Benefits Brochure - SDRMA - 2015-01-01800.537.7790 ✷ WWW.SDRMA.ORG 2015 HEALTH BENEFITS PROGRAM MEDICAL BENEFITS & ANCILLARY COVERAGES Simple Solutions Special District Risk Management Authority
800.537.7790 ✷ WWW.SDRMA.ORG SPECIAL DISTRICT RISK MANAGEMENT AUTHORITY (SDRMA)Special District Risk Management Authority (SDRMA) is a not-for-profit public agency formed under California Government Code Section 6500 et seq. to provide a full-service risk management program for California’s local governments including property, liability and workers’ compensation coverages. In addition, we offer a Health Benefits Program in conjunction with the California State Association of Counties Excess Insurance Authority (CSAC-EIA Health). The Health Benefits Program consists of Medical Benefits and Ancillary Coverages. Medical Benefits include health plans by Blue Shield and Blue Cross with prescription drug programs provided by Express Scripts. Ancillary Coverages include Delta Dental, VSP Vision, VOYA FINANCIAL Life and Long Term Disability and MHN Employee Assistance Program. Public agencies can select which programs they would like to join subject to underwriting approval.We realize selecting a health plan for your agency and your employees is just one of the key decisions you are faced with on an on-going basis. This important decision involves not only the cost of various providers and plans, but also access to doctors and hospitals, prescription drug services, and other additional programs and services. The combination of health plans and providers that is right for your agency depends on a variety of factors, such as your preference for a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO); your premium and out-of-pocket costs; and the need for access to specific doctors and hospitals.We understand that comparing health plan benefits, features, and costs can be complicated. This brochure provides information that will help simplify your decision making process. Our enrollment process is easy and only requires a few simple steps.For more information, please contact us at 800.537.7790 . We are ready to serve you!
800.537.7790 ✷ WWW.SDRMA.ORG MEDICAL BENEFITS SUMMARY
800.537.7790 ✷ WWW.SDRMA.ORG 4 ✷ 2015 HEALTH BENEFITS PROGRAM ✷ MEDICAL BENEFITS SUMMARY PLAN SUMMARY - BLUE SHIELD DEDUCTIBLES/CO-INSURANCE Gold PPO Platinum PPO Calendar Year Deductible(s) (Individual/Family)$500 / $1,000 $300 / $600 Maximum Medical Out of Pocket (Individual/Family)$2,000 / $4,000 $1,300 / $3,600 Medicare Medical Maximum Out of Pocket $1,500 / $3,000 $1,000 / $3,000 Services/Coverages Participating Providers Non-Participating Providers Participating Providers Non-Participating Providers Inpatient Hospital Room, Board & Support Services (prior authorization required)80%50% up to $600 per day 90%50% up to $600 per day Ambulatory Surgery Center 80%50% up to $350 per day 90%50% up to $350 per day Emergency Room Visit Results in Admission as Inpatient 80%90% Visit Does Not Result in Admission 80%, $100 co-pay 90%, $100 co-pay Physician Benefits (office visits)$20 co-pay 50%$20 co-pay 50%Preventative Care No Charge Not Covered No Charge Not Covered Rehabilitation Service (in an office location)80%50%90%50%Acupuncture (26 visits per calendar year/combined with Chiropractic)80%80%90%90%Durable Medical Equipment 80%50%90%50%Hospice 80%Not Covered without prior authorization 90%Not Covered without prior authorization Ambulance 80%90%Home Health Care 100 visits/year (prior authorization required)80%Not Covered without prior authorization 90%Not Covered without prior authorization Chiropractic Services (26 visits per calendar year/combined with Acupuncture)80% up to $50 per visit 50% up to $25 per visit 90% up to $50 per visit 50% up to $25 per visit Prescription Drugs Active/Early Retiree Plans Only Express Scripts Express Scripts Prescription Maximum Out of Pocket $4,600 / $9,200 $5,300 / $9,600 (At Participating Pharmacies only)Generic / Brand / Non-Formulary / Specialty Generic / Brand / Non-Formulary / Specialty Retail - 30 day supply $5 / $30 / $45 / 30% (max co-pay $150)$5 / $30 / $45 / 30% (max co-pay $150)Mail Order - 90 day supply $10 / $75 / $112.50 / 30% (max co-pay $300)$10 / $75 / $112.50 / 30% (max co-pay $300)Brand / Non-Formulary / Specialty Deductible (Individual / Family)None None THIS SUMMARY IS INTENDED TO COMPARE COVERAGE BENEFITS ONLY. THE ACTUAL PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.NON-PARTICIPATING PROVIDER MEMBER COST MAY NOT APPLY TO MAXIMUM OUT OF POCKET COSTS.MEDICAL BENEFITS SUMMARY
