CONTENTS 2016 - Poway Unified School District

Transcription

CONTENTS
EMPLOYEE BENEFITS INFORMATION GUIDE
2016
CONTENTS
Topic
Page
Presenting Your 2016 Benefits
3
What’s New for 2016
4
Eligibility & Enrollment
5
Opt-Out Provision
11
Steps to Enroll
12
Medical Coverage
13
Dental Coverage (Grp #6779-0001)
22
Vision Coverage (Grp #92-005)
24
Life and AD&D Coverage
25
Voluntary Term Life and AD&D Coverage
26
Travel Assistance
28
Employee Assistance Service for Education (EASE)
29
Flexible Spending Account (FSA)
30
Hyatt Metlaw Voluntary Plan
34
Evidence of Coverage
35
Legal Information Regarding Your Plans
37
The Children’s Health Insurance Program (CHIP)
Premium Assistance Subsidy Notice
41
Notes
42
Directory & Resources
43
Medicare Part D Notice
36
All rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without prior written permission of Barney & Barney.
The rates quoted for these benefits may be subject to change based on final enrollment and/or final underwriting requirements.
This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial,
general description of the plan or program benefits and does not constitute a contract. Consult your plan documents (Schedule of
Benefits, Certificate of Coverage, Group Agreement, Group Insurance Certificate, Booklet, Booklet-certificate, Group Policy) to
determine governing contractual provisions, including procedures, exclusions and limitations relating to your plan. All the terms
and conditions of your plan or program are subject to applicable laws, regulations and policies. In case of a conflict between your
plan document and this information, the plan documents will always govern.
PRESENTING YOUR 2016 BENEFITS
To Our Valued Employees,
We recognize how important your peace of mind is. That’s why, at Poway Unified
School District, we’re providing you and your dependents with access to a quality
employee benefits program to support your long-term health and wellness. Each year
when we reevaluate our benefits offering, we keep in mind what’s most important to you
and hope you find a plan option that will meet your needs.
This Benefits Information Guide is a great tool to help you understand the plans and
programs that you and your family will be enrolled in for the plan year. Enclosed you will
find details about:
•
Your medical, dental and vision benefit options, as well as additional benefits
such as life insurance, employee assistance (EASE) program and even more
•
Additional voluntary plans available to you
•
Directory and contact information, in case you have questions
•
Tips and tricks on how to spend your health care dollars wisely
•
And much more!
Here at Poway Unified School District we value the health and well-being of our
employees and their families. For this reason, we’re doing our part to care for you and
develop an environment in which we can all flourish together.
To your health in 2016 and beyond,
Tracy Hogarth
Associate Superintendent of Personnel Support Services
Poway Unified School District
Benefits Information Guide
3
WHAT’S NEW FOR 2016
What’s new for 2016?
Kaiser: All Kaiser copays will remain unchanged for the 2016 plan year, however we are happy to report that a
Hearing Aid benefit has been added to the Kaiser plan effective January 1, 2016. See pages 20-21 for details.
Aetna/Optum RX: All Aetna/Optum RX copays will remain unchanged for the 2016 plan year, however we are
happy to report that a Hearing Aid benefit has been added to the Aetna plans effective January 1, 2016. See
pages 20-21 for details.
Delta Dental: While the existing dental benefits will remain unchanged for the 2016 plan year, we are happy to
report that a Night Guard benefit has been added to the Delta Dental PPO plan effective January 1, 2016. See
page 23 for details.
MES Vision: While the existing vision copays will remain unchanged for the 2016 plan year, we are happy to
report that the frequencies for services has changed from once every 24 months to once every 12 months
effective January 1, 2016. See page 24 for details.
The Standard Life Insurance: Mandatory standard life insurance policy has increased from $20,000 to $25,000 at
no additional cost. Those wishing to elect or increase their voluntary life insurance are being given an Open
Enrollment Opportunity during this Open Enrollment without having to submit a medical history statement. See
pages 25-27 for details.
Do you need to take action?
You need to take action during Open Enrollment from November 2, 2015 – November 13, 2015 if you want to:







Change your plan elections.
Elect a different medical plan
Add or delete dependent coverage
Participate in Medical or Dependent Care Flexible Spending Account (FSA) for plan year 2016.
Enroll in Hyatt Metlaw Legal Plan
Elect or increase voluntary life insurance
Participate or continue to waive benefits/opt-out of coverage and receive cash to warrant
A limited amount of forms can be obtained from your worksite secretary’s Open Enrollment supply box. The
interactive pdf PUSD Benefit Enrollment Form, Flexible Spending Enrollment Forms, and Domestic Partner Forms
can ALWAYS be found on the District website.
YOUR “TO-DO” LIST
Read the material in this Benefits Information Guide
Review the personalized benefits statement included in your packet for accuracy
Complete the 2016 Benefits Enrollment Form if opting out
Decide whether you’re going to make any changes for plan year 2016 or keep the coverage you have
If making changes follow the directions on page 12
All forms are to be submitted to the Insurance Benefits Department located at the District Office.
Need help?
Attend one of our Open Enrollment Help Sessions located at the District Office – Community Room
on:
Monday
Thursday
Friday
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November 2, 2015
November 12, 2015
November 13, 2015
10:00am – 12:00pm & 4:00pm – 6:00pm
4:00pm – 6:00pm
2:30pm – 4:30pm
ELIGIBILITY & ENROLLMENT
If you are a new employee or you are re-evaluating
your choices as a continuing participant, the benefits
program offers a variety of coverage options that are
available to you.
Who Can Enroll
Active Contracted Employees are eligible to participate in the
benefits program if you are:

Classified working 20 hours or more per week

Certificated working 17.5 hours or more per week
Eligible employees may also choose to enroll eligible family
members, including a legal spouse / unregistered domestic partner
and/or children. An “Affidavit of Domestic Partnership / Same
Gender Marriage” must be signed by both parties and returned to
the PUSD Insurance Benefits Department with all appropriate
enrollment forms.
Children are considered eligible if they are:

You or your spouse’s / unregistered domestic partner’s biological children, stepchildren, adopted child or
foster child up to age 26. Dependent child need not be a student, unmarried, tax dependent or living with
parent and only if ineligible for their own employer plan

You or your spouse’s / unregistered domestic partner’s children of any age if they are incapable of selfsupport due to a physical or mental disability
General Eligibility Information
Employees must select the basic plan, which includes: a Medical plan with Dental, Vision and Term Life / AD&D
insurance coverage. Dependent coverage is optional.
When Coverage Begins
Your enrollment choices remain in effect for the benefits plan year, January 1, 2016 through December 31, 2016.
Benefits for newly eligible employees will commence as outlined below:
Benefit Effective Date
Benefit Plan
The first day of the month following your date of hire /
increased contract (you must enroll within 30 days of
becoming eligible)






Medical
Dental
Vision
Life and AD&D
EASE
Voluntary Coverages (Life , AD&D, Pre-Paid Legal)
Please note: If you miss the enrollment deadline, you may not enroll in the benefits program unless you have a
qualified change in status during the plan year. See next page for details.
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Open Enrollment
Open Enrollment occurs during the month of November each year. It is during this time that
you may elect to change your medical plan, add or drop dependents to / from coverage,
enroll in or change voluntary life insurance coverage, enroll in Flexible Spending for Medical
Care Reimbursement and/or Dependent Care Assistance, or enroll in the Hyatt Metlaw
Prepaid Legal plan. Open Enrollment changes are effective the following January 1.
Changes during Mid-Year
You are permitted to make changes to your benefits outside of the Open Enrollment period if you have a qualified
change in status as defined by the IRS.
Generally, you may add or remove dependents from your benefits, as well as add, drop or change coverage. Please
note that you must notify the PUSD Insurance Department of the “qualifying event” within 30 days of event.
Examples include:

Marriage, divorce or legal separation

Birth or adoption of a child

Death of a dependent

You or your spouse’s / unregistered domestic partner’s loss or gain of coverage through our organization or
another employer

Unpaid leave of absence for you or your spouse / unregistered domestic partner causing a loss of other
group coverage

Child’s loss of dependent status, such as attainment of maximum age

Change in residence affecting eligibility or access

Change in employment status where you have a reduction in hours to an average below 30 hours of
service per week, but continue to be eligible for benefits, and you intend to enroll in another plan that
provides Minimum Essential Coverage that is effective no later than the first day of the second month
following the date of revocation of your employer sponsored coverage

You enroll, or intend to enroll, in a Qualified health Plan (QHP) through the State Marketplace (i.e.
Exchange) and it is effective no later than the day immediately following the revocation of your employer
sponsored coverage
If your change during the year is a result of the loss of eligibility or enrollment in Medicaid, Medicare or state health
insurance programs, you must submit the request for change within 60 days.
For a complete explanation of qualified status changes, please refer to the Legal Information Regarding Your Plan
section of this guide.
Pre-Tax Premium Deductions
If you experience a payroll deduction toward all or part of medical, dental or vision premiums for yourself or a
covered dependent; those deductions will automatically be taken from your pay warrant on a “Pre-Tax” basis.
Important: Premiums paid by the employee for a qualified domestic partner and that partner's eligible dependent(s)
may only be payroll deducted on a pre-tax basis when that dependent is considered a Tax-Legal dependent, as
determined by IRS regulations. Consult your personal legal/tax counsel.
If you wish to have deductions taken from your pay warrant on an “After-Tax” basis, complete/return a “Premium
Deduction Card” to the PUSD Insurance Benefits Department by the Open Enrollment deadline.
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Paying for Coverage
Poway Unified School District strives to provide you with a valuable benefits package at a
reasonable cost. Based on your benefit selections and coverage level, you may be required
to pay for a portion of the cost. Please refer to your Bargaining Unit Agreement for details.
All PUSD Benefits are calculated on a tenthly basis. Tenthly is defined as the ten months; Jan through
June and Sept through December. All deductions are tenthly regardless of contracted months worked
or 10/12 pay plans. Benefits coverage continues through months without payroll deductions (July &
August).
It is important when making a plan selection to consider the out of pocket costs you will incur
especially during months with adjusted pay warrants, i.e. Thanksgiving, Winter, February, Spring
breaks and June.
2016 Premium Rates
COST OF 2016 HEALTH PLANS - TENTHLY
DEPENDENT COVERAGE
(Additional Cost)
Employee
Only
(Basic Plan)
Employee + 1
Dependent
Employee + 2 or
More
Dependents
*AETNA VALUE NETWORK
(without Scripps & Encompass)
$873.60
$1,865.91
$2,579.93
*KAISER PERMANENTE HMO
$547.88
$1,066.04
$1,460.80
*AETNA FULL NETWORK HMO
$1,483.58
$3,177.36
$4,379.29
$1,572.42
$3,304.16
$4,553.33
DELTA DENTAL PPO
$72.04
$149.29
$222.37
MEDICAL EYE SERVICES VISION
$8.51
$14.76
$17.37
The STANDARD $25,000 LIFE INSURANCE
(Mandatory for all eligible employees, even
employees who Opt-Out of PUSD medical
coverage)
$2.08
N/A
N/A
HEALTH PLANS
*Select Only One Medical Plan
(with Scripps)
*AETNA OAMC (PPO)
(with Scripps)
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District Contribution is based on your position, contracted hours and designated union.
Please refer to details below in calculating any out of pocket costs or cash to warrant
amounts.
PSEA Members Bargaining Unit Benefit Sheet
Poway Unified School District will provide each eligible PSEA member with a district contribution as listed below to offset
the cost of the basic health insurance package. Please utilize the District Contribution and Premium Supplement listed to
calculate any out of pocket or cash to warrant amounts by adding the District Contribution and the Premium Supplement
based on your medical plan selection and subtracting the premium costs listed on page 7. After premiums for employee
medical, dental, vision, and mandatory basic life insurance and any additional costs for dependent premiums are
deducted from the total amount available; any excess discretionary funds up to $290.40 tenthly ($2904 annually) will be
credited to the employee as “café cash.” Any additional incurred costs will be deducted from the employees warrant.
District Contribution
Contracted Hours
Annual Contribution
4.0 to 8.0 hrs
Tenthly Contribution
$10,079.90
$1,007.99
Tenthly Premium Supplement
Medical Plan
Employee Only
Kaiser Permanente HMO
Aetna Value Network
Employee + 1
Dependent
Employee + 2 or More
Dependents
$0.00
$0.00
$370.63
$135.00
$724.05
$1,381.76
$198.22
$276.00
$406.00
$280.06
$335.00
$521.00
(without Scripps)
Aetna Full Network
(includes Scripps)
Aetna OAMC (PPO)
(includes Scripps)
Opt- Out Option
Employees who provide proof of other medical coverage may Opt-Out of the PUSD Basic Health Insurance Package.
PROOF OF OTHER MEDICAL & DENTAL COVERAGE IS REQUIRED AT THE TIME OF ENROLLMENT. Employees
electing the Opt-Out option must enroll in the district sponsored $25,000 life insurance coverage.
Employees Opting out of medical may enroll in dental or vision coverage for self or dependents at no cost to the
employee.
Annual Cash to Warrant
$3,725
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Tenthly Cash to Warrant
$372.50
SEIU Members Bargaining Unit Benefit Sheet
Poway Unified School District will provide each eligible SEIU member with a district contribution as listed below to offset
the cost of the basic health insurance package. Please utilize the District Contribution and Premium Supplement listed to
calculate any out of pocket or cash to warrant amounts by adding the District Contribution and the Premium Supplement
based on your medical plan selection and subtracting the premium costs listed on page 7. After premiums for employee
medical, dental, vision, and mandatory basic life insurance and any additional costs for dependent premiums are
deducted from the total amount available; any excess discretionary funds up to $350.00 tenthly ($3500 annually) will be
credited to the employee as “café cash.” Any additional incurred costs will be deducted from the employees warrant.
District Contribution
Contracted Hours
Annual Contribution
4.0 to 8.0 hrs
$10,079.90
Tenthly Contribution
$1,007.99
Tenthly Premium Supplement
Medical Plan
Employee Only
Kaiser Permanente HMO
Aetna Value Network
Employee + 1
Dependent
Employee + 2 or More
Dependents
$0.00
$55.00
$150.00
$30.00
$55.00
$150.00
$30.00
$55.00
$150.00
$30.00
$55.00
$150.00
(without Scripps)
Aetna Full Network
(includes Scripps)
Aetna OAMC (PPO)
(includes Scripps)
Opt-Out Option
PROOF OF OTHER MEDICAL & DENTAL COVERAGE IS REQUIRED. Employees electing the Opt-Out option must
enroll in the district sponsored $25,000 life insurance coverage. Employees Opting out of medical, who wish to enroll in
dental or vision coverage for self or dependents may do so. Premiums for dental, vision and mandatory life insurance will
be paid by PUSD.
Contracted Hours
4.00 to 8.00 hrs
Annual Cash to Warrant
$3,725
Tenthly Cash to Warrant
$372.50
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PFT/APSM/Confidential Members
The District will contribute toward the full cost of the EMPLOYEE ONLY basic insurance
package, which includes either the Kaiser HMO or Aetna Value Network medical plan
almong with dental, vision and life insurance. Employees must work on a contracted basis at
a minimum of 50%. An employee on a shared contract may not receive the full district
contribution toward the employee only coverage based on contract agreement. Please
refer to the “Shared Contracts” section of your union agreement for specifics.
Review the chart below to determine the tenthly payroll you will experience based on your
selections. Your payroll deduction for medical premiums will differ from premium rates shown
on page 7 as PUSD is supplementing a portion of that premium cost.
Adjusted Tenthly Employee Premium Deductions
Carriers
EMPLOYEE “OUT-OF-POCKET” TENTHLY COST FOR:
Employee Only
Employee +
One Dependent
Employee +
Two or More
Dependents
District Paid
$270.00
$380.00
Kaiser Permanente
HMO
District Paid
$250.00
$360.00
Aetna Full Network
(includes Scripps)
$609.98
$1,581.45
$2,179.36
$698.82
$1,708.25
$2,353.40
Delta Dental PPO
District Paid
$77.45
$150.33
Medical Eye Services
District Paid
$6.25
$8.86
Aetna Value Network
(without Scripps)
Aetna OAMC (PPO)
(includes Scripps)
Opt- Out Option
PROOF OF OTHER MEDICAL & DENTAL COVERAGE IS REQUIRED. Employees electing the Opt-Out option must
enroll in the district sponsored $25,000 life insurance coverage. Employees Opting out of medical, who wish to enroll in
dental or vision coverage for self or dependents may do so. Premiums will be deducted from Cash to Warrant amount
listed. Employees electing the Opt-Out option receive “Cash to Warrant” funds not to exceed $125.00 tenthly.
10
OPT-OUT PROVISION
Opt-Out Provision
Employees providing “Proof of Other Coverage” may elect to Opt-Out of PUSD health plan
coverage with the possibility of receiving “cash to warrant” funds.
Note: Please refer to your Bargaining Unit Agreement for Details
Please note that if you waive coverage, the next opportunity to enroll in your benefits will be
November, 2016 or when a Qualifying Event Status Change occurs.
Enrollment in “Opt-Out” & proof of coverage is required every year at Open Enrollment.
Failure to reenroll and provide proof of medical and dental coverage during OE for the
upcoming plan year by OE deadlines, will result in forfeiture of your cash to warrant funds for
that plan year. You will be enrolled in the basic plan package for plan year 2016. Your next
opportunity to Opt-Out will be at the following Open Enrollment.
In order to “Opt-Out”, please complete the requirements below:

You must complete a 2016 Employee Enrollment form selecting “Opt Out” and any
other coverage for yourself or dependents that you wish to be enrolled in 2016. Think
of this form as a “snap-shot” of the coverage you are requesting.

Page 2, employee section MUST be completed selecting “NO” to medical and
checking the appropriate boxes for dental and vision. If you are enrolling dependents,
each section MUST be completed along with each dependents DOB and SSN.

Attach a copy of your medical / dental cards to your enrollment form and submit by
Open Enrollment deadline. If you do not have a medical / dental card, you can
provide proof of coverage by another means i.e. Eligibility Statement from website,
Summary of Benefit Coverage from covering employer, a recent EOB from carrier.
11
STEPS TO ENROLL
Steps to Enroll
Newly qualified employees must make their health plan elections no later than 30 days, after
date of hire / qualifying event. Qualified employees should contact the PUSD Benefits
Department at the PUSD District Office to schedule an insurance appointment.
COMPLETING THE PAPERWORK
(1)
Change
Form(s) Required
Add / drop dependents to/from Delta Dental or MES vision
2016 Benefit Enrollment Form
Change medical plan to Aetna or add / drop dependents
to/from Aetna
Change medical plan to Kaiser or add/drop dependents
to/from Kaiser
Opt-out of PUSD medical, dental or vision coverage
2016 Benefit Enrollment Form electing Opt Out, complete
the Opt Out section, attach proof of other coverage. Only
proof of Medical & Dental is required
Apply for, increase, or decrease voluntary life insurance
Standard Voluntary Term Life Insurance / AD&D Application
If you are selecting Kaiser Permanente as your medical
carrier you do not need to select a Primary Care physician at
the time of enrollment
Medical History Statement required for all new Term Life
Applications & requests to increase current Term Life
coverage
Enroll in Medical Care Reimbursement Account and/or
Dependent Care Assistance Account
Flexible Benefit Plan Enrollment Form
Add a Domestic Partner (DP) or same gender Spouse
DP Packet in addition to all other enrollment forms. (includes
Affidavit of Domestic Partnership & Premium Deduction
Card)
To enroll in Hyatt MetLaw Prepaid Legal
2016 Benefit Enrollment Form selecting Hyatt MetLaw
To cancel membership in Hyatt MetLaw Prepaid Legal
Complete a “Cancel deduction” card, located in Payroll Dept.
(minimum 12 month membership required)
Decline Pre-tax Deduction, select “After-tax” premium
deduction
Premium Deduction Card
(1)
12
This form required each year for all new and continuing
participants
Forms can be obtained from your worksite secretary’s Open Enrollment supply box. Interactive pdf of PUSD Benefit Enrollment Form can ALWAYS
be found on the District website.
MEDICAL COVERAGE
Whether you have a common cold or will be undergoing surgery, medical benefits cover a
range of services and can provide peace of mind to help you offset health care costs.
Your Medical Plan Options
Poway Unified School District offers two HMO plans administered by Aetna, another HMO plan administered by
Kaiser as well as an Open Access Managed Choice (OAMC) PPO option managed by Aetna. To help guide your
plan selection, the following pages include details concerning how the plans will operate, as well as plan highlights
and features. District Contribution for any one of these plans is based on your position and designated union.
Option 1: Aetna HMO AVN Network (without Scripps Clinic & Encompass Medical Group)
If you enroll in the Aetna HMO AVN (Value) Network medical plan you must choose an HMO AVN contracting
physician group (does NOT include Scripps physicians). You can access the Provider Directory on the Aetna
website at www.aetna.com under “Provider Search.”
Option 2: Kaiser Permanente HMO
Kaiser Permanente health plan members must receive all care from a Kaiser plan Provider / Facility except for lifethreatening emergencies within the Kaiser service area, or any emergency outside the Kaiser service area.
Members can access additional information from the Kaiser Permanente website at www.kp.org.
Option 3: Aetna HMO Full Network (lesser benefit plan with Scripps Clinic, but without
Encompass)
If you enroll in the Aetna HMO Full Network medical plan you must choose an HMO contracting physician group.
From your physician group you select one doctor to provide basic health care; this is your Primary Care Physician
(PCP). You can access the Provider Directory on the Aetna website at www.aetna.com under “Provider Search.”
Option 4: Aetna PPO (lesser benefit plan w/ Scripps Clinic & Encompass as In-Network
Providers)
Two Levels of coverage under one medical plan. You can access the PPO Provider Directory on the Aetna website
at www.aetna.com under “Find a Doctor.”
Note:
All PUSD Aetna plans use “Optum RX” for prescription coverage. Please see page 18 for more details
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MEDICAL COVERAGE
Your Medical Plan Options (Continued)
Using an Aetna HMO Plan
A Health Maintenance Organization (HMO) plan requires you and enrolled dependents to select an Aetna Primary
Care Physician (PCP) who will direct the majority of your health care needs. Generally, an HMO operates as
follows:

You and any enrolled dependent(s) are not required to see the same Aetna PCP, and you may change
your Aetna PCP at any time

With the exception of an OB/GYN specialist who is affiliated with your selected medical group, you must
receive a referral from your Aetna PCP before receiving services from a specialist

Services may require a fixed-dollar payment up front, referred to as a copayment

You do not have to submit claim forms to your insurance company

Any services rendered out-of-network without the proper referral from your PCP will not be covered
Aetna administers two HMO plans and a summary of their covered services is listed on the following pages. For a
complete listing of covered services for each plan, please refer to your Summary Plan Description (SPD).
A dual network HMO plan provides you the option of selecting either the Aetna AVN HMO plan, with a smaller
network of doctors that does not include Scripps Clinic or Encompass Medical Group, or the Aetna Full Network
HMO plan, which may provide access to more physicians including Scripps Clinic, but still without Encompass
Medical Group. Regardless of your selection, you will be required to use the HMO in the same manner as outlined
above by selecting a Primary Care Physician.
District Contribution and the cost differences between either of these plans are based on your position and
designated union.
How to Find an Aetna HMO Provider
From your physician group (either AVN or Full Network) you select one doctor to provide basic health care; this is
your Primary Care Physician (PCP). Your PCP will provide medically necessary treatment. Specialist care is also
available when authorized in advance through your PCP or physician group. You do not have to choose the same
physician group or PCP for all members of your family. You can access the Provider Directory on the Aetna website
at www.aetna.com under “Find a Doctor.” Once you have entered the www.aetna.com website, follow the detailed
instructions below.
14

Start your search? Select “Search our public directory ( no log-in needed)”

What type of plan are you considering? Select “A Plan Offered by an Employer or Organization”

Select “Doctors (Primary Care)”

Select “All PCP’s” from the drop-down menu

Tell Us Your Location? Enter your preferred zip code

Find Aetna health care professionals that accept your plan

For the Aetna AVN (Value) Network HMO Plan (without Scripps Clinic & Encompass Medical Group) you
will select Aetna Value Network HMO (available in CA and NV only) under the “State Based Plans”

For the Aetna Full Network HMO Plan (with Scripps Clinic, but without Encompass) you will select
Aetna Basic HMO (available in CA only) under the “State Based Plans”
MEDICAL COVERAGE
Your Medical Plan Options (Continued)
Using the Kaiser HMO Plan
As a member of the Kaiser Permanente Health
Maintenance Organization (HMO) plan, you will
receive your medical care from an integrated network
of physicians and specialists at a medical office,
medical center, or affiliated hospital near you.
Additional information regarding the Kaiser
Permanente HMO is outlined below:


You may choose a primary care doctor for
yourself or your family members by reviewing
physician’s profiles at
kp.org/chooseyourdoctor or receive
assistance in selecting a physician and
scheduling your first appointment by calling
888.956.1616 (for Southern CA)
Initial referrals for most specialty care
services will be coordinated by a Kaiser
Permanente physician. However, many
departments such as OB/GYN, Optometry,
Psychiatry & Addiction Medicine are selfreferred

There are no deductibles with the Kaiser
Permanente HMO and no claim forms to
submit unless you receive emergency
services outside of a plan facility

All prescriptions are filled at the Kaiser
Permanente Pharmacy and not in retail
stores

Preventive care is covered at 100%
Kaiser Permanente – On the Go!
The KP App gives members a suite of tools to use on the
go! Use this application with your Kaiser Permanente User
ID and Password to:

See your health history at your fingertips,
including allergies, immunization, Rx details, and
most lab test results

Refill prescriptions for yourself or another member

Check the status of your prescription order

Schedule, view and cancel appointments

Access your message center to email your doctor
or another department

Find locations and facilities near you and get
directions and phone numbers on the spot
Scan the code below with your Smartphone to download
the app!
A summary of covered services under the Kaiser
Permanente HMO plan is listed on the following
pages. For a complete listing of covered services for
each plan, please refer to your Summary Plan
Description (SPD).
15
MEDICAL COVERAGE
Your Medical Plan Option(s) (Continued)
Using Aetna’s OAMC (PPO) Plan
Aetna – On the Go!
With a Preferred Provider Organization (PPO) plan you
have greater flexibility and choice to use both in-network
and out-of-network physicians. However, you are
encouraged to receive services from the Aetna’s innetwork doctors, specialists or facilities. By doing so,
you obtain a higher level of benefit than if services were
rendered from an out-of-network provider. When utilizing
the services of an Out-of-Network provider benefits are
lower and are based on fees deemed to be reasonable
and customary (R&C). The member need not select a
physician at time of enrollment. The member needs to
be aware that at the time they seek medical attention, the
physician they utilize will determine the level of benefits
received.
No matter where you are, you still want easy access to
your health information and tools to make the best
decisions. With AETNA’s Mobile App, you can

Search for a doctor, dentist, hospital or pharmacy

Use the Urgent Care Finder to quickly find urgent
care centers and walk-in clinics

Register for your secure member site to
Additional important information regarding the use of a
PPO plan includes:

You and any enrolled dependent(s) are
permitted to visit any doctor or facility without a
referral from a Primary Care Physician (PCP)

View claims

View coverage and benefits

View your Personal Health Record

View your ID card information

Check drug prices

Contact Aetna by phone or email
Scan the code below with your Smartphone to download
the app!

