Employee Benefit Highlights

Transcription

1 Employee Benefit Highlights

2 Contact Information Human Resources Medical Insurance & Prescription Drug Coverage Health First Health Plans & Insurance (Group# HMO / PPO P13103) Phone: (321) human.resources@mlbfl.org Customer Service: (855) Mail-Order Pharmacy Program Health First Family Pharmacy Customer Service: (321) Fitness Benefit Active&Fit Customer Service: (888) Vision Benefit Dental Insurance Flexible Spending Account Life Insurance Short Term Disability Insurance Long Term Disability Insurance Employee Assistance Program Behavioral Health (for Health First Health Plan Enrollees) Retirement Plans Deferred Compensation Program Health First Health Plans & Insurance DeltaCare DHMO (Group# 76438) Delta Dental PPO (Group# High / Low 02001) TASC Minnesota Life (Group# 34074) Madison National (Group# 33725) Voya Financial Services (Group #676845) Deer Oaks Magellan Health Services Florida Retirement System Police Officers Retirement Trust Fund Firefighters Pension Plan General Employees and Special Risk Class Employees Pension Plan Nationwide 457(b) (Group# ) ICMA - RC Services Customer Service: (855) DeltaCare DHMO Customer Serivce: (800) PPO Low & High Customer Service: (800) Customer Service: (800) Customer Service: (800) ochs@ochsinc.com Customer Service: (800) , Ext ochs@ochsinc.com Customer Service: (888) Customer Service: (866) Customer Service: (800) Customer Service: (844) Jennifer Chase, Payroll/Pension Manager Phone: (321) Jennifer Chase, Payroll/Pension Manager Phone: (321) Jennifer Chase, Payroll/Pension Manager Phone: (321) Customer Service: (877) Agent: Jennifer Massey Office: (407) masseyj3@nationwide.com Investor Services: (800) wwww.icmarc.com

3 Table of Contents Introduction 1 Opt-Out Benefit Incentive 1 Group Insurance Eligibility 2 Qualifying Events and IRS Code Section Medical Insurance 4 Preventive Care Coverage 4 Health First Health Plans HMO Plan At-A-Glance 5 Health First Health Plans PPO Plan At-A-Glance 6 Active&Fit Benefit 7 Vision Program 8 Vision Program At-A-Glance 8 Dental Insurance 9 DeltaCare DHMO Plan At-A-Glance 10 Dental Insurance 11 Delta Dental PPO Low Plan At-A-Glance 12 Dental Insurance 13 Delta Dental PPO High Plan At-A-Glance 14 Flexible Spending Account Basic Life and AD&D Insurance 17 Voluntary Life Insurance Short Term Disability 18 Long Term Disability 18 Employee Assistance Program 19 Behavioral Health 20 Melbourne City Employee Wellness 20 Retirement Plans Deferred Compensation Program 21 Tuition Grant Program Paid Holiday Schedule 22 Notes This booklet is merely a summary of benefits. For a full description, refer to the plan document. Where conflict exists between this summary and the plan document, the plan document controls. City of Melbourne reserves the right to amend, modify or terminate the plan at any time. This booklet should not be construed as a guarantee of employment or coverage.

4 Introduction The City of Melbourne offers a comprehensive benefit package for all eligible employees. A variety of these employee benefit programs have been highlighted in this booklet as a general reference. Please refer to the City s employee benefits website at for detailed descriptions of all available employee benefit programs and stipulations therein. Questions and further clarifications regarding this booklet s contents may be directed to Human Resources. Opt-Out Benefit Incentive The current policy provides that full-time employees opting out of the City s plan will receive $150 per month, paid semi-monthly. This option must be renewed each year, is not available to part-time employees and is considered taxable income. Proof of insurance coverage under another medical plan is required to participate in the Opt-Out Benefit. 1

5 Group Insurance Eligibility APRIL 01 The City s group insurance plan year is April 1 through March 31. Employee Eligibility Employees are eligible to participate in the City s insurance plans if they are full-time employees working a minimum of 30 hours per week. Coverage will be effective the first of the month following 30 days of employment. For example, if an employee is hired on April 11, then the effective date of coverage will be June 1. Termination If an employee separates employment from the City, insurance will continue through the end of month in which separation occurred. COBRA continuation of coverage may be available as applicable by law. Dependent Eligibility A dependent is defined as the legal spouse and/or dependent child(ren) of the participant or spouse. The term child includes any of the following: A natural child A legally adopted child A stepchild A foster child A newborn child (up to the age of 18 months old) of a covered dependent (Florida) A child for whom legal guardianship has been awarded to the participant or the participant s spouse A dependent child may be covered through the end of the calendar year in which the child reaches age 26 for medical. Dependent Age Requirements Medical Coverage: A dependent child may be covered through the end of the calendar year in which the child turns 26. An over-age dependent may continue to be covered on the medical plan through the end of the calendar year in which the child reaches age 30, if the dependent meets the following requirements: Unmarried with no dependents; and A Florida resident, or full-time or part-time student; and Otherwise uninsured; and Not entitled to Medicare benefits under Title XVIII of the Social Security Act, unless the child is disabled. Vision Coverage: A dependent child may be covered through the end of the calendar year in which the child turns age 30. Dental Coverage: A dependent child may be covered through the end of the calendar year in which the child turns age 25. Disabled Dependents Coverage for an unmarried dependent child may be continued beyond age 26 if: The dependent is physically or mentally disabled and incapable of self-sustaining employment (prior to age 26); and Primarily dependent upon the employee for support; and The dependent is otherwise eligible for coverage under the group medical plan; and The dependent has been continuously insured. Proof of disability will be required upon request. Please contact Human Resources if further clarification is needed. Taxable Dependents Employees covering adult children under their medical insurance plan may continue to have the related coverage premiums payroll deducted on a pretax basis through the end of the calendar year in which the child reaches age 26. Beginning January 1st of the calendar year in which the child reaches age 27 through the end of the calendar year in which the child reaches age 30, employees will be charged an additional premium on a post-tax basis to continue coverage for such dependents. Contact Human Resources for further details if covering an adult child who will turn 27 any time during the upcoming calendar year or for more information. 2

