STATE OF ILLINOIS
Department of Central Management Services
Bureau of Benets
FY 2025
State Employees Group
Insurance Program
Benet Choice Period
May 1 - May 31, 2024 • Effective July 1, 2024
ONLINE ENROLLMENT PLATFORM
Making benet elections is simple through the MyBenets website.
Follow these steps:
1. Go to MyBenets.illinois.gov.
2. In the top right corner of the home page, click Login.
3. If you are logging in for the rst time, click Register in the bottom
right corner of the login box and follow the prompts. You will need
to provide your name as printed on the Benet Choice materials
mailed to your home.
4. Enter your login ID and password. After logging in and landing on
the welcome page, explore your benet options by clicking on the
benet tiles.
5. After exploring your benet options and determining which
benets you would like to elect, click on the Benet Choice Event,
located on the Welcome page.
WHAT YOU NEED TO DO
1. Go to MyBenets.illinois.gov to review your benet options.
2. Choose the benets you’d like to elect at MyBenets.illinois.gov
between May 1 - May 31, 2024.
3. Provide, or update your email address at MyBenets.illinois.gov
to receive quick responses and notications through electronic
communications.
4. Take advantage of your new benets which will become
effective July 1, 2024.
Note: If you are not currently enrolled in benets due to previous
nonpayment of premiums, contact the Premium Collection Unit
at 217-558-4783 to discuss your enrollment options.
DISCLAIMER
Monthly health insurance contributions are based on your
March 1st salary, or initial salary for new hires. Your monthly
contribution amount reflected within this site is based on the salary
reported on your paycheck for the rst pay period in March, and will
be adjusted as necessary, if updated information is provided.
Need Help?
AVA, the interactive digital assistant, is available online at
MyBenets.illinois.gov
Or
Contact MyBenets Service Center (toll-free)
844-251-1777, or 844-251-1778 (TDD/TTY) with inquiries.
Representatives are available
Monday – Friday, 8:00 AM - 6:00 PM CT.
Table of Contents
Benet Choice Period
What's New.....................1
Be Well Illinois ..................1
What is Available in Your Area .....2
Monthly Contributions ............3
Dependent Monthly Contributions . .3
Adding a Dependent .............4
Opt-Out........................4
Transition of Care................4
Medicare Requirements . . . . . . . . ..4
Health Plans
HMO Benets...................5
Open Access Plan (OAP) Benets ..6
Quality Care Health Plan
(QCHP) Benets ...............7
Consumer Driven Health Plan
(CDHP) Benets ...............8
Flexible Spending Accounts (FSA) and
Health Savings Accounts (HSA)
MCAP .........................9
DCAP .........................9
HSA...........................9
Vision......................... 10
Dental ........................ 10
Life .......................... 11
Contacts . . . . . . . . . . . . . . . . . . . . . . 12
Federally Required Notices ...... 13
FY2025 Benet Choice Options
SEGIP 1MyBenets.illinois.gov
Benet Choice Period
Elect Your Benets May 1 - May 31, 2024
What’s New
Health Plan Availability
There are several changes this year. It is your responsibility to verify what Health Plans are available in
your area (see page 2).
A New Enhanced Delta Dental Benets Program
The Delta Dental of Illinois’ Enhanced Benets Program integrates medical and dental care – where oral
health meets overall health. This program enhances coverage for individuals who have specic health
conditions that can be positively affected by additional oral health care. These enhancements are based
on scientic evidence that shows treating and preventing oral disease in these situations can improve
overall health. For more information on this program please go to www.deltadentalil.com or by calling
them at 1-800-323-1743.
Additional Vision Benets
The Vision Plan administered by EyeMed now offers additional coverage for Progressive Lenses,
Premium Anti-Reflective Coating and coverage for Photochromic and Polarized lenses. For additional
information, please visit the State Vision Plan page at MyBenets.illinois.gov.
The State of Illinois’ ongoing comprehensive approach to wellness.
The State of Illinois cares about you and your health.
Be Well Illinois is designed to not only focus on supporting your physical
health but also your mental, nancial, and social wellbeing. As a wellness
plan member, you can use this site to access health plan information
and educational resources including wellness webinars, monthly health
awareness causes, nancial wellness, healthy eating, and exercise.
While the decision to make healthy lifestyle changes is your choice and not
a job requirement, the hope is that by creating an environment where these
choices are supported by the work culture makes it easier and supports
your success.
Engaging with Be Well Illinois is easy, connect with us in one of the following ways.
Visit us at www.Illinois.gov/BeWell
Follow us on Facebook at https://www.facebook.com/BeWellIllinois
Or email us at BeW[email protected]v
FY2025 Benet Choice Options
2
What is Available in Your Area in FY25
Review the following map and charts to identify plans available in your county.
Then, review your monthly contribution and plan benets to determine which plan is
best for you.
Please note: This map is
accurate as of the printing of
this book; however changes may
occur without notice. Always
contact the appropriate plan
for verication of provider
status in your area. See page
12 to contact plan providers.
