Public Employees Benefits Program Plan Year 2014 Rates Effective July 1, Table of Contents
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1 Public Employees Benefits Program Plan Year 2014 July 1, 2013 Table of Contents State Active Employee Rates 2 State Active Employee with Domestic Partner Rates (CDHP) 3 State Active Employee with Domestic Partner Rates (HMO Plans) 4 State Active Employee Leave Without Pay Rates 5 State Active Legislator Rates 6 State Retiree and Survivor Rates 7 State Retiree with Domestic Partner Rates 8 State Retiree Subsidy Adjustment Table 9 Non-State Active Employee Rates 10 Non-State Retiree and Survivor Rates 11 Non-State Retiree Subsidy Adjustment Table 12 Medicare Exchange Retiree HRA Contribution 13 Voluntary Dental Insurance Rates for Medicare Exchange Retirees 14 State COBRA Rates 15 Non-State COBRA Rates 16 Page 1
2 State Active Employee Rates Employee Only Employee + Spouse Employee + Child(ren) Employee + Family Page 2
3 State Employee with Domestic Partner Rates Employee + DP Employee + DP's Child(ren) Employee + Children of both Employee + DP + EE's Child(ren) Employee + DP + DP's Child(ren) Pre-Tax Deduction Post-Tax Deduction Employee + DP + Children of both Page 3
4 State Employee with Domestic Partner Rates Hometown Health HMO Plan and (HPN) Employee + DP Employee + DP's Child(ren) Employee + Children of both Employee + DP + EE's Child(ren) Employee + DP + DP's Child(ren) Pre-Tax Deduction Post-Tax Deduction Employee + DP + Children of both Page 4
5 State Employee Leave Without Pay Rates Employee Only Employee + Spouse/DP Employee + Child(ren) Employee + Family , , , , State employees on Leave without Pay and employees on Military leave do not receive a subsidy. Page 5
6 State Active Legislator Rates Employee Only Employee + Spouse/DP Employee + Child(ren) Employee + Family , , , , State active legislators do not receive a subsidy. Page 6
7 State Retiree and Survivor Rates Retiree only Retiree + Spouse Retiree + Child(ren) Retiree + Family Surviving/Unsubsidized Spouse Surviving/Unsubsidized Spouse + Child(ren) To determine your subsidy, refer to the State Retiree Subsidy Table on Page 9. Note: Survivors and unsubsidized dependents are not eligible for a subsidy. Page 7
8 State Retiree with Domestic Partner Rates Retiree + DP Retiree + DP's Child(ren) Retiree + Children of both Retiree + DP + Ret's Child(ren) Retiree + DP + DP's Child(ren) Retiree + DP + Children of both To determine your subsidy, refer to the State Retiree Subsidy Table on Page 9. Page 8
9 State Retiree Subsidy Adjustment Table State Retiree Subsidy For Retirees Enrolled in the CDHP/HMO Plan Years of Service State Subsidy (Base) For participants who retired before January 1, 1994, the participant premium for the selected plan and tier is shown on the tables on the previous pages. For participants who retired on or after January 1, 1994, add or subtract the appropriate subsidy based on the number of years of service to or from the participant premium for the selected plan and tier. Those retirees with less than 15 years of service, who were hired by their last employer on or after January 1, 2010 and who are not disabled do not receive a years of service subsidy or a base subsidy. Those retirees who were hired by their last employer on or after January 1, 2012 do not receive a years of service subsidy or base subsidy. If you are a retiree (or survivor) enrolled in the CDHP or an HMO plan and you pay for Medicare Part B, deduct $ from your premium cost. Page 9
10 Non-State Employee Rates Employee Only Employee + Spouse Employee + Child(ren) Employee + Family 1, , , , , , , Page 10
11 Non-State Retiree and Survivor Rates Retiree only Retiree + Spouse/DP Retiree + Child(ren) Retiree + Family Surviving/Unsubsidized Spouse/DP 1, , , , , , , , Surviving/Unsubsidized Spouse/DP + Child(ren) 1, , To determine your premium, refer to the Non-State Retiree Subsidy Adjustment Table on Page 12. Note: Survivors and unsubsidized dependents are not eligible for a subsidy. Page 11
12 Non-State Retiree Subsidy Adjustment Table Non-State Retiree Subsidy For Retirees Enrolled in the CDHP/HMO Plan Years of Service Non-State Subsidy (Base) For participants who retired before January 1, 1994, subtract the 15 year base subsidy from the participant premium for the selected plan and tier. For participants who retired on or after January 1, 1994, subtract the appropriate subsidy based on the number of years of service from the participant premium for the selected plan and tier. Those retirees with less than 15 years of service who were hired by their last employer on or after January 1, and who are not disabled do not receive a years of service subsidy or a base subsidy. Those retirees who were hired by their last employer on or after January 1, 2012 do not receive a years of service subsidy or a base subsidy. If you are a retiree (or survivor) enrolled in the CDHP or an HMO plan and you pay for Medicare Part B, deduct $ from your premium cost. Page 12
13 Medicare Exchange Retiree HRA Contribution HRA Contribution for Retirees Enrolled in an Extend Health Plan Years of Service Contribution (Base) Participants who retired before January 1, 1994 receive the 15-year ($165) base contribution. For participants who retired on or after January 1, 1994, the contribution is $11 per month, per year of service beginning with 5 years ($55) to a maximum of 20 years or ($220). Spouses/domestic partners and surviving spouses /domestic partners enrolled in the exchange are not eligible for an HRA contribution. Those retirees with less than 15 years of service, who were hired by their last employer on or after January 1, 2010 and who are not disabled do not receive a years of service contribution. Those retirees who were hired by their last employer on or after January 1, 2012 do not receive a years of service contribution. Page 13
14 Voluntary Dental Insurance Rates for Medicare Exchange Retirees Retiree Only Retiree + Spouse/DP Surviving/Unsubsidized Spouse/DP State Retiree Rate Non-State Retiree Rate Page 14
15 COBRA Rates State Employees Participant Participant + Spouse/DP Participant + Child(ren) Participant + Family Spouse/DP Only Spouse/DP + Child(ren) COBRA participants do not qualify for Life Insurance and Long Term Disability. Participants on Regular COBRA do not receive a subsidy , , , , Page 15
16 COBRA Rates State Retirees Participant Participant + Spouse/DP Participant + Child(ren) Participant + Family Spouse/DP Only Spouse/DP + Child(ren) COBRA participants do not qualify for Life Insurance and Long Term Disability. Participants on COBRA do not receive a subsidy , , , , Page 16
17 COBRA Rates Non-State Employees Participant Participant + Spouse/DP Participant + Child(ren) Participant + Family Spouse/DP Only Spouse/DP + Child(ren) COBRA participants do not qualify for Life Insurance and Long Term Disability. Participants on COBRA do not receive a subsidy. 1, , , , , , , , , , Page 17
18 COBRA Rates Non-State Retiree Participant Participant + Spouse/DP Participant + Child(ren) Participant + Family Spouse/DP Only Spouse/DP + Child(ren) COBRA participants do not qualify for Life Insurance and Long Term Disability. Participants on COBRA do not receive a subsidy. 1, , , , , , , , , , Page 18
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