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2020
City of Santa Monica
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New Employee Benefits Overview
TABLE OF CONTENTS
Benefits You Can County On ............................................................................................................................ 2
What’s New In 2020? ..................................................................................................................................... 3
Benefit Highlights .......................................................................................................................................... 6
How To Enroll in Benefits ................................................................................................................................ 8
Who Can You Cover? ...................................................................................................................................... 9
Making the Most of Your Benefits................................................................................................................... 10
Blue Shield of California ............................................................................................................................... 11
Medical ..................................................................................................................................................... 14
Dental........................................................................................................................................................ 21
Vision ........................................................................................................................................................ 22
Cost of Coverage ......................................................................................................................................... 23
Life and Disability Insurance ......................................................................................................................... 24
Special Savings Accounts ............................................................................................................................. 27
Other Programs ........................................................................................................................................... 29
For Assistance ............................................................................................................................................ 32
Key Terms .................................................................................................................................................. 34
Important Plan Notices and Documents ........................................................................................................... 36
Appendix .................................................................................................................................................... 37
Notes......................................................................................................................................................... 38
Medicare Part D Notice: If you and/or your dependents have Medicare or will
become eligible for Medicare in the next 12 months, a federal law gives you more
choices about your prescription drug coverage. Please refer to the Legal Notices
posted on the City of Santa Monica website,
www.smgov.net/Departments/HR/Employees/Employees.aspx or contact Human
Resources at 310.458.8246 for more details.
1
BENEFITS YOU CAN DEPEND ON
At the City of Santa Monica, we believe that you, our employees, are our most important asset.
Helping you and your families achieve and maintain good health—physical, emotional and
financial - is the reason the City of Santa Monica offers you this benefits program. We are
providing you with this overview to help you understand the benefits that are available to you
and how to best use them. Please review it carefully and make sure to ask about any important
issues that are not addressed here. A list of plan contacts is provided in this New Employee
Benefits Overview booklet.
While we've made every effort to make sure that this guide is comprehensive, it cannot provide
a complete description of all benefit provisions. For more detailed information, please refer to
your plan benefit booklets or Evidence of Coverage (EOC) documents at the City of Santa
Monica website, www.smgov.net/Departments/HR/Employees/Employees.aspx. The
plan benefit booklets determine how all benefits are paid.
The benefits in this summary are effective:
January 1, 2020 - December 31, 2020
2
What’s New In 2020?
BENEFIT ADVOCATE - NEW PHONE NUMBER and EMAIL
The City of Santa Monica offers employees a dedicated Benefit Advocate through Alliant Insurance
Services. Your Benefit Advocate will help you navigate the complexities of your benefits plan. This
program is free and completely confidential.
What benefits are covered?
• Medical, RX, Dental, Vision
• Employee Assistance Program (EAP)
• Flexible Spending Account (FSA)
• Life & Disability
• Health Savings Account (HSA)
Your Advocate can assist with:
• Benefits choices during Open Enrollment • Resolving claims and billing issues
• Verifying eligibility and coverage • Coverage changes due to life events
• Finding a physician and access to care (marriage, new child, divorce
• Grievances and appeals
NEW Contact number: 1.888.585.5399, 8:30am – 5:00pm (M-F)
NEW Email: alliantba@alliant.com
BLUE SHIELD – HIGH DEDUCTIBLE HEALTH PLAN (HDHP)
Due to IRS regulations, the individual per Family member deductible is increasing from $2,700 to
$2,800 for the 2020 plan year. The Family deductible will remain the same.
VSP VISION PLAN
The new vision Choice Plan, will have the following frame benefit enhancements:
• Retail Frames – allowance will increase from $115 to $190
• Featured Frame Brand – allowance will increase from $135 to $210
• Costco Frames – allowance will increase from $60 to $105
• Elective Contacts – allowance will increase from $105 to $180
TRIO HMO PLAN – Teladoc Copay and Heal
For members on the Blue Shield Trio HMO plan, the copayment amount for a Teladoc virtual visit is
being reduced to “No Charge”. For detailed information on Teladoc, refer to page 12. The Heal
program is now available on the Trio HMO plan. Heal lets you see a doctor wherever is most convenient
for you – home, work or hotel. The first on-demand visit is $0 copay and following visits are a $20
copay. Learn about Heal at www.heal.com or call 844.644.4325.
3
EMPLOYEE ASSISTANCE PROGRAM (EAP)
Your life’s journey – made easier
No matter where you are on your journey, there are times when a little help can go a long way. From
checking off daily tasks to working on more complex issues, this program offers a variety of resources,
tools and services available to you and your household members.
Key features
• No cost to you
• Includes up to 5 counseling sessions per issue
• Completely confidential
• Available 24/7/365
Core Services
• Counseling – we provide support for challenges such as stress, anxiety, grief, relationship
concerns and more
• Coaching – when you have a goal to achieve, coaches help you create a plan of action and stay
on track
• Online programs – self-guided, interactive programs help improve your emotional well-being for
issue like depression and anxiety
Additional benefits:
• Legal assistance – free one hour with lawyer on phone or in person
• Financial coaching – two free 30-minute telephonic consultations
• Identify theft resolution – free 60-minute consultation with a Fraud Resolution Specialist
• Work-life services – specialists provide guidance and personalized referrals for childcare, adult
care, education, home improvement, consumer information, emergency preparedness and more
• Wellness resources – eat better, move more and be happier and healthier with resources such
as interactive tools and assessments, engaging videos, information on fitness, weight
management and other areas
Register online at www.magellanascend.com and explore the services
that are available, live Chat with a counselor, find a provider and search
the Learning Center.
Company name: City of Santa Monica
Help is available 24/7, 365 days a year.
Contact us at 800.523.5668.
4
WELLVOLUTION NEXT
Achieve your health goals with Wellvolution Next– Blue Shield’s whole-health platform that’s been
designed with you in mind.
Tap into decades of research and leading technology
for a more productive and healthy lifestyle
Our new wellness program has been design to custom fit your particular needs and lifestyle.
Wellvolution incorporates the following:
Prevent disease and reverse existing conditions – cardiovascular disease reversal, diabetes
prevention, 12-week integrated nutrition and movement programs; BlueStar, MySugr, Transform
Manage stress better – physiological, psychosocial and emotional training exercises, cognitive
behavioral therapy; eM Life, Calm, SuperBetter
Sleep better - pattern tracking optimization, relaxation exercises; Sleep Time, Pacifica
Physical activity – movement tracking, guided goad-based exercise plans, workout routines, coaching;
Fitbit, Fitocracy
Eat better – grocery and meal planning, nutritional calculators; Betr, Heath Slate, PlateJoy, Zipongo
Ditch cigarettes – smoking cessation qualified by financial and lifestyle gains, nicotine replacement
therapy; Clickotine, SmokeFree, 2Morow Health
A digital health platform and in-person support network
Focus Support Results
Stay on track and Receive digital All backed by real
progress along the reminders, motivation science for real,
proven path and engagement positive changes
Unveiling your personal
proven path to real health
5
Benefit Highlights
Is the HDHP/HSA right for you?
