health insurance information - home - livingston … insurance information new employees, who are...

Health Insurance Information New employees, who are full-time, will have the opportunity of enrolling in insurance after the New Teacher Orientation on August 3, 2015. YOU MUST SIGN UP WITHIN 30 DAYS OF EMPLOYMENT

TO BE CONSIDERED A NEW ENROLLMENT. If you will be adding dependents, you will need to bring the following documents: Birth certificates to add children Marriage license to add spouse

Coverage becomes effective on the 1st day of the month following a minimum 30 day waiting period. (Example: If hired August 3, insurance is effective October 1.)

Health Insurance Information

(Offered through OGB)

Medical Benefits Comparison Sheet Official Schedule of Rates Enrollment Instructions Life Insurance Information Life Insurance Schedule Enrollment/Change Form OGB Requirements for Vesting at Retirement

If you have questions regarding Life Insurance, please contact Amanda Glascock at [email protected] or (225) 686-4230.

mailto:[email protected]

First Financial Benefits Information Representatives from First Financial Group of America will also be available if you want to enroll in the following plans: Annuity Critical Illness Insurance Dental Insurance Disability Income Protection (short and long term) Flexible Spending Accounts Heart/Stroke Insurance Life Insurance Long Term Care Vision Insurance Medical Reimbursement Dependent/Child Care Reimbursement

If you have questions regarding First Financial’s Benefits, please contact them at (866) 541-5096.

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Active Employee Benefits Comparison: Pelican HRA1000, Pelican HSA775,

Magnolia Local, Magnolia Local Plus,Magnolia Open Access, Vantage Medical Home

Blue Cross Blue Shield benefits effective March 1, 2015 - December 31, 2015

Vantage Medical Home benefits effective January 1, 2015 - December 31, 2015

Pelican HRA 1000 Pelican HSA775 Magnolia Local

NetworkBlue Cross Blue Shield of Louisiana

Preferred Care Providers & BCBS National Providers

Blue Cross Blue Shield of Louisiana Preferred Care Providers & BCBS

National Providers

Blue Cross Blue Shield of Louisiana Community

Blue & Blue Connect

Eligible OGB Members Active Employees Active Employees Active Employees

Network Non-Network Network Non-

Network Network Non-Network

You Pay You Pay You Pay

Deductible

You $2,000 $4,000 $2,000 $4,000 $400 No Coverage

You + 1 (Spouse or child) $4,000 $8,000 $4,000 $8,000 $800 No Coverage

You + Children $4,000 $8,000 $4,000 $8,000 $1,200 No Coverage

You + Family $4,000 $8,000 $4,000 $8,000 $1,200 No Coverage

HRA dollars will reduce this amount HSA dollars will reduce this amount

Out of Pocket Maximum

You $5,000 $10,000 $5,000 $10,000 $2,500 No Coverage

$10,000 $20,000 $10,000 $20,000 $5,000 No Coverage

You + Children $10,000 $20,000 $10,000 $20,000 $7,500 No Coverage

You + Family $10,000 $20,000 $10,000 $20,000 $7,500 No Coverage

State Funding The Plan Pays The Plan Pays The Plan Pays

You $1,000 $775*

Not Available

$2,000 $775*

You + Children $2,000 $775*

You + Family $2,000 $775*

Funding not applicable to Pharmacy Expenses.

$200, plus up to $575 more dollar for dollar match of employee contributions*

Physicians’ Services The Plan Pays The Plan Pays The Plan Pays

Primary Care Physician or Specialist Office

Treatment of illness or injury

80% coverage; subject to deductible



60% coverage;subject todeductible

100% coverage after a $25 PCP

or $50 SPC co-payment

per visit

No Coverage





Magnolia Local Plus Magnolia Open Access Vantage Medical Home

Blue Cross Blue Shield of Louisiana Preferred Care Providers & BCBS National Providers

Blue Cross Blue Shield of Louisiana Preferred Care Provider & BCBS National Providers

