Retiree Benefits Guide

Transcription

1 Retiree Benefits Guide DIXON UNIFIED SCHOOL DISTRICT Effective October 1, 2016 September 30, 2017 $ RETIREES MEDICARE PART D ANNUAL NOTICE ATTACHED

2 Welcome to Your Benefits Guide Your benefits are valuable. Make sure you get the most from them by taking the me to understand your op ons and by selec ng the best coverage for you and your family. For informa on about the specific plans available to you, go online to the District s MyBenefits site: Website: h ps://pcms.plansource.com Username: DUSDRe ree Password: benefits Please note: Username and Password are case sensitive Benefits Help Desk Available through or phone. The Benefits Help Desk can help with Open Enrollment questions, claim resolution, information on benefit plans, balance due bills, and doctor issues. We are here to help! 7:30am 5:00pm (PST) Call at: (877) at: csr@epicbrokers.com Summary of Benefits and Coverage (SBC) These are available on the web at: h ps://pcms.plansource.com. Click on SBC and then the plan you are interested in reviewing. Addi onal informa on regarding the SBCs can be found on page 15. Table of Contents Open Enrollment.3 Enrollment 4 Eligibility and Changes.5 Medical Plans & Prescrip on Drugs..6 Medical Benefit Summaries.7 High Deduc ble Health Plans & Health Savings Account (HSA) 8 Dental Plan.. 9 Voluntary Vision Plan. 10 Monthly Premiums..11 Contacts..12 Medicare Part D Annual No ce.. 13 Important No ces.15 Notice of Creditable Coverage If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, a Federal law gives you more choices about your prescrip on drug coverage. Please see page 13 for more details. IMPORTANT NOTICE: READ CAREFULLY This benefits Guide briefly describes your benefit choices and your op ons to enroll. All benefits, and your eligibility for benefits, are subject to the terms and condi ons of the benefit plans, including group insurance contracts. This Guide is not intended to be a complete descrip on of the benefit plans and it is not a summary plan descrip on or plan document. In the event of any conflict or discrepancy between this Guide and the plan documents, the plan documents will govern. Dixon Unified School District reserves the right to modify or terminate any of the described benefits at any me and for any reason. This Guide is not a guarantee of current or future employment or benefits. 2

3 Open Enrollment Open Enrollment What You Need to Do You will need to make choices about which benefits you d like to par cipate in during this Open Enrollment period. This year s annual Open Enrollment period is August 8, 2016 September 7, Any changes you make during this Open Enrollment period become effec ve October 1, Enrollment forms are due to the District Office no later than 4:00 p.m. on Wednesday, September 7, If you do not wish to make any changes to your benefits, no further ac on is required. Open Enrollment Fair Please join us on August 31, 2016! North Bay Schools Insurance Authority (EAP), Kaiser, Western Health Advantage (WHA), Su er Health Plus (SHP), Delta Dental, as well as the District s broker, EPIC, will be present to help answer any ques ons you may have regarding: Plans Benefits High Deduc ble Health Plan (HDHP)/Health Savings Accounts (HSA) Date/Time: Wednesday August 31, :00 pm to 4:00 pm Loca on: CA Jacobs Middle School Mul Purpose Room 200 N Lincoln St. Dixon, CA All enrollment/change forms must be received in the District Office no later than 4:00 pm on Wednesday, September 7, 2016 in order to be accepted. Important Changes to the Plan Offerings Kaiser Residen al treatment for mental health and chemical dependency when a health plan or insurer covers care in a skilled nursing facility for medical and surgical diagnosis, it s required to cover residen al treatment for mental health and chemical dependency as well. The residen al treatment services covered include services that were previously covered under other benefits. Contracep ve products and services the Contracep ve Coverage Equity Act (SB1053) expands California s coverage mandates to include over the counter contracep ves when prescribed by a plan provider. Western Health Advantage (WHA) Hearing examina on copayment considered an essen al health benefit and will no longer contribute to the out of pocket maximum. Su er Health Plan (SHP) Only Offered to those Re rees who are Under 65* *if you are covering your spouse, you and your spouse must be under 65 Reminder: Prescrip on Drugs are classified as Tier 1 / Tier 2 / Tier 3 / Tier 4 Tier 1 Most generic medica ons and lowcost preferred brands Tier 2 Preferred brand name and nonpreferred generic medica ons Tier 3 Non preferred brand name medica ons (generally have a preferred and o en less costly therapeu c alterna ve) Tier 4 Specialty medica ons, selfadministered medica ons Delta Dental There are no benefit changes reported by the carrier. Vision Service Plan (VSP) There are no benefit changes reported by the carrier. 3

