant change in cost or reduction of benefits. You have 30 days to make enroll- ment changes following a qualifying family status change life event. Contact the Benefits Office for more information. Glossary of Insurance Terms 33 FORMULARY A list of brand name and generic prescription medications that are preferred or recommended for use under a prescription or health plan. FULLY INSURED PLAN A plan where the employer contracts with another organization to assume financial responsibility for the enrollees medical claims and for all incurred administrative costs. GENERIC DRUG A twin to a brand name drug once the brand name companys patent has run out and other drug compa- nies are allowed to sell a duplicate of the original. Generic drugs are less expensive and most prescription and health plans reward clients for choosing generics. Generic Step Therapy Plans used by pharmacies to encourage the use of lower cost generics and preferred brands. These highly effective solutions promote prescription benefit education and help to reduce our overall prescription costs. GINA Title I of the Genetic Information Nondiscrimination Act 2008 prohibits the use of genetic information in employment or health insurance decision-making HOME HEALTH CARE In home health care services for an injury or illness that may include skilled nursing care and physi- cal occupational and speech therapy. HOSPICE CARE Program or facility that provides medical care and support services for terminally ill patients and their families. Its focus is to help make people as comfortable as possible at the end of their life rather than trying to cure their illness or injury. Hospice care includes physical care pain control and counseling. HEALTH MAINTENANCE ORGANIZATION HMO A health benefits program that requires that the member receives care from the doctors and hospitals that are part of the plans network. HMOs also require that the member select a primary care physi- cian PCP generally a family practitioner internist or pediatri- cian who is part of the plans network. A referral is required from the primary care physician to see specialists in the network. HEALTH CARE FLEXIBLE SPENDING ACCOUNT FSA A benefit plan designed to allow employees to set aside pre-tax dollars to pay for eligible medically related expenses such as medical vision or dental exams copays and deductibles as well as other out-of-pocket expenses. Health Insurance Portability And Accountabil- ity Act HIPAA Federal law designed to allow people to change jobs without fear of losing insurance because of a pre- existing condition. HIPAA also requires additional protections for the privacy of health information. INPATIENT CARE Care that you receive in the hospital that requires an overnight stay. MANAGED CARE A general term for organizing doctors and hospitals into health care delivery networks with the intent of lowering costs and managing the medical care. There are many different kinds of managed care plans including Preferred Provider Organization PPO plans and Health Maintenance Organizations HMO plans. MEDICARE A health insurance program administered by the Social Security Administration which is broken into two distinct categories 1 Medicare Part A helps with hospital costs and 2 Medicare Part B requires a monthly fee and is used to pay medical costs for people 65 years of age and older some disabled people under 65 years of age and people with end-stage renal disease permanent kidney failure treated with dialysis or a transplant. WSSC active employees 65 can maintain their regular benefits plans. Contact HR for further details. MEDICARE APPROVED AMOUNT The amount in which Medicare decides is a reasonable payment for a medical service. Medicare generally pays 80 percent of the approved amount and your supplemental WSSC insurance generally pays 20 percent. This rule is different for active 65 employees. Contact HR for further details. MEDICARE SECONDARY PAYER Is the term used by Medicare when Medicare is not responsible for paying first. The private in- surance industry generally talks about Coordination of Benefits when assigning responsibility for first and second payment. MENTAL HEALTH PARITY ACT Health plans that provide coverage for mental health andor substance abuse treatment must provide benefits that are on par with medical and surgical benefits. This means that health plans may no longer apply to mental health and substance abuse treatment limits or financial terms that dont also apply to medical and surgical benefits. NETWORK