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Blaine School District #503YOUR BENEFIT REFERENCE GUIDE FOR THE
2013-2014 SCHOOL YEAR
Benefi ts Fair Open EnrollmentTuesday, August 27 August 12th
8:00 - 11:00 am throughMiddle School Cafeteria September 16th, 2013
Please Note: All plan changes have been outlined in bold.
Applica ons are to be turned into the Payroll Offi ce by no later than 4:00 pm on September 16th.
Open Enrollment
August 12th-September 16th, 2013 for an eff ec ve date of November 1, 2013 for all lines of coverage except Group Health.
Group Health’s eff ec ve date: October 1, 2013.
WEA Select Plans can be previewed beginning Aug 22 at h p://resources.hewi .com/wea.
• If you are currently enrolled in any WEA Select Plan and do not wish to make any changes, you will automa cally stay in your current plan.
• If you are a new hire or wish to make changes, you will need to enroll using the online system or by calling the WEA Select Benefi ts Center at 1-855-668-5039.
The informa on herein is not a contract. It is a summary of the benefi ts available. It is not intended to be an all-inclusive descrip on of Plan benefi ts, limita ons or exclusions, and should not be used in lieu of a Plan book. Be sure to consult your Plan booklet, or consult with the insurance company representa ve before making your selec on. If there are any discrepancies between this summary and the offi cial Plan documents and booklets, the offi cial Plan documents and booklets prevail. Ques ons may be directed to Chris ne Anderson at (360) 332-0712 , Lori Leech at (360) 332-5881 x1710 or The Partners Group at 877-455-5640. This summary was printed on August 7, 2013. Any informa on not provided by that me or revisions by bargaining units or by insurers a er this date could change or modify the informa on contained herein.
Table of ContentsHow To Select a Medical Plan ..................................................................................................................................... 4
Major Insurance Plan Changes for 2013-2014 ............................................................................................................ 5
Basic Medical Benefi ts Comparison ......................................................................................................................... 6-7
Health Insurance Rates ............................................................................................................................................... 8
Medical Plan Op ons ............................................................................................................................................. 9-16
Group Health Coopera ve Tradi onal 250 Plan ..................................................................................................... 9
Group Health Coopera ve Welcome 500 Plan ..................................................................................................... 10
Regence Blue Shield WEIC Engage 80 Plan ........................................................................................................... 11
Regence Blue Shield WEIC High Op on Plan ........................................................................................................ 12
Regence Blue Shield WEIC Innova 500 Plan .......................................................................................................... 13
Regence Blue Shield WEIC Engage 70 Plan ........................................................................................................... 14
Regence Blue Shield WEIC HSA 2.0 Plan ............................................................................................................... 15
HDHP-HSA Plan Ques ons and Answers .............................................................................................................. 16-17
Mandatory Benefi ts ............................................................................................................................................. 18-20
Dental – Washington Dental Service ..................................................................................................................... 18
Vision – Northwest Benefi ts Network ................................................................................................................... 19
State Mandated Re ree Benefi t............................................................................................................................ 19
Long Term Disability – CIGNA ................................................................................................................................ 19
Life Insurance – CIGNA .......................................................................................................................................... 20
Employee Assistance Program .............................................................................................................................. 20
Workers Compensa on ......................................................................................................................................... 20
Voluntary Benefi ts ............................................................................................................................................... 21-22
Salary Insurance – American Fidelity .................................................................................................................... 21
AFLAC Supplemental Insurance ............................................................................................................................ 21
Flexible Spending Account .................................................................................................................................... 22
FMLA ..................................................................................................................................................................... 22
Re rement System.................................................................................................................................................... 23
Con nua on of Coverage ......................................................................................................................................... 23
Basic Health Plan ...................................................................................................................................................... 23
Healthy Kids Now! .................................................................................................................................................... 23
Privacy Act ................................................................................................................................................................ 24
Benefi t Advisory Commi ee & Insurance Support ................................................................................................... 24
Glossary of Terms ..................................................................................................................................................... 25
Whatcom County Benefi t Fair Informa on ..................................................................................................Back Cover
4
HOW TO SELECT A MEDICAL PLANYou have a choice of 7 diff erent plans which off er a variety of plan designs. An explana on of each plan design and the plan names follow:HEALTH MAINTENANCE ORGANIZATION (HMO) type plans provide you with the best benefi ts and the lowest cost at the me of service. However, these plans require that you select a primary care provider (PCP) from their list of providers. Your PCP will then either provide or coordinate all of your care (except in the case of a medical emergency).
HMO Plan: Group Health Coopera ve Tradi onal 250 Plan Group Health Coopera ve Welcome 500 Plan
PREFERRED PROVIDER ORGANIZATION type plans contract with a large number of providers. If you choose to receive your care through a preferred provider the insurance company will pay a percentage of the charges. If you choose to go to a non-preferred provider, then the insurance company will pay a lower percentage of the charges. Services are subject to a copay or deduc ble before the percentage is paid.
Preferred Provider Plan Choices: Regence Blue Shield Whatcom Educa onal Insurance Consor um Engage 80 Plan Regence Blue Shield Whatcom Educa onal Insurance Consor um High Op on Plan Regence Blue Shield Whatcom Educa onal Insurance Consor um Innova 500 Plan Regence Blue Shield Whatcom Educa onal Insurance Consor um Engage 70 Plan Regence Blue Shield K-12 HSA 2.0 Plan
NOTE: The Regence Blue Shield Modifi ed Copay, Engage 80, Engage 70 and HSA plans cover on-the-job injuries for self-employed individuals and their spouses to a $250,000 life me maximum. The Regence WEIC High Op on and Innova 500 plans cover on-the-job injuries for self-employed individuals to a $250,000 life me maximum (employee only). Group Health does not cover on-the-job injuries. Please note that Regence does not cover the cost of care for the pregnancy of a dependent child. Group Health does cover this cost.
All enrollment forms have to be submi ed by 4:00 pm September 16, 2013.
DROPPING COVERAGE: You may only drop coverage for yourself and/or dependents a er open enrollment if there is a qualifying event as defi ned under Sec on 125. Please contact Human Resources/Payroll for addi onal informa on.
SPECIAL ENROLLMENT RIGHTS DESCRIPTION If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in the school district plans, provided that you request enrollment within 30-60 days (depending upon carrier) a er your other coverage ends.
Request for enrollment of a new child by birth, adop on or placement for adop on must be made within 60 days of the date of birth, adop on or placement for adop on. Request for enrollment of all other newly eligible dependents must be made within 30-60 days (depending upon carrier) of the dependent’s a aining eligibility.
Unless the above applies, understand that you may not be able to obtain coverage under the group insurance plan un l the next open enrollment period. Obtaining coverage in the future will be subject to administra ve rules and laws in force at that me. See your HR Department for specifi c melines.
5
MAJOR INSURANCE PLAN CHANGES FOR 2013-2014
State Alloca on for Benefi ts:
State alloca on for employee benefi ts will remain at $768.00. The Re ree Medical Carve out amount will decrease from $65.17 to $64.40.
GROUP HEALTH HMO
Benefi t changes include:
No changes to plan benefi ts.
Rates have increased by 1.24%.
REGENCE BLUE SHIELD
WEIC Modifi ed Copay Plan: Plan has been removed from our off erings.
All other plans: Rates increased by 9.25%.
WASHINGTON DENTAL SERVICE (WDS)
Due to the plan year changing to November 1, Washington Dental Service (WDS) will be extending the benefi t year by one month. All enrollees will receive a set dollar amount of approximately 1/12th of the $2,000 annual benefi t maximum for the month of October. This “extra” benefi t of $170 will be available in addi on to any remaining balance of your 2012-13 benefi t maximum. The full 2013-14 annual benefi t year maximum will be available eff ec ve November 1.
No changes in plan benefi ts.
No rate change.
NORTHWEST BENEFIT NETWORK
No changes in plan benefi ts.
No rate change.
CIGNA
No changes in plan benefi ts.
5% rate decrease.
AMERICAN FIDELITY – Voluntary Disability Plans
No changes to plan benefi ts.
No rate changes.
6
BASI
C M
EDIC
AL B
ENEF
ITS
COM
PARI
SON
201
3-20
14 (
PIF:
Pai
d in
Ful
l)
SERV
ICE
GRO
UP
HEAL
TH C
O-O
PTR
ADIT
ION
AL 2
50M
anag
ed C
are
GRO
UP
HEAL
TH C
O-O
PW
ELCO
ME
500
Man
aged
Car
e
REGE
NCE
/ W
EIC
ENGA
GE 8
0 PL
ANRE
GEN
CEW
EIC
HIGH
OPT
ION
Dedu
c b
le$2
50/p
erso
n$7
50/f
amily
$500
/per
son
$150
0/fa
mily
$200
/per
son
$600
/fam
ily$2
00/p
erso
n$6
00/f
amily
Coin
sura
nce
max
i-m
um$2
000/
pers
on$6
000/
fam
ily$2
000/
pers
on$6
000/
fam
ily$1
000/
pers
on$2
000/
fam
ily$1
000/
pers
on$3
000/
fam
ily
Phys
icia
nsPr
imar
y Ca
re P
hysic
ian
(PCP
) ref
erra
l ne
eded
for a
spec
ialis
t, ex
cept
at G
HC
Spec
ialty
Cen
ters
in S
ea le
and
Bel
-le
vue.
Wom
en m
ay a
lso se
lf re
fer t
o a
wom
en’s
heal
th c
are
prov
ider
.
