Medical Dental Vision Summary of Employee Benefits Disability Plans Effective January 1– December 31, 2011 Life EAP Accident Cancer Hospital Intensive Care Personal Sickness Specified Health FSA Prepared by: John Burnham Insurance Services CA License 0619252 Issued 05.04.11 Our employees are our most valuable asset. That’s why at Grossmont-Cuyamaca Community College District (GCCCD) we are committed to a comprehensive employee benefit program that helps our employees stay healthy, feel secure, and maintain a work/life balance. Stay Healthy… • Medical • Dental • Vision • Flexible Spending Accounts (FSA) Feeling Secure… • Disability Insurance • Life and Accidental Death & Dismemberment (AD&D) • Employee Assistance Program (EAP) • Personal Coverage (AFLAC) Who is Eligible and When… Employees become eligible to participate in the various insurance plans on the first of the month following their contract hire date provided they work at least 20 hours per week (for most plans). If an employee enrolls, they have the option of covering their spouse or domestic partner and/or children (up to the age of 26) for most coverages. Furthermore, employees who retire from GCCCD are covered until they become eligible for Medicare. Contents and Contact Information Refer to this list when you need to contact one of your benefit vendors. For general information, eligibility, forms, status changes, etc. please contact District Services. MEDICAL & PRESCRIPTION DRUGS page 1 KAISER HMO Member Services and Prescription Drug Pharmacy Management: 1-800-499-3001 Online Member Services and Provider Finder: www.kp.org DIRECT HEALTH PLAN Dedicated Member Services: 1-877-427-5105 | Prescription Drug Pharmacy Management: 1-800-460-8988 Online Provider Finder: www.gcccd.edu/benefits then click on HealthPlans and choose either the Sharp or the Anthem/Blue Cross link. First Health Online Provider Finder (outside California): www.firsthealth.coventryhealthcare.com DENTAL page 2 DELTA DENTAL DHMO Member Services: 1-800-422-4234 | PPO Member Services: 1-800-866-3001 Online Member Services and Provider Finder: www.deltadentalins.com VISION page 3 KAISER MEMBERS Available through your Kaiser facilities. Online Member Services and Provider Finder: www.kp.org DIRECT HEALTH MEMBERS/VSP Member Services: 1-800-877-7195 | Online Member Services/Provider Finder: www.vsp.com EMPLOYEE ASSISTANCE PROGRAM (EAP) page 4 HORIZON HEALTH 1-800-342-8111 Online Services: www.horizoncarelink.com (contact District Services to obtain the login and password) LONG TERM DISABILITY/LIFE/ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) page 5 MUTUAL OF OMAHA Member Services: 1-800-948-9478 | Online Member Services/Claims: www.mutualofomaha.com Life Claims Phone: 1-800-775-8805 | Disability Claims Phone: 1-800-877-5176 ACCIDENT/CANCER/DISABILITY/HOSPITAL/INTENSIVE CARE/PERSONAL SICKNESS/SPECIFIED HEALTH page 6 AFLAC Member Services: 1-800-992-3522 | Online Member Services/Claims: www.aflac.com Claims Phone: 1-800-992-3522 | Claims Fax: 1-877-442-3522 FLEXIBLE SPENDING ACCOUNTS (FSA) page 7 AFLAC Member Services: 1-800-322-5391 | Account Information: 1-877-353-9487 | Claims Fax: 1-877-353-9256 BENEFIT ELECTIONS page 8 Contact District Services REQUIRED NOTICES page 9 BB&T – BENEFITS ADVOCATE CALL CENTER 800-914-5096 Medical Insurance GCCCD offers employees two medical plans to choose from. Option 1: Kaiser HMO (Health Maintenance Organization) offers members access to medical care through Kaiser Permanente physicians and hospitals. Option 2: Direct Health Plan, a 3-tier PPO (Preferred Provider Organization) allowing members the freedom to choose any provider or hospital – without the necessity of a designated primary care physician. However, there are significant provider and benefit differences between the 3 tiers of benefits. Members utilizing the Sharp network will receive many cost advantages, but ONLY claims for members utilizing a Sharp provider or hospital will be paid at the Tier 1 level. If a member is referred to any provider outside of the Sharp network, claims will be paid Tier 2 or 3 and will be subject to the $750 deductible. Please note this includes referrals made by Sharp physicians (other than Lab and X-Ray services). If the provider or facility is not in either the Sharp, Anthem or First Health networks, claims will be reimbursed at the Usual, Customary and Reasonable (UCR) charge for that geographic location. The chart below gives a side-by- Direct Health Plan side look at some of the copays/ OPTION 1 OPTION 2 coinsurance members pay under Anthem Kaiser HMO Sharp Non-Network each plan and benefit tier. (First Health o utside CA ) Network Access Level PCP Directed Tier 1 Tier 2 Tier 3 Lifetime Benefits Unlimited Unlimited Member Pays… Member Pays… Member Pays… Member Pays… Annual Out-of-Pocket Maximum $1,500 (2x family) $1,500 (2x family) $1,500 (2x family) $6,000 (3x family) Annual Deductible None None $750 (3x family) $750 (3x family) Primary Care Office Visits $10 copay $15 copay $30 copay* 40% of the bill* Specialists Office Visits $10 copay $25 copay $50 copay* 40% of the bill* Routine GYN and Well Child Visits $10 copay $15 copay $30 copay* 40% of the bill* Adult Physical Exams $10 copay $15 copay $30 copay* 40% of the bill* Urgent Care Visits $10 copay $15 or $25 copay $30 or $50 copay* 40% of the bill* Emergency Room Services $35 copay $35 copay $35 Copay $35 Copay Diagnostic Lab & X-Ray No charge No charge No charge 40% of the bill* Inpatient Hospitalization No charge No charge No charge 40% of the bill* Outpatient Surgery No charge No charge $50 copay* 40% of the bill* Physical/Occupational Therapy $10 copay $15 copay $30 copay* 40% of the bill* Outpatient Mental Health $10 copay $15 copay $30 copay* 40% of the bill* Chiropractic Services $10 copay $15 copay $15 copay* 40% of the bill* Generic Prescriptions $10 copay $10 copay $10 copay Not cov ered Brand Name Prescriptions $20 copay $25 copay $25 copay Non-Preferred Prescriptions n/a $50 copay $50 copay Mail Order 00 up to 1 days at co unter 2x copay = 90 days 2x copay = 90 days n/a * Benefit s apply AFTER t he annual deduct ible has been met . The information provided herein intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriers/administrators. For more detailed information pertaining to your employee benefit plans, including limitations and exclusions, please refer to the plan documents and/or evidence of coverage provided by the carriers/administrators. 