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RetireesMedicare BasicsSFHSS requires all retirees and dependents to enroll inMedicare Part A and Part B at least three months beforeturning 65.The Social Security Administration is the federalagency responsible for Medicare eligibility, enrollmentand premiums. Start by downloading the Medicareand You handbook at medicare.gov.Medicare BasicsMedicare is a federal health insurance programadministered by the Centers for Medicare andMedicaid Services (cms.gov) for people age 65years or older, under 65 with Social Security-qualifieddisabilities or anyone with End Stage Renal Disease(permanent kidney failure requiring dialysis ortransplant). The different parts of Medicare helpcover specific types of services: Medicare Part A: Hospital Insurance Medicare Part B: Medical Insurance Medicare Part D: Prescription Drug CoverageAll eligible retired members and covered eligibledependents must enroll in Medicare Part A andPart B. Failure by a member or dependent to enrollin Medicare by the required deadlines will result in achange or loss of medical coverage.If you are not currently receiving Social Security, itis your responsibility to contact the Social SecurityAdministration to apply for Medicare at leastthree months prior to your 65th birthday or if youbecome disabled. Failure to do so could result inpenalties being assessed by the Social SecurityAdministration and the San Francisco HealthService System.If you have a Social Security-qualified disability or EndStage Renal Disease, you should contact the SocialSecurity Administration immediately to apply forMedicare.2In the case where an SFHSS member and theircovered dependent(s) are enrolled in a Blue Shieldof California HMO plan (Access or Trio HMO), wheneither member or dependent(s) become eligible forMedicare, they must enroll in the UnitedHealthcareMedicare Advantage PPO plan.Medicare Part A: Hospital InsuranceSFHSS rules require all retired members anddependents to enroll in premium-free Medicare PartA as soon as they are eligible. Most people do not paya premium for Part A because they made sufficientcontributions via payroll taxes while working.Medicare Part A helps cover inpatient care inhospitals, including critical access hospitals andskilled nursing facilities (but not custodial orlong-term care). It also helps cover hospice care andsome home healthcare. Beneficiaries must meetcertain conditions to qualify for these benefits.You are eligible for premium-free Medicare PartA if you are age 65 or older and have worked andcontributed to Social Security for at least 10 years(40 quarters). You may also qualify for Medicare PartA through a current, former, or deceased spouse.If you are under age 65 and have End Stage RenalDisease or a Social Security-qualified disability, youmay also qualify for Medicare Part A.If you are under age 65 with a qualifying disability,Medicare coverage generally starts 24 to 30 monthsfollowing eligibility. If you have questions about youreligibility for premium-free Medicare Part A, contactthe Social Security Administration at(800) 772-1213.All SFHSS members are required toenroll in Medicare as soon as theybecome eligible or face penalties.Plan Year 2022

