Santa Ana Unified School District

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1 Classified Employees Santa Ana Unified School District CLASSIFIED EMPLOYEE BENEFITS BROCHURE What s Inside Benefit Plan Highlights Eligibility for Benefits... 3 Medical Plan Summary Dental Plan Summary... 6 Vision Plan Summary... 7 Employee Contributions Basic Life, Voluntary Insurance, & Employee Assistance Program. 10 Flexible Spending Account & Wellness Resources Rules for Benefit Changes During The Year Frequently Asked Questions.. 13 Health Care Reform & Additional Information Important Notice About Your Prescription Drug Coverage and Medicare Your Resources 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 pages for more details. Need Assistance Enrolling Online? Come to the Computer Lab located in the IMC Department during Open Enrollment, Monday through Friday, May Representatives from the Employee Benefits Office will be available to assist you. Dear Valued Employee: The Santa Ana Unified School District takes pride in offering a benefit program that provides flexibility for the diverse and changing needs of our employees and their families. The District offers a full range of benefits that allows you to choose the options that best meet your needs Plan Offerings: Kaiser Medical HMO Blue Shield Medical HMO Blue Shield Medical PPO DeltaCare USA DHMO (Dental HMO) Delta Dental PPO Network Plan Delta Dental PPO Incentive Plan VSP Vision The Standard Basic Life Insurance OptumHealth Employee Assistance Program In addition to the core health plan, you can participate in any of the following voluntary plans and products: American Fidelity Assurance Company Cancer Insurance Disability Income Insurance Section 125 / Flexible Spending Accounts Life Insurance Limited Benefit Accident Only Insurance Conseco Cancer Insurance Enroll Online beginning May 9, 2011, through May 23, 2011 Go to Log in using your Employee Identification Number (six digit number starting with zeros) and your PIN number. Your PIN is welcome. The online Benefit Enrollment screen will appear. Click the SAUSD Employee Online Service tab, then click on the BENEFITS tab. Begin the benefits enrollment process and continue until you obtain a confirmation number and are able to view your confirmation statement. This completes your enrollment. Click continue or close your web browser. If you have trouble accessing the system, please contact the Employee Benefits Office at (714) or (714)

2 What You Need to Do... Read through this guide to familiarize yourself with the decisions you have to make. Gather additional information. Use the websites and the phone numbers on page 20 to see which doctors and other health care providers you can use under the different plan choices. If you have dependents on your plan that live out of state, check on provisions for coverage of members away from home. Attend an employee meeting, if you wish, where you will be able to speak directly with representatives from Blue Shield, Kaiser, Delta Dental, VSP and American Fidelity. The dates and times for the meetings are as follows: Wednesday, May 11 th 2:00 pm 6:00 pm SAUSD District Office Board room & Tuesday, May 17 th 8:00 am 1:00 pm SAUSD District Office Training Room If you do not wish to make any changes you do not need to submit an Enrollment/Change form, and your current elections will continue for the next plan year, with the exception of your Flexible Spending Account(s) elections, which require annual enrollment and contribution elections. Process your Enrollment/Changes using the online enrollment system or by completing the appropriate forms and submitting to the Employee Benefits Office by May 23, You may fax the forms to (714) Whether you plan to fax or mail your forms through the District mail or U.S. postal mail, it is your responsibility to confirm the forms are received by the Employee Benefits Office before the deadline by calling (714) or (714) Your benefit elections will be effective July 1, 2011, and will continue through June 30, Benefit Plan Highlights Kaiser HMO The Kaiser HMO plan offers comprehensive coverage and a broad network of Kaiser physicians and hospital locations from which to choose. Plan benefits include copayments for office visits, hospitalizations and outpatient surgeries. If you are a Kaiser HMO member you will receive your mental health and substance abuse benefits, as well as your vision benefits, through Kaiser. Blue Shield HMO A managed care plan that offers a range of medical services at low, predictable costs called copays. The plan pays benefits only if you seek care from the HMO network of providers. If you use out of network providers you ll pay 100% of the cost of the medical care you receive, except for medical emergencies. If you enroll in the Blue Shield HMO plan you must choose a primary care physician (PCP) from their provider network. This PCP will direct all of your care. Blue Shield PPO A medical plan with a network of health care providers who have contracts with the insurance company to provide their services at discounted rates. The plan pays in network and out of network benefits. However, if you go to an in network provider you receive a higher level of benefits. For most in network and out of network benefits you must meet a deductible before the plan pays benefits, and then you pay a percentage of the cost of all covered services. Delta Dental HMO The plan offers the convenience of scheduled copays for specific procedures, and there are no deductibles or annual maximums. When you enroll in the dental HMO plan, you must select a primary care dentist (PCD) from the DeltaCare USA DHMO network for yourself and any eligible dependents. To receive care you must see your PCD who will take care of your dental care needs. If you require treatment from a specialist, your PCD will refer you to another dentist in the DeltaCare USA DHMO Network. Delta Dental PPO Network Plan When you enroll in the Network PPO plan, the cost for enrolling your dependents is less but you will be required to pay more when you visit an out of network dentist. Delta Dental PPO Incentive Plan You will pay more for covering your dependents, but you will receive richer benefits when you visit an out of network dental provider. Check with Delta Dental to find out which of the DPPO networks your dentist belongs. VSP Vision If you are a Blue Shield member you will receive vision benefits from VSP. The plan provides coverage for vision exams, frames and lenses. VSP has one of the largest network of private vision providers in the nation. The Standard Basic Life Insurance Provides protection for your beneficiary in the event of death. American Fidelity Flexible Spending Account (FSA) Lets you pay for eligible health care and dependent care expenses in a way that reduces your taxes at the same time. See brochure for details. OptumHealth Employee Assistance Program (EAP) Your physical and emotional health is important to SAUSD. OptumHealth connects you with quality referral and counseling services to fit the needs of you and your family. 2

