1 October 1, 2014 through December 31, 2015 employeebenefits
2 employeebenefits BENEFIT CARRIER CONTACT INFORMATION West Ada School District Kesha Lee, Benefits Manager Jamie Zarkos, HR Clerk Gail Carrithers, HR Clerk Nan Wasson, HR Clerk Patsy Lindbloom, HR Clerk Department Fax number: Blue Cross of Idaho - Medical Policy #: / CVS Caremark: Mail Order Pharmacy Benefit Manager Willamette Dental Policy #:Z1390/ID Ameritas - Dental and Vision Policy #: Dental: Vision: LifeMap Assurance Company - Life Policy #: ID 03904I Claims: Standard Insurance Co. - Disability Policy #: / ComPsych - Employee Assistance Program MSD Web ID: MJSD AFLAC - Supplemental Insurance Policy #: & 0GM American Fidelity - Supplemental Insurance Flores and Associates - Cafeteria Plan, Medical/Dependent Care Flex / TSA Consulting Group - 403(b) Plan Retirement Plan - P.E.R.S.I / NC PERS Group Decreasing Term Life Insurance - HealthSmart Benefit Solutions, Inc Moreton & Company - Claims Assistance Kim Baumberger Toll Free: HUMAN RESOURCES: Please contact Human Resources for any benefit related questions including benefit coverage, contributions, enrollment, benefit change forms, notification for changes in status, provider directories, and general carrier information. Employee Paid Leave: Please refer to the following documents for information regarding sick leave, personal days and vacations - Classified Employees: District Policy ; Certified Employees: Master Contract; Administrative Employees: Admin Salary Schedule. IRS REGULATIONS: Failure to meet IRS Deadlines will affect your insurance coverage! IRS regulations govern how and when an employee may make cafeteria plan elections and changes to those elections. These rules require that employers enforce firm deadlines with respect to employee benefit enrollment forms and the related cafeteria plan elections. This means that we cannot accept forms turned in after open enrollment ends. Furthermore, if you experience a qualifying event allowing you to add, drop or modify your coverage and related cafeteria plan election mid-year, we must be notified of such event and the required forms generally must be completed within 30 days of such event, or you cannot make the change. In addition, please be aware that with the exception of the birth, adoption or placement for adoption of a child, any cafeteria plan election changes can only be implemented prospectively, i.e., on the first paycheck or period of coverage following our receipt of the form. Therefore, if you are making a change based on a qualifying event other than a new child, and you want changes implemented as of the date of the event, you must inform us of the change and turn in your form in advance or as soon after the event as possible. If you do not enroll on time, you will not receive coverage or be able to change your elections mid-year unless you have a special enrollment opportunity. SOCIAL SECURITY NUMBERS: Federal law requires you to provide a valid Social Security Number for each person to be covered by any medical plan sponsored by your employer (yourself, your spouse, and all dependent children). MEDICARE PART D: If you have Medicare or will become eligible for Medicare in the next 12 months, Federal law gives you more choices about your prescription drug coverage. See Human Resources for more information. Note: This publication is only a partial summary of benefits and is provided for informational purposes only. It does not describe all elements of the summarized programs. For complete information regarding the benefits, plan provisions, limitations and exclusions, and for a description of claims procedures, refer to the formal benefit documents that will be provided to you after enrollment. In the event of a discrepancy or conflict between the information contained in this publication and the official benefit plan provisions, the official plan documents and insurance contracts will govern. Copies of these documents are available for your review from your Human Resources Department. No rights shall accrue to you and/or your dependents because of any statement, error or omission in this publication.
3 HIPAA PRIVACY NOTICE The Health Insurance Portability and Accountability Act (HIPAA) requires employers to adhere to strict privacy guidelines and establishes employees rights with regard to their personal health information. If you have any questions regarding this federal regulation, please speak with your Moreton & Company Representative or contact Human Resources. WHY IS OPEN ENROLLMENT SO IMPORTANT? Benefits open enrollment for West Ada School District is held each year. You may change your benefit elections as you desire until the enrollment deadline ends. All employee medical, dental, and vision premiums can be deducted from payroll on a pretax basis. Once the Enrollment Period has ended, you may not make or change your benefit elections. If you believe you can make or change an election due to a change in employment or family status, you generally have 30 days to complete and return a new enrollment form. WHO IS ELIGIBLE TO PARTICIPATE IN THE BENEFITS PLAN? Classified employees must work 20+ hours and Administration and Certified employees must work 30+ hours per week; Employees will receive benefits on the first day of the month following 60 days from date of hire (provided forms are properly submitted); Employees will receive coverage for dependents; see your summary plan description s definition of dependent, (children who are less than 26 years of age); Employees hired after the plan year begins will select their coverage choices for the remainder of that plan year at the time of eligibility. All the necessary enrollment and change forms are available through the Human Resources Department. IS IT POSSIBLE TO MAKE CHANGES DURING THE YEAR? After the enrollment deadline, your election is generally irrevocable, meaning you cannot add, modify, or drop coverage for the plan year. You may have a special enrollment right allowing coverage changes for certain losses of coverage eligibility under another plan or if you gain a new spouse or dependent. You also may be entitled, or required, to change your election if you, your spouse, or dependents experience one of the Qualifying Change events below. However, you must contact Human Resources to determine if our plan and if your circumstance allow such a change. If so, you must