2017–
2018
BENEFITS GUIDE
Your Guide to Choice, Quality and Affordable Benefits
California
TABLE OF CONTENTS
2
Eligibility
3
How to Enroll
4
Medical Benefits
6
Summary of Medical Plan Choices
8
Dental Benefits
9
Vision Benefits
10
Flexible Spending Accounts
11
Life and Accidental Death &
Dismemberment Insurance
12
Other Voluntary Benefits
12
Other Green Dot Paid Benefits
13
Contribution Rates
For more information, please contact [email protected]
Important: This document summarizes some of the Green Dot Public Schools’ benefits plans and administration effective
July 1, 2017 for eligible employees. It is not intended to provide all the details on these benefit plans. For more details, see
the summary plan descriptions (SPDs). If there is a discrepancy in the descriptions contained in this document and the
benefits SPD or certificates of coverage, the descriptions in the SPDs or certificates of coverage will prevail. Receipt of
this document is not a guarantee of employment or eligibility for Green Dot Public Schools benefits.
2
May 15-26,
2017
YOUR GUIDE TO
CHOICE, QUALITY AND AFFORDABLE BENEFITS
We have created a solid foundation for helping you build a benefits package for you and, if
appropriate, your family. You are automatically enrolled in some of the benefits and you have the
option to enroll in others.
Your Guide to Choice, Quality and Affordable Benefits will help you learn about your benefits and
your enrollment options. Medical and dental contributions will remain the same as last year.
Any changes to your benefit elections or dependent enrollments will begin on July 1, 2017.
Don’t miss the deadline. You have until May 26
to enroll in your benefits for 2017- 2018.
However, if you are not planning to change your
current benefit elections, add or remove dependents,
you do not have to take any actions. Your current
benefit elections will automatically continue.
1
ELIGIBILITY
You are eligible for benefits if you work 30 or more hours a
week. If you enroll in a medical, dental and/or vision plan, you
can enroll your dependents if they are your:
zz Legal
spouse or domestic partner*
zz Children,
up to age 26, if they are your:
zz Naturally
zz Domestic
born children
partner’s children*
zz Legally
adopted children and children placed with
you for adoption
zz Stepchildren
zz Child
for whom you have legal custody
zz Child
for whom you are required to provide
coverage under a Qualified Medical Child Support
Order (QMCSO)
* Completed and notarized affidavit required.
What to Do
1. Review this guide for your benefit choices.
2. Decide your benefit choices.
3. Go to the enrollment site, add your dependents and elect
your benefits before the deadline. See the How to Enroll
section on the next page.
2
Be sure to add your
eligible dependents or
remove those who are
no longer eligible.
Remember, if you are adding
dependents, you must include
their birthdates and Social
Security numbers as required
by federal law.
HOW TO ENROLL THROUGH WORKDAY
Follow these easy steps to log into our benefits enrollment
website:
!1.
Go to www.greendot.org/workday.
!2.
Click on Login with Google.
!3.
Select your Green Dot Gmail address ending in
either @greendot.org or @animo.org. If your Green
Dot Gmail account is not listed, click Add Account
and enter your Green Dot Google credentials.
!4.
Click Allow.
Once in the enrollment site, you can access your personal
information to help you make your benefit elections and to
add or remove dependents from coverage, if applicable.
After completing the dependent section, you can add eligible
dependents to your medical, dental and/or vision coverage.
You can also choose to enroll your eligible dependents in
supplemental life insurance if you elect coverage yourself.
In addition to enrolling in your benefits during Open
Enrollment, you will also go through Workday if you
experience a qualified change in status during the year and
need to change your benefits or add/drop dependents.
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You can find detailed
enrollment instructions
by clicking HERE.
You can also email
[email protected] if
you need more help.
MEDICAL BENEFITS
You have five medical plan choices as highlighted in the at-a-glance comparison. Details follow on the
next pages.
At-A-Glance Comparison of Medical Plans
VIVITY
HMO
“Free” plan,
Green Dot pays
the premium for
employees and
dependents. 100%
coverage after
copays through the
“Vivity” network
of 7 of the largest
medical groups in LA
and Orange County.
ANTHEM
HMO
100% coverage
after copays
through the
“Blue Cross (CA
Care) Large
Group” network.
KAISER
HMO
100% coverage
after copays
through Kaiser
network providers.
You must choose a Primary Care
Physician/medical group when you
enroll. Go to the Anthem or Kaiser
websites to find providers near you.