Prim
ary
Care
Phy
sicia
n (P
CP) r
efer
ral
need
ed fo
r a sp
ecia
list,
exce
pt a
t GHC
Sp
ecia
lty C
ente
rs in
Sea
le a
nd B
el-
levu
e. W
omen
may
also
self
refe
r to
a w
omen
’s he
alth
car
e pr
ovid
er.
Pref
erre
d, p
ar c
ipa
ng,
or
non-
cont
ract
ed p
rovi
ders
(Cat
-eg
orie
s 1, 2
and
3 re
spec
vel
y)
insid
e or
out
side
the
Rege
nce
Serv
ice
area
.
Pref
erre
d, p
ar c
ipa
ng,
or
non-
cont
ract
ed p
rovi
ders
(Cat
-eg
orie
s 1, 2
and
3 re
spec
vel
y)
insid
e or
out
side
the
Rege
nce
Serv
ice
area
.
Chan
ge P
CPAn
y m
eAn
y m
eN
/AN
/A
Phys
icia
n’s
Offi
ce V
isit
80%
a e
r $30
cop
ay(D
educ
ble
wai
ved)
Visit
s 1-4
100
% a
er $
20 c
opay
, Visi
ts
5+ su
bjec
t to
$20
copa
y, de
duc
ble
; th
en c
over
ed a
t 80%
80%
a e
r ded
uc b
le90
% a
er $
20 c
opay
X-Ra
yLa
bora
tory
Cove
red
at 8
0%Co
vere
d in
full fi r
st $
500
PCY.
Ded
uct-
ible
, the
n 80
% th
erea
er
80%
. De
duc
ble
wai
ved
for
mam
mog
ram
and
pap
smea
r.90
%.
Dedu
c b
le w
aive
d.
Pres
crip
ons
Phar
mac
y(3
0 Da
y Su
pply
)
$15
copa
y ge
neric
.$3
0 co
pay
bran
d.$1
5 co
pay
gene
ric.
$30
copa
y br
and.
$10
copa
y ge
neric
form
ular
y.
$15
copa
y br
and
form
ular
y.N
on-fo
rm: $
30.
$5 c
opay
gen
eric
form
ular
y.
$20
copa
y br
and
form
ular
y.N
on-fo
rm: $
40.
Pres
crip
ons
Mai
l O
rder
(90
Day
Supp
ly)
$30
copa
y ge
neric
$60
copa
y br
and
per 9
0 da
y su
pply
$30
copa
y ge
neric
$60
copa
y br
and
per 9
0 da
y su
pply
$20
copa
y ge
neric
form
ular
y.
$30
copa
y br
and
form
ular
y.N
on-fo
rm: $
60.
$10
copa
y ge
neric
form
ular
y.
$40
copa
y br
and
form
ular
y.N
on- f
orm
: $80
.
Mat
erni
tyDr
. visi
ts 8
0% a
er $
30 c
opay
(ded
w
aive
d); D
eliv
ery
80%
a e
r ded
.Co
vere
d at
80%
a e
r ded
uc b
le.
80%
a e
r ded
uc b
le90
% a
er d
educ
ble
Prev
en v
e Ca
reCo
vere
d in
full.
No
Annu
al M
axim
umCo
vere
d in
full.
No
Annu
al M
axim
umCo
vere
d in
full.
No
Annu
al M
axim
umCo
vere
d in
full.
No
Annu
al M
axim
um
Emer
genc
y ro
om
(cop
ay w
aive
d if
adm
i ed
)$1
00 c
opay
, the
n de
d &
80%
$100
cop
ay, t
hen
ded.
& 8
0%.
$75
copa
y, th
en d
educ
ble
and
80
%;
$75
copa
y, th
en d
educ
ble
and
90
%;
Hosp
ital
Inpa
ent
Cove
red
80%
a e
r ann
ual d
educ
ble
Cove
red
80%
a e
r ann
ual d
educ
ble
.80
% a
er d
educ
ble
90%
a e
r ded
uc b
le.
Ambu
lanc
e80
%80
%80
% a
er d
educ
ble
90%
a e
r ded
uc b
lePl
ease
Not
e: A
ll pl
an c
hang
es h
ave
been
out
lined
in b
old.
Th
is be
nefi t
s com
paris
on p
rovi
des g
ener
al in
form
a o
n on
ly a
nd is
subj
ect t
o pl
an li
mita
ons
and
rest
ric o
ns.
Refe
r to
the
plan
boo
klet
s for
spec
ifi c
cove
rage
.
7
BASI
C M
EDIC
AL B
ENEF
ITS
COM
PARI
SON
201
3-20
14 (
PIF:
Pai
d in
Ful
l)
SERV
ICE
REGE
NCE
WEI
C IN
NO
VA 5
00RE
GEN
CE /
WEI
C EN
GAGE
70
PLAN
REGE
NCE
K-12
HSA
2.0
Dedu
c b
le$5
00/p
erso
n$1
500/
fam
ily$7
50/p
erso
n$2
250/
fam
ily$1
500/
pers
on$3
000/
fam
ily*
Coin
sura
nce
max
imum
$250
0/pe
rson
$750
0/fa
mily
$500
0/pe
rson
$150
00/f
amily
$500
0/pe
rson
$100
00/f
amily
Phys
icia
nsPr
efer
red,
par
cip
a n
g, o
r non
-con
-tr
acte
d pr
ovid
ers (
Cate
gorie
s 1, 2
and
3
resp
ec v
ely)
insid
e or
out
side
the
Rege
nce
Serv
ice
area
.
Pref
erre
d, p
ar c
ipa
ng,
or n
on-c
on-
trac
ted
prov
ider
s (Ca
tego
ries 1
, 2 a
nd
3 re
spec
vel
y) in
side
or o
utsid
e th
e Re
genc
e Se
rvic
e ar
ea.
Pref
erre
d, p
ar c
ipa
ng,
or n
on-c
on-
trac
ted
prov
ider
s (Ca
tego
ries 1
, 2 a
nd
3 re
spec
vel
y) in
side
or o
utsid
e th
e Re
genc
e Se
rvic
e ar
ea.
Chan
ge P
CPN
/AN
/AN
/A
Phys
icia
n’s
Offi
ce V
isit
All o
ffi ce
visi
ts su
bjec
t to
a $1
5 co
pay.
70%
a e
r ded
uc b
le80
% a
er d
educ
ble
X-Ra
yLa
bora
tory
Cove
red
in fu
ll fi r
st $
500
per c
alen
dar
year
. De
duc
ble
, the
n 80
% th
erea
er.
70%
. De
duc
ble
wai
ved
for m
am-
mog
ram
and
pap
smea
r.80
% a
er d
educ
ble
Pres
crip
ons
Phar
mac
y(3
0 Da
y Su
pply
)
$5 c
opay
gen
eric
form
ular
y. $
20
copa
y br
and
form
ular
y.N
on-fo
rm: $
40.
$5 c
opay
gen
eric
form
ular
y. $
20 c
opay
br
and
form
ular
y.
Non
-form
: $40
.
80%
a e
r ded
uc b
le**
Pres
crip
ons
Mai
l O
rder
(90
Day
Supp
ly)
$10
copa
y ge
neric
form
ular
y. $
40
copa
y br
and
form
ular
y.N
on- f
orm
: $80
.
$10
copa
y ge
neric
form
ular
y. $
40
copa
y br
and
form
ular
y.N
on-fo
rm: $
80.
80%
a e
r ded
uc b
le**
Mat
erni
ty80
% a
er d
educ
ble
70%
a e
r ded
uc b
le80
% a
er d
educ
ble
Prev
en v
e Ca
reCo
vere
d in
full.
No
Annu
al M
axim
umCo
vere
d in
full.
No
Annu
al M
axim
umCo
vere
d in
full.
No
Annu
al M
axim
um
Emer
genc
y ro
om
(cop
ay w
aive
d if
adm
it-te
d)$7
5 co
pay,
then
ded
uc b
le a
nd 8
0%;
$75
copa
y, th
en d
educ
ble
and
70%
; 80
% a
er d
educ
ble
Hosp
ital
Inpa
ent
80%
a e
r ded
uc b
le.
70%
a e
r ded
uc b
le80
% a
er d
educ
ble
.
Ambu
lanc
e80
% a
er d
educ
ble
70%
a e
r ded
uc b
le80
% a
er d
educ
ble
Plea
se N
ote:
All
plan
cha
nges
hav
e be
en o
utlin
ed in
bol
d.
This
bene
fi ts c
ompa
rison
pro
vide
s gen
eral
info
rma
on
only
and
is su
bjec
t to
plan
lim
ita o
ns a
nd re
stric
ons
. Re
fer t
o th
e pl
an b
ookl
ets f
or sp
ecifi
c co
ver-
age.
*H
SA 2
.0 :P
rior t
o be
nefi t
s bei
ng p
aid
out f
or a
ny fa
mily
mem
ber,
the
dedu
c b
le m
ust b
e m
et.
The
fam
ily d
educ
ble
app
lies w
ith th
e su
bscr
iber
and
one
or m
ore
depe
nden
ts a
re e
nrol
led.
**HS
A 2.
0: D
educ
ble
Wai
ved
for g
ener
ic a
nd fo
rmul
ary
prev
en v
e dr
ugs f
or a
sthm
a, d
iabe
tes,
hig
h bl
ood
pres
sure
, hig
h ch
oles
tero
l and
toba
cco
addi
c o
n.
