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The District and the Association are committed to maintaining a quality health and welfare benefits program for all employees. The parties agree to a good faith effort and commitment to maintain a program which is comprehensive and cost-effective. |
13.1 |
Medical Plans |
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13.1a |
The District shall provide full-time employees and eligible dependents, including spouses and domestic partners with a medical services insurance plan. The employee shall have a choice from among no less than three (3) plans (Fee for Service, Exclusive Provider Organization, Health Maintenance Organization) provided by the District.
Plans will provide benefits as outlined in the following schedule to be administered as set forth in the Summary Plan Descriptions.
SCHEDULE OF BENEFITS
Medical Pans |
A. |
Fee for Service |
1. |
Plan Deductible |
$300-One person
$600-Two people
$900-Three or more people
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2. |
Plan Co-Pays |
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a. Doctor Visits |
$25 per visit |
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b. Drugs |
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– Tier I Most generic and selected over the-counter |
$5 |
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– Tier II Brand name without generic equivalent and selected generic |
$10 |
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– Tier III Selected medications within each therapeutic class |
$35 |
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– Emergency Room Co-Pay |
$100
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3. |
Plan Co-Insurance
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a. Preferred Provider (PPO) |
80%/20% |
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b. Non-PPO Provider |
70%/30%
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4. |
Out-of-Pocket Cap |
$2,500 in-network to $3,500 out-of-network range
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5. |
Benefits Subject to Inside Limits
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a. Accident: |
100% of first $500, $500 per case |
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b. Inpatient Mental |
60 days per calendar year |
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c. Outpatient Mental @ 50% |
Up to 50 visits per year |
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d. Plan Cap* |
$600 per day maximum per non-PPO inpatient/outpatient hospital and/or freestanding surgical center admission |
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e. Routine Preventative Procedures-(adults only) |
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f. Hospice Care |
60 day maximum
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B. |
Exclusive Provider Organization (EPO Only) |
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1a.EPO/HMO Plan Deductible |
$300-One person
$600-Two people
$900-Three or more people |
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1b. EPO Plan |
In Network pays 100%
Out of Network - Plan pays 0% |
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1c. Out-of-Pocket Max: |
$2500 for an individual I $7500 for a family in network (there is not an out-of-pocket maximum for out of network providers/services). |
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Health Maintenance Organization (HMO)/Exclusive Provider Organization (EPO) |
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Hospital Care Medical/Surgical |
100% |
3. |
Outpatient Care-Medical Surgical |
100% |
4. |
Plan Co-Pays |
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a. Doctor Visits |
$25 per visit |
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b. Emergency Room Treatment |
$100 per visit |
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c. Drugs |
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– Tier I Most generic and selected over-the counter |
$5 (EPO) |
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Tier II Brand name without generic equivalent and selected generic |
$10 (EPO) |
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– Tier III Selected medications within each therapeutic class |
$35 (EPO) |
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HMO – as per plan contract |
C. |
Effective with the 2019 Plan Year, the District will provide Live Health On-Line |
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a. The Live Health Co-Pay shall be $15 |
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13.1b |
The District shall provide a medical services insurance plan for retiring employees to age 65 and for disabled employees, age 50 or older. The retiring or disabled employee shall have a choice from the plans provided by the District. The retiring employee must have served at least ten (10) years and have retired from the District as defined in Education Code Section 22148. The disabled employee must have served fifteen (15) years in the District. A District approved leave shall constitute a year of service for the purpose of eligibility for this benefit.
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13.1c |
The District shall provide medical insurance for the spouse or domestic partner of an employee who qualifies for the provisions in 13.1b.
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13.1d |
Pre-authorization is required in the fee-for-service medical plan for outpatient services as indicated in the Summary Plan Description.
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13.1e |
Mail Order Prescriptions: One co-pay is required for each month's prescription drugs
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13.1f |
The District will provide employees access to an 800 number for medical questions.
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13.1g |
The medical and dental fee-for-service plans will include a third party recovery clause for all employees and a pre-existing condition clause in the medical plan for new hires.
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13.2 |
Dental Plans
The District shall provide full-time employees and eligible dependents, including spouses and domestic partners with a dental services insurance plan. The employee shall have a choice from between two (2) plans (Fee for Service and Pre-Paid) provided by the District.
The plans will provide benefits as outlined in the following schedule to be administered as set forth in the Summary Plan Descriptions
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SCHEDULE OF BENEFITS
Dental Pans |
A. |
Fee-for-Service Dental |
1. |
Dental |
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a. Plan Maximum
b. Plan Deductible
c. Co-insurance |
$2000 per calendar year
$25 per calendar year
90%/10% |
2. |
Orthodontia |
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a. Plan Maximum Payment up to:
b.
