1. No category

Pan A. Yotopoulos
Professor Emeritus,
Food Research Institute
2015
RETIREE
BENEFITS
SUMMARY
Effective January 1, 2015
Contents
Do you Qualify for Retirement?........................................... 4
Mental Health and Substance Abuse.............................. 21
Preparing for Retirement?................................................... 5
Dental Plans......................................................................... 22
Who Is Eligible for Stanford Benefits?............................... 6
Long-Term Care (LTC) Insurance...................................... 23
Participation: Your Options at Retirement ...................... 8
Tuition Grant Program (TGP)............................................ 24
If you are Rehired or Recalled to Work............................ 10
Commit to Your Health with BeWell ............................... 25
When Does Coverage Start?.............................................. 11
Other Retiree Resources and Services............................ 26
Paying for Benefits.............................................................. 12
2015 Benefits Plan Comparison Charts
for Retirees Not Enrolled in Medicare.............................. 27
Health Plans......................................................................... 13
2
Health Plans if you are Not Enrolled in Medicare......... 14
2015 Benefits Plan Comparison Charts
for Retirees Enrolled in Medicare..................................... 33
Health Plans If You Are Enrolled in Medicare................. 17
Delta Dental PPO................................................................. 39
Health Plans If You Are in a “Split Family”...................... 19
Legal Notices........................................................................ 40
Prescription Drugs............................................................... 20
Contact Information........................................................... 48
2015 Retiree Benefits Summary | benefits.stanford.edu
Dear Retiree,
Stanford University is committed to providing you a comprehensive
benefits package from health and dental insurance to educational
assistance and wellness resources.
We understand that selecting benefits is an important process. In addition
to providing an overview of your benefits, this Retiree Benefits Summary
includes health plan comparison charts and other information to assist you
with selecting a plan that is the best fit for you and your family.
Whether you are planning to retire or are currently retired and making
benefits elections during Open Enrollment, this guide is intended to help
you make educated choices.
For updates or additional information regarding your benefits, visit the
Stanford Benefits website, http://benefits.stanford.edu.
In good health,
Stanford Benefits
benefits.stanford.edu | 2015 Retiree Benefits Summary
3
Do You Qualify for Retirement?
To qualify to become an official retiree of Stanford University, you must be a
benefits-eligible employee in good standing and have not been terminated
for misconduct.
In addition, to qualify for retiree medical benefits, you must meet one of the following requirements:
• Hired before January 1, 1992
»» You are at least age 55, and
»» You have at least 10 years of
benefits-eligible service , or
• Rule of 75 (for anyone)
»» Your age + years of benefits eligibleservice equals at least 75, and
»» You complete at least 10 years of
benefits-eligible service
For each month you work at least one day in a benefits-eligible position at Stanford, that month counts
toward a year of service. Each 12-month period is counted as a year of service.
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2015 Retiree Benefits Summary | benefits.stanford.edu
Preparing for Retirement?
When you’re ready to retire, you’ll have to make some important decisions
about your financial and health benefits. It pays to be prepared.
Choosing and personalizing your benefits depends
on your specific needs, preferences and budget.
We’ve made it easier for you to do your homework,
research plans and get your questions answered.
The following Retirement Checklist was created to
help you prepare for this important milestone.
❏❏ Read When Employment Ends –
Retirement, which may be downloaded
from the Stanford Benefits website at
http://benefits.stanford.edu.
❏❏ Request a Retirement Calculation from
Stanford Benefits at 877-905-2985 or
650-736-2985 (press option 9). Results
may take up to 4–6 weeks.
❏❏ Attend a Health Care in Retirement
workshop or view the workshop online.
❏❏ Enroll in your Stanford health plan
by contacting Stanford Benefits at
877-905-2985 or 650-736-2985 (press
option 9).
❏❏ If you are over age 65 and enrolled in
a Medicare Advantage Plan, be sure to
complete the documentation.
❏❏ Look for your new medical plan ID card
in the mail.
❏❏ Talk to your accountant or tax advisor
about your accounts in SCRP and/or
SRAP funds. Or, make an appointment
with a financial counselor available on
campus.
❏❏ Determine how you want to take a
distribution from SCRP and/or SRAP.
❏❏ Review your retiree medical plan
options before you make your medical
and dental elections.
benefits.stanford.edu | 2015 Retiree Benefits Summary
5
Pan A. Yotopoulos
Professor Emeritus
with grandson Mattias and
daughter-in-law
Amy Yotopoulos,
‘93, Program Manager,
WorkLife Office
Who Is Eligible for
Stanford Benefits?
All official retirees are eligible for Stanford benefits. See “Do you Qualify for
Retirement?” on page 4 for details on criteria for retirement.
A retiree’s dependents may also be eligible for
coverage. Eligible dependents include your:
• Spouse, same or opposite sex, if not
legally separated
• Registered domestic partner
• Children to age 26
»» Natural children
»» Stepchildren
»» Legally adopted children
»» Children for whom you are the
legal guardian
»» Foster children
»» Children placed with you for adoption
»» Children of your registered domestic
partner who depend on you for support
and live with you in a regular parent/
child relationship
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2015 Retiree Benefits Summary | benefits.stanford.edu
»» Unmarried children for whom you are
legally responsible to provide health
coverage under the terms of a Qualified
Medical Child Support Order (QMCSO)
• Unmarried children over the age limit if:
»» Dependent on you for primary financial
support and maintenance due to a
physical or mental disability;* incapable
of self-support; and
»» The disability existed before reaching
age 19.
* You may be asked to provide documentation or
proof of disability to your medical plan provider for
review and approval of continued coverage. In most
cases, coverage for a disabled child can continue
as long as the child is incapable of self-support,
unmarried and fully dependent on you for support.
WHO IS ELIGIBLE FOR STANFORD BENEFITS?
Adding Dependents to
Your Benefits
Is Your Spouse/Domestic Partner
a Stanford Employee or Retiree?
We require proof of dependent eligibility for the
dependents you cover. For a list of acceptable
documentation, view the Dependent Eligibility
Documentation Requirements, available on the
Stanford Benefits website at http://benefits.
stanford.edu.
You may not elect coverage as a retiree and also
receive coverage as the dependent of another
Stanford employee or retiree. Only one parent may
cover eligible dependent children.
Why Must I Provide
My Dependent’s Social
Security Number?
When you add a new dependent, you will be
prompted to include their social security number.
Centers for Medicare and Medicaid Services (CMS),
the agency that monitors the claims collections
from employers for Medicare, requires all employers
to provide the social security number of any
retiree and dependent covered through an employersponsored medical plan. CMS uses this to crossreference any Medicare participant who also has
coverage through an employer.
Continued Coverage for
Your Dependents
If you die while eligible for the retiree health
care program, your eligible dependents may
still receive coverage. Your surviving spouse/
registered domestic partner must notify Stanford
of your death and request to enroll (if not already
enrolled) to postpone or continue coverage.
If your eligible surviving spouse/registered domestic
partner dies, then coverage continues for the
remaining eligible children. Although Stanford
provides access to these health care benefits for
your eligible dependents, the surviving dependents
must pay their portion of the cost of the plan.
YOUR SAME-SEX
SPOUSE
YOUR REGISTERED DOMESTIC PARTNER
You may cover your same-sex
is registered with the State of California. You do not have to live in
spouse under your Stanford
benefits if you married in a
state that recognizes same-sex
marriage.
You may cover your registered domestic partner if your partnership
California to register with the state. Visit the California Domestic
Partners Registry at www.ss.ca.gov/dpregistry for information
about domestic partnership in California.
You may register your domestic partner if you share a common
residence and your domestic partner is:
• Age 18 or older
• A member of your household for the coverage period
• Not related to you in any way that would prohibit legal marriage
• Not legally married to anyone else or the same-sex
domestic partner of anyone else
benefits.stanford.edu | 2015 Retiree Benefits Summary
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Participation: Your Options at Retirement
When you become eligible for retiree health care and are ready to retire,
you have three options: enroll for coverage to start at retirement, postpone
coverage until a later date or waive coverage completely. Your decision is very
important, and you should carefully consider these choices.
Enroll for Coverage to Start at Retirement.
Option
1
• You may elect coverage before you leave Stanford so benefits
begin the first day of the month after your retirement date.
This coverage stays in effect until the end of the calendar year
in which you enroll, unless you have a Life Event change (job,
family, personal) or fail to pay your contributions on time.
Failure to pay your monthly contributions will result in your
benefits being waived and losing future eligibility in Stanford
retiree health care benefits.
• During each annual Open Enrollment period, you’ll receive
information that allows you to change your current benefit
elections for the following calendar year. If you do not change
your benefits during the Open Enrollment period, your
elections will continue through the following year as long as
the plan is still available and you remain eligible for that plan.
In addition, you must pay the new costs. You cannot make
any changes until the next Open Enrollment period, unless
you have a Life Event change.
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2015 Retiree Benefits Summary | benefits.stanford.edu
Postpone Coverage Until a Later Date.
Option
2
• You may choose not to enroll at retirement but reserve the
right to enroll in your retiree benefits during any future Open
Enrollment period or if you have a Life Event change. You may
postpone only once when you first retire.
• After you have enrolled in a Stanford retiree health plan, you
no longer have the option to stop coverage and start again at
a later date.
• If you die while eligible for the retiree health care program,
your eligible surviving dependents have a one-time option to
postpone coverage. If your eligible surviving spouse/registered
domestic partner then dies, your surviving children likewise
have a one-time option to postpone coverage. If you do not
enroll or apply to postpone coverage within 31 days of your
retirement, you will be automatically placed in postpone status
indefinitely until you contact Stanford Benefits.
Option
3
Waive Coverage and Permanently Lose Future
Eligibility and Access to Coverage through
Stanford’s Program.
• You may decline or drop retiree health care coverage at
retirement, or at any time, and permanently waive your right
to retiree health care. If you wish to waive coverage, Stanford
Benefits will ask you to confirm your decision.
To learn more about Life Event changes and other conditions of participation, visit the Stanford Benefits
website at http://benefits.stanford.edu or call 877-905-2985 or 650-736-2985 (press option 9) to speak
with a Benefits representative.
Remember: If you enroll for coverage and then terminate coverage for any reason,
you cannot re-enroll. You and your eligible dependents lose all future eligibility for
Stanford retiree health care.
benefits.stanford.edu | 2015 Retiree Benefits Summary
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If You Are Rehired or Recalled to Work
If you return to Stanford University and work fewer than 20 hours a week,
you remain covered under your retiree health care plan.
If you return to work at Stanford University in a benefits-eligible position
and work at least 20 hours per week, the following will apply, depending
on your situation.
If you are:
• Rehired or recalled within the same
• Enrolled in a Medicare Advantage health
• Recalled or rehired after a year, you will
• In “postpone” status when you are
• Enrolled in Medicare, your Stanford active
• Enrolled in a Stanford retiree health care
calendar year you retired, you will
receive the health and life plans you
had as an active employee.
be asked to enroll in one of the active
employee medical plans offered at that
time, as well as all other active benefits.
health care benefits become your primary
health plan, and Medicare becomes your
secondary health plan. You may want
to contact Social Security to discuss
dropping Medicare Part B. You may
re-enroll in Medicare Part B at the time
you lose active coverage in the future.
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2015 Retiree Benefits Summary | benefits.stanford.edu
plan and return to Stanford, contact
us to help you disenroll from the plan
during your period of employment.
recalled or rehired, you return to
postpone status when you terminate
employment again.
plan when you are recalled or rehired, you
may either re-enroll in retiree health care
or waive coverage when you terminate
employment and return to retiree status.
If you waive coverage, you lose all future
eligibility for retiree health care.
When Does Coverage Start?
Your active medical and dental benefits stop on the last day of the month in
which you retire. In order for your retiree benefits to begin on the first day of
the following month, you must make your elections by the 15th of the month.
For example: If your retirement date is May 21,
your active benefits continue through May 31.
If you elected your new benefits by May 15, your
retiree benefits will begin on June 1.
If you miss your election deadline (the 15th of the
month) your retiree health benefits are delayed
and you must find other coverage until your retiree
health coverage begins. A Benefits representative
can give you more information if you miss your
election deadline.
University Contributions
The amount Stanford contributes toward the
cost of your medical benefits depends on when
you were originally hired and the length of your
benefits-eligible employment before retirement.
