Richmond County Board of Education Employee Benefit Guide

Transcription

1 Richmond County Board of Education Employee Benefit Guide 2016

2 Richmond County School System Dear Richmond County Employee, As an eligible employee, you are entitled to enroll in the Section 125 plan, an IRS approved program designed to help you save money on taxes. Certain insurance products are available for purchase on a pre-tax basis, under Section 125. You have the option of deducting your premiums before tax, resulting in increased take-home pay and reduced income taxes. Flexible Spending Accounts are also available under Section 125. Each year, you can elect a portion of your paycheck into an account (on a pre-tax basis) to gain reimbursement for out-of-pocket medical expenses. For 2016, American Fidelity will also be offering the following voluntary benefits: Disability Income Insurance Accident Insurance Cancer Insurance Life Insurance Hospital GAP PLAN Insurance Dental/Vision/Group Life Enrollment specialists will be available throughout the school year to assist you in enrolling in all of your benefits and to answer any questions you may have. Richmond County Schools has developed the following benefit guide to provide you with information about your benefit options for this plan year, explaining the enrollment process, and serve as a valuable resource for information about all the benefits available to you. It s a good idea to take some time to read this guide before completing your enrollment forms. Thank you in advance for taking the time to review this benefit guide and we look forward to seeing you soon.

3 Table of Contents Benefits Enrollment Employee Enrollment... 5 Section 125 Cafeteria Plan... 5 How to Enroll... 5 Insurance Plans SHBP Contact Information... 7 SHBP Health Plan Rates... 8 Dental Plan... 9 Vision Plan...11 Group Life Insurance...13 Disability Income Insurance...15 Accident Only Insurance...16 Cancer Insurance...17 Hospital GAP PLAN Insurance...18 American Fidelity Term Life...19 Flexible Spending Accounts (FSA) Health Flexible Spending Account (FSA)...21 Health FSA Card...22 Filing a Flex Claim...23 Accessing Your FSA...23 Other Information Benefits Resource Directory...24 About this Guide This benefit guide is a compilation guide of Richmond County School System-sponsored Human Resources. It is intended for informational purposes only. The actual benefits available and the full descriptions of these benefits are governed in all cases by the relevant plan document, insurance contracts, and Ordinances and Resolutions of Richmond County School System, and where applicable, collective bargaining agreements. If there are discrepancies between the benefit guide and the actual plan documents, insurance contracts, and Ordinances and Resolutions, the documents, contracts, and Ordinances and Resolutions will govern.

4 PARING FOR 2016 YOUR <SECTION 125> ENROLLMENT BENEFITS ENROLLMENT

5 Your Enrollment & Section 125 Plan Qualifying Event A qualifying event provides you an opportunity to change plans and modify dependent coverage. If eligibility changes during the year, you must notify Human Resources within 31 days of the qualifying event. Important Points to Consider Figure an estimate of out-of-pocket medical expenses. Remember that over-the-counter drugs and medicines now require a prescription to be reimbursed. A worksheet can be found online at Review your beneficiaries. Review American Fidelity s options of portable insurance plans that you can keep if your employment changes. Evaluate your need for life insurance. Consider increasing your Disability Income Insurance policy amount to match your current salary. Save Money With a Section 125 If there was a program available that could dramatically save money on your taxes, would you take advantage of it? That s exactly what the Section 125 Plan does reduces your taxes and increases your spendable income! Plus, the Plan is available to you at no cost* and you re already eligible, all you have to do is enroll. The Plan works like this: You are allowed to deduct needed benefits from gross earnings before taxes are computed. This means that current after-tax expenses, such as insurance products and benefits, can be paid for with pre-tax dollars. The advantage of this Plan is simple: The eligible premiums you pay under the Plan are paid on a pre-tax basis. You could be on your way to increased savings, just by signing up and taking advantage of this Plan! Benefits Eligible For The Section 125 Cafeteria Plan Group Medical, Dental and Vision Insurance Accident Insurance Cancer Insurance Flexible Spending Accounts How to Enroll Richmond County makes it easy for you to enroll in your benefits. Employees can enroll on-site with your American Fidelity representative. Enroll Online For Health Insurance, you must enroll online: What to Bring to Your Appointment Spouse and children s DOB and Social Security card, if considering coverage for them, and legal name. Beneficiary information, including (if a trust) full name and date of trust. Don t Miss It! Have you recently received a pay increase? Have you or are you planning on getting married, having children, or buying a home? What would happen if you were suddenly ill or disabled? These questions and others will be addressed during your benefit consultation to make sure you are properly covered. It takes just a few moments to review your coverage and protect your family. By enrolling onsite you can enroll in: Dental Insurance Accident Only Insurance Vision Insurance Life Insurance Group Life Insurance Hospital GAP PLAN Insurance Disability Income Insurance Health Flex Spending Account Cancer Insurance 5

