ENROLL NOW. Medical, Dental, and Vision Open Enrollment Benefits Guide

Transcription

1 2016 Active Medical, Dental, and Vision Open Enrollment Benefits Guide Employees Open Enrollment September 21 st October 16 th Effective January 1, 2016 ENROLL NOW ***ACTION IS REQUIRED FOR ALL BENEFIT ELIGIBLE EMPLOYEES*** TWIN RIVERS UNIFIED IS OFFERING NEW MEDICAL PLANS THROUGH SELF INSURED SCHOOLS OF CALIFORNIA (SISC) ANNUAL MEDICARE PART D NOTICE INCLUDED

2 WELCOME TO YOUR BENEFITS GUIDE Your benefits are a valuable addition to your overall compensation. Make sure you get the most from them by taking the time to understand your options and by selecting the best coverage for you and your family. For information about the specific plans available to you, go online to the District s MyBenefits site: Website: Username: TRUSDEmployee Password: benefits NOTICE OF CREDITABLE COVERAGE If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, a Federal law gives you more choices about your prescription drug coverage. Please see page 15 for more details. SUMMARY OF BENEFITS AND COVERAGE (SBC) These are available on the web at: See username and password listed above. Click on SBC and then the plan you are interested in reviewing. Additional information regarding the SBCs can be found on page 17. TABLE OF CONTENTS Introduction ENROLL NOW Benefit Changes...3 Benefits Eligibility...4 Get Enrolled Open Enrollment Meetings...5 Choose Your Medical & Rx Benefits...6 Choose Your Dental...7 Choose Your Vision...8 Employee Assistance Program (EAP)... 8 Health Benefit Premiums & District Contributions...9 Frequently Asked Questions (FAQ) Contact Information..14 Medicare Part D Annual Notice. 15 Important Notices IMPORTANT NOTICE: READ CAREFULLY This Benefits Guide summarizes the TRUSD benefits program. Complete descriptions of each benefit are available in the actual plan documents. Every effort has been made to ensure this summary accurately describes these benefits. However, if there is a conflict between this information and the plan documents, the plan documents will govern. In addition, participation in the benefits program does not constitute a right to continued employment with the District. Nothing in this Guide should be construed as a contract or offer to contract for employment for any specific time or under any particular terms and conditions. 2

3 ENROLL NOW from September 21 st to October 16 th At Twin Rivers Unified School District, we recognize the hard work and dedication that goes into your work every day. The District is committed to providing employees and their eligible dependents with a comprehensive benefit package. The District s goals are to provide affordable and high quality medical options to its employees while maintaining access to local hospitals and physicians. To that end, effective January 1, 2016, the District will now offer one (1) Kaiser Permanente plan, two (2) Anthem HMO plans, and two (2) Anthem PPO plans through Self Insured Schools of California (SISC) for all eligible employees and dependents. CalPERS medical benefits will no longer be available after 12/31/15. Open Enrollment for 2016 begins Monday, September 21 st and will remain open until Friday, October 16 th. Due to the change to SISC, ALL eligible employees are required to make a new plan selection. SISC plan year runs through 9/30 each year. Therefore, the benefits you choose will become effective January 1, 2016 through September 30, Subsequent open enrollments will have coverage 10/1 through 9/30. (i.e. 10/1/16-9/30/17) Please review this guide in its entirety to familiarize yourself with the District s new medical coverage including guidance on what is required of each eligible employee and a listing of all informational meetings. MyBenefits website In addition to this Guide, you can find more information about the specific plans available to you by going online to: Login: TRUSDEmployee (case sensitive) Password: benefits (case sensitive) 2016 BENEFIT CHANGES Medical - As stated above, the District will now be offering medical benefits through Self Insured Schools of California (SISC) effective January 1, 2016 through September 30, The following plans are available to eligible employees and their dependents. For a summary of each plan, please refer to page six. As an eligible employee you MUST make a new election this year. Kaiser Anthem Premier HMO 7/25 Rx Anthem Premier HMO 15/50 Rx Anthem PPO G 7/25 Rx Anthem PPO M 15/50 Rx Given the changes being made to the medical plans, it is highly recommended that you attend one of the District s informational meetings. There are multiple meeting dates and locations planned. For the most convenient location and time for you, please refer to page five. Dental Dental will continued to be offered through Delta Dental (1/1-12/31). Premiums are found on pages nine and ten. Vision Vision will continued to be offered through VSP (1/1-12/31). Premiums are found on pages nine and ten. Contributions There have been negotiated changes to the District medical contributions for the 2016 plan year. Please review pages nine and ten for updated contributions per bargaining unit. Employee Assistance Program (EAP) Effective 1/1/2016, all employees will have access to a new EAP through SISC/Anthem. Please refer to pages eight and 14 for contact information. Voluntary Plans will be explained and available by an American Fidelity benefit counselor. 3

