2020 BENEFIT GUIDE MESA COUNTY GOVERNMENT
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2020 BENEFIT GUIDE MESA COUNTY GOVERNMENT
Copyright (c) 2017 (Novo Benefits) - All Rights Reserved. This employee guide is intended solely for the use of participants of the employee benefit plan specified herein. It may contain confidential or privileged information. If you are not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited without the written consent of Novo Benefits.
TABLE OF CONTENTS
This Benefits Guide is an overview
4 Enrollment Guidelines
of the benefits provided by Mesa 5 Benefit Contacts
County Government. It is not a 6 Premiums
Summary Plan Description or 7 Medical
Certificate of Insurance. If a 8 Virtual Visits
question arises about the nature 9 CHP Referral & Precertification
and extent of your benefits under 10 Triad EAP
the plans and policies, or if there is 11 CHP Lifestyle Modification Benefits
a conflict between the informal 12 UNUM EAP
language of this Benefits Decision 13 Travel Benefit
14 Good RX
Guide and the contracts, the
15 Dental
Summary Plan Description and
16 Vision
Certificates of Insurance will govern. 18 VSP Discounts – Eye Care & Hearing Aids
Please note that the benefits in your 19 Rocky Mountain Reserve FSA
Benefits Guide are subject to 23 Flexible Spending Account
change at any time. The Benefits 24 Sample Qualified Expenses
Guide does not represent a 25 Life Insurance
contractual obligation on the part of 27 Voluntary Life Insurance
Mesa County Government. Mesa 29 Long Term Disability
County Government is a non-federal 30 Additional Voluntary Benefits
government entity. All of the 32 Retirement Benefits
benefits presented herein are not
subject to ERISA.
3
ENROLLMENT GUIDELINES
Welcome to the 2020 Benefits Guide for Mesa County Government. This Guide provides a quick
overview of the benefits program and helps to remove confusion that sometimes surrounds employee
benefits. The benefits program was structured to provide comprehensive coverage for you and your
family. Benefit programs provide a financial safety net in the event of unexpected and potentially
catastrophic events.
ELIGIBILITY
You are eligible to enroll in the benefits program Qualified life events are:
if you are a regular employee working 20 or more
hours per week or a temporary, non-seasonal • Marriage • Adoption
employee working at least 30 hours per week. • Divorce • Death
Medical, Dental,, Vision, FSA, Basic Life/AD&D • Birth • Loss of Coverage
and LTD benefits for newly hired employees will
Open Enrollment under your Spouses’ group plan
take effect the first of the month following 30
will also be considered a qualifying event.
days of qualified employment. Voluntary life is
effective the first of the month following 30 days
When you have a qualifying event, you have 31
of application if dated prior to that date.
days to complete and return a new
Otherwise, it’s first of the month following the
enrollment/change form for health, dental,
date of signature (if signed within 30 days of
and/or vision coverage. (You have 60 days to
eligibility). For Benefits other than medical,
complete and return a new enrollment/change
Active at Work Provisions apply, including
form after coverage under Medicaid or CHIP
Dependent Non-Confinement. All other benefits
terminates.)
are effective upon date of hire.
Available Benefits:
Your legal spouse, and your married or unmarried
• Medical/Clinic
dependent children if less than 26 years of age,
• Flexible Spending Account (FSA)
are eligible for medical coverage. Disabled
• Dental
children over age 26 may be eligible to continue
• Vision
benefits after approval of necessary applications.
• 401(a) Defined Contribution
• 457(b) Deferred Compensation
OPEN ENROLLMENT • Basic Life/Accidental Death & Dismemberment
Open enrollment for health, dental, vision, and (AD&D)
flex is once a year and benefit elections will take • Supplemental Life Insurance
effect January 1st. Participants may add or drop • Basic Voluntary Dependent Life Insurance
coverage or make changes to their coverage at • Long-Term Disability (LTD)
this time. Late entrants (employees or • Accident/Critical Illness/Hospital
dependents who apply for coverage more than Indemnity/Legal/Identity Theft
31 days after the date of individual eligibility) are • Sick Leave
also provided an opportunity to enroll for • Vacation
coverage during the plan’s open enrollment. The • Employee Assistance Program (EAP)
elections you make stay in effect the entire plan • Social Security (FICA)
year, unless a qualifying life event occurs.
4
BENEFIT CONTACTS
Anthem
Medical & Rx (800) 542-9402
700 Broadway
PPO Network www.anthem.com
Denver, CO 80273
Contact CHP Partners Hotline for
assistance in determining the
appropriate facility or provider for 1-877-535-2295
CHP Partners Hotline Tier 1 services. Certain types of chp@gjhosp.org
services may be paid at the Tier 1
Network benefit level when
performed at another Anthem ASO
Network facility.
Questions about CHP, CHP Medical
CHP Concierge Clinic providers, hours, and (970) 644-4000
locations
University of Utah Health Care (801) 587-7219
Customer Service
Connect Program https://healthcare.Utah.edu/telehealth/virtual-visits/
Virtual Visits University of Utah Virtual Visit Set up (844) 424-2172
Dental
Delta Dental www.deltadentalco.com
Group #12141
(800) 877-7195
VSP Vision
www.vsp.com
(888) 722-1223
Rocky Mountain Reserve Flexible Spending Account
www.rockymountainreserve.com
Life / AD&D Insurance, Voluntary
(800) 275-8686
UNUM Supplemental Life, & Long Term
www.unum.com
Disability
Alex
https://www.myalex.com/mesacounty/2020
Benefit Overview
Brenda Moore
(970) 244-1695
HR Director
Brenda.Moore@mesacounty.us
Mesa County
Shelley Vehik
(970) 244-1847
Senior Benefits Administrator
shelley.vehik@mesacounty.us
Sharon Bacon (402) 802-9089
Novo Benefits
Account Coordinator sbacon@novobenefits.com
5
PREMIUMS
Employee Contributions (per month)
Effective January 1, 2020
MEDICAL EMPLOYEE COUNTY % CONTRIBUTION TOTAL
Single $40.00 $599.22 93.7% $639.22
Employee + Spouse $300.00 $973.53 76.4% $1,273.53
Employee + Child(ren) $220.00 $863.33 79.7% $1,083.33
Family $340.00 $1,252.16 78.6% $1,592.16
DENTAL EMPLOYEE COUNTY % CONTRIBUTION TOTAL
Single $32.53 $0.00 0% $32.53
Employee + Spouse $68.30 $0.00 0% $68.30
Employee + Child(ren) $55.29 $0.00 0% $55.29
Family $97.58 $0.00 0% $97.58
VISION EMPLOYEE COUNTY % CONTRIBUTION TOTAL
Single $9.57 $0.00 0% $9.57
Employee + One $16.99 $0.00 0% $16.99
Family $27.40 $0.00 0% $27.40
Premium Paid by Employee
VOLUNTARY SUPPLEMENTAL TERM LIFE
Visit your enrollment portal at Mesa Wave to see your age banded rates.