8
Blai
ne S
choo
l Dist
rict
Heal
th In
sura
nce
Rate
s 201
3-20
14(m
onth
ly ra
tes)
Grou
p He
alth
Coop
era
ve
Trad
i on
al 2
50
Plan
Grou
p He
alth
Co
oper
a v
e W
elco
me
500
Plan
Rege
nce
Blue
Sh
ield
WEI
CEn
gage
80
Plan
Rege
nce
Blue
Shi
eld
WEI
CHi
gh O
p o
n
Rege
nce
Blue
Sh
ield
WEI
CIn
nova
500
Rege
nce
Blue
Sh
ield
WEI
CEn
gage
70
Plan
Rege
nce
Blue
Sh
ield
K-12
HSA
2.0*
Med
ical
Subs
crib
er$8
26.9
7$6
28.8
7$8
04.3
9$8
89.8
1$5
96.9
1$4
53.6
5$5
30.1
3Su
bscr
iber
&
Spou
se$1
583.
59$1
202.
59$1
540.
12$1
706.
11$1
145.
82$8
10.4
5$9
02.7
1
Subs
crib
er &
Chi
l-dr
en$1
259.
20$9
56.6
4$1
128.
45$1
250.
85$9
30.3
5$6
70.3
9$7
56.4
4
En re
Fam
ily$2
014.
46$1
529.
39$1
864.
18$2
067.
10$1
479.
26$1
027.
19$1
129.
02*
HDHP
- HSA
Pla
n: Y
our p
rem
ium
dol
lars
incl
ude
a m
onth
ly c
ontr
ibu
on
of $
125
tow
ards
you
r Hea
lth S
avin
gs A
ccou
nt.
Dent
alW
ashi
ngto
n De
ntal
Ser
vice
+
Ort
ho E
Visi
onN
orth
wes
t Ben
efi t
Net
wor
kEA
PHe
alth
Pro
mo
on
Net
wor
k
En re
Fam
ily$1
17.7
5En
re F
amily
$22.
00En
re F
amily
$2.0
9
Plea
se N
ote:
For
exc
lusio
ns, l
imita
ons
and
cla
rifi c
a o
ns se
e th
e in
divi
dual
pla
n bo
okle
ts.
This
com
paris
on is
not
a c
ontr
act.
9
Group Health Coopera ve Tradi onal 250 Plan (Group #1055600)
Eligible Health Care Providers Group Health Par cipa ng Providers. Cost Containment Provisions As specifi ed. Refer to booklet.
MEDICAL COVERAGEAnnual Deduc ble $250 per person / $750 per family. 4th quarter carry over applies.
General Benefi tsReimbursement Formula
Most services provided in full at GHC contracted facili es except for copayments. Annual out-of-pocket limit is $2,000 individual/$6,000 family.
Hospital Inpa ent 80% coinsurance. Subject to deduc ble. GHC Emergency Room
Non-GHC Emergency Room$100 copay per visit (waived if admi ed). Subject to Deduc ble then covered at 80%.$100 copay (waived if admi ed). Pa ent must no fy GHC within 24 hours if admi ed.Subject to Deduc ble then covered at 80%.
Inpa ent SurgeryOutpa ent Surgery
80% coinsurance. Subject to deduc ble.$30 copay, then covered at 80%. Deduc ble does not apply.
Offi ce Calls $30 copay, then covered at 80%. Deduc ble does not apply to offi ce calls. Hearing exams covered once every twelve months.Self referral for Acupuncture visits are limited to 8 per condi on per calendar year.Self referral for Naturopathic visits are limited to 3 per condi on per calendar year.
Diagnos c Lab & X-Ray Outpa ent: Covered at 80% for all covered services. Deduc ble does not apply to Out-pa ent Lab & X-ray. Inpa ent Lab & X-ray is Subject to Deduc ble.
Prescrip on Drugs Most drugs*, including contracep ves, prescribed by and obtained from GHC are covered with a $15 copay for generic / $30 copay for brand name, per 30 day supply**. Mail order available with a $30 copay for generic / $60 copay for brand name, per 90 day supply.** The deduc ble and coinsurance do not apply.
Ambulance Covered at 80%. GHC ini ated non-emergency transfers are covered in full. Mental Health
Inpa ent Services80% coinsurance. Subject to deduc ble. No day limit.
Mental HealthOutpa ent Services
$30 copay, then covered at 80%. deduc ble does not apply. No visit limit.
Chiroprac c Self referral for manipula ve therapy of spine by GHC contracted providers is covered to a maximum of 10 visits per calendar year with a $30 copay per visit, then covered at 80%. Deduc ble does not apply. Medical necessity for manipula ve therapy must meet GHC protocol.
Preven ve Care Covered in full. Vision Care Rou ne eye exam covered once every 12 months, subject to a $30 copay, then covered
at 100%; Deduc ble waived.Maximum Life me Benefi t Unlimited
Life Insurance Not applicable.* Under the Devices, Equipment & Supplies benefi t, external insulin pumps, glucose monitors and orthopedic appliances are covered at 80%, not subject to out of pocket maximum.
10
Group Health Coopera ve Welcome 500 Plan (Group #1147300)
Eligible Health Care Providers Group Health Par cipa ng Providers. Cost Containment Provisions As specifi ed. Refer to booklet.
MEDICAL COVERAGEAnnual Deduc ble $500 per person / $1,500 per family. 4th quarter carry over applies.
General Benefi tsReimbursement Formula
A er the applicable calendar year deduc ble has been met, services are paid at 80%.Annual out-of-pocket limit is $2,000 individual/$6,000 family.
Hospital Inpa ent 80% coinsurance. Subject to deduc ble.
GHC Emergency RoomNon-GHC Emergency Room
$100 copay per visit (waived if admi ed). Deduc ble and 80% coinsurance apply.$100 copay (waived if admi ed). Deduc ble and 80% coinsurance apply.Pa ent must no fy GHC within 24 hours if admi ed.
Inpa ent SurgeryOutpa ent Surgery
80% coinsurance. Subject to deduc ble.$20 copayment, then 80%. Subject to deduc ble.
Offi ce Calls 1st 4 visits per calendar year are not subject to deduc ble and/or coinsurance. $20 copay, 80% coinsurance therea er. Subject to deduc ble. Hearing exams covered once every 12 months. Self referral for Acupuncture visits are limited to 8 per condi on per calendar year. Self referral for Naturopathic visits are limited to 3 per condi on per calendar year.
Diagnos c Lab & X-Ray Covered in full for the fi rst $500 per calendar year. Deduc ble, then 80% therea er.
Prescrip on Drugs Most drugs*, including contracep ves, prescribed by and obtained from GHC are covered with a $15 copay for generic / $30 copay for brand name, per 30 day supply**. Mail order available with a $30 copay for generic / $60 copay for brand name, per 90 day supply.** The deduc ble and coinsurance do not apply.
Ambulance Covered at 80%**. The deduc ble does not apply.
Mental Health Inpa ent Services
Covered at 80% coinsurance when referred by GHC. Subject to deduc ble. No day limit.
Mental HealthOutpa ent Services
$20 copayment, then 80%. Subject to Deduc ble. No visit limit.
Chiroprac c Self-referral for manipula ve therapy of spine & extremi es by GHC providers is cov-ered to a maximum of 10 visits per calendar year with a $20 copay and 80% coinsurance per visit. Medical necessity for manipula ve therapy must meet GHC protocol. Subject to the annual deduc ble.
Preven ve Care Covered in full.
Vision Care Rou ne eye exam covered once every 12 months, subject to a $20 copay**. The deduc ble and coinsurance do not apply.
Maximum Life me Benefi t UnlimitedLife Insurance Not applicable.
11
Regence Blue Shield WEIC Engage 80 Plan
Category 1 – Preferred Providers Category 2 – Par cipa ng Providers
Eligible Health Care Providers
Members may u lize Category 1 (Preferred) or Category 2 (Par cipa ng) providers from the Regence BlueShield Provider Network. Category 1 and 2 Providers agree to accept Regence’s allowance as payment in full. Re-gence BlueShield contracts with providers na onwide. Most services from Category 3 (Non-Contracted) pro-viders are subject to deduc ble and coinsurance and these providers may balance bill members for services.
Cost Containment Provisions
Preauthoriza on is required for some inpa ent hospitaliza on. Refer to booklet. Voluntary second surgical opinion.
MEDICAL COVER-AGE
Annual Deduc ble $200/Individual, $600/Family. 4th quarter carry over applies.General Benefi tsReimbursement
Formula
Subject to annual deduc ble unless indicated. Pre-ferred Providers paid at 80% of allowable charges therea er. Annual out-of-pocket maximum is $1,000/individual, $2,000/family.
Subject to annual deduc ble unless indicated. Par- cipa ng Providers paid at 80% of allowable charges
therea er. Annual out-of-pocket maximum is $1,000/individual, $2,000/family.
Hospital Inpa ent Deduc ble, then 80%. Deduc ble, then 80%.Emergency Room $75 copay per visit, waived if admi ed. Subject to
deduc ble, then covered at 80%.$75 copay per visit, waived if admi ed. Subject to deduc ble, then covered at 80%.
Surgery Deduc ble, then 80%. Deduc ble, then 80%.
Offi ce Calls Deduc ble, then 80% (includes acupuncture, mas-sage therapy and naturopathic treatment). Acupunc-ture is limited to 12 visits per year. Massage therapy requires a prescrip on.
