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2021 Health Benefit SummaryHelping you make an informed decision about your health plan
About CalPERSAbout This PublicationCalPERS is the largest purchaser of publicThe 2021 Health Benefit Summary provides only a generalemployee health benefits in California, and theoverview of certain benefits. It does not include details ofsecond largest public purchaser in the nationall covered expenses or exclusions and limitations. Pleaseafter the federal government. Our programrefer to each health plan’s Evidence of Coverage (EOC)provides benefits for 1.5 million publicbooklet for the exact terms and conditions of coverage.employees, retirees, and their families.Health plans mail EOCs to new members at the beginningDepending on where you reside or work,of the year, and to existing members upon request. In caseCalPERS offers active employees and retireesof a conflict between this summary and your health plan’sone or more types of health plans, whichEOC, the EOC establishes the benefits that will be provided.may include: Health Maintenance Organization (HMO) Preferred Provider Organization (PPO)mation to help you make an informed choice about Exclusive Provider Organization (EPO)compares covered services, copayments, and benefits for(for members in certain California counties)The 2021 Health Benefit Summary provides valuable inforyour health plan and health care providers. This publicationeach CalPERS health plan. It also provides informationabout plan availability by county and a chart summarizingThe CalPERS Board of Administration annually determines health plan availability, coveredbenefits, health premiums, and copayments.Whether you are working or retired, yourimportant differences among health plan types.You can use this information to determine which healthplan offers the services you need at the cost that works for you.The 2021 health plan premiums are available at the CalPERSemployer or former employer makes monthlywebsite at www.calpers.ca.gov. Check with your employercontributions toward your health premiums.to find out how much they contribute toward your premium.The amount of this contribution varies. YourWe recommend that you only use this publication incost may depend on your employer or formerconjunction with the current year’s health premium rateemployer’s contribution to your premium, theschedule and EOCs. To obtain a copy of the health premiumlength of your employment, and the health planrate schedule for any health plan, please go to the CalPERSyou choose. For monthly contribution amounts,website at www.calpers.ca.gov or contact CalPERS atactive employees should contact their employer,888 CalPERS (or 888–225–7377).State retirees should contact CalPERS, andcontracting agency retirees should contactOther Health Publicationstheir former employer.This publication is one of many resources CalPERS offers tohelp you choose and use your health plan. Others include: Health Program Guide: Describes Basic and Medicarehealth plan eligibility, enrollment, and choices CalPERS Medicare Enrollment Guide: Providesinformation about how Medicare works with yourCalPERS health benefitsYou can obtain the above publications and otherinformation about your CalPERS health benefits throughmyCalPERS at my.calpers.ca.gov or by calling CalPERSat 888 CalPERS (or 888–225–7377).
ContentsConsidering Your Health Plan Choices. . . . . . . 2Additional Resources. . . . . . . . . . . . . . . . 14Understanding How CalPERS Health Plans Work . . . 3Health Plan Directory . . . . . . . . . . . .14CalPERS Health Plan Choices . . . . . . . . . . 4Obtaining Health Care Quality Information . . . .15Choosing Your Doctor and Hospital . . . . . . . . 5Enrolling in a Health Plan Using Your ResidentialCalPERS Health Plan Benefit Comparisonor Work ZIP Code . . . . . . . . . . . . . 5Basic Plans. . . . . . . . . . . . . . . . . . . . 16Medicare Plans. . . . . . . . . . . . . . . . . .24Health Plan AvailabilityBasic Plans . . . . . . . . . . . . . . . . 6Medicare Plans . . . . . . . . . . . . . . 8Tools to Help You Choose Your Health Plan . . . . . 10Accessing Health Plan Informationwith myCalPERS . . . . . . . . . . . . .10myCalPERS Health Plan Comparison Feature . . .10Comparing Your Options: Search Health Plans . . . . 11Comparing Your Options: Health PlanChoice Worksheet . . . . . . . . . . . . . 11Health Plan Choice Worksheet. . . . . . . . .12CalPERS Health Plan Member Survey Results . . . .132021 Health Benefit Summary 1
Considering Your Health Plan ChoicesSelecting a health plan for you and your family is oneWe realize that comparing health plan benefits,of the most important decisions you will make. This deci-features, and costs can be complicated. This sectionsion involves balancing the cost of each plan, along withprovides information that can simplify your decision-other features, such as access to doctors and hospitals,making process. As you begin that process, the followingpharmacy services, and special programs for managingare some questions you should ask: Do you prefer to receive your health care from anspecific medical conditions. Choosing the right planensures that you receive the health benefits and servicesHMO or PPO? Your preference will impact the plansthat matter to you.available to you, your access to health care providers,and how much you pay for certain services. See theIf you are a new CalPERS member or you are considering changing your health plan during Open Enrollment,chart on the next page for a summary of the differencesyou will need to make two related decisions: Which health plan is best for you and your family?among plan types.1 What are the costs (premiums, copayments, deduct- Which doctors and hospitals do you want to provideibles, and coinsurance)? Beginning on page 16your care?of this booklet, you will find information about benefits,The combination of health plan and providers that iscopayments, and covered services. Visit the CalPERSright for you depends on a variety of factors, such aswebsite at www.calpers.ca.gov to find out what thewhether you prefer a Health Maintenance Organizationpremiums are for the various plans.(HMO) or Preferred Provider Organization (PPO); your Does the plan provide access to the doctors and hospi-premium and out-of-pocket costs; and whether you wanttals you want? Contact health plans directly for thisto have access to specific doctors and hospitals.information. See the “Health Plan Directory” on page 14of this booklet for health plan contact information.12 2021 Health Benefit SummaryNote that in a few counties where access to HMOs is limited, a thirdoption, Exclusive Provider Organization (EPO), is available. An EPOprovides benefits similar to an HMO with some PPO features.