800.537.7790 ✷ WWW.SDRMA.ORG 2015 HEALTH BENEFITS PROGRAM ✷ MEDICAL BENEFITS SUMMARY ✷ 5 PLAN SUMMARY - BLUE SHIELD Silver PPO EPO HDHP 10% and (20%)$2,000 / $4,000 $300 / $600 $1,300 / $2,600 ($3,000 / $6,000)$5,000 / $10,000 $1,300 / $2,600 $5,000 / $10,000 ($5,950 / $11,900)$3,000 / $6,000 $1,000 / $2,000 Non-Applicable Participating Providers Non-Participating Providers Participating Providers Participating Providers Non-Participating Providers 80%50% up to $600 per day No Charge 90% (80%)50% up to $600 per day 80%50% up to $350 per day No Charge 90% (80%)50% up to $350 per day 80%No Charge 90% (80%)80%, $100 co-pay $100 co-pay 90% (80%), $100 co-pay $30 co-pay 50%$30 co-pay 90% (80%)50%No Charge Not Covered No Charge No Charge Not Covered 80%50%$30 co-pay 90% (80%) up to $25 per visit 50% up to $25 per visit 80%80% $30 co-pay 90% (80%) up $30 per visit 80%50%80%90% (80%)50%80%Not Covered without prior authorization No Charge 90% (80%)Not Covered without prior authorization 80%$50 90% (80%)80%Not Covered without prior authorization $30 co-pay (100 visits/year)90% (80%)Not Covered without prior authorization 80% up to $50 per visit 50% up to $25 per visit $30 co-pay 90% (80%) up $25 per visit 50% up $25 per visit Express Scripts Express Scripts Blue Shield $1,600 / $3,200 $5,300 / $10,600 Combined with Medical Generic / Brand / Non-Formulary / Specialty Generic / Brand / Non-Formulary / Specialty Generic / Brand / Specialty Generic / Brand $10 / $20 / $45 / 30% (max co-pay $150)$10 / $20 / $45 / 30% (max co-pay $150)$7 / $25 / Not Covered $7 / $25 $20 / $40 / $90 / 30% (max co-pay $300)$15 / $50 / $112.50 / 30% (max co-pay $150)$14 / $60 / 30% (max co-pay $150)Not Covered $200 / $500 $200 Subject to Deductible THIS SUMMARY IS INTENDED TO COMPARE COVERAGE BENEFITS ONLY. THE ACTUAL PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.NON-PARTICIPATING PROVIDER MEMBER COST MAY NOT APPLY TO MAXIMUM OUT OF POCKET COSTS.
800.537.7790 ✷ WWW.SDRMA.ORG 6 ✷ 2015 HEALTH BENEFITS PROGRAM ✷ MEDICAL BENEFITS SUMMARY PLAN SUMMARY - BLUE SHIELD DEDUCTIBLES/CO-INSURANCE Access+ HMO 15 Access+ HMO 20 Calendar Year Deductible(s) (Individual/Family)None None Maximum Medical Out of Pocket (Individual/Family)$1,500 / $3,000 $1,500 / $3,000 Medicare Medical Maximum Out of Pocket Non-Applicable Non-Applicable Services/Coverages Participating Providers Participating Providers Inpatient Hospital Room, Board & Support Services (prior authorization required)No Charge $250 / Admit Non Emergency Outpatient Services:Ambulatory Surgery Center Hospital Facility Outpatient Treatment No Charge $100 / Surgery $150 / Surgery No Charge Emergency Room Visit Results in Admission as Inpatient No Charge No Charge Visit Does Not Result in Admission $50 co-pay $100 co-pay Preventative Care No Charge No Charge Office Visits Note: A woman may self-refer to an OB/GYN or family practice physician in her personal physician’s medical group or IPA for OB/GYN services.$15 co-pay $20 co-pay Rehabilitation Service (in a office location)$15 co-pay $20 co-pay Durable Medical Equipment 80%80%Hospice No Charge Routine Home Care and Inpatient Respeit Care - No Charge 24 Hour Continuous Home Care and General Inpatient Care - $150 / day Ambulance $50 co-pay $100 co-pay Home Health Care (prior authorization required)$15 co-pay (100 per year)$20 co-pay (100 per year)Chiropractic Services (combined with Acupuncture)$10 co-pay (30 visits per year)$10 co-pay (30 visits per year)Acupuncture (combined with Chiropractic)$10 co-pay (30 visits per year)$10 co-pay (30 visits per year)Prescription Drugs Active/Early Retiree Plans Only Express Scripts Express Scripts Prescription Maximum Out of Pocket $5,100 / $10,200 $5,100 / $10,200 (At Participating Pharmacies only)Generic / Brand / Non-Formulary / Specialty Generic / Brand / Non-Formulary / Specialty Retail - 30 day supply $5 / $10 / $25 / 20% (max co-pay $100)$10 / $25 / Not Covered / 20% (max co-pay $100)Mail Order - 90 day supply $10 / $20 / $50 / 20% (max co-pay $100)$20 / $50 / Not Covered / 20% (max co-pay $100)Brand Deductible (Individual / Family)None None THIS SUMMARY IS INTENDED TO COMPARE COVERAGE BENEFITS ONLY. THE ACTUAL PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