Co-Insurance |
$2800 Lifetime
50%/50% |
B. |
Pre-Paid Dental |
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1. |
Dental |
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a. Preventative Procedures Co-Pay
b. Restorative Dentistry Co-Pay
c. Crowns/Bridges Co-Pay (gold excluded) |
-0-
-0-
-0- |
2. |
Orthodontia (banding only) |
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a. Co-Payment
b. Co-Payment |
$1500 up to age 23
$2000 age 23 and above
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13.3 |
Vison Plan
The District shall provide full-time employees and eligible dependents, including spouses and domestic partners with a vision insurance plan. The plan shall be special "Plan B" of California Vision Services, or its equivalent, except that tinted or photo-chromatic lenses shall be covered by the plan. The plan will provide as outlined in the following schedule, to be administered as set forth in the Summary Plan Description.
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SCHEDULE OF BENEFITS
Vision Plan |
A. |
Frequency of Services |
1. |
Examinations |
12 Months |
2. |
Lens and contacts |
12 Months |
3. |
Frames |
24 Months |
B. |
Deductible |
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1. |
Examinations/Lens/Frames |
$25 |
2. |
Cosmetic Contacts |
$50 |
C. |
Special Provisions |
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1. |
Cosmetic Contacts |
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2. |
Tints |
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3. |
Non-Panel Doctor Reimbursement |
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4. |
Co-pay of one half of the cost of glasses or contacts if obtaining both in the same 12 months. |
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13.4 |
Life Insurance
The district shall provide all eligible employees with a $50,000 term life insurance policy, to include a provision for dependent life coverage and an age reduction schedule complying with Age Discrimination Act regulations.
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13.5 |
Limitation of Benefits
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13.5a |
All health and welfare benefits shall be maintained and premium increases shall be paid by the District for the duration of this contract.
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13.5b |
Effective with the September 2010 payroll, in order to receive the medical, dental, and vision benefits package described in Sections 13.1a, 13.2, and 13.3, all eligible employees enrolled in the group health program shall make a tenthly payroll deduction contribution based upon the following schedule:
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13.5c |
Effective September 1, 2010, an employee who is eligible to receive the medical benefits described in Sections 13.1b and 13.1c shall make a yearly contribution based on the following schedule:
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13.6 |
Duration of Benefits
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13.6a |
The benefits provided in this Article shall remain in effect during the term of this Agreement.
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13.6b |
The Association shall be consulted before any change in carriers or administrators of the health and welfare benefits plan is made.
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13.6c |
Full-time employees who are absent on account of illness and who have exhausted their accumulated sick leave shall continue to receive full health and welfare benefits paid by the District for six (6) months from the first day of the month following the last day worked, or until exhaustion of all paid leaves, whichever is longer.
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13.6d |
Employees on District-approved leaves of absence without pay shall be given the option of converting to a health and welfare benefit plan for the period of the leave, at the employee's expense.
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13.6e |
An employee who has been actively employed on a regular full-time basis through June 30 of any school year will have continuous coverage until October of that year, unless the employee subsequently gives notice of intent to terminate, in which case coverage ends on the first day of the month following.
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13.7 |
Miscellaneous
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13.7a |
Each employee in the bargaining unit shall receive from the District a full explanation of all health and welfare benefits - including carriers, coverage, and other pertinent information.
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13.7b |
Examinations for tuberculosis will be required every four years. The examination Apr be either an x-ray, a skin test, or questionnaire. The District shall arrange and pay for these tests.
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13.7c |
Employees will be provided the opportunity annually to change health plans during a 30-day open enrollment period.
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13.7d |
Employees will be provided the opportunity to terminate coverage for themselves, or any eligible family member, the first of the month following the submission of a written request to cancel coverage. The enrollment of eligible employees and family members will be in accordance with the Summary Plan Description and shall include the following:
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First of the month following the elected change during the thirty (30) day annual open enrollment period.
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For new spouse or domestic partner, the first of the month following date of marriage or domestic partnership
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Newborns coverage from date of birth.
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An employee, spouse, or domestic partner, or child with coverage outside of the District whose coverage was terminated as a result of the spouse's/domestic partner's termination of employment could be enrolled the first of the month following the date of termination of benefits.
Change requests for items 2, 3, and 4 are to be submitted in writing within thirty (30) days of the date of marriage, domestic partnership, birth, or termination of benefits. |
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13.7e |
The District and the Association agree to participate in an ongoing study, analysis, and education program in health benefits. At least four insurance newsletters shall be prepared and distributed to all employees each school year.
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13.8 |
The District shall provide for employee participation in the Medicare program to begin within the last quarter of the 1991 calendar year.
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