6
BENEFITS
MEDICAL PLAN
PPO Medical Plan
Medical Benefits Tier 1 Tier 2 Tier 3
Community Hospital & Community
Hospital Owned Facilities; Anthem BlueCross BlueShield
Network Non-Contracted Providers
Canyon View Surgery Center; Contracted Providers
University of Utah Health Center
Deductible
$1,250 Single / $2,500 Family $1,250 Single/ $2,500 Family $5,000 Single/ $10,000 Family
Out-of-Pocket Maximum
$5,000 Single/ $10,000 Family $6,850 Single/ $13,700 Family No Maximum
Preventive Care per
Covered 100%, DW Covered 100%, DW Not Covered
Schedule of Benefits
Office Visit $10 copay for office visit. $60 copay for office visit. All
$40 copay for office visit. All other
All other services subject to other services 50%, deductible
services subject to deductible + 20%
deductible + 20% waived
Virtual Visits $0 Copay
Not Available Not Available
University of Utah Only
Specialist Office visit
$45 copay for office visit. $45 copay for office visit. $60 copay for office visit.
All other services subject to All other services subject to deductible All other services 50%,
deductible then 20% then 20% deductible waived
Outpatient Hospital 20% AD 50% AD 50% AD
Inpatient Hospital 20% AD 50% AD 50% AD
Emergency Room $150 Copay per visit for facility and
physician services, then 20% after
Same as in-network Same as in-network
deductible for all other services.
Copay waived if admitted
Pharmacy Deductible $150 Deductible Per Person $150 Deductible Per Person Not Applicable
Retail – 30 day supply
Preventive RX Formulary 100% DW at Canyon View Subject to copay and deductible
Generic Lesser of $20 copay or 20%, AD Lesser of $20 copay or 20%, AD Not Covered
Formulary Lesser of $45 copay or 30%, AD Lesser of $45 copay or 30%, AD Not covered
Non-Formulary Lesser of $60 copay or 40%, AD Lesser of $60 copay or 40% AD Not covered
Specialty only through ESI Lesser of 25% to a maximum of $500 Lesser of 25% to a maximum of $500 Not covered
Pharmacy Management per prescription, AD per prescription, AD
Mail Order – 90 day supply
Generic Lesser of $60 copay or 3 x 20% AD Lesser of $60 copay or 3 x 20%, AD Not covered
Preferred Lesser of $135 copay or 3 x 30% AD Lesser of $135 copay or 3 x 30% AD Not covered
Non-Preferred Lesser of $180 copay or 3 x 40% AD Lesser of $180 copay or 3 x 40% AD Not covered
*Includes Deductible, Copays, & Rx AD – After Deductible DW – Deductible Waived
*The above benefits are meant for illustrative purposes only and are only a brief look at your benefits. See your Plan Document for details
on benefits, network utilization, limitations and exclusions. In the event of a discrepancy the Plan Document will prevail. The Plan
Document is available via your Mesa Wave Portal. Printed documents are available upon request.
7
VIRTUAL VISITS
Online Acute Care through University of Utah
Mesa County-insured have access to virtual visits! If you have a minor illness, but you can’t make it to
a doctor, you can utilize online acute care!
If you are feeling sick and don’t want to leave the comfort of your home, you can speak face-to-face
with a University of Utah provider. You don’t need an appointment, just a Wi-Fi internet connection
on your smartphone, tablet or computer.
• Available 9:00 a.m. - 8:00 p.m. 7 days a week.
• Call from anywhere in Colorado or Utah.
• Virtual Visits are covered with a $0 co-pay through your Mesa County insurance.
To start your visit, please call
(844) 424-2172
*Save this number in your phone!
Symptoms Suitable for Virtual Visits
• Allergies
• Cough, cold and flu
• Eye infections
• Sore throat (adult patients only)
• Minor muscle or joint pain
(adult patients only)
• Nausea, vomiting and diarrhea
• Sinus problems
• Skin issues
• Stomach and digestive issues
• Urinary track issues (adult patients only)
And many more!
Apple users will need to download the “UofU Health Virtual Care” app on the App Store
prior to starting their visit. There is no app requirement for Androidusers.
6
8
CHP HOTLINE
What procedures/services does Community Hospital offer?
What about labs, x-rays, mammograms, MRIs?
What services does Community Hospital not provide?
Our team will help you navigate the health care system and provide answers to your health plan questions.
Call the toll free number below to speak directly with the CHP Partners Hotline team member. Calls or
emails received by 5 p.m. will be returned by 5 p.m. the following business day. To best serve you, calls
and emails can be made to the hotline 24 hours a day, seven days a week. If a team member is not
available at the time of the call, please leave a message. All calls and emails will be returned in a timely
manner.
PRE-CERTIFICATION
Contact CHP Partners Hotline at 1-877-535-2295 for assistance in determining
the appropriate facility or provider for services. Certain types of services may 61% OF THE TIME
also be paid at the in network Tier 1 benefit level when performed at a MEMBERS SELF-REFER
University of Utah facility. TO THE WRONG
SPECIALIST. CALL
Before you receive certain medical services or procedures, your health plan TODAY FOR HELP!
requires a doctor to confirm that these requested services are considered
medically necessary under your plan. This verification process is called "pre-
certification.“ Even if some services or therapies are performed in your
doctor's office, you may still need a pre-certification.
SERVICES REQUIRING PRE-CERTIFICATION
Inpatient Hospitalizations Oncology Care & Services Labor & Delivery
(chemotherapy, radiation therapy, etc.)
Colonoscopies other than at Grand Junction Out-Patient Surgeries other than Canyon View Surgery
Endoscopy and Gastroenterology Associates of Center & Community Hospital
Western Colorado.
