2017 BENEFITS GUIDE New logo options with ame: Staff Perm
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New logo options with flame: 2017 BENEFITS GUIDE
TABLE OF CONTENTS
3 From the Chief HR Officer 20 Income Protection
4 What’s new 22 Retirement Planning
5 Enrollment 24 Other Benefits
6 Eligibility and Qualifying 27 Legal Notices
Life Events 31 Who to Contact
7 Medical Plan Overview
11 HSA Overview
15 Prescription Benefits
16 Flexible Spending Accounts
20
18 Dental Plan Income Protection
19 Vision Plan
At Santander Consumer USA, your benefits
are a key part of your total work-life
experience. This guide will provide you an
overview of your 2017 benefit options.
We encourage you to review this
information thoroughly with your spouse
or other covered dependents in order
7
to understand all of the benefit options
Medical Plan Overview
available to you as an SC Associate.
You must actively enroll by
November 11, 2016, if you want
medical coverage for 2017.
If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, a federal law gives you
more choices about your prescription drug coverage. Please contact SC Benefits for more details.
2
FROM THE CHIEF HR OFFICER
It’s open enrollment time! The 2017 Annual Open Enrollment period
is October 31 – November 11, 2016. During this time, we recommend
that you review the plans offered to select the best benefits plan for
you and your family. Changes have been made to our plans, requiring
all Associates to re-enroll.
Our goal is to use innovative solutions to provide you with flexible options that allow you
to select the program that’s best for you. The changes we made give you choices, while
supporting a healthier workforce and managing healthcare costs.
We have a strong program this year, with many choices for you to consider as you make
your elections. Researching and understanding your benefits enables you to make the best
decisions for you and your family. Please review all the plans closely as there will be changes
to your out-of-pocket expenses in 2017.
Each year we work to create a comprehensive, flexible and attractive benefit program
designed to give you the care you need at competitive costs, while helping you live a
healthier life.
If you have any questions, please reach out to our benefits team at: SCBenefits@
santanderconsumerusa.com. And don’t forget to actively enroll and make your selections
by November 11!
Lisa VanRoekel
Chief Human Resources Officer
3
WHAT’S NEW FOR 2017
Our program for 2017 gives you more opportunity than ever before The new SC HSA Plan gives you
to use your benefits the way you want to use them:
the ability to control your health
BENEFITS ENROLLMENT IS ACTIVE: care dollars. As part of the plan,
Which means you must enroll if you want medical, dental
and vision coverage for 2017. SC will fund your personal health
If you do not make your benefits elections during open
savings account (HSA) with $500
enrollment, you may not be covered under an for single coverage and $1,000
SC medical plan for 2017.
for family coverage annually. The
NEW PAID TIME OFF PROGRAM (PTO): SC HSA gives you flexibility in the
We heard you in your desire for more support and time to
do the things you love, so we’re expanding our paid time way you manage health costs.
off (PTO) program for 2017.
A NEW SC HSA MEDICAL PLAN: SC is offering a new voluntary
Lower out-of- paycheck costs and the opportunity to save, critical illness plan through
tax-free, in a health savings account (HSA). This plan gives
you freedom and flexibility. MetLife to help protect your
family’s budget in an event of
CRITICAL CARE ILLNESS PLAN:
In the event of a critical illness, your expenses may go critical illness.
beyond those covered by traditional medical plans, but
we want you to have the protection you need.
Making the most out of the benefits and programs we
offer is up to you!
Questions?
Please contact SC Benefits:
SCBenefits@SantanderConsumerUSA.com
4
ENROLLMENT - YOU MUST OPT IN
ACTIVE OPEN ENROLLMENT IS OCTOBER 31 THROUGH NOVEMBER 11
If you do not elect or change your coverage for 2017, you may not have medical or flexible spending account coverage
in 2017. Your current life, disability and 401(k) elections will roll over.
Make sure your mailing address is current in Workday, as this is where your tax forms will be mailed.
ENROLL ONLINE:
» Log onto Workday Employee Self Service through Citrix or enroll online from your home using the following
link in your browser: https://wd5.myworkday.com/scusa.
» Y our user name will be your Associate ID number. Your password will be the personal one you created when
you first logged on. If you need to reset your password select forgot password?
» O
nce in your Workday account, you will see a task in your Workday inbox. Click the inbox icon in the upper right
hand corner. Next, click your benefit enrollment event.
– B
e sure to add or update your dependents’ Social Security numbers. These are needed for
government-mandated reporting.
» Select the Elect or Waive button next to each benefit election row.
» In the Enroll Dependents column, you can add or remove dependents as necessary. To add a new dependent
click the Create link. You only need to create dependents one time for all plans.
» Continue through each page until complete. Review your elections for accuracy and, if correct, you must
review and select the Agreement check box and then select the SUBMIT button to finalize your elections.
» T he confirmation will let you know you have successfully submitted your benefits enrollment. Select Print to
generate a printable version of this summary for your records.
If you enroll new dependents into SC Benefits, you will be contacted by the company Hodges Mace to verify your
new dependent(s).
5
ELIGIBILITY
ELIGIBLE ASSOCIATES QUALIFYING LIFE EVENT
Regular, full-time Associates scheduled to work at least The only times you can make a change to your benefit
30 hours per week are eligible for benefits. Part-time elections are during open enrollment or if you have a
Associates are only eligible for PTO. qualifying life event. Election changes must be made within
31 days of the life event date.
WHEN DO MY BENEFITS BEGIN?
Medical, prescription A qualifying life event is:
drug, dental, vision, HSAs, Date of hire
flexible spending accounts » Birth or adoption of a child by the Associate
First of the month following » Marriage or divorce of the Associate
Life and AD&D Insurance 90 days of full-time
employment » Death of the Associate’s spouse and/or dependents
First of the month following » Dependent’s loss of eligibility
Disability 12 months of full-time
employment » G
ain/loss healthcare coverage for Associate’s
To contribute: Date of hire spouse due to employment changes
To receive SC match: » S uch other events permitted under I.R.S. Section
First paycheck following
six months of full-time 125 or any other applicable guidelines by the I.R.S.
