Your Benefits for 2023 - Benefits Open Enrollment Guide MSU RETIREE - MSU Human Resources
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MSU RETIREE
Benefits Open Enrollment Guide
Your Benefits for 2023
Page 4 Page 5 Page 17 Page 19
Steps to Complete Notable Information for FAQs about the Medicare Advantage
Open Enrollment the 2023 Plan Year Humana Plans Information
MSU Retiree,
Welcome to MSU's Open Enrollment period, held You can find all Open Enrollment information,
each year from October 1-31. Please use this time including guides for faculty, academic, support staff
to re-evaluate your benefit needs and make any or individuals on a leave of absence, at
necessary changes, which are effective January 1 – hr.msu.edu/open-enrollment.
December 31, 2023.
This guide contains information about the benefit
options available to eligible MSU Retirees.
MSU Benefits Fair HR Site Labs Humana Presentations
Oct. 19 (In-person) Oct. 6 (In-person/Virtual) Oct. 17 (In-person)
Noon to 7 p.m. Oct. 31 (In-person) Oct. 25 (Virtual)
Breslin Student Events Center 8 a.m. to 5 p.m. OCT. 27 (Virtual)
Humana will also be offering 1407 S. Harrison Rd., Find information about
presentations during the fair. East Lansing, MI 48823 presentation times and location
Learn more on page 7. Learn more on page 7. on page 7.
Contact MSU Human Resources Contact MSU Benefit Providers
We will be available to help at the MSU Aetna Dental Group Medicare Advantage PPO
Benefits Fair and HR Site Labs (see page 7 for 877-238-6200 Plan:
details). We also encourage you to contact the aetna.com our.humana.com/msu/
HR Solutions Center via email or phone. MSU Non-Medicare PPO Plan:
ARAG
our.humana.com/msu-commercial/
SolutionsCenter@hr.msu.edu 800-247-4184
ARAGLegal.com/myinfo Prudential
517-353-4434 (toll-free: 800-353-4434)
877-232-3555
hr.msu.edu/open-enrollment Delta Dental
Prudential.com
800-524-0149
deltadentalmi.com Teladoc Medical Experts
866-904-0910
Humana
teladoc.com/medical-experts
Customer Care:
800-273-2509 VSP Vision Care
Mail Order: 800-400-4569
800-379-0092 msuretirees.vspforme.com
Specialty Mail Order:
800-486-2668
2 Visit hr.msu.edu/open-enrollment for all Open Enrollment Information
Table of Contents
Overview
4 Steps to Complete Open Enrollment
5 Notable Information
6 Do I Need to Do Anything?
7 Learn More or Ask Questions
8 Instructions to Make Changes
9 Child Dependent Age Criteria
Health Care
10 Glossary of Terms
11 Health and Prescription Plan Summary
12 Health Plan Coverage Chart
15 Monthly Health Plan Premiums
17 Humana FAQs
Medicare
18 Action Required if Eligible for Medicare in 2023
19 Medicare Advantage Plans and Prescription Drug
Coverage Rules
Dental
21 Dental Plans and Monthly Premiums
22 Dental Plan Coverage Chart
Life
23 Life Insurance
Voluntary Benefits
24 Legal Insurance
25 Vision Insurance
26 Teladoc Medical Experts
Forms & Additional Information
27 Retiree Open Enrollment/Change Form
29 Consent Form for Electronic Materials
31 Legal Notices
MSU Retiree Benefits Guide 3
Steps to Complete
Overview
Open Enrollment
Not sure where to start? The following steps will help you complete Open
Enrollment by October 31.
Review Open Enrollment Materials
1 Review this Open Enrollment guide completely.
Ask Questions or Learn More
2 Page 2 provides contact information for MSU Human Resources
and benefit providers. Page 7 offers opportunities to ask questions
or learn more about your benefit options.
Make Decisions
3 Read page 6 to determine if you need to take any action by
October 31.
Take Action by October 31
4 Retirees do NOT need to complete the Spouse/Other Eligible
Individual (OEI) Affidavit (yellow form).
Page 8 provides instructions to enroll in/cancel health insurance,
cancel life insurance, enroll in/change/cancel dental insurance,
inform us of the death/divorce of a spouse/OEI, and inform us of
enrollment in another Medicare Advantage plan.
Pages 24-25 provide instructions to enroll in, cancel or change
legal or vision insurance. You may only enroll in, change or cancel
legal insurance during the Open Enrollment period.
Other Items to Consider
5 To receive Open Enrollment materials electronically in the future,
complete the Consent Form for Electronic Distribution of Benefit
Materials and Notices on page 29.
You may want to check if your life insurance beneficiaries are
correct (if applicable). Find instructions at hr.msu.edu/benefits/
beneficiaries.html.
4 Visit hr.msu.edu/open-enrollment for all Open Enrollment Information
Overview
Notable Information
Read the following important changes, updates, and/or reminders regarding this year’s Open Enrollment and the
2023 plan year. Visit the HR website (hr.msu.edu) for the most updated information.
Medicare Open Enrollment Period SilverSneakers
MSU’s Open Enrollment period is from October 1-31 and Individuals enrolled in the Group Medicare Advantage
NOT associated with the Medicare Open Enrollment PPO Plan have access to SilverSneakers, which offers
period from October 15 – December 7. If you and your online workouts, fitness classes, special discounts, a
eligible dependents want to participate in the MSU fitness app and more. Learn more at SilverSneakers.com.
Humana employer-sponsored group health/prescription
plan outlined in this guide and are not currently TruHearing for Hearing Aid Discounts
enrolled, you must follow the enrollment instructions TruHearing offers discounts on hearing aids for members
on page 8. If you and your dependents are currently enrolled in a Humana plan. Humana will mail details
enrolled in the MSU Humana plan and want to continue about TruHearing after you're enrolled.
enrollment, no action is needed. Page 6 will help you
determine if you need to take action. We strongly No Spousal Affidavit
recommend you review the Medicare rules on page 19.
You don’t need to complete the affidavit for your
spouse/OEI. However, in the unfortunate event of a
Action Required if Eligible for More than One
death or divorce in 2022, please let us know if you have
Medicare Advantage (MA) Plan not already by contacting the HR Solutions Center at
Centers for Medicare and Medicaid Services (CMS) SolutionsCenter@hr.msu.edu or 517-353-4434.
allow individuals to be enrolled in only one MA plan at
a time. The Group Medicare Advantage PPO Plan is an Action Required if Eligible for Medicare On or
MA plan. If you or your dependent(s) are enrolled in After January 1, 2023
or have the option to enroll in another MA plan (such
Find out what to expect and steps to take on page 18.
as your spouse's benefits), choose which plan is right
for you and take action. Find instructions on page 8
to enroll or cancel coverage in the Humana plan for MSU Health Care Pharmacy
yourself or your spouse/OEI. If you do not take action, MSU Humana members may use any in-network
CMS will keep you enrolled in the last plan you enrolled pharmacy, which includes the MSU Health Care Pharmacy
in and disenroll you from any previous plan(s). Find on campus. The MSU Health Care Pharmacy offers
information about MA plans on page 19. convenient 90-day supplies for eligible medications.
