2021 Employee Benefits Packet - The University of Memphis
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Employee Benefits
Packet
2021
The University of Memphis is an Affirmative Action/Equal Opportunity Employer
University Benefits Administration
165 Administration Bldg., Memphis, TN 38152, Phone: (901) 678-3573 Fax: (901) 678.1650
Contents
General Insurance Information............................................................................ 1 - 3
Basic Health Insurance ....................................................................................... 4 - 7
Benefit Comparison – State and Higher Education ............................................ 8 , 9
Monthly Premiums for Active Employees .................................................. 10
Pharmacy Benefits................................................................................................ 11
Dental Insurance ................................................................................................... 12
Dental Insurance Plan Comparison .......................................................... 13
Vision Insurance.................................................................................................... 14
Basic Plan ................................................................................................. 14
Expanded Plan .......................................................................................... 14
Vision Insurance Comparison Chart ......................................................... 15
Insurance Cards ................................................................................................... 16
Basic Term Life and Accidental Death & Dismemberment Insurance .................... 17
Voluntary Special Accidental Insurance ................................................................. 17
Voluntary Optional Term Life Insurance ................................................................ 17
Basic Term Life Insurance Chart .......................................................................... 18
Voluntary Accidental Death & Dismemberment Insurance .................................... 19
Flexible Spending Accounts ................................................................................. 20
FSA Contributions Limits........................................................................... 20
Short Term Disability ............................................................................................. 21
Long Term Disability Insurance ............................................................................. 22
State of TN Retirement Programs......................................................................... 25
Hired before July 1, 2014 .......................................................................... 25
ORP and TCRS Comparison Chart .......................................................... 26
Hired before July 1, 2014 .......................................................................... 26
State of TN Retirement Programs......................................................................... 27
Eligibility .................................................................................................... 27
Tennessee Consolidate Retirement System Hybrid Plan .......................... 27
TCRS Program Highlights ......................................................................... 28
TCRS Contributions and Match: ............................................................... 28
Optional Retirement Program (ORP) ........................................................ 29
Optional Retirement Program Highlights ................................................... 29
ORP Contributions and Match: ................................................................. 29
ORP and TCRS Comparison Chart .......................................................... 30
Hired after July 1, 2014 ............................................................................. 30
Tax Deferred Annuity and Deferred Compensation Plans ..................................... 31
Annual Leave and Sick Leave ............................................................................... 32
Sick Leave Banks ................................................................................................. 33
Longevity .............................................................................................................. 33
Workers' Compensation ....................................................................................... 33
Family Medical Leave Act...................................................................................... 34
Educational Assistance Programs ......................................................................... 35
Employee Assistance Program .............................................................................. 36
Employee Discounts ............................................................................................. 37
Notice to TennCare Enrollees ............................................................................... 38
COBRA ................................................................................................................. 39
HIPAA ................................................................................................................... 40
Holiday Schedule .................................................................................................. 41
Quick References ................................................................................................. 42
General Insurance Information
Effective Date of Insurance
The following will be effective on the first day of the month after one (1) full calendar
month of employment from your hire date:
• Health
• Dental
• Vision
• Basic Term Life and Accidental Death and Dismemberment
• Optional Special Accidental Death and Dismemberment
• Short Term Disability
For example, if your hire date is August 23, the above insurance coverage begins
October 1. Optional term life coverage will begin after three (3) full calendar months of
employment.
Payroll deductions for insurance premiums are made a month in advance for most
plans. A few plans, such as Long-Term Disability and Flexible Spending Accounts (FSA),
allow premiums to be paid the same month the coverage is effective. Example: health
insurance premiums are deducted from your paycheck in August for September
coverage, and long-term disability premiums are deducted from your pay in September
for coverage in September.
Employee Eligibility
• Full-time employees regularly scheduled to work a minimum of 30 hours a week
for a period expected to exceed six (6) months
• Faculty employed a minimum of 30 hours a week for the full academic year
• Part-time employees with 24 months of service regularly working a minimum of
1450 hours per year
Dependent Eligibility
• Spouse (legally married)
• Natural (biological) or adopted children
• Stepchild(ren)
• Children whom you are the legal guardian
• Children for whom the plan has received a qualified medical child support order
Dependent children are eligible for coverage through the last day of the month of
their 26th birthday.
PROOF OF ALL DEPENDENT’S ELIGIBILITY IS REQUIRED BY THE STATE OF TN
Review the list of Dependent Definitions and Required Documents on page 2 for
clarification. Dependents must be verified by submitting a copy of the required documentation
before they can be enrolled. Please mark/black out any personal financial information on the
copies of your documents.
1
Dependent Eligibility Definition &
Required Documents
TYPE OF DEPENDENT DEFINITION REQUIRED DOCUMENT(S) FOR VERIFICATION
You will need to provide a document proving marital relationship AND a document proving
joint ownership
Proof of Marital Relationship
• Government issued marriage certificate or license
• Naturalization papers indicating marital status
Proof of Joint Ownership
A person to whom the • Bank Statement issued within the last six (6) months with both name; or
Spouse • Mortgage Statement issued within the last six (6) months with both names; or
participant is legally married
• Residential Lease Agreement within the current terms with both names; or
• Credit Card Statement issued within the last six (6) months with both names; or
• Property Tax Statement issued within the last 12 months with both names; or
• The first page of most recent Federal Tax Return filed showing “married filing jointly” (if
married filing separately, submit page 1 of both returns) or form 8879 (electronic filing)
If just married in the current calendar year, a marriage certificate only is acceptable
proof of eligibility
The child’s birth certificate; or
Certificate of Report of Birth (DS-1350); or
Natural (biological) child
A natural (biological) child
under age 26
Consular Report of Birth Abroad of a Citizen of the United States of America (FS-240); or
Certification of Birth Abroad (FS-545)
Court documents signed by a judge showing that the participant has adopted the child; or
A child the participant has
Adopted child under age 26 adopted or is in the process International adoption papers from country of adoption; or
of legally adopting
Papers from the adoption agency showing intent to adopt
Child whom the participant is A child for whom the
Any legal document that establishes guardianship
legal guardian participant is legal guardian
Verification of marriage between employee and spouse and birth certificate of the child
showing the relationship to the spouse; or
Stepchild under age 26 A stepchild
Any legal document that establishes relationship between the stepchild and the spouse or
the member
A child who is named as an Court documents signed by a judge; or
alternate recipient with
Child for whom the plan has
respect to the participant
received a Qualified Medical
under a Qualified Medical
Child Support Order Medical support orders issued by a state agency
Child Support Order
(QMCSO)
A dependent of any age
(who falls under one of the
categories previously listed)
and due to a mental or
physical disability, is unable Documentation will be provided by the insurance carrier at the time incapacitation is
Disabled dependent to earn a living. The determined
dependent’s disability must
have begun before age 26
and while covered under a
state-sponsored plan.
