EMPLOYEE BENEFIT GUIDE - 2020 | 2021 - Delray Beach
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2020 | 2021 EMPLOYEE BENEFIT GUIDE
City of Delray Beach | Employee Benefit Guide | 2020-2021
Table of Contents
Contact Information 1
Introduction 2
Online Benefit Enrollment 2
Group Insurance Eligibility 3-4
Qualifying Events and Section 125 5
Summary of Benefits and Coverage 5
Wellness Incentive Program 6
Medical Insurance - UnitedHealthcare Core Plan 7
UnitedHealthcare Core Plan At-A-Glance 8
Medical Insurance - UnitedHealthcare Buy-Up Plan 9
UnitedHealthcare Buy-Up Plan At-A-Glance 10
Medical Insurance - UnitedHealthcare Choice Plus Plan (with HRA) 11
UnitedHealthcare Choice Plus Plan (with HRA) At-A-Glance 12
Health Reimbursement Account 13
Employee Health and Wellness Center 14
Other Available Plan Resources 14
Dental Insurance 15
Solstice DHMO S200B Plan At-A-Glance 16
Solstice Dental PPO Plan At-A-Glance 18
Vision Insurance 19
EyeMed Vision Plan At-A-Glance 20
Flexible Spending Accounts 21-22
Basic Life and AD&D Insurance 23
Voluntary Life Insurance 24
Employee Assistance Program 25
Short Term Disability 25
Long Term Disability 25
Voluntary Benefits 26
Supplemental Insurance 26-27
Notes 27
This booklet is merely a summary of 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 City of Delray Beach 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
City of Delray Beach | Employee Benefit Guide | 2020-2021
Contact Information
Sue Radig Phone: (561) 243-7377
Benefits Manager Email: radigs@mydelraybeach.com
Human Resources
B.J. Clay Phone: (561) 243-7154
Specialist, Employee Benefits Email: clay@mydelraybeach.com
Customer Service: (888) 5-Bentek (523-6835)
Online Benefit Enrollment Bentek Support
www.mybentek.com/delraybeach
UnitedHealthcare Customer Service: (800) 357-0978
Medical Insurance
Group Number: 0908721 www.myuhc.com
Prescription Drug Coverage Customer Service: (800) 357-0978
UnitedHealthcare
& Mail-Order Program www.myuhc.com
Customer Service: (800) 357-0978
Health Reimbursement Account UnitedHealthcare
www.myuhc.com
Customer Service: (800) 357-0978
Telehealth UnitedHealthcare – Virtual Visits
www.uhc.com/virtualvisits
Solstice Customer Service: (877)760-2247
Dental Insurance
Group Number: 14058 www.solsticebenefits.com
EyeMed Customer Service: (866) 939-3633
Vision Insurance
Group Number: 1007691 www.eyemed.com
Customer Service: (866) 755-2648
Flexible Spending Accounts UnitedHealthcare
www.myuhc.com
Customer Service: (800) 628-8600
Basic Life and AD&D Insurance The Standard
www.standard.com
Customer Service: (800) 628-8600
Voluntary Life Insurance The Standard
www.standard.com
Customer Service: (866) 248-4096
Employee Assistance Program Employee Assistance and Work Life Program www.liveandworkwell.com
Access Code: Delray
Customer Service: (800) 362-4462
Short & Long Term Disability Insurance Cigna
www.cigna.com
Customer Service: (800) 521-3535
AllState
www.allstatebenefits.com
Customer Service: (800) 918-8877
Trustmark
www.trustmarksolutions.com
Customer Service: (800) 305-6816
Supplemental Insurance Legal Club
www.legalclub.com
Customer Service: (800) 654-7757
LegalShield
www.legalshield.com
Customer Service: (888) 789-7387
Pet Assure
www.petassure.com
Employee Health Center Employee Health and Wellness Center Phone: (561) 243-7612
1 © 2016, Gehring Group, Inc., All Rights Reserved
City of Delray Beach | Employee Benefit Guide | 2020-2021
Online Benefit Enrollment
The City provides employees with an online benefits enrollment
platform through Bentek’s Employee Benefits Center (EBC). The EBC
provides benefit-eligible employees the ability to select or change
insurance benefits online during the annual Open Enrollment Period,
New Hire Orientation, or for Qualifying Life Events.
Accessible 24 hours a day, throughout the year, employee may log
in and review comprehensive information regarding benefit plans,
and view and print an outline of benefit elections for employee and
Introduction dependent(s). Employee also has access to important forms and carrier
links, can report qualifying life events and review and make changes to
The City of Delray Beach provides group insurance benefits to eligible Life insurance beneficiary designations.
employees. The Employee Benefit Guide provides a general summary of the
benefit options as a convenient reference. Please refer to the City of Delray
Beach Administrative Policies and Procedures, applicable Contracts and
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 the City’s Benefits Manager using the contact information provided.
To Access the Employee Benefits Center:
9 Log on to www.mybentek.com/delraybeach
9 Sign in using a previously created username and password or
click "Create an Account" to set up a username and password.
9 If employee has forgotten username and/or password, click
on the link “Forgot Username/Password” and follow the
instructions.
9 Once logged on, navigate using the Launchpad to review
current enrollment, learn about benefit options, and make
any benefit changes or update beneficiary designations.
For technical issues directly related to using the EBC, please
call (888) 5-Bentek (523-6835) or email Bentek Support at
support@mybentek.com Monday through Friday, during regular
business hours 8:30am - 5:00pm.
To access Employee Benefits Center online, log on to:
www.mybentek.com/delraybeach
Please Note: Link must be addressed exactly as written. Due to security reasons,
the website cannot be accessed by Google or other search engines.
© 2016, Gehring Group, Inc., All Rights Reserved
2
City of Delray Beach | Employee Benefit Guide | 2020-2021
Group Insurance Eligibility
OCTOBER The City's group insurance plan year is Disabled Dependents
01 October 1 through September 30. Coverage for a dependent child may be continued beyond age 26 if:
• The dependent is physically or mentally disabled and incapable of self-
sustaining employment (prior to age 26); and
Employee Eligibility • Primarily dependent upon the employee for support; and
• The dependent is otherwise eligible for coverage under the group
Employees are eligible to participate in the City’s insurance plans if they are
medical plan; and
full-time employees working a minimum of 30 hours per week. Coverage will
be effective 31 days following date of hire. For example, if an employee is hired • The dependent has been continuously insured
on April 15, then the effective date of coverage will be May 16. Proof of disability will be required upon request. Please contact the Benefits
Manager if further clarification is needed.