Deduc ble, then 80% (includes acupuncture, mas-sage therapy and naturopathic treatment). Acupunc-ture is limited to 12 visits per year. Massage therapy requires a prescrip on.
Outpa ent Diag-nos c Lab & X-Ray
Deduc ble, then 80%. Deduc ble is waived for a preven ve mammogram and pap smear.
Deduc ble, then 80%. Deduc ble is waived for a preven ve mammogram and pap smear.
Prescrip on Drugs At Par cipa ng pharmacies, paid in full a er $10 co-pay for generic formulary drugs/$15 copay for brand name formulary drugs (30 day supply). Non-formu-lary drugs paid in full a er $30 copay. Mail order available with a $20 copay for generic/$30 copay for brand and a $60 copay for non-formulary drugs (90 day supply).
At Par cipa ng pharmacies, paid in full a er $10 co-pay for generic formulary drugs/$15 copay for brand name formulary drugs (30 day supply). Non-formu-lary drugs paid in full a er $30 copay. Mail order available with a $20 copay for generic/$30 copay for brand and a $60 copay for non-formulary drugs (90 day supply).
Ambulance Deduc ble, then 80%. | Deduc ble, then 80%.Mental Health
Inpa entDeduc ble, then 80%. No day limits Deduc ble, then 80%. No day limits
Mental Health Outpa ent
Deduc ble, then 80%. No visit limits Deduc ble, then 80%. No visit limits
Spinal Manipula- ons
Deduc ble, then 80%. Limited to 12 per year. Deduc ble, then 80%. Limited to 12 per year.
Preven ve Care 100%. Deduc ble is waived.
100%. Deduc ble is waived.
Vision Care Not covered. Not covered.Maximum Benefi t Unlimited Life me; Annual Maximum Benefi t is $2,000,000
Life Insurance Not applicable.
12
Regence Blue Shield WEIC High Op on Plan
Category 1 – Preferred Providers Category 2 – Par cipa ng Providers
Eligible Health Care Providers
Members may u lize Category 1 (Preferred) or Category 2 (Par cipa ng) providers from the Regence BlueShield Provider Network. Category 1 and 2 Providers agree to accept Regence’s allowance as pay-ment in full. Regence BlueShield contracts with providers na onwide. Most services from Category 3 (Non-Contracted) providers are subject to deduc ble and coinsurance and these providers may balance bill members for services.
Cost Containment Provisions
MEDICAL COVERAGE
Refer to benefi t booklet.
Annual Deduc ble $200 (individual) / $600 (family). 4th quarter carry over applies.General Benefi ts Reimbursement
Formula
Preferred Physicians/Hospitals paid at 90% of allow-able charges. $1,000 (individual) / $3,000 (family) coinsurance out-of-pocket max.; 100% therea er.
Par cipa ng Physicians/Hospitals paid at 70% of al-lowable charges. $1,000 (individual) / $3,000 (fami-ly) coinsurance out-of-pocket maximum; 100% there-a er.
Hospital Inpa ent Subject to deduc ble, then covered at 90%. Subject to deduc ble, then covered at 70%.
Emergency Room $75 copay per visit, waived if admi ed. Subject to deduc ble.
$75 copay per visit, waived if admi ed. Subject to deduc ble.
Surgery Inpa ent: Subject to deduc ble, then covered at 90% Outpa ent: Subject to deduc ble, then covered at 90% (no copay).
Inpa ent: Subject to deduc ble, then covered at 70%.Outpa ent: Subject to deduc ble, then covered at 70% (no copay).
Offi ce Calls $20 copay, covered at 90%. Deduc ble waived. $35 copay, covered at 70%. Deduc ble waived.
Outpa ent Diagnos- c Lab & X-ray
Covered at 90%. Deduc ble waived. Covered at 70%. Deduc ble waived.
Prescrip on Drugs At Par cipa ng pharmacies, up to a 30 day supply, paid in full a er: $5 copay/formulary-generic; $20 copay/formulary-brand; $40 copay/non-formulary; Mail Order: (90 day supply) $10/$40/$80.
At Par cipa ng pharmacies, up to a 30 day supply, paid in full a er: $5 copay/formulary-generic; $20 copay/formulary-brand; $40 copay/non-formulary; Mail Order: (90 day supply) $10/$40/$80.
Ambulance Subject to deduc ble, then covered at 90%. Subject to deduc ble, then covered at 90%.Mental Health
Inpa entSubject to deduc ble, then covered at 90%. No day limit.
Subject to deduc ble, then covered at 70%. No day limit.
Mental HealthOutpa ent
90%. Deduc ble Waived. No visit limit. 70%. Deduc ble Waived. No visit limit.
Spinal Manipula ons Subject to deduc ble, then covered at 90%. Maxi-mum of 10 spinal manipula ons per calendar year.
Subject to deduc ble, then covered at 70%. Maxi-mum of 10 spinal manipula ons per calendar year.
Preven ve Care 100%. No Annual Maximum. Deduc ble waived. 100%. No Annual Maximum. Deduc ble waived.
Vision Care Not covered. Not covered.
Maximum Benefi t Unlimited Life me; Annual Maximum Benefi t is $2,000,000
Life Insurance Not applicable.
13
Regence Blue Shield WEIC Innova 500 Plan
Category 1 – Preferred Providers Category 2 – Par cipa ng Providers
Eligible Health Care Providers
Members may u lize Category 1 (Preferred) or Category 2 (Par cipa ng) providers from the Regence BlueShield Provider Network. Category 1 and 2 Providers agree to accept Regence’s allowance as payment in full. Regence BlueShield contracts with providers na onwide. Most services from Category 3 (Non-Contracted) providers are subject to deduc ble and coinsurance and these providers may balance bill members for services.
Cost Containment Provisions
MEDICAL COVER-AGE
Refer to benefi t booklet.
Annual Deduc ble $500 (individual) / $1,500 (family); Deduc ble is waived for professional services per year billed as offi ce visits in the offi ce, home or hospital outpa ent & the fi rst $400 per year of outpa ent diagnos c laboratory & x-ray
services. 4th quarter carry over applies.General Benefi ts Reimbursement
Formula
Preferred Physicians/Hospitals paid at 100% of allow-able charges (for offi ce, home, hospital outpa ent & the fi rst $500 per year of outpa ent diagnos c lab & x-ray); Other Professional Services subject to deduct-ible, then 80% of allowable charges (and diagnos c lab & x-ray exceeding $500 per year). $2,500 (individual) / $7,500 (family) coinsurance out-of-pocket maximum; 100% therea er.
Par cipa ng Physicians/Hospitals paid at 60% of al-lowable charges(for offi ce, home, hospital outpa ent & the fi rst $500 per year of outpa ent diagnos c lab & x-ray); Other Professional Services subject to deduct-ible, then 80% of allowable charges (and diagnos c lab & x-ray exceeding $400 per year). $2,500 (individual) / $7,500 (family) coinsurance out-of-pocket maximum; 100% therea er.
Hospital Inpa ent Subject to deduc ble, then covered at 80%. Subject to deduc ble, then covered at 60%.
Emergency Room $75 copay per visit, waived if admi ed. Subject to de-duc ble, then covered at 80%.
$75 copay per visit, waived if admi ed. Subject to de-duc ble, then covered at 80%.
Surgery Inpa ent: Subject to deduc ble, then covered at 80%.Outpa ent: Subject to deduc ble, then covered at 80% (no copay).
Inpa ent: Subject to deduc ble, then covered at 60%.Outpa ent: Subject to deduc ble, then covered at 60% (no copay).
Offi ce Calls $15 copay, then covered at 100%. Deduc ble Waived. $30 copay, then covered at 100%. Deduc ble Waived. Outpa ent Diag-
nos c Lab & X-rayCovered at 100% (fi rst $500 per calendar year) (no copay, Deduc ble Waived).Subject to deduc ble, then covered at 80% (exceed-ing $500) (no copay).
Covered at 100% (fi rst $500 per calendar year) (no copay, Deduc ble Waived).Subject to deduc ble, then covered at 60% (exceed-ing $500) (no copay).
Prescrip on Drugs At Par cipa ng pharmacies, paid in full a er $5 copay for generic formulary drugs/$20 copay for brand name formulary drugs (30 day supply). Non-formulary drugs paid in full a er $40 copay. Mail order available with a $10 copay for generic/$40 copay for brand and a $80 copay for non-formulary drugs (90 day supply).
At Par cipa ng pharmacies, paid in full a er $5 copay for generic formulary drugs/$20 copay for brand name formulary drugs (30 day supply). Non-formulary drugs paid in full a er $40 copay. Mail order available with a $10 copay for generic/$40 copay for brand and a $80 copay for non-formulary drugs (90 day supply).
Ambulance Subject to deduc ble, then covered at 80%. Subject to deduc ble, then covered at 80%.Mental Health
Inpa entSubject to deduc ble, then covered at 80%. No day limits.
Subject to deduc ble, then covered at 60%. No day limits.
Mental Health Outpa ent
$15 copay, then covered at 100%. Deduc ble Waived. $15 copay, then covered at 100%. Deduc ble Waived.
Spinal Manipula- ons
Subject to deduc ble, then covered at 80%. Maximum of 10 spinal manipula ons per calendar year.
Subject to deduc ble, then covered at 60%. Maximum of 10 spinal manipula ons per calendar year.
Preven ve Care 100%. No calendar year maximum. Deduc ble waived. 100%. No calendar year maximum. Deduc ble waived.