4 BENEFITS ELIGIBILITY Who s Eligible for Coverage? All eligible employees working at least 20 hours or more per week are eligible to enroll in Twin Rivers Unified School District s medical plans. Any Employee working 90% or more of the full-time equivalent for the applicable job classification is required to enroll in a medical plan. If you currently waive medical coverage and work 90% or more of the full-time equivalent, you will be grandfathered and can continue to waive medical coverage if you choose. You will be required to provide proof of other group health plan coverage. Coordinated District contributions for employees whose Spouses or registered domestic partners are also employees of the District will continue. Eligible dependents include: Your spouse or state registered domestic partner 1 Children up to age 26 (includes natural and adopted children, stepchildren and any other children you support and for whom you are the legal guardian or for whom you are required to provide coverage as the result of a qualified medical child support order) Children up to age 26 or older if disabled and incapable of self-support GET ENROLLED! American Fidelity will be scheduling meetings with ALL eligible employees to review Open Enrollment materials. You will make your medical selection at that time together with any other open enrollment changes. Please Note: If you re enrolling Dependent(s), Dependent Certification is REQUIRED! Spouses most recent Federal Tax Form (page one showing married filing status with financial information blacked out) Domestic Partners Certificate of Declaration of Domestic Partnership that was filed with the California Secretary of State. Children birth certificate, adoption paperwork, legal guardianship papers when applicable. Birth certificates must show the names of the parents. Disabled Dependent Children birth certificate, adoption paperwork, legal guardianship papers when applicable. Birth certificates must show the names of the parents. You will also need to provide a copy of your Federal Tax return together with a Disabled Dependent Certification Form. This form is available via the website. (see pages three and 14) PLEASE PLAN ON BRINGING TWO (2) PHOTOCOPIES OF EACH REQUIRED DOCUMENT TO YOUR MEETING WITH THE AMERICAN FIDELITY BENEFIT COUNSELOR. YOU WILL NOT BE ABLE TO COMPLETE YOUR ERNOLLMENT WITHOUT THE REQUIRED DOCUMENTS. It is the employee s responsibility to obtain proof of eligibility and to submit such proof to the District in a timely manner. Failure to submit supporting documentation will result in dependents being denied coverage. IMPORTANT: All documentation must be translated to English if in another language. 1 Due to federal and state tax regulations, benefits provided to domestic partners are generally taxable and therefore deducted from your pay on an after-tax basis. Additionally, any premium contributions made by the District on behalf of your domestic partner are generally considered taxable income to you. Contact the District if you believe your domestic partner is exempt from federal or state taxes. 4

5 2016 INFORMATIONAL MEETINGS The District will be holding multiple information meetings. During these meetings you will learn about the new SISC/Anthem and SISC/Kaiser Permanente Medical options available to you and your family. Here you can meet with District Staff, Anthem, Kaiser Permanente, EPIC (District s Consultant), SISC and selected medical groups, to go over any questions you may have about your coverage. It is highly recommended that you attend at least one of these meetings. You will still be required to meet with an American Fidelity benefit counselor to complete enrollment. DATE TIME LOCATION ADDRESS Monday 9/21/ am District Office Willow & Oak Room 5115 Dudley Blvd McClellan Park, CA Monday 9/21/ pm District Office Cottonwood & Maple Room 5115 Dudley Blvd McClellan Park, CA Tuesday 9/22/2015 Wednesday 9/23/2015 2:30 4:30pm Rio Linda High School 3:30 5:30pm Grant High School 6309 Dry Creek Rd Rio Linda, CA Grand Ave Sacramento, CA Thursday 9/24/ pm General Services/Training Room # Winona Way North Highlands, CA Friday 9/25/ pm Transportation 1400 Grand Ave Sacramento, CA Monday 9/28/ pm District Office Cottonwood 5115 Dudley Blvd McClellan Park, CA Wednesday 10/7/2015 3:30-5:30pm Foothill High School 5000 McCloud Dr. Sacramento, CA Thursday 10/15/ pm District Office Willow & Oak Room 5115 Dudley Blvd McClellan Park, CA Friday 10/16/ pm District Office Willow & Oak Room 5115 Dudley Blvd McClellan Park, CA

