Transcription
PERS Health Insurance Program(PHIP) Medicare Enrollment GuideA comprehensive guide to PHIP and Medicare
The PERS Health Insurance Program (PHIP)offers health insurance coverage for all retirees,their spouses and dependents who meet theeligibility requirements.Mission StatementThe PERS Health InsuranceProgram (PHIP) provides PERSretirees with high-quality,comprehensive coverage(or benefits) at the mostcost-effective rates possible tomeet retiree benefit needs.Our core values are:y Maintain stability of premiumsy Maintain stability of coveragey Maintain stability ofContracted Health PlansMedicare Enrollment GuideThe PERS Health Insurance Program (PHIP) Medicare Enrollment Guide isdesigned to help you understand how your PHIP benefits work with Medicare.To participate in a PHIP Medicare plan, you must live in the United Statesand maintain a permanent residence (not mailing address) within a healthplan’s service area, and be enrolled in both Medicare Part A and Part B.Your PHIP Medicare health plan options include a Medicare Supplement planand Medicare Advantage plans. All PHIP Medicare health plans include aMedicare Part D Prescription Drug Plan (PDP). You can find program-specificinformation through the following additional PHIP member materials:y PERS Health Insurance Program (PHIP) Member Guidey PHIP Benefit Guide (includes premium rates)For more information about your PHIP health benefits, please visit pershealth.comor call customer service at 800-768-7377. To view the complete PHIP eligibilityand enrollment Oregon Administrative Rules (OAR) visit sos.oregon.gov/archives.
ContentsUnderstanding Medicare page 4— Medicare Part A (Hospital) page 4— Medicare Part B (Medical) page 4— Medicare Part C (Medicare Advantage Plan) page 5— Medicare Part D (Prescription Drug) page 5— Medicare Enrollment page 6— Deferred Enrollment in Medicare Part B page 6When to Enroll in a PHIP Medicare Plan page 8— Eligibility for PHIP Medicare Plans page 8— Enrollment in a PHIP Medicare Plan page 8— Work After Retirement page 9Medicare Health Plan Options page 11— Medicare Supplement page 11— Medicare Advantage Plans page 11— HMO— HMO-POS— PPOFrequently Asked Questions page 12Resources page 14— Getting Assistance With Your PHIP Plan page 14— Contacting Your Health Plan page 14— Additional Medicare Information page 14— Appeals page 15Required Notices page 16Definition of Terms page 18Acronyms page 19
Understanding MedicareMedicare is the federal health insuranceprogram for individuals who:y Are 65 years of age or oldery Are under age 65 but have beenreceiving Social Security DisabilityInsurance for more than 24 monthsy Have End-Stage Renal Disease (ESRD) orAmyotrophic Lateral Sclerosis (ALS)The Social Security Administration (SSA) isthe federal agency responsible for Medicareeligibility determination, enrollment andpremiums. The Centers for Medicareand Medicaid Services (CMS) regulatesthe Medicare program. Every year, CMSpublishes the Medicare and You handbook.This handbook provides information aboutMedicare.The following section provides basicinformation about the federal Medicareprogram. For more information, you can visitmedicare.gov.Here are specific timelines for enrollingin Medicare. For general informationon enrollment and eligibility, youcan contact the Social SecurityAdministration (SSA). See AdditionalMedicare Resources on page 14.Medicare Part A (Hospital)Medicare Part A is hospital insurance thathelps pay for inpatient hospital care, limitedhome health services, skilled nursing careand hospice expenses.In general, you are eligible for Medicare PartA if you:y Are age 65 or older and have worked forat least 40 quarters (10 years) in SocialSecurity/Medicare-covered employmenty Are disabled and are receiving SocialSecurity disability benefitsy Have End-Stage Renal Disease (ESRD) orAmyotrophic Lateral Sclerosis (ALS)4 Understanding MedicareIn most cases, you pay no premium to havethis coverage. If you delay enrollment intoMedicare Part A after you first becomeeligible, you may have to pay a federal lateenrollment penalty.Medicare Part B (Medical)Medicare Part B is medical insurancethat helps pay for outpatient expenses,including doctor visits, lab work anddiagnostic services.Generally, if you are eligible for Medicare PartA, you are eligible for Medicare Part B.If you do not enroll in Medicare Part B whenyou are first eligible, you may have to paythe federal late enrollment penalty. If so, yourpremium may be 10 percent higher for each12-month period that you were eligible, butdid not enroll in Medicare Part B. This alsomay lead you to be ineligible for PHIP.You must pay a premium each month tomaintain your enrollment in Medicare PartB. Every year, the SSA determines the basemonthly Medicare Part B premium amount. Ifyour income is above certain thresholds, youmay need to pay a higher premium amount.Premiums for Medicare Part A (if applicable)and Medicare Part B are automaticallydeducted from your Social Security benefits.If you do not yet receive a Social Securitybenefit, you will be billed quarterly bySocial Security.You must pay for and maintainenrollment in Medicare Part A and PartB to remain enrolled in a PHIP Medicarehealth plan.
