Employee Benefits Guide Plans effective January 1, 2017 Regular Part-Time Administrators
Welcome to Montgomery County Community College! Montgomery County Community College (the College) strives to offer you and your dependents a competitive and comprehensive benefits package. We encourage you to take the time to review the benefits available to you, presented in this Guide, and choose the ones that best suit your needs. Once you have made your elections, you will not be able to change them until the next Open Enrollment period, unless you experience a qualified change in status. If you have any questions please contact Brett Schorle in Human Resources. Who is eligible to elect benefits? Medical (which includes prescriptions), dental and vision benefits are available to regular parttime employees by purchasing the plans at 102% of premium cost. Regular part-time administrative employees are eligible to purchase the medical/prescription drug, dental and vision benefits described in this guide, at full cost, provided you regularly work 15 or more hours per week in a College fiscal year. If you are a regular part-time administrative employee and your employment begins on or before the 15 th day of the month, your benefits coverage will be effective the first day of the month following your date of employment. (Example: If your employment begins on February 12 th, your benefits coverage becomes effective March 1 st.) If you are a regular part-time administrative employee and your employment begins on or after the 16 th day of the month, your benefits coverage will be effective the first day of the second month following your date of employment. (Example: If your employment begins on February 16 th, your benefits coverage becomes effective April 1 st.) Please remember that only eligible dependents can be enrolled. Eligible dependents include: Spouse Children until the end of the month of their 26 th birthday. How often can I change plan elections? Unless you experience a qualified change in status, you cannot make changes to the benefits you elect until the next Open Enrollment period. Qualified status changes include: marriage, divorce, birth or adoption of a child, change in child s dependent status, death of spouse, child or other qualified dependent, or change in your spouse s or domestic partner s benefits or employment status. If you are enrolling a dependent(s) for the first time, you will need to provide proof of your dependents eligibility (e.g. birth certificate, marriage certificate, proof of full-time student status, etc.). You must notify Human Resources within 30 days of experiencing a qualified change in status. 1
Medical Plans: Independence Blue Cross Below is a summary of the Personal Choice PPO BASE medical plan effective January 1, 2017. To find a participating provider, please visit www.ibx.com. Deductible Single Family Personal Choice Base Plan $750 $1,500 Out of Network $1,000 $2,000 Out-of-Pocket Max Single $2,000* Family $4,000* Primary Care Physician (PCP) Office Visit Specialist Office Visit Preventive Care Plan pays 100% NO deductible $2,000 $4,000 $15 copay Plan pays 70% after deductible $30 copay Plan pays 70% after deductible Plan pays 70% NO deductible Outpatient Laboratory Plan pays 85% after deductible Plan pays 70% after deductible Outpatient Radiology Plan pays 85% after deductible Plan pays 70 % after deductible Inpatient Hospital Plan pays 85% after deductible Plan pays 70% after deductible Outpatient Surgery Plan pays 85% after deductible Plan pays 70 % after deductible Emergency Room $100 copay after in-network deductible, waived if admitted Durable Medical Equipment Plan pays 85% after deductible Plan pays 70% after deductible Vision Davis Vision $75 Reimbursement Plan *Includes copays, deductible and coinsurance. 2
Medical Plans: Independence Blue Cross Below is a summary of the Personal Choice PPO BUY-UP medical plan effective January 1, 2017. To find a participating provider, please visit www.ibx.com. Deductible Single Family Personal Choice Buy-Up Plan $500 $1,000 Out of Network $1,000 $2,000 Out-of-Pocket Max Single $1,500* Family $3,000* Primary Care Physician (PCP) Office Visit Specialist Office Visit Preventive Care Plan pays 100% NO deductible $2,000 $4,000 $10 copay Plan pays 70% after deductible $20 copay Plan pays 70% after deductible Plan pays 70% NO deductible Outpatient Laboratory Plan pays 90% after deductible Plan pays 70% after deductible Outpatient Radiology Plan pays 90% after deductible Plan pays 70 % after deductible Inpatient Hospital Plan pays 90% after deductible Plan pays 70% after deductible Outpatient Surgery Plan pays 90% after deductible Plan pays 70 % after deductible Emergency Room $100 copay after in-network deductible waived if admitted Durable Medical Equipment Plan pays 90% after deductible Plan pays 70% after deductible Vision Davis Vision $75 Reimbursement Plan *Includes copays, deductible and coinsurance. 3
