Orange County Government Benefits & Wellness ORANGE COUNTY HEALTH C ARE PREVENTION EDUCATION WELLNESS EMOTIONAL LIFESTYLE FINANCIAL FOR LIFE 2014 Domestic Partner Benefits Handbook MY Life MY Health 1 MY Choice
Table of Contents Wellness for Life Benefits for Domestic Partners... 1 What is the definition of a Domestic Partner?... 1 What benefits are available to my Domestic Partner?... 1 When can I add my Domestic Partner to my Benefits?... 2 What documentation is required to add my Partner to my Benefits?... 3 Dependent Eligibility Changes... 4 Can I use my HSA or FSA for the expenses of my Domestic Partner?... 4 Can my Domestic Partner open their own HSA if I cover them on the HDHP... 4 How much High Plan Contribution will I receive when covering my Partner?... 5 Tax Treatment of Domestic Partners... 6 Medical Coverage Taxation Examples... 8 2014 Domestic Partner Premiums... 12 Notice of Continuation Coverage Rights... 14 Note: This booklet summarizes the Benefits for Domestic Partner s in general terms. However, when a conflict arises between this booklet and the offical Plan Documents or Board Approved Agenda Items, this booklet will be secondary. 2
Wellness for Life Benefits for Domestic Partners What is the definition of a Domestic Partner? The term "domestic partner" shall mean a person who has executed and provided the County with a notarized Orange County Declaration of Domestic Partnership affidavit which states and gives proof that the employee and domestic partner: ü ü ü ü ü ü ü Mutually agree that they are and have been in a committed, serious, long- term relationship with each other and intend to remain so indefinitely; and Are of the same sex, at least 18 years of age and mentally competent to consent to a domestic partnership relationship; and Are not married or legally separated to/from anyone else or in a domestic partner relationship with anyone other than the person with whom a Declaration of Domestic Partnership is being executed within Orange County Government; and Are not related by blood to a degree of closeness that would prohibit legal marriage (i.e., siblings or first cousins); and Have shared the same primary residence for at least six consecutive months with each other, and will continue to do so; and Consider each other to be a member of each other's immediate family; and Are jointly responsible for each other's financial welfare and basic living expenses such as food, shelter and common necessities of life. In order to cover the child(ren) of a Domestic Partner, the above criteria must be met to establish the Domestic Partnership, and the children of the Domestic Partner must be: ü the biological or legally adopted child(ren) of your Partner and under the age of 26; or ü between age 26 and 30 and meet the following additional eligibility requirements (Note: premiums will increase to 102% of the total premium): Natural child or legally adopted child; and Unmarried; and Has no dependents of their own; and Not eligible for insurance through their employer or covered under any other medical policy; and Resides in the State of Florida or is a full- time/part- time student What benefits are available to my Domestic Partner? Benefits- eligible employees may add an eligible domestic partner to the following Wellness for Life Plan benefits effective January 1, 2014, provided the employee is also covered. ü Medical (except the TRICARE Supplemental Plan) ü Dental ü Vision ü Domestic Partner Life Insurance (same plan as Spouse Life Insurance) 1
ü Life Insurance for Child(ren) of Domestic Partner (same plan as Child Life Insurance) ü Employee Assistance Program (EAP) ü COBRA- equivalent coverage Please note: Domestic Partners are not eligible for Flexible Spending Accounts, Health Savings Accounts, the ASI fully insured TRICARE Supplemental Plan, and most instances of Family Medical Leave. Other Benefits Offered In addition to the above Wellness for Life Plan benefits offered, employees with a documented domestic partnership on file will be granted the following policy- driven benefits, also effective January 1, 2014: ü Bereavement Leave ü Domestic Violence Leave Note: An Orange County Declaration of Domestic Partnership form must be on file with Human Resources prior to requesting leave benefits (Bereavement Leave or Domestic Violence Leave). When can I add my Domestic Partner to my Benefits? For Bereavement Leave and Domestic Violence Leave No qualifying event is required to complete an Orange County Declaration of Domestic Partnership form for the purpose of ensuring that, should it be needed, you will have access