Washoe Country School District

July 25, 2014

Change Font Size


Employee Benefits - FAQ

PREFERRED PROVIDER (PPO) PLANS with GAP PLAN

 
What are the PPO Plans offered by the District?  The District offers two PPO Plans. They have the same benefits, deductibles, coinsurance, and co-payments. The difference between the two plans is one plan uses a St. Mary’s based provider system and the other plan uses a Renown based provider system. The PPO using the St. Mary’s based provider system is called the PHCN PPO Plan; and the one using the Renown based provider system is called the HHP PPO Plan.
 
What type of plans are the PPO Plans? They are Self-funded Comprehensive Major Medical Plans with a Preferred Provider Organization (PPO) component.
 
Do they cover services worldwide? Yes
 
Do they have a yearly maximum benefit amount? Yes, it’s $2 million.
 
Who processes and administers the claims?
- For the PHCN PPO Plan it is CDS Group Health, PO Box 50190, Sparks, NV 89435-0190, 775/352-6900
 
- For the HHP PPO Plan it is Hometown Health, 830 Harvard Way, Reno, NV 89502, 775/982-3232           
  
What is the GAP Plan? The GAP Plan (through American Fidelity Insurance Company) is designed to help cover some of your out-of-pocket expenses with the EPO Plans. It will pay up to $1,000 per inpatient hospital confinement, up to $200 for certain outpatient services, up to $100 for emergency room visits and up to $25/doctor visit/x-ray or lab (limit of $125/family). If you cover your dependents, they will also have the GAP Plan coverage. To be reimbursed by the GAP Plan, you’ll need to submit to American Fidelity the “Explanation of Benefits” (EOB) you receive from the EPO Plan administrator with an American Fidelity GAP claim form.
 
PREFERRED PROVIDERS
 
What are Preferred Providers? Providers who are contracted to provide services at a contracted fee.
 
What are Non-Preferred Providers? Providers who are not contracted to provide services at a contracted fee.
 
How do I find out if my doctor is a PPO provider?
If you select the PHCN PPO Plan, contact Saint Mary’s Preferred Health Care Network at 775/770-6900 or 800/433-3077. You may also visit their web site at www.saintmaryshealthplans.com.
o   Click on “Health Plans”;
o   Click on “Health Plan Members”;
o   Click on “Provider Directory”;
o   Under “Please select your Health Plan:” choose “Preferred Healthcare Network PPO”;
o   Select the “Northern Nevada Panel”
o   Click at top for a downloadable copy or do query by specialty or doctor name.
 
If you select the HHP PPO Plan, contact Hometown Health at 775/982-3232 or 800/336-0123; or their web page at www.hometownhealth.com:
o   Click on Provider Directory in the Member box;
o   Find Provider by Plan Type;
o   Click on “Employer Sponsored Self-Fund”;
o   Search by Doctor Name or Specialty
 
What are the PPO Hospitals in Washoe County?
If you select the PHCN PPO Plan, it is Saint Mary’s Regional Medical Center and Northern Nevada Medical Center.
 
If you select the HHP PPO Plan, it is Renown Regional Medical Center and Renown South Meadows.
 
What if I need services that cannot be provided by a PPO provider? You will receive reimbursement at the PPO level of benefit (no reduction in level of benefit).
 
What if I receive emergency services from a Non-PPO provider? If it meets the definition of an “Emergency”, you will receive reimbursement at the PPO level of benefit (no reduction in level of benefit).
 
DEDUCTIBLES/CO-INSURANCE/CO-PAYMENTS
 
What is a deductible? It’s the amount of billed charges you must first pay before the plan will pay any charges.
 
The PPO Plans have a calendar year deductible of $500 per person and $1,000 per family when you use preferred providers. If you use non-preferred providers, the deductibles increase to $1,500 per person and $3,000 per family.
  
