Retiree Benefit Summary - EFFECTIVE JANUARY 1, 2022 - Montgomery County Public Schools
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2022
Retiree
Benefit Summary
EFFECTIVE JANUARY 1, 2022
MEDICAL, D E N TA L ,
VIS ION , P R E SC R I P TI ON
D RU G , A N D L I F E
INSURANCE
BENEFITS
Benefits Plan Highlights
¡ There will be no changes to
insurance vendors or plans
for 2022.
Employee and Retiree Service Center ¡ 45 W. Gude Drive, Suite 1200, Rockville, MD 20850
301-517-8100 ¡ www.montgomeryschoolsmd.org/departments/erscBoard of Education
Ms. Brenda Wolff
President
Ms. Karla Silvestre
Vice President
Dr. Judith R. Docca
Mrs. Shebra L. Evans
VISION
Ms. Lynne Harris
We inspire learning by
providing the greatest Mrs. Patricia B. O’Neill
public education to each
and every student. Mrs. Rebecca K. Smondrowski
Ms. Hana O’Looney
MISSION Student Member
Every student will have
the academic, creative Montgomery County Public Schools (MCPS)
problem solving, and Administration
social emotional skills
to be successful in Monifa B. McKnight, Ed.D.
Interim Superintendent of Schools
college and career.
James N. D’Andrea
CORE PURPOSE Chief of Staff
Prepare all students to Eugenia S. Dawson
thrive in their future. Chief of Finance and Operations
Dana E. Edwards
CORE VALUES Chief of Districtwide Services and Supports
Learning
Helen A. Nixon, Ed.D.
Relationships Chief of Human Resources and Development
Respect
Excellence Ruschelle Reuben
Equity Chief of Teaching, Learning, and Schools
Stephanie S. Sheron
Chief of Strategic Initiatives
850 Hungerford Drive
Rockville, Maryland 20850
www.montgomeryschoolsmd.orgEmployee and Retiree Service Center
MONTGOMERY COUNTY PUBLIC SCHOOLS
Rockville, Maryland
October 5, 2021
MEMORANDUM
To: Montgomery County Public Schools Retirees
Through: Mr. Krishna A. Tallur, Director
Employee and Retiree Service Center
From: Richard C. Johnstone, Director
Benefits Strategy and Vendor Relations
Subject: Retiree Benefits Open Enrollment
Montgomery County Public Schools (MCPS) will conduct the annual Retiree Benefits
Open Enrollment Monday, October 11, 2021, through Friday, November 5, 2021. During
Open Enrollment, MCPS retirees will have an opportunity to make changes to their
medical, dental, vision, and prescription plans; drop coverage; or, under certain
circumstances, add coverage that was previously dropped. Changes made during Open
Enrollment will be effective January 1, 2022, which begins the new plan year.
It is important to understand your benefit choices and make sure you take any necessary
action to take advantage of the options available to you. Please read this memorandum
carefully. You should also acquaint yourself with the benefit offerings and premium costs
by reviewing the attached 2022 Retiree Benefit Summary and the 2022 Retiree Benefit
Rate Schedules.
Benefits Plan Highlights
There are no changes to insurance vendors or plans for 2022.
Retiree Benefit Plan Open Enrollment
If you wish to make changes to any component of your benefit plan(s) during the annual
retiree Open Enrollment (October 11 - November 5, 2021), the Employee and Retiree
Service Center (ERSC) must receive your changes by the close of business on Friday,
November 5, 2021.
If you make a change, you will receive a written confirmation of the change. Please review
the confirmation upon receipt so any errors may be corrected promptly. Confirmations will
be mailed twice weekly.MCPS Retirees 2 October 5, 2021
Unbundling Your Benefit Plan
You are given the option to enroll in the full benefit package that includes medical, dental,
vision, and prescription drug coverage or choose only those specific components that
meet your individual needs. For example, if you have medical insurance through another
source and only require prescription coverage, you may choose prescription coverage
only. You and your eligible dependents must be enrolled in the same benefit plan
components.
If you enroll in the Kaiser Permanente HMO, you also must select Kaiser’s prescription
coverage. Kaiser does not permit enrollment in its prescription coverage unless you also
carry medical coverage with Kaiser. Moreover, the CVS/Caremark prescription plan is not
available to Kaiser members.
If you cancel any component of coverage, you may reenroll during a future retiree Open
Enrollment if that coverage was cancelled on or after July 1, 1998. Also, you will need
documented proof that you have had other coverage for the 12 months immediately
preceding reenrollment in the MCPS benefit plan.
Open Enrollment Benefit Webinars
ERSC will hold online Open Enrollment Benefit Webinars again this year. ERSC staff and
representatives from the health plans will be available virtually to answer your benefit
questions. Dates, times, and plan/vendor options are as follows:
BENEFIT WEBINAR DATES/TIMES BENEFIT OPTIONS/VENDORS
Monday, October 11, 2021 CareFirst Indemnity/Medicare Supplement,
4:00–6:00 p.m. POS, and HMO medical plans
Kaiser Permanente HMO medical and
Tuesday, October 12, 2021
prescription plans for Medicare Advantage and
4:00–6:00 p.m.
non-Medicare-eligible retirees
Wednesday, October 13, 2021
CareFirst Dental PPO & Aetna DMO
4:00–6:00 p.m.
Thursday, October 14, 2021 CVS/Caremark and SilverScript prescription drug
4:00–6:00 p.m. plans
New This Year: Open Enrollment Virtual Assistance
In addition to the Open Enrollment Benefit Webinars, ERSC will offer individual assistance
virtually from October 18–29, 2021. Retirees will be able to register for a 20-minute Zoom
session with an ERSC representative. Please visit the Retiree Open Enrollment web page
during Open Enrollment for more information and to sign up.
Retirees may make benefit plan changes between Monday, October 11, 2021, and
Friday, November 5, 2021. To make and submit your benefits decisions, refer to thisMCPS Retirees 3 October 5, 2021
booklet, the 2022 Retiree Benefit Summary, which includes health plan comparison
charts and MCPS Form 455-22, Retiree Benefit Plan Enrollment. Also, review the
2022 Retiree Benefit Rate Schedules, which details the monthly cost of benefits at
each cost sharing arrangement while factoring in Wellness Initiatives credits. Both of
these booklets were mailed to you. They also will be made available online at
www.montgomeryschoolsmd.org/departments/ersc/retirees/benefits/ the week before
Open Enrollment begins.
