2021 Open Enrollment Guide - WHAT'S NEW, WHAT TO DO Benefit Driven. Wellness Focused - City of San Jose
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
2021
Open Enrollment Guide
Benefit Driven. Wellness Focused.
WHAT’S NEW, WHAT TO DO
01/01/2021 – 12/31/2021
P age |1
TABLE OF CONTENTS
BENEFIT DRIVEN. WELLNESS FOCUSED. .................................................................................................................... 2
Open Enrollment .......................................................................................................................................................... 3
Who Can You Cover? ............................................................................................................................................... 12
Medical........................................................................................................................................................................ 14
Getting Care When You Need It Now................................................................................................................... 20
Health Savings Account ........................................................................................................................................... 23
Dental .......................................................................................................................................................................... 24
Vision ............................................................................................................................................................................ 29
Life Insurance.............................................................................................................................................................. 31
Disability Insurance .................................................................................................................................................... 33
Travel Assistance ........................................................................................................................................................ 34
Flexible Spending Account (FSA) ........................................................................................................................... 35
Other Programs .......................................................................................................................................................... 37
Personal Accident Insurance .................................................................................................................................. 38
Wellness ....................................................................................................................................................................... 40
Financial/Retirement ................................................................................................................................................. 41
MyBenefits.LifeTM......................................................................................................................................................... 46
Plan Contacts ............................................................................................................................................................. 47
Words You Need to Know ........................................................................................................................................ 49
Important Plan Notices and Documents .............................................................................................................. 50
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 see the Annual Notices for more details.
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.
P age |2
BENEFIT DRIVEN. WELLNESS FOCUSED.
At City of San José we value your contributions to our success and want to provide
you with a benefits package that protects your health and helps your financial
security, now and in the future. We continually look for valuable benefits that support
your needs, whether you are single, married, raising a family, or thinking ahead to
retirement. We are committed to giving you the resources you need to understand
your options and how your choices could affect you financially.
This guide is an overview and does not provide a complete description of all benefit
provisions. For more detailed information, please refer to your plan benefit booklets or
summary plan descriptions (SPDs). The plan benefit booklets determine how all
benefits are paid.
A list of plan contacts is included at the back of this guide.
The benefits in this summary are effective:
January 1, 2021 - December 31, 2021
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.
P age |3
Open Enrollment
This booklet will give you information about the benefits that are available to you. Please
read the information carefully. To help you make important decisions about your benefits,
Human Resources is available to answer any questions you may have.
Open Enrollment is your once-a-year opportunity to review existing benefit elections and:
• Change your plan choices
• Add or drop dependents (supporting documentation required)
• Sign up for Supplemental life insurance (Medical Underwriting may be required)
• Update your beneficiaries
• Enroll or re-enroll in Flexible Spending Account
• Revisit your Health Savings Account contributions, if you have enrolled in a High Deductible
Health Plan
• Enroll or make changes to your contribution amount or investment choices in your 457
Deferred Compensation Plan
• Enroll or re-enroll in the Wellness Program.
• Update your personal information such as home address, phone number, e-mail address or
emergency contact.
OPEN ENROLLMENT DATES
Beginning on October 19, 2020 until 7:00 PM on November 6, 2020, all plan participants will be
eligible to participate in the annual Open Enrollment period. During Open Enrollment, you
have the right to change group benefit plans and add or delete dependent coverage.
Your new plan benefits will be effective January 1, 2021 and will run through December 31,
2021.
Unlike previous years, we won't be able to have on-site HR Benefit Open Enrollment Office
Hours. However, the Benefits Division has provided all the resources you would normally have
available in person, on our Open Enrollment website.
Remember even though HR Benefit staff are working remotely, we are here to assist you with
any benefit questions. Please reach out if you need assistance at HRBenefits@sanjoseca.gov
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.
P age |4
Open Enrollment
With everyone’s health and safety as the City’s main priority, we will be having all our Open Enrollment
activities virtually this year. In lieu of our annual in-person Benefits Fair, Human Resources has provided
all the resources you would normally have available in person, here in the Guide.
WHAT’S NEW FOR 2021?
The City of San José’ is pleased to announce that there are no major medical plan changes for 2021.
Rate increases, 6.3% for Kaiser, 8% for Anthem. The Anthem HMO $20 Copay Select Plan will still have
the lowest employee contribution for a non-deductible plan.
PLAN CHOICES
HMO Plans PPO Plans HMO Plans
• $20 Copay Select • $100 Deductible Select • $25 Copay
HMO PPO • $1500 Deductible HMO
• $1500 Select • $100 Deductible Classic • $3000 Deductible w/H.S.A
Deductible HMO PPO
• $3000 Deductible w/o H.S.A
• $2500 Deductible Classic
PPO w/ H.S.A.
• $2500 Deductible Classic
PPO w/o H.S.A.
SELF-CARE APPS AVAILABLE
AVAILABLE TO BOTH ANTHEM & KAISER MEMBERS
Everyone needs support for total health — mind, body, and spirit. Digital tools can help you
navigate life’s challenges, make small changes that improve sleep, mood, and more, or
simply support an overall sense of well-being.