Certain services, such as doctor’s visits, may
require a fixed-dollar payment up front, referred
to as a copayment

Before the insurance company will pay certain
medical expenses, you may be required to pay a
plan specific amount, referred to as the
deductible

Once the deductible has been fulfilled, the
insurance company will pay a large percentage
of the cost of your care, known as coinsurance.
You are then financially responsible for the remaining cost up to the out-of-pocket maximum

Claim forms are submitted to the insurance company on your behalf when services are received from within
the network
Administered by Aetna, a summary chart of covered services for the OAMC PPO plan is listed on the following
pages. Please refer to your Summary Plan Description (SPD) for a complete listing of covered services under each
plan.
16
MEDICAL COVERAGE
Your Medical Plan Option(s) (Continued
How to Find an Aetna OAMC (PPO) Provider
Before you go to the doctor or receive health care services, make sure your doctor, facility or specialist is
participating in your plan’s network. This may ensure you receive the highest level of benefit and could reduce your
health care costs. You can access the Provider Directory on the Aetna website at www.aetna.com under “Find a
Doctor.” Once you have entered the www.aetna.com website, follow the detailed instructions below.

Start your search? Select “Search our public directory ( no log-in needed)”

What type of plan are you considering? Select “A Plan Offered by an Employer or Organization”

Select “Doctors (Primary Care)”

Select “All PCP’s” from the drop-down menu

Tell Us Your Location? Enter your preferred zip code

For the Aetna OAMC (PPO) Plan (with Scripps Clinic, but without Encompass) you will select
Managed Choice (Open Access), under the “Aetna Open Access Plans”
17
MEDICAL COVERAGE
Using Prescription Drug Coverage for Aetna Members
Aetna members receive prescription benefits through Optum RX. Members must use their
Optum RX pharmacy card to obtain prescription medications. If you use your Aetna medical
card to obtain prescription medications; you will be denied coverage. Our prescription
program can offer potential savings when members obtain formulary medications and utilize
the prescription mail service.
Members will pay for medications as indicated below

$10 Generic Formulary Medication, 30-day supply

$25 Brand Name Formulary Medication, 30-day supply

$40 Generic or Brand Name Non-Formulary Medication, 30-day supply

Mail Order Copays: 2x copays for a 90-day supply
Many individuals have chronic medical conditions. Some of the more common chronic conditions are allergies,
asthma, heart disease, hypertension, depression and diabetes. These conditions may require the use of
maintenance prescription medications. Oral contraceptives, a preventive medication, are one of the more widely
used maintenance medications.
There is an immediate cost saving when using the Mail Order Service. You will pay 2-copays for a 90 day supply of
prescription medication. A three month supply of Mail Order medications is delivered to your home, eliminating
frequent trips to the pharmacy.
Your mail order prescription will usually arrive within 7 working days after Optum RX receives your order. You can
order your refill three weeks before your medication runs out. Refills are processed within 48 hours. You can order
refills by mail, by phone, or over the Internet at www.optumrx.com.
Generic: A generic medication has the same active ingredients as its brand name counterpart, but is normally only
available after the patent protection expires on a brand name drug. You can save money by using a generic
formulary medication whenever possible.
Brand-name: A brand-name medication is usually available from only one manufacturer and may have patent
protection.
Formulary: A formulary is a list of FDA-approved brand name and generic medications that have been reviewed
and recommended by a committee of physicians and clinical pharmacists for their quality and effectiveness and
approved by Optum RX. Your pharmacy program has a “tiered” formulary, which means your copay is generally
lower for generic and brand name formulary medications and higher for generic or brand name nonformulary medications.
Self-injectable Medications: Some self-injectable medications (example: Lovenox, a blood thinning medication)
may not be covered under your Optum RX pharmacy plan. This type of medication is only covered under your Aetna
medical plan. Ask your Aetna physician to submit the proper prior authorization to the Aetna Pharmacy Department.
Refer to your Aetna medical plan Evidence of Coverage for clarification about your out-of-pocket cost for these
special self-injectable medications. To contact Aetna directly for assistance, please call 800.562.6223.
To check the Optum RX formulary listing, go to their website at www.optumrx.com. Double click on “login”, click on
“Create Account” and then follow the steps to set up your personal account. You then have access to helpful
information including which medications are on the formulary. Individuals who do not have access to the internet can
call Optum RX for general assistance at 800.797.9791 or for mail service assistance call 800.562.6223.
Contact the PUSD Insurance Benefits Department at 858.521.2897, if you would like a“Mail Order” envelope
or go on-line with Optum RX at www.optumrx.com.
18
MEDICAL COVERAGE
Selecting a Plan that’s Right for You
As you evaluate your health plan options and insurance needs,
consider the following factors:

Choice: If you prefer to seek services from specific
physicians, specialists or facilities, check to see if the
medical plan option will cover services from those
providers. While some health plans restrict your
provider selection, others provide greater flexibility
and choice

Coverage: Whether routine, surgical, prescription or
another type of coverage, determine if the plan covers
the services and medical treatments you value most.
Plan exclusions, restrictions and limitations may also
guide your selection process, which are detailed in the
Summary Plan Descriptions

Cost: Cost may be a large determining factor in your
selection and each plan may contain a variety of cost
components. Consider the amount of your payroll
deduction, as well as other plan expenses such as
deductibles, copayments or coinsurance
Free Preventive Health Care
The Federal Health Care Reform law now
requires insurance companies to cover
preventive care services in full, saving you
money and helping you maintain your health.
Such preventive services include:

Routine doctor’s visits

Annual checkups

Well-baby and child visits

Several types of immunizations and
screenings
To confirm that your preventive care services are
covered, refer to your plan documentation.
You are encouraged to review the complete Summary Plan Descriptions (SPD) of each plan.
Do you have questions regarding a plan? To correspond with a plan representative refer to the Directory &
Resources section for important contact information on page 43.
Informing You of Health Care Reform
As of January 1, 2014, most U.S. citizens and legal residents are responsible for paying a penalty if they do
not have qualifying health insurance coverage. For 2016 the penalty is the greater of 2.5% of Modified Adjusted
Gross Income (MAGI) or $695 per adult per year (50% of the adult penalty for children under 18 years of age), per
household.
To avoid paying the penalty this year and in future years, you can obtain health insurance through our benefits
program or purchase coverage elsewhere, such as a State Health Insurance Exchange.
For more information regarding Health Care Reform, please contact the PUSD Insurance Department or visit
www.cciio.cms.gov. You can also visit www.coveredca.com to review information specific to the Covered California
State Health Insurance Exchange.
19
KAISER / AETNA HMO
Kaiser
Aetna AVN HMO
Aetna Full HMO
In-Network Only
In-Network Only
In-Network Only
None
None
None
Medical – Aetna (individual / family)
$1,500 / $3,000
$1,500 / $3,000
$1,500 / $3,000
Prescriptions – Optum RX (individual / family)
$1,500 / $3,000
$1,500 / $3,000
$1,500 / $3,000
Primary Care Physician (PCP) / Specialist
$20 Copay
$20 Copay
$40 Copay
Preventive Care Exam
(refer to Kaiser or Aetna list of covered services)
No Copay
No Copay
No Copay
See Kaiser RX Copays
below
80% or $20 Copay in
Physicians Office
80% or $40 Copay in
Physician’s Office
$10 Copay
$10 Copay
$10 Copay
$2,000 Allowance
$2,000 Allowance
$2,000 Allowance
Diagnostic X-ray
No Copay
No Copay
$40 Copay
Diagnostic Laboratory
No Copay
No Copay
No Copay
Complex Diagnostics (MRI / CT Scan)
No Copay
$100 Copay
$100 Copay
Therapy, including Physical, Occupational and
Speech
$10 Copay
$20 Copay
(limited to 60-day period
of care)
$40 Copay
(limited to 60-day period
of care)
Covered 100%
Covered 100%
$200 Copay per Day
(max. of 4 days of
copays)
Outpatient Surgery
$20 Copay
Covered 100%
$200 Copay per Visit
Emergency Room (copay waived if admitted)
$50 Copay
$100 Copay
$100 Copay
Urgent Care
$20 Copay
$20 Copay
$40 Copay
Plan Highlights
Annual Calendar Year Deductible
Individual / Family
Maximum Calendar Year Out-of-pocket
(1)
Professional Services
Self-Injectable Drugs
Acupuncture & Chiropractic Care
(lim. to 20 combined visits / cal. year)
Hearing Aids (Benefit limited to 1 pair every 36 months)
Hospital Services
Inpatient
Allergy Testing & Treatment
Allergy Testing
Allergy Injections & Serum
$20 Copay
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Covered 100%
$200 Copay per Day
(max. of 4 days of
copays)
$20 Copay
$20 Copay
$40 Copay
Mental Health & Substance Abuse
Inpatient
Outpatient
Retail Prescription Drugs (30-day supply)
Kaiser Pharmacy
Optum RX Provider
Optum RX Provider
Generic
$10 Copay (100-day)
$10 Copay
$10 Copay
Name Brand
$25 Copay (100-day)
$25 Copay
$25 Copay
N/A
$40 Copay
$40 Copay
Kaiser Mail Order
Optum RX Mail Order
Optum RX Mail Order
Generic
$10 Copay (100-day)
$20 Copay
$20 Copay
Name Brand
$25 Copay (100-day)
$50 Copay
$50 Copay
N/A
$80 Copay
$80 Copay
Non-formulary
Mail Order Prescription Drugs (90-day supply)
Non-formulary
(1)
20
Out-of-pocket maximum is based on the maximum allowable charge the carrier allows. This does not include any balance billing that may occur when using
an out-of-network provider. The above information is a summary only. Please refer to your Evidence of Coverage for complete details of Plan benefits,
limitations and exclusions.
AETNA OAMC PPO
Aetna OAMC PPO
Plan Highlights
In-Network
Out-of-Network
$500
$500
$1,500
$1,500
Medical – Aetna (individual / family)
$4,000 / $12,000
$8,000 / $12,000
Prescriptions – Optum RX (individual / family)
$1,200 / $1,200
$1,200 / $1,200
20%
50%
$25 Copay
50% after Deductible
Covered 100%
$25 Copay
Hearing Aids (Benefit limited to 1 pair every 36 months)
Diagnostic X-ray and Lab
Complex Diagnostics (MRI / CT Scan)
$25 Copay
Inpatient
Outpatient Surgery
Annual Calendar Year Deductible
Individual
Family
Maximum Calendar Year Out-of-pocket
(1)
Member Coinsurance
Applies to all expenses unless otherwise stated
Professional Services
Primary Care Physician (PCP) / Specialist
Preventive Care Exam
(refer to Aetna list of covered services)
Self-Injectable Drugs
Acupuncture & Chiropractic Care
(limited to 20 visits / cal. year)
Therapy, including Physical, Occupational and Speech
(limited to 20 visits / cal. year combined)
Hospital Services
Emergency Room (copay waived if admitted)
$100 Copay + 20%
$100 Copay + 20%
Urgent Care
$25 Copay + 20%
Allergy Testing
$25 Copay
Allergy Injections
$25 Copay
Allergy Testing & Treatment
Allergy Serum
Mental Health & Substance Abuse
Inpatient
Outpatient
$25 Copay
Optum RX Provider
Optum RX Provider
Generic
$10 Copay
$10 Copay
Name Brand
$25 Copay
$25 Copay
Retail Prescription Drugs (30-day supply)
Non-formulary
$40 Copay
$40 Copay
Optum RX Mail Order
Optum RX Mail Order
Generic
$20 Copay
$20 Copay
Name Brand
$50 Copay
$50 Copay
Non-formulary
$80 Copay
$80 Copay
Mail Order Prescription Drugs (100-day supply)
(1)
Out-of-pocket maximum is based on the maximum allowable charge the carrier allows. This does not include any balance billing that may occur when using
an out-of-network provider
The above information is a summary only. Please refer to your Evidence of Coverage for complete details of Plan benefits, limitations and exclusions.
21
DENTAL COVERAGE (GRP #6779-0001)
Dental benefits are another important element of your overall health. With proper care, your
teeth can and should last a lifetime.
Your Dental Plan Option
This year, you and your eligible dependents will have the opportunity to enroll in a Dental PPO plan offered by Delta
Dental. We encourage you to learn more about how this plan operates and review some of the coverage information
enclosed.
Using the Plan
Under this PPO plan, you can visit any licensed dentist of your choice, and your family members may select
different dentists. You can change dentists at any time, go to a dental specialist of your choice and receive dental
care anywhere in the world. To make the most of your benefits and pay the lowest out-of-pocket costs under the
Delta Dental PPO plan, we recommend you visit a Delta Dental PPO network dentist.
If you choose a dentist who is not in the PPO network, but you choose to have services from a Delta Dental Premier
dentist, you will benefit from guaranteed copayments limited to the approved Delta Dental Premier fees. You won’t
receive this cost protection and other conveniences when you visit a non-Delta dentist
The PPO plan contains three levels of benefits and depending on the level of benefits utilized, you may a different
selection of dentists or specialist to receive your services from.