complete and return a change form to Human Resources generally within 30 days. QUALIFYING CHANGES (GENERALLY 30 DAYS UNLESS OTHERWISE STATED BELOW) Divorce or legal separation; Marriage, or change in number of dependents; Change in employment status of employee, spouse, or dependent that causes loss of eligibility; Dependent ceases to satisfy eligibility requirements; Change in residence that causes loss of eligibility; Significant changes in company benefit plan(s) including cost change, significant coverage curtailment, additional or significant improvement of company offered benefits; Change in coverage under another employer plan (including mandatory or optional change initiated by your spouse s employer or a change initiated by your spouse); Loss of coverage from government plans/programs or educational institution; COBRA qualifying event (termination/reduction of hours, employee death, divorce/legal separation, ceasing to be a dependent); Other changes resulting from a judgment, decree, or order; Medicare or Medicaid entitlement; or FMLA leave of absence; Loss of CHIP or Medicaid eligibility; Gaining CHIP or Medicaid subsidy eligibility (60 Days). REMEMBER: If you do not turn in your benefit choices on time, you will not receive coverage or be able to change your elections mid-year. GLOSSARY OF TERMS Co-pay: Typically refers to a dollar amount a member pays for services. Deductible: Amount that must be paid by the member prior to the benefits offered and are indicated with AD (After Deductible). Coinsurance: Typically refers to the member's share of covered costs, after any deductible is satisfied. Out of Pocket Maximum: The maximum amount members pay for covered in-network essential health benefit expenses during the benefit year including Co-Pays, Coinsurance and Deductibles. PPO: Preferred Provider Organization - this type of Plan utilizes Network and Non- Network Benefits. Network (In-Network): Providers who have agreed to accept Contracted rates from an Insurance Carrier. Non-Network (Out-of-Network): Any Non-Contracted Providers. The services from these Providers are subject to balance billing meaning members can be billed for the difference between the Insurance Carrier's fee schedule and the billed charges. the plan documents apply. Please refer to the formal plan documents for a complete description of benefits, limitations, and exclusions. 2 enrollmentguidelines
4 medicalplan Blue Cross of Idaho - West Ada School District offers the following medical plan: 3 PREFERRED BLUE Network Non Network * Deductible (Individual / Family) $500 / $1,000 $500 / $1,000 Out of Pocket Maximum (Deductible Not Included) $4,500 / $9,000 $6,000 / $12,000 Coinsurance (Carrier Pays / Member Pays) 80% / 20% 60% /40% Office Visits Primary Care Preventive ** Specialists Chiropractic Prescriptions Network Retail Pharmacy Mail Order Drugs - 90 Days Diagnostic Lab / X-Ray Minor (In Office) Major Hospital Services Outpatient Inpatient Maternity Emergency Services Urgent Care Emergency Room (Co-pay waived if Admitted) Ambulance Mental Health Services Inpatient Outpatient Outpatient - Office MONTHLY EMPLOYEE RATES Employee (EE) EE + Child EE + Children EE + Spouse EE + Spouse + Child EE + Spouse + Children AD: After Deductible : Unity Health office visit requires no co-payment : 90 day supply or 100 unit doses, whichever is less Maximum Allowable of specifically listed services $20 Co-pay (Per Visit) 100% $20 per visit 80 / 20 AD 50 / 50 AD Generic Prescriptions / Brand Name Prescriptions $10 Co-pay + 20% / $20 Co-pay + 20% $10 Co-pay = 20% / $20 Co-pay + 20% $10 Co-pay + 20% / $20 Co-pay + 20% None Covered 100% for the first $100 then 80 / 20 AD 80 / 20 AD 80 / 20 AD 80 / 20 AD 80 / 20 AD $20 Co-pay (Per Visit) $200 Co-pay then 80 / 20 AD 80 / 20 AD 80 / 20 AD 80 / 20 AD $20 Co-pay (Per Visit) * Member will be responsible for amounts billed by non-participating providers in excess of eligible medical expense amount. ** Please refer to your Blue Cross of Idaho provided materials for a full list covered Preventive services. To Find a Provider, please visit For a complete description of benefits, limitations, and exclusions, consult your Summary Plan Description, available from Human Resources or at $25.00 $ $ $ $ $ $200 Co-pay then the plan documents apply. Please refer to the formal plan documents for a complete description of benefits, limitations, and exclusions.
5 2014 Preventive Care Benefits Applies to all non-grandfathered individual and group plans with effective dates on or after January 1, Highlights of your preventive care benefits: You pay nothing; no coinsurance, co-payment or deductible, for covered preventive care services when you visit in-network providers. Preventive care benefits for services from out-of-network providers subject to deductible and coinsurance. COVERED PREVENTIVE CARE SERVICES In-Network Out-of-Network Specifically Listed Services Annual adult physical examinations; routine or scheduled wellbaby and well-child examinations; Bone Density; Chemistry Panels; Cholesterol Screening; Colorectal Cancer Screening (Colonoscopy, Sigmoidoscopy, Fecal Occult Blood Test); Complete Blood Count (CBC); Diabetes Screening; Pap Test; PSA Test; Rubella; Screening EKG; Screening Mammogram; Thyroid Stimulating Hormone (TSH); Transmittable Diseases Screening (Chlamydia, Gonorrhea, HIV, Syphilis, Tuberculosis (TB)); Urinalysis (UA); Aortic Aneurysm Ultrasound; Alcohol Misuse Assessment; Genetic Counseling for High Risk Family History of Breast or Ovarian Cancer; Newborn Metabolic Screening (PKU, Thyroxine, Sickle Cell); Health Risk Assessment for Depression; Newborn Hearing Test; Lipid Disorder Screening; Smoking Cessation Counseling Visit; Dietary Counseling (limited to 3 visits per Member, per Benefit Period); Preventive Lead Screening; Urine Culture for Pregnant Women; Hepatitis B Virus Screening for Pregnant Women; Iron Deficiency Screening for Pregnant Women; Rh (D) Incompatibility Screening for Pregnant Women. The specifically listed Preventive Care Services may be adjusted accordingly to coincide with federal government changes, updates, and revisions. WOMEN S PREVENTIVE HEALTH SERVICES (Applies to group and individual plan members unless otherwise noted.) Well-woman visits (for recommended age-appropriate preventive services); gestational diabetes screening; interpersonal and domestic violence screening and