LOS RIOS COMMUNITY COLLEGE DISTRICT 1919 SPANOS COURT SACRAMENTO, CA 95825

Transcription

1 LOS RIOS COMMUNITY COLLEGE DISTRICT 1919 SPANOS COURT SACRAMENTO, CA DATE: April 24, 2018 TO: FROM: Los Rios Retirees Nicole Keller, Employee Benefits Specialist RE: Open Enrollment for Attached please find a comprehensive Retiree Benefits Guide covering the Los Rios Community College District benefits available to you. Included in this guide is everything you ll need to know about Open Enrollment, including the following topics: NEW PLANS Effective July 1, 2018: o Kaiser High Deductible Health Plan (retirees/dependents under age 65) o United HealthCare Medicare Advantage PPO (replacing Senior Supplement for retirees/dependents 65+) Revised Sutter Health Plus HMO (retirees/dependents under age 65) If you do not wish to make any changes to your coverage, there is nothing you need to do at this time your current election and coverage will remain in effect. However, please be sure to read the attached Benefits Guide for the new premiums which take effect July 1, OPEN ENROLLMENT Open Enrollment is your opportunity to switch to a new medical or dental plan, or to add a spouse or qualified dependent onto your plan. Open Enrollment for Los Rios retirees begins Monday, April 30, 2018, and ends at 5:00 pm May 25, Changes in coverage will become effective on July 1, Original forms must be received in the Employee Benefits Department by 5:00 pm on May 25 th. Faxes, s and postmarks DO NOT meet the receipt deadline, and forms received after 5:00 pm on May 25 th will not be accepted. For more detailed plan information and forms, visit the Employee Benefits Website at: or feel free to contact Kris Kurk at (916) or the Employee Benefits Department at (916) cc: Kris Kurk, Employee Benefits Technician Jamie Matthews, Director, Accounting Services

2 Retiree Benefits Guide Retirees on a Los Rios Medical Plan Effective July 1, June 30, 2019

3 Please Read This Booklet & Retain for Your Records Even if you are not making changes to your benefit elections, we encourage you to read through this booklet, especially the Important Information section on page 2, which highlights changes effective July 1, 2018, and the Medical Plans section which highlights the medical plans offered. In addition, the Contacts page at the back of the booklet offers a convenient one-page listing of plan numbers, phone numbers and web addresses of all of our benefit providers. Please note: you do not need to submit any paperwork if you are not making an election change. Information contained in this Benefits Guide is proprietary and confidential to Los Rios Community College District. No part of this document may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying and recording, for any purpose without the express written permission of Los Rios Community College District.

4 Table of Contents Welcome to Your Retiree Benefits Guide Your benefits are a valuable part of your overall retirement package. Make sure you get the most from them by taking the time to understand your options and by selecting coverage that is a good fit for you and your family. For information about the specific plans available to you, please go to the MyBenefits website at or ask your Employee Benefits Department. This Benefits Guide describes your benefit choices and the medical and dental plan options available to you. Please be sure to read the following Important Notice before you begin. Important Information... 2 Open Enrollment... 3 Eligibility... 5 What s Next?... 6 Mid-Year Changes... 7 Medical Plans... 9 Early Retiree Medical Plans Health Savings Account Medicare Supplement Plans Dental Plans Long Term Care Insurance (b), 457 & Special Pay Plan Contacts Glossary Annual Notice OPEN ENROLLMENT: April 30 th May 25 th, 2018 Important Notice: Read Carefully This Benefits Guide briefly describes your benefit choices and your plan options. All benefits, and your eligibility for benefits, are subject to the terms and conditions of the benefit plans, including group insurance contracts, labor union agreements, and retirement contracts or policies. This guide is not intended to be a complete description of the benefit plans and it is not a summary plan description or plan document. In the event of any conflict or discrepancy between this guide and the plan documents, the plan documents will govern. Retirees 1 of 26

5 Important Information What s Changing from Last Year? Medical Plans Early Retirees (under age 65) There is an added HSA compatible plan, the Kaiser High Deductible Health Plan (HDHP) HMO. Premiums and plan details begin on page11. Due to an IRS mandate, the Calendar Year Deductible for Individuals within a Family who are on either the SHP HDHP HMO or the WHA 1800/0 HDHP HMO will increase from $2,600 to $2,700. The Sutter Health Plus (SHP) ML32 HMO is being replaced by the ML52 HMO. Please make note of some of the changes listed below: (ML32) (ML52) Calendar Year Out-of-Pocket Limit $750 / $1,500 $1,500 / $3,000 Physician/Specialist Office Visits $10 copay $15 copay Outpatient Services No Charge $15 copay Lab Tests $10 copay No charge Diagnostic Imaging (MRI, CT, PET, etc.) $50 copay $15 copay Emergency Room Services (waived if admitted) $30 copay $35 copay Ambulance Services $30 copay No Charge Prescription Drugs Retail (30-day supply) $5 Tier 1 / $20 Tier 2 / $40 Tier 3 $10 Tier 1 / $20 Tier 2 / $35 Tier 3 The information presented in the chart is a summary only. The information does not include all of the detailed explanation of benefits, exclusions and limitations. Plan participants should refer to the Evidence of Coverage (EOC) document for coverage details. In the event information in this summary differs from the EOC, the EOC will prevail. Medicare-eligible Retirees (age 65 and over) The United Healthcare (UHC) Senior Supplement PPO is being replaced by a new plan the United Healthcare Medicare Advantage PPO. If you were previously enrolled in the UHC Senior Supplement PPO, your enrollment will be automatically transferred to the new UHC Medicare Advantage PPO. If you do not wish to have your enrollment transferred to the new plan then you will need to make a new election and complete the appropriate forms. You will continue to have the choice of Kaiser Senior Advantage HMO and United Healthcare Medicare Advantage HMO. Health Net s Seniority Plus is a closed plan and is only available to current participants. Please note: If you do NOT wish to make any changes, you do not need to do anything further. 2 of 26 Retirees

