Options abound for state employees’ health plans

Government employees who want to take advantage of the open-enrollment window — this year, it’s open from Sept. 15 through Oct. 10 – have a number of options for choosing a new health plan, with the change taking effect in January. The following information was provided by the California Public Employees Retirement System, which spends about  $5.7 billion a year on health care programs for some 1.3 million government workers, retireees and their families. The figures apply to those within the CalPERS health-care plans; some counties and local entities have their own health-care programs.

For CalPERS, there is little change from last year, and what change has occurred is positive.

“There are some things to celebrate,” said Gregory Franklin, assistant executive officer for health benefits at CalPERS. “We had the lowest rate increase in a decade, about 4.8 percent for HMO- and PPO- basic.”

Depending on where you live or work, CalPERS has one or more of the following basic HMO health plan options, subject to some restrictions. Those interested in any of the programs should contact CalPERS for details. A great deal of information can be gleaned from the Web site at www.calpers.ca.gov.

• Blue Shield Access+
• Blue Shield NetValue
• Kaiser Permanente*
• California Correctional Peace Officers Association (CCPOA) Medical Plan

HMOs offer members a range of health benefits, including preventive care. The HMO provides a list of doctors from which the applicant selects a primary care provider, or PCP. The PCP coordinates all care, including referrals to specialists. Except for emergency and urgent care, if a member obtains care outside the HMO’s provider network without a referral from the health plan, the member is responsible for the total cost of services.

CalPERS also has basic health plans for Preferred Provider Organizations, or PPO. Again, some restrictions apply and people interested in the programs should go to CalPERS for detailed information.

• PERS Select
• PERS Choice
• PERSCare
• California Association of Highway Patrolmen (CAHP) Health Plan*
• Peace Officers Research Association of California (PORAC) Police and Fire Health Plan.

A PPO is similar to a traditional “fee-for-service” plan, but you must use doctors in 7 the PPO provider network or pay higher co-insurance (percentage of charges).

Unlike an HMO, where a primary care physician directs all your care, a PPO allows you to select a primary care provider and specialists without referral.

In these plans, you must usually meet an annual deductible before some benefi ts apply. You are responsible for a certain co-insurance amount, and the health plan pays the balance up to the allowable amount.

Except for emergency and urgent care, when you use a non-participating provider you are responsible for any charges above the amount allowed for preferred providers.

Another kind of plan is called the Exclusive Provider Organization, or EPO.

In the CalPERS system, that includes the Blue Shield EPO. That program serves only Colusa, Mendocino and Sierra counties. The plan offers the same covered services as the Blue Shield Access+ HMO plan, but members must seek services from Blue Shield’s statewide PPO network of preferred providers. Members are not required to select a personal physician.

There are also choices available to Basic and Medicare-eligible members living outside of California.

• PERSCare (PPO)
• PERS Choice (PPO)
• Kaiser Permanente (HMO) is available, with restrictions, in parts of Colorado, Georgia, Hawaii, Maryland, Ohio, Oregon, Virginia, Washington, and Washington D.C. Costs and some benefits may vary outside of California.