4 Enrollment Get Ready to Enroll 1. Review your op ons, ask ques ons and talk with your family. If you re thinking of changing medical plans or you are choosing for the first me: a. Check with your doctors to find out which plans they par cipate in b. If you take any prescrip on medica ons regularly, contact the new plan to find out how these drugs are covered (for example, formulary or non formulary drugs) Call the medical plan s Member Services number or visit its website (contact details are on page 12 of this Guide). 2. Consider not only your current circumstances but also what may be happening in your life in the future. Outside of Open Enrollment, you will not be able to make changes to your benefits unless: a. You have a HIPAA special enrollment event (for example, you get married or have a child). HIPAA special enrollment events are explained in more detail on page 5 of this Guide. 3. Review this booklet which shows your plan op ons and costs. Consider the following when choosing a medical plan: a. What the plans cover. The Medical Plans sec on of this Guide will help explain what each plan covers. b. Your es mated usage. Does your plan choice adequately cover the services you use most or will need in the future? c. Flexibility in choice of doctors, hospitals and how you receive care. Each plan may include a different set of doctors or hospitals or have different rules for how to receive care. d. Verify service areas and provider availability since all medical plans make ongoing changes during the year. 4. Have the right informa on handy. When you start the enrollment process, you ll need: a. Your Social Security number b. The names, birth dates, and Social Security numbers of any dependents you wish to enroll c. Cer fied marriage license, if from another country transla on must be provided, if enrolling your spouse (for dental only) d. Birth cer ficates (children) if enrolling (for dental only) How to Enroll Enrolling by Paper Form You may turn in your completed enrollment/change form directly to the District Office by hand delivering the form or by mail. All enrollment/change forms must be received in the District Office no later than 4:00 pm on Wednesday, September 7, 2016 in order to be accepted. What Happens After Enrollment ID Cards A er you enroll, you will receive an ID card from the medical plan you select. You will not receive an ID card for dental or vision coverage. When you receive your ID card, confirm that all informa on is accurate. If not, contact the District Office right away. Selec ng Primary Care Physicians (PCP) WHA and SHP requires that you and each of your covered dependents select a PCP from the plan s network when you enroll. If you do not designate your preferred PCP, WHA or SHP will assign one for you. To choose a different PCP, call WHA s or SHP s customer service and request that your PCP be changed. PCP changes are not effec ve immediately. Generally, the change will become effec ve first of the following month. 4

5 Eligibility & Changes Eligibility & Changes Eligibility Under present District policy, you, your spouse, stateregistered domes c partner and eligible dependents may remain par cipant(s) in the DUSD health plan system. However, if at the me of your re rement or at any future date, you choose to leave the District s plans, you and your dependents do not have future eligibility. As a re ree, you can par cipate in the benefits described in this Guide provided you are already enrolled. Coverage begins October 1, 2016 if you are applying for a change in coverage during Open Enrollment. Your Dependents Your eligible dependents include: Your spouse (as defined by applicable state law) Your State Registered domes c partner (Cer ficate of Registra on is required) Your children up to age 26 Your children older than 26 with a physical or mental disability as defined by the Social Security Administra on (verifica on is required) Your children include: You or your domes c partner s natural or adopted children Your stepchildren whom you support and who live with you in a parent child rela onship Children placed in your home for adop on 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. Any falsifica on of this informa on could result in termina on of your coverage. Domes c Partner/Same Sex Spouse Taxa on For informa on regarding the tax implica ons of covering a domes c partner or same sex spouse, and their children, re rees are strongly encouraged to consult with a tax advisor. Making Changes You can change your medical benefit plan during annual enrollment. Coverage will remain in effect for the en re plan year (October 1 September 30). You cannot change your coverage (i.e. add any family members to your coverage) during the plan year, unless you have a HIPAA special enrollment event. HIPAA Special Enrollment Rights Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), a re ree has the right to enroll family members if: You get married Your spouse loses other group coverage You have a child born to or placed for adop on A child born to your dependent child who is a qualified beneficiary For any HIPAA special enrollment event, you must request enrollment with 30 days a er you or your dependent s other coverage ends 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 informa on or to request special enrollment, contact the District Office. Premium Costs The collec ve bargaining contract in effect at the me of your re rement lists the terms and condi ons of your eligibility and defines if you qualify for a District contribu on toward the cost of your re ree health insurance benefits (medical, dental and/or vision). A er the period during which the District has agreed to pay some or all of your premium, you may remain on the DUSD health plan system by paying the en re amount of your own health plan premiums. 2016/17 Health Plan premiums can be found on page 11. 5

