Medical Plans

Medical plans provide employees and eligible dependents with comprehensive coverage for doctor visits, hospitalization, preventive care, and other essential health services.

Medical plans are offered through ASCIP (Alliance of Schools for Cooperative Insurance Programs)

Benefit Comparison.pdf

 

Frequently Asked Questions

When comparing different types of health insurance, you want a plan that lets you see the doctors or specialists you need. You also want one that works for your budget. The most common choice you’ll have is between a health maintenance organization (HMO) and a preferred provider organization (PPO) plan. These options work differently and have different health plan costs you should know about.
 
Key Terms
Deductible - the amount you pay each year before your plan starts to pay.
Copay - a flat fee you pay for covered services like doctor visits.
Coinsurance - your share of health plan costs (a percentage of total costs) after meeting your deductible.
Out-of-Pocket Maximum - the most you have to pay out-of-pocket each year for health care services. once this amount is reached, insurance will pick up 100% of any subsequent qualifying expenses.
Premium - The amount you pay to belong to a health plan.
In Network - Providers who have agreed to render services at a negotiated rate
Out of Network - Providers who have not agreed to provide services at the negotiated rate. Members can still see these providers, but may experience higher fees, balance billing for the difference between the charged fee and the negotiated rate as well as different deductible out of pocket maximum.
 
How HMO plans work?
An HMO is a defined network of health care providers that contracts with a health plan to provide care at preapproved rates. Your personal doctor manages your care and refers you to specialists in the network.
You’ll mostly get care from doctors, nurses, and specialists in the network. But HMO plans sometimes refer members to specialists outside the network when they need specific services. HMO plans also cover medical emergencies. This lets members get care from any emergency room.
 
Do HMO plans require referrals?
In most cases, you’ll need a referral from a personal doctor to get specialty care. But certain specialty services — like ob-gyn and optometry — may be available without a referral.
 
The costs of an HMO plan
HMO plans coordinate care for a set payment. That means you typically have:
  • Lower monthly premiums (the amount you pay each month for coverage)
  • Lower deductibles, or no deductibles (the amount you need to pay before your plan starts contributing to your medical bills)
  • Lower payments for covered services

Remember: If you get nonemergency care from an out-of-network provider, you’ll pay the full cost.

How do PPO plans work?
With a PPO plan, you can see any doctor you want — inside or outside the network. Your PPO plan will have a network of preferred providers. It will probably cost you less money to see them. But you still have the option to see doctors outside that group.

Do PPO plans require referrals?
No. You can get specialty care without a referral from a personal doctor — from both in-network and out-of-network providers.

The costs of a PPO plan
PPO plans often have higher monthly premiums and out-of-pocket costs than HMO plans. You may also need to pay a deductible before your benefits begin. If you see an out-of-network doctor, you’ll usually have to pay the full cost of your visit and then file a claim to get money back from your plan.

the costs of a PPO plan

Which is better — an HMO or a PPO?
It depends on what’s important to you. The best health plan is the one that meets your needs. If you like lower costs and think coordinated care makes things easier, an HMO plan might be a good choice. If you want to continue seeing a doctor or specialist who isn’t in a plan’s HMO network, think about a PPO plan.

Advantages and disadvantages of HMO plans

Advantages
 
  • You pay lower monthly premiums and usually lower out-of-pocket costs,
    including prescriptions.
  • When you get care in the network, you have fewer claims to file.
  • Your personal doctor coordinates your care. This can make it easier to take care of your health.

Disadvantages

  • HMO plans require you to stay inside their network for care, unless it’s a medical
    emergency.
  • If your current doctor isn’t part of the HMO’s network, you’ll need to choose a new personal doctor.

Advantages and disadvantages of PPO plans

Advantages

  • You can see providers both inside and outside the network.
  • You can visit specialists without a referral, including specialists outside the network.

Disadvantages

  • You typically pay higher monthly premiums and costs for care than with HMO plans.
  • You have more responsibility for managing and coordinating your care.

What to consider when choosing a health plan
Before choosing a plan, think about your health care and budget needs. Do you want a personal doctor to coordinate your care? Do you want lower out-of-pocket costs and fewer claims? Do you need health insurance for young adults? Are there specific wellness perks you want included? Once you know the answers to questions like these, you can review the information above and start making your decision.

In-network vs. out-of-network care: How to know the difference
 
Understanding how your health plan works can help you manage your health care expenses. For example, some health plans cover services from providers that are out of your network. You may have higher costs if you get care from those providers. Other health plans only cover services from providers in your network.
You may be able to avoid unexpected bills by knowing if your doctor or medical facility is in network or out of network. Here’s how to tell the difference and how to find doctors in your network.
 
What is in network vs. out of network?
Health plans have a group of contracted doctors and facilities that they negotiated their rates with — this is their network. If your health plan covers services from providers that aren’t in the network, you may have to pay more to see those providers. Getting care from a network provider can save you money. That’s why it’s important to understand the difference between in-network vs. out-of-network care.

In-network care
A doctor, health care professional, or facility that’s in network has a contract with your plan. Your plan decides to pay a specific amount for a service, and the provider agrees to accept that rate. Depending on your coverage, you might pay none or part of that cost yourself, plus your copay, coinsurance, or deductible. These are your out-of-pocket costs.

