State of Tennessee Group Insurance Program New Employee Benefits Orientation Central State Employees - 2013

State of TennesseeGroup Insurance Program

New Employee Benefits OrientationCentral State Employees - 2013

2

Importance of Your Decisions

• The decisions you make now as a new employee will have lasting effects on your benefits

• Please note: some of your decisions can only be made during the new hire period

• Please make sure that you are aware of all the options available to you and that you make an informed decision

• Submit any questions to your Agency Benefits Coordinator (ABC) or Benefits Administration

3

Resource Materials

You will also be provided with an Employee Checklist to confirm that you have been informed of important benefits information

For more detailed information, refer to the Eligibility and Enrollment Guide

provided by your ABC.

4

Resource Materials

The Summary of Benefits Coverage (SBC) describes your health coverage options. You can print a copy on the

Benefits Administration website, or ask your ABC for a copy.

5

About the Plan

• The State Group Insurance Program (also called the Plan) covers three different populations:

• State and Higher Education Employees

• Local Education Employees

• Local Government Employees

• We spend about $1.3 billion annually and cover nearly 300,000 members

• The health plan is self-insured, meaning that the State, not an insurance company, pays claims from premiums collected from members and their employers

• The Division of Benefits Administration manages the State Group Insurance Program and works with your Agency Benefits Coordinator (ABC) to serve our Plan members

6

Who is Eligible for Coverage?

• Generally, full time employees are eligible for health insurance coverage as well as their dependents, who may include:

• Legally married spouses

• Children up to age 26, including natural, adopted or step-children or children for whom the employee is the legal guardian

• There are special circumstances for employees with disabled dependents that may allow for coverage of these dependents after age 26

• For more information about disabled dependents, refer to the Eligibility and Enrollment Guide or consult your ABC

7

Notice to TennCare Enrollees

• You must contact your caseworker at the Department of Human Services (DHS) within 10 days of your date of employment

• Report to DHS your new job, salary and that you have access to medical insurance with your new employer

8

Adding Coverage

There are only three times you may add health coverage:

1. As a new employee

2. During the fall annual enrollment transfer period

3. If you experience a special qualifying event A specific life change, such as marriage, the birth of a baby or something that

results in loss of other coverage Must submit paperwork within 60 days of the event or loss of other coverage A complete list is provided on page three of the enrollment application

9

Annual Enrollment Transfer Period

• During the Annual Enrollment Transfer Period (AETP), you may:

• Add health insurance coverage

• Change health insurance carriers

• Choose a different PPO

• Cancel health insurance coverage

• Changes are effective January 1 of the following year

• Add, cancel or make changes to optional benefits during AETP

The Annual Enrollment Transfer Period occurs each year during the fall, usually around October.

10

Canceling Coverage

• You may only cancel health, dental or vision coverage for yourself or your dependents:

1. During the Annual Enrollment Transfer Period

2. If you become ineligible to continue coverage

3. If you experience a qualifying event listed on the Insurance Cancel Request Application

• You cannot cancel coverage during the plan year, outside of AETP, unless you have a qualifying event or lose eligibility under the plan

11

Definitions

• Premiums are the amount you pay each month for your coverage regardless of whether or not you receive health services

• A co-pay is a flat dollar amount you pay for services and products, like office visits and prescriptions

• A deductible is a set dollar amount that you pay out-of-pocket each year for services that require co-insurance

• Co-insurance is a form of payment where you pay a percentage of the cost for a service, after meeting your deductible

12

Definitions

• The out-of-pocket co-insurance maximum is the limit on the amount of money you will have to pay each year in deductibles and co-insurance

• The out-of-pocket co-pay maximum limits how much you pay for certain in-network services that require co-pays

• A network is a group of doctors, hospitals and other health care providers contracted with a health insurance plan to provide services to members at pre-negotiated (and usually discounted) fees

• The maximum allowable charge (MAC) is the most a plan will pay for a service

For a complete list of definitions, see the Eligibility and Enrollment Guide or visit our website.

