Employee Benefits Brochure

Transcription

1 Employee Benefits Brochure WHAT S INSIDE Eligibility... 2 Rules For Benefit Changes During The Year... 3 Medical Plans... 4 Dental Plan... 6 Vision Plan... 7 Basic Life/AD&D... 7 Supplemental Life... 7 Long Term Disability... 8 Employee Assistance Program... 8 Legal Plan... 8 Long Term Care... 9 Flexible Spending Accounts Frequently Asked Questions Required Federal Notices Health Plan Rates Who Should You Call? Dear Valued Associate: South Orange County Community College District takes pride in offering a comprehensive benefit program to all eligible members. It has been our goal to provide you and your families with a "best-in-class" benefits program and we believe we have achieved that goal. October 1, September 30, 2015 Plan Offerings: Medical HMO Plan by Blue Shield/Self Insured Schools of California (SISC) Medical PPO Plan by Blue Shield/Self Insured Schools of California (SISC) Dental PPO Plan by Delta Dental/ACSIG Vision Plan by VSP/ACSIG Basic Life & AD&D Plan by Reliance Standard Supplemental Life Plan by Reliance Standard Long Term Disability (LTD) Plan by Reliance Standard (not available to Board Members) Employee Assistance Program by OptumHealth EAP and Anthem EAP Legal Plan by Hyatt Long Term Care Insurance by UNUM Flexible Spending Accounts by Self Insured Schools of California (SISC) AD&D Plan by Zurich (SISC) For more information, visit our website at: DISCLAIMER The information in this brochure is a general outline of the benefits offered under the SOCCCD benefits program. Specific details and limitations are provided in the plan documents which may include a Summary Plan Description (SPD), Evidence of Coverage (EOC) and/or insurance policies. The plan documents contain the relevant plan provisions. If the information in this brochure differs from the plan documents, the plan documents will prevail.

2 ELIGIBILITY Who is eligible to enroll in the benefit program? Active Employees All employees working at least 75% per week. Board Members are included in the active employee category. Active Eligible Classes: Academic Administrators, Classified Management, Police Officers Association (POA), & Board Members, Faculty and Classified. What is the effective date of coverage? Effective date of coverage is the first of the month following your date of eligibility. Can I enroll my dependents? Eligible dependents include your spouse, domestic partner, and children up to age 26. Children include stepchildren, children placed under a qualified medical child support order, adopted children or children placed for adoption and children in which you have established legal guardianship. To enroll qualified dependents, you must provide proper documentation, e.g. marriage/birth certificates, state/court documents, etc. This is only a summary of the eligibility requirements and is not intended to modify or supersede the requirements of the plan documents, and the plan documents will govern in the event of any conflict between this summary and the plan documents. What is the definition of domestic partner? Domestic partner is defined as the employee s domestic partner under a legally registered and valid domestic partnership or one that meets certain requirements and provides an affidavit of domestic partnership. How do I add and exclude dependents? Newly acquired dependents may be added to the plan during the year by completing the necessary forms within 30 days of their eligibility. If you do not add dependents within the 30-day period and do not qualify for a special enrollment (see next page), they will not be eligible to enroll until the next open enrollment period each August. When can I make changes to my benefit elections? Other than during the annual open enrollment period, you may not change your coverage unless you qualify for a special enrollment (more about this on next page). In addition, if you are declining enrollment for you or your dependents (including your spouse) because of other group medical coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you qualify for a special enrollment. 2