That’s why as a part of your health care benefits you have access to myStrength, a free
online and mobile program that supports emotional health and well-being.
KAISER MEMBERS ONLY
Calm is an app for daily use that uses meditation and mindfulness to help lower
stress, reduce anxiety, and improve sleep quality. With guided meditations,
programs taught by world-renowned experts, sleep stories narrated by
celebrities, mindful movement videos, and more, Calm offers something for everyone.
To get started, access the apps at kp.org/selfcareapps.
myStrength® is a personalized program that includes interactive activities, in-the-moment coping tools,
inspirational resources, and community support. You can track preferences and goals, current emotional states,
and ongoing life events to improve your awareness and change behaviors.
myStrength® is a wholly owned subsidiary of Livongo Health, Inc.
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.
P age |5
Open Enrollment
NEXT STEPS?
NO ACTION REQUIRED UNLESS:
• You want to participate in Medical Reimbursement Account (MRA) and/or Dependent Care
Assistance Program (DCAP) for the 2021 plan year.
• You want to participate in the 2021 Wellness Rewards Program.
• You are currently enrolled in either the Anthem or Kaiser Health HSA and wish to continue
participation in 2021, must re-enroll during the open enrollment period.
IF YOU NEED MORE INFORMATION ABOUT YOUR BENEFITS, PLEASE VISIT:
• City of San José Open Enrollment Website (2021 Open Enrollment)
• City of San José Employee Events Calendar
• Anthem Microsite (www.anthem.com/ca/csj/ )
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.
P age |6
Open Enrollment
• Kaiser Microsite (https://my.kp.org/cityofsanjose/)
• Virtual Health and Wellness Fair (https://cityofsanjose2020wellnessfair.well-concepts.com/)
• Interactive Open Enrollment Guide
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.
P age |7
Open Enrollment
MEDICAL PLAN RATES
For Full-Time-All Employees (Except Employees Represented by the POA and IAFF, Local 230)
Total Monthly Your Monthly
MEDICAL-Anthem $1500 Deductible Select HMO Cost Cost
Employee Only $558.80 $0.00
Employee + Spouse $1,229.40 $0.00
Employee + Children $1,005.86 $0.00
Employee + Family $1,732.34 $0.00
Total Monthly Your Monthly
MEDICAL-Anthem $20 Copay Select HMO Cost Cost
Employee Only $724.82 $72.48
Employee + Spouse $1,594.58 $159.46
Employee + Children $1,304.68 $130.46
Employee + Family $2,246.90 $224.68
Total Monthly Your Monthly
MEDICAL-Anthem $100 Deductible Select PPO Cost Cost
Employee Only $1,587.22 $953.52
Employee + Spouse $3,491.90 $2,224.52
Employee + Children $2,857.00 $1,748.06
Employee + Family $4,920.42 $3,019.34
Total Monthly Your Monthly
MEDICAL-Anthem $100 Deductible Classic PPO Cost Cost
Employee Only $1,697.56 $1,063.86
Employee + Spouse $3,734.68 $2,467.30
Employee + Children $3,055.62 $1,946.68
Employee + Family $5,262.48 $3,361.40
MEDICAL-Anthem HSA $2500 Deductible Classic Total Monthly Your Monthly
PPO Cost Cost
Employee Only $977.80 $344.10
Employee + Spouse $2,151.16 $883.78
Employee + Children $1,760.04 $651.10
Employee + Family $3,031.20 $1,130.12
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.
P age |8
Open Enrollment
MEDICAL PLAN RATES
For Full-Time-All Employees (Except Employees Represented by the POA and IAFF, Local 230)
Total Monthly Your Monthly
MEDICAL-Kaiser HSA $3000 Deductible HMO Cost Cost
Employee Only $514.34 $0.00
Employee + Spouse $1028.68 $0.00
Employee + Children $900.10 $0.00
Employee + Family $1,543.02 $0.00
Total Monthly Your Monthly
MEDICAL-Kaiser $1500 Deductible HMO Cost Cost
Employee Only $610.44 $0.00
Employee + Spouse $1,220.88 $0.00
Employee + Children $1,068.28 $0.00
Employee + Family $1,831.32 $0.00
Total Monthly Your Monthly
MEDICAL-Kaiser $25 Copay HMO Cost Cost
Employee Only $745.52 $111.82
Employee + Spouse $1,491.04 $223.66
Employee + Children $1,304.64 $195.70
Employee + Family $2,236.56 $335.48
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.
