Open Enrollment 2015 Fullerton School District Employee Benefit Brochure Effective October 1, 2015 through September 30, 2016

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1 Open Enrollment 2015 Fullerton School District Employee Benefit Brochure Effective October 1, 2015 through September 30, 2016

2 Introduction Fullerton School District takes pride in offering a benefit program that provides flexibility for the diverse and changing needs of our employees. We continually evaluate our plans in light of changes within the insurance industry and the law. In an effort to provide the highest quality benefits, Fullerton School District added a new HMO plan to our existing plan offerings for our employees to choose from. The District offers employees and their family members a full range of benefits. You choose the options that best meet your needs. WHAT S INSIDE Introduction... 2 Open Enrollment Eligibility... 4 Rules For Benefit Changes During The Year... 5 Insurance Benefit Plan Designs Medical Plan Summaries Health Savings Account FAQ Dental Plan Summaries Vision Plan Summary Employee Assistance Program (EAP) Cafeteria 125 Flex Savings 16 Basic Life/AD&D Voluntary Life FSO Employee Contribution Schedule HSA Contribution Schedule Required Federal Notices Medicare Part D Who Should You Call? SISC Blue Shield Medical PPO Plans Traditional PPO Maximum Out of Pocket Change High Deductible PPO with Health Savings Account SISC Blue Shield Medical HMO Plans Full-Network HMO with $10 copay SaveNet Narrow Network HMO with $10 copay Full-Network HMO with $25 copay New Plan SISC Kaiser Permanente Medical HMO Plan Delta Dental PPO Plan DeltaCare DHMO Plan ACSIG VSP Vision Plan Anthem Employee Assistance Program (EAP) Rx Copay Change VOYA Basic Life and AD&D (District Paid) VOYA Voluntary Life If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, a Federal law gives you choices about your prescription drug coverage. Please see pages for more details. Discovery Benefits Cafeteria 125 Flex Savings Disability Insurance - Not offered through the District If you are interested in purchasing optional coverage, you may contact your Union Preferred Vendors: CSEA: American Fidelity (866) x385 FETA: The Standard (800) AFLAC: (714) DISCLAIMER The information in this brochure is a general outline of the benefits offered under Fullerton School District benefits program. This brochure may not include all relevant limitations and conditions. 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

3 Open Enrollment PLEASE READ Fullerton School District employees employed 50% (4 hours) or more have the opportunity once-a-year to modify their benefits coverage, if needed. These modifications include: cancellation of benefits, add/drop dependent coverage, and report address/name changes. The District's open enrollment period is from July 30, 2015 through August 13, Open Enrollment Assistance and Q&A sessions will be held on August 3, 2015 (Board Room 8am 5pm), August 5, 2015 (Board Room 2pm 5pm), August 6, 2015 (EvFree/ Welcome Back 10am 12pm), August 12, 2015 (Board Room 8am 5pm) and August 13, 2015 (Board Room 12pm 5pm). Please plan on attending one of the Open Enrollment Assistance and Q&A sessions. Consider your options carefully as benefit changes can only be made during open enrollment, unless you experience a qualified status change (see page 5). All benefit changes will be effective October 1, Here is some important information regarding open enrollment: If you are NOT making any changes, you need only to complete (sign, date, and return) the Benefit Confirmation Statement you received during Summer Break, no later than August 13, If you make ANY changes to your Benefits Confirmation Statement (name, address, dependents, etc.) you MUST complete the necessary enrollment change forms and/or documentation and submit them together. DO NOT submit Benefits Statement without documentation. Full Time Employees (100% / 8 hours) are required to enroll in a minimum of single coverage: There is no cost for single coverage There is no option to waive benefits/opt out (no renumeration given) If an enrollment packet is not received for 100% / 8 hour FTE, the employee will be enrolled in single Kaiser and single Delta Dental PPO Employees with Dual Coverage: Your Fullerton School District coverage will be your primary health coverage Make selections that will be beneficial in coordination with your secondary coverage If your children are on both coverages of married parents, their primary will be based on the parent with the earlier birthday in the year. In the case of divorce or separation, please see the Evidence of Coverage for your plan. If you need assistance, contact Member Services Blue Shield PPO HSA coverage will not allow dual coverage (please see Blue Shield PPO HSA information) You are required to submit a new enrollment form and are required to provide proof of eligibility for your dependents if: You wish to enroll in the Medical, Dental, Vision or Voluntary Life plans You wish to change plans. Example: If you are currently enrolled in a PPO plan and would like to switch to a HMO plan You wish to add or delete dependents Dependent eligibility may be verified by submitting the following documentation with your completed enrollment forms to Insurance Benefits: Proof of Marital Status - State issued Marriage Certificate and a copy of last year s Federal Tax Return Proof of Registered Domestic Partnership Proof of Dependent Relationship - *State issued Birth Certificate (showing you, your spouse and/or same-sex domestic partner as the child s parent) *Certified court approved adoption papers *Placement letter from court/adoption agency *Certified court ordered custody/guardianship papers Enrollment forms and proof of eligibility for your dependents must be received by Insurance Benefits no later than Thursday, August 13,

