1. No category

Employee Benefits
Overview
January 1, 2015 - December 31, 2015
Welcome to the City of Santa Rosa
The City of Santa Rosa takes pride in offering a benefits program that provides flexibility for the diverse and changing needs of
our qualifying employees. The City of Santa Rosa provides qualifying employees with valuable benefits options, including
medical, dental, vision and life and disability.
The purpose of this brochure is to help you select benefit options during the 2015 annual open enrollment period. It highlights
your options and key program features to consider when you enroll.
After you are acquainted with what City of Santa Rosa has to offer you and your family, you must complete an Enrollment Form
and return to the Human Resources Department by either:
A) Mail to 100 Santa Rosa Avenue– Room 1, Santa Rosa, CA 95404
B) Drop off at the Human Resources Department located at 100 Santa Rosa Avenue, Room 1, Santa Rosa
C) Email to [email protected]
The information in this brochure is a general outline of the benefits offered under the City of Santa Rosa’s benefit program.
Specific details and plan limitations are provided in the Summary Plan Description (SPD), which is based on the official Plan
Document that may include policies, contracts and plan procedures. The SPD and Plan Documents that may include policies,
contracts and plan procedures. The SPD and Plan Documents contain all specific provisions of the plans. In the event that the
information in this brochure differs from the Plan Document, the Plan Document will prevail. In addition, there are also CalPERS
options available for those employees who are eligible.
Information about City of Santa Rosa’s
Open Enrollment and benefit information
can also be accessed on our Intranet:
http://ci.santa-rosa.ca.us/departments/hr/
benefits/Pages/default.aspx
| PAGE 2
TABLE OF CONTENTS
What’s Inside
Message from Employee Benefits ................ 2
This package of material will give you information about the benefits
which are available to you. Please read the information carefully. To
help you make important decisions about your benefits, Human
Open Enrollment........................................... 4
Resources is available to answer any questions you may have.
Eligibility for Benefits .................................... 5
Open Enrollment
Dependent Eligibility Verification ................. 6
Beginning on October 1, 2014 and lasting through October 31, 2014, All
When You Can Make Changes to Your Benefits
................................................................... 7-8
open enrollment period. During open enrollment, you have the option to
benefits-eligible employees will be eligible to participate in the annual
change group medical plans and add or drop dependent coverage.
Medicare And The Active Worker ................ 9
Your new plan benefits will be effective January 1, 2015 and will run
Medical Plan Highlights ......................... 10-16
through December 31, 2015. In order to ensure a smooth
implementation, your forms are due no later than 5 p.m. on
Dental Plan Highlights ................................ 17
October 31, 2014. If we do not receive your forms by this date, you will
Vision Plan Highlights.................................. 18
not be able to make a change for January 1, 2015. If there are any errors
Life & AD&D Plan Highlights .................. 19-20
deadline, those items must be corrected by October 31, 2014 or you will
Employee Assistance Program............... 21-22
or omissions in the paperwork Human Resources receives by the
not be able to make a change for January 1, 2015.
Additional Benefits ..................................... 23
Please call (707) 543-3060 if you have any questions.
Flexible Spending Accounts ................... 24-25
Safety Employees (Fire & Police) CalPERS Open Enrollment period is
September 15 – October 16.
Required Federal Notices ...................... 26-31
COBRA Information................................ 32-34
BEN-IQ ......................................................... 35
Important Contact Information .................. 38
Helpful Hints...
Read through this guide to familiarize yourself with what decisions you
have to make.
Think about your current benefit plans. Are they still working for you?
Have you experienced any changes or do you anticipate any that might
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
pages 28 - 29 for more details.
make a different plan more suitable?
Gather additional information. Use the websites and the phone numbers
on the back page to see which doctors and other healthcare providers
you can use under the different plan choices. If you have dependents on
your plan that live out of state, check on provisions for coverage of
members away from home.
IMPORTANT NOTICE
The information in this brochure is a general outline of the benefits offered under the City of Santa Rosa’s
benefits program. This brochure may not include all relevant limitations and conditions. Specific details
and limitations are provided in the plan documents, which may include a Summary Plan Description (SPD),
Evidence of Coverage (EOC), and/or insurance policies. The plan documents contain the relevant plan
provisions. If the information in this brochure differs from the plan documents, the plan documents will
prevail.
| PAGE 3
OPEN ENROLLMENT
Open Enrollment
All plan participants will be eligible to participate in the annual Open Enrollment period. Switching from one
medical plan to another can only occur during Open Enrollment.
Attend the Benefit Fair at the
Finley Center on 10/15/2014
11:00 a.m. to 2:00 p.m.
During Open Enrollment, you have the right to change group medical plans and add or drop dependent coverage.
Your new plan benefits will be effective January 1, 2015 and will run through December 31, 2015.
In order to ensure a smooth implementation, your forms are due no later than October 31, 2014!
If you want to remain with your current benefit plans and level of coverage there is no action required from you
at this time.
Please call (707) 543-3060 if you have any questions.
Benefits Plan Providers
Anthem Blue Cross
Express Scripts
Kaiser Permanente
Delta Dental
VSP
Voya (formerly ING)
EBS
MHN
PPO (Preferred Provider Organization) and EPO (Exclusive Provider Organization)
Pharmacy ( Anthem Blue Cross members only)
HMO (Health Maintenance Organization)
Dental PPO
Vision
Basic Life & AD&D and Supplemental Life
FSA (Flexible Spending Account)
EAP (Employee Assistance Program)
| PAGE 4
ELIGIBILITY
Who is eligible to enroll in the benefit program?
If you are a regular employee working at least 20 hours per week, you are eligible for the City of Santa Rosa sponsored
group benefits.
What is the effective date of coverage?
The first day of the month following date of hire.
Can I enroll my dependents?
●
Your current spouse, or registered domestic partner (state registered)*
●
Your natural children, stepchildren, domestic partner’s children, adopted children, economically dependent children,
of which the employee is the legal guardian. In addition, such children must be:
●
under age 26
●
Your disabled children age 26 or older. Such disabled children must meet the same conditions as listed above
for natural children, stepchildren, domestic partner’s children, adopted children, or foster children, and in
addition are physically or mentally disabled on the date coverage would otherwise end because of age and
continue to be disabled.
●
A child for whom you are required to provide benefits by a court order, who satisfies the same conditions
as listed above for natural children, stepchildren, domestic partner’s children, adopted children, or foster children.
What is the definition of domestic partner?
Domestic partner is defined as the employee’s domestic partner under a legally registered and valid state
registered domestic partnership.
How do I add and exclude dependents?
Newly acquired dependents may be added to the plan during the year by submitting the information to HR and
providing verification documents within 30 days of their eligibility. If you do not add dependents within the 30-day
period and do not qualify for a “special enrollment,” they will not be eligible to enroll until the next “open
enrollment” period.
When can I make changes to my benefit elections?
Other than during the annual “open enrollment” period, you may not change your coverage unless you qualify for a
“special enrollment.” In addition, if you are declining enrollment for you or your dependents (including your spouse)
because of other group medical coverage, you may in the future be able to enroll yourself or your dependents in this
plan, provided that you qualify for a “special enrollment.”
This is a brief description of eligibility requirements and is not intended to modify or supersede the requirements of the
plan documents. The plan document will govern in the event of any conflict between this description and the Plan
Documents.
*CALPERS MEDICAL FOR SAFETY, http://srcity.org/departments/hr/benefits/Pages/oe_public_safety.aspx
| PAGE 5
DEPENDENT ELIGIBILITY VERIFICATION
All employees adding dependents must submit documentation verifying eligibility of their covered
dependents. The following chart is an easy guide to which form and documents must be submitted along with
enrollment/change forms.
For further clarification, please contact the Human Resources department at (707) 543-3060 or email
[email protected].
Adding and Removing Dependents
Enrollment Form
Required
Employee only
Employee & Spouse
Employee & DP
Employee & Child(ren)
Employee, Spouse or DP & Child(ren)
Marriage
Certificate
Required
State of
California or City
DP
Registration
Required
Birth
Certificate
Required
x
x
x
x
x
x
x
x
x
x
x
Coverage/Participation changes are allowed during Open Enrollment or if the employee experiences a Qualified Life
Event. A Qualified Life Event can include Marriage, Divorce, Birth or Adoption and adding or removing dependents is
the only change allowed. Qualifying events include:

Change in marital status, including marriage, divorce, registration or dissolution of domestic
partnership, and death of a spouse

Change in number of dependents, including birth, adoption, or death of a covered dependent