counseling; human papillomavirus testing; sexually transmitted infections screening; human immune-deficiency virus screening; breast-feeding support, supplies and counseling. Prescribed Contraceptives (Grandfathered groups may purchase benefit for an added premium.) Blue Cross of Idaho pays 100% for Women s Preventive Prescription Drugs and devices as specifically listed on the Blue Cross of Idaho website, bcidaho.com; Deductible does not apply. The day supply allowed shall not exceed a 90-day supply at one (1) time, as applicable to the specific contraceptive drug or supply. Prescribed Contraceptive Services Includes diaphragms, intrauterine devices (IUDs), implantables, injections and tubal ligation Blue Cross of Idaho may cover services not specifically listed when medically necessary. Blue Cross of Idaho may cover services not specifically listed when medically necessary. Members pay nothing of the allowed amount for specifically listed preventive care services per person, per benefit period. No co-payment, deductible or coinsurance required. In-Network Members pay nothing of the allowed amount for specifically listed preventive care services per person, per benefit period. No co-payment, deductible or coinsurance required Members pay deductible and coinsurance Members pay coinsurance after meeting deductible. Out-of-Network Members pay coinsurance after meeting deductible. Members pay deductible and coinsurance IMMUNIZATIONS In-Network Out-of-Network Accellular Pertussis, Diphtheria, Hemophilus Influenza B, Hepatitis B, Influenza, Measles, Mumps, Pneumococcal (pneumonia), Poliomyelitis (polio), Rotavirus, Rubella, Tetanus, Varicella (Chicken Pox,), Hepatitis A, Meningococcal, Human papillomavirus (HPV) and Zoster. All Immunizations are limited to the extent recommended by the Advisory Committee on Immunization Practices (ACIP) and may be adjusted accordingly to coincide with federal government changes, updates and revisions. Other immunizations not specifically listed may be covered when Medically Necessary and approved by the BCI Pharmacy and Therapeutics Committee. Members pay nothing for specifically listed immunizations. No co-payment, deductible or coinsurance required. Members pay deductible and coinsurance Members pay deductible and coinsurance Please Note: Your provider must bill these services as preventive/wellness services. The specifically listed preventive care services may be adjusted accordingly to coincide with federal government changes, updates, and revisions. The descriptions above are general in nature, to allow for an overall view of Blue Cross of Idaho s preventive care coverage. For complete descriptions of your policy and policy changes, please read your contract and contract amendment language. the plan documents apply. Please refer to the formal plan documents for a complete description of benefits, limitations, and exclusions. 4 preventivecare
6 employeeassistanceprogram ComPsych Employee Assistance Program - 100% Company Paid ACCESSING SERVICES You and your family members can access ComPsych by phone or Internet twenty-four hours a day, seven days a week. For phone access, simply call toll-free (866) Internet access is at The West Ada School District's Web ID is: WASD COUNSELING SERVICES ComPsych GuidanceConsultantsSM are available to help you with a variety of concerns, including: Marital and Family Conflicts Grief and Loss Drug and Alcohol Abuse Anxiety and Stress Eating Disorders Physical or Emotional Abuse When you call, a ComPsych GuidanceConsultant will listen to your concerns and help schedule an appointment for you with a professional in your area. During your scheduled appointment, an experienced EAP counselor will discuss your situation and help you develop a solution-focused plan of action. You are eligible for up to 6 free counseling sessions per problem per year. If you need additional counseling, ComPsych will work with you to find a provider that suits your needs and your medical benefit plan. FINANCIALCONNECT FINANCIAL SERVICES The FinancialConnect program offers you unlimited telephone access to certified public accountants, certified financial planners, and other financial professionals who are trained and experienced in handling personal financial issues and can offer consulting on issues such as family budgeting, credit problems, tax questions, investment options, money management and retirement programs. LEGALCONNECT LEGAL SERVICES The LegalConnect program provides you with unlimited telephone consultation with attorneys who are trained and dedicated to providing legal information and assistance to clients with such issues as divorce, bankruptcy, family law, real estate purchases and wills. If you need legal representation or extended assistance that cannot be provided by phone, LegalConnect professionals can provide referrals to local attorneys. You or your family member will receive a free 30-minute consultation and, thereafter, a 25% reduction in fees for representation if you choose one of ComPsych s network attorneys. FAMILYSOURCE WORK-LIFE PROGRAMS ComPsych FamilySource Guidance Specialists offer practical advice through telephonic consultation, accurate and timely referral information, and educational literature. Specialists are available to provide assistance on issues such as: Finding and evaluating quality daycare and eldercare Moving and relocation Planning a vacation, wedding, or other major event Understanding programs such as Medicare and Medicaid. Callers receive detailed resource packages containing accurate referral information on community resources, available openings in programs, and guidelines for evaluating in order to make the selection that is best for you. ComPsych will follow-up to make sure you have received all the information necessary to meet your specific needs. GUIDANCERESOURCES ONLINE GuidanceResources Online is a comprehensive interactive service that provides you with instant guidance, information and helpful tools. At GuidanceResources Online, you can: Obtain information about personal, emotional, and life issues Read HelpsheetsSM on your topic Review frequently asked questions Purchase expert-endorsed products and services to support your issue or lifestyle need Get book recommendations Call Visit 5 the plan documents apply. Please refer to the formal plan documents for a complete description of benefits, limitations, and exclusions.