HMO Illinois
Blue Advantage HMO
Health Alliance HMO
Aetna HMO
HealthLink OAP (except Iroquois - no tier 1)
Aetna OAP
Blue Cross Blue Shield OAP
Consumer Driven Health Plan (CDHP)
Quality Care Health Plan (QCHP)
Health Alliance HMO
Aetna HMO
Aetna OAP
BCBS OAP
Consumer Driven Health Plan (CDHP)
Quality Care Health Plan (QCHP)
HMO Illinois
Blue Advantage HMO
HealthLink OAP
Aetna OAP
Blue Cross Blue Shield OAP
Consumer Driven Health Plan (CDHP)
Quality Care Health Plan (QCHP)
HMO Illinois
Health Alliance HMO
Aetna HMO
HealthLink OAP
Aetna OAP
BCBS OAP
Consumer Driven Health Plan (CDHP)
Quality Care Health Plan (CDHP)
Aetna HMO
Aetna OAP
Health Alliance HMO
Consumer Driven Health Plan (CDHP)
Quality Care Health Plan (QCHP)
Aetna HMO
Aetna OAP
BCBS OAP
Health Alliance HMO
Consumer Driven Health Plan (CDHP)
Quality Care Health Plan (QCHP)
Health Alliance HMO
Aetna HMO
HealthLink OAP
Aetna OAP
BCBS OAP
Consumer Driven Health Plan (CDHP)
Quality Care Health Plan (QCHP)
SEGIP 3MyBenets.illinois.gov
Monthly Contributions
The State shares the cost of health coverage with you. While the State covers most of the cost, you must make
monthly contributions determined by your annual salary. The following charts outline monthly contribution rates
for full-time members. Part-time members are required to pay a percentage of the State’s portion of the monthly
contribution in addition to their own. Special rules apply for non-IRS dependents (see MyBenets.illinois.gov for
more information).
Employee
Annual Salary
Aetna
HMO
Blue
Advantage
Health
Alliance
Illinois
HMO
Illinois
Aetna
OAP
BCBSIL*
OAP
HealthLink
OAP
CDHP**
QCHP***
$30,200 & below $130 $104 $130 $108 $124 $124 $138 $105 $144
$30,201 - $45,600 $149 $123 $149 $127 $143 $143 $157 $124 $163
$45,601 - $60,700 $168 $142 $168 $146 $162 $162 $176 $143 $181
$60,701 - $75,900 $186 $160 $186 $164 $180 $180 $194 $161 $200
$75,901 - $100,000 $205 $179 $205 $183 $199 $199 $213 $180 $219
$100,001 - $125,000 $259 $233 $259 $237 $253 $253 $267 $234 $273
$125,001 - and over $292 $266 $292 $270 $286 $286 $300 $267 $306
Members who retire, accept a salary reduction, or return to State employment at a different salary may have their monthly
contribution adjusted based upon the new salary. This applies to members who return to work after having a 10-day or greater
break in State service after terminating employment. This does not apply to members who have a break in coverage due to a
leave of absence.
Dependent Monthly Health Plan Contributions
In addition to monthly contributions for their own health coverage, members must make additional monthly
contributions for dependents they cover. Dependents must be enrolled in the same plan as the member. The
Medicare dependent monthly contribution applies only if the member is a retiree or annuitant and Medicare is
primary for both Parts A and B.
Number of
Dependents
Aetna
HMO
Blue
Advantage
Health
Alliance
Illinois
HMO
Illinois
Aetna
OAP
BCBSIL*
OAP
HealthLink
OAP
CDHP**
QCHP***
1 Dependent $201 $164 $201 $168 $192 $192 $210 $175 $297
2+ Dependents $246 $200 $247 $207 $237 $237 $263 $219 $335
1 Medicare A & B
Primary Dependent
$178 $143 $177 $147 $169 $169 $186 $152 $190
2+ Medicare A & B
Primary Dependents
$220 $178 $221 $184 $211 $211 $233 $193 $251
DISCLAIMER
Retiree, annuitant, and survivor contributions for all health plan options will be in accordance with the levels set forth above
in FY25. For future years, the State reserves the right to designate the plan options which constitute the basic program of
health benets and to require additional contributions in accordance with the law for any optional coverage elected by an
annuitant, retiree, or survivor.
* BCBSIL OAP = Blue Cross Blue Shield of Illinois
** CDHP = Consumer Driven Health Plan
*** QCHP = Quality Care Health Plan
FY2025 Benet Choice Options
4
Adding a Dependent
If you add a dependent for the rst time, or re-enroll a dependent during open enrollment, you must provide
the required documentation to complete enrollment no later than June 10, 2024. Failure to provide adequate
documentation by this deadline, will result in dependents not being added to your plan. Note: Any documentation
received after May 31, 2024, may result in a delay of ID cards.
Opt-Out
Full-time employees, retirees, annuitants, and survivors have the option to opt-out of health coverage if they
have other comprehensive coverage provided by an entity other than the Department of Central Management
Services. Be advised that if you have previously opted out, or waived benets, you can re-enroll during the
Benet Choice Period or if you experience a Qualifying Change in Status.
Transition of Care after Health Plan Change
Members and their dependents who elect to change health plans and are then hospitalized prior to July 1, 2024
and discharged on or after July 1, 2024, are involved in an ongoing course of treatment, or have entered the
third trimester of pregnancy, should contact their new plan administrator before July 1, 2024 to coordinate the
transition of services.
State Employees Group Insurance Program
Medicare Requirements
Retirees and survivors must apply for Medicare benets upon turning age 65. If the Social Security
Administration (SSA) determines that the member and/or dependent is eligible for Medicare Part A and/or Part B,
the member and/or dependent is required by the State to enroll in Medicare Parts A and B. Those on a disability
leave are also required to apply for Medicare Part A and B. Once enrolled in Medicare, the member and/or
dependent is required to fax or email the front-side copy of the Medicare identication card to the State of Illinois
Medicare COB Unit (contact information below).
If the SSA determines that a member and/or dependent is not eligible for premium-free Medicare Part A based
on their own work history or the work history of a spouse (current, ex-spouse or deceased) at least 62 years of
age, the member must request a written statement of the Medicare ineligibility from the SSA. Upon receipt, the
written statement must be forwarded to the State of Illinois Medicare COB Unit to avoid a nancial penalty.
