2014-2015 retiree benefits brochure for classified …...2014-2015 retiree benefits brochure for...

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2014-2015 Retiree Benefits Brochure for Classified Members DISCLAIMER The information in this brochure is a general outline of the benefits offered under the SOCCCD benefits program. Specific details and limitations are provided in the plan documents which may include a Summary Plan Description (SPD), Evidence of Coverage (EOC) and/or insurance policies. The plan documents contain the relevant plan provisions. If the information in this brochure differs from the plan documents, the plan documents will prevail. WHAT’S INSIDE Retiree Benefits Checklist ...................................... 2 Frequently Asked Questions .................................. 3 Medical Plans ........................................................ 6 Dental Plan ......................................................... 10 Vision Plan .......................................................... 10 Rules For Benefit Changes During The Year ......... 11 Required Federal Notices .................................... 12 Health Plan Rates ................................................ 14 Notes .................................................................. 15 Who Should You Call? ......................................... 16 Dear Retiree: South Orange County Community College District takes pride in offering a comprehensive benefit program to all eligible members. It has been our goal to provide you and your families with a "best-in-class" benefits program and we believe we have achieved that goal. 2014/2015 PLAN OFFERINGS: Retirees Under Age 65 Medical: - Blue Shield HMO Plan or - Blue Shield PPO Plan Dental: - Delta Dental PPO Plan Vision: - VSP Plan AD&D: - Zurich Insurance (eligible benefit to age 70) Retirees Age 65+ who are enrolled in Medicare A and B Medical: - Blue Shield COB PPO Plan (retirees and their spouses/domestic partners age 65+) or - Companion Care Medicare Supplement Plan (retirees and their spouses/domestic partners age 65+) or - Blue Shield 65+ HMO Medicare Advantage Plan (retirees age 65+) Dental: - Delta Dental PPO Plan (voluntary/retiree paid) Vision: - VSP Plan (voluntary/retiree paid) AD&D: - Zurich Insurance (eligible benefit to age 70)

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Page 1: 2014-2015 Retiree Benefits Brochure for Classified …...2014-2015 Retiree Benefits Brochure for Classified Members DISCLAIMER The information in this brochure is a general outline

2014-2015 Retiree Benefits Brochure

for Classified Members

DISCLAIMER The information in this brochure is a general outline of the benefits offered under the SOCCCD benefits program. Specific details and limitations are provided in the plan documents which may include a Summary Plan Description (SPD), Evidence of Coverage (EOC) and/or insurance policies. The plan documents contain the relevant plan provisions. If the information in this brochure differs from the plan documents, the plan documents will prevail.

WHAT’S INSIDE

Retiree Benefits Checklist ...................................... 2

Frequently Asked Questions .................................. 3

Medical Plans ........................................................ 6

Dental Plan ......................................................... 10

Vision Plan .......................................................... 10

Rules For Benefit Changes During The Year ......... 11

Required Federal Notices .................................... 12

Health Plan Rates ................................................ 14

Notes .................................................................. 15

Who Should You Call? ......................................... 16

Dear Retiree: South Orange County Community College District takes pride in offering a comprehensive benefit program to all eligible members. It has been our goal to provide you and your families with a "best-in-class" benefits program and we believe we have achieved that goal.

2014/2015 PLAN OFFERINGS: Retirees Under Age 65

Medical: - Blue Shield HMO Plan or

- Blue Shield PPO Plan

Dental: - Delta Dental PPO Plan Vision: - VSP Plan AD&D: - Zurich Insurance (eligible benefit to age 70)

Retirees Age 65+ who are enrolled in Medicare A and B

Medical: - Blue Shield COB PPO Plan (retirees and their spouses/domestic partners age 65+) or - Companion Care Medicare Supplement Plan (retirees and their spouses/domestic partners age 65+) or

- Blue Shield 65+ HMO Medicare Advantage Plan (retirees age 65+)

Dental: - Delta Dental PPO Plan (voluntary/retiree paid) Vision: - VSP Plan (voluntary/retiree paid) AD&D: - Zurich Insurance (eligible benefit to age 70)

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The following must be completed no later than 15 days prior to your Retiree Benefits Effective Date Only Retirees 65+:

Complete Retiree Benefit Election Form

Provide a copy of your Medicare card to District Benefits

Complete Blue Shield Subscriber Change Form, if deleting dependent(s) from coverage

Complete COBRA Enrollment Form, if applicable

Complete Companion Care Enrollment Form, if applicable (Must be returned to District Benefits 60 days prior to Retiree Benefits Effective Date)

