2022 EMPLOYEE BENEFIT HIGHLIGHTS - Palm Beach ...
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2022 EMPLOYEE BENEFIT HIGHLIGHTS
Clerk of the Circuit Court & Comptroller, Palm Beach County | Employee Benefit Highlights | 2022
Table of Contents
Contact Information 1
Online Enrollment 2
Default Benefits 2
Medical Plan Opt-Out Benefit 2
Group Insurance Eligibility 3
Qualifying Events and Section 125 4
Summary of Benefits and Coverage 4
Medical Insurance 5
Telehealth 5
Other Available Plan Resources 5
Cigna OAPIN Plan At-A-Glance 6
Cigna OAP Plan At-A-Glance 7
Clerks for Wellness Program 8
Dental Insurance 9
Cigna Dental Care Access DHMO Plan At-A-Glance 10
Dental Insurance 11
Cigna Total DPPO Base Plan At-A-Glance 12
Dental Insurance 13
Cigna Total DPPO Buy-Up Plan At-A-Glance 14
Dental Insurance: Side-By-Side Plans At-A-Glance 15
Vision Insurance 16
Cigna Vision Plan At-A-Glance 17
Flexible Spending Accounts 18-19
Basic Life and AD&D Insurance 20
Voluntary Life Insurance 20
Whole Life Insurance 21
Short Term Disability 21
Long Term Disability 21
Employee Assistance Program 22
Alternative Employee Assistance Program 22
Supplemental Insurance 23
Credit Union 23
Retirement Plan (FRS) 24
Retirement Plan (Deferred Compensation) 24
Notes 24
This booklet is merely a summary of employee benefits. For a full description, refer to the plan document. Where conflict exists between this summary and the plan document, the plan document controls.
The Clerk of the Circuit Court & Comptroller, Palm Beach County reserves the right to amend, modify or terminate the plan at any time. This booklet should not be construed as a guarantee of employment.
© 2016, Gehring Group, Inc., All Rights Reserved
Clerk of the Circuit Court & Comptroller, Palm Beach County | Employee Benefit Highlights | 2022
Contact Information
Clerk of the Circuit Court & Comptroller, Phone: (561) 355-4172 Option 3
Human Resources/Benefits Department
Palm Beach County Email: benefits@mypalmbeachclerk.com
Customer Service: (800) 244-6224
Medical Insurance Cigna
www.cigna.com
Prescription Drug Coverage Customer Service: (800) 835-3784
Cigna/Express Scripts Pharmacy
& Mail-Order Program www.mycigna.com
Customer Service: (800) Teladoc (835-2362)
Telehealth Teladoc
www.teladoc.com
Customer Service: (800) 244-6224
Dental Insurance Cigna
www.cigna.com
Customer Service: (877) 478-7557
Vision Insurance Cigna
www.cigna.com
Customer Service: (800) 244-6224
Flexible Spending Accounts Cigna
www.cigna.com
Customer Service: (800) 368-1135
Basic Life and AD&D Insurance The Standard
www.standard.com
Customer Service: (800) 368-1135
Voluntary Basic Life and AD&D Insurance The Standard
www.standard.com
Representatives: Janet Froyen & Tara Froyen
Whole Life Insurance MetLife Customer Service: (866) 713-1690
www.metlife.com
Customer Service: (800) 368-1135
Short & Long Term Disability Insurance The Standard
www.standard.com
Customer Service: (877) 622-4327
Employee Assistance Program Cigna
www.mycigna.com
Agent: Mari Maldonado | Phone: (561) 351-3270
Aflac Customer Service: (800) 992-3522
www.aflac.com
Agent: Michael Hogan | Phone: (937) 207-0171
Supplemental Insurance Email: michael.Hogan@pmagent.net
Washington National
Customer Service: (800) 525-7662
www.washingtonnational.com
Representative: Line Doucet | Phone: (561) 704-8483
LegalShield
www.yoursequally.net
Customer Service: (561) 686-4006
Credit Union Guardians Credit Union
www.guardianscu.coop
Customer Service: (866) 446-9377
Florida Retirement System FRS Financial Guidance Line
www.myfrs.com
Agent: Steve Feigelis | Phone: (866) 731-1055
Deferred Compensation Program MissionSquare Retirement Customer Service: (800) 669-7400
www.icmarc.org
1 © 2016, Gehring Group, Inc., All Rights Reserved
Clerk of the Circuit Court & Comptroller, Palm Beach County | Employee Benefit Highlights | 2022
Introduction
The Clerk of the Circuit Court & Comptroller, Palm Beach County provides group insurance benefits to eligible employees. The Employee
Benefit Highlights Booklet provides a general summary of the benefit options as a convenient reference. Please refer to the Clerk's Office
Personnel Policies and/or Certificates of Coverage for detailed descriptions of all available employee benefit programs and stipulations
therein. If employee requires further explanation or needs assistance regarding claims processing, please refer to the customer service
phone numbers under each benefit description heading or contact Human Resources/Benefits Department.
Online Enrollment Default Benefits
Employee Self Service (ESS) System New employees who do not make timely elections for medical, dental, vision,
and group term life benefits within 15 days of employee's date of hire will be
Employees use the Employee Self Service (ESS) system to make their benefit
assigned the following default benefits:
elections. Online enrollment reduces paperwork and complications that may
result from dealing with multiple benefits providers during the enrollment 9 Cigna OAPIN employee-only medical coverage
process. Employees may access ESS to review current benefit elections prior 9 Cigna DHMO employee-only dental coverage
to making any new plan year elections or changes. Information about benefit
options, including employee premiums, is also available to help employees 9 Standard Insurance basic group term life insurance benefits
make informed decisions. Please note: elections/changes for Aflac, Washington If assigned, default benefits will be effective on the first day of the month
National and MetLife coverage are made directly with the representative and following 30 days of employment. Changes to default benefits will not
outside of ESS. be permitted until the next applicable Open Enrollment period unless the
employee can demonstrate a qualified family status change (qualifying event).
Accessing ESS
ESS is available via a Clerk's Office computer by accessing the Clerk's Office
intranet, ClerkNet, as follows: Navigate to ClerkNet > ClerkWorks > Employee
Self Service. ESS is also available from a computer outside of the office via
Medical Plan Opt-Out Benefit
https://myclerkess.mypalmbeachclerk.com. This means that employees can Clerk's Office funds a Health Care Flexible Spending Account (FSA) in the
choose to access and review benefits with another member of their family and amount up to the maximum allowed by the IRS for the entire plan year.
process elections from home. Employee must submit a waiver to show evidence of health insurance under
another health plan that provides minimum essential coverage and meets the
Training materials regarding benefits enrollment and changes are available via minimum value standard as required by the Affordable Care Act. This Health
ClerkNet > under Pay & Benefits > under Open Enrollment. Care FSA can be used by the qualified employee and the employee’s qualified
dependents to request reimbursement for eligible out-of-pocket health care
Employee User ID and Password expenses.