6 Medical Plans Your Medical Plans You have the choice of several medical plans. For your specific plan op ons and costs, please refer to page 11. Re rees Under 65 Kaiser High Op on HMO $15 Office Visit Copay Kaiser Low Op on Deduc ble HMO $20 Office Visit Copay WHA High Op on HMO $15 Office Visit Copay WHA Mid Op on HMO $20 Office Visit Copay WHA Low Op on HMO High Deduc ble Health Plan (HDHP) SHP High Op on HMO $10 Office Visit Copay (only available to re rees and spouses under 65) Re rees Over 65 Health Net Seniority Plus $10 Office Visit Copay Kaiser High Op on Senior Advantage HMO $15 Office Visits Copy Kaiser Low Op on Senior Advantage HMO $20 Office Visits Copy WHA Medicare Supplement HMO $10 Office Visit Copay How to Choose the Best Plan for You and Your Family When choosing a medical plan, it is important to look at your budget, your preferences and the age and health of you and your covered dependents. You should consider the key differences between plan types and choose one that best suits you and your family. The plans differ in the following areas: Cost of coverage, including District contribu ons, if any, and how you and the plan pay for services throughout the year Convenience, covered services, access to providers, ease of use NOTE: If your enrolled spouse is 65 years of age or older, they will need to be enrolled in Medicare and enrolled in the Medicare plan that is associated with your Re ree Under 65 plan under Kaiser, Health Net and WHA. SHP does not offer an associated plan for those re rees/spouses over age 65. Please see page 7 for a descrip on of the plans available to Re rees Under 65. Health Savings Account (Early Re rees) If you enroll in the WHA High Deduc ble Health Plan you will be eligible to open a health savings account (HSA) a tax advantaged way to pay for current medical expenses and save for future needs. To learn more, see page 8. Enrolling in WHA or SHP? Be sure to elect a primary care physician when you enroll otherwise one will be assigned to you! Prescription Drugs Your prescrip on drug coverage is included as part of the medical plan op on you select. You should always use a par cipa ng pharmacy (one that is contracted by your medical plan) to get the best price. You can access a list of pharmacies through your plan s website or by calling Member Services. The medical plans have ered copayments for prescrip on drugs, meaning you pay a different amount for different classes or groups of drugs. Generic drugs generally have the lowest copays, and non formulary brand name drugs generally have the highest copays. A formulary is a list of drugs (both generic and brand name) that are preferred by the health plans. You can learn more about your plan s prescrip on drug coverage, including what drugs are on the formulary, by visi ng your plan s website. Note: Formularies are updated regularly. Please refer to your plan s website to see any updates. Contact informa on is on page 12 of this Guide. It s good to keep checking back to determine if your prescrip ons are a part of the formulary. A note about the High Deduc ble Health Plans: If you enroll in a High Deduc ble Health Plan, you will pay the full cost of your prescrip on drugs un l you meet your. However, if you use a par cipa ng pharmacy, you will receive a discounted price for prescrip on drugs. A er you meet the, the plan will pay 100% of the cost of prescrip on drugs. 6

