RETIREE BENEFITS BROCHURE for Faculty Members

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1 RETIREE BENEFITS BROCHURE for Faculty Members WHAT S INSIDE Retiree Benefits Checklist... 2 Frequently Asked Questions... 3 Rules For Benefit Changes During The Year... 5 Medical Plans... 6 Dental Plan Vision Plan Required Federal Notices Health Plan Rates Who Should You Call? 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. 2012/2013 PLAN OFFERINGS: Retirees Under Age 65 Medical: Blue Shield HMO Plan or Blue Shield PPO Plan Dental: Vision: Delta Dental PPO Plan VSP Plan 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: Vision: Delta Dental PPO Plan (voluntary/retiree paid) VSP Plan (voluntary/retiree paid) 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.

2 RETIREE BENEFITS CHECKLIST 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 (if spouse/domestic partner is electing plan) (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 Provide payment to District Benefits for 1 st 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 2

3 FREQUENTLY ASKED QUESTIONS What are the eligibility requirements for benefits after retirement? Minimum Age 55 Minimum Service Retirement Eligibility Requirements Employed full time with the District for ten (10) consecutive years immediately preceding the date of retirement Concurrent retirement from your applicable retirement system (STRS or PERS) and the District 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 1 st of the month in which you turn 65. If you are a retiree age 65+, you are eligible to receive the District paid Blue Shield COB PPO medical plan provided that you enroll in Medicare A and B, and supply the District with a copy of your Medicare Card. Your eligible dependent(s) is eligible to purchase a medical plan through the District on a self pay basis. You and your eligible dependent(s) are eligible to purchase the District dental and/or vision plans on a self pay basis. 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? You, the retiree, must enroll in Medicare A and B, and supply the District with a copy of your Medicare Card. You are then able to purchase the Blue Shield PPO medical plan for your dependent(s) at the current cost of $552 per month. The cost of the dependent coverage is calculated by subtracting the District s cost of the Blue Shield COB PPO medical plan ($917) from the cost of the Blue Shield PPO medical plan ($1,469). 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 1 st 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 you or your spouse/domestic partner does not enroll in Medicare A and/or B when eligible, or fails to provide the District with a copy of yours or your spouse s/domestic partner s Medicare card, you shall pay any penalty, fee, or other cost imposed by the insurance carrier. If you fail 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. (Continued on next page) 3

4 FREQUENTLY ASKED QUESTIONS 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 $451/month (2012 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 2010 was File Individual Tax Return File Joint Tax Return You Pay $85,000 or less $170,000 or less $99.90 $85,001 $107,000 $170,001 $214,000 $ $107,001 $160,000 $214,001 $320,000 $ $160,001 $214,000 $320,001 $428,000 $ above $214,000 above $428,000 $ If you have questions about your Medicare premiums, you can contact Social Security at 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 1 st 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 15 th 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, PacifiCare EAP, Prudential Life Insurance, Prudential 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. 4

5 RULES FOR BENEFIT CHANGES DURING THE YEAR 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). 5

6 Early Retirees prior to age 65 HMO 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 visiting the Blue Shield website at 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 Medco Pharmacy. If you are taking prescription medications on a regular basis, you may save time and money by using the mail service pharmacy. If you have questions you may call Medco Member Services 24 hours a day, seven days a week toll free at (800) or visit the Medco website at Schedule of Benefits Blue Shield Access + HMO Plan Medical Plan Copays/Limits In Network Lifetime Maximum None Calendar Year Deductible None Calendar Year Out of Pocket Maximum 1 $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 Visit 1 $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) $10/Visit Mental Health / Substance Abuse Inpatient / Facility Based No Charge Outpatient Visit $5/Visit Prescription Drugs (through Medco Pharmacy) Retail (30 day supply) Generic $5 Copay Brand $10 Copay Mail Order (90 day supply) Generic $10 Copay Brand $20 Copay 1. Does not accrue toward calendar year copayment maximum. 6