Separation of Employment
Taxable Dependents
If employee separates employment from the City, insurance will continue
through the end of month in which separation occurred. COBRA continuation Employee covering adult child(ren) under employee's medical insurance plan
of coverage may be available as applicable by law. may continue to have the related coverage premiums payroll deducted on a
pre-tax basis through the end of the calendar year in which the dependent
Dependent Eligibility child reaches age 26. Beginning January 1 of the calendar year in which
A dependent is defined as the legal spouse/domestic partner and/or dependent dependent child reaches age 27 through the end of the calendar year in which
child(ren) of the participant or the spouse/domestic partner. The term “child” the dependent child reaches age 30, imputed income must be reported on the
includes any of the following: employee’s W-2 for that entire tax year and will be subject to all applicable
Federal, Social Security and Medicare taxes. Imputed income is the dollar value
• A natural child • A stepchild • A legally adopted child of insurance coverage attributable to covering each adult dependent child.
• A newborn child (up to the age of 18 months) of a covered Contact the Benefits Manager for further details if covering an adult dependent
dependent (Florida) child who will turn age 27 any time during the upcoming calendar year or for
• A child for whom legal guardianship has been awarded to the more information.
participant or the participant’s spouse/domestic partner
Please Note: There is no imputed income if adult dependent child is eligible to be claimed
as a dependent for Federal income tax purposes on the employee’s tax return.
Dependent Age Requirements
Medical Coverage: A dependent child may be covered through the
end of the calendar year in which the child turns age 26. An over-
age dependent may continue to be covered on the medical plan to
the end of the calendar year in which the child reaches age 30, if the
dependent meets the following requirements:
• Unmarried with no dependents; and
• A Florida resident, or full-time or part-time student; and
• Otherwise uninsured; and
• Not entitled to Medicare benefits under Title XVIII of the
Social Security Act, unless the child is disabled.
Dental and Vision Coverage: A dependent child may be covered
through the end of the calendar year in which the child turns age 26.
Please see Taxable Dependents if covering eligible over-age dependents.
3 © 2016, Gehring Group, Inc., All Rights Reserved
City of Delray Beach | Employee Benefit Guide | 2020-2021
Group Insurance Eligibility (Continued)
Domestic Partner Coverage
Domestic partners are eligible to participate in the City’s group insurance plans. To be eligible for domestic partner coverage, the employee must submit the following
documents to the Benefits Manager:
• Domestic Partnership Certificate of Registration issued by the Palm Beach County Clerk and Comptroller’s Office or County of residence, where available; and
• Certification of Dependent Children of a Domestic Partnership; and
• Agreement to notify the City of the termination of the Domestic Partnership.
The completed documents must be submitted at the time of enrollment. Covered employee may elect coverage for employee's qualifying domestic partner and eligible
dependent(s) of the domestic partnership. IRS guidelines state; employee may not receive a tax advantage on any portion of premium paid, related to domestic partner
coverage. Employee insuring domestic partner and/or child dependent(s) of a domestic partner will see the insurance premium deductions on a post-tax basis and any
amount subsidized by the City will be reported as “imputed income” to the employee. Employee may contact the Benefits Manager for further details and rates if the
employee is covering a domestic partner at any time during the upcoming plan year.
Documentation Requirements
All dependents must have an established legal relationship to employee to
be covered under the benefit program. The types of documentation accepted IMPORTANT NOTES
are as stated in the table below. Employee with dependent(s) enrolled in the
group insurance plans is advised that employee will be required to comply with If employee is electing coverage for an eligible dependent, employee
this process or continued coverage for such dependent(s) may be jeopardized. must provide a copy of:
Dependent Relationship Documentation Required Employee Spouse – Marriage license and Social Security Card
• Copy of legal government issued Employee Domestic Partner – Domestic Partnership Certification
Spouse
marriage certificate issued by the Palm Beach County Clerk’s and Comptroller’s Office or
• Copy of State issued birth certificate(s) County of residence and Social Security Card
OR copy of legal guardianship court Employee Dependent Child(ren) – Birth certificate and Social
Dependent child(ren) under age 26
documents listing employee as legal
guardian Security Card
• Copy of State issued birth certificate(s) Dependents cannot be enrolled in coverage until this information
Step-child(ren) under age 26 • AND the appropriate dependent child is provided. Once this information is received, coverage will be
documentation listed above retroactively provided and employee will be responsible for any
Child(ren) under legal guardianship • Copy of court documents showing legal missing employee payroll premium contributions.
or custody under age 26 guardianship OR legal custody
• Copy of court documents of the legal
Child(ren) adopted or in the process adoption showing relationship to and
of adoption under age 26 placement in employee’s house OR
adoption certificate
• Copy of State issued birth certificate(s)
or legal guardianship court documents,
listing employee or spouse as parent/
Child(ren) age 26-30 legal guardian
• AND Overage Dependent Affidavit
signed by employee
Please Note: Religious documents and registration cards are not acceptable proof.
Employee may “black out” financial information.
© 2016, Gehring Group, Inc., All Rights Reserved
4
City of Delray Beach | Employee Benefit Guide | 2020-2021
Qualifying Events and Section 125
Section 125 of the Internal Revenue Code
Premiums for medical, dental, vision insurance, and/or certain supplemental
policies, and contributions to Flexible Spending Accounts (FSA), are deducted IMPORTANT NOTES
through a Cafeteria Plan established under Section 125 of the Internal Revenue
Code and are pre-taxed to the extent permitted. Under Section 125, changes to If employee experiences a Qualifying Event, the Benefits Manager
employee's pre-tax benefits can be made ONLY during the Open Enrollment period must be contacted within 30 days of the Qualifying Event to make
unless the employee or qualified dependent(s) experience(s) a Qualifying Event and the appropriate changes to employee's coverage. Beyond 30 days,
the request to make a change is made within 30 days of the Qualifying Event. requests will be denied and employee may be responsible, both legally
and financially, for any claim and/or expense incurred as a result of
Under certain circumstances, employee may be allowed to make changes to
employee or dependent who continues to be enrolled but no longer
benefit elections during the plan year if the event affects the employee, spouse
meets eligibility requirements. If approved, changes may be effective
or dependent’s coverage eligibility. An “eligible” Qualifying Event is determined
the date of the Qualifying Event or the first of the month following
by Section 125 of the Internal Revenue Code. Any requested changes must be
the Qualifying Event. Newborns are effective on the date of birth.
consistent with and due to the Qualifying Event.
Cancellations will be processed at the end of the month. In the event
Examples of Qualifying Events: of death, coverage terminates the day following the death. Employee
• Employee gets married or divorced may be required to furnish valid documentation supporting a change
in status or “Qualifying Event.”