Never send original documents. Please mark out or black out any Social Security numbers and any personal information.
2
Special Enrollment Process
If you do not enroll in medical insurance as a new hire, you or your dependents may
apply for coverage by providing supporting documentation that one of the following
qualifying events has occurred within the past 60 days and caused loss of coverage:
• Death of employee’s spouse
• Divorce or legal separation
• Termination of spouse’s employment
• Reduction in spouse’s work hours below number required for benefits Spouse’s
employer discontinues total contributions to spouse’s coverage Loss of
TennCare coverage (excluding loss for lack of payment)
• You may also apply within 60 days of acquiring a new dependent (marriage,
birth/adoption) without proving a loss of coverage.
Annual Enrollment Transfer Period (AETP)
During the fall of each year, you will have an opportunity to:
• Enroll in, cancel or transfer between health options and carriers
• Enroll in, cancel or transfer between dental and vision options
• Enroll in, increase or decrease Voluntary Term Life Insurance
• Enroll in Voluntary Special Accidental Death and Dismemberment Insurance
Most changes you request start the following January 1. However, voluntary term life
coverage may start January 1, February 1 or March 1.
Benefit information will be mailed to you and this information should be reviewed carefully
to make the best decisions for you and your dependents.
Insurance Handbook
The Eligibility and Enrollment Guide includes detailed information related to our
insurance plans and a HIPAA information notice. The Guide may be viewed
at https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/2021Guide_st.pdf
and a printed copy is available during orientation.
You will find links to the Insurance Handbook and all vendor handbooks at this site.
Benefits Administration: http://tn.gov/finance/article/fa-benefits-publications
3Basic Health Insurance
Choice of three health insurance options:
• Premier Preferred Provider Organization (PPO)
• Standard PPO
• Consumer-driven Health Plan (CDHP)
With each healthcare option, you can see any doctor you want. However, each carrier
has a list of doctors, hospitals and other healthcare providers that you are encouraged
to use. These providers make up a network. You can visit any doctor or facility that is in
the network. These providers have agreed to take lower fees for their services. Network
providers will always cost you less. The cost is higher when using out-of-network
providers.
Each healthcare option covers the same services, treatments and products, including
the following:
• Provides the same comprehensive health insurance coverage
• Offers the same provider networks
• Covers in-network preventive care (annual well visit, routine screenings) at no
cost to you
• Covers maintenance prescription drugs without having to first meet a deductible
• Has a deductible
• Has out-of-pocket maximums to limit your costs
However, there are some differences between the PPOs and CDHP.
Preferred Provider Organizations (PPOs)
• Higher monthly premium but have a lower deductible
• Fixed copays for doctor office visits and prescription drugs without first having to
meet your deductible
• Pay deductible first before coinsurance applies
• When out-of-pocket maximum is reached the plan pays 100% for in-network
services
Consumer Driven Health Plan (CDHP)
• Lower monthly premium but have a higher deductible
• You pay the full discounted network cost for ALL healthcare expenses, including
pharmacy, until you meet your deductible
• You receive a tax-free health savings account (HSA) which can be used to cover
your qualified medical expenses, including your deductible
• Coinsurance after you meet your deductible
• Lower total out-of-pocket maximum compared to PPOs
CDHP option:
• If you choose this plan, the state will put $250 for employee coverage or $500 for
family coverage in your HSA for you to use tax free for qualified medical
4expenses.
• New enrollees with coverage effective dates Sept 2 through the end of the year,
will not receive a state contribution in 2021.
Health Savings Account (HSA)
A health savings account (HSA) is a tax-exempt account that individuals can use to pay
or save money for qualified medical expenses on a tax-free basis. The HSA is
administered by PayFlex. The money in the account earns interest and when it reaches
$1,000 you can invest it.
The HSA is triple tax-free:
• Your contributions are made pre-tax,
• Your account balance earns interest tax-free, and
• Your distributions are tax-free if they are used for eligible medical expenses.
You can contribute money through payroll deduction if you wish. The money in the HSA
is your money. The balance rolls over at the end of the year. As long as you use it for
eligible medical expenses it will be tax free. And if you leave or retire, you take it with
you. It can help fund health expenses tax free when you retire and at 65, it can be used
for non-medical expenses with no penalty charges (but it will be taxed). If you use the
HSA money for non-medical expenses prior to 65, you will pay a penalty as well as taxes.
You will set up your own online HSA account when you enroll in the CDHP. You can pay
for services online or with a debit card that will be provided by PayFlex. You can order
additional cards for your spouse or dependent.
HSA Contribution Limits
• IRS guidelines allow total tax-free annual contributions up to $3,600 for individuals
and $7,200 for families in 2021.
• At age 55 and older, you can make an additional $1,000/year contribution.
HSA Restrictions
You cannot enroll in a CDHP if you are enrolled in another plan, your spouse’s plan, or
any government plan (e.g., Medicare A and/or B, Medicaid).
If you are eligible for VA medical benefits and did not receive benefits during the
preceding three months, you can enroll in and make contributions to your HSA. If you
receive VA benefits in the future, then you are NOT entitled to contribute to your account
for another three months. Restrictions may apply. Go to IRS.gov to learn more.
Wellness Program
Members and enrolled spouses can get cash rewards for participating in the voluntary
wellness program. You can get money deposited through payroll* by completing certain
activities and programs.
Regardless of the health plan you choose, members and enrolled spouses will first
complete two requirements that may make them eligible for other programs. These
requirements are:
5• Health risk assessment (online questionnaire)
• Biometric screening at a worksite location or from your doctor
After members complete these two requirements, they will receive a cash deposit into
their paycheck. Then, they’ll find out if they qualify for other rewards and programs.
Members who qualify can also get cash rewards for completing one or more programs.
These additional programs could include:
• Weight loss/weight management program
• Tobacco cessation program
• Wellness counseling (diet, stress, exercise, etc.)
• Disease management program
• Diabetes Prevention Program (DPP)
There will also be wellness challenges, educational tools and other online wellness
resources to help members track their results and progress.
