2022 Open Enrollment Guide - City of Shafter Innovative Solutions. Enduring Principles.
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2022 Open Enrollment Guide
City of Shafter
License No.
License No.0451271
0451271 Innovative Solutions. Enduring Principles.
FDAC EBA Benefit Program Open Enrollment is the one time of the year that you can make changes to your employee benefit elections without a “qualifying event”. If you would like to change from one plan to another, or change your enrollment for yourself or dependents, you must do so during Open Enrollment. The Open Enrollment period is from October 1, 2021 to October 31, 2021. Any changes will go into effect January 1, 2022. Please visit www.shafter.com/openenrollment for information on making health benefit changes; if you are enrolling yourself or your eligible dependents for the first time, please provide marriage or birth certificates for any new dependents. If you are declining coverage, please complete the appropriate section on the Universal Health Form provided on the aforementioned website and return the form to your Benefits Administrator by October 31, 2021. When making your selections you should be aware of the following information: Dental Coverage: No changes in design will be made to the 2022 Dental coverage offered through Delta Dental or MetLife. Vision Coverage: No changes in design will be made to the 2022 Vision coverage offered through VSP. If you’re not making any changes in your benefits, no further action is required. Your current coverage will remain the same. 2 License No. 0451271 Innovative Solutions. Enduring Principles.
FDAC EBA Dental Program
Delta Dental
City of Shafter
Group #05972
Division #01040
FDAC EBA Plan 2C
Coinsurance In-Network Out-of-Network
Preventive & Diagnostic 100% 100%
Basic 90% 80%
Crowns, Jackets & Cast Restorations 60% 50%
Prosthodontics 60% 50%
Deductible*
Per Patient per Calendar Year $50
Per Family per Calendar Year $150
Maximum
Per Patient per Calendar Year $1,500
Orthodontia
Coinsurance 50%
Lifetime Maximum per Patient $1,500
*Does not apply to Preventive & Diagnostic services
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License No. 0451271 Innovative Solutions. Enduring Principles.FDAC EBA Dental Program
MetLife Dental DHMO
City of Shafter
Group #5734740
Member Procedure
DHMO Services
Copayment Code
Office Visit (per visit) $5
Diagnostic Treatment $0 D0120 - D0180
Radiographs/Diagnostic Imaging (X-rays) $0 D0210 - D0350
Tests and Examinations $0 D0460 - D0470
Preventive Services $0 to $30 D1110 - D1555
Restorative Treatment $0 to $80 D2140 - D2394
Crowns $0 to $225 D2510 - D2970
Endodontics $0 to $210 D3110 - D3920
Periodontics $19 to $300 D4210 - D4910
Removable Prosthodontics $0 to $150 D5110 - D5851
Crowns/Fixed Bridges (per unit) $0 to $100 D6210 - D6930
Oral Surgery $0 to $175 D7140 - D7971
Orthodontics $0 to $1,450 D8020 - D8693
Adjunctive General Services $0 to $25 D9110 - D9952
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License No. 0451271 Innovative Solutions. Enduring Principles.FDAC EBA Vision Program
VSP
City of Shafter
Group #12262789
Division #3082
Signature Plan B4
Plan Frequency (Benefit Every # of Months) In-Network Out-of-Network
WellVision Exam 12 12
Lenses 12 12
Frames 24 24
Contact Lens 12 12
VSP Provider Copayment Schedule
WellVision Exam $10 Up to $50
Lenses:
Combined with Up to $50, $75,
Single vision, lined bifocal, lined trifocal lenses
Exam and $100
Polycarbonate lenses for dependent children
Lens Options:
Standard progressive lenses $50
Premium progressive lenses $80 - $90
Custom progressive lenses $120 - $160
Contacts (instead of glasses):
$120 allowance for contacts* Up to $60 Up to $105
Contact lens exam (fitting and evaluation)
Frames:
$130 allowance for a wide selection of frames Combined with
Up to $70
$150 allowance for featured frame brands Exam
20% off amount over your allowance
* Copay does not apply
5
License No. 0451271 Innovative Solutions. Enduring Principles.FDAC EBA Rates
2022 Monthly Premiums
City of Shafter
Delta Dental
Dental PPO Coverage:
PPO
Employee Only $51.47
Employee + Spouse $98.48
Employee + Child(ren) $113.25
Employee + Family $174.02
MetLife Dental VSP
Dental DHMO & Vision Coverage:
DHMO Vision
Employee Only $20.21 $7.92
Employee + 1 Dependent $38.40 $15.89
Employee + Family $53.57 $25.56
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License No. 0451271 Innovative Solutions. Enduring Principles.FDAC EBA Vendor Partners
Contact List
Who to Contact
The quickest way to find answers to your benefits questions is to go directly to the source. This contact list includes web
addresses and phone numbers for the administrators of each of our benefit plans. The insurance company can verify
benefits and coverage or copayment information. We suggest you contact the insurance company prior to seeking care
should you have any questions in regards to your benefits.
COVERAGE MEMBER SERVICES WEBSITE/EMAIL
DENTAL
Delta Dental PPO 800.765.6003 www.deltadentalins.com
MetLife Dental DHMO 800.275.4638 www.metlife.com
VISION
VSP 800.877.7195 www.vsp.com
FDAC EBA Customer Service Center
Customer Service 844.580.6856 fdaceba@keenan.com
ThrivePass (Retiree & COBRA Administration)
Customer Service 866.855.2844 tpa@thrivepass.com
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License No. 0451271 Innovative Solutions. Enduring Principles.The FDAC EBA benefits presented in this packet are in summary format. A complete and detailed
outline of benefits is available through the Summary Plan Description (SPD). FDAC EBA rates are
valid for the 2022 plan year. If you require additional materials, please contact the FDAC EBA
Customer Service Center at (844) 580-6856 or via email at FDACEBA@Keenan.com.
License No.
License No.0451271
0451271 Innovative Solutions. Enduring Principles.You can also read