401(k) Retirement Plan
employment (six-month » G
ain/loss of eligibility for Medicaid/CHIP (60 days to
waiting period applies to new
hires between June 1, 2016, enroll or cancel coverage; rather than the 31 days for
and December 31, 2016) all other qualifying life events)
The change to your benefits election must be consistent
ELIGIBLE DEPENDENTS with the change in family status (e.g. birth of child
» Legal spouses, same or opposite sex allows the plan to add a newborn, not drop your current
coverage). In addition, you must provide supporting
» Any legal dependent up to age 26
documentation before a benefit change will be processed.
» A
ny child under legal guardianship of Associate
up to age 26, except where otherwise noted If you experience a qualifying life event, please report it via
» Stepchildren of Associate up to age 26 email to SC Benefits or through the Benefits Link in the
» Dependent child(ren) ordered to be covered Workday system.
through a Qualified Medical Support Order
» A
ny child meeting the criteria above who is over
the age of 26 and legally incapacitated
6
MEDICAL PLAN OVERVIEW
This year, we are offering two plan options through Aetna for you to consider: the SC PPO and the SC HSA.
» The SC PPO plan features traditional copays and coinsurance costs.
» T he SC HSA Plan offers you the option to contribute to a health savings account (HSA) and receive a pre-tax
benefit for any funds deposited into the account.
THE BASICS: HOW DO THE PLANS COMPARE?
SC PPO SC HSA
Bi-weekly rates Higher Lower
Health savings account for medical,
dental and vision expenses to use
Pre-tax account option Option to elect health care spending now or in the future.
Making pre-tax contributions saves you account for medical, dental and
money on expenses you would already have. vision expenses this year only. Option to elect limited health care
spending account for dental and
vision expenses this year only.
Up to $500 annually for Associate-only
coverage and up to $1,000 annually for
Savings account contribution from SC None Family coverage, deposited quarterly ($125
per quarter for Associate only coverage and
$250 per quarter for Family coverage)
Deductible
Lower, and any one individual, even Higher, and any one individual or
On both plans, you’ll pay the full cost of
on family coverage, is only responsible combination of individuals can
the deductible before the plan begins
for meeting the single deductible. satisfy the entire family deductible.
paying a percentage of the costs.
Yes: Continue paying copays even
Medical Expense Copays No copays
after deductible has been met
Out-of-pocket maximum
On both plans:
– Once you hit the maximum, the plan
covers 100 percent of your costs. Higher Lower
– Any one individual, even on family
coverage, is only responsible for the
single out-of-pocket maximum.
Still not sure which medical plan is right for you? Meet ALEX, your benefits resource.
Visit the SC Source Benefits page to see how he can help you better understand your
benefit options!
7
MEDICAL PLAN OVERVIEW
MEDICAL PLAN DESIGN
2017 SC PPO 2017 SC HSA
FINANCIAL DETAILS: IN-NETWORK OUT-OF-NETWORK IN-NETWORK 0UT-0F-NETWORK
$500
Annual SC HSA Contribution
$1,000
- Associate-only None
($125 deposited quarterly for Associate only
- Family
coverage and $250 per quarter for Family coverage)
Deductible
- Single $1,500 $6,000 $2,500 $10,000
- Family $3,000 $12,000 $5,000 $20,000
Out-of-Pocket Max
- Single $7,000 $28,000 $5,000 $20,000
- Family $14,000 $56,000 $10,000 $40,000
Preventive Care 0% 50% after deductible 0% 50% after deductible
Primary Care Physician $25 copay 50% after deductible 30% after deductible 50% after deductible
Specialist Physician $40 copay 50% after deductible 30% after deductible 50% after deductible
$250 copay then 30% $250 then 50%
Inpatient Hospital 30% after deductible 50% after deductible
after deductible after deductible
Outpatient Surgery 30% after deductible 50% after deductible 30% after deductible 50% after deductible
Chiropractic $25 copay 50% after deductible 30% after deductible 50% after deductible
Emergency Room $350 copay 30% after deductible
Urgent Care $50 copay 30% after deductible
Teladoc through Aetna $25 copay Not Applicable 30% after deductible Not Applicable
ACCESSING AETNA
» Register at www.aetnanavigator.com for access to Explanation of Benefits (EOBs), provider directories
and view plan details, etc.
» To locate a provider in the Aetna Choice POS II network, visit the Aetna Provider Network Directory.
» To print a replacement ID card, log in to www.aetnanavigator.com and click “ID Card” under “Related
Shortcuts.”
The benefits noted here and on other pages are only a summary. For full plan details, request a copy of plan documents from
SC Benefits.
8
MEDICAL PLAN OVERVIEW
MEDICAL RATES: BI-WEEKLY
Rates are changing for 2017. Please be sure to review all plan options available to you in order to determine the best
option for you and your family. Please note, the contributions below are before any credits you receive for reaching
Vitality status.
COVERAGE LEVEL SC PPO SC HSA
Associate Only $29.38 $23.60
Associate + Spouse $171.90 $138.06
Associate + Child(ren) $116.36 $84.96
Associate + Family $255.05 $182.90
Consider enrolling in the
SC HSA. You can save
pre-tax dollars to use on
health expenses now or in
the future.
9
MEDICAL PLAN OVERVIEW
YOUR AETNA HEALTHCARE PLAN PROVIDES CARE OPTIONS 24/7
THROUGH WELLNESS TOOLS AND RESOURCES
Through Aetna, our medical partner, we offer a wide range of tools and programs to help enhance your coverage and
improve the health of you and your family.
TELADOC THROUGH AETNA
Skip unnecessary and time-consuming emergency room and urgent care visits. Use Teladoc, through
Aetna, to speak with a licensed doctor 24/7/365 via phone or video. Teladoc doctors can diagnose and
treat medical conditions. Unlike the WhiteGlove Service, Teladoc expenses apply to your deductible
and out-of-pocket maximum.
Talk to a doctor in minutes (not hours) at (800) Teladoc (835-2362). You can download the Teladoc app
through both iPhone and Android app stores.
AETNA iTRIAGE
Navigate and take charge of your health from the palm of your hand with iTriage, a free mobile app
from Aetna that you can download from the Apple App Store or Google Play. iTriage gives you on-the-go
access to health care information, treatment options and in-network doctors and facilities, saving you time
and money. As a member, you can quickly and easily view your:
» Aetna member ID card
» Claim details and history
» Important Aetna contact numbers
» Research symptoms and manage costs
No smartphone? No problem. Visit www.itriagehealth.com.