3 RULES FOR BENEFIT CHANGES DURING THE YEAR Other than during annual open enrollment, you may only make changes to your benefit elections if you experience a qualified status change or qualify for a special enrollment. If you qualify for a mid-year benefit change, you may be required to submit proof of the change or evidence of prior coverage. Qualified Status Changes include: Change in legal marital status, including marriage, divorce, legal separation, annulment, and death of a spouse. Change in number of dependents, including birth, adoption, placement for adoption, or death of a dependent child. Change in employment status that affects benefit eligibility, including the start or termination of employment by you, your spouse, or your dependent child. Change in work schedule, including an increase or decrease in hours of employment by you, your spouse, or your dependent child, including a switch between part-time and full-time employment that affects eligibility for benefits. Change in a child's dependent status, either newly satisfying the requirements for dependent child status or ceasing to satisfy them. Change in place of residence or worksite, including a change that affects the accessibility of network providers. Change in your health coverage or your spouse's coverage attributable to your spouse's employment. Change in an individual's eligibility for Medicare or Medicaid. A court order resulting from a divorce, legal separation, annulment, or change in legal custody (including a Qualified Medical Child Support Order) requiring coverage for your child. An event that is a special enrollment under the Health Insurance Portability and Accountability Act (HIPAA) including acquisition of a new dependent by marriage, birth or adoption, or loss of coverage under another health insurance plan. An event that is allowed under the Children's Health Insurance Program (CHIP) Reauthorization Act. Under provisions of the Act, employees have 60 days after the following events to request enrollment if: Employee or dependent loses eligibility for Medicaid (known as Medi-Cal in CA) or CHIP (known as Healthy Families in CA). Employee or dependent becomes eligible to participate in a premium assistance program under Medicaid or CHIP. Two rules apply to making changes to your benefits during the year: Any change you make must be consistent with the change in status, AND You must make the change within 30 days of the date the event occurs (unless otherwise noted above). 3

4 HMO MEDICAL PLAN When you enroll in the HMO plan, you choose a primary care physician (PCP) for each enrolled family member from a medical group or IPA. The PCP will coordinate and provide all of your care, including hospital admissions. You can select a PCP by visiting the Blue Shield website at You will need a referral from your PCP if you need to see a specialist. Employees enrolled in the Blue Shield HMO plan will have prescription drug coverage through Navitus. If you are taking prescription medications on a regular basis, you may save time and money by using the mail service pharmacy. If you have questions you may call Navitus Member Services 24 hours a day, seven days a week toll free at (866) or visit the Navitus website at Schedule of Benefits Medical Plan Copays/Limits Lifetime Maximum Calendar Year Deductible Calendar Year Out-of-Pocket Maximum 1 Hospitalization Services Inpatient Outpatient Emergency Room (Copay waived if admitted) Outpatient Professional Services Office and Authorized Specialist Visit Access+ Specialist Visit 1 Adult Routine Physical Exam X-Ray & Lab Procedures Home Health Care Blue Shield HMO Plan In-Network 1. Not all copayments/coinsurance accrue to the out-of-pocket maximum. 2. The Blue Shield HMO Chiropractic Benefit Rider is being enhanced to include Acupuncture services effective 10/1/ Effective 10/1/2014, this plan will feature $0 copays on Generics at Costco as well as through Costco Mail Order. Members can choose to receive 90- supplies of their long-term medications at a Costco walk-in pharmacy. The 90-day copays at Costco walk-in pharmacies will be the same as the Mail Order copays. Costco membership is not required to use the Costco pharmacy. 4. Specialty Medications as well as some narcotic pain medications and cough medications are not included in the Costco lower generic copays or the 90-day supply programs. 5. Due to Medicare Part D restrictions, this program does not apply to the CompanionCare pharmacy benefit. None None $1,000 Individual / $2,000 Family No Charge No Charge $100/Visit $5/Visit $30/Visit No Charge No Charge $5/Visit Durable Medical Equipment 20% Chiropractic Services (up to 30 visits per calendar year) 2 Mental Health / Substance Abuse Inpatient / Facility Based Outpatient Visit Prescription Drugs (through Navitus) 3,4,5 Retail (30 day supply) Generic Brand Mail Order (90 day supply) Generic Brand $10/Visit No Charge $5/Visit $5 Copay $10 Copay $10 Copay $20 Copay 4

