benefits GUIDE
YOUR 2023
JANUARY 1—DECEMBER 31, 2023
Eligibility
You are eligible for benefits if you work 30 or more hours per week. You may also enroll your eligible family members under certain plans you choose for yourself. Eligible family members include: ▪ Your legally married spouse ▪ Your registered domestic partner (RDP) and/or their children, where applicable by state law ▪ Your children who are your natural children, stepchildren, adopted children or children for whom you have legal custody (age restrictions may apply). Disabled children age 26 or older who meet certain criteria may continue on your health coverage.
When Coverage Begins ▪
New Hires: You must complete the enrollment process within 30 days of your date of hire. If you enroll on time, coverage is effective on the first of the month following 30 days from your date of hire. If you fail to enroll on time, you will NOT have benefits coverage (except for company-paid benefits).
▪
Open Enrollment: Changes made during Open Enrollment are effective January 1—December 31, 2023.
Choose Carefully!
Due to IRS regulations, you cannot change your elections until the next annual Open Enrollment period, unless you have a qualified life event during the year. Following are examples of the most common qualified life events: ▪ Marriage or divorce ▪ Birth or adoption of a child ▪ Child reaching the maximum age limit ▪ Death of a spouse, RDP, or child ▪ You lose coverage under your spouse’s/RDP’s plan ▪ You gain access to state coverage under Medicaid or CHIP
Making Changes
To make changes to your benefit elections, you must contact Human Resources within 31 days of the qualified life event (including newborns). Be prepared to show documentation of the event such as a marriage license, birth certificate or a divorce decree. If changes are not submitted on time, you must wait until the next Open Enrollment period to make your election changes.
To enroll online, go to http://agapeim.ease.com Required Information—When you enroll, you will be required to enter a Social Security number (SSN) for all covered dependents. The Affordable Care Act (ACA), otherwise known as health care reform, requires the company to report this information to the IRS each year to show that you and your dependents have coverage. This information will be securely submitted to the IRS and will remain confidential.
Medical We’re proud to offer you a choice of medical plans through California Choice. Kaiser Platinum HMO A
Sutter Platinum HMO B
Sutter Platinum HMO A
Kaiser Gold HMO B
Sutter Gold HMO B
In-Network Only
In-Network Only
In-Network Only
In-Network Only
In-Network Only
$0
$0
$0
$250 / $500
$250 / $500
$3,000 / $6,000
$3,500 / $7,000
$4,500 / $9,000
$7,800 / $15,600
$7,800 / $15,600
$10 / $20 copay
$15 / $30 copay
$20 / $30 copay
$35 / $55 copay
$35 / $55 copay
No charge
No charge
No charge
No charge
No charge
$20 / $40 copay
$15 / $25 copay
$20 / $30 copay
$35 / $55 copay
$35 / $55 copay
$150 copay
$150 copay
$100 copay
$250 copay*
$250 copay*
Chiropractic (20 visits max/year)
$15 copay
Not covered
Not covered
Not covered
Not covered
Ambulance
$150 copay
$100 copay
$150 copay
$250 copay*
$250 copay*
Emergency Room
$200 copay
$100 copay
$150 copay
$250 copay*
$250 copay*
Urgent Care Facility
$10 copay
$15 copay
$20 copay
$35 copay
$35 copay
Inpatient Hospital Stay
$500 copay
$250/day
$250/day
$600/day*
$600/day*
Outpatient Surgery
$300 copay
$125 copay
$125 copay
$335 copay*
$335 copay*
Retail Pharmacy (30-day supply)
$5 / $15 / $15
$5 / $15 / $30
$5 / $20 / $30
$15 / $40 / $40
$15 / $40 / $70
Mail Order (90-day supply)
$10 / $30 / $30
$10 / $30 / $60
$10 / $40 / $60
$30 / $80 / $80
$30 / $80 / $140
Key Medical Benefits
Anthem Gold HMO B
WHA Gold HMO B
WHA Gold HMO C
WHA Gold HMO D
Sutter Silver HMO C
In-Network Only
In-Network Only
In-Network Only
In-Network Only
In-Network Only
$0 / $0
$250 / $500
$1,000 / $2,000
$2,4002 / $4,8002
$2,500 / $5,0002
$6,500 / $13,000
$7,800 / $15,600
$7,800 / $15,600
$4,800 / $9,600
$7,050 / $14,100
$30 / $60 copay
$35 / $55 copay
$40 / $40 copay
$0*
$35 / $50 copay*
No charge
No charge
No charge
No charge
No charge
$15 / $15 copay
$35 / $55 copay
$0 / $40 copau
$0*
$35 / $15 copay*
$250 copay
$250 copay*
$300 copay
$0*
$50 copay*
Key Medical Benefits Deductible (per calendar year) Individual / Family
Out-of-Pocket Maximum (per calendar year) Individual / Family
Covered Services Office Visits (physician/specialist) Routine Preventive Care Outpatient Diagnostic (lab/X-ray) Complex Imaging
Prescription Drugs (Tiers)
Deductible (per calendar year) Individual / Family
Out-of-Pocket Maximum (per calendar year) Individual / Family
Covered Services Office Visits (physician/specialist) Routine Preventive Care Outpatient Diagnostic (lab/X-ray) Complex Imaging Chiropractic (20 visits max/year)
$15 copay
$15 copay
$15 copay
$0*
Not covered
Ambulance
$150 copay
$250 copay*
$0
$0*
25%*
Emergency Room
$325 copay
$250 copay*
$300 copay*
$0*
25%*
Urgent Care Facility
$30 copay
$35 copay
$50 copay
$0*
$35 copay*
Inpatient Hospital Stay
$550 copay
$600/day*
$500/day*
$0*
25%*
Outpatient Surgery
$500 copay
$335 copay*
$500 copay*
$0*
25%*
$10 / $50 / $90
$15 / $40 / $70
$10 / $501 / $751
$0* / $40* / $50*
$20* / $40* / $60*
$0* / $100* / $150*
$40* / $80* / $120*
Prescription Drugs (Tiers) Retail Pharmacy (30-day supply) Mail Order (90-day supply)
$25 / $150 / $270
$38 / $100 / $175
1
$25 / $125 / $188
1
Coinsurance percentages and copay amounts shown in the above chart represent what the member is responsible for paying. *Benefits with an asterisk ( * ) require that the deductible be met before the Plan begins to pay. 1. The amount reflected represents the member’s cost after the pharmacy deductible has been met—$500 Individual, $1,000 Family 2. The deductible applies to both Medical & Rx.
