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City of Santa Monica New Employee Benefits Overview

2020

1

TABLE OF CONTENTS Benefits You Can County On ............................................................................................................................ 2

What’s New In 2020? ..................................................................................................................................... 3

Benefit Highlights .......................................................................................................................................... 6

How To Enroll in Benefits ................................................................................................................................ 8

Who Can You Cover? ...................................................................................................................................... 9

Making the Most of Your Benefits ................................................................................................................... 10

Blue Shield of California ............................................................................................................................... 11

Medical ..................................................................................................................................................... 14

Dental ........................................................................................................................................................ 21

Vision ........................................................................................................................................................ 22

Cost of Coverage ......................................................................................................................................... 23

Life and Disability Insurance ......................................................................................................................... 24

Special Savings Accounts ............................................................................................................................. 27

Other Programs ........................................................................................................................................... 29

For Assistance ............................................................................................................................................ 32

Key Terms .................................................................................................................................................. 34

Important Plan Notices and Documents ........................................................................................................... 36

Appendix .................................................................................................................................................... 37

Notes ......................................................................................................................................................... 38

Medicare Part D Notice: If you and/or your dependents have Medicare or will become eligible for Medicare in the next 12 months, a federal law gives you more choices about your prescription drug coverage. Please refer to the Legal Notices posted on the City of Santa Monica website, www.smgov.net/Departments/HR/Employees/Employees.aspx or contact Human Resources at 310.458.8246 for more details.

https://www.smgov.net/Departments/HR/Employees/Employees.aspx

2

BENEFITS YOU CAN DEPEND ON

At the City of Santa Monica, we believe that you, our employees, are our most important asset. Helping you and your families achieve and maintain good health—physical, emotional and financial - is the reason the City of Santa Monica offers you this benefits program. We are providing you with this overview to help you understand the benefits that are available to you and how to best use them. Please review it carefully and make sure to ask about any important issues that are not addressed here. A list of plan contacts is provided in this New Employee Benefits Overview booklet.

While we've made every effort to make sure that this guide is comprehensive, it cannot provide a complete description of all benefit provisions. For more detailed information, please refer to your plan benefit booklets or Evidence of Coverage (EOC) documents at the City of Santa Monica website, www.smgov.net/Departments/HR/Employees/Employees.aspx. The plan benefit booklets determine how all benefits are paid.

The benefits in this summary are effective:

January 1, 2020 - December 31, 2020

https://www.smgov.net/Departments/HR/Employees/Employees.aspx

https://myportal.alliant.com/eb/CampaignBuilder%20Images/CampaignBuilder%20Theme%20Images/email-header-journeys-collage.png

3

What’s New In 2020?

BENEFIT ADVOCATE - NEW PHONE NUMBER and EMAIL

The City of Santa Monica offers employees a dedicated Benefit Advocate through Alliant Insurance Services. Your Benefit Advocate will help you navigate the complexities of your benefits plan. This program is free and completely confidential.

What benefits are covered?

• Medical, RX, Dental, Vision • Employee Assistance Program (EAP) • Flexible Spending Account (FSA) • Life & Disability • Health Savings Account (HSA)

Your Advocate can assist with:

• Benefits choices during Open Enrollment • Verifying eligibility and coverage • Finding a physician and access to care

BLUE SHIELD – HIGH DEDUCTIBLE HEALTH PLAN (HDHP)

Due to IRS regulations, the individual per Family member deductible is increasing from $2,700 to $2,800 for the 2020 plan year. The Family deductible will remain the same.

VSP VISION PLAN

The new vision Choice Plan, will have the following frame benefit enhancements:

• Retail Frames – allowance will increase from $115 to $190 • Featured Frame Brand – allowance will increase from $135 to $210 • Costco Frames – allowance will increase from $60 to $105 • Elective Contacts – allowance will increase from $105 to $180

TRIO HMO PLAN – Teladoc Copay and Heal

For members on the Blue Shield Trio HMO plan, the copayment amount for a Teladoc virtual visit is being reduced to “No Charge”. For detailed information on Teladoc, refer to page 12. The Heal program is now available on the Trio HMO plan. Heal lets you see a doctor wherever is most convenient for you – home, work or hotel. The first on-demand visit is $0 copay and following visits are a $20 copay. Learn about Heal at www.heal.com or call 844.644.4325.

NEW Contact number: 1.888.585.5399, 8:30am – 5:00pm (M-F)

NEW Email: [email protected]

• Resolving claims and billing issues • Coverage changes due to life events

(marriage, new child, divorce • Grievances and appeals

https://www.heal.com/

4

EMPLOYEE ASSISTANCE PROGRAM (EAP)

Your life’s journey – made easier No matter where you are on your journey, there are times when a little help can go a long way. From checking off daily tasks to working on more complex issues, this program offers a variety of resources, tools and services available to you and your household members.

Key features

• No cost to you • Includes up to 5 counseling sessions per issue • Completely confidential • Available 24/7/365

Core Services

• Counseling – we provide support for challenges such as stress, anxiety, grief, relationship concerns and more

• Coaching – when you have a goal to achieve, coaches help you create a plan of action and stay on track

• Online programs – self-guided, interactive programs help improve your emotional well-being for issue like depression and anxiety

Additional benefits:

• Legal assistance – free one hour with lawyer on phone or in person • Financial coaching – two free 30-minute telephonic consultations • Identify theft resolution – free 60-minute consultation with a Fraud Resolution Specialist • Work-life services – specialists provide guidance and personalized referrals for childcare, adult

care, education, home improvement, consumer information, emergency preparedness and more • Wellness resources – eat better, move more and be happier and healthier with resources such

as interactive tools and assessments, engaging videos, information on fitness, weight management and other areas

Help is available 24/7, 365 days a year.

Contact us at 800.523.5668.

Register online at www.magellanascend.com and explore the services that are available, live Chat with a counselor, find a provider and search

the Learning Center.

Company name: City of Santa Monica

http://www.magellanascend.com/

5

WELLVOLUTION NEXT

Achieve your health goals with Wellvolution Next– Blue Shield’s whole-health platform that’s been designed with you in mind.

Tap into decades of research and leading technology for a more productive and healthy lifestyle

Our new wellness program has been design to custom fit your particular needs and lifestyle. Wellvolution incorporates the following:

Prevent disease and reverse existing conditions – cardiovascular disease reversal, diabetes prevention, 12-week integrated nutrition and movement programs; BlueStar, MySugr, Transform

Manage stress better – physiological, psychosocial and emotional training exercises, cognitive behavioral therapy; eM Life, Calm, SuperBetter

Sleep better - pattern tracking optimization, relaxation exercises; Sleep Time, Pacifica

Physical activity – movement tracking, guided goad-based exercise plans, workout routines, coaching; Fitbit, Fitocracy

Eat better – grocery and meal planning, nutritional calculators; Betr, Heath Slate, PlateJoy, Zipongo

Ditch cigarettes – smoking cessation qualified by financial and lifestyle gains, nicotine replacement therapy; Clickotine, SmokeFree, 2Morow Health

A digital health platform and in-person support network

Focus Support Results

Stay on track and progress along the proven path

Receive digital reminders, motivation and engagement

All backed by real science for real, positive changes

Unveiling your personal proven path to real health

6

Benefit Highlights

Is the HDHP/HSA right for you? If you enroll in the Blue Shield High Deductible Health Plan (HDHP), you can open a Health Savings Account (HSA). They both work together!

HDHP at a glace

• Lower premiums so more money in your paycheck • Higher deductible • Preventive care services are free

HSA is your savings partner

• You keep it even if you leave the City • Your funds can grow, not a use it or lose it account • Use it to pay eligible medical, dental and vision expenses • Helps you save on taxes 3 ways!