6 INSURANCE PLANS Contact Directory Dental Plan Vision Plan Group Life Insurance Disability Income Insurance Accident Insurance Cancer Insurance Critical Illness Insurance Hospital GAP PLAN Insurance AFA Term Life

7 Health Plan Benefits State Health Benefit Plan (SHBP) Contact Directory Vendor Member Services Website Blue Cross Blue Shield of Georgia (BCBSGa) Member Services: Mon - Fri 8:00 a.m. to 8:00 p.m. ET UnitedHealthcare Member Services: Mon - Fri 8:00 a.m. to 8:00 p.m. ET TTY 711 SHBP Eligibility Member Services: Mon - Fri 8:30 a.m. to 5:00 p.m. ET SHBP Call Center Healthways Member Services: Mon - Fri 8:00 a.m. to 8:00 p.m. ET Additional Information Member Services Website Express Scripts Member Services: 24 hours a day/7 days a week TRICARE Supplemental Plan Member Services 8:30 a.m. to 5 p.m. ET Monday Friday PeachCare for Kids Health benefits enrollment will be in the Fall of each year. Information will be communicated and included in this benefits guide when it is available. A Qualifying Event is defined as a change in family status, employment status or change in insurance coverage. When a qualifying event has occurred, the employee must report the change to his/her employing entity within 31 days of the qualifying event. Enrollment in or changes to the current health benefit selection that are not received by SHBP within 31 days of the Qualifying Event will not be allowed. Go to the above website for complete details. 7

8 Health Plan Rates SHBP Rates Below are the State Health Benefit Plan (Healthcare) rates: 2016 Benefit Rate Sheet Effective January 01, 2016 State Health Plans & Rates Plan Type Employee Only Employee + Spouse Employee + Child(ren) Employee + Family BCBS Bronze $66.28 $ $ $ BCBS Bronze *Tob SC $ $ $ $ BCBS Silver $ $ $ $ BCBS Silver *Tob SC $ $ $ $ BCBS Gold $ $ $ $ BCBS Gold *Tob SC $ $ $ $ BCBS HMO $ $ $ $ BCBS HMO *Tob SC $ $ $ $ UHC HMO $ $ $ $ UHC HMO *Tob SC $ $ $ $ UHC HDHP $57.46 $ $ $ UHC HDHP *Tob SC Tricare Supplement $ $ $ $ $60.50 $ $ $