If you enroll in the Blue Shield High Deductible Health Plan (HDHP), you can open a Health Savings
Account (HSA). They both work together!
HDHP at a glace
• Lower premiums so more money in your paycheck
• Higher deductible
• Preventive care services are free
HSA is your savings partner
• You keep it even if you leave the City
• Your funds can grow, not a use it or lose it account
• Use it to pay eligible medical, dental and vision expenses
• Helps you save on taxes 3 ways!
1. No tax on HSA contribution
2. No tax on eligible HSA withdrawals
3. No tax on HSA interest and investment earnings
• Your HSA is your long-term
health fund. The balance
rolls over year after year so
you can use it anytime for
healthcare expenses.
• Your HSA is a smart
addition to your retirement
savings plan. Your post-
retirement healthcare
spending will be tax-free.
After age 65, you can use
HSA dollars for non-health
expenses too (subject to
ordinary income tax).
• You can invest your
Your HSA boosts your account balance. After you
retirement savings plan reach a minimum balance,
you can invest just like a
401K or IRA. You have many
investment options.
6
Connecting with a doctor within minutes is easy.
1. Request a visit with a doctor 24 hours a day,
365 days a year, by web, phone, or mobile.
Want to see the doctor? Choose “video” as the method for your visit. Feeling camera shy? Choose
“phone”. Got a busy schedule? Select a time that’s best for you by choosing “schedule” instead of “as
soon as possible”.
2. Talk to the doctor. Take as much time as you
need…there’s no limits!
You will receive convenient, quality care from a variety of licensed healthcare providers.
Physician Dermatologist Therapist
FOR ISSUES LIKE: FOR ISSUES LIKE: FOR ISSUES LIKE:
Cold & Flu symptoms Skin infection Stress/anxiety
Bronchitis Acne Depression
Allergies Skin rash Domestic abuse
Pink eye Abrasions Grief counseling
Bladder infection Moles/warts Addiction
3. If medically necessary, a prescription will be sent to
the pharmacy of your choice. It’s that easy!
Visit Teladoc.com/bsc and set up an account or call 1.800.835.2362
7
How To Enroll in Benefits
As a new employee, you have 30 days from your date of hire to enroll in the City of Santa
Monica’s benefit programs. After this initial enrollment period, your next opportunity to elect
and enroll in benefits will be during the 2021 Open Enrollment period unless you experience a
Qualifying Event (marriage, divorce, birth/death of a dependent, dependent loss/gain coverage).
What do I need to do?
1. All benefit eligible employees must go to the City’s online enrollment portal,
https://benefits.plansource.com, if you would like to do any of the items on #2.
2. If I want to:
• Enroll in any of the City-sponsored plans and the voluntary benefit for the first time;
• Add dependent coverage. Note that social security numbers are required for all
dependents;
• Add the Voluntary Term Life Plan;
• Participate for the first time in the Healthcare or Dependent Care FSA or participate for
the first time in an HSA;
• Waive participation in City-sponsored medical, dental, vision benefits; and/or
• Combine coverage with a spouse or registered domestic partner who is also a benefit-
eligible City employee.
You must go online to enroll or make changes in the City’s online enrollment website,
www.plansource.com/login. All plan changes, dependent additions or deletions and HSA or
FSA enrollments must be made online.
An electronic copy of the PlanSource Self-Service Enrollment Guide is available on the City’s
website, https://www.smgov.net/Departments/HR/Employees/PlanSource Online
Enrollment System.aspx. This guide will help you establish a username and/or obtain your
password. It also has step-by-step instruction on how to enroll.
Kaiser enrollments: to enroll in a Kaiser plan, you must also complete an Enrollment Form in
addition to enrolling online in the City’s enrollment portal.
What if I want to waive medical coverage?
If you plan to waive medical insurance coverage and are interested in receiving $150/month
(Cash-in-lieu), you will need to complete the Cash-in-Lieu Form and provide the following
documents listed below. You can email the documents to benefits@smgov.net, fax or deliver to
Human Resources Department.
1. Cash-in-Lieu Agreement Form
2. Copy of your medical insurance card
3. A letter or screenshot from the carrier or entity providing the plan that includes
employee name, medical plan, and effective coverage for the 2020 plan year.
8Who Can You Cover?
INELIGIBLE DEPENDENTS
• Former spouse/registered domestic partner even
if you are court ordered to provide the ex-
spouse/former domestic partner with health
coverage
• Children age 26 or older
• Children of former spouse or former registered
domestic partners
• Disabled children over age 26 who were not
enrolled prior to age 26
• Relatives such as grandchildren, grandparents,
WHO IS ELIGIBLE? parents, aunts, uncles, nieces, nephews, etc.
A permanent employee working 20 or more hours
DEPENDENT ELIGIBILITY DOCUMENTATION
per week is eligible for the benefits outlined in this
REQUIREMENTS
overview. Your coverage for health, dental and
If you are adding dependents (spouse and/or
vision benefits will be effective on the first of the
dependent children) during Open Enrollment, the
month following your date of hire.
City of Santa Monica requires that you verify your
ELIGIBLE DEPENDENTS dependent’s eligibility. You have 30 days from date
of hire to submit documentation that verifies your
• Current legal spouse or registered domestic
dependent eligibility to Human Resources. You may
partner (same or opposite gender).
email (benefits@smgov.net), fax (310-656-5705),
• Children (including your domestic partner's
or interoffice the documentation. If the verification
children):
documents for added dependents are not received
o Must be under the age of 26. They do not within 30 days, your dependent(s) will not be added
have to live with you or be enrolled in school. to your health plans for 2020.
They can be married and/or living and working
QUALIFYING LIFE EVENTS
on their own. Make sure to notify Human Resources if you have a
o Eligible children include natural children, qualifying life event and need to make a change
stepchildren, legally-adopted children, or (add or drop) to your coverage election. You have 31
children who have been placed in your days to make you change. These changes include
custody during the adoption process, and (but are not limited to):
physically or mentally handicapped children
who depend on you for support, regardless of • Birth or adoption of a baby or child
age. • Loss of other healthcare coverage, does not
o A child of a covered domestic partner who include private plans
satisfies the same conditions as listed above • Eligibility for new healthcare coverage
for natural children, stepchildren, or adopted • Marriage or Divorce
children, and in addition is not a “qualifying • Death of a dependent
child” (as defined in the Internal Revenue A list of qualifying events can be found in the Legal
Code) of another individual. Document posted on the City’s HR website.