3 Eligibility for Benefits Classified Employee Eligibility You are eligible to participate in our benefits program if you are an active permanent or probationary Classified employee who is regularly working at least 4 hours per week day and 20 hours per week. Some Classifications are excluded from this eligibility effective 2011 (See Article 11 of the CBA Tentative Agreement dated April 18, 2011 for more details.) When Coverage Begins As a new employee, your benefits become effective on the first day of the calendar month coinciding with or following your date of hire or the date you transfer from an ineligible class to an eligible class. Dependent Eligibility The following dependents are eligible for benefits: Your legal spouse. Your domestic partner that has properly filed a Declaration of Domestic Partnership with the California Secretary of State. Note: California state registration is limited to same sex domestic partners and only those opposite sex partners where one partner is at least 62 and eligible for Social Security based on age. (See the definition of domestic partner on page 13.) Your natural children, stepchildren, and/or adopted children of which the employee is the legal guardian, children legally placed with the employee, spouse or eligible domestic partner for adoption, or supported pursuant to a court order imposed on the employee, spouse or eligible domestic partner (including a qualified medical child support order). In addition, such children must be less than 26 years age. (Student or marital status no longer affects eligibility.) Dependent children over age 19 who are mentally or physically handicapped and incapable of self sustaining employment. Verification of handicapped status will be required before the 19th birthday. This is only a summary of the eligibility requirements and is not intended to modify or supersede the requirements of the plan documents and/or the CSEA contract, and the plan documents/contract will govern in the event of any conflict between this summary and the plan documents/contract. Required Information SSN Requirements: The Centers for Medicare and Medicaid Services (CMS) requires that group health plans provide social security numbers (SSN) for enrolled dependents. During the enrollment process you are REQUIRED to enter SSN information for all of your enrolled dependents. If you do not provide this information, your dependents will not be eligible for benefits in

4 HMO Medical Plan Comparison Chart This comparison chart shows only a brief summary of the benefits available. The health plan contracts must be consulted to determine the exact terms and conditions of coverage. Medical Plan Benefits Kaiser HMO Blue Shield Access+ HMO Calendar Year Deductible None None Calendar Year Copayment Maximum $1,500 per individual $3,000 per family $1,000 per individual $2,000 per 2 persons $3,000 per family Lifetime Maximum None None Hospital Care Inpatient Hospital Services $250 per admit $250 per admit Outpatient Hospital Services $20 per procedure No charge Emergency Room Copay (ER copay waived if admitted) Physician Care $100 per visit $100 per visit Office Visit $20 per visit $20 per visit Specialist Office Visit $20 per visit $30 per visit (self referral) Preventive Care No charge No charge Diagnostic Lab & X rays No charge No charge Rehabilitation, Including Physical, Occupational, and Respiratory Therapy $20 per visit $20 per visit Chiropractic Care Not covered $10 per visit; 30 visits per year Durable Medical Equipment (DME) No charge No charge Mental Health / Substance Abuse Call MHSA for Preauthorization Inpatient $250 per admit No charge Outpatient $20 per visit $10 per visit Prescription Drugs Kaiser Medco Deductible None $150 Brand Name Deductible Retail (Up to a 100 day supply) (30 day supply) Generic $10 copay $10 copay Brand Name $20 copay $25 copay (Rx deductible applies) Non Formulary Not applicable $40 copay (Rx deductible may apply) Mail Order (Up to a 100 day supply) (90 day supply) Generic $10 copay $20 copay Brand Name $20 copay $50 copay (Rx deductible applies) Non Formulary Not applicable $80 copay (Rx deductible may apply) New changes effective for plan year July 1,

