benefit guide 2019 - mesa county, colorado · mesa county government is a non-federal government...
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BENEFIT GUIDE 2019
Copyright (c) 2017 (Novo Benefits) - All Rights Reserved. This employee guide is intended solely for the use of participants of theemployee benefit plan specified herein. It may contain confidential or privileged information. If you are not the intended recipient,you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited without thewritten consent of Novo Benefits.
Enrollment GuidelinesBenefit ContactsPremiumsMedical
Virtual VisitsCHP Referral & PrecertificationTriad EAPCHP Lifestyle Modification BenefitsTravel Benefit
GoodRxDental Vision VSP Discounts - Eye Care & Hearing AidsFlexible Spending Account
Sample Qualified ExpensesLife Insurance Voluntary Life InsuranceLong Term DisabilityAdditional Voluntary BenefitsOther Plan BenefitsRetirement Benefits
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TABLE OF CONTENTS
This Benefits Guide is an overview of the benefits provided by Mesa County Government. It is not a Summary Plan Description or a Certificate of Insurance. If a question arises about the nature and extent of your benefits under the plans and policies, or if there is a conflict between the informal language of this Benefits Decision Guide and the contracts, the Summary Plan Description and Certificates of Insurance will govern. Please note that the benefits in your Benefits Guide are subject to change at any time. The Benefits Guide does not represent a contractual obligation on the part of Mesa County Government. Mesa County Government is a non-federal government entity. All of the benefits presented herein are not subject to ERISA.
Qualified life events are:
When you have a qualifying event, you have 31 days to complete and return a new enrollment/change form for health, dental, and/or vision coverage. (You have 60 days to complete and return a new enrollment/ change form after coverage under Medicaid or CHIP terminates.)
ELIGIBILITYYou are eligible to enroll in the benefits program if you are a regular employee working 20 hours or more per week or a temporary, non-seasonal employee working 30 hours or more per week. Medical, Dental, Vision, FSA, Basic Life/AD&D and LTD benefits for newly hired employees will take effect the first of the month following 30 days of qualified employment. Voluntary life is effective the first of the month following 30 days of application if dated prior to that date. Otherwise, it’s first of the month following the date of signature (if signed within 30 days of eligibility). For Benefits other than medical, Actively at Work Provisions apply, including Dependent Non-Confinement. All other benefits are effective upon date of hire.
Your legal spouse and your married or unmarried dependent children are eligible for medical coverage if less than 26 years of age. Disabled children over age 26 may be eligible to continue benefits after approval of necessary applications.
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• Marriage• Divorce• Birth
• Adoption• Death• Loss of Coverage
ENROLLMENT GUIDELINESWelcome to the 2019 Benefits Guide for Mesa County Government. This Guide provides a quick overview of the benefits program and helps to remove confusion that sometimes surrounds employee benefits. The benefits program was structured to provide comprehensive coverage for you and your family. Benefit programs provide a financial safety net in the event of unexpected and potentially catastrophic events.
OPEN ENROLLMENTOpen enrollment for health, dental, vision, and flex is once a year and benefit elections will take effect January 1st. Participants may add or drop coverage or make changes to their coverage at this time. Late entrants (employees or dependents who apply for coverage more than 31 days after the date of individual eligibility) are also provided an opportunity to enroll for coverage during the plan’s open enrollment. The elections you make stay in effect the entire plan year, unless a qualifying life event occurs.
Available Benefits:• Medical/Clinic• Flexible Spending Account (FSA)• Dental• Vision• 401(a) Defined Contribution• 457(b) Deferred Compensation• Basic Life/Accidental Death & Dismemberment
(AD&D)• Supplemental Life Insurance• Basic Voluntary Dependent Life Insurance• Long-Term Disability (LTD)• Accident/ Critical Illness/Legal/Identity Theft• Sick Leave• Vacation• Employee Assistance Program (EAP)• Social Security (FICA)
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BENEFIT CONTACTSAnthem700 BroadwayDenver, CO 80273
Medical & RxPPO Network
(800) 542-9402www.anthem.com
CHP Partners Hotline
Contact CHP Partners Hotline for assistance in determining the appropriate facility or provider for Tier 1 services. Certain types of services may be paid at the Tier 1 Network benefit level when performed at another Anthem ASO Network facility.
1-877-535-2295 [email protected]
CHP Concierge Questions about CHP, CHP Medical Clinic providers, hours, and locations (970) 644-4000
University of Utah Health Care Connect Program Customer Service (801) 587-7219
https://healthcare.Utah.edu/telehealth/virtual-visits/
Virtual Visits University of Utah Virtual Visit Set up (844) 424-2172
Delta Dental DentalGroup #12141 www.deltadentalco.com
VSP Vision (800) 877-7195www.vsp.com
Wage Works Flexible Spending Account (800) 950-0105www.takecareWageWorks.info
UNUMLife / AD&D Insurance, Voluntary Supplemental Life, & Long Term Disability
(800) 275-8686www.unum.com
AlexBenefit Overview https://www.myalex.com/mesacounty/2019
Mesa County
Brenda McKaySenior Benefits Administrator
Shelley VehikHuman Resources Analyst
(970) [email protected]
(970) [email protected]
Novo Benefits Sherry ReandeauAccount Coordinator
(402) [email protected]
Employee Contributions (per month)Effective January 1, 2019
MEDICAL EMPLOYEE COUNTY % CONTRIBUTION TOTAL
Single $36.00 $532.71 94% 568.71Employee + Spouse $272.00 $865.41 76% $1137.41Employee + Child(ren) $198.00 $768.80 80% $986.14Family $310.00 $1,111.76 78% $1,421.76
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VOLUNTARY SUPPLEMENTAL TERM LIFE Premium Paid by Employee
Visit your enrollment portal at Mesa Wave to see your age banded rates.
