page 1 -2: contacts & important notices page 3 -7...

Note: This Comparison Is To Be Used As A Guide Only. Actual Benefits Will Be Governed by The Terms And Conditions of the Master Contract.

- 2: Contacts & Important Notices

Page 3 - 7: Retiree without Medicare

Page 8- 11: Retiree with Medicare

Page 11 - 15: Rx Benefits, Vision Schedule & Basic Life Insurance

10/2/2013

Provider Phone Number Website

CareFirst PPN 1-800-535-2292 www.carefirst.com

CareFirst Medicare Supplemental 1-800-535-2292 www.carefirst.com

ValueOptions Mental Health (CareFirst Only) 1-866-468-5633 www.achievesolutions.net/baltimore

Kaiser Permanente HMO 1-866-248-0715 www.kaiserpermanente.org

Express Scripts Prescription Plan (non-Medicare) 1-800-354-8123 www.express-scripts.com

Express Scripts Prescription Plan (Medicare) 1-877-577-0459 www.express-scripts.com

CareFirst Select Vision 1-800-535-1181 www.carefirst.com

Minnesota Life (Life and AD&D) 1-888-658-0193 www.lifebenefits.com/plandesign/baltimorecity

Baltimore City Retirement System 1-877-273-7136 wwww.bcers.org

Fire & Police Retiremement 1-888-410-1600 www.bcfpers.org

Maryland State Retirement (Pension Information) 1-800-492-5909 http://www.sra.state.md.us/

Employee Benefits Division 410-396-5830/5831 www.baltimorecity.essbenefits.com

Baltimore City Medicare Rx Plan (Medicare Part D) 410-396-1780 www.baltimorecity.essbenefits.com

Employee Benefits Division (TTY) TTY 711 (Maryland) www.baltimorecity.essbenefits.com

Page 1

Contact Phone Numbers & Websites

Retirement Agencies

Employee Benefits Division

Insurance Companies

Out-of-Pocket Maximum

(Non-Medicare Retirees)

Effective January 1, 2014 all non-Medicare retirees, enrolled in the CareFirst BC/BS High Option Plan will have an out of pocket

maximum of $6,350 for individuals and $12,700 for families.

You and your dependents must be enrolled in a City of Baltimore medical plan in order to enroll in a prescription drug plan.Prescription Coverage

Section 1: Important Notices

Please read the information provided in this comparison chart

Dental Coverage

Important Information About Medicare

Dental Benefits for all retirees will be provided through their health plan.

Reminder: Retirees enrolled in the CareFirst Medicare Supplemental Plan do not receive dental benefits.

Important Medicare

Information

Enrollment Website www.baltimorecity.essbenefits.com

Change of Address You must notify your retirement agency about your change of address, in writing.

If you and your spouse/partner are both City employee/retiree, you both cannot enroll each other or the same eligible

dependents on your City medical, dental, vision and prescription plans during any coverage period. You will be notified to adjust

duplicate coverage, if applicable.

Medicare Secondary Payer

(MSP)

Mandatory Reporting

Under the Medicare Secondary Payer (MSP) Mandatory Reporting, federal law requires the mandatory collection and reporting

of social security numbers of all covered participants including employees, retirees and their dependents through employer

group health benefits. Noncompliance may result in the loss of coverage for covered paticipants with invalid or missing social

security numbers.

Duplicate Coverage

Information

Preventive Care &

Coverage of Women's

Preventive Services

Summary Benefits and

Coverage (SBC)

The Patient Protection and Affordable Care Act (PPACA) requires health plans and health insurance issuers to provide a Summary

of Benefits and Coverage (SBC) to applicants and enrollees. The SBC is a concise document providing simple and consistent

information about health plan benefits and coverage. Its purpose is to help health plan consumers better understand the

coverage they have and to help them make easy comparisons of different options when shopping for new coverage. The City of

Baltimore will post this document on its enrollment website: www.baltimorecity.essbenefits.com under its own drop down

menu labeled Summary of Benefits and Coverage.

Administrative Information

Disability Retirees as

Determined

by Social Security

Employers are required to provide some preventive services without charging a copay, coinsurance or deductible, these services

include but are not limited to Well Child Visits, Routine Physical Exams, well woman exams and counseling for various women's

services. Details can be found on the enrollment website: www.baltimorecity.essbenefits.com.

The City requires all its members (including you and your dependents) to enroll in Medicare Part B at the time you become

eligible for Medicare Part A. Once enrolled in Medicare Part B, you must remain enrolled in order to continue receiving the

maximum possible benefit from the City's supplemental medical plan.