IN TOUCH CARE (ITC) COACHING
Aetna’s ITC coaching program provides your own personal nurse for you and your family. You can call with questions
about a new diagnosis, ways to get healthy or questions about finding a provider or having a procedure, and they can
provide you with the support you need. You can connect with a nurse by calling (888) 597-9964.
10HSA PLAN OVERVIEW
HEALTH SAVINGS ACCOUNT
If you enroll in our new SC HSA Plan, you’ll have access to a health savings account administered by Discovery
Benefits. The HSA helps you save pre-tax dollars for use on health expenses now or in the future. The account is yours,
even if you change plans in the future or leave SC. The balance rolls over each year, accruing interest tax-free.
Here’s how the plan works:
1. W
hen you go to the doctor or pharmacy, you pay the full cost of care until you reach the deductible. Preventive
care is covered at no cost, no deductible. For a full list of services designated as preventive care, visit www.aetna.com.
2. Once you reach the deductible, the plan shares the cost of care through coinsurance.
3. S C contributes quarterly into your account up to an annual contribution of $500 single/$1,000 family. You can
contribute pre-tax dollars through payroll deductions up to 2017 IRS limits. See the “Contributing to Your HSA”
section of this guide.
4. A
ll funds remaining in your HSA after the end of the plan year roll over. That allows you to continue saving for
longer-term healthcare expenses, including your healthcare needs in retirement. And if you leave SC, you take your
savings with you.
FREE IN-NETWORK OUT-OF-POCKET
PREVENTIVE CARE HEALTH SAVINGS ACCOUNT MAXIMUM
The plan pays 100 percent of Once your eligible
covered preventive services Employee / Employer Unused money rolls over expenses reach the
with no deductible – including Pre-tax contributions out-of-pocket maximum,
preventive prescriptions – so the plan pays 100 percent
you pay nothing. of eligible expenses
for the year.
You can use your HSA to help pay your deductible,
coinsurance and other qualifying expenses. OR You can save your HSA dollars for the future.
Other qualifying Balance rolls over each
Deductible Coinsurance After age 65
expenses year
You pay 100 percent After you satisfy the Use to pay qualified The HSA balance rolls over After age 65, use funds
of eligible expenses in-network expenses, including each year, accruing interest penalty-free for other
until you meet deductible, the plan those not covered by tax-free, like a retirement expenses (you’ll pay tax for
the deductible. pays 70 percent and medical insurance like account for health expenses. non-health care use).
you pay 30 percent LASIK.
in-network.
11HSA PLAN OVERVIEW
SETTING UP YOUR HSA
If you enroll in the SC HSA plan, you will need to log on to Discovery Benefits at www.discoverybenefits.com and
accept the terms and conditions to activate your account. Don’t miss this important step, as you won’t be
able to access your funds and SC will be unable to make contributions. When you enroll, please enter
the information carefully as this will be used to verify your enrollment information. Your account will be opened
within three business days. If Discovery Benefits needs additional information they will reach out to you. Once you’re
enrolled into Discovery Benefits system by SC, you will receive your debit card within 10 – 14 business days. If you
already have a Discovery Benefits debit card for an HSA, you will continue to use the same card for your HSA.
CONTRIBUTING TO YOUR HSA
You and SC contribute pre-tax money to your account to save for out-of-pocket health care expenses. SC will
contribute $500 for single coverage and $1,000 for family coverage in 2017, deposited in quarterly installments. For
SC to deposit funds on your behalf, you must select the HSA and activate your account - even if you
do not plan on making contributions.
The IRS has set limits on the total amount you can contribute to a health savings account each calendar year. All
contribution limits include both employee and employer contributions. In 2017, the maximum Associate contribution is
$2,900 if you’re on single coverage and $5,750 if you’re on family coverage. If you're over 55, the IRS allows you to
contribute an additional $1,000.
Remember, any money you don’t spend grows year after year and can be used in the future, even after you retire.
INELIGIBLE TO CONTRIBUTE
The HSA is a tax-advantaged account and the IRS has certain restrictions about who is eligible to open or contribute to
an HSA account. You are not eligible if you are:
» Covered by a non-high deductible health plan, whether through SC or your spouse’s or parent’s
» E nrolled in a regular health care flexible spending account, including your spouse’s. (You may be enrolled in a
limited health care flexible spending account.)
» Covered under Medicare or Medicaid
» A veteran enrolled in Tricare
» Claimed as a dependent on someone else’s tax return
Download the free Discovery Benefits mobile app for HSA benefits to check account balances, upload receipts,
view plan dates or contact customer service.
12HSA PLAN OVERVIEW
USING YOUR MONEY
You can use the money in your HSA account to pay for qualified medical, dental and vision expenses, such as
deductibles, coinsurance, prescriptions, dental care, vision care, LASIK, fertility treatments and eye glasses. You can
even use your funds on medical expenses for your dependents who are not covered under our benefits.
For a full list of qualified expenses, go to www.irs.gov and search for Publication 502.
Before you reach the age of 65, if you use HSA funds on ineligible expenses, you will owe a 20 percent penalty tax plus
income tax on the withdrawal. After age 65, if you use HSA funds on ineligible expenses, you will owe income tax only.
When possible, use your HSA debit card to pay for expenses. Make sure you keep records of your receipts. You will need
them to prove that you spent the money on qualified expenses if you are audited by the IRS.
THREE REASONS TO LOVE THE HSA
The HSA is a personal savings account that you can use for eligible healthcare expenses.
1. It’s all yours. You own, manage and control the account. Unused funds earn interest and roll over from year-
to-year. You can keep and use the account for as long as you want, even if you change plans.
2. You get pre-tax advantages. Any contributions you make are automatically deducted from your paychecks
pretax, which lowers your taxable income. The funds in your account earn interest over time, tax-free. And the
funds you use continue to be tax-free as long as you use them for eligible expenses. (See IRS publication 502
for a full list.)
3. You can use it when you want. You can use your HSA to pay for current medical expenses or save it to build
a financial nest egg for the future – even for retirement. If you don’t use it, you don’t lose it. If you leave SC,
your funds go with you.
