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Summaries of Benefits and Coverage (SBCs)
SchoolCare Standard Plans
- HMO ($10 Office Visit Copay, $5/15/35 Prescription Copay)
- POS ($10 Office Visit Copay, $5/15/35 Prescription Copay)
- OA+ ($250/500 Deductible, $5/15/35 Prescription Copay)
- CDHP (Consumer Driven Health Plan w/Choice Fund)
SchoolCare Alternative Plans
- HMO ($10 Office Visit Copay, $10/30/65 Prescription Copay)
- HMO ($20 Office Visit Copay, $10/30/65 Prescription Copay)
- POS ($10 Office Visit Copay, $10/30/65 Prescription Copay)
- POS ($20 Office Visit Copay, $10/30/65 Prescription Copay)
- OA+ ($250/500 Deductible, $10/30/65 Prescription Copay)
SchoolCare Customized Plans for Concord School District
- HMO ($5 Office Visit Copay, $5/15/25 Prescription Copay)
- POS ($10 Office Visit Copay, $5/15/25 Prescription Copay)
Uniform Glossary of Terms
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Other Resources
Key Contacts
The Key Contacts sheet is a valuable tool that has telephone numbers and helpful hints to make staying in touch with your health plan easier and more user-friendly.
Identity
Fraud Expense Reimbursement Coverage • Identity
Theft Recovery Kit
Presents tips and steps to take in the future to safeguard against Identity
Fraud.
Identity
Theft Claim Kit
Provides members with information on how to report an ID Theft, who
to report this theft to and how to be reimbursed for fraudulent charges.
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Enrollment Forms
Enrollment/Change
Form • Instructions
for Enrollment/Change Form
Employees and employers must complete this form for new enrollments
and adding or canceling dependents.
Notice
of Membership Adjustment Form
Employers may use this form as a cover sheet to summarize Enrollment/Change
Forms being submitted.
65+ Retiree Enrollment Form
Retirees must complete this form for enrollment in the SchoolCare 65+ plan for retirees and spouses enrolled in Medicare Parts A & B.
SchoolCare COBRA Notification Request Form
Employers must complete this form when notifying SchoolCare of coverage cancellation for employee and/or dependent(s).
Domestic
Partner Affidavit Form
Each employer group has the option of electing domestic partner coverage
(same and opposite sex). Criteria for standard coverage is indicated
in the form, but the employer group has the right to adopt with more
stringent criteria.
Disabled
Adult Verification Form
For dependents age 19 or older who are physically or mentally incapable
of self-support. Medical proof, including a physical examination by
the physician may be required.
Michelle’s
Law Verification Form
For dependents age 19 through 26 who are full-time students and take
a medically necessary leave of absence from school for a period not
to exceed 12 months. Documentation and certification of the medical
necessity of a leave of absence must be submitted to SchoolCare
by the student's attending physician and shall be considered prima facie
evidence of entitlement to coverage.
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