employee benefits handbook plan year 2013-2014 - pima.edu · pdf filebenefits handbook: plan...
Post on 14-Feb-2018
215 Views
Preview:
TRANSCRIPT
Benefit Handbook
Plan Year July 1, 2013 through June 30, 2014
Contents:
Benefits Enrollment.................................................................................................................................... 1
New Hires/Rehires ................................................................................................................................... 1
Annual Open Enrollment ......................................................................................................................... 1
Qualifying Events During the Plan Year .................................................................................................. 1
Enrollment Forms .................................................................................................................................... 2
Eligibility: Employees............................................................................................................................... 2
Eligibility: Dependents, Domestic Partners ............................................................................................. 3
Your Medical Plan and Pharmacy Options ................................................................................................ 3
Open Access Plus plan ............................................................................................................................. 3
Open Access Plus In-Network plan .......................................................................................................... 4
Health Insurance Waiver ......................................................................................................................... 4
If You Do Not Take Action (Default Coverage) ........................................................................................ 4
Additional Cigna features (both plans) ................................................................................................... 5
Summary & Comparison (both plans) ..................................................................................................... 6
Prescription Coverage through Express Scripts (formerly Medco) .......................................................... 8
Diabetic Supplies through Cigna ............................................................................................................. 8
Plan Year Medical Premiums............................................................................................................................................ 9
Per Pay Period Employee Medical Premiums ........................................................................................................... 10
Domestic Partner Per Pay Period Deduction ......................................................................................... 11
Reimbursement for Inpatient and Outpatient Hospital Costs ............................................................................ 11
Dental Plan Options ................................................................................................................................. 13
Employers Dental Services .................................................................................................................... 13
United Concordia .................................................................................................................................. 13
Summary & Comparison of Plan Benefits (both plans) ......................................................................... 14
Per Pay Period Employee Dental Premiums ........................................................................................... 15
Domestic Partner Dental Costs ............................................................................................................. 15
Life Insurance ........................................................................................................................................... 16
Employee Basic Term Life ...................................................................................................................... 16
Optional Term Life for Employee and Spouse ....................................................................................... 16
Premium Costs for Optional Coverage .................................................................................................. 17
Child(ren) Optional Term Life Insurance…………………………………………………………………………………………..17
Flexible Spending Accounts ..................................................................................................................... 18
FSA Options - Health Care and Dependent Day Care ............................................................................ 18
FSA Spending Account Contributions from the College ........................................................................ 18
FSA Spending Account Rules ................................................................................................................. 19
Identification Cards .................................................................................................................................. 20
Medical Plan/Prescription Plan and Dental Plan .................................................................................. 20
FSA Spending Account Debit Card ......................................................................................................... 20
Verification of Benefit Enrollment ........................................................................................................... 20
Legal Notices ............................................................................................................................................. 21
Qualifying Event .................................................................................................................................... 21
Annual Notice: Women’s Health and Cancer Rights Act (WHCRA) ...................................................... 21
HIPAA Privacy Notice for Group Health Plan ........................................................................................ 21
2013-2014 Plan Year Contact Information .............................................................................................. 22
2013-2014 Benefits Checklist ................................................................................................................... 23
Open Enrollment - Benefits Guide: Plan Year: 2011-2012 1 of 23
Welcome to the 2013-2014 Plan Year Employee Benefits Handbook!
This handbook outlines information on the benefits offered by Pima County Community College District (PCC) for the Plan Year July 1, 2013 to June 30, 2014.
This handbook is intended to help you understand your employee benefits by providing eligibility guidelines, comparison charts, benefit premium costs, summaries of the benefit programs, legal notices and vendor contact information.
Read the information in this handbook along with additional information on the PCC Employee Intranet. This guide is only a summary of your benefits. Where discrepancies exist between the Handbook and insurance contracts, the insurance contracts will dictate.
Benefits Enrollment
New Hires/Rehires
You will have 30 calendar days from your date of hire to make your benefit decisions. After your benefits election forms are received, your benefits will be effective the first day of the following month.
Annual Open Enrollment
This is your annual opportunity to make changes, elect or re-elect medical, dental and/or flexible spending accounts. The event typically takes place in April/May for two weeks with elections becoming effective on July 1 and remaining in effect until June 30. Active employees may also elect or increase supplemental employee life, spouse life and child life insurance during Open Enrollment but are subject to plan requirements for evidence of insurability. Coverage changes become effective once Minnesota Life approves.
Qualifying Events During the Plan Year
Because of the tax advantages of paying for your benefits with before-tax dollars, the IRS has
rules about when you may make changes. In most cases, you may only make benefit changes
during open enrollment. However, you may make changes during the year if you experience a
qualifying change in status (examples below). You must notify the Employee Service Center
(ESC) Benefits Office within 30 calendar days of the qualifying change in status and must
provide documentation specifying the date of the event.
Examples of Qualifying Change in Status Events:
You get married, legally separated, or divorced.
You have a baby or adopt a child.
You or your spouse starts or ends employment.
You or your spouse takes an unpaid leave of absence.
A dependent starts or stops being eligible.
Your spouse’s health care coverage through his or her employer changes.
If you have questions regarding a qualifying change in status please contact the Employee Service
Center at 520-206-4945 or by email at esc@pima.edu.
Benefits Handbook: Plan Year: 2013-2014 2 of 23
Enrollment Forms
Below is a general guide for the forms you will need to complete and submit.
What You Want To Do? Which Form(s) Do You Need to Submit?