During Open Enrollment, ERSC staff members will be available to assist you Monday–
Friday from 8:00 a.m. to 4:30 p.m. via email at ERSC@mcpsmd.org or from 8:00 a.m. to
4:15 p.m. by telephone at 301-517-8100.
KAT:RCJ:mjw
Attachment
Approved: __________________________________________
Robert Reilly, Associate Superintendent of Finance2022
Montgomery County Public Schools
2022 RETIREE BENEFIT SUMMARY
Montgomery County Public Schools (MCPS) provides a comprehensive benefit plan for retirees and their
eligible dependents. As an eligible MCPS retiree, you have a variety of benefit options from which to
choose, including medical, dental, vision, and prescription drug coverage.
The 2022 Retiree Benefit Summary provides an overview of the benefits available to eligible retirees,
effective January 1, 2022. This summary includes information about eligibility for MCPS benefits, access
to benefit costs, important contact information, and enrollment forms.
Keep in mind that this is a summary of the MCPS retiree benefits and is intended to help you understand
and properly enroll in the plan. Full benefit plan details are available on the Employee and Retiree
Service Center (ERSC) website at www.montgomeryschoolsmd.org/departments/ersc. Information
available on the website includes this benefit summary, the Retiree Benefit Rate Schedules, and specific
evidence of coverage documents that provide additional details about each plan.
During Open Enrollment, ERSC staff is available to assist you via email Monday–Friday, from 8:00
a.m.–4:30 p.m. and by telephone from 8:00 a.m.–4:15 p.m. Staff is available throughout the year to assist
you via email or by telephone Monday–Friday from 8:00 a.m.–4:15 p.m. Our email address and telephone
number are below:
Montgomery County Public Schools
Employee and Retiree Service Center
45 W. Gude Drive, Suite 1200
Rockville, Maryland 20850
ERSC@mcpsmd.org
301-517-8100
Important Notice
You are not enrolled automatically in MCPS retiree benefits. New retirees must enroll 30 days prior to their effective date of
retirement or wait for a future Open Enrollment, held each fall, with coverage effective January 1. In addition, if you or your
eligible dependents are Medicare-eligible at your retirement, you will need to submit your Medicare Part A and B card to ERSC
60 days prior to your effective date of retirement. You must complete MCPS Form 455-22, Retiree Benefit Plan Enrollment, to
join the Retiree Benefit Plan. This enrollment form also is used to designate and change beneficiaries for retiree life insurance
or to make changes during Open Enrollment or due to a qualifying life event.
RETIREE BENEFIT SUMMARY2022
Table of Contents
About Your Benefits ................................................................................................................... 1
Who Can Participate in Open Enrollment? ............................................................................................... 1
Who is Eligible For Benefits? ................................................................................................................... 1
Who is Ineligible for Benefits? ................................................................................................................. 1
Eligible Dependents .................................................................................................................................. 1
Disabled Dependents................................................................................................................................. 2
Adding Dependents ................................................................................................................................... 2
Changes in Coverage ................................................................................................................................ 2
Loss of Non-MCPS Coverage................................................................................................................... 3
Paying for Coverage.................................................................................................................................. 3
When Benefits Coverage Ends ................................................................................................................. 3
Continuation of Benefits (COBRA) .......................................................................................................... 3
Out-of-Area Coverage............................................................................................................................... 4
Coordination of Benefits ........................................................................................................................... 4
Enrollment in Medicare ............................................................................................................................ 5
Coordination of Medicare Benefits ........................................................................................................... 6
Medicare Part D ........................................................................................................................................ 7
Benefits Forms Access .............................................................................................................. 7
Your Benefits at a Glance .......................................................................................................... 8
Wellness Initiatives ..................................................................................................................... 9
Medical Coverage ....................................................................................................................... 9
Point-of-Service (POS) Plan ................................................................................................................... 10
Health Maintenance Organizations (HMOs) .......................................................................................... 10
Indemnity/Medicare Supplemental Plan ................................................................................................. 12
Preventive Care Services ........................................................................................................................ 13
Other Benefit Plan Coverage ................................................................................................... 22
Dental Coverage........................................................................................................................ 22
Vision Coverage ........................................................................................................................ 24
Prescription Drug Coverage .................................................................................................... 25
CVS Caremark Prescription Drug Plan................................................................................................... 25
Kaiser Permanente Prescription Drug Plans ........................................................................................... 29
SilverScript/Caremark Medicare Part D Prescription Drug Plan ............................................................ 30
Defined Contribution Plans ..................................................................................................... 31
Life Insurance............................................................................................................................ 31
Retiree Benefit Rates ................................................................................................................ 32
Important Websites and Telephone Numbers ........................................................................ 34
RETIREE BENEFIT SUMMARY2022
About Your Benefits If you retired on or before June 30, 1998,
and did not have coverage at that time, you
and your dependents are not eligible to
WHO CAN PARTICIPATE IN OPEN enroll in the MCPS plan at any time.
ENROLLMENT? If any dependents were not eligible at the
time of your retirement, they are ineligible
Retirees:
for coverage after you retire.
who currently are enrolled in an MCPS
health plan; or
who retired on or after July 1, 1998, and ELIGIBLE DEPENDENTS
opted to discontinue their MCPS coverage You may choose to cover your eligible dependents
(Proof of other coverage during the previous under the MCPS retiree benefit plan. Eligible
12 months is required.) covered dependents must be enrolled in the same
benefits plan in which you are enrolled.
WHO IS ELIGIBLE FOR BENEFITS?