9 Dental Plan MetLife Richmond County Board of Education Dental Plan Benefits January 1, 2016 through December 31, 2016 Network: PDP Plus Benefit Summary Option 1 High Plan Option 2 Low Plan Coverage Type In-Network Out-of-Network Coverage Type In-Network Out-of-Network Type A cleanings, oral examinations Type B fillings Type C bridges and dentures Type D orthodontia 100% of Negotiated Fee* 80% of Negotiated Fee* 50% of Negotiated Fee* 50% of Negotiated Fee* 100% of R&C Fee** Type A cleanings, oral examinations 80% of R&C Fee** Type B filling 50% of R&C Fee** 50% of R&C Fee** Type C bridges and dentures Type D orthodontia 85% of Negotiated Fee* 60% of Negotiated Fee* 40% of Negotiated Fee* 50% of Negotiated Fee* 85% of Negotiated Fee* 60% of Negotiated Fee* 40% of Negotiated Fee* 50% of Negotiated Fee* Deductible In-Network Out-of-Network Deductible In-Network Out-of-Network Individual $50.00 $50.00 Individual $50.00 $50.00 Family $ $ Family $ $ Annual Maximum Benefit: In-Network Out-of-Network Annual Maximum Benefit: In-Network Per Person $1,500 $1,500 Per Person $1,000 $1,000 Orthodontia Lifetime Maximum In-Network Out-of-Network Orthodontia Lifetime Maximum In-Network Per Person $1,000 $1,000 Per Person $1,000 $1,000 Out-of-Network Out-of-Network *Negotiated Fee refers to the fees that participating dentists have agreed to accept as payment in full, subject to any co-payments, deductibles, cost sharing and benefits maximums. Negotiated Fee fees are subject to change. **R&C Fee refers to the Reasonable and Customary (R&C) charge, which is based on the lowest of (1) the dentist s actual charge, (2) the dentist s usual charge for the same or similar services, or (3) the charge of most dentists in the same geographic area for the same or similar services as determined by MetLife. Applies only to Type B & C Services. *Negotiated Fee refers to the fees that participating dentists have agreed to accept as payment in full, subject to any co-payments, deductibles, cost sharing and benefits maximums. Negotiated Fee fees are subject to change. Applies to Type B and C Services If you are a Pre-K Teacher or Pre-K Paraprofessional, you are responsible for the full premium. The Board of Education pays $8.64 towards the cost of Dental Coverage. Monthly Rates The following monthly rates are effective January 1, 2016 through December 31, 2016 Eligibility Options High Plan Low Plan Employee Only $25.38 $13.70 Employee + One $53.95 $28.83 Employee + Family $80.34 $

10 Dental Plan MetLife In Network Savings* Example These hypothetical examples** show how receiving services from a participating dentist can help save you money. High Plan Your Dentist says you need a Crown, a Type C service Negotiated Fee: $ R&C Fee: $1,386.00*** Dentist s Usual Fee: $1, Low Plan Your Dentist says you need a Crown, a Type C service Negotiated Fee: $ R&C Fee: $1,386.00*** Dentist s Usual Fee: $1, IN-NETWORK When you receive care from a participating dentist OUT-OF-NETWORK When you receive care from a non-participating dentist IN-NETWORK When you receive care from a participating dentist OUT-OF-NETWORK When you receive care from a non-participating dentist Dentist s Usual Fee is: The Negotiated Fee is: Your Plan Pays: 50% X $670 Negotiated Fee: Your Out-of- Pocket Cost: $1, $ $ $ Dentist s Usual Fee is: The R&C Fee is: Your Plan Pays: 50% X $1, R&C Fee: Your Out-of- Pocket Cost: $1, $1, $ $ In this example, you save $ ($ minus $335.00) by using a participating dentist. Dentist s Usual Fee is: The Negotiated Fee is: Your Plan Pays: 40% X $670 Negotiated Fee: Your Out-of- Pocket Cost: $1, $ $ $ Dentist s Usual Fee is: The R&C Fee is: Your Plan Pays: 40% X $670 Negotiated Fee: Your Out-of- Pocket Cost: $1, $1, $ $ In this example you save $0 ($ minus $402.00) by using a participating dentist. *Savings from enrolling in the MetLife Preferred Dentist Program will depend on various factors, including how often participants visit the dentist and the cost for services rendered. **Please note: This is a hypothetical example that reviews a porcelain/ceramic crown (D2740) in the Philadelphia area, zip It assumes that the annual deductible has been met. ***Reasonable and Customary (R&C) charge is based on the lowest of (1) the dentist s actual charge, or (2) the charge of most dentists in the same geographic area for the same or similar services as determined by MetLife. The example shown reflects an 80th percentile R&C fee. The R&C percentile used to calculate out-of-network benefits for your plan may differ. 10