Complete Blue Shield 65+ HMO Medicare Enrollment Form, if applicable (Must be returned to District Benefits 60 days prior to Retiree Benefits Effective Date)

Complete Dental and/or Vision Forms, if electing to Self Pay

Complete Accidental Death & Dismemberment Zurich Insurance beneficiary designation form

Provide payment to District Benefits for 1st month of voluntary/self pay benefits, if electing (Make check payable to SOCCCD)

Use Dental and/or Vision benefits by your Retiree Benefits Effective Date, if needed All Retirees:

Provide a copy of your dependent’s Medicare card to District Benefits, if dependent is 65+

Complete and Mail Long Term Care Portability Form to UNUM, if electing to self pay for coverage

Submit FSA Receipts for Reimbursement, if applicable

Utilize Hyatt Legal Benefits, if needed

Complete Accidental Death & Dismemberment Zurich Insurance beneficiary designation form

RETIREE BENEFITS CHECKLISTRETIREE BENEFITS CHECKLISTRETIREE BENEFITS CHECKLIST

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What are the eligibility requirements for benefits after retirement?

What benefits are available to me and my dependents at the time of retirement? If you are a retiree under age 65, you and your eligible dependents are provided the District paid medical, dental, and vision plans you are currently enrolled in. The District will continue to pay 100% of the premiums until the 1st of the month in which you turn 65.

If you are a retiree age 65+, you and your eligible dependent(s) are eligible to purchase a medical plan, dental plan and/or vision plan through the District on a self pay basis provided that you enroll in Medicare A and B, and supply the District with a copy of your Medicare Card. All retirees (with the exception of POA) are eligible to purchase Dental and Vision once they reach age 65 and are eligible for retiree benefits.

Who qualifies as an eligible dependent? An eligible dependent is defined as your spouse/domestic partner, and children up to age 26. Children include stepchildren, children placed under a “qualified medical child support order”, adopted children, or children in which you have established legal guardianship. An employee’s domestic partner is defined as a legally registered and valid domestic partnership. A copy of the declaration of domestic partnership must be supplied to the District upon enrollment.

What happens when I turn 65, but my spouse/domestic partner is still under 65 and/or my dependent is under age 26? The retiree has purchased Medicare A and B coverage, if eligible to purchase such coverage; and the District shall provide retired employees who qualify for continuation of benefits with the option to purchase (at employee expense) medical coverage, provided the retiree has obtained Medicare A and B coverage. The retiree and dependent must stay on the early retiree plan and will be responsible to pay the District’s cost of the early retiree medical coverage for the retiree and dependent(s). The retiree must submit proof of Medicare Parts A and B.

What if my spouse/domestic partner turns 65, but I am still under 65? Your spouse/domestic partner must enroll in Medicare A and B, and provide a copy of their Medicare card to the District. You and your eligible dependents which include your spouse/domestic partner, and children up to age 26, will remain on the District paid benefits plan until the 1st of the month in which you turn 65.

What happens if I or my spouse/domestic partner does not enroll in Medicare when eligible? If the retiree or spouse/domestic partner does not enroll in Medicare A and/or B when eligible, or fails to provide the District with a copy of their Medicare card, the retiree shall pay any penalty, fee, or other cost imposed by the insurance carrier. If the retiree fails to pay any costs associated with coverage, the coverage will be terminated.

Important Medicare Information: You and your spouse/domestic partner must supply a copy of your/their Medicare part A and B card to the District no later than 15 days prior to the first of the month in which you/they turn 65. Members must NOT enroll in Medicare D.

Eligibility Requirements

Minimum Age 60

Minimum Service Employed full-time with the District for ten (10) consecutive years immediately preceding the date of retirement

Retirement

Concurrent retirement from your applicable retirement system (STRS or PERS) and the District

FREQUENTLY ASKED QUESTIONSFREQUENTLY ASKED QUESTIONSFREQUENTLY ASKED QUESTIONS

(Continued on next page)

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How much does Medicare cost? Medicare A: Most people receive Part A premium-free because they or their spouse paid Medicare taxes while working. If you do not qualify for premium-free Part A, you could pay up to $426/month (2014 rate). If you pay a late enrollment penalty, this amount is higher. In most cases, if you choose to buy Part A, you must also purchase Part B.

Medicare B: Most people pay the standard premium amount. However, if your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you may pay more. Premium amounts can change each year depending on your income. Current Medicare Part B premium amounts are listed below. If your yearly income in 2012 was If you have questions about your Medicare premiums, you can contact Social Security at 1-800-772-1213.

What are my options for Dental and Vision coverage after retirement? If you are a retiree under age 65, Dental and Vision benefits will continue to be paid by the District for you and your eligible dependents until the 1st of the month in which you turn 65.

