City of Santa Monica 2020 Retiree Booklet F€¦ · Blue Shield Medical Plans – Under 65 or...

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City of Santa Monica Retiree & Cobra Benefits Overview

2020

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TABLE OF CONTENTS Benefits You Can Depend On ............................................................................................... 3

What’s New In 2020? ............................................................................................................. 4

Medicare Facts ..................................................................................................................... 10

Who Can You Cover? .......................................................................................................... 11

Making the Most of Your Benefits ...................................................................................... 12

Blue Shield of California ..................................................................................................... 14

Blue Shield Medical Plans – Under 65 or Non-Medicare .................................................. 18

Kaiser Medical Plan – Under 65 or Non-Medicare ............................................................ 25

Blue Shield Medicare Plan – Medicare A & B Eligible Retirees ....................................... 26

Cost of Coverage for Retiree Plans ................................................................................... 28

Dental – For Cobra Eligible Participants ........................................................................... 31

Vision – For Cobra Eligible Participants ........................................................................... 32

Employee Assistance Program – For Cobra Eligible Participants .................................. 33

Cost of Coverage for Cobra Plans ..................................................................................... 35

For Assistance ..................................................................................................................... 36

Key Terms ............................................................................................................................ 37

Important Plan Notices and Documents ............................................................................ 39

Appendix .............................................................................................................................. 42

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.

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BENEFITS YOU CAN DEPEND ON

At the City of Santa Monica, we believe that you 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

Retiree 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.

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The benefits in this summary are effective:

January 1, 2020 - December 31, 2020

What’s New In 2020?

For Retirees Under 65 or Non-Medicare Retirees Over 65:

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 11. 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.

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.

For Retirees 65 and Over with Medicare Part A & Part B:

The City of Santa Monica will continue to offer the Blue Shield of California Medicare

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Coordination of Benefits (COB) health Plan for the 2020 plan year. There are no changes

to the benefits for 2020. You must have Medicare Part A and Part B in order to be

eligible for this plan. The Blue Shield Medicare COB plan can be used nationwide. You

have the freedom to see any doctor/hospital that accepts Medicare and is an In-network

Blue Cross PPO provider. These visits will have a $0 copayment amount. Why? Medicare

pays first a scheduled amount for services and then the Blue Shield COB plan pays the

outstanding difference. This plan also offers lower monthly rates. To find out if your

doctor accepts Medicare, ask your doctor’s office if they accept Medicare or go to

https://www.medicare.gov/physiciancompare/ and search for your physician. Then go

to the new Blue Shield microsite, www.bscaplan.com/peotj4, and look up your doctor.

You may also call our Benefit Advocate for assistance. Refer to page 20 for plan

information.

For Cobra Eligible Participants:

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

MAGELLAN HEALTH – EMPLOYEE ASSISTANCE PROGRAM

The City of Santa Monica will be changing their Employee Assistance Program (EAP)

carrier to Magellan Health effective 01/01/2020. Magellan hear offers a comprehensive

EAP program that is available to Cobra participant and member so their household.

Please refer to page 27 for detailed information on the new program.

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The Supplemental Substance Abuse program will no longer be offered effective

01/01/2020. The new EAP program does include substance abuse counseling, referrals

and support.

For All Retirees and Cobra Eligible Participants:

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)

Your Advocate can assist with:

Benefits choices during Open Enrollment

Verifying eligibility and coverage

Finding a physician and access to care

Resolving claims and billing issues

Coverage changes due to life events (marriage, new child, divorce)

Grievances and appeals

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

NEW Email: [email protected]

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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.

Connecting with a doctor within minutes is

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

2. Talk to the doctor. Take as much time as you

need…there’s no limits!

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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

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

3. If medically necessary, a prescription will be sent to

the pharmacy of your choice. It’s that easy!

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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

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Medicare Facts

Medicare Part A – you usually do not pay a monthly premium if you or your spouse paid

Medicare taxes for a certain amount of time while working. This benefit covers hospital

bills, skilled nursing facility care, hospice care and home health care services.

Medicare Part B – some automatically get Part B and others need to enroll. This benefit

covers preventive care and all medically necessary services such as office visits, x-rays,

ambulance, and durable medical equipment.

Part A and Part B sign up periods – when you are first eligible for Medicare, you have a

7-month Initial Enrollment Period to sign up for Part A and /or Part B:

Begins 3 months before the month you turn 65

Includes the month you turn 65

Ends 3 months after the month you turn 65

What do I need to know?

