Chapter 1: Enrollment and Eligibility Information Group Insurance Beneﬁts Please read this handbook carefully as it contains vital information about your benefits. The Bureau of

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Your Responsibilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Chapter 1: Enrollment and Eligibility InformationEligibility Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Enrollment Periods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Enrollment Opportunities Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Documentation Requirements – Adding Dependent Coverage Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Documentation Requirements – Terminating Dependent Coverage Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Documentation Time Limits Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Premium Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15COBRA Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Chapter 2: Health Plan Coverage InformationHealth Plan Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Managed Care Health Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Teachers’ Choice Health Plan (TCHP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Prescription Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Behavioral Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Chapter 3: Optional ProgramsCoordination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Subrogation and Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Claim Filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Claim Appeal Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Chapter 4: ReferenceGlossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Table of Contents

TRIP Benefits HandbookMyBenefits.illinois.gov

Your Group Insurance BenefitsPlease read this handbook carefully as it contains vitalinformation about your benefits.

The Bureau of Benefits within the Department of CentralManagement Services (Department) is the bureau thatadministers the Teachers’ Retirement Insurance Program (TRIP)as set forth in the State Employees Group Insurance Act of 1971(Act). You have the opportunity to review your choices andchange your coverage for each plan year during the annualBenefit Choice Period. If a qualifying change in status occurs,you may be allowed to make a change to your coverage that isconsistent with the qualifying event. See the section‘Enrollment Periods’ for more information.

MyBenefits Service Center (MBSC)The MyBenefits Service Center (MBSC) is a custom benefitssolution service provider for the Department. The MBSC willmanage the detailed enrollment process of member benefitsthrough online technical support via theMyBenefits.illinois.gov website and telephonic support viathe MyBenefits Service Center 844-251-1777. The MBSC isnow the member's primary contact for answering generalquestions you may have about your eligibility for coverage andto assist you in enrolling or changing the benefits you haveselected.

Where To GetAdditional InformationIf you have questions after reviewing this book,please refer to the following:F The Department’s website contains the most up-to-date

information regarding benefits and links to planadministrators’ websites. Visit MyBenefits.illinois.gov forinformation.

F Annual Benefit Choice Options booklet. This bookletcontains the most current information regarding changesfor the plan year. New benefits, changes in premiumamounts and changes in plan administrators are includedin the booklet. Review this booklet carefully as itcontains important eligibility and benefit informationthat may affect your coverage. VisitMyBenefits.illinois.gov to view the booklet.

F TRS is a valuable resource for answering questions youmay have about your eligibility for coverage and to assistyou in enrolling or changing the benefits you haveselected. TRS can be reached at:

Teachers’ Retirement System2815 West Washington

P.O. Box 19253Springfield, IL 62794-9253Phone: 877-927-5877 (877-9-ASK-TRS)TDD: 866-326-0087www.trsil.org

F The MyBenefits Service Center (MBSC) can answer yourbenefits questions or refer you to the appropriate resourcefor assistance. MBSC can be reached at:

MyBenefits Service Center134 N. LaSalle Street, Suite 2200Chicago, IL 60602844-251-1777 or TDD/TTY: 844-251-1778MyBenefits.illinois.gov

F The Department will continue to assist members eligiblefor Medicare, with questions regarding eligibility policiesand rules as well as answer your benefit questions or referyou to the appropriate resource for assistance. The GroupInsurance Division can be reached at:

CMS Group Insurance Division801 S. 7th StreetP.O. Box 19208Springfield, IL 62794-9208800-442-1300 or 217-782-2548TDD/TTY: 800-526-0844

F Each individual plan administrator can provide you withspecific information regarding plan coverageinclusions/exclusions.

ID CardsThe plan administrators produce ID cards at the time ofenrollment. Cards are mailed to the current address on filewith the Bureau of Benefits. To obtain additional cards, contactthe plan administrator. Links to the plan administrators’websites can be found at MyBenefits.illinois.gov.

Health Insurance Portability andAccountability Act (HIPAA)Title II of the federally enacted Health Insurance Portabilityand Accountability Act of 1996, commonly referred to asHIPAA, was designed to protect the confidentiality and security ofhealth information and to improve efficiency in healthcaredelivery. HIPAA standards protect the confidentiality ofmedical records and other personal health information, limitthe use and release of private health information, and restrictdisclosure of health information to the minimum necessary.If you are enrolled in TRIP, a copy of the Notice of PrivacyPractices will be sent to you on an annual basis. Additionalcopies are available on the MyBenefits.illinois.gov website.

Introduction

2 MyBenefits.illinois.govTRIP Benefits Handbook

3 TRIP Benefits HandbookMyBenefits.illinois.gov

It is your responsibility to know your benefits,including coverage limitations and exclusions,and to review the information in this publication.Referral and/or approval for treatment by a physiciandoes not ensure coverage under the plan.

You must notify MyBenefits Service Center (MBSC), or TRSimmediately when any of the following occurs:

F You and/or your dependents experience a change ofaddress. When you move, you must provide writtennotification to TRS. However, when your dependent(s)move, you must utilize the Self-Service Tools online atMyBenefits.illinois.gov to report your dependent(s)' newaddress. Changing your address with the retirementsystem may automatically change your health plan to aplan in that geographic area.

F Your enrolled dependent loses eligibility. Dependentsthat are no longer eligible under TRIP (including divorcedspouses or partners of a dissolved civil union partnership)must be reported immediately by completing the onlineprocess using the Self-Service Tools atMyBenefits.illinois.gov. Failure to report an ineligibledependent is considered a fraudulent act. Any premiumpayments you make on behalf of the ineligibledependent which result in an overpayment will not berefunded. Additionally, the ineligible dependent maylose any rights to COBRA continuation coverage.

F You get married or enter into a civil union, or yourmarriage or civil union partnership is dissolved.

F You have a baby or adopt a child.

F Your enrolled dependent’s employment status changes.

F Your enrolled dependent dies.

F You have or gain other coverage. If you have groupcoverage provided by a plan other than TRIP, or if you oryour dependents gain other coverage during the planyear, you must provide that information immediately bycompleting the online process using the Self-Service Toolsat MyBenefits.illinois.gov

Contact MBSC or TRS if you are uncertain whether or not alife-changing event needs to be reported.

If you and/or your enrolled dependent experience a changein Medicare status or become eligible for Medicarebenefits, a copy of the Medicare card must be provided to TRS.Failure to notify TRS of you and/or your dependent’s Medicareeligibility may result in substantial financial liabilities. Refer tothe ‘Medicare’ section for the Medicare Coordination of BenefitsUnit contact information.

Benefit recipients should periodically review the following toensure all benefit information is accurate:

F Insurance Deductions. It is your responsibility to ensuredeductions are accurate for the insurance coverage you haveselected/enrolled. If your annuity check is insufficient tocover your premiums, you will be billed for the cost ofyour current coverage. Failure to pay the bill may resultin a loss of coverage and/or withholding through theTRS annuity check.

If You Live or SpendTime Outside IllinoisBenefit recipients who move outside of Illinois or the countrywill most likely need to enroll in the Teachers’ Choice HealthPlan (TCHP). For those in certain areas contiguous to the Stateof Illinois, some managed care health plan options may beavailable. Refer to MyBenefits.illinois.gov and login to youraccount to view your available options, or contact themanaged care health plan directly for information on plansavailable.

Dependents Who Live Apart fromthe Benefit Recipient Eligible dependents who are enrolled in an HMO plan andlive apart from the benefit recipient’s residence and are out ofthe plan’s service area for any part of a plan year will belimited to coverage for emergency services only. It is crucialthat benefit recipients who have an out-of-area dependent(such as a college student) contact the HMO plan tounderstand the plan’s guidelines on this type of coverage.

Your Responsibilities

4

Power of AttorneyBenefit recipients may want to consider having a financialpower of attorney on file with both the retirement system andthe health plan to allow a representative to act on their behalf.For purposes of group insurance, a financial or propertypower of attorney is necessary; a healthcare power of attorneydoes not permit changes to health insurance coverage.

Penalty for FraudFalsifying information/documentation or failing to provide in-formation/documentation in order to obtain/continue cover-age under TRIP is considered a fraudulent act. The State ofIllinois will impose a financial penalty, including, but notlimited to, repayment of all premiums the State made on be-half of the benefit recipient and/or the dependent beneficiary,as well as expenses incurred by TRIP.

Your Responsibilities (cont.)

MyBenefits.illinois.govTRIP Benefits Handbook

Chapter 1Chapter 1: Enrollment and Eligibility InformationEligibility Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Enrollment Periods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Enrollment Opportunities Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Documentation Requirements – Adding Dependent Coverage Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Documentation Requirements – Terminating Dependent Coverage Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Documentation Time Limits Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Premium Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15COBRA Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16


6TRIP Benefits Handbook MyBenefits.illinois.gov

This section contains benefit eligibility information whichapplies to all TRIP health plans.

Eligibility RequirementsEligibility is defined by the State Employees Group InsuranceAct of 1971 (5 ILCS 375/1 et seq.) or as hereafter amended(Act), and by such policies, rules and regulations as shall bepromulgated there under. If there is any change in eligibility(qualifying change in status, Medicare eligibility, residentialaddress) notify TRS immediately at 877-927-5877 (877-9-ASK-TRS). Failure to notify TRS of eligibility changes mayresult in loss of benefits and/or premiums.

Eligible as Benefit RecipientTo be eligible, annuitants must be receiving a monthly benefitor retirement annuity from TRS and have at least eight yearsof creditable service under Article 16 (TRS) of the IllinoisPension Code; or (I) have been enrolled in the healthinsurance program offered prior to January 1, 1996; or (II) bethe survivor of a benefit recipient who had at least eight yearsof creditable service under Article 16 (TRS) of the IllinoisPension Code; or (III) be a survivor of a benefit recipient whowas enrolled in the TRS program prior to January 1, 1996; or(IV) be a recipient of a TRS disability benefit.Benefit recipients enrolled in any of the State EmployeesGroup Insurance Program health plans are not eligible forhealth coverage as a member under TRIP.

Dependent Eligibility Eligible dependent beneficiaries of a benefit recipient mayparticipate in TRIP. Dependent coverage is an additional costfor all members. Eligible dependents include the benefit recipient’s:F Spouse (does not include ex-spouses, common-law

spouses, persons not legally married or the new spouseof a survivor).

F Civil Union Partner (enrolled on or after June 1, 2011).

F Parent. Parent must be dependent upon the benefitrecipient for more than one-half of their support and

eligible to be claimed by the benefit recipient as adependent for income tax purposes.

F Child from birth to age 26, limited to:

– Natural child. – Adopted child.– Stepchild or child of a civil union partner.– Child for whom the benefit recipient has permanentlegal guardianship.

– Adjudicated child for whom a U.S. court decree hasestablished a member’s financial responsibility for thechild’s medical healthcare.

F Child age 26 and older, limited to:

– Adult Veteran Child. Unmarried adult child age 26 upto, but not including, age 30, an Illinois resident, hasserved as a member of the active or reservecomponents of any of the branches of the U.S. ArmedForces and received a release or discharge otherthan a dishonorable discharge.

– Disabled. Child age 26 or older who is continuouslydisabled from a cause originating prior to age 26. Inaddition, for tax years in which the child is age 27 orabove, eligible to be claimed as a dependent forincome tax purposes by the benefit recipient.

NOTE: Survivors may add a dependent only if thatdependent was eligible for coverage as a dependent underthe original member.

Eligibility Requirements


Certification ofDependent CoverageIn addition to the following certification periods, TRS may askthe member to certify their dependent either randomly orduring an audit anytime during the year.Birth Date Certification. Benefit recipients must verifycontinued eligibility for dependents turning ages 26 and 30.Members with dependents turning ages 26 and 30 willreceive a letter from TRS several weeks prior to the birthmonth that contains information regarding continuation ofcoverage requirements and options. The member mustprovide the required documentation prior to the dependent’sbirth date. Failure to certify the dependent’s eligibility willresult in the dependent’s coverage being terminated effectivethe end of the birth month.Annual Certification. Benefit recipients are required to certifyall IRS dependents in the following categories on an annualbasis: Parent, Disabled and Adult Veteran Child (age 26 andolder).Reinstatement of Dependent Coverage. If coverage for adependent is terminated for failure to certify and themember provides the required documentation within 30 daysfrom the date the termination was processed, coverage will bereinstated retroactive to the date of termination. After 30 days the coverage will be reinstated only with aqualifying change in status (see qualifying change in statusreasons in the ‘Enrollment Periods’ section later in this chapter).Termination of coverage for failure to certify is not aqualifying change in status.

Contact the MyBenefits Service Center for questionsregarding certification of a dependent.

Eligibility Requirements (cont.)


Benefit recipients have several opportunities to initiallyenroll in TRIP. After the initial enrollment, if the benefitrecipient terminates TRIP coverage, re-enrollmentopportunities are limited.