Eligible dependents include your—
Retirees with at least five cumulative years of spouse, and
MCPS-eligible service who*: eligible children who meet the following age
have a current hire date that is prior to requirements:
July 1, 2006, with no break in employment; or o until the end of the month in which they
retired on or before July 1, 2011; or turn 26 for medical and prescription
were hired prior to July 1, 2011, with at least coverage
30 years of eligible service in the state core o until the end of the month in which they
plan; or turn 24 for dental and vision coverage
were hired prior to July 1, 2011, and were at o until September 30 following their 23rd
least 55 years of age as of July 1, 2011 birthday for life insurance coverage
Retirees with at least 10 cumulative years of The documentation you submit to show
MCPS-eligible service who retired after July 1, eligibility of a spouse or child(ren) must include
2011, and who*: but is not limited to the following:
were hired on or after July 1, 2006, and Spouse:
before July 1, 2019; and Social Security number and
were under 55 years of age as of July 1, 2011 valid marriage certificate or current joint tax
Retirees with at least 10 continuous years of return (signed by both parties or a copy of
MCPS-eligible service who were*: the confirmation of electronic submission)
hired or rehired on or after July 1, 2019* Biological Children:
* from most recent hire or rehire date at the time of retirement Social Security number and
valid birth certificate or valid birth
registration
WHO IS INELIGIBLE FOR BENEFITS?
Stepchildren:
If you or your dependents do not meet
Social Security number and
minimum eligibility requirements as
valid birth certificate or valid birth
outlined above, then you are ineligible for
registration and
coverage under the MCPS plan.
shared or joint custody agreement (court
If you were not eligible for coverage as an validated) up to age 18
active employee, you and/or your dependent(s)
are not eligible for coverage after you retire. Adopted Children, Foster Children, Children in
Guardianship or Custodial Relationships:
RETIREE BENEFIT SUMMARY
PAGE 12022
Social Security number and one of the the dependent’s 24th birthday, dental and
following: vision coverage will be cancelled; and
o adoption documents (court validated) September 30 following the dependent’s 23rd
o guardianship or custody documents birthday, life insurance will be cancelled.
(court validated)
o foster child documents (county, state, or ADDING DEPENDENTS
court validated) Dependents of anyone retired on or before
June 30, 1998, who were not covered at that
DISABLED DEPENDENTS time, are not eligible for coverage. Children may
be added to your retiree benefit plan up to age
Your disabled dependent child(ren)’s benefits
26. To enroll a child in your retiree benefits, you
coverage may be continued beyond the standard
must complete MCPS Form 455-22, Retiree
eligibility if—
Benefit Plan Enrollment. New spouses and any
he or she is permanently incapable of self- children who were not eligible at the time of
support because of intellectual disability or your retirement are not eligible for coverage
physical disability, or under the plan and may not be added after
he or she became disabled and the disability retirement. Spouses and/or dependents who
occurred before he or she reached age 19. were eligible for benefit coverage at the time
Coverage will continue as long as the disabled of your retirement may be added or reenrolled
child is incapacitated and dependent unless with proof of other coverage during the
coverage is otherwise terminated in accordance previous 12 months.
with the terms of the plan. You will be asked to
provide the plan administrator with proof that CHANGES IN COVERAGE
the child’s incapacity and dependency existed
In general, eligible retirees may enroll in or
prior to age 19. Before the plan administrator
make changes to health plans only during Open
agrees to the extension of coverage, the plan
Enrollment. However, benefits changes due to a
administrator may require that a physician,
qualifying life event may be made during the
chosen by your health plan provider, examine
plan year. Qualifying life events include:
the child. The plan administrator may ask for
proof that the child continues to meet these Divorce
conditions of incapacity and dependency. If you Loss or gain of alternative coverage
do not provide proof that the child’s incapacity Change of work status
and dependency existed prior to age 19, as Relocation outside your current plan service
described above, coverage for that child will end area
at the end of the month in which he/she turns Retirement
age 26 for medical and prescription coverage,
Death
and at the end of the month he/she turns age 24
for dental and vision benefits. If you experience a qualifying life event, you
have 60 days from the date of the event to
If you change your medical plan, you will be
submit the required enrollment forms to ERSC.
required to submit for review new medical
You must use MCPS Form 455-22, Retiree
documentation to the new health plan provider.
Benefit Plan Enrollment to change your benefit
It is your responsibility to notify MCPS of the plan enrollment, and you must attach all
child’s incapacity and dependency to be required documentation to the enrollment
considered for continuous benefits coverage. If form before you submit the form. If you fail
MCPS is not notified prior to— to submit all required information with
MCPS Form 455-22, your form will be
the dependent’s 26th birthday, medical and rejected and returned to you.
prescription benefits will be cancelled;
RETIREE BENEFIT SUMMARY
PAGE 22022
If you do not submit the form and required benefits coverage will be effective the first of
documentation within the 60-day period, you the month following your enrollment.
must wait until a future Open Enrollment to
make any changes. PAYING FOR COVERAGE
You may drop a dependent or cancel all Benefit plan premiums are deducted from your
coverage at any time by completing MCPS Form or your surviving spouse’s retirement check or
455-22, Retiree Benefit Plan Enrollment. are direct billed when the retirement check is not
However, you may not cancel individual sufficient to cover the premium..
components of your benefit plan during the plan Refer to the Retiree Benefit Rate Schedules that
year. If you choose to cancel coverage, you must will be mailed to your home address before Open
cancel the entire retiree benefit plan (with the Enrollment for your 2022 health coverage costs.
exception of life insurance coverage).
You may drop one or more components of your WHEN BENEFITS COVERAGE ENDS
benefit plan during the annual Open Enrollment. Retiree coverage is provided to the retiree and
If ERSC receives your changes by the fifth of eligible surviving spouse for life. Please keep in
the month, they will go into effect on the first mind that your medical benefits change when
day of the following month. If the fifth day of you become eligible for Medicare. For more
the month falls on a weekend or holiday, the information about how Medicare affects your
deadline is the last business day prior to the MCPS retiree benefits, see the section in this
fifth. Enrollment forms received after the fifth document titled “Enrollment in Medicare.”
day of the month will have coverage commence Benefits coverage for a dependent child’s
on the first day of the second month. medical and prescription plans automatically
ends at the end of the month in which he/she
IF YOU SUBMIT YOUR YOUR COVERAGE WILL turns 26. Benefits coverage for a dependent
ENROLLMENT FORM: BEGIN ON: child’s dental and vision plans automatically
ends at the end of the month in which he/she
On or before January 5 February 1 turns 24. For life insurance coverage, a
Between January 6 dependent’s coverage ends on September 30t
March 1 following his/her 23rd birthday.
and February 5
On February 10 April 1 CONTINUATION OF BENEFITS
(COBRA)
It is your responsibility to promptly notify
If coverage ends, your dependent(s) may be eligible
ERSC of all changes, including removal of
to continue coverage as provided under COBRA.
coverage or death of dependents and changes to
name, address, and phone number. Removing a Under COBRA, your dependent(s) may continue
dependent’s coverage could change your coverage coverage by paying the full cost of coverage
level and reduce your monthly premium. plus a two percent administrative fee for a
period legally mandated by COBRA regulations
LOSS OF NON-MCPS COVERAGE (generally 18–36 months).
