HEALTH AND WELFARE
1.0 District Contribution Obligations: For fiscal years 1995-96, 1996-97 and 1997-98, the District=s Health and Welfare benefit plan payment obligation shall not exceed $304 million for all District personnel (including the cost of dependent and retiree coverage), and shall not exceed $1.8 million for this bargaining unit (including the cost of dependents and this unit=s pro rata share of retirees). These funds will be used solely for the purpose of funding benefits as approved by the Board of Education, including the costs of administering the benefit program and the expenses of the District-wide Health and Welfare Committee.
Notwithstanding the foregoing, and without limiting it, if in fiscal year 1997-98, the District-wide cost of Health and Medical Benefits exceeds the above-described expenditure cap of $304 million, then the provisions of Appendix C, IV.4.a shall apply for the 1997-98 fiscal year only.
2.0 Plan Revisions through the District-wide Health and Welfare Committee: A District-wide Health and Welfare Committee shall be formed.
a. Composition -- Each union shall be entitled to one (1) Committee member for every 5,000 unit members represented or reaction thereof. The District shall provide resource staff as determined by the Committee, and shall provide adequate paid release time for those Committee members who are employees of the District.
b. Decision Making -- Consensus shall be used in all
Committee deliberations. If a consensus decision cannot be reached, then in the alternative, each union shall have one (1) vote. Any recommended changes to the existing kinds and levels of benefits shall require a 2/3 vote of the unions present and voting.
c. Authority -- Subject to the terms of subsection g. below, the Committee shall have the sole and exclusive right, and duty, to design the Health and Welfare programs of the District, within the cost parameters of the District budget established for that purpose and in effect at the time. That budget figure is the product of the negotiations process. (See 1.0 above for the 1995-98 cost parameters).
d. Proposed changes in the existing kinds and levels of
benefits shall be submitted as recommendations to the Board of Education. The Board of Education shall have the limited authority to either:
(1) approve the Committee recommendations as submitted, or
(2) reject the Committee recommendations as submitted and refer them back to the Committee.
e. The Committee may investigate the creation during the term of this agreement of a joint Employer Health and Welfare Trust. Such Trust might include other public or private sector employees as determined by the Committee. The Committee shall review all existing contracts prior to expiration. No contract shall be for more than one (1) year, or awarded without open bid, except upon Committee approval.
f. Benefit Eligibility -- During the term of this Agreement there shall be no changes in the eligibility requirements for District Benefits (see Section 3.0 below).
g. Effective January 1, 1995, POA shall have the option of informing the District of its intent to remove its Unit A pro rata share of District health benefit expenditures and assume the responsibility of providing a benefit program for its Unit A members, or having the District design and administer a health benefit program for its Unit A members. However, POA shall not opt out of the District=s health benefit program or remove its Unit A pro rata share of District health benefit expenditures before January 1, 1998, and any removal of its Unit A pro rata share of District health benefit expenditures shall be subject to the precondition of nine months= written notice to the District regarding POA=s intent to do so. Further, its removal shall only be effective on a January 1 plan anniversary date.
3.0 Eligibility for Plans: Eligibility requirements for employees and dependents shall be as provided in the applicable plan and also as follows:
a. Every employee who is assigned half-time or more of a full-time assignment in one class, in a status other than substitute, temporary, extra, exchange or relief, shall be eligible to enroll in a plan. The percentage of assignment shall be determined by the District. For employees attaining eligibility under this paragraph, the enrollment year shall be January through December.
b. Employees who do not qualify under the preceding paragraph, but who in the previous school year were in paid status for 800 or more hours as a result of any one assignment or any combination of assignments. For employees attaining eligibility under this paragraph, the enrollment year shall be October through September.
c. In order to remain eligible, the employee must be in paid status within the assignment basis. However, an employee in an unpaid status who later receives compensation from the District for the unpaid period shall be entitled to reimbursement of direct premium payments made which correspond to the period for which such compensation is allowed. To obtain such reimbursement, the employee shall file application therefor with the District's Health Insurance Section.
d. In situations where employees are married to one another or share a domestic partner relationship and are covered by the same plan with one listed as a dependent, the dependent shall not, upon divorce, upon termination of the domestic partnership or upon the retirement or death of the spouse/domestic partner, lose any rights the employee would otherwise have had as an eligible employee or retired employee.
