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Retired Employees

Non-Medicare Retirees (Under 65)

Medicare Retirees

2014 Retiree Benefit Matters
Summary of Benefits and Coverage
Medical Summary Plan Document
Eligibility/Dependent Eligibility
Life Events
Medical
Prescription Drug Benefit
Voluntary Vision Plan Benefit
Voluntary Dental Plan Benefit
HIPPA Notice of Privacy Policies
Medicaid and the Children's Health Insurance Program (CHIP)
Retired Employees of the City of San Antonio (RECOSA)

2014 Retiree Benefit Matters
Eligibility/Dependent Eligibility
Life Events
Medical
Voluntary Vision Plan Benefit
Voluntary Dental Plan Benefit
HIPPA Notice of Privacy Policies
Medicaid and the Children's Health Insurance Program (CHIP)
Retired Employees of the City of San Antonio (RECOSA)

What You Need To Know

Complete plan details are available in the Summary Plan Documents available from the Human Resources Department. In the event of any discrepancy between any document and the official Plan Document, the Plan Document shall govern.

Eligibility

Eligible Retiree
City of San Antonio employees who leave the City with at least 20 years of service or have five years of service and are 60 years of age are eligible for City of San Antonio retiree medical benefits as follows:

  • Employees with a hire date prior to October 1, 2007 are eligible to enroll in a City retiree medical plan with a total combined premium subsidy of 67%.
  • Employees with a hire date on or after October 1, 2007 are eligible as follows:
    • 5-9 years of City service are eligible to participate with no City subsidy
    • 10+ years of City service are eligible to participate with 50% City-subsidized premium

Retirees who meet eligibility requirements for retiree medical benefits must enroll in a City retiree medical plan within
31 days
from the date of separation from service.

Revised as of May 2014! Retirees also have the option to waive coverage. If a retiree chooses to waive coverage,
they must do so at the time they separate from the City. Those who choose to waive coverage are allowed one
opportunity to re-enter the plan at a later date, as long as they provide proof of continuous health insurance
coverage.

The continuous coverage can be a spouse’s plan, employer plan, or individual plan and enrollment must
be requested within 31 days of the loss of that coverage. Retirees may only enroll those dependents who were
covered at the time coverage was waived and must return to the plan when you do; they will not be added to the
plan at a later date.

Those who do not enroll in retiree health insurance coverage at the time of separation and do not elect to waive
coverage will not be allowed on the plan at any time.

Eligible Dependent
Dependents may be enrolled in City retiree health benefits if they were covered at the time of your retirement and you enroll them at the time of your initial retiree medical election. Dependents who continue to meet eligibility requirements will remain on the plan until you remove them, cease to make the required contribution, or the dependent no longer meets the eligibility criteria.

Revised as of May 2014! Retirees who waived coverage at the time of separation and are eligible to come back and enroll in a City retiree medial plan, may only enroll those dependents who were covered at the time coverage was waived. Dependents must return to the plan along with the retiree; they will not be added to the plan at a later date.


Life Events
Selections made during Annual Enrollment will be effective for the upcoming plan year, January 1 through December 31, 2014. There are certain life events that can happen during the year that will allow you to change the level of coverage (retiree only, retiree plus one, or retiree plus two or more) for your health plan.

Those life events are:
• Divorce, Annulment, Dissolution of a Domestic Partnership
• Death of a dependent

You must notify the Employee Benefits Office within 31 calendar days of your life event and provide all required documentation in order for the changes in your coverage to take effect during the calendar year. If you fail to notify the Employee Benefits Office within 31 days and do not provide documentation, you forfeit any past premium refund.


Medical
Under the City of San Antonio 2014 Benefits Program, if you are a Medicare-eligible, non-uniformed retiree or a uniformed retiree who retired prior to October 1, 1989, you are eligible to participate in excellent benefit plans which help pay for your health and dependent care needs.

Two Medicare Benefit Plan Options:
Humana Medicare Advantage PPO & Humana Medicare Advantage HMO

Both the Humana Medicare Advantage PPO and HMO offer comprehensive coverage to meet your health needs. Only you can decide which one is right for you. A few things to consider are described below. You may also wish to visit an Open Enrollment Fair to discuss your personal situation with a Humana representative.

Humana Medicare Advantage Preferred Provider Organization (PPO) Plan

The Preferred Provider Organization (PPO) makes available a national network of healthcare providers. PPO members may select providers in or out of the network anytime healthcare is needed. The plan does NOT require the use of a Primary Care Physician (PCP) and referrals are NOT necessary to see a specialist or other covered healthcare provider.

Note: The Humana Medicare Advantage PPO network DOES include the Methodist Hospital Healthcare system.