7 Medical Plans Retirees Under 65 Only Services Calendar Year Deduc ble Cal. Year Out of Pocket Max Single/Family Life me Maximum Office Visits Preven ve Care Room & Board Hospital Inpa ent (semi private) Outpa ent Services Emergency Room Services (copay waived if admi ed) Prescrip on Drug Copay Retail 2 Prescrip on Drug Copay Mail Order 2 Chiroprac c Care* Eye Exam / Eyewear High Low High Mid Low High Kaiser Kaiser WHA WHA WHA SHP $15 HMO $20 Deduc ble HMO Premier 15 HMO Advantage 70 Western ,3 HMO HDHP HMO ML32 $10 HMO None $1,000 / $2,000 None None $1,800 / $3,600 None $1,500 / $3,000 $3,000 / $6,000 *includes ded* $1,500 / $2,500 $3,000 / $5,000 $1,800 / $3,600 *includes ded* $750 / $1,500 Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited $15 copay $15 copay $50 copay $20 copay a er (ded. waived) 20% a er 20% a er 20% a er $10 G / $10 B 100 day supply $10 G (ded. waived) / $30 B a er $250 brand drug $10 G / $10 B 100 day supply $15 copay up to 20 visits per calendar year Exam: No charge; Eyewear: up to $175 every 2 years 100 day supply Not covered Exam Only: No charge (ded. waived); No eyewear $15 copay $20 copay 30% Office: $15 copay; Facility: $100 copay Office: $20 copay; Facility: 30% $100 copay $100 copay T1: $10 / T2: $20 / T3: $30 30 day supply T1: $25 / T2: $50 / T3: $75 90 day supply $15 copay up to 20 visits per calendar year Exam: $15 copay; Eyewear: allowance per schedule T1: $10 / T2: $30 / T3: $50 30 day supply T1: $25 / T2: $75 / T3: $125 NF 90 day supply $15 copay up to 20 visits per calendar year Exam Only: $20 copay; No eyewear a er (ded. waived) a er a er a er a er a er $15 copay up to 20 visits per calendar year Exam Only: No charge (ded. waived); No eyewear $10 copay $30 copay T1: $5 / T2: $20 / T3: $40 30 day supply T1: $10 / T2: $40 / T3: $ day supply $15 copay up to 20 visits per calendar year Exam Only: No charge; No eyewear The informa on presented in the chart is a summary only. The informa on does not include all of the detailed explana on of benefits, exclusions and limita ons. Plan par cipants should refer to the Evidence of Coverage (EOC) document for coverage details. In the event informa on in this summary differs from the EOC, the EOC will prevail. 1 If you have family coverage, there is no single or out of pocket maximum for each family member; rather, the en re Family or OOPM must be met before WHA becomes responsible for providing covered services for any individual member in the family. 2 G = Generic; B = Brand; NF = Non Formulary; T1: Tier 1, T2: Tier 2, T3: Tier 3 3 All benefits are subject to the unless otherwise stated FULL BENEFIT SUMMARIES FOR THESE PLANS INCLUDING THOSE FOR RETIREES OVER 65 ARE AVAILABLE AT THE OPEN ENROLLMENT FAIR AND THE DISTRICT S MYBENEFITS SITE. 7

8 High-Deductible Health Plan (HDHP) & Health Savings Account (HSA) If you enroll in the Western 1800 WHA High Deduc ble Health Plan, Re rees under 65 are eligible to open a Health Savings Account (HSA). Health savings accounts were created by the federal government to give people a new way to pay for medical expenses and save for future needs. An HSA is considered tax advantaged because you are not taxed at the federal level on contribu ons, earnings or withdrawals and your balance rolls over year to year. You own and manage the account. You can use your HSA to: Pay for current expenses, such as s, prescrip on drugs, coinsurance or other health care expenses Pay for future health care expenses, even if you are no longer enrolled in a High Deduc ble Health Plan Pay for things other than health care (but you will be taxed on those payments and subject to penal es) Important Notes: The High Deduc ble Health Plan has what is called an aggregate family and family out of pocket maximum. This means that if you cover any dependents, your family must pay the total family (not just the individual ) before the plan begins to share costs with you. You must also meet the total family outof pocket maximum before the plan pays 100 percent of covered services. The Deduc ble and Out of Pocket Maximum are calculated on a calendar year (January 1 through December 31), not the District s plan year (October 1 through September 30). Any amounts that are applied towards the and out of pocket maximums reset and do not carry over to the following calendar year. You can contribute to an HSA only if you are enrolled in a qualified High Deduc ble Health Plan. You cannot be covered under any other nonqualified medical plan, including your spouse s plan. You can choose any bank or financial ins tu on for your Health Savings Account. The High Deduc ble Health Plan and your HSA work together. High Deduc ble Health Plans (HDHP) Health Savings Account (HSA) Comprehensive medical coverage a er you pay the Preven ve care (before you meet the ) Out of pocket maximum protects you from high costs You can contribute up to the annual limit each year Helps pay your and other expenses Tax free contribu ons, earnings and payments (for qualified expenses) 8