When you (or your spouse/child(ren)) become disabled as determined by the SSA, you must apply for Medicare Part B through

SSA at the time you become eligible for Medicare Part A and provide Employee Benefits with your Medicare information

immediately. If you decline your Medicare Part B, you will be responsible for all Medicare Part B (Medical) claims that would

ordinarily be covered by Medicare Part B. Your supplemental medical coverage with the City will only cover 20% of the claims

up to the Medicare Allowed Amount.

Kaiser HMO

Out-of-Pocket Maximum$1,500 per individual

$3,000 per family

$3,000 per individual

$6,000 per family


$12,700 per familyN/A


$9,400 per family

Deductible$250 per individual

$500 per family

$500 per individual

$1,000 per familyOnly Under Major Medical Only Under Major Medical N/A

Plan Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited

Dependent Eligibility

Physician's Office Visit $25 Copay 70% Allowed Benefit

100% of allowed benefit after $20 copay

per medical office visit to a primary care

physician

80% allowed benefit $5 copay per visit

Specialist Office Visit $40 Copay 70% Allowed Benefit100% allowed benefit after

$25 copay 80% allowed benefit $5 copay per visit

Routine GYN - One Yearly 100% Allowed Benefit 100% Allowed Benefit 100% allowed benefit 80% allowed benefit Covered in Full

Hearing Exams 90% allowed benefit 70% allowed benefit

Hearing benefits 100% allowed

benefit with medical diagnosis;

one exam every 36 months

(routine exams excluded)

Hearing benefits 80% allowed

benefit with medical diagnosis;

one exam every 36 months

(routine exams excluded)

$5 copay per visit

Immunizations 100% Allowed Benefit 100% Allowed Benefit100% allowed benefit- when

associated w/a routine physical

80% allowed benefit- when

associated w/a routine physicalCovered in full

Mammography, Colorectal

Screening, Prostate

Screening

100% allowed benefit 100% allowed benefit100% allowed benefit -

yearly after age 40

80% allowed benefit -

yearly after age 40Covered in full

Routine Physical - yearly 100% Allowed Benefit 100% Allowed Benefit 100% allowed benefit 80% allowed benefit Covered in full

Well Baby/Child Care 100% Allowed Benefit 100% Allowed Benefit 100% Allowed Benefit 80% allowed Benefit Covered in full

Page 3

Dependent children, until the end of the calendar year they reach age 26, regardless of student status.

Section 2: 2014 Retiree without Medicare Benefit Plan Comparison Chart ** any out-of-network provider can balance bill the difference between the allowed amount and charges

CareFirst PPN High Option

In-Network Out-of-Network* *

Routine & Preventive Services

CareFirst PPN Standard Option


Kaiser HMO






Ambulance Service

(based on medical

necessity)

90% allowed benefit

(Ground Only)

70% allowed benefit

(Ground Only)

Major medical subject to deductible and

coinsurance if applicable (Ground

Only)

Major medical subject to deductible

and coinsurance if applicable (Ground

Only)

covered in full

Emergency Room

(copay waived if admitted)90% allowed benefit 90% allowed benefit 100% of allowed benefit $50 copay 100% of allowed benefit $50 copay $50 copay

Urgent Care$25 Copay 90% allowed

benefit

$25 Copay 70%

allowed benefit$10 copay per visit Will be handled as in-network $5 copay per visit

Anesthesia 90% allowed benefit 90% allowed benefit 100% allowed benefit 100% allowed benefit covered in full

Hospital Services, Including

Room, Board & General

Nursing Services

(Pre-Authorization

required)

90% allowed benefit 70% allowed benefit 100% allowed benefit

$100 deductible per admission, then

plan pays 70% up to $1,500 out of

pocket maximum per admission, then

100% allowed benefit.

covered in full

Medical Surgical

Physician Services90% allowed benefit 70% allowed benefit 100% allowed benefit 80% allowed benefit covered in full

Physical, Speech &

Occupational Therapy

90% allowed benefit -

limit 60 visits combined

yearly

70% Allowed benefit -

limit 60 visits

combined yearly

100% alowed benefit -100 combined

visits yearly (preauth required after

10th lifetime visit)

80% allowed benefit-100 combined

visits yearly (preauth required after

10th lifetime visit)

covered in full

Organ Transplant

(Pre-Authorization

Required)