Vision Care Not covered. Not covered. Maximum Benefi t Unlimited Life me; Annual Maximum Benefi t is $2,000,000
Life Insurance Not applicable.
14
Regence Blue Shield WEIC Engage 70 Plan
Category 1 – Preferred Providers Category 2 – Par cipa ng Providers
Eligible Health Care Providers
Members may u lize Category 1 (Preferred) or Category 2 (Par cipa ng) providers from the Regence BlueShield Provider Network. Category 1 and 2 Providers agree to accept Regence’s allowance as payment in full. Regence BlueShield contracts with providers na onwide. Most services from Category 3 (Non-Contracted) providers are subject to deduc ble and coinsurance and these providers may balance bill members for services.
Cost ContainmentProvisions
Preauthoriza on is required for some inpa ent hospitaliza on. Refer to booklet. Voluntary second surgical opinion.
MEDICAL COVER-AGE
Annual Deduc ble $750/Individual, $2,250/Family. 4th quarter carry over applies.
General Benefi tsReimbursement
Formula
Subject to annual deduc ble unless indicated. Preferred Providers paid at 70% of allowable charges therea er. Annual out-of-pocket maximum is $5,000/individual, $15,000/family.
Subject to annual deduc ble unless indicated. Par- cipa ng Providers paid at 70% of allowable charges
therea er. Annual out-of-pocket maximum is $5,000/individual, $15,000/family.
Hospital Inpa ent Deduc ble, then 70%. Deduc ble, then 70%.
Emergency Room $75 copay per visit, waived if admi ed. Subject to deduc ble, then covered at 70%.
$75 copay per visit, waived if admi ed. Subject to deduc ble, then covered at 70%.
Surgery Deduc ble, then 70%. Deduc ble, then 70%.
Offi ce Calls Deduc ble, then 70% (includes acupuncture, massage therapy and naturopathic treatment). Acupuncture is limited to 12 visits per year. Massage therapy requires a prescrip on.
Deduc ble, then 70% (includes acupuncture, massage therapy and naturopathic treatment). Acupuncture is limited to 12 visits per year. Massage therapy requires a prescrip on.
Outpa ent Diag-nos c Lab & X-Ray
Deduc ble, then 70%. Deduc ble is waived for a pre-ven ve mammogram and pap smear.
Deduc ble, then 70%. Deduc ble is waived for a pre-ven ve mammogram and pap smear.
Prescrip on Drugs At Par cipa ng pharmacies, paid in full a er $5 copay for generic formulary drugs/$20 copay for brand name formulary drugs (30 day supply). Non-formulary drugs paid in full a er $40 copay. Mail order available with a $10 copay for generic/$40 copay for brand and a $80 copay for non-formulary drugs (90 day supply).
At Par cipa ng pharmacies, paid in full a er $5 copay for generic formulary drugs/$20 copay for brand name formulary drugs (30 day supply). Non-formulary drugs paid in full a er $40 copay. Mail order available with a $10 copay for generic/$40 copay for brand and a $80 copay for non-formulary drugs (90 day supply).
Ambulance Deduc ble, then 70%. Deduc ble, then 70%.
Mental Health Inpa ent
Deduc ble, then 70%. No day limits Deduc ble, then 70%. No day limits
Mental Health Outpa ent
Deduc ble, then 70%. No visit limits Deduc ble, then 70%. No visit limits
Spinal Manipula- ons
Deduc ble, then 70%. Limited to 12 per year. Deduc ble, then 70%. Limited to 12 per year.
Preven ve Care 100%. Deduc ble is waived. 100%. Deduc ble is waived.
Vision Care Not covered. Not covered.
Maximum Benefi t Unlimited Life me; Annual Maximum Benefi t is $2,000,000
Life Insurance Not applicable.
15
K-12 Regence BlueShield HSA 2.0 Op on Preferred
Category 1 – Preferred Providers Category 2 – Par cipa ng Providers
Eligible Health Care Provid-ers
Members may u lize Category 1 (Preferred) or Category 2 (Par cipa ng) providers from the Regence BlueShield Provider Network. Category 1 and 2 Providers agree to accept Regence’s allowance as payment in full. Regence BlueShield contracts with providers na onwide. Most services from Category 3 (Non-Con-tracted) providers are subject to deduc ble and coinsurance and these providers may balance bill members for services.
Cost Containment Provisions Preauthoriza on is required for some inpa ent hospitaliza on. Refer to booklet. Voluntary second surgi-cal opinion.
MEDICAL COVERAGE
Annual Deduc ble $1,500 (Individual) / $3,000 (Family) PCY– Combined among category 1, 2 and 3 Providers. Prior to benefi ts being paid out for any family member, the deduc ble must be met. The family deduc ble applies when the subscriber and one or more dependents are enrolled. 4th quarter carryover does
NOT apply. General Benefi ts
Reimbursement FormulaSubject to annual deduc ble unless indicated. Pre-ferred Providers paid at 80% of allowable charges therea er. Annual out-of-pocket maximum is $5,000/individual, $10,000/family. (Includes deduc ble) For family coverage, the family OOP must be met before coverage is paid at 100%
Subject to annual deduc ble unless indicated. Par cipa ng Providers paid at 60% of allowable charges therea er. Annual out-of-pocket maximum is $5,000/individual, $10,000/family. (Includes de-duc ble) For family coverage, the family OOP must be met before coverage is paid at 100%
Hospital Inpa ent Deduc ble, then 80%. Deduc ble, then 60%.
Emergency Room Deduc ble, then 80%. Deduc ble, then 80%.
Surgery Deduc ble, then 80%. Deduc ble, then 60%.
Offi ce Calls Deduc ble, then 80% (includes acupunc-ture, massage therapy and naturopathic treat-ment). Acupuncture is limited to 12 visits per year. Massage therapy requires a prescrip on.
Deduc ble, then 60% (includes acupuncture, mas-sage therapy and naturopathic treatment). Acu-puncture is limited to 12 visits per year. Massage therapy requires a prescrip on.
Outpa ent Diagnos c Lab & X-Ray
Deduc ble, then 80%. Deduc ble is waived for a preven ve mammogram and pap smear.
Deduc ble, then 60%. Deduc ble is waived for a pre-ven ve mammogram and pap smear.
Prescrip on Drugs At par cipa ng pharmacies, 80% subject to deduc ble. Deduc ble waived for generic and formulary preven ve drugs for asthma, diabe-tes, high blood pressure, high cholesterol and tobacco addic on.
At par cipa ng pharmacies, 80% subject to de-duc ble. Deduc ble waived for generic and for-mulary preven ve drugs for asthma, diabetes, high blood pressure, high cholesterol and tobacco addic on.
Ambulance Deduc ble, then 80%. Deduc ble, then 80%.
Mental Health Inpa ent Deduc ble, then 80%. No day limits Deduc ble, then 60%. No day limits
Mental Disorders Outpa ent Deduc ble, then 80%. No visit limits Deduc ble, then 60%. No visit limits
Spinal Manipula ons Deduc ble, then 80%. Limited to 12 per year. Deduc ble, then 60%. Limited to 12 per year.
Preven ve Care 100%. Deduc ble is waived. 100%. Deduc ble is waived.
Vision Care Not covered. Not covered.
Maximum Benefi t Unlimited Life me; Annual Maximum Benefi t is $2,000,000
Life Insurance Not applicable.
16
HDHP-HSA PLAN QUESTIONS AND ANSWERSThis is a brief overview and is not inclusive of all tax laws regarding HSAs. More informa on can be found at www.treasury.gov,
in IRS Publica on 969, or consult your tax professional.
How does the High Deduc ble Health Plan (HDHP) and Health Savings Account (HSA) work?
On the HDHP, the deduc ble must be met prior to your medical plan making payment for any service, except for preven ve care. All services including prescrip ons must be paid for in full un l the deduc ble is met. You can use the funds in your HSA to pay for services and prescrip ons. Once the deduc ble is met, you are responsible for coinsurance including prescrip on drugs. If there is family coverage, the en re family deduc ble must be met prior to your medical plan making payment.
Who is eligible to par cipate in an HSA?
In order to be eligible for an HSA, you must be covered by a HDHP and you or your enrolled spouse cannot be also covered under another medical plan unless the other plan is also an IRS qualifi ed HDHP. If a spouse is covered by the school district, and is also covered by their employer or on an individual basis with a non-HDHP plan, they must choose only one of the medical plans.
If you are no longer covered by a High Deduc ble Health Plan, or you enroll in Medicare, you cannot con nue to contribute to the HSA, but you can con nue to use the funds to pay for qualifi ed medical expenses.
You may not par cipate in an HSA if you can be claimed as a dependent on another person’s tax return.
Any person covered under the HDHP cannot par cipate in a Flex-Spending Account (FSA) or Health Reimbursement Account (HRA), including VEBA, unless it is a non-medical FSA, such as a daycare reimbursement FSA, or an HRA, VEBA or FSA that is limited to non-medical expenses. If your spouse has an FSA that could cover your medical expenses, you cannot par cipate in an HSA.
As the HSA is a bank account, you must be eligible to open a bank account, this process may include a credit check.
Procedure:
1. When going to the doctor or a pharmacy for a prescrip on, always present your medical insurance card at the me of service.