13VITALITY
VITALITY AND RATE-REDUCING CREDITS
Vitality is a program that challenges you to choose healthier habits, improve your “Vitality Age™” and understand how
that impacts your life. With the Vitality Program, you can earn Vitality Points™ by completing healthy activities, such as:
» Assessments: Health, mental well-being and physical activity reviews
» Screenings: including a Vitality Check to measure body mass index, blood pressure, cholesterol and fasting
glucose levels. Be on the lookout for more information on screenings in 2017!
» Physical activity: Gym visits, fitness device tracking, sports league membership, etc.
» Online tools: Nutrition courses, interactive calculators and helpful articles
» Company-wide challenges: Focusing on physical activity, nutrition, earned points, etc.
HOW TO REGISTER
You can register for Vitality any time you are enrolled and active in an SC Aetna medical plan by following the steps:
1. Create your own confidential Vitality member account by logging on to www.powerofvitality.com and click on
Register Now! in the middle of your screen.
2. Complete the short form and choose your own username and password.
3. Once you’re registered, activate your account by completing the Vitality Health Review™, a series of questions
about your current health status. When you’re finished, you will receive your Vitality Age, a measurement of how
your lifestyle and habits may cause you to be younger or older than your actual age.
Your earned points
count toward your Vitality
- $16 Status, which can earn
- $9 you up to $16 off of your
PLATINUM
- $4 bi-weekly medical plan
GOLD
$0
SILVER
rates. Your Vitality Status in
BRONZE
2016 determines your 2017
credit. Contact SC Benefits
VITALITY STATUS LEVEL AND INCENTIVE DOLLAR AMOUNT
for more information.
14PRESCRIPTION BENEFITS
If you enroll in medical coverage, you are automatically enrolled in prescription drug coverage through Express Scripts, Inc. (ESI).
PRESCRIPTION PLAN DESIGN
SC PPO SC HSA
RETAIL HOME DELIVERY RETAIL HOME DELIVERY
IN-NETWORK
(30-DAY SUPPLY) (90-DAY SUPPLY) (30-DAY SUPPLY) (90-DAY SUPPLY)
Same as other you pay $0; 100% you pay $0; 100%
Preventive* Applicable copay
medications covered covered
you pay 30% after you you pay 30% after you
Generic you pay $10 you pay $20
meet deductible meet deductible
you pay 30% after you you pay 30% after you
ESI preferred brand you pay $35 you pay $70
meet deductible meet deductible
you pay 30% after you you pay 30% after you
Non-preferred brand you pay $50 you pay $100
meet deductible meet deductible
Out-of-Network Not Covered Not Covered Not Covered Not Covered
* A
ll drugs deemed preventive by the U.S. Preventive Services Task Force (USPSTF) are covered at 100 percent under both medical plans.
ESI and SC have identified additional preventive medications that are covered at 100 percent under the SC HSA plan only.
You have more control over what you pay for your prescriptions than On the SC HSA plan, you will
you may realize. Here are some helpful features of our program that
help you spend less on the drugs you need. be responsible for the full
1. O
n the SC HSA plan, all preventive drugs are covered cost of your non-preventive
at 100 percent, no deductible. That means prescriptions like
blood pressure medications are provided at not cost for you! medications until you meet
2. E SI’s prescription drug library can be accessed on your
the deductible. Let your
mobile device. Download the ESI app to make sure that you can
access this information while meeting with your doctor. You can doctors know you have an
work with your doctor to find the drug that is clinically appropriate
and cost effective. HSA plan to see if any lower
3. U
se ESI Home Delivery Pharmacy. Visit www.express-scripts. cost prescription options are
com, sign in and choose which of your current maintenance
medications you’d like to receive through home delivery. Or you can available. Don’t forget, SC
call ESI at the toll-free number on your ID card.
contributes funds to your
HSA to help you cover those
initial costs.
15FLEXIBLE SPENDING ACCOUNTS
Flexible spending accounts through Discovery Benefits allow you to set aside pre-tax dollars to cover eligible expenses.
The amount you chose to contribute to your account will be deducted from your paycheck over 26 bi-weekly payments
in 2017.
Some card purchases and all paper-claims purchases may require additional proof through the
www.discoverybenefits.com website or mobile app. Be sure to save receipts showing the date, description of
item/service, and provider/service name.
When you first enroll in the health care or limited health care spending account, you will receive a debit card from
Discovery Benefits. If you already have a card from 2016, you will continue to use it.
HEALTH CARE SPENDING ACCOUNT
A health care spending account (HCSA) covers eligible medical, dental and vision expenses. Associates who enroll
in the SC HSA plan are not eligible to enroll in the HCSA. You can set aside from $100 to $2,600 per year for
eligible expenses. The entire amount of your election is available on the first of the year.
LIMITED HEALTH CARE SPENDING ACCOUNT
Associates enrolling in the SC HSA plan may also enroll in a limited use health care FSA to cover eligible dental and
vision expenses only. You can set aside from $100 to $2,600 per year for eligible expenses.
For a detailed list of expenses
that can be paid with a flexible
spending account, go to
www.discoverybenefits.com.
Refer to your Benergy site for
additional details on the DCSA.
16FLEXIBLE SPENDING ACCOUNTS
DEPENDENT CARE SPENDING ACCOUNT
The dependent care spending account (DCSA) reimburses you for expenses that you incur caring for your dependents
while you and your spouse are at work. Eligible dependents include both children and incapacitated adult dependents.
Common eligible expenses for DCSA are:
» Licensed nursery school and day care facilities for your children
» Child care in or outside your home
» Day care for an elderly or disabled dependent
» Summer day camp
For 2017, dependent care annual household contribution limits are $5,000 if you are single or married but filing jointly,
and $2,500 if you are married and file a separate tax return.
WHICH REIMBURSEMENT ACCOUNT IS RIGHT FOR YOU?
LIMITED HEALTH CARE DEPENDENT CARE
HSA HEALTH CARE FSA
FSA FSA
Only Associates who elect Only Associates who elect
Only Associates who are
Who is eligible? coverage in the new SC coverage in the SC HSA All Associates
NOT on the SC HSA plan
HSA plan Plan
Tax-advantaged? Yes Yes Yes Yes
Balance rolls over each
Yes No – use it or lose it No – use it or lose it No – use it or lose it
year?
