2022 Benefits Guide PHCA ADMINISTRATION LLC - STAFF - Creativa Associates
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2022 Benefits Guide
PHCA ADMINISTRATION LLC
STAFF
Introduction
Welcome! HR/Benefits Website
We are glad you are part of the team. At Novelle Health and our teamcreativa.com/PHCAadmin
family of companies, we’re committed to providing you with a
comprehensive and competitive benefits program. HR/Benefits Phone
813.321.6084
Every year we take steps to ensure we’re offering quality plans at
the lowest possible cost. For 2022, we will be changing medical HR/Benefits Email
providers from FloridaBlue to UnitedHealthcare and also making
hrbenefits@novellehealth.com
some plan design adjustments.
Inside this guide, you can check out the plans that are available
to you. When you make your choices, take into account any
upcoming changes to your health care needs. This will help you
choose the right plans for you and your family. Our Company
strives to improve the lives of patients and we want you to be
healthy too.
Whether you’re just joining the team or have been part of it for a
while, we sincerely encourage you to use the resources you have
available to improve your overall health and well-being. Get
started on being the healthiest you can be by making informed
choices during your enrollment.
Are you using this guide for Annual Enrollment? If
yes, that’s perfect because you’ll find just what you
need to make informed choices for 2022 coverage.
Don’t miss this once-a-year opportunity to enroll
in plans that fit your needs.
Whenever you’d like more details than what’s in this guide, look
at the legal plan documents on your HR/Benefits website — it’s
available to you 24 hours a day, 7 days a week. You can also get
in touch with HR/Benefits by phone or email during normal
business hours.
Best wishes from HR/Benefits for a prosperous and healthy 2022!
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What’s Inside
4 Your Options at a Glance 28 Flexible Spending Accounts
5 Eligibility and Enrollment 32 Employee Assistance Program
10 Medical 33 401(k) Plan
15 Dental 35 Voluntary Programs
17 Vision 40 Holiday, Leave of Absence and PTO
19 Disability 41 Employee Contributions
21 Life and Accident 43 Important Phone Numbers and Websites
What’s New for 2022
Medical Insurance Carrier HSA Administrator
From To From To
FloridaBlue UnitedHealthcare HealthEquity Optum Bank
Medical PPO Plan Medical HDHP HSA Plan
(In-Network) (In-Network)
Individual/Family Annual Individual/Family Annual
Deductible Increased Deductible
From To
No Changes
$500/$1,000 $750/$1,500
Individual/Family Annual Individual/Family Annual
Out-of-Pocket Maximum Increased Out-of-Pocket Maximum Increased
From To From To
$4,500/$9,000 $6,000/$12,000 $4,000/$8,000 $6,550/$13,100
Physician Services
Prescription Drugs
and Prescription Drugs
Minor Increases
Minor Increases
Employee Contribution Increases Employee Contribution Increases
On all coverage tiers On all coverage tiers
HSA IRS Limit Contribution
$3,650/year $7,300/year
individual coverage family coverage
$50 more than in 2021 $100 more than in 2021
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Your Options at a Glance
You are eligible to participate in the employee benefit plans if you are regularly scheduled to work 30 or more hours per week. Below is
a quick summary of the benefits that you can enroll in.
Optional Life and AD&D Plans
Medical Plans
• Optional Life (Employee, Spouse and
• PPO Plan Children)
• HDHP HSA Plan • Optional AD&D (Employee, Spouse
and Children)
Health Savings Account Plan* Employee Assistance Program
Dental Plans
• Low Plan
• Medium Plan
401(k) Plan
• High Plan
• DHMO Plan
Vision Plans
Disability Plans
• Full Feature - Davis Network
• Full Feature - VSP Network • Short Term Disability
• Exam Plus Allowance - Davis Network • Long Term Disability
• Exam Plus Allowance - VSP Network
Flexible Spending Accounts Voluntary Plans**
(FSAs)
• Accident
• Health Care FSA • Critical Illness
• HSA Compatible FSA • Legal
• Dependent Care FSA • Identity Theft
* If you enroll in the HDHP HSA Plan, you may also be eligible to enroll in and make pretax contributions to a health savings account. Learn more on pages 10-14.
** These plans are completely voluntary and not sponsored or endorsed by Novelle Health. Employees pay 100% of the premiums. Please review the insurance
materials carefully before enrolling.
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Eligibility and Enrollment
The Company offers an array of health and welfare benefits, Benefit Plan Eligibility
including:
You are eligible to participate in the health and welfare
• Medical Insurance. employee benefit plans if you are regularly scheduled to work 30
• Health Savings Account. or more hours per week.
• Dental Insurance. You are not eligible for the employee benefit plans if you are:
• Vision Insurance.
• A
n employee who is not regularly scheduled to work 30 or
• Disability Insurance. more hours per week.
• Life and Accident Insurance. • A
n individual who has signed an agreement, or has otherwise
• Flexible
Spending Accounts (Health Care and agreed, to provide services to the Company as an independent
Dependent Care). contractor, regardless of the tax or other legal consequences of
such an arrangement.
• Employee Assistance Program.
• A
leased employee compensated through a leasing entity,
Some benefits are paid entirely by the Company. Other benefits whether or not you fall within the definition of leased
require that you share in the cost for your coverage. In addition employee as defined in Section 414(n) of the Internal Revenue
to the traditional health and welfare plans, the Company also Code (IRC).
provides you with a 401(k) plan, several voluntary plans, paid
time off and holidays. • An employee who is classified as temporary or per diem.
Certain plans also permit you to cover your eligible dependents,
Refer to the section titled “Important Phone Numbers and
which include your:
Websites” or contact HR/Benefits if you have questions or
require additional information. • L
egal spouse (unless legally separated) or same/opposite sex
domestic partner.
• Y
our child who is less than age 26*, including:
HR/Benefits Website – Biological child.
– Stepchild.
teamcreativa.com/PHCAadmin
– Legally adopted child.
HR/Benefits Phone – A child who has been placed with you in anticipation of
adoption.
813.321.6084
In addition, you can also cover the following dependents if they
HR/Benefits Email
are claimed as your dependent for federal income tax purposes:
hrbenefits@novellehealth.com
• Your domestic partner's child**.
• A child for whom you are the legal guardian/legal custodian.
