Employee Benefits Guide. Cowlitz County PUD. Benefits Website: (password: cowlitzpud)

Transcription

1 Cowlitz County PUD For the plan year January 1, 2015 through December 31, 2015 Benefits Website: (password: cowlitzpud) 1

2 Cowlitz County PUD 2

3 Table of Contents Section Page Introduction 3 Employer Contact Info Group Plan Coverage Eligibility 4 Marisa Keeney Human Resources Analyst Cowlitz PUD t: f: e: mkeeney@cowlitzpud.org th Avenue PO Box 3007 Longview, WA Employee Benefit Contacts 5 Network Information 6 Medical Benefits Summary 7 MEDEX Travel Assist 8 Prescription Drug Program 9 Dental Benefits Summary 10 Vision Benefits 11 Ancillary Group Coverage: Life Insurance Information Ancillary Group Coverage: Short Term 12 13/14 Disability, Long Term Disability Coordination of Benefits 15

4 Introduction This benefits guide is meant to be an aid to help you better understand the COWLITZ PUD benefits package and how to utilize it when you need to. COWLITZ PUD has retained the services of LBG Advisors, LLC to help design the plan and assist employees in understanding how to use the plan. Broker/Consultant Info: LBG Advisors, LLC th St SW, Suite 380 Lynnwood, WA Toll Free: (877) Fax: (877) Visit us at : This booklet will briefly highlight the major points of the benefit plan COWLITZ PUD sponsors and it is not intended to replace your detailed insurance contract or other insurance provider coverage booklets. The information is provided for informative, illustrative and comparative purposes only and should be used for casual reference. Your actual benefits are subject to the terms and conditions of each insurance carrier s actual contract. We at LBG Advisors, LLC are here for you and your dependents and available to answer any questions you may have regarding your benefits and coverage. Please do not hesitate to contact us and use our services if you have need. 3

5 Group Plan Coverage Eligibility Determining Eligibility Employees and their dependents are eligible for coverage on the first of the month following the waiting period of 30 days of employment. How Do You and Your Dependents Become Covered? To become a covered person, you must complete and sign an enrollment form within the first 31 days of the employer s eligibility waiting period as designated above. If you are adding a dependent after your initial enrollment, you must complete and sign a new enrollment form or an enrollment change form. You can obtain these forms from your HR Department. Plan Coverage Deadlines Benefit enrollments and enrollment changes must be made either a) during the annual open enrollment period (the month of November before the plan year renews on January 1st), or b) within 31 days of the end of the waiting period after one is hired full-time, or c) within 31 days of a qualifying event. 1. A change in the employee s legal marital status (includes marriage, death of a spouse, divorce, legal separation, and annulment) as well as change in status of domestic partners. Qualifying Events 2. A change in the employee s number of dependents (includes a new birth, a new legal adoption or legal placement for adoption, and the death of a child). 3. Loss or gain of other coverage. If you have any other questions about plan eligibility, deadlines, or qualifying events please ask your HR Department. Employee Benefit Guide 4 5

6 Employee Benefits Contacts Benefits Contact Overview: To the right is a table showing the contacts for employees listed by plan component. If you have questions regarding your benefits, bills, or another related matter, please first call the appropriate toll-free customer service number. If you have tried contacting your plan and still cannot get resolution to your issue, please call LBG Advisors at You can also submit your questions on the Contact Page of (password: cowlitzpud) Medical Administrates the medical coverage. Call this number for claims help/customer service or if you have any questions about the details of your medical coverage and claims information. Local Medical Network Provides the preferred provider network for In-Network provider use. Call this number for claims customer service or if you have any questions about the details of your provider network. Prescription Coverage Administrates the prescription drug services. They also administrate the mail order program, useful if you are on maintenance drugs. Healthcare Plan Consultants Oversees the benefits plan as a whole. If you do not receive satisfaction from any of the above company s customer service systems, please call us. Vision Coverage Dental Administrates the dental plan. Call this number for claims customer service or if you have any questions about the details of your provider network. Long Term Disability (LTD & STD) Life / AD&D 5 EBMS Benefit Administrators Portland Office (866) First Choice Network (800) Magellan Health Services (formerly Partners RX) (800) LBG Advisors, LLC Scott Carson, Benefits Advisor Kris : Client Services x 303 Stacie : Client Services x 314 Toll Free: (877) VSP MetLife MetLife

7 Local and Out of Area Networks Your Preferred Provider Organization (PPO) Your plan has contracted with a different network based on locations to customize the networks for the best selection of preferred providers and hospitals. Other Info: Networks can change frequently and providers can enter or exit a network yearly (or even in the middle of the year). The table to the right shows the networks currently in place on your Outside of Oregon, Washington, Idaho and Alaska the network used will be Global Care. To determine if a provider is in the network you can call the network directly or visit the website. Patients will receive the highest level of benefits available when a preferred provider is utilized instead of a provider who is not. PPO Network Overlay benefit plan Please confirm network participation with the network and your provider In network benefits are typically better than out of network benefits PPO Local network based on location PPO - Outside of Your State Access: Services rendered within the PPO Network enjoy the highest levels of benefits. Use this network if you are out of the WA, OR, ID, AK areas and need non-emergency care. First Choice Health Network Washington, Oregon,Idaho & Alaska 1 (800) Multiplan Urgent Care Services Urgent care facilities can often treat urgent needs without all of the hassle of the emergency room for a lower co-pay than the hospital. Emergency Services Out of Area Services When you are out of service areas and need emergency care, simply go to the nearest emergency facility and get the necessary care. These types of services are considered In-Network as to the benefit levels for necessary emer- gency services provided at any hospital. 6

