Health Benefits Plans and Premiums 2009-2010

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Health Benefits
Plans and Premiums
2009-2010
SISC III
HEALTH PLANS AND PREMIUMS
2009-2010
Table of Contents
Introduction ..................................................................................................................................................................... 1
Guidelines .........................................................................................................................................................................4
Medical Plans & Rates
Additional Features ..................................................................................................................................................12
SISC’S Health Improvement Program .......................................................................................................................13
Hospital Comparison Tool ........................................................................................................................................14
Bluecard Worldwide .................................................................................................................................................15
Routine Preventive Exam ..........................................................................................................................................16
PPO Plans ..................................................................................................................................................................17
Health Savings Account (HSA)...................................................................................................................................21
Anthem Blue Cross ....................................................................................................................................................22
Blue Shield HMO .......................................................................................................................................................23
Health Net Plans HMO ...............................................................................................................................................24
Kaiser Permanente Plans HMO .................................................................................................................................25
Employed Spouse/Domestic Partner Plan ................................................................................................................26
Prescription Drug Plans
Medco Health Plans ...................................................................................................................................................27
Behavioral Health Plans
Behavioral Health Program ........................................................................................................................................29
PacifiCare Behavioral Health .....................................................................................................................................31
Dental Plans & Rates
Delta Dental PPO Premier Incentive Plans ................................................................................................................33
Delta Dental PPO (DPO) Plans ..................................................................................................................................34
Delta Dental Orthodontia Plans ..................................................................................................................................35
Vision Plans & Rates
Medical Eye Services Plans (MES) ............................................................................................................................36
Vision Service Plans (VSP) ........................................................................................................................................38
Life Plans & Rates
Mutual of Omaha Group Life Insurance Program ......................................................................................................41
Retiree Plans & Rates
Direct Billing Self-Pay Retirees...................................................................................................................................43
Individual Retiree Plans..............................................................................................................................................44
CompanionCare .........................................................................................................................................................45
Health Net Seniority Plus ...........................................................................................................................................46
Kaiser Permanente Senior Advantage .......................................................................................................................47
Medicare Part D .........................................................................................................................................................49
Section 125/SISC Flex Plan ...........................................................................................................................................50
Defined Benefits .............................................................................................................................................................53
Procedures .....................................................................................................................................................................54
Forms/Examples
Declination of Coverage for Less Than Full-Time Employees and HIPAA Notification..............................................61
Declination of Coverage for Dependents of Full-Time Active Employees and HIPAA Notification ............................62
Declination of Coverage for Retirees .........................................................................................................................63
Creditable Coverage Disclosure ................................................................................................................................64
Example of Letter for Districts Making Changes ........................................................................................................65
Plan Election Form for Districts Offering Multiple PPO Plans ....................................................................................66
Delta Dental Designation Form ..................................................................................................................................67
CompanionCare Disenrollment Request ....................................................................................................................68
Medicare Advantage Disenrollment Request .............................................................................................................69
Phone Numbers & Addresses
Who to Contact ..........................................................................................................................................................70
Medical Claims/Customer Service Phone Numbers and Addresses..........................................................................71
Our Philosophy – “Schools Helping Schools”
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Pooling resources provides schools with a more stable long term insurance solution than purchasing from commercial carriers
that may be competitive today and out of reach tomorrow. SISC provides a very cost effective rate environment which reflects
its commitment to preventing losses and controlling expenditures. This keeps millions of dollars in the classroom that would
have otherwise been paid out in premiums.
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Our Boards of Directors are elected by member districts. All Board Members are employees of school districts. This insures
that SISC policies are set with the best interests of schools in mind.
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All SISC administrative personnel are employees of the school system. We do not make sales commissions. Our fiduciary
responsibility is to our members...not a profit margin.
Our Ethics
SISC believes ethically responsible organizations service not only their members but all stakeholders: employees, employers,
providers, vendors and local communities. SISC’s commitment is to demand standards of behavior which support professional
practices. All decisions must take into account and reflect a concern for the interests of all stakeholders.
Our Goal
SISC strives to provide the best coverage and service to our members while keeping costs affordable and stable.
SISC I
WORKERS’ COMPENSATION - Established in 1978
Current Membership Summary
# of Educational Agencies
95
# of Counties
12
# of Full Time Equivalent Employees
Annual Payroll
43,849
$1,462,117,505
SISC I self-administers this program with an in-house claims staff. We believe this is the most effective arrangement to assure both
quality care to the injured worker and control over school district funds. SISC I focuses on using managed care through the use of
our customized Medical Provider Network to treat the employee’s injuries promptly and appropriately. We promote the use of preplacement medical assessments, formal return to work programs and other proactive tools in controlling the cost of Workers’
Compensation benefits.
SISC II
PROPERTY & LIABILITY - Established in 1978
Current Membership Summary
# of Educational Agencies
130
# of Counties
14
Total ADA
418,308
Total Insured Value
$11,344.483,747
SISC II self-administers this program with an in-house claims staff. We believe SISC II coverage is broader than that available
anywhere else in the marketplace. It includes:
General Liability Coverage
Other Coverage
● Premises
● Errors and Omissions
● Property
● Products
● Contractual
● Auto Liability and Physical Damage
● Professional
● Completed Operations
● Garage Liability
● Operations
● Cost of Defense
● Boiler and Machinery
● Employment Practices
● Personal Injury
● Crime Coverage
1
Introduction
SISC II includes a Student Accident Coverage Program.
This program is also self-administered with an in-house staff. Its goals are to:
● Provide protection for uninsured students.
● Promote positive public relations with schools.
● Achieve savings in claims dollars by preventing simple injuries from becoming liability cases.
SISC III HEALTH BENEFITS- Established in 1979
Current Membership Summary
# of Educational Agencies
368
# of Counties
39
# of Members
219,813
SISC III is one of the largest school focused health care purchasing pools in California. Our size allows us to access provider
networks at some of the lowest rates available. It also lets us spread our administrative costs and claims risks over a very large
membership base. The non-claims costs of SISC III as a percent of premium are often less than half of what districts would have
access to on their own or through smaller pools.
SISC III offers a wide range of health benefits. This allows member districts to assemble benefit packages that will meet their
budgetary needs while providing employees with quality health care coverage. The medical providers under our umbrella of plans
cover every corner of the state.
Health Benefit Products
Medical
Prescription Drug Card
Behavioral Health
Dental
• Anthem Blue Cross
• Blue Shield
• Health Net
• Kaiser
• Medco
• BHP
• PacifiCare
• Delta Dental
Vision
• Vision Service Plan
• Medical Eye Services
Life Insurance
• Mutual of Omaha
RISK MANAGEMENT SERVICES
This department is reflective of SISC’s dedication to safety and loss prevention. It provides, at no additional charge to member
districts, services such as:
● Consultation on various worker safety, workers’ compensation, liability, property and environmental issues.
● Premises inspections to aid districts in identifying hazards or problem areas.
● Workshops and seminars which provide training on an administrative and employee level.
● AHERA re-inspections and management plans.
The mission of this department is to create an environment of risk and loss management, which is essential to maintain fiscal
responsibility for the organization while focusing individualized attention on specific district needs.
SISC GASB 45 TRUST – Established in 2006
The SISC GASB 45 Trust is an irrevocable, tax-exempt trust under California State law and Internal Revenue Code Section 115.
The Trust has received a favorable Private Letter Ruling from the IRS. The trust will strive to maximize investment return utilizing a
prudent balance of equities and fixed income. SISC will manage the program for a nominal all-inclusive fee of .10% for SISC
member school districts, and .15% for non-members. The program has more than $53.6 million on deposit. Union Bank serves as
Trustee and custodian of assets, while Wachovia Securities is Broker of Record and investment advisor. Quarterly and annual
reports will be provided to assist with GASB 45 compliance. Additional information is available on our website:
http://sisc.kern.org/gasb45, or contact Cindy Mattern at (661) 636-4882, or [email protected], or Megan Hanson at (661) 6364411, or [email protected]
SISC FLEX PLAN - Established in 2002
The SISC Flex Plan allows active employees to use pre-tax dollars to pay for certain medical and dependent care expenses. The
plan is divided into three parts: 1) Premium Only Plan (POP) – Employee-paid medical, dental and vision premiums can be made
on a pre-tax basis; 2) Dependent Care Spending Account – Payments for daycare, home care, or child-care for care of a
dependent child under age 13, a disabled child of any age, a disabled spouse or a disabled dependent parent can be made on a
pre-tax basis through this account; and 3) Health Care Spending Account – Payments for coinsurance, deductibles and most
medical, dental and vision expenses that are not covered by insurance can be made on a pre-tax basis through this account.
Additional information is available at our website: http://sisc.kern.org/flex, or contact the SISC Flex department at (661) 636-4413, or
[email protected]
2
Introduction
SISC DEFINED BENEFIT PLAN - Established in 1994
Savings Over
Social Security Since Inception
Current Membership Summary
# of Educational Agencies
73
School Districts
$25,511,223
# of Counties
11
Employees
$53,975,305
Total
$79,486,528
# of Employees
74,419
Annual Payroll
$78,041,196
The SISC Defined Benefit Plan is an alternative pension plan for part-time, temporary and seasonal (PTS) employees. It can be
offered in place of social security or a defined contribution plan and has the following advantages:
● The 2009 contribution rate is 4.4% from the school district (1.8% lower than Social Security).
● The plan requires no contribution from the employee (employee’s take-home pay goes up).
● Monthly reporting is submitted electronically with little or no ongoing administration required by the district.
.
SISC INVESTMENT POOL - Established in 1994
Annualized return on investment since inception: 5.10%
The SISC INVESTMENT POOL provides districts with a way to maximize the return-on-investment on their long term excess
reserves. Many school districts with excess reserves currently have their funds invested in vehicles that provide for 24-hour
liquidity. If the district does not require use of these excess reserves for three or more years, the SISC INVESTMENT POOL may
be a more appropriate place for these funds. Features of the pool include:
● Compliance with the investment provisions of the California Government Code Section 53601.
● Management by Wachovia Securities.
● Quarterly statements of districts’ net asset value and pool performance.
SISC ADMINISTRATION
Dr. Russell E. Bigler ..............................................................................................................Chief Executive Officer
Cindy Mattern......................................................................................................................Chief Financial Officer
Henry Barker.................................................................................Coordinator of Information Systems
SISC I WORKERS’ COMPENSATION
Gabriel Rodriguez ....................................................................................... Director II of Workers’ Compensation
Joann Voss .............................................................................Supervisor of Workers’ Compensation
SISC II PROPERTY & LIABILITY
Catherine Jones..........................................................................................................Chief Administrative Officer
Duncan Low .................................................................................. Coordinator of Student Insurance
Timothy Beard .................................................................................... Manager of Risk Management
SISC III HEALTH BENEFITS
John Stenerson...............................................................................................................Deputy Executive Officer
Jennifer Bennett ................................................................................. Coordinator of Health Benefits
Revised 04/2009
SISC
1300 17th Street - CITY CENTRE
Bakersfield, CA 93301-4533
Phone (661) 636-4710 - FAX (661) 636-4156
A joint powers authority administered by the Kern County Superintendent of Schools Office, Larry E. Reider, Superintendent
3
Introduction
Guidelines
GUIDELINES
SCHOOL DISTRICTS AND/OR BARGAINING UNITS NEW TO SISC III
Any reference to “school district” in this document is meant to include any publicly funded educational
organization. Educational organizations that are not publicly funded are not eligible to join SISC. In order to
participate in SISC, a school district must abide by SISC Underwriting Guidelines. One hundred percent of the
school district or one hundred percent of the bargaining unit of a school district as defined below must enroll in the
SISC Medical or HMO Plans offered in this manual. Any deviation from SISC Underwriting Guidelines must be
requested in writing by the school district and approved in writing by SISC prior to joining. Our contract year is
from October 1 through September 30 of each year. A school district may elect the first of any calendar month to
join SISC. Once a member district, they must remain with their initial selection of benefits for at least twelve
consecutive months.
The school district will be sent a SISC III Joint Powers Agreement (JPA) and By-Laws. The JPA document
should be signed by the administrator of the school district and returned along with a letter requesting to join SISC
III. The letter should define the benefits selected by each bargaining unit as well as the effective date. The
signed JPA and letter must be received by SISC at least 45 days prior to the effective date of coverage. The
signed and completed Enrollment Forms must be received by SISC 35 days prior to the effective date. The
school district is responsible for notifying its current carrier of cancellation according to the agreement in place.
Additionally, payment of benefits for claims incurred prior to the effective date of SISC coverage is the
responsibility of the school district or its prior carrier.
BARGAINING UNITS
School districts may have two bargaining units; Certificated Employees and Classified Employees. Confidential &
Management and Board Members are not bargaining units and must enroll in the same benefits as either the
certificated or classified bargaining unit that they agree to follow. Retirees may not participate without their active
bargaining unit. Retirees must be offered the same benefits as their active bargaining unit.
BENEFIT CHANGES FOR RENEWING SCHOOL DISTRICTS AND/OR BARGAINING UNITS
Benefit changes will become effective the first day of any month following a 35-day written notification (HMOs
require a 45-day written notice). Once a school district has been enrolled in SISC for a period of time not less
than one year, the school district may change benefits. School districts or bargaining units may change benefits
once per contract year (October 1 through September 30). All of the benefits the school district or bargaining unit
has elected to change should be changed on the same date.
If a bargaining unit changes benefits, the retirees
of that bargaining unit will be changed to the same benefits as the active employees. It is the responsibility of the
school district to notify employees and retirees of changes.
School districts must submit a letter identifying the bargaining unit changing benefits, new benefits selected and
the effective date of the change. An example of a letter notifying SISC of a typical change can be found in the
Forms and Examples section of this manual. The letter must be received by SISC at least 35 days prior to the
effective date of the change. Please fax a copy of your letter to (661) 636-4893 and send the original to SISC at
P.O. Box 1847, Bakersfield, CA 93303-1847.
If the change you make creates new medical group numbers, employees enrolled on these new group numbers
will receive new I.D. cards at their home address. Employees who remain on existing group numbers will not
receive new I.D. cards (unless they are adding or canceling BHP or modifying their PPO plan to add or change an
office visit co-pay). If you change your prescription co-pay, the pharmacy system will be changed to reflect your
new co-pay and new I.D. cards will not be generated.
Because the PPO plan’s eligibility and claims system is driven by the I.D. number (Social Security number or
Health Care I.D. number), when a member’s group number changes, claims continue to process using the
member’s current deductible and co-insurance amounts with no processing problems due to the group number
change. However, the Medco Health prescription drug card portion of their coverage is driven by both the I.D.
number and the GROUP NUMBER. If the member neglects to tell the pharmacist that they have a new group
number, the claim will reject as “member not eligible” or “member canceled”.
4
Guidelines
For Blue Shield districts: Each member will have a separate identification card for medical and prescription
drugs. Changes made to the medical and/or pharmacy benefits are independent of one another.
The revised Rates-At-A-Glance should be produced and posted to the SISC web site within 10 to 15 days of the
date SISC receives the change request. The new group numbers and the plans associated with those group
numbers will be clearly defined on the Rates-At-A-Glance. Plan descriptions are posted automatically to the web
within 30-45 days of the effective date of the change. If you do not receive an e-mail letting you know the revised
Rates-At-A-Glance has been posted within 15 days or you do not receive an e-mail letting you know the plan
descriptions have been posted by the end of the month in which the change was made, please notify SISC by
calling (661) 636-4410.
SCHOOL DISTRICTS THAT OFFER MORE THAN ONE MEDICAL PLAN
1) School districts/bargaining units with less than 10 insured employees in a PPO plan may offer two
different Preferred Provider Organization (PPO) plans, or cancel all PPO coverage and offer one Health
Maintenance Organization (HMO) plan.
2) School districts/bargaining units with 10 through 29 insured employees may offer three different PPO
plans, or cancel all of their PPO coverage and offer one Health Maintenance Organization (HMO) plan.
3) School districts/bargaining units with 30 through 49 insured employees may offer three PPO plans and
one HMO plan.
4) School districts/bargaining units with 50 or more insured employees may offer three PPO plans and one
plan from two different HMOs as long as one plan is Kaiser.
5) School districts/bargaining units with 30 or more insured employees may offer four PPO plans if at least
one plan has a minimum deductible of $1,200 per individual and $2,400 per family.
Only the medical plans shown in this manual may be offered by a SISC school district. There is no additional cost
for offering more than one PPO; however, if a district offers an HMO alongside a PPO plan, the PPO rates will be
adjusted to cover the risk. If you offer an HMO, you must call the SISC office to request PPO rates.
School districts/bargaining units offering more than one PPO, must offer the same dental and vision plan for each
PPO.
You should have a SISC representative present at any HMO negotiations meeting to address how the offering of
an HMO will affect your PPO indemnity rates. Additionally, you should have a SISC representative present at any
HMO presentation or Open Enrollment meetings to explain how the HMO benefits differ from the PPO plans.
HEALTH MAINTENANCE ORGANIZATION (HMO) PLANS
If your district elects to offer an HMO plan, they must select a plan from one of the HMO plans offered in the
Medical Plans & Rates section of this manual. HMOs are not available in all areas and are not available through
SISC outside of California. Please contact the SISC office to verify the HMO is a viable option for your district.
You must use the prescription plans or behavioral health plans that are offered with the HMO. You cannot offer
one of our Medco Health prescription plans or freestanding behavioral health plans to replace those benefits. To
obtain a rate for one of the HMO plans offered in this manual, please call the SISC office at (661) 636-4410. If the
district offers a PPO plan alongside an HMO plan, the PPO plan is adversely affected and the rates for the PPO
plan will need to be adjusted. Before negotiations are completed, please call the SISC office to obtain correct
PPO rates for your district. The published PPO rates are applicable for districts with 100% of their employees
enrolled in a SISC PPO plan and not applicable for districts that offer an HMO.
DOMESTIC PARTNER RIGHTS
AB 205
SISC eligibility for Domestic Partners is AB 205 compliant. AB 205 states that if your plan provides benefits for
spouses, you must also provide the same benefits for domestic partners (i.e. dependent children, health benefits,
COBRA, CalCOBRA, AB 528, etc.). Only same sex domestic partners age 18 and older and opposite sex domestic
partners when one or the other is age 62 or older are eligible under AB 205. The employee/retiree must provide the
district with a certified copy of the Declaration of Domestic Partnership that was filed with California Secretary of State
and submit a completed and signed enrollment or change form within 30 days of the date they register with the state or
5
Guidelines
wait until the October Open Enrollment Period. It is the district’s responsibility to verify domestic partner eligibility and to
submit the documentation timely to SISC. Coverage for Domestic Partners when they cannot be claimed on the
employee’s Federal Income Tax Return is a taxable benefit. A copy of this legislation (pdf file) is available upon
request.
Dependent children of a domestic partner must meet the same eligibility requirements as a dependent child of a
marriage. If both parties desire that the domestic partnership be terminated, eligibility ends six months following
the filing of the Notice of Termination of Domestic Partnership with the Secretary of State.
School districts or bargaining units have the option of covering opposite sex domestic partners ages 18 through
61. The employee must provide the district a signed affidavit when adding an opposite sex domestic partner age
18 through 61 (affidavit may be obtained from SISC). When one or both domestic partners are 62 years of age or
older, they must register with the state of California. This is a negotiated benefit and you must notify SISC in
writing on district letterhead 35 days prior to the effective date. Coverage for Domestic Partners when they
cannot be claimed on the employee’s federal Income Tax return is a taxable benefit.
COMPOSITE RATE STRUCTURES
School districts or bargaining units that elect a composite rate structure (one rate for all contract types; single, two-party,
family) for their medical plan, must have a composite rate structure for any other medical plans offered. This includes
any Drug Card program, Behavioral Health plan or Health Maintenance Organization (HMO) plan.
All retirees will have a 3-tier rate structure---even retirees under age 65 when the district has a composite rate for their
active employees.
THREE-TIER RATE STRUCTURES
School districts or bargaining units that elect a three-tier rate structure (a different rate for each contract type; single,
two-party, family) for their medical plan must have a three-tier rate structure for all medical plans offered. This includes
any Drug Card program, Behavioral Health plan or HMO plan.
School districts that need a three-tier rate structure for the PPO plans must request rates directly from the SISC office.
Please allow 10 business days for a three-tier rate structure quote. You may contact a SISC Account Manager by
calling (661) 636-4410 to ask for assistance.
When the school district has a three-tier rate for their active bargaining unit, the under 65 retirees will have the same
three-tier rate as active employees. Spouses over age 65 will be enrolled in the same coverage as the retiree and may
remain on the under 65 group number if they have Medicare Parts A & B.
RETIREES
Retirees may not be enrolled on the same group suffix with active employees (Composite or Three-Tier Rate
Structures). The district must request a group number from SISC to enroll retirees if one is not available on the RatesAt-A-Glance.
Retirees and their spouses/domestic partners that are 65 years of age or older should have proof of Medicare Parts A &
B. A copy of the retiree’s and spouse’s/domestic partner’s Medicare card must be sent to SISC prior to the first of
the month in which they turn 65 (or first of the prior month if their birthday is on the 1st). If proof of Medicare is not
provided to SISC, the following illustrates the non-refundable surcharge that will be applied to the monthly
premium to under 65 groups. The surcharge will be applied the first of the month in which the member turns 65 until
the Medicare card is produced. If after 3 months SISC does not receive proof of Medicare the Retiree will be moved to
the appropriately rated over 65 group.
Surcharge
$750
$500
$950
Missing Part A:
Missing Part B:
Missing Part A & B:
If the retiree or spouse/domestic partner is under 65 and the other person is missing one or both parts of
Medicare, the above surcharge will be added to the two party under 65 rate. If both parties are 65 years of age or
older and missing a part of Medicare, they will each be enrolled on a single contract and the surcharge will be
6
Guidelines
applied to both premiums. If the retiree is single and missing one or both parts of Medicare, the above rate will be
charged to the single under 65 rate until the retiree obtains the missing parts of Medicare and is moved to the
appropriate over 65 group.
It is the district’s responsibility to get a copy of the Medicare card from the retiree or spouse/domestic partner and
furnish a copy to the SISC office. The premium surcharges are non-refundable and are set at a point to help the
plan compensate for paying primary when Medicare should pay primary.
If the retiree does not elect SISC coverage, their spouse/domestic partner is not eligible to participate.