800.537.7790 ✷ WWW.SDRMA.ORG 2015 HEALTH BENEFITS PROGRAM ✷ 7 MEDICAL BENEFIT RATES FOR 2015 - GUARANTEED UNTIL JANUARY 1, 2016 AREA I - Northern CA: Bay Area Alameda, Amador, Contra Costa, Marin, Napa, Nevada, San Francisco, San Joaquin, San Mateo, Santa Clara, Santa Cruz, Solano, Sonoma, Sutter, Yolo, Yuba PLAN Employee Employee + 1 Employee + 2 or More Gold PPO $707.88 $1,414.74 $1,840.08 Platinum PPO $774.18 $1,548.36 $2,013.48 Silver PPO $507.96 $1,017.96 $1,321.92 EPO $850.68 $1,702.38 $2,212.38 HDHP 10%$573.24 $1,147.50 $1,490.22 HDHP 20%$493.68 $986.34 $1,283.16 Access+ HMO 15 $981.24 $1,962.48 $2,552.04 Access+ HMO 20 $911.88 $1,824.78 $2,372.52 AREA II - Northern CA: Other Counties Alpine, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Lake, Lassen, Mariposa, Mendocino, Merced, Modoc, Mono, Monterey, Plumas, San Benito, Shasta, Sierra, Siskiyou, Stanislaus, Tehama, Trinity, Tuolumne PLAN Employee Employee + 1 Employee + 2 or More Gold PPO $671.16 $1,342.32 $1,743.18 Platinum PPO $734.40 $1,468.80 $1,908.42 Silver PPO $481.44 $963.90 $1,251.54 EPO $821.10 $1,644.24 $2,137.92 HDHP 10%$566.10 $1,134.24 $1,473.90 HDHP 20%$468.18 $934.32 $1,214.82 Access+ HMO 15 $960.84 $1,920.66 $2,496.96 Access+ HMO 20 $894.54 $1,788.06 $2,323.56 AREA III - Southern CA: Los Angeles Area Los Angeles, San Bernardino, Ventura PLAN Employee Employee + 1 Employee + 2 or More Gold PPO $627.30 $1,255.62 $1,634.04 Platinum PPO $687.48 $1,374.96 $1,788.06 Silver PPO $451.86 $902.70 $1,174.02 EPO $734.40 $1,468.80 $1,909.44 HDHP 10%$531.42 $1,061.82 $1,380.06 HDHP 20%$437.58 $874.14 $1,136.28 Access+ HMO 15 $694.62 $1,392.30 $1,810.50 Access+ HMO 20 $646.68 $1,295.40 $1,683.00 Rates shown are for active and retired employees, and public officials. COBRA rates are charged at 102% of the active rates as s hown above.AREA IV - Southern CA: Other Counties Fresno, Imperial, Inyo, Kern, Kings, Madera, Riverside, Or -ange, San Diego, San Luis Obispo, Santa Barbara, Tulare PLAN Employee Employee + 1 Employee + 2 or More Gold PPO $641.58 $1,283.16 $1,668.72 Platinum PPO $705.84 $1,410.66 $1,834.98 Silver PPO $461.04 $922.08 $1,198.50 EPO $750.72 $1,500.42 $1,951.26 HDHP 10%$542.64 $1,084.26 $1,408.62 HDHP 20%$447.78 $894.54 $1,162.80 Access+ HMO 15 $795.60 $1,593.24 $2,069.58 Access+ HMO 20 $739.50 $1,480.02 $1,924.74
800.537.7790 ✷ WWW.SDRMA.ORG 800.537.7790 ✷ WWW.SDRMA.ORG 8 ✷ 2015 HEALTH BENEFITS PROGRAM MEDICAL BENEFIT RATES FOR 2015 - GUARANTEED UNTIL JANUARY 1, 2016 AREA V - Out of State PLAN Employee Employee + 1 Employee + 2 or More Gold PPO $735.42 $1,469.82 $1,911.48 Platinum PPO $803.76 $1,608.54 $2,091.00 Silver PPO $528.36 $1,056.72 $1,373.94 EPO $860.88 $1,718.70 $2,235.84 HDHP 10%$623.22 $1,245.42 $1,618.74 HDHP 20%$512.04 $1,024.08 $1,331.10 AREA VI - Northern CA: Sacramento El Dorado, Placer, Sacramento PLAN Employee Employee + 1 Employee + 2 or More Gold PPO $688.50 $1,377.00 $1,790.10 Platinum PPO $753.78 $1,505.52 $1,958.40 Silver PPO $497.76 $994.50 $1,293.36 EPO $804.78 $1,610.58 $2,092.02 HDHP 10%$585.48 $1,170.96 $1,521.84 HDHP 20%$482.46 $963.90 $1,253.58 Access+ HMO 15 $883.32 $1,767.66 $2,298.06 Access+ HMO 20 $821.10 $1,643.22 $2,136.90 MEDICARE COORDINATION OF BENEFITS (COB)Medicare Supplemental Plans COB Rates Gold PPO Platinum PPO Silver PPO EPO Single (Retiree with Medicare)$441.66 $490.62 $345.78 $530.40 Two Party (Retiree + Dependent both with Medicare)$883.32 $981.24 $691.56 $1,060.80 * Family (All Medicare - reflects rate for 3 enrolled)$1,324.98 $1,471.86 $1,037.34 $1,591.20 Two Party (1 Medicare, 1 Without)$1,149.54 $1,264.80 $853.74 $1,381.08 Family (1 Medicare, 2 or more Without) $1,856.40 $2,038.98 $1,363.74 $2,232.78 Family (2 Medicare, 1 or more Without)$1,591.20 $1,755.42 $1,199.52 $1,911.48 * This rate increases for every family member enrolled in Medicare by the single Medicare rate.EGWP Prescription Program Structure Retail 31 Day Retail 60 Day Retail 90 Day Mail 90 Day Generic $5.00 $10.00 $15.00 $10.00 Brand $20.00 $40.00 $60.00 $40.00 Non Preferred $50.00 $100.00 $150.00 $100.00 Medicare Supplemental Plans are designed specifically for members enrolled in the SDRMA health benefits program who are also enrolled in Parts A (hospital insurance), B (medical insurance) and D (prescription enrollment completed by Express Scripts) of Medicare. This plan is designed to help defray some of the costs for those members enrolled in Medicare, such as Medicare deductibles, co-pays and other additional costs. The rates shown in the table provide a number of cost options depending on the coverage needs of an employee and their dependent(s). Each option includes additional rates for those members who need rates appropriate for a variety of combinations where one or two members of a household have Medicare and others do not. To enroll in Medicare you must be at least age 65 or older - these rates are the same for out of state 65 or older members as well. SDRMA Medical Benefits Program coverages remain the same whether Medicare Supplemental Coverages are Primary or Secondary. Rates shown are for active and retired employees, and public officials. COBRA rates are charged at 102% of the active rates as s hown above.