Your dependent children who are age 26 or over and physically
or mentally incapable of self-support may continue coverage
under certain plans beyond age 26 if they remain totally
incapacitated and dependent on you for support.
If your spouse/domestic partner works for the Company, either
you or your spouse/domestic partner can elect to cover your
dependent children, but not both of you. Your dependent
(spouse/domestic partner or child) is not eligible if they are
covered as an employee, on active duty in the military service of
any country or if you are not enrolled for coverage.
* Dependents may be eligible to receive medical coverage up to the age of
30 if they meet specific eligibility criteria. Contact HR/Benefits for more
information.
** Special guidelines apply when covering a domestic partner or the child
of a domestic partner. Refer to the Domestic Partner Qualifications and
Guidelines on the HR/Benefits website for additional information.
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Eligibility and Enrollment
Initial Eligibility Period How to Enroll
You have 30 days to enroll yourself and your eligible dependents Enrolling into the benefit programs is easy! Shortly after you are
for coverage. This 30-day initial eligibility period begins on your hired, you will receive a benefits package. This benefits package
employment date and ends 29 days after that date. If your will provide you with all the information you need to enroll for
enrollment is not completed on or before the end of your initial benefits.
eligibility period:
Our benefit enrollment process is primarily paperless, except
• Y
ou will have to wait until the next Annual Enrollment period of course for documents you must provide to validate your
to change your benefit elections, except as summarized in the dependent information (e.g., birth certificates, etc.). You should
section titled “Making Changes During the Year”. keep in mind that if you are enrolling any dependents, you will
need their name, Social Security number, date of birth and written
• Y
ou will be automatically enrolled in the core benefit plans
documentation to verify their eligibility (e.g., birth certificate,
that are paid in full by the Company.
marriage license, etc.).
or example: If you are hired on
F After making your benefit elections, be sure to view and print a
April 2, 2022, your initial eligibility benefits confirmation statement. You will not receive a separate
period begins on April 2, 2022 and confirmation statement from HR/Benefits. If you need assistance
ends on May 1, 2022. Your benefit plan enrolling for benefits, contact HR/Benefits via phone during
elections made during this period will be normal business hours and via email anytime to assist you with
generally effective June 1, 2022, subject your HR and benefits questions.
to you providing proper documents as
required under the plans. When Coverage Begins
The table on the next page shows the dates your coverage will be
Special enrollment rules apply if you terminate employment effective under the various benefit plans for:
and are then rehired. Contact HR/Benefits for additional
information. • Newly hired employees.
• Employees who experience a qualifying event.
• Changes made during the Annual Enrollment period.
For more details on when coverage begins for a specific employee
benefit plan, refer to the applicable section of this guide.
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Eligibility and Enrollment
Effective Date of Coverage for Selected Events
Qualifying Event
Plans New Hire Enrollment Annual Enrollment
(Reported within 30 days)
Medical, Dental, Vision and First day of the month following 30 First day of the month following January 1 following Annual
Health Savings Account days of employment (enrollment qualifying event (birth or adoption is Enrollment period
required) date of qualifying event)
Short Term Disability First day of the month following 30 Not applicable January 1 following Annual
days of employment (automatic Enrollment period, subject to
enrollment in 50% option, insurance company EOI approval
enrollment required for 60% option)
Long Term Disability First day of the month following Not applicable Not applicable
30 days of employment (automatic
enrollment)
Basic Life, Basic AD&D First day of the month following Not applicable Not applicable
30 days of employment (automatic
enrollment)
Optional Life – Employee If coverage elected is $250,000 First day of the month following January 1 following Annual
or less, first day of the month qualifying event (birth or adoption is Enrollment period, subject to
following 30 days of employment date of qualifying event), subject to insurance company EOI approval
(enrollment required) insurance company EOI approval
If coverage elected is more than
$250,000, coverage in excess
of $250,000 is effective on the
date approved by the insurance
company (enrollment required)
Dependent Life – Spouse/DP If coverage elected is $25,000 First day of the month following January 1 following Annual
or less, first day of the month qualifying event (birth or adoption is Enrollment period, subject to
following 30 days of employment date of qualifying event), subject to insurance company EOI approval
(enrollment required) insurance company EOI approval
If coverage elected is more than
$25,000, coverage in excess
of $25,000 is effective on the
date approved by the insurance
company (enrollment required)
Dependent Life – Child(ren) First day of the month following 30 First day of the month following January 1 following Annual
days of employment (enrollment qualifying event (birth or adoption is Enrollment period
required) date of qualifying event)
Optional AD&D – Employee, First day of the month following 30 First day of the month following January 1 following Annual
Spouse/DP, Child(ren) days of employment (enrollment qualifying event (birth or adoption is Enrollment period
required) date of qualifying event)
Flexible Spending Accounts First day of the month following 30 First day of the month following January 1 following Annual
days of employment (enrollment qualifying event (birth or adoption is Enrollment period
required) date of qualifying event)
Employee Assistance Program First day of the month following Not applicable Not applicable
(EAP) 30 days of employment (automatic
enrollment)
401(k) First day of employment (automatic Not applicable Not applicable
enrollment)
Voluntary Critical Illness First day of the month following 30 Not applicable January 1 following Annual
Insurance (VCII) days of employment (enrollment Enrollment period
required)
Voluntary Accident Insurance First day of the month following 30 Not applicable January 1 following Annual
(VAI) days of employment (enrollment Enrollment period
required)
LegalGUARD and Experian First day of the month following 30 Not applicable January 1 following Annual
days of employment (enrollment Enrollment period
required)
The effective dates shown in this table assume enrollment has been completed timely and any required paperwork or documentation has been provided. If you
complete your enrollment after your effective date of coverage, retroactive payroll deductions will be calculated and withheld from your first paycheck after elections
are made. It is for this reason you should enroll early to avoid retroactive payroll deductions. If any enrollments require evidence of insurability (EOI), the effective
date of coverage will be the date the insurance company approves insurability. The effective date of coverage may also be delayed due to the actively at work or
confinement for care provisions of the plans.
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Eligibility and Enrollment
Making Changes During the Year Special Enrollment Rules
If you originally declined medical, dental or vision coverage
Generally, after you have made your benefit plan elections, because you had other health coverage, you may be eligible to
you may change those elections only during the next Annual change your elections under the following circumstances:
Enrollment period.