5 PPO Medical Plan Comparison Chart This comparison chart shows only a brief summary of the benefits available. The health plan contracts must be consulted to determine the exact terms and conditions of coverage. Medical Plan Benefits Shield Spectrum PPO In Network Out of Network Calendar Year Deductible 1 (individual / family) $300 / $600 1 $600 / $1,200 1 Calendar Year Copayment Maximum $1,000 per individual $2,000 per individual Lifetime Maximum None None Hospital Care Inpatient Hospital Services 10% 30% 2 Outpatient Hospital Services 10% 30% Emergency Room Copay (ER copay waived if admitted) $100 per visit $100 per visit Physician Care Office Visit $20 per visit (deductible waived) 30% Specialist Office Visit $20 per visit (deductible waived) 30% Preventive Care No charge (deductible waived) 30% Diagnostic Lab & X rays 20% 30% Rehabilitation, Including Physical, Occupational, and Respiratory Therapy Chiropractic Care (up to 50 visits per calendar year) 20% 30% 20% 30% Durable Medical Equipment (DME) 20% 30% Mental Health / Substance Abuse Call MHSA for Preauthorization Call MHSA for Preauthorization Inpatient 10% 30% 2 Outpatient $10 per visit (deductible waived) 30% Prescription Drugs Medco Medco Deductible $150 Brand Name Deductible $150 Brand Name Deductible Retail (30 day supply) (30 day supply) Generic $10 copay $10 copay + 25% Brand Name $25 copay (Rx deductible applies) $25 copay + 25% (Rx deductible applies) Non Formulary $40 copay (Rx deductible may apply) $40 copay + 25% (Rx deductible may apply) Mail Order (90 day supply) Not applicable Generic $20 copay Not covered Brand Name $50 copay (Rx deductible applies) Not covered Non Formulary $80 copay (Rx deductible may apply) Not covered New changes effective for plan year July 1, Deductible & copays marked with a 1 do not accrue towards the calendar year copayment maximum. 2. The maximum allowed charges for non emergency hospital services received from a non preferred hospital is $1,500 per day. Members are responsible for 30 percent of this $1,500 per day, plus all charges in excess of $1,500. 5

6 Dental Plan Comparison Chart This comparison chart shows only a brief summary of the benefits available. The health plan contracts must be consulted to determine the exact terms and conditions of coverage. Dental Plan Benefits Delta DHMO Delta PPO Network Plan Delta PPO Incentive Plan In Network Non Network In Network Non Network Calendar Year Benefit Maximum None $2,000 $1,200 $2,000 $1,500 Calendar Year Deductible Individual / Family None None None $25 / $75 Deductible Waived for Preventive NA NA NA Yes Diagnostic & Preventive Exams No charge No charge 50% Routine Cleanings (2 per year) No charge No charge 50% X rays No charge No charge 50% Fluoride Treatment (to age 19) No charge No charge 50% Space Maintainers $10.00 No charge 50% Basic Restorative Fillings $0 $75 No charge 50% Endodontics $0 $220 No charge 50% Periodontics $0 $195 No charge 50% Extractions $0 $90 No charge 50% Major Services Crowns $35 $195 No charge 50% Inlays $0 $160 No charge 50% Onlays $0 $175 No charge 50% Prosthodontics Complete Denture $100 50% 50% The Incentive Plan pays 70% for diagnostic, preventive, basic and major services during the first year of eligibility. This percentage increases by 10% each year, to a max of 100%, if the enrollee visits the dentist at least once during the year. Year 1 30% Year 2 20% Year 3 10% Year 4 No charge If the enrollee does not use the plan at least once during the calendar year, the percentage remains at the level attained the previous year. Orthodontics Children $1,700 50% 50% Adults $1,900 50% 50% Lifetime Benefit Maximum NA $1,000 $500 Which PPO dental network is right for you? In Network Providers Delta Dental Preferred Providers Non Network Providers Delta Dental Premier Network Out of Network Providers You will receive the highest level of benefits because these dentists have agreed to charge lower rates. Plus, you will pay a lower percentage of these lower, negotiated rates. You will be required to pay the higher, non network percentage of R&C charges instead of the lower, negotiated rates charged by in Network providers. However, you will not be required to pay more than R&C (no balance billing). When you see a non network provider you will pay the deductible, the applicable coinsurance, plus any amount above the R&C charges. 6