Medical
Elect medical coverage for the 2013-14 plan year; OR
Add or delete a dependent from your medical coverage (children up to age 26)
2013-14 Medical Election form *
Waive medical coverage – have other qualified group medical insurance
Accept College contribution to FSA
2013-14 Benefit Waiver (Parts A & C plus proof of qualified group medical insurance coverage)
AND
2013-14 Flexible Spending Account (FSA) Enrollment Agreement
Dental
Elect dental coverage 2013-14 Dental Election Form*
Waive dental coverage 2013-14 Benefit Waiver Form (Parts B & C)
Add or delete a dependent (children up to age 26) 2013-14 Dental Election Form *
Flexible Spending Account
Contribute to a health care or dependent day care flexible spending account
2013-14 Flexible Spending Account (FSA) Enrollment Agreement
(Indicate if you accept the $18 annual fee to elect or renew the Debit Card)
Initial Debit Card option on health care FSA ASIFlex FSA Debit Card Application ($18 annual fee for Debit Card)
Life
Elect Optional Life Insurance
OR
Increase or decrease Optional Life Insurance due to a qualifying life event
Minnesota Life Enrollment and Change Request
Minnesota Life Evidence of Insurability
Update Life Insurance Beneficiary(ies) Minnesota Life Enrollment and Change Request
*When completing either the Medical and/or the Dental Election form, all covered dependents must be listed (including
children up to age 26). Fillable forms are accessed on the MyPima Intranet. After completing a fillable form, you will need to print, sign, and submit to: District Office Employee Service Center (Room C-117), Mail Code DO-1235, or by Fax: 206-4969.
Eligibility
Employees:
Benefit-eligible employees and their qualified dependents may participate in College benefit plans.
Benefit-eligible employees include:
Full-time regular classified employees and administrators.
Regular faculty working at least 30 hours per week.
Regular faculty who, by prior approval, have up to 2/5 unpaid release time.
Faculty on a one-year administrative appointment.
Benefits Handbook: Plan Year: 2013-2014 3 of 23
Probationary employees.
Temporary employees and adjunct faculty are not benefit-eligible.
Dependents:
Dependents up to age 26 regardless of student, marital or tax-dependent status may participate in
all plans including Cigna, United Concordia, Employers Dental Services, and optional life insurance
offered by Minnesota Life.
Domestic partners:
Domestic partners and the domestic partner’s dependent children may participate in College
medical and dental plans. Your domestic partner’s dependent children can participate only in the
benefit(s) that your domestic partner also participates in. Insurance elections for a domestic
partner and the domestic partner’s children can occur at the time of new hire or when the
employee becomes benefit-eligible; otherwise, the employee can only add domestic partner
coverage during the College’s Open Enrollment period, or as a result of a qualifying event (Please
see “Legal Notices – Qualifying Event: Special Enrollment Notice” at the end of this handbook).
To elect medical and/or dental coverage for your domestic partner, you and your partner must
complete and sign a Domestic Partnership Affidavit. You may also need to provide additional
documentation if you wish to cover your domestic partner’s children. If you have previously
completed the Affidavit, you do not need to do so again. Affidavits are available from the
Employee Service Center (520) 206-4945, email ESC@pima.edu, or accessed through your MyPima
Login. Click on the Intranet icon, Employee Service Center, Open Enrollment.
Post-Tax Payroll Deductions -- when you enroll your domestic partner and your domestic partner’s
child(ren) in the medical and/or dental plans, it’s important to be aware of taxation guidelines
established by the Internal Revenue Service (IRS) regarding premium deductions for coverage. The
premium you pay through payroll deduction is taken from your paycheck on a post-tax basis, after
taxes are deducted.
Your Medical Plan and Pharmacy Options
You may choose from two plan options, both offered through Cigna HealthCare. Enrollment in either plan will automatically include enrollment in the Pharmacy plan through Express Scripts (formerly Medco).
Open Access Plus plan (OAP) (similar to a PPO plan)
If you choose the OAP plan you can visit providers both in-network and out-of-network (cost will be
higher for out-of-network care). You will pay co-pays for certain services and there is an in-network
and out-of-network plan year deductible with coinsurance for certain services. Preventative health
services are provided at no cost. The plan year deductible is a flat dollar amount that you must pay
Benefits Handbook: Plan Year: 2013-2014 4 of 23
before the plan begins to pay and once the deductible is met, claims will be paid out by the plan,
less any coinsurance. The coinsurance is your share of the medical costs.
By enrolling in the Cigna OAP plan, you will automatically be enrolled in the Healthy Awards
Account, which is funded by the College. Through the Healthy Awards Account, employees are
reimbursed tax-free for qualified medical expenses such as co-pays, deductibles, and co-insurance
incurred under their Cigna coverage. A pre-set award amount, which is based on the level of plan
coverage you have elected, will be deposited into your Cigna account.
o Employee Only coverage receives $200 (prorated depending on start date)
o Employee + Spouse coverage receives $500 (prorated depending on start date)
o Employee + Child(ren) coverage receives $500 (prorated depending on start date)
o Employee + Family coverage receives $750 (prorated depending on start date)
There are no forms to file, and no claims to submit. For example, when you visit your doctor and
pay your copay, Cigna will use the money in your Account to reimburse you by mailing you a check
along with your Explanation of Benefits (EOB) statement.
Open Access Plus In-Network plan (OAPIN) (similar to an HMO plan)
If you choose the OAPIN plan you must obtain services from an in-network provider. If you choose
to see a doctor who is not in the network, your care will not be covered except in emergencies. This
plan does not have a plan year deductible or coinsurance. Co-pay amounts vary by type of service
provided. Preventative health services are provided at no cost. By enrolling in the Cigna OAPIN
plan you receive coverage under the Cigna Vision Plan benefit (in-network and out-of-network
benefits vary). The Healthy Awards Account does not apply to the OAPIN Plan.
Health Insurance Waiver For the 2013-14 Plan Year, the College will contribute up to $2,400
(prorated based on effective date of enrollment) on your behalf to a flexible spending account if
you waive medical coverage and submit a 2013-14 Flexible Spending Account (FSA) Enrollment
form. The contribution will correspond with the paycheck schedule, and the account of your choice
will be funded as long as you are an eligible participant. You may designate 100 percent of the
$2,400 to be placed in either a health care account or a dependent day care account, or you may
designate that 50 percent ($1,200) go into each account.