• If the other coverage was COBRA and it is now exhausted; or
However, if you experience a qualifying event or other allowable
• The other coverage was not COBRA and either the coverage
event during the year, you may change certain benefit plan
terminated due to loss of eligibility or Company contributions
elections before the next Annual Enrollment period. You must
toward such coverage terminated. Loss of eligibility includes
properly advise HR/Benefits (along with providing the required
legal separation, divorce, termination of domestic partner
supporting documentation) and make the change using the
status, death or termination of employment.
online benefits website within 30 days of the event (date of event
plus 29 days) in order for your mid-year change to be approved. • T
he other coverage was Medicaid or state Child Health
Insurance Program (CHIP) and coverage terminated due to
Your new election must be on account of the event and must loss of eligibility.
correspond with that gain or loss of coverage. A qualifying event
is defined as an event that results in the gain or loss of eligibility • Y
ou or your dependent becomes eligible for state premium
by you or your dependents. For example: assistance under a Medicaid or CHIP plan. (This is an
optional state program under Medicaid or CHIP that pays
• A change in legal marital status. the employee’s share of the premium for group health plan
coverage.)
• A change in number of dependents.
• A change in employment status. If your dependents also had other health coverage and lost
that coverage in the above situations, they may be added to
• Y
our dependent satisfies or ceases to satisfy the requirements your coverage. However, you will not be able to add yourself
for dependents, including a domestic partner or domestic or your dependents to this coverage if the other coverage
partner’s child. was terminated for cause (including failure to timely pay the
• A
change in residence or worksite by you or your dependent required premiums).
that causes a loss or gain of coverage.
In addition to the changes described above, you may enroll
yourself and your spouse/domestic partner (with or without the
or example: If you and your spouse
F new dependent) in a medical plan following marriage or the
previously declined coverage, you may adoption, placement for adoption or birth of a child. You must be
enroll yourself, your spouse and your enrolled in order to cover your dependents.
newborn child immediately following
the birth of the child, as long as you do so
within 30 days of your baby’s birth. You
may not enroll other children at this time
unless another qualifying event makes
them eligible for coverage, such as gaining
legal custody of another eligible child.
The rules regarding changes after your new hire enrollment and
the Annual Enrollment period are very specific; therefore, you
should refer to the information provided on the HR/Benefits
website or contact HR/Benefits if you require assistance.
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Eligibility and Enrollment
When Coverage Ends
The following table shows the dates your coverage ends under
the various employee benefit plans:
Benefit Plans Last Day of Coverage
Medical
Dental
On the last day of the month in
Vision
which you are no longer employed
Employee Assistance Program
LegalGUARD and Experian
Short Term Disability
Long Term Disability
Life and AD&D
Health Care FSA On your last day of active
Dependent Care FSA employment
Voluntary Critical Illness
Insurance
Voluntary Accident Insurance
Coverage for your dependents will end on the date your
dependent no longer meets the definition of an eligible
Special Enrollment Procedure dependent or when your coverage ends, whichever comes
You must enroll for coverage within 30 days of the special first. Premiums for the last month of coverage are not prorated
enrollment event (60 days for CHIP) by going online and making even if coverage ends prior to the end of a month. If you have a
the appropriate change. Supporting documentation must be dependent attaining age 26* in 2022, medical coverage for that
sent to HR/Benefits. dependent continues through the end of the plan year.
If you enroll and provide any required documentation within Under certain circumstances, you may be able to continue
this period, the effective date of coverage will be on the first certain benefit coverage (medical, dental, vision and Health Care
day of the month following the date of the qualifying event FSA) for yourself and your dependents through COBRA. You may
(for birth or adoption, the effective date is the date of the birth also be able to convert or port the life, accident and voluntary
or adoption). Your employee contributions will be deducted plans, as permitted by the insurance companies.
retroactive to the date of the special enrollment event.
When employment terminates, you have up to 90 days to file
If you do not enroll and provide supporting documentation claims for any FSA eligible charges incurred prior to your
within 30 days of the special enrollment event (60 days for termination date. This 90-day period is extended for the
CHIP), you may not enroll until the next Annual Enrollment health care FSA if you elect COBRA continuation coverage. The
period. Dependent Care FSA is not subject to COBRA.
* Dependents may be eligible to receive medical coverage up to the age of
For more information on how your benefits are affected by these 30 if they meet specific eligibility criteria. Contact HR/Benefits for more
life changes, contact HR/Benefits. information.
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Medical
Medical High Deductible Health Plans (HDHPs) and Health Savings
Accounts (HSAs)
The medical plans are designed to help protect you and your If you enroll in the Option 2 HDHP HSA Plan, you will be given
covered dependents against financial loss by paying for a the opportunity to establish an HSA.
substantial portion of eligible expenses incurred for medically
necessary care and treatment. The medical plans are insured by If you establish an HSA, the Company will contribute toward the
UnitedHealthcare. HSA on your behalf in the amount of:
• If you enroll for coverage within your initial eligibility period, • $600 per year ($50 per month) for individual coverage; or
your coverage will be effective on the first day of the month • $1,200 per year ($100 per month) for family coverage.
following 30 days of employment.
The Company contribution is deposited every pay period.
• If you do not enroll for coverage within your initial eligibility
period, you may enroll for coverage during the next Annual In addition to the Company contributions, you can contribute
Enrollment period or in accordance with the section titled to the HSA. The total amount contributed to the HSA (Company
“Making Changes During the Year”. and employee contributions combined) cannot exceed the IRS
allowable amount for the 2022 calendar year of:
You can select from two different plans:
• $3,650 for individual coverage; or
• Option 1 PPO Plan.
• $7,300 for family coverage.
• Option 2 HDHP HSA Plan.
If you are age 55 or older you can also make catch-up
contributions of $1,000 per year, in accordance with federal
An HSA is an account that allows you to regulations.
contribute and set aside pretax dollars to
pay for eligible health care expenses either In deciding your HSA contribution amount, be sure to keep
in the current year or at a later date, such as in mind your medical plan’s premium, deductible and out-
during retirement. of-pocket maximum. You can start, stop or change your HSA
contribution amount at any time. Changes are applied to your
remaining pay periods in the current year.