6 CHOOSE YOUR MEDICAL & Rx BENEFITS You have the choice of several quality and comprehensive medical plans that include prescription drug coverage. When choosing your plan, consider your budget, your preferences, and the health of you and your covered dependents. The information below is a summary of coverage only. For more information about each plan, visit the District s MyBenefit website. Login information can be found on pages three and 14. The deductibles, copays, and coinsurance percentages below indicate the amounts for which you are responsible. Benefits Calendar Year Deductible (Single/Family) HMO Kaiser HMO $20 Copay None HMO Anthem HMO Premier 20 $7/$25 Rx None HMO Anthem HMO Premier 20 $15/$50/$200 Ded Rx None PPO Anthem PPO G $7/$25 Rx In-Network Out-of-Network In-Network Out-of-Network $500 / $1,000 (all benefits are subject to the deductible unless otherwise noted) PPO Anthem PPO M $15/$50/$200 Ded Rx $3,000 / $6,000 (all benefits are subject to the deductible unless otherwise noted) Calendar Year Maximum (Single/Family) $1,500 / $3,000 $1,500 / $3,000 $1,500 / $3,000 $2,000 / $4,000 $4,000 / $8,000 Calendar Year Prescription Copay Max (Single/Family) None $1,500 / $2,500 $2,500 / $3,500 $1,500 / $2,500 $2,500 / $3,500 Physician/Specialist Office Visits $20 $20 $20 $20 (deductible waived) See footnote 2 $40 (deductible waived) See footnote 2 Room & Board Hospital Inpatient (semi-private) No charge $ 200 / admit $ 200 / admit 20% Plan pays up to $600/day 20% Plan pays up to $600/day Outpatient Surgery $20 $100 /admit $100 /admit 20% Plan pays up to $350/day 20% Plan pays up to $350/day X-Ray & Lab No Charge No Charge No Charge 20% Not Covered 20% Not Covered Diagnostic Imaging No charge $100 $100 20% See footnote 2 (benefit limited to $800 per proceudre) 20% See footnote 2 (benefit limited to $800 per proceudre) Emergency Room (copay waived if admitted) $100 $100 $100 $ % $ % of max allowed amount $ % $ % of max allowed amount Urgent Care Visits $20 Skilled Nursing Facility No charge up to 100 days per benefit period $20 No charge up to 100 days per calendar year $20 No charge up to 100 days per calendar year $20 (deductible waived) See footnote 2 $40 (deductible waived) See footnote 2 20% Plan pays up to $600/day 20% Plan pays up to $600/day up to 100 days per claendar year up to 100 days per claendar year Durable Medical Equipment No charge 20% 20% 20% Not covered 20% Not covered Chiropractic Care $10 up to 30 visits per year chiro/acupuncture combined $10 limited to 30 visits/ calendar year chiro/acupuncture combined $10 limited to 30 visits/ calendar year chiro/acupuncture combined 20% Not covered 20% Not covered Acupuncture $10 up to 30 visits per year chiro/acupuncture combined $10 $10 limited to 30 visits/calendar limited to 30 visits/calendar year chiro/acupuncture year combined chiro/acupuncture combined 20% 50% of max allowed amount up to 12 visits per calendar year 20% 50% of max allowed amount up to 12 visits per calendar year Prescription Brand/Specialty Deductible (Single/Family) None None $200 / $500 None N/A $200 / $500 N/A Retail Pharmacy $10 G / $30 B Network: $7 G / $25 B Network: $15 G / $50 B Network: $7 G / $25 B (up to a 30 day supply) 1 Costco: $0 G / $25 B Costco: $5 G / $50 B Costco: $0 G / $25 B Not covered Network: $15 G / $50 B Costco: $5 G / $50 B Not covered Mail Order Pharmacy 1 $20 G / $60 B up to a 100 day supply Costco: $0 G / $60 B 90 days Navitus: Specialty $25 30 days Costco: $15 G / $135 B 90 days Navitus: Specialty $50 30 days Costco: $0 G / $60 B 90 days Navitus: Specialty $25 30 days Not covered Costco: $15 G / $135 B 90 days Navitus: Specialty $50 30 days Not covered 1 G = Generic, B = Brand 2 The plan pays 100% of the fee schedule. The member is responsible for all amounts exceeding the fee schedule. 6