In the case of a retiree two-party contract where one person is over the age of 65 and one is under the age of 65, the
following PPO enrollment options are available:
1)
2)
3)
Both parties remain enrolled on the group suffix for retirees under age 65 (until both parties turn 65); or
Split the enrollment - the under age 65 person enrolls on an under age 65 group number and the over age 65
person enrolls on an over age 65 group number (different group numbers, same benefits); or
The age 65 person with both parts of Medicare can enroll on a SISC Individual Retiree plan (if offered by the
district) and the under age 65 person can remain on the under age 65 group suffix.
All of the above scenarios require the person who is age 65 or older to provide proof of Medicare enrollment to SISC. A
separate enrollment form completed by the spouse or domestic partner is required if they are enrolling on a separate
group number.
If a retiree or spouse/domestic partner age 65 or older is missing a part of Medicare they will be enrolled on an
appropriately rated group number.
Retirees should be enrolled on an over age 65 group number the first of the month in which they turn 65. If they are
enrolled on a two-party contract, they may enroll on an over age 65 group the first of the month in which both parties are
age 65.
Dental/Vision: All retirees, regardless of age or district contribution, will have the same 3-tier rate structure and the
same rates. Retirees are not eligible for orthodontia coverage.
TENTHLY RATES
Tenthly rated school districts or bargaining units that modify benefits for any effective date other than October 1, must
multiply the rates in this manual by 1.2 and round off to the nearest hundredth (two places to the right of the decimal
point) to arrive at a tenthly rate. No adjustment(s) will be made for the pre-paid months of August and September.
Premium for tenthly rated school districts is collected October through July (August and September are the no-pay
months). Tenthly rates may only be implemented with an October 1 effective date.
75% PREMIUM OPTION – COMPOSITE RATES
This option is available to districts with a composite rate structure. When both husband and wife or domestic
partners work for the same district and both are covered by a SISC/PPO medical plan, the district may choose to
reduce the cost to 75% of the composite rate for the self-insured PPO, prescription drug plans and the behavioral
health plans associated with the PPO. All other products will continue to be paid at 100% of the composite rate.
Husband and wife/domestic partners will still be required to participate at 100% of the cost for vision, dental or life
plans through SISC and must continue to participate under SISC Participation guidelines. The following criteria
must be followed in order to participate:
Both husband and wife or domestic partners must be:
1. employees of the same district; and
2. enrolled separately in a SISC PPO plan; and
3. eligible to participate according to SISC Eligibility Guidelines; and
4. enrolled in a SISC PPO plan with a composite rate.
Should either the husband or wife/domestic partner lose eligibility, the cost of the coverage for the
spouse/domestic partner remaining on the plan will increase to 100% the first of the month following the loss of
7
Guidelines
eligibility. To take advantage of the 75% Premium Option, simply report the husband and wife/domestic partners
at 75% on your monthly 75% Maintenance Activity Report. We will not approve any retro active adjustments for
any employees eligible for the 75% premium option.
PREMIUM PAYMENTS
Premium is due by the first of the month for the month covered. If premium is not received by the last working
day of the month an additional one percent (1%) will be attached to the premium.
EXAMPLE:
Month covered:
Amount due for April:
Date due:
No payments received:
Amount due on May 1 with late charge:
April 1 through April 30
$50,000
April 1
April 30
$50,500 due for April plus current amount billed for May
An outstanding balance due on your monthly billing needs to be taken care of in a timely basis. If you believe we have
made an error, please notify us as soon as possible. A credit balance on your monthly billing also needs to be resolved
in a timely manner. If a credit balance is not resolved within 90 days of initial notice, SISC may adjust it to zero for
future billings.
COBRA/CalCOBRA/HIPAA Administration
COBRA (Consolidated Omnibus Budget Reconciliation Act) and HIPAA (Health Insurance Portability and
Accountability Act) are federal laws, CalCOBRA is a state law that attaches itself to COBRA. SISC will administer
COBRA and CalCOBRA at no additional cost for SISC III Member Districts when the district offers a medical plan
through SISC. If the member is on an HMO plan (other than the Anthem HMO), CalCOBRA is administered by
the HMO.
District Responsibility
It is the district’s responsibility to send the initial COBRA/CalCOBRA notice to new employees upon
commencement of coverage. It is also the district’s responsibility to send the initial HIPAA notice; this notice must
be given to all employees who are eligible for coverage---even employees who may decline coverage (i.e. 50%
employee). HIPAA requirements may be satisfied with a Declination of Coverage form. Declination of Coverage
forms may be found in the Forms and Examples section of this manual.
The initial COBRA/CalCOBRA notice must be sent upon commencement of coverage by first class mail and
addressed to the employee. If the employee is married, the notice must be addressed to the employee and the
employee’s spouse. If the employee has dependent children, the notice must be addressed to the employee,
employee’s spouse and family members.
SISC Responsibility
Once an employee and/or dependent lose coverage, SISC prepares and mails the COBRA 14-day notification to
the qualified beneficiary’s last known address. The 14-day notification includes information and rates on all of the
products the qualified beneficiary is enrolled in through SISC immediately preceding the qualifying event (loss of
coverage). If an employee or qualified beneficiary inquires about a product that is not offered through SISC, we
will direct them back to the district for rates and enrollment information on that product. SISC needs the report of
activity from the district four (4) business days prior to the month in which coverage will terminate in order to meet
the notification requirements of COBRA.
8
Guidelines
WHO IS ELIGIBLE
ACTIVE EMPLOYEES
Permanent or probationary employees who work a minimum of 20 hours per week or 50% of a Certificated job
(even though the hours worked may be less than 20 hours per week) are eligible. School districts may limit
coverage to employees who work more than 20 hours per week or more than 50% of the job if they choose to do
so, but they may not negotiate to cover employees who work less than this minimum requirement. Active
employees (employees who are not on an approved leave of absence) who work less than the number of hours
required or do not receive district paid benefits based on a pro rata share of what is contributed towards an eight
hour or full-time employee are not eligible.
An eligible employee who works less than eight hours/full-time or receives less than the amount that is
contributed towards an eight-hour full-time employee may decline coverage. However, if an eligible employee
declines coverage he/she may not enroll until: 1) Open Enrollment, 2) there is an increase in the number of hours
worked, or 3) they have Special Enrollment Opportunity under HIPAA (see Procedures section for details on
HIPAA).
SURVIVING SPOUSE OF ACTIVE CERTIFICATED AND CLASSIFIED EMPLOYEE
California Education Code Section 7000 (AB 528) states that school districts must offer the surviving spouse of a
certificated employee the same medical and dental benefits that active, certificated employees are offered. The
law does not address vision or coverage for dependent children. A copy of this legislation (pdf file) is available
upon request.
There is no law for surviving spouses of active, classified employees; however, if the district has a policy that
allows surviving spouses of classified employees to continue coverage they are considered eligible. SISC must
be notified in writing of this policy. If the school district does not have a policy, the surviving spouse may be
entitled to COBRA.
RETIREES
A retiree must qualify for retirement according to the district’s requirements or the requirements of the State
Teachers’ Retirement System (STRS) or the Pubic Employees’ Retirement System (PERS). A retiree who does
not meet the retirement qualifications of the school district, STRS or PERS is not eligible to continue coverage as
a retiree with the district and will be offered COBRA.
Through STRS, a member may be considered an eligible retiree due to a disability. STRS has two types of
disability elections and only one of the two types qualifies as a disability retirement.
Disability Allowance (STRS Coverage A): A member who previously elected the Disability Allowance Program
is not considered a retiree according to STRS. This member may not continue benefits through the district as a
retiree and would only have the option of COBRA. This member would have the option to stay on an Active plan
with a Board Approved Leave of Absence.
Disability Retirement Program (STRS Coverage B): A member who elects the Disability Retirement Program,
according to STRS is considered a retiree and may enroll in district retiree benefits.
Certificated retirees. California Education Code Section 7000 (AB 528) states that school districts must offer
certificated retirees and their surviving spouse the same medical and dental benefits that active, certificated
employees are offered. The law does not address vision coverage or coverage for dependent children. A copy of
this legislation (pdf file) is available upon request.
Classified retirees. There is no law for classified retirees; however, if the district has a policy that allows
classified retirees to continue coverage, they are eligible. SISC must be notified in writing of this policy. If the
school district does not have a policy, the retiree may be entitled to COBRA.
9
Guidelines
DEPENDENTS
Spouse/Domestic Partner: The employee’s legally wed spouse of the opposite sex or a registered Domestic
Partner as defined by state law. A copy of the marriage certificate that is witnessed and signed immediately
following the ceremony or Certificate of Marriage (legal document from the Hall of Records) must be submitted to
SISC in order to add a spouse. In order to add a domestic partner, the employee must submit a certified copy of
the Declaration of Domestic Partnership that was filed with the California Secretary of State. It is the district’s
responsibility to obtain proof of eligibility of the spouse or domestic partner and to submit the documents to SISC
in a timely manner. Failure to submit supporting documentation timely may result in the spouse or domestic
partner being denied coverage.
Child/Child of Domestic Partner: An unmarried, natural child or step-child from birth to age 19; a legally
adopted child or a child who is in the process of being adopted; a child for whom the member has legal and
physical custody/guardianship. A child who is in the process of being adopted is considered legally adopted when
SISC receives legal evidence of (i) the intent to adopt; and (ii) the member has either: (a) the right to control the
health care of the child; or (b) assumed a legal obligation for full or partial financial responsibility for the child in
anticipation of the child’s adoption. Proof of eligibility will be required when adding a new dependent for an
existing employee and at the time of hire for a new employee.
Once a child reaches age 19 they must be certified annually through age 24; they must remain unmarried and
dependent for Federal Income Tax purposes or unmarried and a full-time student. A full-time student must carry
a minimum of 12 units (9 units for graduate students) at a properly accredited two year community college, four
year college or university, or an accredited post-high school or technical school. SISC will require proof of IRS
dependency or full-time student status for dependent children between the age of 19 and 24 on an annual basis.
Once a dependent child becomes employed with their own health insurance or is on active duty with the armed
forces, they are no longer considered an eligible dependent. A totally disabled dependent child who is covered
through age 24, may remain covered after age 25 when they are unmarried and (a) dependent for Federal
Income Tax purposes or (b) a full-time student. The member must apply within 31 days of loss of coverage. The
completed and signed form must then be reviewed and approved by Medical Review.
APPROVED LEAVE OF ABSENCE
Employees on a Board approved Leave of Absence (LOA) may remain covered the same as an active employee.
If they continue coverage while on an approved LOA, they must remain enrolled in all coverage offered through
SISC by the district. Payments for employees on an approved LOA should be made directly to the district.
They must also be offered the opportunity to continue coverage under COBRA. If they do not wish to pay for
dental, vision or life coverage, the district may terminate their coverage and SISC will offer them continuation of
medical coverage only under COBRA. Dental and vision coverage are optional under COBRA. Life coverage
may not be continued through COBRA.
BOARD MEMBERS AND RETIRED BOARD MEMBERS
Active Board Members may enroll when the district allows participation and contributes at least 50% of the cost
for the benefits. Board Members that enroll must participate in all of the health and welfare benefits the district
offers through SISC. Board Members must elect coverage when first eligible. If Board Members do not enroll
when they first become eligible they must wait until the next Open Enrollment period to enroll or they may enroll
due to a HIPAA qualifying event outside of Open Enrollment.
Active Board Members who are retired from a school district or private employer, have Medicare Parts A & B and
do not need to cover their spouse, may save money by enrolling in CompanionCare; however, if they are an
active Board Member of your district, they cannot be enrolled on your district coverage as a retiree unless they
are also an eligible retiree of your district.
Retired Board Members or Board Members not re-elected who have completed one or more terms of office may
continue coverage when the district has a policy that allows retirees to participate at their own cost. The school
district may elect to pay for Retired Board Members who leave after serving three terms (12 years). See
Government Code Section 53201 for further details.
10
Guidelines
PARTICIPATION REQUIREMENTS
WHO MUST ENROLL IN COVERAGE
•
All eight-hour/full-time employees or employees who receive the same contribution as an eight-hour/fulltime employee must enroll in all coverage offered through SISC. If the district has a three-tier rate
structure, dependent coverage is optional.
WHO MAY DECLINE COVERAGE
•
Permanent part-time employees who work a minimum of four hours or 50% of a Certificated job and
receive contribution based on a pro rata share of the number of hours worked, may enroll when first
eligible or decline coverage. If they enroll, they must enroll in all coverage offered through SISC. If they
decline coverage, they must complete a Declination of Coverage and decline all coverage offered through
SISC. An example of the Declination of Coverage for Less Than Full-Time Active Employees and HIPAA
Notification form can be found in the Forms and Examples section of this manual. According to the
Health Insurance Portability and Accountability Act (HIPAA) of 1996, an employee who declines coverage
for himself/herself and his/her eligible dependents because they are covered elsewhere, must be allowed
to enroll immediately upon loss of coverage. He/she must contact you within 30 days of loss of coverage
(60 days if the loss of coverage is under a Medicaid plan or Children’s Health Insurance Program) and
submit evidence of “loss of coverage elsewhere” with the signed and completed enrollment or change
form.
•
Permanent part-time employees who work a minimum of four hours or 50% of a Certificated job and
receive contribution based on a pro rata share of the number of hours worked, may terminate coverage
on the first of the month following a written notification. Retro terminations will not be allowed. Part-time
employees who terminate coverage may not re-enroll until the next Open Enrollment Period, unless they
are eligible for a Special Enrollment Opportunity under HIPAA.
•
Retirees who decline district coverage may not enroll in any district coverage (medical, dental or vision) at
a subsequent enrollment date. If the retiree elects one of SISC’s Individual Retiree Plans, they may not
enroll in district coverage at any subsequent enrollment date. Dependents are not eligible if the retiree
does not enroll.
•
Employees on a Board Approved Leave of Absence may decline coverage. If they decline coverage for
reasons other than covered elsewhere, they may not re-enroll until they physically return to work from the
approved Leave of Absence or during the next Open Enrollment Period.
11
Guidelines
Medical Plans and Rates
¾
Additional Features
¾
PPO Plans
¾
HSA
¾
Blue Shield HMO
¾
Anthem Blue Cross HMO
¾
Health Net
¾
Kaiser Permanente
¾
Employed Spouse/Domestic
Partner Program
Additional Features Offered By SISC
24/7 NURSE HOTLINE
SISC PPO Plans offer a 24-hour, 7-day a week health information line staffed by nurses with access to a database of
health information to help answer your questions. Each call is confidential and private and offers access to medical
information beyond your medical office’s regular business hours. You can access this service by calling the toll-free
number which is on the back of your medical I.D. card.
ADDITIONAL AD&D LIFE INSURANCE
Employees and Retirees enrolled under a SISC PPO plan are automatically insured for $10,000 Accidental Death &
Dismemberment until age 70. Employees may not designate a beneficiary on this AD&D plan. The benefit is
designated to the employee’s spouse or heirs should the employee expire. The employee’s spouse or heirs must file a
claim for the reimbursement. You may contact the SISC office for claim forms.
HEALTH SMARTS – SISC’s HEALTH IMPROVEMENT PROGRAM
Health Smarts is voluntary, confidential and offered at no cost to our members. SISC is working with our health plan
administrators (Anthem Blue Cross and Blue Shield – both who are supported by WebMD) to offer this comprehensive
program that includes online health information, one-on-one health coaching, condition management and on-site health
screening events.
COBRA/CalCOBRA ADMINISTRATION
COBRA (Consolidated Omnibus Budget Reconciliation Act) is a federal law; CalCOBRA is a state law that attaches
itself to COBRA. SISC will administer COBRA and CalCOBRA at no additional cost for SISC III Member Districts when
the district offers a medical plan through SISC.
DIRECT BILLING SELF-PAY RETIREES
Districts now have the option of SISC managing the monthly billing and collecting of premium of their self-pay retirees.
SISC will administer this program for our member districts at no additional cost.
12
Medical Plans and Rates
SISC’S HEALTH IMPROVEMENT PROGRAM
SISC offers a health improvement program to members enrolled in our PPO plans (HMO members already have
health improvement programs through their HMO plans). The program is called HEALTH SMARTS.
SISC’s vision is to raise health awareness and maximize the value of the health benefits available to our
members. To help create a culture of wellness, SISC has made available the following programs through
HEALTH SMARTS.
Condition Management: PPO members meeting certain criteria are contacted by their medical plan regarding
issues related to following chronic conditions:
•
•
•
•
•
Asthma
Diabetes
Heart Failure
Coronary Artery Disease
Chronic Obstructive Pulmonary Disease
These members receive educational mailings from time to time and have access to a nurse who can provide
support anytime of the day or night. Some members will receive calls inviting them to participate in the condition
management program. If they agree to enroll, a registered nurse works with them by phone to help set specific
goals to improve their condition and develop a plan to realistically achieve those goals.
Online Health Assessment: This online tool can be accessed by visiting http://sisc.kern.org/healthsmarts/ and
clicking the button for the PPO medical plan. The online health assessment will ask the member a variety of
questions regarding their lifestyle. Within minutes of completing the assessment, a confidential report is provided
to the member that identifies their health risks and offers suggestions in areas where they can improve or modify
their lifestyle to strive for better health.
Health Screening Events*: To provide additional support in creating a culture of wellness, SISC has made
available health screening events for member districts that opt to participate. The screening events can be held
at the district office as well as district school sites. Dates will be announced by SISC for next year’s health
screening events. The screening is free, voluntary, and confidential and includes the following:
•
•
•
•
•
Blood pressure
Total cholesterol and HDL
Blood sugar levels
BMI (Body Mass Index)
Body Fat Percentage
Health Smarts is voluntary, confidential and offered at no cost to our members. SISC is working with our health
plan administrators (Anthem Blue Cross and Blue Shield – both who are supported by WebMD) to offer this
comprehensive program that includes online health information, one-on-one health coaching and condition
management.
Please visit the Health Smarts web page for additional information, http://sisc.kern.org/healthsmarts/ or call the
SISC office at (661) 636-4410 and speak to your Account Management Team.
*Minimum participation rules apply; please contact your SISC Account Manager for details.
13
Hospital Comparison
Anthem Blue Cross and Blue Shield
SISC members can access the quality and outcome data for Anthem Blue Cross and Blue Shield contracted hospitals
in their statewide network. The information is made available through companies that provide comprehensive and
independent web-enabled health care decision support tools and information to health plans and employers.
This gives our members valuable access to actual data rather than just subjective opinions. SISC wants our members
to have choices and be empowered with information that helps them make informed decisions concerning their health
care needs and services.
SUBIMO HealthCare Advisor – Anthem Blue Cross
Through Subimo’s proprietary technology and content management process, users are able to securely and privately
navigate through relevant information on their health condition or upcoming medical procedures. The Subimo
Healthcare Advisor will also help Anthem Blue Cross members to research and determine which hospitals best meet
their personal preferences.
To access Subimo enter the Anthem Blue Cross website, www.anthem.com/ca/sisc. Click Subimo’s Healthcare
Advisor under the Health Information heading on the left side of the screen.
Hospital Comparison Tool – Blue Shield
The Hospital Comparison Tool makes it easier for Blue Shield of California members to make informed
healthcare choices. The tool provides:
•
•
Personalized reports that rate network hospitals on procedure volume, complication and mortality
rates, and length of stay
Details on each hospital’s relative cost
To access the tool, log on to www.blueshieldca.com
14
Medical Plans and Rates
BLUECARD WORLDWIDE®
“HOW DO I ACCESS MEDICAL CARE IN A FOREIGN COUNTRY?”
1. Before you leave, contact your Blue Cross Blue Shield Plan for coverage details. Coverage outside the United
States may be different.
2. Always carry your current Blue Cross Blue Shield Plan ID card.
3. In an emergency, go directly to the nearest hospital.
4. If you need to locate a doctor or hospital or need medical assistance services, call the BlueCard Worldwide
Service Center at 1(800) 810-BLUE (2583) or call collect 1(804) 673-1177, 24 hours a day, seven days a
week. An assistance coordinator, in conjunction with a medical professional, will arrange a physician
appointment or hospitalization, if necessary.
5. If you need to be hospitalized, call your Blue Plan for pre-certification or pre-authorization. You can find the
phone number on your Blue Plan ID card. Note: this number is different from the phone number listed above.
6. Call the BlueCard Worldwide Service Center at 1(800) 810-2583 or collect at 1(804) 673-1177 when you need
inpatient care. In most cases, you should not need to pay upfront for inpatient care at participating BlueCard
Worldwide hospitals except for the out-of-pocket expenses (non-covered services, deductible, co-payment and
co-insurance) you normally pay. The hospital should submit your claim on your behalf.
7. You will need to pay upfront for care received from a doctor and/or non-participating hospital. Then complete
a BlueCard Worldwide international claim form and send it with the bills(s) to the BlueCard Worldwide Service
Center (the address is on the form). International claim forms are available from your Blue Plan,
www.BCBS.com/bluecardworldwide, or the BlueCard Worldwide Service Center at 1(800) 810-2583 or collect
at 1(804) 673-1177.
CLAIM FILING INFORMATION:
1. If the BlueCard Worldwide Service Center arranged your hospitalization, the hospital will file the claim for you;
you will need to pay the hospital for the out-of-pocket expenses you normally pay.
2. For outpatient and doctor care or inpatient care not arranged through the BlueCard Worldwide Service Center,
you will need to pay the healthcare provider and submit an international claim form with original bills to the
Service Center.
3. International claim forms are available from your Blue Plan, the Service Center or on-line at
www.bcbs.com/bluecardworldwide.
TO LEARN MORE ABOUT THE BLUECARD WORLDWIDE:
1. Call your Blue Cross Blue Shield Plan.
2. Visit www.BCBS.com/bluecardworldwide.
3. Call the BlueCard Worldwide Service Center at 1(800) 810-2583 or call collect at 1(804) 673-1177.
IMPORTANT:
Call the Bluecard Worldwide Service Center at 1(800) 810-BLUE (2583) or call collect at 1(804) 673-1177 to locate
doctors and hospitals or obtain medical assistance services when outside the United States.
BLUECARD OUT OF STATE
PROTECTION WHEN TRAVELING OR LIVING OUTSIDE YOUR HOME STATE
You and your enrolled dependents may access PPO benefits when you’re traveling or temporarily living outside
your home state with the BlueCard program. The BlueCard also covers enrolled dependents, including students
and family members, who temporarily reside outside your home state. To locate BlueCard providers, call
BlueCard Provider Access at 1(800) 810-BLUE (2583).
BlueCard is not applicable to HMO plans or Medicare Supplement plans.
