Additional Information About Our Program

How STRS Ohio Heath Care Is Funded
The State Teachers Retirement Board established the Health Care Stabilization Fund in 1983 to help fund the STRS Ohio Health Care Program. Currently, there is no dedicated revenue source to fund health care for STRS Ohio retirees. Instead, funding comes from: (1) premiums paid by enrollees in the health care program; (2) employer contributions not needed annually to guarantee pension benefits; and (3) investment earnings on the health care fund.

The Retirement Board’s first and foremost responsibility is to ensure the long-term stability of the pension plan. Access to health care coverage is not guaranteed under Ohio law. However, the board recognizes that health care coverage is important and is focused on providing access to health care for current and future retirees.

Providing affordable health care coverage is not just an STRS Ohio problem, nor a problem affecting only public pension plans. It’s a national concern.

The Retirement Board has shared its concerns about health care funding with members for several years and is working to create a dedicated revenue stream to fund health care expenses. Among STRS Ohio’s expenses for health care are monthly premium subsidies, claims costs, Medicare Part B partial premium subsidies and administrative expenses.

Rising health care costs, increased utilization and the loss of healthier enrollees are depleting money available to subsidize STRS Ohio retirees’ health care premiums at a rapid pace. Changes in the delivery of health care will need to occur at both the state and national levels. In the meantime, the Retirement Board remains focused on ensuring the long-term stability of the pension plan, while working to create a dedicated revenue stream to fund the health care program.

You can keep up to date on health care funding issues through your STRS Ohio newsletters and the STRS Ohio Web site.

Premium Subsidy and Assistance

Subsidy for Service Retirement Benefit Recipients
If you participated in the Defined Benefit or Combined Plan and have 15 or more years of qualifying service credit, STRS Ohio currently subsidizes your individual monthly health care premium at a rate of 2.5% for each year of service, up to a maximum of 75%. STRS Ohio will also pay a portion of your Medicare Part B premium, regardless of whether you are enrolled in an STRS Ohio health care plan.

Keep in mind that benefit recipients with a benefit effective date before Jan. 1, 2004, with less than 15 years of qualifying service credit have access to health care coverage but pay the full cost.

How purchased service credit may affect your monthly premiums
If you purchase certain types of service credit to qualify for retirement benefits, you will pay the full cost for health care coverage until you qualify for benefits without the purchased service. The purchased service credit referred to is: (1) non-Ohio-valued credit, (2) waived Ohio public service, (3) service as an Ohio school board member, and (4) retirement incentive credit purchased for members who retire on or after Sept. 1, 1996. Credit purchased for waived service, school board service or as retirement incentive credit is used in the premium calculation once you qualify for benefits without the purchased service.

Subsidy for Survivors
Most survivors, including eligible dependents, receive a premium subsidy (maximum 75%) for five years, with the first year beginning the latter of Jan. 1, 2004, or the effective date of benefits. After five years, the premium subsidy ends but access to health care coverage continues.

If the benefit recipient was eligible for health care, survivors receive a premium subsidy equal to 2.5% times the actual years of service.
If the active member was eligible to retire and had 15 or more years of service, survivors receive a premium subsidy equal to 2.5% times the actual years of service.
If the active member was not eligible to retire, survivors receive a premium subsidy equal to 2.5% times the greater of actual years of service or 15 years.

Health Care Assistance Program
STRS Ohio offers a Health Care Assistance Program to qualified benefit recipients who need financial assistance with STRS Ohio-sponsored health care plans. The assistance program currently provides eligible benefit recipients medical and prescription drug coverage for no monthly premium.

To qualify for the program, a benefit recipient must have 25 or more years of service as a service retiree or currently be receiving disability benefits. Total annual gross family income must fall at or below $23,800 for the benefit recipient, spouse and any dependent children. In addition, liquid assets for the family cannot exceed $23,800.