Change in employment status, including the start or termination of employment by you, your spouse or your
dependent child

Change in a child’s dependent status, either newly satisfying the requirements for dependent child status or
ceasing to satisfy them
Employees are responsible for notifying Human Resources (707) 543-3060 of any changes in their dependent status
during the plan year (divorce, marriage, birth or adoption). All Qualified Life Event changes must be made within 30
days from the date of the event. A copy of marriage certificate, birth certificate, or adoption paperwork will be
required for this kind of change. All changes will be effective the first of the month following the qualifying event with
the exception of childbirth: EPO/PPO Plans is the actual date of birth; Kaiser is the first of the month following the
date of birth. However, notification and enrollment must be within 30 days from the date of birth.
| PAGE 6
RULES FOR BENEFIT CHANGES DURING THE YEAR
Other than during annual open enrollment, you may only make changes to your benefit elections if you
experience a qualifying event or qualify for a “special enrollment”. If you qualify for a mid-year benefit change,
you may be required to submit proof of the change or evidence of prior coverage.
QUALIFYING EVENTS INCLUDE:
●
●
●
●
●
Change in legal marital status, including marriage, divorce, legal separation, annulment, and death of a spouse.
Change in number of dependents, including birth, adoption, placement for adoption, or death of a dependent
child.
Change in employment status that affects benefit eligibility, including the start or termination of employment by
you, your spouse, or your dependent child.
Change in work schedule, including an increase or decrease in hours of employment by you, your spouse, or your
dependent child, including a switch between part-time and full-time employment that affects eligibility for
benefits.
Change in a child's dependent status, either newly satisfying the requirements for dependent child status or
ceasing to satisfy them.
●
Change in place of residence or worksite, including a change that affects the accessibility of network providers.
●
Change in your health coverage or your spouse's coverage attributable to your spouse's employment.
●
Change in an individual's eligibility for Medicare or Medicaid.
●
●
●
A court order resulting from a divorce, legal separation, annulment, or change in legal custody (including a
Qualified Medical Child Support Order) requiring coverage for your child.
An event that is a “special enrollment” under the Health Insurance Portability and Accountability Act (HIPAA)
including acquisition of a new dependent by marriage, birth or adoption, or loss of coverage under another health
insurance plan.
An event that is allowed under the Children's Health Insurance Program (CHIP) Reauthorization Act. Under
provisions of the Act, employees have 60 days after the following events to request enrollment:
●
●
Employee or dependent loses eligibility for Medicaid (known as Medi-Cal in CA) or CHIP (known as Healthy
Families in CA).
Employee or dependent becomes eligible to participate in a premium assistance program under Medicaid
or CHIP.
Two rules apply to making changes to your benefits during the year:
●
●
Any change you make must be consistent with the change in status, AND
You must make the change within 30 days of the date the event occurs.
| PAGE 7
WHEN YOUR BENEFITS TERMINATE
When Your Benefits Terminate

Insurance benefits will terminate on the last day of the month in which the termination occurs (retirement,
unpaid absence or FMLA exhausting).

When terminating, the employee must work at least one full schedule day in the month to get
coverage for that month. Employees who terminate due to a medical condition / exhaustion of leave should
contact their Administrative Service Officer or Human Resources Department.

COBRA, if elected, will be effective the first of the month following date of termination.
Benefits during the Family and Medical Leave (FMLA) and California Family
Rights Act (CFRA)
An employee who qualifies for and is taking Family Medical Leave will be allowed to continue participating in any
health and welfare benefit plan in which he/she was enrolled before the first day of leave (for a maximum of 12
work-weeks) at the level and under the same conditions of coverage as if the employee had continued in
employment for the duration of such leave. The City will continue to make the same premium contributions as if
the employee had continued working. The continued participation in health benefits begins on the date leave first
begins under the Family and Medical Leave Act (e.g. for pregnancy disability leaves) or under the Family and Medical Leave Act/CFRA (e.g. for all other family care and medical leaves).
In some instances, the City of Santa Rosa may recover premiums it paid to maintain health coverage for you if you
fail to return to work following pregnancy disability leave/FMLA leave.
Any employee who drops their insurance coverage while out on leave must re-enroll again within 30 days of their
return to work. They must complete and submit enrollment paperwork to the Human Resources Department
within that 30-day period. In the event that they do not enroll within the 30 day re-enrollment period, they
would have to wait until the Open Enrollment period in October to re-enroll for insurance benefits which would
go into effect on January 1st of the following year. If you have any questions, please contact the Human
Resources Department.
All employees must notify their Administrative Service Officer or Human
Resources Department at (707) 543-3060 as soon as possible for requesting
FMLA for your own illness or for caring for a family member.
| PAGE 8
MEDICARE AND THE ACTIVE WORKER
If you are an active employee and have reached the age of 65, you may be wondering about Medicare. You
should receive an advisory notice from Medicare about 4 months before your 65th birthday for your initial
enrollment period. Here is some information that you should know about your Medicare options when
working beyond age 65:

You may not enroll in a Medicare Supplemental plan until you retire or are otherwise not eligible for the
group plan.

When you reach 65, you should enroll in Medicare Part A only. Your City group medical plan remains your
primary health insurance.

When you reach 65 and are still an active employee, you must complete the Group Health Certification of
Medicare Status form and defer your enrollment in Medicare Part B until your retirement.

Once you retire, you must sign up for Part B with Medicare during the eight months following the month
that your group health plan coverage or employment ended (whichever is first), also known as the Special
Enrollment Period.

If you choose to defer Part B, please be aware that there may be a 10% federal surcharge added to the
monthly premium for every 12 month period that you were qualified to sign up for Medicare but did not
enroll.

Upon retirement, you will be transferred to the Medicare plan, assuming that you meet other eligibility
requirements.
For additional information on Medicare and your related benefit options, contact Human Resources at
(707) 543-3060 or go to www.medicare.gov.
| PAGE 9
MEDICAL BENEFITS FOR MISCELLANEOUS EMPLOYEES
The goal of the City of Santa Rosa is to provide you with affordable, quality health care benefits. Our medical benefits are designed to help maintain wellness and protect you and your family from major financial hardship in the
event of illness or injury. The City offers a choice of medical plans through Anthem Blue Cross (PPO, ABHP & EPO
plans) , Express Scripts Rx and Kaiser Permanente (HMO).

City Plan - EPO (Exclusive Provider Organization) – EPO plans are similar to HMO plans in that members, in
order to be covered, must visit Anthem Blue Cross contracted doctors only using the PPO Network. NOTE:
EPO members, must visit in-network doctors only. EPO members, however, do not select a primary care
doctor like an HMO plan and do not need a referral to see a specialist as long as the specialist is in the PPO
network. Exceptions for out of network visits are made in the event of an emergency. Prescriptions are filled
through Express Scripts

City Plan - PPO (Preferred Provider Organization) – The PPO plan is designed to provide choice, flexibility
and value. Participants have a choice of using Preferred Providers (PPO) or going directly to any other physician (non-PPO provider) without a referral. Generally, there are annual deductibles to meet before benefits
apply. You are also responsible for a certain percentage of the charges (co-insurance), and the plan pays the
balance up to the agreed upon amount, Prescriptions are filled through Express Scripts

Kaiser Permanente – a Health Maintenance Organization (HMO) in which patients seek medical care within
the plan’s own facilities. Under this plan, most services and medicines are covered with a small co-payment.
You select your doctor, or Primary Care Provider (PCP), from the staff at a local Kaiser Permanente facility.
All of your care is provided at a Kaiser facility. Services outside of a Kaiser facility are not covered except it is
a threatening emergency. More information about Kaiser health plan benefits is available at
http://www.kaiserpermanente.org.

