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02/18/2021 (2)
BOARD OF COUNTY VEIL COMMISSIONERS O D IN IAN RIVER COUNTY FLORIDA O 3 COMMISSION AGENDA j. THURSDAY,FEBRUARY 18,2021 -9:00 AM Commission Chambers J LORr t'$ Indian River County Administration Complex 1801 27th Street,Building A Vero Beach,Florida,32960-3388 www.ircgov.com COUNTY COMMISSIONERS Chairman,Joseph E.Flescher,District 2 Jason E.Brown,County Administrator Vice Chairman, Peter D.O'Bryan,District 4 Dylan Reingold,County Attorney Commissioner Susan Adams,District 1 Jeffrey R.Smith,Clerk of the Circuit Court and Comptroller Commissioner Joseph H.Earman,District 3 Commissioner Laura Moss,District 5 Employee Health Clinic Workshop This meeting can be attended virtually via Zoom. Instructions can be found at the end of this agenda and also online at www.ircgov.com. 1.: CALL TO ORDER 2.A. A MOMENT OF SILENT REFLECTION FOR FIRST RESPONDERS AND MEMBERS OF THE ARMED FORCES 2.B. INVOCATION Mr.Stan Boling,Gracespring Covenant Church 3. PLEDGE OF ALLEGIANCE Commissioner Laura Moss 4. ADDITIONS/DELETIONS TO THE AGENDA/EMERGENCY ITEMS 5. DEPARTMENTAL MATTERS 5.A. Human Resources February 18,2021 Page 1 of 2 5.A.1. Health Plan and Employee Clinic Workshop Attachments:Staff Report Cocoa IRC Schools Martin County BoCC Martin County Sheriff Office Plantation Port St. Lucie St Lucie County Bocc City of Stuart 6. ADJOURNMENT Except for those matters specifically exempted under the State Statute and Local Ordinance, the Board shall provide an opportunity for public comment prior to the undertaking by theBoard of any action on the agenda, including those matters on the Consent Agenda. Public comment shall also be heard on any proposition which the Board is to take action which was either not on the Board agenda or distributed to the public prior to the commencement of the meeting. Anyone who may wish to appeal any decision which may be made at this meeting will need to ensure that a verbatim record of the proceedings is made which includes the testimony and evidence upon which the appeal will be based. Anyone who needs a special accommodation for this meeting may contact the County's Americans with Disabilities Act(ADA)Coordinator at(772)226-1223 at least 48 hours in advance of meeting. Anyone who needs special accommodation with a hearing aid for this meeting may contact the Board of County Commission Office at 772-226-1490 at least 20 hours in advance of the meeting. The full agenda is available on line at the Indian River County Website at www.ircgov.com The full agenda is also available for review in the Board of County Commission Office,the Indian River County Main Library, and the North County Library. Commission Meetings are broadcast live on Comcast Cable Channel 27 Rebroadcasts continuously with the following proposed schedule: Tuesday at 6:00p.m. until Wednesday at 6:00 a.m., Wednesday at 9:00 a.m. until 5:00 p.m., Thursday at 1:00 p.m. through Friday Morning, and Saturday at 12:00 Noon to 5:00 p.m. February 18,2021 Page 2 of 2 dn. DEPARTMENTAL MATTERS INDIAN RIVER COUNTY MEMORANDUM To: Jason Brown County Administrator From: Suzanne BoylI- Human Resources Director Date: February 12, 2020 Subject: Health Plan and Employee Clinic Workshop Background Indian River County provides employee and retiree group health insurance through a partially self-insured plan. Health insurance is available to full-time employees(budgeted at 30 hours per week or more) and eligible retirees of the Board of County Commissioners and the respective Constitutional Officers (Sheriff, Property Appraiser, Tax Collector, Clerk of Courts, and the Supervisor of Elections) to include their eligible dependents. Medical and pharmacy claims and plan administration expenses are funded from contributions made by employer and employee/retiree contributions. The health insurance plan is an essential part of the employee benefit package and important to recruitment and retention efforts. The County goal is to maintain a benefits package that is: ✓ Affordable ✓ Competitive ✓ Sustainable The current premiums and enrollment in the two plans offered through the employee health insurance program are: Enrollment Employee Employer Monthly Premium _ Premium Premium Premier Gold Employee 516 $110.00 $700.00 $810.00 Premier Gold Family 782 $400.00 $1,105.00 $1,505.00 Enrollment Employee Employer Monthly Monthly Monthly Premium Premier Silver Employee 212 $15.00 $700.00 $715.00 Premier Silver Family 165 $207.50 $1,105.00 $1,312.50 1 Recommendations for plan changes are evaluated and made with an emphasis on minimizing disruption to members and maintaining an affordable, competitive, and sustainable plan. Recent cost savings measures that have been implemented include: • Carve out of pharmacy benefit from Prime Therapeutics (BOBS) to RX Benefits (Express Scripts). Improved RX pricing and rebates. • Implementation of additional RX savings programs. o Manufacturer's coupon (SaveOn SP). $293,743 net savings in 2020. o High Dollar Claims Review. $127,552 cost avoidance in 2020. o Low Clinical Value drug exclusion. $63,825 cost avoidance in 2020. • Added the Silver Plan which is a lower premium health plan with higher deductibles, out of pocket maximums, and copays. • Increased ER copays (waived for admission)to encourage non-emergent use in more appropriate setting (urgent care). • Added Telemedicine benefit for low cost visits ($10 In-Network General Medical Copay/$20 In-Network Dermatology Copay). Other Options Explored • In 2018, Lockton marketed the health plan's administrative services. Blue Cross Blue Shield of Florida was ranked #1 and was awarded the Administrative Services Only (ASO) agreement in May 2018. • SurgeryPlus analysis of savings underway. SurgeryPlus is a supplemental benefit for non- emergent surgeries using Surgeons of Excellence Network and bundled pricing for procedures. Performance guarantee for savings. Member deductible and copays are waived. Nationwide access to network to serve all enrolled members. • Marketing of pharmacy underway to explore other Pharmacy Benefits Manager (PBM) models and possible savings. Distribution of Plan Costs Rx Claims less Rx Medical/Rx Rebates Administration 20% 6% 3s Stop Loss Premium 4% Medical Claims Net of ISL & t 70% y D Medical/Rx Administration D Stop Loss Premium ❑Medical Claims Net of ISL D Rx Claims less Rx Rebates 2 Plan Financials Executive Summary: Calendar YTD through December Historical Costs Plan Cost History YTD through December January 2020 thru January 2019 thru December 2020 December 2019 Avera'e Enrollment 1 677 1 664 Com•onent of Cost Total Current PEPM PEPM Medical Rx Administration 1 136 458 5611111110111111111 Sta. Loss Premium •.894 241 •.44 .34 Medical Claims Net of ISL ••14 180 794 •.705 •.704 Rx Claims less Rx Rebates •.4 047 052 •.201 •.246 Total 20 258 544 1 007 1 036 Year-over-Year Trend -2.8% N A Trend History YTD through December January 2020 thru December 2020 Com•onent of Cost Total Current Trend Medical Rx Administration •.1 136 458 9.4% Sto• Loss Premium •4394 241 30.7% Medical Claims Net of ISL •.14 180 794 0.1% Rx Claims less Rx Rebates .4 047 052 -18.4% Total 20 258 544 -2.8% Trend For the period January 2020 through December 2020, the plan is trending -2.8%. Significant reduction in the pharmacy spend has been realized from the prior 12-month period. Primary Cost Drivers: 1.9%of members account for 45%of plan spend High-cost claimants are members who have claims in excess of$50,000 Utilization patterns: Inpatient Admissions- 21%of total cost; (17%decrease from year prior) Emergency Room -6%of total costs (8% increase over year prior) The most costly conditions by spend: Multiple Sclerosis, Ulcerative Colitis/Crohn's, Breast and Gynecological Cancers, End Stage Renal Disease 3 At the June 16, 2020 Board of County Commissioners meeting, the Board directed staff to bring back a proposal related to employee health clinics via a workshop. In preparation for this workshop, Human Resources staff surveyed other public employers as noted below: Agency Response Clinic Cocoa Y y IRC Schools Y Y Martin County SO Y Y Martin County BOCC Y Y Plantation y Y Port St. Lucie Y Y St. Lucie County BOCC y y Stuart Y Y Palm Bay Y Closed Fellsmere y N Vero Beach y N Sebastian Y N Brevard County BOCC Y N Melbourne Y N Brevard County Unable to Schools respond Collier County BOCC No Response Below is some general information noted from the survey responses. The actual responses are attached. • 16 employers surveyed and 14 responses. • 8 employers surveyed have clinics. • 1 employer closed their clinic after determining it was not cost effective. • Consultants were utilized to guide the clinic evaluation and vendor selection process. • Start-up costs can vary. • Annual recurring costs range from $500K to $2.7M (2 locations) and include general medical and limited pharmacy. Smaller city's clinic cost was approximately $250K per year. • Zero copay for employees to utilize the clinic and obtain certain medications. Employers with a clinic perceive it as a valuable benefit for employees. • Clinic staffing models vary based on services provided, equipment, locations, and hours of operation. • Marketing campaigns and incentives for using the clinic and encouraging wellness are typically utilized. • Oversight of clinic, administration, wellness strategies, and billing reconciliation involve consultant and employer staffing in coordination with clinic vendor and providers. At the workshop, the opportunity for additional review and discussion regarding an Employee Health Clinic will be provided. 4 7 c 0 £ v N 0 Y ° L - C w t>oo , .c L L O 5 2 .L„ ° 'C u O N o 4 N E w V OOi 7, E o O p ...V u OC G 7 0 o MW C L - ra -0 c w • a'CL rt: o .o o L- w 0. 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A , 0..,,, s. . .... \,,_________, \•_‘,..,_ Pr- YfLOREDA ........- Employee Benefit Highlights 2020 .... 2021 SERVING OUR COMMUNITY WITH P.R.I.D.EI7 • 1 City of Cocoa I Employee Benefit Highlights 12020-2021 \v Table of Contents Contact Information 1 Introduction 2 Online Benefit Enrollment 2 Group Insurance Eligibility 3-4 Qualifying Events and Section 125 .4 , Benefit Offset 5 i Married Credit 5 I Opt-Out t Benefit 5 j Default Benefits for the Dental and Vision Plans 5 Employee Health Center 5-6 j Medical Insurance 7 Other Available Plan Resources 7 l t--,------_,N\ , Omada 7 i ' ITelehealth .7 „...... .: /1 Cigna Core Plan At-A-Glance 8 ______/ Dental Insurance 9 Cigna Dental PPO Plan At-A-Glance 10 Vision Insurance 11 _'''\ i EyeMed Vision Care Plan At-A-Glance .12 Flexible Spending Accounts 13-14 Basic Life and AD&D Insurance 15 r� r 77--- -- Employee Assistance Program 15 Voluntary Life Insurance 16 P Voluntary Short Term Disability 17 1 ,, Long Term Disability 18 / Voluntary Supplemental Insurance 19 Legal&Identity Theft Plan 20 Deferred Compensation 457(b) 21 Notes .22-24 This booklet is merely a summary of benefits.For a full description,refer to the plan document.Where conflict exists between this summary and the plan document,the plan document controls. The City reserves the right to amend,modify or terminate the plan at any time.This booklet should not be construed as aem uarantee of employment. 9 P 8 ©2016,Gehring Group,Inc.,All Rights Reserved Q.::i' City of Cocoa I Employee Benefit Highlights 12020-2021 Contact Information Phone:(321)433-8440 Human Resources Division Email:humanresources@cocoafl.org SO Claims,Billing&Benefit Assistance Phone:(800)244-3696 cocoa@gehringgroup.com El Online Benefit Enrollment Bentek Support (888)5-Bentek(523-6835) www.mybentek.com/cityofcocoa Medical Insurance Cigna Customer Service:(800)244-6224 Group#3339016 www.mycigna.com 4,11 Prescription Drug Coverage Customer Service:(800)285 4812 &MailOrder Program Cigna Home Delivery www.mycigna.com IV Dental Insurance Cigna Customer Service:(800)244-6224 Group#3339026 www.mycigna.com 0 Vision Insurance EyeMed Customer Service:(866)939-3633 Group#1018011 www.eyemed.com INE Employee Health Center CareATC Customer Service:(800)993-8244 www.careatc.com ES FSA Administrator TASC Customer Service:(800)422-4661 www.tasconline.com Cigna Basic Life and AD&D Insurance Life Policy#FLX964922 Customer Service:(800)732-1603 E•1 AD&D#0K966531 www.mycigna.com Voluntary Life Insurance Cigna Customer Service:(800)732-1603 Policy#FLX964922 www.mycigna.com Voluntary Short Term Disability Cigna Customer Service:(800)732-1603 411,1 Insurance Policy#VDT961221 www.mycigna.com Long Term Disability Insurance Cigna Customer Service:(800)732-1603 Policy#LK963434 www.mycigna.com aEmployee Assistance Program Cigna Behavioral Health Customer Service:(877)622-4327 www.mycigna.com • Voluntary Supplemental Insurance Aflac Customer Service:(800)433-3036 www.aflacgroupinsurance.com Voluntary Legal& U.S.Legal Services Agent:Dixie Kuehn Identity Protection Plans Phone:(321)403-0156 1 Email:dixiekuehn@cfl.rr.com Nationwide Retirement Solutions Customer Service:(877)677-3678 i Policy#0041011001 www.nrsforu.com Voluntary 457 Retirement Plan ICMA Retirement Corporation Customer Service:(800)669-7400 Policy#10-7736 www.icmarc.org 9 1 ©2016,Gehring Group,Inc.,All Rights Reserved 1-- ) City of Cocoa I Employee Benefit Highlights 12020-2021 . ..:,,� At, Online Benefit Enrollment a zfrj'� The City provides employees with an online benefits enrollment ,, ), e platform through Bentek's Employee Benefits Center(EBC).The EBC dik provides benefit-eligible employees the ability to select or change , ,.. insurance benefits online during the annual Open Enrollment Period, '\ New Hire Orientation,or for Qualifying Life Events. --.-s Accessible 24 hours a day,throughout the year, employee may log in and review comprehensive information regarding benefit plans, and view and print an outline of benefit elections for employee and Introduction dependent(s).Employee also has access to important forms and carrier links,can report qualifying life events and review and make changes to The City of Cocoa provides group insurance benefits to eligible employees. Life insurance beneficiary designations. The Employee Benefit Highlights Booklet provides a general summary of the benefit options as a convenient reference. Please refer to the City of Cocoa Personnel Policies and/or Certificates of Coverage for detailed descriptions of m all available employee benefit programs and stipulations therein.If employee Q ®0 requires further explanation or needs assistance regarding claims processing, ® OO please refer to the customer service phone numbers under each benefit o "o ® — _ -- ° e description heading or contact the Human Resources Division for further p p „ ® • o® gi information. To Access the Employee Benefits Center: ✓ Log on to www.mybentek.com/cityofcocoa ✓ Sign in using a previously created username and password or click"Create an Account"to set up a usemame and password. ✓ If employee has forgotten username and/or password,click on the link"Forgot Username/Password"and follow the instructions. ✓ Once logged on, navigate using the Launchpad to review current enrollment,learn about benefit options,and make any benefit changes or update beneficiary designations. For technical issues directly related to using the EBC, please call (888) 5-Bentek (523-6835) or email Bentek Support at support@mybentek.com, Monday through Friday, during regular business hours,8:30am-5:00pm. To access Employee Benefits Center online,log on to: www.mybentek.com/cityofcocoa Please Note:Link must be addressed exactly as written.Due to security reasons, the website cannot be accessed by Google or other search engines. 10 2 ©2016,Gehring Group,Inc.,All Rights Reserved • I� . City of Cocoa I Employee Benefit Highlights 12020-2021 •0.1 Group Insurance Eligibility oc,0B. The City's grout m5urance clan year 15 Dependent Age Requirements(Continued) 111 October I through Se +.ember 30. Dental Coverage:A dependent child may be covered through end of calendar year in which child turns age 26. Please note:Deductible and annual maximums are January 1 to December 31. Vision Coverage:A dependent child may be covered through end of calendar year in which child turns age 26. Employee Eligibility Employees are eligible to participate in the City's insurance plans if they are full- Disabled Dependents time employees working a minimum of 30 hours per week.Coverage will be Coverage for an unmarried dependent child may be continued beyond age 26 if: effective the 1st of the month following 60 days of employment. For example,if an employee is hired on April11,then the effective date of coveragewill be July 1. • The dependent is physically or mentally disabled and incapable of self-sustaining employment(prior to age 26);and Separation of Employment • Primarily dependent upon the employee for support;and If employee separates employment from the City, insurance will continue • The dependent is otherwise eligible for coverage under the group through the end of month in which separation occurred.COBRA continuation medical plan;and of coverage may be available as applicable by law. • The dependent has been continuously insured Proof of disability will be required upon request.Please contact the Human Dependent Eligibility Resources Division if further clarification is needed. A dependent is defined as the legal spouse and/or dependent child(ren)of the participant or spouse.The term"child"includes any of the following: Taxable Dependents • A natural child A legally adopted child Employee covering adult child(ren) under employee's insurance plan may continue to have the related coverage premiums payroll deducted on a pre-tax • A stepchild basis through the end of the calendar year in which dependent child reaches • A newborn child(up to the age of 18 months)of a covered age 26.Beginning January 1 of the calendar year in which dependent child dependent(Florida) reaches age 27 through the end of the calendar year in which the dependent • A child for whom legal guardianship has been awarded to the child reaches age 30, imputed income must be reported on the employee's participant or the participant's spouse W-2 for that entire tax year and will be subject to all applicable Federal,Social -. - - ; Security and Medicare taxes.Imputed income is the dollar value of insurance coverage attributable to covering each adult dependent child.The imputed Dependent Age Requirements income value per pay period for coverage an overage dependent under the Medical Coverage:A dependent child may be covered through the City's medical plan for the period of October 1,2020—September 30,2021 is end of the calendar year in which the child turns age 26. An over- as follows: age dependent may continue to be covered on the medical plan to Imputed Income Value the end of the calendar year in which the child reaches age 30,if the ' 24 Bi Weekly Deductions Per Pay Period Cost dependent meets the following requirements: Plan Income Value • Unmarried with no dependents;and i Cigna Core Plan S25030 • A Florida resident,or full-time or part-time student;and — -- • Otherwise uninsured;and Note:There is no imputed income if an adult dependent child is eligible to be claimed • Not entitled to Medicare benefits under Title XVIII of the • as a dependent for Federal income tax purposes on the employee's tax return.Overage Social Security Act,unless the child is disabled. Dependent Affidavit must be completed and turned into the Human Resources Division. Please see Taxable Dependents if covering eligible over age dependents. This form can be found in Bentek.Contact the Human Resources Division for further details if covering an adult dependent child who will turn age 17 any time during the upcoming calendar year or for more information. 11 3 0 2016,Gehring Group,Inc.,All Rights Reserved City of Cocoa I Employee Benefit Highlights 12020-2021 Group Insurance Eligibilityibilit (Continued) Qualifying Events and Section 125 Please remember the following:In order to enroll or cover dependent(s)on the Section 125 of the Internal Revenue Code City's medical plan,the employee is required to provide documentation verifying the eligibility of such dependents to the Human Resources Division. Premiums for medical, dental, vision insurance, and/or certain supplemental policies and contributions to Flexible Spending Accounts (FSA) are deducted Dependent Relationship Documentation Required through a Cafeteria Plan established under Section 125 of the Internal Revenue Code and are pre-taxed to the extent permitted.Under Section 125,changes to • Official MarriageCertificate AND employee's pre-tax benefits can be made ONLY during the Open Enrollment periodSpouse ___ • SSNforACA purposes(Affordable Care Act) unless the employee or qualified dependent(s)experience(s)a Qualifying Event and • State issued birth certificate(s)OR legal the request to make a change is made within 30 days of the Qualifying Event guardianship court documents,listing the Child(ren)Under Age 26 employee or spouse as parent/legal guardian Under certain circumstances, employee may be allowed to make changes to AND benefit elections during the plan year,if the event affects the employee,spouse • SSNfor ACA purposes(Affordable Care Act) or dependent's coverage eligibility.An"eligible"Qualifying Event is determined by Section 125 of the Internal Revenue Code.Anyrequested changes must be • AND theappropriate de endent child q Step-Child(ren)UnderA e26 p g documentation listed above consistent with and due to the Qualifying Event. Child(ren)under Legal • AND court documents of the legal Examples of Qualifying Events: Guardianship or Custody Under Age 26 guardianship OR legal custody • Employee gets married or divorced Child(ren)adopted arinthe • AND court documents of the legal adoption • Birth of a child process of adoption Under showing relationship to and placement in • Employee gains legal custody or adopts a child Age 26 the employee's house OR adoption certificate • Employee's spouse and/or other dependent(s)die(s) g issued through the courts • Loss or gain of coverage due to employee, employee's spouse and/or I • ANDState issued Birth Certificate(s)of dependent(s)terminate or start of employment child(ren)stating child was borntoaninsured . An increase or decrease in employee's work hours causes eligibility or ineligibility Grandchild(ren)OR other dependent child ofemployee or spouse OR • A covered dependent no longer meets eligibility criteria for coverage children not related • Legal Guardianship/Custody/Document from • A child gains or loses coverage with an other parent or legal guardian the courts listing the employee or spouse as • Change of coverage under an employer's plan parent/legal guardian AND • Gain or loss of Medicare coverage • SSNfor ACA purposes(Affordable Care Act) • Losing or becoming eligible for coverage under a State Medicaid or CHIP Child(ren)Age 26-30 • AND Overage Dependent Affidavit signed by (including Florida Kid Care)program(60 day notification period) employee IMPORTANT All documentation must be either the original document or a notarized/ If employee experiences a Qualifying Event the Human Resources Division must be certified copy of original document.Please note the Human Resources Division contacted within 30 days of the Qualifying Event to make the appropriate changes will need to view the original documents and will make copies for employer to employee's coverage.Beyond 30 days,requests will be denied and employee may files. be responsible,both legally and financially,for any claim and/or expense incurred as a result of employee or dependent who continues to be enrolled but no longer meets Any person who knowingly and with intent to injure, defraud, or deceive eligibility requirements.If approved,changes are effective on the first of the month any insurer,files a statement of claim,or an application containing any false, following the Qualifying Event or date written request for change in coverage is incomplete,or misleading information iis guilty of a felony of a third degree. received by the Human Resources Division.Newborns are effective on the date of birth and marriage is effective on the date of occurrence.Cancellations will be processed at the end of the month.In the event of death,coverage terminates the date following the death.Employee may be required to furnish valid documentation supporting a change in status or"Qualifying Event" 12 4 02016,Gehring Group,Inc.,All Rights Reserved vs • City of Cocoa I Employee Benefit Highlights 12020-2021 Benefit Offset The City of Cocoa provides$100 per benefit payroll period to General Employees.The Benefit Off-Set will be used to help offset the cost of employee's benefits and any remaining funds will be put towards a City sponsored 457 Deferred Compensation benefit.With exception of FMLA or Military leave,employees on a continuous leave of absence without pay in excess of 30 days will not be eligible for this benefit. Married Credit Married couples who both work for the City of Cocoa and are eligible for City benefits are also eligible for the Married Credit.The Married Credit is an opportunity for married employees and dependent(s)to enroll in benefits under one(1)of the married employee's names for family coverage at no cost to either employee.This means that one of the two married employees may enroll with family coverage for medical,dental,and vision insurance at no cost.The other employee must opt-out of all benefits and also enroll for coverage under the employed spouse.The employee,who is opting out of all insurance plans,is not eligible for the opt-out benefit(see below).The employee who is enrolling all family members is required to enroll in the Core Plans available. Opt-Out Benefit Default Benefits for the Dental If eligible employee is covered by another medical plan,and meets certain and Vision Plans criteria as outlined below,the employee and eligible dependents have the opportunity to participate in the City's Employee Health Center.In the event Benefit-eligible employees will automatically be enrolled in employee only the employee opts-out of participating in the City's group medical plan and coverage for medical, dental and vision benefits, unless a different tier of declines participation in the Employee Health Center,the City will share a coverage is selected.Changes to default benefits will not be permitted until portion of monthly premium(an"Opt-out benefit").The amount of the Opt- the next applicable Open Enrollment period unless employee experiences a out benefit may vary from year to year. qualifying family status change(Qualifying Event). For the plan year 2020-2021,the Opt-out benefit available is$100 per month. This benefit is paid in the employee's last check of each month,and is available to benefit-eligible employees covered under another qualified minimum value, minimum essential group or governmental insurance plan as described below. This option must be renewed each year,is not available to non benefit-eligible employees, and is considered taxable income to the employee. Employees receiving the"Married Credit"are not eligible for the Opt-out benefit. As a result of recent legislative guidance,employee must provide proof that the employee,and all of employee's"tax dependents*"have enrolled or will enroll in"qualifying**"minimum value,minimum essential coverage(other than an individual insurance policy)for the plan year.A health coverage opt-out credit form must be completed and returned to the Human Resources Division with proof of coverage.This form can be found in Bentek. *A "tax dependent"includes any person for whom the employee reasonably intends to claim a personal exemption on the employee's tax return during the tax year(s)that begins or ends during the City's medical insurance plan year.The City's medical plan year is October 1,2020-September 30,2021. **"Qualifying"coverage may could include Medicare,Medicaid,TRICARK,student health insurance,or a spouse's employer's group health plan providing minimum value. 13 5 0 2016,Gehring Group,Inc.,All Rights Reserved City of Cocoa I Employee Benefit Highlights I 2020-2021 oo 00 • Employee Health Center City of Cocoa Employee Health Center How to Use the Employee Health Center: The Employee Health Center(EHC)is available to employees,retirees, • Call CareATC at 800-993-8244 to obtain a username and password COBRA participants and eligible dependents enrolled in the City's for each participating member. medical insurance plan at no additional cost.If a benefit-eligible employee • Go to www.careatc.com and click Client Login. is covered by another medical plan,the employee and eligible dependents • Enter username and password to access the secure User Menu. may utilize City's Employee Health Center. • Schedule an appointment, view Personal Health Assessment, or • The EHC is also available to non benefit-eligible employees,along edit personal data. with eligible dependent(s), for a pre-tax monthly deduction of • Access CareATC's mobile website from any smartphone or download $100.Please contact the Human Resources Division for more details. the app from the iPhone® or Android°" with just a tap! Visit a Employees who are not on the medical plan will have an opportunity to utilize smartphone's app store and search for CareATC®to conveniently the EHC per the options above at Open Enrollment only;mid-year changes will access medical history and schedule appointments. not be permitted. Hours of operation are listed below.Appointments are REQUIRED;however, same day appointments may be accommodated based on availability and/or The EHC provides the care employee and dependent(s) need for all non- severity of issue. emergency illnesses.Schedule an appointment with the medical staff to learn more about the Employee Health Center. Cocoa Health Center Hours of Operation The EHC is administered by CareATC,a third-party vendor.Utilization is entirely Monday 7:30am-1130 am,1:00pm-5:00pm voluntary.All visits with Employee Health Center staff are completely confidential and no personal information is shared with the City. Tuesday 8:00 a.m. 12:00 p.m. Wednesday 8:00 a.m.-12:00 p.m.,1:30 p.m.-5:30 p.m. Why choose the Employee Health Center? Thursday 8:00 a.m. 12:00 p.m. ✓ Full range of primary care services available • Online scheduling with dedicated 15-minute appointments Friday J 7:30 a.m. 4:30 p.m. ✓ 100%confidential and HIPAA compliant The hours listed above are subject to change based on usage.The City What can be treated at the Employee Health Center? will notifyemployees ofany changes. ✓ Cold&Flu,Sore Throat ✓ Physicals City of Cocoa(Employee Health Center ✓ Labs&Medications ✓ Hypertension 128 Lemon Street,Cocoa,FL 32922 ✓ Injections ✓ Cholesterol Phone:(800)993-8244 I patients.careatc.com • Minor Procedures V Diabetes V Completion of Personal ✓ Tobacco Cessation Satellite Beach Health Center Hours of Operation Health Assessment(PHA) Monday1:00 p.m:5:00 p.m. — -- - - *Certain medications are also available at the EHC at no cost;please schedule an Tuesday p.m.-5:00 p.m. appointment with a physician for more information. l - Wednesday —1 8:OOa.m.-12:OOp.m. Hourly employees who utilize the EHC will also have up to six(6)visits each [-Thursday j 8:OOa.m.-12:00p.m. fiscal year without using leave hours. The hours listed above are subject to change based on usage.The City will notify employees of any changes. City of Satellite Beach I Employee Health Center 1087 S.Patrick Dr.,Satellite Beach,FL 32937 (Located in the DRS Community Center complex) Phone:(800)993-82441 patients.careatc.com 14 6 02016,Gehring Group,Inc.,All Rights Reserved �.. City of Cocoa I Employee Benefit Highlights 12020-2021 Medical Insurance Summary of Benefits and Coverage The City offers medical insurance through Cigna to benefit-eligible employees. A Summary of Benefits&Coverage(SBC)for the Medical Plan is provided as a The costs per pay period for coverage are listed in the premium table below supplement to this booklet being distributed to new hires and existing employees and a brief summary of benefits is provided on the following page.For more during Open Enrollment.The summary is an important item in understanding employee's benefit options.A free paper copy of the SBC document may be requested detailed information about the medical plans,please refer to Cigna's Summary or is also available as follows: of Benefits and Coverage(SBC)document or contact Cigna's customer service. From: Human Resources Division Medical Insurance—Cigna Core Plan Address: 65 Stone Street 24 Bi-Weekly Deductions-Per Pay Period Cost Cocoa,FL 32922 Tier of Coverage Employee Cost Phone: (321)433-8440 Email: humanresources@cocoafl.org Employee OnlyJ $0 -- Website URL: www.mybentek.com/dtyofcocoa Employee+One f $167.33 Employee+Family $328.36 The SBC is only a summary of the plan's coverage.A copy of the plan document,policy, or certificate of coverage should be consulted to determine the governing contractual provisions of the coverage.A copy of the group certificate of coverage can be reviewed and obtained by contacting the Human Resources Division or www.cocoafl.org. Dependents Age 26-30 If covering an overage dependent(a dependent child who will reach age 27-30 If there are any questions about the plan offerings or coverage options,please contact during the year),please refer to the"Taxable Dependents"section on page 3 as the Human Resources Division at(321)433-8440. employee may be subject to additional income tax. Please note:Rates are based on the plan year October 1 to September 30. Telehealth elehealth However,deductibles and annual maximums are January 1 to December 31. Cigna provides access to two(2)telehealth services as part of the medical plan at no cost to members.AmWell and MDLIVE are convenient phone and video Cigna I Customer Service:(800)244-6224 I www.mycigna.com consultation companies that provide immediate medical assistance for many conditions. Other Available Plan Resources The benefit is provided to all enrolled members.Registration is suggested and Cigna offers all enrolled employees and dependents additional services should be completed prior to using services.This program allows members 24 and discounts through value added programs. For more details regarding hours a day,seven(7)days a week on-demand access to affordable medical other available plan resources, please contact Cigna's customer service at care via phone and online video consultations when needing immediate care (800)244-6224,or visit www.mycigna.com. for non-emergency medical issues.Telehealth should be considered when employee's primary care doctor is unavailable, after-hours or on holidays MotivateMe and Omada for non-emergency needs. Many urgent care ailments can be treated with telehealth,such as: Cigna's MotivateMe program is offered through the City of Cocoa and allows V Sore Throat V Fever V Rash members to earn incentive points and rewarded with a Wellness Day Off. V Headache V Cold And Flu V Acne Employees can earn up to 300 incentive points when certain healthy activities V Stomachache V Allergies V UTIs And More are completed.For more details visit www.mycigna.com. Telehealth doctors do not replace employee's primary care physician but Members who have been diagnosed with pre diabetes and qualify may may be a convenient alternative for urgent care and ER visits. For further participate in Omada. Omada is a personalized lifestyle program designed information please contact Cigna. to help members make gradual changes, in eating, exercise, sleep and managing stress.This program is available at no additional cost to benefit- Cigna eligible employees and covered dependents. For more details, please visit AmWell I Customer Service:(855)667-9722 I www.AmWellforCigna.com omadahealth.com/cocoafl. MDLIVE I Customer Service:(888)726-3171 I www.MDLIVEforCigna.com 15 7 02016,Gehring Group,Inc,All Rights Reserved City of Cocoa I Employee Benefit Highlights I 2020-2021ErLIF1 Cigna Core Plan At-A-Glance Network Open Access Plus Calendar Year Deductible(CYD) In-Network [Single ______________,_ _�_ $2,000 Family $6,000 Coinsurance _ Locate a Provider Member Responsibility 20% 1To search for a participating provider, Calendar Year Out-of-Pocket Limit contact Cigna's customer service or visit f www.mycigna.com.When completing I Single $6,000 the necessary search criteria,select Family J $12,000 Open Access Plus network. f What Applies to the Out-of-Pocket Limit? Coinsurance,Deductible,Copays,and Rx Physician Services I . 0 Primary Care Physician(PCP)through Employee Health Center __j No Charge Primary Care Physician(PCP)Office Visit(No PCP Election Required) $25 Copay I Specialist Office Visit(No ReferralRequired) _ $50 Copay Plan References [Telehealth Services No Charge *La6CorporQuest Diagnostics are the Non-Hospital Services;Freestanding Facility preferred labs for bloodwork through Cigna.When using a lab other than 1 Clinical Lab(bloodwork)through Employee Health Center No Charge LabCorp or Quest please confirm they Clinical Lab(Bloodwork)* No Charge are contracted with agna's Open Access Plus network prior to receiving services. f X-rays _J No Charge Advanced Imaging(MRI,PET CT)-Per Scan,Per Day $100 Copay LOutpatient Surgery in Surgical Center 20%After CYD Physician Services at Surgical Center 1 20%After CYD . 0L t Urgent Care(Per Visit) , $50 Copay - - Important Notes Hospital Services Services received by providers or Inpatient Hospital(Per Admission) - 20%After CYD facilities not in the Open Access Plus [Outpatient Hospital(Per Visit) 20%After CYD network,will not be covered. Physician Services at Hospital 20%After CYD {Emergency Room(Per Visit;Waived if Admitted) $250 Copay Mental Health/Alcohol&Substance Abuse Inpatient Hospital Services(Per Admission) 20%After CYD I Outpatient Services(Per Visit) .1 No Charge Outpatient Office Visit � $50 Copay Prescription Drugs(Rx) Ge eric through Employee Health Center _I No Charge t- r iGeneric —] $20 Copay Preferred Brand Name $40 Copay Non-Preferred Brand Name $70 Copay I Mail Order Drug(90-Day Supply) __ _ - i 2x Retail Copay 16 8 ©2016,Gehring Group,Inc.,All Rights Reserved • City of Cocoa I Employee Benefit Highlights 12020-2021 Dental Insurance Cigna Dental PPO Plan The City offers dental insurance through Cigna to benefit-eligible employees. Out-of-Network Benefits The costs per pay period for coverage are listed in the premium table below Out-of-network benefits are used when member receives services by a non- and a brief summary of benefits is provided on the following page.For more participating Cigna Total DPPO provider. Cigna reimburses out-of-network detailed information about the dental plan, please refer to the carrier's services based on what it determines as the Maximum Reimbursable Charge summary plan document or contact Cigna's customer service. (MRC).The MRC is defined as the most common charge for a particular dental procedure performed in a specific geographic area.If services are received from Dental Insurance—Cigna Dental PPO Plan an out-of-network dentist,the member may be responsible for balance billing. 24 Bi-Weekly Deductions-Per Pay Period Cost Balance billing is the difference between Cigna's MRC and the amount charged Tier of Coverage Employee Cost by the out-of-network dental provider.Balance billing is in addition to any Employee Only $0 - applicable plan deductible or coinsurance responsibility. $ Employee+One $11.40 Calendar Year Deductible Employee+Family ' $18.46 The Dental PPO plan requires a$25 individual or a$50 family deductible to be met for in-network or out-of-network services before most benefits will begin. Default Benefits The deductible is waived for preventive services. Benefit-eligible employees will automatically be enrolled in employee.only Calendar Year Benefit Maximum dental coverage, unless a different tier of coverage is selected. Changes The maximum benefit(coinsurance)the Dental PPO plan will pay for each to default benefits will not be permitted until the next applicable Open covered member is $1,500 for in-network and out-of-network services Enrollment period unless employee experiences a qualifying family status combined.All services,including preventive,accumulate towards the benefit change(Qualifying Event). maximum. Once the plan's benefit maximum is met,the member will be In-Network Benefits responsible for future charges until next calendar year. The Dental PPO plan provides benefits for services received from in-network Cigna I Customer Service:(800)244-62241 www.mycigna.com and out-of-network providers. It is also an open-access plan which allows for services to be received from any dental provider without having to select a Primary Dental Provider(PDP)or obtain a referral to a specialist.The network of participating dental providers the plan utilizes is the Cigna Total DPPO.These participating dental providers have contractually agreed to accept Cigna's contracted fee or"allowed amount:'This fee is the maximum amount a Cigna dental provider can charge a member for a service.The member is responsible for a Calendar Year Deductible(CYD)and then coinsurance based on the plan's charge limitations. Please Note: Total DPPO dental members have the option to utilize a dentist that participates in either Cigna's Advantage network or DPPO network.However,members that use the Cigna Advantage network will see additional cost savings from the added discount that is allowed for using an Advantage network provider. Members are responsible for verifying whether the treating dentist is an Advantage Dentist or a DPPO Dentist. 17 9 ©2016,Gehring Group,Inc.,All Rights Reserved City of Cocoa I Employee Benefit Highlights 12020-20210 Cigna Dental PPO Plan At-A-Glance q Network Total Cigna DPPO Calendar Year Deductible(CYD) In-Network Out-of-Network* Locate a Provider Per Member 1 $25 To search for a participating provider, contact Cigna's customer service or visit Per Family $50 www.mycigna.com.When completing EWaived for Class I Services? Yes the necessary search criteria,select - Total Cigna DPPO or Advantage Calendar Year Benefit Maximum network. Per Member $1,500 Class I Services:Diagnostic&Preventive Care , 0 1 Routine Oral Exam(2 Per Calendar Year) 1 [Routine Cleanings(2 Per Calendar Year) i Plan Pays:100% Plan Pays:100% Plan References DeducObleWaived Deductible Waived •CompleteX-rays(Per 36 Months) (Subjearo8alanceBilling) Out-Of-Network Balance Billing: [Bitewing X-rays(2 Sets Per Calendar Year) For information regarding out-of- _ network balance billing that may be Class II Services:Basic Restorative Care charged by an out-of-network provider, please refer to the Out-of-Network Fillings Benefits section on the previous page. Simple Extractions [Endodontics(Root Canal Therapy) _1 Plan Pays:80%After CYD Oral Surgery Plan Pays:80%After CYD j Billing) (Subject to Balance Billin) ^Periodontal Services [Anesthetics — Important Notes •Each covered family member may Class III Services:Major Restorative Care receive up to two(2)routine cleanings per calendar year covered under the LCrowns • _Bridges Plan Pays:50%After CYD Plan Pays:50%After CYD preventive benefit __ – -- — — --— (Subject to Balance Billing) •For any dental work expected to cost 1 Dentures $200 or more,the plan will provide a "Pre-Determination of Benefits"upon Class IV Services:Orthodontia the request of the dental provider. • [Lifetime Maximum $2,000 This will assist with determining approximate out-of-pocket costs { Plan Pays:50% should employee have the dental work Benefit(Dependent Children and Adults) Plan Pays:50% (Subject to Balance Billing) performed. Deductible Waived DeductibleWaived �_ J •Waiting periods and age limitations may apply. •Benefit frequency limitations may apply to certain services. 18 10 ©2016,Gehring Group,Inc.,All Rights Reserved City of Cocoa I Employee Benefit Highlights 12020-2021 Vision Insurance EyeMed Vision Care Plan The City offers vision insurance through EyeMed to benefit-eligible employees. Out-of-Network Benefits The costs per pay period for coverage are listed in the premium table below Employee and covered dependent(s) may choose to receive services from and a brief summary of benefits is provided on the following page. For vision providers who do not participate in the EyeMed Insight network. more detailed information about the vision plan,please refer to the carrier's When going out of network,the provider will require payment at the time of summary plan document or contact EyeMed's customer service. appointment.EyeMed will then reimburse based on the plan's out-of-network reimbursement schedule upon receipt of proof of services rendered. Vision Insurance—EyeMed Vision Care Plan 24 Bi-Weekly Deductions-Per Pay Period Cost Calendar Year Deductible Tier of Coverage 1 Employee Cost There is no calendar year deductible. Employee only $0 Calendar Year Out-of-Pocket Maximum Employee+Family $237 There is no out-of-pocket maximum.However,there are benefit reimbursement maximums for certain services. Default Benefits Benefit-eligible employees will automatically be enrolled in employee EyeMed Customer Servicer(866)939 3633 www.eyemed.com only vision coverage,unless a different tier of coverage is selected.Changes to default benefits will not be permitted until the next applicable Open Enrollment period unless employee experiences a qualifying family status change(Qualifying Event). In-Network Benefits The vision plan offers employee and covered dependent(s)coverage for routine eye care,including eye exams,eyeglasses(lenses and frames)or contact lenses. To schedule an appointment,employees and covered dependent(s)may select any network provider who participates in the EyeMed Insight network.At the time of service,routine vision examinations and basic optical needs will be covered as shown on the plan's schedule of benefits.Cosmetic services and upgrades will be additional if chosen at the time of the appointment. 19 11 ©2016,Gehring Group,Inc.,All Rights Reserved City of Cocoa I Employee Benefit Highlights 12020-2021 (e)) EyeMed Vision Care Plan At-A-Glance Network Insight Services In-Network Out-of-Network Eye Exam No Charge Up to$40 Reimbursement - - - - Locate a Provider Frequency of Services To search fora participating provider, Examination 12 Months contact EyeMed's customer service or visit www.eyemed.com.When Lenses 12 Months completing the necessary search criteria,select Insight network. Frames 24 Months Contact Lenses 12 Months Lenses 0 Single No Charge Up to$30 Reimbursement Bifocal - No Charge Up to$50 Reimbursement Plan References t Trifocal No Charge Up to$7O Reimbursement *Contact lenses are in lieu of spectacle lenses. i Frames J Allowance Up to$150 Plus 20%Off Balance over$150 Up to$105 Reimbursement [[[[ Contact Lenses* 0 1 Non-Elective(Medically Necessary) No Charge Up to$210 Reimbursement _ Important Notes Up to$150 Allowance Plus 15%Off Conventional Up to$150 Reimbursement •Member options,such as LASIK,UV Balance over$150 coating,progressive lenses,etc.are not Elective(Fitting,Follow-up&Lenses) I - - - P ro 9 Up to$150 Allowance Plus Balance covered in full,but maybe available at iDisposable over$150 Up to$150 Reimbursement a discount. •Members receive additional fixed copayments on lens options including anti-reflective&scratch-resistant coatings. •Aftercopay,standard polycarbonate available at no charge for dependents less than 19 years old. 20 ©2016,Gehring Group,Inc.,All Rights Reserved 12 FSA•s City of Cocoa I Employee Benefit Highlights 12020-2021 Flexible Spending Accounts The City offers Flexible Spending Accounts(FSA)administered through TASC.The FSA plan year is from October"!to September 30. If employee or family member(s)has predictable health care or work-related day care expenses,then employee may benefit from participating in an FSA.An FSA allows employee to set aside money from employee's paycheck for reimbursement of health care and day care expenses they regularly pay.The amount set aside is not taxed and is automatically deducted from employee's paycheck and deposited into the FSA.During the year,employee has access to this account for reimbursement of some expenses not covered by insurance.Participation in an FSA allows for substantial tax savings and an increase in spending power.Participating employee must re-elect the dollar amount to be deducted each plan year.There are two(2)types of FSAs: Health Care FSA Dependent Care FSA This account allows participant to set aside up to an This account allows participant to set aside up to an annual maximum of$5,000 if annual maximum of $2,750. This money will not be single or married and file a joint tax return ($2,500 if married and file a separate taxable income to the participant and can be used to tax return)for work-related day care expenses.Qualified expenses include day care offset the cost of a wide variety of eligible medical j centers,preschool,and before/after school care for eligible children and adults. expenses that generate out-of-pocket costs.Participating employee can also receive reimbursement for expenses Please note,if family income is over$20,000,this reimbursement option will likely related to dental and vision care(that are not classified i save participants more money than the dependent day care tax credit taken on a tax as cosmetic). return.To qualify,dependents must be: • A child under the age of 13,or Examples of common expenses that qualify for reimbursement are listed below. • A child, spouse or other dependent who is physically or mentally incapable of self-care and spends at least eight(8) hours a day in the • participant's household. Please Note:The entire Health Care FSA election is available for use on Please Note:Unlike the Health Care FSA,reimbursement is only up to the amount that has been deducted the first day coverage is effective. from participants paycheck for the Dependent Care FSA. A sample list of qualified expenses eligible for reimbursement include,but not limited to,the following: ✓ Prescription/Over-the-Counter Medications ✓ Physician Fees and Office Visits ✓ LASIK Surgery ✓ Menstrual Products ✓ Drug Addiction/Alcoholism Treatment ✓ Mental Health Care ✓ Ambulance Service ✓ Experimental Medical Treatment ✓ Nursing Services ✓ Chiropractic Care ✓ Corrective Eyeglasses and Contact Lenses ✓ Optometrist Fees ✓ Dental and Orthodontic Fees ✓ Hearing Aids and Exams ✓ Sunscreen SPF 15 or Greater ✓ Diagnostic Tests/Health Screenings ✓ Injections and Vaccinations ✓ Wheelchairs Log on to http'/www.irs.gov/publications/p502/index.html for additional details regarding qualified and non-qualified expenses. 21 13 ©2016,Gehring Group,Inc.,All Rights Reserved mummi City of Cocoa I Employee Benefit Highlights 12020-2021 FF"A A. Flexible Spending Accounts (Continued) FSA Guidelines • Employee may carry over up to $550 of unused Health Care FSA HERE'S HOW IT WORKS!, funds into the next plan year after a plan year ends and all claims have been filed (only if the employee re-enrolls the next year). Employee earning $30,000 elects to place $1,000 into a Health Dependent Care funds cannot be carried over. Care FSA.The payroll deduction is$41.66 based on a 24 pay period • The Health Care FSA has a run out period at the end of the plan year schedule.As a result,health care expenses are paid with tax-free (90 days)to submit reimbursement on eligible expenses incurred dollars,giving the employee a tax savings of$227. during the period of coverage within the plan year(October 1 to September 30). • Dependent Care FSA allows a grace period at the end of the plan witna Withouta year (75 days).The grace period allows additional time to incur 1 Health Care FSA Health Care FSA claims and use any unused funds on eligible expenses after the Salary $30,000 $30,000 plan year ends.Once the grace period ends,any unused funds still FSA Contribution -$1,000 -$0 remaining in the account will be forfeited. , j Taxable Pay $29,000 $30,000 • When a plan year ends and all claims have been filed with the Estimated Tax $6,568 $6,795 exception of the$550 rollover for the Health Care FSA,all unused 22.65%=15%+7.65%FICA funds will be forfeited and not returned. Atter Tax Expenses -$0 -$1,000 • Employee can enroll in either or both of the FSAs only during the Spendable Income $22,432 $22,205 Open Enrollment period,a Qualifying Event,or New Hire Eligibility Tax Savings period. -- • Money cannot be transferred between FSAs. • Reimbursed expenses cannot be deducted for income tax purposes. • Employee and dependent(s)cannot be reimbursed for services not Please Note:Be conservative when estimating health care and/or dependent care received. expenses. IRS regulations state that any unused funds remaining in an ESA,after a plan year ends and after all claims have been filed cannot be returned or carried • Employee and dependent(s)cannot receive insurance benefits or forward to the next plan year with the exception of the$550 carry over that may be any other compensation for expenses reimbursed through an FSA. allowed for the Health Care FSA.This rule is known as"use-it or lose-it." • Domestic Partners are not eligible as federal law does not recognize them as a qualified dependent. Filing a Claim TASC I Phone:(800)422-4661 I Claims Fax:(608)663-2754 www.tasconline.com Claim Form:A completed claim form along with a copy of the receipt as proof of the expense can be submitted by mail or fax.The IRS requires FSA participants to maintain complete documentation,including copies of receipts for reimbursed expenses,for a minimum of one(1)year. Debit Card: FSA participants will automatically receive a debit card for payment of eligible expenses. With the card, most qualified services and products can be paid at the point of sale versus paying out-of-pocket and requesting reimbursement.The debit card is accepted at a number of medical providers and facilities,and most pharmacy retail outlets.TASC may request supporting documentation for expenses paid with a debit card. Failure to provide supporting documentation when requested,may result in suspension of the card and account until funds are substantiated or refunded back to the City.Please keep the issued card for use next year.Additional or replacement cards may be requested,however,a small fee may apply. 1 22 14 ©2016,Gehring Group,Inc.,All Rights Reserved • • Ian City of Cocoa I Employee Benefit Highlights I 2020-2021 Employee Assistance Program Basic Life and AD&D Insurance The City cares about the well-being of all employees on and off the job and Basic Term Life Insurance provides, at no cost, a comprehensive Employee Assistance Program (EAP) The City provides Basic Term Life insurance for all eligible employees at no cost, through Cigna Behavioral Health. EAP offers employee and each family member access to licensed mental health professionals through a confidential through Cigna.The coverage amount will be determined by the following: program protected by State and Federal laws. EAP is available to help • Class I(Mayors)—Flat benefit amount of$50,000 employee gain a better understanding of problems that affect them, locate • Class 2(Full-Time Employees)—One(1)time base annual salary,up the best professional help for a particular problem,and decide upon a plan of to a maximum of$100,000* action.EAP counselors are professionally trained and certified in their fields • Class 3(Retirees)—Flat benefit amount of$10,000 and available 24 hours a day,seven(7)days a week. • Class 4(Executives) —Two (2) times base annual salary, up to a What is an Employee Assistance Program(EAP)? maximum of$200,000* An Employee AssistanceProgra m offers covered employees and fam ily members *lf salary increases or decreases mid plan year,Life benefit amount will adjust at free and convenient access to a range of confidential and professional services start of next plan year. to help address a variety of problems that may negatively affect employee or Accidental Death&Dismemberment Insurance family member's well-being. Coverage includes five (5) face-to-face, visits with a specialist,per person,per issue per year,telephonic consultation,online Also, at no cost to employee, the City provides Accidental Death & material/tools and webinars.EAP offers counseling services on issues such as: Dismemberment(AD&D)insurance,which pays in addition to the Basic Term Life benefit when death occurs as a result of an accident.The AD&D benefit ✓ Child Care Resources ✓ Work Related Issues amount equalsthe Basic Term Life benefit,partial benefits may also be payable. ✓ Legal Resources ✓ Adult&Elder Care Assistance ✓ Grief and Bereavement ✓ Financial Resources Age Reduction Schedule ✓ Stress Management ✓ Family and/or Marriage Issues Benefit amounts are subject to the following age reduction schedule: ✓ Depression and Anxiety V Substance Abuse Reduces to 65%of the benefit amount at age 65 Are Services Confidential? > Reduces to 50%of the benefit amount at age 70 Yes. Receipt of EAP services are completely confidential. If, however, > Reduces to 35%of the benefit amount at age 75 participation in the EAP is the direct result of a Management Referral (a Waiver of Premium Provision referral initiated by a supervisor or manager), we will ask permission to communicate certain aspects of the employee's care(attendance at sessions, In the event employee becomes disabled,employee may waive the premium adherence to treatment plans,etc.)to the referring supervisor/manager.The for Life insurance.The waiver of premium provision applies to both the Basic referring supervisor/manager will not receive specific information regarding and Voluntary coverages and also applies to coverages for the employee, the referred employee's case.The supervisor/manager will only receive reports spouse and dependent(s).There is a waiting period of six(6)months from the on whether the referred employee is complying with the prescribed treatment date that the employee's active service ends.The waiver of premium ends at plan. age 70. To Access Services Always remember to keep beneficiary information Employee and family member(s) must register and create a user ID on updated.Beneficiary information may be updated www.mycigna.com to access EAP services. at anytime through Bentek. Cigna Behavioral Health I Customer Service:(877)622-4327 Cigna I Customer Service:(800)732-1603 I www.mycigna.com www.mycigna.com 23 15 ©2016,Gehring Group,Inc.,AD Rights Reserved City of Cocoa I Employee Benefit Highlights 12020-2021 • • Voluntary Life Insurance Voluntary Employee Life and AD&D Insurance Voluntary Spouse Life and AD&D Insurance Eligible employee may elect to purchase additional Life and AD&D Insurance on a voluntary basis through Cigna. This coverage may be purchased in New Hires may purchase Voluntary Spouse Life insurance without addition to the Basic Term Life and AD&D coverages.Voluntary Life insurance being subject to Medical Underwriting,also known as Evidence offers coverage for employee,spouse or child(ren)at different benefit levels. of Insurability(E01),up to the Guaranteed Issue amount of. $30,000 if the spouse is under age 70. New Hires may purchase Voluntary Employee Life insurance without being subject to Medical Underwriting,also known as Evidence of •. Employee must participate in Voluntary Employee Life plan for Insurability(E01),up to the Guaranteed Issue amount of the spouse to participate. lesser of three times annual salary or$250,000 if employee is • Units can be purchased in increments of$10;000 up to,not to under age 65. exceed a maximum of$50,000,however coverage cannot exceed Please Note:This does not include the Basic Life amount. 50%of the employee's Voluntary Life coverage amount. • Spouse coverage terms on 70th birthdate. • Spouse Life coverage is$0.294 per$1,000 of coverage elected per • Units can be purchased in multiples of employee's annual salary month. (rounded up to the nearest$1,000),but cannot exceed the lesser • Spouse AD&D coverage is$0.04 per$1,000 of coverage elected per of three(3)times annual salary or$300,000;the guaranteed issue month. amount is$250,000*. • Benefit amounts are subject to the following age reduction Dependent Child(ren)Life Insurance schedule: • Employee must participate in the Voluntary Employee Life plan for Reduces to 65%of the benefit amount at age 65 dependent child(ren)to participate. Reduces to 50%of the benefit amount at age 70 • For children who are less than six(6) months old there is a$500 Reduces to 35%of the benefit amount at age 75 benefit amount. • Coverage is$0.254 per$1,000 of coverage elected per month. • For children six(6) months to 19 years(up to 23 years of age,if unmarried and a full-time student) there is a $10,000 benefit • AD&D coverage is$0.04 per$1,000 of coverage elected per month. amount. *If salary increases or decreases mid plan year,Life benefit amount will adjust at • Coverage is$0.184 per$1,000 for any eligible dependent child(ren) start of next plan year. enrolled. Voluntary Family Benefit • Voluntary Dependent Child Life coverage does NOT include AD&D coverage. • Employee must participate in the Voluntary Employee Life plan for family to participate. Please Note:Employees may choose either the Voluntary Family Life benefit or the separate Spouse and/or Dependent Child(ren)Life benefit,but not both. • For legal spouses under the age of 70,there is a$5,000 benefit amount. Cigna I Customer Service:(800)732-1603 I www.mycigna.com • For children 14 days to 19 years(up to 23 years of age,if unmarried and a full-time student)there is a$5,000 benefit amount. • Coverage is a family rate of$1.37 per family unit per month. Please Note:Employees may choose either the Voluntary Family Life benefit or the separate Spouse and/or Dependent Child(ren)Life benefit,but not both. 24 ©2016,Gehring Group,Inc.,All Rights Reserved 16 City of Cocoa I Employee Benefit Highlights 12020-2021 Voluntary Short Term Disability The City offers Voluntary Short Term Disability(STD)insurance to all eligible employees through Cigna.The STD benefit pays employee a percentage of the weekly earnings if employee becomes disabled due to an illness or non-work related injury(Workers Compensation will apply to work-related injury or illness). Voluntary Short Term Disability(STD)Benefits STD Insurance Rates • STD provides a benefit of 60%of employee's weekly earnings up to Monthly Rates per$10 of Weekly Benefit are listed below. a benefit maximum of$1,000 per week. Age Bracket (Based On Employee Age) Insurance Rate • Employee must be disabled for seven(7)consecutive days prior to becoming eligible for benefits(known as the elimination period). <45 $0.276 The elimination period is waived for accidents. 45-49 $0322 • Benefits will begin on the 1st day after the employee is disabled due 50-54 $0.368 to non-work related injury or illness. t 55-59 $0.488 • The maximum benefit period is 13 weeks. 60-64 $0598 • Employee deemed unable to return to work after the STD 13 week 65-69 $0.681 maximum period is exhausted,may be transitioned to Long Term r io-7a $0.745 Disability(LTD). L -- >75 50.809 • Benefit may be reduced by other income. - • • Disability benefits are taxable. • STD insurance coordinates with the City's Sick leave benefits and is reduced by any amount payable to employee from other sources of income such as sick leave,sick leave bank,administrative leave, temporary duty elsewhere and social security. Employee may not receive more than 100%total of all combined income.Please check the City's current leave policy. Calculation for Weekly Disability Benefit $ - 52 = X 60% Enter annual Weekly (Max%of income Max Eligible Amount.Round to nearest dollar. earnings earnings covered) This amount cannot exceed$1,000 Calculation for Cost per Paycheck $ - 10 = $ X $ _ $ X 12 = $ =24 = $ Max Eligible Amount Rate Your Monthly Cost Annual Cost Cost Per Paycheck Cigna ICustomer Service:(800)732-1603 I File a Claim:(800)362-4462 I www.mycigna.com 25 17 ©2016,Gehring Group,Inc.,All Rights Reserved City of Cocoa I Employee Benefit Highlights 12020-2021 Long Term Disability The City provides Long Term Disability(LTD)insurance at no cost to all eligible employees through Cigna.The LTD benefit pays a percentage of monthly earnings if employee becomes disabled due to an illness or non-work related injury. Long Term Disability(LTD)Benefits • LTD provides a benefit of 60%of employee's monthly earnings up to • LTD benefits will be offset with other income such as Social Security, a benefit maximum of$6,000 per month. Workers'Compensation,and retirement benefits,etc. • Employee must be disabled for.90 consecutive days prior to • LTD insurance coordinates with the City's sick leave benefits and is becoming eligible for benefits(known as the elimination period). reduced by any amount payable to employee from other sources • Benefit payments will commence on the 91st day of disability. of income such as sick leave, sick leave bank, administrative • Employee may continue to be eligible for partial benefits if leave, temporary duty elsewhere, social security and Workers' employee returns to work on a part-time basis. Compensation.Employee may not receive more than 100%total of • The LTD maximum benefit period is determined based on age at the all combined income.Please check the City's current leave policy. time of disability. Cigna I Customer Service:(800)732-1603 I File a Claim:(800)362-4462 I www.mycigna.com 26 18 ©2016,Gehring Group,Inc.,All Rights Reserved City of Cocoa I Employee Benefit Highlights 12020-2021 Voluntary Supplemental lementalInsurance Aflac offers a variety of voluntary supplemental insurance plans that may be purchased separately on a voluntary basis and premiums are paid by payroll deduction. During Open Enrollment for the 2020-2021 plan year Aflac will provide information on the following group supplemental products that provide cash benefits when employee or covered family member(s)become sick or injured. ✓ Accident Indemnity Plan ✓ Specified Critical Illness Plans(including Cancer,Stroke,and Heart Attack) ✓ Hospital Indemnity Plan 2020-2021 Aflac 24 Bi-Weekly Premium Deductions Pre Tax Payroll Deductions Employee Employee+ Employee+ Plan Coverage Age Family Only Spouse Child(ren) • Accident Indemnity Plan 24-Hour coverage on and off the job.Wellness 18+ $9.59 $14.43 $16.79 $21.63 $50 per covered person per calendar year payable after 12-months of coverage. Hospital Indemnity Inpatient, outpatient benefits, and physician 18-64 $27.74 $54.09 $48.54 $74.89 visits. • IAfter Tax Payroll Deductions 1 Specified Critical Illness Age $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 Employee Uni-Rate 18-29 $5.96 $8.66 $11.36 $14.06 $16.76 $19.46 $22.16 $24.86 $27.56 $20K EE Guaranteed Issued including Cancer. 30-39 $5.96 $8.66 $11.36 $14.06 $16.76 $19.46 $22.16 $24.86 $27.56 Dependent child(ren) is automatically covered 40-49 $1136 $16.76 $22.16 $27.56 $32.96 $38.36 $43.76 $49.16 $54.56 @25%of the primary insured amount.Wellness 50-54 $16.45 $24.28 $32.10 $39.93 $47.75 $55.58 $63.40 $71.23 $79.05 $50 per covered EE&spouse annually after 30- 55-59 $22.05 $32.68 $43.30 $53.93 $64.55 $75.18 $85.80 $96.43 $107.05 days of coverage. 60-64 $30.55 $45.43 $60.30 $75.18 $90.05 $104.93 $119.80 $134.68 $149.55 65-69 $33.25 $49.48 $65.70 $81.93 $98.15 $114.38 $130.60 $146.83 $163.05 After Tax Payroll Deductions -� Specified Critical Illness Age $5,000 $7,500 $10,000 $12,500 $15,000 $17,500 $20,000 $22,500 $25,000 Spouse Uni-Rate } 18-29 $3.26 $4.61 $5.96 $7.31 $8.66 $10.01 $11.36 $12.71 $14.06 i 30-39 $3.26 $4.61 $5.96 $731 $8.66 $10.01 $11.36 $12.71 $14.06 $10KSpouse Guaranteed Issued including Cancer. 40-49 $5.96 $8.66 $11.36 $14.06 $16.76 $19.46 $22.16 $24.86 $27.56 Wellness$50 per covered EE&spouse annually 50-54 $8.63 $12.54 $16.45 $2036 $24.28 $28.19 $32.10 $36.01 $39.93 after 30-days of coverage. 55-59 $11.43 $16.74 $22.05 $2736 $32.68 $37.99 $43.30 $48.61 $53.93 60-64 $15.68 $23.11 $30.55 $37.99 $45.43 $52.86 $60.30 $67.74 $75.18 65-69 $17.03 $25.14 $33.25 $41.36 $49.48 $57.59 $65.70 $73.81 $81.93 • Aflac I Customer Service:(800)433-3036 1 www.aflac.com Agent:Margaret Pearson I Phone:(561)881-19641 Email:margaret_pearson@us.aflac.com 27 19 ©2016,Gehring Group,Inc.,All Rights Reserved Ark. City of Cocoa I Employee Benefit Highlights 12020-2021 Legal & Identity Theft Plan Premium Schedule:24 Bi-Weekly Premium Deductions Identity Defender Family Defender Plan j $9.38 U.S.Legal Services offers an identity benefit that protects you and your family Identity Defender $4.98 against Identity Theft.With the Identity Defender Plan,your family can fight back against stolen identity and can restore your good credit and your stolen Family Defender Legal Plan funds. Certified Protection Experts available to assist with identity theft matters 24/7.Experts complete all paperwork and make all calls to ensure your The City offers employees the opportunity to participate in a voluntary legal identity is restored.Members have access to an online dashboard and mobile insurance program provided by the U.S. Legal Services. By enrolling in this app for continuous monitoring and alerts.Covered identity services include, plan,participants will have direct access to attorneys who will provide legal but are not limited to: assistance 24 hours a day,seven(7)days a week for a variety of situations that include: • Advanced Fraud Monitoring • Change of Address Monitoring V Divorce V Criminal Defense . Credit&Debit Card Monitoring V Adoption V Traffic Tickets • Dark Web Monitoring* V Civil Litigation V Wills&Living Trusts . Fraud Alert Reminders V Child Custody and V Real Estate • Medical ID Fraud Protection Support V Credit Report Issues • Smart SSN Tracker* V Bankruptcy V Contract Review • Lost Wallet V Name Changes • Stolen Funds Reimbursement The cost to the employee to participate in this legal plan is $18.75 per • month.This includes coverage for the entire household including a spouse IdentityTheft Insurance($1 million)* and dependent children up to age 26 regardless of the number of eligible • Identity Restoration* dependents enrolled in the plan. Plan benefits include unlimited access to • Credit Monitoring an online document library,unlimited telephone consultations,face-to-face • Mobile App consultations with attorneys,review of legal documents,letters/phone calls • Two Adults&Unlimited Dependent Children Covered** to third parties on the participant's behalf and much more.To learn about *Covered for dependents underChildWatch the plan,contact the City's U.S.Legal Services representative,Dixie Kuehn,at **Dependents must be under 26 years old and live in the policy holder's residence. (321)799-2986 or email at dixiekuehn@cfl.rr.com. U.S.Legal Services Agent:Dixie Kuehn I Phone:(321)403-0156 Email:dixiekuehn@cfl.rr.com www.uslegalservices.net 28 20 0 2016,Gehring Group,Inc.,AD Rights Reserved 410. City of Cocoa I Employee Benefit Highlights 12020-2021 Deferred Compensation 457(b) The City offers a voluntary 457 Deferred Compensation retirement savings There are strict Internal Revenue Code limits to the amount an employee plan through either the International City Management Association (ICMA) may contribute each year.There are two(2)"Catch-Up"provisions that allow or Nationwide*.A 457 plan is a supplemental retirement savings program employee to contribute over-and-above the normal annual contribution that allows employee to make contributions on a pre-tax basis.Federal,and amount.However,employee will pay taxes on the amount withdrawn and are in most cases,State income taxes(Florida does not have a State income tax) required to begin withdrawing from the account by a certain age. are deferred until assets are withdrawn, usually during retirement when employee may be in a lower tax bracket.A summary of the 457 plan's benefits *Nationwide and ICMA offer loans under certain circumstances.See plan representative for more details. are provided below. • Employee can reduce current income taxes while investing for **Since dollar cost averaging involves continuous investing,regardless of fluctuating prices,investors must consider their level of comfort in continuing to invest during a retirement. declining market.Dollar cost averaging does not assure profit or protect against loss in • Employee earnings accumulate tax-deferred. a declining market. • Employee can dollar cost average** through convenient payroll deductions. Nationwide Retirement Solutions • Employee may be allowed to make additional'catch-up"contributions Customer Service:(877)677-3678 I www.nrsforu.com if employee is 50(or older)or within three(3)years of normal retirement age and already contributing the maximum to the plan. ICMA Retirement Corporation • If there is a job change,employee has the flexibility to move account Customer Service:(800)669-7400 I www.icmarc.org into employee's new Employer's retirement plan. • If employee retires early,but at least at the age of 591/2,there is no penalty for withdrawals. 457 Plans Advantages Include: • Ability to increase, decrease, stop and restart contributions as employee wishes without fees or penalties. • Choose from a wide range of investment options selected by employer for the plan. There are no restrictions or charges for reallocating investment mix within a reasonable limit and all funds offered are no-load. • There are no minimum investment requirements. • Employee's designated beneficiaries are entitled to receive all remaining funds in employee's account in the event of death(Less any applicable taxes and/or penalties). • Flexible withdrawal payment options are available. Employee can determine the payment schedule that is right for them. • 29 21 ©2016,Gehring Group,Inc.,All Rights Reserved City of Cocoa I Employee Benefit Highlights 12020-2021 Notes • Use this section to make notes regarding.personal benefit plans or to keep track of important information such as doctor's names and addresses or prescription medications • • • • • 30 ©2016,Gehring Group,Inc.,All Rights Reserved 22 City of Cocoa I Employee Benefit Highlights 12020-2021 Notes Use this section to make notes regarding personal benefit plans or to keep track of important information such as doctor's names and addresses or prescription medications. 31 23 0 2016,Gehring Group,Inc.,All Rights Reserved City of Cocoa I Employee Benefit Highlights 12020-2021 Notes Use this section to make notes regarding personal benefit plans or to keep track of important information such as doctor's names and addresses or prescription medications. 32 ©2016,Gehring Group,Inc.,All Rights Reserved 24 ..-„, ; ......., , -1,144\‘ ai (014, a vo.)._, A Irt - , 44 ,s,yd rrGE H RI NG® i, . GROU P EMPLOYEE BENEFITS I RISK MANAGEMENT 4200 Northcorp Parkway,Suite 185 Palm Beach Gardens,Florida 33410 Toll Free:(800)244-3696 1 Fax:(561)626-6970 www.gehringgroup.com 33 FINAL ©2016,Gehring Group,Inc.,All Rights Reserved Last Modified:August 5,2020158 PM n , a - c 3 c aa m > m u v cm E 3 a ° ° ° c C I c C n , C ✓ d o wL a o a y ctIa a c aE c a m a u aE ° v a t1 v -a t ° o t c w r u `;'.:F= t t c a .A13 .' z a m N g 8 $ >« - m m 'm ,_ a o m 0 3 a O 3 o a 3 a a s $ L 11. 1 N 6.L. 2a m a 2 t3 C « u O yy� a `u T30. c E 3 4, -,-.; S , 3 N i v a v y c a c E 9 3 « q a u °1 3 a v .9 a 3 c A c -5= .26-1' Y E E t La. a x °' -o c o v t t v c H .2 a • > - a e 3 m o Op• p a C a t r o s o L 'o a 3 a ° 002 ,,T; a 2 ,9E0 - , °' O a• 3 c L a c N ~ N Ito n c « x ° t ao c r ° 3u ° E in � o 8 c 'c mL c c arj 3 at > cm LC CO E to.ao 0 oa � = mp u e E y w v a .� 2- 14 a c s ; E ,';1 :1), t u > c m c . - a 'o• n d o 3 e a - E a a s 4,313 _ ; = 8 B 2 t 9 ; m c o > > 2m a s O G Ot .c M w O m N > m a D a m a a ` �. ` `c L° - o - d a v` c n c o 2 = > w a t4 t c " a o a i 4 v v o a > ? a a „ .c...... .2 a m m t « z o L?"_ c c L M V a 'L' E IC o a > m °' E _ E o A a m q o a c a OC m t' 10 w m i 3 c a ' m o a = 4 3 .2 « « "-' f' c5 B W. > q . 0 - a t c5 TO m c v " a .u .°-: m8 8 '.=. 01 O O 3 y 2 '.. 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School District of Indian River County Weilcome to your Dstrllct E3enet EroODmeM & iocte Our Commitment to You The School District of Indian River County (the "District") is committed to providing our employees with a benefits program that is both comprehensive and competitive. Our benefits program offers health care, dental and vision coverage,as well as products that help to provide income protection in an emergency. This guide provides a general overview of your benefit choices and enrollment information to help you select the coverage that's right for you. As a new hire and at Open Enrollment, we ask you to make benefit elections for you and your family so that you will be financially prepared for any health and life challenges you may face. Here are two easy steps you can follow to do just that: 1. Review the Benefit Guide. This guide provides highlights of your benefits, points out what is new and tells you where to get more information. 2. Consider your needs and those of your covered dependents. Life changes and so do your healthcare needs. Check to be sure your dependents are eligible for coverage and make sure their Social Security numbers and your beneficiary designations are up-to-date. What's in the Guide? 3 What's Changing This Year? 4-5 Open Enrollment 6-7 Benefit Program Participation 8-9 Eligibility and Leave 10-11 Qualifying Events & Benefit Termination 12-13 How to Enroll 14-15 Medical and Pharmacy/Opt-Out Medical Option 17 Employee Wellness Center. 18 Employee Assistance Program 19 Flexible Spending Accounts 20 Dental 21 Vision 22-23 Life Insurance 24-25 Disability » 26-27 Accident/Critical Illness/Cancer Plans 28 Legal and Identity Theft Protections 29 Retirement : " J•" ' • t:. 30 Important Contacts 31-42 Legal Notices s , 2 What's New This Year? There are several important changes this year. Please be sure to read this entire Benefit Guide thoroughly to ensure you understand these changes. This will be a MANDATORY Open Enrollment. • All employees must enroll this year. • You must complete the enrollment process even if you choose not to elect benefits. • Previous benefit choices for Medical, FSA, Dental, Vision and Legal will NOT automatically carry over. • Previous elections will expire on September 30, 2020 and new elections will begin on October 1, 2020. • New enrollment elections begin with the new plan year that begins on October 1, 2020 and ends September 30, 2021. • The Open Enrollment period begins August 17, 2020 and ends on August 31, 2020 at 5:00pm EST. • Verification must be provided for all NEW dependents who will be covered. Please see page 5 for additional information. • In order to receive the annual opt-out credit you must actively decline medical coverage and provide proof of coverage in the form of your current medical ID card or a letter from the employer confirming your active coverage. Please see page 5 for additional information. • Voluntary Additional Life Insurance— The Standard Insurance Company is offering a one-time opportunity to purchase or increase coverage without a proof of health form , up to the new Guarantee Issue amount of$200,000 for employees and $50,000 for spouses. Please see pages 5, 22 and 23 for additional details. 38 3 Open Enrollment Open Enrollment begins August 17, 2020 and ends on August 31, 2020 at 5:00pm EST. How do I enroll? Review this entire Enrollment Guidebefore beginning the enrollment process.A convenient Enrollment Preparation Worksheet can be found at the back of this guide. Complete the worksheet as you review the Guide to help prepare you for the open enrollment process. To start the enrollment process,go on-line to register at www.sdirc-benefits.com. If you have not logged into the online portal since last year,you will need to re-register.To start the enrollment process,go to www.sdirc-benefits.com and click"Log into your benefits system." "Create New Log in" using your social security number and birth year(see page 12). Open Enrollment begins on August 17, 2020 and ends on August 31, 2020 at 5:00pm EST. No changes can be made after Open enrollment ends on August 31,2020. Open Enrollment is not complete until you print a copy of the CONFIRMATION sheet. Be sure to click"submit" at the end of the enrollment process and note your confirmation number. If you do not receive a confirmation number you have not completed your enrollment and you will not be enrolled in benefits. Be sure you print a hard copy of your new benefits summary to confirm that you have completed the process. You will want a copy of the new benefits summary to compare to your payroll deductions to ensure that the deduction amounts are correct. Benefits cannot be changed after August 31st except for qualifying events (see page 10). Confirm your payroll deductions with the first pay period of the new plan year,October 15, 2020, (or when newly hired)to ensure they are correct. Payroll corrections must be requested in writing by sending an email to sdircbenefits@indianriverschools.org. Payroll corrections must be made within 30 days of the first pay period (by November 15, 2020). Newly hired?Or did you transfer positions or enter a job share position? Eligibility criteria can be found on page 8 of this Guidebook. Enrollment must be completed within 30 days of eligibility. The on-line Open Enrollment platform is managed by"Explain My Benefit" (EMB). Need Open Enrollment Assistance? Open Enrollment can be completed through the online self-enroll system. If you would like additional assistance with the online self-enroll system or prefer to enroll over the phone you can contact The Open Enrollment.Assistance Service Center by calling 1-800-505-8416 (see below for hours). Open Enrollment Assistance is available: • August 17th through August 31st 9:OOam-7:OOpm Eastern Time, Monday through Friday This will be a MANDATORY Open Enrollment ALL employees must enroll this year. You must complete the enrollment process even if you choose not to elect benefits. 39 4 Adding Dependents to your coverage? If you are adding any NEW dependents to your coverage, effective October 1, 2020,you will be required to provide documentation proving the dependent's eligibility. To enroll any new dependents the system will require you to enter their basic demographic information such as:full name,date of birth, social security number and address. In addition to their basic demographic information you will be required to provide documentation as described below: Dependent Type of Documentation Needed Spouse Marriage Certificate and current tax return to show filing as married Child (Under the age of 26) Birth Certificate Child (Age 26-30) Proof of college admission/enrollment or current college schedule These documents must be uploaded to the EMB Enroll Document Management tool in the online enrollment system, prior to August 31, 2020 at 5:00pm EST. Please Note: Documents can not be submitted through the Benefits Department, however documents can be uploaded by logging into the EMB Mobile APP— Photos can be taken using your smart phone and then uploaded, under enrollment(please see page 12). Opting-Out of Medical Insurance? • The District offers an annual flex spending amount of $480 to any employee who actively opts-out of medical coverage during open enrollment. • If you choose to decline the District's medical coverage and opt-out during Open Enrollment, the District will deposit$20.00 per pay period into your flex spending account, beginning October 1, 2020. • In order to be eligible you MUST elect "OPT-OUT" during Open Enrollment and you MUST show proof of other coverage to receive this credit. • The system will require you to upload proof of other coverage, which could be a letter from the employer stating you have active coverage OR your current active insurance card. • If you are a late hire or leave the district early the $480 credit will be prorated based on the time you are with the District during the plan year. Interested in Adding or Increasing your Voluntary Additional Life Insurance? • The Standard Life Insurance is offering an one time Opportunity to Increase Coverage without Proof of Health. • During this year's Open Enrollment coverage, may be increased up the Guarantee Issue amount for employees and dependents. This offer applies to employees and dependents not currently enrolled. It also applies to employees and dependents who are enrolled for less than the Guarantee Issue amount. • Guarantee Issue amounts have been enhanced this year to $200,000 for employees and $50,000 for spouses. • Adding or increasing your Voluntary Additional Life Insurance is ONLY available during Open Enrollment from, August 17, 2020 through August 31, 2020. If you do not elect now, all future increases in coverage will be subject to proof of good health unless you are a new hire applying during your initial period of eligibility. 40 5 Benefit Program Participation: Employee Responsibilities and Agreement Please be aware that when an employee participates in the SDIRC's benefit programs, they agree to the following statements: • Employees are responsible for participating in and completing the online internet enrollment on their own as a new employee or during each Open Enrollment period. • Employees are responsible for carefully reviewing their demographic information to confirm that the information in the system is correct. • Employees are responsible for thoroughly reviewing their choices during their online enrollment and prior to submitting their elections. • Employees are responsible for entering and reviewing all dependent data, including the dependents' dates of birth and their Social Security information within the established enrollment time frames. • Employees are responsible for submitting applicable benefit changes within 30 days of qualifying events. • Employees are responsible for maintaining their personal information, such as keeping their address and phone number current. - • Employees are responsible for providing required documentation within 30 days of coverage to satisfy the eligibility criteria for all enrolled dependents. Otherwise, dependent coverage will be canceled. • Employees are responsible for identifying and updating their life insurance beneficiaries. • Employees are responsible for reviewing their paycheck stub when their benefits become effective in order to verify their enrollment election deductions are correct for the benefits elected. • Employees are responsible for notifying the Benefits Department immediately (within 30 calendar days of the effective date of benefits) if payroll deductions are incorrect and do not correctly reflect the benefit elections made. • Employees are responsible for participating in the Open Enrollment process annually. • Employees are responsible for notifying the Employee Benefits Department immediately (within 30 days) when a covered dependent no longer meets the eligibility requirements as defined under the Dependent Eligibility section. 41 6 Benefit Program Participation: Affirmations Please be aware that when an employee participates in SDIRC's benefit programs, the employee is automatically making the following affirmations: • Employee authorizes SDIRC to deduct payroll premiums for employee benefit elections and employee authorizes the deduction of any missed premiums not deducted from payroll for any reason. Employee acknowledges that employee will be responsible for any and all premiums, deductibles and copays that may apply. • Employee certifies that the information provided on the Explain My Benefits (EMB) enrollment portal is true and correct to the best of employee's knowledge. • Employee acknowledges that employee cannot stop or change benefits paid on a pre-tax basis during the plan year unless employee experiences a Qualifying Event or during the Open Enrollment period. • Employee agrees that SDIRC and its third party administrator are not responsible for employee's failure to read or understand all rules or regulations pertaining to benefits enrollment, nor employee's failure to enroll online accurately or to submit timely elections. • Employee agrees for employee and covered members of employee's family under District insurance plan(s) to be bound by the benefits, deductibles, copayments, exclusions, limitations, eligibility requirements and other terms of the plan contracts, agreements or plan documents for the plan(s) in which employee enrolls. • Employee agrees that they are exclusively responsible for and assume the risks associated with the choice of plan option(s) and covered dependents, selected by the employee, and agrees neither SDIRC or its representatives, employees, agents or insurers are responsible for choosing or providing advice on the plan options available for employee and employee's family. • Employee agrees that employee is responsible for reading, understanding, and asking questions regarding benefits, exclusions and limitations for each plan. Failure to adequately review employee plan options will not be a valid reason for a coverage change once Open Enrollment or New Hire Enrollment concludes. Changes cannot be made once enrollment period closes. 42 7 Eligibility All employees of the School District of Indian River County are considered eligible for benefits if they work 30 hours or more per week. Eligibility is determined at the time of hire, or when you transfer positions,or if you enter a job share position. If you are not sure of your eligibility status, please contact the benefits department by email at sdircbenefits@indianriverschools.org. New Hire Enrollment must be completed within 30 days of the employee's start date. Please see the enrollment instructions found on page 12 and 13 in this Guide. Effective Dates The Open Enrollment effective date of the benefits is based on the Plan Year which is October 1st through September 30th. The effective date of benefits for a newly hired employee is the first of the month,following one full calendar month of continuous active employment. For example, if the hire date is January 5th, then benefits will become effective March 1st.This is also true if you transfer positions or if you enter a job share position. New Hire Enrollment must be completed within 30 days of new hire date. Enrollment is not completed until you click"submit"to confirm and print a copy of the CONFIRMATION sheet. Be sure you print a hard copy of your new benefits summary to compare to your payroll deductions to ensure that the deduction amounts are correct. Please Note: Printing your confirmation will not confirm your enrollment,you must click"submit"to confirm. Dependent Eligibility You can enroll your dependents in plans that offer dependent coverage. Eligible dependents are defined as your legal spouse and eligible children who reside in your household and depend primarily on you for support. This includes:your own children, legally adopted children,stepchildren, a child for whom you have been appointed legal guardian, and/or a child for whom the court has issued a Qualified Medical Child Support Order(QMCSO) requiring you or your spouse to provide coverage.Age limits vary depending on coverage, so be sure to check each benefit. In order to cover dependents under District benefits,you will be required to upload documentation proving their eligibility under each plan. Please see page 5 for a list of required documents. Medical Plan Dependent Coverage Under the Affordable Care Act,you can cover your children under the District's medical plan until the end of the month in which they reach age 26 regardless of full-time student status, marital status or place of residency. Under Florida legislation,you may cover your eligible dependent children through the end of the calendar year in which they turn 30. To qualify,your adult child must meet all of the following eligibility criteria each year and documentation must be provided and verified: • Be unmarried and have no dependent children of his/her own • Be a resident of the state of Florida or a full or part-time student whose parents reside in Florida • Have no medical insurance as a named subscriber, insured enrollee or covered person under any group or not to be entitled to benefits under the Title XVII of the Social Security Act. Other Plans Offering Dependent Coverage (Dental, Vision and Life) Dependent children under the dental plan are covered until the end of the year in which they turn 25.Vision coverage for dependent children will cease at the end of the month in which an eligible dependent reaches age 25, regardless of student status, if the dependent is unmarried. Voluntary child life coverage is available for unmarried children through age 25. 43 8 Benefits and Leave Paying for your Benefits All benefits are paid through payroll deductions, unless you are placed on an "unpaid leave"status(see below). Benefits are payroll deducted to pay for the current month of coverage. Many of the benefits are paid pre-tax. Some of the cost of the benefits are paid by the District,some by you,and some are shared by you and the District. Please refer to the following chart for specifications. BENEFIT WHO CONTRIBUTES? TAX BASIS Medical&Prescription Employee&The District Pre-Tax Basic Life/AD&D, EAP The District Not Applicable Dental,Vision,Health Savings Accounts, Retirement Plans Employee Pre-Tax Additional Life/AD&D, Disability,Additional Elective Benefits Employee Post-Tax Family Medical Leave Act — Approved Leave with Benefits The District will continue to pay the employer's contributions for your medical and employer paid basic life insurance coverages for up to 12 weeks while you are on approved FMLA leave; however,you are responsible for paying the employee cost for any insurance coverage you have elected for yourself, and, if applicable,your family. These payments will continue to be payroll deducted until such time you go into an "unpaid leave status."At that time,you will be required to make premium payments directly to the District for each pay period as premiums are no longer payroll deducted. Failure to pay insurance premiums by the 30th of the month will result in immediate cancellation of coverage. District Payment Instructions: Direct payment can be made by check or money order(cash payments are not accepted)to the address below. Please include your Employee ID on the check and a copy of your benefit confirmation page. Failure to pay insurance premiums by the 30th of the month will result in immediate cancellation of coverage.The amount owed is the amount normally deducted per pay as shown on your paystub in Focus. Make payments to:School District of Indian River County(SDIRC) Mailing Address: Employee Benefit Department 6500 57th Street,Vero Beach, Fl 32967 NON-FMLA Leave If you go out on an approved Non-FMLA leave,you will be responsible for paying 100%of your insurance premiums (for all plans).You will no longer receive the Board paid contribution. Failure to pay insurance premiums by the 30th of the month will result in immediate cancellation of coverage. FMLA or Approved Leave of Absence— Frequently Asked Questions and Answers 1. What happens to my benefits when I go out on Leave? If you are on approved FMLA leave,the District will continue your benefits and pay the District cost of benefits. However,you will be required to pay for your share of the health insurance premiums,see above District payment instructions. If you are on Non-FMLA leave,you will be responsible for paying 100%of the cost of the your medical insurance along with your cost of any other benefits you have elected.You will no longer receive the Board contribution to the medical insurance. 2. How do I know how much I will owe?You may determine the cost your benefits by reviewing your printed hard copy of the benefit confirmation sheet and your most recent pay stub. 3. Can I add my newborn to my policy?Yes,your newborn may be enrolled on your plan within one month of birth by going online to www.sdirc-benefits.com and processing a qualifying event. 