retiree benefit summary - montgomery county public...
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E F F E C T I V E J A N U A R Y 1 , 2 0 1 8
M E D I C A L , D E N TA L ,
VISION, PRESCRIPTION
D RU G , A N D L I F E
I N S U R A N C E
B E N E F I T S
Employee and Retiree Service Center ¡ 45 W. Gude Drive, Suite 1200, Rockville, MD 20850301-517-8100 ¡ www.montgomeryschoolsmd.org/departments/ersc
RetireeBenefit Summary
C H A N G E S F O R 2 0 1 8
¡ Available medical plans are changing. (See page 8 for a list of available medical plans for 2018.)
¡ You may need to attest to whether or not your spouse will be tobacco free throughout 2017. (See page 9 to find out if you do.)
2 0 1 8
VISIONWe inspire learning by providing the greatest public education to each and every student.
MISSIONEvery student will have the academic, creative problem solving, and social emotional skills to be successful in college and career.
CORE PURPOSEPrepare all students to thrive in their future.
CORE VALUESLearning Relationships Respect Excellence Equity
Board of Education
Mr. Michael A. DursoPresident
Dr. Judith R. DoccaVice President
Ms. Jeanette E. Dixon
Mrs. Shebra L. Evans
Mrs. Patricia B. O’Neill
Ms. Jill Ortman-Fouse
Mrs. Rebecca K. Smondrowski
Mr. Matthew PostStudent Member
School Administration
Jack R. Smith, Ph.D.Superintendent of Schools
Maria V. Navarro, Ed.D.Chief Academic Officer
Kimberly A. Statham, Ph.D.Deputy Superintendent of School Support and Improvement
Andrew M. Zuckerman, Ed.D.Chief Operating Officer
850 Hungerford Drive Rockville, Maryland 20850 www.montgomeryschoolsmd.org
2018 Retiree Benefit Summary
oo
oo
2018 Retiree Benefit Summary
are
2018 Retiree Benefit SummaryRetiree Benefit Plan Enrollment
www.montgomeryschoolsmd.org/departments/ersc/retirees/benefits/
2018
2018 Retiree Benefit Summary
www.montgomeryschoolsmd.org/departments/ersc
Retiree Benefit Plan Enrollment,
2018
2018
2018
Consolidated Omnibus Budget Reconciliation Act
RetireeBenefit Plan Enrollment.
Retiree Benefit Plan Enrollment
Retiree Benefit Plan Enrollment
2018
IF YOU SUBMIT YOUR ENROLLMENT FORM:
YOUR COVERAGE WILL BEGIN ON:
Affordable Care Act
2018
Birthday Rule
2018
www.ssa.gov/pubs/EN-05-10536.pdf
2018
Medicare Eligibility and POS Medical Plan
Retiree Benefit Plan Enrollment
2018
www.montgomeryschoolsmd.org/departments/ forms
www.montgomeryschoolsmd.org/departments/er
sc/retirees/forms
RetireeBenefit Plan Enrollment—www.montgomeryschoolsmd.org/departments/forms/455-22.shtm
2018
Benefit Your Options Protecting Your HealthMedical
(Formerly known as CareFirst BlueChoice Advantage (POS/PPO). This is a change in name only; the network has NOT changed.)
(an HMO plan for retirees living outside of the CareFirst service area)
Prescription Drug
Dental
Vision
Protecting Your IncomeBasic Term Life Insurance
Defined Contribution Plans
http://mcps.yourplan.info/index.html
http://mcps.yourplan.info/index.html
Note: If you are employed by MCPS in any capacity after retirement, including as a temporary employee or substitute teacher, you are ineligible to take a distribution from the 457(b) plan based on retirement or separation from service.
2018
employeeretiree
CareFirst BlueChoice plan members
www.montgomeryschoolsmd.org/departments/ersc/retirees/benefits/wellness-initiatives.aspx
www.carefirst.comwww.kp.org
HealthInformation Portability and Accountability Act
2018
www.montgomeryschoolsmd.org/departments/ersc/
Retiree Benefit Plan Enrollment,
2018CareFirst BlueChoice Advantage POS Plan
CareFirst BlueChoice HMO Open Access—Maryland Area Access
www.carefirst.com
www.carefirst.com
*Away From Home Care (AFHC) provides benefits for CareFirst BlueChoice HMO Open Access plan participants residing outside of
2018their local HMO service area for 90 days or more. Some areas of the country do not participate in AFHC. To take advantage of the program, contact CareFirst at 1-888-452-6403 for details and enrollment procedures. AFHC enrollment may alter copays and coverage to the plan available in that service area.