7 CHOOSE YOUR DENTAL Dental Your dental benefits are provided through Delta Dental and are available to you and your dependents. The dental plan(s) feature a network of dentists and specialists who provide services at a discounted rate. So when you elect an in-network dentist, you ll save money. The information below is a summary of coverage only. For more information about each plan, visit the Districts MyBenefits website. Login information can be found on pages three and 14. Key Features Delta Dental Incentive * Delta Dental Alternative * Annual Calendar Year Maximum $2,200 In Network / $2,000 Out of Network $2,200 In Network / $2,000 Out of Network Calendar Year Deductible None None Diagnostic & Preventive (Exams, Cleanings, X-Rays) Basic Services (Fillings, simple tooth extractions, sealants) 70% - 100% 100% 70% - 100% 80% Endodontics (root canals) (covered under Basic Services) Periodontics (gum treatment) (covered under Basic Services) Oral Surgery (covered under Basic Services) Major Services (Crowns, Inlays, Onlays and cast restorations) Prosthodontics (Bridges and dentures, implants) Orthodontics (adults and dependent children) 70% - 100% 80% 70% - 100% 80% 70% - 100% 80% 70% - 100% 50% 50% N/A 50% 50% Orthodontic Maximums $1,500 Lifetime Max Per Person $1,500 Lifetime Max Per Person Dental Accident Benefits 100% (separate $1,000 maximum per person per calendar year) 100% (separate $1,000 maximum per person per calendar year) Limitations or waiting periods may apply for some benefits; some services my be excluded from your plan. Reimbursement is based on Delta Dental contract allowances and not necessarily each dentist s actual fees. *Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and program allowance for non-delta Dental dentists. 7

8 CHOOSE YOUR VISION BENEFITS Vision Plan Summary You and your dependents have access to vision coverage through Vision Service Plan (VSP). For more information about the plan, visit the Districts MyBenefits website. Login information can be found on pages three and 14. Frequency Exam Lenses Frames Contact Lenses Coverage Key Features In-Network Out-of-Network Once every 12 months Once every 12 months Once every 24 months Once every 12 months Eye Exam Covered in full Up to $50.00 Single Lenses Covered in full Up to $50.00 Bi-Focal Covered in full Up to $75.00 Tri-Focal Covered in full Up to $ Progressive Lenses Covered in full Up to $75.00 Frame Allowance Contact Lenses Elective allowance (in lieu of glasses) Additional VSP Benefits: $ % off the amount over your allowance $ includes the contacts and the contact lens exam (fitting & evaluation) Up to $70.00 Up to $ Glasses and Sunglasses - 30% off additional glasses and sunglasses, including lens options from the same VSP doctor on the same day as your WellVision Exam. Or get 20% off from any VSP doctor within 12 months of your last Exam. Primary EyeCare Program - Supplemental coverage for non-surgical medical eye conditions, such as pink eye and other urgent eyecare - $20 copay per visit at Preferred Providers Laser VisionCare Program - Discounts average 15% off or 5% off a promotional offer for laser surgery, including PRK, LASIK, and Custom LASIK at Preferred Providers Employee Assistance Program (EAP) You and your household members have access to EAP coverage through SISC/Anthem EAP. The EAP provides a highly confidential, experienced, professional source of assistance to manage life s challenges that may interfere with personal and/or professional life. All eligible employees and their household members may use the EAP services. The EAP also provides referral services. You and your dependents are eligible for up to 6 in-person counseling sessions per issue per year and unlimited phone consultations. The EAP is available to assist you 24 hours a day, seven days a week. How to access Anthem EAP information and tools: Online: Login: SISC Call Toll Free: (800)