Benefits Handbook: Plan Year: 2013-2014 5 of 23
Additional Cigna features that apply to both plans (OAP and the OAPIN)
Primary Care Physician (PCP) – it is not required that you choose a PCP but it is recommended so that the PCP can help you coordinate care and act as a personal health advocate.
No-referral Specialist Care – you do not need a referral to see a specialist that participates in the Cigna network. Pre-certification may be required for hospitalizations and some types of outpatient care, but there is no paperwork for you to submit.
24/7 Customer Service – by calling the toll-free number printed on the back of your card you can speak to a Customer Service Representative to order replacement ID cards, check on claim status, ask questions and resolve coverage issues.
Access to myCigna.com – by creating a login at www.myCigna.com you can view and track claims history, estimate health care costs, learn more about the plan, search for doctors and find personalized health and wellness recommendations.
Call a nurse 24/7 – by calling 1.800.CIGNA24 (1-800-244-6224) you can speak to a certified nurse specialist trained to discuss your health concern or question.
Cigna Healthy Rewards Program – discounts are available for a variety of health- and wellness-related products and services including: healthy lifestyle products, fitness, tobacco cessation, weight and nutrition management, vision and hearing care, alternative medicine, anti-cavity dental products, and vitamins.
Convenience Care Clinics – for routine medical conditions, such as allergies, strep throat, school physicals, pink eye and minor burns, you can receive services through a facility overseen by doctors and staffed by certified nurse practitioners and physician assistants. With convenient hours and no appointment needed you can experience a shorter wait time. For a complete listing of participating clinics in the Cigna network visit www.myCigna.com or call the toll-free number on the back of your ID card.
A summary and comparison of the two plans is provided on the next two pages. Employees should read the Summary of Benefits provided by Cigna Health and Life Insurance Company to obtain further details on the plan benefits and exclusions. These documents will be available at the Open Enrollment Fairs and on the MyPima Intranet under Employee Service Center – Benefits, or by emailing ESC@pima.edu.
Benefits Handbook: Plan Year: 2013-2014 6 of 23
Summary & Comparison of Cigna Plan Benefits
Open Access Plus (OAP)
Co-pay: $20 - $35; Co-insurance: 20%-40%;
Deductible: $500-$1000
Open Access Plus In-Network
(OAPIN) Co-pays listed below
In-Network Provider
Out-of- Network Non-Participating
Provider In-Network only
You Pay: You Pay: You Pay:
Plan Year Deductible
$500 Individual/$1000 Family
$500 Individual/$1000 Family
$0
Out-of-Pocket Maximum
$2,000 person $4,000 family per plan year (excluding deductibles & co-payments)
$6,000 person $12,000 family per plan year (excluding deductibles & co-payments)
$3,000 person $9,000 family per plan year
Physician Office Visits $20 co-pay for PCP
$35 co-pay for specialist (no referral necessary)
40% co-insurance subject to deductible
$20 co-pay for PCP
$35 co-pay for specialist (no referral necessary)
Preventive Care: Adults and Children -Office Visit; Immunizations; Mammogram; PSA; Pap Smear; Colonoscopy
No charge
Not covered
No charge
Diabetic Supplies $10 for a 30-day supply Not covered by non-contracted pharmacies
$10 for a 30-day supply
Lab and X-ray No charge after office visit co-pay
40% co-insurance subject to deductible
No charge after office visit co-pay
Advance Radiology Testing Services, such as MRI, CAT scans
20% co-insurance subject to deductible
40% co-insurance subject to deductible
$100 co-pay per scan
Convenience Care clinics (CVS Minute Clinics or Walgreens Take Care Clinics)
$20 co-pay per visit N/A $20 co-pay per visit
Benefits Handbook: Plan Year: 2013-2014 7 of 23
Summary & Comparison of Cigna Plan Benefits continued
Open Access Plus (OAP)
Co-pay: $20; Co-insurance: 20%-40%;
Deductible: $500-$1000
Open Access Plus In-Network
(OAPIN) Co-pays listed below
In-Network Provider
Out-of- Network Non-Participating
Provider In-Network only
You Pay: You Pay: You Pay:
Urgent Care (co-pay waived if admitted)
$50 co-pay per visit, then no charge after deductible is met
$50 co-pay per visit
Emergency Room (co-pay waived if admitted)
$125 co-pay per visit, then no charge after deductible is met
$125 co-pay per visit
Inpatient Hospital/Surgical Services
20% co-insurance after plan deductible
40% co-insurance after plan deductible
$500 co-pay per admission
Outpatient Hospital/Surgical Services
20% co-insurance after plan deductible
40% co-insurance after plan deductible
$250 co-pay per service
Outpatient Therapy Services (Physical, Speech, Occupational, Chiropractic, Pulmonary, & Cognitive Therapies)
$35 co-pay per visit (60 day combined maximum per plan year)
40% co-insurance after plan deductible (60 day combined maximum per plan year)
$35 co-pay per visit
(60 day combined maximum per plan year)
Behavioral Health Care - Physician’s Office Outpatient Facility
$35 co-pay per office visit for specialist (no referral necessary)
20% co-insurance after plan deductible
40% co-insurance after plan deductible 40% co-insurance after plan deductible
$35 co-pay per office visit $35 co-pay per outpatient facility visit
Behavioral Health Care – Inpatient Facility
20% co-insurance after plan deductible
40% co-insurance after plan deductible
$500 co-pay per admission
Vision Plan Not offered Not offered 1 exam/24 months, $20 co-pay in network; $45 out of network
Benefits Handbook: Plan Year: 2013-2014 8 of 23
Prescription coverage through Express Scripts (formerly Medco)
(except Diabetic Supplies)
You automatically receive prescription drug coverage through Express Scripts when you enroll in
one of the two medical plan options. Prescription coverage is a component of medical coverage
and cannot be provided separately.
In general, the amount you pay for your medication under the program depends on where your
prescription is filled and the type of medicine prescribed. If you fill a prescription for maintenance
drugs more than two times at a retail pharmacy, you will have a higher co-pay for each subsequent
refill. However, you can save money for maintenance drug prescriptions by using the mail-order
pharmacy. Contact Express Scripts: (800) 711-0917 or at www.express-scripts.com.
