Medical Benefits Analysis

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3 Medical Benefits Analysis (Active and Retired Under Age 65) Insurance Plan Health Net 5KF Kaiser Maximum Lifetime Benefit Deductible Maximum Out-of-Pocket Hospitalization Outpatient Surgery Emergency Room Urgent Care Center Doctor Office Visit Diagnostics, Lab & X-Ray Periodic Health Evaluation Maternity: Outpatient/Physician Hospitalization/Physician Mental Health: (severe) Inpatient Outpatient Mental Health: (other) Inpatient Outpatient Substance Abuse: Inpatient Outpatient Therapy: Physical Speech Occupational Cardiac Rehabilitation Alternative Health Care: Skilled Nursing Facility Home Health Care Hospice Care Chiropractic Care: Other Benefits: Ambulance Transport Orthotics and Prosthetics Durable Medical Equipment Christian Science Treatment Prescription Drugs Mail Order Unlimited $0 Single: $1,000 / Two Party $2,000 / Family: $2,500 $25 copay (copay waived if admitted) $20 copay $0 all age levels /visit unlimited per calendar year /visit unlimited per calendar year /visit unlimited per calendar year /visit unlimited per calendar year /unlimited visits per calendar year /unlimited visits per calendar year (no day limit) (no day limit) $10 copay (max 30 visits per yr.; $50 appliance benefit/yr.) Covered according to plan benefits and limitations $5 tier 1 primarily generic/ $15 tier 2 primarily name brand/ $35 tier 3 primarily non-formulary (30 day supply) : $10 tier 1 primarily generic/ $30 tier 2 primarily name brand/ $70 tier 3 primarily non-formulary (90 day supply) Unlimited $0 Single: $1,500/Family: $3,000 $35 (waived if admitted) (unlimited) $0/visit (unlimited) (unlimited) $0/visit (unlimited) (max 60 days/year) (max 100 days period/year) $10 copay (max 30 visits per yr) Not covered (100 day supply) Available THIS IS ONLY A SUMMARY OF BENEFITS. PLEASE REFER TO INSURANCE CARRIER BENEFIT PACKAGES FOR PLAN DETAILS. Revised 07/28/11

4 Insurance Plan Health Net Seniority Plus-Plan 86S Sacramento City Unified School District Comparison of RETIREE Medicare Plans Effective 11/1/2010 Health Net Medicare Supplement Plan 86P NOT ELIGIBLE FOR KAISER SA OR SENIORITY PLUS HEALTH NET T2 C Kaiser Senior Advantage Inpatient Hospital No Charge No Charge No Charge Skilled Nursing Facility No Charge; maximum of 100 days per benefits period No Charge No Charge; maximum of 100 days per benefits period Physician Office Visits No Charge testing and injection Allergy Testing services and Injections No Charge Serum covered no charge No Charge Emergency Room $20 waived if admitted $25 waived if admitted $20 waived if admitted X-ray and Lab Services No Charge No Charge No Charge Mental Health Inpatient No Charge, unlimited days per No Charge unlimited days per calendar year calendar year No Charge, unlimited visits, AB88 Outpatient $5 per visit/unlimited visits per calendar year $5 / visit unlimited per calendar year No Charge Home Health Care No Charge No Charge (no day limit) No Charge Durable Medical Equipment No Charge No Charge No Charge Podiatry, routine foot care limited 1 No Charge, must be medically visit per mo Not covered necessary ment per visit limited to 20 $10 copayment per treatment, 30 $10 copayment per treatment, 30 Chiropractic visits per year, members choose visits per calendar year, choose visits per calendar year, choose from Benefits from a list of participating providers from list of participating providers list of participating providers Hearing Exam No Charge Vision Benefits Exam No Charge Lenses and Frames Dental Benefits (Must be enrolled to use) Prescription Drugs Pharmacy Mail Order PLEASE NOTE RX CHANGES Service Areas, up to a $100 benefits that renews every 2 years Not Covered $10 copayment for office visits, no charge for teeth cleaning (1 per calendar year), $25 copayment for 2nd teeth cleaning in same year, no charge for bitewing x-rays (1-4 films) and full mouth x-ray Not covered Not covered Pharmacy 30 day supply: $5 tier 1 (most generic) / $15 tier 2 (most brand name) / $35 tier 3 (other nonformulary). Mail Order 90 day supply: $10 tier 1 (most generic) / $30 tier 2 (most brand name) / $70 tier 3 (non-formulary) Varies by county - call Health Net or SCUSD Benefits Office Pharmacy 30 day supply: $5 tier 1 (most generic) / $15 tier 2 (most brand name) / $35 tier 3 (other nonformulary). Mail Order 90 day supply: $10 tier 1 (most generic) / $30 tier 2 (name Brand) / $70 tier 3 (non-formulary) Varies by county - call Health Net or SCUSD Benefits Office $150 frame and lens allowance available every 24 months ment, for up to100 day supply Varies by county - call Kaiser or SCUSD Benefits Office revised Seniority Plus Plan 86S 1 (800) Health Net 1 (800) Kaiser SCUSD (916) Please note the following summary is intended for only as a general description of Plan benefits and that some of the benefits are limited to Medicare approved charges. For a complete description of benefits and Plan exclusion and limitations, please refer to the Plan's "Disclosure Form & Evidence of Coverage" or your Summary Plan Description.