1. If you are eligible or will become eligible for Medicare, you should contact the Center

for Medicare and Medicaid, to go over your benefit options.

2. If you have medical coverage through the City since you retired, are over 65 years

of age and have not enrolled in Part A and Part B, you may apply for Part A and Part

B without incurring a penalty because you have had group coverage since retiring.

3. To enroll in the Blue Shield COB Medicare plan, you must have both Part A and Part

B. You will need to submit a copy of your Medicare card to Human Resources with

your enrollment request.

What does split coverage mean?

Split coverage means that on a two party plan, one person is under 65 (and is enrolled in

an under 65 medical plan) and the other person is 65 or older (and is enrolled in a Medicare

COB plan). Both Kaiser and Blue Shield offer split coverage plans. The 65 or older member

must have both Part A and Part B in order to enroll in a Medicare plan. The benefit of

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having split coverage is that the monthly rates are much lower as noted on page 23 and

24.

For information on the Kaiser Medicare plan,

please contact PacFed Benefits Administration at

800.753.0222.

For information on the Blue Shield Medicare COB

plan, please contact the Blue Shield Concierge line at 855.829.3566.

For more information on Medicare, you may contact:

Medicare at 800.633.4227 or go to www.medicare.gov

HICAP – provides free and objective information and counseling about Medicare.

Call 800.434.0222 or go online to www.cahealthadvocates.org/hicap

Who Can You Cover?

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.

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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), the City of Santa Monica

requires that you verify your dependent’s

eligibility. If the verification documents for added

dependents are not received, your dependent(s)

will not be added to your health plans for 2020.

QUALIFYING LIFE EVENTS

Make sure to notify Human Resources or the P&A

Group 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.

Making the Most of Your Benefits

Click on the icon to watch a

video on Qualifying Events.

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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 13 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

Find an urgent care center by visiting

www.healthy,kaiserpermanente.org/southern

-california/doctors-locations/how-to-find-

care/get-care

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.blueshieldca.com

Go online at www.blueshieldca.com 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

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preventive retinal screenings if you have diabetes

but do not show signs of diabetic eye disease.

Questions? Call VSP at 800.877.7195.

PREVENTIVE OR 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.

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.

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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.

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.

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

Marina Del Rey Hospital

Monterey Park Hospital

Northridge Hospital Medical Center (Roscoe Campus)

PIH Hospital – Downey

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

When should I use

Teladoc?

What kind of symptoms

can be treated? How much will I pay? How do I get started?

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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

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.

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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.

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 LifeReferrals 24/7, 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 or go

online to have a one-to-one chat.

Your Shield Concierge team is

ready to help you.

Call 855.829.3566

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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.

Blue Shield Medical Plans – Under 65 or Non‐Medicare The following are non‐Medicare plans available to under age 65 or over 65 non‐Medicare Retirees.

Have questions? Get answers.

Call the Shield Concierge number at 855.829.3566.

Visit the new Blue Shield microsite

at www.bscaplan.com/peotj4

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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 No Charge

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

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Blue Shield Medical Plans – Under 65 or Non‐Medicare 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

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


video on Prescription Drugs /

Dos and Don’ts.

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Blue Shield Medical Plans – Under 65 or Non‐Medicare

This comparison chart shows a brief summary of the medical benefits available.

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

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.

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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 Co‐pay

40%* 40%*


Covered

Covered



None




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


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


$35 per script Not Covered






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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‐


In‐Network Out‐of‐Network Medical Plan Annual Deductible Lifetime Maximum Annual Co‐pay (Out‐of‐Pocket maximum)

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%*

Not Covered 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






24


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



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%


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

Not Covered


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






25

Kaiser Medical Plan – Under 65 or Non‐Medicare The City of Santa Monica offers you a Kaiser Permanente option for medical insurance.

To enroll in the Kaiser plan, please contact, call PacFed Benefits Administrators at 800.753.0222

and ask for Marty. You may also call to obtain additional plan

information.

2020 Kaiser HMO

In‐Network Only

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

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

Hospital Care Inpatient Surgery Outpatient Surgery Emergency Room Visit


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


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

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 (100‐day supply) $10 Co‐pay Generic $15 Co‐pay Preferred Brand $15 Co‐pay Non‐Preferred Brand (100‐day supply)

26

Blue Shield Medicare Plan – Medicare A & B Eligible Retirees The following is a Medicare plan available over 65 Retirees with both Part A and Part B.

