2 0 1 4 - 2 0 1 5 EMPLOYEE BENEFITS GUIDE

MEDICAL PRESCRIPTION LIFE LONG TERM

CARE 2 0 1 4 - 2 0 1 5 EMPLOYEE BENEFITS GUIDE

MEDICAL PRESCRIPTION LIFE LONG TERM CARE

“Working Together to Make a Difference”

Imperial Valley College

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welcome. The Imperial County Schools Voluntary Employees Benefits Association (ICSVEBA) is a group of school districts, joined

to form a benefit purchasing pool to ensure the best benefits options for employees of these school districts.

Your District believes providing a competitive employee benefits program is one of the most important investments.

We appreciate the tremendous value and contributions of employees and recognize that good employee health is

good business. Each year the benefit programs are evaluated to ensure those covered in the ICSVEBA benefits

continue to have robust, competitive and cost-effective choices.

This guide has been prepared to assist you in making informed decisions regarding your benefits. We are happy to

offer a benefits package with a variety of coverage options which allow you to choose the option that best meets

your needs. We encourage you to read this guide carefully and to keep it as a reference.

Please contact the ICSVEBA Service Center at 800.633.2683 should you have any questions regarding your benefits

package.

contents. 03 Benefits

04 Costs

05 Eligibility

06 Medical

09 EAP

10 Value Added Services

11 Prescription

12 Life Insurance

13 Long Term Care

14 Notices

18 Service Center

Back Contacts

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benefits. BENEFIT COVERAGE OPTIONS

COSTS SHARED BY YOU AND YOUR EMPLOYER

MEDICAL Anthem Blue Cross & SIMNSA

Anthem Blue Cross Comprehensive Option Anthem Blue Cross Basic Option SIMNSA HMO Option

100% OF COSTS PAID BY YOUR EMPLOYER

BASIC LIFE AND AD&D Symetra Life

Benefit equal to a flat $50,000 for employee coverage and $2,500 for dependents

MENTAL HEALTH AND EMPLOYEE ASSISTANCE PROGRAM (EAP) The Holman Group

Offers private sessions at a copay based on your medical option

100% OF COSTS PAID BY YOU

VOLUNTARY LIFE Symetra Life

Employee and Spouse: additional coverage up to $500,000 Child(ren): additional coverage up to $10,000

LONG-TERM CARE Unum

Up to $6,000 per month for you, your spouse, parent or grandparent

Choose Carefully! The benefits you select during enrollment will stay in place through September 30, 2015 unless you have a qualifying event as defined by the IRS.

Examples of a qualifying event include:

You have a change in your marital status

You have a baby or adopt a child (Plan allows 60 days to notify of a newborn)

Your dependent child loses eligibility due to age or marriage

You become disabled

You end your employment with the District

You or your dependent passes away

Your spouse/domestic partner gains or loses coverage

You must notify your employer within 31 days of the qualifying event. Benefits elections will then remain in force for the remainder of the plan period.

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costs.

2014 MONTHLY PREMIUMS (BEFORE YOUR DISTRICT CONTRIBUTION)

COMPREHENSIVE

Employee Only $751.88

Employee + Spouse $1,360.49

Employee + Child(ren) $1,192.20

Employee + Family $1,510.43

BASIC

Employee Only $631.95

Employee + Spouse $1,142.06

Employee + Child(ren) $1,000.78

Employee + Family $1,267.71

SIMNSA

Employee Only $253.82

Employee + Spouse $429.73

Employee + Child(ren) $485.08

Employee + Family $619.72

BASIC LIFE AND AD&D

Employee—$50,000 (100% Employer Paid) $8.50

Dependent Life: $2,500 (100% Employer Paid) $1.00

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eligibility. Who is Eligible You are eligible if you are a regular full-time employee and are working 30 hours or more per week. You may also enroll your eligible dependents in the medical, dental, vision and life insurance plans. Your eligible dependents include:

Your legal spouse

Any children for whom you are required to provide coverage under a Qualified Medical Child Support Order

Your adult children or stepchildren to age 26 regardless of marital or student status

Your unmarried children or step-children of any age, if they are incapable of self-care due to a physical or mental disability

When Coverage Begins Your benefits will commence on the first of the month following your date of hire.

