HUMAN RESOURCES SERVICES GROUP

Transcription

1 HUMAN RESOURCES SERVICES GROUP Forty Seven Fifty San Felipe Rd San José, CA (Benefit s fax) January 21, 2015 To All Adjunct Faculty: On behalf of the Human Resources Department, Welcome to Spring Semester, 2015! The District is pleased to offer a medical plan for adjunct faculty who qualify. Enrollment for the plan, offered through Kaiser Permanente, is available each semester to employees and their eligible dependents. If enrolled this semester, coverage will be in effect from March 1, 2015 through August 31, You will be required to re-enroll, if eligible, each semester. Qualification for the plan is as follows: You must carry at least a 40% cumulative equivalent load of a minimum full-time faculty assignment (either instructional or non-instructional) on February 20, If your load is reduced after that time or classes are cancelled, you may still be eligible to participate. You may not have any other medical coverage and must sign a statement verifying that you have no other coverage. For this fiscal year, 2014/2015, you must pay at least 50% of the premium. Eligible dependents may be enrolled at full cost to the employee. (A certified marriage certificate is required to enroll your spouse, and birth/adoption certificates are required to enroll eligible children. Children may be covered until their 26 th birthday regardless of their dependent or student status. Eligible domestic partners may also be covered.) In order to be covered by this plan, you must sign up between February 9, 2015 and February 23, The Kaiser Enrollment form, the Verification of Eligibility and proof of dependent eligibility (if applicable) are all that is required to enroll. All documents must be submitted to Human Resources by 5:00 p.m., Monday, February 23, Those currently enrolled from Fall 2014 must submit the Verification of Eligibility Form by the due date or your plan will be cancelled. The monthly premium this year (through June 30, 2015) is $ employee only, $1, employee plus spouse/domestic partner, $1, employee plus child/children, and $2, for family coverage. Of these amounts, the District will contribute 50% of the monthly employee only cost ($338.30). By enrolling, you authorize Payroll to deduct your portion of the premium from your paycheck. This deduction is taken out of pre-taxed dollars automatically through the District s Flexible Spending Account. Premiums are deducted in four payroll deductions (March, April, May, and June 2015) however your coverage will be effective March 1, 2015 through August 31, The monthly amount deducted per payroll will be $ for employee only, $1, employee plus spouse/domestic partner, $1, employee plus child/children, and $2, for family coverage. Please advise if you know you will receive less than four paychecks this semester so we can adjust your deduction accordingly. If no deduction is taken in March, two deductions will be taken from your April paycheck. Please also note premiums are subject to increase effective July 1, If you are currently enrolled in the District s plan you must submit the Verification of Eligibility Form to Human Resources by 5:00 pm, February 23, 2015 or your plan will be terminated as of February 28, 2015 COBRA may be offered. You may fax it to New hires and those who did not teach in the Fall may enroll in a Flexible Spending Account (FSA) for the remainder of All employees may pre-designate a physician for work related injuries/illnesses. These forms and more information are available by contacting Michelle McKay or online at The FSA enrollment form is due no later than 5:00pm, Monday February 23, If you have any questions please contact Michelle McKay, Benefits Analyst in Human Resources at michelle.mckay@sjeccd.edu. Enrollment forms and Summary of Benefits and Coverage (SBC s) are available online on the Benefits Page of the District s Human Resources website (see link above). Hard copies are also available by request.

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3 HUMAN RESOURCES SERVICES GROUP Forty Seven Fifty San Felipe Rd San José, CA (fax) Adjunct Faculty Kaiser Plan Verification of Eligibility Spring 2015 Name: Employee Number: (Print) Campus Phone Extension: Campus EVC SJCC Division: Home Telephone #: This is a NEW enrollment, as I did not participate Fall (An enrollment form is also required. Both forms are due in Human Resources no later than 5pm 02/23/2015.) I wish to CONTINUE my coverage in Spring 2015 as I did in Fall 14 (I understand I am not required to complete a new enrollment form, however this form is required and is due in Human Resources no later than 5pm, 02/23/2015.) Your coverage will terminate 02/28/15 if this form is not received in HR by the deadline. I was enrolled Fall 14 and I wish to CANCEL my coverage effective 02/28/2015. terminate my coverage. Please I attest by my signature below that I meet the following eligibility criteria listed: a) Expect to carry a 40% cumulative equivalent load of a minimum full-time faculty assignment (either instructional or non-instructional) b) Am not covered by any other medical plan. c) I agree to pay at least 50% of the premium of this plan for myself, and 100% of the premium for my dependent(s). I authorize payroll to deduct the employee (and dependent if applicable) portion of the plan premium from my paychecks. Signed: Date: For HR Only: Eligibility Verified: Date Processed: Rev 01/15

