West Covina USD Health Benefits. Initial Enrollments and Qualifying Events

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1 2015 Open Enrollment INSIDE THIS Medical Plan Benefits 2 T H E W E S T C O V I N A U N I F I E D S C H O O L D I S T R I C T I S D E D I C A T E D T O U N C O M P R O M I S I N G E X C E L L E N C E I N E D U C A T I O N A N D C I T I Z E N S H I P. Dental, Vision, and Life Benefits Supplemental Insurances Pro- Opt-Out gram REMINDERS: Submit insurance forms to Business and Fiscal Services Health Benefits. If you are enrolling your spouse or child as a dependent for the first time, a copy of your marriage license and/or dependent s birth certificates are required. The annual cost of health coverage is reported on Form W-2 in compliance with the Patient Protection and Affordable Care Act. Health plan information is available on the Business and Fiscal Services website! HEALTH BENEFIT CON- TACTS: Tax Sheltered Annuities Section 125 Cafeteria 5 FAQs 6 Tenthly Payroll Deductions CERTIFICATED EMPLOYEES (626) EXT. 666 CLASSIFIED EMPLOYEES (626) EXT Opt-Out Form Cafeteria Plan Form 1-1 West Covina USD Health Benefits SEPTEMBER 11, 201 OCTOBER 10, 201 All monthly employees and Classified employees who work at least 20 hours per week qualify for health benefits at West Covina Unified School District. The District contributes a maximum of $8, towards employee health benefits, pro-rated for part-time employees. health benefits consist of medical, dental, vision, and life insurance. Supplemental insurances are also offered at the employee s own expense. Initial Enrollments and Qualifying Events Eligible newly hired employees may enroll eligible dependents to their medical, dental, and vision insurance during the initial enrollment period when first employed, within 0 days. Subsequent to the initial enrollment period, employees may add dependents to their existing health plan if they experience a qualifying event such as the birth of a child, a recent marriage, or a loss of coverage. Dependents may be added within 0 days of the qualifying event. Dependents may be dropped at any time, unless prohibited by law. Dependents who are added or deleted from your plan are processed with an effective date of the first of the following month of such request. Health - (Medical, Dental, and Vision) Open Enrollment The Open Enrollment Period allows employees to enroll, change health plans, or add eligible dependents who were not previously enrolled into their insurance. The effective date for all changes made during Open Enrollment is January 1, s who are not making any changes will continue with their existing insurance into the new plan year (no action is needed). Opt-Out Program/ Section 125 Cafeteria Plan The Open Enrollment Period also provides employees the opportunity to participate in the Opt-Out Program and the Section 125 Cafeteria Plan. Please be advised that re-enrollment into the Opt-Out Program and/or the Section 125 Cafeteria Plan is required each year in order to continue. The last day to submit insurance forms for all enrollments and changes made during Open Enrollment is Friday, October 10, 201. Please note that the District open enrollment may not coincide with the CalPERS open enrollment. In order to process a deduction for your plan on a tenthly basis, all changes must be received by October 10, 201. Health Fair Thursday, September 25, 201 Time: 1:00pm :00pm Location: WCUSD District Office, ERC Building 1717 West Merced Avenue, West Covina, CA Plan representatives and vendors will be here to assist in answering questions regarding health plans. Various products and services will also be introduced. s are encouraged to attend. Make sure you sign in! 1 of 15