RetireesMedicare FAQsMedicare Part B: Medical InsuranceSFHSS rules require that all retired members andtheir dependents enroll in Medicare Part B as soonas they are eligible. Medicare Part B helps coverthe cost of doctors’ services and outpatient medicalservices. Most people pay a monthly premium to thefederal government for Part B. The Medicare Part Bmonthly premium, which is based on your incomeper CMS regulations, is usually deducted from yourSocial Security check. If your income decreases afteryou enroll in Part B, you may be eligible for a PartB premium reduction. For information on MedicarePart B premiums or to request a Part B premiumreduction, contact the Social Security Administration.If you do not enroll in Medicare Part B when you firstbecome eligible, your Part B premium will be higherand penalties may be charged when you do enroll.This higher premium and/or penalty will continue forthe entire time you are enrolled in Medicare.QWhat if I’m not eligible for premium-freeMedicare Part A?AIf you are not eligible for premium-free MedicarePart A, you are not required to enroll in MedicarePart A. You must submit a statement to SFHSS fromthe Social Security Administration verifying that youare not eligible for premium-free Medicare Part A.SFHSS still requires you to enroll in Medicare Part B,even if you are not eligible for Medicare Part A.QWhat if either I or my dependent did notenroll in Medicare Part A and/or Part B whenoriginally eligible?AIf you or a dependent were eligible at age 65 orsooner due to a disability, but did not enroll inMedicare Part A and/or Part B, the Social SecurityAdministration may assess a late enrollment penaltyfor each year in which the individual was eligible butfailed to enroll. SFHSS members and dependentsare required to enroll in Medicare in accordance withSFHSS rules, even if they are paying a federal penaltyfor late Medicare enrollment.Plan Year 2022QWhat happens if I enroll after age 65 or changeSFHSS plans during Open Enrollment?AIf you enroll in Medicare after age 65 or changeMedicare plans during Open Enrollment, your planmay ask you for information about your currentprescription drug coverage. If you fail to respondtimely, CMS may assess a Part D Late EnrollmentPenalty (LEP). Contact your new plan or SFHSS ifyou have questions.QWhat is the SFHSS penalty for not enrollingin Medicare Part A and B when eligible orfor failing to pay Medicare premiums afterenrollment?AFor Medicare-eligible SFHSS members not enrolledin Medicare or who fail to pay their Medicarepremium(s), existing SFHSS medical plan coveragewill be terminated and the member will beautomatically enrolled in Blue Shield of CA PPOAccolade 20. For Medicare-eligible dependents notenrolled in Medicare, SFHSS medical coverage willbe terminated. Full SFHSS coverage for a member ordependent may be reinstated at the beginning of thenext available coverage period after SFHSS receivesproof of Medicare enrollment.Blue Shield of CA PPO-Accolade 20 significantlyincreases premium and out-of-pocket costs. UnderAccolade 20, you will be responsible for paying the80% that Medicare would have paid for a coveredservice, plus any amounts above usual and customaryfees.In addition, under Blue Shield of CA PPO-Accolade20, yearly out-of-pocket limits increase to 10,950.For information on Blue Shield of CA PPO-Accolade20, visit sfhss.org/BSC-PPO-Accolade-20.3

RetireesMedicare FAQsDo not enroll in a third party individual Medicare Part Dprescription drug plan. Doing so will result in the termination ofyour SFHSS medical coverage.Medicare Part D: Prescription Drug InsuranceThere are two types of Medicare Part D prescriptionplans: individual and group. Individual Part Dprescription drug coverage is purchased directly byan individual from an insurer or pharmacy.QAIf you are charged a Part D premium, but yourincome changes and falls below the threshold,contact Social Security to request an adjustment.Medicare enrollees with income exceeding certainthresholds are charged a monthly Part D premiumalso known as the Income Related Monthly AdjustedAmount (IRMAA). In most cases, this Part D premiumwill be deducted from your Social Security check.UHC Medicare Advantage PPO members will receiveonly one card that covers medical and pharmacyservices.Should either I or my dependents enroll inMedicare Part D?ADo not enroll in any third party Medicare Part Dprescription drug plan.If you are Medicare-eligible, enhanced groupMedicare Part D drug coverage is included with yourSFHSS Medicare plan.Private insurance companies, pharmacies, and otherentities may try to sell you an individual Medicare PartD prescription drug plan.If you enroll in any private, individual Medicare PartD prescription drug plan, your Medicare coveragewill be assigned to that plan and your SFHSS groupmedical coverage will be terminated.You may be required to pay a Part D premium tothe Social Security Administration if your incomeexceeds acertain threshold.SFHSS members should not enroll in any individualMedicare Part D plan. SFHSS members areautomatically enrolled in group prescription drugcoverage under Medicare Part D when they enrollin any medical plan offered through SFHSS. SFHSSmedical plans offer enhanced group Medicare Part Dprescription drug coverage.QAm I required to pay a premium forMedicare Part D?For information on Medicare Part D premiums,visit ms.html or call Social Security at(800) 772-1213.QWhat is the SFHSS penalty if I or mydependent fail to pay a Part D premium toSocial Security?ARetirees and dependents who fail to pay a requiredPart D premium will result in Part D coverage beingterminated by the Social Security Administration.Consequently, SFHSS medical coverage will alsobe terminated. SFHSS members who have lost PartD eligibility due to lack of payment will be enrolledin Blue Shield of CA PPO-Accolade 20 memberonly coverage and their dependent coverage willbe terminated. Full SFHSS medical coverage fora member or dependent may be reinstated at thebeginning of the next available coverage periodafter SFHSS receives proof of Medicare Part Dreinstatement.If you are enrolled in Medicare, do not enroll in any outside Part D plans. Prescription benefitsare already included in your SFHSS medical plan. Doing so will terminate your coverage.4Plan Year 2022