A group of doctors or health care providers that work with specific health insurance companies. Generally you get your medical care from the health care providers within your insurance companys network. OPEN ENROLLMENT PERIOD The period of time designated by the employers health or other benefit plan when employees may enroll in new benefit plans or make changes to existing bene- fit plans for a new plan year. OUT-OF-PLAN OUT-OF-NETWORK This phrase usually refers to physicians hospitals or other health care providers who are considered non-participants in an insurance plans network. HMO members are generally not covered for out-of-network services except in emergency situations. Members enrolled in Preferred Provider Organizations PPO and Point-of-Service POS plans may go out-of-network but will pay higher out-of- pocket costs. Depending on an individuals health insurance plan expenses incurred by services provided by out-of-network health professionals may not be covered or covered only in part by an individuals insurance company. OUT-OF-POCKET MAXIMUM The maximum dollar amount one would pay out of their own pocket for co-pays coinsurance or deductible for the year excluding premiums. Once the out-of- pocket limit is met the plan pays 100 of the allowed amount for covered services for the rest of the benefit period. OUTPATIENT CARE Medical or surgical care that does not include an overnight stay in a hospital. PATIENT PROTECTION AND AFFORDABILITY CARE ACT PPACA enacted in March 2010. The Patient Protection and Affordable Care Act will ensure that all Americans have access to quality affordable health care and will create the transformation within the health care system necessary to contain costs. Systemic insurance market reform will eliminate discriminatory practices such as pre-existing condition exclusions eliminate lifetime and unreasonable annual limits on benefits and provide assistance for those who are uninsured because of a pre-existing condition. POINT OF SERVICE POS A plan where coverage is provided to participants through a network of selected health care pro- viders such as hospitals and physicians. The insured may go outside the network but would incur larger costs in the form of higher deductibles higher coinsurance rates or non-discounted charges from the providers. Glossary of Insurance Terms 34 PRE-EXISTING CONDITION A pre-existing condition is a health problem that existed before you apply for a health insur- ance policy or enroll in a new health plan. PREMIUM A payment made by or on your behalf for ongoing health insurance coverage. You might pay a premium to Medicare an insurance company or a health care plan. It does not include any deductibles or co-payments the plan may require. PRE-TAX CONTRIBUTIONS Contributions made to a benefit plan that are exempt from all applicable state or federal tax with- holding requirements. PRESCRIPTION DRUG BENEFITS Typically a provision included in a group health plan designed to provide covered employees and their dependents with payment assistance for medically prescribed drugs. PREVENTIVE CARE Care that keeps you healthy or prevents illness. Examples are routine physical exams colorectal cancer screenings mammograms and immunizations. PRIMARY CARE PHYSICIAN PCP A physician who serves as a group members primary contact within the health plan. In a HMO or managed care plan the primary care physician provides basic medical services coordinates and if required by the plan authorizes referrals to specialists and hospitals. Qualified Dependent children Age 1926 Depen- dent children that you may add to your health insurance plans upon completion of WSSCs affidavit form and birth certificate. WSSC will not require that the dependent children live with his or her parents is a dependent on a parents tax return or is a full time student. Both married and unmarried dependent children may have access to coverage. REFERRAL Authorization from your primary care physician or health insurer to see a specialist or receive a special test or procedure. HMOs often require that you obtain a referral for most specialty care. It is important to know what your health insurers rules and procedures are for referrals. REHABILITATIVE SERVICES Health care ordered by your doctor to help you recover from an illness or injury. These services are given by skilled nurses and physical occupational and speech therapists. Examples are working with a physical therapist to help you walk andor with an occupational therapist to help you take a