If you are a retiree age 65+, Dental and Vision benefits are available through the District on a self pay basis. You are eligible to purchase Dental and/or Vision benefits for yourself and your eligible dependents.

When do I enroll in the voluntary/self pay benefits? You must enroll when first eligible. You cannot enroll at a future date. All payments are due by the 15th of the month prior to the month of coverage. If you elect to discontinue participation in the plan, or fail to make timely payments, your benefits will terminate and you will be unable to re-enroll in the plan at a later date.

When am I allowed to make changes to my benefits? You are able to make changes to your voluntary/self pay benefits when you experience a qualifying event (marriage, divorce, loss of coverage, etc.). You must notify the District, and return completed forms within 30 days of the qualifying event, in order to add or delete dependents. If you do not elect coverage in a voluntary/self pay plan when first eligible, then you will not be given the opportunity to enroll during Open Enrollment.

What benefits end upon retirement with the District? Your Hyatt Legal Plan, OptumHealth EAP, Anthem EAP, Reliance Standard Life Insurance, Reliance Standard Long Term Disability, SISC Flexible Spending Account, and UNUM Long Term Care Insurance will all end on the last day of the month in which you retire.

UNUM Long Term Care Insurance is the only portable benefit available to retirees. A UNUM Long Term Care portability form will be mailed to your home after retirement. In order to keep your coverage through UNUM on a self pay basis, you must return the portability form to UNUM within 30 days of your benefits end date.

FREQUENTLY ASKED QUESTIONSFREQUENTLY ASKED QUESTIONSFREQUENTLY ASKED QUESTIONS

(Continued on next page)

File Individual Tax Return File Joint Tax Return You Pay

$85,000 or less $170,000 or less $104.90

$85,001–$107,000 $170,000–$214,000 $146.90

$107,001–$160,000 $214,000–$320,000 $209.80

$160,001–$214,000 $320,000–$428,000 $272.70

above $214,000 above $428,000 $335.70

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What Benefits are available when I become Medicare eligible? The District shall provide retired employees who qualify for continuation of benefits the option to purchase at employee expense supplemental medical coverage, provided the retiree has obtained Medicare A and B coverage. Qualifying members must submit proof that they have obtained Medicare A and B. This benefit is subject to the approval of the District Insurance carrier. The retiree may select from Options A or B subject to the conditions set forth herein.

Option A: The current District supplemental medical plan is available to retirees. The cost for the plan to the retired employee shall be the actual cost paid by the District which is to be paid monthly by the retiree in advance to the District. Payment must be received by the 15th of the month prior to the month of coverage. If payment is not received by the first day of the month of coverage the employee shall be dropped from the coverage and unable to participate in the future. The District reserves the right to establish a separate medical insurance pool for retirees who qualify under this section. Option B: The Companion Care Medicare Supplemental Plan and the Blue Shield 65+ HMO Medicare Advantage Plan will also be offered to retirees as long as the District is covered by the Self-Insured Schools of California (SISC). This program is directly administered by SISC. If a retired member elects one of these plans they cannot return to the District sponsored Supplement plan.

CSEA Retiree 65+ Voluntary Medical Options

What plans are available? District PPO COB Plan Companion Care Supplement Plan (individual plan that is available only to eligible retirees and their

spouses who have Medicare Parts A and B. Enrollment takes a minimum of 45 days.) Blue Shield 65+ HMO Medicare Advantage Plan (individual plan that is available only to eligible retirees

who have Medicare Parts A and B. Enrollment takes a minimum of 45 days.)

What about Medicare? District PPO COB Plan: Members must supply proof of Medicare part A and B to the District prior to the first of the month in which the member turns age 65. Companion Care and Blue Shield 65+ HMO Medicare Advantage Plans: Members must submit proof of part A and B with application at least a minimum of 45 days prior to coverage effective date. Proof of Medicare must be submitted on all enrolled members who are over age 65 (including spouses in the case of Companion Care). If a member is missing part A or B or both, they will only be allowed to enroll in the COB PPO plan and will pay a higher rate. Members must NOT enroll in Medicare D. This is because prescription drug coverage is included in the COB PPO plan, and Medicare Part D enrollment is automatic with Companion Care and Medicare Advantage plans. Please Note: Retiree members with spouses who are under age 65 will remain on the early retiree PPO plan until that spouse becomes Medicare eligible. The retiree member will be charged the early retiree composite rate and must submit proof of Medicare Parts A and B.