4. Can I add other family members to my policy at the same time I add my newborn?Yes,you can add your spouse or other qualified dependent children at the time you add your newborn. 5. What happens to my benefits if I don't come back from leave after my FMLA expires? If you are on leave beyond the FMLA period,you will stop receiving the Board contribution towards the District medical and life insurance coverages and will be responsible for paying the total cost,whether through payroll deductions or direct payment. If payments are not received by the end of each month, benefits will be cancelled immeti4tely. 9 Qualifying Events Making Changes During the Year Choose your benefits carefully! You cannot change your benefit options during the year unless you have a qualified life event. Qualified Life Events include: Marriage or divorce Change in your employment status—Employment termination or obtaining new employment Death of your spouse or dependent Change in spouse's employment status—Employment termination or obtaining new employment Birth or adoption of a child Change in dependent eligibility status ***You have 30 days from the Qualifying Event Date to submit your benefit changes*** Qualifying Events—Additional Information • Newborns will be covered under your medical plan if you have any of the District medical plans for the first month of life at no charge.YOU MUST contact the Employee Benefits Department within the initial 30 days for this coverage to be added to your health insurance deductions. If you wish to enroll the newborn and other eligible dependents to your health insurance, please read below. • If you do not have family coverage,you may enroll the newborn, as well as other eligible dependents, within 30 days of birth. If you do not complete the enrollment for the newborn/other dependents within 30 days from the date of birth,you will not be able to add them until the next Open Enrollment period unless you have another qualifying event. NOTE:You will be required to pay the Employee+ Family premium from the date the insurance coverage is added (back to date of birth). • If you already have family coverage, be sure to complete the Qualifying Event online within 30 days to add the newborn as a new dependent.There is no increase in your family premium when adding the newborn to your existing family coverage. A copy of the birth certificate and any other dependent documentation will be required. Submitting Qualifying Events 1.To submit a qualifying event to Employee Benefits please visit www.sdirc-benefits.com. , f 2. Follow the login instructions on page 13. 3. Select your applicable life event and enter the date of your ' /4-4 life event. 11/4) 4. Follow the instructions provided in the system on each life , event to advise what date should be used. 5. Complete the process by following the system prompts. 6. Upload required documentation by clicking on the paper icon above the Florida Blue section. NorLirj Airadr } 45 10 ,• 1 Benefit Termination Benefit Termination Policy Terminated employees are covered until the last day of the month: • In which employment ends (interim employees are in this category). • In which you cease being in a benefit eligible position. • In which you retire. • In which payments are not received. Family Medical Leave Act (FMLA) FMLA—Approved Leave with Benefits The District will continue to pay the employer's contributions for your medical insurance coverages and employer paid basic life for up to 12 weeks while you are on approved FMLA leave; however,you are responsible for paying the employee cost for any medical insurance coverage you have elected for yourself, and, if applicable,your family. These payments will continue to be payroll deducted until such time you go into an "unpaid leave status."At that time,you will be required to make premium payments directly to the District for each pay period as premiums are no longer payroll deducted. Failure to pay insurance premiums by the 30th of the month will result in immediate cancellation of coverage. District Payment Instructions:Direct payment can be made by check or money order(cash payments are not accepted)to the address below. Please include your Employee ID on the check and a copy of your benefit confirmation page. Failure to pay insurance premiums by the 30th of the month will result in immediate cancellation of coverage.The amount owed is the amount normally deducted per pay as shown on your paystub in Focus. Make payments to:School District of Indian River County(SDIRC) Mailing Address: Employee Benefit Department 6500 57th Street,Vero Beach, Fl 32967 NON-FMLA Leave If you go out on an approved Non-FM LA leave,you will be responsible for paying 100%of your insurance premiums (for all plans).You will no longer receive the Board paid contribution. Failure to pay insurance premiums by the 30th of the month will result in immediate cancellation of coverage. • If you are an instructional employee and you work through the last day of your contract period and subsequently resign, "not retire," coverage will be in force through the period already covered by paid premiums. When an employee leaves the District,either involuntary or voluntarily, benefits will end the last day of the month in which the last day was worked,for all paid benefits. • 46 11 How to Enroll Enrollment has never been easier. It is accessible 24 hours a day, and contains information about all of your options to help you make informed decisions. The School District of Indian River County provides electronic enrollment through Explain My Benefits (EMB). Explain My Benefits provides eligible employees the ability to make group insurance benefit elections and changes online during the annual open enrollment, new hire orientation and qualifying events. You can log into the Explain My Benefits, portal at any time or download the Mobile App to review your bene- fits, access carrier links, update your personal information for yourself and dependents, update your benefi- ciaries and process qualifying life events. How to Enroll Decide which of these two convenient enrollment options best meet your needs: Self-Service Ot • Visit www.SDIRC-Benefits.com,click on the blue "Log into Your Benefit System" button and move through the enrollment system at your own pace. • Please see login instructions on page 13. • If choosing this option, be sure to click"submit" at the end of the process and make note of your confirmation number. If you do not receive a confirmation number you have not completed your enrollment and you will not be enrolled in benefits. • Return to the system anytime and click your confirmation number to view your confirmation statement. Mobile App Log into the EMB mobile app • Download from the APP Store—search "Explain My Benefits" • Enter Company Code— "sdirc" • Select enroll from the menu on the right. • Go through the enrollment process and finalize by clicking"SUBMIT". You may call the EMB Customer Service Center During Open Enrollment at 1-800-505-8416 for assistance with the enrollment portal. I s Reminders ft E Be sure to review this Benefit Guide and plan summaries prior to going through your enrollment process. Be prepared by gathering dependent and beneficiary information (i.e. Social Security Numbers and Dates of Birth).A c.....:11.0001111111 convenient Enrollment Preparation -. -r Worksheet has been provided at the back of this guide to help you prepare4 pr your 12 enrollment. Login Instructions EN18 &ROLL. Explain My Benefits ALL. EMPLOYEES ARE REQUIRED TO CREATE A NEW ACCOUNT FOR OPEN ENROLLMENT CREATE NEW ACCOUNT 0 Create New Account •(Enter SSN (No Dashes) l9 + Hover over the question mark next to each field for specific instructions {Enter B. Year(YYYY) Q. Enter the required SSN(No Dashes)and Birth Year (YYYY)as instructed. C tr --Create Neer Account . aidr-Create New Account- - In the event the system advises that an account already exists,return to the-Loy In-steps above USERNAME AND PASSWORD CRITERIA Create New Account Create Username Referencing 1' (D Username: •Enter Usemame Worm=NI. Teta •At least one (1) letter and one(1) number o Create + r • Between 8 - 32 characters Create Password aid Password • Not the same as your password •Enter Password: • No more than three sequential characters o Choose r• (abc, cba, 723, 321) ' assemd: - Questions%11Jj Answers • No more than three repeating characters o @Continue. (aaa, 111) Choose Security Questions..._-,.- • Permitted special characters: @ .-_* •Security Ouestan t_ _ • Your username must be unique • Answer t; Password: *security Question 2: • At least one(1)uppercase 'letter and one (1) lowercase letter • Answer 2: • At least one(1) number • seeumyoues r,�. - - - Tis3� • Between 8 - 20 characters — • Not the same as your username , •Answer3: QuestionsAnswers • No more than three sequential characters - ado valid Gat°address (abc, cba, 123, 327) E-mail Address EEG required(1)validate • No more than three repeating characters • Enter E-mx1Address. (aaa, 777) identity. • Permitted special characters: @ .-_* • Corson`--natAddress: • Password cannot be the same as your previous 10 passwords on this system comes 48 13 Medical - Florida Blue F ' The District seeks to provide the best possible medical and prescription drug benefits at a reasonable cost to you. The information below is a summary of medical coverage only. Please contact Florida Blue, the Benefit Administrator, at www.floridablue.com,for plan summaries detailing coverage information and exclusions. Blue Options 05770 Blue Options 05772 Blue Options 05774 Benefit In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Annual Calendar Year Deductible Single $1,000 $3,000 $2,000 $6,000 $3,000 $6,000 Family $3,000 $6,000 $6,000 $18,000 $9,000 $18,000 Out-of-Pocket Maximum Single $3,500 $7,000 $5,500 $11,000 $6,350 $15,000 Family $7,000 $14,000 $11,000 $22,000 $12,700 $30,000 Coinsurance (%member pays of bill) 20% 50% 20% 50% 20% 50% Physician Services Doctor's Office Visit $25 50%after ded. $35 50%after ded. $40 50%after ded. Specialist Office Visit $25 50%after ded. $65 50%after ded. $100 50%after ded. Preventive Care No Charge 50% No Charge 50% No Charge 50% Imaging Facility $100 50%after ded. 20%after ded. 50%after ded. 20%after ded. 50%after ded. Hospital Facility Fees Inpatient 20%after ded. $3,500 $100+20%after $500+50% $500+20%after $500+50% ded. after ded. ded. after ded. Ambulatory Ambulatory Ambulatory Surgical Center: Surgical Center: • Surgical Center: Outpatient $150 50%after ded. $250 50%after ded. $350 50%after ded. Hospital Option 1: Hospital Option 1: Hospital Option 20%after ded. 20%after ded. 1:20%after ded. Imaging Center $100 50%after ded. $300 50%after ded. $400 50%after ded. Emergency Care $200 $300 $400 Pregnancy and Maternity Care(prenatal and postnatal) $25 50%after ded. $65 50%after ded. $100 50%after ded. -Office Services Semi-Monthly Per Paycheck Deductions Employee Only $108.50 $59.00 $14.50 Employee+Spouse $363.00 $281.00 $211.00 Employee+Child(ren) $350.00 $270.00 $201.50 Family $438.00 $346.50 $268.50 2 Credit Employee+Spouse $34.00 each $0.00 each $0.00 each 2 Credit Employee+Family $71.50 each $25.75 each $0.00 each Note:The District's Contribution for the 2020/2021 school year is$295.00 per pay or$590.00 per month. Note: Any deductibles ("ded") and copays in the chart above are amounts for which you are responsible. Deductibles, copays and coinsurance accumulate toward the out-of-pocket maximums. Usual, Customary and Reasonable charges apply for all out-of-network benefits. Prior authorization may be required for imaging services. 9 14 Prescription Drugs - Express Scripts With the election of a medical plan, employees are automatically enrolled in the corresponding Express Scripts' Prescription Drug Plan. The information below is a summary of prescription drug coverage only. Please contact Express Scripts, the Prescription Drug Benefits Administrator, at Express-Scripts.com for more information detailing coverage information, limitations and exclusions. The copays shown are amounts for which you are responsible. Blue Options 05770 Blue Options 05772 Blue Options 05774 Benefit In-Network Out-of- In-Network Out-of- In-Network Out-of- Network Network Network Retail (31 day supply) Generic $10 $10 $10 $10 $10 $10 Preferred Brand $30 $30 $50 $50 $50 $50 Non-preferred Brand $60 $60 $80 $80 $80 $80 Mail Order(90 day supply) Generic $20 $20 $20 $20 $20 $20 Preferred Brand $60 $60 $100 $100 $100 $100 Non-preferred Brand $120 $120 $160 $160 $160 $160 Opt-Out Medical Insurance Option The District offers an annual flex spending amount of$480 to any employee who actively opts-out of medical coverage during open enrollment. If you choose to decline the District's medical coverage and opt out, the District will deposit$20.00 per pay period into your flex spending account, beginning October 1, 2020. In order to be eligible you MUST elect the "OPT-OUT" flex during Open Enrollment and you MUST show proof of other coverage to receive this credit. If you are a late hire or leave the district early, the $480 credit will be prorated based on the time you are with the District during the plan year. ..' '17;. ' - .. 'iie.:4 k• • Cb).6°' 8,)i9 ec; , At,n gilt _.... .....4...!.): Q 0 5.-- .- -:" - a-1,..- 11 4 ,fri'\r-2-_- . " %e___- `_. , -.1 :t. - fii ...,4 . I - - . . .,,, ...A .... ..--- 1010111,44 iiall.11.1/1.- -- 4-,312L-',.;11-4/.4. '''I.:.'' .-_ - ' 0011101111111PP.414 ..... „•• -,,.... ''.4,„,,e. 4I ' - ' • • ' ' ka}r-r •-1. itif , ,,,0-'� 7i. r.e � + ti ♦ .74 s. f., ,,44-...!- ,t,,,A.,,,_ 4,,,,,Zzri 'It .).- .- 4:A0%;,,, -,,,,.•14.,,i•-,,,,,,,etvi•• • , -„...i.- .,,,,..i.,, 1 15 Medical Terms Glossary Important Terms Insurance can sometimes sound like a foreign language.Take a moment to review the meaning of these common terms to best understand your benefit plans. Preventive and Non-Preventive Services Annual Deductible Preventive care services are those that are generally Your annual deductible is the amount of money you linked to routine wellness exams. Non-preventive must first pay out-of-pocketbefore your plan begins services are those that are considered treatment or paying for services covered by coinsurance. Some diagnosis for an illness, injury, or other medical services, such as office visits, require copays and do condition. There are limits on how often you can not apply to the deductible. This is an annual receive preventive care treatments and services. You calendar year deductible. should ask your health care provider whether your isit is considered preventive or non-preventive care. After you meet your deductible, the plan pays for a Examples of preventive care include: percentage of eligible expenses (coinsurance) until • Annual routine physicals you meet your out-of-pocket maximum. If you • Bone density tests,cholesterol screening receive services from an out-of-network provider, • Immunizations, mammograms, Paps smears, pelvic exams, PSA examsthe plan pays a lower percentage ofcoinsurance. • Sigmoidoscopies, colonoscopies Refer to your health care plan summaries for more information. Copayment and Coinsurance Out-of-Pocket Maximum copayment (copay) is the fixed dollar amount you Some plans feature an out-of-pocket maximum, pay for certain in network services. In some cases, which limits the amount of coinsurance you will pay ou may be responsible for coinsurance after a copay for eligible health care expenses within:a calendar is made. year. Once you reach that maximum, the plan begins Coinsurance is the percentage of covered expenses to pay 100% of eligible expenses. There may be shared by the employee and the plan. In some cases, separate in and out-of-network annual coinsurance is paid after the insured meets a out-of-pocket maximums. Copays, deductible and deductible. For example, if the plan pays 90% of an coinsurance accumulate towards your out-of-pocket in-network covered charge,you pay 10%. maximum. Care Coordination In-Network Advantage hen you need hospital care or have complex health Within some of the medical, dental and vision plans, care needs, Florida Blue's Care Coordinators are you have the freedom to use any provider. available to assist you and your family. From handling However, when you use an in-network provider, the benefit and approvals, to scheduling follow up care percentage you pay out-of-pocket will be based on a and connecting you with health programs and negotiated fee, which is usually lower than the resources, you'll have extra help so you can focus on actual charges. If you use a provider who is outside :etting well and staying well. Call Florida Blue at of the network, you may be responsible to pay for 888-476-2227. the difference of the Usual, Customary and Reasonable (UCR) charges and what the provider NURSES ON CALL 24/7: bills. You also may need to submit claim forms. hen you need answers right away,call a nurse 24/7. hether you or your family members have health concerns or general health questions, the nurseline is available at no cost.Simply call 877-789-2583. 51 16 Care X71~. . / The Employee Health & Wellness Center The Employee Health &Wellness Center is a primary care facility treating both acute and chronic conditions at NO COST for both employees and dependents enrolled in a District health plan. CareHere also provides NO COST wellness programs and health coaches to guide you through the process of losing weight, quitting smoking, controlling your blood pressure and more. CareHere is a well-known and trusted healthcare organization skilled at delivering innovative, high-quality, cost-effective primary care. • NO COST for visits or 200+generic medications • NO COST for labs • Convenient schedule that includes early morning, late evening and Saturday hours • • 24/7 Scheduling and Nurse Advice Line • Less than 5 minute average wait time • NO COST for annual Health Risk Assessment • NO COST for wellness programs and health coaching • NO COST for well-man, well-woman,sports and school physicals • Certain imaging services available at NO COST when referred by a CareHere provider to Indian River Radiology • Home Delivery Pharmacy program for many chronic medications SCHEDULE ANYWHERE - _- 844.422.7343 I CareHere.com I CareHere App tc, 0 Register with your access code NRSE2 Care ! CareHere abides by all federal HIPAA and confidentiality regulations. Indian River Health &Wellness Center 5255 41st Street I Vero Beach MakeAPPorttment Appointment Activity IMPORTANT NOTICE U tabs - Vitals REGARDING MISSED APPOINTMENTS AT WELLNESS CENTER Effective immediately,we are implementing a new policy that is !,t). designed to reduce the number of"No Shows" at the Wellness Challenges Trackers Center. "No Show" appointments prevent others from being served and add to the cost of our health care.Therefore, after an employee or dependent has missed three appointments in a calendar year without cancelling,that member or dependent wellness(Army CareHere Connect will be charged a $25.00 fee, deducted through payroll.The member will then be charged an additional $25.00 fee for any d rq future missed appointments, without prior cancellation,for the remainder of that calendar year. 17 Employee Assistance Program (EAP) Resources for Living The District has partnered with Aetna's Resources for Living to provide an employer sponsored Employee Assistance Program (EAP). Aetna's Resources for Living, will help you resolve personal, wellness, and professional concerns that can adversely affect workplace productivity. This service is available for all employees, anyone living in your household, and dependent children living out of your home up to the age of 26. Services are free and confidential and available 24 hours a day,7 days a week. Employee Assistance Program (EAP) 1-800-272-3626 www.resourcesforliving.com Username: Indian River County School Board Password: 8002723626 Emotional well-being support .'fit;. You can call 24 hours a day for in-the-moment emotional well-being support. You can also access up to six counseling sessions per issue per year. Visit with a counselor face-to-face, online with televideo or get in-the-moment support by phone. Services are free and confidential. The EAP is available to help with a wide range of issues including: • Relationship Support • Stress Management • Work/Life Balance • Family Issues • Grief and loss • Depression • Anxiety • Substance misuse and more • Self-esteem • Personal development Online Resources IQ Legal Services I•/ Your member website offers a full range of tools and You can get a free 30-minute consultation with a participating resources to help with emotional wellbeing, work/life attorney for each new legal topic related to: balance and more. You'll find: • General • Divorce • Articles and self-assessments • Family • Wills and other document • Adult care and child care provider search tool • Criminal law preparation • Stress resource center • Elder law and estate • Real estate transactions • Video resources planning • Mediation services • Live and recorded webinars • Mobile app If you opt for services beyond the initial consultation you can get a 25 percent discount. You'll also find access to these helpful tools: *Services must be related to the employee and eligible Discount Center household members. Work-related issues are not covered. Find deals on brand name products and services including Discount does not include flat legal fees, contingency fees and electronics, entertainment, gifts and flowers, travel and plan mediator services. more. Financial Services Fitness Discounts Simply call for a free -minute consultation for each new Save on gym memberships at over 9,000 locations financial topic related to: nationwide and home fitness equipment. Participating gyms and programs include 24 Hour Fitness, LA Fitness, Anytime • Budgeting • Credit and debt issues Fitness®,Zumba®, Nutrisystem®and more. • Retirement or other • College funding financial planning • Tax and IRS questions myStrength • Mortgages and refinancing and preparation myStrength offers tools to improve your emotional health You can also get a 25 percent discount on tax preparation and help you overcome depression, anxiety, stress, services. substance misuse and/or chronic pain. *Services must be for financial matters related to the employee and eligible household member. Other Services Identity theft services - One hour fraud resolution phone consultation or coaching about ID theft prevention and credit restoration. Services include a free emergency kit for victims. 53 18 Flexible Spending Account CHARDSNYDER' t Chard Snyder Note:Services must be rendered or purchases made within the plan year of 10/1 -9/30. Employees MUST RE-ENROLL EVERY YEAR. FSA's do not roll over into the new plan year. Are you losing money on your family's health and Does the cost of dependent daycare drain too wellness costs? much of your salary? A Flexible Spending Account will give you significant savings on Save 25-40%off the cost of dependent daycare by using a health and wellness costs not covered by insurance. Dependent Daycare Flexible Spending Account. Pay 25-40% Less for Your Family's Health and Pay Less for Dependent Daycare While You Wellness Costs Work Insurance probably doesn't cover all your family's health costs. Dependent daycare is a big drain on family income and You might have to pay a small copay when you see the doctor or we're all looking for ways to slow the flow. Paying for maybe even some extra charges if your doctor or hospital is not daycare through a dependent daycare flexible spending covered by your plan. Maybe you need services your insurance account can help you keep more of your money in your just doesn't cover. These costs can add up quite a lot over the pocket. course of a year. How does it work? Wouldn't you like to save 25-40%on all those charges? You choose how much to put into the account, and pay It's Simple dependent daycare expenses using tax-free dollars, up to You choose how much to put into the account and pay for health a maximum of$5,000 per household. and wellness expenses using tax-free dollars, up to a maximum Without the FSA you pay for your dependent daycare with of$2,750 yearly. what's left after taxes have been deducted. Instead of the Without the FSA you pay for those expenses with what's left $100 you earned,you actually have only$60 to$75 left to after taxes have been deducted. Instead of the$100 you earned, pay for care. you actually have only$60 to$75 left to spend. With tax-free dollars, $100 put into your account is $100 With tax-free dollars,$100 put into your account is$100 you can you can use to pay for daycare. spend. Your savings will add up quickly. What is an Eligible Expense? Are There Rules? Any type of daycare you choose: A few,and they're easy to follow: In-home babysitter Outside babysitter • You must decide how much you want to put in the plan for the Nursery schools Daycare center year. After-school activities Latchkey program • You can't change your mind later (unless you experience Summer day camp Elder daycare specific work/life events). Elder custodial care • You must use the money for eligible expenses and keep the Dependent Daycare Isn't Just Kid Stuff receipts. If your child is 12 or less, this program is for you. If your • You must spend your money within the deadlines of your plan. dependent of any age can't be left alone for mental or • You may not spend the money for anything cosmetic. physical reasons,this program is for you. Use the Benny Card and Save Your Cash Are There Rules? Benny® helps you keep it all straight. It pays at locations that Yes,but they're simple: offer eligible merchandise and services...and usually knows • Services you claim must be provided while you and your exactly what is eligible. When you use the card your payment spouse are at work, looking for work or attending comes right out of your account. classes as a full-time student. Don't Think an FSA's for You? • You must decide how much you want to put in the plan ' You'll be surprised by some of the items eligible for savings: for the year. Alternative medicine Vision • You can't change your mind later(unless you experience Childbirth classes With a doctor's note: specific work/life events). Dental treatment Herbal supplements • You must spend your money within the claims deadline Learning disability services Massage Therapy for your plan Medical equipment Weight loss programs • You may only be reimbursed for the amount of money Prescriptions Stop smoking aids in your plan at the time of your claim. Speech training • Your provider must report this as income. 54 19 III Dental - Cigna yCigna Dental coverage is key to your overall health. The District offers employees three dental plan options through Cigna. For more information about your plan and to find a Cigna dentist near your, visit www.cigna.com, or call 800-244-6224. Your dental plan covers four main types of expenses: • Preventive and diagnostic services like exams and cleanings,fluoride treatments, and sealants • Basic services such a simple fillings, root canals, oral surgery, and gum disease treatment • Major services such as crowns and dentures • Orthodontia (DHMO Only)* Benefit PPOOblag) PPO L'p DHMO Annual Calendar Year Maximum (Per Enrollee) $1,000 $1,000 N/A Calendar Year Deductible (Per Enrollee) $50 $50 N/A Preventive Services No Charge No Charge No Charge Basic Services No Charge 20% $0-$345 Major Services 40% 50% $20-$415 Semi-Monthly - Paycheck Deductions Employee Only $17.25 $14.80 $10.04 Employee+Spouse $36.94 $31.70 $17.24 Employee + Child(ren) $34.57 $29.67 $17.36 Family $54.38 $46.67 $25.01 Note:Coinsurance shown is member paid for In-Network providers. Non-contracted providers would include balance billing. Members can see dentists that are part of the Advantage network;which is the highest tier providing coverage at the full in-network benefit level,DPPO network which still offers a discount on the services however benefits are paid based on the out of network benefit levels,and full Out of network,your benefits may be lower and you may have to file your own claims.DHMO plan members are encouraged to select a dentist. *Maximum benefit of 24 months of interceptive orthodontics and/or comprehensive treatment. Atypical cases or cases beyond 24 months require an additional payment by the patient. Atirt '.-N,,, , ( 1 \----' -----, ./ I all. 401-25.4 .--.., A i AI, , !,...\ ' *� `it r .t Z t 1� vm l'i I il" it - V . tilr 20 Ig UnitedHealthcare' Vision - United Healthcare Please keep in mind that some providers' network status may have changed. Please confirm with your provider if they are in-network or speak to a UnitedHealthcare representative at 800-638-3120. The District offers employees two vision plans through UnitedHealthcare Group that includes coverage for eye exams and eyeglasses or contact lenses. Please access www.myuhcvision.com and utilize the "Provider Quick Search" feature, or you can call 800-638-3120 to get the names and addresses of the network providers nearest you. y --__�T... ._. __. .. _._..._...� ..d .,.0, JF: i.- ,..- : , * 4 ,-,„- li ‘'i.4 i . I i 2, ic.0 .7 I , ) lif ' kg14 --2 Stet j .,Zi: i ." '. Benefit Option a Option 3 Exam $10 copay $10 copay (Once every 12 months) (Once every 12 months) Frames* (for frames that exceed the allowance, an $130 allowance $130 allowance additional 30%discount may be applied to (Once every 24 months) (Once every 12 months) the overage) Contact .3ai)maGo-`-�' - Contact Lenses (Non Collection) $125 allowance (copay waived) $125 allowance (copay waived) (Once every 12 months) (Once every 12 months) Selection Contact Lenses $25(up to 4 boxes) $25 (up to 4 boxes) (Conventional/Disposable) (Once every 12 months) (Once every 12 months) Medically Necessary(with prior approval) $25 copay $25 copay (Once every 12 months) (Once every 12 months) Semi-Monthly gtai.Paycheck Deductions Employee Only $2.70 $3.00 Employee+Spouse $4.53 $5.05 Employee+Child(ren) $4.63 $5.17 Family $7.32 $8.15 *Please Note:Additional charges may apply for Out-of-Network services. Please refer to the plan summc. 21 Basic Life & AD&D Insurance - meStandard The Standard The Standard is the Group Life and AD&D partner for the District and its employees. The Standard also has offered an expanded AD&D Living Needs Package at no additional cost to District employees. The District provides employees with basic life insurance and accidental death and dismemberment (AD&D) coverage in the amount of$25,000 at no cost to you. Board-paid basic life and AD&D insurance protects your family's financial future if you die or if you experience a loss of limb, eyesight, or other dismemberment. Supplemental term life insurance is an option that gives you the opportunity to enhance the basic life insurance that the District provides for you. Age reductions after age 65 apply to life and AD&D insurance amounts. • Additional Voluntary Life and AD&D—ONE Time Opportunity to Increase Coverage without Proof of Good Health • Active full-time employees may purchase additional voluntary life and AD&D coverage for yourself and de- pendent life coverage for your family. The amount and cost of additional coverage that you may elect can be found on the next page. During this year's Open Enrollment The Standard is offering a one-time oppor- tunity to purchase or increase coverage without a proof of health form (E01), up to the new Guarantee Is- sue amount of$200,000 for employees and $50,000 for spouses. • To purchase coverage for either your spouse or child(ren), you must enroll yourself for voluntary life coverage. You pay 100% of the cost for this coverage. Statement of Health application will be required if you elect coverage for you or your spouse over the guaranteed issue amount.The enrollment platform will automatically re-direct you to the site for the necessary forms.Age reductions after age 65 apply to life and AD&D insurance amounts. • The Open Enrollment referenced above only applies to the Open Enrollment taking place from August 17, 2020 through August 31, 2020. If you do not elect now, all future increases in coverage will be subject to proof of good health (E01) unless you are a new hire applying during your initial period of eligibility. AD&D Living Needs Features: These benefits are included at no additional cost to District employees and the insured: • Career Adjustment Benefit: Pays for qualifying tuition expenses incurred by an employee's eligible spouse for training aimed at obtaining employment or increased earnings within 36 months of the insured's death. • Child Care Benefit: Pays for qualifying child care expenses for all children under age 13 incurred by an employee's eligible spouse within 36 months of the insured's death. • Higher Education Benefit: Covers tuition expenses for up to four consecutive years for children attending or who will be attending college within 12 months after the insured's death. • Seat Belt Benefit: Paid if you or your insured dependent dies as a result of a car accident and is found to be wearing a seat belt. • Occupational Assault Benefit: Pays for qualifying loss resulting from an act of physical violence against the employee while at work;assault must involve a police report and be punishable by law. • Public Transportation Benefit: Pays for qualifying loss of life while riding as a fare-paying passenger on public transportation. Other information: Guaranteed Issue Amounts have been Enhanced • Employee guaranteed issue amount is now$200,000. Spouse life guaranteed issue amount is now$50,000 • The beneficiary you elect for your basic life and AD&D insurance will be the same for your employee voluntary term life insurance. • Employees cannot elect life coverage for a spouse who is also a District employee. • Voluntary spouse life premiums are calculated based on the employee's age. • The child life benefit will be a flat $5,000 or $10,000. If both parents work for the District, botpfannot purchase dependent coverage for the same children. 22 meStandard• Voluntary Life & AD&D Rates Employee (Life/AD&D) Up to$300,000 in increments of$25,000 Spouse (Life only) Increments of$12,500 to a maximum of$75,000. Cannot exceed 100%of employee's Voluntary Life Insurance Child(ren) (Life only) $5,000 or$10,000 Employee Employee Life and AD&D Semi-Monthly Premiums Age $25,000 $50,000 $75,000 $100,000 $125,000 $150,000 $175,000 $200,000 $225,000 $250,000 • $275,000 $300,000 <30 $0.88 $1.75 $2.63 $3.50 $4.38 $5.25 $6.13 $7.00 $7.88 $8.75 $9.63 $10.50 30-34 $1.25 $2.50 $3.75 $5.00 $6.25 $7.50 $8.75 $10.00 $11.25 $12.50 $13.75 $15.00 35-39 $1.38 $2.75 $4.13 $5.50 $6.88 $8.25 $9.63 $11.00 $12.38 $13.75 $15.13 $16.50 40-44 $1.50 $3.00 $4.50 $6.00 $7.50 $9.00 $10.50 $12.00 $13.50 $15.00 $16.50 $18.00 • 45-49 $2.13 $4.25 $6.38 $8.50 $10.63 $12.75 $14.88 $17.00 $19.13 $21.25 $23.38 $25.50 • 50-54 $3.13 $6.25 $9.38 $12.50 $15.63 $18.75 $21.88 $25.00 $28.13 $31.25 $34.38 $37.50 55-59 $5.25 $10.50 $15.75 $21.00 $26.25 $31.50 $36.75 $42.00 $47.25 $52.50 $57.75 $63.00 60-64 ' $7.75 $15.50 $23.25 $31.00 $38.75 $46.50 $54.25 $62.00 $69.75 $77.50 $85.25 $93.00 65-69* $9.91 $19.83 $29.74 $39.65 $49.56 $59.48 $69.39 $79.30 $89.21 $99.13 $109.04 $118.95 70-74* $11.38 $22.75 $34.13 $45.50 $56.88 $68.25 $79.63 $91.00 $102.38 $113.75 $125.13 $136.50 75+* $7.96 $15.93 $23.89 $31.85 $39.81 $47.78 $55.74 $63.70 $71.66 $79.63 $87.59 $95.55 *Coverage amounts for ages 65 and over reduce due to age. Employee Spouse Life Semi-Monthly Premiums ,r Age $12,500 $25,000 $37,500 $50,000 $62,500 $75,000 <30 $0.31 $0.63 $0.94 $1.25 $1.56 $1.88 30-34 $0.50 $1.00 $1.50 $2.00 $2.50 $3.00 S. 35-39 $0.56 $1.13 $1.69 $2.25 $2.81 $3.38 .41 •40-44 $0.63 $1.25 $1.88 $2.50 $3.13 $3.75 ) rr fe..A 45-49 $0.94 $1.88 $2.81 $3.75 $4.69 $5.63r + - 0 �' 50-54 $1.44 $2.88 $4.31 $5.75 $7.19 $8.634 0•••••_ 55-59 $2.50 $5.00 $7.50 $10.00 $12.50 $15.00 60-64 $3.75 $7.50 $11.25 $15.00 $18.75 $22.50 {' G 'T.. \1/4. - 1 65-69* $4.88 $9.75 $14.63 $19.50 $24.38 $29.25 t 70-74* $5.63 $11.25 $16.88 $22.50 $28.13 $33.75 ' 0 0 75+* $3.94 $7.88 $11.81 $15.75 $19.69 $23.63 o a *Coverage amounts for ages 65 and over reduce due to age reduction. 'L7. x."". .."' I Age Child(ren) Life Semi-Monthly Premiums -- $5,000 $10,000$0.25 $0.50 Child ` ; . 58 23 1 • • • • �w!SII s • Short Term Disability - Cigna ir Cigna What is Short Term Disability Insurance? Short Term Disability Insurance helps protect your income for a short duration. If you become disabled and are unable to work, disability insurance can help replace some of your lost income, help you pay bills and protect your long-term savings. Employees are eligible to receive short-term disability (STD) benefits for a qualified non-work illness or injury after being continuously disabled through your elected elimination period. This plan will pay 66.67% of your weekly salary but no more than$2,000(in$100 increments) per week. If you are not in active employment due to injury or sickness, or if you are on a covered layoff or leave of absence, any increased or additional coverage will begin on the date you return to active employment. Option 1: Benefit Waiting Period Maximum Benefit Period 0 Days for Accident 13 Weeks for Accident 7 day waiting period 7 Days for Sickness 12 Weeks for Sickness [Age 1 <24 25-29 30-34 35-39 40-44 45-49 50-54 [Semi-Monthly Rate Per$100 E $2 73 1,$2.94 $2.59 = $2.05 '.r $2.01 i $1.95 ! I $2.32 Ai g e 1 55-59 60-64 65-99 emi-Monthly Rate Per$100 $3.28 ' $3.99 ! $4.33 Option 2: Benefit Waiting Period Maximum Benefit Period 14 Days for Accident 11 Weeks for Accident 14 day waiting period 14 Days for Sickness 11 Weeks for Sickness Age 1 <24 25-29 30-34 35-39 40-44 45-49 50-54 r [Semi-Monthly Rate Per$100--II $2.49 $2.76 ,! $2.29 $1.84 � $.1.67 i $1.67 � $2.01 Age 1 55-59 60-64 65-99 (Semi-Monthly Rate Per-$100 i' $2.59 $3.14-1-- $3.58 1 Option 3: Benefit Waiting Period Maximum Benefit Period 30 Days for Accident 9 Weeks for Accident 30 day waiting period 30 Days for Sickness 9 Weeks for Sickness ;Age <24 25-29 30-34 35-39 40-44 45-49 50-54 i Per Pay Rate Per$100 r $1.64 ' $2.01 $1.64 ' $1.40 -1' $1.30 _F $1.40 $1.81 i Age 55-59 60-64 65-99 rSemi-Monthly Rate Per$100 $2.25 $2.59 $2.70 How to Calculate Your Semi-Monthly Cost: Step 1: Use the chart above to find your monthly rate based on age. Multiply this rate by your gross weekly benefit. Step 2: Divide the total by 100. The result is your semi-monthly cost. Calculate Your Cost x /no = Semi-Monthly Rate Gross Weekly Benefit Semi-Monthly Cost 59 24 •�� •• - )0:( Cigna long Term Disability - Cigna What is Long Term Disability Insurance? Long Term Disability Insurance helps safeguard your financial security by replacing a portion of your income while you are unable to work. LTD benefits are intended to protect your income for a long duration after you have depleted short-term disability or available paid time off. Employees are eligible to purchase long-term disability (LTD) insurance which pays a monthly benefit in the event you cannot work because of a long-term illness or injury. You must be continuously disabled through Your elimination period of 90 days to be eligible for LTD benefits. This plan will pay 66.67% of your monthly salary but no more than $8,000 (in $100 increments) per month. Benefit and maximum period of payment are based on age when disability occurs. .,, r `_z+ < '1,- 1 Semi-Monthly Semi-Monthly • *„ ,.a f,� Age ge Rate Per$100 Age Rate Per$100 <24 $0.082 50-54 $0.875 A} 0 } �1 ; 25_29 $0.106 r 55-59• $0.932 1 30-34 $0.202 60-64 $0.983 35-39 $0.315 65-69 $1.021 40-44 , $0.471 70+ $0.775 I 'r� 45-49 $0.634 ?. - How to Calculate Your Semi-Monthly Cost: 4 ' ! '� Step 1: Use the chart above to find your monthly rate based on age. Multiply this rate by your gross monthly benefit. ). !• Step 2: Divide the total by 100. The result is your semi-monthly -- _ �/ - .-_ • cost. • a 41, Calculate Your Cost `..�: x /100 - - - - a- Semi-Monthly Rate Gross Monthly Benefit Semi-Monthly Cost _., " - i= ---Y l�-- _ - y — -•-- - Ii;.. - __ __ » %S .- -- —...� 60 25 Accident/Cri• tical Illness/ Cancer - MetLife II MetLife These additional benefits are offered to strengthen your overall benefits package. You customize the benefit based on need and affordability. • Ownership - Policies are fully portable and belong to you if you leave your employer, same price and same plan • Benefits are payroll deducted • Cash benefits are paid directly to you, not to a hospital or a doctor • Benefits are paid regardless of any other coverage you may have • Guaranteed Renewable • Designed to provide additional cash flow to assist with out-of-pocket medical costs and other bills Accident Plan Accident insurance provides a financial cushion for life's unexpected events. You can use it to help pay costs that aren't covered by your medical plan. It provides you with a lump-sum payment -one convenient payment all at once -when you or your family need it most. The extra cash can help you focus on getting back on track, without worrying about finding the money to help cover the cost of treatment. The plan provides a lump sum payment for over 150 different covered events, such as: • Fractures • Concussions • Dislocations • Cuts or lacerations • Second and third degree burns • Eye injuries • Skin grafts • Coma • Torn knee cartilage • Broken teeth • Ruptured disc You'll receive a lump sum payment when you have these covered medical services: • Ambulance • Physician follow-up visits • Emergency Care • Transportation • Inpatient Surgery • Home modifications • Outpatient Surgery • Therapy services (including physical and occupational therapy) • Medical Testing Benefits (including X- rays, MRIs, CT scans) Per Pay Period Employee Employee&Spouse Employee&Child(ren) Family High Plan $6.25 $13.29 $12.67 $15.89 Low Plan $3.38 $7.23 $6.77 $8.67 Guaranteed Issue Benefits are paid directly to the employee based on a flat schedule (not reimbursement) and there is no coordination with other insurance coverage.An assignment of benefits to a hospital or healthcare facility will be available when required by applicable law. This plan provides protection for covered events experienced while off the job only. 61 26 Accident/Critical Illness/Cancer - MetLife Critical Illness Critical illness insurance can help safeguard your finances by providing you with a lump-sum payment when your family needs it most. The payment you receive is yours to spend as you see fit and in addition to any other insurance you may have. MetLife Critical Illness Insurance provides a lump-sum payment if you or a covered family member are diagnosed with one of the followingmedical conditions: Full Benefit Cancer,Stroke, Partial Benefit Cancer,CoronaryArteryBypass Graft,All Other Yp Cancer,Kidney Failure,Heart Attack,Alzheimer's Disease,Major Organ Transplant and 22 additional conditions. A Recurrence Benefit is paid for the following covered conditions: Heart Attack, Stroke, Coronary Artery Bypass Graft, Full Benefit Cancer and Partial Benefit Cancer.See Plan Summary for a full explanation of Recurrence Benefit limitations. $50 Health Screening Benefit included: A benefit is paid for health screening tests for each covered person,such as: Annual Physical Exam,HPV Vaccination,Colonoscopy,Pap Smear,Mammogram,Endoscopy. See the Plan Summary for a full list. Critical Illness Per Pay Rate Per$1,000 of Coverage(Non-Tobacco) ' <25 25-29 ' 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+ i J 1 EE 1 $0.30 $0.32 $0.41 $0.51 ,_ $0.71 $0.94 $1.22�. $1.52 ` $1.82 $2.07 ' $2.50 IEE&SP I $0.54 $0.58 $0.72 $0.91 $1.24 $1.62 $2.09 $2.57 $3.03 $3.43 $4.12 rEE&CH ] $0.52 $0.54 $0.63 $0.74 $0.93 $1.16 $1.45 $1.75 $2.05 $2.30 $2.72 Family 1 $0.76 $0.81 $0.95 $1.14 $1.46 $1.85 $2.31 $2.80 $3.26 $3.66 $4.34 Critical Illness Per Pay Rate Per$1,000 of Coverage(Tobacco) [EE J $0.38 $0.41 $0.56 $0.74 $1.08 $1.47 $1.94 $2.45 $2.97 $3.43 $4.21 !EE&SP 1 $0.66 $0.74 $0.97 $1.29 $1.84 $2.50 $3.28 $4.12 $4.93 $5.66 $6.92 ,EE&CH ] $0.60 $0.64 $0.79 $0.97 $1.30 $1.70 $2.17 $2.68 $3.20 $3.65 $4.43 • Family j $0.89 $0.96 $1.20 $1.51 $2.07 $2.72 $3.51 $4.35 $5.15 $5.89 $7.14 Cancer Insurance Cancer insurance works to compliment your medical coverage-and pays a lump sum in addition to what our medical plan may or may not cover. It's coverage that provides financial support when you or a loved one become seriously ill. Preventive measures,early detection,and quality care and treatment are all important in the fight against cancer. While you can't always prevent it,cancer insurance is there to make life a little easier. Upon initial verified diagnosis of a covered cancer condition, it provides you with a lump-sum payment of up to $15,000 or $30,000. If a Full Cancer Benefit was received and there is a recurrence,you will receive 50%of the Full Cancer Benefit. If a Partial Cancer Benefit was received,you will receive 12.5%of the Partial Cancer Benefit. $50 Health Screening Benefit included: A benefit is paid for health screening tests for each covered person, such as: Annual Physical Exam,HPV Vaccination,Colonoscopy,Pap Smear,Mammogram,Endoscopy. See Plan Summary for a full list. Cancer Per Pay Rate Per$1,000 of Coverage(Non-Tobacco) <25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+ EE $0.14 $0.15 $0.19 $0.23 $0.32 $0.42 $0.52 $0.63 $0.71 $0.72 $0.71 EE&SP $0.24 $0.26 $0.32 $0.39 $0.53 $0.69 $0.88 $1.06 $1.20 $1.23 $1.24 EE&CH $0.27 $0.28 $0.32 $0.36 $0.45 $0.54 $0.65 $0.76 $0.84 $0.85 $0.84 Family I $0.37 $0.39 $0.45 $0.52 $0.65 $0.82 $1.01 $1.19 $1.33 $1.36 $1.37 Cancer Per Pay Rate Per$1,000 of Coverage(Tobacco) ,EE $0.20 $0.21 $0.29 $0.38 $0.54 $0.73 $0.94 $1.15 $1.31 $1.35 $1.34 EE&SP $0.32 $0.36 $0.46 $0.61 $0.87 $1.18 $1.55 $1.91 $2.19 $2.27 $2.30 EE&CH I $0.32 $0.34 $0.42 $0.51 $0.67 $0.86 $1.07 $1.28 $1.44 $1.48 $1.47 Family i $0.45 $0.49 $0.59 $0.74 $1.00 $1.31 $1.68 $2.04 $2.32 $2.40 6.43 27 Legal and Identity Theft Protection - Lega(Shield & IDShield LegalShield- IJ IDShield' Affordable Legal and Identity Theft Protection Legal Protection - LegalShield Every year millions of people have legal issues and do not receive the legal counsel they need and deserve. Protect Your Legal Rights with LegalShield LegalShield Plan Benefits Include*: • Legal Consultation and Advice _• Court Representation • Dedicated Law Firm • Legal Document Preparation and Reviews • • Letters and Phone calls Made on Your Behalf 4'3 `{� H : 4 • Speeding Ticket Assistance • 24/7 Emergency Legal Access44, *Restrictions may apply. See your summary plan description for details. Identity Theft Protection - IDShield Millions of people have their identity stolen each year. IDShield provides the identity theft protection and identity restoration services you not only need but deserve. IDShield Plan Benefits Include*: • Identity Consultation and Advice • Identity and Credit Monitoring • Identity and Credit Threat Alerts • Complete IdentityRestoration p • Direct Access to Licensed Private Investigators • • Monthly Credit Score Tracker • Social Media Monitoring • Mobile App *Restrictions may apply. See your summary plan description for details. • LegalShield Only IDShield'Only. Combo Plan cc !Employee Only $7.63 $3.00 $10.13 i Employee+Spouse $7.63 $5.50 $12.63 Employee+Child(ren) $7.63 $5.50 $12.63 Employee+Family 1 $7.63 $5.50 $12.63 63 28 i Retirement Savings The District understands that saving for ! i retirement is an important priority for our ? _ ., 0 - employees. We offer 401(a) Plan and 403 ' - f ,; f`� ' (b)/457(b) Plans, so you can make sure that '- 1 ' .-- , ,. .4106 ' " more of your money is working for your future. •• „� ,` . The plans allow you to save money for \ --. , !�U ,r . __.retirement through convenient pre-tax payroll , •- ' 4 '�` deduction. These are plans available to you in I t - _ addition to the Florida Retirement System (FRS) - - - pension plan, so there is no set contribution and no district contribution. , For additional information regarding any of the plan provisions, please reach out to the vendors / below. 1 Our 403(b)/457(b) Plan Administrator is TSA 'of, ►\ *N110111011 Consulting Group and may be reached at 'f 888-796-3786 or visit www.tsacg.com. , I _ The 401(a) Plan Administrator is Bencor. Please `” >_-I visit www.bencorplans.com for more 1 - • ... information. '' - � ` For more information regarding the FRS plan _" i please visit www.mvfrs.com or call - -f ;`' 866-446-9377. 4 .24/ka J / z J 64 29 Important Contacts Vendor Website Phone Number/E-mail The School District of Indian River sdircbenefits@indianriverschools.org County(the"District") www.indianriverschools.org Amy Yeitter 772-564-3175 www,indianriverschools.ore/employee-benefits Employee Benefits Specialist sdircbenefits@indianriverschools.org Joan Martin www,indianriverschools.org/employee-benefits 772-564-3011 Employee Benefit Admin Assistant sdircbenefits@indianriverschools.org Adalia Medina-Graham 772-564-3001 Retirement/FMLA Coordinator www.indianriverschools.org/human-resources adalia.medina- graham@indianriverschools.org On-Site Representative for www.floridablue.com 772-564-3122 Florida Blue Marianna Platt marlanna.platt@bcbsfl.com Medical www.floridablue.com 800-664-5295 Florida Blue Prescription Drug Express Scripts,Inc.(ESI) www.express-scripts.com 866-262-6427 District Health&Wellness Center 844-422-7343 www.carehere.com CareHere help@carehere.com Employee Assistance Program(EAP) www.resourcesforliving.com Resources for Living Username: Indian River County School Board 800-272-3626 Password:8002723626 Flexible Spending Accounts (t)800-982-7715 Chard Snyder www.chard-snyder.com (f)888-245-8452 askpenny@chard-snyder.com Dental Cigna www.cigna.com 800-244-6224 Vision www.mvuhcvision.com 800-638-3120 United Healthcare Group Life Insurance The Standard www.standard.com 800-628-8600 Disability Cigna www.cigna.com 800-362-4462 Accident/Critical Illness/Cancer MetLife www•metlife.com/MyBenefits 800-438-6388 Legal&Identity Theft Protection membersupport@leealshield.com 888-807-0407 LegalShield 403(b)/457(b)Retirement Plan www.tsacg.com 888-796-3786 TSA Consulting Group 401(a)Retirement Plan Bencor www.bencorplans.com 888-258-3422 Florida Retirement System MyFRS Financial Guidance www.myfrs.com 866-446-9377 Explain My Benefits www.sdirc-benefits.com 800-505-8416 Open Enrollment Assistance 65 30 Important Legal Notices Important Notice About Your Prescription Drug If you go 63 continuous days or longer without creditable Coverage and Medicare prescription drug coverage,your monthly premium may go up Please read this notice carefully and keep it where you can find by at least 1%of the Medicare base beneficiary premium per it. This notice has information about your current prescription month for every month that you did not have that coverage. drug coverage with School District of Indian River County and For example, if you go nineteen months without creditable about your options under Medicare's prescription drug coverage. coverage, your premium may consistently be at least 19% This information can help you decide whether or not you want to higher than the Medicare base beneficiary premium.You may join a Medicare drugplan. Ifyou are consideringjoining, have to pay this higher premium (a penalty) as long as you you have Medicare prescription drug coverage. In addition, you should compare your current coverage,including which drugs are covered at what cost, with the coverage and costs of the plans may have to wait until the following October to join. offering Medicare prescription drug coverage in your area. For More Information about This Notice or Your Current Information about where you can get help to make decisions Prescription Drug Coverage... about your prescription drug coverage is at the end of this notice. Contact Employee Benefits for further information. NOTE: You'll get this notice each year.You will also get it before the There are two important things you need to know about your next period you can join a Medicare drug plan, and if this current coverage and Medicare's prescription drug coverage: coverage through School District of Indian River County • Medicare prescription drug coverage became available in changes. You also may request a copy of this notice at any 2006 to everyone with Medicare.You can get this coverage time. if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers For More Information about Your Options Under Medicare prescription drug coverage.All Medicare drug plans provide Prescription Drug Coverage... at least a standard level of coverage set by Medicare.Some More detailed information about Medicare plans that offer plans may also offer more coverage for a higher monthly prescription drug coverage is in the "Medicare & You" premium. handbook.You'll get a copy of the handbook in the mail every • School District of Indian River County has determined that year from Medicare. You may also be contacted directly by the prescription drug coverage offered through our medical Medicare drug plans. plans, is, on average for all plan participants, expected to For more information about Medicare prescription drug pay out as much as standard Medicare prescription drug coverage:Visit www.medicare.gov. coverage pays and is therefore considered Creditable Call your State Health Insurance Assistance Program (see the Coverage. Because your existing coverage is considered inside back cover of your copy of the "Medicare & You" Creditable Coverage,you can keep this coverage and not pay handbook for their telephone number)for personalized help a higher premium (a penalty) if you later decide to join a Call 800-MEDICARE (800.633.4227). TTY users should call Medicare drug plan. 877.486.2048. If you have limited income and resources,extra help paying for When Can You Join a Medicare Drug Plan? Medicare prescription drug coverage is available. For You can join a Medicare drug plan when you first become eligible information about this extra help, visit Social Security on the for Medicare and each year from October 15 to December 7. web at www.socialsecurity.gov, or call them at 800.772.1213 However, if you lose your current creditable prescription drug (TTY 800.325.0778). coverage,through no fault of your own, you will also be eligible Remember: Keep this Creditable Coverage notice. If you for a two (2) month Special Enrollment Period (SEP) to join a decide to join one of the Medicare drug plans, you may be Medicare drug plan. required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage What Happens to Your Current Coverage If You Decide to Join a and, therefore, whether or not you are required to pay a Medicare Drug Plan? higher premium(a penalty). If you decide to join a Medicare drug plan, your current School District of Indian River County will not be affected. If you do Date:October 2020 decide to join a Medicare drug plan and drop your current School Name of Entity/Sender:School District of Indian River County District of Indian River County coverage, be aware that you and Contact-Position/Office: Employee Benefits Department your dependents may not be able to get this coverage back. Address:6500 57th Street,Vero Beach,FL 32967 Phone Number:772-564-3175 When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan? You should also know that if you drop or lose your current coverage with School District of Indian River County and don't join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty)to join a Medicare drug plan later. 66 31 Important Legal Notices HIPAA Privacy Notice Reminder Woman's Health and Cancer Rights Act of 1998 The health plans offered by School District of Indian River County are If you have had or are going to have a mastectomy,you may required by the Health Insurance Portability and Accountability Act of be entitled to certain benefits under the Women's Health 1996 (HIPAA) Privacy Rule to maintain the privacy of your health and Cancer Rights Act of 1998 (WHCRA). For individuals information.The Notices of Privacy Practices for our Health plans are receiving mastectomy-related benefits, coverage will be available from the insurance carriers;in addition,you may also request provided in a manner determined in consultation with the a copy of a Notice by calling your insurance provider. Be assured attending physician and the patient,for: School District of Indian River County and our insurance carriers fully • All stages of reconstruction of the breast on which the comply with this requirement. mastectomy was performed; Note: Because this reminder is required by law, you will receive • Surgery and reconstruction of the other breast to separate reminders from each of the insurance plans in which you produce a symmetrical appearance; enroll as well as other providers describing the availability of their HIPAA notice of privacy practices and how to obtain a copy. • Prostheses;and • Treatment of physical complications of the mastectomy, HIPAA Special Enrollment Opportunity including lymphedema. If you are declining enrollment for yourself or your dependents These benefits will be provided subject to the same (including your spouse) because of other health insurance or group deductibles and coinsurance applicable to other medical and health plan coverage, you may be able to enroll yourself and your surgical benefits provided under the group medical plan. dependents in this plan if you or your dependents lose eligibility for Summary of Benefits and Coverage (SBC) that other coverage(or if the employer stops contributing toward your Availability Notice or your dependents' other coverage). However, you must request enrollment within 30 days after your or your dependents' other As required under the Patient Protection and Affordable coverage ends (or after the employer stops contributing toward the Care Act, insurance companies and group health plans are other coverage). providing consumers with a concise document detailing, in In addition,if you have a new dependent as a result of marriage,birth, plain language, simple and consistent information about health plan benefits and coverage. The purpose of the adoption, or placement for adoption, you may be able to enroll summary of benefits and coverage document is to help you yourself and your dependents.However,you must request enrollment better understand the coverage you have while allowing you within 30 days after the marriage, birth, adoption, or placement for to easily compare different coverage options. It summarizes adoption. the key features of the plan, such as the covered benefits, Also, if you or your dependents lose eligibility for coverage under cost-sharing provisions, and coverage limitations and Medicaid or the Children's Health Insurance Program (CHIP) or exceptions. become eligible for a premium assistance subsidy under Medicaid or As a result of the Patient Protection and Affordable Care Act CHIP, you may be able to enroll yourself and your dependents in this (i.e. health care reform), School District of Indian River plan. You must request enrollment within 60 days of the loss of County is required to make available a Summary of Benefits Medicaid or CHIP coverage or the determination of eligibility for a and Coverage (SBC), which summarizes important health premium assistance subsidy. plan information such as plan limits, coinsurance, and To request special enrollment or obtain more information, contact copays.The SBC is intended to provide this information in a Florida Blue at 800-545-6565 ext.25305. standard format to help you compare across health plan A federal law called HIPAA requires that we notify your right to enroll options. in the plan under its "special enrollment provision" if you acquire a The SBC is available on the School District of Indian River new dependent,or if you decline coverage under this plan for yourself County's Benefit Landing Page: or an eligible dependent while other coverage is in effect and later lose http://www.explainmybenefits.com/sdirc/ that other coverage for certain qualifying reasons. Newborns'and Mothers'Health Protection Act of 1996 Please note that an SBC is not intended to be a complete Group health plans and health insurance issuers generally may not, listing of all of the plan provisions. For more detailed under Federal law, restrict benefits for any hospital length of stay in information,please refer to the SPD and the plan document, connection with childbirth for the mother or newborn child to less collectively known as the plan documents. If there are any than 48 hours following a vaginal delivery, or less than 96 hours discrepancies between the SBC and the plan documents,the following a cesarean section. plan documents prevail. Plan Documents are also available by contacting the Employee Benefits Department. Federal law generally does not prohibit the mother's or newborn's attending provider,after consulting with the mother,from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 67 32hours(or 96 hours). Important Legal Notices Family Medical Leave Act(FMLA) What does the Family and Medical leave act provide? The Family and Medical Leave Act (FMLA) provides eligible employees up to 12 work weeks of unpaid leave a year, and requires group health benefits to be maintained during the leave as if employees continued to work instead of taking leave. Employees are also entitled to return to their same or an equivalent job at the end of their FMLA leave. Who can take FMLA leave? To be eligible to take leave under FMLA an employee must: • Have worked 1,250 hours during the 12 months prior to the start of the leave (Note: Full-time teachers and other exempt employees are assumed to have worked 1,250 hours unless proven otherwise),and • - Have worked for the employer for 12 months(in total,not consecutive)within the last 7 years. When can an eligible employee use FMLA leave? A covered employer must grant an eligible employee up to a total of 12 workweeks of unpaid,job-protected leave(26 weeks in the case of military caregiver leave described below)in a 12 month period for one or more of the following reasons: • For the birth of a child: • For the placement with the employee of a child for adoption or foster care; • To take medical leave when the employee is unable to work due to a serious health condition; • To care for an immediate family member(spouse,child or parent-but not parent"in-law")with a serious health condition; • To care for a spouse,son,daughter,parent or next-of-kin on covered active duty service with a service-related serious health condition or injury; • To deal with a qualifying emergency arising from a son's, daughter's, spouse's or parent's (but not parent "in-laws") active duty service or call to active duty service for deployment to a foreign country. Responsibilities to the District Employees Requesting Leave. It is the responsibility of the employee to notify their supervisor and iContact: Amy Yeitter,Employee Benefits Specialist provide at least thirty(30) days notice before the date the FMLA leave is to begin if the need for the leave is foreseeable.If the need for the leave Address: 6500 57th Street,Vero Beach,FL 32967 is not foreseeable,you must give notice that you need to take a leave ofPhone:7 772-564-3175 absence as soon as practicable, but in no circumstances later than the next business day after you become aware of the need for the leave,. If Email: j sdircbenefits@indianriverschools.org you fail to adhere to these timeframes for notice,your request for leave may be delayed or denied. The required forms will be provided to you - by the administrative office at your work location or the Human Contact Joan Martin,Employee Benefits Assistant Resources Department. Address: 6500 57th Street,Vero Beach,FL 32967 Procedures on what you should do when taking a leave under FMLA: PP - _1 • Inform your immediate supervisor at your work location. )Phone: 5 772-564-3011 • Request FMLA forms (4 part packet) from your work location or rj Email: sdircbenefits@indianriverschools.org Human Resources. • Submit a request for leave(normal form submitted when taking time off) it can be signed by your administrator to confirm notification but final approval is received from the Human Resources`Contact: Adalia Medina-Graham,Human Resources department. FMLA • Contact Payroll to discuss how this leave will impact your pay. Address: l 6500 57th Street,Vero Beach;FL 32967 • Complete and submit all required forms to HR for processing. • Contact Benefits to discuss premium payment while on unpaid leave Phone: 772-564-3001 OR if leave will be unpaid, contact the Benefits Team to discuss Email: premium payments adalia.medina-graham@indianriverschools.org • 68 33 Important Legal Notices Special Enrollment Provision Name&Title—Adalia Medina-Graham Loss of Other Coverage(Except Medicaid or a State Children's Health Office—Human Resources,FMLA Insurance Program). If you decline enrollment for yourself or for an Address-6500 57th Street,Vero Beach,FL 32967 eligible dependent (including your spouse) while other health Phone-772-564-3001 insurance or group health plan coverage is in effect,you may be able to Email -adalia.medina-graham@indianriverschools.org enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage(or if the employer You can file a grievance in person or by mail,fax,or email. If you stops contributing toward your or your dependents' other coverage). need help filing a grievance,Adalia Medina-Graham is available to However, you must request enrollment within 31 days after your or help you. your dependents' other coverage ends (or after the employer stops You can also file a civil rights complaint with the U.S.Department of contributing toward the other coverage). Health and Human Services, Office for Civil Rights, electronically Loss of Eligibility Under Medicaid or a State Children's Health through the Office for Civil Rights Complaint Portal,available at Insurance Program. If you decline enrollment for yourself or for an https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,or by mail or phone eligible dependent(including your spouse)while Medicaid coverage or at: coverage under a state children's health insurance program is in effect, Department of Health and Human Services you may be able to enroll yourself and your dependents in this plan if 200 Independence Avenue,SW Room 509F,HHH Building you or your dependents lose eligibility for that other coverage. Washington,D.C.20201 However, you must request enrollment within 60 days after your or 1-800-368-1019,800-537-7697(TDD) your dependents'coverage ends under Medicaid or a state children's Complaint forms are available at http://www.hhs.gov/oc r/office/ health insurance program. file/index.html. New Dependent by Marriage, Birth, Adoption, or Placement for Adoption.If you have a new dependent as a result of marriage,birth, Social Security Numbers Generally Required for adoption,or placement for adoption,you may be able to enroll yourself Enrollment and your new dependents. However, you must request enrollment Under Section 111 of the Medicare,Medicaid,and SCHIP Extension within 31 days after the marriage, birth, adoption, or placement for Act of 2007 (MMSEA), the Centers for Medicare and Medicaid adoption. Services (CMS) generally requires Social Security numbers for Eligibility for Medicaid or a State Children's Health Insurance Program. employees and dependents to assist with reporting under the If you or your dependents(including your spouse)become eligible for a Medicare Secondary Payer requirements. Accordingly, School state premium assistance subsidy from Medicaid or through a state District of Indian River will require that you provide Social Security children's health insurance program with respect to coverage under this numbers at the time of enrollment,so that School District of Indian plan,you may be able to enroll yourself and your dependents in this River County can assist its health plan administrator(s) to comply plan.However,you must request enrollment within 60 days after your with this requirement. or your dependents'determination of eligibility for such assistance. For a newborn or newly adopted child, the newborn may be All enrollment changes due to special enrollment rights are subject to enrolled, provided that School District of Indian River County is the approval of the Plan Administrator. notified within 30 days of the birth, adoption, or placement for adoption. However, if a Social Security number is not provided by Discrimination is Against the Law the later of(1)the end of the plan year,or(2)90 days following the School District of Indian River County complies with applicable Federal birth, adoption, or placement for adoption, the child will be civil rights laws and does not discriminate on the basis of race,color, disenrolled from the plan and will no longer be considered eligible national origin, age, disability, or sex. School District of Indian River for coverage.The child cannot be re-enrolled until the Social Security County does not exclude people or treat them differently because of number is provided, and the child meets one of the mid-year race,color,national origin,age,disability,or sex. enrollment or change in status coverage events. School District of Indian River County Provides free aids and services to people with disabilities to COBRA communicate effectively with us,such as: If you,your spouse,or eligible dependent loses coverage under any Qualified sign language interpreters School District of Indian River County group medical or dental plan • Written information in other formats(large print,audio,accessible because of a COBRA-qualifying event, you may have the right to electronic forthats,other formats) continue coverage under the Consolidated Omnibus Budget • Provides free language services to people whose primary language Reconciliation Act(COBRA).For details about qualifying events,refer is not English,such as: to the Initial COBRA Notice. • Qualified interpreters If your coverage ends due to a COBRA-qualifying event, you will • Information written in other languages receive a notice of your continuation rights.At that time,you will If you need these services,contact Equity&Compliance Officer.If you have up to 60 days—from the date of your event or the date you believe that School District of Indian River County has failed to provide received your notice—to decide whether you want to continue your these services or discriminated in another way on the basis of race, health coverage. color, national origin, age, disability, or sex, you can file a grievance If you, your spouse, and/or dependent have a COBRA qualifying with: 69 34 Important Legal Notices Your Group Benefits Under Section 125 Significant cost changes.If the cost you are charged for a coverage option Your employee benefit program is a Premium Conversion Plan ("Plan") significantly increases or decreases during the Plan Year,you may make a that is administered under the provisions of Section 125 of the Internal corresponding change to your Plan election. Changes that may be made Revenue Code ("Code"). These provisions permit your contributions for include commencing participation in the Plan for an option with a decrease various employee benefit plans to be deducted from your gross pay before in cost,or,in the case of an increase in cost,revoking an election for that calculation of withholding taxes.The result is that you have fewer taxes coverage and, in lieu thereof, either receiving on a prospective basis deducted from your paycheck,which increases your take home pay. coverage under a Plan option providing similar coverage or dropping Plan elections you make during your initial enrollment and annual coverage if no option providing similar coverage is available. enrollment periods are binding for the applicable Plan year.In addition to Significant coverage changes curtailment with or without loss of coverage. the HIPAA Special Enrollment Right certain permitted mid-year Plan Significant Curtailment without loss of coverage. If you or your covered election changes are permitted. These permitted election changes are Dependent has a curtailment of coverage under the Plan that is significant, discussed below. but does not represent a total loss of coverage(for example,there is a All enrollment changes due to a permitted election change are subject to significant increase in the deductible,the co-pay,or the out-of-pocket cost the approval of the Plan Administrator.The Plan Administrator will have sharing limit),you may revoke your Plan election and elect to receive on a the discretionary authority to make a determination as to whether an prospective basis coverage under another Plan option providing similar election change has occurred in accordance with the rules and regulations coverage.Coverage under the Plan is significantly curtailed only if there is of the Internal Revenue Service an overall reduction in coverage provided under the Plan so as to Change in Status constitute reduced coverage generally.Thus,in most cases,the loss of one Please see the Notice of HIPAA Special Enrollment Rights for election particular physician in a network does not constitute a significant change during the Plan Year if you experience a Change in Status event. curtailment. You must notifythe Plan Administrator within 31 days of the event.Any Y Significant curtailment with loss of coverage. If you or your covered election change due to a Change in Status event must be on account of Dependent has a curtailment of coverage under the Plan that constitutes a and consistent with your Change in Status as determined by the Plan total loss of coverage,you may revoke your Plan election and elect either Administrator. to receive on a prospective basis coverage under another Plan option Generally, an election change will be considered consistent with your providing similar coverage or to drop coverage if no similar option is Change in Status only if it is on account of and corresponds with a Change available.A loss of coverage means a complete loss of coverage under the in Status that affects an individual's eligibility for coverage under the Plan Plan option or other coverage option. or a plan maintained by the employer of your Dependent. A Change in Addition or improvement of a benefit package option. If the Plan adds a Status that affects eligibility under an employer's health plan includes a new coverage option,or if coverage under an existing coverage option is Change in Status that results in an increase or decrease in the number of significantly improved during the Plan Year,the Plan may permit eligible your Dependents who may benefit from coverage under the Plan. employees(whether or not they have previously made an election under Permitted Change in Status events under the Plan include the following: the Plan or have previously elected a coverage option) to revoke their • Change in your legal marital status due to marriage, divorce, legal election under the Plan and to make an election on a prospective basis for separation,annulment,or death of your spouse,or you enter into a coverage under the new or improved coverage option. domestic partnership, dissolve a domestic partnership or your Change in coverage under another employer plan. You may make a Domestic Partner dies. prospective election change that is on account of and corresponds with a • Change in the number of your Dependents due to birth, death, change made under another employer plan if(i)the other plan permits adoption,or placement for adoption. participants to change an election as described in this section,and(ii)the • Change in employment status of you, your covered Dependents other plan permits participants to make an election for a period of including a termination or commencement of employment, coverage that is other than the Plan Year. For example, if you elect commencement of or return from an unpaid leave of absence, a coverage through your spouse's employer's plan and that plan has a different annual enrollment period from this Plan, you may make a change in worksite, or any other change in employment status, if corresponding election change. such change in employment status affects eligibility under a plan. Family and Medical Leave Act. If you take leave under the Family and • Change in eligibility status of your Dependent Child(ren)on account Medical Leave Act(FMLA)you may revoke an existing Plan election and of age,or any other circumstance affecting eligibility. make another election for the remaining portion of the Plan year as may • Change in residence of you or your covered Dependent. be provided for under the FMLA and regulations of the Internal Revenue Qualified Medical Child Support Orders.If required by a Qualified Medical Service. Child Support Order("QMCSO"),you and/or an eligible dependent will be Exchange Enrollment.Two mid-year election changes will be available to enrolled in the Plan in accordance with the terms of the order. Any participants who meet the requirements of these election changes. required premiums will be deducted from your compensation. Upon Reduction of Hours. If your hours are reduced to an expected average of request to the Plan Administrator,you may obtain,without charge,a copy less than 30 hours per week,you may revoke your election for coverage of the Medical Plan's procedures governing QMCSO determinations. under the Plan if you intend to enroll in coverage offered in a government- You may make an election change to cancel coverage for your child if a sponsored Exchange(Marketplace) or in another group health plan that QMCSO requires your spouse, former spouse, or other individual to offers minimal essential coverage.This election change may be made even provide coverage for the child;and that coverage is actually provided. if the reduction in your hours would not cause you to lose coverage under Entitlement To or.Loss of Entitlement To Medicare or Medicaid.If you or the Plan. You will be required to provide the Plan Administrator with your Covered Dependent becomes entitled to coverage (i.e., becomes evidence that you intend to enroll in another plan with coverage effective enrolled) under Part A or Part B of Medicare or Medicaid, other than no later than the first day of the second month following the revocation coverage consisting solely of benefits under section 1928 of the Social (i.e.,if your coverage is revoked in May,coverage under the new plan must Security Act(the program for distribution of pediatric vaccines),you may begin on July 1). make a prospective election change to cancel or reduce coverage under Obtaining Cover Through the Health Insurance Marketplace. If you are the Plan for you or your applicable covered Dependent.In addition,if you enrolled in the Plan and are eligible to enroll for coverage in a government- or an eligible Dependent has been entitled to coverage under Medicare or sponsored Exchange (Marketplace) during a special or annual open Medicaid and loses eligibility for such coverage, you may make a enrollment period, you may prospectively revoke your election for Plan prospective election to commence or increase your or your eligible coverage, provided that you certify that you and any related individuals Dependent's coverage,as appropriate,under the Plan. whose coverage is being revoked have enrolled or intend to enroll for new Significant Change in Cost or Coverage Changes.You may also change your Exchange coverage that is effective beginning no later than the day election mid-year due to a significant change in Plan cost or coverage,as immediately following the last day of Plan coverage. 70 provided below. 35 Premium Assistance Under Medicaid and the Children's Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you're eligible for health coverage from your employer,your state may have a premium assistance program that can help pay for coverage,using funds from their Medicaid or CHIP programs.If you or your children aren't eligible for Medicaid or CHIP,you won't be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace.For more information,visit www.healthcare.gov If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below,contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP,and you think you or any of your dependents might be eligible for either of these programs,contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply.If you qualify,ask your state if it has a program that might help you pay the premiums for an employer- sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP,as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren't already enrolled.This is called a"special enrollment" opportunity,and you must request coverage within 60 days of being determined eligible for premium assistance.If you have questions about enrolling in your employer plan,contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states,you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31,2020.Contact your State for more information on eligibility— ALABAMA—Medicaid COLORADO—Health FirstColorado(Colorado's Medicaid Program)&Child Health Plan Plus(CHP+) Website:http://myalhipp.com/ Health First Colorado Website:https://www.healthfirstcolorado.com Phone: 1-855-692-5447 Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+:https://www.colorado.gov/pacific/hcpf/child-health-plan- plusCHP+ Customer Service: 1-800-359-1991/State Relay 711 ALASKA—Medicaid FLORIDA—Medicaid The AK Health Insurance Premium Payment Program Website:http://flmedicaidtplrecovery.com/hipp/ Website:http://myakhipp.com/ Phone: 1-877-357-3268 Phone: 1-866-251-4861 Email:CustomerService@MyAKHIPP.com Medicaid Eligibility:http://dhss.alaska.gov/dpa/Pages/Medicaid/ default.aspx CALIFORNIA—Medicaid INDIANA—Medicaid Website:https://www.dhcs.ca.gov/services/Pages/ Healthy Indiana Plan for low-income adults 19-64 TPLRD_CAU_cont.aspx Website:http://www.in.gov/fssa/hip/ Phone: 1-800-541-5555 Phone: 1-877-438-4479 All other Medicaid Website:http://www.indianamedicaid.com Phone 1-800-403-0864 IOWA—Medicaid and CHIP(Hawki) NEBRASKA—Medicaid Medicaid Website:https://dhs.iowa.gov/ime/members Website:http://www.ACCESS Medicaid Phone: 1-800-338-8366 Nebraska.ne.gov Hawki Website:http://dhs.iowa.gov/Hawki Phone: 1-855-632-7633 Hawki Phone: 1-800-257-8563 Lincoln:402-473-7000 Omaha:402-595-1178 KANSAS—Medicaid NEVADA—Medicaid Website:http://www.kdheks.gov/hcf/default.htm Medicaid Website:http://dhcfp.nv.gov Phone: 1-800-792-4884 Medicaid Phone: 1-800-992-0900 KENTUCKY—Medicaid NEW HAMPSHIRE—Medicaid Kentucky Integrated Health Insurance Premium Payment Program(KI Website:https://www.dhhs.nh.gov/oii/hipp.htm -HIPP)Website: Phone:603-271-5218 https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Toll free number for the HIPP program: 1-800-852-3345,ext 5218 Phone: 1-8 55-4 59-6 328 Email:KIHIPP.PROGRAM@ky.govKCHIP Website:https://kidshealth.ky.gov/Pages/index.aspx Phone: 1-8 77-524-4718 Kentucky Medicaid Website:https://chfs.ky.gov 71 36 LOUISANA—Medicaid ®JERSEY—Medicaid and CHIP Website:www.medicaid.la.gov or www.ldh.la.gov/lahipp Medicaid Website:http://www.state.nj.us/humanservices/dmahs/ Phone: 1-888-342-6207(Medicaid hotline)or 1-855-618-5488 clients/medicaid/ (LaHIPP) Medicaid Phone:609-631-2392 CHIP Website:http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 l MAINE—Medicaid NEW YORK—Medicaid Website:http://www.maine.gov/dhhs/ofi/public-assistance/index.html ▪ Website:https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-442-6003 Phone: 1-800-541-2831 TTY:Maine relay 711 MASSACHUSETTS—Medicaid and CHIP NORTH CAROLINA—Medicaid Website:http://www.mass.gov/eohhs/gov/departments/masshealth/ • Website:https://medicaid.ncdhhs.gov/ Phone: 1-800-862-4840 Phone:919-855-4100 1. MINNESOTA—Medicaid NORTH DAKOTA—Medicaid Website:https://mn.gov/dhs/people-we-serve/children-and-families/ Website:http://www.nd.gov/dhs/services/medicalserv/medicaid/ health-care/health-care-programs/programs-and-services/medical- Phone: 1-844-854-4825 assistance.jsp[Under ELIGIBILITY tab,see"what if I have other health insurance?"] Phone: 1-800-657-3739 MISSOURI—Medicaid OKLAHOMA—Medicaid and CHIP Website:http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Website:http://www.insureoklahoma.org Phone:573-751-2005 Phone: 1-888-365-3742 MONTANA—Medicaid OREGON—Medicaid • L � Website:http://dphhs.mt.gov/MontanaHealthcarePrograms/ Website:http://healthcare.oregon.gov/Pages/index.aspxhttp:// HIPPPhone: 1-800-694-3084 www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075 PENNSYLVANIA—Medicaid RHODE ISLAND—Medicaid and CHIP Website:https://www.dhs.pa.gov/providers/Providers/Pages/Medical/ Website:http://www.eohhs.ri.gov/ HIPP-Program.aspx Phone: 1-855-697-4347,or 401-462-0311(Direct Rite Share Line) Phone: 1-800-692-7462 SOUTH CAROLINA—Medicaid VIRGINIA—Medicaid and CHIP Website:https://www.scdhhs.gov Website:haps://www.coverva.org/hipp/ Phone: 1-888-549-0820 Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-855-242-8282 SOUTH DAKOTA—Medicaid WASHINGTON—Medicaid Website:http://dss.sd.gov Website:https://www.hca.wa.gov/ Phone: 1-888-828-0059 Phone: 1-800-562-3022 TEXAS—Medicaid T WEST VIRGINIA—Medicaid Website:http://gethipptexas.com/ Website:http://mywvhipp.com/Toll-free Phone: 1-800-440-0493 phone: 1-855-MyWVHIPP(1-855-699-8447) UTAH—Medicaid and CHIP WISCONSIN—Medicaid and CHIP Medicaid Website:https://medicaid.utah.gov/ Website:https://www.dhs.wisconsin.gov/publications/pl/p10095.pdf CHIP Website:http://health.utah.gov/chip Phone: 1-800-362-3002 Phone: 1-877-543-7669 IVERMONT—Medicaid WYOMING—Medicaid Website:http://www.greenmountaincare.org/ Website:https://wyequalitycare.acs-inc.com/ Phone: 1-800-250-8427 Phone:307-777-7531 To see if any other states have added a premium assistance program since January 31,2020,or for more information on special enrollment rights,contact either:U.S.Department of Labor Employee Benefits Security Administrationwww.dol.gov/agencies/ebsal-866-444-EBSA (3272)or U.S.Department of Health and Human Services Centers for Medicare&Medicaid Serviceswww.cms.hhs.govl-877-267-2323, Menu Option 4,Ext.61565 Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995(Pub.L.104-13)(PRA),no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget(OMB)control number.The Department notes that.a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA,and displays a currently valid OMB control number,and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number.See 44 U.S.G.3507.Also,notwithstanding any other provisions of law,no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number.See 44 U.S.C.3512.The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent.Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information,including suggestions for reducing this burden,to the U.S.Department of Labor,Employee Benefits Security Administration,Office of Policy and Research,Attention:PRA Clearance Officer,200 Constitution Avenue,N.W.,Room N-5718,Washington,DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137. OMB Control Number 1210-0137(expires 1/31/2023) 72 37 New Health Insurance Marketplace Coverage p g Form Approved Options and Your Health Coverage OMB No. 1210-0149 '` (expires 6-30-2023) PART A: General Information When key parts of the health care law take effect in 2014,there will be a new way to buy health insurance:the Health Insurance Marketplace.To assist you as you evaluate options for you and your family,this notice provides some basic information about the new Marketplace and employment based health coverage offered by your employer. What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget.The Marketplace offers"one-stop shopping`'to find and compare private health insurance options.You may also be eligible for a new kind of tax credit that lowers your monthly premium right away.Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1,2014. Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium,but only if your employer does not offer coverage,or offers coverage that doesn't meet certain standards.The savings on your premium that you're eligible for depends on your household income. Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes.If you have an offer of health coverage from your employer that meets certain standards,you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan.However,you may be eligible for a tax credit that lowers your monthly premium,or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards.If the cost of a plan from your employer that would cover you(and not any other members of your family)is more than 9.5%of your household income for the year,or if the coverage your employer provides does not meet the"minimum value"standard set by the Affordable Care Act,you may be eligible for a tax credit.i Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution(if any)to the employer-offered coverage.Also,this employer contribution -as well as your employee contribution to employer-offered coverage-is often excluded from income for Federal and State income tax purposes.Your payments for coverage through the Marketplace are made on an after-tax basis. How Can I Get More Information? For more information about your coverage offered by your employer,please check your summary plan description or contact. The Marketplace can help you evaluate your coverage options,including your eligibility for coverage through the Marketplace and its cost.Please visit HealthCare.gov for more information,including an online application for health Insurance coverage and contact information for a Health Insurance Marketplace in your area. 'An employer-sponsored health plan meets the"minimum value standard"if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs. 73 38 PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace,you will be asked to provide this information. This information is numbered to correspond to the Marketplace application. 3.Employer name 4.Employer Identification Number(EIN) School District of Indian River County 59-6000884 15.Employer address 6.Employer phone number 6500 57th Street 772-564-3175 1 7.City 8.State ZIP code Vero Beach Florida 32967 I10.Who can we contact about employee health coverage at this job? Employee Benefits,Amy Yeitter 11.Phone number(ifdifferentfromabove) 12.Email address n/a sdircbenefits@indianriverschools.org Here are some basic information abouthealth coverage offered by this employer: • As your employer,we offera health plan to: aAII employees.Eligible employees are: All regular employees working at least 30 hours per week. ❑Some employees.Eligible employees are: • With respect to dependents: O We do offer coverage. Eligible dependents are: Spouse—Legally'married;Children—up to age 26 under Health Care Reform. Up to age 30,Florida Statute if child is: 1)Unmarried without dependents of their own AND 2)A Florida resident of a full-time student AND 3) Not covered under any health plan or policy AND 4) Not entitled to coverage under Medicare 1 ❑We do not offer coverage ' 0 If checked,this coverage meets the minimumvalue standard,and the cost of this coverage to you is intended to be affordable,based on employee wages. ** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace.The Marketplace will use your household income, along with other factors,to determine whether you may be eligible for a premium discount. If,for example,your wages vary from week to week(perhaps you are an hourly employee,or you work on a commission basis),if you are newly employed mid-year,or if you have other income losses,you may still qualify fora premium discount. If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to loweryour monthly premiums. 74 39 Important Legal Notices Glossary Patient Protection Provider Choice Florida Blue generally requires the designation of a primary care ACA(Patient Protection andAffordable Care Act) Also provider for members of the HMO plan. You have the right to called Health Care Reform,the intentoftheAffordableCare designate any primary care provider who participates in our Act is to make affordable health care available to all network and who is available to accept you or your family Americans.The ACA became law in March 2010.Sincethen, members. Until you make this designation, Florida Blue designates the ACA has required some changes to medical coverage— one for you. For information on how to select a primary care pro- like coveringdependentchildrentoage26,nolifetimelimits vider,and for a list of the participating primary care providers,con on medical benefits,reduced FSA contributions,free tact Florida Blue at 1-877-352-2583. preventive care,etc. For children,you may designate a pediatrician as the primary care provider. Brand Name Drug—The original manufacturer's version ofa You do not need prior authorization from Florida Blue or from any particular drug.Because the research and development costs other person (including a primary care provider) in order to obtain that went into developingthese drugs are reflected in the price, access to obstetrical or gynecological care from a health care brandnamedrugscostmorethangeneric drugs. professional in our network who specializes in obstetrics or Coinsurance—A percentage of costs you pay"out of pocket" gynecology. The health care professional, however, may be forcoveredexpensesafteryoumeetthedeductible. required to comply with certain procedures, including obtaining prior authorization for certain services, Copay(Copayment)-A fee you have to pay"out of pocket" following a pre-approved treatment plan,or procedures for making for certain services,such as a doctor's office visit referrals. For a list of participating health care professionals who or prescription drug. specialize in obstetrics or gynecology, contact the Florida Blue at 1-877-352-2583. Deductible—The amount you pay"out of pocket"before the health plan will startto pay its share of covered expenses. Patient Protection and Affordable Care Act (PPACA, or Health Care Reform) Employer Contribution—School District of Indian River The Affordable Care Act (ACA) has brought sweeping changes to County provides you with an amount of money that you can the U.S. health insurance system. Its goal is to make health applytowardthecost of your healthcarepremiums.The insurance available to everyone, regardless of medical history or amount of the employer contribution depends on who you ability to pay. Many of the ACA changes have already affected our cover.You canseetheamountyou'Ilreceivewhenyouenroll.lf plans, such as covering adult children through age 26, free you'reenrollingasanewhire,theemployer contribution preventive care, reducing or removing annual or lifetime limits on amount will be prorated based on your date of hire. essential health benefits, and the $2,750 cap on Medical Expense FSA contributions.Some of the biggest changes resulting from the Generic drug—Lower-cost alternative to a brand name drug that law took effect January 1, 2014. These changes are explained be- has the same activeingredients and worksthesame way. low. Medical Plan Enhancements Out-of-pocket maximum—The most you pay each year All of the medical plans offered by School District of Indian River "out of pocket"for covered expenses. Once you've reached comply with the required changes and result in the following the out-of-pocket maximum,the health plan pays 100%for changes: (1)The annual maximum includes the annual deductible. covered expenses. (2) The annual out-of-pocket maximum is capped, lowering the maximum that you could pay for eligible health care expenses in a Plan year—The yearfor which the benefitsyouchooseduring Annual Enrollment remain in effect.Ifyou'reanew employee, year. your benefits remain in effect for the remainder of the plan Social Security Numbers year in which you enroll, and you enroll for the next plan Effective January 2016, the Affordable Care Act (ACA) will require year during the next Annual Enrollment. employers and health insurance carriers to file reports under the Preventive care—Health care services you receive when you Internal Revenue Code to establish compliance with the employer are not sick or injured—so that you will stay healthy. These mandate. As part of this requirement, School District of Indian include annual checkups,gender-and age-appropriate health River County must provide. Social Security numbers for all screenings,well-babycare,and immunizationsrecommended individuals covered by a School District of Indian River County by the American Medical Association. sponsored medical plan.In compliance with the ACA requirements, you will be asked to provide Social Security numbers for yourself and all dependents enrolled in a School District of Indian River County sponsored medical plan. If you are unable to respond to this request our health insurance carrier may also request Social Security numbers for your enrolled dependents. 