Understanding How CalPERS Health Plans WorkThe following chart will help you understand some important differences among health plan types.FeaturesHMOPPOEPOAccessinghealth careprovidersContracts with providers(doctors, medical groups,hospitals, labs, pharmacies,etc.) to provide you servicesat a fixed priceGives you access to a network ofhealth care providers (doctors,hospitals, labs, pharmacies, etc.)known as preferred providersGives you access to the EPOnetwork of health careproviders (doctors, hospitals,labs, pharmacies, etc.)Selecting aprimary carephysician(PCP)Most HMOs require you toselect a PCP who will workwith you to manage yourhealth care needs 1Does not require you to selecta PCPDoes not require you toselect a PCPSeeing aspecialistRequires advance approvalfrom the medical group orhealth plan for some services,such as treatment by a specialistor certain types of testsAllows you access to many typesof services without receiving areferral or advance approvalAllows you access to manytypes of services withoutreceiving a referral oradvance approvalObtaining careGenerally requires you to obtaincare from providers who are apart of the plan networkEncourages you to seek servicesfrom preferred providers to ensureyour coinsurance and copaymentsare counted toward your calendaryear out-of-pocket maximums 2Requires you to obtain carefrom providers who are a partof the plan networkRequires you to pay the totalcost of services if you obtaincare outside the HMO’sprovider network without areferral from the health plan(except for emergency andurgent care services)Paying forservicesRequires you to make a smallcopayment for most servicesAllows you the option of seeingnon-preferred providers, butrequires you to pay a higherpercentage of the bill 3Limits the amount preferred providers can charge you for servicesConsiders the PPO plan paymentplus any deductibles andcopayments you make as paymentin full for services rendered by apreferred providerRequires you to pay the totalcost of services if you obtaincare outside the EPO’sprovider network without areferral from the health plan(except for emergency andurgent care services)Requires you to make asmall copayment formost services1Your PCP may be part of a medical group that has contracted with the health plan to perform some functions, including treatment authorization, referrals tospecialists, and initial grievance processing.2Once you meet your annual deductible and co-insurance, the plan pays 100 percent of medical claims from Preferred Providers for the remainder of thecalendar year; however, you will continue to be responsible for copayments for physician office visits, pharmacy, and other services, up to the annual out-ofpocket maximum.3Non-preferred providers have not contracted with the health plan; therefore, you will be responsible for paying any applicable member deductibles orcoinsurance, plus any amount in excess of the allowed amount.2021 Health Benefit Summary 3
CalPERS Health Plan ChoicesDepending on where you reside or work, your Basic and Medicare health plan options may include the following:Supplement toMedicare PPO &HMO Health PlansBasic EPO & HMOHealth PlansBasic PPOHealth PlansAnthem Blue Cross EPOCalifornia Associationof Highway Patrolmen(CAHP) Health Plan1CAHP Health Plan1PERS SelectAnthem Blue CrossTraditional HMOPERS SelectPERS ChoicePERS ChoiceBlue Shield Access HMOPERSCarePERSCareBlue Shield Access EPOPeace OfficersResearch Associationof California (PORAC)Police and FireHealth Plan1PORAC Police andFire Health Plan1Anthem Blue CrossSelect HMOBlue Shield Trio HMOCalifornia CorrectionalPeace Officers Association(CCPOA) Medical Plan1CCPOA Medical Plan1Medicare ManagedCare Plans(MedicareAdvantage)Out-of-StatePlan ChoicesAnthem MedicarePreferred (PPO)Kaiser Permanente(HMO)2Kaiser PermanenteSenior AdvantagePERS Choice (PPO)Sharp DirectAdvantage (HMO)UnitedHealthcareGroup MedicareAdvantage (PPO)PERSCare (PPO)PORAC Police andFire Health Plan (PPO)1UnitedHealthcareGroup MedicareAdvantage (PPO)Health Net Salud y MásHealth Net SmartCareKaiser PermanenteSharp Performance PlusUnitedHealthcareSignatureValue AllianceWestern Health AdvantageContacting a Health PlanIf you have a specific question about a plan’scoverage, benefits, or participating providers,please contact the plan directly. See the1You must belong to the specific employee association and payapplicable dues to enroll in an Association Plan (CCPOA, CAHPor PORAC)2Plan only available in certain states. Benefits out-of-state may differfrom those in California.“Health Plan Directory” on page 14 for healthplan contact information.4 2021 Health Benefit Summary