Statewide HMO plan offered in all regions of Louisiana

Active Employees Active Employees Active Employees

Network Non-Network Network Non-Network Network Non-Network


Deductible

$400 No Coverage $900 $500 $1,500

$800 No Coverage $1,800 $1,500 $3,000

$1,200 No Coverage $2,700 $1,500 $3,000

$1,200 No Coverage $2,700 $1,500 $3,000

Out of Pocket Maximum

$2,500 No Coverage $2,500 $3,700 $3,000 Unlimited




The Plan Pays The Plan Pays The Plan Pays

Not Available Not Available Not Available


100% coverage after a $25 PCP or $50 SPC co-payment per visit

No Coverage90% coverage;

subject to deductible 70% coverage; subject

to deductible

100% coverage after a $0*/$10 PCP or $35*/$45 SPC co-payment per visit


You + 1 (Spouse or child)

You + 1 (Spouse or child)

$900

$1,800

$2,700

$2,700

3 4







Physicians’ Services The Plan Pays The Plan Pays The Plan Pays

Maternity Care

(prenatal, deliver and postpartum)





100% coverage after a $90 co-payment per pregnancy

No Coverage

Physician Services Furnished in a Hospital

Visits; surgery in general, including charges by surgeon, anesthesiologist, pathologist and radiologist.






No Coverage

Preventative Care Primary Care Physician or Specialist Office or Clinic

For a complete list of benefits, refer to the Preventive and Wellness/Routine Care in the Benefit Plan

100% coverage; not subject to

deductible

100% of fee schedule

amount. Plan participant

pays the difference

between the billed amount

and the fee schedule amount


deductible

100% of fee schedule

amount. Plan participant

pays the difference

between the billed amount

and the fee schedule amount


deductibleNo Coverage

Physician Services for Emergency Room Care







Allergy Shots and Serum

Co-payment per visit is applicable only to office visit





100% coverage after a $25

PCP or $50 SPC per office visit co-payment

per visit; shots and serum 100% after deductible

No Coverage

Outpatient Surgery/Services

When billed as office visits





100% coverage; after a $25

PCP or $50 SPC per office visit co-payment

per visit

No Coverage


When billed as outpatient surgery at a facility






No Coverage

Hospital Services The Plan Pays The Plan Pays The Plan Pays

Inpatient Services

Inpatient care, delivery and inpatient short-term acute rehabilitation services





100% coverage; after a $100 co-

payment per day max $300 per admission

No Coverage









co-payment per pregnancy


subject to deductible


100% coverage after a $0*/$10 co-payment per

pregnancy









deductibleNo Coverage


deductible



deductible








100% coverage after a $25 PCP or $50 SPC per office visit co-payment

per visit; shots and serum 100% after

deductible






100% coverage after a $25 PCP or $50 SPC

per office visit co-payment per visit














co-payment per day max $300 per

admission



70% coverage; subject to

deductible + $50 co-payment per day

(days 1 - 5)

100% coverage after a $100*/$300 co-payment per day

max $300*/$900 per admission;



5 6









Hospital / Facility





100% coverage; after a $100 facility co-

payment per visit

No Coverage

Emergency Room Care - Hospital

Treatment of an emergency medical condition or injury





100% coverage after $150 co-payment per

visit; waived if admitted

100% coverage after $150 co-payment per

visit; waived if admitted

Behavioral Health The Plan Pays The Plan Pays The Plan Pays

Mental Health and Substance Abuse Inpatient Facility







No Coverage

Mental Health and Substance Abuse Outpatient Visits - Professional






co-payment per visit

No Coverage

Other Coverage The Plan Pays The Plan Pays The Plan Pays

Outpatient Acute Short-Term Rehabilitation ServicesPhysical Therapy, Speech Therapy, Occupational Therapy, Other short term rehabilitative services







No Coverage

Chiropractic Care80% coverage;







No Coverage

Hearing AidNot covered for individuals age eighteen (18) and older






No Coverage

Vision Exam (routine) No Coverage

Urgent Care Center80% coverage;







No Coverage

Home Health Care Services80% coverage;