All Prescriptions Maintenance Drug Prescriptions
Drug Type
Retail Pharmacy
30-day supply
1st and 2nd fill
Retail Pharmacy
30-day supply
3rd fill & thereafter
Mail-Order
90-day supply
Generic $5 co-pay $15 co-pay $10 co-pay
Preferred Brand
Name $25 co-pay $60 co-pay $55 co-pay
Non-Preferred
Brand Name $40 co-pay $90 co-pay $85 co-pay
Express Script’s website, www.express-scripts.com, has several useful features which:
List generic alternatives to brand name medications.
Provide cost comparison among medications.
Locate a pharmacy.
Review your medications claim history.
Diabetic Supplies through CIGNA
Present your CIGNA ID card and prescription at your local pharmacy to obtain diabetic supplies.
There is a $10 co-pay per prescription for a 30-day supply. This includes insulin, pre-filled insulin
cartridges for the blind, oral agents for controlling blood sugar, injection aids (e.g. lancets and
lancet devices, alcohol swabs), syringes and needles, glucose test strips, visual reading ketone strips
and urine test strips. Contact CIGNA Customer Service: (800) 244-6224 or at www.cigna.com.
Benefits Handbook: Plan Year: 2013-2014 9 of 23
Plan Year Premiums for Medical and Pharmacy Coverage The charts below and on the following page show the amount of the deduction annually and per
paycheck, depending upon the coverage selected. The deductions are taken pre-tax. Pre-tax means
the premium is deducted from your paycheck before taxes are calculated on your earnings.
Open Access Plus (OAP) plan
Total Annual
Premiums
Total Employee
Annual Deduction
Total College Annual Contribution
Healthy Awards Account
(HAA)
Employee only $ 7484 $ 0 $ 7684 $ 200
Employee plus spouse $ 14,947 $ 4114 $ 10,833 $ 500
Employee plus child(ren) $ 13,454 $ 3,425 $ 10,029 $ 500
Employee plus family $ 21,271 $ 6,182 $ 15,089 $ 750
Open Access Plus In-Network (OAPIN) plan
Total Annual
Premiums
Total Employee
Annual Deduction
Total College Annual
Contribution
Employee only $ 8,045 $ 348 $ 7,697
Employee plus spouse $ 16,071 $ 5,199 $ 10,872
Employee plus child(ren) $ 14,468 $ 4,158 $ 10,310
Employee plus family $ 22,876 $ 9,564 $ 13,312
Benefits Handbook: Plan Year: 2013-2014 10 of 23
Medical and Pharmacy Per-Pay-Period Cost Staff, Administrators and Educational Support Faculty will pay every paycheck: (total of 26 deductions)
CIGNA Plan Name Coverage
CIGNA (Medical) Pretax Premium
Deduction
Express Scripts (Pharmacy) Pretax
Premium Deduction
Combined Medical and Pharmacy
Pretax Deductions
Open Access Plus plan with Medco pharmacy
Employee Only $0.00 $0.00 $0.00
Employee Plus Spouse 111.63 46.60 158.23
Employee Plus Child(ren) 94.45 37.28 131.73
Employee Plus Family 152.05 85.73 237.78
Open Access Plus- In-Network plan with Medco pharmacy
Employee Only $13.40 $0.00 $13.40
Employee Plus Spouse 153.35 46.60 199.95
Employee Plus Child(ren) 122.64 37.28 159.92
Employee Plus Family 282.12 85.73 367.85 Instructional Faculty (9-month employees) will pay every paycheck: (total of 20 deductions)
CIGNA Plan Name Coverage
CIGNA (Medical) Pretax Premium
Deduction
Express Scripts (Pharmacy) Pretax
Premium Deduction
Combined Medical and Pharmacy
Pretax Deductions
Open Access Plus plan with Medco pharmacy
Employee Only $0.00 $0.00 $0.00
Employee Plus Spouse 145.12 60.58 205.70
Employee Plus Child(ren) 122.78 48.47 171.25
Employee Plus Family 197.67 111.45 309.12
Open Access Plus- In-Network plan with Medco pharmacy
Employee Only $17.42 $0.00 $17.42
Employee Plus Spouse 199.36 60.58 259.94
Employee Plus Child(ren) 159.44 48.47 207.91
Employee Plus Family 366.76 111.45 478.21 10-month employees will pay every paycheck: (total of 21 deductions)
CIGNA Plan Name Coverage
CIGNA (Medical) Pretax Premium
Deduction
Express Scripts (Pharmacy) Pretax
Premium Deduction
Combined Medical and Pharmacy
Pretax Deductions
Open Access Plus plan with Medco pharmacy
Employee Only $0.00 $0.00 $0.00
Employee Plus Spouse 138.21 57.70 195.91
Employee Plus Child(ren) 116.94 46.16 163.10
Employee Plus Family 188.25 106.14 294.39
Open Access Plus- In-Network plan with Medco pharmacy
Employee Only $16.59 $0.00 $16.59
Employee Plus Spouse 189.86 57.70 247.56
Employee Plus Child(ren) 151.85 46.16 198.01
Employee Plus Family 349.30 106.14 455.44
Benefits Handbook: Plan Year: 2013-2014 11 of 23
Domestic Partner Per-Pay-Period Deduction for Cigna and Express Scripts
Coverage Per IRS regulations, the health premium deductions for domestic partners and their dependents are on an after-tax basis and are deducted separately from, and in addition to, any of your applicable pre-tax deductions.