4 Open Enrollment Assistance and Q&A Sessions Monday, 8/3/2015 District Board Room 8:00am 5:00pm Vendor Reps Available District Reps Available Wednesday, 08/05/2015 District Board Room 2:00pm 5:00pm No Vendor Reps District Reps Only Thursday, 08/6/2015 EvFree/Welcome Back 10:00am-12:00pm Vendor Reps Available District Reps Available Wednesday, 8/12/2015 District Board Room 8:00am 5:00pm District Reps Only Thursday, 08/13/2015 District Board Room 12:00pm 5:00pm District Reps Only Eligibility Your eligibility is based on current negotiated agreements. Depending on your classification, different eligibility guidelines will apply. New hires will become benefit eligible the first day of the month following the date of hire. Permanent employees returning from a personal Leave of Absence or Military Leave of Absence will become benefit eligible upon return to active status. After your initial benefit enrollment, unless you qualify for a special enrollment, you cannot make changes to your elections or terminate coverage until the next open enrollment. Please refer to the Rules for Benefit Changes During the Year section on the next page for special enrollment qualifications. If you have questions regarding your eligibility please contact Insurance Benefits at (714) Dependent Eligibility The definition of dependent includes: Your legal spouse Children up to the age 26 for medical, dental and vision plans. Children include biological, stepchildren, children placed under a qualified medical child support order, adopted children or children placed for adoption Children in which you have established legal guardianship (only up to age 18). To enroll qualified dependents, you must provide proper documentation, e.g. marriage/birth certificates, state/court documents, etc. Disabled children over the age of 26 (disability must be documented by a physician) Please note: if you elect healthcare coverage for your dependent(s), you must enroll them in the same healthcare plan(s) as you. The definition of a dependent who is NOT eligible for District paid benefits includes: Divorced spouses Spouse of married children Grandchildren Children 26 or older unless disabled at time of coverage criteria. REMINDER It is the employee s responsibility to notify the District of any change in dependent status or eligibility within 31 days of the qualifying event and to complete all the necessary change forms. The employee may be held responsible for substantial charges if services are provided for a person who is found to be ineligible. 4

5 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 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 31 days of the date the event occurs (unless otherwise noted above). 5

6 Insurance Benefit Plan Designs The goal of Fullerton School District is to provide you with affordable, quality health care benefits. Our medical benefits are designed to help maintain wellness and protect you and your family from major financial hardship in the event of illness or injury. Blue Shield - PPO (through SISC program): With a PPO (preferred provider) medical plan, you ll pay a lower share of your medical expenses when you use doctors or hospitals that participate in the PPO network. Your share of expenses includes a deductible, coinsurance and copayments. You won t need a referral to see a specialist. A medical PPO plan will also pay a portion of the cost for services you may receive from non-participating (non-network) providers, but your share of the cost will be higher. It is recommended that you: (1) verify your provider's participation in the network before seeking treatment and (2) confirm PPO participation with your provider when making your appointment. Blue Shield - High Deductible PPO HSA (through SISC program): The PPO HSA plan is a consumer directed plan that combines a high deductible PPO plan with a Health Savings Account. You pay first dollar costs (including prescriptions and excluding preventive care) up to the deductible amount, and then a coinsurance until your maximum annual out of pocket costs are reached. Your premium is lower, and you can set aside pre-tax dollars in the HSA account to pay for your out-of-pocket costs. The District is contributing to your HSA account as well. Blue Shield - HMO (through SISC program) HMO 10 (Full Network): HMO stands for Health maintenance Organization. With this kind of medical plan, you will chose a Primary Care Physician (PCP) from the HMO network. Your PCP will be the doctor you see the most for routine visits and care. They will also coordinate any other health care services you may need. And if you need to see a specialist, your PCP will need to refer you. Features like set co-pays for doctor visits help make your out-of-pocket costs more predictable. HMO 10 (Narrow Network): The SaveNet Narrow Network 10 plan has almost the exact same benefits as the full-network plan the difference is in the network and the prescription costs. The SaveNet network has fewer doctors to choose from, but in return, the premium is lower than the full-network. You choose a Primary Care Physician (PCP) from the SaveNet network who will coordinate any other healthcare services you need. Your current PCP may already be in the SaveNet Network, so be sure to check out the provider listing. NEW HMO 25 (Full Network) The HMO 25 plan is a new plan this year that works the same way as the other two HMO plans. The difference is the copays are higher for office visits, hospitalization, and prescriptions. See page Kaiser Permanente - HMO (through SISC program): With the Kaiser Permanente HMO plan, you ll always know what your costs are. There are no deductibles or percentages to figure out; you will be responsible for the plan s set co-pay amounts. You and your family members must seek care through a Kaiser facility. You can choose to receive care at any of the Kaiser medical facilities and affiliated physicians, depending on where you live. Whenever you go in to receive covered services, you ll only pay your copayment. You can choose your own personal primary care physician. And if you need to see a specialist, your physician can easily refer you. 6