• Birth of a child
• Employee gains legal custody or adopts a child
• Employee's spouse and/or other dependent(s) die(s)
• Loss or gain of coverage due to employee, employee’s spouse and/or Summary of Benefits and Coverage
dependent(s) termination or start of employment A Summary of Benefits & Coverage (SBC) for the Medical Plan is provided as a
• An increase or decrease in employee's work hours causes eligibility supplement to this booklet being distributed to new hires and existing employees
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
• A covered dependent no longer meets eligibility criteria for coverage may be requested or is available as follows:
• A child gains or loses coverage with other parent or legal guardian
From: Benefits Manager
• Change of coverage under an employer’s plan
Address: 100 NW 1st Avenue
• Gain or loss of Medicare coverage Delray Beach, FL 33444
• Losing or becoming eligible for coverage under a State Medicaid Phone: (561) 243-7377
or CHIP (including Florida Kid Care) program (60 day notification Email: radigs@mydelraybeach.com
period) Website URL: www.mybentek.com/delraybeach
Please Note: The forming of a Domestic Partnership, in and of itself, is not considered a
Qualifying Event. 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 the Benefits Manager.
If there are any questions about the plan offerings or coverage options, please contact
the Benefits Manager at (561) 243-7377.
5 © 2016, Gehring Group, Inc., All Rights Reserved
City of Delray Beach | Employee Benefit Guide | 2020-2021
Wellness Incentive Program
The City is committed to encouraging healthy behaviors. The City offers To complete this program:
employee's enrolled in one (1) of the UnitedHealthcare medical plans the 1. Employee must call the City’s Employee Health and Wellness Center
opportunity to earn monetary rewards to reduce employee monthly insurance at (561) 243-7612 to schedule their annual biometric and nicotine
premiums. Employees enrolled in the UnitedHealthcare Choice Plus Plan have screening.
an opportunity to earn additional contributions into an HRA.
› The biometric screening will include a finger stick and immediate
To receive the Wellness Incentives from the City, employee must review of the results. Based on these results, employee may be
participate in the following programs: educated on additional health coaching opportunities and
programs that are available to help improve his or her health.
UnitedHealthcare Core and UnitedHealthcare Buy-Up HMO › The nicotine screening will include a urine test to determine
Plans the use of tobacco. Any employee who is a tobacco user will
Employee enrolled in either the UnitedHealthcare Core or Buy-Up Plan will have have the opportunity to qualify for this portion of the incentive
the opportunity for reduced medical insurance premium payroll deductions by by participating in a four (4) week tobacco cessation program
completing a biometric screening and nicotine screening through the City’s provided at no cost by the City. For information regarding this
Employee Health and Wellness Center. program, please contact the Benefits Manager.
2. Employee will also need to complete the online Rally Health Risk
UnitedHealthcare Choice Plus Plan Assessment on the UnitedHealthcare website www.myuhc.com.
When employee enrolls in the UnitedHealthcare Choice Plus Plan, participation › To complete the Rally Health Risk Assessment, log onto
in the Wellness Incentive Program provides the opportunity to earn additional www.myuhc.com. If employee has not registered, then employee
HRA funding. The City will award an additional $250 for employee only will need to register by providing a user name and password.
coverage or $500 for employee plus dependent coverage. In order to receive Once registered and/or logged in, click on Health Resources
a discount on medical insurance premium payroll deductions, the employee and go directly to the Rally Health Risk Assessment. Click on
will be required to complete a nicotine screening through the City’s Employee "Get Started Now" to begin assessment. Employee will need
Health Center. the results of the biometric screening provided by the Employee
Health and Wellness Center to complete the assessment.
Please Note: To receive any Wellness Incentives from the City, employee must participate
in the biometric and nicotine screenings through the Employee Health and Wellness
Center AND complete the Rally Health Risk Assessment. If employee does not participate in
both, employee will not receive the medical insurance premium reduction and additional
funding to the Choice Plus Plan HRA.
For additional information concerning the Wellness Incentive Program, please
contact the Benefits Manager.
© 2016, Gehring Group, Inc., All Rights Reserved
6
City of Delray Beach | Employee Benefit Guide | 2020-2021
Medical Insurance - UnitedHealthcare Core Plan
The City offers medical insurance through UnitedHealthcare to benefit-eligible employees. The costs per pay period for coverage are listed in the premium table below
and a brief summary of benefits is provided on the following page. For more detailed information about the medical plans, please refer to the carrier's Summary of
Benefits and Coverage (SBC) document or contact UnitedHealthcare's customer service.
Medical Insurance – UnitedHealthcare Core Plan (Salary Under $35,000)
26 Payroll Deductions - Per Pay Period Cost
With Completed Incentive With Completed Incentive Without Completed Incentive Without Completed Incentive
Plan Type
Non-Tobacco User Tobacco User Non-Tobacco User Tobacco User
Employee Only $0.00 $0.00 $0.00 $0.00
Employee + Spouse $79.73 $99.66 $91.69 $111.62
Employee + Child(ren) $63.85 $79.82 $73.43 $89.40
Employee + Family $135.28 $169.10 $155.58 $189.39
Medical Insurance – UnitedHealthcare Core Plan (Salary $35,000 to $50,000)
26 Payroll Deductions - Per Pay Period Cost
With Completed Incentive With Completed Incentive Without Completed Incentive Without Completed Incentive
Plan Type
Non-Tobacco User Tobacco User Non-Tobacco User Tobacco User
Employee Only $0.00 $0.00 $0.00 $0.00
Employee + Spouse $87.70 $109.63 $100.86 $122.78
Employee + Child(ren) $70.24 $87.80 $80.78 $98.34
Employee + Family $148.81 $186.01 $171.13 $208.33
Medical Insurance – UnitedHealthcare Core Plan (Salary Above $50,000)
26 Payroll Deductions - Per Pay Period Cost
With Completed Incentive With Completed Incentive Without Completed Incentive Without Completed Incentive
Plan Type
Non-Tobacco User Tobacco User Non-Tobacco User Tobacco User
Employee Only $0.00 $0.00 $0.00 $0.00
Employee + Spouse $95.68 $119.60 $110.03 $133.95
Employee + Child(ren) $76.62 $95.78 $88.12 $107.28
Employee + Family $162.34 $202.92 $186.69 $227.27
UnitedHealthcare | Customer Service: (800) 357-0978 | www.myuhc.com
7 © 2016, Gehring Group, Inc., All Rights ReservedCity of Delray Beach | Employee Benefit Guide | 2020-2021
UnitedHealthcare Core Plan At-A-Glance
Network Choice
Plan Year Deductible (PYD) In-Network
Single $1,500
Family $3,000
Coinsurance
Locate a Provider
Member Responsibility 20% • To search for a participating provider,
contact UnitedHealthcare's customer
Plan Year Out-of-Pocket Limit service or visit www.uhc.com. When
Single $3,000 completing the necessary search
criteria, select Choice network.