Cost for Coverage As shown in the chart on page 4, your employer pays the full cost for Basic Life and AD&D and Mental Health/EAP insurance.

Contributions, for the plans where you share the cost with your employer are deducted from your pay on a pre-tax basis. This means that the income you use to pay for these benefits is not taxed, putting dollars back into your pocket.

Newly Hired Employees You must make your benefits elections within 31 days of your date of hire. If you do not enroll for coverage during your eligibility period, you must wait until the next open enrollment period unless you have a qualifying event.

Open Enrollment Open Enrollment occurs each year and is your opportunity to review your benefits options to determine what best meets your needs. The selections you make will remain in effect for the entire plan year unless you have a qualifying event.

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medical. We recognize that you have different needs when it comes to your medical options. We provide you with options

that help you and your family achieve optimum health. We offer you the choice of three health options, including:

Anthem Blue Cross Comprehensive Option (PPO)

Anthem Blue Cross Basic Option (PPO)

SIMNSA HMO Option

PPO Options PPO Options offer a network of physicians who have agreed to discount fees for their services. You may choose to

have your treatment provided by an in-network PPO physician and may receive a higher level of benefit with

potentially lower out-of-pocket costs to you.

You may also choose to go outside the network, however,

benefits are generally reimbursed at a lower level and

you may have higher out-of-pocket costs.

With a PPO option, you have a choice every time you need care. Your

in-network physicians will submit claims for you. If you receive

treatment from a non-network physician, they may require you to

pay the entire amount at the time of service and submit a claim for

reimbursement.

SIMNSA HMO Option

The SIMNSA HMO is an option for U.S. workers who reside, or have

dependents, in Mexico (Tijuana and Mexicali). This option offers

comprehensive medical coverage that includes preventive care and

fixed copays for most services. There are no annual deductibles or

lifetime dollar maximums. You will have the ability to choose your

own SIMNSA personal physician who will be responsible for providing

or coordinating all of your medical care, including specialty care

referrals.

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medical. BENEFITS

COMPREHENSIVE BASIC

IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK

Annual Deductible

Individual/Family $750/$2,250 $1,500/$4,500 $1,500/$4,500 $3,000/$9,000

Coinsurance 20% 50% 20% 50%

Out-of-Pocket Maximum (includes deductible)

Individual/Family $3,500/$10,500 $9,000/$27,000 $5,000/$15,000 $10,000/$30,000

Physician Services

Preventive Care Services No charge 50% after deductible No charge 50% after deductible

Office Visit - PCP/Specialist $30 / $60 copay 50% after deductible $35 / $70 copay 50% after deductible

Laboratory and X-Ray No charge 50% after deductible 20% after deductible 50% after deductible

Hospital Services

Inpatient $250 per admission + 20% after deductible

$250 per admission + 20% after deductible

Other Benefits

Emergency Room $250 copay

(waived if admitted) $250 copay

(waived if admitted)

Ambulance 20% after deductible 20% after deductible

Urgent Care $50 copay $50 copay

Mental Health and Employee Assistance Program Provided through The Holman Group, and “carved out” of your core benefits.

Annual Deductible $750/$2,250

In-Network Only

$1,500/$4,500

In-Network Only

Copayment $30 copay $35 copay

Maximums Acute Treatment AB88 Diagnoses Outpatient Inpatient

30 days/year

Unlimited

30 days/year

30 days/year

Unlimited

90 days/year

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medical. BENEFITS

SIMNSA

Stateside benefits only for life threatening medical emergencies

IN-NETWORK ONLY

Annual Deductible

Individual/Family None

Coinsurance None

Out-of-Pocket Maximum

Individual/Family None

Physician Services

Preventive Care Services No charge

Office Visit - PCP/Specialist $5 copay

Laboratory and X-Ray No charge

Hospital Services

Inpatient No charge

Other Benefits

Emergency Room $100 copay

Ambulance Not covered

Urgent Care $25 copay

Mental Health and Employee Assistance Program Provided through The Holman Group, and “carved out” of your core benefits.