7 Ameritas & Willamette Dental - West Ada School District offers the following two dental plans: Dental Option #1 - AMERITAS Deductible (Only on Type 2 & 3 Services) Network Non Network * $50 Per Person Maximum Annual Benefit - Dental $1,500 Per Person Type 1 - Preventive & Diagnostic Services STEP 1 / STEP 2 / STEP 3 Exams, Cleanings, Fluoride, X-Rays Covered 80% / 90% / 100% MAC Covered 80% / 90% / 100% UCR Type 2 - Basic Services STEP 1 / STEP 2 / STEP 3 Fillings, Oral Surgery 60% / 70% / 80% MAC - AD 60% / 70% / 80% UCR- AD Type 3 - Major Services STEP 1 / STEP 2 / STEP 3 Bridges, Crowns, Nonsurgical Periodontics or Dentures 30% / 40% / 50% MAC- AD 30% / 40% / 50% UCR- AD Endodontic & Surgical Periodontic Services Orthodontic Services MONTHLY EMPLOYEE RATES Employee (EE) EE + One EE + Two or More Covered under Type 2 - Basic Services Not Covered $42.45 $82.80 $ AD: After Deductible MAC: Maximum Allowable Charge UCR: Usual and Customary Rate * Member will be responsible for amounts billed by non-participating providers in excess of eligible dental expense amount. AMERITAS PLAN NOTES: Step 1 applies during the first Benefit Period the person becomes insured. Step 2 If the person visits a dentist during each Benefit Period and has a covered dental procedure performed, Step 2 will apply during the second Benefit Period. Step 3 will apply during each Benefit Period after 3. If, during any Benefit Period, the person fails to visit a dentist to have a dental procedure performed, the person will remain at the same Step that applied during the previous Benefit Period. Exception: If, during any Benefit Period, the person has a break in continuous coverage of more than one month, Step 1 will reapply for the balance of that Benefit Period and the person must advance to Steps 2 and 3 as if he or she were newly insured. To find a provider and for a complete description of benefits, limitations, and exclusions, consult your Summary Plan Description, available from Human Resources or at Dental Option #2 - WILLAMETTE DENTAL Deductible (Single / Family) Coinsurance (Carrier Pays / Member Pays) Maximum Annual Benefit - Dental Willamette Providers Only the plan documents apply. Please refer to the formal plan documents for a complete description of benefits, limitations, and exclusions. 6 None See Amounts Below Type 1 - Preventive & Diagnostic Services Exams, Cleanings, Fluoride, X-Rays $10 Co-pay then Covered 100% Type 2 - Basic Services Fillings, Non-Surgical Extractions $10 Co-pay then Covered 100% Type 3 - Major Services Bridges, Crowns, Oral Surgery $10 Co-pay then Covered 100% Specialist Office Visit Orthodontic Services MONTHLY EMPLOYEE RATES Employee (EE) EE + One EE + Two None $30 Co-pay Initial Exam - Study models & X-rays - Comprehensive Ortho Services $150 / $1,500 Co-pay ($150 is credited toward the $1500 if the patient accepts the treatment plan and moves forward.) $49.10 $95.80 $ For more information or to find a provider visit dentalplans
8 visionplans Ameritas - West Ada School District offers the following voluntary vision plan: 7 Network (Member Pays) VSP CHOICE NETWORK Non Network (Reimbursement) Exams (Deductible each benefit period) ONCE EVERY 12 MONTHS Eye Exam Frames and Lenses * Vision Exam $10 $25 Covered in Full $10 $25 Up to $43.00 Frames ONCE EVERY 24 MONTHS Allowance Based on Retail Pricing Up to $ Up to $40.00 Lenses ** ONCE EVERY 12 MONTHS Single Vision Bifocal Trifocal Lenticular Progressive Lenses Photochromatic Lenses (Glass & Plastic) Covered in Full Covered in Full Covered in Full Covered in Full Up to contracted fee for lined bifocal $31 to $82 Up to $26.00 Up to $43.00 Up to $60.00 Up to $91.00 Up to Lined Bifocal allowance No Benefit Lens Options Tint (Solid / Gradient) UV Coating Standard Scratch Resistance Standard Polycarbonate Standard Anti-Reflective Contacts (In Lieu of Glasses) Elective Medically Necessary MONTHLY EMPLOYEE RATES Employee (EE) EE + One EE + Two or More $15 / $17 $16 $17 to $33 Covered in Full for dependent children $33 adults $43 to $85 ONCE EVERY 12 MONTHS Up to $ Covered in Full $8.70 $13.41 $20.75 No Benefit Up to $ Up to $ To Find a Provider, please visit ameritasgroup.com/meridian * Deductible applies to a complete pair of glasses or to frames, whichever is selected. ** Lens Option member costs vary by prescription, option chosen and retail locations The Costco allowance will be the wholesale equivalent. For a complete description of benefits, limitations, and exclusions, consult your Summary Plan Description, available from Human Resources or at the plan documents apply. Please refer to the formal plan documents for a complete description of benefits, limitations, and exclusions.