DENTAL EMPLOYEE COUNTY % CONTRIBUTION TOTAL
Single $32.53 $8.65 21% $41.18Employee + Spouse $68.30 $14.05 17% $82.35Employee + Child(ren) $55.29 $15.29 22% 70.59Family $97.58 $7.32 7% $104.90
VISION EMPLOYEE COUNTY % CONTRIBUTION TOTAL
Single $9.57 $0.00 0% $9.57Employee + One $16.99 $0.00 0% $16.99Family $27.40 $0.00 0% $27.40
PREMIUMS
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MEDICAL BENEFITSPPO Medical Plan
Medical Benefits Tier 1 Tier 2 Tier 3
Network
Community Hospital & Community Hospital Owned Facilities;
Canyon View Surgery Center; University of Utah Health Center
Anthem BlueCross BlueShield Contracted Providers
Non-Contracted Providers
Deductible $1,250 Single / $2,500 Family $1,250 Single/ $2,500 Family $5,000 Single/ $10,000 Family
Out-of-Pocket Maximum$5,000 Single/ $10,000 Family $6,850 Single/ $13,700 Family No Maximum
Preventive Care per Schedule of Benefits
Covered 100%, DW Covered 100%, DW Not Covered
Office Visit $10 copay for office visit. All other services subject to
deductible + 20%
$40 copay for office visit. All other services subject to deductible + 20%
$60 copay for office visit. All other services 50%, deductible
waivedVirtual Visits $0 Copay
University of Utah OnlyNot Available Not Available
Specialist Office visit $45 copay for office visit.All other services subject to
deductible then 20%
$45 copay for office visit. All other services subject to deductible
then 20%
$60 copay for office visit. All other services 50%,
deductible waived
Outpatient Hospital 20% AD 50% AD 50% ADInpatient Hospital 20% AD 50% AD 50% ADEmergency Room $150 Copay per visit for facility and
physician services, then 20% after deductible for all other services.
Copay waived if admitted
Same as in-network Same as in-network
Pharmacy Deductible $150 Deductible Per Person $150 Deductible Per Person Not Applicable
Retail – 30 day supplyPreventive RX Formulary
GenericFormularyNon-Formulary
Specialty only through ESI Pharmacy Management
100% DW at Canyon View Lesser of $20 copay or 20%, ADLesser of $45 copay or 30%, ADLesser of $60 copay or 40%, AD
Lesser of 25% to a maximum of $500 per prescription, AD
Subject to copay and deductibleLesser of $20 copay or 20%, ADLesser of $45 copay or 30%, ADLesser of $60 copay or 40% AD
Lesser of 25% to a maximum of $500 per prescription, AD
Not CoveredNot coveredNot coveredNot covered
Mail Order – 90 day supplyGenericPreferredNon-Preferred
Lesser of $60 copay or 3 x 20% ADLesser of $135 copay or 3 x 30% ADLesser of $180 copay or 3 x 40% AD
Lesser of $60 copay or 3 x 20%, ADLesser of $135 copay or 3 x 30% ADLesser of $180 copay or 3 x 40% AD
Not coveredNot coveredNot covered
*The above benefits are meant for illustrative purposes only and are only a brief look at your benefits. See your Plan Document for detailson benefits, network utilization, limitations and exclusions. In the event of a discrepancy the Plan Document will prevail. The PlanDocument is available via your Mesa Wave Portal. Printed documents are available upon request.
*Includes Deductible, Copays, & Rx AD – After Deductible DW – Deductible Waived
Medical Plan
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How Can I Start a Virtual Visit?• Cold & Flu• Asthma & Allergies• Eye infections• Sinus Issues
Some of the medical health conditions treated:
• Eye Issues• UTI, Yeast
Infections• Upset Stomach• Pediatric Issues
• Sore throat (adults only)
• Rashes & Skin Issues• Minor muscle or join
pain (adults only)
Be PreparedFor the Unexpected!
• Online care from the expert providers at the University of Utah, from your phone, tablet, or computer! You don’t need an appointment, just a connection.• Available 9 a.m. - 9 p.m., 7 days a week• Virtual Visits are covered with a $0 co-pay through your employer sponsored medical clinic partnership with Community Hospital.
For more information visit https://healthcare.utah.edu/telehealth/virtual-visits/ or call (844) 424-2172
Are Virtual Visits Private?All audio and video footage recorded during Virtual Visits is private and secure. Virtual Visits meets all federal patient privacy requirements.