6 Qualifying Events and IRS Code Section 125 IRS Code Section 125 Premiums for medical, dental, vision insurance and/or certain supplemental policies and contributions to FSA accounts (Health Care and Dependent Care FSAs) are deducted through a Cafeteria Plan established under Section 125 of the Internal Revenue Code (IRC) and are pre-tax to the extent permitted. Under Section 125, changes to an employee s pre-tax benefits can be made ONLY during the Open Enrollment period unless the employee or qualified dependents experience a qualifying event and the request to make a change is made within 31 days of the qualifying event. Under certain circumstances, employees may be allowed to make changes to benefit elections during the plan year, if the event affects the employee, spouse or dependent s coverage eligibility. An eligible qualifying event is determined by the Internal Revenue Service (IRS) Code, Section 125. Any requested changes must be consistent with and on account of the qualifying event. Examples of Qualifying Events: Employee gets married or divorced Birth of a child Employee gains legal custody or adopts a child Employee s spouse and/or other dependent(s) die(s) Employee, employee s spouse and/or dependent(s) terminate or start employment An increase or decrease in employees work hours causes eligibility or ineligibility A covered dependent no longer meets eligibility criteria for coverage A child gains or loses coverage with an ex-spouse Change of coverage under an employer s plan Gain or loss of Medicare coverage Losing eligibility for coverage under a State Medicaid or CHIP (including Florida Kid Care) program (60 day notification period) Becoming eligible for State premium assistance under Medicaid or CHIP (60 day notification period) Enrollment in a qualified health plan offered through an Exchange during a special enrollment period Important Employees who experience a qualifying event must contact Human Resources within 31 days of the qualifying event to make the appropriate changes to coverage. Beyond 31 days, requests will be denied and the employee may be responsible both legally and financially for any claim and/or expense incurred as a result of the employee or a dependent who continues to be enrolled but no longer meets eligibility requirements. If approved, changes will take place in accordance with the carrier s policies and procedures, except for newborns which are effective on the date of birth. Employees may be required to furnish valid documentation supporting a change in status or Qualifying Event. Please Note: Newborn coverage shall take effect at the moment of birth provided the Health Plan is notified by the insured to enroll the child within 60 days of the newborn s date of birth. If the insured enrolls the newborn within 31 days of the birth, no premium will be charged for the first 31 days. If the insured fails to enroll the child within 31 days of birth, but enrolls the child within 60 days of birth, the insured will be required to pay premium from the date of birth. If notice of the birth is not given within 60 days of birth, the newborn child will be considered a late enrollee and ineligible to enroll for coverage until the next Annual Open Enrollment Period. 3

7 Medical Insurance The City provides medical insurance through Health First Health Plans to benefit eligible employees. When enrolled in one of the following medical plans, a vision discount benefit is included, as well as a free Active&Fit benefit. For information about the medical plan please refer to the Summary of Benefits and Coverage (SBC) provided. Tier of Coverage Medical Insurance Premiums Health First Health Plans HMO Plan 24 Payroll Deductions - Per Pay Period Cost Employee Cost Employee Only $0 Employee + Family $ Tier of Coverage Medical Insurance Premiums Health First Health Plans PPO Plan 24 Payroll Deductions - Per Pay Period Cost Employee Cost Employee Only $ Summary of Benefits and Coverage A Summary of Benefits & Coverage (SBC) for the medical plan is provided as a supplement to this booklet which is being distributed to new hires and existing employees during open enrollment. The summary is an important item in understanding employee benefit options. A free paper copy of the SBC document may be requested or is available as follows: From: Human Resources Address: 900 E. Strawbridge Ave. Melbourne, FL Phone: (321) human.resources@mlbfl.org At Website URL: The SBC is only a summary of the plan s coverage. A copy of the plan document, policy, or certificate of coverage should be consulted to determine the governing contractual provisions of the coverage. A copy of the actual group certificate of coverage can be reviewed and obtained by contacting Human Resources, or online at If employees have any questions about the plan offerings or coverage options, please contact Human Resources at (321) Employee + Family $ Health First Health Plans Customer Service: (855) Preventive Care Coverage The City encourages employees to take advantage of preventive care services. The goal of preventive care is to detect problems early, before symptoms appear, to prevent serious medical conditions from developing or getting worse. Health First Health Plans provides coverage for preventive care at no charge when seeing a participating provider. Preventive care services are provided when employees don t have any signs or symptoms and haven t been diagnosed with the condition in question. If employees have symptoms of the condition being tested for, or if they have already been diagnosed with the condition, related tests would be considered diagnostic and a cost share may apply. Some examples of preventive services are listed below. Screenings Physical exams Well-woman exams Well-child exams Immunizations Please check the plan summary or contact Health First Health Plans Customer Service for a complete list of preventive exams and for information regarding age, frequency limits and plan requirements. 4

