Benefits Basics

Not sure how insurance works? We're here to help with the basics!

Getting Coverage

When can I enroll in benefits?

• All eligible employees have 30 days from their date of hire to enroll in benefits. Additionally, all eligible employees have 30 days from the date of a qualifying event to enroll or make applicable changes to their benefits. Lastly, all eligible employees are able to make changes to their benefits during Open Enrollment. For Classified staff, Open Enrollment usually takes place in August or September. For Certificated and Management staff, Open Enrollment usually takes place in April or May.

How do I enroll in benefits?

• Classified employees must complete and return a SISC Enrollment form (or a Kaiser Enrollment form if electing Kaiser) and an AUSD Election form to the Benefits department. Certificated and Management employees must complete enrollment online via Benefit Bridge. Benefit Bridge can be acessed here, and directions for registering your account are available here. Additionally, all employees must provide documentation of their dependents to the Benefits Department.

What is considered a qualifying event?

• Examples of qualifing events include changes in employment status, birth or adoption of a child, marriage or divorce, etc. If you're not sure if your situation is considered a qualifying event, contact the Benefits Department.

Who can I add as a dependent and what type of documentation is needed?

• Eligible dependents include legally married spouses; registered domestic partners; biological, step, foster, and adoptive chidlren (up to age 26); any child for which you are the legal guardian (up to age 26). Ex-spouses, parents, and people you live with but are not in a marriage or registered domestic partnership with are not eligible dependents. 

• Eligible documenation includes marriage certificate; certificate of domestic partnership; birth certificate; certificate of placement for foster care or adoption; certificate of legal guardianship. Please note: Classified staff must also provide a copy of their tax return with financial information redacted when adding their spouse. 

Picking the Right Coverage

What is an HMO?

• An HMO is a type of medical plan in which the patient's medical care is directed by a Primary Care Physician (PCP). Your PCP will listen to your concerns and determine your treatment needs - such as visits with a specialist. Your PCP will then provide you with a referal to the appropriate provider within their medical group. While you can ask your PCP to provide you with a referal to a specific provider, they cannot provide you with a referal to a provider that is outside of the medical group. Most medical services and payments will be processed by the medical group. HMOs typically charge a co-pay for services, meaning that your out of pocket expenses are very predictable.

What is a DHMO?

• A DHMO is simply an HMO that charges a deductible for certain services. Out of pocket costs are typically less predictable than HMOs, but more predictable than PPOs.

What is a PPO?

• A PPO is a type of medical plan in which the patient directs their medical care. While most services are still subject to approval by the insurance carrier, the patient does not need to consult with a PCP or receive a referal in order to schedule specialist visits (although they may chose to do so). PPO members are not a part of a medical group, meaning they can chose to receive care from any provider they wish, however, services received by non-network providers (providers the insurance carrier does not have a contract with) will have higher out of pocket expenses. Most medical services and payments will be processed by the insurance carrier. PPOs typically charge dedctibles and co-insurance for services, meaning that your out of pocket expenses are harder to predict. 

Which is Better?

• That depends on what is important to you! Here are some important questions to ask yourself when chosing coverage:
  • How much am I comfortable spending each month to enroll in coverage? How much am I comfortable spending when I receive medical care?
  • Do I go to the doctor frequently or infrequently? Will I need any major services in the next year?
  • Do I like my doctors or am I open to finding new ones? Are my doctors considered in-network? Are my doctors and specialists part of the same medical group?
  • Am I currently taking any prescriptions? Are those prescriptions covered by the plan? 

Understanding the Terminology

What is a deductible?

• A deductible represents the amount a member must pay out of pocket before their plan will provide coverage for certain services. Deductibles usually don’t apply to basic services like a doctor’s visit, but usually do apply to more significant services like surgery. Deductibles run on an annual basis, and once your deductible is met, you won’t have to pay it again until the following year. Deductibles are usually broken out into individual and family amounts. No one individual will have to pay more than the individual deductible amount for their services, however, some individuals may not need to pay a deductible at all if the family deductible has already been met.

• Here’s an example: A family of 4 is on a plan with a $500 individual deductible and a $1,500 family deductible. It’s a big year for the family, and all 4 are using major services. The parents both use their services early in the year. They each pay a $500 deductible for their services, and then the plan pays the coordinating benefit amount. The eldest child uses their services next. The parents pay a $500 deductible for the eldest child, and then the plan pays the coordinating benefit about. The youngest child is the last to use their services. Because the family as a whole has already paid $1,500 worth of deductibles, the plan automatically pays the coordinating benefit amount.

What is co-insurance?

• Co-insurance represents the cost sharing percentage between the insurance plan and a member, and is usually tied to services subject to the annual deductible. When a co-insurance, or percentage, is listed on a benefit summary as the member’s out of pocket responsibility, it means the member will have to pay that percent of the total bill for the services rendered. Generally speaking, in network providers have contracted with the insurance carriers to keep their fees within certain limits. While the total billed cost (and by extension the co-insurance) will depend on factors such as the setting the services were provided in, they can be expected to be relatively similar. Out of network providers typically have not contracted with insurance carriers, meaning the billed costs are usually more volatile. For services that charge a co-insurance, members are encouraged to ask their doctor for a cost estimate prior to receiving care (when possible, of course) so they can better plan for their expenses.

What is a co-pay?

• A co-pay represents the flat out of pocket cost owed each time the applicable service is received. Unless a benefit summary specifically states otherwise, no additional fees are owed when a co-pay is paid.

What is the out of pocket maximum?

• The out of pocket maximum represents the cap that the plan places on a member’s out of pocket expenses during a plan year. Depending on the plan, your deductible and prescription costs may or may not apply to the out of pocket maximum, or your prescription costs may be subject to a separate out of pocket maximum. Unapproved or non-covered services, such as chiropractic care in excess of the plan limits, do not count towards the out of pocket maximum. Any monthly premium that you pay to enroll in the coverage also does not count towards the out of pocket maximum. Once the out of pocket maximum is met, the plan covers 100% of the cost of covered and approved services for the rest of the year. The following year, you will be subject to a new out of pocket maximum, however, some plans will give members credit for amounts paid in the previous quarter. Just like the Deductible, out of pocket maximums are usually broken out into individual and family amounts. No one individual will have to pay more than the individual out of pocket maximum for their services, however, some individuals may pay less than the out of pocket maximum if the family out of pocket maximum has already been met.

• Here’s an example: A family of 4 is on a plan with a $3,000 individual out of pocket maximum and a $9,000 family out of pocket maximum. It’s a big year for the family, and all 4 are using major services. The parents both use their services early in the year. They each pay $3,000 in deductibles, co-pays, and co-insurance for their services, and then the plan pays 100% of any remaining costs for the rest of the year. The eldest child uses their services next. The parents pay $3,000 in deductibles, co-pays, and co-insurance for the eldest child, and then the plan pays 100% of any remaining costs for the rest of the year. The youngest child is the last to use their services. Because the family as a whole has already paid $9,000 worth of out of pocket expenses, the plan automatically pays 100% of any incurred costs.