Accrues interest? Yes No No No
Expenses incurred
Medical, dental, and vision - while providing care for
Dental and vision
Eligible expenses include: including certain items not dependents – including
expenses only
covered under plan, like LASIK elders – like babysitting
or summer day camp.
$3,400 for Associate
Annual contribution limit? Only; $6,750 for all $2,600 $2,600 $5,000
other tiers
You and SC – SC funds up
to $500 for Associate only
Who can contribute? You only You only You only
and up to $1,000 for all
other tiers
Yes - once the balance
Investment options? No No No
reaches $1,000
17DENTAL PLAN
We offer access to two dental plans through Delta Dental: an Enhanced Plan and a Basic Plan. Both plans offer
in-network and out-of-network benefits, but if you visit a dentist in-network, your costs will be lower. Delta Dental ID
cards will be issued to Associates who select dental coverage.
Find an in-network dentist with the PPO or Premier networks by contacting the Delta Dental Customer Service
Department at (800) 521-2651, through www.deltadentalins.com, or on the Delta Dental mobile app.
DENTAL PLAN DESIGN
ENHANCED PLAN BASIC PLAN
MAJOR FEATURES
(Access to PPO and Premier Network) (Access to PPO Network)
BENEFITS IN-NETWORK OUT-OF-NETWORK IN-NETWORK ONLY OUT-OF-NETWORK
Calendar year Deductible for
$50 Single/$150 Family $50 Single/$150 Family $50 Single/$150 Family $50 Single/$150 Family
Basic and Major Services
Maximum Calendar year Benefit
$1,500 $1,500 $1,500 $1,500
(per person)
Orthodontia Coverage Lifetime
Maximum (Child & Adult $1,500 $1,500 None None
coverage)
Preventive Services: six month
check-up, cleaning and 100% 100% 100% 100%
polishing
Basic Services: fillings 80% after deductible 80% after deductible 90% after deductible 90% after deductible
Major Services: bridges,
50% after deductible 50% after deductible 60% after deductible 60% after deductible
dentures, crowns, inlays
Orthodontic Services 50% after deductible 50% after deductible Not covered Not covered
DENTAL BI-WEEKLY RATES Access your dental benefits anytime with the
Rates are not increasing for 2017!
free Delta Dental mobile app. Download the
COVERAGE ENHANCED BASIC app from the App Store or Google Play to:
LEVEL PLAN PLAN » Locate a Delta Dentist
Associate Only $6.47 $3.61 » Check benefits, eligibility, and claim status
Associate + Spouse $14.86 $7.58 » Opt for paperless statements
Associate + Child(ren) $13.72 $8.22 » View or print your ID card
» Compare average dental costs in your area
Associate + Family $23.62 $14.92
18VISION PLAN
You may enroll in vision coverage through Vision Service Plan (VSP). This plan helps pay the cost of periodic vision
examinations, and necessary lenses and frames if prescribed. To get the most out of your benefits, use an in-network
provider. To find a VSP provider, go to www.vsp.com.
VISION PLAN DESIGN
VSP VISION VSP BASIC PLAN VSP ENHANCED OPTION
BENEFITS IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK
Eye Examination
$10 copay $45 allowance $10 copay $50 allowance
(one every calendar year)
Lenses (every calendar
$25 copay N/A $15 co-pay N/A
year)
Single Vision Covered after copay $30 allowance Covered after copay $50 allowance
Lined Bifocal Covered after copay $50 allowance Covered after copay $75 allowance
Lined Trifocal Covered after copay $65 allowance Covered after copay $100 allowance
$130 retail $70 allowance (retail) $150 allowance per year $70 allowance per year
Frames Allowance
(one every other year) (one every other year) (one every calendar year) (one every calendar year)
Contact Lenses (Elective) $130 annual allowance $105 annual allowance $150 annual allowance $105 annual allowance
VISION BI-WEEKLY RATES
No change to Vision rates for 2017!
COVERAGE ENHANCED
BASIC PLAN VISION ID PROCEDURE
LEVEL OPTION
Associate Only $1.22 $2.92 There is no ID card for Vision. All you need to
do is give your provider your VSP identification
Associate + Spouse $2.43 $5.83
number. Your VSP identification number is your
Associate +
$2.60 $6.24 employee ID# with three leading zeros (e.g.,
Child(ren)
000012543).
Associate + Family $4.16 $9.96
19INCOME PROTECTION
LIFE AND AD&D
SC provides company-paid basic Life and AD&D coverage through Sun Life Financial equal to two times your base
annual salary, up to a maximum of $1,000,000.
You may enroll for life insurance during your initial enrollment period or during open enrollment. If you are interested
in enrolling for life insurance when initially eligible, you are guaranteed coverage for up to $350,000 for yourself and
$30,000 for your spouse without completing an evidence of insurability (EOI). If you elect over those guaranteed
amounts or you elect an initial or increased amount at subsequent open enrollment periods, an EOI application must be
completed and approved. Your newly elected life insurance coverage level and deduction for all life plans will not take
effect until your EOI is approved.
Please log onto www.mysunlifebenefits.com to complete your online EOI. Our plan number is #237916.
» Supplemental Associate Life Insurance is available in increments of $10,000 up to $500,000 for Associates.
» S pouse Life Insurance is available in increments of $10,000 up to $150,000 and may not exceed 50 percent of
the Associate’s supplemental coverage*.
» C
hild Life Insurance is available in increments of $5,000 up to a maximum of $10,000. Coverage is available for
children up to age 26.
MONTHLY COST PER $1,000 OF COVERAGE
ASSOCIATE/SPOUSE SUPPLEMENTAL LIFE COVERAGE
0-29 $0.064
30-34 $0.080
35-39 $0.090
40-44 $0.136
45-49 $0.208
50-54 $0.352
55-59 $0.552
60-64 $0.736
65-69 $1.270
Open enrollment is a great time >70 $2.072
CHILD SUPPLEMENTAL LIFE COVERAGE (PER FAMILY)**
to update your beneficiaries. $5,000 $0.80
$10,000 $1.60
Note: Election of supplemental Associate life insurance is required to elect spouse and/or child life insurance. Once you have completed
your life insurance election, please be sure to complete and update your beneficiary election online in Workday. Please keep in mind
that beneficiary proceeds cannot be paid to minors.