7 Vision Plan Comparison Charts Please Note: If you are a Kaiser member, you will receive your vision benefits from Kaiser. If you are Blue Shield member, you will receive your vision benefits from VSP. Kaiser Vision Benefits Plan Benefits Kaiser Facility Exam (no frequency limitation) $20 Eyewear (every 24 months) Covered up to $125 at Kaiser plan medical offices VSP Vision Plan Plan Benefits In Network Out of Network Exam / Materials Copay: $15 Covered up to $50 Standard Lenses: Single Covered in full Covered up to $50 Bifocal Covered in full Covered up to $75 Trifocal Covered in full Covered up to $100 Frame: No charge up to $120 Covered up to $70 Contact Lenses (in lieu of eyeglasses) No charge up to $120 Covered up to $105 Frequency: Exam Lenses Frame Contact Lenses 12 months 12 months 24 months 12 months VSP features a broad provider network with substantial access across the United States in a variety of settings. All VSP network providers are independent optometrists or ophthalmologists in private practice who provide full service. However, you do have the option of using a non network provider under the VSP plan, but the benefit allowances are lower. To find a VSP provider near you visit Please note that VSP does not issue ID cards. Simply give your VSP provider your social security number to verify eligibility. 7

8 Summary of Contributions (for employees hired before October 14, 2008) The total cost of the plan premiums increased this year and both employees and the District will be paying more, with the District absorbing most of the increases. The table below summarizes the employee contribution amounts that will be effective July 1, Remember, your contributions for health care coverage are deducted before taxes and are calculated each pay period, effectively lowering your tax liability. Plan Total Monthly Premium Total Tenthly Premium What the District Pays Tenthly What You Pay Tenthly Kaiser HMO (98% of Cost) (2% of Cost) Employee Only $ $ $ = $9.45 Two Party $ $ $ = $18.91 Family $1, $1, $1, = $26.76 Blue Shield HMO* (95% of Cost) (5% of Cost) Employee Only $ $ $ = $27.85 Two Party $ $1, $1, = $56.97 Family $1, $1, $1, = $81.95 Blue Shield PPO* (80% of Cost) (20% of Cost) Employee Only $ $ $ = $ Two Party $1, $1, $1, = $ Family $1, $2, $1, = $ DeltaCare USA DHMO Employee Only $15.72 $18.86 $18.86 = $0.00 Two Party $25.94 $31.13 $31.13 = $0.00 Family $38.35 $46.02 $46.02 = $0.00 Delta Dental Network DPPO Employee Only $49.53 $59.43 $59.43 = $0.00 Two Party $ $ $55.51 = $ Family $ $ $55.51 = $ Delta Dental Incentive DPPO Employee Only $61.91 $74.30 $74.30 = $0.00 Two Party $ $ $61.91 = $ Family $ $ $61.91 = $ * Blue Shield rates include the Mental Health / Substance Abuse, EAP and VSP vision benefits. 8

9 Summary of Contributions (For employees hired after October 14, 2008 ) The total cost of the plan premiums increased this year and both employees and the District will be paying more, with the District absorbing most of the increases. The table below summarizes the employee contribution amounts that will be effective July 1, Remember, your contributions for health care coverage are deducted before taxes and are calculated each pay period, effectively lowering your tax liability. Plan Kaiser HMO Total Monthly Premium Total Tenthly Premium What the District Pays Tenthly What You Pay Tenthly Employee Only $ $ $ = $9.45 Two Party $ $ $ = $18.91 Family $1, $1, $1, = $26.76 Blue Shield HMO* Employee Only $ $ $ = $93.63 Two Party $ $1, $ = $ Family $1, $1, $1, = $ Blue Shield PPO* Employee Only $ $ $ = $ Two Party $1, $1, $ = $ Family $1, $2, $1, = $1, DeltaCare USA DHMO Employee Only $15.72 $18.86 $18.86 = $0.00 Two Party $25.94 $31.13 $31.13 = $0.00 Family $38.35 $46.02 $46.02 = $0.00 Delta Dental Network DPPO Employee Only $49.53 $59.43 $59.43 = $0.00 Two Party $ $ $55.51 = $ Family $ $ $55.51 = $ Delta Dental Incentive DPPO (98% of Cost) (2% of Cost) Lowest Cost HMO Lowest Cost HMO Difference Between Lowest Cost HMO Difference Between Lowest Cost HMO Employee Only $61.91 $74.30 $74.30 = $0.00 Two Party $ $ $61.91 = $ Family $ $ $61.91 = $ * Blue Shield rates include the Mental Health / Substance Abuse, EAP and VSP vision benefits. 9

