Employee Health Benefits

An employee may only make changes in their health insurance coverage within 60 days of a “qualifying event”, except during open enrollment periods.  A change in health insurance means to either add or drop insurance or to add or drop dependents on your insurance.  “Qualifying events” are:

• Change in legal status, including marriage, death, divorce, death of spouse, legal separation or annulment.
• Change in number of tax dependents, including birth, adoption or placement of adoption, or death,
• Termination or commencement of employment by employee, spouse or dependent
• Change in work schedule, including increase or reduction in work hours by employee, spouse or dependent; also includes commencement or return from an unpaid leave, and
• Dependent satisfies or ceases to satisfy dependent eligibility requirements, including attainment of age, student status, etc.

Five of the options available in our area are Health Maintenance Organization Plans (HMO) and two are Preferred Provider Organization Plans (PPO).  The HMO medical plans include Blue Shield Access +, Blue Shield Trio, Anthem Blue Cross (two plans) and Kaiser Permanente.  The PPO plans offered are PERS Gold and PERS Platinum, both of which are administered under Anthem’s Blue Cross of California Prudent Buyer plan.

Delta Dental’s PPO Incentive Plan has varying coverage; 70% coverage for the first year of participation, 80% for the second, 90% for the third and 100% from then on with a cap of $1,000 maximum per year per person.  Each family member has his or her own percentage of coverage.  If services are provided by a Delta Dental PPO there is no deductible and enrollees receive an annual maximum of $1,200.  If services are provided by non-PPO dentists, there will be $25 deductible for each enrollee up to a limit of $75 per family (except for diagnostic and preventive benefits).   Orthodontics is not covered under this plan. 

The Delta Preferred (PPO) provides $2,000 annual maximum coverage per patient per year.  It also includes a $2,000 lifetime per patient orthodontic benefit for both children and adults.  This plan has a three-tier premium rate structure according to the number of family members insured.  Not all dentists are part of Delta’s PPO network.  You should contact your dentist to determine if he/she is a participant in this plan.  If your dentist is a participant in the Delta Premier Plan, but not in the PPO plan, this plan would pay 60% of the Delta approved fee for most services.

The United Healthcare (UHC) Plan (also called Pacific Union Dental / PUD) covers orthodontics as stated in their brochure, but you must use their network orthodontist.  UHC has 100% coverage from the initial effective date, however, certain procedures have co-payments as listed in their brochure and you must use a UHC network dentist.  There are only a few participating dentists in this plan; you will have minimal control over your selection of dentists and you may encounter significant difficulty in arranging prompt appointments. 

The Delta DentalCare DHMO plan provides unlimited coverage and does include orthodontics.  There are co-payments for some types of services.  This plan has a three-tier premium rate structure.  You must visit a dentist or orthodontist in the Delta DentalCare DHMO network; very few dentists are members of this plan.  You will have minimal control over your selection of dentists and you may encounter significant difficulty in arranging prompt appointments.

Dental wallet cards will be issued for the UHC and Delta DentalCare DHMO plans only.  The group plan number for the plan you have chosen appears on your copy of the Benefit Selection Sheet.  Three of our plans are Delta Dental plans (PPO Incentive, PPO and Delta DentalCare DHMO).  You may inquire online at www.deltadental.com – this web site will allow you to check on your eligibility and also to search for a dentist that accepts your plan. You may also print out an ID card via www.deltadental.com

Prescriptions are covered only through the health plan you choose.  Prescriptions written by anyone other than your primary care doctor may not be covered by our health plans.

You can search for a VSP eye doctor online at www.vsp.com.  This web site will also allow you to verify eligibility for yourself and family members.  Wallet cards are not issued for the vision plan.  However, you can print out an ID card from the website. Using your social security number, your eye doctor’s staff will contact VSP to receive authorization to provide service – no forms are necessary.  If you do not use a VSP doctor, you will be required to prepay services and submit the paid invoices to VSP for reimbursement.