2021 Health Benefit Summary Provides Only a General Employee Health Benefits in California, and the Overview of Certain Benefits

2021 | Health Benefit Summary Helping you make an informed decision about your health plan About CalPERS About This Publication CalPERS is the largest purchaser of public The 2021 Health Benefit Summary provides only a general employee health benefits in California, and the overview of certain benefits. It does not include details of second largest public purchaser in the nation all covered expenses or exclusions and limitations. Please after the federal government. Our program refer to each health plan’s Evidence of Coverage (EOC) provides benefits for 1.5 million public booklet for the exact terms and conditions of coverage. employees, retirees, and their families. Health plans mail EOCs to new members at the beginning Depending on where you reside or work, of the year, and to existing members upon request. In case CalPERS offers active employees and retirees of a conflict between this summary and your health plan’s one or more types of health plans, which EOC, the EOC establishes the benefits that will be provided. may include: The 2021 Health Benefit Summary provides valuable infor- • Health Maintenance Organization (HMO) mation to help you make an informed choice about • Preferred Provider Organization (PPO) your health plan and health care providers. This publication • Exclusive Provider Organization (EPO) compares covered services, copayments, and benefits for (for members in certain California counties) each CalPERS health plan. It also provides information about plan availability by county and a chart summarizing The CalPERS Board of Administration annu- important differences among health plan types. ally determines health plan availability, covered You can use this information to determine which health benefits, health premiums, and copayments. plan offers the services you need at the cost that works for you. Whether you are working or retired, your The 2021 health plan premiums are available at the CalPERS employer or former employer makes monthly website at www.calpers.ca.gov. Check with your employer contributions toward your health premiums. to find out how much they contribute toward your premium. The amount of this contribution varies. Your We recommend that you only use this publication in cost may depend on your employer or former conjunction with the current year’s health premium rate employer’s contribution to your premium, the schedule and EOCs. To obtain a copy of the health premium length of your employment, and the health plan rate schedule for any health plan, please go to the CalPERS you choose. For monthly contribution amounts, website at www.calpers.ca.gov or contact CalPERS at active employees should contact their employer, 888 CalPERS (or 888–225–7377). State retirees should contact CalPERS, and contracting agency retirees should contact Other Health Publications their former employer. This publication is one of many resources CalPERS offers to help you choose and use your health plan. Others include: • Health Program Guide: Describes Basic and Medicare health plan eligibility, enrollment, and choices • CalPERS Medicare Enrollment Guide: Provides information about how Medicare works with your CalPERS health benefits You can obtain the above publications and other information about your CalPERS health benefits through myCalPERS at my.calpers.ca.gov or by calling CalPERS at 888 CalPERS (or 888–225–7377). Contents Considering Your Health Plan Choices . 2 Additional Resources. 14 Understanding How CalPERS Health Plans Work . .3 Health Plan Directory . 14 CalPERS Health Plan Choices . 4 Obtaining Health Care Quality Information . 15 Choosing Your Doctor and Hospital . .5 Enrolling in a Health Plan Using Your Residential CalPERS Health Plan Benefit Comparison or Work ZIP Code . 5 Basic Plans. .16 Health Plan Availability Medicare Plans. .24 Basic Plans . 6 Medicare Plans . 8 Tools to Help You Choose Your Health Plan . 10 Accessing Health Plan Information with myCalPERS . 10 myCalPERS Health Plan Comparison Feature . 10 Comparing Your Options: Search Health Plans . .11 Comparing Your Options: Health Plan Choice Worksheet . 11 Health Plan Choice Worksheet. 12 CalPERS Health Plan Member Survey Results . .13 2021 Health Benefit Summary | 1 Considering Your Health Plan Choices Selecting a health plan for you and your family is one We realize that comparing health plan benefits, of the most important decisions you will make. This deci- features, and costs can be complicated. This section sion involves balancing the cost of each plan, along with provides information that can simplify your decision- other features, such as access to doctors and hospitals, making process. As you begin that process, the following pharmacy services, and special programs for managing are some questions you should ask: specific medical conditions. Choosing the right plan • Do you prefer to receive your health care from an ensures that you receive the health benefits and services HMO or PPO? Your preference will impact the plans that matter to you. available to you, your access to health care providers, If you are a new CalPERS member or you are consider- and how much you pay for certain services. See the ing changing your health plan during Open Enrollment, chart on the next page for a summary of the differences you will need to make two related decisions: among plan types.1 • Which health plan is best for you and your family? • What are the costs (premiums, copayments, deduct- • Which doctors and hospitals do you want to provide ibles, and coinsurance)? Beginning on page 16 your care? of this booklet, you will find information about benefits, The combination of health plan and providers that is copayments, and covered services. Visit the CalPERS right for you depends on a variety of factors, such as website at www.calpers.ca.gov to find out what the whether you prefer a Health Maintenance Organization premiums 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 want tals you want? Contact health plans directly for this to have access to specific doctors and hospitals. information. See the “Health Plan Directory” on page 14 of this booklet for health plan contact information. 1 Note that in a few counties where access to HMOs is limited, a third option, Exclusive Provider Organization (EPO), is available. An EPO provides benefits similar to an HMO with some PPO features. 2 | 2021 Health Benefit Summary Understanding How CalPERS Health Plans Work The following chart will help you understand some important differences among health plan types. Features HMO PPO EPO Accessing Contracts with providers Gives you access to a network of Gives you access to the EPO health care (doctors, medical groups, health care providers (doctors, network of health care providers hospitals, labs, pharmacies, hospitals, labs, pharmacies, etc.) providers (doctors, hospitals, etc.) to provide you services known as preferred providers labs, pharmacies, etc.) at a fixed price Selecting a Most HMOs require you to Does not require you to select Does not require you to primary care select a PCP who will work a PCP select a PCP physician with you to manage your (PCP) health care needs 1 Seeing a Requires advance approval Allows you access to many types Allows you access to many specialist from the medical group or of services without receiving a types of services without health plan for some services, referral or advance approval receiving a referral or such as treatment by a specialist advance approval or certain types of tests Obtaining care Generally requires you to obtain Encourages you to seek services Requires you to obtain care care from providers who are a from preferred providers to ensure from providers who are a part part of the plan network your coinsurance and copayments of the plan network are counted toward your calendar Requires you to pay the total year out-of-pocket maximums 2 Requires you to pay the total cost of services if you obtain cost of services if you obtain care outside the HMO’s Allows you the option of seeing care outside the EPO’s provider network without a non-preferred providers, but provider network without a referral from the health plan requires you to pay a higher referral from the health plan (except for emergency and percentage of the bill 3 (except for emergency and urgent care services) urgent care services) Paying for Requires you to make a small Limits the amount preferred provid- Requires you to make a services copayment for most services ers can charge you for services small copayment for most services Considers the PPO plan payment plus any deductibles and copayments you make as payment in full for services rendered by a preferred provider 1 Your PCP may be part of a medical group that has contracted with the health plan to perform some functions, including treatment authorization, referrals to specialists, and initial grievance processing. 2 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- pocket maximum. 3 Non-preferred providers have not contracted with the health plan; therefore, you will be responsible for paying any applicable member deductibles or coinsurance, plus any amount in excess of the allowed amount. 2021 Health

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