10 Basic Life Basic Life Insurance is an important part of your comprehensive benefits package. For the peace of mind and financial protection of your family in the event of death, District employees are automatically enrolled in the Basic Life Insurance program provided by The Standard Benefit Amount $40,000 Voluntary Benefits During Open Enrollment, you should also consider the voluntary benefits available and decide if you want to enroll or make changes to your current elections. These benefits include: Flexible Spending Accounts Flexible spending accounts allow you to set aside pre tax dollars to pay for eligible health care and dependent care expenses. You will need to plan carefully because you will forfeit any money left in your account(s) at the end of each plan year. If you would like more information, American Fidelity will be at the Open Enrollment meetings. Supplemental Insurance You pay the full cost of these benefits and enroll directly through the following insurance providers: American Fidelity (Cancer, Disability, Voluntary Life, and Accident) Conseco Health Insurance (Cancer) If you want to enroll in any of the District s voluntary benefits, see Your Resources on page 20 for information on how to contact the insurance providers directly. For the supplemental insurance options, you can contact your union for details about how to enroll. Attention Blue Shield Members! Employee Assistance Program (EAP) Because we want our employees to have a well balanced life, Blue Shield members will receive their EAP benefits through OptumHealth. The EAP program is designed to help you manage life s challenges. Everyone needs a helping hand once in a while, and your EAP can provide it. The program can provide referrals to professional counselors for up to 5 free, face to face, confidential visits and live telephonic access 24 hours/365 days that can help you resolve emotional health, family and work issues. This benefit is included in your medical plan and is available to all household members. EAP services include: Parent Child Conflict Aging Parents Anxiety/Depression Financial/Legal Concerns Stress Substance Abuse Marital Problems Life Transition Confidential Access 24/7 By calling OptumHealth at (800) or visiting the website at: 10

11 Flexible Spending Accounts Do you have out of pocket expenses for copays, deductibles, dental or vision care throughout the year? Do you have daycare or eldercare expenses? The District offers its employees a great way to save money over the course of a year through Flexible Spending Accounts (FSAs). These accounts allow you to redirect a portion of your salary, on a pre tax basis, into reimbursement accounts. Money from these accounts is then used to pay for eligible medical and dependent care expenses. You may enroll in the District s FSA plan even if you receive health care insurance through your spouse s employer (as long as it s not an HSA plan). In addition, the FSA can be used for eligible expenses for all your qualified dependents. Health Care Spending Account: This account will reimburse you with pre tax dollars for health care expenses not reimbursed under your family s health care plans. The maximum you may contribute to your Health Care Spending Account is $4,800 per plan year (July 1 through June 30). Dependent Care Spending Account: This account will reimburse you with pre tax dollars for daycare expenses for your child(ren) and other qualifying dependents. The maximum amount you may contribute to a Dependent Care Spending Account is $5,000 per plan year or $2,500 if you are married and file separate tax returns. Eligible Dependents for Dependent Care Spending Account Include: Children under the age of 13 who you have primary custody of; and Children or other dependents of any age who are physically or mentally unable to care for themselves and who qualify. You may use the federal childcare tax credit and the Dependent Care Spending Account; however, your federal credit will be offset by any amount deferred into Dependent Care plan. Flex Debit Card for Unreimbursed Medical Expenses New Option for The Flex Debit card looks and works just like a credit card. When you incur an allowable medical expense, such as a visit to the doctor or the pharmacy, you can use the debit card and avoid having to wait for reimbursement checks. Contact your American Fidelity Account Representative for details. Wellness Resources Take control of your health by accessing the many wellness resources available to Kaiser and Blue Shield members. Kaiser Members visit to access information on living healthy, managing conditions and diseases, and to obtain information about drugs and natural medicines and remedies. Kaiser also offers customized plans for healthier living, classes, discounts on Weight Watchers and more. Register with Kaiser s My Health Manager, and you can schedule appointments, order ID cards, view test results, refill prescriptions and your doctor. Blue Shield Members visit to access the Hospital Comparison Tool, the Symptom Checker, Condition Management information and resources, along with information specific to women s, men s, children s and senior s health. Blue Shield also offers discounts on Weight Watchers and 24 Hour Fitness memberships. And with Blue Shield s NurseHelp 24/7, you can speak with a registered nurse any time, day or night, you have health related questions at (877) Register with Blue Shield, and you can check your benefits and claims, order ID cards, and access additional wellness resources. Health Fair Event June 4th Plan to attend the District s upcoming Health Fair event scheduled for Saturday, June 4th! 11

