fellsmere · where conflict exists between this summary and the plan document, the plan document...

2016 | 2017 EMPLOYEE BENEFIT HIGHLIGHTS

Fellsmere

City of Fellsmere | Employee Benefit Highlights | 2016-2017

Table of Contents

Contact Information 1

Introduction 2

Group Insurance Eligibility 2-3

Qualifying Events and IRS Code Section 125 3

Medical Insurance 4

United Healthcare – Choice Plus HMO Plan At-A-Glance 5

Health Reimbursement Account 6

Dental Insurance 7

Principal Dental PPO Plan At-A-Glance 8

Vision Insurance 9

HumanaVision Care Plan At-A-Glance 10

Basic Life and AD&D Insurance 11

Supplemental Insurance 11-12

Notes 12

This booklet is merely a summary of your 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 Fellsmere reserves the right to amend, modify or terminate the plan at any time. This booklet should not be construed as a guarantee of employment.

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Contact Information

Finance Department

Putnam Moreman Director of Finance and Accounting

Phone: (772) 646-6304 Email: [email protected]

Claudia M. Alvarado Accounting Clerk


Doris Lee Accounting Clerk


Medical Insurance United HealthcareCustomer Service: (866) 873-3903 www.uhc.com

Prescription Drug Coverage& Mail-Order Program Optum Rx

Customer Service: (888) 223-2759 www.optumrx.com

Health Reimbursement Account (HRA) Administrator Eagles Benefits by Design

Customer Service: (800) 726-5603Fax: (772) 334-7059www.takecareplans.com/eaglesbenefits

Dental Insurance Principal Financial Group Customer Service: (800) 247-4695 www.principal.com

Vision Insurance HumanaCustomer Service: (866) 537-0229www.humanavisioncare.com

Basic Life and AD&D Insurance The StandardCustomer Service: (888) 937-4783www.standard.com

Supplemental Insurance Aflac

Agent: John MartinPhone: (772) 532-1362www.aflac.comEmail: [email protected]

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Introduction The City of Fellsmere provides a comprehensive compensation package including group insurance benefits. The Employee Benefit Highlights Booklet provides a general summary of these benefit options as a convenient reference. Please refer to the City’s Personnel Policies, applicable Union Contracts and/or Certificates of Coverage for detailed descriptions of all available employee benefit programs and stipulations therein. If you require further explanation or need assistance regarding claims processing, please refer to the customer service phone numbers under each benefit description heading or contact Putnam Moreman in the Finance Department for further information.

Group Insurance EligibilityThe City's group insurance plan year is October 1 through September 30

Employee EligibilityEmployees are eligible to participate in the City’s insurance plans if they are full-time employees working a minimum of more than 30 hours per week.

Coverage will be effective the first of the month following 30 days. For example, if an employee is hired on April 11, then the effective date of coverage will be June 1.

TerminationIf an employee separates employment from the City, insurance will continue through the end of month in which separation occurred. COBRA continuation of coverage may be available as applicable by law.

Dependent EligibilityA 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:

• A natural child

• A stepchild

• A legally adopted child

• A foster child

• A newborn (up to age 18 months) of a covered dependent (Florida)

• A child for whom legal guardianship has been awarded to the participant or the participant’s spouse

Dependent Age RequirementsMedical Coverage: A dependent child may be covered through the end of the calendar year in which the child turns 26. An over-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:

• Unmarried with no dependents; and

• A Florida resident, or full-time or part-time student: and

• Otherwise uninsured; and

• Not entitled to Medicare benefits under Title XVIII of the Social Security Act, unless the child is disabled.

Dental Coverage: A dependent child may be covered through end of the month in which child turns age 26.

Vision Coverage: A dependent child may be covered through end of month in which child turns 26.

Disabled Dependents Coverage for an unmarried 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; and

• Coverage with the City began prior to age 26.

Proof of disability will be required upon request. Please contact Putnam Moreman in the Finance Department at (772) 646-6304 if further clarification is needed.

OCTOBER

01

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Qualifying Events and IRS Code Section 125IRS Code Section 125Premiums for medical, dental, vision and/or certain Aflac policies are deducted through a Cafeteria Plan established under Section 125 of the Internal Revenue Code (IRC) and are pre-taxed to the extent permitted. Under Section 125, changes to your pre-tax benefits can be made ONLY during the Open Enrollment period unless you or your qualified dependents experience a qualifying event and the request to make a change is made within 30 days of the qualifying event.

