2021 OPEN ENROLLMENT GUIDE - Madison Team Members - UnityPoint Health Total Rewards
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2021 OPEN
ENROLLMENT
GUIDE
Madison Team Members
003465h4h-1 09/20 CS
TABLE OF CONTENTS
For your convenience, we’ve linked each section to its corresponding page in this guide.
Simply click on the section you want to learn more about, and you’ll be taken to the correct page.
Hello.........................................................................................................................................................................1
Enrollment and Eligibility......................................................................................................................................2
What’s New for 2021..............................................................................................................................................4
My Benefits
Compare Your Plans.............................7 Accidental Death and
2021 Quartz Tiered Plan Q&A............8 Dismemberment................................27
Accident Coverage............................27
6
Out of Area Dependent
Coverage.............................................14 Critical Illness......................................28
Health Savings Account.....................18 Hospital Indemnity Insurance...........30
Dental Coverage................................19 Short-Term Disability..........................31
Vision Coverage.................................20 Long-Term Disability..........................31
Flexible Spending Accounts.............22 Legal Service.......................................32
Life Insurance......................................24 Retirement Savings............................32
My Well-Being My Growth and Development
Paid Time Off.................................... 34 Education Assistance..................39
Paid Parental Leave Policy.............. 35
33 Adoption Assistance....................... 35
Care@Work....................................... 36
Team Member Discounts............... 36
38
OnPoint for Health........................... 37
Cost Breakdown.................................................................................................................................................. 43
Vendor Contact List............................................................................................................................................. 45
Availability of Summary Health Information.................................................................................................... 45
ERISA Disclosure Notice..................................................................................................................................... 46
Special Enrollment Rights.................................................................................................................................. 46
Premium Assistance Under Medicaid
The Children’s Health Insurance Program (Chip)........................................................................................... 47
Women’s Health and Cancer Rights Act of 1998 (WHCRA).......................................................................... 49
2021 OPEN ENROLLMENT | 1 |
hello.
As a team member at UnityPoint Health, we’re proud to offer you a
comprehensive Total Rewards program. Total Rewards is the value provided
to our team members and their families throughout their career at UnityPoint
Health by combining Compensation, Benefits, Personal Growth and
Development, Recognition, Well-Being and Purpose into one, simple program.
How to Use this Guide
We know there is a lot of information in this guide, and you might be
feeling a little overwhelmed. We put together a few tips for how to get the
most out of this guide as you’re preparing to select your benefits.
Use the Table of Contents
We know you likely won’t need every benefit we offer. To quickly get
to the information you care about most, reference this guide’s Table of
Contents. We’ve included links, so you simply have to click on the title
you want to learn more about it, and you’ll automatically be taken to
that section.
Know Where to Get the Most Up to Date Information
Some people like to print this document off, so that they can review
it with their spouse or domestic partner. Please remember that these
enrollment guides are sometimes updated throughout the year. For the
most up to date information, head to unitypoint.org/totalrewards. This
site is completely accessible from home, so you can easily review this
information on your personal computer, smartphone or tablet, too.
AskHR is Here to Help!
The AskHR team is comprised of your fellow UnityPoint Health team
members, and they are experts on all our benefit offerings. If you have
questions about anything in the enrollment guide, reach out to AskHR by
creating a case in Lawson or by calling (888) 543-2275.
This booklet highlights the main features of the benefit plans sponsored by
UnityPoint Health. Full details of these benefits are contained in the legal
documents governing the plans. If there is any discrepancy or conflict between
the plan documents and the information presented here, the plan documents will
govern. In all cases, the plan documents are the exclusive source for determining
rights and benefits under the plans. UnityPoint Health reserves the right to change
or discontinue the plans at any time with appropriate notification. Participation in
the plans does not constitute an employment contract. UnityPoint Health reserves
the right to modify, amend, or terminate any benefit plan or practice described in
this booklet. Nothing in this booklet guarantees that any new plan provisions will
continue in effect for any period. Plan documents are available at
unitypoint.org/totalrewards or by calling the AskHR at 888-543-2275.
2021 OPEN ENROLLMENT | 2 |
Enrollment and Eligibility
Eligible team members will be able to participate in Open Enrollment from Tuesday, October 27 – Tuesday,
November 10. You will complete the enrollment process within the Lawson platform. You can find a link to
Lawson and instructions for how to enroll on the Total Rewards Site. We encourage you to complete your
enrollment in Lawson by 5 p.m. on Tuesday, November 10.
Who is Eligible
You are eligible to enroll in UnityPoint Health benefits if you are in a benefits-eligible status. You are eligible for
benefit coverage if you are a:
Full-time Part-time
Part-time team member who is regularly scheduled
Full-time team member who is regularly scheduled to
to work 32-63 hours or more per pay period. (0.4 -
work 64 hours or more per pay period. (0.8 - 1.0 FTE)
0.79 FTE)
Dependents
In most cases, you can also cover your eligible dependents. You must provide a valid Social Security Number
and proof of eligibility (for example: birth certificate/adoption papers, marriage license/federal tax return).
Eligible dependents will not be enrolled unless you provide a valid Social Security Number and proof of
eligibility. You can review the details for submitting that information here.
Eligible dependents include:
Spouse/partner (if legally married under federal law)
Civil union partner (if legally recognized by a government authority)
Domestic partner (if applicable)
Common law spouse (if applicable)
Your children under age 26. “Children” are your biological children, children for whom there are parental
responsibility documents issued by a court, legally adopted children, children of a current same-gender
domestic partner or current civil union partner, children legally placed for adoption or foster care, children
for whom there is a Qualified Medical Child Support Order (QMSCO), and stepchildren as long as the team
member and parent are married.
Unmarried children of any age who are unable to support themselves because of a physical or mental
disability, are not covered by other government programs, were covered under the plan prior to age 26, and
are wholly dependent upon the participant for support and maintenance.
Domestic Partner Imputed Income
If you choose to add your domestic partner to your medical and/or dental coverage, you will be responsible
for imputed income tax on the difference in the employer premium for the additional coverage. Please contact
AskHR with questions or for additional details.
2021 OPEN ENROLLMENT | 3 |
Making Benefit Changes Outside of Open Enrollment During the Year
Based on IRS rules, you can generally make changes during the year only if you have a qualifying life event
that impacts your family or employment status. For example, loss of health coverage, birth of a child(ren),
marriage or, changes in residence. In order to make changes mid-year, you’ll need to complete a “life event” in
Lawson and submit any requested documents within 30 days of that life event in order to change your benefits.
Team members can contact AskHR if they have questions regarding life events. If you transfer employment
to another UnityPoint Health affiliate, your benefits will continue unchanged if you continue to meet eligibility
requirements. You cannot make changes to your benefit elections if you transfer employment as this is not a
qualifying event for making changes during the year.