1. No tax on HSA contribution 2. No tax on eligible HSA withdrawals 3. No tax on HSA interest and investment earnings

Your HSA boosts your retirement savings plan

• Your HSA is your long-term

health fund. The balance

rolls over year after year so

you can use it anytime for

healthcare expenses.

• Your HSA is a smart

addition to your retirement

savings plan. Your post-

retirement healthcare

spending will be tax-free.

After age 65, you can use

HSA dollars for non-health

expenses too (subject to

ordinary income tax).

• You can invest your

account balance. After you

reach a minimum balance,

you can invest just like a

401K or IRA. You have many

investment options.

7

Want to see the doctor? Choose “video” as the method for your visit. Feeling camera shy? Choose “phone”. Got a busy schedule? Select a time that’s best for you by choosing “schedule” instead of “as soon as possible”.

You will receive convenient, quality care from a variety of licensed healthcare providers.

Physician Dermatologist Therapist FOR ISSUES LIKE: FOR ISSUES LIKE: FOR ISSUES LIKE: Cold & Flu symptoms Skin infection Stress/anxiety Bronchitis Acne Depression Allergies Skin rash Domestic abuse Pink eye Abrasions Grief counseling Bladder infection Moles/warts Addiction

Visit Teladoc.com/bsc and set up an account or call 1.800.835.2362

Connecting with a doctor within minutes is easy.

1. Request a visit with a doctor 24 hours a day, 365 days a year, by web, phone, or mobile.

3. If medically necessary, a prescription will be sent to the pharmacy of your choice. It’s that easy!

2. Talk to the doctor. Take as much time as you need…there’s no limits!

https://www.teladoc.com/bsc

8

How To Enroll in Benefits As a new employee, you have 30 days from your date of hire to enroll in the City of Santa Monica’s benefit programs. After this initial enrollment period, your next opportunity to elect and enroll in benefits will be during the 2021 Open Enrollment period unless you experience a Qualifying Event (marriage, divorce, birth/death of a dependent, dependent loss/gain coverage). What do I need to do?

1. All benefit eligible employees must go to the City’s online enrollment portal, https://benefits.plansource.com, if you would like to do any of the items on #2.

2. If I want to:

• Enroll in any of the City-sponsored plans and the voluntary benefit for the first time; • Add dependent coverage. Note that social security numbers are required for all

dependents; • Add the Voluntary Term Life Plan; • Participate for the first time in the Healthcare or Dependent Care FSA or participate for

the first time in an HSA; • Waive participation in City-sponsored medical, dental, vision benefits; and/or • Combine coverage with a spouse or registered domestic partner who is also a benefit-

eligible City employee.

You must go online to enroll or make changes in the City’s online enrollment website, www.plansource.com/login. All plan changes, dependent additions or deletions and HSA or FSA enrollments must be made online. An electronic copy of the PlanSource Self-Service Enrollment Guide is available on the City’s website, https://www.smgov.net/Departments/HR/Employees/PlanSource Online Enrollment System.aspx. This guide will help you establish a username and/or obtain your password. It also has step-by-step instruction on how to enroll. Kaiser enrollments: to enroll in a Kaiser plan, you must also complete an Enrollment Form in addition to enrolling online in the City’s enrollment portal. What if I want to waive medical coverage? If you plan to waive medical insurance coverage and are interested in receiving $150/month (Cash-in-lieu), you will need to complete the Cash-in-Lieu Form and provide the following documents listed below. You can email the documents to [email protected], fax or deliver to Human Resources Department.

1. Cash-in-Lieu Agreement Form 2. Copy of your medical insurance card 3. A letter or screenshot from the carrier or entity providing the plan that includes

employee name, medical plan, and effective coverage for the 2020 plan year.

https://benefits.plansource.com/

http://www.plansource.com/login

https://www.smgov.net/Departments/HR/Employees/PlanSource%20Online%20Enrollment%20System.aspx

https://www.smgov.net/Departments/HR/Employees/PlanSource%20Online%20Enrollment%20System.aspx

mailto:[email protected]

9

Who Can You Cover?

WHO IS ELIGIBLE?

A permanent employee working 20 or more hours per week is eligible for the benefits outlined in this overview. Your coverage for health, dental and vision benefits will be effective on the first of the month following your date of hire.

ELIGIBLE DEPENDENTS

• Current legal spouse or registered domestic partner (same or opposite gender).

• Children (including your domestic partner's children):

o Must be under the age of 26. They do not have to live with you or be enrolled in school. They can be married and/or living and working on their own.

o Eligible children include natural children, stepchildren, legally-adopted children, or children who have been placed in your custody during the adoption process, and physically or mentally handicapped children who depend on you for support, regardless of age.

o A child of a covered domestic partner who satisfies the same conditions as listed above for natural children, stepchildren, or adopted children, and in addition is not a “qualifying child” (as defined in the Internal Revenue Code) of another individual.

INELIGIBLE DEPENDENTS

• Former spouse/registered domestic partner even if you are court ordered to provide the ex-spouse/former domestic partner with health coverage

• Children age 26 or older • Children of former spouse or former registered

domestic partners • Disabled children over age 26 who were not

enrolled prior to age 26 • Relatives such as grandchildren, grandparents,

parents, aunts, uncles, nieces, nephews, etc.

DEPENDENT ELIGIBILITY DOCUMENTATION REQUIREMENTS

If you are adding dependents (spouse and/or dependent children) during Open Enrollment, the City of Santa Monica requires that you verify your dependent’s eligibility. You have 30 days from date of hire to submit documentation that verifies your dependent eligibility to Human Resources. You may email ([email protected]), fax (310-656-5705), or interoffice the documentation. If the verification documents for added dependents are not received within 30 days, your dependent(s) will not be added to your health plans for 2020.

QUALIFYING LIFE EVENTS Make sure to notify Human Resources if you have a qualifying life event and need to make a change (add or drop) to your coverage election. You have 31 days to make you change. These changes include (but are not limited to):

• Birth or adoption of a baby or child • Loss of other healthcare coverage, does not

include private plans • Eligibility for new healthcare coverage • Marriage or Divorce • Death of a dependent A list of qualifying events can be found in the Legal Document posted on the City’s HR website.

Click on the icon to watch a video on Qualifying Events.

https://flimp.me/ASF_QualifyingEvents

10

Making the Most of Your Benefits

WHEN TO USE THE ER

The emergency room shouldn't be your first choice unless there's a true emergency—a serious or life threatening condition that requires immediate attention or treatment that is only available at a hospital. WHEN TO USE URGENT CARE Urgent care is for serious symptoms, pain, or conditions that require immediate medical attention but are not severe or life-threatening and do not require use of a hospital or ER. Urgent care conditions include, but are not limited to: earache, sore throat, rashes, sprains, flu, and fever up to 104°. GET A VIDEO HOUSE CALL

Blue Shield members can video chat, 24/7, with a doctor who can treat common illnesses and, if needed, can send a prescription to your local pharmacy. For more information, see page 12 or visit www.teladoc.com/bsc.

WHEN YOU NEED CARE NOW What do you do when you need care right away, but it’s not an emergency?

Kaiser Permanente Plan Participants

• Call Kaiser's 24/7 NurseLine at 800-464-4000 • For access to care resources and advice go to

https://healthy.kaiserpermanente.org/southern-california/doctors-locations/how-to-find-care/get-advice

Blue Shield Medical Plan Participants

• Call NurseHelp 24/7 and get your health questions answered by a nurse. The phone number is on the back of your Blue Shield ID card.

• Find an urgent care center by visiting www.bscaplan.com/peotj4

• Go online at www.blueshieldca.com/nursehelp and have a one-on-one chat with a nurse anytime.