Medicare Part C (Medicare Advantage)Part D Late Enrollment PenaltyMedicare Part C, also known as MedicareAdvantage (MA) is CMS-approved healthcoverage in which private health insurancecompanies contract with Medicare tocoordinate care. Medicare Advantage plansinclude Medicare Part A and Part B. Whenyou join a MA plan, you agree to that plan’sterms and conditions. You will still pay theMedicare Part B premium, in addition to thehealth plan premium.The late enrollment penalty (LEP) is anamount added to your Medicare Part Dpremium. You may owe a late enrollmentpenalty if, at any time after your initialenrollment period (IEP) is over, there’s aperiod of 63 or more days in a row whenyou do not have Medicare Part D or othercreditable prescription drug coverage.PHIP MA plans include a MedicarePart D Prescription Drug Plan (PDP).Medicare Part D (Prescription Drug Plan)Medicare Part D Prescription Drug Plan (PDP)covers Medicare-approved prescriptionmedications. If you are enrolled in MedicarePart A and Part B, you are usually eligible toenroll in a Medicare Part D plan.Medicare Part D is offered by healthinsurance companies and other privatecompanies that are approved by Medicare.Premiums for Medicare Part D plans are inaddition to your Medicare Part A and PartB premiums. If you or your dependent areMedicare-eligible when you enroll in a PHIPhealth plan, you may need to show prooffrom your prior employer or health plan thatthe prior plan’s prescription drug coveragewas creditable (equal to or more than thebasic Medicare Part D prescription drugbenefit). If the coverage was not creditable,Medicare could impose a penalty of 1 percentper month for each month you did not havecreditable coverage.If you are required to pay the LEP, Medicarewill notify PHIP of that amount. It will beadded to your monthly premium.You will need to pay this penalty toprotect your eligibility to stay enrolled ina PHIP Medicare health plan.Part D-IRMAAPart D Income Related Monthly AdjustmentAmount (Part D-IRMAA) is an assessmentrequired by Medicare for individuals whoseincome is above the Medicare-definedincome threshold and who are enrolled in aMedicare Part D Prescription Drug Plan.If you are receiving a Social Securitybenefit, the assessment will be deductedfrom your monthly benefit. If not, you willbe billed quarterly.To be eligible for PHIP coverage, you mustpay your Part D-IRMAA assessment. If youdo not pay it, Medicare will notify your plan ofnon-payment and your PHIP coverage will end.If you have questions about Part D-IRMAA,please contact either Medicare or the SocialSecurity Administration.Your PHIP coverage will end if youenroll in a second Medicare PartD prescription plan or MedicareAdvantage plan. After that, you cannotre-enroll in PHIP, unless you experiencea new enrollment opportunity.Understanding Medicare 5