Initial EnrollmentBenefit recipients may enroll in TRIP during the annualBenefit Choice Period only if they have never previouslybeen enrolled in TRIP. Benefit recipients who are eligiblefor, but have never enrolled in, one of the health plansunder TRIP may do so during the annual Benefit ChoicePeriod. The coverage becomes effective July 1st.Outside the annual Benefit Choice Period, benefitrecipients may enroll in TRIP when one of the followingoccurs, regardless of whether or not they have ever beenpreviously enrolled in the program:F Upon application of annuity benefits. An enrollment

application must be submitted to TRS no later than 30 daysafter the effective date of the pension benefits. Coveragewill be effective the first day of the first full month ofbenefits or the first day of the month that the enrollmentapplication is received, whichever is later. The effectivedate may be delayed up to 4 months after the effectivedate of the pension benefits; however, TRS must receivethe enrollment form within 30 days of the effective date ofthe pension benefits. The form is used by the retirementsystem to update the member’s insurance record. TheMyBenefits Service Center will receive the member'supdated information which will allow the member to enrollonline on the MyBenefits portal within 30 days of theretirement effective date. If the member does not make anelection within that timeframe, no coverage will beavailable until the next enrollment opportunity.

F The benefit recipient becomes eligible for Medicare.Benefit recipients who become eligible for Medicaremay apply for coverage. Benefit recipients must applywithin 6 months from the date they became Medicareeligible. If the benefit recipient is Medicare eligibledue to turning 65, TRS will send a letter with anapplication for enrollment prior to their 65th birthday.Coverage will be effective the first day of the month inwhich the benefit recipient becomes Medicare eligibleor the first day of the month when the enrollmentapplication is received by TRS, whichever is later.

F The benefit recipient has been determined to beineligible for Medicare. Benefit recipients who areMedicare ineligible have 30 days from their 65thbirthday to apply for coverage. Coverage will beeffective the first day of the month in which the benefitrecipient reaches age 65 or the first day of the monthwhen the enrollment application is received by TRS,whichever is later.

F Coverage is terminated by a former group plan. Benefitrecipients who are eligible to enroll in TRIP but insteadcontinue coverage with another plan, may enroll if theother plan terminates coverage. The benefit recipient has30 days following the loss of other coverage to submit theenrollment application to TRS, along with a letter from theformer plan stating the effective date of termination.Termination of coverage must be initiated by the formergroup plan. Termination for nonpayment of premiumdoes not qualify as loss of coverage by the group plan andtherefore is not an eligible enrollment event. The effectivedate of the coverage is the first day of the month followingcancellation of coverage with the other plan.

Annual Benefit Choice PeriodThe Benefit Choice Period is normally held annually May 1stthrough May 31st. During this 31-day period, benefitrecipients may change their health and dependent coverageelections. Coverage elected during the annual Benefit ChoicePeriod remains in effect throughout the entire plan yearunless the member experiences a qualifying change in statusor the Department institutes a special enrollment periodwhich would allow the member to change their coverageelections.

Benefit recipients may make the following electionsduring the annual Benefit Choice Period:

F Enroll in the Teachers’ Retirement Insurance Program –applies to benefit recipients and dependent beneficiarieswho have never been previously enrolled in TRIP.

F Change health plans.F Add eligible dependents. Social security numbers are

required to add dependent coverage. Refer to the'Dependent Coverage' section for documentationrequirements.

Enrollment Periods


Effective Date of Coverage Due to the AnnualBenefit Choice Period:

All Benefit Choice health and dependent coverage changesbecome effective July 1st.

Qualifying Change in StatusThe Department’s administrative policy prohibits changes in thebenefit recipient’s elections during the plan year unless there isa qualifying change in status. Any request to change anelection mid-year must be consistent with the qualifying eventthe benefit recipient or dependent has experienced.

Qualifying change in status events may include, butare not limited to: F Events that change a benefit recipient’s legal relationship

status, including marriage, civil union partnership, death ofspouse or civil union partner, divorce, legal separation, civilunion dissolution or annulment.

F Events that change a benefit recipient’s number ofdependents, including birth, death, adoption orplacement for adoption.

F Events that cause a dependent to satisfy or cease to satisfyeligibility requirements for coverage.

F A change of permanent residential county for the benefitrecipient, or, a move to a foreign country by an eligibledependent.

Benefit recipients experiencing a qualifying change in statushave 30 days to request a change to their benefit selection.Members are required to notify the MyBenefits Service Center(MBSC) of any qualifying changes by using the Self-ServiceTools online at MyBenefits.illinois.gov. Members must alsosubmit proper supporting documentation to MBSCwithin 30 days in order for the change to become effective (31days for a birth, adoption or marriage). An exception is madefor benefit recipients who move, as they have 60 days from thedate of notification to change plans. Effective Date of Coverage Due to a QualifyingChange in Status:Coverage election changes made due to a qualifying eventare effective the first day of the month following the date ofthe event as long as the request is made within the requiredtime frame.

Qualifying Change in Status Effective Date Exceptions:

F Newborns, natural or adopted. A child is considered anewborn if they are within 31 days of birth. If the requestto add the child is made within 31 days of the birth,coverage may be retroactive to the date of birth.

F Adopted children, other than newborn. Requests to addan adopted child who is 31 days old or older will beeffective the date of the placement of the child, the filing ofthe adoption petition or the entry of the adoption orderprovided that the request is received within 31 days of theplacement of the child, filing of the adoption petition orthe entry of the adoption order.

Dependent CoverageEnrolling DependentsDependent beneficiaries will be enrolled in the same healthplan as the benefit recipient. When both parents* are benefitrecipients, either may elect to cover the dependents. NOTE:Dependents whose coverage was terminated for nonpaymentof premium under one parent cannot be enrolled under theother until all premiums due for that dependent are paid. Benefit recipients must complete the online process using theSelf-Service Tools at MyBenefits.illinois.gov to add dependentcoverage. * The term 'parent' includes a stepparent or a civil unionpartner of the child's parent.Documentation RequirementsDocumentation, including the dependent’s social securitynumber (SSN), is always required to enroll dependents. Failureto provide the required documentation in the allotted timeperiod will result in denial of dependent coverage. If denied,the eligible dependent may be added during the next BenefitChoice Period (if never previously enrolled in TRIP) or upon thebenefit recipient experiencing a qualifying change in status, aslong as the documentation is provided in a timely manner.A time period of 90 days is allotted to provide the SSN ofnewborns and adopted children; however, the election timeframes still apply to request the addition of the dependentcoverage. If the SSN is not provided within 90 days of thedependent’s date of birth or adoption date, coverage will beterminated. Refer to the ‘Documentation Requirements –Adding Dependent Coverage’ chart later in this chapter forspecific documentation requirements.

Enrollment Periods (cont.)


Dependent Beneficiary Enrollment Opportunities

Dependent beneficiaries may be enrolled in TRIP during theannual Benefit Choice Period only if they have never beenpreviously enrolled. The coverage becomes effective July 1st. Outside the annual Benefit Choice Period, dependentbeneficiaries who experience one of the following events maybe enrolled in TRIP, regardless of whether or not they have everbeen previously enrolled:F The dependent beneficiary becomes eligible for

Medicare. Dependent beneficiaries who become eligiblefor Medicare are eligible for TRIP coverage. The coveragemust be applied for within 6 months from the date thedependent beneficiary became Medicare eligible. If thedependent beneficiary is Medicare eligible due to turning65, MyBenefits Service Center (MBSC) will send a letternotifying you that it's time to enroll online atMyBenefits.illinois.gov prior to their 65th birthday.Coverage will be effective the first day of the month inwhich the dependent beneficiary becomes Medicareeligible or the first day of the month when the onlineenrollment process is completed, whichever is later.

F The dependent beneficiary has been determined to beineligible for Medicare. Dependent beneficiaries whohave been determined by the Social SecurityAdministration to be ineligible for Medicare have 30 daysfrom their 65th birthday to apply for coverage. Coveragewill be effective the first day of the month in which thedependent reaches age 65 or the first day of the monthwhen the enrollment process is completed online by usingthe Self-Service tools at MyBenefits.illinois.gov,whichever is later.

F Coverage is terminated by a former group plan.Dependent beneficiaries who are eligible to enroll in TRIPbut instead continue coverage with another plan, mayenroll if the other plan terminates coverage. Thedependent has 30 days following the loss of othercoverage to submit an enrollment application to TRS, alongwith a letter from the former plan stating the effective dateof termination. Termination of coverage must be initiatedby the former group plan. Termination for nonpayment ofpremium does not qualify as loss of coverage by the groupplan and therefore is not an eligible enrollment event. Theeffective date of the coverage is the first day of the monthfollowing cancellation of coverage with the other plan.

Enrollment Periods (cont.)


Reason

Upon application of annuity benefits

Benefit Recipient becomes eligible for Medicare (turning 65/ESRD/disability)

Benefit Recipient determinedineligible for Medicare (turning 65)

Benefit Recipient’s coverage is involuntarily terminated by a former group plan

Annual Benefit Choice Period

Marriage, civil union, adoption orbirth

Dependent Beneficiary becomes eligible for Medicare (turning 65/ESRD/disability)

Dependent Beneficiary determinedineligible for Medicare (turning 65)

Dependent Beneficiary’s coverage isinvoluntarily terminated by a former group plan

Benefit Recipient may en-roll in TRIP for the

first time

X

X

X

X

X

Benefit Recipient may en-roll in TRIP even if

previously enrolled

X

X

X

X

Dependent Beneficiary maybe enrolled in

TRIP for the firsttime

X

X

X

X

X

X

X

X

X

Dependent Beneficiary maybe enrolled inTRIP even if previously enrolled

X

X

X

X

X

X

X

X

Teachers’ Retirement Insurance Program Enrollment Opportunities


Type of DependentAdjudicated ChildBirth up to, but not including, age 26

Adoption or Placement for AdoptionBirth up to, but not including, age 26

Adult Veteran ChildChild age 26 up to, but not including, age 30

Disabled Child age 26 and older(onset of disability must have occurred prior to age 26)

Legal GuardianshipBirth up to, but not including, age 26Natural ChildBirth up to, but not including, age 26Parent

Spouse or Civil Union Partner

Stepchild or Child of Civil Union PartnerBirth up to, but not including, age 26

Supporting Documentation Required• Judicial Support Order from a judge; or• Copy of DHFS Qualified Medical Support Order with the page that indicates thebenefit recipient must provide health insurance through the retirement system

• Adoption Decree/Order with judge’s signature and the circuit clerk’s file stamp,or a

• Petition for adoption with the circuit clerk’s file stamp• Birth Certificate required, and • Proof of Illinois residency, and • Veterans’ Affairs Release form DD-214 (or equivalent), and a• Copy of the tax return

• Birth Certificate required, and a• Statement from the Social Security Administration with the social security disabilitydetermination or a Court Order, and a

• Copy of the tax return

• Court Order with judge’s signature and circuit clerk’s file stamp

• Birth Certificate required

• Benefit Recipient’s Birth Certificate indicating the parent’s name, and • Copy of the tax return

• Marriage Certificate or tax return• Civil Union Partnership Certificate. • Birth Certificate required, and • Marriage or Civil Union Partnership Certificate indicating the member is married to,or the partner of, the child’s parent.

Note: Birth Certificate from either the State or admitting hospital which indicates the benefit recipient is the parent is acceptable.

* A valid social security number (SSN) is required to add dependent coverage. If the SSN has not yet been issued for a newborn or adopted child, the child will be added tothe benefit recipient’s coverage upon receipt of the birth certificate or adoption order without the SSN. The benefit recipient must provide the SSN within 90 days of the datethe coverage was requested in order to continue the dependent's coverage.

Documentation Requirements – Adding Dependent Coverage*


Qualifying Event

Divorce, Dissolution of Civil Union Partnership or Annulment

Legal Separation

Loss of Court-Ordered Custody

Supporting Documentation Required

Divorce Decree or Judgment of Dissolution or Annulment filed in a U.S. Court – firstand last pages with judge’s signature with circuit clerk’s file stamp.

Court Order with judge’s signature with circuit clerk’s file stamp.

Court Order indicating the member no longer has custody of the dependent. Theorder must have judge’s signature with circuit clerk’s file stamp.

Documentation Requirements – Terminating Dependent Coverage

When adding Dependent coverage due to or during the:

Initial Enrollment Period

Annual Benefit Choice Period(Normally held May 1 – May 31 each year)

Qualifying Change in Status (Exception for birth, adoption and marriage– noted below)

Birth of Child (Natural or Adopted)

Adopted Children (Other than newborn)

Marriage

If the coverage is requested…

Day 1 – 30 from the benefit begin date

During the Benefit Choice Period

Before, or the day of, theeventDay 1 – 30 after event

From birth up to 31 days after the birth

Within 31 days of theevent


And if the documentation is provided…Day 1 – 30 from the benefit begin date

Within 10 days of theBenefit Choice Periodending

1 – 30 days after theevent

From birth to 31 daysafter the birth



Dependent coverage will be effective…On the date of commencement ofretirement or annuity benefits, orthe first of the month of theapplication for retirement,whichever is later

July 1st

The first day of the monthfollowing the date of the event

Date of birth

Date of placement of the child,filing of the petition or the entryof the adoption order

The first day of the monthfollowing the date of the event

Documentation Time LimitsDependent coverage may be added with the corresponding effective date when documentation is provided to MyBenefits.illinois.gov orthe MyBenefits Service Center within the allowable time frame as indicated below. If documentation is provided outside the time frames,adding dependent coverage will not be allowed until the next annual Benefit Choice Period (as long as the dependent has never previouslybeen enrolled in TRIP) or until the member experiences a qualifying change in status.