2. Your doctor will then bill your medical plan, or the pharmacy will apply your insurance informa on to the prescrip on. Your medical plan will process the claim, applying the charges to the deduc ble. If you go to a par cipa ng doctor or pharmacy, any discounts your medical plan has nego ated will apply and will reduce your out of pocket costs. You will also receive an Explana on of Benefi ts (EOB) from your medical plan, which will explain what your responsibility is and how much of the charges have been applied to your deduc ble.
3. You can now pay the provider with your HSA debit card. Many providers will bill you and provide space on the bill for you to write in your HSA debit card number to pay for the charges. If a provider or pharmacy does not allow credit card payments, you will need to submit your receipt for reimbursement.
Contribu ons:
You (and/or your employer) can contribute to your HSA up to the federal annual limit. The total allowed contribu ons for 2013, including employer contribu ons, is $3,250 for an individual only; and $6,450 for a family-when the HDHP coverage is employee plus dependent(s). The limit increases to $3,300 for individual and $6,550 for family for 2014. If you are over age 55, you may contribute an addi onal $1,000 per calendar year. A married couple with two separate Health Savings Accounts is limited to a total of $6,250 between the two accounts if one of the spouses has a HDHP with employee + dependent(s) coverage.
To contribute the full limit, you must be enrolled in a HDHP on December 1 of the calendar year. If you are not enrolled in a HDHP on December 1 of a calendar year, you may only contribute 1/12 the annual limit mes the number of months you were covered on a HDHP.
Your contribu ons to your HSA will be deducted from your paycheck on a pre-tax basis and deposited by the school dis-trict.
17
HDHP-HSA PLAN QUESTIONS AND ANSWERS, Con nued
Distribu ons:
Any me you go to the doctor or fi ll a prescrip on before your deduc ble is met, you can use the funds from your HSA. In addi on, you are allowed to use your HSA for any “qualifi ed medical expense” for medical, dental, vision, or other items that are allowed according to IRS Publica on 502. For example, if you have a child who will need braces, you are allowed to contribute to your HSA with pre-tax dollars to pay for the braces. Over-the-counter drugs (with the excep on of insulin) are not eligible expenses unless you have a wri en prescrip on from a physician.
Any distribu on that is not a qualifi ed medical expense is subject to a 20% tax penalty and income taxes.
Important facts about your HSA
The HSA is a bank account in your name that belongs to you. If you leave the school district, the account goes with you, and you can con nue to use the account for qualifi ed medical expenses. Any monthly bank fees for the HSA bank account are your responsibility and will be deducted directly from your HSA.
Unlike an FSA, you can only use funds that have been already been deposited into your HSA account. If you have a bill for $400, but only $200 deposited to date in your HSA, you only have the $200 available to you.
If you use HSA funds for anything that is not a qualifi ed medical expense, there is a 20% tax penalty, and you must report the amount to the IRS as regular income. You should keep all receipts for purchases made with your HSA card, to prove the purchases were a qualifi ed medical expense in case you are audited by the IRS.
If you choose to go to a pharmacy that par cipates with the IIAS system, charges will be auto-adjudicated at the me of purchase. (a list of par cipa ng merchants is available at www.sig-is.org)
You cannot use your HSA funds for any item or service prior to your eff ec ve date on the plan. For example, if your plan was eff ec ve 10/1/13 and den st performed a crown for you on September 5, 2013, and your por on is $400 of the cost of the crown, you cannot use your HSA funds for this service.
You can use HSA funds for qualifi ed medical expenses for any tax dependent, even if they are not covered by your HDHP. However, you cannot use HSA funds for qualifi ed medical expenses for someone who is not a dependent according to the IRS, for example, a child who is over age 26, or a domes c partner who is not a tax dependent.
All deduc bles for HSA eligible High Deduc ble Health Plans reset on January 1 of each calendar year. There is no carry-forward of deduc bles met in the prior year. Therefore, if you join a HDHP October 1, your medical expenses will be subject to the en re annual deduc ble for October, November and December and the en re deduc ble will reset on January 1.
18
MANDATORY BENEFITS FOR ALL DISTRICT EMPLOYEES
WEA DENTAL INSURANCE
WEA – Washington Dental Service Group #00186Brief Plan Descrip on Incen ve Dental Plan AAnnual Maximum Benefi t (Nov 1– Oct 31) $1,750 per person per Benefi t Year (Non PPO
Providers)$2,000 per person per Benefi t Year (PPO Providers)
Preven ve (Exams, X-Rays, Cleaning, Fluoride, Sealants) 70% - 100% Incen veRestora ve (Fillings, Oral Surgery, Endo & Perio) 70% - 100% Incen veOnlays, Crowns 70% - 100% Incen veMajor (Dentures, Bridges, Par als & Implants) 50%Temporomandibular Joint Disorder 50% up to $1,000 Annual Maximum Benefi t
$5,000 Life me Maximum Benefi tOrthodon a $1,250 Life me Maximum for Each Dependent Child
*How the Incen ve Program Works:
This plan encourages regular dental care. During the fi rst Benefi t Year on the plan, 70% of covered benefi ts are paid. This advances by 10% annually (on Nov 1) – providing you use the program at least once each Benefi t Year to a maximum of 100%. Failure to use the program once each Benefi t Year causes your level to drop by 10% points below the last level of payment, but never below the original 70%. Each eligible employee and dependent creates his or her own percentage point level. Percentage point levels do not aff ect the established constant 50% payment level for the cost of allowable prosthe cs (dentures, bridges, and implants) and orthodon cs.
You may select a licensed den st. Tell your den st you are covered by WDS program Group #0186.
If your den st is a member den st, your claims will be submi ed directly to Washington Dental Service and no more than the fi led fee can be charged. Washington Dental Service member den sts are reimbursed based on nego ated, pre-approved fees. Employees are not held responsible for amounts charged in excess of the member den sts’ approved fees. This translates to lower out-of-pocket costs – and no surprises.
Your benefi t dollars will go further if you seek services from a Delta Dental PPO den st. If you visit a Delta Dental PPO den st, you will be able to take advantage of a higher annual plan maximum. Your dental benefi t plan maximum will increase to $2,000 if you select a Delta Dental PPO den st. Delta Dental Premier den sts are members of our tradi onal fee-for-service plan, but they are not part of the Delta Dental PPO network.
If you choose to see a den st who is not a member of Washington Dental Service, you are responsible for having the den st complete and sign claim forms. It will also be up to you to ensure that the claims are sent to Washington Dental Service. Claim payments will be based on actual charges or Washington Dental Service’s maximum allowable fees for nonpar cipa ng den sts, whichever is less. You will be responsible for any balance remaining. Please be aware that Washington Dental Service has no control over nonpar cipa ng den sts’ charges or billing procedures.
Finding a den stYou can fi nd a par cipa ng den st in your area by visi ng the Washington Dental Service web site at www.DeltaDentalWA.com/fi ndaden st. Be sure to select the appropriate plan – Delta Dental PPO or Delta Dental Premier – and follow the prompts.
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MANDATORY BENEFITS (Con nued)VISION INSURANCE
Northwest Benefi t Network (Plan #WS)There is no co-payment required on materials or eye exams for either Panel (Par cipa ng) or Non-Panel Providers. Many benefi ts obtained from Panel Providers are covered at 100%, with a few of the excep ons listed below. For Non-Panel Providers, members pay all charges and are reimbursed up to the allowances listed below under “Non-Panel Providers”. Either contacts or glasses may be obtained in a benefi t period—not both. Children are eligible from birth to age 26.
Payment will be made on behalf of the subscriber as follows:
NBN Panel Non-PanelFrequency † Providers Providers
Eye Exam Every year 100% $35Single Vision Lenses Every year 100% * $30Bifocal Lenses Every year 100% * $40Trifocal Lenses Every year 100% * $45Progressive Lenses Every year 100% ** $40Len cular Lenses Every year 100% * $90Con nuous Blend Every year 100% ** $40Lens Coa ng, Tints, Oversize Every year Some covered Not coveredFrames Every 2 years 100% *** $30Elec ve Contacts Every year $175 **** $90Necessary Contacts Every year 100% $200
* Lenses necessary to correct the visual acuity of the pa ent are fully covered. Specialized lenses, special features and “extras” may not be covered. ** Standard grades of ‘con nuous blend’ lenses are covered.*** Plan pays 100% of a selec on of frames; subscriber pays addi onal amount for more expensive frames. **** $175 contacts allowance is for the exam, fi ng and lenses combined, in lieu of all other services for 365 days.† Every Year = 365 consecu ve days. Every 2 Years = 730 consecu ve days.
If you obtain services or eyewear before you are eligible, you will be responsible for all charges incurred. If a non-covered lens extra or a frame that exceeds the plan allowable is ordered, you are responsible for the addi onal costs, including any fees. Non-panel claims must be submi ed within one (1) year from the date of service to be considered for payment. There will be addi onal Pa ent Responsibility if a Premium version of a covered item is ordered; the plan covers Standard styles of lens extras.
Group Health off ers coverage for eye exams. Group Health subscribers can maximize their NBN contact allowance by billing their eye exam to Group Health.
Please note: This is a summary only of the benefi ts of the plan. Actual benefi ts are based upon the plan agreement, which may contain plan details not specifi ed in this summary. Please contact NBN at (800) 732-1123 if you have any ques ons about the plan benefi ts and/or your eligibility status or you can register online at www.nwadmin.com to review your past claims history, eligibility status, view your plan brochure and print a claim form and more.