11 Vision Plan Davis Vision 11

12 Vision Plan Davis Vision 12

13 Group Term Life Insurance Lifestyle Life and AD&D Life insurance, insured by Unum Life, helps provide for your family s economic well-being in the event of your death. This benefit is paid to your designated beneficiaries. The following is the basic and optional life insurance summary: Eligible Employees for Basic Life Insurance and Optional Life Insurance Eligible employees are guaranteed coverage for new hires only, late entrants must apply for coverage during open enrollment. Employees are eligible for coverage, if they work 20 hours or more per week on a continuing basis. The employee must be actively employed for benefits to be paid. Basic Life Insurance The Richmond County Board of Education will provide $30,000 of Life and Accidental Death Dismemberment coverage at NO COST to the eligible employee. Optional Life Insurance All eligible employees may request optional life insurance to supplement the basic life insurance coverage. Benefits & Cost Summary Group Lifestyle Life and Accidental Death and Dismemberment Insurance Life Insurance Employee Life Benefit Amount 5 X annual earnings rounded to the next higher $10,000 Overall Maximum $500,000 Employee Life Minimum $10,000 Employee Life Non-Medical Maximum $250,000 Employee Life Benefit Reduction Formula Life Benefit Reduces to: - 45% at age 70; and - 30% at age 75; and - 20% at age 80; and - 15% at age 85: and - 10% at age 90 Dependent Life & AD&D Benefit Amount Dependent Coverage Funded by Employee Spouse Children Option A: $10,000 Option B: $20,000 Not to Exceed 50% of the EE Life Amount - Live birth to 14 days: $1, days to 6 months: $1,000-6 months to 19 years (25 years if full-time student): Option A: $5,000 Option B: $10,000 Not to Exceed 50% of the EE Life Amount 13

14 Group Term Life Insurance Lifestyle Life and AD&D AD&D Insurance Employee AD&D Benefit Amount AD&D Maximum 5 X annual earnings rounded to the next higher $10,000 $500,000 Employee AD&D Minimum $10,000 Employee AD&D Benefit Reduction Formula AD&D Benefit Reduces to: - 45% at age 70; and - 30% at age 75; and - 20% at age 80; and - 15% at age 85 Rates and Cost Information: Life Rates Employee Life Monthly Step Rates per $1,000 Spouse and Child Life Monthly Rate Age Rate Option 1: $2.400 per dependent unit Option 2: $4.80 per Dependent unit AD&D Rates Employee AD&D Monthly Rate $0.020 per $1,000 Rate assumes the following: The employee participation level is at least 63%. Rate Guarantee: 3 Year(s) For purposes of calculating benefits and cost, an employee s annual earnings is assumed to mean: gross annual income before taxes, including any pre-tax contributions to a deferred compensation plan, excluding commissions, bonuses, overtime pay or other extra compensation. Cost of Coverage Paid By: Minimum Participation: Employees In order for the case to be effective, the greater of 10 employees or 20% of the eligible employees must participate in the plan. 14

15 Disability Income Insurance American Fidelity Assurance Company How do you pay for your mortgage, bills, food and other monthly expenses? If your paycheck stopped today, could you maintain your current lifestyle? American Fidelity s Disability Income Insurance is designed to help protect you if you become disabled and cannot work due to a covered Accidental Injury or Sickness. How the Plan Works If you become disabled due to a covered accident or sickness, disability income insurance will pay the disability benefit once you have satisfied the elimination period. Your benefit amount is dependent on your salary and the amount you select at the time of application. Disability benefits will be payable up to the benefit period stated in your policy. Optional Riders Enhance your base plan with the following riders: Critical Illness Rider Accident Only Spousal Rider Hospital Indemnity Benefit Rider COBRA Premium Rider Survivor Benefit Rider Coverage Feature Accidental Injury and Sickness Coverage Benefit Paid Directly to You, Regardless of Other Coverage Waiver of Premium Age at Entry Accidental Death Benefit Affordable Premiums Payroll Deducted What It Means To You You are covered in the case of a covered accident that occurs away from work or a covered sickness that causes you to be disabled. Use the money however best fits your financial needs, regardless of other insurance. Premiums are not required while you are disabled based on the length of your disability. Your premiums will be based on the date your policy becomes effective. Receive a benefit if you die as the direct result of an Accidental Injury and death occurs within 90 days after the date of the Accidental Injury. Your monthly premiums could be paid with only one hour of a week s paycheck. Enjoy the convenience of having your premiums deducted straight from your paycheck. Limitations, exclusions and waiting periods apply. Refer to your policy for complete details. Note: Richmond County School System will pay up to $11.40 of your Disability Income Insurance premium for the 2016 plan year. See your American Fidelity account manager for more information. 15

