SEGIP Health Insurance

State Employees Group Insurance Program (SEGIP) health insurance is available to employees who meet the eligibility criteria and to eligible dependents. Three types of health plans are available: Health Maintenance Organizations (HMOs), Open Access Plans (OAPs), and the Quality Care Health Plan (QCHP).

SEGIP coverage is provided through the State of Illinois Department of Central Management Services (CMS). The specific plan administrator is determined by the plan in which you enroll.

Eligibility

To be eligible for SEGIP health insurance benefits, you must meet the following criteria:

  • You must be eligible to participate in SURS.
  • You must be one of the following:
    • A regular employee with an appointment of 50% or more.
    • A temporary employee with an appointment of 50% or more for at least 9 months.
    • An employee hired for at least 4.5 months (one semester) at 100% time.

You may also cover eligible dependents on a SEGIP health plan.

Cost

Your employee contributions for SEGIP health plan premiums are based on your annual salary and deducted from payroll. Dependent premiums are separate and in addition to your employee premium.

See Monthly Contributions for the current premiums. In the employee contributions table, the Managed Care column lists rates for HMO and OAP plans; the Quality Care column lists rates only for the QCHP. Biweekly paid employees will see half the total cost deducted from each of 24 pay checks (no premium is deducted from the third pay when there are three pay checks in the same month).

Eligible part-time employees also pay a portion of the State contribution in addition to the employee cost. See Part-Time Employees.

When you see a health care provider, you will also typically pay some out-of-pocket expenses such as copays, coinsurance, and/or deductibles. Out-of-pocket costs vary between plans – see your plan’s Summary of Benefits and Coverage.

Plan Summary

This information is intended as a general overview of SEGIP health plans. For plan details, refer to the Summary of Benefits and Coverage and the Benefit Choice booklet.

Plan Options & Plan Selection

All SEGIP health plans include coverage for physical health, behavioral/mental health, emergency care, and prescription drugs. The level of coverage for specific services varies among plans. Certain HMO and OAP plans are only available in certain regions. For a map of the health plans available in your area, see the Health Plan Map.

You may enroll in or change your SEGIP health plan only at the following times:

  • Within 30 calendar days of becoming eligible for SEGIP benefits.
  • During the annual Benefit Choice period in May.
  • Within 60 calendar days of an eligible qualifying event.

Health Maintenance Organizations (HMOs)

See HMOs for more details. To find providers, see Provider Directories.

If you choose an HMO, all of your medical care will be coordinated through your selected Primary Care Physician (PCP). The PCP you choose must be within the health plan’s network, which is typically limited to a specific region. Your PCP will manage your health care and treatment plans, and will issue referrals for specialized services.

Out-of-pocket costs in an HMO are usually lower than other plans. Most office visits will require only a copay – see your plan’s Summary of Benefits and Coverage for details. There is an annual plan year deductible for prescription drugs.

You will usually not need to submit any claim forms, unless emergency care takes place outside of your coverage area. Except for emergency services, generally HMOs WILL NOT COVER services rendered by out-of-network doctors or other non-participating providers.

Open Access Plans (OAPs)

See OAPs for more details. To find providers, see Provider Directories.

An OAP combines the benefits of an HMO and traditional health coverage. The provider networks in an OAP are divided into two separate benefit levels called Tier I and Tier II. An out-of-network provider is considered Tier III. You are allowed to mix and match providers among all tiers.

Your out-of-pocket costs in an OAP will vary depending on the tiers you use:

  • Your cost will typically be lowest while using Tier I providers – services are usually covered with only a copay, similar to an HMO.
  • The Tier II network offers an expanded range of providers to choose from, but you will pay copays, coinsurance, and have an annual plan year deductible.
  • Tier III (out-of-network) providers are paid at a percentage of the Maximum Allowable Charge (MAC) based on Medicare rates in a geographical location, after the deductible is met. You will incur high out-of-pocket costs when using Tier III/out-of-network providers. Medicare reimbursement rates are very low and the OAPs pay only 60% of the MAC after any copayment.
  • The deductibles do not cross accumulate across Tier II and Tier III, meaning that the deductible paid for services in one tier are not applied toward the deductible in the other tier.
  • There is a separate annual plan year deductible for prescription drugs.

You are encouraged to use OAP Tier I and Tier II providers. Prior to receiving health care under Tier III, always contact the OAP to obtain preauthorization of benefits to ensure services meet medical necessity criteria. You can ask your OAP for an estimate of the amount that the plan will pay if you provide detailed provider and procedure code information from your doctor.

See your plan’s Summary of Benefits and Coverage for more details.

Quality Care Health Plan (QCHP)

See QCHP for more details. To find providers, see Provider Directories.

The QCHP includes a nationwide network of providers to choose from. If you enroll in the QCHP, you are free to choose any provider, but you will have significantly lower out-of-pocket costs when using an in-network provider. You do not need to designate a Primary Care Physician (PCP) and may see specialists without a referral. However, you or your provider will need to seek pre-authorization for certain services/care.

The QCHP has an annual plan year deductible that applies to most services. Out-of-pocket costs are based on coinsurance, which is a percentage of the lesser of total billed cost or MRC for eligible services.

You are encouraged to use in-network providers for the lowest out-of-pocket costs in the QCHP. Out-of-network providers are paid based on the Maximum Reimbursable Charge (MRC), which is the maximum that the insurance company will pay for billed services, after your deductible is met. Prior to receiving health care out-of-network, always contact the plan to complete the pre-determination process to ensure the services meet medical necessity criteria. You can ask for an estimate of the amount that the plan will pay if you provide detailed provider and procedure code information from your doctor.

There is a separate annual plan year deductible for prescription drugs.

You or your provider must submit a claim form and itemized bills to the QCHP administrator.

Opting Out/Waive SEGIP Coverage

Full-Time Employees

Full-time employees who are eligible for and/or enrolled in SEGIP may, with proof of other non-State comprehensive health coverage, elect not to participate in SEGIP health insurance. If you opt out, you and your dependents will no longer be enrolled in SEGIP health, vision, or dental coverage and COBRA is not available.

You may opt out during your 30 calendar day initial enrollment period, during the annual Benefit Choice period, or within 60 calendar days of an eligible qualifying event. You may opt out of health/vision and dental coverage and provide supporting documentation on CMS MyBenefits. After the opt-out application process, you will be notified by CMS if your request has been approved or denied.

Part-Time Employees

Eligible part-time employees may elect to waive SEGIP coverage. See Part-Time Employees.

Spouses Working for State of Illinois

If you and your spouse (or civil union partner) are both employees of the University of Illinois or any other State of Illinois agency, and both are eligible for SEGIP coverage, then you must each be insured individually. State/University employees may not enroll as a dependent of their spouse in either SEGIP, Local Government Health Plan, Teachers' Retirement Insurance Program, or the College Insurance Program.

Either or both spouse(s) may elect health coverage for dependents; however, the same dependent cannot be enrolled under both spouses for the same type of health, dental, or life insurance coverage.

Additional Resources