to Bereavement or Domestic Violence Leave. This can be done at any time during the year with your HR representative or a Benefits representative. For all other Benefits You may enroll your domestic partner during Open Enrollment or within 60 days from a qualifying event. Qualifying events include: ü Domestic Partner gains eligibility (i.e., Partner newly meets the eligibility criteria) ü Birth or adoption of a child ü Termination of employment (yours or your Domestic Partner s) that results in a change to benefits ü Significant change in coverage due to your Domestic Partner s employment ü Change in employment status that results in a change to benefits eligibility ü You, your Domestic Partner, or your other dependent enrolls in Medicare or Medicaid ü Loss or gain of dependent eligibility If one of these situations occurs, you have 60 days after the date of the event to change your benefits. Any change you make must be consistent with the event allowing you to make the change and documentation of the family status change will be required. If you and your domestic partner terminate your relationship, you must contact HR within 60 days to remove your domestic partner and any dependents of your domestic 2
partner from your coverage. Your domestic partner and his/her covered dependents will be eligible for continuation coverage under the same conditions as all other covered members, as detailed on pages 14 and 15. What documentation is required to add my Partner to my Benefits? Enrolling a Domestic Partner If you choose to enroll your domestic partner and/or eligible dependents of your domestic partner, you must submit the following information to Human Resources: ü Orange County s Declaration of Domestic Partnership form signed by both you and your domestic partner (both signatures must be notarized); and ü Wellness for Life Benefits Enrollment form (Domestic Partner version); and ü Proof of financial interdependence. Two (2) different types of documents from the list below must be submitted. At least one (1) of the documents must reflect joint responsibility for six (6) months prior to submission. Common ownership of real property or a common leasehold interest in property as shown on the deed or lease documents Joint checking account as shown on current bank statements Joint credit cards (current credit card billing statements) Proof of shared living expenses Beneficiary form for life insurance or retirement benefits designating domestic partner as primary beneficiary Proof of joint ownership of a motor vehicle Designation of partner as a Power of Attorney/Health Care Power of Attorney Status of authorized signatory on partner s bank accounts, credit card or charge cards Joint insurance policy (car, property or homeowner s insurance) Redacted copy of the front and signature pages of the most recent jointly- filed tax return Enrolling a Domestic Partner s child If you choose to enroll a child of your domestic partner, you must submit the following information to your department HR Representative: ü Proof of the Domestic Partnership as noted above; and ü Proof of eligibility of the child (birth certificate or adoption papers naming the domestic partner as parent) 3
Dependent Eligibility Changes It is your responsibility to notify your department HR Representative within 60 days when there is a change in dependent eligibility, especially if eligibility is lost. To terminate a Domestic Partnership, you must complete a Statement of Domestic Partnership Termination form. Failure to drop ineligible dependents from the plan within 60 days is considered fraudulent and may result in serious consequences as explained here: Any employee failing to provide the required information and documentation, or falsifying information and documentation, or listing ineligible individuals as eligible dependents, shall cause his or her dependents to be removed from the County s benefit plans. Additionally, that employee may be subject to disciplinary action up to and including termination of employment, may be required to reimburse the County for the benefits costs paid on behalf the ineligible individual(s), and may be excluded from coverage altogether under the County s benefits plans. Can I use my Health Savings Account (HSA) or Flexible Spending Account (FSA) for the expenses of my Domestic Partner? Typically no. You can only use your HSA/FSA to pay for expenses of IRS- qualified dependents (i.e., those the IRS would consider your tax dependents). In most situations, a Domestic Partner and the children of a Domestic Partner are not considered tax dependents