CareFirst Exclusive Provider Option (EPO)
Kaiser Permanente HMO
www.kp.org
www.kp.org/healthyroads
CareFirst BlueChoice Advantage Indemnity/Medicare Supplemental Plan
2018
For Non-Medicare-eligible Retirees Affordable Care Act,
For Medicare-eligible Retirees
2018
* Using in-network providers only
Preventive Services Covered with Zero Copay for Non-Medicare-eligible Retirees* Preventive Service Covered Who is Eligible, Additional Details
2018Preventive Services Covered with Zero Copay for Non-Medicare-eligible Women * Preventive Service Covered Who is Eligible, Additional Details
* Using in-network providers only **Includes surgical, prescription, medical, and OTC services/products. Sterilization is considered a contraceptive method. Abortion is not considered a contraceptive method.
2018Preventive Services Covered with Zero Copay for Children of Non-Medicare-eligible Retirees*Service Who is Eligible, Additional Details
* Using in-network providers only
2018
*Applies to services not specifically listed in the previous preventive care charts. **Does not include diabetic supplies such as lancets, glucose strips, etc. See CVS Caremark Prescription for details. ***Covered in full for non-Medicare-eligible retirees if in-network.
Health Maintenance Organization (HMO) Plans
CareFirst BlueChoice HMO Open Access (Maryland service area) and CareFirst EPO (outside Maryland service area)
Kaiser Permanente HMO
Annual Deductible Preventive CareRoutine Physical Exam Well Baby/Child Care Childhood Immunizations Physician Services Physician Office Visit Specialist Office Visit Lab Work and X-rays Allergy Shots Maternity Care Prenatal and Postnatal Care
Physician Services Hospital Services Emergency Services (when medically necessary)Urgent Care Centers Emergency Room Emergency Physician Services Emergency Ambulance Hospital Services—InpatientSemi-private Room Professional Services Surgical Procedures Specialty Care/Consultation Anesthesia Radiology and Drugs Intensive Care Coronary Care Hospital Services—OutpatientSurgical Procedures Professional Fees Mental Health/Substance Abuse ServicesInpatient Days Outpatient Visits Other ServicesCatastrophic Illness Durable Medical Equipment Home Health Care Hospice Care
Skilled Nursing Care
2018Open Point-of-Service (POS) Plan
CareFirst BlueChoice Advantage (POS) In-Network Out-of-Network
Annual Deductible Preventive Care Routine Physical Exam Well Baby/Child Care Childhood Immunizations Physician Services Physician Office Visit Specialist Office Visit Lab Work and X-rays Allergy Evaluations Allergy Shots Maternity Care Prenatal and Postnatal Care Physician Services Hospital Services Emergency Service (when medically necessary) Urgent Care Centers
Emergency Room
Emergency Physician Services Emergency Ambulance Hospital Services—InpatientSemi-private Room Professional Services Surgical Procedures Specialty Care/Consultation Anesthesia Radiology and Drugs Intensive Care Coronary Care Hospital Services—Outpatient Surgical Procedures Professional Fees Mental Health/Substance Abuse Services Inpatient Days Outpatient Visits Other Services Catastrophic Illness
Durable Medical Equipment Home Health Care/ Skilled Nursing Care Hospice Care
*Applies to services not specifically listed in the previous preventive care charts.**Covered in full for non-Medicare-eligible retirees if in-network.