9 2016 HEALTH BENEFIT PREMIUMS AND DISTRICT CONTRIBUTION INFORMATION MEDICAL PLANS 9 Month Premiums Plan Name Coverage Level (1/1/16-9/30/16) Employee Only $ Kaiser HMO Employee + 1 Dependent $ 1, Employee + Family $ 1, Employee Only $ Anthem Premier $7/$25 Rx Employee + 1 Dependent $ 1, Employee + Family $ 2, Employee Only $ Anthem Premier $15/$50 Rx Employee + 1 Dependent $ 1, Employee + Family $ 1, Employee Only $ Anthem PPO G Employee + 1 Dependent $ 1, Employee + Family $ 1, Employee Only $ Anthem PPO M Employee + 1 Dependent $ 1, Employee + Family $ 1, DENTAL PLANS 12 Month Premiums Plan Name Level (1/1/16-12/31/16) Employee Only $ Delta Dental PPO Employee + 1 Dependent $ Employee + Family $ Employee Only $ Delta Alternative Plan Employee + 1 Dependent $ Employee + Family $ VISION PLANS 12 Month Premiums Level (1/1/16-12/31/16) Employee Only $ Plan B Employee + 1 Dependent $ (Exam & Lenses Every 12 months) Employee + Family $ DISTRICT PAID PROGRAMS Anthem EAP (through SISC) Per Month/ Per Employee Included in Medical Life Ins. $50,000 Per Month/ Per Employee $ 7.80 DISTRICT MEDICAL CONTRIBUTION CSEA, TRSPA, CONF TRUE, MGT, SUP, BRD* Employee Only $ $ Employee + 1 Dependent $ $ Employee + Family $ 1, $ 1, * Subject to ratification/approval Due to changes in the 2016 Benefits premiums, new benefit rates will automatically be deducted from your December 2015 pay warrant. 9

10 2016 SUMMER HEALTH BENEFITS 11 PAY CALCULATIONS TRUE, MGMT SISC 2016 Premium 2016 District Contribution SUMMER 11 Pay EE Portion SUMMER 11 Pay ER Portion Kaiser Employee Only $ $ $ $ Kaiser Employee + 1 Dependent $ 1, $ $ $ Kaiser Employee + Family $ 1, $ 1, $ $ Anthem Premier $7/$25 Employee Only $ $ $ $ Anthem Premier $7/$25 Employee + 1 Dependent $ 1, $ $ $ Anthem Premier $7/$25 Employee + Family $ 2, $ 1, $ $ Anthem Premier $15/$50 Employee Only $ $ $ $ Anthem Premier $15/$50 Employee + 1 Dependent $ 1, $ $ $ Anthem Premier $15/$50 Employee + Family $ 1, $ 1, $ $ Anthem PPO G Employee Only $ $ $ $ Anthem PPO G Employee + 1 Dependent $ 1, $ $ $ Anthem PPO G Employee + Family $ 1, $ 1, $ $ Anthem PPO M Employee Only $ $ $ - $ Anthem PPO M Employee + 1 Dependent $ 1, $ $ 9.73 $ Anthem PPO M Employee + Family $ 1, $ 1, $ $ Delta Dental PPO Employee Only $ $ - $ 6.26 $ - Delta Dental PPO Employee + 1 Dependent $ $ - $ $ - Delta Dental PPO Employee + Family $ $ - $ $ - Delta Alternative Employee Only $ $ - $ 4.16 $ - Delta Alternative Employee + 1 Dependent $ $ - $ 7.91 $ - Delta Alternative Employee + Family $ $ - $ $ - VSP Employee Only $ $ - $ 0.96 $ - VSP Employee + 1 Dependent $ $ - $ 1.82 $ - VSP Employee + Family $ $ - $ 2.78 $ - CSEA, TRSPA, CONF SISC 2016 Premium 2016 District Contribution SUMMER 11 Pay EE Portion SUMMER 11 Pay ER Portion Kaiser Employee Only $ $ $ 8.85 $ Kaiser Employee + 1 Dependent $ 1, $ $ $ Kaiser Employee + Family $ 1, $ 1, $ $ Anthem Premier $7/$25 Employee Only $ $ $ $ Anthem Premier $7/$25 Employee + 1 Dependent $ 1, $ $ $ Anthem Premier $7/$25 Employee + Family $ 2, $ 1, $ $ Anthem Premier $15/$50 Employee Only $ $ $ $ Anthem Premier $15/$50 Employee + 1 Dependent $ 1, $ $ $ Anthem Premier $15/$50 Employee + Family $ 1, $ 1, $ $ Anthem PPO G Employee Only $ $ $ $ Anthem PPO G Employee + 1 Dependent $ 1, $ $ $ Anthem PPO G Employee + Family $ 1, $ 1, $ $ Anthem PPO M Employee Only $ $ $ - $ Anthem PPO M Employee + 1 Dependent $ 1, $ $ 9.73 $ Anthem PPO M Employee + Family $ 1, $ 1, $ $ Delta Dental PPO Employee Only $ $ - $ 6.26 $ - Delta Dental PPO Employee + 1 Dependent $ $ - $ $ - Delta Dental PPO Employee + Family $ $ - $ $ - Delta Alternative Employee Only $ $ - $ 4.16 $ - Delta Alternative Employee + 1 Dependent $ $ - $ 7.91 $ - Delta Alternative Employee + Family $ $ - $ $ - VSP Employee Only $ $ - $ 0.96 $ - VSP Employee + 1 Dependent $ $ - $ 1.82 $ - VSP Employee + Family $ $ - $ 2.78 $ - Due to changes in the 2016 Benefits premiums, summer benefit deductions will change on your paycheck starting December

