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County of Sonoma, California

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Employee Health and Welfare Benefits FAQs

Revised 6/28/2010

General Benefit Questions

Dependents

Medical General

County Health Plan (Anthem Blue Cross)

Kaiser Permanente / UnitedHealthcare

Dental & Vision

Life Insurance

County of Sonoma Benefits Enrollment/Change Form

Ending Employment (not retiring from County of Sonoma)

COBRA

General Benefit Questions

Annual Enrollment

1. When is Annual Enrollment?

Annual Enrollment for health plans for active employees and retirees takes place in the spring with changes effective June 1st.

Flexible spending account annual enrollment for active employees takes place in the fall with changes effective January 1st.

2. Will there be an additional Annual Enrollment in the spring for the Flexible Spending Accounts so I may enroll or adjust my contributions to the plans?

No. Section 125 of the Internal Revenue Code (Treasury Regulation 1.125-4(f) allows very limited mid-year changes to Health FSA elections. The benefit changes taking place this year do not qualify under the code to permit a mid-year change or enrollment to your health FSA.

3. How do Anthem and Kaiser justify the 2012/2013 rate increases?

There are a lot of factors which affect the rates. One factor is that our overall rates were lower than many other comparable public employers in part due to our small increases over the past several years. Another factor is that our overall population is aging, which tends to increase costs. There were also some very clear increases to the overall plan costs driven by increased hospitalizations with longer hospital stays. We also tend to have more cancer claims than average which can mean high cost claims. Our self-insured County Health Plans have a low administrative cost and the rest of the cost is medical claims expense. The more costly the services received are, the more this plan costs each of the members. The health of the participants has a direct impact on the premiums every year.

4. Why did the County not seek less expensive alternatives?

We have looked at plan design changes in recent years and found that raising office visits to $20 or $30 only lowers the premium by a few dollars a paycheck which has not been a popular alternative. The only plan design option that would make a significant change in the rates is a High Deductible Health Plan. This would mean a deductible of at least $1500 per person. Kaiser has declined to offer a bid on this type of plan for the County for the past 2 years. We had an HDHP provided by UHC, but they raised the rates to an unaffordable level because of low participation and high claims costs. At that time, there was nothing viable available on the market to replace the UHC HMO and HDHP plans. We are reviewing all the pieces that drive the costs within all of our plans to see what viable options could be implemented in the future.

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New Hire

3. I am a new employee – When is the deadline for enrolling in a health plan?

If you are a new employee or become newly eligible for benefits during the plan year, you must actively enroll in medical, dental, employee supplemental life insurance, dependent life insurance and flexible spending accounts if you want to participate in these plans.

Your department’s Payroll Clerk will provide you with the forms you need to make your benefit elections. You must make your elections by your enrollment deadline – within 31 days of your initial eligibility date. If you don’t meet your enrollment deadline, you will not be allowed to enroll in benefits until the next annual enrollment period unless you experience an event that qualifies for a Change in Status.

4. I was just hired – when do my benefits begin?

The effective date of benefits will be the first of the month following date of hire. Contact benefits customer service at (707) 565-2900 or benefits@sonoma-county.org for more specific dates or details.

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Address Change

5. Who should I notify of my new address?

Notify your department payroll clerk who will provide the necessary change form.

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Plan ID Card

6. My name is incorrect on my health plan identification card? How do I get it corrected?

Contact Human Resources Benefits Unit at (707) 565-2900

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Eligibility

7. I previously waived medical coverage for myself and my family because we have other group coverage. My son has been terminated on our current coverage because he is no longer eligible due to age. Can I enroll myself and my son in a County plan now?

No, the loss of coverage for just your son does not qualify as an event that allows a change outside of the Annual Enrollment period. You would have to lose coverage in order to allow enrollment of yourself and your son. You can enroll yourself and any dependents at the next Annual Enrollment.

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Traveling

8. I’m traveling out of the health plan service area. If need be, how do I access care in the area I am visiting?

The rules vary depending on the plan. You should check with your plan’s member services department or Evidence of Coverage (EOC) or Summary Plan Description (SPD) for your plan. The member service phone number for your plan is listed on the back of your plan ID card.