2 2015 OPEN ENROLLMENT CalPERS Medical Plans A listing of the eleven plans (8 HMOs and PPOs) offered by the District through CALPERS is provided below. It is very important that you review plan detail information prior to making a decision on a medical plan that meets your needs. Summary plan details are subject to change for 2015, check website for up to date information. Visit the CalPERS website at for complete benefit details, provider networks, or to request an evidence of coverage booklet for more details. Pro- Opt-Out gram INSIDE THIS Medical Plan Benefits 2 Dental, Vision, and Life Benefits Supplemental Insurances Tax Sheltered Annuities Section 125 Cafete- 5 FAQs 6 Tenthly Payroll Deductions REMINDERS: 7-10 Opt-Out Form Cafeteria Plan Form 1-1 Health Care Reform Effective January 1, 2011, CalPERS accepts dependents up to age 26. If your dependent lost coverage prior to this date, an enrollment form must be completed in order for their insurance to be reinstated on January 1, If you change your medical plan during Open Enrollment, you will remain on your current plan until December 1, 201. Effective January 1, 2015, you will change to your new medical plan. If you live in the Other Southern California Region, you can request to enroll using your work zip code. (All services must be received within the Los Angeles Area, except emergency and urgent care). Anthem HMO Select (855) Blue Shield Access + (800) Health Net Salud y Más (888) Kaiser Permanente (800) Pers Choice PPO (877) HMO PLANS* PPO PLANS* PERSCare PPO (877) Anthem HMO Traditional (855) Blue Shield Net Value (800) Health Net Smart Care (888) United Healthcare (877) Pers Select PPO (877) of 15

3 2015 OPEN ENROLLMENT INSIDE THIS Medical Plan Benefits 2 Dental, Vision, and Life Benefits Supplemental Insurances Tax Sheltered Annuities Opt-Out Program Section 125 Cafeteria 5 Other health benefits... Dental Insurance Delta Dental Of California (Premier Plan) $2, maximum benefit paid per calendar year (January-December) per person Diagnostic and Preventative Benefits 100%, Basic Benefits 100%, Crowns and other Cast Restorations 100%, Prosthodontics 50%, No Orthodontic Coverage Vision Insurance Vision Service Plan (VSP) $10.00 co-pay every 12 months Well Vision Exam/Prescription Glasses $10.00 Allowance -or- Contact Lens Care (fitting and evaluation) $ Allowance FAQs 6 Tenthly Payroll Deductions REMINDERS: 7-10 Opt-Out Form Cafeteria Plan Form 1-1 The dental and vision plans are currently negotiated as a composite plan which means there is no additional cost to enroll your eligible dependents. Dental and Vision plans accept single dependents up to age 25. Classified employees who work at least 0 hours per week are eligible for vision insurance. Supplemental insurance policies are a contract between the employee and the insurance carrier. When your policy is approved, authorization is given to the district to deduct your premiums from your payroll check. Life Insurance The Hartford Life Insurance $15, Life, Accidental Death and Dismemberment (AD&D) benefit for the employee only Benefits reduce to $9, at age 65 Benefits reduce to $7, at age 70 Supplemental Insurances Various supplemental insurances for unexpected life events such as cancer, disability, accident, life, and/or income protection are offered through the following insurance carriers. Keep in mind that employees do not pay into the State Disability Insurance (SDI). These voluntary plans are available at the employees own expense to supplement their coverage. Once membership is obtained with the insurance carrier, authorized premiums will be payroll deducted. Brochures are available at the Open Enrollment Health Fair/Business and Fiscal Services office. For more information, contact: THE HARTFORD NATIONAL TEACHER S ASSOCIATES PACIFIC EDUCATORS STANDARD INSURANCE (CTA) ALFAC* (Contact: Jacqueline Luna) Newly hired employees qualify for guaranteed supplemental insurances without medical questionnaires, subject to conditions. Contact insurance carrier for deadlines. * Offers guaranteed renewable policies. of 15