Level 1 utilizes Delta’s Preferred Provider Organization (PPO) group of dentists, a smaller network of
professionals providing deeper discounts

Level 2 utilizes Delta’s Premier group of dentists which is a larger group of professionals also providing
discounts, however their fees are generally higher than the PPO dentist’s fees

Finally, Level 3 may be the most costly of all choices, but gives you the option to see any
dentist who does not participate in either Level 1 or Level 2 networks. However, since these
dentists are not under contract with the insurance company, you will pay more out-of-pocket to
seek services from a Non-Network Level 3 dentist
Helpful Dental Hints

Benefit Predetermination: If total dental charges will
exceed $250 for a course of treatment, it is recommended
that your dentist submit the treatment plan and x-rays to
Delta Dental before treatment commences. Delta Dental
will advise you and the dentist as to which services will be
covered and the amount of benefits that will be paid for
each service

To research Delta Dental’s provider networks, go to
www.deltadentalins.com and use their online dentist
directory

No Dental ID cards are provided for this plan. When
visiting your provider you will simply present the PUSD
group #6779-0001 along with employee’s SSN.
Plan highlights for all tiers of the Dental PPO plan are included on the next page for your
review and consideration.
22
DENTAL COVERAGE (GRP #6779-0001)
Delta Dental PPO
In-Network
Out-Of-Network
Level 1
DELTA PPO
Level 2
DELTA PREMIER
Level 3
NON-DELTA
PPO dentists
have agreed to
charge reduced fees
Premier dentists charge
reduced fees but these fees
are generally higher than PPO
dentist fees
Member responsible for difference if
dentist charges more than Delta
Dental’s approved fees
Per Person
$25
$25
$25
Family Maximum
$75
$75
$75
$2,250
$1,500
$1,500
Office Visit & X-rays
100% of PPO Fee
100% of Premier Fee
100% of Approved Fees
Cleanings
100% of PPO Fee
100% of Premier Fee
Sealants (per tooth)
100% of PPO Fee
100% of Premier Fee
100% of PPO Fee
85% of Premier Fee
(1)
(1)
Scaling & Root Planing
100% of PPO Fee
85% of Premier Fee
(1)
(1)
Gingivectomy
100% of PPO Fee
85% of Premier Fee
(1)
(1)
Pulpotomy
100% of PPO Fee
85% of Premier Fee
(1)
(1)
Root Canals
100% of PPO Fee
85% of Premier Fee
(1)
(1)
General Anesthesia
100% of PPO Fee
85% of Premier Fee
(1)
(1)
Simple Extraction
100% of PPO Fee
85% of Premier Fee
(1)
(1)
Soft Tissue / Bony Impaction
100% of PPO Fee
85% of Premier Fee
(1)
(1)
Plan Highlights
Annual Deductible
(1)
Calendar Year Maximum per Person
Preventive
Basic Services
Fillings
Periodontics (gum treatment)
Endodontics (root canal therapy)
Oral Surgery
Crowns & Bridges
Inlay / Onlay (2 surfaces)
75% of PPO Fee
(1)
50% of Premier Fee
(1)
(1)
Crowns
75% of PPO Fee
(1)
50% of Premier Fee
(1)
(1)
Denture Adjustment
75% of PPO Fee
(1)
50% of Premier Fee
(1)
(1)
Complete or Partial Denture
75% of PPO Fee
(1)
50% of Premier Fee
(1)
(1)
Implants
75% of PPO Fee
(1)
50% of Premier Fee
(1)
(1)
Night Guard
Covered up to $500
Covered up to $500
Covered up to $500
50% of PPO Fee
50% of Premier Fee
$1,000
$1,000
$1,000
Prosthetics (dentures)
Other
(Benefit limited to once every 36 months)
Orthodontia Services
Eligible Dep. Children to age 19 only
Lifetime Ortho Max. Benefit
(1)
Deductible applies to items with
(1)
23
VISION COVERAGE (GRP #92-005)
By practicing healthy eye habits, you and your family members can work towards preserving
your vision for the future.
Your Vision Plan Option
Vision coverage is offered by Medical Eye Services (MES) as a
Preferred Provider Organization (PPO) plan.
Using the Plan
Can You See It?
Common daily symptoms that may suggest a
problem with your vision:

Blurriness, blind spots or halos
You have the freedom to choose any optician, optometrist or
around lights
ophthalmologist (M.D.) for your eye exam and prescription
glasses; however, if you use an Eye Care Network (ECN)

Frequent headaches
provider most services and materials are paid in full. If you use

Loss of sharpness & squinting
another provider, benefits are reduced and paid according to a
schedule. To review the list of contracting Eye Care Network
(ECN) providers, please go to the MES website at www.mesvision.com. Please note that this plan provides benefits
for routine services only. If you have an injury or illness of the eye(s) you must utilize your medical plan provider.
No vision cards are provided for this plan. If you are visiting an “in-network provider” you will simply present the
PUSD group # 92-005 along with employee’s SSN. No form needed!
If you are visiting an “Out of network provider” you should obtain a blank claim form from the MES website and bring it
with you to your appointment. You will need to write PUSD’s group # 92-005 on the form along with your SSN.
Claim Form: Covered members should obtain a vision claim form from MES at www.mesvision.com.
Plan Highlights
Exam – Every 12 Months
Lenses – Every 12 Months
Single
Bifocal
Trifocal
Frames – Every 12 Months
Contacts – Every 12 Months
(1)
Medically Necessary (hard / soft)
Cosmetic (in lieu of lenses & frames)
(1)
Medical Eye Services (MES) Vision PPO
Eye Care Network (ECN)
Out-of-Network Providers
100% of Contracted Fees
$60 Allowance
$115 Allowance
$43 Allowance
$60 Allowance
$75 Allowance
$60 Allowance
$115 Allowance
$200 / $250 Allowance
$100 Allowance
Medically necessary is defined as: following cataract surgery, when visual acuity cannot be corrected to 20/40 in the better eye except with contacts, or
when contacts are necessary due to anisometropia or keratoconus
24
LIFE AND AD&D COVERAGE
In the event of your death, Life Insurance will
provide your family members or other
beneficiaries with financial protection and
security. Additionally, if your death is a result of an
accident or if you become dismembered, your
Accidental Death & Dismemberment (AD&D)
coverage may apply.
Select Your Beneficiary
Beneficiaries are individuals or entities that you
select to receive benefits from your policy.

You can change your beneficiary
designation at any time
Mandatory Term Life Insurance

Poway Unified School District pays the premium to cover each
eligible employee with this term group life and AD&D
insurance. The Standard Insurance Company underwrites this
insurance policy.
You may designate a sole beneficiary or
multiple beneficiaries to receive
payment in the amount you specify

Please contact Human Resources if you
wish to select or change your
beneficiary
Benefit Schedule (age reductions have been
applied)

$25,000 Benefit for Employees age 64 or younger

$16,750 Benefit for Employee age 65 through age 69

$12,500 Benefit for Employee age 70 and older
Age Reductions (as noted above)
At age 65, in force amount reduces to 67% (rounded to the next higher $10,000). At age 70, in force amount
reduces to 50% and similarly rounded.
Other Features

Seat Belt Benefit

Higher Education Benefit – 25% of AD&D amount, up to $20,000

Accelerated Death Benefit – Allows for the advance payment to a terminally ill insured employee with less
than twelve months to live. The maximum amount is 75% of the life insurance amount

Repatriation Benefit – If insured employee dies while more than 200 miles from home benefit of up to
$5,000 or 10% of AD&D amount toward expenses incurred for preparation and transportation of the
deceased’s body to the individual’s home
Accidental Death & Dismemberment (AD&D)
The life benefit doubles in the event of death from a covered accident and pays a portion of the insurance amount in
the event of dismemberment as a result of a covered accidental injury. Accidental Death and Dismemberment
(AD&D) benefits are paid for losses, which occur within one year of an accident. Losses not covered under the
AD&D benefit include losses due to acts of war, service in the armed forces, act of riot or insurrection, disease, any
infection-except a pyogenic infection that occurs from an accidental wound, bodily or mental infirmity, commission of
a felony, suicide, intentional self-inflicted injury, intoxication, or use of any drug, unless it is used as prescribed by a
doctor.
If you would like to purchase additional Term Life insurance coverage
or Accidental Death & Dismemberment insurance coverage,
please refer to pages 26 & 27
25
VOLUNTARY TERM LIFE AND AD&D COVERAGE
Voluntary Life and AD&D
If you would like to supplement your employer paid
insurance, additional Life and AD&D coverage for you
and/or your dependents is available for purchase
through The STANDARD Insurance Company.
Premiums will be deducted from employee’s pay
warrant.
Voluntary Term Life Coverage Benefit
Amounts
For Employees: The employee benefit amount must
be in units of $10,000, with a $20,000 minimum and a
maximum of $500,000 (but not to exceed 5 times the
employee’s annual salary).
For Spouses / Unregistered Domestic Partners
(DP): The spouse / DP benefit amount is available in
units of $5,000 to a maximum of $150,000, but not to
exceed 50% of the employee’s approved amount.
Age Reductions for Employee / Spouse / DP: At
age 70, in force amount reduces to 67% (rounded to
the next higher $10,000). At age 75, in force amount
For Your Children: birth through age 24; child must
be unmarried. Benefit increments are $2,500, $5,000,
$7,500 or $10,000. The dependent child benefit
amount cannot exceed 50% of the employee
approved amount.
Accelerated Death Benefit: Allows for the advance
payment to terminally ill member with less than twelve
months to live. The maximum amount is 75% (up to
$500,000) of the basic supplemental life insurance
amount.
Guarantee Issue: If you do not elect supplemental
life insurance when you are first eligible (within 31
days of date of hire or change in status), you will be
required to submit a health questionnaire to The
Standard Insurance Company, also known as
Evidence of Insurability (EOI). An EOI will also be
required if you wish to become insured for an amount
greater than $250,000 or if you wish to insure a
Spouse / Domestic Partner for an amount greater
than $50,000. Child benefit amount is Guarantee
Issue for timely enrollments (typically within 31 days
of date of hire or a change in status).
Voluntary Accidental Death &
Dismemberment Benefit Amounts
You have the option of selecting Employee Only
benefit or Employee Plus Family benefit.
Employee Amount: Employees may apply for benefit
amounts in the following increments: $10,000 or any
multiple of $25,000 not to exceed $500,000.
Family Amount: The Family benefit amount provides
60% of your benefit amount for your spouse/DP if no
eligible children, or 50% of your benefit amount for
your spouse / DP and 10% of your benefit amount for
each of your eligible children or 25% of your benefit
amount for your children only if you do not have a
spouse / DP. The maximum amount payable is
$180,000 for spouse / DP benefit and $25,000 for
child benefit.
Age Reductions for Employees / Spouse / DP: At
age 70, in force amount reduces to 67% (rounded to
the next higher $10,000). At age 75, in force amount
Evidence of good health is not required. This is
inexpensive insurance for accidental death or
dismemberment only.
See Premium Rate Sheet for
Voluntary Term Life and
AD&D Insurance on Page 27
TAKE NOTE:
During the 2016 Plan Year Open Enrollment Period
(Nov. 2, 2015 – Nov. 13, 2015)
Employees Currently Enrolled in Additional
Life Insurance*
You may elect to increase your Additional Life Insurance in
increments of $10,000 up to $100,000 but not to exceed a
combined total of $250,000, without having to submit
medical history statement.
If you are not currently enrolled in Additional
Life coverage*
You may elect Additional Life Insurance in increments of
$10,000 up to $100,000 without having to submit medical
evidence.
*If coverage was previously declined; medical underwriting
approval is required for any election.
26
VOLUNTARY TERM LIFE AND AD&D COVERAGE
The Standard – Voluntary Term Life Insurance
2016 Tenthly Premium Rates (1)
Employee or Spouse / Domestic Partner
Rates Based on Age
Tenthly Rate per $1,000
of Total Coverage
<20
20 – 24
25 – 29
30 – 34
35 – 39
40 – 44
45 – 49
50 – 54
55 – 59
60 – 64
65 – 69
70+
Child(ren) Rates
(1)
$0.019
$0.029
$0.038
$0.048
$0.067
$0.106
$0.153
$0.259
$0.490
$0.758
$1.344
$2.304
$0.36 for $2,500 in Coverage
Employee coverage amount cannot exceed 5 times the employee’s annual base salary
The Standard – Voluntary AD&D Insurance
2016 Tenthly Premium Rates
Coverage Level
Employee Only Rate
($0.03 per $1,000)
Employee Plus Family Rate
($0.052 per $1,000)
$10,000
$25,000
$50,000
$75,000
$100,000
$125,000
$150,000
$175,000
$200,000
$225,000
$250,000
$275,000
$300,000
$325,000
$350,000
$375,000
$400,000
$425,000
$450,000
$475,000
$500,000
$0.30
$0.75
$1.50
$2.25
$3.00
$3.75
$4.50
$5.25
$6.00
$6.75
$7.50
$8.25
$9.00
$9.75
$10.50
$11.25
$12.00
$12.75
$13.50
$14.25
$15.00
$0.52
$1.30
$2.60
$3.90
$5.20
$6.50
$7.80
$9.10
$10.40
$11.70
$13.00
$14.30
$15.60
$16.90
$18.20
$19.50
$20.80
$22.10
$23.40
$24.70
$26.00
27
TRAVEL ASSISTANCE
Travel Assistance helps you cope with emergencies when you travel more than 100 miles
from home or internationally for trips of up to 180 days. It can also help you with nonemergencies, such as planning your trip. You do not have to enroll. As a participant in your
employer’s Group insurance coverage from Standard Insurance Company, you and your
family members are automatically covered. All services are available 24 hours a day, every
day.
Travel Assistance Offers the Following Services:

Access Support Today!

Trip Assistance including emergency ticket, credit
card and passport replacement assistance, funds
transfer assistance and missing baggage assistance

Travel Assistance is available when
traveling at least 100 miles from home or
in a foreign country

Medical Assistance including locating medical care
providers and interpreter services


In the United States, Canada, Puerto Rico,
U.S. Virgin Islands, and Bermuda, call tollfree 800.722.3273
Legal Assistance including locating a local attorney,
consular officer or bail bond services

In other locations worldwide, call collect
1.410.453-6330
Emergency message service to relay messages to
family members, which can be retrieved at any time

FrontierMEDEX Travel Assistance can
also be reached at
[email protected]

28
Pre-trip Assistance including passport, visa, weather
and currency exchange information, health hazards
advice and inoculation requirements

Emergency Transportation Services including
arranging and paying for emergency evacuation to
the nearest adequate medical facility and medicallynecessary repatriation to the employee’s home, including repatriation of remains

Pet care and return to help arrange for any pet(s) traveling with you to be cared for at a local kennel if you
are unable to travel and require hospitalization due to illness or injury; also assists in arranging for the
pet(s) to be returned to a family member or friend (you will be responsible for all costs)

Personal Security Services including logistical arrangements for ground transportation, housing and/or
evacuation in the event of political unrest and social instability. In more complex situations, assists in
making arrangements with providers of specialized security services
EMPLOYEE ASSISTANCE SERVICE FOR EDUCATION
PROGRAM (EASE)
Poway Unified School District understands that you and your family members might
experience a variety of personal or work related challenges. Through the Employee
Assistance Service for Education (EASE) program, you have access to resources, information
and counseling in order to address situations affecting your work-life balance.
Your EASE Option
Personal problems or work challenges affecting your personal
life or job performance? Call EASE for assistance. This free,
confidential program can be a helpful resource for family
issues, job stress, alcohol and drug problems, and other
challenges. EASE Specialists are licensed, trained therapists
who will assess the nature of your problem(s) during one or
several meetings with you, and assist you with brief problem
solving if appropriate.
Access Support Today!

