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2021
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City of Santa Monica
Employee Benefits Overview
TABLE OF CONTENTS
Benefits For The Way You Live ....................................................................................................... 3
What’s New In 2021? ................................................................................................................... 4
Stay Connected With Your Wellness Resources ................................................................................. 5
Open Enrollment .......................................................................................................................... 9
Who Can You Cover? .................................................................................................................. 10
Preventive Care Or Diagnosis? ...................................................................................................... 11
Blue Shield of California ............................................................................................................. 12
Medical .................................................................................................................................. 15
Dental ...................................................................................................................................... 22
Vision ...................................................................................................................................... 23
Cost of Coverage........................................................................................................................ 24
Life and Disability Insurance ........................................................................................................ 25
Special Savings Accounts ........................................................................................................... 28
Other Programs.......................................................................................................................... 31
For Assistance ........................................................................................................................... 34
Get Educated Virtually!................................................................................................................ 36
Important Plan Notices and Documents .......................................................................................... 37
Appendix .................................................................................................................................. 38
Notes ....................................................................................................................................... 39
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.
1
2
BENEFITS FOR THE WAY YOU LIVE
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 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, 2021 - December 31, 2021
OPEN ENROLLMENT PERIOD:
September 21 – October 16, 2020
3
What’s New In 2021?
No benefit changes were made to the Blue Shield HMO, Trio HMO and PPO medical plan
offerings for the 2021 plan year. There is a slight change to the Blue Shield HDHP plan in
the prescription drug benefit as noted below. The medical benefits will stay the same.
The City is happy to announce that all the Blue Shield medical premiums will be lower by
10.2% for 2021.
The Kaiser HMO medical plan will have no changes for 2021.
There is a slight change to the Blue Shield HDHP plan in the prescription drug benefit. The Tier
4 (High Cost drugs) will increase to 30% up to $250 pre prescription for a 30 day supply.
No other changes to the prescription benefit on all the Blue Shield and Kaiser medical plans for
2021.
No changes were made to the DHMO or DPPO Delta Dental plans for 2021.
No changes were made to VSP’s plan for the 2021 plan year.
New HSA Contribution Limits!
2021 HSA contributions limits will increase to $3,600 for Individuals and $7,200 for
Family coverage. See page 28 for more information. 2021 HealthCare and Dependent Care
FSA contribution limits increases have not been announced by the IRS. These increases
typically are announced in October.
A Special Open Enrollment This Year
Due to COVID-19, the City will not be hosting any onsite Open Enrollment meetings. All Open
Enrollment will be virtual. To view the Open Enrollment presentation, go to
https://www.brainshark.com/alliant/csm2021oe or click on the picture below.
You will be able to find all Open Enrollment materials, summaries and forms at
https://www.smgov.net/Departments/HR/Employees/Employees.aspx. Make sure to look for
emails with more enrollment information.
4
Stay Connected With Your Wellness Resources
The COVID-19 pandemic has brought new challenges and stresses to our lives. During this
unprecedented time, the City would like to highlight the various benefits and resources that you have
available from our benefit carriers. Now is a good time to utilize the many benefit options as virtual
appointments, free online wellness classes and EAP services.
BLUE SHIELD
Accessing Your Mental Health Benefit
Your Blue Shield medical plan provides coverage comprehensive coverage for non-emergency inpatient
and outpatient mental health and substance abuse care through Blue Shield’s mental health service
administrator (MHSA). Contact MHSA at 877.263.9952 for immediate assistance or help finding a
provider. You can also search for a provider in the “Find a Doctor” tool at blueshieldca.com.
Choosing the Right Clinician
Mental health providers are typically differentiated in three groups:
• Master’s-level clinician – provider has a master’s degree in social work, professional counseling,
marriage and family therapy. They are independently licensed in the state were they practice. In
some cases, they may recommend you to a psychiatrist if medication may be needed.
• Psychologist – generally have doctoral degrees in education, child, clinical or counseling
psychology. They provide a variety of services, including assessments, psychological testing and
therapy.
• Psychiatrist – they are medical doctors (MDs) specializing in psychiatry and provide psychiatric
evaluations, therapy, and other psychotherapeutic interventions as well as prescribe
medications. They can specialize in child psychiatry, addiction or geriatrics.
Contact MHSA at 877.263.9952 for assistance.