To apply for the program, you must submit a completed application to STRS Ohio. Applications must be received no later than the 15th of the month to be considered for approval for an effective date starting the next month. STRS Ohio will requalify participants annually. For more information about the program, please call STRS Ohio toll-free at 1-888-227-7877.

Coverage Considerations

Changes in Eligibility
You must immediately notify STRS Ohio by phone or in writing when an eligible dependent no longer meets eligibility requirements and indicate the date your dependent is no longer eligible. Premium deductions from your monthly benefit payment do not guarantee coverage if your dependent no longer meets eligibility requirements.

Coverage Under More Than One STRS Ohio Account
You are only eligible for health care coverage under one account. For example, you cannot be covered as both a benefit recipient and a spouse of a benefit recipient. Your monthly premium cost may be significantly different under each account. Be sure to compare premium rates for each type of account, taking into consideration such factors as years of service and Medicare eligibility. It is your responsibility to contact STRS Ohio each year to determine which account will provide the lower health care premium.

Coverage Under More Than One Ohio Public Retirement System
If you are eligible for health care coverage through more than one Ohio public retirement system, there are guidelines that determine which system is responsible for your health care coverage.

Note: If you are eligible to receive a Medicare Part B premium reimbursement through more than one Ohio public retirement system, there are specific guidelines that apply. It is your responsibility to contact STRS Ohio to determine which system is responsible for providing your reimbursement.

Moving to a New Residence
If you are moving, contact STRS Ohio as soon as you know your new address. STRS Ohio will let you know if your health care plan options will change as a result of your new address.

Changing Plans or Terminating Coverage

Changing Plans
If you enroll in an STRS Ohio-sponsored health care plan, you must remain in the health care plan you select for the calendar year. You will not be permitted to change health care plans during the calendar year unless you experience a qualifying event.

Certain events allow enrollees to change health care plans during the calendar year. Some events allow enrollees to switch plan administrators and/or plan levels, while other events allow enrollees to switch plan administrators only. The difference between plan administrators and plan levels is listed below.

Plan Administrators
There are five plan administrators under the STRS Ohio Health Care Program: Aetna, AultCare, Kaiser Permanente, Medical Mutual and Paramount.

Plan Levels
There are two plan levels under the STRS Ohio Health Care Program. Plan levels are based on the coverage features of the plans.

Level 1 — Aetna Basic Indemnity, Aetna Basic PPO, Medical Mutual Basic Indemnity and Medical Mutual Basic PPO

Level 2 — Aetna Plus Indemnity, Aetna Plus PPO, Medical Mutual Plus Indemnity, Medical Mutual Plus PPO, AultCare PPO, Kaiser Permanente, Kaiser Permanente Medicare Plus, Paramount Health Care and Paramount Elite

Changing Plan Administrators, Plan Levels or Both
Certain qualifying events allow enrollees to change plan administrators and/or plan levels during the calendar year. This means enrollees can switch to any STRS Ohio-sponsored health care plan available in their area, regardless of the plan administrator or plan level.

The following events allow enrollees to change plan administrators and/or plan levels. Please note that any plan change applies to both the benefit recipient and any covered dependents:

Enrollee experiences one of the following events and requests to change plan administrators and/or plan levels within 31 days of the event: marriage; birth, adoption, placement for adoption or legal guardianship of a child; death; divorce or dissolution; or legal separation.
Enrollee turns age 65 and becomes eligible for Medicare. Enrollee must request to change plan administrators and/or plan levels within three months before the effective date of Medicare or three months after the effective date of Medicare.
Enrollee is a new retiree and has not received the first partial STRS Ohio benefit payment. The enrollee must request to change plan administrators and/or plan levels within 31 days of the effective date of health care coverage.
A Kaiser Permanente Medicare Plus or Paramount Elite enrollee may terminate coverage under the Medicare HMO at any time and enroll in any other STRS Ohio-sponsored health care plan available in his or her area. A written request to terminate coverage must be sent to both the HMO plan administrator and STRS Ohio before the termination date becomes effective. The enrollee must request to enroll in a new plan within 31 days of the termination effective date.