How Do I know if My Computer, Tablet, or Phone Will Work?You must have these basic requirements to start a Virtual Visits connection:
1. A desktop, laptop, tablet, or smart phone with audio and video capabilities2. An updated web browser such as Google Chrome or Mozilla Firefox
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PRE-CERTIFICATIONContact CHP Partners Hotline at 1-877-535-2295 for assistance in determining the appropriate facility or provider for services. Certain types of services may also be paid at the in network Tier 1 benefit level when performed at a University of Utah facility.
Before you receive certain medical services or procedures, your health plan requires a doctor to confirm that these requested services are considered medically necessary under your plan. This verification process is called "pre-certification.“ Even if some services or therapies are performed in your doctor's office, you may still need a pre-certification.
61% OF THE TIME MEMBERS SELF-REFER
TO THE WRONG SPECIALIST. CALL TODAY FOR HELP!
CHP HOTLINE
Our team will help you navigate the health care system and provide answers to your health plan questions. Call the toll free number below to speak directly with the CHP Partners Hotline team member. Calls or emails received by 5 p.m. will be returned by 5 p.m. the following business day. To best serve you, calls and emails can be made to the hotline 24 hours a day, seven days a week. If a team member is not available at the time of the call, please leave a message. All calls and emails will be returned in a timely manner.
What procedures/services does Community Hospital offer?What about labs, x-rays, mammograms, MRIs?
What services does Community Hospital not provide?
SERVICES REQUIRING PRE-CERTIFICATIONInpatient Hospitalizations Oncology Care & Services
(chemotherapy, radiation therapy, etc.)Labor & Delivery
Colonoscopies other than at Grand Junction Endoscopy and Gastroenterology Associates of Western Colorado.
Out-Patient Surgeries other than Canyon View Surgery Center & Community Hospital
Services Community Hospital does not currently provide; however, with approval through the CHP Hotline, these services, if authorized by the third party administrator (TPA) as medically necessary and covered by the employer’s health plan, would be paid at the higher level benefit/in-network/Tier 1 for facilities in the employer’s selected provider network including University of Utah.• Cardiac Catheterization• Cardiothoracic Surgery• Neonatal and Pediatric ICU• Neurosurgery
*The above benefits are meant for illustrative purposes only and are only a brief look at your benefits. See your Certificate of Coverage or SBC fordetails on benefits, network utilization, limitations and exclusions. In the event of a discrepancy the plan document will prevail. Plan Documentsare available via your Mesa Wave Portal. Printed documents are available upon request.
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TRIAD EMPLOYEE ASSISTANCE PROGRAM (EAP)Mesa County offers limited counseling sessions per issue at no cost to the employee or members of the employee’s household family. CONFIDENTIAL COUNSELING is available on problem issues relating to work, alcohol and drug abuse, marriage and family, divorce, self-esteem, stress, grief, depression, and other emotional issues. Initial services are provided at no cost to employees and to their family members.
• Available to all Mesa County employees and extends to the employee’s spouse and dependents under the age of 26.
• 5 EAP short-term, solution based counseling sessions are available at no cost to you! This benefit includes legal and financial counseling.
• Crisis counseling is available 24-hours a day, seven days a week
Call Local: 970-242-9536 or Toll Free: 877-679-1100log in to www.triadeap.com Username: mesa / Password: county
As part of your CHP Benefits the following lifestyle modification services are no cost to you!
Our Behavioral Health Specialist can help you with:• Personal relationship problems• Marriage and/or family concerns• Drug and alcohol interventionsFour behavioral health services are available at no cost to you!
To schedule an appointment, please call 242-9026.Available to participants who see a specified CHP Medical Clinic Provider.
Nutrition Education Services Nutritional education is available at no cost to you! Our nutritionists can assist you with:
• Weight loss • Celiac Disease
• Medical nutrition therapy • And more!
Diabetes Education ServicesLearn how to manage your diabetes and thrive! Our Certified Diabetes Educators provide the followingservices at no cost to you:
• Initial assessment• Diabetes medical nutritional therapy
To schedule an appointment, please call 970-263-2664. *A provider referral is required.
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Lifestyle Medicine ProgramThe goal of Lifestyle Medicine is to replace unhealthy behaviors with behaviors that promote health. These include, but are not limited to, optimum nutrition, physical activity, stress management, and improved interpersonal relationships. A team of Lifestyle Medicine trained professionals provide specific interventions designed to improve your health.
The program includes:
• Initial provider visit• Nutrition assessment and plan• Exercise evaluation and plan
* Program offered two times a year, available to participants who see a specified CHP Medical Clinic Provider.
• Cooking Demonstrations• Ongoing support and accountability
To schedule an appointment, please call 970-263-2664. *A provider referral is required.
Free Health CoachingYou can receive up to 12 free coaching visits a year! Health coach services may include:• Access to Primary Care / Appointment Scheduling• Healthcare Liaison Services
»» Referrals to community resources»» Researching medical questions and test/procedure costs»» Assistance with insurance claims/pre-approval process
• Lifestyle Modification»» Nutrition and exercise evaluation/education»» Chronic disease management»» Tobacco cessation
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TRAVEL BENEFIT
• Call Anthem for pre-authorization of services/treatment by calling 800-542-9402
• Travel Reimbursement related to travel to University of Utah for medical care.