7 Insurance Benefit Plan Designs (cont) SISC BlueShield Pharmacy Benefits: For the SISC PPO and HMO plans: Navitus Pharmacy Benefit Manager (through SISC program) - If you elect the Blue Shield PPO or HMO plans, your prescriptions are covered through a pharmacy benefit management (PBM) company, Navitus. There are no separate cards, but all the information you ll need will be on the back of your Blue Shield card. Navitus manages your retail and mail order prescriptions, so if you have any issues with your Rx, you ll need to call the Navitus number on the back of your Blue Shield ID card. For the SISC HSA PPO plan: Blue Shield Pharmacy Benefit (through SISC program) - If you elect the Blue Shield HSA PPO plan, your prescriptions are covered through your Blue Shield plan. There are no separate cards, but all the information you ll need will be on the back of your Blue Shield card. Since Blue Shield manages your retail and mail order prescriptions, any issues with your Rx would be handled by Blue Shield. Delta Dental - PPO: With a PPO (preferred provider) dental plan, you can choose from an extensive network of Delta providers or other providers of choice. However, by using a Delta provider, you can reduce your out-of-pocket costs dramatically. It is recommended that you verify that your dental provider is part of the Delta network and confirm with your dental provider when making your appointment. DeltaCare - HMO: With the DeltaCare DHMO plan you choose a Primary Dental Office from the extensive DeltaCare network. Your Primary Dental Office you select will be your primary dental office for routine visits and care. They will also coordinate any other dental care services you may need. And if you need to see a specialist, your Primary Dental Office will need to refer you. VSP - Vision (through ACSIG program): The VSP vision plan is designed to provide you with access to qualified eye care professionals and coverage for a comprehensive vision examination and materials, including exams, frames, lenses, and/or contacts. Employee Assistance Program (EAP through SISC program): The EAP program is a support program to assist you in finding balance when life throws a challenge your way. EAP is where you and your family can find a solution and restore peace of mind. Assistance is available 24 hours a day, every day of the year. FYI Member ID Cards for Delta PPO and VSP Vision: There are NO member ID cards for your Delta PPO plan or VSP Vision plan, just your social security number will be needed. However, if you prefer to have something to carry, you can register online at the carrier sites and print a temporary ID card. 7

8 Medical Plan Summary SISC Kaiser Permanente HMO BENEFIT ATTRIBUTES Annual Deductible Individual Family Annual Out-of-Pocket Maximum Individual Family Lifetime Maximum SISC Kaiser HMO $0 $0 $1,500 $3,000 None Professional Services Office Visits Primary Care and Specialist $15/visit Preventive Care Chiropractic (limited to 30 visits/calendar year) $10/visit Hospital Services Inpatient Services Outpatient Services Surgery / Therapeutic Lab / X-rays (Major) Emergency Care Ambulance Skilled Nursing Facility Home Health Care (limited to 100 visits/calendar year) Mental Health/Substance Abuse Inpatient Outpatient Prescription Drug Benefits $15/procedure $100/visit $50/trip (up to 100 days per benefit period) $15/visit Through Kaiser Permanente Retail Generic Brand Name (100 day supply) $15 Mail Order Generic Brand Name (100-day supply) $15 8

9 Medical Plan Summary SISC Blue Shield HMO 10 Full Network & SaveNet (Narrow Network) Plans BENEFIT ATTRIBUTES SISC Blue Shield HMO 10 Annual Deductible Individual Family Annual Out-of-Pocket Maximum Individual Family Lifetime Maximum $0 $0 $1,000 $2,000 None Professional Services Office Visits Primary Care and Referred Specialist Access+ Specialist (self-referral) Preventive Care Chiropractic and Acupuncture (Combined limits to 30 visits/calendar year) $10/visit $30 $10/visit Hospital Services Inpatient Services Outpatient Services Surgery / Therapeutic Lab / X-rays (Major) Emergency Care Ambulance Skilled Nursing Facility Home Health Care (limited to 100 visits/calendar year) Mental Health/Substance Abuse Inpatient Outpatient $100/visit $100/trip No copay 1 (limited to 100 days/calendar year) $10/visit $10/visit Prescription Drug Benefits Through Navitus Retail Generic (Costco) Generic (Navitus) Brand Name Mail Order (through Costco) Generic Brand Name Full HMO Network Rx Plan (30-day supply) $0 $5 $20 2 (90-day supply) $0 $50 2 SaveNet (Narrow Network) Rx Plan (30-day supply) $0 $9 $35 2 (90-day supply) $0 $ Pre-authorization required. 2. A generic drug will always be dispensed if one is available. If you purchase a brand-name drug when a generic alternative is available, you will pay the generic co-payment plus the difference in cost between the brand and the generic, even if your doctor writes dispense as written (DAW) on the prescription. 9