What is co-insurance and co-insurance limit? Co-insurance is the percentage of the cost both you and the Plan share for covered expenses after you have met your deductible. The co-insurance limit is the total amount of eligible billed charges that the co-insruance is applied to before the Plan will pay your benefits at 100%. The PPO PLans have an annual out-of-pocket maximum of $3,000 per person and $6,000 per family when you use preferred providers. For non-preferred providers, the annual out-of-pocket maximum is $6,000 per person and $12,000 per family.
 
Here’s how it works: When you use preferred providers the co-insurance percentage is 80% and the co-insurance limit is$15,000 so you would pay 20% of the first $15,000 you incurred during the year or $3,000. This would be your annual out-of-pocket maximum. Any eligible expenses that you would incur during the year that exceeded the $15,000 would be covered at 100% for the remainder of the year.
 
Do the PPO Plans have co-payments? Yes, they have a $25 co-payment for primary care physician office visits, and a $35 co-payment for specialist physician visits. These co-payments are not subject to and do not apply to the $500 deductible. Also, you won’t need to complete any claim forms when you make a co-payment.
 
What are Usual, Customary, and Reasonable Fees (UCR)? The PPO contracted fees, or when applicable, charges that are within the usual level of charges in your locality for similar medical treatment, services, and supplies as determined by the Plan Administrator.
 
PRECERTIFICATION
 
Are there any procedures I must follow to ensure I receive full benefits for certain services? Yes, you must have all inpatient hospital admissions pre-certified. If it is an elective hospitalization, it must be pre-certified before you’re admitted. If it is an emergency, it must be pre-certified within 72 hours of being admitted.  You must also have any outpatient procedure over $10,000 pre-certified.
 
Who pre-certifies these services?
If you select the PHCN PPO Plan, your physician needs to contact Saitn Mary's Preferred Health Care Network (PHCN) at 775/352-6939 or 800/455-4236. 
 
If you select the HHP PPO Plan, your physician needs to contact Hometown Health (HHP) at 775/982-3232 or 800/336-0123.
 
What happens if I don’t follow these procedures? Your allowable charges will be reduced by 50% with payment made against that reduced amount and it will not apply towards your Co-insurance Limit.
 

EXCLUSIVE PROVIDER (EPO) PLANS with GAP PLAN

 

What are the EPO Plans offered by the District? The District offers two EPO Plans. They have the same benefits and co-payments. The difference between the two plans is one plan uses a St. Mary’s based provider system and the other plan uses a Renown based provider system. The EPO using the St. Mary’s based provider system is called PHCN EPO Plan; and the one using the Renown based provider system is called HHP EPO Plan.
 
What type of plans are the EPO Plans? They are self-funded Exclusive Provider Organizations or EPOs.
 
Do they have a yearly maximum benefit amount? Yes, it’s $2 million.   
 
Do I need to live in a certain service area to elect an EPO Plan? Yes, you must reside in the Northern Nevada Service Area (or North Lake Tahoe area).
 
Who processes and administers the claims?
For the PHCN EPO Plan it is CDS Group Health, PO Box 50190, Sparks, NV 89435-0190, 775/ 352-6900
 
For the HHP PPO Plan it is Hometown Health, 830 Harvard Way, Reno, NV 89502, 775/982-3232
 
Are there deductibles or co-insurance requirements and claim forms to complete? No, you will only need to make a “co-payment” when you receive services except for prescription drugs which have an annual $50 per person deductible. No, there are no claims forms to complete.
 
For example, the plans have a $25 co-payment for primary care physician office visits, a $30 co-payment for specialist physician visits, a $100 co-payment for emergency services, a $200 co-payment for Same-Day Surgery Facility services, and a $1,250 co-payment per admit for Inpatient Hospital services.
 
What if I travel outside the EPO Plan’s service area? It will cover emergency and urgent care services only.
 