If you have questions about eligibility
or how our benefit programs work that
are not addressed in this guide, please
contact AskHR.
2021 OPEN ENROLLMENT | 4 |
What’s New for 2021?
Enroll at Home
With the recent Lawson upgrade in September, you are now able to easily access Lawson remotely to enroll
in your benefits from home! Take advantage of this tip sheet to learn how to access Lawson remotely and
begin your benefits enrollment process.
– To access Lawson remotely, you will need to make sure you are enrolled in multifactor authentication first.
Use this tip sheet to learn how to enroll if you haven’t done so already.
• If you have questions about this process, please contact IT at 800-681-2060.
Medical Plan Changes
UnityPoint Health will continue to pay most of the premium cost for medical coverage. For 2021, team
members will not experience an increase in employee premiums from 2020 to 2021.
Vision Plan Changes
Standard progressive glasses lenses will now be covered up to $140, plus 20%, when purchasing in-network.
This is an increased benefit of $90.
Youth polycarbonate (up to age 19), level 1 progressives, and level 2 progressives are now covered in full.
Due to the increased benefits, there will be a slight increase in premiums.
You can find all of the increased vision benefits, on page 20 and 21.
New Vendor for Life, Accidental Death & Dismemberment (AD&D), and Long-Term Disability (LTD) Insurance
An important part of your financial wellness is helping to make sure you’re protected financially against the
unknown. UnityPoint Health recognizes the importance of Life and Accidental Death & Dismemberment
coverages. That’s why we chose The Prudential Insurance Company of America (Prudential) as our new Life,
Accidental Death & Dismemberment (AD&D), and Long-Term Disability (LTD) insurance provider starting
January 1, 2021.
– As part of this change, you will be prompted to enter new elections for Life Insurance, Accidental Death &
Dismemberment (AD&D), and Long-Term Disability (LTD) Buy-Up during your open enrollment process.
• Due to this, make sure to review your current benefits within Lawson, prior to making your 2021 Open
Enrollment elections. Use this tip sheet to learn how to view your current benefits.
• Prudential will take over all current 2020 elections. If you elect the same amount this year, you will not
need to go through Evidence of Insurability (EOI).
Life Insurance Changes
For this years open enrollment only, as a one-time offering, employees may add or increase their voluntary
employee life coverage (not to exceed the guarantee issue limit of the lesser of 3X Base Annual Earnings
(BAE) or $350,000) without evidence of insurability. Elected amounts in excess of the plan guarantee issue
limit are subject to EOI.
– We are removing the “lesser of 50%” component of the voluntary spouse life plan. It will now be a flat
$50,000 guarantee issue limit with the ability to purchase, in increments of $10,000, up to $100,000
maximum.
– For this years open enrollment only, as a one-time offering, employees may add or increase voluntary
spouse/domestic partner life coverage up to $50,000, in increments of $10,000, without EOI. Elected
amounts in excess of the plan guarantee issue limit are subject to EOI.
What’s New for 2021? continued 2021 OPEN ENROLLMENT | 5 |
IMPORTANT REMINDERS:
Paid Time Off
Negative PTO Balances: Effective April 18, 2020, all team members were provided the option to go negative
up to 40 hours in their PTO Banks. Team members will be able to have a negative PTO balance until
December 31, 2020. Starting January 1, 2021, team members will need to begin to work their way out of any
negative balance and any additional time needed for a holiday or approved time off will be unpaid.
Bank Limit Increase: As a reminder, due to the COVID-19 pandemic, we made a temporary change to the
PTO bank limit:
– Effective March 29, 2020, we raised the PTO Bank limit from 320 hours to 400 hours. This allows for team
members to bank an additional 80 hours of PTO. We will reinstate the 320-hour limit on July 3, 2021.
• Team members will be able to use hours above 320 until 7/3/2021. Any hours above 320 as of 7/3/2021
will be forfeited.
After 7/3/2021, team members will no longer accrue PTO beyond 320 hours
•
2021 PTO Cash
Election period is October 27-November 10, 2020.
Benefit eligible supervisors and non-management team members can sell up to 40 hours, in 5-hour
increments, per payout date for a total of 80 hours in 2021.
– The 40 hours per payout date for a total of 80 hours in 2021, is in response to the COVID-19 crisis. The
annual cash out maximum of 40 hours will be reinstated for 2022 PTO Cash.
Payouts will occur on the February 5, 2021 paycheck and/or the July 9, 2021 paycheck.
2021 Wellness Credit
To earn the credit, you and your spouse or domestic partner that is enrolled in a UnityPoint Health medical plan
must complete the following requirements:
omplete an annual physical with your primary care provider (PCP) between December 1, 2019 –
1. C
November 30, 2020.
omplete the 2020 online Health Risk Assessment (HRA) through the OnPoint for Health portal between
2. C
October 1, 2020 – December 31, 2020.
MY BENEFITS Medical, dental and vision coverage, life and disability insurance, and programs to help save for the future, such as 401(k) and Health Savings Account (HSA)
MY BENEFITS | 7 |
CompareYour
Compare YourMedical
Medical Plans
Plans
Tiered Plan (Traditional HMO) High Deductible Health Plan
In-Network
Annual Deductible (Single/Family) $1,000/$2,000 $2,500/$5,000
Annual HSA Contribution* N/A $750/$1,500
Coinsurance 20% 0%
Ded/Coins Max Out of Pocket $2,000/$4,000 N/A
Med Exp Max Out of Pocket $5,350/$10,700 $2,500/$5,000
Physician Services
Office Visit $30 Copay No charge after Ded
Specialty Visit $60 Copay No charge after Ded
E-visit No charge No charge after Ded
Emergency Services
Urgent Care $60 Copay No charge after Ded
Emergency Room $250 Copay No charge after Ded
Hospital Services
Inpatient Services 20% Coins after Ded No charge after Ded
Delivery & Newborn Charges 20% Coins after Ded No charge after Ded
Outpatient Services 20% Coins after Ded No charge after Ded
Diagnostic Services
Lab & X-Ray No charge No charge after Ded
MRI/PET/CAT Scan $150 Copay No charge after Ded
Behavioral Health
Inpatient Services 20% Coins after Ded No charge after Ded
Transitional 20% Coins after Ded No charge after Ded
Outpatient Services $30 Copay No charge after Ded
Other Services
Durable Medical Equipment 20% Coins No charge after Ded
Therapy Services $30 Copay No charge after Ded
Pharmacy Benefits Meriter UW Pharm Other Pharm
Tier 1 $15 Copay $20 Copay No charge after Ded
Tier 2 30% Coins 30% Coins No charge after Ded
Tier 3 50% Coins 50% Coins No charge after Ded
Specialty 30% Coins No charge after Ded
Max Out of Pocket (Single/Family) $2,000/$4,000 N/A
Additional Benefits
Preventive Services No charge No charge
Employee Bi-Weekly Rates (26 pay periods)
Years of Service 0-9 10-19 20+ 0-9 10-19 20+
Employee $48.78 $44.63 $41.86 $34.23 $30.07 $27.30
Employee + 1 $109.75 $105.60 $102.83 $70.14 $65.98 $63.21
Family $158.53 $148.84 $140.99 $119.18 $109.49 $101.64
* UnityPoint Health-Madison contributions will be applied to your Fidelity HSA account beginning the first pay period of 2021. You must be actively employed and enrolled in
the High Deductible Health Plan, and have an open HSA through Fidelity on the date of the contribution. NOTE: If you enroll into an HSA after the first of the year, the
UnityPoint Health contribution will be prorated based on your benefit eligibility date.
