Benefit2016-2017 Plan Year Benefit Plan Year
July 2016 - June 2017
Rates and Medical Plans Bundled with Dental and Vision Coverage Rates reflect per pay period contribution BENEFITS DEDUCTION SCHEDULE
BENEFIT COST FOR 12-MONTHS EMPLOYEES PER PAY PERIOD Deductions 7/1/16 - 6/30/17
EE Only
EE+ Spouse
EE+ Children
EE+ Family
Kaiser EPO
No Cost
$233.9
$199.77
$323.72
Anthem EPO
No Cost
$306.39
$235.85
$426.03
Anthem HSA
No Cost
$263.40
$203.02
$367.40
Anthem PPO
$127.50
$316.29
$243.42
$439.53
BENEFIT COST FOR 10-MONTHS EMPLOYEES PER PAY PERIOD
Important: Your annual benefit premium will be charged and collected within a 9-month period; between September 1st through May 31st (18 pay periods)
Deductions (on 18 pay periods) 9/1/16 - 5/31/17 EE Only
EE+ Spouse
EE+ Children
EE+ Family
Kaiser EPO
No Cost
$311.86
$266.35
$431.62
Anthem EPO
No Cost
$408.52
$314.47
$568.04
Anthem HSA
No Cost
$351.19
$270.69
$489.86
Anthem PPO
$170.00
$421.72
$324.55
$586.03
Eligibility Rules • • • •
All benefit eligible employees working 20+ hours per week. Eligible dependents: spouse (as defined by state law), and children under age 26 . Employees who plan to enroll their dependents in the DSJ health plan will be required to provide documentation of dependent eligibility during enrollment in order for dependent’s coverage to be approved. (Spouse -Marriage certificate, Child- Birth certificate, Adoption/Legal Guardianship – Court documents) For detailed information go to Retatrust.org and review “Eligibility & Enrollment” summary
2016- 2017 Benefits Plan Breakdown
VOLUNTARY OPTIONS
CORE BENEFITS
Health Plans Kaiser
Anthem PPO or EPO
Anthem HSA
Kaiser Vision
VSP Vision
VSP Vision
Kaiser Prescription
Envision Rx Prescription
Anthem Prescription
Delta Dental
Delta Dental
Delta Dental
Waive Medical No vision/presrciption or dental provided Life Insurance, AD&D, LTD are provided
DELTA DENTAL PPO
The Delta Dental PPO* plan makes it easy to find a dentist, visit the dentist of your choice, and save money with a Delta Dental PPO dentist.
VISION – VSP or KAISER VISION
• Anthem will automatically receive the VSP vision plan. • Kaiser will automatically receive the Kaiser vision plan.
LIFE INSURANCE, AD&D, LONG TERM DISABILTY
Employer pays 100% of the premium at no cost to employee on all Health Plan packages.
Term Life and Accidental Death and Dismemberment (AD&D) insurance
Your beneficiary will receive 1x basic annual earnings to a maximum of $125,000.00. Provides a cash benefit to help ensure your loved ones remain financially secure in the event of your death or a covered accident. Benefit reduction commencing at age 65.
Long-term disability (LTD) insurance
LTD is intended to help replace some of your income for an extended period when you cannot work because of a disability. Elimination Period of 180 days. Monthly benefit of 70% of monthly salary up to $5,000 per month. Integrated with other disability benefits you may receive.
DSJ PENSION RETIREMENT
All Benefits Eligible employees hired or rehired are automatically enrolled in the Diocese of San Jose Retirement Plan. The Pension plan is 100% funded by DSJ and administered by Nicolay Pension Services Division (800) 867-0780 x223. A personalized annual statement is available on line after the end of the calendar year at www.hrmecca.com/dsj.
ADDITIONAL LIFE INSURANCE, AD&D
Voluntary Life and Accidental (AD&D) is an employee-paid plan available to all new hires and during open enrollment period. Coverage available to employee and eligible dependents.