* You may not cover a common law spouse or another SC employee under your spouse life benefit.
** If both you and your spouse are SC Associates
20INCOME PROTECTION
DISABILITY
It is important to have a continuing source of income to protect you and your family during periods of extended illness
or injury. SC provides company-paid, short-term and long-term disability benefits through Lincoln Financial.
Short-Term Disability (STD)
The STD plan replaces 60 percent of your base pay up to a weekly maximum benefit of $1,500 for up to 11 weeks after
a 14-day waiting period.
Long-Term Disability (LTD)
After a 90-day waiting period (during which the STD plan may cover you), the LTD Plan replaces 60 percent of your base
annual salary (up to $10,000 a month) while you remain disabled as defined by the Plan.
Note: Associates residing in statutory disability states (California, New York, New Jersey, Rhode Island and Hawaii) are required to utilize
your state coverage before the Lincoln plans will pay out benefits.
CRITICAL CARE ILLNESS PLAN - NEW FOR 2017!
Even with good medical coverage, the cost of a critical illness, such as cancer, heart attack and stroke, can really add up.
Some families spend as much as $14,444 or more during a time of a critical illness and recovery. While critical illnesses
are always unexpected, they don’t have to be financially devastating. Protect your family’s budget by enrolling for
MetLife Critical Illness Insurance today.
Critical illness insurance helps pay for both expected and unexpected expenses that arise from the diagnosis of a
covered critical illness such as cancer, heart attack or stroke for you and your covered family members. With this
voluntary plan, you can receive cash benefits directly from MetLife, giving you total control and flexibility over how you
use the money.
Choose coverage levels of $15,000 or $30,000, with coverage based on your tobacco usage status. Rates are age-
based and coverage is available for both you and your family members. Family members may elect coverage up to 50
percent of Associate election.
Starting January 1, 2017, visit my.benefits.com for access to medical plan information and claim forms. Once you log
on, enter “Santander” to access your medical plan information.
21RETIREMENT PLANNING
401(K) RETIREMENT PLAN
The SC 401(k) Plan is designed to help Associates save for retirement. All full-time and part-time Associates age 21
or older are eligible to participate day 1 of employment.
Fidelity Investments is the administrator of the SC 401(k) plan. Enroll on the Fidelity website at www.netbenefits.com.
You can also call the Fidelity Retirement Benefits Line if you need assistance enrolling at (800) 294-4015. You may
enroll and make changes at any time to your account.
Your next step is to decide how much you want to invest. Through payroll deductions, you may contribute any whole
percentage of your salary up to 75 percent. Currently, the annual limit is $18,000. However, if you are at least 50 years
of age you may be eligible to participate in a catch-up plan, which currently allows an additional $6,000 of contributions
each year.
There is also a Roth 401(k) option. Unlike traditional pre-tax 401(k) the Roth feature allows you to contribute on an after
tax basis but then withdraw tax-free dollars from your account when you retire (provided the distribution is qualified). If
you would like additional details about our Roth 401(k) plan you will find information in the Tools & Learning section of
www.netbenefits.com.
All Associates receive a company match on their contributions of dollar for dollar up to the first six percent that you
contribute on the first paycheck after six months of employment. Therefore, if six percent of your payroll deduction is
$100 – SC will also deposit $100 into your 401(k) account
on your behalf. Matches are made immediately after each
payroll, and you are 100 percent vested in your company
match immediately.
The last step for enrollment is selecting how you want to
invest your contributions among the investment options
available. You may change your investment options of either
accumulated or future funds at any time. You can review all
the investment options available to you at
www.netbenefits.com.
If you currently have a 401(k) plan with another employer
Plan ahead so you can rest assured and would like to roll over those funds into your SC
account, please email us at SC Benefits and we will be
later in life. happy to send you the form and directions on how to
make that happen.
22RETIREMENT PLANNING
REASONS WHY YOU SHOULD INVEST IN YOUR 401(K):
1. It is never too early to prepare for retirement through a tax-deferred plan.
2. W
hen you contribute one to six percent of your earnings into a 401(k), you also get a dollar for dollar match.
That’s free money!
3. T ax benefits. Any pre-tax contribution you make lowers your taxable income, which reduces the amount you
pay in taxes!
4. Payroll deductions for your savings. The 401(k) plan provides an automatic savings device allowing you to put
aside money first before you begin paying your normal living expenses. It is a good disciplined way to save.
5. Loans and withdrawals are available in certain situations of a financial emergency. Keep in mind that there is a
financial penalty for doing so.
6. Potential earnings on your contribution through investments. Below is a hypothetical annual rate of return of
seven percent and how much money you would have if you allowed it to grow over time.
Example of 401k Associate contribution and SC contribution match for an Associate with an annual salary of $50,000.*
ASSOCIATE CONTRIBUTION EMPLOYER MATCH
3% Bi-weekly contribution $ 57 $ 57
6% Bi-weekly contribution $115 $115
10% Bi-weekly contribution $192 $115
*For example purposes only and does not reflect actual Associate salary or contributions.
Have more questions or need additional
help? The Fidelity Retirement Benefits Line
is your one-call resource for answers to
questions about your plan or account. Call
(800) 294-4015 for automated information
24/7 or to speak to a representative call
between 8:30 a.m. and 8:30 p.m. ET any
business day.
23OTHER BENEFITS
EMPLOYEECONNECT
The EmployeeConnect employee assistance program (EAP) is available to all full-time Associates and their
family members.
You may receive free assessment and referral services, short-term counseling (up to three visits per-year) and crisis
intervention for problems such as:
» Marital and/or family issues
» Emotional problems and personal issues
» Alcohol and substance abuse
» Disease-related issues
» Legal-services
» Financial counseling
Contact our confidential EmployeeConnect EAP team at 888-628-4824.
BRIGHT HORIZONS
Bright Horizons provides family solutions for our Associates who find themselves needing short-term well and sick
child care or elder care.
You must enroll in Bright Horizons in 2017, and pre-registration is required online at
www.backup.brighthorizons.com (User name: WeCare101, Password: SCUSA2012) or you can
call: (877) BH-CARES (877-242-2737).