13

Choosing Your Health Insurance Options

Choose between Two Preferred Provider Organization (PPO) Options

Partnership PPO

Standard PPO

Choose between Four Premium Levels

• Employee

• Employee + child(ren)

• Employee + spouse

• Employee + spouse + children

All members have the same choices. After the initial new hire period, changes can only be made if you experience

a special qualifying event or during AETP in the fall.

Choose an Insurance Carrier

• BlueCross BlueShield of Tennessee

• Cigna

14

PPO Options

• There are two health insurance options available to you:• Partnership PPO

• Standard PPO

• Both of these options are Preferred Provider Organizations (PPOs)

• How a PPO Works:

• Visit any doctor or hospital you want

• However, the PPO has a list of in-network doctors, hospitals and other providers that you are encouraged to use

• These in-network providers have agreed to take lower fees so you pay less for services

• You will pay more for services from out-of-network providers

15

Comparing Your PPO Options

Partnership PPO

Rewards members for taking an active role in their health

Commitment to Partnership Promise is required

Standard PPO

No incentives for healthy behaviors

Members pay a greater share of costs

Both options cover the same services, treatments and products. However, under the Partnership PPO, when you take an active role in

your health, you will pay less.

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Partnership PPO

• The Partnership PPO option allows you to pay less for your coverage by taking an active role in your health and fulfilling the Partnership Promise

• The Partnership Promise is an annual commitment

• In order to remain in the Partnership PPO, you must meet your commitment each year by the deadline

• The Partnership Promise requirements may change from one year to the next

Partnership Promise

17

New members and their covered spouses must:

• Complete the online Well-Being Assessment

• Get a biometric health screening

* Both requirements must be completed within 120 days of your insurance coverage effective date.

1818

Partnership Promise

Online Well-Being Assessment (WBA)

• Summarizes your overall health and offers steps you can take to improve

• By completing the confidential assessment online, you will learn more about your physical, emotional and social health and how your lifestyle habits affect your overall well-being

• You must visit www.partnersforhealthtn.gov and create an online well-being account to access the assessment

You will have 120 days to complete the Well-Being Assessment.

19

Partnership Promise

Biometric Health Screening

• You must get a health screening from your health care provider

This includes height, weight, blood sugar, blood pressure and cholesterol level

• You may use screening results from a doctor’s visit within the last 12 months

• Simply ask your doctor to complete the Physician Screening Form, which is available online at www.partnersforhealthtn.gov

• Send the completed form to Healthways by the 120-day deadline

20

If You Cover Your Spouse

• Same PPO Option

• Your spouse must also commit to the Partnership Promise

• Exception: If you and your spouse both work for a Participating Employer you can choose different options

• Partnership Promise is not required for covered children

21

Standard PPO

• The Standard PPO offers the same services as the Partnership PPO, but you will pay more for monthly premiums, annual deductibles, pharmacy co-pays, medical care co-insurance and out-of-pocket maximums

• Members enrolled in the Standard PPO are not required to fulfill the Partnership Promise

22

Choosing an Insurance Carrier

• Once you choose your PPO, you have a choice of two carriers:

• BlueCross BlueShield of Tennessee (Network S)

• Cigna (Open Access Plus)

• You may choose between these two carriers, regardless of the PPO option you select

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• Each carrier has its own network of preferred doctors, hospitals and other health care providers

• Check the networks for each carrier carefully when making your decision

• Provider directories are available

• Online

• By calling the carrier’s customer service phone line

• From your ABC

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• There are three regions (grand divisions): East, Middle and West

• Carrier costs vary by grand division• Cigna is more expensive in the East and Middle

grand divisions• BlueCross BlueShield of Tennessee is more

expensive in the West grand division

• If you live and work in different regions, you can choose between the two

• Before selecting a carrier, review the premium rate and provider network to help you decide

Each carrier offers statewide and national networks, regardless of the region where you live