• Annual maximum benefit is $1,000• Eligible expenses are transportation, parking fees and tolls,
payable to the standard mileage rate per the IRS; • Lodging up to $150 per night• Inform Human Resources you are using this benefit when your
claim form is completed
Retain travel receipts along with your Anthem Claim Form to HR: Attn: Brenda McKay or Shelley [email protected]@mesacounty.us
The above benefits are meant for illustrative purposes only and are only a brief look at your benefits. See your Certificate of Coverage fordetails on benefits, network utilization, limitations and exclusions. In the event of a discrepancy the plan document will prevail.Plan Documents are available via your Mesa Wave Portal. Printed documents are available upon request.
*This is a separate benefit from the Transplant Travel benefits provide under the Anthem benefits explained in your Certificate of Insurance.
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Mesa County Government offers voluntary dental benefits through Delta Dental. This dental plan balancesaffordability with the freedom to go outside the network. You may choose a participating or a non-participating provider. Participating providers have agreed to provide services at a discounted fee. For out-of-network care, you are responsible for charges above the in-network allowance for the same services, inaddition to the deductible and coinsurance. To find a participating provider, visit www.deltadental.com.
DENTAL BENEFITS
Dental Plan In-Network PPO In-Network Premier Out-of-Network
Calendar Year Deductible $50/single$100/family
Calendar Year Maximum Benefit
$2,000/person
Preventive Services• Oral exams – 2 x year• Bitewing X-rays – once
per year• Cleanings – 2 x year• Fluoride (through age
15) – 2 x year
Covered 100%,deductible waived
Covered 100%,deductible waived
Covered 100%, deductible waived
Basic Services• Composite Fillings• Oral Surgery• Endodontics
Covered 80%, afterdeductible
Covered 80%, afterdeductible
Covered 80%, afterdeductible
Major Services• Implants, Crowns• Bridgework & Dentures• Periodontics
Covered 50%, after deductible
Covered 50%, after deductible
Covered 50%, after deductible
Orthodontia(children to age 19 only)
Lifetime Maximum
Covered 50%, deductible waived
$2,000
Covered 50%, deductible waived
$2,000
Covered 50%, deductiblewaived
$2,000
*The above benefits are meant for illustrative purposes only and are only a brief look at your benefits. See your plan document for detailson benefits, network utilization, limitations and exclusions. In the event of a discrepancy the plan document will prevail.Plan Documents are available via your Mesa Wave Portal. Printed documents are available upon request.
DENTAL PLAN
Mesa County Government offers voluntary vision benefits through VSP. The vision plan through VSP providesaccess through a national network including both private practice and retail chain providers. To find aparticipating provider, visit www.vsp.com. The VSP Provider Network is VSP Signature.
VISION BENEFITS
Benefit Description Copay Frequency
Your Coverage with a VSP Provider
WellVision Exam Focuses on your eyes and overall wellness $10 Every 12 months
Prescription Glasses $10 See frame and lenses
Frame• $130 allowance for a wide selection of frames• $150 allowance for featured frame brands• 20% savings on the amount over your allowance
Included in Prescription
GlassesEvery 24 months
Lenses• Single vision, lined bifocal, and lined trifocal
lenses
• Polycarbonate lenses for dependentchildren
Included in Prescription
GlassesEvery 12 months
Lens Enhancements• Standard progressive• Premium Progressive• Custom progressive• Average savings of 35-40% on other lens enhancements
Included$80 - $90
$120 - $160Every 12 months
Contacts (instead of glasses)
• $130 allowance for contacts; copay does not apply
• Contact lens exam (fitting and evaluation)
Up to $60 Every 12 months
Diabetic Eyecare Plus Program
Services related to diabetic eye disease, glaucoma and age-related macular degeneration (AMD). Retinal screening for eligible members with diabetes. Limitations and coordination with medical coverage may apply. Ask your VSP doctor for details.
$20 As needed
Extra Savings
Glasses and SunglassesExtra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details.30% savings on additional g lasses and sunglasses, including lens enhancements, from the same VSP provider onthe same day as your WellVision Exam. Or get 20% from any VSP provider within 12 months of your last WellVision Exam.
Retinal ScreeningNo more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam
Laser Vision CorrectionAverage 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities After surgery, use your frame allowance (if eligible) for sunglasses from any VSP doctor
Your Coverage with Out-of-Network Providers
Visit vsp.com for details, if you plan to see a provider other than a VSP network provider.
Exam ....................................up to $50 Lined Bifocal Lenses ............ up to $75 Progressive Lenses ................... up to $75Frame ................................. up to $70 Lined Trifocal Lenses ........... up to $100 Contacts......................................... up to $105 Single Vision Lenses ....up to $50
VSP guarantees coverage from VSP network providers only. Coverage information is subject to change. In the event of a conflict between this information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location
VISION BENEFITS
VSP Diabetic Eyecare Plus ® Available to Covered Persons who have been diagnosed with type 1 or type 2 diabetes and specific ophthalmological conditions .The Program is intended to be a supplement to Covered Persons group medical plan. Providers will first submit a claim to Covered Persons group medical insurance plan, and then to VSP. Any amounts not paid by the medical plan will be considered for payment by VSP. Examples of symptoms which may result in a Covered Person seeking services under DEP Plus may include, but are not limited to: blurry vision, trouble focusing, transient loss of vision, “floating” spots. Examples of conditions which may require management under DEP Plus may include, but are not limited to: diabetic retinopathy, rubeosis, and diabetic macular edema.