Click on the icon to watch a
video on Qualifying Events.
9Making the Most of Your Benefits
WHEN TO USE THE ER Blue Shield Medical Plan Participants
The emergency room shouldn't be your first choice • Call NurseHelp 24/7 and get your health
unless there's a true emergency—a serious or life questions answered by a nurse. The phone
threatening condition that requires immediate number is on the back of your Blue Shield ID
attention or treatment that is only available at a card.
hospital. • Find an urgent care center by visiting
www.bscaplan.com/peotj4
WHEN TO USE URGENT CARE • Go online at www.blueshieldca.com/nursehelp
Urgent care is for serious symptoms, pain, or and have a one-on-one chat with a nurse
conditions that require immediate medical attention anytime.
but are not severe or life-threatening and do not
require use of a hospital or ER. Urgent care DIABETIC EYECARE PLUS PROGRAM
conditions include, but are not limited to: earache,
sore throat, rashes, sprains, flu, and fever up to VSP has special services if you have diabetic eye
104°. disease, glaucoma or age-related macular
degeneration (AMD). You can receive your routine
eye care and follow-up medical eye care services
GET A VIDEO HOUSE CALL
from your VSP doctor. You can also receive
Blue Shield members can video chat, 24/7, with a preventive retinal screenings if you have diabetes
doctor who can treat common illnesses and, if but do not show signs of diabetic eye disease.
needed, can send a prescription to your local Questions? Call VSP at 800.877.7195.
pharmacy. For more information, see page 12 or
visit www.teladoc.com/bsc.
PREVENTIVE CARE VS DIAGNOSTIC
Preventive care is intended to prevent or detect
illness before you notice any symptoms. Diagnostic
care treats or diagnoses a problem after you have
had symptoms.
Be sure to ask your doctor why a test or service is
ordered. Many preventive services are covered at no
WHEN YOU NEED CARE NOW
out-of-pocket cost to you. The same test or service
What do you do when you need care right away, but
can be preventive, diagnostic, or routine care for a
it’s not an emergency?
chronic health condition. Depending on why it's
Kaiser Permanente Plan Participants done, your share of the cost may change.
• Call Kaiser's 24/7 NurseLine at 800-464-4000 Whatever the reason, it's important to keep up with
• For access to care resources and advice go to recommended health screenings to avoid more
https://healthy.kaiserpermanente.org/southern- serious and costly health problems down the road.
california/doctors-locations/how-to-find-care/get-
To find out what preventive care screenings you
advice
should have based on your age and gender, visit
www.blueshieldca.com/preventive-care.
10Blue Shield of California
TRIO HMO – a special network
The Blue Shield Trio HMO plan is a smarter, more modern way to access health care. The Trio HMO is a special
network of doctors and hospitals that share responsibility for providing high-quality, coordinate care to you and
your family when needed while lowering costs by delivering care more efficiently.
Provider Network
The Trio HMO special network includes medical groups, hospitals and doctors from the HMO Access + network.
With the Trio HMO, you still must select a Primary Care Physician (PCP) to coordinate and direct your healthcare
needs. Below is a partial list of medical groups/IPA and hospitals that participate in this special network. Note
that UCLA is not part of the Trio HMO network.
County IPA/medical group name County Trio ACO HMO Hospitals
Los Angeles Access Medical Group Inc. Los Angeles Alhambra Hospital Medical Center
Access Medical Group Santa Monica Garfield Medical Center
Allied Pacific of California IPA Good Samaritan Hospital
AppleCare Medical Group Whittier Greater El Monte Community Hospital
AppleCare Medical Group Henry Mayo Newhall Hospital
AppleCare Medical Group Select Long Beach Memorial Medical Center
AppleCare Medical Group St. Francis Region Marina Del Rey Hospital
Axminster Medical Group – Little Company of Mary – San Monterey Park Hospital
Pedro Northridge Hospital Medical Center (Roscoe Campus)
Axminster Medical Group – Little Company of Mary IPA – PIH Hospital – Downey
Torrance Pomona Valley Hospital Medical Center
Axminster Medical Group – Providence Care Network – Providence Holy Cross Medical Center
Tarzana Providence Little Company of Mary Medical Center
Axminster Medical Group Inc. San Pedro
Facey Medical Foundation Burbank Providence Little Company of Mary Medical Center
Facey Medical Foundation San Fernando Valley Torrance
Facey Medical Foundation Santa Clarita Providence Saint Joseph Medical Center
Facey Medical Foundation Simi Valley Providence Tarzana Medical Center
Good Samaritan Medical Practice Associates St. John’s Health Center
Korean American Medical Group San Gabriel Valley Medical Center
Greater Newport Physicians (GNP) – Long Beach Simi Valley Hospital and Health Care Services
MemorialCare Torrance Memorial Medical Center
Pomona Valley Medical Group Whittier Hospital Medical Center
Torrance Health IPA
CUSTOM MICROSITE FOR CSM
Blue Shield is going green! We now have a custom website for all Blue Shield members from the City of Santa
Monica. Members will find everything that they need in one simple place.
• View plan information and benefit summaries 24/7
• Find doctors, hospitals, specialists and more
• Explore health programs, care options and services that are available to you
Go to www.bscaplan.com/peotj4.
11TELADOC – A VIRTUAL VISIT
Teladoc is available to all Blue Shield members. This service is a new and convenient way to access care. U.S.
certified doctors are available 24/7/365 to resolve non-emergency medical issues via phone or video consults.
When should I use What kind of symptoms
How much will I pay? How do I get started?
Teladoc? can be treated?
• If you are Teladoc doctors and Trio HMO: No Charge 1. Set up an account.
considering the ER therapists can treat many Visit teladoc.com/bsc,
or urgent care medical conditions, Access+ HMO and PPO complete the required
center for a non- including: Members: information and click on Set
emergency • Cold and flu symptoms $5 copay per consult up account.
• When on vacation, a • Allergies 2. Provide medical history.
business trip or • Bronchitis HDHP Members: Your medical history provides
away from home • Urinary tract infection Members pay a $40 doctors with the information
• For short-term • Respiratory infection consult fee until the they need to make an
prescription refills • Sinus problems deductible is met, then a accurate diagnosis.
• Depression $5 copay. 3. Request a consult.