FREQUENTLY ASKED QUESTIONSFREQUENTLY ASKED QUESTIONSFREQUENTLY ASKED QUESTIONS

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Schedule of Benefits Blue Shield HMO Plan

Medical Plan Copays/Limits In-Network

Lifetime Maximum None

Calendar Year Deductible None

Calendar Year Out-of-Pocket Maximum1 $1,000 Individual / $2,000 Family

Hospitalization Services

Inpatient No Charge

Outpatient No Charge

Emergency Room (Copay waived if admitted) $100/Visit

Outpatient Professional Services

Office and Authorized Specialist Visit $5/Visit

Access+ Specialist Visit1 $30/Visit

Adult Routine Physical Exam No Charge

X-Ray & Lab Procedures No Charge

Home Health Care $5/Visit

Durable Medical Equipment 20%

Chiropractic Services (up to 30 visits per calendar year)2 $10/Visit

Mental Health / Substance Abuse

Inpatient / Facility Based No Charge

Outpatient Visit $5/Visit

Prescription Drugs (through Navitus)3,4,5

Retail (30 day supply)

Generic $5 Copay

Brand $10 Copay

Mail Order (90 day supply)

Generic $10 Copay

Brand $20 Copay

HMO MEDICAL PLANHMO MEDICAL PLANHMO MEDICAL PLAN

When you enroll in the HMO plan, you choose a primary care physician (PCP) for each enrolled family member from a medical group or IPA. The PCP will coordinate and provide all of your care, including hospital admissions. You can select a PCP by visit-ing the Blue Shield website at www.blueshieldca.com/SISC. You will need a referral from your PCP if you need to see a

specialist.

Retirees enrolled in the Blue Shield HMO plan will have prescription drug coverage through Navitus. If you are taking prescrip-tion medications on a regular basis, you may save time and money by using the mail service pharmacy. If you have questions you may call Navitus Member Services 24 hours a day, seven days a week toll free at (866) 333-2757 or visit the Navitus web-site at www.navitus.com.

Early Retirees prior to age 65

1. Not all copayments/coinsurance apply to the out-of-pocket maximum. 2. The Blue Shield HMO Chiropractic Benefit Rider is being enhanced to include Acupuncture services effective 10/1/2014. 3. Effective 10/1/2014, this plan will feature $0 copays on Generics at Costco as well as through Costco Mail Order. Members can choose to

receive 90- supplies of their long-term medications at a Costco walk-in pharmacy. The 90-day copays at Costco walk-in pharmacies will be the same as the Mail Order copays. Costco membership is not required to use the Costco pharmacy.

4. Specialty Medications as well as some narcotic pain medications and cough medications are not included in the Costco lower generic copays or the 90-day supply programs.

5. Due to Medicare Part D restrictions, this program does not apply to the CompanionCare pharmacy benefit.

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PPO MEDICAL PLANPPO MEDICAL PLANPPO MEDICAL PLAN Early Retirees prior to age 65

Schedule of Benefits Blue Shield PPO Plan

Medical Plan Copays/Limits In-Network1 Out-of-Network1 Retiree Pays Calendar Year Deductible $100 Individual / $300 Family

Calendar Year Out-of-Pocket Maximum $400 Individual / $1,200 Family Hospitalization Services

Inpatient 10% No Charge2, 3 (Up to $600/Day)

Outpatient 10% No Charge (Up to $350/Day)

Emergency Room (Copay waived if admitted) 10% + $100/Visit

Outpatient Professional Services

Office and Specialist Visit $10/Visit4 10%2

Adult Routine Physical Exam No Charge4 Not Covered

Well-Baby Care No Charge4 10%2

X-Ray & Lab Procedures $10/Visit 10%2

Home Health Care (100 visit maximum per calendar year) 10% Not Covered 5

Durable Medical Equipment 10% 10%2

Chiropractic Services (up to 20 visits per calendar year) $25/Visit 10%2

Acupuncture (up to 12 visits per calendar year) $25/Visit $25/Visit2

Mental Health / Substance Abuse

Inpatient / Facility Based 10% No Charge2, 3 (Up to $600/Day)

Outpatient Visit $10/Visit 4 10%2

Prescription Drugs (through Blue Shield Pharmacy)

Retail (30 day supply) Member pays 25% of allowable amount plus

the below copayment

Generic $3 Copay2 $3 Copay2 Brand Name6 $15 Copay2 $15 Copay2

Mail Order (90 day supply) Generic $3 Copay2 Not Covered2 Brand Name6 $35 Copay2 Not Covered2