One of the most important factors in addressing your mental health is finding a clinician you trust. Here
are some things to consider when you are deciding on a clinician.
Qualities that are important to you
What type of background or areas of expertise would you like your clinician to have? Would you prefer a
male or female clinician? Would you be more comfortable with a clinician who shares your cultural
background? Should your clinician be close to your home or close to work? Would tele-behavioral health be
a good fit with your busy schedule?
The clinician’s background
What are the clinician’s credentials? What is the clinician’s philosophy or approach?
5
TELADOC - Accessing Medical and Behavioral Telemedicine
Teladoc is a convenient way to access medical and behavioral health care and is available to all Blue
Shield members. U.S. certified doctors are available 24/7/365 to resolve non-emergency issues via
phone or video consults.
When should I use What kind of symptoms
How much will I pay? How do I get started?
Teladoc? can be treated?
• If you are Teladoc doctors and Trio HMO: No Charge 1. Set up an account.
considering the ER therapists can treat many Visit teladoc.com/bsc,
or urgent care medical conditions, Access+ HMO and PPO complete the required
center for a non- including: Members: information and click on Set
emergency • Cold and flu symptoms $5 copay per consult up account.
• When on vacation, a • Allergies 2. Provide medical history.
business trip or • Bronchitis HDHP Members: Your medical history provides
away from home • Urinary tract infection Members pay a $45 doctors with the information
• For short-term • Respiratory infection consult fee until the they need to make an
prescription refills • Sinus problems deductible is met, then a accurate diagnosis.
• Depression $5 copay. 3. Request a consult.
• Anxiety Once your account is set up,
NOTE: the amounts request a consult anytime you
noted above are the need care.
standard charges. Due
to the pandemic,
Teladoc consults are
at no cost until further
notice.
Behavioral health providers are available from the privacy of your home or wherever you are most
comfortable.
• Talk to a therapist or psychiatrist when you are feeling anxious, stressed, down or not like
yourself.
• Access mental health support. If your mental health condition isn’t improving, get guidance for
the right specialists to progress your treatment.
•
Visit Teladoc.com/bsc and set up an account or call 1.800.835.2362
6
EMPLOYEE ASSISTANCE PROGRAM (EAP)
Whether you are feeling lonely, depressed, anxious or angry about the impact of the COVID-19,
Magellan’s EAP provides a variety of resources and tools to help you access and improve your mental
and emotional state. EAP services are available to you and your household members at no cost.
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
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
Help is available 24/7, 365 days a year.
Contact us at 800.523.5668.
7
NO COST ONLINE WELLNESS RESOURCES – available to everyone
PHYSICAL HEALTH
There are many online tools to make exercising at home, fun and effective. Exercise is important for
overall heathy well-being, but it is vital to protect yourself from airborne disease. Below are free fitness
activities to try from your home. These are independent from your medical carriers.
Yoga & Pilates
Corepower Yoga Access free classes through their YouTube channel.
Total Body
Active by POPSUGAR app Sign up for free here to get hundreds of do-anywhere workouts.
Les Mills Free at home workouts.
Running, Dance
Couch to 5K App For those that want to improve on running.
Fitness Marshall Get ready to sweat with Fitness Marshall.
Rhythm and Motion Free 1-hr dance workout videos for all levels.
MadFit Great at home workouts.
Strength Training
BodyFit by Amy At home workouts, both body weight and with dumbbells/kettlebells.
8-min buns No equipment needed for this video.
MENTAL / EMOTIONAL HEALTH
Without a doubt, many of us are feeling anxious as we navigate the uncertainty of COVID-19. Here are
some tools that you can use to take care of your mind and stay grounded. No insurance required.
Meditation and Mindfulness
The app features guided meditations, music and talks by
Insight Timer
contributing experts. Basic service is free.
A free medication app that offers short, meditation sessions
Simple Habit
designed to help busy people manage stress and live better.
Train you mind and body for a healthier, happier life with this app.
Headspace
Both a free (meditations, exercises) and buy-up option.
Resilience and Stress Management
The Happyness Lab, Ten Percent Happier with Dan Harris, Oprah’s
Podcasts Super Soul Conversations podcasts. Inspiring stories, messages and
research around happiness and daily tips to brighten one’s outlook.