90% allowed benefit

70% Allowed Benefit

($30,000 limit per

transplant)**

Kidney, bone marrow, cornea

transplants, liver, heart, heart-lung or

pancreas - 100% allowed benefit

kidney, bone marrow, cornea

transplants, liver, heart,

heart-lung or pancreas - 100% allowed

benefit

covered in full for

non-experimental

transplants

Page 4

Emergency Room and Urgent Care Services

Hospital Inpatient Services

Kaiser HMO






Chemotherapy & Radiation 90% allowed benefit 70% allowed benefit 100% allowed benefit 80% allowed benefit $5 copay per visit

Renal Dialysis 90% allowed benefit 70% allowed benefit 100% allowed benefit 80% allowed benefit $5 copay per visit

Diagnostic Lab Work &

X-rays90% allowed benefit 70% allowed benefit 100% allowed benefit 80% allowed benefit covered in full

Outpatient Surgery 90% allowed benefit 70% allowed benefit 100% allowed benefit 80% allowed benefit $5 copay per visit

Cardiac Rehab 90% allowed benefit 70% allowed benefit 100% allowed benefit 80% allowed benefitCovered at 100%,

if medically necessary

Allergy Testing 90% allowed benefit 70% allowed benefit 100% allowed benefit 80% allowed benefit $5 copay per visit

Allergy Serum

90% allowed benefit,

max benefit $200 per

year


max benefit

$200 per year

100% allowed benefit, max benefit $200

per year

80% allowed benefit, max benefit $200

per yearcovered in full

Pre & Post-Natal Physician

Services 100% allowed benefit 80% allowed benefit 100% allowed benefit 80% allowed benefit

copays, deductibles,

or co-insurance may

apply depending on

services rendered

Newborn Care (Inpatient) 100% Allowed Benefit 80% allowed benefit 100% allowed benefit initial & discharge 80% allowed benefit initial & discharge covered in full

Delivery (Inpatient) 100% Allowed Benefit 80% allowed benefit100% allowed benefit

Pe-authorization Required

$100 deductible per admission,

then plan pays 70% up to $1,500

out of pocket maximum per admission,

then 100% allowed benefit.

Pre-authorization Required

covered in full

Page 5

Allergy Serum

Outpatient Services

Maternity

Kaiser HMO






Fertility Testing & Family

Planning

90% allowed benefit

after deductible

70% Allowed Benefit

after Deductible100% allowed benefit 80% allowed benefit

$5 copay per visit for

family planning. Fertility

testing office visit and

any other fertility

services covered at 50%

In-Vitro Fertilization

Pre-authorization required

90% allowed benefit

after deductible up to

$100,000 Lifetime

Maximum

70% allowed benefit

after deductible up to

$100,000 Lifetime

Maximum


$12,000 lifetime max


$12,000 lifetime max

50% of allowable

charges; $100,000

maximum lifetime

benefit for up to 3

attempts per live birth

Inpatient Mental

Health/Alcohol &

Substance Abuse Benefits

Pre-Authorization Required

90% allowed benefit

after deductible

Provided by Value

Options

70% allowed benefit

after deductible

Provided by Value

Options

100% allowed benefit;

Provided by Value Options

$100 deductible per admission, then

plan pays 70% up to $1,500 out of

pocket maximum per admission, then

100% allowed benefit. Provided by

Value Options

covered in full

Outpatient Mental

Health/Alcohol &

Substance Abuse Benefits

$25 Copay

Provided by Value

Options

70% Allowed Benefit

Provided by Value

Options

100% allowed benefit after $20 copay.

Provided by Value Options

80% allowed benefit.

Provided by Value Options$5 copay per visit

Nutrition & Health

Education

90% Allowed Benefit

after Deductible

70% Allowed Benefit

after Deductiblecovered at 100% 80% allowed benefit $5 copay per visit

Diabetic Supplies 90% Allowed Benefit

after Deductible

70% Allowed Benefit

after Deductible

100% allowed benefit, including lancets

test strips and glucometers

100% allowed benefit, including

lancets, test strips and glucometersCovered in Full

Page 6

Insulin & syringes are covered by the Rx plan

Fertility Testing & Family Planning

Miscellaneous Supplies & Services

Mental Health & Substance Abuse

Kaiser HMO






Durable Medical Equipment 90% Allowed Benefit 70% Allowed Benefit major medical benefit subject to

deductible and coinsurance if applicable

major medical subject to deductible

and coinsurance if applicable covered in full

Private Duty Nursing

(Pre-authorization

required)