15
Medical Plans and Rates
Routine Preventive Exam* Guidelines
Employee and Spouse/Domestic Partner
Health Screens – Up to Age 64
•
•
•
•
•
•
•
•
•
Total Blood Cholesterol & High-Density Lipoprotein (HDL)
Chlamydia Screening
Hepatitis C Screening
Tuberculosis Screening
Screening for rubella susceptibility by history of vaccination or serologic
tests for antibodies
Sexually Transmitted Diseases and HIV Testing
Bone Densitometry
Type II Diabetes
Physical
Health Screens – Age 65 and Older
•
•
•
All screenings listed above and
Visual Acuity
Hearing Impairment
Immunizations – Up to Age 64
•
•
•
•
•
•
•
•
Td Booster (tetanus, diphtheria)
Rubella
Measles, Mumps & Rubella (MMR)
Hepatitis B
Chickenpox (varicella virus)
Influenza (flu)
Lyme Disease
Meningococcal
Immunizations – Age 65 and Older
•
•
All immunizatons listed above and
Pneumococcal
*Cancer Screenings are covered as a separate benefit and do not fall under the Routine Preventive Exam.
The Routine Preventive benefit is applicable to currently marketed PPO book plans.
16
Medical Plans and Rates
100% PPO PLANS
Participating
Services
Providers
Calendar Year Deductible(s)
See Deductible Options Below
Maximum Co-Insurance
Not applicable
Lifetime Maximum
$5,000,000
Office Visits
Deductible Waived
$0, $10, $20 & $30 office visit co-pays available
Inpatient Hospital
Room, Board & Support Services
100%
(prior authorization required)
Ambulatory Surgery Center
100%
Emergency Room (non-emergency)
Facility Expenses:
100%
100%
Professional Expenses:
Accident Care (48 hrs) Emergency Room
Facility Expenses:
100%
Professional Expenses:
100%
Surgeon & Anesthetist
100%
Well Baby/Child Preventive Care
Deductible Waived
Routine Preventive Care -
Deductible Waived
100%
Employee & Spouse/Domestic Partner
100%
Diagnostic X-Ray & Lab
100%
Deductible Waived
100%
100%
(some limits may apply)
Cancer Screenings
Physical Medicine (PT, OT, Chiro)
Speech Therapy
100%
Acupuncture
100% up to
12 visits per year
$50 per visit
Durable Medical Equipment
Rental or Purchase of DME
100%
Hearing Aid
100%
(Up to $700 every 24 months)
Hospice
100%
Ambulance (Ground or Air)
100%
Home Health Care
100 4-hour visits/yr (prior authorization req'd)
100%
Home Infusion
Outpatient Prescription Drugs
See Prescription Drug Plans
Psychiatric and Substance Abuse
See Behavioral Health Plans
100%
PLANS
Individual/Family
Deductible(s):
17
A
B
C
D
$0
$100/$300
$200/$400
$300/$600
Medical Plans and Rates
90% PPO PLANS
Participating
Services
Providers
Calendar Year Deductible(s)
See Deductible Options Below
Maximum Co-Insurance
See Co-Insurance Options Below
Lifetime Maximum
$5,000,000
Deductible Waived
Office Visits
$10, $20 & $30 office visit co-pays available
Inpatient Hospital
Room, Board & Support Services
90%
(prior authorization required)
Ambulatory Surgery Center
90%
Emergency Room (non-emergency)
Facility Expenses:
90%
Professional Expenses:
Accident Care (48 hrs)Emergency Room
Facility Expenses:
90%
Professional Expenses:
Surgeon & Anesthetist
90%
90%
90%
Well Baby/Child Preventive Care
Deductible Waived
Routine Preventive Care-
Deductible Waived
100%
Employee & Spouse/Domestic Partner
100%
Diagnostic X-Ray & Lab
90%
Deductible Waived
Cancer Screenings
90%
Physical Medicine (PT, OT, Chiro)
90%
(some limits may apply)
Speech Therapy
90%
Acupuncture
90% up to
12 visits per year
$50 per visit
Durable Medical Equipment
90%
Rental or Purchase of DME
Hearing Aid
90%
(Up to $700 every 24 months)
Hospice
90%
Ambulance (Ground or Air)
90%
Home Health Care
90%
100 visits/yr (prior authorization required)
Home Infusion
90%
Outpatient Prescription Drugs
See Prescription Drug Plans
Psychiatric and Substance Abuse
See Behavioral Health Plans
PLANS
Indv/Family
Deductible(s):
Max Indv/Fam
Co-Insurance:
A
B
C
D
E
$100/$300
$100/$300
$200/$500
$200/$500
$300/$600
$300 Indv.
$600/$1,800
$300 Indv.
$600/$1,800
$600/$1,800
18
Medical Plans and Rates
80% PPO PLANS
Participating
Services
Providers
Calendar Year Deductible(s)
See Deductible Options Below
Maximum Co-Insurance
See Co-Insurance Options Below
Lifetime Maximum
$5,000,000
Office Visits
Deductible Waived
$10, $20 & $30 co-pays avail.
Inpatient Hospital
Room, Board & Support Services
80%
(prior authorization required)
Ambulatory Surgery Center
80%
Emergency Room (non-emergency)
Facility Expenses:
$50 co-pay
80%
80%
Professional Expenses:
Accident Care (48 hrs)/Emergency Room
Facility Expenses:
$50 co-pay
80%
80%
Professional Expenses:
Surgeon & Anesthetist
80%
Well Baby/Child Preventive Care
Deductible Waived
Routine Preventive Care-
Deductible Waived
100%
Employee & Spouse/Domestic Partner
100%
Diagnostic X-Ray & Lab
80%
Deductible Waived
Cancer Screenings
80%
Physical Medicine (PT, OT, Chiro)
80%
(some limits may apply)
Diagnostic X-Ray & Lab
80%
Speech Therapy
80%
Acupuncture
80% up to
12 visits per year
$50 per visit
Durable Medical Equipment
80%
Rental or Purchase of DME
Hearing Aid
80%
(Up to $700 every 24 months)
Hospice
80%
Ambulance (Ground or Air)
80%
Home Health Care
80%
100 4-hour visits/yr (prior authorization req'd)
Home Infusion
80%
Outpatient Prescription Drugs
See Prescription Drug Plans
Psychiatric and Substance Abuse
See Behavioral Health Plans
PLANS
Indv/Family
Deductible(s):
Max Indv/Fam
Co-Insurance:
A
B
C
D
E
F
G
$100/$300
$100/$300
$200/$500
$200/$500
$300/$600
$400/$800
$500/$1,000
$500/$1,500
$1,000/$3,000
$500/$1,500
$1,000/$3,000
$1,000/$3,000
$1,000/$3,000
$1,000/$3,000
19
Medical Plans and Rates
HIGH DEDUCTIBLE HEALTH PLANS (HDHP)
(HSA compatible)
Participating
Providers
See Deductible Options Below
Services
Calendar Year Deductible(s)
Annual Out-Of-Pocket Maximum
Includes Deductible, co-pays and
co-insurance.
Lifetime Maximum
Office Visits
$5,000 Per Individual
$10,000 Per Family
$5,000,000
90%
Inpatient Hospital
Room, Board & Support Services
(prior authorization required)
Ambulatory Surgery Center
90%
90%
$100 co-pay
90%
90%
$100 co-pay
90%
90%
90%
Deductible Waived
$25 co-pay per visit
Deductible Waived
$25 co-pay per visit
90%
Deductible Waived
90%
Physical Therapy/Chrio Combined
12 visits per year
90% up to $25 per visit
90%
90% up to
$30 per visit
Emergency Room (non-emergency)
Facility Expenses:
Professional Expenses:
Accident Care (48 hrs)/Emergency Room
Facility Expenses:
Professional Expenses:
Surgeon & Anesthetist
Well Baby/Child Preventive Care
(age 0-6)
Routine Preventive Care
(age 7 and older)
Diagnostic X-Ray & Lab
Cancer Screenings
Physical/Occupational Therapy
Speech Therapy
Acupuncture
12 visits per year
Durable Medical Equipment
Rental or Purchase of DME
Hearing Aid
(Up to $700 every 24 months)
Hospice
Ambulance (Ground or Air)
Home Health Care
100 4-hour visits/yr (prior authorization req'd)
Home Infusion
Chiropractic Services
Psychiatric & Substance Abuse
Inpatient (30 days/yr)
Outpatient
Outpatient Prescription Drugs
Administered by medical carrier & subject to deductible
Generic Drugs
Brand Name Drugs
PLANS
Individual/Family
Deductible(s):
90%
90%
90%
90%
90%
90%
Physical Therapy/Chrio Combined
12 visits per year
90% up to $25 per visit
90%
50% up to $20
Retail
30 days
$7
$25
Mail
90 days
$14
$60
A
$1,200/Individual
$2,400/Family
B
$2,500/Individual
$5,000/Family
If the district/bargaining unit elects an HSA, all enrollees will be subject to the plan design based on
Federal guidelines (i.e. deductible accumulator and no last quarter carry over).
When offering a HDHP, districts funding the deductible will adversely affect the premium.
This PPO Plan is offered only with the psychiatric and
substance abuse and pharmacy benefits demonstrated above.
This is only a brief summary of benefits. For a complete list of benefits, please refer to the plan document.
20
Medical Plans and Rates
HEALTH SAVINGS ACCOUNT (HSA)
The HSA enables tax-free savings for the qualified medical expenses of “eligible individuals” and their
dependents.
An “eligible individual” or HSA owner is someone covered under an HSA-compatible, High Deductible
Health Plan (HDHP) and is not covered under a non-HDHP or Medicare and not claimed as a
dependent on another’s tax return.
Qualified medical expenses are defined in Internal Revenue Code Section 213 [d]. In general they
include specified deductibles, co-payments and other medical expenses not covered under the HDHP or
in any other manner.
HSA Advantages:
•
•
•
•
•
HSA contributions are tax-deductible.
Interest on an HSA is tax-deferred.
HSAs are portable and owned by the individual; contributions cannot be taken away.
Unspent balances roll over to the following year and can accumulate over a lifetime to help pay
for uncovered Medicare expenses after retirement.
In the event of the holder’s death, HSA balances pass on free of tax to their designated
beneficiaries.
Frequently Asked Questions:
Q: Who can contribute to an HSA?
A: The HSA is funded by contributions from the employee, employer or both.
Q: What is the maximum amount that can be contributed to an HSA?
A: $3,000 per individual and $5,950 per family (2009)
Q: How does the HSA plan work?
A: Money in the HSA can be used to pay for covered qualified medical expenses and
prescriptions not paid by the HDHP. The HSA dollars used apply towards the plan’s annual
deductible. If all of the dollars are not spent, the money remaining in the account will roll over to
the following year.
Q: Who do I contact to set up an HSA?
A: Insured banks and credit unions are automatically qualified to handle HSAs. Any bank, credit
union or any other entity that currently meets the IRS standards for being a trustee or custodian
for an IRA or Archer Medical Savings Account (MSA) can be an HSA trustee or custodian. SISC
is not qualified to handle HSAs.
SISC offers two HDHP plan options that are HSA compatible. Please contact your SISC Account
Manager regarding plan design details and additional information on the financial component of an HSA
by calling (661) 636-4410.
21
ANTHEM BLUE CROSS - HMO
BENEFIT SUMMARY
PLANS
H5
H17a
H9
PROFESSIONAL SERVICES
Office Visit/Urgent Care
$10 co-pay
$20 co-pay
$15 co-pay
Specialists/Consultants
$10 co-pay
$20 co-pay
$30 co-pay
No charge
X-ray and Laboratory Procedures
No charge
No charge
Surgery, Outpatient
No charge
No charge
No charge
Prenatal, Postnatal Office Visits
$10 co-pay
$20 co-pay
$15 co-pay
Normal Delivery, Cesarean Section
No charge
$250/stay
20% co-pay
50%**
50%**
50%**
No charge
$250/stay**
20% co-pay
Infertility (diagnosis/treatment of causes of infertility)***
**Does not apply to co-pay max.
HOSPITAL AND SKILLED NURSING FACILITY SERVICES
Unlimited Days in a Semiprivate Room
Intensive Care
Emergency Room
Skilled Nursing Facility (100 days/year)
No charge
No charge
20% co-pay
$100 co-pay*
$100 co-pay*
$100 co-pay*
No charge
No charge
20% co-pay
$10 co-pay
$20 co-pay
$15 co-pay
*Emergency room co-pay waived if admitted
MENTAL HEALTH SERVICES
OUTPATIENT
AB88 Severe Diagnosis
Non AB88 Severe or Substance Abuse
Chemical Dependency/Substance Abuse Rehab
$35 co-pay, 20 visit
$35 co-pay, 20 visit
$35 co-pay, 20 visit
per 12 month period
per 12 month period
per 12 month period
Not covered
Not covered
Not covered
No charge
$100 co-pay per day**
$250 per day/co-pay**
No limit
No limit
INPATIENT
AB88 Severe Diagnosis
Days per Calendar Year (medically necessary)
Non AB88 Severe or Substance Abuse
$100 co-pay per day**
No limit
Non AB88 Inpatient not
covered
$250 co-pay per stay**
$100/day plus 20%
30 days
detox days only
detox days only
$100 co-pay per day**
Substance abuse is detox only
Days per Calendar Year
** Does not apply to co-pay max.
OTHER SERVICES
Ambulance/Air Ambulance
No charge
No charge
No charge
Home Health Visits (100 visits/CY) 1 visit by a home health aide
equals 4 hours or less
$10 co-pay
$20 co-pay
$15 co-pay
Durable Medical Equipment ($5,000/year)
No charge
No charge
No charge
Hospice Benefits
No charge
No charge
No charge
$1,500
MAXIMUM CO-PAYMENT LIABILITY
One Member
$1,500
$500
Two Members
$3,000
$1,000
$3,000
Three Members or more
$4,500
$1,500
$4,500
*** Co-payments made for infertility services or inpatient detoxification will not be applied to the Maximum Co-payment limit. This chart
is only a brief summary of benefits.
All medical plans must have one of the following Prescription Drug Plans
PRESCRIPTION DRUG PLANS
RX4
RX14
RX20
Retail 30-day/Mail 90-day Supply
$5/$10
$10/$20
$5/$20/$40
The following benefit can be added to the medical plan.
CHIROPRACTIC PLANS
CHIRO
Co-pay/visits
$10/30
This chart is only a brief summary of benefits. For a complete list of benefits, please refer to the plan document for each plan.
22
Medical Plans and Rates
BLUE SHIELD - HMO
BENEFIT SUMMARY
PLANS
10-0
20-250
25-500
30-20%
$10 co-pay
$10/$30*** co-pay
No Charge
No Charge
No Charge
No Charge
$20 co-pay
$20/$30*** co-pay
No Charge
$150 co-pay
No Charge
No Charge
$25 co-pay
$25/$30*** co-pay
No Charge
$300 co-pay
$30
Hospital Admissions
Copayment Apply
$30 co-pay
$30/$45*** co-pay
No Charge
No Charge
$30
Hospital Admissions
Copayment Apply
PROFESSIONAL SERVICES
Office Visit/Urgent Care**
1
Specialists/Consultants***
X-ray and Laboratory Procedures
Surgery, Outpatient
Prenatal, Postnatal Office Visits
Normal Delivery, Cesarean Section
Infertility
(diagnosis/treatment of causes of infertility)
50% of allowed charges 50% of allowed charges 50% of allowed charges 50% of allowed charges
HOSPITAL AND SKILLED NURSING FACILITY SERVICES
Unlimited Days in Semiprivate Room
Intensive Care
Emergency Room
Skilled Nursing Facility (100 days/year)
No Charge
No Charge
$100 co-pay*
No Charge
$250/Admission
$250/Admission
$100 co-pay*
$100/day
$500/Admission
$500/Admission
$100 co-pay*
$100/day
20%
20%
$150 co-pay*
20%
$10 co-pay
$25 co-pay (20 visits)
$25 co-pay
$20
$25 co-pay (20 visits)
$25 co-pay
$25
$25 co-pay (20 visits)
$25 co-pay
$30 co-pay
$25 co-pay (20 visits)
$25 co-pay
No Charge
unlimited
$250
unlimited
$500/Admission
unlimited
20%
unlimited
No Charge
$250
$500/Admission
20%
$100 co-pay
$10 co-pay
$100 co-pay
$25 co-pay
$100 co-pay
$30 co-pay
$100 co-pay
$20 co-pay
MENTAL HEALTH SERVICES
OUTPATIENT
AB88 Severe Diagnosis
1
Non AB88 Severe or Substance Abuse
Chemical Dependency/Substance Abuse
INPATIENT
AB88 Severe & Non Severe Diagnosis
Days per Calendar Year
Chemical Dependency/Substance Abuse (detox
only)
OTHER SERVICES
Ambulance/Air Ambulance
Home Health Visits
Durable Medical Equipment1
20% of allowed charges 20% of allowed charges 20% of allowed charges 50% of allowed charges
Plan payment $2000
Plan payment $2000
Plan payment $2000
Plan payment $2000
max per calander year max per calander year max per calander year max per calander year
inpatient respite care: inpatient respite care;
$250/Day for 24 hour
$150/Day for 24 hour
general care
continuous care
Calendar-year copayment maximum
$1,000 individual
$2,000 family
*Waived if admitted directly to the hospital as an inpatient
$1,500 individual
$3,000 family
$2,000 individual
$4,000 family
$1,500 per member
**$50 co pay for urgent care if facility is located out of member's service area
***Access+Specialist (self-referred office visits with in your medical group are availble for higher copay please refer to your plan description.)
All medical plans must have one of the following prescription plans
PRESCRIPTION DRUGS
1
$10-20-35/$20-40-70
Retail 30-days/Mail 90-days
$10-25-40/$20-50-80
$5-10-25/$10-20-50
$150 brand ded
The following benefits may be added to the Blue Shield package for an additional cost
CHIROPRACTIC SERVICES
Co-pays/Visits per year
VISION WEAR PLAN
Frame Allowance
1
$10/30 visits
1
$100
1
Does not apply toward calendar-year copayment maximum
This chart is only a brief summary of benefits. For a complete list of benefits, please refer to the plan document for each plan.
23
Medical Plans and Rates
HEALTH NET - HMO
BENEFIT SUMMARY
PLANS
PROFESSIONAL SERVICES
O1A-ZP
L4A-ZT
158-Y1
Office Visit
Specialists/Consultants
$10 co-pay
$10 co-pay
$15 co-pay
$15 co-pay
$20 co-pay
$20 co-pay
X-ray and Laboratory Procedures
No charge
No charge
No charge
Surgery, Outpatient
No charge
Prenatal, Postnatal Office Visits
$10 co-pay
Normal Delivery, Cesarean Section
No charge
Infertility(diagnosis/treatment of causes of inferti
50%
HOSPITAL AND SKILLED NURSING FACILITY SERVICES
No charge
$15 co-pay
No charge
50%
$250*
$20 co-pay
No charge
50%
$500*
$25 co-pay
No charge
50%
$30 co-pay
$60 co-pay
No charge, unless
complex (CT, MRI,
PET, SPECT,
MUGA), then $200
copay
No charge
professional fees,
20% facility
$30 co-pay
No charge
not covered
Unlimited Days in Semiprivate Room
No charge
$250
$500 per day/up to
4 days max
20%
No charge
90K-WX
$25 co-pay
$25 co-pay
No charge, unless
complex (CT, MRI,
PET, SPECT,
MUGA), then $100
copay
91C-571
No charge
$35 co-pay
(ER&UC)
No charge
$35 co-pay
(ER&UC)
$250
$75 co-pay
(ER&UC)
No charge
No charge
$250
$500 per day/up to
4 days max
$100 copay(ER)/$25 (UC)
No charge (1-10)
$25/day (11-100)
$10 co-pay
$30/20 Visits
$30/20 Visits
$15 Co-pay
$30/20 Visits
$30/20 Visits
$20 Co-pay
$20/20 Visits
$20/20 Visits
$25 Co-pay
$30/20 Visits**
$30/20 Visits**
AB88 Severe Diagnosis
Days per Calendar Year
No charge
Unlimited
No charge
Unlimited
No charge
Unlimited
$500 per day, up to
4 days max
20% per admit
Unlimited
Unlimited
Non AB88 Severe or Substance Abuse
Days per Calendar Year
No charge
30 Days
No charge
30 Days
No charge
30 Days
$500 per day, up to
4 days max
20% per admit**
30 Days**
30 Days
Intensive Care
Emergency Room (ER)/Urgent Care (UC)
Skilled Nursing Facility (100 days/year)
MENTAL HEALTH SERVICES
OUTPATIENT
AB88 Severe Diagnosis
Non AB88 Severe or Substance Abuse
Chemical Dependency/Substance Abuse Rehab
INPATIENT
Chemical Dependency/Substance Abuse
Rehab
OTHER SERVICES
Ambulance/Air Ambulance
Home Health Visits (up to 30 days/after 30
days)
20%
$20 Co-pay
$30/20 Visits**
20% per admit
$500 per day, up to
4 days payable. 30 20% per admit/30
days max**
days
No charge/30 days No charge/30 days No charge/30 days
No charge
No charge/$10 copay
No charge
No charge/$15 copay
No charge
No charge/$20 copay
Durable Medical Equipment
Calendar-year copayment maximum
$100
No charge/$25 copay***
$200
No charge/$30 copay***
No charge/$2000
max applies to
some DME
$2,000 individual
$4,000 two party
$6,000 family
No charge/$2000
max applies to
some DME
$3,500 individual
$7,000 two party
$7,000 family
No charge
No charge
No charge
$1,500 individual
$1,500 individual
$1,500 individual
$3,000 two party
$3,000 two party
$3,000 two party
For each family (3 or more members)
$4,500 family
$4,500 family
$4,500 family
* copayment applies to outpatient surgery at hospital or ambulatory surgical center
** Outpatient visit and inpatient days are combined for non-severe mental illnesses and for chemical dependency.
*** limited to 100 visits each calendar year.
All medical plans must have one of the following prescription plans
PRESCRIPTION DRUGS 1
Retail 30-days/Mail 2 co-pays 90-days
20%
$200 copay(ER)/$30 (UC)
$5/$10/$35
$10/$20/$35
$15/$30/$50
The following benefits may be added to the Health Net package for an additional cost
CHIROPRACTIC SERVICES 1
Co-pays/Visits per year
VISION WEAR PLAN
Frame Allowance
$10/30
1
$100
1
Does not apply toward calendar-year copayment maximum
This chart is only a brief summary of benefits. For a complete list of benefits, please refer to the plan document for each plan.