These conditions determine if you receive a
contribution under the Grandfathered Contribution
or Non-Grandfathered Contribution (also called
“Defined Contribution”) method.
Determine Your
Monthly Premium
Grandfathered Retirees
Review the Enrollment Worksheet in your initial or
open enrollment packet for monthly contribution
and rate amounts.
Non-Grandfathered Retirees
Please call us at 877-905-2985 or 650-736-2985
(press option 9). A Benefits representative will help
you determine your plan costs.
Split Family Worksheet for
Grandfathered Retirees
The “Calculate Costs for a Split Family” worksheet
on page 19 will help you calculate your monthly
costs. The Enrollment Worksheet in your Open
Enrollment packet shows you the amounts to use
when calculating your monthly costs.
For more information on Defined Contribution,
read the Retiree Medical Plan FAQs on the Stanford
Benefits website at http://benefits.stanford.edu.
benefits.stanford.edu | 2015 Retiree Benefits Summary
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Paying for Benefits
When you retire, you’ll be sent information by Vita
Administration Company on the cost of coverage
and how to pay. Vita is Stanford University’s billing
administrator. You have the option of mailing your
payments each month using payment coupons, or
using the SurePay program, which automatically
debits your bank account. SurePay is easy to set up.
Simply complete the SurePay Enrollment Form
which is located on the Benefits website at
http://benefits.stanford.edu.
Each year before Open Enrollment begins, Stanford
will send you contribution information for the
following year. Remember to make your payments
in order to remain eligible for retiree health
care benefits. If you have questions about your
contributions, please contact Stanford Benefits for
this information.
NEED MEDICAL SERVICES BEFORE YOU
RECEIVE YOUR ID CARD?
If you made no changes to your medical plan election for Open Enrollment, simply
use your current medical ID card.
If you changed elections for 2015 during the three-week Open Enrollment period,
your ID card will be sent to you by the end of the 2014 calendar year. If you have not
received it and need medical care on or after January 1, 2015, print a copy of your
Confirmation Statement as proof of coverage until you receive your new ID card.
Your doctor’s office or pharmacy may also verify coverage by calling us at
877-905-2985 or 650-736-2985 (Monday through Friday from 7 a.m. to 5 p.m. PT),
and pressing option 9. If you need a prescription filled while waiting for your ID
card, you might have to pay the full cost and then submit a claim to your medical
plan for reimbursement.
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2015 Retiree Benefits Summary | benefits.stanford.edu
Health Plans
Types of Plans
Your health plan options depend on your and your dependents’ Medicare eligibility.
Non-Medicare Plans: If you and your covered dependents are under age 65 and are not enrolled in
Medicare, read about the non-Medicare Plans starting on page 14.
Medicare Plans: If you and all of your covered dependents are enrolled in Medicare, read about the
Medicare Plans starting on page 17.
Non-Medicare + Medicare = Split Family: If your family includes both non-Medicare eligible and
Medicare eligible members, read both the Non-Medicare and Medicare Plans sections, as well as the Split
Family section on page 19.
WHAT HAPPENS IF I
DON’T RE-ENROLL?
If you do not elect a new medical plan for
coverage during the Open Enrollment period,
your benefit elections from 2014 will roll over
automatically. However, the cost will reflect
the 2015 contribution amounts.
benefits.stanford.edu | 2015 Retiree Benefits Summary
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Health Plans If You Are Not Enrolled
in Medicare
These plans are only available if you and all of your
enrolled dependents are not eligible for Medicare,
or if you are in a “Split Family” (see page 19).
Stanford offers a variety of health plans that include
coverage for prescription drugs, mental health
and substance abuse. Choosing and personalizing
your benefits depends on your specific health care
needs, doctor preferences, budget and the type of
plan you prefer.
Stanford HealthCare Alliance (SHCA)
Stanford HealthCare Alliance (SHCA) is a select
network health plan in which providers affiliated
with Stanford Health Care and Stanford Children’s
Health take responsibility for working together
to carefully coordinate and deliver your care.
SHCA features an expanded network of primary
and specialty care physicians who are affiliated
with Stanford Health Care to allow for seamless
coordination of the high-quality care you expect
from this world-class institution.
Your SHCA Member Care Services team provides
personalized assistance in scheduling appointments,
selecting physicians, navigating your care experience
and answering all claims and billing issues. SHCA
covers your expenses only if you go to a SHCA network
doctor and/or facility except for an urgent or lifethreatening emergency if you are outside the SHCA
service area.
With Stanford HealthCare Alliance, you:
• Have no deductible
• Have no claims to file
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2015 Retiree Benefits Summary | benefits.stanford.edu
• Pay a fixed copay for each office visit,
emergency room visit and hospital stay
You are encouraged to select a primary care
physician (PCP) to coordinate and provide all of
your primary care. If you need to see a specialist,
you will need approval and referral from your
Stanford HealthCare Alliance PCP.
Kaiser Permanente (HMO)
Kaiser Permanente is a Health Maintenance
Organization (HMO) that provides patient services,
hospitalization, supplies and prescription drugs
through its own network of doctors, hospitals and
other Kaiser-affiliated health care facilities. Kaiser
covers your expenses only if you go to a Kaiser
provider or facility. You are also covered if you have
a life-threatening emergency when you are outside
a Kaiser service area.
When you enroll in Kaiser, you may select a primary
care physician (PCP) to manage your care using
Kaiser’s network of physicians and facilities. Most
likely, you’ll need approval from your PCP before
seeing a specialist.
Kaiser offers cost-effective managed care and
places a strong emphasis on wellness and
preventive care. With Kaiser, you:
• Have no deductible
• Have no claims to file
• Pay a fixed copay for each office visit,
emergency room visit and hospital stay
To enroll in Kaiser, you must live within a Kaiser
service area (based on your home ZIP code).
HEALTH PLANS IF YOU ARE NOT ENROLLED IN MEDICARE
Blue Shield Exclusive Provider
Organization (EPO)
Blue Shield High-Deductible
Health Plan (HDHP)
The EPO is similar to an HMO because you must
use the physicians and facilities within the EPO
network, unless you have a life-threatening
emergency. When you see a provider in the EPO’s
network, there are no deductibles or claims to file.
You pay a fixed copayment for each office visit,
emergency room visit and hospital stay. If you go
to a doctor or hospital outside the EPO’s network,
you pay the full cost for the care you receive. With
the EPO, you do not need to select a primary care
physician. You may go to any doctor, specialist or
hospital within the network. Pre-authorization may
be required on certain services.
The Blue Shield High-Deductible Health Plan
(HDHP) works the same as the Blue Shield PPO
plan, but there are no fixed copays with this plan.
Instead, all benefits—including prescription
drugs—are covered after you meet your deductible.
(A family deductible applies to claims for all family
members until it is met. There is no individual
limit for each covered family member.) This is the
only plan available through Stanford that works in
conjunction with a Health Savings Account.
Blue Shield Preferred Provider
Organization (PPO)
A PPO provides you with the flexibility to go to the
provider or medical facility of your choice—even if
your provider or the facility is not in the Blue Shield
network. If you see providers and go to facilities
within the Blue Shield network, however, your outof-pocket costs are much lower than if you go out
of network for your care.
• In network: You pay a deductible,
and then, the plan pays 80 percent of
covered costs. You do not have to file
a claim—your provider will submit it to
Blue Shield for you. For routine office
visits, you pay $20 for each visit ($50 for a
specialist). Preventive care is provided at
no charge.
• In network: After you have paid the
deductible, the plan pays 80 percent of
covered costs (the amount Blue Shield
will pay for a specific service). You do not
have to file a claim, as your provider will
submit the claims to Blue Shield for you.
Preventive care is provided at no charge.
• Out of network: Your annual deductible
is the same as your in-network deductible.
The plan pays 60 percent of covered
costs (based on Blue Shield’s allowed
amount) and you must file a claim
for reimbursement of out-of-pocket
costs. You are also responsible for any
remaining amounts that Blue Shield
does not pay.
Remember: Preventive care is not covered if
obtained out of network.
• Out of network: Your annual deductible
is larger. The plan pays 60 percent of
covered costs (based on Blue Shield’s
allowed amount), and you must file a
claim to be reimbursed for out-of-pocket
costs. You are also responsible for any
remaining amounts that Blue Shield
does not pay.
benefits.stanford.edu | 2015 Retiree Benefits Summary
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HEALTH PLANS IF YOU ARE NOT ENROLLED IN MEDICARE
Health Savings Account (HSA)
Medicare and HSA
Available only if you are not enrolled
in Medicare
When you reach age 65, you must defer coverage
under Medicare Parts A and B to continue to
contribute to the HSA. If you have enrolled in
Medicare Parts A and B, you are no longer eligible
to contribute to the HSA. However, you will still
have access to any monies in your HSA account.
If you are interested in setting aside tax-deductible
funds for future health care expenses through
a Health Savings Account (HSA), you must be
enrolled in the Blue Shield High-Deductible Health
Plan (HDHP). In 2015, the HSA limit (the amount
you contribute) is $3,350 for retiree only, and $6,650
for retiree + dependents.
Because of the tax savings and flexibility to
reimburse yourself for medical expenses, an HSA
is worth considering.
If you are enrolled in the HDHP, you may set up
an HSA directly with HealthEquity, Blue Shield’s
financial partner, or with a financial institution
of your choice by making contributions on a
post-tax basis.
If you have questions about how HSAs work
with your HDHP, visit http://healthequity.com/
stanford, or call HealthEquity at 877-857-6810.
You may also find more information about HSAs in
the “Medical & Life” section of the Stanford Benefits
website at http://benefits.stanford.edu.
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2015 Retiree Benefits Summary | benefits.stanford.edu
Once you become Medicare eligible, your HSA
contributions will automatically stop. If you are not
enrolled in the Medicare Parts A and B and want to
continue the HSA, you will need to contact Stanford
Benefits to have them re-enroll you.
Health Plans If You Are Enrolled in Medicare
Once you become eligible for Medicare, you must
be enrolled in Medicare Parts A and B to participate
in any of Stanford’s retiree health plans. Any covered
eligible dependents who are 65 or older, or who
receive Social Security Disability Insurance (SSDI),
must also be enrolled in Medicare Parts A and B.
Prescription drug coverage is included in Stanford’s
retiree health plans, so do not enroll in Medicare
Part D prescription drug plan. If you have questions
about enrolling in Medicare, contact the Social
Security Administration at 800-772-1213 or visit the
website at http://socialsecurity.gov.
Stanford offers a variety of health plans that work
with your Medicare coverage. You may choose from
Medicare Advantage or Medicare Supplement plans.
Medicare Advantage Plans
Medicare Advantage plans require you to enroll in
an HMO and then assign your Medicare benefits to
that HMO. An HMO is a managed care group that
provides services and supplies through its own
network of doctors, hospitals and other health care
facilities. It covers your expenses only if you go to a
health care provider within its network of providers
(unless it’s a life threatening emergency).
When you enroll in an HMO plan, you may be
required to select a primary care physician (PCP)
who manages your care using the HMO network’s
physicians and facilities. You will likely need approval
from your PCP before seeing a specialist.
HMOs offer cost-effective managed care and place
a strong emphasis on wellness and preventive care.
With an HMO, you:
• Have no deductible
• Have no claims to file
• Pay a fixed copay for each office visit,
emergency room visit, hospital stay and
other services
• Pay a fixed copay for prescriptions
How to Enroll in a Medicare
Advantage Plan
To enroll in a Medicare Advantage plan, you must
live in one of the HMO’s service areas (based
on your home zip code). Stanford offers these
Medicare Advantage HMO plans:
• Health Net Seniority Plus
• Kaiser Permanente Senior Advantage
• United Healthcare Group
Medicare Advantage
You must complete a Medicare Advantage Enrollment
Form to assign your Medicare benefits to the HMO
you elect whether you enroll for the first time or change
from one Medicare Advantage plan to another.
A Medicare Advantage Enrollment Form will be
sent to you if needed. You and your spouse must
each complete a separate form when enrolling. In
the event you change to a Medicare Supplement
Plan, you must disenroll. For additional assistance,
you may call Stanford Benefits at 877-905-2985 or
650-736-2985 (press option 9) to speak to a Benefits
representative.
Medicare Advantage Enrollment and Disenrollment
Forms are available on the Stanford Benefits
website at http://benefits.stanford.edu in the
“Resource Library.”
benefits.stanford.edu | 2015 Retiree Benefits Summary
17
HEALTH PLANS IF YOU ARE ENROLLED IN MEDICARE
Medicare Supplement Plans
Under a Medicare Supplement plan, Medicare is the primary medical plan for you and your dependents.