12 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 experience a qualified status change that is eligible for a benefit change, you will be required to submit proof of the change or evidence of prior coverage. Qualified Status Changes include: Change in legal marital status, including marriage, divorce, legal separation, annulment, and death of a spouse. Change in number of dependents, including birth, adoption, placement for adoption, or death of a dependent child. Change in employment status that affects benefit eligibility, including the start or termination of employment by you, your spouse, or your dependent child. Change in work schedule, including an increase or decrease in hours of employment by you, your spouse, or your dependent child, including a switch between part time and full time employment that affects eligibility for benefits. Change in a child's dependent status, either newly satisfying the requirements for dependent child status or ceasing to satisfy them. Change in place of residence or worksite that affects your eligibility for benefits, including 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: 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 notify the Employee Benefits Office and make the change within 30 days of the date the event occurs (unless otherwise noted above). * You are also responsible for notifying the Employee Benefits Office of your dependent(s) that become INELIGBLE as a result of divorce or becoming an overage dependent within 30 days of the event. Failure to do so may jeopardize your dependent s right to elect COBRA. 12

13 FAQs Here are some quick answers to some of our most frequently asked benefit questions. Question Who qualifies for benefits as a domestic partner? Answer To qualify for benefits, a domestic partner must be registered with the California Secretary of State by filing a notarized Declaration of Domestic Partnership form. To qualify for registration, the partnership must include two people who meet all of the following requirements: Are the same sex (or opposite sex if at least one of the partners is over age 62 and eligible for Social Security pension benefits or Supplemental Security Income (SSI) based on age), Are 18 years or older, Share a common residence, Are jointly responsible for each other s basic living expenses, Are capable of consenting to the partnership, Are neither married nor a member of another domestic partnership, Are not related by blood in a way that would prevent them from being married in the State of California, and Consent to the jurisdiction of the California courts for dissolution, nullity, legal separation, or any other proceeding related to the partners rights and obligations. If a legal union (other than marriage) of two persons of the same sex was validly formed in another jurisdiction and that union is considered comparable to a domestic partnership registered in California, California will allow the persons in that union to register as domestic partners with the California Secretary of State. Such unions include civil unions in Connecticut and Vermont and partnerships registered in New Jersey. You must provide proof that your domestic partnership is registered with the state of California before you can enroll your domestic partner for benefits. How do I make a change to my benefits during Open Enrollment? When do the changes I make during Open Enrollment take effect? Are any contribution amounts changing? Follow the instructions for completing your enrollment online at Or, you can complete and return an Open Enrollment/Change form to the Employee Benefits Office no later than 4:30 p.m. on May 23, The changes take effect on July 1, 2011, and are in place the entire plan year July 1, 2011, through June 30, Contribution percentage has not changed; however, contribution amounts will be increasing due to an increase in premium rates. Kaiser HMO will still remain the no cost option. Note: Nonpayment of employee/retiree contributions will result in termination of benefits. How can I find out if my current dentist is a member of the Delta Dental network? If I currently have a flexible spending account (FSA) what do I need to do? By logging onto you can find out if your dentist is in the Delta Dental network. (See page 6 for details.) You can also call Delta Dental and request a directory of network dentists in your area. (See page 20 of this brochure for phone numbers.) If you are currently enrolled in an FSA, you should: Submit your receipts and claim forms to American Fidelity no later than June 30, Re enroll for your FSA(s) if you want to participate for the coming plan year your current FSA elections will not carry over. Contact American Fidelity, if you will not be returning to the District next year. Where do I get more information about my benefits? You can attend an employee meeting during Open Enrollment (see page 2 of this brochure for the meeting schedule) or you can call the carriers directly or visit their websites. Contact information is listed under Your Resources on page