DIABETIC EYECARE PLUS PROGRAM

VSP has special services if you have diabetic eye disease, glaucoma or age-related macular degeneration (AMD). You can receive your routine eye care and follow-up medical eye care services from your VSP doctor. You can also receive preventive retinal screenings if you have diabetes but do not show signs of diabetic eye disease. Questions? Call VSP at 800.877.7195.

PREVENTIVE CARE VS DIAGNOSTIC

Preventive care is intended to prevent or detect illness before you notice any symptoms. Diagnostic care treats or diagnoses a problem after you have had symptoms.

Be sure to ask your doctor why a test or service is ordered. Many preventive services are covered at no out-of-pocket cost to you. The same test or service can be preventive, diagnostic, or routine care for a chronic health condition. Depending on why it's done, your share of the cost may change.

Whatever the reason, it's important to keep up with recommended health screenings to avoid more serious and costly health problems down the road.

To find out what preventive care screenings you should have based on your age and gender, visit www.blueshieldca.com/preventive-care.

https://member.teladoc.com/bsc

https://protect-us.mimecast.com/s/gfSxCZ6rnEtG16pVFz9w7o?domain=healthy.kaiserpermanente.org



http://www.bscaplan.com/peotj4

http://www.blueshieldca.com/nursehelp

http://www.blueshieldca.com/preventive-care

https://vimeo.com/180057401

11

Blue Shield of California

TRIO HMO – a special network The Blue Shield Trio HMO plan is a smarter, more modern way to access health care. The Trio HMO is a special network of doctors and hospitals that share responsibility for providing high-quality, coordinate care to you and your family when needed while lowering costs by delivering care more efficiently.

Provider Network

The Trio HMO special network includes medical groups, hospitals and doctors from the HMO Access + network. With the Trio HMO, you still must select a Primary Care Physician (PCP) to coordinate and direct your healthcare needs. Below is a partial list of medical groups/IPA and hospitals that participate in this special network. Note that UCLA is not part of the Trio HMO network.

CUSTOM MICROSITE FOR CSM Blue Shield is going green! We now have a custom website for all Blue Shield members from the City of Santa Monica. Members will find everything that they need in one simple place.

• View plan information and benefit summaries 24/7 • Find doctors, hospitals, specialists and more • Explore health programs, care options and services that are available to you

Go to www.bscaplan.com/peotj4.

County IPA/medical group name Los Angeles Access Medical Group Inc.

Access Medical Group Santa Monica Allied Pacific of California IPA AppleCare Medical Group Whittier AppleCare Medical Group AppleCare Medical Group Select AppleCare Medical Group St. Francis Region Axminster Medical Group – Little Company of Mary – San Pedro Axminster Medical Group – Little Company of Mary IPA – Torrance Axminster Medical Group – Providence Care Network – Tarzana Axminster Medical Group Inc. Facey Medical Foundation Burbank Facey Medical Foundation San Fernando Valley Facey Medical Foundation Santa Clarita Facey Medical Foundation Simi Valley Good Samaritan Medical Practice Associates Korean American Medical Group Greater Newport Physicians (GNP) – Long Beach MemorialCare Pomona Valley Medical Group Torrance Health IPA

County Trio ACO HMO Hospitals

Los Angeles Alhambra Hospital Medical Center Garfield Medical Center Good Samaritan Hospital Greater El Monte Community Hospital Henry Mayo Newhall Hospital Long Beach Memorial Medical Center Marina Del Rey Hospital Monterey Park Hospital Northridge Hospital Medical Center (Roscoe Campus) PIH Hospital – Downey Pomona Valley Hospital Medical Center Providence Holy Cross Medical Center Providence Little Company of Mary Medical Center San Pedro Providence Little Company of Mary Medical Center Torrance Providence Saint Joseph Medical Center Providence Tarzana Medical Center St. John’s Health Center San Gabriel Valley Medical Center Simi Valley Hospital and Health Care Services Torrance Memorial Medical Center Whittier Hospital Medical Center

https://www.bscaplan.com/peotj4

12

TELADOC – A VIRTUAL VISIT Teladoc is available to all Blue Shield members. This service is a new and convenient way to access care. U.S. certified doctors are available 24/7/365 to resolve non-emergency medical issues via phone or video consults.

MAIL ORDER SERVICES – CVS CAREMARK Blue Shield of California provides access to the mail service drug benefit through CVS Caremark Mail Service Pharmacy™.

Filling your prescription through the mail service pharmacy is easy.

1. Register with CVS Caremark. Online – at www.caremark.com By phone – call CVS Caremark at 866.346.7200.

2. Send your prescription to CVS Caremark. Electronically – ask your doctor to send an electronic 90-day supply prescription to CVS Caremark. By phone or fax – ask your doctor to submit a 90-day supply prescription by faxing 800.378.0323. By mail – mail prescription, complete mail order form and payment to: CVS Caremark, P.O. Box 659541, San Antonio, TX, 78265-9541

3. CVS Caremark delivers. Allow 10 – 14 days business days to receive your medication.

Refills are simple

• Online – register at www.caremark.com and ordering refills is convenient. • By phone – call 866.346.7200 and follow the prompts for the automated reorder system. • By mail – complete the CVS Caremark refill order form included in your last medication shipment and

mail it along with payment to: CVS Caremark, P.O. Box 659541, San Antonio, TX, 78265-9541.

When should I use Teladoc?

What kind of symptoms can be treated? How much will I pay? How do I get started?

• If you are considering the ER or urgent care center for a non-emergency

• When on vacation, a business trip or away from home

• For short-term prescription refills

Teladoc doctors and therapists can treat many medical conditions, including: • Cold and flu symptoms • Allergies • Bronchitis • Urinary tract infection • Respiratory infection • Sinus problems • Depression • Anxiety

Trio HMO: No Charge Access+ HMO and PPO Members: $5 copay per consult HDHP Members: Members pay a $40 consult fee until the deductible is met, then a $5 copay.

1. Set up an account. Visit teladoc.com/bsc, complete the required information and click on Set up account.

2. Provide medical history. Your medical history provides doctors with the information they need to make an accurate diagnosis.

3. Request a consult. Once your account is set up, request a consult anytime you need care.

Talk to a doctor anytime.

For information, go to www.teladoc.com/bsc or call 1-800-TELADOC (835.2362) for help.

https://www.caremark.com/

https://www.caremark.com/



13

BLUE SHIELD CONCIERGE

One phone call to your Blue Concierge team delivers fast help.

Your Shield Concierge is a team of registered nurses, health coaches, social workers, pharmacy technicians, pharmacists and customer service representatives, all working together for you!

They are ready to help you:

• Find a doctor or specialist • Transfer your prescriptions and medical records • Understand your plan benefits • Get answers to your drug/medication questions • Answer questions about your doctor’s instructions • Assist with continuity of care

PROGRAMS AND SERVICES Condition Management Program – Get nurse support, education and self-management tools to help treat

chronic conditions. Programs are available for members with asthma, diabetes, coronary artery disease, heart failure and chronic obstructive pulmonary disease.

LifeReferrals 24/7 – With this program, you can call anytime to talk with experienced professionals ready to help you with personal, family and work issues. Get referrals for three face-to-face or telephone visits in a six-month period with a licensed therapist at no cost.

NurseHelp 24/7 - - registered nurses are available day or night to answer your health questions. Call 877.304.0504 or go online. www.blueshieldca.com/nursehelp, to have a one-to-one chat.

Prenatal Program – Expectant parents get 24/7 phone access to experienced maternity nurses. Program also offers prenatal information, including a choice of a free pregnancy or parenting book.

Shield Support – Our case management program supports members with acute, long-term and high-risk conditions. The program includes short-term care coordination and ongoing case management. The care team includes physicians, registered nurses, licensed social workers and dieticians who provide support and resources to meet member’s needs.