They allow you to seek services from any doctor who accepts Medicare, but your costs will be lower if you
see a provider who is in the plan’s network. Medicare Supplement Plans pay benefits for services after you
receive payment from Medicare.
Stanford offers the following Medicare Supplement plans:
• Blue Shield Retiree Medical Plan:
Available anywhere in the United States
and internationally if you keep your
Medicare coverage.
• United Healthcare Senior
Supplement: Available in most
U.S. locations.
• Health Net COB Plan: Available only
in certain California HMO service areas.
You must receive care from a Health
Net HMO provider. If you choose to go
out of network, your care will be limited
to services covered under Medicare
and must be provided by a doctor who
accepts Medicare.
Medicare Crossover Billing
You might be able to have Medicare and your Medicare Supplement health plan automatically work
together to process your claims. This is called “crossover billing.” If your doctor accepts Medicare, your
physician automatically sends claims to Medicare for you. If you set up Medicare crossover billing, after
Medicare pays its portion of the claim, they notify your health plan of any outstanding balance, so there is
less claims work for you to manage.
How to Set Up Medicare Crossover Billing
After you receive your new medical plan ID card, call your health plan’s member care services number on
the back of your medical ID card. To set up crossover billing, you must provide your health plan with the
following information:
Medicare Claim Number
(usually your
Social Security Number,
followed by a letter)
—and—
The effective date of your
Medicare Part A and Part
B coverage, as found on
your Medicare card.
For additional information on how to set up crossover billing, call your health plan’s member services
number on your medical ID card.
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2015 Retiree Benefits Summary | benefits.stanford.edu
Health Plans If You Are in a “Split Family”
“Split family” describes a family where some members are Medicare eligible
and some are not Medicare eligible. If you’re in a split family, you and your
dependents must enroll in medical plans offered by the same insurance
company, if available. The retiree’s medical plan election determines the
plan choice for other family members.
For example, if you are eligible for Medicare and elect
coverage with the Kaiser Permanente Senior Advantage
plan, your non-Medicare-eligible dependents must
enroll in the Kaiser Permanente HMO.
Rules for a Split Family
If you are in one of the Health Net or United
Healthcare Medicare plans, your non-Medicare
eligible dependents may enroll in one of the Blue
Shield plans.
2. Any family member who is in Medicare may need
to complete special paperwork. (See the Medicare
plans section on page 17 for information on the
need to complete the Medicare Advantage Form or
Disenrollment Form.)
1. Any family member who is in Medicare must be
enrolled in Medicare Parts A and B.
Calculate Costs for a Split Family
Use this worksheet to help you calculate your monthly costs. The Enrollment Worksheet in your Open
Enrollment packet shows you the amounts to use when calculating your monthly costs.
COST OF PLAN
NAME OF PLAN
YOU ELECTED
FOR YOU AND/OR
YOUR ELIGIBLE DEPENDENTS
MEDICARE PLAN:
$
NON-MEDICARE PLAN:
+ $
TOTAL MONTHLY COST:
= $
benefits.stanford.edu | 2015 Retiree Benefits Summary
19
Prescription Drugs
Your medical plan provides prescription drug coverage, so be sure to take your
ID card when you have a prescription filled. New in 2015, all five non-Medicare health
plans will cover prescriptions at 100% once the out-of-pocket maximum is met.
The Blue Shield High-Deductible Health Plan
(HDHP) requires you to pay 20 percent of the cost
of all prescription drugs after you have satisfied the
deductible. If you fill your prescriptions at a Blue
Shield network pharmacy, your costs are lower.
For all other plans, the cost of your prescription
depends on whether or not it can be dispensed in
its generic form and if it is included in your plan’s
list of approved drugs (known as a formulary).
SMART DECISIONS CAN ADD UP TO SAVINGS
No matter which plan you’re in, you can save money by:
Switching to Generic Drugs: They are chemically equivalent to brand-name
drugs but sold under their generic names, usually at a significantly lower
price. If your medication does not have a generic equivalent on the market
yet, ask your doctor if there is a similar generic drug for your condition.
Using Mail-Order Prescription Services: Each medical plan offers a home
delivery prescription drug program through its mail-order prescription benefit.
If appropriate to your situation, ask your doctor to write you a prescription
that specifies up to a 90-day quantity (100-day for Kaiser Permanente) and
includes three refills. Then, mail your prescription and order form to your
plan’s mail-order service.
Checking the Preferred Drug List: Each medical plan has a list of approved
drugs, known as a formulary. If your prescription is not included in your plan’s
formulary, you’ll probably end up paying a higher copay. Talk with your doctor
about whether a formulary alternative is appropriate. Each medical plan’s
formulary is updated throughout the year, so call your medical plan’s Member
Services number listed on your medical plan ID card or visit your plan’s
website if you want information on a specific prescription drug.
20
2015 Retiree Benefits Summary | benefits.stanford.edu
Mental Health and Substance Abuse
Mental health and substance abuse treatment are covered
by your medical plan. For details, contact your plan or see
the comparison chart at the back of this booklet.
New Non-Network Mental Health Coverage for 2015
The allowed amount for non-network outpatient services (psychologists, therapists, counselors, etc.) has
changed for employees who elect a Blue Shield EPO, PPO or a High-Deductible Health Plan (HDHP) and
Stanford HealthCare Alliance. Below are details on the non-network service changes:
PLAN
2014 NON-NETWORK
COVERAGE
2015 NON-NETWORK COVERAGE
Blue Shield EPO
Did not cover nonnetwork services.
80% of up to $300 in allowed charges for professional services
will be covered per visit, for a maximum benefit of $240.*
Blue Shield PPO
60% of non-network
services were covered
after deductible.
80% of up to $300 in allowed charges for professional services
will be covered per visit, for a maximum benefit of $240*.
Blue Shield High
Deductible Health
Plan (HDHP)
60% of non-network
services were covered
after deductible.
80% of up to $300 in allowed charges for professional services
will be covered per visit, for a maximum benefit of $240*.
Stanford HealthCare
Alliance (SHCA)
Did not cover nonnetwork services.
80% of up to $300 in allowed charges for professional services
will be covered per visit, for a maximum benefit of $240*.
For all other services, 60% of allowed charges will be covered.
For all other services, 60% of allowed charges will be covered.
* Example, if bill charge is $350, 80% of $300 will be covered. 80% x $300 = $240.
Faculty Staff Help Center
Stanford’s Faculty Staff Help Center provides up to
10 sessions of professional, confidential, short-term
counseling and consultation services free of charge to
Stanford employees, retirees and their dependents.
You can learn more about the service at
http://helpcenter.stanford.edu.
FACULTY STAFF HELP
CENTER HAS MOVED!
The Faculty Staff Help Center’s main office
has relocated from the Mariposa House to
the Keck Science Building (380 Roth Way).
benefits.stanford.edu | 2015 Retiree Benefits Summary
21
Dental Plans
Good dental care can affect your overall health and wellness. In addition
to coverage for basic and major services, Stanford’s coverage includes
diagnostic and preventive checkups and cleanings.
Delta Dental PPO Group 1149
Stanford retirees have a separate PPO dental plan. This plan gives you the freedom to choose your own
dentist, though out-of-pocket costs will be lower if you see a dentist in Delta’s PPO network. Delta’s
website can help you find a dentist in your area.
Compare network and non-network dental costs at the end of this booklet or see the “Medical & Life”
section of the Stanford Benefits website, http://benefits.stanford.edu.
For 2015 rates, see your Enrollment Worksheet in your Open Enrollment packet or call Stanford Benefits at
877-905-2985 or 650-736-2985 (press option 9).
22
2015 Retiree Benefits Summary | benefits.stanford.edu
Long-Term Care (LTC) Insurance
Long-Term Care (LTC) insurance is an optional benefit that helps pay many
of the day-to-day expenses for nursing home and in-home care not generally
covered by medical or disability plans, Medicare or Medicaid.
LTC insurance is available to Stanford retirees,
covered spouses/registered domestic partners
and enrolled dependents.
LTC insurance is provided through CNA. In
addition to enrollment and customer service,
CNA manages all direct billing for all Long-Term
Care insurance coverage.
You may apply for LTC insurance at any time.
Applicants must complete an Evidence of Insurability
(EOI) long form application, and coverage is not
guaranteed. If the application is approved, CNA will
begin billing you directly.
If you were enrolled in LTC as an active employee,
you and any enrolled dependents can continue
participating in the program. Contact CNA within
31 days after you retire to request continuation of
coverage. Your cost will remain the same but you
will be billed directly by CNA.
Program details can be found on the Stanford
Benefits website at http://benefits.stanford.edu
under the “Medical & Life” section. Call CNA to
request an application packet (see the contact
information on page 48).
IS EVERYTHING CORRECT?
If you think you made an error during your enrollment process, call us
to make corrections at 877-905-2985 or 650-736-2985 (Monday through
Friday from 7 a.m. to 5 p.m. PT).
For Open Enrollment, all corrections must be made by 5 p.m. PT on
November 14, 2014.
When you receive your first bill from Vita Administration Company
with your new payment amounts, compare it to your Confirmation
Statement. If the amount is not correct, call Vita at 800-424-3052 by the
end of December 2014.
benefits.stanford.edu | 2015 Retiree Benefits Summary
23
Tuition Grant Program (TGP)
Stanford will assist retirees who have fulfilled their qualifying service
requirement prior to retirement with up to four years of undergraduate
college tuition costs at approved colleges and universities for eligible
dependent children.
If prior to retirement, an employee is at less than 100% full time employment (FTE) at Stanford, the
grant amount may be prorated depending on FTE history.
For more information on the TGP, call 877-905-2985 or 650-736-2985 (press option 5) or visit TGP
at http://hreap.stanford.edu.
24
2015 Retiree Benefits Summary | benefits.stanford.edu
Commit to Your Health with BeWell
The BeWell program was established in 2008 to encourage benefits-eligible
employees and their spouses or registered domestic partners to adopt
behaviors that can improve their health, well-being and quality of life.
New this year: As an official Stanford retiree,
you will be eligible to participate in limited
BeWell@Stanford programs, at a reduced cost.
Starting January 5, 2015, eligible retirees may take
advantage of the following programs:
BEWELL PROGRAM
COST
The Stanford Health and
Lifestyle Assessment
(SHALA)*—an online health
risk assessment.
FREE
The Wellness Profile: health
screening* and advising
session.
$35.00
Up to two (2) fitness classes
per quarter on a space
available basis.
$30.00 per class
(discount price
after completing
the SHALA)
Healthy Living classes.
Cost varies
(scholarships
available for
one class per
quarter)
Learn more about BeWell@Stanford at
http://bewell.stanford.edu.
Find a class or activity that interests you.
• Health Improvement Program,
http://hip.stanford.edu
• Cardinal Recreation,
http://recreation.stanford.edu
Physical Education and
Recreation Facilities
Through the Department of Athletics, Physical
Education and Recreation, you have access to a
variety of athletic, recreation and wellness facilities
on campus using your Stanford ID card, including
two 75,000-square-foot sports and recreation
centers; a recreational pool; a driving range; tennis
courts; indoor climbing walls; playing fields and a
world-class aquatic center.
With all of these facilities at your disposal, you will
have lots of opportunity to find an activity that
meets your needs and interests and to stay fit.
To access fitness classes and recreational facilities,
you must present your official Stanford Retiree ID
card. If you need a card, visit the Stanford ID Card
Office located at George Forsythe Hall, 275 Panama
Street, Room 90.
* By participating in the SHALA and biometric screening, you will be asked to share your assessment results.
BeWell advisors will review the information with you and may use your results to suggest appropriate health
promotion resources, both on campus and with your medical plan. Your medical plan also may use your
information for the purpose of health promotion and/or disease management outreach. Rest assured that
BeWell and Stanford are committed to protecting the privacy and security of your health information.
benefits.stanford.edu | 2015 Retiree Benefits Summary
25
Other Retiree Resources and Services
As a Stanford retiree, you have access to various
benefits, services, resources and amenities on
campus, such as:
• Use of athletic and recreational facilities
and access to exercise classes and
health seminars through the Health
Improvement Program (see”Commit to
Your Health with BeWell” on page 25
for details)
• Access to Stanford’s libraries, lectures,
plays, concerts, films and exhibits—
often at no cost or at special rates
• Access to Faculty Staff Help Center
mental health services for you and
your family
• Membership in the Stanford Federal
Credit Union
• Membership in Stanford Staffers
News and Information
Stay connected to Stanford as an official retiree
by signing up for the Stanford Retiree Insider, a
digital newsletter delivered quarterly by email
and designed especially for Stanford retirees.