6 Open Enrollment Open Enrollment Open Enrollment gives you the opportunity to switch between plans or change coverage for dependents (spouse/domestic partner or children) without a qualifying change-in-status event. You must be on retiree medical or dental coverage through Los Rios to make changes during Open Enrollment. You may not re-enroll in Los Rios dental coverage if you did not elect it at retirement, or if you cancelled. However, you may be eligible to re-enroll in Los Rios medical coverage if you did not elect it at retirement, or if you canceled (see page 8 for eligibility requirements). Please note, if you do not wish to make any changes, you do not need to do anything. Medical The Los Rios Insurance Review Committee (IRC), District staff, and our insurance brokers, Edgewood Partners Insurance Center (EPIC), work each year to evaluate options to provide the lowest increase in the premiums for our medical plans while maintaining high quality coverage. Below is a list of the retiree plans available to you July 1, (Medical plan details begin on page 9.) Early Retiree Medical Plans (retirees and spouse/dependents younger than age 65 and not yet Medicare-eligible): Kaiser HMO Kaiser Deductible HMO Kaiser HDHP HMO (HSA Compatible) New!! Sutter Health Plus HMO Sutter Health Plus HDHP HMO (HSA Compatible) Western Health Advantage HMO Western Health Advantage 1800/0 HDHP HMO (HSA Compatible) Medicare Supplement Plans: Health Net Seniority Plus HMO -- CURRENT PARTICIPANTS ONLY Kaiser Senior Advantage HMO United Healthcare Medicare Advantage HMO United Healthcare Medicare Advantage PPO New!! (Replacing UHC Senior Supplement) Dental Los Rios offers two retiree dental plans: Delta Dental PPO and DeltaCare HMO. Current premium and plan details for dental begin on page 20. Plan Years Medical and dental plan deductibles and annual maximums are based on the calendar year (January 1 to December 31) Retirees 3 of 26

7 Open Enrollment Open Enrollment Dates & Deadlines Open Enrollment for the Los Rios retiree medical and dental plans will be held from Monday, April 30, 2018 through Friday, May 25, 2018, with all changes effective July 1, Your first payment for the new premium amounts will occur on the July 2018 bank transaction. Paperwork is required to make changes and original, completed forms must be received in the Employee Benefits Department by 5:00 pm on May 25, After May 25, 2018, barring any change-in-status or Health Insurance Portability and Accountability Act of 1996 (HIPAA) qualifying event, the next opportunity to change medical or dental coverage as a retiree will be during the next open enrollment in April/May 2019 with a July 1, 2019 effective date. Fax, and postmarks do NOT qualify as meeting this deadline. How to Enroll Open Enrollment gives you the opportunity to change the dependents you have covered (spouse/domestic partner or children) or switch between plans without needing a reason or qualifying change-in-status event. To enroll dependents and to make election changes, you must complete all necessary enrollment, change or cancelation forms. All forms are available online at and at the Employee Benefits Department. Following is a list of the forms required for the noted changes. ACTION Enrolling in a new plan or adding a dependent Additional paperwork required for Spouse & Domestic Partner Dropping a Dependent Canceling Coverage If canceling coverage, you may be eligible to re-enroll in a Los Rios plan later (see page 8 for eligibility requirements). New Dependents & Enrollment Changes FORM / PAPERWORK REQUIRED Enrollment / Change Form for each plan Copy of Marriage License or Certificate Affidavit of Domestic Partnership or Copy of Registration with State (if applicable) Enrollment / Change Form for each plan Cancelation Form (medical/dental) After Open Enrollment, changes are permitted in limited circumstances and must be done within strict timelines. If changes do not meet the criteria or are not made within the appropriate timeline, with the exception of dropping coverage or dependents, you will have to wait until the next Open Enrollment. 4 of 26 Retirees

8 Eligibility Eligibility You can participate in the medical and dental benefits described in this guide if you are a retiree who qualified for retiree health benefits. (Refer to the individual collective bargaining agreements or District policies for specific qualification requirements.) Your Dependents To maintain eligibility, you agree to notify the Employee Benefits Department immediately upon the failure of a dependent to satisfy any of the criteria listed below. You understand that you must remove ineligible dependents from coverage by submitting the necessary paperwork to the Employee Benefits Department within 31 days of ineligibility, and that it is a fraudulent act to obtain health coverage by misrepresenting any facts stated herein. Failure to do so could result in loss of benefits. If you predecease your spouse/domestic partner or other eligible dependent(s), they may remain on the Los Rios plan provided they maintain eligibility; however, family members are not entitled to the District contribution. The District contribution is for the retiree only. Listed below are the criteria for dependents (spouse/domestic partner and children) to be eligible for coverage: Your eligible dependents include: Your spouse (as defined by applicable state law), which includes same-sex spouse Your same-sex or opposite-sex domestic partner who meets certain criteria Your state-registered domestic partner Your dependent children under the age of 26 for medical insurance, regardless of student or marital status Your dependent children under the age of 25 for dental insurance, regardless of student status Your grandchild(ren) (Kaiser only), only if your child (parent of the grandchild) is covered as an eligible dependent For Long-Term Care insurance: your spouse/domestic partner, parents and in-laws, grandparents and in-laws, siblings and their spouses/domestic partners, children and their spouses/domestic partners and your spouse/ domestic partner s siblings and spouses/domestic partners Your children include: Your or your spouse/domestic partner s natural or adopted children Children placed in your home for adoption provided you have the legal right to direct all medical care Your or your spouse/domestic partner s dependent children over the age limit who are incapable of self-sustaining employment because of total disability (as defined by the carrier), which occurred prior to the limiting age and who are chiefly dependent upon you or your spouse/ domestic partner for support and maintenance Any other children you support for whom you are the legal guardian or for whom you are required to provide coverage as the result of a qualified medical child support order You may be required to provide proof of dependent status. Domestic Partner Eligibility Criteria If you are enrolling a domestic partner, you are required to have met all eligibility requirements listed below: You are each eighteen (18) years of age or older and are capable of consenting to a domestic partnership. You are financially interdependent and are jointly responsible for each others common welfare. You are each other s sole domestic partner and intend to stay in a committed relationship. Neither of you is married nor have you had another domestic partner within the last six (6) months (excluding any domestic partner or spouse who has died in the last 6 months). You are not closely related by blood that a legal marriage would otherwise be prohibited by law. Retirees 5 of 26