75 40 Enrollment Preparation Worksheet ICurrent Election New Election Medical ' Florida Blue Florida Blue 5770 / 5772 / 5774 5770 / 5772 / 5774 Tier EE ES ECH FAM $ EE ES ECH FAM $ Flex Spending Chard-Snyder Chard-Snyder Medical$ Medical$ Dependent Care$ Dependent Care$ Dental Cigna Dental Cigna Dental High PPO / Low PPO / DHMO High PPO / Low PPO / DHMO Tier EE ES ECH FAM $ EE ES ECH FAM $ Vision United Healthcare UnitedHealthcare Option 1 / Option 2 Option 1 / Option 2 Tier EE ES ECH FAM $ EE ES ECH FAM $ Life Insurance The Standard The Standard Employee Coverage$ Employee Coverage$ Deduction$ Deduction$. Spouse Coverage$ Spouse Coverage$ Deduction$ Deduction$ Child(ren)Coverage$ Child(ren)Coverage$ Deduction$ Deduction$ Short Term Disability, Cigna Disability Cigna Disability Monthly Benefit$ Monthly Benefit$ Deduction$ Deduction$ Long Term Disability Cigna Disability Cigna Disability Weekly Benefit$ Weekly Benefit$ Deduction$ Deduction$ Accident/Critical Illness/Cancer MetLife MetLife • Accident Accident EE ES ECH FAM $ EE ES ECH FAM $ Critical Illness Critical Illness EE ES ECH FAM $ EE ES ECH FAM $ Cancer Cancer EE ES ECH FAM $ EE ES ECH FAM $ Legal&Identity LegalShield Only LegalShield Only Theft Protection EE ES ECH FAM $ EE ES ECH FAM $ IDShield Only IDShield Only EE ES ECH FAM .$ EE ES ECH FAM $ Combo Plan Combo Plan EE ES ECH FAM $ EE ES ECH FAM $ • EE=Employee ES=Employee&Spouse ECH=Employee&Child(ren) FAM=Family 76 41 0 � �. 0 11 \.. ,i-A. / \ '0 ts;:,#4 / \ IM t Benefit Guide Description Please Note: This guide provides information regarding the District's benefit program. More detailed information is available from the plan documents and administrative contacts. The plans and policies stated in this information are not a con- tract or a promise of benefits of any kind,and therefore,should not be interpreted as such. About This Guide TO guide highlights lm employee benefits. Official OM fja insurance documents govern tap rights EEO benefits under GEgra plan. Ilts more details about irgiff benefits, including covered expenses, exclusions, erid limitations, please Eby(bag individual summary GM descriptions (SPDs), MB document Cr certificate m coverage for each plan. ®per discrepancy Gag between alb guide ta the official documents, t official documents dB prevail. ¶School District WIndian River County GEGOO ago=make changes egQfiy (j( 'i g benefits, costs aid other provisions relative t benefits. 77 T `o o' \ m a N 2 c 0 E ° m N $ 2 < E o c c ° v 2 x c S 3 d 11 2 a N o m m m e V m E E i ' p m 8i o c ° u r.E c E ° c c = m n ae g 4q g - F ct 2 v E ° z a an- 3e w c = - _m n a o n .4E 2 > --5o E ° _ `o n - as V e m X m tt c g m a E 6' n _ Of ! n g E ° x ; d i E E t a '2 ".11-.A 3 N -2.-2 - ..m - - 2 i 5 c m o C u E E n Y. 4-2-12 E .V d u m E `°' ;10. 2 3 L m E m - .`o - E - m9 aE ° o a ° '02 ';!.3 .°4 oZ. „ .. . 9 y 3 a _8 v rmEy - cu = n cb E - 0 rE _ c c Z'v c I ta c wo o t. 2 E - 5.2', g °o �r c' .1'.g » 33e f N 0 m V v _ u u $ �i c a m o 0 c E_ n A a m C E c .�. E ° u w 3 r m E - n 2 E m r, m 'c z,235. c l9?' _ - c E ° E E t7 c $ ` _ u u °' w "it: u a 0 - .q E w m E c$ o E . « ''--: ;6 n �`' o �3 0 -`, - m c r c E E m 5 3 - z,, Z u ° E_ a m S ° t9 m E c 3 d a - 1'2- c m ,�N = r m c c u a «o m o E - .; a`o y8i aE v _ * u ^m°= 2c .L SE u s : :2k E oc Emc gig - w ncM ' ° d cuu 'mm ' m- + ` 775 ,, 'A ..;,,aa gE 52 '2 v '° 2 uoE v0 ',- .s. 5 ma NE a Nvt Ec in; aL o m Ed Eq ` i r . nv 2H NnNn' - m\ n d S tin Lint r0 ''411E -11 - ti .:"..-k . 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E'o o$ V v c 'o ' £ E '; N y 20d ` a' gt .1, gEEDgE - aro E9 _ E O'SmavEcol E E eg 07' g- m= d g E m a = V y c $ w _:, : S .`. _ ,I m u tea m i, m °- n i a u E _ 5 i.n �+ E= d o 'o ' ': E i Z a m o C 2 o N T >a_ E u q ::i N o c E° 5 a ci ry m o N ° m \ v m a c f v v : Et ` m ocz O rm E u E'O a « «9 a u 5 !4,,s, !av = '-" `ma m E iZ - t u° n'3 s° 4 d n 3 d 3 x° g 2 0 3 3 3 0 3 d 3 o n 3 3 3 s x° o d a oi 2 `3 S o 'o o m 1 2 k E ; { . | . \ i• g E § \ \ •g ° I ) ! ƒ ( . ■ !! 2 f ?279 \ }-.=. \ \\ \ 1111 )"« ) 82 \ \\ } '51 i2lr *g: \ ) k. n �. .\ ._.\/ • , } | ! 7 ) ! - ] } ] ) \ . . • 8 E ') ) �� t' f ; r: § 2 § f { . . 2 E 2 ( § \ / , * ) ) ( § f7{ ,- 01 .0 p \}� \ L\ \j2 2.0 ? �� • 15 g k \ 7 .▪ T1 .22 k1� 1 , 1111111112 , 1121 2 -m1 § . . _- - !!! © !!}\ ! l � ; 1 1- .., • ....._:.• •,••, -,.. ,...,- ...=::=...-- . 13C)&21) OT COURsrtf CONNO@§acnsmag3 sy , ----------.111..OM ems= , ...... 1111111 ..-. 1 . . 1 . „- • .- ,Ilio . , ,..i. ,,.....,.,,,,,,,,...,..t ._..,....„.1.,.,_.. „....,„. 04.1 , — - .,.7 i;•,--. ^, '-4- - -',,i:.' ;„,,,,,-!;,e,A ''•P.-4.. , 'S''',''kr*. . . '''' '*,'''''',4*:.':I....4'.''' . ., ', 7 '''' 't C'''-'. ''';1'e'' ' :'&'. '.-..k rd2; ‘-`X.0",'*, , -,,,.,-',--:^.-T:114 - . :•••' - , , P LI OM --• n N ociu@millicom PLAN YEAR: JANUARY ilo 2021 0 DECEMBER alo 2021 ., '4k .& 'haw-,.,`', =' `,, , d `1 Iii 7' ` . . .. .....,..„,„ ,.., ,„0.,,, _ „.., . , , • A I - �4 7� . - , ,/ . -,r _ ' , • ; x ."'' J. .0!a t, i'4g :t i's„ ,, � `,y: rabga � � UF,t;'% 7 tAt-r), ---;-:;10gA 11,1 I Have you taken advantage of the Martin County Employee Wellness Center Located in the Monterey Medical Center at 1050 Monterey Road,Suite 101 in Stuart Services are FREE! • Exclusively YOURS! • Wait times are MINIMAL! The Employee Wellness Center (EWC) is available to provide the care you and your family need for all non-emergency illnesses. These services are available at no cost for employees and their dependents enrolled under the County's medical plan.Schedule an appointment with the medical staff to learn more about the Employee Wellness Center. On-Site X-rays and Labs If an outside doctor orders blood work for you,simply bring the lab slip to the Employee Wellness Center and we will take care of drawing the blood. On-Site Prescription Dispensing The Employee Wellness Center stocks widely used generic medications at no cost.However,you will be required to schedule a visit with one of the medical providers before a prescription will be dispensed. NEW EXTENDED HOURS! HOURS OF OPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday 7:30 a.m.-5p.m* 7:30 a.m.-5p.m* 7:30 a.m.-7p.m. 7:30 a.m.-5p.m* 7:30 a.m.-5p.m* 9a.m.-1p.m. Closed* *The Urgent Care facility is open to the general public and employees from 5pm-6pm during the week and from 8am-2pm on Sundays. Call or log on(click on the Patient Portal tab)to schedule your appointment today! (772) 872-7304 or www.employeewell.com This document may be reproduced upon request in an alternative format by contacting the County ADA Coordinator(772)320-3131,the County Administration Office(772)288-5400, Florida Relay 711,or by completing our accessibility feedback form at www.martin.fl.us/accessibility-feedback 81 ©2016,Gehring Group,Inc.,All Rights Reserved Martin County Board of County Commissioners I Employee Benefit Highlights 12021 EJTI Table of Contents Contact Information 1 Introduction .2 Online Benefit Enrollment._ 1 0 Group Insurance Eligibility 3 Qualifying Events and Section 125 4 Summary of Benefits and Coverage 4 Medical Insurance 5 4 ) . Dental Plan Premium 5 Other Available Plan Resources 5 Telehealth 5 --( Florida Blue—BlueOptions Plan At-A-Glance 6 �D Dental Insurance 7 Florida Combined Life BlueDental Choice PPO Plus Plan At-A-Glance, 8 ge Vision Insurance. 9 Humana Vision 100 Plan At A Glance_ 10 Health Reimbursement Account, 11-12 Flexible Spending Accounts 13-14 Employee Assistance Program 15 /no Basic Life and AD&D Insurance 15 Voluntary Life Insurance .16 (72i ) i Voluntary Long Term Disability 17 Q. iii.) Supplemental Insurance 18 Additional County Benefits 19 Legal&Identity Theft Plan 19 Notes 20 This booklet is merely a summary of employee benefits.For a full description,refer to the plan document.Where conflict exists between this summary and the plan document,the plan document controls. The Martin County Board of County Commissioners reserves the right to amend,modify or terminate the plan at any time.This booklet should not be construed as a guarantee of employment. 82 ©2016,Gehring Group,Inc.,All Rights Reserved %..3 Martin County Board of County Commissioners I Employee Benefit Highlights 12021 Contact Information Matthew Graham Phone:(772)221-1320 Director of Human Resources Email:mgraham@martin.fl.us Sara Walker Phone:(772)221-1455 Human Resources Manager Email:swalker@martin.tl.us Board of County Commissioners Heather Dayan Phone:(772)463-2885 Human Resources Manager Email:hdayan@martin.fl.us Ashley Collier Phone:(772)463-2855 Human Resources Generalist Email:acollier@martin.fl.us Clerk and Comptroller Stephanie Glasser Phone:(772)463-3264 Human Resources Email:sglasser@martinderk.com Tax Collector Judy Friend Phone:(772)223-7932 Human Resources Email:jfriend@mctc.martin.fl.us Property Appraiser Daina Takao Phone:(772)288-5711 • Director of Operations Email:daina.takacs@pa.martin.fl.us Kerry Sees,CPP Phone:(772)288-5988 Payroll(Board,Clerk&Supervisor of Elections) Payroll Manager Email:ksees@martinclerk.com • Martin County Employee Benefits Contact Brandie LaFave Phone:(772)320-3029 Fax:(772)223-2168 Benefits Specialist Email:blafave@martin.fl.us � Customer Service:(888)5-Bentek(523-6835) l 1 Online Benefit Enrollment Bentek Support www.mybentek.com/martincounty Medical Insurance Florida Blue Customer Service:(800)664-5295 Group Number.91221 www.floridablue.com �(� Prescription Drug Coverage Customer Service:(866)230-7261 ^per &MailOrder Program Express Scripts Pharmacy www.express-scripts.com \` Telehealth Teladoc Customer Service:(800)835-2362 v www.Teladoc.com EZEI Health Reimbursement Account Benefits Workshop Customer Service:(888)537-3539 www.benefitsworkshop.com/martincounty 0 Dental Insurance Florida Combined Life Customer Service:(888)223-4892 Group Number.247L66 www.floridabluedental.com ® Vision Insurance Humana Customer Service:(877)398-2980 Group Number.VS3145 www.humana.com Flexible Spending Accounts Benefits Workshop Customer Service:(888)537-3539 www.benefitsworkshop.com/martincounty 0 0 The Standard Customer Service:(800)247-6888 GM Basic Life and AD&D Insurance Group Number.642407 www.standard.com Long Term Disability Insurance The Standard Customer Service:(800)247-6888 En Employee Assistance Program New Directions Customer Service:(800)624-5544 eap.ndbh.com Agent:Karen Zabaglol Phone:(772)284-3210 Supplemental Insurance Aflac Email:karen_zabaglo@us.aflac.com Agent:Loire Lucas I Phone:(772)708-5931 Email:loire_lucas@us.aflac.com Agent:Steve Baker I Phone:(321)613-0037 Legal&Identity Theft Plan Legal Shield Email:sb@legalshieldassociate.com Cobra Benefits Workshop Customer Service:(888)537-3539 www.benefitsworkshop.com/martincounty 83 1 ©2016,Gehring Group,Inc.,All Rights Reserved Martin County Board of County Commissioners I Employee Benefit Highlights 12021C©131 4 ,0 °Fn `n� Online Benefit Enrollment &N-11The Coun rovides em to ees with an online benefits enrollment �1 tl'P P Y14Wij)fI platform through Bentek's Employee Benefits Center(EBC).The EBC � �I� ��� 44 provides benefit-eligible employees the ability to select or change OF ft,'; 61, insurance benefits online during the annual Open Enrollment Period, New Hire Orientation,or for Qualifying Life Events. Accessible 24 hours a day,throughout the year, employee may log • in and review comprehensive information regarding benefit plans, Introduction and view and print an outline of benefit elections for employee and dependent(s).Employee also has access to important forms and carrier The Martin County Board of County Commissioners provides group insurance links,can report qualifying life events and review and make changes to benefits to eligible employees. The Employee Benefit Highlights Booklet Life insurance beneficiary designations. provides a general summary of these options as a convenient reference.Please refer to the County's Personnel Policies, applicable Union Contracts and/or . , \ - _ -_- Certificates of Coverage for detailed descriptions of all available employee C=I benefit programs, and stipulations therein. If employee requires further - Q .ar.o ` explanation or needs assistance regarding claims processing,please refer to o O ® @ the customer service phone numbers under each benefit description heading @ @ p p • o Q or contact the Martin County Employee Benefits Specialist. O o ., ® • ° © •1i To Access the Employee Benefits Center: ✓ Log onto www.mybentek.com/martincounty ✓ Sign in using a previously created username and password or click"Create an Account"to set up a username and password. ✓ If employee has forgotten username and/or password,click on the link "Forgot Username/Password"and follow the instructions. ✓ Once logged on, navigate using the Launchpad to review current enrollment,learn about benefit options,and make any benefit changes or update beneficiary designations. For technical issues directly related to using the EBC, please call (888) 5-Bentek (523-6835) or email Bentek Support at support@mybentek.com, Monday through Friday during regular business hours 8:30am-5:00pm. To access Employee Benefits Center online,log on to: www.mybentek.com/martincounty Please Note:Link must be addressed exactly as written.Due to security reasons, the website cannot be accessed by Google or other search engines. 84 2 ©2016,Gehring Group,Inc.,All Rights Reserved 0 Martin County Board of County Commissioners I Employee Benefit Highlights 12021 Group Insurance Eligibility 1wu ' The County's grout Insurance !tan year Is Documentation Requirements O�. January I through December 31. All dependents must have an established legal relationship to the employee to be covered under the benefit program.The types of documentation accepted are as stated in the table below. Employee Eligibility Employee with dependents enrolled in the group insurance plan are advised Employees are eligible to participate in the County's insurance plans if they that they will be required to comply with this process or may jeopardize are working a minimum of 30 hours per week.Coverage will be effective the maintaining continued coverage for such dependents. first of the month following 30 calendar days of employment.For example, if employee is hired on April 11,then the effective date of coverage will be Dependent Relationship Documentation Required June 1. •Copy of legal government issued marriage Spouse certificate,Social Security card, Separation of Employment _ _ _ If employee separates employment from the County,insurance will continue •Copy of State issued birth certificate(s)OR copy through the end of the month in which separation occurred. COBRA Dependent Child(ren)Under Age 26 of legal guardianship court documents listing continuation of coverage may be available as applicable by law. the employee as legal guardian. •AND Social Security card. Dependent Eligibility v� •Copy of State issued birth certificate(s),Social A dependent is defined as the legal spouse and/or dependent child(ren)of the Step-Child(ren)Under Age 26 Security card, participant or spouse.The term"child"includes any of the following: •AND copy of State issued marriage certificate. • A natural child • A stepchild • A legally adopted child y �� • A newborn child(up to the age of 18 months)of a covered dependent Child(ren)under Legal Guardianship, 'Copy of court documents showing legal Custody or Foster Care Under Age 26 guardianship OR legal custody OR foster care (Florida) placement. • A child for whom legal guardianship has been awarded to the - - - — _ participant or the participant's spouseChildren)Adopted or in the process •Copy of court documents of the legal adoption of Adoption Under Age 26 showing relationship to and placement in the employee's house OR Adoption Certificate. Dependent Age Requirements Medical, Dental,and Vision Coverage:A dependent child may be covered through the end of calendar year in which the child turns age 26. Disabled Dependents Coverage for a dependent child may be continued beyond age 26 if: • The dependent is physically or mentally disabled and incapable of self-sustaining employment(prior to age 26);and • Primarily dependent upon the employee for support;and • The dependent is otherwise eligible for coverage under the group medical plan;and • The dependent has been continuously insured. Proof of disability will be required upon request.Please contact the Benefits Specialist if further clarification is needed. 85 3 ©2016,Gehring Group,Inc.,All Rights Reserved • Martin County Board of County Commissioners I Employee Benefit Highlights 12021 Qualifying Events and Section 125 Section 125 of the Internal Revenue Code N, Premiums for medical, dental, vision insurance, contributions to Flexible Spending Accounts and/or certain supplemental policies are deducted through IMPORTANT NOTES • a Cafeteria Plan established under Section 125 of the Internal Revenue Code and are pre-taxed to the extent permitted. Under Section 125, changes to If employee experiences a Qualifying Event,the Benefits Specialist employee's pre-tax benefits can be made ONLY during the Open Enrollment must be contacted within 30 days of the Qualifying Event to period unless the employee or qualified dependent(s) experience(s) a make the appropriate changes to employee's coverage. Beyond 30 Qualifying Event and the request to make a change is made within 30 days of days,requests will be denied and employee may be responsible,both the Qualifying Event. legally and financially,for any claim and/or expense incurred as a result Under certain circumstances, employee may be allowed to make changes of employee or dependent who continues to be enrolled but no longer to benefit elections during the plan year if the event affects the employee, meets eligibility requirements.If approved,changes may be effective spouse or dependent's coverage eligibility. An "eligible" Qualifying Event the date of the Qualifying Event or the first of the month following is determined by Section 125 of the Internal Revenue Code.Any requested the Qualifying Event. Newborns are effective on the date of birth. changes must be consistent with and due to the Qualifying Event. Cancellations will be processed at the end of the month.In the event of death,coverage terminates the day following the death.Employees Examples of Qualifying Events: may be required to furnish valid documentation supporting a change • Employee gets married or divorced in status or"Qualifying Event:' • Birth of a child • Employee gains legal custody or adopts a child • Employee's spouse and/or other dependent(s)die(s) Summary of Benefits and Coverage • Loss or gain of coverage due to employee,employee's spouse and/ A Summary of Benefits&Coverage(SBC)for the Medical Plan is provided as a or dependent(s)termination or start of employment supplement to this booklet being distributed to new hires and existing employees during the Open Enrollment period. The summary is an important item in • An increase or decrease in employee's work hours causes eligibility understanding employee's benefit options.A free paper copy of the SBC document or ineligibility may be requested or is also available as follows: • A covered dependent no longer meets eligibility criteria for coverage • A child gains or loses coverage with other parent or legal guardian From: Benefits Specialist • Change of coverage under an employer's plan Address: 2401 SE Monterey Rd. • Gain or loss of Medicare coverage Stuart,FL 34996 • Losing or becoming eligible for coverage under a State Medicaid Phone: (772)320-3029 or CHIP(including Florida Kid Care)program (60 day notification Email: blafave@martin.fl.us period) Website URL: www.mybentek.com/martincounty The SBC is only a summary of the plan's coverage.A copy of the plan document,policy, or certificate of coverage should be consulted to determine the governing contractual provisions of the coverage.A copy of the group certificate of coverage can be reviewed and obtained by contacting the Benefits Specialist. If there are any questions about the plan offerings or coverage options,please contact the Benefits Specialist at(772)320-3029. 86 4 ©2016,Gehring Group,Inc.,All Rights Reserved Martin County Board of County Commissioners I Employee Benefit Highlights 12021 Medical Insurance Other Available Plan Resources The County offers medical insurance through Florida Blue to benefit-eligible Florida Blue offers all enrolled employees and dependents additional services employees.The monthly costs for coverage are listed in the premium table and discounts through value added programs.For more details regarding other below and a brief summary of benefits is provided on the following page.For available plan resources, please log on to www.floridablue.com or contact more detailed information about the medical plan,please refer to the carrier's Florida Blue's customer service. Summary of Benefits and Coverage(SBC)document or contact Florida Blue's customer service. BIue365 Blue365 is provided automatically at no additional cost and offers access to Medical Insurance—Florida Blue—BlueOptions Plan discounted products and services at participating providers. Members can Monthly Premiums log on to www.floridablue.com to learn more about these programs or call Tier of Coverage Employee Cost Employer Cost (800)664-5295. ✓ Fitness club memberships, ✓ Alternative medicine Employee Only $142.26 $541.64 exercise footwear and apparel ✓ Elder care advisory services Employee+Family $356.04 $1,394.72 ✓ Vision care,glasses,and ✓ Hotel rooms and travel Please Note:Payroll deductions include dental insurance coverage contact lenses information ✓ Hearing care and aids ✓ Weight loss management Florida Blue I Customer Service:(800)664-52951 www.floridablue.com Group Number:91221 Telehealth — Teladoc Dental Plan Premium Florida Blue provides access to telehealth services as part of the medical plan. Teladoc is a convenient phone and video consultation company that provides The County offers all benefit-eligible employees medical and dental coverage immediate medical assistance for many conditions. as a"bundled"package.However,employee may elect to opt-out of the dental The benefit is provided to all enrolled members.Registration is required and plan and remain on the medical plan only.In order to opt out of the dental should be completed ahead of time.This program allows members 24 hours coverage,employee will be required to waive this election in Bentek. a day,seven(7)days a week on-demand access to affordable medical care via Please Note:if a participant elects to opt-out of the MCBOCC's sponsored dental phone and online video consultations when needing immediate care for non- plan payroll deduction will remain the same. There will not be a decrease in emergency medical issues.Telehealth should be considered when employee's premium. primary care doctor is unavailable, after-hours or on holidays for non- emergency needs.Many urgent care ailments can be treated with telehealth, such as: ✓ Sore Throat ✓ Allergies ✓ Headache ✓ Rash ✓ Stomachache ✓ Acne ✓ Fever ✓ UTI's and More ✓ Cold and.Flu Telehealth doctors do not replace employee's primary care physician but may be a convenient alternative for urgent care and ER visits. For further information,please contactTeladoc. Teladoc I Customer Service:(800)835-2362 I www.teladoc.com 87 5 ©2016,Gehring Group,Inc.,All Rights Reserved Martin County Board of County Commissioners I Employee Benefit Highlights 1202117E:1 Florida Blue — BlueOptions Plan At-A-Glance Network BlueOptions CalendarYear Deductible(CYD) In-Network Out-of-Network* Single $500 $1,500 ._ _ q Family — $1,500 $4,500 Coinsurance Member Responsibility 20% 50% Locate a Provider To search for a participating provider, CalendarYear Out-of-Pocket Limit contact Florida Blue's customer service Single __ $3,000 $6,000 or visit www.floridablue.com.When Family $6,000 $12,000 completing the necessary search _ ; criteria,select BlueOptions network. What Applies to the Out-of-Pocket Limit? - Deductible,Coinsurance,Copays and Rx Physician Services Primary Care Physician(PCP)Office Visit $25 Copay 50%After CYD ; _ . 0 [pecialist Office Visit - __I $50 Copay 5096 After CYD Telehealth-Teladoc No Charge Not Covered Plan References Non-Hospital Services;Freestanding Facility *Out-ofNetworkBalance Billing: [Clinical Lab(Bloodwork)" -=_ -- No Charge 50%After CYD For information regarding out-of- network balance billing that may be CX rays $50 Copay 50%After CYD charged by out-of-network providers, Advanced Imaging(MRI,PET Q) 20%After CYD 50%After CYD - please refer to the Summary of Benefits and Coverage(SBC)document. [Outpatient Surgery in Surgical Center —1 $50 Copay 50%After CYD 1 Lysician Services at Surgical Center $50 Copay 50%After CYD "Quest Diagnostic is the preferred -— - -_ _ lab for bloodwork through Florida Blue. Urgent Care(Per Visit) $65 Copay $65 Copay after CYD When using a lab other than Quest, please confirm they are contracted with Hospital Services Florida Blue's BlueOptions network prior [Inpatient Hospital(Per Admission) J 20%After CYD So%After CYD ' to receivingservices. Outpatient Hospital(Per Visit) 20%After CYD 50%After CYD Physician Services at Hospital $100 Copay $100 Copay Emergency Room(Per Visit) , $300 Copay $300 Copay Mental Health/Alcohol&Substance Abuse fInpatient Hospital Services(PerAdmission) v` `_ $500 Copay 50%Coinsurance [Outpatient Services(Per Visit) m $25 Copay 50%Coinsurance Outpatient Office Visit $25 Copay 50%Coinsurance Prescription Drugs(Rx) Generic —1 $15 Copay 50%Coinsurance Preferred Brand Name j $30 Copay 50%Coinsurance Non-Preferred Brand Name $50 Copay 50%Coinsurance Lail Order Drug(90-Day Supply) 2x Retail Copay 50%Coinsurance . 88 6 ©2016,Gehring Group,Inc.,All Rights Reserved Martin County Board of County Commissioners I Employee Benefit Highlights 12021 Dental Insurance Florida Combined Life BlueDental Choice Plus PPO Plan The County offers dental insurance through Florida Combined Life,a subsidiary Out-of-Network Benefits of Florida Blue,to benefit-eligible employees. A brief summary of benefits is provided on the following page.For more detailed information about the Out-of-network benefits are used when member receives services by a non- dental plan,please refer to the carrier's summary plan document or contact participating Florida Combined Life BlueDental Choice Plus PPO provider. Florida Combined Life's customer service. Florida Combined Life reimburses out-of-network services based on what it determines as the Usual,Customary and Reasonable(UCR).The UCR is defined Dental Plan Premium as the most common charge for a particular dental procedure performed in a specific geographic area. If services are received from an out-of-network The County offers all benefit-eligible employees,medical and dental coverage dentist,the member may be responsible for balance billing.Balance billing is as a"bundled"package.However,employees can elect to opt-out of the dental the difference between Florida Combined Life's UCR and the amount charged plan and remain on the medical plan only.In order to opt-out of the dental by the out-of-network dental provider.Balance billing is in addition to any plan,employee will be required to waive this election in Bentek. applicable plan deductible or coinsurance responsibility. Please Note:if a participant elects to opt-out of the MCBOCC's sponsored dental Calendar Year Deductible plan payroll deduction will remain the same. There will not be a decreasein premium. The BlueDental Choice Plus PPO plan requires a$50 individual or a$100 Family deductible to be met for in-network or out-of-network services before most In-Network Benefits benefits will begin.The deductible is waived for preventive services. The BlueDental Choice Plus PPO plan provides benefits for services received Calendar Year Benefit Maximum from in-network and out-of-network providers.It is also an open-access plan which allows for services to be received from any dental provider without The maximum benefit(coinsurance)the BlueDental Choice Plus PPO.plan will having to select a Primary Dental Provider(PDP) or obtain a referral to a pay for each covered member is$1,000 for in-network and out-of-network specialist.The network of participating dental providers the plan utilizes is services combined. All services, including preventive services, accumulate the Florida Combined Life BlueDental Choice Plus network.These participating towards the benefit maximum.Once the plan's benefit maximum is met,the dental providers have contractually agreed to accept Florida Combined Life's member will be responsible for future charges until next calendar year. contracted fee or"allowed amount:'This fee is the maximum amount a Florida Combined Life dental provider can charge a member fora service.The member Florida Combined Life is responsible for a Calendar Year Deductible(CYD)and then coinsurance based Customer Service:(888)223-4892 1 www.floridabluedental.com on the plan's charge limitations. Group Number:247L66 89 7 ©2016,Gehring Group,Inc.,All Rights Reserved Martin County Board of County Commissioners I Employee Benefit Highlights I 20210 Florida Combined Life BlueDental Choice PPO Plus Plan At-A-Glance Network BlueDental Choice Plus Calendar Year Deductible(CYD) In-Network Out-of-Network* Per Member J $50 Per Family –V $100 Locate a Provider --––- ---- ----- To search fora participating Waived for Class I Services? Yes provider;contact Florida Combined Life's customer service or visit Calendar Year Benefit Maximum www.floridabluedental.com.When Per Member $1,000 –; completing the necessary search criteria,select BlueDental Choice Plus Class I Services:Diagnostic&Preventive Carenetwork. Routine Oral Exam(2 Per Calendar Year) 1. Plan Pays:100% ' Plan Pays:100%Routine Cleanings(2 Per Calendar Year) 7 Deductible Waived Deductible Waived ' (21 Bitewing X-rays(1 Per Calendar Year) (Subject to Balance Billing) Class II Services:Basic Restorative Care Plan References Complete Xrays j T "Out-of-Network Balance Billing: Fillings For information regarding out-of- network balance billing that may be Simple Extractions charged by an out-of-network provider, Deep Cleaning + Plan Pays:80%After CYD Plan Pays:80%After CYD please refer to the Out-of-Network (Subject to Balance Billing) Benefits section on the previous page. Endodontics(Root Canal Therapy) _ , [Periodontics Oral Surgery0 1' Class Ill Services:Major Restorative Care Crowns Important Notes r Bridges •Each covered family member may -_ Plan Pays:50%After CYD receive upto two(2)routine deanin s f Plan Pays:50%After CYD 9 Dentures (Subject to8amnceBilling) per calendar year covered under the Implants preventive benefit. •For any dental work expected to cost Class IV Services:Orthodontia $200 or more,the plan will provide • — a"Pre-Treatment Review"upon the [Lifetime Maximum $1,000 request of the dental provider.This will IBenef t(Dependent Children Up to Age 26) Plan Pays:100%After CYD Plan Pays:100%After CYD assist with determining approximate (Subject to Balance Billing) ' out-of-pocket costs should employee have the dental work performed. •Waiting periods and age limitations may apply. •Benefit frequency limitations may apply to certain services. 90 8 ©2016,Gehring Group,Inc.,All Rights Reserved Martin County Board of County Commissioners I Employee Benefit Highlights 12021 Vision Insurance Humana Vision 100 Plan The County offers vision insurance through Humana to benefit-eligible Out-of-Network Benefits employees.The monthly costs for coverage are listed in the premium table Employee and covered dependent(s) may choose to receive services from below and a brief summary of benefits is provided on the following page.For more detailed information about the vision plan,please refer to the carrier's vision providers who do not participate in the Humana Insight network. summary plan document or contact Huinana's customer service. When going out of network,the provider will require payment at the time of appointment.Humana will then reimburse based on the plan's out-of-network reimbursement schedule upon receipt of proof of services rendered. Vision Insurance—Humana Vision 100 Plan Monthly Premiums Calendar Year Deductible Tier of Coverage Employee Cost There is no calendar year deductible. Employee Only t $7.24 j !— -4 ___ Calendar Year Out-of-Pocket Maximum Employee+Family $20.52 T — There is no out-of-pocket maximum.However,there are benefit reimbursement maximums for certain services. In-Network Benefits The vision plan offers employee and covered dependent(s)coverage for routine Humana I Customer Service:(877)398-2980 I www.humana.com eye care, including eye exams, eyeglasses (lenses and frames) or contact Group Number:VS3145 lenses.To schedule an appointment,employee and covered dependent(s)may select any network provider who participates in the Humana Insight network. At the time of service,routine vision examinations and basic optical needs will be covered as shown on the plan's schedule of benefits.Cosmetic services and upgrades will be additional if chosen at the time of the appointment. 91 9 2016,Gehring Group,Inc.,All Rights Reserved Martin County Board of County Commissioners I Employee Benefit Highlights I 2021 Humana Vision 100 Plan At-A-Glance Network Insight Services In-Network Out-of-Network IEye Exam $10 Copay Up to$30 Reimbursement Contact Lens Standard Up to$55 Copay Not Covered Premium-10%Off Retail Frequency of Services Locate a Provider Examination T T 12 Months To search fora participating provider, - -- contact Humana's customer service or Lenses 12 Months visit www.humana.com.Login or select —- "Find a doctor or pharmacy"at the Frames 24 Months bottom of the page.Choose"vision" - —� - - - —---- -----, and then choose"Humana Vision T Contact Lenses . 12 Months (Humana Insight Network)".Complete Lenses the additional search criteria and click _ "Get Results". [Single J; , Up to$25 Reimbursement I IBifocal _ $25 Copay Up to$40 Reimbursement ,' ' 0 Trifocal Up to$60 Reimbursement ' Frames — — Plan References Retail Up to$100 Retail Allowance • Up to$50 Reimbursement *Contact lenses are in lieu of spectacle then 20%Discount Over$100 lenses and a frame. Contact Lenses* Non-Elective(Medically Necessary) RequiresPriohAuthorization Up to$200 Reimbursement _— — - - Up to$100 Retail Allowance; Elective(Fitting,follow-up&Lenses) Up to$80 Reimbursement then 15%Discount Over$100 ----_. Important Notes LASIK •Member options,such as LASIK,UV Contact Humana's Customer Service Discount Programs Not Available coating,progressive lenses,etc.are not Discount Programs covered in full,but may be available at for Program Details Out-of-Network a discount. -After copay,standard polycarbonate available at no charge for dependents • underage 19. • 92 10 0 2016,Gehring Group,Inc.,All Rights Reserved 1.0.00 Martin County Board of County Commissioners I Employee Benefit Highlights 12021 Health Reimbursement Account Questions and answers regarding a Health Reimbursement Account(HRA)have been provided below and on the following page to help employees understand how an HRA works in conjunction with their Insurance plans. Employees who enroll in the medical plan automatically will receive a Health Reimbursement Account(HRA)funded by the County.HRA funds can be used for qualified medical,dental,and vision expenses.The HRA provides tax-free funds to cover expenses not paid by the employee's medical,dental,and vision insurance plans. Employee Only:$470 Employee+Family:$940 How are the funds accessed? How do I check the balance on my card? There are two convenient ways to access the HRA funds: If employee is currently enrolled in the BlueOptions Plan, employee may ✓ BenefitsWorkshop Debit MasterCard;and obtain their HRA balance or check on the status of charges by contacting ✓ Manually submit receipts for reimbursements.If this option is selected, BenefitsWorkshop's Customer Service at(888)537-3539 or by logging on to employee must pay for their expenses out-of-pocket and then www.benefitsworkshop.com/martincounty. submit a reimbursement request form along with the appropriate What are the BenefitsWorkshop debit card advantages? documentation to BenefitsWorkshop. The reimbursement request form can be found on Bentek's EBC or on BenefitsWorkshop's website ✓ Eliminates the need to pre pay an expense www.benefitsworkshop.com/martincounty. ✓ Eliminates waiting for reimbursement ✓ Eliminates paperwork on most copays What is a BenefitsWorkshop Debit Card? ✓ Allows online access to account information For those enrolling in the medical plan for the first time,employees will be mailed a debit card along with materials explaining how to use the card. I am enrolled in the BlueOptions Plan. What happens to The BenefitsWorkshop debit card allows immediate access to account funds my unused HRA funds at the end of the Plan Year? for eligible expenses at approved providers that accept MasterCard. When If employee continues coverage in the BlueOptions Plan,any remaining HRA employee has an eligible expense,simply swipe the card and the funds are balance will be added to their new Plan Year HRA funding. automatically deducted from their account(up to the available balance). If purchasing other items or services,employee should use a different payment What happens to my unused HRA funds if I discontinue method for those expenses. For example, if paying for a prescription and participation in the medical plan, separate employment buying a gallon of milk at the pharmacy,employee should only use the debit or retire from the County? card for the prescription portion of expense.There will be a$5.00 charge to replace lost,stolen or damaged cards. Employees benefits under the HRA will generally cease,meaning that expenses incurred after they are no longer a participant will not be reimbursed.The HRA If I use the BenefitsWorkshop debit card,do I still submit debit card will be deactivated effective the last day of employment,but an my receipts? employee will have access to their HRA Funds through the end of the month in Certain expenses, including copayments paid at provider offices or which they terminate employment.If employee retires and elects to continue pharmacies, may be processed without further action on the employee's coverage under the retiree medical/dental plan,they will have access to the part. All other expenses must be documented with a receipt, bill or HRA funds through the end of the plan year in which they retire.However,if insurance statement (Explanation of Benefits) that includes the name employee has been insured under the BlueOptions medical plan for six(6)full of the service provider, name of patient, date of service, the nature of plan years(January 1 to December 31),the HRA balance(if any)is vested.In the service, items purchased, and the amount of the expense. Debit card this case,any unused funds will roll into a Retirement Health Savings(RHS) receipt are not acceptable.The documentation should be mailed or faxed account administered by ICMA.If employee meets the vesting criteria and are to BenefitsWorkshop within ten days of the transaction,along with an HRA separating employment,please contact the Benefits Specialist to discuss the Expense Documentation form available on Bentek or on BenefitsWorkshop's HRA/RHS transition process. website www.benefitsworkshop.com/martincounty. Failure to provide adequate documentation in a timely manner could result in the suspension of their account,the deduction of the ineligible amount from their account, and other actions as BenefitsWorkshop and the employer deem appropriate. 93 11 ©2016,Gehring Group,Inc.,All Rights Reserved Martin County Board of County Commissioners I Employee Benefit Highlights 12021 HRA. Health Reimbursement Account (Continued) Health Care Reimbursement Account(HRA) Flexible Spending Accounts(FSA) ✓ Employer Funded Account V Employee Funded Accounts • V Enrollment is automatic if enrolled in medical plan V Employees must enroll annually V Funds used for eligible medical,dental,and vision expenses f V Funds used foreligible medical,dental,vision&dependent for employees and dependent(s)enrolled in medical plan care for employee and qualified dependent(s) V Unused funds accumulate and roll over year to year ✓ Unused funds will be forfeited at the end of the plan year (once the filing deadlines have expired) • For employees who have the HRA and also elect an FSA,FSA monies will be used first since it is employee funded. What are some examples of qualified expenses that would be eligible for reimbursement? ✓ Acupuncture V Doctor Fees V In Vitro Fertilization ✓ Ambulance Service V Drug Addiction and Alcoholism Treatment V Nursing Services ✓ Birth Control Pills V Prescription Drugs V Orthodontic Fees ✓ Chiropractic Care V Experimental Medical Treatment V Surgery ✓ Corrective Contact Lenses V Eyeglasses V Sunscreen SPF 15 or Greater ✓ Dental Fees V Hearing Aids and Exams V Wheelchairs ✓ DiagnosticTests and Health Screenings V Injections And Vaccinations V X-rays — — -1 Claims Processing Address PO Box 56828,Jacksonville,FL 32241 Fax:(904)880-2830 I Email:info@benefitsworkshop.com BenefitsWorkshop Customer Service:(888)537-35391 www.benefitsworkshop.com/martiincounty 94 12 ©2016,Gehring Group,Inc.,All Rights Reserved F'Sp Martin County Board of County Commissioners I Employee Benefit Highlights 12021 Flexible Spending Accounts The County offers Flexible Spending Accounts(FSA)administered through BenefitsWorkshop.The FSA plan year is from January 1 to December 31. If employee or family member(s)has predictable health care or work-related day care expenses,then employee may benefit from participating in an FSA.An FSA allows employee to set aside money from employee's paycheck for reimbursement of health care and day care expenses they regularly pay.The amount set aside is not taxed and is automatically deducted from employee's paycheck and deposited into the FSA.During the year,employee has access to this account for reimbursement of some expenses not covered by insurance.Participation in an FSA allows for substantial tax savings and an increase in spending power.Participating employee must re-elect the dollar amount to be deducted each plan year.There are two(2)types of FSAs: Health Care FSA Dependent Care FSA -------- This account allows participant to set aside up to an annual , This account allows participant to set aside up to an annual maximum of$5,000 if single maximum of$2,750.This money will not be taxable income or married and file a joint tax return($2,500 if married and file a separate tax return)for to the participant and can be used to offset the cost of a work-related day care expenses.Qualified expenses include day care centers,preschool, wide variety of eligible medical expenses that generate ! and before/after school care for eligible children and dependent adults. out-of-pocket costs.Participating employee can also receive reimbursement for expenses related to dental and vision Please note,if family income is over$20,000,this reimbursement option will likely save care(that are not classified as cosmetic). participants more money than the dependent day care tax credit taken on a tax return.To qualify,dependents must be: Examples of common expenses that qualify for A child under the age of 13,or reimbursement are listed below. • A child,spouse or other dependent who is physically or mentally incapable of self-care and spends at least eight(8) hours a day in the participant's household. Please Note:The entire Health Care FSA election is available for use on Please Note:Unlike the Health Care FSA,reimbursement is only up to the amount that has been deducted the first day coverage is effective. from the participant's paycheck for the Dependent Care FSA. A sample list of qualified expenses eligible for reimbursement indude,but are not limited to,the following: ✓ Prescription/Over-the-Counter Medications ✓ Physician Fees and Office Visits ✓ LASIK Surgery ✓ Menstrual Products ✓ Drug Addiction/Alcoholism Treatment ✓ Mental Health Care ✓ Ambulance Service ✓ Experimental Medical Treatment ✓ Nursing Services ✓ Chiropractic Care ✓ Corrective Eyeglasses and Contact Lenses ✓ Optometrist Fees ✓ Dental and Orthodontic Fees ✓ Hearing Aids and Exams ✓ Sunscreen SPF 15 or Greater ✓ DiagnosticTests/Health Screenings V Injections and Vaccinations V Wheelchairs Log on to http✓/www.irs.gov/publications/p502/index.html for additional details regarding qualified and non-qualified expenses. 95 13 02016,Gehring Group,Inc.,All Rights Reserved Martin County Board of County Commissioners I Employee Benefit Highlights 12021 F'Aa, Flexible Spending Accounts (Continued) - FSA Guidelines �- -, • Employee may carry over$550 of unused Health Care FSA funds into the next plan year after a plan year ends and all claims have been HERE'S HOW IT WORKS! filed (only if the employee re-enrolls the next year). Dependent Care funds cannot be carried over. An employee earning$30,000 elects to place$1,000 into a Health • When a plan year ends and all claims have been filed,all unused Care FSA.The payroll deduction is$83.33 based on a monthly pay funds with the exception of the$550 rollover for the Health Care period schedule.As a result,health care expenses are paid with tax- FSA will be forfeited and not returned. free dollars,giving the employee a tax savings of$227. • Employee can enroll in an FSA only during the Open Enrollment With a Health Without a Health period,a Qualifying Event,or New Hire Eligibility period. Care FSA Care FSA • Money cannot be transferred between FSAs. Salary $30,000 $30,000 • Reimbursed expenses cannot be deducted for income tax purposes. FSA Contribution -$1,000 -$o • Employee and dependent(s)cannot be reimbursed for services they Taxable Pay $29,000 $30,000 have not received. Estimated Tax -$6,568 $6,795 • Employee and dependent(s)cannot receive insurance benefits or 22.bs%=15%+7.bs%FICA any other compensation for expenses reimbursed through an FSA. After Tax Expenses -$0 -$1,000 • Domestic Partners are not eligible as Federal law does not recognize Spendable Income $22,432 $22,205 them as a qualified dependent. 41) Tax Savings Filing a Claim Claim Form A completed claim form along with a copy of the receipt as proof of the expense can be submitted by mail or fax.The IRS requires FSA participants to Please Note:Be conservative when estimating health care and/or dependent maintain complete documentation,including copies of receipts for reimbursed care expenses.IRS regulations state that any unused funds which remain in expenses,for a minimum of one(1)year. an FSA,after a plan year ends and after all claims have been filed,cannot be returned or carried forward to the next plan year with the exception of the S550 Debit Card carry over that may be allowed for the Health Care FSA.This rule is known as FSA participants will automatically receive a debit card for payment of eligible "use-it or loseit." expenses.If member has a BenefitsWorkshop Health Reimbursement Account debit card,the Health Care FSA and Dependent Care FSA available balances will be added to the debit card.Health care expenses will be deducted first BenefitsWorkshop I Customer Service:(888)537-3539 from the Health Care FSA balance and then will be deducted from the HRA. www.benefitsworkshop.com I Email:info@benefitsworkshop.com This way forfeitable money is used first.With the card,most qualified services and products can be paid at the point of sale versus paying out-of-pocket and requesting reimbursement.The debit card is accepted at a number of health care providers and facilities,and most pharmacy retail outlets.BenefitsWorkshop may request supporting documentations for expenses paid with a debit card. Failure to provide supporting documentation when requested,may result in suspension of the card and account until funds are substantiated or refunded back to the County.This card will not expire at the end of the benefit year. Please keep the issued card for use next year.Additional or replacement cards may be requested,however,a small fee may apply. 96 14 0 2016,Gehring Group,Inc.,All Rights Reserved 00 �0 \ Martin County Board of County Commissioners I Employee Benefit Highlights 12021 i� Employee Assistance Program Basic Life and AD&D Insurance The County cares about the well-being of all employees on and off the job The County offers Basic Term Life and Accidental Death& Dismemberment and provides, at no cost, a comprehensive Employee Assistance Program (AD&D)insurance to all eligible employees through The Standard.The County (EAP)through New Directions.EAP offers employee and each family member will contribute a portion of the premium for this coverage and the available access to licensed mental health professionals through a confidential program benefit amount will be determined by employee classification and pay grade protected by State and Federal laws.EAP is available to help employee gain a as provided in the table below. better understanding of problems that affect them,locate the best professional help for a particular problem,and decide upon a plan of action.EAP counselors Basic Life and AD&D Insurance Benefit& are professionally trained and certified in their fields and available 24 hours a Premium Schedule day,seven(7)days a week. Employee Basic Life AD&D Employee Cost What is an Employee Assistance Program? Classification Benefit Benefit Per Month An Employee Assistance Program (EAP) offers covered employees and Elected Officials $250,000 $250,000 $42.48 family members free and convenient access to a range of confidential and Officers $100,000 $100,000 $17.00 professional services to help address a variety of problems that can negatively -_ - �- LDepartment Directors $75,000 $75,000 $12.76 affect employee or family members well-being. Coverage includes six (6) - — - — -- face-to-face visits with a specialist,per person,per issue,per year,telephonic Division Manager/ $50,000 $50,000 $8.50 consultation, online material/tools and webinars. EAP offers counseling Administrators services on issues such as: Active Employees $25,000 $25,000 $4.26 ✓ Child Care Resources ✓ Work Related Issues The Basic Term Life insurance benefit will be paid in the event of the insured's ✓ Legal Resources ✓ Adult&Elder Care Assistance natural death.The AD&D insurance rider pays a benefit in addition to the Basic ✓ Grief and Bereavement ✓ Financial Resources Term Life benefit when death occurs as a result of an accident.The AD&D ✓ Stress Management ✓ Family and/or Marriage Issues benefit amount equals the Basic Term Life benefit,partial benefits may also ✓ Depression and Anxiety ✓ Substance Abuse be payable. Are the services confidential? If employee did not enroll in the Life Insurance plan when first eligible and wants to purchase this coverage,employee will be required to complete The Yes. Receipt of EAP services are completely confidential. The content of Standard's Medical History Statement form, which can be obtained on the conversations with EAP professionals are confidential within the confines of Employee Benefits Center. the law and cannot be shared with employer without consent. If,however, participation in the EAP is the direct result of a Management Referral(a referral Employee's life insurance beneficiary designation(s)may be made online during initiated by a supervisor or manager),New Directions will ask permission to the Open Enrollment period and any time during the plan year.To complete life communicate certain aspects of the employee's care(attendance at sessions, insurance designation(s)online,log on to www.mybentek.com/martincounty. adherence to treatment plans,etc.)to the referring supervisor/manager.The A beneficiary designation confirmation statement may also be printed and referring supervisor/manager will only receive reports on whether the referred retained for records. employee is complying with the prescribed treatment plan. Always remember to keep beneficiary information New Directions I Customer Service:(800)624-5544 eap.ndbh.com updated.Beneficiary information may be updated at Company Code:martinbocc anytime through Bentek. The Standard I Customer Service:(800)247-6888 www.standard.com Policy Number:642407 97 15 ©2016,Gehring Group,Inc.,All Rights Reserved (6 Martin County Board of County Commissioners I Employee Benefit Highlights 12021 �O LJ Voluntary Life Insurance Voluntary Employee Life Insurance Voluntary Spouse Life Insurance Eligible employee may elect to purchase additional Life insurance on a voluntary basis through The Standard.This coverage may be purchased in New Hires may purchase Voluntary Spouse Life insurance addition to the Basic Term Life and AD&D coverage.Voluntary Life insurance without being subject to Medical Underwriting, offers coverage for employee, spouse and/or child(ren) at different benefit also known as Evidence of Insurability(E0l), levels. up to the Guaranteed Issue amount of$25,000. New Hires may purchase Voluntary Employee Life insurance • Employee must participate in the Voluntary Employee Life plan for without being subject to Medical Underwriting, spouse to participate. also known as Evidence of Insurability(EOl), • Employee may elect Spouse Dependent Life coverage in the following up to the Guaranteed Issue amount of$50,000. amounts,not to exceed 100%of employee's Voluntary Life coverage amount: • Employee may elect coverage in the following amounts: Option 1:$25,000 Option 2:$50,000 Option 3:$75,000 Option 1:$25,000 Option 2:$50,000 Option 3:$75,000 • Benefit amounts are subject to the following age reduction schedule: • Benefit amounts are subject to the following age reduction schedule: g> Reduces to 65%of benefit amount at age 70 > Reduces to 50%of benefit amount at age 75 ag > Reduces to 65%of benefit amount at age 70 > Reduces to 50%of benefit amount at age 75 • Premium Calculation: • Premium Calculation: Elected Coverage_$1,000 x Employee Rate(see table)=Monthly Premium Elected Coverage-$1,000 x Employee Rate(see table)=Monthly Premium Voluntary Dependent Child(ren)Life Insurance Voluntary Life Insurance Rate Table • Employee must participate in the Voluntary Employee Life plan for Monthly Premium dependent child(ren)to participate. Age Bracket Employee/Spouse Cost • Coverage is$10,000 for eligible children,not to exceed 100%of the (Based On Employee Age) (Rate Per$1,000 of Benefit) employee's Voluntary Life coverage amount. Late applications are <30 $0.094 subject to medical underwriting approval. —��— — • Employee may cover unmarried dependent children from living birth 30-34 $0.096 through the end of the calendar year in which the child turns age 26. • 35-39 $0.127 • Cost for coverage is $2.00 a month regardless of the number of 40-44 $0.178 eligible children covered. 45-49 $0.269 • If employee did not enroll in the voluntary life plans for dependents when first eligible and now want to purchase this coverage or 50_54 $0.410 increase coverage, employee and/or dependent child will be 55-59 $0.663 required to complete The Standard's Medical History Statement form.The Medical History Statement form can be found on at www. 60-64 $0.8so - mybentek.com/martincounty. i 65-69^ $1.495 y y - --- E70-74 $2.656 The Standard I Customer Service:(800)247-6888 I www.standard.com 75+ -ry 510.072 Group Number:642407 98 16 ©2016,Gehring Group,Inc.,AD Rights Reserved Martin County Board of County Commissioners I Employee Benefit Highlights 12021 Voluntary Long Term Disability The County offers Long Term Disability(LTD)insurance to all eligible employees Long Term Disability Rate Table through The Standard.The LTD benefit pays a percentage of monthly earnings Monthly Rates if employee becomes disabled due to an illness or non-work related injury. Age Bracket Employee Cost Voluntary Long Term Disability(LTD)Benefits (Rased On Employee Age) (Rate Per$100 of Benefit) r- • LTD provides a benefit of 60%of employee's monthly earnings up to 1 <35 $0.196 i a benefit maximum of$5,000 per month. 35-44 1 $0.402 ,. • Employee must be disabled for 90 consecutive days prior to a5 5a $0.883 becoming eligible for benefits(known as the elimination period). 55-99 $1.430 • Benefits will begin on the 91st day of disability. • Employee may continue to be eligible for partial benefits if LTD Premium Calculation employee returns to work on a part-time basis. • Benefits are payable up to age 65 if disability occurs before age The LTD premium will be based on age and salary per$100 of monthly benefit. 62.Please see The Standard's Group Certificate for schedule of age To determine the monthly premium,use thefollowing rate calculation formula: benefits if employee becomes disabled at age 62 or older. Monthly Salary(not to exceed$8,333)x Premium Rate for Age(listed above) • The employee will receive benefits for the first 24 months if unable -$100=Monthly LTD Premium to return to employee's own occupation. • After 24 months,if employee can return to any occupation in which The Standard I Customer Service:(800)247-68881 www.standard.com they are suitably trained, educated, and capable of performing, Policy Number:642407 employee must return to that occupation (if the salary of that occupation does not meet the salary of the employee's own occupation,the plan will pay the difference). • • Benefits may be reduced by other income. • 99 17 ©2016,Gehring Group,Inc.,All Rights Reserved Martin County Board of County Commissioners I Employee Benefit Highlights 12021 Supplemental Insurance Aflac Hospital Choice—Provides employee with cash benefits if they or a covered County employees may purchase supplemental insurance on a voluntary dependent are hospitalized due to a covered accident or illness.This program basis through Aflac.Descriptions of the variety of coverage options available includes,but is not limited to,hospital benefits,surgical benefits,physician are provided below. To learn more about these options or to schedule a visits and major diagnostic benefits. • personal meeting,contact the County's Aflac representatives using the contact Critical Care Protection—Provides employee with cash benefits if they or information provided below. a covered dependent are diagnosed as having had a named specified health All Aflac programs help employees: event.This program includes a first occurrence benefit that grows every year as ✓ Protect their income well as re-occurrence benefits,hospital confinement benefits,continuing care ✓ Supplement their medical plan benefits,ambulance benefits,transportation,and lodging benefits. ✓ Provide a financial safety net for unexpected health issues Dental Insurance-Add to the Florida Blue Dental coverage or choose Aflac's Short-Term Disability—Provides employee with a source of income if they dental coverage alone. Employee may add orthodontic and cosmetic riders are unable to work due to an off-the-job injury or illness.Employee can select to help budget expenses.With Aflac,employee can choose their own dentist since there is no network.There is no annual deductible or pre-certification, a monthly benefit amount,elimination period and benefit period tailored to and wellness benefits begin on the first day of coverage(other waiting periods theirr needs and budget may apply). Accident Advantage — Provides employee with cash benefits if they or Life Solutions Term&Whole Life Insurance—Face amounts are available a covered dependent receives treatment for injuries sustained in a covered up to$500,000 for employee and are offered as 10,20 and 30 Year Term or accident,24/7.This program includes,but is not limited to,hospital benefits, Whole Life Insurance. These policies include an accelerated death benefit wellness benefits, injury and surgical.benefits, accidental death and and other riders, including Term riders to cover employee's spouse and/or dismemberment benefits,physician visit benefits,transportation and lodging dependent child(ren).In addition,Juvenile Life Insurance is available as Term benefits. or Whole Life for dependent children and grandchildren,in coverage amounts Cancer Protection Assurance — Provides employee with cash benefits of$10,000,$20,000 and$30,000. if they or a covered dependent are diagnosed with internal cancer or skin cancer.This policy includes,but is not limited to,a lump sum initial diagnosis Agent:Karen Zabaglo benefit that grows each year,a wellness benefit,hospital benefits,radiation Phone:(772)284-32101 Email:karen_zabaglo@us.aflac.com and chemotherapy benefits,surgical/anesthesia benefits,transportation and Agent:Loire Lucas lodging benefits. Phone:(772)708-59311 Email:loire_lucas@us.aflac.com • 100 18 ©2016,Gehring Group,Inc.,All Rights Reserved i Martin County Board of County Commissioners I Employee Benefit Highlights 12021 Additional County Benefits Legal & Identity Theft Plan The County also offers a variety of non-insurance related benefits such as paid LegalShield leave and holidays,tuition reimbursement,deferred compensation,and other The County offers employees the opportunity to participate in a voluntary pre- ancillary products. Please make sure to contact the Constitutional Office to learn more about all the benefit offerings available. paid legal program offered through LegalShield.By enrolling in the legal plan, a participant and their family will have direct access to a nationwide network 'MetLife (561)104 4378 Agent:Janet Froyen of law firms who will provide direct access for a variety of situations.The plan jfroyen@madisonplanning.com provides assistance,but is not limited to the following benefits: Credit Union-Gold Coast FCU (772)335-2083 www.gcfcu.org ✓ Divorce ✓ Traffic Tickets ✓ Child Custody&Support ✓ Wills&Living Trusts www.dms.myforida.com/ Florida Retirement System(FRS) (844)377-1888 ✓ Civil Lltlgatl0n ✓ Real Estate retirement __ -- - ✓ Bankruptcy ✓ Credit Report Issues MY FRS Financial Guidance (866)446-9377 www.myfrs.com ✓ Name Changes ✓ Contract Review ✓ Criminal Defense ✓ Adoption Deferred Compensation Deferred Compensation is a second retirement source for employees. It is IDShield strictly an employee contributory plan.The County does not match the amount The County also offers employees the opportunity to participate in an identity employee deposits or make any deposits into the account on employee's theft plan called IDShield through LegalShield which protects employee, behalf. It is tax deferred money deposited into an account. Employee pays spouse and/or dependent child(ren).IDShield coverage includes consultation taxes on the money once they withdraw it.The County offers three(3)Deferred with licensed fraud investigators,credit report with analysis,privacy&security Compensation companies: monitoring,credit monitoring and full restoration benefits with a$5 million service guarantee, should employee or covered family member become a Agent:Steve Feigelis ICMA Retirement Corporation (866)731-1055 victim of identity theft.The IDShield coverage also includes access to licensed SFeigelis@icmarcorg investigators available 24/7,lost wallet assistance and fraud alerts. FALIC - (772)418-5031 Agent:Jim McCudden jim.nmccudden@valic.com There are several levels of coverage options that may be purchased.The cost Nationwide Retirement (772)284-9660 ' Agent:Mark Schilling per month,for each option,are as follows: schillm@nationwide.com Employee Cost (Monthly Rates) LegalShield Legal Plan —1 $18.95 + _ IDShield Individual Plan $8.95 IDShield Family Plan $18.95 LegalShield&IDShield Individual Plan Combo $27.90 i LegalShield&IDShield Family Plan Combo $33.90 i i Plan benefits include unlimited phone consultations. For additional information please contact the County's dedicated Agent Steve Baker. Agent:Steve Baker I Phone:(321)613-0037 Email:sb@legalshieldassociate.com LegalShield I Customer Service:(800)654-77571 www.legalshield.com 101 19 ©2016,Gehring Group,Inc.,All Rights Reserved Martin County Board of County Commissioners I Employee Benefit Highlights 12021 Notes Use this section to make notes regarding personal benefit plans or to keep track of important information such as doctors'names and addresses or prescription medications. 102 20 ©2016,Gehring Group,Inc,AU Rights Reserved ttlae� o r tv,„ .#\"-7 % fp 7' ickk, 4 OF IT GEHRING° .: GROUP EMPLOYEE BENEFITS I RISK MANAGEMENT 4200 Northcorp Parkway,Suite 185 Palm Beach Gardens,Florida 33410 Toll Free:(800)244-36961 Fax:(561)626-6970 www.gehringgroup.com 103 FINAL Revised ©2016,Gehring Group,Inc.,All Rights Reserved last Modified:January 5,1021 8:47 AM O c x o v L g ai a c ar. c `a 9 O t r ' u a L « t a m '; L c a - m t 00 2 9 C s C a $ C ry L _m 0 o r .0',77, 50 v 2 8 N c r L to _tag o^ d ua w O w� H u a ' c ; N ›..s . � c Lom c5 ai 52 • '2 1 °' Z,c 01.9a aten al m �+ A - u m ..7, ar « 5uv c c * « >L ca£ o ,s 0 cm c ui L 7 Q taN uQ .04 L u cac F s • .d c u i v c ' c a ° c > .° cu T.c r ° y n ° aEE 3 my ca a i c « c m E > E ' c m u c `a .. o c ° • - O u E 'Z m u > > E 3 E '^ z v .y .� 't o 'o a u n f0 • a t O o a o a = L u E E ., a m a N ry „ " ° :° • • g a u aE c u3 - ac a. d E : o 2LLd 2o aO On Ncc N > L° c a o HoC yA- u Fe: r no c •+ ymNb o « y_ Cot glIE 0873 ..t, 0ju4- o ' o2 am • w Lo .` a axZ• '°c 2 n u° rym F. > c vGNa ,, v L = u « . t :'4z., 1. mo E o a NE '50) ° Eg « ° Nam a d A « E ouo v cSiN a`+ y a H '-°t m m Y c ° 'o 8 L a C n N u v 'a ` m c a c o `w m m '" « N 00-= g a 3 L5 2 cE E a ' a6 = U « EM d A H 2 : « Lu N E V O « Od C U 1 3a a “' .2 0 52 3 c cj.LN $ v •3d = $ waa % ua y 'F wmLcw rn ° u I" « s c v a n > « u zm a 'v y R a 9 u .5 > 3 ou m w $ � E Oy $ ow L ° v - « 2mayuw m '> r ry N y on, a 'N ti N m aTc - c n « to cc_ a coa w wLoocCt E 2 CI' " 1.- o ^ o m ma = m x a WL « S c T. ` dc « m c a > >-« •c m >,5.' -5 ° -o 2• a • a t 'yo00VNpuNoryuLsN « > °6ra t/ N .- oj u a' o . w w — ° EaE ' a o ° a ` s ° F. : oa i--z. > o > a o: u n 1 N N wQ 4u a N m m x Z E vi 3 n w 2 H u ,r, It E Z E 5 2 Q « m a a a: A T a o c ry � a > u O _ 2 a N n L a O a « a m « N dp p E 6 O w cu C d C a u u r. 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N„..,. = ° C O T m `O 3 % , 2E ,9 G J 01 « 00 c 6 N C d C O - c m c 12 3 a>, E •c c .m j .c L 0 5.. 2 -6• o u • • R-5. 1% .7, -5 5•r 1%. : 13 ,117, d O« C ou 3 « TCryC d u iu 3O $ 22 ° u 2a 2 C « D .0Csr d 0 SCVO '^ a �: d' N N N m m 3 O O N. • Q •N •Ul 00• • ECO 0 , N in ami tMD NN in UU L in -LA i ri r-4 AA ri E N `tOi N v LO N L .4N m N: VI .--Ie-.1 I= a I M N I-1 0 i-I m 3 V? t/? N V? V? Nrm1/T if LL dl DD Co • Co m l• N 0^0 O M (NI• N lD O VI. in 0 p m Cil N N V. N to V? N V1 L? d CI- O O O 2 2 a a 0 0 O. a 2 2 0 0 0 0 a s CL CL Cl C -0 -0 CO n a s I = D0 0 0 0 0 00 0 F- � I_ 1_ o 0 0 0 n:s ,... c _. o z z Z Z F- -H I- I U To U '6 O1 01 NI c J ` 2 CO > asI 00 T `� C LI- T `� ^ W O + O + O + O + C C LU W LU LU LU LU LU W C W W LU LU LU LU LU LU 1 1 1 Martin County SHERIFF ' S OFFICE 0 r _L- >_ , J ii' /4,---.N ,-10 ,. ,� coi 20 20 1 20 21 Employee Benefit Highlights II Q Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 Contact Information Deanna Gargan—Benefits Coordinator Phone:(772)220-7143 I Fax:(772)220-7112 Email:dlgargan@sheriff.martin.fl.us Human Resources Unit Yolanda Bills—Assistant Manager Phone:(712)220-70101 Fax:(772)220-7112 Email:ymbills@sheriffmartin.fl.us Aimie M.Pieper—Manager Phone:(772)220-7005 I Fax:(772)220-7112 Email:ampieper@sheriff.martin.fl.us MEI Medical Insurance Florida Blue Customer Service:(800)352-2583 www.floridablue.com Prescription Drug Coverage Customer Service:(888)849 7865 &MailOrder Program Alliance Rx Walgreens Prime www.floridablue.com k. Telehealth Teladoc Customer Service:(800)835-2362 www.Teladoccom a Health Reimbursement Account Discovery Benefits Customer Service:(866)451-3399 www.discoverybenefits.com 11 Dental Insurance Delta Dental Customer Service:(800)521-2651 www.deltadentalins.com 0 Vision Insurance Humana Customer Service:(866)537-0229 www.humana.com fiEl Flexible Spending Account Discovery Benefits Customer Service:(866)451-3399 www.discoverybenefits.com II Basic Life and AD&D Insurance The Standard Customer Service:(888)937-4783 www.standard.com To Report a Claim Contact:Yolanda Bills,Assistant Manager Long Term Disability The Standard Human Resources Unit Phone:(772)220-7010 Customer Service:(800)368-1135 www.standard.com tll Claims Service Center:(800)238-2125 Voluntary Accident Insurance Cigna www.cigna.com 0 Employee Assistance Program New Directions Customer Service:(800)624-5544 www.ndbh.com I Access code:mcso Agent:Loire Lucas I Phone:(772)708-5931 Email:loire_lucas@us.aflac.com Aflac Agent:Karen Zabaglo Chatham I Phone:(772)284-3210 Email:karen_zabaglo@us.aflac.com le Supplemental Insurance Customer Service:(800)992-3522 www.aflac.com Agent:Janet Froyen I Phone:(561)704-4378 Metropolitan Life Insurance Customer Service:(800)638-5433 Agent:Rebecca Smith I Phone:(904)262-2311 Prepaid Legal Benefit LegalShield Customer Service:(800)729-7998 www.legalshield.com• AL III Deferred Compensation Programs Empower Retirement Customer Service:(800)701-8255 www.empowermyretirement.com 108 ©2016,Gehring Group,Inc.,All Rights Reserved Martin County Sheriff's Office I Employee Benefit Highlights ( 2020-2021 1iJ1J Table of Contents Introduction 1 Group Insurance Eligibility 1-2 Qualifying Events and Section 125 2 0 Medical Insurance 3 Summary of Benefits and Coverage 3 Other Available Plan Resources 4 Telehealth—Teladoc 4 (...- r Florida Blue—BlueOptions PPO 3748 Plan At A Glance 5 ----1 Florida Blue—BlueOptions Alternative Health 5360 Plan At-A-Glance 6 _:.'1__) / Health Reimbursement Account 7-8 Dental Insurance 9 Delta Dental Table of Allowance(TOA)Plan At-A-Glance 10 ( r Delta Dental PPO Plan At-A-Glance 12 NVision Insurance 13 AP Humana Vision 130 Plan At-A-Glance 14 Flexible Spending Account 15-16 Basic Life and AD&D Insurance 17 /„__ _,,:, ,, Additional Life and AD&D Insurance 17-18 h = Long Term Disability Insurance .19 1"1— (._:iii. _ , y / Voluntary Accident Insurance 20 In-The-Line-Of-Duty Death Life Insurance 20 (1----L71- \ Employee Assistance Program 21 i 1 \ Credit Unions 21 ----FY Supplemental Insurance 22 �� —— Empower Retirement 23 COBRA 23 MCSO Health Center—Stuart 24 This booklet is merely a summary of employee benefits.For a full description,refer to the plan document.Where conflict exists between this summary and the plan document,the plan document controls. Martin County Sheriff's Office reserves the right to amend,modify or terminate the plan at anytime.This booklet should not be construed as a guarantee of employment. 109 ©2016,Gehring Group,Inc.,All Rights Reserved • do• Martin County Sheriff's Office I Employee Benefit Highlights I 2020-2021 ao\ Introduction ,e,o�,, 0 0`.F s°'�fi, =-0 The Martin County Sheriff's Office provides group insurance benefits to eligible employees.The Employee Benefit Highlights � ;=` AT Booklet provides a general summary of the benefit options as a convenient reference.Please refer to the Sheriff's Office Personnel ''I�9.,oc�, Policies and/or Certificates of Coverage for detailed descriptions of all available employee benefit programs and stipulationsif therein.therein.If employee requires further explanation or needs assistance regarding claims processing,please refer to the customer o 0 service phone numbers under each benefit description heading or contact Human Resources. Group Insurance Eligibility Dependent Age Requirements °clew The Sheriffl5 O44e grout Insurance clan Medical Coverage:A dependent child may be covered through the end of the calendar year in which the child turns age 26. An over- 01 year 15 October I through September 30. age dependent may continue to be covered on the medical plan to the end of the calendar year in which the child reaches age 30,if the dependent meets the following requirements: Employee Eligibility • Unmarried with no dependents;and Employees are eligible to participate in the Sheriff's Office insurance plans if • A Florida resident,or full-time or part-time student;and they are full-time employees working a minimum of 30 hours per week. • Otherwise uninsured;and Coverage will be effective the first of the month following date of hire.For • Not entitled to Medicare benefits under Title XVIII of the example, if employee is hired on January 11, then the effective date of Social Security Act,unless the child is disabled. coverage will be February 1. Dental Coverage:A dependent child may be covered through the end of the calendar year in which the child turns age 26 if the child is Separation of Employment primarily dependent on the employee for support. If employee separates employment from the Sheriff's Office, insurance will Vision Coverage:A dependent child may be covered through the continue through the end of month in which separation occurred. COBRA , end of the calendar year in which the child turns age 26 if the child is continuation of coverage may be available as applicable by law. primarily dependent on the employee for support. Dependent Eligibility Life Insurance:A dependent child may be covered through age 20; A dependent is defined as the legal spouse and/or dependent child(ren)of the or may be extended through age 24 if the dependent is a full-time participant or spouse.The term"child"includes any of the following: student. • A natural child • A stepchild • A legally adopted child Please see Taxable Dependents if covering eligible over-age dependents. • A newborn child(up to the age of 18 months)of a covered dependent(Florida) Disabled Dependents • A child for whom legal guardianship has been awarded to the Coverage for a dependent child may be continued beyond age 26 if: participant or the participant's spouse • The dependent is physically or mentally disabled and incapable of self-sustaining employment(prior to age 26);and • Primarily dependent upon the employee for support;and • The dependent is otherwise eligible for coverage under the group medical plan;and • The dependent has been continuously insured. Proof of disability will be required upon request. Please contact Human Resources if further clarification is needed. 110 1 ©2016,Gehring Group,Inc.,All Rights Reserved 0 Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 Group Insurance Eligibility (Continued) Taxable Dependents Employee covering adult child(ren)under the employee's medical insurance plan may continue to have the related coverage premiums payroll deducted on a pre-tax basis through the end of the calendar year in which the dependent child reaches age 26.Beginning January 1 of the calendar year in which the dependent child reaches age 27 through the end of the calendar year in which the dependent child reaches age 30,imputed income must be reported on the employee's W-2 for that entire tax year and will be subject to all applicable Federal,Social Security and Medicare taxes.Imputed income is the dollar value of insurance coverage attributable to covering each adult dependent child.Contact Human Resources for further details if covering an adult dependent child who will turn age 27 any time during the upcoming calendar year or for more information. Please Note:There is no imputed income if adult dependent child is eligible to be claimed as a dependent for Federal income tax purposes on the employee's tax return. Qualifying Events and Section 125 Section 125 of the Internal Revenue Code Premiums for medical, dental, vision insurance, contributions to Flexible Spending Accounts(FSA),and/or certain supplemental policies are deducted through a Cafeteria Plan established under Section 125 of the Internal Revenue IMPORTANT NOTES � Code and are pre-taxed to the extent permitted.Under Section 125,changesto an employee's pre-tax benefits can be made ONLY during the Open Enrollment period unless the employee or qualified dependent(s) experience(s) a If employee experiences a Qualifying Event, Human Resources Qualifying Event and the request to make a change is made within 30 days of must be contacted within 30 days of the Qualifying Event at the Qualifying Event. (772) 220-7143 to make the appropriate changes to employee's coverage. Beyond 30 days, requests will be denied and employee Under certain circumstances,employee may be allowed to make changes to may be responsible,both legally and financially,for any claim and/ benefit elections during the plan year if the event affects the employee,spouse or expense incurred as a result of employee or dependent who or dependent's coverage eligibility.An"eligible"Qualifying Event is determined continues to be enrolled but no longer meets eligibility requirements. by Section 125 of the Internal Revenue Code.Any requested changes must be If approved,changes may be effective the date of the Qualifying Event consistent with and due to the Qualifying Event. or the first of the month following the Qualifying Event. Newborns are effective on the date of birth.Marriage is effective on the date of Examples of Qualifying Events: occurrence.Cancellations will be processed at the end of the month.In • Employee gets married or divorced the event of death,coverage terminates the day following the death. Employee may be required to furnish valid documentation supporting • Birth of a child a change in status or"Qualifying Event"such as: • Employee gains legal custody or adopts a child • Marriage license • Employee's spouse and/or other dependent(s)die(s) • Divorce decree • Loss or gain of coverage due to employee,employee's spouse and/or • Copies of social security cards for all dependents dependent(s)termination or start of employment • Letter stating gain or loss of coverage and reason why • An increase or decrease in employee's work hours causes eligibility If employee experiences a divorce and is required to keep a former or ineligibility spouse on an insurance plan,the former spouse must be dropped from • A covered dependent no longer meets eligibility criteria for coverage the group plan.Employee may purchase COBRA or a stand alone plan. • A child gains or loses coverage with other parent or legal guardian If employee's former spouse uses the insurance,and the applicable • Change of coverage under an employer's plan carrier determines they are not eligible,employee will be financially responsible for any claims filed during the ineligible time period. • Gain or loss of Medicare coverage • Losing or becoming eligible for coverage under a State Medicaid or CHIP(including Florida Kid Care) program (60 day notification period) 111 2 ©2016,Gehring Group,Inc.,All Rights Reserved Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 Medical Insurance The Sheriffs Office offers medical insurance through Florida Blue to benefit- Non-Tobacco Use Discount eligible employees.The monthly costs for coverage are listed in the premium tables below and a brief summary of benefits is provided on the following The Sheriff's Office recognizes the impact tobacco use has on medical expenses pages. For more detailed information about the medical plans, please refer and insurance costs.Effective October 1,2013 the Sheriff's Office implemented to the carrier's Summary of Benefits and Coverage(SB0 document or contact a Non Tobacco users discount.Employee enrolled in a Sheriff's Office medical Florida Blue's customer service. plan will have a reduced rate per month if they do not use tobacco products,or if they complete a tobacco cessation program.The discount will be applied to any employee who submits a signed Non-Tobacco Users Affidavit,or submits a Medical Insurance—Florida Blue certificate of completion from the MCSO sponsored tobacco cessation program BlueOptions PPO 3748 Plan* (or other equivalent program).Employee who does not submit the Affidavit Payroll Deductions—Monthly Premiums or certificate of tobacco cessation program completion will be charged the Tier of Coverage Employee Cost Non Tobacco Users regular payroll deduction. Employee who falsifies this document(s) and/or fails to be truthful will be subject to disciplinary action up to and including [-Employee Only $165.50 $140.97 termination. Employee who chooses to become tobacco free,or chooses to • Employee+Family $446.89 $380.68 complete a tobacco cessation course during the benefit year will have their medical insurance premium reduced accordingly the following month.Please Group#46006 contact Human Resources to obtain information on the tobacco cessation courses provided through MCSO and other tobacco cessation courses available Medical Insurance—Florida Blue to employee and covered dependent(s). BlueOptions Alternative Health 5360 Plan* Payroll Deductions—Monthly Premiums Florida Blue I Customer Service:(800)352-2583 I www.floridablue.com Tier of Coverage Employee Cost Non-Tobacco Users Employee Only $117.29 $86.88 Summary of Benefits and Coverage F. - - - -- - Employee+Family $316.73 $234.62 A Summary of Benefits&Coverage(SBC)for the Medical Plan is provided as a supplement to this booklet being distributed to new hires and existing employees GroupR46006 during the Open Enrollment period. The summary is an important item in understanding the employee benefit options.A free paper copy of the SBC document may be requested or is available as follows: From: Aimie Pieper-Manager,Human Resources Unit Address: 800 SE Monterey Road Stuart,FL 34994 Phone: (772)220-7005 Email: ampieper@sheriffmartin.fl.us The SBC is only a summary of the plan's coverage.A copy of the plan document,policy, or certificate of coverage should be consulted to determine the governing contractual provisions of the coverage.A copy of the group certificate of coverage can be reviewed and obtained by contacting Human Resources. If there are questions about the plan offerings or coverage options,please contact Human Resources at(772)220-7005. 112 3 ©2016,Gehring Group,Inc.,All Rights Reserved Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 Other Available Plan Resources Telehealth —Teladoc Florida Blue offers all enrolled employees and dependents additional services Florida Blue provides access to telehealth services as part of the medical plan. and discounts through value added programs. For more details regarding Teladoc is a convenient phone and video consultation company that provides other available plan resources,please contact Florida Blue's customer service immediate medical assistance for many conditions. at(800)345-3885,or visit www.floridablue.com. The benefit is provided to all enrolled members. Registration is required BIue365 and should be completed ahead of time.This program allows members 24 Blue365 is a free discount program on products and services available to all hours a day,seven(7)days a week on-demand access to affordable medical members such as: care via phone and online video consultations when needing immediate care for non-emergency medical issues.Teledoc should be considered when ✓ Vision Care,Glasses,and Contact Lenses employee's primary care doctor is unavailable, after-hours or on holidays ✓ Hearing Care and Aids for non-emergency needs. Many urgent care ailments can be treated with ✓ Fitness Club Memberships,Exercise Footwear and Apparel telehealth,such as: ✓ Weight Loss Management ✓ Sore Throat ✓ Allergies ✓ Alternative Medicine V Headache V Rash ✓ Elder Care Advisory Services V Stomach ache V Acne ✓ Hotel Rooms and Travel Information V Fever V UTI's and More For more information,please contact Florida Blue at(800)345-3885 or visit V Cold and Flu www.floridablue.com and select"Members"then"Members Tips&Tools°Click "Discounts&Rewards"and then click"I Agree"on the"Explore Healthy Choices Teladoc providers do not replace employee's primary care physician but may be with Blue 365"website. a convenient alternative for urgent care and ER visits.For further information please contact Teladoc. Florida Blue I Customer Service:(800)345-38851 www.floridablue.com Teladoc I Customer Service:(800)835-2362I www.Teladoc.com 113 . 4 ©2016,Gehring Group,Inc.,All Rights Reserved `; Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 Florida Blue — BlueOptions PPO 3748 Plan At-A-Glance Network BlueOptions Calendar Year Deductible(CYD) In-Network Out-of-Network* Single $0 $500 f Family '. $0- -- - 1 — $1,000 -- Coinsurance Locate a Provider Member Responsibility 20% 40% To search for a participating provider, contact Florida Blue's customer service Calendar Year Out-of-Pocket Limit or visitwww.floridablue.com.When Single $3,000 $6,000 completing the necessary search `-`-- criteria,select BlueOptions network. i Family , $6,000 $12,000 Fit;Applies the Out-of-Pocket Limit? Deductible,Coinsurance,Copays and Rx 0 Physician Services Primary Care Physidan(PCP)Office Visit - $30 Copay 40%After CYD �pedalist Office Visit $60 Copay 40%After CYD Plan References I Telehealth Services No Charge Not Covered *Out-Of-NetworkBalance Billing: Non-Hospital Services;Freestanding Facility For information regarding out-of- network balance billing that may be Clinical lab(Bloodwork)*" $20 Copay 40%After CYD charged by out-of-network providers, X-rays $75 Copay 40%After CYD � please refer to the Summary of Benefits —-- -= -- - - -- and Coverage(SBC)document. Advanced Imaging(MRI,PET,CT) $75 Copay 40%After CYD Outpatient Surgery in Surgical Center $30 Copay 40%After CYD **Quest Diagnostics is the preferred lab for bloodwork through Florida Blue. Physician Services at Surgical Center $60 Copay 40%After CYD When using a lob other than Quest, Lrgent Care Center(Per Visit) 1 $100 Copay $100 Copay After CYD please confirm they are contracted with Florida Blue's BlueOptions network prior Hospital Services to receiving services. Inpatient Hospital(Per Admission)*** _ Option 1:$500 Copay Option 2:$1,000 Copay 40%After CYD **"Option 1 and Option 2 Hospitals:To Outpatient Hospital(Per Visit)*** — _v Option 1:$250 Copay Option 2:$500 Copay 40%After CYD determine if a hospital is Option 1 or -— Option 2,please contact Florida Blue's [Physician Services at Hospital $30 Copay Per Provider's Visit $30 Copay Per Provider Visit customer serviCe. X-rays/Advanced Imaging at Hospital1 Option 1:$250 Copay Option 2:$500 Copay 40%After CYD Emergency Room(Per Visit,Waived if Admitted) 1 $250 Copay $250 Copay Mental Health/Alcohol&Substance Abuse I Inpatient Hospitalization(Per Admission) $500 Copay 40%After CYD Outpatient Services(Per Visit) _I $30 Copay 40%After CYD Physidan Office Visit 1 $60Copay 40%Coinsurance Prescription Drugs(Rx) Generic -- ] $15 Retail Copay Not Covered [Preferred Brand Name $45 Retail Copay Not Covered Non-Preferred Brand Name $75 Retail Copay Not Covered 'Specialty Pharmacy 25%Coinsurance($150 Maximum Per Prescription) Not Covered Mail Order Drug(90 Day Supply) - 5 114_1 $0/$90/$150 Retail Copay II Cgvered ©2016,Gehring Group,Inc.,All Rights Reserved Martin County Sheriff's Office I Employee Benefit Highlights 12020-20210 Florida Blue — BlueOptions Alternative Health 5360 Plan At-A-Glance Network BlueOptions CalendarYear Deductible(CYD) In-Network Out-of-Network* I Single $1,250 $2,500 is - Family $2,500 $5,000q Coinsurance Member Responsibility 1 . 20% 40% Locate a Provider • To search for a participating provider, Calendar Year Out-of-Pocket Limit contact Florida Blue's customer service Single $5,000 $10,000 or visitwww.floridablue.com.When = _ -- -• completing the necessary search I Family $5,000 $10,000 criteria,select BlueOptions network. What Applies to the Out-of-Pocket limit? j. - Deductible,Coinsurance,Copays and Rx Physidan Services Primary Care Physician(PCP)Office Visit 20%After CYD 40%After CYD -; 0 L pedalist Office Visit 20%After CYD 40%After CYD Telehealth Services No Charge Not Covered Plan References "Out-Of-Network Balance Billing: Non-Hospital Services;Freestanding Facility For information regarding our-of- [Clinical Lab B!oodworkt* No Charge 40%After CYD network balance billing that may be X-rays i _— — 20%After CYD 40%After CYD charged by out-of-network providers, please refer to the Summary of Benefits Advanced Imaging(MRI,PET,(7) ---, 20%After CYD 40%After CYD and Coverage(SBC)document. E Outpatient Surgery in Surgical Center 20%After CYD 40%After CYD - -- ; "*Quest Diagnostics is the preferred 1.thysician Services at Surgical Center 20%After CYD40%After CYD _ lab for bloodwork through Florida Blue. Urgent Care Center(Per Visit) 20%After CYD 20%After CYD When using a lab other than Quest, please confirm they are contracted with Hospital Services Florida Blue's BlueOptions network prior - to receiving services. Inpatient Hospital(PerAdm,ssian) Option 1:20%After CYD Option 2:20%After CYD 40%After CYD Outpatient Hospital(Per Visit)"*"` 1 Option 1:20%After CYD Option 2:20%After CYD 40%After CYD ***Option land Option 2 Hospitals:To determine if a hospital is Option 1 or [Physician Services at Hospital 1 20%After CYD 20%After In-Network CYD . Option 2,please contact Florida Blue's X-rays/Advanced Imaging at Hospital 20%AfterCYD 40%After CYD customer service. Emergency Room(Per Visit) 20%After CYD 20%After CYD Mental Health/Alcohol&Substance Abuse LInpatient Hospital Services(Per Admission) - 1 20%After CYD 40%After CYD r Outpatient Services(Per Visit) 20%After CYD 40%After CYD [Outpatient Office Visit 20%After CYD 40%After CYD Prescription Drugs(Rx) Generic $15 Retail Copay Not Covered [Preferred Brand Name $30 Retail Copay Not Covered Non-Preferred Brand Name $50 Retail Copay Not Covered [Specialty Pharmacy ] $75 Retail Copay Not Covered [ail Order Drug(90 Day Supply)) _1 $0/$60/$100 Retail Copay Not Covered 115 6 ©2016,Gehring Group,Inc.,All Rights Reserved •00006 Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 Health Reimbursement Account (For BlueOptions Alternative Health 5360 Plan Participants Only) The Sheriff's Office provides employees who participate in the BlueOptions How to check available HRA balance Alternative Health 5360 Plan, a Health Reimbursement Account (HRA) Balance, activity and account history is available anytime online at through Discovery Benefits. HRA monies are funded by the Sheriffs Office www.discoverybenefits.com or by calling Discovery Benefits at(866)451-3399. and can be used for any qualified medical,dental and vision expenses such as copayments,deductibles and coinsurance for physician services, hospital HRA IRS Guidelines services,prescription drugs,etc. HRAs must be funded solely by an employer.The contribution cannot be paid The Sheriff's Office will fund the HRA based upon successful completion of the through a voluntary salary reduction agreement on the part of an employee. criteria outlined below. Employee is reimbursed tax free for qualified medical, dental and vision 1.Completion of Biometric Screening. expenses up to a maximum dollar amount for a coverage period.An HRA may 2.Completion of a Health Risk Assessment. be offered with other health plans,including Flexible Spending Accounts. HRA funding will be deposited into employee's account the first of the month What are the benefits of an HRA?Employee may enjoy several benefits from following the date employee completes the criteria. Please contact Human having an HRA. Resources for details regarding screening requirements,or within 90 days of hire date for new hires,to qualify for the incentive. • Contributions made by employer can be excluded from employee's gross income. The Sheriff's Office is committed to helping employee's achieve their best • Reimbursements may be tax free if employee pays qualified health.If unable to meet a standard to qualify for the incentive because it is medical,dental and vision expenses. unreasonably difficult due to a medical condition,or it is medically inadvisable • Unused amounts in the HRA can be carried forward for for employee to attempt,please contact Human Resources at(772)220-7143. reimbursements in later years. HRA Funding Allotment Distributions From an HRA • HRA Funding for 2020/2021 is as follows: Distributions from an HRA must be paid to reimburse employee for qualified $625 for Employee Only medical,dental and vision expenses incurred.The expense must have been $1,250 for Employee+Family incurred on or after the date employee enrolled in the HRA.Employee will have • Unused funds roll-over year to year,as long as the total in employee's a 30 day run out period at the end of the plan year to file for reimbursement account does not exceed current plan year deductible. on any eligible medical,dental and vision expenses incurred during period of • If employee contributes to a Health Care Flexible Spending Account coverage within the plan year. (FSA),FSA monies pay first,then HRA. Please Note:Debit cards,credit cards,and stored value cards given to employee can Please Note: If the calendar year deductibles exceed the HRA funding amounts. be used to reimburse participants in an HRA.If the use of these cards meet certain Members will be responsible for any amount over the HRA funding until the calendar substantiation methods,employee may not have to provide additional information to the HRA administrator. year deductible and out-of-pocket limit have been met. Retain Receipts Discovery Benefits Customer Service:(866)451-3399 I www.discoverybenefits.com During the year, employee should keep all receipts and documentation for prescriptions and medical, dental and vision related expenses if needed to verify a claim for Discovery Benefits or for IRS taxes. If asked to produce documentation,a valid Explanation of Benefits(EOB)and receipt of payment for the services rendered will be sufficient. 