VSP DISCOUNTS: EYE CARE & HEARING AIDS
TruHearing® is making hearing aids affordable by providing exclusive savings to all VSP® Vision Care members. You can save up to $2,400 on a pair of hearing aids with TruHearing pricing. What’s more, your dependents and even extended family members are eligible, too.
Best of all, if you already have a hearing aid benefit from your health plan or employer, you can combine it with this program to maximize the benefit and reduce your out-of-pocket expense.
How it worksCall TruHearing. Call 877.396.7194. You and your family members must mention VSP. Schedule exam. TruHearing will answer your questions and schedule a hearing exam with a local provider. Attend appointment. The provider will make a recommendation, order the hearing aids through TruHearing and fit them for you.
Learn more about this VSP Exclusive Member Extra at vsp.truhearing.com or, call 877.396.7194 with questions.
In addition to great pricing, TruHearing provides :• Three provider visits for fitting, adjustments, and
cleanings• 45-day money back guarantee• Three-year manufacturer’s warranty for repairs and
one-time loss and damage• 48 free batteries per hearing aid
Plus, with TruHearing you’ll get:• Access to a national network of more than 4,500
licensed hearing aid professionals• Straightforward, nationally fixed pricing on a
selection of more than 90 digital hearing aids in 400 styles
• Deep discounts on replacement batteries shipped directly to your door
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FLEXIBLE SPENDING ACCOUNTSHealth CareThe Health Care account allows you to set aside up to $2,650 in pre-tax dollars to pay most out-of-pocket medical,dental or vision expenses, including deductibles and copayments, eye glasses, dental and orthodontic work notcovered by insurance.
You decide how much to deposit into your Health Care account. Your election amount is evenly deducted pre-taxfrom your paycheck throughout the plan year. When you have an expense that qualifies, you pay the bill, submit aclaim, and you are reimbursed with tax-free dollars from your account.
If you don’t use all the money you deposited in your account, you will forfeit any balance in the account at the end ofthe plan year. However, if you have unused contributions in your Health Care account from the immediatelypreceding plan year, you can carry over up to $500 at the end of the plan year to the following year. Anything abovethe $500 amount is lost. You have 90 days after the plan year ends to submit claims for expenses incurred during thatplan year.
Dependent CareThe Dependent Care account allows you to set aside tax-free income to pay for qualified dependent care expenses,such as day care, that you would normally pay with after-tax dollars. Qualified dependents include children under age13 and/or dependents who are physically or mentally unable to care for themselves. If your spouse is unemployed ordoing volunteer work, you cannot set up a dependent care account. You must meet the following criteria in order toset up this account:• You and your spouse both work;• You are the single head of household;• Your spouse is disabled or a full-time student.
Each calendar year the IRS allows you to contribute the following amounts, depending on your family status:• If you are single, the lesser of your earned income or $5,000• If you are married, you can contribute the lowest of
o Your (or your spouse’s) earned incomeo $5,000 if filing jointly or $2,500 if filing separately
Once Enrolled, You May Not Change Your ElectionYou cannot change your annual election after the beginning of the plan year. However, there are certain limited situations when you can change your elections if you have qualified change in status.
Flexible Spending Account – Eligible ExpensesYour Health Care Reimbursement Flexible Spending Account lets you pay for medical care expenses not covered byyour insurance plan with pre-tax dollars. The expenses must be primarily to alleviate a physical or mental defect orillness, and be adequately substantiated by a medical practitioner. The products and services listed on the next pageare examples of medical expenses eligible for payment under your FSA, to the extent that such services are notcovered by your medical and/or dental insurance plan.
Unfortunately, we cannot provide a definitive list of “qualified medical expenses”. A determination of whether anexpense is for “medical care” is based on all the relevant facts and circumstances. To be an expense for medical care,the expense has to be primarily for the prevention or alleviation of a physical or mental defect or illness.
Flex Spending Account – Eligible Expenses
• Acupuncture• Adoption (medical expenses)• Alcoholism treatment• Ambulance• Artificial limbs & teeth• Asthma treatments• Bandages/Gauze• Birth control pills• Blood pressure monitoring devices• Blood sugar test kit and test strips• Breast reconstruction surgery
following mastectomy• Chiropractor• coinsurance & deductibles• Contact lenses• Copayments• Counseling (except marriage)• Crutches• Deductibles• Dental treatment (except cosmetic)• Dentures and denture adhesives• Diabetic supplies• Drug addiction treatment
• Oxygen• Personal trainer fees
(if for medical condition)• Physical exams• Physical therapy• Prescription drugs• Preventive care screenings• Prostheses• Psychiatric care• Psychologist• Reading glasses, prescription• Smoking cessation programs
& medications • Speech therapy• Sterilization procedures• Surgery/Operations• Therapy• Thermometers• Ultrasound (prenatal)• Vaccines/Immunizations• Vasectomy and reversals• Wheelchair• X-ray fees
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Flexible Spending Plan Worksheet
This form is designed to help you estimate what you will spend on eligible insurance, dependent care and unreimbursed medicalexpenses during the period of coverage. It is important to estimate your expenses during the last two years. Review yourcheckbook register, tax records and expense vouchers. Use this information to complete the form, but remember to beconservative in your estimates. If you overestimate your expenses and do not use them during the Plan Year, you will lose them.