10 Medical Plan Summary SISC Blue Shield HMO 25 Plan BENEFIT ATTRIBUTES SISC Blue Shield HMO 25 Annual Deductible Individual Family Annual Out-of-Pocket Maximum Individual Family Lifetime Maximum $0 $0 $2,000 $4,000 None Professional Services Office Visits Primary Care & Referred Specialists Access+ Specialist (self-referral) Preventive Care Chiropractic and Acupuncture (combined limits to 30 visits/calendar year) $25/visit $30/visit $10/visit Hospital Services Inpatient Services Outpatient Services Surgery / Therapeutic Lab / X-rays (Major) Emergency Care Ambulance Skilled Nursing Facility Home Health Care (limited to 100 visits/calendar year) Mental Health/Substance Abuse Inpatient Outpatient $500 per admission $150 $100/visit $100/trip $500/admission 1 (limited to 100 days/calendar year) $25/visit $25visit Prescription Drug Benefits Through Navitus Rx Brand-Name Deductible Retail Generic (Costco) Generic (Navitus) Brand Name Mail Order (through Costco) Generic Brand Name $200 individual/$500 family (30-day supply) $0 $10 $35 2 after deductible (90-day supply) $0 $90 2 after deductible 1. Pre-authorization required. 2. A generic drug will always be dispensed if one is available. If you purchase a brand-name drug when a generic alternative is available, you will pay the generic co-payment plus the difference in cost between the brand and the generic, even if your doctor writes dispense as written (DAW) on the prescription. 10

11 Medical Plan Summary PPO (through SISC Blue Shield) BENEFIT ATTRIBUTES In-Network Out-of-Network Annual Deductibles Individual / Family $100 / $300 Annual Out-of-Pocket Maximum Individual / Family (includes deductible, copays, coinsurance) $1,000 / $3,000 Lifetime Maximum None None Professional Services Office Visits Primary Care & Specialists $20/visit 1, (deductible waived) 50% Preventive Care Not Covered Hospital Services Inpatient Services 10% 2 (max $600 per day) Outpatient Services Surgery / Therapeutic Lab / X-rays (Major) 10% 10% 3 (max $350 per day) Not Covered Emergency Care Skilled Nursing Facility (limited to 100 days/calendar year) $100/visit + 10% ($100 deductible waived if admitted) 10% 10% 4 Home Health Care (limited to 100 visits/calendar year) Mental Health/Substance Abuse Inpatient Outpatient/Facility Based Care 2 10% (prior authorization required) 10% $20/visit (deductible waived) Not Covered 2 (max $600 per day) 50% Prescription Drug Benefits (deductible waived) Retail Generic (Costco) Generic (Navitus) Brand Name Mail Order (through Costco) Generic Brand Name Through Navitus (30-day supply) $0 $7 $25 5 Not Covered (90-day supply) $0 $60 5 Not Covered 1. The dollar co-payment applies only to the visit itself. An additional copay applies for any services performed in office (i.e., x-ray, lab, surgery), after any applicable deductible. 2. The maximum plan payment for non-emergency hospital services received from a non-preferred hospital is $600 per day. Members are responsible for all charges in excess of $600 plan payment per day. 3. The maximum plan payment for non-emergency surgery and services performed in a non-participating Ambulatory Surgery Center or outpatient unit of a non-preferred hospital is $350 per day. Members are responsible for all charges in excess of $350 plan payment per day. 4. Services may require prior authorization by the Plan. When services are prior authorized, members pay the preferred or participating provider amount. 5. A generic drug will always be dispensed if one is available. If you purchase a brand-name drug when a generic alternative is available, you will pay the generic co-payment plus the difference in cost between the brand and the generic, even if your doctor writes dispense as written (DAW) on the prescription. 11

