Benefit Forms, Plan Documents and Important Information

Employee Benefit Enrollment/Change Form

FSA Enrollment Form

Supplemental Life Enrollment/Change Form

Life Insurance Beneficiary Form

Life Insurance Beneficiary Form - Spousal Consent, as applicable

Staff Development Reimbursement eForm

P&A Group Health Reimbursement Arrangement (HRA) Form

Domestic Partner Affidavit (SEIU only)

Extra Help Benefit Enrollment/Change Form

Retiree Benefit Enrollment/Change Form

Retiree Benefit Enrollment/Change Form (plan year 2024-2025)

Retiree HRA Premium Reimbursement Auto-Pay Request Form

Kaiser Permanente Senior Advantage Enrollment Form

Kaiser Permanente Senior Advantage Disenrollment Form

Western Health Advantage MyCare Enrollment Form

Life Insurance Beneficiary Form

Life Insurance Beneficiary Form - Spousal Consent, as applicable

Anthem Medicare Advantage and Part D - Medicare Retirees Only

Anthem Medicare Preferred (PPO) Medical and Prescription Drug

County Health Plan (CHP)

County Health Plan (CHP) EPO

County Health Plan (CHP) PPO

Kaiser Permanente

Northern California - Employees and Retirees

Kaiser Permanente Traditional HMO

Kaiser Permanente Hospital Services HDMO

Kaiser Permanente Deductible First HDHP

Kaiser Permanente Traditional HMO - Retiree

Kaiser Permanente Hospital Services DHMO - Retiree

Kaiser Permanente Deductible First HDHP - Retiree

Hawaii - Retirees Only

Kaiser Permanente Hawaii - Retiree

Northwest - Retirees Only

Kaiser Permanente Northwest - Retiree

Sutter Health Plus

Sutter Health Plus Traditional HMO

Sutter Health Plus Hospital Services HDMO

Sutter Health Plus Deductible First HDHP

Western Health Advantage

Western Health Advantage Traditional HMO

Western Health Advantage Hospital Services HDMO

Western Health Advantage Deductible First HDHP - Self only

Western Health Advantage Deductible First HDHP - Family

Anthem Medicare Advanage and Part D - Medicare Retirees Only

Anthem Medicare Preferred (PPO) Medical and Prescription Drug

Kaiser Permanente

Northern California - Employees and Retirees

Kaiser Permanente Traditional HMO

Kaiser Permanente Hospital Services HDMO

Kaiser Permanente Deductible First HDHP

Kaiser Permanente Senior Advantage

Hawaii - Retirees Only

Kaiser Permanente Hawaii Traditional HMO

Kaiser Permanente Hawaii Senior Advantage

Northwest - Retirees Only

Kaiser Permanente Northwest Traditional HMO

Sutter Health Plus

Sutter Health Plus Traditional HMO

Sutter Health Plus Hospital Services HDMO

Sutter Health Plus Deductible First HDHP

Western Health Advantage

Western Health Advantage

Delta Dental

Delta Dental - Employees

Delta Dental - Retiree PPO

Delta Dental - Retiree DeltaCare USA

VSP

Vision Service Plan (VSP)

Full Time Employees

UHC Life Class 2 - DSA

UHC Life Class 3 - Salary Resolution Confidential, Law Library Non-Management

UHC Life Class 4 - Salary Resolution Admin Management, Board of Supervisors, Department and Agency Heads, DSLEM, SCDPDAA, SCLEMA, SCPA, SCTA Management, Law Library Management

UHC Life Class 5 - Local 39, SEIU, SCLEA, SCPDIA

UHC Life Class 7 - ESC

UHC Life Class 10 - WCE

UHC Life Class 11 - Salary Resolution Unrepresented, SCTA Non-Management

Part Time Employees

UHC Life Class 6 - SCLEA

UHC Life Class 8 - ESC

UHC Life Class 9 - DSA

Retirees

UHC Life Class Retiree

If you or your eligible dependents are currently Medicare eligible, or will become Medicare eligible during the next 12 months, you need to be sure that you understand whether the prescription drug coverage that you elect under the County-sponsored medical plans is or is not creditable with (as valuable as) Medicare’s prescription drug coverage.