Important Note about Humana Increase to ARAG Legal Insurance Premiums
Humana will never contact you to enroll in the MSU Monthly premiums for voluntary legal insurance through
Humana employer-sponsored group health/prescription ARAG have increased for the 2023 plan year. Visit
plan. If someone calls you to enroll in an MA plan ARAGLegal.com/myinfo (Access code 17873ret) to view
and you take action, it will impact your eligibility to updated rates. Find instructions to enroll, change or
continue coverage with the MSU plan. cancel coverage on page 24.
Humana FAQs
Find answers to some of your frequently asked
questions about the Humana health plans on page 17.
MSU Retiree Benefits Guide 5
Do I Need to Do Anything?
Overview
Not sure if you need to take any action during Open Enrollment? As an MSU benefits-eligible retiree, answer true or false to
the following statements:
TRUE FALSE
I opted out of health coverage last year for myself and/or my dependent(s),
1 and now I want to enroll myself or them in health coverage for the 2023
plan year.
I want to cancel health coverage for myself and/or my dependent(s).
2 Individuals enrolled in a Humana plan for the 2022 plan year will continue to
be enrolled in that plan for the 2023 plan year.
I am or my dependent(s) is enrolled in another Medicare Advantage plan,
3 and I need to cancel enrollment in the Group Medicare Advantage PPO Plan
for myself and/or my dependent(s). See page 8 for instructions to cancel
and page 19 for more information on Medicare Advantage plans.
I want to enroll in, change or cancel dental insurance for myself and/or my
4 eligible dependent(s).
I want to cancel my life insurance.
5
I want to enroll in, change or cancel my legal insurance. See page 24 for
6 instructions.
Unfortunately, I experienced the death or divorce of a spouse/other eligible
7 individual during the 2022 plan year, and I need to notify MSU Human
Resources. If you've already informed us, no need to get in touch again.
Your Result
If you selected true for any of the above statements, you MUST take action between October 1 – 31. See page 8 for
instructions. If you only selected false for the above statements, you do not need to take any action. However, we
strongly encourage you to review your benefit options to make sure you’re getting the best coverage.
6 Visit hr.msu.edu/open-enrollment for all Open Enrollment InformationOverview
Learn More or Ask Questions
We encourage you to use the following resources to receive assistance during Open Enrollment. Due to the unpredictable
nature of the pandemic, please visit hr.msu.edu/open-enrollment to find the most updated information about the
following opportunities prior to attending. Contact the HR Solutions Center at SolutionsCenter@hr.msu.edu or
517-353-4434 (toll-free: 800-353-4434).
MSU Benefits Fair HR Site Labs
October 19 Oct. 6 (In-person/
Noon to 7 p.m. Virtual)
Breslin Student Events Center Oct. 31 (In-person)
Learn about your benefit options and receive help with enrollment from HR staff and 8 a.m. to 5 p.m.
MSU benefits providers. The MSU Health Care Pharmacy will be offering flu shots 1407 S. Harrison Rd.,
during the fair by appointment only. The appointment calendar will close once all East Lansing, MI 48823
appointments are filled or 48 hours before the event. Make an appointment at hr.msu. Receive in-person
edu/open-enrollment. assistance from HR
Humana Presentations at the Fair: Humana will be presenting during the fair at the staff and Humana
following times. Hear an overview of the Humana tools, learn how to read your Smart representatives. Find a
Summary and Smart EOB, and ask questions about the benefits of your plan. link to the virtual site
Group Medicare Advantage PPO Plan: 2 p.m. to 3 p.m. | 3:30 p.m. to 4:30 p.m. lab at hr.msu.edu/open-
enrollment
MSU Non-Medicare PPO Plan: 5 p.m. to 6 p.m.
Humana Presentations
Humana is mailing out details for how to RSVP to additional in-person/virtual Online MSU Benefit
presentation options. Hear an overview of the Humana tools, learn how to read your
Provider Resources
Smart Summary and Smart EOB, and ask questions about the benefits of your plan.
Can't attend the in-
October 17 (In-person) Headquarters Building 2 person fair? Visit the HR
Group Medicare Advantage PPO Plan: 9 to 11 a.m. Community Room #2055 website to find resources,
MSU Non-Medicare PPO Plan: 1 to 3 p.m. 3899 Coolidge Road videos, webinars and
East Lansing, MI 48823
more from our MSU
October 25 or 27 (Virtual)
benefit providers.
MSU Retiree Benefits Guide 7Instructions to Make Changes
Overview
If you are enrolled in life, health, dental, vision, and/or legal insurance for the 2022 plan year it will carry over
to the 2023 plan year without any action.
Find instructions below to cancel or enroll in health insurance, cancel life insurance, or enroll in, change, or cancel dental
insurance. We encourage you to make changes online – it's fast, easy and you'll receive a confirmation statement to
your MSU email. If you're unable to make changes online, you may submit a paper form (please do NOT do both).
HOW TO MAKE CHANGES ONLINE HOW TO SUBMIT A PAPER FORM
1. Visit ebs.msu.edu. Log in with your MSU NetID. No 1. Please only submit a paper form if you are making
NetID? Visit netid.msu.edu or call 517-432- 6200. changes to your benefits and have NOT already made
changes online. Fill out the Enrollment/Change form
2. Click the My Benefits top navigation tab.
on page 27
3. Click the Benefit/Retirement tile. Select Open
2. Detach the form from the guide and return it to MSU
Enrollment from the dropdown menu, then click
HR by October 31 in the enclosed return envelope.
Next (bottom-right corner of webpage).
4. On the Personal Profile screen, verify name and You may submit forms (such as an enrollment form)
address info and click Next. To make corrections, via email to SolutionsCenter@hr.msu.edu if it does
follow the steps at hr.msu.edu/ebshelp/ not contain a social security number. You may
personalprofile/addresses.html. also drop off forms in the secure mailbox located
5. On the Dependents screen, verify all family outside the HR building at 1407 S. Harrision Rd., East
members/dependents and click Next. If information Lansing, 48823 or mail the forms to this address.
is missing, exit enrollment and submit the Add
a Family Member or Dependent form. If it is
inaccurate, contact MSU HR. SPECIAL NOTES ABOUT ENROLLMENT
6. The Benefits Summary screen displays current Medicare Advantage (MA) Plans
coverage. For additional details about each plan, Centers for Medicare and Medicaid Services (CMS) allows
click on the plan name. When finished reviewing, individuals to be enrolled in only one MA plan at a time.
click Next. The Group Medicare Advantage PPO Plan is an MA plan.