Opt-Out Bonus
If you decide to waive medical coverage, you will receive an “opt- Once you have enrolled in the HDHP HSA Plan, you should open
out” bonus amounting to $100 per month ($46.15 per biweekly your account by visiting optumbank.com. Once your account
pay period; $50.00 per semimonthly pay period) from the is open, Optum Bank will mail you a welcome packet and your
Company. debit card. You can then use your new card to access your
HSA funds.
Your Cost
The Company and you share the cost of medical coverage. HSAs are fully portable. This means that if you terminate
Your cost is generally deducted from your pay on a pretax employment, the money is yours and stays in your account until
basis. (Note: Contributions for domestic partners are generally you use it or close the account. You can continue to contribute
deducted on an after-tax basis, unless otherwise permitted up to the maximum amount each year, as long as you remain
by state or federal law.) Refer to the section titled “Employee eligible and enrolled in a qualified HDHP.
Contributions” for the applicable cost. If you enroll in the HSA
In subsequent years, if you decide not to enroll in a qualified
plan, you will decide if you wish to establish an HSA and how
HDHP, you can continue to use your HSA for qualified medical
much to contribute, subject to IRS maximums.
expenses, but you will no longer be able to contribute to the
HSA.
UnitedHealthcare Website
Optum Bank Mobile App
myuhc.com
The Optum Bank mobile app provides easy, on-the-go access to
First time visitors: You will need to your health savings account. The app provides comprehensive
register and create a HealthSafe ID. tools to help you manage your claims and maximize your
Then, information is available 24/7. health savings.
I n accordance with IRS regulations, if you are enrolled in any other health insurance such as Medicare Part A and/
or Part B, you are not eligible to contribute pretax dollars or receiving Company contributions to an HSA.
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Summary of Medical Plan Provisions
The following table summarizes the key Summary of Benefits and Coverage
features of the medical plans available The Patient Protection and Affordable Care Act (also known as Health Care
to you and your dependents. To receive Reform) requires that you receive a Summary of Benefits and Coverage (SBC).
the highest level of benefits, you should The SBC is designed to help you understand and evaluate your health plan
use in-network providers and fully choices. You can download the SBC from the HR/Benefits website or contact
understand what is expected of you. HR/Benefits and request a copy be sent to you.
Medical Plans (UnitedHealthcare)
Option 1 Option 2
PPO Plan HDHP HSA Plan
Key Features
In-Network Out-of-Network In-Network Out-of-Network
You pay You pay You pay You pay
Calendar Year Deductible (ded.)
Individual $750 $3,000 $3,000 $5,000
Family $1,500 $6,000 $6,000 $10,000
Calendar Year HSA Company Contributions
Individual N/A $600
Family N/A $1,200
Calendar Year Out-of-Pocket Maximum
Individual $6,000 $6,250 $6,550 $10,000
Family $12,000 $12,500 $13,100 $20,000
Physician Services
Office visits $25 copay 30% after ded. 10% after ded. 50% after ded.
Specialist visits $50 copay 30% after ded. 10% after ded. 50% after ded.
Urgent care $50 copay 30% after ded. 10% after ded. 50% after ded.
Preventive Care
Routine physical exams No copay Not covered No copay Not covered
Immunizations No copay Not covered No copay Not covered
Well-woman exams No copay Not covered No copay Not covered
Hospital
Inpatient hospital services 20% after ded. 30% after ded. 10% after ded. 50% after ded.
Outpatient hospital services 20% after ded. 30% after ded. 10% after ded. 50% after ded.
Emergency
Hospital emergency room $350 copay $350 copay 10% after ded. 10% after ded.*
Other Medical Services
Lab testing Designated Network: 30% after ded. Designated Network: 50% after ded.
No copay 10% after ded.
Network: 50% Network: 50% after ded.
X-ray No copay 30% after ded. 10% after ded. 50% after ded.
Imaging (MRI, CAT, PET scans) $200 copay 30% after ded. 10% after ded. 50% after ded.
Prescription Drugs (Retail) – Up to a 31 Day Supply
Tier 1 Retail $10 copay $10 copay $10 copay after ded. $10 copay after ded.
Tier 1 Specialty Retail $10 copay Not covered $10 copay after ded. Not covered
Tier 2 Retail $35 copay $35 copay $35 copay after ded. $35 copay after ded.
Tier 2 Specialty Retail $150 copay Not covered $150 copay after ded. Not covered
Tier 3 Retail $70 copay $70 copay $70 copay after ded. $70 copay after ded.
Tier 3 Specialty Retail $500 copay Not covered $500 copay after ded. Not covered
Prescription Drugs (Mail Order) – Up to a 90 Day Supply
Tier 1 Retail $25 copay Not covered $25 copay after ded. Not covered
Tier 2 Retail $87.50 copay Not covered $87.50 copay after ded. Not covered
Tier 3 Retail $175 copay Not covered $175 copay after ded. Not covered
* In-Network deductible applies.
Both PPO and HDHP HSA plans have embedded deductibles and out-of-pocket maximums.
This summary is provided for general information only. Since exclusions, dollar/frequency limitations and prior authorization may apply, you should refer to the
specific plan documents for detailed information.
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Consider the Advantages of the HDHP HSA Medical Plan
There’s never been a better time to explore the HDHP HSA medical plan. Not only does it provide comprehensive medical and
prescription drug coverage, a lower monthly premium than the PPO plan and the opportunity to contribute to a health savings
account. If you aren’t familiar with the powerful benefits of a health savings account, read on to learn how the HDHP HSA medical
plan with a health savings account may be the right fit for you.
HDHP HSA Plan vs PPO Plan Knowing which plan is right for you can be as simple as taking
these three steps:
The HDHP HSA Plan offers:
Compare the plans’ monthly premium, annual
1.
• Lower monthly premiums deductible and out-of-pocket maximum.
• The opportunity to contribute to a health savings account. Decide whether you prefer to pay lower premium each
2.
month and have a higher deductible (which means
• Health Savings Account contribution money from the
you pay out-of-pocket for services longer before the
Company.
plan starts sharing costs with you) or if you prefer to
How to Choose Your Medical Plan 2022 pay more each month on premiums and have a lower
You have two medical plan options to choose — the PPO Plan deductible (which mean the plan starts sharing costs
and the HDHP HSA Plan. Both provide comprehensive medical with you sooner).
and prescription drug coverage, but only one — the HDHP HSA
Decide if you want to contribute to an HSA and get a
Plan — lets you contribute to a health savings account, or HSA, 3.