Unreimbursed Medical Expenses
MedicalDeductible $ Medical copayments $ Office Visits $ Physical Exams $ Prescription Drugs $ Non-Prescription Drugs $ Hospital Services $ Psychologist Services $ Chiropractic Services $ Medical Aids (crutches, etc.) $
DentalExams $ Fillings $ Braces $ Dentures $
VisionExams $ Eyeglasses $ Contacts $
HearingExams $ Hearing Aids $
Total Unreimbursed $
Medical Expenses
Dependent Care (maximums for dependent care are based on calendar year, per IRS guidelines)Use the total expenses estimated on your Dependent
Care Work Sheet
Total Dependent Care $
• Eyeglasses, prescription• Fertility/Infertility treatments• First aid kits• Flu shots• Genetic testing (only to diagnose med. condition)• Glucose monitoring equipment• Guide dog/other animal aid• Hearing aids• Hospital services• Incontinence supplies• Insulin• IVF (in vitro fertilization)• Laboratory fees• Laser eye surgery/Lasik• Massage therapy (only if recommended by a
physician to treat a specific trauma or injury)• Nutritionist’s professional expenses (if treatment
relates to specifically diagnosed medical condition)• Obstetrical expenses• Optometrist• Organ donors/transplants• Orthodontia• OTC drugs (only with a prescription)
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LIFE INSURANCE
Mesa County provides eligible employees (at no cost to the employee) Basic Life/AD&D coverage. All regular full-time employees scheduled to work at least 20 hours each week and all temporary non-seasonal employees working at least 30 hours per week in active employment in the U.S. will be enrolled in the group life/AD&D plan.
Life Insurance Amount$20,000
Reduction Schedule Benefits are reduced to 65% at age 65; to 40% of the original amount at age 70, and to 25% of the original amount at age 75.
Accidental Death & Dismemberment (AD&D)
Loss must occur while insured and within 365 days after the accident is sustained
The total benefit paid for all losses due to the same accident will not be more than 100%
Loss:LifeOne LimbSpeech & HearingSpeech or HearingThumb & Index Finger of Same HandQuadriplegiaParaplegiaHemiplegiaSight of One Eye
Amount of Additional Benefit Paid:100%50%100%50%25%100%75%50%50%
Accelerated BenefitIf you are certified as terminally ill with a life expectancy of 12 months or less, you may elect to receive a portion of your life insurance benefit up to 75% in advance. Upon death, your beneficiary will receive the balance of your benefit.
Additional Benefits
Safe Driver Benefit (seatbelt & airbag)Dependent Education BenefitChild Care BenefitDisappearance & ExposureChild EducationRepatriationPortability
Basic Employee-Paid Voluntary Dependent Life:
$5,000 Spouse (no age reduction)Child(ren) 14 days to 6 months - $1,000 / Age 19 or 26 if a full-time student -$2,500
*The above benefits are meant for illustrative purposes only and are only a brief look at your benefits. See your plan document for detailson benefits, limitations and exclusions. In the event of a discrepancy the plan document will prevail.Certificate of Insurance is available via your Mesa Wave Portal. Printed documents are available upon request.
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Employer Paid Life/AD&D Insurance Continued…Insured by Unum
This is just a summary of your benefits. Please refer to your certificate booklet for a complete plan description. If the terms of this summary differ from the Certificate, the Certificate will govern.
Life Planning Financial & Legal Resources
Personalized financial counseling provides expert, objective financial counseling to survivors and terminally ill employees at no cost. The financial consultants are master level consultants that will not offer to sell any product or service. They will help develop strategies needed to protect resources, preserve current lifestyles, and build future security.
Waiver of PremiumIf you become totally disabled for 6 months while insured, your life insurance will continue without payment to age 70 if the disability began prior to age 65. If total disability ends, you may exercise the conversion privilege.
Conversion
If your insurance terminates because you are no longer employed full-time, your insurance may be converted to an individual life insurance policy if you apply and include payment of the first premium within 31 days of termination.Conversion does not require proof of medical insurability.
Travel Assistance Benefits
To complement your Group Life Insurance coverage, you and your immediate family have access to Emergency Travel Assistance administered by Assist America. Emergency Travel Assistance offers you and your dependents worldwide medical, travel, concierge and legal and financial assistance services, 24 hours a day, 365 days a year.
If you have a medical emergency while you are more than 100 miles away from home, you don’t have to face it alone. With one phone call you can be connected to Assist America’s staff of medically trained, multilingual professionals who can advise you in a medical emergency, 24x7. No matter where you are in the world, they will help you access or receive:
Pre-qualified, English-speaking professionals working in hospitals, pharmacies, and dental offices; Medical consultation, evaluation and referral; Hospital admission, critical care monitoring, emergency medical evacuation, transportation to return home or to a rehabilitation facility, lost prescription assistance, legal and interpreter services, and more.
