FAQs for Health Plans

If I change medical options from the Blue Shield PPO to the Blue Shield PPO+ HSA will my deductible start over for 2016?

No, Blue Shield will honor the deductible and out-of-pocket maximum satisfied under the PPO if you enroll in the PPO+ HSA.

If the deductible or a portion of it is met in the last quarter of the year will those expenses apply toward the following year’s deductible?

No, you must meet a new deductible every calendar year.

What is preventive care?

Allowable expenses, also known as preventive care, fall under section 502 of the IRS Code.  Most descriptions of preventive care can be found at Department of Managed Health Care and HealthCare.gov.  A Blue Shield resource of preventive care can also be found at Preventive Health Care Overview.

Do benefits for Durable Medical Equipment under both the PPO and PPO+ plans apply to the deductible and out-of-pocket maximum?

The Durable Medical Equipment benefit under both PPO plans is first subject to the deductible. Once the deductible is met, the member is liable for the coinsurance amounts and it will apply towards the out-of-pocket maximum.

Will I receive my new insurance ID card by the beginning of the new plan year on June 1st? If not, will this affect my ability to access benefits?

Every attempt will be made to ensure that your new ID cards will be delivered by June 1st. However, if you do not receive your card by that date, you may continue to access benefits. Since your information has been sent to the carriers, your information is on file and your health care providers will be able to verify your coverage.

Can my dependents enroll in a different plan than the one I select for myself?

No, if you are enrolling your dependents, they must enroll in whichever plan you have selected for yourself.

How long may my dependent children remain on my benefits plans?

Dependents are covered until the end of the month in which they turn age 26.

What is a Qualifying Event?

A qualifying event is a change in your or your dependent's personal lives which may allow you to add, change or terminate some of your benefit elections. If you have experienced a qualifying event, you must notify us within thirty (30) days of the qualifying event date in order to make a change to your benefits. If the thirty (30) days have passed, you must wait until the next open enrollment period to make the change. Some examples of qualifying events are:

  • Change in your marital or domestic partner status, including marriage or meeting the six (6) month requirement for domestic partnership, death of spouse/domestic partner, divorce or dissolution of partnership, legal separation, or annulment.
  • Change in the number of your dependents, including a change due to birth, adoption, or loss of dependent status (e.g., a child reaches the age limit under the plan, at the end of the month in which they turn age 26, or is no longer eligible as a dependent).
  • Change in your employment status, including a beginning or termination of employment, beginning or returning from an unpaid leave of absence, sabbatical, and a change to/from part-time employment.
  • Change in your spouse/domestic partner or dependent's employment status, causing a gain or loss of health coverage for you or your dependent. Some examples are beginning or ending employment, increasing or decreasing hours, strike or lockout.
  • Changes associated with your spouse/domestic partner's open enrollment period, including changes in the type and cost of their coverage like a gain or loss of eligibility for you, your spouse/domestic partner, or your dependents.
How do I make changes to my benefits if I experience a qualifying event?

Please notify Human Resources of the change; you will be asked to complete the appropriate enrollment forms. The information on the form will replace any previous enrollment form submitted by you. Your form is not complete until the printed and signed version has been received by Human Resources within thirty (30) days of the qualifying event date. You will also need to provide the required documentation for your qualifying event in order for the change to be effective. We will accept a letter with the effective date from the new/former insurance company or another new/former HR department.

Please contact us for more information about qualifying events, as this list is not inclusive of all qualified change in status events.

What is the plan year for Cal Lutheran's benefits plans and when do my calendar year deductibles and annual out of pocket maximums renew?

The Cal Lutheran medical, dental, vision, life, accidental death and dismemberment (AD&D) and long-term disability (LTD) plans operates on the June 1st through May 31st plan year. However, for the purposes of deductibles and annual out of pocket maximums, these plans operate on a calendar year. That means that every January you must meet your deductible again.

How/when can I add or drop health/dental/vision insurance coverage?

Generally, you can only add or drop health, dental and/or vision insurance coverage during our plans' open enrollment period, which is from April to May each year for a June 1st effective date. However, if a change in your or your spouse's employment or a change of family status occurs, such as marriage, divorce, birth, or death, then coverage may be added or dropped during the plan year provided the request is made within 30 days of the change and provided the appropriate paperwork is received from you.

Is my doctor/dentist participating in our healthcare/dental plans?

You can check if your doctor and/or dentist is participating in our plans by either looking in the plan's provider directory which is available on-line (links available on the Employee Benefits page). Since doctors may change participation, it is also a good idea to ask the doctors/dentist office when scheduling your appointment whether or not they are a "preferred provider" in your medical, dental or vision plan.

When is open enrollment for benefits?

Annual Open Enrollment for benefits is from April to May for a June 1st to May 31st plan year. Annual Open Enrollment for the Flexible Spending Account will be in November for January to December plan year.

Do our medical insurance plans have restrictions for pre-existing conditions?

Cal Lutheran's Kaiser and Blue Shield HMO medical plans do not have any restrictions for pre-existing conditions.

The Blue Shield PPO plan does exclude pre-existing conditions. Pre-existing conditions are covered only after you have been continuously covered for six (6) consecutive months including Cal Lutheran's waiting period (if any). The pre-existing condition exclusion does not apply to:

  • Pregnancy benefits;
  • Newborns or adopted children who had prior creditable coverage within thirty (30 days of their birth, adoption, or placement for adoption and who enrolled in one of the Blue Shield of California plans within sixty-three (63) days of that prior creditable coverage (excluding any waiting period);
  • Employees and dependents who were validly covered under the present employer's previous group health coverage when that coverage was terminated and who are enrolled on the original effective date of the Blue Shield of California plan within 60 days of the termination of that previous coverage.

To get credit for any creditable coverage, obtain a "Certificate of Creditable Coverage" from your prior employer, insurer or health plan and submit the certificate to Blue Shield of California.

What's the primary difference between the PPO and the HMO?

A Health Maintenance Organization (HMO) only provides care from a network of physicians and hospitals which is authorized in advance by an individual's primary care physician. We currently offer two HMO options, Kaiser HMO and Blue Shield HMO.

A Participating Provider Organization (PPO) is a network of physician and hospital providers offered by Blue Shield to PPO members. These providers have agreed to accept the Blue Shield payment schedule as payment in full for covered services. PPO benefits are higher when provided by a PPO provider than by a non-PPO provider.

What is an Health Savings Account (HSA)?

A health savings account (HSA) is a tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a high-deductible health plan (HDHP). The funds contributed to an account are not subject to federal income tax at the time of deposit.

What is the Mail Service Prescription Drug Program?

In addition to purchasing prescriptions from your local pharmacy, when you are part of Blue Shield HMO or PPO you may order maintenance medications via the mail. It's easy to do! Send in the PrimeMail form along with an original prescription and you will receive a ninety (90) day supply for the cost of two months. It generally takes ten (10) days from the time your prescription is sent in, to your receipt in the mail. Refills or questions about an order are done via phone 866-346-7200 or visiting their website, www.MyPrimeMail.com. Human Resources can provide you with the PrimeMail Order Form.

When does my coverage end after I leave employment at Cal Lutheran?

Coverage ends at 11:59 p.m. on the last night of the month in which your employment with Cal Lutheran terminates. For example, if your end date is June 15th, your coverage ends June 30th at 11:59 p.m.

 How do I find out more about Cal Lutheran benefits?

Contact the Human Resources department with additional questions regarding your Health and Welfare benefits, Workers' Compensation and 403(b) retirement plans. Call extension 3185 or 3177 for more information.

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