If you or your dependent(s) have the option to enroll
7. The next screens display the different types of plans
in another MA plan (such as your spouse's benefits),
available. You can Add, Edit or Delete enrollment
you need to choose which plan to be enrolled in and
in dental insurance, enroll in or cancel coverage in
take action. If you do not take action, CMS will keep you
health insurance or cancel life insurance. You may
enrolled in the last plan you enrolled in and disenroll you
click Cancel at any time, which will exit you out of
from any previous plan(s). Find instructions on this page
the system – all changes will be lost.
to cancel coverage through Humana. Find more info
8. When you reach the Review and Save screen, click about MA plans on page 19.
Save.
9. On the final screen, review info on the Benefit Death or Divorce of a Spouse/OEI
In the unfortunate event of the death/divorce of a
Elections Summary. You may wish to print
spouse/other eligible individual (OEI) in 2022, please let
this summary for your records. You can make
us know (if you haven't already) at
corrections throughout the month of October.
SolutionsCenter@hr.msu.edu or 517-353-4434.
10. You’re done! You should receive a confirmation
email shortly after completing Open Enrollment. More special notes about enrollment on the next page
8 Visit hr.msu.edu/open-enrollment for all Open Enrollment InformationOverview
Voluntary Benefits age 23 with no restrictions such as student enrollment
Find instructions to enroll in, change or cancel optional or IRS dependence. It is your responsibility to cancel
vision and/or legal insurance on pages 24-25. coverage when dependent children no longer qualify in
order to stop premium deductions. Read page 23 if you
Electronic Consent Form have a disabled child over 23.
To receive Open Enrollment materials via email only,
complete the form on page 29. Dental Insurance
Enrolled children who turn age 23 by December 31 will
Qualifying Life Event automatically be removed from dental coverage at the
During Open Enrollment (Oct. 1-31) you make important end of the calendar year. We will send you information
decisions that impact the upcoming plan year, including: about COBRA.
z Add yourself or additional dependents to health or
Health Insurance
dental coverage.
Enrolled children who turn age 26 by December 31 or are
z Cancel or change health or dental coverage for you enrolled as sponsored dependents are no longer eligible
or your dependent(s). for health insurance coverage under retiree plans and will
Your choices are permanent until the next Open automatically be removed from health coverage at the
Enrollment period, with changes effective January 1. end of the calendar year. We will send you information
Carefully review Open Enrollment materials to select the about opportunities to continue coverage through either
plans that best meet your coverage and financial needs. COBRA, Cigna or individual plans. Learn more at hr.msu.
Outside of Open Enrollment changes can be made to edu/benefits/documents/EligibleDependents.pdf
your benefits for certain qualifying life events, including Other eligible children (non-adopted grandchildren,
Medicare eligibility, death/divorce, marriage, childbirth/ nieces/nephews) who are enrolled and turn age 23 by
adoption, loss of existing coverage for you and your December 31 are no longer eligible for health insurance
family members, or retirement. Changes must be made coverage under retiree plans and will be automatically
within 30 days of the qualifying event. Learn more at removed from health coverage at the end of the calendar
hr.msu.edu/benefits/life-change. year. We will send you information about COBRA, Cigna
or individual plans.
Moving Outside of the US
Humana does not offer coverage for individuals living Vision and Legal Insurance
outside the U.S., Puerto Rico or the Virgin Islands. Dependent children are eligible until the end of
Coverage through the Cigna Global Plan may be an the calendar year in which they turn age 23, with
option. For more information, please contact Cigna no restrictions such as student enrollment or IRS
directly at 954-514-6879 or globalsales@cigna.com. dependency.
Add a Dependent to Your Benefits
Child Dependent
Find instructions at hr.msu.edu/open-enrollment.
Age Criteria
Life Insurance
Life insurance dependent children are eligible until the
end of the calendar year during which the child turns
MSU Retiree Benefits Guide 9Glossary of Terms
Health Care
Balance Billing: This occurs when providers bill a Medicare Part A: This is hospital insurance offered through
patient for the difference between the amount they CMS. Part A covers inpatient hospital stays, care in a skilled
charge and the amount the patient's insurance pays. nursing facility, hospice care and some home health care.
Members in the Group Medicare Advantage PPO Plan
Medicare Part B: This is medical insurance offered through
seeking services with a provider that accepts Medicare
CMS. Part B covers certain doctors’ services, outpatient
should not be billed a balance beyond the Medicare
care, medical supplies and preventative services.
allowable fee for any covered service or benefits.
Medicare Part C: This is a Medicare Advantage plan that is
Centers for Medicare and Medicaid Services (CMS):
offered through a private insurance company that contracts
CMS is the federal agency which administers Medicare,
with Medicare to provide coverage for both Medicare Part A
Medicaid, and the State Children's Health Insurance
and Part B, and sometimes Part D.
Programs across the country. It is a division of the
Department of Health and Human Services. Medicare Part D: This is prescription drug coverage offered
through CMS. Part D covers certain prescription drugs,
Co-insurance: Your share of the costs of a covered
including many recommended shots or vaccines.
health care service, calculated as a percent of the
allowed amount for the service. You pay co-insurance Out-of-network: Refers to the use of health care
plus any deductibles you owe. professionals who are not contracted with the health
insurance plan.
Co-payment: A fixed amount you pay for a covered
health care service, usually when you receive the Out-of-pocket Maximum: The highest amount you are
service. The amount can vary by the type of service. required to pay for covered services. Once you reach the
out-of-pocket maximum, the plan pays 100% of expenses
Deductible: A set dollar amount that you must pay
for covered services.
out-of-pocket toward certain health care services
before insurance starts to pay. Deductibles run on a Passive PPO Network: You will have the same level of
calendar-year basis. benefits at any provider nationwide who accepts Medicare
and is willing to submit the claim to Humana regardless of
In-network: Refers to the use of health care
whether the provider is considered in- or out-of-network.
professionals who participate in the health plan’s
provider and hospital network.
Medicare Advantage Prescription Drug Plan (MAPD):
Medicare Advantage plans (also known as Medicare
Part C) are a type of Medicare health plan offered by
a private insurance company. These plans provide all
your Medicare Part A and Part B benefits, and also
offer additional benefits. Some also cover Medicare
Part D benefits. If Medicare Part D benefits are
included, this is called an MAPD plan.
Medicare Beneficiary Identifier (MBI): MBI stands for
Medicare Beneficiary Identifier. In 2018, CMS started
a project to replace the social security number on the
Medicare Health Insurance card. It also replaced the
Health Insurance Claim Number (HICN) that providers
used to process claims. On your Medicare card it is the
11-digit identifier under the title “Medicare Number.”
10 Visit hr.msu.edu/open-enrollment for all Open Enrollment InformationHealth and Prescription Plan Summary
Health Care
Group Medicare Advantage PPO Plan covered at 50%-90% of the approved amount after the
This plan is available to retirees and their dependents who required in-network annual deductible of $100 for single
are eligible for Medicare. and $200 for family. However, not all services are subject
to the deductible. Participants should refer to the type
The plan covers preventive services at 100%. Selected of service for benefit details. The annual out-of-pocket
services are covered at 96%-100% after the required maximum, which consists of applicable deductible and
annual deductible of $192 per member. However, not coinsurance, is $3,000 for single and $6,000 for family
all services are subject to the deductible. Participants per calendar year.
should refer to the type of service for benefit details.