4 2015 OPEN ENROLLMENT INSIDE THIS Medical Plan Benefits 2 Tax Sheltered Annuities Dental, Vision, and Life Benefits Supplemental Insurances Tax Sheltered Annuities Opt-Out Program SchoolsFirst Federal Credit Union is the District s Third Party Administrator for your tax sheltered annuities. SchoolsFirst FCU provides investment guidance, retirement education and plan compliance services. A tax sheltered annuity (TSA) is a voluntary retirement plan option that allows employees to save for their retirement by investing payroll deducted contributions. 0(b) Pre-tax contributions, taxes are paid on withdrawals which can begin at age 59 ½. Penalties may apply to withdrawals taken before this time. Roth 0(b) After-tax contributions, withdrawals can begin at age 59 ½ and are tax free if the account has been opened for at least 5 years. You may withdraw upon severance of employment, or in cases of hardship, disability or death; penalties may apply. Section 125 Cafeteria 5 FAQs 6 Tenthly Payroll Deductions REMINDERS: 7-10 Opt-Out Form Cafeteria Plan Form 1-1 The Los Angeles County Office of Education charges a fee for returned contributions due to any errors in TSA enrollments. This fee will be charged to the employee at the current rate of $25 per returned contribution (fee subject to change). Part-time employees eligible for pro-rated benefits may participate in the Opt- Out Program at a percentage equal to their prorated eligibility. Classified employees who work at least 20 hours per week are eligible to participate in the Opt-Out Program. 57(b) Pre-tax contributions; taxes are paid on withdrawals. Regardless of age, you may withdraw when you leave your employer, or in case of death, disability or unforeseeable emergency. Supporting documentation is required and you may be subject to penalties. Contact a TSA Agent if you are interested in opening a TSA. If you do not have a TSA Agent, please contact Ryan Lozano, Retirement Plan Representative from SchoolsFirst FCU at , ext. 82. To ensure that there s no delay in processing your TSA (i.e. new set-up, change in amount or provider, termination, etc.), please remind your TSA Agent that Salary Reduction Agreements must be sent to SchoolsFirst FCU at the address below for proper processing. Salary Reduction Agreements must be submitted a month prior to the effective date of your request. You can also visit their website at for more information and updates. For a list of approved providers you may log on at: Online : retirement.schoolsfirstfcu.org/ OR Mail: Salary Reduction Agreement (SRA) forms to SchoolsFirst at: P.O. Box 1157 Santa Ana, CA Opt-Out Program s who are currently covered through an outside group medical insurance may opt-out of the district medical insurance. If eligible, employees will receive an opt-out payment of $ per month (annual maximum of $1,700.00), pro-rated for part-time employees. Payment is fully taxable and is paid through payroll. An enrollment form and proof of medical coverage is required (i.e. copy of medical card). For Opt-Out benefits to continue for employees who were previously enrolled, a new enrollment form must be submitted on or before Friday, October 10, 201. of 15

5 INSIDE THIS 2015 OPEN ENROLLMENT Medical Plan Benefits 2 Dental, Vision, and Life Benefits Supplemental Insurances Pro- Opt-Out gram Tax Sheltered Annuities Section 125 Cafeteria 5 FAQs 6 Tenthly Payroll Deductions 7-10 Opt-Out Form Section 125 Cafeteria Plan P&A Group is the District s Third Party Administrator for the Section 125 Cafeteria Plan. The Section 125 Cafeteria Plan, also known as a Flexible Spending Account (FSA), is a program that the Federal Government allows your employer to sponsor. It enables employees to save on Federal, State, and Social Security taxes on the money they use to pay for eligible expenses. s and their eligible dependents can pay for health expenses, dependent care expenses, adoption expenses, and individual premiums on a pre-tax basis. There are four types of accounts you can enroll in: 1. Medical Expense Reimbursement 2. Dependent Care Assistance. Adoption Assistance. Individual Premium Reimbursement s must estimate how much they will spend on eligible expenses over the 12 months (January 2015-December 2015). This amount is divided by ten and deducted from their paychecks on a tenthly basis (ten payroll deductions). Payroll deductions are deposited into a trust account to pay for eligible expenses. There is a $6.00 Administration Fee/Month to participate. Enrollment does not roll forward each year. You must enroll during open enrollment each year to take advantage of the Section 125 Cafeteria Plan pre-tax deduction. Cafeteria Plan Form 1-1 REMINDERS: 2015 Plan Year for the Section 125 Cafeteria Plan: January 2015 through December The Use it or Lose it rule under the IRS guidelines state that if you contribute dollars to a reimbursement account and do not use all of the monies you deposit, you will lose any remaining balance in the account at the end of the plan year (December 2015). A new enrollment form must be submitted on or before October 10, 201. FSA Brochure available o n w e b s i t e : Contributions per plan year for each account Minimum Maximum Medical Expense Reimbursement Account $ $2, Dependent Care Assistance Reimbursement Account No minimum $5, Adoption Assistance Account No minimum $1, Individual Premium Reimbursement Account No minimum $10, Medical insurance premiums are automatically deducted on a pre-tax basis. An enrollment form is not necessary and there are no fees if you are not taking advantage of other qualified expenses. However, should you decide that you would like your insurance premium to be deducted on an after-tax basis, you must contact the Benefits Department in writing. The tenthly Payroll deductions for Health Insurance premiums is calculated by dividing the annual insurance rates by a factor of 10 to determine the monthly deductions. There are no payroll deductions in June & July for Classified employees, and July & August for employees. If an employee terminates during those months, there may be a payment owed to the District. P&A offers a Benefits MasterCard which works like a debit card. As you incur expenses, simply present your Benefits Card to the provider of the goods or services you are purchasing. Eligible expenses are automatically deducted from the trust account that is set up. If you are unable to use your Benefits Card, you can still be reimbursed for eligible expenses by submitting a claim with a copy of your receipt. Please note: Benefits MasterCard may not have funds available until February Eligible expenses at the start of the plan year may require a claims submission for reimbursement, receipts are required. You can also access your account by creating a user name and password at: Simply log in to check your balances 5 of 15