This Benefit Summary is intended to highlight the benefits provided in these plans. Please see your policy, including the Certificate of Coverage and Schedule of Benefits
(SOB) for detailed coverage information, limitations and exclusions.
MY BENEFITS | 8 |
UnityPoint Health - Madison
2021 Quartz – Tiered Health Plan
For questions contact Quartz Member Services: 1-800-362-3310, Pharmacy Services: 1-888-450-4884,
Behavioral Health: 1-800-683-2300 or Website: www.QuartzBenefits.com
______________________________________________________________________________________________
Office Visits and Services:
Q. What will a Primary Care Provider (PCP), Optometrist, Behavioral Health or Chiropractor office visit cost
when utilizing a Quartz network:
A. If it is billed for Affordable Care (ACA) preventative services – $0 copay
If it is billed for an office visit – $30 copay
Q. What will I pay if I see a Specialist, when utilizing a Quartz network specialist?
A. $60 copay
Q. What will I pay for Therapy visits such as physical, speech, occupational, habilitative and home therapy?
A. $30 copay
Q. What will I pay for an Immediate/Urgent Care visit?
A. $60 copay
Q. What will I pay for Durable Medical Equipment?
A 20% up to a maximum of $2,700 per member per year
Q. What will I pay for a Hospital Emergency Room visit?
A. $250 copay per visit (1-4), $500 copay per 5th visit and beyond.
Q. If I have an x-ray, will I pay for the Radiologist to read it?
A. No, x-rays are covered in full. NOTE: Specialty Scans (e.g. CAT scan, MRI/MRA and PET scan) will incur
$150 copay.
Q. Are there any other services that are covered in full, no copay?
A. Yes: lab work, mammograms, prenatal and postnatal maternity care, ultrasounds, immunizations, allergy shots,
radiation therapy, disposable diabetic supplies, specific oral surgeries and ambulance services are all covered
in full under the Quartz Tiered plan.
Q. What will I pay if I need to be hospitalized or have outpatient surgery?
A. $1,000 deductible, plus 20% coinsurance up to an additional $1,000 on the remaining balance of the bill. The
maximum out of pocket cost is $2,000 per member, $4,000 per family.MY BENEFITS | 9 |
Q. What Providers are covered under the Tiered plan?
A. You may see any Quartz network provider, visit https://quartzbenefits.com/findadoctor
(Services from out-of-network providers are not covered, except for emergencies).
Q. What will I pay for prescription drugs?
A. If you use the Meriter Pharmacy (202 S. Park Street) or any UW Health Pharmacy:
$15 for formulary generic drugs
30% of contracted price for formulary brand drugs ($100 per script limit)
50% for non-preferred drugs
If utilizing other participating Pharmacy’s:
$20 for formulary generic drugs
30% of contracted price for formulary brand drugs ($300 per script limit)
50% for non-preferred drugs
Q. How can I determine the cost of my formulary brand name prescription drugs with the 30% co-insurance?
A. You may contact Quartz Pharmacy Services at 1-888-450-4884 to provide the approximate cost.
Q. Does the Tiered plan have any out-of-pocket maximums?
A. Yes, members will have an out of pocket maximum on the following:
- Durable Medical Equipment (DME): $2700 maximum per member per year
- Inpatient/Outpatient Deductible: $1,000 maximum per member and $2,000 max per family
- Inpatient/Outpatient Coinsurance - $1,000 maximum per member and $2,000 max per family
- Prescription Drugs: $2000 maximum per member and $4,000 max per family
The overall maximum for all services combined is $7,350 per member and $14,700 per family.
Q. Do members on the Tiered plan have access to Virtual Care visits?
A. Yes, you have two options to use for $0 (no copay) per visit:
• UW Health Care Anywhere –Visit www.UWHealthCareAnywhere.org
• UnityPoint Health Virtual Care – Visit www.UnityPointVirtualCare.org
Both provide easy, quick access 24/7, to a medical provider, whenever you or your family needs non-
emergency care. From the comfort of your home or work, providing video visits using the app on your
smartphone, tablet or computer equipped with a web camera. Depending on your medical concern, the health
care provider can provide a diagnosis, suggest follow-up care and prescribe medication, when appropriate, for
commonly treated conditions such as abdominal pain, allergies, ear pain, sore throat, low back pain, eye
infections, sprains, minor skin problems and more. Visit their websites to learn more.
.MY BENEFITS | 10 |
UnityPoint Health - Madison
2021 Quartz High Deductible Health Plan (HDHP)
and Fidelity Health Savings Account (HSA)
For questions contact Quartz Member Services: 1-800-362-3310, Pharmacy Services: 1-888-450-4884,
Behavioral Health: 1-800-683-2300 or www.QuartzBenefits.com
__________________________________________________________________________________________
Q. How does the High Deductible Health Plan (HDHP) work?
A. Members are responsible for paying 100% of covered medical expenses (e.g. prescriptions drugs, office visits,
hospitalization, specialty visits, emergency room, urgent care visits, etc.) up to the deductible ($2,500 for single
coverage and $5,000 for employee+1/family coverage). After you reach the deductible, all other covered medical
expenses will be covered in full by Quartz. To further clarify,
1) All “covered medical expenses” will go towards the deductible/maximum out of pocket maximum
($2500/$5000). Services that are not covered (e.g. cosmetic surgery), will not go toward your
deductible/maximum out of pocket maximum ($2500/$5000).
2) The Employee+1/Family deductible out-of-pocket maximum is $5,000. That means one or more family
members (any combination) must reach the $5,000 deductible before all other covered services are paid 100%
by Quartz.