2018Non-Medicare Indemnity Plan CareFirst BlueChoice Advantage
Annual Deductible Preventive Care Routine Physical Exam Well Baby/Child Care Childhood Immunizations Physician Services Physician Office Visit Specialist Office Visit Lab Work and X-rays Allergy Evaluations Allergy Shots Maternity Care Prenatal and Postnatal Care Physician Services Hospital Services Emergency Care (when medically necessary) Urgent Care Centers Emergency Room Emergency Physician Services Emergency Ambulance Hospital Services—Inpatient Semi-private Room Professional Services Surgical Procedures Specialty Care/Consultation Anesthesia Radiology and Drugs Intensive Care Coronary Care Hospital Services—OutpatientSurgical Procedures Professional Fees Mental Health/Substance Abuse Services Inpatient Days Outpatient Visits Other Services Catastrophic Illness Durable Medical Equipment Home Health Care/ Skilled Nursing Care Hospice Care
*Applies to services not specifically listed in the previous preventive care charts. **Does not include diabetic supplies such as lancets, glucose strips, etc. See CVS Caremark Prescription for details. ***Covered in full for non-Medicare-eligible retirees.
2018
2018 Medicare CareFirst BlueChoice HMO**
CareFirst BlueChoice Advantage Medicare Supplemental
Kaiser Medicare Plus HMO**
Pays 80% of approved amount (after Medicare Part B deductible)
Pays all but limited costs (outpatient drugs and 5% of inpatient respite care)
Pays 80% of approved amount (after Medicare Part B deductible)
Pays 80% of approved amount (after Medicare Part B deductible)
Pays full cost for certain services (see current Medicare handbook or www.medicare.gov)
*Benefits provided per calendar year unless otherwise specified. **HMOs provide standard benefit package. Reimbursement is obtained from Medicare up to the limits shown. ***Some preventive care services are covered by Medicare with zero copayments. Please see the Medicare website for additional information.
2018
2018 Medicare CareFirst BlueChoice HMO**
CareFirst BlueChoice Advantage Medicare Supplemental
Kaiser Medicare Plus HMO**
Pays all but Part A deductible
Pays all but Part A deductible
Pays all but Part A deductible
Pays nothing
Pays all but the first 3 pints per calendar year
Pays 80% of approved amount (after Medicare deductible and starting with 4th pint)
Pays 100%
Pays all but Part A Deductible
Pays 100% of approved amount
*Benefits provided per calendar year unless otherwise specified. **HMOs provide a standard benefits package. Reimbursement is obtained from Medicare up to the limits shown.
2018
CareFirst Dental Preferred Provider Organization (PPO)
www.carefirst.com
Aetna Dental Maintenance Organization (DMO)
www.aetna.com/docfind
Kaiser Permanente Dental Plan
2018
Dental Benefits CareFirst PPO Aetna DMO
In-NetworkPlan pays:
Out-of-NetworkPlan pays:
In-Network OnlyPlan pays:
Maximum Annual Benefit
Annual Deductible Class I Class II Class III
Diagnostic (Class I)
Basic (Class II)
Basic (Class II)
Major (Class III)
2018
Davis Vision
SERVICE MAXIMUMBENEFIT LIMITS
Exams:
Frames:
Lenses only, per pair:
Contact Lenses:
www.DavisVisionContacts.com
www.carefirst.com
2018Kaiser Vision Plan
www.montgomeryschoolsmd.org/departments/ersc/retirees/benefits/health/medical/kaiser.aspx
KAISER PERMANENTE VISION PLAN
COPAYS
Exams:
Lenses and frames:
Contact lenses: (
Medically necessary contact lenses:
Low vision aids:
CVS Caremark Prescription Drug Plan(for non-Medicare-eligible retirees)
2018
not
PRESCRIPTIONOPTION A
RETAIL(UP TO 30-DAYSUPPLY)
CVS CAREMARK MAIL SERVICE PHARMACY OR CVS RETAIL PHARMACY(UP TO 90-DAYSUPPLY)
CVS Caremark Generic
CVS Caremark Preferred Brand Name (no generic equivalent)*CVS Caremark Non-preferredBrand Name**
PRESCRIPTIONOPTION B
RETAIL(UP TO 30-DAYSUPPLY)
CVS CAREMARK MAIL SERVICE PHARMACY OR CVS RETAIL PHARMACY(UP TO 90-DAYSUPPLY)
CVS Caremark Generic
CVS Caremark Preferred Brand Name (no generic equivalent)*CVS Caremark Non-preferredBrand Name**
plus
2018
Diabetic Supplies
Kaiser Permanente Prescription Drug Plan (for non-Medicare-eligible and Medicare-eligible retirees)
Retail Pharmacy
www.kp.org
Mail Order Service
2018
KAISERMEDICALCENTERPHARMACY
MAILORDER
KAISERNETWORKPHARMACY
KaiserNon-Medicare
KaiserMedicare
SilverScript/Caremark Medicare Part D Prescription Drug Plan(for Medicare-eligible retirees)
not
PLAN A
CVS RETAILPHARMACY(30-DAYSUPPLY)
NON-CVSRETAILPHARMACY(90-DAYSUPPLY)
CVSNETWORKSERVICEPHARMACY(UP TO 90-DAY SUPPLY)
Generics Brand/PreferredBrandNon-PreferredBrand
PLAN BCVS RETAIL(30-DAYSUPPLY)
NON-CVSRETAILPHARMACY(90-DAYSUPPLY)
CVSNETWORKSERVICEPHARMACY(UP TO 90-DAY SUPPLY)
Generics Brand/PreferredBrandNon-PreferredBrand
2018
Applying for Distribution of Funds from 403(b) and/or 457(b) Accounts
www.irs.gov
www.irs.gov
www.NetBenefits.com/mcps
Life Insurance Continuation at Retirement
Example: Life insurance value was $154,000 as an active employee.