*Members must be in a positive pay status to receive an incentive. The cash incentive
for both the employee and eligible spouse will be deposited directly into the member’s
paycheck and will be taxed.
Basic Features of the Health Options:
PPOs (Premier & Standard) CDHP/HSA
Covered Services Each option covers the same set of services
Preventive Care – Routine screenings and
Covered at 100% (no deductible)
preventive care
Employee Contribution – Premium Higher than the CDHP Lower than the PPOs
Deductible – The dollar amount of covered
services you must pay each calendar year Lower than the CDHP Higher than the PPOs
before the plan begins reimbursement
Physician Office Visits – Includes specialists
You pay fixed copays without having to first meet You pay the discounted network cost until the
and behavioral health and substance use
your deductible deductible is met, then you pay coinsurance
services
Non-Office Visit Medical Services –
Hospital, surgical, therapy, ambulance, You pay the discounted network cost until the deductible is met, then you pay coinsurance
advanced x-rays
You pay for the medication at the discounted
You pay fixed copays without having to first meet network cost until your deductible is met – then
Prescription Drugs
you deductible you pay coinsurance until you meet the out-of-
pocket maximum
Out-of-Pocket Maximum – The most you pay
for coverer services; once you reach the out- Higher than the CDHP Lower than the PPOs
of-pocket maximum, the plan pays 100%
The state will contribute $250 for single coverage
Health Savings Account None and $500 for family coverage to help offset the
deductible – your contributions are pre-tax
Choice of three insurance carrier networks (regardless of whether you choose the
PPOs or the CDHP):
• BlueCross BlueShield of Tennessee Network S — there is no additional cost for
this network. In 2021 in the Memphis market, Methodist facilities will be out-of-
network, and Baptist facilities will be in-network. All Methodist provider groups
(i.e., physicians, nurse practitioners) will remain in-network.
• Cigna LocalPlus — there is no additional cost for this network. This is a smaller
network than Cigna Open Access Plus.
• Cigna Open Access Plus — this is a large network with a choice of more doctors
6and facilities, but you will pay more. In 2021 in the Memphis market, Baptist
facilities will be out-of-network, but Methodist facilities will remain in-network.
Monthly surcharges will apply (included in the premium):
⎯ $40 more each month for employee only coverage
⎯ $40 more each month for employee+child(ren) coverage
⎯ $80 more each month for employee+spouse coverage
⎯ $80 more each month employee+spouse+child(ren) coverage
BlueCross BlueShield of Tennessee and Cigna administer the health insurance options.
Each carrier has its own network of preferred doctors, hospitals and other healthcare
providers. Many doctors are in more than one network. Check the networks carefully
for your preferred doctor or hospital when making your selection.
The carriers' covered services are generally the same whether you choose BlueCross
BlueShield of Tennessee or Cigna. For some procedures, different medical criteria may
apply based on the carrier you select. For detailed information on covered services,
exclusions and how the plans work, view the insurance carriers' member handbooks,
available on the Benefits Administration website.
If both you and your spouse are employees of the State of Tennessee, you have the
choice of enrolling in separate plans or having one spouse cover the other. Be sure to
discuss this with a Benefits staff member as it will affect the Basic Term Life coverage
amount of the dependent spouse.
(There is a chart of covered services and their associated costs on pages 8-9.)
Transferring between health plans
You will have an opportunity to transfer between health insurance plans during the
Annual Enrollment Transfer Period (AETP) held each year during the fall. Changes
made during the AETP become effective January 1 of the following year.
Cancellation of health insurance
Health insurance premiums are automatically paid on a pre-tax basis. Therefore,
cancellations or changes may only be processed with a valid family status change or
during the AETP.
Additional information:
BlueCross BlueShield of TN Network S – (800) 558-6213
• Website: https://www.bcbst.com/members/tn_state/
• Provider Directory: https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/directory_bc_2021pdf
• Hospital Directory: https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/directory_bc_hospitals_2021pdf
CIGNA LocalPlus – (800) 997-1617
• Website: https://www.cigna.com/sites/stateoftn/
• Provider Directory: https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/directory_cigna_lp_2021.pdf
• Hospital Directory: https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/
directory_cigna_lp_hospitals_2021.pdf
CIGNA Open Access Plus – (800) 997-1617
• Website: https://www.cigna.com/sites/stateoftn/
• Provider Directory: https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/directory_cigna_oap_2021pdf
• Hospital Directory: https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/
directory_cigna_oap_hospitals_2021.pdf
7Benefit Comparison – State and Higher Education
PPO services in this table ARE NOT subject to a deductible and costs DO APPLY to the annual out-of-pocket maximum. CDHP services in this table ARE subject to a deductible with the exception of preventive care and 90-day supply maintenance
medications. Costs DO APPLY to the annual out-of-pocket maximum.
