FAQs

Frequently Asked Questions

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How much do I pay for my Health Insurance?

If you are a monthly employee, working an assignment greater than 69% , there is no employee premium contribution for medical, dental, vision and life insurance. The District pays the full premium for the employee. There may be deductions when adding dependents to dental, vision or life insurance.

When should I use Urgent Care instead of the Emergency Room?

Urgent Care facilities should be used when you become sick or injured, but your regular doctor is not available and you can't wait for an appointment. Urgent Care facilities are designed to be used for non-life threatening situations. However, they still have the ability to transfer patients to a Hospital when necessary.

The Emergency Room really is not much different from an Urgent Care facility, except they provide medical care at any time, day or night. They are also equipped and staffed for the most complex or critical needs, including life and threatening situations. (If you have Blue Shield, there is a $100 co-pay for ER visits when not admitted overnight.)

How long may my dependent children remain covered under my benefit plan(s)?

Children may be covered up until they reach 26 years of age. They will be covered up until the last day of their birthday month. At that time, they will be offered COBRA.

What is COBRA (Consolidated Omnibus Budget Reconciliation Act)?

The Consolidated Omnibus Budget Reconciliation Act (COBRA) health benefit provisions amend the Employee Retirement Income Security Act, the Internal Revenue Code and the Public Health Service Act to require group health plans to provide a temporary continuation of group health coverage that otherwise might be terminated.

Where do I get COBRA information from?

COBRA is administered by A.U.S.D. All enrollment and payments should be directed to the Risk Management Department (626) 943-6585. Typically, upon a qualifying event, COBRA information is generated and mailed to your home address on file.

What is considered a COBRA qualifying event?

The qualifying events for employees are:

◦ Voluntary or involuntary termination of employment for reasons other than gross misconduct

◦ Reduction in the number of hours of employment

The qualifying events for spouses are:

◦ Voluntary or involuntary termination of the covered employee's employment for any reason other than gross misconduct

◦ Reduction in the hours worked by the covered employee

◦ Covered employee's becoming entitled to Medicare

◦ Divorce or legal separation of the covered employee

◦ Death of the covered employee

The qualifying events for dependent children are the same as for the spouse with one addition:

◦ Loss of dependent child status under the plan rules

I've recently changed my legal name and/or address. How do I get ID cards with my new name or update my address with carriers?

In order to change your name or address with health benefit carriers, you must first contact Human Resources at (626) 943-3060 and have them update your information within their department . Once this is done, you may request a name change with Risk Management and a request for new ID cards with your new name will be requested.

I have Blue Shield, is the SHINGLES VACCINE covered?

Yes, the shingles vaccine is covered at 100%, however there are age restrictions. You may obtain the vaccine at a doctors office and they will submit the claim on your behalf. If you use a pharmacy, you'll have to pay for the vaccine up-front and submit proof of payment to Risk Management. We will transmit this information to Blue Shield who will process a reimbursement check to the member.

I have Kaiser Permanente, is the SHINGLES VACCINE covered?

Yes, the shingles vaccination is covered under the immunization benefit, or it can be given during a doctor visit. however there are age restrictions

What is the Co-Pay for Blue Shield?

There are very few services requiring a copay on Blue Shield, such as: Hearing Aids, ER Visits (without overnight stay) and Out of Network Providers.

Does Kaiser cover durable goods such as wheel chairs?

Kaiser Permanente offers limited base-covered items in accordance with formulary guidelines. Click to see list (insert link). Prior-Authorization is required.

Do our plans cover breast pumps?

Yes. A prescription from your physician is required.

When can I Add or Drop a Dependent/Spouse?

You may add or drop a dependent within 30 days of a qualifying event (such as marriage, domestic partner registration, divorce, death, birth, adoption, or court order). The effective date of your dependent’s coverage will be retroactive to the date of the qualifying event, provided that your health benefits application and appropriate supporting documentation was submitted within the 30-day enrollment period.

My husband recently lost coverage through his employer. Can I add him to my insurance?

Yes. You may add your spouse to health benefits, as long as health benefits enrollments forms and appropriate supporting documentation is submitted within 30 days from the day your spouse suffered loss of coverage. Proof of loss of coverage will be required.

Are hearing aids covered under Kaiser and Blue Shield?

Hearing aids are covered as follows:

◦ Blue Shield - Covered every 3 years, at 80%. Payment not to exceed $2,500 for each hearing aids.

◦ Kaiser Permanente - Covered every 36 months. Payment not to exceed $1,000 for each hearing aid. Any amount exceeding $1,000 per hearing aid, will be members responsibility.

When can I change plans?

You may change plans/carriers during the Open Enrollment period in the Fall, with coverage effective November 1st.

Is chiropractic or acupuncture covered?

Chiropractic and acupuncture is covered by Blue Shield only. Kaiser Permanente does not cover either service.

What is the maximum benefit for dental?

◦ Delta Dental Premier or Enhanced - $2,000 annual limit per each Calendar year.

◦ DeltaCare HMO - No maximum annual limit on this plan.

Are braces covered under my plan?

Orthodontia is covered under DeltaCare HMO only. Please refer to the Summary of Benefits for specific copay and coverage information (insert DeltaCare Link). Delta Premier and Delta Enhanced does NOT cover any Orthodontia related services.

I am turning 65, and still employed. Am I required to sign up for medicare?

If you are still actively employed and enrolled in a District medical plan, you may postpone Medicare enrollment until retirement.

What are the benefits of using generic prescriptions if I have Blue Shield?

The biggest advantage is the price to the District. Generics average 40% to 60% less than brand name drugs. Ask your physician or pharmacist if it's possible to fill your prescription with a generic instead.

How do I appeal a claim?

If you disagree with a determination of a claim and/or payment, you may file a Grievance by completing and submitting corresponding form below:

◦ Blue Shield - Forms

◦ Kaiser Permanente - Forms

I received a bill from my ER doctor because he was out of the Blue Shield network, but the hospital I was admitted to was in network. Am I responsible for this bill?

In this situation, you may file a grievance with Blue Shield (see “forms” tab to download”). Blue Shield will make a determination within 30 days of when the grievance is received. In most circumstances, the ER doctor will be paid in full and you will not be liable for the bill. It is important all event details are included when filing your grievance. You should include supporting documentation from the ER physician, ER admit/release order, EOB’s, bills, etc.

How do I order ID cards?

Blue Shield - Contact Customer Service (855) 256-9404

Kaiser Permanente - Contact Member Services (866) 752-4737

DeltaCare U.S.A - Contact Member Services (800) 422-4234

Delta Dental Premier - Contact Customer Service (866) 499-3001

Delta Dental Enhanced - Log on to website to print ID cards: www.deltadentalins.com

Vision Service Plan (VSP) - No ID Card Required to obtain Services. Give provider your last name and/or last 4 of your social security number.

Can my dependent parents be covered by my benefit plans?

No. Even if totally dependent on the employee, parents are not eligible for coverage.