5 PPO MEDICAL PLAN Members have a choice of using Preferred Providers (PPO) or going directly to any other physician (non-ppo provider) without a referral. Generally, there are annual deductibles to meet before benefits apply. You are also responsible for a certain percentage of the charges (co-insurance), and the plan pays the balance up to the agreed upon amount. Remember to use contracted in-network providers for primary care and referrals. The carriers have negotiated special rates with in-network providers to help keep costs affordable without sacrificing quality; take advantage of these savings opportunities. Employees enrolled in the Blue Shield PPO plan will have prescription drug coverage through Blue Shield Pharmacy. Blue Shield members can use Blue Shield s mail service pharmacy by calling (866) or visiting their website at Please note: Most specialty drugs require prior authorization for medical necessity. If covered, specialty drugs cannot be obtained from a retail participating pharmacy and must be obtained from a Blue Shield Network Specialty Pharmacy. Your doctor must submit a new prescription to the network specialty pharmacy you choose and you will need to enroll with the network specialty pharmacy prior to asking your doctor to send a new prescription. A Blue Shield Specialty Pharmacy may be located at under Find a Pharmacy. You may also call the customer service phone number listed on your Blue Shield ID card. Schedule of Benefits Blue Shield PPO Plan Medical Plan Copays/Limits In-Network 1 Out-of-Network 1 Calendar Year Deductible Calendar Year Out-of-Pocket Maximum 5 Employee Pays $100 Individual / $300 Family $400 Individual / $1,200 Family Hospitalization Services Inpatient 10% No Charge 2, 3 (Up to $600/Day) Outpatient 10% No Charge 2 (Up to $350/Day) Emergency Room (Copay waived if admitted) Outpatient Professional Services 10% + $100/Visit Office and Specialist Visit $10/Visit 4 10% 2 Adult Routine Physical Exam No Charge 4 Not Covered Well-Baby Care No Charge 4 10% 2 X-Ray & Lab Procedures $10/Visit 10% 2 Home Health Care (100 visit maximum per calendar year) 10% Not Covered 5 Durable Medical Equipment 10% 10% 2 Chiropractic Services (up to 20 visits per calendar year) $25/Visit 10% 2 Acupuncture (up to 12 visits per calendar year) $25/Visit $25/Visit 2 Mental Health / Substance Abuse Inpatient / Facility Based 10% No Charge 3 (Up to $600/Day) Outpatient Visit $10/Visit 4 10% 2 Prescription Drugs (through Blue Shield Pharmacy) Member pays 25% of allowable amount plus Retail (30 day supply) the below copayment Generic $3 Copay 2 $3 Copay 2 Brand Name 6 $15 Copay 2 $15 Copay 2 Mail Order (90 day supply) Generic $3 Copay 2 Not Covered Brand Name 6 $35 Copay 2 Not Covered 1. Member is responsible for copayment in addition to any charges above allowable amounts. 2. Copayments/Coinsurance marked with a footnote do not accrue to Calendar Year copayment maximum. 3. Members are responsible for all charges in excess of the per day maximum payment. 4. Not subject to the calendar-year deductible. 5. Out-of-network home health care and home infusion services are not covered unless they are preauthorized. When these services are preauthorized, members pay the preferred provider copayment. 6. If the member requests a brand-name drug and a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield of California of the brand-name drug and its generic drug equivalent, as well as the applicable generic drug copayment.

6 DENTAL PLAN SUMMARY The dental PPO plan is designed so employees can choose from an extensive network of Delta Dental Dentists or any other provider of your choice. However, by using one of the Delta Dental providers, employees will reduce their out-of-pockets costs. Delta Dental PPO members will be eligible for one additional cleaning per calendar year (for a total of 3 cleanings per calendar year). Members will also be eligible for dental implant coverage. Log on to Delta s website at or call (866) for more information. Schedule of Benefits Calendar Year Deductible In-Network Delta Dental PPO (ACSIG) Out-of-Network $25/Individual (up to $75 per Family) except for diagnostic and preventive Calendar Year Maximum $3,200 $3,000 Diagnostic & Preventive Exams / Cleaning Full Mouth X-rays Fluoride Treatment Space Maintainers Basic Services Oral Surgery Fillings Root Canals Periodontics Crowns & Other Cast Restorations Crowns Inlays / Onlays Prosthodontics Orthodontics Adult and eligible dependent child PLAN PAYS 90% PLAN PAYS 90% after deductible PLAN PAYS 90% after deductible PLAN PAYS 50% after deductible Lifetime Maximum $2,000 6