Calm Vibes, Calming Acoustic, Calming Instrumental Covers,
Playlists Peaceful Piano, Soothe, Calm Classic. Music can have a profoundly
relaxing effect on both minds and body.
Courses and Education
Healbright offers a free mental health course to address the stress
Wellness During Quarantine
caused by the COVID-19 pandemic.
8Open Enrollment
Open Enrollment will take place from September 21 – October 16, 2021. During this time,
you are able to enroll in new programs or make changes to your current benefits.
What do I need to do?
1. If I like my current plan selections (medical, dental, vision and term life plan) and
do not want to change them for 2021? You do not have to do anything. Your selections
will automatically roll over with the exception of your FSA enrollment.
2. If I want to:
• Enroll in any of the City-sponsored plans and the voluntary benefit for the first time;
• Change or cancel your plan choices;
• Add or drop dependent coverage (Please Note: If you cancel a dependent’s coverage
during Open Enrollment, that dependent is not eligible for COBRA). Note that social
security numbers are required for all dependents;
• Add, change, or cancel your Voluntary Term Life Plan;
• Participate for the first time or continue to participate in FSA Healthcare or Dependent
Care or participate for the first time in an HSA for the 2021 plan year;
• 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.
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 benefits@smgov.net, 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 2021 plan year.
9Who Can You Cover?
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
WHO IS ELIGIBLE? • Relatives such as grandchildren, grandparents,
A permanent employee working 20 or more hours parents, aunts, uncles, nieces, nephews, etc.
per week is eligible for the benefits outlined in this
overview. Your coverage for health, dental and DEPENDENT ELIGIBILITY DOCUMENTATION
vision benefits will be effective on the first of the REQUIREMENTS
month following your date of hire. If you are adding dependents (spouse and/or
dependent children) during Open Enrollment, the
ELIGIBLE DEPENDENTS
City of Santa Monica requires that you verify your
• Current legal spouse or registered domestic dependent’s eligibility. You have until October 31,
partner (same or opposite gender). 2020 to email (benefits@smgov.net) documentation
• Children (including your domestic partner's that verifies your dependent eligibility to Human
children): Resources. If the verification documents for added
dependents are not received by October 31, 2020,
o Must be under the age of 26. They do not
your dependent(s) will not be added to your health
have to live with you or be enrolled in school.
plans for 2021.
They can be married and/or living and working
on their own. QUALIFYING LIFE EVENTS
o Eligible children include natural children, Make sure to notify Human Resources if you have a
stepchildren, legally-adopted children, or qualifying life event and need to make a change
children who have been placed in your (add or drop) to your coverage election. You have 31
custody during the adoption process, and days to make you change. These changes include
physically or mentally handicapped children (but are not limited to):
who depend on you for support, regardless of • Birth or adoption of a baby or child
age. • Loss of other healthcare coverage, does not
o A child of a covered domestic partner who include private plans
satisfies the same conditions as listed above • Eligibility for new healthcare coverage
for natural children, stepchildren, or adopted • Marriage or Divorce
children, and in addition is not a “qualifying • Death of a dependent
child” (as defined in the Internal Revenue A list of qualifying events can be found in the Legal
Code) of another individual. Document posted on the City’s HR website.
Domestic Partners: Effective January 1, 2021, only domestic partners who satisfy the California legal
definition shall be eligible for coverage as a dependent. Existing registrants will be grandfathered in so
long as they still prove the requirements of the affidavits as of 2018.
10Preventive Care Or Diagnosis?
You benefit both financially and health-wise when you get annual medical checkups. Preventive care
helps you avoid more serious and costly health problems down the road. Plus, it's fully covered in-
network.
But did you know that, depending on the situation, the same test or service can be considered
preventive (100% covered) or diagnostic (you share the cost)?
Preventive care services Diagnostic services
● Help you stay healthy by checking for ● Check for disease after you have
disease before you have symptoms or symptoms or because of a known health
feel sick issue
● Can include flu shots and other ● Can also include physical exams, lab tests
vaccinations, physical exams, lab tests and prescriptions
and prescriptions
● You pay your share of the cost
● 100% covered when delivered by an in-
network provider
PREVENTIVE: At Don’s annual DIAGNOSTIC: Grace’s doctor orders a
checkup, his doctor orders a blood blood sugar test because she
sugar test to screen for diabetes, even complains of increased thirst,
though Don does not have symptoms. frequent urination, weight loss, and
fatigue—all symptoms of diabetes.