and, therefore, you cannot use your account to pay for their expenses. However, if your Domestic Partner or the child of your Domestic Partner is considered your IRS tax dependent (see definition on page 6), then you may use your HSA or FSA for those expenses. What is the maximum I can contribute to my HSA if I cover my Partner? If your Domestic Partner is not a qualified tax dependent and you have no additional qualified tax dependents on your High Deductible Health Plan, then you can only contribute up to the single maximum amount into your HSA in 2014 (which is $3,330). If you have any qualified tax dependents on the High Deductible Health Plan with you, then you can contribute up to the family maximum of $6,550. Can my Domestic Partner open a HSA if I cover him/her on the High Deductible Health Plan? If you are covering your Domestic Partner on the High Deductible Health Plan (HDHP), then he/she may be able to open up a Health Savings Account (HSA) with the bank of his/her own choosing. However, the Domestic Partner cannot go on the County s group HSA plan with JP Morgan Chase unless the Partner is also a County employee. In order to be eligible to open the HSA, the Partner must also meet the other HSA eligibility criteria, such as not having other health insurance that is not high deductible, 4
not being on Medicare, Tricare, etc. Refer to the 2014 Benefits Handbook for additional information on HSA eligibility. If I choose the High Deductible Health Plan during Open Enrollment and cover my Domestic Partner, what is the County Contribution? If your Domestic Partner or the child of your Domestic Partner is not considered an IRS tax dependent (as defined on page 6), then the County cannot contribute additional dollars on their behalf. Therefore, based on the coverage you select, the High Plan County Contribution for 2014 will only be up to the amount for those who are considered tax qualified. For example, if you select Employee + Domestic Partner on the HDHP and your Domestic Partner is not tax qualified, then your High Plan County Contribution will be $750. However, if you select Employee + Domestic Partner on the HDHP and your Domestic Partner is a qualified tax dependent, then your High Plan County Contribution will be $1,250. If you are covering children of your Domestic Partner on the HDHP (Employee + Children), then the High Plan County Contribution will be $750 if the children are not tax dependents or $1,250 if the children are tax dependents. And, finally, if you are covering your own children on the HDHP along with your Domestic Partner, then you will receive the full $1,250 since your own children are covered. Therefore, if you elect Family Coverage on the HDHP (Employee + Domestic Partner who is not a tax dependent and your natural children), then the High Plan County Contribution amount will be $1,250. In this example, the additional dollars can be attributed to your natural children and are therefore allowable (thus raising your County Contribution from $750 to $1,250). For further clarification about the High Plan County Contribution amounts, contact your Department HR Representative. 5
Tax Treatment of Domestic Partner Benefits Will the premiums for my Domestic Partner Benefits be taken pre- tax? Current IRS regulations do not permit same- sex domestic partner benefits to be paid for with pre- tax dollars unless the domestic partner or domestic partner s children also qualify as an official tax dependent under Section 152 of the Internal Revenue Code. Therefore, unless the below definition is met, then you will not be able to pay premiums for your Domestic Partner or child of your Domestic Partner on a pre- tax basis. Thus, a post- tax deduction will be calculated based on your elections and coverage tier. IRS Section 152 Definition of Dependency Under the definition in Section 152 of the Internal Revenue Code, your domestic partner or domestic partner s child is your dependent if all of the following tests are met: 1. The person is a member of your household during the entire calendar year; and 2. The person has his or her principal place of abode throughout the year in your home; and 3. The person receives more than half of his or her annual financial support from you; and 4. The person is a U.S. citizen, a U.S. national, or a resident of the U.S., Canada or Mexico; and 5. The relationship does not violate local law. If your Domestic Partner or Domestic Partner s child qualifies as an IRS tax dependent then the following information regarding premium calculation and imputed income will not apply to you. Be sure to