P age |9
Open Enrollment
MEDICAL PLAN RATES
For Full-Time-All Employees (Represented by the POA and IAFF, Local 230)
Your Monthly
Total Monthly Cost
MEDICAL-Anthem $1500 Deductible Select HMO Cost
Employee Only $558.80 $0.00
Employee + Family $1,507.96 $0.00
Your Monthly
Total Monthly Cost
MEDICAL-Anthem $20 Copay Select HMO Cost
Employee Only $724.82 $72.48
Employee + Family $1,955.88 $195.58
MEDICAL-Anthem HSA $2500 Deductible Classic Your Monthly
Total Monthly Cost
PPO Cost
Employee Only $977.80 $329.84
Employee + Family $2,638.60 $1,025.20
Your Monthly
Total Monthly Cost
MEDICAL-Anthem $100 Deductible Classic PPO Cost
Employee Only $1,697.56 $939.26
Employee + Family $4,580.90 $2,967.50
Your Monthly
Total Monthly Cost
MEDICAL-Anthem $100 Deductible Select PPO Cost
Employee Only $1,587.22 $939.26
Employee + Family $4,283.12 $2,669.72
Your Monthly
Total Monthly Cost
MEDICAL-Kaiser HSA $3000 Deductible HMO Cost
Employee Only $503.58 $0.00
Employee + Family $1,253.90 $0.00
Your Monthly
Total Monthly Cost
MEDICAL-Kaiser $25 Copay HMO Cost
Employee Only $762.30 $114.34
Employee + Family $1,898.12 $284.72
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.P a g e | 10
Open Enrollment
DENTAL PLAN RATES
For Full-Time-All Employees (Except Employees Represented by the POA and IAFF, Local 230)
Total Monthly Your Monthly
DENTAL-Delta Dental HMO Cost Cost
Employee Only $24.44 $0.00
Employee + Spouse $48.86 $0.00
Employee + Children $42.74 $0.00
Employee + Family $73.30 $0.00
Total Monthly Your Monthly
DENTAL-Delta Dental PPO Cost Cost
Employee Only $50.88 $2.54
Employee + Spouse $111.92 $5.60
Employee + Children $122.12 $6.10
Employee + Family $157.72 $7.88
For Full-Time-All Employees (Represented by the POA and IAFF, Local 230)
Total Monthly Your Monthly
DENTAL-Delta Dental HMO Cost Cost
IAFF & POA employees $41.82 $0.00
Total Monthly Your Monthly
DENTAL-Delta Dental PPO Cost Cost
IAFF & POA employees $105.90 $5.30
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.P a g e | 11
Open Enrollment
VISION PLAN RATES
For Full-Time-All Employees (Represented by MEF,CAMP,ALP AEA, AMSP,UNIT 99)
VSP SIGNATURE Total Monthly Cost Your Monthly Cost
Employee Only $6.98 $0.00
Employee + Spouse $9.96 $0.00
Employee + Children $12.30 $0.00
Employee + Family $19.68 $3.68
VSP-CHOICE Total Monthly Cost Your Monthly Cost
Employee Only $7.34 $0.00
Employee + Spouse $10.48 $0.00
Employee + Children $12.96 $0.00
Employee + Family $20.72 $4.72
FOR FULL-TIME-ALL EMPLOYEES (REPRESENTED BY ABMEI, IAFF, IBEW, OE3, & POA)
VSP SIGNATURE Total Monthly Cost Your Monthly Cost
Employee Only $11.46 $11.46
Employee + 1 Dependent $16.32 $16.32
Employee + 2 or more
$29.24 $29.24
Dependents
VSP-CHOICE Total Monthly Cost Your Monthly Cost
Employee Only $12.04 $12.04
Employee + 1 Dependent $17.18 $17.18
Employee + 2 or more $30.80 $30.80
Dependents
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.P a g e | 12
Who Can You Cover?
Please refer to the Summary Plan Description
WHO IS ELIGIBLE? for complete details on how benefits eligibility is
Full-time and part-time benefited employees determined.
are eligible for benefits described in this
handbook unless otherwise noted in specific WHO IS NOT ELIGIBLE?
sections, the employee’s MOA, Benefits &
Compensation summaries, or plan documents. Family members who are not eligible for
coverage include (but are not limited to):
You can enroll the following family members in
our medical, dental and vision plans. • Parents, grandparents, and siblings.
• Your spouse (the person who you are • Any individual who is covered as an
legally married to under state law, including employee of City of San José cannot also
a same-sex spouse.) be covered as a dependent.
• Your same or opposite sex domestic • Employees who work fewer than 20 hours
partner is eligible for coverage if you have per week, temporary employees who work
completed a Domestic Partner fewer than 20 hours per week, contract
Declaration. Please review the affidavit employees, or employees residing outside
guidelines. The Cost of Coverage section the United States.
explains the tax treatment of domestic
partner coverage.
• Your children (including your domestic
ENROLLMENT PERIODS
partner's children): Coverage for new or promoting employees will
o Under age 26 are eligible to be enrolled be effective the first of the month following the
in medical coverage. They do not have employee’s enrollment date.
to live with you or be enrolled in school.