90% Allowed Benefit 70% Allowed Benefit

Mandatory pre-certification and

medical necessity; major medical

benefit subject to deductible and

coinsurance if applicable

Mandatory pre-certification and

medical necessity; major medical

benefits subject to deductible and

coinsurance if applicable

covered in full

Inpatient Hospice Care

(Pre-authorization

required)

90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 100% allowed benefit

covered in full for

members with life

expectancy of less than

six months

Outpatient Hospice Care

(Pre-authorization

required)

90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 100% allowed benefit

covered in full for

members with life

expectancy of less than

six months

Prosthetic Devices

(such as artificial limbs) 90% allowed benefit 70% Allowed Benefit

Major medical benefit subject to

deductible and coinsurance if applicable

Major medical benefit subject to

deductible and coinsurance if

applicable

covered in full

Major Medical Annual

DeductibleN/A N/A

Major medical expenses only; $200 per

person per policy year

Major medical expenses only; $200 per

person per policy yearN/A

Major Medical Yearly

Out-Of-Pocket Maximum

Costs

N/A N/A

After deductible is satisfied, benefit

percentages for major medical services:

$30,000 paid at 100% allowed benefit

then at 50% allowed benefit.

After deductible is satisfied, benefit

percentages for major medical services:

$30,000 paid at 100% allowed benefit

then at 50% allowed benefit.

N/A

Page 7

Major Medical

Miscellaneous Supplies & Services Continued

CareFirst Medicare Supplemental Kaiser HMOAre Referrals Required? no yes

Dependent Eligibility

Plan Lifetime Maximum Benefit Unlimited Unlimited

Physician's Office Visit covered by major medical $5 copay per visit

Specialist Office Visit covered by major medical $5 copay per visit

Routine GYN Examination

For the year Medicare provides the benefit- 100% of balance

after Medicare; for the year Medicare does not provide a

benefit- 100% of BCBS allowed benefit

Covered in full

Hearing Exams no benefit $5 copay, hearing aids not covered

Immunizations no benefitOffice visit copay may apply, then covered in full for influenza,

pnuemococcal and Hepatitis B vaccine

Mammography, Colorectal Screening,

Prostate Screening100% of balance after the Medicare allowed amount $5 copay per visit

Routine PhysicalLimited to 1 visit per calendar year with $100 maximum per

year (no coverage for lab services)Covered in full

Well Baby/Child Care no benefit Covered in full

Ambulance Service

(based on medical necessity)covered by major medical Covered in full according to Medicare guidelines

Emergency Room

(copay waived if admitted)

100% of balance after the Medicare allowed amount up to the

Medicare allowed amount, if within 72 hours of the accident

or injury.

$50 copay

Urgent Care not applicable - see office visit $5 copay per visit

Page 8

Dependent children, until the end of the calendar year they reach age 26, regardless of student status.

Routine & Preventive Services

Emergency Room and Urgent Care Services

Section 3: 2014 Retiree with Medicare Benefit Plan Comparison Chart

** any our-of-network provider can balance bill the difference between the allowed amount and charges

CareFirst Medicare Supplemental Kaiser HMO



Anesthesia100% of balance after the Medicare allowed amount up to the

Medicare allowed amountcovered in full

Hospital Services, including Room, Board

& General Nursing Services

The plan pays the Medicare deductible for that Medicare Plan

Year in full, lifetime reserved days covered by major medical

covered in full for pre-authorized hospitalization or emergency

admission

Diagnostic Lab Work & X-rays100% of balance after the Medicare allowed amount up to the


Medical Surgical Physician Services100% of balance after the Medicare allowed amount up to the


Physical, Speech & Occupational

Therapy



Organ Transplant

(Pre-Authorization Required)


Medicare allowed amountcovered in full when authorized, according to Medicare guidelines

Cardiac Rehabilitation100% of balance after the Medicare allowed amount up to the

Medicare allowed amount Covered at 100% if medically necessary

Chemotherapy & Radiation100% of balance after the Medicare allowed amount up to the

Medicare allowed amount$5 copay per visit

Renal Dialysis100% of balance after the Medicare allowed amount up to the

Medicare allowed amountcovered in full for out-patient dialysis within the service area