What is the GAP Plan? The GAP Plan (through American Fidelity Insurance Company) is designed to help cover some of your out-of-pocket expenses with the EPO Plans. It will pay up to $1,000 per inpatient hospital confinement, up to $200 for certain outpatient services, up to $100 for emergency room visits and up to $25/doctor visit/x-ray or lab (limit of $125/family). If you cover your dependents, they will also have the GAP Plan coverage. To be reimbursed by the GAP Plan, you’ll need to submit to American Fidelity the “Explanation of Benefits” (EOB) you receive from the EPO Plan administrator with an American Fidelity GAP claim form.  
 
CONTRACTED PROVIDERS
 
Must I receive my care from only contracted providers? Yes, you must receive your care from only the physicians, hospitals, and other health care providers that have contracted to provide services for the EPO Plan you select.
 
If you select the PHCN EPO Plan, you’ll need to use their panel of providers.
If you select the HHP EPO Plan, you’ll need to use their panel of providers. 
 
What happens if I don’t use a contracted provider? No benefits will be paid.
 
What are the EPO Plans’ contracted hospitals?
If you select the PHCN PPO Plan, it is Saint Mary’s Regional Medical Center and Northern Nevada Medical Center.
 
If you select the HHP PPO Plan, it is Renown Regional Medical Center and Renown South Meadows.
 
PRIMARY CARE PHYSICIANS/SPECIALISTS
 
Must I select a Primary Care Physician? What is a Primary Care Physician? Yes, but only if you select the HHP EPO Plan. Members on the PHCN EPO Plan will not need to select a Primary Care Physician but must use a Primary Care Physician fromt he PHCN Provider Panel. Primary Care Physicians include General Practitioners, Internists, and Pediatricians. OB/GYNs are not PCPs and do not direct medical care, however, they fall under the PCP co-payment amount.
 
Who directs my medical care? Your Primary Care Physician.
 
How do I see a medical specialist? Again, your Primary Care Physician will direct all of your medical care including referrals to specialists. If your Primary Care Physician feels you need to see a specialist, he/she will refer you to the appropriate doctor for your condition.
 
What happens if I see a specialist without a referral from my Primary Care Physician? No benefits will be paid even if a contracted specialist performs the services.
 
What if I need to see a specialist that is not available in the service area? Your EPO Plan will refer you to the proper specialist who can handle your medical condition.
 
How do I find out if my doctor is on the EPO Health Maintenance Plan’s physician list?
If you select the PHCN EPO Plan, contact Saint Mary’s Preferred Health Care Network at 775/770-6900 or 800/433-3077. You may also visit their web site at www.saintmarysreno.org:
o   Click on “Health Plans”;
o   Click on “Health Plan Members”;
o   Click on “Provider Directory”;
o   Under “Please select your Health Plan:” choose “Preferred Healthcare Network PPO”;
o   Select the “Northern Nevada Panel”
o   Click at top for a downloadable copy or do query by specialty or doctor name.
 
If you select the HHP EPO Plan, contact Hometown Health at 775/982-3232 or 800/336-0123; or their web page at www.hometownhealth.com:
o   Click on Provider Directory in the Member box;
o   Find Provider by Plan Type;
o   Click on “Employer Sponsored Self-Fund”;
o   Search by Doctor Name or Specialty
 

PRESCRIPTION DRUG BENEFITS

 
Do the PPO Plans and the EPO Plans have a prescription drug benefit? Yes, both plans have the same prescription drug benefit.  It is administered by CVS Caremark – (888)844-2220.         
 
How are prescription drugs covered? There is a $50 per member annual deductible. Once this is met, generic drugs have a $5 per prescription co-payment, “preferred brand name” drugs have a $25 co-payment and “non-preferred brand name” drugs have a $50 co-payment. (Note: If you prefer a brand-name drug and there is no medical necessity for its use over a generic drug, you will be required to pay the brand-name co-payment plus the difference in price between the brand-name drug and its generic equivalent.)
 