Log in with the same User ID and Password used to sign in to the Clerk's Office
computer. FSA Opt-Out required documentation:
1. Medical insurance waiver; and
ClerkNet 2. Proof of medical insurance coverage; and
Find benefit forms, premium sheets, plan documents, and tips for saving 3. Page 5 of Medical Summary of Benefits & Coverage (SBC).
money on ClerkNet. ClerkNet is also where employees will find helpful
information if they need to update their beneficiaries.
© 2016, Gehring Group, Inc., All Rights Reserved
2
Clerk of the Circuit Court & Comptroller, Palm Beach County | Employee Benefit Highlights | 2022
Group Insurance Eligibility
JANUARY The Clerk's Office group insurance plan Disabled Dependents
01 year is January 1 through December 31. Coverage for a dependent child may be continued beyond age 26 if:
• The dependent is physically or mentally disabled and incapable of
Employee Eligibility self-sustaining employment (prior to age 26); and
Employees are eligible to participate in the Clerk's Office insurance plans if they • Primarily dependent upon the employee for support; and
are full-time employees working a minimum of 20 hours per week. Employees • The dependent is otherwise eligible for coverage under the group
working 20 to 23 hours may elect employee-only coverage. Employees working medical plan; and
24 hours or more may elect any level of coverage. Coverage will be effective
• The dependent has been continuously insured
the first of the month following 30 days after date of hire. For example, if an
employee is hired on April 11, then the effective date of coverage will be June 1. Proof of disability will be required upon request. Please contact Human
Resources/Benefits Department if further clarification is needed.
Separation of Employment
If an employee separates employment from the Clerk's Office, medical,
Domestic Partner Coverage
dental, and vision insurance will continue through the end of month in which The Clerk's Office offers domestic partner benefits to eligible same or opposite
separation occurred. COBRA continuation of coverage may be available as sex domestic partners for the purpose of participation in medical, dental, and
applicable by law. vision benefits. The employee and domestic partner must sign an Affidavit
of Domestic Partnership, initial and date the Procedure for Administration of
Dependent Eligibility Domestic Partner Coverage and submit documentation that verifies a joint
A dependent is defined as the legal spouse/domestic partner and/or dependent financial and shared residential arrangement. See the Clerk’s Office Domestic
child(ren) of the participant or the spouse/domestic partner. The term “child” Partner Tax Equity Policy for taxation information.
includes any of the following:
Taxable Dependents
• A natural child • A stepchild • A legally adopted child
Current IRS rules do not permit an employee to receive a tax advantage on any
• A newborn child (up to the age of 18 months) of a covered
portion of premiums paid related to the coverage of a dependent who is not a
dependent (Florida)
qualified tax dependent. Employee covering adult child(ren) under employee's
• A child for whom legal guardianship has been awarded to the medical insurance plan may continue to have the related coverage premiums
participant or the participant’s spouse/domestic partner payroll deducted on a pre-tax basis through the end of the calendar year in
which dependent child reaches age 26. Beginning January 1 of the calendar
Dependent Age Requirements year in which dependent child reaches age 27 through the end of the calendar
year in which the dependent child reaches age 30, imputed income must be
Medical Coverage: A dependent child may be covered through the reported on the employee’s W-2 for that entire tax year and will be subject to
end of the calendar year in which the child turns age 26. An over- all applicable Federal, Social Security and Medicare taxes. Imputed income
age dependent may continue to be covered on the medical plan to is the dollar value of insurance coverage attributable to covering each adult
the end of the calendar year in which the child reaches age 30, if the dependent child. Contact Human Resources/Benefits Department for further
dependent meets the following requirements: details if covering an adult dependent child who will turn age 27 any time
• Unmarried with no dependents; and during the upcoming calendar year or for more information.
• A Florida resident, or full-time or part-time student; and
Please Note: There is no imputed income if adult dependent child is eligible to
• Otherwise uninsured; and
be claimed as a dependent for Federal income tax purposes on the employee’s
• Not entitled to Medicare benefits under Title XVIII of the
tax return.
Social Security Act, unless the child is disabled.
Dental and Vision Coverage: A dependent child may be covered Attestation & Proof
through the end of the calendar year in which child turns age 26. When a dependent is added to the plan, Human Resources/Benefits Department
will require proof of the dependent as well as a completed attestation.
3 © 2016, Gehring Group, Inc., All Rights ReservedClerk of the Circuit Court & Comptroller, Palm Beach County | Employee Benefit Highlights | 2022
Qualifying Events and Section 125
Section 125 of the Internal Revenue Code
IMPORTANT NOTES
Premiums for medical, dental, vision insurance, contributions to Flexible
Spending Accounts (FSA), and/or certain supplemental policies are deducted If employee experiences a Qualifying Event, Human Resources/
through a Cafeteria Plan established under Section 125 of the Internal Revenue Benefits Department must be contacted within 30 days
Code and are pre-taxed to the extent permitted. Under Section 125, changes of the Qualifying Event to make the appropriate changes to
to employee's pre-tax benefits can be made ONLY during the Open Enrollment employee’s coverage. Employee may be required to furnish valid
period unless the employee or qualified dependent(s) experience(s) a Qualifying documentation supporting a change in status or “Qualifying
Event and the request to make a change is made within 30 days of the Qualifying Event”. If approved, changes may be effective the date of the
Event. Qualifying Event or the first of the month following the Qualifying
Under certain circumstances, employee may be allowed to make changes to Event. Newborns are effective on the date of birth. Qualifying
benefit elections during the plan year, if the event affects the employee, spouse Events will be processed in accordance with employer and carrier
or dependent’s coverage eligibility. An “eligible” Qualifying Event is determined eligibility policy. Beyond 30 days, requests will be denied and
by Section 125 of the Internal Revenue Code. Any requested changes must be employee may be responsible, both legally and financially, for
consistent with and due to the Qualifying Event. any claim and/or expense incurred as a result of employee or
dependent who continues to be enrolled but no longer meets
Examples of Qualifying Events: eligibility requirements.