Family $6,000
• When searching providers on
What Applies to the Out-of-Pocket Limit? Deductible, Coinsurance, Copays and Rx www.myuhc.com, choose a Quality
Care or Premium Care provider. Quality
Physician Services Care or Premium Care providers
Primary Care Physician (PCP) Office Visit $40 Copay (doctors, specialists, facilities) offer the
greatest value and cost savings.
Premium Tier 1 Specialist $50 Copay • Ensure that providers still meet Quality
Non-Premium Tier 1 Specialist $65 Copay Care or Premium Care status by looking
for the "Blue Dot". New Quality Care
Telehealth Services $40 Copay
or Premium Care providers will be
classified with two (2) "Blue Hearts".
Non-Hospital Services; Freestanding Facility
Clinical Lab** (Bloodwork)* No Charge
X-rays** No Charge
Advanced Imaging** (MRI, PET, CT) No Charge
Outpatient Surgery in Surgical Center 20% After PYD
Physician Services at Surgical Center 20% After PYD Plan References
Urgent Care (Per Visit; Waived if Admitted) $50 Copay *LabCorp is the preferred lab for
bloodwork through UnitedHealthcare.
Hospital Services When using a lab other than LabCorp,
please confirm they are contracted with
Inpatient Hospital (Per Admission) 20% After PYD UnitedHealthcare's Choice network prior
Outpatient Hospital (Per Visit) 20% After PYD to receiving services.
** Costs may differ if services received at
Physician Services at Hospital 20% After PYD
a hospital facility.
Emergency Room (Per Visit; Waived if Admitted) $500 Copay
Mental Health/Alcohol & Substance Abuse
Inpatient Hospital Services (Per Admission) 20% After PYD
Outpatient Services (Per Visit) $40 Copay
Prescription Drugs (Rx)
Important Notes
Services received by providers and
Tier 1 $20 Retail Copay facilities not in the Choice network, will
Tier 2 $50 Retail Copay not be covered.
Tier 3 $75 Retail Copay
Mail Order Drug (90-Day Supply) 2x Retail Copay
© 2016, Gehring Group, Inc., All Rights Reserved
8City of Delray Beach | Employee Benefit Guide | 2020-2021
Medical Insurance - UnitedHealthcare Buy-Up Plan
The City offers medical insurance through UnitedHealthcare to benefit-eligible employees. The costs per pay period for coverage are listed in the premium table below
and a brief summary of benefits is provided on the following page. For more detailed information about the medical plans, please refer to the carrier's Summary of
Benefits and Coverage (SBC) document or contact UnitedHealthcare's customer service.
Medical Insurance – UnitedHealthcare Buy-Up Plan (Salary Under $35,000)
26 Payroll Deductions - Per Pay Period Cost
With Completed Incentive With Completed Incentive Without Completed Incentive Without Completed Incentive
Plan Type
Non-Tobacco User Tobacco User Non-Tobacco User Tobacco User
Employee Only $31.78 $39.73 $36.55 $44.49
Employee + Spouse $166.31 $207.88 $191.25 $232.83
Employee + Child(ren) $140.89 $176.12 $162.03 $197.25
Employee + Family $255.30 $319.13 $293.59 $357.42
Medical Insurance – UnitedHealthcare Buy-Up Plan (Salary $35,000 to $50,000)
26 Payroll Deductions - Per Pay Period Cost
With Completed Incentive With Completed Incentive Without Completed Incentive Without Completed Incentive
Plan Type
Non-Tobacco User Tobacco User Non-Tobacco User Tobacco User
Employee Only $31.78 $39.73 $36.55 $44.49
Employee + Spouse $182.94 $228.67 $210.37 $256.11
Employee + Child(ren) $154.98 $193.73 $178.23 $216.97
Employee + Family $280.83 $351.04 $322.95 $393.16
Medical Insurance – UnitedHealthcare Buy-Up Plan (Salary Above $50,000)
26 Payroll Deductions - Per Pay Period Cost
With Completed Incentive With Completed Incentive Without Completed Incentive Without Completed Incentive
Plan Type
Non-Tobacco User Tobacco User Non-Tobacco User Tobacco User
Employee Only $31.78 $39.73 $36.55 $44.49
Employee + Spouse $199.56 $249.46 $229.50 $279.39
Employee + Child(ren) $169.07 $211.34 $194.43 $236.70
Employee + Family $306.36 $382.94 $352.31 $428.90
UnitedHealthcare | Customer Service: (800) 357-0978 | www.myuhc.com
9 © 2016, Gehring Group, Inc., All Rights ReservedCity of Delray Beach | Employee Benefit Guide | 2020-2021
UnitedHealthcare Buy-Up Plan At-A-Glance
Network Choice
Plan Year Deductible (PYD) In-Network
Single $750
Family $1,500
Coinsurance
Locate a Provider
Member Responsibility 20% • To search for a participating provider,
contact UnitedHealthcare's customer
Plan Year Out-of-Pocket Limit service or visit www.uhc.com. When
Single $2,500 completing the necessary search
criteria, select Choice network.
Family $5,000
• When searching providers on
What Applies to the Out-of-Pocket Limit? Deductible, Coinsurance, Copays and Rx www.myuhc.com, choose a Quality
Care or Premium Care provider. Quality
Physician Services Care or Premium Care providers
Primary Care Physician (PCP) Office Visit $40 Copay (doctors, specialists, facilities) offer the
greatest value and cost savings.
Premium Tier 1 Specialist $50 Copay • Ensure that providers still meet Quality
Non-Premium Tier 1 Specialist $65 Copay Care or Premium Care status by looking
for the "Blue Dot". New Quality Care
Telehealth Services $40 Copay
or Premium Care providers will be
classified with two (2) "Blue Hearts".
Non-Hospital Services; Freestanding Facility
Clinical Lab** (Bloodwork)* No Charge
X-rays** No Charge
Advanced Imaging** (MRI, PET, CT) No Charge
Outpatient Surgery in Surgical Center 20% After PYD
Physician Services at Surgical Center 20% After PYD Plan References
Urgent Care (Per Visit; Waived if Admitted) $50 Copay * LabCorp is the preferred lab for
bloodwork through UnitedHealthcare.
Hospital Services When using a lab other than LabCorp,
please confirm they are contracted with
Inpatient Hospital (Per Admission) 20% After PYD UnitedHealthcare's Choice network prior
Outpatient Hospital (Per Visit) 20% After PYD to receiving services.
** Costs may differ if services received at
Physician Services at Hospital 20% After PYD a hospital facility.