14 Health Care Reform and Additional Information IMPORTANT Notice of Opportunity to Enroll Children Who Were Previously Ineligible for the Medical Plan by Reason of a Dependent Eligibility Threshold This is to notify you that effective July 1, 2011, due to a change in applicable law, your children generally can be covered under the Plan until they attain age 26, regardless of their student or marital status and regardless of whether your home is their principal place of abode or whether you support them. Thus, children whose coverage under the Plan ended, who were denied coverage, or who were not eligible for coverage, because the availability of dependent coverage of children under the Plan ended before attainment of age 26 may be eligible for coverage under the Plan beginning July 1, Coverage is not available to children who have attained age 26 or who will attain age 26 by July 1, In order for an adult child to be covered under the Plan, you must also be enrolled for coverage. To request coverage for a child who will not attain age 26 as of July 1, 2011, you will need to add the child as a dependent during open enrollment between the dates of May 9 and May 23, If you have any questions, please contact The Employee Benefits Office. Limits on Preexisting Condition Exclusions The Plan s provisions relating to preexisting condition exclusions no longer apply for enrollees age 18 or younger. Annual Limits on Essential Health Benefits No annual dollar limits will be imposed under the Plan for essential health benefits. Non essential health benefits may be subject to an annual limit. The Plan Administrator will determine whether or not a particular benefit is essential using good faith efforts to comply with a reasonable interpretation of the term essential health benefits as that term is used in the Patient Protection and Affordable Care Act. No Lifetime Limits on the Dollar Amount of Essential Health Benefits No lifetime limit on the dollar amount of essential health benefits will be imposed under the Plan. Non essential health benefits may be subject to a lifetime limit on the dollar amount of such benefits. The Plan Administrator will determine whether or not a particular benefit is essential using good faith efforts to comply with a reasonable interpretation of the term essential health benefits as that term is described in the Patient Protection and Affordable Care Act. Coverage of Emergency Services The Plan s rules regarding coverage of emergency services have changed. Emergency services generally must be covered without any prior authorization, even if the services are provided on an out of network basis. They also must be covered without regard to whether the provider is a participating network provider. If the emergency services are provided out of network, the Plan cannot impose any administrative requirement or limitation that is more restrictive than ones imposed on in network providers. The Plan also must follow new cost sharing rules when emergency services are provided out of network. The services must be covered without regard to certain other terms and conditions (but not including some terms and conditions, including coordination of benefit provisions). 14

15 Health Care Reform and Additional Information Updated Appeals Process and New External Review Process A rescission of coverage is treated as an adverse benefit determination that is covered by the Plan s applicable claims and appeal process. A claim for urgent care will be reviewed as soon as possible, taking into account medical exigencies, but not later than 24 hours after receipt of a claim that contains sufficient information. Please note that this paragraph will be effective for the first plan year beginning on or after January 1, For example, if your plan year begins January 1, 2012, then this paragraph will be effective January 1, If your plan year begins July 1, 2012, then this paragraph will be effective July 1, If you wish to appeal a denial of benefits or a coverage determination, you will be permitted to review your claim file and present evidence and testimony as part of the Plan s claims and appeals process. You will receive any new or additional evidence considered, relied upon, or generated by the Plan in connection with your claim. If the Plan intends to issue a final internal adverse benefit determination that is based on a new or additional rationale, the Plan will provide you with the rationale and you will have an opportunity to respond prior to the final benefit determination. You will receive continued coverage pending the outcome of an internal appeal for certain claims that involve an ongoing course of treatment. You may be eligible to participate in an external review process in which your claim may be reviewed by an independent third party. Primary Care Provider and Pediatrician Designation Any enrollee in the Plan is permitted to designate any participating primary care provider who is available to accept him or her as a patient. With respect to coverage of a child, any physician (allopathic or osteopathic) who specializes in pediatrics may be designated as the child s primary care provider if the provider is in network and is available to accept the child as a patient. 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 to 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 benefits provided under this plan. You can contact your health plan s Member Services for more information. 15

