MEDICAL PRESCRIPTION VALUE ADDED SERVICES LONG-TERM CARE LIFE EMPLOYEE BENEFITS GUIDE. WÊÙ» Ä TÊ ã«ù ãê M» D Ù Ä. Imperial Valley College

Transcription

1 EMPLOYEE EAP MEDICAL PRESCRIPTION VALUE ADDED SERVICES LIFE LONG-TERM CARE BENEFITS GUIDE WÊÙ» Ä TÊ ã«ù ãê M» D Ù Ä Imperial Valley College

2 2 welcome. The Imperial County Schools Voluntary Employees Benefits Associa on (ICSVEBA) is a group of school districts, joined to form a benefit purchasing pool to ensure the best benefits op ons for employees of these school districts. Your District believes providing a compe ve employee benefits program is one of the most important investments. We appreciate the tremendous value and contribu ons of employees and recognize that good employee health is good business. Each year the benefit programs are evaluated to ensure those covered in the ICSVEBA benefits con nue to have robust, compe ve and cost-effec ve choices. This guide has been prepared to assist you in making informed decisions regarding your benefits. We are pleased to offer a benefits package with a variety of coverage op ons which allow you to choose the op on that best meets your needs. We encourage you to read this guide carefully and to keep it as a reference. Please contact the ICSVEBA Member Services at should you have any ques ons regarding your benefits package. contents. 03 Benefits 04 Costs 05 Eligibility 06 Member Services 07 Medical 10 Prescrip on 11 EAP 12 Value Added Services 14 Life Insurance 15 Long-Term Care 16 Legal No ces Back Contacts

3 3 benefits. BENEFIT COVERAGE OPTIONS COSTS SHARED BY YOU AND YOUR EMPLOYER MEDICAL Anthem Blue Cross & SIMNSA Anthem Blue Cross Comprehensive Op on Anthem Blue Cross Basic Op on Anthem Blue Cross COB Op on (PPO) SIMNSA HMO Op on 100% OF COSTS PAID BY YOUR EMPLOYER BASIC LIFE AND AD&D Symetra Life MENTAL HEALTH AND EMPLOYEE ASSISTANCE PROGRAM (EAP) The Holman Group Benefit equal to a flat $50,000 for employee coverage Offers private sessions at a copay based on your medical op on 100% OF COSTS PAID BY YOU VOLUNTARY LIFE Symetra Life LONG-TERM CARE Unum Employee and Spouse: addi onal coverage up to $500,000 Child(ren): addi onal coverage up to $10,000 Up to $6,000 per month for you, your spouse, parent or grandparent Choose Carefully! The benefits you select during enrollment will stay in place through September 30, 2018 unless you have a qualifying event as defined by the IRS. Examples of a qualifying event include: You have a change in your marital status You have a baby or adopt a child (Plan allows 60 days to no fy of a newborn) Your dependent child loses eligibility due to age or marriage You become disabled You end your employment with the District You or your dependent passes away Your spouse/domes c partner gains or loses coverage You must no fy your employer within 31 days of the qualifying event. Benefits elec ons will then remain in force for the remainder of the plan period.

4 4 costs MONTHLY PREMIUMS (BEFORE YOUR DISTRICT CONTRIBUTION) MEDICAL COMPREHENSIVE OPTION Employee Only $ Employee + Spouse $1, Employee + Child(ren) $1, Employee + Family $1, MEDICAL BASIC OPTION Employee Only $ Employee + Spouse $1, Employee + Child(ren) $1, Employee + Family $1, MEDICAL COB OPTION Employee Only $ Employee + Spouse $1, Employee + Child(ren) $ Employee + Family $1, MEDICAL SIMNSA OPTION Employee Only $ Employee + Spouse $ Employee + Child(ren) $ Employee + Family $ BASIC LIFE AND AD&D Employee $50,000 (100% Employer Paid) $8.50

5 5 eligibility. Who is Eligible You are eligible if you are a regular full- me employee and are working 30 hours or more per week. You may also enroll your eligible dependents in the medical and life insurance plans. Your eligible dependents include: Your legal spouse Your children or stepchildren up to age 26, regardless of marital or student status Any children for whom you are required to provide coverage under a Qualified Medical Child Support Order Your unmarried children or stepchildren of any age, if they are incapable of self-care due to a physical or mental disability When Coverage Begins Your benefits will commence on the first of the month following your date of hire. Cost for Coverage As shown in the chart on page 4, your employer pays the full cost for Basic Life and AD&D and Mental Health/EAP insurance. Contribu ons, for the plans where you share the cost with your employer are deducted from your pay on a pre-tax basis. This means that the income you use to pay for these benefits is not taxed, pu ng dollars back into your pocket. Newly Hired Employees You must make your benefits elec ons within 31 days of your date of hire. If you do not enroll for coverage during your eligibility period, you must wait un l the next open enrollment period unless you have a qualifying event. Open Enrollment Open Enrollment occurs each year and is your opportunity to review your benefits op ons to determine what best meets your needs. The selec ons you make will remain in effect for the en re plan year unless you have a qualifying event.