8 Health First Health Plans HMO Plan At-A-Glance Network Health First Health Plans Locate a Provider To search for a participating provider, contact Customer Service or visit www. healthfirsthealthplans.com. Under Group Plans, click Provider Directory. Select Health First Group Plans for the Network, complete the additional search criteria, and then click Search. Calendar Year Deductible (CYD) In-Network Single (If Employee Completes the Wellness Assessment) $500 Family (If Employee Completes the Wellness Assessment) $1,000 Single (If Employee Does NOT Complete the Wellness Assessment) $1,000 Family (If Employee Does NOT Complete the Wellness Assessment) $2,000 Coinsurance Member Responsibility 20% Calendar Year Out-of-Pocket Limit Single $3,000 Family $6,000 What Applies to the Out-of-Pocket Limit? Deductibles, Coinsurance, Copays and Rx Plan References *Charges may vary based on the place of service. Important Notes Services received by providers or facilities not in the Health First Health Plans Network, will not be covered Physician Services Primary Care Physician (PCP) Office Visit Specialist Office Visit Non-Hospital Services; Freestanding Facility Clinical Lab (Blood Work)* X-rays* Advanced Imaging (MRI, PET, CT; Prior Authorization Required)* Outpatient Surgery at Surgical Center Physician Services at Surgical Center Urgent Care Facility (Per Visit) Hospital Services Inpatient (Per Admission) Physician Services at Hospital Emergency Room (Waived if Admitted) Mental Health/Alcohol & Substance Abuse Inpatient Services (Per Admission) Outpatient Services (Per Visit) $15 Copay $30 Copay $0 Copay 20% After CYD 20% After CYD 20% After CYD 20% After CYD $50 Copay 20% After CYD 20% After CYD $250 Copay 20% After CYD $20 Copay Prescription Drugs (Rx) In-Network Mail-Order Drug 90 Day Supply Tier 1 - Preferred Generic $2 Copay $4 Copay Tier 2 - Non-Preferred Generic $15 Copay $30 Copay Tier 3 - Preferred Brand $45 Copay $90 Copay Tier 4 - Non-Preferred Brand $90 Copay $180 Copay Tier 5 - Specialty (Only Available in 30 day supply from Health First Family & Pharmacy) 20% After CYD Not Covered 5

9 Health First Health Plans PPO Plan At-A-Glance Network Health First Health Plans Calendar Year Deductible (CYD) In-Network Out-of-Network* Single (If Employee Completes the Wellness Assessment) $1,000 $2,000 Family (If Employee Completes the Wellness Assessment) $2,000 $4,000 Single (If Employee Does NOT Complete the Wellness Assessment) $1,500 $2,000 Family (If Employee Does NOT Complete the Wellness Assessment) $3,000 $4,000 Coinsurance Member Responsibility 20% 30% Calendar Year Out-of-Pocket Limit Single $3,000 $6,000 Family $6,000 $12,000 What Applies to the Out-of-Pocket Limit? Deductibles, Coinsurance, Copays and Rx Physician Services Primary Care Physician (PCP) Office Visit $20 Copay 30% After CYD Specialist Office Visit $40 Copay 30% After CYD Non-Hospital Services; Freestanding Facility Clinical Lab (Blood Work)** No Charge 30% After CYD X-rays** 20% After CYD 30% After CYD Advanced Imaging (MRI, PET, CT; Prior Authorization Required)** $250 Copay 30% After CYD Outpatient Surgery at Surgical Center 20% After CYD 30% After CYD Physician Services at Surgical Center 20% After CYD 30% After CYD Urgent Care Facility (Per Visit) $50 Copay 30% After CYD Locate a Provider To search for a participating provider, contact Customer Service or visit www. healthfirsthealthplans.com. Under Group Plans, click Provider Directory. Select Health First Group Plans for the Network, complete the additional search criteria, and then click Search. Plan References *Out-Of-Network Balance Billing: For information regarding Out-of- Network Balance Billing that may be charged by an out-of-network provider, please refer to the Out-of-Network Benefits section on the previous page. **Charges may vary based on the place of service. Hospital Services Inpatient (Per Admission) $250 Per Day; For Days % After CYD Physician Services at Hospital at Outpatient Facility 20% After CYD 30% After CYD Emergency Room (Waived if Admitted) 20% After CYD 20% After CYD Mental Health/Alcohol & Substance Abuse Inpatient Services (Per Admission) $250 Per Day; For Days % After CYD Outpatient Services (Per Visit) $20 Copay 30% After CYD Prescription Drugs (Rx) In-Network Mail-Order Drug 90 Day Supply Tier 1 - Preferred Generic $2 Copay $4 Copay Tier 2 - Non-Preferred Generic $15 Copay $30 Copay Tier 3 - Preferred Brand $45 Copay $90 Copay Tier 4 - Non-Preferred Brand $90 Copay $180 Copay Tier 5 - Specialty (Only Available in 30 day supply from Health First Family & Pharmacy) 20% After CYD Not Covered 6