24
Medical Plans and Rates
KAISER PERMANENTE - HMO
BENEFIT SUMMARY
PLANS
$10 CO-PAY
$20 CO-PAY
$30 CO-PAY
$500 HOSPITAL ONLY
DEDUCTIBLE**
$10 co-pay
$10 co-pay
No charge
$10 co-pay
$10 co-pay
No charge
50%
$20 co-pay
$20 co-pay
No charge
$20 co-pay
$5 co-pay
No charge
50%
$30 co-pay
$30 co-pay
No charge
$30 co-pay
$5 co-pay
No charge
50%
$20 co-pay
$20 co-pay
$10 co-pay
10% per admit/after ded.
$10 co-pay
10% per admit/after ded.
50%
No charge
No charge
$50 co-pay*
No charge
No charge
No charge
$50 co-pay*
No charge
No charge
No charge
$50 co-pay*
No charge
10% per admit/after ded.
10% per admit/after ded.
10% per admit/after ded.
10% coinsurance
$10 co-pay
$20 co-pay
$30 co-pay
$20 co-pay
$10 co-pay
$20 co-pay
$30 co-pay
$20 co-pay
$10 co-pay
$20 co-pay
$30 co-pay
$20 co-pay
No charge
no limit
No charge
up to 30 days
No charge
no limit
No charge
up to 30 days
No charge
no limit
No charge
up to 30 days
10% per admit/after ded.
no limit
10% per admit/after ded.
up to 30 days
No charge
No charge
No charge
10% per admit/after ded.
$50 co-pay
No charge
20% co-pay
$50 co-pay
No charge
20% co-pay
$50 co-pay
No charge
20% co-pay
$150 co-pay
No charge
20% co-pay
$1,500 individual
$3,000 family
$1,500 individual
$3,000 family
$1,500 individual
$3,000 family
$3,000 individual
$6,000 family
PROFESSIONAL SERVICES
Office Visit/Urgent Care
Specialists/Consultants
X-ray and Laboratory Procedures
Surgery, Outpatient
Prenatal, Postnatal Office Visits
Normal delivery, Cesarean Section
Infertility(diagnosis/treatment of causes of infertility)
HOSPITAL AND SKILLED NURSING FACILITY SERVICES
Unlimited Days in Semi-private Room
Intensive Care
Emergency Room
Skilled Nursing Facility (100 days/year)
MENTAL HEALTH
OUTPATIENT
AB88 Severe Diagnosis (not subject to visit limit
Non AB88 Severe or Substance Abuse (up to a
total of 20 individual and group visits per calendar
Chemical Dependency/Substance Abuse
INPATIENT
AB88 Severe Diagnosis (not subject to visit limit
Days per Calendar Year
Non AB88 Severe or Substance Abuse
Days per Calendar Year
Chemical Dependency/Substance Abuse
Detoxification Only
OTHER SERVICES
Ambulance/Air Ambulance
Home Health Visits (100 two-hour visits per calendar year)
Durable Medical Equipment
1
Calendar-year copayment maximum
* Waived if admitted directly to the hospital.
**Deductible applies toward copayment maximum
All medical plans must have a prescription plan co-pay that matches the medical co-pay
PRESCRIPTION DRUG PLANS
1
CO-PAYS/100-DAY SUPPLY
$10 generic/$20
brand for 100 day
supply
$10.00
$10 generic/$30
brand for 100 day
supply
$10 generic/$30 brand
for 30 day supply
The following benefits may be added to the Kaiser health package for an additional cost
VISION PLANS 1
FRAME AND LENSES ALLOWANCE
CHIROPRACTIC PLANS
CO-PAY/VISITS
1
1
OPTION 164
$150
CHIRO 2
$10/30 vis
Does not apply toward calendar-year copayment maximum
This chart is only a brief summary of benefits. For a complete list of benefits, please refer to the plan document for each plan.
25
Medical Plans and Rates
OPTIONAL EMPLOYED SPOUSE/DOMESTIC PARTNER OVERLAY PROGRAM
FOR DISTRICTS WITH COMPOSITE RATES
This is an optional program that provides for 5% lower medical rates without changing the benefit plan. When medical
benefits are offered on a composite basis, meaning the same rate is paid for single employees, employees with one
dependent and employees with two or more dependents, there is very little incentive for the spouse/domestic partner of
district employees to enroll in the medical coverage provided by their own employer. When this happens a significant
portion of health care costs go toward providing benefits to employees’ spouses/domestic partners who could have
enrolled in coverage through their own employers. Subsidizing those employers reduces the amount of resources
available to put towards benefits for your own employees and their spouses/domestic partners who do not have access
to other employer based coverage.
Given the above as background, SISC has developed a program that can be added to most of the SISC PPO products.
The Employed Spouse/Domestic Partner Program is designed to strongly encourage the spouses/domestic partners of
our district’s employees to enroll in the coverage provided by their own employers if they are eligible. If they do not, he
or she is not eligible to be covered as a dependent under the SISC PPO plan.
Important points concerning the program are as follows:
• This is a negotiated benefit.
•
The district must have composite rates for the active employees – not a 3-tier rate structure.
•
Employee participation must be consistent with the SISC Underwriting Guidelines. A part-time employee of the
district may decline benefits if they are an eligible dependent of their spouse who is also employed at the same
district.
•
Although the medical benefits will not change, SISC will reduce the district’s PPO premium 5 percent.
•
The SISC PPO will continue to provide benefits for the spouses/domestic partners of district employees that do
not work outside the home or are not eligible for benefits where they work. It will also continue to provide
coverage for eligible dependent children and retirees.
•
Secondary coverage will be provided for spouses/domestic partners who are covered for medical benefits
through their employers.
•
The employee’s spouse/domestic partner cannot purchase an individual plan in lieu of his/her employer’s group
plan.
•
According to HIPAA, the employee’s spouse/domestic partner may enroll in their company’s medical coverage
outside of open enrollment due to loss of eligibility under their current (spouses) plan. Therefore, the
employee’s spouse/domestic partner must enroll in their employer’s plan upon commencement of the program.
The employer will require a Certificate of Coverage or evidence of loss of coverage elsewhere.
•
If your spouse/domestic partner is not currently eligible for medical benefits where he or she works, but
becomes eligible at a later date, he or she must enroll in the employer Plan and notify the district office. The
SISC PPO Plan then changes from Primary Carrier to Secondary Carrier.
•
If the Spouse/Domestic Partner is enrolled in an HMO Plan, the claim must be processed first by the HMO.
Once the claim is processed, the member will receive an Explanation of Benefits indicating payment or nonpayment of the claim. The member must then send a copy of the HMO Explanation of Benefits to the
Secondary Carrier, SISC, for processing.
•
What happens if an employee does not comply?
¾
The employee is in violation of the contract. The district will submit paperwork to SISC to terminate the
spouse/domestic partner’s coverage retroactively. SISC will then recover paid claims.
If your district is interested in participating in this program, please contact your SISC Account Manager at (661) 636-4410.
26
Medical Plans and Rates
Prescription Drug Plans
¾ Medco
MEDCO PRESCRIPTION DRUG INFORMATION
Rising Costs & Proper Use of Generics
Drug spending continues to rise rapidly. One of the major causes of this increased spending is the introduction of new
brand name medications that cost significantly more than established alternatives. Also, as very profitable brand name
drugs are scheduled to go off patent, manufacturers often develop new drugs to replace them and the profits they
generate. These new drugs typically provide a limited difference in effectiveness to the drug going off patent. These
new medications are heavily marketed to both doctors and consumers. Generic medications are, simply stated, former
brand name drugs that have gone off patent. Because they are off patent they are available at much lower costs than
brand name products. Our plans feature co-pay structures that recognize the significantly lower cost of generic
medications and pass the savings associated with using them along to our members.
Deductible Plans (on Brand Name Drugs Only)
These plans should be considered if sufficient savings cannot be achieved with co-pays alone. While raising co-pays is
always an option, there comes a point where utilization of necessary medications will be affected because members
cannot afford the co-pays. For example, increasing the brand co-pay $5 creates and additional $360 annual out of
pocket cost for a member using six brand prescriptions per month. ($5 x 6 x 12 months) Adding a $100 or $200
deductible instead of raising the co-pay can maintain adequate overall member cost share while keeping the cost of the
individual prescription affordable. Deductibles also help make members aware of the actual cost of prescription drugs
because they pay full price of the initial prescriptions.
Medco By Mail Pharmacy Service
All Medco cardholders may use the Medco By Mail Pharmacy Service for their maintenance medications. The member
may purchase a 90-day supply of maintenance medications and have them delivered directly to their home (or alternate
address) by paying the co-pays listed on the next page. Everything a member needs to place an order should be
available at the district office or by calling Medco directly. Please note: Not all prescriptions can be filled by mail order.
Generic Substitution
All plans have automatic generic substitution. If a brand name medication has a generic available, the pharmacy or mail
order facility will automatically fill the prescription with a generic when the brand name is not medically necessary. If the
physician or member requests to have a brand name medication dispensed when it is not medically necessary, the
member will pay the difference in the cost of the brand and generic medication plus the generic co-pay. There is a
Clinical Review Process through which it is possible to have a determination made as to whether or not a brand name
drug is medically necessary. The member's physician may contact Medco to initiate the review process. If approved as
medically necessary, the member will pay the brand co-pay.
Current book plans do not cover products under the following categories:
Pigmenting and Depigmenting Products
Fertility Products
Smoking Cessation Products
Anti Flu Products
Multivitamins and Minerals
Anti Wrinkle Products
27
Prescription Drug Card Plans
Medco Prescription Drug Plans
2009-2010
2-Tier Plans
5-10
PLANS
Retail
Consumer Share Plan
3-15
Mail
Retail
Mail
5-20
Retail
Mail
7-25
Retail
PLAN
Mail
CO-PAYS
5-15-35
Retail
Mail
CO-PAYS
Generic
$5
$10
$3
$3
$5
$10
$7
$14
Tier 1
$5
$10
Brand
$10
$20
$15
$35
$20
$50
$25
$60
Tier 2
$15
$35
Tier 3
$35
$80
Days Supply
30
90
Days Supply
30
90
30
90
30
90
30
90
Deductible Plans (on Brand Name Drugs Only)
2-Tier Plans
PLANS
3-15
*$100/$300
10-35
*$200/$500
Retail
Retail
Mail
Mail
BRAND DEDUCTIBLES
Individual
$100
$200
Family
$300
$500
CO-PAYS
Generic
$3
$3
$10
$25
Brand
$15
$35
$35
$90
Days Supply
30
90
30
90
*Deductible is per individual up to family maximum. Unlike the medical PPO plans, Medco Rx plans with a deductible
do not have a last quarter carryover. The deductible renews on January 1 of each calendar year.
Costco $0 Co-Pay Program for Generic Drugs
This program is available to SISC members on participating drug plans . To take advantage of the $0 co-pay for
generic drugs you need to do the following: 1) Take your prescription for a generic medication to a Costco Pharmacy,
2) Present the pharmacist with your insurance card, 3) Get your generic medication with a $0 co-pay (excluding some
narcotic pain medications and some cough medications ). Due to Medicare Part D restrictions, this program does not
apply to the CompanionCare pharmacy benefit.
Generic Co-Pays for Diabetic Supplies
SISC recognizes that diabetic patients use several different diabetic supplies each month. These diabetic supplies are
only available as brand prescriptions and not generic. Therefore, SISC has designed our pharmacy plans to charge
the generic co-payment on these brand only supplies (lancets, test strips and syringes) to help reduce the members
monthly cost.
Prilosec OTC $0 Co-Pay
Prilosec OTC is now available to you through your SISC prescription drug plan with NO co-payment. If you are taking
a prescription PPI (either brand name or generic) and want to take advantage of this program, you will need to talk
with your doctor about switching to Prilosec OTC. If you are already taking Prilosec, you will still need a new
prescription for Prilosec OTC in order to receive this medication at no cost to you through this program. Due to
Medicare Part D restrictions, this program does not apply to the CompanionCare pharmacy benefit.
28
Prescription Drug Card Plans
Behavioral Health Plans
¾
Behavioral Health Program 2000
¾
PacifiCare Behavioral Health
BEHAVIORAL HEALTH PROGRAM - BHP 2000
Employee Assistance Program (EAP)
The Anthem Blue Cross of California Behavioral Health Program provides two components to the plan. The two
components are Behavioral Health and EAP (Employee Assistance Program). Please refer to BHP 2000
Behavioral Health Benefit Summary for behavioral health benefits.
This description addresses the EAP
component of the benefit.
EAP encourages employees to use services early in the progression of a problem before situations significantly
impact work. This is accomplished by promoting service for “normal problems in living” such as:
•
•
•
•
•
Relationships
Stress
Legal & Financial Problems
Career Concerns
Anxiety & Depression
The EAP also serves more serious concerns such as alcohol and drug problems, family violence and threats of
suicide. EAP services are provided at no cost to the employee and/or household members.
Anthem Blue Cross has contracted with licensed mental health professionals to provide employee assistance
services. Appointments are available upon referral by calling the telephone number listed below. If the problem
originally addressed requires more lengthy or specialized treatment than the EAP is intended to provide, the EAP
will refer the employee and/or household member to a resource in the community or to a BHP Provider. This type
of referral will access the Behavioral Health component of the plan.
EAP services may be obtained by calling the 24-hour toll-free number listed below:
1-800-999-7222
Features of the EAP include:
•
•
•
•
•
•
•
•
Evening hours, which reduce time off the job.
Emergencies handled by staff members available by phone 24 hours a day on a toll-free basis.
Every effort is made to see clients within 48 hours.
Appointments are scheduled at employee’s convenience.
People in crisis are provided same-day service.
Management Consultations – consultations on how to deal with employee personal problems as they may
impact job performance.
Critical Incident Debriefings – for employees impacted by incidents such as accidents involving injury or
death, armed robberies, hostage situations and natural disasters.
Reduction in Force (RIF) - program is available to Managers who want to consult on a difficult layoff or in
general get information on dealing with survivor issues.
The employee and all members of the employee’s household are entitled to up to six evaluation and counseling
sessions per course of treatment with an EAP provider.
29
Behavioral Health Plans
BEHAVIORAL HEALTH PROGRAM 2000
BENEFIT SUMMARY
Covered Services
Authorization Process
With
Authorization
In-Network
With
Authorization
Out-of-Network
Without
Authorization
In or Out-of-Network
Members must call (800) 999-7222 for authorization prior to accessing services in
order to receive maximum benefits.
Counseling for Support & Encouragement
(Per household member)
● Personal Related Stress & Parenting
Issues, Crisis Intervention, etc.
100%: 1-6 visits/member
No Benefits
No Benefits
per course of treatment
Psychiatric and Chemical Dependency
(Per eligible member insured under subscriber)
● Outpatient Professional Services for
Psychotherapy and Psychological Testing
100%: 1-6 visits/year,
50% up to $50/visit
50% up to $25/visit
50% up to $50/visit
50% up to $25/visit
then visits 7+ member
pays $15/visit
● Inpatient Professional Services for
Psychotherapy and Psychological Testing
100%
(med. necessity applies)
● Outpatient Day Treatment Center or
Intensive Structured Outpatient Services
100%
(med. necessity applies)
70% of Covered Expense;
50% of Covered Expense;
plus charges in excess of
plus charges in excess of
60/day calendar year
60/day calendar year
maximum***
maximum***
50% of Covered Expense;
50% of Covered Expense;
Psychiatric
100%
● Inpatient Psychiatric Facility or
Residential Center
after $450 deductible
after $700 deductible
per admission
per admission
70% of Covered Expense;
70% of Covered Expense;
Chemical Dependency
100%
● Inpatient Detoxification &
Rehabilitation* (Acute hospital
after $450 deductible
after $700 deductible
or residential center)
per admission
per admission
50% of Covered Expense;
50% of Covered Expense;
● Inpatient Detoxification Only
100%
after $450 deductible
after $700 deductible
per admission**
per admission**
Please note: the EAP and behavioral health networks are not available outside the state of California. Benefits may still be available subject to
pre-authorization.
*
Maximum 1 treatment/year; 2 treatments/lifetime
**
Maximum 5 days/admission; 28 days between admissions. This only applies to out-of-network providers (with or without authorization)
*** The 60 day calendar year maximum underlined above applies to in-network providers (without authorization) and out-of-network providers (with or without authorization)
Emergency Admissions as defined by the plan: If you notify BHP within 24 hours of emergency treatment, 100% inpatient coverage is applied
to non-participating treatment programs and admissions to an out-of-area facility which is certified as necessary and appropriate by BHP.
Admittance to a participating facility will be arranged as soon as such a transfer is in the best interest of the patient. Out of State Programs are
subject to Anthem Blue Cross medical necessity criteria. Please be sure to contact BHP at 800-399-2421 prior to accessing these services.
Unlike the medical PPO plans, behavioral health plans with a deductible do not have a last quarter carryover. The deductible renews on January
1 of each calendar year.
Behavioral Health Plans
30
PACIFICARE BEHAVIORAL HEALTH
(A United Health Group Company)
Employee Assistance Program (EAP)
The PacifiCare Behavioral Health Program provides two components to the plan. The two components are
Behavioral Health and EAP (Employee Assistance Program). Please refer to PacifiCare Behavioral Health
Benefit Summary for behavioral health benefits. This description addresses the EAP component of the benefit.
EAP encourages employees to use services early in the progression of a problem before situations significantly
impact work. This is accomplished by promoting service for “normal problems in living” such as:
•
•
•
•
•
Relationships
Stress
Legal and Financial Problems
Career Concerns
Anxiety and Depression
The EAP also serves more serious concerns such as alcohol and drug problems, family violence and threats of
suicide. EAP services are provided at no cost to the employee and/or household members.
Appointments are available upon referral by calling the telephone number listed below. If the problem originally
addressed requires more lengthy or specialized treatment than the EAP is intended to provide, the EAP will refer
the employee and/or household member to a resource in the community or to a PacifiCare Behavioral Health
Provider. This type of referral will access the Behavioral Health component of the plan.
EAP services may be obtained by calling the 24-hour toll-free number listed below:
1-800-999-9585
Features of the EAP include:
•
•
•
•
•
•
•
•
Evening hours, which reduce time off the job.
Emergencies handled by staff members available by phone 24 hours a day on a toll-free basis.
Every effort is made to see clients within 48 hours.
Appointments are scheduled at employee’s convenience.
People in crisis are provided same-day service.
Management Consultations – consultations on how to deal with employee personal problems as they may
impact job performance.
Critical Incident Debriefings – for employees impacted by incidents such as accidents involving injury or
death, armed robberies, hostage situations and natural disasters.
Reduction in Force (RIF) – telephonic management consultation, training workshops, manager/supervisor
coaching.
The employee and all members of the employee’s household are entitled to up to six evaluation and counseling
sessions per course of treatment with an EAP provider.
31
Behavioral Health Plans
PACIFICARE BEHAVIORAL HEALTH (PCBH)
BENEFIT SUMMARY
Covered Services
Authorization Process
Counseling for Support & Encouragement
(Per household member)
• Personal Related Stress & Parenting
Issues, Crisis Intervention, etc.
Psychiatric and Chemical Dependency
(Per eligible member insured under subscriber)
• Outpatient Professional Services for
Psychotherapy and Psychological Testing
Without
With
With
Authorization
Authorization
Authorization
In-Network
Out-of-Network
In or Out-of-Network
Members must call (800) 999-9585 to receive services. Services not
authorized in advance are not a covered in-netowrk benefit.
100%: 1-6 visits/membe
per course of treatment
No Benefits
No Benefits
Visits 1-6: 100%
$100 deductible
$100 deductible
Visits 7-20: $15 co-pay
50% of Usual &
50% of Usual &
Customary Rates or up Customary Rates or up
Visits 21-50: $30 coto $40/visit
to $40/visit
50 visits max outpatient
• Inpatient Professional Services for
Psychotherapy and Psychological Testing
100%
No Benefits
No Benefits
• Outpatient Day Treatment Center or
Intensive Structured Outpatient Services
100%
No Benefits
No Benefits
100%
Max 30 days combined
Mental Health and
chemical dependency
No Benefits
No Benefits
100%
Max 30 days combined
Mental Health and
chemical dependency
No Benefits
No Benefits
100%
Max 30 days combined
Mental Health and
chemical dependency
No Benefits
No Benefits
Psychiatric
• Inpatient Psychiatric Facility or
Residential Center
Chemical Dependency
• Inpatient Detoxification &
Rehabilitation (Acute hospital
or residential center)
• Inpatient Detoxification Only
• Assessment and referral benefit provides up to 6 visits per incident for all household members. This benefit offers resources for
child or elder care issues, financial or legal issues, as well as stress, difficulties with children, divorce, alcohol, drugs, job worries,
family matters and marital problems. Telephonic coaching is available by calling 800-999-9585. The telephonic coaching is not
therapy and does not replace visits with a provider.
•One chemical dependency treatment program per calendar year. Three treatment programs per lifetime.
Maximum Benefits:
• Outpatient mental health benefits limited to 50 visits per calendar year, combined in-network and out-of-network.
• Outpatient day treatment is considered an inpatient benefit. It is calculated at 60% of one inpatient day, or the equivalent of 50
days of treatment at an outpatient day treatment facility. Benefits are cumulative. Time spent at an outpatient day treatment
program accumulate under the inpatient benefit.
Emergency Admissions:
All emergency admissions certified as medically necessary by PacifiCare Behavioral Health will be considered in-network benefits.
PacifiCare Behavioral Health must be notified within 24 hours of emergency admissions or as soon as reasonably possible. If
facility is not a PacifiCare Behavioral Health contracted facility, admittance to a contracting facility will be arranged as soon as it is in
the best interest of the patient. In-Network Benefits: All In-Network benefits require pre-authorizations which are based on medical
necessity and providers and/or facilites must be contracted with PBH in the state of California.
Unlike the medical PPO plans, behavioral health plans with a deductible do not have a last quarter carryover. The deductible renews
on January 1 of each calendar year.