1 Dental Insurance GCCCD offers employees two dental plans. Option 1: DeltaCare® USA DHMO (Dental Health Maintenance Organization) Services are coordinated though a designated primary care dental group chosen from the list of contracted dental offices. This program is designed to encourage regular dental visits to maintain dental health. Many services are covered at no cost, while others have set copayments. There is no deductible or annual limit on dental benefits under the DeltaCare® USA plan. Option 2: Delta Dental Premier® Incentive Plan A traditional PPO, “Non-Referral” based dental plan that allows members the freedom to choose any recognized dentist, in or out of network. A PPO Dental Plan offers significant cost advantages to members utilizing "in network" PPO providers. This plan is designed to reward members who maintain enrollment, as the benefits increase with years of membership beginning in year 1 through year 4. The chart below gives a side-by-side summary of the two options. ® PREMIER INCENTIVE PLAN OPTION 1 OPTION 2 DHMO PPO Primary Care Group Year 1 Year 2 Year 3 Year 4+ Annual Maximum Benefits Unlimited $2,000 Member Pays… Member Pays… Calendar Year Deductible None None Office Visits No Charge 30% of bill 20% of bill 10% of bill No charge Oral Exams and X-Rays No Charge 30% of bill 20% of bill 10% of bill No charge Teeth Cleaning No Charge 30% of bill 20% of bill 10% of bill No charge Fluoride Treatment No Charge 30% of bill 20% of bill 10% of bill No charge Space Maintainers No Charge 30% of bill 20% of bill 10% of bill No charge Amalgam Fillings No Charge 30% of bill 20% of bill 10% of bill No charge Composite Fillings No Charge 30% of bill 20% of bill 10% of bill No charge Extrations & Oral Surgery No Charge 30% of bill 20% of bill 10% of bill No charge Gingevectomy No Charge 30% of bill 20% of bill 10% of bill No charge Periodontal Scaling & Planing No Charge 30% of bill 20% of bill 10% of bill No charge Crowns No Charge 30% of bill 20% of bill 10% of bill No charge Root Canals No Charge 30% of bill 20% of bill 10% of bill No charge Installation of Dentures No Charge 50% of bill 50% of bill 50% of bill 50% of bill Adult Orthodontics $500 copay Child Orthodontics $500 copay Not Cov ered Lifetime Orthodontics Maximum None The information provided herein intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriers/administrators. For more detailed information pertaining to your employee benefit plans, including limitations and exclusions, please refer to the plan documents and/or evidence of coverage provided by the carriers/administrators. 2 Vision Insurance For those members who are enrolled in Kaiser, the vision services are covered at medical offices or optical sales offices when prescribed by your Kaiser physician or a optometrist. The chart below provides a brief description of the benefits of this plan: Kaiser Plan Schedule of Benefits Kaiser Provider Well Vision Exam Ev ery 12 months Prescription Lenses Ev ery 12 months Fram es Ev ery 24 months Contact Lens Every 12 months (in lieu of glasses) Member Pays… Well Vision Exam $10 copay Materials Member pays any amount over the $125 allowance for frames/lenses or contacts. For those members who are enrolled in the Direct Health Plan, GCCCD includes this comprehensive vision plan through VSP. This is a traditional PPO vision plan or “Non-Referral” based benefit. Members have the freedom to choose any recognized provider. PPO Plan This "open access" allows members to see a provider of choice. VSP has a very broad network of Schedule of Benefits PPO Provider Non-PPO contracted providers. VSP physicians offer Well Vision Exam Ev ery 12 months personalized care that focuses on keeping eyes healthy year after year. Plus, when a VSP doctor is Prescription Lenses Ev ery 12 months utilized, there are lower out-of-pocket costs and Frames Ev ery 24 months satisfaction is guaranteed. After a comprehensive exam, members choose the eyewear that meets Contact Lens Every 12 months (in lieu of glasses) their needs and their budget. From classic styles to the latest designer frames, members are sure to find Member Pays… the eyewear that is right for them. The chart to the Well Vision Exam $10 copay amount over $34 left gives a side-by-side look at the benefits of a PPO amount over or Non-PPO provider. Materials $25 copay allowance Additional discounts are available when utilizing a Single Vision Lenses No charge amount over $34 VSP Provider. An average of 20 to 25% savings on all non-covered lens options, 20% off additional Bifocal Lenses No charge amount over $51 glasses and sunglasses, including lens options, 15% Trifocal Lenses No charge amount over $68 off cost of contact lens exam (fitting and evaluation), and an average Contact Lens amount over $100 amount over $100 15% off the regular price or 5% Frames amount over $75 amount over $40 off the promotional price of Laser Vision Correction. The information provided herein intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriers/administrators. For more detailed information pertaining to your employee benefit plans, including limitations and exclusions, please refer to the plan documents and/or evidence of coverage provided by the carriers/administrators. 