Under certain circumstances, you may be allowed to make changes to your benefit elections during the plan year, if the event affects your own, your spouse’s, or your dependent’s coverage eligibility. An “eligible” qualifying event is determined by the Internal Revenue Service (IRS) Code, Section 125.

Examples of Qualifying Events:• Employee gets married or divorced

• Birth of a child (60 day notice)

• Employee gains legal custody or adopts a child

• Employee's spouse and/or other dependent(s) die(s)

• Employee, employee's spouse or dependent(s) terminate or start employment

• An increase or decrease in employees work hours causes eligibility or ineligibility

• A covered dependent no longer meets eligibility criteria for coverage

• A child gains or loses coverage with an ex-spouse

• Change of coverage under an employer’s plan

• Gain or loss of Medicare coverage

• Losing eligibility for coverage under a State Medicaid or CHIP (including Florida Kid Care) program (60 day notification period)

• Becoming eligible for State premium assistance under Medicaid or CHIP (60 day notification period)

IMPORTANT

If you experience a qualifying event, you must contact Putnam Moreman in the Finance Department within 30 days of the qualifying event to make the appropriate changes to your coverage. Beyond 30 days, requests will be denied and you may be responsible both legally and financially for any claim and/or expense incurred as a result of you or a dependent who continues to be enrolled but no longer meets eligibility requirements. If approved, changes will take place on the first of the month following the latter of the date of the qualifying event or the date of the written request for change in coverage is received by the Finance Department, except for newborns which are effective on the date of birth. Any cancellations will be processed at the end of the month. You may be required to furnish valid documentation supporting a change in status or qualifying event.

Group Insurance Eligibility (Continued) Taxable Dependents

Employees covering adult children under their 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 child reaches age 26. Beginning January 1st of the calendar year in which the child reaches age 27 through the end of the calendar year in which they reach age 30, imputed income must be reported on the employee’s W-2 for that entire tax year. Imputed income is the dollar value of insurance coverage attributable to covering the adult child. Note: There is no imputed income if an adult child is eligible to be claimed as a dependent for federal income tax purposes on the employee’s tax return. Contact Putnam Moreman in the Finance Department at (772) 646-6304 for further details if covering an adult child who will turn 27 any time during the upcoming calendar year or for more information.

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Medical Insurance The City offers medical insurance through United Healthcare to benefit eligible employees. The costs per pay period for coverage are listed in the premium table and a brief summary of benefits is on the following page. For more detailed information about the medical plan, please refer to United Healthcare’s summary of coverage document or contact Customer Service.

Medical Insurance Premiums United Healthcare – Choice Plus Plan

26 Payroll Deductions – Per Pay Period Cost

Tier of Coverage Employee Cost

Employee $0.00

Employee + Spouse $73.94

Employee + Child(ren) $59.04

Employee + Family $154.17

Summary of Benefits and CoverageA Summary of Benefits & Coverage (SBC) for the medical plan is provided as a supplement to this booklet which is being distributed to new hires and existing employees during open enrollment. The summary is an important item in understanding the benefit options. A free paper copy of the SBC document may be requested or is available as follows:

From: Finance Department

Address: 22 S. Orange Street Fellsmere, FL 32948

Phone: (772) 571-1900

Email: [email protected]

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 actual group certificate of coverage can be reviewed and obtained by contacting the Finance Department.

If employees have any questions about the plan offerings or coverage options, please contact the Finance Department at (772) 571-1900.

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Locate a ProviderTo search for a participating provider, contact United Healthcare’s customer service or visit www.uhc.com. When

completing the necessary search criteria, select Choice Plus for the

network.

Plan References*Out-Of-Network Balance Billing: For information regarding Out-of-Network Balance Billing that may be charged by an out-of-network provider for services

rendered, please refer to the plan's summary of coverage document.

**LabCorp is the preferred lab for bloodwork through United Healthcare. When using a lab other than LabCorp,

please be sure to confirm they are contracted with United Healthcare's

Choice Plus Network prior to receiving services.

