Employee Benefits Program 2015 - 2016 A Summary Guide to Your Employee Benefits Medical Voluntary Dental Voluntary Vision Basic Life/AD&D Voluntary Life Disability Employee Assistance Program Health Reimbursement Account Flexible Spending Account Telahealth Paid Holidays Leave Retirement Credit Union Direct Deposit University Services & Discounts WEMS ID Card & Reserved Parking
PAGE 2
EFFECTIVE APRIL 1, 2015
Open Enrollment The choices you make during open enrollment will be effective from April 1, 2015 to March 31, 2016. If you do not enroll during open enrollment, you will not be able to participate until next year’s open enrollment. You CANNOT change elections until the next open enrollment unless you experience a qualifying event, including a Change in Family Status. The changes in family status are:
Marriage or divorce Birth, adoption, or change in custody of your child Death of your spouse or child Change in your spouse’s employment status Child’s loss of dependent status A change in your residence that affects benefit coverage
An Enrollment/Change Form MUST be submitted to Human Resources within 31 days after the qualifying event for the requested changes to become effective, and the change must be consistent with the event. Proof of the qualifying event must be submitted.
Benefit Elections Employees’ contributions for most benefit premiums will be deducted through payroll deductions. Actual take home pay may be higher or lower depending on the coverage selected. Benefits deducted on a pre-tax basis may reduce an employee’s compensation for Social Security purposes; therefore, Social Security benefits may decrease.
Health Coverage Reminder The Patient Protection and Affordable Care Act (PPACA) requires most individuals to have minimum essential health coverage in 2015 or pay a penalty. You may obtain coverage through your employer or through the Marketplace. Visit HealthCare.gov for Marketplace information. REMINDER: You may only purchase insurance through the Marketplace if you experience a qualifying event OR during Open Enrollment. The Federal Marketplace Open Enrollment dates are from November 15, 2014 through February 15, 2015.
TEXAS WESLEYAN UNIVERSITY
PAGE 3
Blue Cross Blue Shield Medical (Pre-tax benefit) Benefit Deductible Individual / Family
$3,000 / $6,000
Maximum Out-of-Pocket *
$5,000 / $10,000
Lifetime Maximum
Unlimited
Coinsurance
80%
Physician Services Preventive Primary Care Specialist Urgent Care
Covered at 100% $30 $50 $75
Other Services Hospital Admission Outpatient Surgery Complex Imaging Emergency Health Services
Deductible + 20% Deductible + 20% Deductible + 20% $200 + Deductible + 20%
Prescription Drug Copays Maximum Out of Pocket Tier 1 - Generic Tier 2 - Preferred Tier 3 - Non-Preferred Mail Order 90-Day Supply
$1,000/$3,000 $20 $40 $70 3 X Copay
Out-of-Network Charges Deductible (Individual / Family) Maximum Out-of-Pocket * Lifetime Maximum Coinsurance
$4,500 / $9,000 $9,000 / $18,000 Unlimited 50%
* Including deductible, coinsurance & medical copays
Medical Rates BCBS
Employee’s Cost
University’s Cost
Employee Only
$
60.00
$561.94
Employee + Spouse
$ 610.05
$633.83
Employee + Child(ren)
$ 500.03
$619.45
Employee + Family
$1,143.59
$703.57
PAGE 4
EFFECTIVE APRIL 1, 2015
Quality Care Dental® Voluntary Benefit
(Pre-tax benefit)
A reduced fee-for-service program. Allows an employee and their dependents to pay for dental services with participating dentist as necessary. Claim forms are not required. Additionally, the benefit plan doesn’t have deductibles or coverage maximums. Pre-existing conditions are covered immediately.
