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Welcome to Open Enrollment

ABC Company has partnered with JD Fulwiler & Co. Insurance to make it easy for eligible employees to access details regarding their employee benefit package. Our annual open enrollment period begins on January 1st, 2017 and will end on January 31st, 2017. This is your opportunity to review your benefits, make plan changes, and add or delete dependents. Please review the information carefully as it provides you with important information for determining your benefit elections.

The 2017 Benefit Changes tab below outlines benefit changes for this plan year. The remaining tabs include benefit information and forms for each plan available to you. Please be sure to review them all. For questions regarding benefits or open enrollment, please contact ___________.

What Do You Need to Do During Open Enrollment?

During Open Enrollment you will need to complete and submit all required forms listed below:

Medical: Carrier Enrollment/Change Form:

  • If you are currently enrolled on the medical plan and are not making any changes, you do not need to complete this form.
  • If you are enrolling on medical for the first time or making changes to your existing enrollment, please complete the Carrier Enrollment/Change Form.
  • If you are currently enrolled on the medical plan and wish to waive coverage, please complete the Carrier Enrollment/Change Form and complete the cancellation portion of the application in section one.

Flexible Spending Account (FSA): Carrier FSA Enrollment Form:

  • Participation in the FSA plan requires annual enrollment. If you wish to participate in the FSA plan for the coming plan year please complete the Carrier FSA Enrollment Form.

Dental/Vision: Carrier Enrollment Form:

  • If you are currently enrolled on the dental/vision plan and are not making any changes, you do not need to complete this form.
  • If you are enrolling in the dental/vision plan for the first time or making changes to your existing enrollment, please complete the Carrier Enrollment Form.
  • If you are currently enrolled on the dental/vision plan and wish to waive coverage, please complete the wavier portion of the Carrier Enrollment Form in section three.

Life: Carrier Enrollment Form:

  • If you are currently enrolled in the the life plan you do not need to complete this form.
  • If you are enrolling in life insurance for the first time or making changes to your existing enrollment, please complete the Carrier Enrollment Form.
  • If three times your annual salary exceeds $300,000 please complete the health statement. The health statement can be found on the Life tab.

Life: Carrier Beneficiary Designation Form:

  • Open Enrollment is a good time to review your beneficiary designation. If you need to make changes to the listed beneficiary on your life insurance, please complete the beneficiary designation form.

To assure proper processing, open enrollment forms should be returned to __________ by January 20th, 2017.

Please Note: After the Open Enrollment Period, you cannot make changes to your coverage during the year unless you experience a change in family status such as: loss or gain of coverage through your spouse, birth or adoption of a child, loss of eligibility of a covered dependent, marriage, divorce, or legal separation, death of your covered spouse or child, or a switch from part-time to full-time. You have 30 days from a change in family status to make changes to your current coverage.

 Summary of Benefit Changes – Effective February 1st, 2017

2017 Changes to Medical

2017 Changes to Silver H.S.A $2,000:

  • In-Network Annual Out of Pocket Maximum: Changes from $5,000 per individual, $10,000 per family to $6,000 per individual, $12,000 per family.
  • Out of Network Deductible: Changes from $4,000 per individual, $8,000 per family to $5,000 per individual, $10,000 per family.
  • Generic medications now have two tiers: Preferred & Non-Preferred. You pay 10% after deductible for preferred and 25% after deductible for non-preferred. You have been paying 25% after deductible for all generic medications.
  • Specialty medications now have two tiers: Preferred & Non-Preferred. You pay 20% after deductible for preferred and 50% after deductible for non-preferred. You have been paying 50% after deductible for all specialty medications.

2017 Changes to Gold $1,000:

  • In-Network Annual Out of Pocket Maximum: Changes from $4,000 per individual, $9,000 per family to $6,000 individual, $12,000 per family.
  • Out-of-Network Deductible: Changes from $3,000 per individual, $6,000 per family to $5,000 per individual, $12,000 per family.
  • Emergency Room: Co-pay changes from $250 to $300. 20% co-insurance and deductible still apply.
  • Generic medications now have two tiers: Preferred & Non-Preferred. You pay $4 for preferred and 25% for non-preferred. You have been paying $10 for all generic medications.
  • Specialty medications now have two tiers: Preferred & Non-Preferred. You pay 20% for preferred and 50% for non-preferred. You have been paying 50% for all specialty medications.