9 What s Next? Effective Date of Coverage and First Deduction Changes made during this Open Enrollment will take effect July 1, Your first payment for the new premium amounts will occur on the July 2018 bank transaction. (Bank transactions usually occur on or around the 2nd of the month.) ID Cards If you change medical plans, you will receive a new ID card for the medical plan you select. You will not receive an ID card for dental coverage. When you receive your ID card, confirm that all information is accurate. If not, contact the carrier immediately. You will not receive a card for dental coverage, but you can print a generic dental wallet card from the Delta Dental website. See page 24 for carrier contact information. Selecting a Primary Care Physician If you are switching to a new HMO plan, you will need to designate your choice of primary care physician (PCP). If you don t designate your preferred PCP, the HMO carrier will assign one for you. To choose a different PCP, call the insurance carrier and request that your PCP selection be changed to one of your choice in the network. Changes will be made the first of the month following your request. It is recommended you make an appointment within the first 3 months with your new PCP to establish yourself as a patient and become familiar with your doctor. 6 of 26 Retirees

10 Mid-Year Changes What Happens if You Don t Enroll or Make Election Changes Now? If you don t change anything during the Open Enrollment period, you will continue to receive your current year s medical and dental insurance coverage elections for yourself and your covered dependents. With the exception of canceling coverage, you will not be able to make changes to your elections until the next annual Open Enrollment period, unless you experience a qualified change-in-status event, become Medicare eligible, or if one of your dependents experiences a HIPAA special enrollment event. You may be eligible to re-enroll in a Los Rios plan once you cancel your coverage. (See page 8 for eligibility requirements). Acceptable change-in-status events are listed below. You have up to 31 days from the date of your qualifying event to make benefit election changes, including adding a new spouse or domestic partner, or you must wait until the next Open Enrollment. To make election changes as a result of such an event, contact the Employee Benefits Department as the original forms must be received by the Employee Benefits Department within the 31-day time frame. Exceptions will not be made if you miss this deadline, you must wait until the next Open Enrollment to make the change. Qualified Change-In-Status Events Marriage, Divorce, Legal Separation, Annulment Establishing or Ending a Domestic Partnership Birth, Adoption, Legal Guardianship of a Child, Death of a Dependent Employment Status Change of the Spouse, Domestic Partner or Dependent Change in other coverage (spouse, domestic partner or child gains or loses eligibility for coverage under another plan, such as through other employment) Dependent Child no longer eligible due to age A change in residence of the Retiree, Spouse, Domestic Partner or Dependent If you think an event in your life may qualify or require you to make a change to your benefits, contact the Employee Benefits Department within the 31-day window to confirm. For Example: New spouses may be enrolled within 31 calendar days of the marriage date. Retirees may enroll domestic partners or their children within 31 calendar days of the date the affidavit of Domestic Partnership is notarized or of registration with the California Secretary of State. Spouses/Domestic Partners may be enrolled within 31 days of loss of other group coverage. Medicare Eligibility If you are an early retiree or have a dependent who becomes Medicare eligible and wish to remain on a Los Rios sponsored plan, contact the Employee Benefits Department two to three months prior to your Medicare effective date. The Employee Benefits Department will review your insurance options and provide you all the required paperwork for your transition to a Medicare plan. Do NOT complete paperwork sent to you directly from a carrier. If you complete and return their application, it may result in the loss of your Los Rios coverage and placement in an individual plan. Original enrollment forms for the Medicare plan must be received by the Employee Benefits Department before the last working day of the month prior to your Medicare effective date. For example: if your Medicare is effective November 1, 2018, forms must be received no later than October 31, Carriers cannot retroactively enroll you in a Medicare plan due to Center for Medicare and Medicaid Services (CMS) guidelines. Late paperwork may result in a significantly higher insurance premium being assessed for each month you are Medicare eligible but are not enrolled in a Medicare plan. (See page 16 for additional information.) Retirees 7 of 26

11 Mid-Year Changes Option to Re-enroll in a District Medical Plan You have the option of canceling the District coverage without forfeiting your ability to re-enroll in a District medical plan when becoming Medicare eligible. In order to re-enroll in a District plan, you must provide evidence of continued coverage from the date of cancelation of the District coverage, provide evidence of enrollment in Medicare, and elect a District medical plan upon turning 65, or otherwise becoming Medicare eligible. You will have a seven month window to contact the Employee Benefits Department to obtain the appropriate enrollment forms and return them. This seven month period includes the three months prior to your 65th birthday, the month of your birthday, and the three months after your 65th birthday. If you become Medicare eligible prior to age 65, the seven month window is the three months before, the month of, and the three months after your Medicare eligibility date, NOT your 65th birthday. A second enrollment window will NOT be given when you then reach 65. If you do cancel your District medical insurance, it is your responsibility to contact the Employee Benefits Department within the specified time frame if you wish to re-enroll in a District sponsored health plan specific correspondence or reminders will not be sent by the District. This provision does not extend to surviving spouses or dependents, i.e. if a retiree passes away, the surviving spouse and/or dependents are not eligible to re-elect a Los Rios plan, or drop a Los Rios plan and return at Medicare eligibility. Removing Ineligible Dependents (e.g. ex-spouse, over-age dependent, etc.) If a dependent becomes ineligible during the plan year, you must remove the dependent from your coverage within 31 calendar days of the event. Even if you miss this deadline, it is your responsibility to contact Employee Benefits as soon as possible and request a retroactive termination of coverage based on when that dependent lost eligibility. Retroactive terminations are not always allowed and must be approved by the individual carriers. It is not the responsibility of the Employee Benefits Department to monitor this for you, and you may be liable for claims paid during the period of ineligibility. HIPAA Special Enrollment Rights Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), if you decline company-sponsored medical or dental coverage for your dependents because they have other health insurance coverage (for example, through your spouse s employment), you may be able to enroll your dependents in our health care plan during the plan year if: Your dependents lose eligibility for the other coverage The other employer stops contributing toward the other coverage Your dependents lose eligibility for Medicaid or Children s Health Insurance Program (CHIP) coverage Your dependents become eligible for a state s premium assistance program under Medicaid or CHIP For any HIPAA special enrollment event, you must request enrollment within 31 days after your dependent s other coverage ends (or after the other employer stops making a contribution toward the other coverage) or you acquire the new dependent. If the event is gaining or losing eligibility for coverage or premium assistance under Medicaid or CHIP, you have up to 60 days to request a change. For more information or to request special enrollment, contact the Employee Benefits Department. 8 of 26 Retirees