shower or get dressed. SELF-FUNDEDSELF-INSURED A benefit plan whereby the employer assumes all the risk paying for claims while saving the cost of any associated premiums. SKILLED NURSING CARE Care ordered by your doctor that must be given or supervised by a licensed registered nurse. Examples are giving shots providing oxygen to help you breathe and changing the dressing on a wound. Help from family members or care you give yourself is not considered skilled nursing care. SKILLED NURSING HOME OR SKILLED NURSING FACILITY A place with the staff and equipment to give skilled nursing andor rehabilitative care. SPECIALIST A specialist is a physician who provides non-routine care. Examples include Cardiologists heart Psychiatrists Mental Health Oncologists cancer and Rheumatologists arthritis. SUMMARY OF BENEFITS AND COVERAGE SBC The Summary of Benefits and Coverage document is intended to provide consumers with a concise document explaining in plain language simple and consistent information about health plan benefits and coverage. It will summarize the key features of the plan such as the covered benefits cost-sharing provisions and coverage limitations and exceptions. SUMMARY PLAN DESCRIPTION SPD A document which describes your Benefits as well as your rights and responsibilities under the Plan. UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT USERRA The Act provides for the continuation of health benefits for persons who are absent from work to serve in the military services. The three employee regulatory requirements include 1 the right to continue health benefit coverage 2 a right to reinstate and 3 the maximum payable in premiums. URGENT CARE Walk-in center that should be considered for problems that are urgent but not severe enough to warrant a trip to the ER such as a fracture or deep cut that may need stitches. USUAL CUSTOMARY AND REASONABLE UCR CHARGES Conventional indemnity plans 8020 operate based on usual customary and reasonable UCR charges. UCR charges mean that the charge is the providers usual fee for a service that does not exceed the customary fee in that geographic area and is reasonable based on the circumstances. Instead of UCR charges PPO plans often operate based on a negotiated fixed schedule of fees that recognize charges for covered services up to a negotiated fixed dollar amount. WELLNESS PROGRAM Programs such as on-site or subsidized fitness centers health screenings smoking cessation weight reductionmanagement health awareness and education that target keeping employees healthy thereby lowering employers costs associated with absenteeism lost productivity and increased health insurance claims. WORKERS COMPENSATION State laws enacted to provide workers with protection and income replacement benefits due to an illness or injury suffered on the job. Employers must carry appropriate workers compensation insurance as required by state law or have a sufficient source of funding for claims incurred. Glossary of Insurance Terms 35 Where Water Matters WSSC Contacts Open Enrollment Hotline openenrollmentwsscwater.com 301-206-7034 HR Benefits hr_benefitswsscwater.com Miriam McMillan Miriam.McMillanwsscwater.com 301-206-8692 Susan Menefee Susan.Menefeewsscwater.com 301-206-8702 Kelly Ryan Kelly.Ryanwsscwater.com 301-206-8695 Regina Rodriguez Regina.Rodriguezwsscwater.com 301-206-8696 Carole Silberhorn Carole.Silberhornwsscwater.com 301-206-8691 Customer Service Contacts Other Contacts CVScaremark Prescription Services Group WSSCX www.caremark.com 1-888-790-4271 Email customerservicecaremark.com Centers for Medicare and Medicaid Services www.cms.hhs.gov 1-800-633-4227 TTY 877-486-2048 ComPsych EAP Provider www.GuidanceResources.com 1-855-737-8665 Deltacare USA HMO Delta Dental PPO Group 5804 www.deltadentalins.com 1-800-932-0783 Kaiser Permanente HMO Group 4418 www.kp.org 1-800-777-7902 Medical Advice Line 1-800-777-7904 MetLife Life Insurance Group 109925 www.metlife.com 1-800-638-6420 National Vision Administrators www.e-nva.com 1-800-672-7723 SilverScript Prescription Drug Plan wssc.silverscript.com 844-819-3073 Note The phone line may not be active until mid-October Social Security Administration www.ssa.gov 1-800-772-1213 TTY 1-800-325-0778 UnitedHealthcare Group 712974 www.myuhc.com 1-800-697-3481 UnitedHealth Wellness www.myuhc.com UnitedHealth Cancer Resource Services 1-866-936-6002 UnitedHealth Healthy Pregnancy www.healthy-pregnancy.com 1-800-411-7984 UnitedHealth Vision www.myuhcvision.com 1-877-426-9300 My Nurse Line 1-800-401-7396