10 Active&Fit Benefit Employees enrolled in one of the Health First Health Plans' medical plans will receive a free Active&Fit benefit, which allows employees to customize a fitness plan that works for their lifestyle. This includes the benefit of selecting either the Home Fitness Program or the Fitness Center Program at no additional cost. Home Fitness Program Starting January 1, 2017, employees have the opportunity to exercise in the privacy and convenience of their own home. The Home Fitness Program offers: Home Fitness Kits (choose up to two of the 17 offered each benefit year) 9 9A searchable library of Online Education Classes, which can be viewed on the Active&Fit website 9 9Active&Fit Connected!, a tool that allows employees to track their exercise and activity, using one of the 150+ wearable wireless fitness devices, mobile applications, and exercise equipment 9 9Access to the quarterly Active&Fit newsletter Fitness Center Program As part of the new Fitness Center Program, employees may choose one fitness center of choice. (Changes can be made monthly.) To search our nationwide network of participating fitness centers (or nominate a gym to participate), visit ActiveandFit.com The Fitness Center Program also offers: 9 9A searchable library of Online Education Classes, which can be viewed on the Active&Fit website 9 9Active&Fit Connected!, a tool that allows employees to track their exercise and activity, using one of the 150+ wearable wireless fitness devices, mobile applications, and exercise equipment 9 9Access to the quarterly Active&Fit newsletter Get Started! 1. Go to ActiveandFit.com. 2. Register to use website. 3. Choose a fitness center or sign up for the Home Fitness program. 4. Take the fitness card to the fitness center. 5. If employees prefer, they can call toll-free 1 (800) (TTY/TDD relay: 1 (877) ) 8 a.m. to 9 p.m. (Eastern Time), seven days a week to find a fitness center near them or to enroll in the Home Fitness Program. 7

11 Vision Program The City provides a vision plan through Health First Health Plans when enrolled in one of the group s medical plans. The vision plan benefits are highlighted below. For more details on coverages, exclusions and stipulations, please refer to Health First Health Plans benefit summary or contact Customer Service. In-Network Only Benefits The vision plan provides employees and their covered dependents with a routine eye exam, eyeglasses (lenses and frames) or contact lenses at a discounted rate. To schedule an appointment, covered members can select any optometrist or ophthalmologist that participates in the Health First Health Plans Network only. At the time of service, routine vision examination services and basic optical needs will be discounted as shown on the summary below. Cosmetic services and upgrades will be an additional charge. There is no coverage for services provided by a non-participating network provider. Vision Program At-A-Glance Network Frequency of Services Eye Exam Lenses / Contact Lenses Frames Services Eye Exam Materials Lenses Single Vision Bifocal Trifocal Frames Reimbursement Contact Lenses* Non-Elective; Medically Necessary Elective Health First Health Plans 12 Months 12 Months 12 Months $15 Copay 20% Discount 20% Discount 20% Discount 20% Discount 20% Discount Available for a Discounted Price and there may be a charge for Contact Exam 8

12 Dental Insurance DeltaCare DHMO Plan The City offers dental insurance through Delta Dental to benefit eligible employees. The costs per pay period for coverage are listed in the premium table below and a brief summary of benefits is provided on the following page. For more detailed information about the dental plan, please refer to Delta Dental s summary plan document or contact Delta Dental s customer service. Dental Insurance Premiums DeltaCare DHMO Plan 24 Payroll Deductions - Per Pay Period Cost Tier of Coverage Full-Time & Part-Time Cost Employee Only $7.04 Employee + 1 Dependent $13.07 Employee + 2 or more Dependents $19.09 In-Network Benefits The DHMO dental plan is an in-network only plan that requires all services be received by a Primary Dental Provider (PDP). Employees and their dependents may select any participating dentist in the DeltaCare USA network to receive covered services. There is no coverage for services received out-of-network. The DHMO plan s schedule of benefits is set forth by the Patient Charge Schedule (fee schedule) which is highlighted on the following page. Please refer to the plan s summary of coverage document for a detailed listing of charges and what is covered. Out-of-Network Benefits The DHMO plan does not cover any services rendered by out-of-network facilities or providers. Plan Year Deductible There is no Plan Year Deductible. Plan Year Benefit Maximum There is no benefit maximum. Important NOTES Each covered family member may receive two free cleanings per calendar year (1 every 6 months) covered under the preventative benefit. Additional cleanings are available at the charge of a copay. Referrals and prior authorizations are required to see specialists (oral surgeon, periodontist, orthodontist, etc.) within the network. Waiting periods and age limitations may apply for some services. Out-of-area dental emergencies are covered at $100 if Delta Dental deems it as a true emergency. Employees must receive services from facilities and providers in the DeltaCare USA Network for benefits to be covered. The summary on the following page has been provided as a convenient reference. For a full listing of covered services, please see the plan s Schedule of Benefits or contact DeltaDental Customer Service. DeltaCareUSA Customer Service: (800) Group Plan Number:

13 DeltaCare DHMO Plan At-A-Glance Network Plan Year Deductible (PYD) Per Member Per Family DentalCare USA In-Network Only None None Plan Year Benefit Maximum Per Member None Class I Services: Diagnostic & Preventative Care In-Network Code Routine Oral Exam No Charge 0120 Routine Cleanings* $5 Copay 1110/20 Bitewing X-rays No Charge 0274 Complete X-rays No Charge 0210 Sealants (Up to Age 15) Per Tooth $15 Copay 1351 Fluoride Treatments No Charge 1203 Class II Services: Basic Restorative Care Fillings (Amalgam 3 Surfaces, Posterior) $18 Copay 2160 Fillings (Composite 3 Surfaces, Anterior) $30 Copay 2332 Fillings (Composite 3 Surfaces, Posterior) $85 Copay 2393 Root Canal Therapy Molar** $365 Copay 3330 Simple Extraction of Erupted Tooth $55 Copay 7210 Surgical Removal of Impacted Tooth (Soft Tissue) $70 Copay 7220 Surgical Removal of Impacted Tooth (Completely Bony) $120 Copay 7240 Full Mouth Debridement $60 Copay 4355 Periodontal Maintenance $45 Copay 4910 Locate a Provider To search for a participating provider, contact Delta Dental customer service or visit When completing the necessary search criteria, select DeltaCare USA for the network. Plan References *An additional cleaning may be received for the cost of a $45 copay. **Excludes Final Restoration. Class III Services: Major Restorative Care Bridges (Porcelain Fused to High Noble Metal) $395 Copay 6240 Crowns (Porcelain Fused to High Noble Metal) $395 Copay 2750 Dentures $365 Copay + Lab 5110/20 Class IV Services: Orthodontia Benefit Child (Up to Age 19) $1, /8080 Benefit Adults and Dependent Children (Age 19 and Over) $2, Retention $275 Copay