PREMIER PPO STANDARD PPO CDHP / HSA
[1] [1]
COVERED SERVICES IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK [1]
PREVENTIVE CARE
Office Visits
• Well-baby, well-child visits as recommended
• Adult annual physical exam
• Annual well-woman exam
• Immunizations as recommended No charge $45 copay No charge $50 copay No charge 40% coinsurance
• Annual hearing and non-refractive vision screening
• Screenings including colonoscopy, mammogram and colorectal, Pap
smears, labs, bone density scans, nutritional guidance, tobacco
cessation counseling and other services as recommended
OUTPATIENT SERVICES
Primary Care Office Visit
• Family practice, general practice, internal medical, OB/GYN and
pediatrics
• Nurse practitioners, physician assistants and nurse midwives (licensed $25 copay $45 copay $30 copay $50 copay 20% coinsurance 40% coinsurance
healthcare facility only) working under the supervision of a primary care
provider
• Including surgery in office setting and initial maternity visit
Specialist Office Visit
• Including surgery in office setting
$45 copay $70 copay $50 copay $75 copay 20% coinsurance 40% coinsurance
• Nurse practitioners, physician assistants and nurse midwives (licensed
healthcare facility only) working under the supervision of a specialist
Behavioral Health and Substance Abuse [2]
$25 copay $45 copay $30 copay $50 copay 20% coinsurance 40% coinsurance
• Including virtual visits
Telehealth $15 copay N/A $15 copay N/A 20% coinsurance N/A
Allergy Injection 100% covered 100% covered up to MAC 100% covered 100% covered up to MAC 20% coinsurance 40% coinsurance
$25 copay primary; $45 copay primary; $30 copay primary; $50 copay primary;
Allergy Injection with Office Visit 20% coinsurance 40% coinsurance
$45 copay specialist $70 copay specialist $50 copay specialist $75 copay specialist
Chiropractors Visits 1-20: $25 copay Visits 1-20: $45 copay Visits 1-20: $30 copay Visits 1-20: $50 copay
20% coinsurance 40% coinsurance
• Limit of 50 visits per year Visits 21-50: $45 copay Visits 21-50: $70 copay Visits 21-50: $50 copay Visits 21-50: $75 copay
PHARMACY
$7 copay generic; $14 copay generic;
Copay plus amount Copay plus amount 40% coinsurance plus
30-Day Supply $40 copay preferred; $50 copay preferred; 20% coinsurance
exceeding MAC exceeding MAC amount exceeding MAC
$90 copay non-preferred $100 copay non-preferred
$14 copay generic; $28 copay generic;
90-Day Supply (Retail-90 network pharmacy or mail order) $80 copay preferred; N/A – no network $100 copay preferred; N/A – no network 20% coinsurance N/A – no network
$180 copay non-preferred $200 copay non-preferred
$7 copay generic; $14 copay generic; 10% coinsurance
90-Day Supply (certain maintenance medications from Retail-90 network
$40 copay preferred; N/A – no network $50 copay preferred; N/A – no network without first having to N/A – no network
pharmacy or mail order) [3]
$160 copay non-preferred $180 copay non-preferred meet deductible
10% coinsurance; 10% coinsurance;
Specialty Medications (30-day supply specialty network pharmacy) N/A – no network N/A – no network 20% coinsurance N/A – no network
Min $50; max $150 Min $50; max $150
CONVENIENCE CLINICS AND URGENT CARE
Convenience Clinics $25 copay $45 copay $30 copay $50 copay 20% coinsurance 40% coinsurance
Urgent Care Facilities $45 copay $70 copay $50 copay $75 copay 20% coinsurance 40% coinsurance
EMERGENCY ROOM
$150 copay $175 copay
Emergency Room Visit 20% coinsurance
(services subject to coinsurance may be extra) (services subject to coinsurance may be extra)
8All services in this table ARE subject to a deductible (with the exception of hospice under the PPO options. Eligible expenses DO APPY to the annual out-of-pocket maximum.
PREIMER PPO STANDARD PPO CDHP / HSA
COVERED SERVICES IN-NETWORK OUT-OF-NETWORK [1] IN-NETWORK OUT-OF-NETWORK [1] IN-NETWORK OUT-OF-NETWORK [1]
PREVENTIVE CARE
• Screenings including colonoscopy, mammogram and colorectal,
No charge 40% coinsurance No charge 40% coinsurance No charge 40% coinsurance
colorectal, bone density scans and other services as recommended
OTHER SERVICE
Hospital/Facility Services
• Inpatient care; outpatient surgery [4] 10% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
• Inpatient behavioral health and substance abuse [2][4]
Maternity
• Global billing for labor and delivery and routine services beyond the 10% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
initial office visit
Home Care [4]
10% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
• Home health; home infusion therapy
Rehabilitation and Therapy Services
• Inpatient and skilled nursing facility [4]; outpatient
10% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
• Outpatient IN-NETWORK physical, occupational and speech
therapy [5]
X-Ray, Lab and Diagnostics
10% coinsurance 20% coinsurance 20% coinsurance 40% coinsurance
• Not including advanced x-ray, scans and imaging [5]
Advanced X-Ray, Scans and Imaging
• Including MRI, MRA, MRS, CT, CTA, PET and nuclear cardiac 10% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
imaging studies [4]
[5]
All Reading, Interpretation and Results 10% coinsurance 20% coinsurance 20% coinsurance
Ambulance
10% coinsurance 20% coinsurance 20% coinsurance
• Air and ground
Equipment and Supplies [3]
• Durable medical equipment and external prosthetics 10% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
• Other supplies (i.e., ostomy, bandages, dressings)
Certain limited Dental benefits, Hospice Care and Out-of-Country Charges are also covered subject to applicable deductible and coinsurance.
Also Covered
See separate sections in the Member Handbook for details.
DEDUCTIBLE
Employee Only $500 $1,000 $1,000 $2,00 $1,500 $3,000
Employee + Child(ren) $750 $1,500 $1,500 $3,300 $3,000 $6,000
Employee + Spouse $1,000 $2,000 $2,000 $4,000 $3,000 $6,000
Employee + Spouse + Child(ren) $1,250 $2,500 $2,500 $5,000 $3,000 $6,000
OUT-OF-POCKET MAXIMUM – MEDICAL AND PHARMACY COMBINED
Employee Only $3,600 $4,000 $4,000 $4,500 $2,500 $4,500
Employee + Child(ren) $5,400 $6,000 $6,000 $6,750 $5,000 $9,000
Employee + Spouse $7,200 $8,000 $8,000 $9,000 $5,000 $9,000
Employee + Spouse + Child(ren) $9,000 $10,000 $10,000 $11,250 $5,000 $9,000
CDHP STATE HEALTH SAVINGS ACCOUNG (HSA) CONTRIBUTION
State contribution to HSA:
For individuals who enroll in the CDHP/HSA N/A N/A $250 for employee only; $500 employee + child(ren),
employee + spouse, and employee + spouse + child(ren)
Only eligible expenses will apply toward the deductible and out-of-pocket maximum. Charges for non-covered services and amounts exceeding the maximum allowable charge will not be counted. For PPO Plans, no single-family member will be subject to
a deductible or out-of-pocket maximum greater than the “employee only” amount. Once two or more-family members (depending on premium level) have met the total deductible and/or out-of-pocket maximum, it will be met by all covered family members.
For CDHP Plans, the out-of- pocket maximum amount can be met by one or more persons.
[1] Subject to maximum allowable charge (MAC). The MAC is the most a plan will pay for a service from an in-network provider. For non-emergent care from an out-of-network provider who charges more than the MAC, you will pay the copay or coinsurance
PLUS difference between MAC and actual charge.
[2] The following behavioral health services are treated as “inpatient” for the purpose of determining member cost-sharing: residential treatment, partial hospitalization, and intensive outpatient therapy. For certain procedures, such as applied behavioral
analysis, electroconvulsive therapy, transcranial magnetic stimulation and psychological testing, prior authorization (PA) is required.
[3] Applies to certain antihypertensives for coronary artery disease (CAD) and congestive heart failure (CHF); oral diabetic medi cations, insulin and diabetic supplies; statins; medications for asthma, COPD (emphysema and chronic bronchitis) and
depression.