6 6 member services. ICSVEBA MEMBER SERVICES is here to answer your ques ons and help make your employee benefits easier to use. ICSVEBA Member Services is the only number you need to call with employee benefit and wellness ques ons...and best of all, it s free! Within 24 hours of your ini al call, Member Services will either have the issue resolved or will update you on any further ac ons including the me frame for resolu on. Below are some of the ques ons Member Services can answer. Benefit Ques ons I need to have surgery; does my insurance cover it? How much will my por on of the cost be? Referral I need to see a specialist, but I m having trouble ge ng a referral. What do I do? Claims Assistance I received a bill from my doctor. I thought these services were covered. What do I do now? Eligibility Issues I tried to pick up a prescrip on today, but the pharmacy is saying that I m not covered. Why? ICSVEBAService@hubinterna onal.com Fax: Monday - Friday 7:30 a.m. to 4:30 p.m. PT All inquiries will be responded to within 24 hours of your call or .

7 7 medical. We recognize that you have different needs when it comes to your medical op ons. We provide you with op ons that help you and your family achieve op mum health. We offer you the choice of four health op ons, including: Anthem Blue Cross Comprehensive Op on (PPO) Anthem Blue Cross Basic Op on (PPO) Anthem Blue Cross COB Op on (PPO) SIMNSA HMO Op on PPO Options The Anthem PPO Op ons offer a network of physicians who have agreed to discount fees for their services. You may choose to have your treatment provided by an in-network PPO physician and may receive a higher level of benefit with poten ally lower out-of-pocket costs to you. You may also choose to go outside the network, however, benefits are generally reimbursed at a lower level and you may have higher out-of-pocket costs. With a PPO op on, you have a choice every me you need care. Your in-network physicians will submit claims for you. If you receive treatment from a non-network physician, they may require you to pay the en re amount at the me of service and submit a claim for reimbursement. SIMNSA HMO Option The SIMNSA HMO is an op on for U.S. workers who reside, or have dependents, in Mexico (Tijuana, Mexicali, and Tecate). This op on offers comprehensive medical coverage that includes preven ve care and fixed copays for most services. There are no annual deduc bles or life me dollar maximums. You will have the ability to choose your own SIMNSA personal physician who will be responsible for providing or coordina ng all of your medical care, including specialty care referrals.

8 8 medical. COMPREHENSIVE BENEFITS BASIC IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK $650/$1,950 $1,500/$4,500 $1,500/$4,500 $3,000/$9,000 20% 50% 20% 50% $3,000/$9,000 $9,000/$27,000 $6,600/$13,200 $10,000/$30,000 Preventive Care Services No charge 50% a er Deduc ble No charge 50% a er deduc ble Office Visit PCP/Specialist $10 / $20 copay 50% a er deduc ble $35 / $70 copay 50% after deductible Diagnostic Lab and X-Ray No charge 50% a er deduc ble 20% after deductible 50% after deductible $250 per admission + 20% after deductible $250 per admission + 50% after deductible $250 per admission + 20% after deductible $250 per admission + 50% after deductible Annual Deductible Individual/Family Coinsurance Out-of-Pocket Maximum (includes deductible) Individual/Family Physician Services Hospital Services Inpatient Other Benefits Emergency Room $250 copay (waived if admitted) $250 copay (waived if admitted) Ambulance 20% after deductible 20% after deductible Urgent Care $30 copay $30 copay Durable Medical Equipment 20% (maximum $500 out-of-pocket) 50% after deductible 20% (maximum $500 out-of-pocket) 50% after deductible Mental Health and Employee Assistance Program Provided through The Holman Group, and carved out of your core benefits. Annual Deductible $650/$1,950 $1,500/$4,500 $1,500/$4,500 $3,000/$9,000 Copayment $10 copay 50% of UCR a er deduc ble $35 copay 50% of UCR a er deduc ble Maximums Acute Treatment AB88 Diagnoses Outpatient Inpatient 30 days/year 30 days/year Unlimited 30 days/year Unlimited 90 days/year