12 Medical Plans Your Medical Plans You have the choice of the following medical plans. For your specific plan options and costs, please refer to pages for early retiree plans and for Medicare plans. Early Retiree Medical Plans: Kaiser HMO Kaiser Deductible HMO (DHMO) Kaiser HDHP HMO (HSA Compatible) NEW!! Sutter Health Plus HMO Sutter Health Plus HDHP HMO (HSA compatible) Western Health Advantage HMO Western Health Advantage 1800/0 HDHP HMO (HSA compatible) Medicare Plans: Health Net Seniority Plus HMO -- CURRENT PARTICIPANTS ONLY Kaiser Senior Advantage HMO United Healthcare Medicare Advantage HMO United Healthcare Medicare Advantage PPO NEW!! (Replacing UHC Senior Supplement) You Must Remain Enrolled to have Los Rios Medical Coverage With the exception of early retirees, you must enroll at the time of retirement and remain enrolled in a Los Rios medical plan to participate in the annual Open Enrollment. You may make changes during the year when you experience a qualified change-in-status event, you become Medicare eligible, or when one of your dependents experiences a HIPAA special enrollment event. If you do not elect a change during Open Enrollment, you will remain on the plan you are currently in. Important Information Regarding the Kaiser Network When you join the Los Rios sponsored Kaiser plan, you are enrolling in Northern California Kaiser. When visiting southern California, you can receive care as a visiting member. If you move to southern California, you may remain in the Los Rios sponsored plan under an inter-regional transfer. Contact the Los Rios Employee Benefits Department and they will coordinate the necessary paperwork. Kaiser coverage for retirees residing outside of California in a state in which Kaiser is an option, such as Oregon, requires disenrollment from the Los Rios sponsored plan and enrollment in an individual Kaiser plan in the state where the retiree resides. The Kaiser plan would no longer be the Los Rios group plan, therefore premiums and coverage may differ from the Los Rios plan and premiums would be paid by the retiree directly to Kaiser. You may be eligible to reenroll in a Los Rios plan once you cancel your coverage (see page 8 for eligibility requirements). If you elect an outside insurance plan, you will need to provide annual proof of your premium to continue receiving the District contribution. Retirees 9 of 26

13 Medical Plans Early Retiree Medical Plans You must reside in the plan s service area to be eligible for a Los Rios retiree plan. When you were an active employee, you worked in the plan s service area so you could enroll in our plan. Your eligibility is still based on the plan s live/work rule, and now that you are retired, you must live in the plan s service area to enroll. Visit the carrier s website or call member services to confirm that you reside in their service area. (Carrier contact information can be found on page 24.) Below is a list of the facilities and medical groups associated with each of the carriers: KAISER SUTTER HEALTH PLUS WESTERN HEALTH ADVANTAGE Roseville Medical Center Sutter Medical Group Hill Physicians Medical Group Sacramento Medical Center Sutter Independent Physicians Dignity Health/Mercy Medical Group South Sacramento Medical Center Sutter Gould Medical Group Dignity Health/Woodland Healthcare With the following medical offices: Sutter Medical Group of the Redwoods Meritage Medical Network Davis, Elk Grove, Fair Oaks, Folsom, Lincoln, Point West, Promenade, Rancho Cordova, and Roseville NorthBay Healthcare Plan details and premiums for these carriers are listed on pages of 26 Retirees

14 Early Retiree Medical Plans KAISER PERMANENTE General Plan Provisions HMO Deductible HMO Calendar Year Deductible Individual / Family Calendar Year Out-of-Pocket Limit Individual / Family None $500 / $1,000 $1,500 / $3,000 $3,000 / $6,000 (includes deductible) Lifetime Maximum None None Outpatient Services Doctor Office Visit Co-Pay $15 copay $20 (deductible waived) Annual Adult Physical Exams No Charge No Charge Most Lab & X-ray No Charge $10 (deductible waived) Chiropractic Not Covered Not Covered Acupuncture $15 copay 1 $10 copay 1 Outpatient Surgery $15 copay per procedure 10% coinsurance (after deductible) Inpatient Services Hospitalization No Charge 10% coinsurance (after deductible) Emergency Services Emergency Room $100 copay/ waived if admitted 10% coinsurance (after deductible) Ambulance No Charge $150 per trip (deductible waived) Mental Health Inpatient No Charge 10% coinsurance (after deductible) Outpatient Durable Medical Equipment (DME) $15 copay per individual visit $7 copay per group visit $20 per individual visit / $10 per group visit (deductible waived) DME No Charge 20% coinsurance (deductible waived) Prescription Drugs (Up to a 30-day supply) Generic $10 $10 (deductible waived) Brand Formulary $20 $30 (deductible waived) Brand - Non-Formulary n/a n/a Specialty Medications Mail Order 10% coinsurance not to exceed $100 (up to a 30-day supply) $20 Generic / $40 Brand Name (up to 100-day supply) 10% coinsurance not to exceed $100 (up to a 30-day supply) $20 Generic / $60 Brand Name (up to 100-day supply) Monthly Contributions* Los Rios Retiree Los Rios Retiree Retiree Only $ $ $ $ Dependent n/a $1, n/a $1, Retiree plus Dependent $ (for retiree) $2, $ (for retiree) $2, Typically provided only for the treatment of nausea or for the treatment of chronic pain *Monthly cost to Retiree is based on current District contributions and may be subject to change Please note: This chart is a brief overview of benefits and coverage for the medical plan. To more thoroughly compare plans, please also review the detailed disclosure/summary documents for each plan available at the MyBenefits website at or from the Employee Benefits Department. For questions about a specific procedure, service or provider, please contact the medical carrier directly. Retirees 11 of 26