The premium for coverage under the Teachers' RetirementInsurance Program (TRIP) is subsidized by the TRIP plan. Thesubsidy amount will be based on the type of coverage elected. Benefit recipients will receive a 75% premium subsidy, if,based on their permanent residence:

F they enroll in a managed care plan when a managed careplan is available.

F they enroll in the TCHP plan if no managed care plan isavailable.

F their county of residence has a managed care plan that isonly partially available and they enroll in either thatmanaged care plan or the TCHP plan.

Benefit recipients will receive a 50% premium subsidy, if amanaged care plan is available in their county of residenceand they choose to enroll in TCHP.The premium amount due each month is based upon thecoverage elections in effect on the 1st of the month.Premiums will not be prorated when a benefit recipientchanges their coverage elections or terminates from TRIP on aday other than the 1st. Benefit recipients whose annuity checkis insufficient to have premiums deducted will be direct billed.It is your responsibility to verify the accuracy of premiumspaid, whether deducted from the annuity or direct billed,and to notify TRS of any errors.

All benefit recipients are responsible for the cost of electivedependent coverage. Dependents who are Medicare primaryand are enrolled in a managed care plan, or in the TCHP planwhen no managed care plan is available, will receive apremium subsidy. Premiums for dependent coverage areestablished annually and reflected on theMyBenefits.illinois.gov website. These contributions/premiums are subject to change each plan year.

Benefit Recipients Direct BilledBilling Procedure and Time Frames The law requires that the premium for coverage be deducted

from the annuity received by the benefit recipient. If theannuity is insufficient to cover the premium, a direct billstatement will be sent which requires the benefit recipient tosubmit monthly payments. Premium payment is requiredthrough the month of cancellation or death.

Nonpayment of PremiumIf payment is not received by the final due date, coverage willbe terminated effective the last day of the current month.Failure to pay the bill may result in a loss of coverage and/orwithholding through the TRS annuity check.

Please be advised that benefit recipients and theirdependents who are terminated for nonpayment of premiumwill not be eligible to re-enroll in TRIP, or be covered underanother member, nor are they eligible for continuation ofcoverage through COBRA.

COBRA ParticipantsWhile a plan participant is on COBRA, a monthly bill isgenerated by TRS for the premium amount due. Bills aremailed the first week of each month and must be paid by thedue date to ensure continuation of coverage. Planparticipants who do not receive a bill should contact TRS forassistance. Failure to submit payment will result intermination of coverage retroactive to midnight the last day ofthe month for which full payment was received.

Premium RefundsPremium refunds based on corrections to a benefit recipient’sinsurance elections may be processed retroactively up to sixmonths. Benefit recipients who fail to notify TRS within 60days of a dependent’s ineligibility will not receive a premiumrefund.

Premium UnderpaymentsUnderpaid premiums are the responsibility of the annuitantor survivor and must be paid in full, regardless of the timeperiod for which the underpayment occurred.

Premium Payment

Penalty for FraudFalsifying information/documentation or failing to provide information/documentation in order to obtain/continue coverageunder TRIP is considered a fraudulent act. The State of Illinois will impose a financial penalty, including, but not limited to,repayment of all premiums the State made on behalf of the benefit recipient and/or the dependent beneficiary, as well asexpenses incurred by TRIP.


The coverage of a benefit recipient and any dependents willterminate upon the request of the benefit recipient, thebenefit ceasing, the benefit recipient’s death or upon thecoverage being terminated for nonpayment of premium.When a dependent experiences an event which terminatestheir coverage, such as a benefit recipient’s death, thedependent’s health coverage, in most cases, can be continuedunder the Consolidated Omnibus Budget Reconciliation Act(COBRA). See the 'COBRA Coverage' section for moreinformation.

Termination of the BenefitRecipient’s CoverageA benefit recipient’s coverage terminates at midnight:

F On the date of benefit recipient’s death.

F On the last day of the month for which payment is notreceived following the issuance of a final notice ofpremium due from TRS (member and all dependents willbe ineligible for COBRA).

F On the last day of the month in which the benefitrecipient’s annuity benefit ceases.

F On the last day of the month in which the benefitrecipient requested the termination of coverage.

Termination of DependentBeneficiary’s CoverageAn enrolled dependent’s coverage terminates at midnight:

F Simultaneous with termination of the benefit recipient’scoverage.

F On the last day of the month in which the benefitrecipient requested termination of the dependent'scoverage.

F On the last day of the month in which a dependent loseseligibility.

F On the last day of the month following receipt of thewritten request to terminate dependent coverage. Re-enrollment opportunities are limited – see theenrollment section for details (these dependents will beineligible for COBRA).

F On the date of dependent's death.

F On the last day of the month in which the benefitrecipient fails to certify continued eligibility for coverageof the dependent child.

F On the day preceding the dependent's:

– enrollment in TRIP as a benefit recipient.

– divorce or civil union partnership dissolution from thebenefit recipient. The divorce or civil union partnershipdissolution terminates the coverage for the spouse orcivil union partner and all applicable stepchildren orchildren of the civil union partner.

NOTE: Benefit recipients who fail to notify TRS within 60 daysof the dependent’s ineligibility will not receive a premiumrefund, nor will the dependent be eligible for COBRA.

Termination


OverviewThe Consolidated Omnibus Budget Reconciliation Act of 1985(COBRA) and Sections 367.2, 367e and 367e.1 of the IllinoisInsurance Code provides eligible covered benefit recipientsand their eligible dependents the opportunity to temporarilyextend their health coverage when coverage under the healthplan would otherwise end due to certain qualifying events.COBRA rights are restricted to certain conditions under whichcoverage is lost. The election to continue coverage must bemade within a specified election period. If elected, coveragewill be reinstated retroactive to the date following terminationof coverage.

An initial notice is provided to all new members uponenrollment in TRIP. This notice is to acquaint individualswith COBRA law, notification obligations and possiblerights to COBRA coverage if loss of group health coverageshould occur. If an initial notice is not received, benefitrecipients should contact TRS.

EligibilityCovered benefit recipients and dependents who lose coveragedue to certain qualifying events (see the ‘COBRA QualifyingEvents’ chart at the end of this section) are considered qualifiedbeneficiaries and may be allowed to continue coverage under theprovisions of COBRA. A qualified beneficiary is an individual(including the member, spouse, civil union partner or child) wholoses employer-provided group health coverage and is entitled toelect COBRA coverage. The individual must have been covered bythe plan on the day before the qualifying event occurred andenrolled in COBRA effective the first day of eligibility or be anewborn or newly adopted child of the covered member. Anyvoluntary termination of coverage will render the benefitrecipients and any dependents ineligible for COBRA coverage.

Coverage available under COBRA for qualified beneficiaries isidentical to the health insurance coverage provided to TRIPmembers.

Covered dependents retain COBRA eligibility rights even ifthe benefit recipient chooses not to enroll. Qualifiedbeneficiaries electing continuation of coverage under COBRAwill be enrolled as a member. NOTE: If the benefitrecipient’s spouse, civil union partner or dependentchild(ren) live at another address, TRS must be advisedimmediately so that notification can be sent to the properaddress(es).

Notification of COBRA EligibilityThe benefit recipient or qualified beneficiary must notify TRSwithin 60 days of the date of the termination event, or the dateon which coverage would end, whichever is earlier. Failure tonotify TRS within 60 days will result in disqualification of COBRAcontinuation coverage.

TRS will send a letter to the qualified beneficiary regardingCOBRA rights within 14 days of receiving notification of thetermination. Included with the letter will be an enrollmentform, premium payment information and important deadlines.If a letter is not received within 30 days and you notified TRSwithin the 60-day period, you should contact the retirementsystem immediately for information.

COBRA EnrollmentIndividuals have 60 days from the date of the COBRA eligibilityletter to elect enrollment in COBRA and 45 days from the date ofelection to pay all premiums. Failure to complete and return theenrollment form or to submit payment by the due dates willterminate COBRA rights. If the enrollment form and all requiredpayments are received by the due dates, coverage will bereinstated retroactive to the date of the qualifying event.

Medicare or Other GroupCoverage - Impact on COBRAQualified beneficiaries who become eligible for Medicare orobtain other group insurance coverage (which does notimpose preexisting condition limitations or exclusions) afterenrolling in COBRA are required to notify TRS in writing of theirMedicare eligibility or other group coverage. These individualsare ineligible to continue COBRA coverage and will beterminated from the COBRA program.

TRS reserves the right to retroactively terminate COBRAcoverage if an individual is deemed ineligible. Premiumswill not be refunded for coverage terminated retroactivelydue to ineligibility.

COBRA ExtensionsF Disability ExtensionQualified beneficiaries covered under COBRA who havebeen determined to be disabled by the Social SecurityAdministration (SSA) may be eligible to extend coverage

COBRA Coverage


from 18 months to 29 months at an increased cost.Enrolled nondisabled family members are also eligible forthe extension. See ‘Premium Payment under COBRA’ laterin this section for premium information.

To be eligible for the extension, the qualified beneficiarymust either (1) become disabled during the first 60 daysof COBRA continuation coverage or (2) be determineddisabled prior to the date of COBRA eligibility. In eithercase, the determination must have been made by theSocial Security Administration (SSA) and a copy of the SSAdetermination letter must be submitted to TRS within 60days of the date of the SSA determination letter or the firstday of COBRA coverage, whichever is later.

The affected qualified beneficiary must also notify TRS ofany SSA final determination of loss of disability status. Thisnotification must be provided within 30 days of the SSAdetermination letter.

F Second Qualifying Event ExtensionIf a member who experienced a qualifying event thatresulted in an 18-month maximum continuation periodexperiences a second qualifying event before the end ofthe original 18-month COBRA coverage period, thespouse, civil union partner and/or dependent child (mustbe a qualified beneficiary) may extend coverage anadditional 18 months for a maximum of 36 months.

Waiver of COBRA Rights andRevocation of that WaiverA qualified beneficiary may waive rights to COBRA coverageduring the 60-day election period and can revoke the waiver atany time before the end of the 60-day period. Coverage willbe retroactive to the qualifying event.

Premium Payment under COBRAThe qualified beneficiary has 45 days from the date coverage iselected to pay all premiums. Individuals electing COBRA areconsidered members and will be charged the member rate. Adivorced or widowed spouse (including a former civil unionpartner) who has a dependent child on their coverage would beconsidered the member and charged the member rate, with thechild being charged the applicable dependent rate. If only adependent child elects COBRA, then each child would beconsidered a member and charged the member rate.

Once the COBRA enrollment form is received and thepremium is paid, coverage will be reinstated retroactive to thedate coverage was terminated. Monthly billing statementswill be mailed to the member’s address on file on or aboutthe 5th of each month. Bills for the current month are due bythe 25th of the same month. Final notice bills (those with abalance from a previous month) are due by the 20th of thesame month. Failure to pay the premium by the final duedate will result in termination of coverage retroactive to thelast day of the month in which premiums were paid.

It is the member’s responsibility to promptly notify TRS inwriting of any address change or billing problem.

The Teachers’ Retirement Insurance Program does notcontribute to the premium for COBRA coverage. Most COBRAmembers must pay the applicable premium plus a 2%administrative fee for participation. COBRAmembers whoextend coverage for 29 months due to SSA’s determination ofdisability must pay the applicable premium plus a 50%administrative fee for all months covered beyond the initial18 months.

COBRA Coverage (cont.)


Adding Dependents - SecondQualifying Event LimitationsNewly-acquired dependents, including spouses, civil unionpartners, children of civil union partners and stepchildren,may be added to existing COBRA coverage. Even thoughthese dependents are eligible for COBRA coverage, unlessthey are a newborn child or a newly adopted child, they arenot considered “qualified beneficiaries” and therefore wouldbe ineligible for an extension if a second qualifying eventwould occur.

Existing dependents who are not enrolled on the first day thebenefit recipient becomes eligible for COBRA continuationcoverage are not considered qualified beneficiaries. Thesedependents may only be added during the annual BenefitChoice Period (if they have never previously been enrolled inTRIP) and are also not eligible for second qualifying eventextensions.

Documentation requirements must be met to add dependents.See the ‘Documentation Requirements – Adding DependentCoverage’ chart in this chapter for details.

Termination of Coverage underCOBRACOBRA coverage terminates when the earliest of thefollowing occurs:

F Maximum continuation period ends.

F Failure to make timely payment of premium.