You may enroll in an MCPS-provided benefits MCPS does not share the cost of COBRA
plan during the plan year if you or your benefits- coverage. A COBRA rate chart can be found on
eligible dependents lose coverage provided by a the ERSC website. If your dependents’ coverage
business or organization other than MCPS. Your ends, he/she will receive a qualifying event
RETIREE BENEFIT SUMMARY
PAGE 32022
notice directly from Benefits Strategies, the BlueChoice service area, you may access care
MCPS third-party COBRA administrator. while traveling/visiting outside your specific
service area by contacting a CareFirst customer
Benefits may also be available through a State service representative at 1-888-452-6403. Any
Health Insurance Exchange or the national dependent or retiree who resides or attends school
Affordable Care Act website. outside the service area will only be covered for
urgent care or emergency services. You have
OUT-OF-AREA COVERAGE access to the AFHC Program, which provides
Each health plan has different requirements benefits for participants residing outside of the
when retirees travel or reside outside of the local HMO service area for 90 days or more. Some
coverage area. areas of the country do not participate in AFHC.
To take advantage of AFHC, contact CareFirst
Retirees enrolled in the Kaiser Permanente BlueChoice at 1-888-452-6403 for details and
Health Maintenance Organization (HMO) are enrollment procedures.
required to live in the Kaiser Permanente service
area (mid-Atlantic). If you are covered by the Members of the CareFirst BlueChoice POS plan
Kaiser Permanente HMO and you live or move have access to a national network of
outside of the Kaiser Permanente service area, approximately 1 million PPO providers. This
please consult ERSC for additional plan options. plan allows you to seek care in-network
Eligible dependents who reside or attend school nationally. If you are covered by the CareFirst
outside the service area of the HMO will be BlueChoice POS plan, you also have the option
covered only for urgent care or emergency to see a nonparticipating provider, but your out-
services. There is no authorization required for of-pocket expense will be higher if you do. If
emergency services received in an emergency you receive services from a provider outside of
room while out of the Kaiser Permanente service the network, you will have to—
area. Your dependents must contact the medical pay the provider’s actual charge at the time
plan for authorization before receiving out-of- you receive care,
area medical care, and the plan may deny out-of- file a claim for reimbursement, and
area care only for cases in which care is not satisfy a deductible and coinsurance.
administered in an emergency room.
If you are enrolled in the CareFirst BlueChoice COORDINATION OF BENEFITS
HMO Open Access plan, any dependent or
If you or one of your dependents is covered by
retiree who resides or attends school outside the
more than one insurance plan, there is an order
service area will only be covered for urgent care
of benefits determination established by the
or emergency services. You have access to the
National Association of Insurance
Away From Home Care (AFHC) Program,
Commissioners. The primary plan will be the
which provides benefits for participants residing
first to consider the medical services rendered
outside of the local HMO service area for 90
for coverage. Any medical care not covered in
days or more. Some areas of the country do not
full by the primary plan will be considered for
participate in the AFHC Program. To take
payment by the secondary plan. Your plan is
advantage of AFHC, contact CareFirst
primary coverage over any other plan that covers
BlueChoice at 1-888-452-6403 for details and
you as a dependent spouse.
enrollment procedures. Enrollment in this
program may alter copays and coverage to the If you or your eligible dependents are covered
plan available in that service area. by Medicare Parts A and B, Medicare always
will be primary. For more detailed information see
If you are enrolled in the CareFirst Exclusive
“Enrollment in Medicare” later in this booklet.
Provider Option (EPO), an HMO plan for
retirees living outside of the CareFirst
RETIREE BENEFIT SUMMARY
PAGE 42022
Birthday Rule the health insurance plan through MCPS will be
If dependent children are enrolled for insurance the secondary medical coverage.
coverage with both biological parents (one
If you and/or your covered dependent(s) deferred
MCPS plan, one non-MCPS plan), the primary
enrollment in Medicare Part B because you were
insurance plan for the children is determined by
actively employed, you must contact the SSA at
the birthday of the parents.
least three months prior to your retirement date
The plan of the parent with the birthday that to enroll in Medicare Parts A and B to coincide
comes first in the calendar year (month and day with your retirement date. You must submit a
only) is primary for the child(ren). This order of copy of the Medicare card with Parts A and B to
benefits determination for dependent children is ERSC with your retirement forms. Instructions
known as the birthday rule. for enrolling online in Medicare Part B are
available at https://www.ssa.gov/pubs/EN-05-
All medical plans offered by MCPS use the 10531.pdf. If you are enrolled in Medicare Part
birthday rule for primary insurance plan A, be sure to contact your local SSA office
determination. The birthday rule does not apply before enrolling online.
to stepchildren. Primary care for dependent
stepchildren is determined by the courts. Once you apply for Medicare Part B, please
visit www.Medicare.gov, register and create a
username and password. This will allow you to
ENROLLMENT IN MEDICARE
track the progress of your Medicare Part B
MCPS requires all participants in the MCPS application at the SSA and provide you with
retiree benefit plan to enroll in Medicare Parts A access to a PDF version of your Medicare Part B
and B when first eligible for Medicare in order card. Please email the pdf version of your
to maintain medical and prescription benefits Medicare Part B card to ERSC at ersc@mcpsmd.org.
through MCPS.