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Dependents

Adding a Dependent

9. How long do I have to add my newborn to my health coverage?

You have 31 days from the date of birth to submit the completed benefits enrollment change form to the Benefits Unit. If you miss this deadline, your newborn cannot be added until the annual enrollment in the spring. This will leave your child without coverage until June 1st of the next plan year.

10. I have obtained legal guardianship of my grandchild/niece/nephew and would like to add him/her to my coverage. What do I need to do?

You must complete the benefits enrollment change form within 31 days of obtaining legal guardianship and submit with a copy of the guardianship paperwork.

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Dropping a Dependent

11. My child is no longer eligible for health coverage. What should I do to delete him from my insurance?

You need to complete a benefits enrollment change form immediately to drop your dependent from the health plan(s). If your child is no longer eligible due to age or loss of student status, he/she will be offered COBRA to continue their benefits at their own cost, if eligible.

12. Can I drop my legally separated spouse from my health coverage?

No. You must wait until the divorce is final to drop your ex-spouse. Your ex-spouse will be offered COBRA to continue their benefits at their own cost.

13. I have found an individual policy for my son that is much cheaper than what I am paying for County coverage. Once he has been approved on the individual plan, how do I drop him from my County coverage?

Enrollment in an individual policy does not allow you the option to drop coverage for your dependent mid-year. Only enrollment in group coverage is allowed outside of the Annual Enrollment period based on Section 125 of the Internal Revenue Code (Treasury Regulation 1.125-4(f). You must wait until the Annual Enrollment to delete your son from your County coverage. Contact Human Resources Benefits Unit for a list of the allowable mid-year changes.

14. My daughter is over the age limit on her next birthday. When does her coverage end?

The last day of the dependent’s coverage is the last day of the month in which they become over-age.

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Dependent Age Limits

15. What is the age limit for covering my dependent children on my health & welfare plans?

The age limits are:

All medical plans: Any dependent child under age 26 is eligible provided he/she is not eligible for his/her own group coverage. An unmarried dependent child over the limiting age described above is eligible if incapable of supporting self due to mental or physical disability incurred prior to reaching the limiting age, who is chiefly dependent upon the subscriber for support.

  • Delta Dental and VSP allow coverage of unmarried children up to age 19; up to age 23 if a full-time student.
  • Dependent Life Insurance allows any dependent child under age 26.

Full-time student status is generally 12 units/credits at an accredited school, college or university. Unmarried children who meet the criteria of a disabled dependent prior to the limiting age are not subject to the age limits. Check with your health plan to determine if your child meets the criteria of a disabled dependent. Your health plan will require proof of student or disabled dependent status.

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Out of Area Dependent Child

16. My child is attending college and there are no in-network providers in the area. Can my child still receive services?

Urgent/Emergent care is covered while your child attends college. Routine care must be sought while your child is home during school breaks.

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Medical General

Prescription Coverage

17. How do I find out if a particular prescription medication is covered by my medical plan?

All of the county offered medical plans maintain a list of preferred and non-preferred drugs or formulary drugs and generally make that available to their members. The medical plans update their list of preferred/formulary drugs frequently. In order to obtain the list of drugs, visit the plan’s website or contact their customer service line:

  • Kaiser Permanente
    Website:
    www.kp.org
    Phone:
    (800) 464-4000 Work
  • UnitedHealthcare UHC HMO
    Website:
    www.pacificare.com
    Phone:
    (800) 624-8822 Work
  • UnitedHealthcare UHC-HDHP
    Website:
    www.uhc.com
    Phone:
    (866) 873-3903 Work
  • Anthem Blue Cross/CVS-Caremark
    Website:
    www.caremark.com
    Phone:
    (800) 966-5772 Work

You pay more out-of-pocket for non-preferred or non-formulary drugs. Brand name drugs will also cost you more than the generic equivalent. Ask you doctor to specify that a generic substitution is authorized – or ask if there is an over-the-counter equivalent for the drug being prescribed. Generic drugs are mandatory under the County Health Plans. Refer to the Health and Welfare Benefit booklet or the CHP Summary Plan Description for the complete details or contact CVS-Caremark.