12 Medical Plan Summary High-Deductible PPO HSA (through SISC Blue Shield) BENEFIT ATTRIBUTES In-Network Out-of-Network Annual Deductibles 1 Individual / Family Annual Out-of-Pocket Maximum 1 Individual / Family (includes deductible, copays, coinsurance) $5,000 / $10,000 3,000 / $5,000 N/A except for emergencies Lifetime Maximum None None Professional Services Office Visits Primary Care & Specialists 10% 10% Preventive Care Hospital Services (deductible waived) Not Covered Inpatient Services 10% 2 (max $600 per day) Outpatient Services Surgery / Therapeutic Lab / X-rays (Major) 10% 10% 3 (max $350 per day) Not Covered Emergency Care Skilled Nursing Facility (limited to 100 days/calendar year) $100/visit + 10% ($100 deductible waived if admitted) 10% 10% 4 Home Health Care (limited to 100 visits/calendar year) Mental Health/Substance Abuse Inpatient Outpatient/Facility Based Care 2 10% (prior authorization required) 10% 10% Not Covered 2 (max $600 per day) 50% Prescription Drug Benefits * (must meet deductible before copay applies) Retail (30-day supply) Generic Brand Name Mail Order (90-day supply) Generic Brand Name Through Blue Shield (30-day supply) $7 $25 5 Not Covered (90-day supply) $14 $25 5 Not Covered 1. For individuals on a family plans, the deductible and out of pocket maximums will be met when the individual thresholds are met. 2. The maximum plan payment for non-emergency hospital services received from a non-preferred hospital is $600 per day. Members are responsible for all charges in excess of $600 plan payment per day. 3. The maximum plan payment for non-emergency surgery and services performed in a non-participating Ambulatory Surgery Center or outpatient unit of a non-preferred hospital is $350 per day. Members are responsible for all charges in excess of $350 plan payment per day. 4. Services may require prior authorization by the Plan. When services are prior authorized, members pay the preferred or participating provider amount. 5. A generic drug will always be dispensed if one is available. If you purchase a brand-name drug when a generic alternative is available, you will pay the generic co-payment plus the difference in cost between the brand and the generic, even if your doctor writes dispense as written (DAW) on the prescription. 12

13 Medical Plan Summary Health Savings Accounts Discover an easy, hassle-free health savings account (HSA) and discover the best way to save for health care, and a great way to save on taxes. What is a Health Savings Account (HSA)? An HSA is a tax-free savings account that works with a qualified health plan to help you pay for the cost of out of pocket health care and prescription medication expenses. You take the money you would have paid for higher health insurance premiums and use it to pay for qualified medical expenses or save it and let it grow! What s more: Your HSA money is yours ALWAYS! You won t lose it if you don t spend it, change jobs, retire or change health plans. You never pay taxes on withdrawals for qualified medical expenses. Your money earns interest and you don t pay taxes on the interest earned. Your contributions are tax-free and reduce your overall taxable income. (Non-Applicable for CA taxes) You can change your contribution to the HSA on a quarterly basis. Who is Eligible for an HSA? Anyone meeting the following requirements is eligible for an HSA: Is enrolled in SISC Blue Shield PPO HSA qualified medical plan, Is not covered under another medical plan that is not HSA compatible, Is not currently participating in a Section 125 Healthcare Spending Account, either of their own or their spouse Is not enrolled in Medicare, Is not eligible to be claimed on another person s tax return, Is not active in the military, and Is a U.S. resident. Individual HSA Contribution Limit Family HSA Contribution Limit $3, TBD $6, TBD Catch-Up HSA Contribution Limit For participants age 55 or older - $1,000 You are allowed to contribute the entire year s limit when you first become eligible for the HSA (even if that is in December); however, you must remain eligible for at least 12 months after that date, or you will be subject to taxes and penalties on the amount you contributed. HSA Contributions You choose how much you d like to contribute to your HSA each year by electing automatic pre tax contributions made from your paycheck. Each year the IRS sets contribution limits, which are listed above. You may also make deposits outside of payroll deductions by making check deposits. You would deduct these deposits when you file your taxes at the end of the year. Your HSA will be administered by a third party vendor, Sterling Administration 13

14 Dental Plans The District provides dental coverage that is designed to help keep you and your family smiling, with coverage through a choice of dental plans, the DeltaCare DHMO Plan or the Delta Dental PPO Plan. DeltaCare DHMO Plan You and your eligible dependents must select a primary dentist from the DeltaCare DHMO directory. You have the option of changing your dentist as often as once a month. Network providers may be accessed online through The DeltaCare DHMO Plan (CAA16) contains copays for every American Dental Association (ADA) code. Please refer to the DeltaCare DHMO plan summary for more information. Delta Dental PPO Plan Under the Delta Dental PPO plan, Delta Dental pays a percentage of the allowed fees for covered diagnostic, preventive, basic and major services. Delta s PPO network dentists accept reduced fees for covered services they provide you, so you ll usually pay the least when you visit a PPO network dentist. Delta Dental has many network dentists to choose from, visit to search Delta s dental directory by location or specialty. No ID cards are distributed with this dental plan you simply need to provide your dentist with your name, social security number, and that you are on a Delta Dental PPO plan. BENEFIT ATTRIBUTES DeltaCare DHMO In-Network In-Network PPO Network Dentist Delta Dental PPO Member s share: Out-of-Network Non-PPO Dentist Benefits Maximum None $2,500 $2,000 Deductible Individual Family None $25 $75 (deductible waived for preventive) Diagnostic/ Preventive X-Rays Oral Exams Cleanings Basic Services Fillings Endodontic Periodontic Oral Surgery/Extractions Major Services Crowns Inlays/Onlays Restoration Refer to DeltaCare s plan summary. Refer to DeltaCare s plan summary. Refer to DeltaCare s plan summary. 20% 20% 20% 20% 50% 50% Prosthodontics Refer to DeltaCare s plan summary. 50% 50% Orthodontics Benefit Level Coverage Lifetime Maximum Refer to DeltaCare s plan summary. 50% Children Only $1,000 50% Children Only $1,000 14