New or promoting employees will have 30 days
They can be married and/or living and
working on their own. from date of promotion or date of hire
(Eligibility Date) to enroll in benefit plans.
o Over age 26 ONLY if they are
incapacitated due to a disability and New or promoting employees who do not
are primarily dependent on you for complete the enrollment process within 30
support. days will automatically be enrolled in the
o children 19 through 23 years of age Anthem $1500 Deductible Select HMO
may qualify as dependents only if they employee only level for medical, and the
are full-time students DeltaCare HMO employee only level for
dental.
o Named in a Qualified Medical Child
Support Order (QMCSO) as defined by After that, Open Enrollment is the one time
federal law. each year that employees can make changes
to their benefit elections without a qualifying
life event.
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.P a g e | 13 Who Can You Cover? Notify Human Resources within 30 days if you have a qualifying life event and need to add or drop dependents outside of Open Enrollment. Life events include (but are not limited to): • Birth or adoption of a baby or child • Loss of other healthcare coverage • Eligibility for new healthcare coverage • Marriage or divorce The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions. Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.
P a g e | 14
Medical
The City’s medical plans are designed to help maintain wellness and protect you and your
family from major financial hardships in the event of illness or injury. The City offers a choice
of medical plans through Anthem Blue Cross and Kaiser Permanente.
WHICH PLAN IS RIGHT FOR YOU?
Consider an HMO (Health Maintenance Organization) if:
• You want lower, predictable out-of-pocket costs Plans To Consider
• You like having one doctor manage your care • Anthem $20 Copay
• You are happy with the selection of network Select HMO
providers • Anthem $1500
• You don’t see any doctors that are out-of-network Deductible Select HMO
• Kaiser $25 Copay
• Kaiser $1500 Deductible
HMO
Consider a PPO (Preferred Provider Organization) if:
• You want to be able to see any provider, even a Plans To Consider
specialist, without a referral • $100 Deductible Select
• You want access to one of the largest national PPO
• $100 Deductible Classic
networks in the Country, with the ability to see
PPO
any licensed provider in the nation, regardless of
whether or not the provider is in the network
Consider a High Deductible Health Plan (HDHP) if:
• You want to be able to see any provider, even a Plans To Consider
specialist, without a referral (Not applicable for the
• Anthem $2500
Kaiser $3000 Deductible HMO Plan)
Deductible Classic PPO
• You are willing to pay more to see out-of-network w/ H.S.A.
providers (Not applicable for the Kaiser $3000
• Anthem $2500
Deductible HMO Plan)
Deductible Classic PPO
• You want tax-free savings on your healthcare costs w/o H.S.A.
• You want to build a savings account for future • Kaiser $3000 Deductible
healthcare costs for you and your eligible family w/H.S.A
members
• Kaiser $3000 Deductible
• You want an extra way to add to your retirement w/o H.S.A
savings
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.P a g e | 15
Medical
ANTHEM MEMBER EXCLUSIVE PERKS
Partnership with Santa Clara County IPA (SCCIPA)
Santa Clara County IPA is the largest network of independent physicians in the county with
over 900 physicians throughout Santa Clara County. SCCIPA providers are focused on
providing personalized care to each of their members.
Partnering with Anthem Blue Cross and the City of San José, SCCIPA is proud to provide a
high performing network of independent physicians. SCCIPA members also can participate
in the Care Concierge Program. If you have a hospital stay or a complex health condition,
the SCCIPA team is there to help transition to home and follow your care through recovery.
SCCIPA provides:
• Direct 24-hour help line 24/7
• Enrolled patients receive a Local nurse as Concierge
• Personalized experience with proven health outcomes
ANTHEM CONCIERGE
Anthem members have access to a concierge exclusive to City of San
José Anthem members!
Our Concierge service includes:
• Communicating the benefit design packages to members as defined by The City of
San José at their on-site locations (City Hall & Retirement Services)
*Due to Covid-19, Concierge is temporarily off site.
• Interacting with members in a multi-channel environment verbally (e.g., chat,
telephone, face to face, video chat) and in written form to ensure appropriate
engagement is achieved.
• Interpreting plan benefit design, resolving claim, benefit, and enrollment issues
• Assisting in increasing member's engagement into appropriate Anthem programs and
offerings.
• An additional resource and educator on health care related inquiries.
• Availability from Monday – Friday, 8am – 5pm
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.P a g e | 16
Medical
Medical coverage provides you with benefits that help keep you healthy, like preventive care
screenings and access to urgent care. It also provides important financial protection if you have a
serious medical condition.