15 General Plan Provisions Calendar Year Deductible Individual / Family Calendar Year Out-of-Pocket Limit Individual / Family (includes deductible) Lifetime Maximum Outpatient Services Doctor Office Visit Co-Pay Preventive Care Well-Baby & Well-Child Care Most Lab & X-ray Chiropractic Early Retiree Medical Plans KAISER HDHP HMO Kaiser HDHP HMO (HSA Compatible) Self only: $1,800 Individual w/family coverage: $2,700 Family coverage: $3,600 Self only: $3,600 Individual w/family coverage: $3,600 Family coverage: $7,200 None No Charge (after deductible) No Charge (deductible waived) No Charge (deductible waived) No Charge (after deductible) Not Covered Acupuncture No Charge (after deductible; referral required) 1 Outpatient Surgery Inpatient Services No Charge (after deductible) Hospitalization Emergency Services Emergency Room Ambulance Mental Health No Charge (after deductible) No Charge (after deductible) No Charge (after deductible) Inpatient Outpatient Durable Medical Equipment (DME) DME Prescription Drugs Generic Brand Formulary Brand Non-formulary Specialty Medications No Charge (after deductible) No Charge (after deductible) No Charge (after deductible) Up to a 30-day supply $10 (after deductible) $30 (after deductible) N/A $50 (after deductible, up to a 30-day supply) Mail Order $20 Generic / $60 Brand Name (after deductible, up to 100-day supply) Monthly Contributions* Los Rios Retiree Retiree Only $ $ Dependent n/a $ Retiree plus Dependent $ (for retiree) $1, Typically provided only for the treatment of nausea or for the treatment of chronic pain *Monthly cost to Retiree is based on current District contributions and may be subject to change Please note: This chart is a brief overview of benefits and coverage for the medical plan. To more thoroughly compare plans, please also review the detailed disclosure/summary documents for each plan available at the MyBenefits website at or from the Employee Benefits Department. For questions about a specific procedure, service or provider, please contact the medical carrier directly. Retirees 12 of 26

16 Early Retiree Medical Plans SUTTER HEALTH PLUS (SHP) HMO Plans General Plan Provisions SHP ML52 HMO SHP HDHP HMO (HSA Compatible) Plan Year Deductible Individual / Family Plan Year Out-of-Pocket Limit Individual / Family 13 of 26 Retirees None $1,500 / $3,000 Self only: $1,500 Individual w/family coverage: $2,700 Family coverage: $3,000 Self only: $3,000 Individual w/family coverage: $3,000 Family coverage: $6,000 (includes deductible) Lifetime Maximum None Unlimited Outpatient Services Doctor Office Visit Co-Pay $15 copay No Charge (after deductible) Annual Adult Physical Exams No Charge No Charge (deductible waived) Well-Baby & Well-Child Care No Charge No Charge (deductible waived) Most Lab & X-ray No Charge Lab / X-ray: No Charge (after deductible) Chiropractic Not Covered Not Covered Acupuncture $15 copay 1 No Charge (after deductible) 1 Outpatient Surgery $15 copay No Charge (after deductible) Inpatient Services Hospitalization No Charge $50 copay per admittance (after deductible) Emergency Services Emergency Room $35 copay/ waived if admitted No Charge (after deductible) Ambulance No Charge No Charge (after deductible) Mental Health Inpatient No Charge No Charge (after deductible) Outpatient $15 copay No Charge (after deductible) Durable Medical Equipment (DME) DME No Charge No Charge (after deductible) Prescription Drugs Up to 30-day supply Tier 1 $10 No Charge (after deductible) Tier 2 $20 No Charge (after deductible) Tier 3 $35 No Charge (after deductible) Specialty Medications 20% coinsurance not to exceed $100 (up to a 30-day supply) No Charge (after deductible) (up to 30-day supply) Mail Order $20 Tier 1/ $40 Tier 2 / $70 Tier 3 (up to 90-day supply) No Charge (after deductible) (up to 100-day supply) Monthly Contributions* Los Rios Retiree Los Rios Retiree Retiree Only $ $ $ $ Dependent n/a $ n/a $ Retiree plus Dependent $ (for retiree) $1, $ (for retiree) $ Typically provided only for the treatment of nausea or for the treatment of chronic pain *Monthly cost to Retiree is based on current District contributions and may be subject to change. Please note: This chart is a brief overview of benefits and coverage for the medical plan. To more thoroughly compare plans, please also review the detailed disclosure/summary documents for each plan available at the MyBenefits website at or from the Employee Benefits Department. For questions about a specific procedure, service or provider, please contact the medical carrier directly.