9 9 medical. COB BENEFITS This is a secondary payor op on only. Select to coordinate benefits with your spouse; if you have children and your spouse s birthday is 1st in the year. SIMNSA Stateside benefits only for life threatening medical emergencies IN-NETWORK OUT-OF-NETWORK IN-NETWORK ONLY Individual/Family None None None Coinsurance 70% 70% of UCR None None None $6,350/$12,700 No charge 70% of UCR No charge Office Visit - PCP/Specialist 70% 70% of UCR $5 copay Diagnostic Lab and X-Ray 70% 70% of UCR No charge 70% 70% of UCR No charge Emergency Room 70% 70% of UCR $250 copay Ambulance 70% 70% of UCR No charge Urgent Care 70% 70% of UCR $25 copay Durable Medical Equipment 70% 70% of UCR Not Covered Annual Deductible Out-of-Pocket Maximum Individual/Family Physician Services Preventive Care Services Hospital Services Inpatient Other Benefits Mental Health and Employee Assistance Program Provided through The Holman Group, and carved out of your core benefits. Annual Deductible None None Copayment 70% 70% of UCR Maximums Acute Treatment AB88 Diagnoses Outpatient Inpatient 30 days/year EAP only Unlimited 90 days/year

10 10 prescription. It is important to be an informed consumer, especially with your prescrip on drug op ons. All of your medical plan op ons include prescrip on drug coverage through Rx Benefits. Present your medical plan ID card at a par cipa ng pharmacy. You will receive up to a 30-day supply for your prescrip on. You will pay a copay based on the type of prescrip on you receive. Who is RxBenefits? RxBenefits will act as an informed advocate for ICSVEBA members and their covered dependents regarding their prescrip ons. ICSVEBA will s ll be using the Express Scripts network, however, any ques ons you have regarding your prescrip ons will be handled by RxBenefits. Team members are available to answer your ques ons from 5:00 a.m. to 4:00 p.m. PST, Monday thru Friday. Members can also RxBenefits at RxHelp@rxbenefits.com. Who handles mail order scripts and specialty medica ons? Express Scripts and Accredo. There should be no disrup on with specialty scripts. Members can con nue to refill and receive their mail order and specialty medica ons as they currently do. BENEFITS COMPREHENSIVE BASIC COB SIMNSA Generic $5 copay $5 copay $5 copay $5 Preferred $25 copay $25 copay $25 copay N/A Non-Preferred $55 copay $55 copay $55 copay N/A Specialty 20% coinsurance per prescrip on, up to annual out-of-pocket maximum of $1,000 N/A Save Money on Your Medica ons You can save money by asking for generic drugs. The FDA requires that generic drugs have the same high quality, strength, purity, and stability as brand-name drugs. The next me you need a prescrip on, ask your doctor to prescribe a generic drug when it is available and appropriate.

11 11 eap. Life is full of challenges and some mes balancing it is difficult. We are proud to provide a program dedicated to suppor ng the emo onal health and well-being of our employees and their families. Employee Assistance Program Administered by The Holman Group, the Employee Assistance Program (EAP) is a confiden al program for you, your family and all household members. The services are offered to you, at no cost. EAP Benefit Unlimited telephonic access 24-hour crisis response by licensed counselors, seven days a week Each member of your household receives 5 in-person visits per issue per year Confidential Clinical Counseling EAP benefits include up to five sessions per incident per calendar year and can help with such issues as: Bereavement or grief Legal Financial Childcare/eldercare referrals Marital/rela onship issues Paren ng issues Substance abuse Depression/anxiety Anger Stress management Weekly webinars The Holman Group

