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SFUSD EmployeesAdult Disabled ChildrenTo qualify a dependent disabled adult child (“AdultChild”), the adult child must be incapable of selfsupport because of a mental or physical conditionthat existed prior to age 26, continuously live withdisability after turning 26, and meet each of thefollowing criteria:1. Disabled Adult Child is enrolled in a SanFrancisco Health Service System medical planon their 26th birthday; and2. Adult Child has met the requirements of being aneligible dependent child under SFHSS memberRules Section B.3 before turning 26; and3. Adult Child must have been physically or mentallydisabled on the date coverage would haveotherwise terminated due to age (turning 26),and continue to be disabled from age 26 on; and4. Adult Child is incapable of self-sustainingemployment due to the physical or mentaldisability; and5. Adult Child is dependent on SFHSS member forsubstantially all of their economic support, andis declared as an exemption on member’s federalincome tax return;6. Member is required to comply with their enrolledmedical plan’s disabled dependent certificationprocess and recertification process every yearthereafter or upon request.7. An Adult Child who qualifies for Medicare dueto a disability is required to enroll in Medicare(see SFHSS Member Rules Section J). Membersmust notify SFHSS of the Adult Child’s eligibilityfor Medicare, as well as the Adult Child’ssubsequent enrollment in Medicare.8. To maintain ongoing eligibility after the AdultChild has been enrolled, the Member mustcontinuously enroll the Adult Child in an SFHSSmedical plan without interruption and mustensure that the Adult Child remains continuouslyenrolled with Medicare A/B (if eligible) withoutinterruption.9. A newly hired employee who adds an eligibledependent Adult Child, who is age 26 or older,must meet all requirements listed, except 1. and2. above and comply with their enrolled medicalplan’s disabled dependent certification processstated in 6. within 30 days of hire date.Plan Year 2022Medicare Enrollment Requirementsfor Dependents of Active Employees Who HaveReceived a Disability Social Security BenefitSFHSS Rules require domestic partners, dependentswith End Stage Renal Disease (ESRD) and childrenwho have received Social Security insurance for morethan 24 months, to enroll in premium-free MedicarePart A and in Part B. Medicare coverage begins30 months after disability application. A memberor dependent with ESRD may be prohibited fromchanging medical plan enrollment.Medicare Enrollment RequirementsUpon RetirementRetirees and dependents who are eligible forMedicare must already be enrolled in Medicare Part Aand Part B when retiring. Proof of Medicare coverageis required by SFHSS before any Medicare-eligibleindividual can be enrolled in retiree health coverage.Failure to enroll in Medicare when first eligible mayalso result in a late-enrollment penalty from Medicare.Medicare applications placed with Social Security cantake three months to process.Dependent Eligibility Audits and Penalties forFailing to Disenroll Ineligible DependentsAll members are required to notify SFHSS within30 days and cancel coverage for a dependent whobecomes ineligible. Dependent eligibility may beaudited by SFHSS at any time. Audits may requiresubmission of documentation that substantiates andconfirms that the dependent’s relationship with theemployee or retiree is current.Acceptable documentation may include, but is notlimited to, current federal tax returns and otherdocumentation that demonstrates cohabitationor financial interdependency. Enrollment of adependent who does not meet the plan’s eligibilityrequirements as stated in SFHSS Rules andenrollment materials, or failure to disenroll when adependent becomes ineligible, will be treated as anintentional misrepresentation of a material fact, orfraud. If a member fails to notify SFHSS, the membermay be held responsible for the costs of ineligibledependent’s health premiums and any medicalservice provided. Dependents can be dropped duringOpen Enrollment without penalty.3

SFUSD EmployeesTemporary Employee EligibilityFor temporary teachers, speech therapists, psychologists,nurses, substitutes and other SFUSD temporary employees.Temporary Certificated EmployeesTemporary certificated employees with contracts thatend June 30 are as follows: Emergency Teachers (ETs) Categorical Teachers (CTCs) University Interns (ITs)If you are a Temporary Certificated employee whosecontract ends on June 30, your last day of coveragewill be June 30.If you are a temporary teacher whose contract endsprior to June 30, your last day of coverage will bethe last day of the month in which employmentterminates.Temporary School-Term Biweekly EmployeesCOBRA: The federal Consolidated Omnibus BudgetReconciliation Act (COBRA), enacted in 1986, allowsemployees