Services Community Hospital does not currently provide; however, with approval through the CHP Hotline,
these services, if authorized by the third party administrator (TPA) as medically necessary and covered by the
employer’s health plan, would be paid at the higher level benefit/in-network/Tier 1 for facilities in the
employer’s selected provider network including University of Utah.
• Cardiac Catheterization
• Cardiothoracic Surgery
• Neonatal and Pediatric ICU
• Neurosurgery
*The above benefits are meant for illustrative purposes only and are only a brief look at your benefits. See your Certificate of Coverage or SBC for 9
details on benefits, network utilization, limitations and exclusions. In the event of a discrepancy the plan document will prevail. Plan Documents
are available via your Mesa Wave Portal. Printed documents are available upon request.
LIFESTYLE MODIFICATION
Outpatient Behavioral Health
Our Behavioral Health Specialists can help you with:
• Personal relationship problems
• Anxiety and depression
• Drug and alcohol interventions
• Work stress
• And more!
Behavioral health services are available at no cost to
you! To schedule an appointment, please call (970) 242-
9026. Available to participants who see a CHP Medical
Clinic Provider.
EAP Services
Triad EAP is a prepaid, confidential service offered by Mesa County. This
benefit is available to all Mesa County employees and extends to the
employee’s spouse and dependents under the age of 26. Five EAP
short-term, solution based counseling sessions are available at no cost
to you! This benefit includes legal and financial counseling.
Crisis counseling is available 24-hours a day, seven days a week.
Triad works with highly trained and qualified professionals who are experts in the fields such as
wellbeing, family matters, relationships, debt management, consumer rights, and much more.
For information regarding your benefits or to see a list of counselors, log in to www.triadeap.com.
Username: mesa / Password: county, or call (970) 242-9536 (local) or 877-679-1100 (toll free).
Nutritional Education Services
Nutritional education is available at no cost to
you! Our dieticians can assist you with:
• Weight loss
• Medical nutrition therapy
• And more!
To schedule an appointment, please call 263-2664.
*A referral from a CHP Medical Clinic Provider is required.
8
10CHP Resources
Your CHP Resources
Utilize these resources to enhance wellness and navigate the healthcare system.
Navigation
Contact your CHP Coordinator by calling (970) 644-4000 or emailing chp@gjhosp.org.
Your CHP Coordinator can help you with the following:
• Find a primary care provider
• Assist with the new patient process
• Find in-network health care services and facilities
• Specialist referrals/questions
• Narrow network exception process (CHP Hotline)
• Miscellaneous benefit questions
Health Coaching
Health coaching is a FREE personal approach to enhance wellness.
Through a series of interactions, your health coach will help you
determine health priorities, develop strategies and create a plan
of action for:
• Nutrition and exercise evaluation/education
• Chronic disease management
You can receive up to 12 free coaching visits a year!
Can’t leave work? Crunched for time?
We offer telephonic health coaching appointments! Danielle Wells, RN, CHWC
Health Coach
(970) 263-2639
dwells@gjhosp.org
10
11Help, when you need it most
With your Employee Assistance Program and
Work/Life Balance services, confidential assistance
is as close as your phone or computer.
Employee Assistance Program (EAP)
Your EAP is designed to help you lead a happier and more productive life at home and at
Always by your side work. Call for confidential access to a Licensed Professional Counselor* who can helpyou.
• Expert support 24/7
A Licensed Professional Counselor can help you with:
• Convenient website
• Short-term help • Stress, depression, anxiety • Family and parenting problems
• Referrals for additional care • Relationship issues, divorce • Anger, grief and loss
• Monthly webinars • Job stress, work conflicts • And more
• Medical Bill Saver TM
—helps you save on medical bills Work/Life Balance
You can also reach out to a specialist for help with balancing work and life issues. Just
Who is covered? call and one of our Work/Life Specialists can answer your questions and help you find
Unum’s EAP services resources in your community.
are available to all
Ask our Work/Life Specialists about:
eligible employees, their spouses
or domestic partners, dependent • Child care • Financial services, debt management, credit report issues
children, parents and parents-in-law. • Elder care • Even reducing your medical/dental bills!
• Legal questions • And more
• Identity theft
Help is easy to access:
Online/phone support: Unlimited, confidential, 24/7.
In-person: You can get up to 3 visits available at no additional cost to you with a
Licensed Professional Counselor. Your counselor may refer you to resources in your
community for ongoing support.
Employee Assistance Program —Work/Life Balance
Toll-free 24/7 access: Turn to us, when
1-800-854-1446 (multi-lingual) you don’t know
www.unum.com/lifebalance where to turn.
* The counselors must abide by federal regulations regarding duty to warn of harm to self or others. In Services are not valid after coverage terminates. Please contact your Unum representative for details.
these instances, the consultant may be mandated to report a situation to the appropriate authority. Insurance products are underwritten by the subsidiaries of Unum Group.
Unum’s Employee Assistance Program and Work/Life Balance services, provided by HealthAdvocate, unum.com
are available with select Unum insurance offerings. Terms and availability of service are subject to © 2018 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of
change. Service provider does not provide legal advice; please consult your attorney for guidance. Unum Group and its insuring subsidiaries.
EN-2055 (5-18) FOR EMPLOYEES
12TRAVEL BENEFIT
• Call Anthem for pre-authorization of services/treatment by calling
800-542-9402
• Travel Reimbursement related to travel to University of Utah for
medical care.
• Annual maximum benefit is $1,000
• Eligible expenses are transportation, parking fees and tolls,
payable to the standard mileage rate per the IRS;
• Lodging up to $150 per night
• Inform Human Resources you are using this benefit when
your claim form is completed
Retain travel receipts along with
your Anthem Claim Form to HR:
Attn: Brenda Moore or Shelley Vehik
shelley.vehik@mesacounty.us
brenda.moore@mesacounty.us
*This is a separate benefit from the Transplant Travel benefits provide under the Anthem benefits
explained in your Certificate of Insurance.
The above benefits are meant for illustrative purposes only and are only a brief look at your benefits. See your Certificate of Coverage for
details on benefits, network utilization, limitations and exclusions. In the event of a discrepancy the plan document will prevail.