15 Vision Plan The ACSIG VSP Vision plan is designed to provide you with access to qualified eye care professionals and coverage for a comprehensive vision examination and materials (eye glasses and contact lenses). The ACSIG VSP Vision plan is available to all benefit-eligible employees however those who participate in Kaiser may NOT enroll in VSP as vision is provided through Kaiser. Network providers may be accessed on-line at No ID cards are needed for your VSP Vision plan simply provide the eye doctor with your name, social security number and that your plan is VSP. BENEFIT ATTRIBUTES ACSIG VSP Vision In-Network Out-of-Network Frequency Eye Exam $25 copay $ 45 allowance Every 12 months Lenses Single Vision Lined Bifocal Lined Trifocal $25 $25 $25 $ 30 allowance $ 50 allowance $ 65 allowance Every 12 months Every 12 months Every 12 months Frames $120 allowance $70 Costco allowance 20% off amount over allowance $70 allowance Every 24 months Contact Lenses ¹ $105 allowance $105 allowance Every 12 months 1. In-lieu of frames. 15

16 Employee Assistance Program (EAP) The SISC Anthem Blue Cross Employee Assistance Program (EAP) can be a valuable resource for you and your family when personal issues arise. All information is CONFIDENTIAL., EAP is not facilitated through the District. Whether you re sweating the small stuff or facing a major life crisis, your Employee Assistance Program (EAP) can help. No problem is too small (or too big) for their highly trained and caring EAP staff. EAP services are provided at no cost to you and everyone who lives in your home. There s no need to sign up, you re automatically enrolled. Call the Anthem Blue Cross EAP at their toll-free number, or if you d rather not talk about your issue, you can still get information through their website, There you will find helpful resources including: Ways to manage dilemmas in both your personal and work life Interactive search tools to locate child care and elder care services in your area Financial calculators to help you plan for major purchases or life events Practical tips on topics like safety, travel and pets EAP is available 24 hours a day, every day of the year. Cafeteria 125 Flex Savings (FSA) NEW PLAN YEAR OCT 1 SEPT 30 Discovery Benefits Flexible Spending Accounts (FSA) allow you to pay some of your health care and dependent care expenses in a manner that reduces your taxes at the same time. You can set up one FSA for health care expenses and another to pay for the cost of caring for your dependents while you are at work. The FSA allows you to use pre-tax dollars to pay for eligible expenses for which you are not reimbursed by another medical, dental, vision plan, and/or tax credit. Such expenses include medical and dental deductibles, coinsurance, copayments, prescription glasses, contact lenses, LASIK eye surgery, or child/elder care expenses. A complete list of eligible expenses can be found on Health Care Spending Account Maximum Annual Contribution: $2,500 Health Care Claims: All Claims must be incurred during the plan year, October 1 through September 30, or until you are no longer eligible to participate in the plan. Dependent Care Reimbursement Account Maximum Annual Contribution: $5,000 Dependent Care Claims: All Claims must be incurred during the plan year, October 1 through September 30, or until you are no longer eligible to participate in the plan. Contributions are deducted from Payroll Each pay period, your contributions are deducted equally on each pay check. Claim Submittal: Health Care FSA claims must be incurred by September 30, 2016, and submitted to Discovery Benefits within 90 days after the plan year ends. You may use the Discovery Benefits debit card at the point of service, or submit a Claim Form to request your reimbursements. Employees may also visit the Discovery Benefits website to track claims Health Care Spending Account Rollover: You may rollover up to $500 into the new plan year if you don t use it during the plan year. It must be used within the following plan year. Discovery Benefits (866)