Diagnostic Lab Work & X-rays covered by major medical covered in full

Outpatient Surgery100% of balance after the Medicare allowed amount up to the


Physical, Speech & Occupational

Therapy

covered by major medical up to 100 combined visits per

calendar year

$5 copay per visit, Medicare guidelines apply for medical necessity

and length of treatment

Page 9

Hospital Inpatient Services

Outpatient Services




Allergy Testing covered by major medical $5 copay per visit

Allergy Serum covered by major medical $5 copay per visit

Pre/Post-Natal Physician Services no benefitcopays, deductibles, or co-insurance may apply depending on

services rendered

Delivery (Inpatient) no benefit covered in full

Newborn Care (Inpatient) no benefit covered in full

Fertility Testing & Family Planning no benefit$5 copay per visit- infertility 50% of allowable charges for testing,

lab and x-ray charges

In-Vitro Fertilization no benefit50% of allowable charges; $100,000 maximum lifetime benefit for

up to 3 attempts per live birth

Inpatient Mental Health

Benefits/Alcohol & Substance Abuse100% after Medicare covered in full

Outpatient Mental Health

Benefits/Alcohol & Substance Abusecovered by major medical $5 copay per visit

Nutrition and Health Education Not Covered unlimited visits

Diabetic Supplies100% of balance after Medicare, including test strips, lancets

& glucometers

$5 copay per visit for Medicare covered self-monitoring training;

covered in full for lancets, test strips & glucometers

Page 10

Insulin & Syringes Are Covered By Your Rx Plan

Miscellaneous Supplies & Services

Mental Health & Substance Abuse

Fertility Testing & Family Planning

Maternity

Outpatient Services Continued




Private Duty Nursing

(pre-authorization required)Covered by major medical Subject to medical Review.

Home Health Care 100% of balance after Medicare- 90 days per calendar year. covered in full according to Medicare guidelines

Extended Care Facility/Skilled Nursing

Facilities

The plan pays the per day copay for that Medicare plan year

for days 21-100; additional days no benefits.covered in full for up to 100 days per benefit period

Hospice Care 100% of balance after Medicare covered in full

Prosthetic Devices

(Such as artificial limbs)covered by major medical covered in full according to Medicare guidelines

Major Medical Annual Deductible deductible waived with Medicare N/a

Major Medical Yearly

Out-Of-Pocket Maximum Costsfirst $30,000 paid at 100%, than paid at 50% N/a

Page 11

Miscellaneous Supplies & Services Continued

Major Medical

Retiree Prescription Premium

Section 4

20142014

Section 4: 2014 Express Scripts Copays

You Pay:

Single Vision Single Vision Balance

Bifocal Bifocal Balance

Trifocal Trifocal Balance

Double Bifocal Double Bifocal Balance

Cataract (Aphakic)

Cataract

(Aphakic) Balance

Medically Required*

Not Medically

Required. Single

Vision.**

Not Medically

Required. Bifocal **

Page 14

CareFirst Select Vision- Schedule of Benefits (Retirees: MAPS, Police & Fire Only)If you go to a ….

Participating Provider Non-Participating Provider

Covered Service (Note: Plan allows one pair of glasses or contacts, per member, in a 24 month period.)

Vision Exam Plan Pays 100% of Allowed Benefit.

$41.50 $41.50

Plan Pays 100% of allowed Benefit; you pay the balance.

$67.00$67.00

$100.50 $100.50

$89.50

Plan pays up to: Plan pays up to:

** In place of glasses (frames and lenses)

Frames Per Pair

Plan Pays up to $29.50 and you pay $0 for select

frames. (If you select more expensive frames then

you pay the balance.) Play pays up to $29.50; you pay the balance.

Contact Lenses** Covered only if medically necessary or instead of glasses

Plan pays up to $221.

* Following cataract surgery or when visual acuity of at least 20/70 in the better eye is possible with the use of contact lenses.

$156.50

$89.50

Glasses

Plan pays up to $221; you pay the balance.

$156.50

NOTE: The Only Retirees Eligible for the CareFirst Select Vision Benefits Are MAPS, FIRE & Police

Plan pays up to $71. Plan pays up to $71; you pay the balance.

Plan pays up to $96.50. Plan pays up to $96.50; you pay the balance.

Section 4

Benefit Amount

$8,500

$7,000

$7,000

$1,500

$5,000

$5,000

$5,000

Page 15

AFSCME Local 2202

AFSCME Local 44

CUB

UNION

Retiree Life Insurance

MAPS

Fire

Police

AFSCME Local 558 (Nurses)

Beneficiary forms are available on the City of Baltimore Enrollment website:

www.baltimorecity.essbenefits.com

Section 4

NOTES PAGE

CCCCITY OFITY OFITY OFITY OF BBBBALTIMOREALTIMOREALTIMOREALTIMORE

Employee Benefits Division201 E. Baltimore Street- Suite 500

Baltimore, MD 21202Phone: 410-396-5830

TTY 711 (Maryland)website: www.baltimorecity.essbenefits.com

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