• Employee gets married or divorced
• Birth of a child
• Employee gains legal custody or adopts a child
• Employee's spouse and/or other dependent(s) die(s)
Summary of Benefits and Coverage
• Loss or gain of coverage due to employee, employee’s spouse and/or
A Summary of Benefits & Coverage (SBC) for the Medical Plan is provided as a
dependent(s) termination or start of employment supplement to this booklet being distributed to new hires and existing employees
• An increase or decrease in employee's work hours causes eligibility during the Open Enrollment period. The summary is an important item in
or ineligibility understanding employee's benefit options. A free paper copy of the SBC document
may be requested or is available as follows:
• A covered dependent no longer meets eligibility criteria for coverage
• A child gains or loses coverage with other parent or legal guardian From: Human Resources/Benefits Department
Address: 301 North Olive Avenue, 9th Floor
• Change of coverage under an employer’s plan West Palm Beach, FL 33401
• Gain or loss of Medicare coverage Phone: (561) 355-4172, Option 3
Email: benefits@mypalmbeachclerk.com
• Losing or becoming eligible for coverage under a State Medicaid or
At Website URL: ClerkNet (See page 1 for instructions)
CHIP (including Florida Kid Care) program (60 day notification period)
The SBC is only a summary of the plan’s coverage. A copy of the plan document, policy,
or certificate of coverage should be consulted to determine the governing contractual
provisions of the coverage. A copy of the group certificate of coverage can be reviewed
and obtained by contacting Human Resources/Benefits Department.
If there are any questions about the plan offerings or coverage options, please contact
Human Resources/Benefits Department at (561) 355-4172, Option 3.
© 2016, Gehring Group, Inc., All Rights Reserved
4Clerk of the Circuit Court & Comptroller, Palm Beach County | Employee Benefit Highlights | 2022
Medical Insurance Other Available Plan Resources
The Clerk's Office offers medical insurance through Cigna to benefit-eligible Cigna offers all enrolled employees and dependents additional services
employees. The costs per pay period for coverage are listed in the premium and discounts through value added programs. For more details regarding
tables below and a brief summary of benefits is provided on the following page. other available plan resources, please contact Cigna's customer service at
For information about the medical plans, please refer to the carrier's Summary (800) 244-6224 or visit www.cigna.com.
of Benefits and Coverage (SBC) document or contact Cigna's customer service.
24-Hour Help Information Hotline (800) CIGNA-24
Medical Insurance – Cigna OAPIN Plan
26 Payroll Deductions - Per Pay Period Cost The Cigna 24-Hour Health Information Line provides access to helpful, reliable
information and assistance from qualified health information nurses on
Tier of Coverage Employee Cost a wide range of health topics 24 hours a day, any day of the year. Not sure
Employee Only $14.64 what to do for a child who has a fever in the middle of the night? Not sure if
treatment from a doctor is necessary for an injury? There are over 1,000 topics
Employee + 1 Dependent $116.63
in the Health Information Library to help weigh the risks and advantages of
Employee + 2 or More Dependents $187.14 treatment options. The call is free and is strictly confidential.
Medical Insurance – Cigna OAP Plan Healthy Rewards
26 Payroll Deductions - Per Pay Period Cost
Cigna’s Healthy Rewards is provided automatically at no additional cost and
Tier of Coverage Employee Cost offers access to discounted health and wellness programs at participating
providers. Members can register on www.mycigna.com and select Healthy
Employee Only $32.02
Rewards to learn more about these programs or call (800) 870-3470.
Employee + 1 Dependent $127.79
9 Vision Care 9 Fitness Club Discounts
Employee + 2 or More Dependents $210.41
9 Lasik Vision Correction 9 Nutrition Discounts
Services 9 Hearing Care
Cigna | Customer Service: (800) 244-6224 | www.cigna.com
The myCigna Mobile App
Telehealth The myCigna mobile app is an easy way to organize and access important
health information. Anytime. Anywhere. Download it today from the App
The Clerk's Office provides access to telehealth services as part of the medical StoreSM or Google Play™. With the myCigna mobile app, members can:
plan. Teladoc is a convenient phone and video consultation company that 9 Find a doctor, dentist or health care facility
provides immediate medical assistance for many conditions.
9 Access maps for instant driving directions
The benefit is provided to all enrolled members. Registration is required and 9 View ID cards for the entire family
should be completed ahead of time. This program allows members 24 hours
9 Review deductibles, account balances and claims
a day, seven (7) days a week on-demand access to affordable medical care via
phone and online video consultations when needing immediate care for non- 9 Compare prescription drug costs
emergency medical issues. Telehealth should be considered when employee's 9 Speed-dial Cigna Home Delivery Pharmacy™
primary care doctor is unavailable, after-hours or on holidays for non-emergency 9 Add health care professionals to contact list right from a claim
needs. Many urgent care ailments can be treated with telehealth, such as: or directory search
9 Sore Throat 9 Fever 9 Rash
Headache Cold and Flu
Cigna Behavioral Health
9 9 9 Acne
9 Stomachache 9 Allergies 9 UTIs and More For covered services related to mental health and substance abuse, participants
have access to the Cigna Behavioral Health network of providers. To access
Telehealth doctors do not replace employee's primary care physician but
services, visit www.mycigna.com to search for a video telehealth specialist or
may be a convenient alternative for urgent care and ER visits. For further
call to make an appointment with your selected provider. Telehealth visits with
information please contact Teladoc.
Cigna Behavioral Health network providers cost the same as an in-office visit.
Teladoc | Customer Service: (800) 835-2362 | www.teladoc.com
5 © 2016, Gehring Group, Inc., All Rights ReservedClerk of the Circuit Court & Comptroller, Palm Beach County | Employee Benefit Highlights | 2022
Cigna OAPIN Plan At-A-Glance
Network Open Access Plus
Calendar Year Deductible (CYD) In-Network
Single $0
Family $0
Locate a Provider
Coinsurance To search for a participating provider,
Member Responsibility 0% contact Cigna's customer service or visit
www.cigna.com. When completing the
Calendar Year Out-of-Pocket Limit necessary search criteria, select Open
Access Plus, OA Plus, Choice Fund
Single $0
OA Plus Network.
Family $0
What Applies to the Out-of-Pocket Limit? Not Applicable
Physician Services
Primary Care Physician (PCP) Office Visit $15 Copay
Specialist Office Visit $25 Copay Plan References
*LabCorp and Quest Diagnostics are the
Non-Hospital Services; Freestanding Facility
preferred labs for bloodwork through
Clinical Lab (Bloodwork)* No Charge Cigna. When using a lab other than
X-rays No Charge LabCorp or Quest, please confirm they
are contracted with Cigna’s Open Access
Advanced Imaging (MRI, PET, CT) No Charge Plus network prior to receiving services.
Outpatient Surgery in Surgical Center $50 Copay
Physician Services at Surgical Center No Charge
Urgent Care (Per Visit) $25 Copay
Hospital Services
Inpatient Hospital (Per Admission) $150 Copay Important Notes
• Services received by providers or
Outpatient Hospital (Per Visit) $50 Copay
facilities not in the Open Access Plus
Physician Services at Hospital No Charge network not be covered, will not be
covered.
Emergency Room (Per Visit; Waived if Admitted) $100 Copay
• The Cigna OAPIN plan allows for
Mental Health/Alcohol & Substance Abuse 90-day prescription fills through Cigna
Home Delivery and now the plan also
Inpatient Hospitalization (Per Admission) $150 Copay allows these scripts to be filled at
Outpatient Services (Per Visit) No Charge retailers like Target, CVS, and Walmart.