1. Member is responsible for copayment in addition to any charges above allowable amounts. 2. Copayments/Coinsurance marked with this footnote do not accrue toward the Calendar Year copayment maximum. 3. Members are responsible for all charges in excess of the per day maximum payment. 4. Not subject to the calendar-year deductible. 5. Out-of-network home health care and home infusion services are not covered unless they are preauthorized. When these services are

preauthorized, members pay the preferred provider copayment. 6. If the member requests a brand-name drug and a generic drug equivalent is available, the member is responsible for paying the difference

between the cost to Blue Shield of California of the brand-name drug and its generic drug equivalent, as well as the applicable generic drug

Members have a choice of using Preferred Providers (PPO) or going directly to any other physician (non-PPO provider) without a referral. Generally, there are annual deductibles to meet before benefits apply. You are also responsible for a certain percentage of the charges (co-insurance), and the plan pays the balance up to the agreed upon amount. Remember to use contracted in-network providers for primary care and referrals. The carriers have negotiated special rates with in-network providers to help keep costs affordable without sacrificing quality; take advantage of these savings opportunities. Retirees enrolled in the Blue Shield PPO plan will have prescription drug coverage through Blue Shield Pharmacy. Blue Shield members can use Blue Shield’s mail service pharmacy by calling (866) 346-7200 or visiting their website at www.myprimemail.com. Please note: Most specialty drugs require prior authorization for medical necessity. If covered, specialty drugs cannot be obtained from a retail participating pharmacy and must be obtained from a Blue Shield Network Specialty Pharmacy. Your doctor must submit a new prescription to the network specialty pharmacy you choose and you will need to enroll with the network specialty pharmacy prior to asking your doctor to send a new prescription. A Blue Shield Specialty Pharmacy may be located at www.blueshieldca.com/SISC under Find a Pharmacy. You may also call the customer service phone number listed on your Blue Shield ID card.

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COMPANION CARE MEDICAL PLAN *COMPANION CARE MEDICAL PLAN *COMPANION CARE MEDICAL PLAN * Retirees 65+ Medicare Eligible

SERVICES MEDICARE

2014 Benefits

COMPANIONCARE Based on 2014 Medicare Benefits

Inpatient Hospital (Part A) Pays all but first $1,216 for 1st 60 days Pays $1,216

Pays all but $304 a day for the 61st to 90th day Pays $304 a day

Pays all but $608 a day Lifetime Reserve for 94st to 150th day

Pays $608 a day

Pays nothing after Lifetime Reserve is used

(refer to Evidence of Coverage) Pays 100% for 151st day to 515th day

Skilled Nursing Facilities Pays 100% for 1st 20 days Pays nothing

(Must be approved by Medicare) Pays all but $152 a day for 21st to 100th day Pays $152 a day for 21st to 100th day

Pays nothing after 100th day Pays nothing after 100th day

Deductible (Part B) $147 Part B deductible per year Pays $147

Basis of Payment (Part B) 80% Medicare Approved (MA) charges after

Part B deductible Pays 20% MA charges including 100% of

Medicare Part B deductible Medical Services (Part B) Doctor, x-ray, appliances, & ambulance lab

80% MA charges Pays 20% MA charges

Physical/Speech Therapy (Part B) 80% MA charges up to the Medicare annual

benefit amount Pays 20% MA charges up to the Medicare

annual benefit amount( PT & ST combined)

Blood (Part B) 80 MA charges after 3 pints Pays 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 the

medically necessary services for 90 days of treatment per lifetime

Outpatient Prescription Drugs Prescription drug plan enhancement through Navitus Health Solutions

Due to Medicare restrictions, the following programs are not available with CompanionCare:

Retail Pharmacy: 30 day $9 Generic copay 90 day $18 Generic copay

$35 Brand copay $90 Brand copay

$0 generic copay at Costco & Diabetic Supplies for Generic copay

Pharmacy benefits are administered through Navitus Health Solutions Medicare Rx using a Med D formulary. Some exclusions and prior authorizations may apply. Members that have questions regarding their medication coverage can call Navitus Solutions Medicare Rx at 1-866-270-3877 or TYY users please call 711.

*Available only to retirees and their spouses/domestic partners who are 65+ and have enrolled in Medicare Parts A and B. Enrollment forms must be turned into the District office no later than 60 days prior to effective date.

CompanionCare is a Medicare Supplement plan that pays for medically necessary services and procedures that are considered a Medicare Approved Expense. SISC will automatically enroll CompanionCare Members into Medicare Part D. No additional premium is required. SISC plans are NOT subject to the “doughnut hole”.

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.

Provider Network: Physicians who accept Medicare assignment. For additional Medicare benefit information, please go to www.medicare.gov or call 1-800-medicare (1-800-633-4273). For additional Navitus Medicare Rx prescription drug information, please go to www.navitus.com or call 1-866-270-3877.

