Open Enrollment focus What s New in FY18? It s here again! This May s Open Enrollment is the opportunity for pre-medicare retirees and Medicare retirees to make insurance changes. Any change will be effective July 1, 2017. Good News!! Look forward to these enhanced s and coverage starting July 1 st : Introducing Delta Dental s Prevention First program. Beginning July 1 st, the Prevention First program will be in place! Costs associated with preventive care and diagnostics (typically your cleanings, oral exams and X- rays) will NOT count against the $1,500 annual maximum. This means that your annual maximum benefit of $1,500 will go further in covering your other dental s such as fillings, crowns, and extractions. Your preventive s will still be covered at 100% by Delta Dental. Open Enrollment Information Meetings Tuesday, May 2 nd, 10:30 AM 12:30 PM ACREA Luncheon Little Falls Presbyterian Church 6025 Little Falls Road, Arlington Wednesday, May 17 th, 1 PM to 3 PM Central Library Auditorium 1015 N. Quincy Street, Arlington We have heard your frustration with Cigna s mail order pharmacy and now have a great alternative. Cigna introduces 90 Now, a new option for filling your 90-day prescriptions at a local pharmacy! Effective July 1 st, 90 Now will enable you to get your 90-day medications from certain retail stores including CVS, Target, Walmart Pharmacy, and Harris Teeter Pharmacy for the same two copays as mail order drugs. If you currently use a preventive medication and pay $0 through mail order, you can now do the same at one of the select retail pharmacies and you still save money! 90 Now is only available at certain pharmacies. To see a full list, go to www.cigna.com/rx90network. Our plan requires maintenance medications to be filled via Cigna Mail Order or the new 90 Now program. Note: Specialty medications must still be filled through Cigna s Specialty Pharmacy. Premiums Premiums for Delta Dental and pre-medicare plan health insurance (Cigna & Kaiser HMO) are increasing July 1 st. Please review the charts on pages 6 & 7 to see your new share of the monthly premium. Premium changes for the Kaiser Medicare Plus plan and the AmWINS Medicare Supplement Plan will not be known until the Fall 2017. Any changes will not be effective until January 1, 2018. Open Enrollment is May 10th to May 24th
P A G E 2 What Can I Do During Open Enrollment? Pre-Medicare retirees may: Switch from Cigna to Kaiser or vice versa Choose a different Cigna plan Add/drop eligible dependents Enroll in or cancel Delta Dental coverage Medicare participants may: Switch from AmWINS to Kaiser Medicare Plus or vice versa Add/drop eligible dependents Enroll in or cancel Delta Dental coverage Are You Eligible for Open Enrollment? To participate in this Open Enrollment period, you must meet one of the criteria below: and/or dependent who is currently enrolled in Cigna or Kaiser and/or dependent who is currently enrolled in AmWINS or Kaiser Medicare Plus who retired after 6/30/2008, who is not currently enrolled in a plan, but who can demonstrate continuous medical coverage in another plan How Do I Make Insurance Changes? Open Enrollment is from May 10 th to May 24 th. Visit www.arlingtonva.us/retirement and click on Open Enrollment to access all of the enrollment forms, rate charts, and plan summaries for our health and dental plans. To make changes, please fill out the appropriate enrollment form(s) Submit completed forms via mail or email no later than May 24 th : Arlington Human Resources ATTN: Benefits 2100 Clarendon Blvd., Suite 511 Arlington, VA 22201 OR Email: benefits@arlingtonva.us Subject: Open Enrollment All changes are effective July 1, 2017. No changes? Sit back and relax there s nothing for you to do! Questions? Call us at 703-228-3500 option 1 or email your questions to benefits@arlingtonva.us