PREVENTIVE: As part of her well DIAGNOSTIC: Darla visits her doctor
woman exam, Vanessa receives a because she found a lump. Her
mammogram to make sure there have doctor schedules a mammogram and
been no changes since last time. a biopsy to check for cancer.
PREVENTIVE: Aki’s doctor orders lab DIAGNOSTIC: Hector was diagnosed
work during his annual physical, with high cholesterol two years ago.
including a cholesterol check. He has blood tests twice a year to
check his cholesterol levels and make
sure his medication is the right dose.
If you're unsure why a test was ordered, ask your doctor. And don't forget to schedule your preventive
care visits. Many people use a key date like their birthday or anniversary as a reminder to make their
appointments each year.
11Blue Shield of California
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.
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.
County IPA/medical group name County Trio ACO HMO Hospitals
Los Angeles Access Medical Group Inc. Los Angeles Alhambra Hospital Medical Center
Access Medical Group Santa Monica Garfield Medical Center
Allied Pacific of California IPA Good Samaritan Hospital
AppleCare Medical Group Whittier Greater El Monte Community Hospital
AppleCare Medical Group Henry Mayo Newhall Hospital
AppleCare Medical Group Select Long Beach Memorial Medical Center
AppleCare Medical Group St. Francis Region Marina Del Rey Hospital
Axminster Medical Group – Little Company of Mary – San Monterey Park Hospital
Pedro Northridge Hospital Medical Center (Roscoe Campus)
Axminster Medical Group – Little Company of Mary IPA – PIH Hospital – Downey
Torrance Pomona Valley Hospital Medical Center
Axminster Medical Group – Providence Care Network – Providence Holy Cross Medical Center
Tarzana Providence Little Company of Mary Medical Center
Axminster Medical Group Inc. San Pedro
Facey Medical Foundation Burbank Providence Little Company of Mary Medical Center
Facey Medical Foundation San Fernando Valley Torrance
Facey Medical Foundation Santa Clarita Providence Saint Joseph Medical Center
Facey Medical Foundation Simi Valley Providence Tarzana Medical Center
Good Samaritan Medical Practice Associates St. John’s Health Center
Korean American Medical Group San Gabriel Valley Medical Center
Greater Newport Physicians (GNP) – Long Beach Simi Valley Hospital and Health Care Services
MemorialCare Torrance Memorial Medical Center
Pomona Valley Medical Group Whittier Hospital Medical Center
Torrance Health IPA
Plan Highlights
The HMO Trio plan include the following features and benefits:
Self-refer to specialists ( within the same medical group as your PCP)
$0 copay for virtual care consults and mental health support 24/7 with Teladoc
$0 copay first visit to Heal, on-demand doctor house calls
Healthy Savings grocery discount program
12HEAL – for the Trio HMO and PPO plans
Heal lets you see a doctor wherever is most convenient for you – home, work or hotel. For Trio
members, the first visit is $0 copay and following visits are a $20 copay. For PPO members, after you
meet your deductible, the co-insurance amount applies. All preventive services for Trio and PPO are at
no cost. Learn about Heal at www.heal.com or call 844.644.4325.
WELLVOLUTION
Achieve your health goals with Wellvolution – Blue Shield’s whole-health platform that’s been designed
with you in mind. 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
To discover our proven path, visit wellvolution.com.
13BLUE SHIELD 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.
HELPFUL BLUE SHIELD VIDEOS
Understanding your Trio HMO plan
Making use of wellness programs
Click on any subject you
Creating your online account
want to watch a video on.
Savings on prescriptions
Understanding your plan
Have questions? Get answers. Call the Shield
Concierge number at 855.829.3566.
Visit the City’s custom Blue Shield microsite at
https://choose.blueshieldca.com/smgov.
14Blue Shield Medical Plans
This comparison chart shows a brief summary of the medical benefits available.