Q. What is the maximum out-of-pocket expense for the HDHP?
A. The maximum out-of-pocket expense is the same as your deductible:
$2,500 for Single coverage
$5,000 for Employee + 1 and Family coverage
Q. What do members pay for prescription drugs?
A. Members pay 100% of the cost until you reach your deductible as described above. However, Affordable Care
(ACA) preventive care prescription drugs (e.g., women’s FDA approved contraceptive drugs) will be paid by Quartz
in full.
Q. What services are covered in full where I don’t need to pay 100% until I reach the deductible?
A. Affordable Care (ACA) preventive services are covered in full (e.g. annual physicals, mammograms, colonoscopy
if over age 50, immunizations).
Q. What Providers are covered under the High Deductible Health Plan?
A. You may see any Quartz (Unity) network provider, visit https://quartzbenefits.com/findadoctor
(Services from out-of-network providers are not covered, except for emergencies).
Q. Do members on the HDHP have access to Virtual Care visits that would apply to the deductible?
A. Yes, you have two options to use for $49 per visit:
• UW Health Care Anywhere - Visit www.UWHealthCareAnywhere.org
• UnityPoint Health Virtual Care – Visit www.UnityPointVirtualCare.org
Both provide easy, quick access 24/7, to a medical provider, whenever you or your family needs non-
emergency care. From the comfort of your home or work, providing video visits using the app on your
smartphone, tablet or computer equipped with a web camera. Depending on your medical concern, the health
care provider can provide a diagnosis, suggest follow-up care and prescribe medication, when appropriate, for
commonly treated conditions such as abdominal pain, allergies, ear pain, sore throat, low back pain, eye
infections, sprains, minor skin problems and more. Visit their websites to learn more.MY BENEFITS | 11 |
How do you determine if the High Deductible Health Plan is right for you?
1. Compare health insurance plan options available to you.
2. Annualize the monthly premiums to determine annual premium cost for each plan option.
3. Calculate your expected medical cost based on each health plan design.
4. Factor in UnityPoint Health – Madison’s contribution to your HSA to help cover your medical expenses
under the HDHP.
5. Consider the tax advantages of contributing to the HSA (contributions are not taxed or are deductible on
your tax return), earnings are tax-free and withdrawals for eligible medical expenses are tax free).
6. Understand what it means when electing the HDHP, you must pay 100% of covered medical expenses up
to the deductible/maximum out of pocket expense ($2,500/Single coverage and $5,000/Employee+1 &
Family coverage) before the plan begins to pay, with the exception of certain preventive services that the
ACA requires to be paid by the plan in full.
NOTE: UnityPoint Health - Madison does not sponsor or maintain any HSA for any employee. An HSA is
your personal bank account. The terms of the HSA are contained in your agreement with Fidelity, and your
rights and benefits under the HSA are governed solely by your agreement with Fidelity and by Federal and
state tax laws. UnityPoint Health - Madison does not monitor your eligibility for contributions to an HSA or
the amounts you contribute to the HSA. You are solely responsible for determining whether you are eligible to
contribute to an HSA for any month of the year and for complying with the IRS limits on contributions to an
HSA. You are responsible for ensuring that you use the HSA for eligible medical expenses. UnityPoint Health
– Madison does not provide any investment advice with respect to your HSA.MY BENEFITS | 12 |
For questions on the Health Savings Account (HSA) contact Fidelity: (1-800-544-3716) or
www.netbenefits.com/unitypoint
----------------------------------------------------------------------------------------------------------------------------------------------
How does the Health Savings Account (HSA) work in conjunction with an HDHP?
• It’s a health savings account that you use to pay qualified medical (health, dental, vision) expenses for you,
your spouse and your eligible dependents (domestic partner/child must be your tax dependent to be eligible).
• Triple tax advantage: contributions, earned interest, and withdrawals for qualified expenses are tax free.
• You may increase/decrease your payroll contribution amount at any time on Fidelity’s website.
• There’s no deadline for reimbursing eligible medical expenses, your account can be used for current or future
eligible medical expenses.
• Unused money carries over from year to year, there’s no “use it or lose it” rule.
• Your HSA allows both pre-tax and after tax (tax deductible) contributions.
• You may choose to invest your HSA dollars.
• If you are no longer covered under UnityPoint Health – Madison’s HDHP, your HSA stays active and
remaining funds can still be used for qualified medical expenses in the future.
• Your HSA is portable. It belongs to you & goes with you, even into retirement.
Eligibility requirements to contribute to the Fidelity-HSA:
• You must be enrolled in UnityPoint Health – Madison’s High Deductible Health Plan;
• You cannot be enrolled in any other non-HDHP coverage, either through another employer or someplace else;
• You may not be entitled to Medicare, Tricare or Tricare for Life or enrolled in Badgercare or Medicaid;
• You may not be claimed as a dependent on someone else’s tax return; and
• Neither, you, nor your spouse may be enrolled/participating in an FSA-medical or HRA account. A limited
purpose FSA or HRA is permitted for dental and/or vision expenses only).
• HSA Contribution limits are established by the IRS (indexed for inflation). 2021 limits -
o Single coverage: $3,600 (This amount includes UnityPoint Health – Madison contributions)
o Employee+1 & Family coverage: $7,200 (This amount includes UnityPoint Health – Madison
contributions)
o Catch-up Contributions (if you are age 55+ at any point in the year) you may contribute an additional
$1,000.
o If employee and spouse are both 55 and HSA-eligible, you both may make a catch-up contribution to
your respective HSA’s.
o Combined contributions made to your HSA by you and UnityPoint Health - Madison count toward the
limit.
o To determine your annual contribution limit, if enrolled in HDHP less than 12 months of the year,
calculate the pro-rated contribution amount based on actual months of HDHP coverage.
o To determine your annual contribution limit, if changing coverage during the year, calculate the pro-
rated contribution amount based on actual months of family coverage and single coverage.
o It is the employee’s responsibility to monitor their contributions to avoid going over their limit.
o If you contributed more than the limit allowed, contact Fidelity to request excess funds (refund) before
the tax-filing deadline to correct the error and pay the tax on the amount over the HSA limit. If you do
not remove excess contributions by April 15th following the contribution year, you will be subject
to standard income tax rates plus a 6% penalty.
• UnityPoint Health - Madison pays the HSA administrative fees to Fidelity and contributes to Health
Savings Accounts for active employees with an FTE of 0.4 or greater:
o UnityPoint Health - Madison contributions are not included in your income (tax-free benefit to your
HSA).
o Your 2021 UnityPoint Health contribution will be applied to your Fidelity HSA account beginning the
first pay period of 2021. (NOTE: If you enroll into an HSA after the first of the year, these amounts
will be prorated based on your benefit eligibility date.)
▪ $750 - Single coverage
▪ $1,500 - Employee+1 & Family coverageMY BENEFITS | 13 |
• Using your HSA for a non-qualified medical expense:
o Paying for anything other than qualified medical expenses with your HSA, will become taxable
income;
o Plus, if you are age 64 or younger, you will pay an additional 20% tax penalty.