Does this program have a mail order prescription drug program? Yes, but only for prescription drugs that have been determined by CVS Caremark be maintenance prescription drugs. You will receive a 90-day supply through mail order rather than a 30-day supply from your pharmacy. The co-payment amount for the 90-day supply would be twice the applicable co-payment for the 30-day supply and there is no deductible on mail order. (Note: If you prefer a brand-name drug and there is no medical necessity for its use over a generic drug, you will be required to pay the brand-name co-payment plus the difference in price between the brand-name drug and its generic equivalent.)
 
What are “preferred-brand” name drugs? Brand-name drugs that are included on the plan’s preferred brand name list (formulary).
 
Can the list of “preferred-brand” name drugs change? Yes, the list changes every year. So, a preferred-brand name drug not on the list in 2013 could be on the list in 2014. Likewise, a preferred-brand name drug on the list in 2013 may not be on the list for 2014. The formulary may also change during the year if a drug brand name drug goes generic or over-the-counter.
 
To find out if a drug(s) is on the formulary and what the co-payment please contact CVS Caremark at (866)844-2220.
  

DENTAL PLAN

 

What type of dental plan does the District offer? The District offers the Self-funded Dental Plan with a Preferred Provider Dentist component.  

 Are my dependents covered for dental? Yes, if they are covered by a District medical plan.
 
What happens if I don’t use a Preferred Provider Dentist? Any expenses from a non-preferred dentist that exceed the amount the plan would pay a preferred provider dentist would be your responsibility.
 
How do I find out if my dentist is on the Dental Plan's Preferred Provider dentist list? Contact Guardian Dental at 1-888-600-9200 or visit their web page at www.guardiananytime.com/.
 

BASIC GROUP TERM LIFE

 
What type of life insurance coverage is it? It’s Group Term Life Insurance with Accidental Death & Dismemberment Coverage. It does not build “cash value”.
 
How much coverage do I have? Certified/Classified: $40,000; Confidential Classified: $50,000; and Administrators: $250,000
 
How much does this coverage cost me? Your life insurance and AD&D coverage is District-paid so there is no cost to you unless you are a part-time contracted teacher in which case your District-paid premiums will be prorated based on FTE.
 
Will my limits ever change? Yes, currently the amount will reduce by 50% at age 70.
 
What do I need to do if I need to change my beneficiary? Contact Risk Management immediately if you need to change your life insurance beneficiary for any reason e.g., marriage, divorce, or death. 
 

SUPPLEMENTAL GROUP TERM LIFE

 
EMPLOYEES
What type of life insurance coverage is it? It is Supplemental Group Term Life Insurance only and it does not build “cash value”.
 
How much will this coverage cost me? Premiums are age rated. Below are the current monthly rates per $1,000 of coverage by age band.  
< 29                                  $0.05                                                      30-34                     $0.08
35-39                                $0.09                                                      40-44                     $0.10
45-49                                $0.18                                                      50-54                     $0.28
55-59                                $0.50                                                      60-64                     $0.77
65-69                                $1.11                                                      70-72                     $1.32
73-74                                $1.57                                                      75-76                     $1.66
77-78                                $1.78                                                      79-80                     $2.40
81-82                                $3.42                                                      83-84                     $3.81
85-86                                $4.23                                                      87-88                     $5.89
89-90                                $6.35                                                      91-92                     $7.10
93-94                                $9.58                                                      95-96                   $11.05
97-98                              $13.15                                                      99+                       $25.00
 
To calculate your premium: 1. Find the rate for your age band. (Use the age you will be as of December 31, 2009.) 2. Multiply your current supplemental term life limits by this rate; 3. Divide the total by $1,000.
 
Will my limits ever change? At age 70, limits reduce by 50%, e.g., if you have $50,000 of term life and you turn 70, the amount will reduce to $25,000.
 
How much may I purchase? You may purchase limits in increments of $25,000 up to a maximum of $250,000 but you must do so within 90 days of your eligibility date or during the Districts annual Open Enrollment  subject to acceptable evidence of insurability. 
 