To find out whether the prescription drug coverage under the medical plan options offered by the County are or are not creditable you should review the Plan’s Medicare Part D Notice of Creditable Coverage below.

Important Notice from the County of Sonoma about your prescription drug coverage and Medicare - Your Medicare Part D Notice

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with the County of Sonoma and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. County of Sonoma has determined that the prescription drug coverage offered by the County sponsored medical plans are, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage.

**Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.**

When Can You Join A Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?

As an employee, if you decide to join a Medicare drug plan, your current active employee County of Sonoma coverage will not be affected. As a retiree, if you decide to join a Medicare drug plan, your current retiree County of Sonoma coverage will be affected. For further information on how your coverage will be affected, please contact your benefit office or CareCounsel at the number below.
If you do decide to join a Medicare drug plan and drop your current County of Sonoma coverage, be aware that you and your dependents will not be able to get this coverage back.

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?

You should also know that if you drop or lose your current coverage with the County of Sonoma and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For More Information about This Notice or Your Current Prescription Drug Coverage…

See contact information below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through the County of Sonoma changes. You also may request a copy of this notice at any time.

For more information about Medicare prescription drug coverage:

• Visit www.medicare.gov
• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help
• Call (800) MEDICARE ((800) 633-4227). TTY users should call (877) 486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov or call them at (800) 772-1213 (TTY (800) 325-0778).

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).

Date: March 1, 2022
Name of Entity/Sender: County of Sonoma
Contact—Position/Office: Human Resources Benefits Unit
Address: 575 Administration Dr., Suite 116B, Santa Rosa, CA 95403
Phone Number: (707) 565-2900 or benefits@sonoma-county.org

Health Insurance Counseling and Advocacy Program (HICAP): (800) 434-0222
Healthcare Advocacy, CareCounsel: (888) 227-3334

The Women’s Health and Cancer Rights Act of 1998 (WHCRA) requires group health plans that provide coverage for mastectomies to also provide coverage for reconstructive surgery and prostheses following mastectomies.

Because the group health plans offered by the County provide coverage for mastectomies, WHCRA applies to your plan. For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient for:

1. All stages of reconstruction of the breast on which the mastectomy has been performed
2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
3. Prosthesis; and
4. Treatment of physical complications of all stages of mastectomy, including lymphedemas.

This coverage will be subject to the same annual deductible, coinsurance and/or copay provisions otherwise applicable to medical and surgical services under the policy/plan.

If you have questions about this Notice, contact HR Benefits Unit at (707) 565-2900 or benefits@sonoma-county.org.

Hospital Length of Stay for Childbirth:

Under federal law, group health plans, like this Plan, (including medical plans sponsored by the County) generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or the newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, the Plan may pay for a shorter stay if the attending Physician (e.g., Physician, or Health Care Practitioner), after consultation with the mother, discharges the mother or newborn earlier.

Also, under federal law, plans may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, the Plan may not, under federal law, require that a Physician or other Health Care Practitioner obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain precertification. For information on precertification for a length of stay longer than 48 hours for vaginal birth or 96 hours for C-section, contact your plan provider to precertify the extended stay. If you have questions about this Notice, contact HR Benefits Unit at (707) 565-2900 or benefits@sonoma-county.org.

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in a County-sponsored plan if you or your dependents lose eligibility for that other coverage (or if your employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 31 days after your or your dependents’ other coverage ends (or after the employer stops contributing towards the other coverage).

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption. You and your dependents may also enroll in this plan if you (or your dependents):

• Have coverage through Medicaid or a State Children’s Health Insurance Program (CHIP) and you (or your dependents) lose eligibility for that coverage. However, you must request enrollment within 60 days after the Medicaid or CHIP coverage ends.
• Become eligible for a premium assistance program through Medicaid or CHIP. However, you must request enrollment within 60 days after you (or your dependents) are determined to be eligible for such assistance.

To request special enrollment or obtain more information, contact HR Benefits Unit at (707) 565-2900 or benefits@sonoma-county.org.

If you are in a benefits-eligible position and choose not to be covered by one of County of Sonoma’s medical plan options, remember that you must maintain medical plan coverage elsewhere or you can purchase health insurance through a Marketplace (www.healthcare.gov), typically at the Marketplace annual enrollment in the fall each year.