7 Schedule of Benefits VISION PLAN SUMMARY The VSP plan offered covers vision exams, frames and lenses. The VSP plan has the largest network of private vision providers in the nation. All VSP network providers are independent optometrists or ophthalmologists in private practice who provide full service. You do have the option of using a non-network provider but the benefit allowances are lower. Log on to VSP s website at or call (800) for more information. In-Network VSP Vision Out-of-Network Eye Examination, every 12 months $10 Copay Up to $45 Standard Lenses, every 12 months Single Up to $45 Bifocal Covered in Full Up to $65 Trifocal after $10 Copay Up to $85 Lenticular Up to $125 Frame, every 12 months Contact Lenses, every 12 months Medically Necessary Covered Contacts Up to $ % off over your allowance Covered in Full after $10 Copay Covered in Full after $50 Copay Up to $47 Up to $250 Up to $250 + $50 Copay Second pair of glasses, every 12 months $20 Copay N/A BASIC LIFE AND AD&D Basic Life insurance & AD&D provides protection for your beneficiary in the event of your death. Life / AD&D Insurance is an important part of your comprehensive benefits package. For peace of mind and the financial protection for you and your family in the event of death or a serious accident, all benefit eligible associates are automatically enrolled in the Basic Life and Accidental Death and Dismemberment Insurance Program through Reliance Standard Life Insurance Company. The District provides coverage for at least two times annual salary up to a maximum (varies based on current negotiated contracts) at no cost to you. For more information, contact Reliance Standard at (800) SUPPLEMENTAL LIFE In addition to the Basic Life Insurance the District provides, eligible employees may elect additional coverage by enrolling in a Supplemental Term Group Life Insurance plan underwritten by Reliance Standard. Employee: Coverage from $10,000 to $500,000 in $10,000 increments, not to exceed 5 times your annual salary. New Hires: You can elect up to $200,000 (not to exceed 5 times your annual salary) without satisfying medical evidence of insurability if you enroll when first eligible. Open Enrollment: Current participants can elect up to an additional $40,000 during annual open enrollment up to $200,000 (not to exceed 5 times your annual salary) without satisfying medical evidence of insurability (provided you were not previously denied). Current employees who waived coverage in the past can elect up to $40,000 during open enrollment without satisfying medical evidence of insurability. If you would like to elect Supplemental Life coverage or increase your current Supplemental Life coverage outside of the annual open enrollment period, medical evidence of insurability will be required for all coverage amounts. Spouse: Coverage from $5,000 to $250,000 in $5,000 increments, not to exceed 100% of the total amount of Employee Supplemental Life coverage. You can elect up to $35,000 (not to exceed 100% of the total amount of Employee Supplemental Life coverage) for Spouse Supplemental Coverage without satisfying medical evidence of insurability if you enroll when first eligible. The employee must be enrolled in the Supplemental Life Insurance. Dependent child(ren): Coverage is available up to $10,000 in increments of $2,500 (birth but less than 6 months) and increments of $2,000 (6 months up to age 26). The employee must be enrolled in the Supplemental Life Insurance. 7

8 LONG TERM DISABILITY (LTD) When an illness or injury makes it impossible for you to work for an extended period of time, your income may be continued under the District s Long-Term Disability (LTD) plan administered by Reliance Standard. Under the plan, if you are disabled for more than 90 days, you may be eligible to receive a benefit of 66 2/3% of your monthly earnings up to a maximum of $10,000 per month. The calculated benefit amount will be REDUCED by any payments from California State Disability Insurance and/or other income benefit payments. For more information, contact Reliance Standard at (800) ACCIDENTIAL DEATH & DISMEMBERMENT (AD&D) All active employees of the policyholder currently enrolled in a SISC medical plan up (not including individual retirement plans), up to age Hour Accident Protection, Business & Pleasure Excluding Corporate Owned or Leased Aircraft, H-1. For more information access the Zurich AD&D Claim form on the SISC website at sisc.kern.org/hw/formsandnotices/. Refer to Plan Number GTU EMPLOYEE ASSISTANCE PROGRAM (EAP) The District provides two Employee Assistance Programs (free and confidential) 24 hours a day, every day of the year. When you or someone in your family needs help with a personal problem, highly trained staff members can offer information and advice to help you solve a wide range of problems -- from relationship and family concerns to anxiety, depression, substance abuse, stress, grief, and even financial or legal issues. EAP through OptumHealth provides up to three sessions, per problem, per six month period by an on -site EAP professional. For more information, contact OptumHealth at (800) , or visit liveandworkwell.com. EAP through Anthem provides up to six sessions for each issue you re facing. After you make the first phone call to Anthem EAP, they can refer you to a licensed counselor in your area who s a member of their network. For more information, contact Anthem EAP at (800) , or visit anthemeap.com. Hyatt Legal Plan membership provides participating employees and family members with access to legal advice and services including: telephone advice and office consultations on an unlimited number of matters with an attorney of your choice. For more information, contact Hyatt at (800) , or visit legalplans.com. This plan is provided by the District. Will & Estate Matters Wills and Codicils & Living Wills Trusts (revocable & irrevocable) Powers of Attorney (healthcare, financial, childcare) Probate Document Preparation Affidavits Deeds Demand Letters Elder Law Matters Mortgages Traffic Offenses Defense of traffic tickets (excludes DUI) Driving Privileges Restoration Juvenile court defense LEGAL PLAN Real Estate Matters Sale, Purchase or Refinancing of your primary residence Eviction and Tenant Problems (primary residence) Security Deposit Assistance for Tenant Family Law Prenuptial Agreement Uncontested Adoption Uncontested Guardianship Name Change Consumer Protection Disputes over consumer goods and services Personal Property Protection Small Claims Assistance 8 Financial Matters Negotiations with Creditors Debt Collection Defense Identity Theft Personal Bankruptcy Tax Audits Defense of Civil Lawsuits Administrative Hearings Civil Litigation Defense Incompetency Defense Immigration Assistance Advice and Consultation Review of Immigration Documents Preparation of Affidavits and Powers of Attorney