2018www.montgomeryschoolsmd.org/
departments/ersc/retirees/benefits/
Retiree Benefit Plan Enrollment.
Accelerated Death Benefit
are notbase
(see page 9)
Retiree Benefit Rate Schedules
Determining Your Cost Share
2018
PAGE 33
MCPS ELIGIBLE SERVICE UPON RETIREMENT
RETIREE PAYS MCPS PAYS
10 up to 15 years 60% 40%
15 up to 20 years 50% 50%
20 or more years 36% 64%
All retiree benefit rate combinations can be found in the Retiree Benefit Rate Schedules, which will be mailed to retirees the first week of October 2017. The 2018 rate schedules also are available during Open Enrollment at:
http://www.montgomeryschoolsmd.org/departments/ersc/retirees/benefits/open-enrollment.aspx
2018
PAGE 34
www.montgomeryschoolsmd.org/departments/ ersc
www.montgomeryschoolsmd.org/departments/ personnel
www.aetna.com
www.carefirst.com/mcps
www.carefirst.com/mcps
(for services prior to 1/1/2018)
www.cigna.com
www.caremark.com
www.benstrat.com
(provided through CareFirst)
www.carefirst.com/mcps
www.kp.org
www.sra.state.md.us
www.netbenefits.com/mcps
www.montgomeryschoolsmd.org/departments/mcpsretirees/
www.medicare.gov
www.MCPS.SilverScript.com
www.ssa.gov
MCPS Form 455-22October 2017
Page 1 of 2
Retiree Benefit Plan EnrollmentEmployee and Retiree Service Center (ERSC)MONTGOMERY COUNTY PUBLIC SCHOOLS
45 West Gude Drive, Suite 1200 • Rockville, Maryland 20850
INSTRUCTIONS: All new retirees must make a selection in each category. Complete, sign electronically or manually on both sides of this form, and return to the Employee and Retiree Service Center (ERSC). You may fax the signed form to 301-279-3651 or 301-279-3642, or e-mail a PDF of the signed form to [email protected]. This form must be signed at the bottom of pages 1 and 2. Please do not mail copies to ERSC once you have faxed or e-mailed the enrollment form. A confirmation of your requested change(s) will be sent to you. Unsigned forms will be returned to you and become your responsibility to resubmit to ERSC by the appropriate deadline.
SECTION I: RETIREE INFORMATION—Please print. If your address has changed, please submit MCPS Form 445-1, Change in Personal Information with your benefit enrollment form. Benefit enrollment confirmations are sent to the address on file.
SECTION V: RETIREE BENEFIT PLAN ENROLLMENT INFORMATION—You must make a selection in each category A-D. Please consult the Retiree Benefit Summary for benefit plan enrollment qualifications. Medicare-eligible retirees (and their eligible dependents) must enroll in Medicare Parts A and B to continue coverage with MCPS. If you enroll in a private Medicare Part D plan, all MCPS prescription coverage will be cancelled.