NO DEDUCTIBLE HMO PLANS
Anthem $20 Copay Kaiser Permanente
Select HMO $25 Copay HMO
In-Network In-Network
Annual Deductible $0 per individual $0 per individual
$0 per family $0 per family
Annual Out-of-Pocket $1,500 per individual $1,500 per individual
Max $3,000 family limit $3,000 family limit
Office Visit
Primary Provider $20 copay $25 copay
Specialist $20 copay $25 copay
Preventive Services Plan pays 100% Plan pays 100%
Chiropractic Care $20 copay Not covered
(up to 60 visits combined with rehab benefits)
Lab and X-ray No charge No charge
Inpatient Hospitalization $100 per admission $100 per admission
Outpatient Surgery $100 per admission $100 per procedure
Urgent Care $20 copay $25 copay
Emergency Room $100 per visit $100 per visit
(copay waived if admitted) (copay waived if admitted)
Prescription
Retail (30-day supply)
Generic $10 per refill $10 per refill
Preferred $30 per refill $25 per refill
Non-Preferred $60 per refill $25 per refill
Specialty Drug $60 per refill $25 per refill
Mail Order (90/100d
supply)
Generic $20 per refill $20 per refill
Preferred $60 per refill $50 per refill
Non-Preferred $120 per refill $50 per refill
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.P a g e | 17
Medical, continued
DEDUCTIBLE HMO PLANS
Anthem $1500 Deductible Kaiser $1500
Select HMO Deductible HMO
In-Network In-Network
Annual Deductible
Self Only Coverage $1,500 $1,500 per individual
Family Coverage
Each member $1,500 $3,000 family limit
Entire Family of 2+ $3,000
Annual Out-of-Pocket
Max
Self Only Coverage $4,000 $4,000 per individual
Family Coverage
Each member $4,000
Entire Family of 2+ $8,000 family limit
$8,000
Office Visit
Primary & Specialist $20 copay $40 copay
Preventive Services Plan pays 100% Plan pays 100%
Chiropractic Care $20 copay (up to 60 combined with Not covered
rehab benefits)
Acupuncture $20 copay Not covered
Lab and X-ray $10 copay per procedure $10 per encounter
$50 copay per test (MRI/PET/CT) 30% up to $50 per test (MRI/PET/CT)
Inpatient Hospitalization 30% after deductible 30% after deductible
Outpatient Surgery 30% after deductible 30% after deductible
Urgent Care $20 copay $40 copay
Emergency Room 30% after deductible 30% after deductible
Prescription
Retail (30-day supply)
Generic $10 per refill $10 per refill
Preferred $30 per refill $30 per refill
Non-Preferred $60 per refill $30 per refill
Specialty Drug (30-day) $60 per refill $30 per refill
Mail Order (100-day supply)
$20 per refill $20 per refill
Generic
$60 per refill $60 per refill
Brand Name/Formulary
$120 per refill
Non-Formulary $30 per refill
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.P a g e | 18
Medical, continued
ANTHEM BLUE CROSS PPO PLANS
Anthem $100 Deductible Anthem $100 Deductible
Select PPO Classic PPO
In-Network Out-of-Network In-Network Out-of-Network
Annual Deductible
Individual | Family $100 | $200 $100 | $200
Annual Out-of-Pocket
Max
$2,100 | $4,200 $2,100 | $4,200
Individual | Family
Office Visit
Primary & Specialist $25 copay 30% $25 copay 30%
Preventive Services Plan Pays 100% 30% Plan Pays 100% 30%
Chiropractic Care
10% 30% 10% 30%
(20 visits per calendar year)
Acupuncture 10% 10% 10% 10%
Lab and X-ray 10% 10%
10% up to $800 30% 10% up to $800 30%
(MRI/PET/CT) (MRI/PET/CT)
Inpatient Hospitalization 10% 30% up to $1,000 10% 30% up to $1,000
per day per day
Outpatient Surgery $100 copay per 30% up to $350 $100 copay per 30% up to $350 per
admission + 10% per visit admission + 10% visit
Urgent Care $25 copay 30% $25 copay 30%
Emergency Room $100 per visit (waived if admitted) $100 per visit (waived if admitted)
Prescription
Retail (30-day supply)
Generic $10 per refill 25% up to $250 $10 per refill 25% up to $250
Preferred $25 per refill 25% up to $250 $25 per refill 25% up to $250
Non-Preferred/ $40 per refill 25% up to $250 $40 per refill 25% up to $250
Specialty
Mail Order
(100-day supply)
$20 per refill Not Covered $20 per refill Not Covered
Generic
$50 per refill Not Covered $50 per refill Not Covered
Preferred
$80 per refill Not Covered $80 per refill Not Covered
Non-Preferred/
Specialty
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.P a g e | 19
Medical, continued
HEALTH SAVINGS ACCOUNT (HSA) QUALIFIED PLANS
Anthem $2500 Kaiser $3000
Deductible Classic PPO with HSA Deductible With HSA
In-Network Out-of-Network In-Network
Annual Deductible
Self Only Coverage $2,500 $3,000
Family Coverage $3,000
Each member $2,800 $6,000
Entire Family of 2+ $5,000
Annual Out-of-Pocket Max $5,950
Self Only Coverage $4,000 $9,000
Family Coverage
Each member $4,000 $ 9,000 $ 5,950
Entire Family of 2+ $8,000 $18,000 $11,900
Office Visit 20% after deductible 30% after deductible 30% after deductible
Preventive Services Plan pays 100% Plan pays 100% Plan pays 100%
Chiropractic Care
20% after deductible Not covered Not covered
(30 visits per calendar year)
Acupuncture 20% after deductible Not covered Not covered
(20 visits per calendar year)
Lab and X-ray
20% after deductible 30% after deductible 30% after deductible
Inpatient Hospitalization 20% after deductible 30% after deductible 30% after deductible