City Plan – ABHP (Account Based Health Plan) – The Account Based Health Plan has differences from the
traditional PPO or HMO in that you pay the annual deductible amount before coverage begins for all services except preventive care services (which are covered at 100%). Once you have satisfied your annual
deductible your traditional health coverage applies. You pay the appropriate coinsurance for covered services, up to the annual out-of-pocket maximum. Typically you won’t pay at the time you receive services.
Instead the office staff will file the claim for you to benefit from the network discounts. Pay applicable copays for prescription drugs after you have satisfied your annual deductible (January 1, 2015 - December 31,
2015). ABHP is available to non-represented employees only.
| PAGE 10
MEDICAL PLAN HIGHLIGHTS
Anthem Blue Cross Exclusive Provider Organization
(EPO) Plan: Anthem Blue Cross EPO members must
receive services from Anthem Blue Cross PPO network.
Out-of-network benefits are not available under the
EPO plan. With the exception of an emergency or urgent
care, all care must be provided at a participating
provider hospital.
Anthem Blue Cross
Claims Address
P.O Box 60007
Los Angeles, CA 90060-007
Customer Service: (800) 967-3015
Hours: 8:30 a.m. to 4:15 p.m. Monday—Friday
EPO Plan
Website: www.anthem.com/ca/EIAHealth/
IN-NETWORK ONLY
Calendar Year Deductible
(Individual / Family)
Calendar Year Out-of-Pocket
Maximum (Individual / Family)
None
$1,500 Individual/
$3,000 2-Party/$4,500
Family
Physician Care
Primary Physician Office Visit
$25 / Visit
Specialist Office Visit
$25 / Visit
Preventive Care
No Charge
Lab and X-Ray
No Charge
MRI, CT and PET
No Charge
Hospital Care
Emergency Room
Inpatient
Outpatient
Prescription Drugs
(Express Scripts)
Pharmacy Out-of-Pocket
Maximum
$75 Copay
(waived if admitted)
$250/ Admit
$250/ Visit
Tier 1 / Tier 2/ Tier 3
$5,100/$8,700
Retail Participating Pharmacy
(up to a 30 day supply)
$10 / $25 / $55
Mail Order
(up to a 90 day supply)
$20 / $45 / $95
Anthem Mobile App
 Search for providers, hospitals
and urgent care
 View, email or fax your ID card
Download Instructions
 Go to the app store on your
smartphone or mobile device
 Search for Anthem Blue Cross
 Select the app and start the
free download
To use the application you must be registered
on the Anthem secure member site and have a
username and password
| PAGE 11
MEDICAL PLAN HIGHLIGHTS
Anthem Blue Cross Preferred Provider Organization (PPO) Plan: The Anthem Blue
Cross PPO allows you and your dependents to seek needed medical care from any
Hospital, Physician, or other provider you wish. To avoid higher charges and
reduced benefit payments, you are urged to obtain such care from Preferred
Providers (in-network) whenever possible.
Anthem Blue Cross
Claims Address
P.O Box 60007
Los Angeles, CA 90060-007
Customer Service:
(800) 967-3015
Hours: 8:30 a.m. to 4:15 p.m.
Traditional PPO Plan
IN-NETWORK
Calendar Year Deductible
(Individual / Family)
Calendar Year Out-of-Pocket
Maximum
(Individual / Family)
OUT-OF-NETWORK
Monday—Friday
Website: www.anthem.com/
ca/EIAHealth/
$300 Individual/ $900 Family
$1,800/ $3,900
None
Physician Care
Primary Physician Office
Visit
$20/ Visit
40% (deductible waived)
Specialist Office Visit
$20/ Visit
40%
Preventive Care
No Charge
40%
Lab and X-Ray
20%
40%
MRI, CT and PET
20%
40%
20%
40%
$75 (waived if
admitted) + 20%
$75 (waived if admitted)
+ 40%
Inpatient
20%
40%
Outpatient
20%
40%
Tier 1 / Tier 2/ Tier 3
Tier 1 / Tier 2/ Tier 3
$4,800/$9,300
None
$5 / $20 / $50
$5 / $20 / $50
$10 / $35 / $85
Not Covered
Hospital Care
Urgent Care
Emergency Room
Prescription Drugs
(Express Scripts)
Pharmacy Out-of-Pocket
Maximum
Retail Participating Pharmacy
(up to a 30 day supply)
Mail Order
(up to a 90 day supply)
Anthem Mobile App
 Search for providers, hospitals and
urgent care
 View, email or fax your ID card
Download Instructions
 Go to the app store on your
smartphone or mobile device
 Search for Anthem Blue Cross
 Select the app and start the free
download
To use the application you must be
registered on the Anthem secure
member site and have a username
and password
| PAGE 12
MEDICAL PLAN HIGHLIGHTS
Express Scripts (ESI): Your plan covers a broad range of
medications that fall into three categories.
 Generic Medications (Tier 1)
May cost you less than plan-preferred and nonpreferred medications.

Plan-preferred medications (Tier 2)
A broad list that includes more than 1,800 brandname drugs. Drugs on this list may cost you less
than non-preferred medications.