7 Early Retirees prior to age 65 PPO MEDICAL PLAN 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 innetwork 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) or visiting their website at 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 under Find a Pharmacy. You may also call the customer service phone number listed on your Blue Shield ID card. Schedule of Benefits Blue Shield Spectrum PPO Plan Medical Plan Copays/Limits In Network 1 Out of Network 1 Retiree Pays Calendar Year Deductible 2 $100 Individual / $300 Family Calendar Year Out of Pocket Maximum 2 $300 Individual / $900 Family Hospitalization Services Inpatient 10% No Charge 2, 3 (Up to $600/Day) Outpatient 10% No Charge 2 (Up to $350/Day) Emergency Room (Copay waived if admitted) Outpatient Professional Services 7 10% + $100/Visit Office and Specialist Visit $10/Visit 4 10% 2 Adult Routine Physical Exam No Charge 4 Not Covered Well Baby Care No Charge 4 10% X Ray & Lab Procedures $10/Visit 10% Home Health Care (100 visit maximum per calendar year) 10% Not Covered 5 Durable Medical Equipment 10% 10% Chiropractic Services (up to 20 visits per calendar year) $25/Visit 10% Acupuncture (up to 12 visits per calendar year) $25/Visit (Max of $50/Visit) Mental Health / Substance Abuse Inpatient / Facility Based 10% No Charge 2, 3 (Up to $600/Day) Outpatient Visit $10/Visit 4 10% 2 Prescription Drugs (through Blue Shield Pharmacy) Member pays 25% of allowable amount plus Retail (30 day supply) the below copayment Generic $3 Copay $3 Copay Brand Name 6 $15 Copay $15 Copay Mail Order (90 day supply) Generic $3 Copay Not Covered Brand Name 6 $35 Copay Not Covered 1. Member is responsible for copayment in addition to any charges above allowable amounts. 2. Does not accrue toward calendar year out of pocket 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 copayment.

8 PPO COB MEDICAL PLAN * Retirees 65+ Medicare Eligible SERVICES MEDICARE 2012 Benefits 1, 2, 3 BLUE SHIELD PLAN 65 Enrollees Must Be Enrolled in Both A & B of Medicare In Network Out of Network HOSPITALIZATION Semi private room and board, general nursing, and other hospital services. Benefit Medicare Pays Patient Pays Day 1 60 All but $1,156 $1,156 Day All but $289 a day $289 a day Day All but $578 a day $578 a day Pays Medicare Part A deductible and Medicare's coinsurance or Medicare's co insurance and the difference between Blue Shield's billed and Medicare's allowed charges for non assigned providers.* Day 151 Nothing All costs SKILLED NURSING FACILITY CARE You must have been in a hospital for at least 3 days, enter a Medicare allowable facility generally within 30 days after discharge, and meet other program requirements. Benefit Day 1 20 Day Day 101+ Medicare Pays 100 % of allowable amount All but $ a day Nothing Patient Pays Nothing $ a day All costs Pays Medicare's co insurance. MEDICAL EXPENSES Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, and other services. Medicare pays 80% of allowable amount for medical services in or out of the hospital after $140 deductible. Pays Medicare Part B deductible and then 20% of Medicare's allowed charges. BLOOD In most cases, the hospital or provider gets blood from a blood bank at no charge, and you won t have to pay for it or replace it. If the hospital or provider has to buy blood for you, you must either pay the costs for the first 3 units of blood you get in a calendar year or have the blood donated by you or someone else. For inpatient: Medicare Part A deductible plus cost of first 3 units of blood if applicable. For outpatient: member pays Medicare Part B deductible of $140, plus copayment for the blood processing and handling services for every unit of blood and cost of first 3 units of blood if applicable. For inpatient, pays Medicare Part A deductible. Medicare coverage is 100%. For outpatient, pays Medicare Part B deductible. PRESCRIPTION DRUGS Medicare pays 80% of the Medicare approved amount for covered Part B prescription drugs that you get in a doctor s office or pharmacy. In a hospital outpatient setting, you pay a copayment. However, if you get drugs in a hospital outpatient setting that aren t covered under Part B, you pay 100% for the drugs unless you have Part D or other prescription drug coverage. In that case, what you pay depends on whether your drug plan covers the drug, and whether the hospital is in your drug plan s network. Contact your prescription drug plan to find out what you pay for drugs you get in a hospital outpatient setting. Retail: $3 generic / $15 brand (30 day supply) Mail Order: $0 generic / brand (90 day supply) CHIROPRACTIC CARE 80% of allowable charges on manual manipulation of spine after $140 deductible Pays Medicare Part B deductible, then 20% of Medicare's allowed charges. CLINICAL LABORATORY SERVICES Blood test, urinalysis and more. Medicare pays 100% for Medicare approved lab services. Medicare pays 80% of allowable charges for covered diagnostic tests and X rays done in a doctor s office or independent testing facility. You pay a copayment for diagnostic tests and X rays in the hospital outpatient setting. Pays Medicare Part B deductible, then 20% of Medicare's allowed charges. Medicare coverage for Medicareapproved lab services is 100%.* HOME HEALTH CARE Medically necessary skilled care, home health aide services, medical supplies, and other services. Medicare pays 100% for cost of services; 80% of allowable amount for durable medical equipment after $140 deductible. Pays Medicare Part B deductible and then 20% of Medicare's allowed charges for medical supplies/equipment. Medicare coverage of other services is 100%.* OUTPATIENT HOSPITAL TREATMENT Medicare pays 80% of allowable after $140 deductible. Reasonable and necessary services for the *You pay a coinsurance (for doctor services) or a copayment amount for most outpatient diagnosis or treatment of an illness or hospital services. injury. Pays Medicare Part B deductible and then 20% of Medicare's allowed charges. * Retirees only 1. For a Medicare Assigned Provider, the Provider agrees to accept Medicare's allowed amount as payment in full. On this plan, Blue Shield would reimburse the Medicare deductible and co insurance leaving the member with no out of pocket. 2. For a Non Medicare Assigned Provider, the Provider can bill the member the difference between Medicare's allowed amount and the billed amount. 3. Once Medicare coverage has been exhausted, Blue Shield co pays will apply. For example, if a retiree exhausts all coverage under Medicare, he/she will then be subject to the Blue Shield Plan Physician co pay of $10. 8