Medicare EnrollmentYou will become eligible for Medicare at age65, regardless of whether you are receivinga Social Security benefit at the time. Youare entitled to Medicare the first day of thecalendar month in which you turn 65.If your birthday falls on the first day of themonth, you are entitled to Medicare the firstday of the prior month.Medicare eligibility could occur earlier thanage 65 if you are awarded Social SecurityDisability Insurance. Medicare eligibility dueto disability would become effective thefirst day of the 25th month after your SocialSecurity disability benefits began.You should receive your Medicareinformation, including your Medicare Part Aand Part B card, approximately three monthsprior to your 65th birthday or when youbecome eligible for Medicare due to disability.If you do not receive your Social Securitybenefit prior to age 65, you will need to contactthe Social Security Administration (SSA) or visityour local Social Security office approximatelythree months prior to your 65th birthday andapply for Medicare Part A and/or Part B.Medicare due to End-Stage Renal DiseaseEnd-stage renal disease (ESRD) is the stageof kidney impairment that appears irreversibleand permanent. It needs a regular course ofdialysis or a kidney transplant. If you haveESRD, coverage is available through OriginalMedicare (Supplement Plan) or beginningJanuary 1, 2021, a Medicare Advantage plan.Prior to January 2021, Medicare Advantageenrollment due to ESRD was only availablein certain situations. Eligibility for Medicarecoverage based on ESRD works differentlythan other types of Medicare eligibility. Pleasecontact either Medicare or the Social SecurityAdministration for more information.Deferred Enrollment in Medicare Part BYou or your spouse can defer enrollment inMedicare Part B if either of the following apply:y You are currently working for anemployer that has 20 or more employeesand have active employer-sponsoredgroup coverage through your job.6 Understanding Medicarey You have employer-sponsored groupcoverage through your spouse who iscurrently working for an employer thathas 20 or more employees.If your employer has fewer than 20employees, you may not be able to defer yourMedicare Part A and Part B.Enrolling After Deferred Medicare Part B- Special Enrollment Period (SEP)Once your employer-sponsored groupcoverage ends, you will have eight monthsto sign up for Medicare Part B without apenalty. If you do not sign up for MedicarePart B during that time, you may have to paya penalty for as long as you are enrolled inMedicare Part B.Additionally, if you do not sign up duringthis time, you will not be able to enroll inMedicare Part B until the General EnrollmentPeriod which is from Jan. 1 — March 31. Yourcoverage will not begin until July 1 of thatyear. This may cause a gap in healthcarecoverage and you may lose your enrollmentopportunity with PHIP.PHIP recommends you enroll in yourMedicare Part B approximately 90days before your employer-sponsoredgroup coverage ends. Submit yourPHIP Enrollment Request Form andcopy of your Medicare Card showingenrollment in Medicare Part A and PartB prior to your group coverage ending:This avoids a gap in coverage. PHIPallows up to 30 days to enroll after lossof employer-sponsored group coverageends. Any Enrollment Request Formreceived after 30 days of loss ofemployer-sponsored group coverageis considered outside of the PHIPenrollment opportunity and will beineligible. See "Work After Retirement"on page 9 for more information on yourPHIP enrollment opportunity.