Outpatient Surgery 20% after deductible 30% after deductible 30% after deductible
Urgent Care 20% after deductible 30% after deductible 30% after deductible
Emergency Room 20% after deductible (waived if admitted) 30% after deductible
Retail (30-day supply)
Generic $10 per refill 40% coinsurance $10 per refill
Preferred $30 per refill Up to $250 $30 per refill
Non-Preferred $60 per refill $30 per refill
$60 per refill
Specialty Drug (30-day) $30 per refill
Mail Order (100-day supply)
Generic $20 per refill $20 per refill
Preferred $60 per refill NOT COVERED $60 per refill
Non-Preferred $120 per refill $30 per refill
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.P a g e | 20
Getting Care When You Need It Now
APPROPRIATE ACCESS & CONTACT
TYPE FOR EXAMPLES INFO
Nurseline Quick answers • Identifying symptoms 24/7
from a trained • Decide if immediate Anthem Blue Cross:
nurse care is needed (800) 977-0027
• Home treatment
Kaiser:
options and advice
(800) 464-4000
Online visit Minor illnesses • Common cold, flu, 24/7
and conditions fever
• Headache, migraine Anthem Blue Cross:
• Skin conditions livehealthonline.com
• Allergies Kaiser:
www.kp.org
Office visit Routine medical • Preventive care Office Hours
care • Illnesses, injuries
and overall • Managing existing To locate a provider:
health conditions • Anthem PPO
management • Anthem HMO
• Kaiser Permanente
Urgent Non-life- • Stitches Vary, up to 24/7
care, threatening • Sprains
Walk-in conditions • Animal bites To locate a facility:
clinic requiring prompt • Ear-nose-throat • Anthem PPO
attention infections • Anthem HMO
• Kaiser Permanente
Emergency Life-threatening • Suspected heart 24/7
room conditions attack or
requiring • stroke To locate a facility:
immediate • Major bone breaks • Anthem PPO
medical • Excessive bleeding • Anthem HMO
expertise • Severe pain • Kaiser Permanente
• Difficulty breathing
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.P a g e | 21
Medical
TELE-HEALTH
Now you can get the health care you need without all the hassle.
With LiveHealth Online, you don’t have to schedule an appointment, drive to a provider’s office, and
then wait for your appointment. You don’t even have to leave your home or office. Healthcare
providers can answer questions, make a diagnosis, and even prescribe basic medications when
needed. All online visits U.S. board-certified doctors, psychiatrists or licensed therapists are private,
secure and convenient.
LiveHealth Online LiveHealth Online LiveHealth Online
Medical Psychology Psychiatry
If you are coping with a
Whenever you have a If you’re feeling stressed, common behavioral health
Type of health concern and don’t worried or having a tough condition psychiatrists are
service want to wait. time & you need to speak available to provide an
with a licensed therapist. evaluation and medication
management
Cold and flu symptoms
Stress, anxiety, depression, Anxiety, stress, depressions,
such as a cough, fever
Conditions relationship or family issues, bipolar disorder, obsessive
and headaches, allergies,
addressed grief, panic attacks or stress compulsive disorder or post-
sinus infections or family
from coping with a sickness. traumatic stress disorder.
health questions
How soon
can you Doctors are available 24/7, Appointments within 14
Appointments within 4 days
meet with a 365 days days
provider
For your first visit, set up a time To schedule an
How to get • Enroll for free at
by: appointment, all you have
started www.livehealthonline.c
to do is:
om • Online: Visit
www.livehealthonline.com • Just visit
• Download their mobile and sign up or log in. www.livehealthonline.com
app then sign up or log Select LiveHealth Online or
in. Psychology. • Call 1-888-548-3432
• Mobile app: Download
• You’re ready to see a mobile app and then sign
doctor. up or log in. Choose
LiveHealth Online
Psychology.
• Phone: Call 1-844-784-8409
from 7 a.m. to 11 p.m. ET or
PT.
Cost1 $0 copay $0 copay $0 copay
1For those enrolled in High Deductible Health Plans, $0 copay applies once deductible is met.
These services are for non-emergency health issues only.
If you are experiencing life threatening emergency, please call 911.
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.P a g e | 22
Medical
ALTERNATIVE OPTIONS TO ACCESS CARE
Get the care you need the way you want it. No matter which option you choose, your providers can
see your health history, update your medical record, and give you personalized care that fits your life.
Choose where, when, and how you get care
Call Kaiser Permanente anytime at 1-866-454-8855 (TTY 711) to make an appointment or to
speak to an advice nurse.
24/7 care advice Need care now?
Get medical advice and care guidance in the
moment from a Kaiser Permanente provider. Know before you go.
In-person visit Urgent care
Same-day appointments are often available. Sign An urgent care need is one
on to kp.org anytime, or call us to schedule a visit. that requires prompt
Email medical attention, usually
within 24 or 48 hours, but is
Message your doctor’s office with non-urgent
questions anytime. Sign on to kp.org or use our
not an emergency medical
mobile app condition.