[4] Prior authorization (PA) required. When using out-of-network providers, benefits for medically necessary services will be reduced by half if PA is required but not obtained, subject to the maximum allowable charge. If services are not medically necessary,
no benefits will be provided. (For DME, PA only applies to more expensive items.)
[5] For PPO Plans, the deductible DOES NOT apply. For CDHP, the deductible DOES apply as required.
9Monthly Premiums for Active Employees
State and Higher Education
ALL REGIONS AND CARRIERS
CIGNA CIGNA OPEN
BCBST EMPLOYER SHARE
LOCALPLUS ACCESS
Premier PPO
Employee Only $140 $140 $180 $558
Employee + Child(ren) $210 $210 $250 $837
Employee + Spouse $292 $292 $372 $1,172
Employee + Spouse + Child(ren) $362 $362 $442 $1,451
STANDARD PPO
Employee Only $95 $95 $135 $558
Employee + Child(ren) $143 $143 $183 $837
Employee + Spouse $200 $200 $280 $1,172
Employee + Spouse + Child(ren) $248 $248 $328 $1,451
CDHP/HSA
Employee Only $62 $62 $102 $558
Employee + Child(ren) $91 $91 $131 $837
Employee + Spouse $129 $129 $209 $1,172
Employee + Spouse + Child(ren) $158 $158 $284 $1,415
10Pharmacy Benefits
Your health insurance benefits include pharmacy benefits. You do not have to make a
choice about your pharmacy benefits. This benefit is automatically included for you and
all enrolled dependents when you choose either health options. Pharmacy benefits are
administered by CVS/Caremark, one of the largest pharmacy benefits managers in the
country and the number one provider of prescriptions. Their network of more than
67,000 independent and chain pharmacies are available throughout the United States.
The state's prescription drug plan requires either a copay or coinsurance, depending on
your health insurance option. How much you pay depends on how the prescription is
filled.
• A generic drug (also called a tier one drug) is a Food and Drug Administration
(FDA)-approved equivalent of a brand-name drug. It is equal to the brand-
name product in safety, effectiveness, quality and performance. You pay the
least when you fill a prescription with a generic drug.
• A preferred brand (also called a tier two drug) is a drug that is included on the
drug list. Your cost will be higher for a preferred brand than for a generic but
less than for a non-preferred brand.
• A non-preferred brand (also called a tier three drug) is a brand-name drug that
is not on the drug list. You will pay the most if your prescription is filled with a
non-preferred brand.
• A specialty drug tier for specialty drugs. For PPOs, 10% coinsurance will apply
with a member minimum ($50, unless the drug cost is under $50, then you
would pay the full cost of the drug) and a maximum ($150) out-of-pocket.
Members enrolled in a CDHP will pay coinsurance for specialty drugs.
All offer 30-day prescriptions. If you take a longer-term medication, more than 916
Tennessee "mail at retail" pharmacies also fill 90-day prescriptions. Mail service is also
available. If you want to find a 30-day or 90-day network pharmacy, call the number or
visit the website listed below.
The chart below shows prescription drug co-pays and coinsurances under the PPO and
CDHP health options.
PREMIER PPO STANDARD PPO CDHP/HSA
In-Network Out-Of-Network In-Network Out-Of-Network In-Network Out-Of-Network
$7 copay generic; $14 copay generic; 40% coinsurance
Copay plus amount Co-pay plus amount
30-Day Supply $40 copay preferred; $50 copay preferred; 20% coinsurance plus amount
exceeding MAC exceeding MAC
$90 copay non-preferred $100 copay non-preferred exceeding MAC
$14 copay generic; $28 copay generic;
90-Day Supply
$80 copay preferred; N/A – no network $100 copay preferred; N/A – no network 20% coinsurance N/A – no network
(Retail-90 network pharmacy or mail order)
$180 copay non-preferred $200 copay non-preferred
90-Day Supply $7 copay generic; $14 copay generic; 10% coinsurance
(certain maintenance medications from Retail-90 $40 copay preferred; N/A – no network $50 copay preferred; N/A – no network without first having N/A – no network
network pharmacy or mail order) [3] $160 copay non-preferred $180 copay non-preferred to meet deductible
Specialty Medications (30-day supply specialty 10% coinsurance; 10% coinsurance;
N/A – no network N/A – no network 20% coinsurance N/A – no network
network pharmacy) Min $50; max $150 Min $50; max $150
[3] Applies to certain antihypertensives for coronary artery disease (CAD) and congestive heart failure (CHF); oral diabetic medications, insulin and diabetic supplies; statins; medications for asthma, COPD
(emphysema and chronic bronchitis) and depression.
Additional Information:
Caremark – 1.877.522.TNRX (8679)
http://info.caremark.com/stateoftn
11Dental Insurance
Choice of two dental insurance options:
• State of Tennessee Prepaid Plan
• Dental Preferred Provider Organization
The State of Tennessee Prepaid Plan, offered through Cigna DHMO, provides dental
services at predetermined copayment amounts, which are reduced fees for dental
treatments when members receive services from their pre-selected Participating
General Dentist or from a Participating Specialist. There are no deductibles, no claims
to file, no waiting periods for covered members, and no annual dollar maximum. Pre-
existing conditions are covered.
The Dental Preferred Provider Organization (DPPO), offered through MetLife Dental,
offers flexibility in that members may choose any dentist; however, members receive
maximum benefits when visiting a PDO Network Provider. No referrals are required
with the PDO option, and you or your dentist will file claims for covered services. Some
services require waiting periods, and limitations and exclusions apply. Please refer to
the vendor materials for complete information on coverage, limitations and exclusions.
Coverage is available to you and eligible dependents. The chart below depicts the
monthly cost of each plan.
CIGNA METLIFE
PREPAID PLAN DPPO
Employee Only $13.84 $23.64
Employee + Spouse $28.75 $44.72
Employee + Child(ren) $27.54 $54.36
Employee + Spouse + Child(ren) $33.74 $87.50
If you do not enroll as a new employee, you may elect coverage for you and/or your
dependents during the Annual Enrollment Transfer Period. You will also have the
opportunity to add, change or cancel your dental coverage.