If you and/or your covered dependent(s) become
You are eligible for Medicare if you: eligible for Medicare after you retire, you must
are age 65 (or over if you have been contact the SSA at least three months before you
employed and covered by an active group become eligible to enroll in Medicare Parts A
health plan), or and B. It is the retiree and/or dependent’s
receive disability benefits from the Social responsibility to enroll in Medicare Parts A and
Security Administration (SSA) and are B and submit a copy of the Medicare card to
beginning the 25th month of entitlement, or ERSC three months prior to the effective date of
have end-stage renal disease (ESRD). Medicare coverage. Sending the Medicare card
to ERSC will initiate the process to notify the
You are eligible for Medicare the first day of the insurance carriers and update your benefit
month that you turn age 65 if you have not enrollment plan, thereby reducing your monthly
qualified for enrollment before age 65. If you premium.
will be age 65 on the first day of the month, you
will be eligible for Medicare the first day of the If you and/or your covered dependent(s) become
previous month. ERSC requires that a copy of Medicare eligible through Social Security
the Medicare card or a benefit entitlement letter Disability Benefits or ESRD, you must contact
from SSA be submitted 60 days prior to the ERSC at 301-517-8100.
effective date of Medicare coverage. For Important note about the Medicare Part B
example, if your birthday is December 16, the premium as it applies to enrollment in a
Medicare effective date is December 1, and medical and/or prescription plan through
ERSC must receive the Medicare card by MCPS: Since 2007, Medicare beneficiaries with
October 1. As of your Medicare eligibility date, high incomes have paid higher monthly
Medicare will be the primary medical plan, and premiums than the standard monthly premium
RETIREE BENEFIT SUMMARY
PAGE 52022
for Medicare Part B. Using the income reported Medicare Eligibility and POS
for the previous two years on your Internal Medical Plan
Revenue Service (IRS) income tax returns, the Retirees and/or covered dependents enrolled in
SSA determines if you will have an income- the CareFirst BlueChoice Advantage POS plan
related monthly adjustment amount (IRMAA). may not remain on the plan once they are eligible
The IRMAA is effective from January 1 through for Medicare. If you are enrolled with two-party
December 31 each calendar year. The SSA or family coverage and one individual becomes
refigures your Medicare Part B premium amount Medicare eligible, the remaining individual(s) on
each year when the IRS updates the information. the plan may NOT remain on the POS plan. You
At the time of your Medicare Part B enrollment, will then have the following two options:
if the SSA determines that you must pay a
higher Medicare Part B premium, you are Option (1): You and your covered dependent(s)
advised to contact the SSA to find out if you will be transferred automatically to the CareFirst
qualify for one of its eight life-changing events BlueChoice Advantage Indemnity/Medicare
that might reduce your IRMAA. Additional Supplemental Plan.
information is available by reviewing the SSA
publication “Medicare Premiums: Rules for For the non-Medicare individual(s), the
Higher-Income Beneficiaries,” found at CareFirst Indemnity plan will be the default
www.ssa.gov/benefits/medicare/. medical coverage. With this plan, the non-
Medicare-eligible individual will have a yearly
deductible and co-insurance for all medical
COORDINATION OF MEDICARE services. For the Medicare-eligible individual,
BENEFITS Medicare will be the primary medical plan and
To ensure the proper coordination of Medicare the CareFirst BlueChoice Advantage plan will
benefits, members of CareFirst and Kaiser be the secondary coverage. If you do not elect
Permanente must submit a copy of their Option 2, you and your covered dependent(s)
Medicare cards to ERSC 60 days prior to the will be transferred automatically to this option.
effective date of their Medicare coverage. Option (2): You may choose to enroll in the
If you are a Kaiser Permanente member, you CareFirst BlueChoice HMO Open Access medical
have additional requirements. Kaiser will send plan offered by MCPS as long as you reside
its Medicare application to you two to three within the plan’s Maryland service area. If you
months prior to your or your dependent’s 65th reside outside the Maryland service area, you may
birthday. Complete and return the application to choose the CareFirst Exclusive Provider Option
ERSC. Kaiser Permanente Medicare includes (EPO) plan. This is an HMO plan for retirees
enrollment in Kaiser Medicare Part D (prescription living outside of the CareFirst service area.
drug benefit program). If you enroll in another You must submit a completed MCPS Form 455-
Medicare Part D plan, your Kaiser Permanente 22, Retiree Benefit Plan Enrollment, to ERSC by
Medicare membership (prescription and medical) the fifth of the month PRIOR to the Medicare
will be terminated on the start day of your new effective date. If the fifth day of the month falls
Medicare Part D plan. on a weekend or holiday, the deadline is the last
All of the medical plans will update Medicare business day prior to the fifth. You and your
with all pertinent information, and your health covered dependent(s) will be transferred to the
provider will submit medical claims first to new plan with a start date of the Medicare
Medicare. Medicare determines the allowed effective date.
amount, pays the Medicare portion of the claim If you do not meet the deadline for Option 2,
(80 percent), and then submits the claim to your you and your covered dependent(s) will be
medical plan for secondary payment (20 percent enrolled automatically in the CareFirst
of the Medicare-allowed amount). BlueChoice Advantage Indemnity/Medicare
RETIREE BENEFIT SUMMARY
PAGE 62022
Supplemental plan and may not make Enter a form name, number, or keyword in this
changes until the next Open Enrollment. search box to see a list of results to match your
search. Navigate to the form you need.
MEDICARE PART D
SEARCH THE MCPS FORMS
MCPS offers a Medicare prescription drug
DIRECTORY
benefit program, Medicare Part D, to Medicare-
eligible individuals through SilverScript, a All MCPS forms are available on the MCPS
Caremark owned company. Private, Medicare- forms directory web page, which can be found at
approved Part D prescription plans also are www.montgomeryschoolsmd.org/departments/
available, but if you opt to enroll in a private forms. Enter a form name, number, or keyword
plan, neither you nor your dependents will be in the search box to see a list of results that match
able to enroll or continue in the SilverScript/ your search. Navigate to the form you need.
Caremark Part D plan.