LAKE

DYER

GIBSON

WEAKLEY

OBION

CARROLL

BEN TON

HENRY

HAYWOO D MADISON

CROCKETT

LAUDERDALE

TIPTON

SHELBY HARDEMANFAYETT EHARDIN

CHESTER

MCNAI RY

DECATUR

HENDERSON

WAYNE

PER RY

HUMPHREYS

LEWIS

LAWRENC E

HICKMAN

DICKSON

HOUSTON

STE WART MONTGOME RY

CHEATHAM

SUMNERROBE RTSO N

DAVIDSO N

RUTHERFORDWILLIAMSON

MAU RY

GILES

MARSHALL

MOORE

LINCOLN

BEDFORDCOFFEE

FRANKLIN

GRUNDY

CANNON

WARRENVAN BURE N

WILSON

TROUSDALE

MACON

SMITH

DEKALB

CLAY

JACKSON

PUTNAM

OVE RTON

WHITECUMBERLAND

PICKETT

FENTRESS

BLEDSOE

SEQU ATCHIE

MARIONHAMI LTON BRADLEY

MEIGS

RHEA

MCMINN

POLK

MONROE

LOUDON

ROANE

BLOUNT

KNOX

ANDERSONMORGAN

CAMPBELLSCOTT

UNION

HANCOCK

GRAINGER

CLAIBORNE

JEFFERSON

HAMBLEN

SEVIER

COCKE

GREENE

HAWKIN SWASHING TON

CARTER

UNICOI

SULLIVAN JOHNSON

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Choosing Your Premium Level

• The amount you pay in premiums depends on the PPO you choose and the number of people you cover under the plan

• There are four premium levels (tiers) available:

• Employee Only

• Employee + Child(ren)

• Employee + Spouse

• Employee + Spouse + Child(ren)

Remember: The Partnership PPO premiums are lower than the premiums for the Standard PPO.

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Choosing Your Premium Level

• If your spouse works for a participating employer, you have another option:

• Choose premium level separately (employee only)

• Choose your PPO option and insurance carrier separately

• If you and your spouse are both State and Higher Education employees:

• You may each want to consider enrolling in employee only coverage or employee + children, if you have children, to ensure that you receive the maximum life insurance benefit. However, an individual may only be covered under one policy

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Premiums: State Plan

Premium Level Partnership PPO Standard PPO

Employee Only $108.52 $133.52

Employee + Child(ren) $162.78 $187.78

Employee + Spouse $227.89 $277.89

Employee + Spouse + Child(ren) $282.15 $332.15

Employee Share of Monthly Premiums*

The State pays 80% of the total premium cost for active employees.

*This chart shows the premiums for the less expensive carrier in your region

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Covered Services

• The Partnership PPO and the Standard PPO both cover the same services, treatments and products, including the following:

• Preventive care

• Primary care

• Specialty care

• Hospitalization and surgery

• Laboratory and x-rays

• A comparison chart that lists covered services and their costs is available in the Eligibility and Enrollment guide and on the ParTNers for Health website

• A pre-existing condition exclusion period of 12 months may apply unless you can provide proof of prior creditable coverage

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Co-Pays

Partnership PPO Standard PPO

In-Network Out-of-Network* In-Network Out-of-Network*

Preventive Care No charge $45 co-pay No charge $50 co-pay

Well-baby or Well-child Visits

No charge $45 co-pay No charge $50 co-pay

Primary Care $25 co-pay $45 co-pay $30 co-pay $50 co-pay

Specialty Care $45 co-pay $70 co-pay $50 co-pay $75 co-pay

Prescription Drugs (30-day supply at Retail Pharmacy)

$5 co-pay generic

$35 co-pay preferred brand

$85 co-pay non-preferred brand

Co-pay for applicable tier plus amount over MAC

$10 co-pay generic



Co-pay for applicable tier plus amount over MAC

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Free In-Network Preventive Care

• Annual preventive care check-up offered to members at no cost

• Lab work related to the preventive care visit covered at 100%

• You need to visit an in-network provider to receive preventive care services at no cost

Regular preventive care is one of the most important things you can do to stay healthy.