CIGNA Plan Name Coverage
Staff, Admin and Ed
Support Faculty will
pay every paycheck:
(total of 26 deductions)
Instructional Faculty
will pay every
paycheck:
(total of 20 deductions)
10-month employees
will pay every
paycheck:
(total of 21 deductions)
Open Access Plus
plan with Express
Scripts pharmacy
Domestic Partner Only $287.83 $374.18 $356.36
Domestic Partner Plus
Domestic Partner’s
Child(ren)
$517.48 $672.73 $640.69
Open Access Plus-
In-Network plan
with Express
Scripts pharmacy
Domestic Partner Only $309.43 $402.27 $383.11
Domestic Partner Plus
Domestic Partner’s
Child(ren)
$556.45 $723.41 $688.96
Reimbursement for Inpatient and Outpatient Hospital Costs
Employees participating in the College's Medical/Rx coverage for the 2013-14 Plan Year will be offered
the Reimbursement for Inpatient and Outpatient Hospital Costs program. The College will reimburse a
portion of each inpatient hospital and outpatient hospital cost, including co-pay(s), deductible or
coinsurance(s) incurred during the Plan Year, for eligible employees or their dependent(s) enrolled in a
College CIGNA HealthCare plan.
The maximum reimbursement for the OAP plan is $550 for each inpatient expense and/or outpatient
service incurred. The maximum is reduced if the employee receives payments for the service through
their Healthy Awards HRA. Employee must provide documentation on the Healthy Awards HRA
account reimbursements with their request, including all expenses associated with the service (i.e.
facility, surgeon, anesthesia, assistant surgeon, etc.). CIGNA provides an Explanation of Benefits (EOB)
for all medical services a member receives. The EOB itemizes charges, discounts, insurance company
payments, HRA reimbursements and member responsibility. By accessing your myCIGNA.com account,
you will be able to print any EOBs that have been processed. Please include them as documentation in
your reimbursement request.
Maximum reimbursement for the OAPIN plan is $350 for each inpatient cost, adjusted for any
discounts by the medical facility. Maximum reimbursement for the OAPIN plan is $150 for each
outpatient cost, again adjusted for any discounts by the medical facility.
Benefits Handbook: Plan Year: 2013-2014 12 of 23
Regardless of the plan option an employee elects, under this reimbursement program there are no
circumstances under which the College will reimburse employee for 100 percent of their financial
responsibility for the hospital service received. The minimum responsibility the employee must pay for
an inpatient hospital cost is $150. The minimum responsibility for an outpatient hospital cost is $100.
After the service has been received, you may request reimbursement by completing the
Reimbursement for Inpatient and Outpatient Costs form and attaching copies of the Explanation of
Benefits (EOB) from CIGNA and a copy of a paid receipt with itemized billing from the provider(s). The
request should be submitted to the Employee Service Center (mail code DO-1235). The
reimbursement request form is available online or at the Employee Service Center. Reimbursements
are processed on the next available regular payroll check after the request has been approved.
Emergency Room co-pays/visits are excluded from this program.
Requests for reimbursement must include all supporting documentation and be received no later than
September 28, 2014 (90 days after the end of the Plan Year).
Benefits Handbook: Plan Year: 2013-2014 13 of 23
Dental Plan Options
You may choose from two dental plan options. Both plans provide coverage for preventive care
(cleanings and X-rays) and basic services. The plans differ in how they work, how you pay for
services, and which dentists you may use. The plans offered are:
Employers Dental Services DMO (EDS)
Under this plan, you select a primary dental office for you and your entire family. No referral is
necessary to see a specialist, but the specialist must be within the EDS network.
For 2013-14 EDS has:
Continued website access providing members features including “Ask a Dentist” and dental wellness information.
VSP Visions Discounts and the APN Prescription Discounts available to members.
If you are enrolling in EDS for the first time, you may select and notify EDS of your choice of a
primary dentist before you can receive services. If you do not complete this selection process, EDS
will automatically assign you a dentist. To search for a dentist, visit the Employers Dental Services
website at www.mydentalplan.net. From the homepage, look at the Quick Links area on the left
side of the webpage and click on Find a Dentist. You may search by multiple criteria, including
dentist name or location. Submit the Member Request Form or contact EDS Customer Service via
email at EDSCS@mydentalplan.net or by phone, (520) 696-4343. You may change your selection
each month. To select a different dentist, follow the same instructions describe above.
United Concordia PPO/Indemnity (UCCI)
This plan offers members the flexibility of receiving care from either a participating or a non-
participating dentist. Using a non-participating dentist rather than a network dentist will result in a
higher out-of-pocket cost to the member. With network dentists, members enjoy the convenience
of out-of-pocket savings and no claims to file. Visit United Concordia’s website at www.ucci.com
and click on “Find a Dentist.” Click on the Concordia Advantage Plus national network.
In 2013-14, the United Concordia plan includes:
The Preventive Incentive Feature program.
Davis Vision Discount Plan.
Nitrous Oxide for children younger than 12 and adults with special needs.
Benefits Handbook: Plan Year: 2013-2014 14 of 23
Summary & Comparison of Plan Benefits Dental Plan:
(This is only a brief summary of the dental plans offered. Please refer to the applicable coverage documentation provided by Employers Dental Services and United Concordia for full benefit descriptions.)
Employers Dental Services
DMO
United Concordia
PPO/Indemnity Dental Plan
In-Network only In-Network– Concordia
Advantage Plus Out-of-network
Plan Year Deductible $0 $25 person
$75 family
$50 person
$150 family
Diagnostic and preventive
services (cleanings, X-rays,
exams)
You pay a $5 co-pay for routine office
visits; $7 for an adult or $5 for a child
“healthy-mouth” cleaning. You pay
nothing for initial exam, periodic oral
exam, X-rays, and children’s fluoride
treatment. There are no restrictions or
service maximums for the treatments
determined by the dentist in the plan
year [See note below].
You pay 10%; deductible is
waived (2 exams per year)
With the “Preventive
Incentive” program, charges
for Class I Diagnostic and
Preventive services do not
count toward your annual
maximum.
You pay 20%; deductible is
waived.
Basic services (fillings,
endodontics, periodontics,
oral surgery)
Member responsibility is based on
services received. There are no
restrictions or service maximums for the
treatments determined necessary by
the dentist in the plan year. Co-pays
range from $13 to $400 + lab depending
on the individual service performed [See
note below].