800.537.7790 ✷ WWW.SDRMA.ORG ANCILLARY COVERAGES SUMMARY
800.537.7790 ✷ WWW.SDRMA.ORG 10 ✷ 2015 HEALTH BENEFITS PROGRAM ✷ ANCILLARY COVERAGES SUMMARY DELTA DENTAL PPO - RATES GUARANTEED UNTIL JANUARY 1, 2016 ANCILLARY COVERAGES SUMMARY DENTAL BENEFITS Low Plan Medium Plan High Plan PPO Non-PPO PPO Non-PPO PPO Non-PPO Calendar Year Maximum $1,000 $750 $1,500 $1,250 $2,000 $1,500 (Per patient per calendar year)(Per patient per calendar year)(Per patient per calendar year)Calendar Year Deductible Individual / Family $50 / $150 (Waived for Preventive)$50 / $150 (Waived for Preventive)$50 / $150 (Waived for Preventive)Age Limitations Dependents to Age 26 Dependents to Age 26 Dependents to Age 26 Diagnostic and Preventive 100%100%100%100%100%100%Oral Exam Routine Cleaning X-Rays Fluoride Treatment Space Maintainers Specialist Consultations Basic Services 80%80%80%80%80%80%Fillings Endodontics (Root Canal)Periodontics (Gum Treatment)Tissue Removal (Biopsy)Extractions & Other Oral Surgery Sealants Major Services 50%50%60%60%80%80%Crown Repair Inlays, Onlays Cast Restorations Bridges Partial and Full Dentures Orthodontics 50%50%50%50%Eligible for Benefit Not Covered Child & Adult Child & Adult Lifetime Maximum $500 $1,000 (Employer Contributes 51-100% of dependent cost):(Employer Contributes 51-100% of dependent cost):Rates Employee Only $31.21 $42.84 $55.18 Employee + 1 Dependent $53.65 $72.73 $92.72 Employee + 2 or More Dependents $86.70 $114.24 $141.07 (Employer Contributes 0-50% of dependent cost):(Employer Contributes 0-50% of dependent cost):Rates Employee Only $31.21 $42.84 $55.18 Employee + 1 Dependent $57.12 $77.21 $98.43 Employee + 2 or More Dependents $94.96 $124.95 $154.43 THIS SUMMARY IS INTENDED TO COMPARE COVERAGE BENEFITS ONLY. THE ACTUAL PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
800.537.7790 ✷ WWW.SDRMA.ORG 2015 HEALTH BENEFITS PROGRAM ✷ ANCILLARY COVERAGES SUMMARY ✷ 11 DELTA DENTAL PPO - RATES GUARANTEED UNTIL JANUARY 1, 2016 DENTAL BENEFITS Low Plan Medium Plan High Plan PPO Non-PPO PPO Non-PPO PPO Non-PPO Calendar Year Maximum $1,000 $750 $1,500 $1,250 $2,000 $1,500 (Per patient per calendar year)(Per patient per calendar year)(Per patient per calendar year)Calendar Year Deductible Individual / Family $50 / $150 (Waived for Preventive)$50 / $150 (Waived for Preventive)$50 / $150 (Waived for Preventive)Age Limitations Dependents to Age 26 Dependents to Age 26 Dependents to Age 26 Diagnostic and Preventive 100%100%100%100%100%100%Oral Exam Routine Cleaning X-Rays Fluoride Treatment Space Maintainers Specialist Consultations Basic Services 80%80%80%80%80%80%Fillings Endodontics (Root Canal)Periodontics (Gum Treatment)Tissue Removal (Biopsy)Extractions & Other Oral Surgery Sealants Major Services 50%50%60%60%80%80%Crown Repair Inlays, Onlays Cast Restorations Bridges Partial and Full Dentures Orthodontics 50%50%50%50%Eligible for Benefit Not Covered Child & Adult Child & Adult Lifetime Maximum $500 $1,000 (Employer Contributes 51-100% of dependent cost):(Employer Contributes 51-100% of dependent cost):Rates Employee Only $31.21 $42.84 $55.18 Employee + 1 Dependent $53.65 $72.73 $92.72 Employee + 2 or More Dependents $86.70 $114.24 $141.07 (Employer Contributes 0-50% of dependent cost):(Employer Contributes 0-50% of dependent cost):Rates Employee Only $31.21 $42.84 $55.18 Employee + 1 Dependent $57.12 $77.21 $98.43 Employee + 2 or More Dependents $94.96 $124.95 $154.43 THIS SUMMARY IS INTENDED TO COMPARE COVERAGE BENEFITS ONLY. THE ACTUAL PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
800.537.7790 ✷ WWW.SDRMA.ORG 12 ✷ 2015 HEALTH BENEFITS PROGRAM ✷ ANCILLARY COVERAGES SUMMARY VSP VISION - RATES GUARANTEED UNTIL JANUARY 1, 2017 Vision Benefits Option 1 - Plan A Option 2 - Plan B Option 3 - Plan B Option 4 - Plan C Option 5 - Plan C In-Network Non-Network In-Network Non-Network In-Network Non-Network In-Network Non-Network In-Network Non-Network Copay $25 for Exam and/or Materials $25 for Exam and/or Materials $15 for Exam and/or Materials $25 for Exam and/or Materials $0 for Exam and/or Materials Exam Covered after Copay Plan pays up to: Covered after Copay Plan pays up to:Covered after Copay Plan pays up to:Covered after Copay Plan pays up to:Covered after Copay Plan pays up to:$50 $50 $50 $50 $50 Lenses Single Covered after Copay $50 Covered after Copay $50 Covered after Copay $50 Covered after Copay $50 $0 $50 Bifocal Covered after Copay $75 Covered