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Co-Insurance


In-Network Out-of-Network* In-Network Out-of-Network*

Inpatient Care (Including Mental Health and Substance Abuse)

You pay 10% You pay 40% You pay 20% You pay 40%

Advanced X-ray, Scans and Imaging You pay 10% You pay 40% You pay 20% You pay 40%

Occupational Therapy, Physical Therapy, Speech Therapy

You pay 10% You pay 40% You pay 20% You pay 40%

Durable Medical Equipment You pay 10% You pay 40% You pay 20% You pay 40%

Note: prior authorization is required for inpatient care, advanced x-ray, scans and imaging, inpatient therapy and certain medical equipment.

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Annual Deductibles


Annual Deductible In-Network Out-of-Network In-Network Out-of-Network

Employee only $450 $800 $800 $1,500

Employee + Child(ren) $700 $1,250 $1,250 $2,350

Employee + Spouse $900 $1,600 $1,600 $3,000

Employee + Spouse + Child(ren) $1,150 $2,050 $2,050 $3,850

You pay the annual deductible before co-insurance benefits kick in.

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Out-of-Pocket Maximums


Out-of-Pocket Co-insurance Maximum In-Network Out-of-Network* In-Network Out-of-Network*

Employee Only $1,550 $2,900 $1,900 $3,600

Employee + Child(ren) $2,450 $4,600 $3,100 $5,900

Employee + Spouse $3,100 $5,800 $3,800 $7,200

Employee + Spouse + Child(ren) $4,000 $7,500 $5,000 $9,500

*Members are responsible for 100% of non-emergency out-of-network provider charges above the maximum allowable charge (MAC).


Out-of-Pocket Co-pay Maximum In-Network Out-of-Network* In-Network Out-of-Network*

Per Individual $900 N/A $1,100 N/A

*Out-of-Pocket Co-Pay maximum does not apply to out-of-network providers.

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Take Note!

• Deductibles and out-of-pocket maximums for in-network and out-of-network services add up separately

• Services received in network count toward your in-network deductible and out-of-pocket maximum

• Services received out of network count toward your out-of-network deductible and out-of-pocket maximum

Ineligible expenses, including non-covered services and expenses over the MAC don’t count toward

deductibles and out-of-pocket maximums.

Deductible Out-of-Pocket Max

In-Network $450 $1,550

Deductible Out-of-Pocket Max

Out-of-Network $800 $2,900

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Pharmacy Benefits

• Your health plan also includes pharmacy benefits

• The covered drug list is the same for both the Partnership PPO and Standard PPO, although co-pays differ between the two

• Pharmacy benefits are administered by CVS Caremark, one of the largest pharmacy benefits managers in the country with over 1,600 in-network pharmacies statewide

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• Co-pay amounts are based on three different factors: the type of pharmacy you use, your PPO option and the drug level (tier) of the medication

• There are three drug levels:

Generic Drug (tier one) is a generic medicine that is FDA-approved and equal to the brand-name product in safety, effectiveness, quality and performance

– Least expensive option

Preferred Brand (tier two) is a brand-name drug included on the drug list

– More expensive option

Non-preferred Brand (tier three) is a brand-name drug not on the drug list

– Most expensive option

Pharmacy Benefits

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Prescription Drug Co-pays


In-Network Out-of-Network In-Network Out-of-Network

30-Day Supply

(only from pharmacies in the 30-day network)

$5 co-pay generic



Co-pay, plus any amount exceeding MAC

$10 co-pay for generic

$45 co-pay for preferred brand

$95 co-pay for non-preferred brand


90-Day Supply

(90-day network pharmacy or mail order)

$10 co-pay generic




$20 co-pay for generic

$85 co-pay for preferred brand

$185 co-pay for non-preferred brand


90-Day Supply

(certain maintenance medications from 90-day pharmacy or mail order)

$5 co-pay generic




$10 co-pay generic




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Mental Health and Substance Abuse Treatment

• Employees and dependents who are enrolled in health coverage are also eligible for mental health and substance abuse services

• Mental Health and Substance Abuse services generally include:

• Individual and group treatment

• Hospitalization

• Aftercare

• Costs are based on your health plan

• Prior authorization is required for some services

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Eligible employees can choose between two dental options

• Each year during the Annual Enrollment Transfer Period, eligible employees can enroll in or transfer between dental options

• Unlike health insurance where a portion of the premium is paid by the employer, dental insurance is paid 100% by the member

Optional Dental Benefits

Prepaid Plan

• Participating dentists only

• Fixed co-pays

PDO Plan

• Any dentist

• Pay less with network providers

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Prepaid Plan

• The Prepaid plan is administered by Assurant Employee Benefits

• The Prepaid Plan provides dental services at predetermined co-pay amounts from a limited network of participating dentists and specialists

• This means you must select a provider from a limited network of dentists and submit your selection to Assurant before any services will be covered

• The are no deductibles, no claims to file, no waiting periods, no annual dollar maximum, pre-existing conditions are covered and referrals are not required

• To find a dentist in Assurant’s network, visit the dental section of the ParTNers for Health website or call Assurant’s number listed in the Eligibility and Enrollment Guide

41

Preferred Dental Organization

• The PDO is administered by Delta Dental of Tennessee

• Under the Preferred Dental Organization (PDO), you may use any dentist

• Referrals are not necessary with the PDO and you or your dentist file claims for covered services

• There is a one-year waiting period for some services, such as orthodontia

• Calendar year maximum of $1,500 per person

• Lifetime orthodontics maximum of $1,250 per person

• To find a dentist in Delta Dental’s network, visit the dental section of the ParTNers for Health website or call the number listed on the inside cover of the Eligibility and Enrollment Guide

42

Optional Dental Benefits

Dental services for both the Prepaid Plan and the Dental PDO include:

• Periodic oral evaluations • Routine Cleanings • Amalgam fillings

• Endodontic • X-rays • Extractions

• Major restorations • Orthodontics • Dentures

Premiums Prepaid Plan PDO Plan





43

Optional Vision Insurance

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Eligible employees can choose between two vision plans

• Full list of vision benefits is available in the Eligibility and Enrollment Guide and on the ParTNers for Health website

• Administered by EyeMed Vision Care

• Members have access to EyeMed’s Select Network

Basic Plan

• Discounted rates

• Allowances

Expanded Plan

• Co-pays

• Allowances

• Discounted rates

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Optional Vision Insurance

Premiums Basic Plan Expanded Plan





Both plans offer the same services:

• Annual routine eye exam • Eyeglass lenses

• Frames • Contact lenses

• Discount on Lasik/refractive surgery

Each year during AETP, eligible employees can enroll in or transfer between vision options.

45

Additional Benefits

• State employees are also eligible for:

• ParTNers Employee Assistance Program

• ParTNers for Health Wellness Program

• Life Insurance

• Long-Term Care Insurance

• Sick Leave Bank

• Flexible Benefits

• Deferred Compensation

Did You Know? Services provided by ParTNers EAP are FREE regardless of whether you enroll in health insurance!

Learn more about these valuable services on the following slides.

46

ParTNers EAP

• ParTNers Employee Assistance Program (EAP) helps you and your family members deal with problems we all experience during our daily lives

• Your EAP can handle issues related to:

• Stress, depression and anxiety

• Family, relationship or marital issues

• Child and elder care

• Grief and loss

• You receive up to 5 free counseling sessions per separate incident

• Your EAP also offers free financial and legal consultations

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ParTNers EAP

• There is no cost to you for services provided by ParTNers EAP, and your confidentiality is always a top priority

• ParTNers EAP is administered by Magellan Health Services

• Services are available 24/7 at www.Here4TN.com or by calling Magellan at the number listed on the inside cover of your Eligibility and Enrollment Guide.