F Covered member or dependent becomes a participant inanother group health plan which does not impose apreexisting condition exclusion or limitation (for example,through employment or marriage).

F Covered member or dependent becomes entitled toMedicare. Special rules apply for End-Stage RenalDisease. Contact TRS for more information.

F Covered member or dependent reaches the qualifyingage for Medicare.

F Covered dependent gets divorced from COBRA member(includes when the COBRA member's civil unionpartnership with the covered dependent is dissolved).

F Covered dependent child loses eligibility.

F Upon the member’s death for any dependent notconsidered a qualified beneficiary.

Refer to the ‘COBRA Qualifying Events’ chart in this chapter formore information.

Conversion Privilege for HealthCoverageWhen COBRA coverage terminates, members may have theright to convert to an individual health plan. Members areeligible for this conversion unless group health coverageended because:

F the required premium was not paid, or

F the coverage was replaced by another group health plan,including Medicare, or

F the COBRA coverage was voluntarily terminated.

Approximately two months before COBRA coverage ends, TRSwill send a letter providing instructions on how to apply forconversion. To be eligible for conversion, members musthave been covered by the current COBRA health plan for atleast 3 months and requested conversion within 31 days ofexhaustion of COBRA coverage. The converted coverage, ifissued, will become effective the day after COBRA coverageended. Contact the appropriate health plan administratorfor information regarding conversion. TRS is not involvedin the administration or premium rate structure ofcoverage obtained through conversion.




Qualifying EventsBENEFIT RECIPIENTBenefit Recipient’s termination of disability benefitsBenefit Recipient’s loss of eligibilityDEPENDENT BENEFICIARYBenefit Recipient’s termination of benefitsLegal separation from Benefit Recipient*Loss of eligibility as a dependent childBenefit Recipient’s death• Spouse under age 55• Spouse age 55 or older if already enrolled in Medicare• Spouse age 55 or older

• Dependent child Dissolution of Marriage or Civil Union Partnership*• Ex-Spouse under age 55• Ex-Spouse age 55 or older if already enrolled in Medicare• Ex-Spouse age 55 or older

• Stepchild or Child of a Civil Union Partner

Maximum Eligibility Period

18 months18 months

18 months36 months36 months

36 months36 months Until obtains Medicare or reaches the qualifying age for Medicare36 months

36 months36 monthsUntil obtains Medicare or reaches the qualifying age for Medicare36 months

COBRA QUALIFYING EVENTSA COBRA qualifying event is any of the events shown below that result in a loss of coverage.

The term 'Spouse' in this chart includes civil union partners; 'Ex-spouse' includes civil union partnerswhose partnership has been dissolved.

* Dropping a spouse’s coverage during the annual Benefit Choice Period in anticipation of a divorce, civil union partnership dissolution orlegal separation will result in the spouse losing coverage effective July 1st. The spouse will be eligible for COBRA only once the divorce,dissolution or legal separation actually occurs. Spouses whose coverage was terminated due to a divorce, dissolution or legal separationmust contact our office within 30 days of the event in order to be offered COBRA coverage.

Falsifying information/documentation or failing to provide information/documentation in order to obtain/continue coverage underCOBRA is considered a fraudulent act. Premiums paid will not be refunded for coverage terminated retroactively due to ineligibility.



* Dropping a spouse’s coverage during the annual Benefit Choice Period in anticipation of a divorce, civil union partnership dissolution orlegal separation will result in the spouse losing coverage effective July 1st. The spouse will be eligible for COBRA only once the divorce,dissolution or legal separation actually occurs. Spouses whose coverage was terminated due to a divorce, dissolution or legal separationmust contact our office within 30 days of the event in order to be offered COBRA coverage.

Qualifying EventsCOBRA MEMBER

SSA Disability determination within the first 60 days of COBRA

COBRA DEPENDENT

Loss of eligibility as a dependent child

Legal separation from COBRA member*COBRA member’s death• Spouse under age 55• Spouse age 55 or older if already enrolled in Medicare

• Spouse age 55 or older

• Dependent child Divorce from/Dissolution of civil union partnership with COBRA member*• Ex-Spouse under age 55• Ex-Spouse age 55 or older if already enrolled in Medicare• Ex-Spouse age 55 or older

• Stepchild or Child of Civil Union Partner

Maximum Eligibility Period

Additional 11 months for a maximum of 29 months

Additional 18 months for amaximum of 36 months


Until obtains Medicare or reaches the qualifying age for Medicare



SECOND QUALIFYING EVENTSThe events shown below will extend coverage for a qualified beneficiary

if it occurs during the original 18-month COBRA period.The term 'Spouse' in this chart includes civil union partners; 'Ex-spouse' includes civil union partners

whose partnership has been dissolved.

Falsifying information/documentation or failing to provide information/documentation in order to obtain/continue coverage under

A qualified beneficiary is an individual (including the member, spouse, civil union partner or child) who loses employer-providedgroup health coverage and is entitled to elect COBRA coverage. The individual must have been covered by the plan on the daybefore the qualifying event occurred and enrolled in COBRA effective the first day of eligibility or be a newborn or newly adoptedchild of the covered member.

Chapter 2Chapter 2: Health Plan Coverage InformationHealth Plan Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Managed Care Health Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Teachers’ Choice Health Plan (TCHP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Medical Benefits Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Prescription Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Behavioral Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Benefits HandbookMyBenefits.illinois.gov 21


OverviewThe Teachers’ Retirement Insurance Program (TRIP) offers avariety of health plans from which to choose. Each planprovides health, behavioral health and prescription drugbenefits; however, the benefit levels, exclusions and limitationsmay differ. When making choices, benefit recipients shouldconsider health status, coverage needs and servicepreferences. Dependents will have the same health plan asthe benefit recipient under whom they are enrolled.The MyBenefits.illinois.gov website provides a listing of thehealth plans available and the Illinois counties in which theyprovide coverage.Benefit recipients who change their health plan outside theBenefit Choice Period, regardless of the basis for thechange, will be responsible for any deductibles required bythe new plan, even if the plan participant met alldeductibles while covered by the previous health plan.

Types of Health PlansThe types of health plans available are:F Managed Care Plans• Health Maintenance Organizations (HMOs)• Open Access Plans (OAPs)

F Teachers’ Choice Health Plan (TCHP)

Disease Management Programsand Wellness OfferingsDisease management programs are utilized by the healthplans as a way to improve the health of plan participants.Plan participants may be contacted by their health plan toparticipate in these programs.Wellness options and preventive measures are offered andencouraged by the health plans. Offerings range from health riskassessments to educational materials and, in some cases,discounts on items such as gym memberships and weight lossprograms. These offerings are available to plan participants andare provided to help plan participants take control of theirpersonal health and well-being. Information about the variousofferings is available on the plan administrators’ websites.

Managed Care Health Plans Managed care is a method of delivering healthcare through asystem of network providers. Managed care plans providecomprehensive health benefits at lower out-of-pocket costs byutilizing network providers. Managed care health planscoordinate all aspects of a plan participant’s healthcareincluding medical, prescription drug and behavioral healthservices.There are two types of managed care plans, health maintenanceorganizations (HMOs) and open access plans (OAPs). Benefitrecipients who enroll in an HMO must select a primary carephysician/provider (PCP) from the health plan’s providerdirectory, which can be found on the plan’s website. Planparticipants should contact the physician’s office or the HMOplan administrator to find out if the PCP is accepting newpatients. Plan participants are required to use participatingphysicians and hospitals for maximum benefits. Benefitrecipients enrolled in an OAP do not need to select a PCP. Forcomplete information on specific plan coverage or providernetworks, contact the managed care health plan and review theSummary Plan Document (SPD).Like any health plan, managed care plans have planlimitations including geographic availability and limitedprovider networks. Managed care coverage is offered incertain counties called service areas. Ordinarily, managed careplans only cover members within the State; however, plansthat have networks outside the State of Illinois may providecoverage. Members should contact the managed care planadministrator to ascertain if coverage is available outside theirgeographic area. Eligible dependents that live apart from thebenefit recipient’s residence for any part of a plan year may besubject to limited service coverage. It is critical that memberswho have an out-of-area dependent (such as a college student)contact the managed care plan to understand the plan’sguidelines on out-of-area coverage.Some managed care health plans are self insured, meaning allclaims are paid by TRIP even though managed care health planbenefits apply. These plans are not regulated by the IllinoisDepartment of Insurance and are not governed by theEmployees Retirement Income Security Act (ERISA).In order to have the most detailed information regarding aparticular managed care health plan, benefit recipients shouldask the plan administrator for its summary plan document(SPD) which describes the covered services, benefit levels, andexclusions and limitations of the plan’s coverage. The SPD mayalso be referred to as a certificate of coverage or a summaryplan document.

Health Plan Options


Benefit recipients should pay particular attention to themanaged care plan’s exclusions and limitations. It isimportant that plan participants understand which servicesare not covered under the plan. Benefit recipients decidingto enroll in a managed care health plan should read theSPD before seeking medical attention. It is the benefitrecipient’s responsibility to become familiar with all of thespecific requirements of the health plan.

Most managed care health plans impose benefit limitations ona plan year basis (July 1 through June 30); however, somemanaged care health plans impose benefit limitations on acalendar year basis (January 1 through December 31). Refer to the MyBenefits.illinois.gov website for planadministrator information.

Health Maintenance Organization (HMO)HMO members must choose a primary care physician/provider (PCP) who will coordinate the healthcare,hospitalizations and referrals for specialty care. In most casesa referral for specialty care will be restricted to those servicesand providers authorized by the designated PCP. Additionally,referrals may also require prior authorization from the HMO.To receive the maximum hospital benefit, your PCP orspecialist must have admitting privileges to a networkhospital. Like any health plan, HMOs have plan limitations includinggeographic availability and participating provider networks.HMO coverage is offered in certain counties called serviceareas. There is no coverage outside these service areasunless preapproved by the HMO. When traveling outside ofthe health plan’s service area, coverage is limited to life-threatening emergency services. For specific informationregarding out-of-area services or emergencies, call the planadministrator. NOTE: When an HMO plan is the secondaryplan and the plan participant does not utilize the HMOnetwork of providers or does not obtain the requiredreferral, the HMO plan is not required to pay for services.Refer to the plan’s description of coverage for additionalinformation.Preventive care is paid at 100 percent when services are obtainedthrough a network provider. HMO provider networks are subject to change. Benefit recipientswill be notified in writing by the plan administrator when a PCPnetwork change occurs. If the designated PCP leaves the HMOnetwork, you must choose another PCP within that plan.When an HMO member’s primary care physician (PCP) leavesthe plan’s network, the member will only be allowed tochange health plans if the HMO network experienced a

significant change in the number of medical providersoffered, as determined by CMS.HMO Out-of-Pocket Maximums After the out-of-pocket maximum has been satisfied, the planwill pay 100 percent of covered expenses for the remainder ofthe plan year for eligible medical, behavioral health andprescription drug charges. Charges that apply toward the out-of-pocket maximum for HMOs are:F Medical and prescription copayments; andF Medical coinsurance.

Open Access Plans (OAPs) Open access plans combine similar benefits of an HMO withthe same type of coverage benefits as a traditional healthplan. Members who elect an OAP will have three tiers ofproviders from which to choose to obtain services. The benefitlevel is determined by the tier in which the healthcareprovider is contracted. Members enrolled in an OAP can mixand match providers and tiers.

F Tier I offers a managed care network which providesenhanced benefits. Tier I benefits require copaymentswhich mirror an HMO plan’s copayments, but do notrequire a plan year deductible.

F Tier II offers another managed care network, in addition tothe managed care network offered in Tier I, and alsoprovides enhanced benefits. Tier II requires copayments,coinsurance and is subject to an annual plan yeardeductible.

F Tier III covers all providers which are not in the managedcare networks of Tiers I or II (i.e., out-of-network providers)and does not have an out-of-pocket maximum. Using TierIII can offer members flexibility in selecting healthcareproviders, but involve higher out-of-pocket costs. Tier III hasa higher plan year deductible and has a higher coinsuranceamount than Tier II services. In addition, certain services,such as preventive/wellness care, are not covered whenobtained under Tier III. Furthermore, plan participants whouse out-of-network providers will be responsible for anyamount that is over and above the charges allowed by theplan for services, which could result in substantial out-of-pocket costs (i.e., allowable charges, Usual and Customarycharges (U&C), Maximum Reimbursable Charges (MRC),Maximum Allowable Charges (MAC)). When using out-of-network providers, it is recommended that the participantobtain preauthorization of benefits to ensure that medicalservices/stays will meet medical necessity criteria and willbe eligible for benefit coverage.

Health Plan Options


Members who use providers in Tiers II and III will beresponsible for the plan year deductible. In accordance withthe Affordable Care Act, these deductibles will accumulateseparately from each other and will not ‘cross accumulate.'This means that amounts paid toward the deductible in onetier will not apply toward the deductible in the other tier.Preventive care is paid at 100 percent without having to meetthe annual deductible when services are obtained through aTier I or Tier II network provider.