Plan Documents are available via your Mesa Wave Portal. Printed documents are available upon request. 13GoodRx – Stop paying too much for your prescriptions
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14Delta Dental PPO plus Premier
MESA COUNTY – Group # 12141
MAXIMUM BENEFIT $2,000 per member, per calendar year
Calendar Year Maximum
CALENDAR YEAR DEDUCTIBLE Individual Deductible – $50.00 Combination of in and out-of-network
Applies to Basic and Major Services Family Deductible – $100.00 Combination of in and out-of-network
PPO PREMIER NON-PAR
COVERED SERVICES BENEFIT INFORMATION (subject to Delta Dental guidelines)
Dentist Dentist Dentist
DIAGNOSTIC AND PREVENTIVE SERVICES
Twice each in a calendar year. Two additional cleanings may be covered
Oral Exams and Cleanings
for those with a documented EBD condition.
Sealants Once per tooth in a 36-month period for unrestored permanent
molars, through age 14
Bitewing X-Rays Once in a calendar year
100% 100% 100%
Full Mouth X-Rays Once in a 60-month period
Fluoride Twice in a calendar year, through age 15
Space Maintainers One per quadrant, per lifetime to maintain space for eruption of
permanent posterior teeth, through age 13
BASIC SERVICES
Fillings (Composite or Amalgam) Once per tooth in a 12-month period
Simple Extractions
80% 80% 80%
Oral Surgery
Endodontics
MAJOR SERVICES
Periodontics
Crowns Once per tooth in a 60-month period. Not a benefit under age 12.
50% 50% 50% Implants Once per tooth in a 60-month period. Not a benefit under age 16.
Once in a 60-month period, only when existing prosthesis cannot be made
Dentures, Bridges
serviceable. Fixed bridges or removable partials are not a benefit under age
16.
ORTHODONTICS $2,000 lifetime maximum
50% 50% 50% For covered children to age 19
You are enrolled in a Delta Dental PPO plus Premier plan. You and your family members may visit any licensed dentist, but will enjoy the greatest out-of-
pocket savings if you see a Delta Dental PPO dentist. There are three levels of dentists to choose from.
PPO Dentist - Payment is based on the PPO dentist's allowable fee, or the actual fee charged, whichever is less.
Premier Dentist - Payment is based on the Premier Maximum Plan Allowance (MPA), or the fee actually charged, whichever is less.
Non-Participating Dentist - Payment is based on the non-participating Maximum Plan Allowance. Members are responsible for the difference between
the non-participating MPA and the full fee charged by the dentist. You will receive the best benefit by choosing a PPO dentist.
Open Enrollment applies. Members may add coverage once per year.
This is a brief description of services covered under your dental plan. Please refer to the Employee Benefit Booklet for full plan details. If differences
exist between this summary and the Employee Benefit Booklet, the Employee Benefit Booklet will govern.
15A L O O K AT Y O U R
VSP VISION COVE RAGE
S E E H E A LT H Y A N D L I V E H A P P Y
WITH H E L P FROM MESA C O U N T Y
G O V E R N M E N T A N D VSP.
Enroll in VSP® Vision Care to get personalized care from a
VSP network doctor at low out-of-pocket costs.
VALUE AND SAVINGS YOU LOVE. U s i n g your benefit is easy!
Save on eyewear and eye care when you see a VSP network Create an account on v s p . c o m
doctor. Plus, take advantage of Exclusive Member Extras to view your in-network
for additional savings. coverage, find the VSP network
P R O V I D E R C H O I C E S Y O U WANT. doctor who’s right for you, and
With an average of five VSP network doctors within six discover savings with exclusive
miles of you, it’s easy to find a nearby in-network doctor member extras. At your
or retail chain. Plus, maximize your coverage with bonus appointment, just tellthem you
offers and additional savings that are exclusive to Premier have VSP.
Program locations.
Prefer to s h o p online? Use your vision benefits on
Eyeconic®—the VSP preferred online retailer.
QUALITY VISION C A R E YOU NEED.
You’ll get great care from a VSP network doctor, including
a WellVision Exam®—a comprehensive exam designed to
detect eye and health conditions.
G E T Y O U R P E R F E C T PAIR
EXTRA $20 + UP
TO 40%
TO SPEND ON SAVINGS ON L E N S
F E AT U R E D FRAME BRANDS* ENHANCEMENTS
S E E M ORE BRAN DS AT V S P . C O M / O F F E R S .
Contact us: 8 0 0 . 8 77. 7195 or
vsp.com
16VSP DISCOUNTS: EYE CARE & HEARING AIDS
VSP Diabetic Eyecare Plus ®
Available to Covered Persons who have been diagnosed with type 1 or type 2
diabetes and specific ophthalmological conditions .The Program is intended
to be a supplement to Covered Persons group medical plan. Providers will
first submit a claim to Covered Persons group medical insurance plan, and
then to VSP. Any amounts not paid by the medical plan will be considered for
payment by VSP. Examples of symptoms which may result in a Covered
Person seeking services under DEP Plus may include, but are not limited to:
blurry vision, trouble focusing, transient loss of vision, “floating” spots.
Examples of conditions which may require management under DEP Plus may
include, but are not limited to: diabetic retinopathy, rubeosis, and diabetic
macular edema.
TruHearing® is making hearing aids affordable by providing exclusive savings to all VSP® Vision Care members.
You can save up to $2,400 on a pair of hearing aids with TruHearing pricing. What’s more, your dependents
and even extended family members are eligible, too.
In addition to great pricing, TruHearing provides : Plus, with TruHearing you’ll get:
• Three provider visits for fitting, adjustments, and • Access to a national network of more than 4,500
cleanings licensed hearing aid professionals
• 45-day money back guarantee • Straightforward, nationally fixed pricing on a
• Three-year manufacturer’s warranty for repairs and selection of more than 90 digital hearing aids in
one-time loss and damage 400 styles
• 48 free batteries per hearing aid • Deep discounts on replacement batteries shipped
directly to your door
Best of all, if you already have a hearing aid benefit from your health plan or employer, you can combine it
with this program to maximize the benefit and reduce your out-of-pocket expense.
How it works
Call TruHearing. Call 877.396.7194. You and your family members must mention VSP.
Schedule exam. TruHearing will answer your questions and schedule a hearing exam with a local provider.
Attend appointment. The provider will make a recommendation, order the hearing aids through TruHearing
and fit them for you.
Learn more about this VSP Exclusive Member Extra at vsp.truhearing.com or, call 877.396.7194
with questions.
18FLEXIBLE SPENDING ACCOUNT
ENROLLMENT GUIDE
What is a Flexible Spending Account?