Company contribution in your account.
and comes with a company contribution for your account.
The chart below can help you compare your plan options.
Features Option 1 Option 2
(Staff) PPO Plan HDHP HSA Plan
Lower
Monthly Premium ü
Premium for Non-Tobacco Individual Premium for Non-Tobacco Individual
coverage coverage
$323.20 per month ($3,878.40 per year) $72 per month ($864.00 per year)
Premium for Non-Tobacco Family coverage Premium for Non-Tobacco Family coverage
$1,343.83 per month ($16,125.96 per year) $540.00 per month ($6,480.00 per year)
Lower
In-Network Deductible ü
In-Network Deductible for Individual In-Network Deductible for Individual
coverage coverage
$750 per calendar year $3,000 per calendar year
In-Network Deductible for Family coverage
In-Network Deductible for Family coverage
$1,500 per calendar year
$6,000 per calendar year
Lower
Out-of-Pocket Maximum ü
In-Network Out-of-Pocket Maximum for In-Network Out-of-Pocket Maximum for
Individual coverage Individual coverage
$6,000 per calendar year $6,550 per calendar year
In-Network Out-of-Pocket Maximum for In-Network Out-of-Pocket Maximum for
Family coverage Family coverage
$12,000 per calendar year $13,100 per calendar year
Lets you contribute
pretax dollars to an HSA ü
Comes with a Company
contribution to your HSA ü
$600 per calendar year for individual coverage
$1,200 per calendar year for family coverage
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Rally Health & Wellness Program Real Appeal Weight Loss Program
When it comes to your health, we want you to reach your goals. The Real Appeal program is designed to help you build healthy
That’s why you can use Rally® Health and Wellness through habits across key areas, such as nutrition, fitness, sleep and
your medical coverage. Rally is a digital health platform that stress to support weight loss. This program is available to
provides the tools you need to create healthy habits. By taking eligible members and dependents enrolled for coverage. Login
small steps, you can achieve great results and earn rewards. It’s through Rally to begin the Real Appeal program.
as simple as 1, 2, 3.
Real Appeal members will have access to:
Take the Online Health Survey
1. Online Coaching
All you have to do is answer a few questions to set up
your health profile. Your results are used to help you Support from an online coach who leads group
set healthy goals. These goals can range from losing sessions and helps you set goals.
weight, quitting smoking, improving your mental
Motivational Resources
well-being, and everything in-between.
Digital tools to track your food, activity and weight
Get Personalized Recommendations loss progress. Stream workouts and more with your
2. online dashboard.
Once your goals are set by taking the Health Survey,
you get personalized recommendations on activities
Success Kit
and programs. You can choose which recommendations
A Success Kit that includes scales, recipes and
you’d like to participate in.
workout DVDs.
Earn Rewards
3.
Earn Rally Coins for your participation. You can use
your Rally Coins for: Ready to Start?
• Sweepstake entries. Go rallyhealth.com/well or download the Rally app from
the App Store® or Google Play™ and use the registration
• Discounts on products.
code BeWell to get started. The app is also compatible
• Donations to charitable organizations. with most wearable devices.
13
teamcreativa.com/PHCAadminMedical
UHC Mobile App
The UnitedHealthcare App puts your plan at your finger tips.
When you’re out and about, you can do everything from managing
your plan to getting convenient care. Download the app to:
• Find nearby options in your network.
• Estimate costs.
• View and share your health plan ID card
• See your claim details and progress towards your deductible.
• Link your Optum Bank HSA account for direct access to your
HSA funds.
PPO HDHP
A Preferred Provider Organization (PPO) is a type of health A high deductible health plan (HDHP) is a high deductible
plan that contracts with hospitals, doctors and other PPO plan that meets IRS requirements with regard to
providers. You determine at time of service whether to use minimum deductibles and maximum out-of-pocket
an in-network or out-of-network provider. When you use amounts.
an in-network provider, you will pay lower medical out-of-
pocket costs and will not be subject to balance billing.
Find a Medical Provider
Visit www.myuhc.com to find a Medical Provider in your area and follow the
steps below:
1. Click on the Find a Provider link
2. Choose the type of provider your are looking for: Medical
3. Choose a type of plan: Employer and Individual Plans
4. What plan are you looking for: Choice Plus
5. Begin your search by provider, service or condition
Instructions are also provided on the HR/Benefits website.
14
Visit the HR/Benefits Website atDental
Dental Website Access
The plans also offer additional value-added benefits as
The dental plans are designed to assist you and your covered described on the Guardian website. After registering online with
dependents by paying a portion of eligible expenses incurred for Guardian, you will be provided with the online tools to:
a wide range of dental services. The dental plans are insured by
Guardian. • Find a network dentist and receive driving directions.
• Verify eligibility and view benefit information.
• If you enroll within your initial eligibility period, your
coverage will be effective on the first day of the month • Print an ID card and download claim forms.
following 30 days of employment. • Find the average cost of a dental procedure in your area.
• If you do not enroll for coverage within your initial eligibility • Access dental tips and other oral health information.
period, you may enroll for coverage during the next Annual
• Contact customer service and subscribe to online services.
Enrollment period or in accordance with the section titled
“Making Changes During the Year”. • Get answers to frequently asked questions.
• View specifics related to any of your claims.
You can select from the following options:
Rollover Provision*
• Option 1 - PPO Low Plan.
If you enroll in Option 3 (PPO High Plan), Guardian will
• Option 2 - PPO Medium Plan. automatically rollover unused dental funds into the next year as
• Option 3 - PPO High Plan. follows:
• Option 4 - DHMO Plan. • If you only use in-network providers and your claims for the
current year do not exceed $700, $500 will be rolled over into
Your Cost
the following year for your use.
The Company and you share the cost of dental coverage. Your
cost is generally deducted from your pay on a pretax basis. • If you use any out-of-network providers and your claims for the
(Contributions for domestic partners are generally deducted on current year do not exceed $700, $350 will be rolled over into
an after-tax basis, unless otherwise permitted by state or federal the following year for your use.
law.) Refer to the section titled “Employee Contributions” for the
Each covered person in a family has a separate rollover account.
applicable cost.
The maximum rollover account limit is $1,250.
* You must submit at least one dental claim in order to be eligible for the
Rollover Provision.