48

ParTNers for Health Wellness Program

• The Wellness Program is designed to provide opportunities to manage and improve your health

• Services are free to all members enrolled in health coverage and their covered spouses and dependents

The Nurse Advice Line gives you medical information and support 24/7

Health coaching offers professional support to create and meet goals to

improve your health

Well-Being Connect, the ParTNers for Health Web Portal, links you to powerful online tools and health information at your fingertips (look for My Wellness Login)

49

ParTNers for Health Wellness Program

An online Well-Being Assessment is available to help you learn more about your health and identify any potential risks

Sign up for weekly health tips by email to receive a short email with each week’s healthy living tip

Fitness center discounts are available to plan members for fitness centers across the state

• To access any of the services listed here, visit the wellness webpage

on the ParTNers for Health website

50

Basic Term Life and Accidental Death and Dismemberment

• The State provides, at no cost to every full-time employee:

• $20,000 of basic term life insurance

• $40,000 of basic accidental death and dismemberment (AD&D)

• If you are enrolled in health insurance, your coverage increases with your salary up to:

• $50,000 for term life insurance

• $100,000 for AD&D insurance

• If you enroll in health insurance, your eligible dependents are also covered for $3,000 of basic dependent term life coverage and an amount for basic AD&D based on your salary and family composition

51

Optional AD&D Insurance

• In addition to basic coverage, you and your dependents may also enroll in optional accidental death and dismemberment insurance

• For a premium, this coverage pays an additional amount in the case of accidental death or dismemberment

• You may enroll as a new employee or during AETP

• Coverage is available at low group rates, no questions asked

Basic Term Life, Basic AD&D and Optional AD&D are administered by Dearborn National

52

Optional Term Life Insurance

• Premiums are based on age and the amount of coverage requested

• Coverage is also available for spouses and dependent children

Spouses: maximum level of coverage is $30,000 Children: $5,000 or $10,000 term rider

• Must enroll in first 30 days of employment for guaranteed issue coverage and coverage is effective after 3 months of employment

• You can apply later during AETP by answering health questions

• Select up to 5 times your annual base salary when first eligible

Minimum coverage level: $5,000 Maximum coverage level: $500,000

Optional Term Life Insurance is administered by Minnesota Life

53

Long-Term Care Insurance

• Covers services for qualified members who are unable to care for themselves without the assistance of others

• Nursing home care

• Assisted living

• Home health care

• You have 90 days to enroll with guaranteed-issue coverage

• Your spouse, dependent children, parents and parents-in-law may also apply through medical underwriting

• Premiums are based on the age of the insured at the time of enrollment

• Plan administered by MedAmerica

• Home care

• Adult day care

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Sick Leave Bank

• The Sick Leave Bank for state employees, administered by the Tennessee Department of Human Resources, provides additional sick leave benefits

• Available to members who have exhausted sick, compensatory, and annual leave balances due to personal illness, injury, medical condition or quarantine

• Receive up to 90 days of sick leave from the bank within a 12-month period

• You must be employed for at least 12 months and have at least six days of sick leave as of October 31st to enroll

• Initially, four days of sick leave are deducted and donated to the Bank

• New members are not eligible to receive grants from the Bank for pre-existing conditions until November 1st of the year following enrollment

• To learn more, visit www.tn.gov/dohr/employees/sickleave.html

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Flexible Benefits

• Lowers your income taxes

• Available to all state employees

• Set aside pre-tax earnings to pay for eligible expenses• Medical

• Dependent day care

• Parking

• Transportation

• Simply fill out a reimbursement form for eligible charges and money is directly deposited into your bank account when the expense is approved

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Flexible Benefits Reimbursement Accounts

Medical Expense Reimbursement Account

• Contribute up to $2,500 per year

• Reimburse yourself for eligible medical, dental and vision care expenses

Dependent Day Care Reimbursement Account

• Reimburse yourself for eligible dependent day care expenses

• Contribution depends on tax filing status

• New employees have 30 days to enroll for these accounts or during AETP

• Must enroll during AETP each year to continue participation

• You must use the money in your Medical and/or Dependent Daycare Flexible Benefits accounts each year or you will lose it

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Flexible Benefits Reimbursement Accounts

Parking Reimbursement Account

• Use the account to reimburse yourself for parking expenses

• May enroll at any time

Transportation Reimbursement Account

• Use the account to reimburse yourself for transportation expenses

• May enroll at any time

For more information about the program, including eligible expenses, visit www.treasury.state.tn.us/flex/.