For more information regarding the Medicare Advantage Prescription Drug “TRAIL” Program, go to
https://cms.illinois.gov/benets/trail.html, or contact:
State of Illinois Medicare COB Unit
PO Box 19208
Springeld, Illinois 62794-9208
[email protected]v
Fax: 217-557-3973
SEGIP 5MyBenets.illinois.gov
HMO Benets
Health Maintenance Organization (HMO) members are required to stay within the health plan provider network.
No out-of-network services are available, other than listed below. Members will need to select a primary care
physician (PCP) from a network of participating providers. The PCP will direct all healthcare services and make
referrals to specialists and hospitalization. Benets are outlined in each plan’s Summary Plan Document (SPD). It
is the member’s responsibility to know and follow the specic requirements of the HMO plan selected. For a copy
of the SPD, contact the plan administrator (see page 12).
HMO Plan Design
Plan Year Out-of-Pocket Maximum $3,000 Individual $6,000 Family
Hospital Services
In-Network Out-of-Network
Emergency Room Services $275 copayment per visit $275 copayment per visit
Inpatient Hospitalization $425 copayment per admission Not covered
Inpatient Alcohol and Substance Abuse $425 copayment per admission Not covered
Inpatient Psychiatric Admission $425 copayment per admission Not covered
Outpatient Surgery $300 copayment per visit Not covered
Skilled Nursing Facility 100% covered Not covered
Diagnostic Lab and X-ray 100% covered Not covered
Complex Imaging (CT/Pet Scans/MRIs) $30 copayment Not covered
Transplant Services
Organ and Tissue
Transplants
$375 copay limited to network transplant facilities as determined by the medical plan administrator.
To assure coverage, the transplant candidate must contact your plan provider prior to beginning
evaluation services.
Professional and Other Services
In-Network Out-of-Network
Preventive Care/Well-Baby/Immunizations 100% covered Not covered
Physician Ofce Visit $30 copayment per visit Not covered
Specialist Ofce Visit $40 copayment per visit Not covered
Telemedicine $10 copayment Not covered
Outpatient Psychiatric and Substance
Abuse
$30 or $40 copayment per visit Not covered
Durable Medical Equipment 80% covered Not covered
Home Health Care $40 copayment per visit Not covered
Complex Imaging (CT/Pet Scans/MRIs) $30 copayment Not covered
Prescription Drugs
Plan Year Pharmacy Deductible – $150 per enrollee Preventive Prescription Drugs – $0
Reduced Tier I * Tier I Tier II Tier III
Copayments (30-day supply) $4.00 $20.00 $35.00 $60.00
Copayments (90-day supply) $10.00 $50.00 $87.50 $150.00
* Applies to specic medications as dened by the plan.
Some HMOs may have benet limitations based on a calendar year.
FY2025 Benet Choice Options
6
Open Access Plan (OAP) Benets
Open Access Plan (OAP) members will have three tiers of providers from which to choose to obtain services.
• Tier I offers a managed care network which provides enhanced benets and operates similar to an HMO.
• Tier II offers an expanded network of providers and is a hybrid plan operating like an HMO and PPO.
• Tier III covers all providers which are not in the managed care networks of Tiers I or II (out-of-network
providers). It is the member’s responsibility to know and follow the specic requirements of the OAP.
Benets are outlined in the plan's Summary Plan Document (SPD). For a copy of the SPD, contact the
plan administrator (see page 12).
Benet Tier I Tier II
Tier III (Out-of-
Network)**
Plan Year Out-of-Pocket Maximum
• Per Individual
• Per Family
$3,000 (includes eligible charges from Tiers I & II combined)
$6,000 (includes eligible charges from Tiers I & II combined)
Not Applicable
Plan Year Deductible (must be
satised for all services)
$0
$300 per enrollee* $400 per enrollee*
Hospital Services (Percentages listed represent how much is covered by the plan)
Emergency Room Services $275 copayment per visit $275 copayment per visit $275 copayment per visit
Inpatient Hospitalization
$425 copayment per admission
90% of network charges after
$475 copayment per admission*
60% of allowable charges after
$575 copayment per admission*
Inpatient Alcohol and
Substance Abuse
$
425
copayment per admission
90% of network charges after
$475 copayment per admission*
60% of allowable charges after
$575 copayment per admission*
Inpatient Psychiatric Admission
$
425
copayment per admission
90% of network charges after
$475 copayment per admission*
60% of allowable charges after
$575 copayment per admission*
Outpatient Surgery $300 copayment per visit
90% of network charges after
$300 copayment*
60% of allowable charges after
$300 copayment*
Skilled Nursing Facility 100% covered 90% of network charges* Not covered
Diagnostic Lab and X-ray 100% covered 90% of network charges* 60% of allowable charges*
Complex Imaging (CT/Pet Scans/MRIs)
$30 copayment 90% of network charges* 60% of allowable charges*
Transplant Services
Organ and Tissue
Transplants
Tier I: 100% covered. Tier II: 90% of network charges. Tier III: Not covered. To assure coverage,
the transplant candidate must contact your plan provider prior to beginning evaluation services.
Professional and Other Services
Preventive Care/Well-Baby
/Immunizations
100% covered 100% covered Not covered
Physician Ofce Visits $30 copayment 90% of network charges* 60% of allowable charges*
Specialist Ofce Visits $40 copayment 90% of network charges* 60% of allowable charges*
Telemedicine $10 copayment Not covered Not covered
Outpatient Psychiatric and
Substance Abuse
$30 or $40 copayment 90% of network charges* 60% of allowable charges*
Durable Medical Equipment 80% of network charges 80% of network charges* 60% of allowable charges*
Home Health Care $40 copayment 90% of network charges* Not covered
Prescription Drugs
Plan Year Pharmacy Deductible – $150 per enrollee Preventive Prescription Drugs – $0
Tier I Tier II Tier III
Copayments (30-day supply) $20.00 $35.00 $60.00
Copayments (90-day supply)*** $50.00 $87.50 $150.00
Maintenance Choice (90-day supply)**** $25.00 $43.75 $75.00
* A plan year deductible must be met before Tier II and Tier III plan benets apply. Benet limits are measured on a plan year basis.