A health Flexible Spending Account (FSA) allows individuals to use pre-tax dollars to pay for medical expenses not
covered by insurance.
A dependent care FSA, also known as a Dependent Care Assistance Plan (DCAP) allows individuals to use pre- tax dollars
for day care or dependent care expenses. The dependent care FSA (DCAP) cannot be used to pay for medical expenses.
Individuals elect to contribute a portion of their paychecks to either a health FSA or dependent care FSA and save 25% to
40% in taxes.
Know the Rules: expenses are defined by IRS rules. Expenses gener- ally include
Rules for both the Health FSA and Dependent Care FSA: items and services for the diagnosis, cure, mitigation,
treatment, or prevention of disease, or for the purpose of
• Contributions are subject to the IRS “use-it-or-lose- it” rule. affecting any structure or func- tion of the body. See IRS
However, for the health FSA, the employer may adopt a Publication 502.
provision allowing up to a $500 carry over of unclaimed • Only “out-of-pocket” medical expenses are eligible for
monies. Unclaimed monies not carried over are forfeited at reimbursement. Medical expenses covered by insurance or any
the end of the plan year. other plan or program are not eligi- ble for reimbursement.
• Elections cannot be changed during the plan year, unless the • Expenses for general health, personal use or cos- metic surgery
participant has a change of status. IRS Regulations define a are not eligible for reimbursement. See IRS Publication 502.
change of status.
• Medical expenses reimbursed under the health (medical) FSA
• Expenses must be incurred by a participant, spouse or may not be used to claim a federal income tax deduction.
eligible dependents during the current plan year and while
participating. Expenses are incurred when the medical care is
provided and not when the ex- pense is billed, the bill is due
or when the bill is paid.
Limited Health (dental & vision) FSA
• Every employer sets the deadline when claims and • Employees contributing to a HSA may only partici- pate in a
documentation must be submitted after the end of the “limited” health FSA not a “general” health FSA. A limited
plan year. It is usually 60 or 90 days after the end of the health FSA can only be used to pay for “out of pocket” dental
plan year. and vision expenses.
Health (medical) FSA Dependent Care FSA
• Participants may claim and be paid out their entire • Participants may only be paid what they have con- tributed at
annual election at any time. any point in time.
• Every expense must be substantiated. Participants must be • Participants must be ready to provide receipts for dependent
care expenses.
able to provide receipts, statements or bills for all
expenses if substantiation is requested. Docu- ments must • Dependent care expenses reimbursed by the
include the date, amount and descrip- tion of the expense dependent care FSA may not be used to claim the
or service. day care credit.
• Only eligible expenses can be reimbursed. Medical
Tax Savings Examples:
Dave, a single taxpayer, earns $27,000 per year, and has eligible medical expenses
of $1,200 per year.
Dave’s annual savings realized by participating in the FSA is $327.
Michael and Sharon, working parents, earn a total of $48,000 per year. They have $5,000 in child care
expenses and $1,000 per year in eligible medical expenses.
Their annual savings realized by participating in the FSA is $1,637.
19
Assumptions are based off of 15% Federal, 4.63% State, and 7.65% FICA tax
PO Box 631458 ·Littleton, CO 80163 · (888) 722-1223 · FAX (866) 557-0109
www.RockyMountainReserve.comELIGIBLE EXPENSES
The term “medical care” means diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body.
Common Eligible Medical Over-The-Counter Items: Dual Purpose Expenses
Expenses: That Potentially Qualify:
• Band-aids/bandages The expense must be for a spe-
• Acupuncture • Cold/hot packs for injuries cific medical reason and be ac-
• Ambulance • Condoms companied by a Prescription.
• Bandages • Contact lens solutions
• Birth control pills • Diabetic supplies • Massage therapy
• Breast pumps • First aid kits • Vitamins
• Chiropractor • Medical alert bracelets/necklaces • Supplements
• Coinsurance, deductibles • Pregnancy test kits • Herbal supplements
• Contact lenses • Thermometers • Natural medicines
• Crutches, splints, casts • Aromatherapy
Health Care Reform & • Weight-loss program
• Dental treatment
Over-the-Counter DRUGS: • Health club dues
• Diagnostic devices
• Eyeglasses, eye exams, sunglass- Over-the-Counter Medicine and
es (prescription) Drugs require a Prescription to Ineligible Expenses:
• Eye surgery be eligible for reimbursement un-
der the plan. • Cosmetic surgery
• Fertility enhancement • Long term care
• HMO expenses • Allergy medications • Feminine care
• Hearing aids, batteries, and exams • Antacids • Hair transplant/re-growth
• Hospital services • Anti-diarrhea medicine • Maternity clothes
• Immunizations, vaccines, flu shots • Bug-bite medication • Nutritional supplements
• Laboratory fees • Cold medicine • Personal use items: such as toilet-
• LASIK eye surgery • Cough drops and throat lozenges ries, cotton swabs, tooth brush,
• Medicines (prescribed) • Diaper rash ointments tooth paste, facial care, shampoo
• Obstetric services • Hemorrhoid medication • Teeth whitening
• Optometrist • Incontinence supplies • Drunk driving classes
• Orthodontia • Laxatives
• Prescription drugs • Muscle/joint pain products/rubs
• Psychiatric care • Nicotine medications, gum, patch-
• Psychologist es
• Speech therapy • Pain relievers
• Stop smoking programs • Sinus medications, nasal sprays,
nasal strips
• Surgery/operations
• Sleep aids
• Therapy
• Wart removal medication
• Vasectomy
• Wheelchair These are only examples and this list is not all-inclusive - it only provides some of the
• X-rays more common expenses. Additional information is available in IRS Publication 502
and on our website:
https://www.rockymountainreserve.com
Dependent Care Eligible Expenses:
• A dependent receiving care must be a child under the age of 13, or a tax dependent unable to
provide for their own care, who resides with you. The care must be necessary for you or your
spouse to be gainfully employed or to go to school. Care may be provided by anyone other than
your spouse or your children under the age of 19. Expenses for schooling, kindergarten, over-
night care, and nursing homes are not reimbursable. See IRS Publication 503.
• The maximum you can elect, in a calendar year, is equal to the smallest of the following:
-$5,000 – Married and filing federal taxes jointly or a single parent
-$2,500 – Married and filing separate federal tax return
• The amount contributed year-to-date, is available for reimbursement.