By Phone: 800.722.3273
If ongoing assistance is necessary, your referral options will be discussed with you. Any referral may involve
charges which will be your responsibility.
The purpose of the program is to provide confidential assistance at no-cost for a wide range of personal topics such
as:

Information for Caregivers

Denial

Exercise & Mental Health

Toxic Relationships

Loss

Anxiety

Substance Abuse

Stress about Electronic Communication

Feeling Overwhelmed

Family Stress

When the Going Gets Tough

Empowering Ourselves

Economy-related Stress

Life Balance

Coping with Trauma

Alcohol & Drug Abuse
29
FLEXIBLE SPENDING ACCOUNT (FSA)
Stretch your health care and dependent care dollars by using pre-tax dollars for qualified
medical and/or dependent care costs by contributing to a Flexible Spending Account.
FSA Eligibility
MEDICAL CARE REIMBURSEMENT ACCOUNT
Maximum Annual
Contribution
Maximum Tenthly
Contribution
$1,000
$100
$2,500
$250
Eligibility Requirements
Certificated employees working 17.5 hrs: Non-permanent
Classified working 20 hours or more: 6 Months - 2 years contracted service
Certificated employees working 17.5 hrs: Permanent & Temporary w/2 years
Classified working 20 hours or more: More than 2 years contracted service
FSA Overview
During the PUSD annual Open Enrollment, qualified employees can enroll in a Flexible Benefit Account
administered by IGOE Administrative Services. You may have the option to enroll in and contribute towards one or
both of the following types of Flexible Spending Accounts (FSAs), helping to reduce your taxable income and pay for
eligible expenses for yourself, your spouse and your eligible dependents, on a tax-free basis. The FSA plan
operates on a calendar year basis from January 1 through December 31. You may participate in one or all of the
following accounts:

A Health Care FSA can reimburse for health care expenses that are not covered, or are only partially
covered, by your medical, dental and vision insurance plans including other eligible expenses. You will have
immediate access to the entire annual contribution amount from the first day of the benefit year, before all
scheduled contributions have been made.

The Dependent Care FSA can be used to pay for qualified child care and/or caregivers for a disabled family
member living in the household who are unable to care for themselves. Unlike the Health Care FSA, you can
only access the money that is currently in the account.
With regards to the FSA types available,

The plan administrator is IGOE Administrators

Contributions are deducted from your paycheck in equal amounts, over a 10 month period before federal,
state and social security taxes are taken out

Since you are not paying federal, state or social security taxes on the contributions, your taxable income is
reduced and your spendable income actually increases
Enrolling in an FSA
To participate in the FSA program, enrollment must be completed each year during the Open Enrollment period for
both new and active employees up to the maximum amounts allowed. An annual contribution amount must be
determined at the time of enrollment.
Once enrolled, you will have online access to view your FSA balance(s), check on a reimbursement status and
more. If you’re a first time enrollee, register as a new user. Visit www.goigoe.com to access IGOE Administrators
online portal.
The following sections provide additional information on contributing towards the FSA and using funds, as well as
how reimbursements are complete
30
Using Your Funds
To file a claim visit www.goigoe.com and set up a personal account (the following PIN is required for first time
set up: 0075). By setting up an online account you can request to receive monthly balance reminder emails
and plan year deadlines. You can also reference the download forms section for information regarding what
form to use, how to submit your request, and reimbursement request review deadlines.
The types of expenses reimbursable by your spending accounts are determined by the IRS. Examples of eligible
expenses and additional information are below.
Account Type
Health Care FSA
Eligible Expenses



Dependent Care FSA



(1)
Deductibles, copays and coinsurance, as well as out-of-pocket costs for medical, dental
and vision services, including chiropractic and acupuncture services
Prescription drugs and over-the-counter medications with a prescription are considered
eligible
Explicit guidelines for determining eligible expenses have yet to be provided by the
Internal Revenue Service (IRS); for a list of potential eligible expenses that may be
covered by a Flexible Spending Account (FSA), review Internal Revenue Code (IRC)
section 213 (d). IRS Publication 502 (Medical and Dental Expenses) may be used as a
guide for what expenses may be considered by the IRS to be for medical care; however,
the guidelines should be used with caution when trying to determine what expenses are
(1)
reimbursable under an FSA
Eligible child care, nanny services or residential disabled adult daycare for your
dependents
Dependents claimed on your federal income tax return, including those under age 13
and those of any age who are unable to care for themselves, who live with you for more
than half of the taxable year and do not provide more than half of his/her own support
would be considered eligible dependents for this FSA
To determine potential eligible employment-related expenses view IRC sections 129 and
21. IRS Publication 503 (Child and Dependent Care Expenses) may also be used as a
guide for what expenses that may be considered employment-related; however,
Publication 503 should be used with caution when trying to determine what expenses are
(1)
reimbursable under a Dependent Care FSA
Please note: This is informational only and not intended to serve as legal, tax, or financial advice. Participants in a Health Care FSA or Dependent
Care FSA should consult their tax advisor before making any changes to their plan.
If you are at a participating FSA merchant when you incur eligible expenses, use your FSA debit card to complete
your transaction. Each FSA enrolled employee receives one debit card, which is mailed to the address on file with
IGOE Administrators. One additional card is free, upon request only. The card will be automatically activated when
you use it the first time. You will continue to use the same FSA debit card for subsequent enrolled years.
Keep itemized receipts in a safe place. The IRS or IGOE Administrators may requests a copy to substantiate a
claim. If you are required to submit a receipt or some form of claim documentation and fail to comply,
reimbursement may be denied.
The FSA Health Plan and Termination
If you are a participant in your Health FSA plan and you are terminated, your funds may be preserved and you may
have other options available to you at the time of termination, if applicable. It is important that you check your
Summary Plan Description or contact the PUSD Insurance Department if you have any further questions regarding
your FSA health plan funds at the time of termination. Your failure to act in conjunction with your Health FSA plan
may cause your funds to be permanently forfeited after your termination.
31
Contributing to Your Accounts
Each account allows participants to contribute a set annual amount, as outlined in the chart below.
Account Type
Contribution Limit
Health Care FSA

You can contribute up to $2,500 pre-tax in 2016
Dependent Care FSA

If you are single, you can contribute up to $5,000 pre-tax in 2016
If you are married and filing a joint tax return, you can contribute up to $5,000
pre-tax in 2016
If you are married and file separately, you can contribute up to $2,500 pre-tax
in 2016


Please note: Consult your tax advisor for additional taxation information or advice.
Not sure how much to contribute? By estimating the eligible expenses you and your family might incur during the plan
year, you will have a better sense of how much your annual contribution towards the FSA should be. The Planning
Worksheets below may help you determine an amount to contribute to the Health Care FSA and/or Dependent Care FSA.
Remember, this plan has a “use or lose” feature, so be conservative in your funding estimates.
Health Care FSA Worksheet
Eligible Expenses
Enter the amount not covered or reimbursed by your health care plans:
Annual Estimated
Amount
Deductibles (medical, dental and vision)
$
Copayments and coinsurance amounts
$
Charges above the amount payable by your health care plans
$
Medical, dental, orthodontia and vision care expenses not covered by your or your
dependents’ health care plans
Prescription drug expenses
Other potential eligible expenses as identified in IRC section 213 (d) and IRS
Publication 502
$
$
$
Total Estimated Health Care Expenses
$
(maximum annual allowed contribution of $2,500)
Dependent Care FSA Worksheet
Annual Estimated
Amount
Eligible Expenses
Tax deductible wages or salary paid to a baby-sitter or companion in or outside of
your home residence
$
Services of a daycare center and/or nursery school
$
Cost of care at facilities away from home, such as family daycare or adult daycare
centers
$
Wages paid to a housekeeper for providing care for an eligible dependent
$
Other potential eligible expenses as identified in IRC sections 129 and 21 and IRS
Publication 502
$
Total Estimated Dependent Care Expenses
$
(maximum annual allowed contribution of $5,000)
32
2 ½ Month Extension
Poway Unified School District has elected to offer an extension for the Flexible Benefits Plan. What this means to
you as a participant under the Plan is as follows:

Although the Plan Year runs from January 1, 2016 through December 31, 2016, you will have the
opportunity to still incur expenses after December 31, 2016 and get reimbursed. Employees must be active
on the last day of the plan year to be eligible for 2 ½ month extension. Terminated Employees are not
eligible for the grace period,

The plan will allow a “grace period” through March 15, 2017, allowing you to incur expenses 2 1/2 months
after the plan year ends on December 31, 2016. If you have not had the opportunity to incur expenses
during the plan year, this provision allows you additional time to incur expenses to be submitted.

You will then have until March 31, 2017 to submit claims for services that qualify under the Plan Year.

Eligible expenses will be those received (incurred) from January 1, 2016 through March 15, 2017.
Remember, should you not submit qualified claims to IGOE Administrators by March 31, 2017, any
amounts remaining in the account are forfeited. FSA Funds do not roll over.
Receiving Reimbursements
You will have until March 31, 2017 to submit a reimbursement request for claims incurred between January 1, 2016
and March 15, 2017. If you do not receive automatic reimbursement by using your Flex debit card, you can submit a
manual reimbursement request by:

Email: [email protected]

Fax: (800) 456-9083

Mail: IGOE Administrative Services,
PO Box 501480, San Diego, CA 92150-1480
You may receive your manual reimbursement by check in the mail or by means of direct deposit into your personal
Checking or Savings Account.
Saving with an FSA
Whether you are single, a working couple or have a family of four, an FSA provides more take-home pay and
reduces your taxable income. The scenarios below highlight potential tax savings available through the FSA
program.
Single Person
Family of Four
Without FSA
With FSA
Without FSA
With FSA
$36,000
$36,000
$80,000
$80,000
$0
$2,000
$0
$5,000
$36,000
$34,000
$80,000
$75,000
($11,034)
($10,421)
($24,520)
($22,988)
Annual After Tax Expenses
($2,000)
$0
($5,000)
$0
Annual Take-home Pay
$22,966
$23,579
$50,480
$52,013
Annual Salary
Annual Pre-tax Contribution
Taxable Income
Taxes Withheld
(1)
Increase in Annual
Take-home Pay with FSA
(1)
$613
$1,533
Please note: For example purposes, taxes were estimated at 30.65%. The tax advantages you receive will vary depending on your annual salary, tax filing
status and annual contribution amount.
33
HYATT METLAW VOLUNTARY PLAN
In addition to employer paid coverage, a variety of optional benefits are available for
purchase if you are seeking additional insurance.
Legal Services
When you need guidance on personal legal matters, Hyatt MetLaw Pre-Paid Legal Plan can provide you with
access to a network of qualified attorneys. Whether you prefer telephonic or in-office consultation, you may
receive guidance on topics such as:

Setting up a Living Trust, Will or Power of Attorney

Legal Advice Regarding Elder Law Matters

Foreclosure / Repossession / Bankruptcy / Debt Collection Defense

Contested / Uncontested Adoption / Guardianship Issues

Traffic Offenses, Driving Privileges Restoration

Family Law, Adoption, Uncontested Guardianship, Name Change, Prenuptial Agreement

Document Preparation, Affidavits, Deeds, Demand Letters, Mortgages, Notes

Immigration Assistance, Advice and Consultation, Review of Immigration Documents, Affidavits
Upon new hire or during the PUSD annual Open Enrollment, qualified employees can join the Hyatt MetLaw PrePaid Legal Plan for $23.10 Tenthly. Initial enrollment is for a minimum of 12 months; after that initial membership
period is met the employee can terminate participation by completing / returning a PUSD Cancellation Notice Card
to the PUSD Payroll Department. Payroll deadlines apply to all cancellation requests.
To utilize this plan once enrolled, visit www.info.legalplans.com and enter access code 1680010 or METLAW or call
the Client Service Center at 1-800-821-6400.
34
EVIDENCE OF COVERAGE
Evidence of Coverage
The benefit summaries listed on the previous pages are brief summaries only. They do not fully describe the
benefits coverage for your health and welfare plans. For details on the benefits coverage, please refer to the plan’s
Evidence of Coverage. The Evidence of Coverage or Summary Plan Description is the binding document between
the elected health plan and the member.
A health plan physician must determine that the services and supplies are medically necessary to prevent,
diagnose, or treat the members’ medical condition. These services and supplies must be provided, prescribed,
authorized, or directed by the health plan’s network physician unless the member enrolls in the PPO plan where the
member can use a non-network physician.
The HMO member must receive the services and supplies at a health plan facility or skilled nursing facility inside the
service area except where specifically noted to the contrary in the Evidence of Coverage.
For details on the benefit and claims review and adjudication procedures for each plan, please refer to the plan’s
Evidence of Coverage. If there are any discrepancies between benefits included in this summary and the Evidence
of Coverage or Summary Plan Description, the Evidence of Coverage or Summary Plan Description will prevail.
35
MEDICARE PART D NOTICE
Important Notice about Your Prescription Drug Coverage and Medicare
Model Individual CREDITABLE Coverage Disclosure (for use on or after 04/01/2011)
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage and about
your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare prescription
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 prescription drug coverage in your area. Information about where you can get help to make decisions about
your prescription drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:
1.
Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare
Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription 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.
Your employer has determined that the prescription drug coverage offered is expected to pay, on average, as much as standard Medicare
prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing 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 15 to December 7. However, if you lose your
current creditable prescription 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 prescription drug plan.
What Happens to Your Current Coverage if You Decide to Join a Medicare Prescription Drug Plan?
Individuals who are eligible for Medicare should compare their current coverage, including which drugs are covered, with the coverage and cost of the
plans offering Medicare prescription drug coverage in their area.
If you are eligible for Medicare and do decide to enroll in a Medicare prescription drug plan and drop your employer’s group health plan prescription drug
coverage, be aware that you and your dependents may not be able to get this coverage back.
Please contact Human Resources for more information about what happens to your coverage if you enroll in a Medicare prescription drug
plan.
Your medical benefits brochure contains a description of your current prescription drug benefits.
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 your employer and don’t join a Medicare prescription drug plan within 63
continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous
days or longer without creditable prescription 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 prescription drug coverage. In addition, you may have to wait until the following October to join.
For More Information about This Notice or Your Current Prescription Drug Coverage…
Contact your Human Resources Department for further information NOTE: You will receive this notice annually, before the next period you can join a
Medicare prescription drug plan, and if this coverage through your employer changes. You also may request a copy of this notice at any time.
For More Information about Your Options Under Medicare Prescription Drug Coverage…
More detailed information about Medicare plans that offer prescription 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 information about Medicare
prescription drug coverage:

Visit www.medicare.gov

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 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help,
visit the Social Security Administration (SSA) online at www.socialsecurity.gov, or call SSA at 1-800-772-1213 (TTY 1-800-325-0778).
Remember:
36
Keep this Creditable Coverage notice. If you decide to join one of the Medicare prescription drug plans, you may be
required to provide a copy of this notice 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).
LEGAL INFORMATION REGARDING YOUR PLANS
Required Notices
HIPAA Privacy Notice
Women’s Health & Cancer Rights Act
Notice of Health Information Privacy Practices
The Women’s Health and Cancer Rights Act (WHCRA) requires group health plans to make certain
benefits available to participants who have undergone or who are going to have a mastectomy. In
particular, a plan must offer mastectomy patients benefits for:
This notice describes how medical information about you may be used and disclosed, and how you can
obtain access to this information. Please review it carefully.