STATE-MANDATED RETIREE BENEFIT
A Washington State health care reform bill enables re rees and disabled school employees to purchase health care insurance from the state Health Care Authority. In order to support the K-12 re ree health care plan, school districts are required to forward to the Health Care Authority sixty-four and 40/100 ($64.40) per month per full me employee.
LONG-TERM DISABILITY INSURANCECIGNA
Descrip on Mandatory long-term disability. Eligibility: Mandatory coverage for all eligible district employees working 17.5 hours or more.Benefi t Amount: 60% of salary to a maximum monthly benefi t of $6,000.Wai ng Period: 90 days from the onset of disability.
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CIGNA LIFE INSURANCE COMPANY
All District Employees are eligible for $30,000 of Life insurance coverage through CIGNA. If you leave the District,
conver bility to an individual policy is available. At age 70, benefi t reduces by 50%.
EMPLOYEE ASSISTANCE PROGRAM EAP
Health Promo on Network (EAP) is a voluntary and confi den al, professional assessment and referral program for employees and the members of their household. Dependent upon the counselor’s assessment of the situa on, up to 4 visits can be available at no cost to the employee. The EAP off ers assessments and referral sessions, short-term counseling, and 24-hour emergency consulta on services. It is staff ed by trained and licensed professionals. The EAP line is 800-244-6142 or 360-715-6565.
WORKERS COMPENSATION & OCCUPATIONAL SAFETY & ACCIDENTPREVENTION PROGRAM
The Blaine School District is an insured employer through the Washington State Department of Labor & Industries. Our occupa onal safety and accident preven on program applies to any work-related injury or illness. If you sustain a work-related injury, the following steps are to be followed:
Immediately report any injury (treated or untreated) to your supervisor and complete the Accident Report Form.
The Return to Work Release Form is to be completed by the doctor and returned to the District Claims Manager prior to returning to work.
If me loss is required or transi onal work possible a Physical Capaci es Evalua on is to be completed by the doctor and returned to the District Claims Manager prior to returning to work.
Obtain the Washington State Fund Report of Industrial Injury or Occupa onal Disease Form from the doctor and mail to the State. The employer por on is mailed to the district for comple on of “Employer Informa on”.
The Blaine School District’s Return to Work Program is a team eff ort involving the injured employee, immediate supervisor, district safety offi cer, claims manager, personnel administrator and doctor. Should you become injured, it is important that you return to employment as early as it is medically safe for you to do so. We will stay in contact with you and your doctor to keep up to date on your recovery process. We have developed transi onal duty assignments for employees who are unable to return to their normal du es while recovering from their injuries. Medical studies show that transi onal work speeds the healing process.
The Blaine School District has a sick leave buy back process. Should you receive compensa on from the State Fund for me off work due to an injury, bring it to the Payroll Offi ce to buy back a por on of your sick leave.
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VOLUNTARY BENEFITS FOR ALL DISTRICT EMPLOYEESThe following voluntary products are not endorsed by the Blaine School District, but are off ered as benefi t enhancements.
WEA SELECT AMERICAN FIDELITYEligible Classes: Voluntary short-term disability (Brochure SB-26243-0713)
Descrip on: Administra ve, Cer fi cated, Clerical Classifi ed and Non-Represented Employees (These classes fall under the Labor & Industries code #613)
Benefi t Amount: Up to 66 2/3% of your monthly income to a maximum of $7,500/month Elimina on Period: 0 days for injury / 7 days for sickness (benefi ts begin on the 8th day for sickness)
Benefi t Period: 90 days
Eligible Classes: Voluntary short-term disability (Brochure SB-26243-0713)
Descrip on: Non-Clerical Classifi ed(These classes fall under the Labor & Industries code #614)
Benefi t Amount: Up to 66 2/3% of your monthly income to a maximum of $7,500/monthWai ng Period: 0 days for injury / 7 days for sickness (benefi ts begin on the 8th day of sickness)Benefi t Period: 90 days
These plans include a limita on to off set with other sources of income. Par cipants will be eligible to receive up to 70% of their monthly earnings, which includes other income received, such as sick pay or unemployment compensa on. Injury or Sickness arising out of or in the course of any occupa on for wage or profi t for which you are en tled to Worker’s compensa on will not be covered under the plans.
The above informa on does not cons tute a contract. It only highlights some general informa on. These products contain limita ons and exclusions. Please be sure to consult the appropriate WEA Select American Short-Term brochure for a summary of the plan’s rates, specifi c benefi ts, limita ons, and exclusions informa on before making your selec on. The brochure is available in the human resource department and/or through an American Fidelity Assurance Company representa ve at 1-866-576-0201 between 8:00 AM and 5:00 PM or via the Internet at www.americanfi delity.com.
AFLAC SUPPLEMENTAL INSURANCE
Employees have the opportunity to select supplemental insurance coverage through AFLAC. Most policies can be paid on a pre-tax basis through payroll deduc on. AFLAC provides supplemental insurance policies to help with medical and living expenses associated with serious injuries or illnesses. Policy benefi ts are paid directly to you, unless assigned, regardless of any other coverage you may have. Benefi ts cannot be reduced because of other insurance. Also, payroll rates may be retained upon re rement or job change. AFLAC policy lines include: Personal Short Term Disability, Accident, Intensive Care, Cancer Expense, Life Assurance, Dental and Personal Recovery (a policy for heart a acks, strokes and more). NOTE: Not all benefi ts available in every district. Contact Elena Johnson at (360) 676-4848 for more informa on.
VOLUNTARY LONG TERM CARE INSURANCE
Medical plans provide li le to no coverage for long term care, from home care to nursing home care. The District off ers you the opportunity to purchase permanent long term care insurance through UNUM Insurance Company at low group rates and you may keep the plan beyond re rement. Long term care insurance provides you with benefi ts to pay for care when you cannot take care of yourself and need services either in your own home, an assisted living facility or a convalescent care facility. This can include short or long term rehabilita ve care, which is very expensive. The coverage is available to all benefi t eligible employees, spouses, parents and grandparents. Employees, who enroll within 30 days of eligibility, are guaranteed acceptance regardless of medical condi ons. You may also enroll any year during open enrollment with medical underwri ng for acceptance. All other family members require medical underwri ng. This is a very fl exible plan, which allows you to purchase the amount and type of coverage that makes sense for you and your family. Monthly premium depends on your age and the amount purchased.
For more informa on, please contact Lori Leech at (360) 332-5881 x1710 OR you may contact the plan administrator directly: Terry Wood at Lehmann/Wood & Associates, Inc. at 800.696.1939 or www.lehmannwood.com
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FLEXIBLE BENEFIT SPENDING ACCOUNTS / PLAN 125
American Fidelity Assurance Company:There are three ways to save by par cipa ng in the Sec on 125 Plan – by pre-taxing eligible insurance premiums, by par cipa ng in the dependent day care expense reimbursement account, and by par cipa ng in the unreimbursed medical expense account. Sec on 125 enables par cipa ng employees to reduce their tax liability by se ng aside pre-tax dollars from their earnings to pay for eligible out-of-pocket premiums, health care and dependent care costs. Consider the following reasons to par cipate:
Tax Advantages – The plan helps you lower the amount you pay in taxes and thereby, increase your take-home pay.
Control – You decide how much to put into the plan. Out-of-Pocket Medical / Dental / Vision Expenses – You can pre-tax eligible medical and dental expenses,
such as orthodon a, copayments, deduc bles, etc. You must have a medical prac oner’s prescrip on on fi le in order to be reimbursed for over-the-counter drugs and medicines.
Dependent Care Expenses – The dependent day care expense reimbursement account reimburses for certain eligible dependent care costs (e.g., daycare) with pre-tax dollars and thus reduces your taxable income.
The eligible insurance plans include dental, health and vision insurance premiums. These benefi ts will automa cally be placed under the plan. If an employee does not want to par cipate in this plan, they must sign and return a “Premium Payment Plan Refusal” form to Lori Leech by September 30th, 2013. Elec ons made under the Sec on 125 plan must remain in place for the length of the plan year unless the employee experiences an allowable elec on change event mid-plan year (consult your employer for more details). An employee cannot change or revoke their unreimbursed medical expense account elec on during the contract year. Cancella on or changes for this account are allowed only during the next annual open enrollment period.
To take advantage of either or both of the unreimbursed medical expense account or dependent day care expense reimbursement account, you must complete an elec on form and return it to the payroll offi ce prior to September 30th, 2013. Employees currently par cipa ng in either of the fl exible spending accounts also need to submit a new elec on form for 2013 to the payroll offi ce.
NOTE: You cannot par cipate in a Flex-Spending Account for out of pocket Medical/Dental/Vision expenses if you are covered under a High Deduc ble Health Plan (HDHP).SB-26243-0713
FAMILY MEDICAL LEAVE ACT OF 1993 (FMLA)
The Federal Family and Medical Leave Act (FMLA) was signed into law in February 1993. The law took eff ect on August 5, 1993 and guarantees up to 12 weeks of unpaid leave each year to workers who need me off for birth or adop on of a child, to care for a spouse or immediate family member with a serious illness, or who are unable to work because of a serious health condi on.
The FMLA is an employer law; it covers employers with 50 or more employees and aff ects many job-related rights of employees. Among other things, this law also aff ects the health benefi t plans maintained by employers who are required to comply. Employers are required by FMLA to con nue to provide group health benefi ts at the same level and under the same condi ons as if the employee had con nued to be ac vely at work. A person who fails to return from an FMLA leave may be en tled to con nua on of coverage under COBRA. For specifi c ques ons, contact the personnel department or contact the Department of Labor for a copy of the FMLA law.