Blue Shield Access+ HMO Blue Shield Trio HMO
In-Network Only 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 $0 Individual/$0 Family $0 Individual/$0 Family
Lifetime Maximum Unlimited Unlimited
Annual Co-pay (Out-of-Pocket $1,500 Individual/$3,000 Family $1,500 Individual/$3,000 Family
maximum)
Hospital Care
Inpatient
- Physician No Charge No Charge
- Facility Services $100/ Admission $100/Admission
Outpatient Surgery No Charge No Charge
Emergency Room Visit
- Not resulting in admission $100 Co-pay $100 Co-pay
- Resulting in hospital admission Inpatient Facility Services charge applies Inpatient Facility Services charge applies
Physician Care
Office Visit $20 Co-pay $20 Co-pay
Specialist Visit $20 Co-pay or $30 Access+ (self-referral) $20 Co-pay or $30 for Trio (self-referral)
Telemedicine – Virtual Visit $5 Co-pay (Teladoc) No Charge (Teladoc)
Preventive Care/Annual Physical No Charge No Charge
X-Ray. Lab & Pathology Services No Charge No Charge
CT/PET scans, MRIs, MRAs No Charge No Charge
Immunizations No Charge No Charge
Outpatient Rehabilitation Therapy $20 Co-pay $20 Co-pay
- Physical, Speech, Occupational,
Respiratory
Chiropractic Services $15 Co-pay, 20 visits per year $15 Co-pay, 20 visits per year
Acupuncture Services Not Covered Not Covered
Mental Health/Substance Abuse
Inpatient - Mental Health $100/ Admission $100/ Admission
Outpatient - Mental Health $20 Co-pay at doctor’s office $20 Co-pay at doctor’s office
Chem. Dependency Rehab - Outpatient $20 Co-pay at doctor’s office $20 Co-pay at doctor’s office
Detoxification - Inpatient (Detox Only) $100/Admission $100/ Admission
Other
Ambulance - ER or authorized transport No Charge No Charge
Prosthetics No Charge No Charge
Durable Medical Equipment No Charge No Charge
Home Healthcare Services No Charge (up to 100 visits) No Charge (up to 100 visits)
Hospice No Charge No Charge
15Blue Shield Medical Plans
This comparison chart shows a brief summary of the medical benefits available.
Blue Shield Access+ HMO Blue Shield Trio HMO
In-Network Only In-Network Only
Other - Continued
Pregnancy/Maternity Care No Charge No Charge
Family Planning
- Counseling No Charge No Charge
- Tubal ligation No Charge No Charge
- Vasectomy No Charge No Charge
- Infertility Services (Diagnosis 50% of allowed charges 50% of allowed charges
and treatment of causes only)
Diabetes Care
Devices and non-testing supplies No Charge No Charge
Diabetes self-management training $20 Co-pay $20 Co-pay
Care Outside of Service Area
(benefits provided by the BlueCard Not Covered except for Not Covered except for
Program, for out-of-state Emergency Care Emergency Care
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
Prescription Drugs Annual Deductible: Annual Deductible:
None None
Out-of-Pocket Maximum: Out-of-Pocket Maximum:
None None
Retail: Generic/Brand/Non- $10 / $20/ $35 / $35 (30-day supply) $10 / $20/ $35 /$35 (30-day supply)
formulary/High Cost Drugs
Mail Order: Generic/Brand/Non- $20 / $40 / $70/ $70 (90-day supply) $20 / $40/ $70/ $70 (90-day supply)
formulary/ High Cost Drugs
Specialty Medications $35 per script $35 per script
Click on the icon to watch a
video on Prescription Drugs /
Dos and Don’ts.
16Blue Shield Medical Plans
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 Individual: $500 - Family: $500/$1,000
Lifetime Maximum Unlimited
Annual Co-pay (Out-of-Pocket maximum) $3,000 Ind / $6,000 Family (combined In & Out-of-Network)
Hospital Care
Inpatient
- Physician 20%* 40%*
- Facility Services 20%* 40%* up to $1,500/day
Outpatient Surgery 20%* 40%* up to $600/day
Emergency Room Visit
- Not resulting in admission $100/ visit $100/ Visit
- Resulting in hospital admission 20%* 40%* up to $1,500/day
Physician Care
Office Visit $20 Co-pay 40%*
Specialist Visit $20 Co-pay 40%*
Telemedicine – Virtual Visit $5 Co-pay (Teladoc) Not Covered
Preventive Care/Annual Physical No Charge Not Covered
X-Ray. Lab & Pathology Services 20%* 40%*
CT/PET scans, MRIs, MRAs 20%* 40%*
Immunizations No Charge Not Covered
Outpatient Rehabilitation Therapy 20%* 40%*
- Physical, Speech, Occupational,
Respiratory
Chiropractic Services $20 Co-pay, 20 visits per year 40%*, 20 visits per year
Acupuncture Services Not Covered Not Covered
Mental Health/Substance Abuse
Inpatient - Mental Health 20%* 40%* up to $1,500/day
Outpatient - Mental Health $20 Co-pay at doctor’s office 40%*
Chem. Dependency Rehab - Outpatient $20 Co-pay at doctor’s office 40%*
Detoxification - Inpatient (Detox Only) 20%* 40%* up to $1,500/day
Other
Ambulance - ER or authorized transport 20%* 20%*
Prosthetics 20%* 40%*
Durable Medical Equipment 20%* 40%*
Home Healthcare Services No Charge, 120 visits/year* Not Covered
Hospice No Charge* 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.
