2016 COBRA Guide

ST. VRAIN VALLEY SCHOOLS’

COBRA OPEN ENROLLMENT 303-776-6200 • 395 S. PRATT PKWY.• LONGMONT, CO 80501 • SVVSD.ORG

KAISER PERMANENTE (DHMO) PLAN The Kaiser Permanente plan is a non-profit Deductible Health Maintenance Organization (DHMO) plan that provides services through the Kaiser Permanente network of doctors, partner hospitals and other health care facilities.

There is no out-of-network coverage unless you experience a life-threatening injury or illness that requires ambulance and/or emergency room assistance.

Each time you visit a Kaiser Permanente pharmacy or other provider for care, you pay a copay or an amount based on your deductible and coinsurance responsibility. Your out-of-pocket costs for eligible expenses are capped annually at $2,500 for an individual or $5,000 for a family.

CNIC PPO PLAN The self-insured CNIC Plan is a Preferred Provider Organization (PPO) plan that offers a large network of contracted doctors and hospitals to choose from whenever care is needed. In Colorado, the Plan utilizes the Rocky Mountain Health Network and if you are outside of Colorado, you will want to access the Aetna Signature Network to maximize your savings. After you meet your annual deductible, you are responsible for paying a portion of remaining eligible expenses (your coinsurance).

KEY DEFINITIONS • Deductible – the amount of

covered expenses you must pay before charges are paid by your medical plan

• Copayment – a fixed-

dollar amount you pay for covered services through your medical plan

• Coinsurance – your share

of the cost of covered services, calculated as a percentage (for instance, you pay 10% and the Plan pays 90%); typically payable after you have met your deductible

• Out-of-Pocket Maximum - the maximum

amount you pay in a calendar year for covered expenses under your health plan (once you or your covered dependent reach the OOP Maximum, the plan covers 100% of eligible expenses for the remainder of the year)

When you enroll in the CNIC HRA plan, you automatically receive prescription drug coverage through NPS (National Pharmaceutical Services). You must use an innetwork pharmacy to receive a benefit under the NPS pharmacy plan.

Most national pharmacy chains and local pharmacies participate in the NPS Network.

(Please visit the NPS website at www.pti-nps.com to view the most up-to-date listing of pharmacy providers near you.)

When picking up your prescription at the pharmacy, show your ID card and pay your copay. It’s that simple! Your benefit will be processed onsite (no claim needed).

There are two ways you can receive your prescription drug benefits: • Retail Pharmacy – You receive up to a 30-day supply.

• Mail Order – If you are taking a maintenance medication (for a medical condition that requires ongoing use of medications such as high blood pressure, diabetes or a thyroid condition), you may want to use the mail-order prescription service through Integrated HMO Pharmacy. When you order prescriptions by mail, you can receive up to a 90-day supply and you’ll typically save money.

OTHER RESOURCES Medical Contacts

Dental

Healthcare Blue Book 800-426-7453 healthcarebluebook.com/ cc/stvrain password: hcbbstvrain

Vision

Kaiser Permanente 800-632-9700 kp.org

PERA 303-832-9550 copera.org

CNIC 800-426-7453 cnichs.com

Delta Dental 800-610-0201 deltadentalco.com

VSP 800-877-7195 vsp.com

Retirement

Pharmacy

Connect Your Care

Integrated HMO (Mail Order) 800-633-7928 pti-nps.com

(p): 855-687-2021 (f): 443-681-4606 cobraservice@ connectyourcare.com www.myrsc.com

NPS (Retail) 800-546-5677 pti-nps.com

COBRA Dept.

PO Box 873682 Kansas City, MO 64187

KEEP IN MIND Using in-network providers can save you money in several ways: • You have a lower upfront deductible and the Plan reimburses at a higher level for in-network charges • In-network providers have agreed to negotiated fees that are typically lower than out-ofnetwork providers • The Healthcare Bluebook, a service provided at no additional cost to all CNIC plan participants, provides online tools to help you identify the fair market price for thousands of medical procedures, tests, and other services. Check it out at: www.healthcarebluebook.com/cc/stvrain Password: hcbbstvrain

CONNECT YOUR CARE • 877-292-4040 • CONNECTYOURCARE.COM

MEDICAL SERVICES HRA Contribution (funded by SVVSD) Deductible (excludes RX/Vision copays) Out-of-Pocket Maximum

CNIC (PPO) IN-NETWORK

$750 Individual; $1,500 E $2,000 Individual/ $4,000 Employee + Dependent(s) $2,500 Individual/ $5,000 Employee + Dependent(s)

(excludes RX/Vision copays; includes deductibles)

Lifetime Maximum

Unlim

Preventive Care

Covered at 100%

Women’s Preventive Care (includes contraceptive devices, drugs and services)

Covered at 100%

Office Visits

10% coinsurance*

Diagnostic Lab/X-Ray Diagnostic CT, PET, MRI

10% coinsurance*

Chiropractic Care

10% coinsurance*

Outpatient Surgery

10% coinsurance*

Inpatient Hospital Services

10% coinsurance*

Ambulance

10% coinsurance*

Emergency Room

10% coinsurance*

Urgent Care

10% coinsurance*

Outpatient Mental Health/Substance Abuse

10% coinsurance*

Therapies (PT/OT/Speech) • Inpatient • Outpatient • Chiropractic

10% coinsurance* 10% coinsurance* 10% coinsurance*

Durable Medical Equipment

10% coinsurance*

Routine Vision Exam

$10 copay (one exam every 24 months)

Prescription Drugs (Retail Pharmacies) Up to a 30-day supply

$10 Copay Generic $45 Copay Brand Name, Formulary $60 Copay Brand Name, Non-Formulary

Prescription Drugs (Retail Pharmacies) Up to a 90-day supply

$25 Copay Generic $113 Copay Brand Name, Formulary $150 Copay Brand Name, Non-Formulary

*After plan deductible is met.