17 Early Retiree Medical Plans WESTERN HEALTH ADVANTAGE General Plan Provisions Premier 15 HMO 1800/0 HDHP HMO (HSA Compatible) Calendar Year Deductible Individual / Family Calendar Year Out-of-Pocket Limit Individual / Family None Self only: $1,800 Individual w/ Family coverage: $2,700 Family coverage: $3,600 Self only: $3,600 $1,500 / $2,500 Individual w/ Family coverage: $3,600 Family coverage: $7,200 (includes deductible) Lifetime Maximum None None Outpatient Services Doctor Office Visit Co-Pay $15 copay No Charge (after deductible) Annual Adult Physical Exams No Charge No Charge (deductible waived) Most Lab & X-ray No Charge No Charge (after deductible) Chiropractic & Acupuncture Outpatient Surgery Inpatient Services $15 copay (up to 20 visits/calendar year) Office Setting: $15 copay Outpatient Facility: $100 copay No Charge (after deductible) (up to 20 visits/calendar year) No Charge (after deductible) Hospitalization No Charge No Charge (after deductible) Emergency Services Emergency Room $100 copay / waived if admitted No Charge (after deductible) Ambulance No Charge No Charge (after deductible) Mental Health Inpatient No Charge No Charge (after deductible) Outpatient $15 copay No Charge (after deductible) Durable Medical Equipment (DME) DME 20% No Charge (after deductible) Prescription Drugs Up to a 30-day supply Up to a 30-day supply Tier 1 $10 No Charge (after deductible) Tier 2 $30 No Charge (after deductible) Tier 3 $50 No Charge (after deductible) Self-injectables 20% coinsurance not to exceed $100 No Charge (after deductible) (30-day supply) (up to a 30-day supply) $25 Tier 1 / $75 Tier 2 / $125 Tier 3 No Charge Tier 1/$75 Tier 2/$125 Tier 3 Mail Order (up to 90 day supply) (after deductible) (up to 90 day supply) Monthly Contributions* Los Rios Retiree Los Rios Retiree Retiree Only $ $ $ $ Dependent n/a $ n/a $ Retiree plus Dependent $ (for retiree) $1, $ (for retiree) $ *Monthly cost to Retiree is based on current District contributions and may be subject to change. Please note: This chart is a brief overview of benefits and coverage for the medical plan. To more thoroughly compare plans, please also review the detailed disclosure/summary documents for each plan available at the MyBenefits website at or from the Employee Benefits Department. For questions about a specific procedure, service or provider, please contact the medical carrier directly. Retirees 14 of 26

18 Medical Plans Health Savings Account If you are an early retiree and you elect the Kaiser HDHP HMO, the Western Health Advantage 1800/0 HDHP HMO or the Sutter Health Plus HDHP HMO, which are High Deductible Health Plans (HDHP), you may be eligible to fund a Health Savings Account (HSA). An HSA is a Federal tax-exempt trust or custodial account with a qualified HSA trustee and is used to pay or reimburse yourself for certain medical expenses. As a participant in an HDHP, you may be able to contribute to an HSA so long as you meet all the criteria outlined by the IRS, which includes the following: You must be covered by a High Deductible Health Plan (HDHP). You have no other non-hdhp medical coverage (such as a traditional HMO through WHA, Kaiser, etc.) You are not enrolled in Medicare. You cannot be claimed as a dependent on someone else s tax return. You or your spouse does not participate in a Medical Flexible Spending Account (FSA). What are the Benefits of an HSA? You may enjoy several benefits from having an HSA: You can use HSA funds to pay for qualified medical, dental and vision expenses. When you enroll in Medicare, you can no longer fund an HSA, but you can use remaining HSA funds to pay Medicare premiums. An HSA rolls from year to year and is not subject to any use it or lose it rule. You may make elective contributions on an after-tax basis and you may take a Federal tax deduction when you file your personal tax return (HSA contributions are not tax deductible for California state taxes). The contributions remain in your account until you use them. The interest or other earnings on the assets in the account are Federal tax free and distributions may be tax free if you pay for qualified medical expenses. Contribution Limits The amount you or any other person can contribute to your HSA depends on the type of HDHP coverage you have, your age, the date you become an eligible individual, and the date you cease to be an eligible individual. The 2018 contribution limit is $3,450 for self-only coverage and $6,850 for family coverage. If you are an eligible individual who is age 55 or older by December 31, 2018, your contribution limit is increased by $1,000. For example, if you have self-only coverage, you can contribute up to $4,450 (the contribution limit for self-only coverage of $3,450 plus additional catchup contribution of $1,000). For more information, please visit and enter HSA contribution limits in the search box. If you are interested in participating in one of the High Deductible Health Plans (HDHP), and corresponding HSA, please be sure you fully understand the plan and the rules for funding and using an HSA. Contact the Los Rios Employee Benefits Department if you have any questions. 15 of 26 Retirees