Rate Effective October 1, 2014 Total Cost Per Person Retirees with Medicare A & B Southern Region: $370.00 (SISC will enroll members in part D)

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BLUE SHIELD 65+ HMO MEDICARE ADVANTAGE PLAN *BLUE SHIELD 65+ HMO MEDICARE ADVANTAGE PLAN *BLUE SHIELD 65+ HMO MEDICARE ADVANTAGE PLAN * Retirees 65+ Medicare Eligible

* Office visit co-pay may apply Members must live in an approved Zip Code of the Blue Shield of California GMA-PD Service Area. Please refer to the Group Benefit Summary or Evidence of Coverage for details at http://www.blueshieldca.com/SISC. For additional Medicare benefit information, please go to www.medicare.gov or call 1-800-medicare.

The Blue Shield 65+ HMO is a Medicare Advantage Plan that is offered through a Health Maintenance Organization (HMO) in lieu of Medicare benefits. This plan may be offered to retirees over the age of 65 with Medicare Parts A & B. Retirees cannot use their Medicare benefits while enrolled in this plan. If a member is missing a part of Medicare or does not assign their Medicare to Blue Shield, then the member would not be eligible. Members enrolled in this plan must have continuous Medicare Part A and Part B coverage.

SERVICES BENEFITS

Ambulance $0 copay per trip

Annual Physical Exam - Includes pap smears

$0 copay* $10 copay per visit

Durable Medical Equipment (DME) Medicare covered services

$0 copay

Hospitalization - Inpatient - Outpatient hospital services - Emergency Room

$0 copay per admission

$20 copay $50 copay/waived if admitted within 24 hours for same

condition

Immunizations - Includes flu shots and all Medicare approved immunizations

$0 copay

Laboratory Services No Charge

Manual Manipulation of the Spine $10 copay per visit (subject to medical necessity)

Mental Health - Inpatient No charge for day 1-150. Member pays 100% from day 151+

Mental Health - Outpatient unlimited visits $20 copay

Physician Services/Basic Health Services

- Office visits - Consultation, diagnosis & treatment by a specialist

$20 copay $20 copay

Prescription Drugs (Retail-30 day/Mail Order-90 day supply)

- Generic - Preferred Brand - Non-Preferred Brand - Injectables - Specialty

10/30/50 Three Tiered Plan $10 Retail, $20 Mail Order $30 Retail, $60 Mail Order

$50 Retail, $100 Mail Order 20% up to $100 per prescription Retail, $300 Mail Order 20% up to $100 per prescription Retail, $300 Mail Order

Skilled Nursing Facility Covered in full for 100 days per benefit period

X-Ray Services -Includes routine annual mammography

$0 copay*

*Available only to retirees and their spouses/domestic partners who are 65+ and have enrolled in Medicare Parts A and B. Enrollment forms must be turned into the District office no later than 60 days prior to effective date.

Rate Effective October 1, 2014 Total Cost Per Person Retirees with Medicare A & B (SISC will enroll members in part D) Southern Region: $199.00

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DENTAL PLAN SUMMARYDENTAL PLAN SUMMARYDENTAL PLAN SUMMARY

The dental PPO plan is designed so employees can choose from an extensive network of Delta Dental Dentists or any other provider of your choice. However, by using one of the Delta Dental providers, employees will reduce their out-of-pockets costs. Delta Dental PPO members will be eligible for one additional cleaning per calendar year (for a total of 3 cleanings per cal-endar year). Members will also be eligible for dental implant coverage. Log on to Delta’s website at www.deltadentalins.com or call (866) 499-3001 for more information.

Voluntary Dental Plan for Retirees 65+

The VSP plan offered covers vision exams, frames and lenses. The VSP plan has the largest network of private vision providers in the nation. All VSP network providers are independent optometrists or ophthalmologists in private practice who provide full service. You do have the option of using a non-network provider but the benefit allowances are lower. Log on to VSP’s website at www.vsp.com or call (800) 877-7195 for more information.

