Sioux City Community Schools -

Q. When is Open Enrollment for 2024-2025?

A. Open enrollment begins on May 1, 2024, and ends on May 31, 2024. Your Benefit Information Enrollment changes are due to the Human Resources Department by May 31, 2024.

Flexible Spending Account enrollment forms are also due by May 31, 2024. A Flex enrollment form is required for enrollment each year. If you do not submit a Flex enrollment form by May 31, you will not be enrolled for the new plan year.

Q. What if I have a mid-year insurance change or am a new employee in the district?

Mid-year insurance changes are only allowed for qualifying events. HR must be notified of these events within the specific timeframes listed below.

Marriage – 31 days from the event
Death – 31 days from the event
Divorce – 31 days from the event
Loss or addition of other coverage – 31 days from the event
Baby or adoption – 60 days from the event

Full-time employees are eligible for insurance benefits. Employees who begin on the first day of the month will receive insurance benefits that same month. Employees who begin after the first day of the month will receive benefits beginning the first day of the following month. New employees should work with HR to complete new employee benefit forms.

Q. What’s new for the plan year?

• Medical Plan: 0% premium increase with the addition of a new $5,500 HDHP

• Dental Plan: No premium change and no plan design change

• Vision Plan: Premium increase with no plan design change

• Life Insurance Vendor: No premium change and no plan design change

• FSA/HSA/COBRA/Retiree Billing Vendor: remain with WEX

• Flexible Spending Account (FSA for those on a traditional health plan) medical account limitations have increased to $3,200 for the 2024 – 2025 plan year. Dependent care limitations have remained unchanged at $5,000.

• Health Savings Account: (HSA for those on the High Deductible plan) limitation have increased to $4,150 for self only coverage and $8,300 for family coverage.

  • Those new to an HSA will need to set up an account through WEX for payroll contributions.

Q. Will new medical cards be sent to me?

A. You will not be receiving a new medical card unless you change coverage between plans. You will not be receiving a new dental card unless you are newly signed up this year. VSP, our vision insurance carrier does not send out cards. If you would like to print one, you will need to create an account at VSP.

Q. What is a co-pay?

A. Health insurance co-pays are the fixed amounts ($10, $25, $40, or $50) you pay at the time you receive care for doctor visits, specialists, and chiropractic care under the Value $1,500 plan. Higher co-pays also apply for emergency room visits and some urgent care. When you go to the doctor, you pay a small portion of the cost and your insurer pays the balance. You may be billed for additional charges that are subject to your deductible.

Q. What is a deductible?

A. A deductible is an amount that you owe for health care services before your health insurance begins to pay. For example, if your deductible is $1,500, your health insurance will start paying their portion after you have met your $1,500 deductible for covered health care services. The deductible may not apply to all services, such as those covered by your co-pay.

Q. What is co-insurance?

A. Co-insurance is a type of co-pay, but rather than paying a specified dollar amount, you pay a percentage of the covered costs after meeting your deductible. For example, if you have a hospital stay, you will have to pay the deductible and the remaining cost of the claim will be shared by you and the insurance company. The insurance company will pay 80% of the cost, and you will pay 20% up to your out-of-pocket maximum.

Q. What is an out-of-pocket maximum?

A. An out-of-pocket maximum (OPM) is the most you pay during the calendar year before your health insurance plan starts to pay 100% for covered essential health benefits. OPMs will include all deductibles, co-pays (for prescription drugs and office visits), and co-insurance amounts for your health plan. The OPM does not include your payroll contributions or charges for health care the plan does not cover.

Q. What is a high deductible health plan (HDHP)?

A. A high-deductible health plan (HDHP) is a health insurance plan with a high minimum deductible for medical expenses in lieu of a lower monthly premium payment. A deductible is an amount the member pays prior. Once an individual has paid that portion of a claim, the insurance company will cover the remaining portion.

Q. When do premiums and out-of-pocket maximums restart?

A. Although the new benefit plan year will begin on July 1, 2024, the deductibles and out-of-pocket maximums for UnitedHealthcare are accumulated on a calendar year basis from January 1 – December 31. Deductibles and out-of-pocket maximums accumulated from January 1 – June 30 will transfer to your plan election for July 1 – December 31. If you change plans on July 1st, you may owe the difference between the two plan deductibles and out-of-pocket maximums.

Q. How do I find in-network providers/doctors?

A. To locate a provider or to find out if your provider is contracted with UHC, follow the directions below.

1. Go to MYUHC Page

2. Under Links and Tools (right-hand side) select: Find Medical, and Mental Health Providers and Facilities

3. Choose what type of provider you are looking for.

4. Under choose a type of plan, select: All UnitedHealthcare Plans

5. Select: Choice Plus (8th down on the list of plans)

6. Enter the zip code for your care provider

7. Click on the People or Places boxes to locate providers, or enter the doctor’s name in the search field for a particular doctor

Q. What is my prescription benefit?

A. The VALUE PLAN drug benefit has three tier levels. The co-pay amounts are listed below.

Under the High Deductible Health Plan prescriptions, drugs will be subject to the member’s deductible prior to UHC payment coverage. Prescriptions covered under the ACA will continue to be paid at 100% with both medical plans.

Prescription Drug List

To determine which tier your medication is listed under you can go to the www.myuhc.com website. Click on Pharmacy information on the right-hand side of the webpage.