Blue Shield

Coordination of Benefits (COB) Medicare Plan How it Works You may see any provider when you need care. You decide whether to see an in‐


Using Participating Providers Using Non‐Participating Provider Medical Plan Annual Deductible Lifetime Maximum Annual Co‐pay (Out‐of‐Pocket maximum)

$0 Ind / $0 Family

Unlimited $500 Ind / $1,000 Family

$500 Ind / $1,000 Family

Unlimited $2,000 Ind / $4,000 Family





$0 Co‐pay $0 Co‐Pay $0 Co‐Pay $0 Co‐Pay $0 Co‐Pay

50%* 50%* up to $600/day** 50%* up to $350/day** $0/ Visit 50%* up to $600/day**




$0 Co‐pay $0 Co‐pay $5 Co‐pay (Teladoc )* No Charge $0 Co‐pay $0 Co‐Pay $0 Co‐Pay $0 Co‐Pay $0 Co‐pay, 12 visits per year $0 Co‐pay, 20 visits per year

50%* 50%* Not Covered Not Covered 50%* 50%* Not Covered 50%* 50%*, 12 visits per year 50%*, 20 visits per year


$0 Co‐oay $0 Co‐pay $0 Co‐pay $0 Co‐pay

50%* up to $600/day** 50%* 50%* 50%* up to $600/day**


$0 Co‐pay $0 Co‐pay $0 Co‐pay $0 Co‐pay, 100 visits/year $0 Co‐pay

$0 Co‐pay 50%* 50%* Not Covered Not Covered


**Up to $600 per day plus 100% of additional charges.

Note for Non‐Participating Provider benefits ‐ member is responsible for coinsurance in addition to any charges over the

allowable amount. When members use non‐participating 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.

27

Blue Shield Medicare Plan – Medicare A & B Eligible Retirees This comparison chart shows a brief summary of the medical benefits available.


Using Participating Providers Using Non‐Participating Providers Other ‐ Continued Pregnancy/Maternity Care Family Planning ‐ Counseling ‐ Tubal ligation ‐ Vasectomy ‐ Infertility Services (Diagnosis and treatment of causes only)

$0 Co‐pay $0 Co‐pay $0 Co‐pay $0 Co‐pay Not Covered



$0 Co‐pay $0 Co‐pay

50%* 50%*


Covered

Covered



None




$10 / $20/ $35 / $35 (30‐day supply) In‐Network Copay + 25% of purchase price


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


$35 per script Not Covered


Note for Non‐Participating Provider benefits ‐ member is responsible for coinsurance in addition to any charges over the

allowable amount. When members use non‐preferred 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.

28

Cost of Coverage for Retiree Plans

BLUE SHIELD PLANS

Medical Plans for Retirees Under 65 or Non‐Medicare Medical

Monthly Premium

Blue Shield Access + HMO

Retiree Only $837.89

With 1 Dependent $1,675.78

Two + Dependents $2,178.51

Blue Shield Trio HMO





Retiree Only $1,091.61



Blue Shield PPO Savings (High Deductible Health Plan)