9 Flores & Associates - January 1, 2015 through December 31, 2015 Reimbursement accounts enable you to pay certain qualified expenses using taxfree dollars. Depending on your personal tax rate, this can save you 10% to 30% or more on medical, dental, vision and/or dependent care out-of-pocket costs. THE FOLLOWING ACCOUNTS MAY BE AVAILABLE TO YOU: FLEXIBLE SPENDING ACCOUNT (FSA) This account allows you to set aside up to $2,500 in pretax dollars to pay most out-of-pocket medical, dental or vision care expenses, including: Medical and Dental Deductibles and Co-payments, Eye Glasses, Dental and Orthodontic work not covered by insurance. As of January 1, 2013, under the Affordable Care Act, the maximum amount that can be contributed to a Flexible Spending Account is $2,500 per year. DEPENDENT CARE ASSISTANCE PLAN (DCAP) This account lets you set aside up to $5,000 in pre-tax dollars to pay for eligible dependent care expenses so you (and if married, your spouse) can work. THE ADVANTAGES There are some significant advantages to using the above reimbursement type accounts. Income directed to a reimbursement account is tax free. When you pay less in taxes, you receive more spendable income. The accounts can save you 10% to 30% or even more, depending on your personal tax rate. Convenient payroll deductions help assure that you will have money available for out-of-pocket health and/or dependent care expenses. HOW IT WORKS During annual enrollment, you decide how much you want to deposit into your reimbursement account(s). That amount is deducted evenly during the calendar year from your paycheck before taxes are taken out. When you have an expense that qualifies, you pay the bill, submit a claim, and you are reimbursed with tax-free dollars from your account. For example: JOHN'S EXPENSES LENSES & FRAMES $280 ORTHODONTIA $1,000 CO-PAYS $120 ANTICIPATED SURGERY $1,100 TOTAL FOR THE YEAR $2,500 JOHN'S SITUATION WITHOUT THE ACCOUNT JOHN'S ANNUAL EARNINGS $30,000 TAXES (25%) - $7,500 NET PAY $22,500 EXPENSES (AFTER TAXES) - $2,500 TAKE HOME PAY $20,000 JOHN'S SITUATION WITH THE ACCOUNT JOHN'S ANNUAL EARNINGS $30,000 EXPENSES (BEFORE TAXES) - $2,500 TAXABLE PAY $27,500 TAXES (25%) $6,875 TAKE HOME PAY $20,625 JOHN'S TAKE HOME PAY INCREASES $625 BY USING THE REIMBURSEMENT ACCOUNT ELIGIBILITY You will be eligible to participate in the account(s) on the first day of the month following your first pay check. Following are additional guidelines for determining eligible expenses: Expenses are for services received during the calendar year (Jan. 1 to Dec. 31). Expenses are not covered by any health care plan in which you are enrolled. The IRS would otherwise let you deduct the expenses on your income taxes. THE DEPENDENT CARE ASSISTANCE PLAN With the Dependent Care account you can set aside tax-free income to pay for qualified dependent care expenses, such as day care, that you normally pay with after-tax dollars. You must meet the following criteria in order to set up this account: You and your spouse both work; You are a single head of household; or Your spouse is disabled or a full-time student. Qualified dependents include children under 13 and/or dependents who are physically or mentally handicapped and the expense must be incurred to allow you to work. If your spouse is unemployed or doing volunteer work you cannot set up a reimbursement account. Each calendar year the IRS allows you to contribute the following amounts, depending on your family status: If you are single, the lesser of your earned income or $5,000 If you are married, you can contribute the lowest of: Your (or your spouse s) earned income. $5,000 if filing jointly, or $2,500 if filing separately. ROLLOVER OPTION If you don t use all the pre-tax dollars you deposited in your FSA account during the plan year, you may roll-over up to $500 into the next plan year. (The roll-over amount does not count toward the $2,500 yearly maximum FSA contribution limit.) Any remaining unused balance at the end of the plan year will be forfeited. If you do not use all of the pre-tax dollars you deposited in your DCAP account, you will forfeit any balance in the account at the end of the plan year. You have until March 31, 2015 to submit claims for expenses incurred during that plan year. ONCE ENROLLED, YOU MAY NOT CHANGE Once you have designated how much you want to contribute on an annual basis to one or both of your reimbursement accounts, you cannot stop or change your contributions unless you have a qualifying Change Event as defined and limited by the IRS. See Qualifying Change rules earlier in this guide. REIMBURSEMENTS To claim reimbursements, fill out a claim form and attach any supporting information. For health care this will include receipts of the amount you paid and the date(s) on which you or a dependent received services. For dependent care this may include any contracts, letters, or receipts. You may send this information to Flores & Associates via , fax, or standard mail. Fax: Mailing Address: PO Box Charlotte, NC the plan documents apply. Please refer to the formal plan documents for a complete description of benefits, limitations, and exclusions. 8 reimbursementaccounts
10 lifeinsuranceplans LifeMap Assurance Company Basic Life, AD&D - 100% Company Paid Each eligible employee can receive basic life insurance for themselves and their eligible dependents. Benefits reduce to 65% at 65, 50% at 70. AD&D benefits match this reduction schedule. Life and AD&D benefits terminate upon retirement. Basic Term Life insurance includes waiver of premium coverage. The waiver of premium does not apply to any AD&D benefits. 9 BENEFITS CLASS 1 ADMINISTRATORS CLASS 2 ALL OTHER STAFF Life Insurance - Employee $100,000 $50,000 Accidental Death & Dismemberment (AD&D) - Employee Only 80% to $80,000 max 80% to $40,000 max Seatbelt Benefit - Employee Only (Paid for a death resulting from an auto accident while properly wearing a seatbelt) $10,000 $10,000 Life Insurance - Spouse $1,000 $1,000 Life Insurance - Child(ren) - live birth to age 26 $1,000 $1,000 Please see Certificate of Coverage summary for more detailed benefit information. National Conference on Public Employee Retirement Systems (NCPERS) Voluntary Group Life Insurance - 100% Employee Paid SIMPLE-AFFORDABLE-PAYROLL DEDUCTED - An NCPERS supplemental survivor's benefit and insurance plan is available to enhance the financial security of PERSI members. It is voluntary and administered through payroll deduction. Simple - For a flat monthly cost, a member can further guarantee the financial security of survivors, even after retirement! Affordable - $16 monthly buys this great value, coordinated with the members pension survivor benefit. Payroll Deducted - The cost will be deducted from the member's paycheck. FACTS ABOUT THE PLAN - All active employees at time of enrollment of participating employers may enroll. Employees must be "actively at work". The plan will pay a benefit in addition to other insurance plans. The plan is completely voluntary, and can be terminated at any time. If you cease to be a member you can convert your Group Decreasing Term Life Insurance to a Prudential individual life policy within 31 days following termination of insurance. Dependent term life coverage can also be converted if you cease to be a member or you die. Benefit checks of $5,000 or more are deposited in a special interest bearing checking account, on which the beneficiary can write checks immediately after the claim is approved. WANT TO PARTICIPATE? If you want to participate, here are the simple steps you need to take: 1. Contact your employer. If your employer has agreed to participate in the PERSI/NCPERS plan by authorizing payroll deductions, you may enroll during the next open enrollment period. Open enrollments are held each year from September 1st through November 30th. New employees may enroll immediately, within 90 days of hire. 2. Employers whose employees are members of PERSI may participate in the life insurance program simply by authorizing the payroll deduction. A special open enrollment period may be held for such employees not previously eligible for coverage. ELIGIBILITY FOR MEMBERS - All actively employed members of PERSI are eligible for this insurance if their current employer has adopted the plan. Eligible dependents are your spouse or domestic partner ($16 plan only) and unmarried children 14 days to 21 years old. Dependent children are your legally adopted children, step-children and foster children who depend on you for support. Dependents in military service are not eligible. There are no medical exams or health requirements. HealthSmart Benefit Solutions, Inc. Address: East Dry Creek Road, Suite 200, Englewood, CO Phone: (800) Fax: (303) the plan documents apply. Please refer to the formal plan documents for a complete description of benefits, limitations, and exclusions.