inform the HR Representative who completes your enrollment forms that your dependents meet the above conditions, so the paperwork can be completed appropriately. You will be required to sign an additional form to certify that your Domestic Partner or Domestic Partner s child qualifies as an IRS tax dependent. Premium Calculation for Post- Tax Deductions The premium for the benefits you elect will be taken on a post- tax basis for dependents who do not meet the IRS definition of dependency. In order to determine the portion of the premium that will be deducted post- tax, we will take into account the coverage tier you have elected (for example: Employee plus Domestic Partner, Employee plus Child of Domestic Partner, etc.) and calculate the portion that is for each covered dependent type.* The three possible dependent types are: Domestic Partner, Domestic Partner s Child(ren), and Employee s Child(ren). The portion of the premium attributed directly to you (if any) will remain on a pre- tax basis, as will the portion of the premium attributed to any of your natural children or IRS considered tax dependent types. Only the portion of the premium attributed to the non- IRS tax dependent types will be taken on a post- tax basis. * In the event that you have multiple children on the plan, we will only factor the portion for each dependent type (or category of dependent) in order to calculate the portion of premium that should be pre- tax and post- tax. For example, if you cover a Domestic Partner, two children of your Domestic Partner, and two natural children, we would consider this to be three dependent types even though you are covering five dependents. Thus, we would divide the dependent premium by three in order to determine how much is pre- tax and how much is post- tax. 6
Refer to the chart on pages 12 and 13 to see the premiums for 2014 benefit plans with Domestic Partner coverage. Depending on the coverage that you select, the premiums will be taken before or after- tax as shown in the charts. Are there any other tax implications I need to know? In addition to premiums being taken on a post- tax basis for Domestic Partner coverage, the current federal tax code also requires employers to report the value of benefits (the amount that Orange County is contributing) provided to a Domestic Partner and/or Domestic Partner s child(ren) as imputed income. Imputed income is added to your earned wages on your paycheck and W- 2 forms, and applicable taxes must be paid on those dollars. Payroll will process the taxation of the imputed income on a bi- weekly basis, so that you do not have a large tax liability at the end of the year. Will all benefit elections result in Imputed Income being calculated for my Domestic Partner? No, not all benefits will result in imputed income. Dental, Vision, Partner and Child Life insurance benefits are completely paid for by the employee. Thus, there will be no imputed income requirement for those benefit elections. However, because the County subsidizes the premium makes a contribution to that coverage on behalf of the employee of the HDHP and LDHP medical plans, the portion attributable to a Domestic Partner or a Domestic Partner s Child is taxable (inputed income). Below is an explanation of how the County will calculate the value of the Domestic Partner benefits that must be reported as imputed income for medical coverage. It is similar to the method used to calculate the tax treatment of premiums. Imputed Income Calculation The County- paid portion of the medical benefits you elect will be considered imputed income for dependents who do not meet the IRS definition of dependency. In order to determine the amount that will be reported as taxable imputed income, we will take into account the coverage tier you have elected (e.g., Employee plus Domestic Partner, Employee plus Child of Domestic Partner, etc.) and calculate the portion for each covered dependent type.* The portion of County- paid dollars attributed directly to you (if any) will remain non- taxable, as will the portion attributed to any of your natural children or IRS- considered tax dependent types. Only the portion of County paid dollars attributed to the non- IRS tax dependent type(s) will be considered imputed income. * In the event that you have multiple children on the plan, we will only factor the portion for each dependent type (or category of dependent) in order to calculate the portion of premium that should be pre- tax and post- tax. For example, if you cover a Domestic Partner, two children of a Domestic Partner, and two natural children, we would consider this to be three dependent types even though you are covering five actual dependents. Thus, we would divide the County paid dollars by three in order to determine how much is to be reported as imputed income. Refer to pages 12 and 13 to see the imputed income schedule for the 2014 benefit plans with Domestic Partner coverage. Depending on the coverage that you elect and the tax status of your dependents, the amounts shown on the chart will be reported as imputed income. The amount of taxes that are paid for the imputed income will depend on your tax withholding status (W- 4). 7