Pre-Medicare Plans Overview Kaiser Permanente Signature HMO Provides one-stop medical care at Kaiser facilities throughout the DC metro area Preventive Care covered at 100% Coverage for non-kaiser providers only in cases of emergency Most economical plan in terms of monthly premiums and copays Cigna All Cigna Plans Offer: Open Access Plus (OAP) network a national network of providers and facilities Preventive Care covered at 100% Emergency and Urgent Care covered 24/7 worldwide Prescription drug coverage is the same for all three plans Three tiers: generic, preferred brand, nonpreferred brand New! Maintenance medications may be filled using mail order OR the new Cigna 90 Now program. (See page 1.) Certain preventive generic drugs are FREE via mail order or 90 Now. Review the Cigna formulary on the retiree website. If your doctor prescribes a non-preferred brand name drug, you may be required to try a generic or preferred brand drug before the more expensive drug is authorized Delta Dental Use any licensed dentist for your dental care Save money when you use a dentist who participates in the Delta Dental Premier or Preferred network The plan pays: 100% of reasonable and customary fees for cleanings and x-rays (preventive care) 80% for Basic Services (e.g., fillings) 50% for Major Services (e.g., crowns) Annual calendar year for Basic and Major Services of $55 individual/$110 family Plan pays maximum of $1,500 per calendar year. New! Costs of preventive care do not count toward the $1,500 annual maximum. What are the differences between Cigna plans? P A G E 3 Open Access Plus In-Network (OAP IN) Coinsurance Choose doctors, health professionals and facilities that are in the Cigna OAP national network (no coverage for out-of-network providers) You pay 10% of the allowable cost for s; the plan pays for 90% Lowest premiums of all Cigna plans No Out-of-pocket maximum (OOPM) is $2,250 individual/$4,500 family* Open Access Plus IN (OAP IN) Copay Choose the doctors, health professionals and facilities that are in the Cigna OAP national network (no coverage for out-of-network providers) You pay a flat dollar copay for s No Out-of-pocket maximum is $6,600 individual/ $13,200 family* Open Access Plus (OAP) Most expensive premiums across all plans Choose any doctors, health professionals or facilities that are in or out-of-network Select a provider in the Cigna OAP network and pay 10% of the allowable cost for s Pay a when you use an out-ofnetwork provider; the pays 70% of allowable charges after the is met Out-of-pocket maximums are: in-network $2,250 individual/$4,500 family; and out-ofnetwork $3,250 individual/$6,500 family *Monthly premium deductions do not count toward your out-of-pocket maximum To see if your provider is in the OAP network: Go to www.cigna.com and Click on Find a Doctor Fill in your search criteria and Click Search If OAP is listed under Plans Accepted, your provider is in-network.