Out-of-network care
An out-of-network doctor or facility doesn’t have a contract with your plan. Getting care out of network could cost you more than in network because the rate isn’t negotiated beforehand. The provider decides how much to charge for a service, and your plan may not cover the entire cost. You’ll likely pay the difference, as well as your out-of-pocket costs — your coinsurance or deductible. (Out-of-network care doesn’t usually include a copay.)
Most plans don’t cover any care outside of their network unless it’s for an emergency. In that case, you could be responsible for the entire cost of any out-of-network care you get. To be safe, confirm your care will be covered before you go.
 
When to check if care is in network or out of network
There are many times when you might confirm whether a doctor or location is in your network. For example:
  • You change plans and need to find a new primary care doctor.
  • Your primary care doctor recommends you see a specialist.
  • You move to a different town and want a new doctor closer to home.
  • You want to see a mental health or substance use disorder professional.
  • Your doctor orders a lab test, X-ray, or treatment that’s not available at their office.
  • You need to visit an urgent care and you’re not sure where to go.

When you have an emergency, you usually don’t need to worry about your care being out of network. Health plans generally consider emergency care to be in network.

What type of care can I get?
Whether you can choose between an in-network or out-of-network doctor depends on what type of plan you have. The most common types are known as HMOs and PPOs.

  • Health maintenance organization (HMO) plans — Only in-network care is covered. Your primary care doctor will refer you to most specialty care. HMO
    plans often have lower monthly costs.
  • Preferred provider organization (PPO) plans — Both in-network and out-of-network care are covered, but at different rates. You can see a specialist without a referral. PPO plans offer more choice and flexibility, usually at a higher monthly cost.

If you have a plan that covers out-of-network care, there are a few reasons you might choose to get care that way, even if the out-of-pocket costs are higher. For example:

  • You need to get care in an area where no in-network options are available.
  • Your doctor has left your network, but you still want to see them.
  • You need to see a type of specialist that isn’t available in your network.

How do I find doctors in my network?
There are a few ways to make sure a doctor or facility is in your plan’s network.

Your plan likely has an online directory where you can search for doctors, specialists, hospitals, pharmacies, labs, and other clinicians that are in your network. If you need help, call the number on your ID card.

You can also contact the doctor’s office or facility and confirm whether they’re in your plan’s network.

Kaiser Permanente has been providing high-quality health care and coverage for more than 75 years. By connecting care with coverage, we initiated a history of innovation and a new model for health care, where everything is designed to work together to help our members live healthy lives. Our care model enables our teams to think and work as one, coordinating your care seamlessly, so you don’t have to — and delivering better care when it matters most...

more information

You may seeSISCon many of the plan documents. ASCIP partners with SISC (Self Insured School of California) to administer its billing and eligibility functions for Anthem and Blue Shield HMO and PPO plans. This partnership ensures that ASCIP districts benefit from the negotiating leverage of the larger SISC pool while still having access to the local support and unique programs offered through ASCIP.

Benefits are effective on the first of the month following your date of hire, or first of the month following change in status from part-time to full-time

Once hired, you will receive an email from the Employee Benefit Office with enrollment details. Our online benefit system provider American Fidelity will contact you via your district email address to schedule an online enrollment appointment. The system you will have access to during your appointment is called AFenroll which will provide all the employee insurance plans available for you to select from.

Eligible dependents include:

  • Legal spouse or domestic partner
  • Dependent children under 26 years of age
  • Your unmarried children who are deemed disabled by their physician and approved by your insurance carrier.

Eligible children include:

  • Your natural and adopted children
  • Stepchildren, if you are married to your stepchildren's parent. If you and your spouse divorce, your former dependent stepchildren are no longer eligible for coverage
  • Children of your domestic partner. If you and your domestic partner separate, the children of your former domestic partner are no longer eligible for coverage
  • Children for whom you have permanent legal guardianship issued by a court of law
  • Your children or stepchildren who must be covered under a Qualified Medical Child Support Order

Please note you will be required to provide documentation of your dependent's eligibility by submitting marriage and/or birth certificates, legal documents for custody or adoption, the Social Security and medical provider's determination of disability for an
adult child, the first page of your most recent Federal Tax form for spouse verification.

ID cards are mailed at the end of the month prior to your effective date or within 2 weeks after enrollment.

Call the Employee Benefits Office at 714-480-7567.

You will receive a Benefit Confirmation Statement at time of initial enrollment. A copy is also available during Open Enrollment by accessing the online employee benefit portal called AFenroll. Please contact the Employee Benefits Office if you require a copy mid-year.

In general, you may only make changes to your benefits once a year during Open Enrollment period in October for an effective date of January 1 of the following year.
However, the plan does allow for changes during the year if you experience a "family status change" as defined by the IRS. Examples of a family status change include:

  • Marriage or divorce
  • Birth, adoption, or death
  • Change in your spouse or domestic partner's employment that would affect
    coverage, such as gain or loss of coverage
  • Change in court order for custody or visitation, or requirement to provide health
    insurance coverage
  • If you have an eligible qualifying event, a request for change must be made within 30-days of the event; otherwise, you must wait until the next open enrollment period.

You will need to bring the following proof that your dependent is eligible and proof of the life event change to the Benefits office before the change goes into effect.

  • Marriage license
  • Birth Certificate
  • Court adoption papers
  • Registration of domestic partnership
  • Income tax returns
  • Employer documentation of loss of coverage

Additional ID cards are available by contacting the insurance carrier directly.

Medical Plan Options