6 INSIDE THIS 2015 OPEN ENROLLMENT Medical Plan Benefits 2 Frequently Asked Questions Dental, Vision, and Life Benefits Supplemental Insurances Tax Sheltered Annuities Opt-Out Program Where do I submit my forms? Submit forms through interoffice mail/usps mail to: West Covina USD Business and Fiscal Services Attn: Health Benefits -or- Classified Health Benefits, 1717 West Merced Avenue, West Covina, CA You may also submit your forms in person. Supporting documents must be attached (i.e. marriage license, birth certificates, proof of coverage, etc.). Forms must be received by October 10, 201. Late forms will not be accepted. If I enroll in the Opt-Out Program, am I eligible to participate in the dental, vision, and life insurances? The Opt-Out Program applies to medical insurance only. You are eligible to opt-out of the medical insurance and still enroll in the dental, vision, and life insurance. Section 125 Cafeteria 5 FAQs 6 Tenthly Payroll Deductions REMINDERS: CalPERS will provide a uniform Summary of Benefits and Coverage for all health plans to applicants and enrollees under the Patient Protection and Affordable Care Act (Federal Health Care Reform law) with their Open Enrollment materials. To obtain a 2015 Health Benefit Summary and Health Program Guide, please mail the postcard from the CalPERS Open Enrollment packet by September 18, 201. To access doctor directories, explore health plan features and view overall plan satisfaction ratings, Visit Opt-Out Form Cafeteria Plan Form 1-1 If I enroll in a single medical plan, can I still add my dependents to my dental and vision insurance? Yes. The District carries individual policies for each health insurance plan. If you enroll in a single medical plan, you can still add your dependents to your dental and vision insurance. Likewise, if you enroll in a two party or family medical plan, your dependents will not be enrolled into your dental and vision unless you submit an enrollment form to add them. How are my tenthly payroll deductions calculated? Tenthly payroll deductions reflect rates from January 2015 December Twelve months of health premiums less the district s contribution towards your plan is then divided into ten equal payroll deductions. If I make a health plan change during Open Enrollment, will the Tenthly Payroll Deductions on page 7-10 show what my new rates will be? Depends. If you are making a health plan change (i.e. change in medical plan, change in dependent coverage, etc.) during Open Enrollment or if you experience a qualifying event which allows a change mid-year, your tenthly payroll deduction may be adjusted. Inquire with the Benefits Department. What happens if my dependents are dropped from my plan due to overage limits? Do they have the option to continue? The Consolidated Omnibus Budget Reconciliation Act (COBRA) allows enrolled dependents who experience a loss of district health coverage to enroll and pay at the employee s own expense for continued membership in the medical, dental, and vision insurance plans when their benefits terminate under eligibility guidelines. If I experience a qualifying event mid-year and my dependents are dropped from my plan, will I receive a refund for the amounts that have been prepaid? Since the annual cost of your benefits is divided into 10 payments, you may qualify for a refund if you experience a change in benefits mid-year. Once a change is made, annual costs are re-calculated and a refund will be issued to you if you have overpaid. Refunds typically take 2- months to process. Why does my insurance cost more if I live in the Other Southern California Region? Since health care costs vary throughout California, regional pricing adjusts premiums to reflect the actual cost of health care in your specific region. Premiums under the CalPERS Health Program are adjusted to each specific region. If your residential zip code falls within the following areas: Fresno, Imperial, Inyo, Kern, Kings, Madera, Riverside, Orange, San Diego, San Luis Obispo, Santa Barbara, or Tulare, you will pay the Other Southern California Region rate. To take advantage of lower premiums in the Los Angeles Area, you can request to enroll using your work zip code. If you do, all covered services must be received within the Los Angeles Area, except emergency and urgent care. When does the first tenthly deduction for 2015 start? For Monthly Classified s, the first tenthly deduction will start with their December 0, 201 payroll. For Monthly s, the first tenthly deduction will start with their January 5, 2015 payroll. 6 of 15