4.0 Retirement Benefit Coverage: Employees who retire from the District receiving a PERS/STRS allowance for either age or disability shall be eligible to continue District-paid hospital/medical, dental and vision coverage in which the employee was enrolled at the time of retirement. For the purposes of this section, qualifying years consist of school years in which the employee was in paid status for at least 800 hours and was eligible for District-paid insurance coverage. The following shall not count toward, but shall not constitute a break in the service requirement: (a) time spent on authorized leave of absence and, (b) any time intervening between resignation and reinstatement with full benefits within 39 months of the last day of paid service. The employee must meet the following requirements:
a. For employees hired prior to March 11, 1984, 5 consecutive years of qualifying service immediately prior to retirement shall be required in order to qualify for retiree health benefits for the life of the retiree.
b. For employees hired on or after March 11, 1984, 10 consecutive years of qualifying service immediately prior to retirement shall be required in order to qualify for retiree health benefits for the life of the retiree.
c. For employees hired on or after July 1, 1987, 15 consecutive years of qualifying service immediately prior to retirement shall be required in order to qualify for retiree health benefits for the life of the retiree.
d. For employees hired on or after June 1, 1992, consecutive years of qualifying service and age must total at least 80 in order to qualify for retiree health benefits for the life of the retiree.
e. In order to maintain coverage, the retiree must continue to receive a PERS/STRS allowance and must enroll in those parts of Medicare for which eligible.
f. Employees on "Continuation of Enrollment" pursuant to Section 6.0 below shall, if otherwise qualifying under this section, be eligible for coverage under the District paid insurance plans upon receiving a PERS/STRS retirement allowance.
5.0 Enrollment: For the hospital-medical, dental and vision care plans, an unenrolled employee eligible for enrollment may submit application for enrollment in a plan at any time. However, an employee who has previously been enrolled in a plan during the current enrollment year must, upon re-enrollment in that same enrollment year, select the same plan. Such an employee must wait until the next open enrollment period to effect a change of plans. The District shall process applications so as to make coverage effective on the earliest practicable date consistent with the plan provisions, and in no case shall this be later than the first day of the calendar month following the receipt of the completed application.
5.1 For the District-paid basic life insurance plan, all eligible employees are automatically covered. No application is necessary to obtain this benefit. Employees eligible for enrollment in the employee-paid life insurance plan may enroll without evidence of insurability, provided that completed applications are received by the District's Health Insurance Section no later than sixty (60) days from the date the employee is first notified of eligibility.
Employees not submitting applications during the period specified above may enroll by providing evidence of good health acceptable to the plan. Applications for employee-paid life insurance shall be processed to provide coverage at the earliest date consistent with the plan provided and payroll deduction schedules.
5.2 Dependents not enrolled as provided in this Section may be enrolled by providing evidence of good health acceptable to the plan. Dependents may be enrolled without evidence of insurability provided that:
a. Application for dependent coverage is submitted by the employee during the open enrollment period specified for employees; or
b. If the employee does not have eligible dependents at the time of enrollment, application for newly acquired dependent(s) is received by the Health Insurance Section within thirty (30) days of the acquisition of such dependent; or
c. Newborn children of the employee are automatically covered for the first thirty days following birth, provided that an application for dependent coverage is received by the Health Insurance Section before the end of the 30 day period.
Documents Required (copy)
Child, to age 19
Birth Certificate (in case of newborn, evidence of birth until birth certificate is available)
Stepchild, to age 19
Birth Certificate and income tax return showing dependent status
Adopted Child, to age 19
Child who is a Legal Ward to age 19
Court order establishing legal guardianship
Child over 19, to age 25
In addition to the appropriate documents listed above, proof of full-time student status is required at least annually.
Note: The children of a domestic partner are not eligible for coverage unless they have been adopted by the employee or the employee is the legal guardian. In such cases, the required documentation for adoption or legal guardianship must be provided.
e. A domestic partner of the same or opposite sex of an eligible employee may be covered as a dependent if all of the following criteria are met.
The employee and his/her partner:
(1) have shared a regular and permanent residence for the past 12 months immediately preceding the application for coverage with the LAUSD;
(2) are engaged in an exclusive committed relationship for mutual support and benefit to the same extent as married persons and intend to stay together indefinitely;
(3) are jointly responsible to each other for basic living expenses; basic living expenses are defined as the expenses supporting daily living, i.e., shelter, food, clothing (contributions need not be equal);
(4) are not currently married to another person;
(5) have not signed a declaration of a domestic partnership with another individual in the previous 12 month period;
(6) are at least 18 years of age;
(7) are not blood relatives any closer than would prohibit legal marriage in the state of residence;
(8) are mentally competent to consent to a contract;
(9) are financially interdependent as proven by providing at least two of the following documents: common ownership of real property or a common leasehold interest in real property, common ownership of a motor vehicle; joint bank account or joint credit account; designation as a beneficiary for life insurance or retirement benefits.
f. No other dependents or family members are eligible for coverage, except that disabled children who meet the disability standards of the plan(s) and who have been enrolled prior to age 19 may continue to be covered beyond age 19.
