HEALTH BENEFITS 101 Lucia Mar Unified School District Presented by Michelle Rogers Human Resources Technician May 11th, 2016

How does your health plan work? Lets take a few minutes and take a look…

Choosing the right health plan Do not pick the plan your friend or neighbor thinks you should take Each person or family has different needs and each employee must review those needs Current usage – How many times did you or your family go to the doctor, hospital, x-ray, lab, etc. Did you meet your deductible? Medications – The monthly co-pays for each generic medication and each brand Review payroll deduction for each plan

First, understand the differences in your plan options All SISC plans cover the same benefits The only change is the member’s out-of-pocket expense Co-pays Deductibles Co-insurance

Three separate types of member out-of- pocket expense 1. Co-pays – Is a flat dollar amount payment for a specific service (office or emergency room visit) 2. Deductibles – This is the amount a member must pay before the plan begins to pay on all services except office visits 3. Co-insurance – This is the amount the member pays after the deductible is satisfied and the plan starts to pay (90% plan, 10% is co-insurance) The Out-of-Pocket maximum does not include prescription co-pays.

Let talk dollars and cents - when comparing plans it’s important to consider your “fixed cost” and your “variable cost” to find a plan that works for you. Family Coverage With PPO Dental Monthly premium (fixed) Total Annual cost for coverage (fixed) Deductible (variable) Maximum out of Pocket cost (variable) Total Maximum cost for coverage (variable) Plan 1$634.05X 10$6,340.50$500$1,000$7, Plan 4$188.85X10$1,888.50$3,000$4,000$ Potential Savings $445.20X10$ $1,452.00

Ways to save Talk to your doctor about using generics rather than brand  Most generics at Costco are available at a $0 co-pay Using Urgent Care rather than the emergency room  Be careful, if the UCC is attached a hospital, you may be charged an ER co-pay Routine Preventative Care and Well Baby Care is covered at 100%  Be sure when making an appointment you specify you are making your annual routine preventative care appointment as covered by your plan’s preventative guidelines Get procedures pre authorized before scheduling services  Doing this helps you plan for the cost. Your doctor’s office can help you with this.

Member’s responsibility  It is the member’s responsibility to find out if a provider or facility is contracting in the Anthem Blue Cross PPO, Medco, Delta Dental or VSP network.  Key word: “Contracting” This means that the provider is accepting the negotiated fee and will write off charges beyond that allowable amount.  Non-contracting providers have the right to balance bill you  If your not sure you can always call member services at

Tiered vs Composite Rate Examples Rate structure selections are chosen by insurance committees, based on enrollment trends. Groups must have the same rate structure for all plans. Mid Range Plan: 80-G (with PPO dental) Composite Rate: $517.26/mo Tiered Rates: $0, $473 and $940.26/mo (Single, Two-party, Family) Composite Tiered

Introducing - Grand Rounds Free new benefit for you and your family 100% covered by SISC. Use Grand Rounds to receive second opinions and schedule office visits with top doctors. Whether you want to learn about a new diagnosis, confirm a course of treatment or find a great specialist in your insurance network, Grand Rounds can help. Collecting health records from previous doctors. Providing support and guidance.

Coverage while traveling abroad. With BlueCard Worldwide

$5 dollar doctor visits with MDLIVE

Employee Assistance Program password: SISC Offering help with: Workplace safety Child and elder care Tobacco cessation Grief and Loss Family Health Home Improvement Addiction & Recovery Dealing with Identity theft.

Management Health Benefit Changes Prescription Coverage change for plans M3 & M4 $15 dollar generic prescriptions $50 dollar Single source Brand Name Drugs No free generics at Costco for plans M3 & M4

Classified Health Benefit Changes No plan changes for the plan year. Minimal monthly premium increase

Certificated Insurance Changes No plan changes for the plan year. Minimal monthly premium increase

2 Tier Anchor Bronze a brief overview

Other Items to mention Primary vs Secondary Insurance  Subscriber enrollment is primary  Dependent enrollment is secondary  For children, parent’s month of birth (first in calendar year is primary) Coordination of Benefits (COB)  All SISC plans have COB on medical plans. You must check your secondary plans COB rules. SISC does not have COB on out patient prescription drug plans at this time. Deductibles  Deductibles follow the calendar year and will re-start January 1 st of every year.  Any amount already paid toward your deductible will count toward your new selection for the 16-7 plan year.  If you had previously met your deductible and choose a plan with a higher deductible for the plan year you will be responsible for satisfying the new deductible amount.

Qualifying Events for mid-year changes Definition – An event that triggers a change in a policyholder’s insurance coverage. Some examples include:  Birth/Adoption of a child  Marriage  Death  Loss of coverage If you have a qualifying events during the year, you are able to make dependent changes only. Your plan selection will remain the same until the conclusion of the plan year. To make a change you will need a SISC membership change form and supporting documents to show eligibility.

Questions?