** Using out-of-network services may signicantly increase your out-of-pocket expense. Amounts over the plan’s allowable charges do not count
toward your plan year out-of-pocket maximum; this varies by plan and geographic region.
*** If a member or dependent elects a higher Tier drug where a lower Tier drug is available, the member or dependent is responsible for the higher
copayment plus the difference in cost between the drugs.
**** Medications received at CVS Caremark® Retail Pharmacy or through CVS Caremark® Mail Service Pharmacy.
SEGIP 7MyBenets.illinois.gov
Quality Care Health Plan (QCHP) Benets
Quality Care Health Plan (QCHP) members may choose any physician or hospital for medical services; however,
when receiving services from a QCHP in-network provider, members receive enhanced benets, resulting
in lower out-of-pocket costs. QCHP has a nationwide network of providers through Aetna PPO. Benets are
outlined in the plan’s Summary Plan Document (SPD). It is the member’s responsibility to know and follow the
specic requirements of the QCHP. For a copy of the SPD, contact the plan administrator (see page 12).
Plan Year Maximums and Deductibles
Employee’s Annual Salary (based on each
employee’s annual salary as of March 1st)
Individual Plan
Year Deductible
Family Plan Year
Deductible Cap
$60,700 or less $425 $1,000
$60,701 - $75,900 $525 $1,250
$75,901 and more $575 $1,375
Retiree/Annuitant/Survivor $425 $1,000
Dependents $425 N/A
Out-of-Pocket Maximum Limits
In-Network Individual
$1,750
In-Network Family
$4,375
Out-of-Network Individual
$7,000
Out-of-Network Family
$13,500
Hospital Services (Percentages listed represent how much is covered by the plan)
In-Network Out-of-Network*
Emergency Room Services $450 per visit; Deductible applies $450 per visit; Deductible applies
Inpatient Hospitalization
85% of network charges; Deductible applies
after $200 per admission
60% of allowable charges; Deductible applies
after $800 per admission
Inpatient Alcohol and Substance Abuse
85% of network charges; Deductible applies
after $200 per admission
60% of allowable charges; Deductible applies
after $800 per admission
Inpatient Psychiatric Admission
85% of network charges; Deductible applies
after $200 per admission
60% of allowable charges; Deductible applies
after $800 per admission
Outpatient Surgery 85% of network charges; Deductible applies 60% of allowable charges; Deductible applies
Skilled Nursing Facility 85% of network charges; Deductible applies 60% of allowable charges; Deductible applies
Diagnostic Lab and X-ray 85% of network charges; Deductible applies 60% of allowable charges; Deductible applies
Complex Imaging (CT/Pet Scans/MRIs) 85% of network charges; Deductible applies 60% of allowable charges; Deductible applies
Transplant Services
Organ and Tissue
Transplants
85% after $200 transplant deductible, limited to network transplant facilities as determined by
the medical plan administrator. Benets are not available unless approved by the Notication
Administrator. To assure coverage, contact Aetna prior to beginning evaluation services.
Professional and Other Services
In-Network Out-of-Network*
Preventive Care/Well-Baby/Immunizations 100% covered 60% of allowable charges; Deductible applies
Physician Ofce Visit
85% of network charges; Deductible applies
60% of allowable charges; Deductible applies
Specialist Ofce Visit
85% of network charges; Deductible applies
60% of allowable charges; Deductible applies
Telemedicine
85% of network charges; Deductible applies
Does Not Apply
Outpatient Psychiatric and Substance Abuse
85% of network charges; Deductible applies
60% of allowable charges; Deductible applies
Durable Medical Equipment
85% of network charges; Deductible applies
60% of allowable charges; Deductible applies
Home Health Care
85% of network charges; Deductible applies
60% of allowable charges; Deductible applies
Prescription Drugs
Plan Year Pharmacy Deductible – $175 per enrollee Preventive Prescription Drugs – $0
Tier I Tier II Tier III
Copayments (30-day supply) $20.00 $40.00 $65.00
Copayments (90-day supply) $50.00 $100.00 $162.50
Maintenance Choice (90-day supply)** $25.00 $50.00 $81.25
* Using out-of-network services may signicantly increase your out-of-pocket expense. Amounts over the plan’s allowable charges do
not count toward your plan year out-of-pocket maximum; this varies by plan and geographic region.
** Medications received at CVS Caremark® Retail Pharmacy or through CVS Caremark® Mail Service Pharmacy.
FY2025 Benet Choice Options
8
Consumer Driven Health Plan (CDHP) Benets
This is a high-deductible health plan as dened by the IRS. Consumer Driven Health Plan (CDHP) members
may choose any physician or hospital for medical services; however, when receiving services from a CDHP
in-network provider, members receive enhanced benets, resulting in lower out-of-pocket costs. CDHP has
a nationwide network of providers through Aetna PPO. CDHP is available for active employees only, under
the State Employees’ Group Insurance Program. This plan is not available to retirees. Benets are outlined in
the plan’s Summary Plan Document (SPD). It is the member’s responsibility to know and follow the specic
requirements of the CDHP. For a copy of the SPD, contact the plan administrator (see page 12).