17Blue Shield Medical Plans
This comparison chart shows a brief summary of the medical benefits available.
Blue Shield Full PPO
In-Network Out-of-Network
Other - Continued
Pregnancy/Maternity Care No Charge 40%*
Family Planning
- Counseling No Charge Not Covered
- Tubal ligation No Charge Not Covered
- Vasectomy 20%* Not Covered
- Infertility Services (Diagnosis Not Covered Not Covered
and treatment of causes only)
Diabetes Care
Devices and non-testing supplies 20%* 40%*
Diabetes self-management training $20 Co-pay 40%*
Care Outside of Service Area
(benefits provided by the BlueCard Covered Covered
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
Prescription Drugs Annual Deductible: Annual Deductible:
None None
Out-of-Pocket Maximum: Out-of-Pocket Maximum:
None None
Retail: Generic/Brand/Non- $10 / $20/ $35 / $35 (30-day supply) In-Network Copay + 25%
formulary/High Cost Drugs
Mail Order: Generic/Brand/Non- $20 / $40 / $70/ $70 (90-day supply) Not Covered
formulary/High Cost Drugs
Specialty Medications $35 per script 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.
18Blue Shield Medical Plans
This comparison chart shows a brief summary of the medical benefits available.
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
Medical Plan
Annual Deductible Individual: $1,800 - Family: $2,800/$3,600
Lifetime Maximum Unlimited
Annual Co-pay (Out-of-Pocket maximum) $4,500 Ind/ $9,000 Family $8,000 Ind / $16,000 Family
Hospital Care
Inpatient
- Physician 20%* 40%*
- Facility Services $100 Co-pay + 20%* 40%* up to $1,500/day
Outpatient Surgery 20%* 40%* up to $600/day
Emergency Room Visit
- Not resulting in admission $150 /visit + 20%* $150/ Visit + 20%*
- Resulting in hospital admission $100 Co-pay + 20%* 40%* up to $1,500/day
Physician Care
Office Visit 20%* 40%*
Specialist Visit 20%* 40%*
Telemedicine – Virtual Visit $5 Co-pay (Teladoc)* Not Covered
Preventive Care/Annual Physical No Charge Not Covered
X-Ray. Lab & Pathology Services 20%* 40%*
CT/PET scans, MRIs, MRAs 20%* 40%*
Immunizations No Charge Not Covered
Outpatient Rehabilitation Therapy 20%* 40%*
- Physical, Speech, Occupational,
Respiratory
Chiropractic Services 20%*, 20 visits per year 40%*, 20 visits per year
Acupuncture Services 20%*, 20 visits per year 20%*, 20 visits per year
Mental Health/Substance Abuse
Inpatient - Mental Health $100 Co-pay + 20%* 40%* up to $1,500/day
Outpatient - Mental Health 20%* 40%*
Chem. Dependency Rehab - Outpatient 20%* 40%*
Detoxification - Inpatient (Detox Only) $100 Co-pay + 20%* 40%* up to $1,500/day
Other
Ambulance - ER or authorized transport 20%* 20%*
Prosthetics 20%* 40%*
Durable Medical Equipment 20%* 40%*
Home Healthcare Services 20%*, 100 visits/year* Not Covered
Hospice No Charge* 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.
19Blue Shield Medical Plans
This comparison chart shows a brief summary of the medical benefits available.
