employee benefits handbook plan year 2013-2014 - pima.edu · pdf filebenefits handbook: plan...

Employee Benefits Handbook Plan Year 2013-2014

PCC-ESC 04/11/13

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 [email protected].

mailto:[email protected]

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.


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 [email protected], 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



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.


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 [email protected].



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


No charge after office visit co-pay

Advance Radiology Testing Services, such as MRI, CAT scans



$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


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


Inpatient Hospital/Surgical Services

20% co-insurance after plan deductible


$500 co-pay per admission

Outpatient Hospital/Surgical Services



$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)


(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)


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



$500 co-pay per admission

Vision Plan Not offered Not offered 1 exam/24 months, $20 co-pay in network; $45 out of network


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.

http://www.express-scripts.com/


http://www.cigna.com/


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


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 Family 282.12 85.73 367.85 Instructional Faculty (9-month employees) will pay every paycheck: (total of 20 deductions)



Deduction


Premium Deduction


Pretax Deductions


Employee Only $0.00 $0.00 $0.00





Employee Only $17.42 $0.00 $17.42



Employee Plus Family 366.76 111.45 478.21 10-month employees will pay every paycheck: (total of 21 deductions)



Deduction


Premium Deduction


Pretax Deductions


Employee Only $0.00 $0.00 $0.00





Employee Only $16.59 $0.00 $16.59





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.


Staff, Admin and Ed

Support Faculty will

pay every paycheck:

(total of 26 deductions)

Instructional Faculty

will pay every

paycheck:


10-month employees

will pay every

paycheck:


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.


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).


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 [email protected] 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.

http://www.mydentalplan.net/


http://www.ucci.com/


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.


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.


waived.


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.



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


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.


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


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.


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.


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.


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.


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: [email protected]

* Please retain this Contact Information page in your records for reference throughout the plan year.

http://www.cigna.com/


http://www.ucci.com/


http://www.lifebenefits.com/

http://www.asiflex.com/

http://www.ceridian.com/

http://www.azasrs.gov/

http://www.tiaa-cref.org/

http://www.psprs.com/

http://www.fidelity.com/

http://www.tiaa-cref.org/

http://www.valic.com/

http://www.pima.edu/



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

[email protected]

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