Additional information:
Cigna Dental DHMO Prepaid Plan – (800) 997-1617
• Provider directory: http://www.cigna.com/sites/stateoftn/index.html
• Prepaid handbook: https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/dental_pre19.pdf
MetLife Dental DPPO – (855) 700-8001
• Provider directory: http://www.mybenefits.metlife.com/stateoftennessee (select State of Tennessee)
• Prepaid handbook: https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/dental_dppo19.pdf
12Dental Insurance Plan Comparison
Covered Dental Services
CIGNA PREPAID DHMO METLIFE DPPO
COVERED SERVICES GENERAL DENTIST SPECIALIST DENTIST IN-NETWORK OUT-OF-NETWORK
$25 single; $75 family, $100 single; $300 family,
Annual Deductible None
per policy year [1] per policy year [1]
Annual Maximum Benefit None $1,500 per person, per policy year
Pre-existing Conditions Covered Some exclusions
Office Visit $10 copay [2] No charge 20% of MAC
Periodic Oral Evaluation No charge No charge 20% of MAC
Routine Cleaning – Adult No charge No charge 20% of MAC
Routine Cleaning – Child No charge $15 copay No charge 20% of MAC
X-ray – Intraoral, Complete Series No charge $5 copay 20% of MAC 40% of MAC
Amalgam (silver) Filling Permanent teeth $8 copay $10 copay 20% of MAC 40% of MAC
Endodontics – Root Canal Therapy Molar
$125 copay $600 copay 50% of MAC
(excluding final restoration)
Major Restorations – Crowns $200 copay, plus lab fees [3] 50% of MAC [4]
Extraction of Erupted Tooth
$15 copay $70 copay 20% of MAC 40% of MAC
(minor oral surgery)
Removal of Impacted Tooth – Complete
Bony $100 copay $120 copay 50% of MAC
(complex oral surgery)
Dentures – Complete Upper $310 copay, plus lab fees [3] 50% of MAC [4]
$140 monthly copay for treatment equal or less than
Orthodontics 50% of MAC
24 months. Then, full charge. [6]
• Annual Deductible None None
$3,360 copay ($140 x 24 months) for treatment fee
• Lifetime Maximum only. Then, member pay full charge after initial 24 $1,250 [5]
months. [6]
• Waiting Period None 12 months
• Age Limit None Up to age 19
MAC – Maximum Allowable Charge is the lesser of the amount charged by the dentist or the maximum payment amount that in-network dentists have agreed to accept in full
for the dental service. When a participant receives dental services from an out-of-network provider, MetLife will reimburse a percentage of the MAC. The participant is then
responsible for everything over the percentage of MAC reimbursed up the charged submitted by the out-of-network dentist.
The benefits listed are a sample of the most frequently utilized dental treatments. Refer to vendor materials for complete information on coverage, limitations and exclusions.
[1]
Does not apply to diagnostic and preventive benefits such as periodic oral evaluation, cleaning and x-ray.
[2]
A charge may apply for a missed appointment when the member does not cancel at least 24 hours prior to the scheduled appointment.
[3]
Members are responsible for additional lab fees for these services.
[4]
A 6-month waiting period applies.
[5]
The orthodontics lifetime maximum is for a dependent member enrolled in the state group dental insurance program even if the member has been covered under different
employing agencies.
[6]
Additional copays apply for specific orthodontic procedures. Orthodontic treatment after a member’s effective date will not be covered under the Cigna plan if it began
prior to member’s effective date.
13Vision Insurance
Regular full-time and eligible part-time employees may enroll in optional vision insurance
as a new employee. The State of Tennessee offers coverage through Davis Vision.
This plan offers two coverage plans; a basic plan and an expanded plan. Services and
materials must be received from a participating provider to receive the highest benefit.
Basic Plan
• Free complete eye exam
• 20% off contact lens exam
• $55 discount on eyeglass lenses & contact lenses
• 20% off eyeglass lens options (scratch-resistant, progressives, etc…)
• $55 discount on frames, then 20% discount on remaining cost
Expanded Plan
• $10 co-pay for complete eye exam
• Maximum $50-60 co-pay for contact lens exam (fitting and evaluation)
• $0 co-pay for eyeglass lenses – glass or plastic, single vision, lined bifocal, lined
trifocal, or lenticular prescriptions
• $50-140 co-pay for various eyeglass lens options (scratch-resistant, anti-
reflective, progressives, etc…)
• $150 discount for eyeglass frames or contact lenses up to a retail price of $140,
20% discount on remaining cost
Both plans offer the same services, including:
• Annual routine eye exam once every calendar year
• Frames once every two calendar years
• Choice of eyeglasses or contact lenses once every calendar year
• Discount on LASIK/Refractive surgery
DAVIS VISION
BASIC EXPANDED
Employee Only $3.07 $5.56
Employee + Spouse $5.82 $10.57
Employee + Child(ren) $6.13 $11.12
Employee + Spouse + Child(ren) $9.01 $16.35
If you do not enroll as a new employee, you may elect coverage for you and/or your
dependents during the Annual Enrollment Transfer Period. You will also have the
opportunity to add, change or cancel your dental coverage.
Additional information:
Davis Vision – (800) 208-6404
www.davisvision.com/stateoftn
14Vision Insurance Comparison Chart
The following side-by-side comparison is being provided to ensure you have the information
needed to make the benefit choice most appropriate for you and your family.
DAVIS VISION
COVERED SERVICES BASIC PLAN EXPANDED PLAN
Routine Eye Exam $0 copay $10 copay
Retina Imaging Benefit $39 copay $39 copay
$55 allowance; $150 allowance;
Frames 20% discount off balance above the 20% discount off balance above the
allowance allowance
Eyeglass Lenses (includes plastic or glass)
• Single $0 copay $0 copay
• Bifocal, trifocal, lenticular $0 copay $0 copay
• Standard progressive Lens $55 allowance; 20% off balance over $55; $50 copay
not to exceed $65 out-of-pocket
• Premium progressive Lens $55 allowance; 20% off balance over $55; $50-140 copay [1]
not to exceed $105 out-of-pocket
Eyeglass Lens Options (upgrades) 20% discount off all options with out-of-
pocket not to exceed amount shown below
• Anti-reflective Up to $40 $40 copay
• Polycarbonate Adults $35; Children $0 Adults $30; Children $0
• Photochromic Up to $70 20% off retail price; not to exceed $70 out-
• Scratch resistance coating $0 of-pocket
• UV coating Up to $15 $0 copay
• Tints Up to $15 $10 copay
• Polarized Up to $75 $15 copay
• Premium anti-reflective Up to $55 20% off retail; not to exceed $75 out-of-
• Scratch protection plan: single vision/multifocal $20 copay/$40 copay pocket $20-69 copay [1]
lenses $20 copay/$40 copay
• All other eyeglass lens options 20% discount
Exam for Contact Lenses (fitting and evaluation) 20% discount off retail price $50-60 copay
Contact Lenses [2]
• Elective
• Conventional or disposable $50 allowance; 20% off balance over $55 $140 allowance; 20% off balance over $140
• Medically Necessary [3] $155 allowance; 20% off balance over $155 covered at 100%
15% discount off retail price or 15% discount off retail price or
Lasik/Refractive Surgery (for select providers)
5% off promotional price 5% off promotional price
Out-of-Network Benefits
• All Eye Exams $35 allowance up to $50 allowance
• Frames up to $55 allowance (frames & lenses up to $75 allowance
• Eyeglass Lenses combined)
• Single Vision up to $35 allowance
• Lined Bifocal up to $55 allowance
• Lined Trifocal up to $70 allowance
• Elective contacts (conventional of disposable) $30 allowance up to $55 allowance
• Medically Necessary Contacts [3] $80 allowance up to $200 allowance
• Lens options-UV, polycarbonate, up to $10 allowance
photochromic/transitions plastic
Frequency
• Eye Exam Once every calendar year Once every calendar year
• Eyeglass Lenses and Contacts Once every calendar year Once every calendar year
• Frames Once every two calendar years Once every two calendar years
DISCLAIMER: This summary is intended to provide a brief description of benefits and services. If there is an inconsistency between this summary
and the plan document, the plan document will govern.