Guardian
guardiananytime.com
First time visitors: You will need to To find out the amount of rollover dollars
establish a user ID and password. Then, you received from last year, register online
information is available 24/7. with Guardian at guardiananytime.com.
15
teamcreativa.com/PHCAadminDental
Summary of Dental Plan Provisions
The following table summarizes the key features of the dental Finding an In-Network Dentist Provider
plans available to you and your dependents. To receive the Visit tinyurl.com/6llq4fl to find a Dental Provider in your
highest level of benefits, you should use in-network providers area and follow the two steps below:
and fully understand what is expected of you. If you decide to 1. Select Your Plan Type: PPO or DHMO - Managed
enroll in the Dental HMO (DHMO) plan, you should review the Dental Care
provider network to confirm the provider list is acceptable to
2. Enter Zip or City and State
you and your family.
Instructions are also provided on the HR/Benefits website.
Dental Plans (Guardian)
Option 1 Option 2 Option 3 Option 4
PPO Low Plan PPO Medium Plan PPO High Plan DHMO Plan
Key Features
Out-of- Out-of- Out-of-
In-Network In-Network In-Network In-Network Only
Network** Network** Network**
You Pay You Pay You Pay You Pay
Calendar Year Deductible (ded.)
Individual $50 $50 $50 None
Family $150 $150 $150 None
Plan Pays Plan Pays Plan Pays Plan Pays
Calendar Year Maximum
$1,500 plus
Benefits (per person, $1,000 $1,250 No maximum
maximum rollover***
excluding orthodontia)
Lifetime Orthodontia
Not Covered $1,000 $1,250 No maximum
Maximum
Diagnostic and Preventive
Oral exams (once/6 mos)
$5 office copay plus any
Cleanings (once/6 mos)
100%* 100%* 100%* 100%* 100%* 100%* copays applicable to
Fluoride treatments specific procedures
(once/6 mos, up to age 14)
Basic Services
X-rays
Fillings
$5 office copay plus any
Simple extractions 80% 80% 80% 80% 90% 90%
copays applicable to
Sealants (up to age 16, after ded. after ded. after ded. after ded. after ded. after ded.
specific procedures
once/30 mos)
Space maintainers
Major Restorative Services
Bridges & dentures
Endodontic services
Single crowns
Complex extractions
Crown, bridge & denture
repair
$5 office copay plus any
General anesthesia 50% 50% 60% 60%
Not covered Not covered copays applicable to
Perio maintenance after ded. after ded. after ded. after ded.
specific procedures
(once/6mos)
Combined cleanings &
perio maintenance
(twice/12 mos)
Periodontal surgery
Inlays, onlays & veneers
Orthodontia 50%* 50%* 50%* 50%*
Not covered Not covered (children (children (children (children Varies by schedule
only) only) and adults) and adults)
* Deductible waived. This summary is provided for general information only. Since exclusions, dollar/
** Out-of-Network claims are reimbursed at the maximum allowable charge as frequency limitations and prior authorization may apply, you should refer to the
determined by Guardian. Using out-of-network providers may result in you specific plan documents for detailed information.
being balance-billed by the provider.
*** You may be eligible to rollover unused benefit dollars each year you are
16
continuously enrolled under this plan. Refer to the section titled “Rollover Visit the HR/Benefits Website at
Provision” or call Guardian for more information.Vision
Vision You can select from the following options:
The vision plans provide preventive care through regular eye • Option 1 - Exam Plus Allowance (Davis Network).
exams and early corrective treatment. You have the option of • Option 2 - Exam Plus Allowance (VSP Network).
enrolling for a plan that covers your vision exam and provides
• Option 3 - Full Feature (Davis Network).
an allowance for materials or a full-feature plan. In addition to
selecting the plan design you want, you will also need to select • Option 4 - Full Feature (VSP Network).
either the Davis or VSP provider network. The vision plans are
insured by Guardian. Your Cost
You pay the full cost of vision coverage. Your cost is generally
• If you enroll for coverage within your initial eligibility period, deducted from your pay on a pretax basis. (Contributions for
your coverage will be effective on the first day of the month domestic partners are generally deducted on an after-tax basis,
following 30 days of employment. unless otherwise permitted by state or federal law.) Refer to the
section titled “Employee Contributions” for the applicable cost.
• If you do not enroll for coverage within your initial eligibility
period, you may enroll for coverage during the next Annual Summary of Vision Plan Provisions
Enrollment period or in accordance with the section titled The following table summarizes the key features of the vision plans
“Making Changes During the Year”. available to you and your dependents. To receive the highest level of
benefits, utilize in-network providers and fully understand what is
Practice good vision health. Obtain an eye exam expected of you.
every year and help stop vision loss before it starts.
Vision Plans (Guardian)
Option 1 Option 2 Option 3 Option 4
Exam Plus Allowance Exam Plus Allowance Full Feature Full Feature
Key Features Davis Network VSP Network Davis Network VSP Network
Out-of- Out-of- Out-of- Out-of-
In-Network In-Network In-Network In-Network
Network Network Network Network
You Pay You Pay You Pay You Pay
Exam Copay $0 $0 $10 $10
Materials Copay $0 $0 $25 $25
Plan Pays Plan Pays Plan Pays Plan Pays
Frequency Exam: Every 12 months Exam: Every 12 months
Exam: Every 12 months Exam: Every 12 months
Lenses: Every 12 months Lenses: Every 12 months
Materials: Every 12 months Materials: Every 12 months
Frames: Every 24 months Frames: Every 24 months
Exams 100% Up to $46 100% Up to $39 100% Up to $50 100% Up to $39
Lenses
Single 100% Up to $48 100% Up to $23
Bifocal 100% Up to $67 100% Up to $37
Trifocal 100% Up to $86 100% Up to $49
Lenticular 100% Up to $126 100% Up to $64
Up to $50 allowance Up to $50 allowance
Medically Necessary on frames and lenses on frames and lenses 100%; after
100% Up to $210 Up to $210
$25 copay
Elective Up to $130 Up to $105 Up to $130 Up to $100
Frame Benefit Up to $130 Up to $130
then 20% Up to $48 then 20% Up to $46
discount discount
This summary is provided for general information only. Since exclusions, dollar/frequency limitations and prior authorization may apply, you should refer to the
specific plan documents for detailed information.
