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Health Plans & Programs

Health Plan Overview

As the Plan Administrator, the Georgia Department of Community Health has delegated full responsibility for claims administration to the following Claims Administrators for the 2015 plan options:

  • Blue Cross Blue Shield of Georgia (BCBSGa), UnitedHealthcare and Kaiser Permanente of Georgia (KP) for medical benefits
  • Express Scripts, Inc. (ESI) for pharmacy benefits for BCBSGa and UnitedHealthcare members; and
  • Healthways, Inc. for well-being benefits and programs administration for BCBSGa and UnitedHealthcare members.

There are six non-Medicare Advantage State Health Benefit Plan (SHBP) options offered to SHBP members (including new hires) and their eligible dependents through BCBSGa, UnitedHealthcare and KP. Former employees continuing coverage who are enrolled in Medicare may also choose to enroll in one of the two SHBP Medicare Advantage (MA) Plans also administered by UnitedHealthcare.

Additionally, TRICARE Supplement Plan coverage is available as an alternative to SHBP coverage for eligible retired military personnel (and their dependents) under age 65; and children of SHBP members may be eligible for enrollment in PeachCare for Kids.®   Please note that SHBP does not administer the TRICARE plan or PeachCare for Kids.


Claims Administration

Blue Cross Blue Shield of Georgia (BCBSGa) will provide medical claims administration and medical management services for the State Health Benefit Plan during 2015. Through BCBSGa, the State Health Benefit Plan offers active members and pre-65 retirees a choice of three Health Reimbursement Arrangement (HRA) Plan options:  Gold HRA, Silver HRA and Bronze HRA.  Additionally, BCBSGa offers a statewide Health Maintenance Organization (HMO) plan option

  • Health Reimbursement Arrangement Participating Provider Option (HRA): The HRA is a consumer-driven health plan featuring a participating provider network. Members receive treatment at discounted rates from network providers, and network providers will not bill for amounts that exceed the discounted rates.  Members have the flexibility of receiving treatment from out-of-network providers, but SHBP does not pay for any charges that exceed 110% of the amount Medicare would pay for the treatment.  The HRA features an annual contribution funded by the SHBP to provide first-dollar coverage for members' medical expenses and pharmacy. For more information, go to www.bcbsga.com/shbp.
  • Health Maintenance Organization (HMO) option: An HMO allows you to receive covered medical services from in-network providers only (except for emergency care).  Members are not required to select a Primary Care Physician (PCP) with a statewide HMO. The HMO plan option pays 100% of covered services provided by in-network providers that are properly coded as “preventive care” within the meaning of the Affordable Care Act (ACA).  The HMO offers a statewide and national network of providers across the United States.

UnitedHealthcare  will provide medical claims administration and medical management services for the State Health Benefit Plan during 2015. Through UnitedHealthcare, the State Health Benefit Plan offers active members and pre-65 retirees a choice of a statewide HMO plan option and a High Deductible Health Plan (HDHP) plan option.

  • Health Maintenance Organization (HMO) option: An HMO allows you to receive covered medical services from in-network providers only (except for emergency care).  Members are not required to select a Primary Care Physician (PCP) with a statewide HMO.  The HMO plan option pays 100% of covered services provided by in-network providers that are properly coded as “preventive care” within the meaning of the Affordable Care Act (ACA).  The HMO offers a statewide and national network of providers across the United States.
  • High Deductible Health Plan (HDHP)option: The HDHP offers in-network and out-of-network benefits and provides access to a network of providers on a statewide and national basis across the United States.  The HDHP has a low monthly premium; however, you must satisfy a high dedcutible that applies to all medical and pharmacy expenses (except preventive care).  Also, you may qualify to establish a Health Savings Account (HSA) to set aside tax-free dollars to pay for eligible health care expenses.
  • Medicare Advantage Preferred Provider Organization (MA PPO):  Eligible retirees enrolled in at least Part B Medicare may choose from two Medicare Advantage PPO options:  Standard or Premium.  This plan is offered to retirees and/or their dependents enrolled in at least Medicare Part B; it provides the benefits covered under original Medicare as well as additional benefits not covered by traditional Medicare covered by traditional Medicare.

Kaiser Permanente of Georgia (KP) offers a regional HMO plan option to SHBP-eligible employees who either live or work in one of the 27 counties within the Metro Atlanta Service Area.

An HMO allows you to receive covered medical services from in-network providers only (except for emergency care).  You are responsible for selecting a Primary Care Physician (PCP) from a list of participating providers.  The HMO plan option pays 100% of covered services provided by in-network providers that are properly coded as “preventive care” within the meaning of the Affordable Care Act (ACA).  

Barrow Cherokee Dawson Forsyth Heard Newton Rockdale
Barton Clayton DeKalb Fulton Henry Paulding Spalding
Butts Cobb Douglas Gwinnett Lamar Pickens Walton
Carroll Coweta Fayette Haralson Meriwether Pike  

      

Healthways, the State Health Benefit Plan’s new wellness partner, will provide members and covered spouses with comprehensive well-being resources and incentive programs.  Healthways will also administer the 2 action-based Health Reimbursement Arrangement (HRA) incentives that will allow members and covered spouses to earn additional dollars for their HRA account.  Non-Medicare Advantage members can easily participate in all wellness activities and incentives, starting with their registration at www.BeWellSHBP.com

Express Scripts, Inc., SHBP’s new pharmacy benefit partner, will provide members with safety, care and convenience for their prescription needs.  Non-Medicare Advantage members can manage their prescriptions, enjoy savings on 90-day orders and get prescriptions delivered through the new portal at www.express-scripts.com/GeorgiaSHBP.  KP provides pharmacy benefits for its members. The pharmacy benefit for retirees covered under a SHBP Medicare Advantage plan is administered through UnitedHealthcare.

Qualifying Events

A Qualifying Event (QE) or life event change is defined as a personal change in status which may allow you to change your benefit elections.  Examples of a QE are a change in marital status, number of dependents, employment status or eligibility for health coverage. The QE rules that apply to you will depend on whether you are an active employee, former employee continuing coverage, or a surviving spouse or surviving child.  These rules are set forth in your Summary Plan Description Eligibility and Enrollment Document.

Other Important Information

For further information, please refer to the various sub-menu pages listed in the left navigation of this web page.

For more information, visit:

                 

                               

* Please note that SHBP does not administer the Tricare plan or PeachCare for Kids.