8 Medical Benefits Summary Medical Benefits Summary Quick Notes: Your medical insurance plan is administrated by EBMS. This plan design carries a per person calendar year deductible of $200 and a individual maximum out-of-pocket of $1,000 (both figures assume Network Provider use) Cowlitz PUD Participant Deductibles per Calendar Year* Out-of-Pocket Maximum per Calendar Year Covered Services $200 per Covered Person In network Max of 3 per Family In Network Provider $600 per Family In network $1,000 per Covered Person Max of 2 per Family + deductible $2,000 per Family Non Network Provider Preventative Care 100% no copay 100% no copay Professional Office Visits $10 copay 80% after deductible The coinsurance level begins after the deductible has been reached, again assuming you are using a Network Provider. See percentages in table to the right. Preventive Services (x-ray, lab) subject to age limitations LAB and XRAY Inpatient Hospital Stay 100% Deductible Waived 100% Deductible Waived 90% after deductible 80% after deductible 90% after deductible 80% after deductible Outpatient Surgery 90% after deductible 80% after deductible Immunizations Paid 100% - no copay 80% after deductible Alternative Care 12 visit limit $10 Copay 80% after deductible Emergency Room Services 90% after deductible 80% after deductible Physical Therapy 15 visit limit Ambulance Service $10 copay 80% after deductible 80% after deductible 80% after deductible Most Other Covered Expenses 90% after deductible 70% after deductible 7

9 Metlife Travel Assistance (Effective 1/1/15) Travel Assistance helps you cope with emergencies when you travel more than 100 miles from home or internationally for trips of up to 180 days. Travel Assist can also help you with non emergencies, such as planning your trip. You do not have to enroll. As a participant in your employers Group Life Insurance coverage from Metlife, you and your family members are automatically covered. Metlife Travel Assist offers the following services: Pre trip Assistance including passport, visa, weather and currency exchange information, health hazards advice and inoculation requirements. Medical Assistance Services including locating medical care providers and interpreter services Travel Assistance Services including emergency ticket, credit card and passport replacement assistance, funds transfer assistance and missing baggage assistance Metlife Travel Assistance h,p://webcorp.axa-assistance.com Login: axa Password: travelassist Legal Assistance Services including locating a local attorney, consular officer or bail bond services Emergency Transportation Services including arranging and paying for emergency evacuation to the nearest adequate medical facility and medically necessary repatriation to the employee s home, including repatriation of remains* Personal Security Services including evacuation and logistical arrangements in the event of political unrest, social instability, weather conditions, health or environmental hazards Worldwide Assistance Travel Assistance can provide medical and emergency transportation services worldwide whenever you and eligible family members travel 100 miles or more from home or internationally for trips of up to 180 days. Locating Medical Care Assists you in locating medical care providers or local sources of medical care referrals Prescription Drug Assistance Coordinates transfer of prescriptions or personal medical items, such as corrective lenses, that were forgotten, lost or depleted while traveling 8 9

10 Prescription Drug Program Quick Notes: Your prescription Drug Program is administered by Magellan Health Services. Contact Magellan at: or Please talk to your doctor about using generic alternatives to brand name drugs. Prescription Drug Program Summary Rx Benefit Retail Pharmacy 34 Day Supply Tier 0: OTC $0 copay Tier 1: Generic $5 copay Tier 2: Preferred Brand Name 20% copay $15 min- $50 max Tier 3: Non Preferred Brand Name 20% copay $15 min- $50 max Please also talk to your doctor about using Over The Counter (OTC) drugs. Mail Order Pharmacy 90 Day Supply $0 copay $10 copay 20% copay $15 min- $100 max 20% copay $30 min- $100 max A full formulary is available from Magellan Health Services. 9

11 Dental Benefits Summary Dental Benefits MetLife Quick Notes: Your Dental Benefits are administered by MetLife. Annual Max. Benefit Orthodontia Lifetime Benefit (Dependent Children only) Dental Benefit Coinsurance Levels Class A $1,500 per member $2,000 per member 100% Staying in network may make your total annual max benefit stretch further. Please remember to have your dentist Pre-Authorize any large procedure before you have that procedure done. Preventive Services Class B Basic Services Oral Evaluations Prophylaxis and Fluoride Bitewings (adult/child) Sealants All Other X-Rays-Panoramic 1 every 5 years 100% Consultations General Anesthesia Fillings and Restorations Oral Surgery Simple and Surgical Extractions Root Canal Class C Major Services Class D Orthodontia 50% Bridges and Crowns Dentures and Implants Inlays and Onlays 50% 10