• Anxiety Once your account is set up,
request a consult anytime you
need care.
Talk to a doctor anytime.
For information, go to www.teladoc.com/bsc or call 1-800-TELADOC (835.2362) for help.
MAIL ORDER SERVICES – CVS CAREMARK
Blue Shield of California provides access to the mail service drug benefit through CVS Caremark Mail Service
Pharmacy™.
Filling your prescription through the mail service pharmacy is easy.
1. Register with CVS Caremark.
Online – at www.caremark.com
By phone – call CVS Caremark at 866.346.7200.
2. Send your prescription to CVS Caremark.
Electronically – ask your doctor to send an electronic 90-day supply prescription to CVS Caremark.
By phone or fax – ask your doctor to submit a 90-day supply prescription by faxing 800.378.0323.
By mail – mail prescription, complete mail order form and payment to:
CVS Caremark, P.O. Box 659541, San Antonio, TX, 78265-9541
3. CVS Caremark delivers. Allow 10 – 14 days business days to receive your medication.
Refills are simple
• Online – register at www.caremark.com and ordering refills is convenient.
• By phone – call 866.346.7200 and follow the prompts for the automated reorder system.
• By mail – complete the CVS Caremark refill order form included in your last medication shipment and
mail it along with payment to: CVS Caremark, P.O. Box 659541, San Antonio, TX, 78265-9541.
12BLUE SHIELD CONCIERGE
One phone call to your Blue Concierge team delivers fast help.
Your Shield Concierge is a team of registered nurses, health coaches, social workers, pharmacy technicians,
pharmacists and customer service representatives, all working together for you!
They are ready to help you:
• Find a doctor or specialist Your Shield Concierge team is
• Transfer your prescriptions and medical records ready to help you.
• Understand your plan benefits
Call 855.829.3566
• Get answers to your drug/medication questions
• Answer questions about your doctor’s instructions Monday – Friday between 7 a.m. and 7 p.m.
• Assist with continuity of care
PROGRAMS AND SERVICES
Condition Management Program – Get nurse support, education and self-management tools to help treat
chronic conditions. Programs are available for members with asthma, diabetes, coronary artery disease, heart
failure and chronic obstructive pulmonary disease.
LifeReferrals 24/7 – With this program, you can call anytime to talk with experienced professionals ready to help
you with personal, family and work issues. Get referrals for three face-to-face or telephone visits in a six-
month period with a licensed therapist at no cost.
NurseHelp 24/7 - - registered nurses are available day or night to answer your health questions. Call
877.304.0504 or go online. www.blueshieldca.com/nursehelp, to have a one-to-one chat.
Prenatal Program – Expectant parents get 24/7 phone access to experienced maternity nurses. Program also
offers prenatal information, including a choice of a free pregnancy or parenting book.
Shield Support – Our case management program supports members with acute, long-term and high-risk
conditions. The program includes short-term care coordination and ongoing case management. The care team
includes physicians, registered nurses, licensed social workers and dieticians who provide support and
resources to meet member’s needs.
ID protection and credit monitoring – Blue Shield offers identity protection services such as credit monitoring,
identity repair assistance and identity theft insurance to our eligible plan members and their covered family
members. These services are at no charge.
Wellness discount programs – Blue Shield offers a wide range of discount programs to help you save money and
get healthier. These include discounts for Weight Watchers; membership with 24 Hour Fitness, ClubSport
and Renaissance ClubSport; acupuncture, chiropractic services and massage therapy; and eye exams,
frames, contact lenses and LASIK surgery. Visit www.blueshield.com/hw to learn more.
Have questions? Get answers.
Call the Shield Concierge number at 855.829.3566.
Visit the new Blue Shield microsite
at www.bscaplan.com/peotj4
13Blue Shield Medical Plans
This comparison chart shows a brief summary of the medical benefits available.
Blue Shield Access+ HMO Blue Shield Trio HMO
In-Network Only In-Network Only
How it Works You must use a Blue Shield HMO contracted provider or your care will not be
covered. There are no Out-of-Network benefits with these plans, except in the
case of an emergency.
Medical Plan
Annual Deductible $0 Individual/$0 Family $0 Individual/$0 Family
Lifetime Maximum Unlimited Unlimited
Annual Co-pay (Out-of-Pocket $1,500 Individual/$3,000 Family $1,500 Individual/$3,000 Family
maximum)
Hospital Care
Inpatient
- Physician No Charge No Charge
- Facility Services $100/ Admission $100/Admission
Outpatient Surgery No Charge No Charge
Emergency Room Visit
- Not resulting in admission $100 Co-pay $100 Co-pay
- Resulting in hospital admission Inpatient Facility Services charge applies Inpatient Facility Services charge applies
Physician Care
Office Visit $20 Co-pay $20 Co-pay
Specialist Visit $20 Co-pay or $30 Access+ (self-referral) $20 Co-pay or $30 for Trio (self-referral)
Telemedicine – Virtual Visit $5 Co-pay (Teladoc) No Charge (Teladoc)
Preventive Care/Annual Physical No Charge No Charge
X-Ray. Lab & Pathology Services No Charge No Charge
CT/PET scans, MRIs, MRAs No Charge No Charge
Immunizations No Charge No Charge
Outpatient Rehabilitation Therapy $20 Co-pay $20 Co-pay
- Physical, Speech, Occupational,
Respiratory
Chiropractic Services $15 Co-pay, 20 visits per year $15 Co-pay, 20 visits per year
Acupuncture Services Not Covered Not Covered
Mental Health/Substance Abuse
Inpatient - Mental Health $100/ Admission $100/ Admission
Outpatient - Mental Health $20 Co-pay at doctor’s office $20 Co-pay at doctor’s office
Chem. Dependency Rehab - Outpatient $20 Co-pay at doctor’s office $20 Co-pay at doctor’s office
Detoxification - Inpatient (Detox Only) $100/Admission $100/ Admission
Other
Ambulance - ER or authorized transport No Charge No Charge
Prosthetics No Charge No Charge
Durable Medical Equipment No Charge No Charge
Home Healthcare Services No Charge (up to 100 visits) No Charge (up to 100 visits)
Hospice No Charge No Charge
14Blue Shield Medical Plans
This comparison chart shows a brief summary of the medical benefits available.