11 OPEN ENROLLMENT FREQUENTLY ASKED QUESTIONS (FAQs) 1. What is Open Enrollment? Open Enrollment is the specific period of time each year during which you may enroll eligible dependents not presently covered, change insurance carriers, and enroll in one or more supplemental insurance programs including the Unreimbursed Medical Flexible Spending account and the Dependent Care Flexible Spending account, supplemental life insurance, and other voluntary benefits. TRUSD is partnering with American Fidelity Assurance (AFA) to assist with open enrollment. This partnership will streamline your enrollment, provide you with information as you make your benefit elections for the coming year. AFA will contact officials at different sites/departments to setup locations to meet with employees. All benefit eligible employees (working 20 hours or more per week) are required to meet with a benefit counselor from AFA. 2. When is Open Enrollment? This year s Open Enrollment period begins September 21 st and closes October 16 th. Benefit counselors from AFA will be available for one-on-one meetings at school sites, at the District Office and at the various informational meetings scheduled throughout open enrollment. 3. When do plan changes go into effect? January 1, If I don t want to make any changes do I need to do anything? Yes. You must meet with a benefit counselor from AFA. If currently enrolled in a medical plan through CalPERS, you will need to select a new SISC medical plan. 5. Can I waive medical coverage if I already have coverage through a spouse? Full-time employees working 90% or greater who waived medical coverage in 2015 can waive coverage under SISC. These employees will be grandfathered and do not need to enroll in a medical plan but will need to provide proof of other group coverage. Employees working less than full time may waive medical coverage. Please plan to meet with an AFA benefits counselor to review other plan options and enroll or re-enroll in your flexible spending accounts (Dependent Care Flexible Spending Account & Health Care Flexible Spending Account) if you would like to continue to participate. 6. If I currently waive coverage do I need to do anything? Yes. During this open enrollment period, all employees waiving benefits will need to provide current proof of other health coverage. This proof can be provided with a copy of your current insurance card, a letter from your current insurance carrier stating you are currently covered, or a letter from the employer that carries the other health insurance stating you are currently covered. Proof must be provided to the benefit counselor from AFA during the one-on-one appointment. 7. How do I make changes to medical and/or dental coverage? Review the Open Enrollment Benefits Guide and the options available to you especially for medical. Plan to attend one of the informational meetings. Make an appointment to meet with an AFA benefit counselor. Please be sure to bring copies of your supporting documentation such as Federal tax forms, birth certificates, certificate of domestic partnership if adding dependents. Social Security numbers are also required for all dependents. 11