Voluntary Vision Plan for Retirees 65+

Schedule of Benefits VSP Vision

In-Network Out-of-Network

Eye Examination, every 12 months $10 Copay Up to $45

Standard Lenses, every 12 months

● Single Covered in Full after $10 Copay

Up to $45

● Bifocal Up to $65

● Trifocal Up to $85

● Lenticular Up to $125

Frame, every 12 months Up to $120 + 20% off over your allowance

Up to $47

Contact Lenses, every 12 months

Medically Necessary Covered Contacts

Covered in Full after $10 Copay Covered in Full after $50 Copay

Up to $250

Up to $250 + $50 Copay

Second pair of glasses, every 12 months $20 Copay N/A

Schedule of Benefits Delta Dental PPO (ACSIG) In-Network Out-of-Network

Calendar Year Deductible $25/Individual (up to $75 per Family) except for diagnostic and preventive

Calendar Year Maximum $3,200 $3,000

Diagnostic & Preventive PLAN PAYS Exams / Cleaning

90% Full Mouth X-rays Fluoride Treatment Space Maintainers

Basic Services PLAN PAYS Oral Surgery

90% after deductible Fillings Root Canals Periodontics

Crowns & Other Cast Restorations PLAN PAYS

Crowns 90% after deductible Inlays / Onlays

Prosthodontics

Orthodontics PLAN PAYS

Adult and eligible dependent child 50% after deductible

Lifetime Maximum $2,000

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Other than during annual open enrollment, you may only make changes to your benefit elections if you experience a qualified status change or qualify for a “special enrollment”. If you qualify for a mid-year benefit change, you may be required to submit proof of the change or evidence of prior coverage. Qualified Status Changes include:

Change in legal marital status, including marriage, divorce, legal separation, annulment, and death of a

spouse.

Change in number of dependents, including birth, adoption, placement for adoption, or death of a dependent

child.

Change in employment status that affects benefit eligibility, including the start or termination of

employment by you, your spouse, or your dependent child.

Change in work schedule, including an increase or decrease in hours of employment by you, your spouse, or

your dependent child, including a switch between part-time and full-time employment that affects eligibility

for benefits.

Change in a child's dependent status, either newly satisfying the requirements for dependent child status or

ceasing to satisfy them.

Change in place of residence or worksite, including a change that affects the accessibility of network

providers.

Change in your health coverage or your spouse's coverage attributable to your spouse's employment.

Change in an individual's eligibility for Medicare or Medicaid.

A court order resulting from a divorce, legal separation, annulment, or change in legal custody (including a

Qualified Medical Child Support Order) requiring coverage for your child.

An event that is a “special enrollment” under the Health Insurance Portability and Accountability Act

(HIPAA) including acquisition of a new dependent by marriage, birth or adoption, or loss of coverage under

another health insurance plan.

An event that is allowed under the Children's Health Insurance Program (CHIP) Reauthorization Act. Under

provisions of the Act, employees have 60 days after the following events to request enrollment if:

Employee or dependent loses eligibility for Medicaid (known as Medi-Cal in CA) or CHIP (known as Healthy Families in CA).

Employee or dependent becomes eligible to participate in a premium assistance program under Medicaid or CHIP.

Two rules apply to making changes to your benefits during the year:

Any change you make must be consistent with the change in status, AND

You must make the change within 30 days of the date the event occurs (unless otherwise noted above).

RULES FOR BENEFIT CHANGES DURING THE YEARRULES FOR BENEFIT CHANGES DURING THE YEARRULES FOR BENEFIT CHANGES DURING THE YEAR

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REQUIRED FEDERAL NOTICESREQUIRED FEDERAL NOTICESREQUIRED FEDERAL NOTICES

NOTICE OF SPECIAL ENROLLMENT RIGHTS FOR MEDICAL/HEALTH PLAN COVERAGE

If you decline enrollment in a South Orange County Community College District health plan for you or your dependents (including your spouse) because of other health insurance or group health plan coverage, you or your dependents may be able to enroll in a South Orange County Community College District health plan without waiting for the next open enrollment period if you:

Lose other health insurance or group health plan coverage. You must request enrollment within [30/31] days after the loss of other coverage.

Gain a new dependent as a result of marriage, birth, adoption, or placement for adoption. You must request [medical plan OR health plan] enrollment within [30/31] days after the marriage, birth, adoption, or placement for adoption.

Lose Medicaid or Children’s Health Insurance Program (CHIP) coverage because you are no longer eligible. You must request medical plan enrollment within 60 days after the loss of such coverage.

If you request a change due to a special enrollment event within the [30/31] day timeframe, coverage will be effective the date of birth, adoption or placement for adoption. For all other events, coverage will be effective the first of the month following your request for enrollment. In addition, you may enroll in South Orange County Community College District medical plan if you become eligible for a state premium assistance program under Medicaid or CHIP. You must request enrollment within 60 days after you gain eligibility for medical plan coverage. If you request this change, coverage will be effective the first of the month following your request for enrollment. Specific restrictions may apply, depending on federal and state law. Note: If your dependent becomes eligible for a special enrollment rights, you may add the dependent to your current coverage or change to another medical plan or health plan. Any other currently covered dependents may also switch to the new plan in which you enroll.