3 Employee Assistance Program (EAP) We all experience times when we need a little help with life’s challenges. GCCCD understands this and is providing the Horizon Health EAP (employee assistance program) to offer support, guidance and resources to help you and your family resolve personal issues. What can the Horizon Health EAP programs do for me? A master’s level Member Advocate from Horizon Health EAP services will confidentially consult with you over the telephone and help you find solutions and resources to meet life’s challenges. The Member Advocate will provide you with consultation, resources, an action plan and information to help you address your issue. Your program also includes 8 face-to-face assessment and counseling sessions per issue, per year. Horizon will work with you to schedule appointments according to your needs. You may also receive referrals to support groups, community resources, a Horizon network counselor or your health plan. Horizon Health EAP services can help with the following issues, among others: • Child care and elder care • Depression • Alcohol and drug abuse • Emotional well-being • Life improvement • Financial and legal concerns • Difficulties in relationships • Grief and loss • Stress and anxiety with work or family • Identity theft and fraud resolution Is it confidential? Your calls and all counseling services are completely confidential. Information will be released only with your permission or as required by law. When is it available? Telephone consultation and online access to EAP services are always available. Simply call the toll-free number 1-800-342-8111 or log on to www.horizoncarelink.com. In emergency situations, you may call the toll- free number to speak with a licensed staff counselor who can also connect you to emergency services. HorizonCareLinkSM A broad range of educational materials and guide books on dependent care topics are available online, but in addition, HorizonCareLinkSM online services can save you countless hours by researching and providing referrals for important issues such as • Child care or elder care services • Healthy lifestyle guidance • Pet care and veterinarians • Self Assessment • Adoption resources • Videos and articles on topics like understanding depression, • Health clubs and fitness centers nutrition advice and preparing for childbirth Legal/Financial Services Services include legal/financial consultation, guidance, and advice from qualified legal and financial professionals. Each member receives an initial 30-minute telephonic consultation for each separate legal or financial matter. Virtually all types of legal matters are eligible for these services, excluding work/employer- related issues. Typical financial matters include credit counseling, debt and budgeting assistance, tax planning, and retirement and college planning. Members also receive a 25% discount when retaining attorney services, free online will program, complicated wills and trust preparation, identity theft consultation, mediation services, and telephonic tax consultation. The information provided herein intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriers/administrators. For more detailed information pertaining to your employee benefit plans, including limitations and exclusions, please refer to the plan documents and/or evidence of coverage provided by the carriers/administrators. 4 Long Term Disability and Life/AD&D Insurance GCCCD provides Long Term Disability (LTD) income benefits though Mutual of Omaha. In the event you become disabled from an injury or sickness for more than 90 days, disability income benefits will be provided to you in the amount of 66 2/3% of your pre-disability earnings up to a maximum benefit of $7,000 per month. If you remain disabled, this plan will continue to pay until you would have otherwise reached 70 years of age (65 for those employees with less than 5 years of service). Other features of this plan include a vocational rehabilitation services, accidental dismemberment or loss of sight benefits, survivorship benefit and individual policy conversion. Life/Accidental Death & Dismemberment (AD&D) insurance provides valuable financial protection when death or injury occurs. That’s why GCCCD provides each employee with a basic Life/AD&D benefit insured by Mutual of Omaha in the amount $50,000. Life insurance benefits are payable if you die. . In addition, if you die as the result of an accident, the AD&D benefit pays your beneficiary. Other features of this plan include a seatbelt benefit, living benefit should you become diagnosed with a terminal condition, continuation of coverage during a layoff or leave of absence, and individual policy conversion. The unexpected death of a family member is devastating for survivors. Too frequently, the hardships are compounded by financial losses that could have been avoided with adequate life insurance. The right amount of life insurance can protect loved ones against the financial hardships caused by death by giving them the means to manage certain expenses. Voluntary Term Life insurance is available now to you and your family at coverage levels that meet your family’s financial needs. This insurance is voluntary because, as an employee you pay 100% of the premium through a convenient deduction from your paycheck. If you sign up for the voluntary term life during your enrollment period, you’ll receive a guaranteed dollar amount of coverage of 5 times your annual salary up to $50,000. By signing up for even the minimum amount of coverage initially, you protect the ability to buy additional coverage