[1] Copays for premium progressive lens are subject to change
[2] Instead of eyeglass lenses
[3] If medically necessary as first contact lenses following cataract surgery or multiple pairs of rigid contact lenses for treatment of keratoconus
Davis Vision offers some additional discounts which include:
• Free pair of eyeglass frames
• 40% off retail under the in-network Expanded plan and 30% discount off retail under the in-
network Basic plan for an additional pair of eyeglasses, except at Walmart, Sam’s Club or Costco
• 20% off conventional or disposable contact lenses under the in-network Expanded plan
• One-year warranty for breakage of moat eyeglasses
• 30% to 60% off the cost of brand name hearing aids through EPIC Hearing Healthcare
15Insurance Cards
Your insurance cards will be mailed to you three (3) to four (4) weeks after your application is
processed. You may call the insurance carrier to ask for extra cards or print a temporary card
from the carrier’s website.
Please be mindful of your coverage effective date when scheduling an appointment with a
physician. If you are at a doctor’s office or pharmacy and services are declined after your
effective date, please call Benefits Administration at 1-800-253-9981, press option "5" for
assistance.
Health Insurance Cards
BlueCross BlueShield of Tennessee Cigna Healthcare
Phone: (800) 558-6213 Phone: (800) 244-6224
www.bcbst.com/members/tn_state www.cigna.com/stateoftn
Dental Insurance Cards
Cigna Dental DHMO Prepaid Plan MetLife Dental PDO
Phone: (800) 997-1617 Phone: (855) 700-8001
www.cigna.com/stateoftn www.mybenefits.metlife.com/stateoftn
Prescription Card Vision Insurance Information
Caremark Prescription Davis Vision
Phone: (877) 522-8679 Phone: (800) 208-6404
www.caremark.com www.davisvision.com/stateoftn
16Basic Term Life and Accidental Death &
Dismemberment Insurance
All benefit eligible employees are provided a $20,000 basic term and $40,000 basic accidental
death and dismemberment life insurance coverage at no cost to the employee. If you are
enrolled in the health insurance plan the coverage amounts increase, up to $50,000 term life
and $100,000 of accidental death and dismemberment, based on your age and salary. In
addition, any dependents enrolled in the health plan receive $3,000 term life insurance. The
dependents are also covered for an additional amount of accidental death and dismemberment
based on the employee’s salary. Please see the chart on page 18 for coverage amounts and
premiums.
Voluntary Special Accidental Insurance
Voluntary Special Accidental and Dismemberment Insurance is offered through Securian
(Minnesota Life) Insurance Company. It is offered in addition to the life and accident coverage
included in the basic health and life insurance program. A chart of the coverage and monthly
premium amounts can be found on page 19. The plan pays 100% of the plan benefits for
accidental death and up to 50% for dismemberment. Please see the chart on page 19 for
coverage amounts and premiums.
If you and/or your eligible dependents do not elect coverage as a new employee for this plan,
you may enroll during the Annual Enrollment Transfer Period with no health questions.
Voluntary Optional Term Life Insurance
Employees may enroll in the Voluntary Term Life Insurance plan available through Securian
(Minnesota Life) Insurance Company. During your first 30 days of employment you may apply
for coverage for up to five times your annual salary without proving insurability.
And you may apply for up to seven times your salary (maximum $500,000) by completing a
health questionnaire. The effective date of coverage will be two months after the effective
date of your health insurance. If you terminate employment with the University, you may
continue the optional life insurance on a direct billing with Minnesota Life.
Voluntary Term Life is a death benefit only; there is no cash value. The premiums are based on
your age and increase over time. You may also insure your eligible dependents. If you do not
elect coverage as a new employee, you may apply for coverage during the Annual Enrollment
Transfer Period. You will be subject to a health questionnaire.