17 Basic Life and AD&D Life / AD&D Insurance is an important part of your comprehensive benefits package. For peace of mind and financial protection for you and your family in the event of death or a serious accident, all benefit eligible employees are automatically enrolled in the Basic Life and Accidental Death and Dismemberment Insurance Program administered through Voya. The District provides both a Basic Life and a Accidental Death and Dismemberment (AD&D) benefit for all eligible employees of $100,000. In addition, the District also provides a $1,500 benefit for your spouse or domestic partner, and up to $1,500 for each child between 6 months and 26 years ($500 for children under 6 months). Voluntary Life (Employee Paid) If you feel your family needs more Life/AD&D insurance, the District provides you the opportunity to purchase additional voluntary coverage. If you are a newly eligible employee, you can elect coverage up to the guaranteed issue amount with no medical underwriting. Employee Life You can elect to purchase life insurance for yourself of up to 5 times your annual salary in $10,000 increments, not to exceed a maximum of $500,000. During your initial election period, benefit amounts elected in excess of $50,000 will require evidence of insurability to be submitted. You can elect to increase your coverage amount by $10,000 increments up to a total of $50,000 without providing proof of good health during the annual enrollment period. Spouse Life You can elect to purchase life insurance for your spouse in $10,000 Increments up to a maximum of $500,000. If you are covered for Basic Life, you may elect supplemental coverage for your spouse even if you do not elect coverage for yourself. During your initial election period, benefit amounts elected in excess of $50,000 will require evidence of insurability to be submitted. Child Life You can elect to purchase life insurance for your child(ren) in $2,500 increments up to a maximum of $10,000 (child benefit limited to $1,000 from age 15 days to 6 months). Total cost for one child is the same as for multiple children. Please contact Insurance Benefits at (714) or naidene_warren@fullertonsd.org for additional information regarding voluntary life. VOYA/Reliastar Customer Service (800)

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20 Required Federal Notices NOTICE OF AVAILABILITY OF HIPAA PRIVACY NOTICE The Federal Health Insurance Portability and Accountability Act (HIPAA) requires that we periodically remind you of your right to receive a copy of the Insurance Carriers HIPAA Privacy Notices. You can request copies of the Privacy Notices by contacting the Insurance Benefits Office or by contacting the insurance carriers directly. THE WOMEN S HEALTH AND CANCER RIGHTS ACT The Women s Health and Cancer Rights Act (WHCRA) requires employer groups to notify participants and beneficiaries of the group health plan, of their rights to mastectomy benefits under the plan. Participants and beneficiaries have rights for coverage to be provided in a manner determined in consultation with the attending Physician 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 procedures provided under this plan. You can contact your health plan s Member Services for more information. NOTICE OF CHOICE OF PROVIDERS The Blue Shield and Kaiser HMO plans generally requires the designation of a primary care provider. You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members. Blue Shield and Kaiser designates a primary care provider automatically until you make a designation. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact Blue Shield Member Services at or Kaiser Member Services at

21 Required Federal Notices CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA) If you re an employee with medical, dental or vision coverage through the District, you have the right to choose continuation coverage if you lose your group health coverage due to reduction in your hours of employment or the termination of your employment for reasons other than gross misconduct. Your eligible dependents may also have the right to elect and pay for continuation of coverage for a temporary period in certain circumstances where coverage under the plan would otherwise end, such as divorce, or dependent children who no longer meet eligibility requirements. Important Notice: This brief summary of the right you and your dependents have to continue insurance is not intended as the official notice of your rights required by federal and state law. We ve included this brief summary to inform you that you have these rights. You ll receive a separate, detailed explanation of your right to continue health insurance coverage when applicable. Specific information is also available from the District Benefits Department. SUMMARY OF BENEFITS AND COVERAGE Fullerton School District offers a variety of benefit plans for eligible employees and their family members. The federal health care reform law requires that eligible members of Rent-A-Tire, L.P. employer plans receive a Summary of Benefits and Coverage (SBC) for any medical and pharmacy plan available. The SBC is intended to provide important plan information to individuals, such as common benefit scenarios and definitions for frequently used terms. The SBC is also intended to serve as an easy-to-read, informative summary of benefits available under a plan. The SBC s share a Uniform Glossary with common terms and definitions. The SBCs and Glossary can be found on the District Home Page or by contacting Insurance Benefits to obtain a copy. SUMMARY OF BENEFITS AND COVERAGE AVAILABLE Blue Shield of CA Medical and Rx Plans Navitus Rx Plans Kaiser Permanente Medical and Rx Plan SBC Uniform Glossary 21