ID protection and credit monitoring – Blue Shield offers identity protection services such as credit monitoring, identity repair assistance and identity theft insurance to our eligible plan members and their covered family members. These services are at no charge.

Wellness discount programs – Blue Shield offers a wide range of discount programs to help you save money and get healthier. These include discounts for Weight Watchers; membership with 24 Hour Fitness, ClubSport and Renaissance ClubSport; acupuncture, chiropractic services and massage therapy; and eye exams, frames, contact lenses and LASIK surgery. Visit www.blueshield.com/hw to learn more.

Your Shield Concierge team is ready to help you.

Call 855.829.3566

Monday – Friday between 7 a.m. and 7 p.m.

Have questions? Get answers. Call the Shield Concierge number at 855.829.3566.

Visit the new Blue Shield microsite at www.bscaplan.com/peotj4

https://www.blueshieldca.com/nursehelp

http://www.blueshield.com/hw



14

Blue Shield Medical Plans This comparison chart shows a brief summary of the medical benefits available.

Blue Shield Access+ HMO In-Network Only

Blue Shield Trio HMO In-Network Only

How it Works You must use a Blue Shield HMO contracted provider or your care will not be covered. There are no Out-of-Network benefits with these plans, except in the case of an emergency.

Medical Plan Annual Deductible Lifetime Maximum Annual Co-pay (Out-of-Pocket maximum)

$0 Individual/$0 Family Unlimited $1,500 Individual/$3,000 Family

$0 Individual/$0 Family Unlimited $1,500 Individual/$3,000 Family

Hospital Care Inpatient

- Physician - Facility Services

Outpatient Surgery Emergency Room Visit

- Not resulting in admission - Resulting in hospital admission

No Charge $100/ Admission No Charge $100 Co-pay Inpatient Facility Services charge applies

No Charge $100/Admission No Charge $100 Co-pay Inpatient Facility Services charge applies

Physician Care Office Visit Specialist Visit Telemedicine – Virtual Visit Preventive Care/Annual Physical X-Ray. Lab & Pathology Services CT/PET scans, MRIs, MRAs Immunizations Outpatient Rehabilitation Therapy

- Physical, Speech, Occupational, Respiratory

Chiropractic Services Acupuncture Services

$20 Co-pay $20 Co-pay or $30 Access+ (self-referral) $5 Co-pay (Teladoc) No Charge No Charge No Charge No Charge $20 Co-pay $15 Co-pay, 20 visits per year Not Covered

$20 Co-pay $20 Co-pay or $30 for Trio (self-referral) No Charge (Teladoc) No Charge No Charge No Charge No Charge $20 Co-pay $15 Co-pay, 20 visits per year Not Covered

Mental Health/Substance Abuse Inpatient - Mental Health Outpatient - Mental Health Chem. Dependency Rehab - Outpatient Detoxification - Inpatient (Detox Only)

$100/ Admission $20 Co-pay at doctor’s office $20 Co-pay at doctor’s office $100/Admission

$100/ Admission $20 Co-pay at doctor’s office $20 Co-pay at doctor’s office $100/ Admission

Other Ambulance - ER or authorized transport Prosthetics Durable Medical Equipment Home Healthcare Services Hospice

No Charge No Charge No Charge No Charge (up to 100 visits) No Charge

No Charge No Charge No Charge No Charge (up to 100 visits) No Charge

15


Blue Shield Access+ HMO In-Network Only

Blue Shield Trio HMO In-Network Only

Other - Continued Pregnancy/Maternity Care Family Planning - Counseling - Tubal ligation - Vasectomy - Infertility Services (Diagnosis and treatment of causes only)

No Charge No Charge No Charge No Charge 50% of allowed charges

No Charge No Charge No Charge No Charge 50% of allowed charges

Diabetes Care Devices and non-testing supplies Diabetes self-management training

No Charge $20 Co-pay

No Charge $20 Co-pay

Care Outside of Service Area (benefits provided by the BlueCard Program, for out-of-state emergency and non-emergency care, are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) · Within US: BlueCard Program · Outside US: BlueCard Worldwide

Not Covered except for Emergency Care

Not Covered except for Emergency Care

Prescription Drugs Annual Deductible:

None Annual Deductible:

None

Out-of-Pocket Maximum: None


Retail: Generic/Brand/Non-formulary/High Cost Drugs

$10 / $20/ $35 / $35 (30-day supply) $10 / $20/ $35 /$35 (30-day supply)

Mail Order: Generic/Brand/Non-formulary/ High Cost Drugs

$20 / $40 / $70/ $70 (90-day supply) $20 / $40/ $70/ $70 (90-day supply)

Specialty Medications

$35 per script $35 per script

Click on the icon to watch a video on Prescription Drugs / Dos and Don’ts.


16


Blue Shield Full PPO

How it Works You may see any provider when you need care. You decide whether to see an in-

network or an out-of-network provider each time you need care. When you see in-network providers you typically pay less. In-Network Out-of-Network


Individual: $500 - Family: $500/$1,000

Unlimited $3,000 Ind / $6,000 Family (combined In & Out-of-Network)





20%* 20%* 20%* $100/ visit 20%*

40%* 40%* up to $1,500/day 40%* up to $600/day $100/ Visit 40%* up to $1,500/day




$20 Co-pay $20 Co-pay $5 Co-pay (Teladoc) No Charge 20%* 20%* No Charge 20%* $20 Co-pay, 20 visits per year Not Covered

40%* 40%* Not Covered Not Covered 40%* 40%* Not Covered 40%* 40%*, 20 visits per year Not Covered


20%* $20 Co-pay at doctor’s office $20 Co-pay at doctor’s office 20%*

40%* up to $1,500/day 40%* 40%* 40%* up to $1,500/day


20%* 20%* 20%* No Charge, 120 visits/year* No Charge*

20%* 40%* 40%* Not Covered Not Covered

* After annual deductible is met.

Note for Out-of-Network benefits - member is responsible for coinsurance in addition to any charges over the allowable amount. When members use non-contracted providers, they must pay the applicable copayment/coinsurance plus any amount that exceeds Blue Shield’s allowable amount. Charges in excess of the allowable amount do not count toward the calendar year deductible or out-of-pocket maximum.

17


Blue Shield Full PPO

In-Network Out-of-Network Other - Continued Pregnancy/Maternity Care Family Planning - Counseling - Tubal ligation - Vasectomy - Infertility Services (Diagnosis and treatment of causes only)

No Charge No Charge No Charge 20%* Not Covered

40%* Not Covered Not Covered Not Covered Not Covered


20%* $20 Co-pay

40%* 40%*


Covered

Covered

Prescription Drugs Annual Deductible:

None Annual Deductible:

None




$10 / $20/ $35 / $35 (30-day supply) In-Network Copay + 25%

Mail Order: Generic/Brand/Non-formulary/High Cost Drugs

$20 / $40 / $70/ $70 (90-day supply) Not Covered


$35 per script Not Covered



18


Blue Shield High Deductible Health Plan (PPO)

How it Works You may see any provider when you need care. You decide whether to see an in-

network or an out-of-network provider each time you need care. When you see in-network providers you typically pay less. In-Network Out-of-Network


Individual: $1,800 - Family: $2,800/$3,600

Unlimited $4,500 Ind/ $9,000 Family $8,000 Ind / $16,000 Family





20%* $100 Co-pay + 20%* 20%* $150 /visit + 20%* $100 Co-pay + 20%*

40%* 40%* up to $1,500/day 40%* up to $600/day $150/ Visit + 20%* 40%* up to $1,500/day




20%* 20%* $5 Co-pay (Teladoc)* No Charge 20%* 20%* No Charge 20%* 20%*, 20 visits per year 20%*, 20 visits per year

40%* 40%* Not Covered Not Covered 40%* 40%* Not Covered 40%* 40%*, 20 visits per year 20%*, 20 visits per year


$100 Co-pay + 20%* 20%* 20%* $100 Co-pay + 20%*

40%* up to $1,500/day 40%* 40%* 40%* up to $1,500/day


20%* 20%* 20%* 20%*, 100 visits/year* No Charge*

20%* 40%* 40%* Not Covered Not Covered



19


Blue Shield High Deductible Health Plan (PPO)

In-Network Out-of-Network Other - Continued Pregnancy/Maternity Care Family Planning - Counseling - Tubal ligation - Vasectomy - Infertility Services (Diagnosis and treatment of causes only)

20%* No Charge No Charge 20%* Not Covered

40%* Not Covered Not Covered Not Covered Not Covered


20%* 20%*

40%* 40%*


Covered

Covered

Prescription Drugs You must meet the annual deductible first before the noted co-payment

amounts apply.