Outpatient Office Visit $25 Copay
Prescription Drugs (Rx)
Generic $10 Copay
Preferred Brand Name $20 Copay
Non-Preferred Brand Name $40 Copay
Mail Order Drug (90-Day Supply) 2x Retail Copay
© 2016, Gehring Group, Inc., All Rights Reserved
6Clerk of the Circuit Court & Comptroller, Palm Beach County | Employee Benefit Highlights | 2022
Cigna OAP Plan At-A-Glance
Network Open Access Plus
Calendar Year Deductible (CYD) In-Network Out-of-Network*
Single $50 $200
Family $150 $600
Locate a Provider
To search for a participating provider, Coinsurance
contact Cigna's customer service or visit Member Responsibility 10% 20%
www.cigna.com. When completing the
necessary search criteria, select Open Calendar Year Out-of-Pocket Limit
Access Plus, OA Plus, Choice Fund
OA Plus network. Single $1,500 $1,500
Family $4,500 $4,500
What Applies to the Out-of-Pocket Limit? Coinsurance Only (Excludes Copays, Deductible, and Rx)
Physician Services
Primary Care Physician (PCP) Office Visit $15 Copay 20% After CYD
Plan References Specialist Office Visit $25 Copay 20% After CYD
*Out-Of-Network Balance Billing:
For information regarding out-of- Non-Hospital Services; Freestanding Facility
network balance billing that may be Clinical Lab (Bloodwork)** 10% After CYD 20% After CYD
charged by out-of-network providers,
please refer to the Summary of Benefits X-rays 10% After CYD 20% After CYD
and Coverage (SBC) document. Advanced Imaging (MRI, PET, CT) 10% After CYD 20% After CYD
**LabCorp and Quest Diagnostics are Outpatient Surgery in Surgical Center 10% After CYD 20% After CYD
the preferred labs for bloodwork through
Cigna. When using a lab other than Physician Services at Surgical Center 10% After CYD 20% After CYD
LabCorp or Quest, please confirm they Urgent Care (Per Visit) $25 Copay $25 Copay
are contracted with Cigna’s Open Access
Plus network prior to receiving services. Hospital Services
***PAD: Per Admission Deductible
Inpatient Hospital (Per Admission) 10% After CYD $100 PAD*** + 20% After CYD
Outpatient Hospital (Per Visit) 10% After CYD 20% After CYD
Physician Services at Hospital 10% After CYD 20% After CYD
Emergency Room (Per Visit) 10% Coinsurance 10% Coinsurance
Important Notes. Mental Health/Alcohol & Substance Abuse
• The Cigna OAP plan allows for 90-day Inpatient Hospitalization (Per Admission) 10% After CYD $100 PAD*** + 20% After CYD
prescription fills through Cigna Home
Outpatient Services (Per Visit) 10% Coinsurance 20% After CYD
Delivery and now the plan also allows
these scripts to be filled at retailers like Outpatient Office Visit $25 Copay 20% After CYD
Target, CVS, and Walmart.
Prescription Drugs (Rx)
Generic $10 Copay
Preferred Brand Name $20 Copay
Not Covered
Non-Preferred Brand Name $40 Copay
Mail Order Drug (90-Day Supply) 2x Retail Copay
7 © 2016, Gehring Group, Inc., All Rights ReservedClerk of the Circuit Court & Comptroller, Palm Beach County | Employee Benefit Highlights | 2022
Clerks for Wellness Program
Our award-winning Wellness Program has been recognized by the American Heart Association, South Florida Business Journal, WELCOA, and Cigna for implementing
and achieving results through innovative programs that promote the health and well-being of our employees and their families. Partnering with Cigna, we provide a
series of programs designed to build a healthier workplace and help our employees lead a healthier and happier life. The mission of the Clerks for Wellness program is to
educate and engage the Clerk's Office employees and their families in the overall improvement of their physical, emotional and financial health - their total well-being.
Wellness Rewards
The cornerstone of our wellness program is Wellness Rewards, which allows eligible employees to earn up to $425* by completing wellness goals by established
deadlines. All employees actively enrolled in the Clerk’s Office medical or dental plans are eligible to participate.
The first step to earning rewards is to complete a full physical exam with complete lab work, and use the numbers to take the online health assessment at
www.mycigna.com. Once employee completes the health assessment a $100 reward will be processed. If the health assessment is completed by the pre-established
deadline, employees will be eligible for up to an additional $275 in rewards if employees participate in specific programs and/or preventive screenings. In addition,
employees are eligible for an additional $50 when the employee's spouse/domestic partner completes the health assessment by the established deadline.
Employees can log into ESS to view all available Wellness Rewards for which they are eligible. Employees can also view rewards for which they have been approved or
paid. ClerkNet contains detailed instructions on how to use this feature in ESS.
Wellness Hours
Our Wellness program provides all regular, full-time or part-time employees with four (4) Wellness Hours annually. The wellness hours may be used to attend your own
or immediate family member's preventive screening appointments or a designated Wellness Lunch & Learn sessions offered during the year.
Wellness Policy
The Clerk's Office has established a wellness policy that outlines the tools and strategies utilized to empower employees to realize positive lifestyle changes. The policy
is located under the Policies & Forms section of ClerkNet.
The Internal Revenue Service code considers fringe benefits to employees as taxable and, as such, gift cards or cash awarded to employees are considered taxable fringe benefits and must be
included on the employee’s payroll. Rewards will be “grossed up” so that employees will enjoy the full value of the cash reward in their take home pay.
Many of the Clerks for Wellness activities are participatory. Should a program activity be health contingent, the following disclaimer will apply:
“Rewards are available to all similarly situated individuals. A reasonable alternative standard or waiver is available to any individual for whom it is unreasonably difficult to participate due
to a medical condition or when it is medically inadvisable to satisfy the otherwise applicable standard. A statement from an individual’s personal physician will be accommodated. Individuals
should contact the Clerk's Office Wellness team at clerks4wellness@mypalmbeachclerk.com to obtain the alternative.”
8Clerk of the Circuit Court & Comptroller, Palm Beach County | Employee Benefit Highlights | 2022
Dental Insurance
Cigna Dental Care Access DHMO Plan
The Clerk's Office offers dental insurance through Cigna to benefit-eligible Out-of-Network Benefits
employees. The costs per pay period for coverage are listed in the premium
The Dental Care Access DHMO plan does not provide benefits for services
table below and a brief summary of benefits is provided on the following
rendered by providers or facilities who do not participate in the Cigna Dental
page. For more detailed information about the dental plan, please refer to the
Care Access network (considered “out of network”) or by an in-network
carrier's summary plan document or contact Cigna's customer service.
provider not designated as the primary dental provider (unless referred by an
Dental Insurance – Cigna Dental Care Access DHMO Plan employee's primary dental provider). Employee will pay out of pocket if they
24 Payroll Deductions - Per Pay Period Cost utilize any out-of-network providers.
Tier of Coverage Employee Cost Calendar Year Deductible
Employee Only $4.97 There is no calendar year deductible.