12 12 value added services. Anthem Live Health Online Anthem Live Health Online is a service that offers a convenient way for VEBA members on a stateside plan to talk with and get treatment from a doctor at You can have live, instant or planned visits with a U.S. board-cer fied doctor 24 hours a day, seven days a week. The service uses two-way video conferencing, along with instant messaging, to allow access from the convenience of your home or work. Delta TeamCare Managing for Tomorrow Managing for Tomorrow is a unique health improvement program available to all eligible employees and their dependents. It is being offered by Imperial County Schools Voluntary Employees Benefits Associa on (ICSVEBA), in associa on with Delta TeamCare. This program offers personalized health informa on and tools that are tailored to your situa on. You can learn about living a healthy lifestyle, managing your health, and working with your doctor to stay healthy. Disease Management - Maternity Management - Nurse Hotline Delta TeamCare Health Education and Personal Health Coaching All employees and family members also have access to a TeamCare health educator that collaborates with you to make lifestyle changes so you can live a healthier life. The programs include: Weight Management Physical Ac vity Nutri on Stress Management Pre and Post Natal Tobacco Cessa on Enroll today by calling Wellvolution Effec ve October 1, 2017, ICSVEBA members are able to par cipate in the Wellvolu on Program; which includes rewards contests, financial incen ves, and a physical ac vity program called Walkadoo that gives you a Fitbit device for tracking, and more! Members will have to register to par cipate. Please visit on.com to register and for more informa on.

13 13 value added services. Carrum Health Carrum Health is a new way to get surgery. Having an opera on can be overwhelming; from figuring out the best surgeon to determining how much it will cost, to ge ng through the recovery. That s where Carrum Health comes in. Carrum works with your current medical plan, and with no addi onal cost, you get: Exclusive access to top-quality surgical care at Scripps Health for hip/knee replacement, spinal fusion and coronary bypass surgeries No medical bills! You pay zero out of pocket costs Personalized "Concierge" support throughout your journey from selec ng the best surgeon, gathering the paperwork to post-discharge recovery care A $500 gi card if you use Carrum for your next eligible surgery! To learn more or get started with the program, contact Carrum Health toll free at or visit my.carrumhealth.com/icsveba. CCS LivingConnected Diabetes Program ICSVEBA members have access to a new Diabetes Program through CCS Medical. They will provide you high-quality products and support you with personalized service. Diabetes supplies will be provided at 100% coverage with no out-of-pocket costs. Supplies such as: state-of-the-art cellular and Bluetooth glucose meters, test strips, lancing devices, and lancets are available. They offer free home delivery of supplies as you need them, with no out-ofpocket expenses, alerts and coaching from a CCS nurse when your readings are out of range, live ongoing personalized health coaching from Cer fied Diabetes Educators, and 24/7/365 toll-free access to live nursing support! Please note that par cipa on in the CCS LivingConnected program is voluntary and you must ac vely enroll to par cipate. Please contact their Customer Support team at , from 5:00 a.m. to 4:00 p.m. PST, Monday through Friday if you have any ques ons. Identity Theft (IDT) You have an opportunity to purchase Iden ty The Protec on and Resolu on Services through IDT, brought to you by the ICSVEBA. Secure your privacy with complete detec ve and restora ve iden ty protec on around the clock. IDT will watch over your personal and financial informa on on public and private databases, social media and the Internet. They also provide you with proac ve measures and educa onal tools so you can take steps to protect yourself. Their fraud specialists are a phone call away 24 hours a day, seven days a week to help you every step of the way. The monthly cost is $8.95/ Individual and $17.95/Family. Family includes up to 3 dependents over age 18. All dependent minors have full restora on services included. REACH Air Ambulance Since 2010, ICSVEBA has nego ated with REACH Air Medical to provide a benefit to all ICSVEBA members and their families. If you are in an emergency situa on and in need of an air ambulance, if REACH is dispatched first to transport you, there will be no out of pocket costs to you as an ICSVEBA member or for your family living in the same household!

14 14 life insurance. Basic Life and AD&D Symetra Basic Life and Accidental Death & Dismemberment (AD&D) insurance coverage helps you protect your loved ones and ensures their financial security. As a full- me, eligible employee, you are automa cally enrolled in the Group Basic Life and AD&D plan. The benefit is equal to a flat $50,000, with no medical underwri ng required. This policy is provided at no cost to you. Voluntary Life If you determine you need more than the Basic Life coverage provided to you, you may want to purchase addi onal coverage for yourself and your eligible dependents. We offer Voluntary Employee, Spouse and Child Life, at group rates, to supplement your employer-paid Basic Life Insurance. Unlike Basic Life Insurance, Voluntary Life is 100% employee-paid. Voluntary Life premium is deducted from your paycheck and is portable, allowing you to con nue coverage should you ever leave the company. You may elect Voluntary Life coverage for yourself or your spouse to a maximum of $500,000. You may also elect Voluntary Life coverage for your children to a maximum of $10,000.