DEPENDENTS 
May I purchase coverage for my spouse? Yes, so long as you have or are purchasing supplemental life for yourself, you may purchase up to 50% of your supplemental life limit not to exceed $25,000 in increments of $5,000..
 
How much will my spouse’s coverage cost me? Premiums are age rated. Below are the current monthly rates per $1,000 of coverage by age band.
< 29                                  $0.05                                                      30-34                     $0.08
35-39                                $0.09                                                      40-44                     $0.10
45-49                                $0.18                                                       50-54                    $0.28
55-60                                $0.50                                                      60-64                     $0.77
65-70                                $1.11                                                      70-72                     $1.32
73-75                                $1.57                                                      75-76                     $1.66
77-79                                $1.78                                                      79-80                     $2.40
81-83                                $3.42                                                      83-84                     $3.81
85-87                                $4.23                                                      87-88                     $5.89
89-91                                $6.35                                                      91-92                     $7.10
93-95                                $9.58                                                      95-96                   $11.05
97-98                              $13.15                                                      99+                      $25.00
 
To calculate the premium: 1. Find the rate for your spouse’s age band. (Use the age your spouse will be as of December 31, 2009). 2. Multiply your spouse’s current supplemental term life limits by this rate; 3. Divide the total by $1,000. 
 
Will my spouse’s limits ever change? Yes, at age 65 they will reduce by 35% and will terminate the earlier of age 70 or when the employee ceases to be an eligible employee.
 
May I purchase coverage for my child(ren)? Yes, you may purchase coverage for your child(ren) who are of the age of 6 months to age 19 (25 if full-time student) with a choice of limits of $5,000 or $10,000 per child.
 
How much will this coverage cost me? The premium is $.86/month for the $5,000 limit and $1.72/month for the $10,000 limit. These premiums are per family unit (if you have one child or five children, the premium is the same - $.86/month for the $5,000 limit and $1.72/month for the $10,000 limit.)
 

VISION BENEFITS

 
Who provides my vision coverage? A company called Vision Service Plan (VSP).
 
Who is covered and do I have to pay any premiums for this coverage? You and your eligible dependents are covered and the premium is District-paid so there is no cost to you unless you are a part-time contracted teahcer in which case your District-paid premiums are prorated based on FTE.
  
Do I have to have my dependents covered by District medical coverage to have vision coverage? No
 
How do I find out when I am or my dependents are eligible for an exam, lenses and/or frames? Visit the VSP website at www.vsp.com.
  
What are the benefits?
· Eye Examination - Once each 12 months (From your last date service)
· Spectacle Lenses - Once each 24 months (From your last date service)
· Frames - Once each 24 months (From your last date service)
 
Does the vision plan have a preferred provider list? Yes
 
Do I have to use a preferred provider? No, but benefits will be paid at a reduced reimbursement schedule if you use a non-preferred provider.
 
Are there any “out-of-pocket” costs for me? Yes, there is a $10 per member co-payment for the eye examination. There may also be additional charges for such items as: Blended and/or Oversize Lenses; Contact Lenses; Progressive Lenses; Photochromic or tinted lenses other than Pink 1 or 2; Coated or Laminated Lenses; A frame that exceeds the plan allowance; UV protected Lenses.
 

GROUP LEGAL SERVICES PLAN

   
What is the Comprehensive Group Legal Services Plan? It’s a voluntary benefit through Hyatt Legal Plans and it covers certain legal services for you. Please note that if you enroll in this plan you may not stop coverage for one year.
 
What is the cost of the plan? The cost is currently $19.80 per month or $9.14 biweekly which is payroll deducted.
 
What does it cover? In addition to the fully covered services such as wills, real estate closings and debt collection defense, the plan also includes unlimited telephone advice and office consultation with a local attorney. If you use a Participating Attorney, there are no claims forms or out-of-pocket expenses for the attorney’s fees.
 