Assist America pays for 100% of the services it arranges for and provides.
Your spouse and dependent children up to age 19 are also covered.
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VOLUNTARY LIFE & AD&D INSURANCE
Coverage Amounts(Term Life and AD&D)
Employee: Up to 5 times earnings in increments of $10,000. Not to exceed $400,000.
Spouse: Up to 100% of employee amount or $200,000, in increments of $5,000.
Children: Up to 100% of employee amount in increments of $2,000 not to exceed $10,000. Maximum death benefit for a child between the ages of live birth and 6 months is $1,000.
Reduction ScheduleBenefits are reduced to 65% at age 70, and to 50% of the original amount at age 75
Guarantee Issue$200,000 for yourself and any amount of coverage up to $30,000 for your spouse. Any Life insurance coverage over the Guarantee Issue amount(s) will be subject to evidence of insurability.
Accidental Death & Dismemberment (AD&D)
The total benefit paid for all losses due to the same accident will not be more than 100%
Loss:LifeBoth HandsBoth FeetSight of Both EyesOne Hand & Sight of One EyeOne Foot & Sight of One EyeSpeech & Hearing
Other losses may be covered.
Amount of Benefit Paid:100%100%100%100%100%100%100%
Additional AD&D Benefits
Education Benefit: If you or your insured spouse die within 365 days of an accident, an additional benefit is paid to your dependent child(ren). Your child(ren) must be a full-time student beyond grade 12.
Seat Belt/Air Bag Benefit: If you or your insured dependent(s) die in a car accident and are wearing a properly fastened seat belt and/or are in a seat with an air bag, an amount will be paid in addition to the AD&D benefit.
*The above benefits are meant for illustrative purposes only and are only a brief look at your benefits. See your plan document for detailson benefits, limitations and exclusions. In the event of a discrepancy the plan document will prevail.Certificate of Insurance is available via your Mesa Wave Portal. Printed documents are available upon request.
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Each year you will be given the opportunity to change your Life and AD&D coverage, and may purchase additional life insurance up to the guarantee issue amounts without evidence of insurability as long as you are already enrolled in the plan (even at a minimum of $10,000).
If you waived coverage when you were first eligible and want to apply at a later date, all amounts are subject to evidence of insurability – there is no guarantee issue available.
Accelerated Benefit
If you become terminally ill and are not expected to live beyond a certain time period as stated in your certificate booklet, you may request up to 75% of your life insurance amount up to $250,000, without fees or present value adjustments. A doctor must certify your condition in order to qualify for this benefit. Upon your death, the remaining benefit will be paid to your designated beneficiary(ies).
Life Planning Financial & Legal Resources
Personalized financial counseling provides expert, objective financial counseling to survivors and terminally ill employees at no cost. The financial consultants are master level consultants that will not offer to sell any product or service. They will help develop strategies needed to protect resources, preserve current lifestyles, and build future security.
Waiver of Premium
If you become disabled (as defined by your plan) and are no longer able to work, your premium payments may be waived during the period of disability.
Portability/Conversion
If you retire, reduce your hours or leave your employer, you can take this coverage with you according to the terms outlined in the contract. However, if you have a medical condition which has a material effect on life expectancy, you will be ineligible to port your coverage. You may also have the option to convert your Term life coverage to an individual life insurance policy.
Suicide Exclusion
Life benefits will not be paid for deaths caused by suicide in the first twenty-four months after your effective date of coverage.
Voluntary Life/AD&D Insurance Continued…Insured by Unum
This is just a summary of your benefits. Please refer to your certificate booklet for your complete plan description. If the terms of this summary differ from the Certificate, the Certificate will govern.
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Long-Term Disability Insurance (UNUM)
This is just a summary of your benefit. Please refer to your certificate booklet for your complete plan description. If the terms of this summary differ from your Certificate, the Certificate will govern.
Monthly Benefit 60% of monthly earnings to a maximum benefit of $6,000, reduced by other income
Elimination Period Benefits will begin after 180 days of disabilityBenefit Duration Your duration of benefits is based on your age when the disability occurs. Your LTD benefits are
payable for the period during which you continue to meet the definition of disability up to the Social Security Normal Retirement Age. If your disability occurs on or after age 62, benefits would be paid for a reduced period of time.
Disability Definition You are disabled when Unum determines that: • you are limited from performing the material and substantial duties of your regular occupation
due to your sickness or injury; and• you have a 20% or more loss in weekly earnings due to the same sickness or injury.• After benefits have been paid for 24 months, you are disabled when Unum determines that due to
the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience.
You must be under the regular care of a physician in order to be considered disabled.
Gainful Occupation Gainful occupation means an occupation that is or can be expected to provide you with an income within 12 months of your return to work that exceeds:• 80% of your indexed monthly earnings, if you are working• 60% of your indexed monthly earnings, if you are not working
Pre-Existing Conditions If you received treatment 3 months prior to your effective date under this plan and are disabled from that condition within the first 12 months, that disability will be excluded.