15 15 long-term care. Help protect yourself, your parents and your family from the high cost of long-term care. Whether care is provided at home or in a facility, the costs and caregiver challenges quickly add up. ICSVEBA partners with Unum to provide you with valuable coverage, tools, and resources to help with your personal care challenges. Long-term care insurance may help reimburse covered charges for both facility and home care. With long-term care insurance you can: Cover yourself and/or eligible family members Stay in your home to receive care as long as possible Relieve the burden of future care from loved ones Newly hired employees have 30 days to enroll a er becoming benefit eligible to receive reduced underwri ng.

16 16 legal notices. Wellness Amendment Your District may, from me to me, implement or adopt one or more wellness programs or disease management programs under this plan that offer you the opportunity to qualify for discounts on the cost of benefit op ons or other financial incen ves if you and/or your eligible family members par cipate in the program or sa sfy certain health standards. If Your District chooses to offer a wellness program or disease management program, its terms and condi ons will be communicated to you and it will be administered in compliance with all applicable laws. If you or your family members choose not to par cipate, or stop or otherwise fail to qualify in one of these wellness or disease management programs, any adjustments will be automa cally applied to the cost of your Benefit Op ons and to your salary reduc ons (if any) under our cafeteria plan. If it is unreasonably difficult due to a medical condi on for you to achieve the standards for the reward under this program, or if it is medically inadvisable for you to a empt to achieve the standards for the reward under this program, call The ICSVEBA Service Center at to discuss another way to qualify for the reward. Special Open Enrollment Rights If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contribu ng toward your or your dependents other coverage). However, you must request enrollment within 31 days a er your or your dependents other coverage ends (or a er the employer stops contribu ng toward the other coverage). In addi on, if you have a new dependent as a result of marriage, birth, adop on, or placement for adop on, you may be able to enroll yourself and your dependents. However, you must request enrollment within 31 days a er the marriage, birth, adop on, or placement for adop on. Effec ve April 1, 2009, if either of the following two events occur, you will have 60 days from the date of the event to request enrollment in your employer s plan: your dependents lose Medicaid or CHIP coverage because they are no longer eligible; your dependents become eligible for a state s premium assistance program. To take advantage of special enrollment rights, you must experience a qualifying event and provide the employer plan with mely no ce of the event and your enrollment request. To request special enrollment or obtain more informa on, contact The ICSVEBA Service Center at Women s Health & Cancer Rights Act The Women s Health and Cancer Rights Act of 1998 requires group health plans to make certain benefits available to par cipants who have undergone a mastectomy. In par cular, a plan must offer mastectomy pa ents benefits 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 Treatment of physical complica ons of the mastectomy, including lymphedema Our plan complies with these requirements. Benefits for these items generally are comparable to those provided under our plan for similar types of medical services and supplies. Of course, the extent to which any of these items is appropriate following mastectomy is a ma er to be determined by the pa ent and her physician. Our plan neither imposes penal es (for example, reducing or limi ng reimbursements) nor provides incen ves to induce a ending providers to provide care inconsistent with these requirements. If you would like more informa on about WHCRA required coverage, contact your Plan Administrator. CA Maternity Coverage Group health plans and health insurance issuers with policies or contracts issued in the State of California generally may not, under California 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, the law generally does not prohibit the mother s or newborn s trea ng physician, a er consul ng with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In addi on, California law requires the Plan to cover a post-discharge follow up visit for the mother and newborn within 48 hours of discharge when prescribed by the trea ng physician. The visit shall be provided by a licensed health care provider whose scope of prac ce includes postpartum care and newborn care. The visit shall include, at a minimum, parent educa on, assistance and training in breast or bo le feeding, and the performance of any necessary maternal or neonatal physical assessments. The trea ng physician shall disclose to the mother the availability of a postdischarge visit, including an in-home visit, physician office visit, or plan facility visit. The trea ng physician, in consulta on with the mother, shall determine whether the post-discharge visit shall occur at home, the plan s facility, or the trea ng physician s office a er assessment of certain factors. These factors shall include, but not be limited to, the transporta on needs of the family, and environmental and social risks. Furthermore, the Plan may not: Reduce or limit the reimbursement of the a ending provider for providing care to an individual enrollee in accordance with the coverage requirements. Provide monetary or other incen ves to an a ending provider to induce the provider to provide care to an individual enrollee in a manner inconsistent with the coverage requirements.