How can I get more information about the plan? Contact the Risk Management Office at 775/348-0343 for a brochure. 

SECTION 125 BENEFIT PROGRAM

 
What is a Section 125 Benefit Program? It’s a program under Section 125 of the Internal Revenue Code that allows an employer to take certain employee deductions on a “pretax” or “before tax” basis.
 
What kind of deductions can I make under the Section 125 Benefit Program? The program consists of two parts that include:
1. Premium Conversion Plan – Allows dependent medical/health and cancer insurance premiums to be paid on a pretax basis.
 
2. Flexible Spending Accounts – There are two types:

Dependent Day Care Expenses – Allows you to set aside up to $5,000 per year on a pretax basis to pay for day care expenses for your children under the age of 13.

Non-reimbursed Medical Expenses – Allows you to set aside up to $2,500 per year on a pretax basis to pay for expenses not covered by insurance such as deductibles, co-payments, and orthodontia; and certain over-the-counter drugs.

 
How does the Section 125 Program work?  Example:  
After-Tax
$2,000        Monthly Salary                                                            
$   500        Tax – 25%                                                                   
$1,500        Net Income Before Deductions                                    
$   200        Monthly Insurance Premium                                         
$1,300        Final Net Income                                                         
 
Pretax Under Section 125 Program
$2,000        Monthly Salary                                                            
$   200        Monthly Insurance Premium                                         
$1,800        Income Before Tax                                                      
$   450        Tax – 25%                                                                   
$1,350        Final Net Income                                                         
 
As you can see, you would have an extra $50 in your take-home pay under the Section 125 Program.
  
When does the Section 125 Plan Year start and end?  It runs from January 1 through December 31.
 
When are deductions made? They’re taken from your check each month if you’re Certified/Administrator and biweekly if you’re a classified employee.
 
Are there any fees for the Premium Conversion Plan? No
 
Are there any fees for the Flexible Spending Accounts? No
 
Who administers the Flexible Spending Accounts? American Fidelity
 
How do I get reimbursed if I sign up for a Flexible Spending Account? You simply submit a receipt and voucher to American Fidelity. You will receive additional information and vouchers from American Fidelity after you enroll.
 
Whe can I enroll into a Sectionn 125 Benefit Program? During the District's annual Open Enrollment.
   
What happens if I don’t use all the money set aside in my Flexible Spending Account by the end of December? You will forfeit any unused moneys.
 
Can I stop my Section 125 Benefit Program deductions at anytime? No, you cannot stop your deductions until the beginning of the next plan year unless you have a qualifying event. However, remember that all Section 125 changes/elections must be renewed every year. 
 

EMPLOYEE ASSISTANCE PROGRAM

 
What is an Employee Assistance Program? A confidential, licensed counseling service that is available to you and your immediate family members.
 
Is there any cost for this service? The District offers an Employee Assistance Program to you and your dependents at no cost to you.
 
How many EAP visits are allowed? Three counseling sessions per problem per year are allowed. 
 
Who provides this service? This service is provided through Mountain EAP,  775-322-6066; 800-449-4902; www.mountaineap.com
 

WELLNESS PROGRAM

  
The District has implemented a comprehensive Wellness Program for employees and spouses covered by District medical insurance. It offers programs that promote healthy lifestyles, decrease the risk of disease, and enhance the quality of life. 
 
Employees may reduce their premiums by $40 per month if they complete and submit an annual Health Appraisal. The premium for their spouse, if covered by District medical insurance, may also be reduced by $40 per month by having their spouse complete and submit an annual Health Appraisal.
 
Visit the Wellness Program website at www.washoecountyschools.org/staff/wellness-program for more information.
 

BENEFITS OVERVIEW

 
Please note that this information is not meant as a full explanation of the benefits provided by these programs. Please refer to the plan document or contract for specific benefits and provisions. Copies are available from the Risk Management Office. Any conflict between the information contained herein and any plan document or contract shall be governed by the provisions of said plan document or contract.