20ACCESS TO YOUR FSA MONEY
Mobile Application
Take a picture of your receipt and submit it with your reimbursement request
through the mobile application. You can also look up your account balance and
recent transactions. To download the mobile application:
Search for “RMR Benefits”
Claim Submission
Participants may file requests for reimbursement directly to Rocky Mountain Reserve through fax, mail, e-mail, mobile applica-
tion or by uploading them directly through the participant website. Disbursements are issued by check or direct deposit.
Claim Forms and Direct Deposit Authorization Forms are online at https://www.rockymountainreserve.com.
Fax: 866.557.0109 E-mail: claims@rmrbenefits.com Mail: PO Box 631458 Littleton, CO 80163
Benefits of Using the Debit Card
• Easy to use- the Benefits Card is a stored value card that simplifies the process of paying for qualified expenses.
• Restricted by merchant code (MCC) to healthcare related merchants where MasterCard is accepted.
• It pays directly at the point of sale - No waiting for reimbursement!
• You can use it to pay for online mail-order prescriptions.
• You must save all receipts and be prepared to provide receipts if they are requested.
No Receipt Retailers
Some retailers have installed an inventory information approval system and for
most medical expenses receipts will not be requested.
Please note: Under current law the debit card cannot be used to pay for
over-the-counter drugs. Below is a sample of some of the retailers who have
installed the inventory information approval system:
1-800 Contacts CVS Rite Aid Walgreens
Albertsons Drugstore.com Safeway Walmart
City Market King Soopers Sam’s Club VisionDirect.com
Costco Kroger Target
Save All Receipts For Purchases Made With The Benefit Card
Please remember to keep receipts for all purchases made with the Benefit Card. Per IRS regulations, Rocky
Mountain Reserve may request itemized receipts to verify the eligibility of purchases made with the card.
• All receipts or other proofs of purchase must include the date of service, name of provider, dollar amount,
and a description of the purchased service or product.
• Any receipt that does not contain the detailed information described above is not acceptable. Credit card
receipts and cancelled checks are not acceptable.
• If the requested receipt is lost or otherwise unavailable, most providers can provide a detailed statement
documenting FSA eligible purchases. Explanation of Benefits (EOB’s) are sufficient documentation to sub-
stantiate a transaction.
• Additional documentation will be requested UNLESS the transaction matches a co-payment, a previously
approved repetitive expense, or was at a merchant that has installed the inventory information approval
system referenced above.
• If a receipt is requested, Rocky Mountain Reserve will email a request within hours. Participants can mail,
fax, email, upload the receipt online, or take a picture and submit it through the mobile app.
21ONLINE ACCESS
https://www.rockymountainreserve.com
Online Access Includes:
• View balance.
• View transaction history.
• Download statements.
• Submit claims and upload receipts.
• View debit card receipt requests
and upload receipts.
To Create Your Online Account:
1. Go to https://www.rockymountainreserve.com
2. Click on: Employee.
3. Click on: FSA/HRA.
4. Click on: Create Account.
5. Follow the Instructions.
6. Username will be the name you use to login for the web portal and mobile application.
7. The password must contain 3 of 4 requirements: Upper case letter, lower case letter, special charter, or
number.
8. For Employee ID Use SS# or other assigned Employee ID.
9. For Registration ID select “Card Number” which is your “Benefits Card” MasterCard. If you do not have a
MasterCard your Employer will be assigned an Employer ID for all employees.
MOBILE APPLICATION
GAIN REAL-TIME ACCESS TO YOUR
FLEXIBLE SPENDING ACCOUNT (FSA)
HEALTH REIMBURSEMENT ARRANGEMENT (HRA)
HEALTH SAVINGS ACOUNT (HSA)
SEARCH FOR:
“RMR BENEFITS”
For questions or problems logging into your account, please call our help center at: 888.722.1223.
22FLEXIBLE SPENDING ACCOUNTS
Health Care
The Health Care account allows you to set aside up to $2,700 in pre-tax dollars to pay most out-of-pocket medical,
dental or vision expenses, including deductibles and copayments, eye glasses, dental and orthodontic work not
covered by insurance.
You decide how much to deposit into your Health Care account. Your election amount is evenly deducted pre-tax
from your paycheck throughout the plan year. When you have an expense that qualifies, you pay the bill, submit a
claim, and you are reimbursed with tax-free dollars from your account.
If you don’t use all the money you deposited in your account, you will forfeit any balance in the account at the end of
the plan year. However, if you have unused contributions in your Health Care account from the immediately
preceding plan year, you can carry over up to $500 at the end of the plan year to the following year. Anything above
the $500 amount is lost. You have 90 days after the plan year ends to submit claims for expenses incurred during that
plan year.
Dependent Care
The Dependent Care account allows you to set aside tax-free income to pay for qualified dependent care expenses,
such as day care, that you would normally pay with after-tax dollars. Qualified dependents include children under age
13 and/or dependents who are physically or mentally unable to care for themselves. If your spouse is unemployed or
doing volunteer work, you cannot set up a dependent care account. You must meet the following criteria in order to
set up this account:
• You and your spouse both work;
• You are the single head of household;
• Your spouse is disabled or a full-time student.
Each calendar year the IRS allows you to contribute the following amounts, depending on your family status:
• If you are single, the lesser of your earned income or $5,000
• If you are married, you can contribute the lowest of
o Your (or your spouse’s) earned income
o $5,000 if filing jointly or $2,500 if filing separately
Once Enrolled, You May Not Change Your Election
You cannot change your annual election after the beginning of the plan year. However, there are certain limited
situations when you can change your elections if you have qualified change in status.
Flexible Spending Account – Eligible Expenses
Your Health Care Reimbursement Flexible Spending Account lets you pay for medical care expenses not covered by
your insurance plan with pre-tax dollars. The expenses must be primarily to alleviate a physical or mental defect or
illness, and be adequately substantiated by a medical practitioner. The products and services listed on the next page
are examples of medical expenses eligible for payment under your FSA, to the extent that such services are not
covered by your medical and/or dental insurance plan.
Unfortunately, we cannot provide a definitive list of “qualified medical expenses”. A determination of whether an
expense is for “medical care” is based on all the relevant facts and circumstances. To be an expense for medical care,
the expense has to be primarily for the prevention or alleviation of a physical or mental defect or illness.