in the future under this plan, should your needs change. You can also purchase spouse coverage up to 50% of your benefit, not to exceed $150,000. Coverage for your unmarried children up to the age of 21 (25 if full-time student) is also available in the amount of $10,000. Additional Voluntary AD&D insurance is also available to you. This plan offers protection on a worldwide basis, 24 hours a day, 365 days a year against any covered accident in the course of business or pleasure, including accidents on or off the job, in or away from the home, commuting, traveling by train, airplane, automobile or other private and public conveyances. You can purchase increments of $10,000 up to $300,000. Under a full family plan your spouse’s principal sum is 50% of yours and each child’s principal sum is 10% of yours. If there are no children covered, your spouse’s benefit increases to 60% of yours. If there is no spouse covered, each child’s benefit increases to 20% of yours. NOTE: Spouse and/or all children coverage cannot be purchased on a “standalone” basis, i.e., Employee participation is also required. The information provided herein intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriers/administrators. For more detailed information pertaining to your employee benefit plans, including limitations and exclusions, please refer to the plan documents and/or evidence of coverage provided by the carriers/administrators. 5 Accident, Cancer, Disability Hospital, Personal Sickness and Specified Health The Accident Plan is a way to stay ahead of the medical and out-of-pocket expenses that add up so quickly after an accidental injury – not just for emergency treatment, hospital stays and medical exams, but for other expenses you may face, such as transportation and lodging needs. When you have a covered accident, AFLAC will send cash benefits directly to you and you decide the best way to spend them. It's as simple as that. You'll receive cash benefits for expenses that may not be fully covered by your major medical insurance including broken teeth, concussions, intensive care unit confinement, ground and air ambulance, emergency room visits and lacerations. The lump sum Cancer insurance policy provides you with a pre-established amount if you or another covered person is diagnosed with cancer. You can use the money to help pay the expenses that you'll have at the time, from medical costs to everyday bills. These benefits can be used to help pay for the expenses associated with cancer that may not be fully covered by your major medical insurance, including transportation to and from medical facilities, including parking, out-of-network specialists, experimental treatments, rehabilitation, extended hospital stays and daily living expenses. The Short Term Disability insurance plan pays benefits for a period of time while you are disabled. You select the right amount of disability insurance benefits for your needs, as well as the length of time they are payable. You should choose a level of disability coverage that best meets your needs for the price you feel you can afford, income requirements, the amount of monthly benefits you'll want, the period of time you want benefits to last, the number of days before coverage kicks in and any optional riders. No matter how good your medical insurance is, when you're hospitalized for an injury or illness there will probably be medical expenses and out of pocket costs that aren’t covered. The Hospital Confinement Indemnity insurance policy provides cash benefits to use as you see fit. The benefits are predetermined and paid regardless of any other insurance you have, and you have a choice of applying for basic to extensive hospital coverage. The Hospital Intensive Care insurance policy provides cash benefits for accidents or illnesses that result in an admission to a hospital intensive care unit. These cash benefits are paid directly to you, unless you instruct AFLAC to direct them elsewhere, no matter what other insurance you have. The hospital intensive care insurance policy has a straightforward benefit design that complements your major medical, limited benefit or short-term health insurance plans. Additional advantages include Initial cash benefit for first seven days in the ICU, with an increased benefit for the next eight days, progressive benefits that build over time, ambulance benefit, and major human organ transplant benefit. The Personal Sickness Indemnity insurance policies help ease the financial burden of hospital stays due to illness by providing you with cash benefits. While the primary benefits of the policy pay for hospital care, there's also a physician visit feature for those times when you're sick, have an accident, or just need a routine exam. Some of the policy benefits include hospital confinement, major diagnostic exams, surgery, and ambulance transportation. There are different levels of coverage to suit your needs and budget. A serious health event such as heart attack, end-stage renal failure or third-degree burns is not only a life-altering physical event, but a devastating financial one as well. Specified Health Event Protection insurance may make all the difference by providing cash benefits as you concentrate on your recovery. Some other covered health events also include stroke, paralysis, coronary artery bypass surgery, persistent vegetative state, major human organ transplant, and coma. This policy helps with the medical expenses related to a covered life-threatening health event. The information provided herein intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriers/administrators. For more detailed information pertaining to your employee benefit plans, including limitations and exclusions, please refer to the plan documents and/or evidence of coverage provided by the carriers/administrators. 