Employee + 1 Dependent $8.03
Calendar Year Benefit Maximum
Employee + 2 or More Dependents $11.86
There is no benefit maximum.
In-Network Benefits
The Dental Care Access DHMO dental plan is an in-network only plan that
requires all services be received by a Primary Dental Provider (PDP). Employee
and dependent(s) may select any participating dentist in the Cigna Dental Care IMPORTANT NOTES
Access network to receive covered services. There is no coverage for services
received out-of-network. • Each covered family member may receive up to two (2) routine cleanings per
calendar year covered under the preventive benefit. Members can also receive two
(2) additional cleanings at the charge of a copay.
The Dental Care Access DHMO plan’s schedule of benefits is set forth by the
• Referrals and prior authorizations are required to see certain specialists (Oral
Patient Charge Schedule (fee schedule) which is highlighted on the following
Surgeon, Periodontist, Orthodontist, etc.) within the network.
page. Please refer to the summary plan document for a detailed listing of • Prior authorization is not required for specialty referrals to Pediatric Dentist and
charges and benefits. Endodontist.
• Children under age 13 may visit a pediatric dentist. Contact Cigna for a list of
pediatric dentists in the network. Once the child reaches age 13, a referral with
approved medical reasons by Cigna will be required prior to being seen by a pediatric
dentist provider.
• Services performed by providers or facilities not in the Cigna Dental Care Access
Network will not be covered.
Cigna | Customer Service: (800) 244-6224 | www.cigna.com
9 © 2016, Gehring Group, Inc., All Rights ReservedClerk of the Circuit Court & Comptroller, Palm Beach County | Employee Benefit Highlights | 2022
Cigna Dental Care Access DHMO Plan At-A-Glance
Network Cigna Dental Care Access
Calendar Year Deductible (CYD) In-Network Only
Per Member Does Not Apply
Per Family Does Not Apply
Locate a Provider
Waived for Class I Services? Not Applicable
To search for a participating provider,
contact Cigna’s customer service
Calendar Year Benefit Maximum
or visit www.cigna.com. When
Per Member Does Not Apply completing the necessary search
criteria, select Cigna Dental Care Access
Class I Services: Diagnostic & Preventive Care Code In-Network network.
Office Visit 9430 $0 Copay
Routine Oral Exam 0120 $0 Copay
Routine Cleanings (2 Per Calendar Year) 1110/1120 $0 Copay
Bitewing X-rays 0272 $0 Copay
Complete X-rays (1 Set Every 3 Years) 0330 $0 Copay Plan References
Fluoride Treatments (2 Per Calendar Year) 1208 $0 Copay *Excluding final restoration.
Sealants - Per Tooth 1351 $0 Copay
Space Maintainers 1510 $0 Copay
Emergency Care to Relieve Pain (During Regular Hours) 9110 $0 Copay
Class II Services: Basic Restorative Care
Fillings (Amalgam) 2140 $0 Copay Important Notes
Fillings (Composite; 1 Surface: Anterior) 2330 $0 Copay • The summary has been provided
as a convenient reference. For a full
Fillings (Composite; 1 Surface: Posterior) 2391 $47 Copay listing of covered services, exclusions
Simple Extractions 7140 $12 Copay and stipulations please see the plan’s
Schedule of Benefits or contact Cigna’s
Root Canal Therapy 3330 $280 Copay* customer service.
Periodontal Scaling (Per Quadrant; Limit 4 Annually) 4341 $49 Copay
General Anesthesia (Each 15 Minute Increment) 9223 $95 Copay
Repairs to Dentures 5510 $66 Copay
Class III Services: Major Restorative Care
Crowns 2752 $355 Copay
Bridges 5213/5214 $580 Copay
Dentures 5110/5120 $505 Copay
Class IV Services: Orthodontia
Benefit (Children and Adults) 8670 $1,584 / $2,328 Copay
Retention 8680 $345 Copay
© 2016, Gehring Group, Inc., All Rights Reserved
10Clerk of the Circuit Court & Comptroller, Palm Beach County | Employee Benefit Highlights | 2022
Dental Insurance
Cigna Total DPPO Base Plan
The Clerk's Office offers dental insurance through Cigna to benefit-eligible Out-of-Network Benefits
employees. The costs per pay period for coverage are listed in the premium
Out-of-network benefits are used when member receives services by a non-
table below and a brief summary of benefits is provided on the following
participating Total Cigna DPPO provider. Cigna reimburses out-of-network
page. For more detailed information about the dental plan, please refer to the
services based on what it determines as the Maximum Reimbursable Charge
carrier's summary plan document or contact Cigna’s customer service.
(MRC). The MRC is defined as the most common charge for a particular dental
Dental Insurance – Cigna Total DPPO Base Plan procedure performed in a specific geographic area. If services are received from
24 Payroll Deductions - Per Pay Period Cost an out-of-network dentist, the member may be responsible for balance billing.
Balance billing is the difference between Cigna's MRC and the amount charged
Tier of Coverage Employee Cost by the out-of-network dental provider. Balance billing is in addition to any
Employee Only $9.79 applicable plan deductible or coinsurance responsibility.
Employee + 1 Dependent $17.35
Calendar Year Deductible
Employee + 2 or More Dependents $30.82 The Cigna Total DPPO Base plan requires a $50 individual or a $150 family
deductible to be met for in-network or out-of-network services before most
In-Network Benefits benefits will begin. The deductible is waived for Class I services.
The Cigna Total DPPO Base plan provides benefits for services received from
Calendar Year Benefit Maximum
in-network and out-of-network providers. It is also an open-access plan which
allows for services to be received from any dental provider without having The maximum benefit (coinsurance) the Cigna Total DPPO Base plan will
to select a Primary Dental Provider (PDP) or obtain a referral to a specialist. pay for each covered member is $1,000 for in-network or out-of-network
The network of participating dental providers the plan utilizes is the Total services combined. All services, including preventive and diagnostic services,
Cigna DPPO network. These participating dental providers have contractually accumulate towards the benefit maximum. Once the plan's benefit maximum
agreed to accept Cigna’s contracted fee or “allowed amount.” This fee is the is met, the member will be responsible for future charges until next calendar
maximum amount a Cigna dental provider can charge a member for a service. year.
The member is responsible for a Calendar Year Deductible (CYD) and then
coinsurance based on the plan’s charge limitations. Cigna | Customer Service: (800) 244-6224 | www.cigna.com
Please Note: Total DPPO dental members have the option to utilize a dentist that
participates in either Cigna’s Advantage network or DPPO network. However, members
that use the Cigna Advantage network will see additional cost savings from the added
discount that is allowed for using an Advantage network provider. Members are
responsible for verifying whether the treating dentist is an Advantage Dentist or a DPPO
Dentist.