Annual Deductible

EAP only

Copayment

Maximums Acute Treatment AB88 Diagnoses Outpatient Inpatient

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eap. Life is full of challenges and sometimes balancing it is difficult. We are proud to provide a program dedicated to

supporting the emotional health and well-being of our employees and their families.

Employee Assistance Program Administered by The Holman Group, the Employee Assistance Program (EAP) is a confidential program for you, your

family and all household members. The services are offered to you, at no cost.

EAP Benefit

Unlimited telephonic access

24-hour crisis response by licensed counselors, seven days a week

Each member of your household receives 5 in-person visits per issue per year

Confidential Clinical Counseling EAP benefits include up to five sessions per incident per calendar year and can help with such issues as:

Marital/relationship issues

Parenting issues

Substance abuse

Depression/anxiety

Anger

Stress management

Bereavement or grief

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value added services. DELTA TEAMCARE – Managing for Tomorrow® Managing for Tomorrow® is a unique health improvement program available to all eligible employees and their

dependents. It is being offered by Imperial County Schools Voluntary Employees Benefits Association (ICSVEBA), in

association with Delta Team Care. This program offers personalized health information and tools that are tailored to

your situation. You can learn about living a healthy lifestyle, managing your health, and working with your doctor to

stay healthy.

Disease Management - Maternity Management - Nurse Hotline

DELTA TEAMCARE – LivingWise

LivingWise is an impressive website that allows participants easy access to detailed (not personal) health information

and self -directed resources in a completely pop-up free environment. Visit www.deltahealthsystems.com and click

on the blue apple.

DELTA TEAMCARE – My ePHIT

Whether you want to lose weight permanently, build muscle, have more energy, become more optimistic, or just

simply get more enjoyment out of life, My ePHIT will help you. Utilizing the latest, most innovative web-technology,

our Personalized Health Improvement Training program takes into consideration your unique goals, lifestyle and

personal situations, and creates a customized plan exclusively for you.

Satori World Medical

Satori World Medical is a payor-supported, employer-sponsored , consumer-choice global healthcare network which

provides individuals, employers and payors with world-class healthcare, excellent client service and significant

financial benefit. Satori is the first global healthcare network specifically designed to deliver high quality healthcare

services, share the tremendous cost savings with plan sponsors and their employees and coordinate all medical

travel services for individuals who need care.

Typically the cost for a major surgical procedure is 40-80% less then that of the US, in international hospitals that

rival top US Institutions, staffed with equal or higher quality doctors, and with no-out-of pocket expense to the

patient.

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prescription. It is important to be an informed consumer, especially with your prescription drug options. All of your medical plan

options include prescription drug coverage through Express Scripts.

Present your medical plan ID card at a participating pharmacy. You will receive up to a 30-day supply for your

prescription. You will pay a copay based on the type of prescription you receive.

Save Money on Your Medications! You can save money by asking for generic drugs. The FDA requires that generic drugs have the same high quality,

strength, purity, and stability as brand-name drugs. The next time you need a prescription, ask your doctor to

prescribe a generic drug when it is available and appropriate.

BENEFITS COMPREHENSIVE BASIC SIMNSA

Generic $15 copay $15 copay $5

Preferred $35 copay $35 copay N/A

Non-Preferred $55 copay $55 copay N/A

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life insurance. Basic Life and AD&D

Symetra Basic Life and Accidental Death & Dismemberment (AD&D) insurance

coverage helps you protect your loved ones and ensures their financial security.

As a full-time, eligible employee, you are automatically enrolled in the Group Basic

Life and AD&D plan. The benefit is equal to a flat $50,000, with no medical

underwriting required. Your dependents are covered at a flat amount of $2,500

each. These policies are provided at no cost to you.