6 Flexible Spending Accounts (FSA) GCCCD offers you the opportunity to participate in tax-savings accounts through payroll deduction. With these plans, money is taken out of your paycheck before taxes and set aside—so you don’t pay taxes on the contributions. Then, the money is used to reimburse you for your eligible health care and dependent care expenses. However, health insurance premiums that are automatically deducted by your employer from your paycheck are not eligible for reimbursement. Under the FSA plan, deductions of your medical, dental and vision insurance premiums are also made before taxes. This plan is also administered by AFLAC. Here are three ways you can save with an FSA: 1. Pre-tax Health Care Premiums. If you have health care premiums CHANGES AFECTING CHANGES AFECTING (including dental and vision) that you pay for, GCCCD can deduct YOUR FSA PLAN: YOUR FSA PLAN: those premiums pre-tax. Effective January 1, 2011, Effective January 1, 2011, 2. Health Care Account. If you know how much you’ll spend on health all over-the-counter all over-the-counter care, you can set aside that money in an FSA health care account. medicines and drugs will medicines and drugs will Eligible expenses include copayments, deductibles, coinsurance, and require a physician‘s require a physician‘s some services your medical, dental and vision plans may not cover. prescription to be eligible prescription to be eligible You can set aside up to $5,000 per year on a pre-tax basis for reimbursement under for reimbursement under the flexible spending the flexible spending 3. Dependent Care Account. If you pay someone (a licensed account. account. professional) to watch your dependents while you work, you can set aside up to $5,000 per year on a pre-tax basis. Some samples of the most popular qualified health related expenses are: • Medical & Dental plan copays • Prescription eyewear • Medical & Dental plan deductibles • Hearing aids • Dentistry & Orthodontics • Lamaze classes • Diabetic supplies • Physical therapy • Counseling visits • Occupational therapy Sample: Sample: Without FSA Without FSA With FSA With FSA Gross Pay Gross Pay $50,000 $50,000 $50,000 $50,000 FSA Health Care Contributions FSA Health Care Contributions $0 $0 -$2,000 -$2,000 FSA Dependent Care Contributions FSA Dependent Care Contributions $0 $0 -$5,000 -$5,000 Salary You're Taxed On Salary You're Taxed On $50,000 $50,000 $43,000 $43,000 Less Federal Income Tax (est. 15%) Less Federal Income Tax (est. 15%) -$7,500 -$7,500 -$6,450 -$6,450 Less Social Security (est. 7.65%) Less Social Security (est. 7.65%) -$3,825 -$3,825 -$3,290 -$3,290 Less After-Tax Health Care Expenses Less After-Tax Health Care Expenses -$2,000 -$2,000 $0 $0 Less After-Tax Dependent Care Expenses Less After-Tax Dependent Care Expenses -$5,000 -$5,000 $0 $0 Your Take-Home Pay Your Take-Home Pay $31,675 $31,675 $33,261 $33,261 You'd save $1,586 in taxes by using these tax-free benefits! You'd save $1,586 in taxes by using these tax-free benefits! The information provided herein intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriers/administrators. For more detailed information pertaining to your employee benefit plans, including limitations and exclusions, please refer to the plan documents and/or evidence of coverage provided by the carriers/administrators. 7 Benefit Elections and Making Changes Benefit Elections… GCCCD provides, eligible employees, with a comprehensive employee benefit package that is 100% paid for by your EMPLOYER. The EMPLOYER-paid plans for employee and family coverage are as follows: • Medical: Kaiser HMO and Direct Health Plan • Dental: DeltaCare USA DHMO and Delta Premier Incentive Plan • Vision: VSP PPO (if enrolled in Direct Health Plan) • Long Term Disability: Mutual of Omaha • Life: Mutual of Omaha Basic Term Life/AD&D • EAP: Horizon Health Employees can also choose to “buy-up” for: • Voluntary Life/AD&D: Mutual of Omaha • Accident: AFLAC • Cancer: AFLAC • Short Term Disability: AFLAC • Hospital Confinement: AFLAC • Intensive Care: AFLAC • Personal Sickness Indemnity: AFLAC • Specified Health Event: AFLAC • Health and Dependent Care FSA: AFLAC Making Changes… Each year, during GCCCD’S annual Open Enrollment, which occurs prior to the first day of each plan year (January 1), you will be offered the opportunity to change your benefit elections for the upcoming plan year. The coverage(s) you elect during Open Enrollment cannot be changed during the plan year unless you have a qualifying life event as recognized under IRS regulations such as: • Loss or gain of coverage through your spouse • Loss of eligibility of a covered dependent • Birth or adoption of a child • Marriage, divorce, or legal separation • Switch from part-time to full-time Any change due to a qualifying life event must be made within 30 days of the event. Employees are responsible for notifying District Services of all changes to their benefit status, including over-age dependents. The information provided herein intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriers/administrators. For more detailed information pertaining to your employee benefit plans, including limitations and exclusions, please refer to the plan documents and/or evidence of coverage provided by the carriers/administrators. 