You pay 10%, after the
deductible.
You pay 20%, after the
deductible.
Major services (crowns,
bridges, dentures)
Member responsibility is based on
services received. There are no
restrictions or service maximums for the
treatments determined necessary by
the dentist in the plan year. Co-pays
range from $280 + lab to $400 + lab for
major services [See note below].
You pay 40%, after
deductible.
You pay 50%, after
deductible.
Orthodontia
EDS contracted orthodontists offer 25%
off their normal and customary fees for
adults and children.
You pay 40%; deductible is
waived.
You pay 40%; deductible is
waived.
Plan Year Maximum Benefit None $2,000 per person $1,500 per person
Lifetime Orthodontic Max. None $2,000 per person $1,500 per person
Note: A full mouth debridement is an intensive cleaning and members are charged considerably more for this
service than for healthy mouth cleanings. Before having your teeth cleaned, you are encouraged to confirm with
your dentist the type of cleaning to be received and the related charge. The EDS Schedule of Benefits listing all
procedures and corresponding member cost(s) is available from EDS at www.mydentalplan.net, or the Employee
Service Center.
Benefits Handbook: Plan Year: 2013-2014 15 of 23
Plan Year 2013-14 Premium Costs for Dental Coverage
The College contributes the full cost of the employee-only DMO (EDS) premium of $8.26 per month
toward the cost of your dental coverage. The following chart shows how much you will pay on a
per-paycheck deduction for the coverage elected. These rates are for employees and their tax-
qualified dependents.
Note that deductions will be taken from all applicable paychecks throughout the Plan Year. This
allows employees to receive consistent paycheck amounts.
Plan and Coverage 12-month employees
will pay every paycheck (total of 26 deductions)
9-month employees will pay per paycheck
(20 deductions)
Employers Dental Services DMO
Employee Only $0.00 $0.00
Employee Plus One $3.55 $4.61
Employee Plus All $7.06 $9.18
United Concordia PPO/Indemnity
Employee Only $14.99 $19.49
Employee Plus One $32.02 $41.62
Employee Plus All $49.04 $63.74
Domestic Partner Dental Costs
Due to IRS regulations, the premiums for domestic partners and their dependents are on an after-tax basis and are deducted separately from and in addition to your pre-tax deductions.
Plan and Coverage 12-month employees
will pay every paycheck (total of 26 deductions)
9-month employees will pay per paycheck
(20 deductions)
Employers Dental Services DMO
Domestic Partner Only $3.92 $5.10
Domestic Partner Plus One Child
$7.47 $9.71
Domestic Partner Plus Children
$10.98 $14.28
United Concordia PPO/Indemnity
Domestic Partner Only $18.91 $24.59
Domestic Partner Plus One Child
$35.94 $46.72
Domestic Partner Plus Children
$52.96 $68.84
Benefits Handbook: Plan Year: 2013-2014 16 of 23
Life Insurance
Employee Basic Term Life Insurance
The College provides Basic Term Life and Accidental Death and Dismemberment (AD&D) insurance
for employees at no cost. The death benefit is 1.5 times annual salary with a minimum of $50,000.
Coverage is discontinued upon termination of employment or retirement, although conversion
options are available. You may select/change your designated beneficiary(ies) at any time by
submitting a Minnesota Life Enrollment/Change Form to the Employee Service Center.
Minnesota Life also offers additional benefit programs including:
Will preparation and legal services through Ceridian LifeWorks.
Travel assistance services through Global Rescue.
Beneficiary financial counseling program through PricewaterhouseCoopers LLP.
Optional Term Life Insurance for Employee and Spouse
You may purchase optional term life insurance for yourself, your spouse, and/or your child(ren).
Here are your options:
Employee optional term life insurance
As a new benefits-eligible employee you may elect up to $100,000 of optional life insurance
without answering any health questions. You may choose coverage in increments of $10,000,
up to $500,000 or seven (7) times your annual salary, whichever is less. Any amount that
exceeds the guaranteed issue amount of $100,000 will require the Evidence of Insurability (EOI)
form to be completed.
Spouse optional term life insurance
If you purchase optional life insurance for yourself, you may buy coverage for your spouse in
increments of $5,000, up to 50 percent of the amount of optional life insurance you have. The
employee is automatically the beneficiary for this benefit.
The amount you pay for optional life insurance for yourself and your spouse depends on your
age (or your spouse’s age) and the amount of coverage you elect. The chart on the next page
shows your cost for coverage per month. Unlike your other benefits, your contributions for
term life insurance are deducted from only one paycheck each month as a post-tax deduction.
Note: During open enrollment or a Qualified Life Event you may elect to purchase optional life
insurance for the first time or increase your current coverage but the amount will require the
Evidence of Insurability form to be completed.
Benefits Handbook: Plan Year: 2013-2014 17 of 23
Premium costs for Optional Term Life Coverage
Employee and Spouse Optional Costs
Age
Employee
Monthly cost per $1,000
of coverage
Spouse
Monthly cost per $1,000
of coverage
0-29 $0.05 $0.07
30-34 $0.06 $0.09
35-39 $0.07 $0.11
40-44 $0.08 $0.12
45-49 $0.11 $0.18
50-54 $0.18 $0.27
55-59 $0.33 $0.51
60-64 $0.50 $0.78
65-69 $0.97 $1.49
70-74 $1.57 $2.42
75 plus $2.06 $2.42
*Note: 9-10-11 month employees will have deductions adjusted to their normal pay schedule.
Example: If you buy $10,000 of coverage for yourself and you’re 37 years old, your cost
would be $0.70 per month ($0.07 x 10 = $0.70).
Child(ren) Optional Term Life Insurance
If you purchase optional life insurance for yourself, you may choose one of the coverage
amounts listed below for dependent children who are between birth and 26 years of age.
The amount of coverage cannot exceed 50 percent of your optional coverage.
Your cost for child coverage depends on the level of coverage you choose – not how many
children you cover. All children over 6 months of age are covered for the same amount.