Enrollment Opportunities 7
When to Enroll in a PHIPMedicare PlanEligibility for PHIP Medicare PlansEnrollment in a PHIP Medicare PlanOAR 459-035-0070A completed PHIP Enrollment Request Formmust be submitted when you are initiallyenrolling, adding a dependent or making achange to your PHIP coverage either at planchange or due to a family status change.OAR 459-035-0080In order to avoid a gap in coverage orforfeiting your enrollment opportunity,please submit all requested informationand/or documentation with thecompleted Enrollment Request Formprior to your requested effective date.PERS retirees can enroll within 90 daysof initial Medicare eligibility, if enrolledin both Medicare Part A and Part B,whether due to age or disability.Your eligibility to enroll in Medicare Part Aand Part B due to Social Security Disabilityis effective the first day of the 25thmonth after your Social Security Disabilitybenefits began. In this instance, becomingMedicare-eligible due to disability isconsidered your initial Medicare eligibility.Becoming Medicare-eligible at age 65will not be a new opportunity to enrollin a PHIP Medicare health plan, unlessyou have had 24 months of continuousemployer-sponsored group coverageimmediately before enrollment in PHIP.If you or your dependents are enrolled ina PHIP non-Medicare plan and becomeMedicare eligible, you must enroll in aPHIP Medicare plan within 30 days ofyour initial Medicare enrollment datein order to continue in PHIP.OPSRP disability benefit recipientsare not eligible for PHIP until theyare an eligible retiree underORS 238.305, 238.315, 238.195,or 238A.4008 When to Enroll in a PHIP Medicare PlanIf your Enrollment Request Form ismissing information or additionaldocumentation, your applicationwill be considered incomplete.If you are unable to provide the necessaryinformation and/or documentation priorto your requested effective date, youreffective date will change to the first of thenext month, as long as you are still withinthe PHIP enrollment opportunity period.You will receive enrollment informationfrom PHIP approximately 90 days prior tothe month you turn 65. This informationprovides you with the requirements neededto enroll in a PHIP Medicare health plan.During peak enrollment times (e.g.,plan change, peak retirement periods,end of month), delays may occur.Please allow time for PHIP to processyour application and notify your selectedhealth plan. If you need immediateaccess to your health plan information,please contact PHIP customer service.To enroll in a PHIP Medicarehealth plan you must:y Meet a PHIP Medicare enrollmentopportunityy Be an eligible PERS Retiree, spouse ordependenty Be enrolled in and maintain MedicarePart A and Part B
y Complete the PHIP Enrollment RequestForm: Include spouse or dependentinformation only if they are enrolling inPHIPy Submit a photocopy of either theMedicare card or Letter of Entitlement(Letters of Eligibility are not accepted)showing Medicare effective datesfor Part A and Part B for eachMedicare-eligible individual applyingy Provide your Medicare BeneficiaryIdentifier (MBI). This is found on yourMedicare cardThe retiree, spouse and dependent(if over 18) must sign if enrolling.Enrollment Request Forms will needto be signed and received prior to therequested effective date of coverage.Additional documentation may berequired. This may include a dependent’sbirth certificate, adoption paperwork,PERS disability approval letter, Affidavitof Domestic Partnership or marriagecertificate (if last names are different).Work After RetirementIf you chose to work following your PERSretirement, and have employer-sponsoredgroup health coverage (your own or withyour spouse) you may enroll in PHIP at anytime as long as you have been coveredunder another employer-sponsored grouphealth plan for 24 consecutive monthsimmediately preceding enrollment in PHIP.Employer-sponsored group coverage can be:y Employer-sponsored group coverage youhad as an active or retired employee thatis terminatingy Employer-sponsored group coverageyou had under an eligible spouse’s activeemployment or as a retired employeethat is terminatingy Employer-sponsored group coveragecontinued through COBRA followingtermination of employment: COBRA coverage is secondary toMedicare, except when the Medicarebeneficiary has ESRD COBRA coverage is primary toMedicare during the 30-month ESRDcoordination periodFor the purposes of PHIP, healthcarecoverage under worker’s compensation,Medicare or any other governmententitlement program (includingforeign healthcare) does not qualify asemployer-sponsored group health coverage.To ensure you are selecting the correct