16 Accident Only Insurance Limited Benefit Accident Only Insurance American Fidelity Assurance Company Whether a weekend warrior with an active lifestyle or the stay at-home type, accidents can happen anytime, anywhere, without warning. Being prepared for the unexpected can make all the difference. American Fidelity s Accident Only Insurance policy provides you a solution for those unforeseen accidents that life sometimes delivers. Our Limited Benefit Accident Only Insurance is designed to help pay for the unexpected medical expenses an individual may incur for the treatment of covered injuries received in an accident. How the Plan Works Our Accident Only Insurance policy pays according to a wide-ranging schedule of benefits. In addition, the policy provides 24-hour coverage for accidents that occur both on and off the job. All benefits are only paid as a result of Injuries received in an Accident that occurs while coverage is in force. All treatment, procedures, and medical equipment must be diagnosed, recommended and treated by a Physician. All benefits are paid once per Covered Person per Covered Accident unless otherwise specified in the Limitations and Exclusions section. Optional Riders Enhance your base plan with the following rider: Accident Benefit Enhancement Rider Coverage Feature Plan Options: Basic, Enhanced, and Enhanced Plus Four Choices of Coverage: Individual, Individual and Spouse, Individual and Child, or Family Wide-Ranging Schedule of Benefits Wellness Benefit Accident Emergency Treatment Benefit Benefit Paid Directly to You, to use as you see fit Guaranteed Renewable 24-Hour Coverage Portable Additional Coverage Options Payroll Deducted What It Means For You Choose the plan to meet your financial needs. Choose the coverage that fits your lifestyle. Covers all types of covered injuries. After the policy has been in force for 12 months, you receive a benefit for an annual routine exam, including immunizations and preventive testing once per policy per calendar year. Receive a benefit when emergency treatment in a Physician s office or emergency room occurs within 72 hours of a covered accident. Use the benefit however best fits your financial needs. Keep your coverage as long as premiums are paid as required. You are covered on or off the job. You own the policy. Take the coverage with you if you choose to leave your current job. Your premiums will remain the same. Enhance the base plan by adding an optional rider. Enjoy the convenience of having your premiums deducted straight from your paycheck. Limitations, exclusions and waiting periods apply. Refer to your policy for complete details. This product is inappropriate for people who are eligible for Medicaid coverage. The premium and amount of benefits provided vary dependent upon the plan selected. The company has the right to change premiums by class (AO-03 Series). 16

17 Cancer Insurance Limited Benefit Cancer Indemnity Insurance Policy American Fidelity Assurance Company A cancer diagnosis may be overwhelming. Even with a good medical plan, the out-of-pocket costs of cancer treatment, such as travel, childcare, and loss of income, are considerable and may not be covered. American Fidelity s Cancer Insurance can help offer financial protection so you can focus your attention on fighting cancer. We offer plans that can help assist with out-of-pocket costs often associated with a cancer diagnosis. How the Plan Works Our plan is designed to help cover expenses if you are diagnosed with a covered Cancer. With over 20 benefits available to you, this plan provides benefits for the treatment of cancer, transportation, hospitalization and more. We provide the money directly to you, to be used however you see fit. Optional Riders Enhance your base plan with the following riders: Critical Illness Rider Includes a cancer benefit and a heart attack/stroke benefit Hospital Intensive Care Unit Rider Coverage Feature Plan Options: Basic, Enhanced and Enhanced Plus Three Choices of Coverage: Individual, Single Parent Family, or Family Wide-Ranging Schedule of Benefits Benefit Paid Directly to You Guaranteed Renewable Diagnostic and Prevention Benefit Transportation and Lodging Portable Additional Coverage Options Payroll Deducted What It Means For You Choose the plan to meet your financial needs. Choose the coverage that fits your lifestyle. Covers a wide range of treatments. Use the money however best fits your financial needs. Keep your coverage as long as premiums are paid as required. Receive a benefit for visiting your doctor for a cancer screening test, which helps with early detection. Receive benefits if you travel more than 50 miles from your home using the most direct route for covered treatment. You own the policy. Take the coverage with you if you choose to leave your current job. Your premiums will remain the same. Enhance the base plan by choosing from a selection of optional riders. Enjoy the convenience of having your premiums deducted straight from your paycheck. Limitations, exclusions and waiting periods apply. Please refer to your policy for complete details. This product is inappropriate for people who are eligible for Medicaid coverage. The company has the right to change premiums by class. The premium and amount of benefits provided vary dependent upon the plan selected. 17