Emergency Room (Per Visit; Waived if Admitted) $300 Copay
Mental Health/Alcohol & Substance Abuse
Inpatient Hospital Services (Per Admission) 20% After PYD
Outpatient Services (Per Visit) $40 Copay
Prescription Drugs (Rx) Important Notes
Services received by providers and
Tier 1 $20 Retail Copay facilities not in the Choice network, will
Tier 2 $40 Retail Copay not be covered.
Tier 3 $65 Retail Copay
Mail Order Drug (90-Day Supply) 2x Retail Copay
© 2016, Gehring Group, Inc., All Rights Reserved
10City of Delray Beach | Employee Benefit Guide | 2020-2021
Medical Insurance - UnitedHealthcare Choice Plus Plan (with HRA)
The City offers medical insurance through UnitedHealthcare to benefit-eligible employees. The costs per pay period for coverage are listed in the premium table below
and a brief summary of benefits is provided on the following page. For more detailed information about the medical plans, please refer to the carrier's Summary of
Benefits and Coverage (SBC) document or contact UnitedHealthcare's customer service.
Medical Insurance – UnitedHealthcare Choice Plus Plan (Salary Under $35,000)
26 Payroll Deductions - Per Pay Period Cost
With Completed Incentive With Completed Incentive Without Completed Incentive Without Completed Incentive
Plan Type
Non-Tobacco User Tobacco User Non-Tobacco User Tobacco User
Employee Only $12.02 $15.02 $12.02 $15.02
Employee + Spouse $60.26 $75.32 $60.26 $75.32
Employee + Child(ren) $50.30 $62.88 $50.30 $62.88
Employee + Family $100.61 $125.76 $100.61 $125.76
Medical Insurance – UnitedHealthcare Choice Plus Plan (Salary $35,000 to $50,000)
26 Payroll Deductions - Per Pay Period Cost
With Completed Incentive With Completed Incentive Without Completed Incentive Without Completed Incentive
Plan Type
Non-Tobacco User Tobacco User Non-Tobacco User Tobacco User
Employee Only $12.02 $15.02 $12.02 $15.02
Employee + Spouse $75.32 $94.15 $75.32 $94.15
Employee + Child(ren) $59.66 $74.58 $59.66 $74.58
Employee + Family $119.33 $149.16 $119.33 $149.16
Medical Insurance – UnitedHealthcare Choice Plus Plan (Salary Above $50,000)
26 Payroll Deductions - Per Pay Period Cost
With Completed Incentive With Completed Incentive Without Completed Incentive Without Completed Incentive
Plan Type
Non-Tobacco User Tobacco User Non-Tobacco User Tobacco User
Employee Only $12.02 $15.02 $12.02 $15.02
Employee + Spouse $90.38 $112.98 $90.38 $112.98
Employee + Child(ren) $71.53 $89.42 $71.53 $89.42
Employee + Family $143.08 $178.85 $143.08 $178.85
UnitedHealthcare | Customer Service: (800) 357-0978 | www.myuhc.com
11 © 2016, Gehring Group, Inc., All Rights ReservedCity of Delray Beach | Employee Benefit Guide | 2020-2021
UnitedHealthcare Choice Plus Plan (with HRA) At-A-Glance
Network Choice Plus
Plan Year Deductible (PYD) In-Network Out-of-Network**
Single $1,500 $3,000
Family $3,000 $6,000
Locate a Provider
Coinsurance • To search for a participating provider,
Member Responsibility 10% 40% contact UnitedHealthcare's customer
service or visit www.uhc.com. When
Plan Year Out-of-Pocket Limit completing the necessary search
criteria, select Choice Plus network.
Single $3,000 $9,500
• When searching providers on
Family $6,000 $19,000 www.myuhc.com, choose a Quality
What Applies to the Out-of-Pocket Limit? Deductible, Coinsurance, Copays and Rx Care or Premium Care provider. Quality
Care or Premium Care providers
Physician Services (doctors, specialists, facilities) offer the
greatest value and cost savings.
Primary Care Physician (PCP) Office Visit 10% After PYD 40% After PYD
• Ensure that providers still meet Quality
Premium Tier 1 Specialist 10% After PYD 40% After PYD Care or Premium Care status by looking
for the "Blue Dot". New Quality Care
Non-Premium Tier 1 Specialist 20% After PYD 40% After PYD
or Premium Care providers will be
Telehealth Services 10% After PYD Not Covered classified with two (2) "Blue Hearts".
Non-Hospital Services; Freestanding Facility
Clinical Lab (Bloodwork)* 10% After PYD 40% After PYD
X-rays 10% After PYD 40% After PYD
Advanced Imaging (MRI, PET, CT) 10% After PYD 40% After PYD
Outpatient Surgery in Surgical Center 10% After PYD 40% After PYD Plan References
Physician Services at Surgical Center 10% After PYD 40% After PYD *LabCorp is the preferred lab for
bloodwork through UnitedHealthcare.
Urgent Care (Per Visit; Waived if Admitted) 10% After PYD 40% After PYD When using a lab other than LabCorp,
please confirm they are contracted with
Hospital Services UnitedHealthcare's Choice Plus network
Inpatient Hospital (Per Admission) 10% After PYD 40% After PYD prior to receiving services.
Outpatient Hospital (Per Visit) 10% After PYD 40% After PYD **Out-of-Network Balance Billing:
For information regarding out-of-
Physician Services at Hospital 10% After PYD 40% After PYD network balance billing that may be
Emergency Room (Per Visit) 10% After PYD 10% After PYD charged by an out-of-network provider
for services rendered, please refer to
Mental Health/Alcohol & Substance Abuse the plan's Summary of Benefits and
Coverage document.
Inpatient Hospital Services (Per Admission) 10% After PYD 40% After PYD
Outpatient Services (Per Visit) 10% After PYD 40% After PYD
Prescription Drugs (Rx)
Tier 1 $20 Retail Copay
Tier 2 $40 Retail Copay
Not Covered
Tier 3 $60 Retail Copay
Mail Order Drug (90-Day Supply) 2x Retail Copay
© 2016, Gehring Group, Inc., All Rights Reserved
12City of Delray Beach | Employee Benefit Guide | 2020-2021
Health Reimbursement Account
The City provides employees who participate in the UnitedHealthcare Choice What is the difference between an HRA and an FSA?
Plus Plan, a Health Reimbursement Account (HRA) through UnitedHealthcare.
The City’s HRA benefits are administered by UnitedHealthcare. HRA monies are Health Reimbursement Account (HRA)
funded by the City and can be used for any qualified medical expenses such
as copayments, deductibles and coinsurance for physician services, hospital
services, prescription drugs, etc. 9 Employer funded account
9 Enrollment is automatic if enrolled in medical plan
2020-2021 HRA Funding Allotment 9 Funds used for eligible medical expenses for employee
Employees enrolled in the City's medical plan will receive $500 for Employee and dependent(s) enrolled in medical plan
Only coverage or $1,000 for Employee + Dependent coverage for the plan year.