17
teamcreativa.com/PHCAadminVision
Dual Option Provider Network
Finding an In-Network Vision Provider
When you make your vision plan election (either Exam Plus Visit tinyurl.com/y4pzhfdc to find a Vision Provider in
Allowance or Full Feature), you will also need to select a provider your area and follow the steps below:
network. Both provider networks cover a significant number of
vision providers. Many individuals prefer private practice vision 1. Select your Vision Network: Davis Vision or VSP
care specialists, while other individuals prefer large retailers.
The choice is up to you. Your Location: Enter Zip Code or Street Address,
2.
City and State
VSP Vision Network Davis Vision Network
Over 88,000 access points, Over 100,000 provider locations
more than 15,000 retail chain
locations like Costco, Pearle
including retailers like Costco,
J.C. Penney, Pearle Vision, Sam’s
Guardian
Vision, Visionworks and the Club, Sears, Target and Walmart. guardiananytime.com
largest nationwide network of
independent doctors. First time visitors: You will need to
establish a user ID and password. Then,
For more information and to find a vision provider go to information is available 24/7.
guardiananytime.com.
Whether you use an in-network or out-of-network provider, benefit authorization is recommended before you
receive services.
Using an In-Network Versus an Out-of-Network Provider
In-Network Out-of-Network
Use any licensed eye care provider outside
Provider Must use an in-network provider
the network
The plan gives you a choice when it
comes to receiving eye care. You may Your network provider obtains
receive services from either in-network You must contact your provider to obtain
Benefit authorization from your vision plan when
or out-of-network providers. authorization before you visit your out-of-
Authorization you make your appointment and identify
network provider
yourself as an enrolled member
Although you are not required to use
in-network providers, your out-of-pocket
costs will be lower when in-network The plan pays a higher benefit level, which The plan pays a lower benefit level, which
Benefits
providers are used. means less out-of-pocket cost for you means more out-of-pocket cost for you
This table compares some of the key You must file your own claims with your
Claims Your provider files claims on your behalf
differences between receiving care from vision provider
an in-network versus an out-of-network
Additional Available, which means your share of the
provider.
Discounts and cost for additional purchases will be less Not available
Savings (e.g., Lasik surgery, etc.)
18
Visit the HR/Benefits Website atDisability
Disability Short Term Disability (STD)
You are automatically enrolled in the STD 50% option on the first
The disability plans are designed to replace a portion of your day of the month following 30 days of employment. The STD
income if you are unable to work due to an accident or illness. 50% option is paid in full by the Company.
These plans cover you continuously with both short term and
long term benefits for qualifying disabilities. These coverages In addition, you have the opportunity to increase (“buy-up”)
also provide the vital support, services and assistance you need your STD coverage to the 60% option.
to get back to work and to an independent lifestyle. The Short
• If you enroll for the buy-up coverage within your initial
Term Disability (STD) and Long Term Disability (LTD) plans are
eligibility period, your 60% option will be effective on the first
insured by Lincoln Financial Group.
day of the month following 30 days of employment.
The following table summarizes the key features of the plans. • If you do not enroll for the buy-up coverage within your initial
eligibility period, you may enroll for coverage during the next
Disability Plans (STD and LTD) Annual Enrollment period. You should keep in mind that you
Benefit Benefit Maximum will be required to provide evidence of insurability satisfactory
Plan
Percentage Begins Benefit to the insurance company before the coverage will become
effective.
Short Term Disability
$1,250 per STD benefits generally begin the first day of an accident or
Option 1 50% of pay 1st day of week (up to eighth day of sickness if you are unable to perform all of the
accident or 13 weeks) material and substantial duties of your own occupation and as
8th day of $1,500 per long as you are not engaged in any occupation for wage or profit,
Option 2 60% of pay sickness week (up to as determined by the insurance company. STD benefits will be
13 weeks) reduced by any other benefits you may be eligible for such as
Long Term 91st day of $10,000 per state disability benefits. STD benefits pay up to:
60% of pay
Disability disability month
** Benefits begin after any PTO benefits or elimination periods have been met. Your weekly benefit amount depends on the option you elected:
This summary is provided for general information only. It does not provide
coverage details, exclusions or limitations. You should refer to specific plan • Option 1: 50% of pay (maximum $1,250 per week).
documents for detailed information.
• Option 2: 60% of pay (maximum $1,500 per week).
STD benefits continue for up to 13 weeks as long as you remain
disabled as determined by the insurance company.
19
teamcreativa.com/PHCAadminDisability
Long Term Disability (LTD)
You are automatically enrolled for LTD insurance on the first
day of the month following 30 days of employment. LTD benefits
begin after you have been disabled for 90 days, as determined by
the insurance company. LTD benefits pay up to:
• 60% of your pay to a maximum of $10,000 per month.
LTD benefits generally continue as long as you remain totally
disabled, up to age 65 (longer if your disability begins at age 60
or later).
LTD benefits will be reduced by any other benefits you may
be eligible to receive such as state disability benefits, workers’
compensation or Social Security disability benefits.
There are several other additional special benefit Annual Pay
provisions available under the LTD plan as follows:
For purposes of the disability plans, “pay” or “annual
• Social Security assistance. pay” is defined as current base pay excluding any forms
of extra compensation.
• Rehabilitation during disability.
• Return to work incentive benefits.
• Survivor benefits.
Your Cost
The Company pays the full cost of the STD 50% option and the
full cost of the LTD plan. You pay the full cost of the STD 60%
buy-up option.
Refer to the section titled “Employee Contributions” for the
applicable cost.
20
Visit the HR/Benefits Website atLife and Accident
Life and Accident
The life and accident insurance plans provide you with basic
life and accident insurance paid for by the Company. In
addition, optional life, dependent life and accidental death and
dismemberment (AD&D) insurance coverage is available at group
rates. The life and accident plans are insured by Lincoln Financial
Group.
The following table summarizes the key features of the plans
available to you and your dependents.
Life and Accident Plans (Lincoln Financial Group)
Coverage Available
Enrollment
Plan Spouse/Domestic Paid By
Employee Each Child Required
Partner
1 times annual base
Basic Life pay (maximum – – No Company
$50,000)
1 – 8 times annual
Optional Employee Life $25,000 – $250,000 $5,000 – $25,000*
base pay (maximum Yes Employee
& Dependent Life (increments of $25,000) (increments of $5,000)
$750,000)
1 times annual base
Basic AD&D pay (maximum – – No Company
$50,000)
Optional Employee 1 – 8 times annual
$25,000 – $250,000 $5,000 – $25,000*
AD&D & Dependent base pay (maximum Yes Employee
(increments of $25,000) (increments of $5,000)
AD&D $750,000)
* Coverage for a child from birth to 6 months is limited to $5,000.