Changing Plan Administrators Only
Certain qualifying events allow enrollees to change plan administrators but not plan levels during the calendar year. This means enrollees can change plan administrators as long as they remain in the same plan level.

The following events allow enrollees to switch plan administrators only. Please note that any plan administrator change applies to both the benefit recipient and any covered dependents.

PPO or HMO enrollee experiences the loss of a key provider from the network.
Enrollee moves to another service area, which results in different plan options being available.
A Kaiser Permanente HMO or an AultCare PPO enrollee wants to add a sponsored dependent (the eligibility requirements for these health care plans do not permit the enrollment of sponsored dependents).

Note: If you experience a qualifying event during the calendar year and choose to change plan administrators, your medical deductible and out-of-pocket maximums will not transfer to the new plan administrator.

Terminating Your Coverage
You may terminate your health care coverage at any time. Call STRS Ohio for more information.

Terminating Spouse’s Coverage After Divorce
In the event of a divorce, your spouse’s health care coverage will terminate the first month following finalization of the divorce. However, your spouse may be eligible for continuation of health care coverage through the plan administrator. Call STRS Ohio for more information.

Quality Standards
To be offered as an STRS Ohio health care plan option, a plan must meet the following quality standards:

Adhere to high performance standards related to enrollees’ access to medical providers, claims payment accuracy, processing time and the quality of service provided by the plan’s customer service department.
Allow medical providers to speak with plan enrollees about reasonable care options, including those not covered by the plan, and about how services are reimbursed.
Support surveys of enrollees to assess satisfaction with the plan. Use survey results to improve customer service and the quality of health care provided.
Provide a coverage-appeal process for enrollees that includes, as a final level of appeal, deliberation by an independent health care professional(s).
Show a commitment to improving the health of the plan’s older adult enrollees.
Have business associate agreements that safeguard protected health information and are in compliance with the Health Insurance Portability and Accountability Act (HIPAA) regulations.

In addition, HMO and PPO plans are encouraged to have or be pursuing accreditation by the National Committee for Quality Assurance (NCQA) or the American Accreditation Health Care Commission (URAC), or have programs in place to ensure the delivery of quality care to enrollees. NCQA and URAC use nationally recognized standards to measure plan performance in the areas of quality of care, access to care, utilization management and consumer satisfaction.

Confidentiality Statement
By accepting coverage under an STRS Ohio-sponsored health care plan, all enrollees, including any enrolled dependents, shall:

Furnish STRS Ohio or its designees any and all information STRS Ohio may reasonably require pertaining to health care coverage and the operations of its health care plan.
Enroll in Medicare Part A (if applicable) and Medicare Part B at age 65 or whenever eligible, and provide STRS Ohio proof of Medicare enrollment.
Authorize and direct any physician or other health care provider, health plan, pharmacy, pharmacy benefits manager or program administrator to furnish STRS Ohio or its designees any and all information and records (or copies of records) relating to care or services provided directly to the enrollee or services provided indirectly to the enrollee related to the administration of the health care program.

Any and all records pertaining to health care services that STRS Ohio in its sole discretion determines are necessary to implement and administer the terms of health care coverage and/or are necessary for the appropriate review and management of health care plans may be used by and released to STRS Ohio and its designees, or used by and released among STRS Ohio designees.

All individually identifiable information and records pertaining to health care coverage and services are considered by STRS Ohio to be confidential and will not be given, sold or transferred to any person or organization not designated by STRS Ohio.

Statement of Health Insurance Portability and Accountability Act (HIPAA) Rights
The following information is an explanation of your rights under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. As an STRS Ohio Health Care Program enrollee, HIPAA may be important to you if you or your dependents terminate health care coverage under STRS Ohio and obtain coverage from another group health care plan that includes preexisting conditions.