12 8. How do I enroll or make changes to my Flexible Spending Account options? During your meeting with an AFA benefit counselor, you will receive assistance with making these changes. If you have any questions, you may contact AFA at or As a part-time employee, am I eligible to enroll in health benefits? Part-time employees are eligible to elect coverage if you work 20 or more hours per week. To determine if you are eligible, please contact your payroll & benefits technician at (A-L ext ) (M-Z ext ). 10. If one of my dependents loses health insurance due to a change in employment status, am I required to wait until Open Enrollment to add him or her? No. You will need to complete an enrollment/change form within 30 days of the event. You must also obtain a letter from the employer or health care provider verifying end of coverage and the reason. These documents must then be turned into your payroll & benefits technician at the District office. Dependent verification will also be required (i.e., tax return, birth certificate, etc.) 11. Do I have an opportunity to drop insurance coverage? If you currently work full-time and are already enrolled in a medical plan, you must enroll in a SISC medical plan. You are not allowed to drop this coverage. However, you may drop your dental and/or your vision coverage. Full-time employees currently waiving medical coverage may continue to waive medical coverage and may drop dental and/or vision coverage. If you currently work part-time, you may drop coverage. Please be sure you bring proof of other coverage when you meet with an AFA benefit counselor. 12. Do I have to select a primary care physician (PCP)? Yes, but only if you are enrolling in one of the Anthem HMO plans. If you don t select a PCP at the time of enrollment, you will be auto assigned to a PCP. You may change this PCP at any time by contacting Anthem using the number on the back of your ID card. 13. Do I have to select a new primary care physician (PCP)? In most cases, you may keep your current PCP and other specialists. You may contact your providers to see if they are contracted with Anthem HMO or PPO or visit the Anthem website to see if your PCP/Specialist is contracted ( or you may login to the District s MyBenefits site to view the Anthem directory. 14. I currently have Blue Shield coverage. Will I have access to the same providers under one of the Anthem plans? Most likely. Many providers are contracted with multiple carriers. You may access the Anthem provider directory online at or you may login to the District s MyBenefits site to view the Anthem directory. Please note that contracting may differ between the HMO and PPO plans. Be sure to check this when viewing the website. 15. I currently have United HealthCare coverage. Will I have access to the same providers under one of the Anthem plans? Most likely. Many providers are contracted with multiple carriers. You may access the Anthem provider directory online at or you may login to the District s MyBenefits site to view the Anthem directory. Please note that contracting may differ between the HMO and PPO plans. Be sure to check this when viewing the website. (Note: Anthem and Sutter Medical Group and Hospitals are currently in contract negotiations for January 1, 2016 effective date). 16. Will I get a new ID card? If you are a current Kaiser member and enroll with Kaiser, you will not receive a new ID card. If you enroll in one of the Anthem plans, you will receive a new ID card prior to January 1,

13 17. Who may I contact if I have questions regarding the drug formulary on any of the Anthem plans? You may call Navitus at (866) and identify yourself as being a part of SISC but not yet active. Provide them with the Rx plan you would like to enroll in either the $7/$25 or the $15/$50. Navitus will be able to assist you with how your current drugs will be covered under the new Anthem plans. 18. I am currently using mail order to obtain my prescriptions. What will I need to do to transfer my prescriptions? If you are enrolling in Kaiser, you do not need to do anything. If you are enrolling in any non-kaiser plan, you will need to obtain a new prescription and submit it to Costco, the mail-order vendor. You may download the mail order form from the Costco website: Additional information regarding Costco s mail order program can be found: YOU WILL NOT BE ABLE TO SUBMIT YOUR FORM TO COSTCO UNTIL THE ELIGIBILITY INFORMATION HAS BEEN SENT TO SISC. WE ANTICPATE THIS TO BE ON OR ABOUT DECEMBER 1, I also will have coverage under my spouse s plan, how will benefits be coordinated between the two plans? The District s plan that you enroll in as an employee will be considered your primary plan and the benefits pay first. Your spouse s plan will be your secondary plan. Coordination of benefits is dependent upon whether or not your spouse s plan coordinates benefits. The Evidence of Coverage booklet for your spouse s plan will detail whether or not benefits are coordinated and, if so, how they will be coordinated. For dependent children who are dual covered, the plan of the parent whose birthdate falls first in the year is primary and will pay first. There is limited coordination of benefits between two different HMO plans or an HMO and PPO. Typically, coordination of benefits is mostly between two PPO plans. Likewise, there may be some coordination between two Kaiser traditional plans. For more information regarding coordination of benefits, please contact the carriers to discuss your specific questions. 13

14 Contact Information For Questions About Contact Call Website/ Medical Anthem HMO Anthem PPO (800) Medical Kaiser (800) Medical Prescription Drugs (Anthem HMO & PPO Plans Only) Prescription Drugs (Anthem HMO & PPO Plans Only) *SISC MDLive (Anthem Plans Only) (888) Navitus Prescriptions (866) Costco Mail Order (800) Dental Coverage Delta Dental (866) Vision Coverage VSP (800) Employee Assistance Program Anthem EAP (800) Login: SISC TRUSD Benefits Laura Walker (A-L) Gina Shannon (M-Z) (916) ext (916) ext MyBenefits Site n/a n/a Username: TRUSDEmployee Password: benefits *SISC MDLive Anthem Plans Only Get 24 hours a day, 7 days a week, 365 days a year access to doctors and pediatricians anytime, anywhere via online video, phone call or through secure e mail advice. When to use MDLIVE? If you're considering the emergency room or urgent care center for a non emergency medical issue Your primary care doctor is not available Request prescriptions or get refills Traveling and in need of medical care During or after normal business hours, nights, weekends and even holidays 14