OAP Out-of-Pocket Maximums Eligible medical, behavioral health and prescription drugcharges will be covered at 100 percent for the remainder ofthe plan year after the plan’s out-of-pocket maximum hasbeen satisfied. Charges that apply toward the out-of-pocketmaximum for an OAP plan (only applies to Tier I and Tier IIproviders) are:F Annual medical plan year deductible (Tier II)F Medical and prescription copaymentsF Medical coinsurance. Eligible charges from Tiers I and II will be added togetherwhen calculating the out-of-pocket maximum. Tier III doesnot have an out-of-pocket maximum.

For complete information regarding specific plan coverageand the plan administrator’s network, refer to the summaryplan document on the plan administrator’s website.

Teachers’ Choice Health Plan (TCHP) The Teachers’ Choice Health Plan (TCHP) is a self-insured healthplan offering a comprehensive range of benefits. All claims andcosts are paid by the Teachers’ Retirement Insurance Program(TRIP) through a third-party administrator. Benefitenhancements are available by utilizing the:

F Nationwide TCHP physician, hospital, ancillary servicesand transplant network.

F Pharmacy network.F Behavioral health network.Each of these three components is discussed separately in thissection. Each component has its own plan administrator. For complete information regarding specific plan coverageand the plan administrator’s network, refer to the summaryplan document on the plan administrator’s website.

Hospital Bill Audit Program

The Hospital Bill Audit Program applies to TCHP and non-TCHP hospital charges. Under the program, a member ordependent who discovers an error or overcharge on a hospitalbill and obtains a corrected bill is eligible for 50% of theresulting savings. There is no cap on the savings amount.Related nonhospital charges, such as radiologists andsurgeons are not eligible charges under this program. Thisprogram applies only when TCHP is the primary payer.Reimbursement documentation required:

– Original incorrect bill,– Corrected copy of the bill, and– Benefit recipient’s name, telephone number and lastfour digits of the SSN.

Submit Documentation to:

Hospital Bill Audit ProgramCMS Group Insurance Division801 S. 7th StreetP.O. Box 19208Springfield, IL 62794-9208

Health Plan Options


OverviewPlan participants enrolled in any Teachers’ RetirementInsurance Program (TRIP) health plan have prescription drugbenefits included in the coverage. For all health plans,except the Teachers’ Choice Health Plan (TCHP), a prescriptioncopayment applies to each plan participant. Membersenrolled in TCHP are subject to either a 20% coinsuranceamount or a minimum / maximum copayment amount. Theminimum and maximum copayments are published on theMyBenefits.illinois.gov website. If the cost of the prescriptionis less than the plan’s prescription copayment, the planparticipant will pay the cost of the prescription. However, if aplan participant elects a brand name drug and a generic isavailable, the plan participant must pay the cost differencebetween the brand product and the generic product, in additionto the brand copayment. With the exception of the Teachers' Choice Health Plan,prescription copayments paid by participants will apply towardthe out-of-pocket maximum. Once the maximum has been met,eligible medical, behavioral health and prescription drug chargeswill be covered at 100 percent for the remainder of the plan year.The out-of-pocket maximum amount for each type of health planvaries (but does not apply to TCHP) and is outlined on theMyBenefits.illinois.govwebsite. Prior authorizationmay be required for a select group ofmedications. If a prescription is presented for one of thesemedications, the pharmacist will indicate that a priorauthorization is needed before the prescription can be filled.To receive a prior authorization, the prescribing physicianmust provide medical information including a diagnosis tothe prescription drug plan administrator for review. Once aprior authorization is in place, the prescriptions may be filleduntil the authorization expires, usually one year.Plan participants who have additional prescription drugcoverage, including Medicare, should contact theirprescription plan administrator for coordination of benefits(COB) information.

Formulary ListAll prescription medications are compiled on a formulary list (ie.,drug list) maintained by each health plan's prescription benefitmanager (PBM). Formulary lists categorize drugs into levels: Eachlevel requires a different copayment/coinsurance amount.Formulary lists are subject to change any time during the planyear. To compare formulary lists, cost-savings programs and to

obtain a list of network pharmacies that participate in the varioushealth plans, plan participants should visit the website of theirhealth plan or PBM. Certain health plans, or the PBM notify planparticipants by mail when a prescribed medication they arecurrently taking is reclassified into a different formulary category.If a formulary change occurs, plan participants should consult withtheir physician to determine if a change in prescription isappropriate.

Health Maintenance Organizations (HMOs)Health maintenance organizations (HMOs) use a separateprescription benefit manager (PBM) to administer theirprescription drug benefits. Benefit recipients who elect one ofthese health plans must utilize a pharmacy participating in theplan’s pharmacy network or the full retail cost of the medicationwill be charged. If a plan participant uses a nonparticipatingpharmacy, partial reimbursement may be provided if the planparticipant files a claim with the health plan. It should be notedthat most plans do not cover over-the-counter drugs or drugsprescribed by medical professionals (including dentists), otherthan the plan participant’s primary care physician (PCP) or anyspecialist the plan participant was referred to by their PCP.

Open Access Managed Care Plansand the Teachers’ Choice HealthPlan (TCHP) Open access managed care plans and the Teachers’ ChoiceHealth Plan (TCHP) have prescription drug benefitsadministered through the self-funded insurance plans’prescription benefit manager (PBM). Prescription drugbenefits are independent of other medical services and are notsubject to the medical plan year deductible. Most drugspurchased with a prescription from a physician or dentist arecovered; however, most over-the-counter drugs are notcovered, even if purchased with a prescription. TCHP Prescription Out-of-Pocket Maximum – The TCHP has anannual prescription drug out-of-pocket maximum that appliesto each plan participant. Once this out-of-pocket maximumhas been met, prescriptions obtained for the remainder of theplan year will be covered at 100%. Amounts paid forprescription coinsurance and copayments apply toward theprescription out-of-pocket maximum. Prescriptions obtainedat an out-of-network pharmacy do not count toward theprescription annual out-of-pocket maximum, nor does the

Prescription Coverage


Prescription Coverage (cont.)cost difference that a plan participant is charged when theyobtain a brand drug (for any reason) when a generic isavailable. Refer to the MyBenefits.illinois.gov website for theannual out-of-pocket maximum amount.Prescription Drug Step Therapy (PDST) is required formembers who have their prescription drug benefitsadministered through TCHP or one of the open accessmanaged care plans. PDST requires the member to first try oneor more specified drugs to treat a particular condition beforethe plan will cover another (usually more expensive) drug thattheir doctor may have prescribed. PDST is intended to reducecosts to both the member and the plan by encouraging the useof medications that are less expensive but can still treat themember’s condition effectively. Members taking a brand medication that requires PDST,which has not received prior authorization approval, willreceive a rejection at a retail or mail order pharmacy as theplan requires a generic in that drug class be tried first. Ifthe physician believes the original brand medication isneeded, he/she may request a review to override the steptherapy requirement.

Compound drugs are covered under the prescription drugplan. If the compound drug contains an ingredient not coveredby the plan, the entire compound drug will be denied.Injectable and intravenous medicationsmay be obtainedthrough a retail network pharmacy or through the prescriptiondrug plan administrator’s mail order pharmacy.If a network pharmacy does not stock a particular drug orsupply and is unable to obtain it, call the prescription drugplan administrator for further direction.Prepackaged prescriptions – A copayment is based on a 1 to30-day supply as prescribed by the physician. Sincemanufacturers sometimes prepackage products in amountsthat may be more or less than a 30-day supply as prescribed,more than one copayment may be required.Prescribed medical supplies are supplies necessary for theadministration of prescription drugs such as coveredhypodermic needles and syringes. Copayments/Coinsurancemay apply.Diabetic supplies and insulin that are purchased with aprescription are covered through the plan and are subject tothe appropriate copayment/coinsurance. Some diabetic supplies are also covered under Medicare PartB. If the plan participant is not Medicare Part B primary, the

appropriate copayment must be paid at the time of purchaseat a network pharmacy. If Medicare Part B is primary, the planparticipant is responsible for the Medicare coinsurance at thetime of purchase. The claim must first be submitted toMedicare for reimbursement. Upon receipt of the MedicareSummary Notice (MSN), a claim may be filed with theprescription drug plan administrator for any secondary benefitdue. If the diabetic supplies are billed by a physician ormedical supplier, the supplies would be paid by the healthplan administrator. Insulin pumps and their related supplies are not covered underthe prescription drug plan. In order to receive coverage for theseitems, contact the health plan administrator listed on theMyBenefits.illinois.govwebsite.

Mail Order PrescriptionsThe mail order pharmacy option provides participants theopportunity to receive medications directly from the PBM.Both maintenance and nonmaintenance medications may beobtained through the mail order process. When planparticipants use the mail order pharmacy for maintenancemedications they will receive a 90-day supply of medication(equivalent to 3 fills) for only two copayments. To utilize themail order pharmacy, plan participants must submit anoriginal prescription from the attending physician. Formaintenance medication, the prescription should be writtenfor a 90-day supply and include up to three 90-day refillstotaling one year of medication. The original prescriptionmust be attached to a completed Mail Order form and sent tothe address indicated on the form. Order forms can beobtained by contacting the PBM or by accessing theMyBenefits.illinois.gov website.

Coordination of BenefitsTRIP coordinates with Medicare and other group plans. Theappropriate copayment will be applied for each prescriptionfilled.

Exclusions and LimitationsTRIP reserves the right to exclude or limit coverage of specificprescription drugs or supplies.


OverviewBehavioral health services are for the diagnosis and treatment ofmental health and/or substance abuse disorders. Eligiblecharges are for those covered services deemed medicallynecessary by the plan administrator. The coverage ofbehavioral health services (mental health and substanceabuse) complies with the federal Mental Health Parity andAddiction Equity Act of 2008. This federal law requires healthplans to cover behavioral health services at benefit levelsequal to those of the plan’s medical benefits. Coverage for behavioral health services is provided under allof the TRIP health plans. There are no restrictions regardingthe number of visits and hospital days allowed per plan year.The charges for behavioral health services are included in a planparticipant’s annual plan deductible if applicable and annualout-of-pocket maximum. Covered services for behavioralhealth must still meet the plan administrator’s medicalnecessity criteria and will be paid in accordance with themanaged care benefit schedule. Please contact the healthplan for specific benefit information.

Teachers’ Choice Health Plan (TCHP)Covered services for behavioral health which meet the planadministrator’s medical necessity criteria are paid inaccordance with the Teachers’ Choice Health Plan (TCHP)benefit schedule for in-network and out-of-network providers.Please contact the behavioral health plan administrator forspecific benefit information and for a listing of in-networkhospital facilities and participating providers. Authorization Requirements for Behavioral Health Services

Behavioral HealthIn an emergency or a life-threatening situation, call 911, or goto the nearest hospital emergency room. Plan participantsmust call the behavioral health plan administrator within 48hours to avoid a financial penalty. Authorization requirementsstill apply when plan participants have other coverage.F Inpatient services must be authorized prior to admission orwithin 48 hours of an emergency admission to receive in-network or out-of-network benefits. Authorization isrequired with each new admission. Failure to notify thebehavioral health plan administrator of an admission to an

inpatient facility within 48 hours could result in a financialpenalty and risk incurring noncovered charges.

F Partial hospitalization and intensive outpatient treatmentmust be authorized prior to admission to receive in-network or out-of-network benefits. Authorization isrequired before beginning each treatment program.Failure to notify the behavioral health plan administratorof a partial hospitalization or intensive outpatient programcould result in a financial penalty and risk incurringnoncovered charges.

F Outpatient services received at the in-network benefit levelmust be provided by a TCHP network provider. Mostroutine outpatient services (such as therapy sessions andmedication management) will be covered without theneed for prior authorization. Authorization requirementsfor certain specialty outpatient services are noted below.Outpatient services that are not consistent with usualtreatment practice for a plan participant’s condition will besubject to a medical necessity review. The behavioralhealth administrator will contact the plan participant’sprovider to discuss the treatment if a review will beapplied. Outpatient services received at the out-of-networkbenefit level must be provided by a licensed professionalincluding licensed clinical social worker (LCSW), registerednurse, clinical nurse specialist (RN CNS), licensed clinicalprofessional counselor (LCPC), licensed marriage andfamily therapist (LMFT), psychologist or psychiatrist to beeligible for coverage.

F Electroconvulsive therapy, psychological testing and appliedbehavioral analysis must be authorized to receive in-networkor out-of-network benefits. Failure to obtain authorizationwill result in the risk of incurring noncovered charges.

F Residential services must be authorized prior toadmission to receive in-network or out-of-networkbenefits. Authorization is required with each newresidential admission. Failure to notify the behavioralhealth plan administrator of an admission to a residentialfacility could result in a financial penalty and riskincurring noncovered charges.

ExclusionsWilderness programs and/or therapeutic boarding schoolsthat are not licensed as residential treatment centers.

