Health Maintenance Organizations (HMO) and Preferred Provider Organizations (PPO)
Health Maintenance Organizations (HMO)
An HMO is a plan that provides healthcare from specific doctors and hospitals under
contract with the plan. Employees and their eligible dependents select a primary care
physician who coordinates all medical care including referrals to specialists. The
employee and eligible dependents can each select a different primary care physician/medical
group within the HMO plan. These plans generally have restricted service areas in
California (based on zip code), co-payments for some services, no deductibles, and
no claim forms. Emergency services rendered out of the service area or California
must be reported to the HMO plan.
Preferred Provider Organizations (PPO)
As a PPO health plan member, you get maximum benefit coverage when you use the PPO
network (Blue Cross of California) of physicians and hospitals. A PPO is similar to
a traditional "fee-for-service" plan, but you must use doctors in the PPO provider
network or pay higher co-insurance (percentage of charges). A PPO allows you to select
a primary care provider and specialists without referral. In these plans, you must
usually meet an annual deductible before some benefits apply. You are responsible
for a certain co-insurance amount, and the plan pays the balance up to the allowable
amount.
For additional information about the HMO & PPO plans offered, please reference the
Medical Provider List below.
Health Insurance Portability and Accountability Act (HIPAA)
The Health Insurance Portability and Accountability Act (HIPAA) imposes numerous requirements
on the use and disclosure of individual health information by employer health plans.
These requirements apply to all employees and family members who are enrolled in
a health, dental, vision or HealthCare Reimbursement Account (Flexible spending)
plan. HIPAA protects the confidentiality between you and your health care provider.
In accordance with HIPAA, should you need HR/Benefits to assistance you with your
health care claims, an Authorization to Use and/or Disclose Personal Health Plan Information
Form must be completed and provided to HR/Benefits.
If you have questions regarding HIPAA., please contact the Campus Privacy Contact,
HR Benefits Manager, at (559) 278-5336.
Additional Information.
Benefit eligible employees may enroll in one of two dental plans for themselves and their eligible dependents.
The premiums for these dental plans are paid by the CSU. Both plans are administered
by Delta Dental.
Within 60 days of your hire or eligibility, please complete the Benefits Enrollment Worksheet to make a dental plan election. Return this form to Human Resources via MoveIt. If you have questions about completing the Benefits Worksheet or wish to obtain
additional information, contact Human Resources at (559) 278-2032.
Delta Dental (PPO) 800-626-3108
Delta Dental plan is a group dental plan that allows you to choose any dentist. The
benefits described in the Summary Brochure are guaranteed only when services are provided
from a Delta member dentist. Your collective bargaining unit determines your level
of dental coverage.
- Enrollees may select a dentist of their choice.
- Members may choose a dentist in the Delta Premier or Delta PPO network and pay less.
- The plan sets the limits it pays for each specific type of dental treatment. Members
are responsible for paying any remaining balance.
- You may read the Evidence of Coverage for information on covered benefits.
- You will need to complete and submit your own claim forms for services provided by
a non-Delta dentist.
Delta Care USA (HMO) 844-519-8751
DeltaCare USA is a prepaid plan. Many of the services are covered at no cost to the
employee while some services require a co-payment. Your collective bargaining unit
determines your level of dental coverage.
- Enrollees and their eligible dependents are required to use a dentist who is a contracted
DeltaCare provider.
- Most basic services are covered at no cost. Please consult with your dentist the cost
of the services to be rendered and if the services are covered in full.
- View the Evidence of Coverage for information on covered benefits. DeltaCare® USA website.
- When enrolling in DeltaCare USA you must choose a provider from their list. You can
view the Directory of Dentists to find a provider. Similar to a HMO, you will receive
a membership card and evidence of coverage that describes the covered benefits. The
membership card will have the telephone number and address of your dentist. If you
wish to change your dentist, you can do so by contacting DeltaCare USA at 844-519-8751.
Dental Plan Summary by employee category
- Units 1, 2, 3, 4, 5, 6, 7, 8, 9,10, C99, M98, M80 and FERP Annuitants
- Unit 11 and Teaching Associates
Delta Dental (PPO) (800) 626-3108
Benefit Highlights Enhanced PPO
Be Network Savvy
SmileWay Wellness
Delta Care USA (HMO) (844) 519-8751
Benefit Highlights Enhanced HMO
All benefit eligible employees appointed half-time or more for a period of more than six months, and their eligible
dependents, are automatically enrolled in the basic vision insurance plan.
- Premiums are paid by the CSU.
- May visit any licensed ophthalmologist, optometrist or dispensing optician of choice.