9 LONG TERM CARE INSURANCE The District provides basic Long Term Care coverage through UNUM Life Insurance Company. Long Term Care Insurance provides assistance with daily living activities such as bathing, eating, and dressing when you or a family member are no longer able to perform these activities. The Plan provides options for care in a variety of settings, including nursing homes, assisted living facilities, adult day care facilities, hospices, or your own home. If you would like more protection, you may purchase Buy-Up Long Term Care coverage. Premiums are based on age, type of care, and benefit amount. For more information, contact Unum at (800) Long Term Care Base Plan (Employer-Paid) Employer Paid LTC Base Plan Academic Administrators, Classified Management, Board Members & Classified & POA Employees Faculty Facility Monthly Benefit $1,000 $2,000 Facility Benefit Duration 4 Years 3 Years Daily Assisted Living Benefit 60% 75% Home Care Benefit 50% 75% Elimination Period 180 Days 180 Days Lifetime Maximum $48,000 $72,000 If you would like more protection, you may purchase Buy-Up Long Term Care coverage. Premiums are based on age, type of care, and benefit amount. For more information, contact Unum at (800) , or visit websites unuminfo.com/socccd/index.aspx for Academic, and unuminfo.com/socccd-classified/index.aspx for Classified to access Employee Calculator. Long Term Care Buy-Up Plan (Employee-Paid) Employee-Paid LTC Buy-Up Plan Nursing Facility Benefit $1,000- $6,000 Academic Administrators, Classified Management, Board Members & Faculty $1,000- $6,000 $1,000- $6,000 $2,000- $8,000 Classified & POA Employees $2,000- $8,000 $2,000- $8,000 Facility Benefit Duration 4 Years 6 Years Unlimited 3 Years 6 Years Unlimited Daily Assisted Living Benefit 60% 60% 60% 75% 75% 75% Home Care Benefit 50% 50% 50% 75% 75% 75% Total Home Care Option 50% 50% 50% 75% 75% 75% Inflation Protection Option Lifetime Maximum (per $1,000 increments) Simple Capped Simple Capped Simple Capped Compound Compound Compound $48,000 $72,000 Unlimited $36,000 $72,000 Unlimited 9