and their covered dependents to electtemporary extension of healthcare coverage in certaininstances where coverage would end. The COBRAadministrator will notify you of the opportunity toelect COBRA coverage. You have 60 days from thenotification date to complete COBRA enrollment.With COBRA you pay the full cost of premiums.Individual Coverage: You may be able to purchaseindividual health coverage from your healthcare planor other insurers. Contact plans directly for details andcosts. All employees and dependents covered underan SFHSS-administered medical plan are entitled to acertificate showing evidence of prior health coverage.Temporary School-Term Biweekly employees includebut are not limited to: Clerical Workers Paraeducators Security AidesIf you are a Temporary School-Term Biweeklyemployee, coverage will end on the last day of the payperiod in which your employment is concluded.Eligible Temporary Exempt EmployeesAs needed intermittent or substitute temporary/temporary exempt employees who have worked atleast 20 hours a week in a consecutive 12-monthperiod typically become eligible to enroll in medicaland dental benefits. The determination of eligibility ismade by the SFUSD Benefits Office.Options for Maintaining CoverageCovered California: The state health insuranceexchange, created under the federal PatientProtection and Affordable Care Act, allows you tocompare and shop for health insurance. In somecases, you may qualify for Medi-Cal, tax credits andother assistance to make health insurance moreaffordable. Call (888) 975-1142 or visitcoveredca.com.4Rehired in the Fall?If you are hired in fall with an eligibleSFUSD assignment, you must re-enroll forhealthcare benefits through SFHSS and theSFUSD Benefits Office within 30 calendardays of your rehire date.Plan Year 2022

SFUSD EmployeesChanging Benefit Elections: Qualifying LifeEventsYou may change health benefits elections outside ofOpen Enrollment if you have a Qualifying Life Event.Certain life events count as a “Qualifying Life Event” where you can modify your benefits elections. Ifyou have a Qualifying Life Event, you can submit your elections and upload all required documentationonline using eBenefits, which you can access from the Life Events link under Employee Links on the City’sEmployee Portal. Visit sfhss.org/how-to-enroll to get started. Your elections and documentation are due nolater than 30 calendar days after the qualifying event occurs.New Spouse or Domestic PartnershipLegal Guardianship or Court OrderEnroll a new spouse or domestic partner and eligiblechildren of spouse or domestic partner online usingeBenefits on the San Francisco Employee Portal.Visit sfhss.org/how-to-enroll to get started. Be sureto upload copies of your certified marriage certificate,certificate of domestic partnership and birthcertificate for each child. Your election and requireddocuments must be submitted within 30 days of thelegal date of the marriage or partnership. You can alsosubmit an Enrollment Application form and copies ofrequired documentation by fax or mail. Certificates ofdomestic partnership must be issued in the UnitedStates. A Social Security number must be provided foreach enrolling family member. Proof of Medicare isalso required for a domestic partner who is Medicareeligible due to age or disability. Coverage for yourspouse or domestic partner is effective the first dayof the coverage period following receipt and approvalof required documentation.Coverage for a child under legal guardianship or courtorder shall begin upon effective date of guardianshipor court order is submitted by the 30-day deadline.Coverage for a dependent per a court order will beeffective the date of court order, if all documentationis submitted to SFHSS by the 30-day deadline. UseeBenefits to submit documentation and enroll online.Newborn or Newly Adopted ChildCoverage for an enrolled newborn child begins onthe child’s date of birth. Your election and requireddocuments must be submitted within 30 days ofthe birth or date of legal adoption. Coverage foran enrolled adopted child will be effective on thedate the child is placed. SFHSS provides a onetime benefit reimbursement of up to 15,000 toan eligible employee or eligible retiree for qualifiedexpenses incurred from an eligible adoption or eligiblesurrogacy. For more details, visit sfhss.org/surrogacyand-adoption. A Social Security number must beprovided to SFHSS within six months of the date ofbirth or adoption, or your child’s coverage may beterminated. Use eBenefits to submit documentationand enroll online.Plan Year 2022Divorce, Separation, Dissolution, AnnulmentA member must immediately notify SFHSS andprovide documentation in writing when the legalseparation, divorce or final dissolution of marriageor termination of domestic partnership has beengranted. Coverage of an ex-spouse, step-children,domestic