116 7 ©2016,Gehring Group,Inc.,All Rights Reserved Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 HRA ' • Health Reimbursement Account(for BlueOptions Alternative Health 5360 Plan Participants Only)(Continued) What is the difference between an HRA and an FSA? Health Reimbursement Account(HRA) Flexible Spending Accounts(FSA) ✓ Employer Funded Account ✓ Employee Funded Account ✓ HRA funds will be deposited upon timely completion of ✓ Employee does not have to be enrolled in the Alternative Biometric Screening and Health Risk Assessment Health 5360 Plan to participate ✓ Funds for employee and dependent(s)who are enrolled in ✓ Employee must enroll annually the Alternative Health 5360 Plan and complete criteria ✓ Unused funds will be forfeited at the end of the plan year, ✓ Unused funds may be rolled over year to year as long as except the$550 rollover amount allowed by the IRS(once accumulated amount and funded amount does not exceed the filing deadlines have expired). If employee does not current plan year deductible enroll annually, any accumulated rollover funds will be forfeited What are some examples of qualified expenses that would be eligible for reimbursement? ✓ Ambulance Service ✓ Drug Addiction/Alcoholism Treatment ✓ Nursing Services ✓ Birth Control Pills ✓ Prescription Drugs ✓ Optometrist Fees ✓ Chiropractic Care ✓ Experimental Medical Treatment ✓ Surgery ✓ Corrective Eyeglasses and Contact Lenses ✓ Hearing Aids and Exams ✓ Wheelchairs ✓ Dental and Orthodontic Fees ✓ Injections and Vaccinations ✓ X-rays ✓ Diagnostic Tests/Health Screenings ✓ In Vitro Fertilization ✓ Doctor Fees ✓ LASIK Surgery Please Note:For information on these methods,see Revenue Ruling 2003-43 on page 935 of Internal Revenue Bulletin(IRB)2003-21 at www.irs.gov/pubfirs-irbs/irb03-21.pdf,Notice 2006-69,2006-31 I.R.B.107 available at www.irs.gov/irb/2006-31_IRB/arl0.html,and Notice 2007-2,2007-21.R.B.254 available at www.irs.gov/rb/1007-2 IRB/ar09.html If employee has the HRA and also elects an FSA,FSA monies will be used first.FSA is employee funded and allows a maximum of$550 of unused funds to rollover,year to year. Discovery Benefits I Customer Service:(866)451-33991 www.discoverybenefits.com 117 8 02016,Gehring Group,Inc.,All Rights Reserved Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 Dental Insurance Delta Dental Table of Allowance (TOA) Plan The Sheriff's Office offers dental insurance through Delta Dental to Out-of-Network Benefits benefit-eligible employees. The monthly cost for coverage is listed in the premium table below and a brief summary of benefits is provided on the Out-of-network benefits are used when member receives services by a non- following page.For more detailed information about the dental plan,please participating Delta Dental PPO provider. Delta Dental reimburses out of refer to the carrier's summary plan document or contact Delta Dental's network services based on what it determines is the Maximum Plan Allowance customer service. (MPA).The MPA is defined as the most common charge for a particular dental procedure performed in a specific geographic area.If services are received from an out-of-network dentist,the member may be responsible for balance billing. Dental Insurance Balance billing is the difference between Delta Dental's MPA and the amount Delta Dental Table of Allowance(TOA)Plan* charged by the out-of-network dental provider.Balance billing is in addition to Premium Deductions-Monthly Premiums any applicable plan deductible,plan allowances or coinsurance responsibility. Tier of Coverage Employee Cost Using a non-Delta Dental provider usually results in the highest out of pocket costs,there is no limit to the amount the dentist may charge,causing member Employee only $7:99 to be responsible for any fees not covered by the plan's Maximum Plan Employee+Family $19.59 Allowance. *6roupk 01276 Calendar Year Deductible In-Network Benefits The TOA plan requires a$50 individual or a$150 family deductible to be met for in-network or out-of-network services before most benefits will begin. The TOA plan provides benefits for services received from in-network and The deductible is waived for diagnostic,preventive and orthodontic services. out-of-network providers. It is also an open-access plan which allows for Once $150 total (aggregate) is met for the in-network and out-of-network services to be received from any dental provider without having to select a deductible for a family,regardless of who incurs the expenses,the deductible Primary Dental Provider(PDP) or obtain a referral to a specialist. Although will then be considered met for all covered members in that family. the Delta Dental TOA plan allows member the freedom to visit any licensed dentist, member will receive greater cost savings by utilizing participating Calendar Year Benefit Maximum dental providers in the Delta Dental PPO network.These participating dental The maximum benefit(coinsurance) the dental TOA plan will pay for each providers have contractually agreed to accept Delta Dental's PPO dental fee covered member is$1500 for in-network or out-of-network services combined. or"allowed amount."This dental fee is the maximum amount a Delta Dental provider can charge a member for a service.The member is responsible for a All services, including diagnostic and preventive, accumulate towards the Calendar Year Deductible(CYD)and then the difference of the Maximum Plan benefit maximum.Once the plan's benefit maximum is met,the member will Allowance(MPA)charge and the"allowed amount."The MPA is generally less be responsible for future charges until next calendar year. than the allowed amount. Orthodontia Lifetime Benefit Maximum Please Note:If a member is not able to use a Delta Dental PPO provider,then services The maximum benefit the dental TOA Plan will pay for each covered member can be received from a Delta Dental Premier®provider.Delta Dental Premier®providers per lifetime for the treatment of orthodontia is$1,500 for in-network and out- are considered out-of-network dentists.The dentists have agreed to accept Delta Dental's of-network services.Once the dental plan pays$1,500 for services,member's Maximum Plan Allowance(MPA)for each single procedure however,the provider may plan benefits will cease for the lifetime of that covered member for orthodontic bill for the difference of the MPA and the Premier Dental Agreement amount.Member is responsible for verifying whether the treating Dentist is a PPO Dentist ora Premier services. Dentist. Delta Dental I Customer Service:(800)521-2651 I www.deltadentalins.com 118 9 ©2016,Gehring Group,Inc.,All Rights Reserved Martin County Sheriff's Office I Employee Benefit Highlights 12020-20210 Delta Dental Table of Allowance (TOA) Plan At-A-Glance Network Delta Dental PPO Calendar Year Deductible(CYD) In Network and Out of Network Combined i Per Member _-�i $50 - - Q Family $150 Waived for Diagnostic&Preventative Services? Yes i. Locate a Provider CalendarYear Benefit Maximum To search for a participating provider, Per Member $1,500 • contact Delta Dental's customer service or visit www.deltadentalins.com. Maximum Plan When completing the necessary Diagnostic&Preventive Services Code Allowance(MPA) search criteria,select Delta Dental PPO [Comprehensive Oral Exam D0120 Up to$45 network. Routine Cleanings—Adult/Child(2 Per Year) D1110/20 Up to$98/$70 . [Bitewing X-rays* ! . D0272 Up to$30 Panographic X-rays(1 Set Every 5 Years) - J D0330 Up to$75 Intraoral/Complete Series X-Rays D0210 Up to$94 •Full Mouth Depridement(Deep Cleaning) D4355 Up to$84 Plan References *Bitewing X-rays:One(1)set per Basic Services calendaryear for employee and spouse. r Two(2)sets per calendar year for LAmalgamFillings(3Surfaces;Permanent orPrimary) _1. D2160 Up to$120 dependent children enrolled. Resin-based Composite Filling(3 Surfaces,Anterior) ] D2332 Up to$144 Resin-based Composite Filling(3 Surfaces,•Posterior) ] D2393 Up to$120 Simple Extraction—Removal of Erupted Tooth or Root D7140 Up to$80 Surgical Extraction—Removal of Impacted Tooth - D7240 Up to$228 41111) Endodontics(Root(anal.Molar)—Excluding Final Restoration 03330 Up to$557 Important Notes Periodontal Maintenance Services(2 Per Year) D4910 Up to$83 •Each covered family member Major Services may receive up to two(2)routine [t cleanings per calendar year covered Deep Sedation/General Anesthesia(Each 15 Minute Increment) ] D9223 Up to$50 under the preventive benefit. Crown—Porcelain Fused to High Noble Metal 1 D2750 Up to$370 •A pretreatment estimate is Pontic=Porcelain Fused to High Noble Metal D6240 Up to$360 recommendedfor all work that is considered expensive.Member rComplete Denture—Maxillary D5110 Up to$485 must ask their dentist to submit the request to Delta Dental. Orthodontia •Waiting periods and age limitations I Lifetime Maximum 1 Up to$1,500 mayappty. Benefit i 50%Coinsurance of MPA •Benefit frequency limitations may apply to certain services. •for a full list of covered services and the MPA payable,please refer to the carrier's summary plan document. 119 ©2016,Gehring Group,Inc.,All Rights Reserved 10 Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 Dental Insurance Delta Dental PPO Plan The Sheriff's Office offers dental insurance through Delta Dental to benefit- Out-of-Network Benefits eligible employees.The monthly cost for coverage is listed in the premium table below and a brief summary of benefits is provided on the following Out-of-network benefits are used when members receive services by a non- page.For more detailed information about the dental plan,please refer to the participating Delta Dental PPO provider. Delta Dental reimburses out of carrier's summary plan document or contact Delta Dental's customer service. network services based on what it determines is the Maximum Plan Allowance (MPA).The MPA is defined as the most common charge for a particular dental procedure performed in a specific geographic area.If services are received from Dental Insurance—Delta Dental PPO* an out-of-network dentist,the member may be responsible for balance billing. Payroll Deductions-Monthly Premiums Balance billing is the difference between Delta Dental's MPA and the amount Tier of Coverage Employee Cost charged by the out-of-network dental provider.Balance billing is in addition to any applicable plan deductible or coinsurance responsibility. Employee Only T� $11.07 Employee+Family $27.15 Calendar Year Deductible *Group#01176 The dental PPO plan requires a$50 individual or a$150 family deductible to be met for in-network or out-of-network services before most benefits will begin. In-Network Benefits The deductible is waived for diagnostic,preventive and orthodontic services. Once$150 total (aggregate)is met for the in-network and out-of--network The dental PPO plan provides benefits for services received from in-network deductible for a family,regardless of who incurs the expenses,the deductible and out-of-network providers.It is also an open access plan which allows for will then be considered met for all covered members in that family. services to be received from any dental provider without having to select a Primary Dental Provider(PDP)or obtain a referral to a specialist.The network Calendar Year Benefit Maximum of participating dental providers the plan utilizes is the Delta Dental PPO The maximum benefit(coinsurance)the dental PPO plan will pay for each network. These participating dental providers have contractually agreed to accept Delta Dental's contracted fee or"allowed amount"This fee is the covered member is $1500 for in network and out-of-network services maximum amount Delta Dental provider can charge a member for a service. combined.Diagnostic and preventive services do not accumulate towards the The member is responsible for a Calendar Year Deductible (CYD) and then benefit maximum.Once the plan's benefit maximum is met,the member will coinsurance based on the plan's charge limitations. be responsible for future charges until next calendar year. Please Note:If a member is not able to use a Delta Dental PPO provider,then services can Orthodontia Lifetime Benefit Maximum be received from a Delta Dental Premier®Provider.Delta Dental Premier®Providers are The maximum benefit the dental PPO plan will pay for each covered member considered out-of-network dentists.These dentists have agreed to accept Delta Dental's per lifetime for the treatment of orthodontia is $1,500 for in-network and Maximum Plan Allowance(MPA)for each single procedure;however,the provider may out-of-network services.Once the dental PPO plan pays$1,500 for services, still bill for the difference of the MPA and the Premier Dental Agreement amount. The member's plan benefits will cease for the lifetime of that covered member for member is responsible for verifying whether the treating dentist is a PPO Dentist or Premier Dentist orthodontic services. Delta Dental I Customer Service:(800)521-2651 I www.deltadentalins.com 120 11 ©2016,Gehring Group,Inc.,All Rights Reserved Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021ti? i Delta Dental PPO Plan At-A-Glance Network Delta Dental PPO Calendar Year Deductible(CYD) In-Network Out-of-Network* • • Per Member $50 Per Family $150 _ - _ - Waived for Diagnostic&Preventative Services? Yes Locate a Provider Calendar Year Benefit Maximum • .. . To search for a participating provider, Per Member $1,500 contact Delta Dental's customer service or visit www.deltadentalins.com. Diagnostic&Preventive Care When completing the necessary search criteria,select Delta Dental PPO Routine Oral Exam(2 Per Year) network. Routine Cleanings(2 Per Year) Bitewing X-rays"" Plan Pays:100% Plan Pays:100% Deductible Waived [—CompleteX-rays(1 Every 5Years) - 7 Deductible Waived (Subject roBalance Billing) Sealants Deep Cleaning Plan References Basic Services *Out-Of-Network Balance Billing: Fillings(Amalgam and Composite) For information regarding out-of- [ -"��" network balance billing that may be • imple Extractions charged by an out-of-network provider, Endodontics(Root Canal Therapy) , plea se refer to the Out-of-Network — Plan Pays:100%After CYD Plan Pays:80%After CYD Oral Surgery (Subject to Balance Billing) Benefits section on the previous page. `Periodontics "Bitewing X-rays:One(1)set per ` calendar year for employee and spouse. General Anesthesia(Limitations Apply) Two(2)sets per calendar year for Major Services dependent children enrolled. — Crowns Dentures -I Plan Pays:60%After CYD Plan Pays:50%After CYD (Subject to Balance Billing) Bridges Orthodontia Important Notes Lifetime Maximum $1,500 •Each covered family member may Plan Pays:50% receive up to two(1) cleanin Benefit Plan Pays:50% Deductible Waived per calendar year coveredroutine under the Deductible Waived reventive benefit. (SubjecttoBalanceBilling) D •A pretreatment estimate is recommended for all work that is considered expensive.Member must ask their dentist to submit the request to Delta Dental. •Waiting periods and age limitations may apply. •Benefit frequency limitations may apply to certain services. 121 ©2016,Gehring Group,Inc.,All Rights Reserved 12 Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 Vision Insurance Humana Vision 130 Plan The Sheriff's Office offers vision insurance through Humana to benefit-eligible Out-of-Network Benefits employees.The monthly cost for coverage are listed in the premium table Employee and covered dependent(s) may choose to receive services from below and a brief summary of benefits is provided on the following page.For more detailed information about the vision plan,please refer to the carrier's vision providers who do not participate in the Humana Insight network. summary plan document or contact Humana's customer service. When going out of network,the provider will require payment at the time of appointment.Humana will then reimburse based on the plan's out-of-network reimbursement schedule upon receipt of proof of services rendered. Vision Insurance—Humana Vision 130 Plan* Payroll Deductions—Monthly Premiums Calendar Year Deductible Tier of Coverage Employee Cost There is no calendar year deductible. Employee Only $4.95 ' Calendar Year Out-of-Pocket Maximum 1 Employee+Family $14.11 s There is no out-of-pocket maximum.However,there a re benefit reimbursement *Group#1003955 maximums for certain services. In-Network Benefits Humana I Customer Service:(866)537-0229 I www.humana.com The vision plan offers employee and covered dependent(s)coverage for routine eye care, including eye exams, eyeglasses (lenses and frames) or contact lenses.To schedule an appointment,employee and covered dependent(s)may select any network provider who participates in the Humana Insight network. At the time of service,routine vision examinations and basic optical needs will be covered as shown on the plan's schedule of benefits.Cosmetic services and upgrades will be additional if chosen at the time of the appointment. 122 13 ©2016,Gehring Group,Inc.,All Rights Reserved Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 Humana Vision 130 Plan At-A-Glance Network Insight Services In-Network Out-of-Network Eye Exam $10 Copay Up to$30 Reimbursement n Standard* Upto$55Allowance Not Covered �„V[ Contact Lens Fit and Follow up premium'" 10%Off Retail Allowance ; Not Covered -- --- Locate a Provider Reimbursement Based on Materials $15 Copay Type of Service To search for a participating provider, --- — _ - _ contact Humana's customer service Retinal Imaging Upto$39Copay Not Covered or visitwww.humana.com.When completing the necessary search Frequency of Services Per Calendar Year criteria,select Humana Insight network. Examination 12 Months Lenses 12 Months 1 [Frames 24 Months l Contact Lenses 12 Months Lenses Plan References Single $15 Copay Up to$25 Reimbursement "Standard Contact lens fitting is ____ _ _ __ __ _ __ , considered single vision standard fitting Bifocal _ $15Copay • Up to$40 Reimbursement with follow up evaluation. 'Trifocal $15 Copay Up to$60 Reimbursement "Premium Contact lens fitting is considered multifocal/monovision or Frames extended/overnight wear,etc,with Up to$130 Retail Allowance Plus follow up evaluation. Allowance Up to$65 Retail Reimbursement 20%Off Balance Over$130 '""Contact lenses ore in lieu of spectacle lenses and a frame. Contact Lenses*** Non-Elective(Medically Necessary) No Charge • Up to$200 Reimbursement Up to$130 Allowance Plus Conventional U to$104 Reimbursement Elective 15%Off Balance P 0 (Evaluation,Fitting Fee and Materials) _ l Disposable Upto$130Allowance Up to$104 Reimbursement Important Notes Member options,such as LASLK,UV coating,progressive lenses,etc.are not covered in full,but may be available at a discount. 123 14 ©2016,Gehring Group,Inc.,All Rights Reserved FSCis, Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 Flexible Spending Account The Sheriff's Office offersa Flexible Spending Account(FSA)administered through Discovery Benefits.The FSA plan year is from October 1 through September 30. If employee or family member(s)has predictable health care expenses,then employee may benefit from participating in an FSA.An FSA allows employee to set aside money from employee's paycheck for reimbursement of health care expenses they regularly pay.The amount set aside is not taxed and is automatically deducted from employee's paycheck and deposited into the FSA.During the year,employee has access to this account for reimbursement of some expenses not covered by insurance. Participation in an FSA allows for substantial tax savings and an increase in spending power.Participating employee must re-elect the dollar amount to be deducted each plan year. Health Care FSA This account allows participant to set aside up to an annual maximum of$2,750.This money will not be taxable income to the participant and can be used to offset the cost of a wide variety of eligible medical expenses that generate out-of-pocket costs.Participating employee can also receive reimbursement for expenses related to dental and vision care(that are not classified as cosmetic). Examples of common expenses that qualifyfor reimbursement are listed below. p P Please Note:The entire Health(are FSA election is available to employee on the first day coverage is effective. A sample list ofqualified expenses eligible for reimbursement include,but not limited to,the following: P P 9 9 ✓ Prescription/Over-the-Counter Medications V Physician Fees and Office Visits ✓ LASIK Surgery ✓ Menstrual Products V Drug Addiction/Alcoholism Treatment V Mental Health Care ✓ Ambulance Service V Experimental Medical Treatment ✓ Nursing Services ✓ Chiropractic Care ✓ Corrective Eyeglasses and Contact Lenses V Optometrist Fees ✓ Dental and Orthodontic Fees V Hearing Aids and Exams V Sunscreen SPF 15 or Greater ✓ Diagnostic Tests/Health Screenings V Injections and Vaccinations V Wheelchairs Log on to http://www.irs.gov/publications/p502/index.html for additional details regarding qualified and non-qualified expenses. If employee has the HRA and also elects an FSA,FSA monies will be used first,as itis employee funded and only rolls over a maximum of$550 of unused funds year to year. 124 15 ©2016,Gehring Group,Inc.,All Rights Reserved Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 FSA,,„„ Flexible Spending Account (Continued) FSA Guidelines - - l \ • Employee must enroll annually to participate each year. • Employee may carry over up to$550 of unused Health Care FSA HERE'S HOW IT WORKS! funds into the next plan year after a plan year ends and all claims An employee earning$30,000 elects to place$1,000 into a Health have been filed. • The Health Care FSA has a run out period at the end of the plan year Care FSA.The payroll deduction is$83.33 based on a monthly pay (30 days)to submit reimbursement on eligible expenses incurred period schedule. As a result,the insurance premiums and health care expenses are paid with tax-free dollars,giving the employee during the period of coverage within the plan year. a tax savings of$227. • When a plan year ends and all claims have been filed,all unused funds with the exception of the$550 rollover for the Health Care With a Health Without a Health FSA will be forfeited and not returned. Care FSA Care FSA • Employee can enroll in an FSA only during the Open Enrollment Salary $30,000 $30,000 period,a Qualifying Event,or New Hire Eligibility period. FSA Contribution -$1,000 -$0 • Reimbursed expenses cannot be deducted for income tax purposes. Taxable Pay $29,000 $30,000 • Employee and dependent(s)cannot be reimbursed for services not Estimated Tax -$6,568 $6,795 received. 22.65%=15%+7.65%FICA • Employee and dependent(s) cannot receive insurance benefits After Tax Expenses $0 $1,000 or any other compensation for expenses which are reimbursed Spendable Income $22,432 $22,205 through an FSA. Tax Savings , • Domestic Partners are not eligible as Federal law does not recognize them as a qualified dependent. _ Filing a Claim Please Note: Be conservative when estimating health care expenses. IRS Claim Form regulations state that any unused funds remaining in an FSA,after a plan year A completed claim form along with a copy of the receipt as proof of the ends and after all claims have been filed,cannot be returned or carried forward to the next plan year,with the exception of the$550 carry over that may be allowed expense can be submitted by mail or fax.The IRS requires FSA participants to for the Health Care FSA.This rule is known as"use-it or lose-it.” maintain complete documentation,including copies of receipts for reimbursed expenses,for a minimum of one(1)year. Discovery Benefits Debit Card Customer Service:(866)451-33991 www.discoverybenefits.com FSA participants will automatically receive a debit card for payment of eligible expenses.With the card,most qualified services and products can be paid at the point of sale versus paying out-of-pocket and requesting reimbursement. The debit card is accepted at a number of medical providers and facilities,and most pharmacy retail outlets. Discovery Benefits may request supporting documentation for expenses paid with a debit card. Failure to provide supporting documentation when requested,may result in suspension of the card and account until funds are substantiated or refunded back tothe Sheriff's Office.Please keep the issued card for use next year.Additional or replacement cards may be requested,however,a small fee may apply. 125 16 ©2016,Gehring Group,Inc.,All Rights Reserved 00 �}: Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 Basic Life and AD&D Insurance Additional Life and AD&D Insurance Basic Term Life Insurance Eligible employee may elect to purchase additional Life and AD&D insurance The Sheriff's Office offers a contribution of 50%toward the cost of a$20,000 on a voluntary basis through the Standard.This coverage may be purchased Basic Term Life and Accidental Death & Dismemberment (AD&D) benefit in addition to the Basic Term Life and AD&D coverage.Voluntary life insurance through The Standard,for all active employees.Employees with dependent(s) offers coverage for employee, spouse and/or child(ren) at different benefit may also elect a Basic Dependent Life insurance benefit of$5,000 for a spouse levels.Employee will be responsible for 100%of the premium for this policy. and/or a$2,500 benefit on each dependent child(from birth through age 20, Eligibility Requirements or through age 24 if a full-time student). To be eligible for this plan: Accidental Death&Dismemberment Insurance • Employee must participate in the Basic Term Life and AD&D plan offered by the Sheriff's Office. Also, included with the enrollment in the Basic Term Life insurance, the • Employee must be an active employee of the Martin County Sheriff's Sheriff's Office offers Accidental Death&Dismemberment(AD&D)insurance, Office,excluding temporary and seasonal employees,full-time members which pays in addition to the Basic Term life benefit when death occurs as of the Armed Forces,leased employees and independent contractors. a result of an accident.The AD&D benefit amount equals the Basic Term Life • Employee must be regularly working at least 20 hours each week. benefit,partial benefits may also be payable. • For Dependent Life Insurance;employee's spouse or dependent child(ren) must not be full-time members of the Armed Forces. Age Reduction Schedule Benefit amounts are subject to the following age reduction schedule: Additional Employee Life Coverage Amount • Reduces to 65%of the benefit amount at age 65 • Units can be purchased in increments of$10,000 to the maximum of • Reduces to 50%of the benefit amount at age 70 $300,000. • If employee elects an amount of additional life coverage greater than • Reduces to 35%ofthe benefit amount at age 75 $100,000(the Guaranteed Issue amount),the excess will be subject to The reduction will be effective January 1 following the employee's birthday. Medical Underwriting approval. Basic Life and AD&D Insurance Additional Spouse Life Coverage Amount Payroll Deductions Monthly Premiums • Units can be purchased in increments of $10,000 to a maximum of $300,000 not to exceed 100%of the employee's combined Basic and Tier of Coverage Employee Cost Voluntary Life coverage amount. • Employee Only $3.00 • If employee elects an amount of spouse life coverage greater than Employee+Family $3.72 $20,000 (the Guaranteed Issue amount), the excess will be subject to Medical Underwriting approval. Retirees Age Reduction Schedule Upon retirement,employee may continue the Basic Term Life coverage with Benefit amounts are subject to the following age reduction schedule: a reduced benefit amount of$5,000(AD&D for retirees is not available and • Reduces to 65%of the benefit amount at age 70 dependent coverage,if previously elected,will be terminated). • Reduces to 45%of the benefit amount at age 75 • Reduces to 30%of the benefit amount at age 80 Always remember to keep beneficiary information updated. • Reduces to 20%of the benefit amount at age 85 Beneficiary information may be updated at anytime through • Reduces to 15%of the benefit amount of age 90 Human Resources. • Reduces to 10%of the benefit amount at age 95 The reduction will be effective January 1 following the employee/spouse The Standard I Customer Service:(888)937-4783 I www.standard.com birthday. Please Note:Applications for all plans will be subject to Medical Underwriting approval(Except new hires under the Guarantee Issue.) 126 17 ©2016,Gehring Group,Inc.,All Rights Reserved 00 Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 GM Additional Life and AD&D Insurance (Continued) Employee/Spouse Rates Additional Dependent Child(ren)Life Coverage Amount If employee elects additional life with AD&D insurance,the monthly premium • Employee may elect Additional Dependent Life and AD&D insurance rate for this plan is indicated in the table below.Premiums for coverage will be for eligible dependent child(ren). deducted directly from employee's paycheck. • Employee may elect one(1)of the following options for dependent life coverage: To calculate the premium: > $2,000 1.Amount elected:Write this amount on the > $5,000 additional life requested amount line on line 1: > $10,000 employee Enrollment and Change Form. • AD&D insurance from The Standard Insurance Company is included Line 2: in the above mentioned plans. 2.Line 1 divided by$1,000 • Monthly premium rates for Additional Dependent Child(ren) Life Line 3: insurance coverage are listed in the table to the below. 3.Select rate from the rate table Line 4: Please Note: Applications for all plans will be subject to Medical 4.Line 2 multiplied by Line 3=Monthly cost. Underwriting approval.(Except new hires under the Guarantee Issue.) Additional Life and AD&D insurance Rate Table Additional Dependent Child(ren)Life and AD&D Insurance Monthly Premium Monthly Premium Age Bracket Employee/Spouse Benefit Amount Rate Per Benefit Amount (Based on Employee Age) (Rate Per$1,000ofBenefit) .- ._. . $2,000 $0.40 <30 $0.140 30-34 $0.150 0,000 $2.00 $5,000 $1.00 —_ - -- -- 1 •Y- _ 35-39J $0.185 F--- 40-44 J $0.250 The Standard I Customer Service:(800)247-6888 I www.standard.com • 45-49 $0.405 50-54 $0.590 55-59 $0.965 60-64 J $1.090 i 65-69 $1.980 I 70-75 $3.220 i - i 75+ $10.50 • 127 18 02016,Gehring Group,Inc.,AD Rights Reserved Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 Long Term Disability Insurance The Sheriff's Office provides Long Term Disability(LTD)insurance at no cost to all eligible employees through The Standard.Eligible employees are automatically enrolled in LTD coverage.The LTD benefit pays a percentage of monthly earnings if employee becomes disabled due to an illness or non-work related injury.An LTD"Q&A"is provided below that answers commonly asked questions regarding LTD benefits. Employee qualifies as disabled for the first two(2)years of disability if: • Not working and cannot perform the duties of employee's normal occupation due to injury or illness;or • Working part-time or on a limited basis due to injury or illness and have lost at least 20%of employee's income earned before being disabled. Do I qualify as disabled? Thereafter,employee qualifies as disabled if: • Not working and cannot perform any occupation employee is reasonably qualified to perform based on background, training,or education; • Working part-time or on a limited basis due to injury or illness and have lost at least 40%of employee's income earned before being disabled. When does the LTD benefit begin? The LTD benefit begins after employee has been disabled for 90 days. = - - - - What is the LTD benefit? The LTD benefit equals 60%of employee's monthly pre-disability earnings,to a benefit maximum of$6,000 per month.This benefit may be reduced by other income(answered later). • If employee is disabled and working on a limited or part-time basis,the"Return to Work Incentive"would apply.Under the"Return to What is the LTD benefit iflamdisabled but working? Work Incentive"for the first 12 months after retu ming to work,the employee's LTD benefit will not be reduced until work eamings plus the LTD benefit exceed 100%of the pre-disability earnings.After that period,only S0%of work earnings are deducted. t. How long does the LTD benefit last? The benefit will continue while continuously disabled with a maximum period determined based on employee's age at the time of disability. • Retirement payments or disability payments from Social Security or other government agencies; What other income may reduce the LTD benefit? • Payments from pension plans; • Workers'Compensation. Benefits end when employee's disability ends or employee: • Reaches the maximum benefit payment period; • Fails to provide proof of disability; •What would cause the LTD benefit to terminate? Dies; • Ceases to be under the care of a physiaan; • Fails to report income from other sources; • Fails to pursue Social Security Disability Income(SSI)benefits(when appropriate); • Fails to submit to required medical exams. L The LTD benefit does not pay a benefit for disabilities resulting from: • Willful self-injury; • War or act of war; What disabilities does the LTD plan exclude? • A sickness or injury covered by Workers'Compensation or arising out of or in the course of employment for wage or profit; • A new or continuing disability after the benefit payment period ends and the insured has not returned to active work; • Pre-existing condition. The Standard I To Report a Claim Contact:Yolanda Bills,Assistant Manager,Human Resources Unit I Phone:(772)220-7010 128 19 02016,Gehring Group,Inc.,All Rights Reserved Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 OQ; Voluntary Accident Insurance Sheriff's Office employees may elect to purchase Voluntary Accident Insurance through Cigna Insurance Company.Personal Accident Insurance will help protect against losses due to accidents.Employee and covered dependent(s)are eligible 24 hours a day,365 days a year with worldwide coverage at work,home,traveling on business or while on vacation.Eligible dependents under this plan are employee's spouse(under age 70),and unmarried children under age 25 who are primarily supported by the covered member and either live in their household or are full-time or part-time students.Employee Only or Employee plus Family coverage is offered in this plan,in increments of$50,000.Employee may select a minimum of$50,000 of coverage to a maximum of$250,000 of coverage.Post tax per pay period deductions are provided in the table below. Benefit Amount Employee Only Employee+Family 550,000 $1.80 $2.60 $100,000 $3.60 $520 - - $150,000 $5.40 $7.80 $200,000 — $7.20 $10.40 $250,000 $9.00 $13.00 Life Insurance Company of North America(Cigna)I Claims:(800)238-2125 I www.mycigna.com For Policy Information,contact Human Resources Unit:(772)220-7143 In-The-Line-Of-Duty Death Life Insurance The Sheriff's Office provides In-The-Line-of-Duty Death Life benefit at no cost for all eligible employees.The death benefit is$75,000 and is payable subsequent to a death while in the line-of-duty. Coverages In accordance with Florida Statutes 112.19,the Company will pay the benefits for covered insureds as shown in the table below: Class 1 Circumstance Benefit C 62 Is acddentally killed or receives bodily injury which results in the Insured Person's death or $75,000(Accidental Death and Dismemberment) dismemberment in the line of duty. I Is accidentally killed while responding,at the time of injury,in fresh pursuit or to an Additional$75,000(Accidental Death) emergency or what was reasonably believed to be an emergency. tf 3t Is unlawfully and intentionally killed by another or receives bodily injury which is unlawfully $225,000(Accidental Death) and intentionally inflicted by another and which results in the Insured Person's death. Principal Sum Any payments made shall consist of the statutory amount adjusted to reflect price level changes based on the Consumer Price Index for all urban consumers published by the United States Department of Labor.Adjustments shall be made by July 31 of each year and updated accordingly using the most recent month data is available at the time of adjustment. Hartford(Administered by Florida Sheriffs Risk Management Fund I Customer Service:(850)320-6880 129 20 ©2016,Gehring Group,Inc.,All Rights Reserved • Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 Employee Assistance Program Credit Unions The Sheriff's Office cares about the well-being of all employees on and off the As an employee of the Sheriff's Office,employee and family member's are job and provides,at no cost,a comprehensive Employee Assistance Program eligible to join the Credit Unions listed below. Credit unions are member- (EAP)through New Directions.EAP offers employee and each family member owned financial service cooperatives established to serve members by access to licensed mental health professionals through a confidential program offering better dividends on savings,lower rates on loans and fewer service protected by State and Federal laws.EAP is available to help employee gain a fees than other financial institutions.As a member/owner of the Credit Union, better understanding of problemsthat affect them,locate the best professional employee's have voting privileges and are eligible to serve on the Board of help for a particular problem,and decide upon a plan of action.EAP counselors Directors or on other volunteer committees. are professionally trained and certified in their fields and available 24 hours a day,seven(7)days a week. New member information and account forms are available in Human Resources.Examples of common services include: What is an Employee Assistance Program(EAP)? V Checking Accounts V Student Loans An Employee Assistance Program offers covered employees and family members V Savings Accounts V First Mortgages free and convenient access to a range of confidential and professional services V Consumer Loans V Home Improvement Loans to help address a variety of problems that may negatively affect employee or V College Fund Account V Auto Lease Program family member's well-being.Coverage includes six(6)face-to-face visits with V Credit Cards a specialist, per person, per issue, per year,telephonic consultation, online material/tools and webinars.EAP offers counseling services on issues such as: Connect Credit Union ✓ Child Care Resources V Adult&Elder Care Cynthia Ryan I Phone:(772)287-4057 ext.1207 ✓ Legal Resources Assistance 1993 S.Kanner Highway,Stuart,FL 34994 ✓ Grief and Bereavement V Financial Resources ✓ Stress Management V Family and/or Marriage Gold Coast Federal Credit Union V Depression and Anxiety Issues Debi Bisbano I Phone:(772)408-1837 V Work Related Issues ✓ Substance Abuse 10570 S.Federal Highway,Suite 1001Port St.Lucie,FL 34952 Are Services Confidential? Yes. Receipt of EAP services are completely confidential. If, however, participation in the EAP is the direct result of a Management Referral(a referral initiated by a supervisor or manager),we will ask permission to communicate certain aspects of the employee's care(attendance at sessions,adherence to treatment plans, etc.)to the referring supervisor or manager.The referring supervisor or manager will not receive specific information regarding the referred employee's case.The supervisor or manager will only receive reports on whether the referred employee is complying with the prescribed treatment plan. New Directions I www.ndbh.com Access Code:mcso New Directions'Customer Service:(800)624-5544 130 21 ©2016,Gehring Group,Inc.,All Rights Reserved Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 Supplemental Insurance Aflac LegalShield Aflac offers a variety of voluntary supplemental insurance plans that may The Sheriff's Office employees havethe opportunity to enroll in a voluntary pre- be purchased separately on a voluntary basis with premiums paid by payroll paid legal program through LegalShield.By enrollingin this plan,employee deduction. Payroll deductions will be taken on a pre-tax basis for all plans will have direct access to attorneys who will provide legal assistance,24 hours except the Short Term Disability plan.Aflac pays money directly to member, a day,seven(7)days a week,for a variety of situations that include: regardless of what other insurance plans member may have.Certain levels of ✓ Divorce ✓ Criminal Defense Short Term Disability,Hospital&Accident plans are Guaranteed Issue,contact ✓ Child Custody and Support ✓ Traffic Tickets Aflac representative for more details.Available Aflac plans include: ✓ Adoption ✓ Wills&Living Trusts ✓ Cancer Protection Assurance ✓ Civil Litigation ✓ Real Estate • Accident Advantage ✓ Bankruptcy ✓ Credit Report Issues • Hospital Choice Plan ✓ Name Changes ✓ Contract Review ✓ Short Term Disability Plan Employee may purchase LegalShield for $14.95 per month. This includes Aflac I Customer Service:(800)992-3522 coverage for the entire household including employee's spouse and dependent www.aflac.com I Claims Fax:(877)442-3522 child(ren) regardless of the number of eligible dependents enrolled in the Agent:Loire Lucas I Phone:(772)708-5931 plan.All premiums will be payroll deducted on a post-tax basis. Agent:Karen Zabaglo Chatham I Phone:(772)284-3210 LegalShield I Customer Service:(800)729-7998 MetLife Agent:Rebecca Smith I Email:rjsmith@smithterry.com MetLife Insurance offers a permanent Life Insurance Policy that may be purchased separately on a voluntary basis for employee spouse,minor children and grandchildren with premiums paid by payroll deductions post tax.The Permanent Life Insurance Policy can be purchased as a supplement to the basic life and voluntary life insurance your employer offers.The voluntary universal life coverage is also portable.Even when employee changes jobs or retire,as long as employee pay the necessary premium employee may continue the policy. To learn more about.the MetLife Life Insurance plan or to schedule an appointment,contact the groups local MetLife Agent. Metropolitan Life Insurance I www.metlife.com Agent:Janet Froyen I Phone:(561)704-4378 Email:jfroyen@madisonplanning.com Agent:Tara Froyen I Phone:(561)602-2827 Email:tfroyen@madisonplanning.com 131 22 ©2016,Gehring Group,Inc.,MI Rights Reserved 0 o Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 Empower Retirement Employees of the Sheriff's Office are eligible to enroll in voluntary Deferred Compensation Plan(s).Through payroll deduction,employee can make pre-tax contributions from 1-100%of employee base wages.An Internal Revenue Service(IRS)dollar limit cap applies.Visit www.irs.gov for information on the IRS limits for the current calendar year.Employee can designate contribution as a pre-tax deferral,a Roth deferral or a combination of both.Roth deferrals are after-tax contributions,but earnings on these contributions accumulate tax-free in your account and withdrawals at retirement may be exempt from federal income tax. The Sheriffs Office plan allows for the rollover or transfer of an existing qualified retirement plan account from a prior employer.Employee is always 100%vested in any rollover or transfer to the plan,plus any earnings they generate. Generally,money may be withdrawn from employee's account for death,disability,unforeseeable emergency,in-service withdrawals of rollover contributions,loans and termination of employment.Please contact Empower Retirement for additional information. If an employee needs assistance with investment selection,contact the Sheriff's Office Investment Advisor:Brad Larsen at(866)606-4015 or brad@efadvisor.com. Please Note:New hires are automatically enrolled with a 2%contribution rate. Empower Retirement I Customer Service:(800)701-8255 I www.empowermyretirement.com Erisa Fiduciary Advisor:Brad Larsen,NFP Retirement I Phone:(561)722-4511 Advisor:Yerandy Del Prado Reguera I Phone:(239)962-0230 COBRA The Consolidated Omnibus Budget Reconciliation Act(COBRA)requires that most employers sponsoring group medical plans offer employees and dependent family members the opportunity for a temporary extension of group insurance coverage at group rates in certain instances where coverage under the plan would otherwise end.These coverages include medical,HRA,dental,and vision.Ifemployee or a family member experience any of the events provided below and wish to continue coverage,employee must contact Human Resources within 30 days from when the event occurred. Employee: 1.Reduction in hours of employment(that disqualifies group insurance participation eligibility);or 2.Termination of employment(for reasons other than gross misconduct). 1.The death of your spouse;or 2.A termination of spouse's employment(for reasons other than gross misconduct)or a reduction in your spouse's hours of Spouse of an Employee: employment;or 3.Divorce or legal separation from spouse;or 4.Spouse becomes entitled to Medicare. 1.The death of a parent;or 2.A termination of the parent's employment(for reasons other than gross misconduct)or a reduction in the parent's hours Dependent Child of an Employee: of employment with the Martin County Sheriff's Office;or 3.Parent's divorce or legal separation;or 4.Parent becomes entitled to Medicare;or 5.The dependent child ceases to be a"dependent child"according to the plan's eligibility definition. 132 23 ©2016,Gehring Group,Inc.,All Rights Reserved Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 MCSO Health Center — Stuart The MCSO Health Center was established to provide Sheriff's Office employees easy and cost-free access to quality medical care.The Health Center is available to individuals who are enrolled in the Sheriff's Office medical insurance plans,including employees,retirees,spouses and dependents.All visits to the MCSO Health Center are completely confidential and no personal information is shared with the Sheriff's Office. Stuart Primary Care Office 11980 East Ocean Blvd. Stuart Urgent Care Office 11050 SE Monterey Rd.,Suite 101 To schedule an appointment:Phone:(772)872-7380 Phone:(772)419-0560 Online scheduling:www.tcprimarycare.com The Urgent Care Office is a walk in facility,and does not require appointments. The Primary Care Office requires covered members to schedule an appointment The Urgent Care Office was established to assist covered members with an prior to being seen. illness/injury that does not appear to be life-threatening,but cannot wait for a Primary Care Office appointment. What Services are Performed at the Primary Care Office? ✓ Wellness check-ups What Services are Performed at the Urgent Care Office? ✓ Diabetes management Acute Illness,such as: ✓ Diagnosed maintenance care ✓ Vomiting,Diarrhea,Dehydration ✓ Health Risk Assessment and Biometric Screenings ✓ Fever and Flu ✓ Annual work physical ✓ Severe Sore Throat and Cough ✓ Acute and Chronic Illness ✓ Minor Broken Bones and Fractures ✓ On-site X-Rays Primary Care Office—Hours of Operation I Monday ] 8:O0am-5:OOpm Urgent Care Office—Hours of Operation r Tuesday 8:00am-5:00pm Monday 8:00am-6:00pm Wednesday 8:00am-5:00pm [Tuesday 8:00am-6:00pm Lhursday 8:00am-5:00pm c Wednesday 8:00am-7:00pm Friday 8:OOam-5:00pm if Thursday 8:00am-6:00pm [ turday 9:OOam-1:OOpm Lriday 8:OOam-6:00pm 8:00am-2:00 i m `Sunday Closed Saturday y - P f Sunday 8:OOam-2:00pm Prescription Medications The MCSO Health Center stocks widely used generic medications that can be dispensed to patients,at no cost.Staff can prescribe generic medications for a variety of acute conditions. Medications can also be dispensed for chronic conditions including high blood pressure,cholesterol,acid reflux,and diabetes.If a prescribed medication is not stocked,the staff will provide a script to take to the local pharmacy for purchase through the Sheriff's Office medical insurance plan. 133 24 ©2016,Gehring Group,Inc.,All Rights Reserved jt44, 4, co)°' 1-71 F =gi d + fif 2 1 5 i Ohm ���'W % �� 1 r� GEHRING® .o GROUP EMPLOYEE BENEFITS I RISK MANAGEMENT 4200 Northcorp Parkway,Suite 185 Palm Beach Gardens,Florida 33410 Toll Free:(800)244-3696 I Fax:(561)626-6970 www.gehringgroup.com 134 FINAL ©2016,Gehring Group,Inc.,All Rights Reserved Last Modified:August 18,20209:58ANI q a v $' .e t a co coN J C n -0 m m o v m o u E ' c ` a 3 3 r r c E a E' u ° E E 'c ,aJ, = m J J 3 « 5 o `a u • 41 'a 5 a z c �, o .m G N y m " w = N 3 z 0 N a > ° R L 3 3 al, c - r ' L 5 « v 5 Po .2 i c a E $ 4r '`s 3 c 5 $ cy�a>i, o a -g ( o c n E m 1•' ai 3 c s 5n ° c -2 " 3 v 57 > ` a g N E a E J = a > J a C E - a M a u c c c3 t Ta E r 'Ag •3 E '- 10 N c a t c = v+ N 5 to cc ? y t °' a >oE `c a s s5 o m m • 5 « '3cm g a a5 L. m .2 u a c - _ a 3 a '. 3 °a c Q •c I" W2. v v .4 N c uN « ° .'' u u a myE cm az °R.' ma a u c c c Ln • a E p c a Ea u ,n £ a>N ' N « c ac s N oH o a c v 0 ' c ' 4 ' '''-..o a ao vc c .f-,-,1 `o c u i sN i ma 6 '„ L >• m noniO, LLv m« o, _ £ r i y - van > a £ E. oj0. 0-d O1q apay o > Na• « u E E av .i p a v v n m > 'a L A ° moa L '003 w, � N J . y n N w e r v u 2 v N > 2 ' o a N w 13 P c s g Ec > '^ aa J o m > c a oa3a _dc « m 'aL o o AoO WN d of t m a 5o o wc o310 « ` o f ` c" o9 N d > 0 0 c o+ y a , c, 2o aw' • m c %c c LEv A £ 3 x c A " a w oY E 'n = 1J E 12• N Ny =° a11 y C c Na T. 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E£ a rWnw 0 a' c E c o ^ 0 0 ' N Y u5 YE Y N N > • a, E c oZi c v • o '= oc E c v 8 a '3 E E i- el 0 w• c • C 3 - 0c a ii p a « n wmrj = 040Oa' O O U OY 40 : Si !- a C. aaom • L %• 3 > c EE t 'Lo o udoL :+ : u a pm o0 mv> n > " y oN ti L >'6 . r -0 2 a3 .cE0a ., a g c a. w > r ' La -A ° v cw ° 1ik� uxa do 0 o, 0 � a w E o $ x $ .. 3ti City of Plantation Plantation the grass is greener 2020-2021 BENEFITS GUIDE Effective April 1, 2020 through March 31, 2021 Updated 01/21/20 137 1 Welcome Benefits are an important part of your full-time employment with the City of Plantation.As a City of Plantation employee, you earn more than just your paycheck. You also receive a competitive package of benefits offering flexibility, financial protection, and a foundation for future security. Our 2020 benefit package has a lot to offer and this guide will help you determine which benefits best fit your needs. I encourage you to take time to learn about all these plans by reviewing your Benefits Guide within the first week of your employment. There are always a few points to remember when completing your enrollment First, remember that you have 30 days from your date of hire to make your elections. Once you have made a decision on your elections, you will need to go to Human Resources— Benefits office to sign off on your elections. Second, if you are covering a spouse and/or dependent child(ren) you will want to be aware that you will be asked for acceptable proof of dependent eligibility. Third, as a new hire, you can elect additional life insurance coverage without completing an Evidence of Insurability(EOI) form. If you elect or increase your voluntary life insurance any time after your initial hire date you will be required to complete an EOI form. So be thoughtful on how much voluntary life insurance you would like to elect as a new hire. Once you have completed the benefits enrollment, keep your Benefits Guide in a place that you can refer to it easily. This guide contains important information about our plans. On the back cover is a list of all plan administrators and their contact information for your reference. If for some reason you lose your Benefits Guide, the guide and other benefits information is available within the City of Plantation's Employee Intranet site. You may download this guide, claim forms, policies and summary plan documents any time that you may need to retrieve benefits information or you may contact HR for a copy. As always, feel free to contact the Human Resources Benefits Department at 954-797-2244 or bambrosio(a�plantation.orq or Cassie Miller at cmillerplantation.orq if you have any questions. Sincerely, 2).Fktky, Beverly Ambrosio Benefits and Wellness Manager 138 2 Enrollment This Benefit Guide tells you where to go to find claim forms, summary plan descriptions,benefit contact numbers, and other important City of Plantation benefits information beginning April 1, 2020. Here are some important details that you need to consider when it comes time to enroll. ENROLLING TIMELY It is very important that you enroll on time. Otherwise some of your benefits will be waived until the annual enrollment period or until you have a qualifying event. This could leave you and your dependents without coverage for a length of time. Health Care Reform requires employers to automatically enroll new full-time employees into the medical plan; however, this does not include the dental and vision benefits. o Full-Time Employees are eligible for benefits the first day of the month following 30 days from hire date. • E 1010 mob -- I REMEMBER: IF YOU MISS YOUR ENROLLMENT DEADLINE, THEN YOU WILL AUTOMATICALLY BE ENROLLED IN OPTION 2 HEALTH PLAN AND WILL HAVE TO WAIT UNTIL THE NEXT PLAN YEAR ANNUAL ENROLLMENT TO ENROLL IN THE DENTAL/VISION PLAN AND/OR CHANGE PLANS. 139 3 Contents Making Benefit Changes 5 Eligibility—Who You Can Cover 6 Healthcare ... 7 Overview of Benefits 8 Overview of Voluntary Benefits 9 Medical 10 UnitedHealthcare Choice 11 Plan Comparisons 12 Plan Eligibility 13 Prescription Drug Plan 14 UnitedHealthcare Extras Discount Program 15 Diagnostic Testing 16 Mental Healthcare Plan 18 Employee Assistance Program 19 Care 24 . 20 Health4me app .. 21 Employee Health &Wellness Care Center 22 3 Steps to Wellness .. 24 Dental Plan Option 26 Dental Benefits Options 27 DHMO- Dental Copay 28 DPPO— Dental Plan 39 Vision Care Benefits 41 Life Insurance 45 Long Term Disability . 46 Employee Contributions 47 Voluntary Insurance Benefits 48 Enhanced Vision Plan 50 Accident Policy 52 Short Term Disability 54 Universal Life (Whole) 56 Critical Illness 58 Term Life Insurance 60 Flexible.Spending Accounts 61 Preferred Legal Plan 66 Group Auto Insurance 69 Veterinarian Pet Insurance . 70 457(b) Retirement Plan 71 Contact Information . 72 Additional Resources 73 140 4 Making Benefit Changes INFORMATION The choices you make during your new hire enrollment will YOU SHOULD remain in effect until March 31st of the current plan year. You KNOW may also make changes during annual enrollment or if you have a qualified change in status (or life event). If you provide false information A QUALIFIED CHANGE IN STATUS INCLUDES: or documents that do not a Marriage; provide credible a Divorce or legal separation; support as a Registered Domestic Partnership with Broward County verification of a Death of a spouse or a dependent; dependent a Birth, adoption, or placement of adoption of a child; eligibility when a Loss or gain of a dependent's eligibility; enrolling your a Loss or gain of a spouse's or a dependent's medical or dental dependents, your coverage through another employer; and benefite ' endents claims a Change in a spouse's employment from full-time to part-time, may be denied, or loss or gain of employment. coverage will be terminated You have 31 days from the date of the qualified change in status retroactively, to make a change to your benefits. Changes must be consistent and premiums with the change in status (life event). The enrollment changes will not be you make in conjunction with a qualified status change are refunded. In subject to IRS rules. IRS rules limit what can be a qualified addition, if you status change, govern when an enrollment change can be provide false effective, and require your change in enrollment to be consistent information when with the qualified status change. Unfortunately, the IRS rules that govern pre-tax benefits plans are very strict and the City of enrolling or Plantation must follow these rules completely. Any change verifying your requested after 31 days will not be accepted and will not be dependents, you processed—there are no exceptions. may also be subject to Before requesting any change that adds healthcare disciplinary coverage for your spouse, domestic partner or dependents, action — up to please review the eligibility rules on the next page. City of and including Plantation will audit all life events that correspond with placing a termination. new dependent on coverage. Benefit Change forms are located in the Human Resources Benefit department. If your change form is not completed within 31 days of the qualified change it L will not be processed. 141 5 Eligibility ELIGIBILITY City of Plantation offers benefit coverage to you and your eligible dependents. You can choose from four coverage categories: a Employee Only n Employee + Spouse or Registered Domestic Partner n Employee + Child(ren); and n Employee + Family WHO CAN YOU COVER a You, full-time City of Plantation employee scheduled to work 30 hours or more a week n Legal Spouse, registered domestic partner, and not enrolled or eligible for group coverage regardless if enrolled. a Children defined as: ❑ Biological o Adopted ❑ Stepchildren ❑ Legal Guardian o Under the age of 26 and not working full-time or eligible for insurance coverage regardless if enrolled o Children whom you are required to cover under terms of Qualified Medical Child Support Order DEPENDENT AUDITS In order for the City of Plantation to manage healthcare costs for our employees, dependent audits are preformed annually which require current andnew hire employees to provide proper documentation for each dependent coverage under the City of Plantation benefit plans. These audits will confirm that all dependents are and continue to be eligible for coverage according to the definition of an "eligible dependent". Please refer to the above section on this page that refers to "Eligibility — whom you can cover." If you fail to provide the information requested, your dependent(s) will be taken off the coverage and will not be eligible until the following open enrollment if they meet eligibility. 142 6 Healthcare HEALTHCARE COSTS FOR 2019 USE YOUR PLAN THE RIGHT The City of Plantation offers you a high quality WAY TO GET THE MOST OUT benefit program with flexibility and choice. Use OF YOUR HEALTHCARE this guide as a tool for those benefits. Your DOLLARS. TAKE ADVANTAGE healthcare needs, family situation and budget • OF TOOLS AND PROGRAMS TO maybe very different from those of your co- IDENTIFY HEALTHCARE workers. This makes it very important that you PROBLEMS BEFORE THEY learn as much as you can and choose the START. benefits that meet your needs. At the City of Plantation, we are working hard to keep the healthcare costs as low as possible while at the same time continuing to provide valuable and competitive benefits for you and your family. The City of Plantation continues to pay the majority of the cost of your healthcare. Healthcare costs continue to rise. There are many reasons why. The high cost of prescription drugs, caring for an aging population, treating the growing number of uninsured Americans, and technological advances in medicine all contribute. While you can't control these costs, you can choose to take an active roll in managing your health and your healthcare costs. When it comes to your healthcare, choice matters. As a member of the UnitedHealthcare plan, you are able to choose doctors, hospitals and other providers from one of the largest networks of contracting providers in the country. When you have questions, you have access to innovative online information or you can speak with the United Healthcare customer service representatives who make it their priority to get you the answers you need, quick and accurately. 143 7 Overview of Your Benefits MEDICAL CARE PLAN Two Medical Plan choices for 2020 c Option 1 o Option 2 PRESCRIPTION DRUG Express Scripts offers: Retail Pharmacy COVERAGE Mail Order Pharmacy MENTAL HEALTH United Behavioral Health is included with your medical coverage. EMPLOYEE Offering 24/7 free confidential assessment and crisis ASSISTANCE PROGRAM counseling available through ACI Specialty Benefits. (EAP) ON-SITE CARE CENTER You and your covered dependents over the age of 12 will have access to the Employee Health &Wellness Care Center for your healthcare needs operated by Marathon Health. DENTAL CARE PLAN UnitedHealthcare (Solstice) -Two options available: ▪ DPPO Dental Plan ▪ DHMO Dental Plan VISION CARE PLAN UnitedHealthcare (Solstice)—Two options available: ▪ Basic Vision ▪ Buy Up Vision LIFE &AD&D Value: 1 times your Annual Earnings, rounded to the next INSURANCE highest multiple of$1,000. The maximum amount is $50,000. LONG TERM If approved, will cover 60% of eligible employees salary until DISABILITY employee can return to work or becomes Medicare eligible. 144 8 Overview of Your Voluntary Benefits TERM LIFE INSURANCE You have the option of electing Voluntary Life insurance RELIANCE STANDARD coverage, Voluntary Accidental Death &Dismemberment (AD&D) single or family coverage and/or Dependent life coverage. These options are in addition to the City provided Life and AD&D coverage. WHOLE LIFE Whole Life locks in premium costs per lifetime, this policy also INSURANCE WITH LONG includes a Long Term Care payment option. These options are in TERM CARE additional to the city provided Life and AD&D coverage. PREFERRED LEGAL Free or reduced legal fees for various attorney services. PLAN Membership is portable. ACCIDENT INSURANCE, You have the option of electing Accident Insurance. Critical SHORT TERM Illness Insurance and Interest Bearing Whole Life for yourself DISABILITY AND/OR and/or dependents. The options are in addition to other CRITICAL ILLNESS healthcare and insurance offerings. INSURANCE FLEXIBLE SPENDING For new hires who elect a Healthcare Spending Account, the ACCOUNTS debit card is available for your convenience. The card is an option to the traditional paper reimbursement method. Annual FSA contribution limits are covered later in your enrollment kit. You also have the option to elect a Dependent Care Flexible Spending Account to help pay for dependent care expenses. GROUP AUTO You could receive special savings and value-added benefits at no INSURANCE - additional cost available through the group rate. VOLUNTARY PET INSURANCE (VPI) Pet insurance is available for employees for a variety of animals. You can receive a group rate for this valuable coverage. 145 9 Medical MEDICAL BENEFITS Medical insurance represents the largest component of the City of Plantation's Benefit program. If you want to enroll in the Medical Care Plan, you may choose from the UnitedHealthcare Choice Option 1 or 2. While both options cover the same types of medical services, each provides coverage at a different level co-pays. Each plan also requires that you contribute a different amount per pay period toward the premium. By referring to the City of Plantation Medical Plan Comparison on page 12, you can decide which plan you would like to participate in. IN-NETWORK UnitedHealthcare Preferred Choice and Standard Choice are in-network only plans with providers throughout the United States. It is very important that you determine if your doctor is in or out of network. To receive benefits, you must use an in-network provider or in-network facility for services. DEDUCTIBLES & COINSURANCE A deductible is a set amount of medical expenses a patient must pay before the benefits plan can pay. For example, deductibles can apply when you have inpatient or out patient services. Once the deductible is met, then a percentage of the allowed amount is paid otherwise referred to as coinsurance. COPAYMENTS Copayments are set amounts you pay for specific services in the plan, such as office visits and prescription drugs. 146 io UnitedHealthcare Choice The City of Plantation has contracted with UnitedHealthcare Choice, this is an "open access" health care plan. You can choose any provider you'd like to see in the UnitedHealthcare national network. There are over 645,000 physicians and health care professionals and 5,105 hospitals nationwide. Members must stay in the network to receive benefits You have the freedom to choose their physician or specialist without visiting a "primary care physician" for a referral. Visit United Healthcare's website www.myuhc.com ® for information on benefit eligibility, coverage, account history, claims status, physician's and hospitals, estimated out-of pocket costs, health and wellness topics, health records and much more. What Can you do at myuhc.com? /Find a doctor. /Look up claims. /Order prescriptions online— and save. /Chat with a nurse. /Save money on services. /Replace your health plan ID card. /Keep track of your family's medical history. /Estimate costs ahead of time. /See your benefits. /And much, much more. What do you need to register? Just your ID card. Simply answer a few questions, create a security question and you'll be set to go. 147 11 1 1 Plan Comparison United Health Care Choice Covered Services Option 1 I Option 2 1 In-Network Benefits Only N In-Network Benefits Only Doctors Office Visit $10 I $20.00 1 Specialist office visit,including OB/Gyn 100%after$35 copay N $50.00 Preventive Care I 100% . 100% Hospital inpatient stay,including maternity 100%after$100 copay M $200.00 1 Emergency room visit 100%after$200 copay I $250.00 Urgent Care Center 100%after$25 copay M $35.00 Outpatient surgical 100% II $100.00 • Diagnostic x-ray 100% $25.00 Lab tests 100% $20.00 MRI/PET/CAT scan 100% 1 $100.00 Chiropractic visit *spinal 100%after$10 copay(max 24 visits manipulation per calendar year) I Not Covered Chiropractic Visit`massage therapy Not Covered , Not Covered 100%after$10 copay individual$10 co-pay group(max 30 visits) Mental health (limited 30 outpatient visits) $20.00 Calendar Year deductible I $0.00 1 $0.00 $4,000 Individual $6,000 Individual Maximum Annual Out Of Pocket $6,000 Family I $8,000 Family •110%of Medicare Allowable Charges **Certain procedures may require pre-certification. See page 38 for premium information. Emergencies are covered anywhere in the world with both plans 148 12 Plan Eligibility United Health Care Choice Plans Option 1 or Option 2 A Complete the '3 Steps Employee to Wellness' and Contribution receive a discount of 11% 4% - Employee 8% - Dependents 149 13 Prescription Copayment per Prescription Order or Refill HOW CAN YOU BETTER MANAGE Your copayment is PRESCRIPTION DRUG COSTS: determined by the tier to which the Prescription Drug List Management o Use the Healthcare FSA to cover prescription Committee at UnitedHealthcare has drug copayment amounts. See page 45 for assigned the Prescription Drug an explanation of how to use the FSA. Product. All Prescription Drug o Use the mail order service for maintenance Products on the Prescription Drug List are assigned to a Tier 1,Tier 2 or prescriptions to receive a 90-day supply of Tier 3. Please access maintenance drugs. www.myuhc.com through the o Talk to your pharmacist. Pharmacists are Internet, or call the Customer Service qualified to answer many questions about number on your ID card to determine tier status. your medications and are often aware of Also note that some alternative treatments available for your Prescription Drug Products require condition that may not include prescription that you notify us in advance to drugs. If that is the case, you can talk to your determine whether the Prescription physician about the alternative. Drug Product meets the definition of a Covered Health service and is not Experimental, Investigational or Unproven. United Healthcare Prescription Drug Benefits With Option 1 With Option 2 Tier 1 - $10 Tier 1 - $20 Tier 2 - $25 Tier 2 - $40 31 -day supply- Retail Tier 3 - $60 Tier 3 - $60 Tier 1 - $ 30 Tier 1 - $ 60 Tier2 - $ 75 Tier2 - $120 90 -day supply- Mail Order Tier 3 - $180 Tier 3 - $180 Retail Prescription Drug Programs offer$4.00 Rx's Walmart, Publix, Winn-Dixie and Target offer reduced RX's on several medications — Stop into Humana Resources for a complete listing to see if you can take advantage of these programs. 150 14 UnitedHealthcare Extras Medical Supply Discount Programs o Look better. Feel better. Save money. It's easy with UnitedHealth Allies®! o UnitedHealth Allies is a health discount program that can help you and your family save up to 50 percent on a wide range of health-related products and services that are not covered by your benefit plans. To discover the discounted services available to you, log into your www.myuhc.com account and click on `Extra Programs & Discounts'. Why pay full price for non- covered services, when you can save with UnitedHealth Allies! o You'll find discounts on things like: o Gym Membership ❑ Acupuncture o Medical supplies ❑ Vitamins ❑ Cosmetic Dental ❑ Alternative Care ❑ Infertility Treatment o UnitedHealth Allies is not a health insurance plan. It is a money-saving program that complements any medical, dental, and vision coverage you currently have. Your Place for Everyday Savings. 151 15 Mental Health The Mental Healthcare provided can help if you or a covered family member suffers from an emotional or substance abuse problem. When you need assistance, call 1-800-888-2998 or simply find a provider on line at www.liveandworkwell.com. LiveandWorkWell.com This online member portal helps employees easily find the critical information they need to make informed health and well-being decisions. Employees can access this secure password-protected Web site to review their schedule of benefits, search our network directory, and use an array of industry-leading, self-help tools to help manage their life events and adopt healthy lifestyles. Mental health is more than the absence of mental illness. It includes having a positive mental and emotional attitude based in reality. Mental illnesses are real diseases but they can be successfully treated. You can live your life to the fullest in recovery. Resiliency allows you maintain balance in the face of life's ups and downs. We all worry and experience mood swings. Many people wonder sometimes if they have mental problems and some are afraid to get help. They may feel sad or elated, anxious, depressed, overwhelmed, fearful disoriented, or forgetful. Relationships may become difficult. Something feels wrong. Life may be a struggle. If feelings or symptoms are affecting life, consider getting help. Professional Mental Health Help Medications and a variety of therapies (psychological, talk,play, art and more) can help. There are many types of mental health specialists that help with mental, emotional and behavioral problems.You will find detailed information on finding and selecting a mental health clinician. Centers After you login to the member side of this site,the "BeWell" area has resource centers for many mental health issues. Each center provides clinician reviewed information about the symptoms, diagnosis, tests, treatment, prevention and recovery. Self-screeners and a variety of self-help programs are included in some of the centers. "BeWell" centers include stress,mental health conditions such as depression,ADHD,Alzheimer's, and PTSD,as well as addictions, substance abuse, tobacco cessation, eating disorders, grief, traumatic brain injury, healthy aging, recovery and resiliency and more.A Suicide Prevention training program is available. There are separate centers for young people since symptoms and treatments may vary. Each center links you to real people who can help.A behavioral health clinician search tool is available to help you find the right mental health service provider near you. Members can access a 24/7 support line (support number is available on the site after you login). REMEMBER—WHEN YOU ENROLL IN THE MEDIAL CARE PLAN,YOU'LL AUTOMATICALLY RECEIVE PRESCRIPTION DRUG AND MENTAL HEALTH COVERAGE. 152 16 Employee. loyee Assistance Program (EAP) g Managed Care Concepts For free confidential assistance, call your EAP Emergency Coverage Available 1 (800) 899-3926 24 hours a day, 7 days a week counselors available 9:00a.m. - 5:00p.m. What is an Employee Assistance Program An Employee Assistance Program Provides employees and family members with professional counseling for a variety of issues. Early detection and assistance can often prevent more serious difficulties from developing. The EAP offers personal confidential counseling services for a wide rangeof concerns including: • Marital/Family/Relationship Issues • Stress • Depression •Interpersonal problems on the job •Drug •Alcohol EAP? Abuse abuse vvny nave an EAP s The City of Plantation is made up of individuals with personal lives as well as professional lives. The two are interrelated. Issues in either area affects both. We care about your wellbeing both on and off the job, and having an in-depth EAP gives you confidential and professional resources to turn to for help. Who can use the EAP The EAP is available for employees and their dependent family members at no cost. 153 17 Care24 Health Care needs doesn't begin and end with the work day. Neither should member benefits. Our skilled Care24® nurses offer round-the-clock information and resources to help employees manage complex, time- consuming health conditions and treatments. Members can call Care24 at 1 -888-887-4114 to: a Get treatment decision support Employees receive accurate information about your conditions and doctor-recommended treatment options. Find the right doctor Care 24 will help you identify doctors with a strong history of medical testing, diagnosis, treatment, medications and follow-up care for their condition. a Arrange appointment scheduling Employees save time and avoid hassles when Care24 arranges doctor appointments and assists with coordinating medical records. a Access health coaching Registered nurses help you understand medication interactions, learn self-care techniques or connect with outside resources for your conditions. a Receive emotional support Trained specialists help you manage stress, anxiety, depression, grief and more. Health care isn't just a 9-to-5 job. 154 18 Health4Me The new app from UnitedHealthcare vi Your family's health, in your hands. hi a • Key Features • Search for Physicians or rommummemmemenNI\ Facilities by location or specialty .dl 1:30 PM ti • Store favorite sicians and Facilities F UnitedHealthcare Ph y at, • View Claims Alice smith ,i t Menu • Have an Easy Connect Representative contact , 1 Urgent Care 1 ER 15.1 Search for nearby met gency.Came you to answer any questions e�— ID Card • View and share health View and share you member info plan ID card information • Contact an experienced rw Account Balances View HSA,HRA or FSAba'ances registered nurse 24/7 • Choose to view plan op Benefit Amounts members inde pendently aec,uctweand ca,t-at-PocFetstatus P Y or the plan a whole • Locate Urgent Care facilities and ER's • Complete confidentiality 155 19 Employee Health & Wellness Care Center well,„. F� • • mI. The City of Plantation has opened a health clinic for employees, spouses, and dependents over the age of 12. The Care Center provides convenient access to high-quality healthcare, An important medication dispensing, blood draws, and wellness services for individuals who want to message: improve their health. We want you to • The Care Center is operated by Marathon understand that any Health, specialists in employee health, treatment you receive offering primary care and health coaching at the health clinic is at the worksite. completely • Services at the clinic are very similar to confidential, and like what your primary care doctor provides, with the added benefit of convenient access your own doctor visits, to care, more immediate focused attention is protected by the from the Care Center's healthcare provider, Health Insurance flexible scheduling, and a focus on helping you to achieve your very best health. Portability and • The Care Center is staffed by two nurse Accountability Act, practitioners and a registered known as HIPAA. By dietitian/health coach under the careful law, Marathon Health guidance of a local supervising physician. cannot and will not • You will have access to a complete health share any of your website from Marathon Health with a personal health health library, nutrition and activity trackers to help you manage or monitor your diet information to your and exercise, and a personal health record. employer without your • Your office visit copay will be waived for express written visits to the Care Center and you do not permission. have to take sick leave when you go to the clinic for acute services. • Disease Management services are also offered. 156 20 What Services are offered to You: Primary Care Watch For Your `Welcome •Lab Services Package ' From Marathon •Medication Dispensing Health with your temporary Common Illnesses user name and Password. •Allergies •Digestive Hours: •Headaches Monday— 7:30am — 4:30pm •Skin Conditions Tuesday— 7:30am — 8:00pm •Respiratory •Urinary symptoms Wednesday— 7:30am — 4:30pm Minor Injury Thursday— 11 :OOam — 8:OOpm •Back Pain Friday— 7:30am — 4:30pm •Burn •Extremity Pain To schedule your appointment: •Joint Pain www.marathon-health.com •Nosebleed Or •Sprains/Strains 954-513-3530 •Stitch removal Other Services Your Cost to Visit the Care Center? •EKG Co-Payment for visit= $0 •Disease Management Co-Payment for RX = $0 •Health Assessment •Health Coaching •Registered Dietitian •Certified Personal Trainer 157 21 What are the `3 Steps to Wellness'? • Step 1 ❑ Bio-metric screening (finger prick) or o Blood work • Step 2 ❑ Health Risk Assessment (HRA) • Step 3 o Comprehensive Health Review (CHR) - :- Receive the reward of not only taking charge of your health but a discount in employee contribution for participating! The City of Plantation feels that employee health and wellness is the single most important factor in preventing catastrophic disease, such as heart attacks, strokes and diabetes, and controlling future health care costs. Completing the bio-metric screening, completing the health risk assessment, and reviewing the results with the Employee Health & Wellness Care Center clinicians, may identify health conditions, such as cholesterol, high blood pressure, chronic stress or being overweight. They can coach you on lifestyle changes that could prevent future serious illnesses. 158 22 3 Steps to Wellness — It's Your Choice STEP 1: Bio-Metric Screening(finger prick or blood work) o Choice 1: Schedule an appointment at the Employee Health & Wellness Care Center u To schedule your Screening: ❑ Call 954-513-3530 or ❑ Schedule online at www.Marathon-Health.com 'screening' o Choice 2: Your physician may complete the `Physician's Lab Report Form' available at the Employee Health & Wellness Care Center or Human Resources. ❑ Mail or fax completed form directly to the Employee Health &Wellness Care Center ❑ 401 NW 70th Terrace, Plantation, FL 33317 or ❑ Fax: 954-515-3539 Please Note: This form will ONLY be accepted at the Employee Health &Wellness Care Center. STEP 2: Health Risk Assessment (HRA) ▪ Choice 1: Login to www.Marathon-Health.com under"Manage My Health" (HRA is located on the left side of the page). u Need your username and password: Contact Lisa Tribble-Brown at the Employee Health & Wellness Care Center 954-513-3530 o Choice 2: Complete paper Health Risk Assessment(available at the Employee Health &Wellness Care Center or Human Resources). u Mail, fax or inter-office completed assessment directly to the Employee Health &Wellness Care Center u 401 NW 70th Terrace, Plantation, FL 33317 or ❑ Fax: 954-515-3539 Please note: This form will ONLY be accepted at the Employee Care Center. STEP 3:Comprehensive Health Review (CHR) a Choice 1: Schedule a face to face appointment at the Employee Health &Wellness Care Center(a review of Step 1 & 2). To schedule your Comprehensive Health Review: ❑ Call 954-513-3530 or ❑ Schedule online at www.Marathon-Health.com 'Comprehensive Health Review' o Choice 2: Schedule a telephonic appointment at the Employee Health & Wellness Center(a review of Step 1 & 2). To schedule your Comprehensive Health Review: ❑ Call 954-513-3530 or ❑ Schedule online at www.Marathon-Health.com 'Telephonic-Comprehensive Health Review' *New Hires have 3 months from the date your insurance becomes effective to complete the `3 Steps to Wellness" or you will not be eligible for the discount 159 23 Dental — UnitedHealthcare — Solstice HEALTH AND TREATMENT OPTIONS When you visit the dentist, be sure to share your dental and medical history and any Taking care of your teeth is as important as taking care of the rest prior complications. of your body. If you visit your dentist for regular checkups now, Dentists can identify signs you are more likely to catch potential—and expensive problems of more serious health conditions and should be that may surface later.A great smile is something that everyone made aware of health notices! information that may be critical to your dental care. DENTAL CARE PLANS Your hygienist is a great resource for dental health To get the most out of your dental plan using in-network information to help you provider means less out of pocket for you. guard against tooth decay Always verify your dentist's is in the UnitedHealthcare — and gum disease. Ask your Solstice DHMO or DPPO network. Simply asking if a dentist dentist to explain the pros and cons of each dental "accepts UnitedHealthcare" does not guarantee he or she is an in- treatment option, including network provider with your specific plan. the future costs or Make sure you specifically consequences of postponing DHMO S100 or DPPO 30 plans. or avoiding treatment. CHECK YOUR ELIGIBILITY AND BENEFITS ON-LINE If you are visiting the www.myuhc.com website for the first time, ADDITIONAL SAVINGS you will need to complete a one-time registration to log in and verify your eligibility, check your benefits for covered services, Orthodontic in your future, and view maximums and deductible information. You may also be sure to refer to your FSA Print replacement ID cards. document on page 51 on how this can save you WWW.MYUHC.COM monies through pre-tax. You will find all the information you need on your plan on the website, from provider and claims to how to use your benefits. Check it out! 160 24 Dental Benefits Options The City of Plantation offers two dental plans to choose from: DHMO Dental or DPPO Dental you will be required to choose your election upon initial enrollment and will have the opportunity to change plans each open enrollment period. UnitedHealthcare UnitedHealthcare UnitedHealthcare DHMO DPPO DPPO In-Network Only In Network Out of Network Annual Deductible N/A $50—Single $50— Single Preventative care Waived $100-Family $100- Family Preventative Services No Copayment 100% of allowable 70% allowable Oral Exams, cleanings, • bitewing X-ray, fluoride, emergencies Basic Services No Copayment 90% of allowable 70% of allowable Full intraoral x-rays, after deductible after deductible amalgam &resin restorations, extractions, endodontics, periodontics Major Services Specific copayment 90% of allowable 50% of allowable Crowns,pontics, partial & refer to schedule after deductible after deductible complete dentures of benefits Orthodontics $2,100—Under 19 70% of allowable 50% of allowable Lifetime Maximum yrs after deductible after deductible $2,300—Over 19 $1500 lifetime max $1500 lifetime max yrs Plan Year Maximum No maximum $2,500 $2,500 benefit SCHEDULE OF BENEFITS For a complete listing of all copayments, covered services, limitations and maximum amounts please login to the www.mvuhc.com website. 161 25 DHMO Dental S�istic � Urntedllealtheare Solstice S1OOB-SHP/D1O83 Dental Plan Schedule of Benefits Members of the 5100 -SHP Dental Plan are eligible to receive benefits immediately upon the effective date of coverage with: • No waiting Periods • No Deductibles or Maximums • No claim forms to submit The Member co payments listed are offered by a participating iin-network general dentist.The member receives: S Most diagnostic&preventive care at No Charge ,e Cosmetic&Orthodontia treatment covered Members can locate a;participating provider at a irb+ir.myuhc.com Member Services Department:800-955-4137 The member is ultimately responsible for verifications of the accuracy and appropriateness of all fees applicable to any dental benefit'provided by a network provider.We urge all of members to verify all fees for proposed treatment via this"Schedule of Benefits"and/or with our Member Services Department prior to treatment. The following Member co-payments apply when a participating General Dentist performs services.An"'" denotes limitations on certain benefits(see"Exclusions/Limitations"). CODE DESCRIPTION MEMBER CODE DESCRIPTION MEMBER SPAY COPAY cUt+trcas_ORAL EVALIMMIDDIS - 0E4040511C 1MAt,tNG 0012 *Periodic oral evalmitiiva-established patient 0 100210 *Intraoral-complete series limctmdingbites:ingsl 0 00140 Limited oral evaluation-problem focus-ed 0 00220 antraoral-piapical first radiographic images 4 00145 "•Dralesaluatinfrifor apatient underthree years olfage arid 0 00250 Intraoral-periapical each additional radiographic ima es 2 counseling with priority caregiver Dttd$0 •,Cxtrnprteheeasiveoral evaluation-new orestablish ed 0 00240 Intraoral-occlusal radiographici images 0 patient 00150 •Detatied and extensive oral evaluation-problem c isecl, 0 00250 abeam!-first radiographic images 0 by report O 0170 pe-eiraluatiom-llimited,problem focused gestabliited 0 00250 Extraoral-each.additional racMographicimages 0 patient:not post-operative visit 00171 Re-evaluation-post-ow/Bare 0 00270 *bite ng-single radiographic images 0 09180 '•Ctmmgrrehensiiveperiodontalevaluation-nearor 0 100272 •Brteuangs-two radiographic images 0 established patient 09310 •comsmltation-diagnostic service provided&yrd ar 25 D8273 •8rtewings-three radiographic images 0 physician other than requesting dentist CM plrisncian 09430 Office visit for observation during regullarlyschedaded 0 D0274 *Bitewings-four radivp aphic images 0 horrrs)-no other set as patfomred' 09440 Office visit-after regularly scheduled(hours 25 00277 *Vertical bitewings-7.to8radiographic images 2d9 09450 Case presentation,detailed and extensive treatment 0 00290 Postetior-anterior or lateral skull and facial bane survey 150 planning radogsaphic images O 9955 Missed appointment 25 00310 sialography 150 162 Underwritten by Solstice Benefits,Inc. 01083 213-11624 Administered by Dental Benefit Providers,inc. CODE ESERIPlIDN MEh+BER. CEDE DESCRIPTION MEMBER COPAY COPAY 0033220 Tennporormandbularjoint arthrogram,>ndodiaginjection 250 00531 ,Adjunctive pre-diagaostictestthat.aidhindea tivmof 65 mucosal abnormafities including premaligbare.and nrafiignant lesions,inotto include cytology or biopsy. procedures 00521 Other tempcemrnandibuflarjoint radiographic irnags y 150 00460 Pulp vitalityt sts 0 report 1)5322 Tomograptmcsurrey 150 00470 0innostic casts 0 1)0130 *Panoramic radliograpfticmrra es 0 ORAL PATHOLOGY LABORATORY 00340 'Cephalometric radiographic images 75 00472 Accession of tissue,gross examination,:preparation and 0 transmission of written report omisso 20 oral/facial photographic mage obtained int a-orallyror 20 00173 Accession of tissue,gross and microscopic examination, 0 extra-orally preparation and transmission of written report 00354 '`Cane beam cr capture and interpretation with Wanted 140 00474 A cssion of tissue,gross and microscopic examination, 0 field mfview-leu than care whale jaw incdudirg assessment ofsurgical margins for,presenceo# disease,preparation and transmission of written report 00 *Cone beam CI-capture and interpretation with SaId of 130 170480 A.coexsion of exfoliative cytologic smears,microscopic 0 ',delve one hill dental arch-simandiffee examination,preparation and transmission emitters report 0036 Cone b mc*COM beEtll Cr captureand'interpretation with rrfrs8dof 130 00486 tlborato accession of brudri biopsy sarnIe microscopic '0 acv of one full dental arch-nraaolia„With O a rman examination,,preparation and'transmission ofwrritten Cranium report 00367 `CRome beam Cicaptrure and interpretation v field of view 175 00502 Other oral pathology procedures,byreport 0 of both jawsrwitfiortivithoartcranium, O 0 *Corse bears CT capture end'intairprsetatic nr fartrAr 130 00601 Caries risk assessment and documentation,with a trading 0 iinduding two or more exposures of tow risk 00360 41dtaxillofacisi l capture and i to premaion 150 00502 Caries frisk assessment and docu rnentatitrn,with a finding 0 of moderate risk 00370 etntasillofaoial othrasound capture aad intirpretatio+n 150 00603 Cis risk assessment and dodrnrerutatitnn,with.a finding, 0 of 40 risk 00371 *Saalloencloscopy'capture and ieterpretatian 160 DENTAL PROPHYLAXIS 00300 *Corm beam CT image capture with Iry utat fddl of view- 146 09110 *Prophylaxis-amt 0 less thane's whole jaw 00301 'Cone beam CT image rapture with fold of view of one felt 130 01110 Additional propp'hy'laxis-adult 15 dental arch-mandible O 0342 *cone Beam CTimagecapture widafield cifv of onefet 130 01120 •lPraphyiaxis-child 0 d ental arch-rinatthin,,Willi or without cranium O 0303 *Cone'beam ct image capture with Said of limoof bath 175 01120 Additional prophylaxis child jaws*Thor without cranium 00304 *Carse beam'CT image capture forted seriesindhrr]ing to o 130 TOPICAL FLUORIDE ORIDE TRIP HENT(OFFICE IPEt00E INSPE) e r more expoaaares 00655 "MaaiilofaciialMBimage capture 160 01206 "Topical fluoride varnish '5 01835 *Nrauralloffacialultrasonndhinge capture 160 01206 *Topical application ooffluoride-minding varnish 0 00303 *Treatmentsimnffation using'SB linage volume 0 109910 'Application of desensitizingtredicament 20 00384 Dig6al SLibtrati0fl of two or more images or imrga 0 OTHER PREVENTIVE SERVICES volumes of the samemoclalityr 00393 *Erosion of two or more 30 linage%alhenri s of mem more 0 01310 Illutritional counseling for control of dental'disease 0 Modalities TESTS ASID EXAMINATIONS 01320 Tobacco cooersseling for the comtrcl and,prevenrtion of oral 0 disease 00415 collection of mietvorgamisms for culture and susitinity 0 01330 Oral hygiene instructions 0 00423 Caries susceptibdfity tests 0 01351 "Sealant-per tooth 0 Underwritten by Solstice Benefits,inc. 163 D 1083 213-11524 Administered by Dental Benefit Providers,Inc. CODE DESCRIPTION MEMBER (CODE DESCRIPTON MEiMBER. COPAY COPAY 01352 *.Preventive resin res ratan in a moderate to high caries 0 02644 Onlay porcelain/ceramic-four or more surfaces 350* risk patient-pemre:nemt tooth 01353 Seatatrt repair-per tooth 0 02650 Inlay-resin-based composite-one surface WO SPACE MAINTAINERS(PASSIVE A.PPUANCES) 02651 Inlay resin-based composite-two surfaces 100 D1510 *Space mainta -foxed-unilateral 0 02652 Inlay-resin-based composite-three or more=laces 250 01515 *Space maintainer-fixed-la/lateral - 0 02662 .Onby-resin-based composite-two surfaces 223 01520 *space maintafiner-removable-unilateral 0 02663 Orrfay-resin-based composite-three surfaces 245 01525 *Space maintainer-remoeabie-bilateral 0 02564 Onlay-resitr-basedcomposite-fouror more-surfaces 275 01550 Re-cent'botaticn or re-bond space maintainer 10 CROWNS-SINGLE RESTORARONS+0NL1! 01555 Removal of fMed space maintainer 1002710 *Crown-resin-based composite lmdirect) 196 AMALGAMS RESTORATIONS�tcurDCNG POtrSecIraGJ '!02712 'Crown-M resin-based compositepacked) 195 02140 Amalgam-one surfacer primary or permanent 0 02720 *Crown-resin with high noble metal 195* 02150 Ammatgarrr-twosurfaces„primaycur permanent 0 02721 *Crown-resin with predominantly base metal 195! 02350 Amre l m-three iw fetes,primary cur permsuent 0 02722 'Crown-resin with noble metal .tea 02151 Amalgam-four or more sorfacm,primaryor penman= 0 02740 *Crorwn-porcelain/omen sic:substrate 195* RESIN BASED CCT4POSSITEP]5Tt7RATICINS-DIRECg 02750 'Crown--porcelain fused to'highnoble metal 193• 02330 Resin based composite-one surface anterior 0 02751 'Crow n-porcelain fused to predoniinantly'base metal 195' 02331 Resmr-based composite-too surfaces,,anterior 0 02752 *Crown porcelain fused to noble metal 195* 02332 Resin-based composite-three surfaces,anterior 0 02760 *Crown-3/4 cast Nab noble metal 193 02335 Resin-based corturposite-for or more surfaces or ioecfl rine; 0 02751 *Crown-3/4 cast preductirtarely base metal 195* hu'isal angle,l;anterour 02390 Resmo-based composite[frown;,anterior 0 027.62 *Crown-3/4 cast noble metal 195* 02391 Resin-based composite-one surface,posterior 0 02763 *Crown-3/4 porcelankfceramric 195* 02392 Resin-based composite-too surfaces,posterior 0 02790 'Crown-full cast high no e metal X195* 02393 Resimbasedccamosrse-three surfaces,postrrior 0 02791 *Crown-full cast predominantly base metal 195' 02394 Resin-basedcomposite-foto or more surfaces,posterior 0 02792 *Crown-full cast noble metal 195* GOLD FOR RESOTR#TION5 02794 *Crown-titanium 195* 02410 cold foil-one surface 65 02799 . •IPrc'isioraalcrown-further treatment orcormpletionof 115 diagnosis necessary prior to final impression 02420 Gold foil-twos rates 90 OTHER.RES 0RATt1'ESER'WICES 02430 God foil-three surfaces 120 02910 Re-cement or re-bond inlay,coley,%snee,or,partial' 10 coverage restoretbra ENL YIONIIAYRESTOIRATIONS 02915 Re-cement or re-bond indrrectfy'fabricated or 10 prefabricated post end core 02510 Inlay-rn tallic-one surface 60 02920 IRe-cementor:re-bond croon 10 02520 Imilay-metallhlc-two surfaces 90 02921 IReattaclnarentaftooth fragmaeptririoisaledge or cusp 10 02530 Inlay-metallic-three or more surfaces 115 02929 •IPrefabeicatedporcelain/ceramic MGM-primary tooth 34* 02542 ,Onley-metallic-two surfaces 250 02930 Prefabricated stainless steel crown-primary tooth 35 02543 Colley-metalk-three surfaces 270 02931 Prefabricated stainless steel ce- errttocth 40 02544 Ordlay-metallic-four or more surfaces 290 02932 Prefabricated resin crown 90 02510 Inlay-porcelainnjcenarnic-cne surface 225* 02933 Prefabricated gainless sted croonnwith:re£snwindow 135 02.620 Inilap-porrelaWceramic-two surfaces- 250* 02940 Protective restoration 5 :02530 Wei-porcelain$,^uric-three Off more surfaces 275* 02941 Interim therapeutic restoration-prrmaaydentition 5 82542 Onlay-por elaimf eramic-taro surfaces 310* 02949 Pestcrath'e foundation for an ledIretrastoration 24 0254.3 rlmtlay-porcelain/ceramic-three surfaces 340*102950 Core buildup„including any pins 35 ! Underwritten by Solstice Benefits,Inc. 4 01053 "213-1/624 Administered by Dental Benefit Providers,inc. 6 6 28 CODE DESCRIPTIO'N MEMBER CODE DESCRIPTION MEMBER COPAY COPAY 02951 Pin retention=per Moth,€inaddition to restoration: 10 ENDODONTIC THERAPY I[INCWIDtNGMAWEl+:ENTPIAN, CLINICAL PROCEDURES&60UO W-UP CARE) 07952 Past and core inadd5tiontocrown indirectly fabricated 50 03310 (Endodontic$harpy,anterior tooth(exdludiogfinal 100 restoration) 02953 Each adoStianalindirect'yfabricated past-same tooth 95 03320 Endodbratictherapy,bicuspidtooth:(exdudrgfinal' 175 restoration) 02954 Prefabricated post and core iinaddition tonom 75 03330 Endodontic therapy,molar)excludsggfinal restoration) 210 02955 Post remora! 