32
Behavioral Health Plans
Dental Plans & Rates
¾ Delta Dental
DELTA DENTAL PREMIER INCENTIVE PLANS
Benefit Summary and 2009-10 Monthly Rates
SERVICES
IN-NETWORK
OUT-OF-NETWORK
PROVIDER NETWORK
PPO Dentists
Premier Network Dentists
Non-Delta Dentists
DIAGNOSTIC &
PREVENTATIVE
70% 1st Year
70% 1st Year
70% UCR 1st Year
Exams, X-rays, Cleanings
80% 2nd Year
80% 2nd Year
80% UCR 2nd Year
& Emergency Treatment
90% 3rd Year
90% 3rd Year
90% UCR 3rd Year
100% 4th Year and After
100% 4th Year and After
100% UCR 4th Year and After
OTHER BASIC SERVICES
70% 1st Year
70% 1st Year
70% UCR 1st Year
Oral Surgery, Fillings,
80% 2nd Year
80% 2nd Year
80% UCR 2nd Year
Periodontic Procedures,
90% 3rd Year
90% 3rd Year
90% UCR 3rd Year
Root Canals & Sealants
100% 4th Year and After
100% 4th Year and After
100% UCR 4th Year and After
CROWNS
70% 1st Year
70% 1st Year
70% UCR 1st Year
Crowns, Jackets & Cast
80% 2nd Year
80% 2nd Year
80% UCR 2nd Year
Restorations
90% 3rd Year
90% 3rd Year
90% UCR 3rd Year
100% 4th Year and After
100% 4th Year and After
100% UCR 4th Year and After
50%
50%
50% UCR
When using a PPO contracted dentist,
the annual maximum will be increased
by $200.
When using a Delta Premier contracted
dentist, Delta will pay up to the Annual
Maximum elected by the district or
bargaining unit.
When using a non-Delta Dentist, Delta
will pay Usual, Customary and
Reasonable up to the Annual Maximum
elected by the district or bargaining unit.
PROSTHODONTICS
Dentures, Bridges, and Implants1
ANNUAL PLAN
MAXIMUM:
$1,000
$1,500
$2,000
Unlimited*
RATES FOR ACTIVE EMPLOYEES ONLY:
Single
$45.00
$54.00
$60.00
$66.00
Two-Party
$93.00
$111.00
$124.00
$136.00
Family
$128.00
$153.00
$170.00
$187.00
Composite
$89.00
$108.00
$120.00
$131.00
RATES FOR ALL RETIREES:
Single
$56.00
$68.00
$75.00
$82.00
Two-Party
$112.00
$136.00
$150.00
$164.00
Family
$147.00
$179.00
$197.00
$216.00
All SISC Incentive Plans were enhanced to inlcude a PPO advantage. As a result, when the member or dentist accesses benefit
information from Delta Dental the subscriber will show active on a PPO plan. This does not mean that their benefits are being reduced in
any way. The title of the plan has been changed to include the PPO indicator for network purposes.
1
Dental Implants - Plan pays 50% up to the annual maximum. Unlimited dental benefit has an annual $2,000 benefit maximum for
dental implants.
*If the plan has an Unlimited annual maximum, members will receive 60% coverage for Prosthodontics when using a PPO dentist.
Locate a provider at: www.deltadentalins.com
33
Dental Plans and Rates
DELTA DENTAL PPO PLANS
Benefit Summary and 2009-10 Monthly Rates
(Formerly known as Delta Preferred Option)
SERVICES
IN-NETWORK
OUT-OF-NETWORK
PROVIDER NETWORK
PPO Dentists
Premier Network Dentists
Non-Delta Dentists
ANNUAL DEDUCTIBLE
No deductible
$25 per member/$75 per family
$25 per member/$75 per
family
ANNUAL MAXIMUM
Plan maximum selected by
district
Limited to $1,000
regardless of plan maximum
BASIS OF PAYMENT
Participating Fee Allowance
Usual, Customary and Reasonable
100%
50%
50%
100%
50%
50%
100%
50%
50%
50%
50%
50%
Limited to $1,000
regardless of plan maximum
Usual, Customary and
Reasonable
DIAGNOSTIC &
PREVENTATIVE
Exams, X-rays, Cleanings
& Emergency Treatment
OTHER BASIC SERVICES
Oral Surgery, Fillings,
Periodontic Procedures,
Root Canals & Sealants
CROWNS
Crowns, Jackets & Cast
Restorations
PROSTHODONTICS
Dentures, Bridges, and Implants1
ANNUAL PLAN
MAXIMUM:
$1,500
$2,000
$3,000
Unlimited
RATES FOR ACTIVE EMPLOYEES ONLY:
Single
$36.00
$39.00
$41.00
$44.00
Two-Party
$74.00
$80.00
$84.00
$91.00
Family
$102.00
$111.00
$116.00
$125.00
Composite
$72.00
$77.00
$81.00
$88.00
Single
$45.00
$48.00
$51.00
$55.00
Two-Party
$90.00
$96.00
$102.00
$110.00
Family
$118.00
$126.00
$134.00
$145.00
RATES FOR ALL RETIREES:
.
The PPO Plan can be offered as a dual choice with one of the traditional Delta Incentive Plans.
.
Members may change from the PPO to the PPO Incentive Plan during open enrollment.
If they make this change, their incentive level will start at 70% for the employee and all dependents.
.
PPO subscribers can use any Delta Specialist (i.e. orthodontist, periodontist, endodontist, oral surgeon).
1
Dental Implants - Plan pays 50% up to annual maximum. The Unlimited dental benefit has an annual $2,000 benefit maximum
for dental implants.
Locate a provider at: www.deltadentalins.com
34
Dental Plans and Rates
NON-VOLUNTARY ORTHODONTIC
FOR ALL DELTA DENTAL PLANS
100% District-Paid Participation
2009-10 Monthly Rates
50/50 Co-Pay
*MAXIMUM:
$500
$1000
$1500
75/25 Co-pay
$2000
$750
$1500
100% Paid
$2250
$1000
$2000
$3000
COVERAGE FOR DEPENDENT CHILDREN ONLY:
Single
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Two-Party
$0.40
$0.80
$1.00
$1.30
$0.60
$1.20
$1.70
$0.80
$1.70
$2.50
Family
$3.90
$7.50
$10.60
$12.90
$6.00
$11.90
$17.20
$8.30
$17.00
$25.00
Composite
$3.40
$6.70
$9.60
$11.70
$5.30
$10.70
$15.50
$7.50
$15.30
$22.60
COVERAGE FOR ADULTS AND DEPENDENT CHILDREN:
Single
$0.40
$0.70
$0.90
$1.20
$0.60
$1.10
$1.50
$0.80
$1.50
$2.20
Two-Party
$1.00
$2.00
$2.80
$3.40
$1.60
$3.10
$4.50
$2.20
$4.40
$6.50
Family
$4.50
$8.70
$12.50
$15.20
$7.00
$14.00
$20.20
$9.80
$19.90
$29.30
Composite
$4.10
$7.90
$11.40
$13.80
$6.40
$12.80
$18.40
$8.90
$18.10
$26.70
3RD CLEANING:
Single
$1.30
Two-Party
$2.60
Family
$3.90
Composite
$2.60
*Lifetime Maximum per covered individual.
Orthodontia coverage is only offered as an Active employee benefit.
35
Dental Plans and Rates
Vision Plans & Rates
¾
Medical Eye Services (MES)
¾
Vision Service Plan (VSP)
MEDICAL EYE SERVICES (MES)
BENEFIT SUMMARY
SERVICES
BENEFITS
Eligibility
Spouse and unmarried, dependent children to age 25.
Benefit Renew
January 1 of each year or every two years depending on the plan chosen
by the district.
Oversize Lenses
Covered in full up to 61mm.
As a MES member, you are entitled to a 15% discount through any one of
the TLC Laser Eye Centers in the Nation. For more information on Lasik,
the providers and discounts contact TLCVision at 877-PLAN-TLC (877-7526852) or visit their web site at www.tlcvision.com.
Laser Vision Care (Lasik)
Sunglasses and Tinted Lenses
Standard (solid) tints covered under all plans.
Photosensitive Lenses
Covered under Plan C only.
Elective Contact Lenses
$105 Cosmetic Contact Lens allowance. Covers daily, weekly, monthly,
disposable, hard or soft contact lenses.
(In Lieu of Frames & Lenses)
Medically Necessary Contact Lenses Covered in full through participating providers.
Warranty
No specific warranty it varies at each location. Patient complaints are
handled quickly and resolved through the formal appeals & grievance
process.
Choice of Frames
Approximately 87% of the frames available statewide are covered in full.
Coverage up to $130 retail through Participating Providers.
Choice of Providers
Largest vision network in California. Panel includes 5,400
Ophthalmologists, Optometrists and Opticians, including Lenscrafters,
Sears Optical, Target Optical, WalMart Vision Center and Sam's Club just
to name a few.
PATIENT OPTIONS
Patients who choose to purchase options (above the vision plan coverage) may do so with a 20% discount at certain
provider locations. Patients should check The Eye Care Network (ECN) Discount Vision Program. Examples of
discounted options that patients may choose include:
Progressive Lenses (such as no-line or blended type)
Contact Lenses & contact lens fitting (other than noted below)
Custom Tinted Lenses (other than noted above)
Frame amount exceeding retail cost of $130
Oversize Lenses (61mm or greater)
Laminating of Lenses
Scratch Coating
Ultra Violet Coating
Additional pairs of glasses
The discount does not apply to lost or replacement contact lenses, eyewear repairs, medical or surgical treatment of
the eyes (covered under your medical plan) and promotional offers.
PLAN
A
B
C
EXAMINATION
every calendar year
every calendar year
every calendar year
LENSES
every two calendar years*
every calendar year
every calendar year
FRAMES
every two calendar years
every two calendar years
every calendar year
*Plan A provides lenses every 24 months, with new lenses available at a 12 month interval if there is a change in
prescription.
Medical Eye Services plans cannot be offered as a dual-choice with Vision Service Plans.
Vision Plans and Rates
36
MEDICAL EYE SERVICES (MES)
Active Employees Only
2009-10 Monthly Rates
Exam & Materials Co-pay
$5
$0
$10
$15
$20
PLAN A (Exam every 12 months, Lenses & Frames every 24 months)
Single
$5.70
$5.10
$4.80
$4.50
$4.00
Two-Party
$11.40
$10.20
$9.60
$9.00
$8.00
Family
$17.10
$15.30
$14.40
$13.50
$12.00
Composite
$12.60
$11.30
$10.60
$10.00
$8.80
PLAN B (Exam & Lenses every 12 months, Frames every 24 months)
$6.40
$5.90
$5.60
$5.20
$5.00
Two-Party
Single
$12.80
$11.80
$11.20
$10.40
$10.00
Family
$19.20
$17.70
$16.80
$15.60
$15.00
Composite
$14.10
$13.20
$12.50
$11.50
$11.00
$8.20
$7.80
$7.40
$7.10
$6.60
Two-Party
$16.40
$15.60
$14.80
$14.20
$13.20
Family
$24.60
$23.40
$22.20
$21.30
$19.80
Composite
$18.30
$17.40
$16.40
$15.80
$14.60
PLAN C (Exam, Lenses and Frames every 12 months)
Single
*Plan A provides lenses every 24 months, with new lenses available at a 12-month interval if there is a change in prescription.
All Retirees - Under and Over Age 65
Exam & Materials Co-pay
$5
$0
$10
$15
$20
PLAN A (Exam every 12 months, Lenses & Frames every 24 months)
Single
$7.10
$6.30
$6.00
$5.60
$4.90
Two-Party
$14.20
$12.60
$12.00
$11.20
$9.80
Family
$21.30
$18.90
$18.00
$16.80
$14.70
$7.90
$7.40
$7.00
$6.50
$6.20
Two-Party
$15.80
$14.80
$14.00
$13.00
$12.40
Family
$23.70
$22.20
$21.00
$19.50
$18.60
PLAN B (Exam & Lenses every 12 months, Frames every 24 months)
Single
PLAN C (Exam, Lenses and Frames every 12 months)
Single
$10.30
$9.80
$9.20
$8.90
$8.20
Two-Party
$20.60
$19.60
$18.40
$17.80
$16.40
Family
$30.90
$29.40
$27.60
$26.70
$24.60
*Plan A provides lenses every 24 months, with new lenses available at a 12-month interval if there is a change in prescription.
37
Vision Plans and Rates
VISION SERVICE PLAN (VSP)
BENEFIT SUMMARY
SERVICES
BENEFITS
Eligibility
Spouse and unmarried, dependent children/students to age 25.
Benefits Renew
January 1 of each year or every other year depending on the plan.
Oversize Lenses
Covered in full up to 61mm.
Laser Vision Care (Lasik)
Benefits provided at a discounted fee through VSP approved center. Visit
www.vsp.com or contact VSP's Customer Service for additional information.
Note: Your health plan does not provide benefits for eye surgery solely for the
purpose of correcting refractive defects of the eye.
(In Lieu of Frames & Lenses)
$105 paid towards the cost of evaluation, fitting and lenses when member
doctor is used. New and current contact wearer's may be eligible for a covered
in full contact program (contact a VSP provider or VSP's customer service
department for details).
Medically Necessary Contact Lenses
Covered in full with prior authorization.
Elective Contact Lenses
Warranty
No specified warranty. If the member is unsatisfied with the services rendered,
please contact VSP's Customer Service Department at 1-800-877-7195.
Choice of Frames
You will receive a $130 allowance toward any frame of your choice plus 20%
off any amount over the allowance.
Large network of independently contracted providers. Member may go outside
network and still receive limited benefits.
Choice of Providers
Value Added Discounts
30% off unlimited additional pairs of prescription glasses and/or nonprescription sunglasses (same day as the members eye exam and from the
same doctor). Or get 20% off unlimited additional pairs of glasses 12 months
from the covered eye exam with any VSP doctor.
PATIENT OPTIONS
Patients who choose to purchase options may do so with a 30 - 40% savings (savings will vary depending on the lens
option chosen). The patient should check with a VSP participating doctor to verify whether items are covered or are
considered options. Examples of options patients may choose include:
Progressive Bifocals
Blended (seamless) Bifocals
Contact Lenses (except as noted)
Oversize Lenses (61mm or greater)
Tinted Lenses
Fashion and Gradient Tinting
Scratch Coating
Laminating of Lenses
A frame that costs more than the plan allowance
Cosmetic Lenses
Ultra Violet Coating
These cosmetic options are not covered in full by VSP; however, due to our agreements with VSP participating doctors and
laboratories, these services are provided at a controlled cost, available only to VSP subscribers.
PLAN
EXAMINATION
LENSES
FRAMES
A
every calendar year
every other calendar year
every other calendar year
B
every calendar year
every calendar year
every other calendar year
Plan A and B cover tinted pink #1 and #2 only. Basic benefits are the same on Plan A and B with the exception of
frequency on lenses.
C
every calendar year
every calendar year
every calendar year
Plan C covers all tints and photochromic lenses.
Vision Service Plans cannot be offered as a dual-choice with Medical Eye Services.
38
Vision Plans and Rates
VISION SERVICE PLAN (VSP)
Active Employees Only
2009-10 Monthly Rates
SINGLE CO-PAY PLANS *
Exam & Materials Co-pay
$5
$0
$10
$15
$20
PLAN A (Exam every 12 months, Lenses & Frames every 24 months)
Single
Two-Party
Family
Composite
$8.50
$17.00
$25.50
$18.80
$7.60
$15.20
$22.80
$16.90
$7.10
$14.20
$21.30
$15.80
$6.70
$13.40
$20.10
$14.90
$5.90
$11.80
$17.70
$13.10
$8.90
$17.80
$26.70
$19.70
$8.40
$16.80
$25.20
$18.60
$7.70
$15.40
$23.10
$17.20
$7.40
$14.80
$22.20
$16.40
$11.70
$23.40
$35.10
$26.00
$10.90
$21.80
$32.70
$24.30
$10.40
$20.80
$31.20
$23.00
$9.80
$19.60
$29.40
$21.80
$10
$25
$15
$25
$20
$25
$5.50
$11.00
$16.50
$12.20
$5.20
$10.40
$15.60
$11.60
$4.40
$8.80
$13.20
$9.70
$6.80
$13.60
$20.40
$15.10
$6.70
$13.40
$20.10
$14.80
$6.30
$12.60
$18.90
$14.00
$5.90
$11.80
$17.70
$13.00
Single
$10.20
$9.60
Two-Party
$20.40
$19.20
Family
$30.60
$28.80
Composite
$22.70
$21.30
* Your benefit and co-payment amount renews on January 1.
$8.80
$17.60
$26.40
$19.60
$8.10
$16.20
$24.30
$17.90
$7.90
$15.80
$23.70
$17.60
PLAN B (Exam & Lenses every 12 months, Frames every 24 months)
Single
Two-Party
Family
Composite
$9.50
$19.00
$28.50
$21.10
PLAN C (Exam, Lenses and Frames every 12 months)
Single
Two-Party
Family
Composite
$12.30
$24.60
$36.90
$27.40
DUAL CO-PAY PLANS *
Exam co-pay
Materials co-pay
$0
$25
$5
$25
PLAN A (Exam every 12 months, Lenses & Frames every 24 months)
Single
Two-Party
Family
Composite
$6.40
$12.80
$19.20
$14.20
$5.90
$11.80
$17.70
$13.20
PLAN B (Exam & Lenses every 12 months, Frames every 24 months)
Single
Two-Party
Family
Composite
$7.60
$15.20
$22.80
$16.90
PLAN C (Exam, Lenses and Frames every 12 months)
SUPPLEMENTAL BENEFITS
Single
Two-Party
Family
Composite
Elective Contact Lenses
$50 Deductible
$3.50
$7.00
$10.50
$7.70
2nd Pair of Glasses
$20 Deductible
$1.60
$3.20
$4.80
$3.50
39
Vision Plans and Rates
VISION SERVICE PLAN (VSP)
All Retirees - Under and Over Age 65
2009-10 Monthly Rates
SINGLE CO-PAY PLANS *
Exam & Materials Co-pay
$5
$0
$10
$15
$20
PLAN A (Exam every 12 months, Lenses & Frames every 24 months)
Single
$10.60
$9.50
$8.90
$8.40
$7.40
Two-Party
$21.20
$19.00
$17.80
$16.80
$14.80
Family
$31.80
$28.50
$26.70
$25.20
$22.20
$10.40
$9.70
$9.20
PLAN B (Exam & Lenses every 12 months, Frames every 24 months)
Single
$11.90
$11.10
Two-Party
$23.80
$22.20
$20.80
$19.40
$18.40
Family
$35.70
$33.30
$31.20
$29.10
$27.60
PLAN C (Exam, Lenses and Frames every 12 months)
Single
$15.40
$14.60
$13.70
$12.90
$12.20
Two-Party
$30.80
$29.20
$27.40
$25.80
$24.40
Family
$46.20
$43.80
$41.10
$38.70
$36.60
$10
$25
$15
$25
$20
$25
$6.90
$6.50
$5.40
DUAL CO-PAY PLANS*
Exam co-pay
Materials co-pay
$0
$25
$5
$25
PLAN A (Exam every 12 months, Lenses & Frames every 24 months)
Single
$8.00
$7.40
Two-Party
$16.00
$14.80
$13.80
$13.00
$10.80
Family
$24.00
$22.20
$20.70
$19.50
$16.20
PLAN B (Exam & Lenses every 12 months, Frames every 24 months)
$9.50
$8.50
$8.30
$7.90
$7.30
Two-Party
Single
$19.00
$17.00
$16.60
$15.80
$14.60
Family
$28.50
$25.50
$24.90
$23.70
$21.90
PLAN C (Exam, Lenses and Frames every 12 months)
Single
$12.80
$12.00
$11.00
$10.10
$9.90
Two-Party
$25.60
$24.00
$22.00
$20.20
$19.80
Family
$38.40
$36.00
$33.00
$30.30
$29.70
*Your benefit and co-payment amount renews on January 1.
SUPPLEMENTAL BENEFITS
Elective Contact Lenses
2nd Pair of Glasses
$50 Deductible
$20 Deductible
Single
$4.30
Two-Party
$8.60
$4.00
$12.90
$6.00
Family
40
$2.00
Vision Plans and Rates
Group Life Insurance
Plans & Rates
¾ Mutual of Omaha
Mutual of Omaha
GROUP LIFE INSURANCE PROGRAM
BASIC GROUP LIFE COVERAGE (NON-VOLUNTARY, 100% PARTICIPATION)
The Basic Life coverage provides level term Group Life insurance, with Accidental Death and Dismemberment (AD&D) benefits.
Coverage is purchased in increments of $5,000 to a maximum of $50,000. Each bargaining unit can have only one level of
coverage. Confidential / Management employees and Board Members are not a bargaining unit and can only participate in the
group life program with a classified or certificated bargaining unit.
Basic Group Life
$0.07 per $1,000 of benefit
Accidental Death & Dismemberment
$0.015 per $1,000 of benefit
Total Basic Group Life with AD&D
$0.085 per $1,000 of benefit
DEPENDENT GROUP LIFE INSURANCE COVERAGE-BASIC LIFE WITH AD&D
(NON-VOLUNTARY, 100% PARTICIPATION)
A bargaining unit may elect to purchase dependent coverage in addition to the Basic Life coverage.
RATE: $0.36 PER FAMILY UNIT
Dependent
Coverage
Spouse
$1,500
Each child age 6 months to 24 years
$1,500
Each child age 14 days to 6 months
$ 100
*Dependent children may be covered from age 21 to age 25 provided they are a full-time student.
UNDERWRITING GUIDELINES FOR LIFE INSURANCE PROGRAM
1.
Employees must work at least 20 hours per week or not less than half of the total hours of a full time contracted position
and be "Actively-at-Work" to be eligible for coverage. An exception is made for Board Members. Eligible employees
and Board Members can have coverage with only one district at any one time. Former Board Members and retirees are
not eligible. See Participation Requirements – employees who are eligible according to these requirements must enroll in
all products offered through SISC or decline all products offered through SISC.
2.
If an insured employee ceases to be on the job due to leave of absence or short-term disability, the insured's group
life insurance may be continued (1) at the school district's option and (2) by timely payment of premium (see Waiver of
Premium); otherwise coverage will end the last day you are in active employment. An insured may elect to convert
their basic life or port their supplemental life by completing an application form within 31 days after the coverage ends.
3.
Coverage is automatically terminated on the first of the month after the employee leaves the district either through
termination, retirement or no longer being considered "Actively-at-Work.” An employee has 31 days to convert the group
life insurance coverage to an individual life policy (see the "Conversion" section of the Basic Group Life Policy). It is the
district’s responsibility to notify the employee of this option.
4.
When an employee reaches age 70, the face value of the Basic Life insurance and AD&D benefit is reduced by 50
percent, and continues to be reduced by 50 percent every five years.
5.
When an employee reaches age 70, the face value of the Supplemental Life benefit is reduced according to the Age
Discrimination in Employment Act (ADEA) chart (see the schedule of benefits section of the “Voluntary Term Life” policy).
6.