partner and children of domestic partner willterminate on the last day of the coverage period of theevent date. Use eBenefits to submit documentationand dis-enroll any former dependent(s) online.Loss of Other Health CoverageSFHSS members and eligible dependents who loseother health care coverage may enroll within 30 daysin SFHSS benefits. Once required proof of loss ofother health coverage documentation is submitted toand processed by SFHSS, coverage will be effectiveon the first day of the next coverage period. UseeBenefits to submit documentation and enroll online.Obtaining Other Health CoverageYou may waive SFHSS coverage for yourself or adependent who enrolls in other health coverageby providing proof of alternate coverage on officialletterhead within 30 days of the event. If you waivecoverage, all coverage for enrolled dependentswill also be waived. After submitting the requireddocumentation is submitted, your SFHSS coveragewill terminate on the last day of the coverage period.Use eBenefits to submit documentation and updateyour elections online.5

SFUSD EmployeesMoving Out of Your Plan’s Service AreaIf you move your residence to a location outside ofyour plan’s service area, you can enroll in an SFHSSplan that offers service where your new address islocated. Coverage will be effective the first day of thecoverage period following receipt and approval ofrequired documentation. Please note that if your newresidence remains within your current SFHSS plan’sservice area, you cannot enroll in a different SFHSSPlan, as a result of the change in residence.Members on an unpaid leave of absencemay request to waive dental and medicalcoverage for the duration of their unpaid leave ifappropriate notice and documentation is givento SFHSS, in advance or immediately uponthe commencement of the unpaid leave.Members who have waived medical and dentalcoverage during their unpaid leave of absence mayrequest to re-enroll in their medical and dentalcoverage within 30 days of returning to work.Death of a DependentIn the event of the death of a dependent, notifySFHSS as soon as possible and submit a copyof the death certificate within 30 days of theevent to disenroll the deceased dependent.Death of a MemberIn the event of a member’s death, the survivingdependent or survivor’s designee should contactSFHSS to obtain information about eligibility forsurvivor health benefits. Upon notification, SFHSS willmail instructions to the spouse or partner, includinga list of required documents for enrolling in survivingdependent health coverage. If the deceased memberqualifies for retiree benefits, the surviving dependentor survivor’s designee may be eligible to continuebenefits as a surviving spouse or will have to takeCOBRA. A surviving spouse or partner who is notenrolled on the deceased member’s health plan atthe time of the member’s death may be eligible forcoverage, but must wait until the Open Enrollmentperiod to enroll.Changing FSA ContributionsPer IRS regulations, some qualifying events mayallow you to initiate or modify your Flexible SpendingAccount (FSA) contributions. Contact SFHSS at(628) 652-4700 or visit padmin.com.Responsibility for Premium ContributionsChanges in coverage due to a qualifying eventmay change premium contributions. Review yourpaycheck to make sure premium deductions arecorrect. If your premium deduction is incorrect,contact SFHSS. You must pay any premiumsthat are owed. Unpaid premium contributionswill result in termination of coverage.6Failure to notify SFHSS of yourdependent(s) ineligibility can result insignificant financial penalties equal to thetotal cost of benefits and services providedto ineligible dependent(s).Plan Year 2022

SFUSD EmployeesMedical Plan OptionsThese medical plan options are available to members and eligible dependents.What is a Health Maintenance Organization?What is a Preferred Provider Organization?An HMO is a medical plan that offers benefits througha network of participating physicians, hospitals andother healthcare providers. A Primary Care Physician(PCP) must be designated to coordinate all nonemergency care and services including access tocertain specialists, programs and treatments.A PPO is a medical plan that offers benefits throughin-network and out-of-network healthcare providers.PPOs allow for a greater selection of providershowever, out-of-network providers cost more.Blue Shield of CA HMO members can change theirPrimary Care Physician (PCP) at any time throughoutthe year, up to one-time per month, as long as thenew PCP is a part of a medical group that participatesin your elected HMO plan. If your new PCP is in adifferent medical group, all specialist physiciansmust also be part of the new medical group. KaiserPermanente HMO and Health Net CanopyCare HMOmembers can change their Primary Care Physician atany time for any reason.Compared to