P A G E 4 Coming Soon! Coming in May Web Member Services is getting a new look and a new name! We think you ll find the site easier to navigate. You ll still use the same link: www.arlingtonva.us/retirement and your current Username and Password. Life Insurance Coverage and Rate Changes in Your April 2017 Pension Payment Basic Life If you turned 65 after April 1, 2016 your basic life insurance coverage reduced from $10,000 to $8,000 effective April 1, 2017. Supplemental Life If you turned 65 after April 1, 2016, your supplemental life insurance coverage reduces to $10,000 and the premium deduction will change accordingly in your April 2017 pension payment. Supplemental life insurance premiums are based on your age and tobacco use. Rates are divided into five-year bands until you reach age 70. If you have changed age bands since April 1, 2016 (e.g., age 59 to 60), your new deduction in April 2017 will reflect a higher premium. Turning 65? Welcome to Medicare! s and their dependents who participate in the health insurance plan must enroll in Medicare Part B when they turn 65 in order to continue on a health plan. At age 65, Medicare becomes your primary health insurance, and the plan provides access to coverage beyond traditional Medicare. Either plan is used in conjunction with Medicare Parts A and B, and provides you with Part D prescription drug coverage. Kaiser Medicare Advantage Plus: Plan A with D Only available to enrollees in the Washington, DC Metropolitan area. One-stop medical s at Kaiser facilities; referral required for network hospitals and specialists $15 copay for in-network Medicare-covered primary and specialist office visits $15 copay for diagnostic hearing exam; $15 copay for routine eye exams Retail prescription drug copays of $10 / $15/ $25 (Preferred mail order/ Preferred retail / standard retail) AmWINS Medicare Supplement See any provider who accepts Medicare No Part B to meet $20 Primary and $40 Specialist office visit copays Coverage for routine hearing and vision exams Retail prescription drug copays of $10/$30/$55 (Tier 1, Tier 2, Tier 3)
Service FY18 Pre-Medicare Health Plan Options Out-of-Pocket Costs (excluding premiums) Effective July 1, 2017 Kaiser Copay Plans Coinsurance Plans Cigna OAP IN In-Network Only Cigna OAP IN In-Network Only Annual Deductible* $0 $0 $0 $0 Out-of-Pocket Maximum** $3,500 Individual $9,400 Family $6,600 Individual $13,200 Family PCP Office Visit $20 $30 Specialist Office Visit $40 $60 Physical Therapy $40 $45 $2,250 Individual $4,500 Family ($8 - $12) *** ($20 - $30)*** ($8 - $12)*** Cigna OAP In-Network Out-of-Network $2,250 Individual $4,500 Family $300 Individual $600 Family $3,250 Individual $6,500 Family 30% Coinsurance after 30% Coinsurance after 30% Coinsurance after Preventive Care No Charge No Charge No Charge No Charge No Charge Inpatient Hospital $200/admission $500/admission Outpatient Surgery/ Procedures Specialty Imaging (MRI, CT Scan) $100/visit $250/visit $75/test $100/visit Urgent Care $40/visit $75/visit Emergency Room $150/visit $200/visit Prescription Drugs- Retail (generic/preferred/ nonpreferred) Prescription Drugs Mail Order 90 day supply $15 / $30/ $55 KP $20 / $45 / $60 Network $30 / $60 / $110 ($400 - $2,000)*** ($80 - $559)*** ($50 - $200)*** ($30 - $100)*** ($50 - $200)*** $10 / $30 / $55 $10 / $30 / $55 $10 / $30 /$55 $20 / $60 / $110 Certain generics available at $0 via mail $20 / $60 / $110 Certain generics available at $0 via mail $20 / $60 / $110 Certain generics available at $0 via mail $250 plus 30% Coinsurance $250 plus 30% Coinsurance 30% Coinsurance after after after In-Network coverage only In-Network coverage only NOTE: All Cigna plans use the Open Access Plus (OAP) network. This is a national network of providers. * Annual Deductible member must pay this amount out-of-pocket before the plan will cover s. ** Out-of-Pocket Maximum (OOPM) the Plan will pay 100% for covered s after a member reaches this limit. The OOPM is tracked on a Calendar Year basis and resets every January 1 st. Monthly premiums do not count toward reaching the annual OOPM. *** These are estimated average ranges for your out-of-pocket costs. Your actual costs may vary. P A G E 5
P A G E 6 2017 Medicare Plans Monthly Premiums - Retired before 1/15/12 Rates Effective January 1, 2017 December 31, 2017 Coverage Level Kaiser Medicare AmWINS Supplement Delta Dental (if not at Max. Subsidy) Dental GROUP 1: Chapter 21 20+ yrs svc; 25+ yrs svc Max. Subsidy $960 1 on Medicare $ 24.74 $ 222.68 $ 39.60 $ 356.40 $ 7.24 $ 28.96 2 on Medicare $ 49.48 $ 445.36 $ 79.20 $ 712.80 $ 14.44 $ 57.76 GROUP 2: 23-24 years of Max. Subsidy $883 1 on Medicare $ 42.56 $ 204.86 $ 68.11 $ 327.89 $ 9.41 $ 26.79 2 on Medicare $ 85.11 $ 409.73 $ 136.22 $ 655.78 $ 18.77 $ 53.43 GROUP 3: 20-22 years of Max. Subsidy $768 GROUP 4: 15-19 years of Max. Subsidy $576 GROUP 5: 10-14 years of Max. Subsidy $384 GROUP 6: 0-9 years of Max. Subsidy $192 1 on Medicare $ 69.28 $ 178.14 $ 110.88 $ 285.12 $ 13.03 $ 23.17 2 on Medicare $ 138.56 $ 356.28 $ 221.76 $ 570.24 25.99 $ - $ $ 46.21 1 on Medicare $ 113.81 $ 133.61 $ 182.16 $ 213.84 $ 18.82 $ 17.38 2 on Medicare $ 227.63 $ 267.21 $ 364.32 $ 427.68 $ 37.54 $ 34.66 1 on Medicare $ 158.35 $ 89.07 $ 253.44 $ 142.56 $ 24.62 $ 11.58 2 on Medicare $ 316.70 $ 178.14 $ 506.88 $ 285.12 $ 49.10 $ 23.10 1 on Medicare $ 202.88 $ 44.54 $ 324.72 $ 71.28 $ 30.41 $ 5.79 2 on Medicare $ 405.77 $ 89.07 $ 649.44 $ 142.56 $ 60.65 $ 11.55 2017 Medicare Plans Monthly Premiums - Retired on or after 1/15/12 GROUP 1: Chapter 21 20+ yrs svc; 25+ yrs svc Max. Subsidy $600 GROUP 2: 23-24 years of Max. Subsidy $552 GROUP 3: 20-22 years of Max. Subsidy $480 GROUP 4: 15-19 years of Max. Subsidy $360 GROUP 5: 10-14 years of Max. Subsidy $240 Coverage Level Kaiser Medicare (If not at Max. Subsidy) Dental 1 on Medicare $ 24.74 $ 222.68 $ 39.60 $ 356.40 $ 7.24 $ 28.96 2 on Medicare $ 49.48 $ 445.36 $ 192.00 $ 600.00 $ 14.44 $ 57.76 1 on Medicare $ 42.56 $ 204.86 $ 68.11 $ 327.89 $ 9.41 $ 26.79 2 on Medicare $ 85.11 $ 409.73 $ 240.00 $ 552.00 $ 18.77 $ 53.43 1 on Medicare $ 69.28 178.14 2 on Medicare $ 138.56 356.28 $ 285.12 $ 480.00 $ 110.88 $ 312.00 $ $ 23.17 $ $ 46.21 $ 13.03 $ $ 25.99-1 on Medicare $ 113.81 $ 133.61 $ 182.16 $ 213.84 $ 18.82 $ 17.38 2 on Medicare $ 227.63 $ 267.21 $ 432.00 $ 360.00 $ 37.54 $ 34.66 1 on Medicare $ 158.35 89.07 2 on Medicare $ 316.70 178.14 AmWINS Supplement $ 142.56 $ 240.00 $ 253.44 $ 552.00 Delta Dental $ $ 11.58 $ $ 23.10 $ 24.62 $ 49.10