United Healthcare – Choice Plus Plan At-A-GlanceNetwork Choice Plus

Calendar Year Deductible (CYD) In-Network Out-of-Network*Single $5,000 $5,000

Family $10,000 $10,000

CoinsuranceMember Responsibility 0% 30%

Calendar Year Out-of-Pocket LimitSingle $6,250 $10,000

Family $12,500 $20,000

What Applies to the Out-of-Pocket Limit? Deductible, Coinsurance, Copays and Rx

Physician ServicesPrimary Care Physician (PCP) Office Visit $15 After CYD 30% After CYD

Specialist Office Visit (No Referral Required) $30 After CYD 30% After CYD

Non-Hospital Services; Freestanding Facility Clinical Lab (Blood Work): LabCorp** 0% After CYD 30% After CYD

X-rays 0% After CYD 30% After CYD

Advanced Imaging (MRI, PET, CT) (Per Scan) 0% After CYD 30% After CYD

Outpatient Surgery at Surgery Center 0% After CYD 30% After CYD

Physician Services at Surgical Center 0% After CYD 30% After CYD

Hospital ServicesInpatient Hospital (Per Admission) 0% After CYD 30% After CYD

Outpatient Hospital (Per Visit) 0% After CYD 30% After CYD

Physician Services at Hospital 0% After CYD 30% After CYD

Emergency Room 0% After CYD 0% After the In-Network CYD

Urgent Care $75 After CYD 30% After CYD

Mental Health/Alcohol & Substance AbuseInpatient Hospitalization (Per Admission) 0% After CYD 30% After CYD

Outpatient Services (Per Visit) 0% After CYD 30% After CYD

Prescription Drugs (Rx) Tier 1 $10 After CYD $10 After CYD

Tier 2 $35 After CYD $35 After CYD

Tier 3 $60 After CYD $60 After CYD

Mail Order Drug (90 Day Supply) 2.5x Copay After CYD Not Covered

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Health Reimbursement AccountThe City uses Eagles Benefits by Design for the administration of the Health Reimbursement Account (HRA). HRA monies are funded by the City and can be used for any qualified health-related expenses incurred for medical, dental, or vision care. The HRA monies provide tax-free funds to cover those expenses incurred under the City’s group insurance plans. Examples of qualifying expenses include copayments, deductibles and coinsurance for physician services, inpatient hospital stays, prescription drugs, etc. Employees can also receive reimbursement for expenses related to dental and vision care (that are not classified as cosmetic).

HRA Funding for 2016-2017 If all requirements are met, the City will fund the HRA account as follows:

• Up to $5,000 for Employee Only.

• Up to $8,700 For Employee + Dependents.

HRA IRS GuidelinesHRAs must be funded solely by an employer. The contribution cannot be paid through a voluntary salary reduction agreement on the part of an employee. Employees are reimbursed tax free for qualified medical expenses up to a maximum dollar amount for a coverage period. An HRA may be offered with other health plans, including Flexible Spending Accounts.

What are the benefits of an HRA? You may enjoy several benefits from having an HRA.

• Contributions made by your employer can be excluded from your gross income.

• Reimbursements may be tax free if you pay qualified medical expenses.

• Any unused amounts in the HRA can be carried forward for reimbursements in later years.

Expenses Eligible for ReimbursementEmployees may request reimbursement of expenses for yourself or your dependents covered under the City’s medical plan. Eligible expenses must be necessary for the diagnosis, treatment, cure, mitigation or prevention of a specific medical condition. Expenses you incur to improve general medical or cosmetic expenses are not eligible. Reimbursement checks will be issued to the employee throughout the year for incurred expenses up to the maximum annual benefit amount.

How to File a ClaimPaper Claim

Employees may submit claim forms to Eagles Benefits with an Explanation of Benefits form from the insurance carrier or receipts for eligible medical services throughout the plan year to the claim mailing address listed below.

Distributions From an HRAGenerally, distributions from an HRA must be paid to reimburse you for qualified medical expenses you have incurred. The expense must have been incurred on or after the date you are enrolled in the HRA.

Claims Mailing Address 2336 SE Ocean Blvd., Ste 301 | Stuart, FL 34996-3310

Eagles Benefits by Design | Customer Service: (800) 726-5603 www.takecareplans.com/eaglesbenefits

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Dental InsurancePrincipal PPO PlanThe City offers dental insurance through Principal to benefit eligible employees. The costs per pay period for coverage are listed in the premium table and a brief summary of benefits is provided below. For more detailed information about the dental plan, please refer to Principal’s summary plan document or contact Customer Service.

Dental Insurance Premiums Principal – Dental PPO Plan



Employee $0.00




In-Network BenefitsThe PPO plan provides benefits for services received 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 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 Principal Dental PPO network. These participating dental providers have contractually agreed to accept Principal’s contracted fee or “allowed amount.” This fee is the maximum amount a Principal 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.