Medical and Pharmacy have combined Out-of-Pocket Maximum


$10 / $25/ $40/ 30% up to $200 max per script* (30-day supply)

In-Network Copay + 25%

Mail Order: Generic/Brand/Non-formulary/ High Cost Drugs

$20 / $50 / $80 / 30% up to $400 per script* (90-day supply)

Not Covered


30% up to $200 max per script* Not Covered



20

Kaiser Medical Plan The City of Santa Monica offers you a Kaiser Permanente option for medical insurance.

For information on the Kaiser plan, please contact PacFed Benefits Administration at 800.753.0222. Refer to page 31 for additional services from PacFed.

2019 Kaiser HMO

In-Network Only

2020 Kaiser HMO

In-Network Only


None Unlimited $1,500 Individual/$3,000 Family

None Unlimited $1,500 Individual/$3,000 Family

Hospital Care Inpatient Surgery Outpatient Surgery Emergency Room Visit

- Not resulting in admission - Resulting in hospital

admission

No Charge $15 Co-pay per procedure $50 Co-pay No Charge

No Charge $15 Co-pay per procedure $50 Co-pay No Charge

Physician Care Office Visit Specialist Visit Urgent Care Preventive Care/Annual Physical X-Ray. Lab & Pathology Services CT/PET scans, MRIs, MRAs Immunizations Physical/Occupational Therapy

$15 Co-pay $15 Co-pay $15 Co-pay No Charge $5 Co-pay per encounter $5 Co-pay per procedure No Charge $15 Co-pay

$15 Co-pay $15 Co-pay $15 Co-pay No Charge $5 Co-pay per encounter $5 Co-pay per procedure No Charge $15 Co-pay


No Charge $15 Co-pay $15 Co-pay No Charge

No Charge $15 Co-pay $15 Co-pay No Charge

Other Ambulance Prosthetics Durable Medical Equipment Home Healthcare Services Hospice

$50 per transport No Charge 20% Coinsurance No Charge (up to 100 visits) No Charge

$50 per transport No Charge 20% Coinsurance No Charge (up to 100 visits) No Charge

Prescription Drugs Retail: Mail-Order:

$10 Co-pay Generic $15 Co-pay Preferred Brand $15 Non-Preferred Brand Specialty: $15 Co-pay per script No Non-Formulary Coverage (30-day supply) $10 Co-pay Generic $15 Co-pay Preferred Brand $15 Co-pay Non-Preferred Brand (100-day supply)

$10 Co-pay Generic $15 Co-pay Preferred Brand $15 Non-Preferred Brand Specialty: $15 Co-pay per script No Non-Formulary Coverage (30-day supply) $10 Co-pay Generic $15 Co-pay Preferred Brand $15 Co-pay Non-Preferred Brand (100-day supply)

21

Dental Regular visits to your dentists can protect more than your smile; they can help protect your health.

Delta Dental DHMO DeltaCare USA Delta Dental PPO Plan

In-Network In-Network Out-Of-Network

Calendar Year Deductible

$0 Individual

$0 Family

$0 Individual

$0 Family

$50 Individual

$150 Family

Annual Plan Maximum Unlimited $2,000/person $1,000/person

Waiting Period None None None

Diagnostic and Preventive

Plan pays 100% Plan pays 100% Plan pays 80%

Basic Services

Fillings $0-$50 copay (varies by service, see contract for fee schedule)

Plan pays 90% after deductible


Root Canals $5-$75 copay (varies by service, see contract for fee schedule)



Periodontics $5-$150 copay (varies by service, see contract for fee schedule)



Major Services $5-$125 copay (varies by service, see contract for fee schedule)



Orthodontic Services

Orthodontia

Lifetime Maximum N/A $1,000 (combined in and out-of-network)

Child $1,600 Plan pays 50% Plan pays 50%

Adult $1,800 Plan pays 50% Plan pays 50%

When first enrolling in a DHMO plan, you must choose a primary dentist. If you do not select a dentist, one will automatically be selected for you. If you would like a different dentist than the one that was auto-assigned, you will need to call Delta Dental at 800.422.4234.

Click on the icon to watch a video on Dental Insurance.

http://flimp.me/ASF_DentalInsurance

22

Vision Routine vision exams are important, not only for correcting vision but because they can detect other serious health conditions. The City of Santa Monica offers you a vision plan through Vision Service Plan.

VSP – Choice Plan

In-Network Out-Of-Network

Examination

Benefit $25 copay then plan pays 100% Plan pays up to the $45 allowance

Frequency 1 x every 12 months In-network limitations apply

Materials Combined with examination Combined with examination

Eyeglass Lenses

Single Vision Lens Plan pays 100% of basic lens Up to $30 allowance

Bifocal Lens Plan pays 100% of basic lens Up to $50 allowance

Trifocal Lens

Standard Progressive

Plan pays 100% of basic lens

Plan pays 100%

20% off all other lens options

Up to $65 allowance

Up to $50 allowance


Frames

Benefit Up to $190 retail allowance, then 20% off amount above the allowance

Up to $210 allowance for featured brand

Up to $105 allowance at Costco

Up to $70

Up to $70

N/A


Contacts (Elective)

Elective Up to $180 allowance (instead of eyeglasses) Up to $105 allowance (instead of eyeglasses)

Medically Necessary $25 copay Up to $210 allowance

Frequency 1 x every 12 months 1 x every 12 months

Low Vision Benefit

$1,000 maximum benefit every two years (for severe vision problems) Not covered

Laser Vision Correction 15% fee discount Not covered

Suncare

Frequency

$25 copay, up to $190 allowance for ready-made non-prescription sunglasses

1 x every 24 months

Up to $70

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwjjq_qs0PDdAhV7wcQHHZTICDkQjRx6BAgBEAU&url=http://seekvectorlogo.com/vision-service-plan-vsp-vector-logo-svg/&psig=AOvVaw0et0BsqtZHiCLTVrPFqcxD&ust=1538874474667648

23

Cost of Coverage

The City of Santa Monica pays for 100% of the premiums for Dental, Vision, the Employee Assistance Program, basic Life and Accidental Death & Dismemberment (AD&D), and Long Term Disability (LTD) coverage.

Please note that medical rates can be found at www.smgov.net/departments/hr/.

Dental

Premium City

Contribution Employee

Contribution

Delta Dental DHMO Dental Plan

Employee Only $35.41 ($35.41) $0

With 1 Dependent $35.41 ($35.41) $0

Two + Dependents $35.41 ($35.41) $0

Delta Dental DPPO Dental Plan

Employee Only $91.08 ($91.08) $0

With 1 Dependent $91.08 ($91.08) $0

Two + Dependents $91.08 ($91.08) $0

Vision

Premium City

Contribution Employee

Contribution

VSP Vision Plan

Employee Only $11.76 ($11.76) $0

With 1 Dependent $11.76 ($11.76) $0

Two + Dependents $11.76 ($11.76) $0

https://www.smgov.net/departments/hr/

24

Life and Disability Insurance If you have loved ones who depend on your income for support, having life and accidental death insurance can help protect your family's financial security.