Coverage for a child under 6 months of age is $500.
Child(ren) Optional Costs
Child term life insurance
coverage amount
Your monthly cost (includes all
eligible children)
$ 2,500 $0.50
$ 5,000 $1.00
$ 7,500 $1.50
$10,000 $2.00
Benefits Handbook: Plan Year: 2013-2014 18 of 23
Flexible Spending Accounts
Flexible Spending Accounts (FSAs) help you save money by allowing you to set aside part of your
salary on a pre-tax basis to pay for health care and/or dependent day care expenses. As indicated
earlier in this Handbook, pre-tax deductions from your paycheck reduce taxes withheld today and
lower your taxable income.
ASIFlex administers the Flexible Spending Account (FSA) plans for the College. Their services
include:
Optional Medical FSA Debit Card ($18 cost per Plan Year).
75-day grace period for participants to incur qualified expenses.
Online claim submission.
Toll-free fax number for claim submission (1-866-381-9682 Fax).
Questions about reimbursement eligibility should be directed to ASIFlex at (800) 659-3035, and all
claims should be submitted directly to them.
FSA Options:
You may contribute to one or both of the spending account options:
1. Health Care Flexible Spending Account
You may contribute up to $2,500 of your own contributions to reimburse yourself for
eligible expenses. College contributions (for those employees who waive medical benefits
through the College) will be up to $2,400 per plan year. Eligible expenses include amounts
not paid under a medical, prescription drug, or dental plan (i.e. co-pays and deductibles) for
you or your dependents (but not a domestic partner or their dependents).
2. Dependent Day Care Flexible Spending Account
You may contribute up to $5,000 (including the College’s contribution, if any) to reimburse
yourself for day care expenses for your eligible dependents. If you are married, your spouse
must be employed, actively seeking employment, or attending school full time to be eligible
for this type of account. Expenses for a domestic partner’s dependents are not covered.
Flexible Spending Account Contributions from the College
For the 2013-14 Plan Year; the College will contribute up to $2,400 (prorated based on effective
date of enrollment) on your behalf to a flexible spending account if you waive medical coverage
and submit a 2013-14 Flexible Spending Account (FSA) Enrollment form. The contribution will
correspond with the paycheck schedule, and the account of your choice will be funded as long as
you are an eligible participant. You may designate 100 percent of the $2,400 to be placed in either
a health care account or a dependent day care account, or you may designate that 50 percent
($1,200) go into each account.
Benefits Handbook: Plan Year: 2013-2014 19 of 23
Flexible Spending Account Rules
Before you enroll in a flexible spending account, there are a few things you should consider:
1. Once you elect to participate in a flexible spending account, your election stays in effect for
the remainder of the Plan Year. You may change or stop contributions during the year only
if you have a qualifying change in status (see page 4 for details). Any unused money in
either account at the end of the plan year grace period is forfeited – use it or lose it. That is
why it is important to carefully estimate your medical, dental and vision or dependent day
care expenses.
2. As of January 1, 2011, certain over-the-counter medications do not qualify for
reimbursement from your healthcare FSA unless the claim is accompanied by a prescription
from your healthcare provider. Please check with the IRS or the Employee Service Center-
Benefits regarding details on requirements and exclusions.
3. IRS regulations limit employee contributions to medical flexible spending accounts to
$2,500 per calendar year. This limit was applied as of the College’s plan year beginning July
1, 2012.
4. IRS regulations limit use of dependent day care flexible spending accounts to $5,000 per
calendar year per household.
5. The total funds to be contributed by you or the College over the Plan Year to your health
care FSA are available to you on the first of the month following your regular date of hire. If
you are electing an FSA during open enrollment the funds will be available on July 1.
6. Funds contributed to your dependent day care FSA are available only when the contribution
is made.
7. In FY 2013-14, FSA participants will have an additional 75 days (until September 15, 2014) to
incur claims and use monies set aside during the plan year. This grace period means
participants have 14.5 months to expend dollars contributed to the FSA account between
July 1, 2013 and June 30, 2014.
8. You will have 90 calendar days after the end of the grace period (December 15, 2014) to
submit a claim for eligible health or day care expenses incurred during the prior plan year or
grace period.
9. If you receive reimbursement for a medical expense from your Healthy Awards HRA
account, you cannot file a claim against your FSA for the same expenses.
Benefits Handbook: Plan Year: 2013-2014 20 of 23
Identification Cards
New hires: you will receive ID cards for your initial benefit elections within 7-14 business days from
date of enrollment.
Active employees: you will receive ID cards under the following circumstances during the Annual
Open Enrollment or a Qualified Life Event (QLE).
o Medical Plan/Prescription Plan and Dental Plan
You will receive new cards from CIGNA and Express Scripts only if you are changing medical
plans, or electing medical coverage for the first time for yourself or any of your dependents.
If you elect the OAPIN plan, you will also receive separate ID cards for the vision plan.
If you are enrolling for the first time or changing dental plans, you will receive cards from
either Employers Dental Services or United Concordia, as appropriate.
o Flexible Spending Account Debit Card
The Flexible Spending Debit card issued to you in prior Plan Years will remain activated if you accept the $18 annual fee for the 2013-14 Plan Year. You will receive a new card for your Medical FSA only if you are electing this service for the first time. If you need a replacement card, contact ASIFlex directly. You will be assessed a $5.00 fee for the replacement card.
Verification of Benefit Enrollment
You may access your Benefits Statement through the College website via your MyPima Login.
Go to:
►www.pima.edu ►MyPima [right-hand side bar] ►Log in. For assistance please call the Help Desk at 206-4900. ►@Work Tab [top page tab near center] ►Quick-Links - @Work ►My Benefits Statement ►Current ►click Select
It is essential that you carefully review your benefits to ensure your elections are correct. To
make corrections or inquiries please contact the Employee Service Center at 206-4945.