Note that, if you are a resident in certain states, including California, you may be subject to a state income tax penalty if you fail to maintain medical plan coverage that meets that state’s minimum coverage requirements. Consult with your own state’s insurance department for information on whether you state has adopted or will be adopting a state individual Mandate penalty.

If you choose to not be covered by a medical plan sponsored by County of Sonoma at this enrollment time, your next opportunity to enroll for County of Sonoma’s medical plan coverage is at the next annual open enrollment time, unless you have a mid-year change event that allows you to add coverage in the middle of County of Sonoma’s plan year.

Under the Affordable Care Act, starting in early 2016, employers (and in some cases insurance companies) are required to provide full-time employees, as well as other employees enrolled in a medical plan, with IRS Form 1095C. It will be provided to you on or by March 3, 2023.

For each month of 2022 that you were enrolled in a medical plan, this 1095C form documents that you (and any enrolled family members) met the federal requirement to have “minimum essential coverage or MEC,” meaning group medical plan coverage.

If you receive a 1095C form, you do not need to attach the form to your personal income tax return or wait to receive the form before filling your tax return. If you receive a form this year, you should keep it in a safe place with your other tax records because you may need to produce it if requested by the IRS. (For large employers, a copy of the form 1095C will also be provided to the IRS.)

Designation of a Primary Care Provider (PCP):

The Kaiser, Sutter, and Western Health Advantage medical plan generally requires the designation of a primary care provider (PCP). You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members. Until you make this designation, the health insurance company designates one for you. For children, you may designate a pediatrician as the primary care provider. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact the health insurance company at the number provided on page 49.

Direct Access to OB/GYN Providers:

You do not need prior authorization (pre-approval) from Kaiser, Sutter, Western Health Advantage, Anthem or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological (OB/GYN) care from an in-network health care professional who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the health plan carrier at the phone number or website address provided on page 49.

YOU ARE REQUIRED TO PROVIDE TIMELY NOTICE

You or your Dependents must promptly furnish to the County’s HR Benefits Unit information regarding change of name, address, marriage, divorce or legal separation, change in Domestic Partnership status, death of any covered family member, birth or change in status of a Dependent Child, Medicare enrollment or disenrollment, an individual meets the termination provisions of the Plan, or the existence of other coverage. Proof of legal documentation will be required for certain changes.

Notify the Plan preferably within 31 days, but no later than 60 days, after any of the above noted events.

Failure to give the County a timely notice of the above noted events may:

• Cause you, your Spouse and/or Dependent Child(ren) to lose the right to obtain COBRA Continuation Coverage,
• Cause the coverage of a Dependent Child to end when it otherwise might continue because of a disability,
• Cause claims to not be able to be considered for payment until eligibility issues have been resolved,
• Result in your liability to repay the Plan if any benefits are paid to an ineligible person. The Plan has the right to offset the amounts paid against the participant’s future [medical, dental, and/or vision] benefits.

In accordance with the requirements in the Affordable Care Act, your employer will not retroactively cancel coverage (a rescission) except when premiums are not timely paid, or in cases when an individual performs an act, practice or omission that constitutes fraud, or makes an intentional misrepresentation of material fact that is prohibited by the terms of the Plan. Keeping an ineligible dependent enrolled (for example, an ex-spouse, overage dependent child, etc.) is considered fraud. If you have questions about eligibility contact HR Benefits Unit at (707) 565-2900 or benefits@sonoma-county.org.

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have the following protections:

You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

Your health plan generally must:

• Cover emergency services without requiring you to get approval for services in advance (prior authorization).
• Cover emergency services by out-of-network providers.
• Base what you owe the provider or facility (cost-sharing) on what it would pay an in network provider or facility and show that amount in your explanation of benefits.
• Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact CMS No Surprises Helpdesk at 1-800-985-3059.

Visit https://www.cms.gov/nosurprises for more information about your rights under federal law.

Family Care & Medical Leave & Pregnancy Disability Leave

Your Rights Under USERRA - The Uniformed Services Employment and Reemployment Rights Act

New Health Insurance Marketplace Coverage Options and Your Health Coverage

Premium Assistance Under Medicaid and the Children's Health Insurance Program (CHIP)