This can include minor
Phone appointment injuries, backaches,
Save yourself a trip to the doctor’s office for minor earaches, sore throats,
conditions or follow-up care. coughs, upper-respiratory
symptoms, and frequent
Video visit urination or a burning
Meet face-to-face online with a doctor on your sensation when urinating.
computer, smartphone, or tablet for minor Kaiser is available 24/7 to
conditions or follow-up care. guide you.
Call at 1-866-454-8855
(TTY 711).
Emergency care
A life-threatening injury or illness
that requires care right away.
• Trouble breathing
• Severe chest pains
• Very bad injuries or
wounds
If you think you have a
medical or psychiatric
emergency, call 911 or go to
the nearest hospital.
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.P a g e | 23
Health Savings Account
A Health Savings Account (HSA) is a special “tax advantaged” account owned by an
individual that is used in conjunction with a High Deductible Health Plan (HDHP).
• This account comes with a debit card that you can use to pay for qualified medical expenses.
For a detailed list of qualified medical expenses and further information, please refer to the
plan documents.
• In 2021, you can contribute a maximum of $3,600 for employee only or $7,200 for employee +
one or more. This maximum includes both employer and employee contributions.
• Since your medical expenses may change within the year, you may change (increase or
decrease) your contributions at any time.
This money to help pay for qualified medical expenses.
• If you have remaining funds at the end of the year, they will roll over into next year, there is no
“use it or lose it” rule.
• These funds can also earn interest or you can choose to invest the funds using the online
investment tool. (Plan minimums may apply)
• If you decide you do not want to continue to be enrolled in the HDHP plan, this account stays
with you.
• You may only contribute to the account if you are enrolled in a HDHP plan.
You may not continue to contribute to an HSA account once you are enrolled in Medicare. When you
turn 65, you can use any unused funds in the account for any purpose, penalty free, but you will be
subject to ordinary income tax.
If you elect of enroll in one of the HDHP plans offered through Kaiser or Anthem for 2021, you are not
eligible to enroll in the City’s Flexible Spending Medical Reimbursement Account (MRA).
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.P a g e | 24
Dental
Regular visits to your dentists can protect more than your smile; they can help protect your health.
Recent studies have linked gum disease to damage elsewhere in the body and dentists are able to
screen for oral symptoms of many other diseases including cancer, diabetes, and heart disease.
City of San José lets you choose between two dental plans from Delta Dental. Either way, you’ll get
reliable dentist networks and affordable preventive care.
Your options are:
PPO Plan Dental HMO
• This preferred provider plan offers the • Under this HMO-type plan, you’ll
convenience and flexibility of visiting have your choice of skilled primary
any licensed dentist, anywhere. care dentists from the DeltaCare USA
network.
• Covered services are paid based on a
percentage — if, for example, fillings •
Select a primary care dentist, who will
are covered at 80%, you pay the then coordinate any needed
remaining 20%. referrals to a specialist.
• Get the most plan value by choosing a • Covered services provided by your
Delta Dental PPO dentist. PPO network DeltaCare USA dentist have preset
dentists complete claim forms for you copayments (dollar amounts), which
and can help advise you on questions are listed in your plan booklet.
regarding your share of the payment.
• There are no maximums or
deductibles.
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.P a g e | 25
Dental
PLAN COMPARISON
Delta Dental PPO DeltaCare USA
You can visit any licensed You must select a DeltaCare
dentist to receive coverage, USA primary care dentist and
Can I go to any dentist?
but you’ll save the most at an visit this dentist to receive
in-network dentist. benefits.2
Your plan covers a wide range Your plan covers over 300
of services, with no exclusions procedures, with no exclusions
for most pre-existing conditions. for most pre-existing conditions.
What procedures are covered?
Preventive care, like routine Preventive care, like routine
cleanings and exams, is offered cleanings and exams, has no
at no cost. copayments.
No deductible however Delta
Are there deductibles and No, there are no annual
Dental will only pay up to
maximums? deductibles or maximums.
$1,500 per calendar year.
Coverage is provided only for Coverage is provided only for
treatment started and treatment started and
Am I covered for treatment
completed after your effective completed after your effective
I began under a different
date. date.
employer-sponsored dental
plan?
Orthodontic treatment may be Orthodontic treatment may be
an exception to this rule. an exception to this rule.
You are responsible for the
What if I started orthodontic Typically, Delta Dental pays the
copayments and fees subject
treatment under my previous remaining benefit not paid by
to the provisions of your prior
dental plan? your prior dental plan.
dental plan.
Contact your DeltaCare USA
What happens if I need to see You do not need a referral from
primary care dentist to
a specialist? your dentist.
coordinate your referral
You have a limited benefit to
What is my out-of-area You can visit any licensed
go out of network for
coverage? dentist.
emergency care.
You can change your dentist at You can change your selected
How do I change my dentist? any time without contacting or assigned primary care
Delta Dental. dentist online or by telephone.