Preexisting condition exclusions. Some group health care plans restrict coverage for medical conditions present before an individual’s enrollment. These restrictions are known as “preexisting condition exclusions.” A preexisting condition exclusion can apply only to conditions for which medical advice, diagnosis, care or treatment was recommended or received within six months before your “enrollment date.” Your enrollment date is your first day of coverage under the health plan, or, if there is a waiting period, the first day of your waiting period. In addition, a preexisting condition exclusion cannot last for more than 12 months after your enrollment date (18 months if you are a late enrollee). Finally, a preexisting condition exclusion cannot apply to pregnancy and to a child who is enrolled in health care coverage within 31 days after birth, adoption or placement for adoption.

If a health plan imposes a preexisting condition exclusion, the length of the exclusion must be reduced by the amount of your prior creditable coverage. Most health care coverage is creditable coverage, including group health plan coverage, COBRA continuation coverage, coverage under an individual health policy, Medicare, Medicaid, State Children’s Health Insurance Program (SCHIP), coverage through high-risk pools and the Peace Corps. Not all forms of creditable coverage are required to provide certificates. If you do not receive a certificate for past coverage, please talk to your new health plan administrator.

You can add up any creditable coverage you have. However, if at any time you went for 63 days or more without any coverage (called a break in coverage), a health plan may not have to count the coverage you had before the break. Therefore, once your coverage ends, you should try to obtain alternative health care coverage as soon as possible to avoid a 63-day break.

Right to obtain special enrollment in another health plan. Under HIPAA, if you lose your health plan coverage, you may be able to enroll in another health plan for which you are eligible (such as a spouse’s plan) — even if the plan generally does not accept late enrollees — if you request enrollment within 31 days. Additional special enrollment rights are triggered by marriage, birth, legal guardianship, adoption and placement for adoption. Therefore, once your health plan coverage ends, if you are eligible for coverage in another plan (such as a spouse’s plan), you should request special enrollment as soon as possible.

Prohibition against discrimination based on a health factor. Under HIPAA, a group health plan may not keep you (or your dependents) out of the plan based on anything related to your health. Also, a group health plan may not charge you — or your dependents — more for coverage, based on health status, than the amount charged to a similarly situated individual.

Right to individual health coverage. Under HIPAA, if you are an “eligible individual,” you have a right to buy certain individual health policies (or in some states, to buy coverage through a high-risk pool) without a preexisting condition exclusion. To be an eligible individual, you must meet the following requirements:

You have had coverage for at least 18 months without a break in coverage of 63 days or more;
Your most recent coverage was under a group health plan;
Your group coverage was not terminated because of fraud or nonpayment of premiums;
You are not eligible for COBRA continuation coverage or you have exhausted your COBRA benefits (or continuation coverage under a similar state provision); and
You are not eligible for another group health plan, Medicare or Medicaid and you do not have any other health insurance coverage.

The right to buy individual health care coverage is the same whether you are laid off, fired or quit your job. Therefore, if you are interested in obtaining individual coverage and you meet the other criteria to be an eligible individual, you should apply for this coverage as soon as possible to avoid losing your eligible individual status due to a 63-day break.

State flexibility. This information describes minimum HIPAA protections under federal law. States may require insurers and health maintenance organizations (HMOs) to provide additional protections to individuals in that state.

For more information. If you have questions about your HIPAA rights, you may contact your state insurance department or the U.S. Department of Labor, Employee Benefits Security Administration (EBSA), toll-free at 1-866-444-3272. You may also call this number to request free HIPAA publications about changes in health care laws. Additionally, you may also contact the Centers for Medicare and Medicaid Services (CMS) publication hotline toll-free at 1-800-633-4227. Ask for the publication Protecting Your Health Insurance Coverage. These publications and other information are also available at the U.S. Department of Labor’s interactive Web pages at www.dol.gov/elaws, or www.cms.hhs.gov/hipaageninfo.