9 Employees may carry over $500 of unused HRA Funds
HRA amounts will be prorated for new hires eligible outside the City's annual into the next year with a cap of $1,000 for Employee Only
Open Enrollment period. and $2,000 for Employee with Family
Funds not used in any given plan year, up to $500, can be rolled over to the next
plan year period, up to an accumulated cap of $1,000 for Employee Only and Flexible Spending Accounts (FSA)
$2,000 for Employees with Family. This funding is in addition to any awarded
Wellness Incentive monies earned.
9 Employee funded accounts
Employee has an opportunity to earn additional monies to be placed in 9 Employee must enroll annually
employee's HRA by participating in the City’s Wellness Initiative Program. The
9 Health Care FSA funds can be used for eligible medical,
City will award an additional $250 for Employee Only coverage or $500 for dental and vision expenses
Employee + Dependent coverage.
9 Employee may carry over $550 of unused Health Care FSA
Please Note: The plan year deductible exceeds the HRA funding amounts. Members will funds into the next plan year
be responsible for any amount over the HRA funding until the plan year deductible and
out-of-pocket limit have been met for the plan year. 9 Dependent Care FSA funds may be used to pay for work-
related day care expenses
How to Check Available HRA Balance
Balance, activity and account history is available anytime online at If employee has the HRA and also elects an FSA,
the HRA funds will be used first, then FSA funds will be used.
www.myuhc.com or by calling UnitedHealthcare at (800) 357-0978.
Expenses Eligible for Reimbursement Retain Receipts
Employee may request reimbursement of expenses for employee or covered During the year, employee should keep all receipts and documentation for
dependent(s). Eligible expenses must be necessary for the diagnosis, prescriptions and medical related expenses if needed to verify a claim for
treatment, cure, mitigation or prevention of a specific medical condition. UnitedHealthcare or for IRS tax purposes. If asked to produce documentation,
Cosmetic expenses are not eligible for reimbursement. Reimbursement a valid Explanation of Benefits (EOB) and receipt of payment for the services
checks will be issued to employee throughout the year for incurred expenses rendered will be sufficient.
up to the maximum annual benefit amount. Employee has the option to
have reimbursement checks direct deposited into employee's bank account. File a Claim
For more information regarding eligible expenses, visit www.myuhc.com or Employee may submit claim forms to UnitedHealthcare and must include a
contact UnitedHealthcare at (800) 357-0978. copy of carrier's Explanation of Benefits or receipts for eligible medical services
received. Claim forms can be submitted via fax or mail, indicated on the claims
form, or electronically at www.myuhc.com.
UnitedHealthcare | Customer Service: (800) 357-0978 | www.myuhc.com
13 © 2016, Gehring Group, Inc., All Rights ReservedCity of Delray Beach | Employee Benefit Guide | 2020-2021
Employee Health and Wellness Center Other Available Plan Resources
The Employee Health and Wellness Center is available to all employees and UnitedHealthcare offers all enrolled employees and dependents additional
dependents (spouses, domestic partners, and child(ren) two (2) years and services and discounts through value added programs. For more details
over) enrolled in the City's medical plan. regarding other available plan resources, please contact UnitedHealthcare's
customer service at (800) 357-0978 or visit www.myuhc.com.
Employee utilization of the Health and Wellness Center is completely voluntary
and private. Employee's medical information will not be shared with the City.
The Employee Health and Wellness Center can help lower out-of-pocket
costs and improve employee health with short wait times and no co-pays or Virtual Visits
deductibles. All services and generic prescription medications received at the UnitedHealthcare provides access to telehealth services as part of the medical
Employee Health and Wellness Center are provided at no charge. plan. Virtual Visits is a convenient phone and video consultation company that
The Employee Health and Wellness Center provides the care that employee and provides immediate medical assistance for many conditions.
family member(s) need for all non-emergency illnesses, at no cost. The benefit is provided to all enrolled members. Registration is suggested and
Available Services include: should be completed ahead of time. This program allows members 24 hours a
9 Primary Care 9 Labs Performed On-site 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 Well Woman Visits 9 EKG’s
emergency medical issues. Virtual Visits, through UnitedHealthcare, should be
9 Prescription Dispensing 9 Health Risk Assessments considered when employee's primary care doctor is unavailable, after-hours
9 School Physicals 9 Maintenance Drugs or on holidays for non-emergency needs. Many urgent care ailments can be
treated via Virtual Visits, such as:
9 Annual Adult Physicals 9 Acute Illness
9 Sore Throat 9 Allergies
The Employee Health and Wellness Center hours of operation are: 9 Headache 9 Rash
Hours of Operation 9 Stomachache 9 Acne
9 Fever 9 UTI’s and More
Monday 8:00 a.m. – 5:00 p.m. 9 Cold And Flu
Virtual Visit doctors do not replace a member's primary care physician but may
Tuesday 8:00 a.m. – 5:00 p.m.
be a convenient alternative for urgent care and ER visits. For further information,
please contact UnitedHeathcare's customer service at (800) 357-0978.
Wednesday 8:00 a.m. – 5:00 p.m.
UnitedHealthcare Customer Service
Thursday 7:30 a.m. – 5:00 p.m.
(800) 357-0978 | www.uhc.com/virtualvisits
Friday 7:00 a.m. – 1:00 p.m.
To schedule an appointment, contact (561) 243-7613.
Employee Health and Wellness Center
525 NE 3rd Avenue, Delray Beach, FL 33444 | Phone: (561) 243-7312
© 2016, Gehring Group, Inc., All Rights Reserved
14City of Delray Beach | Employee Benefit Guide | 2020-2021
Dental Insurance
Solstice DHMO S200B Plan
The City offers dental insurance through Solstice to benefit-eligible employees. Out-of-Network Benefits
The costs per pay period for coverage are listed in the premium table below
The DHMO S200B plan does not cover any services rendered by out-of-network
and a brief summary of benefits is provided on the following page. For more
facilities or providers.
detailed information about the dental plan, please refer to the carrier's
summary plan document or contact Solstice's customer service. Calendar Year Deductible
There is no calendar year deductible.
Dental Insurance – Solstice DHMO S200B Plan
26 Payroll Deductions - Per Pay Period Cost
Calendar Year Benefit Maximum
Tier of Coverage Employee Cost There is no benefit maximum.
Employee Only $4.56
Solstice Wellness Rewards
Employee + Spouse $8.37
Solstice offers a Wellness Rewards program to all enrolled employees and
Employee + Child(ren) $9.24
qualified dependents. Solstice Wellness Rewards allow members to earn points
Employee + Family $13.04 for routine dental and vision care services. For more detailed information,
please refer to www.solsticebenefits.com.