15 MEDICARE PART D NOTICE Important Notice from Twin Rivers Unified School District About Your Prescription Drug Coverage and Medicare This Notice Applies to You (or Dependent) ONLY if such person is (1) enrolled in a group medical plan offered by Twin Rivers Unified School District AND (2) eligible for Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Twin Rivers Unified School District and about your options under Medicare s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. Twin Rivers Unified School District has determined that the prescription drug coverage offered by SISC is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your new coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Twin Rivers Unified School District coverage may be affected. Your current coverage pays for other health expenses in addition to prescription drugs. If you enroll in a Medicare prescription drug plan, you and your eligible dependents may not be eligible to receive all of your current health and prescription drug benefits. If you do decide to join a Medicare drug plan and drop your current Twin Rivers Unified School District coverage, be aware that you and your dependents may not be able to get this coverage back. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Twin Rivers Unified School District and don t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. 15

16 For More Information About This Notice Or Your Current Prescription Drug Coverage Contact the person listed below for further information. NOTE: You ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Twin Rivers Unified School District changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage More detailed information about Medicare plans that offer prescription drug coverage is in the Medicare & You handbook. You ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Visit Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the Medicare & You handbook for their telephone number) for personalized help Call MEDICARE ( ). TTY users should call If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at or call them at (TTY ). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Date: September 9, 2015 Name of Entity/Sender: Twin Rivers Unified School District Contact--Position/Office: Ellie Winter, Director, Financial Services Address: 5115 Dudley Blvd. McClellan Park, CA Phone Number: (916)

17 IMPORTANT NOTICES Summary of Benefits and Coverage (SBC) As an employee, the health benefits available to you represent a significant component of your compensation package. They also provide important protection for you and your family in the case of illness or injury. Your plan offers a series of health coverage options. Choosing a health coverage option is an important decision. To help you make an informed choice, your plan makes available a Summary of Benefits and Coverage (SBC), which summarizes important information about any health coverage option in a standard format, to help you compare across options. The SBCs and a uniform glossary are available on the District s MyBenefits website at: A paper copy is also available, free of charge by calling Use ext If your last name begins with A-L or ext if your last name begins with M-Z. Newborns and Mothers Health Protection Act Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother s or newborn s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). If you would like more information on maternity benefits, contact your health plan. Special Enrollment Notice If an eligible employee declines enrollment in a group health plan for the employee or the employee s spouse or dependents because of other health insurance or group health plan coverage, the eligible employee may be able to enroll him/herself and eligible dependents in this plan if eligibility is lost for the other coverage (or because the employer stops contributing toward this other coverage). However, the eligible employee must request enrollment within 30 days after the other coverage ends (or after the employer ceases contributions for the coverage). In addition, if an eligible employee acquires a new dependent as a result of marriage, birth, adoption or placement for adoption, the eligible employee may be able to enroll him/herself and any eligible dependents, provided that the eligible employee requests enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. If the eligible employee otherwise declines to enroll, he/she may be required to wait until the District s next open enrollment to do so. The eligible employee also may be subject to additional limitations on the coverage available at that time. Furthermore, eligible employees and their eligible dependents who are eligible for coverage but not enrolled, shall be eligible to enroll for coverage within 60 days after becoming ineligible for coverage under a Medicaid or Children s Health Insurance Plan (CHIP) plan or being determined to be eligible for financial assistance under a Medicaid, CHIP, or state plan with respect to coverage under the plan. Women s Health and Cancer Rights Act Annual Notice (WHCRA) 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 will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. If you would like more information on WHCRA benefits, contact your health plan. Patient Protection Notice Kaiser and Anthem generally requires the designation of a primary care provider for the HMO plans. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. Until you make this designation, Kaiser and Anthem will designate one for you. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact Kaiser or Anthem member services at the number on your insurance card. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from Kaiser, Anthem or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact member services at the number on your insurance card. 17

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