7 LA-R1 WEST COVINA UNIFIED SCHOOL DISTRICT 2015 Tenthly Payroll Deductions - Los Angeles Area (Los Angeles, San Bernadino and Ventura) Dental 1 Vision 1 Life 2 Medical (HMO) The Hartford Life Vision Service Plan Delta Dental of California Health Net SmartCare Health Net Salud y Más Blue Shield NetValue Blue Shield Access+ Anthem Traditional HMO Anthem Select HMO Coverage Classified s s 100% 6-8 Hours Only $161.7 $25.2 $85.95 Two Party $587.9 $ $66.67 $ $7.9 $ Family $9.19 $1,7. $1,019.5 $ $77.60 $1,177.1 $5. $0. $118.2 $ $1.7 $ $10.7 $ % N/A Only $5.09 Two Party $ $1,08.92 $ $ $556.7 $887.6 Family $1,062. $1,9.68 $1,18.78 $1,07.51 $ $1, $185.0 $8.05 $ $182.0 $ $ N/A 5.5 Hours Only $5.82 $0.5 Two Party $77.26 $1, $82.99 $ $62.81 $95. Family $1, $1, $1, $1,10.59 $9.92 $1,6.7 $222.0 $85.1 $28.81 $218. $19.82 $09.5 N/A 5 Hours Only $65.79 $0.6 Two Party $811.5 $1,1.25 $ $792.5 $ $ Family $1, $1, $1,2.12 $1,11.85 $ $1,00.99 $26.8 $00.21 $26.71 $2.00 $206.7 $2. 60% N/A Only $70.17 $10.67 $0.68 Two Party $826. $1, $ $ $ $1, Family $1, $1, $1, $1, $ $1,15.89 $296.0 $59.8 $2. $ $258. $ % Hours Only $87.71 $1. $0.85 Only Two Party $ $1, $9.78 $ $75.60 $1, Family $1,21.0 $1,672.5 $1,17.6 $1,216.8 $1,05.71 $1, of Composite Plan: Only, Two Party and Family plans are negotiated as one rate. No additional cost to enroll eligible dependents. 2. Group term life insurance for the employee only.