8 Patient Protection and Affordable Care Act (PPACA) Mandatory Notices Opportunity to enroll or re-enroll dependents under the age of 26 If you have a dependent whose coverage ended, or who was denied coverage (or was not eligible for coverage), because coverage for dependent children under the plan previously ended before they were age 26, they are eligible to enroll or reenroll in our medical plan. You may request enrollment for such children who are under age 26 for 30 days from the date this notice is received. Enrollment will be effective as of the first day of our first plan year beginning on or after September 23, 2010, even if that results in retroactive enrollment. For more information contact District Services or call the medical carrier at the telephone number on your insurance identification card. Lifetime limit not applicable and enrollment opportunity The lifetime limit on the dollar value of benefits under our medical plan no longer applies. Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan. Individuals have 30 days from the date of this notice to request enrollment. For more information contact District Services or call the medical insurance carrier at the telephone number on your identification card. Notice on Patient Protections The medical HMO plan generally allows the designation of a primary care provider. You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members. Until you make this designation, the medical carrier designates one for you. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact the medical insurance carrier at the number listed on your identification card. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from the medical insurance carrier 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 the 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 the medical insurance carrier at the number listed on your identification card. 2011 Changes to OTC Drug Reimbursements for FSAs/HSAs Under the new Health Care Reform law (PPACA), the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained. The change does not affect insulin, even if purchased without a prescription, or other health care expenses such as medical devices, eyeglasses, contact lenses, co-pays and deductibles. The new standard applies only to purchases made on or after January 1, 2011, so claims for medicines or drugs purchased without a prescription in 2010 can still be reimbursed in 2011. A similar rule goes into effect on January 1 for Health Savings Accounts (HSAs). The IRS has also posted a questions and answers section on its website http://www.irs.gov/newsroom/article/0,,id=227308,00.html concerning these provisions. The information provided herein intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriers/administrators. For more detailed information pertaining to your employee benefit plans, including limitations and exclusions, please refer to the plan documents and/or evidence of coverage provided by the carriers/administrators. 9 Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Our Pledge to You This notice is intended to inform you of the privacy practices followed by the Grossmont-Cuyamaca Community College District (GCCCD) Employee Benefit Plan (the Plan) and the Plan’s legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The notice also explains the privacy rights you and your family members have as participants of the Plan. It is effective on April 14, 2011. The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions. We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy. GCCCD requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined below. Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule. Generally, protected health information is information that identifies an individual created or received by a health care provider, health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions, provision of health care, or payment for health care, whether past, present or future. How We May Use Your Protected Health Information Under the HIPAA Privacy Rule, we may use or disclose your protected health information for certain purposes without your permission. This section describes the ways we can use and disclose your protected health information. n Payment. We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits, seek reimbursement from a third party, or coordinate benefits with another health plan under which you are covered. For example, a health care provider that provided treatment to you will provide us with your health information. We use that information in order to determine whether those services are eligible for payment under our group health plan. n Health Care Operations. We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities, resolution of internal grievances, and evaluating plan performance. For example, we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs. n Treatment. Although the law allows use and disclosure of your protected health information for purposes of treatment, as a health plan we generally do not need to disclose your information for treatment purposes. Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment, payment, and health care operations. n As permitted or required by law. We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law. We are permitted by law to share information, subject to certain requirements, in order to communicate information on health-related benefits or services that may be of interest to you, respond to a court order, or provide information to further public health activities (e.g., preventing the spread of disease) without your written authorization. We are also permitted to share protected health information during a corporate restructuring such as a merger, be a or acquisition. We will also disclose health information documents The information provided herein intended tosale, summary of benefits only and in no way supersedes the actual planabout you when required by law, for example, in order to prevent serious harm to you or others. provided by the insurance carriers/administrators. For more detailed information pertaining to your employee benefit plans, including limitations and exclusions, please refer to the plan documents and/or evidence of coverage provided by the carriers/administrators. 