CATEGORY A (Medical Plans)—
PLEASE SELECT ONE (1) OF THE FOLLOWING OPTIONSS
HEALTH MAINTENANCE ORGANIZATION (HMO) PLANS□ CareFirst BlueChoice HMO/CareFirst Exclusive Provider
Option (EPO) (an HMO option for retirees living outside the CareFirst service area)
□ Kaiser Permanente HMO
OPEN POINT-OF-SERVICE (POS) PLANS1
□ CareFirst BlueChoice Advantage
INDEMNITY/MEDICARE SUPPLEMENTAL PLANS□ CareFirst BlueChoice Advantage Indemnity/Medicare
Supplemental Plan□ I decline medical coverage□ No change to medical plan2
CATEGORY B (Prescription Drug Plans)—Please select one□ Caremark (available to all non-Medicare-eligible retirees except Kaiser HMO members) □ Option A □ Option B□ SilverScript/Caremark Part D plan for Medicare-eligible participants
(available to ages 65 + only) □ Option A □ Option B□ Kaiser (only available to Kaiser HMO members)□ I decline prescription drug coverage□ No change to prescription drug plan2
CATEGORY C (Dental Plans)—Please select one□ CareFirst Preferred Provider Organization (PPO)□ Aetna Dental Maintenance Organization (DMO) (Benefit plan participant must reside in a DMO service area.)□ I decline dental coverage□ No change to dental plan2
CATEGORY D (Vision Plan)—Please select one□ Davis Vision (provided through CareFirst)□ I decline vision coverage□ No change to vision plan2
1When a retiree or dependent becomes Medicare-eligible, your health plan will coordinate with Medicare. At that time, plan changes will be required.2If you are a new retiree, you may not select “No Change to Plan.”
Name Employee ID # __________________________ SSN #
Address Street City State Zip
Home Phone # - - E-mail Retiree Date of Birth / /
Retirement Date / / (new and existing retirees) Spouse Date of Birth / /
Last 4 digits
(continue on reverse side)SIGNATURE REQUIRED I understand that my electronic submission of this form, and my electronic signature, are intended to be, constitute, and are equivalent to my personal signature.
/ /on pages 1 and 2 Signature Date
SECTION II: RETIREE ENROLLMENT INFORMATION□ Continuation of Benefits in Retirement (new retirees only)□ Open Enrollment□ Transfer to active spouse MCPS plan
(must include MCPS Form 455-20: Employee Benefit Plan Enrollment)□ Reenrollment/Qualifying Event (if coverage was canceled after 7-1-98)□ Change from POS to Medicare
□ Drop dependent(s)□ Deceased dependent—date of death / /□ Change of Beneficiary only—
skip to SECTION VII, LIFE INSURANCE BENEFICIARY DESIGNATION□ I cancel/decline all benefit plan enrollment
effective / / (Date of cancellation must adhere to deadline rules in RBS)—skip to SECTION VI, LIFE INSURANCE OPTION
SECTION III: RETIREE LEVEL OF HEALTH COVERAGE
□ Individual
□ Two-Party
□ Family
SECTION IV: TOBACCO ATTESTATIONMCPS requires that you answer the following question ONLY if— • you and your spouse are covered by an MCPS-provided medical plan, AND • one or both of you are NOT eligible for Medicare.
Question: Answer ONLY for those who are NOT Medicare-eligible.Will you and your spouse be tobacco free throughout 2017? □ Yes □ No
MCPS Form 455-22Page 2 of 2
First Name Last Name MI Social Security #Date of
Birth SexEnroll/Drop
Spouse □/□
Child □/□
Child □/□
FOR ADDITIONAL COVERED DEPENDENTS, PLEASE ATTACH A SEPARATE SHEET OF PAPER.
SECTION VI: COVERED PARTICIPANTS—To enroll or drop dependent(s).
SECTION VII: BASIC TERM LIFE INSURANCE
□ Continue at retirement
□ I cancel/decline Basic Term Life Insurance (You may not reenroll once life insurance is cancelled.)
□ Change of beneficiary only
□ No change
SECTION VIII: LIFE INSURANCE BENEFICIARY DESIGNATION• Benefits shall be divided equally among primary beneficiaries (or contingent beneficiaries), unless otherwise stated.
• The contingent beneficiary(ies) shall be entitled to life insurance benefits in the event there is no surviving primary beneficiary.