Choosing Your Doctor and HospitalOnce you choose a health plan, you should select achoose a health plan, you should call the health plan'sprimary care physician. Except in the case of an emer-member services to inquire about physician availability.gency, the doctors you can use — and the medical groupsEither way, you should confirm that the doctor is takingand hospitals you will have access to — will depend onnew patients in the plan you select.your choice of health plan.If you need to be hospitalized, your health plan orMany people find their doctor by asking neighbors ormedical group will have certain hospitals that you are ableco-workers for a doctor’s name. Others receive referralsto use. If you prefer a particular hospital, you should makefrom doctors they already know. Still others simply selectsure the health plan you select contracts with that hospital.a physician from their health plan who happens to beSee page 15 for a list of resources that can help you evalu-nearby. You can also use the Search Health Plans toolate and select a doctor and hospital.(described on page 10), which is available by logging intoyour myCalPERS account at my.calpers.ca.gov. Before youEnrolling in a Health Plan Using Your Residential or Work ZIP CodeSome of our health plans are available only in certainIf you use your residential ZIP Code, all enrolled depen-counties and/or ZIP Codes. As you consider your healthdents must reside in the health plan’s service area. Whenplan choices, you should determine which health plans areyou use your work ZIP Code, all enrolled dependents mustavailable in the ZIP Code in which you are enrolling.receive all covered services (except emergency and urgentIn general, if you are an active employee or a workingCalPERS retiree, you may enroll in a health plan usingeither your residential or work ZIP Code.If you are a retired CalPERS member, you may selectcare) within the health plan’s service area, even if they donot reside in that area.To determine if the health plan you are consideringprovides services where you reside or work, see the “Healthany health plan in your residential ZIP Code area. YouPlan Availability by County” chart on the following page.cannot use the address of the CalPERS-covered employerYou can also use the Health Plan search by ZIP Code, whichfrom which you retired to establish ZIP Code eligibility.is available on the CalPERS website at www.calpers.ca.gov,To enroll in a Medicare Advantage plan, you must useto find out which plans are available in your area. If youyour residential address. In addition, Medicare Part Dhave questions about plan availability or coverage, or wishEmployer Group Waiver plans require you to provide ato obtain a copy of the Evidence of Coverage, contact thephysical address.health plans using the “Health Plan Directory” on page 14.If you have a combination of Basic and Medicaremembers on your health plan, you must choose a healthplan that has both Basic and Medicare plan options available within your residential ZIP Code area.2021 Health Benefit Summary 5
Health Plan Availability by County: Basic PlansSome health plans are available only in certain countiesalso use our online service, the Health Plan Searchand/or ZIP Codes. Use the chart below to determine if theby ZIP Code, available at www.calpers.ca.gov.AlpineAmador Butte Calaveras Contra Costa Fresno GlennHumboldt Kings Inyo Lake Lassen Los Angeles Madera Marin Mariposa MendocinoMerced Modoc Mono Monterey Napa Nevada Orange 6 2021 Health Benefit Summary Western HealthAdvantage HMOUnitedHealthcareSignatureValueAlliance Kern El DoradoImperial ColusaDel Norte Sharp PerformancePlus PORAC PERS Select,PERS Choice, &PERSCareCCPOA CAHPBlue Shield Trio HMO Blue ShieldAccess EPO Blue ShieldAccess HMOAnthem Blue CrossTraditional HMOAlamedaAnthem Blue CrossSelect HMOCountyAnthem Blue CrossEPOnetwork is accepting new patients in your area. You mayKaiser Permanentemake sure they cover your ZIP Code and that their providerHealth plan covers all or part of county.Available out-of-state for PERS Choice andPERSCare, not available for PERS Select.Only applies to some agencies; does not apply to publicagencies or schools.Health NetSmartCare Health NetSalud y Máshealth plan you are considering provides services whereyou reside or work. Contact the plan before enrolling to