23Flex Spending Account – Eligible Expenses
• Acupuncture • Eyeglasses, prescription • Oxygen
• Adoption (medical expenses) • Fertility/Infertility treatments • Personal trainer fees
• Alcoholism treatment • First aid kits (if for medical condition)
• Ambulance • Flu shots • Physical exams
• Artificial limbs & teeth • Genetic testing (only to diagnose med. condition) • Physical therapy
• Asthma treatments • Glucose monitoring equipment • Prescription drugs
• Bandages/Gauze • Guide dog/other animal aid • Preventive care screenings
• Birth control pills • Hearing aids • Prostheses
• Blood pressure monitoring devices • Hospital services • Psychiatric care
• Blood sugar test kit and test strips • Incontinence supplies • Psychologist
• Breast reconstruction surgery • Insulin • Reading glasses, prescription
following mastectomy • IVF (in vitro fertilization) • Smoking cessation programs
• Chiropractor • Laboratory fees & medications
• coinsurance & deductibles • Laser eye surgery/Lasik • Speech therapy
• Contact lenses • Massage therapy (only if recommended by a • Sterilization procedures
• Copayments physician to treat a specific trauma or injury) • Surgery/Operations
• Counseling (except marriage) • Nutritionist’s professional expenses (if treatment • Therapy
• Crutches relates to specifically diagnosed medical condition) • Thermometers
• Deductibles • Obstetrical expenses • Ultrasound (prenatal)
• Dental treatment (except cosmetic) • Optometrist • Vaccines/Immunizations
• Dentures and denture adhesives • Organ donors/transplants • Vasectomy and reversals
• Diabetic supplies • Orthodontia • Wheelchair
• Drug addiction treatment • OTC drugs (only with a prescription) • X-ray fees
Flexible Spending Plan Worksheet
This form is designed to help you estimate what you will spend on eligible insurance, dependent care and unreimbursed medical
expenses during the period of coverage. It is important to estimate your expenses during the last two years. Review your
checkbook register, tax records and expense vouchers. Use this information to complete the form, but remember to be
conservative in your estimates. If you overestimate your expenses and do not use them during the Plan Year, you will lose them.
Unreimbursed Medical Expenses
Hearing
Medical Exams $
Deductible $ Hearing Aids $
Medical copayments $
Office Visits $ Total Unreimbursed $
Physical Exams $
Prescription Drugs $ Medical Expenses
Non-Prescription Drugs $
Hospital Services $ Dependent Care (maximums for dependent care are
Psychologist Services $ based on calendar year, per IRS guidelines)
Chiropractic Services $ Use the total expenses estimated on your Dependent
Medical Aids (crutches, etc.) $ Care Work Sheet
Dental Total Dependent Care $
Exams $
Fillings $
Braces $
Dentures $
Vision
Exams $
Eyeglasses $
Contacts $ 24LIFE INSURANCE
Mesa County provides eligible employees (at no cost to the employee) Basic Life/AD&D coverage. All regular full-time
employees scheduled to work at least 20 hours each week in active employment in the U.S. will be enrolled in the group
Life/AD&D plan.
Life Insurance Amount
$20,000
Reduction Schedule Benefits are reduced to 65% at age 65; to 40% of the original amount at age 70,
and to 25% of the original amount at age 75.
Accidental Death &
Dismemberment (AD&D) Loss: Amount of Additional Benefit Paid:
Life 100%
Loss must occur while One Limb 50%
insured and within 365 days Speech & Hearing 100%
after the accident is Speech or Hearing 50%
sustained Thumb & Index Finger of Same Hand 25%
Quadriplegia 100%
The total benefit paid for all Paraplegia 75%
losses due to the same Hemiplegia 50%
accident will not be more Sight of One Eye 50%
than 100%
If you are certified as terminally ill with a life expectancy of 12 months or less, you
Accelerated Benefit
may elect to receive a portion of your life insurance benefit up to 75% in advance.
Upon death, your beneficiary will receive the balance of your benefit.
Safe Driver Benefit (seatbelt & airbag)
Dependent Education Benefit
Child Care Benefit
Additional Benefits Disappearance & Exposure
Child Education
Repatriation
Portability
$5,000 Spouse (no age reduction)
Basic Employee-Paid
Child(ren) 14 days to 6 months - $1,000 / Age 19 or 26 if a full-time student -
Voluntary Dependent Life: $2,500
*The above benefits are meant for illustrative purposes only and are only a brief look at your benefits. See your plan document for details
on benefits, limitations and exclusions. In the event of a discrepancy the plan document will prevail.
Certificate of Insurance is available via your Mesa Wave Portal. Printed documents are available upon request. 25Employer Paid Life/AD&D Insurance Continued…
Insured by Unum
Personalized financial counseling provides expert, objective financial counseling to
survivors and terminally ill employees at no cost. The financial consultants are
Life Planning Financial &
master level consultants that will not offer to sell any product or service. They will
Legal Resources
help develop strategies needed to protect resources, preserve current lifestyles,
and build future security.
If you become totally disabled for 6 months while insured, your life insurance will
Waiver of Premium continue without payment to age 70 if the disability began prior to age 65. If total
disability ends, you may exercise the conversion privilege.
If your insurance terminates because you are no longer employed full-time, your
insurance may be converted to an individual life insurance policy if you apply and
Conversion
include payment of the first premium within 31 days of termination.
Conversion does not require proof of medical insurability.
To complement your Group Life Insurance coverage, you and your immediate family
have access to Emergency Travel Assistance administered by Assist America.
Emergency Travel Assistance offers you and your dependents worldwide medical,
travel, concierge and legal and financial assistance services, 24 hours a day, 365 days
a year.
If you have a medical emergency while you are more than 100 miles away from
home, you don’t have to face it alone. With one phone call you can be connected to
Assist America’s staff of medically trained, multilingual professionals who can advise
you in a medical emergency, 24x7. No matter where you are in the world, they will
help you access or receive:
Travel Assistance Benefits
Pre-qualified, English-speaking professionals working in hospitals, pharmacies, and
dental offices; Medical consultation, evaluation and referral; Hospital admission,
critical care monitoring, emergency medical evacuation, transportation to return
home or to a rehabilitation facility, lost prescription assistance, legal and interpreter
services, and more.
Assist America pays for 100% of the services it arranges for and provides.
Your spouse and dependent children up to age 19 are also covered.