9 Dental Plan Your Dental Plan Dixon Unified School District offers its re rees a PPO plan through Delta Dental. Unless you elected this coverage when you re red, you are not able to elect this benefit during this Open Enrollment. The Delta Dental PPO plan gives you the freedom to choose your own den st and receive coverage from in network and out of network providers. This plan is a preferred provider organiza on (PPO) made up of general den sts and specialists who have agreed to provide dental care at discounted fees. If you go to a den st who par cipates in the PPO, you qualify for in network coverage and benefit from discounted rates. Below is a summary of the key features for both in network and out of network services. IN PPO Network Out of PPO Network Delta Dental PPO Den st Delta Dental Premier Den sts & Non Delta Dental Den sts You will usually pay the lowest amount for You are responsible for the difference between the amount services when you visit a Delta Dental PPO Delta Dental pays and the amount your non Delta Dental den st den st. bills. You will usually have the highest out of pocket costs when you visit a non Delta Dental den st. PPO den sts agree to accept a reduced fee for PPO pa ents. You are charged only the pa ent's share at the me of treatment. Delta Dental pays its por on directly to the den st. PPO den sts will complete claim forms and submit them for you at no charge. Delta Premier den sts may not balance bill above Delta Dental's approved amount, so your out of pocket costs may be lower than with non Delta Dental den sts' charges. Non Delta Dental den sts may require you to pay the en re amount of the bill in advance and wait for reimbursement. Delta Premier den sts charge you only the pa ent's share at the me of treatment. You may have to complete and submit your own claim forms, or pay your non Delta Dental den st a service fee to submit them for you. Delta Premier den sts will complete claim forms and submit them for you at no charge. Delta Dental In / Out of Network Calendar Year Deduc ble None Calendar Year Maximum Benefit $1,700 $1,500 Diagnos c and Preven ve 70% 100% 70% 100% Basic 70% 100% 70% 100% Crowns, Jackets, Inlays, Onlays, and Cast Restora ons 70% 100% 70% 100% Prosthodon cs 50% 50% Orthodon a (Adult/Children) Not covered Not covered Life me Orthodon a Maximum N/A Wai ng Period None The informa on presented in the chart is a summary only. The informa on does not include all of the detailed explana on of benefits, exclusions and limita ons. Plan par cipants should refer to the Evidence of Coverage (EOC) document for coverage details. In the event informa on in this summary differs from the EOC, the EOC will prevail. 9

10 Vision Your Vision Plan Dixon Unified School District offers vision coverage through Vision Service Plan (VSP). Unless you elected this coverage when you re red, you are not able to elect this benefit during Open Enrollment. Under this plan, you can use a VSP provider or another provider of your choice. However, when you obtain vision care through a non network provider, you will receive a reduced level of benefits. Below is a summary of covered services. Services Co payments Eye Exams Primary Eye Care Materials Frequency Exam Lenses Frames Contact Lenses Coverage In Network Out of Network $10 copay $20 copay $0 a er exam copay is met Once every 12 months Once every 12 months Once every 12 months Once every 12 months Eye Exam Covered in full a er copay up to $45 Single Lens Covered in full up to $30 Bi Focal Lenses Covered in full up to $50 Tri Focal Lenses Covered in full up to $65 Len cular Lenses $55 $175 copay up to $100 Progressive Lenses $55 copay up to $50 Frame Allowance up to $130 up to $70 Costco Frame Allowance* up to $70 Contact Lenses Medically Necessary Covered in full up to $210 Elec ve up to $130 allowance up to $105 The informa on presented in the chart is a summary only. The informa on does not include all of the detailed explana on of benefits, exclusions and limita ons. Plan par cipants should refer to the Evidence of Coverage (EOC) document for coverage details. In the event informa on in this summary differs from the EOC, the EOC will prevail. *Allowance is equivalent to the frame allowance at preferred providers and other affiliate loca ons. Average frame at Costco is $70 Addi onal VSP Benefits Addi onal Pairs of Glasses 20% off unlimited addi onal pairs of prescrip on glasses and/or nonprescrip on sunglasses Primary Eye Care Program Supplemental coverage for non surgical medical eye condi ons, such as pink eye and other urgent eye care $20 copay per visit at Preferred Providers Laser Vision Care Program Discounts average 15 20% off or 5% off a promo onal offer for laser surgery, including PRK, LASIK, and Custom LASIK at Preferred Providers Low Vision Supplemental tes ng covered every two years. 75% coverage for approved low vision aids, up to $1,000 (less any amount paid for supplemental tes ng) every two years at Preferred Providers Eye Health Management Program Exam reminder le ers sent to VSP members with diabetes who have not had an eye exam in 14 months Primary Eyecare Program is designed for the detec on, treatment and management of ocular condi ons and/or systemic condi ons which produce ocular or visual symptoms. A member can seek care from their vision provider versus their medical primary care physician for Symptoms including but not limited to: ocular discomfort transient loss of vision flashes or floaters red eyes swollen lids pain in or around the eyes diplopia ocular trauma Condi ons including but not limited to: ocular hypertension glaucoma cataracts pink eye sty corneal abrasion corneal dystrophy macular degenera on re nal nevusble Blephari s 10