Imputed Income

The Internal Revenue Service (IRS) requires that your employer report the value of

any Company-paid life insurance coverage over $50,000 on your W-2. This value is

called imputed income and is subject to federal, state and Social Security taxes.

Voluntary Life

If you determine you need more than the Basic Life coverage provided to you, you

may want to purchase additional coverage for yourself and your eligible

dependents.

We offer Voluntary Employee, Spouse and Child Life, at group rates, to supplement

your employer-paid Basic Life Insurance. Unlike Basic Life Insurance, Voluntary Life

is 100% employee-paid. Voluntary Life premium is deducted from your paycheck

and is portable, allowing you to continue coverage should you ever leave the

company.

You may elect Voluntary Life coverage for yourself or your spouse to a maximum of

$500,000. You may also elect Voluntary Life coverage for your children to a

maximum of $10,000.

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long-term care. Help protect yourself, your parents and your family from the high cost of long-term care. Whether care is provided at

home or in a facility, the costs and caregiver challenges quickly add up. ICSVEBA partners with Unum to provide you

with valuable coverage, tools, and resources to help with your personal care challenges.

Long term care insurance may help reimburse covered charges for both facility and home care. With long term care

insurance you can:

Cover yourself and/or eligible family members

Stay in your home to receive care as long as possible

Relieve the burden of future care from loved ones

Newly hired employees have 30 days to enroll after becoming benefit eligible to receive reduced underwriting.

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legal notices. Wellness Amendment Your District may, from time to time, implement or adopt one or more wellness programs or disease management programs under this plan that offer you the opportunity to qualify for discounts on the cost of benefit options or other financial incentives if you and/or your eligible family members participate in the program or satisfy certain health standards. If Your District chooses to offer a wellness program or disease management program, its terms and conditions will be communicated to you and it will be administered in compliance with all applicable laws. If you or your family members choose not to participate, or stop or otherwise fail to qualify in one of these wellness or disease management programs, any adjustments will be automatically applied to the cost of your Benefit Options and to your salary reductions (if any) under our cafeteria plan. If it is unreasonably difficult due to a medical condition for you to achieve the standards for the reward under this program, or if it is medically inadvisable for you to attempt to achieve the standards for the reward under this program, call The ICSVEBA Service Center at 800.633.2683 to discuss another way to qualify for the reward. Special Open Enrollment Rights 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 this plan if you or your dependents lose eligibility for that other coverage (or if the 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 toward 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. Effective April 1, 2009, if either of the following two events occur, you will have 60 days from the date of the event to request enrollment in your employer’s plan: your dependents lose Medicaid or CHIP coverage because they are no longer eligible; your dependents become eligible for a state’s premium assistance program. To take advantage of special enrollment rights, you must experience a qualifying event and provide the employer plan with timely notice of the event and your enrollment request. To request special enrollment or obtain more information, contact The ICSVEBA Service Center at 800.633.2683. Women’s Health & Cancer Rights Act The Women’s Health and Cancer Rights Act of 1998 requires group health plans to make certain benefits available to participants who have undergone a mastectomy. In particular, a plan must offer mastectomy patients benefits for:

All stages of reconstruction of the breast on which the mastectomy was performed

Surgery and reconstruction of the other breast to produce a symmetrical appearance