20 03331 Treatment of root canal Obstruction;non-surgical access 35 02957 Each additional prefabricated post-same tooth 30 03332 Incomplete eradodontictherapy;inoperable,unrestorable 75 or fractured tooth 02960 tab®f veneer(resin laminate)-chairside 200 03333 Internal root repair off perforation defects 225 02961 Labial veneer(resin Ilamilnte)-laboratory 225• ENDODONTIC RETREATMENT fN'/A 0029652 Labial veneer(porcelfainlaniims7el-laboratory 350' 03345 Retreatment ofprevious root canal therapy-anterior 259 02970Tuo4Purarycrcuriaa(fracturedtooth) 75 03347 Retreatmentofprevious root canal therapy-bicuspid 235 02971 Additional procederrestoconstruct new cro.r*nrmader 45 03348 Retreatment of:previous root canal therapy-malar 350 existing partial denture fraroenorh 02975 Coping 95 APE CIFICa n0NJ RECALCNFWATION PROCEDURES 02930 Morn repair ne ssdatedbyrestorativemateriialfaiure 95 03351 Apexifcationvfre®Icfication 90 Weir tdlairrepairneoessitated)1QyrestaratiTamaterianfailorre 95 03352 t9peacifcatiortd'recalcification-interim rned6cation 90 replacement(apical cliosurelcakahcrepair of:perforatians,, root resorption,pulp space doe election,etc.) 02952 cNrdayrepairnRo itz*e!byrestoratiw9failure 95 03353 tpexifecatianvhecaltiFcation-final visit(inchirdescompleted 90 root canal therapy-apical closur4(caItific repair of perforations,root resorption,etc_i. 0.2933 'yerewrrepalirnecessitate+rbryrestorativeniaterialfaihare 95 iAPDCOEC1OMY/PERIRADUCtiLARSERVIC1S 02990 Resin infiltration of incipient smooth surface lesions 29 03410 Apitaectomy anterior 95 PUItPC,APPING 03421 Apicoectomy bicuspid(first root') 300 03110 Pulp cap-direct(texdbr Ing final restoration) 10 03425 apicoectomy-molar(first root) .859 03120 Pulp cap-indirect.Q.cludingferal restoration) 10 03425 .Apicoectomy(each additional Mot) 75 PULPOTOMY 03427 Periradindar surgery without apicoectomy 95 031749 Therapeutic pollpotoropOesclutfingfinal restoration)- 20 03420 Bone graft iTConajUlltaaunwith peradiodlarsrrrgeiy-per 32 removal of map conerall Mode dentinocament)unction tooThs single site and exaltation of macaroon 03221 Pulpal dem printry and permanent teeth 95 03429 . Bone graft in conjunction with periradisadlar surgery)-each 25 additional contiguous tooth®i the same surgicalsite 03222 Partial milpotormyfor apexagenesis-permanent tooth 75 03430 Retrograde filling-,per root 55 with incomplete root demi:mines EL+N000D0111C1111ERAPYC3IPRINNA#YT1EIN 03431 Biologic reaterials to a .in soft and osseants tissue 854 regeneration in conjunction wrath periradicular surgery 03230 Puipalt}recap,f(reaubablefilling)-anterior,primary;+tooth 40 D3432 Guided tissue:regenerationinconjunction with 150 (excliuding final restoration) periradindar 03240 Pulpal therapy(resor6ablefd6ng)-posterior,primary tooth 40 03450 IRaot amputai ion-per root 315 terelnifare fanai restoration) 03460 lErtododontric enckisromus implant 535 03470 Intentional reimplantation(inducting necessary!sprinting) 175 Underwritten by Solstice Benefits,Mc. 165 01083 21.3-11624 Administered by Dental Benefit Providers,inc. CODE DESCRIP110N MEMBER IICODEDESCRIPTION MEMBER COPAY COPAY OTHER ENDOCIONIIC PROCEDURES 04275 Soft tiSsue allograft sea 03910 Surgical procedure for isolation of tooth with rubber darn 95 04276 Combined connective tissue and denabielpedide graft,per 65 • tooth 03920 Remise:boat Cutoluring any Also/remora],not includng :60 04277 Free soft tissue pet procedure(including donor site 215 root Wel therapy surgery),first tooth or edentulous tooth position in graft 03950 Canal preparation and fitting of pneformed dcnvel OT post 75,04276 free soft tissue graft procedure rmdteding donor site 73 • surgerd.ea du additional contiguous Moth or edentulous tooth position in sane graft site SUIDGICALSERVIO5(INCLUDING USUAL POSTOPERATIVE NON SURGICAL PERODDONTAL SERVICE CARO 04210 Girchrectomy Or gingnoplasty-four or Imre oonttuous 175 04320 Provisional spiinting intracoronal 100 teeth Off tooth bounded swam-per quadrant 04211 Giitivectorny or gingivoplasty-one to three contiguous 66 04321 Provisional spfinting extra:atonal 100 teeth or moth bounded spaces per quadrant 04212 GiurOvectonly or g.ingiverplasty allow access for 40 04341 'Periodontal scaling and root,planirig-four OT more teeth 36* • restorative prwotudo e,per tooth per gradrant 04240 Gingival flap procedure including root planing,-four CIF 163 04342, *Periodontal scalirg and root planing-orrue no three teeth 29* mare issatigumns teeth or tooth bounded spaces per per quadrant qua ch-ant 04241 Gingirat flap procedure,inducting mot planing,-one to, 150 04355 *full mouth debridement to ereble comprelmilve 3S three contiguous teeth or tooth imarrided spaom per evaluation andifkagnosis mach= 04243 npically positioned fkp 150 04361 *Load-toed delivery of antimicrobial agents via controeled 43* release veltaide into&teased creviouilar tissue per tooth,by report 04249 Clinical crown lengthening-hard tissue 175 OMER PERIODONTAL SERVICES 04260 Osseous surgeqf(ndiuving elevation of a full thickness flap 375 04910 *Periodontalntenance 40 and donne)—four or more tontine:los teeth or tooth bcamddsioes ner quadrant 04251 Osseous surgery rarodurifing elevation of a full thickness flap - 325 04910 additional periodontal maintenance 100 and dosurre]r—ore to three contiguous teeth or tooth bounded spaces per quadrant 04263 Bone replacement L(v,tfl-first skein quadrant 450 04970 Unscherbiled dressing change(by someone other than 20 treating demist] 04264 Elone replacement graft-each adifirtional site in quadrant 325 04921 Gingival irription-per quadrant 15 04265 Biologic materials to airl insafft and otsmoustinstoe 325 04999 Unspecified periodontal prooadhare,by report regeneration 04266 Gruirledlissue regeneration-resorbdate harrier,per she 325 COMPLETE DENTURES(INCULIDENG ROUTINE POST- DIEUVERY WEI 04267 osseounsurgert gructuding elevation of a full thickness flap 325 051111 *Complete denture-maxillary 210' • and oil:smell—onto three contiguous teeth or tooth bourndedl 3:paces per quadrant • 04268 Surgical revision procedure,per tooth • 0 05120 'Complete denture-mad:Molar 210* 04275 Pedide softtissue graft procedure • :235 05130 *Immediate denture-maxillary 210* 04273 Subepitheliial comnectivetissue graft procedures,per tooth 280 05140 *immediate dentine-mandibular • 210* 04274 Distal or proximal wedge procedure Iwitera not performed 100 • PARTIAL IMMURES(INCWDING ROUTINE POST- • corriuncLion with surgical pros in tin sane • DELIVERY CARE) anatomlal area) • 05211 thlamilary partial denture-resin base(inducing arty conventional dasps,rests and teeth) • Underwritten by Solstice Benefrts; c. • 166 D1083 213-11624 Administered by Dental Benefit Providers,Mc. CODE DESCRIPTION MEMBER CODE DESCRIPTION MEMBER COPAY COPAY 05212 '"MemsEibadlarpartial denture-resin base Iinducig any 210• 05761 *Reline mand3balarpartial dentine(labctatare 35* cormenniomai clasps„rests acrd Meth) 05213 *6aTaxillarypartial denture-cast Metal framework With .220' 117ITSRJMPRO51111E515 rest-indenture bases(including way conventional drips, rests orad teeth) 05224 *nracrd;inglarpartial denture-cast metal framework with 220* 05010 *interim Complete dentoreImakillanyj 220'' resin denture bases(including arrycomentionaI eta, • rastsa ntteeth) 05225 *rttaadlarfirartiraidenture-flexiblebase[including any 220' 05511 'ilmterintcomplete denture{mandilrrdui- 20* cusps,rests endteeth} 05226 'Manrdlbrdlar partial.denture-flexible base('snchrdirig any 220':3.5E20 .',Interim partial&suture(rmazll • 220* clasps,mets and teeth] 05281 *Removable unilateral partial denture-one piece cast 235' 05021 *interim partial denturei@ararariibular], 220* • •mend("ucfnd ngdda sps and teeth ettl STMEISTSTODEItILURES EHEREM0iMS1EPROSTIEE515 05410 Adjustccrasp lete dent-srraaillary 8 05550 tissue conditioning,maxillary 25 05411 4vdjuast=plan:&stature-marusillbarlar S 05551 tissue conditioning,man d66rdar - 25 • 05421 Miran partial deystrae-maxillary 10 05562 Precision attadumesrt try repot ISO 05422• Adletpartial denture-mmamdlbadar 10 05599 !Unspecified removable prostbadcrnticprocedure,byreport 0 R 10510€OMPLETE0EIh1310115 •NON fl NCt4IPROQEDUUICE5 • 05510 *I raiirbrokerdcmrmpletedentuureebase 15' 05902 Surgical stun 1011* 05520 *Replace robing mrbrohenteeth-complete denture leach 10' 05907 Commimiresplint 100' Wolk REPAIRS TO PARTIAL.DENTURES 05906 Surgical splint 1110* 05610 *Repair reaiacloture base 15' IPICE-SURG1CALSER10CES 05620 *Reeganrcasttframework 30' 06190 Radiographic/surgical:implant iiadm,by report 235 05630 *Repel-or rwlace brolkendarup 15' SNRGVCCL'►'►LSERViCE5 05640 *Replace broken teeth-pertootha• 10' 105010 *Surgical placement ofimplant body 950 05650 *Add tooth to existing partial denture 30* 06012 'Surgical placement ofinterim bcdyfortransitianall 950 prosthesis 051 *Arkidesptoe ng,partial denture 304 06100 Implant removal,:byreport 700 05670 *Peplamatllteeth and acrylic encast metal framework 100• IMPLANT SUPPORTED IPROSTIEETIC5 CmIN 05671 *Replace a teeth and acrylic on cast metal framework 100* 06055 *iPrefabricated Abutment 385 Ernanrdvular} 05710 *Rehasecomgplete marxlliamydenture 75* 06057 *Custom Abutment • 495 05711 *Rause complete mandibular denture 75' 06050 •*Abutment supported,pcmcelaintfceramiccrown 695 05720 'Rebase maxllarypartialdenture 75* 06059 *Abutment supported.porcelain fused to mecrown 655 (high noble null 05721 ' rbasemandlbularr partial denture 75* 06060 *Abutment supported porcelain fused tomeralmown 695 . fpredlomninarttlyrbase metal) 05730 *Reline completemarEary denture K4hairssdei 45' 06051 *Abutment supported per aim fused to metal crown 695 (noble metal]. 05731 *Reline aomrpleee mandibular denture(clsaiirsidel . 45* 06062 *n;butment supported cast rmeral crown(high noble metal) 695 05740 *Reline maxillary partial denture(chairsideli 45' 05063 *Abutment supported cast metalcrown4'predomrinantiy 655 blase metal) 05741 *'Reline rnandllbular partial demure E&airide} 45' 06064 '*Abutment supported cast metal crown(noble metal], • 695 05750. *Reline aaanplete rmaillarydenture lltaboratord 35* 06065 *iImplant supported porcallainiceramic crown 695 05751 *Regie complete mandibular dentine paboratery.( . 35' 06066 *Implant supported porcelain fused to metal crown 693 (titanium„thanium:alloy,high noble metal)] 05760 *Reline maxillary partial denture Paboratory) 35'' 06067 *Implant supported metal crown ltitanium,titamiiumallloy 595 highs ruble metal) Underwritten by Solstice Benefits,Int_ 167 D1083 213-11624 Administered by Dental Benefit',Providers,Inc J1 • CODE DESCRIPTION MEMBER 'WOE DE-SCRIP-RON MEMBER COPAY COPAY 06863 *Abutment supported retainer for parcetainfteramic FPD 695 06241 'Pontic-portelain fused to predommiasotlyp base metal 195* 06069 *Abutment supported retainer for parcetain fused to metal 695 06242 *Aortic porcelain fused to noble metal 193" FPD(hit noble metal) 06970. *Abutment supported retainer for porcelain fused to metal 695 06245 *Pontic-porcelain#ceramric 195° IPO(predominantly base metal) 0601/1 *Abutment supported retainer for porcelain fused to metal 695 06250 *mantic-resin with high noble metal 195* FPD(noble metal) 06072 :*Abutment supported retainer for cast metal FPD(high 695 106251 *Antic-resin with predominantly base metal 195* noble Foetal) 06013 '!busnent supported retainer for cast metal#PD 695 106252 *Pontic-resin with nob%e metal 193* (predominantly base metal) 06073 ' 2buzniust supported retainer for cast metal FPD nble 695 06253 *PodisianaiPlinth-further treatment orcompletion of 0 metal) diagnosis necessary prior tof nal"urorpressicmr 06675 *Implantsupported retainer for•cer-emir-1FPD 695 FIXED PARTIAL DEN URE RETAINERS-tNLAYS/076AY5 06076 tla tsapportedretainerforporcelainfusedtometal 695 0656.5 Retainer-cast metal for resin bonded bedpost:lamas 190 FPD(titadirrrn,titanium alloy,or high noble metal) 06077: 'Impllaacpported retainer fair cast metal FP0[titanium 695 06548 iPetairoer-porcelain/Ceramic for resin bonded fried 225* titanium allloy,or high noble metal( prosthesis 06094 *Abutment supported mom-(titanium) 695 06600 Ilnlay-ponelainfcerammt,,tura surfaces 95* 06138 'Imp mt/abetment supported removable denture for 1200 06501 Inlay-poreelain;fterammt,,,three or more surfaces 195* edentulous 06111 *Implant'abutment supported removable..denture for 1200 06602 inlay-cast high noble metal,trssurfaces 135* edentulous arch-mandfirular 06112 *Magda rt ialutment supported removable denture for 940 06603 Inlay-cast hid o nrolde metal,three or more surfaces 195* partially edentulous arch-maxillary 06113 'Implant'alhtment supported removable denture for 940 06604 Inlay-cast predoniiinarnly base metal trra surfaces 145* partially edentulous arch-mand'ibuiar 06114 *Unplaut,Pal:cementsupported fixed denture for 3500 D6605 Inlay-cast predominantly base meta(,three cormore 995*' edentulous er h-mancillarf surfaces 06115 •Ilmpllant/abutment supported fixed denture for 3000 D6606 inlay-cast noble meta(,two surfaces 193* edentulous arth-mandibular ar 06116 'F ant hatment supported tIred denture for partially 2200 06607 Inlay-cast noble metal,three or more surfaces 195* edentulous arch-maxiMaryi 06117 *Implant,P`aliatmentsupported fined denture for partially 2200 06603 Onlay-p<orc laiinrd Bram tura surfaces 195* edenmdons arch-mandibular OTHER DAP1ANT SERVICES 05609 Onfay-parcelainfceramnic three or more surface 195* 0630 mmplan naintemance proced'axes,inc ludimg removal of 180 06610 Orday-cast high noble metal,two surfaces 195* prosttesie !deeming of prosthesis and abutments and reinsertion of p rostbesis 06480 Repair implant supported prosthesis,by report 400 06611 onlay-cast hia noble metal;three or more surfaces 195* 06062 Remittent imgplarati'abertnmet supported crown 45 D6612 {inlay-cast predominantly base metal,two surfaces 195* 06¢83 Recurrent implant/abutment supported fixed partial 65 06613 Way-cast predominantly baso emetal,,threeormore 195* denture solaces 06395 Repair implant abutrment,by report 220 06614 Orday-cast noble meta(,too surfaces 195* RXED PART L063111106 PONTiCS 06615 Onlay-cast noble metals three or=resurfaces 195* D6265 *Pantie-indirect resin based composite 695 06624 Inlay-titanium 195* 06210 'Poetic-cast highnoble metal 195* 06634 Onlay-titanium Il95* 06211 *Panic-cast e iredaminantlyWpm.metal 195'* AXED PARTIAL DEMURE RETAINERS-CROWNS 06212 *Pontic-cast noble metal 195* 06710 *Crown-indirect resin based composite 195* 06214 'Pontic-titanium 195'* 06720 *Crown-resin with high noble metal 193* 06249 *Poetic-porcelain fused to high noble metal 195'_06721 *crown-resin with predominantly base metal 195* Underwritten by Solstice Benefits,Inc 01053 213-11624 Administered by Dental Benefit(Providers,tris 168 32 CODE DESCRIPTION MEMBER CODE DESCRIPION MEMBER COPAY 1 COPAY 06722 *Crown-resin with noble metal 195' 07261 Primary closure of a sinus perforation 275 06740 *Crown-porcelain/ceramic 195* 07270 Tooth reimplantation and/or stabilization of aoddentafly 50 eased or displaced tooth 06750 *Crown-porcelain fusedto high noble metal 195* 07272 Tooth transplantation(includes reimplaratation fraaoa ci a 100 site to another and sp5nting andior stabilization) 06751 `Crown-porcelain fused to predominantly base metal 195* O7230 Surgical access of an unerupted tooth 125 06752 "0113W11-porcelain fused',tonoble metal 195• 07282 MobI on of erpted or positioned tooth to aid 125 eruption 06780 *Grown-314 cast high noble metal 195• 07233 Placernentofdevice tofadl teeruptionofimpacted SO tooth 06781 *Cwwn 314 cast predneiñnantiy base metal 195* O7205 Incisional'biopsy oforal tissue-hartf one tooth 115 06782 *Crown-5/4 cast noble metal 195* 07236 iincisioa[al biopsy of oraltiissuesift 6 06783 . *Drown-314porcefainfoeramic 195* 07237 Wand= 30 06790 *Cram-full cast high noble metal 195* 07233 Snob biopsy-transepithei®lsample collection 25 06791 '"'Crown-fulat predonsinantfy base metal 195* 07291 Transs ptalfiberotarrref supra(testa fiberotoury by,report 30 06792 *Crown-full cost noble metal 195* ALVEOWPTAASTY-SURGICAL PREPARATION OFRIDGE 06793 *Provisional retainer croon-furthertreatment or 125 077310 4iueoloplasty im conjueration with Edractinans-fourcr 20 winged=of diagnosis necessary prior to final impression more teeth or tooth spaces,per media= 06794 *Crown-titanium 195* 07311flteautophsty inconjuntion with esiractiona-one to three 20 teeth or tooth spaces,per quadrant OTHER FRIED PARTIAL DENTURE SERVICES 07320 Alveoloplasty not in conjunction with extractions-four or S0 nacre teeth or tooth spaces,per quadrant 05030 Re-cement or fixed partialdenture 1O 17732.1 Angioplasty not 6ommjunttioniwith WAd„tioms--OW.ta 30 three teeth or tooth spares,per quadrant 06940 Stress breaker 125 VESTCSULOPIASYY 06350 Prensirnm.attachment 125 07340 Vestibuloplasty-ridge extension(secondary 370 epriheialirationj 06980 rued partial denture repair are cessitated by restorative SO 07358 Vestibuttplascy-ridge extension(inducting soft tissue 990 material failure ,grafts muscle reattachment,recisionofsoft tissue attachment and management of hypertrophied and: hyperpliastic tissue) EXTRACTIONS(INCLUDES LOCAL ANESTKPOIA SUTURING, SURGICAL EXCISION Off SOGPT1SSUE LESIONS IFNEEDED,AND ROUTINEPOST OPERATCARE} O7111 Estraction coronal remnants-deciduous tooth: 45 177410 Ereeisioas of benign lesion upto1.25an 25 07140 Extraction,erupted tooth eropined root.(elevation 10 074111 iDarisitnofbentrulesion,geaterthan1.23an S0 =Oar forceps removal 07210 Surgical rearmed of erupted tooth requiring elevation of 25 07412 E tision of benign lesiosT cost plicated 55 mucopesiiosteal flap and removal of bone anchor section of tooth Oiti IE R SURGICAL PROCEDURES SURGICAL EXCISION Off INITRA-C165EOUS EESION5 07220 Remnasul:afinnpacted tooth-soft tissue 40 07.450 Removal of benignodoastogeniccyst ortumor-lesion 65 diameter up to L25 cm 07230 Remcwalafianpacted tooth-partially bony 55 07451 Removal of benign odd ontogeniccyistortamnaT-lesion 96 diameter greater than 1.23 cm 07240 Removal of impacted tooth-completely bony 63 EXCISION OF SONE TISSUE 07241 Removal of=puled tooth-completely bony,with 100 07471 Removal of lateral exostosis(maxilla or mandible) 95 unusual surgical complications 07250 Surgical removal 0f residual tooth roots(cutting procedure) 25 07472 Removal of torus palatinus 93 07251 Comeuectornyr-intentional partial tooth removal 270 074.73 Removal of torus mandibularis 95 07260 .Oroantral fistula dosure 160 07405 Surgical reduction of osseus tuberosity 95 Underwritten by Solstice Benefits,Inc_ 01083 213-11624 Administered by Oental Benefit Fo oviders,Inc. 169 33 CODE DESCRIPTION MEMBER CODE DESCRIPTION MEMBER COPAY COPAY SURGICAL INCISION 05570 Periodic orthodontic treatment visit 0 07510 Incision and drainage of abscess-intraoral soft tissue 20 05560 Orthodontic retention{remora]off appliances,contraction 300 and placement of retained* 07511 Incision and drainage of abscess-intraoral soft Sissue- 20 06593 Rebonding,,or recementarag;aur4/or repak as required,of 0 corriplicated(includes drainage of mrdtipie fascial spaces) fixed retainers 07520 Incision and drainage of abscess-extra oral soft tissue 20 135.999 Unspecified orthodontic procedure,byreport 230 07521 Incision and drainage of abscess-extraoral soft tissue- 20 UNCLASSISEEDTR)EA1WIENT complicated(hydrides drainage of multiple fascia!space) REPAIR OF TRAUMATIC 09110 Pa9(iathe( rgenc+,r)tre0an utofdentalpain-minor 0 procedure 07910 Suture of recent small wounds nap to 5 cm 35'09120 Mired partial denture sectioning 0 OTHER REPAIRPROCEDURES ANESTHESIA ESIA 07921 Caillection and appimtion of arandlogous blood concentrate 125 09210 Local anesthesia trot in coojainctiran with operative or 0 paodhret surgical procedures 07950 Osseous,asteoperiostea9„or cartilage graft of the mandible 350 09211 Regiamal black anesthesia 0 o r maxilla-au oieneous or-autogeneous or rionautogeneous,by report 01951 .Vitus augmentation with'bone or hone sribst totes via a :600 09212 Trigeminal division block anesthesia 0 lateral open approach 07952 Sinus augmentation,via avertical approach 350 09215 Local anesthesia 0 07953 Hone rlesernent graft for ridge ervaticrm—persite 100 309220 Demasedation/general anesthesia-first 30 minutes 125 07950 EoenOfectbrunry(hrereto:Huycrfrenotomy)-separate 50 09221 Deep:sedation/generalanwtheaa—each additional 15 15 'procedure minutes 07963 Erentioplesty .50 09230 eaalgesiaa anxiolysis.inhalation of nitrous oxide 20 07970 Excision of hypetTllastic tissue-,per arch 140.09241 Intaarerraus emotimate(conscious)sedation/analgesia— :125 first 30 minutes 07971 Extrisian of Pentagonal Gingiva 102 309242 Intravenous oma nate(conscious)sedation/analgesia— 55 each additional 15 minutes. 07972 Surgical re irof:fibroustuberosiiy 125 09245 floah;intrauenousmoderate lmms ioes)sedation 15 LIMITED ORTHODONTIC TREATMENT DRUGS O 5019 Limited orthodontic treatment ofthe primary dentition 1000 09510 Thrrapeuticparenteral dhug„singleadi inmstration 15 O 5629 Limited orthodontic treatment of the transitional dentition 1000 09530 Other dregs andifor mrettaxmeaurs,,by report 15 06030 Limited orthodontic treatneemtofthe adolescent dentition 11300 blISCEtEANEOUSSERVIC S 05050 Limited Cl bodcmatictreatrnentofthe.adultdentition 1350 09910 *Application ofdl nrstzingmadramtent 20 ,CDP4PREIfE41SrEORTHODONTIC TREATMENT 09910 *Application ofdesensitizing nssdlrraanent 20 00070 Ecmnprehemsive.orthodontic treatramtoftluetransiticanal 1000 09930 Treatment of complications(past:-srargical umasna1 0 dentition dreumstances„by report 05659 comprehensive orthodontic treatment of the adolescent 1650 09931 Cleaning and inspsstion of a removable appliance 0 dentition 05690 Conaprehertsio.eCo orthodontic treatment of the adult 1950 09940 •occlusal g e ,+,by report 250 d entitioon atITIOR TREATMENT TO CONTROL HARMFUL NA51TS 09942. Repair andfor refine of Occlusal dasai guard40 05210 Rermoaableappliance therapy 103 09950 Occlusion analyfis-mounted case 75 05229 fired appfence therapy 103 09951 Ocdusa➢adjustment-[limited 25 ORTHODONTIC SERVICES 09952 Oclusaladjustment-complete 75 06660 Pre-orthodontic treatment examrinationtomonitor growth 35 09973 Externalbreaching-pertaath 30 and development 09975 External bleaching for home appaliretion„per arch;includes 240 materials and fabrication of custom trays Undaer ritten by Solstice Benefits,Inc_ 01083 213-11624 Administered by Dental Benefit Providers,.tic 170 34 Specialty Services 1 This Member Schedule.of benefits applies When(fisted dental services are performed by a participating General Centist,unless otherobe•authorized by Solstice. 2 Procedures not listed on the Schedule of Benefits that are performed bre a participating General Dentist will be charged at the participating General Dentist's usual and customary fee less 25%. 3 The partidpatirrg General Dentist you select may not perform all procedures listed The top macs ts'slt en apply to participating General Dentists. 4 Should the services of a specialist t(Oral Surgeon,Endodontist Ped,odcntist,or Pediatric Dentist)be merry,you may receive this care in either of two ways:(1( You may go directly to a participating speoatist with no referral and receive a 25%reduction off the providers usual and customary fee;or(2)You may obtain prior written authorization from o1stice and rec&'especieltytreatment by an approved participating specialist at the listed amernments.Please refute the sPecialty Care it Policy in your Member 5 Should the services of an Orthodontist be necessary,you may receive care in'either of two ways(111You may go directly to a participating specialist with no referral and receive a 25%recruction4nff the pre/eiders usual and customary fee;or(2)You=wombat:rilemberServicestolc teyournearstparticipatingOrthodontist who will perform co.ered services.at the Fisted mevnber co-pay. • 6 Members seeking implanitreatmentshould refer totheir participating implantolegist„a select fretwork.of providers.lint ail providers perform the implant procedures at the ropey listed on the Scbedtdle of Benefits Exclusions 1 Services performed by.a dentist or dentalspecialist,rant contracted With Solstice vdthout prior approval_ 2 Any dental services or appliances.which are determined to'be not reasonable andfor necessary for maintaining or urmprceing the Members dental health or amerimental in nature,as determined by the participating Sciatice dentist_ 3 0 gap!icsurgerr or proceduresandappliancesforthetreatmentofmyohmtxti nal,myosi eletalortemporomandlibularjointdisordersunlssot enWise specified as an orttrodantic benefit onthe Schedule of amens, 8 Any inpatient/outpatient hospital dnarges of any bond inhaling dentist and'/or pbysidan dnarges,presort:dons,or nn cations. 5 Treatment of rrraftgrnandes,cysts,or neoplasms,without proof of medical necessity and prior Solstice appraal. 6 Dental;procedures initiated Mier to the Anembu"s eligibility under this benefit pram or started after the Member's tundiation from the plan. 7 Any dental proteduire,or treatment unable to be,performed in the dental office due to the general!manor phytiralllmitatioesoftheMember rnduding but not limited'to,physical or emotional resistance,inability toivisit the dental office.,or allergy to common*yutilizrl local anesthetic: Limitations 1 Any oral evaluation(excluding problem]is limited to One(1]time per consecutive sir(6]months;ccrnprehensive exams can only be coveted'one(1]time per 36 months,if and only if patient is considered to be new or arm established patient All subsequenut oral evaluations will l at a 25%rea an off the dentist's usual and customary fee without a frequency limitation. 2 All le-tering x-rays are limited to nne set in any twelve(12]consecut e month period. 3 The dental prophylaxis orperiodontal nwitrtenance;procedure is limited to one(1)time in any consecutive six(6)month puled_raw additional procedures will folio 01110 and D4910 Member copayments as listed in the Schedule of emsaf 4 Fluoride treatment 6tonne(1)in any twelve(12]consecutive month period focdrldiiren under the age of 16.. 5 Sealants(D1351or0D1352)are limited toone(1)time pert:merlinarty three(.31consecutive year peeririod.rinds isonly allowedforunrestoredpermanentnnolarteeth for,children under the age of le. 6 Space maintainers and all adjustments are lirdited to,children rasder the age off 16. 7 /Marini habit applianms are limited to one 11.1 time per person[under the age of 16_ S General anesthesia,or GL*sedation is available wheal-rued en tire Schedule of nessefits,Medically necessary„and previously approved by Solstice. 9 Newt dentures include.one fit)reline within the first six(6]rtriontlis 10 Replacement of crowns,implants and fixed bridges or dentures is limited to one(1)time every consecutive free(5)yam. • Underwritten by Solstice Benefits,Ing 01083 213-11624 .x ddrninlsteied by Dental Benefit Providers,lmc 171 35 l Limitations Continued 11 When atm :implanrt amber bridgework exceed six(6)consecutive orbs,there will been ad:kiamal drarge of 530_00.per unit. 12 .copayments reoarked!by "do not include the cost of material and laboratory fees.Addiitional cost to patient is as follows:, -High a noble metal(predo's}up to$145+00 -iltamium metal up to$120(watered with proof of allergy to other metals} -noble metal(semi-preaousp op to$120.130 Predominantly base metal(non;precious}up to 555.O0 -Crown laboratory fees up to 5155.00 Laboratory fees an dentures up to$225.00 -Porcelain laboratory fees for D2610-D2644„0.2529,D2S 61,102952a,'D5600,06501„D5600;,and 0550P up to 555.00 -Denture repair laboratory fees lop to$50.00 -.All ceramic and'i'orporcelain c owtofees up'CO 5155.00 13 .Copayments marked by't"are not eft sle ata speciafst 14 Either 00210 or 00330 are reimbursable one 0.1 t ee every five(5).comseanliive years 15 Copies of x-rays can be obtained for 52 per per®petal storm op toe maxim mmo of 534_Panoramic x-ray can lie obtainedifora$15 fee_ 15 00274,00277 or 00220 are payable only when other inclusive image have mot been taken(paid)within the last six(6,i months. 17 All denture arryustment fees are for dentures width were not fabricated at the present tafrme 4lldenture ad}ustmentfcrnew dentures made 1sithin 12months.areat no fee to the mender. 13 Emergency treatment is available for patliatiue treatment for the abatement regain to$1100.00 per occurrence_ 19 surgical remenelofwisdom tooth covered when pathology(dsease(edsts.Surgicalten wale wisdurr teetitif3nd molar Wher lodoes not exist wiS be covered at 25%off of the general dentists or specialists usual and customary fees.Orrthodontic related)emeries(except D721a0}needed to relieve crowding or to fatilitneeruption are availableate.25%reductionoff ofthe dodoes mud and customary fess. 21 Member may choose linisalige gilace of traditional Orthodantk treatment,and=add pee tile sum of the!listed member Ortho co-pay plus the difference in cost for the enhanced treatment. 22 Or tinsel Guard(s};isLimited toone fill time in any cnsecutivethirtn sii{55lmonthsfarthepuurposesoofhabitualgrin. goil3rukism.. 23 00554-00393 is limited to one(1}time per sixty(6t4 months,covered only in educe!seining and not ins a radmgraplmt inxagimlg center_ tlr denuritten by Solstice Benefits,lnc_ D1083' 213-11624 Administered by Dental 8enefnt Providers,Inc. 172 36 DPPO - Dental United HealthCare Services,Inc. OstalI � Cantribut• O..,ions.PPC 301 covered dental services CustamtNEIN!4T4 NOty-CRrrroCOrc:r8 CeRTFEDDOWC43 NETWORK NON-R TVOR.K. NuIWFORC INON44IWORK Ewen:"Annual Dedecatle Slag Sraa Sa 40 ,:• mum.flee sum anal Ne t ctt and rem-Nehrzettbetert'aIt mcteretey 12:-`a7=PEE= E3rM mtr,Geaa t Ger KEW Per ten=ter $1:EEE Iereercn FIE *mull ctmtiman) Garotter Year a ender Year Mem teteme emetteetemThE mitt Nene Annual deductible applies to preventive and diagnostic services Na Eln N=site) +ria{ouc Netavrki Annual Deductible Applies to Orthodontic Services 'Orthodontic ,-- R-• - -nt Aloes CMS DVERED SERVICS @u -,urn`DRK.PLAN Rmry Rst PLEN IPATS•• 5„E,,,,, SEREST QUIOEUEE8 PA DIAGNOSTIC SERVICES -emit Ora^IEsrzFuattm Zee Erctu:tcrt:.93'a 6rm 'ora section tone! tr.a' Er% Qiletttete. anal Gem Dtermete Tett to s Et% PREVEIMVE SERVICES -.-- :gr:lea7ttgn t_aia EE% Eee Emit-Atm wad rsetlaes,',:•Duet patentee. _ .1 Tireamleat I r mertde), tint.% SE% one ttru% BJ.'SIC SERVICES ceeract r. +rA abS c tr Grtttpalte9 Tc% Zee EnctuEn t:and eltr-t 't es Imam Merttene!t guaemes. .rr&ercy Tra .,2,GenertlEttukre Et% Unlit%MECuorz 9'++ TE% Curget trnCL=Vat et in=ter. TE% -t'.necettr. mss =areae z% IBLIOR SERVICES .ta, 1SY-7Errwns SE% Bee SW/m=arr].ftttt�7.r.:ase tin ex tenet s•..L...i:arCRes'tarae€irsc atet= SE% - petit Des=roe CHV-Ars) Si% SE% Mort Net Gmel ORTHODONTIC SERVICES +�.gracemrcaned eraser, olMeMete able SE% J ' War n a 1 part proelmes Mat ratan tam ontnus protesa nnaly am: r> i nEM:netz'ma a clEnal cotdinna€rte.yourplan erases reimbursement On Me read awilytreai e t-teandt r.Cyan and ymE boilIst aarel art a trsannem Mt n%mum=say mora the teal .03-1 an Mal Ins p13m benefit Is based,you WI be cesponsalle Tar 11w arnt>ebstaesttateS fru eerTererxt anaOre i is m tote pun adcrann,a pre-2esarerEestimate IsrEsron11718XedTOT any; raIne estimated b east area I:Ease axtrerit your d=d=_rnla —The'mmnnF`ortpscstargeorbens.=Isbased anOe monarxt'a awy fess In gengrapnrc oras Pttintaaleexpens sareIncorrem —The norrnetrmlt pa-cottage at bt-reti;a E5 baastl ala tte wtrIl arc'.cuslamary'7 In Ote sbn aram a tralcll ate expenses ate Inconel. Inatccr icenttn Ire mruts.stalerepTrtr,sort.aprow lena0741 Mtn IslncluntS tteaur0DmcT Eltsnenntra..Faracopp15aoeserpmonctt poi ra Coverage. mare Teter 4;D Tow Certtift ?Dr WORM. The Prenatal Denial Care(rot ava1Iab e e VIA},and OraI0aacea Screening pragants are coal tuncl it Et pan. The mrere1 el c otaTc .T I*ate acre Ent b ru natnnEannat purposes arlgraidb cot as mer Clare Ftase rote sir ore stove Ent prro 4ritles only a We;gneeral CemlnrOn,cemeragearxrasesneCuGtasxUkra.acants=Faracorrpurei SWcryncrri7w►r ', =VS= e,please refer Eyttar Cstttl£er crCm=_rge arta spurn rrents ea atinn.arnr._frerCara,gea exLV Centel C?Iu DIEVnarycr EEnss and}ecu CerrEE of Onveragecems • anantc!rrar,tranceurT.rmtecenernSa ataltraaDr^✓b@'agmen.AViirEISa'fU=EL=arEDtfg?arecr st&rat:ArrdntSreeanti1ecreneLtc.SEMmam Tac Jenai ITN astklr 1t xela aryl sine'nlrr"tn an a max VSEeiae'cR,ara•3IIRESES iE'6.ass, tflc=ct!leatttire DEW ct?tranc FPO Fan b east'rEMEtIr �a c rpnm11 Tay IIs TeThtt±attCaar Entrance Gower- hi;ri10rd,Cannes tau UnErt reaamCre =trance Iomaanya;,rlitw Ya it ut1tuvpar12 New Yts'k=mete Mamrenr'(=Tani,LataQCJV_-e,elle ncemty Mane=Life instrence carvanyctrryew YGVF,Hew Ycr New Y„nartlnxe1HeatCare r►tCesyiris. 03,13 C12D13-2014 41rtbd t;1a-aIG,aCare;mune,tine 173 37 Unitedilealt careeDental'Exdlusions and Limitations Dental'Services dmcritaed VII lois sedan are mend teen such writes ave_ Mecewey: E.Provideddyrorunderthe&mtdanalaDentistccAdlerappropriateproviderasspectrMa[l result/Ed; C.The least costal..choicely accepted trEeert rt&,old D.Nat meted as descraed Im 1he.. :12on entified.Genera Exra»ans. GESS..LCMffATIOy1S 1 PERDDDIC ORAL EVALUATION ltlrited to,2 MOSS ser cansecrdree 12 endrdls. 2 COMPLETE SERIES OR PANOREX RADIOGRAPHS Limited 1iD 1 time per c,3a15eca titre 36 marlin. 3 MEWING RAII!IDGRAPHS Lareed ID 1 sores,att iron per calendar year_ 4 E0 TiMEFSL RADDOGRAPM limped to 2 Ms per wielda'r year. 5 DENTAL P.ROPHLYAXI;Mi ed to 4 tis per ons?c re 12 rauI : 6 FLUORIDE TT.EATrAENTT.0 limited"t o covered persons under tape age at 16 years.arid Molted to 2 threes per onoseadve 12 morals. 7 5PPOE MAINTAINERS tanned to covered perms under Ione age at 16 years Manna to fl perconsecuilme 60 monies_6ene0t Mnotodes all adjustments within morals 261nEtatellon. 6 SEALANTS Limited to covered persons cnteM the age ort 16 years,,Aad an*per GLM;commend pEnaarrc-n4 snot emery consecoMe 36 months. e RESToR4.i1'DONGt analgalnorCon:postte)Matlipe restoration art are surface Wide treated asasingleMinlg. 10 PIN RETE1,1310N Ladled.to 2!pens pert ant.covered Mace=M ca'=Leatw.iTln. 11 INLAYS AND ONLAYS Landed to 1 time per Mitt percorrs=c In 60 orurwT,b.Covered ocryMei a 2ilr:6amoot mime ate MM. 12 CROWNS L1mlted to 1 trate per man per consEcatis€0 motets.Covered activities atillnp camna2 restore are doer. 13 POST AND CORES Covered array Tar teeill,rod Mime Mad met own therapy_ 14 MDATIVE FILLINGS Crimea as a separate lSerer&may Itt welter service,Ow Mara 14ays ertd SX2313,i 7314 p ea,ant ins same toot chiming die Volt. 15 ` 4LING AND ROOT PLANING Malted to 1 One perauadtara percrntsecutive 224aooe13 16 ROOT CANAL THERAPY Limited tc 1 dime per tooth per OMIT*. 17 PERDDDObtT LMAINTENANANCE thritIM/111)2tides per axms fve12m.m.L'Mo1bi;L+Altsp=insara ucrduepenbtIonteltherapy',exclueve clgrossd=_Gr13erneat 18 FULL DENTURES MOM lo 1 Woe every COSEed.3160maths.NoadationaI',allaean tar pr_e4lanoasemD-ps na8acernertis. 12 PARTIAL DENTURES L.IthltedID1Maevery cclnseautfieEacaarn s.NOacirbnalat$denesldrpr lsnorrsend-precleoatlac1rents. 29' RELINING AND REEASIADG COIFFURES thmthd'�t celminsi1reD fin kneel ends tear 6 martin arer die Initial f error.United to 1'tae per,consecutive 12 mid. 21 EPR TO FULL DENTURES,PARTIAL t7ENTWRES.EF.111GE0 Lel-di to texas or atiuE3nE1 s perraored more tont 12 ohm=anter Me =edge. Ladled MD 1 per Onmseculve S mmints. 22 PALLIATIVE ATTIVE TREATMSIENT Omered as a seaa1afe®em?fit Drag Mt no other setatce.Valertaan ave:exam and ramtrgraptra,mere pe1?own?d cer b sere dorrt9l cluratg Me vTaIL 23 C ODUJZiL GUARDS LMmMed to 1 grrera emrlry 000sela4tue 35 merit=and oily covered IG,presatt d Gm=tool toatnlaai granting. 24 FULL MOUTH DEERIDE4` ENT Landed to l Moe every cone olive 35=Ms. 25 GENEr,ALAN STHMW,Covered oaf etaendlrtttallynecessary. . 2i . OSSEOUS GRAFTs ulturem per quadrant ar One leer cnisentice 36,=rem.. 27 PIERDDDODtTAL 1.11 GEmRY;tird Moue and stRttssue pe wdaanl=wry are Ptmtfad imp 1'gwelrart ozone pm a riselbe the 35 sial hs aerological wee. 2d REPLACEMENT OFCOMPLETE DEtTUMRES,,FMCS QM•R6N1OJAEI:EFM:ZEALDEN WRE%CROWNS,INL YSCRONLAYS Replacement orMaples 4Em1UTP5,Med ar rerr)373G14 par111 denfmres,croons,Mega or seep predator),SUCnmlfbed Mr papime t ender Me pin is Molted t 4 Moe per me AI Ne SEA roman from Iota ar cilal host nenL li ria in1ludss retainers,Watt apodecote,and any dame=rermova hex- ptive arthcdeotdc applIances. 174 38 . Vision Care Benefits How To Use Your Vision. Care Benefits Step I. Review your customized benefits Carefully review your customized benefits to determine your plan design and applicable copays. A copy of your benefits brochure may be obtained from your benefits representative, or you can access the My Benefits page of our Web site to see the specifics of your plan. Step 2.Find a conveniently located provider You may easily locate providers by selecting the Find a Provider option, both before and after you log in to our Web site_ Step 3. Schedule your appointment Once a provider is chosen, simply call the provider directly to schedule your appointment. Be prepared to identify yourself as a Uailestleatlarate,,Vision member and provide the member identification number, primary insured's last name, patient's name and date of birth_ To help ensure the provider is able to process your insurance be sure to take this ID card to your appointment. Step 4. Receive your eye exam The network provider, a state-licensed optometrist or ophthalmologist, will perform a complete eye exam, which includes a case history of the patient and an examination for eye disease and vision impairment. Should vision correction be required your provider will determine your specific prescription for glasses or contacts. Should a disease or eye disorder be found you may be referred to your health plan for medical eye coverage. Step 5. Choose your eyewear If prescription eyewear is necessary, your provider will assist you with your selection and order your prescription_ Prescription eyewear includes eyeglasses and/or contacts depending on your plan coverage. Once your eyewear is complete your provider will schedule a time for pick up. Eyewear is dispensed at the provider's office to ensure optical accuracy and proper fit. if you have any questions or concerns about your glasses or contacts let your provider know; they are there to help you both during and after your appointment Out-of-network benefits* While the greatest benefit is applied if you stay with a network provider, most plans cover a portion of your exam and eyewear should you choose to use an out-of-network provider. You will be required to pay for your purchases at the time of service and request reimbursement from ttattegyision. To confirm if you have out-of-network coverage please consult your benefit summary or the out-of-network reimbursement link located on the My Benefits page of the Web site. Please confirm that out-of-network benefits are available prior to scheduling your appointment. In order to receive reimbursement, simply submit the itemized paid receipt(s), along with the member identification number and patient's name and date of birth. 175 39 UnitedHealthcare City of Plantation, c,�rrtt ' Vision, Benefit Summary Ben&Fit Plan Year 10/1/2017 3/3112020 Customer Service and Provider Locator,(800)638-3120 myohcvision.com Un tcdFteaithcare vision has been trusted fix more than 50 years to deliver affordable,innovative vision care solutions to the nation's leading employers through experienced,customer focused people and the nation's most accessible,diversified vision care inetaerk, In-network covered!-bifid!benefits(up to the plan allowance and after app&cable copay)include a comprehensive exam„eyeglasses with standard single vision,lined bifocal,lined trifocal,or lenticular lenses.standard scratch-resistant coating and the frame,or contact tenses in lieu of eyeglasses. Exam wth'Materials Benefit Frequency Comprehensive Exams Once= 12 months Spectacle Lenses Once every_12,rnonths_. Frames Circe evon 24 months l Contact Lenses in Ueu of Eyeglasses Once every 12 months Inletvork Seryioes Cpes Exam(J J S 10,00 Materials $15.00 Frame Benefit(for holes that exceed the allowance,en addi5onaI 30%discount may be applied to the overage)/ Private Practice Provider $130.00 retailfrane alowance Retail Chain Provide •• • $130.00 retail frame allowance Lens pp5Ons Standard Scratch-resistant Coating?olycarbonate Lenses for Dependent Children(up to age 19) -covered in full. Other optional Ions upgrades may be offered at a discount(discount vades by provider).The Lens Options list can be found at myuhcvisidn cor0. Contact''Lens Benefit'(Selection contact lenses refers to our formulary contact'list.Contact lenses not( ted on the formulary are referred to as non-selection.A copy of the list can be found at myuhcvision.comL Selection contact lenses if you choose disposable contacts,up to 4 The littingfevaluation fees,contact lenses,and up to two boxes are included when obtained from farow-up visits are covered in full atter copay(if appricabte). en in-nomad:provider. Non-selection contact lin An anowance is applied toward the purcltase of contat r,„ 5105d0`f lenses outside the selection.Materials copay(d applicable) --- is waived. 1 Necessary contact iennsesa Covered in full after copay(if applicable). Out-of-Network Reimbursements(Copays do not sooty) Exam(s) Up to$40.00 ' Frames - Up to$45.00 Single Vision Lenses Up to$40.00 Lined Bifocal'Lenses Up to$60.00 Lined Trifocal Lenses Up to$80:00 Lenticular LensesUP to$80.00 ' Elective Contacts in Lieu of Eyeglasses/ Up to$105,001 ,t Necessary Contacts in Lieu of Eyeglasses Up to$210,00 176 40 Discounts 'Laser vision. UnitedHealthcare'has partnered with the Laser Vision Network of America(LVt4A)to provide our members with access to discounted laser vision correction providers.IMembers receive 15%off standard or 5%off promotional pricing at more.than 550 network provider locations and even greaterdirscounts through set pribing at LasirRusD locations.For more information,call 1488-563.4497 or visit us at wurv.uhdasik.com. Additional Niseerlal At a participating in-network provider you receive up to a 20%dscount on an addilicnal pat*of eyeglasses or contact lenses.This prooran is available after your vision benefits have been exhausted.Please note that this discount shad not be considered insurance, and that UnitedHealthcare shall neither pay nor reimburse the;provider or member for any funds owed or spent.Additional materials do not have to be purchased at the time of initial material purchase. - Fleming Aids As a Unitedtiealthcare vision plan member,you can save on high-quality hearing aids when you buy them from hi Healthlnnovationsm. To find out more go to hifleathInnovations.com.When placing your order use promo code myVision to get the special price discount. '30%&Daunt available at most palpating in-neti+01k provide,locations.May mrdude certain frame maindacurers.Please verify al disocunts wiih your,pre1dar. 'Corte lenses are in lieu of eyeglass lenses andror eyeglass frames.Coverage for Selection contact lentos does not apply at Coster,Vdrimart o*Sam's Club locations.The allowance for Nor aoloct(on contact lenses applies to materials.'Na partial ++i1 be exdusxuety applied to the frig and evaluation. 'Necessary contact lenses are detemr led at the provirus d1s etion for one or more of the fobbing conditions:t=000rwing cataract surgery without binocular lens implant to correct extreme Crsio n prederrs that cancra be tcireded with eyeglass Imes miter frames;with cert.*conditions sure as anisomotro cia, keratoconus,irregtia comeanstigmatsm.apha`da,facie'deformity:or corneal deform y.if your provider considers your contacts necessary.you should ask your provider to contact UoftedHealthcare vision confirming the reimbursement that UnitedHeafthcare will make before y-ou;purchse such contacts. Important to Remember ln-Networit •Always identify yourself as a UnitedHeatthcare vision member when making your appointment This will assist the provider inobtaMing your benefit information. •Your participating provider will help you determine which contact lenses are available in the UnitedHeahhcam selection. Your$105.00 contact fens allowance applies to materials.No portion will be exclusively applied to the fitting and evaluation,Your material copay is waved when purchasing non-selection contacts. +.Patient options such as tJV coating,progressive lenses,etc.,which are not covered-in-furl,may be avalabie at a(Exeunt at participating providers.The Lens Options Est can be found at myuearsion.com. Choice and Access of Vision Care Proriders Urtitedelealthcare offers Its vision program through a national network including both private;practice and retail chain providers.To access the Provider Locator service or for a printed directory,visit our website myuhcvisioneom or call(800)638-3120.24 hours a day,seven days a Retain this UniiedHeatthcare v benefits,benefiit summary welch includdees{det IDtcard online at m and nstruc week.You mayalso view your an Titin' ailed benefit information and instructions Whew to use the program, Please refer to your Certificate of Coverage for a full explanation of benefits. In-Network Provider-Copays and non-oovered patient options are paid to provider by program participant at the time of service. t -of Metwak Proelder-Participant pays furl fee to the provider,and UnitedMealthcare reimburses the participant for services rendered up to the maximum allowance.Copays do not apply to out-of-network benefits.All receipts must be submitted at the same time to the following address:UnkedHeatihcare Vision,Attn.Claims Department,P.O.Box 30978,Salt Lake City.LIT 84130.Written proof of loss should be given to the Company Within 90 days after the date of loss.It it was not reasonably possible to give written proof in the time required,the Company wil not reduce or deny the claim far this reason.However,proof must be flied as soon as reasonably possible,but no later than 1 year after the date of sereice unless the Covered Person was legally incapacitated. r Customer Service is mashie b)11-free at(m0638-3120 frau 8:00 at m.to 11:00,p.m.Erste s Time M ay through Friday, and 9`00 am.to 6:30 p.m.err Time on Saturday. This Benefit Summary is intended only to highlight your benefits and should not be relied upon to fully determine coverage.This benefit plan may not cover at of your healthcare expenses.More complete descriptions of benefits and the tents under which they are provided are contained in the certificate of coverage that you will receive upon enrolling In the plan.if this Benefit Summary conflicts in any way with the Policy issued to your employer,the Pdicy shall prevail. UnitedHea$hcare vision coverage provided by or through Undadl toalthcare Insurance Company,located in Hartford.Connecticut,UrritedHeatthcore Insurance Compaq of New York,located in Wanda,New York,or its affilates.kdmin'sfat've services provided by Spectera,Inc..Unaited HmIthCare Services,'Inc.or Hers afff . Plans sold in Texas use iPoky form number VPOLOS,TX o^VPOL 13TX and associated COC form number VCOC:INT.06.TX or VCOC.CER.13.TX.Plans sold in Virginia use potty form number VPOL.06.VA orVPOL.13.VA and associated CCC form number VCOCJMT.06.VA or VCOC.CE t.13.VA. 177 U.1J tp h ,r '14211•0V 06117 62017 tdn d iahCeo Service w523S03512I-1-N0 toouail 1Oil207-03r311202a int t1 -01Ctv3.0) Vision Plan Contact Lens Selection List Maximize your benefit with these popular contact lens brands. Your UnitedHealthcare vision plan offers you a selection of popular contact lenses to help you,get the most out of your coverage.Your eye doctor can help determine which contact lenses are best for you. Contact lens selection list' Daily Wear2 °I'VE �'A$ Alcon'DAILIES AquaComfort Ruse(30 lenses per box) "tG<C Alcon DAILIES AquaCornfort Plus Toric(30 lenses per box) CooperVision'Proclear'1 day(30 lenses per box) APRIL 1-Day ACUVUE'Moist(30 lenses,per box) 2017 Bl-weekly Wear2 Alcon FreshLook'Handling Tint(6 lenses pr box) CooperVision Avairae(6 lenses per box) CooperVision Biornedics'55 premier(6 lenses per box) Bausch+Lomb Softens'38(6 lenses per box) Your contact lens cover may vary. ACUVUE 2(6 lenses per box) Log in to myuhcvision.com to see your coverage details, Monthly Wear2 Alcon AIR OPTD('AQUA(6 lenses per box) CooperVision Biofinity'(6 lenses per box) CooperVision Frequency'55 aspheric(6 lenses per box) CooperVision Proclear'sphere(6 lenses per box) Bausch+Lomb PureVisione2(6 lenses per box) Bausch+-Lomb Ultra'(6 lenses per box) ACUVUE Vita'(6 lenses per box) ;,` 1 t tl c re• 'The corral lera let IasutlecttoCrar{le.TM CreSild apply et Castme Walnut orSanrsatsltlocalism "Nliirwearing r"am:Wle rnapterr'tut loolorx{bail you r w Ernta orange your contact Imam Ail trademark'ars the property Whet me:scr a genera. The company does not discriminate on the basis of race,color,national origin,sex,age,or disability in health programs and activities. We provide free services to help you communicate with us. Such as,letters in other languages or large print Or,you can ask for an interpreter.To ask for help,please call 1-800-638-3120,TTY 711. ATENaON:Si,habla es eiiol(Spanish),hay de asist+encta de idiomas,sin cargo,a su disposicic n.Lanie al n imero de telefono gratuito que aparece en su tarjeta de identificacic n. Malik PDR,-1=4:13Z 3c(Chinese' -PA 1-800-638-3120,TTY 711 Tris potty raaazc iabns irritalicf s and Mere'el tarHrich lhe pal=l maybe cod rued fniir e or dardrrlint ed rtarMeal and complete delete a cdaataga(=tact Urias-eatllcsre Iralrance Cautery. UrfletlHaathcerevision o eragepiothdtiarthr©ughUriledliaattrlrareInsura ce Carper%Icated h Hartfora ConreclbrtlefedHaatthcareInsurance Carr .7403hYoh,lociin MiEnCira,NaxYerIcorihalrMeta.The cdriraclhgartilylor:;aeclera PisanNerean iuspecter',Ina.Admlrt4rat e rites prorkiaci try Spachra, ttitat1HarallfrOare Sa tikes.Ina thetatr1I ea Plans sea hi res usepothyimanrmbarVPCLOB.TXaYPCt_13TXare esaccfa dCOOrarenumberWCCCJNT. 'MTXor%CCCCtRraTXPtamaaldInVrlriausepatet. to nrumberVPCLG9.#A,aePCLlaVAareasaocfakidCOGtarnnumberVCOC.INT_ VAor CO21113.'14. MT-112150Si 4117 .02017Urft3dMaatlt are Senion int'.17-8E0A • i N . Life Insurance The City of Plantation provides you with Basic Life and Basic AD&D insurance through Reliance Standard. Value: \ [ - - -- -- — -- One (1 ) times your annual earnings, rounded to the next higher $1,,000, subject toia T. maximum Amount oelnsurance {of $50,000. / 11 I a (Definition of 'Accidental You may purchase Death & Dismemberment additional Voluntary Life, ;Insurance AD&D' Employee/Family AD&D, AD&D covers death by and Dependent Life accidental means (rather Insurance. See page 46 [ _ than natural causes) and & 50 for more dismemberment, which information. includes loss of the use of I 1 - ,certain body parts - - -Fora copy of the Certificate of — t 1(including limbs or Coverage simply check the t ie Employee Intranet or contact esi ht. -Yg -- - Human Resources 1 I 179 43 i Long Term Disability The City Of Plantation's Long Term Disability (LTD) insurance is administered by Reliance Standard. LTD is an income replacement program that protects you in the event of a permanent non-service incurred disability and leaves you unable to perform the material and substantial duties of your job and meet the insurance company's eligibility requirements. New employees are covered 30 days after the first day of the next month of being hired; regular full time police officers are covered for the first five (5) years of, employment only. Ifou become ill or injured, and are unable y to work due to your non-service incurred disability for 90 consecutive days, this program will provide you with: ❑ A benefit of up to 60% of your gross monthly salary, $5,000 max. ❑ A benefit for mental health disabilities and for partial disabilities —2 year limit ❑ 24-hour, 365-days-a-year unlimited telephonic legal and financial counseling for families affected by disability ❑ Benefits are reduced by other income sources, such as Social Security disability, in most cases benefits continue until the age of 65 180 44 Insurance Bi-Weekly Contributions Your insurance contribution: Emp + Active Employee Deductions Single Children Emp + Sp Family Option 1 with PPO Dental & Vision $42.39 $91.46 $95.82 $143.95 Option 1 with DHMO Dental & Vision $42.39 $86.91 $90.64 $133.34 Option 2 with PPO Dental & Vision $39.38 $85.43 $89.49 $136.32 Option 2 with DHMO Dental & Vision $39.38 $80.88 $84.31 $125.72 Receive a Discount! Complete the '3 Steps to Wellness' Emp + • Active Employee Deductions Single Children Emp + Sp Family Option 1 with PPO Dental & Vision $15.42 $52.92 $56.12 $93.17 Option 1 with DHMO Dental & Vision $15.42 $48.37 $50.95 $82.57 Option 2 with PPO Dental & Vision $14.32 $35.32 $36.86 $58.68 Option 2 with DHMO Dental & Vision $14.32 $30.76 $31.69 $48.07 , New Hires *you have 3 months from the date your insurance becomes effective to complete the '3 Steps to Wellness" and be eligible for the discount. *To be eligible for the discount covered spouse need to participate. 181 45 Voluntary Insurance Benefits • What are Voluntary Benefits? Voluntary benefits are insurance products that you may choose to purchase through the City of Plantation and payroll deductions at rates that are lower than you could get on your own. A few examples of voluntary benefits are life, disability, supplemental health and cancer insurance. • Voluntary insurance can play an important role in your benefit package, filling gaps in coverage,. Voluntary benefits give you the opportunity and convenience of buying coverage through payroll deduction at work to help maintain financial and physical well-being. • For example, for a little extra money that's simply deducted from your paycheck each month, you can purchase short term disability insurance that will help offset loss of income if you are unable to work due to sickness or injury. You can choose supplemental insurance to cover co pays, deductibles or other costs of care not covered by your regular health insurance. And benefits are paid directly to the employee, so you can use the money however you need to. • Most people don't plan for loss of income, or for expenses like childcare and travel that are necessitated by illness or injuries but not covered by medical insurance. Yet studies show that unexpected illness and injuries account for more than 350,000 bankruptcies every year. By enrolling in these voluntary benefits, you are rewarded with greater peace of mind. As an added bonus, the premiums for most voluntary benefits are paid using pre-tax dollars 182 46 Voluntary Plans ■ Enhanced Vision Plan • Trustmark ❑ Accident Insurance ❑ Critical Illness Insurance w/ Cancer • Short Term Disability Insurance • Whole Life Insurance ❑ Interest Bearing ❑ Long Term Disability Rider • Term Life Insurance • Flexible Spending Account (FSA) ❑ Dependent Day Care ❑ Unreimbursed Medial • Preferred Legal Plan • Group Auto Insurance ■ AIG Retirement • Pet Insurance 183 47 • BuyUp Vision Plan City ofPta ,t Un tedH ea CI thcar Enhanced Buy Up Vision Pian Vision BenefitSummary Benefit Plan Year 10/112017-313112020 Cuskirnier Service and Provider Locator(800)638-312{ tnytthwision_cam U&tedHleafthcare vision has been trusted for more than 50 years to&Ever affordable,innovative vision care salaatans to the nation's leading employers through experienced,customer=focused people and the nation's most access/le,dirersiled vision care network Ion etwork,covered-in-full bend(up to the plan allowance and air applicable cupari)include a comprehensive exam,eyeglasses With standard single vision,lined Vocal,Erred trifocal,or lernficular'fenses,standard scratch-resistant coating mid the frame,or contact lenses in lieu of eyeglasses. Exam Wit Materials Benefit Frequency Comprehensive Exam(s) Once every 1t2 months. Spectacle Lenses Once every 12 months Frames Once every 1i2 months • Contart'Lenses in Lieu of Eyeglasses Once every 12 months In-Network Services COPalfa Exam(s) S 1000 Materiels 315 O0 Frame Benefit(for frames that exceed the allowance,an additional 30%&iscoareat may be appFed tGt the overage)' Private IPractice Provider S130110 retalfl allot/mace Retail Chain Provider S130.O0 retail frame allowance Lens Options Standard Scrath-resistant Coating,Polycadronate Lenses for Dependent Chldren(up to age 19) —covered in fu©_ Other optional lens upgrades may Ibe offered at a discount(discount varies by provides).The Lens Options Est can'be found at mvuhrareinn corn Contact Lens Bene fif=(Selection contact lenses refers to our formulary contact Est Conte lenses not rated on the formulary are referred to as norn-selectins.A copy of the first can be found at myi horision.oarn). Selection contact lenses If you Mose dispmsafrl contacts,rap to 4 The fttiingfevralaration fees,contact lenses,and nap to two boxes are indtudded when obtained from follow-up visits are covered in M after=pay Ufa appEcabfel. an in-network,provider_ Non-selection contact lenses An allowance is applied toward the purchase of contact 5125.00 lenses outside the selection.Materials copay(if applicable) is waived. Necessary contact lenses3 Covered in full after copay(if app>ficable)_ Out-of-Network Reimbursements(Copays do riot apply) Exam(s) Up to$0.00 Frames Up to$45.00 Single Vision Lenses Up to$4000 Lined Bifocal Lenses Up to 110. Lined Trifocal Lenses _ Up to, ';0_00 Lentio filar Lenses Up to$00.00 Elective Contacts in Lieu of Eyeglasses` Up to$125.00 • Necessary Contacts in Lieu of Eyeglasses3 Up ta$210.00 184 48 • Buy Up Vision Plan Discounts Laser vision UnitedHealthcare has partnered with the Laser Vision Network of America(MA)to provide our members with access to discounted laser vision correction providers.Members receive 15%off standard or 5%off promotional pricing at more than 550 network provider locations and even greater tfiscount through set pricing at LasikRims locations_For more information,call 1-8t -563-4497 or visit us at w .uhdasikcoom_ Additional'Material At a participating in-network pr der you will receive op to a 29%discount on an additional pair of eyeglasses or contact'lenses,This program is,available after your vision benefits have been exhausted.IP[ease note that this discount shall not be considered insurance, and that UUnitedHealtvcare shall neither pay nor reimburse the provider or member for any funds owed or spent Additional materials do not have to be purchased at the time of initial material purchase. Hearing Aids As a Urritedllealthcare vision plan member,you can save on hagli-quafity'hearing aids when you buy them from hi IReatthlnnovations To find out more go to hilleatthlnnovatians:com.When placing your order use promo code myVision to get the special price discount. '30%disccur t available at most part;xipating in-nOivoirk,prrnrader taxations:May exclude certain fie manufacturers.Please verify all cfiscaunts with your,prarider. 2Coratact(lenses are in leu of eyeglass tenses char eyeglass frames_Coverage for Select =tact lenses does cot apply at Costco,Walmart or Son's Club locations.The allowance for Nan-selection=tact applies lamateria`s,.No patois nfll be exhdusrrely applied lathe Ong and evatua5on. Necessary contact lenses are determined at the provider's dis+rretron for one or more of t e following cont ions:Feawing cataract surgery inhout intraocdlar lens implant;to correct extreme vision maxis that cannot be correct-id viva eyegtess lis andf r tam ; cern In conditions such as ardsometropia, keratoconus,irregular corneaWasligrnet5srn.aphakia,ttaaat detour or corral dafcrrrnly.i f your porkier corsiders your oantac necessary,you should ask your pro.ider to contact thvteeleaIthcrare vision cortm-isvg the reimbursement that Unrled2ieencare welt mate(before you purchase ouch contacts. !important to Remember IIIn-Network •Alavays identify yourself as a Uniiadliealthwre vision member when mak ng your appointment This will assist the provider in obtaining your benefit information. •Your participating provider will help you determine Which contact tenses are available in the Unitedl4eallfacare selection. •Your$125.00 contact lens allowance applies to materials_No portion*11 be exclusively appbed to the fitting and evaluation.Your material copay its waived when!,purchasing non-selection contacts, •Patient options such as UV coating,progressive lenses,et,which are not cove,may be available ata discount at participating providers.The Lens^Diptions list can be found at rrrryss"hcvision.com. Choice and Access of Vision Care Providers _ - - UnitedHea7thcare offers its vision program through a national network including both private practice and retail chain providers.To access the Provider Locator sena or fora printed directory,visit our website rnytrhavision.cor s or call OM 638-3120,24 hours a day,seven days a week.You may also view your benefit,search for a provider or print an CCD card online at myancevisinn_corn. Retain this iUnitedHealtthcare vision'benefit summary which includes detailed benefit informaion and instructions on how to use the pprogram. Please refer to your.Certificate of Coverage fora full explanation of Iberref . hi-Network Provider-Copays and iron-convered patient options are ipaid to provider by program participant at the time of service. (hit-of-Network Provider-Participant pays full fee to the provider,and Unitedtlealthcare reimburses the participant for services rendered up to the maximum allowance.Copays do not apply to out-of-network benefit_All receipt must be srahrmitted at the same time to the following address:UnitedHealEhcare Vision,Atm.Claims Department,P.O.Box 30978,Salt Lake City,UT 84130.Writen proof of loss should be given to the Company within 90 days after the dale of loss_If it was.not reasonably(possible to give written proof in the time required,the Company will not reduce or deny the claim far this reason.However,proof must be fled as soon as reasonably possible,but no later than 1 year after the date of service unless the Covered Person was legally incapacitated. Customer Service is mailable toll-free at(800)638-3120 from 8100 airs.toll:00 pm.Eastern Time Monday through Friday, and 9:00 a.m.to 6:30 p.m.Eastern Time on Saturday. This Benefit Summary is intended only to(highlight your benefits and should not be relied upon to fully determine coverage.This benefit plan may not cover all of your healthcare expenses.More complete descriptions of benefit and the terms under which they are provided are contained in the certificate of coverage that you will receive upon enroll-mg in the plan.If this Benefit Summary conflicts in any way with the Pokcy issued to your employer,thePofrcy shall prevaiL • 185 United}ieafthcare vision coverage provided by or through UnitedHealtthcare'Insurance Company,located in Hartford,Cotirecbout,UnitedFtealthcare Insurance Company of New York,(located in Ilslandia,New York,or it aftlliates.Admiiiistaative services provided by Speetea,(Inc.,Linked!Health.Care Services,Inc.or their affiates. Plans sold in Texas use poky form number VPOL06.TX or VPOLI3TX and associated COC form number VCOC.INT_0S_TX or VCOC.CER.13.TX.Plans sold in Virginia use pokey form number VPOL.O6-VA or VPOL.I3.VA and associated COC form number VCOC.INT.O6.VA or VCOC_CEIt13.VA Trustmark — Accident Policy Sometimes life can take a tumble. o You do everything you can to keep your family safe, but accidents do happen. When they do, it's good to know you have help to manage the unexpected bills that come with them. o Trustmark Accident insurance is designed to cover unexpected expenses that result from all kinds of accidents, even sports-related and household mishaps. It provides cash benefits to cover things your primary health insurance may not, such as: o Deductibles • Copayments o Transportation and lodging costs o Everyday bills and more o What's more, your benefits come directly to you without any restrictions on how you can use them. You can't predict when unexpected accidents will happen, but you can help protect your family from the expenses accidents bring with them. o Trustmark's voluntary Accident insurance helps provide a financial cushion to help you take care of bills, so you can take care of each other. o It's that simple. 186 50 1 . , , . 1 Trustmark — Accident Policy Schedule of Benefits' Effective 8/1 rim Accident Insurance Provides 24-Hour Coverage Benefit Amount I Benefit Amount Initial Care injuries Hospital Benefits Fractures Admission Benefit per admission) 53;200 Open reduction up to 515,000 Confinement Benefit(per day up to 365 days) $500 Closed reduction up to 57,500 ICU Benefit(per day up to 15 days) 51,000 Chips 25%of dosed amount Emergency Room Treatment 5150 Dislocations Ambulance Open reduction up to 512,000 Ground 5600. Closed reduction up to 57,500 Air 52,500 Laceration 55041,000 Initial Doctor's Office Visit $200 Bums Lodging(per night up to 30 days per accident) $200 Fri amount for _ Third-degree 35 or more sq-in. 525,000 Surgery Benefit Third-degree 9-34 in. $4,000 Se Open,abdominal,thoracic 52,000 Second-degree for 36%or more of body $2,000 Exploratory 5200 Concussion $200 Blood,Plasma and Platelets $600 Eye Injury Emergency Dental Benefit $150 Requires surgerygery or removal of foreign body 5400 Extraction $450 Ruptured Disc 51,000 Follovv-Up Care---'---- Loss of'Fmger,Toe,Hand,Foot or Sight Loss of both hands,feet sight of both eyes Accident Follow-Up Treatment 5200 or any combination of two or more losses 530,000 Physical Therapy Loss of one hand,foot or sight of one eye 515,000 Up to six visits per person per accident $100 Loss of taro or more fingers,toes or any Appliance --- 5250 combination of two or more losses $3,000 ---.-----. Loss of one finger or one toe 51,500 Transportation Tendon/Ligament/Rotator Cuff Injury 100+smiles,up to three trips 5600 Repair of more than one $1,500 Prosthetic Device or Artificial Umb Repair of one $1,000 More than one 52.000 Exploratory surgery without repair $200 One_____-- —•—____• 51,000 Tom Knee Cartilage 51,250 Skin Grafts 25%of burn benefit Exploratory surgery 5200 Accidental Death •----� Wellness Benefit �----•--- Employee - $100,000 Two per person annually 5100 Spouse2 550,000 Routine physicals,immunizations and health screening Child 525,000 tests.60-day waiting period applies. Accidental Death-Common Carrier Employee $200,000 $ Spouse2 $100,000 Type of Coverage Bi-Weekly Rate(26 per year) Child 550,000 [Employee $ .50 Catastrophic Accident (Employee and Spouse $16.64] Employee $150,000 [Employee and Children) _ 522.92 Spouse 575,000 �� - Child $75,000 k.!!91 ---- -- � Tamil are p gable oa f as to resift al o cavern=get finals reap pal kf lite cal afford tenefts rrsrf 6e oft*in son strtes.Nast berms are pad once pet perwm per mewl ar,073011 unless ciente estri la surae struts,spare,&cot proem dell trim From rt 187 51 Trustmark — Short Term Disability Imagine life without a paycheck. o You count on your paycheck to provide the things you need today and to achieve the dreams you have for tomorrow. But, what would happen if it were suddenly taken away because of an unexpected injury or illness? Think about it. a 75% of Americans live paycheck to paycheck. n Unexpected illness and injury cause 350,000 personal bankruptcies each year. o More than 70% of American households rely on two incomes to make ends meet. o Voluntary Disability Income insurance replaces part of your paycheck when you are disabled and unable to work. It can help you meet financial obligations when you don't have a paycheck coming in. n What's more, your disability insurance benefits are yours to use any way you want. Use them to help with: a Rent or mortgage n Credit card and automobile payments a Child care and housekeeping • Medical insurance co pays and deductibles a Bottom line: Disability Income insurance helps protect your financial future by going to work when you can't. n It's that simple. Why do you need it? a Take a moment now, to think about life as you know it. Then ask yourself this: a If you get sick or hurt off the job, how would you manage life without a paycheck? a How long could you go without a'paycheck? • a Would you be able to pay your mortgage or rent? a Could you afford the new expenses that come with disability? 188 52 Trustmark - Short Term Disability Why do you need it? Total disability defined' " Take a moment,now, to think about life as you During the first year of disability,totally disabled means know it. Then ask yourself this:If youget sick you are: or hurt off the job,how would you manage life • Unable to work at your job without a paycheck? • Not working at your current employer • How long could you go without a paycheck? • Under a doctor's care for the injury or covered sickness causing your disability • Would you be able to pay your mortgage or rent? After the first year of disability,totally disabled means • Could you afford the new expenses that come you are: with disability? • Unable to work at any job for which you are qualified by reason of training,education or experience • Not working at a gainful job for pay or benefits • Under a doctor's care for the injury or covered sickness causing your total disability Tkisnk Abouf i.4- ` i n • 7.52 °f Amerieans live Payekeek 4_. Payheck.' hUnexPce{ed illness end injury cense 3gp,000 personal ` 4 j� s ` 7 -1 bankrupfeies cock ycar-3 More f kart 707 °f Aneriean h°asekolds rely °n r fwo incomes •l-o make ends w,ee{." Definition may vary by stole.See your potty or certificate for complete defirtnoainyour slate. How.Disability benefits add up Getting Paid in America survey,2008 Council of Disability Awareness,2009 ‘LIMPIs Life insurance consume studies,2010 Disabifiry Insurunce Awareness Month Example:$1,000 monthly benefits I Jake ruptured a disc and continued to be disabled. after his elimination period for another two months What's covered? and 15 days. Total disability due to: Benefits Paid • Non-occupational sickness Jake's benefits following his • Non-occupational injury elimination period and first $1,000 • Pregnancy(10 months month of disability after effective date) Jake's benefits for his second • Complications $1,000 of pregnancy month of disability Benefit poymeras subject to Jake's benefits for his last $500 ramsand ton torsdc 15 days of disability Pre-existing(orations may ep4• qr A A r `- .: Total Benefits Paid' $2,500 „for-• • ,Benefit pod may vary.See your poky/confute f tate for details. 189 53 Trustmark — Universal Life Events fi:r •. K : ,•.., ---"`"4-0-,,,,_ * 2'i " r - g�aq�) j r VVV 1."/ .,-, .. �r I .11 Kr r ll i eilli,4 ,... - /11- ev" i_lik , 7 mer_ it- fa / .411;.`". .*i..., fiveri9 life I (/„.1, 1104'.,_,/ ‘ ,4t1 lass a. s+or . You have a picture of the way you want your That's when Trustmark Universal LifeEvents°insurance life to go. can help.It can help you live your story,your way. Now imagine if something happens that not only l changes your picture,it changes your life story. What is Universal LifeEvents? How does it work? LifeEvents is permanent life insurance that helps shield With LifeEvents,benefits can be paid under the Accelerated Death Benefit Insurance Rider,under the Long-Term Care your family from financial hardship if you or your Insurance Rider,or as a combination of both. spouse is suddenly out of the picture.It's that simple. Accelerated Death Benefit Insurance Rider c The main reason people have life insurance is for the death LifeEvents: A. 4 benefit.A death benefit puts money in your family's hands • ..' quickly when they need it most.It's money they can use • Helps provide permanent financialany way they want to help with expenses such as: protection i° \s o--"'",. • Funeral costs • • Is a financial tool that helps you Rent or mortgages • A college education for your children manage life at every stage— �• ' r/ or grandchildren from supporting a family to *:_ 1 • Household debt sending your children to • Retirement and more college to the need for ?'' long-term care _ ,i Long-Term Care Insurance Rider � t This benefit makes it easy to accelerate • Builds cash value over time part of your death benefit to help pay that you can access for ``''. i for home healthcare,assisted living, life's challenges and life's `,�i , ' nursing care and adult day care opportunities 1, services, when you are chronically 1 ill should you ever need them. (1. . . V*.l....4i) ----y, 190 54 Trustmark - Universal Life Events 0,-,„. . _ Why do you need it? Take a moment,now,to think about '� 1 171911, r'* f ) life as you know it.Then ask yourself . ' . ? .11.4.4. �dl this:If something happens to you, .. " `•• • ,t i' what happens to your family? IP ri _ 'is,.•. `r ......-- IP ii .. 41 •Will they be able to keep your home? iyi (�' .''�* t • �•� '�.�. ; When someone dies,family income i +t, . AV�� , '�' i .� �y : - ^.•4 may be significantly reduced. • r' 41,:,-• ^' or • How much would your children's # a • . + lives change? _ . Without you,how will their college 1 S 1 { ..... `1 ,,,,,. dreams come true? f. t r - :1� _ _— — _.— • If you need long-term care,will �'' _ {� _ ` your choices be limited? �.--a'i i >✓�s"' Long-term care maybe needed . � at any age,and paying for -0-tn�- �k s---t--k7-e--s— ` frpt� ,r___,--.-- it Y it yourself may deplete ,���-"S 5tX011V 1 .7 r0'nWw-J - -f- your savings. reGovet! , _ ;`" t v' - '2009 Mettle Finandal Impact of Premature Death Study, ' " hep://www.metfdacam/about/press•room/usprens-eleoses/2009/utdex.html?compD-15908 The LifeEvents advantage * How Living Benefits add up ' LifeEvents is designed to match your needs throughout your lifetime.It pays a: Example:$100,000 Maximum Benefit • Higher Death Benefit during working years when Death Benefit Amount expenses are high and your family needs maximum protection.Then,at age 70 when financial needs are Long-Term Care Insurance Rider(LTC)t typically lower,the death benefit reduces to one- Pays a monthly benefit equal to third;however,your benefits for the Long-Term Care 4 percent of your death benefit for up $(00,000 Insurance Rider never reduce. to 25 months.The Long-Term Care Insurance Rider accelerates the death • Consistent Level for Long-Term Care Insurance benefit and proportionately reduces it. Rider during retirement,which is when you may be —•----•----------.•-•-•--_�_.._____.._—_—__.._—_...._ susceptible to becoming chronically ill and may need Benefit Restoration Insurance Rider long-term care services. Restores the death benefit'that is reduced by the Long-Term Care S/OO 000 LifeEvents in action Insurance Rider,so your family receives ' the full death benefit amount when they (Example:35-year-old,$8/week premium,$75,000 benefit) need it most. .....__.._...._._.___•-.--------------•-•-•------------------------ Before Age 70 Age 70+ Total.Maximum Benefit Living Benefits may double the f.00i000 value of your life insurance. Death Benefit$75,000 LTC Benefit 575,000 ' LTC Benefit $75,000 Death Benefit2 $25,000vW The Long-Term Care(11(1 Insurance Atcelerated Death Benefit Rider is an acceleration of the death benefit and is not tong-Term Cate Insurance.It begins to pay after 90 days of Death benefit reduces to one•tti d at the beer of:age 10 or the 1 5th certificate confinement or services,and to qualify for benefits you must be chronically it.Preexisting anniversary.Issue age is 64 mid under. condition imitation may apply.Please consult your certificate for complete details. 191 55 Trustmark - Critical Illness Insurance Life can change in an instant. a Facing a critical illness is difficult. There is so much to think about — from deciding between your treatment options to managing your family's everyday • needs to maintaining your financial and emotional stability. What's covered? a Heart attack a Stroke a Invasive cancer (excludes most skin cancer) • a Renal (kidney) failure a Occupational HIV a Blindness a ALS (Lou Gehrig's disease) a Transplant of a major organ a Paralysis of at least two limbs a Carcinoma in situ (25% benefit) a Coronary artery by-pass surgery (25% benefit) a Benefits may vary by state and certain benefits may not be available in all states. Trustmark's voluntary Critical Illness insurance helps provide immediate financial relief from the overwhelming expenses of a serious illness, such as a heart attack, stroke or cancer. It pays a lump-sum cash benefit when you are diagnosed with a covered illness to help ease your financial worries. In short, Trustmark Critical Illness insurance helps provide a financial cushion to help you manage your illness, your way. It's that simple. Y p • Why do you need Critical Illness insurance? Take a moment now, to think about life as you know it. Then ask yourself this: If you were diagnosed with a critical illness, how would you manage life during your recovery? Who will care for your children? And your home? What are your treatment options? Are there other doctors, specialists or hospitals outside your neighborhood available to you? If you were unable to work during your recovery, would you need additional funds? 192 56 Trustmark — Critical Illness Insurance Why do you need it? Take a moment now, to think about life as you know -Tkirnk �bo it. Then ask yourself this:If you were diagnosed with u� a critical illness,how would you manage life during Eves-y 90 seconds your recovery? f• s°e.eoNt iN eke S Iles:orviobutt:ikur:eps+se.y.rittwr4-eek_e • Who will care for your children?And your home? aff er�,a{be • What are your treatment options?Are there °� a �uavftes of other doctors,specialists or hospitals outside were insured.' your neighborhood available to you? ,• If you were unable to work during your recovery, 'Me American bums!of Medicine,August 2009. would you need additional funds? What's covered?2 How do you know if your treatment • Heart attack • Paralysis of at least is right? Best Doctors° can help. •Stroke two limbs Best.Doctors°is a company that provides medical • Coronary artery by-pass decision support • Renal(kidney)failure pp through an online network of more than surgery(25%benefit)3 50,000 world-class medical specialists.Whether you need • Blindness • Invasive cancer(excludes help resolving conflicting diagnoses,finding a specialist •ALS(Lou Gehrig's most skin cancer)3 or knowing what questions to ask,Best Doctors can help disease) . Carcinoma in situ when you need it most.Membership is automatic at no •Transplant of a (25%benefit)3 additional cost to you while your coverage is in force. major organ 1 'Please consult year polky/group certificate for specific covered conditions and details. I If the insured receives the benefit for coronary artery bypass surgery or carcinoma in situ,the remaining benefit will be available for another covered condition,or double benefit if included,Most skin cancer is excluded. Health Screening Benefit' Double benefitt To help you stay well,the Health Screening Benefit What happens if you experience a second covered pays the cost of one screening test or immunization per condition?With the purchase of the double benefit you calendar year(up to$50 or$100 maximum).Some of can receive a second cash payment equal to the first.The the many screening tests covered include: second illness must be a different covered condition than • Low dose mammography • Stress test the first and must occur at least six months later. • Pap smear(women over,18) • Colonoscopy • Serum cholesterol • Bone marrow p ,' • Prostate specific antigen • Chest X-ray T Pre-Existing.Limitation7 r s In most states,no benefit will be paid for any condition �,.. . caused by or resulting from a pre-existing condition, 1 y which vary by state. tetL1 A wailingperiod m o may apply,which may wry by stole.Only tests performed after the applicable wailing period qualify for reimbursement. Pre-existing Imitations may vary by state. 'Separation periods between diagnoses may apply.Not aveloble in all states. t Please consult your policy/group certificate for complete details. 193 57 Term Life — Reliance Standard Benefit Amount • Employee and Spouse:Choose from a minimum of$10,000 to a maximum of$500,000(in$10,000)increments)for yourself and/or your spouse. The benefit amounts chosen need not be the same. Eligible Dependent Child(ren): Age 14 days to 6 months:$1,000 Age 6 months to 20 years of age(26, if full-time student):choice of$2,500,$5,000,$7,500 or$10,000 Choose one benefit amount for all eligible children in family. Guarantee Issue (Initial Eligibility Period Only) Employee: Under age 60:$100,000 Age 60 but under age 70:$10,000 Age 70 or older:none Spouse: Under age 60: $30,000 Age 60 or older:none Guarantee Issue is subject to underwriting rules and is not available in all circumstances. Features: ■ Conversion Privilege a Portability ■ Waiver of Premium Exclusions Death by suicide is not covered during the first two years an issured's insurance is in force. Insurance coverage is incontestable after it has been in force tow years during the insured's lifetime,except for nonOpayment of premium. For a comprehensive list of exclusions and limitations,please refer to the Certificate of Insurance. The Certificate also provides all requirement necessary to be eligible for coverage and benefits. 81-WEEKLY PREMIUM RATES Dependent Children Bi we k y PER 510,000 OF LIFE INSURANCE (6 months to age 2 6) Cost Age(last birthday Rate Benefit- as of the anniversary date) $ 2,500 $ .33 Under age 30 $ -40 5,000 A9 30-34 .42 7:500 .66 35-39 60 10,000 .83 40-44 .97 45-49 139 50-54 2.54 55-59 4.20 60-64 5495 65-69 8.08 70 and Over* 15.44 194 58 Flexible Spending Account Your Dependent Daycare Flexible Spending Account Can Save You Hundreds of Dollars Are you paying for the care of dpetnrdent dhvldlren under dm • age of 13 or dependents of any age Who are un lbte to.care for `� ' � � then rves?NOW you can pafyrfcryourdependents'daycare t while yoiuare atwrmtkcorschool!and sawagrgoReGntaxes on r ,. wry dorIar. " • (I6 Partes ntO itrr Rest enrdllintram FLan ittringpourbenefits opmi enplaned mind are excise the Rtrray: Pagzsayou mnamrtysm riu:3'trn p assftfor claprzne.Thearinnill crmn:mum aJhnusdhdld anal se dbensrffiebraLsecial ssninefea zendeissgoAll:r,ruc c s,filbig #nj each set mid!upta yo n Qiernmed canamunar muslin t r„una• cruFILehutildder tyle aurvfeastefor sgsedhllndes. f TRW$?i lfixdal .......................... lin-free an Enures aur aartill al l trn ur di=nt tar aosdurrt Chao�,ymiram>gumi dk ' ! IPaF' � depen � �rsm�am xnallsd�amr_s batbn>r:,lftrie miy,sues}rare prodder and elhmstihniit a ir!dues Farcrsmliurseme it changalt exit rsyi drangn Theptlana dentinga incurtsztyrsacmarinihfm the din tuFinviihrs,4-nu ;rnnr .�u.,•.2you iinyr�uran:muntatdetinmayy rd` .Iffyouri imi nr fur a aati�f;erytarwrtli" *untie trdhrxeiin mount,t'he tut cf$our china kvill pi:At/h n a•e=My' aurrzr; isatfeed. . .......................... Urn=Truman FluidalWilla yen ardynursgaraaramar, Esamptesor Eitoble IlDgdenr3ECIT ee pe'nsesnta/11=rlt dissisasa emcee tCr_cerci. . . 'tsuits your sin:Mica t?yn>i,sutiics • Iki!hamsItatrysitter • 'Gelid!t alter groat tsmmLarpfaat3:ddtrr ; Nursrays lmi . E1dern�tz (care aiiannrnm:pbnyaa:.*h.nur as. CLOYS • LasitEeyi'Ip-4:;.w 5fianyumniamplalind'tivpur Sumner day canny) • Eldtedaprare mud]num=mt.* Rtusi uk:!iamauyrninaaa. arbtrair d brims ham Fla inthE MP tstatertvwld do'ct Vd cora aza.crna:. CHARDS NYDER' 1p, remYixiuedis 195 59 FSA with Debit Card Ws Easy to Manage Your Account Chard Snyder offers you thetoors you need to aan make iuting your Flexible Spending Accmunt easy. 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I:: Nu matter ritnrrimuntbna 2 Chan tle cenuitestratynu prase k.VMS r • ffp111JJ l - aukecl tedmi les receipt,rapflanatica cf tarcentsfOR,cr Milan prod.Veer ince printiA-ere ddie di the 491FeTISC,2 030),CSC at(MONA 1kiL44Itie.r4 di theitetn the'name af the stare 4111.-'f raf • cr pects+3.xatui the=aunt you jpiit Yam coperne in=ham CIEELICTutICIIITiimen time Fesio?' 1 named kr ravrivihmilkmplanectrepratiEdimeftweusstsnartrrt Otmccripsapermntamsz pnut Finn_ rev • 198 62 FSA — Estimate Your. 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Call Today! it _,_„:„.- 0 ____.--- - ,..,,,- ` pp. 1 800 'GET-MET J ( 1-800-438-6388) 203 67 Veterinarian Pet Insurance I 1 , _ , ,, hoo , . pet health plane m r , fir. .. t fit your needs : , /„ 44_� F aottt t�lyilaUoeyvaictet`a Rdto�t choice to America for M insurance \ � y *-t- a Major Medical Planik Ma or Medical Ptan + Pet Wellness B tsics' . a comprehensivecompreher'tsi+ve ev=eryday Cara ilizoi ,° eitness coverage" s19d Si 3'I a ydicck' Sgr o.cne " p�sycfiect' R Y ck � Y ci .a(' ar 5 or or 41Iatttirittt' . itttOytth' tt 8Intortth' nodded t,irstiurievz faros. Nr V casting broken bows catnrnori Ohioan, ; WictvQina ear irdptl ens;ra'. %. I ✓ vomiting end draiitt'ee Sedousdchronic Obsessses. irnizidirpcomet chetrctos I .V endenergies Handitary pandittein' if V Procedueoshon4a4.irCtvdir , V #r r�+trsEaits:Melt and V Wehooss sorvkas..W+c$txrnh morns,tnnationtand V Ossa/ho.rtx}aa to rearangveS S2s0 tor readied claims Annual deductftalc tzso so For rrannon claims Sample reimbursement ESN Esram„X.r7YS,sureary„treatment ss5oo Tr T ',' s7 a �aectdrriradsaved.Cauyrsai 1 When Biscuit needed ; Eiiio e 1 'via+twrree emergency surgery after eating alae*-- 0 wrudtwepoi....:s+ a handful of pebbles,the mos— ,iMil dratah r Major Medical plan reimbursed bent— ,` m„.,r.ar,.„tt4,K sl., a . ,t � 100%of her vet bill. wasa,wase<,..144/.et-,ownrn.,r»-144vv,a so Sign up during open enrollment and receive your discount 877-Pets-VPI • PetsVPL.com Veterinary s i Nationwide vPet.Insurance 6«1 add at 144.4.4,44,40"."..”`041.4.,1 'Vmr+s-a+ait kw*mo 011.01.dne pot Wei.ellk,et V,wMxiil.tto.44*Val cif wallKt1Rf..sy it%nen xawmlw.arra)liKW P.r..^ttidcf..ilwimimmir ass*ww PAP fRtteftX1.0 r 0144it,"InZitert te44.44E2014f.4 KAMM$It efy.•NMV Gbssot4,1,0444109,14:GWeM✓&.fflwewrung4.4.61.4,444 A/SW 1...1141,410A),.. .14,4Ste FkhSl bra&fendRrrr1 t]IWige40 YW+nD1 IxS.64.rt.Iltotxt tano0ev40.1e41.4”MMMn 1M 40.44peo.t0.14,144m0ryNl JO/p✓.i r045ii4*avows sin VW Nava 44'<7,0 4444,i.01c:eM...mlfi1Fsrlw7M wve.nt.caltimw rtAa.EMkt 0,204 t!'3C:: 44.1.f,trR�f.FisSip4rt adert 9 Pn .ir'piiaiur441 4,,4A +4....1kyna..aaMTMAlnw ^drM:Ivo Yrs S'Rar Xi'tiilh.Yi7 VH me mem ocr.t ar artiws;'#'rtrerwy Gula,^,COI*vowel ter ru4441r34,(1m044,xmxnzw4.C*auctre, 44vnieiv are. 204 a 68 AIG Retirement (457b & Roth 457b) We understand how important financial security during retirement is to you. By partnering with AIG Retirement, we are taking steps to help you prepare for the future ■ Tailor retirement income to meet your needs ❑ Wide array of investments from well-known mutual fund companies ❑ Experienced and trusted financial advisors who are dedicated to providing personal, face-to-face service ❑ Access to comprehensive planning and investment education ❑ Secure account access 24/7 through the AIG Retirement online ❑ No sales or surrender charges on contributions to the mutual funds ❑ Choose, change or stop your bi-weekly contributions at any time. You have a variety of options to turn your savings into a stream of guaranteed retirement income. Guarantees are backed by the claims-paying ability of The Variable Annuity Life Insurance. Company. How to Enroll: Contact the City of Plantation Financial Advisor to set up your account (page 70). Once your account is set up you can log in to monitor or change your account: www.AlG.com. AIG 205 69 Contact Information Contact Department Telephone E-Mail/Website UnitedHealthcare-Medical Customer Service 1-866-633-2446 www.myuhc.com -Mental Health United Behavioral 1-800-888-2998 www.liveandworkwell.com Health United Allied Discount Programs www.myuhc.com Employee Assistance Program 1-800-899-3926 (EAP) Care24 24/7 Nurse Hotline 1-888-887-4114 Dental Customer Service 1-877-816-3596 www.myuhc.com Vision Customer Service 1-800-638-3120 www.myuhc.com Long Term Disability(Reliance Report a claim 1-800-351-7500 www.reliancestandard.com Standard) Reliance Standard Customer Service 1-800-351-7500 Local Office 954-846-7374 Chard Snyder Customer Service 1-800-982-7715 www.askpenny(a,chard-snyder.com Claims Fax Number: 1-888.245.8452 Trustmark Customer Service 1-800-918-8877 Trustmark Enrollment: Innovative Benefits 561-508-9494 cityofplantationna,simplenroll.net 457(b)AIG Retirement Customer Service 1-800-448-2542 www.AlG.com Local Representative: . Steve Sallee 561-684-3775 • Preferred Legal Plan Customer Service 1-888-577-3476 www.preferredlegal.com MetLife Free Quote 1-800-GET MET8 Veterinarian Pet Insurance Customer Service 1-877-738-7874 (VPI) Beverly Ambrosio,Benefits& Human Resources 954-797-2244 bambrosio@plantation.org Wellness Manager Cassie Miller,Benefits& Human Resources 954-414-8878 cmiller(a,plantaiton.org Wellness Specialist 206 70 Additional Resources Department Representative ■ Employee Intranet ❑ Internal on-line resource for P & R Kiera Adamo forms and information HR Beverly Ambrosio • Claim Forms Utilities JJ Ameno ■ Plan Documents Police Deetra Council • Annual Notices PZD Diana Berchielli a Contact Information P1W Darren Brown ❑ http://internal.plantation.org I.T. Cindy Craven ■ Pen & Ink Building Maritza Grajales o Quarterly Employee Fire Cary Blanchard Newsletter Library Meg Knaus • Benefits Committee Finance Linda Murray o Please know your HR Cassie Miller Departments Benefit Committee representative. Eng Judy McBride Should you have any Administration Pam Ponce de Lean questions, suggestions or ideas please let your City Clerk Sarah Fortunate committee member know. P/W Wilma Wallisa P/W Dave Wilson 207 71 Notes 208 72 • Open Enrollment Plan Year 04/01/2020 — 03/31/2021 Enclosed you will find information regarding your options and any actions you may be required to take. 209 OPEN ENROLLMENT - 3/2/20 THRU 3/20/20 Contents • It's Open Enrollment!What should you do? 3 Key Things to Know 3 United Healthcare-What can you.do 4 United Healthcare-Plan Options 4 Dental/Vision .5 Premium&Eligibility for Premium Discount 6 Employee Assistance Program(EAP) 6 Voluntary Plans 7. Buy-Up Vision (Pre-tax) 7 Trustmark(Pre&After Tax) 7 Preferred Legal/Protect My ID 7 Flexible Spending Accounts(Pre-Tax) 7 AIG 457(b) Retirement Plan 8 Reliance Standard 8 . Met Life 8 Veterinary Pet Insurance (VPI) 8 Open Enrollment Fair 9 Wellness Incentives-So Many Choices 10 How to Earn Wellness Paints 11 Marathon eHealth Portal 12 Notice Regarding Wellness Program 13 Protections from Disclosure of Medical Information 14 Notice of Availability City of Plantation Notice of Privacy Practices 15 Premium Assistance Under Medicaid and the Children's Health Insurance Program (CHIP)16 City of Plantation Medicare Creditable Notice 20 Special Enrollment Notice 22 Women's Health and Cancer Rights Act(WHCRA)Notice 22 Page 2 210 OPEN ENROLLMENT - 3/2/20 THRU 3/20/20 It's Open Enrollment! What should you do? Open enrollment for the City of Plantation will run from Monday, March 2 through Friday, March 20. Open enrollment offers employees an opportunity to review their current benefits and consider changes to their coverages that will become effective 04/01/20. Key Things to Know • Employees and/or dependents will automatically be re-enrolled in their current medical/dental/vision plan if no changes are made effective 04/01/20 • Employees must re-enroll if they want to participate in the flexible spending accounts Unreimbursed Medical and/or Dependent Day Care. • Employees should carefully review their current coverage and the open enrollment packet for detailed information. Page 3 211 OPEN ENROLLMENT - 3/2/20 THRU 3/20/20 United Healthcare — What can you do 1. Retain Current coverage: If you wish to make no changes to your insurance, do nothing and your coverages will remain the same. 2. Add/remove dependents: Open Enrollment is the time you are able to enroll/remove eligible dependents without having a qualifying event. The change of dependents may affect your premium.You will need to complete the appropriate paperwork with Human Resources/Benefits. 3. Change insurance plan: The City of Plantation offers two plans under UnitedHealthcare at various costs and co-payments. United Healthcare - Plan Options Covered Services Lption;ll Lption 2 In-Network Benefits Only In-Network Benefits Only Doctors Office Visit $10 $20.00 Specialist office visit,including OB/Gyn 100%after$35 copay $50.00 Preventive Care 100% 100% Hospital inpatient stay,including 100%after$100 copay $200.00 maternity Emergency room visit 100%after$200 copay $250.00 Urgent Care Center 100%after$25 copay $35.00 Outpatient surgical 100% $100.00 Diagnostic x-ray 100% $25.00 Lab tests 100% $20.00 MRI/PET/CAT'scan 100% $100.00 Chiropractic visit *spinal manipulation 100%after$10 copay(max Not Covered 24 visits per calendar year) Chiropractic Visit*massage therapy Not Covered Not Covered Mental health 100%after$10 copay $20.00 individual$10 co-pay group (max 30 visits) (limited 30 outpatient visits) Prescription Drug Benefits $10/25/60-30 day supply- $20/40/60-30 day $30/75/180-Mail order $60/120/180-Mail Order $150-Compound Drugs $150 Compound Drugs Calendar Year deductible $0.00 $0.00 Maximum Annual Out-Of Pocket $4,000 Individual $6,000 Individual $6,000 Family $8,000 Family Page 4 212 OPEN ENROLLMENT - 3/2/20 THRU 3/20/20 Dental/Vision 1. Retain Current Coverage: If you wish to make no changes to your insurance, do nothing and your coverages will remain the same. 2. Change Dental Plan:The City of Plantation offers two plan options under UnitedHealthcare at various costs and co-payments. UnitedHealthcare UnitedHealthcare UnitedHealthcare DHMO DPPO DPPO In-Network Only In Network Out of Network Annual Deductible N/A $50—Single $50—Single $100-Family $100-Family Preventative Services No Copayment 100%of allowable 70%allowable Basic Services No Copayment 90%of allowable 70%of allowable after deductible after deductible Major Services Specific copayment 90%of allowable 50%of allowable refer to schedule after deductible after deductible of benefits Orthodontics $1850—Under 19 70%of allowable 50%of allowable yrs after deductible after deductible $1950—Over 19 yrs $1500 lifetime max $1500 lifetime max Plan Year Maximum No maximum $2,500 $2,500 benefit Page 5 213 OPEN ENROLLMENT - 3/2/20 THRU 3/20/20 Premium & Eligibility for Premium Discount Your insurance contribution: Emp+ Active Employee Deductions Single Children Emp+Sp Family Option 1 with PPO Dental&Vision $42.39 591.46 I $95.84 $143.95 Option 1 with DHMO Dental&Vision $42.39,__586.91 I $90.64 $133.34 Option 2 with PPO Dental&Vision $39.38 S85.43 $89.49`. $136.32 Option 2 with DHMO Dental&Vision $39.38 580.88 $84.311 $125.72 Receive a Discount! Complete the `3 Steps to Wellness' Emp Active Empjyee Deductions Single- _Children I-Em -__±.5s) Family tion 1 with PPO Dental&Vision I $15.42 $52.92 $56.12 $93.17! ption 1 with DHMO Dental&Vision I $15.42 _$48.37_-I $50.95 $82.57 ption 2 with PPO Dental&Vision I $14.32 $35.32 I $36.86 $58.68 ption2 with DHMO Dental&Vision -_-I--$14.32 _$30.76 I-- $31.69 $48.071 Employee Assistance Program(EAP) Managed Care Concepts EAP provides professional and confidential services to help employees and family members address a variety of issues: • Marital/Family/Relationship issues • Stress • Depression • Personal or Work-related issues • Drug Abuse • Alcohol Abuse • And much more EAP benefits are 100%confidential,available for employees and their dependent family members at NO COST and is easily accessible 24/7. Contact Human Resources/Benefits for more information or call Managed Care Concepts toll- free at 1-800-899-3926. Page 6 214 OPEN ENROLLMENT= 3/2/240 no 3/240/2® Voluntary Plans Buy-Up Vision (Pre-tax) /f'` Employees have the option to 'buy up'to a higher level of benefit. The Buy-Up vision provides additional benefits such as: Frames annually and higher allowable . . up for frames. To Enroll: Contact Human Resources/Benefits to complete enrollment form. � � Trustmark(Pre&After Tax) Voluntary products are designed to help with those extra expenses that many don't have in their budget after an unexpected event like a cancer diagnosis, a 0111 --' heart attack, disability, or a trip to the emergency room. Voluntary benefits can ® give policyholders the peace of mind to know that they have a check in the mail ,\ when they need it most. • Accident Insurance • Short Term Disability • Critical Illness/Cancer • Whole Life Insurance w/Long Term Care To Enroll: , Call: 561-508-9494 or online at cityofplantation@simplenroll.net 4-...:f.--.._.- Preferred Legal/ Protect My ID Enroll in One or Both at a discounted rate. ,1 211111*11111" • Unlimited legal advice k— - �-- ._ -' • Simple Wills for member and spouse • • Legal forms • Many more services available included To Enroll: Contact Human Resources/Benefits to complete enrollment form Flexible Spending Accounts (Pre-Tax) With the Flexible Spending Account there are two ways for you to save on taxes �' which is money in your pocket: • 1.Unreimbursed Medical Use your Pre-Paid Benny card to pay for services from medical providers such as hospital, clinic, doctor or dentist as well as your prescription medications. 2.Dependent Day Care Are you paying for the care of dependent children under the age of 13 or dependents of any age that are unable to care for themselves? Using the Flexible Spending account allows you to save 25-40% because you don't pay federal or social security taxes on the money you spend for daycare. Page 7 215 ®PEN C ]RO'LLM Q 3/2/2® 7N12111 3/20/20 To Enroll: Contact Human Resources/Benefits to complete enrollment form AIG 457(b) Retirement Plan etc =_ e • •owliVi,�' `T1 ; The City of Plantation through AIG Retirement Plan offers you tax advantages to build savings towards your retirement. Start now with the flexibility to stop/start { your deductions at any time. To Enroll: Contact Steve Sallee, Financial Advisor: Cell: 954-702-1362 --Work: 561-684-3775 i-avvfts, Reliance Standard Additional Term Life policies are available through Reliance Standard. Enrollment forms and additional information is available in Human Resources/Benefits. • •.,,, To Enroll: Contact Human Resources/Benefits to complete enrollment form. _. _--- Met Life Offers Group Auto Insurance to employees For additional information contact Met Life at the phone number below or Human Resources/Benefits. 414 To Enroll: Contact Met Life at 1-800-438-6388 Veterinary Pet Insurance (VPI) VPI provides coverage a variety of veterinary expenses. From accidents and illnesses to optional wellness coverage. Provides reimbursement for the preventive care necessary to keep them healthy year after year. Policies are s.