11 © 2016, Gehring Group, Inc., All Rights ReservedClerk of the Circuit Court & Comptroller, Palm Beach County | Employee Benefit Highlights | 2022
Cigna Total DPPO Base Plan At-A-Glance
Network Total Cigna DPPO
DPPO Advantage DPPO
Calendar Year Deductible (CYD) In-Network In-Network Out-of-Network*
Per Member $50 $50 $50 Locate a Provider
Per Family $150 $150 $150 To search for a participating provider,
Waived for Class I Services? Yes Yes Yes contact Cigna’s customer service
or visit www.cigna.com. When
Calendar Year Benefit Maximum completing the necessary search
criteria, select Total Cigna DPPO (Cigna
Per Member $1,000 $1,000 $1,000 Advantage and Cigna DPPO) network.
Class I Services: Diagnostic & Preventive Care
Routine Oral Exam (2 Per Calendar Year)
Routine Cleanings (3 Per Calendar Year)
Bitewing X-rays (2 Per Calendar Year)
Complete X-rays (1 Series Every 3 Calendar Years) Plan Pays: 80% Plan References
Plan Pays: 100% Plan Pays: 80%
Fluoride Treatments (1 Per Calendar Year) Deductible Waived *Out-of-Network Balance Billing:
Deductible Waived Deductible Waived
(Subject to Balance Billing) For information regarding out-of-
Sealants - Per Tooth network balance billing that may be
(Children Under Age 14; Every 3 Calendar Years) charged by an out-of-network provider,
Space Maintainers (Non-Orthodontic Treatment) please refer to the Out-of-Network
Benefits section on the previous page.
Emergency Care to Relieve Pain
**Late entrant and plan limitations
apply, contact Cigna for additional
Class II Services: Basic Restorative Care information.
Fillings
Simple Extractions
Endodontics (Root Canal) Plan Pays: 80%
Plan Pays: 80% Plan Pays: 80%
After CYD After CYD
Oral Surgery After CYD
(Subject to Balance Billing)
Periodontal Services
Important Notes
Anesthesics
• Each covered family member may
receive up to three (3) routine
Class III Services: Major Restorative Care** cleanings per calendar year covered
Crowns under the preventive benefit.
Bridges Plan Pays: 50% • Teeth missing prior to coverage under
Plan Pays: 50% Plan Pays: 50%
After CYD the plan will not be covered.
Dentures After CYD After CYD
(Subject to Balance Billing) • For any dental work expected to cost
Prosthesis Over Implant $200 or more, the plan will provide a
“Pre-Determination of Benefits” upon
Class IV Services: Orthodontia** the request of the dental provider.
This will assist with determining
Lifetime Maximum $1,500 $1,500 $1,500
approximate out-of-pocket costs
should employee have the dental work
Plan Pays: 50% performed.
Benefit (Children and Adults) Plan Pays: 50% Plan Pays: 50%
(Subject to Balance Billing) • Waiting periods and age limitations
may apply.
• Benefit frequency limitations may
apply to certain services.
© 2016, Gehring Group, Inc., All Rights Reserved
12Clerk of the Circuit Court & Comptroller, Palm Beach County | Employee Benefit Highlights | 2022
Dental Insurance
Cigna Total DPPO Buy-Up Plan
The Clerk's Office offers dental insurance through Cigna to benefit-eligible Out-of-Network Benefits
employees. The costs per pay period for coverage are listed in the premium
Out-of-network benefits are used when member receives services by a non-
table below and a brief summary of benefits is provided on the following
participating Total Cigna DPPO provider. Cigna reimburses out-of-network
page. For more detailed information about the dental plan, please refer to the
services based on what it determines is the Maximum Reimbursable Charge
carrier's summary plan document or contact Cigna’s customer service.
(MRC). The MRC is defined as the most common charge for a particular dental
Dental Insurance – Cigna Total DPPO Buy-Up Plan procedure performed in a specific geographic area. If services are received from
24 Payroll Deductions - Per Pay Period Cost an out-of-network dentist, the member may be responsible for balance billing.
Balance billing is the difference between Cigna's MRC and the amount charged
Tier of Coverage Employee Cost by the out-of-network dental provider. Balance billing is in addition to any
Employee Only $13.19 applicable plan deductible or coinsurance responsibility.
Employee + 1 Dependent $23.40
Calendar Year Deductible
Employee + 2 or More Dependents $41.56 The Cigna Total DPPO Buy-Up plan requires a $25 individual or a $75 family
deductible to be met for in-network or out-of-network services before most
In-Network Benefits benefits will begin. The deductible is waived for Class I services.
The Cigna Total DPPO Buy-Up plan provides benefits for services received from
Calendar Year Benefit Maximum
in-network and out-of-network providers. It is also an open-access plan which
allows for services to be received from any dental provider without having The maximum benefit (coinsurance) the Cigna Total DPPO Buy-Up plan will
to select a Primary Dental Provider (PDP) or obtain a referral to a specialist. pay for each covered member is $2,000 for in-network or out-of-network
The network of participating dental providers the plan utilizes is the Total services. All services, including preventive and diagnostic services, accumulate
Cigna DPPO network. These participating dental providers have contractually towards the benefit maximum.
agreed to accept Cigna’s contracted fee or “allowed amount.” This fee is the
maximum amount a Cigna dental provider can charge a member for a service. Cigna | Customer Service: (800) 244-6224 | www.cigna.com
The member is responsible for a Calendar Year Deductible (CYD) and then
coinsurance based on the plan’s charge limitations.
Please Note: Total DPPO dental members have the option to utilize a dentist that
participates in either Cigna’s Advantage network or DPPO network. However, members
who use the Cigna Advantage network will see additional cost savings from the added
discount that is allowed for using an Advantage network provider. Members are
responsible for verifying whether the treating dentist is an Advantage Dentist or a DPPO
Dentist.
13 © 2016, Gehring Group, Inc., All Rights ReservedClerk of the Circuit Court & Comptroller, Palm Beach County | Employee Benefit Highlights | 2022
Cigna Total DPPO Buy-Up Plan At-A-Glance
Network Total Cigna DPPO
DPPO Advantage DPPO
Calendar Year Deductible (CYD) In-Network In-Network Out-of-Network*
Per Member $25 $25 $25 Locate a Provider
Per Family $75 $75 $75 To search for a participating provider,
Waived for Class I Services? Yes Yes Yes contact Cigna’s customer service
or visit www.cigna.com. When
Calendar Year Benefit Maximum completing the necessary search
criteria, select Total Cigna DPPO (Cigna
Per Member $2,000 $2,000 $2,000 Advantage and Cigna DPPO) network.