10 Notice of Privacy Practices n Pursuant to your Authorization. When required by law, we will ask for your written authorization before using or disclosing your protected health information. If you choose to sign an authorization to disclose information, you can later revoke that authorization to prevent any future uses or disclosures. n To Business Associates. We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan. We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information. For example, we may disclose your protected health information to a Business Associate to administer claims. Business Associates are also required by law to protect protected health information. n To the Plan Sponsor. We may disclose protected health information to certain employees of GCCCD for the purpose of administering the Plan. These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA, unless you have authorized additional disclosures. Your protected health information cannot be used for employment purposes without your specific authorization. Your Rights n Right to Inspect and Copy. In most cases, you have the right to inspect and copy the protected health information we maintain about you. If you request copies, we will charge you a reasonable fee to cover the costs of copying, mailing, or other expenses associated with your request. Your request to inspect or review your health information must be submitted in writing to the person listed below. In some circumstances, we may deny your request to inspect and copy your health information. To the extent your information is held in an electronic health record, you may be able to receive the information in an electronic format. n Right to Amend. If you believe that information within your records is incorrect or if important information is missing, you have the right to request that we correct the existing information or add the missing information. Your request to amend your health information must be submitted in writing to the person listed below. In some circumstances, we may deny your request to amend your health information. If we deny your request, you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information. n Right to an Accounting of Disclosures. You have the right to receive an accounting of certain disclosures of your protected health information. The accounting will not include disclosures that were made (1) for purposes of treatment, payment or health care operations; (2) to you; (3) pursuant to your authorization; (4) to your friends or family in your presence or because of an emergency; (5) for national security purposes; or (6) incidental to otherwise permissible disclosures. Your request to for an accounting must be submitted in writing to the person listed below. You may request an accounting of disclosures made within the last six years. You may request one accounting free of charge within a 12-month period. n Right to Request Restrictions. You have the right to request that we not use or disclose information for treatment, payment, or other administrative purposes except when specifically authorized by you, when required by law, or in emergency circumstances. You also have the right to request that we limit the protected health information that we disclose to someone involved in your care or the payment for your care, such as a family member or and in no The information provided herein intended to be a summary of benefits only friend. way supersedes the actual plan documents provided by the insurance carriers/administrators. For more detailed information pertaining to your employee benefit plans, including Your request for restrictions must be submitted in writing to the person listed the carriers/administrators. limitations and exclusions, please refer to the plan documents and/or evidence of coverage provided by below. We will consider 11 Notice of Privacy Practices your request, but in most cases are not legally obligated to agree to those restrictions. However, we will comply with any restriction request if the disclosure is to a health plan for purposes of payment or health care operations (not for treatment) and the protected health information pertains solely to a health care item or service that has been paid for out-of-pocket and in full. n Right to Request Confidential Communications. You have the right to receive confidential communications containing your health information. Your request for restrictions must be submitted in writing to the person listed below. We are required to accommodate reasonable requests. For example, you may ask that we contact you at your place of employment or send communications regarding treatment to an alternate address. n Right to be Notified of a Breach. You have the right to be notified in the event that we (or one of our Business Associates) discover a breach of your unsecured protected health information. Notice of any such breach will be made in accordance with federal requirements. n Right to Receive a Paper Copy of this Notice. If you have agreed to accept this notice electronically, you also have a right to obtain a paper copy of this notice from us upon request. To obtain a paper copy of this notice, please contact the person listed below. Our Legal Responsibilities We are required by law to protect the privacy of your protected health information, provide you with certain rights with respect to your protected health information, provide you with this notice about our privacy practices, and follow the information practices that are described in this notice. We may change our policies at any time. In the event that we make a significant change in our policies, we