The Retiree Insider provides news and information
about staying connected to the university, and
highlights a variety of benefits, perks and services
available to retirees. View past issues of the retiree
newsletter and sign up to receive future issues by
visiting http://uhr.stanford.edu/stanford-insider.
You may also get the latest news from Stanford
from the Stanford Report, which is delivered daily
to your email address. Simply sign up at
http://news.stanford.edu/subscribe.
26
2015 Retiree Benefits Summary | benefits.stanford.edu
Stanford Events
For information on lectures, concerts, athletic
events, exhibits and much more, sign up for
Stanford for You, a free monthly e-newsletter about
fun, affordable events on campus. Register for
Stanford for You at http://foryou.stanford.edu.
Your Stanford Identification Card
A Retiree ID card, offered at no cost to retirees, may
be secured through the Stanford ID Card Office.
The Retiree ID card provides retirees access to
recreational facilities, libraries and other university
resources including the golf course, special offers
and discounts to many ticketed events.
The Stanford ID Card office also issues courtesy
cards to retirees’ spouses or domestic partners.
ID and courtesy cards are only issued in person at
the ID Card Office. Card eligibility is determined
by Information Technology Services. For more
information, visit the Card Center website,
https://itservices.stanford.edu/service/campuscard.
Location: George Forsythe Hall, 275 Panama
Street, Room 90
Hours:
Open 8 a.m. to 5 p.m., Monday through
Friday. Closed daily between 12:30 and
1 p.m.
Phone:650-498-2273
$20 copay primary/$50 copay
specialist
PENALTY for not pre-authorizing:
the services will be considered
not covered by the plan and the
member is responsible for the full
amount of the service.
Pre-authorization from your
primary care provider is required
for the following services:
Advanced Imaging (CT, MRI,
MRA and PET); all electively
scheduled inpatient admissions;
all elective outpatient procedures
(example- endoscopic procedures,
arthroscopic procedures,
epidural steroid injections, etc.);
physical therapy; durable medical
equipment; speech therapy.
There is no benefit if you see a
non-network provider, except for
emergency care or when clinically
appropriate and prior authorized
by Stanford HealthCare Alliance.
The Stanford HealthCare Alliance
ACO plan requires you designate
a primary care provider to
coordinate all of your care. You
may visit any Stanford HealthCare
Alliance network doctor or
hospital. Some services require
prior authorization from your
primary care physician.
Stanford HealthCare Alliance
ACO Plan - Group #976248
Benefits Plan Comparison Charts
Office copay
Pre-Authorization
Requirement
Overview
Benefit
Description
Network: $20 copay primary/$50
copay specialist
Non-Network: 60% after deductible
PENALTY for not pre-authorizing:
benefit reduced to 50% of Blue
Shield Allowed Amount. Maximum
reduction of $1,000. You pay
balance of all charges not covered
by Blue Shield. Out-of-Pocket
Maximum does not apply. Certain
benefits may be denied in full for
failure to pre-authorize.
PENALTY for not pre-authorizing:
benefit reduced to 50% of Blue
Shield Allowed Amount. You pay
balance of all charges not covered
by Blue Shield. Out-of-Pocket
Maximum does not apply.
$20 copay primary/$50 copay
specialist
Pre-authorization required for
all hospital stays and certain
outpatient procedures.
When you see a non-network
provider you are responsible for
the balance of your bill that is not
covered by Blue Shield. The Out-ofPocket Maximum does not apply to
the balance of the bill not covered
by Blue Shield.
When you see a non-network
provider you are responsible for
the balance of your bill that is not
covered by Blue Shield. The Out-ofPocket Maximum does not apply to
the balance of the bill not covered
by Blue Shield.
benefits.stanford.edu | 2015 Retiree Benefits Summary
$20 copay primary/$50 copay
specialist
PENALTY for not pre-authorizing:
not covered.
PENALTY for not pre-authorizing:
benefit reduced to 50% of Blue
Shield Allowed Amount. Maximum
reduction of $1,000. You pay
balance of all charges not covered
by Blue Shield. Out-of-Pocket
Maximum does not apply. Certain
may be denied in full for failure to
pre-authorize.
Network: 80% after deductible
Non-Network: 60% after deductible
Pre-authorization required for all
elective inpatient and outpatient
procedures.
27
You may use only Kaiser
Permanente doctors and facilities
except in emergencies.
Kaiser Permanente HMO (CA)
Group #7145 (Northern CA)
Group #230178 (Southern CA)
Pre-authorization required for
all hospital stays and certain
outpatient procedures.
This plan is compatible with an
individual Health Savings Account
(HSA), that you establish at a
financial institution of your choice.
You may visit any doctor or
hospital. You receive a higher
level of benefits when you use
Blue Shield PPO providers. You
are responsible for ensuring all
providers are in the network.
Blue Shield High Deductible
PPO Plan - Group #170293
You may visit any doctor or
hospital. You receive a higher
level of benefits when you use
Blue Shield PPO providers. You
are responsible for ensuring all
providers are in the network.
Blue Shield PPO Plan
Group #170292
Pre-authorization required for all
elective inpatient and outpatient
procedures.
There is no benefit if you see a
non-network provider, except for
emergency or urgent care.
For certain services or procedures
Blue Shield may require use of
certain providers within their
network.
You may visit any Blue Shield PPO
network doctor or hospital.
Blue Shield EPO Plan
Group #976109
2015 Benefits Plan Comparison Charts for Retirees Not Enrolled in Medicare
Benefits Plan Comparison Charts
Prenatal Visits
100%
A single out-of-pocket maximum
applies to all coverage under
the plan, including medical and
prescription drugs. (This will
cover prescriptions and medical
expenses at 100% once the out-ofpocket maximum is met.)
A single out-of-pocket maximum
applies to all coverage under
the plan, including medical and
prescription drugs. (This will
cover prescriptions and medical
expenses at 100% once the out-ofpocket maximum is met.)
Maternity
$3,000 per individual
$6,000 per family
$3,000 per individual
$6,000 per family
Out-of-Pocket
Maximum
100%
100% after applicable copays
100% after applicable copays
Coinsurance
No deductible
Blue Shield EPO Plan
Group #976109
No deductible
Stanford HealthCare Alliance
ACO Plan - Group #976248
Deductible
Benefit
Description
Network: $20 copay (first visit)
Non-Network: 60% after deductible
A single out-of-pocket maximum
applies to all coverage under
the plan, including medical and
prescription drugs. (This will
cover prescriptions and medical
expenses at 100% once the out-ofpocket maximum is met.)
Non-Network:
$7,500 per individual
$15,000 per family
100%
28
A single out-of-pocket maximum
applies to all coverage under
the plan, including medical and
prescription drugs. (This will
cover prescriptions and medical
expenses at 100% once the out-ofpocket maximum is met.)
$1,500 per individual
$3,000 per family
100% after applicable copays
No deductible
Kaiser Permanente HMO (CA)
Group #7145 (Northern CA)
Group #230178 (Southern CA)
benefits.stanford.edu | 2015 Retiree Benefits Summary
Network: 80% after deductible
Non-Network: 60% after deductible
A single out-of-pocket maximum
applies to all coverage under
the plan, including medical and
prescription drugs. (This will
cover prescriptions and medical
expenses at 100% once the out-ofpocket maximum is met.)
Combined Network or
Non-Network
$3,500 per individual
$7,000 per family
Non-Network: 60% of allowed
charges after deductible, including
prescriptions
Non-Network: 60% of allowed
amount after deductible
Network:
$3,500 per individual
$7,000 per family
Network: 100% for preventive care;
80% after deductible for all other
services, including prescriptions
Network: 100% for preventive care
after applicable copays; 80% after
deductible for other services
The family deductible applies to
claims for all family members until
the deductible is met. There is no
individual limit for each covered
family member.
Combined network or non-network
Non-network: $1,000 per
individual/$3,000 family
The family deductible applies to
claims for all family members until
the deductible is met. There is no
individual limit for each covered
family member.
$1,500 per individual/$3,000 per
family
Blue Shield High Deductible
PPO Plan - Group #170293
Network: $500 per
individual/$1,500 per family
Blue Shield PPO Plan
Group #170292
Stanford HealthCare Alliance
ACO Plan - Group #976248
OUTPATIENT CARE
[no visit limit]
Network: $20 copay per visit
Non-Network: 80% of billed
charges (up to $300 maximum
allowed charges) for professional
services only.
* The maximum allowed amount
will not exceed $300 for each office
visit. For example, if the billed
charge is $350, the plan will pay
80% of {the lesser of $300 or the
billed charge} = 80% x $300 = $240.
OUTPATIENT CARE
[no visit limit]
Network: $20 copay per visit
Non-Network: 80% of billed
charges (up to $300 maximum
allowed charges) for professional
services only.
* The maximum allowed amount
will not exceed $300 for each office
visit. For example, if the billed
charge is $350, the plan will pay
80% of {the lesser of $300 or the
billed charge} = 80% x $300 = $240.
Network: $20 copay per visit
Non-Network: 80% of billed
charges (up to $300 maximum
allowed charges) for professional
services only.
* The maximum allowed amount
will not exceed $300 for each office
visit. For example, if the billed
charge is $350, the plan will pay
80% of {the lesser of $300 or the
billed charge} = 80% x $300 = $240.
Network: $20 copay per visit
Non-Network: 80% of billed
charges (up to $300 maximum
allowed charges) for professional
services only.
* The maximum allowed amount
will not exceed $300 for each office
visit. For example, if the billed
charge is $350, the plan will pay
80% of {the lesser of $300 or the
billed charge} = 80% x $300 = $240.
Pre-certification is required by you
or your provider.
INPATIENT CARE
$100 copay per admission
OUTPATIENT CARE
[no visit limit]
Network: $20 copay per visit
Non-Network: 80% of billed
charges (up to $300 maximum
allowed charges) for professional
services only.
The maximum allowed amount
will not exceed $300 for each office
visit. For example, if the billed
charge is $350, the plan will pay
80% of {the lesser of $300 or the
billed charge} = 80% x $300 = $240.
Pre-certification is required by you
or your provider.
INPATIENT CARE
$100 copay per admission
OUTPATIENT CARE
[no visit limit]
Network: $20 copay per visit
Non-Network: 80% of billed
charges (up to $300 maximum
allowed charges) for professional
services only.
The maximum allowed amount
will not exceed $300 for each office
visit. For example, if the billed
charge is $350, the plan will pay
80% of {the lesser of $300 or the
billed charge} = 80% x $300 = $240.
OUTPATIENT CARE
[no visit limit]
Network: $20 copay per visit
Non-Network: 80% of billed
charges (up to $300 maximum
allowed charges) for professional
services only.
The maximum allowed amount
will not exceed $300 for each office
visit. For example, if the billed
charge is $350, the plan will pay
80% of {the lesser of $300 or the
billed charge} = 80% x $300 = $240.
OUTPATIENT CARE
[no visit limit]
Network: $20 copay per visit
Non-Network: 80% of billed
charges (up to $300 maximum
allowed charges) for professional
services only.
The maximum allowed amount
will not exceed $300 for each office
visit. For example, if the billed
charge is $350, the plan will pay
80% of {the lesser of $300 or the
billed charge} = 80% x $300 = $240.
29
Transitional Residential Recovery
Services
$100 copay per admission
OUTPATIENT CARE
[no visit limit]
$20 copay per visit, individual
$5 copay per visit, group
INPATIENT DETOXIFICATION
$100 copay per admission
OUTPATIENT CARE
[no visit limit]
$20 copay per visit, individual
$10 copay per visit, group
INPATIENT CARE
$100 copay per admission
Kaiser Permanente must approve
mental health care.
Kaiser Permanente HMO (CA)
Group #7145 (Northern CA)
Group #230178 (Southern CA)
benefits.stanford.edu | 2015 Retiree Benefits Summary
INPATIENT CARE
Network: 80% after deductible
Non-Network: 60% after deductible
INPATIENT CARE
Network: 100% after deductible
Non-Network: 60% after deductible
Pre-certification is required by you
or your provider.