ANTHEM
EPO
100% coverage
after copays
through the “EPO”
network only
(limited out-ofnetwork coverage.)
ANTHEM
PPO
Covers both in- and
out-of-network
expenses through
the national “Blue
Cross PPO (Prudent
Buyer) Large Group”
network. For innetwork expenses,
you pay 10% after
deductible and copay,
until the out-ofpocket maximum is
reached.
You do not have to choose
a Primary Care Physician.
You may be eligible to receive $75 per month if you opt out of medical
coverage through Green Dot and can prove you have coverage elsewhere.
You will only receive the payment if you actively log into the enrollment system and elect
“decline medical plan.” You will not receive the incentive if you miss the enrollment deadline.
4
MEDICAL BENEFITS
Comparing the Three HMO Choices
The HMOs pay 100% of eligible medical and prescription
drug expenses after copayments. They do not have
deductibles or coinsurance. If your copayments total up to
the out-of-pocket maximum, the plan pays 100% of eligible
expenses for the rest of the calendar year. See the table on
page 7 for the maximum amounts.
If you enroll in an HMO, you must select a Primary Care
Physician to manage your healthcare and who refers you
to medical specialists and facilities when needed. You
can search for Primary Care Physicians and other medical
providers at the HMO’s websites or call the service center
(see the table on page 6). You can change your Primary
Care Physician if necessary.
The Anthem Vivity HMO
The Anthem Vivity HMO is the “free” plan (no paycheck
deductions). Green Dot pays the premium for you and your
eligible dependents. The Vivity HMO network is formed
from a partnership between Anthem and seven of the
largest medical groups in LA and Orange County:
zz Cedars
zz Good
Sinai
Samaritan Hospital
zz Huntington
Memorial Hospital
zz MemorialCare
zz PIH
Health System
Health
zz Torrance
zz UCLA
Memorial Medical Center
Health
Kaiser HMO
Kaiser automatically assigns a Primary Care Physician when
you enroll. If you prefer, you may change your Primary Care
Physician after you enroll. If you were enrolled in the Kaiser
HMO Plan before, your ID number will be the same one you
had earlier.
Anthem California Care HMO
The network features only California medical providers.
When you enroll, you select a Primary Care Physician who
will manage your healthcare and refer you to other medical
providers if needed.
5
IMPORTANT
In the HMO Plans, expenses
from out-of-network providers
will not be covered and you will
pay the full cost of services.
However, in the Anthem EPO
or Anthem PPO plans, if you
have expenses from out-ofnetwork providers, you may
be responsible for any charges
that the provider bills above
the covered amount (called
“balance-billing”).
In an Emergency, go to
the nearest emergency
room and contact your
Medical Group as soon
as possible for coverage.
SUMMARY OF MEDICAL PLAN CHOICES
Decision Factors
Is my doctor in the
network?
Anthem
Vivity
HMO
Anthem
California Care
HMO
Kaiser
HMO
Anthem
EPO
Anthem
PPO
Each plan has its own network.
To see if your doctor is in the network, go to the website listed in the next table.
Do I need to choose a
Primary Care Physician
(PCP)?
Yes
No
Does the plan cover outof-network expenses?
No
Yes
Does the plan have a
deductible?
(individual/family)
No
How does the plan cover
expenses?
What are my copays?
(Also see prescription
drugs table)
Plans cover 100% of eligible expenses.
Is preventive care covered?
What are the contribution
rates per paycheck?
$250/$750
$10 for most
services. $50 for
emergency room.
$10 for most
services. $100 for
emergency room.
Yes at 100% when using in-network providers.
What’s the maximum I will
pay out of pocket for the
calendar year?
(individual/family)
What expenses are covered
for maternity?
In-network
$0
In– or out-of-network,
after deductible Plans cover a
percentage of eligible expenses.
In-network, after copays
$10 for most services. $50 for emergency room.
In-network
In-network
In-network
In-network
$1,500/$3,000
$1,500/$4,500
$2,000/$4,000
In-network
In-network
Plans cover at 100%, after copays.
Plans cover at 100%, after deductible
Green Dot pays
See page 13
See page 13
Finding Primary Care Physicians and Network Providers
Use the links or phone numbers in the following table to find a primary care physician to select if you are
enrolling in an HMO, or to find other medical providers for all medical plan options.