Non-preferred medications (Tier 3)
Brand-name drugs that are not included on the plan
preferred list. You may pay the most toward the
cost of these drugs.
ESI Rx plan does not apply to Kaiser’s HMO plan and
Anthem’s Account Based Health Plan.
At Express-Scripts.com you can log in and
complete the one-time registration. You are then
routed to the member website for a personalized,
plan-specific experience.
| PAGE 13
MEDICAL PLAN HIGHLIGHTS
Your Express Scripts prescription drug benefit co-payments at a glance
Show this to your doctor and discuss ways to pay less for the medications you need. If you need a
medication on a long-term basis, you’ll save money by using your mail-order pharmacy, instead of a drugstore.
We’ll deliver up to a 90-day supply of your medication right to you–and standard shipping is free.
Express Scripts is not available to Anthem’s ABHP & Kaiser members.
EPO Plan
Retail
Mail Order
Generic Drugs
$10
$20
Preferred Brand
Non-Preferred
brand name drugs
(no generics)
Non-Preferred
brand name drugs
(generics available)
$25
$45
$55
$95
$55
$95
Traditional PPO Plan
Retail
Mail Order
Generic Drugs
$5
$10
Preferred Brand
Non-Preferred
brand name drugs
(no generics)
Non-Preferred
brand name drugs
(generics available)
$20
$35
$50
$85
$50
$85
Express Scripts member services:
You may call Express Scripts Member Services at
1 (877) 554-3091, 24 hours a day, 7 days a week
(except Thanksgiving and Christmas) for more details
on your plan.
| PAGE 14
MEDICAL PLAN HIGHLIGHTS
Kaiser Permanente (HMO) Plan:
Kaiser members must receive services from a Kaiser
Facility. Out -of-network benefits are not available under
the Kaiser HMO Plan.
Member Service Call Center
(800) 464-4000
Monday to Friday – 7:00 AM to
7:00 PM
You may also visit us at
www.kp.org
Kaiser Permanente HMO
IN-NETWORK ONLY
Calendar Year Deductible
(Individual / Family)
Calendar Year Out-of-Pocket
Maximum (Individual /
Family)
None
$1,500 / $3,000
Physician Care
Primary Physician Office Visit
$20 / Visit
Specialist Office Visit
$20 / Visit
Preventive Care
No Charge
Most Lab and X-Ray
No Charge
MRI, CT and PET
No Charge
Most Physical Therapy
$20 / Visit
Hospital Care
Urgent Care
$20 Copay
Emergency Room
$75 Copay
(waived if admitted)
Inpatient
$100 per admission
Outpatient
$20 per procedure
Prescription Drugs
Retail Participating
Pharmacy
(up to a 100 day supply)
Mail Order
(up to a 100 day supply)
Tier 1 / Tier 2
$10
$10
Kaiser Permanente Mobile App
 E-mail your doctor
 Schedule, view and cancel appointments
 Refill prescriptions and check the status of a
prescription order
 Access your medical record
 Use location finder to pinpoint Kaiser medical
facilities
Download Instructions
 Visit your app store
 Search Kaiser Permanente and download
To use the application you must be registered on the
Kaiser secure member site and have a username and
password
| PAGE 15
MEDICAL PLAN HIGHLIGHTS
Anthem Blue Cross Account Based Health Plan (ABHP): The Anthem Blue Cross
ABHP is a consumer-driven health plan, which is designed to educate you about
health care decisions and employer you to take control of your health, as well as
the dollars you spend on your care. The ABHP is similar to the Traditional PPO such
as visiting any doctor without a referral. ABHP is available to non-represented
employees only.
New!
Anthem Blue Cross
Claims Address
P.O Box 60007
Los Angeles, CA 90060-007
Customer Service:
800-967-3015
Account Based Health Plan (ABHP) Plan
Rx: Anthem Blue Cross
IN-NETWORK
OUT-OF-NETWORK
Hours: 8:30 a.m. to 4:15 p.m.
Monday—Friday
Website: www.anthem.com/
ca/EIAHealth/
Calendar Year Deductible
(Individual / Family)
$2,000/$6,000
$2,000/$6,000
Calendar Year Out-of-Pocket
Maximum (Individual / Family)
$6,350/ $12,700
$6,600/ $15,000
Primary Physician Office Visit
20%
20%
Specialist Office Visit
20%
40%
Preventive Care
No Charge
40%
Lab and X-Ray
20%
40%
MRI, CT and PET
20%
40%
Urgent Care
20%
40%
Emergency Room
20%
40%
Inpatient
20%
40%
Outpatient
20%
40%
Physician Care
Hospital Care
Prescription Drugs
(Rx: Anthem Blue Cross)
Pharmacy Out-of-Pocket
Maximum
Retail Participating Pharmacy
(up to a 30 day supply)
Tier 1 / Tier 2/ Tier 3
Medical Deductible Applies
20%
20%
Not Covered
Mail Order
(up to a 90 day supply)
Tier 1 / Tier 2/ Tier 3
20%
Anthem Mobile App
 Search for providers, hospitals and
urgent care
 View, email or fax your ID card
Download Instructions
 Go to the app store on your
smartphone or mobile device
 Search for Anthem Blue Cross
 Select the app and start the free
download
To use the application you must be
registered on the Anthem secure
member site and have a username
and password
| PAGE 16
DENTAL PLAN HIGHLIGHTS
Save money with a Delta Dental PPO dentist.
Our PPO network dentists accept reduced fees for covered services they provide you, so you’ll usually pay the
least when you visit a PPO network dentist. This also
ensures Delta Dental PPO dentists won’t balance bill you
the difference between the contracted amount and their
usual fee.
Delta Dental Mobile App
Dental PPO
In-Network
Calendar Year
Deductible
Individual/Family
Maximum Annual
Benefit (per member)
Preventive Services
(deductible waived)
Oral Exams
Cleaning (2x per year)
Sealants
Fluoride treatment
None
$2,100
$2,000
100%
100%
Basic Services
Amalgam Fillings
Most Extractions
Oral Surgery
Endodontics
Periodontics
80%
Major Services
Surgical Extractions
Bridgework
Dentures
Crowns
80%
Orthodontia
Covered for Adults &
Children
Out-OfNetwork
80%
* Limitations or waiting periods may apply for some benefits; some
services may be excluded from your plan.
Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’s
submitted fees.
** Reimbursement is based on PPO contracted fees for PPO dentists,
Premier contracted fees for Premier
dentists and program allowance for non-Delta Dental dentists.
Customer Service
80%
(800) 765-6003
Claims Address
P.O. Box 997330
Sacramento, CA 95899-7330
50%
$2,000
Lifetime
Maximum
50%
$2,000
Lifetime
Maximum
deltadentalins.com
This benefit information is not intended or designed to replace or
serve as the plan’s Evidence of Coverage or
Summary Plan Description. If you have specific questions regarding
the benefits, limitations or exclusions for your Plan.
| PAGE 17
VISION PLAN HIGHLIGHTS
VSP provides participants with access to a large network of vision care providers. To locate a network provider visit
www.vsp.com. If you decide not to see a VSP doctor, the plan co-pay still applies. This choice is yours—either way,
your VSP benefits are a tremendous part of your overall benefits package. There are no ID cards necessary for this
plan.
VSP Vision
VSP Signature Plan
Vision Plan Highlights
Type of Service
Eye examination
(Once Every 12 Months)
Standard Lenses
(Once Every 12 Months)
 Single
 Bifocal
 Trifocal
Frame
(Once Every 12 Months)
In-Network
Out-of-Network
Copay
Plan Pays
$20 Copay
Up to $50
Covered after copay
Covered after copay
Covered after copay
Up to $50
Up to $75
Up to $100
$150 Allowance + 20% Off
the Amount Over the
Allowance
Up to $70
NOTE: Costco frame
allowance is $70
Contact Lenses*
(Once Every 12 Months, in Lieu of Eyeglasses)
 Elective
$125 Allowance
Up to $105
* When you choose contacts instead of glasses, your $150 allowance applies to the cost of your contacts
and the contact lens exam (fitting and evaluation). This exam is in addition to your vision exam to ensure
proper fit of contacts.
| PAGE 18
LIFE INSURANCE
Life insurance provides protection for your beneficiary in the event of your death. City of Santa
Rosa currently provides Basic Life and Accidental Death and Dismemberment (AD&D) insurance as
follows at no cost to employees.
Basic Life/AD&D
Unit
Unit Name
Life/Amount AD&D Amount
Dependent
Life*
Unit 2
Firefighters
$12,000
N/A
N/A
Unit 3
Maintenance
$20,000
N/A
N/A
Unit 4
Support Services
$20,000
N/A
N/A
Unit 5
Police
$10,000
N/A
N/A
Unit 6
Professional
$20,000
N/A
N/A
Unit 7
Technical
$20,000
N/A
N/A
Unit 8
Transit
$20,000
N/A
N/A
Unit 9
Public Safety Management
$30,000
$30,000
$1,500
Unit 10
Executive Management
$50,000
$50,000
$1,500
Unit 11
Mid Management
$50,000
$50,000
$1,500
Unit 12
Confidential
$50,000
$50,000
$1,500
Unit 14
Police Civilian Technical
$50,000
$50,000
$1,500
Unit 16
Utilities Systems Operators (USOs)
$20,000
N/A
N/A
Unit 17
Professional Attorneys
$50,000
$50,000
$1,500
Unit 18
Miscellaneous Mid-Management
$50,000
$50,000
$1,500
*Dependent life coverage is provided by the City of Santa Rosa, not Voya. There is no double coverage. For example,
at the loss of a child and both parents are City employees, the total amount of dependent life paid under the City plan
would be $1,500.
Please remember to update
your Beneficiary information
whenever there is a family
status change.
PLEASE NOTE: The Internal Revenue Code (IRC) requires that premiums for basic life insurance in
excess of $50,000 will be included as taxable income at the close of each tax year. This will most
likely not impact your tax status, but you may wish to check with your financial planner if you are
concerned.
| PAGE 19
LIFE INSURANCE
Supplemental Life / Accidental Death & Dismemberment Insurance
Employees may purchase supplemental life insurance (in increments of $10,000) up to a maximum of
$200,000 or $50,000 for a spouse or domestic partner (medical underwriting required).
Premiums for supplemental life insurance are age-banded and will automatically increase in July of
the year you turn an age that ends in 0 or 5. AD&D may be purchased in the same amount as the
supplemental life, (the total amount of supplemental life and AD&D must be equal)...
Supplemental Life Insurance
(Voluntary Employee Paid)
Rate Per $1,000
Age Range
Employee Rate
Spouse Rate
Under age 25
$0.05
$0.05
25-29
$0.06
$0.06
30-34
$0.08
$0.08
35-39
$0.09
$0.09
40-44
$0.10
$0.10
45-49
$0.15
$0.15
50-54
$0.23
$0.23
55-59
$0.41
$0.41
60-64
$0.61
$0.61
65-69*
$1.22
$1.22
70-74
$2.03
$2.03
75-99
$2.03
$2.03
AD&D (added to age rate)
$0.05
$0.05
*At age 65, your supplement life insurance coverage decreases to
65% and at age 70, it decreases to 50%.
| PAGE 20
EMPLOYEE ASSISTANCE PROGRAM
Employee Assistance Program
About the Employee Assistance Program
The Employee Assistance Program (EAP) from MHN is
designed to help with short-term counseling needs. It
offers quick and easy access to confidential,
professional assistance and resources to assist
employees address difficulties related to emotional
concerns, relationships, substance abuse, legal and
financial concerns.
If it is determined that you need or your family
members need more than the 5 face-to-face sessions
that you are eligible for, (See below), the EAP will help
coordinate your needs under your medical plan.
All services are confidential and in accordance with
professional ethics and federal and state laws. Use of
the EAP is strictly voluntary.
Example of problems the EAP can help resolve are:
 marital and family conflict
 stress and anxiety
 alcohol and drug abuse
 grief and loss
 depression
 physical abuse
 Eating disorders
Work & Life Services:
Depending on your plan, telephonic consultation may
be available for:
Federal Tax Assistance – Help with IRS audits and
unfiled or past-due tax returns (not a tax
representation or preparation service).
Pre-Retirement Planning – Guidance for planning a
quality retirement (does not include investment, tax
or legal advice).
Organizing Life’s Affairs – Help organizing records and
vital documents and with arranging “final details” for
a loved one.
Concierge Services – Referrals for everyday errands,
travel, event planning and more (does not cover the
cost, nor guarantee delivery, of services).
Legal Services – Telephonic or face-to-face legal
consultations for issues relating to civil, consumer,
personal and family law, financial matters, business
law, real estate, criminal matters, the IRS and estate
planning (excluding disputes or actions between
members and their employer or MHN).
Access MHN website at:
www.members.mhn.com
Enter your company Web ID: santarosa
Or call toll-free at (800) 242-6220
Child and Eldercare Assistance – Help accessing
available community and financial resources and
referrals to pre-screened providers for childcare,
eldercare and more. We’ll help identify needs and
search our extensive directories to find the right care.
You may also be entitled to help with adoption,
parenting skills, child development, special needs,
emergency care, relocation services and educational
issues.
Financial Issues – Budgeting, credit and financial
guidance (tax or investment advice, loans and bill
payments not included).
| PAGE 21
WELLNESS COACHING PROGRAM
MHN’s Personalized Wellness Coaching
Live Healthy
About the Wellness Coaching Program
Individuals living with chronic or specialty health conditions
can maintain a healthy lifestyle, when their condition is
managed by their medical providers, and supported by our
Wellness Coaches. Coaches offer basic support,
information and referrals for conditions such as:
• Arthritis
• Asthma
• Back and neck pain
• Heart conditions
• Diabetes
• Pregnancy
• Menopause
Your employer is now offering Wellness Coaching to help
you assess your current lifestyle, and create plans for
achieving the healthy lifestyle you want to live. All Coaches
are trained specialists qualified to assist you with weight
management, nutrition, exercise, and specialty/chronic
conditions. You will be better equipped to get the results
you want with the support of a Wellness Coach who will
work with you every step of the way.
Live Lean
Losing weight and keeping it off isn’t easy. Our Wellness
Coaches understand the struggle, and work with each
individual to develop a personalized plan for living a
healthy life. In conjunction with the online LivingLean
program, your Wellness Coach assesses your specific
situation, and provides the guidance you need to succeed
through:
• Controlling food cravings
• Portion control
• Creating a fitness program
• Helping you stay motivated
Live Smoke-Free
If you want to quit smoking, but have found it difficult to
stop, let our Wellness Coaches, certified by the American
Cancer Society, help. Paired with our online LivingFree
program, your coach will help you:
• Understand tobacco dependence
• Learn to eliminate the desire to smoke
• Adhere to a withdrawal strategy
Live Fit
Maintaining a fitness routine is much easier with support
from a coach. Regardless of your current fitness level, a
Wellness Coach can work with you one-on-one to assess
your fitness aptitude, set goals for greater fitness, and
develop a personalized program to help you establish and
maintain a healthful lifestyle. Your coach will help you:
• Select fitness routines that will be most effective for
you
• Locate resources in your area to support your fitness
routine
• Remain motivated to make fitness part of your lifestyle
The Services Are Free For You
• Wellness coaching via phone or instant messaging
Monday through Friday 9am to 8pm EST
• Create a Personalized Wellness Plan with a coach
• Educational materials on fitness and health-related
topics
• Online wellness programs available 24/7
• Online articles and tools including more than 40
questionnaires and health profiles, multi-media videos,
diet and fitness tracking tools, and downloadable tip
sheets
• Online video based interactive training modules:
LivingLean- weight management; Living Free-smoking
cessation; LivingFit: Fitness and walking
• Online journaling on wellness goals; Internet live radio
educational sessions and more
• Secure personalized Web portal used to communicate
with your Coach
Access MHN website at:
www.members.mhn.com
Enter your company Web ID: santarosa
Or call toll-free at (800) 242-6220
| PAGE 22
ADDITIONAL BENEFITS
Travel Assistance
(Administered by Voya formerly ING)
The City of Santa Rosa is pleased to offer the Voya Travel
Assistance program. The Voya Travel Assistance program
offers you enhanced security for your leisure and business
trips.
The VOYA Travel Assistance website provides additional
sources of travel-related information. We encourage you to
visit the website to access a detailed program description
and convenient wallet cards. These documents provide
important contact information for VOYA Travel Assistance.
Access the VOYA Travel Assistance website at:
www.europassistance-usa.com
User Name: voya
Password: assistance
Or call toll-free at (800) 859-2821
Insurance products and services provided by ReliaStar Life
Insurance Company. VOYA Travel Assistance services
provided by Europa Assistance USA, 1825 K St. NW, Suite
1000, Washington, D.C. 20006.
●
Concierge services at or near the time of death, to
provide personal assistance including planning a
funeral or memorial service and negotiating prices with
the funeral home(s) selected by the family.
Additional Information & Access
To access this benefit go to the Everest Enrollment site to
create your personal user ID and pro-file which can be used
to enter Everest’s Planning Tools Center.
www.everestfuneral.com/voya
If you do not have internet access, or would like further
information or assistance, contact an Everest Service
Advisor at 1(877) 456-5050.
Insurance products are issued by ReliaStar Life Insurance
Company (Minneapolis, MN) and ReliaStar Life Insurance
Company of New York (Woodbury, NY), members of the
VOYA family of companies. Only Reli-aStar Life Insurance
Company of New York is admitted and its products issued,
within the state of New York. Products and services may
not be available in all states. Funeral Planning and
Concierge Service provided by Everest Funeral Package,
LLC., 1300 Post Oak Blvd., Suite 1210, Houston, TX 77056
Funeral Planning & Concierge Service
(Administered by Voya formerly ING)
The death of a family member is one of life’s most stressful
times. It requires grieving survivors to quickly make many
decisions about funeral services, something most of us
know little about. City of Santa Rosa employees and eligible
family members have access to Everest Funeral Planning
and Concierge Service to assist with funeral planning and
negotiation at time of need as well as pre-planning tools
that can be used to research and document decisions and
wishes. Everest is an independent service that works
exclusively on behalf of their clients and is not associated
with any funeral home or service provider.
Services Provided by Everest
Employees eligible for Group Life coverage, their spouse/
partner and children under the age of 25 are entitled to the
following services at no cost:
●
●
Unlimited use of Everest's secure, online planning tools
to include personalized PriceFinde Reports that
compare local funeral home prices nationwide.
Round-the-clock, toll-free access to Everest Advisors
who can answer general funeral planning questions.
| PAGE 23
FLEXIBLE SPENDING ACCOUNTS
Flexible Spending Account
The Flexible Spending Account (FSA) offered through
EBS allows you to pay for eligible healthcare and
dependent care expenses using tax-free dollars.
When you participate in an FSA plan via salary
reduction, you reduce your federal, FICA, social
security, Medicare (and in some cases, state) taxes
and increases take-home pay. The money that is
deposited into your FSA comes straight out of your
gross pay, therefore reducing your taxes.
●
If you claim the dependent care credit on
your tax return or collect compensation
through your Dependent Care FSA, you must
report the name, address, and tax payer
identification number of each dependent care
provider.
HEALTH CARE FSA: This plan allows you set aside pretax dollars to help pay for certain out-of-pocket health
care expenses. Contributions are made annually and
can range from $100 - $2,500 per year. This plan
offers a benefit debit card for your convenience.
Dependent Care FSA Eligible Expenses:
● Care for your child who is under age 13
before and after-school care
● Baby sitting and nanny expenses
● Day care, nursery school, and preschool
● Summer day camp
● Care for a relative who is physically or
mentally incapable of self-care and lives in
your home
Health FSA Eligible Expenses:
●
Medical expenses: co-pays, co-insurance, and
deductibles
●
Dental expenses: exams, cleanings, X-rays, and
braces
●
Vision expenses: exams, contact lenses and
supplies, eyeglasses, and laser eye surgery
●
Professional services: chiropractor and
acupuncture
●
Prescription drugs and insulin
THE “USE IT OR LOSE IT” RULE:
This rule states that if you contribute your pre-tax
dollars to an FSA and then do not use all of the dollars
you
deposit, you will lose the remaining balance in the
account at the end of the plan year. For this reason,
it is essential that you plan ahead before deciding
how much to contribute to your two FSA accounts
and that you put in those dollars you are confident
you will use.
DEPENDENT CARE FSA: This plan allows you to set
aside pre-tax dollars that can be used to help pay for
day care services for eligible dependents. The
maximum amount you can contribute to this plan
annually is $5,000 (if you are married but filing
separately, federal regulations limit the use of a
Dependent Care FSA to $2,500 each year). In order to
qualify for Dependent Care FSA the IRS has
established the following regulations:
● An eligible dependent is any child under the
age of 13 or and eligible dependent who is
physically or mentally incapable of caring for
his or her own needs, such as an invalid
parent
| PAGE 24
FLEXIBLE SPENDING ACCOUNTS
When you elect to participate in a Health Care FSA, you elect an annual amount for the plan year. This
amount will be deducted from your paycheck on a pre-tax basis to cover your expected out-of-pocket
health care expenses for the plan year.
These are the reimbursement options available:


Debit Card
Cash reimbursement (paper claim)
Health Care—General Plan Provisions
Minimum Employee Contribution
$540.00 Annual / $20.00 Per pay period
$2,499.93 Annual / $92.59 Per pay period
Maximum Employee
Contribution
Total combined family benefit = $5,000
Claim Deadline
March 15
When you elect to participate in the Dependent Care FSA, you elect an annual amount for the plan year.
This amount will be deducted from your paycheck on a pre-tax basis to cover your out-of-pocket eligible
dependent care expenses for the plan year. These are the reimbursement options available:


Cash reimbursement (paper claim)
Submit bill from provider
After you have incurred an eligible expense, you may be reimbursed using your card or a paper claim
form, up to the current contribution amount at the time of the reimbursement
request. Claims submitted for expenses that exceed your current account balance will remain pending
until additional contributions are applied to your account.
Dependent Care - General Plan Provisions
Minimum Employee Contribution
$540.00 Annual / $20.00 Per pay period
Maximum Employee Contribution
$4,999.86 Annual / $185.18 Per pay period
Claim Deadline
March 15
27 pay periods in 2015
| PAGE 25
REQUIRED FEDERAL NOTICES
Premium Assistance Under Medicaid and the
Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP
and you are eligible for health coverage from your
employer, your State may have a premium assistance
program that can help pay for coverage. These States use
funds from their Medicaid or CHIP programs to help
people who are eligible for these programs, but also have
access to health insurance through their employer. If you
or your children are not eligible for Medicaid or CHIP, you
will not be eligible for these premium assistance
programs.
If you or your dependents are already enrolled in
Medicaid or CHIP and you live in a State listed below, you
can contact your State Medicaid or CHIP office to find out
if premium assistance is available.
If you or your dependents are NOT currently enrolled in
Medicaid or CHIP, and you think you or any of your
dependents might be eligible for either of these programs,
you can contact your State Medicaid or CHIP office or dial
1-877-KIDS NOW or www.insurekidsnow.gov to find out
how to apply. If you qualify, you can ask the State if it has
a program that might help you pay the premiums for an
employer-sponsored plan.
Once it is determined that you or your dependents are
eligible for premium assistance under Medicaid or CHIP,
as well as eligible under your employer plan, your
employer must permit you to enroll in your employer plan
if you are not already enrolled. This is called a “special
enrollment” opportunity, and you must request coverage
within 60 days of being determined eligible for premium
assistance. If you have questions about enrolling in your
employer plan, you can contact the Department of Labor
electronically at www.askebsa.dol.gov or by calling tollfree 1-866-444-EBSA (3272).
If you live in one of the following States, you may be
eligible for assistance paying your employer health plan
premiums. The following list of States is current as of
January 31, 2014. You should contact your State for
further information on eligibility.
ALABAMA – Medicaid
Website: http://www.medicaid.alabama.gov
Phone: 1-855-692-5447
INDIANA – Medicaid
Website: http://www.in.gov/fssa
Phone: 1-800-889-9949
ALASKA – Medicaid
Website: http://health.hss.state.ak.us/dpa/programs/medicaid/
Phone (Outside of Anchorage): 1-888-318-8890
Phone (Anchorage): 907-269-6529
IOWA – Medicaid
Website: www.dhs.state.ia.us/hipp/
Phone: 1-888-346-9562
ARIZONA – CHIP
Website: http://www.azahcccs.gov/applicants
Phone (Outside of Maricopa City): 1-877-764-5437
Phone (Maricopa City): 602-417-5437
COLORADO – Medicaid
Medicaid Website: http://www.colorado.gov/
Medicaid Phone (In state): 1-800-866-3513
Medicaid Phone (Out of state): 1-800-221-3943
FLORIDA – Medicaid
Website: https://www.flmedicaidtplrecovery.com/
Phone: 1-877-357-3268
GEORGIA – Medicaid
Website: http://dch.georgia.gov/
Click on Programs, then Medicaid, then Health Insurance Premium
Payment (HIPP)
Phone: 1-800-869-1150
IDAHO – Medicaid
Medicaid Website: www.accesstohealthinsurance.idaho.gov
Medicaid Phone: 1-800-926-2588
KANSAS – Medicaid
Website: http://www.kdheks.gov/hcf/
Phone: 1-800-792-4884
KENTUCKY – Medicaid
Website: http://chfs.ky.gov/dms/default.htm
Phone: 1-800-635-2570
LOUISIANA – Medicaid
Website: http://www.lahipp.dhh.louisiana.gov
Phone: 1-888-695-2447
MAINE – Medicaid
Website: http://www.maine.gov/dhhs/ofi/publicassistance/index.html
Phone: 1-800-977-6740
TTY 1-800-977-6741
MASSACHUSETTS – Medicaid and CHIP
Website: http://www.mass.gov/MassHealth
Phone: 1-800-462-1120
MINNESOTA – Medicaid
Website: http://www.dhs.state.mn.us/
Click on Health Care, then Medical Assistance
Phone: 1-800-657-3629
| PAGE 26
REQUIRED FEDERAL NOTICES
MISSOURI – Medicaid
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
Phone: 573-751-2005
PENNSYLVANIA – Medicaid
Website: http://www.dpw.state.pa.us/hipp
Phone: 1-800-692-7462
MONTANA – Medicaid
Website: http://medicaidprovider.hhs.mt.gov/clientpages/
clientindex.shtml
Phone: 1-800-694-3084
RHODE ISLAND – Medicaid
Website: www.ohhs.ri.gov
Phone: 401-462-5300
SOUTH CAROLINA – Medicaid
Website: http://www.scdhhs.gov
Phone: 1-888-549-0820
NEBRASKA – Medicaid
Website: www.ACCESSNebraska.ne.gov
Phone: 1-800-383-4278
SOUTH DAKOTA - Medicaid
Website: http://dss.sd.gov
Phone: 1-888-828-0059
NEVADA – Medicaid
Medicaid Website: http://dwss.nv.gov/
Medicaid Phone: 1-800-992-0900
TEXAS – Medicaid
Website: https://www.gethipptexas.com/
Phone: 1-800-440-0493
NEW HAMPSHIRE – Medicaid
Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-271-5218
UTAH – Medicaid and CHIP
Website: http://health.utah.gov/upp
Phone: 1-866-435-7414
NEW JERSEY – Medicaid and CHIP
Medicaid Website: http://www.state.nj.us/humanservices/
dmahs/clients/medicaid/
Medicaid Phone: 1-800-356-1561
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
VERMONT– Medicaid
Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
NEW YORK – Medicaid
Website: http://www.nyhealth.gov/health_care/medicaid/
Phone: 1-800-541-2831
VIRGINIA – Medicaid and CHIP
Medicaid Website: http://www.dmas.virginia.gov/rcp-HIPP.htm
Medicaid Phone: 1-800-432-5924
CHIP Website: http://www.famis.org/
CHIP Phone: 1-866-873-2647
NORTH CAROLINA – Medicaid
Website: http://www.ncdhhs.gov/dma
Phone: 919-855-4100
NORTH DAKOTA – Medicaid
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: 1-800-755-2604
OKLAHOMA – Medicaid and CHIP
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742
OREGON – Medicaid
Website: http://www.oregonhealthykids.gov
http://www.hijossaludablesoregon.gov
Phone: 1-877-314-5678
WASHINGTON – Medicaid
Website: http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm
Phone: 1-800-562-3022 ext. 15473
WEST VIRGINIA – Medicaid
Website: www.dhhr.wv.gov/bms/
Phone: 1-877-598-5820, HMS Third Party Liability
WISCONSIN – Medicaid
Website: http://www.badgercareplus.org/pubs/p-10095.htm
Phone: 1-800-362-3002
WYOMING – Medicaid
Website: http://health.wyo.gov/healthcarefin/equalitycare
Phone: 307-777-7531
To see if any more States have added a premium assistance program since January 31, 2014, or for more information on
special enrollment rights, you can contact either:
U.S. Department of Labor
Employee Benefits Security Administration
www.dol.gov/ebsa
1-866-444-EBSA (3272)
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
www.cms.hhs.gov
1-877-267-2323, Menu Option 4,Ext. 61565
| PAGE 27
IMPORTANT NOTICE ABOUT YOUR PRESCRIPTION
DRUG COVERAGE AND MEDICARE
Please read this notice carefully and keep it where you can find it. This notice has information about your current
prescription drug coverage with The City of Santa Rosa and about your options under Medicare’s prescription drug
coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are
considering joining, you should compare your current coverage, including which drugs are covered at what cost,
with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information
about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and Medicare’s prescription drug
coverage:
Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this
coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that
offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by
Medicare. Some plans may also offer more coverage for a higher monthly premium.
The City of Santa Rosa has determined that the prescription drug coverage offered by Anthem Blue Cross is, on
average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage
pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you
can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 th
through December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of
your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?
If you do decide to join a Medicare drug plan and drop your current The City of Santa Rosa prescription drug
coverage, be aware that you and your dependents will may not be able to get this coverage back.
Please contact us for more information about what happens to your coverage if you enroll in a Medicare prescription
drug plan.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with The City of Santa Rosa and don’t join a
Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a
penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may
go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have
that coverage. For example, if you go nineteen months without creditable coverage, your premium may
consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher
premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait
until the following October to join.
Continued...
| PAGE 28
IMPORTANT NOTICE ABOUT YOUR PRESCRIPTION
DRUG COVERAGE AND MEDICARE
For More Information About This Notice Or Your Current Prescription Drug Coverage…
Contact the City’s Human Resources Department at (707) 543-3060.
NOTE: You'll get this notice each year. You will also get it before the next period you can join a Medicare drug plan,
and if this coverage through the City of Santa Rosa changes. You also may request a copy of this notice at any time.
For More Information About Your Options Under Medicare Prescription Drug Coverage…
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You”
handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted
directly by Medicare drug plans.
For more information about Medicare prescription drug coverage: Visit www.medicare.gov.
Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare &
You” handbook for their telephone number) for personalized help Call 1-800-MEDICARE (1-800-633-4227). TTY
users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available.
For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at
1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug
plans, you may be required to provide a copy of this notice when you join to show whether or
not you have maintained creditable coverage and, therefore, whether or not you are required to
pay a higher premium (a penalty).
Date:
Name of Entity:
Contact:
Address:
Phone Number:
January 1, 2015
City of Santa Rosa
Human Resources
100 Santa Rosa Avenue, Room 1, Santa Rosa, CA 95404
(707) 543-3060
| PAGE 29
REQUIRED FEDERAL NOTICES
The following notices are mandatory notices that all
employers are required to provide their employees.
The contents of the messages may or may not apply
to you. If you have any questions about these notices,
please contact Human Resources at (707) 543-3060.
Notice of Availability of HIPAA Privacy Notice
The federal Health Insurance Portability and
Accountability Act of 1996 (“HIPAA”) requires that we
periodically remind you of your right to receive a copy
of the City’s HIPAA Privacy Notice. You can request a
copy of the Privacy Notice by contacting City of Santa
Rosa Human Resources Department at 100 Santa Rosa
Avenue - Room 1, Santa Rosa, CA 95404.
HIPAA Privacy Notices that pertain to other City health
plans may be obtained by contacting your insurance
carrier directly, at the address provided in the
Evidence of Coverage booklets.
HIPAA Notice of Special Enrollment Rights for
Medical/Health Plan Coverage
If you decline enrollment in the City of Santa Rosa’s
health plan for you or your dependents (including
your spouse) because of other health insurance or
group health plan coverage, you or your dependents
may be able to enroll in the City of Santa Rosa’s health
plan without waiting for the next open enrollment
period if you:


●
Lose other health insurance or group health plan
coverage. You must request enrollment within
*30/31+ days after the loss of other coverage.
Gain a new dependent as a result of marriage,
birth, adoption, or placement for adoption. You
must request *medical plan OR health plan+
enrollment within *30/31+ days after the marriage,
birth, adoption, or placement for adoption.
Lose Medicaid or Children’s Health Insurance
Program (CHIP) coverage because you are no
longer eligible. You must request medical plan
enrollment within 60 days after the loss of such
coverage.
If you request a change due to a special enrollment
event within the *30/31+ day timeframe, coverage will
be effective the date of birth, adoption or placement
for adoption. For all other events, coverage will be
effective the first of the month following your request
for enrollment. In addition, you may enroll in the City
of Santa Rosa’s medical plan if you become eligible for
a state premium assistance program under Medicaid
or CHIP. You must request enrollment within 60 days
after you gain eligibility for medical plan coverage. If
you request this change, coverage will be effective the
first of the month following your request for
enrollment. Specific restrictions may apply, depending
on federal and state law.
Note: If your dependent becomes eligible for a special
enrollment rights, you may add the dependent to your
current coverage or change to another health plan.
Michelle’s Law Notice
Extended dependent medical coverage during student
medical leaves
The City of Santa Rosa’s plans may extend medical
coverage for dependent children if they lose eligibility
for coverage because of a medically necessary leave of
absence from school. Coverage may continue for up to
a year, unless your child’s eligibility would end earlier
for another reason. Extended coverage is available if a
child’s leave of absence from school — or change in
school enrollment status (for example, switching from
full-time to part-time status) — starts while the child
has a serious illness or injury, is medically necessary
and otherwise causes eligibility for student coverage
under the plan to end. Written certification from the
child’s physician stating that the child suffers from a
serious illness or injury and the leave of absence is
medically necessary may be required. If your child will
lose eligibility for coverage because of a medically
necessary leave of absence from school and you want
his or her coverage to be extended, Contact the City of
Santa Rosa’s Human Resource Department as soon as
the need for the leave is recognized. In addition,
contact your child’s health plan to see if any state laws
requiring extended coverage may apply to his or her
benefits.
| PAGE 30
REQUIRED FEDERAL NOTICES
The following notices are additional mandatory notices that all employers are required to provide their employees.
The contents of the messages may or may not apply to you. If you have any questions about these notices, please
contact Human Resources at (707) 543-3060.
The Women’s Health and Cancer Rights Act (WHCRA)
The Women’s Health and Cancer Rights Act (WHCRA) requires employer groups to notify participants and
beneficiaries of the group health plan, of their rights to mastectomy benefits under the plan. Participants and
beneficiaries have rights for coverage to be provided in a manner determined in consultation with the attending
Physician for:

All stages of reconstruction of the breast on which the mastectomy was performed;
 Surgery and reconstruction of the other breast to produce a symmetrical appearance;
 Prostheses; and
 Treatment of physical complications of the mastectomy, including lymphedema.
These benefits are subject to the same deductible and co-payments applicable to other medical and surgical
procedures provided under this plan. You can contact your health plan’s Member Services for more information.
The Newborns’ and Mothers’ Health Protection Act
Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any
hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours
following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally
does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from
discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and
issuers may not, under federal law, require that a provider obtain authorization from the plan or the issuer for
prescribing a length of stay not in excess of 48 hours (or 96 hours).
| PAGE 31
COBRA INFORMATION
Continuation Coverage Rights Under COBRA
Introduction
You are receiving this notice because you recently
have become covered under a group health plan (the
Plan). This notice contains important information
about your right to COBRA continuation coverage,
which is a temporary extension of coverage under the
Plan. This notice explains COBRA continuation
coverage, when it becomes available to you and your
family, and what you need to do to protect the right
to receive it.
The right to COBRA continuation coverage was
created by a federal law, the Consolidated Omnibus
Budget Reconciliation Act of 1985. COBRA
continuation coverage can become available to you
when you otherwise would lose your group health
coverage. It also can become available to other
members of your family who are covered under the
Plan when they otherwise would lose their group
health coverage. For additional information about
your rights and obligations under the Plan and under
federal law, you should review the Plan's summary
plan description or contact the Plan administrator.
What Is COBRA Continuation Coverage?
COBRA continuation coverage is a continuation of Plan
coverage when coverage otherwise would end
because of a life event known as a qualifying event.
Specific qualifying events are listed later in this notice.
After a qualifying event, COBRA continuation coverage
must be offered to each person who is a qualified
beneficiary. You, your spouse, and your dependent
children could become qualified beneficiaries if
coverage under the Plan is lost because of the
qualifying event. Under the Plan, qualified
beneficiaries who elect COBRA continuation coverage
MUST PAY COBRA continuation coverage.
If you are an employee, you will become a qualified
beneficiary if you lose your coverage under the Plan
because of either one of the following qualifying
events happens:
 your hours of employment are reduced, or