Non-Network: 80% of billed
charges
Non-Network: 60% of allowed
charges
OUTPATIENT CARE
[no visit limit]
OUTPATIENT CARE
[no visit limit]
Pre-certification is required by you
or your provider.
Network: 80% after deductible
INPATIENT CARE
$100 copay per admission
Network: 100% after deductible
Blue Shield must approve mental
health care.
INPATIENT CARE
$100 copay per admission
Blue Shield High Deductible
PPO Plan - Group #170293
INPATIENT CARE
Pre-Certification is required by you
or your provider.
Blue Shield PPO Plan
Group #170292
INPATIENT CARE
Pre-Certification is required by you
or your provider.
Blue Shield EPO Plan
Group #976109
Stanford HealthCare Alliance must
approve mental health care.
Benefits Plan Comparison Charts
Substance Abuse
Mental Health
Mental Health/Autism/Substance Abuse
Benefit
Description
100%
Home Health Care
Benefits Plan Comparison Charts
Office visit copayment, or
Emergency Room copayment,
depending on the facility.
Urgent Care
100%
Office visit copayment, or
Emergency Room copayment,
depending on the facility.
$100 copay (waived if admitted)
In-network providers only
In-network providers only
$100 copay (waived if admitted)
Up to 20 visits per year
Up to 20 visits per year
Emergency Room
$20 copay
$20 copay
Chiropractors
100% after $50 copay
100% after $50 copay
Office copay may apply.
Office copay may apply.
In-network providers only
In-network providers only
100%
Up to 20 visits per year
Up to 20 visits per year
100%
$20 copay
Blue Shield EPO Plan
Group #976109
$20 copay
Stanford HealthCare Alliance
ACO Plan - Group #976248
Ambulance
Charges
Allergy Tests
Acupuncture
Other Services
Benefit
Description
Lab/ancillary/professional charges
paid at 80% after deductible,
network or non-network
(copay waived if admitted)
Non-Network: 60% after deductible
Non-Network: 60% after deductible
[3 visits per day max]
30
Up to 100 two-hour visits/calendar
year
100%
$20 copay at Kaiser Permanente
facility
$100 copay (waived if admitted)
American Specialty Health (ASH)
Plans Participating Chiropractors
Up to 40 combined chiropractic
and acupuncture visits per year
$15 copay
100% after $50 copay
$20 copay
American Specialty Health (ASH)
Plans Participating Acupuncturists
Up to 40 combined chiropractic
and acupuncture visits per year
$15 copay
Kaiser Permanente HMO (CA)
Group #7145 (Northern CA)
Group #230178 (Southern CA)
benefits.stanford.edu | 2015 Retiree Benefits Summary
Network: 80% after deductible
Network: 80% after deductible
$50 copay; lab/other services 80%
after deductible, network or nonnetwork
Network or Non-Network: 80%
after deductible
Non-Network: 80% after deductible
Non-Network: $100 copay per visit
Lab/ancillary/professional charges
paid at 80% after deductible for
Network or Non-Network
Network: 80% after deductible
Up to 20 combined network and
non-network visits per year
Non-Network: 60% after deductible
Network: 80% after deductible
Network or Non-Network: 80%
after deductible (if medically
approved)
Non-Network: 60% after deductible
Network: 80% after deductible
Up to 20 combined Network and
Non-Network visits per year
Non-Network: 60% after deductible
Network: 80% after deductible
Blue Shield High Deductible
PPO Plan - Group #170293
Network: $100 copay per visit
Up to 20 combined network and
non-network visits per year
Non-Network: 60% after deductible
Network: 80% after deductible
Network or Non-Network: 80%
after deductible (if medically
approved)
Non-Network: 60% after deductible
Network: $50 copay
Up to 20 combined Network and
Non-Network visits per year
Non-Network: 60% after deductible
Network: 80% after deductible
Blue Shield PPO Plan
Group #170292
Limited to screen and refraction
exams only
100%
$20 copay primary/$50 copay
specialist
$50 copay
Limited to screen and refraction
exams only
Laboratory
Charges
Office Visits
Vision Care
Network: 50% of Blue Shield
allowed charges for professional
and diagnostic services; limited
to three cycles of intrauterine
insemination (IUI).
Non-Network: 60% after deductible
Non-Network: 60% after deductible
Network: 50% of Blue Shield
allowed charges after deductible
for professional and lab services;
limited to three cycles of
intrauterine insemination (IUI).
Network: 80% after deductible
Network: 80% after deductible
Network: 50% of Blue Shield
allowed charges after deductible
for professional and lab services;
limited to three cycles of
intrauterine insemination (IUI).
Pre-Certification required by you or
your provider.
Blue Shield High Deductible
PPO Plan - Group #170293
Pre-Certification required by you or
your provider.
Blue Shield PPO Plan
Group #170292
100%
100%
Discount program available for
vision hardware
$20 copay primary/$50 copay
specialist
100%
Non-Network: 60% after deductible
Non-Network: 60% after deductible
100%
31
Eye exams only. Discount program
for vision hardware
100%
$20 copay primary/$50 copay
specialist
100%
Fertility Drugs: Covered under drug
benefits at 50%; In Vitro, GIFT, and
ZIFT: Not covered.
50%
$100 copay per admission
Kaiser Permanente HMO (CA)
Group #7145 (Northern CA)
Group #230178 (Southern CA)
benefits.stanford.edu | 2015 Retiree Benefits Summary
Network: 80% after deductible
Limited to screen and refraction
exams only
Limited to screen and refraction
exams only
Network: 80% after deductible
Network: 100%
Non-Network: Not covered
Non-Network: 60% after deductible
Network: 100%
Non-Network: Not covered
Non-Network: 60% after deductible
Network: 80% after deductible
Non-Network: 60% after deductible
Non-Network: 60% after deductible
Network: $20 copay primary/$50
copay specialist
Network: 80% after deductible
Network: 80% after deductible
In Vitro, GIFT, and ZIFT: Not covered Non-Network: Not covered
Non-Network: Not covered
In Vitro, GIFT, and ZIFT: Not covered Fertility drugs: see Pharmacy
In Vitro, GIFT, and ZIFT: Not covered In Vitro, GIFT, and ZIFT: Not covered
Fertility drugs: see Pharmacy
Fertility drugs: see Pharmacy
Fertility drugs are covered at 50%
after deductible, up to $5,000
lifetime maximum
Benefits Plan Comparison Charts
X-rays
$50 copay
Network: 50% of Stanford
HealthCare Alliance allowed
charges for professional and
diagnostic services; limited to three
cycles of intrauterine insemination
(IUI).
Infertility
Treatment
Pre-Certification required by you
or your provider. $100 copay per
admission
Pre-Certification required by you
or your provider. $100 copay per
admission
Hospital Stay
Blue Shield EPO Plan
Group #976109
Stanford HealthCare Alliance
ACO Plan - Group #976248
Benefit
Description
Must use Blue Shield mail-order service
Must use Blue Shield mail-order service
Travel immunizations not covered.
Benefits Plan Comparison Charts
100%
Travel immunizations not covered.
100%
Immunizations
Well-Woman Visits
100%
100%
Mammograms
100%
100%
100%
(as part of the office visit)
100%
(as part of the office visit)
$20 generic; $60 brand name; $150
non-formulary—up to a 90-day
supply
100%
32
Office visit copay applies if
provided during doctor office visit
100%
100%
100%
Brand: $30 up to a 30-day supply;
$60 for a 31-100 day supply
Generic: $10 up to a 30-day supply;
$20 for a 31-100 day supply
KAISER PERMANENTE
MAIL ORDER PHARMACY
Brand: $30 for up to a 30-day
supply, $60 for a 31- to 60-day
supply, or $90 for a 61- to 100-day
supply
KAISER PERMANENTE PHARMACY
Generic: $10 for up to a 30-day
supply, $20 for a 31- to 60-day
supply, or $30 for a 61- to 100-day
supply
Kaiser Permanente HMO (CA)
Group #7145 (Northern CA)
Group #230178 (Southern CA)
benefits.stanford.edu | 2015 Retiree Benefits Summary
Network: 100%
Non-Network: Not covered
Travel immunizations not covered.
Travel immunizations not covered.
Network: 100%
Non-Network: Not covered
Network: 100%
Non-Network: Not covered;
Network: 100% if part of annual
preventive
Non-Network: Not covered
Network: 100% if part of annual
preventive
Non-Network: Not covered
Must use Blue Shield mail-order service
80% after deductible
Fertility drugs: see Infertility
Treatment
Network or Non-Network: 80%
after deductible
Blue Shield High Deductible
PPO Plan - Group #170293
Network: 100%
Non-Network: Not covered;
Network: 100% if part of annual
preventive
Non-Network: Not covered
Network: 100% if part of annual
preventive
Non-Network: Not covered
Must use Blue Shield mail-order service
$20 generic; $60 brand name; $150
non-formulary—up to a 90-day
supply
Fertility drugs covered at 50%
(deductible does not apply); max
benefit of $5,000 per lifetime
Fertility drugs covered at 50%
(deductible does not apply); max
benefit of $5,000 per lifetime
Fertility drugs covered at 50%
(deductible does not apply); max
benefit of $5,000 per lifetime
$20 generic; $60 brand name; $150
non-formulary—up to a 90-day
supply
Non-Network pharmacy: Member
pays copayment plus 25% of billed
charges
Non-Network pharmacy: Member
pays copayment plus 25% of billed
charges
Non-Network pharmacy: Member
pays copayment plus 25% of billed
charges
Blue Shield Network pharmacy:
$10 generic; $30 brand name; $75
non-formulary -- up to a 30-day
supply
Blue Shield PPO Plan
Group #170292
Blue Shield Network pharmacy:
$10 generic; $30 brand name; $75
non-formulary—up to a 30-day
supply
Blue Shield EPO Plan
Group #976109
Stanford HealthCare Alliance uses the
Blue Shield Network pharmacy: $10
generic; $30 brand name; $75 nonformulary—up to a 30-day supply
Stanford HealthCare Alliance
ACO Plan - Group #976248
Pap Smears
Preventive Care
Mail-Order Drug
Program
Pharmacy (Retail)
Prescription Drugs
Benefit
Description
Non-Medicare Approved:
$100 per individual/$300
family
Medicare-Approved:
Deductibles Waived
Non-Medicare Approved:
80% after deductible
Medicare-Approved: 100%
As a Medicare Supplement
plan, this plan coordinates
with Medicare. Many of the
expenses that are covered by
Medicare are paid at 100%
of the Medicare Allowable
Amount. Many of the nonMedicare approved services
are first subject to the
deductible and are covered
at 80%.
You will have lower costs
if you use a provider who
accepts Medicare assignment
and is a Blue Shield PPO
network provider.
This plan provides coverage
from any licensed physician
anywhere in the world,
and pays Medicare Part A
and Part B deductibles and
coinsurance for all Medicareapproved services. This plan
covers some services not
covered by Medicare.
Blue Shield Retiree
Medical Plan
Group #975719
Benefits Plan Comparison Charts
Deductible
Office Copay
Overview
Benefit
Description
You do not get benefits
from this plan if you receive
non-emergency care outside
the network. If you obtain
care outside the network,
your benefits are limited
to services covered by
Medicare, and services must
be provided by a doctor
that accepts Medicare
assignment. If your doctor
does not accept Medicare
assignment you may be
billed for the balance.
You do not get benefits from
this plan or from Medicare if
you receive non-emergency
care outside the network.
When you enroll in this plan,
you assign your Medicare
benefits to the plan.
No deductible
No deductible
$25 copay
You will pay a copay for
certain services.
You will pay a copay for
certain services.
$25 copay
This plan pays benefits when
you get care from your Health
Net network doctor and
when your doctor refers you
to a hospital or specialist in
the network. Most covered
expenses are paid at 100%.
You must choose a Primary
Care Physician (PCP) from
the network to coordinate all
your services.
Health Net Medicare COB
Group #58004B
This plan pays benefits
when you get care from your
Seniority Plus network doctor
and when your doctor refers
you to a hospital or specialist
in the network. Most covered
expenses are paid at 100%.
You must choose a Primary
Care Physician (PCP) from
the network to coordinate all
your services.
Health Net Seniority Plus
Group #5800SP
No deductible
$25 copay
No deductible
$25 copay
You do not get benefits from
this plan or from Medicare if
you receive non-emergency
care outside the network.