RetireesEnrolling in Retiree Health BenefitsNEW Retirees: Don’t Miss the 30-Day Deadline. Thetransition of health benefits from active employee toretiree status does not happen automatically.You must enroll in retiree health coverage as a retireeby submitting a Retiree Enrollment Application formand supporting documents by fax to (628) 6524701 or mail to SFHSS by the required deadlines.Get started by visiting sfhss.org/benefits/gettingready-to-retire.If a new Retiree does not complete enrollment inretiree health coverage within 30 calendar days ofyour retirement date, you will only be able to enrollin benefits during the next Open Enrollment period(unless you have a Qualifying Life Event).New retirees should plan ahead. If you are Medicareeligible, you must be enrolled in Medicare to keepSFHSS benefits. See pages 3 and 4 for MedicareFAQs.Your SFHSS retiree premium contributions will bededucted from your monthly pension check. Be sureto review your monthly check to verify that the correctpremium contribution is being deducted. If yourpension check does not cover your required premiumpayment, you must make payments directly throughthe City of San Francisco Payment Portal.To create an account to make online payments, visitsfhss.org/how-make-payment. You can schedulerecurring payments through the portal. There are noservice fees for payment by electronic check.All Medicare-eligible retirees and dependentsmust maintain continuous enrollment in Medicare.To ensure that there is no break in your medicalcoverage, you must pay all Medicare premiums thatare due to the federal government on time.Open Enrollment is your annual opportunity tochange your benefit elections for you and your eligibledependents without a qualifying event. Changes madeduring the October Open Enrollment period becomeeffective January 1, 2022.Outside of Open Enrollment, you can only makechanges to benefit elections during the plan year ifthere is a Qualifying Life Event.To be eligible for retiree health benefits, employeeshired after January 9, 2009 must have at least fiveyears of credited service with a City employer: Cityand County of San Francisco, San Francisco UnifiedSchool District, City College of San Francisco, orSuperior Court of San Francisco. Other governmentservice is not credited.Make sure you understand the City Charterrules determining your eligibility and premiumcontributions before finalizing your retirement date.See page 27 for more information.And remember.Depending on your retirement date, there can be agap between when employee coverage endsand retiree coverage begins. Setting your retirementdate at the end of the month will help to avoid gapsin SFHSS coverage.For instructions on how to make online payments, goto sfhss.org/how-make-payment.Questions about health benefits, premiumcontributions or eligibility documentation?Call (628) 652-4700.Plan Year 20225

RetireesService Areas for Retirees without MedicareCountyAlamedaBlueShieldof CAHealthNetKaiserPerm.CanopyCare HMONonMedicareHMOTrio HMONonMedicareHMOAccess neAmador ButtenCalaverasColusaContra CostanBlueShieldof CACountyPPOAccoladeNonMedicarePPOBlueShieldof CAHealthNetCanopyCare HMONonMedicareHMOTrio HMONonMedicareHMOKaiserPerm.Access HMONonMedicareHMOnOrangennnnPlacer nnPlumasnRiverside n nnSacramento nnnnSan BenitonSan Bernardino n nnnnnnnnnnnSan DiegoEl Dorado nSan FranciscoFresno n nSan JoaquinnnnSan Luis Obispo nnSan MateonnnSanta BarbaraGlennHumboldtImperial Kingsnnnnnnn nSanta Clarannn n nSanta Cruznnn nn InyoKernPPOAccoladeNonMedicarePPOnnDel NorteTraditionalNonMedicareHMOBlueShieldof CAnnnShastanLakenSierranLassennSiskiyounLos Angelesn nSolano n nSonoma nnnStanislaus Ventura n nnYolo n nnYuba nOutside CA n evada nnnn nnnnn n nn Available in this county Available in some zip codes OR, WA, HIBlue Shield of California PPO AccoladeNon-Medicare members and their non-Medicare dependents who lack geographic access to Trio HMO or Access HMO, both offered by Blue Shield of California, Health Net CanopyCare HMO, or Kaiser Permanente HMO, areeligible to enroll in Blue Shield of California Accolade PPO with lower premiums.6Plan Year 2022