14 Dental Insurance Delta Dental PPO Low Plan The City offers dental insurance through Delta Dental to benefit eligible employees. The costs per pay period for coverage are listed in the premium tables and a brief summary of benefits is provided on the following page. For more detailed information about the dental plans, please refer to Delta Dental s summary plan document or contact Delta Dental s customer service. Dental Insurance Premiums Delta Dental Low PPO Plan 24 Payroll Deductions - Per Pay Period Cost Tier of Coverage Employee Cost Employee Only $15.44 Employee + 1 Dependent $30.68 Employee + 2 or more Dependents $45.11 In-Network Benefits The PPO plan provides benefits for services received from in-network and out-of-network providers. It is also an open access plan which allows for services to be received from any dental provider without having to select a Primary Dental Provider (PDP) or obtain a referral to a specialist. The network of participating dental providers the plan utilizes is the Dental PPO network. These participating dental providers have contractually agreed to accept Delta Dental s contracted fee or allowed amount. This fee is the maximum amount a Delta dental provider can charge a member for a service. The member is responsible for a Plan Year Deductible (PYD) and then coinsurance based on the plan s charge limitations. Please Note: If a member is not able to use a Delta Dental PPO provider, then services can be received from a Delta Dental Premier Provider. Delta Dental Premier Providers are considered out-of-network dentists. These dentists have agreed to accept Delta Dental s Maximum Plan Allowance (MPA) for each single procedure; however, the provider may still bill for the difference of the MPA and the Premier Dental Agreement amount. The member is responsible for verifying whether the treating dentist is a PPO Dentist or Premier Dentist. Out-of-Network Benefits Out-of-network benefits are used when members receive services by a nonparticipating Delta Dental provider. Delta Dental reimburses out-of-network services based on what it determines is the Maximum Reimbursable Charge (MRC). The MRC is defined as the most common charge for a particular dental procedure performed in a specific geographic area. If services are received from an out-of-network dentist, the member will pay the out-of-network benefit plus the difference between the amount that Delta Dental reimburses (MRC) for such services and the amount charged by the dentist. This is known as balance billing. Balance billing is in addition to any applicable plan deductible or coinsurance responsibility. Plan Year Deductible The dental PPO plan requires a $50 individual or a family $150 deductible to be met for in-network or out-of-network services before most benefits will begin. The deductible is waived for preventative services. Plan Year Benefit Maximum The maximum benefit (coinsurance) the dental PPO plan will pay for each covered member is $1000 benefit maximum amount for in-network or out-ofnetwork services combined. Diagnostic and preventive accumulate towards the benefit maximum. Delta Dental Customer Service: (800) Group Plan Number:

15 Delta Dental PPO Low Plan At-A-Glance Network Delta Dental PPO Plan Year Deductible (PYD) In-Network Out-of-Network* Per Member $50 Per Family $150 Waived for Class I Services Plan Year Benefit Maximum Per Member $1,000 Class I Services: Diagnostic & Preventative Care Routine Oral Exam Routine Cleanings Bitewing X-rays Complete X-rays Plan Pays: 100% Deductible Waived Yes Plan Pays: 100% Deductible Waived (Subject to Balance Billing) Locate a Provider To search for a participating provider, contact Delta Dental s customer service or visit When completing the necessary search criteria, select Delta Dental PPO for the network. Class II Services: Basic Restorative Care Fillings (Amalgam) Simple Extractions Deep Cleaning Endodontics (Root Canal Therapy) Periodontics Oral Surgery Plan Pays: 70% After PYD Plan Pays: 70% After PYD (Subject to Balance Billing) Plan References *Out-Of-Network Balance Billing: For information regarding Out-of- Network Balance Billing that may be charged by an out-of-network provider, please refer to the Out-of-Network Benefits section on the previous page. Class III Services: Major Restorative Care Crowns Dentures Bridges Plan Pays: 40% After PYD Class IV Services: Orthodontia Benefit Maximum $1,000 Benefit Dependent Children Only Plan Pays: 40% Coinsurance Plan Pays: 40% After PYD (Subject to Balance Billing) Plan Pays: 40% Coinsurance (Subject to Balance Billing) Important Notes The above summary has been provided as a convenient reference. For a full listing of covered services, exclusions and stipulations please see the plan s Schedule of Benefits or contact Delta Dental s Customer Service. 12