an HMO, enrolling in a PPO usuallyresults in higher out-of-pocket costs. Unlike HMOplans, PPOs may have deductibles. You must pay aplan year deductible and a coinsurance percentageeach time you access service. Because Blue Shieldof CA PPO-Accolade is a self-insured plan, individualpremiums are determined by the total cost of servicesused by the plan’s group of participants.There is no plan year deductible before accessing yourbenefits. Most services are available for a fixed dollaramount (co-payment). SFHSS offers the followingHMO medical plans: *NEW* Health Net CanopyCare HMO:You will have access to five prominent medicalgroups with 5,000 physicians, 22 contractedhospitals/medical centers, and 42 urgentcare centers. Your Primary Care Physiciancoordinates all medical care, across the nineBay Area counties, to specialists across the vastCanopyCare network. You must live or work in azip code serviced by the plan to enroll. Trio HMO - Blue Shield of California:A network of local doctors, specialists andhospitals working closely together to coordinateyour care. Trio has a dedicated Concierge Servicebased on location. California Pacific MedicalCenter (CPMC) is included in the network. Youmust live or work in a zip code serviced by theplan to enroll. Access HMO - Blue Shield of California:Your PCP coordinates all your care and refers youto specialists and hospitals within their medicalgroup/Independent Practice Association (IPA).Each family member can choose a differentphysician and medical group/IPA. You must live orwork in a zip code serviced by the plan to enroll.You are not assigned to a PCP, giving you moreresponsibility for coordinating your care.SFHSS offers the following PPO plan: *NEW* Blue Shield of California PPO-AccoladeHow To Enroll in Medical BenefitsEligible full-time employees must enroll in an SFHSSmedical plan within 30 calendar days of their workstart date. City and County of San Francisco membersmay enroll online using eBenefits (go to sfhss.org/how-to-enroll to get started) or by completing andsubmitting an Enrollment Application form by fax ormail, along with required eligibility documentation byrequired SFHSS deadlines.If you do not enroll by the required deadline, you willonly be able to enroll in benefits during the next OpenEnrollment period or for a Qualifying Life Event (seepages 5 and 6).Coverage following a Qualifying Life Event will start thefirst day of the coverage period following receipt andapproval of required eligibility documentation. Onceenrolled, you must pay all required employee premiumcontributions.SFHSS does not guarantee the continued participationof any particular doctor, hospital or medical group inany medical plan.You cannot change benefit elections outside of OpenEnrollment because a doctor, hospital or medicalgroup chooses not to participate. You will be assignedor must select another provider. Kaiser Permanente HMO:Most medical services are under one roof (ex.specialty care, pharmacy, lab work). No referralsrequired for certain specialties, like obstetricsgynecology. You must live or work in a zip codeserviced by the plan.Plan Year 20227

SFUSD EmployeesMedical Plan Service AreasHealth NetCanopyCareHMOBlue Shield of CATrio HMOBlue Shield of CAAccess HMOKaiserPermanenteHMOBlue Shield of CAPPO-AccoladeAlamedann Contra Costann Marinnn n n CountyNapaSacramentoSan FrancisconSan JoaquinSan Mateonn Santa Clarann Santa Cruznn Solano Sonoma Stanislaus Tuolumne Outside of CAUrgent/ERCare OnlyUrgent/ERCare OnlyUrgent/ERCare OnlyUrgent/ERCare OnlyNo ServiceArea Limits Available in this county Available in some zip codes; verify your zip code with the plan to confirm availabilityBlue Shield of California HMO, Health Net CanopyCare HMO, and Kaiser Permanente HMO: ServiceArea LimitsYou must reside in a zip code serviced by the plan. If you do not see your county listed above, contact the medicalplan to see if service is available to you. For Blue Shield of California’s Trio HMO, call (855) 747-5800. For BlueShield of California’s Access HMO, call (855) 256-9404. For Health Net CanopyCare HMO, call(833) 448-2042. For Kaiser Permanente HMO, call (800) 464-4000.Blue Shield of California PPO-Accolade: No Service Area LimitsBlue Shield of California PPO-Accolade, does not have any service area requirements. If you have questions,contact Blue Shield of California PPO-Accolade at (866) 336-0711.Blue Shield of California PPO Accolade:Members who lack geographic access to other m

1 SS mployees Plan Year 2022 2 Eligibility 4 Temporary Employee Eligibility 5 Changing Benefit Elections: Qualifying Life Events 7 Medical Plan Options 8 Medical Plan Service Areas 9 Selecting Your Medical Plan 10 Medical Plans 12 Vision Plans 13 Vision Plan Benefits-at-a-Glance 14 SFUSD Provides Your Dental Benefits 15 Additional SFUSD Benefits 16 Mental Health and Substance Abuse Benefits