PHIPeffective date, verify your current health plancoverage end date with your employer. Toavoid a gap in coverage, select the first of themonth after your employer-sponsored groupcoverage ends as the PHIP effective date.To enroll, submit your completed PHIPEnrollment Request Form 30 days prior toyour employer-sponsored group coverageending to prevent a gap in coverage. PHIPallows up to 30 days to enroll after loss ofemployer-sponsored group coverage ends.However, if the Enrollment Request Form isreceived after your group coverage ends (oris incomplete), your PHIP effective date willbe the first of the month after PHIP receivesyour completed Enrollment Request Form.Any Enrollment Request Form receivedafter 30 days of loss of employer groupcoverage is considered outside of the PHIPenrollment opportunity and will be ineligible.When to Enroll in a PHIP Medicare Plan 9
10 Health Plan Options
Medicare Health Plan OptionsTo qualify for a PHIP health plan, you mustlive in the United States and maintain apermanent residence (not mailing address)within a health plan’s service area, and beenrolled in Medicare Part A and Part B.PHIP Medicare Supplement PlanThe PHIP Medicare Supplement with aMedicare Part D Prescription Drug Plan (PDP)plan covers medical and prescription drugs.It is similar to a Medigap plan in that it fills thegaps in Original Medicare. Original Medicarewill process the claim first and pay its shareand the PHIP Medicare Supplement withMedicare Part D PDP plan will then payits portion.You can live anywhere in the United States,travel outside the U.S. for up to six monthsand still maintain coverage. You will have topay the monthly Medicare Part B premium inaddition to your PHIP Medicare Supplementpremium. The PHIP Medicare Supplementplan allows you to choose any physician whois a Medicare participating provider.PHIP Medicare Advantage (MA) PlansThe PHIP Medicare Advantage (MA) planscover medical and prescription drugs. MAplans contract with hospitals and physiciansto provide care. When you enroll in any MAplan, that plan becomes the administrator ofyour Medicare Part A and Part B benefits. Youwill have to pay the monthly Medicare Part Bpremium in addition to your PHIP MedicareAdvantage premium.To be enrolled in a MA plan, you must residein that health plan’s service area. All availableplans have some limitations and exclusions.PHIP offers the following types of MA plans:Health Maintenance Organization (HMO)HMO plans offer healthcare services througha closed network of providers and hospitalsat a fixed price (copay). Most HMO plansrequire you to select a primary care provider(PCP) who will work with you to manage yourhealthcare needs through an integrated caresystem. Under an HMO plan, you may need areferral to see a specialist and out-of-networkservices may not be covered.HMO-Point-of-Service (POS)POS plans work similar to an HMO plan witha more flexible network that allows careoutside of the traditional HMO network. Youmay have a higher copay or coinsurancefor using services outside of the traditionalHMO network. A primary care provider (PCP)may be required and often a referral will benecessary to see a specialist.Preferred Provider Organization (PPO)PPO plans give you access to a network ofhealthcare providers known as preferred(in-network) providers. It also allowsyou the option of seeing non-preferred(out-of-network) providers at a highercoinsurance rate. Typically, a PPO plan willnot require you to select a primary careprovider (PCP) and you may get serviceswithout requiring a referral.You can be enrolled in only one MAplan at a time. By enrolling in a PHIPMedicare Advantage plan, any prior MAcoverage will be terminated.Medicare Health Plan Options 11
Frequently Asked QuestionsQ: My spouse will be Medicare-eligiblebefore me and will no longer be able tostay on my retiree plan. Can my spouseenroll in PHIP while I stay on my retireeplan?A: Yes. Your spouse may enroll in PHIP duringtheir initial Medicare eligibility while you stayon your group-sponsored retiree plan. Thereverse is also true: If you, as the retiree, areMedicare-eligible before your spouse, thespouse may stay on the group-sponsoredretiree plan, while you enroll in a Medicareplan under PHIP. When your spouse becomesentitled to Medicare, they may be eligibleto enroll in PHIP as a dependent under yourPHIP plan.Q: What happens if I cancel my MedicarePart B benefits? How does this affect myPHIP Medicare plan?A: You must have Medicare Part B in order tocontinue your enrollment in a PHIP Medicareplan. If you stop paying your Medicare PartB premiums or cancel your Medicare Part Bcoverage, you will lose all your