529 SAVINGS PLAN
The 529 Savings Plan is a flexible college savings program that can be used to pay for qualified education expenses,
such as tuition, fees, room and board, books and other supplies needed at an institution of higher learning. Contact
SC Benefits to request a 529 enrollment form.
24OTHER BENEFITS
TRANSIT AND PARKING BENEFITS
Similar to the FSA, these transit and parking benefits allow Set aside pre-tax dollars for
you to set aside pre-tax dollars to be reimbursed for qualified
transportation expenses, such as parking and mass transit costs. qualified transportation expenses.
You may change your election or terminate participation each
month before expenses are incurred. All contributions are made
on a monthly basis.
Discovery Parking:
» Set aside up to $250 per month pre-tax
se for parking reimbursement at work-site or public
» U
transportation facilities
se of funds or ID cards only available while active on
» U
the plan, and all claims must be filed within 180 days
SC Transit:
» Discount through DART
» Regional passes $100 per month
» Local passes $50 per month
» Premiums paid through pre-tax deduction
THX Parking:
irect access to Thanksgiving Tower Garage and
» D
LAZ Tower Garage
» Premiums paid through pre-tax deduction
WHITEGLOVE SERVICE
Members of the SC PPO have access to concierge medical care, WhiteGlove Health Membership Service, with
$25 home visits through July 2017. Your sick visit includes a medical consultation and generic prescriptions at no
additional charge, if needed. Members of the SC PPO also have access to Teladoc effective January 2017. Teladoc
replaces WhiteGlove starting August 2017 when the WhiteGlove program closes. Call WhiteGlove Membership
Support for login information at (877) 329-8081.
25OTHER BENEFITS
PAID TIME OFF DISCOUNT PROGRAMS
SC encourages work-life balance. One way to do that is As a member of the SC family, you are afforded a variety
by offering paid vacation time. Our paid time off (PTO) of discount programs. Discounts range from items like
program is expanding for 2017, giving you more time to phone service, hotels, fitness programs and a large variety
do the things you love. of entertainment discounts.
All full-time and part-time Associates accrue vacation In addition, Associates and their family members are
days from date of hire. Vacation, sick, personal and eligible for automotive purchasing discounts as part of
floating holidays have been combined into one bank, the Chrysler Employee Advantage Discount Program.
allowing you to use your time as you want.
Log onto the SC Source for more information about
FULL TIME ASSOCIATE ACCRUALS1 employee discounts. Please note the discount programs
are subject to change at any time.
2016 2017 VPTO
TENURE CHANGE
TOTAL TOTAL DAYS3
Year 1
14 22 +8 1
(Operations)2
Year 1
19 22 +3 1
(Back Office)2
Year 2-4 19 24 +5 1
Year 5-9 24 27 +3 1
10+ 29 32 +3 1
PART TIME ASSOCIATE ACCRUALS1
2016 2017 VPTO
TENURE CHANGE
TOTAL TOTAL DAYS3
Year 1 2 6 10 +4 0.5
Year 2-4 7.5 11 +3.5 0.5
Year 5-9 10 12.5 +2.5 0.5
10+ 12.5 15 +2.5 0.5
1
All numbers represent days.
2
Previous program included a 90-day waiting period.
3
Associates are eligible to receive VPTO after 6 months of
employment.
SC wants you to enjoy life. Take
Also note, SC observes six holidays a year – New Year’s
Day, Memorial Day, Independence Day, Labor Day, advantage of your PTO.
Thanksgiving Day and Christmas Day.
26LEGAL NOTICES
IMPORTANT NOTICE ABOUT YOUR PRESCRIPTION delivery, or less than 96 hours following a cesarean section. However,
DRUG COVERAGE AND MEDICARE federal law generally does not prohibit the mother’s or newborn’s
If you (and/or your dependents have Medicare or will become eligible attending provider, after consulting with the mother, from discharging
for Medicare in the next 12 months, a federal law gives you more the mother or her newborn earlier than 48 hours (or 96 hours as
choices about your prescription drug coverage. applicable). In any case, plans and issuers may not, under federal
law, require that a provider obtain authorization from the plan or the
In compliance with Medicare Part D requirements, we provide annual
issuer for prescribing a length of stay not in excess of 48 hours (or 96
notices of creditable coverage to all members that are eligible for
hours).
Medicare coverage. This notice has information about your current
prescription drug coverage and about your options under Medicare’s
NOTICE OF SPECIAL ENROLLMENT RIGHTS FOR
prescription drug coverage. This information can help you decide
whether or not you want to join a Medicare drug plan. If you are MEDICAL/HEALTH PLAN COVERAGE
considering joining, you should compare your current coverage, A federal law called HIPAA requires that we notify you about a very
including which drugs are covered at what cost, with the coverage important provision in the Plan. The provision is your right to enroll in
and costs of the plans offering Medicare prescription drug coverage the Plan under its “special enrollment provision” if you acquire a new
in your area. If you would like information about these notices, a dependent, or if you decline coverage under this Plan for yourself or
full listing can be found on the company Intranet or by contacting an eligible dependent while other coverage is in effect and later lose
HR Help. that other coverage for certain qualifying reasons.
» Loss of Other Coverage (Excluding Medicaid or a State
Children’s Health Insurance Program). If you decline enrollment
WOMEN’S HEALTH AND CANCER RIGHTS ACT for yourself or for an eligible dependent (including your spouse)
The Women’s Health and Cancer Rights Act (“WHCRA”) requires
while other health insurance or group health plan coverage is in
us to notify participants and beneficiaries of our Group Health Plan
effect, you may be able to enroll yourself and your dependents
(the “Plan”), of their rights to mastectomy benefits under the Plan.
in this Plan if you or your dependents lose eligibility for that
Participants and beneficiaries have rights to coverage to be provided
other coverage (or if the employer stops contributing toward
in a manner determined in consultation with the attending
your or your dependents’ other coverage). However, you
Physician for:
must request enrollment within 30 days after your or your
» All stages of reconstruction of the breast on which the
dependents’ other coverage ends (or after the employer stops
mastectomy was performed;
contributing toward the other coverage).