Medical Coverage Taxation Examples Note: All examples use Monthly Premiums (not bi- weekly) Total Premium = Full Premium for Medical which includes the County Paid portion (Employer Contribution) and the employee paid portion (Employee Deduction). Example 1: The employee adds a Domestic Partner (DP) and a DP s children on the High Deductible Health Plan. The total premium used in this example is HDHP employee + family. + + = Family Coverage on Employee Domestic Partner Partner s Children High Deductible Plan Premium: Pre- Tax Imputed Income: No Premium: After- Tax Imputed Income: Yes Premium: After- Tax Imputed Income: Yes Employee premium for Employee + Family Coverage $ 335.83 Amount of premium for the employee - 0.00 Amount of premium for the dependents $ 335.83 On the High Plan, the employee premium is $0.00. So, in this example, there is nothing to remove. To recap: Since the employee pays $335.83 per month for medical coverage for the DP and the Children of the DP, this amount must be paid on an after- tax basis. Next, let s examine how much imputed income will be assessed. Total Premium for Employee + Family HDHP $ 1,487.11 Minus the Employee Only premium - 497.32 Amount of premium for dependents 989.79 Amount paid by the employee - 335.83 Amount paid by the County for the dependents $ 653.96 To recap: Since the County is paying $653.96 per month for medical coverage for the DP and the Children of the DP, then this amount must be reported as imputed income on the employee s paycheck and the employee will pay taxes on this amount each month. 8
Example 2: The employee adds a DP on the High Deductible Health Plan. The premium used in this example is HDHP employee + partner. + = Employee + Partner Coverage on the High Deductible Plan Employee Premium: Pre- Tax Imputed Income: No Domestic Partner Premium: After- Tax Imputed Income: Yes Employee premium for Employee + Partner Coverage $ 166.83 Amount of premium for the employee - 0.00 Amount of premium for the dependents $ 166.83 On the High Plan, the employee premium is $0.00. So, in this example, there is nothing to remove. To recap: Since the employee pays $166.83 per month for medical coverage for the DP, this amount must be paid on an after- tax basis. Next, let s examine how much imputed income will be assessed. Total Premium for Employee + Partner HDHP $ 1,094.82 Minus the premium for Employee Only - 497.32 Amount of premium for the Partner 597.50 Amount paid by the employee - 166.83 Amount County pays for the dependents $ 430.67 To recap: Since the County is paying $430.67 per month for medical coverage for the DP, then this amount must be reported as imputed income on the employee s paycheck and the employee will pay taxes on this amount each month. 9
Example 3: This employee covers their own birth children and adds on a DP on the Low Deductible Health Plan. The premium used in this example is LDHP employee + family. + + = Family Coverage on Low Deductible Plan Employee Premium: Pre- Tax Imputed Income: No Employee s children Premium: Pre- Tax Imputed Income: No Domestic Partner Premium: After- Tax Imputed Income: Yes Employee premium for Employee + Family Coverage $ 368.33 Amount of premium for the employee (DEDUCTED PRE- TAX) - 21.67 Amount of employee premium for the dependents 346.66 Divide by the # of dependent types (Children and Partner) 2 Premium per dependent type $ 173.33 Amount of dependent premium $ 346.66 Minus the portion for the non- taxable children (DEDUCTED PRE- TAX) - 173.33 Amount paid by the employee for the Partner: $ 173.33 To recap: Since the employee pays $173.33 per month for medical coverage for the DP, this amount must be paid on an after- tax basis. The other $173.33 for the children will be paid pre- tax along with the $21.67 employee portion, for a total of: $195.00 pre- tax and $173.33 after- tax. Next, let s examine how much imputed income will be assessed. Total Premium for Employee + Family LDHP $ 1,535.76 Minus the Employee Only premium - 533.33 Amount of premium that is for the dependents 1,002.43 Amount paid by employee for dependents - 346.66 Amount paid by the County for the dependents 655.77 Divide by the # of dependent types (Children and Partner) 2 Premium per dependent type $ 327.89 Amount paid by the County for the dependents $ 655.77 Minus the portion for the non- taxable children - 327.89 Amount paid by the County for the Partner $ 327.88 To recap: Since the County is paying $327.88 per month for medical coverage for the DP, then this amount must be reported as imputed income on the employee s paycheck and the employee will pay taxes on this amount each month. 10