All stages of reconstruction of the breast on which the mastectomy was performed;

Surgery and reconstruction of the other breast to produce a symmetrical appearance;

Prostheses; and
 Treatment of physical complications of the mastectomy, including lymphedema.
These benefits will be provided subject to the same deductibles and coinsurance applicable to other
medical and surgical benefits provided under this plan.
This notice is required by law under the federal Health Insurance Portability and Accountability Act of
1996 (HIPAA). One of its primary purposes is to make certain that information about your health is
handled with special respect for your privacy. HIPAA includes numerous provisions designed to maintain
the privacy and confidentiality of your protected health information (PHI). PHI is health information that
contains identifiers, such as your name, address, social security number, or other information that
identifies you.
Our Pledge regarding Health Information

We understand that health information about you and your health is personal.

We are committed to protecting health information about you.
Health Insurance Portability & Accountability Act Non-discrimination
Requirements

This notice will tell you the ways in which we may use and disclose health information about you.

Health Insurance Portability & Accountability Act (HIPAA) prohibits group health plans and health
insurance issuers from discriminating against individuals in eligibility and continued eligibility for benefits
and in individual premium or contribution rates based on health factors.
We also describe your rights and certain obligations we have regarding the use and disclosure of
health information.
We are required by Law to
Your plans comply with these requirements.
These health factors include: health status, medical condition (including both physical and mental
illnesses), claims experience, receipt of health care, medical history, genetic information, evidence of
insurability (including conditions arising out of acts of domestic violence and participation in activities such
as motorcycling, snowmobiling, all-terrain vehicle riding, horseback riding, skiing, and other similar
activities), and disability.
If you are declining enrollment for yourself or your dependents (including your spouse) because of other
health insurance or group health plan coverage, HIPAA Special Enrollment Rights require your plan to
allow you and/or your dependents to enroll in your employer’s plans (except dental and vision plans
elected separately from your medical plans) if you or your dependents lose eligibility for that other
coverage (or if the employer stopped contributing towards your or your dependents' other coverage).
However, you must request enrollment within 30 days (60 days if the lost coverage was Medicaid or
Healthy Families) after your or your dependents' other coverage ends (or after the employer stops
contributing toward the other coverage).
In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for
adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment
within 30 days after the marriage, birth, adoption, or placement for adoption.
Other midyear election changes may be permitted under your plan (refer to “Change in Status” section).
To request special enrollment or obtain more information, contact your Human Resources
Representative.
“HIPAA Special Enrollment Opportunities” include:
COBRA (or state continuation coverage) exhaustion

Loss of other coverage (1)

Acquisition of a new spouse or dependent through marriage
or birth (1)

Loss of state Children’s
(60-day notice) (1)

Employee or dependents become eligible for state Premium Assistance Subsidy Program (60-day
notice)
Insurance
(1)
Program
, adoption
coverage
(1)
, placement for adoption
(e.g.,
Healthy
(1)
Families)
“Change in Status” Permitted Midyear Election Changes

Due to the Internal Revenue Service (IRS) regulations, in order to be eligible to take your premium
contribution using pre-tax dollars, your election must be irrevocable for the entire plan year. As a
result, your enrollment in the medical, dental, and vision plans or declination of coverage when you
are first eligible, will remain in place until the next Open Enrollment period, unless you have an
approved “change in status” as defined by the IRS.
Examples of permitted “change in status” events include:

Change in legal marital status (e.g., marriage

Change in number of dependents (e.g., birth

Change in eligibility of a child

Change in your / your spouse’s / your unregistered domestic partner’s employment status (e.g.,
reduction in hours affecting eligibility or change in employment)

A substantial change in your / your spouse’s / your unregistered domestic partner’s benefits coverage

A relocation that impacts network access

Enrollment in state-based insurance Exchange

Medicare Part A or B enrollment

Qualified Medical Child Support Order or other judicial decree

A dependent’s eligibility ceases resulting in a loss of coverage
(2)
(2)

Follow the terms of the notice that are currently in effect.
Treatment: The plan may use your health information to assist your health care providers (doctors,
pharmacies, hospitals and others) to assist in your treatment. For example, the plan may provide a
treating physician with the name of another treating provider to obtain records or information needed for
your treatment.
Regular Operations: We may use information in health records to review our claims experience and to
make determinations with respect to the benefit options that we offer to employees.
Business Associates: There are some services provided in our organization through contracts with
business associates. Business associate agreements are maintained with insurance carriers. Business
associates with access to your information must adhere to a contract requiring compliance with HIPAA
privacy and security rules.
As Required by Law: We will disclose health information about you when required to do so by federal,
state or local law.
Workers’ Compensation: We may release health information about you for Workers’ Compensation or
similar programs. These programs provide benefits for work-related injuries or illness.
, divorce or legal separation)
Public Health: We may also use and disclose your health information to assist with public health
activities (for example, reporting to a federal agency) or health oversight activities (for example, in a
government investigation).
Your Rights Regarding Your Health Information
Although your health record is the physical property of the entity that compiled it, the information belongs
to you. You have the right to:

Request a restriction on certain uses and disclosures of your information, where concerning a service
already paid for;

Obtain a paper copy of the Notice of Health Information Practices by requesting it from the plan
privacy officer;

Inspect and obtain a copy of your health information;

Request an amendment to your health information;

Obtain an accounting of disclosures of your health information;

Request communications of your health information be sent in a different way or to a different place
than usual (for example, you could request that the envelope be marked "Confidential" or that we send
it to your work address rather than your home address);

Revoke in writing your authorization to use or disclose health information except to the extent that
action has already been taken, in reliance on that authorization.
, adoption (2) or death)
The Plan’s Responsibilities
The plan is required to:
(3)

Loss of other coverage

Change in employment status where you have a reduction in hours to an average below 30 hours of
service per week, but continue to be eligible for benefits, and you intend to enroll in another plan that
provides Minimum Essential Coverage that is effective no later than the first day of the second month
following the date of revocation of your employer sponsored coverage
(2)

You enroll, or intend to enroll, in a Qualified health Plan (QHP) through the State Marketplace (i.e.
Exchange) and it is effective no later than the day immediately following the revocation of your
employer sponsored coverage.
You must notify Human Resources within 30 days of the above change in status, with the exception of the
following which requires notice within 60 days:

Give you this notice of our legal duties and privacy practices with respect to health information about
you;
Law Enforcement: We may disclose your health information for law enforcement purposes, or in
response to a valid subpoena or other judicial or administrative request.


Make sure that health information that identifies you is kept private;

The Plan will use Your Health Information for
Special Enrollment Rights
Health

Loss of eligibility or enrollment in Medicaid or state health insurance programs (e.g., Healthy Families)

Maintain the privacy of your health information;

Provide you with a notice as to our legal duties and privacy practices with respect to information we
collect and maintain about you;

Abide by the terms of this notice;

Notify you if we are unable to agree to a requested restriction, amendment or other request;

Notify you of any breaches of your personal health information within 60 days or 5 days if conducting
business in California;

Accommodate any reasonable request you may have to communicate health information by
alternative means or at alternative locations.
The plan will not use or disclose your health information without your consent or authorization, except as
provided by law or described in this notice.
The plan reserves the right to change our health privacy practices. Should we change our privacy
practices in a material way, we will make a new version of our notice available to you.
(1)
(2)
(3)
Indicates that this event is also a qualified “Change in Status”
Indicates this event is also a HIPAA Special Enrollment Right
Indicates that this event is also a COBRA Qualifying Event
37
For More Information or to Report a Problem
Why am I getting this notice? (Continued)

If you have questions or would like additional information, or if you would like to make a request to
inspect, copy, or amend health information, or for an accounting of disclosures, contact the plan
privacy officer. All requests must be submitted in writing.

If you believe your privacy rights have been violated, you can file a formal complaint with the plan
privacy officer; or with the U.S. Department of Health and Human Services. You will not be penalized
for filing a complaint.
 Divorce or legal separation (36 months of COBRA for the ex-spouse)
 Entitlement to Medicare (36 months of COBRA for the spouse and dependents)
 Loss of dependent child status (36 months of COBRA for the dependent)
Federal law requires that most group health plans (including this plan) give employees and their families
the opportunity to continue their health care coverage through COBRA continuation coverage when
there’s a “qualifying event” that would result in a loss of coverage under an employer’s plan.
Other Uses of Health Information
What’s COBRA continuation coverage?
Other uses and disclosures of health information not covered by this notice or the laws that apply to us
will be made only with your written authorization. If you authorize us to use or disclose health information
about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization we
will no longer use or disclose health information about you for the reasons covered by your written
authorization. You understand that we are unable to take back any disclosures we have already made
with your authorization, and that we are required to retain our records of the payment activities that we
provided to you.
COBRA continuation coverage is the same coverage that the plan gives to other participants or
beneficiaries who aren’t getting continuation coverage. Each “qualified beneficiary” (described below)
who elects COBRA continuation coverage will have the same rights under the plan as other participants
or beneficiaries covered under the plan.
Important Information on how Health Care
Reform Affects Your Plan
Primary Care Provider Designations
For plans and issuers that require or allow for the designation of primary care providers by participants or
beneficiaries:

Your HMO generally requires the designation of a primary care provider. You have the right to
designate any primary care provider who participates in our network and who is available to accept
you or your family members. For information on how to select a primary care provider, and for a list of
the participating primary care providers, contact your Human Resources office
For plans and issuers that require or allow for the designation of a primary care provider for a child:
 For children, you may designate a pediatrician as the primary care provider
For plans and issuers that provide coverage for obstetric or gynecological care and require the
designation by a participant or beneficiary of a primary care provider:

You do not need prior authorization from your insurance provider 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 authorization
for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a
list of participating health care professionals who specialize in obstetrics or gynecology, contact your
Human Resources office.
Grandfathered Plans
If your group health plan is grandfathered then the following will apply. As permitted by the Affordable
Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in
effect when that law was enacted. Being a grandfathered health plan means that your plan may not
include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the
requirement for the provision of preventive health services without any cost sharing. However,
grandfathered health plans must comply with certain other consumer protections in the Affordable Care
Act, for example, the elimination of lifetime limits on benefits.
Questions regarding which protections apply and which protections do not apply to a grandfathered
health plan and what might cause a plan to change from grandfathered health plan status can be directed
to the plan administrator.
Prohibition on Excess waiting Periods
Each person (“qualified beneficiary”) from the list below may qualify to elect COBRA continuation
coverage:
 Employee or former employee
 Spouse or former spouse
 Dependent child(ren) covered under the plan on the day before the event that caused the loss of
coverage
 Child who is losing coverage under the plan because he or she is no longer a dependent under the
plan
Contact your Human Resources Representative to determine eligibility for spouse and dependents.
Are there other coverage options besides COBRA Continuation
Coverage?
Yes. Instead of enrolling in COBRA continuation coverage, there may be other more affordable coverage
options for you and your family through the Health Insurance Marketplace, Medicaid, or other group
health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment
period.” Some of these options may cost less than COBRA continuation coverage.
You should compare your other coverage options with COBRA continuation coverage and choose the
coverage that is best for you. For example, if you move to other coverage you may pay more out of
pocket than you would under COBRA because the new coverage may impose a new deductible.
When you lose job-based health coverage, it’s important that you choose carefully between COBRA
continuation coverage and other coverage options, because once you’ve made your choice, it can be
difficult or impossible to switch to another coverage option.
If I elect COBRA continuation coverage, when will my coverage begin and
how long will the coverage last?
In the case of a loss of coverage due to end of employment or reduction in hours of employment,
coverage generally may be continued for up to a total of 18 months. In the case of losses of coverage due
to an employee’s death, divorce or legal separation, the employee’s becoming entitled to Medicare
benefits or a dependent child ceasing to be a dependent under the terms of the plan, coverage may be
continued for up to a total of 36 months. When the qualifying event is the end of employment or reduction
of the employee's hours of employment, and the employee became entitled to Medicare benefits less
than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries
other than the employee lasts until 36 months after the date of Medicare entitlement. This notice shows
the maximum period of continuation coverage available to the qualified beneficiaries. Contact your
Human Resources Representative for specific start and end dates for COBRA coverage.
Continuation coverage may end before the date noted above in certain circumstances, like failure to pay
premiums, fraud, or the individual becomes covered under another group health plan.
Can I extend the length of COBRA continuation coverage?
Group health plans may not apply a waiting period that exceeds 90 days. A waiting period is defined as
the period that must pass before coverage for an eligible employee or his or her dependent becomes
effective under the Plan. State law may require shorter waiting periods for insured group health plans.
California law requires fully-insured plans to comply with the more restrictive waiting period limitation of no
more than 60-days.
Preexisting Condition Exclusion
Effective for Plan Years on or after January 1, 2014, Group health plans are prohibited from denying
coverage or excluding specific benefits from coverage due to an individual’s preexisting condition,
regardless of the individual’s age. A PCE includes any health condition or illness that is present before
the coverage effective date, regardless of whether medical advice or treatment was actually received or
recommended
Important Information about COBRA
Continuation Coverage and other Health
Coverage Alternatives
Note: For use by single employer group health plans.
This notice has important information about your right to continue your health care coverage in
your company’s plan, as well as other health coverage options that may be available to you,
including coverage through the Health Insurance Marketplace at www.healthcare.gov or call
800.318.2596. You may be able to get coverage through the Health Insurance Marketplace that
costs less than COBRA continuation coverage. Please read the information in this notice very
carefully before you make your decision.
Why am I getting this notice?
You’re getting this notice because your coverage under the plan will end on the last day of the month in
which the following “qualifying events” occur:
 Termination of employment (18 months of COBRA)
 Reduction in hours of employment (18 months of COBRA)
 Death of employee (36 months of COBRA for the spouse and dependents)
38
Who are the qualified beneficiaries?
If you elect continuation coverage, you may be able to extend the length of continuation coverage if a
qualified beneficiary is disabled, or if a second qualifying event occurs. You must notify Human
Resources of a disability or a second qualifying event within a certain time period to extend the period of
continuation coverage. If you don’t provide notice of a disability or second qualifying event within the
required time period, it will affect your right to extend the period of continuation coverage.
For more information about extending the length of COBRA continuation coverage visit
http://www.dol.gov/ebsa/publications/cobraemployee.html.
How much does COBRA continuation coverage cost?
Generally, each qualified beneficiary may be required to pay the entire cost of continuation coverage. The
amount a qualified beneficiary may be required to pay may not exceed 102 percent (or, in the case of an
extension of continuation coverage due to a disability, 150 percent) of the cost to the group health plan
(including both employer and employee contributions) for coverage of a similarly situated plan participant
or beneficiary who is not receiving continuation coverage. The required payment for each continuation
coverage period for each option is described in this notice.
Other coverage options may cost less. If you choose to elect continuation coverage, additional
information about payment will be provided to you after your election is received by the plan. Important
information about paying your premium can be found at the end of this notice.
You may be able to get coverage through the Health Insurance Marketplace that costs less than
COBRA continuation coverage. You can learn more about the Marketplace below.
What is the Health Insurance Marketplace?
The Marketplace offers “one-stop shopping” to find and compare private health insurance options. In the
Marketplace, you could be eligible for a new kind of tax credit that lowers your monthly premiums and
cost-sharing reductions (amounts that lower your out-of-pocket costs for deductibles, coinsurance, and
copayments) right away, and you can see what your premium, deductibles, and out-of-pocket costs will
be before you make a decision to enroll. Through the Marketplace you’ll also learn if you qualify for free
or low-cost coverage from Medicaid or the Children’s Health Insurance Program (CHIP). You can
access the Marketplace for your state at www.healthcare.gov.
Coverage through the Health Insurance Marketplace may cost less than COBRA continuation coverage.
Being offered COBRA continuation coverage won’t limit your eligibility for coverage or for a tax credit
through the Marketplace.
When can I enroll in the Marketplace coverage?
Important Information about Payment (Continued)
You always have 60 days from the time you lose your job-based coverage to enroll in the Marketplace.
That is because losing your job-based health coverage is a “special enrollment” event. After 60 days your
special enrollment period will end and you may not be able to enroll, so you should take action right away.
In addition, during what is called an “open enrollment” period, anyone can enroll in Marketplace coverage.
Periodic payments for continuation coverage. After you make your first payment for continuation
coverage, you’ll have to make periodic payments for each coverage period that follows. The amount due
for each coverage period for each qualified beneficiary may be obtained by contacting Human Resources.
The periodic payments can be made on a monthly basis. Under the plan, each of these periodic
payments for continuation coverage is due on a specified date for that coverage period. If you make a
periodic payment on or before the first day of the coverage period to which it applies, your coverage
under the plan will continue for that coverage period without any break. The plan will not send periodic
notices of payments due for these coverage periods.
To find out more about enrolling in the Marketplace, such as when the next open enrollment period will be
and what you need to know about qualifying events and special enrollment periods, visit
www.healthcare.gov.
If I sign up for COBRA continuation coverage, can I switch to coverage in
the Marketplace? What about if I choose Marketplace coverage and want
to switch back to COBRA continuation coverage?
If you sign up for COBRA continuation coverage, you can switch to a Marketplace plan during a
Marketplace open enrollment period. You can also end your COBRA continuation coverage early and
switch to a Marketplace plan if you have another qualifying event such as marriage or birth of a child
through something called a “special enrollment period.” But be careful though - if you terminate your
COBRA continuation coverage early without another qualifying event, you’ll have to wait to enroll in
Marketplace coverage until the next open enrollment period, and could end up without any health
coverage in the interim.
Once you’ve exhausted your COBRA continuation coverage and the coverage expires, you’ll be eligible
to enroll in Marketplace coverage through a special enrollment period, even if Marketplace open
enrollment has ended.
If you sign up for Marketplace coverage instead of COBRA continuation coverage, you cannot switch to
COBRA continuation coverage under any circumstances.
Can I enroll in another group health plan?
You may be eligible to enroll in coverage under another group health plan (like a spouse’s plan), if you
request enrollment within 30 days of the loss of coverage.
If you or your dependent chooses to elect COBRA continuation coverage instead of enrolling in another
group health plan for which you’re eligible, you’ll have another opportunity to enroll in the other group
health plan within 30 days of losing your COBRA continuation coverage.
What factors should I consider when choosing coverage options?
When considering your options for health coverage, you may want to think about:
Premiums: Your previous plan can charge up to 102% of total plan premiums for COBRA coverage.
Other options, like coverage on a spouse’s plan or through the Marketplace, may be less expensive.
Provider Networks: If you’re currently getting care or treatment for a condition, a change in your health
coverage may affect your access to a particular health care provider. You may want to check to see if
your current health care providers participate in a network as you consider options for health coverage.
Drug Formularies: If you’re currently taking medication, a change in your health coverage may affect
your costs for medication – and in some cases, your medication may not be covered by another plan.
You may want to check to see if your current medications are listed in drug formularies for other health
coverage.
Severance payments: If you lost your job and got a severance package from your former employer,
your former employer may have offered to pay some or all of your COBRA payments for a period of time.
In this scenario, you may want to contact the Department of Labor at 1-866-444-3272 to discuss your
options.
Service Areas: Some plans limit their benefits to specific service or coverage areas – so if you move to
another area of the country, you may not be able to use your benefits. You may want to see if your plan
has a service or coverage area, or other similar limitations.
Other Cost-Sharing: In addition to premiums or contributions for health coverage, you probably pay
copayments, deductibles, coinsurance, or other amounts as you use your benefits. You may want to
check to see what the cost-sharing requirements are for other health coverage options. For example, one
option may have much lower monthly premiums, but a much higher deductible and higher copayments.
For More Information
This notice doesn’t fully describe continuation coverage or other rights under the plan. More information
about continuation coverage and your rights under the plan is available in your summary plan description
or from the Plan Administrator.
If you have questions about the information in this notice, your rights to coverage, or if you want a copy of
your summary plan description, contact your Human Resources Representative.
For more information about your rights under the Employee Retirement Income Security Act (ERISA),
including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health
plans, visit the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) website at
www.dol.gov/ebsa or call their toll-free number at 1-866-444-3272. For more information about health
insurance options available through the Health Insurance Marketplace, and to locate an assister in your
area who you can talk to about the different options, visit www.healthcare.gov.
Grace periods for periodic payments. Although periodic payments are due on specified dates (contact
Human Resources for this information), you’ll be given a grace period of 30 days after the first day of the
coverage period to make each periodic payment. You’ll get continuation coverage for each coverage
period as long as payment for that coverage period is made before the end of the grace period.
If you pay a periodic payment later than the first day of the coverage period to which it applies, but before
the end of the grace period for the coverage period, your coverage will be suspended as of the first day of
the coverage period and then retroactively reinstated (going back to the first day of the coverage period)
when the periodic payment is received. This means that any claim you submit for benefits while your
coverage is suspended may be denied and may have to be resubmitted once your coverage is reinstated.
If you don’t make a periodic payment before the end of the grace period for that coverage period, you’ll
lose all rights to continuation coverage under the plan.
Contact your Plan Administrator for information for where your first payment and all periodic payments for
continuation coverage should be sent.
Separate USERRA Rights for Military Service: The COBRA health care coverage continuation rights
discussed above are separate from USERRA health care coverage continuation rights for qualifying
military service.
If you leave employment to enter military service, you should contact Human Resources to determine
whether you also have USERRA health care coverage continuation rights.
OMB Control Number 1210-0123 (expires 10/31/2016)
Employee Rights & Responsibilities under the
Family Medical Leave Act
Basic Leave Entitlement
Family Medical Leave Act (FMLA) requires covered employers to provide up to 12 weeks of unpaid, job
protected leave to eligible employees for the following reasons:

For incapacity due to pregnancy, prenatal medical care or child birth;

To care for the employee's child after birth, or placement for adoption or foster care;

To care for the employee's spouse, son or daughter, child or parent, who has a serious health
condition; or

For a serious health condition that makes the employee unable to perform the employee's job.
Military Family Leave Entitlements
Eligible employees whose spouse, son, daughter or parent is on covered active duty or call to covered
active duty status may use their 12-week leave entitlement to address certain qualifying exigencies.
Qualifying exigencies may include attending certain military events, arranging for alternative childcare,
addressing certain financial and legal arrangements, attending certain counseling sessions, and attending
post-deployment reintegration briefings.
FMLA also includes a special leave entitlement that permits eligible employees to take up to 26 weeks of
leave to care for a covered servicemember during a single 12-month period. A covered servicemember is:
(1) a current member of the Armed Forces, including a member of the National Guard or Reserves, who
is undergoing medical treatment, recuperation or therapy, is otherwise in outpatient status, or is otherwise
on the temporary disability retired list, for a serious injury or illness (1); or (2) a veteran who was
discharged or released under conditions other than dishonorable at any time during the five-year period
prior to the first date the eligible employee takes FMLA leave to care for the covered veteran, and who is
undergoing medical treatment, recuperation, or therapy for a serious injury or illness. (1)
Benefits & Protections
During FMLA leave, the employer must maintain the employee's health coverage under any "group health
plan" on the same terms as if the employee had continued to work. Upon return from FMLA leave, most
employees must be restored to their original or equivalent positions with equivalent pay, benefits, and
other employment terms.
Use of FMLA leave cannot result in the loss of any employment benefit that accrued prior to the start of
an employee's leave.
Eligibility Requirements
Keep Your Plan Informed of Address Changes
Employees are eligible if they have worked for a covered employer for at least 12 months, have 1,250
hours of service in the previous 12 months (2), and if at least 50 employees are employed by the employer
within 75 miles.
To protect your and your family’s rights, keep the Plan Administrator informed of any changes in your
address and the addresses of family members. You should also keep a copy of any notices you send to
the Plan Administrator.
Definition of Serious Health Condition
Important Information about Payment
First payment for continuation coverage. You must make your first payment for continuation coverage
no later than 45 days after the date of your election (this is the date the Election Notice is postmarked). If
you don’t make your first payment in full no later than 45 days after the date of your election, you’ll lose all
continuation coverage rights under the plan. You’re responsible for making sure that the amount of your
first payment is correct. You may contact Human Resources to confirm the correct amount of your first
payment.
A serious health condition is an illness, injury, impairment, or physical or mental condition that involves
either an overnight stay in a medical care facility, or continuing treatment by a health care provider for a
condition that either prevents the employee from performing the functions of the employee's job, or
prevents the qualified family member from participating in school or other daily activities.
Subject to certain conditions, the continuing treatment requirement may be met by a period of incapacity
of more than 3 consecutive calendar days combined with at least two visits to a health care provider or
one visit and a regimen of continuing treatment, or incapacity due to pregnancy, or incapacity due to a
chronic condition. Other conditions may meet the definition of continuing treatment.
(1)
(2)
The FMLA definitions of “serious injury or illness” for current servicemembers and veterans are distinct from the FMLA
definition of “serious health condition”
Special hours of service eligibility requirements apply to airline flight crew employees
39
Use of Leave
What Happens if You do not Elect to Continue Coverage?
An employee does not need to use this leave entitlement in one block. Leave can be taken intermittently
or on a reduced leave schedule when medically necessary. Employees must make reasonable efforts to
schedule leave for planned medical treatment so as not to unduly disrupt the employer's operations.
Leave due to qualifying exigencies may also be taken on an intermittent basis.
If you fail to submit a timely, completed Election Form as instructed or do not make a premium payment
within the required time, you will lose your continuation rights under the Plan, unless compliance with
these requirements is precluded by military necessity or is otherwise impossible or unreasonable under
the circumstances.
Substitution of Paid Leave for Unpaid Leave
If you do not elect continuation coverage, your coverage (and the coverage of your covered dependents,
if any) under the Plan ends effective the end of the month in which you stop working due to your leave for
uniformed service.
Employees may choose or employers may require use of accrued paid leave while taking FMLA leave. In
order to use paid leave for FMLA leave, employees must comply with the employer's normal paid leave
policies.
Premium for Continuing Your Coverage
The premium that you must pay to continue your coverage depends on your period of service in the
uniformed services. Contact Human Resources for more details.
Employee Responsibilities
Employees must provide 30 days advance notice of the need to take FMLA leave when the need is
foreseeable. When 30 days’ notice is not possible, the employee must provide notice as soon as
practicable and generally must comply with an employer's normal call-in procedures.
Employees must provide sufficient information for the employer to determine if the leave may qualify for
FMLA protection and the anticipated timing and duration of the leave. Sufficient information may include
that the employee is unable to perform job functions; the family member is unable to perform daily
activities, the need for hospitalization or continuing treatment by a health care provider; or circumstances
supporting the need for military family leave. Employees also must inform the employer if the requested
leave is for a reason for which FMLA leave was previously taken or certified. Employees also may be
required to provide a certification and periodic recertification supporting the need for leave.
Employer Responsibilities
Covered employers must inform employees requesting leave whether they are eligible under FMLA. If
they are, the notice must specify any additional information required as well as the employees' rights and
responsibilities. If they are not eligible, the employer must provide a reason for the ineligibility.
Covered employers must inform employees if leave will be designated as FMLA-protected and the
amount of leave counted against the employee's leave entitlement. If the employer determines that the
leave is not FMLA protected, the employer must notify the employee.
Length of Time Coverage Can Be Continued
If elected, continuation coverage can last 24 months from the date on which employee's leave for
uniformed service began. However, coverage will automatically terminate earlier if one of the following
events takes place:

A premium is not paid in full within the required time;

You fail to return to work or apply for reemployment within the time required under USERRA (see
below) following the completion of your service in the uniformed services; or

You lose your rights under USERRA as a result of a dishonorable discharge or other conduct
specified in USERRA.
We will not provide advance notice to you when your continuation coverage terminates.
Reporting to Work / Applying for Reemployment
Your right to continue coverage under USERRA will end if you do not notify Human Resources of your
intent to return to work within the timeframe required under USERRA following the completion of your
service in the uniformed services by either reporting to work (if your uniformed service was for less than
31 days) or applying for reemployment (if your uniformed service was for more than 30 days). The time
for returning to work depends on the period of uniformed service, as follows:
Unlawful Acts by Employers
Period of Uniformed
Service
FMLA makes it unlawful for any employer to:

Interfere with, restrain, or deny the exercise of any right provided under FMLA;

Discharge or discriminate against any person for opposing any practice made unlawful by FMLA or for
involvement in any proceeding under or relating to FMLA.
Less than 31 days
The beginning of the first regularly scheduled work period
on the day following the completion of your service, after
allowing for safe travel home and an eight-hour rest period,
or if that is unreasonable or impossible through no fault of
your own, then as soon as is possible
31–180 days
Submit an application for reemployment within 14 days after
completion of your service or, if that is unreasonable or
impossible through no fault of your own, then as soon as is
possible
181 days or more
Submit an application for reemployment within 90 days after
completion of your service
Any period if for purposes of an
examination for fitness to perform
uniformed service
Report by the beginning of the first regularly scheduled work
period on the day following the completion of your service,
after allowing for safe travel home and an eight-hour rest
period, or if that is unreasonable or impossible through no
fault of your own, as soon as is possible
Any period if you were hospitalized for
or are convalescing from an injury or
illness incurred or aggravated as a
result of your service
Report or submit an application for reemployment as above
(depending on length of service period) except that time
periods begin when you have recovered from your injuries
or illness rather than upon completion of your service.
Maximum period for recovering is limited to two years from
completion of service but may be extended if circumstances
beyond your control make it impossible or unreasonable for
you to report to work within the above time periods
Enforcement
An employee may file a complaint with the U.S. Department of Labor or may bring a private lawsuit
against an employer.
FMLA does not affect any Federal or State law prohibiting discrimination, or supersede any State or local
law or collective bargaining agreement which provides greater family or medical leave rights.
FMLA section 109 (29 U.S.C. § 2619) requires FMLA covered employers to post the text of this notice.
Regulations 29 C.F.R. § 825.300(a) may require additional disclosures.
For additional information:
www.wagehour.dol.gov
(866)
4US-WAGE
((866)
487-9243)
TYY:
(877)
889-5627
Uniformed Services Employment &
Reemployment Rights Act Notice of 1994,
Notice of Right to Continued Coverage under
USERRA
Right to Continue Coverage
Under the Uniformed Services Employment & Reemployment Rights Act of 1994 (USERRA), you (the
employee) have the right to continue the coverage that you (and your covered dependents, if any) had
under the Company Medical Plan if the following conditions are met:

You are absent from work due to service in the uniformed services (defined below);

You were covered under the Plan at the time your absence from work began; and

You (or an appropriate officer of the uniformed services) provided your employer with advance notice
of your absence from work (you are excused from meeting this condition if compliance is precluded by
military necessity or is otherwise impossible or unreasonable under the circumstances).
Definitions
For you to be entitled to continued coverage under USERRA, your absence from work must be due to
“service in the uniformed services.”

“Uniformed services” means the Armed Forces, the Army National Guard, and the Air National Guard
when an individual is engaged in active duty for training, inactive duty training, or full-time National
Guard duty (i.e., pursuant to orders issued under federal law), the commissioned corps of the Public
Health Service, and any other category of persons designated by the President in time of war or
national emergency

“Service in the uniformed services” or “service” means the performance of duty on a voluntary or
involuntary basis in the uniformed services under competent authority, including active duty, active
and inactive duty for training, National Guard duty under federal statute, a period for which a person is
absent from employment for an examination to determine his or her fitness to perform any of these
duties, and a period for which a person is absent from employment to perform certain funeral honors
duty. It also includes certain service by intermittent disaster response appointees of the National
Disaster Medical System (NDMS)
How to Continue Coverage
If the conditions are met, you (or your authorized representative) may elect to continue your coverage
(and the coverage of your covered dependents, if any) under the Plan by completing and returning an
Election Form 60 days after date that USERRA election notice is mailed, and by paying the applicable
premium for your coverage as described below.
40
Report to Work Requirement
THE CHILDREN’S HEALTH INSURANCE PROGRAM
(CHIP) PREMIUM ASSISTANCE SUBSIDY NOTICE
Premium Assistance under Medicaid and the Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your State may have a premium assistance program that can help pay for coverage,
using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs, but you may be able to buy
individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your State Medicaid
or CHIP office or dial (877) KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your State if it has a program that might help you pay the premiums for an employersponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you
aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions
about enrolling in your employer plan, you can contact the Department of Labor at www.askebsa.dol.gov or call (866) 444-EBSA (3272).
If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums. The following list of States is current as of January 31, 2015.
Contact your State for more information on eligibility.
ALABAMA – Medicaid
Website: www.myalhipp.com
Phone: (855) 692-5447
ALASKA – Medicaid
Website: health.hss.state.ak.us/dpa/programs/medicaid/
Phone (outside of Anchorage): (888) 318-8890
Phone (Anchorage): (907) 269-6529
COLORADO – Medicaid
Website: www.colorado.gov/hcpf
Phone (in-state): (800) 866-3513
Phone (out-of-state): (800) 221-3943
FLORIDA – Medicaid
Website: https://www.flmedicaidtplrecovery.com/
Phone: (877) 357-3268
GEORGIA – Medicaid
Website: dch.georgia.gov/
Click on Programs, then Medicaid, then Health Insurance
Premium Payment (HIPP)
Phone: (800) 869-1150
INDIANA – Medicaid
Website: www.in.gov/fssa
Phone: (800) 889-9949
IOWA – Medicaid
Website: www.dhs.state.ia.us/hipp/
Phone: (888) 346-9562
MINNESOTA – Medicaid
Website: www.dhs.state.mn.us/
Click on Healthcare, then Medical Assistance
Phone: (800) 657-3629
MISSOURI – Medicaid
Website:
www.dss.mo.gov/mhd/participants/pages/hipp.htm
Phone: (573) 751-2005
MONTANA– Medicaid
Website: Medicaid.mt.gov/member
Phone: (800) 694-3084
PENNSYLVANIA – Medicaid
NEBRASKA – Medicaid
Website: www.accessnebraska.ne.gov
Phone: (855) 632-7633
NEVADA – Medicaid
Medicaid Website: dwss.nv.gov/
Medicaid Phone: (800) 992-0900
SOUTH DAKOTA – Medicaid
Website: dss.sd.gov
Phone: (888) 828-0059
TEXAS – Medicaid
Website: https://www.gethipptexas.com/
Phone: (800) 440-0493
NEW HAMPSHIRE – Medicaid
Website: www.dhhs.nh.gov/oii/documens/hippapp.pdf
Phone: (603) 271-5218
UTAH – Medicaid and CHIP
Medicaid Website: health.utah.gov/upp
CHIP Website: health.utah.gov/chip
Phone: (866) 435-7414
VERMONT– Medicaid
Website: www.greenmountaincare.org/
Phone: (800) 250-8427
Website: www.dpw.state.pa.us/hipp
Phone: (800) 692-7462
RHODE ISLAND – Medicaid
Website: www.ohhs.ri.gov
Phone: (401) 462-5300
SOUTH CAROLINA – Medicaid
Website: www.scdhhs.gov
Phone: (888) 549-0820
KANSAS – Medicaid
Website: www.kdheks.gov/hcf/
Phone: (800) 792-4884
NEW JERSEY – Medicaid and CHIP
Medicaid Website:
www.state.nj.us/humanservices/dmahs/clients/medicaid/
CHIP Website: www.njfamilycare.org/index.html
CHIP Phone: (800) 701-0710
NEW YORK – Medicaid
Website: www.nyhealth.gov/health_care/medicaid/
Phone: (800) 541-2831
KENTUCKY – Medicaid
NORTH CAROLINA – Medicaid
Website: chfs.ky.gov/dms/default.htm
Phone: (800) 635-2570
Website: www.ncdhhs.gov/dma
Phone: (919) 855-4100
LOUISIANA – Medicaid
Website: www.lahipp.dhh.louisiana.gov
Phone: (888) 695-2447
MAINE – Medicaid
Website:
www.maine.gov/dhhs/ofi/public-assistance/index.html
Phone: (800) 977-6740
TTY: (800) 977-6741
MASSACHUSETTS – Medicaid and CHIP
NORTH DAKOTA – Medicaid
Website: www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: (800) 755-2604
OKLAHOMA – Medicaid and CHIP
VIRGINIA – Medicaid and CHIP
Medicaid Website: www.dmas.virginia.gov/rcphipp.htm
CHIP Website: http://www.covera.org/programs_
premium_assistance.cfm
CHIP Phone: (855) 242-8282
WASHINGTON – Medicaid
Website: www.hca.wa.gov/medicaid/premiumpymt/
pages/index.aspx
Phone: (800) 562-3022 ext. 15473
WEST VIRGINIA – Medicaid
Website: www.dhhr.wv.gov/bms/
Phone: (877) 598-5820, HMS Third Party Liability
WISCONSIN – Medicaid
Website: www.insureoklahoma.org
Phone: (888) 365-3742
Website: www.badgercareplus.org/pubs/p-10095.htm
Phone: (800) 362-3002
OREGON – Medicaid
Website: www.oregonhealthykids.gov
www.hijossaludablesoregon.gov
Phone: (800) 699-9075
WYOMING – Medicaid
Website: www.mass.gov/masshealth
Phone: (800) 462-1120
Website: health.wyo.gov/healthcarefin/equalitycare
Phone: (307) 777-7531
To see if any other States have added a premium assistance program since January 31, 2015, or for more information on special enrollment rights, contact either:
U.S. Department of Labor
Employee Benefits Security Administration
www.dol.gov/ebsa
(866) 444-EBSA (3272)
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
www.cms.hhs.gov
(877) 267-2323, Menu Option 4, ext. 61565
OMB Control Number 1210-0137 (expires 10/31/2016)
41
NOTES
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42
DIRECTORY & RESOURCES
Below, please find important contact information and resources for Poway Unified School
District.
Information Regarding
Poway Unified Benefits Department
Group / Policy #
Contact Information
N/A
858.521.2897
Carin Freitas: [email protected]
Chris Gold: [email protected]
104206-0000
800.464.4000
www.kp.org
866283
866283
866294
800.370.4526
800.370.4526
855.281.8858
www.aetna.com
Bin #610494
Group #PSD
Carrier #PSI2428
800.797.9791
www.optumrx.com
6779-0001
866.499.3001
www.deltadentalins.com
92-005
800.877.6372
www.mesvision.com
800.628.8600
www.standard.com
Medical Coverage
Kaiser Permanente
• HMO
Aetna
• HMO Value Network (AVN)
• HMO Full Network
• OAMC PPO Member Services
Pharmacy Provider for Aetna Members
Optum RX – Applies to Aetna Members only
Dental Coverage
Delta Dental PPO
• PPO and Premier Dentists
Vision Coverage
Medical Eye Services
• PPO: ECN (Eye Care Network Providers)
Life and AD&D
The Standard
• Group Life / AD&D
• Supplemental Life / AD&D
Flexible Spending Account
IGOE Administrators
• Medical Reimbursement Account
• Dependent Care Reimbursement Account
P: 800.633.8818
F: 858.777.5424
www.goigoe.com
Employee Assistance Plan
EASE (EE Assistance for Service Education)
800.722.3273
Voluntary Prepaid Legal Plan
MetLaw / Hyatt Legal Plans
N/A
800.821.6400
www.legalplans.com
800.321.4696
www.barneyandbarney.com
858.875.3046
858.875.3026
858.875.3065
858.550.4980
[email protected]
[email protected]
[email protected]
[email protected]
Benefits Broker
Barney & Barney, a Marsh & McLennan
Insurance Agency LLC company
9171 Towne Centre Dr., Ste. 500
San Diego, CA 92122
Dianne Wingfield – Principal
Elicia David – Client Manager
Christy Sineni – Client Service Executive
Shannon O’Neill – Benefits Analyst
43
44

CONTENTS 2016 - Poway Unified School District

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