your employment ends for any reason other
than your gross misconduct.
If you are the spouse of an employee, you will become
a qualified beneficiary if you lose your coverage under
the Plan because any of the following qualifying
events happens:
 your spouse dies;
 your spouse's hours of employment are
reduced;
 your spouse's employment ends for any
reason other than his or her gross misconduct;
 your spouse becomes entitled to Medicare
benefits under Part A, Part B, or both; or
 you become divorced or legally separated
from your spouse.
Your dependent children will become qualified
beneficiaries if they lose coverage under the Plan
because any of the following qualifying events
happens:
 the parent-employee dies;
 the parent-employee's hours of employment
are reduced;
 the parent-employee's employment ends for
any reason other than his or her gross
misconduct;
 the parent-employee becomes entitled to
Medicare benefits under Part A, Part B, or
both;
 the parents become divorced or legally
separated; or
 the child stops being eligible under the Plan as
a dependent child.
Sometimes, filing a bankruptcy proceeding under title
11 of the United States Code can be a qualifying
event. If a bankruptcy proceeding is filed with respect
to the City of Santa Rosa, and that bankruptcy results
in loss of coverage for any retired employee under the
Plan, the retired employee will become a qualified
beneficiary with respect to the bankruptcy. The
retiree employee's spouse, surviving spouse, and
dependent children also will become qualified
beneficiaries if bankruptcy results in loss of their
coverage under the Plan.
| PAGE 32
COBRA INFORMATION
When Is COBRA Coverage Available?
The Plan offers COBRA continuation coverage to
qualified beneficiaries only after the Plan
administrator has been notified that a qualifying event
has occurred. When the qualifying event is the end of
employment or reduction in hours of employment,
death of the employee, or the employee's becoming
entitled to Medicare benefits (under Part A, Part B, or
both), the employer must notify the Plan
administrator of the qualifying event.
children can last up to 36 months after the date of
Medicare entitlement, which is 28 months (36 minus 8
months) after the date of the qualifying event.
You Must Give Notice of Some Qualifying Events
For other qualifying events—divorce or legal
separation of the employee and the spouse, or a
dependent child's losing eligibility for coverage as a
dependent child—you must notify the Plan
administrator within 60 days after the qualifying event
occurs.
Disability extension of 18-month period of
continuation coverage: If you or anyone in your
family covered under the Plan is determined by the
Social Security Administration to be disabled and you
notify the Plan administrator in a timely fashion, you
and your entire family might be entitled to receive an
additional 11 months of COBRA continuation
coverage, for a total of 29 months. The disability
would have to have started at some time before the
60th day of COBRA continuation coverage and must
last at least until the end of the 18-month period of
continuation coverage. Notice must be provided to
Employee Benefit Specialists (EBS), the COBRA
administrator at the following address:
5934 Gibraltar Drive Suite 206, Pleasanton 94588
How Is COBRA Coverage Provided?
Once the Plan administrator receives notice that a
qualifying event has occurred, COBRA continuation
coverage will be offered to each qualified beneficiary.
Each qualified beneficiary has an independent right to
elect COBRA continuation coverage. Covered
employees can elect COBRA continuation coverage on
behalf of their spouses, and parents can elect COBRA
continuation coverage on behalf of their children.
COBRA continuation coverage is a temporary
continuation of coverage. When the qualifying event
is the death of the employee, the employee's
becoming entitled to Medicare benefits (under Part A,
Part B, or both), your divorce or legal separation, or a
dependent child's losing eligibility as a dependent
child, COBRA continuation coverage lasts for up to 36
months. When the qualifying event is the end of
employment or reduction of the employee's hours of
employment, and the employee became entitled to
Medicare benefits less than 18 months before the
qualifying event, COBRA continuation coverage for
qualified beneficiaries other than the employee lasts
until 36 months after the date of Medicare
entitlement. For example, if a covered employee
became entitled to Medicare 8 months before the
date on which employment terminated, COBRA
continuation coverage for his or her spouse and
Otherwise, when the qualifying event is the end of
employment or reduction of the employee's hours of
employment, COBRA continuation coverage generally
lasts for only up to 18 months. There are two ways in
which this 18-month period of COBRA continuation
coverage can be extended:
Second qualifying event extension of 18-month period
of continuation coverage: If your family experiences
another qualifying event while receiving 18 months of
COBRA continuation coverage, your spouse and
dependent children can get up to 18 additional
months of COBRA continuation coverage for a
maximum of 36 months, if notice of the second
qualifying event is properly given to the Plan. This
extension can become available to the spouse and any
dependent children receiving continuation coverage if
the employee or former employee dies, becomes
entitled to Medicare benefits (under Part A, Part B, or
both), or gets divorced or legally separated, or if the
dependent child stops being eligible under the Plan as
a dependent child, but only if this second event would
have caused the spouse or dependent child to lose
coverage under the Plan had the first qualifying event
not occurred.
| PAGE 33
COBRA INFORMATION
If You Have Questions concerning your Plan or your
COBRA continuation coverage rights, they should be
addressed to the contact or contacts identified below.
For more information about your rights under the
Employee Retirement Income Security Act (ERISA),
including COBRA, the Health Insurance Portability and
Accountability Act (HIPAA), and other laws affecting
group health plans, contact the nearest regional or
district office of the U.S. Department of Labor's
Employee Benefits Security Administration in your
area or visit the EBSA Web site at http://www.dol.gov/
ebsa/ . Addresses and telephone numbers of regional
and district EBSA offices are available on the agency's
Web site.
family members who otherwise would lose coverage
must inform the HR department of their election of
COBRA coverage within 60 days of the qualifying
event.
Keep Your Plan Informed of Address Changes: To
protect your family's rights, you should keep the Plan
administrator informed of any changes in the
addresses of family members. You also should keep
for your own records a copy of any notices you sent to
the Plan administrator.
This policy statement is a brief description of the
health care continuation plan and does not fully
explain employees' rights under COBRA. Employees
should read the COBRA notice they received when
they first enrolled in the group health plan or the
summary plan description for a fuller explanation.
Copies of the COBRA notice and summary plan
description can be obtained from the Benefits
department.
Plan Contact Information:
 City of Santa Rosa Human Resources
Department: 100 Santa Rosa Avenue - Room
1, Santa Rosa, CA 95404
 Employee Benefit Specialists (EBS): 5934
Gibraltar Drive Suite 206, Pleasanton, CA
94588
There is no waiting period, no exclusion for preexisting conditions, and no physical examination when
electing continuation coverage. Any amounts already
paid toward deductibles and co-insurance during the
current year count under the continuation policy.
Employees and family members can elect full
coverage or medical coverage without dental
insurance and can choose from the three different
health plans offered to active employees.
©2007, The Bureau of National Affairs, Inc.
Health Care Continuation Rights Policy: If a qualifying
event occurs that causes you, your spouse, or your
dependent children to lose coverage under Santa
Rosa’s group health care plan, you have a legal right
under COBRA to purchase a temporary extension of
group health coverage. Qualifying events include
reduction in work hours, termination of employment
(except for gross misconduct), death of the employee,
legal separation or divorce, or loss of eligibility for
dependent coverage.
The purchase price of continuing coverage is the full
cost of the premium for similarly situated active
employees, plus 2 percent (50 percent in certain
cases) to help pay for administrative costs. The period
for which the coverage can be continued depends on
the nature of the qualifying event. Employees or
| PAGE 34
BEN-IQ
Meet Ben-IQ
 Plan Information
 Contact an advocate or nurse line
 HR push messaging ability
 Locate a provider
 Cost of care information
 Wellness incentive plan/tips
 Benefits FAQ
 Terms and benefits language
Download Instructions
 Download the Ben-IQ app on the App Store for
your mobile device(s)
 iPhone and Andriod compatible
 Username: santarosa
 Accept the terms and log in
| PAGE 35
NOTES
| PAGE 36
NOTES
| PAGE 37
IMPORTANT CONTACT INFORMATION
PLAN
PROVIDER
MEMBERSHIP
SERVICES PHONE #
WEB SITE
Anthem Blue Cross
(800) 333-0912
www.anthem.com/ca/
EIAHEALTH/
Express Scripts
(877) 554-3091
www.express-scripts.com
Kaiser Permanente
(800) 464-4000
www.kp.org
Delta Dental
(800) 765-6003
www.deltadentalins.com
VSP
(800) 877-7165
www.vsp.com
Voya
(800) 362-4462
www.voya.com
Voya
Travel Assistance
(800) 859-2821
EBS (FSA)
(888) 327-2770
www.ebsbenefits.com
Employee Assistance
Program (EAP)
(800) 242-6220
www.members.mhn.com
HUMAN RESOURCES
Email
www.europassistanceusa.com
(707) 543-3060
[email protected]
Above is a listing of numbers you can call with questions about benefit coverage and providers in your area. You can also use the
website addresses to access provider information as well as additional discount programs available through each carrier.
Employee Benefits Brochure designed and developed by
in conjunction with the City of Santa Rosa
| PAGE 38