State Employees Group Insurance Program (SEGIP) health insurance is available to employees who meet the eligibility criteria and to eligible dependents. Four types of health plans are available: Health Maintenance Organizations (HMOs), Open Access Plans (OAPs), Quality Care Health Plan (QCHP), and the Consumer Driven Health Plan (CDHP) with a companion Health Savings Account (HSA).
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.
Note: A social security number (SSN) is required for an employee to enroll in the program. A social security number (SSN) or a letter from SSA verifying SSN ineligibility is required within 30 calendar days of enrollment for a spouse and dependent(s).
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 the health plan selected and are deducted from payroll. Dependent premiums are separate and in addition to your employee premium.
See Employee and Dependent Rates for the current premiums that vary based on your salary and chosen health plan. 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.
NOTE: Although your employment status may be classified as full-time, your eligibility for the State Employee Group Insurance Program could be classified as part-time based on an annual review of hours worked conducted by Central Management Services (CMS).
Unprotected dock time (e.g., unapproved absences, unpaid personal leave, suspension) greater than 30 days during the audit period (June 1 – May 31 each year) will result in this change to part-time status for State group insurance purposes (effective 9/1). In this case, you will be responsible for a portion of the State’s contribution to your group insurance premium cost in addition to your employee contribution. For additional details, refer to the following sections of the State Employee Benefits Handbook: Eligibility Requirements beginning on page six, Contribution Payment beginning on page 17, and Time Away from Work beginning on page 20.
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. Availability of OAP Tiers varies by county. View the Health Plan Map to see coverage in your area.
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 60% of the plan’s allowable charges (varies by geographic region), after the plan year deductible and any applicable copay. Amounts over allowable charges do not count toward your plan year out-of-pocket. You will incur high out-of-pocket costs when using Tier III/out-of-network providers.
- 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.
See your plan’s Summary of Benefits and Coverage for more details.
Consumer Driven Health Plan (CDHP)
See CDHP for more details. To find providers, see Provider Directories.
The CDHP is a high-deductible health plan as defined by the IRS. If you enroll in the CDHP, you may choose any provider or hospital for medical services, however, you will experience lower out-of-pocket costs when receiving services from a CDHP in-network provider.
The CDHP has an annual plan year deductible that applies to medical services and prescription drugs. Out-of-pocket costs are based on a percentage of in-network charges and out-of-network allowable charges, after the plan year deductible is met.
See your plan’s Summary of Benefits and Coverage for more details.
Health Savings Account (HSA)
Companion to CDHP enrollment only. See HSA for more details.
To qualify for an HSA, you must:
The HSA is a tax-favored, interest bearing account that active employees can use to pay for qualified medical expenses now, or in the future. Distributions are tax-free when used for qualified medical expenses.
Your HSA is funded by a State contribution of one-third of the CDHP deductible. You may contribute an additional amount to your HSA through pre-tax payroll deductions or a post-tax direct payment. HSAs are portable. Unlike a Flexible Spending Account, there is no “use-it-or-lose-it” rule with HSAs. Learn more about the difference between HSAs and FSAs.
Note: After you elect an HSA, you must also open an account with Optum Financial, the HSA vendor. Once enrolled, the State contribution will automatically continue each year as long as you continue enrollment in the CDHP, but you must elect your employee contribution amount each plan year during the annual Benefit Choice period to continue your employee contribution.
You cannot be enrolled in both an HSA and the MCAP Flexible Spending Account.
You must open an account with Optum Financial within 90 days of enrolling in the HSA to take advantage of your benefits. After opening an account, you will receive an Optum Financial Mastercard to access your account.
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 or vision 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 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