Districts new to the Life Insurance Program will be required to submit claims experience and a census. This information
will be utilized to determine rates to participate in the program.
7.
Certificates of Insurance and Plan Booklets are provided to employees by Self-Insured Schools of California/Mutual of
Omaha and should be referenced for additional information.
* Dependent eligibility for the Life program is different from eligibility for other SISC insurance coverage (according to the
Life carrier).
41
Life Plans & Rates
EXTENDED LIFE COVERAGE-CONTINUATION OF LIFE INSURANCE (Waiver of Premium)
Extended life insurance coverage applies to the insured employee's level term Basic Life and Supplemental Life coverage only.
Certain conditions must be met by the insured employee to qualify for extended life coverage, which includes becoming totally and
permanently disabled prior to reaching age 60 while insured under this policy. For a list of additional conditions, refer to the
“Continuation of Life Insurance Due to Total Disability” section of the Certificate of Insurance booklet.
ACCELERATED BENEFITS (EMPLOYEE ONLY)
In the event that a covered employee is diagnosed with a terminal illness and has less than 12 months to live, 50 percent of the
employee’s Basic Group Life and Supplemental Life insurance benefit is immediately made available. The individual must meet
requirements of the "Accelerated Benefits" provision of the group policy.
SUPPLEMENTAL LIFE COVERAGE (VOLUNTARY DOES NOT INCLUDE AD&D)
All provisions applicable to the Basic Life coverage apply to the Supplemental Life plan. Supplemental Plans have the added
feature of being portable. If an employee leaves the district, continuation of voluntary coverage up to age 70, including coverage
for spouse and children is available at the same rates charged to SISC members. The employee will be billed directly by insurance
carrier. Employee must apply for portability within 31 days of losing coverage from the district. It is the district’s responsibility to
notify the employee of this option.
For Employee: Coverage is available on an individual basis if the employee has Basic Life coverage. The employee may purchase
additional protection in increments of $10,000 up to a maximum of $500,000, not to exceed 5 times their annual salary. Within 31
days of the initial enrollment, or of becoming newly eligible, an employee may take advantage of the $100,000 guarantee issue
amount. After 31 days, evidence of insurability is required.
For Spouse: If the employee purchases supplemental coverage, then coverage for the spouse may be purchased in increments of
$5,000 to a maximum of 50% of employee supplemental life benefits, up to $100,000 and age 70. The rates are based on the age
of the spouse. Within 31 days of the employee’s initial enrollment, or of becoming newly eligible, there is a $25,000 guarantee issue
amount for spouse coverage. After the 31 days, evidence of insurability is required.
For Children/Dependents: If the employee purchases supplemental coverage, then coverage for the dependent may be
purchased in increments of $1,000 with a minimum of $2,000 per child to a maximum of $10,000. Each child/dependent must be
covered for the same amount. After 31 days, evidence of insurability is required.
AGE
PER $1,000 OF BENEFIT
Effective 10/01/2009
Under 25
$0.05
25 – 29
$ 0.06
30 – 34
$ 0.07
35 – 39
$ 0.08
40 – 44
$ 0.10
45 – 49
$ 0.16
50 – 54
$ 0.24
55 – 59
$ 0.49
60 – 64
$ 0.67
65 – 69
$ 1.14
70 to 74 and Over (for active employees only)
$ 2.16
75 and Over (for active employees only)
$ 3.02
Each Child/Dependent
$0.10/$1000
Please note: Rates will increase as you change from one age band to another.
42
Life Plans & Rates
Retiree Plans & Rates
¾ Rates for Retirees <65 and
>65 with District Coverage
¾ CompanionCare
¾ Medicare Advantage Plans
Direct Billing Self-Pay Retirees
SISC offers this value added service to our member districts at no cost to the retiree or the district. Districts now have
the option of SISC managing the monthly billing and collection of premium (acceptable payment methods:
MasterCard, VISA, or auto payment from checking account) for their self-pay retirees.
In order to be eligible for this service the retiree must meet the following guidelines:
•
•
•
The retiree must pay 100% of their medical, dental and vision (no district contribution)
The retiree must be enrolled in one of the following Individual Retiree Plans:
o CompanionCare
o Kaiser Senior Advantage
o Health Net Seniority Plus
The retiree will have the option of the following dental and/or vision plan:
o VSP C $20
o Delta Dental Premier Incentive Plan $1500
If the district makes any type of monthly contribution toward the retiree’s benefits (health, dental and/or vision) then the
retiree is not eligible for this program. Dental and vision are optional products and do not have to be purchased;
however, the retiree must be currently participating in the dental and/or vision product in order to purchase them from
SISC.
If the district elects for SISC to provide this service, the retiree’s benefits will be administered entirely by the SISC
Health Benefits Department and no longer by the individual school district. All communication regarding the retiree’s
benefits and payments will be coming from, and directed to, the SISC office. Please be assured that this change in
process does not affect the retiree’s benefit(s) or the cost. The dental and vision plans listed above are the only
choices offered under this program. If the retiree currently has a different dental or vision plan with the school district
and they wish to continue with one or both of these products, they will have to change to the plans listed above in order
to participate in this program.
If you are interested in this program and would like additional information, please contact the SISC office at (661) 6364410. SISC will need a 60 day advance notice to implement this program.
Retiree Plans and Rates
43
INDIVIDUAL RETIREE PLANS
Retirees on an Individual Retiree Plan may retain their district vision and/or dental coverage, but they must pay
the appropriate retiree rate for vision and/or dental coverage.
The spouse of a retiree is only eligible for the products in which the retiree is currently enrolled. Once the retiree
and spouse enroll in an Individual Retiree Plan, neither the retiree nor the retiree’s spouse may re-enroll in district
coverage during a subsequent Open Enrollment period.
•
Retro enrollments and disenrollments are not allowed on the Medicare Advantage Plans or
CompanionCare.
•
All enrollments and disenrollments require a 45 day advance notice.
COMPANIONCARE CLAIM-FREE PLAN
The CompanionCare plan is a supplement to Medicare. The plan is “claim free” only when a provider accepts
assignment of Medicare Benefits. When the member uses a provider who does not accept assignment of
Medicare Benefits, the provider of service or member must file the claim twice; once for the Medicare payment
and then again for the plan payment.
This plan may be offered to retirees over 65 with Medicare Parts A & B (see www.medicare.gov for information on
Medicare) and retirees under age 65 with Medicare for the disabled. In order to be eligible, the member must be
retired and enrolled in both Medicare Part A and Medicare Part B (no exceptions).
SISC will automatically enroll CompanionCare members in Medicare Part D for prescription medications. This
prescription drug plan is enhanced through Medco. CompanionCare members already enrolled in non-SISC
Medicare Part D plans will be automatically disenrolled from those plans.
A copy of the Medicare card must be presented with the enrollment form. If the card is not available, enrollment
into CompanionCare will be delayed until the card is received.
MEDICARE ADVANTAGE PLANS
A Medicare Advantage Plan is a plan that is offered through a Health Maintenance Organization (HMO) in lieu of
Medicare benefits. The HMO contracts with Centers for Medicare and Medicaid Services (CMS) to provide a
wide variety of benefits. Although the retiree must have Medicare in order to enroll in a Medicare Advantage
Plan, they cannot use their Medicare benefits while enrolled in a Medicare Advantage Plan.
Retirees enrolling in Medicare Advantage Plans will be automatically enrolled in Medicare Part D for prescription
drug coverage. This automatic enrollment in Medicare Part D through the Medicare Advantage Plan will cause
the retiree to be automatically disenrolled from Medicare Part D coverage through other plans.
The school district is responsible for collecting the premium from the retiree and sending the enrollment form to
the SISC office. If a retiree or spouse decides to cancel the Medicare Advantage Plan, a disenrollment form must
be completed. Please refer to the SISC website to obtain a Disenrollment Form. Until the cancellation process is
complete, the retiree cannot use their Medicare benefits. If the retiree has a dependent under the age of 65, their
dependent may participate in the same HMO; however, their coverage is different.
SISC offers two Medicare Advantage Plans: Seniority Plus through Health Net and Senior Advantage through
Kaiser Permanente. Provider changes and benefit changes on these plans are communicated directly to the
members by the health plan. Benefit summaries and rates for our Medicare Advantage Plans are on the following
pages.
Although the HMO coverage may be offered in the city and ZIP Code of the retiree’s permanent residence, the
Medicare Advantage Plan may not be available in that ZIP Code area. Before submitting a completed and signed
application for any of our Medicare Advantage Plans, please contact the SISC office to make certain that it is
offered in the ZIP Code where the retiree resides. Medicare Advantage Plans are not available through SISC
outside the state of California.
44
Retiree Plans and Rates
COMPANIONCARE/Medicare Supplement Plan
BENEFIT SUMMARY
(Based on Calender Year)
SERVICES
Inpatient Hospital (Part A)
MEDICARE
COMPANIONCARE
2009 Benefits
Based on 2009 Medicare Benefits
Pays all but first $1068 for 1st 60 days
Pays $1068
Pays all but $267 a day for the 61st
to 90th day
Pays $267 a day
Pays all but $534 a day Lifetime
Reserve for 91st to 150th day
Pays $534 a day
Pays nothing after Lifetime Reserve
is used
Pays 100% for 151st day to 515th day
Pays 100% for 1st 20 days
Pays nothing
Pays all but $133.50 a day for 21st
to 100th day
Pays $133.50 a day for 21st to 100th day
Pays nothing after 100th day
Pays nothing after 100th day
Deductible (Part B)
$135 Part B deductible per year
Pays $135
Basis of Payment (Part B)
80% Medicare Approved (MA)
charges after Part B deductible
20% MA charges including 100% of Medicare Part B
deductible
Medical Services (Part B)
Doctor, x-ray, appliances & ambulance
Lab
80% MA charges
20% MA charges
100% MA charges
Pays nothing
Physical/Speech Therapy (Part B)
80% MA charges up to the Medicare
annual benefit amount.
20% MA charges up to the Medicare annual benefit
amount. (Physical & Speech Therapy Combined)
Blood (Part B)
80% MA charges after 3 pints
Pays 1st 3 pints unreplaced blood and 20%
MA charges
Travel Coverage
(when outside the US for less
than 6 consecutive months)
Not covered
Pays 80% inpatient hospital, surgery, anesthetist
and in hospital visits for medically necessary
services for 90 days of treatment per lifetime
Outpatient Prescription Drugs
SISC will automatically enroll CompanionCare
Prescription drug plan enhanced through Medco Health
Generic: $7 co-pay for a 30-day supply at a
members into Medicare Part D.
No additional premium required. SISC plans are
retail pharmacy or $14 co-pay for a 90-day
supply through home delivery service.
not subject to the 'doughnut hole' .
Brand: $25 co-pay for a 30-day supply at a
retail pharmacy or $60 co-pay for a 90-day
supply through home delivery service.
Skilled Nursing Facilities
(Must be approved by Medicare)
COMPANIONCARE is a Medicare Supplement plan that pays for medically necessary services and procedures that are considered a Medicare Approved
Expense.
Due to Medicare restrictions, the prescription drug plan attached to the CompanionCare product is not eligible for the following programs:
Costco and Prilosec $0 Co-pay program and Diabetic Supplies for a Generic Co-pay.
Eligibility:
Member must be retired and enrolled in Medicare Part A (hospital) and Medicare Part B (medical) coverage.
Retirees under age 65 with Medicare for the disabled (Parts A&B) may enroll in CompanionCare.
Enrollment:
Enrollment forms and a copy of the Medicare card must be received by SISC 45 days in advance of requested effective date - no
exceptions. SISC will automatically enroll members in Medicare Part D for outpatient prescription medications. Members already
enrolled in non-SISC Medicare Part D plans will be automatically disenrolled from those plans.
Disenrollment:
Members can enroll into Medicare Part D plans outside of SISC with a January 1 effective date. Please note they will lose SISC
medical coverage at the same time. SISC requires that members be enrolled in both medical and prescription drug (Medicare Part
D) coverage. Members can not enroll into a Medicare Part D plan outside of SISC and retain SISC medical coverage.
Provider Network: Physicians who accept Medicare Assignment.
For additional Medicare benefit information, please go to www.medicare.gov or call 1-800-medicare.
For additional Medco prescription drug information, please go to www.medco.com or call 1-800-596-7986.
Rate Effective October 1, 2009
Total Cost Per Person
Retirees with Medicare A & B (SISC will enroll members in part D)
$381.00
45
Retiree Plans and Rates
HEALTH NET
SENIORITY PLUS MEDICARE ADVANTAGE PLAN
BENEFIT SUMMARY EFFECTIVE 1/1/2009
SERVICES
BENEFITS
Hospital
•
No charge for unlimited days.
Inpatient and Outpatient
Skilled Nursing Facility
No charge for 100 days if determined to be medically
necessary by Seniority Plus plan physician.
Physician Services/Basic Health Services
•
Office visits
•
Consultation, diagnosis, and treatment by a
specialist
$10 co-pay per visit
$10 co-pay per visit
X-Ray Services
No charge
•
Including annual mammography when
authorized by your Seniority Plus physician
Laboratory Services
No charge
Annual Physical Examination
Includes pap smear
•
$10 co-pay per visit
Vision Care
•
Examination for eyeglasses (Refraction)
•
Eye glasses/lenses ($100 frame benefit
limit every two years)
$10 co-pay per visit
No charge
Dental Care
•
Preventive Services
No charge
Hearing Examination
$10 co-pay per visit
Immunizations
Includes flu injections and all Medicare
•
approved immunizations
•
Immunizations for foreign travel or
occupational
$10 co-pay per visit
20% charge
Prescription Drugs
A $10 co-pay for generic, $15 co-pay for brand name, or
$35 co-pay for non-formulary drugs per 30-day supply, when
when prescribed by a Seniority Plus doctor and filled at
a Health Net pharmacy. Prescriptions of up to a 90-day
supply are offered through the mail order program.
The co-pays are 2 X the above applicable co-pays. No
annual dollar limit.
Chiropractic Care
$5 co-pay per visit. 20 visits per year subject to
limitations stated in the Evidence of Coverage.
Rates Effective October 1, 2009
Age 65 & Over with Medicare A & B
$395.00
Retiree Only
$985.00
Retiree & Spouse, one with Medicare*
$790.00
Retiree & Spouse, both with Medicare
$1,507.00
Retiree & Spouse, one Medicare, plus dependent children*
$1,380.00
Retiree & Spouse, both Medicare, plus one dependent child*
Retiree & Spouse, both Medicare, plus dependent children*
$1,902.00
*Under age 65 non-Medicare dependents will have SISC/Health Net HMO Plan N2A-ZK, Rx $5/$10/$35, Chiro $5/20, and
Health Net eyewear benefits. Dental benefits are not included for under 65 dependents.
Retiree Plans and Rates
46
KAISER PERMANENTE/NORTHERN REGION
SENIOR ADVANTAGE MEDICARE PLAN
BENEFIT SUMMARY EFFECTIVE 1/1/2009
SERVICES
BENEFITS
Hospitalization
• Inpatient
• Emergency Room
$200/Admit
$50 co-pay/waived if admitted
Skilled Nursing Facility
Covered in full for 100 days per benefit period
Physician Services/Basic Health Services
• Office visits
• Consultation, diagnosis, and treatment by a
specialist
$10 co-pay per visit
$10 co-pay per visit
X-Ray Services
• Includes routine annual mammography
No charge
Laboratory Services
No charge
Annual Physical Examination
• Includes pap smears
$10 co-pay per visit
Outpatient Mental Health/20 visits
$10 co-pay per visit
Vision Care
• Examination for eyeglasses
• Glaucoma testing
• Standard frame/lenses every 24 months
$10 per visit
$10 co-pay per visit
$150 frame and lens allowance every 24 months
Dental Care (DeltaCare)
Not covered
Hearing Examination
$10 co-pay per visit
Immunizations
• Includes flu injections and all Medicare approved
immunizations
No charge
Ambulance
$50/Trip
Manual Manipulation of the Spine
$10 co-pay per visit (subject to medical necessity)
Prescription Drugs
$10 co-pay per generic/$20 co-pay per brand name
up to 100 day supply at Kaiser pharmacies
• Prescription drugs related to sexual dysfunction
50% co-insurance; limited to 27 doses in any 100-day
period.
Rates Effective October 1, 2009
Age 65 and Over with Medicare A & B
Retiree Only
$299.00
Retiree & Spouse, one with Medicare*
$760.00
$598.00
Retiree & Spouse, both with Medicare
$1,142.00
Retiree & Spouse, one Medicare, plus dependent children
Retiree & Spouse, two Medicare, plus dependent children
$980.00
Under age 65
Retiree Only *
$461.00
$922.00
Retiree & Spouse *
Retiree & Spouse plus dependent children *
$1,304.00
*Under age 65 non-Medicare dependents will have no eyeglasses or manual manipulation of the spine covered.
Members must live in an approved Zip Code of the Kaiser Permanente California Service Area.
47
KAISER PERMANENTE/SOUTHERN REGION
SENIOR ADVANTAGE MEDICARE PLAN
BENEFIT SUMMARY EFFECTIVE 1/1/2009
SERVICES
BENEFITS
Hospitalization
• Inpatient
• Emergency Room
$200/Admit
$50 co-pay/waived if admitted
Skilled Nursing Facility
Covered in full for 100 days per benefit period
Physician Services/Basic Health Services
• Office visits
• Consultation, diagnosis, and treatment by a
specialist
$10 co-pay per visit
$10 co-pay per visit
X-Ray Services
• Includes routine annual mammography
No charge
Laboratory Services
No charge
Annual Physical Examination
• Includes pap smears
$10 co-pay per visit
Outpatient Mental Health/20 visits
$10 co-pay per visit
Vision Care
• Examination for eyeglasses
• Glaucoma testing
• Standard frame/lenses every 24 months
$10 per visit
$10 co-pay per visit
$150 frame and lens allowance every 24 months
Dental Care (DeltaCare)
Not covered
Hearing Examination
$10 co-pay per visit
Immunizations
• Includes flu injections and all Medicare approved
immunizations
No charge
Ambulance
$50/Trip
Manual Manipulation of the Spine
$10 co-pay per visit (subject to medical necessity)
Prescription Drugs
$10 co-pay per generic/$20 co-pay per brand name
up to 100 day supply at Kaiser pharmacies
• Prescription drugs related to sexual dysfunction
50% co-insurance; limited to 27 doses in any 100-day
period.
Rates Effective October 1, 2009
Age 65 and Over with Medicare A & B
Retiree Only
$206.00
Retiree & Spouse, one with Medicare*
$570.00
$412.00
Retiree & Spouse, both with Medicare
Retiree & Spouse, one Medicare, plus dependent children
$870.00
Retiree & Spouse, two Medicare, plus dependent children
$712.00
Retiree only with Medicare Part A only
$824.06
Retiree only with Medicare Part B only
$1,137.07
Under age 65
Retiree Only *
$364.00
Retiree & Spouse *
$728.00
$1,028.00
Retiree & Spouse plus dependent children *
* Under age 65 non-Medicare dependents will have no eyeglasses or manual manipulation of the spine covered.
Members must live in an approved Zip Code of the Kaiser Permanente California Service Area.
48
Creditable Coverage - Medicare Part D
Medicare’s prescription drug plan started January 1, 2006 and is available to everyone with Medicare Parts A &
B through various vendors that have been approved by Medicare to provide this benefit.
Retirees enrolled in CompanionCare, HMO plans or Medicare Advantage plans through SISC will be
automatically enrolled in Medicare Part D; the prescription benefit under these plans will remain unchanged.
Retirees enrolled in all other SISC PPO plans are not required to enroll in a Medicare Part D plan. All drug
plans offered by SISC are considered Creditable Coverage (as good as or better than standard Medicare D
prescription drug coverage).
Per Centers for Medicare and Medicaid Services (CMS) guidelines, entities offering Creditable Coverage are
required to send members a Creditable Coverage Disclosure. This notice will be sent to all Medicare eligible
th
members (active or retired) by SISC prior to November 15 of each plan year (see Forms and Examples
section).
Detailed information about Medicare Part D is available in the “Medicare and You” pamphlet published annually
by the Social Security Administration, or by visiting Medicare’s website at www.medicare.gov.
Questions can also be answered by calling 1-800-MEDICARE (1-800-633-4227).
49
Retiree Plans and Rates
Section 125
SISC Flex
SECTION 125 PLAN
“SISC FLEX”
The Section 125 Plan, known as “SISC FLEX,” is a benefit plan which SISC offers to our member districts as a
value added service at no cost to the employee or the employer. The plan began October 2002. Section 125 of
the Internal Revenue Code allows employees to purchase their selected “SISC FLEX” benefits with pre-tax
payroll contributions. Both employees and employers participating in the plan may experience significant tax
savings. Savings are realized by a reduction in Federal, State, Social Security, and Medicare tax contributions.
The employer’s role is to deduct contributions for participating employees on a pre-tax basis. The amount
depends on the dollar amount elected by the employee for the plan year, in any of the following benefit options:
1. PREMIUM ONLY PLAN (No Annual Maximum)
The plan allows pre-tax payroll deductions for amounts employees are required to contribute for their employer
sponsored group health insurance. The deduction amount will automatically be adjusted to reflect any changes
in premium in future years.
2. HEALTH CARE SPENDING ACCOUNT ($5,000 Per Employee Annual Maximum)
The plan allows employees to redirect a portion of their salary, on a pre-tax basis, to pay for eligible
unreimbursed medical expenses. Each plan year, employees elect the dollar amount to be contributed to their
flexible spending account based on their estimated out-of-pocket medical expenses. Employees submit claim
forms to be reimbursed for eligible medical expenses incurred during the plan year. Eligible participants in this
account will receive a stored-value VisaCard to pay for current year qualifying medical expenses. Refer to the
provided list for examples of eligible medical expenses. Participants have until March 15th of the following year
to incur eligible expenses for the current Plan Year. While this does not eliminate the use-it-or-lose-it rule
completely, participants now have more time to avoid forfeiting unused funds. You and your employees can find
further information and forms on our web page at http://sisc.kern.org/flex/.
3. DEPENDENT CARE SPENDING ACCOUNT ($5,000 Per Family Annual Maximum)
The plan allows employees to redirect a portion of their salary, on a pre-tax basis, to pay for employment
related dependent care expenses. Each plan year, participating employees elect the amount to be contributed
to their flexible spending account based on their estimated dependent care expenses. Employees submit claim
forms to be reimbursed for qualifying dependent care expenses incurred during the plan year. Qualifying
dependents include a participating employee’s tax dependents under age thirteen, as well as incapacitated tax
dependents age thirteen and over, who reside with the employee.