18 Hospital GAP PLAN Insurance Hospital Limited Benefit Medical Expense Insurance Policy American Fidelity Assurance Company Hospital GAP PLAN Insurance from American Fidelity Assurance Company can help policyholders pay for their out-of-pocket expenses. Supplementing their medical insurance with gap insurance can help cover their expenses so they can focus on getting well. Three Primary Benefits In-Hospital** Outpatient Physician Outpatient Treatment ** Hospital shall not include any institution used as a place for rehabilitation, a place for rest or for the aged, a nursing or convalescent home, a long term nursing unit or geriatrics ward, or an extended care facility for the care of convalescent, rehabilitative or ambulatory patients. Coverage Feature In-Hospital Benefit Outpatient Benefit Physician Outpatient Treatment Benefit What It Means for the Policyholder This is payable for covered for out-ofpocket expenses up to the maximum benefit selected per confinement. This is payable for the difference between the actual outpatient expenses incurred and the amount paid by the primary medical plan for out-of-pocket Covered Charges up to a maximum outpatient benefit of $ for outpatient treatment in a Hospital emergency room, outpatient surgery in a Hospital outpatient facility or free-standing outpatient surgery center, and diagnostic testing in a Hospital outpatient facility or MRI facility. All benefits for the same or related conditions will be subject to the maximum outpatient benefit, unless such conditions are separated by 90 consecutive days, then a new maximum outpatient benefit will apply. This is payable for Physician visits. This benefit pays up to $25.00 per visit, for up to five visits ($125.00) per family per calendar year, for outpatient treatment due to Sickness, or outpatient emergency care for an injury due to an Accident, provided the Covered Person is covered by Another Medical Plan when such charges are incurred, at a Hospital outpatient clinic, freestanding emergency care clinic, or Physician office for out-of-pocket Covered Charges. THIS IS A LIMITED POLICY. This highlights the important features of the policy. Limitations, exclusions, and waiting periods apply. Refer to the policy for complete details. This product is inappropriate for people who are eligible for Medicaid coverage. If the policyholder resides in a state other than their employer s state of domicile, where required by law, policy provisions and benefits may vary. 18

19 Individual Term Life Insurance American Fidelity Assurance Company Life insurance is an important factor to any family. It serves as a foundation to help in the case of a loved one s premature death. Plan today to make the right move for your loved ones. American Fidelity offers an Individual Term Life Insurance policy to help with your financial needs for your short-term and long-term goals. How the Plan Works Individual Term Life Insurance is a death benefit protection with no cash accumulation feature. The policy is initially written for a 10, 20 or 30-year term period, but may be renewed at the insured s option for the same level renewal period depending upon the term chosen. The last level renewal period is no later than age 70 for the 10-year term policy and age 60 for the 20-year term policy. Thereafter, premiums are renewable annually up to age 90. The 30-year term policy is renewable annually after the initial 30-year term period up to age 90. Renewal rates will be based on the insured s age at the time of renewal. Optional Riders Enhance your base plan with the following riders: Spouse Term Rider Children s Term Rider Coverage Feature Three Plan Options: 10, 20 and 30-Year Level Term Coverage Guaranteed Premium Guaranteed Death Benefit Accelerated Death Benefit Conversion Benefit What It Means To You Choose the coverage period to meet your financial needs. Your premiums are guaranteed for each applicable period. Your death benefit is guaranteed for the life of the policy provided premiums are paid. Receive a portion of the chosen death benefit if you are diagnosed with a terminal condition. Limitations and exclusions may apply. Turn your policy into a permanent plan any time up to age 75. The rate for your new plan will be based on your attained age. Guaranteed Renewable Renew your policy up to age 90 regardless of your health. Interim Coverage You will be covered from the date of your application if you are insurable for the requested coverage on the date the policy takes effect. This Interim Coverage will remain in force until the policy has been issued or declined. Enhance Your Coverage Add an optional Spouse Term or Children s Term Rider to expand your policy. Easy Application No medical exams and minimal health questions. 1 Portable Payroll Deducted You own the policy. Take the coverage with you if you choose to leave your current job. Enjoy the convenience of having your premiums deducted straight from your paycheck. 1 Issuance of the policy may depend on the answer to these question. 19