The annual out-of-pocket maximum is $1,200 per Prescription drug coverage is included in this plan and
member per calendar year (extra services, plan premiums has an annual out-of-pocket maximum of $1,000. This
and prescriptions do not apply to this out-of-pocket chart shows co-pays for prescription drugs:
maximum).
Prescription drug coverage is included in this plan and has
Prescription Co-Pays for
an annual out-of-pocket maximum of $1,000. This chart
MSU Non-Medicare PPO Plan
shows co-pays for prescription drugs: Drug Tier 30-Day 90-Day 90-Day Supply
Supply Supply Co-Pays at Mail
Co-Pays Co-Pays at Order or MSU
Prescription Co-Pays for Group Medicare at retail retail Pharmacy
Advantage PPO Plan Generic $10 $30 $20
Drug Tier 30-Day 90-Day 90-Day Supply Preferred $30 $90 $60
Supply Supply Co-Pays at Mail Brand Name
Co-Pays Co-Pays Order or MSU Non-Preferred $60 $180 $120
at retail at retail Pharmacy Brand Name
Generic* $10 $20 $20 Specialty Drugs $75 N/A* N/A*
Preferred $30 $60 $60 Annual Out-of-Pocket Co-Pay Maximum
Brand Name Individual: $1,000 Family: $2,000
Non-Preferred $60 $120 $120 *Specialty medications limited to 30-day supply.
Brand Name
For questions about specific coverage details visit
Specialty Drugs $75 N/A** N/A**
our.humana.com/msu-commercial/ or call Humana at
Annual Out-of-Pocket Co-Pay Maximum
800-273-2509.
Individual: $1,000 Family: $2,000
*Some generics may be on higher tiers.
**Specialty medications limited to 30-day supply. Humana Transition PPO Plan
For questions about specific coverage details visit This plan is for families with both Medicare eligible and
our.humana.com/msu/ or call Humana at 800-273-2509. non-Medicare eligible people.
Those enrolled in Medicare should refer to the summary
MSU Non-Medicare PPO Plan of the Group Medicare Advantage PPO Plan and those
This plan is available to retirees and their dependents who not enrolled in Medicare should refer to the summary of
are NOT eligible for Medicare. the MSU Non-Medicare PPO Plan.
The plan covers in-network preventive services at 100%.
The majority of the in-network diagnostic services are
covered at 100% of the approved amount after either the
required co-payment or annual deductible of $100 for
single and $200 for family. Select in-network services are
MSU Retiree Benefits Guide 11Health Plan Coverage Chart
Health Care
Benefit Medicare Advantage PPO Plan* MSU Non-Medicare PPO Plan
The in-network and out-of-network benefits In-Network Out-of-Network
are structured the same for any member
of this plan. Any provider who is eligible
to participate in Medicare can treat and
receive payment from Humana. Humana
pays providers according to the Original
Medicare fee schedule less any member
plan responsibility. Medicare participating
providers may not balance bill members.
Preventive Services8
Health Maintenance Exam (1 per Covered – 100% Covered – 100% Covered – 80% after deductible
calendar year) Routine Physical Exam
Annual Gynecological Exam (1 per Covered – 100% Covered – 100% Covered – 80% after deductible
calendar year)
Pap Smear Screening (lab services Covered – 100% Covered – 100% Covered – 80% after deductible
only); See Humana explanation of Every 24 Months for Preventive
coverage description for details
Contraceptive Devices (IUD, Not a Preventive service1 Covered – 100% Covered – 80% after deductible
Diaphragm, Norplant) Note: Male
Contraceptives are not covered
Contraceptive Injections Not a Preventive service1 Covered – 100% Covered – 80% after deductible
Mammography Screening (1 per Covered – 100% Covered – 100% Covered – 80% after deductible
calendar year)
Immunizations (as recommended Part B: Influenza and Pneumococcal Covered – 100% Covered – 80% after deductible
by the Advisory Committee Immunizations – Covered 100%
on Immunization Practices or Part D: Other immunizations (example
mandated by the Affordable Care Shingrix) are subject to co-pay through
Act)6 pharmacy benefit based on tier
*Some immunizations require a
determination to classify as Part B or Part D
Prostate Exam (1 per calendar year2) Covered – 100% Covered – 100% Covered – 80% after deductible
Fecal Occult Blood Screening (1 per Covered – 100% Covered – 100% Covered – 80% after deductible
calendar year)
Preventive Colonoscopy Covered – 100%; Every 24 Months for Covered – 100% Covered – 80% after deductible
Preventive
Flexible Sigmoidoscopy Exam Covered – 100% Covered – 100% Covered – 80% after deductible
Every 48 Months for Preventive
Prostate Specific Antigen Test Covered – 100% Covered – 100% Covered – 80% after deductible
(1 per calendar year2)
Physician Office Services (Medically Necessary)
Office Visits/Consultations Covered - 96% after deductible Co–pay: $20 Covered – 80% after deductible
Emergency Medical Care (7)
Hospital Emergency Room Co-pay: $50 (waived if admitted within 24 Co-pay: $50 (waived if Co-pay: $50 (waived if admitted
hours) admitted during visit) during visit)
Emergency Room Physician’s Covered – 100% Covered – 100% Covered – 100%
Services
Urgent Care Center Covered - 96% Co–pay: $25 Co–pay: $25
Ambulance Service (Must be Covered – 96% after deductible, ground and Covered – 80% after Covered – 80% after in-network
medically necessary) air deductible, ground and air deductible, ground and air
Diagnostic Services
Laboratory and Pathology Tests Covered – 100% Covered – 100% for Covered – 80% after deductible
outpatient; Covered – 100%
after deductible for inpatient
*Also referred to as the Group Medicare Advantage PPO Plan.
12 Visit hr.msu.edu/open-enrollment for all Open Enrollment InformationHealth Care
Benefit Medicare Advantage PPO Plan MSU Non-Medicare PPO Plan
In-Network Out-of-Network
Diagnostic Services Cont.