8 LA-R2 WEST COVINA UNIFIED SCHOOL DISTRICT 2015 Tenthly Payroll Deductions - Los Angeles Area (Los Angeles, San Bernadino and Ventura) Dental 1 Vision 1 Life 2 Medical (PPO) Medical (HMO) The Hartford Life Vision Service Plan Delta Dental of California Coverage Kaiser (CA) UnitedHealthcare PERS Choice PERS Select PERSCare Classified s s 100% 6-8 Hours Only $29.20 $ $95.57 $180.2 Two Party $65.62 $50.76 $ $787.6 $ Family $1, $85.05 $1, $1,202. $1,22.77 $18. $ $225.2 $21.82 $ % N/A Only $5.09 $5. $0. Two Party $77.86 $62.00 $927.6 $ $1, Family $1,19.11 $95.29 $1,8.79 $1,21.67 $1,52.02 $ $172.0 $292.2 $ $66.6 N/A 5.5 Hours Only $5.82 $0.5 Two Party $80.9 $ $99.5 $97.68 $1,1.17 Family $1, $1,021.7 $1,15.87 $1,88.75 $1, $ $206. $29.58 $19.15 $0.90 N/A 5 Hours Only $65.79 $0.6 Two Party $ $728. $1,01.80 $1,010.9 $1,180. Family $1,25.5 $1,058.6 $1,5.1 $1,26.01 $1,66.5 $ $ $.9 $.06 $ % N/A Only $70.17 $10.67 $0.68 Two Party $89.10 $7.25 $1,06.70 $1, $1,195. Family $1,268.5 $1,07.5 $1,68.0 $1,0.91 $1, $27.1 $275.2 $0.11 $9.68 $ % Hours Only $87.71 $1. $0.85 Only Two Party $ $ $1,106.2 $1,085.7 $1,25.96 Family $1,27.98 $1,1.16 $1, $1,500.5 $1, of Composite Plan: Only, Two Party and Family plans are negotiated as one rate. No additional cost to enroll eligible dependents. 2. Group term life insurance for the employee only.

9 OS-R1 WEST COVINA UNIFIED SCHOOL DISTRICT 2015 Tenthly Payroll Deductions - Other Southern California Region (Orange, Riverside and San Diego) Dental 1 Vision 1 Life 2 Medical (HMO) The Hartford Life Vision Service Plan Delta Dental of California Health Net SmartCare Health Net Salud y Más Blue Shield NetValue Blue Shield Access+ Anthem Traditional HMO Anthem Select HMO Coverage Classified s s 100% 6-8 Hours Only $ $295.5 $ $77.09 $28.9 $99.6 Two Party $97.1 $1, $80.57 $750.0 $65.20 $ Family $1,.17 $1,722.2 $1, $1,15.8 $1, $1, % N/A Only Two Party 1, , Family 1,56.1 1, , , , ,2.26 N/A 5.5 Hours Only Two Party 1, ,7.59 1, Family 1,60.9 1, ,57.9 1,0.70 1,21. 1,99. N/A 5 Hours Only Two Party 1, , , , Family 1, , , , , , % N/A Only Two Party 1, , , ,0.98 Family 1, , , , , , % Hours Only Only Two Party 1, ,85.8 1, , ,09.60 Family 1, , , ,52.9 1,26.1 1, of 15 1 Composite Plan: Only, Two Party and Family plans are negotiated as one rate. No additional cost to enroll eligible dependents. 2 Group term life insurance for the employee only

10 OS-R2 WEST COVINA UNIFIED SCHOOL DISTRICT 2015 Tenthly Payroll Deductions - Other Southern California Region (Orange, Riverside and San Diego) Dental 1 Vision 1 Life 2 Medical (PPO) Medical (HMO) The Hartford Life Vision Service Plan Delta Dental of California Coverage Kaiser (CA) UnitedHealthcare PERS Choice PERS Select PERSCare Classified s s 100% 6-8 Hours Only $99.5 $ $106.8 $ Two Party $795.0 $81.62 $80. $ $981.5 Family $1, $80.98 $1,258.1 $1,20.80 $1, % N/A Only Two Party , Family 1, , ,50.0 1,57.86 N/A 5.5 Hours Only Two Party , , Family 1, ,.6 1, ,60.9 N/A 5 Hours Only Two Party 1, ,05.9 1, ,20.9 Family 1,6. 1, , ,5.8 1, % N/A Only Two Party 1, , , ,219.8 Family 1, ,0.6 1, , , % Hours Only Only Two Party 1, , , ,279.6 Family 1, , , , , of 15 1 Composite Plan: Only, Two Party and Family plans are negotiated as one rate. No additional cost to enroll eligible dependents. 2 Group term life insurance for the employee only