16 Health Care Reform and Additional Information Preventive Health Coverage Subject to some limitations, the Plan will provide benefits for the following categories of in network preventive health services ( Preventive Services ) and will not impose any cost sharing with respect to such benefits: Evidence based items or services that have in effect an A or B rating in the current recommendations of the United States Preventive Services Task Force with respect to the individual involved; Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved; With respect to infants, children, and adolescents, evidence informed preventive care and screenings provided for in the guidelines supported by the Health Resources and Services Administration; and With respect to women, evidence informed preventive care and screening provided for in comprehensive guidelines supported by the Health Resources and Service Administration. The complete list of Preventive Services that will be covered can be found at regulations/prevention/recommendations.html. If a Preventive Service is not billed or tracked separately from another item or service, the Plan may impose costsharing requirements if the primary purpose of the office visit is not the delivery of a Preventive Service. The Plan may impose cost sharing requirements for Preventive Services provided by out of network providers. The Plan may use reasonable medical management techniques to determine the frequency, method, treatment or setting for Preventive Services, unless otherwise specified by applicable law. HIPAA Pre Existing Condition Exclusion Rules Your medical benefit plan may impose a pre existing condition exclusion. That means that if you have a medical condition before coming to our plan, you might have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis, care, or treatment was recommended or received within 6 months. Generally, the 6 month period ends the day before your coverage becomes effective. However, if you were in a waiting period for coverage, the 6 month period ends on the day before the waiting period begins. The pre existing condition exclusion does not apply to pregnancy nor to a child who is enrolled in the plan or who has other creditable coverage within 30 days after birth, adoption, or placement for adoption. This exclusion may last up to 12 months from your first day of coverage or, if you were in a waiting period, from the first day of your waiting period. However, you can reduce the length of this exclusion period by the number of days of your prior creditable coverage. Most prior health coverage is creditable coverage and can be used to reduce the pre existing condition exclusion if you have not experienced a break in coverage of at least 63 days. 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 HIPAA Privacy Notice. You can request a copy of the Privacy Notice by contacting your Human Resources Department. 16

17 Health Care Reform and Additional Information Limits on Rescission The Plan cannot rescind coverage with respect to an individual unless the individual performs an act, practice or omission that constitutes fraud, or unless the individual makes an intentional misrepresentation of a material fact. The Plan reserves the right to rescind coverage if an individual commits such fraud or makes such a misrepresentation. The Plan will provide you with at least 30 days advance written notice if the Plan will rescind your coverage. Medicaid and the Children s Health Insurance Program (CHIP) Offer Free or Low Cost Health Coverage to Children and Families If you are eligible for health coverage from your employer but are unable to afford the premiums, some States have premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer sponsored health coverage, but need assistance in paying their health premiums. If you or your dependents are already enrolled in Medicaid or CHIP, you can 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, you can contact your State Medicaid or CHIP office or dial KIDS NOW or visit to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer s health plan is required to permit you and your dependents to enroll in the plan as long as you and your dependents are eligible, but not already enrolled in the employer s plan. This is called a special enrollment opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you live in California, you may be eligible for assistance paying your employer health plan premiums. This information is current as of April 16, You should contact your State for further information on eligibility. CALIFORNIA MEDICAID Website: Phone: If you live outside of California, please contact either 877 KIDS NOW or visit to find your state s information. 17

18 Important Notice from Santa Ana Unified 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 Santa Ana 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. Santa Ana Unified School District has determined that the prescription drug coverage offered by the plan 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 November 15 th through December 31 st. 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 Santa Ana Unified School District prescription drug coverage, be aware that you and your dependents may not be able to get this coverage back. Please contact our office 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 Santa Ana 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. 18

19 Important Notice from Santa Ana Unified School District About Your Prescription Drug Coverage and Medicare 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 November to join. 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 Santa Ana 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, or 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: May, 2011 Name of Entity: Santa Ana Unified School District Contact: Benefits Office Address: 1601 East Chestnut Santa Ana, CA Phone: (714)

20 Santa Ana Unified School District takes pride in offering a rich benefits program for you and your family members. Below are some important phone numbers and websites that you may need in order to locate providers or get answers to your questions. You can also contact the Benefits Office at (714) or (714) Your Resources INSURANCE CARRIERS/ADMINISTRATORS Carrier Phone Number Carrier Website Kaiser HMO (800) Blue Shield PPO (800) Medical Blue Shield HMO (800) Blue Shield Mental Health Service Administrator (877) Medco Pharmacy (800) Dental Delta Dental DPPO (Network & Incentive) (866) DeltaCare USA DHMO (800) Vision VSP (800) Section 125 Plan American Fidelity (800) group.com Employee Assistance Program (EAP) Supplemental Insurance Other OptumHealth (800) American Fidelity (800) group.com Conseco (800) PERS (888) STRS (800) Keep this summary as a reference guide for quick answers about your benefits. The information presented in this announcement contains only highlights of the District s benefit plans. Plan documents and the insurance contracts contain full provisions. If there is a discrepancy between the material in these charts and the plan documents or insurance contracts, the plan documents or insurance contracts will govern. 20

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