Diagnostic Tests and Covered – 96%- 100% Covered – 100% after deductible Covered – 80% after deductible
X–Rays (other than Prior authorization may be required Prior authorization may be required
advanced imaging)
Radiation Therapy Covered – 100% Covered – 100% after deductible Covered – 80% after deductible
Prior authorization may be required
Maternity Services Provided by a Physician
Pre–Natal and Post–Natal Covered at the applicable service/place of Covered – Same as Other Physician Covered – Same as Other
Care treatment cost share Services Physician Services
Delivery and Nursery Care Covered at the applicable service/place of Covered – 100% after deductible Covered – 80% after deductible
treatment cost share
Hospital Care
Semi–Private Room, General Covered – 100% after deductible Covered – 100% after deductible Covered – 80% after deductible
Nursing Care, Hospital (unlimited days) (unlimited days)
Services and Supplies Prior authorization required Prior authorization required
Inpatient Consultation Covered – 100% Covered – 100% after deductible Covered – 80% after deductible
Chemotherapy Covered – 100% (Inpatient)
1
Covered – 100% after deductible Covered – 80% after deductible
Alternatives to Hospital Care
Skilled Nursing Care Covered – 100% (combined in–network Covered – 100% after deductible Covered – 80% after deductible
(must meet medical criteria) and out–of–network benefits limited to 100 (combined in–network and out–of– (combined in–network and
days per benefit period) network benefits limited to 100 days out–of–network benefits limited
Prior authorization required per calendar year) to 100 days per calendar year)
Prior authorization required Prior authorization required
Hospice Care Covered under Original Medicare while on Covered – 100% after deductible Covered – 80% after deductible
the plan Prior authorization required Prior authorization required
Home Health Care Covered - 100% Covered – 100% after deductible Covered – 80% after deductible
(Medically necessary) Excludes Personal Home Care (combined in–network and out–of– (combined in–network and out–
network benefits limited to 60 days of–network benefits limited to
per calendar year) 60 days per calendar year)
Surgical Services
Surgery and Related Covered – 96% - 100% Covered 100% after deductible Covered – 80% after deductible
Surgical Services Prior authorization may be required
Mental Health Care and Substance Abuse Treatment (In approved facilities)
Inpatient Mental Health/ Covered 100% (190 day limit in a Covered 100% after deductible Covered 80% after deductible
Substance Abuse Care psychiatric facility) Prior authorization required
Prior authorization required
Outpatient Mental Health Covered 96% - 100% after deductible Covered 100% Covered 80% after deductible
Care Prior authorization may be required
Outpatient Substance Covered 96% - 100% after deductible Covered 100% Covered 80% after deductible
Abuse Care Prior authorization may be required
Other Services
Allergy Testing and Therapy Covered 96% after deductible Covered 100%; Office visit co–pay Covered 80% after deductible
(includes allergy injections) may apply to consultations
Spinal and Osteopathic Covered 96% after deductible Co–pay: $20; (Combined in–network Covered 80% after deductible
Manipulation No Visit Limit and out-of-network benefits limited Prior authorization may be
to 24 visits per calendar year) required and number of visit
limits may apply
Outpatient Diabetes Covered 100% Covered 100% Covered 100%
Management Program Diabetic training Diabetic training Diabetic training
(certified providers)
MSU Retiree Benefits Guide 13Health Care
Benefit Medicare Advantage PPO Plan MSU Non-Medicare PPO Plan
In-Network Out-of-Network
Other Services Cont.
Outpatient Physical, Covered 100% after deductible Co–pay: $20 Covered 80% after deductible
Speech, and Occupational Prior authorization may be required (Combined in– and out–of–network Prior authorization may be required
Therapy No visit limit benefits limited to 60 visits per and number of visit limits may apply
calendar year)
Prior authorization required
Durable Medical Covered 96%-100% after deductible Covered 80% after deductible Covered 80% after deductible
Equipment and Medical Prior authorization may be required Prior authorization may be required
Supplies (including
breastfeeding equipment)
Private Duty Nursing Covered 80% after deductible Covered 80% after deductible Covered 80% after deductible
Autism Spectrum Disorder Covered 96%-100% after deductible Covered 80% after deductible Covered 80% after deductible
(applied behavioral (Limited to Medicare covered services)
analysis treatment – when Prior authorization may be required
rendered by an approved
board–certified behavioral
analyst – is limited
through age 19)
Foreign Travel5
Foreign Travel 20% co-insurance for emergency services Emergency care received while Emergency care received while
outside the U.S. and its territories after traveling outside the U.S. or taking traveling outside the U.S. or taking
a $100 deductible. Benefit is limited to a cruise is covered. Members will be a cruise is covered. Members will be
$250,000 each plan year or 60 consecutive required to pay for services received required to pay for services received
days, whichever is reached first. Benefit and submit a claim to Humana for and submit a claim to Humana
does not apply to combined annual reimbursement along with proof of for reimbursement along with
deductible or combined annual out-of- payment and any medical information proof of payment and any medical
pocket maximum. or records available from the provider. information or records available
The charges will be converted to from the provider. The charges
U.S. currency and reimbursed to the will be converted to U.S. currency
member under the out-of-network and reimbursed to the member
benefits after first applying either the under the out-of-network benefits
$50 emergency room co-payment after first applying either the $50
or the out-of-network deductible of emergency room co-payment or the
$500 and 20% member co-insurance, out-of-network deductible of $500
depending on services received. and 20% member co-insurance,
depending on services received.
Deductibles, Co–pays, and Dollar Maximums
Deductibles $192 per member per calendar year. Not all $100 per member/$200 per family $500 per member/$1,000 per family
services are subject to the deductible. Refer per calendar year per calendar year
to the type of service for benefit details
Fixed Dollar Co–pays As noted in chart As noted in chart As noted in chart
Percent Co–pays As noted in chart As noted in chart As noted in chart
Out-of-Pocket Maximum $1,200 per member per calendar year $3,000 per member/ $6,000 per $3,000 per member/$6,000 per
(includes deductible, family per calendar year for medical family per calendar year for medical
co-insurance and co-pays, services only3 services only3 (Does not include
where applicable) deductible or copayments)
Transplant Maximum No maximum No maximum No maximum
1. Covered at the applicable service/place of treatment cost share. at 100%. For the MSU Non-Medicare PPO Plan, immunization coverage
2. Age limits may apply. is determined by the Affordable Care Act. Immunizations at a pharmacy
3. Two separate limits apply to In-Network and Out-of-Network services. usually result in the lowest cost to you and the pharmacy can verify
Contact the provider for more info about out-of-network services. coverage or other as applicable.
4. Example: $100 total visit charge would cost $4 for member after 7. For those enrolled in the MSU Non-Medicare PPO Plan Only: If you are
deductible (when applicable). hospitalized in an out of network facility, Humana may require that you be
5. Individuals living internationally are not eligible for the Humana plans. transferred to an in-network facility as soon as you are stabilized, if you
6. Coverage for immunizations on the Group Medicare Advantage PPO refuse you will be charged out-of-network from the date of stabilization.
plan is determined by whether it is a Part B or Part D, which is decided 8. Preventive services are covered per the percentage noted, subject to the
by Medicare. If the immunization is Part D, such as Shingrix, it will have frequency and age limits as detailed in the evidence of coverage and/or
a co-pay, whereas Part B immunizations, such as influenza, are covered summary plan descriptions.