11 West Covina Unified School District Business and Fiscal Services Opt-Out Program All employees and Classified employees who work at least 20 hours per week, qualify to participate in the Opt-Out Program. The Opt-Out Program allows employees to opt-out of medical insurance if they already have existing medical coverage. s may choose not to enroll for medical insurance and instead, receive an opt-out payment of up to $ per month (maximum of $1, annually). Opt-out payments are pro-rated for part time employees. Attach the following: 1. Proof of medical coverage. (i.e. Copy of insurance card, letter from insurance carrier, etc.) 2. If you are currently enrolled in the District s medical insurance plan, a cancellation form must be completed. Classified (please check ) s Name: SSN (last four digits): Work Location: Job Title: Telephone Number: Work Hours/Day: Subscriber s Name: Subscriber s Insurance Company s Name: I elect to opt-out of the District s medical insurance plan and receive an opt-out payment in lieu of medical benefits for the 2015 Calendar Year. I will provide proof of my current medical insurance. I understand that if I should lose my medical insurance coverage and wish to enroll in the District medical insurance, I must cancel my participation in the Opt-Out Program in order to enroll into the District s medical insurance plan within 0 days of loss of coverage. ( must provide proof of loss of coverage.) I certify that I have a current medical insurance coverage. Signature Date This form must be returned to Business and Fiscal Services Attention: or Classified Enrollment Deadline: Friday, October 10, 201 s who do not submit their forms by October 10, 201 will no longer qualify for the Opt-Out Program 11 of 15

12 West Covina Unified School District Business and Fiscal Services Opt-Out Program s who are currently covered through an outside group medical insurance may opt-out of the district medical insurance, subject to the following conditions: The employee eligible for West Covina Unified School District medical insurance must provide satisfactory evidence of current enrollment in another medical insurance plan of similar scope. An enrollment form and proof of medical coverage is required (i.e. copy of medical card). s cannot opt out of district health coverage unless they are covered by another group medical insurance. If eligible, employees will receive an opt-out payment of $ per month (annual maximum of $1,700.00), pro-rated for part-time employees. Payment is fully taxable and is paid through payroll. Part time employees eligible for pro-rated benefits are eligible to participate in the Opt-Out Program at a percentage equal to their pro-rated eligibility. Classified employees must work at least 20 hours per week to be eligible. Eligible employees who wish to enroll in the Opt-Out Program must submit an enrollment form and proof of medical coverage during the Open Enrollment Period. The enrollment form must be turned in annually. s enrolled in the Opt-Out Program may enroll in District Dental, Vision and Life insurance. FOR ELIGIBLE EMPLOYEES ONLY 12 of 15

13 West Covina Unified School District Business and Fiscal Services Section 125 Cafeteria Plan Name: SS#: (last four digits) Address: Telephone Number: ( ) Date of Birth: School Site/Department: Classified (check ) Male / Female (circle) Spouse Name: Dependent Name: Dependent Name: Single / Family (circle) Date of Birth: Date of Birth: Date of Birth: Accounts Monthly Amount (10 reductions) Minimum Maximum Medical Expense Reimbursement $ $15.00 $ Dependent Care Assistance + $ No minimum $ Adoption Assistance + $ No minimum $1,19.00 Individual Premium Reimbursement + $ No minimum $1, Administration Fee + $ 6.00 N/A Per Pay Period Total: = $ N/A Payroll Reduction Authorization I hereby authorize the above payroll reduction as my contribution(s) to the West Covina Unified School District Section 125 Cafeteria Plan which must be renewed each successive plan year in writing. I understand that changes to the Cafeteria Plan can only be made by me at the end of the plan year unless there is a change in family status. Any amount that is not spent by the end of the plan year (December 1, 2015) will be forfeited. I will have 90 days following the end of the plan year to submit claims for expenses incurred within the plan year. Claims must be received by P&A Group no later than March 1, This authorization replaces any previous authorizations I have made. Participant Signature: Date: Waiver of Pre-tax Benefits Under the Section 125 Cafeteria Plan I certify that the features and benefits under the Cafeteria Plan have been explained to me completely. I elect to waive all pre-tax benefits under this plan and understand that the benefits may be elected on an after-tax basis. Except for a change in family status, I understand that I cannot elect pre-tax benefits until the next anniversary date, and that any after-tax coverage shall be outside the plan. Participant Signature: Date: This form must be returned to Business and Fiscal Services Attention: or Classified Enrollment Deadline: Friday, October 10, 201 Information in this packet is subject to change. Updated information available on Click Benefits under Staff section 1 of 15