# available for dogs, cats, birds, reptiles and other exotic pets. To Enroll: Contact 877-PETS-VPI or online at: PetsVPl.com Page 8 216 OPEN ENROLLMENT - 3/2/20 THRU 3/20/20 Open Enrollment Fair 4 Oen Enrollment Fair March 18, 2020 7:00am— 12:00pm Central Park Gymnasium 9151 NW 2nd St Plantation, FL 33324 Your opportunity to make changes to your Plans. ! Medical Dental Voluntary Benefits. ! i . _ . _ . _ . _ . _ . _ . _ . _ . _ . _ . _ . _ . _ . _ . _ . _ . _ . _ . _ . _ . _ . _ . J Vendors will be on-site from: • linitedHealthcare • Preferred Legal • General Retirement Representative . We Florida Financial • Employee Health and Wellness • Tnistmark Care Center • EAP-Managed Care Concepts • Human Resources • Chard Snyder-FSA • AIG 457b&Rothb Retirement • And More!! The Biometric Screening will NOT be offered at this event, will be available at the September Health Fair= Door Prizes for All Attendees 1 111111111)°.111.1111111111 For additional information or to enroll please do not hesitate to contact any of the below: BEVERLY AMBROSIO CASSIE MILLER BENEFITS & WELLNESS MANAGER BENFITS &WELLNESS SPECIALIST 954-797-2244 954-414-8878 BAMBROSIO@PLANTATION.ORG CMILLER@PLANTATION.ORG Page 9 217 OPEN gag RO LLmagr 0 3/2/2® ¶G3 tLJ 3/20/20 Wellness Incentives- So Many Choices Plantation Parks&Rec Walmart Regal Movie Gift Card Winn Dixie Payroll Incentives for the 2020/2021 Plan Year Preserve Target .Golf Course .. Publix ,Shell Gas Home Depot` Page 10 218 • OPEN ENROLLMENT - 3/2/20 THRU 3/20/20 How to Earn Wellness Points How to Earn Wellness Points 5 Points = $75 10 Points = $75 1 Biometric.Screening..... ,... Point Health Risk Assessment'(HHRA) 1 Point 1 Comprehensive Health Review(CHR) .......••....,. Point Annual Physical ... 1 Point Preventative Screening....... ......... 3 •Labs Points •Well women Exam •Prostate Exam •Flu Vaccine •Dental •Vision •Dermatology Participation ...................... . Points •Challenges •Wellness Wednesdays •Health Fair •On-line Workshops •Plantation Preserve o Golf Course o Lessons •Plantation Parks&Rec o Fitness/Wellness Classes c Gym Memberships o Sports Leagues c Aquatics Please refer to the Benefit Guide for incentive guidelines. Page 11 219 OPEN C NRO 1 LL[J - 3/2/20 TQu 3/24@/2® Marathon eHealth Portal Employee Health and Wellness care 'Center Access the Marathon eHealth Portal anytime! / te a. far \<,...,./ Features include: Get started today by visiting • Scheduling a ppointments,viewing results, my.marathon-health.com and updating your and secure message your clinician from profile information by clicking on"My Settings any computer,tablet,or smart phone. You can also update your wellness profile by • Vies*ryour results,upcomingappointments, ta'kingtheHealthHistoryandRiskAssessment health goals,and latest news related to CHH RA)within the Questionnaires tab. your health on the customized dashboard. Notsureofyourusernameorpassword?Follow • Review personalized health and wellness the prompts to reset at my.marathon-heafth.com information related to your health goals. • Sign up fortext message and email appointment reminders. Add an icon to your smartphone for quick access iPhone Android Windows Phone Tapthe Share icon in r � 11-1 Tapthisiconiconinihe Tap this Icon icon in the Safaris lower menu bar . j tcp right menu bar lower right of the screen O Tap the Add to Select Add to Select Pin to Start Home Screen icon Home Screen u ked to Homo Sentin Marafin ) rny.marat'hon-health.corn It an Fntr life. .. J Page 12 220 OPEN ENROLLMENT - 3/2/20 THRU 3/20/20 Notice Regarding Wellness Program The City of Plantation has a voluntary wellness program available to all full-time employees. The program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease,including the Americans with Disabilities Act of 1990,the Genetic Information Nondiscrimination Act of 2008,and the Health Insurance Portability and Accountability Act,as applicable,among others. If you choose to participate in the wellness program you will be asked to complete a voluntary health risk assessment or "HRA"that asks a series of questions about your health- related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer,diabetes,or heart disease).You will also be asked to complete a biometric screening, which will include a blood test for glucose,lipid panel,triglycerides,LDL, HDL and total cholesterol. You are not required to complete the HRA or to participate in the blood test or other medical examinations. The employee contribution for medical insurance is 11%of the premium. Employees and their spouse /domestic partners who choose to participate in the wellness program by completing the'3 Steps to Wellness' (Bio-metric, HRA and CHR) will receive an incentive of a reduced employee contribution for medical insurance. Although you are not required to complete the HRA or participate in the biometric screening,only employees and spouse/domestic partners who do so will receive the incentive of a reduced contribution. Additional incentives of up to $150.00 maybe available for employees who participate in certain health-related activities: 3 Steps to Wellness,annual physical, 3 preventative screenings and participate in 3 wellness events/challenges. If you are unable to participate in any of the health-related activities you may be entitled to a reasonable accommodation or an alternative standard.You may request a reasonable accommodation or an alternative standard by contacting Beverly Ambrosio, Benefits&Wellness Manager at 954-797-2244 or bambrosio@plantation.org The information from your HRA and the results from your biometric screening will be used by the Employee Health&Wellness Care Center to provide you with information to help you understand your current health and potential risks,and may also be used to offer you services through the wellness program,such as Wellness Wednesday topics and challenges. You also are encouraged to share your results or concerns with your own doctor. Page 13 221 OPEN ENROLLMENT - 3/2/20 THRU 3/20/20 Protections from Disclosure of Medical Information Protections from Disclosure of Medical Information We are required by law to maintain the privacy and security of your personally identifiable health information.Although the wellness program and City of Plantation may use aggregate information it collects to design a program based on identified health risks in the workplace, Marathon Health will never disclose any of your personal information either publicly or to the employer,except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the wellness program, or as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the wellness program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment. Your health information will not be sold,exchanged,transferred,or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the wellness program,and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive. Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by the same confidentiality requirements.The only individual(s) who will receive your personally identifiable health information is (are) the Nurse Practitioners and the Employee Health&Wellness Care Center Staff in order to provide you with services under the wellness program. In addition,all medical information obtained through the wellness program will be maintained separate from your personnel records,information stored electronically will be encrypted,and no information you provide as part of the wellness program will be used in making any employment decision.The Employee Health&Wellness Care Center has a separate drop line for their Internet and records and is kept totally separate from the City of Plantation.Appropriate precautions will be taken to avoid any data breach,and in the event a data breach occurs involving information you provide in connection with the wellness program,we will notify you immediately. You may not be discriminated against in employment because of the medical information you provide as part of participating in the wellness program,nor may you be subjected to retaliation if you choose not to participate. If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation,please contact Paulina Gainey, Human Resources Coordinator at 954-797-2241. Page 14 222 OPEN ENROLLMENT - 3/2/20 THRU 3/20/20 Notice of Availability City of Plantation Notice of Privacy Practices THIS NOTICE DESCRIBES HOW YOU MAY OBTAIN A COPY OF THE PLAN'S NOTICE OF PRIVACY PRACTICES,WHICH DESCRIBES THE WAYS THAT THE PLAN USES AND DISCLOSES YOUR PROTECTED HEALTH INFORMATION. UnitedHealthcare (the"Plan") provides health benefits to eligible employees of City of Plantation (the "Company") and their eligible dependents as described in the summary plan description(s) for the Plan. The Plan creates,receives,uses,maintains and discloses health information about participating employees and dependents in the course of providing these health benefits.The Plan is required by law to provide notice to participants of the Plan's duties and privacy practices with respect to covered individuals'protected health information,and has done so by providing to Plan participants a Notice of Privacy Practices, which describes the ways that the Plan uses and discloses protected health information.To receive a copy of the Plan's Notice of Privacy Practices you should contact Beverly Ambrosio, Benefits&Wellness Manager,who has been designated as the Plan's contact person for all issues regarding the Plan's privacy practices and covered individuals'privacy rights.You can reach this contact person at: 400 NW 73rd Avenue Plantation, FL 33313, 954-797-2244 fax: 954-797-2727. Page 15 223 OPEN ENROLLMENT - 3/2/20 THRU 3/20/20 Premium Assistance.Under Medicaid and the Children's Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you're eligible for health coverage from your employer,your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren't eligible for Medicaid or CHIP,you won't be eligible for these premium assistance programs butyou may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information,visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP,and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify,ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP,as well as eligible under your employer plan,your employer must allow you to enroll in your employer plan if you aren't already enrolled.This is called a"special enrollment"opportunity,and you must request coverage within 6o days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-4.4.4-EBSA(3272). If you live in one of the followingstates,you maybe eligible for assistance paying in your t� P Y1 g employer health plan premiums.The following list of states is current as of July 31,2019. Contact your State for more information on eligibility- • • Page 16 224 OPEN ENROLLMENT - 3/2/20 THRU 3/20/20 ALABAMA–Medicaid tLHRIDA–Medicaid Website:htfp-/Jmyaj$jpp:comf • Website btiW,Mh d;cthdt alP _corn/hippf •',I re:1-855`69x 7 Phone1-3w-357-326S ALASKA 57- ALASISA–Medicaid GEORGIA–Medicaid The AK Health larance Premium Payment Fromm Websitehttps:Ifinedicaid_g'eosgia.govihealt - Website: http•/fmyakhipp corn/ ya rce-premium-pa Bent-pr ram$iap Phone: 1-.3,&b-_ 4561 Phone63-854-1162 ext rU Fr nai CustomeaService@MyAKHIPP rnrrt Medicaid Fligiblhity:: http:/fdhss.alaskagavidpalPages, edicaidldefatiltasp x ARKANSAS–Medicaid IN LANA–Medicaid Website:http://m}arhipp_com/ Healthy Indiana Plan for low-income adults 19-64 Phone:r-&55-MyARHIPP(S=z`69=-74.,67) Website http://ww . govif adhipf Phone:1-30-7- All other Medicaid Website:b -S.+ +tts+.- dianarnedicad_com Phone 1 40-o864 COLORADO–Health First Colorado (Colorado's Medicaid Program)&Child IOWA–Medicaid Health Plan PIus(CRP-) Heal First Colorado Website Website-. jgttpc•fIwww healthfiastcolorado con/ bttp1/dbc inutaiThiwl.1 Health First Colorado Member Contact Center: Phoney a-Soo=5r3563 r-800-221-3943/State Relay pi CFtP+: s-liw.colt+gado.;erovipac c}hepPcb ld-health plan-plus Cf P+CustomeService:r-ecao- j •gmf State Reid- Page 17 225 OPEN ENROLLMENT - 3/2/20 THRU 3/20/20 KANSAS—Medicaid NEW HNTW HAMPSHIRE—Medicaid Website:http-//w•wwkdhPkxgov/hcf/ Website:htilm//ww lhlrc l�govlaiii htrn Phone:1,735-:....96-353.2 Phone:6o 5 Toll number for the HIPP pro ram:r-Soo-852- ext�•. KEMU=—Medicaid NEW JERSEY—Medicaid and CHIP Website:https://difs.ky.gov Medicaid Website: Phone:a-8oa-635- 7o .1Aim w state.nr.vsIhamaanse1Vices/ drmahs/dients/medicaid( Medicaid Phone:6n-651.-239z CHIP Website CHIP IP Plhone=r •- o LOUISIANA—Medicaid NEW YORK—Medicaid Website: Website: http-//dhhlouisiana gov/index rfrn/suhborrheii/n/33T Mipsliwww health n}govlhealthLcare/medicaid/ Phone 2-888-695-24/17 Phone:2-Soo-542-28 • —Medicaid NORTH CAROLINA—Medicaid Website:http:/fwwwrnaine.gov/dhhsloffpublic- Website: haps:/Amedicaid.ncdhhs:go / assistance/index.html Phone: gi9-$55-41ea Phone:3-8ao-442-6003 ITV Maine relay pz M. SSACHUSETIS—Medicaid and CHIP NORTH DAKOTA—Medicaid Website: Website: http://www.mass.gov/eohhs/govidepartments/masshe ://w% ctgovAdhs/servicesfrnedicalserv/medicaid alth/ I Phone:1-800-862 Phone: r MIIISESOTA—Medicaid OKLAHOMA—Medicaid and CHIP Webssite-, Website http://t'w- ± eollahoma.arg https://mn.gov/dhs/people-we-servelseniorslhealth- Phone:1-8843,565-3742 care/health-care-prograrns/prro rams-and- serviceslother-insurance.isp Phone r-800-6- . MISSOURI—Medicaid OREGON—Medicaid Website: Website t'it.- a &•• 4- ei• 1101'it'. •1••ate■nt.,16, t...,_e nn•J• bi,•//heaTtbrare aT rl gg9/Paus/indexasps htm $tttp-ilwztitc nrezpmhealthaare g t/index-ec html Phone 51,/51-2,005 Phone:1Soo-69g-935 MONTANA—Medicaid PENNSYLVANIA—Medicaid Website: lialebsiate: http://dphhs.mtgov/Montana1IealthcareProgarslFII ht p /wwiv dhs pa__gov/provider/medicalass stance/he PP anceplem urnpavmenthipppmgram/rndexht Phone:2-800-694-3084 r1 Phone:3. . 2 62 NEBRASKA—Medicaid RHODE ISLAND—Medicaid and CHIP Website: http•//mvACCFSSNebraska ne gov Website:http llwww eohhsAgpv/ • Phone:(S55)6527633 Phone:455-697-4347,or 4o2-466-o3u{Direct Rite Share Lincoln:(402)473-7000 Line) NEVADA—Medicaid SOUTH CAROLINA—Medicaid Medicaid Website: https://dhcfpnv.gov Website:https_Th wscdhhs.,gov Medicaid Phone: r-Boo-ggz-ogoo Phone:2-1388-549-082o Page 18 226 • OPEN ENROLLMENT - 3/2/20 THRU 3/20/20 SOUTH DAKOTA-Medicaid WASHINGTON—Medicaid Website bttp l ldss.sd goy Website Itttpc iwww bra Asa govt Phone:1-838-$23-0059 Phone: n-Soo-562-3o=ext. is TEXAS—Medicaid WEST V RG) —Medicaid Website http:l/gethipptexas.coml Website: http:/Imy'wvhipp.corn/ Phone:i.-Sc o-44o-o4g3 Toll-free phone 1-355-MyWV P(1-855-699-8447) UTAH—Medicaid and CHIP WISCONSIN—Medicaid and Medicaid Website:haps://medicaid_utah.ggovi Website: GUI Website:bttp-l/healt t.utah.aovicbp tpe-iiww'w dltswisconsin ovlpublicationslp+llrsoo47.p Phone:1-S77-540-1,7669 ' Phone 1400362-3oo= VERMONT—Medicaid WYOMING—Medicaid Website http://www.greenmountaincareorgi Website Itttps:f rtrvequality care.acs-inccom/ Phone:1-800-250.84.27 Phone so rr VIRGINIA—Medicaid and CHIP Medicaid Website: http://www.coverva.orgtprogam.s premium assistance c�n Medicaid Phone_ 1-Soo-432-5gat4 CHIP Webste http://www.00veTva_orgiprocgams premium assistance. cfm OUP Phone:r• To see if any other states have added a premium assistance program since July 31, 2019, or for more information on special enrollment rights, contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare&Medicaid Services g • www.dol. ov/a encies/ebsa g www.cros.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565 Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L.104-13) (PRA),no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget(OMB) control number.The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA,and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number.See 44 U.S.C.3507.Also,notwithstanding any other provisions of law,no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number.See 44 U.S.C.3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information,including suggestions for reducing this burden,to the U.S. Department of Labor,Employee Benefits Security Administration,Office of Policy and Research, Attention:PRA Clearance Officer,200 Constitution Avenue, N.W., Room N-5718,Washington,DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137. Page 19 227 OPEN ENROLLMENT - 3/2/20 TH R U 3/20/20 City of Plantation Medicare Creditable Notice Important Notice from City of Plantation About Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it.This notice has information about your current prescription drug coverage with the City of Plantation and about your options under Medicare's prescription drug coverage.This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining,you should compare your current coverage, including which drugs are covered at what cost,with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare's prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare.You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO)that offers prescription drug coverage.All Medicare drug plans provide at least a standard level of coverage set by Medicare.Some plans may also offer more coverage for a higher monthly premium. 2.The City of Plantation has determined that the prescription drug coverage offered by the United Healthcare plans are,on average for all plan participants,expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage,you can keep this coverage and not pay a higher premium(a penalty)if you later decide to join a Medicare drug plan. When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescription drug coverage,through no fault of your own,you will also be eligible for a two (2) month Special Enrollment Period (SEP)to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan,your current City of Plantation coverage will not be affected (you can keep this coverage if you elect part D and this plan will coordinate with Part D coverage). If you do decide to join a Medicare drug plan and drop your current City of Plantation coverage, be aware that you and your dependents may not be able to get this coverage back unless there is a qualifying event or open enrollment. Page 20 228 OPEN ENROLLMENT - 3/2/20 THRU 3/20/20 When Will You Pay A Higher Premium (Penalty)To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with the.City of Plantation,and don't join a Medicare drug plan within 63 continuous days after your current coverage ends,you may pay a higher premium (a penalty)to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage,your monthly premium may go up by at least 1%of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium.You may have to pay this higher premium (a penalty)as long as you have Medicare prescription drug coverage. In addition,you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage... Contact the person listed below for further information or call Service Planning Corporation at(954)492- 0640. NOTE:You'll get this notice each year.You will also get it before the next period you can join a Medicare drug plan, and if this coverage through the City of Plantation changes.You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage... More detailed information about Medicare plans that offer prescription drug coverage is in the"Medicare &You" handbook.You'll get a copy of the handbook in the mail every year from Medicare.You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: + www.medicare.gov + Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the "Medicare&You" handbook for their telephone number)for personalized help + Call 1-800-MEDICARE (1-800-633-4227).TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help,visit Social Security on the web at www.socialsecurity.gov,or call them at 1- 800-772- 1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and,therefore,whether or not you are required to pay a higher premium (a penalty). Page 21 229 OPEN ENROLLMENT - 3/2/20 THRU 3/20/20 Special Enrollment Notice If you are declining enrollment for yourself or your dependents (including your spouse/ domestic partner) because of other health insurance or group health plan coverage,you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents'other coverage). However,you must request enrollment within 30 days after your or your dependents' other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption,you may be able to enroll yourself and your dependents. However,you must request enrollment within 30 days after the marriage, birth, adoption,or placement for adoption. To request special enrollment or obtain more information, please contact: City of Plantation Human Resources Department 400 NW 73rd Avenue Plantation, FL 33317 (954)797-2244 Women's Health and Cancer Rights Act (WHCRA) Notice If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women's Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: • All stages of reconstruction of the breast on which the mastectomy was performed • Surgery and reconstruction of the other breast to produce a symmetrical appearance; • Prostheses;and • Treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance or copays applicable to other medical and surgical benefits provided under this plan as shown in the Summary of Benefits. If you would like more information on WHCRA benefits, please contact: United Healthcare (866) 633-2446 Page 22 230 W ° 0 � 0 d a C C u 6'. d 72 O a' Y m y fa 7 •i0 Pi y d a c c o ° E • w d H o E r 3 c c 'N E �j N 7 O . 0 0 1`0 d d c o 3 r m m 0. C d t c!9 % t d d c o 3 C �o _ c r C E N •o u 0 0 0 a0. d L U .-' U N Y O C r 3 fo a o 0 fa 2 r"to w m : 3 ._ `: 3 E .Co N c 0 d M fa v .o 0 2 1 " 2 m w u y n 3 a 5 v > E x c 0 a. £ .o. o m E a, c L .c 3 > a3`, ' m E E E o 13 z 11,,' ai 2 - a3 E C _4 .0 o N x O — d O N N U �' fo N rl i, • d a' E £ L a c y " c v NO t o m 2 a7 3 E 3 0 r u >- to u 0 o a a d d O d c N 3 .c t m 'c t n cu Wo . d .d c . mo • dUca3E fa to I w a3 ? > r w c .- d •° d O t f, 15 a 0 C da Cw ? fo00 « dO N .6) ,.i a 3 N r .:.4gE a C N = m c n ; N a c E c a fn u . 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O u 0 8 L ° Wm E O L O 'v; okQOR7"sl Villi L',1 •(6* v - m N. k0RID !/ 2020 12021 EMPLOYEE BENEFIT HIGHLIGHTS ._. . .. .. .. . .. . . ... ..... .. . .. .. .. . . . .... . .. .. . .. . . . . .. .... 446 , L.= PS Employee: ‘..-1:6- - rude > PSL Strong! i1/4,174„,...... - K. ;�.. t �j c ?hi., t-a - ,i (Y�I taaal , ,I S,. fSL 4 Format,. r.... AM7 ir ri #IAmPSI _..... • ., `_ .+ ., l ,��' ova I' jAI* 'k. ii•tl . I Ali I !�=l • aI i1 <1 , I 1510 Li 1, ' L._ i.:3", i..111-'ii, lillii 110\ , MI .`j 1 r . .,_. ming aCitY f r. 'Tt1.s 1:..11)%e''''.\ .a Ployoo:Is ,--r V(a " "% Really Coop .. { ! �r .7.,o.,, '1 - 41 1."` �y`. - -:2.� 1. .lei#1 - '�. - . Y. PSL Strong 71 � 1� : ADOPT A STREET .:' 4. Mur 1 .--'1 #IArnPSL 11iiER CONTROL „LA.. B cew!�� . '.. EST Pt qce 1 I ini 2.-nri @ickf ;1 'PL a,l4 ti TO WORK/1 J t" • I UK p'- '"�► '� Y '° 1pz°' '1 ll 1 • 1_ 0..wirowt! al' ,�� — ��" - ..e :4' -/ 7i 111 I i. ti, r 5J. �+ OurBenefit4 ���.r-/-rr - .'1 1 y - — , / _ awaiKta 1a,,t�i" ,-""� I'Slt ' " _ `'( WELLNf55-. ''� ® �1 .Are put Of '�y�+ c i.,,,,..-,,,,h ..\ , �`,�e1F.,4 > _, ..,�1 Thi6Worldl' 7 p y v � i .1J D: 1l1111�({ ' Yi A. —�� sa A% - ..' SW•\ . . A . r _ .ai'.•-• , ot..-,. Si ail .-*, Y_ OE D.C. .r r'Le, a (,p�\Me For •water' h +'�,, :1,�s. V 1 �^.....a') t►v 4 HEALTH �,. Your HR �!' .4...,1_11 you doing for r � of :, II�� i 15 -Mai Needs! f - w` your health? -";%!;;�, .1.i.a. e 1 A WEALTH t- r -'..y L .1} "s _. a .�r� i:, . . .. .. .. .. . ... . . .... ... .. . . . .. . ...... . .. . .... .. . . . .. ..^.,. l • City of Port St.Lucie I Employee Benefit Highlights 12020-2021 Er)---) Table of Contents • Contact Information 1 Introduction 2 Online Benefit Enrollment2 Group Insurance Eligibility ' 3-4 Qutn 1 5 SummalifyingaryEvents of BenefitsandSecand ioCoverage25 5 Medical Insurance 6 Other Available Plan Resources 6 C\ --- Florida Blue—BlueChoice Side-By-Side Plans At-A-Glance 7 Health Reimbursement Account(For Wellness InProgram Participants Only) 8 Dental Insurance 9 Florida Combined Life BlueDental Choice Plus Plan At-A-Glance 10 Vision Insurance 11 111111:7:2 VSP Choice Plan At-A-Glance 12 1 40 Flexible Spending Accounts 13-14 Short Term Disability 15 _____.) Long Term Disability 15 Basic Life and AD&D Insurance 15 Voluntary Life Insurance 16 Employee Assistance Program 17 Life Assistance Program 17 , 000 Supplemental Insurance 18 Supplemental Travel Insurance 18 Supplemental Pet Insurance 18 • (---T;L:. ....\ 1 Police Officer State Death Benefit 18 \\"-----.1.1),) Legal Insurance 19 Retiree Healthcare Coverage 19 Retirement Plans 20 Employee Health/Urgent Care Center 21 Claims,Billing&Benefit Assistance 22 . Notes 22-24 This booklet is merely a summary of employee benefits.For a full description,refer to the plan document.Where conflict exists between this summary and the plan document,the plan document controls. The City of Port St.Lucie reserves the right to amend,modify or terminate the plan at any time.This booklet should not be construed as a guarantee of employment. 236 0 2016,Gehring Group,Inc.,All Rights Reserved i City of Port St.Lucie I Employee Benefit Highlights 12020-2021 Contact Information Phone:(772)344-4369 Assistant HR Director Natalie Cabrera Email:ncabrera@cityofpsl.com HR Manager Claudia McCaskill Phone:(772)344-4081 Email:cmccaskill@cityofpsl.com Phone:(772)879-3374 HR Generalist I Alyssa Figur �-� Email:afigur@cityofpsl.com n Online Benefit Enrollment Bentek Support (888)(8ww 5-Bentek(523-68 c2-d35) yofpsl 10 Customer Service:(800)352-2583 Medical Insurance Florida Blue www.floridablue.com Prescription Drug Coverage Customer Service:(888)849-7865 C &Mail-Order Program Alliance Rx Walgreens Prime www.floridablue.com aHealth Reimbursement Account Chard-Snyder Customer Service:(800)982-7715 www.chard-snydercom 0 Dental Insurance Florida Combined Life Customer Service:(888)223-4892 www.floridablue.com ® Vision Insurance Vision Service Plan Customer Service:(800)877-7195 www.vsp.com a Flexible Spending Accounts Chard-Snyder Customer Service:(800)982-7715 www.chard-snyder.com Short&Long Term Disability Insurance Cigna Customer Service:(800)362-4462 www.cigna.com Basic Life and AD&D Insurance Cigna Customer Service:(800)362-4462 O O www.cigna.com Qmt1 Customer Service:(800)362-4462 Voluntary Life Insurance Cigna www.cigna.com IlLi Employee Assistance Program Magellan Healthcare Customer Service: www.MagellanHealth.com/member Aflac Customer Service:(800)992-3522 www.aflac.com GO Supplemental Insurance Metropolitan Life Insurance Customer Service:(866)713-1690 www.madison plan ning.com Customer Service:(800)729-7998 `lam Legal Insurance legalsheild www.legalshield.com Customer Service:(772)807-4430 Employee Health/Urgent Care Center-Port St.Lucie Employee Family Health Center www.cpslhealth.com Access Code: Employee Health/UrgentCustomer Service:(772)Care Center-Stuart Treasure Coast Medical Associates ( )692-8082 www.stuarturgentcare.com Employee Health/Urgent Care Center-Okeechobee Treasure Coast Medical Associates Customer Service:(863)484-8154 www.tcmahealthcare.com 0 Claims,Billing&Benefit Assistance Gehring Group Customer Service:(800)244-3696 Email:cityofpsl@gehringgroup.com 237 1 ©2016,Gehring Group,Inc.,All Rights Reserved City of Port St.Lucie I Employee Benefit Highlights 12020-2021 oORTs ` Online Benefit Enrollment _ n The City provides employees with an online benefits enrollment V J in platform through Bentek's Employee Benefits Center(EBC).The EBC , provides benefit-eligible employees the ability to select or change insurance benefits online during the annual Open Enrollment Period, t 0 R1O14 New Hire Orientation,or for Qualifying Life Events. Accessible 24 hours a day, throughout the year,employee may log in and review comprehensive information regarding benefit plans, and view and print an outline of benefit elections for employee and Introduction dependent(s).Employee also has access to important forms and carrier links,can report qualifying life events and review and make changes to The City of Port St. Lucie provides group insurance benefits to eligible Life insurance beneficiary designations. employees. The Employee Benefit Highlights Booklet provides a general summary of the benefit options as a convenient reference.Please refer to the City's Handbook,Union Contract and/or the group's insurance Certificates of - ti Coverage for detailed descriptions of all available employee benefit programs and stipulations therein.If an employee requires further explanation orfurthe • O O O U __ • assistance regarding claims processing,please refer to the customer service © O 4 — — -- G phone numbers under each benefit description heading or contact Human Q '��`,A, o Q Resources for further information. O O Q O To Access the Employee Benefits Center: ✓ Log on to www.mybentek.com/cityofpsl ✓ Sign in using a previously created username and password or dick"Create an Account"to set up a username and password. ✓ If employee has forgotten usemame and/or password,click on the link "Forgot Username/Password"and follow the instructions. ✓ Once logged on, navigate using the Launchpad to review current enrollment,learn about benefit options,and make any benefit changes or update beneficiary designations. For technical issues directly related to using the EBC, please call (888) 5-Bentek (523-6835) or email Bentek Support at support@mybentek.com, Monday through Friday, during regular business hours,8:30am-5:00pm. To access Employee Benefits Center online,log on to: www.mybentek.com/cityofpsl Please Note:Link must be addressed exactly as written.Due to security reasons, the website cannot be accessed by Google or other search engines. 238 2 ©2016,Gehring Group,Inc.,All Rights Reserved e II v City of Port St.Lucie I Employee Benefit Highlights 12020-2021 vspor Group Insurance Eligibility Y oc1ow The Gty's grout insurance 'plan year 15 01 October I through Sertember 30. Dependent Age Requirements Medical, Dental and Vision Coverage: A dependent child may General Employee Eligibility be covered through the end of calendar year in which the child turns age 26. Employees are eligible to participate in the City's group insurance plans if they An over age dependent may continue to be covered through the are full-time employees.Coverage will be effective the first day of the month end of the calendar year in which the child reaches age 30, if the following 60 calendar days of employment.For example:If employee is hired on April 11,effective date will be July 1. If eligible employee is reinstated dependent meets the following requirements: (<1yr)the employee's insurance will be reinstated as of the first of the month • Unmarried with no dependents;and following date of reinstatement. f • A Florida resident,or full-time or part-time student;and • Otherwise uninsured;and Police Officer Eligibility • Not entitled to Medicare benefits under Title XVIII of the Police Officer's are eligible to participate in the City's group insurance plans Social Security Act,unless the child is handicapped. if they are full-time employees.Coverage will be effective the first day of the ! Please Note:Plan Carriers may require proof of full-time student status if month following full-time date of hire.For example:If employee is hired on , over-age dependent April 11,effective date will be May 1. 1 Elected Officials Eligibility Deductions Related to"Over-Age"Dependents • Elected Officials are eligible to participate in the City's group insurance plans. IRS guidelines state that an employee may not receive a tax advantage on any Coverage will be effective the first day of the month following swear-in date. portion of premium paid related to an Over-Age(Non-Qualified)Dependent. For example:If employee is sworn in on November 11,effective date will be Employees insuring Over-Age Dependents will see the insurance premium December 1. deductions post-tax and should consult their tax expert. Contact Human Please Note:Newly hired employees working an average of 30 hours per week or more Resources for information and rates. will be considered'full-time"for the purposes of benefit eligibility status. Disabled Dependents Separation of Employment Coverage for an unmarried dependent child may be continued beyond age 26 if: If employee separates employment from the City, insurance will continue • The dependent is physically or mentally disabled and incapable of through the end of the month in which the separation occurred. COBRA self-sustaining employment(prior to age 26);and continuation of coverage may be available as applicable by law. • Primarily dependent upon the employee for support;and • The dependent is otherwise eligible for coverage under the group's Dependent Eligibility insurance plan;and A dependent is defined as the legal spouse(legally valid existing marriage as • The dependent has been continuously insured. defined by Florida Law)and/or dependent child(ren)of the participant or the Proof of disability will be required upon request. Please contact Human spouse.The term"child"includes any of the following: Resources if further clarification is required. • A natural child • A stepchild • A legally adopted child • A newborn child(up to the age of 18 months old) of a covered dependent(Florida) • A child for whom legal guardianship has been awarded to the participant or the participant's spouse 239 3 ©2016,Gehring Group,Inc.,All Rights Reserved • City of Port St.Lucie I Employee Benefit Highlights 12020-2021 �� • Group Insurance Eligibility (Continued) Please note:To enroll new dependents on the City's group insurance plan(s),maintain enrollment for current dependents,or enroll new dependents in the City's group insurance plan(s)during the open enrollment period,employee will be required to provide documentation verifying the eligibility of employee's dependents to Human Resources. Dependent Relationship Document(s)employee will need to provide to verify eligibility • Official Marriage Certificate AND l Spouse • Certificate of Dependent Eligibility signed by employee • State issued birth certificates)OR legal guardianship court documents,listing , Child(ren)Under Age 26 employee or spouse as parent/legal guardian AND • Certificate of Dependent Eligibility signed by employee Stepchild(ren)Under Age 26 • AND the appropriate dependent child documentation listed above Child(ren)under Legal Guardianship or Custody Under Age 26 - AND court documents of the legal guardianship OR legal custody • Child(ren)under Foster Care Under Age 18 • AND court documents of legal guardianship • AND court documents of the legal adoption showing relationship to and Child(ren)adopted or in the process of adoption Under Age 26 placement in the employee's house OR adoption certificate issued through the courts • AND State issued Birth Certificate of child(ren)stating child was born to an Grandchild(ren)OR other children not related insured dependent child of employee or spouse OR • Legal Guardianship/Custody/Foster Care Document from the courts • State issued birth certificate(s)OR legal guardianship court documents,listing employee or spouse as parent/legal guardian AND Child(ren)Age 26 30 • Certificate of Dependent Eligibility signed by employee • AND Overage Dependent Affidavit signed by employee All documentation must be either the original document or a notarized/certified copy of original document.Please note:Human Resources will need to view the original documents and will make copies for employee files,unless the document was uploaded through the Document Center in Bentek. Any person who knowingly and with intent to injure,defraud,or deceive any insurer,files a statement of claim or an application containing any false,incomplete,or misleading information is guilty of a felony of the third degree. It is the employee's responsibility to notify Human Resources when employee's dependent is no longer eligible to be covered under the plan in order to remove them and/or end dependent coverage and applicable deductions.Retro adjustments may not be able to be made.Please understand that any misstatements regarding your dependent's eligibility may result in disciplinary action up to and including termination of employment. 240 4 ©2016,Gehring Group,Inc.,All Rights Reserved City of Port St.Lucie I Employee Benefit Highlights 12020-2021 • _) Qualifying Events and Section 125 Section 125 of the Internal Revenue Code Premiums for medical, dental, vision insurance, contributions to Flexible Spending Accounts(FSA),and/or certain supplemental policies are deducted IMPORTANT NOTES • through a Cafeteria Plan established under Section 125 of the Internal Revenue Code and are pre-taxed to the extent permitted.Under Section 125,changes If employee experiences a Qualifying Event,Human Resources must to employee's pre-tax benefits can be made ONLY during the Open Enrollment be contacted within 30 days of the Qualifying Event to make period unless the employee or qualified dependent(s) experience(s) a the appropriate changes to employee's coverage. Beyond 30 days, Qualifying Event and the request to make a change is made within 30 days of requests will be denied and employee may be responsible,both legally the Qualifying Event. and financially,for any claim and/or expense incurred as a result of Under certain circumstances,employee may be allowed to make changes to employee or dependent who continues to be enrolled but no longer benefit elections during the plan year if the event affects the employee,spouse meets eligibility requirements.If approved,changes may be effective or dependent's coverage eligibility.An"eligible"Qualifying Event is determined the date of the Qualifying Event or the first of the month following by Section 125 of the Internal Revenue Code.Any requested changes must be the Qualifying Event or date written request for change in coverage is consistent with and due to the Qualifying Event. received by Human Resources.Newborns are effective on the date of birth.Marriage is effective the date of occurrence.Cancellations will Examples of Qualifying Events: be processed at the end of the month.In the event of death,coverage • Employee gets married or divorced terminates the day following the death. Employee may be required • Birth of a child to furnish valid documentation supporting a change in status or • Employee gains legal custody or adopts a child "Qualifying Event:' • Employee's spouse and/or other dependent(s)die(s) • Loss or gain of coverage due to employee,employee's spouse and/or dependent(s)termination or start of employment Summary of Benefits and Coverage • An increase or decrease in employee's work hours causes eligibility A Summary of Benefits&Coverage(SBC)for the Medical Plans is provided or ineligibility as a supplement to this booklet being distributed to new hires and existing • A covered dependent no longer meets eligibility criteria for coverage employees during the Open Enrollment Period.The summary is an important item in understanding employee's benefit options.A free paper copy of the SBC document • A child gains or loses coverage with other parent or legal guardian may be requested or is also available as follows: • Change of coverage under an employer's plan • Gain or loss of Medicare coverage From: Human Resources • Losing or becoming eligible for coverage under a State Medicaid Address: 121 SW Port St.Lucie Blvd. or CHIP(including Florida Kid Care) program (60 day notification Port St.Lucie,FL 34984 period) Phone: (772)344-4081 Email: cmccaskill@cityofpsl.com Website URL: www.mybentek.com/dtyofpsl The SBC is only a summary of the plan's coverage.A copy of the plan document,policy, or certificate of coverage should be consulted to determine the governing contractual provisions of the coverage.A copy of the group certificate of coverage can be reviewed and obtained by contacting Human Resources or at www.mybentek.com/cityofpsl. If there are any questions about the plan offerings or coverage options,please contact Human Resources at(772)344-4081. 241 5 ©2016,Gehring Group,Inc.,All Rights Reserved City of Port St.Lucie I Employee Benefit Highlights 12020-2021 Medical Insurance The City offers medical insurance through Florida Blue to benefit-eligible employees.The costs per month for coverage are listed in the premium table(s)below and a brief summary of benefits is provided on the following page.For more detailed information about the medical plan(s),please refer to the carrier's Summary of Benefits and Coverage(SBC)document or contact Florida Blue's customer service. Medical Insurance—Florida Blue—BlueChoice 0727 Basic Plan Monthly Premium Cost Tier of Coverage City Contribution Employee Contribution* Retirees Employee Only _ J $605.17 $52.62 $657.79 Employee+Spouse $1,38136 $263.11 $1,644.47 Employee+Child(ren) $1,022.20 $194.71 $1,216.91 • Employee+Family $2,072.04 $394.67 $2,466.71 *Employee contribution ratesare subject to rhangedue to collective bargaining or,for non-bargaining unit employees,revised budgetary policies. Please Note:Coverage for over-age dependents will indude an additional monthly premium amount. Medical Insurance—Florida Blue—BlueChoice 0702 Traditional Plan Monthly Premium Cost Tier of Coverage City Contribution Employee Contribution* Retirees • Employee Only $649.82 $80.32 $730.14 fEmployee+Spouse _ $1,487.68 $337.69 $1,825.37 Employee+Child(ren) $1,100.88 $249.89 $1,350.77 Employee+Family $2,172.00 $493.03 $2,665.03 *Employee contribution rates are subject to change due to collective bargaining or,for non-bargaining unit employees,revised budgetary policies. Please Note:Coverage for over-age dependents will include an additional monthly premium amount. Florida Blue I Customer Service:(800)352-2583 I www.floridablue.com Other Available Plan Resources Florida Blue offers all enrolled members and dependent(s) additional services and discounts through value added programs. For more details regarding other available plan resources,please contact Florida Blue customer service at(800)352-2583 or visit www.floridablue.com. Hearing Aid/Exam Reimbursement Benefit The Florida Blue Mobile App The City provides active employees and their disabled dependent children, Florida Blue'smobilewebsitecanbeaccessedfromanysmartphoneordownload covered under The City's medical plan,a lifetime maximum benefit of up to the app from iPhone®or Android''with just a tap!Visit the smartphone's app $1,000 for the reimbursement of hearing aids and hearing exams.This benefit store and search for Florida Blue or visit http://apps.floridablue.com. is outside the normal parameters of The City's medical plan coverage, and therefore,must go through the Human Resources department for processing. For details of this policy, please contact Human Resources for further information. 242 6 ©2016,Gehring Group,Inc.,All Rights Reserved 0 City of Port St.Lucie I Employee Benefit Highlights I 2020-2021 Florida Blue — BlueChoice Side-By-Side Plans At-A-Glance Plan BlueChoice 0727 Basic BlueChoice 0702 Traditional Network BlueChoice BlueChoice Calendar Year Deductible(CYD) In-Network Out-of-Network* In-Network Out-of-Network* Single $750 $1,500 $300 $300 Family $1,500 $3,000 $900 $900 Locate a Provider T Coinsurance To search for a participating provider, - - ,. - contact Florida Blue's customer service Member Responsibility 3096 60% 10% 30% _ or visit www.floridablue.com.When completing the necessary search Calendar Year Out-of-Pocket Limit . criteria,select BlueChoice network. Single $3,000 $6,000 $1,500 $1,500 1 Family J, $6,000 $12,000 $4,500 $4,500 • atAp Whplies to the Out-of-Pocket Limit? Deductible,Coinsurance,Copays and Ru Deductible,Coinsurance,Copays and Rx0 y Physician Services Primary Care Physican(PCP)OfficeVisit $30Copay 60%AfterCYD $20Copay 30%AfterCYD -- ` 6 -- = Plan References 5pedalistOffice Yisit $60 Copay 60%AfterCYD $40 Copay 30%After CYD `Out-Of-NetworkBalance Billing: - - For information regarding out-of- Non-Hospital Services;Freestanding Facility ' network balance billing that may be Clinical Lab(Bloodwork)"* j . $20 CopaY 60%AfterCYD 10%Coinsurance 30%Coinsurance charged by out-of-network providers, - please refer tothe Summary ofBenefits I X-rays at IndependentFadlityr" 30%After CYD 60%AfterCYD $40Copay 30%AfterCYD and Coverage document. Advanced Imaging(MRI,PET,(T 30%After CYD 60%After CYD $40 Copay 30%After CYD ""Quest Diagnostics is the preferred [Outpatient Surgery in Surgical Center 30%After CYD 60%After CYD $40 Copay 30%After CYD II lab for bloodwork through Florida Blue. Physician Services at Surgical Center 30%After CYD 60%After CYD $35 Copay Per Provider 30%After CYD When using a lab other than Quest or - -- -- - _ - -- -. Urgent Care(Per Visit) $100 Copay $100 Copay After CYD Copay$20 $20(opa After CYD when having labsdoneinoprovider's Y 9 _ office,please confirm they are contracted with Florida Blue's BlueChoice network Hospital Services prior to receivingservices. $300 PAD""+ Inpatient Hospital(Per Admission) j 30%After CYD 60%After CYD 10%After CYD 30%After CYD 'Charges may varybased on facility - I - — - - __ -- _ of service. Outpatient Hospital(Per Visit) $500 Copay 60%AfterCYD 10%After(YD 30%AfterCYD 1 Physician Services at Hospital 1- $60 Copay $60 Copay 10%After CYD 10%After CYD * "* *AAD:Per Admission Deductible _ r x Emergency Room i $50 Copay+ $50 Copay+ (Per Visit;Copay Waived if Admitted) + $500 Copay $500 Copay 10%After CYD 10%After CYD Mental Health/Alcohol&Substance Abuse • Inpatient Hospital Services(Per Admission) - 30%After CYD 60%After CYD 10%After CYD 10%After CYD i [Outpatient Services(Per Visit) I $500 Copay 60%After CYD 10%After CYD 30%After CYD I Outpatient Office Visit J I $60 Copay 60%After CYD $40 Copay 30%After CYD Prescription Drugs(Rx) LGeneric f $10 Retail Copay 50%Coinsurance $10 Retail Copay 50%Coinsurance - Preferred Brand Name , $45 Retail Copay 50%Coinsurance $30 Retail Copay 50%Coinsurance [Non-Preferred Brand Name I $75 Retail Copay S0%Coinsurance $50 Retail Copay 50%Coinsurance F Mail Order Drug(90-Day Supply) j . $20/$90/$150 Copay Not Covered $20/$40/$60 Copay Not Covered 243 7 ©2016,Gehring Group,Inc.,All Rights Reserved City of Port St.Lucie I Employee Benefit Highlights 12020-2021 Health Reimbursement Account(For Wellness Incentive Program Participants Only) The City's Health Reimbursement Account(HRA)is administered by Chard Snyder.HRAs are only for employees who have received wellness incentives by meeting and achieving wellness targets or completing wellness activities while on the City's BlueChoice Health Plan(s)during the 10/1/20 through 9/30/21 plan year.HRA monies are funded by the City and may be used for any qualified medical,dental and vision expenses incurred. Retain Receipts Health Reimbursement Account(HRA) During the year,employee should keep all receipts and documentation for . prescriptions and medical,dental and vision related expenses if needed to verify Employer Funded Account a claim for Chard Snyder or for IRS taxes.If asked to produce documentation, a valid Explanation of Benefits(EOB)and receipt of payment for the services ✓ Enrollment is automatic if enrolled in medical plan rendered will be sufficient. ✓ Funds used for eligible medical, dental, and vision expenses for employees and their dependents who are Check Available HRA Balance enrolled in medical plan Balance, activity and account history information is available online at ✓ Unused funds accumulate and roll over year to year www.chard-snyder.com or by calling Chard Snyder at(800)982-7715. • Expenses Eligible for Reimbursement Flexible Spending Accounts(FSA) Employee may request reimbursement of expenses for employee or covered - • — -• dependent(s). Eligible expenses must be necessary for the diagnosis, ✓ Employee Funded Accounts treatment cure, mitigation or prevention of a specific medical condition. ✓ Employees must enroll annually Cosmetic expenses are not eligible for reimbursement.Reimbursement checks ✓ Funds used for eligible medical, dental, vision & will be issued to employee throughout the year for incurred expenses up to dependent care expenses for employees and their the maximum annual benefit amount. Employee has the option to have qualified dependents reimbursement checks direct deposited into employee's bank account. For more information regarding eligible expenses,visit Chard Snyder online at ✓ Unused funds will be forfeited at the end of the plan year www.chard-snyder.com. (once the filing deadlines have expired) File a Claim Please Note:lfan employee has the HRA and also elects an FSA,FSA monies will be used first since it is employee funded. Debit Card Each eligible employee will be provided a prepaid benefit card to use for payment of out-of-pocket medical expenses.This may prevent the employee from having to pay an expense first and then seek reimbursement.However, employee may be required to submit documentation of any expenses that do not match a copay associated with a specific service under the medical plan. Paper Claim Employee may submit claim forms to Chard Snyder and must include a copy of carrier's Explanation of Benefits or receipts for eligible medical services received.Claim forms can be submitted by mail,email or fax. Claims Mailing Address 6867 Cintas Blvd.,Mason,OH 45040 Chard Snyder I Customer Service:(800)982-7715 I www.chard-snyder.com Email:askpenny@chard-snyder.com I Fax:(888)245-8452 244 8 ©2016,Gehring Group,Inc.,All Rights Reserved City of Port St.Lucie I Employee Benefit Highlights 12020-2021 Dental Insurance Florida Combined Life BlueDental Choice Plus Plan The City offers dental insurancethrough Florida Combined Life to benefit-eligible employees.The costs per month for coverage are listed in the premium table below and a brief summary of benefits is provided on the following page.For more detailed information about the dental plan,please refer to the carrier's summary plan document or contact Florida Combined Life's customer service. Dental Insurance—Florida Combined Life BlueDental Choice Plus Plan Monthly Premium Cost Tier of Coverage City Contribution Employee Contribution* Retirees - Employee Only $29.10 $2.55 1 $31.65 Employee+Spouse $102.10 $20.90 $123.00 Employee+Child(ren) , $57.80 $11.85 $69.65 Employee+Family $102.95 $21.10 $124.05 *Employee contribution rates are subject to change due to collective bargaining or,for non-bargaining unit employees,revised budgetary policies. Please Note:Coverage for over-age dependents,will include an additional monthly premium amount. In-Network Benefits Calendar Year Deductible The BlueDental Choice Plus plan provides benefits for services received from The BlueDental Choice Plus plan requires a $50 individual or a $100 family in-network and out-of-network providers.It is also an open access plan which deductible to be met for in-network or out-of-network services before most allows for services to be received from any dental provider without selecting a benefits will begin.The deductible is waived for preventive services. Primary Dental Provider(PDP)or obtain a referral to a specialist.The network of participating dental providers the plan utilizes is the Florida Combined Calendar Year Benefit Maximum Life BlueDental Choice Plus Network.These participating dental providers The maximum benefit(coinsurance)the BlueDental Choice Plus plan will pay have contractually agreed to accept Florida Combined Life's contracted fee or for each covered member is$1,500.All services,including preventive services, "allowed amount."This fee is the maximum amount a Florida Combined Life accumulate towards benefit maximum.Once the plan's benefit maximum is dental provider can charge a member for a service.The member is responsible met the member will be responsible for future charges until next calendar year. for a Calendar Year Deductible(CYD)and then coinsurance based on the plan's charge limitations. • Claims Mailing Address1 Dental Claims Administrator Out-of-Network Benefits PO Box 1047,Elk Grove Village,IL 60009-1047 Out-of-network benefits are used when member receives services by a non-participating Florida Combined Life BlueDental Choice Plus provider. Florida Combined Life Florida Combined Life reimburses out-of-network services based on what it Customer Service:(888)223-48921 www.floridablue.com determines is the Usual,Customary,and Reasonable(UCR)charge.The UCR is defined as the most common charge for a particular dental procedure performed in a specific geographic area.If services are received from an out-of- network dentist,the member may be responsible for balance billing.Balance billing is the difference between Florida Combined Life's UCR and the amount charged by the out-of-network dental provider.Balance billing is in addition to any applicable plan deductible or coinsurance responsibility. 245 9 ©2016,Gehring Group,Inc.,All Rights Reserved City of Port St.Lucie I Employee Benefit Highlights 12020-2021 Florida Combined Life BlueDental Choice Plus Plan At-A-Glance Network BlueDental Choice Plus Calendar Year Deductible(CYD) In-Network Out-of-Network* q [Per Member _1 $50 $50 Per Family $100 $100 Locate a Provider Waived for Class I Services? Yes Yes To search for a participating provider, Calendar Year Benefit Maximum contact Florida Blue's customer service or visit www.8oridablue.com.When • Per Member $1,500 $1,500 completing the necessary search criteria,select Dental-BlueDental Class I Services:Diagnostic&Preventive Care Choice&Choice Plus(PPO)network. LRoutine Oral Exam(1Every 6Months) Routine Cleanings(1 Every6Months) Plan Pays:100% Plan Pays:100% BitewingX-rays(1Every 6Months) Deductible Waived Deductible Waived (Subject to Balance Billing) •Complete X-rays(1Set Every3 Years) Class II Services:Basic Restorative Plan References 'Out-Of-Network Balance Billing: L Fillings{Amalgam&CComposite) For information regarding out-of- Simple Extractions _j network balance billing that may be Endodontia(Root Canal Therapy) —I Plan Pays:80%After CYD Plan Pays:80%After CYD charged by an out of network provider, (Subject to Balance Billing) please refer to the out-of-network Periodontal Services benefits section on the previous page LAnesthesia(in Connection with Covered Dental Charge) Class III Services:Major Restorative Care Crowns Plan Pays:50%After CYD Plan Pays:50%After CYD (Subject to Balance Billing) [Dentures Dentures j Important Notes •Each covered family member may Class IV Services:Orthodontia receive up to two(2)routine cleanings 1 Lifetime Maximum $1,000 $1,000 per calendar year under the preventive [ neñt lbenefit.Cleanings mast be six(6) Plan Pays:50% Plan Payz:50% months apart. (Subject to Balance Billing) • •For any dental work expected to cost S500 or more,the plan will provide o "Pre-Determination of Benefits"upon the request of the dental provider. This will assist with determining approximate out-of-pocket costs should employee have the dental work performed. •Waiting periods and age limitations may apply for certain benefits. •Benefit frequency limitations may apply to certain services. 246 0 2016,Gehring Group,Inc.,All Rights Reserved 10 City of Port St.Lucie I Employee Benefit Highlights 12020-2021 Vision Insurance VSP Choice Plan The City offers vision insurance through Vision Service Plan(VSP)to benefit-eligible employees.The costs per month for coverage are listed in the premium table below and a brief summary of the benefits is provided on the following page.For detailed information about the vision plan,please refer to the carrier's summary plan document or contact VSP's customer service. Vision Insurance—VSP Choice Plan Monthly Premium Cost Tier of Coverage City Contribution Employee Contribution* Retirees Employee Only $5.82 $0.51 $6.33 Employee+Spouse $20.42 $4.18 $24.60 Employee+Child(ren) $11.56 $2.37 $13.93 Employee+Family $20.59 $4.22 $24.81 *Employee contribution rates are subject to change due to collective bargaining or,for non-bargaining unit employees,revised budgetary policies. Please Note:Coverage for over-age dependents will include an additional monthly premium amount. In-Network Benefits Calendar Year Deductible The vision plan offers employee and covered dependent(s)coverage for routine There is no calendar year deductible. eye care, including eye exams, eyeglasses (lenses and frames) or contact lenses.To schedule an appointment,covered employee and dependent(s)can Calendar Year Out-of-Pocket Maximum select any network provider who participates in the VSP Choice network.At There is no out-of-pocket maximum.However,there are benefit reimbursement the time of service,routine vision examinations and basic optical needs will maximums for certain services. be covered as shown on the plan's schedule of benefits.Cosmetic services and upgrades will be additional if chosen at the time of the appointment. VSP I Customer Service:(800)877-7195 I www.vsp.com Out-of-Network Benefits Employee and covered dependent(s)may also choose to receive services from vision providers who do not participate in the VSP Choice network.When going out of network,the provider will require payment at the time of appointment. VSP will then reimburse based on the plan's out-of-network reimbursement schedule upon receipt of proof of services rendered. • 247 11 02016,Gehring Group,Inc.,All Rights Reserved City of Port St.Lucie I Employee Benefit Highlights 12020-2021 USP Choice Plan At-A-Glance Network VSP Choice Services In-Network Out-of-Network q Eye Exam No Charge Up to$45 Reimbursement Frequency of Services Locate a Provider [Examination -. 12 Months 12 Months To search fora participating provider, contact VSP's customer service or visit Lenses 12 Months 12 Months www.vsp.com.When completing the `Frames 12 Months 12 Months necessary rch criteria,select VSP _ _ _ ____ _ _ ___ Choice network.sea [ntact Lenses 12 Months 12 Months Lenses r Single No Charge Up to$30 Reimbursement Bifocal No Charge Up to$50 Reimbursement --- -- __ _ — - . Plan References Trifocal No Charge Up to$65 Reimbursement - *Contact lenses are in lieu ofspectade Frames lenses and a frame. Up to$115 Allowance; Allowance Up to$135 Allowance for Up to$70 Reimbursement Featured Frame Brands Contact Lenses* 0 1Non-Elective(Medically Necessory) _� _� No Charge Up to$210 Reimbursement Important Notes Elective(Fining,Follow-up&Lenses) Up to$115 Allowance Up to$105 Reimbursement Member options,such as LASIK,UV After Maximum$60 Copay coating,progressive lenses,etc.are not covered in full,but maybe available at LASIK a discount. Discount Programs Contact VSP for Program Details Not Available ' 248 12 ©2016,Gehring Group,Inc.,All Rights Reserved FSA.. City of Port St.Lucie I Employee Benefit Highlights 12020-2021 Flexible Spending Accounts The City offers Flexible Spending Accounts(FSA)administered through Chard-Snyder.The FSA plan year is from October 1,2020 through September 30,2021. If employee or family member(s)has predictable health care or work-related day care expenses,then employee may benefit from participating in an FSA.An FSA allows employee to set aside money from employee's paycheck for reimbursement of health care and day care expenses they regularly pay.The amount set aside is not taxed and is automatically deducted from the employee's paycheck and deposited into the FSA.During the year,the employee has access to the account for reimbursement of certain expenses not covered by insurance.Participation in an FSA allows for substantial tax savings and an increase in spending power.Participating employee must re-elect the dollar amount to be deducted each plan year.There are two types of FSAs: Health Care FSA Dependent Care FSA This account allows participant to set aside up to an annual , This account allows participant to set aside up to an annual maximum of$5,000 if single maximum of$2,750.This money will not be taxable income or married and file a joint tax return($2,500 if married and file a separate tax return)for to the participant and can be used to offset the cost of a work-related day care expenses.Qualified expenses indude day care centers,preschool, wide variety of eligible medical expenses that generate and before/after school care for eligible children and dependent adults. out-of-pocket costs.Participating employee can also receive reimbursement for expenses related to dental and vision Please note,if family income is over$20,000,this reimbursement option will likely save care(that are not classified as cosmetic). participants more money than the dependent day care tax credit taken on a tax return.To qualify,dependents must be: Examples of common expenses that qualify for • reimbursement are listed below. A child under the age of 13,or • A child,spouse or other dependent that is physically or mentally incapable of self-care and spends at least eight(8)hours a day in the participant's household. _ Please Note:The entire Health Care FSA election is available the first Please Note:Unlike the Health Care Reimbursement Account,reimbursement is only up to the amount day coverage is effective. that has been deducted from the participant's paycheck for the Dependent Care Reimbursement Account. A sample list of qualified expenses eligible for reimbursement indude,but not limited to,the following: ✓ Prescription/Over-the-Counter Medications ✓ Physician Fees and Office Visits ✓ LASIK Surgery ✓ Menstrual Products ✓ Drug Addiction/Alcoholism Treatment ✓ Mental Health Care ✓ Ambulance Service ✓ Experimental Medical Treatment ✓ Nursing Services ✓ Chiropractic Care ✓ Corrective Eyeglasses and Contact Lenses ✓ Optometrist Fees ✓ Dental and Orthodontic Fees ✓ Hearing Aids and Exams ✓ Sunscreen SPF 15 or Greater ✓ Diagnostic Tests/Health Screenings ✓ Injections and Vaccinations ✓ Wheelchairs Log on to http://www.irs.gov/publications/p5O2/index.html for additional details regarding qualified and non-qualified expenses. 249 13 ©2016,Gehring Group,Inc.,All Rights Reserved City of Port St.Lucie I Employee Benefit Highlights 12020-2021 Flexible Spending Accounts (Continued) FSA Guidelines • The Health Care and Dependent Care FSA allow a 2.5 month grace Chard-Snyder may request supporting documentations for expenses paid with period at theendoftheplanyear.Thegraceperiodallowsadditional a debit card.Failure to provide supporting documentation when requested, time to incur claims and use any unused funds on eligible expenses may result in suspension of the card and account until funds are substantiated after the planyear ends.Once thegraceperiod ends,anyunused or refunded back to Chard-Snyder.This card will not expire at the end of the Y P funds still remaining in the account will be forfeited. benefit year. Please keep the issued card for use next year. Additional or • The Health Care FSA has a run out period at the end of the plan year replacement cards may be requested,however,a small fee may apply. (90 days)to submit reimbursement on eligible expenses incurred during the period of coverage within the plan year and/or grace period. • When a plan year and grace period ends and all claims have been HERE'S HOW IT WORKS! filed all unused funds will be forfeited and not returned. —•--•—•--•—•-----.�.� • Employee can enroll in either or both of the FSAs only during the An employee earning$30,000 elects to place$1,000 into a Health Open Enrollment period,a Qualifying Event,or New Hire Eligibility. Care FSA.The payroll deduction is$83.33 based on a monthly pay • Money cannot be transferred between FSAs. period schedule.As a result,the insurance premiums and health • Reimbursed expenses cannot be deducted for income tax purposes. care expenses are paid with tax-free dollars,giving the employee • Employee and dependent(s)cannot be reimbursed for services not a tax savings of$227. received. With a Health Without a Health • Employee and dependent(s) cannot receive insurance benefits or Care FSA Care ISA any other compensation for expenses reimbursed through an FSA. Salary $30,000 $30,000 • Domestic Partners are not eligible as federal law does not recognize FSA Contribution -$1,000 -$0 them as a qualified dependent. Taxable Pay $29,000 $30,000 Filinga Claim Estimated Tax -$6,568 -$6,795 22.65%=15%+7.65%FICA Claim Form After Tax Expenses -$0 -$1,000 A completed claim form along with a copy ofthe receipt as proof ofthe expense Spendable Income $22,432 $22,205 can be submitted by mail,email or fax.The IRS requires FSA participants to maintain complete documentation,including copies of receipts for reimbursed Tax swings 46, expenses,fora minimum of one(1)year. Debit Card FSA participants enrolled in the HRA,will use the same debit card for both Please Note:Beconservativewhen estimating health care and/or dependent care the HRA and FSA eligible expenses. Newly enrolled FSA participants will expenses.IRS regulations state that any unused funds remaining in an fSA,after a plan year ends and after all claims hove been bled,cannot be returned or carried automatically receive a debit card for payment of eligible expenses. If an forward to the next plan year.This rule is known as"use itorlose it." employee has the HRA and also elects an FSA,FSA monies will be used first since it is employee funded.With the card,most qualified services and products can be paid at the point of sale versus paying out-of-pocket and Claims Mailing Address requesting reimbursement.The debit card is accepted at a number of medical 6867 Cintas Blvd.,Mason,OH 45040 providers and facilities,and most pharmacy retail outlets. Chard Snyder Customer Service:(800)982-7715 I www.chard-snyder.com Email:askpenny@chard-snyder.com I Fax:(888)245-8452 250 14 ©2016,Gehring Group,Inc.,All Rights Reserved i I City of Port St.Lucie I Employee Benefit Highlights 12020-2021 Short Term Disability Basic Life and AD&D Insurance The City provides ShortTerm Disability(STD)insurance at no cost to all eligible Basic Term Life Insurance employees through Cigna.The STD benefit pays employee a percentage of the The City provides BasicTerm Life insurance for all eligible employees at no cost, weekly earnings if employee becomes disabled due to an illness or non-work related injury. through Cigna.Eligible employees will receive a benefit amount of$50,000. Short Term Disability(STD)Benefits Accidental Death&Dismemberment Insurance • STD provides a benefit of 60%of employee's weekly earnings up to Also, at no cost to employee, the City provides Accidental Death & a benefit maximum of$1,500 per week. Dismemberment(ADO)insurance,which pays in addition to the Basic Term • Employee must be disabled for 29 consecutive days prior to Life benefit when death occurs as a result of an accident.The AD&D benefit becoming eligible for benefits(known as the elimination period). amount equals the BasicTerm Life benefit. • Benefits will begin on the 30th day after the employee is disabled Age Reduction Schedule due to non-work related injury or illness. Benefit amounts are subject to the following age reduction schedule: • The maximum benefit period is 26 weeks. • Employee deemed unable to return to work after the STD 26 week > Reduces to 45%of the benefit amount at age 70 maximum period is exhausted,may be transitioned to Long Term > Reduces to 35%of the benefit amount at age 75 Disability(LTD). > Reduces to 25%of the benefit amount at age 80 • Benefit may be reduced by other income. Always remember to keep beneficiary information updated. • Disability benefits are taxable. Beneficiary information may be updated at anytime through Cigna 1 Customer Service:(800)362-44621 www.cigna.com Bentekby visiting www.mybentek.com/cityofpsl. Cigna 1Customer Service:(800)362-44621 www.cigna.com Long Term Disability The City provides Long Term Disability(LTD)insurance at no cost to all eligible employees through Cigna.The LTD benefit pays employee a percentage of monthly earnings if employee becomes disabled due to an illness or non-work related injury. Long Term Disability(LTD)Benefits • LTD provides a benefit of 60%of employee's monthly earnings up to a benefit maximum of$5,000 per month. • • Employee must be disabled for 180 consecutive days prior to becoming eligible for benefits(known as the elimination period). • Benefit payments will commence on the 181st day of disability. • Employee may continue to be eligible for partial benefits if employee returns to work on a part-time basis. • The maximum benefit period is determined based on age at the time of disability. • Benefits may be reduced by other income. Cigna 1 Customer Service:(800)362-44621 www.cigna.com 251 15 ©2016,Gehring Group,Inc.,All Rights Reserved 0 City of Port St.Lucie I Employee Benefit Highlights 12020-2021 00(?: Voluntary Life Insurance Voluntary Employee Life Insurance Voluntary Dependent Child(ren)Life Insurance Eligible employee may elect to purchase additional Life insurance on a • Employee must participate in Voluntary Employee Life plan for voluntary basis through Cigna.This coverage may be purchased in addition dependent child(ren)to participate. to the Basic Term Life and AD&D coverages.Voluntary Life insurance offers • For eligible unmarried children,from date of birth up to age 26. coverage for employee,spouse or child(ren)at different benefit levels. • Units may be purchased in increments of$5,000 to a maximum of $10,000. New Hires may purchase Voluntary Employee Life insurance without • Rates are $0.46 per month for $5,000 or $0.92 per month for having to go through Medical Underwriting,also known as Evidence of $10,000;regardless of number of dependent child(ren)enrolled. Insurability(E01),up to the Guaranteed Issue amount of$200,000. Voluntary Life Rate Table Rate Per$1,000 of Benefit • Units may be purchased in increments of$10,000 to a maximum of $500,000,up to five(5)times the employee's annual salary. Age Bracket Employee/Spouse (Based On Employee Age) (Rate Per 51,000 of Benefit) • Benefit amounts are subject to the following age reduction 0_Z9 $o.o7s schedule: -- 30-34 $0.085 • Reduces to 45%of the benefit amount at age 70 35-39 $0.130 > Reduces to 35%of the benefit amount at age 75 �--_�=------� 40-44 $0150 Reduces to 25%of the benefit amount at age 80 ------- _ _ • Group coverage cancels at retirement or if employment with the 45-49 $0.230 City is terminated. _ 50 54 50.360 55-59 J $0.670 Voluntary Spouse Life Insurance - _ 6G-64 $1.020 New Hires may purchase Voluntary Spouse Life insurance without 65-69 51.970 having to go through Medical Underwriting,also known as Evidence of 70-74 _ 53.190 Insurability(E01),up to the Guaranteed Issue amount of$50,000. 75-79 $5.150 80+ 55.150 • Employee must participate in the Voluntary Employee Life plan for spouse to participate. Itis the employee's responsibility to notify Human Resources when • Units may be purchased in increments of$5,000,to a maximum employee's dependent is no longer eligible to be covered under the of$250,000 not to exceed 100%of the employee's Voluntary Life plan in order to remove them and/or end dependent coverage and coverage amount. applicable deductions.No retro adjustments will be made. • Benefit amounts are subject to the following age reduction schedule,reducing as the employee ages: Cigna I Customer Service:(800)362-4462 I www.cigna.com • Reduces to 45%of the benefit amount at age 70 • Reduces to 35%of the benefit amount at age 75 • Reduces to 25%of the benefit amount at age 80 252 16 ©2016,Gehring Group,Inc.,All Rights Reserved a � City of Port St.Lucie I Employee Benefit Highlights I 2020-2021 Employee Assistance Program Life Assistance Program As part of the employee's benefits package the City provides a comprehensive The City cares about the well-being of all employees on and off the job and Employee Assistance Program (EAP) available to employee and each family provides,at no cost,a comprehensive Life Assistance Program(LAP)through member through Magellan Healthcare. Magellan Healthcare offers access Cigna.LAP offers employee and each family member access to licensed mental to licensed mental health professionals through a confidential program health professionals through a confidential program protected by State and protected by state and federal laws.The EAP program is available to assist in Federal laws.LAP is available to help employee gain a better understanding understanding problems that affect employee or household member,locate of problems that affect them,locate the best professional help for a particular the best professional help for a particular concern,and decide upon a plan of problem,and decide upon a plan of action.LAP counselors are professionally action. All EAP counselors are professionally trained,certified and licensed. trained and certified in their fields and available 24 hours a day,seven(7)days Master-level counselors are available 24 hours a day,seven(7)days a week. a week. The EAP also includes eight(8)free face-to-face sessions,per member,per issue. What is a Life Assistance Program(LAP)? A Life Assistance Program offers covered employees and family members free What is an Employee Assistance Program? and convenient access to a range of confidential and professional services to An Employee Assistance Program (EAP) offers covered employee and help address a variety of problems that may negatively affect employee or family member(s)free and convenient access to a range of confidential and family member's well-being.Coverage includes three (3)face-to-face visits professional services to help address a variety of problems that can negatively with a specialist,per person,per issue,per year,telephonic consultation,online affect well-being such as: material/tools and webinars.LAP offers counseling services on issues such as: ✓ Anxiety V Stress V Child Care Resources V Adult&Elder Care ✓ Legal and Financial V Grief and Bereavement V Legal Resources Assistance Concerns V Substance Abuse V Grief and Bereavement V Financial Resources ✓ Depression V Legal&Financial V Stress Management V Family and/or Marriage ✓ Life Improvement Consultation V Depression and Anxiety Issues ✓ Family and/or V Eight(8)face-to-face V Work Related Issues V Pet Care Marriage Issues counseling sessions Are Services Confidential? The City recognizes that employees'personal responsibilities may,at times, spill over into the workplace.To help ensure employee is able to address these Yes. Receipt of LAP services are completely confidential. If, however, concerns with minimal disruption,the program provides employee and family participation in the LAP is the direct result of a Management Referral (a members assistance for a variety of concerns — including child care, elder referral initiated by a supervisor or manager), we will ask permission to care,daily living issues,and other issues that may effect employee or family communicate certain aspects of the employee's care(attendance at sessions, member(s). adherence to treatment plans,etc.)tothe referring supervisor/manager.The referring supervisor/manager will not receive specific information regarding Are Your Services Confidential? the referred employee's case.The supervisor/manager will only receive reports Yes.Receipt of EAP services is completely confidential.If,however,participation on whether the referred employee is complying with the prescribed treatment in the EAP is the direct result of a Management Referral(a referral initiated by plan. a supervisor or manager),they will ask permission to communicate certain Cigna's Life Assistance Program aspects of the employee's care(attendance at sessions,adherence to treatment Customer Service:— I www.cignalap.com plans, etc.) to the referring supervisor/manager. The referring supervisor/ manager will not,however,receive specific information regarding the referred employee's case.The supervisor/manager will only receive reports on whether the referred employee is complying with the prescribed treatment plan. Magellan Healthcare Customer Service: www.MagellanHealth.com/member 253 17 ©2016,Gehring Group,Inc.,All Rights Reserved City of Port St.Lucie I Employee Benefit Highlights 2020-2021 Supplemental Insurance Supplemental Travel Insurance Aflac Cigna Secure Travel Aflac offers a variety of supplemental insurance plans that may be purchased The City provides members that are enrolled in the Voluntary Group Accidental separately on a voluntary basis and premiums paid by payroll deduction on a Dealth and Dismemberment(AD&D)plan,additional travel programs to help pre-tax basis.Aflac pays money directly to employee,regardless of what other with unforeseen issues while traveling at no cost,through Cigna. insurance plans employee may have.To learn more about these Aflac plans V 24 Hour Toll Free Emergency Service Line and/or to schedule a personal appointment, contact the local Aflac agent V Emergency Medical Assistance Details regarding available Aflac plans and services are also available online ✓ Emergency Personal Services at www.aflac.com. ✓ Pre-Trip Information Available plans include: V Emergency Documentation Replacement • Group Critical Illness with Cancer Plan(GI)—Provides a flat benefit amount of$30,000 for employee or$15,000 for employee's Cigna Customer Service:(888)226-4567 spouse when needed to help with treatment costs for covered critical illness and cancer. • Group Hospital Indemnity Plan(GI)—Provides cash benefits for Supplemental Pet Insurance illness or injury resulting in hospitalization,daily ICU confinement, in-patient and out-patient services,and wellness. ASPCA • Accident Plan—Pays cash benefits for expenses resulting from The City provides the employees the opportunity to purchase pet insurance injuries on or off the job,including:hospitalization,office and ER benefits on a voluntary basis directly through ASPCA.Coverage includes exam visits,physical therapy,and other medical expenses. fees,diagnostics and treatments for: • Dental Plan—Provides benefits for checkups,deanings,x-rays, Dogs and cats: fillings,crowns,cosmetic,orthodontic services and more. V Accidents V Hereditary Conditions • Vision Plan—Covers eye exams and reimbursement for contacts V Illness V Behavioral Issues or glasses. ✓ Cancer V Dental Disease Aflac I Customer Service:(800)992-35221 www.aflaccom Pets must be older than 8 weeks to enroll and a 14 day waiting period will Agent:Margaret Pearson I Phone:(561)881-1964 apply at enrollment.To learn more and sign up visit the ASPCA website or call Email:margaret_pearson@us.aflac.com customer service. MetLife ASPCA I Customer Service:(877)343-5314 MetLife Insurance is offered through Madison Planning Group and may be www.aspcapetinsurance.com/CityofPSL I Priority Code:EB20CityofPSL purchased separately on a voluntary basis.It is available for employee,spouse, children,and grandchildren with premiums paid by payroll deduction after tax. This permanent life insurance policy can be purchased as a supplement to the Police Officer State Death Benefit basic group life insurance offered through the City.The policies are portable, even if you change jobs or retire,as long as you pay the necessary premium you Please refer to Florida State Statue 112.19 for qualifying benefits and amounts. may continue the policy.To learn more about the MetLife Insurance Plan or to schedule an appointment,contact Janet or Tara Froyen. Risk Management I Customer Service:(772)871-7371 Metropolitan Life Insurance Agent:Janet Froyen I Phone:(561)704-4378 Email:jfroyen@madisonplanning.com Agent:Tara Froyen I Phone:(561)602-2827 Email:tfroyen@madisonplanning.com www.madisonplanning.com 254 18 ©2016,Gehring Group,Inc.,All Rights Reserved p Q City of Port St.Lucie I Employee Benefit Highlights 12020-2021 Legal Insurance Retiree Healthcare Coverage LegalShield Benefit-eligible employees participating in the City's group insurance plan(s) The City offers legal insurance through LegalShield on a voluntary basis via at the time of retirement shall be afforded the option to continue coverage payroll deduction.The LegalShield plan gives members access to professional as a Retiree. The retiree contribution rate is established at 100% of the legal counsel not only for traditional legal problems,but for everyday events determined costs for the class of coverage elected,and is assessed annually for such as buying a house or a car,creating a will,handling a problem with an rate adjustments each October 1.The City will not pay the costs,or a portion insurance company,dealing with identity theft and other instances in which thereof, of any such continuation of coverage for its retirees and eligible dependent(s). legal review should be considered. To learn more about the types of legal plans available, including Identity Employees Hired Before 7/12/10: Theft Shield,contact the City's LegalShield Representative.Employee can also A"Retiree"is defined as an employee who voluntarily withdraws from one's contact LegalShield's customer service at(800)729-7998 for assistance. position and has satisfied at least one of the following conditions: IDShield • Completed at least five(5)years of full-time service • Reached the age of 55 LegalShield also offers a voluntary pre-paid identity theft protection program, • Otherwise qualifies as a retiree under the City's Code of Ordinances IDShield.IDShield offers comprehensive privacy and security monitoring.This or Section 112.0801(2),Florida Statutes plan will give employee and spouse access to their credit report,plus daily monitoring of credit report.If victim of identity theft,this membership will Employees Hired On or After 7/12/10: provide an investigator to help with the restoration process.This includes A"Retiree"is defined as an employee who voluntarily withdraws from one's contacting the State DMV, the Medical Information Bureau, all 3 Credit position and has satisfied at least one of the following conditions: Repositories, Financial Institutions, the Social Security Administration, and even Criminal Records.To learn more about the benefits of this plan,contact • Employee's combined attained age in whole years and Credited Rebecca Smith by using the contact information provided below. Service in whole years equals at least 75(i.e.,The Rule of 75)with a minimum of ten(10)years of full-time service and has reached the age of 55 Legal Insurance • Otherwise qualifies as a retiree under the City's Code of Ordinances Monthly Premium Cost or Section 112.0801(2),Florida Statutes LegalShield& The Retiree and any eligible dependent(s)may continue participation under the LegalShield IDShield IDShield Plan effective the first day of the subsequent month following the employee's • Member $14.95 $8.95 $23.90 separation of service.The benefits continued under retiree coverage include Family $14.95 $18.95 $29.90 the same health, prescription, vision and dental coverage the employee received as an active participant in the Plan.Retiree who continues medical LegalShield www.legalshield.com coverage may also continue to participate in the City's Group Life Insurance Agent:Rebecca Smith)Office:(800)729-7998 Cell:(904)237-1070 policy for the retiree only,by making the applicable monthly contribution. Fax:(904)239-54671 www.8007297998.com For further information regarding benefits at retirement, please contact Claudia McCaskill in Human Resources. Retiree Healthcare Subsidy Employees hired on or before 10/25/10,who meet the criteria,may be eligible for a Retiree Healthcare Subsidy. For details of this policy, please contact Human Resources. 255 19 ©2016,Gehring Group,Inc.,All Rights Reserved amfb City of Port St.Lucie I Employee Benefit Highlights 12020-2021 Retirement Plans General Employees Police Officers ICMA-RC 401(a)Defined Contribution Pension Plan Municipal Police Officers Retirement Trust Fund Customer Service:(800)669-7400 www.icmarc.org Provided under Florida State Statue 185.The plan has a"5-years+1 day of The City contributes an amount equal to 11.4%of an eligible employee's eligible service"vesting requirement. The plan offers an early retirement bi-weekly earnings into the ICMA-RC 401(a) Defined Contribution Plan. option at age 50 with 10 years or more of service.Normal retirement age is Employees are required to make a contribution of one percent(1%)of their 52 with 25 years of service,or age 55 with 10 years of service.Police Officers gross taxable wages to the ICMA-RC 401(a)and is only mandatory for FOPE shall contribute 9%of pre-taxed gross earnings.Employee becomes eligible and OPEIU employees at this time.The Plan has a 5-years of eligible service on date of hire. or age 55 vesting requirement. There are no loan provisions. Employee becomes eligible on the first month following 60 calendar days of full-time ICMA-RC 457 Deferred Compensation Plan employment. Customer Service:(800)669-7400 www.icmarc.org Employee may choose to contribute their own dollars into the ICMA-RC 457 Please Note:Exempt Employee may choose to have their City contribution distributed Deferred Compensation Plan.IRS regulates the maximum amount of deferral into the 457 Deferred Compensation Plan. allowed annually in the 457 plan.A participant may not exceed the annual ICMA-RC 457 Deferred Compensation Plan maximum amount of deferral.A loan option is available for this plan.Employee Customer Service:(800)669-74001 www.icmarc.org becomes eligible on date of hire. Full and part-time employees may choose to contribute their own dollars into ICMA-RC Roth IRA Plan the ICMA-RC 457 Deferred Compensation Plan. IRS regulates the maximum Customer Service:(800)669-7400 I www.icmarc.org • amount of deferral allowed annually in the 457 plan.A participant may not exceed that annual maximum amount of deferral.A loan option is available for This plan allows both full and part-time employees the ability to make after this plan.Employee becomes eligible on date of hire. tax contributions to the Roth IRA through payroll deduction.Participant may take tax-free withdrawals of their contributions or earnings at any time,from ICMA-RC Roth IRA Plan the Roth IRA under certain conditions, first time home purchases, higher Customer Service:(800)669-74001 www.icmarc.org education expenses,un-reimbursed medical expenses or disability, etc.IRS This plan allows both full and part-time employees the ability to make after- regulates the maximum amount of annual contributions.Employee becomes tax contributions to the Roth IRA through payroll deduction.Participant may eligible on date of hire. take tax-free withdrawals of their contributions or earnings at anytime from Elected Officials the Roth IRA under certain conditions, first time home purchases, higher education expenses, un-reimbursed medical expenses or disability, etc. IRS Florida Retirement System(FRS) regulates the maximum amount of annual contributions.Employees become www.myfrs.com eligible on date of hire. City Council members may participate in the Florida Retirement System(FRS) under the Elected Officers Class.The participant must make application for either the FRS Pension Plan or the FRS Investment Plan.There are different vesting requirements and distribution requirements for each of the plans.The required contribution is determined by the State Legislation annually for each class. • For additional information,please contact: Sandy Steele I Phone:(772)344-4070 I Email:ssteele@cityofpsl.com Jason Suskey I Phone:(772)344-4223 I Email:jsuskey@cityofpsl.com 256 20 ©2016,Gehring Group,Inc.,All Rights Reserved ❑ � City of Port St.Lucie I Employee Benefit Highlights 12020-2021 aca Employee Health / Urgent Care Center Participants in the City's medical insurance plan may utilize any of the following locations for primary and urgent care medical services(all of which are operated by Treasure Coast Medical Associates): Employee Family Health Center(West of City Hall) Treasure Coast Medical Associates(Okeechobee Urgent Care Location) 2266 SW Best Street,Port St.Lucie,FL 34984 Phone:(772)807-4430 305-B NE Park Street,Okeechobee,FL 349721 Phone:(863)484-8154 Fax:(772)873-63521 www.cpslhealth.com 1 Access Code: Fax:(863)484-81321 www.tcmahealthcare.com Email:cpslclinic@tcmahealthcare.com Email:stuart@tcmahealthcare.com Hours of Operation Hours of Operation [Monday 8:00 am—7:00 pm Monday 8:00 am—7:00 pm Tuesday i 8:00 am—7:00 pm Tuesday 8:00 am—7:00 pm 1 'Wednesday 8:00 am—5:00 pm Wednesday 8:00 am—7:00 pm Lursday 8:OOam-7:OOpm I Thursday - 8:OOam-7:OOpm [Friday 8:OOam-7:OOpm [Friday ] 8:OOam-7:OOpm Saturday , 1000am-1:00 pm Saturday 8:00 am—3:00 pm Sunday Closed [inday j 9:00 am—3:00 pm The Best Street location uses the 8am-9am hour for blood draws only;calls are answered as of 9am. The answering service will answer calls while the office is closed. The Clinic will be dosed on the following holidays:New Year's Day,Memorial Day,July 4th,Labor Day,Thanksgiving Day,and Christmas Day. Treasure Coast Medical Associates(Stuart Urgent Care Location) Highland Urgent Care 3405 NW Federal Highway,Jensen Beach,FL 349571 Phone:(772)692-8082 7195 S George Blvd.,Sebring,FL 338751 Phone:(863)451-5860 Fax:(772)232-9383 www.stuarturgentcare.com www.highlandurgentcare.com Email:stuart@tcmahealthcare.com Email:highlands@tcmahealthcare.com Hours of Operation Hours of Operation Monday 8:30 am-7:OOpm ' Monday 8:OOam-7:OOpm [Tuesday _ 8:30 am—7:00 pm I Tuesday 8:00 am—7:00 pm l.• I J 8:30 am—7:00 pm ;Wednesday 8:00 am—7:00 pm Thursday ] 8:30 am-7:00 pm [Thursday , 8:00 am-7:00 pm friday 8:30 am—7:00 pm i Friday 8:00 am—7:00 pm [Saturday 8:30 am—3:00 pm L aturday ] 8:00 am—3:00 pm Sunday r 9:00 am-3:OOpm i Sunday`— ] 9:OOam-3:OOpm Services Provided Treasure Coast Medical Associates(TCMA)will see patients two months of age and older at all locations;however their services should not be used as a replacement for a primary pediatrician.In addition to primary care services,TCMA will provide urgent care services at all locations.Walk-ins are welcome,but patients with appointments will be given preference(except in cases of emergency). 257 21 ©2016,Gehring Group,Inc.,All Rights Reserved City of C ty Port St.Lucie I Employee Benefit Highlights I 2020-2021 . Notes , ' Use this section to make notes regarding personal benefit plans or to keep track L-?j • of important information such as doctors'names and addresses or prescription medications. Claims,Billing&Benefit Assistance - - - - - - - - - If employees have questions on claims, receive bills from providers which they do not understand or would like general information on any of the employee benefits provided, please contact the Gehring Group Service Team. --••- -•• •--••--•--•-•• The Gehring Group Service Team works directly with the City and - - ....—....-...—....—....—..—..--..—.... its employees to provide claims and benefits service and will assist employees with their concerns.Please remember this is in addition to the City's Human Resources and is not replacing assistance employee may need from Human Resources. Employee may contact a claims specialist by: 1.Email:dtyofpsl@gehringgroup.com Please include your name,contact information and a brief description - - - -•- - ••--••- --•---• of the issue.A Gehring Group Claims Specialist will respond via email or phone call to gather additional information. OR - - _.... _ _ _...._...._ _..._..... 2.Call:(800)244-3696 _....._...._._ _...-- -.... . When calling,pleaseidentifyyourselfasanemployeeoftheCityofPort St.Lucie and ask to speak to a Claims Specialist or another member of the City's designated team to assist with questions or concerns. - - - - —- Office hours are Monday through Friday,8:30am-5:00pm.If calling after office hours, please leave a message indicating you are a City employee who would like to speak with a Claims Specialist. Please leave full name,contact information and a brief message and a Claims ' Specialist will be in contact with you the following business day. At the Gehring Group,our goal is to be your advocate and ensure issues are resolved as quickly as possible. - _ _...._ _....• 258 22 02016,Gehring Group,Inc.,All Rights Reserved _ J City of Port St.Lucie I Employee Benefit Highlights 12020-2021 Notes Use this section to make notes regarding personal benefit plans or to keep track of important information such as doctors'names and addresses or prescription medications. 259 • 23 ©2016,Gehring Group,Inc.,All Rights Reserved City of Port St.Lucie I Employee Benefit Highlights 12020-2021 )6;.> Notes • Use this section to make notes regarding personal benefit plans or to keep track of important information such as doctors'names and addresses or prescription medications. • • • • • • • • • • • • • • • • • • • • • • • • • • - - 260 • ©2016,Gehring Group,Inc.,All Rights Reserved 24 • • 4° Rrs Ap V m Atte GEHRING GROUP EMPLOYEE BENEFITS I RISK MANAGEMENT 4200 Northcorp Parkway,Suite 185 Palm Beach Gardens,Florida 33410 Toll Free:(800)244-3696 I Fax:(561)626-6970 www.gehringgroup.com 261 FINAL ©2016,Gehring Group,Inc.,All Rights Reserved Lan Modified.Ady 20,20203:35 PM d d cc a z T Y14 o a 5 u N ° 0 3 :43" C `c n « L To N 2 cc o no n nn 'IS' N N - E N d C O «O y c V 8 O O y In 'C 8 m C V 9 o.T m Qo O nd ..c30' V mu L° 28 ti ao d3V vn C s :1y c E E. 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C/) LJ-.1 gli U : Contents Welcome Letter 3 Vision 22-23 Benefit Highlights 4 Life Insurance 24 Our Benefit Goals 5 Disability Insurance and AD&D , 25 Benefits Eligibility&Enrollment 6-7 Employee Assistance Program(EAP) 26 Medical 8-12 Glossary of Benefit Terms 27 Health Wellness Center 13-15 Voluntary Benefits 28-39 Medical Flexible Spending Account 16-17 FloridaBlue Information 40-45 Dependent Care Flexible Spending Account 18 Annual Notices 46 Dental 19-21 Benefit Costs Summary 47 Contacts Medical,Dental,Life&Disability Employee Assistance Program(EAP) Renee Vickers,On-site Florida Blue Representative Resources for Life(formerly MHNet) 772.462.1549 www.mylifevalues.com Renee.Vickers@floridablue.com 800.272.3626 Medical Plan Flexible Spending Accounts Florida Blue Healthy Equity www.floridablue.com www.healthequity.com 800.352.2583 866.346.5800 New Directions Behavioral Health Life&Disability www.ndbh.com USAble Life 800.528.5763 800.370.5856 custsery@usablelife.com Prescriptions PRIME Therapeutics AD&D 888.849.7865 The Hartford 800.563.1124 Health&Wellness Center www.carehere.com Voluntary Benefits 877.423.1330 US Enrollment Services 800.282.0732 Dental Plan Florida Combined Life Benefits Enrollment Website www.floridabluedental.com Benefitfocus 888.223.4892 https://sic.hrintouch.com Vision Plan This booklet provides a summary of plan highlights.Please consult EyeMed Vision Care the carrier's contract for complete information on covered charges, www.eyemedvisioncare.com limitations,and exclusions.This is not a binding contract.The carrier's 866.723.0596 contract will prevail.If you have questions,please contact the carrier or Relation Insurance Services.. 