RetireesService Areas for Retirees with MedicareKaiserPermanenteUnitedHealthcareSenior AdvantageHMOMedicareAdvantageOrangennnPlacer nnPlumasButtenRiverside nCalaverasnSacramentonnColusanSan BenitonSan Bernardino nnSan Diego or AdvantageHMOMedicareAdvantagennAlpineAmador Contra CostanDel NorteCountyPPOPPOnnEl Dorado nSan FrancisconnFresno nSan JoaquinnnGlennnSan Luis ObispoHumboldtnSan MateoImperialnSanta BarbaraInyonnnnnSanta Clara nKern nSanta Cruz nKings nShastannSierranLakeLassennSiskiyouLos Angeles nSolanonnMadera nSonoma nMarinnnStanislausnnMariposa nSutter TuolumneMontereynVentura nnYolo nnYuba nOutside CA NapanNevadan nn Available in this county Available in some zip codes OR, WA, HI Service area includes all 50 states, District of Columbia, Puerto Rico, the United States Virgin Islands, Guam,American Samoa, and the Northern Mariana IslandsMoving? Change of Address? Contact SFHSS (628) 652-4700 or visit sfhss.org/change-address.If you move out of the service area covered by your plan, you must elect an alternate medical plan thatprovides coverage in your area. Failure to change your elections may result in non-payment of claimsfor services rendered.Plan Year 20227

Retirees2022 Medical PlansHEALTH NET CANOPYCAREBLUE SHIELD OF CALIFORNIACANOPYCARE HMOTrio HMO and Access HMODEDUCTIBLESNo DeductibleNo DeductibleAnnual out-of-pocket maximum 2,000/individual; 4,000/familyAnnual out-of-pocket maximum 2,000/individual; 4,000/familyRoutine PhysicalNo chargeNo chargeMost Immunizations and InoculationsNo chargeNo chargeWell Woman Exam and Family PlanningNo chargeNo chargeRoutine Pre/Post-Partum CareNo chargeNo charge visits limited; see EOCOffice and Home Visits 25 co-pay 25 co-payInpatient Hospital VisitsNo chargeNo chargePharmacy: Generic Drugs 10 co-pay 30-day supply 10 co-pay 30-day supplyPharmacy: Brand-Name Drugs 25 co-pay 30-day supply 25 co-pay 30-day supplyPharmacy: Non-Formulary Drugs 50 co-pay 30-day supply 50 co-pay 30-day supplyMail Order: Generic Drugs 20 co-pay 90-day supply 20 co-pay 90-day supplyMail Order: Brand-Name Drugs 50 co-pay 90-day supply 50 co-pay 90-day supplyMail Order: Non-Formulary Drugs 100 co-pay 90-day supply 100 co-pay 90-day supplyDeductible and Out-of-Pocket Maximum(Medical)PREVENTIVE CAREPHYSICIAN AND OTHER PROVIDER CAREPRESCRIPTION DRUGS20% coinsurance20% coinsuranceup to 100 per prescription, 30-day supplyup to 100 per prescription, 30-day supplyNo chargeNo charge 100 co-pay waived if hospitalized 100 co-pay waived if hospitalized 25 co-pay in-network and out-of-network 25 co-pay in-networkInpatient 200 co-pay per admission 200 co-pay per admissionOutpatient 100 co-pay per surgery 100 co-pay per surgerySpecialty DrugsOUTPATIENT SERVICESDiagnostic X-ray and LaboratoryEMERGENCYHospital Emergency RoomUrgent Care FacilityHOSPITAL / SURGERY82019Plan Year 2022