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SCHOOL EMPLOYEE’S RETIREMENT SYSTEM
Ques ons regarding PERS / SERS / TRS benefi t informa on please contact the Department of Re rement Systems @ 800-547-6657.
Department of Re rement Systems Internet Site Address: www.wa.gov/drs/drs.htm
CONTINUATION OF COVERAGE
If you leave the District, certain insurance coverages, which have been provided, may be con nued. Should you decide to con nue coverage, con nua on will become eff ec ve when your current plan normally would have terminated. For addi onal informa on please refer to your plan booklet.
1. GROUP MEDICAL INSURANCE - Medical insurance may be con nued under COBRA. It is also conver ble to a guaranteed individual policy. The benefi ts of the policy will vary and are usually less than provided by your group policy. Other medical plans are available on an individual basis.
2. GROUP DENTAL/VISION INSURANCE - Dental and/or Vision insurance may be con nued under COBRA. This is not conver ble to individual policies.
Federal law requires most group health plans maintained on behalf of 20 or more employees to off er employees and their families the opportunity to elect a temporary extension of health coverage (called “con nua on coverage” or “COBRA coverage”) in certain cases. A “group health plan” includes any employer-provided medical, dental, vision care, or prescrip on drug coverage. If you or a qualifying family member wish to provide no ce of any required events aff ec ng your COBRA coverage, or have any ques ons about COBRA, please contact your employer representa ve Lori Leech, Blaine School District, (360) 332-5881.
BASIC HEALTH OF WASHINGTON
Basic Health is a low cost health insurance program off ered through the State of Washington, for residents who qualify. If you qualify for a subsidized rate (depending upon total family monthly income and family size) you could receive health insurance coverage for your children at a low cost through this program. Parents do not have to enroll in Basic Health in order to enroll their children. For more informa on on Basic Health, please call 1-800-660-9840 or visit www.basichealth.hca.wa.gov.
HEALTHY KIDS NOW!Free or Low-Cost Health Insurance for Kids & Teens in Washington State
Infants through teenagers can receive free or low-cost health insurance. Many families in Washington State qualify and don’t know it. These programs are fl exible and cover kids in many types of households. This health insurance program covers a full range of services that all children need to stay healthy. For more informa on, please call 1-877-543-7669 or visit www.insurekidsnow.gov
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BENEFITS ADVISORY COMMITTEERussell Carleton JJ JensenLori Leech Chris ne Anderson
ADVISORY COMMITTEE SUPPORTHuman Resources---------- Chris ne Anderson---------- (360) 332-0712------------ [email protected] ------------------------- Lori Leech --------------------- (360) 332-0710------------ [email protected] Consultants----- The Partners Group 1-877-455-5640 x311---- eaus [email protected]
Medical Group Health Coopera veGroup #1055600 (Tradi on Plan)Group #1147300 (Welcome Plan)Customer Service – (888) 901-4636 (www.ghc.org) Contract and Rates Renew: October 1Annual Benefi t Maximums Renew: January
AFLAC- Supplemental InsuranceElena Johnson (360) 676-4848
Employee Assistance ProgramHealth Promo on Network(www.peacehealth.org/whatcom/eap)(800) 244-6142, (360) 715-6565
Regence Blue Shield (Group #60017856)Customer Service - (888) 367-2112(www.wa.regence.com)Contract and Rates Renew: November 1Annual Benefi t Maximums Renew: January 1
VEBA Service Group, LLCHealth Reimbursement PlanLocal Rep: Mike Smolko ([email protected])Customer Service - (800) 422-4023(www.veba.org)Benefi t Ques ons: 888-828-4953(Meritain Health)
DENTALWashington Dental Service (Group #186)Washington Educa on Associa onCustomer Service - (800) 554-1907(www.deltadentalwa.com) Contract and Rates Renew: November 1Annual Benefi t Maximums Renew: November 1
Department of Re rement Systems(800) 547-6657 (www.drs.wa.gov)
American FidelityFlexible Spending AccountSalary & Cancer InsuranceWashington Educa on Associa onCustomer Service - (866) 576-0201(www.afadvantage.com)Contract and Rates Renew: N/AFSA Plan Year Renews: April 1
Unum Long Term CareLehmann/Wood & Associates, Inc.(800) 696-1939 ([email protected])www.lehmannwood.com/school/blaine_index.htm
“Addi onal” Employee Assistance ProgramCIGNA Behavioral HealthCustomer Service – (800) 538-3543(www.cignabehavioral.com/cgi)
*NBN Vision benefi t maximums renew every 365 or 730 days a er last service date, depending upon service provided.Should you have any ques ons, please contact any of the above insurance carriers or our agent, The Partners Group, at
877-455-5640 - Emily Aus n, ext. 311.
VISIONNorthwest Administrators (Group #WS)Northwest Benefi t Network - VisionCustomer Service - (800) 732-1123(www.nwadmin.com)Contract and Rates Renew: October 1Annual Benefi t Maximums Renew: *See belowLONG TERM DISABILITYCIGNACustomer Service – (800) 362-4462(h ps://dmswebintake.group.cigna.com)Contract and Rates Renew: November 1Annual Benefi t Maximums Renew: N/ALIFE INSURANCECIGNACustomer Service – (800) 362-4462(www.cigna.com)Contract and Rates Renew: November 1Annual Benefi t Maximums Renew: N/ALife & Long Term Disability InsuranceCustomer Service – (800) 362-4462(h ps://dmswebintake.group.cigna.com)
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*******Glossary of Terms*******Allowed charges – Services rendered or supplies furnished by a health provider that qualify as covered expenses and for which insurance coverage will pay in whole or in part, subject to any deduc ble, coinsurance or table of allowances included within the plan design.
Co-insurance – A provision under which the enrollee and the carrier each share a percentage of the cost of a covered service. A typical coinsurance arrangement is 80% / 20%. This means the carrier will pay 80% of eligible charges and the enrollee will pay 20%.
Deduc ble – The amount of out-of-pocket expenses that must be paid for health services by the covered person before the carrier will begin to pay benefi ts.
Explana on of benefi ts (EOB) – A descrip on, sent to pa ents by health insurance carriers, that describes what benefi ts were paid for a par cular claim. Also called a “Claims Processing Report”.
Family deduc ble – A deduc ble that is sa sfi ed by the combined expenses of all family members. For example, a program with a $200 deduc ble may limit its applica on of the deduc ble to a maximum of three deduc bles ($600) for the family, regardless of the number of family members enrolled. On HSA plans with more than one enrollee, the family deduc ble must be sa sfi ed before benefi ts are payable for ANY enrollee.
Maximum allowable charges – The largest dollar amount to which an insurance carrier will apply plan benefi ts.
Maximum benefi t – The largest dollar amount the plan will pay toward the cost of a specifi c benefi t or for health care overall. The maximum benefi t available under most tradi onal plans for instance is usually between $1,000,000 and $2,000,000 (annually per enrollee).
Open enrollment – A period during which subscribers in a health benefi t program have an opportunity to make changes in their health coverage (select an alterna ve program, for insurance); or a period when uninsured individuals can obtain coverage without presen ng evidence of insurability (health statements).
Out-of-pocket expenses – Those health care expenses for which the enrollee is responsible. These include deduc ble, coinsurance, copayments and any costs above the amount the insurer considers usual and customary or reasonable (unless the provider has agreed not to charge the enrollee for those amounts).
Out-of-pocket maximum – The amount that the enrollee must pay for deduc bles, coinsurance and copayments in a defi ned period (usually a calendar year) before the insurer covers all remaining eligible expenses at 100%.
Outpa ent services – Services provided to an individual who has not been admi ed to a hospital or other facility. These services may be provided in the outpa ent department of a hospital, in a doctor’s offi ce or in some other se ng.
Referral – A formal process that authorizes a Health Maintenance Organiza on (HMO) or Point of Service (POS) member to receive care from a specialist or hospital.
***NOTES***
***NOTES***
If you are unable to a end the Blaine School District Benefi ts Fair…
…many of our vendors will be a ending the following Whatcom County School District benefi ts fairs.
Bellingham School District, Tuesday, August 27th, 2:00 – 6:00 p.m.Kulshan Middle School
1250 Kenoyer St., Bellingham, WA 98226Also at the fair: A discussion of Re rement, Medicare and Social Security issues
pertaining to K-12 employeesIn the Kulshan Middle School Library - 2 sessions: 3:00-4:00 and 5:00-6:00
Ferndale School District, Tuesday, September 10th, 2:00-6:00 p.m.Ferndale High School Cafeteria
5830 Golden Eagle DriveFerndale, WA 98248-0428
Lynden School District, Thursday, August 29h, 2:30-5:00 p.m.Lynden High School Cafeteria
1203 Bradley Rd.Lynden, WA 98264
Meridian School District, Thursday, August 29th, 3:30-5:00 p.m.High School Cafeteria
194 W. Laurel Rd.Bellingham, WA 98226-9699
Mount Baker School District, Wednesday, August 28th, 1:00-3:00 p.m.Mount Baker High Commons
4936 Deming RoadDeming, WA 98244-0095
Nooksack Valley School District, Tuesday, August 27th, 10:00 a.m. – 12:00pmNooksack Valley High School
Performing Arts Center Commons3326 E. Badger RoadEverson, WA 98247
Summary Prepared by The Partners Group for the Blaine School District
765 H Street, Blaine, WA 98230, (360) 332-5881