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Cost of Medical Coverage

18. If the County’s contribution towards medical insurance doesn’t cover the total premium of the plan I select, will I get a bill from the insurance company each month to pay the balance?

No. If you select a medical plan with a premium cost in excess of the County’s contribution, the additional premium amount will be deducted from your paycheck on a pre-tax basis for you and your IRS qualified dependents.

19. What if I don’t have enough earnings to cover my portion of the medical premium?

For periods of leave without pay or insufficient funds, employees are billed for their share of the premiums due by the Auditor-Controller’s Payroll office.

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Part-Time Proration

20. Will the County contribution towards medical insurance be pro-rated for part-time employees and if so, what will the pro-ration be based on?

Yes. For most employees, the County shall contribute a flat dollar amount not to exceed $229.98 per pay period toward the cost of a County offered medical plan for eligible full-time regular employee’s and their eligible dependent(s). The County shall contribute to part-time eligible employees on a pro-rated basis. Proration shall be based on the number of qualified hours in the pay period, excluding overtime. Refer to your MOU or Salary Resolution for complete details.

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Three Pay Dates in a Month

21. Twice a year there are three pay periods in a single month. Does the County contribution towards medical insurance fluctuate based on the pay periods?

The County contribution has been converted into a biweekly amount, therefore the contribution will be a consistent amount each pay period regardless of the number of pay periods in a month (prorated based on pay status hours if you are part-time).

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Waiving Coverage

22. If I waive/decline coverage under a County offered medical plan, will I still receive the County’s contribution to use towards other medical coverage?

No. You must be enrolled in a County offered medical plan in order to receive the County contribution towards medical insurance.

23. Can an employee waive medical insurance coverage at any time or do they have to wait until the next Annual Enrollment?

An employee may only waive medical insurance coverage during Annual Enrollment or within 31 days of a qualified life/employment event that allows this type of change.

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Kaiser and UnitedHealthcare – Live or Work Rule

24. Does the "live or work" service area rule apply to active employees only in the Kaiser plan?

This rule applies to both Kaiser and UnitedHealthcare plans offered to active employees.

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County Health Plan (Anthem Blue Cross)

In-Network/Preferred Providers

25. What providers are available under the County Health Plan?

The providers vary depending on whether you are enrolled in the EPO or the PPO .

  • EPO (Exclusive Provider Organization): you may obtain services from in-network providers. In-network providers participate in the Anthem Blue Cross network and have agreed to a negotiated rate for services.
  • PPO (Preferred Provider Organization): you may obtain services from either in-network or out-of-network (non-preferred) providers. Out-of-network providers do not participate in the Anthem Blue Cross network and have not agreed to a negotiated rate.

You will pay a lower co-insurance percentage if you obtain care with an In-Network provider (refer to the Summary Plan Description for the rates). A directory of Anthem Blue Cross providers is available at http://www.anthem.com/ca (www.bluecares.com if you live outside California)  select Blue Cross PPO (Prudent Buyer) or by calling the provider access number (800) 759-3030. In addition, out-of-pocket costs incurred for non-covered services such as out-of-network services that exceed reasonable and customary charges allowed by the plan are not applied toward the out-of-pocket maximum. These non-covered charges are therefore the plan participant’s financial responsibility. Out-of-network services other than emergencies are not covered under the CHP-EPO plan.

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Co-payment

26. I am enrolled in County Health Plan PPO . Am I responsible for the $20 physician office visit co-payment?

Your out-of-pocket cost varies depending on whether the physician is In-Network or Out-of-Network.

  • In-Network: The deductible is waived and you are responsible for the $20 co-payment, even after you have met your deductible.
  • Out-of-Network: You must first meet your deductible, and then you are responsible for a 40% co-insurance payment.

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Oral Surgery

27. Is oral surgery covered under the County Health Plan?

Only to treat an accidental injury to your natural teeth.

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Kaiser Permanente / UnitedHealthcare

Out of Area

28. I’m going to be moving soon and there is no Kaiser near my new address. Do I have to wait until Annual Enrollment to switch to a different plan?