19 Medicare Plans Medical Plans Medicare plans are available to Los Rios retirees over the age of 65 or otherwise Medicare eligible, and requires enrollment in Medicare Part A and B. If you elect a Medicare HMO plan, you must reside in the plan s service area in order to be eligible for coverage. The Centers for Medicare and Medicaid Services (CMS) monitors your residence and will instruct the carrier to cancel coverage if you are living outside the service area. You may not be enrolled in two Medicare plans at the same time, and CMS monitors enrollment. If you have more than one Medicare plan, CMS will automatically dis-enroll you from the plan you enrolled in first. All of the Los Rios Medicare plans have Medicare Part D (prescription drug coverage) associated with them, so it is not necessary to enroll in a separate supplemental Part D plan; doing so will result in the cancelation of your Los Rios Medical Plan by CMS. Please note that high income earners may have a Medicare Part D Income Related Monthly Adjustment Amount (IRMAA) in addition to the premium for the Los Rios Medicare plan. Failure to pay the IRMAA premium will result in dis-enrollment from the Los Rios Medicare plan. Retirees or Dependents Who Become Covered by Medicare in Just prior to turning 65, you may begin receiving information from various carriers, including Kaiser, offering Medicare plans. Paperwork you receive directly from Kaiser or any other carrier is NOT for the Los Rios group plans. If you complete and return their application, it WILL result in the loss of your Los Rios coverage and placement in an individual plan. Please contact the Los Rios Employee Benefits Department for an application approximately 2 months prior to turning 65, if you want to remain enrolled in a Los Rios group plan. There are strict timelines set by CMS for submitting forms. Failure to complete paperwork within the required timelines can result in a significant premium increase for the months without Medicare coverage. Individual plans may have different premiums as well as different coverage, even if the name is the same as the Los Rios plan name. For example, Los Rios offers a Kaiser Senior Advantage plan and there is an individual Senior Advantage plan available directly through Kaiser. If you cancel your Los Rios Medicare plan or elect not to enroll in a Los Rios Medicare Plan, you may not enroll in the Los Rios group plan at a later date. Retirees are still eligible for the District contribution upon providing proof of the premium. Retiree Only Coverage: At the time you turn age 65 or otherwise become eligible for Medicare, you will have the choice of Kaiser Senior Advantage or one of the United Healthcare (UHC) plans when you enroll in Medicare. Sutter Health Plus (SHP) and Western Health Advantage (WHA) do not have Medicare plans. Retiree Plus Spouse/Domestic Partner Coverage: If you cover a spouse or domestic partner on your plan, your choices when you or your spouse/domestic partner turns age 65 are as follows: Kaiser The individual under age 65 would remain in the Kaiser HMO, DHMO, or HDHP HMO plan and the Medicare-eligible individual would enroll in Kaiser Senior Advantage. Sutter Health Plus & Western Health Advantage The individual under age 65 would remain in the SHP or WHA plan and the Medicare-eligible individual could choose between the UHC Medicare Advantage HMO and PPO plans. If the retiree chooses to enroll in Kaiser, both the retiree and dependent must be in Kaiser. Retirees 16 of 26

20 Medical Plans Medicare Advantage Plan Enrollment in the Health Net Seniority Plus plan is closed, and only those who were enrolled in the plan prior to June 30, 2014 can remain on this plan. New enrollments will NOT be accepted, except for qualified spouses/domestic partners or dependents of retirees who are already enrolled in this plan. General Plan Provisions Health Net Seniority Plus HMO Calendar Year Deductible Individual / Family Calendar Year Out-of-Pocket Limit Individual / Family Lifetime Maximum None $3,400 None Outpatient Services Doctor Office Visit Co-Pay $15 Annual Adult Physical Exams and Preventative Care Most Lab & X-ray Chiropractic Outpatient Surgery No Charge No Charge $15 Medicare Approved Visit (PCP referral) / $5 for Self-Referral to participating provider (up to 20 visits/calendar year) No Charge Inpatient Services Hospitalization No Charge Emergency Services Emergency Room $35 (waived if admitted) Ambulance Durable Medical Equipment (DME) DME Prescription Drugs Tier 1 Tier 2 Tier 3 Tiers 4 & 5 Mail Order No Charge No Charge $5 for up to 30-day supply $15 for up to 30-day supply $30 for up to 30-day supply 25% coinsurance Tier 1: $10, Tier 2: $30, Tier 3: $60, Tiers 4 & 5: 25% coinsurance for up to 90-day supply Monthly Contributions Los Rios Retiree Retiree Only $ $ Dependent n/a $ Retiree plus Dependent $ (for retiree) $ Please note: This chart is a brief overview of benefits and coverage for the medical plan. To more thoroughly compare plans, please also review the detailed disclosure/summary documents for each plan available at the MyBenefits website at or from the Employee Benefits Department. For questions about a specific procedure, service or provider, please contact the medical carrier directly. 17 of 26 Retirees

21 Medical Plans Medicare Advantage Plan General Plan Provisions Calendar Year Deductible Individual / Family Calendar Year Out-of-Pocket Limit Individual / Family Lifetime Maximum Outpatient Services Doctor Office Visit Co-Pay Annual Adult Physical Exams and Preventative Care Most Lab & X-ray Chiropractic & Acupuncture Outpatient Surgery Kaiser Senior Advantage HMO None $1,500 / $3,000 None $25 per visit No Charge No Charge Not Covered $25 per visit Inpatient Services Hospitalization $500 per admission Emergency Services Emergency Room $50 (waived if admitted) Ambulance Durable Medical Equipment (DME) DME Prescription Drugs Generic Brand Formulary Brand Non-formulary Mail Order $50 per trip No Charge $10 for up to 30-day supply $25 for up to 30-day supply N/A Generic: $10 for up to a 30-day supply; $20 for day supply Brand: $25 for up to a 30-day supply; $50 for day supply Monthly Contributions Los Rios Retiree Retiree Only $ $11.55 Dependent n/a $ Retiree plus Dependent $ (for retiree) $ Please note: This chart is a brief overview of benefits and coverage for the medical plan. To more thoroughly compare plans, please also review the detailed disclosure/summary documents for each plan available at the MyBenefits website at or from the Employee Benefits Department. For questions about a specific procedure, service or provider, please contact the medical carrier directly. Retirees 18 of 26

22 Medical Plans Medicare Advantage Plans United Healthcare Medicare Advantage HMO Medicare Advantage PPO General Plan Provisions Calendar Year Deductible Individual / Family Calendar Year Out-of-Pocket Limit Individual / Family None None $6,700 N/A Lifetime Maximum None None Outpatient Services Doctor Office Visit Co-Pay $5.00 No Charge Annual Adult Physical Exams No Charge No Charge Most Lab & X-ray No Charge No Charge Chiropractic $5 Not Covered Acupuncture Not Covered Not Covered Outpatient Surgery No Charge No Charge Inpatient Services Hospitalization Emergency Services No Charge No Charge (up to 365 lifetime additional reserve days) Emergency Room $50 (waived if admitted) No Charge Ambulance No Charge No Charge Durable Medical Equipment (DME) DME No Charge No Charge Prescription Drugs Tier 1 Tier 2 Tier 3 & 4 Mail Order $5 for up to a 30-day supply $15 for up to a 30-day supply $30 for up to a 30-day supply Tier 1: $10, Tier 2: $30, and Tier 3 & 4: $60 for up to a 90-day supply Monthly Contributions Los Rios Retiree Los Rios Retiree Retiree Only $ $ $ $ Dependent n/a $ n/a $ Retiree plus Dependent $ (for retiree) $ $ (for retiree) $ Please note: This chart is a brief overview of benefits and coverage for the medical plan. To more thoroughly compare plans, please also review the detailed disclosure/summary documents for each plan available at the MyBenefits website at or from the Employee Benefits Department. For questions about a specific procedure, service or provider, please contact the medical carrier directly. 19 of 26 Retirees