CNIC (PPO) OUT-OF-NETWORK

Employee + Dependent(s)

KAISER (DHMO) IN-NETWORK ONLY N/A

$4,000 Individual/ $8,000 Employee + Dependent(s)

$250 Individual/$500 Employee + Dependent(s)

$5,000 Individual/ $10,000 Employee + Dependent(s)

$2,500 Individual/ $5,000 Employee + Dependent(s) (includes copays and deductibles)

50% coinsurance*

Covered at 100%

50% coinsurance*

Covered at 100%

50% coinsurance*

$25 copay (PCP) / $40 copay (Specialist)

50% coinsurance*

Lab covered at 100%; Diagnostic x-ray, 10%* coinsurance; CT, PET, MRI $100 copay per procedure

50% coinsurance*

Not Covered

50% coinsurance*

10% coinsurance*

mited

Unlimited

50% coinsurance*

10% coinsurance*

10% coinsurance*

10% coinsurance, up to $500

10% coinsurance*

$150 copay

50% coinsurance*

$50 copay at a KP after-hours medical office

50% coinsurance*

$25 copay

50% coinsurance* 50% coinsurance* 50% coinsurance*

10% coinsurance* $25 copay Not Covered

50% coinsurance*

10% coinsurance*

Up to $100 allowance (one exam every 24 months)

$25 copay (one exam every 12 months)

Not Covered

$15 Copay Generic $40 Copay Brand Name 20% Coinsurance, Specialty (max. $250 per fill)

Not Covered

$30 Copay Generic $80 Copay Brand Name 20% Coinsurance, Specialty (max. $250 per fill)

DENTAL INSURANCE The self-insured dental plan, administered through Delta Dental of Colorado, is designed to help you maintain a healthy smile through regular preventive dental care, and to fix any problems as soon as they occur. Because preventive dental care is so important, the plan covers these services in full with no deductible or copay when you visit a Delta Dental PPO dentist. Although you are free to visit any licensed dentist for your care, you will save money by visiting a Delta Dental PPO or Premier® dentist.

For in-network providers, visit www.deltadentalco.com and use the “Find a Dentist” search tool. See summary of dental benefits below: DENTAL SERVICES

PPO DENTIST 1

Annual Deductible (waived for preventive services)

PREMIER DENTIST 2

NON-PARTICIPANT DENTIST 3

$50 Individual/$100 Employee + Dependent(s)

Preventive Services (oral exams, x-rays, cleanings)

100%

80% after deductible

80% after deductible

Basic & Restorative Services (fillings, endodontics, periodontics)

80% after deductible

80% after deductible

80% after deductible

Major Services (dentures, crowns, bridges)

50% after deductible

50% after deductible

50% after deductible

Orthodontia (children up to 19 years of age) Annual Benefit Maximum

50% up to $1,000 lifetime maximum. Deductible waived $1,500 per person

The PPO percentage of benefits is based on the PPO Schedule of Allowance The Premier percentage of benefits is limited to the Premier Maximum Plan Allowance.

The Non-Participating percentage of benefits is limited to the non-participating Maximum Plan Allowance.

You are responsible for the difference between the non-participating Maximum Plan Allowance and the fee charged by the dentist.

1 2 3

ID Cards are mailed after enrollment or visit deltadentalco.com to print your own.

ALL PREMIUMS ON BACK PAGE.

VISION INSURANCE The VSP vision plan includes benefits for eye exams, eyeglasses, and contact lenses. When you visit a VSP provider, you must pay a copay to your provider at the time of service.

Your provider will file claims for you and will be reimbursed directly by the insurance carrier for allowable charges. No need to show an insurance card, simply tell your vision provider you have VSP. To find a VSP provider, go to www.vsp.com. Reference the “choice” network to find an in-network VSP doctor.

When you visit an out-of-network provider for your vision care, you must pay your expenses in full at the time of service and submit a claim to VSP for reimbursement up to plan allowances, which are shown in the table below: VISION SERVICES Vision exam (every 12 months)

IN-NETWORK YOU PAY

OUT-OF-NETWORK REIMBURSEMENT

$10 copay

$45

Frames (every 12 months)

Up to $140, then receive 20% discount

$70

Lenses (every 12 months): Single vision lenses Bifocal lenses Trifocal lenses

$10 copay $10 copay $10copay

$30 $50 $65

Elective contact lenses, fitting and evaluation (in lieu of glasses)

Up to $140

$105

Discounts are available for non-covered services such as additional glasses and sunglasses, contact lenses and laser vision correction surgery.

CONNECT YOUR CARE • 877-292-4040 • CONNECTYOURCARE.COM

COBRA MONTHLY PREMIUMS Medical Plan

Employee Share

CNIC PPO Employee Only (EE)

$632.11

EE + Spouse

1,270.52

EE + Child(ren)

$1,135.56

EE + Family

$1,760.02

Kaiser Permanente Employee Only (EE) EE + Spouse EE + Child(ren) EE + Family

$511.12 $1,124.52 $920.02 $1,380.08

Delta Dental of Colorado Employee Only (EE)

$29.55

EE + Spouse

$63.22

EE + Child(ren)

$81.23

EE + Family

$116.96

VSP Employee Only (EE)

$7.78

EE + Spouse

$15.61

EE + Child(ren)

$16.41

EE + Family

$26.69