Yes. You are only allowed to change plans if you no longer live or work within 30 miles of a Kaiser Permanente facility. If you are about to retire and will not be within a Kaiser service area, you will be able to switch to another plan at the time of your change of address (within 31 days of your move) or when you enroll in medical coverage at the time of retirement.

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Employee with Medicare Coverage

29. I am a county employee with Medicare; can I enroll in a Medicare advantage plan (i.e. Kaiser Senior Advantage or UnitedHealthcare Secure Horizons)?

You may be able to enroll in a Medicare advantage plan – contact the health plan directly to find out your options. There is no County premium difference for employees with Medicare, so there is no premium savings to an employee who elects to enroll in a Medicare advantage plan.

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Dental & Vision

Dental Providers

30. Who are the dental providers for the Delta Dental plan?

Contact Delta Dental for the most current list of Delta Dental Premier providers at (800) 765-6003 or www.deltadentalins.com.

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Dental Enrollment

31. I signed up for dental coverage & I still don’t have it. (Premium was not deducted from my paycheck).

Contact the Benefits unit at (707) 565-2900 or benefits@sonoma-county.org and we will check your benefits file to confirm if an enrollment form has been submitted. If it was we will contact your payroll clerk to process a Change-of-Status form to turn on the dental premium deduction.

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Dental & Vision for Dependents

32. I’m only enrolling myself in a medical plan, but I have two children who live with my ex-spouse. Can they be covered on my dental and vision plans?

Yes. Enrollment in both Delta Dental and VSP is family coverage. All eligible dependents can be enrolled, including the employee’s own children who are not living in the employee’s home. Be sure to list your children in the dependent section of the County of Sonoma Benefits Enrollment/Change form to ensure they are enrolled in the dental and vision plans.

33. Can a County retiree be covered as a dependent under a County employee’s dental policy?

Yes, but only if the retiree is not also covered under a County offered retiree dental plan. When someone retires, they can waive their own retiree dental and become a dependent on their active spouse/DP policy, provided they do so within 31 days of the loss of their own active dental coverage. This would be a qualified employment status event for the new retiree. County policy prohibits dual-coverage on more than one employee/retiree health plan.

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Out-of-Pocket or Lifetime Maximums

34. Is there an out-of-pocket or lifetime maximum for dental services?

There is a $3000 out-of-pocket annual maximum per individual. There is no lifetime maximum benefit for Delta Dental.

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Life Insurance

Hartford

35. Does The Hartford require all supplemental life insurance applicants to undergo physicals or specific tests before they approve their applications?

Based on the review of your Personal Health Application, The Hartford may request you undergo exams or tests. The Hartford will notify you in writing if any exams or tests are required.

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County of Sonoma Benefits Enrollment/Change Form

Enrollment/Change Form Completion

36. Do employees have to complete all sections of the form if they are only changing their address?

In order to ensure that we have current and accurate information, we require all sections of the form be completed, regardless of the change being made.

37. Do employees have to fill out all sections of the form if making changes during Annual Enrollment?

If a section is left blank we do not know if you left it blank in error. Therefore, we do require that you complete each section, even if you are not making a change for those areas. Each new form replaces the old one on file.

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FTE

38. What does "__ FTE to __ FTE" stand for (Section 1a)?

FTE stands for "Full Time Equivalent" and should be marked as a reason for change if an employee’s normal hours change (for example: status changes from part-time to full-time).

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Dependent Section

39. If employees have no eligible dependents, what do they write in Section 7?

They should write "N/A" or "None".

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IRS Qualified Status

40. What is the difference between IRS & Non-IRS qualified dependents in Section 7?

These two boxes on this form indicate whether or not your dependent is eligible for tax free health insurance benefits as defined by the IRS.