after Copay $75 Covered after Copay $75 Covered after Copay $75 $0 $75 Trifocal Covered after Copay $100 Covered after Copay $100 Covered after Copay $100 Covered after Copay $100 $0 $100 Frames $130 Allowance 20% off amount over allowance $70 $130 Allowance 20% off amount over allowance $70 $130 Allowance 20% off amount over allowance $70 $130 Allowance 20% off amount over allowance $70 $130 Allowance 20% off amount over allowance $70 Contact Lenses - Elective $130 Allowance $105 $130 Allowance $105 $130 Allowance $105 $130 Allowance $105 $130 Allowance $105 Contact Lenses -Medically Necessary Covered after Copay $210 Covered after Copay $210 Covered after Copay $210 Covered after Copay $210 No Copay $210 Contact Lenses - Fitting Fee (exam)Not to exceed $60 Not to exceed $60 Not to exceed $60 Not to exceed $60 Not to exceed $60 Frequency of Services Eye Examination 12 months 12 months 12 months 12 months 12 months Lenses 24 months 12 months 12 months 12 months 12 months Frames 24 months 24 months 24 months 12 months 12 months Contact Lenses¹24 months 12 months 12 months 12 months 12 months Rates Employee Only $6.53 $7.55 $7.96 $10.81 $17.24 Employee + 1 Dependent $12.65 $14.69 $15.30 $21.22 $33.86 Employee + 2 or More Dependents $19.99 $23.26 $24.38 $33.76 $54.26 * Entities must contribute a minimum of 100% of the cost for active employees only and must have at least 75% of eligible emp loyees enrolled to participate.¹ Contact lenses are in lieu of spectacle lenses and frames THIS SUMMARY IS INTENDED TO COMPARE COVERAGE BENEFITS ONLY. THE ACTUAL PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
800.537.7790 ✷ WWW.SDRMA.ORG 2015 HEALTH BENEFITS PROGRAM ✷ ANCILLARY COVERAGES SUMMARY ✷ 13 VSP VISION - RATES GUARANTEED UNTIL JANUARY 1, 2017 Vision Benefits Option 1 - Plan A Option 2 - Plan B Option 3 - Plan B Option 4 - Plan C Option 5 - Plan C In-Network Non-Network In-Network Non-Network In-Network Non-Network In-Network Non-Network In-Network Non-Network Copay $25 for Exam and/or Materials $25 for Exam and/or Materials $15 for Exam and/or Materials $25 for Exam and/or Materials $0 for Exam and/or Materials Exam Covered after Copay Plan pays up to: Covered after Copay Plan pays up to:Covered after Copay Plan pays up to:Covered after Copay Plan pays up to:Covered after Copay Plan pays up to:$50 $50 $50 $50 $50 Lenses Single Covered after Copay $50 Covered after Copay $50 Covered after Copay $50 Covered after Copay $50 $0 $50 Bifocal Covered after Copay $75 Covered after Copay $75 Covered after Copay $75 Covered after Copay $75 $0 $75 Trifocal Covered after Copay $100 Covered after Copay $100 Covered after Copay $100 Covered after Copay $100 $0 $100 Frames $130 Allowance 20% off amount over allowance $70 $130 Allowance 20% off amount over allowance $70 $130 Allowance 20% off amount over allowance $70 $130 Allowance 20% off amount over allowance $70 $130 Allowance 20% off amount over allowance $70 Contact Lenses - Elective $130 Allowance $105 $130 Allowance $105 $130 Allowance $105 $130 Allowance $105 $130 Allowance $105 Contact Lenses -Medically Necessary Covered after Copay $210 Covered after Copay $210 Covered after Copay $210 Covered after Copay $210 No Copay $210 Contact Lenses - Fitting Fee (exam)Not to exceed $60 Not to exceed $60 Not to exceed $60 Not to exceed $60 Not to exceed $60 Frequency of Services Eye Examination 12 months 12 months 12 months 12 months 12 months Lenses 24 months 12 months 12 months 12 months 12 months Frames 24 months 24 months 24 months 12 months 12 months Contact Lenses¹24 months 12 months 12 months 12 months 12 months Rates Employee Only $6.53 $7.55 $7.96 $10.81 $17.24 Employee + 1 Dependent $12.65 $14.69 $15.30 $21.22 $33.86 Employee + 2 or More Dependents $19.99 $23.26 $24.38 $33.76 $54.26 THIS SUMMARY IS INTENDED TO COMPARE COVERAGE BENEFITS ONLY. THE ACTUAL PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