PHIP medical,pharmacy and dental coverage. After that,you may not re-enroll in PHIP unless youexperience a new enrollment opportunity.Q: I am Medicare-eligible, but my spouseis still working and I am covered undermy spouse’s active employer-sponsoredgroup health plan. When should I enroll inMedicare Part B?A: You may enroll in Medicare Part B wheneligible due to age or Social SecurityDisability while your spouse is employedand you are covered under their activeemployer-sponsored group health plan,or you may defer your Medicare Part Benrollment until your spouse retires andloses employer-sponsored group coverage.12 Frequently Asked QuestionsWhen loss of active employer-sponsoredgroup coverage ends, your Medicare Part Benrollment should be the first of the monthafter your active employer-sponsored groupcoverage ends.Example: Active employer-sponsored groupcoverage ends March 31; your Medicare PartB enrollment should be effective April 1.This will also be your PHIP Medicare effectivedate. You may submit your completed PHIPEnrollment Request Form up to 30 daysprior to your active employer-sponsoredgroup coverage ending to prevent a gapin coverage. You will need to provideproof of Medicare enrollment (copy of yourMedicare Part A and Part B card or Letter ofEntitlement) and 24 months of continuousemployer-sponsored group coverageimmediately before your PHIP requestedenrollment effective date. Any EnrollmentRequest Form received after 30 days of lossof employer-sponsored group coverageis considered outside of the enrollmentopportunity and will be ineligible.Q: I am under 65 and currently enrolledin a PHIP non-Medicare plan. I have beenapproved for Medicare due to SocialSecurity Disability. Do I need to enroll in aPHIP Medicare plan?A: Your eligibility to enroll in Medicare Part Aand Part B, due to Social Security Disability,becomes effective the first day of the 25thmonth after your Social Security Disabilitybenefits began. In this situation, becomingMedicare-eligible due to disability isconsidered your initial Medicare eligibility.If you are currently enrolled in a PHIPnon-Medicare plan, you must complete a newEnrollment Request Form 30 days prior toyour Medicare eligibility date in order to makeyour PHIP Medicare health plan selection.
Failure to submit a new Enrollment RequestForm for Medicare coverage will result incancellation of your non-Medicare healthplan coverage under PHIP, upon Medicareeligibility. You will not have any futureopportunities to enroll.becoming Medicare-eligible at age 65 willnot be a new opportunity to enroll in a PHIPhealth plan unless you have had 24 monthsof continuous employer-sponsored coverageimmediately preceding enrollment in PHIP.The 90-day initial Medicare eligibilityenrollment opportunity will apply in thissituation. If you miss this opportunity,Frequently Asked Questions 13
ResourcesGetting Assistance With Your PHIP PlanContacting Your Health PlanIf you are a PERS member and areconsidering retirement or are already retiredand will be turning 65 years of age within thenext 12 months, or if you have eligibility andenrollment questions, please contact PHIP:Contact information for your health plancan be found in the PHIP Member ProgramGuide. You can also visit the PHIP website atpershealth.com.Onlinepershealth.comBy PhoneIn Portland: (503) 224-7377Toll-free: (800) 768-7377For questions on plan benefits, limitationsand exclusions, or deductibles, please referto your health plan’s Evidence of Coverage(EOC). You can get your EOC by contactingyour health plan directly or from your healthplan's microsite under pershealth.com.For Medicare Supplement members, referto your Medicare & You handbook for planbenefits, limitations and exclusions.Monday through Friday, 7:30 a.m. to 5:30 p.m.Additional Medicare InformationTTY: 711Centers for Medicare and Medicaid Services(CMS)By MailToll-free: (800) 633-4227PERS Health Insurance ProgramPO Box 40187Portland, OR 97240By FaxIn Portland: (503) 765-3452Toll-free: (888) 393-2943In PersonCall PHIP and schedule an appointment.14 ResourcesTTY: (877) 486-2048medicare.govSocial Security Administration (SSA)Toll-free: (800) 772-1213TTY: (800) 325-0778ssa.gov