17 17 legal notices. Deny a mother or her newborn eligibility, or con nued eligibility, to enroll or to renew coverage solely to avoid the coverage requirements. Provide monetary payments or rebates to a mother to encourage her to accept less than the minimum coverage requirements. Restrict inpa ent benefits for the second day of hospital care in a manner that is less than favorable to the mother or her newborn than those provided during the preceding por on of the hospital stay. Require the trea ng physician to obtain authoriza on from the health plan prior to prescribing any services covered by this sec on. Con nua on of Benefits under COBRA If a qualifying event occurs that causes you, your spouse, or your children to lose coverage under our group health care plan, you have a legal right under COBRA to purchase a temporary extension of group health coverage. Qualifying events include reduc on in work hours, termina on of employment (except for gross misconduct), death of the employee, legal separa on or divorce, or loss of eligibility for child coverage. The purchase price of con nuing coverage is the full cost of the premium for similarly situated ac ve employees, plus 2 percent (50 percent in certain cases) to help pay for administra ve costs. The period for which the coverage can be con nued depends on the nature of the qualifying event. Employees or family members who otherwise would lose coverage must inform the COBRA Administrator of their elec on of COBRA coverage within 60 days of the qualifying event. No fy both the par cipant and the alternate recipient(s) or his/her designee that a MCSO has been received. Provide each party a copy of the wri en procedures that will be used in determining whether or not the MCSO is qualified. Determine, within a reasonable me, whether or not the MCSO is qualified. No fy the affected par es of its decision. If the MCSO is determined to be qualified, enroll the alternate recipient(s) in accordance with the order. SPDs must contain a wri en QMCSO procedure or provide no ce that the procedure is available from the Plan Administrator. Privacy Rights Your District is commi ed to the privacy of your health informa on. The administrators of the Your District Health Benefits Plan use strict privacy standards to protect your health informa on from unauthorized use or disclosure. The Plan s policies protec ng your privacy rights and your rights under the law are described in the Plan s No ce of Privacy Prac ces. You may receive a copy of the no ce by contac ng Human Resources. There is no wai ng period, no exclusion for pre-exis ng condi ons, and no physical examina on when elec ng con nua on coverage. Any amounts already paid toward deduc bles and coinsurance during the current year count under the con nua on policy. Employees and family members can elect full coverage or medical coverage without dental insurance and can choose from the three different health plans offered to ac ve employees. This policy statement is a brief descrip on of the health care con nua on plan and does not fully explain employees rights under COBRA. You should read the COBRA no ce you received when you first enrolled in the group health plan or the summary plan descrip on for a fuller explana on. Copies of the COBRA no ce and summary plan descrip on can be obtained from Corporate Human Resources. Qualified Medical Child Support Orders (QMCSO) The Omnibus Budget Reconcilia on Act of 1993 (OBRA 93), enacted on August 10, 1993, created a new kind of child support order ( MCSO ). A qualified MCSO is an order manda ng that a qualified child, known as an alternate recipient, be covered by the group health plan to which the order is directed. To be qualified, the order must meet the requirements described below. Sec on 609 of the Employee Income Re rement Security Act of 1974 (ERISA) defines these criteria. Establish wri en procedures for determining whether or not a medical child support order ( MCSO ) is qualified. These procedures must be tailored for each employer and should be reviewed by legal counsel and must be available in wri ng to all plan par cipants upon request or included in the Summary Plan Descrip on.

18 18 notes.

19 19 notes.

20 contacts. COVERAGE POLICY NUMBER TELEPHONE WEBSITE/ ICSVEBA MEMBER SERVICES N/A onal.com MEDICAL Delta Health Systems Comprehensive Basic COB SIMNSA HMO PRESCRIPTION Rx Benefits LIFE AND AD&D (BASIC & VOLUNTARY) Symetra Life MENTAL HEALTH & EAP The Holman Group VOLUNTARY LONG-TERM CARE Unum Contact Your District Office to file a claim ICSVEBA VALUE ADDED SERVICES Anthem Live Health Online Delta TeamCare Disease Management Maternity Management Health Educa on and Coaching Carrum Health N/A my.carrumhelath.com/icsveba CCS LivingConnected N/A N/A This guide is intended to provide an overview only of the benefits offered by ICSVEBA. It is not an offer of coverage or intended to offer medical advice. It does not contain all plan provisions, limita ons and exclusions. Consult your plan documents (Schedule of Benefits, Cer ficate of Coverage, Group Insurance Cer ficate, Booklet, Booklet-Cer ficate, Group Policy) to determine governing contractual provisions rela ng to your plan. In the event of a conflict between this guide and your plan document, the plan documents will always govern.