11 LifeMap Assurance Company Employee Voluntary Supplemental Life - 100% Employee Paid Supplemental Group Term Life Insurance is available on a voluntary basis. This coverage is in addition to the company provided amounts and the premiums are 100% employee paid through payroll deduction. Coverage is available only to employees eligible for benefits and covered under the basic Group Term Life Insurance provided by West Ada School District. Employees may select any amount from $10,000 to $300,000 in increments of $10,000. All Supplemental Insurance amounts can be purchased at any time and are subject to evidence of insurability. Each applicant must complete a Group Life Health Form. Insurance will become effective on the first of the month following underwriting approval by LifeMap. Supplemental Life benefits will reduce to 65% at the insured's age 65, to 50% at age 70. Benefits terminate upon retirement. Supplemental Life offers a Right of Conversion. Enrollment forms are available from Human Resources. Please see Certificate of Coverage summary for more detailed benefit information. ESTIMATED PREMIUM CALCULATIONS Desired Amount of Employee Coverage 1,000 = x = x 12 = 12 = Number of 1,000's NEW HIRES - GUARANTEED ISSUE Employee $200,000 Rate from Table Estimated Monthly Premium * * The premiums calculated are estimates ONLY. Please refer to your LifeMap plan documents for full premium breakdowns. MONTHLY RATES PER $1,000 OF COVERAGE Number of Pay Periods Estimated Premium Per Pay Period * the plan documents apply. Please refer to the formal plan documents for a complete description of benefits, limitations, and exclusions. 10 Age Non Tobacco Under 30 $ to 34 $ to 39 $ to 44 $ to 49 $ to 54 $ to 59 $ to 64 $ to 69 $ to 74 $ to 79 $3.20 Vol. AD&D (Per $1,000) $0.02 lifeinsuranceplans
12 lifeinsuranceplans EFFECTIVE JANUARY 1, 2015 WEST ADA SCHOOL DISTRICT WILL BE OFFERING... LifeMap Assurance Company Dependent Voluntary Supplemental Life - 100% Employee Paid Supplemental Group Term Life Insurance is available on a voluntary basis. This coverage is in addition to the company provided amounts and the premiums are 100% employee paid through payroll deduction. Coverage is available only to employees eligible for benefits and covered under the basic Group Term Life Insurance provided by West Ada School District. Employees may select any amount from $10,000 to $300,000 in increments of $10,000. All Supplemental Insurance amounts can be purchased at any time and are subject to evidence of insurability. Each applicant must complete a Group Life Health Form. Insurance will become effective on the first of the month following underwriting approval by LifeMap. Supplemental Life benefits will reduce to 65% at the insured's age 65, to 50% at age 70. Benefits terminate upon retirement. Supplemental Life offers a Right of Conversion. Enrollment forms are available from Human Resources. The waiver of premium does not apply to any AD&D benefits. ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) BENEFITS Employee 11 $10,000 increments to a maximum of the lesser of $300,000 or 5 times annual earnings Spouse $10,000 increments to $300,000 max * Children AD&D coverage will terminates * This AD&D plan is offered as an automatic, matching benefit to the Life Insurance. Please see Certificate of Coverage summary for more detailed benefit information. ESTIMATED PREMIUM CALCULATIONS Desired Amount of Employee Coverage $2,000 increments to $10,000 max When the insured employee is no longer eligible or retires 1,000 = x = x 12 = 12 = Number of 1,000's NEW HIRE GUARANTEED ISSUE Employee $200,000 Spouse $50,000 Dependent Child(ren) All amounts Rate from Table Estimated Monthly Premium * ** The premiums calculated are estimates ONLY. Please refer to your LifeMap plan documents for full premium breakdowns. MONTHLY RATES PER $1,000 OF COVERAGE Age Rate Under 30 $ to 34 $ to 39 $ to 44 $ to 49 $ to 54 $ to 59 $ to 64 $ to 69 $ to 74 $ to 79 $3.220 Monthly Dependent Life $0.026 per $2,000 increment (regardless of number of children) Number of Pay Periods Estimated Premium Per Pay Period ** the plan documents apply. Please refer to the formal plan documents for a complete description of benefits, limitations, and exclusions.