800.537.7790 ✷ WWW.SDRMA.ORG 14 ✷ 2015 HEALTH BENEFITS PROGRAM ✷ ANCILLARY COVERAGES SUMMARY VOYA FINANCIAL BASIC LIFE AND AD&D - RATES GUARANTEED UNTIL JULY 1, 2017 For Groups with 10 (+) lives For Groups with less than 10 lives Basic Life and AD&D Benefits Basic Life and AD&D Benefits Eligibility: All Eligible Employees working at least 20 hrs/wk Eligibility: All Eligible Employees working at least 20 hrs/wk Life Benefits: Groups must elect a flat amount of: $10,000-$100,000 in $10,000 increments Basic life benefits have to be defined by class of employee;i.e. City manager, confidential employees, etc.or All employees as one class or 1x Annual Salary or 2x Annual Salary Life Benefits: Groups must elect a flat amount of: $10,000-$100,000 in $10,000 increments Basic life benefits have to be defined by class of employee;i.e. City manager, confidential employees, etc.or All employees as one class or 1x Annual Salary or 2x Annual Salary AD&D Benefits:Same as Life AD&D Benefits:Same as Life Guaranteed Issue Amount $100,000 Guaranteed Issue Amount $100,000 Benefit Reduction Formula Age % of Original Benefit Benefit Reduction Formula Age % of Original Benefit 65 65%65 65%70 50%70 50%Accelerated Death Benefit 50% of Life Benefits if less than 6 Month Life Expectancy Accelerated Death Benefit 50% of Life Benefits if less than 6 Month Life Expectancy Waiver of Premium Included Waiver of Premium Included Seat Belt Benefit (AD&D)Included Seat Belt Benefit (AD&D)Included Rate per $1,000 $0.276 Basic Life Rate per $1,000: Under Age 30 $0.206 Basic Life Rate per $1,000: Age 30-39 $0.268 Basic Life Rate per $1,000: Age 40-49 $0.374 Basic Life Rate per $1,000: Over Age 49 $0.516 * Entities must contribute a minimum of 100% of the cost for active employees only.THIS SUMMARY IS INTENDED TO COMPARE COVERAGE BENEFITS ONLY. THE ACTUAL PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.Sample for 10+ lives $100,000 of life insurance:$29.00 ($100,000 ÷ $1,000 x $0.29)
800.537.7790 ✷ WWW.SDRMA.ORG 2015 HEALTH BENEFITS PROGRAM ✷ ANCILLARY COVERAGES SUMMARY ✷ 15 VOYA FINANCIAL SUPPLEMENTAL LIFE - RATES GUARANTEED UNTIL JULY 1, 2017 Supplemental Life Benefits*Eligibility All Eligible Employees working at least 20 hrs/wk Employee Benefit Minimum $20,000 Maximum $250,000 Increments of:$10,000 Guaranteed Issue Amount Under Age 60: $100,000 Age 60 and Over: $50,000 Spouse Benefit Not to Exceed 50% of Employee’s Supplemental Life Benefit Minimum $20,000 Maximum $125,000 Increments of:$5,000 Guaranteed Issue Amount $25,000 Dependent Child(ren) Benefit Minimum $5,000 Maximum $10,000 Increments of:$5,000 Guaranteed Issue Amount $10,000 Benefit Duration Age % of Original Benefit 65 65%70 50%Waiver of Premium Included Portability Included Rates Rates per $1,000 Employee Rate (AD&D)Spouse Rate (1) (2) (No AD&D)Under Age 25 $0.116 $0.071 Age 25-29 $0.116 $0.071 Age 30-34 $0.147 $0.102 Age 35-39 $0.167 $0.122 Age 40-44 $0.218 $0.173 Age 45-49 $0.300 $0.255 Age 50-54 $0.483 $0.439 Age 55-59 $0.779 $0.734 Age 60-64 $1.167 $1.122 Age 65-69 $2.187 $2.142 Over Age 70 $3.513 $3.468 Dependent Child Rate per $1,000 $0.204 $0.204 (1) The age of the employee is used when calculating the premium for Supplemental Life for the spouse.(2) The spouse or dependents can only enroll in Supplemental Life if the employee is enrolled in Supplemental Life.* Supplemental Life is only available if the Entity is enrolled in ING Basic Life and AD&D.THIS SUMMARY IS INTENDED TO COMPARE COVERAGE BENEFITS ONLY. THE ACTUAL PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
800.537.7790 ✷ WWW.SDRMA.ORG 16 ✷ 2015 HEALTH BENEFITS PROGRAM ✷ ANCILLARY COVERAGES SUMMARY VOYA FINANCIAL LONG TERM DISABILITY - RATES GUARANTEED UNTIL JULY 1, 2017 For Groups with 10 (+) lives For Groups with less than 10 lives Long Term Disability Benefits Option 1 Option 2 Long Term Disability Benefits Option 1 Option 2 Eligibility: All Eligible Employees working at least 20 hrs/wk All Eligible Employees working at least 20 hrs/wk Eligibility: All Eligible Employees working at least 20 hrs/wk All Eligible Employees working at least 20 hrs/wk Elimination Period 90 Days (1)180 Days (2)Elimination Period 90 Days (1)180 Days (2)Monthly Benefit Percentage 60%60%Monthly Benefit Percentage 60%60%Maximum Monthly Benefit $5,000 $5,000 Maximum Monthly Benefit $5,000 $5,000 Own Occupation Definition 24 Months 24 Months Own Occupation Definition 24 Months 24 Months Disability Earnings Test 80%80%Disability Earnings Test 80%80%Definition of Disability Earnings & Occupation Earnings & Occupation Definition of Disability Earnings & Occupation Earnings & Occupation Recurrent Disabilities 6 Months 6 Months Recurrent Disabilities 6 Months 6 Months Mental Health/Substance Abuse Limitations 24 Months 24 Months Mental Health/Substance Abuse Limitations 24 Months 24 Months Maximum Benefit Duration To Age 65 or SSNRA To Age 65 or SSNRA Maximum Benefit Duration To Age 65 or SSNRA To Age 65 or SSNRA Pre-Existing