ADDITIONAL IMPORTANT POINTS
A. To be eligible for SISC Flex you must be an active employee of a participating school district.
B. The SISC Flex Plan year is January 1st through December 31st each year. Participants have 90 days
(run out period) following the end of the plan year to file claims for the current year. All claims and
supporting documentation must be received by the SISC office no later than March 31st in order to be
considered filed during the run-out period.
C. Reimbursement can only be made for eligible expenses incurred during the plan year, or the 2 ½ month
grace period immediately following the plan year end. The grace period only applies to eligible medical
expenses, not dependent care expenses.
D. Unused contributions remaining in a participant’s flexible spending account after the close of the plan
year must be forfeited.
E. A participant is prohibited from changing their elections during the plan year, except for the allowed
status change events outlined in the plan document.
F. Funds cannot be transferred between a participant’s medical and dependent care flexible accounts.
G. Participation in a Section 125 Plan may affect your future Social Security retirement; as income subject
to Social Security deductions decreases, the Social Security deduction also decreases.
50
Section 125/SISC Flex Plan
Self-Insured Schools of California
Section 125 Plan
“SISC FLEX”
Examples of Eligible Medical Expenses
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Adoption - Medical Expense (incurred before
adoption is finalized)
Alcoholism Treatment
Ambulance
Artificial Limbs
Artificial Teeth
Braille Books/Magazine (difference between
regular material and Braille materials)
Car Controls for Handicapped
Chiropractic Services
Christian Science Practitioners (payments
for medical care)
Coinsurance Amounts and Deductibles
Contact Lenses and Solution
Crutches
Dental Treatment
Diagnostic Tests
Drug Addiction Treatment
Eye Examinations and Eyeglasses
Guide dog or Other Animal (purchase,
training, and care of animal)
Hearing Aids and Examinations
Hospital Services
Injections
Insulin
Laboratory Fees
Lasik Eye Surgery
Learning Disabled Child:
Special School/Teacher
Medical Monitoring and Testing Devices (if
prescribed by physician for a particular
ailment).
Medicines (If prescribed by physician to treat
a specific ailment and if only available by
prescription.)
Occlusal Guards (to prevent teeth grinding)
Operations (Legal operations which treat a
specific ailment)
Optometrist
Organ Transplants
51
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Orthodontia (unless for cosmetic purposes)
Osteopath
Over-the-Counter Drugs and Medicines (if
they are primarily for medical care and not
for personal, general health or cosmetic
purposes)
Oxygen
Periodontal Fees
Physical Exams (except for employmentrelated physicals)
Physical Therapy (for specified medical
purpose)
Prescription Sunglasses
Private Hospital Room
Psychiatric Care
Psychoanalysis
Psychologist
Radial Keratotomy
Surgery
Telephone for the Deaf
Transportation for Seminar on Medical
Condition
Cost of Seminar on Medical Condition
Vaccinations
X-Rays
This list is non-inclusive and does not represent
all allowable or non-allowable charges. You may
refer any further questions regarding allowable
and non-allowable charges to SISC.
Section 125/SISC Flex Plan
Self-Insured Schools of California
Section 125 Plan
“SISC FLEX”
Example of Possible Savings
Whether you’re a single person, single parent, part of a dual-income household, or a family person with a nonworking spouse, SISC FLEX will provide you with more take home pay.
Working Couples
Single Parents
In the illustration below, the single
parent earns $24,000 and has two
children. SISC FLEX is used to pay
the premium for medical coverage
and to pay for the cost of medical
deductibles and dental care this
year. In addition, this parent has
opted to use SISC FLEX to pay
dependent care expenses with pretax dollars. In this way, the
individual increases their takehome pay by $112 each month...or
$1,344 this year.
Both husband and wife work in
this example. They have two
children. The husband makes
$29,000 and his wife earns
$19,000 per year. They use SISC
FLEX to pay the premium for
medical coverage and pay for the
orthodontist bills for the children.
With both of them working, they
also utilize the plan to pay for
necessary childcare expenses.
The chart shows that this couple
increases their monthly takehome pay by $180 ... or $2,160
this year.
The Single Parent
Total Monthly Pay
Less Non-Taxable Benefits
Insurance Premiums
Medical/Dental Expenses
Childcare Expenses
Total Pay Subject
To Tax
Less Deductions
Federal & State Taxes*
Social Security Tax
After Tax Income
Family Person with NonWorking Spouse
With grown children, and only
one spouse working, this
couple has no childcare
expenses. The annual salary of
the working spouse is $60,000.
They use SISC FLEX to pay the
premium for medical coverage,
meet their medical deductibles,
and pay dental expenses. SISC
FLEX gives this couple an
additional $84 monthly takehome ... or $1,008 this year.
Working Couples
Family Person
Without
SISC FLEX
With
SISC FLEX
Without
SISC FLEX
With
SISC FLEX
Without
SISC FLEX
With
SISC FLEX
$2,000
$2,000
$4,000
$4,000
$5,000
$5,000
0
0
0
___________
$2,000
$60
$175
$200
_________
$1,565
0
0
0
________
$4,000
$175
$100
$400
________
$3,325
0
0
0
________
$5,000
$150
$150
$0
_______
$4,700
$230
$153
___________
$1,617
$151
$120
_________
$1,294
$446
$306
________
$3,248
$318
$254
_______
$2,753
$640
$383
________
$3,977
$579
$360
_______
$3,761
$60
$175
$200
___________
$1,182
0
0
0
_________
$1,294
$175
$100
$400
________
$2,573
0
0
0
_______
$2,753
$150
$150
$0
________
$3,677
0
0
0
_______
$3,761
After Tax Expenses
InsurancePremiums
Medical/Dental Expenses
Child-Care Expenses**
Spendable Income
Annual Increase In
Take-Home Pay
*
**
$1,344
$2,160
$1,008
Federal and State taxes reflect 2009 Federal Tax rates and typical CA state taxes.
Does not include any available tax credit for child care expenses.
52
Section 125/SISC Flex Plan
SISC DEFINED BENEFIT PLAN
The SISC Defined Benefit Plan is an alternative pension plan for part-time, temporary and seasonal
(PTS) employees. It can be offered in place of social security or a defined contribution plan providing
substantial savings to both the school district and PTS employees. Seventy-three districts from 11
counties are currently in the plan. Of the 73 member districts, seven are County Offices of Education.
ACTUAL SISC DATA
AS OF 12/31/2008
Number of PTS Employees
2008 Payroll of PTS Employees
74,419
$78,041,196
School District Contribution (Based on Actual SISC Data Above)
Contribution Rate
Contribution
•
Social Security
Defined Contribution
SISC Defined Benefit
6.2%
$4,838,554
3.75%
$2,926,545
3.5%____
$2,731,442
2008 Savings to Districts over Social Security……………………$2,107,112
PTS Employees Contribution Comparison (Based on Actual SISC Data Above)
Contribution Rate
Contribution
•
Social Security
Defined Contribution
6.2%
$4,838,554
3.75%
$2,926,545
SISC Defined Benefit
None______
$ -0-
2008 Savings to PTS Employees over Social Security……………………$4,838,554
This represents a rare opportunity for a “win-win” situation between a school district and its employees.
•
•
•
•
2009 SISC Defined Benefit Plan contribution rate is 4.4% of PTS employee’s wages. This is the total
cost to the employer, no additional costs are required.
In 2009 Districts save 1.8% over the cost of Social Security. PTS employees save the full 6.2% cost
of Social Security because the plan is entirely employer paid.
Ease of implementation and administration for the employer. No enrollment forms; information is
downloaded from your existing payroll/personnel system.
No employee contributions, thereby decreasing costs, paperwork, record keeping and employee
questions.
Additionally, the SISC Defined Benefit Plan offers a benefit to PTS employees that, in many cases, is more appropriate
than Social Security. Examples are:
•
Social Security requires an employee to earn 40 quarters of coverage before he/she is eligible to receive a
pension benefit. The SISC Defined Benefit Plan has no qualifying restraints. All participants will receive a
benefit regardless of length of service.
•
Under Social Security, many PTS employees will be eligible for a larger Social Security pension benefit based on
their spouse’s pay history rather than his/her own pay history. By participating in the SISC Defined Benefit Plan,
these PTS employees could receive both the Social Security “spouse” benefit and the SISC benefit. Some Social
Security benefits may be reduced by the Government Pension Offset Provision.
SISC Defined Benefits
53
Procedures
WHEN TO ADD
EMPLOYEES
New employees should be added the first of the month following their Date of Hire (DOH). DOH is the first day
the employee works and is paid for that day. If the DOH is the first working day of the month, even though it is not
the first calendar day of the month (first calendar day fell on a weekend or holiday), the employee may be added
the first of that month. Employees may also be added the first of the following month.
However your district elects to handle this, make certain that your policy for assigning the effective date of
coverage for your employees is consistent; otherwise, you may be leaving the district open for a discrimination
suit.
If the employee who works less than full-time subsequently becomes full-time or has an increase in the number of
hours worked, or declined coverage because they were covered elsewhere (they must notify you within 30 days
of loss of eligibility/60 days if the loss of eligibility is under a Medicaid plan or Children’s Health Insurance
Program and provide proof of their loss of coverage with their enrollment form), they may enroll the first of the
month following the date of that event. If they did not decline coverage because they were covered elsewhere, or
they do not notify you within 30 days of their loss of eligibility elsewhere (or 60 days if loss of eligibility is under a
Medicaid plan or Children’s Health Insurance Program), they must wait until the next Open Enrollment Period.
BOARD MEMBERS
When the district has a policy that allows active Board Members to participate, Board Members should be added
the first of the month following the date they are elected to office. If the date they are elected is the first of the
month, they should be added the date elected.
RETIREES
Retirees must be transferred to a retiree plan the first of the month following their date of retirement. There can
be no lapse in coverage. If the retiree does not maintain continuous coverage or if they elect to enroll in one of
our individual retiree plans, they cannot enroll in district medical coverage at a subsequent Open Enrollment.
Members enrolled on a retiree plan that are age 65 or older are required to enroll in both Medicare Part A
(hospital benefits) and Medicare Part B (medical benefits). The rates for retirees and spouses/domestic partners
who are not in Medicare Part A and/or B are much higher.
Retirees should be enrolled on an over age 65 group number the first of the month in which they turn 65. If they are
enrolled on a two-party contract, they may enroll on an over age 65 group the first of the month in which both parties are
age 65.
Please refer to the Guidelines section of the book for additional information regarding retirees.
DEPENDENTS
Spouse: First of the month following the date of marriage (legal marriage to a partner of the opposite sex).
Domestic Partners: First of the month following the date they register with the State of California. Their eligible
dependent children must be added at the same time.
Children: May be added the first of the month following;
• the date of birth (Blue Shield enrollees will be effective on their date of birth), or
• the first of the month following the date of marriage for new step-children; or
• the date an adoption is in process and the member has fiduciary responsibility or the right to control the
health care. An adopted child from a foreign port must be added the date they leave the foreign port.
Dependents: If the employee has a family contract (three or more persons already covered) or the district is
paying a composite rate, the dependent may be enrolled immediately (provided they are eligible) back to the most
recent Open Enrollment.
54
Procedures
WHEN TO TERMINATE
EMPLOYEES TERMINATING
Employees should be removed at the end of the month in which their termination occurs. A district may not
bargain to extend benefits beyond this date. Less than 12 month employees who have completed their
contractual obligation to teach/work through a given date, may be terminated at the end of the contract.
RETIREES
Certificated retirees and the surviving spouse of a certificated retiree must be offered lifetime benefits according to
California Education Code Section 7000 (AB 528). These laws apply to certificated employees/retirees for
medical and dental coverage only. These laws do not obligate the school district to pay for coverage, just to offer
the same medical and dental benefits provided to active certificated employees. Unless the school district has a
policy that allows classified employees to continue coverage after they retire, they should be terminated at the
end of the month in which they retire. These retirees may be eligible for continuation coverage under COBRA
and subsequently CalCOBRA.
You must advise retirees who do not continue medical coverage upon retirement that they may not re-enroll
during any subsequent Open Enrollment Period. To protect yourself from the “nobody told me” syndrome, please
have the retiree complete a Declination of Coverage for Retirees. A copy of the form can be found in the Forms
and Examples section of this manual.
The following website may be used as a helpful tool in order to keep track of district paid retirees:
http://ssdi.rootsweb.com
DEPENDENTS
It is the employee’s responsibility to notify the district of any changes in eligibility status for their spouse or
dependent(s). The district is required to notify SISC in a timely manner of these changes. Any paid claims on a
non-eligible spouse or dependent will be recovered.
Spouse – At the end of the month in which one of the following events occurs:
• The covered employee/retiree leaves district coverage; or
• They expire; or
• The final divorce decree is reached; or
• The first of the month following the date you receive a completed and signed change form requesting
deletion.
Domestic Partners – At the end of the month in which:
• They expire; or
• The Notice of Termination of Domestic Partnership or nullity of the domestic partnership is complete.
• The first of the month following the date you receive a completed and signed change form requesting
deletion.
Dependent Children - At the end of the month in which one of the following events occur:
• They expire; or
• They marry; or
• They become employed with their own health insurance; or
• If they are a step-child, when the final divorce is reached; or
• In active service of the armed forces; or
• From age 19 through age 24, at the end of the month in which they are no longer an IRS dependent or
full-time student. If the member does not return the over age dependent certification form, they are
automatically removed at the end of the month in which their birthday occurs; or
• When they reach age 25 they are automatically removed. If the dependent is disabled, the member must
contact us within 30 days of the date the dependent is removed and request a Disabled Dependent
Certification form. This form will be forwarded to the Medical Review Department for approval before the
dependent can be certified and reinstated; or
• The first of the month following the date you receive a completed and signed change form requesting
deletion.
55
Procedures
Board Members – At the end of the month in which one of the following events occur:
• They are replaced; or
• Their term ends;
• The first of the month following written notice.
TERMINATING FROM AN HMO (with Medicare)
Employees enrolled on an HMO in active or retired status (with a dependent or the employee enrolled in Medicare
Parts A & B) must complete a Disenrollment Form and submit to SISC 45 days prior to the requested termination
date. This is a rule imposed by the HMO in order for the member to have their Medicare rights restored – the
form must be signed by the member who assigned their Medicare. Only advance termination dates with a 45 day
notice will be allowed. Please refer to the SISC website for the Medicare Disenrollment Form.
TERMINATING FROM A TENTHLY GROUP
Employees terminating coverage (as a result of leaving employment or retirement) on a tenthly group number for
any effective date other than October 1 will not receive credit for the pre-paid months.
56
Procedures
WHEN EMPLOYEES/RETIREES ARE ALLOWED PLAN CHANGES
ACTIVE EMPLOYEES
Current employees may elect a new plan option only during the designated Open Enrollment period for an
effective date of October 1. The Open Enrollment period is determined by the district and is usually between
August 15 and September 1. It is the district’s responsibility to notify their members timely of Open Enrollment
and allow enough time for the district to submit the Maintenance Activity Report (MAR) to SISC by September 10
(or the last working day prior to September 10).
RETIREES
Retirees are subject to the same Open Enrollment period as Active Employees. The only exception to this would
be if the retiree is choosing to enroll in the Medicare Supplement Plan or a Medicare Advantage Plan offered by
SISC such as:
•
Companion Care – A Medicare Supplement Plan, or
•
•
Health Net Seniority Plus – A Medicare Advantage Plan
Kaiser Senior Advantage – A Medicare Advantage Plan
Please refer to the Retiree Plans & Rates Section of this manual for benefit summaries.
Enrollment or Disenrollment in a Medicare Advantage Plan or a Medicare Supplement Plan requires a 45 day
advance notice.
If a retiree moves to the Medicare Supplement Plan or a Medicare Advantage Plan listed above, he/she may not
move back to a district benefit plan such as a PPO or standard HMO plan. The retiree must complete the
“Declination of Coverage for Retirees” form found in the Forms & Examples section of this manual. This form is
for the district’s protection and clearly advises the retiree of SISC rules on transferring between district plans and
Individual Retiree Plans.
The exception to the above rule would be if the retiree moves out-of-state and the benefits are not offered in the
location of their new residence.
SPECIAL ENROLLMENT PERIOD
SISC will allow a Special Enrollment Period and/or a plan change outside of Open Enrollment due to the following
circumstances:
1. When an employee retires, they may elect another plan offered by the district at the time of retirement.
All subsequent plan changes are subject to the rules listed above.
2. In accordance with HIPAA, an employee may enroll outside of Open Enrollment due to the following
qualifying events (part-time employees who may have declined benefits):
• Loss of eligibility for coverage elsewhere
• New marriage
• Birth
• Adoption
The employee must notify the district within 30 days of their qualifying event in order to be eligible for the Special
Enrollment (60 days if the qualifying event is loss of eligibility under a Medicaid plan or CHILDREN’S HEALTH
INSURANCE PROGRAM).
57
Procedures
HOW TO REPORT
SPOUSE AND DOMESTIC PARTNER
When an employee enrolls a Spouse or Domestic Partner, he/she must provide proof of marriage or domestic
partnership to SISC. A copy of the following forms should be submitted to the SISC office along with the
completed and signed enrollment or change form.
• Spouse – A copy of the marriage certificate duly witnessed and signed by both parties or a copy of the
Certificate of Marriage.
• Domestic Partner – A certified copy of the Declaration of Domestic Partnership that was filed with
California Secretary of State (once filed, the form is stamped by the state).
ENROLLMENT/CHANGE FORMS
Unless your district has life insurance or a Delta Dental PPO (DPO/PPO) plan through SISC, the employee only
needs to complete the applicable enrollment or change form for the medical plan he selects in order to enroll or
add/delete dependents. Although a signature is required on an enrollment form for a new employee/retiree, and a
signature is recommended on the change form, we do not require a signature to add or delete a dependent.
Screen the enrollment or change forms for missing information (i.e. date of birth, date of hire, signature and etc.),
write the appropriate group number and the effective date in the upper right hand corner on each form. Complete
a Maintenance Activity Report (MAR) for Additions and Terminations of Subscribers Only form for all group
suffixes. If you have any employees adding or deleting a dependent, retiring and/or changing from one group
suffix to another because of a job change, you need to complete a MAR for Changes/Transfers. These forms are
in Microsoft Excel. We can e-mail them to you or you can print them from our website listed on the front of this
manual. The MAR for Additions and Terminations of Subscribers Only form needs to be completed and
forwarded to SISC each month (four days prior to the month you are reporting), even when you do not have any
changes, new employees or employees terminating. If you have no activity to report, simply complete the top of
the form, draw a line across the center of the form, and write “NO ACTIVITY TO REPORT” and mail it to the SISC
office.
Multiple PPO Plans: If your district offers more than one PPO plan, the employee must also complete a Plan
Election Form. The Plan Election Form should be designed to fit the benefits and/or payroll deduction for your
district. Once the employee signs this form, use it to assign the correct group suffix for the benefits he has
elected and place the election form in his permanent personnel file---please do not send the election form to
SISC. An example of a Plan Election Form can be found in the Forms & Examples section of this manual.
Delta Dental PPO: If your school district offers the Delta Dental PPO plan as a dual option, the employee must
complete the Delta Dental Designation Form. You may staple this form to the back of the medical enrollment
form or you may place the Delta Dental Designation Form in the employee’s personnel file and write “Incentive” or
“PPO” at the top of the medical enrollment form. An example of a Delta Dental Designation Form may be found in
the Forms & Examples section of this manual.
Mutual of Omaha Life Insurance: New employees must always complete the Basic Life/AD&D Insurance
Enrollment Form. The district should verify the following information before sending the enrollment form to SISC:
date of birth, Social Security number, coverage amount, number of hours worked and district I.D. If the district
offers Supplemental Coverage and the employee would like to apply for Supplemental Insurance, the
Supplemental Term Life Insurance Enrollment Form must be completed. If the employee requests Supplemental
Insurance that is not considered Guarantee Issue, the employee must complete an Evidence of Insurability (EOI)
form. All forms must accompany the medical enrollment form. If the district offers Supplemental Coverage, use
the Supplemental Life Billing to report new employees, terminations and changes. Once completed, make a copy
of the billing and send it to SISC along with your enrollment forms four business days prior to the effective date.
58
Procedures
DUE DATES
Additions/Terminations & Changes: Activity is due four (4) business days prior to the effective date—do not
hold it to send with your premium payment. You must include your Maintenance Activity Report (MAR),
enrollments and changes.
Premium: Premium is due by the first of the month for the month covered. If premium is not received by the first
day of the month immediately following the coverage month, an additional one percent (1%) will be attached to the
premium.
EXAMPLE: Month covered:
Amount due for April:
Date due:
No payments received:
Amount due on May 1 with late charge
April 1 through April 30
$50,000
April 1
May 1
$50,500 due for April plus current amount billed for May
You must include a copy of the first page of your billing along with your payment to SISC III and mail the payment
to:
SISC Finance
P.O. Box 1808
Bakersfield, CA 93303-1808
INDIVIDUAL RETIREE PLANS
If a retiree drops coverage or declines district coverage and elects one of our individual retiree plans, he/she must
complete the “Declination of Coverage for Retirees” form found in the Forms & Examples section of this manual.
This form is for your protection—it covers those uncomfortable “nobody told me” situations.
CompanionCare: CompanionCare is an individual supplement to Medicare. Each individual must be age 65
with Medicare Part A (hospital coverage) and Medicare Part B (medical coverage) or may be retired under age 65
with Medicare for the disabled. They must each complete a Claim-Free Companion Care Application Form and
attach a copy of their Medicare I.D. card. A 45 day notification is required for enrollment. It is the district’s
responsibility to advise retirees that once they elect CompanionCare coverage, they will not be eligible for district
coverage at any subsequent enrollment. If the retiree is under the age 65 and the spouse is over the age 65 or if
the retiree is over the age of 65 and the spouse is under 65, the one under age 65 may opt to enroll in district
coverage and the one over age 65 may enroll in CompanionCare.
Medicare Advantage Plans: Health Net Seniority Plus and Kaiser Permanente Senior Advantage are Medicare
Advantage plans. These plans assume the risk of Medicare and offer affordable coverage through an HMO. It is
no longer necessary for the retiree’s spouse to enroll in the same Medicare Advantage Plan as the retiree, but the
retiree must be enrolled in order for the spouse to be eligible (unless a surviving spouse of a retiree). Before
offering one of these plans to a retiree, make certain that he/she is in a ZIP Code area that offers the Medicare
Advantage Plan being chosen. Retirees must complete the appropriate enrollment form for the plan they have
chosen (Medicare Election form and/or enrollment form for Kaiser Senior Advantage) and attach a copy or copies
of their Medicare I.D. card(s). Applications for a Medicare Advantage Plan must be submitted 45 days prior to the
effective date. No exceptions. It is the district’s responsibility to advise retirees that once they elect the Medicare
Advantage Plan, they will not be eligible for district coverage at any subsequent enrollment.