Plan Year Medical Deductibles
In-Network Individual
$1,600
In-Network Family
$3,200
Out-of-Network Individual
$1,600
Out-of-Network Family
$3,200
Out-of-Pocket Maximum Limits
In-Network Individual
$3,000
In-Network Family
$6,000
Out-of-Network Individual
$3,000
Out-of-Network Family
$6,000
Hospital Services (Percentages listed represent how much is covered by the plan)
In-Network Out-of-Network*
Emergency Room Services 90% of coinsurance; Deductible applies 90% of coinsurance; Deductible applies
Inpatient Hospitalization 90% of network charges; Deductible applies 65% of allowable charges; Deductible applies
Inpatient Alcohol and Substance Abuse 90% of network charges; Deductible applies 65% of allowable charges; Deductible applies
Inpatient Psychiatric Admission 90% of network charges; Deductible applies 65% of allowable charges; Deductible applies
Outpatient Surgery 90% of network charges; Deductible applies 65% of allowable charges; Deductible applies
Skilled Nursing Facility 90% of network charges; Deductible applies 65% of allowable charges; Deductible applies
Diagnostic Lab and X-ray 90% of network charges; Deductible applies 65% of allowable charges; Deductible applies
Complex Imaging (CT/Pet Scans/MRIs) 90% of network charges; Deductible applies 65% of allowable charges; Deductible applies
Transplant Services
Organ and Tissue
Transplants
90% after plan year deductible, limited to network transplant facilities as determined by the medical
plan administrator. Not covered out-of-network. Benets are not available unless approved by the
Notication Administrator. To assure coverage, contact Aetna prior to beginning evaluation services.
Professional and Other Services
In-Network Out-of-Network*
Preventive Care/Well-Baby/Immunizations 100% covered 65% of allowable charges; Deductible applies
Preventive Services (IRS-allowed)**
90% of network charges; No Deductible
65% of allowable charges; Deductible applies
Physician Ofce Visit
90% of network charges; Deductible applies
65% of allowable charges; Deductible applies
Specialist Ofce Visit
90% of network charges; Deductible applies
65% of allowable charges; Deductible applies
Telemedicine
90% of network charges; Deductible applies
Does Not Apply
Outpatient Psychiatric and Substance Abuse
90% of network charges; Deductible applies
65% of allowable charges; Deductible applies
Durable Medical Equipment
90% of network charges; Deductible applies
65% of allowable charges; Deductible applies
Complex Imaging (CT/Pet Scans/MRIs)
90% of network charges; Deductible applies
65% of allowable charges; Deductible applies
Prescription Drugs
Preventive Prescription Drugs – $0 Preventive Prescription Drugs (IRS-allowed) **
90% covered; No Deductible
Tier I Tier II Tier III
Copayments (30-day supply) 90%; Deductible Applies 90%; Deductible Applies 90%; Deductible Applies
Copayments (90-day supply) 90%; Deductible Applies 90%; Deductible Applies 90%; Deductible Applies
Maintenance Choice (90-day supply)*** 95%; Deductible Applies 95%; Deductible Applies 95%; Deductible Applies
* Using out-of-network services may signicantly increase your out-of-pocket expense. Amounts over the plan’s allowable charges do
not count toward your plan year out-of-pocket maximum; this varies by plan and geographic region.
** Contact Aetna for IRS-allowed services and prescriptions.
*** Medications received at CVS Caremark® Retail Pharmacy or through CVS Caremark® Mail Service Pharmacy.
SEGIP 9MyBenets.illinois.gov
Health Savings Accounts (HSA) for Active State Employees -
Companion to CDHP Enrollment ONLY
EMPLOYEE CONTRIBUTION MUST BE RE-ELECTED EACH PLAN YEAR
An HSA is like a 401(k) for healthcare, yet the HSA tax benets are far greater. Administered by Optum Financial,
the HSA is a tax-favored, interest-bearing account that active State employees can use to pay for qualied
medical expenses now, or in the future. Active State employees who qualify (see Qualifying for an HSA below),
can save, or invest the account funds. Paired with the Consumer Driven Health Plan (CDHP), an HSA is a
powerful nancial tool that gives you more control of your healthcare decisions.
The State will contribute a third of the deductible to an active State employee's HSA. Maximum HSA
contributions (Employer + Employee) for FY25 will be:
• Be covered under a high-deductible health plan.
• Have no other health coverage (except what is
permitted under Other health coverage:
https://www.irs.gov/publications/p969#en_
US_2019_publink1000204039)
• Not be enrolled in Medicare. This includes Part A.
• Not be claimed as a dependent on someone
else’s tax return.
Qualifying for an HSA
To be an eligible individual and qualify for an HSA, you must:
You cannot be enrolled in BOTH an HSA and MCAP Flexible Spending Account.
Contributions to your HSA can be made through pre-tax payroll deductions or post-tax direct payment. Active
State employees can make tax-free withdrawals to pay for qualied medical expenses, for you and your eligible
dependents. HSAs are portable and all contributions rollover to the next plan year. If the employee invests
HSA funds, those funds remain in the investment account. HSAs may be used for future healthcare expenses
including out-of-pocket expenses after retirement, Medicare, and long-term care (LTC) premiums, up to IRS limits
and certain LTC expenses. There are no income limitations.