10 FLEXIBLE SPENDING ACCOUNTS November 1, 2014 begins a great way to save money over the course of a year is to participate in the Flexible Spending Accounts (FSAs). These accounts allow you to redirect a portion of your salary on a pre-tax basis into reimbursement accounts. Money from these accounts is then used to pay eligible expenses, such as health plan copays, dental work, doctor s fees, eye exam, glasses and contact lenses, LASIK eye surgery, hearing aids, chiropractic care, lab fees, and dependent care expenses. The District s Flexible Spending Accounts is administered by Self Insured Schools of California (SISC). You may use the Health Care Spending Account, the Dependent Care Spending Account, or both. When you enroll, you decide how much money to contribute to your personal accounts for the coming year. These contributions are gradually deducted from your paychecks throughout the year and deposited into your account. Health Care Spending Account This account will reimburse you with pre-tax dollars for health care expenses not reimbursed under your family s health care plans. Eligible expenses may be incurred by you or your eligible dependents as defined by the IRS. Dependents do not need to be enrolled in the District s health plans to incur reimbursable expenses. Change in the Maximum Health Care FSA Reimbursement Limit January 1, 2013, the maximum salary reduction amount for the Health Care Expense is $2,500. This is part of Health Care Reform. Dependent Care Spending Account This account will reimburse you with pre-tax dollars for daycare expenses for your child(ren) and other qualifying dependents. Qualifying dependents include 1) Children under the age of 13 who qualify as dependents on your federal tax return and 2) Children or other dependents of any age who are physically or mentally unable to care for themselves and who qualify as dependents on your federal tax return. You may use the federal childcare tax credit and the Dependent Care Spending Account; however, your federal credit will be offset by any amount deferred into the dependent care plan The maximum amount you may contribute for the Plan Year January 1 through December 31, 2014 is $5,000 a year or $2,500 if you are married and file separate tax returns. How your FSA Account Works Each year during the Open Enrollment period, you decide how much you want to contribute to the Health Care and/or the Dependent Care Spending Account. Each pay period, the money deducted before taxes is withheld in equal increments from your pay and contributed to your Health Care and / or Dependent Care spending account(s). SISC Flex Card Employees who enroll receive two cards the first year they enroll. The cards are good for 3 years, and are reloaded yearly with the new election amount. Your SISC Flex Card cannot be used at dependent care facilities. Use your card to pay for eligible expenses at the point of sale, thereby reducing having to pay out of pocket and waiting for a reimbursement check. The SISC Flex Card works like a credit card. Even though it says Debit on the front of the card, when making a purchase with a keypad or screen, select credit. The card does not have a PIN so you must select credit and sign for the transaction. You cannot get cash with the card. When making a purchase without a keypad or screen, give your card to the clerk and sign the receipt. If you are asked whether it s a credit or debit purchase, say credit. If debit is used, your purchase will be declined. When necessary, you will be required to furnish receipts and documentation for review so save all receipts. Claim forms and instructions are available on the SISC website at or call (661) or (800) ext for more information. Be Cautious!! Only qualifying medical and dependent care expenses incurred during the plan year will be eligible for reimbursement. Use it or lose it! Money in the accounts must be claimed within 90 days after the end of the plan year or it will be subject to the use-it-or-lose-it rule and be forfeited. 10

11 FREQUENTLY ASKED QUESTIONS Q. HOW DO I ADD/DROP DEPENDENTS TO/FROM MY INSURANCE IF I HAVE A CHANGE IN STATUS? A. Submit a SISC Membership Change Form and supporting documents to District Benefits. Q. HOW DO I MAKE CHANGES TO MY PERSONAL INFORMATION SUCH AS ADDRESS CHANGE, BENEFICIARIES, ETC.? A. Submit a SISC Membership Change Form and supporting documents to District Benefits. You may also want to update your beneficiary(ies) for Basic Life and/or AD&D. If so, fill out and submit a Beneficiary Designation Form to District Benefits. Q. HOW DO I KNOW IF MY DOCTOR IS IN THE BLUE SHIELD NETWORK? A. You can find a list of contracted doctors on the Blue Shield website at Click on Find a Provider Now. At this point you have the option to log-in with your name and password or you can elect to skip the log-in and search for a provider. You can search for doctors, hospitals or other facilities. In addition, it is important to also check with your doctor to confirm that they are a contracted doctor with Blue Shield. Q. HOW WILL I BE AFFECTED IF MY PRIMARY CARE PHYSICIAN (PCP) LEAVES THE NETWORK (HMO PLAN ONLY)? A. If your doctor leaves the network, you will be asked to select another Blue Shield participating provider. You can find a new PCP who participates in your network on your secure member website by clicking on Find a Provider Now. At this point you have the option to log-in with your name and password or you can elect to skip the log-in and search for a provider. You can search for doctors, hospitals or other facilities. In addition, it is important to also check with your doctor to confirm that they are a contracted doctor with Blue Shield. Q. HOW CAN I GET A NEW ID CARD, CHANGE MY PCP (HMO PLAN) OR VIEW DETAILED CLAIM INFORMATION? A. You can either call the number on the back of your ID card or log onto Blue Shield s website at and click on the Register Now link located on the left hand side. You will need your member ID which is located on your Blue Shield ID card. Follow the step-by-step instructions. Once you have completed the registration process, you can log in by entering your user name and password (located on the left hand side under I m a member ) and immediately access your account and begin taking full advantage of your personalized website. You will be able to print a temporary ID card, change your PCP, view detailed claim information and more. Q. WHAT IS COVERED OUT OF THE HMO SERVICE AREA? A. If you are out of the service area (out-of-state), the only coverage available is for emergency treatment for potential life and limb-threatening conditions. Out-of-state coverage on the HMO plan is always subject to approval by Blue Shield before the claims will be paid as an emergency. Q. WHAT IS COVERED OUT OF THE SERVICE AREA ON THE PPO PLAN? A. Many states have Blue Cross/Blue Shield networks. This network is called BlueCard. Blue Cross and Blue Shield share this network. If you are out of California, it is important to utilize the Blue Card network so benefits will be paid at the higher in-network level. If you choose to see a non-network provider, the benefits will be paid at the lower nonnetwork level. Claims for Blue Card benefits are filed in the state where services were received and are sent electronically to Blue Shield for payment. Blue Card information can be obtained by calling (800)