If you or your spouse enroll in another Medicare USE THE ERSC FORMS WEB PAGE
Part D plan while enrolled in the MCPS ERSC maintains a forms web page where links
sponsored SilverScript/Caremark prescription to all retiree benefits forms are compiled. This
drug plan, the SilverScript/Caremark web page is located at www.montgomeryschools
prescription drug plan will be terminated on the md.org/departments/ersc/retirees/forms. You can
start date of the other Medicare Part D plan. browse for forms by benefit type. For example, a
Kaiser Permanente Medicare includes CareFirst claim form would be located in the
enrollment in Medicare Part D. If you enroll in “health benefits” section under
another Medicare Part D plan, your Kaiser “medical forms.”
Permanente Medicare membership (including
medical) will be terminated on the start date of USE THE DIRECT LINK
your other Medicare Part D plan.
The following is a direct link to the benefit
enrollment form, MCPS Form 455-22, Retiree
Benefit Plan Enrollment: ww2.montgomeryschools
Important Notice md.org/departments/forms/pdf/455-22.pdf.
Your medical and prescription coverage with MCPS will be
cancelled if you fail to enroll in Medicare Parts A and B and Please note: If you are not making changes to
provide ERSC with a copy of the Medicare card OR if you your benefits plan during Open Enrollment,
fail to maintain coverage with Medicare. please do not submit MCPS Form 455-22.
SUBMITTING BENEFITS FORMS
Benefit Forms Access All forms must be submitted to ERSC. Forms
can be submitted in the following ways:
Forms to enroll in benefits, make changes, and Mail: 45 W. Gude Drive, Suite 1200,
file claims are available online. Most forms are Rockville, Maryland 20850
available in Adobe Portable Document Format Email: ERSC@mcpsmd.org
(PDF) and require Adobe Reader to download. Fax: 301-279-3651 or 301-279-3642
There are several ways to access benefits forms:
If you choose to submit a form via email, please
note that you must submit an electronically
SEARCH THE MCPS WEBSITE signed Adobe PDF file. You also may scan a
The MCPS website includes a search box in the copy of your form with your original signature
upper right corner of every MCPS web page. and attach it to an email.
RETIREE BENEFIT SUMMARY
PAGE 72022
Your Benefits at a Glance
The chart below is a brief overview of your benefit options for 2022. For more information, refer to the
appropriate section in this benefits summary.
Benefit Your Options
Protecting Your Health
Medical
Point-of-Service (POS) Health Plan CareFirst BlueChoice Advantage (POS)
Health Maintenance Organizations CareFirst BlueChoice HMO Open Access
(HMO) Health Plans CareFirst Exclusive Provider Option (EPO)
(an HMO plan for retirees living outside of the CareFirst service area)
Kaiser Permanente HMO
Indemnity (PPO) Plan CareFirst BlueChoice Advantage Indemnity/Medicare Supplemental Plan—
fee-for-service plan
Prescription Drug CVS Caremark Prescription Drug Option A or B
(only available to CareFirst BlueChoice plan participants)
Kaiser Permanente Prescription Drug
(only available to Kaiser Permanente medical plan participants)
Medicare Part D (SilverScript/Caremark) Option A or B
Dental CareFirst Dental Plan Preferred Provider Organization (PPO)
Aetna Dental Maintenance Organization (DMO)
Vision Davis Vision (provided through CareFirst)
Protecting Your Income
Basic Term Life Insurance MetLife
Defined Contribution Plans
403(b) Tax Shelter Savings Plan Fidelity—Participants in the MCPS 403(b) plan become eligible for distributions,
without penalty, upon attaining age 59½ (regardless of employment status) or
separation from service after attaining age 55. For directions to obtain distributions,
please visit www.NetBenefits.com/mcps .
457(b) Deferred Compensation Plan Fidelity—Participants in the MCPS 457(b) plan become eligible for distributions
upon separation from service or attaining age 59½. For directions to obtain
distributions, please visit www.NetBenefits.com/mcps .
Note: When 403(b) and/or 457(b) plan participants under the age of 59½ separate
from service and then become re-employed by MCPS in any capacity, penalty-
free withdrawals are not permitted.
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PAGE 82022
HEALTH RISK ASSESSMENT
Wellness Initiatives Health risk assessments are online surveys that
Each year, if you are a non-Medicare eligible ask basic health and lifestyle questions to
retiree who is covered by an MCPS-provided provide you with a baseline of your current
medical insurance plan through CareFirst or health status. If you complete a health risk
Kaiser Permanente, you can reduce your assessment by the deadline, your contribution to
contributions to your health insurance by your health insurance will be reduced by 1 percent.
participating in the Wellness Initiatives program.
Your online health risk assessment must be
To receive these incentives, you must complete a
completed through the medical plan in which
biometric health screening and a health risk
you are enrolled. If you have not already done
assessment between the first day of fall Open
so, you will need to create an online account
Enrollment and the Friday before the next
with your medical plan. To set up your account,
Open Enrollment begins a year later. After
visit your medical plan’s website (listed below)
you complete your biometric health screening
and complete a simple registration process:
and/or health risk assessment, the incentive(s)
will go into effect January 1 of the calendar year • Carefirst—www.carefirst.com
that follows the deadline. If you retire after • Kaiser Permanente—www.kp.org
having completed your screening and assessment
as an employee, you will need to complete them MCPS will not receive the results of your
again by the deadline—as a retiree—to receive biometric health screening or health risk
the rate reductions for the next calendar year. assessment. Your health insurance carrier will only
indicate whether you have completed your
BIOMETRIC HEALTH SCREENINGS screening and/or assessment. Your personal
information is protected by the federal Health
Biometric health screenings monitor for disease Information Portability and Accountability Act.
and assess risk for future medical problems. By
completing a biometric health screening of your
blood pressure, blood sugar, body mass index DIABETES SUPPLIES
(BMI), and cholesterol, you will be eligible for a If you have diabetes and enroll in your medical
1 percent increase in MCPS contributions toward plan’s diabetes case management program,
your health insurance. This means that your copayments for diabetic supplies (not including
contribution to your health insurance will be medications) will be waived for a year.
reduced by 1 percent if you complete the
biometric screenings within the above timeframe.