Blue Shield Access+ HMO Blue Shield Trio HMO
In-Network Only In-Network Only
Other - Continued
Pregnancy/Maternity Care No Charge No Charge
Family Planning
- Counseling No Charge No Charge
- Tubal ligation No Charge No Charge
- Vasectomy No Charge No Charge
- Infertility Services (Diagnosis 50% of allowed charges 50% of allowed charges
and treatment of causes only)
Diabetes Care
Devices and non-testing supplies No Charge No Charge
Diabetes self-management training $20 Co-pay $20 Co-pay
Care Outside of Service Area
(benefits provided by the BlueCard Not Covered except for Not Covered except for
Program, for out-of-state Emergency Care Emergency Care
emergency and non-emergency
care, are provided at the preferred
level of the local Blue Plan
allowable amount when you use a
Blue Cross/Blue Shield provider)
· Within US: BlueCard Program
· Outside US: BlueCard Worldwide
Prescription Drugs Annual Deductible: Annual Deductible:
None None
Out-of-Pocket Maximum: Out-of-Pocket Maximum:
None None
Retail: Generic/Brand/Non- $10 / $20/ $35 / $35 (30-day supply) $10 / $20/ $35 /$35 (30-day supply)
formulary/High Cost Drugs
Mail Order: Generic/Brand/Non- $20 / $40 / $70/ $70 (90-day supply) $20 / $40/ $70/ $70 (90-day supply)
formulary/ High Cost Drugs
Specialty Medications $35 per script $35 per script
Click on the icon to watch a
video on Prescription Drugs /
Dos and Don’ts.
15Blue Shield Medical Plans
This comparison chart shows a brief summary of the medical benefits available.
Blue Shield Full PPO
How it Works You may see any provider when you need care. You decide whether to see an in-
network or an out-of-network provider each time you need care. When you see in-
network providers you typically pay less.
In-Network Out-of-Network
Medical Plan
Annual Deductible Individual: $500 - Family: $500/$1,000
Lifetime Maximum Unlimited
Annual Co-pay (Out-of-Pocket maximum) $3,000 Ind / $6,000 Family (combined In & Out-of-Network)
Hospital Care
Inpatient
- Physician 20%* 40%*
- Facility Services 20%* 40%* up to $1,500/day
Outpatient Surgery 20%* 40%* up to $600/day
Emergency Room Visit
- Not resulting in admission $100/ visit $100/ Visit
- Resulting in hospital admission 20%* 40%* up to $1,500/day
Physician Care
Office Visit $20 Co-pay 40%*
Specialist Visit $20 Co-pay 40%*
Telemedicine – Virtual Visit $5 Co-pay (Teladoc) Not Covered
Preventive Care/Annual Physical No Charge Not Covered
X-Ray. Lab & Pathology Services 20%* 40%*
CT/PET scans, MRIs, MRAs 20%* 40%*
Immunizations No Charge Not Covered
Outpatient Rehabilitation Therapy 20%* 40%*
- Physical, Speech, Occupational,
Respiratory
Chiropractic Services $20 Co-pay, 20 visits per year 40%*, 20 visits per year
Acupuncture Services Not Covered Not Covered
Mental Health/Substance Abuse
Inpatient - Mental Health 20%* 40%* up to $1,500/day
Outpatient - Mental Health $20 Co-pay at doctor’s office 40%*
Chem. Dependency Rehab - Outpatient $20 Co-pay at doctor’s office 40%*
Detoxification - Inpatient (Detox Only) 20%* 40%* up to $1,500/day
Other
Ambulance - ER or authorized transport 20%* 20%*
Prosthetics 20%* 40%*
Durable Medical Equipment 20%* 40%*
Home Healthcare Services No Charge, 120 visits/year* Not Covered
Hospice No Charge* Not Covered
* After annual deductible is met.
Note for Out-of-Network benefits - member is responsible for coinsurance in addition to any charges over the allowable amount.
When members use non-contracted providers, they must pay the applicable copayment/coinsurance plus any amount that
exceeds Blue Shield’s allowable amount. Charges in excess of the allowable amount do not count toward the calendar year
deductible or out-of-pocket maximum.
16Blue Shield Medical Plans
This comparison chart shows a brief summary of the medical benefits available.
Blue Shield Full PPO
In-Network Out-of-Network
Other - Continued
Pregnancy/Maternity Care No Charge 40%*
Family Planning
- Counseling No Charge Not Covered
- Tubal ligation No Charge Not Covered
- Vasectomy 20%* Not Covered
- Infertility Services (Diagnosis Not Covered Not Covered
and treatment of causes only)
Diabetes Care
Devices and non-testing supplies 20%* 40%*
Diabetes self-management training $20 Co-pay 40%*
Care Outside of Service Area
(benefits provided by the BlueCard Covered Covered
Program, for out-of-state
emergency and non-emergency
care, are provided at the preferred
level of the local Blue Plan
allowable amount when you use a
Blue Cross/Blue Shield provider)
· Within US: BlueCard Program
· Outside US: BlueCard Worldwide
Prescription Drugs Annual Deductible: Annual Deductible:
None None
Out-of-Pocket Maximum: Out-of-Pocket Maximum:
None None
Retail: Generic/Brand/Non- $10 / $20/ $35 / $35 (30-day supply) In-Network Copay + 25%
formulary/High Cost Drugs
Mail Order: Generic/Brand/Non- $20 / $40 / $70/ $70 (90-day supply) Not Covered
formulary/High Cost Drugs
Specialty Medications $35 per script Not Covered
* After annual deductible is met.
Note for Out-of-Network benefits - member is responsible for coinsurance in addition to any charges over the allowable amount.
When members use non-contracted providers, they must pay the applicable copayment/coinsurance plus any amount that
exceeds Blue Shield’s allowable amount. Charges in excess of the allowable amount do not count toward the calendar year
deductible or out-of-pocket maximum.
17Blue Shield Medical Plans
This comparison chart shows a brief summary of the medical benefits available.
Blue Shield High Deductible Health Plan (PPO)
How it Works You may see any provider when you need care. You decide whether to see an in-
network or an out-of-network provider each time you need care. When you see in-
network providers you typically pay less.