59
Procedures
RETROACTIVE ADJUSTMENTS
All full-time employees must be added back to the date when they first became eligible. If you fail to report a new
part-time employee timely, we will allow you to add a new part-time employee three months retro (i.e. report date
is 1/1/2008, employee was hired 9/28/2007 and should be effective 10/1/2007). If you fail to report the
termination of an employee timely, we will allow you to terminate the employee three months retro; however, if in
the meantime the employee/retiree or the employee’s/retiree’s dependents have incurred claims and these claims
have been paid, we will only allow the retro back to the first of the month following the date the last claim was
paid. HMOs do not allow retroactive terminations.
Medicare Advantage plans and Medicare Supplement Plans require that an application for enrollment be
submitted 45 days prior to the effective date and retroactive adjustments are not allowed. Once the application is
received, the retiree is added to a list which is sent to Medicare only once per month. If the enrollment is not
submitted 45 days in advance, the retiree may not get the effective date he requested. Always recommend to the
retiree that he/she remain on his/her current coverage until the plan effective date has been confirmed.
Once enrolled, if the retiree wishes to terminate coverage, or transfer to another Medicare Advantage Plan,
he/she must submit a Disenrollment Request form at least 45 days in advance. If the retiree does not give you
sufficient notice to be disenrolled from the Medicare Advantage Plan/Medicare Supplement Plan and have their
Medicare benefits restored, then the district is responsible for any premiums until he/she is disenrolled. The
disenrollment date is governed by Centers for Medicare and Medicaid Services, not SISC. A Medicare
Advantage Disenrollment Request form can be found in the Forms & Examples section of the manual.
60
Procedures
FORMS & EXAMPLES
Most of the forms and examples in this section can be e-mailed to you at your request. We also have placed many of
these forms on our website (http://sisc.kern.org/healthandwelfare/) so you may access and print them as needed. If
you would like one of these forms e-mailed to you, please contact the SISC office at (661) 636-4410.
The following forms can be found in this section:
•
Declination of Coverage for Less Than Full Time Active Employees and HIPAA Notification
•
Declination of Coverage for Dependents of Full Time Active Employees and HIPAA Notification
•
Declination of Coverage for Retirees
•
Creditable Coverage Disclosure
•
Sample Plan Change Letter
•
Sample Plan Election Form
•
Delta Dental Designation Form
•
CompanionCare Disenrollment Form
•
Medicare Advantage Disenrollment Request
Forms/Examples
EXAMPLE
DECLINATION OF COVERAGE FOR LESS THAN FULL-TIME
ACTIVE EMPLOYEES AND HIPAA NOTIFICATION
If you work less than full-time and receive less than the amount that is contributed towards a full-time employee, you
may decline coverage. If you decline coverage, you and your dependents will not be allowed to enroll until the Open
Enrollment Period. Members who enroll during the Open Enrollment Period will become effective October 1 of the
same year.
If you decline coverage and subsequently become a full-time employee or begin receiving the same contribution as a
full-time employee, you must enroll in the plan the first of the month following the date of this event. If the number of
hours worked increases or payment of coverage by your school district increases, you may choose to enroll the first of
the month following the date of that occurrence.
If you are declining coverage for you and your dependent(s) because you and/or your dependents have coverage
elsewhere and you subsequently lose coverage, you may enroll yourself or your dependents immediately provided you
notify the district within 30 days of loss of coverage. Effective April 1, 2009 loss of coverage under a Medicaid plan,
loss of coverage under Children’s Health Insurance Program (CHIP) or eligibility to participate in a premium assistance
program under Medicaid or CHIP gives rise to special enrollment rights. You must notify the district within 60 days of
loss of coverage or becoming eligible for premium assistance. You must submit a completed and signed enrollment or
change form along with a copy of the Certificate of Coverage from the “coverage elsewhere” or evidence of loss of
coverage elsewhere.
In addition, if you have a new dependent as a result of marriage, birth, adoption, placement for adoption, or placed in
your home as a result of court ordered custody or guardianship, you may enroll yourself and your dependents, provided
you request enrollment within 30 days following the date of this event. Again, you must submit a completed and signed
enrollment or change form.
If you fail to notify your employer that your dependent(s) is no longer eligible for coverage under your plan, they may
not be eligible for continuation coverage under the COBRA or CalCOBRA law.
I have read and understand the above notification. I understand that, if I decline coverage, I will be not be able to enroll
in coverage until the district’s Open Enrollment period for an October 1 effective date or because of one or more of the
events listed above.
I am declining health care coverage due to the following reason(s):
_____________________________________________________________________________________________
____________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Print Name: ________________________________________________________________________________
Signature: ______________________________________________
Date:_____________________________
Social Security Number: ____________________________________
61
Forms/Examples
EXAMPLE
DECLINATION OF COVERAGE FOR DEPENDENTS OF FULL-TIME
ACTIVE EMPLOYEES AND HIPAA NOTIFICATION
If you are declining coverage for your dependent(s) because they have coverage elsewhere and they subsequently
lose coverage, you may enroll your dependents immediately provided you notify the district within 30 days of loss of
coverage. Effective April 1, 2009 loss of coverage under a Medicaid plan, loss of coverage under Children’s Health
Insurance Program (CHIP) or eligibility to participate in a premium assistance program under Medicaid or CHIP gives
rise to special enrollment rights. You must notify the district within 60 days of loss of coverage or becoming eligible for
premium assistance. You must submit a completed and signed change form along with a copy of the Certificate of
Coverage from the “coverage elsewhere” or evidence of loss of coverage elsewhere.
In addition, if you have a new dependent as a result of marriage, birth, adoption, placement for adoption, or placed in
your home as a result of court ordered custody or guardianship, you may enroll your dependents, provided you request
enrollment within 30 days following the date of this event. You must submit a completed and signed enrollment or
change form.
If you fail to notify your employer that your dependent(s) is(are) no longer eligible for coverage under your plan, they
may not be eligible for continuation coverage under the COBRA or CalCOBRA law.
I have read and understand the above notification. I understand that, if I decline coverage for my dependents, I will not
be able to enroll them in coverage until the district’s Open Enrollment period for an October 1 effective date or because
of one or more of the events listed above.
I am declining health care coverage for my dependents due to the following reason(s):
_____________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Print Name: ________________________________________________________________________________
Signature: _______________________________________________
Date: __________________________
Social Security Number: ____________________________________
62
Forms/Examples
DECLINATION OF COVERAGE FOR RETIREES
I,
, understand that as a retiree of
________________________________________ School District, I am eligible to continue the same district coverage
that active employees enjoy. If I decline district coverage, I may enroll in one of the SISC Individual Retiree Plans if
offered by my school district. If I enroll in a SISC Individual Retiree Plan, I give up my right to enroll in district coverage
at any subsequent date. If I do not elect SISC coverage, my spouse/dependents may not participate in any SISC
coverage. If I do not enroll in dental and/or vision coverage at the time of my retirement, I may not enroll in dental
and/or vision at any subsequent date.
I have chosen to enroll in the following product(s) and the enrollment form(s) for me and my eligible dependent(s) is/are
attached:
( )
CompanionCare (a Medicare Supplement)
( )
Health Net Seniority Plus
( )
Kaiser Permanente Senior Advantage
Or
( )
Dental and vision only
( )
Dental only
( )
Vision only
Or
( )
I decline any and all coverage offered by SISC
Effective Date:_________________
I understand that by declining district coverage and the individual retiree plan coverage offered through SISC, that I
give up my right to enroll in any SISC coverage at any subsequent date. I further understand that my decision is
irrevocable.
Retiree Signature: ______________________________________ Date: ________________________
For district use only. Please do not forward to SISC.
63
Forms/Examples
CREDITABLE COVERAGE DISCLOSURE
Important Notice From SISC About Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it.
No action is needed to keep your current SISC benefits in place.
SISC has determined that the prescription drug coverage through your school district is creditable. This means
that the amount the plan expects to pay on average for prescription drugs for individuals covered by the plan in
2009 is the same or more than what standard Medicare prescription drug coverage (Medicare D) would be
expected to pay on average.
Creditable coverage is important. It means you can keep your benefits through the school district and if you later
decide to enroll in Medicare D you will not have to pay extra.
Medicare’s new prescription drug coverage began effective January 1, 2006 and will be available for an additional
premium to everyone with Medicare A & B through various vendors that have been approved by Medicare to
provide this benefit. All of these Medicare D plans will provide at least a standard level of coverage set by
Medicare. Some plans might also offer more coverage for a higher monthly premium.
Because your existing coverage is, on average, at least as good as standard Medicare D prescription
drug coverage, you can keep your existing coverage and not pay extra if you later decide to enroll in a
Medicare D plan.
th
People with Medicare A & B can enroll in a Medicare D prescription drug plan between November 15 and
st
December 31 . Unless you plan on dropping your existing SISC benefits, it would not be worthwhile to purchase
a Medicare D plan. The SISC plan and the Medicare D plan will not coordinate in any way.
If you decide to enroll in a Medicare D prescription drug plan and drop your SISC coverage, be aware that
you cannot come back to SISC coverage at a later date.
You should also know that if you drop or lose your coverage with SISC and do not enroll in a Medicare D
prescription drug plan after your current coverage ends, you may pay more to enroll in a Medicare D prescription
drug plan later. If you go without prescription drug coverage for 63 days or longer that is at least as good as
Medicare’s prescription drug coverage, your monthly premium for Medicare D would be at least 1% higher per
month for every month after you do not have coverage. For example, if you go 19 months without creditable
coverage, your Medicare D premium will always be at least 19% higher than what other people pay for Medicare
D. You will have to pay this higher Medicare D premium as long as you have Medicare D coverage. In addition,
you may have to wait until next November to enroll.
More detailed information about Medicare D plans that offer prescription drug coverage is available in the
Medicare & You 2008 handbook. You will get a copy of the handbook in the mail from Medicare. You may also
be contacted directly by Medicare-approved prescription drug plans. You can also get more information about
Medicare prescription drug plans from these resources:
●
●
●
Visit www.medicare.gov for personalized help.
Call your State Health Insurance Assistance Program (see your copy of the Medicare & You 2009
handbook for their telephone number).
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available.
Information about this extra help is available from the Social Security Administration (SSA). For more information
about this extra help, visit SSA online at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800325-0778).
64
Forms/Examples
XYZ School District
12345 Main Street
Any Town, California 12345
Telephone: (555) 123-4567 Fax: (555) 765-4321
August 25, 2009
(Please only list changes and/or new plan options
no need to list benefits that will not change)
SISC Account Manager (Insert Name)
SISC
P.O. Box 1847
Bakersfield, CA 93303-1847
Dear SISC Account Manager (Insert Account Manager name):
The certificated and classified employees of our school district have elected to implement the following changes
and/or new plan. The changes/new plans they will be offering effective October 1, 2009, are listed below.
EXAMPLE OF NEW PLAN OFFERING
EXAMPLE OF BENEFIT CHANGE
PPO 100%-B - $10 co-pay
$557.00
Rx $5-10
137.00
(These are the only two benefits that will
change)
PPO 90%-D - $10 co-pay
$484.00
Rx $3-15
120.00
Delta Dental $1,000
72.00
VSP B $10
17.52
Life
1.40
(No need to list existing benefits that will not
change)
Total:
Total:
$694.00
$694.92
We would also like to offer employees an additional dental plan; Delta Preferred Option, $1,500 with Ortho A
50%/$2,000 for $63.80 monthly. Current employees will complete a plan election form and we will submit a listing
of employees who have elected Plan #1 or #2 by September 10th.
If you should have questions, please call my administrative assistant Betty White at the phone number given
above.
Sincerely,
John Smith
Superintendent
65
Forms/Examples
PLAN ELECTION FORM
ABC SCHOOL DISTRICT
OCTOBER 1, 2009
Employees may choose between one of the following medical plans. Please make your choice by
checking the box under the plan and initial your choice.
100-C
$200/$400
Not Applicable
100%
100%
100%
Non-Par Fee
BHP 2000
$5-10/$10-20
Medical Plan:
Individual/Family Deductible(s):
Co-Insurance Maximum:
Hosp, Surg, X-Ray and Lab:
Doctor Visits:
Other Professional:
Out-of-Network Payment:
Behavioral Health Plan:
Prescription Drug Co-pay:
90-A
$100/$300
$300 per individual
90%
$10 co-pay
90%
Non-Par Fee
BHP 2000
$5-10/$10-20
Check one of the boxes to the
right and initial your selection.
Initial
Initial
I understand that the only time that I may change from one medical plan to another plan is during the
district's designated Open Enrollment Period for an effective date of October 1. If I gain a dependent (i.e.
marriage, birth or adoption), I can add those dependents by completing a change form, but I cannot
change from one medical plan to another medical plan at anytime except during the Open Enrollment
Period for an effective date of October 1.
PRINT YOUR NAME CLEARLY
DATE
SIGNATURE
This form will be placed in your personnel file.
Please do not send this form to SISC.
Forms/Examples
66
For District Use Only
Group Number
Eff. Date
DELTA DENTAL DESIGNATION FORM
1. DISTRICT NAME:
DISTRICT ID #:
2. PERSONAL INFORMATION:
NAME:
[
[
] MALE
] FEMALE
Last
Street Address
City
Social Security Number
Birthdate
First
State
Zip
MI
Phone
(
)
3. SELECT COVERAGE:
[
] DELTA PREMIER INCENTIVE PLAN
[
] DELTA PPO (DPO) PLAN
By choosing the PPO/DPO Plan I understand that I am responsible for a greater portion of my dental costs
when I use a non-preferred provider. I realize that I cannot change to the Delta Traditional Incentive Plan
until a subsequent Open Enrollment period generally held in September with an October 1 effective date. I
also understand that if I choose to change to the Incentive Plan during an Open Enrollment, my benefits will
start at 70%.
4. SIGNATURE:
Subscriber's Signature
Date
Forms/Examples
67
COMPANIONCARE / MEDICARE SUPPLEMENT
DISENROLLMENT REQUEST
SISC GROUP PLAN
PLEASE PRINT IN INK
FIRST
MI.
MEMBER I.D.
ADDRESS
CITY
STATE
ZIP
TELEPHONE #
SEX
DATE OF BIRTH
MEMBER NAME
LAST
‫ ڤ‬MALE
MEDICARE #
COUNTY
‫ ڤ‬FEMALE
GROUP #
SOCIAL SECURITY #
PLEASE READ CAREFULLY AND COMPLETE THE INFORMATION BELOW BEFORE SIGNING AND DATING THE DISENROLLMENT FORM.
CURRENT HEALTH PLAN
( ) CompanionCare/Medicare Supplement
( ) I WISH TO DISENROLL FROM COMPANION CARE / MEDICARE SUPPLEMENT.
When the medical portion of this plan is terminated then the Medicare Part D prescription drug plan is also
terminated automatically with the same termination date.
( )
I WISH TO ENROLL WITH THE PLAN LISTED BELOW.
NEW HEALTH PLAN (DISTRICT MUST OFFER PLAN)
( ) Health Net Seniority Plus
( ) Other_________________________________
( ) Kaiser Senior Advantage
Effective Date_________________________________
Requested disenrollment date: _____________________________
Disenrollment request must be 45 days advance notice. No exceptions.
Member Signature:
Date: __________________
SISC USE ONLY
Date received:
Date submitted to Health Plan:
Processed by: __________________________
Forms/Examples
68
MEDICARE ADVANTAGE PLANS
DISENROLLMENT REQUEST
SISC GROUP PLAN
PLEASE PRINT IN INK
FIRST
MI.
MEMBER I.D.
ADDRESS
CITY
STATE
ZIP
TELEPHONE #
SEX
DATE OF BIRTH
MEMBER NAME
LAST
‫ ڤ‬MALE
MEDICARE #
COUNTY
‫ ڤ‬FEMALE
GROUP #
SOCIAL SECURITY #
PLEASE READ CAREFULLY AND COMPLETE THE INFORMATION BELOW BEFORE SIGNING AND DATING THE DISENROLLMENT FORM.
CURRENT HEALTH PLAN
( ) Health Net Seniority Plus
( ) Kaiser Senior Advantage
( ) I WISH TO RETURN TO MEDICARE COVERAGE.
( ) I WISH TO DISENROLL FROM THE ABOVE HMO PLAN AND ENROLL WITH THE PLAN LISTED BELOW.
NEW HEALTH PLAN (DISTRICT MUST OFFER PLAN)
( ) Health Net Seniority Plus
( ) Other_________________________________
( ) Kaiser Senior Advantage
Effective Date_________________________________
Members who have requested disenrollment must continue to receive all medical care (except for
emergencies, out-of-area urgent care, or authorized referrals) from their HMO plan until the effective date of
the disenrollment.
Requested disenrollment date: _____________________________
Medicare benefits may only be restored on the first of the month. The process to restore your Medicare benefits
requires a minimum of forty-five (45) days; therefore, this disenrollment form must be received by SISC at least
forty-five (45) days prior to the date you need your Medicare benefits restored. No exceptions.
Member Signature:
Date received:
Date: __________________
SISC USE ONLY
Date submitted to Health Plan:
Processed by: ____________________________
Forms/Examples
69
TELEPHONE NUMBERS - Who to Contact
Please furnish employees with one of the following phone numbers when they need a new I.D. card or have questions regarding
benefits or claims (phone numbers beginning with 800 or 866 are toll-free):
CLAIMS & CUSTOMER SERVICE
BEHAVIORAL HEALTH PLANS
PacifiCare Behavioral Health (Customer Service and Authorization of Services – www.pbhi.com)...........(800) 999-9585
Behavioral Health Program (Customer Service only – www.anthemeap.com).................………………….(800) 825-5541
Behavioral Health Program (Authorization of Services only)……………………………….………………….(800) 999-7222
ANTHEM BLUE CROSS (www.anthem.com/ca/sisc) ..…………………………………………………………….See I.D. Card
BLUE SHIELD (www.blueshieldca.com) …………………………………………………………………………….See I.D. Card
DELTA DENTAL (www.deltadentalins.com) ……………………………………………………………………..(866) 499-3001
MEDCO (www.medcohealth.com)
Customer Service and Mail Order Service ………………………………………………………..………..…...(800) 987-5241
HEALTH MAINTENANCE ORGANIZATION (HMO) PLANS
Blue Shield HMO (www.blueshieldca.com) .............................................................................................(800) 642-6155
Anthem Blue Cross HMO (www.anthem.com/ca/sisc)…………………………………………...….………..(800) 227-3771
Health Net (www.healthnet.com) ……………………………………………………………………...….……..(800) 522-0088
Kaiser Permanente (www.kaiserpermanente.org) ……………………………………………………….……(800) 464-4000
INDIVIDUAL RETIREE PLANS/MEDICARE ADVANTAGE PLANS
CompanionCare……………………………………………………………………………………………………...(800) 825-5541
Health Net Seniority Plus……………………………………………………………………………………………(800) 275-4737
Kaiser Senior Advantage……………………………………………………………………………………………(800) 464-4000
VISION SERVICE PLAN (VSP) (www.vsp.com)………………………………………………………………… .(800) 877-7195
MEDICAL EYE SERVICES (www.mesvision.com)…………………………………………………………………(800) 877-6372
COBRA
Hilda Tapia ([email protected])…................……………………………………………………………………..(661) 636-4651
I.D. CARDS .............................................................................................................................................. See Vendor Website
The following SISC phone numbers should be used by district personnel to address questions regarding eligibility or reporting
procedures.
Eligibility Technicians
Fax (661) 636-4094
DIRECT LINES
Rita Bright
([email protected]) ........................................................................................................ (661) 636-4869
Julie Coleman
([email protected]) .................................................................................................. (661) 636-4508
Nicole Henry
([email protected])....................................................................................................... (661) 636-4408
Maria Pierce
([email protected]).................................................................................................... (661) 636-4397
Bobbie Wellwood ([email protected])................................................................................................. (661) 636-4307
SISC Account Management Teams
Fax (661) 636-4893
Raquel Acebedo
Heather Clark
([email protected]) …………………………………………………………………...…..(661) 636-4713
([email protected]) ….……………………………………………………………………..... (661) 636-4533
Lola Nickell
Karen Morovich
([email protected]) …………………………………………………………………………. (661) 636-4669
([email protected])…………………………………………………………………...…..(661) 636-4622
Lauri Phillips
Kim Lyon
([email protected]) ……………………………………………………………………….....(661) 636-4711
([email protected]) ……………………………………………………………….………...… .(661) 636-4626
70
Phone Numbers and Addresses
CUSTOMER SERVICE PHONE NUMBERS & ADDRESSES FOR
CLAIMS INFORMATION & PROCESSING
The SISC III office does not process medical claims. Our medical claims are processed by one of the offices listed
below. Physicians or subscribers should forward their claim to address on the member’s I.D. card.
ALL CLAIMS SENT TO OUR OFFICE WILL BE RETURNED DIRECTLY TO THE DOCTOR OR THE SUBSCRIBER
WHO SENT IT TO THE SISC OFFICE.
ANTHEM BLUE CROSS PPO PLANS
Foundation for Medical Care of Kern County
PO Box 12020
Bakersfield, CA 93389-2020
5701 Truxtun Avenue #100
Bakersfield, CA 93309
(661) 327-7581/(800) 322-5709
Foundation for Medical Care of Tulare & Kings Counties, Inc.
3335 South Fairway
Visalia, CA 93277
(559) 734-1321/(800) 662-5502
Coastal Healthcare Administrators
Post Office Box 80308
Salinas, CA 93912
(800) 564-7475
Anthem Blue Cross of California
Rancho Cordova
P.O. Box 60007
Los Angeles, CA 90060-0007
(800) 365-0020
ANTHEM BLUE CROSS PPO OR HMO PLANS
Anthem Blue Cross of California
Woodland Hills
Post Office Box 60007
Los Angeles, CA 90060-0007
(800) 825-5541
BLUE SHIELD HMO PLANS
Blue Shield of California
(800) 642-6155
BLUE SHIELD PPO PLANS
Blue Shield of California
P.O. Box 272550
Chico, CA 95927-2250
(800) 642-6155
71
Phone Numbers and Addresses
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