• Limited Purpose Flex Spending Account (FSA)-Medical -
o Employees enrolled in the UnityPoint Health - Madison HDHP/HSA are not eligible to contribute to
an FSA-medical plan but may contribute to a Limited Purpose FSA-medical plan.
o Reimbursement from a Limited Purpose FSA-medical plan is limited to dental and/or vision
(glasses/contacts) expenses only. Note, if eye exams are a covered benefit under your health plan,
expenses for eye exams will be denied under the TASC Limited Purpose FSA-medical plan.
o Dental and vision expenses are covered under your HSA. However, an employee who is contributing
the maximum limit to their HSA may be looking for additional tax savings by claiming dental and
vision expenses under a Limited Purpose FSA-medical plan rather than using their HSA for those
expenses.
o The Limited Purpose FSA-medical plan has the same “use it or lose it” rules as the traditional FSA-
medical plan.
o For employees switching to UnityPoint Health – Madison’s HDHP/HSA during Open Enrollment,
balances up to $500 remaining in their TASC FSA-medical plan will rollover to the TASC Limited
Purpose FSA-medical plan. And only dental and vision expenses will qualify for reimbursement in the
new year.
• Employees ending employment or becoming benefit ineligible (e.g. FTE below 0.4, layoff):
o HDHP coverage ends the last day of the month in which your last day of work occurs at a 0.4 FTE or
greater.
o Your HSA may stay with Fidelity with no admin fees. Or, you may transfer your Fidelity-HSA to
another HSA in your name.
o You will no longer be eligible to make payroll contributions to your HSA.
o You may continue to contribute (after tax dollars) to your HSA if you are enrolled in a qualified HDHP
(e.g. under your spouse’s plan or under COBRA).
o You may continue to use your HSA funds for eligible medical expenses.
• Tax Reporting
o HSA contributions (both employer and employee pre-tax) will be noted on UnityPoint Health –
Madison’s W-2’s.
o Participants complete IRS Form 8889 and file with their taxes.
• Fidelity-HSA (1-800-544-3716)
o Once your HSA is open and contributions begin, you can use it to pay for qualified medical expenses.
o Three ways to make contributions/deposits: Payroll deductions (pre-tax savings). Or, online using
your personal checking account or mail in a personal check, both provide a tax savings when filing
taxes. However, you will not pay Social Security and Medicare taxes (known as “FICA”) and no tax
will be withheld from your pay when you are contributing on a pre-tax basis. If you contribute on an
after-tax basis, both income tax and FICA will be withheld from your pay, but you can claim an
income tax deduction on your tax return after the end of the year.
o Pay your medical bills using your HSA debit card, online bill-pay from your HSA, pay out of pocket
and allow your HSA investments to stay in your account and grow for the future or reimburse yourself
for qualified expenses by requesting a distribution from your HSA, with no deadline.
o Don’t forget – Save your receipts in case you are audited by the IRS or you wish to claim the expense
in the future. Fidelity’s portal includes an online storage chest where you can store copies of your
receipts.
o Choose a beneficiary when you set up your account. If spouse is the designated beneficiary, your
spouse will become the owner and assume it as their own HSA. If someone other than a spouse is
beneficiary, your account will cease to be an HSA. The money in your account will pass to your
beneficiary(s) or become a part of your estate, and it will be subject to applicable taxes.
o Fidelity offers investment options if you choose to invest your HSA dollars.
• To review the IRS list of qualified medical expenses, visit: https://www.irs.gov/pub/irs-pdf/p502.pdfMY BENEFITS | 14 |
OUT-OF-AREA DEPENDENT COVERAGE
AVAILABLE ON LARGE GROUP HMO PLANS IN WISCONSIN OFFERED BY
QUARTZ HEALTH BENEFIT PLANS CORPORATION.
Do you have a dependent child or grandchild on your plan who lives outside of our service area at least
three months per year? Quartz makes it easy for them to get medical care by providing coverage for office
visits as if they were in-network. Here’s how it works –
⊲ During the portion of the year they are living inside Quartz’s service area, your dependent must seek care with
in-network providers. The costs will be covered at the in-network level of benefits. Cost-sharing for covered
services will count towards your out-of-pocket maximum.
⊲ During the three-months or more portion of the year they are living outside Quartz’s service area, they first need
our okay before getting care from an out-of-network provider. Call (888) 829-5687 and ask for prior authorization
before making an appointment. Even though the service is out-of-network, the costs will be covered at the
in-network level of benefits. Allowed amounts for cost-sharing will be based on usual and customary charges.
Cost-sharing for covered services will count towards your out-of-pocket maximum. Amounts in excess of usual
and customary charges are your responsibility and do not count toward your out-of-pocket maximum.
Eligible services include –
Primary care Chiropractic Behavioral / In-office therapy services Routine procedures
care mental health and care in office
Other services (outpatient surgery or non-emergency hospitalization, for example) require the dependent to return to
the Quartz service area for care. As a reminder, you or your dependents must show your valid Quartz ID card when
seeking services from any provider.
QUESTIONS? CONTACT CUSTOMER SERVICE AT (800) 362-3310.
QA00797 (0519)
Your health plan is offered by Quartz Health Benefit Plans Corporation.