Prescription Drug Plan: Express Scripts Below are the prescription drug benefits for the 2017 Plan Year. If you elect to participate in either medical plan, you are automatically enrolled in the prescription drug plan. You will receive a separate ID card for the prescription drug plan. Prescription Drug Plan nn Out-of-Network Retail (up to a 30-day supply) Generic Preferred Brand Non-preferred Brand Mail Order (up to a 90-day supply) Generic Preferred Brand Non-preferred Brand $10 copay $30 copay $50 copay 50% $20 copay $60 copay $100 copay Why should I use mail order instead of the retail pharmacy? Using the mail order program for your maintenance medications will save you money. You will receive a 90-day (3-month) supply for the equivalent of two (2) retail copays. In addition to the savings, your prescriptions will be delivered right to your home. To begin using mail order, simply complete a mail order form and send along with your prescription(s) written for a 90-day supply of medication. Forms can be obtained online at www.express-scripts.com. 4
Dental Plan: Delta Dental Below is a summary of the Delta Dental of PA plan and the premium for dental coverage is paid in full by the employee. Your dependent child (ren) are covered for dental until the end of the month in which they turn 26. Proof of full-time student status is not required. Below is a summary of the dental plan effective January 1, 2017. You can visit any dentist you wish. However, if you visit a dentist from Delta s Premier preferred provider network, you can reduce your out-of-pocket expenses. To find an in-network provider, please visit www.deltadentalins.com. If you utilize an out-of-network provider, you may be subject to balance billing the provider can bill you for the difference in what they charge and what Delta Dental pays for the service. Dental Plan Out-of-Network Annual Maximum (per patient) $1,500 $1,500 Orthodontia Benefits (child age 19 and under) Preventive Care Visits, X-rays and Teeth cleaning Plan pays 50% up to a lifetime maximum amount of $1,500 Plan pays 100% Plan pays 50% of UCR* charges up to a lifetime maximum amount of $1,500 Plan pays 100% of UCR* charges Basic Care (excluding periodontal services) Inlays & Crowns, Oral exams, Full mouth X-rays, Fluoride treatments, Lab work & tests, Fillings, Oral surgery, Endodontics & General Anesthesia, Vizilite Basic Care Periodontics Plan pays 100% Plan pays 80% Plan pays 100% of UCR* charges Plan pays 80% of UCR* charges Major Care Pontics (artificial teeth), Removable bridge, Denture, Repair to crown & bridges Plan pays 50% Plan pays 50% of UCR* charges *UCR refers to the usual, customary and reasonable charges for the service as per Delta Dental s guidelines. 5
Vision Plans: Davis Vision Davis Vision Both the Personal Choice Base and Buy-Up PPO plans have a $75 vision rider included in the medical plan at no additional cost to you. This allows reimbursement to a member for covered eyewear purchases up to $75 every 24 months. Find a participating provider at www.davisvision.com. $75 Vision Program Eye Exam Including refraction & glaucoma screening and dilation as indicated Frames: Participating or Davis Collection Lenses Single Vision Bifocal Trifocal Lenticular Contact Lenses In lieu of eyeglasses (Including standard, specialty and disposable lenses and evaluation and fitting) Benefits Out-of-Network Reimbursements $0 copay Up to $35 Up to $60 Davis Collection $0-$20 Up to $75 $0 copay $0 copay $0 copay $0 copay Up to $75 Up to $75 Up to $75 Up to $75 Up to $75 Up to $75 Frequency Comprehensive Exam Lenses Frames Contact Lenses Every 24 Months All Services 6