11 Monthly Premiums Retirees Under 65 Plans Current Rate New Rate Single $ $ Kaiser HMO $15 Two Party $1, $1, Family $2, $2, Single $ $ Kaiser HMO $20 Two Party $1, $1, Family $1, $1, Single $ $ WHA HMO $15 Two Party $1, $1, Family $2, $2, Single $ $ WHA HMO $20 Two Party $1, $1, Family $1, $1, Single $ $ WHA HMO HDHP Two Party $ $1, Family $1, $1, Single $ $ Sutter Health Plus $10 HMO Two Party $1, $1, Family $1, $1, Different rates apply if you have a spouse over 65 Retiree Over 65 Plans Current Rate New Rate Health Net Seniority Plus Kaiser Senior Advantage HMO $15 Kaiser Senior Advantage HMO $20 WHA Medicare Supplement Single Single Single Single $ $ $ $ $ $ $ $ Two Party Two Party Two Party Two Party $1, $ $ $1, $1, $ $ $1, Different rates apply if you have a spouse under 65 All Retirees Current Rate New Rate Single $55.89 $54.25 Delta Dental Two Party $ $ Family $ $ Single $16.34 $16.34 VSP Vision Two Party $25.38 $25.38 Family $40.25 $

12 Contacts If you have ques ons you can contact Payroll and Benefits at (707) or the plan carriers. Use this chart to help guide you to the right resource on the first try. PLAN GROUP # TELEPHONE # WEBSITE MEDICAL Kaiser 1072 (800) WHA (888) Su er Health Plus (SHP) (855) erhealthplus.org DENTAL Delta Dental 7010 (866) VISION Vision Service Plan (VSP) (800) BENEFIT PLAN INFORMATION MyBenefits h ps://pcms.plansource.com Username: DUSDRe ree Password: benefits Benefits Help Desk (877) csr@epicbrokers.com 12

13 Medicare Part D Notice Important No ce from Dixon Unified School District About Your Prescrip on Drug Coverage and Medicare This No ce Applies to You (or Dependent) ONLY if such person is (1) enrolled in a group medical plan offered by Dixon Unified School District AND (2) eligible for Medicare Please read this no ce carefully and keep it where you can find it. This no ce has informa on about your current prescrip on drug coverage with Dixon Unified School District and about your op ons under Medicare s prescrip on drug coverage. This informa on can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescrip on drug coverage in your area. Informa on about where you can get help to make decisions about your prescrip on drug coverage is at the end of this no ce. There are two important things you need to know about your current coverage and Medicare s prescrip on drug coverage: 1. Medicare prescrip on drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescrip on Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescrip on drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. Dixon Unified School District has determined that the prescrip on drug coverage offered by Kaiser, Western Health Advantage (WHA), Su er Health Plus (SHP), and Health Net is, on average for all plan par cipants, expected to pay out as much as standard Medicare prescrip on drug coverage pays and is therefore considered Creditable Coverage. Because your exis ng coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescrip on drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Dixon Unified School District coverage may be affected. Your current coverage pays for other health expenses in addi on to prescrip on drugs. If you enroll in a Medicare prescrip on drug plan, you and your eligible dependents may not be eligible to receive all of your current health and prescrip on drug benefits. If you do decide to join a Medicare drug plan and drop your current Dixon Unified School District coverage, be aware that you and your dependents may not be able to get this coverage back. 13