P A G E 7 Pre-Medicare Plans Monthly Premiums Retired before 1/15/12 Rates Effective July 1, 2017 June 30, 2018 Coverage Level Copay Plans Coinsurance Plans Kaiser HMO Cigna OAP IN Cigna OAP IN Cigna OAP Delta Dental (if not at Max. Subsidy) Dental GROUP 1: Chapter 21 20+ yrs svc; 25+ yrs svc Max. Subsidy $960 Single $ 29.76 $ 492.93 $ 168.74 $ 545.16 $ 103.84 $ 545.16 $ 397.14 $ 545.16 $ 7.24 $ 28.96 + Spouse/ Adult Dependent $ 140.69 $ 960.00 $ 503.50 $ 960.00 $ 370.50 $ 960.00 $ 971.80 $ 960.00 $ 14.44 $ 57.76 + Child(ren) $ 128.46 $ 841.25 $ 319.11 $ 930.19 $ 205.61 $ 930.19 $ 765.91 $ 930.19 $ 15.64 $ 62.56 Family $ 635.26 $ 960.00 $ 1,181.70 $ 960.00 $ 987.00 $ 960.00 $ 1,866.90 $ 960.00 $ 22.02 $ 88.08 1 Medicare $ 54.50 $ 715.61 $ 208.34 $ 901.56 $ 143.44 $ 901.56 $ 436.74 $ 901.56 $ 14.44 $ 57.76 GROUP 2: 23-24 years of Max. Subsidy $883 Single $ 66.73 $ 455.96 $ 209.63 $ 504.27 $ 144.73 $ 504.27 $ 438.03 $ 504.27 $ 9.41 $ 26.79 + Spouse/ Adult Dependent $ 217.69 $ 883.00 $ 580.50 $ 883.00 $ 447.50 $ 883.00 $ 1,048.80 $ 883.00 $ 18.77 $ 53.43 + Child(ren) $ 193.17 $ 776.53 $ 390.66 $ 858.64 $ 277.16 $ 858.64 $ 837.46 $ 858.64 $ 20.33 $ 57.87 Family $ 712.26 $ 883.00 $ 1,258.70 $ 883.00 $ 1,064.00 $ 883.00 $ 1,943.90 $ 883.00 $ 28.63 $ 81.47 1 Medicare $ 109.28 $ 660.82 $ 277.74 $ 832.16 $ 212.84 $ 832.16 $ 506.14 $ 832.16 $ 18.77 $ 53.43 GROUP 3: 20-22 years of Max. Subsidy 768 Single $ 128.36 $ 394.33 $ 277.77 $ 436.13 $ 212.87 $ 436.13 $ 506.17 $ 436.13 $ 13.03 $ 23.17 + Spouse/ Adult Dependent $ 332.69 $ 768.00 $ 695.50 $ 768.00 $ 562.50 $ 768.00 $ 1,163.80 $ 768.00 $ 25.99 $ 46.21 + Child(ren) $ 301.02 $ 668.68 $ 509.92 $ 739.38 $ 396.42 $ 739.38 $ 956.72 $ 739.38 $ 28.15 $ 50.05 Family $ 827.26 $ 768.00 $ 1,373.70 $ 768.00 $ 1,179.00 $ 768.00 $ 2,058.90 $ 768.00 $ 39.64 $ 70.46 1 Medicare $ 197.64 $ 572.47 $ 388.65 $ 721.25 $ 323.75 $ 721.25 $ 617.05 $ 721.25 $ 25.99 $ 46.21 GROUP 4: 15-19 years of Max. Subsidy $576 Single $ 226.97 $ 295.72 $ 386.80 $ 327.10 $ 321.90 $ 327.10 $ 615.20 $ 327.10 $ 18.82 $17.38 + Spouse/ Adult Dependent $ 524.69 $ 576.00 $ 887.50 $ 576.00 $ 754.50 $ 576.00 $ 1,355.80 $ 576.00 $ 37.54 $34.66 + Child(ren) $ 462.80 $ 506.90 $ 688.80 $ 560.50 $ 575.30 $ 560.50 $ 1,135.60 $ 560.50 $ 40.66 $37.54 Family $ 1,019.26 $ 576.00 $ 1,565.70 $ 576.00 $ 1,371.00 $ 576.00 $ 2,250.90 $ 576.00 $ 57.25 $52.85 1 Medicare $ 340.78 $ 429.33 $ 568.96 $ 540.94 $ 504.06 $ 540.94 $ 797.36 $ 540.94 $ 37.54 $34.66 GROUP 5: 10-14 years of Max. Subsidy $384 Single $ 325.57 $ 197.12 $ 495.84 $ 218.06 $ 430.94 $ 218.06 $ 724.24 $ 218.06 $ 24.62 $11.58 + Spouse/ Adult Dependent $ 716.69 $ 384.00 $ 1,079.50 $ 384.00 $ 946.50 $ 384.00 $ 1,547.80 $ 384.00 $ 49.10 $23.10 + Child(ren) $ 635.37 $ 334.33 $ 879.61 $ 369.69 $ 766.11 $ 369.69 $ 1,326.41 $ 369.69 $ 53.18 $25.02 Family $ 1,211.26 $ 384.00 $ 1,757.70 $ 384.00 $ 1,563.00 $ 384.00 $ 2,442.90 $ 384.00 $ 74.87 $35.23 1 Medicare $ 483.92 $ 286.19 $ 749.28 $ 360.62 $ 684.38 $ 360.62 $ 977.68 $ 360.62 $ 49.10 $23.10 GROUP 6: 0-9 years of Max. Subsidy $192 Single $ 424.18 $ 98.51 $ 604.87 $ 109.03 $ 539.97 $ 109.03 $ 833.27 $ 109.03 $ 30.41 $5.79 + Spouse/ Adult Dependent $ 908.69 $ 192.00 $ 1,271.50 $ 192.00 $ 1,138.50 $ 192.00 $ 1,739.80 $ 192.00 $ 60.65 $11.55 + Child(ren) $ 797.14 $ 172.56 $ 1,058.49 $ 190.81 $ 944.99 $ 190.81 $ 1,505.29 $ 190.81 $ 65.69 $12.51 Family $ 1,403.26 $ 192.00 $ 1,949.70 $ 192.00 $ 1,755.00 $ 192.00 $ 2,634.90 $ 192.00 $ 92.48 $17.62 1 Medicare $ 627.06 $ 143.04 $ 929.59 $ 180.31 $ 864.69 $ 180.31 $ 1,157.99 $ 180.31 $ 60.65 $11.55 All rate charts may be found on the s website at www.arlingtonva.us/retirement and then by clicking on Open Enrollment.