In-Network Out-of-Network
Medical Plan
Annual Deductible Individual: $1,800 - Family: $2,800/$3,600
Lifetime Maximum Unlimited
Annual Co-pay (Out-of-Pocket maximum) $4,500 Ind/ $9,000 Family $8,000 Ind / $16,000 Family
Hospital Care
Inpatient
- Physician 20%* 40%*
- Facility Services $100 Co-pay + 20%* 40%* up to $1,500/day
Outpatient Surgery 20%* 40%* up to $600/day
Emergency Room Visit
- Not resulting in admission $150 /visit + 20%* $150/ Visit + 20%*
- Resulting in hospital admission $100 Co-pay + 20%* 40%* up to $1,500/day
Physician Care
Office Visit 20%* 40%*
Specialist Visit 20%* 40%*
Telemedicine – Virtual Visit $5 Co-pay (Teladoc)* Not Covered
Preventive Care/Annual Physical No Charge Not Covered
X-Ray. Lab & Pathology Services 20%* 40%*
CT/PET scans, MRIs, MRAs 20%* 40%*
Immunizations No Charge Not Covered
Outpatient Rehabilitation Therapy 20%* 40%*
- Physical, Speech, Occupational,
Respiratory
Chiropractic Services 20%*, 20 visits per year 40%*, 20 visits per year
Acupuncture Services 20%*, 20 visits per year 20%*, 20 visits per year
Mental Health/Substance Abuse
Inpatient - Mental Health $100 Co-pay + 20%* 40%* up to $1,500/day
Outpatient - Mental Health 20%* 40%*
Chem. Dependency Rehab - Outpatient 20%* 40%*
Detoxification - Inpatient (Detox Only) $100 Co-pay + 20%* 40%* up to $1,500/day
Other
Ambulance - ER or authorized transport 20%* 20%*
Prosthetics 20%* 40%*
Durable Medical Equipment 20%* 40%*
Home Healthcare Services 20%*, 100 visits/year* Not Covered
Hospice No Charge* Not Covered
* After annual deductible is met.
Note for Out-of-Network benefits - member is responsible for coinsurance in addition to any charges over the allowable amount.
When members use non-contracted providers, they must pay the applicable copayment/coinsurance plus any amount that
exceeds Blue Shield’s allowable amount. Charges in excess of the allowable amount do not count toward the calendar year
deductible or out-of-pocket maximum.
18Blue Shield Medical Plans
This comparison chart shows a brief summary of the medical benefits available.
Blue Shield High Deductible Health Plan (PPO)
In-Network Out-of-Network
Other - Continued
Pregnancy/Maternity Care 20%* 40%*
Family Planning
- Counseling No Charge Not Covered
- Tubal ligation No Charge Not Covered
- Vasectomy 20%* Not Covered
- Infertility Services (Diagnosis Not Covered Not Covered
and treatment of causes only)
Diabetes Care
Devices and non-testing supplies 20%* 40%*
Diabetes self-management training 20%* 40%*
Care Outside of Service Area
(benefits provided by the BlueCard Covered Covered
Program, for out-of-state
emergency and non-emergency
care, are provided at the preferred
level of the local Blue Plan
allowable amount when you use a
Blue Cross/Blue Shield provider)
· Within US: BlueCard Program
· Outside US: BlueCard Worldwide
Prescription Drugs You must meet the annual deductible first before the noted co-payment
amounts apply.
Medical and Pharmacy have combined Out-of-Pocket Maximum
Retail: Generic/Brand/Non- $10 / $25/ $40/ 30% up to $200 max In-Network Copay + 25%
formulary/High Cost Drugs per script* (30-day supply)
Mail Order: Generic/Brand/Non- $20 / $50 / $80 / 30% up to $400 per Not Covered
formulary/ High Cost Drugs script* (90-day supply)
Specialty Medications 30% up to $200 max per script* Not Covered
* After annual deductible is met.
Note for Out-of-Network benefits - member is responsible for coinsurance in addition to any charges over the allowable amount.
When members use non-contracted providers, they must pay the applicable copayment/coinsurance plus any amount that
exceeds Blue Shield’s allowable amount. Charges in excess of the allowable amount do not count toward the calendar year
deductible or out-of-pocket maximum.
19Kaiser Medical Plan
The City of Santa Monica offers you a Kaiser Permanente option for medical insurance.
2019 Kaiser HMO 2020 Kaiser HMO
In-Network Only In-Network Only
Medical Plan
Annual Deductible None None
Lifetime Maximum Unlimited Unlimited
Annual Co-pay (Out-of-Pocket $1,500 Individual/$3,000 Family $1,500 Individual/$3,000 Family
maximum)
Hospital Care
Inpatient Surgery No Charge No Charge
Outpatient Surgery $15 Co-pay per procedure $15 Co-pay per procedure
Emergency Room Visit
- Not resulting in admission $50 Co-pay $50 Co-pay
- Resulting in hospital No Charge No Charge
admission
Physician Care
Office Visit $15 Co-pay $15 Co-pay
Specialist Visit $15 Co-pay $15 Co-pay
Urgent Care $15 Co-pay $15 Co-pay
Preventive Care/Annual Physical No Charge No Charge
X-Ray. Lab & Pathology Services $5 Co-pay per encounter $5 Co-pay per encounter
CT/PET scans, MRIs, MRAs $5 Co-pay per procedure $5 Co-pay per procedure
Immunizations No Charge No Charge
Physical/Occupational Therapy $15 Co-pay $15 Co-pay
Mental Health/Substance Abuse
Inpatient - Mental Health No Charge No Charge
Outpatient - Mental Health $15 Co-pay $15 Co-pay
Chem. Dependency Rehab - Outpatient $15 Co-pay $15 Co-pay
Detoxification - Inpatient (Detox Only) No Charge No Charge
Other
Ambulance $50 per transport $50 per transport
Prosthetics No Charge No Charge
Durable Medical Equipment 20% Coinsurance 20% Coinsurance
Home Healthcare Services No Charge (up to 100 visits) No Charge (up to 100 visits)
Hospice No Charge No Charge
Prescription Drugs
Retail: $10 Co-pay Generic $10 Co-pay Generic
$15 Co-pay Preferred Brand $15 Co-pay Preferred Brand
$15 Non-Preferred Brand $15 Non-Preferred Brand
Specialty: $15 Co-pay per script Specialty: $15 Co-pay per script
No Non-Formulary Coverage No Non-Formulary Coverage
Mail-Order: (30-day supply) (30-day supply)
$10 Co-pay Generic $10 Co-pay Generic
$15 Co-pay Preferred Brand $15 Co-pay Preferred Brand
$15 Co-pay Non-Preferred Brand $15 Co-pay Non-Preferred Brand
(100-day supply) (100-day supply)
For information on the Kaiser plan, please contact PacFed Benefits Administration at 800.753.0222. Refer to page 31
for additional services from PacFed.
20Dental
Regular visits to your dentists can protect more than your smile; they can help protect your health.
