Congratulations on your decision to retire! We are pleased to provide benefit plan information for retirees for the 2015 calendar year. We encourage you to review this communication and the enclosed information thoroughly and carefully. STEPS YOU ARE REQUIRED TO TAKE TO CONTINUE COVERAGE Complete the enclosed enrollment form to election benefit coverage(s) o If you are age 65 or older AND are electing the Humana Medicare Employer Preferred Provider Plan, complete and sign the paper enrollment form enclosed in the HUMANA envelope. This communication will include: 2015 Medical Plan Offerings and Rates 2015 Dental Plan Rates 2015 Vision Plan Rates NEW Relationship with Chard-Snyder to collect retiree premium payments Next Steps Required enrollment form Information included in this packet 2015 Medical Plan Offerings For the 2015 calendar year, Xavier University will continue to offer three medical benefit options: National Point of Service Plan (with a deductible change to $500/$1,000) High Deductible Health Plan (with a deductible change to $2,600/$5,200) Humana Medicare Employer Preferred Provider Plan National Point of Service (NPOS) Plan and High Deductible Health Plan (HDHP) Based on national medical plan average increases of 8 to 10% on average and Xavier University s health plan claims experience, plan design changes and rate increases are required for 2015. The NPOS deductible will increase from $300 for single coverage and $600 for family coverage to $500 for single coverage and $1,000 for family coverage. Additionally the HDHP deductible will increase from $2,500 for single coverage and $5,000 for family coverage to $2,600 for single coverage and $5,200 for family coverage. Enclosed, please find additional information on the plan including rates and coverage by plan. Humana Medicare Employer Preferred Provider Plan Xavier is pleased to continue to offer the Humana Medicare Advantage plan to our retirees. A summary plan design and rate page is included. The Humana Medicare Employer Preferred Provider Organization (PPO) plan gives you access to any Medicare provider or facility. If you use Humana s broad network of primary care doctors, specialists, and hospitals, your out-of-pocket costs may be less. You never need a referral to see any provider. You must have both Medicare Part A and Part B. Enclosed please find more detailed information from Humana regarding the Medicare Advantage Plan. Please review the materials carefully. If you have questions about this plan, please call Humana Group Medicare Customer Care at 1-866-396-8810 (TTY: 711). You can call Monday through Friday from 8 a.m. to 9 p.m. Eastern time.
2015 Dental Plan Offering If you are currently enrolled with Dental Care Plus, you may continue coverage or decline. Plan summary and rates are enclosed. 2015 Vision Plan Offering If you are currently enrolled with Humana Vision, you may continue coverage or decline. Plan summary and rates are enclosed. NEW Relationship with Chard-Snyder to process retiree s benefit payments Effective January 1, 2015, Xavier University will partner with Chard-Snyder for purposes of billing and collecting payments for retiree benefits. As a result, retirees will now submit payment of retiree benefit premiums to Chard-Snyder. Additional information is enclosed describing the new process and the added conveniences offered by Chard-Snyder. NEXT STEPS: Review the enclosed information. Once you have reviewed the information, complete any applicable form(s) such as the Retiree Benefit Change Form and/or a Humana Medicare Advantage application and return no later than 30 days following your date of retirement: Via mail: Xavier University, Office of Human Resources, 3800 Victory Parkway, Cincinnati, OH 45207-5400 Via email (scan and email): benefits@xavier.edu Via fax: 513-745-3644 If you have any other questions about the benefits reviewed above, please contact Maggie Kroeger at Horan Associates at 513-587-2707 or 1-800-544-8306 or the Office of Human Resources at 513-745-3638. This communication is intended as a material modification to amend benefits offered to retirees for calendar year 2015. Medical, dental and vision benefits and rates are subject to change at the discretion of Xavier University. I understand that I am required to submit contribution payments on a monthly basis for the benefits elected. If my payments are not submitted timely, I understand that my benefits are subject to being terminated and are not eligible for reinstatement.