P A G E 8 Pre-Medicare Plans Monthly Premiums Retired on or after 1/15/12 Rates Effective July 1, 2017 June 30, 2018 Copay Plans Coinsurance Plans Kaiser HMO Cigna OAP IN Cigna OAP IN Cigna OAP Delta Dental Coverage Level (If not at Max. Subsidy) Dental GROUP 1: Chapter 21 20+ yrs svc; Single $ 29.75 $ 492.94 $ 168.74 $ 545.16 $ 103.84 $ 545.16 $ 397.14 $ 545.16 $ 7.24 $ 28.96 + Spouse/ Adult Dependent $ 500.69 $ 600.00 $ 863.50 $ 600.00 $ 730.50 $ 600.00 $ 1,331.80 $ 600.00 $ 14.44 $ 57.76 + Child(ren) $ 369.70 $ 600.00 $ 649.30 $ 600.00 $ 535.80 $ 600.00 $ 1,096.10 $ 600.00 $ 15.64 $ 62.56 25+ yrs svc Family $ 995.26 600.00 Max. Subsidy $600 $ $ 1,541.70 $ 600.00 $ 1,347.00 $ 600.00 $ 2,226.90 $ 600.00 $ 22.02 $ 88.08 1 Medicare $ 170.11 $ 600.00 $ 509.90 $ 600.00 $ 445.00 $ 600.00 $ 738.30 $ 600.00 $ 14.44 $ 57.76 GROUP 2: 23-24 years of Single $ 66.73 $ 455.96 $ 209.63 $ 504.27 $ 144.73 $ 504.27 $ 438.03 $ 504.27 $ 9.41 $ 26.79 + Spouse/ Adult Dependent $ 548.69 $ 552.00 $ 911.50 $ 552.00 $ 778.50 $ 552.00 $ 1,379.80 $ 552.00 $ 18.77 $ 53.43 + Child(ren) $ 417.70 $ 552.00 $ 697.30 $ 552.00 $ 583.80 $ 552.00 $ 1,144.10 $ 552.00 $ 20.33 $ 57.87 Max. Subsidy $552 Family $ 1,043.26 $ 552.00 $ 1,589.70 $ 552.00 $ 1,395.00 $ 552.00 $ 2,274.90 $ 552.00 $ 28.63 $ 81.47 1 Medicare $ 218.11 $ 552.00 $ 557.90 $ 552.00 $ 493.00 $ 552.00 $ 786.30 $ 552.00 $ 18.77 $ 53.43 GROUP 3: 20-22 years of Single $ 128.36 $ 394.33 $ 277.77 $ 436.13 $ 212.87 $ 436.13 $ 506.17 $ 436.13 $ 13.03 $ 23.17 + Spouse/ Adult Dependent $ 620.69 $ 480.00 $ 983.50 $ 480.00 $ 850.50 $ 480.00 $ 1,451.80 $ 480.00 $ 25.99 $ 46.21 + Child(ren) $ 489.70 $ 480.00 $ 769.30 $ 480.00 $ 655.80 $ 480.00 $ 1,216.10 $ 480.00 $ 28.15 $ 50.05 Max. Subsidy $480 Family $ 1,115.26 $ 480.00 $ 1,661.70 $ 480.00 $ 1,467.00 $ 480.00 $ 2,346.90 $ 480.00 $ 39.64 $ 70.46 1 Medicare $ 290.11 $ 480.00 $ 629.90 $ 480.00 $ 