Delta Dental DHMO
DeltaCare USA Delta Dental PPO Plan
In-Network In-Network Out-Of-Network
Calendar Year $0 Individual $0 Individual $50 Individual
Deductible
$0 Family $0 Family $150 Family
Annual Plan Maximum Unlimited $2,000/person $1,000/person
Waiting Period None None None
Diagnostic and Plan pays 100% Plan pays 100% Plan pays 80%
Preventive
Basic Services
Fillings $0-$50 copay (varies by Plan pays 90% after Plan pays 80% after
service, see contract for fee deductible deductible
schedule)
Root Canals $5-$75 copay (varies by Plan pays 90% after Plan pays 80% after
service, see contract for fee deductible deductible
schedule)
Periodontics $5-$150 copay (varies by Plan pays 90% after Plan pays 80% after
service, see contract for fee deductible deductible
schedule)
Major Services $5-$125 copay (varies by Plan pays 70% after Plan pays 50% after
service, see contract for fee deductible deductible
schedule)
Orthodontic Services
Orthodontia
Lifetime Maximum N/A $1,000 (combined in and out-of-network)
Child $1,600 Plan pays 50% Plan pays 50%
Adult $1,800 Plan pays 50% Plan pays 50%
When first enrolling in a DHMO plan, you must choose a primary dentist. If you do not select a dentist, one will
automatically be selected for you. If you would like a different dentist than the one that was auto-assigned, you
will need to call Delta Dental at 800.422.4234.
Click on the icon to watch a
video on Dental Insurance.
21Vision
Routine vision exams are important, not only for correcting vision but because they can detect other serious
health conditions. The City of Santa Monica offers you a vision plan through Vision Service Plan.
VSP – Choice Plan
In-Network Out-Of-Network
Examination
Benefit $25 copay then plan pays 100% Plan pays up to the $45 allowance
Frequency 1 x every 12 months In-network limitations apply
Materials Combined with examination Combined with examination
Eyeglass Lenses
Single Vision Lens Plan pays 100% of basic lens Up to $30 allowance
Bifocal Lens Plan pays 100% of basic lens Up to $50 allowance
Trifocal Lens Plan pays 100% of basic lens Up to $65 allowance
Standard Progressive Plan pays 100% Up to $50 allowance
20% off all other lens options
Frequency 1 x every 12 months In-network limitations apply
Frames
Benefit Up to $190 retail allowance, then 20% off Up to $70
amount above the allowance
Up to $210 allowance for featured brand Up to $70
Up to $105 allowance at Costco N/A
Frequency 1 x every 24 months In-network limitations apply
Contacts (Elective)
Elective Up to $180 allowance (instead of eyeglasses) Up to $105 allowance (instead of
eyeglasses)
Medically Necessary $25 copay Up to $210 allowance
Frequency 1 x every 12 months 1 x every 12 months
Low Vision Benefit $1,000 maximum benefit every two years (for
severe vision problems) Not covered
Laser Vision Correction 15% fee discount Not covered
Suncare $25 copay, up to $190 allowance for ready-
Up to $70
made non-prescription sunglasses
Frequency 1 x every 24 months
22Cost of Coverage
The City of Santa Monica pays for 100% of the premiums for Dental, Vision, the Employee Assistance Program,
basic Life and Accidental Death & Dismemberment (AD&D), and Long Term Disability (LTD) coverage.
Please note that medical rates can be found at www.smgov.net/departments/hr/.
Dental City Employee
Premium Contribution Contribution
Delta Dental DHMO Dental Plan
Employee Only
$35.41 ($35.41) $0
With 1 Dependent
$35.41 ($35.41) $0
Two + Dependents
$35.41 ($35.41) $0
Delta Dental DPPO Dental Plan
Employee Only
$91.08 ($91.08) $0
With 1 Dependent
$91.08 ($91.08) $0
Two + Dependents
$91.08 ($91.08) $0
Vision City Employee
Premium Contribution Contribution
VSP Vision Plan
Employee Only
$11.76 ($11.76) $0
With 1 Dependent
$11.76 ($11.76) $0
Two + Dependents
$11.76 ($11.76) $0
23Life and Disability Insurance
If you have loved ones who depend on your income for support, having life and accidental death
insurance can help protect your family's financial security.
BASIC LIFE and AD&D
Basic Life Insurance pays your beneficiary a lump sum if you die. AD&D provides another layer of
benefits to either you or your beneficiary if you suffer from loss of a limb, speech, sight, or hearing, or
if you die in an accident. The cost of coverage is paid in full by the City of Santa Monica. Coverage
is provided by The Hartford.
Eligible Group Basic Life Amount Basic AD&D Amount
Class 1: ATA, EPP, FEMA, HRO, MTA, PALSSU, 2 x basic annual salary 2 x basic annual salary
PAU, RCL, RCM, STA, SUE, POA(Lieutenant, up to $500,000 up to $500,000
Police Captain, Deputy Police Chief)
Class 2: FIRE $75,000 $10,000
Class 3: MEA $50,000 $10,000
Class 4: EAC, SMART $10,000 $10,000
Class 5: STA and ATA reclassified into MEA 2 x basic annual salary 2 x basic annual salary
prior to January 1, 2010. up to $500,000 up to $500,000
Class 6: IBT $100,000 $20,000
Taxes: Due to IRS regulations, a life insurance benefit of $50,000 is considered a taxable benefit. You
will see the value of the benefit included in your taxable income on your paycheck and W-2.
Note: Your amount of Life and AD&D will decrease to 65% of original coverage on your 70th birthday
and 50% of original coverage at age 75.
BENEFICIARY REMINDER
Beneficiary means a person you name to receive death benefits.
You may name one or more beneficiaries. Make sure that you
have named a beneficiary for your basic life insurance. You may
change your beneficiary at any time. Note that some states
require a spouse be named as a beneficiary unless they sign a
waiver. Remember that a divorce or separation will not
automatically affect a beneficiary designation, so review your
beneficiary election(s) annually to ensure it accurately reflects
your wishes. Go to www.plansource.com/login , to change your
beneficiary.
24LONG-TERM DISABILITY INSURANCE
Long-Term Disability coverage pays you a certain percentage of your income if you can't work because
an injury or illness prevents you from performing any of your job functions over a long time. It's
important to know that benefits are reduced by income from other benefits you might receive while
disabled, like Workers' Compensation and Social Security.
If you qualify, long-term disability benefits begin after short-term disability benefits end. The cost of
coverage is paid in full by the City of Santa Monica. Coverage is provided by The Hartford.