In-Network Benefits
The DHMO S200B 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 Solstice S200B network to receive IMPORTANT NOTES
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
The DHMO S200B plan’s schedule of benefits is set forth by the Patient Charge calendar year (once every six (6) months) covered under the preventive benefit.
Schedule (fee schedule) which is highlighted on the following page. Please • Should a member need to see a specialist under this plan (Oral Surgeon,
refer to the summary plan document for a detailed listing of charges and Periodontist, Orthodontist, etc.), member must be referred by their Primary Dental
Provider.
benefits.
• Waiting periods and age limitations may apply.
• A member must receive services from facilities and providers in the S200B
network for benefits to be covered.
Solstice | Customer Service: (877) 760-2247 | www.solsticebenefits.com
15 © 2016, Gehring Group, Inc., All Rights ReservedCity of Delray Beach | Employee Benefit Guide | 2020-2021
Solstice DHMO S200B Plan At-A-Glance
Network S200B
Calendar Year Deductible (CYD) In-Network Only
Per Member
Per Family Does Not Apply
Waived for Class I Services?
Class I Services: Diagnostic & Preventive Care Code In-Network
Locate a Provider
To search for a participating provider,
Routine Oral Exam 0120 No Charge contact Solstice's customer service
Routine Cleanings (1 Every 6 Months) 1110/20 No Charge or visit www.solsticebenefits.com.
When completing the necessary search
Bitewing X-rays 0274 No Charge
criteria, select S200B network.
Complete X-rays 0330 $35 Copay
Sealants (1 Per Molar; Child to Age 16) 1351 No Charge
Class II Services: Basic Restorative Care
Fillings (Amalgam; 3 Surfaces) 2160 No Charge
Fillings (Resin; 3 Surfaces, Posterior) 2393 $80 Copay Plan References
Extractions (Erupted Tooth or Exposed Root) 7140 $10 Copay *Excluding final restoration.
Root Canal Therapy (Molar)* 3330 $210 Copay **Copays for these services do not
include the additional cost of precious
Surgical Removal of Tooth (Erupted) 7210 $25 Copay (High Noble) and semi-precious (Noble)
Surgical Removal of Tooth (Impacted) 7240 $63 Copay metal. The additional cost of precious
metal shall not exceed $145 per unit and
Full Mouth Debridement (Deep Cleaning) 4355 $35 Copay
$120 per unit for semi-precious metal.
Class III Services: Major Restorative Care
Crowns (Porcelain Fused to High Noble Metal)** 2752 $195 Copay
Bridges (Porcelain Fused to High Noble Metal)** 6242 $195 Copay
Dentures 5110/20 $210 Copay
Class IV Services: Orthodontia
Benefit — Child 8070/8080 $1,800/$1,850 Copay
Benefit — Adults 8090 $1,950 Copay
Retention (Child/Adult) 8680 $300 Copay
© 2016, Gehring Group, Inc., All Rights Reserved
16City of Delray Beach | Employee Benefit Guide | 2020-2021
Dental Insurance
Solstice DPPO Plan
The City offers dental insurance through Solstice to benefit-eligible employees. Calendar Year Deductible
The costs per pay period for coverage are listed in the premium tables below
The DPPO plan requires a $50 individual or a$150 family deductible to be met
and a brief summary of benefits is provided on the following page. For more
for in-network or out-of-network services before most benefits will begin. The
detailed information about the dental plan, please refer to the carrier's
deductible is waived for preventive services.
summary plan document or contact Solstice's customer service.
Calendar Year Benefit Maximum
Dental Insurance – Solstice DPPO Plan The maximum benefit (coinsurance) the dental PPO plan will pay for each
26 Payroll Deductions - Per Pay Period Cost
covered member is $1,500 for in-network and out-of-network services
Tier of Coverage Employee Cost combined. All services, including preventive, do not accumulate towards the
Employee Only $15.41 benefit maximum. Once the plan's benefit maximum is met, the member will
be responsible for future charges until the next calendar year.
Employee + Spouse $30.45
Employee + Child(ren) $33.66 Solstice Wellness Rewards
Employee + Family $48.79 Solstice offers a Wellness Rewards program to all enrolled employees and
qualified dependents. Solstice Wellness Rewards allow members to earn points
for routine dental and vision care services. For more detailed information,
In-Network Benefits please refer to www.solsticebenefits.com.
The DPPO plan provides benefits for services received from in-network and
out-of-network providers. It is also an open-access plan which allows for Solstice Benefit Booster Program
services to be received from any dental provider without having to select Solstice Benefit Booster program allows employee to carryover part of the
a Primary Dental Provider (PDP) or obtain a referral to a specialist. The unused annual maximum. Employee earns Benefit Boosters by submitting
network of participating dental providers the plan utilizes is the Solstice at least one (1) claim for dental expenses incurred during the benefit year,
PPO network. These participating dental providers have contractually while staying at or under the threshold amount for benefits received for that
agreed to accept Solstice’s contracted fee or “allowed amount.” This fee is year ($750). Employee and covered dependent(s) may accumulate rewards
the maximum amount a Solstice dental provider can charge a member for a up to the maximum carryover amount ($400), and then use those rewards
service. The member is responsible for a Calendar Year Deductible (CYD) and for any covered dental procedures subject to applicable coinsurance and plan
then coinsurance based on the plan’s charge limitations. provisions. If a plan member doesn’t submit a dental claim during a benefit
year, all accumulated rewards are lost for that year, but employee can begin
Out-of-Network Benefits earning rewards again the very next year. In addition, if employee stays in the
Out-of-network benefits are used when member receives services by a non- PPO network employee will earn an Annual PPO Bonus of $100.
participating Solstice DPPO provider. Solstice reimburses out-of-network
services based on what it determines as the Usual and Customary (U&C) Benefit Threshold $750
Dental benefits received for the year
Charge. The U&C is defined as the most common charge for a particular dental cannot exceed this amount.
procedure performed in a specific geographic area. If services are received from Amount added to the following year’s
Annual Carryover Amount $400
an out-of-network dentist, the member may be responsible for balance billing. benefit maximum.
Balance billing is the difference between Solstice's U&C and the amount Additional bonus is earned if the
Annual PPO Bonus $100
charged by the out-of-network dental provider. Balance billing is in addition covered member sees a PPO provider.
to any applicable plan deductible or coinsurance responsibility. Maximum possible accumulation
Maximum Carryover $3,000 for benefit rollover and PPO bonus
combined.