5.3 For an employee whose spouse/domestic partner has other insurance coverage, reimbursement will be limited to the maximum percentage allowed by the higher individual policy. An employee whose spouse/domestic partner is also a District employee will not be covered as both an employee and as a dependent within the same plan. A married couple who both work for the District or domestic partners who both work for the District may include their qualifying children on their individual policies, but such children may not be covered more than once within the same plan.
5.4 Once each year there shall be an open enrollment period during which an enrolled employee may change hospital-medical benefit plans, dental plans and/or vision care plans. The District's Health Insurance Section shall establish and announce the date of said open enrollment period.
5.5 It is the responsibility of the employee to notify the Health Insurance Section immediately regarding the termination of his/her domestic partner relationship. The employee must submit LAUSD Form DP2.0. AStatement of Disenrollment or Termination of Domestic Partnership.@ The coverage for a domestic partner shall end on the last day of the month in which the relationship and/or living arrangement terminates and/or for which either party is no longer eligible for coverage.
6.0 Continuation of Enrollment: With respect to the hospital- medical, dental and vision care plans, if an employee is in an unpaid status and not eligible for District contribution, the employee may arrange for continuance of enrollment under COBRA (see 9.0 - 9.3 below.)
6.1 With respect to the District-paid life insurance plan, coverage for an employee on an unpaid leave of absence other than for illness or industrial injury/illness shall not be provided until such time as the employee returns to active service in an eligible assignment. Coverage for an employee on an unpaid leave of absence for illness or industrial injury/illness shall continue for one year after which termination of coverage shall be processed and a conversion plan offered.
6.2 With respect to the employee-paid life insurance plan, employees who receive no salary or who receive insufficient salary to permit deduction of the required premium after all other deductions are made may continue coverage for a period not to exceed one (1) year by making direct payments of the appropriate premiums by check or money order payable to the plan and sent to the Health Insurance Section.
6.3 With respect to employees who decline to make the above continuation payments, coverage shall be terminated and they shall not be eligible to re-enroll in a plan until returning to active service in an eligible assignment and, with respect to the employee-paid life insurance plan, submitting evidence of good health acceptable to the plan.
7.0 Termination of Enrollment: The enrollment of an employee shall terminate:
a. For failure of the employee to make direct payment as provided under Sections 8.0 and 9.0, in which case coverage shall terminate at the close of the month for which the last premium was paid;
b. At the request of an employee, in which case coverage shall terminate at the close of the month in which the request was submitted;
c. Upon termination of employment, in which case coverage shall terminate at the close of the month in which the employment termination was effective; except for District paid life insurance in which case coverage shall terminate on the date the employee ceases to be employed.
d. In the event of the employee's loss of eligibility, in which case coverage shall terminate at the close of the enrollment year, except for the District-paid life insurance plan, which shall terminate coverage on the date of loss of eligibility; and
e. For District-paid life insurance, upon the employee's loss of eligibility or termination of employment, in which case coverage shall terminate on the date the employee ceases to be eligible or employed.
7.1 With respect to hospital-medical plan coverage, if the employee's participation is terminated at the plan's request for other than non-payment of premium, the employee may enroll in another of the District's hospital and medical plans by making proper application to the District's Health Insurance Section.
8.0 Conversion of Enrollment: With respect to the hospital- medical plans, an employee who is enrolled in a plan for at least two (2) consecutive calendar months and whose enrollment terminates because of (a) failure to make direct payment when required, (b) loss of eligibility, or (c) termination of employment, shall be given the opportunity to exercise the right of conversion of such individual coverage as provided by the plan, at the employee's expense. With respect to the life insurance plan, an employee whose enrollment terminates because of (a) failure to make direct payments when required, (b) termination of employment, or (c) loss of eligibility, shall be given the opportunity to convert, at the employee's expense, to a permanent form of insurance (other than term insurance) pursuant to the provisions of the plan.