Eligible Group: Class 1 Plan pays 60% of your basic monthly income
Employees in job classes represented by: $8,333 is maximum amount
Active full-time or permanent part-time employee
represented by or who receive the benefits of the: Benefits begin after 60 days of disability
Executive Pay Plan (Exec), Hearing Examiner
Representation Organization (Hero), Public Social Security normal retirement age is
Attorney's Union (PAU), Employees of the maximum payment period*
Society for Union Employment (SUE), Rent
Control Managers, Administrative Team
Association (ATA), Management Team
Association (MTA), Fire Executive Management
Association (FEMA) employee, working a
minimum of 20 hours per week
Eligible Group: Class 2 Plan pays 60% of your basic monthly income
Employees in job classes represented by: $6,667 is maximum amount
Active full-time or permanent part-time employee
represented by or who receive the benefits of the: Benefits begin after 60 days of disability
City Council, Municipal Employee Association
(MEA), International Brotherhood of Teamsters Social Security normal retirement age is
(IBT), Employees Action Committee of the Rent maximum payment period*
Control Board (EAC, Rent Control Letters of
Employment, Supervisory Team Associates
(STA), Public Attorneys' Legal Support Staff
Union (PALSSU) employee working a minimum of
20 hours per week
Eligible Group: Class 3 Plan pays 60% of your basic monthly income
Employees in job classes represented by: $5,000 is maximum amount
Active full-time or permanent part-time employee
represented by or who receive the benefits of the: Benefits begin after 60 days of disability
International Association of Sheet Metal, Air, Rail,
and Transportation workers - Transportation Social Security normal retirement age is
Division (SMART-TD) employee working a maximum payment period*
minimum of 20 hours per week
*The age at which the disability begins may affect the duration of the benefits.
25VOLUNTARY TERM LIFE INSURANCE
Voluntary Term Life Insurance allows you to purchase additional life insurance to protect your family's
financial security. Coverage is provided by The Hartford.
Employee Voluntary Term Can elect from $10,000 to $300,000 in increments of $10,000
Life Amount not to exceed five (5) times your salary. Guaranteed issue
amount is three (3) times basic annual earnings or $100,000
whichever is less.*
Spouse or Domestic Partner Can elect from $10,000 to $150,000 in increments of
Voluntary Term Life Amount $10,000. Guaranteed issue amount is $30,000.
Child(ren) Voluntary Term Can elect $2,500 or $5,000 or $7,500 or $10,000 (from 6
Life Amount months to age 26). Guaranteed issue amount is $10,000.
*Guaranteed issue amount is only available to new hires. If you do not enroll during your initial new
hire period, you will need to submit an Evidence of Coverage (EOI) form.
.
Monthly Rates
Employee and Spouse Supplemental Life
Child Life Insurance Rates
Insurance Rates
Coverage Cost of Coverage
Age Cost per $1,000 of
Levels
Coverage $2,500 each $0.54
Under 20 $0.04 child
20-24 $0.04
25-29 $0.04 $5,000 each $0.80
child
30-34 $0.052
35-39 $0.064 $7,500 each $1.09
40-44 $0.101 child
45-49 $0.167
$10,000 each $1.36
50-54 $0.282 child
55-59 $0.486
60-64 $0.628
65-69 $0.883
70-74 $1.767
75+ $1.767
26Special Savings Accounts
FLEXIBLE SPENDING ACCOUNT (FSA)
The City of Santa Monica offers you a Healthcare and Dependent Care Flexible Spending Account (FSA)
through the P&A Group. You may participate in one or both plans.
Healthcare FSA Account
This plan allows you to pay for eligible healthcare expenses with pre-tax dollars. Eligible expenses include
medical, dental, or vision costs such as plan deductibles, copays, coinsurance amounts, and other non-
covered healthcare costs for you and your tax dependents. For 2020, you can set aside up to $2,750.
Dependent Care FSA Account
This plan allows you to set aside up to $5,000 per household to pay for eligible out-of-pocket dependent
care expenses with pre-tax dollars. Eligible expenses may include daycare centers, in-home child care,
and before or after school care for your dependent children under age 13. Other individuals may qualify
if they are considered your tax dependent and are incapable of self-care. It is important to note that you
can access money only after it is placed into your dependent care FSA account.
NOTE: IRS regulations require annual Non-Discrimination testing on the Dependent Care FSA
Accounts. Highly compensated individuals may have their contribution amount adjusted during the
year in order to pass the non-discrimination requirements.
IMPORTANT CONSIDERATIONS
• You must use all of your FSA funds by March 15, 2021 or else you will lose them. The Healthcare
FSA plan has a Grace Period that allows you to continue to incur new claims up to 03/15/21, with
any remaining funds from your 2020 elected amount. You have till 06/30/21 to submit these claims.
• Elections cannot be changed during the plan year, unless you have a qualified change in family status.
• FSA funds can be used for you, your spouse, and your tax dependents only.
• You must re-enroll every year during Open Enrollment. Your elected amount will not roll over for
the next plan year.
How do I enroll in an FSA for 2020?
• Go to www.plansource.com/login
• Create a new User Name and Password to login
• Choose the amount you would like deducted from your
paycheck in 2020.
How do I manage my FSA account?
You have the option to use P&A’s online portal on your laptop or on your phone. Go to
www.padmin.com. Upload your claims by simply logging into your account through your smartphone.
For assistance, call P&A Customer Service at 800.688.2611.
27HEALTH SAVINGS ACCOUNT (HSA)
A Health Savings Account (HSA) is available to employees who participate in the Blue Shield High
Deductible Health Plan (HDHP). This is a tax-advantaged savings account that allows you to save pre-
tax dollars to pay for qualified health expenses. To open an HSA account or change your contributions,
you must go online to the City’s Open Enrollment website at www.plansource.com/login.
Why have an HSA Account?
• An HSA account is owned by you.
• Use pre-tax dollars to pay for qualified medical, dental and vision expenses.
• The HSA is portable; it goes with you if you leave employment.
• You elect the contribution amount to your HSA each pay
period, up to the IRS maximum before taxes are withheld. You
may change the deduction amounts at any time. The annual
employee contribution amount is subject to CA state taxes.
• If you and your spouse are both enrolled in a HDHP and
contribute into an HSA, your combined HSA contribution
cannot be more than the 2020 IRS maximum, even if your
spouse does not work for the City.
• Simply use your HSA debit card to pay for qualified expenses.
• HSA funds can be used to pay for qualified medical expenses of IRS tax dependents, even if the
dependent is not enrolled in your HDHP.
NOTE: you are not eligible to elect an HSA if you are covered by another health plan, such as a health
plan sponsored by your spouse’s employer, Medicare, Tricare, or if an employee is claimed as a
dependent on another’s tax return.
HSA Contribution Limits for 2020
Annual Single Contribution Maximum $3,550
Annual Family Contribution Maximum $7,100
Annual Catch-Up Contribution Maximum (for $1,000
HSA participants that are 55 years or older)
Want to learn more?
Click on the icon to watch a video on how
a High Deductible Health Plan works
alongside a Health Savings Account.
28You can also read