©2019 Quartz Health Solutions, Inc. QuartzBenefits.comMY BENEFITS | 15 |
No Discriminación & Acceso a Lenguajes
Quartz es el nombre de la marca de un grupo de compañías nacionalidad, edad, discapacidad o sexo, puede presentar un
comprometidas para su salud: Quartz Health Benefit Plans reclamo a la siguiente persona –
Corporation, Quartz Health Insurance Corporation, Quartz Kristie Meier, Oficial de Control / Compliance Officer
Health Plan Corporation, y Quartz Health Plan MN Corporation. 840 Carolina Street
Estas compañías son entidades legales separadas. En esta Sauk City, WI 53583
notificación “nosotros” nos referimos a todas las compañías Teléfono: (800) 362-3310
de Quartz. TTY: 711 o toll-free (800) 877-8973
Para asistencia entendiendo estos materiales en otro idioma Fax: (608) 644-3500
que no sea inglés, llame al (800) 362-3310 y un representante Correo electrónico: AppealsSpecialists@quartzbenefits.com
de Servicio al Cliente lo asistirá. Usuarios TTY deben llamar al Puede presentar el reclamo en persona o por correo postal,
711 o al (800) 877-8973. fax o correo electrónico. Si necesita ayuda para hacerlo,
Nosotros cumplimos con las leyes federales de derechos Kristie Meier, Oficial de Control / Compliance Officer, está a
civiles aplicables y no discriminamos por motivos de raza, su disposición para brindársela. También puede presentar
color, nacionalidad, edad, discapacidad, o sexo. un reclamo de derechos civiles ante la Oficina de Derechos
Proporcionamos asistencia y servicios gratuitos a las personas Civiles (Office for Civil Rights) del Departamento de Salud
con discapacidades para que se comuniquen de manera eficaz y Servicios Humanos de EE.UU. (Department of Health and
con nosotros, como los siguientes – Human Services), de manera electrónica a través del portal
electrónico Office for Civil Rights Complaint Portal, disponible
J Intérpretes de lenguaje de señas capacitados en ocrportal.hhs.gov/ocr/portal/lobby.jsf o por correo postal
J Información escrita en otros formatos (letra grande, audio, a la siguiente dirección o por teléfono a los números que
formatos electrónicos accesibles, otros formatos) figuran a continuación –
Proporcionamos servicios lingüísticos gratuitos a personas U.S. Department of Health and Human Services
cuya lengua materna no es el inglés, como los siguientes – 200 Independence Avenue, SW
J Intérpretes capacitados Room 509F, HHH Building
J Información escrita en otros idiomas Washington, D.C. 20201
(800) 368-1019; (800) 537-7697 (TDD)
Si necesita recibir estos servicios, comuníquese con el
Departamento de Servicio al Cliente de Quartz al (800) 362-3310. Puede obtener los formularios de reclamo en el sitio web
hhs.gov/ocr/office/file/index.html
Si considera que Quartz no le proporcionó estos servicios o lo
discriminó de otra manera por motivos de origen étnico, color, Quartz en ciertos estados es un emisor Calificado de Planes
de Salud en el Mercado de Seguros Médicos. Para conocer
más visite la página web del Mercado de Seguros Médicos en
HealthCare.gov.
For help to translate or understand this, please call (800) 362-3310, TTY: 711 / (800) 877-8973.
Spanish – Este Aviso contiene información importante. Este aviso Chinese – 本通知含有重要的訊息 本通知對於您透過 Quartz
contiene información importante acerca de su solicitud o cobertura
a través de Quartz. Preste atención a las fechas clave que contiene 所提 出的申請或保險有重要的訊息 請在本通知中查看重要的
este aviso. Es posible que deba tomar alguna medida antes de 日期 您可能要在特定的截止日期之 前採取行動，以保留您的
determinadas fechas para mantener su cobertura médica o ayuda 健康保險或有助於省錢 您有權利免費以您的母語得到幫助和
con los costos. Usted tiene derecho a recibir esta información
y ayuda en su idioma sin costo alguno. Llame al (800) 362-3310.
訊息 請致電 (800) 362-3310：711 / (800) 877-8973.
TTY / TDD: 711 / (800) 877-8973. Russian – Настоящее уведомление содержит важную
информацию. Это уведомление содержит важную информацию
Hmong – Tsab ntawv tshaj xo no muaj cov ntshiab lus tseem ceeb.
о вашем заявлении или страховом покрытии через Quartz.
Tsab ntawv tshaj xo no muaj cov ntsiab lus tseem ceeb txog koj daim
Посмотрите на ключевые даты в настоящем уведомлении.
ntawv thov kev pab los yog koj qhov kev pab cuam los ntawm Quartz.
Вам, возможно, потребуется принять меры к определенным
Saib cov caij nyoog los yog tej hnub tseem ceeb uas sau rau hauv
предельным срокам для сохранения страхового покрытия или
daim ntawv no kom zoo. Tej zaum koj kuj yuav tau ua qee yam uas
помощи с расходами. Вы имеете право на бесплатное получение
peb kom koj ua tsis pub dhau cov caij nyoog uas teev tseg rau hauv
этой информации и помощь на вашем языке. Звоните по телефону
daim ntawv no mas koj thiaj yuav tau txais kev pab cuam kho mob los
(800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
yog kev pab them tej nqi kho mob ntawd. Koj muaj cai kom lawv muab
cov ntshiab lus no uas tau muab sau ua koj hom lus pub dawb rau koj. Laotian – ແຈ້ງການສະບັບນ
ີ້ ມ ້ ມ
ີ ໍຂ ີ່ີ ໍສາຄັນ.
ູ ນທ
Hu rau (800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
ແຈ ້ ງການສະບັບນ ີ້ ມ
ີ ໍຂ ້ ມ
ູ ນທ ີີ່ ໍສາຄັນກ ີ່ ຽວກັບໃບສະຫມັກ ຼືຫ
Vietnamese – Thông báo này cung cấp thông tin quan trọng. Thông ການຄ ້ ມຄອງຂອງທ ີ່ ານຜ ີ່ ານ Quartz. ຊອກຫາວັນທ ີ ໍສາຄັນ
báo này có thông tin quan trọng bàn về đơn nộp hoặc hợp đồng
bảo hiểm qua chương trình Quartz. Xin xem ngày then chốt trong
ໃນຫນັງສ ຼື ແຈ ້ ງການສະບັບນ ີ ້ .ທ
ີ່ ານອາດຈ ໍ າເປ ັ ນຕ ້ ອງປະຕ ິ ບັດຕາມເວລາ
ີ່ີ ທກ ໍ ານ ົ ດໄວ ້ ີ່ີທແນ ີ່ ນອນເພ ີ່ຼື ອຮັກສາໄວ ້ ການຄ ້ ມຄອງສຂະພາບຂອງທ ີ່ ານ
thông báo này. Quý vị có thể phải thực hiện theo thông báo đúng
trong thời hạn để duy trì bảo hiểm sức khỏe hoặc được trợ trúp ຫ
ຼື ຊ ີ່ ວຍເຫ ຼື ອດ ້ ານຄ ີ່ າໃຊ ້ ຈ ີ່ າຍ.ທ ີ່ ານມ
ີ ິສດທ ີີ່ ຈະໄດ ໍ້ ມ
້ ຮັບຂ ູ ນນີ ້ ແລະ
thêm về chi phí. Quý vị có quyền được biết thông tin này và được trợ ຄວາມຊ ີ່ໍ ເສຍຄ
ີ່ ວຍເຫ
ຼື ອໃນພາສາຂອງທ ີ່ ານໂດຍບ ີ່ າ. ໂທຫາເບ
ີ (800)
giúp bằng ngôn ngữ của mình miễn phí. Xin gọi số (800) 362-3310.