16 Dental Insurance Delta Dental PPO High Plan The City offers dental insurance through Delta Dental to benefit eligible employees. The costs per pay period for coverage are listed in the premium tables and a brief summary of benefits is provided on the following page. For more detailed information about the dental plans, please refer to Delta Dental s summary plan document or contact Delta Dental s customer service. Dental Insurance Premiums Delta Dental High PPO Plan 24 Payroll Deductions - Per Pay Period Cost Tier of Coverage Employee Cost Employee Only $19.54 Employee + 1 Dependent $38.82 Employee + 2 or more Dependents $57.08 In-Network Benefits The PPO plan provides benefits for services received from in-network and out-of-network providers. It is also an open access plan which allows for services to be received from any dental provider without having to select a Primary Dental Provider (PDP) or obtain a referral to a specialist. The network of participating dental providers the plan utilizes is the Dental PPO network. These participating dental providers have contractually agreed to accept Delta s contracted fee or allowed amount. This fee is the maximum amount a Delta dental provider can charge a member for a service. The member is responsible for a Plan Year Deductible (PYD) and then coinsurance based on the plan s charge limitations. Please Note: If a member is not able to use a Delta Dental PPO provider, then services can be received from a Delta Dental Premier Provider. Delta Dental Premier Providers are considered out-of-network dentists. These dentists have agreed to accept Delta Dental s Maximum Plan Allowance (MPA) for each single procedure; however, the provider may still bill for the difference of the MPA and the Premier Dental Agreement amount. The member is responsible for verifying whether the treating dentist is a PPO Dentist or Premier Dentist. Out-of-Network Benefits Out-of-network benefits are used when members receive services by a nonparticipating Delta Dental provider. Delta Dental reimburses out-of-network services based on what it determines is the Maximum Reimbursable Charge (MRC). The MRC is defined as the most common charge for a particular dental procedure performed in a specific geographic area. If services are received from an out-of-network dentist, the member will pay the out-of-network benefit plus the difference between the amount that Delta Dental reimburses (MRC) for such services and the amount charged by the dentist. This is known as balance billing. Balance billing is in addition to any applicable plan deductible or coinsurance responsibility. Plan Year Deductible The dental PPO plan requires a $50 individual or a family $150 deductible to be met for in-network or out-of-network services before most benefits will begin. The deductible is waived for preventative services. Plan Year Benefit Maximum The maximum benefit (coinsurance) the dental PPO plan will pay for each covered member is $1500 for in-network or out-of-network services combined. Diagnostic and preventative services accumulate towards the benefit maximum. Delta Dental Customer Service: (800) Group Plan Number:

17 Delta Dental PPO High Plan At-A-Glance Network Delta Dental PPO Plan Year Deductible (PYD) In-Network Out-of-Network* Per Member $50 Per Family $150 Waived for Class I Services Plan Year Benefit Maximum Per Member $1,500 Class I Services: Diagnostic & Preventative Care Routine Oral Exam Routine Cleanings Bitewing X-rays Complete X-rays Plan Pays: 100% Deductible Waived Yes Plan Pays: 100% Deductible Waived (Subject to Balance Billing) Locate a Provider To search for a participating provider, contact Delta Dental s customer service or visit When completing the necessary search criteria, select Delta Dental PPO for the network. Class II Services: Basic Restorative Care Fillings (Amalgam) Simple Extractions Deep Cleaning Endodontics (Root Canal Therapy) Periodontics Oral Surgery Plan Pays: 80% After PYD Plan Pays: 80% After PYD (Subject to Balance Billing) Plan References *Out-Of-Network Balance Billing: For information regarding Out-of- Network Balance Billing that may be charged by an out-of-network provider, please refer to the Out-of-Network Benefits section on the previous page. Class III Services: Major Restorative Care Crowns Dentures Bridges Plan Pays: 50% After PYD Class IV Services: Orthodontia Benefit Maximum $1,000 Benefit Dependent Children Only Plan Pays: 50% Coinsurance Plan Pays: 50% After PYD (Subject to Balance Billing) Plan Pays: 50% Coinsurance (Subject to Balance Billing) Important Notes The above summary has been provided as a convenient reference. For a full listing of covered services, exclusions and stipulations please see the plan s Schedule of Benefits or contact Delta Dental s Customer Service. 14

18 Flexible Spending Account The City offers Flexible Spending Accounts (FSA) administered through TASC. The FSA plan year is from April 1 to March 31. If an employee or their family has predictable health care or work-related day care expenses, then he/she may benefit from participating in an FSA. An FSA allows employees to set aside money from their paycheck for reimbursement of health care and day care expenses that they regularly pay. The amount set aside is not taxed and is automatically deducted from the employee s paycheck and deposited into the FSA. During the year, the employee has access to this account for reimbursement of some expenses that are not covered by insurance. Participation in an FSA allows for substantial tax savings and an increase in spending power. Participating employees must re-elect the dollar amount they wish to have deducted each plan year. There are two types of FSAs: Health Care FSA This account allows participants to set aside up to an annual maximum of $2,600 ($ bi-weekly deduction). This money will not be taxable income to the participant and can be used to offset the cost of a wide variety of eligible medical expenses that generate out-of-pocket costs. Participating employees can also receive reimbursement for expenses related to dental and vision care (that are not classified as cosmetic). Examples of common expenses that qualify for reimbursement are listed below. Dependent Care FSA This account allows participants to set aside up to an annual maximum of $5,000 ($ bi-weekly deduction) if the participating employee is single or married and file a joint tax return ($2,500 if they are married and file a separate tax return) for work-related day care expenses. Qualified expenses include day care centers, preschool, and before/after school care for eligible children and adults. Please note that if a family s income is over $20,000, this reimbursement option will likely save participants more money than the dependent day care tax credit taken on a tax return. To qualify, dependents must be: A child under the age of 13, or A child, spouse or other dependent that is physically or mentally incapable of self-care and spends at least 8 hours a day in the participant s household. Please Note: The entire Health Care FSA election is available for use on the first day coverage is effective. Please Note: Unlike the Health Care FSA, reimbursement is only up to the amount that has been deducted from the participant s paycheck for the Dependent Care FSA. A sample list of qualified expenses eligible for reimbursement include, but are not limited to, the following: Ambulance service 9 9Experimental medical treatment 9 9Nursing services 9 9Chiropractic care 9 9Corrective eyeglasses and contact lenses 9 9Optometrist fees 9 9Dental and orthodontic fees 9 9Hearing aids and exams 9 9Prescription drugs 9 9Diagnostic tests/health screenings 9 9Injections and vaccinations 9 9Medically necessary sunscreen 9 9Physician fees and office visits 9 9LASIK surgery 9 9Wheelchairs 9 9Drug addiction/alcoholism treatment 9 9Mental health care Dependent Care Expenses Fees for licensed day care or adult care facilities Before and after school care programs for dependents under age 13 Nanny expenses attributed to dependent care Nursery school (preschool) fees Summer Day Camp - primary purpose must be custodial care and not educational in nature Late pick-up fees Amounts paid for services (including babysitters or nursery school) provided in or outside of the employee's home Log on to for additional details regarding qualified and non-qualified expense.