Class I Services: Diagnostic & Preventive Care
Routine Oral Exam (2 Per Calendar Year)
Routine Cleanings (3 Per Calendar Year)
Bitewing X-rays (2 Per Calendar Year)
Complete X-rays (1 Series Every 3 Calendar Years) Plan Pays: 80% Plan References
Plan Pays: 100% Plan Pays: 80%
Fluoride Treatments (1 Per Calendar Year) Deductible Waived *Out-of-Network Balance Billing:
Deductible Waived Deductible Waived
(Subject to Balance Billing) For information regarding out-of-
Sealants - Per Tooth network balance billing that may be
(Children Under Age 14; Every 3 Calendar Years) charged by an out-of-network provider,
Space Maintainers (Non-Orthodontic Treatment) please refer to the Out-of-Network
Benefits section on the previous page.
Emergency Care to Relieve Pain
**Late entrant and plan limitations
apply, contact Cigna for additional
Class II Services: Basic Restorative Care
information.
Fillings
Simple Extractions
Endodontics (Root Canal) Plan Pays: 80%
Plan Pays: 80% Plan Pays: 80%
After CYD After CYD
Oral Surgery After CYD
(Subject to Balance Billing)
Periodontal Services
Important Notes
Anesthesics
• Each covered family member may
receive up to three (3) routine
Class III Services: Major Restorative Care**
cleanings per calendar year covered
Crowns under the preventive benefit.
Bridges Plan Pays: 50% • Teeth missing prior to coverage under
Plan Pays: 50% Plan Pays: 50%
After CYD the plan will not be covered.
Dentures After CYD After CYD
(Subject to Balance Billing) • For any dental work expected to cost
Prosthesis Over Implant $200 or more, the plan will provide a
“Pre-Determination of Benefits” upon
Class IV Services: Orthodontia** the request of the dental provider.
Lifetime Maximum $1,500 $1,500 $1,500 This will assist with determining
approximate out-of-pocket costs
should employee have the dental work
Plan Pays: 50% performed.
Benefit (Children and Adults) Plan Pays: 50% Plan Pays: 50%
(Subject to Balance Billing)
• Waiting periods and age limitations
may apply.
• Benefit frequency limitations may
apply to certain services.
© 2016, Gehring Group, Inc., All Rights Reserved
14Clerk of the Circuit Court & Comptroller, Palm Beach County | Employee Benefit Highlights | 2022
Dental Insurance: Side-By-Side Plans At-A-Glance
Summary of Benefits DHMO Plan Base DPPO Plan Buy-Up DPPO Plan
Network Cigna Dental Care Total Cigna DPPO Total Cigna DPPO
Advantage Advantage
Calendar Year Deductible (CYD) In-Network Only In-Network Out-of-Network In-Network Out-of-Network
Per Member Does Not Apply $50 $50 $25 $25
Per Family Does Not Apply $150 $150 $75 $75
Waived for Class I Services? Does Not Apply Yes Yes Yes Yes
Calendar Year Benefit Maximum
Per Member Does Not Apply $1,000 $1,000 $2,000 $2,000
Class I Services: Diagnostic & Preventive Care
Routine Oral Exam 0120 $0 Copay
Routine Cleanings 1110/1120 $0 Copay
Bitewing X-rays 0272 $0 Copay Plan Pays: 80% Plan Pays: 80%
Plan Pays: 100% Deductible Waived Plan Pays: 100% Deductible Waived
Complete X-rays 0330 $0 Copay
Deductible Waived (Subject to Deductible Waived (Subject to
Fluoride Treatments 1208 $0 Copay Balance Billing) Balance Billing)
Sealants 1351 $0 Copay
Space Maintainers 1510 $0 Copay
Class II Services: Basic Restorative Care
Fillings (Amalgam) 2140 $0 Copay
Simple Extractions 7140 $12 Copay Plan Pays: 80% Plan Pays: 80%
Plan Pays: 80% After CYD Plan Pays: 80% After CYD
Root Canal Therapy/Endodontics 3330 $280 Copay
After CYD (Subject to After CYD (Subject to
Periodontics 4341 $49 Copay Balance Billing) Balance Billing)
General Anesthesia 9223 $95 Copay
Class III Services: Major Restorative Care
Crowns 2752 $355 Copay Plan Pays: 50% Plan Pays: 50%
Plan Pays: 50% After CYD Plan Pays: 50% After CYD
Bridges 5213/5214 $580 Copay
After CYD (Subject to After CYD (Subject to
Dentures 5110/5120 $505 Copay Balance Billing) Balance Billing)
Class IV Services: Orthodontia
Lifetime Maximum Does Not Apply Does Not Apply $1,500 $1,500
$1,584 / $2,328 Plan Pays: 50% Plan Pays: 50%
Benefit (Children and Adults) 8670 Plan Pays: 50% (Subject to Plan Pays: 50% (Subject to
Copay Balance Billing) Balance Billing)
Retention 8680 $345 Copay
15 © 2016, Gehring Group, Inc., All Rights ReservedClerk of the Circuit Court & Comptroller, Palm Beach County | Employee Benefit Highlights | 2022
Vision Insurance
Cigna Vision Plan
The Clerk's Office offers vision insurance through Cigna to benefit-eligible Out-of-Network Benefits
employees. The costs per pay period for coverage are listed in the premium
Employee and covered dependent(s) may also choose to receive services
table below and a brief summary of benefits is provided on the following
from vision providers who do not participate in the Cigna Vision network.
page. For more detailed information about the vision plan, please refer to the
When going out of network, the provider will require payment at the time of
carrier’s summary plan document or contact Cigna’s customer service.
appointment. Cigna will then reimburse based on the plan’s out-of-network
Vision Insurance – Cigna Vision Plan reimbursement schedule upon receipt of proof of services rendered.
24 Payroll Deductions - Per Pay Period Cost
Calendar Year Deductible
Tier of Coverage Employee Cost
There is no calendar year deductible.
Employee Only $4.89
Employee + 1 Dependent $9.36 Calendar Year Out-of-Pocket Maximum
Employee + 2 or More Dependents $15.18 There is no out-of-pocket maximum. However, there are benefit reimbursement
maximums for certain services.
In-Network Benefits
Claims Mailing Address
The vision plan offers employee and covered dependent(s) coverage for routine
PO Box 385018, Birmingham, AL 35238-5018
eye care, including eye exams, eyeglasses (lenses and frames) or contact
lenses. To schedule an appointment, employee and covered dependent(s) may
select any network provider who participates in the Cigna Vision network. At
Cigna Vision | Customer Service: (877) 478-7557 | www.cigna.com
the time of service, routine vision examinations and basic optical needs will
be covered as shown on the plan’s schedule of benefits. Cosmetic services and
upgrades will be additional if chosen at the time of the appointment.