Under Age 55
Individual Family
Employer Contribution = $533.34 $1,066.68
Employee Contribution = $3,616.66 $7,233.32
Max IRS Allowed Contribution =
$4,150 $8,300
Aged 55 and older
Individual Family
Employer Contribution = $533.34 $1,066.68
Employee Contribution = $4,616.66 $8,233.32
Max IRS Allowed Contribution =
$5,150 $9,300
Medical Care Assistance Program (MCAP) - Companion to your
HMO, OAP, QCHP, or CDHP (if not enrolled in an HSA)
EMPLOYEES MUST RE-ENROLL EACH PLAN YEAR
The MCAP maximum contribution limit is $3,200 for the FY25 plan year period. Funds must be used within the
plan year, July 1, 2024 – June 30, 2025, and all claims must be submitted by September 30, 2025. The rollover
of unused FY25 funds will be capped at $640.00. Participants who do not re-enroll for the new plan year will
forfeit any amount eligible for rollover.
Dependent Care (Day Care) Assistance Program (DCAP)
DCAP is an account that allows you to set aside pre-tax contributions per pay period to pay for dependent care
(Day Care) expenses, for children aged 12 and under, or care for a physically or mentally disabled dependent.
DCAP cannot be used for dependent medical expenses or for children for which you are not considered the
primary or custodial parent. The DCAP maximum contribution limit is $5,000 for the FY25 plan year period. Any
unused DCAP funds at the end of the plan year will be forfeited.
FY2025 Benet Choice Options
10
Vision
Vision coverage is provided at no cost to all members enrolled in a State health plan and is administered by EyeMed.
All enrolled members and dependents receive the same vision coverage regardless of the health plan selected.
Service In-Network Out-of-Network** Benet Frequency
Eye Exam $30 copayment $30 allowance Once every 12 months
Standard Frames $30 copayment
(up to $175 retail
frame cost; member responsible
for balance over $175)
$70 allowance Once every 24 months
Vision Lenses* (single, bifocal
and trifocal)
$30 copayment $50 allowance for
single
vision lenses. $80 allowance
for bifocal and trifocal lenses
Once every 12 months
Contact Lenses
(All contact
lenses are in lieu of vision lenses)
$120 allowance $120 allowance Once every 12 months
* Vision Lenses: Member pays all optional lens enhancement charges. In-network providers may offer additional discounts on lens
enhancements and multiple pair purchases.
** Out-of-network claims must be led within one year from the date of service.
Dental
Employees have the option to enroll in Dental Only coverage. However, if you enroll in health coverage and
choose dental coverage, dependents must mirror the coverage of the member.
The State’s Quality Care Dental Plan (QCDP) offers a comprehensive range of benets and is available to all members
and is administered by Delta Dental of Illinois. Visit MyBenets.illinois.gov for a Dental Schedule of Benets.
Deductible and Plan Year Maximum
Plan year deductible for preventive services N/A
Plan year deductible for all other covered services $175
Plan Year Maximum Benet (Orthodontics + All Other Covered Expenses = Maximum Benet)
In-network plan year maximum benet $2,500
Out-of-network plan year maximum benet $2,000
It is strongly recommended that plan members obtain a pretreatment estimate through Delta Dental for any service more than $200. Failure
to obtain a pretreatment estimate may result in unanticipated out-of-pocket costs.
Child Orthodontia Benet
Length of Orthodontia Treatment* Maximum Benet
In-Network Out-of-Network
0 - 36 Months $2,000 $1,500
0 - 18 Months $1,820 $1,364
0 - 12 Months $1,040 $780
Member Monthly Quality Care Dental Plan (QCDP) Contributions**
Member Only Member + 1 Dependent Member + 2 or More Dependents
$15.00 $25.00 $27.50
* Orthodontia Treatments must start prior to age 19.
** Part-time employees are required to pay a percentage of the State’s portion of the contribution in addition to the member contribution.
Special rules apply for non-IRS dependents (see MyBenets.illinois.gov for more information).
SEGIP 11MyBenets.illinois.gov
Member Optional Life coverage is provided at a cost
to all active employees, retirees, and annuitants.
• For active employees, and retirees and
annuitants under age 60 – coverage is available
up to 8 times their Basic Life amount.
• For retirees and annuitants aged 60 or older –
coverage is available up to 4 times their Basic
Life amount.
The maximum benet allowed for Member Optional
Life plus Basic Life is $3,000,000. Rate changes due to
age will be effective the rst pay-period following the
member’s birthday.
Optional Term Life Rate
Member Age Monthly Rate Per $1,000
Under 30 $0.03
30-39 $0.05
40-44 $0.09
45-49 $0.12
50-54 $0.19
55-59 $0.36
60-64 $0.56
65-69 $1.26
70 and Over $2.06
Accidental Death & Dismemberment (AD&D)
coverage is available to eligible members in an
amount equal to either their Basic Life amount or the
combined amount of their Basic and Member Optional
Life. This coverage is subject to a total maximum of 5
times the Basic Life amount or $3,000,000, whichever
is less.
AD&D Monthly Rate per $1,000
$0.02
Beneciary Elections
Don’t forget to elect your beneciaries at
metlife.com/stateollinois/ and make the appropriate
updates when necessary to ensure that your Life
Insurance benet is paid out according to your
wishes. Remember, you may also have death benets
through various state-sponsored programs, each
having a separate beneciary form, including Life
Insurance, retirement benets, and the Deferred
Compensation Program.
Spouse life coverage is available in a lump sum
amount of $10,000 for:
• The spouse of an active employee.
• The spouse, under age 60, of a retiree or an
annuitant.
A spouse, aged 60 and older, of a retiree or an
annuitant, will have coverage available in the amount
of $5,000. Rate changes due to age will be effective
the rst day of the pay period following the spouse’s
birthday.
Spouse Life Monthly Rates
Spouse Life $10,000 Coverage
(Members, retirees, and annuitants under
aged 60)
$5.70
Spouse Life $5,000 Coverage
(Retirees and annuitants aged 60 and older)
$2.85
Child life coverage is available in a lump sum amount
of $10,000 per child. The monthly contribution applies
to all dependent children regardless of the number
of children enrolled. Eligible children include children
aged 25 and under or, children in the disabled
category.