Blue Shield High Deductible Health Plan (PPO)
In-Network Out-of-Network
Other - Continued
Pregnancy/Maternity Care 20%* 40%*
Family Planning
- Counseling No Charge Not Covered
- Tubal ligation No Charge Not Covered
- Vasectomy 20%* Not Covered
- Infertility Services (Diagnosis Not Covered Not Covered
and treatment of causes only)
Diabetes Care
Devices and non-testing supplies 20%* 40%*
Diabetes self-management training 20%* 40%*
Care Outside of Service Area
(benefits provided by the BlueCard Covered Covered
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
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
Retail: Generic/Brand/Non- $10 / $25/ $40/ 30% up to $250 max In-Network Copay + 25%
formulary/High Cost Drugs per script* (30-day supply)
Mail Order: Generic/Brand/Non- $20 / $50 / $80 / 30% up to $500 per Not Covered
formulary/ High Cost Drugs script* (90-day supply)
Specialty Medications 30% up to $200 max per script* 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.
20Kaiser Medical Plan
The City of Santa Monica offers you a Kaiser Permanente option for medical insurance.
2021 Kaiser HMO
In-Network Only
Medical Plan
Annual Deductible None
Lifetime Maximum Unlimited
Annual Co-pay (Out-of-Pocket maximum) $1,500 Individual/$3,000 Family
Hospital Care
Inpatient Surgery No Charge
Outpatient Surgery $15 Co-pay per procedure
Emergency Room Visit
- Not resulting in admission $50 Co-pay
- Resulting in hospital admission No Charge
Physician Care
Office Visit $15 Co-pay
Specialist Visit $15 Co-pay
Urgent Care $15 Co-pay
Preventive Care/Annual Physical No Charge
X-Ray. Lab & Pathology Services $5 Co-pay per encounter
CT/PET scans, MRIs, MRAs $5 Co-pay per procedure
Immunizations No Charge
Physical/Occupational Therapy $15 Co-pay
Mental Health/Substance Abuse
Inpatient - Mental Health No Charge
Outpatient - Mental Health $15 Co-pay
Chem. Dependency Rehab - Outpatient $15 Co-pay
Detoxification - Inpatient (Detox Only) No Charge
Other
Ambulance $50 per transport
Prosthetics No Charge
Durable Medical Equipment 20% Coinsurance
Home Healthcare Services No Charge (up to 100 visits)
Hospice No Charge
Prescription Drugs
Retail: $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)
Mail-Order: $10 Co-pay Generic
$15 Co-pay Preferred Brand
$15 Co-pay Non-Preferred Brand
(100-day supply)
For information on the Kaiser plan, please contact PacFed Benefits Administration at 800.753.0222. Refer to page 32
for additional services from PacFed.
21Dental
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 $0 Individual $0 Individual $50 Individual
Deductible
$0 Family $0 Family $150 Family
Annual Plan Maximum Unlimited $2,000/person $1,000/person
Waiting Period None None None
Diagnostic and Plan pays 100% Plan pays 100% Plan pays 80%
Preventive
Basic Services
Fillings $0-$50 copay (varies by Plan pays 90% after Plan pays 80% after
service, see contract for fee deductible deductible
schedule)
Root Canals $5-$75 copay (varies by Plan pays 90% after Plan pays 80% after
service, see contract for fee deductible deductible
schedule)
Periodontics $5-$150 copay (varies by Plan pays 90% after Plan pays 80% after
service, see contract for fee deductible deductible
schedule)
Major Services $5-$125 copay (varies by Plan pays 70% after Plan pays 50% after
service, see contract for fee deductible deductible
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 after Open Enrollment with your selection.
22Vision
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 Plan pays 100% of basic lens Up to $65 allowance
Standard Progressive Plan pays 100% Up to $50 allowance
20% off all other lens options
Frequency 1 x every 12 months In-network limitations apply
Frames
Benefit Up to $190 retail allowance, then 20% off Up to $70
amount above the allowance
Up to $210 allowance for featured brand Up to $70
Up to $105 allowance at Costco 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 $25 copay, up to $190 allowance for ready-
Up to $70
made non-prescription sunglasses
Frequency 1 x every 24 months
23Cost 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.
The 2021 medical rates and City contribution amounts are posted on the City’s website,
https://www.smgov.net/Departments/HR/Employees/Employees.aspx.