5 Sacramento City Unified School District Health and Welfare Rates Effective 07/01/11 AMENDED 08/1/11 MEDICAL ONLY Monthly Premium Health Net Plan ***Total Premium District Paid* Retiree Paid* Retiree Only under 65 $1, $1, $0.00 Retiree < Dep <65 $2, $1, $1, Retiree < dep > 65 in Seniority Plus $1, $1, $ Retiree Only in Seniority Plus $ $ $0.00 Retiree > dep > 65 Both in seniority Plus $ $ $ Kaiser Retiree only under 65 $ $ $0.00 Retiree only over 65 Senior Advantage (SA) $ $ $0.00 Retiree under dependent under 65 $1, $ $ Retiree under dependent over 65 SA $1, $ $ Retiree over 65 with SA + 1 dep over 65 with SA $ $ $ Retiree only over 65 Senior Advantage - B ONLY $ $ $0.00 Health Net - Out of Area Plans (not eligible for HMO plans Kaiser or Health Net) Health Net PPO CA or PPO Non-CA Retiree Only under 65 $1, $1, $0.00 Retiree < dep < 65 $2, $1, $1, Retiree >65 with Parts A&B in AARP + 1 Dep <65 $1, $ $1, Retiree > dep > 65 Both with Parts A&B in AARP $ $ $ Retirees living outside SA or Seniority Plus Service area Retiree Only > 65 with Medicare either A& B or B only $ $ $0.00 Retiree > 65 with Medicare A&B or B only+ 1 dep < 65 $1, $ $1, See Open Enrollment Letter: Retiree and Dependent, upon reaching age 65, MUST APPLY for Medicare Part B and apply for Part A (if eligible) Not all rates are listed - Contact Benefits Office for additional rates DENTAL, VISION AND LIFE PLANS DELTA DENTAL (NO CHANGE) must match health One Party $61.00 $0.00 $61.00 Two Party $ $0.00 $ Family $ $0.00 $ ACCESS DENTAL (NO CHANGE) must match health One Party $26.32 $0.00 $26.32 Two Party $47.38 $0.00 $47.38 Family $78.96 $0.00 $78.96 Vision (NO CHANGE) Emp Only $19.44 $0.00 $19.44 Family $19.44 $0.00 $19.44 Life (NO CHANGE) must match health enrollment One Party $1.66 $0.00 $1.66 Two Party $2.14 $0.00 $2.14 Family $2.36 $0.00 $2.36 PLEASE NOTE: * District paid amount is for fully vested retirees who retired after 1974 **For those with <10 years of service or a spouse of a deceased retiree must pay the total premium amount *** For those who retired prior to 1974, the District contributes $121 toward the total premium amount ***NOTE: Retiree and/or spouse with Medicare A&B out of HN or Kaiser area Must be enrolled in AARP. Questions call Benefits Offi Page 1

6 Retiree Health Selection and Deduction Agreement for Dental/Vision/Life/Dependent Coverage Name (PRINT): Date of Birth: (Last) (First) S S #: Phone: Address: (Street) (City and State) (Zip) I want to change my current benefits as indicated below. To be eligible for Dental, Vision and Life, I must be enrolled in a medical plan or have an approved waiver on file. Refer to current rate sheet for premiums. Pension Plan: STRS PERS Medical Waiver Waiver form and proof of other group coverage attached. OPT OUT District Medical Health Net: Health Net Seniority Plus Out of Area Plans PPO CA PPO Non CA Kaiser: Kaiser Senior Advantage CalPERS Medical Medicare Delta Dental AARP Kaiser Blue Shield BS NetValue PChoice PCare PSelect If eligible, the District or agent will reimburse me up to the Kaiser active rate minus the CalPERS minimum contribution. $ / month Retirees over 65 must purchase B and must enroll in A if eligible Part A Part B Please attach copy of Medicare Card I do not elect coverage I elect dental coverage/must match health Single, Two-Party Dental or Family Dental Access Dental I do not elect coverage I elect dental coverage/must match health SCTA Members Only Single, Two-Party Dental or Family Dental Selected Dentist: Vision Life Dependent Coverage Retiree: Spouse: I do not elect coverage I elect family vision I elect retiree only vision I do not elect coverage I elect life insurance/must match health Single Life, Two-Party Life, Family Life I do not elect coverage I elect dependent coverage/must match options - - / / NAME OF DEPENDENT SOCIAL SECURITY NO. DOB RELATIONSHIP - - / / NAME OF DEPENDENT SOCIAL SECURITY NO. DOB RELATIONSHIP I agree that STRS/PERS shall deduct monthly from my pension the following amounts: $ I understand and agree that my STRS/PERS retirement pension will be reduced by my selected options and/or any health deductions. I also understand if my STRS/PERS retirement pension does not cover the total amount now or any time in the future, I will need to make personal payments to the District or District s agent. Changes to your selections can be made only during Open Enrollment or with a qualifying event. Dependents can be deleted any time. Signature Date INTERNAL USE : Current Age Approved STRS/PERS Years of Qualified Service BRMS Code District Retirement Date: Effective Date for Selection(s): Authorized Retirement Benefits Employee Benefit Office th Avenue BOX 840B Sacramento, CA FAX White : SCUSD Yellow: Member 6/15/11, Rev.E RSK F002A page 1 of 1

7 Kaiser and Health Net Members Important Notice from Sacramento City 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 Sacramento City 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. SCUSD has determined that the prescription drug coverage offered by the Kaiser or Health Net 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, your current SCUSD coverage will be affected. Coverage under the entity s plan will end for the individual and all covered dependents. If you do decide to join a Medicare drug plan and drop your current SCUSD coverage, be aware that you and your dependents will not be able to get this coverage back until the next Open Enrollment Period and proof that you dropped other coverage. CMS Form CC Updated April 1, 2011

8 Kaiser and Health Net Members 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 SCUSD 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 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 SCUSD 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: August 1, 2011 Name of Entity/Sender: Sacramento City Unified School District Contact--Position/Office: Employee Benefit Office Address: th Avenue, Sacramento, California Phone Number: CMS Form CC Updated April 1, 2011