Prostheses

Treatment of physical complications of the mastectomy, including lymphedema

Our plan complies with these requirements. Benefits for these items generally are comparable to those provided under our plan for similar types of medical services and supplies. Of course, the extent to which any of these items is appropriate following mastectomy is a matter to be determined by the patient and her physician. Our plan neither imposes penalties (for example, reducing or limiting reimbursements) nor provides incentives to induce attending providers to provide care inconsistent with these requirements. If you would like more information about WHCRA required coverage, contact your Plan Administrator. CA Maternity Coverage Group health plans and health insurance issuers with policies or contracts issued in the State of California generally may not, under California law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, the law generally does not prohibit the mother’s or newborn’s treating physician, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In addition, California law requires the Plan to cover a post-discharge follow up visit for the mother and newborn within 48 hours of discharge when prescribed by the treating physician. The visit shall be provided by a licensed health care provider whose scope of practice includes postpartum care and newborn care. The visit shall include, at a minimum, parent education, assistance and training in breast or bottle feeding, and the performance of any necessary maternal or neonatal physical assessments. The treating physician shall disclose to the mother the availability of a post-discharge visit, including an in-home visit, physician office visit, or plan facility visit. The treating physician, in consultation with the mother, shall determine whether the post-discharge visit shall occur at home, the plan’s facility, or the treating physician’s office after assessment of certain factors. These factors shall include, but not be limited to, the transportation needs of the family, and environmental and social risks. Furthermore, the Plan may not: Reduce or limit the reimbursement of the attending provider for

providing care to an individual enrollee in accordance with the coverage requirements.

Provide monetary or other incentives to an attending provider to induce the provider to provide care to an individual enrollee in a manner inconsistent with the coverage requirements.

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Deny a mother or her newborn eligibility, or continued eligibility, to enroll or to renew coverage solely to avoid the coverage requirements.

Provide monetary payments or rebates to a mother to encourage her to accept less than the minimum coverage requirements.

Restrict inpatient benefits for the second day of hospital care in a manner that is less than favorable to the mother or her newborn than those provided during the preceding portion of the hospital stay.

Require the treating physician to obtain authorization from the health plan prior to prescribing any services covered by this section.

Continuation of Benefits under COBRA If a qualifying event occurs that causes you, your spouse, or your children to lose coverage under our group health care plan, you have a legal right under COBRA to purchase a temporary extension of group health coverage. Qualifying events include reduction in work hours, termination of employment (except for gross misconduct), death of the employee, legal separation or divorce, or loss of eligibility for child coverage. The purchase price of continuing coverage is the full cost of the premium for similarly situated active employees, plus 2 percent (50 percent in certain cases) to help pay for administrative costs. The period for which the coverage can be continued depends on the nature of the qualifying event. Employees or family members who otherwise would lose coverage must inform the COBRA Administrator of their election of COBRA coverage within 60 days of the qualifying event. There is no waiting period, no exclusion for pre-existing conditions, and no physical examination when electing continuation coverage. Any amounts already paid toward deductibles and coinsurance during the current year count under the continuation policy. Employees and family members can elect full coverage or medical coverage without dental insurance and can choose from the three different health plans offered to active employees. This policy statement is a brief description of the health care continuation plan and does not fully explain employees’ rights under COBRA. You should read the COBRA notice you received when you first enrolled in the group health plan or the summary plan description for a fuller explanation. Copies of the COBRA notice and summary plan description can be obtained from Corporate Human Resources. Qualified Medical Child Support Orders (QMCSO) The Omnibus Budget Reconciliation Act of 1993 (OBRA ‘93), enacted on August 10, 1993, created a new kind of child support order (“MCSO”). A qualified MCSO is an order mandating that a qualified child, known as an alternate recipient, be covered by the group health plan to which the order is directed. To be qualified, the order must meet the requirements described below. Section 609 of the Employee Income Retirement Security Act of 1974 (ERISA) defines these criteria. Establish written procedures for determining whether or not a

medical child support order (“MCSO”) is qualified. These procedures must be tailored for each employer and should be reviewed by legal

counsel and must be available in writing to all plan participants upon request or included in the Summary Plan Description.

Notify both the participant and the alternate recipient(s) or his/her designee that a MCSO has been received.

Provide each party a copy of the written procedures that will be used in determining whether or not the MCSO is qualified.

Determine, within a reasonable time, whether or not the MCSO is qualified.

Notify the affected parties of its decision. If the MCSO is determined to be qualified, enroll the alternate recipient(s) in accordance with the order.