Your health screening may be completed by your
primary care physician (PCP) during your annual
Medical Coverage
physical or at one of your medical plan’s health The following medical plan options are offered
screenings sponsored by Well Aware. to eligible MCPS retirees:
CareFirst BlueChoice plan members—If you Point-of-Service (POS) option:
opt to have your physician complete your health CareFirst BlueChoice Advantage (POS Plan)
screening, your physician must complete and
sign a CareFirst Health and Wellness Evaluation Health Maintenance Organization (HMO) options:
form. You will need to log in to the CareFirst CareFirst BlueChoice HMO Open Access
website to access and submit the online form. CareFirst Exclusive Provider Option (EPO)
Instructions are available on the Wellness (an HMO for retirees living outside of the
Initiatives for Retirees web page at CareFirst area)
www.montgomeryschoolsmd.org/departments/er Kaiser Permanente HMO
sc/retirees/benefits/wellness-initiatives.aspx.
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PAGE 92022
Indemnity Plan (traditional fee-for-service) option: No PCP selection required
CareFirst BlueChoice Advantage Indemnity/ No PCP referral required to see a specialist
Medicare Supplemental Plan Pay copays when you receive care from an
in-network provider
POINT-OF-SERVICE (POS) PLAN Preventive services, including well child
A POS plan combines features of an HMO and an visits, annual adult physicals, and routine
indemnity plan. You receive care in one of two cancer screenings
ways. There is an in-network HMO-like
The BlueChoice Advantage POS offers you the
component offering a full range of services
flexibility and freedom to choose from both in-
provided or authorized by your PCP or by an in-
and out-of-network providers.
network specialist. In addition, there is an out-of-
network component similar to traditional When care is rendered in Maryland, D.C., or
indemnity insurance. The out-of-network benefit Northern Virginia, use the CareFirst BlueChoice
provides payment for treatments received from network to receive the highest level of coverage
non-network physicians or specialists after the co- and pay lower out-of-pocket costs.
insurance and a yearly deductible are met. You
also will be responsible for any charge above the Members seeking care outside the CareFirst
usual, customary, and reasonable (UCR) charges service area will lower costs by using a national
determined by the plan. BluePreferred provider. You will still have the
option to seek service outside the BluePreferred
With this plan, you have the option to go to any network, but will pay a higher out-of-pocket
medical provider and facility. However, when expense if you do. If you receive services from a
choosing in-network providers, your level of provider outside of the network, you must—
benefit coverage will be greater than opting to pay the provider’s actual charge at the time
receive services outside the network. you receive care,
The POS plan does not require you to obtain a file a claim for reimbursement, and
referral to visit a participating in-network physician satisfy a deductible and coinsurance.
or specialist for medically necessary care. Refer to
the POS comparison chart later in this document HEALTH MAINTENANCE
for more details. ORGANIZATIONS (HMOs)
An HMO offers a full range of services provided
or authorized by your PCP or by an in-network
Please Note specialist. You may receive benefits only for
Once Medicare eligible, participants may not remain in the
medical services and supplies received from a
POS plans.
network provider, except in a true emergency.
However, you do not have to meet a deductible
before the plan pays applicable benefit costs.
CareFirst BlueChoice Advantage Refer to the HMO comparison chart later in this
POS Plan document for more details.
The BlueChoice Advantage POS plan offers in-
and out-of-network benefits and has the added
CareFirst BlueChoice HMO
advantage of access to either the local Open Access—Maryland Area Access
BlueChoice (POS) network or the national CareFirst BlueChoice is an individual practice
BluePreferred (PPO) network. HMO in which you select a PCP from a list of
participating doctors at www.carefirst.com/mcps
Benefits of BlueChoice Advantage: or by telephoning CareFirst at 1-800-545-6144.
Access to more than 1 million providers Your PCP will offer medical care and may refer
nationally you to an in-network specialist, as necessary.
RETIREE BENEFIT SUMMARY
PAGE 102022
However, the plan is an open access plan, and However, the plan is an open access plan, and
referrals are not necessary to see an in-network referrals are not necessary to see an in-network
specialist. Pre-authorization is necessary for specialist. Pre-authorization is necessary for
certain coverage, such as laboratory and X-ray certain coverage, such as laboratory and X-ray
services. Each covered family member may services. Each covered family member may select
select a different PCP. You must select your a different PCP. You must select your PCP prior
PCP prior to your first appointment by to your first visit by phone at 1-800-545-6199 or
contacting CareFirst BlueChoice directly online online at www.carefirst.com/mcps.
or by phone at 1-800-545-6199.
Specialty care benefits are covered as follows:
Specialty care benefits are covered as follows: Chiropractic manipulation: 20 visits/year,
Chiropractic manipulation: 20 visits/year, $15 copay/visit
$15 copay/visit Diabetic education/training: $15 copay
Diabetic education/training: $15 copay (benefits are paid at 100 percent of the
(benefits are paid at 100 percent of the allowed amount)
allowed amount) Physical, speech, and occupational therapy:
Physical, speech, and occupational therapy: 30 visits/year, $15 copay/visit, 100 percent
30 visits/year, $15 copay/visit, 100 percent of allowed amount
of allowed amount
Away From Home Care* Kaiser Permanente HMO
Kaiser Permanente is a center-based HMO with
CareFirst BlueChoice HMO Open Access more than 30 medical centers in the MCPS
Diabetic Supplies for Medicare Part B service area. You may receive information about
Enrollees—CareFirst BlueChoice HMO Open locations at www.kp.org or from the provider
Access covers diabetic supplies only for retirees directory. Medical centers are staffed by doctors,
enrolled in Medicare Part B. Copays for diabetic nurses, and specialists and offer a wide range of
supplies are waived for Medicare-enrolled HMO services such as pharmacy, laboratory, X-ray
plan members. To confirm network participation services, ambulatory surgery, and health education.
for a particular pharmacy or copay for a You should select a center and PCP that best meet
particular supply, you may check with your your needs when you enroll in the plan. If you
pharmacist or visit the online pharmacy service do not choose a center, Kaiser automatically will
at www.carefirst.com. assign a center nearest to your residence of record.