Example 4: This employee covers their birth children and adds a DP and the DP s Child on the Low Deductible Health Plan. The premium used in this example is LDHP employee + family. + + + = Family Coverage on Low Deductible Plan Employee Employee s children Domestic Partner Partner s child Premium: Pre- Tax Imputed Income: No Premium: Pre- Tax Imputed Income: No Premium: After- Tax Imputed Income: Yes Premium: After- Tax Imputed Income: Yes Employee premium for Employee + Family Coverage: $ 368.33 Employee premium (DEDUCTED PRE- TAX) - 21.67 Amount of dependent premium 346.66 Divide by the # of dependent types (Children, Partner, & Partner Child) 3 Premium per dependent type $ 115.55 Amount of dependent premium $ 346.66 Minus the portion for the non- taxable children (DEDUCTED PRE- TAX) - 115.55 Amount employee pays for Partner & Partner s child $ 231.11 To recap: Since the employee pays $231.11 per month for medical coverage for the DP and the DP s Child, this amount must be paid on an after- tax basis. The other $115.55 for the employee s child will be paid pre- tax along with the $21.67 employee portion, for a total of: $137.22 pre- tax and $231.11 after- tax. Next, let s examine how much imputed income will be assessed. Premium for Employee + Family LDHP $ 1,535.76 Minus the premium for Employee Only - 533.33 Amount of dependent premium 1,002.43 Amount paid by the employee for dependents - 346.66 Amount paid by the County for the dependents 655.77 Divide by the # of dependent types (Children, Partner, & Partner Child) 3 Premium per dependent type $ 218.59 Amount paid by the County for the dependents $ 655.77 Minus the portion for the non- taxable children - 218.59 Amount paid by the County for the Partner & Partner s Child $ 437.18 To recap: Since the County is paying $437.18 per month for medical coverage for the DP and the Child of the DP, then this amount must be reported as imputed income on the employee s paycheck and the employee will pay taxes on this amount each month. 11
2014 Domestic Partner Premiums Medical & Vision Plans VISION Coverage Category 2014 Total Monthly Premium MEDICAL (HIGH DEDUCTIBLE HEALTH PLAN) EMPLOYEE PREMIUMS Before- Tax After- Tax COUNTY PAID PREMIUMS Non- Taxable to the Employee Taxable to the Employee (Imputed Income) Employee Only 497.32 0 0 497.32 0 Employee + Spouse 1,094.82 166.83 0 927.99 0 Employee + Children 1,009.49 151.67 0 857.82 0 Employee + Family (Spouse / Child) 1,487.11 335.83 0 1,151.28 0 EE + Domestic Partner 1,094.82 0 166.83 497.32 430.67 EE + Family (DP / DP Child / Child) 1,487.11 111.94 223.89 715.31 435.97 EE + DP Children + Children 1,009.49 75.84 75.83 677.57 180.25 EE + DP Children 1,009.49 0 151.67 497.32 360.50 EE + DP + DP Child 1,487.11 0 335.83 497.32 653.96 EE + DP + Child 1,487.11 167.92 167.91 824.30 326.98 MEDICAL (LOW DEDUCTIBLE HEALTH PLAN) Employee Only 533.33 21.67 0 511.66 0 Employee + Spouse 1,134.25 193.92 0 940.33 0 Employee + Children 1,054.56 178.75 0 875.81 0 Employee + Family (Spouse / Child) 1,535.76 368.33 0 1,167.43 0 EE + DP 1,134.25 21.67 172.25 511.66 428.67 EE + Family (DP / DP Child / Child) 1,535.76 137.22 231.11 730.25 437.18 EE + DP Children + Children 1,054.56 100.21 78.54 693.74 182.07 EE + DP Children 1,054.56 21.67 157.08 511.66 364.15 EE + DP + DP Child 1,535.76 21.67 346.66 511.66 655.77 EE + DP + Child 1,535.76 195.00 173.33 839.55 327.88 Employee Only 5.07 5.07 0 n/a n/a Employee + 1 (Spouse or Child) 10.16 10.16 0 n/a n/a Employee + 2 or more (Spouse / Child) 14.93 14.93 0 n/a n/a EE + 1 (DP or DP Child) 10.16 5.07 5.09 n/a n/a EE + 2 or more (DP / Child) 14.93 10.00 4.93 n/a n/a EE + 2 or more (DP / DP Child) 14.93 5.07 9.86 n/a n/a EE + 2 or more (DP Child) 14.93 5.07 9.86 n/a n/a EE + 2 or more (Child / DP Child) 14.93 10.00 4.93 n/a n/a EE + 2 or more (DP, DP Child, Child) 14.93 8.36 6.57 n/a n/a 12 Note: Non-Domestic Partner Premiums are included for comparison purposes and are shaded in light green.