SPDs must contain a written QMCSO procedure or provide notice that the procedure is available from the Plan Administrator.

Privacy Rights Your District is committed to the privacy of your health information. The administrators of the Your District Health Benefits Plan use strict privacy standards to protect your health information from unauthorized use or disclosure. The Plan’s policies protecting your privacy rights and your rights under the law are described in the Plan’s Notice of Privacy Practices. You may receive a copy of the notice by contacting Human Resources. Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

legal notices.

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If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2014. Contact your State for more information on eligibility –

legal notices.

ALABAMA – Medicaid

Website: http://www.medicaid.alabama.gov

Phone: 1-855-692-5447

ALASKA – Medicaid

Website: http://health.hss.state.ak.us/dpa/programs/medicaid/

Phone (Outside of Anchorage): 1-888-318-8890

Phone (Anchorage): 907-269-6529

ARIZONA – CHIP

Website: http://www.azahcccs.gov/applicants Website: https://

www.flmedicaidtplrecovery.com/

Phone (Outside of Maricopa County): 1-877-764-5437

Phone (Maricopa County): 602-417-5437

COLORADO – Medicaid

Medicaid Website: http://www.colorado.gov/

Medicaid Phone (In state): 1-800-866-3513

Medicaid Phone (Out of state): 1-800-221-3943

FLORIDA – Medicaid

Website: https://www.flmedicaidtplrecovery.com/

Phone: 1-877-357-3268

GEORGIA – Medicaid

Website: http://dch.georgia.gov/ - Click on Programs, then Medicaid, then Health

Insurance Premium Payment (HIPP)

Phone: 1-800-869-1150

IDAHO – Medicaid

Medicaid Website: http://healthandwelfare.idaho.gov/Medical/Medicaid/

PremiumAssistance/tabid/1510/Default.aspx

Medicaid Phone: 1-800-926-2588

MAINE – Medicaid

Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html

Phone: 1-800-977-6740

TTY 1-800-977-6741

MASSACHUSETTS – Medicaid and CHIP

Website: http://www.mass.gov/MassHealth

Phone: 1-800-462-1120

MINNESOTA – Medicaid

Website: http://www.dhs.state.mn.us/

Click on Health Care, then Medical Assistance

Phone: 1-800-657-3629

MISSOURI – Medicaid

Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

Phone: 573-751-2005

MONTANA – Medicaid

Website: http://medicaidprovider.hhs.mt.gov/clientpages/clientindex.shtml

Phone: 1-800-694-3084

NEBRASKA – Medicaid

Website: www.ACCESSNebraska.ne.gov

Phone: 1-800-383-4278

NEVADA – Medicaid

Medicaid Website: http://dwss.nv.gov/

Medicaid Phone: 1-800-992-0900

NEW HAMPSHIRE – Medicaid

Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf

Phone: 603-271-5218

NEW JERSEY – Medicaid and CHIP

Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/

Medicaid Phone: 609-631-2392

CHIP Website: http://www.njfamilycare.org/index.html

CHIP Phone: 1-800-701-0710 INDIANA – Medicaid

Website: http://www.in.gov/fssa

Phone: 1-800-889-9949

IOWA – Medicaid

Website: www.dhs.state.ia.us/hipp/

Phone: 1-888-346-9562

KANSAS – Medicaid

Website: http://www.kdheks.gov/hcf/

Phone: 1-800-792-4884

KENTUCKY – Medicaid

Website: http://chfs.ky.gov/dms/default.htm

Phone: 1-800-635-2570

LOUISIANA – Medicaid

Website: http://www.lahipp.dhh.louisiana.gov

Phone: 1-888-695-2447

NEW YORK – Medicaid

Website: http://www.nyhealth.gov/health_care/medicaid/

Phone: 1-800-541-2831

NORTH CAROLINA – Medicaid

Website: http://www.ncdhhs.gov/dma

Phone: 919-855-4100

NORTH DAKOTA – Medicaid

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/

Phone: 1-800-755-2604

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legal notices.