23 Dental Plans Your Dental Plans Los Rios has two Delta Dental plans available to retirees who have remained continuously enrolled in Los Rios dental coverage. There is no District contribution toward the retiree dental coverage--this benefit is paid entirely by the retiree. Delta Dental PPO DeltaCare HMO Delta Dental PPO The Delta Dental PPO plan gives you the freedom to choose your own dentist anywhere in the United States and receive coverage from either in-network or out-of-network providers. This plan is a preferred provider organization (PPO) made up of general dentists and specialists who have agreed to provide dental care at discounted fees. If you go to a dentist who participates in the PPO, you qualify for in-network coverage and benefit from discounted rates. If you go to a dentist who is out-of-network, you receive a lower plan benefit and may pay more for services. The percentage of coverage for Diagnostic, Preventive Care, and Basic Care increases by 10% each year you visit the dentist to a maximum coverage of 100%. If you do not use your dental plan, the percentage remains at the level you reached the previous year. It will drop back to 70% if you switch to the DeltaCare HMO plan and then become covered again by the Delta Dental PPO plan. If your dependent drops coverage and then re-enrolls, your dependent s coverage will drop back to 70%. See page 24 for contact information and the Delta Dental website address. Below is a summary of the key features and costs. Delta Dental PPO In-Network Out-of-Network Diagnostic and Preventative 70%-100% 70%-100% Basic 70%-100% 70%-100% Crowns and Cast Restorations 70% 70% Prosthodontics 50% 50% Per Patient Per Calendar Year Maximum Benefit Monthly Contributions $1,700 $1,500 Retiree Retiree Only $ Retiree plus Dependent $ Retiree plus Family $ Please note: This chart is a brief overview of benefits and coverage for the dental plan. To more thoroughly compare plans, please also review the detailed disclosure/summary documents for each plan available at the MyBenefits website at or from the Employee Benefits Department. For questions about a specific procedure, service or provider, please contact the dental carrier directly. Retirees 20 of 26

24 Dental Plans DeltaCare HMO The Delta Dental HMO plan works just like a medical HMO in that you must go to an in-network provider in California. Although the network of HMO dentists is relatively small, Los Rios added this program as an alternative to the PPO plan for retirees who would like dental insurance coverage, are okay with choosing an in-network dentist, and like the idea of lower premiums offered by this HMO plan. This plan offers services at a set co-pay depending on the services performed, materials used, etc. The table below is a brief summary of some of the benefits. For a full listing of covered services and related costs, visit the MyBenefits website at and select Dental. See page 24 for contact information and the Delta Dental website address. Sample Fee Schedule Delta Dental HMO Your Cost Diagnostic $0 Cleaning 1 per 6 month period $0 Additional cleaning within 6 months $45 Amalgam filling $0 Resin-based composite filling $35-$85 Crown $50 - $240 Complete dentures maxillary $145 Per Patient Per Calendar Year Maximum Benefit Monthly Contributions None Retiree Retiree Only $25.72 Retiree plus Dependent $45.50 Retiree plus Family $49.46 Please note: This chart is a brief overview of benefits and coverage for the dental plan. To more thoroughly compare plans, please also review the detailed disclosure/summary documents for each plan available at the MyBenefits website at or from the Employee Benefits Department. For questions about a specific procedure, service or provider, please contact the dental carrier directly. 21 of 26 Retirees

25 Long Term Care Insurance Long Term Care Insurance Los Rios Community College District offers Long Term Care Insurance (LTC) through Unum. As a retiree who is eligible for the Los Rios retiree medical program, you are eligible to apply for this benefit provided you are younger than age 80. LTC helps pay for a variety of personal and medical services that are provided for people who can no longer care for themselves over a period of time. Services can be provided in a nursing home, residential care facility or at your own home. The Unum Long Term Care insurance offers the following coverage amounts: Benefits Unum Long Term Care Facility Monthly Benefit Amount $3,000 - $9,000 Facility Benefit Duration Elimination Period Lifetime Maximum 2 Years Lifetime 90 Days Monthly Benefit Amount x Benefit Duration This coverage is completely voluntary and is paid by the retiree. You will be billed directly from Unum for the cost of this coverage. You will be subject to medical underwriting for any amount elected and you may be denied coverage. The younger you are when you enroll, the lower the premiums will be. Rates will not increase due to your age after you are enrolled. Family Coverage Family members such as your spouse/domestic partner, child(ren), mother, father, sister, brother and even in-laws are all eligible to apply for this benefit even if you do not elect it for yourself. Coverage for family members are billed directly from Unum to the participant. All family members must be between the ages of 18 and 80 and go through medical underwriting, which means they may be denied coverage. Caregiver Resources Even if you haven t elected Long Term Care Insurance through Los Rios, the AGIS Network provides a wealth of resources and tools, such as caregiving hotlines, assistance finding local and long distance facilities and services, and online tools to help you organize family and friends around caregiving needs. Confronted with the need to provide or arrange for a loved one s care, many first-time caregivers feel overwhelmed by all the decisions and details. A little guidance can help you make sound decisions, even in urgent circumstances. You can find more details at Retirees 22 of 26