No Coverage








100% coverage; after a $100 facility





100% coverage after a $100*/$300

co-payment per visit; subject to

deductible


100% coverage after $150 co-payment

per visit; waived if admitted

100% coverage after $150 co-payment

per visit; waived if admitted

$150 co-payment per visit; waived if admitted 100% coverage after a $200 co-payment per visit; subject to

deductible

100% coverage after a $200 co-payment per visit; subject to

deductible




100% coverage after $100 co-payment per day max $300

per admission



70% coverage; subject to

deductible + $50 co-payment per day

(days 1-5)


co-payment per day max $900 per admission; subject

to deductible



payment per visitNo Coverage



100% coverage; after a $10 PCP or

$45 SPC per co-payment per visit














payment per visit








No Coverage100% coverage; after a $45 co-

payment per visit


100% coverage after a $50 co-payment

per visitNo Coverage




per visit


100% coverage subject to deductible






7 8

NOTE: Prior Authorizations and Visit Limits may apply to some benefits - refer to your Plan Document for details

This comparison chart is a summary of plan features and is presented for general information only. It is not a guarantee of coverage. For full details of the plan, refer to the official plan document. Benefits outlined in the Vantage Medical Home column were provided by Vantage Health Plan. OGB is not responsible for the accuracy of this information.1 Prescription drug benefit - 31 day fill; 2 Member who chooses brand-name drug for which approved generic version is available pays cost difference between brand-name drug & generic drug, plus co-pay for brand-name drug; cost difference does not apply to $1,500 out of pocket max; 3 Prescription drug benefit - 30 day fill

* Benefits available for Affinity Health Network Providers








Skilled Nursing Facility Services







No Coverage

Hospice Care80% coverage;






No Coverage

Durable Medical Equipment (DME) - Rental or Purchase





80% coverage of the first

$5,000 allowable; 100%

in excess of $5,000 per plan year; subject to

deductible

No Coverage

Transplant Services80% coverage;






No Coverage

Pharmacy You Pay You Pay You Pay

Tier 1 - Generic 50% up to $30 1 $10; subject to deductible 1 50% up to $30 1

Tier 2 - Preferred 50% up to $55 1,2 $25; subject to deductible 1 50% up to $55 1,2

Tier 3 - Non-Preferred 65% up to $80 1,2 $50; subject to deductible 1 65% up to $80 1,2

Tier 4 - Specialty 50% up to $80 1,2 $50; subject to deductible 1 50% up to $80 1,2

90 day supplies for maintenance drugs from mail order OR at participating 90-day retail network pharmacies

Two and a half times the cost of your applicable co-payment

Applicable co-payment; Maintenance drugs not subject

to deductible


After the out-of-pocket amount of $1,500 is met:

Tier 1 - Generic $0 co-payment 1 – $0 co-payment 1

Tier 2 - Preferred $20 co-payment 1,2 – $20 co-payment 1,2

Tier 3 - Non-Preferred $40 co-payment 1,2 – $40 co-payment 1,2

Tier 4 - Specialty $40 co-payment 1,2 – $40 co-payment 1,2








100% coverage; after $100 co-



subject to deductible70% coverage;



per day





subject to deductible 80% coverage;



80% coverage of the first $5,000

allowable; 100% in excess of $5,000 per

plan year; subject to deductible



subject to deductible 80% coverage;







subject to deductibleNo Coverage


50% up to $30 1 50% up to $30 1 Low Cost Generics - $3 co-payment 3 Non Preferred Generics - $10 co-payment 3

50% up to $55 1,2 50% up to $55 1,2 $45 co-payment 3

65% up to $80 1,2 65% up to $80 1,2 $95 co-payment 3

50% up to $80 1,2 50% up to $80 1,2 33% up to $150 3



30-day supply for 1 co-pay; 60-day supply for 2 co-pays; 90-day supply for 3 co-pays – All

tiers but Tier 5

After the out-of-pocket amount of $1,500 is met:

$0 co-payment 1 $0 co-payment 1 –

$20 co-payment 1,2 $20 co-payment 1,2 –



STATE OF LOUISIANA - OFFICE OF GROUP BENEFITS - ENROLLMENT/CHANGE FORMAGENCY NUMBER AGENCY NAME DATE OF HIRE ANNUAL SALARY EMPLOYEE NAME CHANGED TO

PURPOSE Waiver of Coverage Agency Transfer New Enrollment Reinstate Coverage Re-enrollment - Previous Employment Rehired Retiree

Annual Enrollment Add/Delete Dependent(s)_________________________ Reason for Addition/Deletion_____________________________________________

Surviving Spouse/Dependent Special Enrollment Late Applicant Retired ______________________________

Employment Terminated ______________________________ Deceased ______________________________

Cancel all coverage (health and life) ________________________________________ Other _________________________________________

PERSONAL INFORMATION (Please print or type)NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NUMBER DATE OF BIRTH

ADDRESS CITY STATE ZIP CODE

PHONE NUMBER

( )EMAIL ADDRESS SEX

M F

MARITAL STATUS

SINGLE MARRIED

DATE OF MARRIAGE DATE OF DIVORCE

HEALTH PLAN SELECTED (Write in health plan selection) No coverage Employee Only Employee + Children/Child Employee + Spouse FamilyLEVEL OF MEDICAL COVERAGE

NAME(LAST, FIRST, MIDDLE INITIAL)

RELATIONSHIP SEX BIRTH DATE(MM/DD/YYYY)

ADD/ DELETE

SOCIAL SECURITY NUMBER HEALTH DEP. LIFE

SPOUSE M

F

ADD

DELETE YES YES

DEPENDENT M

F

ADD

DELETE YES YES

DEPENDENT M

F

ADD

DELETE YES YES

DEPENDENT M

F

ADD

DELETE YES YES

DEPENDENT M

F

ADD

DELETE YES YES

C.O.B.R.A. Prior F/T Terminated Divorced Spouse Dependent

MEDICAREEMPLOYEE SPOUSE

No Coverage Hospital (Part A) Medical (Part B) Drugs (Part D)

No Coverage Hospital (Part A) Medical (Part B) Drugs (Part D)

A COPY OF MEDICARE CARD MUST BE ATTACHED

RETIREE 100 Employee Only Dependent Only Employee + 1 Dependent

LIFE INSURANCE (check one only)

No Coverage

BASIC BASIC PLUS SUPPLEMENTAL

Employee/No Dependent Coverage Employee/Dependent Coverage Eligible Spouse $1000 Eligible Child $500 Employee/Dependent Coverage Eligible Spouse $2000 Eligible Child $1000

Employee/No Dependent Coverage Employee/Dependent Coverage Eligible Spouse $2000 Eligible Child $1000 Employee/Dependent Coverage Eligible Spouse $4000 Eligible Child $2000

Annual Salary _____________ Date of Last Salary Increase ______________ Face Life _______________ WAIVER OF COVERAGEI waive all coverage offered through the Office of Group Benefits. I understand that if I enroll for OGB offered life insurance at a future date, the cover-age I receive will be subject to evidence of insurability.

NOTE TO AGENCY REPRESENTATIVE: If the employee waives his/her right to all coverage, he/she must sign an enrollment document. A copy of this document is to be retained by the agency as evidence the employee was offered coverage within 30 days of eligibility and the employee declined. The original of this document is to be transmitted to the Office of Group Benefits.

ACKNOWLEDGEMENT OF COVERAGE LIMITATIONS » I understand that I must provide appropriate documents to OGB to verify eligibility of all covered dependents. I acknowledge that my application

for dependent coverage will not be approved until all required documents are received. » I acknowledge that I have reviewed the descriptive literature about OGB health plans available to me. I apply for participation or a change in my

participation in the named health plan and agree to be bound by its terms and conditions. » I authorize deductions from my earnings or retirement check to pay for insurance for myself and my dependents, if applicable. » I certify that the information provided on this form is true and correct. I understand that if I provide false information on this form, it may result in

denial or recision of coverage retroactive to the initial day of coverage. A copy of my signature is as valid as the original. » I accept that this declaration will become a part of my application for coverage.