Out-of-Network Benefits Out-of-network benefits are used when members receive services by a non-participating Principal provider. Principal reimburses out-of-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 procedure performed in a specific geographic area. If services are received from an out-of-network dentist, the member will pay the out-of-network benefit plus the difference between the amount that Principal reimburses (MAC) for such services and the amount charged by the dentist. This is known as balance billing. Balance billing is in addition to any applicable plan deductible or coinsurance responsibility.

Calendar Year DeductibleThe dental PPO plan requires a $50 individual or a family $150 deductible to be met for in-network or out-of-network services before most benefits will begin. The deductible is waived for Unit I : Preventative Services.

Calendar Year Benefit MaximumThe maximum benefit (coinsurance) the dental PPO plan will pay for each covered member is $1000 benefit maximum amount for in-network or out-of-network services combined. Unit I: Preventative Services accumulate towards this benefit maximum.

Principal Financial Group Customer Service: (800) 247-4695 | www.principal.com

IMPORTANT NOTES

• Each covered family member may receive up to 2 FREE cleanings per calendar year under the preventative benefit.

• Waiting periods and age limitations may apply for certain services.

• Certain limitations may apply on composite filings

• For any dental work expected to cost $200 or more, the plan will provide a “Pre-Determination of Benefits” upon request of your dental provider. This will assist you with determining your approximate out-of-pocket costs should you have the dental work performed.

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Principal – Dental PPO Plan At-A-GlanceNetwork Dental PPO

Calendar Year Deductible (CYD) In-Network and Out-of-Network CombinedPer Member $50

Per Family $150

Waived for Class I Services? Yes

Calendar Year Benefit Maximum In-Network Out-of-Network*Per Member $1,000

Unit I Services: PreventativeRoutine Oral Exam (2 Per Calendar Year)

Plan Pays: 100%Deductible Waived

Plan Pays: 80%Deductible Waived

(Subject to Balance Billing)Routine Cleanings (2 Per Calendar Year)

Bitewing X-rays (2 Sets Per Calendar Year)

Unit II Services: BasicComplete X-rays (Once Every 5 Years)

Plan Pays: 80% After CYD Plan Pays: 60% After CYD(Subject to Balance Billing)

Fillings (Amalgam or Composite)

Deep Cleaning

Simple Extractions

Oral Surgery

Anesthesia

Endodontics (Root Canal)

Periodontics

Unit III Services: MajorCrowns

Plan Pays: 50% After CYD Plan Pays: 40% After CYD(Subject to Balance Billing)

Bridges

Dentures

Locate a ProviderTo search for a participating provider, contact Principal’s customer service or visit www.principal.com. When completing the necessary search criteria, select Principal Plan PPO for the network.

Plan References*Out-of-Network Balance Billing: For information regarding out-of-network balance billing that may be charged by an out-of-network provider for services rendered, please refer to the Out-of-Network Benefits section on the previous page.

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Vision InsuranceHumana VisionCare PlanThe City offers vision insurance through Humana to benefit eligible employees. The costs per pay period for coverage are listed in the premium table and a brief summary of benefits is provided below. For more information about the vision plan, please refer to the carrier’s benefit summary or contact Humana’s Customer Service.

Vision Insurance Premiums Humana – VisionCare Plan



Employee $0.00




In-Network BenefitsThe vision plan offers employees and their covered dependents coverage for routine eye care, including eye exams, eyeglasses (lenses and frames) or contact lenses. To schedule an appointment, covered employees and their dependents can select any network provider who participates in the Humana VisionCare Plan (VCP) 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.

Out-of-Network BenefitsEmployees and their covered dependents may also choose to receive services from vision providers who do not participate in the Humana VisionCare Plan (VCP) network. 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.

Calendar Year Deductible There is no Calendar Year Deductible.

Calendar Year Out-of-Pocket MaximumThere is no out-of-pocket maximum. However, there are benefit reimbursement maximums for certain services.

Humana | Customer Service: (888) 537-0229 | www.humanavisioncare.com

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Humana – VisionCare Plan At-A-GlanceNetwork VisionCare Plan VCP

Services In-Network Out-of-Network

Eye Exam $15 Copay Up to $35 Reimbursement

Frequency of Services

Examination 12 Months

Lenses 12 Months

Frames 24 Months

Contact Lenses 12 Months

Lenses

Single $20 Materials Copay Up to $25 Reimbursement

Bifocal $20 Materials Copay Up to $40 Reimbursement

Trifocal $20 Materials Copay Up to $60 Reimbursement

Frames

Allowance Up to $40 Allowance Up to $40 Reimbursement

Contact Lenses*

Non-Elective (Medically Necessary)**No Charge

After $20 Materials CopayUp to $210 Reimbursement

Elective (Fitting, Follow-up & Lenses) Up to $110 Allowance Up to $110 Reimbursement

Locate a ProviderTo search for a participating provider, contact customer service or go to www.humanavisioncare.com; selecting “Humana Vision VCP Provider Locator” for your plan type.