Retirees without MedicareKAISER PERMANENTEBLUE SHIELD OF CALIFORNIA PPO-ACCOLADETraditional HMOIn-Network or Out-of-AreaNo DeductibleOut-of-Network 250 Deductible Retiree only 500 Deductible 1 750 Deductible 2 or more 500 Deductible Retiree only 1,000 Deductible 1 1,500 Deductible 2 or moreAnnual out-of-pocket maximum 3,750/person; 7,500/FamilyAnnual out-of-pocket maximum 7,500/personNo charge100% covered no deductible50% covered after deductibleNo charge100% covered no deductible100% covered no deductibleNo charge100% covered no deductible50% covered after deductibleNo charge visits limited; see EOC85% covered after deductible50% covered after deductible 20 co-pay85% covered after deductible50% covered after deductibleNo charge85% covered after deductible50% covered after deductible 5 co-pay 30-day supply 10 co-pay 30-day supply 15 co-pay 30-day supply 25 co-pay 30-day supplyPhysician authorized only 50 co-pay 30-day supply 10 co-pay 100-day supply 20 co-pay 90-day supplyNot covered 30 co-pay 100-day supply 50 co-pay 90-day supplyNot coveredPhysician authorized only 100 co-pay 90-day supplyNot covered 50 co-pay 30-day supply 50 co-pay, plus 50% Coinsurance;30-day supplyNo charge85% covered after deductible50% covered after deductible; prior notification 100 co-pay waived if hospitalized85% covered after deductible; if non-emergency50% after deductible85% covered after deductible; if non-emergency50% after deductible 20 co-pay85% covered after deductible50% covered after deductible 100 co-pay per admission85% covered after deductible; notification required50% covered after deductible; notification required 35 co-pay85% covered after deductible50% covered after deductibleAnnual out-of-pocket maximum 1,500/individual; 3,000/family20% coinsurance up to 100 perprescription, 30-day supply 10 co-pay plus 50% coinsurance;30-day supply 25 co-pay plus 50% coinsurance;30-day supply 50 co-pay, plus 50% coinsurance;30-day supplyEach plan’s Evidence of Coverage (EOC) contains a complete list of benefits and exclusions. If any discrepancy exists9between the information provided in this Guide and the EOC, the EOC shall prevail. Download EOCs at sfhss.org.Plan Year 2019

Retirees2022 Medical PlansHEALTH NET CANOPYCAREBLUE SHIELD OF CALIFORNIACANOPYCARE HMOTrio HMO and Access HMOREHABILITATIVEPhysical/Occupational TherapyAcupuncture/Chiropractic 25 co-pay per visit 25 co-pay per visit 15 co-pay 30 visits of each max per 15 co-pay 30 visits of each max perplan year; ASH networkplan year; ASH networkGENDER DYSPHORIAOffice Visits and Outpatient SurgeryCo-pays applyauthorization requiredCo-pays applyauthorization requiredDURABLE MEDICAL EQUIPMENTHome Medical EquipmentNo chargeNo chargeNo chargeNo chargebased upon allowed chargesbased upon allowed chargesNo chargeNo chargewhen medically necessarywhen medically necessaryEvaluation no charge up to 5,000combined for both ears, every 36 monthsEvaluation no charge 1 aid per ear,every 36 months, up to 2,500 eachInpatient Hospitalization 200 co-pay per admission 200 co-pay per admissionOutpatient Treatment 25 co-pay non-severe and severe 25 co-pay non-severe and severeInpatient Detox 200 co-pay per admission 200 co-pay per admissionResidential Rehabilitation 200 co-pay per admission 200 co-pay per admissionNo chargeNo chargeup to 100 days/yearup to 100 days/yearNo chargeNo chargeauthorization requiredauthorization requiredUrgent care 25 co-payUrgent care 50 co-pay guest membershipbenefits for college students in some areasDiabetic Monitoring SuppliesProsthetics/OrthoticsHearing AidsMENTAL HEALTHEXTENDED & END-OF-LIFE CARESkilled Nursing FacilityHospiceOUTSIDE SERVICE AREACare Access

STEP 7:Complete your eBenefits elections online. Refer to the enclosed Self-Service instructions attached to your letter or go to sfhss.org/ebenefits to get started. Be sure to click Save and Continue through each screen. You must click Submitat the end in order to complete your enrollment. Otherwise your elections will not be recorded.