14 Medicare Part D Notice When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Dixon Unified School District and don t join a Medicare drug plan within 63 con nuous days a er your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 con nuous days or longer without creditable prescrip on drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescrip on drug coverage. In addi on, you may have to wait un l the following October to join. For More Informa on About This No ce Or Your Current Prescrip on Drug Coverage Contact the person listed below for further informa on. NOTE: You ll get this no ce each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Dixon Unified School District changes. You also may request a copy of this no ce at any me. For More Informa on About Your Op ons Under Medicare Prescrip on Drug Coverage More detailed informa on about Medicare plans that offer prescrip on drug coverage is in the Medicare & You handbook. You ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more informa on about Medicare prescrip on drug coverage: Visit Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the Medicare & You handbook for their telephone number) for personalized help Call MEDICARE ( ). TTY users should call If you have limited income and resources, extra help paying for Medicare prescrip on drug coverage is available. For informa on about this extra help, visit Social Security on the web at or call them at (TTY ). Remember: Keep this Creditable Coverage no ce. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this no ce when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Date: August 8, 2016 Name of En ty/sender: Dixon Unified School District Contact Posi on/office: Payroll/Benefits Department Address: 180 S. First Street, Ste 6 Phone Number: (707)

15 Important Notices Newborns and Mothers Health Protec on Act Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connec on with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean sec on. However, federal law generally does not prohibit the mother s or newborn s a ending provider, a er consul ng with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authoriza on from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). If you would like more informa on on maternity benefits, contact your health plan. Pa ent Protec on No ce Dixon Unified School District s WHA and SHP HMO plans generally require the designa on of a primary care provider. You have the right to designate any primary care provider who par cipates in the network and who is available to accept you or your family members. Un l you make this designa on, the plan designates one for you. For informa on on how to select a primary care provider, and for a list of the par cipa ng primary care providers, contact member services. For children, you may designate a pediatrician as the primary care provider. You do not need prior authoriza on from Kaiser, WHA or SHP or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authoriza on for certain services, following a pre approved treatment plan, or procedures for making referrals. For a list of par cipa ng health care professionals who specialize in obstetrics or gynecology, contact member services. Special Enrollment No ce If an eligible re ree acquires a new dependent as a result of marriage, birth, adop on or placement for adop on, the eligible re ree may be able to enroll any eligible dependents, provided that the eligible re ree requests enrollment within 30 days a er the marriage, birth, adop on, or placement for adop on. If the eligible re ree otherwise declines to enroll, he/she may be required to wait un l the group s next open enrollment to do so. The eligible re ree also may be subject to addi onal limita ons on the coverage available at that me. Furthermore, eligible re rees and their eligible dependents who are eligible for coverage but not enrolled, shall be eligible to enroll for coverage within 60 days a er (a) becoming ineligible for coverage under a Medicaid or Children s Health Insurance Plan (CHIP) plan or (b) being determined to be eligible for financial assistance under a Medicaid, CHIP, or state plan with respect to coverage under the plan. Women s Health and Cancer Rights Act Annual No ce If you have had or are going to have a mastectomy, you may be en tled to certain benefits under the Women s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy related benefits, coverage will be provided in a manner determined in consulta on with the a ending physician and the pa ent, for: All stages of reconstruc on of the breast on which the mastectomy was performed; Surgery and reconstruc on of the other breast to produce a symmetrical appearance; Prostheses; and Treatment of physical complica ons of the mastectomy, including lymphedema. These benefits will be provided subject to the same s and coinsurance applicable to other medical and surgical benefits provided under this plan. If you would like more informa on on WHCRA benefits, call member services. Summary of Benefits and Coverage (SBC) As required by the Affordable Care Act (ACA), health plans and employer groups must provide the Summary of Benefits and Coverage (SBC) to eligible re rees and family members, who are: Currently enrolled in one of the group health plans or Eligible to enroll in one of the plans, but not yet enrolled As such, we are providing you and your covered dependents an SBC for the health plan you are currently enrolled in, if applicable. The SBC provides important informa on about the Plan s benefits and your rights as a Plan par cipant. ACA also provides for a Uniform Glossary of insurance and medical terms. A paper copy of this Glossary is available upon request. All SBCs and the Glossary can be found on the District s MyBenefits website. 15