This summary reviews the plan features in general terms, but is not a full description of coverage. The MSU Explanation of Coverage (EOC) Medicare Advantage
PPO document and the MSU Non-Medicare PPO Summary Plan Description provides more detail. You may access these guides online at our.humana.com/msu for
the Group Medicare Advantage PPO Plan and at our.humana.com/msu-commercial for the MSU Non-Medicare PPO Plan or by calling Humana Customer Care at
1-800-273-2509 (TTY: 711). Information provided in this guide may be updated periodically to ensure we provide the clearest and most accurate information.
14 Visit hr.msu.edu/open-enrollment for all Open Enrollment InformationMonthly Health Plan Premiums
Health Care
The following charts show monthly health plan rates based on the Medicare eligibility of you and your dependents. These
are for retirees that are 100% vested. Rates are prorated for part-time contributions. For part-time retiree rates, email
SolutionsCenter@hr.msu.edu or call 517-353-4434 (toll-free 800-353-4434).
Retired Support Staff Hired Before July 1, 2002 and Retired Faculty Hired Before July 1, 2005
Coverage Group Medicare MSU Non-Medicare PPO Plan Humana Transition PPO Plan
Advantage PPO Plan (Non-Medicare Eligible Only) (Mix of Medicare Eligible &
(Medicare Eligible Only) Non-Medicare Eligible)
Retiree only Paid by MSU Paid by MSU N/A
2 Person Paid by MSU Paid by MSU Paid by MSU
Family Paid by MSU Paid by MSU (1 with Medicare): Paid by MSU
(2 with Medicare): Paid by MSU
(3 or more with Medicare): Paid by MSU
Retired Support Staff Hired July 1, 2002 – June 30, 2010
Coverage Group Medicare MSU Non-Medicare PPO Plan Humana Transition PPO Plan
Advantage PPO Plan (Non-Medicare Eligible Only) (Mix of Medicare Eligible &
(Medicare Eligible Only) Non-Medicare Eligible)
Retiree only Paid by MSU Paid by MSU N/A
2 Person $117.49 $1,260.90 $533.32
Family $234.98 $2,395.71 (1 with Medicare): $1,116.58
(2 with Medicare): $650.81
(3 or more with Medicare): $768.30
Retired Faculty Hired July 1, 2005 – June 30, 2010 with 100% or 50%/50% MSU Coverage
The following rates are for faculty that have elected 100% MSU coverage for themselves and 0% for a spouse/other
eligible individual (OEI) OR 50% MSU coverage for themselves and 50% for a spouse/OEI while both retiree and spouse/
OEI are living.
Coverage Group Medicare MSU Non-Medicare PPO Plan Humana Transition PPO Plan
Advantage PPO Plan (Non-Medicare Eligible Only) (Mix of Medicare Eligible &
(Medicare Eligible Only) Non-Medicare Eligible)
Retiree only Paid by MSU Paid by MSU N/A
2 Person $117.49 $1,260.90 $533.32
Family $234.98 $2,395.71 (1 with Medicare): $1,116.58
(2 with Medicare): $650.81
(3 or more with Medicare): $768.30
Find more charts on the following page
MSU Retiree Benefits Guide 15Health Care
Retired Faculty Hired July 1, 2005 – June 30, 2010 with 50% MSU Coverage
The following monthly rates are for faculty that have elected 50% MSU coverage for themselves and 50% for a spouse/OEI
AND either the retiree or spouse/OEI is deceased, or they have divorced after retirement.
Coverage Group Medicare MSU Non-Medicare PPO Plan Humana Transition PPO Plan
Advantage PPO Plan (Non-Medicare Eligible Only) (Mix of Medicare Eligible &
(Medicare Eligible Only) Non-Medicare Eligible)
Retiree only $58.75 $630.44 N/A
2 Person $176.24 $1,891.34 $592.07
Family $293.73 $3,026.15 (1 with Medicare): $1,175.33
(2 with Medicare): $709.56
(3 or more with Medicare): $827.05
Retired Faculty Hired July 1, 2005 – June 30, 2010 with 100% Coverage
The following rates are for faculty that have elected 100% MSU coverage for themselves and 0% for a spouse/OEI AND the
retiree is deceased. The following premiums would be paid by the spouse/OEI.
Coverage Group Medicare MSU Non-Medicare PPO Plan Humana Transition PPO Plan
Advantage PPO Plan (Non-Medicare Eligible Only) (Mix of Medicare Eligible &
(Medicare Eligible Only) Non-Medicare Eligible)
Surviving $117.49 $1,260.90 N/A
Spouse
2 Person $234.98 $2,521.80 $650.81
Family $352.47 $3,656.61 (1 with Medicare): $1,234.07
(2 with Medicare): $768.30
(3 or more with Medicare): $885.79
16 Visit hr.msu.edu/open-enrollment for all Open Enrollment InformationHumana FAQs
Health Care
Please read the following frequently asked questions about the Group Medicare Advantage (MA) PPO Plan and the MSU
Non-Medicare PPO Plan. Additional Open Enrollment FAQs can be found at hr.msu.edu/open-enrollment.
Is the Group Medicare Advantage PPO Plan provider We recommended members verify provider participation
network similar to the provider network I had access to as prior to seeking services. You may need to present your
an active employee? Humana medical card to the provider customer service
Yes, the provider network is similar but not exactly the representative and point out that the network also
same. The Group Medicare Advantage PPO Plan has a includes Cofinity (that information is on the back of the
passive provider network. This means you have the same card) – which gives you access to a larger network of
level of benefits at any provider nationwide, whether they providers.
are in-network or out-of-network, as long as they accept
Medicare and are willing to submit the claim to Humana. How do I confirm in-network participation?
To confirm in-network participation, you may call Humana
If a provider informs a Group Medicare Advantage PPO Customer Care at 1-800-273-2509 (TTY: 711) Monday to
Plan member that they are not in-network, how should Friday, 8:00 a.m. to 8:00 p.m. EST.
the member respond?
You may also find a provider online at Humana.com.
The Group Medicare Advantage PPO Plan has a passive Select Member Resources from the top navigation tab
provider network. This means members have the same and then Find a Doctor. Enter your zip code and select
level of benefits at any provider nationwide, whether they distance from zip code to search. Click Select a lookup
are in-network or out-of-network, if the provider accepts method and enter your Member ID into the Member
Medicare and is willing to submit a claim to Humana. Some ID option. If you do not have your Member ID, select
providers are confused about passive provider network Coverage Type and then Medicare or Medicare-Medicaid.
participation. Since Humana offers many individual Click Network and select Medicare PPO. Select Search
MA plans that do not offer passive provider network Category and enter Name, specialty, and condition.
participation, many providers will incorrectly assume they
do not accept the Group Medicare Advantage PPO Plan.