265 1S�T7�. L Ct COUNTY FLORIDA Human Resources St.Lucie County Dear Fellow Employees, Board of county commissioners Each year, it is our goal to improve the culture, health and wellness of our employees and their families. Last year, it was the addition of our new Employee FRANNIE HUTCHINSON Health and Wellness Center in Port St. Lucie. This year, it was our mission to give CHAIR some much needed renovations to the Fort Pierce location, and the final DISTRICT 4 results turned out beautifully. We have expanded the center's hours so that our employees and their families now have quality medical care available to them 7 LINDA BARTZ days a week from 7am to 7pm. Everything is moving in a positive direction. VICE-CHAIR DISTRICT 3 Open Enrollment for 2020, will take place from October 1st through the 31st. This year will be a PASSIVE ENROLLMENT, which means any elections that you currently have in place will roll over into 2020,unless you actively change them. If CHRIS DZADOVSKY you wish to the keep the same medical, dental or vision benefits in 2020, you will DISTRICT 1 not be required to re-enroll. FSA's are the only exception. Per IRS regulations, you MUST RE-ENROLL in Flexible Spending Accounts if you wish to continue these elections. SEAN MITCHELL DISTRICT 2 Employees who are currently enrolled in Supplemental Life Insurance who would like to elect a guaranteed issue $10,000 increase to their current election (up to CATHY TOWNSEND $150,000) may do so during Open Enrollment, but this increase must be elected DISTRICT 5 through the benefits enrollment system. The 2020 Employee Benefits Guide provides a comprehensive overview of the HOWARD N.TIPTON County's benefit package. We recommend that you take the time to carefully review COUNTY ADMINISTRATOR the selection of employee benefits that the County offers so that you can make informed decisions about which benefits best meet the needs of you and your family. All benefit elections/changes must be made by logging onto the enrollment DAN MCINTYRE website https://slc.hrintouch.com with the username and password that you COUNTY ATTORNEY created. If you have forgotten your login information,you can click the link to have them reset. MAILING ADDRESS 2300 VIRGINIA AVENUE Through education and expanded wellness programs, we will continue to partner FORT PIERCE, FL 34982 with you to keep St. Lucie County healthy and thriving. If you have any questions about the benefits offered to you,please contact Kate Hartman,Benefits&Wellness PHONE Coordinator,at 772-462-1613 or HartmanK@stlucieco.org. (772)462-1546 Sincerely, TDD %�Q/�i 61a114Q/1l0 DIA&�f (772)462-1428 FAX Mark Wishard Ceretha Leon (772)462-236 1 HR& Risk Manager Human Resources Director St. Lucie County BOCC St. Lucie County BOCC E-MAIL HARTMANK@STLUCIECO.ORG WEBSITE 266 WWW.STLUCIECO.GOV ST. LUCIE WORK 2020 BENEFITS HIGHLIGHTS EFFECTIVE JANUARY 1, 2020 As always,St. Lucie County BOCC is pleased to offer a comprehensive and competitive benefits package to our employees and their families.Overall,the County will continue to pay the majority of your health care premiums,even though health care costs continue to rise.Partner with us to keep costs low-use the information in this brochure to make the right health care choices for you and your family.; This will help maximize your benefits and save money. __ . _ _. - _-- - ---. --- __ - _ _ -- - MEDICAL 4) Florida Blue will remain our carrier and we will continue to offer two 0 medical plan options. Medical benefit details can be found on pages 8- 12. FLEXIBLE SPENDING ACCOUNTS(FSA) 0 Health Equity will remain our vendor. Flexible Spending Accounts for Medical and Dependent Care require you to re-enroll for 2020. Information regarding your FSA coverage are listed on pages 16- 18. DENTAL Florida Combined Life (FCL) will remain our carrier. Benefits and Co- pays will remain the same for 2020. Information regarding your dental benefits are listed on pages 19-21. VISION DC EyeMed will remain our carrier. Benefits and Co-pays will remain the same for 2020. Information regarding your vision benefits are listed on pages 22-23. LIFE INSURANCE/DISABILITY USAble is our carrier for Basic and Supplemental Life Insurance and for our Short-Term and Long-Term Disability. The Hartford will remain our carrier for Supplemental Accidental Death & Dismemberment coverage. Premiums will remain the same for 2020. Information regarding your life and disability coverage are listed on pages 24 25. 267 1 • ' 1 k f • 4 • j.' q,! i • 4 = OUR BENEFIT GOALS 1 j -0 _ We evaluate our benefit programs each year to make sure that we • accomplish several goals. V. ' • LWe strive to: i ► Promote health and wellness among St. Lucie County I ` employees and their dependents 1 > 4116 ► Provide employees with affordable access to • 410 health benefits le ► Provide competitive benefits programs ' ► Educate employees on the appropriate use of health benefits I ► Provide resources to support employees and their ri4/OT _ -:.'"4 dependents as they make important decisions about their - health and health care • : ; ► Educate employees on all of the benefits and resources available to them • • f I (::-...,.........,, 1 r 1. �^ THINGS WORTH NOTING: ` ► Most types of preventive care continue to be covered at `,-,F� 100%on our health plan,so there is no charge to you when • _- you visit an in-network provider • ► Out of pocket maximums include deductibles,coinsurance, i �,•' a w and co-pays . :- n $ r" E Z0 1 r • ' _ ► Over-the-counter drugs require a prescription from your : ,� doctor to be eligible for reimbursement under the medical U :_ Flexible Spending Account(FSA) a It sii . .- , • " ::' ' YOUR BE ARE PAID FOR ���� �' PRE-TAX DOLLARS 9 t, EVERY PENNY YOUR PAYCHECK COUNTS. T .YS'` • I:3 9 %help'gm stretch your income,ug established 1 i G. Flexible Benefit Plan that allows J!Jt Ij for most ca_ benefits using pre-tax money. WHAT DOES A CAFETERIA PLAN MEAN TO ME? ' D B L 1 4 bh Federal • •-- ! O `tp save V.65%flialgan 2G8 ;i GROUP COVERAGE ELIGIBILITY THE COUNTY'S GROUP INSURANCE PLAN YEAR IS JANUARY- DECEMBER WHO IS ELIGIBLE FOR MEDICAL COVERAGE? " All full-time employees are eligible to participate in the County's group • U * 0, -4' . 10v , coverage. .. : `„” `• ' . -- - i ii DEPENDENT ELIGIBILITY "' 0 '��,�. Employees may extend any benefits in which they are currently enrolled ,. °° '"� to their dependents,so long as the dependents meet the elegibility it al , f requirements.Coverage will be effective 1/1/2020 for dependents " = .0,- r.- *` added during Open Enrollment. Dependents added through Life Events .. 'k' will be effective on the date of the event.Dependents added during New "' 10 Hire Enrollment will be subject to the same waiting period as N t ' the employee. f WHAT DEPENDENTS ARE ELIGIBLE TO ENROLL? 17 ► Spouses:Employee's legally married spouse. Common Law Marriage partners are not recognized by the state , of Florida and are not eligible.Former Spouses are not eligible under the plan,regardless of any legal settlement. 1 ► Children(birth to age 26):A natural child,a stepchild,a legally adopted child,Children for whom you or your legal spouse are F. the legal guardian or have the legal responsibility for providing ` -r medical coverage as defined by court order. ' , NOTE:Vision coverge ends at 25. 1-,-,; , 41-,-; vir-- i .. .fr, 4 „. i ► Children(Age 26-30):Includes a child who is unmarried and ...,: . has no dependents of their own;a child is a Florida resident or a t full-time or part-time student;a child otherwise uninsured;and/ - _000 , ; or a child not entitled to benefits under Title XVIII of the Social t Security Act unless the child is a handicapped dependent child. 1s ► Disabled Children:Includes children considered to be disabled �� % i through Social Security Administration regardless of whether i iVi / ii �' ,, the child receives Social Security Income or not;single and 1 ( ; incapable of self-sustaining employment by reason of mental ..w ;.: retardation or physical handicap; chiefly dependent upon - - the employee for support and maintenance provided that the . ilttoo .. alk 4-_-. \\. ' symptoms or causes of the child's handicap existed prior to the . 4 /r child's 30th birthday ` . AM I REQUIRED TO PROVIDE PROOF OF DEPENDENT ELIGIBILITY? , 117 Please see"Required Documentation"section the next page for / I more information. fy / . " SEPARATION OF EMPLOYMENT If an employee separates employment from the County,insurance coverage will continue through the end of the month in which the separation occurred.COBRA continuation of coverage may be available as applicable by law. 269 QUALIFYING EVENTS AND IRS CODE SECTION 125 IRS CODE SECTION 125 Premiums for medical,dental,vision insurance and contributions to FSA accounts(Health Care and Dependent Care FSAs)are deducted on a pre-tax basis,therefore,your ability to make changes to these benefits is restricted by the IRS.Changes to an employee's pre-tax benefits can be made ONLY during the Open Enrollment period unless the employee or qualified dependents experience a qualifying event. Under certain circumstances,employees may be allowed to make changes to benefit elections during the plan year,if the event affects the employee,spouse or dependent's coverage eligibility.An"eligible"qualifying event is determined by the IRS,Section 125.Any requested changes must be consistent with and on account of the qualifying event. THE MOST COMMON LIFE STATUS CHANGES: ► Marriage or divorce ► Birth or adoption ► Change in your or your spouse's work status that affects your benefits or an eligible dependent's benefits ► Change in health coverage due to your spouse's annual Open Enrollment period ► Change in eligibility for you or a dependent for Medicaid or Medicare ► Receipt of a Qualified Medical Child Support Order,or other court order TO MAKE BENEFIT CHANGES AS A RESULT OF YOUR LIFE STATUS CHANGE AS ALLOWED UNDER SECTION 125 OF THE IRS CODE,YOU MUST: ► Notify Human Resources within 30 days of the date of the qualifying event(60 days if due to the loss of CHIP or Medicaid), ► Provide proof of your life status event,and ► Complete and submit your online enrollment change request through the website at slc.hrintouch.com AM I REQUIRED TO PROVIDE PROOF OF DEPENDENT ELIGIBILITY? For a marriage or divorce,you will need a marriage certificate or divorce decree. To add dependent children,you will need a birth certificate, adoption decree, child support order, proof of legal guardianship, or,for added step- children, a marriage certificate and a birth certificate; For loss of other coverage or gain of other coverage,you will need a letter from the Plan Administrator to support this change; Be sure to review your dependents'eligibility and data to ensure birth dates and Social Security numbers are up-to-date. Be sure to remove ineligible dependents within 30 days of their change in eligibility status. Note: Employees will be responsible for any claims incurred on ineligible dependents. IMPORTANT If you experience a qualifying event,Human Resources must be contacted within 30 days of the event to make the appropriate changes to your coverage.Beyond 30 days,requests may be denied and you may be responsible both legally and financially for any claim and/or expense incurred. If approved,changes will take place the first of the month following the date of the qualifying event or the BenefitFocus request for change of coverage,with the exception of newborns which are effective the date of birth.Termination of coverage will be processed at the end of the month. Employees will be required to provide valid documentation supporting a change in status or a qualifying event.To make a change to your benefits please visit slc.hrintouch.com 270 r IL MEDICAL COVERAGE FLORIDA BLUE Ili:Al' _ , YOU HAVE CHOICES WHEN IT COMES TO THE COST OF YOUR HEALTH CARE.We understand how important it is to provide an equitable l and sustainable medical program for our employees and their dependents. One of our goals as your employer is to provide you with the best benefit options available. In 2020,there will be no modifications to the current plans. There will still be two medical plans offered, providing you the opportunity to choose the best coverage for you andy",... your family's needs.There are a few crucial facts that you will need to consider before making a decision. Below are a few FAQs to help you with making a decision. i WHAT'S THE DIFFERENCE? fy No matter which plan you choose,you'll get the same: p\ '✓ ► Access to doctors, specialists and hospitals ', ► Preventive services that are covered in full • ' I i WHICH PLAN WILL BE BETTER FOR MY NEEDS? This will depend on your individual and family needs. The / , benefits summary listed on the next page will clearly lay out �_di / how much you will have to pay out of pocket for services. - Cost-sharing options vary, so your goal is to narrow down ;' choices based on out-of-pocket costs. // Plan 3766(A)may work best for you if: Plan 5773 (B) may work best for you if: ► You regularly take expensive medications that can ► Most of your medications can be obtained only be obtained through a retail pharmacy through CareHere or at a low cost through a ► You are expecting a baby, or have children under the retail pharmacy age of three requiring frequent medical care ► Most of your medical Conditions can be ► You've been recently diagnosed with a chronic managed through CareHere condition that cannot be managed through CareHere ► You are in fairly good health In addition,those enrolled in the medical plan will continue to have access to the St. Lucie County Employee Health and Wellness Centers at NO COST. (Refer to pages 13 - 15 for more information) 2020 MEDICAL BENEFITS COSTS* COVERAGE LEVEL MEDICAL PLAN 3766(A) I MEDICAL(Z1in Employee Only $66.80 Semi-monthly $18.53 Semi-monthly Employee+One $147.33 Semi-monthly $39.22 Semi-monthly Family $217.55 Semi-monthly $67.57 Semi-monthly 271 *Pre-tax amount SUMMARY OF MEDICAL BENEFITS BlueOptions BlueOptions COST SHARING Plan A Plan B Maximums shown are Per Benefit Period(BPM)unless 3766 5773 noted Deductible(DED)(Per Person/Family Agg) In-Network $500/$1,500 $2,500/$5,000 Out-of-Network $1,000/$3,000 $5,000/$10,000 Coinsurance(Member Responsibility) In-Network 20% 20% Out-of-Network 50% 50% Out of Pocket Maximum(Per Person/Family Agg) Includes DED,Coins.Copays and Includes DED,Coins.Copays and Rx Rx In-Network $4,000/$13,200 $6,850 1$13,700 Out-of-Network $8,0001 Unlimited Max per Family $13,7001 Unlimited Max per Family Lifetime Maximum No Maximum No Maximum PROFESSIONAL PROVIDER SERVICES Office Services In-Network Family Physician DEC+20% DED+20% In-Network Specialist DED+20% DED+20% Out-of-Network DED+50% DED+50% Maternity(Due at Initial Visit only) - In-Network Specialist DED+20% DED+20% Out-0f-Network DED+50% DED+50% E-Office Visit Services In-Network Family Physician DED+20% DEO+20% In-Network Specialist DED+20% DEO+20% Out-of-Network DED+50% OED+50% Allergy Injections In-Network Family Physician DED+20% DEO+20% In-Network Specialist DED+20% DED+20% Out-of-Network DED+50% DED+50% Provider Services at Hospital and ER In-Network Family Physician/Specialist DEC+20% DED+20% Out-of-Network ln-Ntwk DED+20% In-Ntwk DED+20% Provider Services at Locations other than office,hospital or ER In-Network Family Physician DED+20% DED+20% In-Network Specialist DED+20% DED+20% Out-of-Network DED+50% DED+50% Radiology,Pathology and Anesthesiology Provider Services at Ambulatory Surgical Center In-Network Specialist DED+20% OED+20% Out-of-Network In-Ntwk DEC+20% In-Ntwk DED+20% Advanced Imaging Services in Physician's Office (MRI,MRA,PET,CT,Nuclear Medicine) In-Network Family Physician DED+20% DED+20% In-Network Specialist DED+20% DED+20% Out-of-Network DED.+50% DED+50% PREVENTIVE CARE Adult Wellness Office Services In-Network Family Physician $0 $0 In-Network Specialist/Netwk Blue&Traditional Specialist $0 $0 Out-of-Network/Non-Participating Physicians 50%(No DEO) 50%(No DED) -Colonoscopies(Routine) Age 50*then Frequency Schedule Age 50+then Frequency Schedule Applies Applies In-Network $0 $0 Out-off-Network $0 $0 Mammograms(Routine) In-Network $0 $0 Out-of-Network $0 $0 Well Child Office Visits In-Network Family Physician/Specialist $0 $0 Out-of-Network 50%(No DED) 50%(No DED) 272 BlueOptions I BlueOptions COST SHARING Plan A Plan B Maximums shown are Per Benefit Period(BPM)unless i 3766 5773 noted 1 AMBULANCE I URGENT/CONVENIENT CARE ' Ambulance Maximum(combined ground,air and water-per No Maximum No Maximum day) In-Network DED+20% DED+20% Out-of-Network In-Ntwk DED+20% In-Ntwk DED+20% Convenient Care Centers(CCC) - In-Network DED+20% DED+20% Out;off-Network DED+50% DEQ.+50% Urgent Care Centers(UCC) In-Network DED+20% DED+20% Out-of-Network Out-of-Ntwk DED+20% Out-of-Ntwk DED+20% FACILITY SERVICES-HOSPITAL(SURGICAL/LAB!INDEPENDENT DIAGNOSTIC TESTING FACILITY Inpatient Hospitalization(Per Admit) In-Network-Option 1 Option 1-DED+20% Option 1-DED+20% In-Network-Option 2 Option 2-DED+20% Option 2-DED+20% Out-of-Network DED+50% DED+50% Inpatient Rehab Maximum 30 Days _ 30Days 1 Outpatient Hospitalization(Per Visit) I In-Network-Option 1 Option 1- DED+20% Option 1-DED+20% In-Network-Option 2 Option 2- DED+20% Option 2-DED+20% 1 Out-of-Network DED+50% DED+50% Therapy at Outpatient Hospital - - In-Network-Option 1 Option 1-DED+20% Option 1-DED+20% In-Network-Option 2 Option 2-DED+20% Option 2-DED+20% Out-of-Network DED+50% DED+50% Emergency Room(Per Visit) ' In-Network $250+DED+20% $250+DED+20% Out-of-Network $250+In-Ntwk DED+20% $250+In-Ntwk DED+20% Ambulatory Surgical Center In-Network DED+20% DED+20% Out-of-Network DED+50% DED.+50% Independent Clinical Lab In-Network $0 $0 Out-of-Network DED+50% DED+50% Independent Diagnostic Testing Facility- - Xrays and AIS(Includes Physician Services) In-Network-Advanced Imaging Services(AIS) DED+20% DED+20% In-Network-Other Diagnostic Services DED+20% DED+20% Out-of-Network DED+50% DED+50% r • M NTAL H ALTH AND.SUBSTANCE ABUSE . _, Inpatient Hospitalization(per admit) In-Network-Option 1 Option 1 -DED+20% Option 1 -DED+20% In-Network-Option 2 Option 2-DED+20% Option 2-DED+20% Out-of-Network DED+50% DED+50% Outpatient Hospitalization(per visit)In-Network-Option 1 Option 1 -DED+20% Option 1 -DED+20% In-Network-Option 2 Option 2-DED+20% Option 2-DED+20% Out-of-Network DED+50% DED+50% Provider Services at Hospital and ER In-Network Family Physician or Specialist DED+20% DED+20% Out-of-Network Provider In-Ntwk DED+20% In-Ntwk DED+20% Physician Offce Visit In-Network Family Physician or Specialist DED+20% DED+20% Out-of-Network Provider DED+50% DED+50% Emergency Room (per visit) — - In-Network $250+DED+20% $250+DED+20% Out-of-Network $250+In-Ntwk DED+20% $250+In-Ntwk DED+20% Provider Services at Locations other than Hospital and ER In-Network Family Physician or Specialist DED+20% DED+20% Out-of-Network Provider DED+50% DED+50% r OTHER SPECIAL SERVICES AND LOCATIONS Birthing Center I In-Network DED+20% I DED+200 DED+50% Out-of-Network DED+50% 273 10 • BlueOptions BlueOptions COST SHARING Plan A Plan B Maximums shown are Per Benefit Period(BPM)unless 3766 5773 noted Diabetic Equipment In-Network DED+20% DED+20% Out-of-Network DED+50% DED+50% • Diabetic Supplies" In-Network Rx.Coverage Rx Coverage Out-of-Network 50% 50% Durable Medical Equipment,Prosthetics,Orthotics BPM No Maximum No Maximum In-Network DED+20% DED+20% Out-of-Network DED+50% DED+50% Enteral Formula No Maximum No Maximum In-Network DED+20% DED+20% Out-of-Network DED+50% DED+50% Home Health Care BPM 40 Visits 40 Visits In-Network DED+20% DED+20% Out-of-Network DED+50% DED+50% Hospice - No Maximum No Maximum In-Network DED+20% DED+20% Out-of-Network _ DED+50% DED+50% Outpatient Therapy:Cardiac,Physical, Occupational, 70 Visits(Includes up to 26 Spinal 70 Visits(Includes up to 26 Spinal Speech and Massage Manipulations) Manipulations) Outpatient Rehab Therapy Center In-Network DED+20% DED+20% Out-of-Network DED+50% DED+50% Spinal Manipulations,Chiropractic Services BPM 26 Visits(Not to exceed therapy 26 Visits(Not to exceed therapy maximum) maximum Skilled Nursing Facility BPM 120 days 120 days In-Network DED+20% DED+20% Out-of-Network DED+50% DED+50% PRESCRIPTION DRUGS Deductible $0 $0 In-Network Retail(30 days) Generic/Preferred Brand/Non-Preferred $6/$50/$75 $10/$50/$100 Mail Order(90 days) Generic/Preferred Brand/Non-Preferred $12/$100/$150 $20/$100 1$200 Out-of-Network Retail(30 days). Generic/Preferred Brand/Non-Preferred 50%/50%/50% 50%/50%/50% Mail Order(90 days) Generic/Preferred.Brand/Non-Preferred 50%/50%/50% 50%/.50%/50% Medical Pharmacy Monthly In-Network OOP $200 .$200 Maximum(Provider-Administered Rx)' In-Network 20% 20% Out-of-Network DED+50% DED+50% • Diabetic Equipment(insulin pumps,tubing)are always covered under the medical benefits. • Diabetic Supplies(lancets,strips,etc.)are covered under the Rx benefit This is not an insurance contract or Benefit Booklet.The above Benefit Summary-is only a partial description of the many benefits and services covered by Blue Cross and Blue Shield of Florida,Inc.,an independent licensee of the Blue Cross and Blue Shield Association. For a complete description of benefits and exclusions,please see Blue Cross and Blue Shield of Florida's Benefit Booklet and Schedule of Benefits;their terms prevail. 274 11 PRESCRIPTION BENEFIT MYBLUE MOBILE APP IMPORTANT INFORMATION ABOUT THE MYBLUE MOBILE APP GIVES YOU A SIMPLE WAY PRESCRIPTION DRUG BENEFITS TO PERSONALIZE, ORGANIZE AND ACCESS YOUR IMPORTANT HEALTH INFORMATION — ON THE GO. Whenever possible,members should utilize generic medications to receive the highest level of benefits and lowest The app includes many helpful features such as: co-payment.The medical PPO plan includes a 3-tier formulary ► My Coverage-Get a snapshot of your benefits and drug program.If a generic drug isn't available,or you prefer accumulators such as deductible,out-of-pocket max,and to purchase the brand medication,you will need to access more Florida Blue's Formulary listing to determine what copayment ► View ID Card-Access and see an image of your FloridaBlue will apply. Member ID card from your phone If the medication is listed in the formulary with a drug tier 2, ► Find a Doctor-Find a doctor,hospital or specialist in the the drug is considered a preferred brand and will be charged provider directory customized to your plan.Get details and a$50 co-payment(or$100 if you obtain a 90-day supply- map it using your GPS location mail order)on both medical plans.If the drug is listed as a ► Compare Drug Prices-Save money by comparing drug costs, non-preferred brand with a drug tier 3,it is considered non- at local pharmacies from wherever you are.Map the closest formulary and is charged at the highest co-payment level of pharmacy $100 on plan 5773(30 day supply)or$200(90 day supply)or ► Contact Us-Click to call the 24-hour nurse line,call a Care $75 on plan 3766(30 day supply)or$150(90 day supply).The Consultant or get in touch with FloridaBlue whenever you formulary listing should be checked regularly as it is subject to need to change on a quarterly basis. It is important to note that every therapeutic class of COMPARE COSTS medication is represented within the formulary.If your PARTNER WITH US TO BECOME BETTER CONSUMERS medication is listed as a non-preferred brand and you are OF HEALTH CARE. interested in reducing your co-payment,speak with your doctor to find out if you can switch to a preferred medication You have choices when it comes to the cost of your health care. ' within the formulary to treat your condition. ► Shop,compare and estimate your medical costs ► The quality and price of medical services can vary depending Formulary Prescription Drug Listing: on where you go for office visits,imaging services,and surgery,including inpatient and outpatient care Step 1:Go to www.floridablue.com ► Compare qualityand cost beforeyougo,and then decide P Step 2:Click on Members what's best for your care Step 3:Click on Pharmacy benefits(middle of the page) ► Cost estimates are based on your plan and where you Step 4:Login stand with your deductible.Your costs are lower after your , deductible is met Step 5:Use Drug Comparison Tool ► You could save hundreds of dollars,or more on your health ; care services! Log in at floridablue.com from a computer or mobile phone. Three easy ways to compare: Select Compare Drug Prices: Click-Access www.floridablue.com to log in/ Step 1:Enter the drug name(or search by alphabet) register on MyBlueServiceSelect Estimate Costs for Medical Services Step 2:Select pharmacies based on zip code j 9 d Call-A Care Consultant at 1-888-476-2227 Step 3:Compare prices and lower cost options,when I available.Plus,see when Step Therapy,Prior Authorization or er Visit Us-in-person at a Florida Blue center near other requirements may apply you. For locations,go to floridablue.com 275 HEALTH AND WELLNESS CENTER In partnership with CareHere,we are pleased to offer a FREE&CONFIDENTIAL path to wellness for all employees and their families on the County's medical plan.Some of the benefits and services that you have access to include: ► Health Risk Assessments,a full physical exam including a 28 panel blood work test to assess health status ► Annual HRA printed booklet explaining in detail how to interpret and understand your blood work results ► CareHere Health Coaches 41rty rn ► No co-pays for health center visits ► No co-pays for generic medicines at the health centerSk%; 1` 1 Ow. CareHere can provide you with mail order prescriptions ` ► Ntrj Online or telephone appointment scheduling , 7►� _ , ► Minimum 20 minute appointment face-to-face with the 4411 provider with an average wait time of less than 5 minutes *'- ► Appointments available 7:00 am to 7:00 pm,7 days a week ► Also available to children three years of age and over There are over 300 generic medications available at no cost to eligible employees within the Employee Health and Wellness Center formulary. For example,just to name a few,if you have... Allergies?We have Loratadine(Claritin*) Pre-diabetes or diabetes?We have Metformin HCL(Glucophage*) Asthma?We have Ventolin HRA* High Blood Pressure?We have Lisinopril(Prinivil*,Zestril*)and Losartan/Hydrochlorothiazide(Hyzaar*) High Cholesterol?We have Simvastatin(Zocor*) Thyroid Disorder?We have Levothyroxine(Synthroid*) Important Reminders: ; ; To schedule or change an All medicines dispensed,including refills,require an appointment online: appointment with a provider.Please maker2 back-to-back appointments when you have 3+medicines needed. Click"Appointments"on the left sidebar. We recommend you bring a listof any medicines you are currently taking to your firstihealth center visit. Click"Schedule Appointment"under the type of To schedule an appointment,download the"CareHere appointment you want to make(Medical,Nurse&Labs,or Appointments"mobile app.,login at www.carehere.com or Health Coaching). call 877-423-1330. You may editor delete your appointment at any time prior Click a valid day on the calendar and then complete the to the appointment time.However,if you fail to cancel your What,Where and Who sections at the bottom and click appointment atileast+30 minutes prior to your scheduled "Get Appointments:' appointment time,you will be subject to a$25.00 no show fee. You will only be able to view details about your own You will see the available appointment times click on appointment.This information is confidential and may notibe "Make Appointment"next to the time of your choosing. viewed by anyone else other than the health center team. 276 Car& /-ogoorg'"'"-- 0,,„. „, ''') ) . ..,-, ,„ , ic--- , ... ,,, .. } ____�,' '__---..., _- ;gip ..._.411 10 . ,"....,...,,..,,,,,._ ,,,--,- . , A -,...,,,,i„,. . _., .,,.... - _ .,.....„.. . r_.,_ . ii, - ,- . ,, lit 7 , , • 4 1 M \ ), , '-'re.., ? - e ) * -'A., .,- i it 1/ -1- rIrgs I gsto _,...._ Ab ; - • 0..,_ ..,- - . - rill gin C e r g v 11 U. n YO U or When Scheduling an Appointment KNOI:i ili Schedule 2 back-to-back 20-minute il a appointments for first-time visits, annual You can schedule an appointment by logging physicals, and men and women health exams. into your account with your Schedule a separate appointment to have your computer,smartphone, or tablet to by going to CareHere.com medications refilled. with your device. (If you have more than 3 medications that need to be refilled, it will require 2 back-to-back appointments.) Cancel your appointment, if you can't make it. ,: This helps ensure the minimal wait times :,. �_ � . it with CareHere. � � �' '�� r----- ' ��—�' 'o Please, don't be late. If you are more than '_ 10 minutes late, you may be rescheduled. 277 Connect with us,and loam more about L acre `eul. Carel-fere abides by all federal HIPAA and confidentiality regulations. 877.423.1330 • www.CareHere.com • Ili 111 1,1 Care*L / ADDITIONAL WALK- IN HOURS NOW AVAILABLE L SINCE YOU CANNOT SCHEDULE ILLNESS, ADDITIONAL WALK-IN HOURS WILL BE AVAILABLE STARTING SEPTEMBER 30TH. MONDAY- FRIDAY WALK-IN HOURS: PSL check in between 6:45 AM - 7:45 AM & 4:40 PM - 5:40 PM Fort Pierce check in between 7:40 AM - 8:40 AM SATURDAY FORT PIERCE: Check in between 7:40 AM - 8:40 AM & 4:40 PM - 5:40 PM SUNDAY PSL: Check in between 7:40 AM - 8:40 AM & 4:40 PM - 5:40 PM GENERAL HOURS: Fort Pierce Monday- Saturday 7:00 AM - 7:00 PM PSL Sunday - Friday 7:00 AM - 7:00 PM We care for ages 3 and up for acute visits, and we continue to care for ages 10 and up for chronic care. yJ wucsr` SCHEDULE ANYWHERE ("y 'ri CO oNTT,Y 1. WI 877.423.13301 CareHere.com I NEW CareHere App iso CareHere abides by all federal HIPAA and confidenti t7 gulations. FLEXIBLE SPENDING ACCOUNTS A FLEXIBLE SPENDING ACCOUNT(FSA)ALLOWS EMPLOYEES TO USE PRE-TAX MONEY FOR QUALIFIED EXPENSES. Determine how much you anticipate spending on qualified expenses throughout the year and fund your FSA for that amount through semi-monthly pre-tax payroll deductions.You can then use those funds to pay for eligible expenses using a debit card at the time of service or by submitting a receipt after-the-fact.With Health Equity's health care FSAs,the entire elected amount is available to you on the first day of the health plan year.You don't have to wait for your payroll contributions to accumulate before paying expenses with your FSA. Health Care FSA—Used to pay for qualified medical,dental,and vision expenses incurred by you and your dependents during the plan year.See box for examples of eligible expenses Health Care FSA Eligible Expenses ► Annual maximum contribution is$2,700 ► Medical plan co-pays and deductibles ► You have access to your full annual contribution at any time during the ► Dental and orthodontia expenses plan year for qualified expenses incurred during the plan year ► Vision care expenses including lasik,glasses and ► You cannot change your annual contribution amount during the plan contact lenses year,so be conservative in determining the amount you decide ► Over-the-counter drugs prescribed by your physician to contribute ► Tobacco cessation programs and related drugs ► Deadline to incur claims for this plan year is March 15,2021 with a doctor's prescription ► Deadline to submit claims is March 31,2021 ► Infertility treatment ► Psychology and psychoanalysis medical expenses Visit www.irs.gov for a full list of eligible expenses and exclusions. EASY A inc 5.k stb . your _r • 200 P 100'% WqM D V , feahEqui y D you are. Building Health Savings Username Password I. IHealthEquity mobile apps ® R . available FREE LOGIN Mr ()Apple' App Store` roreot panwdd7 New hcce?5gnup! Google PIayTM 279 Health Equity QUALIFIED EXPENSES • Acupuncture • Chiropractor • Oxygen • Alcoholism(rehab,transportation for • Contact lenses • Stop-smoking programs medically advised attendance at AA) • Crutches • Surgery,other than unnecessary • Ambulance • Dental treatments cosmetic surgery • Amounts not covered under another • Prescription eyeglasses/eye surgery • Telephone equipment and repair health.plan • Hearing aids for hearing-impaired • Annual physical examination • Long-term care expenses • Therapy • Artificial limbs/teeth • Medicines(prescribed,not imported • Transplants • Birth control pills/prescription from other countries) • Weight-loss program(if prescribed contraceptives • Nursing home medical care by a physician for a specific disease) • Body scans • Nursing services • Wheelchairs • Breast reconstruction surgery • Optometrist • Wigs(if prescribed) following masectomy for cancer • Orthodontia Visit: HealthEquity,com/QME NON-QUALIFIED EXPENSES • Concierge services • Future medical care • Nutritional supplements,unless • Dancing lessons • Hair transplants recommended by a medical practitioner • Diaper service • Health club dues as treatment for a specific medical • Elective cosmetic surgery • Insurance premiums other condition diagnosed by a physician • Electrolysis or hair removal than those explicitly included • Teeth whitening • Funeral expenses • International medicines • Over-the-counter medicine (OTC) The IRS no longer allows FSA funds to be used for OTC medicines13( without a prescription.Consider obtaining a prescription for OTC medicines or supplies that you frequently use.You can use your FSA to pay for these items. 280 I °• '' Is, DEPENDENT CARE FLEXIBLE „r; •:-. • -�' SPENDING ACCOUNTS r , , ' Dependent Care FSA ,+, ' - Dependent Care FSA is used to pay for qualified ,, 4,--e4s t I dependent child care or elder care expenses incurred during the plan year,to allow you(and/or your spouse if married)to work or go to school full-time. . 4 ► Annual maximum contribution is$5,000 - 9 ► You ONLY have access to funds that have . 4- I been withheld from your paycheck.If you submit receipts for a higher amount,you will s �, be automatically reimbursed as future payroll -44 ,-; } deductions are deposited into your account ► Deadline to incur claims for this plan year is December 31,2020 o Dependent Care FSA Expenses ► Care at a licensed nursery school or day care facility ► Before and after school care for children 12 and under ► Day Camps ► Nannies and Au Pairs 4 ► Elder Care Expenses / l/ Dependent Care Ineligible Expenses - , ► Services provided by a dependent € %'�'""` (son,daughter,or spouse) \• I ► Overnight camp expenses - ► Baby-sitting expenses for time when you are not working or at school ' 1_1 ► Late payment fees ► Tuition expenses for school Important Rules Regarding FSAs ► Accounts are separate and you cannot co- mingle funds ► Accounts are subject to the USE IT OR LOSE IT provision;unused balances do not carry over and cannot be refunded I , - --„, I DENTAL COVERAGE It's About More Than a Pretty Smile Our oral health affects our ability to speak,smell,taste, , - chew,and swallow.However,oral diseases,which can range from cavities to oral cancer,cause pain and i disability for millions of people each year.Plan F - - members can take advantage of discounts by using a network provider. Visit Your Dentist Regularly Regular preventive visits to your dentist can help protect your health,and we are talking about more - than just your mouth.As long as you utilize an in- network provider,our plan covers preventive services ,;" i at 100%in-network,with no deductible. Members can \ visit a provider four times a year for a cleaning and the ,rr plan will pay 100%.4444, s ' ' _ \ HELPFUL TIP _, r ' - If you choose to use an out-of-network provider, services may not be paid at 100%,and you may be balance billed the difference between the charge and it the allowed amount. ii k-- - 2020 DENTAL BENEFITS COSTS* 111, f' _ COVERAGE KO WELD P 0 s Employee Only $16.98 Semi-monthly $18.04 Semi—monthly I iltik Employee+One $32.47 Semi-monthly $33.11 Semi—monthly Family $46.77 Semi-monthly $47.84 Semi—monthly ‘III" ! *Pre-tax amount I A. NI • It' e- (4/ 'il\/7" ----- 282 �- .-t SUMMARY OF `w- ' E N TA L BENEFITS COST SHARING BlueDental Low Option High Option In-Network Out-of-Network In-Network Out-of-Network Deductible(Basic&Major Services Only) Per Person Per Plan Year $50 $50 $50 $50 Per Family Per Plan Year $150 $150 $150 $150 In-Network deductible credits apply to Out-of- Network deductible and Out-of-Network deductible credits apply to In-Network deductible. Coinsurance* We Pay You Pay We Pay You Pay We Pay You Pay We Pay You Pay PREVENTIVE** 100% 0% 90% 10% 100% 0% 90% 10% BASIC** 100% 0% 70% 30% 80% 20% 70% 30% MAJOR** 50% 50% 40% 60% 50% 50% 40% 60% SERVICE HIGHLIGHTS Oral Evaluations(Exams) Preventive Preventive Bitewing X-ray Prophylaxis(Cleanings)4 per benefit yr.–Adult/Child Fluoride Treatment(Child Only) Office Visits X-rays–Intraoral/Complete Series/Panoramic Sealants Amalgam Restorations(Silver Fillings) Basic Basic —Resin-Based Restorations(Anterior and Posterior) Extractions Surgical Extractions Root Canal Therapy Periodontal Treatment Crowns Major Major Osseous Surgery Partial Dentures Fixed Partial Dentures(Bridges) Surgical Placement of Implant Body:Endosteal Implant Implant Supported Porcelain Fused to Metal Crown (titanium,high noble metal) Orthodontia Service's None Adult and Child Orthodontia Lifetime Maximum $500 BlueDental Pays 50% Benefit Waitin• Period None WAITING PERIOD:(MAJOR SERVICES) NONE NONE CALENDAR YEAR MAXIMUM PER PERSON $1,000 $1,500 PROCEDURES PERFORMED BY SPECIALIST COVERED COVERED DENTAL ROLLOVER YES YES BlueDental Maximum Rollover FtoricaMae KIM In the pursuit of health' Maximum Rollover for BlueDental Choicdm Plan Members Maximum Rollover is a BlueDental Choice member'benefit that rewards you just for visiting the dentist. There are no fees for Maximum Rollover and no paperwork to complete.Whenever you use less than the yearly threshold amount, you'll receive Rollover dollars for the following year. What if you could use your Rollover dollars for unexpected visits the next year? Or wouldn't those extra dollars come in handy when you have to pay out-of-pocket for expensive dental work in the following year? See the chart below for some examples.Any available Rollover dollars will be added to your Rollover account approximately 60 days after the end of your plan year. It's that easy. Maximum Rollover* is applied to your BlueDental Choice, BlueDental Choice Plus sMor BlueDental Choice Copayments"^ plan automatically as long as you: • Receive at least one covered service during your plan year • Are an active member of the plan on the last day of the plan year • Don't exceed the claim payment threshold in your plan year Use the chart below to see what your Maximum Rollover dollars could add up to. 1. Look in the first column to find your plan option. 2. Next, find the threshold amount for your plan in the second column. If we pay out less than this amount in benefits, you'll automatically receive Maximum Rollover dollars next year. • 3. Check the third column for the maximum amount of dollars you qualify for next year. 4. The last column provides the maximum amount of rollover dollars that you can accumulate. 2.YearlyThreshold 3. Maximum Rollover 4. Maximum Rollover you 1. Plan Option Amount you'll receive next year can accumulate Low Option $500 .L _ $350 i $1,000 High Option $700 $500 $1,250 Questions?Want to learn more about Maximum Rollover or any of our other products and services? Our BlueDental Customer Service Representatives can help. Just call 1-888-223-4892 or find us online at FloridaBlueDental.com. *Maximum Rollover is not available for our BlueDental Cares"'plans. Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. BlueDental plans are offered through Florida Combined Life Insurance Company, Inc., D/B/A Florida Combined 284 VISION COVERAGE Besides helping you see better,routine eye exams can detect a number of serious health conditions,such as glaucoma,cataracts,diabetes and even cancer.Plus, eye exams for kids can detect problems that can impact learning and development. • As an EyeMed Vision Care member,you can improve "law your health by taking care of your vision and having s routine eye exams,while saving money on all of your \ eye care needs. . A dependent child living in your household,primarily dependent on you for support or is a full-time or part- time student may be covered though the calendar year immiumw in which the child turns 25. 2020 VISION BENEFITS COSTS* SUMMARY OF COVERAGE LOW PLAN HIGH PLAN LEVEL Employee Only $1.03 Semi-monthly $2.78 Semi-monthly 13/1 3E Employee+One $1.91 Semi-monthly $5.28 Semi-monthly BENEFITS Family $2.78 Semi-monthly $7.76 Semi-monthly *Pre-tax amount EyeMed Option 1 In Network Out of Network Member Cost Reimbursement Exam with Dilation as Necessary $10 Copay FT Up to$35 Frames 35%off retail price N/A Standard Plastic Lenses $50 Copay Single Vision $70 Copay N/A Bifocal $105 Copay N/A Trifocal. N/A Lens Options (paid by the member and added to the base price of the lens) N/A UV Treatment $15 N/A Tint(Solid and Gradient) $15 N/A Standard Plastic Scratch Coating $15 N/A Standard Polycarbonate $40 N/A Standard Anti Reflective Coating $45 N/A Standard Progressive Lens(Add on to Bifocal) $65 N/A Other Add Ons and Services 20%off retail price N/A Contact Lenses(discount applied to materials only) Conventional -- — —� —— 15%off retail price N/A Laser Vision CorrectionA LASIK or PRK from U.S.Laser Network 15%off retail price or 5%off N/A promotional price Frequency Examination Once every 12 months Lenses or Contact Lenses Unlimited Frame Unlimited 285 *Frame,lens,&Lens Option discount applies only when purchasing a complete pair of eyeglasses EyeMed Option 2 In-Network Out-of-Network Member Cost Reimbursement Exam With Dilation as Necessary $10 Copay Up to$35 Frames $0 Copay,$100 Allowance;20%off Up to$40 balance over$100 _ Standard Plastic Lenses Single Vision $25 Copay Up to$25 Bifocal $25 Copay Up to$40 Trifocal $25 Copay Up to$60 Standard Progressive Lens $90 Up to$40 Premium Progressive Lens $90,80%of charge less$120 Up to$40 Allowance Lens Options (paid by the member and added to the base price of the lens) N/A UV Treatment $15 N/A Tint(Solid and Gradient) $15 N/A Standard Plastic Scratch Coating $15 N/A Standard Polycarbonate $40 N/A Standard Anti-Reflective Coating $45 N/A Other Add-Ons and Services _ _ 20%off retail price _ N/A Contact Lens Fit and Follow-up Standard Contact Lens Fit&Follow-up Up to$55 N/A Premium Contact Lens Fit&Follow-up 10%off retail N/A Contact Lenses(discount applied to materials only) Conventional $0 Copay,$115 Allowance; Up to$81 15%off balance over$115 Disposable $0 Copay,$115 Allowance; Up to$81 ,plus balance over$115 . Laser Vision Correction LASIK or PRK from U.S. Laser Network 15%off retail price or 5%off N/A promotional price Frequency Examination Once every 12 months Lenses or Contact Lenses Once every 12 months Frame Once every 24 months Questions? 0 III Visit EyeSiteOnWellness.com 286 USAble LIFE INSURANCE COVERAGE Life Insurance and AD&D l St.Lucie County provides all full-time employees with a basic ' Why buy life insurance? life insurance benefit equal to one times basic annual earnings, . Life insurance provides a lump sum cash benefit rounded to the next highest$1,000,up to a maximum of$200,000. to surviving dependents to cover immediate The County also provides Accidental Death and Dismemberment, • expenses such as funeral expenses or ongoing which pays an additional benefit equal to the basic life benefit if living expenses.Life insurance benefits often help a death is due to an accident.These benefits are provided at NO survivors adjust to the loss of income related to the COST to the employees death of a wage earner or provide funds for college Supplemental Life Insurance or retirement for the survivors. In addition to the insurance provided free by the County,you can purchase additional life insurance in increments of$10,000 up to Benefit Reduction $300,000 for yourself,and up to 50%of the employee benefit for Your benefits will reduce to 65%at age 70. your spouse in$10,000 increments up to$150,000,and$10,000 ._ _ for a child(ren).Eligible children include: Lk/ , , �' ► Unmarried,less than age 30 ! ► Living in your household or a full-or part-time student /, dia .0 ► Depends on you for more than 50%of his/her support ``"'- - ► /ji/ A handicapped child age 30 or over,who was insured under this policy before reaching age 30 9,, A Evidence of Insurability , �f _- .� Evidence of Insurability requires you to complete a medical �... / , . . questionnaire,obtain a physical(at the carrier's request),and receive carrier approval before your insurance takes effect. �,tij , Life enrollment time frames are limited as detailed below: g / ► New Hires-You may apply for coverage up to the amount requiring Evidence of Insurability through the normal enrollment process. IMmsmimmmmmmmm ► Marriage,Adoption or Birth-If you are already enrolled in employee life,you can enroll new dependents as long as you follow normal event deadlines.If you wish to increase your employee life amount,you must complete the Evidence of Insurability Form and submit it within the normal life event deadlines. _. ► Annual Election to Increase Supplemental Life by One Increment-Each year at open enrollment,the life insurance carrier allows employees currently enrolled in lir the Supplemental Life Insurance coverage to increase their Life Volume by one plan increment of$10,000 up to the $150,000 guarantee issue maximum without the need for evidence of insurability.Only employees currently enrolled _ may participate in this feature(spouses and dependent children are not eligible).Enrollment and Evidence ofill Insurability forms must be submitted and approved to increase employee coverage over$10,000 or any increase in spouse and dependent child coverage. 287 USAble DISABILITY COVERAGE . .. `' Short-Term Disability(STD)insurance provides income continuation if r r i y you are ever unable to work due to a non-work related accident or illness. 4, ,-. , R� : Long Term Disability(LTD)insurance provides income continuation for �'� both non-work and work-related accidents or illnesses.The County PY a s 1 ,� I1 1 the full cost of both STD and LTD for full-time employees. . E w Short-Term Disability(STD) *• Alk* - STD begins on the later of the 15th day,or the end of accumulated •- • sick leave/vacation(whichever is greater)after a qualifying accident or , - illness.STD lasts for 13 weeks and pays a weekly benefit equal to 60%of your basic weekly earnings to a maximum of$1,900 per week. f at': ".;_ Long Term Disability(LTD) ' 4'` LTD begins on the 91st day after a qualifying accident or illness and pays `{ r' ._ a monthly benefit equal to 60%of your monthly income up to$8,000 v4 per month.The maximum benefit period is to age 65 Reducing Benefit , 4 - ; ' Duration. .1 r t t I 1 THE HARTFORD ACCIDENTAL DEATH ;ri • r tit , &DISMEMBERMENT . ; 1 Accidental Death&Dismemberment benefits offered through CNA Hartford provide a specific benefit for loss of life,limbs,speech,hearing or sight as defined in the policy.If enrolled,benefits under this policy are separate from,and pay in addition to,the Life&AD&D benefits available through the County's Group Life policy.Losses caused by medical or surgical treatment of sickness or disease are not covered. You can enroll the following dependents: C�� A& ► Your Legal Spouse as indicated by Florida Law lir Age 'eduction ► Your Dependent Child who is 18 years of age or younger and (applies to Employee&Spouse coverage) who is chiefly dependent upon you for support and maintenance Age 69 or younger 100% or who is living in your household 70-74 65% ► Your Dependent child who is 19 through the calendar year in 75-79 45°i° which the child reaches 25,provided such child is attending an 80-84 30% accredited school on a full or part time basis,is dependent upon 85 and dft V& you for support and maintenance or is living in your household Principal Sums ► Employee:$10,000 to$250,000 in increments of$10,000.Principal sums in excess of$150,000 may not exceed 10 times your basic annual salary ► Spouse:50%of your original principal sum if there are no insured dependent children covered at the time of accident;or 40%of your original principal sum if there are insured dependent children covered at the time of the accident ► Children:15%of your original principal sum if there is no spouse at the time of accident;or 10%of your original principal sum if there is an insured spouse at the time of the accident 288 EMPLOYEE ASSISTANCE PROGRAM(EAP) Life presents challenges to each and every one of us.Sometimes we need a little extra help.St.Lucie County provides a comprehensive and 100%confidential employee assistance program through Resources for Living.These EAP benefits are available for all full-time employees,and all members of your household and your adult children up to the age of 26,regardless of your medical insurance coverage.Services are confidential and are available 24 hours a day,7 days a week.You are automatically enrolled with no ID required. Counseling and Relationship Support ► Unlimited,toll-free telephonic access to EAP dedicated staff, 24 hours per day ► Telephonic access to licensed behavioral health professionals A L p e 2, o ► Support,consultation and resources for stress,family relationship issues,anger management,substance abuse,and helping you ) balance work and home life ct�r m,`, I www.mylifevalues.com ► 6 face to face counseling sessions per issue per year,with licensed sducieao I] sswo .8002723626 network professionals,at no cost to you;i.e.,no copays or deductibles Online Services Online information and provider search features for locating resources that families need,such as: ► Child care-Convenience/personal services-Adoption ► Parenting-Pet care-Temporary back-up care ► Special needs-Elder care-School/college planning ► Urgent/daily living needs-Caregiver support-Consumer information ► Summer care-Care for people with disabilities ► On-line Discounts on brand-name products and services,including categories such as computers&electronics,theme parks,movie tickets,local attractions,travel,gifts,apparel,child and elder care,flowers,jewelry,fitness centers and more Legal Services Half-hour free consultation with a participating attorney for each new legal topic(each plan year)related to: ► General Law(excluding employment law)-Special Needs,including emergency matters ► Mediation Services-Document Preparation ► A discount of 25%off the hourly rate charged by the participating attorney for any legal services not covered and/or beyond the 1/2 hour initial consultations referenced above ► All services must be for legal matters related to the employee and eligible household members Financial Support Half-hour free consultation on new financial counseling topics each plan year ► Topics include Budgeting,Credit,Debt,Retirement,College Funding,Buying vs.Leasing,Mortgages/Refinancing,Financial Planning,Tax Questions&Preparation,IRS Matters,Tax Levies&Garnishments,Consumer Credit Counseling,Community Services ► A discount of 25%off the tax preparation services ► All services must be for financial matters related to the employee and eligible household members Other Services Identity Theft Services—One hour telephonic fraud resolution consultation as well as coaching and direction on prevention and restoring credit for victims of ID Theft,and a free Identity Theft,Emergency Response Kit for victims of ID Theft. 289 GLOSSARY OF BENEFIT TERMS In order to obtain a complete understanding of your health plan benefits and spend your health care dollars the best way possible,you should be familiar with the following terms: Coinsurance Your share of health care expenses for covered services.After your deductible requirement is met,a percentage of the allowed amount will be paid by the plan.The remaining percentage is your patient responsibility. Balance Bill You may receive a bill from an out of network provider for the difference between the actual charges and the plan's allowed amount.In-network providers will not balance bill anything above and beyond the deductible,co-payment and coinsurance as indicated by the plan. Co-payment A fixed dollar amount that you are responsible to pay for a specified service. Deductible An amount you are responsible to pay for certain service's before the plan begins to pay its share of the eligible expenses. The deductible is a requirement each calendar year.Please refer to the Evidence of Coverage document for a full listing of , services subject to the deductible. { Dependent Care Spending Account Lets you set aside pre-tax dollars to pay for eligible childcare expenses.Because the reimbursement account contributions { are not taxed,you decrease your taxable income while increasing your available cash.Funds do not roll over year to year, are not portable and do not accrue. Explanation of Benefits(EOB) Explains how a health benefits claim was paid.A fixed dollar amount that you are responsible to pay for a specified service. Flexible Medical Spending Account A tax-advantaged account that can be used to pay for medical expenses.Contributions to the FSA are made by the employee.Funds can only be used to pay for claims in the year they are accrued.Unused funds are forfeited. Funds are not portable and do not accrue interest. { Out of Pocket Maximum The maximum amount that you will pay towards deductible,coinsurance,and co-payment during a given calendar year. Once the stated out of pocket maximum has been satisfied,benefits will be paid for eligible expenses at 100%. Pre-certification/Authorization Requirements Please remember that there are certain services that require a pre-certification or authorization.Failure to follow these guidelines may result in a reduction or denial of benefits. Pre-Existing Condition Effective January 1,2014,all pre-existing condition exclusions were removed from the plan. 290 VOLUNTARY BENEFITS The Voluntary programs sponsored by St.Lucie County are individual policies offered through convenient payroll deductions, which are portable should you change employment.That means you can take the coverage with you.County employees and family members have preferred underwriting with most enrollment requiring no medical questions or exams.Below is a brief overview of these plan offerings: Trustmark Accident 24 Hour Protection Plan This plan covers you for both on and off-the-job accidental injuries.You can go to any facility in the country and receive benefits.It is great for families with children in sports. ► Policy pays cash benefits directly to you,over-and-above any other coverage and protects you 24 hours a day and , provides benefits for injuries that occur either on or off-the-job ► Benefits include:ER,Hospital admissions,ambulance,fractures,dislocations,burns,lacerations,follow-up visits, emergency dental,Accidental Death Benefit ► $100 Wellness Benefit is payable up to two visits per person,per year.Wellness Benefit includes routine physicals, immunizations and health screen tests To enroll in these voluntary benefits. call US Enrollment Services at 800.282.0732 Benefit Amount ' Benefit Amount Initial Care Injuries Hospital Benefits Fractures Admission Benefit(per admission) $3,200 Open reduction up to $15,000 Confinement Benefit(per day up to 365 days) $500 Closed reduction up to$7,500 ICU Benefit(per day up to 15 days) $1,000 Chips 25% of closed amount ' Emergency Room Treatment $150 Dislocations Ambulance Open reduction . up to $12,000 Ground $600 Closed reduction up to$6,000 Air $2,500 Laceration $50-$1,000 Initial Doctor's Office Visit $200 Burns Lodging (per night up to 30 days per accident) $200 Flat amount for: Third-degree 35 or more sq. in. $25,000 Surgery Benefit Third-degree 9-34 sq. in. $4,000 Open, abdominal,thoracic $2,000 Second-degree for 36%or more of body $2,000 Exploratory $200 Concussion $200 Blood, Plasma and Platelets $600 Eye Injury Emergency Dental Benefit Requires surgery or removal of foreign body $400 Extraction $150 Crown $450Ruptured Disc $1,000 Follow-Up Care Loss of Finger, Toe, Hand, Foot or Sight Loss of both hands, feet, sight of both eyes Accident Follow-Up Treatment $200 or any combination of two or more losses $40,000 Physical Therapy Loss of one hand,foot or sight of one eye $20,000 1 Up to six visits per person per accident $100 Loss of two or more fingers,toes or any Appliance $250 combination of two or more losses $4,000 Loss of one finger or one toe $2,000 Transportation Tendon/Ligament/Rotator Cuff Injury 100+ miles, up to three trips $600 Repair of more than one $1,500 Prosthetic Device or Artificial Limb Repair of one $1,000 More than one $2,000 Exploratory surgery without repair $200 One $1,000 Torn Knee Cartilage $1,250 ' Skin Grafts 25% of burn benefit Exploratory surgery $250 291 VOLUNTARY BENEFITS Trustmark Universal Life with Long Term Care Policy This program lets you provide a lifetime of coverage by locking in your rate at today's age.It gives peace of mind that comes with knowing there are funds available when they are needed most. ► Guaranteed Issue for Newly Hired employees age 65 and under and contingent guaranteed issue for New Hires age 66-70 and all spouses and children if you enroll when initially eligible ► Spouses can apply even if employee elects to waive coverage ► Guaranteed premiums for life and guaranteed death benefits for life ► Guaranteed cash values as long as you pay the premiums Universal Life Insurance 65+ Trustmark Universal LifeEvents insurance is permanent life insurance that helps shield your family from financial hardship if you or your spouse is suddenly out of the picture.It: ► Helps provide permanent financial protection ► Is a financial tool that helps you manage life at every stage from supporting a family to sending your children to college to the need for long-term care ► Builds cash value over time that you can access for life's challenges and life's opportunities ► Benefits can be paid as a Death Benefit,as Living Benefits,or as a combination of both.What's covered? The LifeEvents Advantage LifeEvents is designed to match your needs throughout your lifetime.It pays a: ► Higher death benefit during working years when expenses are high and your family needs maximum protection.Then, at age 70 when financial needs are typically lower,the death benefit reduces to one-third ► Consistent Level of Living Benefits throughout retirement when you are most likely to need long-term care services Living Benefits Long-Term Care Benefit(LTC)pays a monthly benefit equal to 4%of your death benefit for up to 25 months.The LTC benefit accelerates the death benefit and proportionately reduces it. Benefit Restoration Restores the death benefit that is reduced to pay for LTC,so your family receives the full death benefit amount when they need it most. Additional Benefits ► Children's Term Life Insurance—Covers newborns to age 23 and is convertible to Universal Life insurance Optional benefit ` ► Waiver of Premium—Waives policy payments if • your doctor determines you are totally disabled Y �'` ► Accidental Death Benefit—Doubles the death ''` benefit if death occurs by accident prior to age 75 ..r. .. t 1 • x`292 k _ VOLUNTARY BENEFITS ,-F l,. •.t. Trustmark Critical Illness Coverage 4• �,, . If you are diagnosed with a Critical Illness,where does the money come from to cover the ,.:t}f,•.: I"�" deductibles,coinsurance,and out�f pocket expenses.This plan pays cash benefrts directly . '. to you,over-and-above any other benefits that you may be eligible to receive. '. `' ► Pays a tax-free lump sum that you choose between$10,000 $100,000 of , coverage upon the diagnosis of a covered critical illness.Does not require any -«-- treatment or hospitalization to trigger a claim,only certain diagnostic criteria of the ° condition `'- ` •a. ► Covered conditions include:Heart Attack,Stroke,Internal Cancer,Organ •' f Transplant,Renal(Kidney)Failure,Paralysis,and Coma.Partial payments for: Coronary Artery Bypass Surgery,Carcinoma in Situ ` .'. ► An annual$50 wellness benefit is payable per insured for any preventive screening, chest x-ray,certain blood tests Critical Illness insurance Trustmark Critical Illness Insurance pays benefits upon the first diagnosis of a covered ;-'.1'1- critical illness.It provides a cash payment for expenses and treatments not covered by most medical plans,and it pays before most high-deductible health plan benefits begin.A •�..� health screening benefit identifies and reduces health risks,making it easier for you and your ! covered family members to stay healthy. ` '-' Covered Conditions ::77 Invasive cancer•Heart attack•Stroke•Renal(kidney)failure•Blindness•ALS(Lou Gehrig's ' 'I" ~` disease)•Major organ transplant•Paralysis of at least two limbs•Coronary artery bypass •"'" surgery(25%benefit)•Carcinoma in situ(25%benefit) Benefits you'll appreciate ,,, , 3 ► Lump-sum benefit—Paid directly to you,regardless of any other coverage you have . ► Subsequent condition benefit Pays a lump-sum cash payment when you are -, , t4PA,4 diagnosed with any covered condition included in your policy.There are no limits to the number of payouts for each insured family member and no reduction in payouts for later-diagnosed conditions . ► Best Doctors@ medical advice when you need it most.Receive one-on-one 4141 support in connecting you to the medical information you may need for covered Ilk ,) _ conditions -_ 4•�. ► Heahh Screening Benefit—To help you stay well,the Health Screening Benefit pays the cost of one screening test per calendar year($50 maximum).Some i of the many screening tests covered include: •Low dose mammography Chest X-ray•Pap smear(women over 18)•Bone marrow•Serum cholesterol• 1 Colonoscopy•Prostate specific antigen•Stress test 4" t Optional benefit Y ► EZ Value automatic increases ► Waiver of Premium—Waives premium payments if your doctor determines you are totally disabled • .4>,, 4.*,..' ,''',. 4100.),,,k,,."_ -•4yu• VOLUNTARY BENEFITS Aflac Hospital Confinement Indemnity Insurance How would your family carry on if you were unexpectedly hospitalized?This program lets you create a more comprehensive medical plan with options to cover the following: DESCRIPTION HOSPITAL CONFINEMENT Pays$500;$1,000;$1,500;or$2,000.You choose the benefit amount at the time of application.Payable once per calendar year,per covered person. REHABILITATION FACILITY Pays$100 per day;limited to 15 days per confinement. Limited to 30 days per calendar year,per covered person. HOSPITAL EMERGENCY ROOM Pays$100 for treatment in a hospital emergency room. Limited to 2 payments per calendar year,per covered person. HOSPITAL SHORT-STAY Pays$100 for hospital stays of less than 23 hours.Limited to 2 payments per calendar year,per policy. -" 4 WAIVER OF PREMIUM Yes Choose the Policy Riders that Best Fit Your Needs Below 7 t. OPTIONAL RIDERS DESCRIPTION tl f P «3 r '...n L_- , , EXTENDED BENEFITS RIDER Physician Visit Benefit:Pays$25 for visits(including telemedicine) I 1 to a physician,psychologist or urgent care center. 2 . 1 Individual Coverage: Limited to 3 visits per calendar year,per 1 a IE _'S , r policy. f i 1, ' �, 1}r ,� ' 1) 1 j Insured/Spouse&Family Coverage: Limited to 6 visits per 1. ,. * ` • fir. 1 ��IJ l calendar year,per policy. �1 f . Li" �- j__ I Laboratory Test and X-Ray Benefit:Pays$35;limited to 2 r, '4A • • payments per covered person,per calendar year. i•-•-•-.4-4-____-.4 .t.._....... c _�---- '_.� (.r 7 Medical Diagnostic and Imaging Exams Benefit:Pays$150 for a ^ ', / f / ` " • �`-� covered exam,limited to 2 exams per covered person,per Y..',,), � rt"."*"..3 JTcalendar year.Benefits payable for a variety of medical i _ diagnostic and imaging exams,including sleep studies. f `v I X11 t Ambulance Benefit:Pays$200(ground)or$2,000(air)for VV transportation to or from a hospital.The benefit is limited to two 1 trips,per calendar year,per covered person. • r } HOSPITAL STAY AND SURGICAL Initial Assistance Benefit:Pays$100 once per calendar year,per t CARE RIDER rider,when a coveredperson requires a hospital admission. p t t. q p s I + tti ISurgery Benefit:Pays$50-$1,000 for a covered surgery.Limited to one payment per 24-hour period,per covered person. ,N �'�yr_ "" Invasive Diagnostic Exams Benefit:Pays$100 for one covered /,' 1'` exam,per covered person,per 24-hour period. 4.144•:.-•• rig % :, ; ( ;:, Hospital Intensive Care Unit Confinement Benefit:Pays$500 per .4 `. •• ...6...t . '..."'-- day,per covered person,for up to 30 days. / / ..w. 4, �f ...... �'�' _e•=� .�a■�" . Daily Hospital Confinement Benefit:Pays$100 per day,per covered person,for up to 365 days. 11111 1 11,41 Second Surgical Opinion Benefit:Pays$50 once per covered • person,per calendar year. • . 294 EIil —� 31 t VOLUMTARY BEMERITS Aflac Cancer Protection Policy Why Cancer Insurance? The costs to fight the disease have escalated beyond the means of most individuals and have become the target of limitations and restrictions within many medical policies. It gives peace of mind that comes with knowing there are funds available during treatment. A cancer insurance policy can also help protect your income and savings from expenses that aren't covered by your major medical health insurance policy,including: ► Hospitalization Benefits ► Continuing Care Benefits ► Experimental cancer treatment ► Travel and lodging when treatment is far away from home 4 �+►.r.�_.'� / 741411111110b .,r (J .j \v ' i/ 295 AFLAC Cancer Protection CANCER INDEMNITY INSURANCE Added Protection for You and Your Family Chances are you know someone who's been affected, directly or indirectly, by cancer.You also know the toll it's taken on them—physically, emotionally,and financially.That's why we've developed the Aflac Cancer insurance policy.The plan pays a cash benefit upon initial diagnosis of a covered cancer,with a variety of other �. benefits payable throughout cancer treatment.You can use these cash benefits to help pay out-of-pocket medical expenses,the rent or mortgage,groceries, or utility bills—the choice is yours. And while you can't always predict the future, here at Aflac we believe it's good to be prepared.The Aflac Cancer plan is here to help you and your family better cope financially—and emotionally—if a positive diagnosis of cancer ever occurs.That way you can worry less about what may be ahead. HOW IT WORKS AFLAC Policyholder Physician visit AFLAC CANCER suffers from &bone marrow CANCER $23,575 a PROTECTION frequent biopsy reveals • PROTECTION infections& diagnosis of insurance policy coverage is high fevers. leukemia. provides the TOTAL BENEFITS selected. following: The above example is based on a scenario for Aflac Cancer Protection Assurance—Option 2 that includes the following benefit conditions: Bone Marrow Biopsy(Cancer Screening Benefit)of$75,Initial Diagnosis Benefit of$4,000,IV Chemotherapy for 3 months(Physician- Administered Radiation Therapy,Chemotherapy,Immunotherapy,or Experimental Chemotherapy Benefit)of$3,600,Immunotherapy (Physician-Administered Radiation Therapy,Chemotherapy,Immunotherapy,or Experimental Chemotherapy Benefit)for 6 months of • $7,200,Antinausea Benefit(9 months)of$900,Stem Cell Transplant Benefit of$7,000,Hospital Confinement Benefit(4 days)of$800. Benefits and/or premiums may vary based on state and benefit option selected.Riders are available for an additional premium.The policy has limitations,exclusions,and pre-existing condition limitations that may affect benefits payable.The policy may contain a waiting period.This brochure is for illustrative purposes only.Refer to the policy for complete benefit details,definitions,limitations and exclusions. FACT NO. 01 FACT NO. 02 IN THE UNITED STATES,MEN HAVE SLIGHTLY LESS THAN A IN THE UNITED STATES,WOMEN HAVE SLIGHTLY MORE THAN A -in- ic-in- LIFETIME RISK OF DEVELOPING CANCER.' LIFETIME RISK OF DEVELOPING CANCER.' 'Cancer Facts&Figures 2012,American Cancer Society. The policy has imitations and exclusions that may affect benefits payable.For costs and complete details of the coverage,contact your Aflac insurance agent/producer. This brochure is for illustrative purposes only.Refer to the policy for benefit details,definitions,limitations,and exclusions. Aflac herein means American Family Life Assurance Company of Columbus. To enroll in these voluntary benefits. call US Enrollment Services at 800.282.0732 33 Pet 6, A Assure ro, What is Pet Assure? Pet Assure is a veterinary discount plan. Get savings on your pet's veterinary care, including: g Wellness Visits 412 Dental Cleanings D. Dental Exams and X-Rays CI Allergy Treatments Sick Visits Cancer Care 41 Emergency Care Hospitalization And all other in-house medical services Veterinarians are not required to discount take-home products, like food or flea products;non-medical services, like grooming or boarding and outsourced services,like bloodwork sent to an off-site laboratory. 25% Discount on Medical Services- No Claim Forms, No Deductibles! 24/7 Lost Pet Recovery Included! All Pets are Eligible! Covers Pre-Existing Conditions! Single Pet: $4.00 semi-monthly \ r Unlimited Pets: $5.50 semi-monthly 1 , .a Website for in-network providers: www.petbenefits.com/search 297 it pETplusTm Save upto 50% on Your Pet' s Prescriptions, Preventatives, Food, :1 Toys & More ! ! II All Dogs and cats are eligible for PetPlus, regardless of their age or breed. PetPlus even covers pets with pre-existing conditions. Get Members-Ontypricing On Brand Name: Q Prescription Medications Flea &Tick Products • Heartworm Preventatives Vitamins & Supplements ri Food (Rx & Non-Rx) b Toys &Treats, tj, Grooming Supplies V° Accessories &Apparel Free shipping on all orders! Pickup medications at Caremark Pharmacies including Walgreens, Target, CVS, and others! Easy-to-use App, Prescription verification at your veterinarian! Only $1.88 semi-monthly for Single Pet Only $3.75 semi-monthly for Unlimited Pets 298 I � _ _ 1 1 Be ifuflOy oro © d and c© kkcrit wirla Legag Unee ,,,.f lega ns ax r an •ro-f •1 7, , ti"' ' offe e•'it' � 1 Employee , S -11 @liE ' @CM NT'Y 4i-, .01; :, '/ - V roteG *o f,fa d '3 i +jam 4 ; ma egaE • S= i LegaIEASE offers valuable benefits to shield your family and savings from unexpected personal legal issues. -0/1-----N_ ha 1 _if '\ARG e•aEASE i • i • An attorney with expertise specific • ....„.,7* ` to your personal legal matter I '' '` .,. • Access to a national network of attorneys with exceptional ` °=: , • _/" experience that are matched to i'�.. . ,,.,„,; meet your needs • In and out-of-network coverage (,`X I • Concierge help navigating common individual or family legal issues nro I ow to i&L Ca ,AS nsurance 'la . To learn more: Call: 1(800) 248-9000 Visit: legaleaseplan.com/stlucie Member Services: 1(888)416-4313 41101 i1 kGALEASE � __ `. 99 A legal insurance plan can ease the biggest stresses - finding i and paying for legal expertise when you need it most. LegaIEASE offers an insurance plan that provides support and protection from unexpected personal legal issues. Plan Details: $8.94 semi-monthly*, Who's -Employee Spouse Dependent Children - Up to age l9;Age 79.26 via payroll deduction covered: enrolage1 ;Afull-time 19-2 accredited university i *Based on a 24 pay-period deduction schedule The value of a LegaIEASE insurance plan. ' Being a member saves costly legal fees and provides coverage for: thHOME& RESIDENTIAL AUTO&TRAFFIC Purchase, Sale, Refinancing of Primary Residence/ Serious Traffic Matters (Resulting in Suspension Vacation or Investment Home,Tenant Dispute, or Revocation of License), License Suspension Tenant Security Deposit Dispute, Landlord Dispute (Administrative Proceeding),Traffic Ticket, with Tenant, Security Deposit Dispute with Tenant, First-Time Vehicle Buyer Construction Defect Dispute, Neighbor Dispute, • Noise Reduction Dispute, Foreclosure FINANCIAL&CONSUMER 0 FAMILY MI Debt Collection Defense,Bankruptcy,Tax Audit, jj Separation, Divorce, Name Change, Student Loan Refinancing/Collection Defense, Guardianship/Conservatorship,Adoptions, Document Preparation, Consumer Dispute, Small Juvenile Court Proceedings, Prenuptial Agreement Claims Court, Mail Order/Internet Purchase Dispute, Bank Fee Dispute,Cell Phone Contract Dispute, Warranty Dispute,Financial Advisor,Identity Theft I Defense ESTATE PLANNING&WILLS i� GENERAL di Will or Codicil, Living Will or Health Care Power Iomm Civil Litigation Defense,Initial Law Office � of Attorney, Probate of Small Estate, Living Trust `um'"„ Consultation,Review of Simple Documents, Document Mediation,Misdemeanor Defense, Incompetency Defense, Identity Theft Assistance,Discounted Contingency Fees 1 Limitations apply.Please visit https://www.legaleaseplan.com/stlucie for specific plan benefits. i, For more information, visit: U https://www.Iegaleaseplan.com/stlucie To learn more, call: EGALEASE- ® 1(800) 248-9000, and reference "St. Lucie County" ' Member Services: 1(888)416-4313 Limitations and exclusions apply.This benefit summaryis intended onlyto highlight benefits and should not be relied upon to fullydetermine coverage. P More complete descriptions of benefits and the terms under which they are provided are received upon enrolling in the plan.If this benefit summary conflicts 1 in any way with the Policy issued,the policy shall prevail.Group legal plans are administered by Legal Access Plans,L.L.C.or LegaIEASE Home Office: 5151 San Felipe,Suite 2300,Houston,TX.This legal plan may not be regulated as insurance in some states.Product available in all states.Underwritten by Nationwide Mutual Insurance Company and affiliated companies in all states except HI,ID,NH,NC,OH,PA,SC,TX,and WY,where underwriting is i not required.©2019 Nationwide Mutual Insurance Company.SHR-0159M1_NW INS_Enroll_1 PG_StLucieCounty_2019-09 • 300 I 1 1 . , t LifeLock. \___..) with€Norton I Benefit Plans 11 1My Norton Jordan Smith.., co i ', 2 of t 0 licenses used 1 ACTIVE FEATURES - v` �w'` — Device Security --'- -_— Installed , 1 , __ ii., _ ■ ■ Theft Protection i iD ,.. ktom'torirg attire fi Credit Score&Report L i 3 bureaus f r I Password Manager More and autordt DassntlWs - ' Cloud Backup 11.9C,13 of l SO Ga Used Screen modified for demonstration purposes. Features may differ depending on plan. . CI. iiii7, .. H �/ L f i J J L i _� �y__} -\,. -LifeLockldentity Theft Protection and Norton Device Security are redefining what it means to be safer in the digital world. Everyday activities like online shopping, banking,and even browsing can expose your personal information, making you more vulnerable to cybercriminals. LifeLock with Norton Benefit Plans combine leading identity theft protection and device security against online threats,viruses, ransomware and malware, at home and on-the-go. Let us help protect your identity, your devices and your online privacy, in an always connected world. ELECT YOUR PLAN DURING BENEFITS ENROLLMENT. E Benefit Pricing - Semi Monthly Rates ['LifeLockrtEssential • LifeLock- Premier F _mi I Employee Only(18+Years Old) $3.75 $6.00 •• �j,s. Employee+Family° $7.49 $11.99 E • e The LlfeLock Benefit Junior plan is.for minors under the age of 18.LifeLock enrollment is limited to employees and their eligible dependents.Eligible dependents must live within the employees household.or be financially dependent on employee. LifeLock services will only be provided after receipt and applicable verification of certain information about you and each family member.Please refer to employer group for the required information under your plan.In the event you do not complete • the enrollment process for any family member,those individuals will not receNe LifeLock services,but you will continue to be charged the full amount of the monthly membership selected until you cancel or modify your plan at your employer's . next open enrollment period,which may be annually.Please note that we will NOT refund or credit you for any period of'time during which we are unable to provide LlfeLock services to any family member on your plan after your benefit effective date due to your failure to submit the information necessary to complete enrollment.if you do not complete the enrollment process for each family member,you may continue to pay more for Lifelock services than you otherwise would if you had selected a lower tier plan. - 1 • LifeLock Identity Alert".System' i • • • •Payday-Online Lending Alerts' • . - • - '• • • •Credit Alerts&Social Security Alerts' • • • LifeLock Mobile App(Android"&IOS)" . • • .• .cm nloadig the aro does not prodder protection. . 1 Dark Web Monitoring" I • . • • LifeLock Privacy Monitor" • • . . • • • USPS Address Change Verification '. • • Lost Wallet Protection • . . • Reduced Pre-Approved Credit Card Offers • • • • Fictitious Identity Monitoring j •- • Data Breach Notifications i • • • -4— Credit,Checking&Savings Account Activity Alerts" • .F • •• z t• • .Checking&Savings Account Application Alerts'" - • V oBank Account Takeover Alerts'- I • . • 0 l, 401K&Investment Account Activity Alerts'" • . . - • r File Sharing Network Searches ; • _ • z Sex Offender Registry Reports . f • • • y a • Online Account Monitoring- 1 • • •_, Expected evavalury 2020 sbkm to longe. • Prior Identity Theft Remediation' . I This feature Is separate from our Millon Ooler Protection'Package and does not provide coverage kr ha.*n pma end ereindasernere of • • stolen finds a compensation for personal arenas for events waning during the 12 months prior toeNPanent See disclaine fordetais, . U.S.-based Identity Restoration Specialists • • • 24/7 Live Member Supporta �� • • • • Million Dollar Protection"Package"' i . • •Stolen Funds Reimbursement i Up to 51 Million each • Up to Si Million each . •Personal Expense Compensation •Coverage for Lawyers and Experts . . . � - •Credit Application Alerts" . One-Bureau One-Bureau • • •• Credit •Monitoring'" � One-Bureau Three-Bureau • r Annual Credit Report&Credit Score'" I The creel sores provided reevantpeSmre Jo O credit scores based ondinafrom Emits,.Erb..and Translluion respecdoey.mad E Three-Bureau parties use many different types of credo scores and are Theyto use dneent type or credit score to assess rat creditworthiness. . • .Monthly Credit Score Tracking'" ..Tile credit sate proAled b evantapesme 30 credit core based on E9uirax dao.Third parties use fn.).didfeadtypes oroedv scaea t . One-Bureau and ore lkeyto use a different type of attic score to assess your creditworthiness. 1 Secures PCs,Macs,Smartphones/Tablets" Up to 3 devices 'Up to 5 devices - (Farah getsa devices) (Family gets devices) Online Threat Protection" : 0 0 Password Manager" . •� 0 . •' O - • Parental Controls, I 0 0 • Smart Firewall' 0 • -- O Vy • • Cloud Backup' ' 10 GB -----�50 GB . `> SafeCam''• i 0 O - o • t � Norton- . . OLifeLock 'n your plan includes credit reports,tape°.and/or area mahahg features(*Cm.Features),two reguireneT mum be met to receive said featum; '""Reknboamant and Expose Catpetw'.brl eachxdrhhmda of up to Sl milk.for Ufelodr with Norton Benefit EsseMkland Ufet rkussh Norton n yourdendty must besccessfully verged with Equifax and(2)Equfax muni be able to locate your credit frier and it must marten sunxdent credit 1 Benefit Premier and up o525po0 for Benefit Juries,and up to Sl million kr coverage for lavyes and experts llFleecier(for ae plans.Benita under the • history information.IP EITHER OF THE FOREGOING REONREMENTS ME NOT METvOU WILL NOT RECEIVE CREDIT FEATURES FROM AM BUREAU.If Master Policy ere lowed and covered hat United Specially Insurance Cowpony(Stare National Insurance Cowpony,Inc.fo NV State members).Pokey year plan also includes Crest Excises horn Epedan and/or TransUNon the grave verification oocesamust also be auctesaf140 completed with terseondron and exnbbre.v UlefackeorMegd. Caperton and/or TramUnlort as eppicable.If verification b suoussruey compel.]with Equifax but not with Experien and/or TransUdort asePpecable. yyweuw�rotrn EvA Cndit Feature nom wM baeau(s)unitl dTrorfoatbn p/d ruko auocesvM1/lycanpteM end sNi then you nanyone-c un,,, -Tyuese features ere not meted tom mmlham.M mbv must take acoonm aRMmetlla protecVoh. Featuehan0polax0nyoedc en uy npfom Fmpebne rmbolhionwiaokewont dayaobegnaRepo°usessfnpbne h,uddu rnl $ •SCRat o ek@Titiy requirements Permed n Terms 6 Cmdnbm s holo/Ms+wFreloekcon/lepaVpriaNcicah tion S/muntec reserve the right note Math ode a enjoy all Moues h your down On scenes bath accoutalerRaedn moNtamg.and credit retorts.It nay require addnloal { change and/or cease seMces at sly tine. Mbit hon you and may not be amiable wail mhpletbn I •English only' •If your plan includes as Btvem Credit Appiba-,im Nem,two requirements must be metro receive sad realises,(i)your identity must be successfully I No one can prevent aseevvay theft or cybeopne. MfiedwithTonstlrhi Sand n Tnnslhion must be able to kcareyuanawn file and It nos',carob sufaietoeer Na:ay hdomatlon IF EITHER OF Unity,*andNorton bySymta ere no„„,,,,,,,Ukl.Ms THE FOREGOING REQUIREMENTS ARE NOT MET YOU WILL NOT RECEIVE ONE BUREAU CREDIT APPLICATION ALERTS.One Btreau Credit Application/ ,mp19 a:bseveralAlertsniake several days o begin ane you successful successful Welsch plan enrolment t CaPlripin Symantec Corporn Ad rights reseved.Symm ae:the Symarcec Logo,the Checkmark Logo.Norton Norton by Symantec,Ufelxrit •Not at brutes ere wank/ea,ore ptsrortm.Naton Family Parental Controls,Nonni Cloud Backup and PC SaroCam are pteseedynoi ahppatedm 1 a and the lkMan Logo are tnm deada o registered trademarks or Syrnama Coryoadoncr its affiliates in the U.S.and other canoe.Ocher amen may Mae05'. be trademark.of their respective owners.Norton Ufeto do b the Consumer DMalon or Symanttt. 'LifeLock doesnot monitor antrensadbns at all businesses I • _ GPPM855a • -• 302 1 i � • j • 1 NaN A oo,V • Fori a Blue Cares W .ri®eNaidmi#tHu wtbD manage your ongolig ! h amrdittintr4? FEdiih jgovenala6 ddniiil haill!yin'irressailto imennvornber about your mn>ediicalI ttmmri? HbrIzeippeeezbfrririnIckhooviliaffklxiiiiika LILEE(Zrres. T Kb E El cid eld3Ble 3 aaeI eearrnwarliEsftm-In:di-iim--Mand with your Pl ersieiianT6ggdtlee myeeFfnittyyckuall.alwamimiterof all we . d doYa'ood el eldiael±earaet mi nuttuthies doctors,nurses, plpirarrraaisiKssooialalmemllerss,oHeitttiaTE6a lot hers_ • .„," l Ya6oiarf 'riga sepdian irrldudes these ' ' _ A_ 4.1 74 seevdd� a ... ` f. 'i ,..\:,,. 081\_lit : 1, ,... ,N44,,( Art AkI�ikiabEe& tearnwir{'mn r 6yawsr best �� � �} 'SE y hisekltltl6�irtimarit�y ;� . � �``� /;7. q. - f � ',Dddalieteelchmasesswilmoft �armsii„ nlrfying `= 'Qis hbehlthceamaalir�y�ourr nyourhealth i, �, � ;g ..A. ..c eggeklS 4' f4. lirPRYgg3raras3aalthssesstto�tyya�xurj�ourney PO ( �' ,- a.: ..... •~' *�.'f tct�b erhlae�dlth4 �/ ' c' 4F Aceesacbaconnrrmuniit yr n t$hs�tt help with 1r ,14..„::.„4. 1... .... ' '� � _. trimsispora n,f��0.,.,ffo►tu� well more.R r{ ',�. \ _ 4 J e a Ilithiae 4ttr � ; rvat - .,-, - . . 1 FiriatittleElitte ndlirm seem have. .r.- 0'►, , t'� ,� �. - ' Td-cfifir:lC ttif1{ffhiBS po3NEa This{ Tryouu„ iread f. � ��� i 1 _i � B EMI stjryonnt ca �ll WIC at ,, -- ~y}��-1+\ t 1 1380C9S15555692arailselkatt ellittimn 3. OA- , ' `\. ' -- - . tit ' ' 40 `-` - - litre Eie 0:791,,V. r See . How791, . ©„,, A , , - glue,„..,, ,a, Care `beam Makes iffe epee . , ,. ,,, III1ik'r sswifitfioH;;usi:::u:::;:... o Flblrariali3 Ede EnarseeJdenifitherreaiil 1 II I riensil611 help O O ccna n ilfiig4lsibhiodc esiar. �oall::1.iHriiun-in her help. Agksftrdi4isteedddA38111,J rrnirfikerl� e l arrr : 0 •Bikfvwash'taliiicigcjiesriussdiline ocauttj�yttte?em r His doctor said he shnrrdkdl. BEliIb RIalian e elch bccedetaikaiditthEeanatttmfffinisirrusulin. •H bl a labcsisipppeldeetinigthislikamil sugar Eb se he ran out of suflies. •A,kldive stsipppelcbeecceiirirsiliimm rrnP Ifs fhb a blister on his foot drat waor1ttF1 ihirgy. BitiIlsisvoDid Cid)boon t sdikbiefdamctt i®mr_ Jelainirfrifetalidkeld td38ilb tffIowttroff�lrnnr1inncontrol of his diabetes.Slhtvtte4 rtl: II lfifivairin>G4abez he ctolald ggtettli2ilakitticbststitigge,Hoi satlwHatttthrroast.She also helped 3�111 u rai:ftttattg terEhhistsppp es &anal la RD out31)-hattcwcicIFF.33tvidierrmaiyannaEttrinnuire_She also called Bl rs ,wytoopasessicilibeltha B tit tytypebihisrskutirt eia13811beana fucd.:.Ills rallbo suggested that al nnurrsrpaatttt¢mrterviAi i::1Iblab bore e. Mete fiireig III i im Hi is home, the nurse re$emrz1 illttowneedziodriohdg4ist. T19113ityippw6fippeizilitit; trt is l Ilixiimg with diabetes.The en diiind ttt 11hleeneeddddcto gagtitnincpctegantereeernimsawrf-fisisANTEIiexell acrd kidneys. The mopo iatalimN lIkbgetiaavirisBsts fofidn ils islsbessAMrolchlabeabfeohleittlamsli:.III wake arm appointment witlirtla aaggdae do etitirtaan iFteeciliti tion fhel l Bill learn 1 F.,,,' ,tk, 4 N. a labolulnd tti4dodcEbbidesstmlieb ol6umerrNriS Iblbod sugar. ; i , . j' F S z-,01';\\,,,:' _ t ' !1 ,, ` t N vdi111iiekeiodcits arissiate rc actil.:i wsanik with t — Jekermirfi r$Blill;ke ttfhe power P ' '''' Ziltio ) ofdfi auziviigg aclei itia6Ea RuattinznswuNittNn you. ..., - -c„1,,,11 Ita ael frtrskiti ggsomeemeeeffeettpIIIl idim-tine details kf = ....."7.0" - scsgwirranarfcfoussaorf lirgmmurkiti t. • k^ J 4 ... ,t . ir-i17%1 *4t. ' ,''1: Li 10ct k b'erisamenefig ggiil ipp yFCdddd. 1:weijsaa-n1 I iittifinnikniiffiirensee of the Blue GuSanti ElrESYii ,le I,seoiatitionl a Iylyvihiith*Ilabiblhe:.ii,,:raivilvil rigli to nihdofoctedidistrirmri..:eaorthbEbbataso6fraace,colboi,ratio ..Iorigin,age,disability ero;,, I pu .03114316141Sbhbbb4:,peaq ikeeie arsdimiin iliomasee®orkios gr2gra;n,1;tni,tdaibrligdyiefittcallllereeib11188Qb03122witit((flfri`f.Alli-955-8773).ATANSYQ Ik:Siuupml1EIQt:,l:,ti i,,... epg ersis6sisdcbcrmdel ildiii.,:ihiOrgtiat�pou 8 0 ou.Ret 5352 yr.,,gf�tY3=680W953387Y9.)u+x:i'Pao( on ad Blue Shield of Florida,,Mit.la flibaitr:: yt, A�II tig4kdse r c. 304 951E32731M 9 41 Know Before You Go - nand Blue OU Urgent Care vs. Emergency Room n the pursuit of health' 4,,___-/ 41 tiv gm, 51 CliI �- f URGENT CARE _ EMERGENCY CENTER ROOM Cold, flu, or feverChest pain III Strains, sprains, or breaks Abdominal pain Infections Stroke Mild burns Severe head injury Allergies Major trauma [ 7 1 0 of emergency department visits are unnecessary or could have been avoided. • ff 1O1 LOWER HIGHER copay applies2 • 0 • copay applies2 � Average length of `iJ You will usually (`^�' time spent in he ER ; be seen in under nationwide3 _ •2U 20minutes =2•I� hours qnnnno, *nano 215j minutes MII EXTENDED HOURS Open7 OPEN 24 24/7 WEEKENDS If you have a life-threatening illness or injury, go to the ER or call 911 right away. 305 Fier Visit FIori a B lue,com to Sign Up and Log In B i& BVI In the pursuit of health. ,- _ If you are already signed up for �. �. . rr'` OEM �. ti an account,.sirnpfyerrteryour � _'� � —ti-- --�-- �----- UM User ID and Password to log in. I I fir Valehanw �,�-- , ,,., If you forgot these, lick Forgot r:„a�.F,�,r ...�._- _ -- F /, q your User IDIor Password. You'll 1.""" . � ,-�, - - - - 4.r "' .h' — need your(Florida Blue Member 1" �:�,>,.. ` \A _ "crMe'- ID to recover your User ID. 11 Y 4 3 — 1 su..f.1 .1-4,:_ __ _ _ . __ __ , A F , >!, Mil If you have trouble logging in, 1 — call 800-352-2593 for help. t t torri4.�Mr+be. k ,1!,n P' S" '" rRk Yrs a Rsia_ffisQ 51rmiter New User Sign Up 6 b....`� rfe,Weellt-E4rff Oti 4650 Step 1:To Sign up for your Welcome New User(' Member Account,you'll need your Member Number(shown Entc-r Your Wails&cicrA. on your ID card), On nvrglt 4h9►a 1.dr4 Vt*Iittik.. 4., eet>Fia+®-ara. ( � r Q Vs. Step 2:Fill in all 'of the boxes, A V..4.:2 WWI avt4�� 2 ,t IV v,V and click Next. IMINEpil r pa asi1•elewangsycuun acermrtramesalg.voin (cwntirnuad mod pagaj .-.*,ic l,er$Y . 6 _.^ _ Ill 0 0 In Pt, ; l Rex Plp-wt I m'.d eel. I 1 ,t= New User Sign Up (continued) -- '' ftp Step 3: Choose and type Florida,Elmo 10 � i in a User ID (click on User ID suggestion for help on User IDs). Welcome New User! Sign Up Now Step 4: Choose and type in a Password.The Password must <re,snorted yby+iogi thePal&belwr. be typed in twice for security Choose Use/ rra ffia, purposes. Click Next. Choana..m.& i--._.. ! Password 5uaq_s/ion A!us be 6-15 dva-xcsts lana-See helck=al for If you opt-in for electronic ers specific ci`ra`t e communications, a screen for Re-.,::c3<nr Password, 4. email address will also appear p, Y..1 war,to receive el ft.re cornous,.ncstu.s Ecner3 so'real m.o." on this screen. If so, enter your email address twice, and Set Up Your Security Questions click Next. (not applicable for everyone) if you ever forget yon"password and need to ream,t.well ask you:seaaaity yuerinns based on what you flu ante below.Be sure to Write dawn what yaac14 art bore because gms°G;have ro enter your Note: Write down your User ID answers warty the same way_ and Password in case you forget Security Question 1 them later. Create a Quesdom 1 Question Suggestion Eraser+your.B.s..,avea_ I----- -1 Security Question 2 Step 5:Type three different Create aca _ security questions and type an — -- answer to each. Click Next. Easter yow,Arrserert: Note: The security questions will Security Question 3 be used if you forget your User Create a Q.wscioo: l--- - ----- ID or Password. Eraser gsnr Rnsarer t_ Back 112. You're Ready To Sign In. Ott Cont-=x to u.«w yr,.ac.:ssra Step 6: Click Continue, and you'll be taken to the member lat.:mn.. website homepage. 6. Contrnue Health insurance is offered by Blue Cross and Blue Shield of Florida,Inc.,DBA Florida Blue.HMO coverage is offered by Health Options,Inc.,DBA Florida Blue HMO,an affiliate of Florida Blue.These companies are Independent Licensees of the Blue Cross and Blue Shield Association.We comply with applicable Federal civil rights laws and do not discriminate on the basis of race,color,national origin,age,disability or sex.ATENCION:Si habla espanol,tiene a su disposition servicios gratuitos de asistencia linguistica.Llame al 1-800.352-2583(TTY:1-877-955-8773).307 ATANSYON:Si w pale Kreyal Ayisyen,gen skis ed pou lang ki disponib gratis pou ou.Rele 1-800-352-2583(TTY:1-800-955-8770). FlGy' d Z?iue °°. d In the pursuit of health` D© r py m© than you sh© kI0 Know Before You Go Quality and cost are important factors when making health care decisions. As a member, you can compare quality and cost—before you receive medical care or buy prescriptions. Get cost estimates based on your plan benefits, and see treatment options that may save you money. Costs vary depending on where you go for treatment. And prescription prices vary based on the brand you buy—and where you buy them. 0 Price and Compare Online Cost Comparison Examples Log in at floridablue.com. Make the drug MRI of the Knee pricing and medical services cost estimator Facility A $1,569.00 tools work for you. Facility B $689.00 0 Talk with a Care Consultant Savings $880.00 Our Care Consultants are experts when 30 Cholesterol Pills it comes to explaining quality care and Brand Name $115.00 treatment options,that can help save you money. Call 1-888-476-2227 or stop in a Generic $5.65 Florida Blue Center. Visit floridablue.com Savings $109.35 for locations. The savings to you is based on I your plan benefits. + l ! 4,. Download the Florida Blue iI ' mobile app! Compare drug 1` ,. .-. prices on the spot and map J \. }y the nearest pharmacy. / / ' l , - - .• I.► - .i. , , -- _______- – ____ ___T_ 308 J :F: d� +fit q,'f .. 1 'a'—" ANNUAL NOTICES Jr- ms,c;._ x ` r�4 WOMAN'S HEALTH AND CANCER RIGHTS ACT OF 1988 If you have had or are going to have a mastectomy,you may be entitled to ;kr,''''''''t s' ; •i.--r-,1 , certain benefits under the Women's Health and Cancer Rights Act of 1998 --- (WHCRA).For individuals receiving mastectomy-related benefits,coverage -1RF� zf will be provided in a manner determined in consultation with the attending , , •F, physician and the patient,for. ki- ,.., ci,,,, ► All stages of reconstruction of the breast on which the mastectomy � ---.�� was performed; `-- 0 ► Surgery and reconstruction of the other breast to produce a symmetrical appearance; `Mill '' ► Prostheses;and ► Treatment of physical complications of the mastectomy,including _ lymphedema These benefits will be provided subject to the same deductibles and , coinsurance applicable to other medical and surgical benefits provided under, this plan.If you would like more information on WHCRA benefits,call your Plan -- Administrator. "`\„/ } NEWBORNS'AND MOTHERS'HEALTH PROTECTION ACT „ Group health plans and health insurance issuers generally may not,under federal law,restrict benefits for any hospital length of stay in connection with Y childbirth for the mother or newborn child to less than 48 hours following a -1 , • ,s;.„ ,.. - vaginal delivery,or less than 96 hours following a cesarean section.However,' �:� federal law generally does not prohibit the mother's or newbom's attending ' , provider,after consulting with the mother,from discharging the mother or her' newbom earlier than 48 hours(or 96 hours as applicable)after delivery.In y " , any case,plans and issuers may not,under federal law,require that a provider-. /`, obtain authorization from the plan or the issuer for prescribing a length of stay ", �,. 1 not in excess of 48 hours(or 96 hours). t .. NOTICE OF SPECIAL ENROLLMENT RIGHTS "".; Special enrollment events allow you and your eligible dependents to enroll i for health coverage outside the Open Enrollment period under certain - ,"" _ circumstances if you lose eligibility for other coverage,become eligible for -y-�' state premium assistance under Medicaid or the State Children's Health s Insurance Program(S-CHIP),or acquire newly eligible dependents.This is 1 ' required under the Health Insurance Portability and Accountability Act(HIPAA). „ -'.•`.y ' If you decline enrollment in the Medical and Dental plans for you or your dependents(including your spouse)because of other health insurance `._ •-'�"i • coverage,you or your dependents may be able to enroll in the Medical and • `' ' Dental plans without waiting for the next Open Enrollment period if you: - D Lose other coverage:You must request enrollment within 31 days , after the loss of other coverage .5•`::„.._.-4-P'.-: P Gain a new dependent as a result of marriage,birth,adoption,or .r_ placement for adoption:You must request enrollment within 31 days after the marriage,birth,adoption,or placement for adoption .' D Lose Medicaid or Children's Health Insurance Program(S-CHIP) `, '. coverage because you are no longer eligible:You mustrequest enrollment within 60 days after the loss of such coverage In addition,you may enroll in the Medical and Dental plans if you become _r•,)ti' ;, eligible for a state premium assistance program under Medicaid or S-CHIP.You must request enrollment within 60 days after you gain such coverage. " To request special enrollment or obtain more information,contact Kate Hartman,Benefits and Wellness Coordinator,772.462.1613.309 1 46 1 SUMMARY OF BENEFITS COSTS . PRE-TAX BENEFIT DEDUCTION AMOUNT MONTHLY DEDUCTION AMOUNT EMPLOYEE ONLY EMPLOYEE +ONE FAMILY MEDICAL 3766 $133.60 $294.66 $435.09 • MEDICAL 5773 $37.05 $78.44 $135.13 DENTAL-LOW OPTION $33.96 $64.94 $93.54 1 - DENTAL-HIGH OPTION $36.08 $66.22 $95.68 ^ VISION-OPTION 1 $2.06 $3.82 $5.55 VISION-OPTION 2 $5.56 $10.56 $15.52 1 1 I PER PAY DEDUCTION AMOUNT EMPLOYEE ONLY EMPLOYEE +ONE FAMILY i MEDICAL 3766 $66.80 $147.33 $217.55 MEDICAL 5773 $18.53 $39.22 $67.57 DENTAL-LOW OPTION $16.98 $32.47 $47.84 DENTAL-HIGH OPTION $18.04 $33.11 $46.77 VISION-OPTION 1 $1.03 $1.91 $2.78 i 1 VISION-OPTION 2 $2.78 $5.28 $7.76 • POST-TAX MONTHLY BENEFIT EMPLOYEE SUPPLEMENTAL LIFE RATES SPOUSE SUPPLEMENTAL LIFE RATES ' AGE RATE PER$1,000 AGE RATE PER$1,000 UNDER 30 $0.09 UNDER 30 $0.07 { 30-39 $0.11 30-39 $0.09 40-44 $0.17 40-44 $0.15 45-49 $0.29 45-49 $0.27 50-54 $0.43 50-54 $0.41 55-59 $0.70 55-59 $0.68 • 60-64 $0.79 60-64 $0.77 • 65-69 $1.37 65-69 - $1.35 70-74 $2.23 _ 70-74 $2.21 75+ $3.83 75+ ! $3.81 $5,000 Supplemental Life Insurance-Child(ren) $1.00 $10,000 Supplemental Life Insurance-Child(ren) $2.00 --J ACCIDENTAL DEATH&DISMEMBERMENT(AD&D) EMPLOYEE $0.034 PER$1,000 FAMILY $0.050 PER$ c It C/) CC LL-1 C C/)_ Oo fLia C.1U 7CD =1:= -1:// Vp Q y CO For More Information Contact KATE HARTMAN Benefits&Wellness Coordinator Q1(C)BOCC HUMAN RESOURCES 2)462-1613 ° 1['T Places co MNTYto 311 ST.'LUCIE COUNTY iI V OU U D O • gam R .,- 2 o a « = c a . 3 --z.v w o v E T. 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N., *41,X.W., - in— i.34-.1...I.' ..,-.1...1..........--4.s.....,...-_ . r. lk r. ft., • 0 •ti • Allilk 4PITAL°I 2020r 2021 , EMPLOYEE BENEFIT HIGHLIGHTS City of Stuart I Employee Benefit Highlights 12020-2021 nC Table of Contents Contact Information 1 Introduction 2 Online Benefit Enrollment 2 Group Insurance Eligibility 3 0 Qualifying Events and Section 125 4 Summary of Benefits and(overage 4 Medical Insurance 5 Premium Savings Incentive Program .5 Medical Plan Opt-Out Benefit 5 Other Available Plan Resources .6 Telehealth 6 Q Cigna LocalPlus Basic Plan At-A-Glance 7 Cigna OAP Buy-Up Plan At-A-Glance 8 Dental Insurance 9 Cigna Dental Care DHMO Plan At-A-Glance 10 Cigna DPPO Advantage Plan At-A-Glance 12 ; /D Vision Insurance 13 Cigna Vision Plan At A Glance 14 , Flexible Spending Accounts 15-16 Employee Assistance Program 17 11, Basic Life and AD&D Insurance 17 Voluntary Life Insurance.. .. 