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Deferred Compensation

• Two optional, tax-deferred retirement savings plans are operated by the state• 401(k) plan• 457 plan

• You also have the option of a Roth 401(k)

• Department of Treasury administers this supplemental retirement savings program along with Great West Retirement Services

• You may enroll in one or both plans and change your contribution amounts in either plan at any time

• Contributions are made through regular payroll deductions

• You cannot withdraw funds before leaving your job (a few exceptions apply)

• You choose how much to defer and how to direct your contributions among a variety of investment options.

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Deferred Compensation

• Both pre-tax plans allow you to Invest part of your current salary and defer paying income tax on that money until it is withdrawn, usually at retirement

• Roth 401(k) allows you to invest after-tax money instead of pre-tax money

401(k) Plan

• State matches contribution up to $50 per month

• Early withdrawal penalty of 10% (before age 59 ½)

457 Plan

• No State match

• No early withdrawal penalty for withdrawals before age 59 ½

For more information about the plans, visit the Department of Treasury’s website at www.treasury.tn.gov/dc/.

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Enrolling in Benefits

• Two ways to enroll:

• Enrollment Change Application

• Edison Employee Self Service (ESS)

• Enrollment must be completed within 31 days of your hire date

• Any required dependent verification must also be submitted during this timeframe

• See page 2 of the enrollment application or the publications and forms section of our website for information about dependent verification

To enroll in optional benefit products such as life insurance, use the separate enrollment forms provided by your ABC.

STATE OF TENNESSEE GROUP INSURANCE PROGRAMENROLLMENT CHANGE APPLICATIONState of Tennessee • Department of Finance and Administration • Benefi ts Administration312 Rosa L.ParksAvenue • Suite 2600 • Nashville, TN37243 • Fax:615.741.8196

Part 3: Health Coverage SelectionSelect a Benefit Option Select a Carrier Select Region Where You Live orWork Select a Health Premium Level

Standard PPO

Partnership PPO

Limited PPO (available to local government only)

BlueCross BlueShield NetworkS

Cigna Open Access Plus

East

Middle

West

See page 4 for map andinformation for out of stateresidents

employee only

employee + child(ren)

employee + spouse

employee + spouse + child(ren)

Part 4: Dental Coverage Selection Part 5:Vision Coverage SelectionSelect a Plan Select a Dental Premium Level Select a Plan Select aVision Premium Level

Delta PDO

Assurant Prepaid

employee only


employee + spouse


Basic Plan

Expanded Plan

employee only


employee + spouse


Active employees should return this completed form to your agency benefi ts coordinator. COBRA participants should send to Benefi ts Administration.

Part 6: Dependent Information— attach a separate sheet if necessaryName (First, MI, Last) Date of Birth Relationship Gender Acquire date * Social Security Number Health Dental Vision

M F

M F

M F

* The acquire date is the date of marriage, birth, adoption or guardianship.Proof of a dependent’s eligibility must be submitted with this application for all new dependents (see page 2).

Agency Section —Return this Form to your Agency Benefits CoordinatorOriginal Hire Date Coverage Begin/End Date Position Number Edison ID (Optional) Notes to Benefi ts Administration

Agency Benefi ts Coordinator Signature Date

FA-1043 (rev 9/12)

A separate sheet with moredependents is attached

Part 1: ActionRequested — please see page 4 for instructionsType of Action Coverage Participants Reason for This Action

Add Coverage

Change Coverage

Terminate Coverage

Affected

Health

Dental

Vision

Affected

Employee

Spouse

Child(ren)

New Hire/Newly Eligible

Terminate Employment

Special Qualifying Event (also complete page 3)

Court Order

Legal Guardianship

Newborn/Adoption

Other (specify)