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5 Benefit Summary SAN JOSE/EVERGREEN COMMUNITY Principal Benefits for Kaiser Permanente Traditional Plan (7/1/14 6/30/15) The Services described below are covered only if all of the following conditions are satisfied: The Services are Medically Necessary The Services are provided, prescribed, authorized, or directed by a Plan Physician and you receive the Services from Plan Providers inside our Northern California Region Service Area (your Home Region), except where specifically noted to the contrary in the Evidence of Coverage (EOC) for authorized referrals, hospice care, Emergency Services, Post-Stabilization Care, Out-of- Area Urgent Care, and emergency ambulance Services Health Plan believes this coverage is a "grandfathered health plan" under the Patient Protection and Affordable Care Act. If you have questions about grandfathered health plans, please call our Member Service Call Center. Annual Out-of-Pocket Maximum for Certain Services For Services subject to the maximum, you will not pay any more Cost Share during a calendar year if the Copayments and Coinsurance you pay for those Services add up to one of the following amounts: For self-only enrollment (a Family of one Member)... $1,500 per calendar year For any one Member in a Family of two or more Members... $1,500 per calendar year For an entire Family of two or more Members... $3,000 per calendar year Plan Deductible None Lifetime Maximum None Professional Services (Plan Provider office visits) Most primary and specialty care consultations, evaluations, and treatment... $15 per visit Routine physical maintenance exams, including well-woman exams... No charge Well-child preventive exams (through age 23 months)... No charge Family planning counseling and consultations... No charge Scheduled prenatal care exams... No charge Eye exams for refraction... No charge Hearing exams... No charge Urgent care consultations, exams, and treatment... $15 per visit Most physical, occupational, and speech therapy... $15 per visit Outpatient Services Outpatient surgery and certain other outpatient procedures... $15 per procedure Allergy injections (including allergy serum)... $5 per visit Most immunizations (including the vaccine)... No charge Most X-rays and laboratory tests... No charge Covered individual health education counseling... No charge Covered health education programs... No charge Hospitalization Services Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs... No charge Emergency Health Coverage Emergency Department visits... $50 per visit Note: This Cost Share does not apply if admitted directly to the hospital as an inpatient for covered Services (see "Hospitalization Services" for inpatient Cost Share). Ambulance Services Ambulance Services... $50 per trip Prescription Drug Coverage Covered outpatient items in accord with our drug formulary guidelines at Plan Pharmacies or through our mail-order service: Most generic items... $10 for up to a 100-day supply Most brand-name items... $15 for up to a 100-day supply Durable Medical Equipment Most covered durable medical equipment for home use in accord with our durable medical equipment formulary guidelines... 20% Coinsurance Mental Health Services Inpatient psychiatric hospitalization... No charge S San Jose/Evergreen Community (continues)

6 Benefit Summary Individual outpatient mental health evaluation and treatment... $15 per visit Group outpatient mental health treatment... $7 per visit Chemical Dependency Services Inpatient detoxification... No charge Individual outpatient chemical dependency evaluation and treatment... $15 per visit Group outpatient chemical dependency treatment... $5 per visit Home Health Services Home health care (up to 100 visits per calendar year)... No charge Other Skilled nursing facility care (up to 100 days per benefit period)... No charge Covered external prosthetic devices, orthotic devices, and ostomy and urological supplies... No charge All Services related to covered infertility treatment... 50% Coinsurance Hospice care... No charge (continued) This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-of-pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts. For a complete explanation, please refer to the EOC. Please note that we provide all benefits required by law (for example, diabetes testing supplies) S San Jose/Evergreen Community S

7 Limitations & Exclusions for Out of Area HMO Members: The live/work eligibility rule applies to HMO group members only. Retirees are not eligible. Please note: Members who live outside of our service area may have limited or no coverage for skilled nursing, home health, hospice, and durable medical equipment. For information about the terms and conditions of coverage (including limitations of coverage for members who live outside our service area), please call Durable Medical Equipment: Coverage for durable medical equipment is limited to the standard item that adequately meets the medical need of the member. Health Plan determines whether DME will be rented or purchased and selects the vendor. The member must return the equipment to Health Plan or pay the fair market value when a Plan physician no longer prescribes the equipment. The following equipment is specifically excluded: Comfort, convenience, luxury equipment or features Exercise or hygiene equipment Dental appliances Electronic monitors of the heart or lungs, except apnea monitors for newborns Devices for testing blood or other body substances, except blood glucose monitors for diabetics Non-medical items such as sauna baths or elevators Modifications to a home or car Repair or replacement of DME due to loss, theft, or misuse The following equipment is covered: If you live outside our Service Area, we cover the following DME items (subject to the Cost Sharing and all other coverage requirements that apply to DME for home use inside our Service Area) when the item is dispensed at a Plan Facility: Standard curved handle cane Standard crutches For diabetes blood testing, blood glucose monitors and their supplies (such as blood glucose monitor test strips, lancets, and lancet devices) from a Plan Pharmacy Insulin pumps and supplies to operate the pump (but not including insulin or any other drugs), after completion of training and education on the use of the pump Nebulizers and their supplies for the treatment of pediatric asthma Peak flow meters from a Plan Pharmacy Updated May 2010

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