Solstice | Customer Service: (877) 760-2247 | www.solsticebenefits.com
17 © 2016, Gehring Group, Inc., All Rights ReservedCity of Delray Beach | Employee Benefit Guide | 2020-2021
Solstice DPPO Plan At-A-Glance
Network Solstice PPO
Calendar Year Deductible (CYD) In-Network and Out-of-Network Combined
Per Member $50
Per Family $150
Waived for Class I Services? Yes
Locate a Provider
Calendar Year Benefit Maximum In-Network Out-of-Network*
To search for a participating provider,
Per Member (Includes Class I Services) $1,500 contact Solstice's customer service
or visit www.solsticebenefits.com.
Class I Services: Diagnostic & Preventive Care When completing the necessary search
Routine Oral Exam (2 Per Year) criteria, select Solstice PPO network.
Routine Cleanings (2 Per Year) Plan Pays: 100%
Plan Pays: 100%
Deductible Waived
Bitewing X-rays (1 Series of Films Per Year) Deductible Waived
(Subject to Balance Billing)
Complete X-rays (1 Series Every 3 Calendar Years)
Class II Services: Basic Restorative Care
Fillings (Amalgam or Composite) Plan References
Plan Pays: 80%
Plan Pays: 90% *Out-of-Network Balance Billing:
Simple Extractions (1 Per Tooth Per Lifetime) After CYD
After CYD For information regarding out-of-
(Subject to Balance Billing)
Anesthetics network balance billing that may be
charged by an out-of-network provider,
Class III Services: Major Restorative Care please refer to the Out-of-Network
Crowns (1 Per Tooth Every 5 Years) Benefits section on the previous page.
Bridges (1 Per Tooth Every 5 Years)
Dentures Plan Pays: 50%
Plan Pays: 60%
After CYD
Periodontal Services After CYD
(Subject to Balance Billing)
Endodontics (Root Canal Therapy)
Oral Surgery Important Notes
• Each covered family member may
Class IV Services: Orthodontia receive up to two (2) routine cleanings
Lifetime Maximum $2,000 $2,000 per calendar year (Once every six (6)
months) covered under the preventive
benefit.
Plan Pays: 50%
Benefit (Children and Adults) Plan Pays: 50% • For any dental work expected to cost
(Subject to Balance Billing)
$300 or more, the plan will provide a
“Pre-Determination of Benefits” upon
the request of the dental provider.
This will assist with determining
approximate out-of-pocket costs
should employee have the dental work
performed.
• Waiting periods and age limitations
may apply.
• Benefit frequency limitations may
apply to certain services.
© 2016, Gehring Group, Inc., All Rights Reserved
18City of Delray Beach | Employee Benefit Guide | 2020-2021
Vision Insurance
EyeMed Vision Plan
The City offers vision insurance through EyeMed to benefit-eligible employees. Out-of-Network Benefits
The costs per pay period for coverage are listed in the premium table below
Employee and covered dependent(s) may choose to receive services from
and a brief summary of benefits is provided on the following page. For more
vision providers who do not participate in the EyeMed Insight network.
information about the vision plan, please refer to the carrier’s summary plan
When going out of network, the provider will require payment at the time of
document or contact EyeMed’s customer service.
appointment. EyeMed will then reimburse based on the plan’s out-of-network
reimbursement schedule upon receipt of proof of services rendered.
Vision Insurance – EyeMed Vision Plan
26 Payroll Deductions - Per Pay Period Cost Plan Year Deductible
Tier of Coverage Employee Cost There is no plan year deductible.
Employee Only $2.30 Plan Year Out-of-Pocket Maximum
Employee + 1 Dependent $4.48 There is no out-of-pocket maximum. However, there are benefit reimbursement
Employee + 2 or More Dependents $6.43 maximums for certain services.
EyeMed | Customer Service: (866) 939-3633 | www.eyemed.com
In-Network Benefits
The vision plan offers employee and covered dependent(s) coverage for routine
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 EyeMed Insight network.
At 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.
19 © 2016, Gehring Group, Inc., All Rights ReservedCity of Delray Beach | Employee Benefit Guide | 2020-2021
EyeMed Vision Plan At-A-Glance
Network Insight
Services In-Network Out-of-Network
Eye Exam $10 Copay Up to $40 Reimbursement
Standard Lens Up to $55 Copay Not Covered
Contact Lens Fit and Follow-Up
Premium Lens 10% Off Retail Price Not Covered
Locate a Provider
Frequency of Services To search for a participating provider,
contact EyeMed’s customer service
Examination 12 Months
or visit www.eyemed.com. When
Lenses 12 Months completing the necessary search
criteria, select the Insight network.
Frames 24 Months
Contact Lenses 12 Months
Lenses
Single Up to $30 Reimbursement
Bifocal $15 Copay Up to $50 Reimbursement Plan References
* Contact lenses are in lieu of spectacle
Trifocal Up to $70 Reimbursement
lenses and frames.
Frames
$130 Retail Allowance;
Basic, Preferred or Non-Preferred Up to $98 Reimbursement
Then 20% Discount Over Allowance
Contact Lenses*
Important Notes
Non-Elective; Medically Necessary (Prior Authorization Required) No Charge Up to $210 Reimbursement Member options, such as LASIK, UV
Up to $130 Allowance; coating, progressive lenses, etc. are not
Conventional Up to $110 Reimbursement covered in full, but may be available at
Then 15% Discount Over Allowance
Elective (Fitting, Follow-up & Lenses) a discount.
Disposable Up to $130 Allowance Up to $110 Reimbursement
© 2016, Gehring Group, Inc., All Rights Reserved
20City of Delray Beach | Employee Benefit Guide | 2020-2021
Flexible Spending Accounts
The City offers Flexible Spending Accounts (FSA) administered through UnitedHealthcare. The FSA plan year is from October 1 to September 30.
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 participant to set aside up to an annual maximum of $5,000 if single
This account allows participant to set aside up to an annual
or married and file a joint tax return ($2,500 if married and file a separate tax return) for
maximum of $2,750. This money will not be taxable income
work-related day care expenses. Qualified expenses include day care centers, preschool,
to the participant and can be used to offset the cost of a
and before/after school care for eligible children and dependent adults.
wide variety of eligible medical expenses that generate
out-of-pocket costs. Participating employee can also receive Please note, if family income is over $20,000, this reimbursement option will likely save
reimbursement for expenses related to dental and vision participants more money than dependent day care tax credit taken on a tax return. To
care (that are not classified as cosmetic). qualify, dependents must be:
Examples of common expenses that qualify for • A child under the age of 13, or
reimbursement are listed below. • A child, spouse or other dependent who is physically or mentally incapable
of self-care and spends at least eight (8) hours a day in the participant’s
household.
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.
To contribute to an FSA in the 2020/2021 plan year, employee must log into Bentek and elect contribution amount for either the Health Care FSA and/or the Dependent
Care FSA. If employee is currently enrolled in an FSA, coverage does not rollover to the new plan year, employee must make a new election.
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