FLEXIBLE SPENDING ACCOUNT (FSA)
Participating in FSA can help save you money on taxes. The money you set aside in FSA is not subject to federal income or Social Security tax. This allows you to benefit from more of the money you earn.
Health Care Flexible Spending (HFSA)
HFSA allows you to set aside a portion of your salary, before-tax, to reimburse certain amounts expended for medical care. Contribution may not exceed $1,200.
Dependent Day Care Flexible Spendin (DFSA)
DFSA allows you to set aside a portion of your salary, before-tax, to reimburse amounts spent for eligible dependent day care expenses that are necessary in order for you, and if you are married, your spouse, to work or look for work. Under federal tax law. Maximum annual contribution may be up to $5,000 ($2,500 maximum if you are married, filing separate income tax returns).
403(b) TAX SHELTERED ANNUITY (TSA)
As an employee of the Diocese of San Jose, you are eligible to participate in a 403(b) TaxSheltered Annuity (TSA) plan. An individual’s 403(b) annuity can be obtained only under an employer’s TSA plan. Participation in the 403(b) TSA is voluntary and may be done at any time at the employee’s discretion. The plan is administered by Employee Benefits Services (EBS). Employee may choose any investment company as long as it meets the Information-Sharing Agreement with the Diocese of San Jose as an approved company. Investment options include mutual funds and annuities. To enroll in the 403(b) TSA, please contact a financial advisor of your choice or Employee Benefits Services (EBS) DSJ Plan Administrator at 408-978-1000. There will be no matching contribution.
Visit www.retatrust.org for Plan Summary and Evidence Coverage Booklets Anthem Plan Designs
PREMIUM Plan: PPO 100/80
CORE Plan: EPO
Plan: HSA 80/60
Annual Out-of-Pocket Maximum (Includes Deductible & CoInsuance) per calendar year For any one Member in the same Family Unit
$250 In / $2,950 Out network
$800 No Coverage out of network
$5,000 In / $6,000 Out network
For an entire Family Unit of two or more Members
$500 In / $5,900 Out network $250 Ind / $500 Fam (combined in and out)
$2,400 No Coverage out of network None
$10,000 In / $12,000 Out network $1500 Ind / $3,000 Fam (combined in and out)
Office Visit Co-payments
$20 Copay In (deductible waived) 20% Out
$15 Copay In Network No Coverage out of network
20% In / 40% Out
Preventive Services
100% In/ 80% Out
100% No Copay in Network No Coverage out of Network
0% In / 40% Out (deductible waived)
Well Child Care (Birth to age 2)
100% In/ 80% Out
No Copay In Network No Coverage out of network
0% In / 40% Out (deductible waived for In)
Outpatient surgery
No Copay In / 20% Out
No Copay In Network No Coverage out of network
20% In / 40% Out
Allergy injection visits
No Copay In / 20% Out (deductible waived) $20 Office Visit may apply
No Copay In Network No Coverage out of network $15 Office Visit may apply
20% In / 40% Out
X-rays and lab tests
No Copay In / 20% Out
No Copay In Network No Coverage out of network
20% In / 40% Out
MRI, CT and PET
No Copay In / 20% Out
No Copay In Network No Coverage out of network
20% In / 40% Out
$250 per admission then paid at 100%
20% In / 40% Out
In Network Deductible per Calendar Year Professional Services
Outpatient Services
Inpatient Services ($500 deduct non-preauthorized hospitalization) Room and board, surgery, anesthesia, Xrays, lab tests, and drugs
$100 per admission then 0% In / 20% Out
Emergency Health Coverage ($100 deductible is wavied if admitted to hospital directly from ER) Emergency Department visits