Marriage

Divorce

Death

Part 2: Employee InformationFirst Name MI Last Name Date of Birth Gender

M FMarital Status

S M D W

Social Security Number Employing Agency Employer Group: UT TBRState Local Ed Local Gov

Your Current Status Active COBRA

Home Address City ST ZIP Code County

Part7: Employee Authorization

Accept I confirm that all of the information above is true. If I chose thePartnership PPO, then I agree to the terms and conditions of thePartnershipPromise for the plan year indicated on page4. I know that I can losemy insurance if I give false information. I may also face disciplinary and legalcharges. If my dependents lose eligibility, I know that I must tell my benefi ts coordinator within one calendar month. If I do not, then I will have to paythe plan back for all of my dependent’s healthcare bills. I authorizemy employer to take deductions frommy paycheck to pay for my benefi ts costs.Finally, I authorize healthcare providers to givemy insurance carrier the medical and insurance records for me and my dependents.

Refuse I have been given the opportunitybymy employer to apply for the group insurance program and have decided not to take advantage of this offer.I understand that if I later wish to apply, I or my dependents will have to provide proof of a special qualifying event.

Employ

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Online Enrollment through ESS

• Select your health insurance and other benefit options online

• Log on to Edison» www.edison.tn.gov

» Use username and temporary password provided by your Human Resource office

» Navigate to Employee Self Service > Benefits > Benefits Enrollment

» Click the SELECT button

» Follow the prompts to enroll

• If you are covering dependents, you can submit dependent verification by:

» Uploading electronic documentation

» Faxing documentation to Benefits Administration service center

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When Will Coverage Begin?

• Health, dental and vision coverage begin on the first day of the month following your hire date

• For example, if you are hired on September 15th, your coverage would begin on October 1st

• Ask your ABC if you have questions about when your coverage begins

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When Are Premiums Paid?

• Your ABC will tell you when your premiums will be deducted from your paycheck

• To avoid a large deduction from your first paycheck, submit your benefit selections in ESS or your enrollment forms to your ABC as soon as possible

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When Will My ID Cards Arrive?

• Within three weeks of the date your application is processed

• CVS Caremark will send separate ID cards for your pharmacy benefits (Note: each family member’s card may arrive in a separate envelope)

• If you enroll in dental or vision benefits, you will also receive your ID cards within three weeks

BlueCross BlueShield

• Will send up to two ID cards automatically, both with the member’s name

• These may be used by any covered dependent

Cigna

• Will send separate ID cards for each insured family member with each participant’s name

• There may be up to four ID cards in each envelope

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Your Privacy

• Your personal health information is strictly confidential

• Your health privacy rights are protected through a federal law called “HIPAA”

• Benefits Administration can only discuss benefits information with the head of contract (HOC)

• The Authorization for Release of Protected Health Information form must be completed before Benefits Administration can discuss benefits information with your spouse or other authorized representative

To print and complete a release form, visit http://www.tn.gov/finance/ins/forms.html.

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Insurance Carrier Websites

• BlueCross BlueShield, Cigna and CVS Caremark each offer member websites that allow you to:

• View detailed information about your claims

• Print temporary ID cards

• Access other helpful member services

BlueCross BlueShield Cigna CVS Caremark

www.bcbst.com/blueaccess www.mycigna.com www.caremark.com

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Who to Contact

• Your primary point of contact is your agency benefits coordinator (ABC)

• If you have questions about a provider or insurance claim, contact your insurance carrier directly at the number listed on the inside cover of the Eligibility and Enrollment Guide, visit your carrier’s member website or use the number on the back of your ID card

• If you have questions about eligibility and enrollment, call the Benefits Administration service center at 1-800-253-9981

• Benefits Administration www.tn.gov/finance/ins

• ParTNers for Health www.partnersforhealthtn.gov

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Thank you for your attention during this presentation.

More information is available at www.TN.gov/finance/ins.

If you have questions, please ask your Agency Benefits Coordinator at this time.

Documents

State of Tennessee Group Insurance Program New Employee Benefits Orientation Central State Employees - 2013