Home Our Reputation Our Expertise Our Services Your Plan References
Contact Us
FAQ
Forms
Links
San Joaquin Health Care 2004 JPA Handbook

HMO Plans / Disclosure Information
YOUR BLUE SHIELD & KAISER HMO PLANS
Your Primary Care Physician (PCP) will arrange for referrals to specialists, hospitals and/or any other covered health care services (which are medically necessary and covered under your Plan) and will provide you with a written referral authorizing such services. Any services, other than emergencies, obtained without the advanced referral of your PCP will not be covered. Blue Shield eliminated coverage for Infertility treatment. Kaiser reduced coverage for Infertility treatment to 50%.
Services received from a specialist, or at his or her request, may require prior authorization from your health Plan. For specific guidance regarding prior authorization, please call your health Plan’s customer services department. The telephone number for Kaiser is 800-464-4000. The telephone number for Blue Shield is 800-424-6521.
If you need assistance, please call Legacy Enterprises Insurance Services, Inc. at 209-957-3185 or 800-232-3185.

  1. Plan Name
    The name of the Plan is, “Self-Insured Schools of California” (SISC III).
    SISC
    P.O. Box 1847
    1300 17th Street- City Centre
    Bakersfield, CA 93303-1847

  2. Type Of Plan
    The Plan is an employee welfare benefit plan that provides medical, prescription drug, dental and vision benefits. The Plan is also a cafeteria plan that provides the ability of eligible employees to cover certain expenses on a pre-tax compensation reduction basis.

  3. Type Of Administration
    The Plan is administered with the assistance of the third parties mentioned elsewhere in this Employee Benefit Handbook. Benefits under the Plan are payable on a self-insured basis except for the Plan’s insured benefits as identified elsewhere in this Employee Benefit Handbook. The Plan has no obligation under this plan with respect to such insured benefits beyond the payment of the employer’s share of the appropriate insurance premiums and the remittance of each eligible employee’s share of the premiums, if any, to the insurance company(ies)/administrators to the extent that such premiums have been paid to the employer by the employee or withheld from the employee’s wages.

  4. Plan Administrator
    Self-Insured Schools of California (SISC III) is the “Plan Administrator”

  5. Service of Process
    The designated agent for service of legal process is:
    Russ Bigler – Chief Executive Officer
    SISC III
    P.O. Box 1847
    1300 17th Street-City Centre
    Bakersfield, California 93303-1847
    Service of legal process may also be made upon the applicable Plan Administrator.

  6. Plan Year / Benefit Year
    The plan year is the period from October 1st through September 30th.
    The benefit deductibles and maximums are calendar year January 1st through December 31st.

  7. Effective Dates
    The Plan was amended effective as of October 1, 2004.

  8. Loss Of Benefits
    An employee, or his or her dependent, may lose benefits that the employee, or his or her dependent, might have otherwise received under the Plan if:

    1. The employee fails to meet the eligibility requirements at any time;
    2. The employee ceases to be an eligible employee after commencing participation in the Plan;
    3. The employee, or his or her dependent, fails to submit a written claim for benefits in a timely manner as required by the Plan;
    4. The employee, or his or her dependent, fails to follow the insurance carrier’s procedures for obtaining benefits;
    5. The employee’s, or his or her dependent’s, claims are for expenses not covered under the Plan;
    6. The employee’s, or his or her dependent’s, claims that are incurred during a plan year exceed the limitations in effect for the benefit for the plan year;
    7. The employee goes on a leave of absence during which no benefits are paid, and the employee, or his or her dependent, does not elect continuation coverage;
    8. The employee terminates employment, and the employee, or his or her dependent, does not elect continuation coverage; or
    9. The SJJPA terminates the benefit program.

  9. Claims For Benefits Provided Under The Insurance Contracts
    If you are making a claim for benefits under any of the insured benefits provided under the Plan, you should follow the claims procedures set forth in the information supplied by the insurance carriers /administrators as defined in the Evidence of Coverage.


  10. Other Claims For Benefits
    If you are making a claim for benefits under the general terms of the Plan, such as a claim that you or a dependent have improperly been denied the right to participate, or for uninsured benefits, such a claim should be processed under the following procedures and not under the insurance carrier’s/administrator’s procedures. Claims for uninsured benefits must be made within 90 days after the end of the plan year in which they were incurred. Delinquent claims will not be paid.

    1. All general claims under the Plan (which are not covered by an insurance contract) should be directed to the Plan Administrator.
    2. If such a claim under the Plan is denied in whole or in part, you or your dependent will receive written notification. Notification will include the reasons for the denial with reference to the specific provisions of the Plan on which the denial was based, a description of any additional information needed to process the claim and an explanation of the claims review procedure. If the Plan Administrator fails to respond within 90 days, your claim is treated as denied. In some cases this period may be extended an additional 90 days in order to give the Plan Administrator more time to make its determination.
    3. Within 60 days after denial, you or your dependent may submit a written request for reconsideration of the claim to the Plan Administrator. Any such request should be accompanied by documents or records in support of your appeal. You or your dependent (as well as your authorized representative) may review pertinent documents and submit issues and comments in writing.
    4. The Plan Administrator will review the claim and provide, within 60 days, a written response to the appeal. This period may be extended an additional 60 days under certain circumstances. In this response, the Plan Administrator will explain the reason for the decision with specific reference to the provisions of the Plan on which the decision is based. The Plan Administrator has the exclusive right to interpret the Plan’s provisions. Decisions of the Plan Administrator are conclusive and binding.



©2006 Legacy Consulting Insurance Services, Inc.
811 W Fremont Street
SUITE B
Stockton, CA 95203
Phone: (209) 546-0402 ~ Fax: (209)546-0824
San Joaquin JPA Handbook 2004