BASIC LIFE and AD&D

Basic Life Insurance pays your beneficiary a lump sum if you die. AD&D provides another layer of benefits to either you or your beneficiary if you suffer from loss of a limb, speech, sight, or hearing, or if you die in an accident. The cost of coverage is paid in full by the City of Santa Monica. Coverage is provided by The Hartford.

Eligible Group Basic Life Amount Basic AD&D Amount

Class 1: ATA, EPP, FEMA, HRO, MTA, PALSSU, PAU, RCL, RCM, STA, SUE, POA(Lieutenant, Police Captain, Deputy Police Chief)

2 x basic annual salary up to $500,000


Class 2: FIRE $75,000 $10,000

Class 3: MEA $50,000 $10,000

Class 4: EAC, SMART $10,000 $10,000

Class 5: STA and ATA reclassified into MEA prior to January 1, 2010.



Class 6: IBT $100,000 $20,000

Taxes: Due to IRS regulations, a life insurance benefit of $50,000 is considered a taxable benefit. You will see the value of the benefit included in your taxable income on your paycheck and W-2.

Note: Your amount of Life and AD&D will decrease to 65% of original coverage on your 70th birthday and 50% of original coverage at age 75.

BENEFICIARY REMINDER Beneficiary means a person you name to receive death benefits. You may name one or more beneficiaries. Make sure that you have named a beneficiary for your basic life insurance. You may change your beneficiary at any time. Note that some states require a spouse be named as a beneficiary unless they sign a waiver. Remember that a divorce or separation will not automatically affect a beneficiary designation, so review your beneficiary election(s) annually to ensure it accurately reflects your wishes. Go to www.plansource.com/login , to change your beneficiary.


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LONG-TERM DISABILITY INSURANCE

Long-Term Disability coverage pays you a certain percentage of your income if you can't work because an injury or illness prevents you from performing any of your job functions over a long time. It's important to know that benefits are reduced by income from other benefits you might receive while disabled, like Workers' Compensation and Social Security.

If you qualify, long-term disability benefits begin after short-term disability benefits end. The cost of coverage is paid in full by the City of Santa Monica. Coverage is provided by The Hartford.

Eligible Group: Class 1

Employees in job classes represented by: Active full-time or permanent part-time employee represented by or who receive the benefits of the: Executive Pay Plan (Exec), Hearing Examiner Representation Organization (Hero), Public Attorney's Union (PAU), Employees of the Society for Union Employment (SUE), Rent Control Managers, Administrative Team Association (ATA), Management Team Association (MTA), Fire Executive Management Association (FEMA) employee, working a minimum of 20 hours per week

Plan pays 60% of your basic monthly income

$8,333 is maximum amount

Benefits begin after 60 days of disability

Social Security normal retirement age is maximum payment period*


Employees in job classes represented by: Active full-time or permanent part-time employee represented by or who receive the benefits of the: City Council, Municipal Employee Association (MEA), International Brotherhood of Teamsters (IBT), Employees Action Committee of the Rent Control Board (EAC, Rent Control Letters of Employment, Supervisory Team Associates (STA), Public Attorneys' Legal Support Staff Union (PALSSU) employee working a minimum of 20 hours per week






Employees in job classes represented by: Active full-time or permanent part-time employee represented by or who receive the benefits of the: International Association of Sheet Metal, Air, Rail, and Transportation workers - Transportation Division (SMART-TD) employee working a minimum of 20 hours per week





*The age at which the disability begins may affect the duration of the benefits.

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VOLUNTARY TERM LIFE INSURANCE

Voluntary Term Life Insurance allows you to purchase additional life insurance to protect your family's financial security. Coverage is provided by The Hartford.

Employee Voluntary Term Life Amount

Can elect from $10,000 to $300,000 in increments of $10,000 not to exceed five (5) times your salary. Guaranteed issue amount is three (3) times basic annual earnings or $100,000 whichever is less.*

Spouse or Domestic Partner Voluntary Term Life Amount

Can elect from $10,000 to $150,000 in increments of $10,000. Guaranteed issue amount is $30,000.

Child(ren) Voluntary Term Life Amount

Can elect $2,500 or $5,000 or $7,500 or $10,000 (from 6 months to age 26). Guaranteed issue amount is $10,000.

*Guaranteed issue amount is only available to new hires. If you do not enroll during your initial new hire period, you will need to submit an Evidence of Coverage (EOI) form.

.

Monthly Rates

Employee and Spouse Supplemental Life Insurance Rates

Age Cost per $1,000 of Coverage

Under 20 $0.04 20-24 $0.04 25-29 $0.04 30-34 $0.052 35-39 $0.064 40-44 $0.101 45-49 $0.167 50-54 $0.282 55-59 $0.486 60-64 $0.628 65-69 $0.883 70-74 $1.767 75+ $1.767

Child Life Insurance Rates

Coverage Levels

Cost of Coverage

$2,500 each child

$5,000 each

child

$7,500 each child

$10,000 each

child

$0.54

$0.80

$1.09

$1.36

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Special Savings Accounts

FLEXIBLE SPENDING ACCOUNT (FSA)

The City of Santa Monica offers you a Healthcare and Dependent Care Flexible Spending Account (FSA)

through the P&A Group. You may participate in one or both plans.

Healthcare FSA Account

This plan allows you to pay for eligible healthcare expenses with pre-tax dollars. Eligible expenses include medical, dental, or vision costs such as plan deductibles, copays, coinsurance amounts, and other non-covered healthcare costs for you and your tax dependents. For 2020, you can set aside up to $2,750.

Dependent Care FSA Account

This plan allows you to set aside up to $5,000 per household to pay for eligible out-of-pocket dependent care expenses with pre-tax dollars. Eligible expenses may include daycare centers, in-home child care, and before or after school care for your dependent children under age 13. Other individuals may qualify if they are considered your tax dependent and are incapable of self-care. It is important to note that you can access money only after it is placed into your dependent care FSA account.

NOTE: IRS regulations require annual Non-Discrimination testing on the Dependent Care FSA Accounts. Highly compensated individuals may have their contribution amount adjusted during the year in order to pass the non-discrimination requirements.

IMPORTANT CONSIDERATIONS

• You must use all of your FSA funds by March 15, 2021 or else you will lose them. The Healthcare FSA plan has a Grace Period that allows you to continue to incur new claims up to 03/15/21, with any remaining funds from your 2020 elected amount. You have till 06/30/21 to submit these claims.

• Elections cannot be changed during the plan year, unless you have a qualified change in family status.

• FSA funds can be used for you, your spouse, and your tax dependents only.

• You must re-enroll every year during Open Enrollment. Your elected amount will not roll over for the next plan year.

How do I enroll in an FSA for 2020?

• Go to www.plansource.com/login • Create a new User Name and Password to login • Choose the amount you would like deducted from your

paycheck in 2020.

How do I manage my FSA account?

You have the option to use P&A’s online portal on your laptop or on your phone. Go to www.padmin.com. Upload your claims by simply logging into your account through your smartphone.

For assistance, call P&A Customer Service at 800.688.2611.

https://www.plansource.com/login

https://www.padmin.com/

28

HEALTH SAVINGS ACCOUNT (HSA)

A Health Savings Account (HSA) is available to employees who participate in the Blue Shield High Deductible Health Plan (HDHP). This is a tax-advantaged savings account that allows you to save pre-tax dollars to pay for qualified health expenses. To open an HSA account or change your contributions, you must go online to the City’s Open Enrollment website at www.plansource.com/login.

Why have an HSA Account?

• An HSA account is owned by you.

• Use pre-tax dollars to pay for qualified medical, dental and vision expenses.