What can I do if I think I am being charged by a provider
Here’s how to respond: for something that should have been covered by
Humana?
z Show the provider your Humana medical card and
explain you are part of a “group” plan – not an Humana mails a SmartSummary statement for the Group
individual plan. Medicare Advantage PPO Plan and a Smart EOB for the
MSU Non-Medicare PPO Plan to any member that has
z If further help is needed, call Humana Customer Care received services. This summary includes a line item
at 1-800-273-2509 (TTY:711), Monday to Friday, 8 a.m. that indicates “patient responsibility.” If it is $0, you are
to 8 p.m. EST. You may also find a provider at not responsible for any charges. If it has an amount you
Humana.com. disagree with, you should contact Humana Customer Care
at 1-800-273-2509 (TTY: 711) Monday to Friday, 8:00 a.m.
Will I have to change providers to receive coverage in the to 8:00 p.m. EST.
MSU Non-Medicare PPO Plan?
Individuals enrolled in the MSU Non-Medicare PPO Plan How can I be placed on a do not call list with Humana?
have access to Humana’s large provider network and You may call Humana Customer Care at 1-800-273-2509
can maximize benefits by seeking services from these (TTY: 711) Monday to Friday, 8:00 a.m. to 8:00 p.m. EST. to
providers. While the provider network is similar to the make this request.
active employee plans, the network is not exactly the same.
MSU Retiree Benefits Guide 17Action Required if Eligible for Medicare
Medicare
in 2023
The information below is important for individuals who will become eligible for Medicare
on or after January 1, 2023.
About Medicare and Eligibility If action is not taken, you will lose your health care
Medicare is the federal health insurance program for coverage 30 days after your Medicare eligibility date.
individuals age 65 or older and some people with
disabilities under age 65. It is administered by the 90 Days Prior to Turning 65 (approx.)
Centers for Medicare and Medicaid Services (CMS). A Contact Medicare to enroll in Medicare
person becomes eligible for Medicare the first day of Parts A and B (see note on Medicare
the month in which that individual turns age 65, unless Parts A and B below).
their birthday falls on the first of the month, in which
case Medicare eligibility is the first of the prior month. 45 Days Prior to Becoming Eligible for
Medicare (approx.)
Action Required If Eligible for Medicare Soon Provide a copy of your Medicare card
If you and/or your dependent(s) are turning 65 on or
to MSU HR and enroll in the Group
after January 1, 2023, you (or they) will become eligible
Medicare Advantage PPO plan using the
for Medicare soon. You must complete the following
steps to continue receiving health care through the Enrollment/Change form provided in the
MSU health plan administered by Humana when you letter sent from MSU HR.
turn 65.
Note About Medicare Parts A and B
The Group Medicare Advantage PPO Plan is the MSU When an individual becomes eligible for Medicare, they
health care option available to you and/or your covered must enroll in and retain Medicare Parts A and B in
dependents once an individual is eligible for Medicare. order to enroll in the health care plan offered by MSU
If you choose not to enroll, you may not elect the plan and continue health care coverage. Medicare Part D is
again until you have a qualified life event or during the included in MSU’s Group Medicare Advantage PPO plan,
next MSU Open Enrollment period in October. which means you do not need to enroll in Medicare
Part D; enrollment in Medicare Part D is automatic as
What to Expect and Steps to Follow part of the Group Medicare Advantage PPO plan.
Approximately 90 days prior to being eligible for
Medicare, you will receive a letter from MSU Human
Resources (HR) regarding upcoming Medicare eligibility
for you or your dependents. You as the retiree will take
action to enroll in the plan at MSU for yourself and/
or your dependent(s). The letter will be sent to the
address on file with MSU and include an Enrollment/
Change form. Following that letter, Humana will send
a packet of information advising you to take certain
actions to initiate the change in coverage to the Group
Medicare Advantage PPO Plan.
18 Visit hr.msu.edu/open-enrollment for all Open Enrollment InformationMedicare Advantage Plans
Medicare
MSU's Group
Medicare Advantage
and Prescription Drug
PPO Plan Includes:
(Also known as an MAPD Plan
Coverage Rules
or Medicare Part C)
The information below and on page 20 is important for
individuals who are currently eligible for Medicare or will
become eligible for Medicare before January 1, 2023.
Centers for Medicare and Medicaid Services (CMS) allows you to be enrolled
Medicare Part A in only one Medicare Advantage (MA), Medicare Advantage Prescription Drug
(Hospital Insurance) (MAPD), or Medicare Part D plan at a time. The MSU Group Medicare Advantage
PPO plan is an MAPD plan.
Please determine if you and/or any dependent(s) you want covered in the Group
Medicare Advantage PPO plan are already enrolled in any other MA, MAPD or
Medicare Part D prescription drug plan. If you and/or a dependent are enrolled in
another plan, you should review each plan and make an informed decision about
which plan is right for you and/or each covered dependent.
Medicare Part B Rules if You and/or Your Dependents are Eligible or Currently
(Medical Insurance)
Covered on More than One Medicare Plan
The Group Medicare Advantage PPO plan is an MAPD plan. An MAPD plan—
sometimes called "Medicare Part C" – bundles Medicare Part A (Hospital
Insurance), Medicare Part B (Medical Insurance) and Medicare Part D (Prescription
Drug Insurance) into an all in one plan, along with additional benefits.
MSU's Group Medicare Advantage PPO plan provides all the benefits of original
Medicare in one plan and you do not lose any benefits or coverage of original
Medicare.
Medicare Part D
(Prescription Drug
Insurance) Review Medicare's Rules:
Those eligible for Medicare should review Medicare’s rules about what types of
coverage you can add or combine when you are enrolled in the MSU Humana
employer-sponsored group health plan.
z To participate in the Group Medicare Advantage PPO Plan you need to
continue enrollment in Medicare Parts A and B the entire time.
z In order to enroll in the MSU Humana employer-sponsored health plan, you
must enroll through MSU Human Resources and not through Humana or
Additional Benefits
an agent.
(Wellness Programs)
z If you are responsible for any premiums, those amounts will be billed directly
by MSU Human Resources.
Continued on next page
MSU Retiree Benefits Guide 19Medicare
z You and any eligible dependents may be enrolled in only one MA, MAPD, Questions About
or Medicare Part D plan at a time. Medicare
z The last plan you enroll in is the plan CMS considers to be your final Enrollment in Medicare may
decision. have exceptions and nuances
z If you are in another MA, MAPD or Medicare Part D plan and have specific to each individual’s
determined you want to remain enrolled in the MSU Humana employer- situation.
sponsored group health plan, we advise you to actively disenroll in the Visit medicare.gov or call
other plan. 800-633-4227 for more
z You may receive information about non-MSU employer-sponsored health information.
plans available through the healthcare marketplace via various methods. TTY users should call
You should compare the plans in detail before choosing a plan. 877-486-2048, 24 hours/
day, 7 days/week to find out
Action Required: Make a Decision more about how to enroll in
If you and/or your dependents are eligible for Medicare or will become eligible Medicare.
for Medicare by January 1, 2023, you must make a decision about which option
to be enrolled in.