If you visit a Delta Dental
dentist, the dental office will file
the claim for you. If you go to a There are generally no claim
Do you need to fill out claims?
non–Delta Dental dentist, you forms under your plan.
may have to submit the claim
yourself.
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.P a g e | 26
Dental
Dental PPO
In-Network Out-Of-Network1
Calendar Year Deductible $0 per individual $0 per individual
$0 per family $0 per family
Annual Plan Maximum $1,500 per individual per calendar year
Waiting Period None None
Diagnostic and Preventive
Plan pays 100% Plan pays 85%
Exams, 2 cleanings & x-rays
Basic Services
Fillings, simple tooth Plan pays 85% Plan pays 85%
extractions and sealants
Endodontics (root canals) Plan pays 85% Plan pays 85%
Periodontics Plan pays 85% Plan pays 85%
(gum treatments)
Oral Surgery Plan pays 85% Plan pays 85%
Major Services
Crowns, inlays, onlays, and Plan pays 85% Plan pays 85%
cast restorations
Prosthodontics
Plan pays 65% Plan pays 60%
Bridges and dentures
Orthodontic Services (Adults and dependent children up to age 19 or 24 if full-time student)
Orthodontia Plan pays 60%
Lifetime Maximum $2,000
1 Out of network dentists may directly bill the patient for the difference between Delta Dental’s payment and their actual charge
for services (balance billing).
For dental services amounting to at least $300, it is suggested that you ask your provider’s office to request a
pre-determination estimate from Delta Dental. This ensures that your procedure is covered and helps you plan
your payment in advance.
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.P a g e | 27
Dental
DeltaCare USA
Dental HMO
In-Network
Diagnostic & Preventive
Office Visit No Cost
Teeth Cleaning – 1 per 6 months
X-rays
Sealants – per tooth
Restorative
Amalgam filling – 1-3 surfaces $0
Composite filling – 1-3 surfaces $25-$55
Periodontics
Scaling and root planning – per quad No Cost
Gingivectomy
Osseus Surgery
Endodontics
Pulp Cap No Cost
Therapeutic Pulpotomy
Root Canal Therapy
Prosthodontics
Immediate – Upper or lower No Cost
Complete – Upper or lower
Partial denture – Upper or lower
Crown and Bridge
Inlay/onlay No Cost
Crown – Porcelain/ceramic substrate $175
Crown – Porcelain fused with high noble metal $175
Crown – Full cast high noble metal $175
Oral Surgery
Extractions – Impacted tooth: soft tissue No Cost
Extractions – Impacted tooth: partial bony
Extractions – Impacted tooth: full bony
Orthodontic Services
Adult $1,000
Dependent Child (up to 19 or 24 if full time $1,000
student)
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.P a g e | 28
Dental
DELTA DENTAL MEMBER DISCOUNTS
While your oral health remains the top priority, Delta Dental also care about the bigger picture — your
overall well-being1. That’s why dental member now have access to preferred pricing on hearing aid
and LASIK services through Amplifon Hearing Health Care and QualSight2.
62% average savings off retail hearing
Access to 40-50% off the national average price
aid pricing,3 backed by a best price
sizeable savings of Traditional LASIK5
guarantee4
Convenient Broad nationwide network of
1,000+ LASIK locations6
locations providers
Access to the nation’s leading brands Experienced LASIK surgeons who have
Quality care and
featuring the latest hearing aid collectively performed 6.5+ million
products
technology procedures6
Amplifon acts as your personal
A QualSight care manager will walk
concierge at every step, from
Customized you through the program, coordinate
appointment scheduling and hearing
support care and help select the right
aid selection to coordinating follow-
physician and procedure.
up care.
Amplifon’s hearing aid discounts, visit QualSight’s LASIK discounts, visit
www.qualsight.com/-delta-dental or
www.amplifonusa.com/deltadentalins
For more call 1-855-248-2020.
or call 1-888-779-1429.
information
A care manager will explain the
Patient Care Advocate will help you
find a hearing care provider near you. program and answer any questions.
1DeltaDental of California, Delta Dental Insurance Company, Delta Dental of Pennsylvania, Delta Dental of New York, Inc. and our affiliated
enterprise companies.
2 TheVision Corrective Services and hearing health care services are not insured benefits. Delta Dental makes the Vision Corrective Services
program available to enrollees to provide access to the preferred pricing for LASIK surgery. Delta Dental makes the hearing health care services
program available to enrollees to provide access to the preferred pricing for hearing aids and other hearing health services.
3 Amplifon Hearing Health Care utilization database, January-December 2018. Discounts or savings may vary by manufacturer and technology
level of the hearing aid device.
4 Amplifon offers a price match on most hearing devices; some exclusions apply. Not available where prohibited by law. Visit
www.amplifonusa.com/deltadentalins or call 1-888-779-1429 for more details.
5 Refractive Quarterly Update, Market Scope LLC, November 2018. Discounts or savings may vary by provider.
6 QualSight provider file, February 2019
The information in this booklet is a general outline of the benefits offered under the City of San José benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.You can also read