Humana Medicare Advantage Health Maintenance Organization (HMO) Plan

The Health Maintenance Organization (HMO) makes available a network of healthcare providers. HMO members select a Primary Care Physician (PCP) who takes responsibility for overseeing healthcare provided to his/her patients. When appropriate, the PCP makes referrals to specialists or other healthcare providers. HMO members must obtain a referral to specialists or other caregivers to receive benefits from this plan. This plan offers the lowest contribution and out-of-pocket costs to City retirees.

Note: The Humana Medicare Advantage HMO network does NOT include the Methodist Hospital Healthcare system.


Vision
Retirees continue to have a voluntary vision plan benefit available to them. The City's vision plan benefit, administered by Davis Vision, provides you and your dependents with access to a national network of doctors and retail providers to help you care for your eyes. Eye exams, eyeglasses, and contacts are available to you at only the cost of applicable co-pays. To locate a vision provider near you or for additional information, log onto www.davisvision.com, click on the Members tab, and enter the 2471 (City's Client Code) in the Open Enrollment section. You can also call Davis Vision at 1-800-448-9372. View page 10 of the 2014 Retiree Benefit Matters for additional vision plan details.

Contact Lens and Frame Benefits
Contact lenses selected (in lieu of eyeglasses) from Davis Vision's Contact Lens Collection are covered in full. With Davis Vision's Frame Collection, you have access to several designer and brand name frames (in lieu of contacts) at only the cost of applicable co-pays. Plan eyewear includes a one-year eyeglass breakage warranty at no cost to you.

Davis Vision Collection
To maximize your vision plan benefit, consider purchasing frames or contact lenses from the Davis Vision Collection. The Collection is available at most participating independent provider locations. Independent providers do not include retail stores such as Visionworks or Walmart. To locate a participating independent provider near you, visit www.davisvision.com.

Benefit Summary

Comprehensive Eye Exam - $10 co-pay, one exam per year

Frames (in lieu of contacts)

Contacts (in lieu of eyeglasses)

Once per calendar year beginning January 1.

Once per calendar year beginning January 1.

$130 retail allowance toward any frame from provider, plus 20% off balance³.

$150 retail allowance toward Non Collection Contact lenses, plus 15% off balance².

                                          OR                                           OR

Any Fashion or Designer frame from Davis Vision’s Collection¹ (value up to $175).

Any contact lenses from Davis Vision’s Contact Lens Collection¹.

One year eyeglass breakage warranty included at no additional cost.

Contact Lens Evaluation, Fitting & Follow Up
Care - Once per calendar year beginning January 1. Collection contact lenses covered in full, including fitting fee. Fitting fee is an additional charge minus 15% discount if Non Collection contact lenses².

Spectacle Lenses - Once per calendar year beginning January 1. For standard single-vision, lined bifocal, or trifocal lenses.

 

¹The Davis Vision Collection is available at most participating independent provider locations.
²For dependent children, monocular patients, and patients with prescriptions of 6.00 diopters or greater.
³Additional discounts not applicable at Walmart or Sam’s Club locations.


Dental
Retirees now have the opportunity to participate in a voluntary dental benefit administered by Delta Dental. For detailed plan information, including a directory of dental providers, the enrollment form, premiums, and plan highlights, visit www.deltadentalins.com/cityofsanantonio/retirees.html. You can also call 1-800-422-4234.

DeltaCare Dental HMO administered by Delta Dental

The DeltaCare Dental HMO is a dental plan that provides comprehensive dental care when services are obtained from an
in-network primary dentist. During open enrollment, select a dentist within a 35-mile radius of your zip code from the DeltaCare network to serve as your primary dentist.

With this plan, you are only responsible for the co-pays for any covered services you receive from your selected dentist. There are no deductibles, yearly maximums, or paperwork claims to file. Examples of common services and co-pays are listed below.

Description

Procedure Code

Co-Pay

Office Visit

D0999

$5

Oral exam, x-rays, and fluoride treatment

N/A

No cost

Prophylaxis (teeth cleaning twice a year)

D1110

No cost

Periodontal scaling and root planning, per quadrant

D4341

$40

Fillings (amalgam or resin) for one surface, anterior

D2140

$5

Surgical extraction, erupted tooth

D7210

$45

Root canal – molar (excluding final restoration)

N/A

$280

Crown– porcelain fused to predominantly base metal

D2750

$295

Orthodontics for children and adults

D8070 (children) / D8090 (adults)

$1,700 / $1,900



HIPAA Notice of Privacy Policies
Click here to view the HIPAA Notice of Privacy Policies.


Medicaid and the Children's Health Insurance Program (CHIP) Notice
Click here to view the Medicaid and CHIP notice.