Benefits Handbook: Plan Year: 2013-2014 21 of 23
Legal Notices
Qualifying Event: Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of
other group health plan coverage, you may be able to enroll yourself and your dependents in this
plan if you or your dependents lose eligibility for that other coverage (or if the employer stops
contributing toward your or your dependents' other coverage). However, you must request
enrollment within 30 calendar days after your coverage or your dependent’s other coverage ends
(or after the employer stops contributing toward the other coverage).
In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for
adoption, you may be able to enroll yourself and your dependents. However, you must request
enrollment within 30 calendar days after the marriage, birth, adoption, or placement for adoption.
To request special enrollment or to obtain more information, please contact the Employee Service
Center: (520) 206-4945.
Annual Notice: Women’s Health and Cancer Rights Act (WHCRA)
Your group health plan, as required by the Women’s Health and Cancer Rights Act of 1998,
provides benefits for mastectomy-related services including reconstruction and surgery to achieve
symmetry between the breasts, prostheses, and complications resulting from a mastectomy
(including lymphedema). For more information call CIGNA at (800) 244-6224.
HIPAA Privacy Notice for Group Health Plan
HIPAA Privacy pertains to the following group health plan benefits sponsored by Pima County
Community College District:
Pharmacy plan administered by Express Scripts.
Health Care Flexible Spending Account administered by ASIFlex.
COBRA administered by Ceridian.
Medical Reimbursement plan.
To obtain a copy of this HIPAA Notice of Privacy Practice for the above noted group health plan
benefits, write to the Employee Service Center at 4905C East Broadway Blvd., Tucson, AZ 85709-
1235 or call: (520) 206-4945.
HIPAA Privacy Notices that pertain to the insured medical and dental benefits offered by Pima
Community College can be obtained by contacting CIGNA HealthCare (800) 244-6224, Employers
Dental Services at (520) 696-4343, and United Concordia at (800) 332-0366.
Benefits Handbook: Plan Year: 2013-2014 22 of 23
2013-14 Plan Year - Contact Information
Benefit Phone number Web site
Medical
CIGNA Healthcare (800) 244-6224 www.cigna.com
Dental
Employers Dental Services (520) 696-4343 www.mydentalplan.net
United Concordia (800) 332-0366 www.ucci.com
Prescription drug
Express Scripts (formerly Medco)
(800) 711-0917
www.express-scripts.com
Term life insurance
Minnesota Life Insurance
(866) 293-6047
www.LifeBenefits.com
Flexible Spending Accounts
ASIFlex
(800) 659-3035
www.asiflex.com
COBRA
Ceridian Benefit Services
(800) 877-7994
www.ceridian.com
AZ State Retirement System (520) 239-3100 www.azasrs.gov
Optional Retirement Plan (866) 548-3705 www.tiaa-cref.org
Public Safety Personnel Retirement System
(602) 255-5575 www.psprs.com
Tax Deferred Annuity Vendors Fidelity Investments TIAA-CREF VALIC Retirement
(866) 588-2612 (866) 548-3705 (800) 448-2542
www.fidelity.com www.tiaa-cref.org www.valic.com
PCC Employee Service Center
(520) 206-4945
www.pima.edu
e-mail: ESC@pima.edu
* Please retain this Contact Information page in your records for reference throughout the plan year.
Benefits Handbook: Plan Year: 2013-2014 23 of 23
2013-2014 BENEFITS CHECKLIST MANDATORY: MEDICAL ELECTION, BENEFIT WAIVER – MEDICAL AND FLEXIBLE SPENDING ACCOUNT (FSA)
A. MEDICAL ELECTION
1. I am electing medical coverage and have completed the 2013-14 Medical Election Form. OR
2. I am making a change to my medical coverage by adding or removing a dependent and have completed a 2013-14 Medical Election Form.
I selected dependent coverage and have included information on my dependent(s), i.e., name, social security number, date of birth, etc.
I completed sections A & B and signed my medical election form.
OR
B. BENEFIT WAIVER-MEDICAL
1. I am electing to waive medical benefits and have completed the following:
A completed 2013-14 Benefit Waiver form (medical portion, Parts A & C)
Proof of qualified group medical coverage
A completed Flexible Spending Account (FSA) Enrollment Agreement Form
Yes_____ No_____
Yes_____ No_____
Yes_____ No_____ Yes_____ No_____
Yes_____ No_____
C. FLEXIBLE SPENDING ACCOUNT (FSA) 1. I included my employee identification number and signed the Flexible Spending Account
Enrollment Agreement form.
2. I calculated my annual and per paycheck amounts based upon my position. 26 Deductions = 12 Month Administrator, Staff & Educational Support Faculty 21 Deductions = 10/11 Month Staff 20 Deductions = 9 Month Staff and Instructional Faculty
Yes_____ No_____ Yes_____ No_____
OPTIONAL: DENTAL AND/OR LIFE INSURANCE
A. Dental Election
1. I am electing dental coverage for the 2013-14 plan year (if Yes, skip to Option C- Optional Life Insurance section).
I included information on my dependent(s), i.e., name, social security number, date of birth, etc.
I completed sections A & B and signed my dental election form.
OR
B. Benefit Waiver - Dental
1. I am waiving dental coverage for the Plan Year 2013-14 and have signed my Benefit Waiver form (dental portion, Parts B & C).
Yes_____ No_____
Yes_____ No_____
Yes_____ No_____
Yes_____ No_____
C. Optional Life Insurance
1. I am electing Optional life insurance coverage. 2. I am requesting a change to my Optional Life Insurance coverage and have submitted the
proper form(s).
3. I have completed the Beneficiary Designation form to change or update my beneficiary designation for my Basic Term Life and/or Optional Term Life Insurance Coverage.
Yes_____ No_____
Yes_____ No_____
Yes_____ No_____
PLEASE RETAIN COPIES OF ALL BENEFIT FORMS FOR YOUR RECORDS PRIOR TO SUBMITTING TO THE EMPLOYEE SERVICE CENTER – DISTRICT OFFICE-ROOM C117 (DO 1235) or FAX: 206-4969 or scan and email from your college email account to
ESC@pima.edu
top related