Behavioral Health


Chapter 3Chapter 3: MiscellaneousCoordination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Subrogation and Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Claim Filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Claim Appeal Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37


If a plan participant enrolled in the Teachers’ RetirementInsurance Program (TRIP) is entitled to primary benefits underanother group plan, the amount of benefits payable under TRIPmay be reduced. The reduction may be to the extent that thetotal payment provided by all plans does not exceed the totalallowable expense incurred for the service. Allowable expenseis defined as a medically necessary service for which part of thecost is eligible for payment by this plan or another plan(s). Under coordination of benefits (COB) rules, TRIP’s plan firstcalculates what the benefit would have been for the claim ifthere was no other plan involved. The TRIP plan then considersthe amount paid by the primary plan and pays the claim up to100% of the allowable expense. NOTE: When a managed care health plan is thesecondary plan and the plan participant does not utilize themanaged care health plan’s network of providers or doesnot obtain the required referrals, the managed care healthplan is not required to pay. Refer to the managed careplan’s summary plan document for additionalinformation.

TRIP coordinates benefits with the following:F Any group insurance plan. F Medicare.F Any Veterans’ Administration (VA) plan.F Any “no-fault” motor vehicle plan. This term means a

motor vehicle plan which is required by law and providesmedical or dental care payments which are made, in wholeor in part, without regard to fault. A person who has notcomplied with the law will be deemed to have received thebenefits required by the law.

TRIP does not coordinate benefits with the following:F Private individual insurance plans.F Any student insurance policy (elementary, high school

and college).F Medicaid or any other State-sponsored health insurance

program.F TRICARE. It is the member’s responsibility to provide other insuranceinformation (including Medicare) to the Department'sMedicare COB Unit. Any changes to other insurancecoverage must be reported promptly to the Department'sMedicare COB Unit (contact information located in theMedicare section).

Order of Benefit DeterminationTRIP’s medical plans follow the National Association ofInsurance Commissioners (NAIC) model regulations. Theseregulations dictate the order of benefit determination, exceptfor members who are eligible for Medicare due to End-StageRenal Disease (ESRD). Refer to the ‘Medicare’ section fordetails regarding coordination of benefits for plan participantseligible for Medicare. The rules below are applied insequence. If the first rule does not apply, the sequence isfollowed until the appropriate rule that applies is found.Special rules apply for adult children and children of civilunion partners. Contact the Department's MedicareCoordination of Benefits Unit at 800-442-1300 or 217-782-7007 for more information.MemberThe plan that covers the plan participant as an active memberis primary:1. Over the plan that covers the plan participant as adependent.

2. Over the plan that covers the plan participant as aretiree.

3. Over the plan that covers the plan participant underCOBRA.

4. If it has been in effect the longest, back to the originaleffective date under the employer group, whether or notthe insurance company has changed over the course ofcoverage.

Dependent Children of Parents Not Separated or DivorcedThe following “Birthday Rule” is used if a child is covered bymore than one group plan. The plans must pay in thefollowing order:1. The plan covering the parent whose birthday* falls earlierin the calendar year is the primary plan.

2. If both parents have the same birthday, the plan that hasprovided coverage longer is the primary plan.

* Birthday refers only to the month and day in a calendar year,not the year in which the person was born.

NOTE: Some plans not covered by state law may follow theGender Rule for dependent children. This rule states thatthe father’s coverage is the primary carrier. In the event of adisagreement between two plans, the Gender Rule applies.

Coordination of Benefits


Dependent Children of Separated or DivorcedParentsIf a child is covered by more than one group plan and theparents are separated or divorced, the plans must pay in thefollowing order:1. The plan of the parent with custody of the child; 2. The plan of the spouse of the parent with custody of thechild;

3. The plan of the parent not having custody of the child.NOTE: If the terms of a court order state that one parent isresponsible for the healthcare expenses of the child and thehealth plan has been advised of the responsibility, that plan isprimary payer over the plan of the other parent.

Dependent Children of Parents with Joint CustodyThe Birthday Rule applies to dependent children of parentswith joint custody.

Coordination of Benefits (cont.)


OverviewMedicare is a federal health insurance program for individualsage 65 and older, individuals under age 65 with certaindisabilities and individuals of any age with End-Stage RenalDisease (ESRD).

The Social Security Administration (SSA) or the RailroadRetirement Board (RRB)** determines Medicare eligibility uponapplication and enrolls eligible plan participants into theMedicare Program. The Medicare Program is administered bythe Centers for Medicare and Medicaid Services (also known asthe federal CMS).

Medicare has the following parts:F Part A is insurance that helps pay for inpatient hospital

facility charges, skilled nursing facility charges, hospicecare and some home healthcare services. Medicare Part Adoes not require a monthly premium contribution fromplan participants with enough earned work credits. Planparticipants without enough earned work credits have theoption to enroll in Medicare Part A and pay a monthlypremium contribution.

F Part B is insurance that helps pay for outpatient servicesincluding physician office visits, labs, x-rays and somemedical supplies. Medicare Part B requires a monthlypremium contribution.

F Part C (also known as Medicare Advantage) is insurance thathelps pay for a combination of the coverage provided inMedicare Parts A, B and sometimes D. An individual mustalready be enrolled in Medicare Parts A and B in order toenroll in a Medicare Part C plan. Medicare Part C requires amonthly premium contribution.

F Part D is insurance that helps pay for prescription drugs.Generally, Medicare Part D requires a monthly premiumcontribution.

Medicare Due to AgePlan Participants Age 65 and olderTRIP requires all plan participants to contact the SSA andapply for Medicare benefits three months prior to turningage 65.

Medicare Part AEligibility for premium-free Medicare Part A occurs when anindividual is age 65 or older and has earned at least 40 workcredits from paying into Medicare through Social Security. Anindividual who is not eligible for premium-free Medicare PartA benefits based on his/her own work credits may qualify forpremium-free Medicare Part A benefits based on the workhistory of a current, former or deceased spouse. All planparticipants that are determined to be ineligible for MedicarePart A based on their own work history are required to applyfor premium-free Medicare Part A on the basis of a spouse(when applicable).

If the SSA determines that a plan participant is eligible forpremium-free Medicare Part A, TRIP requires that the planparticipant accept the Medicare Part A coverage and submita copy of the Medicare identification card to the Department'sMedicare COB Unit upon receipt.

If the SSA determines that a plan participant is not eligiblefor Medicare Part A benefits at a premium-free rate, TRIP doesnot require the plan participant to purchase Medicare Part Acoverage; however, TRIP does require the plan participant toprovide a written statement from the SSA advising of his/herMedicare Part A ineligibility. The plan participant is requiredto submit a copy of the SSA statement to the Department'sMedicare COB Unit upon receipt.

Medicare Part B Most plan participants are eligible for Medicare Part B uponturning the age of 65.

Medicare

In order to apply for Medicare benefits, plan participants should contact the local Social SecurityAdministration (SSA) office or call the SSA at 800-772-1213. Plan participants may enroll in Medicareon the SSA website at ssa.gov/Medicare.

** Railroad Retirement Board (RRB) participants should contact their local RRB office or callthe RRB at 877-772-5772 to apply for Medicare.


TRIP does not require plan participants to enroll in MedicarePart B; however, plan participants must have Medicare astheir primary insurance (i.e., be enrolled in both Medicare Aand B) in order to receive the lower monthly TRIP premium.Participants must contact the SSA in order to enroll inMedicare Part B benefits.

Medicare Due to DisabilityPlan Participants Age 64 and UnderPlan participants are automatically eligible for Medicare(Parts A and B) disability insurance after receiving SocialSecurity disability payments for a period of 24 months.

Medicare Part A

Plan participants who become eligible for Medicare disabilitybenefits are required to accept the Medicare Part A coverageand submit a copy of the Medicare identification card to theDepartment's Medicare COB Unit upon receipt.

Medicare Part B

TRIP does not require plan participants to enroll inMedicare Part B; however, plan participants must haveMedicare as their primary insurance (i.e., be enrolled in bothMedicare A and B) in order to receive the lower monthly TRIPpremium. Participants must contact the SSA in order to enrollin Medicare Part B benefits.

Medicare Due to End-Stage RenalDisease (ESRD)All TRIP plan participants who are receiving regulardialysis treatments or who have had a kidney transplanton the basis of ESRD are required to apply for Medicarebenefits.

Plan participants eligible for Medicare on the basis of ESRD,must contact the Department's Medicare Coordination ofBenefits (COB) Unit at 800-442-1300. The Department'sMedicare COB Unit calculates the 30-month coordinationperiod in order for plan participants to sign up for Medicarebenefits on time to avoid additional out-of-pocketexpenditures.

Medicare Part A

Plan participants who become eligible for Medicare benefitson the basis of ESRD are required to accept the Medicare PartA coverage and submit a copy of the Medicare identificationcard to the Department's Medicare COB upon receipt.

Medicare Part B

TRIP does not require plan participants to enroll in MedicarePart B; however, plan participants must have Medicare astheir primary insurance (i.e., be enrolled in both Medicare Aand B) in order to receive the lower monthly TRIP premium.Participants must contact the SSA in order to enroll inMedicare Part B benefits.

Medicare Coordination with theTeachers’ Choice Health Plan (TCHP)When Medicare is the primary payer, TCHP will coordinatebenefits with Medicare as follows:

Medicare Part A - Hospital Insurance

In-Network Provider: After Medicare Part A pays, TCHP pays80% of the Medicare Part A deductible after the TCHP annualplan deductible has been met.

Out-of-Network Provider: After Medicare Part A pays, TCHPpays 60% of the Medicare Part A deductible after the TCHPannual plan deductible has been met.

Medicare Part B - Medical Insurance

In-Network Provider: After Medicare Part B pays, TCHP pays80% of the balance after the TCHP annual plan deductible hasbeen met.

Out-of-Network Provider: After Medicare Part B pays, TCHPpays 60% of the balance after the TCHP annual plandeductible has been met.

Services and Supplies Not Coveredby MedicareServices and supplies that are not covered by Medicare will bepaid in the same manner (i.e., same benefit levels and

Medicare (cont.)


deductibles) as if the plan participant did not have Medicare(provided the services and supplies meet medical necessityand benefit criteria and would normally be eligible forcoverage).

Medicare Crossover -TCHP MembersMedicare Crossover is an electronic transmittal of claim datafrom Medicare (after Medicare has processed their portion ofthe claim) to the TCHP plan administrator for secondarybenefit determination.

In order to set up Medicare Crossover, plan participants mustcontact the TCHP plan administrator and provide the MedicareHealth Insurance Claim Number (HICN) located on the frontside of the Medicare identification card.

Private Contracts with Providerswho Opt Out of MedicareSome healthcare providers choose to opt out of the Medicareprogram. When a plan participant has medical servicesrendered by a provider who has opted out of the Medicareprogram and the plan participant is enrolled in Medicare Part B,a private contract is usually signed explaining that the planparticipant is responsible for the cost of the medical servicesrendered. Neither providers nor plan participants are allowed tobill Medicare. Therefore, Medicare will not pay for the service(even if it would normally qualify as being Medicare eligible) orprovide a Medicare Summary Notice to the plan participant. Ifthe service(s) would have normally been covered by Medicare,the plan administrator will estimate the portion of the claim thatMedicare Part B would have paid. The plan administrator willthen subtract that amount from the total charge and adjudicatethe claim for an eligible secondary reimbursement amount isthe member's responsibility.

Medicare (cont.)

For More InformationContact the State of Illinois Medicare Coordination of Benefits (COB) Unit at 800-442-1300 or 217-782-7007.


Subrogation and Reimbursement OverviewDepartment plans will not pay for expenses incurred forinjuries received as the result of an accident or incident forwhich a third party is liable. These plans also do not providebenefits to the extent that there is other coverage undernongroup medical payments (including automobile liability)or medical expense type coverage to the extent of thatcoverage. However, the plans will provide benefits otherwise payableunder one of these plans, to or on behalf of its coveredpersons, but only on the following terms and conditions:F In the event of any payment under one of these plans, the

plan shall be subrogated to all of the covered person’s rightsof recovery against any person or entity. The coveredperson shall execute and deliver instruments anddocuments and do whatever else is necessary to securesuch rights. The covered person shall do nothing after lossto prejudice such rights. The covered person shallcooperate with the plan and/or any representatives of theplan in completing such documents and in providing suchinformation relating to any accident as the plan by itsrepresentatives may deem necessary to fully investigatethe incident. The plan reserves the right to withhold ordelay payment of any benefits otherwise payable until allexecuted documents required by this provision have beenreceived from the covered person.

F The plan is also granted a right of reimbursement fromthe proceeds of any settlement, judgment or otherpayment obtained by or on behalf of the covered person.This right of reimbursement is cumulative with and notexclusive of the subrogation right granted in the precedingparagraph, but only to the extent of the benefits paid bythe plan.

F The plan, by payment of any proceeds to a coveredperson, is thereby granted a lien on the proceeds of anysettlement, judgment or other payment intended for,payable to or received by or on behalf of the coveredperson or a representative. The covered person inconsideration for such payment of proceeds, consents tosaid lien and shall take whatever steps are necessary tohelp the plan secure said lien.