Child Life Monthly Rate
Child Life $10,000 Coverage
$0.60
Underwriting
A Statement of Health (SOH) is required for members
to add/increase optional life or to add Spouse Life
(unless you are a new hire, or this is a newly acquired
spouse/civil union partner). A Statement of Health is
not needed to add Child Life coverage or AD&D.
Life Insurance
Basic Life Insurance coverage is provided by MetLife at no cost to all active employees, retirees, and annuitants
through the State Employees Group Insurance Program.
• Active employees, retirees, and annuitants under the age of 60, receive a
benet amount equal to their annual salary.
• Retirees and annuitants, age 60 or older, receive a $5,000 benet.
FY2025 Benet Choice Options
12
Contacts
Purpose
Administrator Name and Address
Phone Website
Enrollment MyBenets – MyBenets Service Center (MBSC)
134 N. LaSalle Street, Suite 2200, Chicago, IL 60602
844-251-1777
844-251-1778 (TDD/TTY)
mybenets.illinois.gov
Health Plan Aetna HMO (Group Number 285654)
Aetna OAP (Group Number 285650)
Consumer Driven Health Plan (CDHP) - Aetna PPO
(Group Number 285658)
Quality Care Health Plan (QCHP) - Aetna PPO
(Group Number 285658)
Address for all Aetna Plans:
PO Box 981106, El Paso, TX 79998-1106
855-339-9731
800-628-3323 (TDD/TTY)
Fax: 859-455-8650 Attn: Claims
aetnastateollinois.com
BlueAdvantage HMO (Group Number B06800)
HMO Illinois (Group Number H06800)
Blue Cross Blue Shield OAP (Group Number 263995)
Address for all Blue Cross Plans:
PO Box 805107, Chicago, IL 60680-4112
800-868-9520
866-876-2194 (TDD/TTY)
855-810-6537
bcbsil.com/stateollinois
Health Alliance Medical Plans HMO
(Group Number 2001688)
3310 Fields South Drive, Champaign, IL 61822
800-851-3379
800-526-0844 (TDD/TTY
healthalliance.org/stateollinois
HealthLink OAP (Group Number 160000)
PO Box 419104, St. Louis, MO 63141-9104
877-379-5802
877-232-8388 (TDD/TTY)
healthlink.com/soi/learn-more
Prescription Drug Plan CVS Caremark® (for QCHP, CDHP, or OAP Plans)
Group Numbers: (QCHP 1400SD3)
(CDHP 1400SD9)
(Aetna OAP 1400SCH)
(BCBSIL OAP 1400SCJ)
(HealthLink OAP 1400SCF)
Paper Claims: CVS Caremark®
PO Box 52136, Phoenix, AZ 85072-2136
Mail Order Rx: CVS Caremark®
PO Box 94467, Palatine, IL 60094-4467
877-232-8128
800-231-4403 (TDD/TTY)
caremark.com
Vision Plan EyeMed Out-of-Network Claims
PO Box 8504, Mason, OH 45040-7111
866-723-0512
TTY users, call 711
eyemedvisioncare.com/stil
Dental Plan Delta Dental of Illinois (Group Number 20240)
PO Box 5402, Lisle, IL 60532
800-323-1743
800-526-0844 (TDD/TTY)
soi.deltadentalil.com
Life Insurance
MetLife Insurance Company, Group Life Claims
PO Box
6100, Scranton, PA 18505
800-880-6394
TTY users, call 711
metlife.com/stateollinois
Flexible Spending
Accounts (FSA) and
Health Savings
Accounts (HSA)
Optum Financial
PO Box 622317, Orlando, FL 32862-2317
888-469-3363
800-526-0844 (TDD/TTY)
443-681-4602 (fax)
Optumnancial.com
Commuter Savings Program
(CSP)
Edenred Benets Claims Administrator
265 Winter Street, 3rd Floor, Waltham, MA 02451
888-235-9223
844-878-0594 (TDD/TTY)
login.commuterbenets.com/
Employee Assistance
Program (EAP)
ComPsych Corporation
455 N. Cityfront Plaza Drive, Chicago, IL 60611
833-955-3400
800-697-0353 (TDD/TTY)
guidanceresources.com
ComPsych Member Web ID Code:
StateofIllinois
Personal Support Program
(PSP – AFSCME EAP)
AFSCME Council 31
205 N Michigan 2100, Chicago, IL 60601
800-647-8776 (statewide)
800-526-0844 (TDD/TTY)
afscme31.org
State Employees’
Retirement System
2101 South Veterans Parkway
PO Box 19255, Springeld, IL 62794-9255
217-785-7444
866-321-7625 (TDD/TTY)
srs.illinois.gov
State Universities
Retirement System
1901 Fox Drive, Champaign, IL 61820 800-275-7877
800-526-0844 (TDD/TTY)
217-378-8800 (dial direct)
217-378-9800 (fax)
surs.org
Teachers’ Retirement
System (TRS)
2815 West Washington Street
PO Box 19253, Springeld, IL 62794-9253
877-927-5877
(877-9-ASK-TRS)
866-326-0087 (TDD/TTY)
trsil.org
CMS Bureau of Benets
Group Insurance
PO Box 19208, Springeld, IL 62794-9208 800-442-1300
800-526-0844 (TDD/TTY)
benetschoice.il.gov
MyBenets.illinois.gov SEGIP 13
Federally Required Notices
Notice of Creditable Coverage
Prescription Drug information for State of Illinois Medicare-eligible Plan Participants
This Notice conrms that the State Employees Group Insurance Program (SEGIP) has determined that the
prescription drug coverage it provides is Creditable Coverage. This means that the prescription coverage offered
through SEGIP is, on average, as good as, or better than the standard Medicare prescription drug coverage
(Medicare Part D). You can keep your existing group prescription coverage and choose not to enroll in a
Medicare Part D plan.