» Surgery and reconstruction of the other breast to produce a
» Loss of Coverage For Medicaid or a State Children’s Health
symmetrical appearance;
Insurance Program. If you decline enrollment for yourself or for
» Prostheses and treatment of physical complications of the
an eligible dependent (including your spouse) while Medicaid
mastectomy, including lymphedema.
coverage or coverage under a state children’s health insurance
These benefits are subject to the same deductible and co-payments
program is in effect, you may be able to enroll yourself and your
applicable to other medical and surgical benefits provided under
dependents in this Plan if you or your dependents lose eligibility
this Plan. For further details, please refer to the Plan’s Summary
for that other coverage. However, you must request enrollment
Plan Description.
within 60 days after your or your dependents’ coverage ends
under Medicaid or a state children’s health insurance program.
NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION » New Dependent by Marriage, Birth, Adoption, or Placement for
ACT NOTICE Adoption. If you have a new dependent as a result of marriage,
The following is the amended sample notice that a group health plan birth, adoption, or placement for adoption, you may be able to
may use to satisfy the Newborns’ and Mothers’ Health Protection enroll yourself and your new dependents. However, you must
Act disclosure requirement: Group health plans and health insurance request enrollment within 30 days after the marriage, birth,
issuers generally may not, under federal law, restrict benefits for adoption, or placement for adoption.
any hospital length of stay in connection with childbirth for the
mother or newborn child to less than 48 hours following a vaginal
27LEGAL NOTICES
» Eligibility for Medicaid or a State Children’s Health Insurance total cholesterol, LDL and HDL cholesterol, cholesterol/HDL ratio
Program. If you or your dependents (including your spouse) and triglycerides. You are not required to complete the HRA or to
become eligible for a state premium assistance subsidy from participate in the blood test or other medical examinations.
Medicaid or through a state children’s health insurance program However, employees who choose to participate in the wellness
with respect to coverage under this Plan, you may be able to program will receive an incentive of Vitality points that can be
enroll yourself and your dependents in this Plan. However, redeemed for merchandise in the Vitality store and a premium
you must request enrollment within 60 days after your or your discount based on status earned through Vitality. Although you
dependents’ determination of eligibility for such assistance. are not required to complete the Vitality Check or participate in
the biometric screening, only employees who do so will receive the
MICHELLE’S LAW NOTICE incentive.
If you live in certain states, our plan may extend medical coverage
Additional incentives including Vitality points that can be redeemed
for dependent children if they lose eligibility for coverage because of
for merchandise in the Vitality store and premium discount based
a medically necessary leave of absence from school. Coverage may
on status earned through Vitality may be available for employees
continue for up to a year, unless your child’s eligibility would end
who participate in certain health-related activities, including
earlier for another reason.
assessments, screenings, physical activity initiatives, online tools, and
Extended coverage is available if a child’s leave of absence from company-wide challenges. If you are unable to participate in any of
school — or change in school enrollment status (for example, the health-related activities or achieve any of the health outcomes
switching from full-time to part-time status) — starts while the child required to earn an incentive, you may be entitled to a reasonable
has a serious illness or injury, is medically necessary and otherwise accommodation or an alternative standard. You may request a
causes eligibility for student coverage under the plan to end. Written reasonable accommodation or an alternative standard by contacting
certification from the child’s physician stating that the child suffers HR Help.
from a serious illness or injury and the leave of absence is medically
The information from your HRA and the results from your biometric
necessary may be required.
screening will be used to provide you with information to help you
If your child will lose eligibility for coverage because of a medically understand your current health and potential risks, and may also be
necessary leave of absence from school and you want his or her used to offer you services through the wellness program, such as
coverage to be extended, contact Human Resources as soon as the health coaching. You also are encouraged to share your results or
need for the leave is recognized. In addition, contact your child’s concerns with your own doctor.
health plan to see if any state laws requiring extended coverage may
apply to his or her benefits.
PROTECTIONS FROM DISCLOSURE OF MEDICAL
INFORMATION
NOTICE REGARDING WELLNESS PROGRAM We are required by law to maintain the privacy and security of your
SC Wellness Program is a voluntary wellness program available to personally identifiable health information. Although the wellness
all employees. The program is administered according to federal program and SC may use aggregate information it collects to
rules permitting employer-sponsored wellness programs that seek design a program based on identified health risks in the workplace,
to improve employee health or prevent disease, including the SC Wellness Program will never disclose any of your personal
Americans with Disabilities Act of 1990, the Genetic Information information either publicly or to the employer, except as necessary
Nondiscrimination Act of 2008, and the Health Insurance Portability to respond to a request from you for a reasonable accommodation
and Accountability Act, as applicable, among others. If you choose needed to participate in the wellness program, or as expressly
to participate in the wellness program you will be asked to complete permitted by law. Medical information that personally identifies you
a voluntary health risk assessment or “Vitality Check” that asks a that is provided in connection with the wellness program
series of questions about your health-related activities and behaviors will not be provided to your supervisors or managers
and whether you have or had certain medical conditions (e.g., cancer, and may never be used to make decisions regarding
diabetes, or heart disease). You will also be asked to complete a your employment.
biometric screening, which will include a blood test for glucose,
28LEGAL NOTICES
Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out
specific activities related to the wellness program, and you will not be asked or required to waive the confidentiality of your health information
as a condition of participating in the wellness program or receiving an incentive. Anyone who receives your information for purposes of
providing you services as part of the wellness program will abide by the same confidentiality requirements. The only individual(s) who may
receive your personally identifiable health information are Aetna health nurses and Vitality staff in order to provide you with services under the
wellness program.
In addition, all medical information obtained through the wellness program will be maintained separate from your personnel records,
information stored electronically will be encrypted, and no information you provide as part of the wellness program will be used in making
any employment decision. Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving
information you provide in connection with the wellness program, we will notify you immediately.
You may not be discriminated against in employment because of the medical information you provide as part of participating in the wellness
program, nor may you be subjected to retaliation if you choose not to participate.
If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact HR Help.
PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a
premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t
eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance
coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP
office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you
or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW
or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums
for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your
employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and
you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your
employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of
states is current as of July 31, 2016. Contact your State for more information on eligibility to see if any other states have added a premium
assistance program since July 31, 2016, or for more information on special enrollment rights, contact either:
U.S. Department of Labor U.S. Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare & Medicaid Services
www.dol.gov/ebsa www.cms.hhs.gov
1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565
OMB Control Number 1210-0137 (expires 10/31/2017)
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