• The HSA is portable; it goes with you if you leave employment.

• You elect the contribution amount to your HSA each pay

period, up to the IRS maximum before taxes are withheld. You

may change the deduction amounts at any time. The annual

employee contribution amount is subject to CA state taxes.

• If you and your spouse are both enrolled in a HDHP and

contribute into an HSA, your combined HSA contribution

cannot be more than the 2020 IRS maximum, even if your

spouse does not work for the City.

• Simply use your HSA debit card to pay for qualified expenses.

• HSA funds can be used to pay for qualified medical expenses of IRS tax dependents, even if the

dependent is not enrolled in your HDHP.

NOTE: you are not eligible to elect an HSA if you are covered by another health plan, such as a health plan sponsored by your spouse’s employer, Medicare, Tricare, or if an employee is claimed as a dependent on another’s tax return.

HSA Contribution Limits for 2020

Annual Single Contribution Maximum $3,550

Annual Family Contribution Maximum $7,100

Annual Catch-Up Contribution Maximum (for HSA participants that are 55 years or older)

$1,000

Want to learn more?

Click on the icon to watch a video on how a High Deductible Health Plan works alongside a Health Savings Account.

https://www.plansource.com/login


29

Other Programs TRAVEL ASSISTANCE

The Hartford offers you free Travel Assistance services provided by Europ Assistance USA.

Emergency Medical Assistance

• Medical referrals • Medical evacuation • Repatriation • Traveling companion assistance • Emergency medical payments • Return of mortal remains

Pre-trip Information • Visa and passport requirements • Immunization requirements • Embassy and consular referrals

Emergency Personal Services

• Medication and eyeglass prescription assistance

• Emergency travel arrangements • Locating lost items

Call Europ Assistance USA at 800.243.6108.

What you have ready:

4. Your employer’s name – City of Santa Monica 5. Phone number where you can be reached 6. Nature of the problem 7. Travel Assistance Identification Number – GLD-09012 8. Your policy number - GLT-804075

BENEFICIARY ASSIST COUNSELING SERVICES

The Beneficiary Assist program is offered to you by The Hartford and provides you with counseling services by ComPsych at no cost.

Professional help after a loss or terminal illness

Program provides you and immediate family members with unlimited 24/7 phone access when coping with a loss. Program includes:

• Legal advice, financial planning and emotional counseling for up to one year from the date the life claim is filed.

• Up to five face-to-face sessions or equivalent professional time for one service or a combination of services.

30

Health Advocacy Services and Support

Health care support services through HealthChampion are available if you become disabled from an accident or are diagnosed with a critical illness.

Support services include:

• Guidance through your health care options • Connecting you with the right resources • Advocating for time and fair resolution of issues

If additional medical support is needed, you have unlimited access to HealthChampion specialists who walk you through all aspects of your health care issues, helping you to ensure you are fully supported.

Learn more. Call 800.411.7239.

When you need it most, we are here to help.

FUNERAL CONCIERGE SERVICES

Losing a loved one is one of life’s most shocking experiences. To help you through this difficult time, The Hartford offers you a funeral concierge service

Features

24/7 Advisor Assistance • Round the clock access to expert advisors • Personal support from licensed funeral directors

PriceFinder research report • Nationwide database of funeral home prices • Detailed online price comparisons

Pre-planning tools • Document and store your wishes so they can be shared with family when needed

Online planning tools • Unlimited use of online funeral planning, research and knowledge tools

At-need family support • Communicate your funeral plan with your selected

funeral home • Cost negotiations often leads to significant savings

Hartford express pay • Delivers benefits in as little as 48 hours • Allows beneficiaries to use proceeds immediately for

funeral expenses

To learn more call 866.854.5429 or visit

www.everestfuneral.com/hartford and use code: HFEVLC

https://www.everestfuneral.com/hartford

31

PACFED BENEFITS ADMINISTRATORS – For the Kaiser plan only

If you enroll in the Kaiser plan, PacFed can assist you with your benefit plan.

Their Members Assistance Center assists members with Kaiser enrollment, coverage, claims and information such as:

• Benefits inquiry • Claims assistance • Eligibility • Materials and forms • Provider network inquiries • Referrals and pre-authorization • Adding and deleting dependents • ID cards

For Assistance, call 800.753.0222 or email [email protected]

MEET BEN-IQ

Ben-IQ is a free app that includes much of the information that's included in this overview, but in a place that's always at your fingertips — your smartphone. Ben-IQ is available for Android and iPhone.

WHY BEN-IQ?

• Get 24/7 access to your benefit plans • Find carrier phone numbers • Store and organize your ID cards • Find out how much care should cost • Access answers to frequently asked benefit questions. • Receive important messages from your HR/benefits team • Covered family members can also use

GETTING STARTED WITH BEN-IQ

1. Download and launch the app.

2. Enter your assigned username: CSM

3. Read and agree to the Terms and Conditions.

Take a tour of Ben-IQ clicking on the cell or going online at www.brainshark.com/alliant/beniq-hd

http://www.brainshark.com/alliant/beniq-hd

32

For Assistance If you need to reach our plan providers, here is their contact information:

Plan Type Provider Phone Number Website

Medical and Pharmacy Blue Shield – all medical plans

Teladoc – virtual visit

855.829.3566

800.835.2362

www.bscaplan.com/peotj4

www.teladoc.com/bsc

Kaiser Permanente 800.753.0222 www.members.kp.org

Dental Delta Dental

DHMO/ Group #71468

DPPO / Group #01509

800.422.4234

800.765.6003

www.deltadentalins.com/enrollees

Vision VSP/ Group #00105559 800.877.7195 www.vsp.com

Flex Spending Accounts and Cobra Coverage

P & A Group 800.688.2611 www.padmin.com

Health Savings Account (HSA)

Health Equity 877.857.6810 Email: [email protected]

Life and AD&D

Conversion/Portability

Evidence of Insurability -EOI

The Hartford

Group #804075

888.563.1124

877.320.0484

800.331.7234

Email: [email protected]

[email protected]

Long-Term Disability Plan The Hartford 888.301.5615 Email: [email protected]

Voluntary Term Life Plan The Hartford 800.523.2233 Email: [email protected]

Employee Assistance Program (EAP)

Magellan Health 800.523.5668 www.magellanascend.com Company Name: City of Santa Monica

For Plan/Benefits Assistance Benefits Advocate 888.585.5399 Email: [email protected]

PlanSource -Employee Self-Service

www.plansource.com/login

Member Assistance Center for Kaiser plan

PacFed Benefits Administrators

800.753.0222 Email:

[email protected]



http://www.members.kp.org/

http://www.deltadentalins.com/enrollees

http://www.vsp.com/

http://www.padmin.com/


http://www.magellanascend.com/


33

Retirement Plans Provider Phone Number Website

Retirement Pensions Public Employees Retirement System (PERS)

888.225.7377 www.calpers.ca.gov

Nationwide Retirement Solutions – Deferred Compensation

457(b) ROTH - Group #0036653-01

OBRA Plan (as-needed employees only) - Group #0036653-02

401(a) - Group #0036653-03

PEHP (FIRE,PALSUU) – Group #0039040-001

Loren Farfan, Sr. Retirement Specialist

Rochelle Davis, Sr. Retirement Specialist

877.677.3678

818.642.8191

323.823.4282

www.nrsforu.com

Email:

[email protected]

[email protected]

Benefits Staff Phone Number Email

Amanda Elek-Truman, Sr. Human Resource Analyst

310.458.8256 [email protected]

Diane Esquivel, Employee Benefits Specialist


Jennifer Garcia. Employee Benefits Specialist


Human Resources

1685 Main St. Rm: 101

Santa Monica, CA 90401

310.458.8246

Fax: 310.656.5705

[email protected]

http://www.calpers.ca.gov/

http://www.calpers.ca.gov/

http://www.nrsforu.com/


34

Key Terms

MEDICAL/GENERAL TERMS Allowable Charge - The most that an in-network provider can charge you for an office visit or service.