TTY / TDD: 711 / (800) 877-8973. 362 3310. TTY / TDD: 711 / (800) 877 8973.MY BENEFITS | 16 |
German – Diese Benachrichtigung enthält wichtige Informationen. Pennsylvanian Dutch – Die Bekanntmaching gebt wichdichi
Diese Benachrichtigung enthält wichtige Informationen bezüglich Auskunft. Die Bekanntmaching gebt wichdichi Auskunft baut dei
Ihres Antrags auf Krankenversicherungsschutz durch Quartz. Suchen Application oder Coverage mit Quartz. Geb Acht fer wichdiche
Sie nach wichtigen Terminen in dieser Benachrichtigung. Sie Daadem in die Bekanntmachung. Es iss meeglich, ass du ebbes
könnten bis zu bestimmten Stichtagen handeln müssen, um Ihren duh muscht, an beschtimmde Deadlines, so ass du dei Health
Krankenversicherungsschutz oder Hilfe mit den Kosten zu behalten. Coverage bhalde kannscht, odder bezaahle helfe kannscht. Du
Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer hoscht es Recht fer die Information un Hilf in deinre eegne Schprooch
Sprache zu erhalten. Rufen Sie an unter (800) 362-3310. TTY / TDD: griege, un die Hilf koschtet nix. Kannscht du (800) 362-3310 uffrufe.
711 / (800) 877-8973. TTY / TDD: 711 / (800) 877-8973.
Arabic – يتضمن هذا.يحتوي هذا اإلشعار على معلومات مهمة Polish – To ogłoszenie zawiera ważne informacje. To ogłoszenie zawiera
ważne informacje odnośnie Państwa wniosku lub zakresu świadczeń
ابحث.Quartz اإلشعار معلومات هامة حول طلبك أو تغطيتك عبر poprzez Quartz.Prosimy zwrócic uwagę na kluczowe daty zawarte w tym
قد تحتاج إلى إجراء تدابير.عن التواريخ الرئيسية في هذا اإلشعار ogłoszeniu aby nie przekroczyć terminów w przypadku utrzymania polisy
معيّنة وفقا ً لمواعيد معيّنة من أجل الحفاظ على تغطيتك الصحية أو ubezpieczeniowej lub pomocy związanej z kosztami. Macie Państwo
ليدك الحق في الحصول على هذه المعلومات.المساعدة في التكاليف prawo do bezpłatnej informacji we własnym języku. Zadzwońcie pod
(800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
اتصل على.وعلى المساعدة في لغتك دون أي تكلفةTTY / TDD:
711 / (800) 877-8973 / (800) 362-3310. Hindi – इस सच ू ण जानकारी शाममल है। इस सच
ू ना में महत्वपर् ू ना में
Quartz से जड़
ु े आपके आवेदन या कवरे ज के बारे में महत्वपर्
ू ण जानकारी
French – Cet avis a d’importantes informations. Cet avis a d’importantes
informations sur votre demande ou la couverture par l’intermédiaire de शाममल है। इस सूचना में महत्वपर्
ू ण तारीखों को दे खना न भूलें। स्वास््य
Quartz. Rechercher les dates clés dans le présent avis. Vous devrez कवरे ज जारी रखने या खचे में मदद के मलए आपको कुछ तय तारीखों तक
peut-être prendre des mesures par certains délais pour maintenir
votre couverture de santé ou d’aide avec les coûts. Vous avez le droit कारणवाई करनी ज़रूरी है। आपके पास अपनी भाषा में , बबना ककसी शुल्क के
d’obtenir cette information et de l’aide dans votre langue à aucun coût. इस जानकारी और सहायता को पाने का अधिकार है। (800) 362‑3310.
Appelez (800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
TTY / TDD: 711 / (800) 877‑8973 पर कॉल करें ।
Korean – 본 통지서에는 중요한 정보가 들어 있습니다. 즉 이 통지서는
Albanian – Ky njoftim përmban informacion të rëndësishëm. Ky njoftim
귀하의 신청에 관하여 그리고 Quartz을 통한 커버리지 에 관한 정보를 përmban informacion të rëndësishëm për aplikimin ose mbulimin tuaj
포함하고 있습니다.본 통지서에서 핵심이 되는 날짜들을 찾으십시오. 귀하는 nëpërmjet Quartz. Kontrolloni për data të rëndësishme në këtë njoftim.
귀하의 건강 커버리지를 계속유지하거나 비용을 절감하기 위해서 일정한 Mund t’ju duhet të ndërmerrni veprim brenda afatave të caktuara për të
마감일까지 조치를 취해야 할 필요가 있을 수있습니다. 귀하는 이러한 mbajtur mbulimin tuaj shëndetësor ose për ndihmën me koston. Keni
të drejtë ta merrni këtë informacion dhe ndihmë falas në gjuhën tuaj.
정보와 도움을 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가있습니다.
Telefononi numrin (800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
(800) 362-3310로 전화하십시오. TTY / TDD: 711 / (800) 877-8973.
Somali – FIIRO GAAR AH: Haddii aad ku hadashid af Soomaali,
Tagalog – Ang Paunawa na ito ay naglalaman ng mahalagang
adeegyada caawimada luuqada, ayaa waxaa laguugu siinayaa
impormasyon. Ang paunawa na ito ay naglalaman ng mahalagang
impormasyon tungkol sa iyong aplikasyon o pagsakop sa pamamagitan bilaash, waa laguu heli karaa. 1-800-362-3310
ng Quartz. Tingnan ang mga mahalagang petsa dito sa paunawa. (TTY: 1-800-877-8973) bilbilaa.
Maaring mangailangan ka na magsagawa ng hakbang sa ilang mga
itinakdang panahon upang mapanatili ang iyong pagsakop sa kalusugan
o tulong na walang gastos. May karapatan ka na makakuha ng ganitong
impormasyon at tulong sa iyong wika ng walang gastos. Tumawag sa
(800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
Cushite – Oroomiffa XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa
(800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
Amharic –
Karen –
Mon-Khmer, Cambodian –
Serbocroatian – OBAVJEŠTENJE: Ako govorite srpskohrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite
(800) 362‑3310 TTY‑ Telefon za osobe sa oštećenim govorom ili sluhom: 711 / (800) 877‑8973.
Thai – เรียน: ถา้ คุณพดู ภาษาไทยคุณสามารถใชบ้ ริการช่วยเหลือทางภาษาไดฟ้ รี โทร (800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
Gujarati –
Urdu –
Italian – ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero
(800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
Greek – ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται
δωρεάν. Καλέστε (800) 362-3310. TTY / TDD: 711 / (800) 877-8973.MY BENEFITS | 17 |
Health Savings Account
To Receive and Make Contributions:
• You will need to open an account with Fidelity (Instructions below.)