When you enroll in this plan,
you assign your Medicare
benefits to the plan.
You will pay a copay for
certain services.
This plan pays benefits
when you get care from your
Group Medicare Advantage
network doctor and when
your doctor refers you to
a hospital or specialist in
the network. Most covered
expenses are paid at 100%.
You must choose a Primary
Care Physician (PCP) from
the network to coordinate all
your services.
United Healthcare Group
Medicare Advantage
Group #240689
No deductible
100%
33
As a Medicare Supplement
plan, this plan coordinates
with Medicare. All claims
must be submitted to
Medicare first. Many of the
expenses that are covered by
Medicare are paid at 100%
of the Medicare Allowable
Amount.
You will have lower costs
if you use a provider
who accepts Medicare
assignment.
This plan provides coverage
from any licensed physician
anywhere in the US, and pays
Medicare Part A and Part B
deductibles for all Medicareapproved services. This plan
covers some services not
covered by Medicare.
United Healthcare Senior
Supplement
Group #00014837-SN01
benefits.stanford.edu | 2015 Retiree Benefits Summary
You do not get benefits from
this plan or from Medicare if
you receive non-emergency
care outside the network.
When you enroll in this plan,
you assign your Medicare
benefits to the plan.
You will pay a copay for
certain services.
This plan pays benefits when
you get care from your Kaiser
Permanente doctor and
when your doctor refers you
to a hospital or specialist in
the network. Most covered
expenses are paid at 100%.
Kaiser Permanente
Senior Advantage
Group #7145 (Northern CA)
Group #230178 (Southern CA)
2015 Benefits Plan Comparison Charts for Retirees Enrolled in Medicare
Medicare-Approved or NonMedicare Approved: $1,000
per individual
Out-of-Pocket
Maximum
Non-Medicare Approved:
80% after deductible
Non-Medicare Approved:
80% after deductible
Medicare Approved: 100%
OUTPATIENT CARE
[no visit limit]
Non-Medicare Approved:
60% after deductible
Medicare Approved: 100%
Pre-Certification is required
by you or your provider.
INPATIENT CARE
Benefits Plan Comparison Charts
Mental Health
Mental Health/Substance Abuse
Prenatal Visits
Medicare Approved: 100%
100% for Medicare Approved
services; 100% for Preventive
Services; 80% after
deductible for Non-Medicare
Approved or other services
Coinsurance
Maternity
Blue Shield Retiree
Medical Plan
Group #975719
Benefit
Description
Health Net Medicare COB
Group #58004B
Kaiser Permanente
Senior Advantage
Group #7145 (Northern CA)
Group #230178 (Southern CA)
United Healthcare Group
Medicare Advantage
Group #240689
MHN must approve mental
health care.
INPATIENT CARE
100%
OUTPATIENT CARE
[no visit limit]
$25 copay per visit
INPATIENT CARE
100%
OUTPATIENT CARE
[no visit limit]
$25 copay per visit
100%
$1,500 per individual/$4,500
family
MHN must approve mental
health care.
$25 copay
$3,400 per individual
OUTPATIENT CARE
[no visit limit]
$25 copay per visit
INPATIENT CARE
100%
Up to 190 days per lifetime
First visit only
$25 copay
$3,400 per individual
OUTPATIENT CARE
[no visit limit]
Medicare Approved: 100%
INPATIENT CARE
Medicare Approved: 100%
Not covered
34
No out of pocket maximum
100% for Medicare Approved
and some other services.
United Healthcare Senior
Supplement
Group #00014837-SN01
benefits.stanford.edu | 2015 Retiree Benefits Summary
OUTPATIENT CARE
[no visit limit]
$25 copay per visit, individual
$12 copay per visit, group
INPATIENT CARE
100%
Kaiser Permanente must
approve mental health care.
100%
$3,000 family
$1,500 per individual
100% after applicable copays, 100% after applicable copays, 100% after applicable copays. 100% after applicable copays.
unless otherwise noted
unless otherwise noted
Health Net Seniority Plus
Group #5800SP
OUTPATIENT CARE
[no visit limit]
$25 copay per visit
OUTPATIENT CARE
[no visit limit]
$25 copay per visit
Non-Medicare Approved:
60% after deductible
Must use American Specialty
Health (ASH) providers
Non-Medicare Approved:
80% after deductible
Benefits Plan Comparison Charts
Non-Medicare Approved:
80% of the allowed amount
after $50 copay
Medicare-Approved: 100%
after $50 copay
Ambulance
Charges
$50 copay
Not covered
Office copay may apply
Non-Medicare Approved:
80% after deductible
Not covered
100%
Office copay may apply
Non-Medicare Approved:
80% after deductible
Medicare-Approved: 100%
100%
Medicare-Approved: 100%
Up to 20 visits per year
Medicare-Approved and
Non-Medicare Approved
combined.
$15 copay, limited to 20 visits
Medicare-Approved: 100%
Non-Medicare Approved:
80% after deductible
Medicare Approved: 100%
[no visit limit]
$50 copay
Not covered
Office copay may apply
100%
Office copay may apply
100%
Must use American Specialty
Health (ASH) providers
$15 Copay, limited to 20 visits
(combined with chiropractic)
100%
100%
Medicare Approved: 100%
OUTPATIENT CARE
INPATIENT CARE
INPATIENT CARE
Pre-Certification is required
by you or your provider.
Health Net Medicare COB
Group #58004B
MHN must approve
substance abuse care.
Health Net Seniority Plus
Group #5800SP
MHN must approve
substance abuse care.
INPATIENT CARE
Blue Shield Retiree
Medical Plan
Group #975719
Alternative
Medicine
Allergy
Treatment
Allergy Tests
Acupuncture
Other Services
Substance
Abuse
Benefit
Description
Up to 190 days per lifetime
OUTPATIENT CARE
[no visit limit]
$25 copay per visit
OUTPATIENT CARE
[no visit limit]
$25 copay per visit, individual
$5 copay per visit, group
$50 copay
Not covered
$3 copay for injections
$25 copay
American Specialty Health
(ASH) Plans Participating
Acupuncturists
$50 copay
Not covered
$25 copay
$25 copay
Medicare-Approved: 100%
Not covered
Medicare-Approved: 100%
Medicare-Approved: 100%
35
$25 copay up to 20 visits/year
Medicare Approved: 100%
[no visit limit]
OUTPATIENT CARE
Medicare Approved: 100%
INPATIENT CARE
United Healthcare Senior
Supplement
Group #00014837-SN01
benefits.stanford.edu | 2015 Retiree Benefits Summary
Up to 40 combined
chiropractic and acupuncture
visits per year
$25 copay up to 20 visits
100%
100%
$15 copay
INPATIENT CARE
United Healthcare Group
Medicare Advantage
Group #240689
INPATIENT DETOXIFICATION
Kaiser Permanente
Senior Advantage
Group #7145 (Northern CA)
Group #230178 (Southern CA)
Not covered
Non-Medicare Approved:
80% after deductible
Medicare Approved: 100%
Non-Medicare Approved:
80% after deductible
Medicare-Approved: 100%
Non-Medicare Approved:
80% after deductible
Medicare-Approved: 100%
Non-Medicare Approved:
80% after $50 facility copay
per visit (copay waived if
admitted)
Medicare-Approved: 100%
after $50 facility copay
per visit (copay waived if
admitted)
Including emergency room
professional and lab/
ancillary charges
Non-Medicare Approved:
80% after deductible
Benefits Plan Comparison Charts
Infertility
Treatment
Hospital Stay
Home Health
Care
Urgent Care
Services
Emergency
Room
Up to $1,500 max benefit per
calendar year
Chiropractors
Medicare-Approved: 100%
Blue Shield Retiree
Medical Plan
Group #975719
Benefit
Description
Not covered
100%
100%
$25 copay
$65 copay (waived if
admitted)
Discount program available.
Coverage is limited to manual
manipulation of the spine
to correct subluxation. You
pay the full cost of routine
care. Limited to Medicare
allowable coverage.
$20 copay
Health Net Seniority Plus
Group #5800SP
Fertility Drugs: Covered under
drug benefits; In Vitro, GIFT,
and ZIFT: Not covered.
Fertility Drugs: Covered
under drug benefits; In Vitro
Fertilization (IVF), GIFT and
ZIFT: Not covered
Not covered
100%
100%
$20 copay if outside Secure
Horizons Service Area
$20 copay
$65 copay (waived if
admitted)
$10 copay; 12 visit maximum
United Healthcare Group
Medicare Advantage
Group #240689
Not covered
36
Plan pays 100% of Medicare
Approved services up to a
lifetime maximum of 365
days.
Medicare-Approved: 100%
Medicare-Approved: 100%
Medicare-Approved: 100%
$10 copay; 12 visit maximum
United Healthcare Senior
Supplement
Group #00014837-SN01
benefits.stanford.edu | 2015 Retiree Benefits Summary
$25 copay
100%
100%
$25 copay
$65 copay (waived if
admitted)
American Specialty Health
(ASH) Plans Participating
Chiropractors
Up to 40 combined
chiropractic and acupuncture
visits per year
$15 copay
Kaiser Permanente
Senior Advantage
Group #7145 (Northern CA)
Group #230178 (Southern CA)
50%
100%
100%
$25 copay
$100 copay (waived if
admitted)
Discount program available
Must use American Specialty
Health (ASH) providers
$15 copay. Limited to
20 visits (combined with
acupuncture)
Health Net Medicare COB
Group #58004B
Non-Medicare Approved:
80% after deductible
Medicare-Approved: 100%
Non-Medicare Approved:
80% after deductible
Medicare-Approved: 100%
Non-Medicare Approved:
80% after deductible
Up to a 30-day supply
Up to a 30-day supply
$20 Tier I; $60 Tier II
(formulary brand); $150 Tier
III
Up to a 90-day supply
Prescription drug coverage is
provided by Health Net.
$20 Tier I; $60 Tier II
(formulary brand); $150 Tier
III
Up to a 90-day supply
$20 generic; $60 brand name;
$150 non-formulary—up to a
90-day supply
Prescription drug coverage is
provided by Health Net.
Generic: $10 for up to a 30day supply, $20 for a 31- to
60-day supply, or $30 for a
61- to 100-day supply
$10 Tier I; $30 Tier II
(formulary brand); $75 Tier III
$10 Tier I; $30 Tier II
(formulary brand); $75 Tier III
Up to a 90-day supply
Up to a 90-day supply
37
$20 generic; $60 formulary
brand/preferred; $150 nonformulary/non-preferred
Up to 30 day supply
Up to 30 day supply
$20 generic; $60 formulary
brand/preferred; $150 nonformulary/non-preferred
$10 generic; $30 brand
preferred; $75 non-formulary
non-preferred
Medicare-Approved: 100%
100% if medically necessary
Medicare-Approved: 100%
United Healthcare Senior
Supplement
Group #00014837-SN01
$10 generic; $30 brand
preferred; $75 non-formulary
non-preferred
100%
$25 copay
100%
United Healthcare Group
Medicare Advantage
Group #240689
benefits.stanford.edu | 2015 Retiree Benefits Summary
Brand: $30 up to a 30-day
supply; $60 for a 31-100 day
supply
Generic: $10 up to a 30-day
supply; $20 for a 31-100 day
supply
KAISER PERMANENTE MAIL
ORDER PHARMACY
Brand: $30 for up to a 30-day
supply, $60 for a 31- to 60-day
supply, or $90 for a 61- to 100day supply
KAISER PERMANENTE
PHARMACY
100%
$25 copay
100%
Kaiser Permanente
Senior Advantage
Group #7145 (Northern CA)
Group #230178 (Southern CA)
Prescription drug coverage is
provided by Health Net.
100%
$25 copay
100%
Health Net Medicare COB
Group #58004B
Prescription drug coverage is
provided by Health Net.
100%
$25 copay
100%
Health Net Seniority Plus
Group #5800SP
Must use Blue Shield Mail
Order Service
Drugs for intrauterine
insemination (IUI) are limited
to three cycles
In-Network only: Infertility
Drugs covered at 50% of
charges, up to a $5,000
lifetime maximum.
Non-Network Pharmacy:
80%, no deductible
Blue Shield Network
pharmacy: $10 generic; $30
brand name; $75 nonformulary—up to a 30-day
supply.