Review the Following Scenarios:
z If you and/or your dependents are enrolled in the MSU Group Medicare
Advantage PPO plan and later enroll in another MA, MAPD, or Medicare
Part D plan, or are auto-enrolled via a family member's employer group
plan, and you do not opt out, CMS will automatically disenroll you from the
MSU Group Medicare Advantage PPO plan.
z If you and/or your dependents cancel or CMS disenrolls you from the MSU
Group Medicare Advantage PPO plan, you may not enroll in coverage
through MSU again until the next Open Enrollment period in October
unless you have a qualifying life event.
z If you are enrolled in a Medicare Supplement Insurance plan – sometimes
called Medigap policies – please note that the MSU Group Medicare
Advantage PPO plan does not coordinate with these plans. This means
Medigap policies can't be used to pay your plan co-payments, deductibles
or premiums.
20 Visit hr.msu.edu/open-enrollment for all Open Enrollment InformationDental Plans
Dental
Provider Contact In a Dental Maintenance Organization (DMO) like Aetna Premium DMO,
Information enrollees select a participating primary care dentist. Their primary dental
care is provided by that dentist and only at locations and by dentists that
Aetna Dental participate in the plan. Although choice of providers is more limited, a DMO
877-238-6200 tends to cover a greater range of services at lower co-pays than traditional
aetna.com dental plans.
Aetna app available If you plan to enroll in the Aetna Premium DMO, please verify that
the dentist you want to use accepts “Aetna Premium DMO” rather
Delta Dental than just “Aetna” to avoid rejected claims.
800-524-0149
The Delta Dental PPO plan typically allows more freedom in selecting service
deltadentalmi.com
providers and services performed but tends to have higher out-of-pocket costs
Delta Dental app available
compared to a DMO plan. Delta offers hundreds of participating providers
and allows you to seek care from both participating and non-participating
More Dental providers. Note: You may incur additional costs if you use a non-participating
Information provider. Contact Delta Dental for information on participating providers.
Visit hr.msu.edu/benefits/ Important Note: Please reference the appropriate chart to determine your
dental/index.html to learn monthly premium contribution. These premiums assume full university
more about MSU dental plans. contribution. If you need additional info about part-time retiree requirements,
email SolutionsCenter@hr.msu.edu or call 517-353-4434.
Information about Find more premium charts on the next page
Moving
Retired Support Staff Hired Prior to July 1, 2002 and Retired Faculty
Please contact Aetna using the Hired Prior to July 1, 2005
phone number above prior to PLAN FULL-TIME (90% - 100%)
moving to confirm there is a
Aetna Single $11.34
provider available in your new
Premium 2 Person $21.19
city and/or state. DMO Family $36.47
Delta Single Paid by MSU
Dental 2 Person Paid by MSU
PPO Family Paid by MSU
Retired Support Staff Hired between July 1, 2002 and June 30, 2010
PLAN FULL-TIME (90% - 100%)
Aetna Single $11.34
Premium 2 Person $38.96
DMO
Family $77.87
Delta Single Paid by MSU
Dental 2 Person $17.77
PPO
Family $41.40
MSU Retiree Benefits Guide 21Retired Faculty Hired July 1, 2005 to DELTA
DENTAL SERVICE AETNA PREMIUM DMO
June 30, 2010 (MSU Contributes 100% DENTAL
or 50%/50%) Diagnostic and Preventative
Dental
The following rates are for faculty retirees that Exams No co–pay 50% co–pay
have elected 100% MSU coverage for themselves Cleanings No co–pay 50% co–pay
and 0% for a spouse/other eligible individual (OEI)
or 50% MSU coverage for themselves and 50% for X–rays No co–pay 50% co–pay
their spouse/OEI while both retiree and spouse/ Fluoride No co–pay 50% co–pay
OEI are living. (1 per year under age 16) (less than age 19)
PLAN FULL-TIME (90% - 100%) Sealants (to prevent decay $10 co–pay per tooth Not covered
of permanent molars for
Aetna Single $11.34 dependents)
Premium 2 Person $38.96 Space maintainers $80 co–pay 50% co–pay
DMO (fixed and removable) (less than age 19)
Family $77.87
Delta Single Paid by MSU Minor Restorative
Dental 2 Person $17.77 Amalgam (silver) fillings No co–pay 50% co–pay
PPO Composite (resin) fillings No co–pay 50% co–pay
Family $41.40
(anterior teeth)
Prosthetics
Retired Faculty Hired July 1, 2005 to Crowns (semi–precious) $315 co–pay 50% co–pay
June 30, 2010 (MSU Contributes 50%) Bridges (per unit) $315 co–pay 50% co–pay
The following rates are for faculty retirees that Denture (each) $320 co–pay 50% co–pay
have elected 50% coverage for themselves and Partial (each) $320 co–pay 50% co–pay
50% for a spouse/OEI AND either the retiree or
spouse/OEI is deceased or they have divorced Oral Surgery
after retirement. Simple extraction No co–pay 50% co–pay
PLAN FULL-TIME (90% - 100%) Extraction – erupted tooth No co–pay 50% co–pay
Aetna Single $21.07 Extraction – soft tissue $60 co–pay 50% co–pay
Premium 2 Person impaction
$48.69
DMO Extraction – partial bony $80 co–pay 50% co–pay
Family $87.60 impaction
Delta Single $9.73 Extraction – complete bony $120 co–pay 50% co–pay
Dental 2 Person $27.50 impaction
PPO Endontics
Family $51.13
Root canal – anterior $120 co–pay 50% co–pay
Root canal – bicuspid $180 co–pay 50% co–pay
Retired Faculty Hired July 1, 2005 to Root canal – molar $300 co–pay 50% co–pay
June 30, 2010 with 100% Coverage Apicoectomy $170 co–pay 50% co–pay
The following rates are for faculty that have elected Periodontics
100% MSU coverage for themselves and 0% for
a spouse/OEI AND the retiree is deceased. The Gingivectomy (per quadrant) $125 co–pay 50% co–pay
following premiums would be paid by the spouse/ Osseous surgery $375 co–pay 50% co–pay
OEI. (per quadrant)
PLAN FULL-TIME (90% - 100%) Root scaling (per quadrant) $60 co–pay 50% co–pay
Aetna Single $30.79 Orthodontics
Premium 2 Person $58.41 Child (under age 19) $1,500 co–pay 1 50% co–pay
DMO Adult (age 19 or older) $1,500 co–pay 1
Not covered
Family $97.32
1. Includes screening exam, diagnostic records, orthodontic treatment and orthodontic
Delta Single $19.45
retention. Phase 1 orthodontic services are not covered, which includes treatment to
Dental 2 Person $37.22 prepare the mouth to be fully banded or possibly avoid a comprehensive treatment
PPO plan.
Family $60.85
Dental Plan Maximums
Annual No maximum $600 maximum
Lifetime Orthodontics No maximum $600 maximum
The plan summary on this page is intended to help you compare your options. It is not
intended to be a full description of coverages.
22 Visit hr.msu.edu/open-enrollment for all Open Enrollment InformationYou can also read