• If designating a Trust as a beneficiary, please provide a copy of the title, trustee, address, and signature pages of the Trust.
Please check Primary or Contingent for each designated beneficiary. If neither box is checked, the named beneficiary will be deemed as a primary beneficiary.
□ No change
□ Primary
Name
Address
Share % Relationship
□ Primary □ Contingent
Name
Address
Share % Relationship
□ Primary □ Contingent
Name
Address
Share % Relationship
□ Primary □ Contingent
Name
Address
Share % Relationship
FOR ADDITIONAL BENEFICIARIES, PLEASE ATTACH A SEPARATE SHEET OF PAPER.
This form must be signed for selections and designations to be valid. I understand that my electronic submission of this form, and my electronic signature, are intended to be, constitute, and are equivalent to my personal signature.
SIGNATURE REQUIRED / /on pages 1 and 2 Signature Date
Printed name Employee ID # __________________________
M C P S N O N D I S C R I M I N A T I O N S T A T E M E N T
Montgomery County Public Schools (MCPS) prohibits illegal discrimination based on race, ethnicity, color, ancestry,
national origin, religion, immigration status, sex, gender, gender identity, gender expression, sexual orientation, family/
parental status, marital status, age, physical or mental disability, poverty and socioeconomic status, language, or other
legally or constitutionally protected attributes or affiliations. Discrimination undermines our community’s long-standing
efforts to create, foster, and promote equity, inclusion, and acceptance for all. Some examples of discrimination include
acts of hate, violence, insensitivity, harassment, bullying, disrespect, or retaliation. For more information, please review
Montgomery County Board of Education Policy ACA, Nondiscrimination, Equity, and Cultural Proficiency. This Policy
affirms the Board’s belief that each and every student matters, and in particular, that educational outcomes should never
be predictable by any individual’s actual or perceived personal characteristics. The Policy also recognizes that equity
requires proactive steps to identify and redress implicit biases, practices that have an unjustified disparate impact, and
structural and institutional barriers that impede equality of educational or employment opportunities.
For inquiries or complaints about discrimination against MCPS staff *
For inquiries or complaints about discrimination against MCPS students *
Office of Employee Engagement and Labor RelationsDepartment of Compliance and Investigations850 Hungerford Drive, Room 55Rockville, MD [email protected]
Office of School Administration Office of School Administration Compliance Unit850 Hungerford Drive, Room 162Rockville, MD 20850301-279-3444 [email protected]
* Inquiries, complaints, or requests for accommodations for students with disabilities also may be directed to the supervisor of the Office of Special Education, Resolution and Compliance Unit, at 301-517-5864. Inquiries regarding accommodations or modifications for staff may be directed to the Office of Employee Engagement and Labor Relations, Department of Compliance and Investigations, at 240-314-4899. In addition, discrimination complaints may be filed with other agencies, such as: the U.S. Equal Employment Opportunity Commission, Baltimore Field Office, City Crescent Bldg., 10 S. Howard Street, Third Floor, Baltimore, MD 21201, 1-800-669-4000, 1-800-669-6820 (TTY); or U.S. Department of Education, Office for Civil Rights, Lyndon Baines Johnson Dept. of Education Bldg., 400 Maryland Avenue, SW, Washington, DC 20202-1100, 1-800-421-3481, 1-800-877-8339 (TDD), [email protected], or www2.ed.gov/about/offices/list/ocr/complaintintro.html.
This document is available, upon request, in languages other than English and in an alternate format under the Americans
with Disabilities Act, by contacting the MCPS Public Information Office, at 301-279-3853, 1-800-735-2258 (Maryland Relay),
or [email protected]. Individuals who need sign language interpretation or cued speech transliteration may contact
the MCPS Office of Interpreting Services at 240-740-1800, 301-637-2958 (VP) or [email protected].
MCPS also provides equal access to the Boy/Girl Scouts and other designated youth groups.
ROCKVILLE, MARYLAND
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COPYRIGHT © 2017 MONTGOMERY COUNTY PUBLIC SCHOOLS
Montgomery County Public SchoolsEmployee and Retiree Service Center (ERSC)45 West Gude Drive, Suite 1200Rockville, MD 20850
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