Medical Plan
Name of Network
Website
Service Center
Anthem Vivity
Vivity
Anthem.com/ca
844-497-5954
Blue Cross HMO (CA Care)
Large Group
Anthem.com/ca
800-888-8288
Kaiser HMO
No name needed. On the site,
click on “Find a Doctor.”
kaiserpermanente.org
800-464-4000
Anthem EPO
EPO
Anthem.com/ca
800-888-8288
Anthem PPO
Blue Cross PPO
(Prudent Buyer) Large Group
Anthem.com/ca
800-888-8288
Anthem HMO (CA Care)
6
MEDICAL BENEFITS
Comparing EPO and PPO Plan Choices
In both plans, you pay a deductible before the plan pays benefits (as shown in the table) and both plans cover
eligible expenses from in-network and out-of-network providers.
EPO
Feature
In-network
PPO
Out-of-network
In-network
Out-of-network
Calendar-year deductible
Per person
None
$3,000
$250
Family maximum
None
$6,000
$750
After the deductible
Plan covers 100%
after copays.
Plan covers 50%
of expenses up to
applicable limits.
Plan covers 90%
of eligible expenses
after copays.
Plan covers 70%
of expenses up to
applicable limits.
Calendar-year out-of-pocket
maximum for medical
expenses
Per person
$1,500
$ 9,000
$2,000
$ 6,000
Family maximum
$4,500
$18,000
$4,000
$12,000
Prescription Drug Benefits – The plans differ on how they cover your costs for prescription drugs.
Comparing EPO and PPO Prescription Drug Benefits
Anthem EPO
Drug Categories
Anthem PPO
In-Network
Retail Pharmacy
(30-day supply)
Mail-Order Pharmacy
(90-day supply)
Mail-Order Pharmacy
(30-day supply)
Mail-Order Pharmacy
(90-day supply)
Tier 1
$10
$10
$10
$10
Tier 2
$20
$40
$20
$40
Tier 3
$35
$70
$35
$70
Comparing HMO Plan Prescription Drug Copays
Anthem Vivity HMO
Drug
Categories
Anthem California Care HMO
Kaiser HMO
In-Network
Retail Pharmacy
(30-day supply)
Mail-Order
Pharmacy
(90-day supply)
Mail-Order
Pharmacy
(30-day supply)
Mail-Order
Pharmacy
(90-day supply)
In-Network
Retail Pharmacy
(30-day supply)
Mail-Order
Pharmacy
(90-day supply)
Tier 1
$10 copay
$10 copay
$10 copay
$10 copay
$10 copay
$20 copay
Tier 2
$20 copay
$40 copay
$20 copay
$40 copay
$20 copay
$ 40 copay
Tier 3
$35 copay
$70 copay
$35 copay
$70 copay
n/a
n/a
Comparing Medical Plan Paycheck Rates
The amount deducted from paychecks after enrolling in a medical plan option is another factor to
consider when choosing a medical plan. All contributions are deducted from your paychecks before
payroll taxes are withheld, saving you money.
7
DENTAL BENEFITS
If you enroll in the Anthem
DHMO Plan, Green Dot pays
the premium for you and your
enrolled dependents. Check to
see which plan is best for you.
You have three choices in dental plans through Anthem.
Which plan is best for you depends on your dental care
needs, the dentists in the Anthem network, your need for
orthodontic services and the amount you pay per paycheck.
To find network providers, go to the Find a Doctor drop-down
menu on anthem.com/ca and scroll to the dentist section.
Network names are listed in the following table.
Put Your Well-Being First
Be sure to see your dentist twice
a year for your free preventive
care checkups.
Comparing Dental Plan Choices
Anthem
DHMO Plan
Features
In-network Only
Anthem
Dental Complete Low Plan
In-Network
Anthem
Dental Complete High Plan
Out-of-Network
In-Network
Check at
anthem.com/ca
using Dental Net
HMO Network
Check at anthem.com/ca
using Dental Complete Network
Does the plan cover expenses
from out-of-network dentists?
No
Yes
What is the maximum amount
that the plan pays each
calendar year?
No maximum
$1,500
$1,000
No
$50 per person,
up to $150 family
maximum
$75 per person,
up to $225 family
maximum
$0
($5 for sealants)
$0
No deductible
20%
No deductible
Is my dentist in the network?
Do I have to meet an annual
deductible before the plan
pays benefits?
What do I pay for Diagnostic
and Preventive Care services?