0% In & Out for initial 48 hours / Out 20% thereafter $100 per visit, waived if admitted
0% In & Out for initial 48 hours 20% In / Out / No Out coverage thereafter $100 per visit, waived if admitted
Retail Pharmacy - up to 30 day supply
$10 Generic 30% Brand Formulary 50% Brand Non Formulary $2,000/Member OOP; Based on RVO Program
$10 Generic 30% Brand Formulary 50% Brand Non Formulary $2,000/Member OOP; Based on RVO Program
$10 Generic 30% Brand Formulary 50% Brand Non Formulary Must meet HSA Ded
Mail-order Pharmacy - up to 90 day supply
$20 Generic 30% Brand Formulary 50% Brand Non Formulary $2,000/Member OOP; Based on RVO Program
$20 Generic 30% Brand Formulary 50% Brand Non Formulary $2,000/Member OOP; Based on RVO Program
$20 Generic 30% Brand Formulary 50% Brand Non Formulary Must meet HSA Ded
0% In/ 20% Out network
No Copay in Network
20% In / 40% Out network
Prescription Drug Coverage
Durable Medical Equipment Covered durable medical equipment for home use in accord with our DME formulary
Visit www.retatrust.org for Plan Summary and Evidence Coverage Booklets RETA TRUST - TRUSTOR
Kaiser
RetaTrust – BAS 877-303-7382 www.retatrust.org * Enrollment Process * Password & Username * Benefit Election Assistance * Misc. questions: Medical, Dental, and Vision, FSA, Plans Summary
CORE Plan: EPO Annual Out-of-Pocket Maximum for Certain Services For any one Member in the same Family Unit
$1,500 per calendar year
For an entire Family Unit of two or more Members
$3,000 per calendar year
Deductible
None
MEDICAL PLANS
Anthem Blue Cross www.anthem.com/ca * Order New Cards * Coverage detail PPO Group #1841KA-KM EPO Group #1724V HSA Group #1850
Professional Services (Plan Provider office visits) Office Visit Co-payments
$15 per visit
Preventive Services
100%
Well-child preventive care visits (0-23 months)
100%
Kaiser
888-722-1077
800-663-1771 www.kp.org * Order New Cards * Coverage detail EPO Medical Group #8441
DENTAL PLANS
Delta Dental PPO
800-765-6003 www.deltadentalins.com * Order New Cards * Coverage detail Group #15887 Outpatient Services Outpatient surgery
$15 per procedure
Allergy injection visits
$5 per visit
Lab test
No Charge
MRI, CT and PET
No Charge
VISION PLANS
VSP Vision 800-877-7195 www.vsp.com * Order New Cards * Coverage detail Employee’s Social Security #
Kaiser Vision
800-464-4000 www.kp.org * Order New Cards * Coverage detail EPO Vision Group #8441
PRESCRIPTION PLANS
Inpatient Services
Anthem EPO - PPO
Room and board, surgery, anes$250 per admission thesia, X-rays, lab tests, and drugs, Mental Health and Substance Abuse (Detox)
EnvisionRx
844-852-7437 www.EnvisionRx.com
AnthemHSA Rx 888-722-1077 www.anthem.com/ca Group #1850 DA-DM
Kaiser Rx 800-464-4000 www.kp.org EPO Prescription Group #8441
Emergency Health Coverage Emergency Department visits
$100 per visit (does not apply if admitted directly to the hospital as an inpatient)
Prescription Drug Coverage Retail Pharmacy Mail Order Pharmacy
$10 Generic $20 Brand
RETIREMENTS
Nicolay Pension Services Division
E.B.S. 408-978-1000 800-867-0780 x223 www.hrmecca.com/dsj FLEX SPENDING LIFE INSURANCE
Benny Card RetaTrust – BAS Lincoln National
800-423-2765 www.lfg.com * Life, AD&D, LTD * Critical Illness and Accident
877-303-7382 www.retatrust.org
Same as retail
Durable Medical Equipment Covered durable medical equipment for home use in accord with our DME formulary
403 (B) Savings Plan
20% coinsurance
WebMD Support 877-936-1970 www.webmdhealth.com/reta * Enrollment Process * Password & Username