This will allow your payroll contributions and the UnityPoint Health
contribution to be deposited at Fidelity. GENERAL NEED-TO-KNOW
• In order to make pre-tax contributions to your HSA, you will need to • If you enroll in the Health
elect those contributions within the Fidelity website. This will be the Savings Medical Plan for
only method of making and changing your contributions throughout 2021 but do not open
your account with Fidelity
the year.
between October 27, 2020
• Beginning October 27th, login to your Fidelity account to make your and December 31, 2020,
2021 HSA pre-tax contribution election. Elections made by December you will forfeit the UnityPoint
15th, will be applied beginning the first pay period of 2021. Health HSA contributions for
the 2021 calendar year.
• Team members currently enrolled in an HSA, will have their 2020 HSA
pre-tax contribution election roll over into 2021, if no action is taken. • Your 2021 payroll
and UnityPoint Health
Opening an account with Fidelity contributions will be applied
When you’re ready, opening and managing your HSA with Fidelity is to your new Fidelity HSA
fast and easy. You’ll get information on investment choices, payment account beginning the first
options, and ongoing support to help you build and manage your pay period of 2021.
savings. For convenience, you can open a Fidelity HSA online.
Here’s how it works:
• Log into NetBenefits® at NetBenefits.com/UnityPoint.
• From the home page, click “Open” next to Health Savings Account.
• If you do not have access to NetBenefits, contact a Fidelity Representative at 1-800-544-3716.
2021 Annual HSA Contribution Limits
Individual health care coverage $3,600*
Family health care coverage $7,200*
Additional catch-up contribution (if age 55 or older) $1,000
*The maximum amount you may contribute to your HSA, assuming you enroll at the start of 2021. These amounts include UnityPoint Health
contributions. If you enroll into an HSA after the first of the year, this amount will change based on the prorated UnityPoint contribution.MY BENEFITS | 18 |
Dental Coverage
You will have the choice to elect dental coverage from two plans:
01 Premier Plan
02 Basic Plan
About the Dental Plans
Both dental plans provide coverage for preventive and basic care services. When you enroll in the Premier Plan,
orthodontia and major services will be covered for you and your eligible dependents. The Basic Plan will have
significantly lower premiums as a result of not covering major services and orthodontia. If you and your eligible
dependents don’t have orthodontia (under age 19) or major dental service needs, the Basic Plan offers you a
way to save money while still getting coverage for your diagnostic, preventive and routine restorative services.
Delta Dental contracts with dentists and other dental care providers in all of the communities where UnityPoint
Health affiliates are located. When you see a dental provider who is in the Delta Dental PPO network, you will
commonly pay less than when you see a dental provider who is in the Delta Dental Premier network or an out-
of-network provider. You can review the coverage levels and premium information for each dental plan below
to help you determine which plan is best for you. The percentages in the following table are the percentages
you pay.
If you and your eligible dependents
don’t have orthodontia or major
dental service needs, the Basic Plan
offers you a way to save money
while still getting coverage for your
diagnostic, preventive and routine
restorative services.Dental Coverage continued MY BENEFITS | 19 |
Dental Benefit Coverage Basic Premier Plan
Delta Premier/ Delta Premier/
Delta PPO Delta PPO
Out of Network Out of Network
Deductible/Individual $25 $50 $15 $25
Annual Maximum $750 $750 $1,500 $1,500
Diagnostic & Preventive
Exams, cleanings, fluoride,
space maintainers
100% covered 100% covered 100% covered 100% covered
Sealants
X-rays
Routine Restorative Services
Simple extractions, surgical
services 10% after 20% after 10% after 20% after
Emergency Treatment deductible deductible deductible deductible
Routine Oral Surgery
Posterior Composites 50% after deductible 50% after deductible
Major Services
Endodontics - root canal therapy
20% after 20% after
Periodontics -conservative and Not covered Not covered
deductible deductible
maintenance therapies
Periodontics - complex
procedures
Crowns, inlays, onlays 50% after 50% after
Not covered Not covered
deductible deductible
Bridges and dentures
Repairs and adjustments
Orthodontics (Dependent Children Under 19)
Appliances, treatment & related
50%
services
Not covered Not covered
Lifetime Maximum per
$2,000
dependent child
Dental Premium Cost
Annual Annual
Per Pay Period (Based on 26 Per Pay Period (Based on 26
Pay Periods) Pay Periods)
Employee Only $5.11 $132.86 $8.28 $215.28
Employee + Spouse/DP $10.05 $261.30 $16.54 $430.04
Employee + Child(ren) $11.47 $298.22 $18.78 $488.28
Family $15.20 $395.20 $25.06 $651.56MY BENEFITS | 20 |
Vision Coverage
Under the vision plan, you may purchase your eyeglasses and contacts at the eye care provider of your choice.
However, when you use an Avesis network provider, you receive the highest level of plan benefits and have the
lowest out-of-pocket costs.
For routine eye exams, you can see any Optometry provider; in or out-of-network. However, for non-routine eye
care, you’ll need to visit an in-network provider.
Vision Care Services In-Network Out-of-Network Reimbursement
Routine Annual Eye Exam $10 copay Up To $35
Materials $10 copay* See Below
Glasses Frames $10 copay then covered 100% up to Up to $45
$150 retail / $50 wholesale value
Glasses Lenses
Single Vision Covered in full after $10 copay $25
Bifocal Covered in full after $10 copay $40
Trifocal Covered in full after $10 copay $50
Lenticular Covered in full after $10 copay $80
Standard Progressives Covered up to $140, plus 20% discount Up to $48
Lens Package Details
Polycarbonate
(Single Vision/Multi-Focal) $40/$44 N/A
Youth Polycarbonate
Covered in full Up to $10
(Up to age 19)
Standard Scratch-Resistant
$17 N/A
Coating
Ultra-Violet Screening $15 N/A
Solid or Gradient Tint $17 N/A
Standard Anti-Reflective
Coating $45 N/A
Level 1 Progressives Covered in full Up to $40
Level 2 Progressives Covered in full Up to $48
Transitions
(Single Vision/Multi-Focal) $70/$80 N/A
Polarized $75 N/A
PGX/PBX $40 N/A
Other Lens Options Up to 20% discount N/AVision Coverage continued MY BENEFITS | 21 |
Contact Lenses (in lieu of glasses)
Elective Up to $150 Up to $130
Medically Necessary** Covered in full Up to $250
Surgery
Refractive Laser Surgery $150 lifetime allowance, plus provider $150 lifetime allowance
discount up to 25%
Frequency
Exam Once every 12 months Once every 12 months
Glasses Lenses or Once every 12 months Once every 12 months
Contact Lenses
Glasses Frames Once every 24 months Once every 24 months
Employee + Employee +
Vision Premium Cost Employee Only Family
Child(ren) Spouse/DP
Full & Part Time Rates $3.29 $7.16 $6.32 $9.38
* Applies to eyeglasses frames up to $150 retail value ($50 wholesale value) and standard lenses (excluding progressive lenses)
** Prior authorization requiredYou can also read