Because your existing coverage is Creditable Coverage, you will not be penalized if you later decide to enroll in
a Medicare prescription drug plan. However, you must remember that if you drop your coverage through SEGIP
and experience a continuous period of 63 days or longer without Creditable Coverage, you may be penalized
if you enroll in a Medicare Part D plan later. If you choose to drop your SEGIP coverage, the Medicare Special
Enrollment Period for enrollment into a Medicare Part D plan is two months after your SEGIP coverage ends.
If you keep your existing group coverage through SEGIP, it is not necessary to join a Medicare prescription drug
plan this year. Plan participants who decide to enroll in a Medicare prescription drug plan may need to provide a
copy of the Notice of Creditable Coverage to enroll in the Medicare prescription plan without a nancial penalty.
Participants may obtain a Benets Conrmation Statement as a Notice of Creditable Coverage by contacting the
MyBenets Service Center (toll-free) 844-251-1777, or 844-251-1778 (TDD/TTY).
Summary of Benets and Coverage (SBC) and Glossary
Under the Affordable Care Act, health insurance issuers and group health plans are required to provide you with
an easy-to-understand summary about a health plan’s benets and coverage. The summary is designed to help
you better understand and evaluate your health insurance choices.
The forms include a short, plain language Summary of Benets and Coverage (SBC) and a glossary of terms
commonly used in health insurance coverage, such as “deductible” and “copayment.”
All insurance companies and group health plans must use the same standard SBC form to help you compare
health plans. The SBC form also includes details, called “coverage examples,” which are comparison tools that
allow you to see what the plan would generally cover in two common medical situations. You have the right to
receive the SBC when shopping for, or enrolling in coverage, or if you request a copy from your issuer or group
health plan. You may also request a paper copy of the SBCs and glossary of terms from your health insurance
company or group health plan. All State health plan SBCs are available on MyBenets.illinois.gov.
Notice of Privacy Practices
The Notice of Privacy Practices will be updated at MyBenets.illinois.gov, effective July 1, 2024. You have a right
to obtain a paper copy of this Notice, even if you originally obtained the Notice electronically. We are required to
abide by the terms of the Notice currently in effect; however, we may change this Notice. If we materially change
this Notice, we will post the revised Notice on our website at MyBenets.illinois.gov.
Printed by the Authority of the State of Illinois. SEGIP WebADA 042924 IOCI 23-0840
Illinois Department of
Central Management Services
Bureau of Benets
PO Box 19208
Springeld, IL 62794-9208
PRSRT STD
U.S. POSTAGE
PAID
SPRINGFIELD, IL
PERMIT NO. 489
Benet Choice Fairs
CMS Sponsored Benet Choice Open Enrollment Member Fairs are scheduled from 9:00 am to 4:00 pm with three
identical presentations given at 10:00 am, 12:00 pm and 3:00 pm, with time for questions to be addressed. Events are
open to all active and retired members not enrolled in a Medicare Advantage Prescription Drug (MAPD) Plan. CMS
representatives, as well as benet vendors, available in your area, will be present during the fairs to answer questions.
Date Agency/Location Address
Weds. May 1, 2024 IL State Library 300 S. 2nd Street, 403/404 Rooms and Atrium, Springeld, IL 62701
Fri. May 3, 2024 UIUC-iHotel and Conf Center 1900 S. 1st St, Quad Room and Technology Room, Champaign, IL 61820
Mon. May 6, 2024 Governor State University One University Parkway, Engbertson Hall and Hall of Honors, University Park, IL 60484
Tues. May 7, 2024 CMS-Chicago-Downtown 555 W. Monroe, Lincoln and Peoria Conf. Rooms, Chicago, IL 60661
Weds. May 8, 2024 NIU DeKalb 340 Carroll Avenue, Holmes Student Center, DeKalb, IL 60115
Thurs. May 9, 2024 IDOT District 1 Headquarters 201 W. Center Court, Schaumburg, IL 60196
Fri. May 10, 2024 UIC Student Center East 750 S Halsted St, Cardinal Room and Ft Dearborn Room, Chicago, IL 60607
Mon. May 13, 2024 IDOT Springeld 2300 South Dirksen Parkway, Auditorium, Springeld, IL 62764
Tue. May 14, 2024 ISU 100 N. University St, Prairie Room, Normal, IL 61790
Weds. May 15, 2024 NEIU 5500 N St Louis Ave, FA Building Room 202 and Cafeteria 01A Chicago, IL 60625
Thur. May 16, 2024 WIU Moline 3300 River Drive, W Riverfront Hall Rm 102/103/104, Moline, IL 61265
Fri. May 17, 2024 WIU Macomb
1 University Circle, University Union is on Murray Street, located in building 4N, Macomb, IL 61455
Mon. May 20, 2024 IDOT District 8 1102 Eastport Plaza Drive, Collinsville, IL 62234
Tues. May 21, 2024 SIU Carbondale 1255 Lincoln Drive, Student Center, Ballroom B and Corker Lounge, Carbondale, IL 62901
Weds. May 22, 2024 EIU Charleston 1720 7th. St, MLK Student Union Bldg, Charleston, IL 61920
Thur. May 23, 2024 IDOT Springeld 2300 South Dirksen Parkway, Auditorium, Springeld, IL 62764
To view a recorded version of the Member Fair presentation, click here:
https://cms.illinois.gov/benets/benet-choice-fairs.html