How many times a year can I get
a routine checkup?
Out-of-Network
$1,500
$25 per person,
up to $75 family
maximum
$50 per person,
up to $150 family
maximum
$0
No deductible
Two times
Note: An additional cleaning is available to dental plan participants who are also active in an
Anthem health plan’s diabetic or maternal health care management program.
What do I pay for fillings,
extractions and other Basic
Care services?
$20-$45 copay,
depending on
service
20% after
deductible
What do I pay for crowns,
bridges, Periodontics,
Endodontics, oral surgery,
dentures and other Major
Care services?
$5-$170 copay,
depending on
service
50% for crowns,
20% for other
services after the
deductible
Does the plan cover
Orthodontic services?
Yes, $1,695/child
to age 18 and
$1,895/adult
after copays
What are my paycheck
contributions?
Green Dot pays
50% after
20% for other services
after deductible
deductible
50% after
deductible
Yes, plan pays 40% up to a $1,000
lifetime maximum per adult and child
50% for crowns, 20% for other
services after the deductible
Yes, plan pays 40% up to a $2,500
lifetime maximum per adult and child
See page 13
8
VISION BENEFITS
The following table summarizes the vision plan benefits.
Using in-network vision care providers will save you money.
To find a network provider near you, go to the Find a Doctor
drop-down menu on anthem.com/ca and scroll to the vision
provider section and find the Blue View Vision network.
If you enroll in the Vision Plan,
Green Dot pays the premium
for you and your dependents.
Anthem Blue View Vision Plan
Benefits and Services
In-Network
Out-of-Network
Exams (every 12 months)
You pay $10
Plan pays up to $50
Lenses (every 12 months)
for standard:
Single
Bifocal
Trifocal
Allowance:
You pay $25 copay
$50
$75
$100
You pay:
Progressive lenses
$0 for children
Not available
$75 for adults
Frames
(every 12 months)
Medically necessary contact
lenses in lieu of lenses
(every 12 months)
Elective contact lenses in lieu
of lenses
(every 12 months)
Plan pays up to $120 allowance plus
20% off of the amount over $120
Plan pays up to $70 allowance
You pay $25 copay
Plan pays up to $210 allowance
Plan pays up to $120 for conventional
and disposable contacts, plus 15% off
of the amount over $120
Plan pays up to $105 allowance
9
FLEXIBLE SPENDING ACCOUNTS
You can enroll in either one or both Flexible Spending
Accounts (FSAs) in November, during the annual Flexible
Spending Account enrollment period for the plan year that
begins January 1. When you enroll, you choose how much to
contribute up to the maximum annual contribution amount.
Healthcare Reimbursement Account
Use your account to pay eligible healthcare expenses,
including deductibles, copays, dental care, vision care,
counseling, prescription drugs and prescribed over-thecounter drugs and products not covered by a health plan.
Dependent Care Reimbursement Account
(for child or elderly parent)
Use your account to pay eligible expenses while you and your
spouse are working or, if applicable, your spouse is in school.
Eligible expenses include those for before- and after-school
programs, daycare and nursery schools, pre-school programs
and elder care.
If you are currently enrolled in one of the FSAs, participation
ends on December 31, 2017 unless you re-enroll in November.
Elections do not carry over to the next year.
2017 Maximum Annual Contributions*
Healthcare
Dependent Care
$2,600
(if you are age 50 or older, you can add
$1,000 more)
$5,000
($2,500 if married and filing separate
tax returns)
* Subject to change for the 2018 plan year.
10
Plan Carefully!
You can use the money to pay
eligible expenses incurred
between the effective date and
the end of the calendar year.
LIFE AND ACCIDENTAL DEATH &
DISMEMBERMENT INSURANCE
Life insurance provides important financial protection for your family in the event of your death. Accidental
death and dismemberment (AD&D) insurance provides additional coverage if you die or become seriously
injured in an accident.
For You: Green Dot pays for your Basic Life and AD&D coverage equal to one times your annual earnings
up to $200,000 and at no cost to you. You may supplement this basic benefit with Voluntary Life and AD&D
insurance through Anthem. You may purchase life insurance separately from AD&D.
For Your Dependents: You may also purchase coverage for your eligible dependents if you elect voluntary
coverage for yourself. None of your dependents may be covered more than once. As a newly hired employee,
you may purchase coverage up to certain limits without evidence of insurability (a medical questionnaire that
Anthem must review and approve before coverage is effective) as shown in the table. However, if you waive
coverage as a newly hired employee, evidence of insurability may be required if you enroll at a later date.