Dental Rates Quality Care Dental
QCD
Employee Only
$0.00
Employee + Spouse
$8.00
Employee + Child(ren)
$10.00
Employee + Family
$12.00
CIGNA Voluntary Dental DHMO (Pre-tax benefit) Benefit
DHMO
Routine Office Visit
No co-payment
Deductible per Policy Year
None
Coinsurance Preventive X-ray Routine Prophylaxis Endodontics Periodontics Orthodontia (Adult & Child)
Scheduled copay Scheduled copay Scheduled copay Scheduled copay Scheduled copay Scheduled copay
Policy Year Maximum
Unlimited
Network
CIGNA Dental Care
Waiting Periods
None
Dental Rates CIGNA Dental
DHMO
Employee Only
$13.05
Employee + Spouse
$22.17
Employee + Child(ren)
$22.96
Employee + Family
$31.90
TEXAS WESLEYAN UNIVERSITY
PAGE 5
CIGNA Voluntary Dental DPPO (Pre-tax benefit) Benefit
DPPO
Deductible per Policy Year Individual / Family
$50 / $150
Deductible Waived
Type I dental services
Policy Year Maximum
$1,000
Type I - Preventive
90%
Type II - Basic
60%
Type III - Major
50%
Type IV Orthodontia
50% (Up to age 19)
Ortho Lifetime Maximum
$1,000
Waiting Periods (New Entrants)
24 Months Orthodontia
Network
CIGNA Dental Choice
Out of Network
Maximum Allowable Charges
Dental Rates CIGNA Dental
DPPO
Employee Only
$27.54
Employee + Spouse
$54.42
Employee + Child(ren)
$56.36
Employee + Family
$78.29
* Please refer to your Benefit Summary for more information.
EFFECTIVE APRIL 1, 2015
PAGE 6
VSP Voluntary Vision Base (Pre-tax benefit) Benefit
In Network
Out of Network
Exams Materisl
$10 Copay $25 Copay
N/A N/A
Exams (Every 12 Months)
100% After $10 Copay
Maximum $45
Lenses (Every 12 Months) Single Bifocal Trifocal Progressive
100% After $25 Copay 100% After $25 Copay 100% After $25 Copay 100% After $25 Copay
Maximum $30 Maximum $50 Maximum $65 Maximum $50
Frames (Every 24 Months)
$130 Allowance then 20% off of balance
Maximum $70
Contacts (Every 12 Months)
$130 Allowance
Maximum $105
VSP Voluntary Vision Premier (Pre-tax benefit) Benefit
In Network
Out of Network
Exams Materisl
$10 Copay $25 Copay
N/A N/A
Exams (Every 12 Months)
100% After $10 Copay
Maximum $45
Lenses (Every 12 Months) Single Bifocal Trifocal Progressive
100% After $25 Copay 100% After $25 Copay 100% After $25 Copay 100% After $25 Copay
Maximum $30 Maximum $50 Maximum $65 Maximum $50
Frames (Every 24 Months)
$150 Allowance then 20% off of balance
Maximum $70
Contacts (Every 12 Months)
$150 Allowance
Maximum $105
Vision Rates VSP Vision
Base
Premier
Employee Only
$ 7.38
$13.01
Employee + Spouse
$11.81
$20.91
Employee + Child(ren)
$12.06
$21.35
Employee + Family
$19.44
$34.42
TEXAS WESLEYAN UNIVERSITY
PAGE 7
Dearborn National Voluntary Life (After-tax benefit) Benefit
Coverage
Benefit - Employee Spouse Child
$10,000 increments up to the lesser of 5X salary or $500,000 $5,000 increments up to 100% of employee amount $2,000 increments up to the lesser of $10,000 or 100% of employee amount
Guarantee Issue - Employee $100,000.00 Spouse $ 25,000.00 Child $ 10,000.00 Portable
Yes
Conversion
Yes
Accelerated Death Benefit
50% of Benefit
Waiver of Premium
Yes
Dearborn National Voluntary Life Insurance Rates Age
Employee Non-Smoker (Per $10,000)
Employee Smoker (Per $10,000)
Spouse (Per $5,000)