2017 Changes to Platinum+ $250

  • In-Network Annual Out of Pocket Maximum: Changes from $2,000 per individual, $4,000 per family to $3,000 per individual, $6,000 per family.
  • Out of Network Annual Out of Pocket Maximum: Changes from $5,000 per individual, $10,000 per family to $10,000 per individual, $20,000 per family.
  • Emergency Room: Co-pay changes from $200 to $250. 10% co-insurance and deductible still apply.
  • Generic medications now have two tiers: Preferred & Non-Preferred. You pay $4 for preferred and 25% for non-preferred. You have been paying $10 for all generic mediations.
  • Specialty medications now have two tiers: Preferred and Non-Preferred. You pay 20% for preferred and 50% for non-preferred. You have been paying 50% for all specialty medications.

2017 Changes to Dental

  • The deductible has been removed from the policy. There will now be a $20 co-pay for each visit, along with applicable co-insurance.

Cost Summary

ABC Company will contribute up to $ per month, per employee for benefits. You may use these funds for yourself and dependents. If the cost of your coverage is less than $, you may choose to put the remaining funds into the Flexible Spending Account (maximum annual contribution is $2,500 for medical and $5,000 for dependent care) or you may elect to have the extra funds added to your payroll. If you add the additional funds to payroll it will be subject to applicable taxes.

Medical Silver H.S.A Medical Gold Medical Platinum+ Medical + Vision
Employee Only $0.00 $0.00 $0.00 $0.00
Employee + Spouse $0.00 $0.00 $0.00 $0.00
Employee + Family $0.00 $0.00 $0.00 $0.00
Employee + Child(ren) $0.00 $0.00 $0.00 $0.00

*Additionally, ABC Company pays the full cost of life insurance for each eligible employee.

To calculate the monthly cost of coverage for yourself and/or family:

  • Select the plan(s) you wish to enroll in for the coming plan year
  • Add the total premiums for the plans together
  • Subtract the contribution that ABC Company makes

Example:

  • Medical plan selected: Gold
  • Rate for employee + spouse = $0.00
  • Subtract ABC Company’s Contribution of $
  • Monthly cost for medical coverage for self and spouse is: $0.00

Medical

Carrier provides the medical coverage for ABC Company. You have a choice of three different medical plans.

Medical Plan: Silver H.S.A

  • Deductible: $2,000 individual, $4,000 family
  • Preventive Care: Paid 100%
  • Primary Care Copay: 30% after deductible
  • Co-insurance: you pay 30% after deductible
  • Prescriptions: 10%-25% / 35% / 20%-50% after deductible depending on tier
  • Out-of-Pocket Maximum: $6,000 individual, $12,000 family

Medical Plan: Gold $1,000 

  • Deductible: $1,000 individual, $2,000 family
  • Preventive Care: Paid 100%
  • Primary Care Copay: $30
  • Co-insurance: you pay 20% after deductible
  • Prescriptions: $10 / $40 / 50% depending on tier
  • Out-of-Pocket Maximum:  $6,000 individual, $12,000 family

Medical Plan: Platinum+ $250 

  • Deductible: $250 individual, $500 family
  • Preventive Care: Paid 100%
  • Primary Care Copay: $20
  • Co-insurance: you pay 10% after deductible
  • Prescriptions: $5 / $25 / 50% depending on tier
  • Out-of-Pocket Maximum: $3,000 individual, $6,000 family

Enrollment Forms, Benefit Summaries and Additional Benefit Information available are provided below.

Provider Website:
Benefit Summaries:

  • Silver H.S.A. $2,000 Benefit Summary
  • Gold $1,000 Benefit Summary
  • Platinum+ $250 Benefit Summary

Additional Benefits:

  • Wellness Incentive
  • Advice 24
  • Quit for Life
  • BabyWise

Enrollment/Waiver Forms:

  • Carrier Enrollment/Change Form
  • Carrier Waiver Form

Dental

Carrier provides the dental benefits for ABC Company. In addition to the dental insurance, the plan includes the option to use up to $200 of your $1,000 dental plan benefit to pay for covered vision care expenses.