9 COMPANION CARE MEDICAL PLAN * Retirees 65+ Medicare Eligible SERVICES Inpatient Hospital (Part A) MEDICARE 2012 Benefits Pays all but first $1,156 for 1st 60 days Pays $1,156 COMPANIONCARE Based on 2012 Medicare Benefits Skilled Nursing Facilities (Must be approved by Medicare) Deductible (Part B) Basis of Payment (Part B) Medical Services (Part B) Doctor, x ray, appliances & ambulance Lab Physical/Speech Therapy (Part B) Blood (Part B) Travel Coverage (when outside the US for less than 6 consecutive months) Outpatient Prescription Drugs Pays all but $289 a day for the 61st to 90th day Pays all but $578 a day Lifetime Reserve for 91st to 150th day Pays nothing after Lifetime Reserve is used Pays 100% for 1st 20 days Pays all but $ a day for 21st to 100th day Pays nothing after 100th day $140 Part B deductible per year 80% Medicare Approved (MA) charges after Part B deductible 80% MA charges 100% MA charges 80% MA charges up to the Medicare annual benefit amount. 80% MA charges after 3 pints Not covered SISC will automatically enroll CompanionCare members into Medicare Part D. No additional premium required. SISC plans are not subject to the 'doughnut hole'. Pays $289 a day Pays $578 a day Pays 100% for 151st day to 515th day Pays nothing Pays $ a day for 21st to 100th day Pays nothing after 100th day Pays $140 20% MA charges including 100% of Medicare Part B deductible 20% MA charges Pays nothing 20% MA charges up to the Medicare annual benefit amount. (Physical & Speech Therapy Combined) Pays 1st 3 pints unreplaced blood and 20% MA charges Pays 80% inpatient hospital, surgery, anesthetist and in hospital visits for medically necessary services for 90 days of treatment per lifetime Prescription drug plan enhanced through Medco Health Generic: $7 co pay for a 30 day supply at a retail pharmacy or $14 co pay for a 90 day supply through home delivery service. 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. * 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 in to the District office no later than 60 days prior to effective date. Rate Effective October 1, 2012 Total Cost Per Person Retirees with Medicare A & B (SISC will enroll members in Part D $