_____________________________________________________________________________________________________________________________

Date

Date

Date Date

Reason for Cancellation

Employee Signature Date Agency Representative Signature Date

GB-01REV 1-14

IMPORTANT INFORMATION ABOUT THE STATE'S CONTRIBUTION

TOWARD RETIREE HEALTH PLAN PREMIUMS

(including surviving spouse and/or dependents of retiree)

In 2001, the Louisiana Legislature enacted a law that established a schedule for the amount

that the state, school boards and other participating agencies (collectively, "the state") shall

contribute toward the premium for retiree coverage based upon years of participation in an

OGB health plan before retirement.Here are some important things you should know about the

"participation schedule" established in that law.

1. Your state contribution is not affected by the participation schedule if you retired before

January 1, 2002, and continued your health coverage through OGB. Under the law, you will

continue to receive the state contribution toward the premiums that is currently set at 75

percent.

2. Your state contribution is not affected by the participation schedule if you were covered by an

OGB health plan before January 1, 2002, and you maintain continuous coverage through

retirement. Under the law, you will receive the state contribution toward the premiums for

retiree coverage that is currently set at 75 percent.

3. Your state contribution is affected by the participation schedule if:

a. your coverage in an OGB health plan began on or after January 1, 2002; or

b. you previously had coverage in an OGB health plan, dropped coverage, and rejoined on

or after January 1, 2002; or

c. you have a break in coverage after January 1, 2002.

4. If it applies to you, the participation schedule sets the state's contribution toward the premium

for retiree coverage as follows:

Retiree Participation Schedule

Years of OGB Plan

Participation

State’s Share of Total

Monthly Premium

20 years or more 75 percent

15 years but less than 20

years 56 percent

10 years but less than 15

years 38 percent

less than 10 years 19 percent

5. This schedule also applies to the state's contribution toward the premium for coverage of

retirees' surviving spouses and dependents whose coverage in an OGB health plan began on

or after July 1, 2002, or who had previous coverage, dropped that coverage and rejoined on or

after July 1, 2002, or who experienced a break in coverage after July 1, 2002.

6. Participation in an OGB health plan includes all participation in health plans available to

employees of OGB participant employers, for which the state contributes a share of the

premium, including self-insured plans such as the PPO and HMO plans, fully-insured

plans such as the MCO plan the Medical Home HMO plan, consumer driven plan such

as the CD-HSA, and other health plan options such as the LSU System health plan.

Participation also includes COBRA continuation coverage in an OGB health plan.

7. If the participation schedule does apply to you, then at the time of retirement, your years of

participation in OGB health plans must be certified by the employer from which you will retire.

. The certification must be based on business records maintained by your employer or provided

by you.

a. The business records must be available to OGB, the Division of Administration and the

Legislative Auditor upon request.

b. Not more than 120 days before your scheduled date of retirement, and upon request,

OGB will provide to your employer all information in its possession relating to your

participation.

c. At the time of application for surviving spouse and/or surviving dependent coverage,

OGB will, upon request, provide all information in its possession relating to participation

of such surviving spouse and/or surviving dependent.

8. When applicable, the participation schedule sets the state's contribution toward the premium

for retiree coverage. It does not establish eligibility for retiree coverage. To be eligible for

retiree coverage, you must:

. be a covered employee in an OGB health plan immediately prior to retirement;

a. elect to continue your coverage at the time of retirement; and

b. immediately receive retirement benefits from an approved state or governmental

defined benefit plan.

Life Insurance Information (Offered through OGB by Prudential)

New employees, who are full-time, will have the opportunity of enrolling in insurance after the New Teacher Orientation on August 3, 2015. You must sign up within 30 days of employment; otherwise you’ll be subject to a medical evaluation. If you wish to enroll in our life insurance policy, you’ll need to complete an enrollment form. These are available upon request. Please refer to the following page for plans & rates.