*Away From Home Care (AFHC) provides When scheduling an appointment, be sure to ask
benefits for CareFirst BlueChoice HMO Open for your PCP. You may call and change your
Access plan participants residing outside of PCP or medical center location at any time.
their local HMO service area for 90 days or Each of your covered family members may
more. Some areas of the country do not select a separate center and PCP. Your PCP is
participate in AFHC. To take advantage of the responsible for coordinating all health needs,
program, contact CareFirst at 1-888-452-6403 including hospital and specialty care if needed.
for details and enrollment procedures. AFHC If you enroll in the Kaiser Permanente HMO,
enrollment may alter copays and coverage to the your prescription drug benefits and diabetic
plan available in that service area. supplies are provided under this plan.
CareFirst Exclusive Provider Option (EPO) Kaiser Permanente Additional Benefits
Like the local HMO option, CareFirst is offering Silver and Fit Membership—This no-cost gym
an HMO option for retirees living outside the membership at participating fitness centers also
CareFirst Maryland access area—a national plan. includes up to three at-home fitness kits. Learn
more at silverandfit.com.
Your PCP will offer medical care and may refer
you to an in-network specialist, as necessary.
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PAGE 112022
Transportation—Kaiser Permanente’s services. Medicare Part B is the medical insurance
Medicare Advantage includes 24 one-way rides and covers 80 percent of the Medicare-allowed
for non-urgent medical appointments at Kaiser amount for Medicare-approved outpatient
Medical Centers and contracted facilities. services after the Medicare Part B yearly
deductible. The “allowed amount” or “approved
Brain HQ—These online exercises that you can charge” is the amount the federal government sets
do on a computer or mobile device improve for medical services. The CareFirst Medicare
cognitive function (including memory, attention, Supplemental Plan pays the Medicare Part A
and processing speed) as well as daily life (safe hospital deductible, the Medicare Part B yearly
driving, improved balance, and better mood). deductible, and the Medicare Part B co-insurance
Once you become a Kaiser Permanente of 20 percent. If your medical service is not
Medicare Advantage Member, you will receive a eligible for Medicare coverage, the service is
new member welcome kit with instructions to not eligible for coverage under the CareFirst
set up your no-cost account. Medicare Supplemental Plan.
INDEMNITY/MEDICARE When you receive care from a participating
SUPPLEMENTAL PLAN Medicare provider for Medicare-approved
medical services and the medical provider
MCPS requires all participants in its retiree accepts Medicare assignment, you should not
benefit plan to enroll in Medicare Parts A and B have any out-of-pocket expenses. Medicare will
when first eligible for Medicare to maintain pay 80 percent of the Medicare-allowed amount
medical and prescription benefits through MCPS. and your MCPS-sponsored supplemental plan
will pay the other 20 percent. If you receive care
CareFirst BlueChoice Advantage from a nonparticipating Medicare provider for
Indemnity/Medicare Supplemental Plan Medicare-approved medical services, this means
As of your Medicare eligibility date, Medicare that the medical provider does not accept the
will be the primary medical plan and the medical allowable amount. You will receive benefits
insurance coverage through MCPS will be the from Medicare that are limited to the Medicare-
secondary medical coverage. Medicare-eligible allowed amount. The CareFirst Medicare
retirees may choose the CareFirst BlueChoice Supplemental Plan will not cover any expense
Advantage Indemnity/Medicare Supplemental that exceeds the Medicare-allowed amount, and
plan. This plan provides coverage for Medicare- you will be responsible for the additional
eligible individuals that is secondary to Medicare. charges. It is important that you check with your
provider about Medicare assignment and any
MCPS retirees who experience a Medicare split, charges for which you may be responsible prior
whereby one member of the family is Medicare to receiving services. If you have questions
eligible and the other plan participant(s) are not, regarding your provider’s charges, you should
also may choose to enroll in the CareFirst contact Medicare prior to receiving services.
Indemnity/Medicare Supplemental plan. In this
case, the plan provides primary coverage for the CareFirst will update Medicare with all pertinent
non-Medicare-eligible individual(s) and information and your health provider will submit
secondary coverage to the Medicare-eligible medical claims first to Medicare. Medicare
individual. The primary coverage benefits are determines the eligible amount, pays the
similar to those listed on the non-Medicare Medicare portion of the claim (80 percent), and
Indemnity chart for the CareFirst BlueChoice then submits the claim to CareFirst for
Advantage plan on page 19 of this booklet. secondary payment (20 percent of the Medicare-
eligible amount). A chart outlining the benefits
For Medicare enrollees, Medicare Part A is the paid by Medicare and the Medicare
hospital insurance and generally will pay all but Supplemental Plan is included in this booklet.
the deductible on Medicare-approved inpatient
RETIREE BENEFIT SUMMARY
PAGE 122022
CareFirst Medicare Supplemental Plan and
Diabetic Supplies for Medicare Part B
Enrollees—Diabetic supplies are covered for
Medicare Part B enrollees under the CareFirst
medical plan or the Medicare Part D prescription
plan. If you are enrolled in the CareFirst
Medicare Supplemental Plan, you must choose
to receive your diabetic supplies through either
of these plans. You must contact the member
services toll-free number on the back of your
insurance card to obtain a list of approved
providers. You will be responsible for any
copays for your diabetic supplies.
PREVENTIVE CARE SERVICES
For Non-Medicare-eligible Retirees
As a result of the Affordable Care Act, certain
preventive care procedures no longer have
copays when they are provided by in-network
providers. The specific procedures provided for
adults and children are listed separately in the
following charts. Preventive care procedures not
listed specifically will be covered by in-network
providers with copays outlined in the HMO and
POS comparison charts on the following pages.
Out-of-network coverage remains unchanged,
and coinsurance is listed in the POS comparison
chart later in this document.
For Medicare-eligible Retirees
Medicare participants receive coverage for certain
preventive care services with zero copayments. For
more information about Medicare coverage of
preventive services, see the booklet “Your Guide
to Medicare’s Preventive Services,” available at
https://www.medicare.gov/Pubs/pdf/10110-
Medicare-Preventive-Services.pdf.
RETIREE BENEFIT SUMMARY
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