Balance Billing - Non-network providers are allowed to charge you more than the plan's allowable charge. This is called Balance Billing.

Coinsurance - The cost share between you and the insurance company. Coinsurance is always a percentage totaling 100%. For example, if the plan pays 70%, you are responsible for paying the remaining 30% of the cost.

Copay - The fee you pay to a provider at the time of service.

Deductible - The amount you have to pay out-of-pocket for expenses before the insurance company will cover any benefit costs for the year (except for preventive care and other services where the deductible is waived).

Explanation of Benefits (EOB) - The statement you receive from the insurance carrier that explains how much the provider billed, how much the plan paid (if any) and how much you owe (if any). In general, you should not pay a bill from your provider until you have received and reviewed your EOB (except for copays).

Family Deductible - The maximum dollar amount any one family will pay out in individual deductibles in a year. IMPORTANT: If you enroll for family coverage on the 2020 plan, one or more family members will need to meet the deductible.

Individual Deductible - The dollar amount a member must pay each year before the plan will pay benefits for covered services. Important: If you enroll for family coverage on the 2020 plan, the individual deductible does not apply.

In-Network - Services received from providers (doctors, hospitals, etc.) who are a part of your health plan's network. In-network services generally cost you less than out-of-network services.

Out-of-Network - Services received from providers (doctors, hospitals, etc.) who are not a part of your health plan's network. Out-of-network services generally cost you more than in-network services. With some plans, such as HMOs and EPOs, out-of-network services are not covered.

Out-of-Pocket - Healthcare costs you pay using your own money, whether from your bank account, credit card, Health Reimbursement Account (HRA), Health Savings Account (HSA) or Flexible Spending Account (FSA).

Out-of-Pocket Maximum – The most you would pay out-of-pocket for covered services in a year. Once you reach your out-of-pocket maximum, the plan covers 100% of eligible expenses.

Preventive Care – A routine exam, usually yearly, that may include a physical exam, immunizations and tests for certain health conditions.

PRESCRIPTION DRUG TERMS Brand Name Drug - A drug sold under its trademarked name. A generic version of the drug may be available.

Generic Drug – A drug that has the same active ingredients as a brand name drug, but is sold under a different name. Generics only become available after the patent expires on a brand name drug. For example, Tylenol is a brand name pain reliever commonly sold under its generic name, Acetaminophen.

Dispense as Written (DAW) - A prescription that does not allow for substitution of an equivalent generic or similar brand drug.

Maintenance Medications - Medications taken on a regular basis for an ongoing condition such as high cholesterol, high blood pressure, asthma, etc. Oral contraceptives are also considered a maintenance medication.

Non-Preferred Brand Drug - A brand name drug for which alternatives are available from either the plan's preferred brand drug or generic drug list. There is generally a higher copayment for a non-preferred brand drug.

35

Preferred Brand Drug - A brand name drug that the plan has selected for its preferred drug list. Preferred drugs are generally chosen based on a combination of clinical effectiveness and cost.

Specialty Pharmacy - Provides special drugs for complex conditions such as multiple sclerosis, cancer and HIV/AIDS.

Step Therapy - The practice of starting to treat a medical condition with the most cost effective and safest drug therapy and progressing to other more costly or risky therapy, only if necessary.

DENTAL TERMS Basic Services - Generally include coverage for fillings and oral surgery.

Diagnostic and Preventive Services - Generally include routine cleanings, oral exams, x-rays, sealants and fluoride treatments. Most plans limit preventive exams and cleanings to two times a year.

Endodontics - Commonly known as root canal therapy.

Implants - An artificial tooth root that is surgically placed into your jaw to hold a replacement tooth or bridge. Many dental plans do not cover implants.

Major Services - Generally include restorative dental work such as crowns, bridges, dentures, inlays and onlays.

Orthodontia - Some dental plans offer Orthodontia services for children (and sometimes adults too) to treat alignment of the teeth. Orthodontia services are typically limited to a lifetime maximum.

Periodontics - Diagnosis and treatment of gum disease.

Pre-Treatment Estimate - An estimate of how much the plan will pay for treatment. A pre-treatment estimate is not a guarantee of payment.

Click on the icon to watch a video on Key Health Insurance Terms.

https://flimp.me/ASF_KeyTerms

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Important Plan Notices and Documents

CURRENT HEALTH PLAN NOTICES Notices must be provided to plan participants on an annual basis are available on the City of Santa Monica’s website, www.smgov.net/Departments/hr and include:

• Medicare Part D Notice Describes options to access prescription drug coverage for Medicare eligible individuals.

• Women's Health and Cancer Rights Act Describes benefits available to those that will or have undergone a mastectomy.

• Newborns' and Mothers' Health Protection Act Describes the rights of mother and newborn to stay in the hospital 48-96 hours after delivery.

• HIPAA Notice of Special Enrollment Rights Describes when you can enroll in health coverage outside of open enrollment.

• Children's Health Insurance Program Reauthorization Act (CHIPRA) Describes availability of premium assistance for Medicaid eligible dependents.

CURRENT PLAN DOCUMENTS Important documents for our health plans are available on the City of Santa Monica’s benefits website, www.smgov.net/Departments/hr or thru Human Resources, 310.458.8246, and include:

Summary of Benefits and Coverage (SBCs)

A Summary of Benefits and Coverage (SBC) is a document required by the Affordable Care Act (ACA) that presents benefit plan features in a standardized format. The following SBCs are available:

• Blue Shield HMO

• Blue Shield Trio ACO HMO Plan

• Blue Shield PPO Plan

• Blue Shield HDHP Plan

• Kaiser HMO Plan

Evidence of Coverage (EOCs)

An Evidence of Coverage (EOC) is a document that describes your benefits under the plan as well as plan rights and obligations to participants and beneficiaries. The following EOC plan descriptions are available:

• Blue Shield HMO

• Blue Shield Trio ACO HMO Plan

• Blue Shield PPO Plan

• Blue Shield HDHP Plan

• Kaiser HMO Plan

http://www.smgov.net/Departments/hr



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Appendix DEPENDENT ELIBIGILITY DOCUMENTATION

Dependent Type

Required Documentation Resources to Obtain

Documentation

Dependent Spouse (same or opposite gender)

Marriage Certificate

• County office that issued original

marriage • Certificate • www.vitalchek.com

Registered Domestic Partner

State of California, County, or City issued Declaration/Certificate of Domestic partnership and/or Domestic Partner Affidavit. Requirements vary per medical plan carrier.

• County/City office that issued

original certificate • http://www.sos.ca.gov/dpregistry

Dependent child by birth

Birth Certificate (must include parents name), and/or copies of any court orders, divorce decrees or other legal documents relating to custody, health coverage or income tax exemptions.

• County office that issued original birth certificate

• Hospital in which child was born • U.S. Department of State (for

children born outside of the U.S) • Social Security Administration • www.vitalchek.com

Dependent child by Adoption

Final Adoption Papers, and/or copies of any court orders, divorce decrees or other legal documents relating to custody, health coverage or income tax exemptions.

• State agency that issued final

adoption papers • Adoption agency that issued

placement papers • Social Security Administration

Dependent stepchild(ren)

Birth Certificate (must include parents name), and/or copies of any court orders, divorce decrees or other legal documents relating to custody, health coverage or income tax exemptions.

• County office that issued original

birth certificate • Hospital in which child was born • U.S. Department of State (for

children born outside of the U.S) • Social Security Administration • www.vitalchek.com

http://www.vitalchek.com/

http://www.sos.ca.gov/dpregistry



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