2014 Domestic Partner Premiums Dental Plans DENTAL (LOW) Coverage Category 2014 Total Monthly Premium EMPLOYEE PREMIUMS Before- Tax After- Tax COUNTY PAID PREMIUMS Non- Taxable to the Employee Taxable to the Employee (Imputed Income) Employee Only 10.13 10.13 0 n/a n/a Employee + 1 (Spouse or Child) 20.64 20.64 0 n/a n/a Employee + 2 or more (Spouse / Child) 37.75 37.75 0 n/a n/a EE + 1 (DP or DP Child) 20.64 10.13 10.51 n/a n/a EE + 2 or more (DP / Child) 37.75 23.94 13.81 n/a n/a EE + 2 or more (DP / DP Child) 37.75 10.13 27.62 n/a n/a EE + 2 or more (DP Child) 37.75 10.13 27.62 n/a n/a EE + 2 or more (Child / DP Child) 37.75 23.94 13.81 n/a n/a EE + 2 or more (DP, DP Child, Child) 37.75 19.34 18.41 n/a n/a DENTAL (MIDDLE) Employee Only 17.64 17.64 0 n/a n/a Employee + 1 (Spouse or Child) 36.55 36.55 0 n/a n/a Employee + 2 or more (Spouse / Child) 68.73 68.73 0 n/a n/a EE + 1 (DP or DP Child) 36.55 17.64 18.91 n/a n/a EE + 2 or more (DP / Child) 68.73 43.19 25.54 n/a n/a EE + 2 or more (DP / DP Child) 68.73 17.64 51.09 n/a n/a EE + 2 or more (DP Child) 68.73 17.64 51.09 n/a n/a EE + 2 or more (Child / DP Child) 68.73 43.19 25.54 n/a n/a EE + 2 or more (DP, DP Child, Child) 68.73 34.67 34.06 n/a n/a DENTAL (HIGH) Employee Only 28.74 28.74 0 n/a n/a Employee + 1 (Spouse or Child) 58.82 58.82 0 n/a n/a Employee + 2 or more (Spouse / Child) 106.33 106.33 0 n/a n/a EE + 1 (DP or DP Child) 58.52 28.74 29.78 n/a n/a EE + 2 or more (DP / Child) 106.33 67.54 38.79 n/a n/a EE + 2 or more (DP / DP Child) 106.33 28.74 77.59 n/a n/a EE + 2 or more (DP Child) 106.33 28.74 77.59 n/a n/a EE + 2 or more (Child / DP Child) 106.33 67.54 38.79 n/a n/a EE + 2 or more (DP, DP Child, Child) 106.33 54.61 51.72 n/a n/a 13 Note: Non-Domestic Partner Premiums are included for comparison purposes and are shaded in light green.
Notice of Domestic Partner Continuation Coverage Rights This notice generally explains DOMESTIC PARTNER continuation coverage, when it may become available to you and your family, and what you need to do to receive it. The Orange County Board of County Commissioners (OCBCC) offers covered employees and covered family members the opportunity for a temporary extension of health coverage (called Continuation Coverage ) at group rates when coverage under the plan would otherwise end due to certain qualifying events. Qualifying Events for Covered Employee If you are the employee of OCBCC, you may have the right to elect this continuation coverage if you lose your group health coverage because of a termination of your employment (for reasons other than gross misconduct on your part) or a reduction in your hours of employment. Qualifying Events for Covered Domestic Partner and the Legal Dependent Children of the Domestic Partner If you are the covered domestic partner of an employee of OCBCC covered under the flexible benefits program, you may elect continuation coverage for yourself if you lose group health coverage under the flexible benefits program because of any of the following reasons: 1. A termination of OCBCC employee s employment, or reduction in hours of employment with OCBCC 2. The death of OCBCC employee 3. Termination of the Domestic Partnership 4. OCBCC employee becomes entitled to Medicare 5. Dependent Child ceases to be a dependent child under the terms of the plan It is the responsibility of the employee, domestic partner, or other family member to inform their HR Representative of termination of domestic partnership or child losing dependent status under the terms of the plan. This notification must be made within 60 days from whichever date is later the date of the event or the date of the end of coverage under the plan. If this notification is not completed in a timely manner, rights to Continuation Coverage may be forfeited. Election Period and Coverage Once your department HR Representative is notified that a qualifying event has occurred, the covered individuals will be notified of their ability to elect continuation coverage. The covered individual will then have 60 days from loss of coverage or notification, whichever is later, to elect coverage by completing and returning the election form. If the covered individual does not elect continuation coverage within this election period, their right to continue health insurance will end. 14
Length of Continuation Coverage 18 Months: 1. Termination of employment or reduction in work hours 2. Social Security Disability (which can be extended to 29 months if the Social Security Administration determines the date of disability to go back to the date of the qualifying event) 3. Another 18 month extension can occur if during the 18 months of continuation coverage, a second event takes place (divorce, death, Medicare entitlement, or dependent child ceasing to be a dependent) 36 Months (if the original event causing the loss of coverage is one of the following): 1. Death 2. Termination of Domestic Partnership 3. Medicare entitlement 4. Dependent child ceasing to be a dependent under the plan terms A domestic partner participant will pay monthly the employer and employee premium plus a 2% administration charge. Non- payment is cancellation of coverage. If You Have Questions Questions concerning the flexible benefit program, your domestic partner continuation coverage rights, or premium rates should be directed to your HR Representative. Keep Your Plan Informed of Address Changes You should keep the Plan Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. 15
1 Revised: September 17 2013