Medical Anthem Gold PPO E
Key Medical Benefits
Anthem Silver PPO C
In-Network Only
Out-of-Network1
In-Network Only
Out-of-Network1
$500 / $1,500
$2,000 / $4,000
$1,700 / $3,400
$3,400 / $6,800
$7,700 / $15,400
$15,400 / $30,800
$9,100 / $18,200
$18,200 / $36,400
$30 / $60 copay
50%*
$50 / $95 copay
50%*
Deductible (per calendar year) Individual / Family
Out-of-Pocket Maximum (per calendar year) Individual / Family
Covered Services Office Visits (physician/specialist) Routine Preventive Care Outpatient Diagnostic (lab/X-ray) Complex Imaging Chiropractic
No charge
Not covered
No charge
Not covered
$15 / $15 copay
50%*
$20 / $20 copay
50%*
$100 copay then 20%*
50%*
$100 copay then 40%*
50%*
50%
Not covered
50%
Not covered
Ambulance Emergency Room Urgent Care Facility Inpatient Hospital Stay Outpatient Surgery
20%*
40%*
$250 copay then 20%*
$300 copay then 40% *
$30 copay
50%*
$50 copay
50%*
20%*
50%*
40%*
50%*
$200 copay then 20%*
50%*
$200 copay then 40%*
50%*
$10 / $50 / $90
Not covered
$15 / $702 / $1102
Not covered
Prescription Drugs (Tiers) Retail Pharmacy (30-day supply) Mail Order (90-day supply)
$25 / $150 / $270
Not covered
2
$38 / $210 / $330
2
Not covered
Coinsurance percentages and copay amounts shown in the above chart represent what the member is responsible for paying. *Benefits with an asterisk ( * ) require that the deductible be met before the Plan begins to pay. 1. If you use an out-of-network provider, you will be responsible for any charges above the maximum allowed amount. 2. The amount reflected represents the member’s cost after the pharmacy deductible has been met—$300 Individual, $600 Family
Dental We are proud to offer you a choice of dental plans with SmileSaver through CaliforniaChoice.
Key Dental Benefits Deductible (per calendar year) Individual / Family
SmileSaver 1000 DHMO
SmileSaver 3000 DHMO
In-Network Only
In-Network Only
N/A
N/A
Benefit Maximum (per calendar year; Preventive, Basic and Major services combined) Per Individual
None
None
Covered Services Preventive Services
No charge
No charge
Basic Services
$0 - $95
$9 - $185
Major Services
$50 - $175
$110 - $225
$1,600 Max; See schedule
$1,600 Max; See schedule
Orthodontia (Child only)
Coinsurance percentages shown in the above chart represent what the member is responsible for paying. *Benefits with an asterisk ( * ) require that the deductible be met before the Plan begins to pay. 1. If you use an out-of-network provider, you will be responsible for any charges above the maximum allowed amount.
Cost of Benefits Your contributions toward the cost of benefits are automatically deducted from your paycheck before taxes. The amount will depend upon the plan you select and if you choose to cover eligible family members. We will contribute up to $350 per month towards employee medical coverage. Dental Cost
SmileSaver 1000
SmileSaver 3000
Employee (EE) Only
$21.25
$11.92
EE + 1
$35.44
$23.83
EE + 2
$49.31
$34.28
Contact Information Coverage
Carrier
Phone #
Website/Email
Medical
California Choice
(800) 558-8003
www.calchoice.com
Dental
California Choice
(800) 558-8003
www.calchoice.com
Benefits Website Our benefits website http:// www.agapeim.ease.com can be accessed anytime you want additional information on our benefit programs.
Questions? If you have additional questions, you may also contact: HUB Employee Advocate Hotline (877) 838-4779 [emailprotected] Nicole Carillo (916) 784-2800 [emailprotected]
DISCLAIMER: The material in this benefits brochure is for informational purposes only and is neither an offer of coverage or medical or legal advice. It contains only a partial description of plan or program benefits and does not constitute a contract. Please refer to the Summary Plan Description (SPD) for complete plan details. In case of a conflict between your plan documents and this information, the plan documents will always govern. Annual Notices: ERISA and various other state and federal laws require that employers provide disclosure and annual notices to their plan participants. The company will distribute all required notices annually.