AppealsPHIP Enrollment or Eligibility Appeals:Pursuant to Oregon Administrative Rule(OAR) 459-001-0030, if you receive a letterdenying PHIP eligibility (program or subsidy)or enrollment and you disagree with thatdetermination, you may request a review bywriting to the PERS Director within 60 daysafter, the date of the letter.Oregon Revised Statutes are available fromthe Office of Legislative Counsel, or can belocated on the Internet at oregonlegislature.gov/. Oregon Administrative Rules areavailable from the Oregon State Archives sos.oregon.gov/archives.Your request must include the followinginformation:(a) A description of the determinationyou want reviewed(b) A short statement describing howand why you think the determinationis wrong(c) A statement of facts that you believeshows the determination is wrong(d) A list of any statutes, rules, or courtdecisions that you believe supportyour positionMail Appeal to:Public Employees Retirement SystemAttn: AppealsPO Box 23700Tigard, OR 97281-3700When the Director receives your request,they may ask a Division Administrator to acton it. Your request for review may be deniedif it does not contain the required informationlisted above. You will be mailed a responseletter within 45 days after we receive yourrequest.Health Plan Appeals:Appeals, complaints or grievances relatedto your health plan benefits or claims shouldbe directed to the health plan in which youare enrolled. Refer to your health plan’sEvidence of Coverage (EOC) booklet for moreinformation about your health plan’s appealand grievance process. You can get yourEOC by contacting your health plan directlyor from your health plan's microsite underpershealth.com.(e) A statement of the action you seek(f) A request for reviewResources 15
Required NoticesWomen’s Health and Cancer Rights ActCOBRA Continuation of CoverageBeginning in 1999, federal law requiresgroup health plans to provide coveragefor the following services to an individualreceiving plan benefits in connection with amastectomy:In accordance with federal and stateof Oregon guidelines, PHIP providesopportunities for the continuation ofcoverage through COBRA following specificqualifying events.y Reconstruction of the breast on whichthe mastectomy has been performed;y Surgery and reconstruction of theother breast to produce a symmetricalappearance; andy Prostheses and coverage for physicalcomplications for all stages of amastectomy, including lymphedemas(swelling associated with the removal oflymph nodes).The health plan must determine the mannerof coverage in consultation with the attendingphysician and patient. Coverage for breastreconstruction and related services will besubject to deductibles, coinsurance amountsand copayments that are consistent withthose that apply to other benefits underthe plan.If you experience one of the qualifying eventslisted below, please contact PHIP for additionalinformation. A qualifying event will occur ifeligibility for coverage is lost because of:Power of Attorney/Authorization toDisclose InformationPHIP requires that a Power of Attorney (POA)or Authorization to Disclose Information beon file with the program office for anyoneacting on a member’s behalf. PHIP is unableto release information to anyone who is notauthorized by the PHIP member. To discloseor change information after the death of amember, please provide one of the following:executor, letter of probate or trusteedocumentation, or Last Will and Testament.16 Required Noticesy Cancellation of PERS retirement status.y The divorce or legal separation of aretiree’s covered spouse; PHIP must benotified within 60 days from the signedDissolution of Marriage document.y A spouse or dependent child no longermeeting eligibility requirements (e.g., achild reaches the maximum age limit, ora spouse loses coverage because theretiree does not enroll in PHIP upon thelast enrollment opportunity).Timely COBRA Premium PaymentsOnce COBRA has been secured, timelypayment of premiums is essential. The initialpremium must be paid within 45 days of thedate COBRA is elected. Thereafter, premiumsare due the first day of each month for thatmonth’s coverage.If payment is not postmarked or received onor before the 45th day (for the initial premium)or the 30th day following the monthly duedate, coverage will be terminated and cannotbe reinstated.
Providence Health Assurance Plans 17
Definition of TermsCoinsuranceCoinsurance is the portion of cost that amember will pay for healthcare services. It’susually shown as a percentage.The doctor agrees to accept the amountof the Medicare-approved charge as fullpayment.Medicare Participating ProviderCopay/copaymentA provider who accepts Medicare patients.A fixed amount that the member pays atthe time of receiving a healthcare service.Gen
y PERS Health Insurance Program (PHIP) Member Guide y PHIP Benefit Guide (includes premium rates) For more information about your PHIP health benefits, please visit pershealth.com or call customer service at 800-768-7377. To view the complete PHIP eligibility and enrollment Oregon Administrative Rules (OAR) visit sos.oregon.gov/archives.