Adult Dental/Vision: benefits listed below apply to adults ages 19+

  • Deductible: none
  • $20 Copay all visits
  • Preventive services: paid in full – exams, cleanings, x-rays, fluoride treatment
  • Basic services: 20% after deductible – fillings, endodontics, periodontics, sealants, simple extractions
  • Major services: 50% after deductible – crowns, bridges, complex extractions, onlays, anesthesia, space maintainers – 12 month waiting period applies 
  • Annual benefit maximum per person, per calendar year: $1,000
  • Vision – you can use up to $200 of your $1,000 annual benefit to pay for any covered eye expense

Pediatric Dental: ages 0-19  

  • Deductible: $80 per child
  • Preventive services: paid in full after deductible has been met – exams, cleanings, x-rays, fluoride treatment, sealants, space maintainers
  • Basic services: 45% after deductible – fillings, non-surgical periodontics, extractions, anesthesia, onlays
  • Major services: 65% after deductible – endodontics, surgical periodontics, crowns
  • Pediatric dental does not have an annual maximum benefit. It has an annual out-of-pocket maximum. The most you will pay for dental services for one child is $350. The most you will pay for more than one child is $750. Once this maximum has been met the cost of dental care is paid in full by insurance.

Enrollment Forms and Benefit Summaries are provided below.

Provider Website:
Benefit Summaries:

  • Carrier Dental/Vision Benefit Summary

Enrollment/Waiver Forms:

  • Carrier Enrollment/Change Form
  • Vision Reimbursement Request

Life Insurance

Carrier provides the life insurance for ABC Company. ABC Company pays the full cost of life insurance for each eligible employee.

  • Benefit available is three times annual salary to a maximum of $600,000. The guarantee issue amount is $300,000. If your benefit amount will be more than $300,000, a health statement will be required to get the additional benefit amount.
  • Benefits will reduce to 65% of benefit at age 65 and 50% at age 70.
  • Please refer to plan documents for additional plan details.

Employee Assistance Plan

  • The Carrier work-life employee assistance plan (EAP) offers unlimited access to master’s level consultants by telephone, resources and tools online, and up to three face to face visits with a consultant to help with a short term problem.  Example of services:
    • Locate child or eldercare services
    • Speak with financial experts by phone regarding budgeting, controlling debt, and more
    • Work through complex or sensitive issues. Get a referral to a local attorney for a free, 30-minute in person or telephonic legal consultation
    • Unlimited access to lifebalnce.net, booklets, life articles guides, online seminars, and more
    • Online legal forms, wills, powers of attorney, and estate planning

Enrollment Forms and Benefit Summaries are provided below.

Benefit Summaries:

  • Life Insurance Benefit Summary

Enrollment/Waiver Forms:

  • Carrier Enrollment/Change Form
  • Carrier Evidence of Insurability Form
  • Carrier Beneficiary Designation Form

FSA & HSA Information

The flexible spending account is administered by Carrier.

Please Note: If you are enrolled in the H.S.A. medical plan you will NOT be able to participate in the Full Flexible Spending Account. You can participate in the Dependent Care Expense Account and the Limited Flexible Spending Account (LFSA). Details are provided in the benefit overview and the LFSA Eligible Expenses documents provided below.

Flexible Spending Account: Set aside funds, via pre-tax payroll deduction, to pay for eligible medical expenses.

  • Set aside up to $2,500 per year to pay for eligible medical expenses. If, at the end of the plan year (May), you still have funds remaining in your account you can roll $500 of the balance to the following year.
  • Eligible Expenses (this is not a comprehensive list and is only intended to give you an idea of the types and services you can pay for with your flexible spending account): doctor visit copays, prescription drug copays, vision exam copays, glasses, contacts, dental services, orthodontia services, bandages, carpal tunnel wrist supports, chiropractor, acupuncture, cold/hot packs and more.
  • A “Benny Card” will be provided to you that you can use to pay for expenses directly from the FSA Account without having to submit receipts to get the reimbursement. PacificSource Administrators will ask for receipts on some transactions that are paid for with the Benny Card. Be sure to save all receipts.

Dependent Care: Set aside funds, via pre-tax payroll deduction, to pay for eligible dependent care expenses. 

  • Set aside up to $5,000 per plan year to pay for eligible dependent care expenses.
  • Eligible Expenses include after school care, agency fees, au pair, day camps, day care center, elder care, nanny and more.

Enrollment Forms and Benefit Summaries are provided below.

Benefit Summaries:

  • Benefit Overview
  • My Flex Online
  • Benefits (Benny) Card
  • FSA Eligible Expenses
  • LFSA Eligible Expenses

Enrollment/Waiver Forms:

  • Enrollment Form
  • Reimbursement Request Form
  • Dependent Care Reimbursement Request Form
  • Direct Deposit Setup Form