29

Medical Plan for Retiree 65+ with Medicare Part A & Part B Medical

Monthly Premium

Blue Shield Coordination of Care (COB) Plan

Retiree with Medicare $560.13

Retiree with Medicare + Spouse Non‐Medicare $1,651.78

Retiree Non‐Medicare + Spouse with Medicare $1,651.74

Retiree with Medicare + Spouse with Medicare $1,120.26

Retiree with Medicare + Child Non‐Medicare $1,215.11

Retiree with Medicare + Children Non‐Medicare $1,215.11

Retiree with Medicare + Spouse with Medicare + Child Non‐Medicare $1,775.24

Retiree with Medicare + Spouse Non‐Medicare +Child Non‐Medicare $2,306.76

Retiree Non‐Medicare + Spouse with Medicare + Child Non‐Medicare $2,306.72

Subscriber with Medicare + Spouse with Medicare + Child Non‐Medicare $1,775.24

Retiree with Medicare + Spouse Non‐Medicare + Children Non‐Medicare $2,306.76

Retiree Non‐Medicare + Spouse with Medicare + Children Non‐Medicare $2,306.73

30

KAISER PERMANENTE PLANS

Medical Plan for Retirees Under 65 or Non‐Medicare Medical

Monthly Premium

Kaiser HMO




Medical Plan for Retiree 65+ with Medicare Part A & Part B Medical

Monthly Premium

Kaiser Medicare Plan

Retiree with Medicare $248.00

Retiree with Medicare + Spouse Non‐Medicare $1,184.00

Retiree Non‐Medicare + Spouse with Medicare $1,184.00

Retiree with Medicare + Spouse with Medicare $473.00

Retiree with Medicare + Child Non‐Medicare $1,184.00

Retiree with Medicare + Children Non‐Medicare $1,965.00

Retiree with Medicare + Spouse with Medicare + Child Non‐Medicare $1,248.00

Retiree with Medicare + Spouse Non‐Medicare +Child Non‐Medicare $1,965.00

Retiree Non‐Medicare + Spouse with Medicare + Child Non‐Medicare $1,965.00

Subscriber with Medicare + Spouse with Medicare + Child Non‐Medicare $1,248.00

Retiree with Medicare + Spouse Non‐Medicare + Children Non‐Medicare $1,965.00

Retiree Non‐Medicare + Spouse with Medicare + Children Non‐Medicare $1,965.00

For all Kaiser plan questions, please contact PacFed Benefits Administrators.

They will be able to answer any questions or problems concerning the offered

Kaiser medical plans (under 65 plan and over 65 Medicare plan).

Call 800.753.0222 for assistance.

31

Dental – For Cobra Eligible Participants 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

$0

$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

Plan pays 80% after

deductible

Root Canals $5-$75 copay (varies by


schedule)

Plan pays 90% after

deductible

Plan pays 80% after

deductible

Periodontics $5-$150 copay (varies by


schedule)

Plan pays 90% after

deductible

Plan pays 80% after

deductible

Major Services $5-$125 copay (varies by


schedule)

Plan pays 70% after

deductible

Plan pays 50% after

deductible

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%

32

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.

Vision – For Cobra Eligible Participants 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 Vision Plan

In-Network Out-Of-Network

Examination

Benefit $25 copay then plan pays 100% Plan pays up to the $50 allowance

Frequency 1 x every 12 months In-network limitations apply

Materials Combined with examination (see schedule

below)

Combined with examination (see schedule

below)

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

Frequency 1 x every 12 months or 1 every 12 months

if change in prescription

In-network limitations apply


video on Dental Insurance.

33

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

Frequency 1 x every 24 months In-network limitations apply

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

Employee Assistance Program – For Cobra Eligible Participants The City of Santa Monica offers their Cobra eligible participants an Employee Assistance

Program.

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

34

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

35

Cost of Coverage for Cobra Plans NOTE – All Cobra rates noted do not include the 2% Administration fee.

Dental Monthly Premium

Delta Dental DHMO Dental Plan

Cobra Member Only $19.34

With 1 Dependent $31.93

Two + Dependents $47.58

Delta Dental DPPO Dental Plan




Vision Monthly Premium

VSP Vision Plan




Employee Assistance Program Monthly Premium

Magellan Health ‐ Employee Assistance Plan


36

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.blueshieldca.com

www.teladoc.com/bsc

PacFed Benefits

Administrators – for

Kaiser Plans

800.753.0222

Dental Delta Dental

DHMO/ Group #71468

DPPO / Group #01509

800.422.4234

800.765.6003

www.deltadentalins.com/enrollee

s

Vision VSP 800.877.7195 www.vsp.com

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]

Retiree Billing and Cobra

Billing

P&A Group 800.688.2611 www.padmin.com

Human Resources 1685 Main St., Rm: 101

Santa Monica, CA 90401

310.458.8246

www.smgov.net/Departments/HR

/Employees/Employees.aspx

or email: [email protected]

37

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.

38

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.

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.

39

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.

Important Plan Notices and Documents

CURRENT HEALTH PLAN NOTICES Click on the icon to watch a

video on Key Health

Insurance Terms.

40

Notices must be provided to plan participants on

an annual basis and are available on the City of

Santa Monica’s website,

www.smgov.net/Departments/hr , are mailed

out in October 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

41

Blue Shield PPO Plan

Blue Shield HDHP Plan

Kaiser HMO Plan

42

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.


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

State agency that issued final

adoption papers

Adoption agency that issued

43

documents relating to custody,

health coverage or income tax

exemptions.

placement papers


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.


birth certificate

Hospital in which child was born

U.S. Department of State (for

children born outside of the U.S)


www.vitalchek.com

44

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