will provide you with a revised copy of this notice. You can also request a copy of our notice at any time. For more information about our privacy practices, contact the person listed below. If you have any questions or complaints, please contact: Amber Herrmann, Director, Employment Services Grossmont-Cuyamaca Community College District 8800 Grossmont College Drive, El Cajon, CA 92020 Phone: 619-644-7631 Email: Amber.Herrmann@gcccd.edu Complaints If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the person listed above. You also may send a written complaint to the U.S. Department of Health and Human Services — Office of Civil Rights. The person listed above can provide you with the appropriate address upon request or you may visit www.hhs.gov/ocr for further information. You will not be penalized or retaliated against for filing a complaint with the Office of Civil Rights or with us. The information provided herein intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriers/administrators. For more detailed information pertaining to your employee benefit plans, including limitations and exclusions, please refer to the plan documents and/or evidence of coverage provided by the carriers/administrators. 12 Medicare Part D Creditable Coverage 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. The current prescription drug coverage offered is, on average for all plan participants, expected to pay out 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. You can join a Medicare drug plan when you first become eligible for Medicare and each year from November 15th through December 31st. 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 drug plan. If you decide to join a Medicare drug plan, your current coverage will not be affected. Your current coverage pays for other health expenses in addition to prescription drug. If you enroll in a Medicare prescription drug plan, you and your eligible dependents will still be eligible to receive all your current health and prescription drug benefits. If you do decide to join a Medicare drug plan and drop your current coverage, be aware that you and your dependents will be able to enroll back into the current benefit plan during the annual open enrollment period. You should also know that if you drop or lose your current coverage and don’t join a Medicare 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 November to join. For more information about this notice or your current prescription drug coverage, contact District Services. NOTE: You will receive this notice each year, before the next period you can join a Medicare drug plan, and if the current coverage changes. You also may request a copy of this notice at any time. 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 or 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 Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you The information provided herein intended to be a summary of benefits only and in no way supersedes the actual plan documents whether or not you have maintained detailed information pertaining therefore, whether or not you are join to show the insurance carriers/administrators. For more creditable coverage and,to your employee benefit plans, including provided by limitations pay a higher premium (a penalty). required toand exclusions, please refer to the plan documents and/or evidence of coverage provided by the carriers/administrators. 13 Other Mandatory Notices Women’s Health and Cancer Rights Act of 1998 If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: • 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. If you would like more information on WHCRA benefits, call your plan administrator. CHIP-Children's Health Insurance Program (CHIP) Reauthorization Act of 2009 Medicaid and the Children’s Health Insurance Program (CHIP) offer free or low-cost health coverage to children and families. If you are eligible for health coverage from your employer, but are unable to afford the premiums, some States have premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage, but need assistance in paying their health premiums. If you or your dependents are already enrolled in Medicaid or CHIP, you can contact your state Medicaid or CHIP office to find out if premium assistance is available. For a list of the contacts in each State, go to www.dol.gov/ebsa/chipmodelnotice.doc. 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 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can then contact the State to find out if it has a program that might help you pay the premiums for an employer- sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer’s health plan is required to permit you and your dependents to enroll in the plan – as long as you and your dependents are eligible, but not already enrolled in the employer’s plan. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. The information provided herein intended to be a summary of benefits only and in no way supersedes the actual plan documents provided by the insurance carriers/administrators. For more detailed information pertaining to your employee benefit plans, including limitations and exclusions, please refer to the plan documents and/or evidence of coverage provided by the carriers/administrators. 14 Prepared by: The information in this Benefits Summary is presented for illustrative purposes and is based on information provided by the employer. The text contained in this Summary was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In case of discrepancy between the Benefits Summary and the actual plan documents the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996. If you have any questions about this summary, contact District Services.
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