22 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 either 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 and you live in a state listed below, 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, you can ask you 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 permit 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, you can contact the Department of Labor electronically at or by calling toll-free EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, You should contact your state for further information on eligibility. ALABAMA Medicaid Website: Phone: ALASKA Medicaid Website: Phone (Outside of Anchorage): Phone (Anchorage): COLORADO Medicaid Medicaid Website: Medicaid Customer Contact Center: FLORIDA Medicaid Website: Phone: GEORGIA Medicaid Website: - Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone: INDIANA Medicaid Website: Phone: IOWA Medicaid Website: Phone: KANSAS Medicaid Website: Phone: LOUISIANA Medicaid Website: Phone: MAINE Medicaid Website: Phone: TTY MASSACHUSETTS Medicaid and CHIP Website: Phone: MINNESOTA Medicaid Website: Click on Health Care, then Medical Assistance Phone: MISSOURI Medicaid Website: Phone: MONTANA Medicaid Website: Phone: NEBRASKA Medicaid Website: Phone: NEVADA Medicaid Medicaid Website: Medicaid Phone: KENTUCKY - Medicaid Website: Phone:

23 Required Federal Notices Children s Health Insurance Program (Con t) NEW HAMPSHIRE Medicaid Website: Phone: NEW JERSEY Medicaid & CHIP Medicaid Website: dmahs/clients/medicaid/ Medicaid Phone: CHIP Website: CHIP Phone: NEW YORK Medicaid Website: Phone: NORTH CAROLINA Medicaid Website: Phone: NORTH DAKOTA Medicaid Website: Phone: OKLAHOMA Medicaid and CHIP Website: Phone: OREGON Medicaid Website: Phone: PENNSYLVANIA Medicaid Website: Phone: RHODE ISLAND Medicaid Website: Phone: SOUTH DAKOTA - Medicaid Website: Phone: TEXAS Medicaid Website: Phone: UTAH Medicaid and CHIP Website: CHIP: Phone: VERMONT Medicaid Website: Phone: VIRGINIA Medicaid and CHIP Medicaid Website: Medicaid Phone: CHIP Website: CHIP Phone: WASHINGTON Medicaid Website: Phone: ext WEST VIRGINIA Medicaid Website: Phone: , HMS Third Party Liability WISCONSIN Medicaid Website: Phone: WYOMING Medicaid Website: Phone: SOUTH CAROLINA Medicaid Website: Phone: To see if any more states have added a premium assistance program since January 31, 2015, or for more information on special enrollment rights, 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) , Menu Option 4, Ext OMB Control Number (expires 10/31/2016) Please note that California does not currently provide any premium assistance programs. 23

24 Medicare Part D Important Creditable Coverage Notice from Fullerton School District About Your Prescription Drug Coverage and 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 Fullerton 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. Fullerton School District has determined that the prescription drug coverage offered by the medical plans 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 existing 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 15 th through December 7 th. 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 and drop your current Fullerton School District prescription drug coverage, be aware that you and your dependents may not be able to get this coverage back. Please contact us for more information about what happens to your coverage if you enroll in a Medicare prescription drug plan. 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 Fullerton 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. 24

25 Medicare Part D For More Information About This Notice Or Your Current Prescription Drug Coverage Contact the office 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 Fullerton 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: October 1, 2015 Name of Entity: Fullerton School District Contact: Insurance Benefits Address: 1401 W. Valencia Drive, Fullerton, CA Phone Number: (714)

26 INSURANCE BENEFITS CARRIER CONTACT INFORMATION PLAN INSURANCE CARRIER PHONE # WEBSITE / SISC Blue Shield HMO (800) /7 NurseLine for Blue Shield HMO (877) SISC Blue Shield PPO (800) MEDICAL 24/7 MDLIVE (Physician) for Blue Shield PPO Navitus Health Solutions (SISC Blue Shield Plans) (888) (866) Kaiser Permanente HMO (800) Kaiser NurseLine (800) EAP for ALL Employees SISC Employee Assistance Program (EAP) sponsored through Anthem Blue Cross (800) DENTAL ACSIG Delta Dental PPO (866) DeltaCare USA (HMO) (800) VISION ACSIG VSP Vision (800) LIFE INSURANCE VOYA/ReliaStar (800) FLEX SAVINGS ACCOUNT Discovery Benefits (866) INSURANCE BENEFITS REPRESENTATIVE Naidene Warren Sakamoto 7:30am 4:00pm (714) Naidene_Warren@fullertonsd.org INSURANCE BENEFITS TECH (714) The information in this booklet is only a general outline of the Fullerton School District Group Health Benefits Plan. Specific details and plan limitations are provided in various documents, which may include the summary plan descriptions, policies, contracts, certificates and other plan documents. The official documents contain all the specific provisions of the plans. If there are any discrepancies between this summary booklet and the official documents, the official documents will govern. As this booklet is only a summary, it does not detail all the benefits for which you may be eligible or all the conditions to which such benefits may be subject. Contact the above carriers or Insurance Benefits for more information. 26

27 To get started: Download the BenIQ App from ITunes or Google Play Launch the app Enter the username: fullertonsd Accept the Terms & Conditions 27

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