The health care reform regulations that were enacted in 2010 made this simpler for dependent children. However it is still somewhat unclear for domestic partners and same gender spouses. Since we cannot give tax advice, you are strongly encouraged to check with a tax professional or the IRS at www.irs.gov. However, the following should help provide some general guidance:

In response to the health care reform law, a new Internal Revenue Code provision was enacted March 30, 2010, allowing group health plans like ours to provide health coverage on a tax-free basis to any eligible child of the plan participant through the end of the calendar year in which the child turns 26. Therefore, if your eligible dependent is your spouse, your own child, your stepchild, adopted child, child lawfully placed for adoption, or eligible foster child, you may check the IRS Qualified box (through the end of the calendar year in which he/she turns 26) regardless of whether or not the child is claimed as a dependent on your taxes at the end of the year.

Covered dependents that may not be eligible for tax free health care (Check the non-IRS Qualified box):

The above does not generally apply to your domestic partner or any of the children of your domestic partner unless you have adopted them, or dependents for whom you are legal guardian, as these individuals are not recognized as federal tax dependents, and are therefore IRS non-qualified, unless they meet the definition of Qualifying Child or Qualifying Relative as described below.

To be an IRS Qualified Dependent a dependent must fall into one of two categories defined by the IRS. They must either be a Qualifying Child, or a Qualifying Relative. There are specific tests that must be met under both categories for them to be considered IRS Qualified Dependents. Refer to the Overview of the Rules for Claiming an Exemption for a Dependent in IRS Publication 17 at www.irs.gov/pub/irs-pdf/p17.pdf (PDF: 6.29 MB).

Note: The above Q&A is about taxation only. Refer to the Health and Welfare Booklet for current eligibility rules and age limitations.

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Form Accuracy Check

41. Who will be checking the form for completeness? Who will ensure no mistakes are inadvertently made by an employee (for example, an employee doesn’t list all covered dependents)?

Payroll clerks are responsible for making sure all required fields on the form are completed. The Human Resources Benefits Unit also checks the form to ensure completeness and contacts employees in case of errors.

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Ending Employment (not retiring from County of Sonoma)

Dental & Vision

42. I am leaving County employment; can I still have Dental and Vision coverage?

Yes, you may be eligible for COBRA continuation of your Delta Dental and VSP Vision coverage at your own expense. Federal COBRA provides for 18 months. The cost of coverage is the same whether you are covering one person or a family. Call (707) 565-2900 or e-mail benefits@sonoma-county.org for the most current rate. See additional information in the COBRA section of this document.

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Survivor Benefits

43. If I die before I retire, can my dependents keep their health insurance?

Upon the death of an employee, there is no continuation of health benefits for dependents except as provided by COBRA (Consolidated Omnibus Budget Reconciliation Act). COBRA allows for the eligible dependents of the deceased employee to continue their existing medical, dental, and vision coverage at 102% of the total premium cost for 36 months. Once the Sonoma County Human Resources Benefits Unit has been notified of the death, the COBRA administrator will send the eligible dependent a written election notice with all of the details (see COBRA section for more information about the election process). Some employees may qualify for a disability retirement upon death which may provide survivor continuation benefits. Refer to SCERA for pension qualifications and the Salary Resolution for retiree medical survivor benefits.

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COBRA

Definition of COBRA

44. What is COBRA?

Consolidated Omnibus Budget Reconciliation Act of 1985 is federal legislation that allows for the continuation of your benefits at group rates, provided you are not eligible for Medicare. You may continue your current medical, dental, and vision coverage for up to 18 months after you separate from employment. You pay the total cost of the premiums. The rate you pay will be the county’s group rate plus 2% for administration costs.

Cal-COBRA allows for an additional 18 of medical coverage when federal COBRA ends. It does not apply to dental or vision coverage. Contact Kaiser or UnitedHealthcare if you are interested in continuing coverage through Cal-COBRA. Cal-COBRA does not apply to the self-funded County Health Plans.

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Last Day of Employee Coverage

45. I have just left County employment – when do my benefits end and COBRA begins?

The last day of coverage is generally the last day of the month you left employment. If you elect COBRA and pay the premium by the deadline, the coverage begins the first of the following month so there will be no lapse in coverage.

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Electing COBRA

46. What do I need to do to obtain COBRA coverage?

You will receive a COBRA election notice from our COBRA administrator within 45 days of your last day of coverage.

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