Retiree Benefit Enrollment Form Change forms must be returned to the Office of Human Resources no later than 30 days following your date of retirement. (Please print) Please note: You may cover those dependents you are currently covering on each respective benefit plan during retirement. Dependents cannot be added to plans they are not currently participating in with the exception of the Humana Medicare Preferred PPO plan. Retiree Name Social Security Number Phone Number Street Address (if different than on your retirement letter) City State Zip Code Email address MEDICAL PLAN BENEFIT ELECTION (Please choose option(s) below and enter monthly rate) Humana Medicare Preferred (PPO) Group (for Medicare eligible retirees) Retiree Single (monthly rate of $296 for 2015) Retiree + Spouse (monthly rate of $592 for 2015) Enter rate for election below Humana $300 Deductible Retiree Only (monthly rate of $554 for 2015) Retiree + Spouse (monthly rate of $1,104 for 2015) Humana $2,500/$5,000 High Deductible Health Plan Retiree Only (monthly rate of $480 for 2015) Retiree + Spouse (monthly rate of $955 for 2015) I am declining participation in Xavier University Retiree Health Coverage* For myself (monthly rate of $0) For my dependent spouse (monthly rate of $0) DENTAL PLAN BENEFIT ELECTION (Please choose option(s) below and enter monthly rate) Dental Care Plus Voluntary Dental Plan Retiree Single (monthly rate of $28.18 for 2015) Retiree + Spouse (monthly rate of $54.24 for 2015) Enter rate for election below I wish to decline participation in Xavier University dental coverage For myself (monthly rate of $0) For my dependent spouse (monthly rate of $0)
VISION PLAN BENEFIT ELECTION (Please choose option(s) below and enter monthly rate) Humana Voluntary Vision Plan Retiree Single (monthly rate of $5.80 for 2015) Retiree + Spouse (monthly rate of $10.56 for 2015) Enter rate for election below I wish to decline participation in Xavier University vision coverage* For myself (monthly rate of $0) For my dependent spouse (monthly rate of $0) TOTAL MONTHLY PREMIUM DUE: Sum amounts indicated for elections above Dependent Information for medical, dental and/or vision elections made above Dependent Name/Relationship Date of birth Social Security Number Read the statement below. Then sign and date this form. This election form represents my retirement elections for calendar year 2015. Medical, dental and vision benefits and rates are subject to change at the discretion of Xavier University. I understand that I will not be able to change plans during 2015 unless I have a qualifying event during 2015. I understand if I decline one or all of the benefits plans above, I forfeit the right to these benefits at any future date. I understand that I am required to submit contribution payments on a monthly basis for the benefits elected above. If my payments are not submitted timely or during the grace period I understand that my benefits, as elected above, are subject to being terminated and are not eligible for reinstatement. Signature Date
2015 Retiree Monthly Premium Contributions Retiree Premium Monthly Rate Qualification: 1) Retired prior to 1994 your medical premium is paid 100% by Xavier 2) If not 50 years old as of 1995, you have access to coverage and pay 100% of medical premium rate 3) If 50 years old as of 1995, you will receive $135 susidy per month from Xavier (monthly premium rate - $135) 4) Retired before 12/31/94, meet requirements of age 62 with 7 years of service, you receive a subsidy of $135 a month for single coverage and $270 a month for double or family coverage $15/$40/$60 Humana NPOS Humana HDHP Humana Medicare Advantage Tier Total Premium Rates Total Premium Rates Total Premium Rates Single $554 $480 EE+ Spouse $1,104 $955 $1,049 $908 $296 $1,725 $1,493 Plan Options: NPOS and HDHP offered to retirees under age 65 NPOS and HDHP offered to retirees over age 65, Medicare is Primary (not eligible for Health Savings Account) Medicare Advantage offered to age 65+, employee/spouse enrolled as individuals, enrolled in Medicare Part B and paying premium, plan replaces Medicare and is sole coverage Humana NPOS Humana HDHP Humana Medicare Advantage Benefits In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Deductible Calendar Year/Policy Year? Calendar year Calendar year Calendar year Calendar year Calendar year Calendar year Individual/ $500/$1,000 $1,000/$2,000 $2,600/$5,200 $2,600/$5,200 None Coinsurance 90/10% 60/40% 100% 70/30% 100% 70/30% Out-of-Pocket Maximum Deductible Included? Yes Yes Yes Yes Yes Yes Copays Included? Medical Only N/A N/A N/A Medical Only Medical Only Individual/ $2,000/$4,000 $4,000/$8,000 $2,600/$5,200 $5,200/$10,400 $2,500 $5,000 Lifetime Maximum Unlimited Unlimited Unlimited Inpatient Hospital Facility Ded, 90/10% Ded, 60/40% Ded, 100% Ded, 70/30% $175 copay 30% Physician Ded, 90/10% Ded, 60/40% Ded, 100% Ded, 70/30% 100% 30% Outpatient Facility Ded, 90/10% Ded, 60/40% Ded, 100% Ded, 70/30% $50 copay 30% Physician Ded, 90/10% Ded, 60/40% Ded, 100% Ded, 70/30% 100% 30% Emergency Room $150 copay $150 copay Ded, 100% $150 copay $65 copay $150 copay Urgent Care $35 copay Ded, 60/40% Ded, 100% Ded, 70/30% $15 copay Ded, 70/30% Office Visit Primary Care Physician $20 copay Ded, 60/40% Ded, 100% Ded, 70/30% $5 copay Ded, 70/30% Specialist Physician $40 copay Ded, 60/40% Ded, 100% Ded, 70/30% $15 copay Wellness 100% Ded, 60/40% Covered in Full Ded, 70/30% Covered in Full Ded, 70/30% Prescription Drugs Out-of-Pocket Max $2,500/$5,000 N/A Ded, 100% N/A See Below* Tier 1/Tier 2/Tier 3 Mail-Order Wholesale rate less copays and less 30% Ded, 100% Ded, 70/30% $5/$30/$60/33% $30/$100/$150 Not Covered Ded, 100% Not Covered $15/$90/$180 Difference between pharmacy contracted rate and allowable rate *There is a slight change to the Rx plan for 2015 the out of pocket that triggers the catastrophic is increasing from $4,550 to $4,700, and the 30 day mail order cost sharing from catastrophic to unlimited is increasing from the greater of $2.55 for generic/multiple source drugs to the greater of $2.65 for generic/ multiple source drugs. This benefit summary is intended to describe the highlights of the plan(s). Please note that it does not include, nor does it describe all benefit exclusions. Please reference the Summary Plan Description for complete details. In the event of a discrepancy between the summaries and Summary Plan Descriptions, the terms of the Summary Plan Description will prevail.