© 2016, Gehring Group, Inc., All Rights Reserved
16Clerk of the Circuit Court & Comptroller, Palm Beach County | Employee Benefit Highlights | 2022
Cigna Vision Plan At-A-Glance
Network Cigna Vision
Services In-Network Out-of-Network
Eye Exam $0 Copay Up to $45 Reimbursement
Locate a Provider Frequency of Services
To search for a participating provider, Examination 12 Months
contact Cigna’s customer service or visit
www.cigna.com. When completing Lenses 12 Months
the necessary search criteria, select the Frames 24 Months
Cigna Vision network.
Contact Lenses 12 Months
Lenses
Single Up to $32 Reimbursement
Bifocal Covered at 100% Up to $55 Reimbursement
Plan References Trifocal Up to $65 Reimbursement
* Contact lenses are in lieu of
spectacle lenses. Frames
Allowance Up to $130 Retail Allowance Up to $71 Reimbursement
Contact Lenses*
Important Notes Non-Elective (Medically Necessary) Covered at 100% Up to $210 Reimbursement
• Benefits are valid once per 12 months Elective (Fitting, Follow-up and Lenses) Up to $130 Retail Allowance Up to $105 Reimbursement
and cannot be used in conjunction
with other discounts, promotions or
prior orders. A member who elects to
use other discounts and/or promotions
in lieu of his/her vision benefits may
file a claim to receive reimbursement
according to the out-of-network
reimbursement amounts.
• Members receive 20% savings on
additional purchase of frames and
lenses with a valid prescription.
• Members receive up to 20% savings on
contact lens services, such as fitting,
and evaluation.
17 © 2016, Gehring Group, Inc., All Rights ReservedClerk of the Circuit Court & Comptroller, Palm Beach County | Employee Benefit Highlights | 2022
Flexible Spending Accounts
The Clerk's Office offers Flexible Spending Accounts (FSA) administered through Cigna. The FSA plan year is from January 1 to December 31.
If employee or family member(s) has predictable health care or work-related day care expenses, then employee may benefit from participating in an FSA. An FSA allows
employee to set aside money from employee's paycheck for reimbursement of health care and day care expenses they regularly pay. The amount set aside is not taxed
and is automatically deducted from employee’s paycheck and deposited into the FSA. During the year, employee has access to this account for reimbursement of some
expenses not covered by insurance. Participation in an FSA allows for substantial tax savings and an increase in spending power. Participating employee must re-elect
the dollar amount to be deducted each plan year. There are two (2) types of FSAs:
Health Care FSA Dependent Care FSA
This account allows the participant to set aside up to an This account allows the participant to set aside up to an annual maximum of $5,000 if the
annual maximum allowed by the IRS. This money will not participating employee is single or married and files a joint tax return ($2,500 if married
be taxable income to the participant and can be used to and file a separate tax return) for work-related day care expenses. Qualified expenses
offset the cost of a wide variety of eligible medical expenses include day care centers, preschool, and before/after school care for eligible children and
that generate out-of-pocket costs. Participating employees adults.
can also receive reimbursement for expenses related to
dental and vision care (that are not classified as cosmetic). Please note, if family income is over $20,000, this reimbursement option will likely save
participants more money than the dependent day care tax credit taken on a tax return. To
Examples of common expenses that qualify for qualify, dependents must be:
reimbursement are listed below.
• A child under the age of 13, or
• A child, spouse or other dependent that is physically or mentally incapable of
self-care and spends at least eight (8) hours a day in the participant’s household.
• Employer Funded Dependent Care is available for $62.50 per pay period or
$1,500 annually.
Please Note: The entire Health Care FSA election is available for use on Please Note: Unlike the Health Care FSA, reimbursement is only up to the amount that has been deducted
the first day coverage is effective. from the participant’s paycheck for the Dependent Care FSA.
A sample list of qualified expenses eligible for reimbursement include, but not limited to, the following:
9 Prescription/Over-the-Counter Medications 9 Physician Fees and Office Visits 9 LASIK Surgery
9 Menstrual Products 9 Drug Addiction/Alcoholism Treatment 9 Mental Health Care
9 Ambulance Service 9 Experimental Medical Treatment 9 Nursing Services
9 Chiropractic Care 9 Corrective Eyeglasses and Contact Lenses 9 Optometrist Fees
9 Dental and Orthodontic Fees 9 Hearing Aids and Exams 9 Sunscreen SPF 15 or Greater
9 Diagnostic Tests/Health Screenings 9 Injections and Vaccinations 9 Wheelchairs
Log on to http://www.irs.gov/publications/p502/index.html for additional details regarding qualified and non-qualified expenses.
© 2016, Gehring Group, Inc., All Rights Reserved
18Clerk of the Circuit Court & Comptroller, Palm Beach County | Employee Benefit Highlights | 2022
Flexible Spending Accounts (Continued)
FSA Guidelines
• The Health Care FSA allows a grace period at the end of the plan
year. The grace period allows additional time to incur claims and HERE’S HOW IT WORKS!
use any unused funds on eligible expenses after the plan year ends.
Once the grace period ends, any unused funds still remaining in the An employee earning $30,000 elects to place $1,000 into a Health
account will be forfeited. Care FSA. The payroll deduction is $41.66 based on a 24 pay period
• Any unused funds after a plan year and grace period ends and all schedule. As a result, health care expenses are paid with tax-free
claims have been filed cannot be returned or carried forward to the dollars, giving the employee a tax savings of $197.
next plan year. With a Health Without a Health
• Employee can enroll in an FSA only during the Open Enrollment Care FSA Care FSA
period, a Qualifying Event, or New Hire Eligibility period. Salary $30,000 $30,000
• Money cannot be transferred between FSAs. FSA Contribution - $1,000 - $0
• Reimbursed expenses cannot be deducted for income tax purposes. Taxable Pay $29,000 $30,000
• Employee and dependent(s) cannot be reimbursed for services not Estimated Tax
- $5,698 - $5,895
received. 19.65% = 12% + 7.65% FICA
• Employee and dependent(s) cannot receive insurance benefits or After Tax Expenses - $0 - $1,000
any other compensation for expenses reimbursed through an FSA. Spendable Income $23,302 $23,105
• Domestic Partners are not eligible as Federal law does not recognize Tax Savings $197
them as a qualified dependent.
Filing a Claim
Claim Form
A completed claim form along with a copy of the receipt as proof of the Please Note: Be conservative when estimating health care and/or dependent
expense can be submitted by mail or fax. The IRS requires FSA participants to care expenses. IRS regulations state that any unused funds remaining in an FSA,
maintain complete documentation, including copies of receipts for reimbursed after a plan year ends and after all claims have been filed, cannot be returned or
carried forward to the next plan year. This rule is known as “use-it or lose-it.”
expenses, for a minimum of one year.
Cigna | Customer Service: (800) 244-6224 | www.cigna.com
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