Additional information:
Minnesota – (866) 881-0631
• Provider: www.lifebenefits.com
• Handbook: https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/life_handbook_2021df
17Basic Term Life Insurance Chart
Basic Term Life Insurance Amounts
Amount of Term Life Insurance*
Schedule Annual
Number Salary Under Age 65 Age 65 – 69 Age 70 – 74 75 & Over
Amount EE EE/CH EE/SP Family Amount EE EE/CH EE/SP Family Amount EE EE/CH EE/SP Family Amount EE EE/CH EE/SP Family
Less than
1 $20,000 $0.00 $0.41 $0.90 $1.20 $13,000 $0.00 $0.37 $0.79 $1.09 $9,000 $0.00 $0.35 $0.72 $1.03 $6,000 $0.00 $0.33 $0.68 $0.98
$15,000
$15,000 to
2 $22,000 $0.40 $0.80 $1.32 $1.62 $14,300 $0.26 $0.63 $1.06 $1.37 $9,900 $0.18 $0.53 $0.92 $1.22 $6,600 $0.12 $0.45 $0.80 $1.11
17,499
$17,500 to
3 $25,000 $0.99 $1.42 $1.96 $2.27 $16,250 $0.65 $1.04 $1.49 $1.79 $11,250 $0.45 $0.81 $1.21 $1.51 $7,500 $0.30 $0.64 $1.00 $1.30
19,999
$20,000 to
4 $30,000 $1.98 $2.41 $3.03 $3.32 $19,500 $1.29 $1.68 $2.18 $2.48 $13,500 $0.89 $1.25 $1.69 $1.98 $9,000 $0.59 $0.93 $1.32 $1.62
22,499
$22,500 to
5 $33,500 $2.67 $3.13 $3.78 $4.07 $21,775 $1.74 $2.14 $2.66 $2.97 $15,075 $1.20 $1.58 $2.02 $2.32 $10,050 $0.80 $1.15 $1.54 $1.84
24,999
$25,000 to
6 $37,000 $3.37 $3.85 $4.52 $4.83 $24,050 $2.19 $2.61 $3.15 $3.45 $16,650 $1.52 $1.90 $2.36 $2.66 $11,100 $1.01 $1.37 $1.77 $2.07
27,499
$27,500 to
7 $40,500 $4.06 $4.57 $5.28 $5.57 $26,325 $2.64 $3.08 $3.64 $3.94 $18,225 $1.83 $2.23 $2.70 $3.00 $12,150 $1.22 $1.58 $1.99 $2.29
29,999
$30,000 to
8 $44,000 $4.75 $5.29 $6.03 $6.33 $28,600 $3.09 $3.55 $4.12 $4.42 $19,800 $2.14 $2.55 $3.03 $3.34 $13,200 $1.42 $1.80 $2.21 $2.51
32,499
$32,500 to
9 $47,500 $5.45 $5.98 $6.77 $7.06 $30,875 $3.54 $4.00 $4.61 $4.91 $21,375 $2.45 $2.86 $3.37 $3.66 $14,250 $1.63 $2.00 $2.44 $2.74
34,999
$35,000
10 $50,000 $5.94 $6.50 $7.30 $7.61 $32,500 $3.87 $4.34 $4.96 $5.26 $22,500 $2.68 $3.10 $3.62 $3.92 $15,000 $1.78 $2.16 $2.60 $2.90
and over
* This is the employee term life coverage amount. Employee also receives accidental death and dismemberment for an amount equal to 2 times the employee’s term life insurance coverage; schedule for spouse
and eligible dependent accident coverage is listed in your Group Term Life Handbook furnished by Securian (Minnesota Life).
** If spouse is also a State of TN employee, spouse coverage is $20,000 of term life and $40,000 of accidental death and dismemberment coverage.
18Voluntary Accidental Death & Dismemberment Insurance
Schedule of Benefits and Premiums
Coverage Cost
Schedule
Base Annual Earnings
Number Employee Spouse, no Spouse with children
Single Family
only child Spouse Each child
1 Less than $3,000 $6,000 $4,000 $2,000 $1,000 $0.11 $0.29
2 $3,000 - $3,999 9,000 5,000 3,000 1,000 0.16 0.34
3 $4,000 - $4,999 12,000 7,000 4,000 2,000 0.22 0.40
4 $5,000 - $5,999 15,000 9,000 5,000 2,000 0.27 0.45
5 $6,000 - $6,999 18,000 11,000 7,000 2,000 0.32 0.50
6 $7,000 - $7,999 21,000 13,000 8,000 3,000 0.38 0.56
7 $8,000 - $8,999 24,000 15,000 10,000 3,000 0.43 0.61
8 $9,000 - $9,999 27,000 17,000 11,000 3,000 0.49 0.67
9 $10,000 - $12,499 32,000 19,000 13,000 3,000 0.58 0.76
10 $12,500 - $14,999 38,000 23,000 15,000 4,000 0.68 0.86
11 $15,000 - $17,499 44,000 26,000 18,000 4,000 0.79 0.97
12 $17,500 - $19,999 50,000 30,000 20,000 5,000 0.90 1.08
13 $20,000 and over 60,000 36,000 25,000 5,000 1.08 1.26
The Voluntary Special Accident Insurance is paid totally by the employee. Employees whose spouse works for another State of TN agency must carry family coverage if they wish to cover
their dependent children; the spouse is not covered unless he/she is under the single coverage.
19Flexible Spending Accounts
The Flexible Benefits Plan, often called a cafeteria plan, is a plan that allows you to pay
for certain benefits on a tax-free basis. The plan, sanctioned under the Internal
Revenue Code Section 125, is administered by Optum Bank. There are three benefit
options to this plan.
• Medical Expense Flexible Spending Account: You may elect to have an additional reduction
of salary made each pay period to an account on a tax-free basis for eligible medical
expenses. As eligible expenses (e.g. deductibles, co-payments, contact lenses or glasses, dental
procedures and/or prescription drugs) are incurred, tax-free withdrawals from your account may
be made to reimburse yourself. This election must be made as a new employee and then again
each year during the annual transfer period.
• Dependent Care Expense Flexible Spending Account: You may also elect to have an
additional reduction of salary made each pay period to an account on a tax-free basis for
dependent care expenses. As the expenses are incurred, tax-free withdrawals from your account
may be made to reimburse yourself. This election must be made as a new employee and then
again each year during the annual transfer period.
• Limited Purpose Spending Account: You do not qualify for a medical FSA if you are enrolled
in the CDHP/HSA. However, you can put money in a limited purpose FSA for dental and vision
expenses.
FSA Contributions Limits
Account Minimum Contribution Amount Maximum Contribution Amount
Health Care FSA $10 $2,750 [1]
Dependent Care FSA $10 $5,000 [2]
Limited Purpose FSA $10 $2,750 [3]
[1] If you and your spouse each have a health care FSA, you can each contribute $2,650.
[2] The maximum contribution amount for a dependent care FSA depends on your tax filing status.
[3] You can use the limited purpose FSA to pay for certain dental and vision costs not covered by insurance.
You do not have to be enrolled in the group insurance program in order to
participate in the medical reimbursement or dependent day care accounts.
Elections are effective the first of the month after one full calendar month of employment
and ends on December 31 of that calendar year. You are locked into your elections for
the calendar year unless you have a family status change, such as changes in spouse’s
employment or acquiring a new dependent.
You must re-elect the options during each Annual Enrollment Transfer Period for
the next calendar year.
Please refer to the Flexible Benefits Accounts booklet for more detailed information
about plan options.
Additional Information:
Payflex – (855) 288-7936
Website: https://stateoftn.payflexdirect.com
FSA Guide: http://www.memphis.edu/benefits/pdf/2021fsaguide.pdf
Limited Purpose: https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/payflex_limited_purpose_flier.pdf
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