Sacramento San Benito San Diego San Francisco San Joaquin San Luis Obispo San Mateo Santa Barbara Santa Clara Santa Cruz Siskiyou Tehama Trinity Tuolumne Sutter Tulare Ventura Yolo YubaOut-of-State Sierra Sonoma ShastaSolano Western HealthAdvantage HMO UnitedHealthcareSignatureValueAlliance San Bernardino Sharp PerformancePlus RiversideStanislausPORACPlumasPERS Select,PERS Choice, &PERSCare Kaiser Permanente Health NetSmartCare Health NetSalud y MásCCPOA CAHPBlue ShieldAccess HMO Blue Shield Trio HMOAnthem Blue CrossTraditional HMO Blue ShieldAccess EPOAnthem Blue CrossSelect HMOPlacerAnthem Blue CrossEPOCounty 2021 Health Benefit Summary 7
Health Plan Availability by County: Medicare PlansSome health plans are available only in certain countiesalso use our online service, the Health Plan Searchand/or ZIP Codes. Use the chart below to determine if theby ZIP Code, available at www.calpers.ca.gov.health plan you are considering provides services where you reside or work. Contact the plan before enrolling to make sure they cover your ZIP Code and that their providerHealth plan covers all or part of county.Available out-of-state for PERS Choice andPERSCare, not available for PERS Select.AlpineAmador Butte Calaveras ColusaContra Costa Del Norte UnitedHealthcareGroup MedicareAdvantage PPO Sharp DirectAdvantage (HMO) PORAC MedicareSupplement PERS Select,PERS Choice, &PERSCare MedicareSupplementKaiser PermanenteSenior Advantage CCPOA MedicareSupplementAlamedaCAHP MedicareSupplementCountyAnthem MedicarePreferred PPOnetwork is accepting new patients in your area. You may El Dorado Fresno Glenn Humboldt Imperial Inyo Kern Kings Lake Lassen Los Angeles Madera Marin MariposaMendocino Merced Modoc Mono Monterey Napa Nevada Orange 8 2021 Health Benefit Summary
PlumasUnitedHealthcareGroup MedicareAdvantage PPO Sharp DirectAdvantage (HMO) PORAC MedicareSupplement PERS Select,PERS Choice, &PERSCare MedicareSupplementKaiser PermanenteSenior Advantage CCPOA MedicareSupplementAnthem MedicarePreferred PPOPlacerCAHP MedicareSupplementCounty Riverside Sacramento San Benito San Bernardino San Diego San Francisco San Joaquin San Luis Obispo San Mateo Santa Barbara Santa Clara Santa Cruz Shasta Sierra Siskiyou Solano Sonoma Stanislaus Sutter Tehama Trinity Tulare Tuolumne Ventura Yolo Yuba Out-of-State 2021 Health Benefit Summary 9
Tools to Help You Choose Your Health PlanThis section provides a variety of information that can helpyou evaluate your health plan choices. Included here aredetails about using your myCalPERS account, the SearchHealth Plans tool, and the Health Plan Choice Worksheet.Accessing Health Plan Information with myCalPERSYou can use myCalPERS at my.calpers.ca.gov, our secure,forms, and find additional information about CalPERSpersonalized website, to get one-stop access to all of yourhealth plans. If you are a retiree, CalPERS is your Healthcurrent health plan information, including details aboutBenefits Officer. Retirees may change their health planwhich family members are enrolled. You can also use it toduring Open Enrollment by calling CalPERS toll freesearch for other health plans that are available in your area,at 888 CalPERS (or 888–225–7377) or by using your myCal-compare health plans, access CalPERS Health ProgramPERS account.myCalPERS Health Plan Comparison FeatureHealth Plan ResourcesSave Your SearchesChoosing a health plan that’s right for you is unique forSave as many as ten comparison scenarios with ability toevery person or family. myCalPERS includes additionalreview, rename, or delete at a later date.re
Once you meet your annual deductible and co-insurance, the plan pays 100 percent of medical claims from Preferred Providers for the remainder of the calendar year; however, you will continue to be responsible for copayments for physician office visits, pharmacy, and other services, up to the annual out-of-