14 West Covina Unified School District Business and Fiscal Services Whether you are single, part of a dual-income household or a family with a non-working spouse, the Section 125 Cafeteria Plan (also known as a Flexible Spending Account) will provide you with additional benefits and more take home pay if you have eligible expenses, see page 5 for more details. Example of Tax Savings INDIVIDUAL WORKING COUPLE WITH DEPENDENTS COUPLE ONE WORKING SPOUSE Without FSA With FSA Without FSA With FSA Without FSA With FSA GROSS MONTHLY INCOME $2,500 $2,500 $6,000 $6,000 $,500 $,500 LESS NON-DEDUCTIBLE BENEFITS INSURANCE PREMIUMS $75 $150 $100 MEDICAL/DENTAL EXPENSES $75 $150 $100 DEPENDENT CARE EXPENSES() $00 TOTAL MONTHLY INCOME SUBJECT TO TAX $2,500 $2,50 $6,000 $5,00 $,500 $,00 MONTHLY FEDERAL AND STATE TAXES* $19 $286 $587 $ $262 $220 MONTHLY SOCIAL SECURITY AND MEDI- CARE TAX $191 $180 $59 $05 $ $29 AFTER TAX INCOME $1,990 $1,88 $,95 $,61 $,89 $,751 AFTER TAX EXPENSES INSURANCE PREMIUMS $75 $150 $100 MEDICAL/DENTAL EXPENSES $75 $150 $100 DEPENDENT CARE EXPENSES $00 MONTHLY SPENDABLE INCOME $1,80 $1,88 $,25 $,61 $,69 $,751 ANNUAL INCREASE IN TAKE HOME PAY $528 $2,8 $68 *Federal and State taxes reflect 2011 federal tax rates and typical state taxes with standard deductions and exemptions. A. Individual: In the illustration, the single employee earns $0,000. She uses flex Plan to pay for her health insurance copayments and deductibles. By enrolling in this plan, she is able to use pre-tax dollars to pay for her eligible expenses which reduced her taxable income for the year. By doing so, she has increased her take home pay by an additional $528. B. Working Couple with Dependents: A working couple have decided to participate in the Section 125 Cafeteria Plan because they have health and day care expenses that they are obligated to pay for the year. They have a dual income of $72,000. This program has allowed them to deduct their monthly day care fees directly from their paycheck, pre-tax. These funds have been deposited into an account which they now use to pay for their children s daycare. They have also used this program to pay for their children s braces. Since they knew these expenses were definite, they benefited by enrolling into the flex Plan because it has allowed them to use pre-tax dollars to pay for their eligible expenses. Their take home pay was increased by $2,8 because their taxes were reduced. C. Couple One Working Spouse: With grown children, and only one spouse working, this couple has no daycare expenses. The annual salary of the working spouse is $5,000. They enroll into the flex Plan because they have dental expenses and health insurance copayments that they expect to incur throughout the next plan year. By enrolling and using pre-tax dollars to pay for these eligible expenses, they have increased their take home pay by $68. Effective January 1, 2011, over-the-counter medicines will only be reimbursable if submitted with a doctor s prescription. Sample eligible expenses without a doctor s prescription include: Band aids, Elastic bandages & wraps, Birth control, First aid supplies, catheters, insulin/diabetic supplies, contact lens supplies and solutions. Please refer to or call customer service at (800) for additional details. 1 of 15

15 West Covina Unified School District Business and Fiscal Services 2015 Open Enrollment OPEN ENROLLMENT SEPTEMBER 11 - OCTOBER 10, 201 HEALTH FAIR THURSDAY, SEPTEMBER 25, 201 1:00 P.M. :00 P.M. 15 of 15