10 BLUE SHIELD 65+ HMO MEDICARE ADVANTAGE PLAN * Retirees 65+ Medicare Eligible NEW! 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. Ambulance SERVICES $0 co pay per trip BENEFITS Annual Physical Examination Includes pap smears $0 co pay* $10 co pay per visit Durable Medical Equipment (DME) Medicare covered services Hospitalization Inpatient Outpatient hospital services Emergency room Immunizations Includes flu injections and all Medicare approved immunizations Laboratory Services Manual Manipulation of the Spine $0 co pay $0 co pay per admission $20 co pay $50 co pay/waived if admitted within 24 hours for same condition $0 co pay* No charge $10 co pay per visit (subject to medical necessity) Mental Health Inpatient No charge for day Member pay 100% from day 151+ Mental Health Outpatient unlimited visits Physician Services/Basic Health Services Office visits Consultation, diagnosis & treatment by a specialist Prescription Drugs (Retail 30 day supply/mail Order 90 day supply) Generic Preferred Brand Non Preferred Brand Injectables Specialty Skilled Nursing Facility X Ray Services Includes routine annual mammography $20 co pay $20 co pay $20 co pay 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 Covered in full for 100 days per benefit period $0 co pay* * 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 For additional Medicare benefit information, please go to or call medicare. * Available only to retirees who are 65+ and have enrolled in Medicare Parts A and B. Enrollment forms must be turned in to the District office no later than 60 days prior to effective date. Rate Effective October 1, 2012 Total Cost Per Person (So Region) Retirees with Medicare A & B (SISC will enroll members in Part D $

11 DENTAL PLAN SUMMARY Voluntary Dental Plan for Retirees 65+ 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. NEW! Effective October 1, 2012, Delta Dental PPO members will be eligible for one additional cleaning per calendar year (for a total of 3 cleanings per calendar year). Members will also be eligible for dental implant coverage. Log on to Delta s website at or call (866) for more information. Schedule of Benefits Calendar Year Deductible In Network Delta Dental PPO (ACSIG) Out of Network $25/Individual (up to $75 per Family) except for diagnostic and preventive Calendar Year Maximum $3,200 $3,000 Diagnostic & Preventive Exams / Cleaning Full Mouth X rays Fluoride Treatment Space Maintainers Basic Services Oral Surgery Fillings Root Canals Periodontics Crowns & Other Cast Restorations Crowns Inlays / Onlays Prosthodontics Orthodontics Adult and eligible dependent child PLAN PAYS 90% PLAN PAYS 90% after deductible PLAN PAYS 90% after deductible PLAN PAYS 50% after deductible Lifetime Maximum $2,000 11

12 VISION PLAN SUMMARY Voluntary Vision 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 or call (800) for more information. Schedule of Benefits In Network Out of Network Eye Examination, every 12 months $10 Copay Up to $45 Standard Lenses, every 12 months Single Up to $45 Bifocal Covered in Full Up to $65 Trifocal after $10 Copay Up to $85 Lenticular Up to $125 Frame, every 12 months Contact Lenses, every 12 months Medically Necessary Covered Contacts Up to $ % off over your allowance Covered in Full after $10 Copay Covered in Full after $50 Copay VSP Vision Up to $47 Up to $250 Up to $250 + $50 Copay Second pair of glasses, every 12 months $20 Copay N/A 12