12 FREQUENTLY ASKED QUESTIONS (CON T) Q. I WOULD LIKE TO UTILIZE THE MAIL ORDER OPTION FOR MY PRESCRIPTIONS. HOW DO I SUBMIT A PRESCRIPTION? A. You will need to obtain a 90 day prescription from your physician and submit mail order paperwork to Blue Shield if you are a PPO member and Navitus if you are an HMO member. Blue Shield mail order forms can be found at Navitus mail order forms can be found at and they are also available from District Benefits. Q. HOW DO I KNOW IF A PROCEDURE OR TEST WILL REQUIRE PREAUTHORIZATION AND IF SO, HOW TO I OBTAIN PREAUTHORIZATION? A. Often your doctor will know whether or not Blue Shield requires preauthorization and will obtain that authorization for you. However, any time you are unsure, you can call Customer Service at (800) and inquire. If preauthorization is required, you should ask your doctor to request it. The doctor can best communicate the type of test or procedure and the medical necessity for the procedure. Please note that Blue Shield is contracted with National Imaging Associates, Inc. (NIA) to provide medical necessity reviews and prior authorization for selected outpatient radiology procedures (PET/CAT Scans, MRI s, etc). Q. WHO DO I CONTACT WITH CLAIMS/BILLING QUESTIONS? A. You should call the number on the back of your ID card. Q. WHAT NETWORK DO I USE IF I AM SEARCHING FOR A MENTAL HEALTH CARE PROVIDER? A. If you are enrolled in the Blue Shield PPO plan, you can access Mental Health Care providers under the Blue Shield PPO network. If you are on the HMO plan, you can find a provider through Blue Shield of California s Mental Health Service Administrator (MHSA) provider network. You can access a listing of providers for both the Blue Shield Network and MHSA network at and click on Find a Provider Now. If you are a PPO member, the website will provide you with two network choices: Blue Shield and MHSA. It is important that you elect the Blue Shield network for your search of Network providers. Q. CAN I USE ANY BLUE SHIELD CONTRACTED DOCTOR TO PERFORM BARIATRIC SURGERY? A. Bariatric surgery is covered when preauthorized by Blue Shield. However, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura Counties ("Designated Counties"), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons; coverage is not available for bariatric services from any other preferred provider and there is no coverage for bariatric services from non-preferred Providers. In addition, if prior authorized by Blue Shield of California, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Evidence of Coverage for further benefit details. 12