Plan References*Contact lenses are in lieu of spectacle lenses and a frame

**Prior authorization is required. Contact Humana for additional information.

Important NotesMember options, such as LASIK, UV coating, progressive lenses, etc. are not covered in full, but may be available at a discount.

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Basic Life and AD&D InsuranceBasic Term LifeThe City provides Basic Term Life insurance for all eligible employees at no cost through The Standard. Employees are provided a benefit amount equal to one times their annual salary, up to a maximum of $150,000.

Accidental Death & DismembermentAlso at no cost to the employee, the City provides Accidental Death & 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 amount equals the Basic Term Life benefit amount and a partial benefit is also payable based on the schedule of benefits. For detailed coverages, exclusions and stipulations please refer to the carrier’s benefits summary or contact The Standard’s Customer Service.

Always remember to keep your beneficiary forms updated. Beneficiary forms are available in the Finance Department and

may be updated at anytime.

The Standard | Customer Service: (888) 937-4783 | www.stardard.com

Supplemental InsuranceThe City offers a variety of supplemental insurance plans through Aflac. These plans may be purchased separately on a voluntary basis and premiums payroll deducted. Aflac pays money directly to you, regardless of what other insurance plans you may have. A description of each available plan has been provided below.

Cancer Care Policy99 A Cancer Wellness Benefit of $75 per year

99 An initial treatment benefit of $4,000

99 An Injected Chemotherapy benefit of $600 per week

99 An Oral Chemotherapy benefit of $250 per Rx, per month

99 A Radiation Therapy benefit of $350 per week

99 Hospital benefits, Surgical benefits and Continuing care benefits

99 Transportation and Ambulance benefit

Hospital Advantage PolicyThe Hospital Advantage policy offers multiple options and levels that includes hospital confinement benefits of up to $1,000, physician and diagnostic options, as well as surgical and ambulance transportation options for all ages.

Personal Accident Indemnity PlanAflac will pay emergency treatment, follow-up treatments, initial hospitalization, hospital confinement, physical therapy, accidental death, a wellness benefit, plus much more to help cover the expenses associated with an accidental injury.

Life ProtectorLife insurance is not “what if” insurance, but “when.” Protect your loved ones with the money they will need in your absence. Ten, 20 and 30-Year Term, Whole-Life and Term to 25 policies are now available. Face amounts are now available for up to $200,000. You can also provide policies for your spouse, child(ren) and grandchildren.

Employees are provided a benefit amount equal to one times their annual salary, up to a maximum of $150,000.

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Supplemental Insurance (Continued)

Personal Disability Income ProtectorThe Short Term Disability plan helps you with lost income if you become disabled due to off-the-job accidents or sickness, including maternity. You have the choice of monthly benefit amount (based on your annual income), elimination period, and how long the benefit pays (from 3 months to 24 months).

OR

Guarantee Issue Short Term Disability• You may select from two options of coverage:

› Option 1: This benefit election offers coverage that allows a guaranteed issue amount up to $3,000 per month with either a 3 month or 6 month benefit period (subject to income requirements).

› Option 2: This benefit election offers coverage that allows you to be covered for up to $6,000 per month (subject to income requirements). The member may elect a benefit period of 3, 6, 12, 18 or 24 months. Please note that electing this option requires applicants to go through underwriting for approval of benefits.

• Benefits paid regardless of any other insurance and Guaranteed-renewable to age 70

To learn more about these Aflac plans and/or schedule a personal appointment, contact the City’s Aflac Agent.

Aflac | Agent: John Martin | Phone: (772) 532-1362 Email: [email protected] | www.aflac.com

NotesUse this section to make notes regarding your personal benefit plans or to keep track of important information such as doctor’s names and addresses or prescription medications.

I N S U R A N C E B R O K E R S & C O N S U L T A N T S

11505 Fairchild Gardens Ave., Suite 202Palm Beach Gardens, Florida 33410

Toll Free: (800) 244-3696; Fax: (561) 626-6970www.gehringgroup.com

Last Modified: September 15, 2016 9:27 AM

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