19 Flexible Spending Account (Continued) FSA Guidelines Employees may carry over $500 of unused Health Care FSA funds into the next plan year after a plan year ends and all claims have been filed. Dependent Care funds cannot be carried over. The Health Care FSA has a run out period at the end of the year (June 29) to submit reimbursement on eligible expenses incurred during the period of coverage within the plan year (April 1- March 31). When a plan year and grace period ends and all claims have been filed with the exception of the $500 rollover for the Health Care FSA, all unused funds will be forfeited and will not be allowed to be returned. Employees can enroll in either or both of the FSAs only during the open enrollment period, a qualifying event, or new hire eligibility. Money cannot be transferred between FSAs. Reimbursed expenses cannot be deducted for income tax purposes. Employees and their dependents cannot be reimbursed for services they have not received. Employees and their dependents cannot receive insurance benefits or any other compensation for expenses which are reimbursed through an FSA. Domestic Partners are not eligible as federal law does not recognize them as a qualified dependent. The IRS requires FSA participants to maintain complete documentation, including copies of receipts for reimbursed expenses, for a minimum of one year. How to Access FSA Funds As eligible expenses are incurred, employees have two options to access their available FlexSystem FSA funds: TASC Benefits Card Upon enrollment into the Plan, employees will receive a TASC Card in the mail, which can be used to pay for eligible expenses at the point of purchase. Simply swipe the TASC Card where MasterCard is accepted. Request a Reimbursement Simply submit a request for reimbursement to FlexSystem using one of the following methods: Submit via MyTASC Mobile App (free download) Submit via MyTASC Text Message (SMS) Download Request for Reimbursement form online (paper) Reimbursement is direct deposited into the employee's MyCash account or a designated bank account. MyCash funds are accessible via their TASC Card to be used for any type of purchase or ATM cash withdrawal. Here s How It Works! FlexSystem FSA is offered through the City and is administered by TASC. When an employee chooses to enroll in a FlexSystem Healthcare FSA and/or Dependent Care FSA, they must determine the dollar amount they want to contribute to each account based on their estimated expenses for the upcoming Plan Year. Contributions will be deducted in equal amounts from each paycheck, pre-tax, through the Plan Year. The more you contribute to these accounts, the more you reduce your taxable gross salary and with less taxes taken, your take-home pay increases! The total annual Healthcare FSA contribution amount is available immediately at the start of the Plan Year. Dependent Care FSA funds are available up to the current account balance only. Without a Health Care FSA With a Health Care FSA Gross Monthly Pay $3,500 $3,500 Pre-Tax Contributions Medical/Dental Premiums $0 - $125 Medical Expenses $0 - $75 Depdendent Care Expenses $0 -$400 TOTAL $0 -$600 Taxable Monthly Income $3,500 $2,900 Taxes (federal, state, FICA): - $968 - $802 Out-of-pocket Expenses: - $600 $0 Taxable Monthly Income $1,932 $2,098 Net Increase in Take-Home Pay = $166/mo! Please Note: Be conservative when estimating medical and/or dependent care expenses. IRS regulations state that any unused funds which remain in FSA after a plan year ends and after all claims have been filed cannot be returned or carried forward to the next plan year with the exception of the $500 carry over that may be allowed for the Health Care FSA. This rule is known as use it or lose it. Claims Mailing Address 2302 International Lane, Madison, WI TASC Customer Service: (800) Fax: (608)

20 Basic Life and AD&D Insurance Basic Term Life The City provides Basic Term Life insurance for all eligible employees through Minnesota Life, at no cost to the employee. Employees are covered for an amount equal to one times their annual earnings, rounded to the next higher multiple of $1,000, not to exceed $100,000. Accidental Death & Dismemberment Also at no cost to the employee, the City provides Accidental Death & Dismemberment (AD&D) insurance, which pays in addition to the Basic Term Life benefit when death occurs as a result of an accident. The AD&D benefit amount equals the Basic Term Life. Always remember to keep beneficiary forms updated. Employees may update their beneficiary information anytime by contacting the City s Human Resources Department. Minnesota Life Customer Service: (800) Voluntary Life Insurance Voluntary Employee Life and AD&D Insurance Eligible employees may elect to purchase additional life insurance on a voluntary basis through Minnesota Life. This coverage may be purchased in addition to the Basic Term Life and AD&D coverages. Voluntary Life Insurance offers coverage for employees, their spouse or child(ren) at different benefit levels. Units can be purchased in increments of $10,000, with a maximum of $500,000, or 5 times annual salary. The Voluntary Life Benefit includes an AD&D Benefit that matches the Voluntary Life amount elected. Rates are subject to increase annually and are based on the employees age bracket. Group coverage with the City will end upon termination. New Hires can purchase Voluntary Employee Life insurance without having to go through Medical Underwriting, also known as Evidence of Insurability (EOI), to the Guaranteed Issue amount of up to 3x annual earnings (not to exceed $350,000). Voluntary Spouse Life and AD&D Insurance Units can be purchased in increments of $5,000, not to exceed a maximum of $250,000. However, coverage cannot exceed the employee s combined Basic and Voluntary Life coverage amount. A spouse is not eligible if they are eligible as an employee. Spouse coverage includes AD&D coverage equal to the spouse term life amount. Coverage ends when the employee terminates employment or retires with the City. New Hires can purchase voluntary spouse life insurance without having to go through Medical Underwriting, also known as Evidence of Insurability (EOI), up to the Guaranteed Issue amount of $25,