THE WOMEN’S HEALTH AND CANCER RIGHTS ACT

If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

All stages of reconstruction of the breast on which the mastectomy was performed;

Surgery and reconstruction of the other breast to produce a symmetrical appearance;

Prostheses; and

Treatment of physical complications of the mastectomy, including lymphedema. These benefits are subject to the same deductible and co-payments applicable to other medical and surgical benefits provided under this plan. Therefore, the following deductible and coinsurance apply:

HMO Plan - No Charge

PPO Plan - 10% coinsurance You can contact your health plan’s Member Services for more information.

Notice of Availability of HIPAA Privacy Notice The Federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) requires that we periodically remind you of your right to receive a copy of the HIPAA Privacy Notice. You can request a copy of the Privacy Notice by contacting District Benefits.

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REQUIRED FEDERAL NOTICESREQUIRED FEDERAL NOTICESREQUIRED FEDERAL NOTICES

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor

at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). This information is current as of January 31, 2014. For more information, you can contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Ext. 61565

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HEALTH PLAN RATESHEALTH PLAN RATESHEALTH PLAN RATES OCTOBER 1, 2014 OCTOBER 1, 2014 OCTOBER 1, 2014 --- SEPTEMBER 30, 20145SEPTEMBER 30, 20145SEPTEMBER 30, 20145

RETIREE PAID (Voluntary/Self Pay)*rates quoted are monthly

MEDICAL PLANS Retiree Retiree + 1 Retiree + Family Composite

Blue Shield of California PPO (for retirees 65+ with dependents under age 65)

$1,679.00

Medicare COB No Medicare Ret 65+ $1,817.00 $3,634.00 $4,058.00

Medicare COB (with Part A & B) $847.00 $1,694.00 $2,118.00

Medicare COB (with Part A only) $1,267.00 $2,534.00 $2,958.00

Medicare COB (with Part B only) $1,397.00 $2,794.00 $3,218.00

Companion Care Medicare Supplement (When Enrolled in Medicare A & B)

$370.00

Blue Shield 65+ HMO Medicare Advantage (When Enrolled in Medicare A & B)

$199.00

MEDICAL PLANS AVAILABLE TO SPOUSE/DOMESTIC PARTNER Spouse/Domestic

Partner

Blue Shield PPO (for Spouse/Domestic Partner under 65) $832.00 *

Blue Shield COB PPO (When Enrolled in Medicare A & B) $847.00

Companion Care Medicare Supplement (When Enrolled in Medicare A & B) $370.00

DENTAL & VISION PLANS AVAILABLE Retiree Retiree + 1 Retiree + Family

Delta Dental PPO $123.67 $210.23 $321.54

VSP Plan $36.25 $72.55 $85.25

* Rates assume enrollment with Retiree, and not offered as a stand alone.

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NOTESNOTESNOTES

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INSURANCE CARRIERS/ADMINISTRATORSINSURANCE CARRIERS/ADMINISTRATORSINSURANCE CARRIERS/ADMINISTRATORS

Membership Contact InformationMembership Contact InformationMembership Contact Information

CARRIER PHONE NUMBER GROUP ID# WEBSITE

HMO by Blue Shield/SISC (800) 642-6155 See I.D. Card www.blueshieldca.com/SISC

Navitus (for Blue Shield HMO members) (866) 333-2757 www.navitus.com

PPO by Blue Shield/SISC See I.D. Card See I.D. Card www.blueshieldca.com/SISC

Blue Shield Pharmacy (for Blue Shield PPO members) (866) 346-7200 www.myprimemail.com

NurseHelp 24/7 Program (for Blue Shield HMO members) See I.D. Card www.blueshieldca.com

MDLIVE 24/7 Program (for Blue Shield PPO members) (888) 632-2738 www.mdlive.com/sisc

Blue Shield 65+ HMO Medicare Advantage (800) 776-4466 www.blueshieldca.com

CompanionCare (800) 825-5541 www.blueshieldca.com

Dental PPO by Delta/ACSIG (866) 499-3001 0928 www.deltadentalins.com

Vision by VSP/ACSIG (800) 877-7195 00104565 www.vsp.com

Anthem EAP/SISC (800) 999-7222 www.anthemeap.com

CalPERS (888) 225-7377 N/A www.calpers.ca.gov

STRS (800) 228-5453 N/A www.strs.ca.gov

District Benefits (949) 582-4898 N/A http://www.socccd.edu/

humanresources/EmployeeBenefits.html

CONTACT INFORMATIONCONTACT INFORMATIONCONTACT INFORMATION

Employee Benefits Brochure designed and developed by

in conjunction with South Orange County Community College District