This is just a summary of your benefits. Please refer to your certificate booklet for a complete plan description. If
the terms of this summary differ from the Certificate, the Certificate will govern.
26VOLUNTARY LIFE AND AD&D INSURANCE
Employee: Up to 5 times earnings in increments of $10,000. Not to exceed $400,000.
Spouse: Up to 100% of employee amount or $200,000, in increments of $5,000.
Coverage Amounts
(Term Life and AD&D) Children: $10,000 of coverage if eligible. Maximum death benefit for a child between
the ages of live birth and 6 months is $1,000.
Reduction Schedule
Benefits are reduced to 65% at age 70, and to 50% of the original amount at age 75
$200,000 for yourself and any amount of coverage up to $30,000 for your spouse. Any
Guarantee Issue Life insurance coverage over the Guarantee Issue amount(s) will be subject to
evidence of insurability.
Loss: Amount of Benefit Paid:
Accidental Death &
Life 100%
Dismemberment
Both Hands 100%
(AD&D)
Both Feet 100%
Sight of Both Eyes 100%
One Hand & Sight of One Eye 100%
The total benefit paid for
One Foot & Sight of One Eye 100%
all losses due to the same
Speech & Hearing 100%
accident will not be more
than 100%
Other losses may be covered.
Education Benefit: If you or your insured spouse die within 365 days of an accident, an
additional benefit is paid to your dependent child(ren). Your child(ren) must be a full-
Additional AD&D time student beyond grade 12.
Benefits Seat Belt/Air Bag Benefit: If you or your insured dependent(s) die in a car accident and
are wearing a properly fastened seat belt and/or are in a seat with an air bag, an
amount will be paid in addition to the AD&D benefit.
*The above benefits are meant for illustrative purposes only and are only a brief look at your benefits. See your plan document for details
on benefits, limitations and exclusions. In the event of a discrepancy the plan document will prevail.
Certificate of Insurance is available via your Mesa Wave Portal. Printed documents are available upon request. 27Voluntary Life/AD&D Insurance Continued…
Insured by Unum
Each year you will be given the opportunity to change your Life and AD&D coverage, and may purchase additional
life insurance up to the guarantee issue amounts without evidence of insurability as long as you are already
enrolled in the plan (even at a minimum of $10,000).
If you waived coverage when you were first eligible and want to apply at a later date, all amounts are subject to
evidence of insurability – there is no guarantee issue available.
If you become terminally ill and are not expected to live beyond a certain time
period as stated in your certificate booklet, you may request up to 75% of your life
Accelerated Benefit insurance amount up to $250,000, without fees or present value adjustments. A
doctor must certify your condition in order to qualify for this benefit. Upon your
death, the remaining benefit will be paid to your designated beneficiary(ies).
Personalized financial counseling provides expert, objective financial counseling to
survivors and terminally ill employees at no cost. The financial consultants are
master level consultants that will not offer to sell any product or service. They will
Life Planning Financial &
help develop strategies needed to protect resources, preserve current lifestyles, and
Legal Resources build future security.
If you become disabled (as defined by your plan) and are no longer able to work,
your premium payments may be waived during the period of disability.
Waiver of Premium
If you retire, reduce your hours or leave your employer, you can take this coverage
with you according to the terms outlined in the contract. However, if you have a
medical condition which has a material effect on life expectancy, you will be
Portability/Conversion ineligible to port your coverage. You may also have the option to convert your Term
life coverage to an individual life insurance policy.
Life benefits will not be paid for deaths caused by suicide in the first twenty-four
months after your effective date of coverage.
Suicide Exclusion
This is just a summary of your benefits. Please refer to your certificate booklet for your complete plan description.
If the terms of this summary differ from the Certificate, the Certificate will govern. 28LONG-TERM DISABILITY INSURANCE
Monthly Benefit 60% of monthly earnings to a maximum benefit of $6,000, reduced by other income
(UNUM)
Elimination Period Benefits will begin after 180 days of disability
Benefit Duration Your duration of benefits is based on your age when the disability occurs. Your LTD benefits are
payable for the period during which you continue to meet the definition of disability up to the Social
Security Normal Retirement Age. If your disability occurs on or after age 62, benefits would be paid
for a reduced period of time.
Disability Definition You are disabled when Unum determines that:
• you are limited from performing the material and substantial duties of your regular occupation
due to your sickness or injury; and
• you have a 20% or more loss in weekly earnings due to the same sickness or injury.
• After benefits have been paid for 24 months, you are disabled when Unum determines that due to
the same sickness or injury, you are unable to perform the duties of any gainful occupation for
which you are reasonably fitted by education, training or experience.
You must be under the regular care of a physician in order to be considered disabled.
Gainful Occupation Gainful occupation means an occupation that is or can be expected to provide you with an income
within 12 months of your return to work that exceeds:
• 80% of your indexed monthly earnings, if you are working
• 60% of your indexed monthly earnings, if you are not working
Pre-Existing Conditions If you received treatment 3 months prior to your effective date under this plan and are disabled from
that condition within the first 12 months, that disability will be excluded.
Rehabilitation and Unum has a vocational Rehabilitation and Return to Work Assistance program available to assist you
Return to Work in returning to work. We will make the final determination of your eligibility for participation in the
Assistance program, and will provide you with a written Rehabilitation and Return to Work Assistance plan
developed specifically for you. This program may include, but is not limited to the following benefits:
• coordination with your Employer to assist your return to work;
• adaptive equipment or job accommodations to allow you to work;
• vocational evaluation to determine how your disability may impact your employment options;
• job placement services;
• resume preparation;
• job seeking skills training; or
• education and retraining expenses for a new occupation.
If you are participating in a Rehabilitation and Return to Work Assistance program, we will also pay an
additional disability benefit of 10% of your gross disability payment to a maximum of $1,000 per
month. In addition, we will make monthly payments to you for 3 months following the date your
disability ends, if we determine you are no longer disabled while:
• you are participating in a Rehabilitation and Return to Work Assistance program; and
• you are not able to find employment.
Survivor Benefit If you die after receiving benefits for 180 or more consecutive days, your eligible survivors will receive
a lump sum benefit equal to three months of your gross disability payment.
This is just a summary of your benefit. Please refer to your certificate booklet for your complete plan description. If the terms of this summary
differ from your Certificate, the Certificate will govern. 29You can also read