13 Standard Insurance Company Short-Term Disability - 100% Employer Paid Short Term Disability (STD) Insurance replaces a percentage of your income on a weekly basis in the event that you are unable to work due to an accident or illness. Please see Certificate of Coverage summary, provided by The Standard, for more detailed benefit information. BENEFITS Weekly Benefit Maximum Benefit Period Benefit Waiting Period - Injury / Sickness Maternity Definition of Earnings Pre-Existing Condition Restrictions CLASS 2 CLASSIFIED MEMBERS 66 2 /3 of the first $1,500 of pre-disability earnings reduced by deductible income. 60 days minus the length of the Benefit Waiting Period Accidental Injury = None Physical Disease, Pregnancy, or Mental Disorder = 5 days Covered as any other Sickness - See Certificate for more Details Your Pre-disability Earnings means your 'daily rate' of earnings from your Employer in effect on your last full day of Active Work times 5 and includes: 1. Contributions you make through a salary reduction agreement, 2. an executive non-qualified deferred compensation arrangement or 3. amounts contributed to your fringe benefits according to a salary reduction agreement under an IRC Section 125 plan None Voluntary Short-Term Disability - Shared Cost with Employer West Ada School District will contribute $12 monthly to Administrators and Certified Staff STD premium. Short Term Disability (STD) Insurance replaces a percentage of your income on a weekly basis in the event that you are unable to work due to an accident or illness. Please see Certificate of Coverage summary, provided by The Standard, for more detailed benefit information. BENEFITS Weekly Benefit Maximum Benefit Period Benefit Waiting Period - Injury / Sickness Maternity Definition of Earnings Pre-Existing Condition Restrictions CLASS 1 ADMINISTRATORS & CERTIFIED STAFF 66 2 /3 of the first $3,000 of pre-disability earnings reduced by deductible income 60 days minus the length of the Benefit Waiting Period Accidental Injury = None Physical Disease, Pregnancy, or Mental Disorder = 5 days Covered as any other Sickness - See Certificate for more Details Your Pre-disability Earnings means your 'daily rate' of earnings from your Employer in effect on your last full day of Active Work times 5 and includes: 1. Contributions you make through a salary reduction agreement, 2. an executive non-qualified deferred compensation arrangement or 3. amounts contributed to your fringe benefits according to a salary reduction agreement under an IRC Section 125 plan None RATES EFFECTIVE JANUARY 1, 2015 $0.30 per $10 of Weekly Benefit the plan documents apply. Please refer to the formal plan documents for a complete description of benefits, limitations, and exclusions. 12 disabilityinsuranceplans
14 disabilityinsuranceplans Standard Insurance Company Voluntary Long-Term Disability - 100% Employee Paid Long Term Disability (LTD) Insurance replaces a percentage of your income on a monthly basis in the event that you are unable to work due to an accident or illness. Please see Certificate of Coverage summary, provided by The Standard, for more detailed benefit information. BENEFITS Monthly Benefit Maximum Benefit Period Benefit Waiting Period - Injury / Sickness Own Occupation Definition Of Disability Any Occupation Definition Of Disability Mental & Nervous / Substance Abuse Definition of Earnings Pre-Existing Condition Restrictions 13 60% of first $10,000 or monthly earnings $6,000 before reduction by deductible income 60 Days You are Disabled from your Own Occupation if, as a result of Physical Disease, Injury, Pregnancy or Mental Disorder: 1. You are unable to perform with reasonable continuity the Material Duties of your Own Occupation; and 2. You suffer a loss of at least 20% in your Indexed Pre disability Earnings when working in your Own Occupation. You are Disabled from all occupations if, as a result of Physical Disease, Injury, Pregnancy or Mental Disorder, you are unable to perform with reasonable continuity the Material Duties of Any Occupation. Payment limited to 24 months during your entire lifetime Your Pre-disability Earnings means your 'daily rate' of earnings from your Employer in effect on your last full day of Active Work times 5 and includes: 1. Contributions you make through a salary reduction agreement, 2. an executive non-qualified deferred compensation arrangement or 3. amounts contributed to your fringe benefits according to a salary reduction agreement under an IRC Section 125 plan Continuously insured under the group policy for 12 months; and actively at work for a least one full day after the end of that 12 months. RATES PER $100 OF COVERAGE the plan documents apply. Please refer to the formal plan documents for a complete description of benefits, limitations, and exclusions. Age Monthly Rate 29 & Under $ to 34 $ to 39 $ to 44 $ to 49 $ to 54 $ to 59 $ to 64 $ & Over $1.162
15 Public Employee Retirement Systems of Idaho (PERSI) These benefits generally are NOT sponsored or endorsed by your employer including for purposes of Federal and State law, so Federal ERISA law is inapplicable. PERSI Retirement Plan You become a PERSI member when you go to work in an eligible position with a PERSI employer. When you earn 60 months of service credit you will be vested to receive a lifetime benefit at retirement. The 60-month vesting period (5 months for elected and some appointed officials) does not have to be with the same PERSI employer. So unless you leave public employment altogether, changing jobs should not affect your PERSI membership. Base Plan Benefits Enrollment in the PERSI Base Plan (pension) is mandatory. Both you and your employer make contributions to PERSI: Employee contributes 6.79% and Employer contributes 11.32%. Your contributions are credited to your personal account, while employer contributions are pooled in a trust to cover benefits. The actual value of your benefit exceeds your contributions. When you retire as a vested member, PERSI will pay you every month for as long as you live - and if you select a retirement option with survivor benefits, your Contingent Annuitant will receive a benefit for life after your death. Portability of Funds Your Base Plan contributions are always yours. If you leave a PERSI employer, but keep your Base Plan money in PERSI and later work for another PERSI-covered employer, you retain the service credit earned in your previous job. All service credit you earn while working for a PERSI employer is automatically combined into a single account for you. The Choice 401(k) Plan The Choice 401(k) Plan is an optional defined contribution retirement savings plan available to active members. Unlike the Base Plan, participation in The Choice 401(k) Plan is completely voluntary. It allows you to contribute a portion of your salary on a tax-deferred basis via payroll deduction. This means your contributions come out of your paycheck before taxes, thereby reducing the amount of taxes you pay during the year. The Choice 401(k) Plan includes a loan provision where members may take a loan for any reason as long as they have a balance of $2,000 or more in their account, excluding any gain sharing amounts. The Choice 401(k) Plan has 12 