- By choosing a participating provider in the Vision Service Plan (VSP) network, the
insurance will cover more out-of-pocket costs.
- Administrator is Vision Service Plan (VSP).
All benefit eligible employees and their eligible dependents, also have an option
to enroll in the Vision Premier Plan as a new hire, if a qualifying event occurs outside
of Open Enrollment or during Open Enrollment. There is a monthly out of pocket premium
paid for by the employee. Click here to review the comparison.
The Basic vision plan includes:
- One comprehensive eye exam every calendar year.
- One pair of lenses every other calendar year (or calendar year if your prescription
changes) and one frame every other calendar year.
- Contact lenses every other calendar year when contact lenses are provided in lieu
of all other lens and frame benefits.
The Premier Vision plan includes:
- One comprehensive eye exam every calendar year.
- One pair of lenses every calendar year and one frame every calendar year.
- Contact lenses every other calendar year when contact lenses are provided in lieu
of all other lens and frame benefits.
Accessing Benefits
- Claim form is not required when using standard in-network benefits.
- For employees eligible for the Video Display Terminal benefit, print the VDT Claim
Form and present this to the VSP Select Network doctor or non-VSP provider.
- Services provided by a non-VSP provider must be paid in full by the employee. For
reimbursement, complete a VSP Out-of-Network Reimbursement form.
Health Care Reimbursement Account (HCRA)
This voluntary benefit plan offers eligible employees the ability to pay for eligible
out-of-pocket health care expenses with pre-tax dollars:
Enrollment Information
- Enroll by completing Enrollment Form and returning to Human Resources within 60 days
of hire or eligibility. The Effective date will be determined by the date the form
is submitted to Human Resources within the 60 day period.
- Employee may contribute between $20 to $229.16 each month ($2,750 maximum per year)
in 2021 to personal account.
- Contributions are deducted from pay before federal, state and Social Security (FICA)
taxes.
- Employee must re-enroll during the annual open enrollment period during the month of September to participate during following calendar year. Contribution
amount may be changed at that time.
- Once the plan year has begun, you cannot make changes (increase, decrease, or stop deduction) in your authorization unless there has been
a change in your status as defined by the Internal Revenue Services (IRS). Refer
to HCRA Brochure.
Submitting a Claim Form
- File claim for reimbursement by completing Claim Form, attaching documentation and
mailing to ASI, P.O. Box 6044, Columbia, MO 65205-6044 or fax to (573) 874-0425.
- Expenses eligible to be reimbursed must be:
- medically necessary,
- incurred by an employee, employee’s spouse, or eligible dependents (including domestic
partner), and
- not covered by the employee’s own or another insurance plan.
- Refer to HCRA Brochure for a list of reimbursable and non-reimbursable expenses.
- Any money left in employee’s account after expenses have been paid for the year is
forfeited.
Dependent care Reimbursement Account (DCRA)
This voluntary benefit plan offers eligible employees the ability to pay for eligible
out-of-pocket expenses for dependent care with pre-tax dollars if the care is required
in order for the employee (and spouse, if married) to work.
Enrollment Information
- Complete Enrollment Form and return to Human Resources within 60 days of hire or eligibility.
The Effective date will be determined by the date the form is submitted to Human Resources
within the 60 day period.
- Employee may contribute between $20 to $416.66 each month ($5,000 maximum per year)
to personal account.
- Deducted from pay before federal, state and Social Security (FICA) taxes.
- Employee must re-enroll during the annual open enrollment period during the month of September to participate during following calendar year. Contribution
amount may be changed at that time.
- Once the plan year has begun, you cannot make changes (increase, decrease, or stop deduction) in your authorization unless there has been
a change in your status as defined by the Internal Revenue Services (IRS). Refer
to DCRA Brochure.
Submitting a Claim Form
- File claim for reimbursement by completing Claim Form, attaching documentation and
mailing to ASI, P.O. Box 6044, Columbia, MO 65205-6044 or fax to (573) 874-0425.
- For expenses to be eligible:
- Dependent must be child under 13 for whom employee or spouse is entitled to claim
dependent status on income tax return, or spouse who is unable to care for him/herself,
or a financially dependent member of employee’s household; and
- Care must be required in order for employee to be gainfully employed and, if married,
spouse also must be employed or actively looking for work.
- Refer to DCRA Brochure for additional eligibility rules.
- Any money left in employee’s account after expenses have been paid for the year is
forfeited.
Flexible Spending Plan Information
ASI (website)
Claim and Enrollment Forms
DCRA Brochure
HCRA Brochure