F The subrogation and reimbursement rights and liensapply to any recoveries made by or on behalf of thecovered person as a result of the injuries sustained,including but not limited to the following:

• Payments made directly by a third party tortfeasoror any insurance company on behalf of a thirdparty tortfeasor or any other payments on behalf ofa third party tortfeasor.

• Any payments or settlements or judgments orarbitration awards paid by any insurance companyunder an uninsured or underinsured motoristcoverage, whether on behalf of a covered personor other person.

• Any other payments from any source designed orintended to compensate a covered person forinjuries sustained as the result of negligence oralleged negligence of a third party.

• Any Workers’ Compensation award or settlement.F The parents of any minor covered person understand and

agree that the State’s plan does not pay for expensesincurred for injuries received as a result of an accident orincident for which a third party is liable. Any benefits paidon behalf of a minor covered person are conditional uponthe plan’s express right of reimbursement. No adultcovered person hereunder may assign any rights that suchperson may have to recover medical expenses from anytortfeasor or other person or entity to any minor child orchildren of the adult covered person without the expressprior written consent of the plan. In the event any minorcovered child is injured as a result of the acts or omissionsof any third party, the adult covered persons/parentsagree to promptly notify the plan of the existence of anyclaim on behalf of the minor child against the third partytortfeasor responsible for the injuries. Further, the adultcovered persons/parents agree, prior to thecommencement of any claim against the third partytortfeasors responsible for the injuries to the minor child,to either assign any right to collect medical expenses fromany tortfeasor or other person or entity to the plan, or attheir election, to prosecute a claim for medical expenseson behalf of the plan.


Subrogation and Reimbursement (cont.)In default of any obligation hereunder by the adult coveredpersons/parents, the plan is entitled to recover the conditionalbenefits advanced plus costs (including reasonable attorneys’fees), from the adult covered persons/parents.F No covered person shall make any settlement which

specifically excludes or attempts to exclude the benefitspaid by the plan.

F The plan’s right of recovery shall be a prior lien againstany proceeds recovered by a covered person, which rightshall not be defeated nor reduced by the application of anyso-called “Made-Whole Doctrine,” “Rimes Doctrine” or anyother such doctrine purporting to defeat the plan’srecovery rights by allocating the proceeds exclusively tononmedical expense damages.

F No covered person under the plan shall incur anyexpenses on behalf of the plan in pursuit of the plan’srights to subrogation or reimbursement, specifically, nocourt costs nor attorneys’ fees may be deducted from theplan’s recovery without the prior express written consentof the plan. This right shall not be defeated by any so-called “Fund Doctrine,” “Common Fund Doctrine” or“Attorney’s Fund Doctrine.”

F The plan shall recover the full amount of benefits paidhereunder without regard to any claim of fault on the partof any covered person, whether under comparativenegligence or otherwise.

F The benefits under this plan are secondary to anycoverage under no-fault, medical payments or similarinsurance.

F This subrogation and reimbursement provision shall begoverned by the laws of the State of Illinois.

F In the event that a covered person shall fail or refuse tohonor its obligations hereunder, the plan shall have aright to suspend the covered person’s eligibility and beentitled to offset the reimbursement obligation againstany entitlement for future medical benefits, regardless ofhow those medical benefits are incurred. The suspensionand offset shall continue until such time as the coveredperson has fully complied with his obligations hereunder.


In general, most medical and behavioral health providers fileclaims for reimbursement with the insurance carrier. Insituations where a claim is not filed by the provider, themember must file the claim within a specific period of time. All claims should be filed promptly. Claim forms areavailable on the plan administrators’ website and on theMyBenefits.illinois.gov website. F In-network TCHPmedical and behavioral health claims

must be filed within 90 days from the date in which thecharge was incurred.

F Out-of-network TCHPmedical and behavioral healthclaims must be filed within 180 days from the date inwhich the charge was incurred.

F Out-of-network pharmacy claims for the open accessplans (OAPs) and TCHPmust be filed no later than one-year from the ending date of the plan year in which thecharge was incurred.

Filing deadlines for managed care plans, including behavioralhealth services offered under the managed care plan, may bedifferent. Contact the managed care plan directly fordeadlines and procedures.

Claim Filing ProceduresAll communication to the plan administrators must include thebenefit recipient's social security number (SSN) andappropriate group number as listed on the identification card.This information must be included on every page ofcorrespondence.F Complete the claim form obtained from the appropriate

plan administrator.F Attach the itemized bill from the provider of services to

the claim form. The itemized bill must include name ofpatient, date of service, diagnosis, procedure code and theprovider’s name, address and telephone number.

F If the person for whom the claim is being submitted hasprimary coverage under another group plan or Medicare,the explanation of benefits (EOB) or Medicare SummaryNotice (MSN) from the other plan must also be attached tothe claim.

F The plan administrator may communicate directly withthe plan participant or the provider of services regardingany additional information that may be needed to process aclaim.

F The benefit check will be sent and made payable to themember (not to any dependents), unless otherwiseindicated by law, or benefits have been assigned directlyto the provider of service.

F If benefits are assigned, the benefit check will be madepayable to the provider of service and mailed directly tothe provider. An EOB is sent to the plan participant toverify the benefit determination.

F TCHP claims are adjudicated using industry standardclaim processing software and criteria. Claims arereviewed for possible bundling and unbundling of servicesand charges.

Claim Filing


Under the Teachers’ Retirement Insurance Program there areformal procedures to follow in order to file an appeal of anadverse benefit determination. The appropriate planadministrator will provide more information regarding theplan administrator’s internal appeal process.

Categories of AppealThere are two separate categories of appeals: medical andadministrative. The plan administrator determines thecategory of appeal and will send the plan participant writtennotification regarding the category of appeal, the planparticipant’s appeal rights and information regarding how toinitiate an appeal from the plan administrator.F Medical Appeals. Medical appeals pertain to benefit

determinations involving medical judgment, includingclaim denials determined by the plan administrator to bebased on lack of medical necessity, appropriateness,healthcare setting, level of care or effectiveness; denialspursuant to Section 6.4 of the State Employees GroupInsurance Act; and denials for services determined by theplan administrator to be experimental or investigational.Medical appeals also pertain to retroactive cancellations ordiscontinuations of coverage, unless the cancellation ordiscontinuation relates to a failure to pay requiredpremiums or contributions.

F Administrative Appeals. Administrative appeals pertainto benefit determinations based on plan design and/orcontractual or legal interpretations of plan terms that donot involve any use of medical judgment.

Teachers’ Choice Health Plan (TCHP)and Open Access Managed CarePlans Appeal ProcessMembers enrolled in either the TCHP or one of the openaccess managed care plans may utilize an internal appealprocess which may be followed by an external review, ifneeded. For urgent care situations, the plan participant maybypass the internal appeal process and request an expeditedexternal review (see “Expedited External Review- MedicalAppeals Only” for urgent care situations in the box).

Expedited External Review - Medical Appeals Only For medical appeals involving urgent care situations, theplan participant may make a written or oral request forexpedited external review after the plan administratormakes an adverse benefit determination, even if the planadministrator’s internal appeal process has not beenexhausted. The external reviewer will review the request todetermine whether it qualifies for expedited review. If theexternal reviewer determines that the request qualifies forexpedited review, the external reviewer will provide a finalexternal review decision within 72 hours after the receipt ofthe request. If the external reviewer decides in favor of theplan participant, the decision shall be final and binding onthe plan administrator.

Step 1: Internal Appeal Process

The internal appeal process is available through the healthplan administrator. The plan administrator’s internal appealprocess must be followed before the plan participant mayseek an external review, except for urgent care situations. Forurgent care situations, the plan participant may request anexpedited external review (see “Expedited External Review-Medical Appeals Only” for urgent care situations).

First-Level Internal Appeals

First-level appeals must be initiated with the planadministrator within 180 days of the date of receipt of theinitial adverse benefit determination. All appeals will bereviewed and decided by an individual(s) who was notinvolved in the initial claim decision. Each case will bereviewed and considered on its own merits. If the appealinvolves a medical judgment, it will be reviewed andconsidered by a qualified healthcare professional. In somecases, additional information, such as test results, may berequired to determine if additional benefits are available.Once all required information has been received by the planadministrator, the plan administrator shall provide a decisionwithin the applicable time frame: 15 days for pre-serviceauthorizations, 30 days for post-service claims, or 72 hours forurgent care claims.

Claim Appeal Process


Step 2: External Review Process

After the completion of the plan administrator’s internalappeal process, the plan participant may request an externalreview of the plan administrator’s final internal benefitdetermination. The process for external review will dependon whether the appeal is an administrative appeal or medicalappeal.

Administrative Appeals

For administrative appeals, if, after exhausting every level ofreview available through the plan administrator, the planparticipant still feels that the final benefit determination bythe plan administrator is not consistent with the publishedbenefit coverage, the plan participant may appeal the planadministrator’s decision to CMS’ Group Insurance Division.For an appeal to be considered by CMS’ Group InsuranceDivision, the plan participant must appeal in writing withinsixty (60) days of the date of receipt of the planadministrator’s final internal adverse benefit determination.All appeals must be accompanied by all documentationsupporting the request for reconsideration.

Submit Administrative Appeal Documentation to:CMS Group Insurance Division801 S. 7th StreetP.O. Box 19208Springfield, IL 62794-9208

The decision of CMS’ Group Insurance Division shall be finaland binding on all parties.

Medical Appeals

External ReviewFor medical appeals, if, after exhausting every level of reviewavailable through the plan administrator, the plan participantstill feels that the final benefit determination is not consistentwith the published benefit coverage, the plan participant mayrequest an independent external review of the planadministrator’s decision. A request for an external reviewmust be filed in writing within four (4) months of the date ofreceipt of the plan administrator’s final internal adversebenefit determination. The plan administrator will providemore information regarding how to file a request for externalreview. The plan participant will be given the opportunity tosubmit additional written comments and supporting medicaldocumentation regarding the claim to the external reviewer.

The external reviewer will provide a final external reviewdecision within 45 days of the receipt of the request. If theexternal reviewer decides in favor of the plan participant, thedecision shall be final and binding on the plan administrator.

Appeal Process for Fully-InsuredManaged Care Health PlansThe Department of Central Management Services (CMS) doesnot have the authority to review or process fully-insuredmanaged care health plan appeals. Fully-insured managedcare health plans must comply with the Managed CareReform and Patient Rights Act. In order to file a formalappeal, refer to the process outlined in the managed carehealth plan’s summary plan document (SPD) or certificate ofcoverage. Specific timetables and procedures apply. Planparticipants may call the customer service number listed ontheir identification card to request a copy of such documents.

Assistance with the Appeal Process For questions regarding appeal rights and/or assistancewith the appeal process, a plan participant may contact theEmployee Benefits Security Administration at 866-444-EBSA (3272). A consumer assistance program may alsobe able to assist the plan participant. Requests forassistance from the consumer assistance program shouldbe sent to:

Office of Consumer Health InsuranceConsumer Services Section122 S. Michigan Ave., 19th FLChicago, IL 60603insurance.illinois.gov877-527-9431Email: [email protected]

or

Illinois Department of Insurance320 W. Washington St, 4th FloorSpringfield, IL 62727

Claim Appeal Process (cont.)

39 TRIP Benefits HandbookMyBenefits.illinois.gov 39

Chapter 4Chapter 4: ReferenceGlossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44


Additional Deductible: Deductibles that are in addition tothe annual plan deductible.

Admission: Entry as an inpatient to an accredited facility,such as a hospital or skilled care facility, or entry to astructured outpatient, intensive outpatient or partialhospitalization program.

Adverse Claim Determination: A denial, reduction,termination of or failure to pay for a benefit, whether in wholeor in part. Adverse claim determinations include rescissionsof coverage.

Allowable Charges: The maximum amount the plan will payan out-of-network healthcare professional for billed services.

Allowable Expense: A medically necessary service for whichpart of the cost is eligible for payment by this plan or anotherplan(s).

Authorization: The result of a review that approves treatment asmeeting medical necessity criteria and appropriateness ofcare.

Benefit: The amount payable for services obtained by planparticipants and dependents.

Benefit Choice Period: A designated period when membersmay change benefit coverage elections, ordinarily held May 1through May 31.

Benefit Recipient: An annuitant or survivor enrolled in theTeachers' Retirement Insurance Program.

Certificate of Coverage: A document containing adescription of benefits provided by licensed insurance plans.Also known as a summary plan document (SPD).

Civil Union: Civil union means a legal relationship betweentwo persons, of either the same or opposite sex, establishedpursuant to the Illinois Religious Freedom Protection and CivilUnion Act.

Civil Union Partner: A party to a civil union.

Claim: A paper or electronic billing. This billing must include fulldetails of the service received, including name, age, sex,identification number, the name and address of the provider, anitemized statement of the service rendered or furnished, the dateof service, the diagnosis and any other information which a planmay request in connection with services rendered.