20 FLEXIBLE SPENDING ACCOUNTS Health FSA Debit Card Filing a Claim Accessing Your FSA 20

21 Flexible Spending Accounts American Fidelity Assurance Company Flexible Spending Accounts are a great cost savings tool to help with common medical and/or dependent care expenses not covered by your insurance. You can elect a portion of your pay to be deducted, on a pre-tax basis, from each paycheck to use for reimbursements of qualified out-of-pocket expenses throughout the plan year. Flexible Spending Account Savings Example With FSA Without FSA $30,000 Annual Gross Income $30,000 - $2,400 Health FSA Deposit $0 - $2,500 Dependent Care Account Deposit $0 $25,100 Taxable Gross Income $30,000 - $5,020 Estimated Federal Tax (20%) - 6,000 - $1, Estimated FICA (7.65%) - 2,295 $18, Annual Net Income $21,705 $0 Cost of Recurring Medical Expenses - $2,400 $0 Cost of Recurring Dependent Care Expenses - $2,500 $18, Spendable Income $16,805 With an FSA you have a potential annual savings of: $1, By using an FSA to pay for eligible recurring expenses, you can cut down on your taxable income which will result in additional spendable income. Health Flexible Spending Account (FSA) A Health FSA allows you to allocate money on a pre-tax basis to reimburse yourself for qualified medical expenses for you and your family. Qualified expenses include anything from co-payments, medical deductibles, prescriptions and much more. Maximum Annual Deposit: $2,550 Partial List of Eligible Expenses for Health FSA Copays/coinsurance Deductibles Dental treatments Diabetic supplies Prescription drugs and medicines Eye exams, eyeglasses, contact lenses, contact lens solution and enzyme Flu shots Immunizations Lab fees Laser/Lasik/RK surgery Medical exams Orthodontia Psychiatric care Wheelchair X-rays For a complete list of eligible expenses, please visit Carryover Provision for Health Flexible Spending Accounts The Internal Revenue Service (IRS) gives employers the ability to allow Health Flexible Spending Account (Health FSA) participants to carry over up to $500 of unused contributions from one plan year to the next. This is called the Carryover Provision. This carryover amount may then be used to reimburse eligible medical expenses incurred anytime during the next plan year. 21