Condition 3/12 3/12 Pre-Existing Condition 3/12 3/12 Annual Salary Option 1 – 90 days Option 2 – 180 days Annual Salary Option 1 – 90 days Option 2 – 180 days Rate per $100 $0.497 $0.373 Rate per $100: Under age 25 $0.134 $0.105 Rate per $100: Age 25-29 $0.182 $0.134 Rate per $100: Age 30-34 $0.230 $0.172 Rate per $100: Age 35-39 $0.297 $0.219 Rate per $100: Age 40-44 $0.383 $0.287 Rate per $100: Age 45-49 $0.497 $0.373 Rate per $100: Age 50-54 $0.650 $0.488 Rate per $100: Age 55-59 $0.851 $0.641 Rate per $100: Over age 60 $1.109 $0.831 THIS SUMMARY IS INTENDED TO COMPARE COVERAGE BENEFITS ONLY. THE ACTUAL PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.Sample for Annual Salary of $50,000, 10+ lives, option 1:$20.83 ($50,000 ÷ $100 ÷ 12 x $0.50)(1) Benefit begins after 90 days (2) Benefit begins after 180 days Definitions:Elimination period – Benefits begin the day after the elimination period ends.Own occupation – Employee’s disability will be evaluated on their ability to perform their own occupations to a certain degree.Recurrent disabilities – Refers to the instance where an employee recovers temporarily from a disability and returns to work, but then the disability resurfaces. If the disability resurfaces within a set time frame, the elimination period does not have to be satisfied again.
800.537.7790 ✷ WWW.SDRMA.ORG 2015 HEALTH BENEFITS PROGRAM ✷ ANCILLARY COVERAGES SUMMARY ✷ 17 VOYA FINANCIAL LONG TERM DISABILITY - RATES GUARANTEED UNTIL JULY 1, 2017 For Groups with 10 (+) lives For Groups with less than 10 lives Long Term Disability Benefits Option 1 Option 2 Long Term Disability Benefits Option 1 Option 2 Eligibility: All Eligible Employees working at least 20 hrs/wk All Eligible Employees working at least 20 hrs/wk Eligibility: All Eligible Employees working at least 20 hrs/wk All Eligible Employees working at least 20 hrs/wk Elimination Period 90 Days (1)180 Days (2)Elimination Period 90 Days (1)180 Days (2)Monthly Benefit Percentage 60%60%Monthly Benefit Percentage 60%60%Maximum Monthly Benefit $5,000 $5,000 Maximum Monthly Benefit $5,000 $5,000 Own Occupation Definition 24 Months 24 Months Own Occupation Definition 24 Months 24 Months Disability Earnings Test 80%80%Disability Earnings Test 80%80%Definition of Disability Earnings & Occupation Earnings & Occupation Definition of Disability Earnings & Occupation Earnings & Occupation Recurrent Disabilities 6 Months 6 Months Recurrent Disabilities 6 Months 6 Months Mental Health/Substance Abuse Limitations 24 Months 24 Months Mental Health/Substance Abuse Limitations 24 Months 24 Months Maximum Benefit Duration To Age 65 or SSNRA To Age 65 or SSNRA Maximum Benefit Duration To Age 65 or SSNRA To Age 65 or SSNRA Pre-Existing Condition 3/12 3/12 Pre-Existing Condition 3/12 3/12 Annual Salary Option 1 – 90 days Option 2 – 180 days Annual Salary Option 1 – 90 days Option 2 – 180 days Rate per $100 $0.497 $0.373 Rate per $100: Under age 25 $0.134 $0.105 Rate per $100: Age 25-29 $0.182 $0.134 Rate per $100: Age 30-34 $0.230 $0.172 Rate per $100: Age 35-39 $0.297 $0.219 Rate per $100: Age 40-44 $0.383 $0.287 Rate per $100: Age 45-49 $0.497 $0.373 Rate per $100: Age 50-54 $0.650 $0.488 Rate per $100: Age 55-59 $0.851 $0.641 Rate per $100: Over age 60 $1.109 $0.831 (1) Benefit begins after 90 days (2) Benefit begins after 180 days THIS SUMMARY IS INTENDED TO COMPARE COVERAGE BENEFITS ONLY. THE ACTUAL PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
800.537.7790 ✷ WWW.SDRMA.ORG 18 ✷ 2015 HEALTH BENEFITS PROGRAM ✷ ANCILLARY COVERAGES SUMMARY MHN EMPLOYEE ASSISTANCE PROGRAM - RATES GUARANTEED UNTIL JULY 1, 2015 Employee Assistance Program Number of Sessions 3 Sessions per incident per member Frequency No limit in frequency of telephone/web-video Counseling/Consultation Sessions Employee Services Telephonic Counseling & Referral for Counselling Sessions Work Life Life Management Services Legal Legal Referral Service – Up to 30 minutes/session & 25% rate reduction off hourly fee Dependent Care Child & Elder Care Referral Service Financial Financial Consultations to include Pre-retirement and tax consultations Education Referrals Education and Schooling Referrals Concierge Daily Living Services Employer Services Brown Bag Seminars 10 hours/year/member group CISD – Critical Incident Stress Debriefing 20 hours per incident/member group Management Consultations Unlimited Management Training Unlimited On-site Orientation No Limits Reports Annual Utilization reports Newsletter and Collateral Materials Yes, No Charge Internet Service members.mhn.com EAP Rate – Per Employee Per Month $2.97 THIS SUMMARY IS INTENDED TO COMPARE COVERAGE BENEFITS ONLY. THE ACTUAL PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