13 REQUIRED FEDERAL NOTICES HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) Your medical benefit plan may impose a preexisting condition exclusion upon enrollees age 19 and older. That means that if you are age 19 or older and have a medical condition before coming to our Plan, you might have to wait a certain period of time before the Plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis, care, or treatment was recommended or received within the 6 month period. Generally, this 6 month period ends the day before your coverage becomes effective. However, if you were in a waiting period for coverage, the 6 month period ends on the day before the waiting period begins. The preexisting condition exclusion does not apply to pregnancy. This exclusion may last up to 12 months from your first day of coverage or, if you were in a waiting period, from the first day of your waiting period. However, you can reduce the length of this exclusion period by the number of days of your prior creditable coverage. Most prior health coverage is creditable coverage and can be used to reduce the preexisting condition exclusion if you have not experienced a break in coverage of at least 63 days. To reduce the exclusion period by your creditable coverage, you should provide the new carrier with a copy of any certificates of creditable coverage (HIPAA Certificates) you have. If you do not have a Certificate, but you do have prior health coverage, you can obtain one from your prior plan or issuer. 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. THE WOMEN S HEALTH AND CANCER RIGHTS ACT The Women s Health and Cancer Rights Act (WHCRA) requires employer groups to notify participants and beneficiaries of the group health plan, of their rights to mastectomy benefits under the plan. Participants and beneficiaries have rights to coverage to be provided in a manner determined in consultation with the attending Physician 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. You can contact your health plan s Member Services for more information. 13

14 REQUIRED FEDERAL NOTICES THE CHILDREN S HEALTH INSURANCE PROGRAM REAUTHORIZATION ACT (CHIPRA) OF 2009 If you are eligible for health coverage from your employer, but are unable to afford the premiums, some States have premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer sponsored health coverage, but need assistance in paying their health premiums. If you or your dependents are already enrolled in Medicaid or CHIP you can 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, you can contact your State Medicaid or CHIP office or dial KIDS NOW or to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer s health plan is required to permit you and your dependents to enroll in the plan as long as you and your dependents are eligible, but not already enrolled in the employer s plan. This is called a special enrollment opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. You may be eligible for assistance paying your employer health plan premiums. You should contact your State for further information on eligibility. This information is current as of January 31, 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 EBSA (3272) , Ext

15 HEALTH PLAN RATES OCTOBER 1, 2012 SEPTEMBER 30, 2013 MEDICAL PLAN AVAILABLE TO RETIREE DISTRICT PAID (Retiree Only) Retiree Blue Shield COB PPO (When Enrolled in Medicare A & B) 1 $ RETIREE PAID (Voluntary/Self Pay)*rates quoted are monthly Blue Shield 65+ HMO Medicare Advantage (When Enrolled in Medicare A & B) MEDICAL PLANS AVAILABLE TO SPOUSE/DOMESTIC PARTNER 2 $ Spouse/Domestic Partner Blue Shield PPO (for Spouse/Domestic Partner under 65) $ Blue Shield COB PPO (When Enrolled in Medicare A & B) $ Companion Care Medicare Supplement (When Enrolled in Medicare A & B) $ DENTAL & VISION PLANS AVAILABLE Retiree Retiree + 1 Retiree + Family Delta Dental PPO $ $ $ VSP Plan $38.24 $76.53 $ The District will provide supplemental medical coverage for the retired faculty member provided the retiree has purchased Medicare A and B coverage. If the retiree has not purchased Medicare A and B coverage, the retiree pays the difference between the cost of the insurance and the cost of the District paid insurance, including any penalty, fee, or other cost imposed by the insurance carrier unless the Retiree elects to decline coverage. The costs are listed in the table below. Medicare COB (No Medicare Ret 65+) $ Medicare COB (with Part A only) $ Medicare COB (with Part B only) $ The retiree must pay for their dependent s coverage if the retiree wishes to continue such coverage. 15

16 CONTACT INFORMATION INSURANCE CARRIERS/ADMINISTRATORS Membership Contact Information CARRIER PHONE NUMBER GROUP ID# WEBSITE HMO by Blue Shield/SISC (800) See I.D. Card Medco Pharmacy (for Blue Shield HMO members) (800) PPO by Blue Shield/SISC See I.D. Card See I.D. Card Blue Shield Pharmacy (for Blue Shield PPO members) (866) NurseHelp 24/7 Program See I.D. Card Blue Shield 65+ HMO Medicare Advantage (800) CompanionCare (800) Dental PPO by Delta/ACSIG (866) Vision by VSP/ACSIG (800) CalPERS (888) N/A STRS (800) N/A District Benefits (949) N/A humanresources/employeebenefits.html Employee Benefits Brochure designed and developed by in conjunction with South Orange County Community College District 16