Benefits Plan Comparison Charts
Mail-Order
Drug Program
Pharmacy
(Retail)
Blue Shield Retiree
Medical Plan
Group #975719
Medicare-Approved: 100%
Prescription Drugs
X-rays
Office Visits
Laboratory
Charges
Benefit
Description
100%
foreign travel/occupational
services: 80%
100%
100%
Medicare-Approved: 100%
Non-Medicare Approved:
100%
Medicare-Approved: 100%
100%
100%
Health Net Seniority Plus
Group #5800SP
100%
Network & Non-Network Combined: $1,000 per individual
Non-Network:
- All services: 50% of usual & customary charges
Network:
- Preventive and diagnostic: 100% of the negotiated rate
- Basic procedures: 80% of the negotiated rate
- Major restorative procedures: 50% of the negotiated rate
Coinsurance
Benefits Plan Comparison Charts
100%
Travel immunizations not
covered
100%
100%
100%
Not covered
United Healthcare Group
Medicare Advantage
Group #240689
Included as part of $250
annual allowance
38
When office visit not required;
travel immunizations not
covered
100%
Included as part of $250
annual allowance
Included as part of $250
annual allowance
Not covered
United Healthcare Senior
Supplement
Group #00014837-SN01
benefits.stanford.edu | 2015 Retiree Benefits Summary
You are encouraged to obtain a predetermination of benefits from Delta for services greater than $300, or for crowns or bridges.
If your network dentist does not provide or authorize your care, the charges are considered out-of-network.
Network: $0 per individual/$0 per family
Non-network: $50 per individual/$150 family
Annual Maximum
Delta Dental PPO - Plan #1149
100%
When office visit not required
When office visit not required;
foreign travel/occupational
services: 80%
Deductible
Overview
100%
100%
100%
100%
100%
Kaiser Permanente
Senior Advantage
Group #7145 (Northern CA)
Group #230178 (Southern CA)
100%
100%
100%
100%
Health Net Medicare COB
Group #58004B
This plan pays in-network benefits when your care is either provided or authorized by your Delta Dental PPO network dentist.
Non-Medicare Approved:
100%
Medicare-Approved: 100%
Benefit Description
Well-Woman
Visits
Travel immunizations not
covered
2014 Retiree
Dental
Plan When office visit not required;
Non-Medicare
Approved:
Immunizations
Mammograms
Medicare-Approved: 100%
Pap Smears
Non-Medicare Approved:
100%
Not Covered
Blue Shield Retiree
Medical Plan
Group #975719
Physical Exams
for Children
Preventive Care
Benefit
Description
Preventive and Diagnostic service: Network: 100%, Non-Network: 50% (deductible waived)
Preventive and Diagnostic service: Network: 100%, Non-Network: 50% (deductible waived)
Preventive and Diagnostic service: Network: 100%, Non-Network: 50% (deductible waived)
Preventive and Diagnostic service: Network: 100%, Non-Network: 50% (deductible waived)
Fluoride Treatments
Routine Exams
Space Maintainers
X-rays
Basic procedures service: Network: 80%, Non-Network: 50% after deductible
Basic procedures service: Network: 80%, Non-Network: 50% after deductible
Basic procedures service: Network: 80%, Non-Network: 50% after deductible
Basic procedures service: Network: 80%, Non-Network: 50% after deductible
Basic procedures service: Network: 80%, Non-Network: 50% after deductible
Basic procedures service: Network: 80%, Non-Network: 50% after deductible
Extractions
Fillings
Gingivectomy
Oral Surgery
Root Canals
Sealants
Major Restorative procedures service: Network: 50%, Non-Network: 50% after deductible
Major Restorative procedures service: Network: 50%, Non-Network: 50% after deductible
Major Restorative procedures service: Network: 50%, Non-Network: 50% after deductible
Major Restorative procedures service: Network: 50%, Non-Network: 50% after deductible
Crown
Inlays
Implants
Onlays
Benefits Plan Comparison Charts
Major Restorative procedures service: Network: 50%, Non-Network: 50% after deductible
Bridges
Major Procedures
Basic procedures service: Network: 80%, Non-Network: 50% after deductible
Anesthesia
Basic Procedures
Preventive and Diagnostic service: Network: 100%, Non-Network: 50% (deductible waived)
Delta Dental PPO - Plan #1149
Cleanings
Preventive Type of Care
Benefit Description
benefits.stanford.edu | 2015 Retiree Benefits Summary
39
Legal Notices
HIPAA Privacy Notice
The Health Insurance Portability and Accountability
Act of 1996 (HIPAA) requires health plans to
protect the confidentiality of your private health
information. More detailed information is provided
in the health plan’s notice of HIPAA privacy. You
may request a copy of the notice by contacting the
Stanford Benefits Office.
Women’s Health and Cancer
Rights Act
If you have had or are going to have a mastectomy,
you may be entitled to certain benefits under the
Women’s Health and Cancer Rights Act of 1998
(WHCRA). For individuals receiving mastectomyrelated benefits, coverage will be provided in
a manner determined in consultation with the
attending physician and the patient, for:
• All stages of reconstruction of the
breast on which the mastectomy
was performed;
• Surgery and reconstruction of
the other breast to produce a
symmetrical appearance;
• Prostheses; and
• Treatment of physical complications
of the mastectomy, including
lymphedema.
These benefits will be provided subject to the same
deductibles and coinsurance applicable to other
medical and surgical benefits provided under our
medical plans. If you have any questions concerning
this provision, please contact your medical provider.
40
2015 Retiree Benefits Summary | benefits.stanford.edu
Important Notice about
Prescription Drug Coverage
and Medicare
Please read this notice carefully and keep it where
you can find it. This notice has information about
your current prescription drug coverage available
under the retiree medical plans and about your
options under Medicare’s prescription drug coverage.
This information can help you decide whether or
not you want to join a Medicare drug plan. If you are
considering joining, you should compare your current
coverage, including which drugs are covered at what
cost, with the coverage and costs of the plans offering
Medicare prescription drug coverage in your area.
There are two important things you need to know
about your current coverage and Medicare’s
prescription drug coverage:
• Medicare prescription drug coverage
became available in 2006 to everyone
with Medicare. You can get this coverage
if you join a Medicare Prescription Drug
Plan or join a Medicare Advantage Plan
(like an HMO or PPO) that offers prescription
drug coverage. All Medicare drug plans
provide at least a standard level of
coverage set by Medicare. Some plans
may also offer more coverage for a
higher monthly premium.
• Stanford University has determined
that the prescription drug coverage
offered under the retiree medical plans
are, on average for all plan participants,
expected to pay out as much as standard
Medicare prescription drug coverage pays
and is therefore considered Creditable
Coverage. Because your existing coverage
is Creditable Coverage, you can keep this
coverage and not pay a higher premium
(a penalty) if you later decide to join a
Medicare drug plan.
LEGAL NOTICES
When can you join a Medicare drug plan?
You can join a Medicare drug plan when you first
become eligible for Medicare and each year from
October 15th through December 7th.
However, if you lose your current creditable
prescription drug coverage, through no fault of your
own, you will also be eligible for a two (2) month
Special Enrollment Period (SEP) to join a Medicare
drug plan.
What happens to your current coverage if
you decide to join a Medicare drug plan?
If you decide to join a Medicare drug plan, your
current medical coverage will not be affected. Your
current coverage pays for other health expenses
in addition to prescription drugs. If you enroll in
a Medicare prescription drug plan, you and your
eligible dependents will still be eligible to receive
all of your current health benefits. However, if you
have chosen Medicare as your primary health plan,
you will not be able to receive any benefits under
your current coverage.
If you do decide to join a Medicare drug plan and
drop your current coverage, be aware that you
and your dependents will not be able to get this
coverage back until January 1 following the next
annual Open Enrollment period.
When will you pay a higher premium
(penalty) to join a Medicare drug plan?
You should also know that if you drop or lose your
current coverage and don’t join a Medicare drug
plan within 63 continuous days after your current
coverage ends, you may pay a higher premium (a
penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without
creditable prescription drug coverage, your
monthly premium may go up by at least 1% of the
Medicare base beneficiary premium per month for
every month that you did not have that coverage.
For example, if you go nineteen months without
creditable coverage, your premium may consistently
be at least 19% higher than the Medicare base
beneficiary premium. You may have to pay this
higher premium (a penalty) as long as you have
Medicare prescription drug coverage. In addition,
you may have to wait until the following October
to join.
For more information about this notice or your
current prescription drug coverage, visit the
website or call the number listed below. Note: You’ll
get this notice each year. You will also get it before
the next period you can join a Medicare drug plan,
and if this retiree coverage changes. You also may
request a copy of this notice at any time.
More information about your options under
Medicare prescription drug coverage and more
detailed information about Medicare plans that
offer prescription drug coverage is in the Medicare &
You handbook. You’ll get a copy of the handbook in
the mail every year from Medicare. You may also
be contacted directly by Medicare drug plans.
For more information about Medicare prescription
drug coverage:
• Visit http://www.medicare.gov
• Call your State Health Insurance Assistance
Program for personalized help
• Call (800) MEDICARE [(800) 633-4227];
TTY users should call (877) 486-2048
benefits.stanford.edu | 2015 Retiree Benefits Summary
41
LEGAL NOTICES
If you have limited income and resources, extra help
paying for Medicare prescription drug coverage is
available. For information about this extra help,
visit the Social Security website at http://www.
socialsecurity.gov, or call them at (800) 772-1213
(TTY (800) 325-0778).
Remember: Keep this Creditable Coverage notice.
If you decide to join one of the Medicare drug
plans, you may be required to provide a copy of
this notice when you join to show whether or not
you have maintained creditable coverage and
therefore, whether or not you are required to pay
a higher premium (a penalty).
Notice Date:
October 15, 2014
Name of Entity/Sender: Benefits Office
Contact-Position/Office: Benefits Manager
Address:
3160 Porter Drive
Suite 250
Palo Alto, CA 94304-8443
Phone Number:
(650) 736-2985 (option 9)
Medicaid and the Children’s
Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or
CHIP and you are eligible for health coverage from
your employer, your state may have a premium
assistance program that can help pay for coverage.
These states use funds from their Medicaid or CHIP
programs to help people who are eligible for these
programs, but also have access to health insurance
through their employer. If you or your children are
not eligible for Medicaid or CHIP, you will not be
eligible for these premium assistance programs.
If you or your dependents are already enrolled
in Medicaid or CHIP and you live in a state listed
below, you can contact your state Medicaid or CHIP
office to find out if premium assistance is available.
42
2015 Retiree Benefits Summary | benefits.stanford.edu
If you or your dependents are not currently
enrolled in Medicaid or CHIP, and you think you
or any of your dependents might be eligible for
either of these programs, you can contact your
state Medicaid or CHIP office or dial (877) KIDS-NOW
(543-7669) or visit the website at http://www.
insurekidsnow.gov to find out how to apply. If you
qualify, you can ask the state if it has a program
that might help you pay the premiums for an
employer-sponsored plan.
Once it is determined that you or your dependents
are eligible for premium assistance under Medicaid
or CHIP, as well as eligible under your employer
plan, your employer must permit you to enroll in
your employer plan if you are not already enrolled.
This is called a “special enrollment” opportunity
and you must request coverage within 60 days of
being determined eligible for premium assistance.
If you have questions about enrolling in your
employer plan, you can contact the Department of
Labor electronically at https://www.dol.gov or by
calling toll-free at (866) 444-EBSA (3272).
If you live in one of the following states, you may
be eligible for assistance paying your employer
health plan premiums. The following list of states
is current as of July 31, 2013. You should contact
your state for further information on eligibility.