Programs and Limits

The letters next to the medications refer to the pharmacy benefit programs. If you ever have questions about your prescription drug coverage please call Member Services listed on the back of your ID card.

*Depending on your benefit you may have notification or medical necessity requirements for select medications.

90 Day Supply / Mail Order Pharmacy / CVS Pharmacy Discount

You may save money by having your doctor prescribe a 3-month supply of eligible medication. Through OptumRx, your medications are mailed to you with standard shipping at no additional cost. You can also take advantage of this savings by using the Walgreens or CVS pharmacy located in Target.

How to setup Optum Rx Mail Service Pharmacy

• By Phone:

  • Just call the member phone number on the back of your health plan ID card to talk with a customer service representative. It’s helpful to have your health plan ID card and medication bottle available. For your convenience, the representative can also contact your doctor directly if you need a new prescription.

• By Mail:

  • Ask your doctor for a new prescription for up to a three-month supply, plus refills for up to one year. Next go to www.myuhc.com and download the new Prescription Order Form. Then mail it to the address provided on the bottom of the form.

• By Fax/ePrescribe:

  • Ask your doctor to call 1-800-788-4863 for instructions on how to fax your prescription directly to OptumRx Mail Service Pharmacy. Or your doctor can send an electronic prescription to OptumRx Mail Service Pharmacy.

Once OptumRx receives your complete order for a new prescription, your medication should arrive within 10 business days. Completed refill orders should arrive in about seven business days.

Q. What are Virtual Visits?

A. A virtual visit lets you see and talk to a doctor 24/7 from your mobile device or computer without an appointment. Most visits take about 10-15 minutes and doctors can write a prescription if needed, that you can pick up at your local pharmacy. And, it’s part of your health benefits.

Doctors can diagnose and treat a wide range of non-emergency medical conditions, including:

• Bladder infection

• Diarrhea

• Rash

• Bronchitis

• Migraine/Headaches

• Fever

• Sore throat

• Cold/Flu

• Pink Eye

• UTI

• Stomach ache

• Sinus problems

Log in to myuhc page and choose from provider sites where you can register for a virtual visit. After registering and requesting a visit you will pay your portion of the co-pay, and then you will enter a virtual waiting room. During your visit, you will be able to talk to a doctor about your health concerns, symptoms, and treatment options.

Q. Who and what are premium providers?

A. Premium designations are given to providers who meet higher quality standards while still providing cost-efficient care. Make sure to look for the Premium Care Physician designation when choosing your next provider.

Q. How do I appeal a decision that UnitedHealthCare has made?

A. If you disagree with either a pre-service request for Benefits determination, post-service claim determination, or a recession of coverage determination, you can contact UnitedHealthcare in writing to formally request an appeal, or you can fax to 801-938-2109. Your request for an appeal should include:

• The patient’s name and the identification number from the ID card.

• The date(s) of medical service(s).

• The provider’s/doctor’s name.

• The reason you believe the claim should be paid.

• Any documentation or other written information to support your request for claim payment.

Your first appeal request must be submitted to UnitedHealthcare within 180 days after you receive the denial of a pre-service request for Benefits or the claim denial. For further information on the appeal process, please view the Summary Plan Description on the District website under the Human Resources Department.

Q. Can I get a mobile app for UnitedHealthCare?

A. UnitedHealthcare has a Health4Me app that can search for a physician near you, check the status of a claim, view your health plan ID card, or allow you to speak directly with a health care professional.

Instructions to download the free health4Me app:

1. Click on the store icon (App Store for iPhones; Google Play for Android)

2. Type Health4Me option

3. Click on the Health4Me option

4. Click Download or Install

Q. I am retiring this year, what do I need to do to get retirement benefits?

A. If you are retiring this year, you will be receiving a letter at your home address in early June with information on how to sign up for retiree benefits. We offer medical and dental benefits to our early retirees, who have not reached Medicare eligibility. You and/or your dependents will be required to pay full premium amounts to remain on the District’s plan.

Q. What is the difference between a health savings account and a flexible spending account?

A. A Health Savings Account (HSA) is only for those who have a high deductible health plan. HSA can be sent up through a vendor of the employee’s choice. The single HSA contribution maximum for 2024 is $4,150 and family is $8,300. You can elect pre-tax contributions be made through payroll to your HSA. WEX will administer new payroll contributions. HSA contributions made through payroll prior to 7/1/2021 may continue with the HSA banking arrangement in place.

Medical, dental, and vision expenses that are eligible for reimbursement through an FSA can also be reimbursed under an HSA. Although FSA dollars must be spent during the plan year elected, HSA money can be rolled from year to year, and may also be treated as a pre-tax retirement account.

Q. What is a flexible spending account?

A. A Flexible Spending Account (FSA) allows an employee to set aside pre-tax dollars to pay for eligible medical, dental, vision, and daycare expenses incurred during the plan year. You can include out-of-pocket expenses incurred by you, your spouse, and your qualified dependents. The maximum annual contribution for a Health Care FSA is $3,200, and the maximum annual contribution for a Dependent Care FSA is $5,000 if single or married filing jointly, and it is $2,500 if married and file separate tax returns.

The amount you contribute to an FSA reduces your taxable income. Lower taxable income means lower Federal, Social Security, and state taxes.

Although the tax advantage of your FSA will vary depending on your salary level, tax filing status, and contributions amounts, the following examples show the potential tax savings (Federal and Social Security taxes only) available through the reimbursement account program.