22 Flexible Spending Accounts Health FSA Card Health FSA Card American Fidelity will provide a Health FSA Card to all employees who elect to participate in a Health FSA. The card gives immediate, convenient access to Health FSA funds at the point of sale for prescriptions, copays, and other common qualified medical expenses. The card can only be used for the Health FSA and is not available for the Dependent Care Account. Using Your Health FSA Card Simply swipe your Health FSA Card like you would with any other credit card. Whether at the doctor s office or the dentist, the amount of your eligible expenses will be automatically deducted from your Health FSA account. The Health FSA Card can be used at: Healthcare related facilities which include: hospitals, physician offices, dental offices, vision offices; and, Merchants participating in the Inventory Information Approval System (IIAS). Recurring expenses You will need to submit your first claim manually and state this will be a recurring claim from the same provider at the same dollar amount. It will be noted on your account that this will be a recurring expense, and additional substantiation will not be required for that plan year. Activating Your Card You will receive your card at your home address and can begin using your card at the beginning the first day of your plan year. Your card will be automatically activated when you use it for the first time for an eligible expense. Guidelines for Your Health FSA Card Keep your receipts. Claims not approved automatically will need to be submitted manually. If a provider does not accept the Health FSA Card, you can request reimbursement by completing the Health FSA Expense Reimbursement Voucher and submit with the required documentation. Health FSA reimbursement vouchers can be found online at If card swipes do not match up with pre-set benefits from your employer, or, we do not receive all the necessary information electronically from the card vendors to automatically approve the Health FSA Card swipe, manual claims substantiation will be requested. If you cannot provide the substantiation requested, that claim will be determined to be ineligible and funds for that claim must be reimbursed back to the plan. Acceptable substantiation to accompany the request is a professional bill or receipt that includes the provider of service, type of service rendered, charges for the service, and original date of service; insurance company explanation of benefits; pharmacy statement that includes Prescription number and name of prescription. Your card claim will be automatically approved without further information requested for: Copay Amounts If your employer provides the necessary information for your medical carrier, the copay amounts can be automatically approved if your copay is stated as a flat dollar amount. If your medical coverage is stated as a coinsurance percentage, additional information will be necessary to approve the expenses. 22

23 Flexible Spending Accounts Filing a Claim Filing a Claim 1. Complete an Expense Reimbursement Voucher, along with the thirdparty documentation of the expense. Health FSA and Dependent Care vouchers can be found online at 2. Submit your completed form and documentation to American Fidelity s Flex Department. You can either mail it to the address located on the bottom of the voucher or fax it toll-free to Your claim will be processed on an average of 5-7 business days from the date all required claim information is received. The Health FSA reimbursement check will be for the expenses claimed up to the annual election for the plan year minus any previously reimbursed amounts. The Dependent Care expense reimbursement will be for the services provided limited to the amount you have in your account. If the Dependent Care expense claim is in excess of your account balance, the balance of the claim will be paid to you as additional contributions are received. Accessing Your FSA By visiting American Fidelity s web site you will have a wealth of information available to you without the use of any customer IDs or passwords. Through the public site you have access to: Claim forms Section 125 Flex Reimbursement Forms Customer FAQs Contact information Secure Account Management Tools American Fidelity s Online Service Center is a convenient, secure web site that gives you access to information regarding your American Fidelity account. Available any time of day from home, work or any computer with Internet access, the Online Service Center provides valuable options. Check claim status Review detailed insurance policy information Access Health FSA information and balances Submit address changes Direct Deposit By selecting to have your reimbursements directly deposited to your bank account you can get your reimbursements faster without having to wait for the check to arrive in the mail. Each time a reimbursement is deposited into your bank account, you will be mailed an Explanation of Benefits that shows the deposit as well as a summary of your account. 23

24 Benefits Directory Medical Benefits Blue Cross Blue Shield of Georgia UnitedHealthcare SHBP Eligibility TRICARE Supplemental Plan PeachCare for Kids Dental Insurance MetLife Insurance Company Customer Service Vision Insurance Davis Vision Insurance Customer Service Voluntary Insurance Benefits American Fidelity Assurance Company Disability Income, Cancer, Accident, Life, and GAP 900 Circle 75 Parkway S.E., Suite 1340 Atlanta, GA / Section 125 Services & Flexible Spending Accounts American Fidelity Assurance Company 900 Circle 75 Parkway S.E., Suite 1340 Atlanta, GA FSA Customer Service / Other Contact Information American Fidelity Assurance Company Jimmy Jackson, State Manager Georgia Branch Office 900 Circle 75 Parkway S.E., Suite 1340 Atlanta, GA , ext American Fidelity Assurance Company Greg Riddle, School Benefits Specialist Georgia Branch Office 900 Circle 75 Parkway S.E., Suite 1340 Atlanta, GA Benefits Insurance Specialist Gregory Jones - Classified Employees Jonesgr@boe.richmond.k12.ga.us 864 Broad Street, Suite 208 Augusta, GA (706) Benefits Insurance Specialist Larissa Briggs - Certified Employees briggla@boe.richmond.k12.ga.us8 864 Broad Street, Suite 208 Augusta, GA

25 This page is intended to be blank. 25