1 SISC HEALTH BENEFITS 101 South Orange County Community College District August 11, 2015
2 SISC Schools Helping Schools Established in 1979, Self-Insured Schools of California (SISC) operates as a public school Joint Powers Authority (JPA) administered by the Kern County Superintendent of Schools Office. Our staff members are certificated and classified public school employees. SISC pools resources of over 400 school districts throughout the state to share risk and provide long term health benefit solutions. We are largest school focused public entity risk pool in the United States. South Orange County Community College District has been a SISC member district for over 10 years.
Blue Shield of California Blue Shield is dedicated to providing access to high-quality health care at an affordable price Blue Shield has been part of California s healthcare landscape since 1939. Blue Shield s networks are some of the largest in California. Blue Shield Member Services team are available to provide personal assistance from 7 a.m. to 7 p.m., Monday through Friday 3
The three types of member out-of-pocket expenses Co-pay - A flat dollar amount payment for a specific service or prescription Deductibles The amount a member must pay before the plan begins to pay on all services. This is waived for office visits. Coinsurance This is the percentage the member is responsible to pay after the deductible is satisfied and the plan begins to pay (90% plan=10% is coinsurance) 4
5 SISC PPO Plan Preferred Provider Organization (PPO): A type of managed care organization that has a panel of preferred providers who are paid according to a discounted fee schedule. The enrollees do have the option to go to out-of-network providers at a higher level of cost sharing. Blue Shield s PPO network includes more than 70,000 physicians and 350 hospitals. Plan features Co-pay: $10 office visit; $0 preventive; $100 ER Annual Deductible: $100 individual/$300 family Coinsurance for Participating Providers: 10% Annual Out of Pocket Maximum: $500 individual/$1,500 family Prescriptions: $3 generic; $15 brand; 30% specialty Limited Out of Network Benefits
6 PPO - Member Tips It is the member s responsibility to ensure a provider or facility is contracted with Blue Shield or a participating provider. Non-participating providers have the right to balance bill you Call the customer service with the provider s tax ID number, name, address and telephone number Ways to save Talk to your doctor about using generics rather than brand Using Urgent Care rather than the emergency room Routine Preventive Care and Well Baby Care are covered at 100%
7 Blue Shield HMO Plan Health Maintenance Organization (HMO): An organization that provides a wide range of comprehensive health care services for a specified group at a fixed periodic payment. Members then receive all the medical services they need through a group of contracting doctors and hospitals, often with limited copayments or fees. Members are generally limited to using providers designated by the HMO. Blue Shield s HMO network has more than 40,000 physicians and 300 hospitals. Plan features Co-pay: $5 office visit; $0 preventive; $100 ER Annual Out of Pocket Maximum: $1,000 individual/$2,000 family Prescriptions: $5 generic; $10 brand; $0 generics at Costco All care must be approved and authorized by the member s primary care doctor and medical group
8 Choosing the right health plan Do not pick the plan your friend or neighbor thinks you should take! Understand the differences in your choices HMO Minimal out-of-pocket costs; easier to use; more restrictive PPO- Less restrictive; more complex; more out of pocket costs Each employee has different needs that should be considered Current usage How many times did you or your family go to the doctor, hospital, x-ray, lab, etc. Do you or your family members see specialists? How many medications do you take? Do you need the full PPO access?
9 Blue Shield Website Why am I being sent a bill? Explanation of Benefits (EOB) What is covered on my plan? Plan Information Who is covered on my plan? Eligibility Information How can I access services without an ID card? Print a Temporary ID Card Can I get a discount anywhere just for being a Blue Shield member? Resources Can I access plan information from my cell phone? Smart Phone Application Register as a member at: www.blueshieldca.com/sisc to get these questions answered and much more!
10 Benefits you didn t know you had! PPO - MD Live - $5 virtual office visits HMO - 24/7 nurse line Free advice from a registered nurse $0 generics at Costco nonmembers are welcome SISC Employee Assistance Program (EAP) Free counseling Six Free Visits Consultation with an Attorney Assistance with Financial Planning ID Theft Recovery and Monitoring Resources for Managers and Supervisors Skill Builders
11 Questions Thank you!