This summary is provided for general information only. Certain maximums apply to each level of coverage and evidence of insurability may be required. In addition,
life and AD&D coverage is reduced according to an age reduction schedule beginning at age 70. You should refer to specific plan documents for detailed information.
What is the Right Amount of Life Insurance?
How much is enough life insurance? To begin to determine how much you need, consider both your family’s immediate
and long-term financial needs, such as:
• M
ortgage expenses. • C
redit card debt. • Charitable giving goals. • Final
expenses for a simple
funeral, which can cost
• D
ay care and everyday • C
ollege costs. • F
inancial goals.
$10,000 or more.
expenses.
Visit the Lincoln Financial online life insurance calculator to determine the amount of insurance you need at
tinyurl.com/5z45zmbt.
Annual Pay
For purposes of the life and accident plans, “pay” or “annual
pay” is defined as current base pay excluding any forms of
extra compensation.
21
teamcreativa.com/PHCAadminLife and Accident
Basic Life
Things to Consider About Life Insurance
Basic life insurance is equal to one times your annual base pay Most people don’t like to think about needing life
rounded to the next higher multiple of $1,000 (if the coverage insurance. But when an unexpected death happens to
amount is not a multiple of $1,000). The maximum amount of a wage earner, we realize how important life insurance
basic life insurance is $50,000. can be. You can minimize the impact of an unexpected
death by selecting the right amount of life insurance.
You are automatically enrolled for basic life insurance on the
first day of the month following 30 days of employment.
Optional Life – Employee
Your basic life insurance coverage reduces automatically
to the amounts shown in the following table on the first of Optional life insurance is available in amounts from 1 – 8 times
the month immediately following the attainment of the your annual base pay, rounded to the next higher multiple of
specified age. $1,000 (if the coverage amount is not a multiple of $1,000). The
maximum amount of optional life insurance is $750,000.
Age Percentage of Available Amount
70 65% Your optional life insurance coverage reduces automatically
75 50% to the amounts shown in the following table on the first of
For example, if you are age 69 and have $50,000 of coverage, your benefit the month immediately following the attainment of the
payable would be the full $50,000. Upon turning age 70, your benefit
payable would be $32,500 (calculated as $50,000 x 0.65 = $32,500).
specified age.
Age Percentage of Available Amount
If your annual base pay changes (either increases or decreases),
70 65%
your basic life insurance will automatically change to the new
coverage amount on the first of the following month. 75 50%
For example, if you are age 69 and have $100,000 of coverage, your
benefit payable would be the full $100,000. Upon turning age 70, your
benefit payable would be $65,000 (calculated as $100,000 x 0.65 =
$65,000).
• If you enroll for coverage and your enrollment is received
within your initial eligibility period, your coverage amount for
optional life insurance of up to $250,000 will be effective on
the first day of the month following 30 days of employment.
• If your enrollment in optional life insurance results in over
$250,000 of coverage, you will be required to provide evidence
of insurability satisfactory to the insurance company before
coverage in excess of $250,000 will become effective.
• If you do not enroll for optional life insurance during your
initial eligibility period, you may only enroll during the
next Annual Enrollment period or within 30 days of a
qualifying event.
You should also keep in mind that if you enroll or increase
coverage after your initial eligibility period (including during
the Annual Enrollment period), you will be required to provide
evidence of insurability satisfactory to the insurance company
before the new or increased coverage will become effective.
If your annual base pay changes (either increases or decreases),
your optional life insurance will automatically change to the
new coverage amount on the first of the following month.
Your employee premiums will also change as of the date your
optional life insurance coverage changes.
22
Visit the HR/Benefits Website atLife and Accident
Dependent Life – Spouse/Domestic Partner Dependent Life – Children
If you enroll for optional life insurance, you are eligible to If you enroll for optional life insurance, you are eligible
enroll for dependent life insurance for your spouse/domestic to enroll for dependent life insurance for your children.
partner. Dependent life insurance is available in amounts Dependent life insurance is available in amounts* from $5,000,
from $25,000 – $250,000 in increments of $25,000. However, $10,000, $15,000, $20,000 and $25,000. If you enroll one child,
spouse/domestic partner coverage may not exceed 100% of all eligible children are covered.
your combined basic and optional life insurance coverage. Your * Coverage for a child from birth to 6 months is limited to $5,000.
spouse/domestic partner life insurance coverage terminates
when your spouse/domestic partner attains age 70. • If you enroll for dependent life insurance for your children
and your enrollment is received within your initial eligibility
• If you enroll for dependent life insurance for your period, your coverage amount for insurance of up to $25,000
spouse/domestic partner and your enrollment is received will be effective on the first day of the month following 30 days
within your initial eligibility period, your coverage amount for of employment.
dependent life insurance of up to $25,000 will be effective on
• If you do not enroll for dependent life insurance for your
the first day of the month following 30 days of employment.
children during your initial eligibility period, you may enroll
• If your enrollment in dependent life insurance for your for coverage during the next Annual Enrollment period or
spouse/domestic partner results in over $25,000 of coverage, within 30 days of a qualifying event. (Evidence of insurability
your spouse/domestic partner will be required to provide is not required for dependent children.)
evidence of insurability satisfactory to the insurance company
before coverage in excess of $25,000 will become effective. Your Cost
The Company pays the full cost of basic life insurance. You pay
• If you do not enroll for dependent life insurance for your
the full cost of any optional life insurance and dependent life
spouse/domestic partner during your initial eligibility
insurance. Your cost is deducted from your pay on an after-tax
period, you may only enroll during the next Annual
basis. Refer to the section titled “Employee Contributions” for
Enrollment period or within 30 days of a qualifying event.
the applicable cost.
You should also keep in mind that if you enroll or increase
coverage after your initial eligibility period (including during
the Annual Enrollment period), your spouse/domestic partner
will be required to provide evidence of insurability satisfactory
to the insurance company before the new or increased coverage
will become effective.
23
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