13 REQUIRED FEDERAL NOTICES NOTICE OF SPECIAL ENROLLMENT RIGHTS FOR MEDICAL/HEALTH PLAN COVERAGE If you decline enrollment in a South Orange County Community College District health plan for you or your dependents (including your spouse) because of other health insurance or group health plan coverage, you or your dependents may be able to enroll in a South Orange County Community College District health plan without waiting for the next open enrollment period if you: Lose other health insurance or group health plan coverage. You must request enrollment within [30/31] days after the loss of other coverage. Gain a new dependent as a result of marriage, birth, adoption, or placement for adoption. You must request [medical plan OR health plan] enrollment within [30/31] days after the marriage, birth, adoption, or placement for adoption. Lose Medicaid or Children s Health Insurance Program (CHIP) coverage because you are no longer eligible. You must request medical plan enrollment within 60 days after the loss of such coverage. If you request a change due to a special enrollment event within the [30/31] day timeframe, coverage will be effective the date of birth, adoption or placement for adoption. For all other events, coverage will be effective the first of the month following your request for enrollment. In addition, you may enroll in South Orange County Community College District medical plan if you become eligible for a state premium assistance program under Medicaid or CHIP. You must request enrollment within 60 days after you gain eligibility for medical plan coverage. If you request this change, coverage will be effective the first of the month following your request for enrollment. Specific restrictions may apply, depending on federal and state law. Note: If your dependent becomes eligible for a special enrollment rights, you may add the dependent to your current coverage or change to another medical plan or health plan. Any other currently covered dependents may also switch to the new plan in which you enroll. Notice of Availability of HIPAA Privacy Notice The Federal Health Insurance Portability and Accountability Act of 1996 ( HIPAA ) requires that we periodically remind you of your right to receive a copy of the HIPAA Privacy Notice. You can request a copy of the Privacy Notice by contacting District Benefits. THE WOMEN S HEALTH AND CANCER RIGHTS ACT If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: All stages of reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; Prostheses; and Treatment of physical complications of the mastectomy, including lymphedema. These benefits are subject to the same deductible and co-payments applicable to other medical and surgical benefits provided under this plan. Therefore, the following deductible and coinsurance apply: HMO Plan - No Charge PPO Plan - 10% coinsurance You can contact your health plan s Member Services for more information. 13

14 REQUIRED FEDERAL NOTICES Premium Assistance Under Medicaid and the Children s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren t eligible for Medicaid or CHIP, you won t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit If you or your dependents are already enrolled in Medicaid or CHIP, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial KIDS NOW or to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren t already enrolled. This is called a special enrollment opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at or call EBSA (3272). This information is current as of January 31, For more information, you can contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services EBSA (3272) , Ext

15 HEALTH PLAN RATES OCTOBER 1, SEPTEMBER 30, 2014 DISTRICT PAID Faculty, Classified, Classified Management Single 2 Party Family Composite MEDICAL PLANS Blue Shield Of California HMO $1, Blue Shield Of California PPO $1, DENTAL AND VISION PLANS ACSIG Delta Dental PPO 1 $ ACSIG VSP Vision Service Plan $46.32 LONG TERM CARE AND LEGAL PLANS Long Term Care (Unum) Age Rated Legal (Hyatt) $

16 CONTACT INFORMATION INSURANCE CARRIERS/ADMINISTRATORS Membership Contact Information CARRIER PHONE NUMBER GROUP ID# WEBSITE HMO by Blue Shield/SISC (800) See I.D. Card Navitus (for Blue Shield HMO members) (866) PPO by Blue Shield/SISC See I.D. Card See I.D. Card Blue Shield Pharmacy (for Blue Shield PPO members) (866) NurseHelp 24/7 Program (for Blue Shield HMO members) See I.D. Card MDLIVE 24/7 Program (for Blue Shield PPO members) (888) Dental PPO by Delta/ACSIG (866) Vision by VSP/ACSIG (800) Life/AD&D by Reliance Standard (800) Long Term Disability by Reliance Standard (800) Flexible Spending Account by SISC (661) or (800) ext Employee Assistance Program by OptumHealth (800) Socccd Employee Assistance Program by Anthem (800) Legal Plan by Hyatt (800) Long Term Care Insurance by UNUM (800) / SchoolsFirst Federal Credit Union (800) N/A CalPERS (888) N/A STRS (800) N/A District Benefits (949) N/A humanresources/employeebenefits.html Employee Benefits Brochure designed and developed by in conjunction with South Orange County Community College District 16