If you have questions regarding Life Insurance, please contact Amanda Glascock at [email protected] or (225) 686-4230.

mailto:[email protected]

BASIC AND SUPPLEMENTAL LIFE SCHEDULE 1INSURANCE SCHEDULE FOR Effective January 1, 2013

ACTIVE AND RETIRED EMPLOYEESUNDER AGE 65

Includes Accidental Death & Dismemberment (AD&D)*

ANNUAL EARNINGS** MAXIMUM TOTAL PREM. EMPLOYEESINSURANCE WITH AD&D*** SHARE

BASIC LIFE: $ 5,000 $5.40 $2.70

BASIC ANDSUPPLEMENTALLIFE: 2,000.01 - 2,666.66 6,000 6.48 3.24

2,666.67 - 3,333.33 7,000 7.56 3.783,333.34 - 4,000.00 8,000 8.64 4.324,000.01 - 4,666.66 9,000 9.72 4.864,666.67 - 5,333.33 10,000 10.80 5.405,333.34 - 6,000.00 11,000 11.88 5.946,000.01 - 6,666.66 12,000 12.96 6.486,666.67 - 7,333.33 13,000 14.04 7.027,333.34 - 8,000.00 14,000 15.12 7.568,000.01 - 8,666.66 15,000 16.20 8.108,666.67 - 9,333.33 16,000 17.28 8.649,333.34 - 10,000.00 17,000 18.36 9.18

10,000.01 - 10,666.66 18,000 19.44 9.7210,666.67 - 11,333.33 19,000 20.52 10.2611,333.34 - 13,333.33 20,000 21.60 10.8013,333.34 - 14,000.00 21,000 22.68 11.3414,000.01 - 14,666.66 22,000 23.76 11.8814,666.67 - 15,333.33 23,000 24.84 12.4215,333.34 - 16,000.00 24,000 25.92 12.9616,000.01 - 16,666.66 25,000 27.00 13.5016,666.67 - 17,333.33 26,000 28.08 14.0417,333.34 - 18,000.00 27,000 29.16 14.5818,000.01 - 18,666.66 28,000 30.24 15.1218,666.67 - 19,333.33 29,000 31.32 15.6619,333.34 - 20,000.00 30,000 32.40 16.2020,000.01 - 20,666.66 31,000 33.48 16.7420,666.67 - 21,333.33 32,000 34.56 17.2821,333.34 - 22,000.00 33,000 35.64 17.8222,000.01 - 22,666.66 34,000 36.72 18.3622,666.67 - 23,333.33 35,000 37.80 18.9023,333.34 - 24,000.00 36,000 38.88 19.4424,000.01 - 24,666.66 37,000 39.96 19.9824,666.67 - 25,333.33 38,000 41.04 20.5225,333.34 - 26,000.00 39,000 42.12 21.0626,000.01 - 26,666.00 40,000 43.20 21.6026,666.01 - 27,333.33 41,000 44.28 22.1427,333.34 - 28,000.00 42,000 45.36 22.6828,000.01 - 28,666.66 43,000 46.44 23.2228,666.67 - 29,333.33 44,000 47.52 23.7629,333.34 - 30,000.00 45,000 48.60 24.3030,000.01 - 30,666.66 46,000 49.68 24.8430,666.67 - 31,333.33 47,000 50.76 25.3831,333.34 - 32,000.00 48,000 51.84 25.9232,000.01 - 32,666.66 49,000 52.92 26.4632,666.67 - And Over 50,000 54.00 27.00

*Accidental Death & Dismemberment benefits are included for all active and retired employees who are under the age of sixty-five (65).

**Annual Earnings for those academic employees who work less than twelve months of the calendar year shall be the salary for that period of time required by their regular job duties as defined at the beginning of the academic year. For retired employees "annual earnings" means that salary level for which benefits were provided as an active employee on the last day of the month immediately preceeding the actual last day of work.

***Total includes both state and employee share of the premium.

health insurance information - home - livingston … insurance information new employees, who are...

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