Claim Payment: The benefit payment calculated by a plan,after submission of a claim, in accordance with the benefitsdescribed in this handbook and the on theMyBenefits.illinois.gov website.

Coinsurance: The percentage of the charges for eligibleservices for which the plan participant is responsible after anyapplicable deductible has been met.

Coordination of Benefits: A method of integrating benefitspayable under more than one group insurance plan.

Copayment: A specific dollar amount the plan participant isrequired to pay for certain services covered by a plan.

Covered Services: Services that are eligible for benefitsunder a plan.

Creditable Coverage: The amount of time a plan participanthad continuous coverage under a previous health plan.

Custodial Care: Room and board or other institutional ornursing services which are provided for a patient due to age ormental or physical condition mainly to aid in daily living; or,medical services which are given merely as care to maintainpresent state of health and which cannot be expected to improvea medical condition.

Deductible: The amount of eligible charges plan participantsmust pay before insurance payments begin.

Department: The Department of Central ManagementServices, also referred to as CMS.

Dependent Beneficiary/Dependent: A benefit recipient’sspouse, civil union partner, child, parent or other person asdefined by the State Employees Group Insurance Act of 1971,as amended (5 ILCS 375/1 et seq.).

Glossary


Diagnostic Service: Tests performed to diagnose a condition dueto symptoms or to determine the progress of an illness or injury.Examples of these types of tests are x-rays, pathology services,clinical laboratory tests, pulmonary function studies,electrocardiograms (ECG), electroencephalograms (EEG),radioisotope tests and electromyograms.

Eligible Charges: Charges for covered services and supplieswhich are medically necessary and based on charges asdetermined by a plan administrator.

Emergency Services: Services provided to alleviate severepain or for immediate diagnosis and/or treatment ofconditions or injuries such that in the opinion of the prudentlayperson might result in permanent disability or death if nottreated immediately.

Exclusions and Limitations: Services not covered under theTeachers’ Retirement Insurance Program, or services that areprovided only with certain qualifications, conditions or limits.

Experimental: Medical services or supplies in which newtreatments or products are tested for safety and effect onhumans. Explanation of Benefits (EOB): A statement from a planadministrator explaining benefit determination for servicesrendered.

Final Internal Determination: The final benefitdetermination made by a plan administrator after a planparticipant has exhausted all appeals available through theplan administrator’s formal internal appeals process.

Fiscal Year (FY): Begins on July 1 and ends on June 30.

Formulary (Prescription Drugs): A list of drugs and ancillarysupplies approved by the prescription drug planadministrator for inclusion in the prescription drug plan. Theformulary list is subject to change.

Fully Insured: All claims and costs are paid by the insurancecompany.

Generic Drug: Therapeutic equivalent of a brand name drugand must be approved by the U.S. Food and DrugAdministration for safety and effectiveness.

Hospice: A program of palliative and supportive services forterminally ill patients that must be approved by a planadministrator as meeting standards including any legallicensing requirements.

Hospital: A legally constituted and licensed institutionhaving on the premises organized facilities (includingorganized diagnostic and surgical facilities) for the care andtreatment of sick and injured persons by or under thesupervision of a staff of physicians and registered nurses onduty or on call at all times.

Identification Card: Document identifying eligibility forbenefits under a plan.

Independent External Review: An external review,conducted by an independent third party of a planadministrator’s adverse claim determination or final internaldetermination.

Injury: Damage inflicted to the body by external force.

Inpatient Services: A hospital stay of 24 or more hours.

Intensive Outpatient Program (Behavioral HealthServices): Services offered to address treatment of mentalhealth or substance abuse and could include individual,group or family psychotherapy and adjunctive services suchas medical monitoring.

Investigational: Procedures, drugs, devices, services and/orsupplies which (a) are provided or performed in specialsettings for research purposes or under a controlledenvironment and which are being studied for safety, efficiencyand effectiveness, and/or (b) are awaiting endorsement by theappropriate National Medical Specialty Teachers’ or FederalGovernment agency for general use by the medical community atthe time they are rendered to a covered person, and (c) withrespect to drugs, combination of drugs and/or devices, whichhave not received final approval by the Food and DrugAdministration at the time used or administered to thecovered person.

Itemized Bill: A form submitted for claim purposes; musthave the name of the patient, description, diagnosis, date andcost of services provided.

Glossary (cont.)


Medical Documentation: Additional medical informationrequired to substantiate the necessity of proceduresperformed. This could include daily nursing and doctor notes,additional x-rays, treatment plans, operative reports, etc.

Medicare: A federally operated insurance program providingbenefits for eligible persons.

Medicare Summary Notice (MSN): A quarterly statementfrom Medicare explaining benefit determination for servicesrendered.

Member: Benefit recipient or COBRA participant.

MyBenefits Service Center (MBSC): The MyBenefits ServiceCenter (MBSC) is a custom benefits solution service providerfor the Department. The MBSC will manage the detailedenrollment process of member benefits through onlinetechnical support via the MyBenefits.illinois.gov website andtelephonic support via the MyBenefits Service Center 844-251-1777. The MBSC is now the member's primary contactfor answering questions you may have about your eligibilityfor coverage and to assist you in enrolling or changing thebenefits you have selected.

Nonpreferred Brand Drug: Prescription drugs available atthe highest copayment. Many high cost specialty drugs fallunder the nonpreferred drug category.

Out-of-Pocket Maximum: The maximum dollar amount paidout of pocket for covered expenses in any given plan year.After the out-of-pocket maximum has been met the planbegins paying at the 100% of allowable charges for eligiblecovered expenses.

Outpatient Services (Behavioral Health Services): Carerendered for the treatment of mental health or substanceabuse when not confined to an inpatient hospital setting.

Outpatient Services (Medical/Surgical): Services provided in ahospital emergency room or outpatient clinic, at anambulatory surgical center or in a doctor’s office.

Partial Hospitalization (Behavioral Health Services): Servicesoffered to address treatment of mental health or substanceabuse and could include individual, group or familypsychotherapy. Services are medically supervised and

essentially the same intensity as would be provided in ahospital setting except that the patient is in the program lessthan 24 hours per day.

Physician/Doctor: A person licensed to practice under theIllinois Medical Practice Act or under similar laws of Illinois orother states or countries; a Christian Science Practitioner listedin the Christian Science Journal at the time the medicalservices are provided.

Plan: A specifically designed program of benefits.

Plan Administrator: An organization, company or other entitycontracted to review and approve benefit payments, payclaims, and perform other duties related to the administrationof a specific plan.

Plan Participant: An eligible person enrolled and participating inthe Teachers’ Retirement Insurance Program.

Plan Year: July 1 through the following June 30.

Preferred Brand Drug: A list of drugs, biologicals and devicesapproved by the pharmacy benefit manager for inclusion inthe prescription drug plan. These drugs are proven to be bothclinically and cost effective. The preferred brand drug list issubject to change.

Prescription Drugs: Medications which are lawfully obtainedwith a prescription from a physician/doctor or dentist.

Preventive Service: Routine services which do not require adiagnosis or treatment of an illness or injury.

Primary Care Physician/Primary Care Provider (PCP): Thephysician or other medical provider a plan participant selectsunder a managed care plan to manage all healthcare needs.

Professional Services: Eligible services provided by alicensed medical professional, including but not limited to aphysician, radiologist, anesthesiologist, surgeon, physicaltherapist, etc.

Program: The Teachers’ Retirement Insurance Program asdefined by the State Employees Group Insurance Act of 1971,as amended (5 ILCS 375/1 et seq.).

Glossary (cont.)


Provider: Any organization or individual which providesservices or supplies to plan participants. This may includesuch entities as hospitals, pharmacies, physicians, laboratories orhome health companies.

Qualified Beneficiary: A qualified beneficiary is an individual(including member, spouse, civil union partner or child)who loses employer-provided group health coverage and isentitled to elect COBRA coverage. The individual must havebeen covered by the plan on the day before the qualifyingevent occurred and enrolled in COBRA effective the first day ofeligibility or be a newborn or newly adopted child of thecovered member.

Residential Treatment: 24-hour level of care that providespersons severe mental disorders and persons with substance-related disorders with long-term care. This care is medicallymonitored, with 24-hour medical and nursing servicesavailability. Residential care typically provides less intensivemedical monitoring than acute hospitalization care. Residentialcare includes treatment with a range of diagnostic andtherapeutic behavioral health services. Licensure for residentialis at the residential intermediate level of care or as anintermediate level of care.

Second Opinion: An opinion rendered by a second physicianprior to the performance of certain nonemergency, electivesurgical procedures or medical treatments.

Self Insured: All claims and costs are paid by the Teachers’Retirement Insurance Program.

Self-Service Tools: Using the Self-Service tools online allowsthe member to create a life event (such as getting married,adding a child etc) online as the electronic version ofsubmitting a paper form to the Department.

Skilled Nursing Service: Noncustodial professional servicesprovided by a registered nurse (RN) or licensed practical nurse(LPN) which require the technical skills and professionaltraining of such a licensed professional acting within thescope of their licensure.

Spouse: A person who is legally married to the benefitrecipient as defined under Illinois law and pursuant to theInternal Revenue Service Code.

State Employees Group Insurance Act: The statutoryauthority for benefits offered by the Department (5 ILCS 375/1et seq.).

Survivor: Spouse, civil union partner, dependent child(ren) ordependent parent(s) of a deceased member as determined bythe Teachers' Retirement System.

Surgery: The performance of any medically recognized,noninvestigational surgical procedure including specializedinstrumentation and the correction of fractures or completedislocations and any other procedures as reasonablyapproved by a plan.

Teachers’ Choice Health Plan (TCHP) Hospital: A hospital orfacility with which the Teachers’ Choice Health Plan plan hasnegotiated favorable rates.

Telemedicine/telehealth: The remote diagnosis andtreatment of patients by means of telecommunicationstechnology that is compliant with HIPAA requirements.

Urgent Care Claim: Any claim for medical care or treatmentwith respect to the application of the time periods for makingnonurgent care determinations could: 1) seriously jeopardizethe life or health of the claimant or the ability of the claimantto regain maximum function; or 2) in the opinion of thephysician with knowledge of the claimant's medicalcondition, would subject the claimant to severe pain thatcannot be adequately managed without the care or treatmentthat is the subject of the claim.

Wilderness Program: A planned, systematic service approachthat includes a variety of therapeutic services provided in theoutdoor environment for individuals with medical conditionsand behavioral health disorders.

Glossary (cont.)


– A –Annual Benefit Choice Period ...................................8

– B –Behavioral Health Coverage ...................................28

– C –Certification of Dependent Coverage........................7Claim Appeal Process..............................................38Claim Filing.............................................................37COBRA.....................................................................16Contributions..........................................................14Conversion Privilege Health Coverage ...................18Coordination of Benefits.........................................30

– D –Dependent Coverage ................................................9Direct Billing ...........................................................14Documentation RequirementsAdding Dependent Coverage .............................12Terminating Dependent Coverage .....................13

Documentation Time Limits....................................13

– E –EligibilityEligible as Benefit Recipient.................................6Eligible as Dependents.........................................6

Enrolling Dependents...............................................9Enrollment Opportunities Chart .............................11Enrollment Periods ...................................................8

– F –Formulary................................................................26

– G-H –Group Insurance Division..........................................2Health Maintenance Organizations (HMOs)...........23Health Plan Options................................................22HIPAA ........................................................................2Hospital Bill Audit Program ....................................24

– I –ID Cards.....................................................................2Initial Enrollment ......................................................8

– J-K-L –

– M –Managed Care Health Plans ...................................22Medicare.................................................................32MyBenefits Service Center (MBSC) ...........................2

– N –Nonpayment of Premium.......................................14

– O –Open Access Plan....................................................23

– P –Premium Payment ..................................................14Premium Refunds...................................................14Premium Underpayments ......................................14Prescription Coverage.............................................25Prescription Drug Step Therapy ..............................26Prior Authorization (Prescription Drugs) .................26

– Q –Qualifying Change in Status .....................................9

Index


– R-S –Self-Service Tools.......................................................3Subrogation and Reimbursement ..........................34

– T –Teachers' Choice Health Plan..................................24Termination of Dependent Beneficiary Coverage............................................................ 15

Termination of Benefit Recipient Coverage ............15Termination of Coverage under COBRA..................18

– U-V-W-X-Y-Z –

Index (cont.)

Printed by the Authority of the State of Illinois. 1/18 IOCI 18-342

The State of Illinois intends that the terms of this plan are legally enforceable and that the plan is maintained for the exclusivebenefit of Members. The State reserves the right to change any of the benefits, program requirements and contributions described inthis Handbook. Changes will be communicated through addenda as needed on the MyBenefits.illinois.gov website and the annualBenefit Choice Options Booklet. If there is a discrepancy between this Handbook or any other Department publications, and state orfederal law, the law will control.

Documents

Chapter 1: Enrollment and Eligibility Information Group Insurance Beneﬁts Please read this handbook carefully as it contains vital information about your benefits. The Bureau of