12 Ancillary Group Coverage: Vision Benefits Quick Notes: The group vision coverage is provided by VSP. VISION BENEFITS VSP Benefits in the chart to the right pertain to VSP providers: Co Pay Exam and Glasses $25 copay To find a VSP doctor, visit vsp.com or call Frames Every other year Lens /Contacts 1 Per 12 months 11

13 Ancillary Group Coverage: Life Insurance Information MetLife Life AD&D Quick Notes: The group term life coverage is provided by the MetLife. Basic Life Coverage Amount Your Basic Life coverage amount is 2 times your annual earnings to a maximum of $250,000. Basic AD&D Coverage Amount For a covered accidental loss of life, your Basic AD&D coverage amount is equal to your Basic Life coverage amount. For other covered losses, a percentage of this benefit will be payable. Benefits and Features Waiver of Premium If you become totally disabled while insured under this plan and under age 60, and complete a waiting period of 180 days, your Basic and Additional Life Insurance may continue without premium payment until age 65 provided you give us satisfactory proof that you remain totally disabled. Accelerated Benefit If you become terminally ill, you may be eligible to receive up to 75 percent of your combined Basic and Additional Life benefit to a maximum of $500,000. Portability Conversion Age Reductions If your insurance ends because your employment terminates, you may be eligible to buy portable group insurance coverage. If your insurance ends or reduces, you may be eligible to convert your life insurance to an individual life insurance policy without submitting proof of good health. Basic Life and AD&D insurance coverage amounts reduce by 35 percent at age 65, by 50 percent at age 70, and by 65 percent at age

14 Ancillary Group Coverage: MetLife Short Term Disability (STD) Quick Notes: The group term life coverage is provided by MetLife. ELIGIBILITY MAXIMUM WEEKLY BENEFIT MAXIMUM BENEFT DURA TION DEFINTION OF TOTAL DISABILITY ELIMINATION PERIOD PREGNANCY NON OCCUPATIONAL BENEFIT REDUCTIONS Your benefits may be reduced if: 13 All full time active employees working a minimum of 30 hours per week. If you are totally disabled beyond the Elimination Period due to a covered injury or sickness, you will be eligible to receive a weekly benefit of: 70% of weekly salary up to $1,000 per week 90 working days Total Disability is defined as the inability to perform each of the main duties of your regular occupation due to injury or sickness Benefits begin on the 11th working day for disability due to an accident. Benefits begin on the 11th working day for disability due to an illness. Pregnancy is treated as an illness. The Elimination Period has to be completed before benefits would begin. Public Utility District #1 of Cowlitz County Short Term Disability plan covers non-occupational injury or sickness. Worker s compensation normally covers an employee s work-related accident, injury or illness. You are receiving benefits from any compulsory benefit, act or law, such as a state disability plan. Any governmental retirement system earned as a result of working for the current policyholder; Any Social Security, or similar plan or act, benefits; Any disability or retirement benefit received under a retirement plan Earnings the insured earns or receives from any form of employment.

15 Ancillary Group Coverage: Disability Coverage Information MetLife Long Term Disability (LTD) Quick Notes: The group term life coverage is provided by MetLife. Monthly Benefit 60% Maximum Benefit $6,000/ Monthly Benefits and Features Maximum Benefit Duration Latter of Age 65 or Social Security Normal Retirement Age Own Occupation Period 24 Months (occupation employed in prior to disability as defined by DOL Dictionary of occupational titles) Elimination Period 90 Days (Number of days you must be disabled before collecting benefits) Pre Existing Condition You may not be eligible for benefits if you have received treatment for a condition within 3 months prior to your effective date under this policy until you have been covered under the policy for 12 months Waiver of Premium You will not be required to pay premium during any time of approved total or partial disability. Benefit Limitations Mental Illness: 24 months Substance Abuse: 24 months Benefit Exclusions You will not receive benefits in following circumstances: Your disability is the result of a self-inflicted injury You are not under the regular care of a doctor when requesting disability benefits You were involved in a felony commission, act of war, or participation in a riot You were residing outside of the United States or Canada for more than 12 consecutive months for purposes other than employment with your Employer Coverage Termination Coverage will terminate when you terminate employment with this policyholder or at your retirement. 14

16 Coordinaon of Benefits The Cowlitz PUD benefit plan is the primary insurance for the employee. If a spouse or dependent has other medical coverage through an employer or other source, that plan is the primary insurance to the spouse or dependent. The Cowlitz PUD plan does offer coordination of benefits as a secondary payer to dependents that have primary medical coverage through an employer or other source. If an employee has secondary coverage through a spouse, dependent upon the plan design of the spouse s coverage, they may be able to submit an Explanation of Benefits (EOB) to the spouses coverage for coordination of benefits if the spouse's plan allows. detailed benefit description and exclusions. This LBG Advisors does not provide coverage. While this guide is believed to be accurate as of the date of first use. Plan designs, coverages and vendors may change during or at the end of the plan year. Please consult your HR department for updates to your plan and coverage