To see if any more states have added a premium
assistance program since July 31, 2013, or for more
information on special enrollment rights, you can
contact either:
• U.S. Department of Labor
Employee Benefits Security Administration
http://www.dol.gov/ebsa
(866) 444-EBSA (3272)
• U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
http://www.cms.gov
(877) 267-2323, Menu Option 4, Ext. 61565
LEGAL NOTICES
Alabama
Medicaid
http://www.medicaid.
alabama.gov
(855) 692-5447
Iowa
Medicaid
http://www.dhs.state.ia.us/
hipp
(888) 346-9562
Alaska
Medicaid
http://health.hss.state.
ak.us/dpa/programs/
medicaid
(888) 318-8890 (Outside of
Anchorage)
(907) 269-6529 (Anchorage)
Kansas
Medicaid
http://www.kdheks.gov/hcf
(800) 792-4884
Kentucky
CHIP
http://www.azahcccs.gov/
applicants
(877) 764-5437 (Outside of
Maricopa County)
(602) 417-5437 (Maricopa
County)
Medicaid
http://chfs.ky.gov/dms/
default.htm
(800) 635-2570
Louisiana
Medicaid
http://www.lahipp.dhh.
louisiana.gov
(888) 695-2447
Maine
Medicaid
http://www.maine.gov/dhhs/
ofi/public-assistance/index.
html
(800) 977-6740
TTY (800) 977-6741
Massachusetts
Medicaid and CHIP
http://www.mass.gov/
MassHealth
(800) 462-1120
Minnesota
Medicaid
http://www.dhs.state.mn.us
Click “Health Care”, then
“Medical Assistance”
(800) 657-3629
Missouri
Medicaid
http://www.dss.mo.gov/
mhd/participants/pages/
hipp.htm
(573) 751-2005
Montana
Medicaid
http://medicaidprovider.
hhs.mt.gov/clientpages/
clientindex.shtml
(800) 694-3084
Nebraska
Medicaid
http://www.
ACCESSNebraska.ne.gov
(800) 383-4278
Nevada
Medicaid
http://dwss.nv.gov
(800) 992-0900
Arizona
Colorado
Medicaid
http://www.colorado.gov
(In state): (800) 866-3513
(Out of state): (800) 221-3943
Florida
Medicaid
http://www.
flmedicaidtplrecovery.com
(877) 357-3268
Georgia
Medicaid
http://dch.georgia.gov
Click on “Programs”, then
“Medicaid”, then “Health
Insurance Premium Payment
(HIPP)”
(800) 869-1150
Idaho
Medicaid
http://www.
accesstohealthinsurance.
idaho.gov
(800) 926-2588
CHIP
www.medicaid.idaho.gov
(800) 926-2588
Indiana
Medicaid
http://www.in.gov/fssa
(800) 889-9949
benefits.stanford.edu | 2015 Retiree Benefits Summary
43
LEGAL NOTICES
New
Hampshire
Medicaid
http://www.dhhs.nh.gov/oii/
documents/hippapp.pdf
(603) 271-5218
New Jersey
Medicaid
http://www.state.nj.us/
humanservices/dmahs/
clients/medicaid
(609) 631-2392
CHIP
http://www.njfamilycare.
org/index.html
(800) 701-0710
44
South Carolina
Medicaid
http://www.scdhhs.gov
(888) 549-0820
South Dakota
Medicaid
http://dss.sd.gov
(888) 828-0059
Texas
Medicaid
http://www.gethipptexas.com
(800) 440-0493
Utah
Medicaid
http://health.utah.gov/upp
(866) 435-7414
New York
Medicaid
http://www.nyhealth.gov/
health_care/medicaid
(800) 541-2831
Vermont
North Carolina
Medicaid
http://www.ncdhhs.gov/dma
(919) 855-4100
Medicaid
http://www.
greenmountaincare.org
(800) 250-8427
Virginia
North Dakota
Medicaid
http://www.nd.gov/dhs/
services/medicalserv/
medicaid
(800) 755-2604
Medicaid
http://www.dmas.virginia.
gov/rcp-hipp.htm
(800) 432-5924
Oklahoma
Medicaid and CHIP
http://www.
insureoklahoma.org
(888) 365-3742
Oregon
Medicaid and CHIP
http://www.
oregonhealthykids.gov
Spanish: http://www.
hijossaludablesoregon.gov
(800) 699-9075
Pennsylvania
Medicaid
http://www.dpw.state.
pa.us/hipp
(800) 692-7462
Rhode Island
Medicaid
http://www.ohhs.ri.gov
(401) 462-5300
2015 Retiree Benefits Summary | benefits.stanford.edu
CHIP
http://www.famis.org
(866) 873-2647
Washington
Medicaid
http://hrsa.dshs.wa.gov/
premiumpymt/Apply.shtm
(800) 562-3022 ext. 15473
West Virginia
Medicaid
http://www.dhhr.wv.gov/bms
(877) 598-5820, HMS Third
Party Liability
Wisconsin
Medicaid
http://www.badgercareplus.
org/pubs/p-10095.htm
(800) 362-3002
Wyoming
Medicaid
http://www.health.wyo.gov/
healthcarefin/index.html
(307) 777-7531
LEGAL NOTICES
Genetic Information
Nondiscrimination Act
Congress passed the Genetic Information
Nondiscrimination Act (GINA) establishing a
national and uniform standard to protect workers
from genetic discrimination. In addition to
prohibitions on discrimination in employment
practices, GINA prohibits group health insurers and
group health plans from adjusting premiums or
contributions based on genetic information. Also,
GINA amended the HIPAA privacy rules to include
genetic information in the definition of protected
health information.
HIPAA Special Enrollment Rights
You have special enrollment rights if you acquire
a new dependent, or if you decline coverage
under the Stanford University retiree health plan
for yourself or an eligible dependent while other
coverage is in effect and later lose that other
coverage for certain qualifying reasons.
Loss of Other Coverage (Excluding
Medicaid or a State Children’s Health
Insurance Program)
If you decline enrollment for yourself or for an
eligible dependent (including your spouse/registered
domestic partner) while other health insurance or
group health plan coverage is in effect, you may be
able to enroll yourself and your dependents if you
or your dependents lose eligibility for that other
coverage. However, you must request enrollment
within 30 days after your or your dependents’
other coverage ends (or after the employer stops
contributing toward the other coverage).
Loss of Coverage for Medicaid or a State
Children’s Health Insurance Program.
If you decline enrollment for yourself or for an
eligible dependent (including your spouse/
registered domestic partner) while Medicaid
coverage or coverage under a state children’s
health insurance program is in effect, you may be
able to enroll yourself and your dependents in this
plan if you or your dependents lose eligibility for
that other coverage. However, you must request
enrollment within 60 days after your or your
dependents’ coverage ends under Medicaid or a
state children’s health insurance program.
New Dependent by Marriage, Birth,
Adoption or Placement for Adoption.
If you have a new dependent as a result of
marriage, birth, adoption or placement for
adoption, you may be able to enroll yourself and
your new dependents. However, you must request
enrollment within 30 days after the marriage, birth,
adoption or placement for adoption.
Eligibility for Medicaid or a State Children’s
Health Insurance Program.
If you or your dependents (including your spouse/
registered domestic partner) become eligible for a
state premium assistance subsidy from Medicaid or
through a state children’s health insurance program
with respect to coverage under this plan, you may
be able to enroll yourself and your dependents in
this plan. However, you must request enrollment
within 60 days after your or your dependents’
determination of eligibility for such assistance.
Summary of Benefits
and Coverage
The Patient Protection and Affordable Care Act (also
known as the Health Care Reform law) requires that
you receive a Summary of Benefits and Coverage
(SBC). The SBC is designed to help you understand
and evaluate your health plan choices. To obtain
copies of the SBC for each of the Stanford University
sponsored medical plans, please visit the Benefits
website at http://benefits.stanford.edu and
search for “SBC” in the “Resource Library.” Paper
copies are also available, free of charge, from the
Benefits Office by calling (650) 736-2985 (option 9).
benefits.stanford.edu | 2015 Retiree Benefits Summary
45
LEGAL NOTICES
Health Insurance
Marketplace Notice
Effective January 1, 2014, the Affordable Care Act—
also known as “health care reform”—requires most
Americans to have health insurance. Individuals
who don’t have coverage by January 1, 2014, will
be required to pay a penalty.
The Health Insurance Marketplace (“health insurance
exchange”) was created to ensure that everyone
has access to affordable health insurance. The
Marketplace is an option for someone who does not
have employer-provided health coverage or for
someone who chooses not to enroll in employerprovided health coverage. Because you have the
option for employer-provided health coverage, it is
unlikely that you will be eligible for federal subsidies.
Why am I receiving this notice?
This notice provides you with information about the
Health Insurance Marketplace and where you can
access more information about health plans offered
to you by either your state or the U.S. Department of
Health and Human Services.
Stanford University is required to send the enclosed
notice to every retiree to comply with rules under
the federal Affordable Care Act (ACA).
What do I need to do?
You’re currently eligible to participate in a
Stanford University sponsored medical plan. If
you participate in the medical plan, you and the
University share in the cost of your coverage. Your
share of the cost is paid with after-tax dollars.
If you choose not to participate in a Stanford
University plan and you buy insurance in the
Marketplace, you will be responsible for paying the
entire premium yourself with after-tax dollars.
What is the individual mandate tax?
Under the ACA, most Americans are required to
have health insurance or pay a penalty. If you
elect coverage through Stanford University, you
will satisfy this requirement. For more information
about the individual mandate, please visit: http://
www.irs.gov/uac/Newsroom/Affordable-CareAct-Tax-Provisions-Questions-and-Answers.
WHAT THIS MEANS FOR YOU
• Stanford has you and your family
covered. As a benefits-eligible retiree,
you and your eligible dependents
have access to health care coverage
through Stanford University.
• Our plans are affordable. You’ll hear
about new coverage options available
in the Health Insurance Marketplace,
but in most cases, Stanford’s coverage
will continue to provide the greatest
value. And because our plans exceed
the federally required “minimum value
standards,” it is unlikely that our retirees
will be eligible for federal subsidies.
• We’ll keep you updated. As we get
updates, we’ll provide resources and
support to help you understand the
impact of health care reform and to
feel confident about your personal
coverage decisions.
Questions?
Call (800) 318-2596;
TTY: (855) 889-4325
or visit https://www.healthcare.gov.
46
2015 Retiree Benefits Summary | benefits.stanford.edu
LEGAL NOTICES
Important Information about Medicare Prescription Drug Coverage
If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months,
a federal law gives you more choices about your prescription drug coverage.
This guide provides a brief summary of the benefit plans in effect on January 1, 2014, generally offered to
retirees of Stanford University. It is not a Summary Plan Description (SPD). However, this guide serves as
the “Summary of Material Modification” to the retiree benefit plans in accordance with the requirements
of the Retiree Retirement Income Security Act of 1974, as amended (ERISA). If there is a discrepancy
between this guide and the applicable insurance contract, agreement, SPD, or plan document, the
applicable insurance contract, agreement, SPD or plan document will prevail.
Every effort is made to ensure this guide contains the most current information available. Keep in mind a
more current version may be available on the Benefits website at http://benefits.stanford.edu.
Stanford University reserves the right to change (including, but not limited to, the right to amend, suspend
or terminate) or make exceptions to its policies, procedures and benefit plans, or to change contributions
at its discretion at any time and without prior notice.
Benefits Office
3160 Porter Drive, Suite 250
Palo Alto, CA 94304-8443
Phone: (650) 736-2985 (option 9)
Fax: (650) 723-7766
benefits.stanford.edu | 2015 Retiree Benefits Summary
47
Medical
Medical Plans
800-873-3605
Mail-Order Prescriptions
866-346-7200
Member Care Services
855-345-7422
Health Net HMO
(healthnet.com)
Medical Plans
800-522-0088
Mail-Order Prescriptions
888-624-1139
Kaiser Permanente
(kp.org)
HMO
800-464-4000
Mail-Order Prescriptions
800-464-4000
United Healthcare
(uhcwest.com)
Medical Plans
800-624-8822
Mail-Order Prescriptions
800-562-6223
Direct Pay Administrator for Retiree Health Care
800-424-3052
Blue Shield Plans
(blueshieldca.com/stanford)
Stanford HealthCare Alliance
(stanfordhealthcarealliance.org)
Vita Administration Company
(vitacompanies.com)
Dental
Delta Dental
(deltadentalca.org/stanford)
800-765-6003
Mental Health and Substance Abuse Counseling
Stanford Faculty & Staff Help Center
(helpcenter.stanford.edu)
650-723-4577
Retirement Savings Plans
Stanford Retirement Manager
(netbenefits.com)
888-793-8733
TIAA-CREF
(tiaa-cref.org)
800-842-2888
Staff Retirement Annuity Plan (SRAP)
650-736-2985
(press option 3)
Long Term Care
CNA Insurance Company
(ltcbenefits.com)
800-528-4582
Disability
Liberty Mutual (Short- and Long-Term Disability)
(mylibertyconnection.com)
Claimant Service ID: stanford
800-896-9375
Stanford Benefits Service Center: 877-905-2985 or 650-736-2985 (press option 9)