565.00 $ 480.00 $ 858.30 $ 480.00 $ 25.99 $ 46.21 GROUP 4: 15-19 years of Single $ 226.97 $ 295.72 $ 386.80 $ 327.10 $ 321.90 $ 327.10 $ 615.20 $ 327.10 $ 18.82 $ 17.38 + Spouse/ Adult Dependent $ 740.69 $ 360.00 $ 1,103.50 $ 360.00 $ 970.50 $ 360.00 $ 1,571.80 $ 360.00 $ 37.54 $ 34.66 + Child(ren) $ 609.70 $ 360.00 $ 889.30 $ 360.00 $ 775.80 $ 360.00 $ 1,336.10 $ 360.00 $ 40.66 $ 37.54 Max. Subsidy $360 Family $ 1,235.26 $ 360.00 $ 1,781.70 $ 360.00 $ 1,587.00 $ 360.00 $ 2,466.90 $ 360.00 $ 57.25 $ 52.85 1 Medicare $ 410.11 $ 360.00 $ 749.90 $ 360.00 $ 685.00 $ 360.00 $ 978.30 $ 360.00 $ 37.54 $ 34.66 GROUP 5: 10-14 years of Single $ 325.57 $ 197.12 $ 495.84 $ 218.06 $ 430.94 $ 218.06 $ 724.24 $ 218.06 $ 24.62 $ 11.58 + Spouse/ Adult Dependent $ 860.69 $ 240.00 $ 1,223.50 $ 240.00 $ 1,090.50 $ 240.00 $ 1,691.80 $ 240.00 $ 49.10 $ 23.10 + Child(ren) $ 729.70 $ 240.00 $ 1,009.30 $ 240.00 $ 895.80 $ 240.00 $ 1,456.10 $ 240.00 $ 53.18 $ 25.02 Max. Subsidy $240 Family $ 1,355.26 $ 240.00 $ 1,901.70 $ 240.00 $ 1,707.00 $ 240.00 $ 2,586.90 $ 240.00 $ 74.87 $ 35.23 1 Medicare $ 530.11 $ 240.00 $ 869.90 $ 240.00 $ 805.00 $ 240.00 $ 1,098.30 $ 240.00 $ 49.10 $ 23.10 GROUP 6: 0-9 years of Single $ 424.18 $ 98.51 $ 604.87 $ 109.03 $ 539.97 $ 109.03 $ 833.27 $ 109.03 $ 30.41 $ 5.79 + Spouse/ Adult Dependent $ 980.69 $ 120.00 $ 1,343.50 $ 120.00 $ 1,210.50 $ 120.00 $ 1,811.80 $ 120.00 $ 60.65 $ 11.55 + Child(ren) $ 849.70 $ 120.00 $ 1,129.30 $ 120.00 $ 1,015.80 $ 120.00 $ 1,576.10 $ 120.00 $ 65.69 $ 12.51 Max. Subsidy $120 Family $ 1,475.26 $ 120.00 $ 2,021.70 $ 120.00 $ 1,827.00 $ 120.00 $ 2,706.90 $ 120.00 $ 92.48 $ 17.62 1 Medicare $ 650.11 $ 120.00 $ 989.90 $ 120.00 $ 925.00 $ 120.00 $ 1,218.30 $ 120.00 $ 60.65 $ 11.55 Open Enrollment is May 10 th to May 24 th Questions about Open Enrollment? HR Benefits Customer Service at 703.228.3500, Option 1 Email Benefits@arlingtonva.us