18 Voluntary Long Term Disability 19 Voluntary ShortTerm Disability 19 ° City of Stuart Employee Wellness Centers 20 =7 Working on Wellness(WOW) 20 (------(C 'ctTJj Personal Supplemental Insurance 21 21 22 23 Legal&Identity Protection Plans Pet Insurance 1 1 DreamTrips Vacations l Liberty Mutual Insurance Offerings 23 Retirement Plans 24 _1)) City Programs 25 Probationary Periods and Leave Provisions 25 Employee Handbooks 25 Compensation 26 Notes 27-28 This booklet is merely a summary of employee benefits.For a full description,refer to the plan document.Where conflict exists between this summary and the plan document,the plan document controls.. The City of Stuart reserves the right to amend,modify or terminate the plan at any time.This booklet should not be construed as a guarantee of employment 315 ©2016,Gehring Group,Inc.,All Rights Reserved City of Stuart I Employee Benefit Highlights 12020-2021 Contact Information City of Stuart Benefit Inquiries • Phone:(772)288-5315 Human Resources Department Human Resources Customer Service:(888)5-Bentek(523-6835) 'ate' Online Benefit Enrollment Bentek Support www.mybentek.com/dtyofstuart Email:support@mybentek.com • Medical Insurance Cigna Customer Service:(800)244-6224 www.dgna.com Telehealth Cigna—MDLIVE Customer Service:(888)726-3171 www.MDLIVEforCigna.com Prescription Drug Coverage Customer Service:(800)835 3784 &MailOrder Program Cigna Home Delivery www.mycigna.com Dental Insurance Cigna Customer Service:(800)244-6224 www.dgna.com 0 Vision Insurance Cigna Customer Service:(877)478-7557 www.dgna.com 512 Flexible Spending Accounts Discovery Benefits Customer Service:(877)765-8810 www.discoverybenefits.com Employee Assistance Program Aetna Resources for Living Customer Service:(866)611-2826 www.resourcesforliving.com • Customer Service:(800)732-1603 Basic Life and AD&D Insurance Cigna 1 a www.dgna.com Voluntary Life Insurance Cigna Customer Service:(800)732-1603 www.dgna.com Long Term Disability Insurance Cigna Customer Service:(800)732-1603 www.dgna.com Agent Jewel Sands I Phone:(772)631-8192 Short Term Disability Insurance Aflac Email:jewel_sands@us.aflac.com www.aflac.com Personal Supplemental Insurance Agent Jewel Sands'Phone:(772)631-8192 (Various Afiac Products) Aflac • Email:jewel_sands@us.aflac.com www.afiac.com • • Agent:Tamara Bailey,CPCU,API I Phone:(954)991-5600 Liberty Mutual Insurance Offerings Liberty Mutual Email:Tamara.Bailey@LibertyMutual.com www.libertymutual.com/stuart • � Agent Dixie Kuehn I Phone:(321)403-0156 • `l- Legal&Identity Protection Plans US Legal Services Customer Service:(321)799-2986 www.uslegalservices.net Pet Assure • Customer Service:(800)891-2565 t• petbenefits.com/land/cityofst • • Pet Insurance • Nationwide, Customer Service:(800)540-2016 www.petinsurance.com/cityofstuart Educational/Investment:(866)446-9377 Florida Retirement System Agency#53100 www.myfrs.com Pension Department:(844)377-1888 71 https://www.rol.frs.state.fl.us/login.aspx ICMA-RC Plan#301448 Agent:Torn Pilla I Phone::(772)577-6578 Email:tpilla@icmarc.org I www.icmarc.org 316 1 ©2016,Gehring Group,Inc.,All Rights Reserved City of Stuart I Employee Benefit Highlights 1 2020-2021 STU�T• O'4OvyORATEb Online Benefit Enrollment / 1 U '>-; The City provides employees with an online benefits enrollment I o platform through Bentek's Employee Benefits Center(EBC).The EBC o� provides benefit-eligible employees the ability to select or change sy� s' insurance benefits online during the annual Open Enrollment Period, �pITAL o New Hire Orientation,or for Qualifying Life Events. Accessible 24 hours a day,throughout the year,employee may log in and review comprehensive information regarding benefit plans, Introduction and view and print an outline of benefit elections for employee and ' dependent(s).Employee also has access to important forms and carrier • links,can report qualifying life events and review and make changes to The City of Stuart provides group insurance benefits to eligible employees. life insurance beneficiary designations. The Employee Benefit Highlights Booklet provides a general summary of the benefit options as a convenient reference. Please refer to the City's Personnel Policies,applicable Union Contracts,and/or Certificates of Coverage c== for detailed descriptions of all available employee benefit programs and � ®0 stipulations therein. If an employee requires further explanation or needs O O O O assistance regarding claims processing,please refer to the customer service ® �'o © p 0 i ©• � __ phone numbers under each benefit description heading or contact Human ® o ® Resources. 0. 0% • To Access the Employee Benefits Center: ✓ Log onto www.mybentek.com/cityofstuart ✓ Sign in using a previously created username and password or • dick"Create an Account"to setup a username and password. ✓ If employee has forgotten usemame and/or password,click on the link"Forgot Username/Password"and follow the instructions. ✓ Once logged on, navigate using the Launchpad to review current enrollment,learn about benefit options,and make any benefit changes or update beneficiary designations. For technical issues directly related to using the EBC, please call (888) 5-Bentek (523-6835) or email Bentek Support at support@mybentek.com, Monday through Friday, during regular business hours,8:30am-5:00pm. To access Employee Benefits Center online,log on to: Cover Photo Credit:Judy Browning,Financial Services Department www.mybentek.com/cityofstuart The City's WOW programming invites employees,their families and loved ones , to engage in a variety of healthy habits,and prizes are awarded for reaching Please Note:Link must be addressed exactly as written.Due to security reasons, milestones.Judy won this bike as a grand prize winner a few years ago,and the website cannot be accessed by Google or other search engines. she's a regular rider now!She added the mask for nostalgia,knowing we'll look back someday and remember how we maintained wellness during a worldwide , pandemic. 317 2 ©2016,Gehring Group,Inc.,All Rights Reserved 1 • •• City of Stuart I Employee Benefit Highlights 12020-2021 Group Insurance Eligibility The Gty'6 group in6urance plan year 15 Disabled Dependents 01 October I through September 3o. Coverage for a dependent child may be continued beyond age 26 if: • The dependent is physically or mentally disabled and incapable of self-sustaining employment(prior to age 26);and Employee Eligibility • Primarily dependent upon the employee for support;and Employees are eligible to participate in the City's insurance plans if they are, • The dependent is otherwise eligible for coverage under the group full-time employees working a minimum of 30 hours per week.Coverage is medical plan;and effective the first of the month following 60 days.For example,if employee is, • The dependent has been continuously insured. hired on April 11,then the effective date of coverage will be July 1. Proof of dependent's disability will need to be submitted to the carrier Separation of Employment within 31 days of turning age 26.Please contact Human Resources if further If employee separates employment from the City, insurance will continue clarification is needed. through the end of month in which separation occurred.COBRA continuation; Taxable Dependents of coverage may be available as applicable by law. Employee covering adult child(ren) under employee's medical, dental and Dependent Eligibility vision insurance plans may continue to have the related coverage premiums A dependent is defined as the legal spouse/domestic partner and/or payroll deducted on a pre-tax basis through the end of the calendar year in dependent child(ren)of the participant or spouse/domestic partner.The term! which dependent child reaches age 26.Beginning January 1 of the calendar "child"includes any of the following: year in which dependent child reaches age 27 through the end of the calendar, • A natural child • A stepchild • A legally adopted child year in which the dependent child reaches age 30,imputed income must be reported on the employee's W-2 for that entire tax year and will be subject • A newborn child(up to the age of 18 months)of a covered to all applicable Federal,Social Security and Medicare taxes.Imputed income dependent(Florida) is the dollar value of insurance coverage attributable to covering each adult • A child for whom legal guardianship has been awarded to the dependent child.Contact Human Resources for further details if covering an participant or the participant's spouse/domestic partner adult dependent child who will turn age 27 any time during the upcoming • - - calendar year or for more information. Dependent Age Requirements Please Note:There is no imputed income if adult dependent child is eligible to be Medical Coverage:A dependent child may be covered through the ' ; claimed as a dependent for Federal income tax purposes on the employee's tax end of the calendar year in which the child turns age 26.An over- return. age dependent may continue to be covered on the medical plan to the end of the calendar year in which the child reaches age 30,if the Domestic Partner Coverage dependent meets the following requirements: Domestic Partners may be eligible to participate in the City's group medical, • Unmarried with no dependents;and dental and vision insurance plans and will be required to complete a • A Florida resident,or full-time or part-time student:and Declaration of Domestic Partnership.The IRS guidelines state that employee • Otherwise uninsured;and l may not receive a tax advantage on any portion of premium paid related to • Not entitled to Medicare benefits under Title XVIII of the domestic partner coverage.Employee is required to pay imputed income tax Social Security Act,unless the child is disabled. on subsidy amounts and should consult a tax advisor.Please contact Human Dental Coverage:A dependent child may be covered through the Resources for further details and rates if covering a domestic partner at any end of the calendar year in which the child turns age 30. time during the upcoming plan year. Vision Coverage:A dependent child may be covered through the end of the calendar year in which the child turns age 30. 318 3 ©2016,Gehring Group,Inc.,All Rights Reserved • • City of Stuart I Employee Benefit Highlights 12020-2021 • • Qualifying Events and Section 125 Section 125 of the Internal Revenue Code Premiums for medical, dental, vision insurance, contributions to Flexible Spending Accounts(FSA),and/or certain supplemental policies are deducted IMPORTANT NOTES • through a Cafeteria Plan established under Section 125 of the Internal Revenue Code and are pre-taxed to the extent permitted.Under Section 125,changes to If employee experiences a Qualifying Event,Human Resources must an employee's pre-tax benefits can be made ONLY during the Open Enrollment be contacted within 30 days of the Qualifying Event to make period unless the employee or qualified dependent(s) experience(s) a the appropriate changes to employee's coverage. Beyond 30 days, Qualifying Event and the request to make a change is made within 30 days of requests will be denied and employee may be responsible,both legally the Qualifying Event. and financially,for any claim and/or expense incurred as a result of Under certain circumstances,employee may be allowed to make changes to employee or dependent who continues to be enrolled but no longer benefit elections during the plan year,ifthe event affectsthe employee,spouse meets eligibility requirements.If approved,changes may be effective or dependent's coverage eligibility.An"eligible"Qualifying Event is determined the date of the Qualifying Event or the first of the month following the by Section 125 of the Internal Revenue Code.Any requested changes must be Qualifying Event.Newborns are effective on the date of birth.Marriage consistent with and due to the Qualifying Event. is effective on the date of occurrence.Cancellations will be processed at the end of the month.In the event of death,coverage terminates the Examples of Qualifying Events: day following the death.Employee may be required to furnish valid • Employee gets married or divorced documentation supporting a change in status or"Qualifying Event" • Birth of a child • • Employee gains legal custody or adopts a child • Employee's spouse and/or other dependent(s)die(s) Summary of Benefits and Coverage • Loss orgainofcoverageduetoemployee,employee'sspouseand/or A Summary of Benefits&Coverage(SBC)for the Medical Plan is provided as a dependent(s)termination or start of employment supplement to this booklet being distributed to new hires and existing employees • An increase or decrease in employee's work hours causes eligibility during the Open Enrollment period. The summary is an important item in or ineligibility understanding the employee's benefit options.A free paper copy of the SBC document may be requested or is available as follows: • A covered dependent no longer meets eligibility criteria for coverage • A child gains or loses coverage with other parent or legal guardian From: Human Resources • Change of coverage under an employer's plan Address: 121 SW Flagler Ave. • Gain or loss of Medicare coverage Stuart F134994 • Losing or becoming eligible for coverage under a State Medicaid Phone: (772)288-5315 or CHIP(including Florida Kid Care)program (60 day notification Email: rjohnson@ci.stuart.fl.us period) Website URI: www.mybentek.com/dtyofstuart The SBC is only a summary of the plan's coverage.A copy of the plan document,policy, or certificate of coverage should be consulted to determine the governing contractual • provisions of the coverage.A copy of the group certificate of coverage can be reviewed and obtained by contacting Human Resources. If there are questions about the plan offerings or coverage options,please contact Human Resources at(772)288-5315. 319 4 ©2016,Gehring Group,Inc.,All Rights Reserved , j ` City of Stuart I Employee Benefit Highlights 12020-2021 4. I Medical Insurance i The City offers medical insurance through Cigna to benefit-eligible employees.The costs per pay period for coverage are listed in the premium tables below and a brief summary of benefits is provided on the following pages.For more detailed information about the medical plans,please refer to the carrier's Summary of Benefits and Coverage(SBC)document or contact Cigna's customer service. Medical Insurance—Cigna LocalPlus Basic Plan ' 24 Payroll Deductions-Per Pay Period Cost Tier of Coverage WITH Non-Tobacco use and WITH Non-Tobacco use or WITHOUT Premium HRA Premium Savings HRA Premium Savings Incentive , I . — - - Employee Only $30.00 $55.00 $80.00 Employee+Spouse $113.85 $138.85 $163.85 Employee+Child(ren) $86.63 $111.63 $136.63 Employee+Family $187.00 $212.00 $237.00 . Medical Insurance—Cigna OAP Buy-Up Plan 24 Payroll Deductions-Per Pay Period Cost , Tier of Coverage WITH Non-Tobacco use and WITH Non-Tobacco use or WITHOUT Premium ' HRA Premium Savings HRA Premium Savings Incentive [Employee Only _1 $61.20 $86.20 $111.20 i Pmployee+Spouse $209.76 $234.76 $259.76 Employee+Child(ren) _ii $166.80 $191.80 $216.80 Employee+Family $307.74 $332.74 $357.74 , Cigna I Customer Service:(800)244-62241 www.cigna.com 1 Premium Savings Incentive Program Medical Plan Opt-Out Benefit Benefit-eligible employees are offered the opportunity to save monthly ' In an effort to ensure equitable contribution to the health care of every premium dollars through premium saving incentives valued up to$100 per ; employee, the City offers an "opt-out"option to eligible employees who month.In order to save premium dollars,the following must be completed: • have waived participation in the City's Medical Plan and provides evidence of • Save $50 monthly by demonstrating you are a non-tobacco user medical insurance under another medical plan.If employee chooses to receive completing the cotinine test at the Employee Wellness Centers or by the"opt-out"benefit, employee will receive $100 per month. If employee completing a Tobacco Cessation Program. completes the Premium Savings Incentive Program requirements employee • Save$50 monthly by completing all three(3)steps of your annual may receive an additional$100 per month credit($200 per month maximum). Health Risk Assessment(HRA)Process with the Employee Wellness Please Note:The deadline to increase the stipend for the opt-out benefit is September Centers. 15 of each fiscal year. Please Note:The deadline for saving premium dollars is September 15 of each fiscal year. 320 5 ©2016,Gehring Group,Inc.,All Rights Reserved it City of Stuart I Employee Benefit Highlights 12020-2021 Other Available Plan Resources Telehealth Cigna offers all enrolled employees and dependents additional services and Cigna provides access to telehealth services as part of the medical plan. discounts through value added programs. For more details regarding other MDLIVE is a convenient phone and video consultation company that provides available plan resources,please refer to the Summary of Benefits and Coverage immediate medical assistance for many conditions. (SBC)document,contact Cigna's customer service at(800)244-6224,or visit www.cigna.com. The benefit is provided to all enrolled members.Registration is required and should be completed ahead of time.This program allows members 24 hours Healthy Rewards a day,seven(7)days a week on-demand access to affordable medical care via Cigna's Healthy Rewards is provided automatically at no additional cost and phone and online video consultations when needing immediate tare for non- offers access to discounted health and wellness programs at participating emergency medical issues.Telehealth should be considered when employee's providers. Members can log on to www.mycigna.com and select Healthy primary care doctor is unavailable, after-hours or on holidays for non- Rewards to learn more about these programs or call(800)870-3470. emergency needs.Many urgent care ailments can be treated with telehealth, such as: V Vision Care V Nutrition Discounts V Sore Throat V Allergies V LASIK Vision Correction V Hearing Care V Headache V Rash Services V Tobacco Cessation V Stomachache V Acne V Fitness Club Discounts V Alternative Medicine V Fever ✓ UTIs And More The myCigna Mobile App V Cold and Flu The myCigna mobile app is an easy way to organize and access important Telehealth doctors do not replace your primary care physician but may be,a health information. Anytime. Anywhere. Download it today from the App convenient alternative for urgent care and ER visits. For further information Stores"'or Google Play'"".With the myCigna mobile app,members can: please contact Cigna. • Find a doctor,dentist or health care facility • Access maps for instant driving directions Cigna • View ID cards for family members MDLIVE I Customer Service:(888)726-3171 I www.MDLIVEforCigna.com' • Review deductibles,account balances and claims • Compare prescription drug costs • Speed-dial Cigna Home Delivery Pharmacy'' • Store and organize all important contact info for doctors,hospitals, and pharmacies • Add health care professionals to contact list direct from a claim or directory search • And,much more! 24 Hour Help Information Hotline(800)CIGNA-24 The Cigna 24-Hour Health Information Line provides access to helpful,reliable information and assistance from qualified health information nurses on a wide range of health topics 24 hours a day,any day of the year.Not sure what to do for a child who has a fever in the middle of the night?Not sure if treatment from a doctor is necessary for an injury?There are over 1,000 topics in the Health Information Library that include free audio,video and printed information on aging,women's health,nutrition,surgery and specific medical conditions to help weigh the risks and advantages of treatment options.The . call is free and is strictly confidential. • 321 6 ©2016,Gehring Group,Inc.,All Rights Reserved I City0 of StuartEmployee Benefit Highlights 2020-2021 I Cigna LocalPlus Basic Plan At-A-Glance f Network LocalPlus Plan Year Deductible(PYD) In-Network Out-of-Network* C Single $1,000 $1,500 Family - $3,000 $3,000 Locate a Provider Coinsurance To search fora participating provider, Member Responsibility 7- 20% 50% 1- • contact Cigna's customer service or visit Plan Year Out-of-Pocket Limit www.cigna.com.When completing - . the necessary search criteria,select [Single $4,000 $7,000 LocalPlus network. - y Family $8,000 $14,000 [-What Applies to the Out-of-Pocket Limit? Deductible,Coinsurance,Copays and Rx Physidan Services 0 • L - Primary Care Physician(PCP)Office Visit $25 Copay 50%After PYD I 2 . Plan References SpecialistOffice Visit(No Referral Required) - - -- _j $50 Copay - 50%After PYD T. "Out-Of-Network Balance Billing: Telehealth $15 Copay Not Covered for information regarding out-of- network balance billing that may be Non-Hospital Services;Freestanding Facility Y charged by out-of-network providers, [Clinical Lab(Bloodwork)* No Charge 50%After PYD please refer to the Summary of Benefits - - _ - -- - - - -- v. and Coverage(SBC)document X-rays 20%After PYD 50%After PYO [dvanced Imaging(MRI,PET,CT)-Per Scan _ 20%After PYD 50%After PYD **LobCorp and Quest Diagnostics are Outpatient Surgery in Surgical Center 20%After PYD 50%After PYD Y the preferred labs for bloodwork through Cigna.When using a lab other than [Physician Services at Surgical Center 20%After PYD 50%After PYD LabCorp or Quest please confirm they Urgent Care(Per Visit) $60 Copay $60 Copay - are contracted with Ggnat lomlPlus T' network prior to receiving services. Hospital Services ' Inpatient Hospital(Per Admission) 20%After PYD 50%After PYD j ***Mail Order Drug provides a 90-Day ------_-- .- - --_ - -- ---_ - - 4.; Supply for the cost of a Retail 60-Day `Outpatient Hospital(Per Visit) 20%After PYD 50%After PYD Supply. [Physician Services at Hospital 20%After PYD 50%After PYD Emergency Room(Per Irsit) 20%After PYD 20%After PYO Mental Health/Alcohol&Substance Abuse 1. [Inpatient Hospitalization(Per Admission) 20%After PYD 50%After PYD C Outpatient Services(Per Visit) _ - -4,----_ _ _ No Charge 50%After PYD x rOutpatient Office Visit(Per Visit) R No Charge 50%After PYD 4 Prescription Drugs(Rx) [Generic-Preventive _ $5 Retail Copay Not Covered , Generic-Other Generic $15 Retail Copay Not Covered I -Preferred Brand Name $40 Retail Copay Not Covered I Non-Preferred Brand Name $75 Retail Copay Not Covered Mail Order Drug(90-Day Supply)*** _ _] $10/$30/$80/$150 Retail Copay Notfavgred 7 JLL ©2016,Gehring Group,Inc.,All Rights Reserved City of Stuart I Employee Benefit Highlights 12020-20210 Cigna OAP Buy-Up Plan At-A-Glance . Network Open Access Plus Plan Year Deductible(PYD) In-Network Out-of-Network* Single j $500 $1500 Family $1,500 l $3,000 q . Coinsurance . Locate a Provider Member Responsibility 20% 40% • To search for a participating provider, Plan Year Out-of-Pocket Limit contact Cigna's customer service or visit . www.cigna.com.When completing the Single $3,000 $7,500 necessary search criteria,select Open •Family -� $5,750 $14,725 Access Plus network. What Applies to the Out-of-Pocket Limit? Deductible,Coinsurance,Copays and Rx Physician Services 0 Primary Care Physician(PCP)Office Visit $20 Copay 40%After PYD SpecialistofficeVis it(No Referral Required) $40 Copay 40%After PYD Plan References Telehealth $15 Copay Not Covered + • *Out-Of-Network Balance Billing: Non-Hospital Services;Freestanding Facility For inform otion regarding out-of- - network balance billing that may be [Clinical Lab(Bloodwork)"* No Charge 40%After PYD charged by out-of-network providers, X-rays __ __ 20%After PYD 40%After PYD Please refer to the Summary of Benefits __ and Coverage(SBC)document 'Advanced imaging(MRI,PET,CT)-Per Scan $150 Copay 40%After PYD Outpatient Surgery in Surgical Center 20%After PYD 40%After PYD **LabCorp and Quest Diagnostics are - - the preferred labs for bloodwork through Physician Services atSurgical Center ��- i 20%AfterPYD 40%After PYO Cigna.When using a lab other than • Urgent Care(Per Visit) $50 Copay $50 Copay LabCorp or Quest,please confirm they are contracted with Ggna's Open Access Hospital Services Plus network prior to receiving services. [Inpatient Hospital(Per Admission) 20%After PYD 40%After PYD ***Mail Order Drug provides o 90-Day Outpatient Hospital(Per Visit) ] 20%After PYD 40%After PYD Supply for the cost of a Retail 60-Day - - Physician Services at Hospital 1 20%After PYD 40%After PYD Supply. Emergency Room(Per Visit;Waived if Admitted) $250 Copay $250 Copay Mental Health/Alcohol&Substance Abuse Inpatient Hospitalization(Per Admission) 20%After PYD 40%After PYD [Outpatient Services(Per Visit) - W ' No Charge 40%After PYD _ --- Outpatient Office Visit(Per Visit) No Charge 40%After PYD Prescription Drugs(Rx) Generic-Preventive 1. $5 Retail Copay Not Covered ---- ----- Generic-Other Generic $15 Retail Copay Not Covered Preferred Brand Name _ $40 Retail Copay Not Covered , Non-Preferred Brand Name $75 Retail Copay Not Covered [ -Mail _ `, S10/$30/$80/$150 Retail Copay Not Covered 323 0 2016,Gehring Group,Inc.,All Rights Reserved 1 � I 1 City of Stuart I Employee Benefit Highlights 12020-2021 Dental insurance Cigna Dental Care DHMO Plan The City offers dental insurance through Cigna to benefit-eligible employees., Plan Year Deductible The costs per pay period for coverage are listed in the premium table below I and a brief summary of benefits is provided on the following page.For more 1 There is no plan year deductible. detailed information about the dental plan, please refer to the carrier's ; Plan Year Benefit Maximum summary plan document or contact Cigna's customer service. There is no benefit maximum. Dental insurance—Cigna Dental Care DHMO Plan ; 24 Payroll Deductions-Per Pay Period Cost ._ _ _ _ Tier of Coverage Employee Cost ' • LEmployeeOnly _ s0_-. IMPORTANT NOTES Employee+Family $9,79 i • Each covered family member may receive two(2)routine deanings per calendar year(One(1)everysix(6)months)covered under the preventive benefit.Members can also receive two(2)additional deanings at the charge of a$45 copy. In-Network Benefits i • Waiting periods and age limitations may apply. The Dental Care DHMO plan is an in-network only plan that requires all services • Participants covering young children may be seen byo pediatric dental provider up to the child's 13th birthday.Once the child reaches age 13,a referral with be received by a Primary Dental Provider(PDP).Employee and dependent(s) medical reasons will berequired prior tobeing seen byapediatricdental may select any participating dentist in the Cigna Dental Care Access network provider. to receive covered services.There is no coverage for services received out-of- • Services received by providers or fadlities not in the Cigna Dental Care Access network. network will be denied. • Additional lab fees may apply for some services. The Dental Care DHMO plan's schedule of benefits is set forth by the Patient _ Charge Schedule(fee schedule)which is highlighted on the following page. Please refer to the summary plan document for a detailed listing of charges Cigna I Customer Service:(800)244-62241 www.cigna.com • and what is covered. Out-of-Network Benefits The Dental Care DHMO plan does not cover any services rendered by out-of- network facilities or providers. • I ' 324 9 02016,Gehring Group,Inc.,All Rights Reserved 1 i 1 i Cityof StuartEmployee Benefit Highlights 2020-2021 '` I � �' Cigna Dental Care DHMO Plan At-A-Glance Network Cigna Dental Care Access Plan Year Deductible(PYD) In-Network Only Per Member �;`------ -- ----- ---- - --- -- - - ------ PerFamily Does Not.Apply Q Plan Year Maximum 4-4 Locate.a Provider Class I Services:Diagnostic&Preventive Care Code In-Network Toward,for artid alio provider, +— — -1— — P P g . Office Visit* N/A $5 contact Cigna's customer service or visit «- —--r.---— --- __--._. __ . -: -- www•dgna.com.When completing the Routine OralEvaluation 0120 $0 ; 4 - _ l necessary search criteria,select Cigna Routine Cleanings(2 Per Calendar Year) , ^1110/20 $0 Dental Care Access network. Bitewing X-rays(2 Films) 0272 $0 IComplete X-rays(1 Every3 Years) 0210 $0 IFluoride Treatments(2 Per Calendar Year) 1208 $0 Sealants(Per tooth) 1351 512 Emergency Care to Relieve Pain(During Regular Hours) 9110 $0 Plan References Class II Services:Basic Restorative Care *Each patient is responsible fora$S 4- office visit fee,peroffice visit.The$S fee Fillings(Amalgam) 2140 $0 • is in addition to any other applicable fillings(Composite—3Surfaces,Anterior/Posterior) 2332/2393 $0/582 ' patient charges. • ISimple Extractions(Erupted Tooth/Exposed Root) ` 7140 $12 '"Porcelain/Ceramicsubstrate crowns ' — _ on molar teeth are not covered I Oral Surgery(Removal ofImpacted Tooth) 7240 $115 Root Canal Therapy(Molar) 3330 1 $335 General Anesthesia(First 30 Minutes) 9220 $190 Repairs to Denture Base 5510 $88 Class III Services:Major Restorative Care ' [Bridges(Porcelain Fused to High Noble Metal) 6240 $320 , ICrowns(Porcelain Fused to Noble Metal)'* 6752 $355 Dentures 5110/20 $400 Class IV Services:Orthodontia-24 Month Treatment Max. ' • • Benefit-Child(Up to Age 19) , 8670 $2,040 • Benefit-Adult 8670 $2,376 • i 325 0 2016,Gehring Group,Inc.,All Rights Reserved 10 City of Stuart I Employee Benefit Highlights 12020-2021 Dental Insurance Cigna DPPO Advantage Plan The City offers dental insurance through Cigna to benefit-eligible employees. Out-of-Network Benefits The costs per pay period for coverage are listed in the premium table below and a brief summary of benefits is provided on the following page.For more Out-of-network benefits are used when member receives services by a non- detailed information about the dental plan, please refer to the carrier's participating Cigna DPPO Advantage provider. Cigna reimburses out of summary plan document or contact Cigna's customer service. network services based on what it determines is the Maximum Allowable Charge(MAC).The MAC is defined as the most common charge for a particular Dental Insurance—Cigna DPPO Advantage Plan dental procedure performed in a specific geographic area. If services are 24 Payroll Deductions-Per Pay Period Cost received from an out-of-network dentist,the member may be responsible for balance billing.Balance billing is the difference between Cigna's MAC and the Tier of Coverage Employee Cost amount charged by the out-of-network dental provider.Balance billing is in Employee Only $o addition to any applicable plan deductible or coinsurance responsibility. Employee-f Family $14.48 Plan Year Deductible The Cigna DPPO Advantage plan requires a$100 per member deductible to be In-Network Benefits met for in-network orout-of-network services or a combination of both before The Cigna DPPO Advantage plan provides benefits for services received from most benefits will begin.The deductible is waived for diagnostic,preventive in-network and out-of-network providers.It is also an open-access plan which and orthodontia services. I allows for services to be received from any dental provider without having to , select a Primary Dental Provider(PDP)or obtain a referral to a specialist.The I Plan Year Benefit Maximum network of participating dental providers the plan utilizes is the Cigna DPPO The maximum benefit (coinsurance) the Dental PPO Advantage plan will Advantage network.These participating dental providers have contractually pay for each covered member is $1000 for in-network or out-of-network agreed to accept Cigna's contracted fee or"allowed amount': This fee is services combined.All services,including preventive,accumulate towards the the maximum amount a Cigna dental provider can charge a member for a benefit maximum.Once the plan's benefit maximum is met,the member service.The member is responsible for a Plan Year Deductible(PYD)and then responsible for future charges until next plan year. � coinsurance based on the plan's charge limitations. Please Note:Cigna DPPO Advantage dental members have the option to utilize a 1. dentist that participates in either Cigna Advantage network or DPPO network.However, • members that use the Cigna Advantage network will see additional cost savings from , IMPORTANT NOTES the added discount that is allowed for using an Advantage network provider.Members who see a DPPO provider may be subject to balance billing.Members are responsible for •Each covered family member may receive up to two(2)routine deanings per plan verifying whether the treating dentist is an Advantage Dentist ora DPPO Dentist i year.Each cleaning must be six(6)months apart. •Waiting periods and age limitations may apply for certain services. •A Pre-Determination of Benefits is recommended for all work that is considered expensive.The plan will provide oPre-Determination of Benefits"upon the • request of the dental provider.This will assist with determining approximate out- of-pocket costs should employee have the dental work performed. I • •Benefit frequency limitations mayapply to certain services. • Cigna I Customer Service:(800)244-62241 www.cigna.com 326 11 ©2016,Gehring Group,Inc.,All Rights Reserved • City of Stuart I Employee Benefit Highlights 12020-2021 (1-....---Z Cigna DPPO Advantage Plan At-A-Glance 1 Network Cigna DPPO Advantage Plan Year Deductible(PYD) In-Network Out-of-Network' ' Per Member $100 'Waived for Class I Services? Yes ---; q . Plan Year Benefit Maximum Locate a Provider `Per Member(Includes Class 1,11&Ill Services) — $1,000 • To search for a participating provider, Class I Services:Diagnostic&Preventive Care contact Cigna's customer service or visit _ _ - _ - .. www.cigna.com.Whencompletingthe Routine Oral Exam(1 Every 6 Months) necessary search criteria,select Cigna Routine Cleanings(1 Every 6 Months) Plan Pays:100% Plan Pays:100% DPPO Advantage network. DeductibleWaived Deductible Waived Compl ete X rays(1 Per 60 Consecutive Months) + (Subject to Balance Billing) Bitewing X-rays(1 Set Every 11 Months) 0 Class II Services:Basic Restorative Care fillings(Amalgam) -_ __.i . l Plan References Simple Extractions "Out-Of-Network Balance Billing: Endodontics(Root Canal Therapy) __ Plan Pays:80%After PYD for information regarding out-of- Plan Periodontal Services Pays:80%After PYD (Subject to Balance Billing) network balance billing that may be Oral Surgery charged by an out-of-network provider, 9 ry _ please refer to the Out-of-Network General Anesthesia Benefits section on the previous page. Class III Services:Major Restorative Care ICrowns • Bridges Plan Pays:50%After PYD Plan Pays:50%After PYD (Subject to Balance Billing) Dentures v T Class IV Services:Orthodontia Lifetime Maximum $1,000 Plan Pays:50% Plan Pays:50% Benefit(Dependent Children Up To Age 19) Deductible Waived Deductible Waived (Subject to Balance Billing) 327 12 ©2016,Gehring Group,Inc.,All Rights Reserved City of Stuart I Employee Benefit Highlights 12020-2021 I Vision Insurance Cigna Vision Plan The City offers vision insurance through Cigna to benefit-eligible employees. Out-of-Network Benefits The costs per pay period for coverage are listed in the premium table below,, Employee and covered dependent(s) may also choose to receive services and a brief summary of benefits is provided on the following page.For more information about the vision plan,please refer to the carrier's summary plan from vision providers who do not participate in the Cigna Vision Network. document or contact Cigna's customer service. When going out of network,the provider will require payment at the time of appointment.Cigna will then reimburse based on the plan's out-of-network reimbursement schedule upon receipt of proof of services rendered. Vision Insurance—Cigna Vision Plan 24 Payroll Deductions-Per Pay Period Cost Plan Year Deductible • Tier of Coverage Employee Cost There is no plan year deductible. Employee Only $4.36 Plan Year Out-of-Pocket Maximum Employee+spouse $8.72 There is no out-of-pocket maximum.However,there are benefit reimbursement I Employee+Child(ren) _ $8.81 maximums for certain services. Employee+Family • $14:06 Cigna I Customer Service:(877)478-7557 I www.cigna.com In-Network Benefits The vision plan offers employee and covered dependent(s)coverage for routine I eye care, including eye exams, eyeglasses (lenses and frames) or contact lenses.To schedule an appointment,covered employee and dependent(s)can select any network provider who participates in the Cigna Vision network.At the time of service,routine vision examinations and basic optical needs are covered as shown on the plan's schedule of benefits.Cosmetic services and upgrades are additional if chosen at the time of the appointment. 328 13 ' ©2016,Gehring Group,Inc.,All Rights Reserved tl City of Stuart I Employee Benefit Highlights 12020-2021 (4b:' Cigna Vision Plan At-A-Glance Network Cigna Vision Services In-Network Out-of-Network q eExam $10 Coy Up to$45 Reimbursement Reimbursement Based on Materials $25 Copay Locate a Provider Type of Service ' To search for a participating provider, Frequency of Services contact Cigna's customer service or visit - j - www.cigna.com.When completing the Examination 12 Months necessary search criteria,select Cigna Lenses t 12 Months Vision network. c Frames i12 Months , .,„. _ _ _ _ _ _ 4 0 Contact Lenses 12 Months • t • r - - - ' Lenses ISingle Up to$32 Reimbursement Plan References Bifocal y No{harge Up to$55 Reimbursement "Contadlenses are inlieu ofspectacle _ _ After$25 Materials Copay _ - lenses and a frame. Trifocal Up to$65 Reimbursement 1 Frames • 0 Allowance Up to$130 Retail Allowance Up to$71 Reimbursement After$25 Materials Copay Contact Lenses* Important Notes iNon-Elective(Medically Necessary) No Charge Up to$210 Reimbursement Member options,such as LASIK,UV —_ _ .: _ - - _ . coating,progressive lenses,etc.are not Elective(Fitting,Follow-up&Lenses) Up to$130 Retail Allowance Up to$105 Reimbursement covered in full,but may be available at a discount. • 329 14 ©2016,Gehring Group,Inc.,All Rights Reserved ("4•11-117119 City of Stuart I Employee Benefit Highlights 12020-2021 Flexible Spending Accounts The City offers Flexible Spending Accounts(FSA)administered through Discovery Benefits.The FSA plan year is from October 1 through September 30. If employee or family member(s)has predictable health care or work-related day care expenses,then employee may benefit from participating in an FSA.An FSA allows employee to set aside money from employee's paycheck for reimbursement of health care and day care expenses they regularly pay.The amount set aside is not taxed and is automatically deducted from employee's paycheck and deposited into the FSA.During the year,employee has access to this account for reimbursement of some expenses not covered by insurance.Participation in an FSA allows for substantial tax savings and an increase in spending power.Participating employee must re-elect the dollar amount they wish to have deducted each plan year.There are two(2)types of FSAs: Health Care FSA Dependent Care FSA This account allows participant to set aside up to an annual This account allows participant to set aside up to an annual maximum of$5,000 if single maximum of$2,750.This money will not be taxable income or married and file a joint tax return($2,500 if married and file a separate tax return)for to the participant and can be used to offset the cost of a work-related day care expenses.Qualified expenses include day care centers,preschool, wide variety of eligible medical expenses that generate and before/after school care for eligible children and dependent adults. out-of-pocket costs.Participating employee can also receive reimbursement for expenses related to dental and vision Please note,if a family's income is over$20,000,this reimbursement option will likely care(that are not classified as cosmetic). save participants more money than the dependent day care tax credit taken on a tax return.To qualify,dependents must be: Examples of common expenses that qualify for • A child under the age of 13,or reimbursement are listed below. • A child,spouse or other dependent that is physically or mentally incapable of self-care and spends at least eight(8)hours a day in the participant's household. Please Note:The entire Health Care FSA election is available for use on Please Note:Unlike the Health Care FSA,reimbursement is only up to the amount that has been deducted the first day coverage is effective. from the participant's paycheck for the Dependent Care FSA. A sample list of qualified expenses eligible for reimbursement indude,but are not limited to,the following: ✓ Prescription/Over-the-Counter Medications ✓ Physician Fees and Office Visits ✓ LASIK Surgery ✓ Menstrual Products ✓ Drug Addiction/Alcoholism Treatment ✓ Mental Health Care ✓ Ambulance Service ✓ Experimental Medical Treatment ✓ Nursing Services ✓ Chiropractic Care ✓ Corrective Eyeglasses and Contact Lenses ✓ Optometrist Fees ✓ Dental and Orthodontic Fees ✓ Hearing Aids and Exams ✓ Sunscreen SPF 15 or Greater ✓ Diagnostic Tests/Health Screenings ✓ Injections and Vaccinations ✓ Wheelchairs Log on to http//www.irs.gov/publications/p5O2/index.htm/for additional details regarding qualified and non-qualified expenses. 330 15 ©2016,Gehring Group,Inc.,Al Rights Reserved City of Stuart I Employee Benefit Highlights 12020-2021 FSA" Flexible Spending Accounts (Continued) FSA Guidelines - . • Employee may carry over up to $550 of unused Health Care FSA funds into the next plan year after a plan year ends and all claims HERE'S HOW IT WORKS! have been filed.Dependent Care funds cannot be carried over. • The Health Care FSA has a run out period at the end of the plan year An employee earning$30,000 elects to place$1,000 into a Health (90 days)to submit reimbursement on eligible expenses incurred Care FSA.The payroll deduction is$38.46 based on a 26 pay period during the period of coverage within the plan year. schedule.As a result,health care expenses are paid with tax-free • When a plan year ends and all claims have been filed,all unused dollars,giving the employee a tax savings of$227. funds with the exception of the$550 rollover for the Health Care With a Health Without a Health FSA will be forfeited and not returned. Care FSA Care FSA • Employee can enroll in an FSA only during the Open Enrollment Salary $30,000 $30,000 period,a Qualifying Event,or New Hire Eligibility Period. ESA contribution -$1,000 -$0 • Money cannot be transferred between FSAs. Taxable Pay $29,000 $30,000 • Reimbursed expenses cannot be deducted for income tax purposes. Estimated Tax -$6,568 S6,795 • Employee and dependent(s)cannot be reimbursed for services not 22.65%=15%+7.65%FICA received. After Tax Expenses -$0 -$1,000 • Employee and dependent(s) cannot receive insurance benefits or Spendable Income $22,432 $22,205 any other compensation for expenses reimbursed through an FSA. 4130 Tax Savings • Domestic Partners are not eligible as Federal law does not recognize them as a qualified dependent. - , Filing a Claim Claim Form Please Note:Be conservative when estimating health care and/or dependent A completed claim form along with a copy ofthe receipt as proof of the expense care expenses.IRS regulations state any unused funds which remain in an FSA, after a plan year ends and after all claims have been filed,cannot be returned or can be submitted by mail,fax,online or through the Benefits Mobile App.The carried forward to the next plan year with the exception of the$550 carry over IRS requires FSA participants to maintain complete documentation,including that may be allowed for the Health Care FSA.This rule is known as"use-it copies of receipts for reimbursed expenses,for a minimum of one(1)year. orlose-it." Debit Card FSA participants will automatically receive a debit card for payment of eligible 1 expenses.With the card,most qualified services and products can be paid at Claims Mailing Address:P.O.Box 2926,Fargo,ND 58108 the point of sale versus paying out-of-pocket and requesting reimbursement. Fax:(866)451-3245 Email:forms@discoverybenefits.com The debit card is accepted at a number of medical providers and facilities,and File Online:www.DiscoveryBenefits.com/benefitslogin most pharmacy retail outlets. Discovery Benefits may request supporting - documentation for expenses paid with a debit card. Failure to provide Discovery Benefits supporting documentation when requested,may result in suspension of the Customer Service:(877)765-88101 www.discoverybenefits.com card and account until funds are substantiated or refunded back to the City. This card will not expire at the end of the benefit year.Please keep the issued card for use next year.Additional or replacement cards may be requested. 331 16 02016,Gehring Group,Inc.,All Rights Reserved i City of Stuart I Employee Benefit Highlights I 2020-2021 Employee Assistance Program Basic Life and AD&D Insurance The City cares about the well-being of full-time and part-time employees on' Basic Term Life Insurance and off the job and provides,at no cost,a comprehensive Employee Assistance The City provides Basic Term Life insurance for all eligible employees at no cost, Program(EAP)through Aetna Resources for Living.EAP offers full-time and through Cigna.Coverage amount will be determined by the employee's annual part-time employees and each family member access to licensed mental base salary,excluding overtime,as illustrated in the benefit table below. health professionals through a confidential program protected by State and Federal laws.EAP is available to help employee gain a better understanding Benefit Amount Class Description of problems that affect them,locate the best professional help fora particular problem,and decide upon a plan of action.EAP counselors are professionally $50,000 1 Full-lime Employees with annual earning of$40,000or trained and certified in theirfields and available 24 hours a day,seven(7)days __ more,induding Employees dassfied as City Manager + a week. Full-Time Employees with annual earning of$30,000 $40,000 2 but less than$40,000 What is an Employee Assistance Program(EAP)? - — — An Employee Assistance Program offers covered employees and family [s3000O 3 butes than$e 30,0swithannualeamingaf$20,000 but less than$30,000 members/domestic partners free and convenient access to a range of - — - _ _ _-_ - _— - _ confidential and professional services to help address a variety of problems . $20,000 4 Full-Time Employees with annual earning of$15,000 that may negatively affect employee or family member's well-being.Coverage ' but less than$20,000 includes six(6)face-to-face visits with a specialist,per person,per issue,per - _ _ —_ _ year,telephonic consultation,online material/tools and webinars.EAP offers $s,000(Life Only) 5 Retirees counseling services on issues such as: -- - - _ - __ _ — — ✓ Child Care Resources ✓ Work Related Issues $50,000 6 Full-Time Employees classified as Elected Officials • ✓ Legal Resources ✓ Adult&Elder Care Assistance - ✓ Grief and Bereavement ✓ Financial Resources Accidental Death&Dismemberment Insurance ✓ Stress Management ✓ Family and/or Marriage Issues Also, at no cost to employee, the City provides Accidental Death & ✓ Depression and Anxiety ✓ Substance Abuse Dismemberment (AD&D) insurance through Cigna. AD&D insurance pays in addition to the Basic Term Life benefit when death occurs as a result of an Are Services Confidential? accident.The AD&D benefit amount equals the Basic Term Life benefit,partial Yes. Receipt of EAP services are completely confidential. If, however, , benefits may also be payable. participation in the EAP is the direct result of a Management Referral (a referral initiated by a supervisor or manager), Aetna Resources for Living , Always remember to keep beneficiary information will ask permission to communicate certain aspects of the employee's care updated.Beneficiary information may be updated at (attendance at sessions,adherence to treatment plans,etc.)to the referring anytime through Bentek. supervisor or manager.The referring supervisor or manager will not receive specific information regarding the referred employee's case.The supervisor Cigna I Customer Service:(800)732-16031 www.cigna.com or manager will only receive reports on whether the referred employee is , complying with the prescribed treatment plan. Aetna Resources for Living I Customer Service:(866)611-2826 www.resourcesforliving.com Username:CityofStuart I Password:EAP 332 17 ©2016,Gehring Group,Inc.,All Rights Reserved r , City of Stuart I Employee Benefit Highlights 12020-2021 O adOo 1J � w Voluntary Life Insurance Voluntary Employee Life Insurance Voluntary Spouse Life Insurance Eligible employee may elect to purchase additional Life Insurance on a' voluntary basis through Cigna.This coverage may be purchased in addition New Hires can purchase Voluntary Spouse Life insurance without to the Basic Term life and AD&D coverage. Voluntary life insurance offers being subject to Medical Underwriting,also known as Evidence coverage for employee,spouse or child(ren)at different benefit levels. of Insurability(E0l),up to the Guaranteed Issue amount of $35;000 if the employee is under age 70. New Hires can purchase Voluntary Employee Life insurance without being subject to Medical Underwriting,also known as Evidence Please Note:lfspouse is age 70 or older,employee is ineligible to enroll in the Voluntary of Insurability(EDI),up to the Guaranteed Issue amount of Spouse Life insurance plan. $70,000 if the employee is under age 70. • Employee must participate in the Voluntary Employee Life plan for • spouse to participate. • Units can be purchased in increments of$10,000 to a maximum of • Units can be purchased in increments of$5,000,not to exceed a $200,000,up to six(6)times the employee's annual salary. maximum of$100,000. • Benefit amounts are subject to the following age reduction • Spouse life insurance coverage will terminate at the end of the schedule: month in which the spouse turns age 70. > Reduces to 65%of benefit amount at age 70 • Premium calculation:Elected coverage_$1,000 x Employee rate • Premium calculation:Elected coverage—$1,000 x Employee rate (see table to the left)x 12 months-24 annual deductions=per (see table below)x 12 months_24 annual deductions pay cycle premium. =per pay cycle premium. Voluntary Dependent Child(ren)Life Insurance • Employee must participate in Voluntary Employee Life plan for Voluntary Life Insurance Rate Table dependent child(ren)to participate. Monthly Premium • For eligible unmarried child(ren),from 14 days up to age 19, or Age Bracket Employee/Spouse* up to age 25 if a full-time student,employee can elect a$10,000 (Based On Employee Age) (Rate Per S1,000 of Benefit) benefit amount. Under25 $0.08 • Dependent child(ren)less than six(6)months old may be covered 25-29 $0.09 fora benefit amount of$500. rrn $0.10 ' • Coverage is a flat$2.25 per month for the Dependent Child coverage 35-39 $0.13 no matter how many Dependent Children are covered. 40-44 $0.20 Always remember to keep beneficiary information updated. 45-49 $033 Beneficiary information maybe updated at anytime through 50-54 $0.56 Bentek/Human Resources. 55-59 j $0.91 60 64 $1.14 Cigna ICustomer Service:(800)732-16031 www.cigna.com 65-69 , $1.98 ; 70-74 1 $3.21 - 75+ ] $4.94 - - *Spouse coverage terminates at age 70. 333 18 ©2016,Gehring Group,Inc.,All Rights Reserved City of Stuart ( Employee Benefit Highlights 12020-2021 Voluntary Long Term Disability Voluntary Short Term Disability The City offers Voluntary Long Term Disability(LTD) insurance to all eligible' The City offers a Voluntary Short Term Disability(STD)insurance to all eligible employees through Cigna.The LTD benefit pays a percentage of gross monthly employees through Aflac.The plan allows employees to customize the length earnings if employee becomes disabled due to an illness or non-work related' of the benefit to coordinate coverage with any other plan the employee may injury.The premium rate is based on the employee's age and covered salary at I own such as the Long Term Disability Plan. the time of the disabling event. Plan Highlights Voluntary Long Term Disability(LTD)Benefits • Employees may select from two options of coverage: • The LTD benefit pays 60%ofthe employee's monthly earnings up to ' Option 1:Benefit election offers coverage that allows a a benefit maximum of$5,000 per month. guaranteed issue amount up to$4,000 per month with either • Employee must be disabled for 180 consecutive days prior to ; a three(3)month or six(6)month benefit period(subject to becoming eligible for benefits(known as the elimination period). income requirements). • Benefit payments will begin on the 181st day of disability. ' Option 2:Benefit election offers coverage that allows • The LTD benefit will be offset by Workers'Compensation or Social employee to be covered for up to$6,000 per month(subject to. I Security. income requirements).The member may elect a benefit period • Employee may continue to be eligible for partial benefits if of 3,6,12,18 or 24 months.Please note,electing this option employee returns to work on a part-time basis. 1 requires applicant to go through underwriting for approval of • Periodic evaluations may occur at the discretion of Cigna. benefits. • The employee will continue to receive benefits for 24 months if • Benefits paid regardless of any other insurance. unable to return to their own occupation. • Guaranteed-renewable to age 75. • The maximum benefit payable will be determined by the employee's Employee may contact Aflac to receive customized information and rates. age at the time the disabling event occurs. • After 24 months,if the employee can return to any occupation Aflac www.aflac.com for which they are suitably trained, educated, and capable of I Agent:Jewel Sands I Phone:(772)631-8192 performing,the employee must return to that occupation(if the Email:jewel_sands@us.aflac.com salary of that occupation does not meet the salary of the employee's l own occupation,the plan will pay the difference). Cigna I Customer Service:(800)732-16031 www.cigna.com 1 334 19 ©2016,Gehring Group,Inc.,All Rights Reserved City of Stuart I Employee Benefit Highlights 12020-2021 (1-+ D City of Stuart Working on Wellness (WOW) I Employee Wellness Centers Our WOW Program has been a tremendous success since it began in the , Spring of 2012.We believe that a healthy, vibrant workforce with healthy, The Employee Wellness Center (EWC) is available to employees enrolled supportive families will enhance our performance and service levels and lower in the City's medical insurance plans. Employee who opts out of the City's our medical insurance costs. We offer creative and enlightening programs medical insurance plans may use the EWC under limited conditions. Please to improve health and quality of life addressing disease control,cancer and contact Human Resources for more information.The EWC can provide the care diabetes prevention. employee and family may need for all non emergency illnesses, at no cost to employee.Schedule an appointment with the medical staff to learn more The"WOW"Initiative offers a variety of Wellness Programs as listed below:; about what the EWC can provide. • Completion of HRA's through the Employee Wellness Center • Wellness Seminars and Lunch and Learns on topics such as: Primary Care Office I Phone:(772)872-7380 1 > Exercise 1 1980 East Ocean Blvd.I Stuart,FL 34996 www.tcprimarycare.com > Nutrition > Walking and Running Primary Care Hours of Operation > Financial Goal Setting Monday 8::O0am-5:00 pm i I > Stress and Change Management , - — > Various health related topics Tuesday 8:00 am—5:00 pm 1 — • Fitness Challenges Wednesday 8:00 am—5:00 pm -_ • Fruit and healthy snack delivery I Thursday 8:OO am—5:00 pm Massages Friday 7, 8:00 am—5:00 pm • WOW Clubs to foster Group Participation • . Please Note:The Primary Care Office is available to covered members by appointment. Look for upcoming events to help you live healthy and be happy! cligliti I Urgent Care Office I Phone:(772)419-0560 1050 SE Monterey Rd.,Suite 101 I Stuart,FL 34994 www.tcurgentcare.com Urgent Care Hours of Operation • Monday j 8:OOam-6:OOpm Tuesday __, 8:OO am-6:OO pm Working On Wellness Wednesday J 8:00 am-7:00 pm Thursday 8:00 am—6:00 pm Friday 8:00 am—6:00 pm • [Saturday 8:00 am—2:00 pm Sunday 8:00 am—2:00 pm Please Note:The Urgent Care Office is available to covered members without an appointment or after Primary Care Hours. 335 1 0 2016,Gehring Group,Inc.,All Rights Reserved 20 City of Stuart I Employee Benefit Highlights 12020-2021 Personal Supplemental Insurance Legal & Identity Protection Plans Aflac U.S.Legal Services The City offers a variety of voluntary supplemental insurance plans through The City offers employees the opportunity to participate in a voluntary legal Aflac.These policies may be purchased separately and the premiums payroll insurance program provided by U.S.Legal Services.By enrolling in the plan, deducted.The available Aflac plans are listed below. participants will have direct access to attorneys who will provide services for a ✓ Hospital Choice variety of situations that include: ✓ Cancer Care Classic Plan ✓ Divorce ✓ Criminal Defense ✓ Critical Care and Recovery ✓ Child Custody and Support ✓ Traffic Tickets ✓ Accident Indemnity Advantage ✓ Adoption ✓ Wills&Living Trusts ✓ Group Critical Illness ✓ Civil Litigation ✓ Real Estate ✓ Group Dental ✓ Bankruptcy ✓ Contract Review ✓ Group Short Term Disability ✓ Name Changes I To learn more about Aflac's available coverages or to schedule a personal The cost to the employee to participate in this legal plan is$18.75 per month. appointment,contact the City's Aflac representative,Jewel Sands,using the This includes coverage for the employee,spouse and dependent children up to contact information provided below. age 23,if enrolled full-time in an accredited college or university.Plan benefits include phone and face-to-face consultations with an attorney, and much Aflac I www.aflac.com more. Agent:Jewel Sands I Phone:(772)631-8192 Email:jewel_sands@us.aflac.com Identity Defender Identity Defender can be purchased separately or added to the legal insurance plan for$9.95 per month.This plan covers employee,spouse and dependent child(ren), up to the age of 26,who reside in the policy holders residence. The Identity Defender Plan covers advance fraud monitoring, fraud alerts, and restoration.The plan also includes assisting members with stolen funds reimbursement and credit monitoring.The Identity Defender Plan is backed by$1 million-dollar identity theft insurance for each plan member and has certified protection experts available 24 hours a day,seven(7)days a week. *identity theft services are powered byldentityForce.Insurance underwritten by member companies of AIG." To learn about these plans, please contact the City's U.S. Legal Services' representative,Dixie Kuehn,using the contact information provided below. , U.S.Legal Services I www.uslegalservices.net Agent:Dixie Kuehn I Office:(321)799-29861 Mobile:(321)403-0156 Email:DixieKuehn@cfl.rr.com 336 21 ©2016,Gehring Group,Inc.,All Rights Reserved 1 I I 0 0 City of Stuart I Employee Benefit Highlights 2020-2021 Q/n'Q C i l Pet Insurance Pet Benefit Solutions Nationwide 1 The City provides employees the opportunity to purchase pet discount plans on The City provides employees the opportunity to purchase pet insurance on a a voluntary basis through Pet Benefit Solutions. voluntary basis through Nationwide.Reimbursements are made on veterinary services. ' Pet Assure is a veterinary discount program that provides a 25%discount on in-, house medical services at participating veterinarians.Visitwww.petassure.com Pet Insurance—Nationwide l for a complete list of local providers.Employees may enroll any pet regardless of age,health,or type—no exclusions!Members also have access to ThePetTag, My Pet Protection a lost pet recovery service. j with Wellness My Pet Protection ~ Common Illnesses V V ' PetPlus is a pet products,prescriptions,and preventatives discount plan that; • provides members-only savings on items such as:flea and tick products,foodsurgeries and Hospitalization ✓ V (including Rx),toys,treats,and more.Members also have access to a 24/7 pet' X-rays,MRIs and CT Scans V V i _ _ -. help line powered by whiskerpocs. Prescription Medications ✓ ✓ Employees can choose to enroll in Pet Assure,PetPlus,or both. [Wellness Exams V Pet Benefits—Pet Assure&PetPlus Preventive Dental Cleaning V Pet Assure PetPlus Spay/Neuter ✓ Common Illnesses r ✓ _ Routine Blood Tests V _ Heartworm Testing and 1 Surgeries and Hospitalization ✓ ✓ I _ LPrevention X rays ✓ Dog $33.74/pay period $25.32/pay period Wellness Visits ✓ Cat $20.18/pay period , $15.81/pay period f Dental Care V — T — Vethel line-free service available to all et insurance members unlimited Spay/Neuter - access,24 hours a day,seven(7)days a week to a veterinary professional. [Prescription Medications ] V = Nationwide:Enrollment Process i Flea and Tick Products V i = 1.Go directly to:www.petinsurance.com/cityofstuart Vitamins and Supplements ✓ 2.Visit petsnationwide.com and enter your company name . Heartworm Preventative 1 ✓ 3.Call(800)540-2016 and ask for the City of Stuart Group Plan—My Pet Specialty RIM ✓ Protection 1 1 One Pet 58/month $4.50/month Nationwide�Customer Service:(800)540-2016 I (Any Pet) (Dog or Cat Only) www.petinsurance.com/cityofstuart ' All Pets $11/month $8.50/month 1 (Any Pet) (Dog or Cat Only) ' Pet Benefit Solutions Customer Service:(888)913-73871 petbenefits.com/land/cityofst I 337 ©2016,Gehring Group,Inc.,All Rights Reserved 22 I City of Stuart I Employee Benefit Highlights 12020-2021 DreamTrips Vacations Liberty Mutual Insurance Offerings The City offersemployeesthe opportunity to enroll in a DreamTrips Membership City employees can enjoy exclusive savings on Liberty Mutual's Insurance Program for the cost of$12.50 per pay period.Monthly deductions may be products. These insurance plans can be purchased separately and payroll applied to the purchasing cost of packages. deduction is also available: ✓ Auto ✓ Boat DreamTrips Members will enjoy: l ✓ Home ✓ Recreational Vehicle(RVs) • Access to hundreds of vacation packages to destinations around the world ./ Renters ✓ Umbrella Policy • Vacations that appeal to all ages ./ Condo ✓ Life and Annuities • 5-star vacations for 2-to 3-star prices ✓ Motorcycle • 24hoursaday,seven(7)daysaweekonlineaccessfortotalbooking To learn more about Liberty Mutual's available coverages or to schedule a convenience personal appointment, contact the City's representative using the contact • A DreamTrips representative(host)on all full vacations to ensure information provided below. complete satisfaction Liberty Mutual Membership provides the employee and his/her immediate family access to Agent:Tamara Bailey,CPCU,API I Phone:(954)991-5600 the entire selection of vacations.Members can take an unlimited number of Email:Tamara.Bailey@LibertyMutual.com I www.libertymutual.com/stuart trips.No annual fee and no contract. Employees can cancel at any time by contacting Human Resources. A website to view current and archived vacations is available to members.Just point,click and go(no planning tours,transfers other details,etc.)! Contact Human Resources for further details. Rovia DreamTrips Vacations I CMRTravelsinc.com Agent:Lonnie Roberts I Phone:(305)582-1428 and(954)589-8046 l I ' II II + I 338 23 J 2016,Gehring Group,Inc.,All Rights Reserved Ait• City of Stuart I Employee Benefit Highlights 12020-2021 NIF Retirement Plans Deferred Compensation Retirement Plans • , Florida Retirement System(FRS) Deferred compensation retirement plans are governed by Section 457 of Effective July 1,2011,all members of the FRS Pension Plan achieve vested the Internal Revenue Service (IRS) Code. City employees have the option status upon completing eight(8)years of creditable service(including military of selecting a wide variety of market-responsive investment options for leaves of absence);FRS Investment Plan members achieve vested status upon retirement planning and asset allocation strategizing. Employees may completing 1 year of creditable service.Additionally,effective July 1,2011,all contribute 100%of salary up to$19,000(participants 50 years of age or older members are required in accordance with Florida State Statute to contribute may contribute an additional$6,000). 3% of their earnings (pre-tax) toward their total retirement contributions, the majority of which is paid by the City.For additional information related Loan Provision to retirement under FRS, deciding which plan to choose, and many other A loan provision in each of the deferred compensation contracts is available. specifics,visit www.myfrs.com or call Ernst&Young(affiliated with FRS)at A participant loan provision enables employees to borrow from their ICMA (866)446-9377. plan. The loan guidelines are set by the IRS: eligibility; maximum loan amounts; interest rates; repayment method; default fees; etc. The loan . Choice Period option is an individual decision and requires the employee to be accountable New eligible employees are initially enrolled as members of the FRS Pension and responsible for taking money out of their retirement account.This loan . Plan by default and have the opportunity to enroll in the FRS Investment provision is separate and in addition to the emergency withdrawal provision. Plan.Effective January 1,2018,new employees are reported as Pension Plan members during the first election period until an active election is received ICMA Retirement Corporation I Plan#301448 or default membership occurs.If no active election is made within the eight Agent:Torri Pilla I Phone:(772)577-6578 (8) calendar months after the month of hire, Special Risk Class members Email:tpilla@icmarc.org www.icmarc.org will default to Pension Plan membership while members in all other classes default to Investment Plan membership.ALL FRS members also have a single additional opportunity to transfer on their own initiative into the opposite plan prior to termination. To learn more about the benefits of the FRS and each plan option,contact FRS at www.myfrs.com or through the MyFRS Financial Guidance Line at (866)44-MyFRS(69377). Florida Retirement System Education/Investment Plan Customer Service:(866)446-9377 I www.myfrs.com City of Stuart Agency#:53100 Florida Retirement System Pension Plan Customer Service:(844)377-1888 https://www.rol.frs.state.fl.us/login.aspx City of Stuart Agency#:53100 339 24 ©2016,Gehring Group,Inc.,All Rights Reserved City of Stuart 1 Employee Benefit Highlights 1 2020-2021 City Programs Probationary Periods and Safety Program Leave Provisions City Management has the responsibility for the establishment of a comprehensive safety program and for the administration and on-going Probationary Period • development of safety education and training. Supervisory job analysis as The initial probationary period for new hires is dependent upon the employee applied to safety may be defined as planning,analyzing hazards,arranging classification,generally six(6)months or longer.Upon successful completion of operations,providing equipment,providing instruction and supervising in a' the initial probationary period,employees are designated"regular employees" manner and to a degree necessary to adequately ensure an employee's safety of the City. throughout a job.Employment by the City will be limited to those who accept responsibility for their own safety and who cooperate fully in eliminating Paid Time Off accidents and injuries. Paid Time Off(PTO) is a combined benefit that encompasses vacation,sick, and personal leave.PTO begins accruing on an eligible employee's first day of Family Friendly Policy employment;however,access to accrued hours occurs after six(6)months or The City is sensitive to unusual family-related circumstances that affect the successful completion of the initial probationary period.Thereafter,the the attendance of an employee. There are occasional-instances when an PTO rate of accrual increases according to an employee's length of service. employee may have to decide between coming to work and devoting time to an unanticipated family need.Under limiting guidelines,a City employee may Other Leave Provisions bring a family member to the employee's work site for a limited period of time. The City offers additional leave provisions to include bereavement,jury duty Please contact Human Resources to seek guidance should you wish to explore (civil leave),military,domestic violence,and FMLA. this policy. Please Note:Please refer to the applicable Collective Bargaining agreement or Personnel Service Recognition Policies as applicable to your position for details regarding probationary periods and leave provisions. All eligible full-time employees will be presented gift awards based on the number of years of continuous service to the City. The employee service , recognition program award gift value schedule is shown in the table below. Employee Handbooks Service Recognition Program Award Gift Value Schedule All employees are expected to read the Employee Handbook,located on the 5YearsofContinuousService 1 Award Gift Value of$100 City's Intranet, Employee Handbook, CBAs and Forms page.The Employee _- - , Handbook addresses employment-related topics to include recruitment and lOYears of Continuous Service Award Gift Value of$200 hiring,probationary periods,promotions,and performance evaluations.City 15 Years of Continuous Servicer Award Gift Value of$300 policies are contained therein, including safety, harassment, civility, drug- 20 Years of Continuous Service Award Gift Value of$400 free workplace,hours of work,and disciplinary guidelines among many other ` = provisions.It is every employee's responsibility to become familiar with 25 Years of Continuous Service Award Gift Value of$500 the policies addressed in this very important document. 30 Years of Continuous Service 1 Award Gift Value of$600 • Employees covered under a collective bargaining agreement(IAFF or PBA)will Education also find respective agreements on the Intranet,Employee Handbook,CBAs and Forms page.Employees covered under one of the collective bargaining The City may offer an educational reimbursement program on a fiscal year units are also responsible for becoming familiar with the Employee Handbook. basis.Please check with your Department Manager and/or Human Resources , for details. . 340 25 ©2016,Gehring Group,Inc.,All Rights Reserved City of Stuart I Employee Benefit Highlights ( 2020-2021 Compensation Hours of Work Uniforms l The City Manager shall establish the hours of work for all departments and Uniforms may be furnished to employees,where applicable,as determined employees of the City,considering the functions and operations involved.The appropriate by the City. City Manager shall establish uniform starting and ending times for supervisors and employees on all shifts.The standard number of working hours for full- Cellular Phone Issuance time employees during any work week is 40 hours unless otherwise specified. The City recognizes the benefit of cellular phone use to increase employee productivity, safety, and timely services to the residents of the City.'As Pay Period appropriate to the dassification,and as authorized by Department Directors, Payroll is issued on a"bi-weekly"basis every two(2)weeks. Paychecks are cellular phones may be issued to employees in accordance with the City's pro- typically issued to each Department by noon every other Friday. curement procedures. Direct Deposit Cellular Phone Stipends Employees may elect to have paychecks directly deposited into any Dependent upon an employee's position and responsibilities, and upon the participating financial institution account of their choosing. Up to four(4) prior written approval of the employee's Department Director,employees may direct deposit arrangements can be managed through payroll.Employees may provide their own cell phone to use for City business.If the Department finds also determine the amount of each paycheck that is to be direct deposited as this advantageous and necessary,a stipend may be issued to offset cell phone follows: costs in recognition of the phone's use for City business. ✓ Total net pay Three(3)cell phone stipends have been established:one(1)for"voice only" ✓ Percentage of net pay at the rate of$40 per month;one(1)for"smart phones with a data package" ✓ Fixed amount of net pay at the rate of$85 per month(exempt employees only);and one(1)for"smart phones with data package and tablet"at the rate of$115 per month(Directors Holidays only;others at the discretion of the City Manager).This program is initiated at All eligible full-time employees are eligible for"holiday pay"for the holidays the Department level and approved by Human Resources. listed at right.If a holiday falls on Saturday,it shall be observed on the Friday preceding.If a holiday falls on a Sunday,it will be observed on the following City of Stuart Holiday Schedule Monday.Holidays will be regarded as hours worked. New Year's Day 1 Furthermore,one (1) optional holiday is also provided for regular full-time - employees who have completed six(6)months of employment with the City. Martin Luther King,Jr.Day The use of optional holidays must be requested and approved at least 48 hours Memorial Day in advance and are not payable at the time of termination or separation. Independence Day In addition to these nine(9) holidays,an employee receives a Birthday Day Labor Day which may be taken before the end of the fiscal year.Full-time employees are - - - - Veterans Day eligible following the completion of six(6)months employment with the City. Thanksgiving Day *Please visit the Collective Bargaining Agreement or City Policy that pertains to your Day after Thanksgiving classification. Christmas Eve Christmas Day 341 26 ©2016,Gehring Group,Inc.,All Rights Reserved City of Stuart I Employee Benefit Highlights 12020-2021 Notes Use this section to make notes regarding personal benefit plans or to keep track of important information such as doctors'names and addresses or prescription medications. r ; 342 27 ©2016,Gehring Group,Inc.,All Rights Reserved City of Stuart I Employee Benefit Highlights 12020-2021 Notes Use this section to make notes regarding personal benefit plans or to keep track of important information such as doctors'names and addresses or prescription medications. 343 28 ©2016,Gehring Group,Inc.,All Rights Reserved • QgyORATE) /`� c j9l9 0 Ptk to �� 1 O ter : , tP4'. Ark VITAL Mil GEHRING® .❑ GROU P EMPLOYEE BENEFITS I RISK MANAGEMENT 4200 Northcorp Parkway,Suite 185 Palm Beach Gardens,Florida 33410 Toll Free:(800)244-3696 I Fax:(561)626-6970 www.gehringgroup.com 344 FINAL. ©2016,Gehring Group,Inc.,All Rights Reserved Last Modified:August 27,20202:45 PM • City of Stuart Medical and Dental Insurance Rates , FY20 Employee 'Employee' ' City City ' ' ' ' Percent ' I I Semi- I 1 I I I I Total Monthly'Total Annual I I Plan Monthly , :Semi-Monthly: Monthy : ,Funded by Monthly Cost . . Premium ; Cost Cost Cost City ' 1 Cost CIGNA 3333805 1 Local Plus Network PPO Basic Medical Premiums: .Employee . $ 30.00 . $ 60.00 . . $ 270.000• $ 540.00 . . $ 600.00 . $ 7,200.00 . 90.00%1 !Employee+SP/DP I $ 113.85 I $ 227:70 I I $ 566.150 1 $ 1,132.30 ! I $ 1,360.00 1 $ 16,320.00 ! 83.26%! IEmployee I+Child(ren) $ 86.63 I $ 173.25 1 I $ 533.375 j $ 1,066.75 1 I $ 1,240.00 ' $ 14,880.00 ' 86.03%1 ;Employee+Family $ 187.00 ; $ 374.00 ; ; $ 818.000 ;$ 1,636.00 J ; $ 2,010.00 ; $ 24,120.00 ; 81.39%; Open Access Plus PPO Buy-Up Medical Premiums: I :Employee : $ 61.20 ; $ 122.40 : : $ 348.800 : $ 697.60 : : $ 820.00 ; $ 9,840.00 ! 85.07%:; !Employee+SP/DP ! $ 209.76 ! $ 419.52 ! ! $ 700.240 ! $ 1,400.48 ! ! $ 1,820.00 ! $ 21,840.00 ! 76.95%11 1 IEmployee+Child(ren) I $ 166.80 I $ 333.601 I $ 668.200 I $ 1,336.40 I I $ 1,670.00 I $ 20,040.001 80.02%I: . : t. ■ t . ■1 t . IEmployee+Family 1 $ 307.74 1 $ 615.48 1 I $ 1,032.260 1 $ 2,064.52 1 1 $ 2,680.00 1 $ 32,160.00 1 77.03%1 NOTE: Basic and Buy-Up rates shown are the"best rates"(3-step HRA completion AND"negative"cotinine test results) CIGNA Dental Care DHMO Plan Dental Premiums: !Employee I $ - I $ - 1 1 $ 8.240 I $ 16.48 I I $ 16.48 I $ 197.76 I 100.00%1 IEmployee+SP/DP 1 $ 19.57 I 1 $ 11.120 1 $ 22.24 1 1 $ 41.81 1 $ 501.72 j 53.19%1 '▪Employee+Child(ren) ' $ 9.79 ' $ 19.57 ' ' $ 11.120 ' $ 22.24 ' ' $ 41.81 ' $ 501.72 ' 53.19%' :Employee+ Family : $ 9.79 : $ 19.57 : : $ 11.120 : $ 22.24 : : $ 41.81 : $ 501.72 : 53.19%: CIGNA Dental DPPO Core Plan Dental Premiums: !Employee I $ - I $ - ! ! $ 14.480 I $ 28.96 ! ! $ 28.96! $ 347.52 I 100.00%! ; '▪Employee+SP/DP 1 $ 14.48 1 $ 28.96 1 1 $ 14.485 1 $ 28.97 1 1 $ 57.93 1 $ 695.16 1 50.01%1 jEmployee+Child(ren) j $ 14.48 j $ 28.96 i i $ 14.485 i $ 28.97 j i $ 57.93 j $ 695.16 j 50.01%; I I 1 1 I I I 1 1 Employee+ Family : $ 14.48 : $ 28.96: : $ 14.485 ! $ 28.97 : : $ 57.93 : $ 695.16 ; 50.01%: CIGNA VISION PLAN Vision Premiums !▪Employee 1 $ 4.36 1 $ 8.72 1 1 $ - 1 $ - I I $ 8.72 1 $ 104.64 I $ - 1 . . . . . . . . . . . 'Employee+SP/DP ' $ 8.72 ' $ 17.44' ' $ - ' $ - ' ' $ 17.44 ' $ 209.28 ' $ 1;I :Employee+Child(ren) : $ 8.81 ; $ 17.62 ; : $ - ; $ - ; ; $ 17.62 ; $ 211.44 : $ - ; I I II II I I I I .Employee+ Family . $ 14.06 . $ 28.12 . Ow '" . $ .' . Ow 28.12 . $ 337.44 . $ - . 345 City of Stuart 1 Medical and Dental Insurance Rates FY21 Employee 'Employee' ' City ' City ' ' ' ' Percent 1' ' Semi- 1 1 1 I I Total Monthly'Total Annual I 'I Plan , Monthly , ,Semi-Monthly; Monthy , ,Funded by Monthly , ,, Premium Cost Cost Cost Cost Ci Cost , , City , CIGNA 3333805 Local Plus Network PPO Basic Medical Premiums: 'Employee • $ 30.00 • $ 60.00 . a $ 278.220 I $ 556.44 . • $ 616.44 . $ 7,397.28 • 90.27%1 (Employee+SP/DP ! $ 113.85 1 $ 227.70 1 ! $ 584.780 ! $ 1,169.56 I ! $ 1,397.26 ! $ 16,767.12 1 83.70%! ' '▪Employee+Child(ren) 1 $ 86.63 ' $ 173.25 1 1 $ 550.365 ' $ 1,100.73 ' 1 $ 1,273.981 $ 15,287.76 1 86.40%I ;Employee+Family ; $ 187.00 ; $ 374.00 ; ; $ 845.535 ; $ 1,691.07 ; ; $ 2,065.07 ; $ 24,780.84 '� 81.89%; Open Access Plus PPO Buy-Up Medical Premiums: I I I I I I I I I I I ;Employee : $ 61.20 : $ 122.40 : : $ 360.035 : $ 720.07 : : $ 842.47 ; $ 10,109.64 : 85.47%^. I I I 11 I I I I II ▪Employee+SP/DP . $ 209.76 . $ 419.52 . . $ 725.175 . $ 1,450.35 . .$ 1,869.87 . $ 22,438.44 . 77.56%. 'Employee+Child(ren) 1 $ 166.80 1 $ 333.60 1 1 $ 691.080 1 $ 1,382.161 1 $ 1,715.761 $ 20,589.12 1 80.56%1: . : I ■ ■ : . . : : ■ (Employee+ Family 1 $ 307.74 1 $ 615.48 1 1 $ 1,068.975 1 $ 2,137.95 1 I $ 2,753.43 1 $ 33,041.16 1 77.65%1' NOTE: Basic and Buy-Up rates shown are the"best rates"(3-step HRA completion AND"negative"cotinine test results) CIGNA Dental Care DHMO Plan , Dental Premiums: 'Employee I $ - I $ - I I $ 8.240 1 $ 16.48 I ! $ 16.48 1 $ 197.76 1 100.00%1 , 'Employee+SP/DP I $ 9.79 ' $ 19.57 ' 1 $ 11.120 ' $ 22.24 ' I $ 41.81 I $ 501.72 ' 53.19%I . . . . . . . I I I . I Employee+Child(ren) i $ 9.79 i $ 19.57 i i $ 11.120 i $ 22.24 i i $ 41.81 � $ 501.72 53.19%' :Employee+ Family : $ 9.79 : $ 19.57 : : $ 11.120 1.1 $ 22.24 : : $ 41.81 I $ 501.72 : 53.19%. CIGNA Dental DPPO Core Plan i Dental Premiums: • !Employee ! $ - ! $ - ! ! $ 14.480 I. $ 28.96 1 I $ 28.96 ! $ 347.52 ! 100.00%! '▪Employee+SP/DP 1 $ 14.48 I $ 28.96 I 1 $ 14.485 I $ 28.97 I I $ 57.93 1 $ 695.16 1 50.01%1 1 Employee+Child(ren) j $ 14.48 j $ 28.96 j j $ 14.485 j $ 28.97 j j $ 57.93 j $ 695.16 j 50.01%i I I I I I I 1 1 I I 1 ▪Employee+ Family • $ 14.48 ' $ 28.96 • : $: 14.485 ' $ 28.97 ' • $ 57.93 ' $ 695.16 ! s.A-. r 3/12/2021 Indian River County Board of County Commissioners Health Plan and Employee Health Clinic Lockton resources ■ Health Risk Solutions Agenda — IRC Workshop • Indian River County Plans • Distribution of Costs • Cost-saving Measures Implemented • Plan Financial Overview • Clinic Survey—Area Employers • Clinic Information • Discussion and Next Steps { 346,A - 1 3/12/2021 • Health Risk Solutions Indian River County Plans • Total Members: 3,678 — Employee Only: 728 — Family: 947 • Enrollment and Payroll Deductions* by Plan: Gold Silver Employee Only 516 $ 55.00 212 $ 7.50 Family 782 $200.00 165 $103.75 "(based on 24 payroll deductions) I • Health Risk Solutions Indian River County Plan Design Overview F BIu eOptions Blueop4ions 1, Pre mier Gold Plan-03559 Premier Silver Plan-05302 Cost Sh- ;g Memb rs Responaiiii r " _._ _—.1Deductible(DED) fr of e P n/f ilyAggreg te) Embedded Embedded., _ I Ntwork�'-"P f60S12 T 0/ 00 _ _ 52 f1000-7-f2,000 ^ 7.T_] . r O t- -Neii-va - 51,200/02,400 • 000/$4000 Coi (BC9Sf Pets/Member )T ll -- .__ . _ u �tnN oki 8096/20% -• 70%70%' _-._ ' E- ,-s._,,,:_.Ou-o(-Ntwork70%/30% --60%%40% 1 Out of Pocket M m - ) • (Pe P on(FemiyAggreg te) 16 Embedded _ _ Embedded _ __ In-Nelworkl, - f3,000/3 6000_ - $60007512p00_ _ Outol-IJetvrorg00 � f0/.f8000 - ' s6,000/S16.000 _1 Office Visite - ' ir 7 [ In-Network'Physician. $30 Copayment - $40 Copayment _ . In-Network Specialist .____i.$50Copeyment $65 Copayment 1 r---_-:------Out-f-Netwonc -DED•30% DED s_40% o_ , Telemedi Ina Servlcea� - is — .�� _ _ [ In,NetwoBGenerelMedkel $10CopeymentT__ $10Copayme t 7771 r":„.---"7:: _In-Network Demiatology.--:--...._$20Copayment =s2_Copayment _22 71 ]' Outof-Network.= INIA N/A _ ] ProcttiptIon Drupe(RX Benelhe)- J-_— - ] 1X elender Year DED Per Pei - NIA S100(must be tbelce Copayments apply)I F._ _ Generk" _S10 _Copap " SS Copey_ Tom_ Pi-e-Ored Sra'nd Neiiii- _ $SO Cop ay '�— 565 Copey -:—...r. - Non-Preferred Strand Netne 075 Copey - 195 Copey Mail Order(90-Disy Supply),• .Express Script 2X Retell Copey Express Script 2X Retail Copey -MaintenanceMedketloni_.2X Copey et Covered Phamracles - 2X Copay at Covered Pharmacies_ • . I • ,31f4A)a2 • 3/12/2021 Health Risk Solutions Distribution of Plan Costs • Rx Claims less Medical/Rx Rx Rebates Administration6% 20% u � ti ��� Stop loss ' Premium ° Medical Claims ��, Net of ISL 70% December 2020 ■ Health Risk Solutions Goals / • Maintain a health plan that is: — Affordable — Competitive — Sustainable • Limited change with emphasis on minimizing member disruption q I ■ I 3 31{4A-3 1 • . • I• • i . . 3/12/2021 a • • Health Risk Solutions ` i • Cost-Saving• Measures Implemented , • °Carve out offpharmacy benefit from�Prime Therapeutics (BCBS)to RX �r s / t j I' r rx__. fir, L 4.,..µr:, f Benefits Exp ress Sin is ' Irn roved to ncrn antl rebates ( P ti ) P P 9 F.._ .q r i a '+r' S _ I • aImplementation of�addit jonal RX savings programs, 14 r " a� �•4; 'Manufact▪urers coupon (SaveOn SP)„'$293,743 net savings 2020' Hi h Dollar Claims Review $127 552 cost avoida..,..,-,014",-.4-,,,,,4,-,--20-- .. ce12020 `im i • 1, 4 , 1 a rv , , l 9 4 'Low�Clinical Value drug;exc�lusion $63,825 cost avoidance 202 u ": �y� a ui'I„ yrsY y i t p3 I ' . • ig 'rr a r a 4 - t . • • ;'Added the Silver Plan which is'a'loweripremium'healthtplan with 4 nhigher deductibles'out of,pocket maximums, and copays v" i` • s• iIncreased'ER copays (waived four admission)to encourage none �Y.r ,a emergent use in'more appropriate setting (urgent care)4� y • '� r y r L 1 4. S^ w j�1F J ' ' • a' ii lehattia t ! ,k i .15a!;,.,5,,,--: '"- . � Addedi Telemedicine benefit Jforlow(cost visits (:$1`0%$20)r i t • • • • Health Risk Solutions Other. Options-Explo • red • In 201;8; Loc• ktonmarketed he health lents ailil dministrative se : ,. rvic• es . . p Blue Cross BluetShield of Floridalwas ranked #,1 and was awarded'theu • :ASO agreemen'trin'May 2018'faY t r 1 'T, '' I YI r t .. .. y , I .4 d I ql i �' • ,.:r �r,rf ,}j f e : r�1`. • ._ " : til II J 11 i ' A 'I h 'i • r rl 4 5 i I F'2' r Yj K 9J y SurgeryPlus analysis of savings underway SurgeryPlus is a � supplemental for.non�em1, ergent surgeries toy ,include • Surgeons ofrExcellence Network rtrl a r •' Bundled pacing for procedures µ Sn k 3 1 r *r '" 3 Y'1 I:: ,4 P w.rr i r ! •' Performance$ uarantee for Savin s r J r IS •, �,. -+ -n '`1 rt "r" g :: v �l I' '� rrpY '� • Incentives waiving member deductible and copays F r� 4• Nationwide,access to''network to serve all enrolled"members yl 7a• 1 - } 3 I- -'S 1,11 '�, f,su 1 r .sr to L.JY . r' uY _: ' .� x .. �+ s -1 ,� I r t-.1 drigia. irk .tr 1 Tc�i. J' r"� 5 1 -ice t44 •, ,Mark•eting of pharmacy{torexplore otherPBMsmodels and possibler . ,,i x 7 , .. t, N ('F-yr'E_.i r 1 i._ s 1 *'x, t 4.1 i..I 1 rsavings Currently out to marketC; ,ii n iib r • J r.„,,,„.„.....„„„,,,,,„„1,,,,,:,,,,-„,,,,,,,,,,,-.15,,,,,. ▪.. 1 1 r 1 t r 1 1 - _m r .-4s ini:^..is d �... �._a':'•x�.,:.., r _._u..-._�,e w.r_.i ...- _ -....�...'.. .....�b -�x Y..,...w...-� .i..,,-..w ! _ • - - , - • • • r. • 4 3/12/2021 Health Risk Solutions IRC Plan Financials Plan Financials Executive Summary: YTD through December Historical Costs Plan Cost History D through December January 2020 thru January 2019 thru December 2020 December 2019 _ 1 677 1 664 M.11 1.11111111111 .1111 edical Rx Administration IMINEXEMINENME=MINIMMEMINI__ .to.Loss Premium ' - - 14� 180 794 • Claims less Rx Rebates -.4 047 052 rEall... ar=EM --20 258 545 1 006.75 -1 036.05 MEEMINMEMIIMII rend History D through December January 2020 thru mmnrizmi December 2020 edical Rx Administration IMENENEME 9.4% MEMCEIMIIMIMEZEMEI 30.7 MIIMMEN 14 180 794 • Claims less Rx Rebates .,RrrEilMIEBE ® EZMEI • Health Risk Solutions InfoLock Analysis of Primary Cost Drivers — (snort recent 12 months) . 1.9%of members account for 45%of plan spend High-cost claimants are members who have claims in excess of$50,000 0t Utilization patterns: Inpatient Admissions-21%of total cost; (17%decrease from year prior) Emergency Room-6%of total costs(8%increase over year prior) i f;The most costly conditions by spend: Multiple Sclerosis, Ulcerative Colitis'/Crohn's, Breast and Gynecological Cancers, End Stage Renal Disease 5 3,4L -5 3/12/2021 Health Risk Solutions Clinic Survey of Area Employers • 16.employers surveyed and 14 responses. • 8 employers surveyed have clinics. • 1 employer closed their clinic after determining it was not cost effective. • Consultants were utilized to guide the clinic evaluation and vendor selection process. • Start up costs can vary. • Annual recurring costs range from $500K to $2.7M (2 locations) and include general medical and limited pharmacy. Smaller city's clinic cost was approximately$250K per year. • Zero copay for employees to utilize the clinic and obtain certain medications. ■ Health Risk Solutions Clinic Survey of Area Employers • Employers with a clinic perceive it as a valuable benefit for employees. • Clinic staffing models vary based on services provided, equipment, locations,and hours of operation. • Marketing campaigns and incentives for using the clinic and encouraging wellness are typically utilized. • Oversight of clinic,administration,wellness strategies,and billing reconciliation involve consultant and employer staffing in coordination with clinic vendor and providers. 6 3 4q,1 F • ` 3/12/2021 { • • • Health Risk Solutions j • - Clinic Service Options �� limilmw .� xxF _. ..r'+ - mut 4 s. fr r �l' a,{ q T' ,� - Aing _ i Acute care .,,...-.'„,.4,- r, v„i„,„:„„„.„,,,,,„,„,:,„.„.„,„,-,,,,,,, tgit Health improvement, 1r`ograms w 7 4-: i i } of .1. Pnmary care , � s f t r x Occupational health ti '4 'y arm . '; t r , xL ent g rChonic cre mangem . � f ryPa '..-"L'..:-,144,-.1:---.:•-;,."4. 4k lli xIa hacya£ AP ttk rOn Ite F i r Specialty care • a4 Alternate clinic lio I Mental or behavioral health pr"' - modelslarerbest On sitennavigation • or conciergie k .r alignedrby tying�` �` 'k r wr em loxersclinic a Finanaallcounseltng r X34 gals and Dental care �6% e r gillieiNgt Specialt•y drug.infUSion �a All centers. ■•Some centers Iµ ati r, toge hement strategy tia �-' � ,.A.u *ca.me,n.b�• .. t:r �-.-.k y �-iy�i 'I,�. r1vat �I � • �u 1...,,-o_.�i ._c�...:-.,_�:u Yom..,.. : ,••• _-__-...,.�_.��-.�...: .sl. +..-r��-_�.___.., ..�J=..T�,J I I , • . j- Health Risk Solutions • Types of Clinic Staffing • r ` Medical Doctor,' r e Nurse Practitioner(NP)or .yRegiste:ed•Nurse • Physician Assistant(PA) • Focus on condition focus on condition • Focus on patient care, management management diagnosis,and treatment • • Triage episodic and • Potential for pre-packed May work with a NP on more occupational care(including medication dispensing and complex patient needs first aid) OTC needs May prescribe and dispense • May support over the .May support wellness medications counter(OTC)needs initiatives • • • May support wellness initiatives • Opportunity:Lowest hourly . Opportunity:Moderate hourly Opportunity: Most robust scope wage wage with increased scope of of work practice Challenge: Challenge: 1 Challenge: • Scope of work is limited • Can not diagnose or • Cost Can not diagnose or independently prescribe • Harder to hire and retain, , independently prescribe medications For full value on investment, medications need strong member engagement strategy Ell I 3/12/2021 Health Risk Solutions • Clinic Locations On-site and Near-site • Higher participation and productivity • Target clinic located within 10 miles of primary population • Greater employer visibility with operations c • Access for emergent needs and employee outreach e • Best for acute/episodic care,primary care and occupational health services a a. 0 • Requires dedicated real estate • Employer has full financial responsibility for the clinic d • Requires higher level of employee trust e • Requires scale to provide financial return(-750-1,000'employees in one location) over several years(3+) L V Health Risk Solutions • Clinic Locations Virtual Retail/Community Based Direct Primary Care • On-demand services for • Episodic'and disease • Providers spread smaller populations management throughout community d • Flexibility in hours • Geographic dispersion of • Lower start up and • • Less financial commitment clinic locations ongoing costs • • and resources required • No/low start up and O ongoing costs a a. 0 • A clinician may be required • Less employee visibility • Less visibility of clinics on-site to assist with • Provider continuity not • Provider continuity not virtual appointments guaranteed guaranteed c • Requires population to be • Employer has less control technologically capable over services and reporting ■ 8 3468 i • • 3/12/2021 • • Health Risk Solutions . Evaluating Clinic Results Quantitative Qualitative • • Estimated value of clinic services • Hiring and retention tool • Top ten procedure groups for onsite, • Productivity measurement community divertible,and community • Focus groups non-divertible • Health risk migration and condition • Surveys: compliance f • Satisfaction • Opportunities for Improvement • • h a ,�, W 2 i 1.,�- r)4 f ...-NMi r g 4_8LJI'kjAg N 5 4 fes* ,'A'r', , T " r �Measunng„outcomes requires having the right tools in place including,member surveys payroll/HR reports for productively a strong,clinic partner and a1datat , aanalyhcs engine,Infolock Vr 'i ,, ti I i,i, •Lockton will negotiate quantitate and qualitative performance guarantees during the RFP process as part of proposed Clini Consulting process. - ' Health Risk Solutions • Client Clinic Example ,•,>�'�:�s;Goal�Be Scope<r_`K?'� Staff and Availability Budget • Offer a competitive • Staffed by a Nurse Practitioner $600K Year 1 to include: benefit to members with • Clinic open 32-40 hours per week • $75K implementation a 3-year goal for risk for employees enrolled on the fee reduction and medical medical plan J • $21 PEPM admin fee* plan savings • Phased approach to allow access to • Provider fee* • Provide episodic and spouses • Pass-through fees for primary care labs and supplies* • Targeted outreach for • Real-estate chronic condition • expansion/build out management +$300 PEPY Engagement incentive reducing premium for completing biometrics in the _ clinic* a F r a'' �` !P� !:d_``r 5 MlifiljkAjtiglantnijn elk ! - r e 1 .1 879 xt :15241.42,0,70#01 ° .Top ViSIt Types Key' I 1 ,FEshmattd Valuer- $4561460Hypertensloi laiii I�,Performance' I ; elintc Users Productivity. S,nusins ', Indicators„ IJovemberzots Servtcte �i n I atoaerzozo Services it Sdvtngs i elometncs i ,,� li 1 tl _Coach,n r ” Provided . a y1 — 9 ' Budget figures are obtained from competitive clinic proposal for a similarly situated client. =ongoing fees • • 3/12/2021 • Health Risk Solutions Indian River County Data (mast pant 12 montbr) s'- . +5._., i rt :_ Il may._. ' 4 -:i Clintc,rE rn can be demonstrated in plan savings through diversion of community visits and risk reduction a 1 l e r _ t ) _..:...,� ...:,A..v�.._.r L. - .. I..i»'.w_W-...�t_riY. - _ ui�.�P h'u!_-_.'___a...._ av�� cost' • $318.60 $128.85 amatILLNESS BURDEN ' 16.7%of population has 43.2%(Norm 33.100 of the Medicel Paid PMPM ex Paw Parma 3.,conditions and costs population has one or more 4.3% 6.1 x more than members chronic conditions and /tws S3/+1,'P Norm StV1 43 """'_"'-' -- 7. 4 '• 6"7without chronic Obsess. represents 76:9%(Norm 73.5%) 1, 818N 76 , 2 r 1 $447 46 of plan casts. • ', ` ` >.<=°. ' ii:if a4k:44'.`=_ • 61%of employees have had a primary preventive care visit • aug i10e ruat4.s • 15% of employees have had no paid . • ' Jaiy 2059` Jui)2ft2O claims Atln,lssl°nsn006 83 77 • 54%(845)IRC employees live within Office Visits/1000 4465 4264 ER VisitsrltWD 1.59 239 10 miles of 32960 zip code ' nvai4sibls ER Visits 415% 39.54E Preventive Visits/1000 130 550 Health Risk Solutions Lockton Clinic Consulting •>r oa_ DETERMINE THE PROPER SCALE AND SCOPE („„, ,,, ,,,,,�,.p�,, 1 l G • Budget,staffing,services provided,location Locktons Clinic I • -Consulting will • Who can use,hours of operation *support building a; • Does it make sense for our organization?Analysis of medical claims and ;ibest in class program.'includingl utilization patterns -ing r,i developscope GETTING EMPLOYEES THROUGH THE DOOR _gathenrig i `1 &R �':.'. competitive ' • Awareness and engagement are key =proposals ands + n: facilitating l a '" • Confidentiality and trust implementation itlit • Leverage data to outreach target populations or individuals __over a 12 month RTP- forar �^ p,„ SAVINGS IMPACT I $75000.project fee t, t l G. i �` Jr ���1 • ROI can be challenging since no industry standard "� • Wellness models will take longer to show s1avings than primary care • Time savings may be substantial dependent on employee base • • I ■ 10 r l 3/12/2021 { Health Risk Solutions Staff Recommendation • Staff is unable to confirm the establishment of Employee Health Clinic would result in plan savings since the primary drivers of plan costs would likely not be impacted by a clinic. Further comprehensive analysis would be needed to determine how and through what time frame such cost drivers may impact plan savings. • Survey respondents with a clinic have indicated that they perceive a savings and overall value. Their overall funding for their health plan appears to be higher than IRC based on stated premiums. • 54% of our members live within 10 miles of 32960. For the members who utilize a clinic, visiting the clinic would be a free benefit since there would be no out of pocket cost to the member. Diversion of care from other community settings to the clinic is where quantitative savings could be expected. At this time, it is unknown exactly what the potential savings of diverted care could be based on employees who may utilize the clinic. } Health Risk Solutions Staff Recommendation • Implementing a strategic wellness strategy into the clinic could likely result in a positive impact to those individuals who adhered to recommended lifestyle changes and potentially impact future claims. • Establishing an Employee Health Clinic and implementing a comprehensive wellness strategy would be an additional service that would need to be administered and managed and require additional staffing (TBD). • Our current plan trend is -2.8%. The implementation of a clinic would be an additional expense (TBD) and staff is unable to provide any assurances that overall plan costs would be reduced by the implementation of a clinic. 11 996,9 / 3/12/2021 Health Risk Solutions Staff Recommendation • Although staff is unable to recommend that implementing an Employee Health Clinic would result in overall savings to the plan, if the Board of County Commissioners determines it is in the best interest of the plan and its covered members to pursue adding an Employee Health Clinic, staff will bring back an agenda item recommending the Board engage the services of Lockton Companies Clinic Consulting Services to support building a best-in-class program including, conducting a needs analysis with claims and utilization information to ensure it makes sense for our organization, developing scope, gathering competitive proposals, and facilitating implementation over a 12-month period for a $75,000 project fee. Health Risk Solutions Discussion &Next Steps • { ■ 12 3 /^fid •