2015 Retiree Monthly Premium Contributions Retiree Premium Monthly Rate Qualification: 1) Retired prior to 1994 your medical premium is paid 100% by Xavier Humana NPOS Humana HDHP Tier Total Premium Rates Total Premium Rates Single EE+ Spouse Humana Medicare Advantage Rate per retiree/spouse Total Premium Rates 2) If not 50 years old as of 1995, you have access to coverage and pay 100% of the medical premium rate Tier Single EE+ Spouse Humana NPOS Humana HDHP Humana Medicare Advantage Rate per retiree/spouse Total Premium Rates Total Premium Rates Total Premium Rates $554.00 $480.00 $1,104.00 $955.00 $1,049.00 $908.00 $296.00 $1,725.00 $1,493.00 3) If 50 years old as of 1995, you will receive $135 subsidy per month from Xavier Tier Humana NPOS Humana HDHP Humana Medicare Advantage Rate per retiree or spouse Total Premium Rates Total Premium Rates Total Premium Rates Single $419.00 $345.00 Retiree $161.00 EE+ Spouse $969.00 $820.00 Spouse $296.00 $914.00 $1,590.00 $773.00 $1,358.00 4) Retired before 12/31/94, meet requirements of age 62 with 7 years of service, you will receive a subsidy of $135 a month for single coverage and $270 a month for double or family coverage Tier Single EE+ Spouse Humana NPOS Humana HDHP Humana Medicare Advantage Rate per retiree/spouse Total Premium Rates Total Premium Rates Total Premium Rates $419.00 $345.00 $834.00 $685.00 $914.00 $773.00 $161.00 $1,455.00 $1,223.00
XAVIER UNIVERSITY VOLUNTARY PLAN Effective January 1 December 31, 2015 DESCRIPTION OF BENEFITS Individual Maximum per Calendar Year...$1,000 $50 Annual Individual Deductible $150 Annual Deductible on Basic and Major Benefits only Percentage Paid by Dental Care Plus Preventive Benefits...100% Basic Benefits... 60% Major Benefits...40% Orthodontic Benefits...50% + $500 Individual Lifetime Maximum + Limited to eligible dependent children under age 19 A complete description of benefits, limitations and exclusions are available in the Individual Certificate. Members must receive services from a Dental Care Plus dentist. Monthly Employee Rates Single - $28.18 Double - $54.24 - $95.56
Xavier University Humana Voluntary Vision Outline and Employee Monthly Contributions January 1, 2015 Renewal Rates Employee Only Double Benefits Exam with Dilation as Necessary Standard Plastic Lenses Single Vision Bifocal Trifocal Frames/Frame Allowance Contact Lenses Contact Lens Allowance Conventional Disposables Medically Necessary Laser Vision Correction (Lasik or PRK) Allowed Frequencies Exams Frames Lenses Contact Lenses Rate Guarantee Renewal Humana $5.80 $10.56 $16.08 In-Network Out-of-Network $20 Up to $35 $20 Up to $25 $20 Up to $40 $20 Up to $60 $50 wholesale Up to $40 retail Up to $150 Up to $150 Up to $150 Up to $150 Up to $150 Up to $150 Covered in full Up to $250 Discount N/A 12 months 24 months 12 months 12 months 2 years Please note: Members receive additional fixed copayments on lens options including: anti-reflective and scratch-resistant coatings
Change to Retiree Monthly Premium Payments Process Effective January 1, 2015 Xavier University is pleased to announce effective January 1, 2015; Chard Snyder has been selected as our new Retiree Benefits Billing Administrator. Chard Snyder s reputation is in high regard and we believe they will provide each of you with great customer service. Chard Snyder will be sending you a welcome letter containing instructions for your future premium payments. You will receive the welcome letters during December. Some highlights of the services you will receive from Chard Snyder are as follows: 24-hour internet access at www.chard-snyder.com for eligibility and payment status information. Even if you pay before the due date, you ll see that payment information. Ability to e-mail Chard Snyder or speak with a Customer Service Representative with any questions relating to your eligibility, payments, etc. The hours are 8am to 8pm, EST. You will receive payment coupons for monthly premiums. Ability to make payments online (either one time or recurring) through Chard Snyder s website or directly from your personal banking institution. The Office of Human Resources will no longer have the ability to process retiree payments for 2015 premium payments. Questions? Contact Chard Snyder at 888-993-4646.