Anthem Voluntary Life and AD&D Insurance Coverage
Coverage
Without Medical Questions
For You
Includes equal coverage for AD&D
insurance
For your spouse
Not more than 50% of your Green Dot
voluntary life insurance coverage
With Medical Questions
(for Anthem to approve evidence of insurability)
Up to $150,000 in units of $10,000
Up to $500,000 (not to exceed five times
your annual covered salary)
Up to $20,000 in units of $5,000
Up to $250,000
For eligible children
Ages six months to 26 years
$10,000
No evidence of insurability required
For eligible children
Under age six months
$1,000
LIFE INSURANCE
Monthly Contribution Rates – Employee and Dependents
Employee
Age
Per $1,000 in
Coverage
Employee
Age
Per $1,000 in
Coverage
Under 25
$0.058
50-54
$0.499
25-29
$0.070
55-59
$0.527
30-34
$0.093
60-64
$0.765
35-39
$0.104
65-69*
$1.473
40-44
$0.116
70 and over
$2.389
45-49
$0.174
Children
$0.98 for $1,000 coverage covers all eligible dependent children
* At age 65, your coverage or your spouse’s coverage will decrease to 65% of the
benefit amount and at age 70 to 50%.
11
Optional Accidental
Accident and
Dismemberment Insurance
Add $0.028 per
$1,000 in coverage
OTHER VOLUNTARY BENEFITS
You are eligible to enroll in Aflac benefits as a newly hired employee, at the time of a life event or during
Open Enrollment:
zz Personal
Accident Coverage
zz Hospital
Indemnity Plan
zz Personal
Cancer Coverage
zz Critical
Illness/Injury and Intensive Care
For more information or to enroll, please contact Jacob Burns at 661-733-2979 or email at Jacob_burns@
us.aflac.com.
OTHER GREEN DOT PAID BENEFITS
Benefit
Disability Insurance
What it is
You are automatically enrolled when eligible
for Short Term and Long Term Disability
coverage which replaces part of your income
while on a disability leave for a covered offwork illness or injury.
What you need to do
Nothing, enrollment is automatic
and paid by Green Dot.
zzThe
Short Term Disability benefit replaces
60% of eligible income up to $1,500/week
zzThe
Long Term Disability benefit replaces
60% of eligible income up to $10,000/month
Employee Assistance
Plan
Confidential counseling and referral services
available to you and your dependents for a
wide range of work, family and personal issues
available through Resource Advisor.
Enrollment is automatic and at no
cost to you. For more information
please call 888-209-7840.
Retirement Benefits
The Green Dot 401(k) Plan
To enroll, go to www.drs401k.com
zzNational
Employees Plan #2445
zzCalifornia
Employees Plan #1719
Email [email protected] for an
enrollment kit.
12
CONTRIBUTION RATES — PER PAY PERIOD
Effective July 1, 2017
Teachers / Counselors (22 pay periods)
Employee Only
Employee + 1 Dependent
Employee + Family
$0
$0
$0
Anthem HMO
$24.68
$51.83
$74.05
Kaiser HMO
$24.68
$51.83
$74.05
Anthem EPO
$46.60
$97.86
$139.80
Anthem PPO
$149.70
$314.39
$449.11
$0
$0
$0
Complete Low Plan
$10.96
$20.03
$38.91
Complete High Plan
$24.10
$43.04
$77.51
$0
$0
$0
Employee Only
Employee + 1 Dependent
Employee + Family
$0
$0
$0
Anthem HMO
$22.63
$47.51
$67.88
Kaiser HMO
$22.63
$47.51
$67.88
Anthem EPO
$42.72
$89.71
$128.15
Anthem PPO
$137.23
$288.19
$411.69
$0
$0
$0
Complete Low Plan
$10.05
$18.37
$35.67
Complete High Plan
$22.10
$39.45
$71.05
$0
$0
$0
Medical Benefits
Vivity HMO*
Dental Benefits
Net DHMO Plan*
Vision Benefits
Blue View Vision Plan*
Administrative Staff (24 pay periods)
Medical Benefits
Vivity HMO*
Dental Benefits
Net DHMO Plan*
Vision Benefits
Blue View Vision Plan*
* Green Dot pays 100% of the premium.
13