21 Voluntary Life Insurance (Continued) Voluntary Life/AD&D Monthly Rate Table Rate Per $1,000 of Benefit Age Bracket (Based On Age) Non-Tobacco User Tobacco User Under 25 $0.09 $ $0.07 $ $0.08 $ $0.10 $ $0.14 $ $0.17 $ $0.28 $ $0.54 $ $1.12 $ $1.84 $ $2.88 $3.78 Dependent Child(ren) Life a Insurance For all eligible unmarried children, from birth up to age 20, or up to age 25 if a full-time student, employees can elect coverage in increments of $5,000 or $10,000. Coverage is a flat $0.07 per month per $1,000, for all eligible dependent children enrolled, regardless of how many. Coverage ends when the employee terminates employment or retires with the City. Plan Features Waiver of Premium - (Class I) If an employee becomes disabled before age 60, their life insurance premiums may be waived until recovery or age 70. Accidental Death and Dismemberment (AD&D) - Provides an additional insurance benefit if death results from an accident, or pays a benefit if there is a loss from an injury as defined in the plan. Accidental Death Benefit - If an employee becomes terminally ill with 12 months or less to live, they may request early payment of up to 100 percent of their life insurance amount. Conversion - Employees have the option to convert their group life coverage to an individual life policy when their group coverage ends. Premiums will be higher than those paid by active employees. Portability - If an employee leaves or retires, prior to age 70, employees may be eligible to take their Basic and Voluntary Term Life coverage with them and pay premiums directly to Minnesota Life. Premiums will be higher than those paid by active employees. Minnesota Life Customer Service: (800) Short Term Disability The City offers voluntary Short Term Disability (STD) insurance to all eligible employees through Madison National. The STD benefit pays employees a percentage of their monthly earnings if they become disabled due to a nonwork related illness or injury. Evidence of Insurability (EOI) will be required if benefit is not elected at initial offering. Short Term Disability (STD) Benefits The STD program offers a benefit of 50% of an employee's weekly earnings, subject to a benefit maximum of $1,000 per week. An employee must be disabled for 14 days prior to becoming eligible for benefits (known as the elimination period). Benefit payments will commence on the 15th day of disability. The maximum benefit period is 26 weeks. Please Note: Benefits are not taxable and premiums are deducted on a post tax basis. Madison National Customer Service: (800) , Ext Long Term Disability The City offers voluntary Long Term Disability (LTD) insurance to all eligible employees through Voya Financial Services. The LTD pays employees a percentage of their weekly earnings if they become disabled due to an illness or injury. Evidence of Insurability (EOI) will be required if benefit is not elected at initial offering. Long Term Disability (LTD) Benefits The LTD program offers a benefit of 60% of an employee's monthly earnings, subject to a benefit maximum of $5,000 per month. An employee must be disabled for 180 days prior to becoming eligible for benefits (known as the eligibility period). Benefit payments will commence on the 181st day of disability. Employees may continue to be eligible for benefits if they return to work on a part-time basis. Benefits will be reduced by other income. Employees maximum benefit period will be determined by their age at the time of disability. Please Note: Benefits are not taxable and premiums are deducted on a post tax basis. Voya Financial Services Customer Service: (888)

22 Employee Assistance Program As a part of the employee benefits package, the City provides a comprehensive Employee Assistance Program (EAP) available to employees and each member of their family through Deer Oaks. Deer Oaks offers access to licensed mental health professionals through a confidential program that is protected by state and federal laws. The EAP program is available to help employees gain a better understanding of problems, locate the best professional help for their particular problem, and decide upon a plan of action. Employees have a benefit of six visits per person, per problem, per year. All EAP counselors are professionally trained and are certified and licensed in their fields. Master-level counselors are available 24 hours a day, 7 days a week. What is an Employee Assistance Program? An Employee Assistance Program (EAP) offers covered employees and their family members free and convenient access to a range of confidential and professional services to help them address a variety of problems that can negatively affect their well-being such as: 9 9Anxiety 9 9Legal and financial concerns 9 9Depression 9 9Life improvement 9 9Family and/or marriage problems 9 9Stress 9 9Grief and bereavement 9 9Substance abuse 9 9Legal & financial consultation What is Deer Oaks Services? The City recognizes that employees personal responsibilities may, at times, spill over into the workplace. To help ensure employees are able to address these concerns with minimal disruption, the program provides employees and their family members assistance for a variety of concerns including child care, elder care, daily-living issues, and other issues they may encounter. Are Services Confidential? Yes. Receipt of EAP services is completely confidential. If, however, participation in the EAP is the direct result of a Management Referral (a referral initiated by a supervisor or manager), we will ask permission to communicate certain aspects of the employee s care (attendance at sessions, adherence to treatment plans, etc.) to the referring supervisor/manager. The referring supervisor will not, however, receive specific information regarding the referred employee s case. The supervisor will only receive reports on whether the referred employee is complying with the prescribed treatment plan. Deer Oaks Customer Service: (866) The City Login and Password: MELB 19