800.537.7790 ✷ WWW.SDRMA.ORG HEALTH BENEFITS PROGRAM ELIGIBILITY REQUIREMENTS 2015 HEALTH BENEFITS PROGRAM ✷ 19 1. Entity must be a public agency formed under California law.2. Entity must have a minimum of two full-time active employees to join. An active full-time employee is an employee who is eligible for enrollment in employee sponsored benefits paid for by the Entity. Part-time employees may be considered active employees only if they are currently part of the benefit eligible population and work a minimum of twenty hours weekly. 3. Active Employees: Medical Benefits - Entity must contribute a minimum of 75% of the cost for active employees. Ancillary Coverages - Entity must contribute a minimum of 100% of the cost for active employees.4. Dependents: Medical Benefits - If the Entity offers coverage to dependents, it is recommended the Entity contribute a minimum of 50% of the cost for dependents. Ancillary Coverages - If the Entity offers coverage to dependents, it is recommended the Entity contribute a minimum of 50% of the cost for dependents. 5. Retirees: Medical Benefits - Entity may offer coverage to retirees only if they are currently being covered by the Entity. Ancillary Coverages - Retirees only eligible for Dental and Vision.6. Public Officials: Entity may offer coverage to public officials (board members, etc) only if they are currently being covered and Entity’s enabling act, plans and policies allow it. Entity is required to cover 100% of the cost for public officials when covering their medical benefits/ancillary coverages. Participation for public officials is limited to their term of office. 7. Entity must have at least 75% of eligible employees (and public officials if they are offered coverage by the Entity) enrolled in order to participate. Public Officials, retirees and dependents may not be covered unless active employees are covered. 8. Premiums are based on a full month and will begin the first day of the month following notification of enrollment. There are no partial months or prorated premiums. Each Entity can establish the waiting period for medical benefits/ancillary coverages to become effective.9. The maximum dependent child age is 26. Disabled dependent children are not subject to the dependent age restrictions; however, a verification form will be required certifying the disability. 10. Each prospective new Entity must complete and submit the SDRMA Interest Forms including a large claimant disclosure form (Medical Benefits only) detailing any knowledge of and information pertaining to large and/or ongoing claims. Each Entity is subject to underwriting review and may or may not be accepted for coverage. The underwriting process may take up to two weeks for completion. 11. Entity’s governing body must approve a resolution authorizing participation in SDRMA’s health benefits program and execute the Memorandum of Understanding (MOU).12. Once an Entity is approved by the underwriter and has submitted all required documentation to join the program including the MOU and resolution, the participants should receive their medical identification cards within three weeks.13. Medical Benefits - Not all Plans will be offered and available to Entities joining the medical benefits program. The Access+ HMO 15 and 20 Plans are not available in all areas. Please check with SDRMA at the time you are submitting your request for underwriting approval to see if the HMO plans are available in your area. Entities selecting one of the medical benefits program HDHP High Deductible Plans (HSA Compatible) are responsible for adhering to IRS rules and regulations and maintenance of the HSA account. SDRMA does not provide this service but can provide contact information for a financial institution that is currently offers this type of service. 14. Ancillary Coverages - Entity will choose the particular dental and/or vision plan option to offer its employees.The employees are only allowed to enroll in that particular plan.
Special District Risk Management Authority 800.537.7790 ✷ WWW.SDRMA.ORG 1112 Street, Suite 300 Sacramento, CA 95814-2865 T 916.231.4141 T 800.537.7790 F 916.231.4111