investment options. One of the most popular is the PERSI Total Return Fund (TRF), which mirrors the Base Plan investments. The TRF is the default investment fund. Your contributions are automatically invested in the TRF unless you elect otherwise. The TRF has no investment manager fee; however, fees are associated with the other 11 investment options. Unlike the Base Plan, you manage your Choice 401(k) Plan funds. In most cases, you may change deferral amounts and investments at any time. No fee is charged for making changes to your account. PERSI pays the record keeping fees for active members. Money from other qualified retirement plans, such as a 401(a), 457, pre-tax IRA, 403(a) or 403(b), or another 401(k) account, can be rolled over to The Choice 401(k) Plan at PERSI. After-tax contributions cannot be rolled into The Choice Plan. For More Information To learn more about PERSI, or for more detailed information about your retirement options and benefits, visit the PERSI Website at: You may also contact the PERSI Answer Center Monday thru Friday between 7:30 am and 5:30 pm (Mountain Time) by calling (208) in the Boise area, or toll free (800) from other parts of the state. Your Human Resources Department and/ or payroll personnel will gladly assist you as well. the plan documents apply. Please refer to the formal plan documents for a complete description of benefits, limitations, and exclusions. 14 retirementprogram
16 additionalretirementprogram TSA Consulting Group 403(b) Plan - 100% Employee Contribution These benefits generally are NOT sponsored or endorsed by your employer including for purposes of Federal and State law, so Federal ERISA law is inapplicable. The 403(b) Plan is a valuable retirement savings option available through West Ada School District. Plan administrative services for the 403(b) are provided by TSA Consulting Group, Inc. (TSACG). Visit the TSACG website (tsacg.com) for information about enrollment in the Plan, investment product providers available, distributions, enrollment, exchanges or transfers, 403(b) loan and roll overs. All employees with the exception of private contractors, school board members and student workers are eligible to participate in the 403(b) plan immediately upon employment. Employees may make voluntary elective deferrals to the 403(b) plan. Participants are fully vested in their contributions and earnings at all times. Employees who wish to enroll in the Supplemental 403(b) Retirement Plan must first select the provider and investment product best suited for their 403(b) account. Upon establishment of the account with the selected provider, a "Salary Reduction Agreement"(SRA) form and any disclosure forms must be completed and submitted to West Ada School District. This form authorizes the District to withhold 403(b) contributions from your pay and send those funds to the Investment Provider on your behalf. A SRA must be completed to start, stop or modify contributions to a 403(b) account. Upon enrollment, participants designate a portion of their salary that they wish to contribute to their 403(b) account up to their maximum annual contribution amount on a pre-tax basis, thus reducing the participant's taxable income. Salary deferral contribution to the participant's 403(b) account are made from income paid through West Ada School District's payroll system. Taxes on contributions and any earnings are deferred until the participant withdraws their funds. Participants in defined contribution plans are responsible for determining which, if any, investment vehicles best serve their retirement objectives. The 403(b) Plan assets are invested solely in accordance with the participant's instructions. The participant should periodically review whether his/her objectives are being met, and make changes as appropriate. Careful planning with a tax advisor or financial planner may help to ensure that the supplemental retirement savings plan meets your needs. TSACG monitors 403(b) plan contributions and notifies the employer in the event of an excess contribution. 15 the plan documents apply. Please refer to the formal plan documents for a complete description of benefits, limitations, and exclusions.
17 TSA and Retirement Vendor Listing Additional Deductions - Voluntary. Contact vendor excluding PERSI TAX SHELTERED ANNUITIES (TSA) 403B PRE-TAX AMERICAN FIDELITY ASSURANCE Address: 621 W Mallon Ave, Suite 301, Spokane WA Kimberly Edwards: Web site: HORACE MANN ANNUITY CO. Address: 1111 S Orchard Ste 204, Boise ID Michael Sallee: Web site: RELIASTAR LIFE INS CO. ("ING") Address: 6154 N Meeker PI Ste 175, Boise ID Scott Gull: WADDELL 8, REED - Boise Office Address: 225 N 9th St Ste 420, Boise ID Mike Fuhriman: Web site: SECURITY BENEFIT GROUP Address: 1795W Broadway,PMB 260,Idaho Falls, ID Jim Hancock: OPPENHEIMER FUNDS SERVICES Address: PO Box 5270, Denver CO Phone: Fax: Web site: VALIC Address: 430 Ryman St Ste 102, Missoula MT Ext John Rutter, Financial Advisor: Web site: 401K THRU PERSI PERSI CHOICE * 401(k) optional program Address: PO Box 83720, Boise ID Web site: (Please see Web site for eligibility requirements and details) DEFERRED COMPENSATION SECURITY BENEFIT GROUP Address: 1795W Broadway,PMB 260,Idaho Falls, ID Jim Hancock: VALIC Address: 430 Ryman St Ste 102, Missoula MT Ext John Rutter, Financial Advisor: Web site: ROTH 403B - AFTER TAX SECURITY BENEFIT GROUP Address: 1795W Broadway,PMB 260,Idaho Falls, ID Jim Hancock: the plan documents apply. Please refer to the formal plan documents for a complete description of benefits, limitations, and exclusions. 16 additionalretirementprogram
18 worksiteproducts AFLAC Voluntary Supplemental Coverage - 100% Employee Paid These benefits generally are NOT sponsored or endorsed by your employer including for purposes of Federal and State law, so Federal ERISA law is inapplicable. Good Insurance is an important asset not only for good health but also for your financial wellbeing. Being proactive now can help prevent financial hardships in your future. You can supplement your major medical insurance with Aflac polices that provide cash insurance for daily living and out of pocket expenses that major medical insurance does not cover. There is a wide range of plans available that can fit most budgets, needs or concerns, such as: Cancer (considered to be the leading cause of medical bankruptcy) Hospital- in & out patient, ER; surgeries, Dr. visits, diagnostic testing Intensive care Accident (can also include some disability for your working spouse) Critical Illness- heart attach/stroke, end stage renal failure & more Life, whole, term, juvenile, supplemental dental Aflac usually processes claims within 4 working days, so while you are focusing on your health, they focus on getting you cash as quickly as possible. For more information or claims assistance, please contact: Gerri Schoonderwoerd Phone: Fax: the plan documents apply. Please refer to the formal plan documents for a complete description of benefits, limitations, and exclusions.
19 Notes the plan documents apply. Please refer to the formal plan documents for a complete description of benefits, limitations, and exclusions. 18 yournotes
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