Rehabilitation and Return to Work Assistance
Unum has a vocational Rehabilitation and Return to Work Assistance program available to assist you in returning to work. We will make the final determination of your eligibility for participation in the program, and will provide you with a written Rehabilitation and Return to Work Assistance plan developed specifically for you. This program may include, but is not limited to the following benefits:• coordination with your Employer to assist your return to work;• adaptive equipment or job accommodations to allow you to work;• vocational evaluation to determine how your disability may impact your employment options;• job placement services;• resume preparation;• job seeking skills training; or• education and retraining expenses for a new occupation.
If you are participating in a Rehabilitation and Return to Work Assistance program, we will also pay an additional disability benefit of 10% of your gross disability payment to a maximum of $1,000 per month. In addition, we will make monthly payments to you for 3 months following the date your disability ends, if we determine you are no longer disabled while:• you are participating in a Rehabilitation and Return to Work Assistance program; and• you are not able to find employment.
Survivor Benefit If you die after receiving benefits for 180 or more consecutive days, your eligible survivors will receive a lump sum benefit equal to three months of your gross disability payment.
Aflac Group Accident Insurance Introducing added protection for life’s unexpected moments.If you’re like most people, you don’t budget for life’s unexpected moments. But at some point, you may make an unexpected trip to your local emergency room. Andthat could add a set of unexpected bills into the mix.That’s the benefit of the Aflac group Accident Advantage Plus plan.
In the event of a covered accident, the plan pays cash benefits fast to help with the costs associated with out-of-pocket expenses and bills—expenses major medical maynot take care of, including:• Ambulance rides.• Wheelchairs, crutches, and other medical appliances.• Emergency room visits.• Surgery and anesthesia.• Bandages, stitches, and casts.
Aflac Group Critical Illness Insurance You can win the battle against a critical illness, but can you handle the added costs? A group critical illness plan helps prepare you for the added costs of battling a specific critical illness. The good news is that many people with a critical illness survive these life-threatening battles. Unfortunately, as the recovery process begins, people become aware of the medical bills that have piled up. Your recovery doesn’t have to be spoiled by medical bills. With this plan, our goal is to help you and your family cope with and recover from the financial stress of surviving a critical illness.
Legal Shield Legal Plan Imagine having access to top-rated legal professionals, without worrying about high hourly costs. • Protect your family• Save money and time• Enjoy peace of mind… for pennies a day!Preventive Law – Unlimited phone calls, letters and phone calls on your behalf, legal contract and document review, will preparation and annual updates, access to legal forms.Trial Defense – Defense of civil actions, pre-trial and trial assistance, coverage increases each year for the first 5 years.Family services, motor vehicle, IRS audit services, 25% member discount for services not covered on this plan.
LifeLock Identity Theft Protection Plan
Secure your privacy with complete detective and restorative identity protection around the clock. We watchover your personal and financial information on public and private databases, social media and the Internet.We also share proactive measures and educational tools so you can take steps to protect yourself. Our fraudspecialists are a phone call away—24 hours a day, seven days a week—to help you every step of the way.
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ADDITIONAL VOLUNTARY BENEFITS
This benefit summary was provided by Mesa County and Novo Benefits is not responsible for any discrepancies.
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OTHER PLAN BENEFITSBanking Services
Grand Junction Federal Credit Union and Wells Fargo offer Mesa County employees special banking services. Please visit http://mesawave/Employee%20Discounts.htm for information.
Fitness Facilities
Mesa County has discounted memberships with Crossroads Fitness, Gold’s Gym and Anytime Fitness. Please visit http://mesawave/Employee%20Discounts.htm for information.
Grand Valley Transit
Obtain a sticker to place on your Mesa County ID and ride for free! Please visit http://mesawave/Employee%20Discounts.htm for information.
Movie Tickets
Employees can buy discounted Regal Cinema movie tickets for $8.50 at the Human Resources office. Please visit http://mesawave/Employee%20Discounts.htm for information.
Microsoft Employee Purchase & Home Use Program
Employees can purchase Microsoft applications that are used at Mesa County. Please visit http://mesawave/Employee%20Discounts.htm for information.
Pearl Vision
Mesa County employees who are not currently enrolled in the VSP vision plan now have a visions savings option through Pearleviews. Please visit http://mesawave/Employee%20Discounts.htm for information.
Verizon Wireless
Employees can enjoy 18% off their monthly bill and up to 25% off of accessories through Verizon Wireless. Please visit http://mesawave/Employee%20Discounts.htm for information.
This benefit summary was provided by Mesa County and Novo Benefits is not responsible for any discrepancies.
*Additional discounts and services can be found on MesaWave.
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RETIREMENT BENEFITS
Retirement Plan (Defined Contribution)• Mesa County has a 401(a) retirement plan through Colorado County Officials and Employees Retirement
Association (CCOERA). As a condition of employment at initial hire, an employee is required to contribute 3% of their gross base monthly salary which Mesa County matches at 100%.
• The employee becomes 100% vested after completion of the third year of service. Should an employee leave employment prior to completion of the third year of service, the match made by Mesa County is forfeited.
Retirement Plan (Deferred Compensation)• The 457 plan is available at any time to employees as an additional option for retirement savings. Pre-tax
contributions and after tax contributions (Roth IRA) are available as investment options.
This benefit summary is provided by Mesa County. Novo Benefits is not responsible for any discrepancies between this documentand the contracts that govern each of your benefits .