OREGON – Medicaid

Website: http://www.oregonhealthykids.gov

http://www.hijossaludablesoregon.gov

Phone: 1-800-699-9075

PENNSYLVANIA – Medicaid

Website: http://www.dpw.state.pa.us/hipp

Phone: 1-800-692-7462

RHODE ISLAND – Medicaid

Website: www.ohhs.ri.gov

Phone: 401-462-5300

SOUTH CAROLINA – Medicaid

Website: http://www.scdhhs.gov

Phone: 1-888-549-0820

SOUTH DAKOTA - Medicaid

Website: http://dss.sd.gov

Phone: 1-888-828-0059

TEXAS – Medicaid

Website: https://www.gethipptexas.com/

Phone: 1-800-440-0493

RHODE ISLAND – Medicaid

Website: www.ohhs.ri.gov

Phone: 401-462-5300

SOUTH CAROLINA – Medicaid

Website: http://www.scdhhs.gov

Phone: 1-888-549-0820

SOUTH DAKOTA - Medicaid

Website: http://dss.sd.gov

Phone: 1-888-828-0059

TEXAS – Medicaid

Website: https://www.gethipptexas.com/

Phone: 1-800-440-0493

UTAH – Medicaid and CHIP

Website: http://health.utah.gov/upp

Phone: 1-866-435-7414

VERMONT– Medicaid

Website: http://www.greenmountaincare.org/

Phone: 1-800-250-8427

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service center.

THE ICSVEBA SERVICE CENTER is here to answer your questions and help make your employee benefits easier to use.

The ICSVEBA Service Center is the only number you need to call with employee benefit and wellness questions...and

best of all, it’s free!

Within 24 hours of your initial call, the Service Center will either have the issue resolved or will update you on any

further actions including the time frame for resolution. Below are some of the questions the Service Center can answer.

800.633.2683

ICSVEBAService@hubinternational.com. Fax: 866.214.2211

Monday - Friday

7:00 a.m. to 5:30 p.m. PT

All inquiries will be responded to within 24 hours of your call or e-mail.

Benefit Questions

I need to have surgery; does

my insurance cover it? How

much will my portion of the

cost be?

Referral

I need to see a specialist, but

I’m having trouble getting a

referral. What do I do?

Claims Assistance

I received a bill from my

doctor. I thought these

services were covered. What

do I do now?

Eligibility Issues

I tried to pick up a

prescription today, but the

pharmacy is saying that I’m

not covered. Why?

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This guide is intended to provide an overview only of the benefits offered by ICSVEBA. It is not an offer of coverage or intended to offer medical advice.

It does not contain all plan provisions, limitations and exclusions. Consult your plan documents (Schedule of Benefits, Certificate of Coverage, Group

Insurance Certificate, Booklet, Booklet-Certificate, Group Policy) to determine governing contractual provisions relating to your plan. In the event of a

conflict between this guide and your plan document, the plan documents will always govern.

contacts.

COVERAGE POLICY NUMBER TELEPHONE WEBSITE/EMAIL

MEDICAL Delta Health Systems Comprehensive Basic SIMNSA HMO

712

660

866.691.2443

800.424.4652

www.deltahealthsystems.com

www.simnsa.com

PRESCRIPTION Express Scripts

712 877.783.2288 www.expressscripts.com

LIFE AND AD&D (BASIC & VOLUNTARY) Symetra Life

01-015024-00 Contact Your District Office to file a claim

MENTAL HEALTH & EAP The Holman Group

ICSVEBA 800.321.2843 www.holmangroup.com

VOLUNTARY LONG TERM CARE Unum

522828 800.227.4165 www.unum.com

VALUE ADDED SERVICES Delta Health Systems Disease Management Maternity Management Satori World Medical

712

ICSVEBA

866.691.2443

619.704.2009

www.dhsdirect.com

www.satoriworldmedical.com

ICSVEBA Service Center N/A 800.633.2683 ICSVEBAService

@hubinternational.com