Dental City Employee
Premium Contribution 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
$93.81 ($93.81) $0
With 1 Dependent
$93.81 ($93.81) $0
Two + Dependents
$93.81 ($93.81) $0
Vision City Employee
Premium Contribution 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
24Life 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, 2 x basic annual salary 2 x basic annual salary
PAU, RCL, RCM, STA, SUE, POA(Lieutenant, up to $500,000 up to $500,000
Police Captain, Deputy Police Chief)
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 2 x basic annual salary 2 x basic annual salary
prior to January 1, 2010. up to $500,000 up to $500,000
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 please review
your beneficiary election(s) to ensure it accurately reflects your
wishes. Go to www.plansource.com/login , to change your
beneficiary.
25LONG-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 Plan pays 60% of your basic monthly income
Employees in job classes represented by: $8,333 is maximum amount
Active full-time or permanent part-time employee
represented by or who receive the benefits of the: Benefits begin after 60 days of disability
Executive Pay Plan (Exec), Hearing Examiner
Representation Organization (Hero), Public Social Security normal retirement age is
Attorney's Union (PAU), Employees of the maximum payment period*
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
Eligible Group: Class 2 Plan pays 60% of your basic monthly income
Employees in job classes represented by: $6,667 is maximum amount
Active full-time or permanent part-time employee
represented by or who receive the benefits of the: Benefits begin after 60 days of disability
City Council, Municipal Employee Association
(MEA), International Brotherhood of Teamsters Social Security normal retirement age is
(IBT), Employees Action Committee of the Rent maximum payment period*
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
Eligible Group: Class 3 Plan pays 60% of your basic monthly income
Employees in job classes represented by: $5,000 is maximum amount
Active full-time or permanent part-time employee
represented by or who receive the benefits of the: Benefits begin after 60 days of disability
International Association of Sheet Metal, Air, Rail,
and Transportation workers - Transportation Social Security normal retirement age is
Division (SMART-TD) employee working a maximum payment period*
minimum of 20 hours per week
*The age at which the disability begins may affect the duration of the benefits.
26VOLUNTARY 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 Can elect from $10,000 to $300,000 in increments of $10,000
Life Amount 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 Can elect from $10,000 to $150,000 in increments of
Voluntary Term Life Amount $10,000. Guaranteed issue amount is $30,000.
Child(ren) Voluntary Term Can elect $2,500 or $5,000 or $7,500 or $10,000 (from 6
Life Amount 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
Child Life Insurance Rates
Insurance Rates
Coverage Cost of Coverage
Age Cost per $1,000 of
Levels
Coverage $2,500 each $0.54
Under 20 $0.04 child
20-24 $0.04
25-29 $0.04 $5,000 each $0.80
child
30-34 $0.052
35-39 $0.064 $7,500 each $1.09
40-44 $0.101 child
45-49 $0.167
$10,000 each $1.36
50-54 $0.282 child
55-59 $0.486
60-64 $0.628
65-69 $0.883
70-74 $1.767
75+ $1.767
27Special 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 2021, 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, 2022 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 03/15/22, with
any remaining funds from your 2021 elected amount. You have till 06/30/22 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 2020 elected amount will not roll
over for 2021.
How do I enroll in an FSA for 2021?
• 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 2021.
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.
28HEALTH 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 2021 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 2021
Annual Single Contribution Maximum $3,600
Annual Family Contribution Maximum $7,200
Annual Catch-Up Contribution Maximum (for $1,000
HSA participants that are 55 years or older)
29Feel more confident about participation in you Nationwide retirement plan
30Other Programs
TRAVEL ASSISTANCE
The Hartford offers you free Travel Assistance services provided by Europ Assistance USA.
• Medical referrals
• Medical evacuation
• Repatriation
Emergency Medical Assistance: • Traveling companion assistance
• Emergency medical payments
• Return of mortal remains
• Visa and passport requirements
Pre-trip Information: • Immunization requirements
• Embassy and consular referrals
• Medication and eyeglass prescription
assistance
Emergency Personal Services: • Emergency travel arrangements
• Locating lost items
What you will need:
1. Your employer’s name – City of Santa Monica
2. Phone number where you can be reached
3. Nature of the problem
4. Travel Assistance Identification Number – GLD-09012
5. Your policy number - GLT-804075
Call Europ Assistance USA at 800.243.6108.
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.
31You can also read