9.0 COBRA: Pursuant to the Consolidated Omnibus Budget Reconciliation Act (COBRA), eligible employees or dependents may have continuation of coverage for a given period of time at their own expense under the District's health, dental and vision care plans in the event of termination of coverage due to one of the following causes: Death of covered employee, termination of covered employee (under certain conditions) or reduction in covered employee's hours of employment, divorce or legal separation of the covered employee, or a dependent child ceasing to be eligible for coverage as a dependent child under the District's health and welfare plans. In accordance with COBRA regulations, domestic partners are not considered qualified beneficiaries and are ineligible for COBRA continuation coverage.
9.1 The monthly premium for continued coverage shall be determined at the time of eligibility and shall be subject to change; however, the premium charged to employees will not exceed 102 percent of the premium paid by the District for active employees and/or dependents in a comparable status. The continuation coverage shall be the same as the coverage available to continuing employees, regardless of the employee's health at the time.
9.2 It shall be the responsibility of the employee or the dependent to notify the Health Insurance Section of a divorce, legal separation or loss of eligibility of a dependent child at the time of such an event. At the time of eligibility for continuation coverage, and upon such notification, an election form shall be provided by the District.
9.3 COBRA shall be administered pursuant to federal law, and all decisions and rules with respect to eligibility, premium costs, qualification for benefits, and level of benefits shall be in accordance with published federal government guidelines. Accordingly, it is expressly understood that all such
matters, as well as any other questions or issues relating to COBRA, are excluded from the grievance and arbitration provisions of Article V (Grievance Procedure).
10.0 Miscellaneous Provisions
10.1 If any premium is refunded by a Plan carrier/administrator, it shall be retained by the District, unless it is the result of a direct payment made by an employee in which case it shall be refunded to the employee. If any injury or illness is caused or alleged to be caused by any act or omission of a third party, payments will be made according to the terms of the Plan for the services of physicians, hospitals and other providers; however, the Plan Member must reimburse the Plan for any amount paid by the Plan, up to the amount of any settlement or judgment the Member, the Member's estate, parent or legal guardian receives from or on behalf of the third party on account of such injury or illness. The Plan may, in its discretion, condition payment upon execution by the Member, the Member's estate, parent or legal guardian of an agreement (1) to reimburse the Plan accordingly, and (2) to direct the Member's attorney to make payments directly to the Plan.
10.2 The controlling documents regarding all health plans are the applicable contracts between the District and the carriers/plan administrators. All disputes regarding coverage and benefits are to be resolved under the plan's own grievance procedures rather than under Article V of this Agreement.
11.0 Employee Assistance Program
a. General: An Employee Assistance Program (EAP) shall be established for employees and dependents eligible for other benefits pursuant to Section 3.0 of this Article. The objectives of the program shall be to provide confidential, professional counseling and referral services for a wide range of employee concerns including but not limited to: personal, marital and family problems; psychological and emotional problems; alcohol and substance abuse and dependency; or problems arising out of financial or legal matters. In addition, referral to confidential counseling by a professional familiar with the problems of law enforcement personnel shall also be available.
The program shall be designed to provide employees with the information, resources and opportunities to resolve personal, family and work problems before job performance is affected and to assist employees in correcting problems contributing to substandard performance. The program is not intended
to supplant other forms of assistance or medical referrals currently permitted under this Agreement, Board Rules or the law.
b. Confidentiality: The program is to be based upon strictest confidentiality and privacy, so that appropriate assistance can be offered by the District and/or sought by employees without adverse effect upon the employment relationship. EAP personnel shall not divulge to the District information relating to the decision of any individual employee to seek or decline EAP assistance, referrals or follow-up treatment. Neither the employee nor the District may refer to the following matters in any evaluation or disciplinary action, or appeal:
1. The decision of employees to utilize EAP services, or not to do so or actual participation in the EAP.
2. The recommendation by anyone, including administration, that an employee should utilize EAP services, or the failure to make such a recommendation. The existence of the EAP shall stand as conclusive evidence that the District has offered appropriate assistance for any personal problems which may have a bearing upon job performance of employees eligible for EAP and which fall under the purview of EAP.
c. Employee Accountability: Employees remain personally accountable for their job performance. The existence and/or utilization of the EAP and other services shall not serve as an excuse for inadequate job performance or as a defense in any evaluation or disciplinary action.
13.0 The IRS 125 Flexible Spending Account program currently available to certain certificated employees shall be expanded to enable eligible Unit A employees to enroll.