Vision Plans: Superior Vision Superior Vision Employees enrolled in the Personal Choice PPO Plans may also elect a different vision plan through Superior Vision. The premium is 100% paid by the employee. Please refer to the chart below for a list of benefits. Your dependent child(ren) are covered for vision until the end of the year in which they turn 26. Proof of full-time student status is not required. To find a participating provider, visit www.superiorvision.com. Superior Vision Plan Gold Preferred Plan Comprehensive Eye Exam By an Ophthalmologist By an Optometrist Benefits $10 copay $10 copay Out-of-Network Reimbursements Up to $52 Up to $44 Frames Up to $100 Up to $54 Lenses Single Vision Bifocal Trifocal Lenticular Contact Lenses Medically Necessary Cosmetic (Elective) Standard Contact Lens Fitting Exam Fee Specialty Contact Lens Fitting Exam Fee Covered in full Up to $100 Up to $40 Up to $56 Up to $72 Up to $100 Up to $210 Up to $100 Not covered Not covered Frequency Comprehensive Exam Lenses Frames Contact Lenses Once every 12 months Once every 12 months Once every 24 months Once every 12 months 7
Additional Benefits/Resources Tuition Waiver Regular part-time administrative employees working at least 15 hours or more per week are eligible to participate in the tuition waiver program for courses at MontgomeryCounty Community College. Qualified dependent children (age 25 or younger) and the legally married spouse of a parttime administrative employee are eligible to participate in the tuition waiver for courses at Montgomery County Community College as well. Retirement Plan Regular part-time administrative employees working at least 500 hours in a fiscal year are invited to participate in the TIAA/CREF Retirement Plan. The College will contribute 11% of your base pay, provided you enroll in the program and agree to contribute 5% of your base pay. If you are a current member of PSERS or SERS, you may elect to continue that retirement plan. If you are not a current member, these plans are not available. Benefit Express If you choose to enroll in the medical/prescription drug, dental and/or vision plan, you will receive a coupon booklet from Benefit Express. If you have any questions about your coupon booklets, or your monthly premium please contact them directly at 1-877-837-5017. 8
Monthly Employee Contributions If you choose to enroll, you will receive a booklet from Benefit Express with payment coupons. Your payment is due the first of the month of coverage for example, for coverage during the month of August, your premium is due by August 1 st. If you have any questions about your coupon booklet, or your monthly premium, please contact Benefit Express at 1-877-837-5017. Your monthly employee contributions for Personal Choice Medical with Prescription (Express Scripts), Delta Dental of PA and Superior Vision are listed below. Tiers PPO Base Plan PPO Buy Up Plan Delta Dental of PA Plan Superior Vision Plan Single $817.15 $850.17 $57.72 $5.92 Parent/Child $1293.84 $1344.40 $121.25 $14.86 Parent/Children $1720.53 $1793.47 $121.25 $14.86 2 Adults $1879.64 $1955.57 $121.25 $14.86 Family $2410.56 $2508.15 $121.25 $14.86 9
Questions & Answers When is the completion date for all enrollments? All enrollments must be completed within 30 days of becoming eligible. Please return your completed forms to Brett Schorle in Human Resources. Whom should I contact with questions? Contact Brett Schorle in Human Resources of Benefit Express at 1-877-837-5017. At what age does a Dependent Child become no longer eligible for coverage under my plan? Medical plans: coverage for the dependent(s) will terminate at the end of the month they turn age 26. No proof of full-time status will be required. Dental plan: coverage will terminate at the end of the month they turn age 26. No proof of full-time status will be required. Vision plan: coverage for dependent child(ren) will terminate at the end of the year in which they turn age 26. No proof of full-time status will be required. Will I receive a separate Prescription Card? Yes, you receive a separate prescription ID card from our carrier, Express Scripts. Please present this card to the pharmacy when presenting your prescription to be filled. For a card or assistance, call 1-800-711-0917. Montgomery County Community College reserves the right to modify, amend, suspend or terminate any plan, in whole or in part, at any time. The information in this Enrollment Guide is presented for illustrative purposes and is based on information provided by the employer. The text contained in this Guide was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, discrepancies, or errors are always possible. In case of discrepancy between the Guide and the actual plan documents the actual plan documents will prevail 10